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Pauline has managed a number of key PR accounts and campaigns for a variety of businesses and has experience in crisis communications.
In her time away from the office, Pauline enjoys going to gym and practices advanced Pilates. Donna has experience of both consumer and business-to-business PR, and manages a number of key accounts operating in a variety of industries including oil and gas service firms, professional services and hotels.
At the end of a busy week Donna likes nothing more than putting her feet up with a large glass of wine! Yvette has experience of both consumer and business-to-business PR and has written features, blogs and newspaper columns for national and local press as well as weekly magazines and trade publications. At the weekend Yvette can be found at the top of Scolty Hill trying to control her crazy dog or with her family planning their next trip abroad! Dannielle is a communications graduate with three years experience in the communications and PR industry, working with both B2B and B2C clients world-wide. Jenna MacCulloch is our Inverness-based PR account manager first point of call for our Highland clients. A former award-winning journalist, Jenna has over six years experience in both print and broadcast media, formally holding the position of chief reporter at one of the top newspaper titles in the Highlands, before making the move into the PR industry.
Jenna has experience in consumer and business-to-business PR, PR crisis and managing accounts in the tourism, food and drink and renewables industry. Born and bred Inverness, Jenna is passionate about all things Highland and loves nothing more than sampling locally sourced cuisine in restaurants.
A great many people have put a lot of hard work into the production of this book and the accompanying courses and resources.The authors would like to thank all the contributors for their efforts. The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988. Designations used by companies to distinguish their products are often claimed as trademarks.
The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient.
This manual is a resource developed by the UK NTSP to help promote and facilitate the safe management of tracheostomies and laryngectomies. We have attempted to make the resource a a€?one-stop shopa€™ covering all aspects of tracheostomy and laryngectomy management by collecting together resources from surgical, anaesthetic, nursing, intensive care and allied health backgrounds, along with guidance from key national stakeholder organisations. We have also reviewed many local, regional, national and international guidelines, policies and resources during the preparation of this manual. This unique document has been developed by consulting as widely as possible, across traditional professional boundaries using expertise and existing guidance from around the world.
This guidance is applicable for a novice first responder looking after a patient with a tracheostomy or laryngectomy for the first time, through to an airway expert secondary responder. This project would not have been possible without the valued time and contributions of a great many people.
Mr Alan Ryan, National Programme Director, Heath Education England e-Learning for Healthcare (HEE e-LfH) for permission to use graphics and images developed with e-LfH, used in this manual. Mr Dev Chandramani & Mr Deepak Sharma from Boxsail for Website and SmartPhone App design. Special thanks to Emma McGrath, Ali Atkinson, Claire Moore, Damian Bates and all of our extended families for the support and assistance, childcare and facilitating all of the late nights that have made this project possible. The NTSP has received funding from the Intensive Care Society (ICS) and assistance from the Royal College of Anaesthetists (RCoA) (allowed use of in-house programmers) specifically to contribute towards the e-learning for healthcare modules developed as part of this project.
The project has also received sponsorship from the following companies: Smiths-Medical (Portex), Cook, Kapitex, Ambu a-Scope, Olympus, Astellas Pharma and Pfizer. While this information has been collected and designed to help in clinical management, the authors do not accept any responsibility for any harm, loss or damage arising from actions or decisions based on the information contained within this publication, the associated website and materials. Every effort has been made by the authors to use materials and sources that are reliable and provide information that is compatible with the standards generally accepted at the time of publication.
A patient with a tracheostomy or laryngectomy is at risk of death or harm if inappropriate or inadequate care is provided. This project started with a group of four Intensive Care Doctors working in Manchester, UK, who wanted to improve the management of patients with tracheostomies. We have focused our attentions in two key areas: the emergency management algorithms and improving routine care by developing educational resources aimed at preventing neck-breathing patients developing life-threatening emergencies. We developed and tested our emergency guidance with high-fidelity simulators using specific scenarios to ensure that nursing staff, doctors and allied health professionals could follow our algorithms. The resources are supported by an extensive e-learning package, developed in partnership with the UK Department of Health's e-Learning for Healthcare project and the Royal College of Anaesthetist's e-Learning in Anaesthesia project.
