Vera and her daughter, Veronica, celebrating Christmas

Vera and her daughter, Veronica, celebrating Christmas

Vera’s illness began with a soft tissue infection called cellulitis probably brought on by a whirlpool bath treatment. She was hospitalized and treated with Intravenous antibiotics. She was discharged to home and told to stay off her foot, and while at bed rest developed pneumonia. She required readmission to the hospital. While being fed dinner she choked on her food and the food ended up in her lung. She required placement of a breathing tube, respirator support, and transfer to the ICU. Despite several attempts to take her off the respirator her thick secretions repeatedly led to worsening respiratory failure requiring replacement of the breathing tube. Because prolonged respiratory support was anticipated she underwent an elective tracheostomy.

At 90 years old Vera remained alert and very intellectually engaged. While in the ICU she listened to classical music and danced with her arms. After about 2 weeks, she had improved sufficiently to warrant transfer to a less acute facility where weaning her from the respirator could be completed. Soon she was managing up to 40 hours breathing on her own. On her 6th day in her new facility the nurses experienced some difficulty suctioning her thick mucous secretions and decided to take out her tracheostomy tube and replace it with a smaller one.  This procedure was conducted without the supervision of an experienced physician. A little after midnight, without a physician’s order, her tracheostomy tube was again changed to an even smaller size.

Worried, her daughter Veronica called every two hours throughout the night, and each time was told her mother was stable. However the following morning while in church her daughter received bad news. Veronica was told her mother suffered an “event”. While being rolled over in bed her small tracheostomy tube came out, and Vera remained without significant oxygen for a prolonged period. As a consequence she suffered irreversible anoxic brain damage resulting in waxing and waning coma, and a loss of the ability to speak. Over the next 6 months Vera continued to require hospitalization. Her downhill course was complicated by a large and painful pressure ulcer (13cm, Stage Four ulcer that developed within 3 weeks of her brain injury), followed by C. difficile diarrhea, sepsis, renal failure and death.

Vera, an intelligent, talented and deeply loved mother was taken from her daughter by mismanagement of a tracheostomy tube. Veronica quit her job to take care of Vera. She lost her mother twice. First, after anoxic brain damage, and second after the many complications led to her death. Veronica remains a second victim suffering from depression and post traumatic stress syndrome. I hope that sharing her mother’s story will help Veronica to heal and to transform her into a survivor.

Lessons learned from Vera and Veronica’s experience:
Tracheostomy tube accidents are all too common. The number of injuries and deaths due to tracheostomy mismanagement is unknown. There were three major problems associated with the management of Vera’s tracheostomy:

Problem – The tracheostomy tube was replaced without the supervision of an experienced physician.
Solution – Guidelines from experts in the field recommend that an Ear, Nose and Throat (ENT) surgeon be present the first time a tracheostomy tube is changed. Tube exchange after a new tracheostomy (incision below the Adams apple that creates an air passage below the vocal cords) can result in the accidental closing off of the tracheostomy site and this complication may require emergent surgical intervention.
The Guidelines state, “An initial tracheostomy tube change should normally be performed by an experienced physician with the assistance of nursing staff, a respiratory therapist, medical assistant, or assistance of another physician.”

Problem – The tracheostomy tube came out and Vera could not be properly ventilated for a prolonged period. The tube was not properly tied down, and it is likely that the diameter of the tracheostomy tube was too small. These two conditions allowed the tube to be easily dislodged.
Solution – Tracheostomy tubes should always be anchored with a tie-down ribbon around the neck to prevent the tube from becoming dislodged. Guidelines specifically state “Tracheostomy tube ties should be used unless the patient recently underwent local or free flap reconstructive surgery or other major neck surgery.” Second, an ENT surgeon should have decided on the diameter of the tracheostomy tube.  A number of factors need to be considered when deciding on the diameter and type of tracheostomy tube.
Guidelines state:
1. “When determining the appropriate diameter tracheostomy tube, lung mechanics, upper airway resistance, and airway clearance should be considered.”
2. “When determining the appropriate diameter tracheostomy tube, indications for the procedure, trachea size, and shape should be considered.”
3. “When determining the appropriate diameter tracheostomy tube, clearance for ventilation and communication/speech needs should be considered”

Problem: The exact events that resulted in Vera’s anoxic brain damage remain to be fully clarified; however based on the outcome it is clear that the emergency response was inadequate, and in all likelihood the caregivers were not properly trained in tracheostomy care.
Solutions: All caregivers and family members should be properly trained in how to manage tracheostomies, including emergency care.
Guidelines state:
1. “Utilization of a defined tracheostomy care protocol for patient and caregiver education prior to discharge will improve patient outcomes and decrease complications related to their tracheostomy tube.”
2. “Patients and their caregivers should receive a checklist of emergency supplies prior to discharge that should remain with the patient at all times”
3. “Patients and their caregivers should be informed of what to do in an emergency situation prior to discharge.”

Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg. Jan 2013;148(1):6-20