“Patient in room 26 with respiratory distress, saturating 88%. Please assess ASAP.” My stomach drops as the message scrolls across my pager. Although the task of assessing acute hypoxemia as an intern makes me nervous, I recognize most of my anxiety centers on doing so in a child with complex medical needs like this patient, Mary. Mary suffered a perinatal hypoxic event that has led to multiple chronic medical problems, including seizure disorder, intellectual disability, tracheostomy dependence, and gastrostomy tube dependence. She was admitted for altered mental status of unclear cause. With little experience treating hospitalized children with similar medical complexity, her imposing list of comorbidities, medications, and confusing medical equipment have made it challenging for me to care for her as effectively as I would like. As I enter the room to examine Mary, her thin chest heaves effortfully as saliva pools around her tracheostomy site. Her eyes convey a sense of panic that requires no translation, a fear that I share as I recognize my lack of experience troubleshooting respiratory distress in patients with tracheostomies. I call my senior resident who arrives promptly and provides much-needed clarity: deep suction resolves the hypoxemia without requiring transfer to the PICU. Reflecting on this encounter later, I found my primary response was one of shame, something I would experience recurrently intern year when encountering challenging clinical scenarios for … Address correspondence to Benjamin W. Frush, MD, MA, Vanderbilt Internal Medicine and Pediatrics Residency Program, Vanderbilt University Medical Center, 1215 21st Ave S, Medical Center East 7th Floor, Suite 2, Nashville, TN 37232-8300. E-mail: benjamin.w.frush{at}vumc.org