The various resources have been peer reviewed by a number of different processes, including open peer review of draft resources posted on our website and the websites of a number of partner organisations. Full details of the literature, review process and development of these guidelines are described in McGrath et al.'s (2012) manuscript3 in Anaesthesia. Tracheostomies are performed in head and neck surgical practice, with over 5000 procedures performed yearly in England. This has implications for the safety of patients who may be cared for on wards without the necessary competencies and experience to manage this challenging cohort and local measures need to be in place to ensure that safe routine and emergency care can be provided.
Figure 2.1 A sagittal section through the upper airway anatomy showing a tracheostomy in situ. While tracheostomies are increasingly commonplace, patient safety incidents associated with their use are unfortunately increasing. The majority of these incidents are due to the same recurring themes and the resources we have developed as part of this project are specifically aimed at addressing these. There is more detail on tracheostomy and laryngectomy problems in the complication, red flags and emergency management section.
The laryngectomy patient has had the normal upper airway humidification mechanisms bypassed, in the same way as a tracheostomy patient.
One of the commonest problems with a laryngectomy, particularly in an emergency, is that responders fail to appreciate that the patient has actually had the larynx removed. The green bedhead sign, depicted in Figure 2.3, is paired with the green emergency algorithms and indicates a (potentially) patent upper airway that can be used in an emergency.
Figure 2.3 Green and red bedhead signs designed to clarify a patient's airway condition and support the emergency management. The classical indication for a tracheostomy is upper airway obstruction and this is why the first recorded tracheostomies were performed.
Because of the nature of the underlying medical conditions that often lead to a tracheostomy, patients who receive a tracheostomy often have poor survival prospects. There are a variety of tracheostomy techniques but they all aim to enter the trachea around the gap between the second and third tracheal rings. There are many important structures that lie in the neck in close proximity to the trachea (Figure 3.3). The doctor leading an emergency services overhaul tells Sky a third of patients could be diverted to GPs, pharmacists and others.
Our products and services address the health policies and programmes implemented by NHS England. She then went on to enjoy the glamorous world of consumer marketing before jumping ship to the even more glitzy PR business in London.
Her specialisms include oil and gas and property, and recently she completed the Basic Drilling Awareness course at Aberdeen Drilling School and oil and gas training at the University of Aberdeen. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose.
The scope includes hospital in-patient specialist areas, such as critical care, head and neck units and specialist wards, but is also applicable to more general wards, outpatient and community settings. These include the Difficult Airway Society, Intensive Care Society, the Royal College of Anaesthetists, ENT UK, British Association of Oral and Maxillofacial Surgeons, College of Emergency Medicine, Resuscitation Council UK, Royal College of Nursing, Royal College of Speech and Language Therapists, Association of Chartered Physiotherapists in Respiratory Care, British Laryngological Association, Faculty of Intensive Care Medicine, National Association of Laryngectomy Clubs and the National Patient Safety Agency.
Many such groups have previously developed excellent resources for the care of a€?neck breathersa€™, but these were often focused on specific areas of practice. The manual attempts to pull together the different pieces of the jigsaw that already existed, as well as devising new resources where we felt they were needed.
Please contact us if you have any further comments or resources that you feel would add to this project.
This sponsorship has specifically been used to reduce the cost of medical, nursing and allied health staff attending our tracheostomy safety courses and has not influenced the production or development of these resources.
Because of the nature of medical practice, we recommend that the reader always consults current research and institutional policies before performing clinical procedures. This patient group requires airway devices to be safely inserted, securely positioned and appropriately cared for, in order to continue to provide the patient with a patent airway.


