The scariest part of my job is intubating people — medical terminology for putting a tube down someone’s throat so that a machine can breathe for them. This is something that happens regularly in Emergency Departments: people’s hearts or lungs fail them — or they are victims of gunshot or knife wounds or high-speed automobile accidents — and they require intubation. Although I do not do it every shift, there is enough disease, gang violence, and motor-vehicle badness where I practice that I intubate patients several times a month. Maybe even once a week.

It still scares me. However slick programs like ER and Grey’s Anatomy make trauma and medical resuscitations look on TV, in reality, they are always intense experiences. This comes from several factors. First, intubations almost always happen in a big hurry. Someone is either maintaining their airway or not, and there is usually not much warning that the subtle line between living-and-breathing and impending doom is about to be crossed. Add to this the fact that it takes four or five well-trained people to intubate someone, and every intubation represents a mad, last-minute scramble to place a foreign object in someone’s mouth and down their throat before they go without oxygen long enough to die. A physician readies the necessary equipment. Nurses and paramedics establish IV lines, hook up monitors and give medicines. A pharmacist draws up sedating and paralyzing drugs, and a respiratory therapist prepares the ventilator. And all this takes place at a rapid pace and in a crowded room with a patient who is often gasping for air and quickly turning blue.

This pace and intensity is complicated by the fact that placing a tube in someone’s airway is not an easy task. God or millions of years of elegant evolution have created humans to be very protective of their airways, and every intubation is an argument against the anatomy that has evolved to protect our lungs. For this reason, a successful intubation requires a fair amount of know-how and some serious upper-body strength. In the moments before I intubate someone, I am often afraid that I will pee my pants.

* * *

I did a particularly difficult intubation last week. A young man with a chronic neuromuscular disease and a new upper respiratory infection had come into the ED. He was in the care of his brother and sister — adults with busy lives of their own who were also their brother’s primary caregivers. They all understood that night, the same thing I did: that with a greatly diminished ability to use the muscles in his chest and neck to breathe, the same infection that would make most people miss a day of work could threaten their brother’s life.

At first, his ED course went well. Blood work and chest X-ray revealed no obvious source of infection, but when a measurement of his negative inspiratory force, or “NIF,” showed a decreased ability to suck air into his lungs, my attending physician and I decided to prophylactically start him on antibiotics. I spoke with the patient’s primary care doctor and his neurologist, and arranged to have him admitted to the hospital. I then explained all this to the patient and his family. The patient looked tired, but was still talking in full sentences, and when I left the room his oxygen saturation — a measurement of oxygen content in the blood — was 100%.

* * *

Every person has two parallel tubes running down their neck and into their torso. The tube in front is the trachea, a semi-rigid structure that delivers oxygen into the lungs. Behind it sits the esophagus, a softer, more flexible tube that transfers food from the mouth to the stomach. At the top of these two tubes sits a big floppy glob of flesh called the epiglottis. It is the epiglottis’s job to keep food from going into the trachea: when you swallow, the epiglottis flops over and covers the top of the trachea. The coughing fits associated with the phrase “Something must have gone down the wrong pipe,” signal times when the epiglottis has failed. The involuntary paroxysm of coughing that results, expels the foreign body from the trachea and protects the lungs from a subsequent infection. It is a testament to how well this system works that more people do not die of aspiration pneumonia, the disease caused by breathing foreign material into our lungs.

But this elegant two-tube system is also the bane of intubations, because before I can place a breathing tube in someone’s trachea, I have to find the epiglottis, move it out of the way, and then discern the trachea from the esophagus. This is not always easy to do, since both tubes are pink, and both are frequently covered with mucous, blood or vomit. I accomplish this task with a device called a “laryngoscope,” which is basically a long blade that is placed at a 90-degree angle on the end of a handle. There are different styles and sizes of laryngoscopes, but they all enable the physician to perform the inelegant task of rummaging around in the back of someone’s throat until they find the trachea.

* * *

On the night I performed the difficult intubation, I was seeing multiple other sick people — a man who had a heart attack that we stabilized and then sent to the cardiac catheterization lab, a middle-aged woman with pancreatitis, and a teenage girl who was miscarrying her first child. In and around all this, I also looked at a couple of sore throats and stitched up a laceration. Interacting with these patients exemplifies another reason intubation is scary: your head and heart and hands are often in a very different place — like someone else’s vagina — when you get the news that a patient down the hall has stopped breathing.

Nevertheless, I try to stay aware of which patients in the department might be getting sicker. And so even though officially I had transferred the young man with a tenuous respiratory status to his primary care doctor, I kept carrying him around in my head. And when his nurse called, I knew it would not be good news. She had been starting IV antibiotics when she noticed that he could not say more than one word at a time — a sure sign of impending respiratory failure. I left what I was doing and ran to the next room, but by the time I got there he could only nod his head “yes” or “no.” He did not have the strength to speak or even gasp for air. Because I had spoken with him just an hour before, seeing him like this just about broke my heart. The power of his underlying disease to kill him was unfolding in front of my eyes, and save intubating him, there was nothing else I could do. With each shallow, ineffective breath, he was asphyxiating to death.

