So this “middle aged” guy comes to the ER, with a recent surgery for throat cancer. The swelling after surgery was giving him difficulty breathing, but he still had a patent “stoma” from the tracheostomy placed after surgery to keep his airway open. His doctor asked us to place a new trach in the old stoma while the swelling was still minimal…before an emergency airway situation arose.

I told my colleague out loud, “I don’t want it!”…it sounded like a potential nightmare case to me…something just wasn’t right about it. Afterwards, (I lied) and said, “Oh, I would really like to have the opportunity to place another trach.” I had only placed one before. Naturally, this is a good airway technique to know and be familiar with…but really… this guy has a hole in the front of his neck, going straight into the depths of his lungs. Creepy.

I was nervous on the inside, but I pulled the #6 Shiley “trach” and stuck the instruction book out of the front so his wife didn’t notice. I spent 15 minutes reading the preparatory information. I invited the resident to watch because she had never placed one before. As they say, “See one, do one, teach one…” So I was on step 3 of 3, except I had never seen one placed prior to my first placement. And this was only my second.

The patients wife says, “How long have you been a doctor?”

I hesitated. What she really means is how long have you been in ‘private practice’. Most patients do not have a solid understanding of the training process that physicians go through, so when I said, ” I graduated medical school about 4 years ago,” I was being truthful in saying that I had been a doctor for four years. What she said next shocked me.

“You seem so confident.”

Gulp. I lied again. “It’s easy to be confident when you feel comfortable with what you’re doing.”

I prepared the trach, talking the resident through the proceedure (that I had only done once). I prepared the patient. When teh moment of truth came to insert the trach, I didn’t pause for dramatic effect. I didn’t want the patient to pick up on my apprehension. I must have pulled it off pretty well, because the trach went in easily, and in no time, he was breathing without any difficulty through the brand new #6 Shiley in his neck.

The resident thanked me. The patient thanked me. I stepped out of the room and wiped the sweat from my brow and under my armpits. My heart had stopped pounding. I called his doctor and confidently told him that he was now breathing without difficulty through the trach, respiratory care was on the way, and he was recieving antibiotics for the post operative cellulits.

Sometimes it’s good to be able to fake it.