The following notes should be memorized. 1. Essentials: Knife and pair of hands (but full equipment better). [295] 2. Don't do a laryngotomy, or stabbing. 3. "Two stage, finger guided" operation better. 4. Sand bag or substitute. 5. Press back danger lines with left thumb and middle finger, making safety line and trachea prominent. 6. Memorize Jackson's tracheotomic triangle. 7. Incise exactly in middle line from Adam's apple to sternum. 8. Feel for tracheal corrugations with left index in pool of blood, following trachea with finger downward from superficial Adam's apple. 9. Pass knife along index and incise trachea (not too deeply, may cut posterior wall). 10. Don't mind bleeding; but keep middle line and keep head straight; keep head low; don't bother about thyroid gland. 11. Don't expect hiss when trachea is cut if patient has stopped breathing. 12. Start artificial respiration. 13. Amyl nitrite. Oxygen. 14. Practice palpation of the neck until the tracheal landmarks are familiar. 15. Practice above technic, up to point of incision, at every opportunity. 16. _Jackson's tracheotomic triangle_: A triangulation of the front of the neck intended to facilitate a proper emergency tracheotomy. Apex at suprasternal notch. Sides anterior edge sternomastoids. Base horizontal line lower edge cricoid. RESUME OF AFTER-CARE OF A TRACHEOTOMIC CASE 1. Always bear in mind that tracheotomy is not an ultimate object. The ultimate object is to pipe air down into the lungs. Tracheotomy is only a means to that end. 2. Sterile tray beside bed should contain duplicate (exact) tracheotomy tube, Trousseau dilator, hemostat, thumb forceps, silver probe, scissors, scalpel, probe-pointed curved bistoury. Sterile gloves ready. 3. Special nursing necessary for safety. 4. Laxative. 5. Sponge away secretions before they are drawn in. 6. Cover wound with wide large gauze square slit so it fits around cannula under the tape holder. Pull off ravelings. Keep wet with 1 : 10,000 Bichloride solution. 7. Change dressing every hour or oftener. 8. Abundance of fresh air, temperature preferably about 70 degrees. 9. _Nurse should remove inner cannula as often as needed and clean it with pipe cleaner before boiling._ 10. Outer cannula should be changed every day by the surgeon or long-experienced tracheotomy nurse. A pilot should be used and care should be taken not to injure the cut ends of the tracheal cartilage. 11. A sterile, bent probe may be inserted downward in the trachea with both cannulae out to excite cough if necessary to expel secretions. An aspirating tube should be used, when necessary. 12. A patient with a properly fitted cannula free of secretions breathes noiselessly. Any sound demands immediate attention. 13. If the respiratory rate increase it is much more likely to be due to obstruction in, malposition of, or shortness of the cannula than to lung complications. 14. Be sure that: