We as a nation love medical dramas. It has to be a fact, as 91 shows related to the genre have been produced since 1951 in North America alone. What's not to love? A fast-paced environment, strong characters and a little bit of health advice along the way! Except… with such popularity, a lot of writers seem to get their facts confused in order to instill a bit more drama in the story.  Similar to other ill-informed portrayals of medical techniques (bad CPR, needle to the heart, using electroshock while flat lining, removing bullets, etc.) produced by Hollywood, a delicate procedure like a tracheotomy is often performed by the protagonist and without medical training (or with very little guidance). Of course, there have been plenty of doctors portrayed performing the procedures as well, but the ratio is a bit too even for our liking. Before we dive into depictions, what exactly is a tracheotomy?

A tracheotomy is a procedure where an incision in the windpipe is made to relieve an obstruction to breathing. This can be necessary for a host of reasons but not limited to inflammation, suffocation, facial trauma, tumors, etc.  So where have we seen this? Well, surprisingly lot of places. Batman performed the procedure in All-Star Batman and Robin. House M.D. did it twice, first the pilot episode on a woman whose airways shut down during an MRI and then in another episode, House performs it on a man going into anaphylactic shock with a ballpoint pen. The gore fest film series known as Saw V had a character perform it on himself with a pen to avoid drowning. Another trach performed with a ballpoint pen? Grey's Anatomy, Malcom in the Middle, ER, Anaconda (warning: do not watch if squeamish), Princess Warrior, Salvador, of course M*A*S*H (twice) and later parodied on Lost. Even the main character in the book Choke, who would con people into performing the Heimlich maneuver while deliberately choking, worried about one day an idiot showing up with a steak knife and a ballpoint pen.

There's a lot of people wandering around with ballpoint pens and good intentions, so to keep the record and people's windpipes intact, we sat down with Dr. Albert Rizzo, Senior Medical Advisor to the American Lung Association, and asked him a couple questions.

How does a tracheotomy work?
A tracheotomy is a surgical procedure which consists of making an incision on the front of the neck, just below the Adam's apple and opening a direct airway into the trachea (windpipe). The resulting stoma (hole), or tracheostomy, can serve independently as an airway or as a site for a tracheostomy tube to be inserted; this tube allows a person to breathe without the use of his or her nose or mouth. In an emergency situation, the more appropriate term is a cricothyroidotomy—an opening in the membrane below the Adam's apple and before the firmer cartilage of the trachea begins.

Are tracheotomies commonly used in emergency situations?
No, fortunately, a properly performed Heimlich maneuver can resolve many situations that occur due to anatomical obstruction of the airway by food particles. Complete airway obstruction (not able to breathe at all) is the reason to do a Heimlich and if unsuccessful, an emergency trach. The emergency trach should only be done in situations where trained staff and equipment are not readily available.

Should/Could tracheotomies be performed by someone who is not medically trained?
Only as a very last resort when the airway is completely obstructed and the Heimlich maneuver has been unsuccessful. A call to 911 should be placed as soon as possible.

The ballpoint pen – really? Is it safe to use just any ballpoint pen?
The ball point pen reference is prevalent and yes it could be used to make the opening if no other sharp object is available. The pen can also act as a hollow tube (with the ink refill removed) to keep the opening clear until a more secure airway can be maintained by emergency personnel.

There you have it — the ballpoint pen actually is a realistic tool for an emergency trach (once modified), just like knowing and using the Heimlich maneuver first. While it's certainly heroic and brings with it a good life-time feeling of saving a life, tracheotomies should be treated as a last resort in a dire situation and with medical staff guiding along or on their way. Because remember: tracheotomies add drama on TV, but add a lot more than you might bargain for in real life.

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