Identify a clinical lead in each National Health Service (NHS) Trust or institution to coordinate the management of patients with tracheostomies. Trusts must have a local policy in place, which outlines the expected management of patients with a tracheostomy or laryngectomy. Identify appropriate environments in which to manage patients with tracheostomies and laryngectomies. Identify a comprehensive risk assessment of the patient that is agreed upon locally to determine the dependency of the patient, the level of the observation and visibility required. The frequency of risk assessment should be determined by the patient's condition, clinical environment, staffing levels, skills and competence. Trusts that are unable to develop systems to reduce risks effectively in all clinical areas should consider identifying designated areas where the risks are reduced.
Equipment for the management of the tracheostomy including suction should be kept near the patient at all times. Emergency equipment must remain immediately available at the bedside and accompany the patients if they leave their base location. The inner cannula should be regularly checked and cleaned, as this greatly reduces the risk of a tracheostomy tube becoming blocked.
Patients with tracheostomies must be cared for by staff who have been appropriately trained and are currently considered competent in tracheostomy care. Staff must be able to access appropriate training and support in order to deliver appropriate care, identify risk factors and initiate management of complications. Trusts must ensure that training programmes are in accordance with best evidence-based guidelines on the management of a tracheostomy. Staff escorting the patient outside of the clinical area must be competent in dealing with suctioning and in managing a tracheostomy emergency.
All staff caring for patients with tracheostomies and laryngectomies must be competent to do so, both in routine care and in the emergency situation.
These recommendations can be extended to carers outside of the hospital environment, in nursing homes, patients' own homes and to those responding to patients who are community based. Emergency algorithms should be taught, displayed and used to manage tracheostomy or laryngectomy emergencies.
Essential information can be displayed at the bedside to assist in managing an emergency at which the attending staff may not know the history of the patient.
International Quality Improvement Collaboratives exist to improve care by rapidly disseminating best practice initiatives. We had identified recurrent themes common to tracheostomy and laryngectomy emergencies and recognised that in order to improve care, educational resources and innovative ways to teach them were urgently required. We have also introduced this guidance in a number of different trusts in the UK and developed the project incorporating multi-site, multi-speciality peer review and feedback.
We have provided as much information as possible in video, diagram and schematic format, with many links from the text of this manual direct to YouTube videos and the resources of our website.2 This was in response to feedback received when we started to disseminate this information more widely. The emergency guidelines, algorithms, bedhead signs and supporting manuscript have been endorsed by the Difficult Airway Society, Intensive Care Society, the Royal College of Anaesthetists, ENT UK, British Association of Oral and Maxillofacial Surgeons, College of Emergency Medicine, Resuscitation Council UK, Royal College of Nursing, Royal College of Speech and Language Therapists, Association of Chartered Physiotherapists in Respiratory Care, National Association of Laryngectomy Clubs and the National Patient Safety Agency.
We estimate around 10 000a€“15 000 percutaneous tracheostomies are performed each year in England's critical care units, although the actual figure is currently unknown. This manual has evolved to provide information to those caring for patients with temporary or permanent tracheostomies, either regularly or occasionally. Over 1700 incidents were reported to the NPSA between 1 January 2005 and 31 December 2008, including over 30 deaths. These are usually squamous cell carcinomas and can be treated by radiotherapy and surgery, depending on the site and the general condition of the patient.
Remember though that tracheostomies are often performed because of actual or anticipated difficulty with the upper airway, so upper airway patency cannot be guaranteed. It can be difficult to tell the difference at the bedside between a laryngectomy and a surgical tracheostomy, particularly close to major surgery. However, in modern medical practice, the indications have widened both for temporary and permanent tracheostomy. A review of over 23 000 American inpatient records where a tracheostomy was performed demonstrated that only 80% survived to hospital discharge, with as few as 60% surviving if they had significant co-morbidities (Shah et al., 2012). For specific circumstances, such as extensive elective head and neck surgery, the decision is straightforward. Emergency access to the airway can be achieved through the relatively avascular cricothyroid membrane. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. The majority of the content is for adult patients, with a new paediatric chapter developed with colleagues from Great Ormond Street Hospital. We have also received many hundreds of comments on draft resources and further advice from around the world. Previous work is referenced and accredited where appropriate, and we are grateful for the permissions that have been granted for use of other materials.
We are particularly interested to hear if the emergency algorithms have been used successfully.
