View Full Version : Help-Nurse With No Trach Experience?

Ainsley's Mom
05-04-2009, 09:33 PM
Our nurse gave 1 week's notice. She's moving her mom to the Philippines. But we were having some issues anyway so it's okay. The agency found me someone and she started today. There was no time for training but it worked out since the kids' school was closed I stayed home and did the training. She seems nice and did fine until the end of the day when we did a trach change and it was apparent she'd never done a trach change or even changed trach ties. I knew she was an RN that used to be an ER nurse. She said she'd had trach patients but it came out today what she meant was that she'd suctioned some trachs in the ER on occasion and I think they were mainly adults. I don't think she's ever done long term care of a trach patient. She seems trainable but I am nervous. We all know that things can go wrong. I'm afraid she has an oversimplified view of what a trach is and the care involved and that she could overlook a plug.

I just pointed out to my husband that Ainlsey's been having trouble drying out and getting plugs and that even after 2 years of caring for a trached child he has been unable to clear them adequately. And the other nurse that left had 5 years 1-on-1 experience caring for a pediatric trach patient and she missed some plugs too. Even I have trouble and I have thousands of hours of experience.

I'm going to drop the kids at school Wednesday (they reopened the schools) and come back to the house and stay. I think I'll have a better sense after Wednesday but like I said, I'm nervous. I wish she had more experience.

In this situation how many days do you think it would take until you were comfortable?

05-04-2009, 09:45 PM
I would never feel comfortable, honestly. There's just too much information to learn. I'm surprised your nursing agency is allowing her to work your case without experience.

05-04-2009, 10:09 PM
I know how you feel, most of my nurses have never had ANY trach experience with adult or pediatrics. If I though picked it up in just 3 trach changes then I feel my nurses would be fine doing it. We had been leaving Autumn alone with one nurse and it wasn't until like 3 weeks later that we learned she had never changed a trach so now I'm extremely overprotective with it all. I can tell right off if I think the nurse will be capable in an emergency situation. If after Wednesday you still have that feeling I would speak up and not leave her alone with the nurse until you feel comfortable.

05-04-2009, 10:28 PM
If she's a former ER nurse, she's used to dealing with the unexpected and she's used to having to make quick decisions. Personally, I'd have her do a few more trach changes just so she can get a feel for it, but I think I'd be comfortable giving her a chance. But, you are the one who was in the same room with her, so you've got to go with your "gut" feeling.

05-04-2009, 10:33 PM
To get a sense of comfortableness, I would drill her... tell her exactly why too. If she has been an ER nurse, she is probably able to think on her feet and cool under pressure. (or the complete opposite). We had NICU nurses who watched Ayden that had hardly changed a trach (maybe never), BUT I trusted them and that they could get through anything with Ayden. They all changed a trach at least 1x w/in the first week. So, with that... I think go w/ your mommy gut... you will know best.

05-04-2009, 10:35 PM
Ironically, our "main" nurse came to us without trach experience. I too was a little nervous about that, considering we were so new to it ourselves. However, she came from the hospital setting with Labor and Delivery on the baby resuscitation team. She's amazing; very cool under pressure...and she learned the trach care very quickly. So, I wouldn't necessarily judge the nurse just by trach specific experience. I would have missed out on an amazing nurse had I dismissed her because of her lack of trach exposure.

05-04-2009, 10:45 PM
If I had nickle for every nurse that came to my house claiming trach experience they didn't really have ... well I could probably go to dinner with the money. We once had a nurse who finally confessed to me that her "trach experience" that she told the agency she had was that she watched her instructor in nursing school change a trach once.

Susan, I have to confess, I really despised that particular nurse, but it was related to other things. She was willing to learn, and I was willing to train her, and she did absorb the information well. In fact, in some ways she was preferable to the more seasoned nurses who wanted to tell me what to do and how I was to do it. Eventually I had her replaced, but the lack of trach experience was actually not the reason. In general, she lacked good day to day judgment on very basic things, and I felt like I couldn't leave her unsupervised for fear that she would do something really dumb, like give the baby a bath and spill water all over the 75 year old picture of my father as an infant (which she did because it didn't occur to her to either move the picture or move the bathtub from the table). Or the fact that she didn't know how to burp a baby or even that it was something that could/should be done. (After I told her she had to, she put him on her shoulder and said, "now burp, Alex." I am NOT kidding. When I took him back and started thumping his back, she looked shocked.)