* * *

Recently, intubation has gotten a bad rap. News stories about individuals like Terri Schiavo — who was actually not intubated at the time her legal case made her a household name — create fear of established medicine and of losing control of one’s body. People are encouraged to draft living wills that prohibit care they would not want and to make these wishes well known to family and friends. I routinely have conversations with patients who do not want to be kept “artificially alive” or be on “breathing machines.” They cite stories like Terri Schiavo’s and argue that they would never want to be that “out of control” with happened to their body.

I think this fear of breathing machines and not being in charge comes from a healthy place. I will be the first to admit that for a long time medicine failed to respect patients’ autonomy and wishes about medical emergencies and end-of-life planning. But there is also something very different about the theory of not wanting to be put on a breathing machine and the reality that being on that machine might save your life. More than once, I have had the uncomfortable experience of a patient refusing intubation but not really understanding what that meant. A woman with chronic obstructive pulmonary disease (COPD) insisted through wheezing, gasping breaths that she did not want to be intubated. When I told her that I was happy to respect her wishes, but that she might die, she accused me of lying. A few minutes later, when her oxygen saturation was 85% and falling, my attending physician told her that we had exhausted all other modalities and that if we did not intubate her soon, she would die. She looked shocked, but also nodded her head up and down as fast as she could. “Do it,” she said, glaring at me, and then we placed the tube.

This woman walked out of the hospital five days later. After treatment for pneumonia and a COPD exacerbation, a respiratory therapist and ICU physician calmly removed the tube and she began to breathe again on her own. Time on the ventilator had healed her lungs.

But for every “COPDer” who extubates and walks out of the hospital, there are others that die on the ventilator or — like Christopher Reeve — end up tethered to it for life. And it is this component of not knowing the outcome that makes intubation so scary for patients — and physicians. Will intubation be a temporizing measure on the road to health, or will actions taken in a moment of extreme duress confine a patient to a long-term treatment she or he would not have wanted? Add to this the heartache loved ones experience when confronted with the decision of whether or not to pull the tube later, and intubation is a complicated thing, indeed. Families either look back at it as a life-saving event or a terrible decision that culminated in a family member’s demise.

* * *

In addition to lying in front of the esophagus, the trachea’s other key characteristic is that just behind the epiglottis lie the vocal cords: two thin, white structures, each several millimeters wide and several more millimeters long that stand guard on either side at the top of the trachea. After a lot of rummaging around, locating the cords can feel like finding a gold mine, and is almost always announced: “I can see the cords” the physician will shout out, and everyone in the room will breathe a collective sigh of relief. An endotracheal tube is then passed between the cords and placed in the trachea. The respiratory therapist attaches the tube to an air-filled bladder and squeezes it. Everyone in the room watches to make sure that the chest rises and places their stethoscopes on the chest to make sure they can hear breath-sounds. If they do — and if the technical monitors in the room show that the patient is getting enough oxygen and exchanging it for carbon dioxide — the intubation has been a success. If not, the tube is in the esophagus, and it must be pulled out and the whole process undertaken, again. Because the patient has had a longer period of time with difficulty breathing, second and third attempts are always fraught with more anxiety and adrenaline than the first.

When multiple attempts at intubation fail, you move onto rescue maneuvers. There are different gadgets called boughies and stylets that can help visualize the cords, and a technique called a retrograde intubation, but the most fail-safe plan is to cut a hole in the front of the neck, through the crichoid cartilage and into the trachea. A breathing tube is then inserted directly into this hole. Crichothyroidotomy is a bloody, miserable procedure that leaves patients with disfiguring scars. No matter what you see on television, it is not something than can be easily accomplished on a restaurant floor using a pocketknife and a drinking straw — or the plastic tube that surrounds a ballpoint pen. It is a difficult trick for even the most trained professionals to pull off well, and a last ditch effort when everything else fails. An attending physician I respect tells me that he never got good at the procedure until he worked as an army doctor at a battlefield hospital in Iraq — a comment that speaks volumes about the challenge of the procedure and the severity of injury generated by the war.

* * *

Back in the room with my sick patient, I explained to him and his siblings what we had to do. They had already known it was coming: the young man had been intubated and spent a week on a ventilator a year before for the same reason. So when I asked for permission to intubate, he nodded his head and then his brother and sister left the room. As I moved about the room getting equipment ready, I watched tears well up at the corners of his eyes and roll down both sides of his face. He did not have the strength to wipe them away. I stopped and put my hand on his shoulder. I wanted to promise him that everything would be OK, but I did not know if that was true. Instead, we just locked gazes for a moment. Then I nodded, and left him alone. Even though his body was failing him, he knew exactly what was going on, and in my mind I was trying to preserve some dignity for him by acknowledging — but not making a big deal about — his tears.

