Tracheostomy With Bedside Simultaneous Gastrostomy Vs Usual Care Tracheostomy And Delayed Gastrostomy Placement

Inclusion Criteria: * 18 years old- 85 years old * Admitted under the NSICU service * Shared-decision making with surrogate decision maker and primary neuro-intensivist agreement to proceed with tracheostomy and gastrostomy with documented discussion. * have indications for tracheostomy and gastrostomy * Subjects or their SDM or legally authorized representative (LARs) must voluntarily provide informed consent prior to the initiation of any study-specific procedure in a form approved by an independent IRB. In the absence of subject's ability to provide informed consent, informed consent must be given by a person who has the legal right to act on behalf of the subject in accordance with local laws. Exclusion Criteria: * Patients who require tracheostomy only or gastrostomy only * history of prior gastrostomy, tracheostomy, laryngectomy, gastrostomy prior to tracheostomy decision, known head and neck and gastrointestinal abnormality (cancer, congenital abnormality, anatomic variants) * withdrawal of care, a transfer from another service or hospital if patient has been there for \>24hr. * known social discharge issues anticipating hospital stay \>100 days * Patients with nonsurvivable injuries, anticipated mortality \<72 hours * standard of care contraindications for either bedside tracheostomy and gastrostomy * Absolute contraindications for gastrostomy: gastric outlet obstruction, significant gastroparesis, significant gastroesophageal reflux, a proximal high-output entercu…