This OR operations case involves a patient in Arizona who underwent a surgical procedure to remove part of his colon. A preoperative workup including a pulmonary and critical care consultation was conducted by the defendant pulmonologist. The consultation revealed that the patient likely had a paralyzed left diaphragm from a workplace accident that occurred many years prior. The defendant recommended deep incentive spirometry. He also recommended that long acting opiates should be limited, and the suggested pain control should be by epidural analgesia to decrease the risk of respiratory depression. On the morning of the surgery the patient underwent a pre-anesthesia assessment. The anticipated anesthetic plan was listed as general. His anesthesia pre-op orders called for him to receive benzodiazepine as well as an opioid pain medication. The patient was taken to the operating room where an additional dose of benzodiazepine was given, and the patient was immediately intubated. Surgery ended and the anesthesiologist noted that the surgeon requested the patient remain on a ventilator. The patient was extubated. Instead of taking the patient to the surgical intensive care unit as ordered the patient was left in the post-anesthesia care unit waiting area. He was later seen by the defendant who observed him to be sleepy. He informed the post-anesthesia care unit staff to be careful about the use of narcotics in the light of the patient’s present clinical situation and past medical history. He was later found to be unresponsive, and was declared dead shortly afterwards.