Some of the history was obtained after the fact...some details have been changed or omitted to protect the innocent. Old lady had ACDF 24 hours ago. She was doing fine, and getting ready to go home. She was finishing up her hospital lunch, and managed to gag on a piece of chicken. The coughing spell which ensued caused her to develop a rapidly expanding hematoma in her neck. She went from hard time swallowing to hard time breathing in minutes.....I got to watch her neck swell to bullfrog size before my eyes while I wheeled her emergently to an open OR. On the way, I managed to snag extra help including other anesthesia folks, an ENT, and an OR crew. By the time that we were in the OR, I was fairly confident that I would not be able to intubate her with a blade, and even more confident that I would not have time to do an awake fiberoptic intubation. I slap the mask on her face, and told her that she might remember some of this and cranked the SEVO to 8 percent, and ask my ENT to cut the neck open. While the surgeons are working, I squirt some Afrin in the nose and tried to get her more deeply anesthetized..kind of hard with a partially obstructed a/w. When I thought she was ready, I tried to do a nasal fiber optic.....first mistake...patient wasn't deep enough....caused larygospasm and lost the airway. Surgeons continue to work...I give sux and manage to re-establish a mask a/w. I gave DL one try....no view. So I moved to an oral fiber...this goes in pretty easy...although airway anatomy was clearly not normal. Case finishes ...patient does fine..... Interesting point to me: patient ate a full meal...this full meal made her cough and caused the hematoma.... She had a mask induction.....She had an airway operation......She suffered through 3 different attempts at intubation before the airway was secured....absolutely no sign of aspiration...she didn't even vomit post op. Seems to me that normal people with normal body habitus very rarely aspirate whether they have a full stomach or not....just my observation which doesn't sit well with the ASA's guidelines.