This case involves a 27-year-old male who underwent an elective procedure to correct a cleft palate. After the surgery, he was observed for approximately one hour before being released. A few hours later, he contacted the surgery center asking for a nurse to come to his house in order to address complaints of swelling, difficulty breathing and general discomfort. The nurse arrived at the man’s house with a suction machine and began performing multiple rounds of suction on the patient. The patient continued to complain of difficulty breathing, and the nurse checked his oxygen levels multiple times by pulse oximetry, however all of the readings were within the normal range. The patient continued to deteriorate over the next few hours and pleaded to be taken to the hospital, however the nurse insisted that it would not be necessary. Eventually, the patient became unresponsive. EMS was called, and the EMTs attempted intubation, but were unsuccessful due to swelling. An emergency tracheotomy was performed and the patient was transported to the hospital. He has since suffered ongoing difficulties due to hypoxic brain injuries.