This case involves a 35-year-old male patient with a history of low platelet levels who underwent a splenectomy. The patient had a past medical history of obesity and asthma for which he was receiving high dose steroids and immunoglobulins. The patient had an abnormal preoperative chest x-ray which was interpreted as a partial lung collapse. The patient underwent general endotracheal anesthesia with a thoracic epidural. During the procedure, the patient lost the CO2 waveform and suffered from oxygen desaturation. A code was called. The patient subsequently underwent multi-organ failure and died. It was alleged that the attending nurse anesthetist (CRNA) failed to maintain the patient’s steroid regimen and failed to take his comorbidities into consideration when clearing him for anesthesia during the surgery.