Scenario:You have just performed the most altruistic act in the practice of anesthesia: giving a lunch break to someone in the GI lab. Of course, the ERCP is just getting started and the morbidly obese patient has just been positioned prone. He is sedated on a propofol drip, mouth stretched open with a green plastic ring, oxygen saturations holding steady at 95 percent for the moment. The procedure begins and the advancing endoscope does its job inciting gagging and coughing, necessitating a pause in the surgery as propofol is titrated. Unfortunately, this patient’s physiology is not accepting of the combined insult of surgery, breathing spontaneously and intravenous sedation. Airway maneuvers performed have minimal effect. Then the moment declares itself and crisis is upon you. Within seconds, the stable patient has become the opposite and all eyes are on...

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