2018Jane Doe was a patient at a nursing home, rehabbing from a stroke. She had an underlying condition that required a tracheostomy and a had a permanent trach. Doe was alert and summonsed help because she was having difficulty breathing. Help was delayed approximately 3 minutes. The responding LPN removed the inner cannula of the trach, which had an obstructing mucus plug, but instead of cleaning out the mucus plug, he set it aside and tried emergency rescue breathing through an ambu bag. However, the ambu bag connection would not seal with the trach because of the missing inner cannula. An EMT arrived and cleared the inner cannula of the obstruction and transported Doe to the ER. She was without an airway for about 9 minutes. Doe suffered anoxic brain damage and died about 6 weeks later.