Heart transplant volume in the United States had remained relatively stable from the early 1990s until 2012, falling in the 2,100-2,200 transplants per year range. Since that time, there has been consistent annual growth, including throughout the COVID-19 pandemic. In 2022, 4,111 heart transplants were performed in the U.S. and over 6,000 worldwide, including 491 pediatric (<18 years) patients in the U.S. However, despite the increase in heart transplants, there continues to be a shortage, with over 3,300 patients remaining on the waitlist in the U.S. alone.

How much do you really know about this giant government program, including its expansion during the pandemic and current state efforts at contraction? It has obvious benefits for society. One in three school-aged children are covered by Medicaid or CHIP. The program also covers 41% of all births. Medicaid provides coverage for 62% of all nursing home residents and 43% of all disabled, nonelderly adults. These benefits, however, fail to address concerns voiced by policymakers about sustainability or costs and also fail to address longstanding concerns from those caring for patients.

In this case report, a 78-year-old male presented with a right femoral head fracture and developed bone cement implantation syndrome (BCIS) during surgery. The patient possessed numerous high-risk criteria to develop BCIS, including advanced age, male sex, ASA Physical Status 3 status with severe cardiopulmonary disease/COPD, and preoperative diuretic usage. While advanced monitoring was not initially placed, a TEE placed after the patient suffered a full cardiac arrest confirmed a diagnosis of BCIS and helped guide fluid and vasopressor management.

It has become well established that cognitive biases are a significant problem in medical decision-making. Flaws in judgment, rather than lack of knowledge, are central to diagnostic error. We must acknowledge the contributions of bias to our medical decision-making and embrace the opportunity to use metacognition techniques to think critically, be open to alternate analyses, and be reflective in our practices.