But, I digress. I say, give her some time and use your gut to see how she handles things. She might surprise you. One of our best caregivers was a non-nurse aid we hired because I was having problems with inconsistent nursing staff. (6 days of nursing a week, and 4 nurses to fill the dayshift -- it wasn't sitting well with Alex, I needed to work, and he needed consistency). She worked with the nurses until our hours were cut, but I trained her on trach care. We had exactly one emergency while she was in the house, and she handled it beautifully. I felt more comfortable with her than with many of the folks the agency sent. (But not with all, TBH. Some of the nurses were extraordinary.)

So, my long-winded point is -- I'd give her a week or two if you can be there to supervise. If by then you still feel uneasy ... let her go and try again. But that is just me.

Andrew's Mommy
05-05-2009, 12:33 AM
My nurse right now for Mr. Andy was a new grad and never had experience with a trach patient, never had to deal with a pediatric patient and has never had a child. I was extremely nervous about her.

I took a week off of work so i could make sure she was comfy with him. I warned her about everything. Sounds a little dry turn on the humidifier start saline treatments, sleepy all day check o2 check trach..ect.

She was not allowed to do dressing changes unless i was there to watch or my husband or mom. It took her a month to be okay to do it on her own but that's only because during one of the times that she was changing his dressings and ties(under my supervision) he got upset because she wouldn't let him play with toys while she did it(bad habit i taught him) and she was taking too long for his liking. So he yanked his trach half way out and turned blue in less than 5 seconds. But she's comfy with him now. She can change the trach im just really controlling about that.

So about a month. And if my son hadn't been in madly in love with her and if she had not been teachable I would have kicked her out so fast. But she is really a good nurse and I would be missing out right now. Go with your gut mommy's always know best.

Big Al
05-05-2009, 04:50 AM
She evaluating my co workers I have found five things that need considered.
1. Can they and do they want to learn? If they want I and can learn you at halfway there if they know everything you will me stuck.
2. Are the reasonably smart either book or common sence. You may be able to get by with on or the other by you can't be missing both.
3. Can they assess a client. Assessment is an art as much as a skill can they do it do they have a gut that tells them somethings not right during their assessment? This gut has saved my bacon more then once. It takes time to get if you have a provider who comes with it your all set?
4. Can they apply all of the above skill when the poop hits the fan. A person who is calm and in control can turn a cluster into just a bad day.
5. Most importantly do they lie? You can train the ignorant but you can NEVER reform a lier.
For all it's worth theirs my two cents I've been training people foe years on our ambulance and have found these to be rules to live by.

05-05-2009, 08:10 AM
Hrm. I think that being comfortable with someone around our kids is more than just training - but training helps.

We had a nurse in the NICU who had done pediatric nursing, done PICU, done home care with trach/vent kids, and was then working in the NICU...and I still didnt' trust her farther than I could throw her when it came to Alexander. My distrust was proven out on at least 2 occasions before I learned we could ask not to have her taking care of him.

Training means they know the typical things to look for and the things that have to be done - how to suction, how to check O2, how to listen to the lungs, how to change a trach, etc etc etc. On short notice, I'd take someone well trained who didn't know Alexander at all over someone with no training who gets along with Alexander any day.

But *anyone* with a brain can be trained to do these things - most of us weren't nurses when we were thrown into this, after all. What then becomes important is that the caregiver actually care about the child, and be interested in the child, willing to learn what they don't know, and reasonably good at thinking on their feet.

05-05-2009, 08:16 AM
If she's a former ER nurse, she's used to dealing with the unexpected and she's used to having to make quick decisions. Personally, I'd have her do a few more trach changes just so she can get a feel for it, but I think I'd be comfortable giving her a chance. But, you are the one who was in the same room with her, so you've got to go with your "gut" feeling.

I completely agree with Ann here. You and I didn't have any medical back ground and we learned. She's an RN and the ER experience is a big bonus. Is she open to learning? Is she receptive to your teaching? Those would also be big bonuses.

