This case involves a male patient who presented to the ER with acute abdominal pain. He was diagnosed with gallstones, however it was noted that there was no evidence of obstruction. The decision was made to take the patient for an ERCP, a medical imaging procedure in which an endoscope is used to introduce contrast medium into the patient’s bile ducts to allow visualization on a subsequent x-ray. The patient was classified as a “high risk” for complications from the procedure, based on his history of obesity, hypertension, and smoking. Nevertheless, he had no cardiac or pulmonary examination or clearance prior to proceeding with the procedure. After undergoing the procedure he was extubated, however he required re-intubation almost immediately, after his breathing was found to be dangerously slow and labored. At this point, he was transferred to the post-anesthesia care unit, where doctors again attempted to extubate the patient. Almost immediately after the patient was extubated, he suffered cardiac arrest. Doctors were unable to successfully revive the patient, and he expired in the PACU.