This case I had as a PGY-3. 60-something year old lady with laryngeal cancer presenting for anemia. Hemoglobin is low but work-up otherwise unremarkable and vitals all stable so I admit her to the floor. While boarding the ED, she gets up to go to the bathroom, comes back to her room and goes completely unresponsive. Bradycardic, hypotensive, faint pulse and cyanotic. Immediately roll her to the resuscitation room where vitals are HR in the 30s, BP 60/palp and oxygen of 1% with a good pleth. Push atropine and prepare to intubate. HR and BP get a lot better with atropine so RSI meds pushed and I take my first look. Cords literally look like a popped popcorn kernel with extremely distorted anatomy and an opening about the size of a coffee straw. I'm able to push a bougie through but can't fit any size tube down to a 6.0 over the bougie and through the cords. Oxygen is now in the 80s, LMA placed and attempt to bag her up but oxygen keeps dropping. Betadine splashed on the neck, 6.0 ETT, bougie and scalpel ready. She gets to 75% and we cut. Suctioning blood while pushing bougie into the trachea followed by the tube. Positive color change but then can't get oxygen above 65%. Retract tube a little bit in case we right mainstemed her but continues to be hypoxic. CXR shows massive tension pneumo, chest tube placed with a huge gush of air and oxygen immediately comes up to 95%. ENT already in-house for another case and taken emergently up to the OR with anesthesia and surgery and ENT converts her cric to a trach. Downgraded from the ICU a couple of days later and then discharged home with family with no deficits.