So I had a case today for knee replacement for 50 year-old male. Patient prefers spinal with general back up. 5'9, 300lbs.PMH: HTN, GERD, Hep C, all labs okay. Had a knee scope 4 years ago as only surgery.

I sit him up and lots of back fat with concave appearance so pretty much guessing at landmarks. I try 2 different levels and am unable to get CSF hitting bone repeatedly....I abort that and go for general. Pt has MP III with decent ROM. Induce with propofol, fentanyl....easy BMV so I give sux and attempt DL and know right off it ain't going to happen. Glide at bedside and can't see any helpful structures....soft tissue and secretions. I manipulate head and have cricoid applied and nothing. Call in for someone for a second look and see a bit of epiglottis but nothing else. Still easy to ventilate but concerned about airway irritation and some trauma with multiple attempts so abort case. This was my first case of the day. I remember the phrase in school that you are only as good as your last anesthetic....humbling case!!!