We have also been granted permission to use images, documents, videos and resources from many sources. The authors accept no responsibility for the persistence or accuracy of urls for external content referred to in this publication.
Many of the recommendations originate from the National Patient Safety Agency (NPSA) multi-professional external reference group, comprising representatives from key a€?National Bodiesa€™ and expert clinicians. Failure to do so may lead to a displaced or blocked tube, which, if not dealt with immediately, may be fatal within minutes. Exceptions to this must be clearly documented in the patient's medical record and a date for review determined. This includes designated wards and clinical areas, and also acute services, such as acute medical units and emergency departments, that may be expected to see tracheostomy complications.
This can range from keeping an adverse incident record or contributing to a large database. Data may be submitted to track improvements in care and to allow benchmarking with similar institutions. We initially sought the help of other colleagues in Critical Care, Anaesthesia, ENT surgery and maxillofacial surgery, forming a multi-disciplinary, multi-site working party to develop these resources. A lot of tracheostomy-related procedures are best learned when you can actually see someone doing it a€“ either at the bedside locally, or via some of the videos we have provided. There have also been contributions from The British Laryngological Association and the Faculty of Intensive Care Medicine. It aims to provide basic background information and the rationale for tracheostomy care (Figure 2.1). We know from research with the NPSA that when a clinical incident occurs relating to a tracheostomy, the chance of some harm occurring is between 60% and 70%, depending on the location in which that the patient is being cared for [see links to these abstracts for NPSA papers in Thomas and McGrath (2009) and McGrath and Thomas (2010)]. Surgical resection of the tongue base or epiglottis may not necessarily involve removal of the larynx and is sometimes referred to as a supraglottic laryngectomy. The airway is often more secure than with a temporary tracheostomy, as the trachea is stitched onto the front of the neck. There are many incident reports of patients, following a laryngectomy, who are mistakenly given oxygen via the face or who have had attempts at managing their upper airway fail because there is no connection between the face and lungs. The signs also allow details of the nature and date of the tracheostomy to be recorded, along with details of the airway, and whom to call (and how) in an emergency (Figure 2.3). However, balancing the risks of managing an airway with prolonged endotracheal tube (ETT) intubation versus the risks of tracheostomy (procedural and post-placement) is difficult and must be made on an individual basis (Box 3.1). It is sold on the understanding that the publisher is not engaged in rendering professional services. We are grateful to the many individuals who have contributed to this project in this way and have acknowledged as many as possible where appropriate. The inclusion in this publication of material relating to a particular product or method does not amount to an endorsement of its value, quality or the claims made by its manufacturer.
The website will provide you with a new page to download and replace the existing page in your book. This group grew to incorporate input from nursing, physiotherapy and speech therapy colleagues, along with patients and patient groups and other medical and allied health professionals.
The resources in the manual have arisen from extensive collaboration between local, national and international stakeholder groups and have built on previously published guidelines, resources and expert opinion. The NTSP manual has been reviewed by many of these groups, either formally or informally, and also revised by a multi-disciplinary NTSP editorial board. This is partly due to pressures on intensive care beds and the increasing drive to de-escalate care quickly, along with increasing numbers of patients benefiting from temporary tracheostomies.
It is sometimes possible to resect only one half of the larynx for localised disease with a hemilaryngectomy.


Likewise, we know of situations where following radical head and neck surgery, carers have failed to manage a patient's upper airway after assuming that they had had a laryngectomy when, in fact, they had not. The tube enables airflow to enter the trachea and lungs directly, bypassing the nose, pharynx and larynx.
The further down the neck towards the chest you palpate, the deeper into the neck the trachea goes.
If professional advice or other expert assistance is required, the services of a competent professional should be sought. We have included urls in the footnotes, where relevant, to the specific sections of the website and our resources. These guidelines should not constitute a minimum standard of practice nor should they be regarded as a substitute for good clinical judgement.
We saw our role as putting together the individual pieces of the jigsaw that often existed in respect to specialised areas of tracheostomy and laryngectomy care.
