In this Best Case Ever with Dr. Scott Weingart, the brains behind EMcrit.org, we hear the devastating story of a tracheostomy gone bad. Dr. Weingart shares with us what he has learned about how to manage massive hemoptysis in tracheostomy patients, and in particlar, a step-wise approach to managing a tracheo-innominate fistula. We discuss the balance between providing maximal aggrressive critical care while maintaining a deep respect for the risks associated with the procedures we perform. Recorded at North York General's EM Update Conference 2015.