My First Intubation

Residency Years, Part II

In emergency medicine, it all begins with the airway. If a patient can’t breathe, nothing else matters. That’s why we’re trained—above all else—as airway specialists.

In the OR, intubation is a measured dance—controlled environment, fasting patient, cooperative anatomy. The vibe is calm. Planned. Polished.

In the ED, it’s the exact opposite.

We intubate when there’s no other choice. The patient’s crashing, vomiting, bleeding, or already halfway to unconsciousness. Their stomachs are full, their mouths often a mess, and if they’re still breathing when you start, count yourself lucky.

We use Rapid Sequence Intubation—RSI. First, oxygen. Sometimes with a bag-valve mask if they’re struggling. Then a hefty dose of sedative to knock them out, followed by a paralytic to stop them from breathing. Yes, stop them. You paralyze a person who’s already teetering, and then you have a couple of minutes to put the tube in before the monitor starts screaming.

A laryngoscope helps us visualize the cords, but real airways rarely look like the ones on mannequins. You aim to thread the tube between the vocal cords and into the trachea, hoping for clean passage and bilateral breath sounds. But tubes can go rogue—down the esophagus, into one lung, or nowhere at all. And if you miss, things get real, fast.

My first intubation attempt came early in residency. The patient was an elderly man in respiratory failure from pneumonia. He was fading—less responsive, breathing fast and shallow. I suggested intubation, and my attending agreed.

He didn’t protest. He barely had the energy to speak. This wasn’t a crash airway, but it wasn’t far off.

I’d run this scenario dozens of times in sim lab. I had my meds ready. I chose a Mac blade, a 7.5 tube. Assessed the airway—nothing tricky. No beard, small tongue, decent mouth opening.

My attending—brilliant and eight months pregnant—stayed seated behind me. She was visibly uncomfortable and understandably reluctant to waddle around the department. I made it my mission that shift to minimize her movement. This was my patient. My airway. My moment.

We pre-oxygenated. I double-checked the monitors. The nurse pushed the sedative. The patient’s eyes rolled back. Gone.

“Paralytic now,” I said, trying to sound composed.

And then it hit me—hard.

I was about to switch off his ability to breathe. Permanently, unless I got that tube in.

His chest twitched. Then stopped. He was mine now.

I gripped the laryngoscope, opened his mouth, swept the tongue, and peered in.

Nothing.

Just pink, fleshy shadows. No cords. No landmarks. No roadmap.

“External pressure,” I said, hoping it would reveal what I couldn’t see.

The nurse pressed on his neck. My view collapsed further. It was like looking into a tunnel that led nowhere.

I pulled out, heart pounding, sweat beading under my gloves. Took a breath. Repositioned. Tried again.

There—just a sliver. A whisper of white cords flickered into view.

I went for it.

But the monitor blared before I could advance.

“Ninety-two percent,” the nurse said.

My hands trembled. I adjusted. The tip of the tube hovered, unsure.

“Eighty-seven.”

I froze. My field narrowed. Time stretched and warped. All I could hear was the beep, beep, beep of falling oxygen.

This was supposed to be routine. I had drilled it a hundred times. But now, with a man’s life on the line, I couldn’t even find the damn airway.

“Eighty-two.”

I felt the weight of every second.

If I pushed blindly, I could fill his stomach. If I pulled out again, I might not get another shot. He needed air. Now.

“Eighty.”

That’s when she appeared beside me—calm, centered, and eight months pregnant.

“May I take a look?” she asked, gently.

I nodded and stepped back, grateful she was there.

She lowered the bed, angled herself carefully, and slid the blade in.

The room held its breath.

Seconds later, she reached out a hand.

“Tube.”

She passed it cleanly, smoothly. Breath sounds returned. The monitor climbed. Eighty-five. Ninety. Ninety-five.

She turned to me.

“Don’t worry,” she said quietly. “You’ll get it. This is how you learn.”

I nodded, but the words barely registered. My adrenaline was still spiking, my scrub top soaked through. I had come within seconds of losing him—and I knew it.

I looked at the monitor: 97%. Normal. Stable. Alive.

He would never know how close it had been. How my hands had fumbled, how the cords had vanished right when I needed them most.

I stepped away from the bedside and found a quiet corner to lean against. My knees were unsteady. My confidence, shaken. But I was also profoundly grateful—not just for her intervention, but for the reminder that this job humbles you quickly, and often.

I had walked into that room thinking I was ready. That the sim lab reps, the textbook doses, the smooth mannequin mouths had prepared me.

They hadn’t.

The real thing doesn’t blink. It twitches, seizes, vomits, craters. It drops its saturation like a stone the moment you hesitate. And yet, this is where we learn—on the edge of failure, heart racing, sweat fogging the inside of your face shield.

I didn’t get the airway that day.

But I got the lesson.

And I carry it with me—every time I pick up a blade.

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Postscript
I’ve lost count of how many airways I’ve secured since that night. I’ve missed a few. Saved many. But that first attempt? It still visits me. Not out of shame, but as a reminder: the stakes are always real, and the work is always humbling.