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Artist’s Statement: The Tracheostomy

Paff, Michelle MD

doi: 10.1097/ACM.0b013e31828c6ad7
Cover Art

Dr. Paff is a first-year neurosurgery resident, University of California Irvine Medical Center, Orange, California; e-mail:

Throughout the grueling four-year duration of medical school, aspiring physicians struggle to attain all the medical knowledge that hundreds of years of scientific discovery has produced. With countless hours of reading, highlighting, and painful memorization, medical students hope to acquire all that it takes to be a competent and insightful physician. However, selecting “insert external ventricular drain” on an answer sheet cannot be compared to performing one alone for the first time when a patient with a head injury suddenly becomes obtunded. Regardless of how hard junior residents studied during medical school, they will eventually encounter a situation in which a patient’s life depends on them, and they may be utterly unprepared to act. All the knowledge in the world cannot give someone the confidence needed to act quickly to save a life. This is gained only through experience during practice and is part of the transformation of a student into a physician.

The Tracheostomy depicts a surgery intern performing her first tracheostomy. This scene is inspired by my experience as a third-year medical student watching an intern serve as the first assistant to an elderly general surgeon. The surgeon had been consulted by the medical intensive care unit team to perform a tracheostomy on a critically ill woman with thrombocytopenia. With some uncertainty, the intern carefully performed the dissection under the supervision of the senior attending. After a significantly bloodier-than-usual dissection, the tracheostomy tube was inserted. The nurse anesthetist extubated the patient and handed the ventilator tube to the surgeons so that they could ventilate the patient through the tracheostomy.

Suddenly, the nurse anesthetist looked confused. There was no air flow through the patient’s lungs. There must have been a simple blockage somewhere, but after several reinsertions of the tracheostomy there was no change. The nurse anesthetist turned to the attending surgeon, who appeared troubled. Seeing the look on the attending surgeon’s face, the intern frantically dug into the bloody wound in a desperate attempt to locate the tracheal lumen. She never anticipated something going wrong during such a minor procedure, and she had no idea of how to troubleshoot. What would happen if the patient died? After what felt like an hour of repositioning the tracheostomy tube, we heard the nurse anesthetist announce that there was air flow, and we all immediately felt a rush of relief. This was the first time in the intern’s training that she had experienced the feeling of having a patient’s life in her hands, and it reminded me that I would inevitably face that feeling myself one day soon.

The transformation that students undergo to become physicians is a process in which they gradually learn to trust their own judgment and skills. Over time, medical and surgical training shapes physicians such that the appropriate action in any circumstance becomes instinctive. Nevertheless, experience also teaches physicians that with any procedure, no matter how big or small, anything can go wrong. Regardless of one’s level of experience, the choice of whether or not to operate will always involve taking a leap of faith.

The Tracheostomy

The Tracheostomy

© 2013 Association of American Medical Colleges