She was 70, and her family noticed she wasn't moving quite right.
By the time she got to the ED, her entire left side was paralyzed and her mental status was poor at best. The massive, ongoing stroke was getting worse by the minute. Her pupil was getting progressively more and more dilated. Gurgling, choking sounds were emanating from her throat - a sure sign that if she hadn't already swallowed a large volume of stomach juices and oral secretions into her lungs, she would soon.
First and foremost. ABC: the axiom by which Emergency Medicine doctors live. A is for Airway, the first and most important part of any emergent case. She has officially failed to Protect The Airway, and it's time for me to do it for her.
I've just finished my anesthesia rotation and for the rest of my career, I'm officially cleared to intubate when needed. More importantly, I've done enough of these that I feel comfortable handling myself without guidance.
Equipment: check. Always make sure your equipment works first. It'll save your ass when the clock is ticking and you suddenly realize your light doesn't work.
Drugs: pushed through the IV. Now she's sedated and comfortable, and the paralytic quickly starts working. I give her oxygen with an ambu bag because she can't breathe for herself. Completely paralyzed, her life is in my hands - a responsibility not to be taken lightly.
And so. Scissor the teeth open. Blade carefully inserted through the open mouth, tongue swept aside for easy visualization. Vollecula pulled upwards and out. Momentary pause - I don't see vocal cords. Gentle pressure applied to the throat - ah, there they are - assistant's hand placed just so to keep them in view.
Hands steady, I slide the endotracheal tube gently through the vocal cords. I inflate the cuff to keep it in place, and hook her up to the ventilator. Oxygen flows to her lungs. Immediate crisis averted. One of the nurses gives me a wink, "Doctor Z, you made that look easy!"
There is a particular satisfaction when you glimpse the beginnings of competency. A month ago, I wouldn't have known how to do this. I'm far from an expert - but it will come. I've got my whole life to practice.