Description of Event or Problem · 0
PATIENT PRESENTED WITH DISLODGED TRACHEOSTOMY TUBE, STABLE AT TIME OF PRESENTATION. MD ATTEMPTING TO REINSERT NEW TRACHEOSTOMY TUBE 6.0 FR, AND BOUGIE TIP BROKE OFF INTO PATIENT AIRWAY WHEN ATTEMPTING TO REPLACE CURRENT TRACHEOSTOMY WITH NEW TRACH. FIRST AND A SECOND MD WERE PRESENT AT BEDSIDE AT TIME OF PROCEDURE. STORZ FIBER OPTIC SCOPE USED BY MD'S TO VISUALIZE AIRWAY. BOUGIE PLASTIC TUBE SHORTER, WITH CRACKED/JAGGED EDGE UPON INSPECTION. PATIENT MEDICATED WITH ETOMIDATE DURING TRACHEOSTOMY TUBE REPLACEMENT, BAG-VALVE-MASK (BVM) TO SUPPORT BREATHING/OXYGENATION UNTIL MEDICATION WORE OFF. PATIENT ALERT AFTER ETOMIDATE WORE OFF, AIRWAY PATENT, VITAL SIGNS STABLE ON ROOM AIR. REQUIRED TRANSFER TO ANOTHER HOSPITAL FOR RESOURCES NOT AVAILABLE AT CURRENT ED. SIGNIFICANT RESISTANCE MET WHEN USING MODERATE PRESSURE TO RE-INSERT TRACHEOSTOMY TUBE THAT HAD BECOME DISLODGED. INTRODUCER WAS INSERTED FIRST TIME AND ATTEMPT TO RE-INSERT TRACHEOSTOMY WAS MET WITH RESISTANCE. UPON THE SECOND ATTEMPT WITH THE INTRODUCER WAS WHEN THE INTRODUCER SNAPPED. ADDITIONAL INTRODUCERS WERE PULLED FROM STOCK AND FOUND TO ALSO SNAP/CRACK WITH MODERATE PRESSURE. ALL DEVICES WERE PULLED FROM HOSPITAL STOCK AND PATIENT AREAS.