Last night I was at St.D's and had a close call. We had a young quadraplegic who came in with shortness of breath. He looked okay, but his chest XRay was terrible: total whiteout of the left hemithorax. We discussed intubation, but I pussy-footed around aand never really pushed it. He looked good and was doing fine on oxygen. But he was trending down. Not dramatically, but just incrementally his pulse ox dropped from the high nineties to the mid nineties to the low nineties and then he was at 88 and I had let myself get behind the curve on him. Still I wasn't too worried--we got ready to tube him. Then I considered his airway a little more closely: post trach, kind of an odd shaped jaw, etc. The PA asked if she could try the tube and I let her, but with misgivings. Things went badly right from the start. The PA was flailing from the start, the guys's pulse ox plummted to seventy within a dozen seconds, and then as we bagged him it dropped into the sixties. I went in and it was an absolute mess in this guy's oropharynx. No landmarks at all, just mucus, tissue, and odd dark shadows and crevices. I make a half hearted attempt, fail, and bail out to try again at bagging. Pulse ox in the thirties, dropping, and the guys getting bradycardic. We give atropine, and the RT askes if he can give it a shot. I assent and he muscles the tube down and in--it required some real force. At last we're saved. The pulse ox is up in the nineties ten second later and I'm off the hook. But, oh!, it was close. Hubris. U-561