OK guys, so it's not that I think my way of doing things was perfect--I'm leaving in my mistakes for all to see--but what the administrators of the exam said was "right" that pisses me off. Long rant, but read on if you're bored. 64 yo "smoker" (with apparently a mysterious medical past) on a medicine floor s/p biliary stenting for pancreatic mass now with decreased mental status. You have no other info. The patient will be DEAD in 10 minutes unless you make EXACTLY the right interventions. First thing we ask for vitals than examine "patient". 38.6 120 24 90/60 95% @ RA Drowsy, oriented to name only. Will not follow commands but screams loudly when you touch her abdomen. LTCAB, RRR, etc, abd SND diffuse tenderness no guarding/rebound, weak pulses. 22 gauge AC only. Recent chest x-ray is normal. Ordered 2L NC, two large bore IVs and and a liter of fluids full blast, put on monitor, nurses refuse to do capnometry on the floor...morphine 10 IV for possible splinting (woops). 7.5 minutes left. Re-examine lungs, nl. Patient coughing hard now and yelling about pain. Fluids running through 22 g, morphine in. While "nurses are putting in the IVs", pt new vitals are 130 30 60/30 90% @ 2LNC Pt now unconscious, breathing, weak carotid pulse. 5 minutes left. IVs are in, order 2 more bags full blast. 100% non-rebreather. Get airway cart ready ("sorry, we need to call anesthesia to intubate on the floor, they can be here in 5 minutes") Ask for vasopressin (obviously thinking sepsis here)..."we can't run that through a peripheral" --just do it-- "can't do a pressor drip on the floor" grrr...Fine...bolus 20 phenylephrine 160 (narrow complex) 30 and ronchorous 40/0 O2 unreadable Pulseless...but breathing at 30... 2 minutes. Access, oxygen, fluids, pressors...ummm... Hands in pockets. Patient dead. Now, I know morphine to a septic patient was not good, but it's not what killed her. And I'm not even going to say I did a good job at my attempted resuscitation.... BUT the administrators come in and give us the third degree about EGDT!!! WTF? Where the hell is the magic EGDT algorithm that concerns a patient who goes from talking to you to dead in 10 minutes? They then go on to explain that successful completion of this simulation required: empiric abx central line (fast enough to have it done and pushing things through it before patient crashes at about 4 minutes into the simulation, all this on the general medicine floor, mind you) abg, cbc, cmp, coags, pan cx, heavy fluids if we had followed this, pt would have lived and not needed pressors or tube. because, you see, the abx would have taken effect, the labs would have come back, and we could have dumped a hot-tub full of lactated ringers down the magically appearing central line and saved the patient in just 10 minutes! ohhhh I'm so bitter. thanks for listening, SDN!