ERCP with sedation: A big MAC (monitored anesthesia care), supersized!

The case A brand-new anesthesia attending, you have just finished a case and the anesthesia coordinator asks you to go get some lunch and then go to the endoscopy unit for an ERCP (endoscopic retrograde cholangiopancreatography). ERCP? You remember learning about it in medical school but never got a chance to observe one being done. While wolfing down a greasy cheeseburger deluxe from the cafeteria, you Google it and find that it is usually done prone and under sedation. “Easy MAC, let me grab a bunch of propofol,” you think to yourself. You reach the endoscopy unit after getting lost a few times on the way there and introduce yourself to the gastroenterologist. He explains that the patient is in-house and “not that sick” and that the gastroenterologist needs to get to office hours, “so can we do this quickly?” Wanting to develop a good rapport in the endoscopy suite as a new attending, you reassure him that you'll get things moving along – it's just a MAC case after all! You then go to the room, draw up your propofol syringes, and, as a final thought, crack open the succinylcholine vial. The patient arrives. She is a 52-year-old female with a history of hypertension (HTN), 65 kg, and recently diagnosed with gallstone pancreatitis. She looks as if she's in pain. You approach the patient and introduce yourself.