Introduction: Among the varied complications of tracheostomy, a displaced tube is a dreaded one, especially with an immature tract.
Case description: We present a young lady at 3 weeks post emergency tracheostomy, done at another hospital, presumably for Ludwig's angina. With no medical details available, the soiled outer Jackson's tracheostomy tube required change. Her financial constraints, supplemented with the resource shortfalls, contributed to Fuller's tube. Furthermore, when dislodgement into a false tract was suspected, there were delays and dilemmas in reaching out to the least possible appropriate investigations, given her financial inadequacy.
Conclusion: In resource-constrained hospitals, limited choice of tracheostomy tubes available for emergencies, the financial shortfalls of the patient limiting further assessment in clinical care, and the insufficient supervision of the presumably proficient residents may be few deficiencies to be defined to dodge any preventable complications.
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