critical Scenarios

Working in critical care medicine is about constantly having to critically think. Each organs way of reacting to an insult intercedes within another; this, along with the fact that we can’t perfectly monitor hemodynamics/volume status/perfusion with a magic number makes some clinical scenarios particularly difficult to interpret. Think about the situations below and what you would do; how you would manage these situations. Use the evidence you’ve learned throughout training to guide you. Remember, sometimes its not about making the right choice, it’s about making a choice.

Scenario 1

You have a patient in septic shock from C. Diff on the ventilator. He is from a nursing home and at baseline is non-functional. The nurse reports that he has gone from 0.3 mcg/kg/min of levophed to 1.0 mcg/kg/min; at bedside, the patient has an arterial line placed with a slightly dampened waveform correlating with the heart rate. The a-line pressure reads 84/30 with a MAP of 59 while the cuff pressure reads 120/72 with a MAP of 88.


You hear a code blue overhead. Being the connoisseur you are, you check the EPIC app on your phone as you are running towards the room; it states the patient is DNR. You arrive to the room and compressions/ACLS are actively being performed. Another provider (a MD) is running the code. You see a 400 lb 6’5” man at bedside, aggressively screaming to continue. You see another woman sobbing outside the room; she states she is his wife, and he had wanted to be DNR.