In third year of Family Practice residency, I supplement my income by working in an emergency room.

It is outside of Portland, a small satellite hospital of a slightly larger hospital, about an hour away.

I do night shifts and I am the only doctor there.

The nurses know I am a resident and give me shit. "Don't worry, we've already had our gun shot wound for the week. Guy drives up to the doors in a pick up and pretty much empties another guy out and roars off."

We don't DO trauma. Any trauma goes by ambulance to the bigger hospital. But we do trauma if it gets dumped out of a car.

"You've certainly relieved my mind," I say. They continue to tell me horror stories about the last month.

I have nightmares the night before I work there. One night I dream about intubation over and over. I dream about trying to see the vocal cords and slide the tube down, praying the person won't die.

I am at the emergency room doing the eternal paperwork when the nurse grabs me. "Old guy, can't breathe."

He is an old guy. In his 80s. He is breathing, mouth open, rasping breaths. He is not quite drooling.

In an emergency, first check your own pulse. Mine is at about 150. My voice automatically drops and slows, to help keep me and everyone else calm. We move him into a room.

He is running a fever of 102. He can't really talk. He can barely breathe, but he is breathing. His heart rate is up a bit, oxygenation is actually ok, and we are drawing labs.

All I can think of is epiglottitis and that is kids.... but that is the most dangerous intubation because the swelling in the throat blocks the airway. Sometimes you have to do a tracheostomy. I have read about them and we have a trach tray. I have the nurse get it all out, intubation equipment, trach tray, labs are pending, we have an iv in order to sedate him if we have to....

And I am on the phone to the bigger hospital. "I want to move him." I say, "Get him to you so you can have anesthesia and an Ear Nose and Throat specialist intubate him if needed. He's ok, barely."

"Epiglottits?" says the other doc, "In an 80 year old?"

He's a little worse. Well, if it looks like a duck and acts like a duck... I order a subcutaneous dose of epinephrine. Also cold humidified oxygen. If it's acting like croup, I am going to treat it like croup. We have iv antibiotics going on board and blood cultures. I do not dare swab his throat.

The epinephrine helps. The ambulance arrives. They load him up and I give orders, another dose of subcutaneous epinephrine on the way if needed. They roar off.

I get a call a few hours later. "Supraglottitis." says the ER doctor. "Very interesting. Acute bacterial infection of the area above the epiglottis. Haven't seen that before. It's swollen as hell. ENT and anesthesia are standing over him, but so far it's looking like the antibiotics are working and he may not need a trach. Good job."

And I wonder what I will dream of before the next night in the rural ER.....

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