If you informally survey EMS providers and ask which skill they avoid the most, suctioning would be near the top of the list. This truly lifesaving skill receives less than its due share of attention by many providers and instructors. Even experienced providers miss the suction unit during operational unit checks and often “forget” to include it among the basic equipment they bring to the patient’s side. It receives brief mention in EMS standards and not more than a couple of pages in most textbooks.
These standards and texts largely focus on the very basics of the end procedure and stress the times when suction should be applied, and not how suction should be applied. Instructors spend little time on the actual preparation necessary to ensure this important procedure is available and put to proper use during patient care. Troubleshooting and backup considerations aren’t usually mentioned, leaving many providers to learn these important tasks on the job or from fellow providers. As educators, we must focus on more than the psychomotor skill of the application of negative pressure to the airways of our patients.
Many EMS students are initially introduced to the suction unit as a classroom prop. It may be an older model formerly carried on a unit, and it may not be in the best working order. You can bet that many will have dead batteries from not being charged during storage.
Using an old unit may be an effective way of teaching the psychomotor skill, of suctioning, but that can downplay its importance. When possible, the suction units used in class should be the same models the providers will use in the field. The unit should meet the operational standard of 300 mmHG vacuum when the hose is crimped (simulating a unit under full work load conditions) and have a battery that will maintain that suction for the optimal period of time.
The battery is the key component to the modern, portable suction unit. Stress to your students the importance of not only maintaining the battery in a charged condition but also keeping a battery in the unit that’s within its service life.
As emergency responders, we can’t wait until a battery is at the end of its life to replace it. In other words, the time to find out a battery is at the end of its service life isn’t when your patient’s airway is full of blood. Having the manufacturer’s recommendations on batteries and preventive maintenance to share with the students will help.
For those of us who remember tearing down and cleaning suction units, the disposable canisters of the modern units are among the greatest innovations EMS systems have seen. But with this innovation comes the problem of preparing the canister for use. Walk the student through its preparation, including attaching all the required caps, tubing and adaptors. As with any other psychomotor skill, show it once, fully assembling the unit. Then break down the steps, showing why each connection is important. Finally, discuss the proper disposal of the used canister and supplies.
Manual Suction Units
Murphy’s law—the more that can go wrong, will—was never more true than when applied to the suction unit. Manually powered suction units take away a major cause of suction failure: the battery. So keep it simple and effective. Use a glass of water or cup of soup and a timer to demonstrate this skill. This will allow you to show the suction power, speed and ease of each manual suction unit compared with battery-operated models. If you’re teaching first responders, emphasize the compact size and easy maintenance of these units. Placing these hand-operated units in your training kits for use in scenarios will allow students to practice with them during training scenarios.
Wall-Mounted Suction Units
Instructors should highlight the operational readiness of wall-mounted suction units early in a student’s training. Many EMS systems have only one provider in the patient compartment during most transports so it’s critical that each student be able to locate, activate, adjust and deploy the onboard suction device. If the suction isn’t operable with the simple activation of the vacuum switch, a dangerous delay in patient care could result from the lone caregiver troubleshooting the unit.
Tell your students the canister should be prepared with caps, adaptors and the suction line being attached. Activate the vacuum pump on the ambulance during each vehicle check to ensure operation and obtain a vacuum at the patient port. Ambulance equipment checklists often require tubing and catheters to be carried but don’t list where they’re stored.
Emphasize the need to store these tools within easy reach of a seated and belted provider. Suction tubing should be preconnected and ready to use with a rigid catheter. One technique is to tear open the packaging enough to connect the tubing, but leave the cover on the catheter.
In some mass casualty situations, it may be necessary to carry more than one patient per ambulance. Most suction tubing is around six feet long, but will that reach a patient whose head is to the rear of the patient compartment? A simple demonstration of using a double male-suction tubing connector to join two sections of tubing together will allow your student to learn how to rapidly extend their reach. This skill may also be useful in tight spaces that limit equipment near the patient, such as an entrapment.
Impromptu Suction Devices
In 1995, I was reading a Reuters news report of the tragic school bus vs. train accident in Fox River Grove, Ill., and part of the story intrigued me.1 A nurse was asking for something to help her clear a young victim’s airway of blood. A bystander went into a nearby residence and brought her a turkey baster. After I read this, I thought either someone got very lucky or they understood the principles of suctioning and its use to clear an airway.
As educators, we need to teach our students that same kind of resourcefulness. Such items as a 60 cc syringe, a urinary catheter irrigation syringe or even a turkey baster are great examples of an improvised suction devices. Challenge your students to think of an item on their own that will work in a pinch and share it with the class. This is one area in which the instructor can learn from the inventiveness of the student.
Although the focus of this article is suctioning, the best tool to clear the airway is a gloved hand. Emphasizing universal precautions (e.g., gloves, eye, face and even gown), you should first teach the basics of airway positioning. Tilting the patient’s head to the side or turning the immobilized patient on their side must be the first step in clearing an unconscious patient’s airway. Also emphasize gravity. Placing the patient flat or slightly head down helps because fluid flows out naturally.
Before proceeding further in your instruction, focus on the provider’s personal safety. Show them how to position an oral airway in the corner of the patient’s mouth between the teeth to improvise a bite block that will also allow them complete access to clear the airway. Skipping this step could result in a painful injury for the provider and the patient not receiving care.
Next, use fingers to begin clearing the airway and remove large emesis. Speed and teamwork are important for this step, so have one student begin clearing the airway while another obtains and prepares the suction unit. Explain that it’s unacceptable to do nothing to care for the patient while the suction unit is obtained and prepared. Fingers can remove emesis the suction unit cannot.
If you have an airway manikin you can decontaminate, simulated emesis is a great teaching tool. Start simple with new students by using water or simulated blood as a prop. Use wet cereal in an airway manikin to test how well the skill was learned.
Measuring the catheter (either rigid or flexible) from the lips to the angle of the jaw will keep the catheter in the oral cavity and make it less likely to stimulate a gag reflex. It also keeps it from going past the base of the tongue as stated in the standards.2
Teach your students that the standard for suctioning is 15 seconds during withdraw of the catheter. If a copious amount of emesis is occurring, then suggest using two suction units simultaneously.
An often forgotten step is clearing the catheter and tubing with a water or saline flush. Storing a small bottle of water with the suction unit will aid in clearing the tubing and allow for a more efficient suction pressure during repeated use on the same patient.
Suctioning is a skill that’s often repeated during patient care. It’s rarely needed just once. Coach the student to have the suction ready during patient moves and at all times when the patient is immobilized.
The act of suctioning itself is a relatively easy psychomotor skill that can be improved by adding some simple nuances to the training. By adding emphasis to the often overlooked operational issues, the educator can help ensure a working suction unit is available when the patient needs it. JEMS
1. Reuters. Retrieved Oct. 25, 1995. America Online.
2. National Highway Traffic Safety Administration. U.S. Department of Transportation. EMT-Basic: National Standard Curriculum. www.nhtsa.gov. This article originally appeared in June 2011 JEMS as “Suction Skills: Be positive about negative pressure.”
This article originally appeared in June 2011 JEMS as “Suction Skills: Be positive about negative pressure.”