Finally, the e-Learning for Healthcare resources have been reviewed by e-Learning Anaesthesia at the Royal College of Anaesthetists. However, if a total laryngectomy is required, this involves complete surgical removal of the larynx, which disconnects the upper airway (nose and mouth) from the lungs. We have developed colour-coded bedhead signs and algorithms to immediately distinguish laryngectomies from tracheostomies, as recommended by the NPSA and ICS. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. Increasing numbers of patients with tracheostomies are being cared for on wards outside the specialist ward [typically ENT or maxillofacial wards, or sometimes neurosurgical or neurology wards] or critical care infrastructure.
This is a permanent and irreversible procedure (although partial laryngectomies are possible). There are a variety of covers, valves and humidification devices available, which can make distinguishing between a tracheostomy and laryngectomy very difficult.
The trachea is transected (cut) and then the open end is stitched onto the front of the neck. Tubes are sometimes inserted into laryngectomy stomas, especially when they have just been created; the patient needs invasive ventilation or requires repeated suctioning.
THESE VERY SAME ENFORCEMENT AGENCIES, WHO HAVE SWORN TO PROTECT AND SERVE, OUR COUNTRY, AND CITIZENS ,ARE BUT SOME, OF THE CORRUPT,GREEDY TRAITORS .ENGAGED IN THE TYRANNY AND TORTURE. Once this has been performed, the patient will never be able to breathe or be oxygenated or ventilated through the upper airway again.
An animation showing the difference between a tracheostomy and a laryngectomy1 can be found in the link provided in the footnote. The use of bedhead signs to alert staff that a patient does not have an upper airway is extremely useful, especially when the patient cannot tell you because of acute illness or not being able to talk following a laryngectomy. The school district has moved to a biometric identification program, saying students will no longer have to use an ID card to buy lunch.A  BIOMETRICS TO TRACK YOUR KIDS!!!!!i»?i»?A TARGETED INDIVIDUALS, THE GREEDY CRIMINALS ARE NOW CONDONING THEIR TECH! Paul Weindling, history of medicine professor at Oxford Brookes University, describes his search for the lost victims of Nazi experiments. The chairman of the board at ESL a€” then proprietor of the desert wasteland in Nevada known as a€?Area 51a€? a€” was William Perry, who would be appointed secretary of defense several years later. EUCACH.ORG PanelIn a 2-hour wide-ranging Panel with Alfred Lambremont Webre on the Transhumanist Agenda, Magnus Olsson, Dr. Henning Witte, and Melanie Vritschan, three experts from the European Coalition Against Covert Harassment, revealed recent technological advances in human robotization and nano implant technologies, and an acceleration of what Melanie Vritschan characterized as a a€?global enslavement programa€?.Shift from electromagnetic to scalar wavesThese technologies have now shifted from electromagnetic wave to scalar waves and use super quantum computers in the quantum cloud to control a€?pipesa€? a reference to the brains of humans that have been taken over via DNA, via implants that can be breathed can breach the blood-brain barrier and then controlled via scalar waved on a super-grid.
Eventually, such 'subvocal speech' systems could be used in spacesuits, in noisy places like airport towers to capture air-traffic controller commands, or even in traditional voice-recognition programs to increase accuracy, according to NASA scientists."What is analyzed is silent, or sub auditory, speech, such as when a person silently reads or talks to himself," said Chuck Jorgensen, a scientist whose team is developing silent, subvocal speech recognition at NASA Ames Research Center in California's Silicon Valley. We numbered the columns and rows, and we could identify each letter with a pair of single-digit numbers," Jorgensen said.
People in noisy conditions could use the system when privacy is needed, such as during telephone conversations on buses or trains, according to scientists."An expanded muscle-control system could help injured astronauts control machines. If an astronaut is suffering from muscle weakness due to a long stint in microgravity, the astronaut could send signals to software that would assist with landings on Mars or the Earth, for example," Jorgensen explained. These are processed to remove noise, and then we process them to see useful parts of the signals to show one word from another," Jorgensen said.After the signals are amplified, computer software 'reads' the signals to recognize each word and sound. Our Research and Development Division has been in contact with the Federal Bureau of Prisons, the California Department of Corrections, the Texas Department of Public Safety, and the Massachusetts Department of Correction to run limited trials of the 2020 neural chip implant.
