Challenging case last night. BMI 40. OSA. Difficult access. U/S guided 20G in forearm. 1 midaz effective pre art line. In it goes. Positioned. 200fent. Some effect. Props for induction after 100mg lignocaine flush. High resistance at 100mg props.....

Vecuronium to follow, as well as props tci. Notice swelling increasing in forearm. Patient becoming uncooperative and partially induced. 8% sevo turned on and went in to gain access, mask in hands of assistant......

Impossible to gain access. Even 22G. Called for assistance as secretions suctioned at top end under instruction. Could see it was getting away from me. 1 anaesthetist responded and several assistants. Best thing- anaesthetist asked what I wanted- replies- iv access anywhere/size

Finally got access in long saph as the ultrasound came in. Flushed with remainder 100mg props and vecuronium. Amazingly sats only dipped to 91% and was mask ventilatable. Tubed. Clear secretions suctioned off chords. Seemingly no signs otherwise if aspiration .

Afterward thanked all that attended. Surgeon commented on hardness of this patient, and that I looked so calm, as did fellow anaesthetist. I thought, you’re kidding right? !? Sat down. Sweat. Hr110. Geez. Nice last case.... like a duck ..calm on the surface, crazy underwater

Things learnt. Sometimes even the best looking cannula fails. Usually in the worst patient. Call for help early. I asked particularly for anaesthetic assistance rather than the cavalry. This escalated the situation perfectly. Projecting calmness even when you felt out of control