This pair of cases highlight the immediate and long-term consequences of delayed recognition of compartment syndrome, despite patients presenting with symptoms such as severe pain, numbness, and swelling in the affected limbs. The commentary discusses the importance of a multifactor assessment when compartment syndrome is suspected, effective processes for trainees and non-physician staff to escalate concerns to attending physicians when compartment syndrome is suspected, and improving post-discharge follow-up practices to identify patients requiring further evaluation.

A 77-year-old man was admitted for coronary artery bypass graft surgery with aortic valve replacement. The operation went smoothly but the patient went into atrial fibrillation with hypotension during removal of the venous cannula. The patient was shocked at 10 Joules but did not convert to sinus rhythm; the surgeon requested 20 Joules synchronized cardioversion, after which the patient went into ventricular fibrillation and was immediately and successfully defibrillated with 20 Joules. While the patient was being transferred to his gurney, the operating room team noticed that the electrocardiogram cable that enables synchronized cardioversion was only connected into the anesthesia monitor and was never connected to the patient’s defibrillator. The commentary discusses the risks of unsynchronized shocks or pacing, the role of standardized processes to ensure that operating room equipment is prepared and set-up correctly, and the importance of operating room team preparation to urgently address life threatening complications