We have established representatives of our interests in both management and institutional level positions within these departments.
Federal regulations do not yet permit testing of implants on prisoners, but we have entered nto contractual agreements with privatized health care professionals and specified correctional personnel to do limited testing of our products. We need, however, to expand our testing to research how effective the 2020 neural chip implant performs in those identified as the most aggressive in our society. In California, several prisoners were identified as members of the security threat group, EME, or Mexican Mafia.
They were brought to the health services unit at Pelican Bay and tranquilized with advanced sedatives developed by our Cambridge,Massachussetts laboratories. The results of implants on 8 prisoners yielded the following results: a€?Implants served as surveillance monitoring device for threat group activity. However, during that period substantial data was gathered by our research and development team which suggests that the implants exceed expected results. One of the major concerns of Security and the R & D team was that the test subject would discover the chemial imbalance during the initial adjustment period and the test would have to be scurbbed.
However, due to advanced technological developments in the sedatives administered, the 48 hour adjustment period can be attributed t prescription medication given to the test subjects after the implant procedure. One of the concerns raised by R & D was the cause of the bleeding and how to eliminate that problem. Unexplained bleeding might cause the subject to inquire further about his "routine" visit to the infirmary or health care facility. Security officials now know several strategies employed by the EME that facilitate the transmission of illegal drugs and weapons into their correctional facilities.
One intelligence officier remarked that while they cannot use the informaiton that have in a court of law that they now know who to watch and what outside "connections" they have. The prison at Soledad is now considering transferring three subjects to Vacaville wher we have ongoing implant reserach. Our technicians have promised that they can do three 2020 neural chip implants in less than an hour. Soledad officials hope to collect information from the trio to bring a 14 month investigation into drug trafficking by correctional officers to a close. Essentially, the implants make the unsuspecting prisoner a walking-talking recorder of every event he comes into contact with.
There are only five intelligence officers and the Commisoner of Corrections who actually know the full scope of the implant testing. In Massachusetts, the Department of Corrections has already entered into high level discussion about releasing certain offenders to the community with the 2020 neural chip implants. Our people are not altogether against the idea, however, attorneys for Intelli-Connection have advised against implant technology outside strick control settings.
While we have a strong lobby in the Congress and various state legislatures favoring our product, we must proceed with the utmost caution on uncontrolled use of the 2020 neural chip.
If the chip were discovered in use not authorized by law and the procedure traced to us we could not endure for long the resulting publicity and liability payments. Massachusetts officials have developed an intelligence branch from their Fugitive Task Force Squad that would do limited test runs under tight controls with the pre-release subjects.
Correctons officials have dubbed these poetnetial test subjects "the insurance group." (the name derives from the concept that the 2020 implant insures compliance with the law and allows officials to detect misconduct or violations without question) A retired police detective from Charlestown, Massachusetts, now with the intelligence unit has asked us to consider using the 2020 neural chip on hard core felons suspected of bank and armored car robbery.
He stated, "Charlestown would never be the same, we'd finally know what was happening before they knew what was happening." We will continue to explore community uses of the 2020 chip, but our company rep will be attached to all law enforcement operations with an extraction crrew that can be on-site in 2 hours from anywhere at anytime. We have an Intelli-Connection discussion group who is meeting with the Director of Security at Florence, Colorado's federal super maximum security unit. The initial discussions with the Director have been promising and we hope to have an R & D unit at this important facilitly within the next six months. Napolitano insisted that the department was not planning on engaging in any form of ideological profiling.
I will tell him face-to-face that we honor veterans at DHS and employ thousands across the department, up to and including the Deputy Secretary," Ms.
Steve Buyer of Indiana, the ranking Republican on the House Committee on Veterans' Affairs, called it "inconceivable" that the Obama administration would categorize veterans as a potential threat.



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