A five-year-old girl presented to the emergency department (ED) with symptoms of an upper respiratory tract infection. A viral swab was negative for SARS-CoV2, influenza, and respiratory syncytial virus. A throat swab was positive for group A Streptococcus. The patient returned the next day with worsening symptoms but the treating physician again did not order imaging and attributed all findings to pharyngitis. The child was sent home with a prescription for amoxicillin. On day 3 after the first ED visit, the child was brought back to the ED by ambulance with pulseless electrical activity at a heart rate of 70 bpm and oxygen saturation of 40% with no spontaneous respirations. On examination during resuscitation, there was skin mottling and petechiae. She was pronounced dead after resuscitative efforts failed. Autopsy showed bilateral pneumonia and right-sided empyema. Empyema cultures grew Streptococcus pyogenes and Klebsiella pneumoniae. The commentary discusses the importance of timely recognition and proper management of potential bacterial infections to prevent downstream morbidity and mortality from sepsis.

A patient who was 39-weeks pregnant presented to the hospital in active labor, admitted to the Labor and Delivery unit and confirmed to have a full-term singleton fetus in vertex presentation. After several hours on oxytocin, the fetal head was still relatively high and the fetal heart rhythm suggested hypoxemia. The physician attempted delivery using a vacuum, but ultimately performed an emergency cesarean delivery of a healthy newborn. The procedure was complicated by the need to extend the lower uterine segment incision bilaterally for safe extraction of the fetus. The operator’s note described post-delivery repair of the right uterine incision but did not comment on the left side. Following the delivery, the patient was noted to be hypotensive and tachycardic and went into cardiac arrest. Another physician opened the patient’s incision and found nearly three liters of blood had collected in her abdomen, apparently due to complete transection of the left uterine artery. The commentary highlights the risk factors for obstetric hemorrhage, summarizes standardized risk assessments used to alert for potential obstetric hemorrhage and use of obstetric simulation training to improve team communication and performance.

A 60-year-old woman with a history of cirrhosis arrived at the emergency department (ED) with an open right ankle injury and moderate blood loss after falling at home. A tourniquet was placed and her initial point-of-care hemoglobin was 7 mg/dl, so a “massive transfusion protocol” was initiated. The patient progressed to cardiac arrest and chest tubes were placed on both sides of the chest. After return of spontaneous circulation, fluid was identified in the abdomen, so the patient was immediately transferred to the operating room (OR) for exploratory laparotomy. Bleeding was noted to be coming from lacerations in the lateral chest wall and in the right lateral aspect of the liver, which was enlarged and visibly cirrhotic with splenomegaly. Multiple packing maneuvers were attempted but definitive hemorrhage control could not be obtained. This commentary highlights the challenges in managing blunt trauma in actively bleeding patients with a history of cirrhosis and the importance of frameworks and protocols (e.g., Advanced Trauma Life Support [ATLS], Massive Transfusion Protocol [MTP]) to protect against misadventures in the trauma bay.

A 32-year-old woman was admitted to the hospital for endoscopic retrograde cholangiopancreatography (ERCP) under monitored anesthesia care (MAC). As the endoscope was advanced into the stomach, the patient vomited. She was immediately turned supine but copious vomitus obstructed the suction catheter. The patient started to decompensate with decreasing oxygen saturation. The anesthesia team attempted to secure the airway by endotracheal intubation but was unable to place a tube due to poor view and vomitus. The patient went into cardiac arrest and ultimately passed away. The commentary discusses safety considerations for ERCP under MAC, weighing the risks and benefits of MAC versus general anesthesia, and airway management during emergencies.

A 38-year-old woman with class 3 obesity required removed of a gastric balloon under general anesthesia. She required a relatively large dose of rocuronium for endotracheal intubation, and she was given intravenous sugammadex (200 mg) at the end of the procedure to reverse the neuromuscular block. A quantitative neuromuscular block monitor was not used, but reliance was placed on clinical signs. Shortly after arrival in the post-anesthesia care unit, she couldn’t move or open her eyes and became jittery with low oxygen saturation. Quantitative blockade monitoring revealed a “train of four” (TOF) ratio less than 70%, so she was given another 200 mg of intravenous sugammadex with return of normal motor function.