I can say this about myself. That first trach change was hard because I didn't know what to expect. But second was easy. I would imagine the same would be for her.

In the end, you have to trust your own judgement though.

05-05-2009, 09:12 AM
I agree with what Karin said.

When looking for a nurse I opted for nurses without trach experience so we could train them the way we wanted. We've had bad luck with more seasoned nurses who are "stuck in their ways" (if I had a dollar for everytime one of them told me I suctioned too much). We looked for someone that had ""critical care" experience, but was a blank slate for us to train. (How controlling, eh?)

05-05-2009, 10:16 AM
I haven't had time to read other responses-but here is mine.

We've had good nurses who have had no trach experiences. What I do if they seem like the trach is no big deal-I scare the crap out of them. I tell them Mitchell's scariest stories. I have a video of him when he has stopped breathing-then I show them that. :) (if they are really relaxed about the trach)
That seems to get them to understand that this is serious. Sometimes it causes them to be too careful but I guess I'd rather have that then not.
Good luck-starting a new nurse is never easy. :hug: :hug:

05-05-2009, 02:02 PM
Personally when we had nurses if they were not trach and vent trained I turned them around out that door. We did a lot of nights without nursing for that very reason, but that worked out ok for us.

I would say give her a week or so and have her do the changes and such in front of you several times. Only you can know when things feel right

05-05-2009, 03:24 PM
I would give her a chance as long as you feel like she is "learning" and she seems willing to do the things you ask of her. My main problem with some of the nurses at Gabriel's daycare is they say they'll do something, when I know the second I leave they do as they please. Gabriel is really dry since he won't wear his HME, and has had several plugs recently, so I've really been bugging his nurses to give him saline neds, if necessary. However, I seriously doubt that he's had any extra treatments. I hope you end up feeling comfortable with her...training new staff must be so trying!

Ainsley's Mom
05-05-2009, 09:33 PM
Thanks guys. I really appreciate you all taking the time to respond. I guess we all look at it differently and some good points were raised. Especially that this is an opportunity to train someone the way I choose based on the mass of information I've collected from this forum and my 2+ years of experience.

Today I confirmed with the agency that she agreed to be "our" nurse, so at least I'm not dealing with a temporary arrangement. She has 4 kids of her own and I think she is only recently back to work but I found out she's been with them for 4 months. I'm just hoping she really wants to be here because I think that will make all the difference.

I think she'll pick things up well enough. It's the subtle things like hearing when the secretions are too sticky to suction without saline, knowing how much saline to use, being able to tell that the inner cannula is cleared of build-up, or knowing when the PMV needs to be taken off that I think requires experience. And just the ability to "hear" that things are okay or not. More than all of that I fear that she thinks because she's suctioned a few trachs in the ER that she "knows" the care, and that she isn't really getting that, even though I've told her, in the extremely unlikely event that Ainsley's trach pops out and she doesn't notice, she'll be dead in minutes. Like you Kate, I'd rather scare her and be sure she really gets it. I think it's hard because Ainsley has a really complex airway. The diagnosis is edema so I think it's easy to misunderstand the problem because there is the paradox that she is extremely healthy and stable (sats at 99-100% never desats and is on no meds or treatments) she can even tolerate capping sometimes for up to an hour so I think it give a false sense of safety. If the trach comes out she lasts less than a minute before she is blue. And you've seen what happens when she's capped and cries. I'd feel so much better if she wasn't plugging up so much recently and if she could go a little longer without the trach (just in case).

I'll let you all know how things go after tomorrow. Thanks!!!

Ainsley's Mom
05-08-2009, 11:58 AM
Oops I forgot to follow up like I promised. But Wednesday things went pretty well. There was one time that I think Ainsley was working on a plug so I was able to explain what the dry whistly sound meant and how to clear it if the secretions are extra sticky, which they often are these days.

My sense is that this may not be a fit for long term but should at least get me through the end of the school year. So I'm feeling better.

On Monday when I had her change Ainsley's trach (her first change) she had some difficulty. And yesterday I noticed she developed some granulation tissue at the stoma from the trauma. So I'm hoping that goes away and we can give it another shot next week. I hate to risk having that happen again but at the same time I want to know that the nurse can put it in if it comes out before I leave them alone all day.