* * *

In the crass, fly-by-the-seat-of-your-pants environment of the ER, nicknames for intubation abound: “We’re going tubing,” someone might say as they set up intubation equipment, or ” I just tubed a patient” after an intubation is done. “Snorkeled” refers to patients post-intubation, and “gut tubes” are tubes misdirected into the esophagus. “Getting the gus” — pronounced “goose” and short for “esophagus” — is another term for misplacing a tube in the gut. And “adrenaline tubes” are those pushed too far and hard: in the heat of the moment it is easy to find the trachea and keep on going, not stopping until you reach the right lung.

Not surprisingly, in the still male-dominated field of Emergency Medicine, the act of placing a phallic object in a narrow space also generates sexual jokes and innuendo. A difficult tube placed between closed vocal cords might get described as “tight” and “deep” by the smiling, satisfied physician who managed to get the job done. Other patients are “easy” or even “loose.” Everyone understands the sexual connotation behind these comments, but however offensive, they mostly get ignored. It is hard to sit in judgment of a foul-mouthed colleague who just completed a difficult task you are glad you did not have to do yourself.

* * *

A minute or two before I performed the difficult intubation, I slipped out of the patient’s room and ran to the bathroom. Nurses were establishing an extra IV site, and this gave me a chance to pee. I was still nervous and in need of comfort, so I also said a prayer. I am not always sure whom I pray to anymore, but I do believe in a power greater than medicine and certainly in one greater than myself. I did not ask to save this patient. Instead, I simply prayed not to harm him, and that whatever happened in the next few minutes would be what he and his family wanted.

With an empty bladder, but still afraid I might pee my pants, I walked back into the room. The pharmacist was ready with sedating drugs, and the respiratory therapist was standing on the right side of the bed. I took my place at the patient’s head, and then a familiar sequence of events unfolded. Drugs were pushed, the patient fell into a deep sleep, became paralyzed, and then I entered his mouth, pushing his tongue out of the way with my blade and looking for the cords. After suctioning a glob of mucous from the back of his throat, the cords appeared and I passed the tube. Good breath sounds and 100% oxygenation later, the intubation was a success.

I thanked the team for everything they had done. The intubation had been remarkably slick, and I was grateful. With his struggle against disease and the attention of devoted siblings, this young man had gotten under all of our skins. His entire ER course had been one long attempt to avoid the very procedure we had just accomplished.

But out in the hallway, his brother was pacing. Angry, he confronted me: If we had given the antibiotic sooner, could we have avoided intubation? Were we sure we had done the right thing? I told him that giving antibiotics sooner would probably not have made a difference, but my reassurance did not matter. This man loved his brother, and in his mind, the events of the last several hours — the time spent in the waiting room, and waiting for X-ray and lab results to return — was time wasted. He was fierce and possessive, but powerless against his brother’s disease. He also had the same kind of anger and intensity I want a family member to feel for me when I am deathly ill, on a ventilator, and need someone to speak for me.

Still, his words stung, and I carried them with me for the rest of the shift, into the next week, and then into the generation of this essay. It was not his brother’s question about antibiotics that hurt — I am sure starting them earlier would not have made much of a difference. Rather, the sting came because his questions highlighted the things everyone who had participated in the intubation were thinking and feeling, but not speaking. Namely, the difficulty of not knowing what would happen next, the pain of not being sure if we had done what was right, and the distress of being powerless in the face of a disease process larger than any of us. Staring at each other on that cold February night, my patient’s advocate and I confronted things about being human that many of us know but like to forget: that life is always uncertain and often a very big mess. Intubation had reminded both of us of these realities. Remembering them had made both of us a little bit mad.

* * *

When I left academia and decided to go to medical school, I had some notion of service and of contributing to the greater good. I was old and beat-up enough by life to not have grandiose ideas about saving lives or being a hero, but I did feel called to make a certain kind of contribution.

Now I even question that. After two years of premed, four years of medical school, and now three of residency, I understand that there is very little I can fix, and that mostly I am trained to intervene. Because these interventions are often brutal and severe, I am not even sure I am able to comfort, something else I came to medical school to do.

But because I have invested too much in this education to believe it is all a waste — and because however cynical I become I cannot function in life as a fatalist — I look for other reasons to keep doing my job. I don’t have many yet, but I think they have something to do with tolerating moments like the one my patient’s brother and I sat through the other night. Intubation brought us face-to-face with his brother’s humanity — and our own. There was supreme discomfort in that moment, but there was also honesty and truth. The veneer of pretense that guards so much of our inner lives was stripped away, and there we were: not powerful or all-knowing or correct, but simply present and wearing our humanity and the mess of life in an unpracticed, but completely authentic way.

I think about living like this a lot, now. I am not very good at it, yet. In the meantime, I am trying to be grateful for uncomfortable moments and for the privilege of sharing them with other human beings that struggle as much as I do. I am coming to understand that the scariest part of my job is not intubating people. Intubating people is actually the scariest thing I do.