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WebM&M Cases

Cognitive Overload in the ICU

• SPOTLIGHT CASE
 
• CME/CEU

Commentary by Vimla L. Patel, PhD, and Timothy G. Buchman, PhD, MD

Admitted to the intensive care unit (ICU) with acute respiratory distress syndrome due to severe pancreatitis, an older woman had a central line placed. Despite maximal treatment, the patient experienced a cardiac arrest and was resuscitated. The intensivist was also actively managing numerous other ICU patients and lacked time to consider why the patient's condition had worsened.

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Getting the (Right) Doctor, Right Away

Commentary by Kiran Gupta, MD, MPH, and Raman Khanna, MD

A woman with a history of chronic obstructive pulmonary disease underwent hip surgery and experienced shortness of breath postoperatively. A chest radiograph showed a pneumothorax, but the radiologist was unable to locate the first call physician to page about this critical finding.

Falling Between the Cracks in the Software

Commentary by Julia Adler-Milstein, PhD

Because the hospital and the ambulatory clinic used separate electronic health records on different technology platforms, information on a new outpatient oxycodone prescription for a patient scheduled for total knee replacement was not available to the surgical team. The anesthesiologist placed an epidural catheter to administer morphine, and postoperatively the patient required naloxone and intubation.