In Critical Care, the game adds injury tokens to each patient’s chart and the players try to remove them. The magic comes in through building that basic structure - Brain, Heart, Lung, Blood, Inflammation and Crisis tokens, which marks the general risk for getting sicker - onto existing physiologic interactions, like getting a Complication. When drawn, Complications only manifest if that patient already has specific tokens on their board. With the Complication “Aspiration,” something (ex: food) has gone down the trachea instead of the esophagus, causing Lung injury. This Complication only happens to the patient if the patient already has a Brain injury. If they do, they immediately add Lung injury tokens, which expose them to Lung-related complications. This is real! Aspiration often happens to people with a neurological problems that limit the gag reflex and the ability to protect their airway. The game doesn’t tell you that lung damage can result from impaired swallowing due to brain damage, you enact it yourself and recognize it through experience rather than didactic. 

While all players can generally see these connections, those with health care experience see a much deeper level of connection as the cards tell thematic stories about what happens in the ICU. For example, even though you’d think it would be efficient in the game to focus your efforts on a patient that isn’t sick and cure them so you have more bandwidth as a team for the rest of the game, this isn’t often how it works - you often lose when you cure a patient early! When you neglect a sick patient in the game, they get sicker much faster. This is just like real life - you always triage to provide care to the sickest patients first. This is why it is, in real life, hard to transfer patients out of the ICU in a timely manner - you’re only preparing their discharge paperwork after the sickest people have their plans put in place. 

One of the most powerful examples of the way the theme drives the mechanisms is through the Goals of Care track. Cards that advance a patient towards hospice scale proportionally with how sick the patient is, just like our bedside conversations change as someone’s illness progresses. If you play some of those cards on a patient that isn’t that sick, you’ll get a limited benefit - but if you play them strategically as a team when the patient is in true crisis, the impact is potent. Not only do you get the weight of those conversations in these tense moments, but you may literally win the game because of it. That moment when you work together to turn the game from impending doom to a graceful victory is a little bit like what it feels like when we work with families to recognize the end is near and to guide them through that most intense time in their life. 

In real life, we always give the most attention the sickest patient, and this makes it quite hard to move patients out of the ICU - you can't go and get the patient ready for transfer out of the ICU until you've ensured the sickest patients have plans in motion. The game punishes you for giving more attention to the less sick patient; it takes very little to start the cascade and it takes a lot to recover from it. So you’ll often see players try to quickly cure a patient and get them out of the ICU - “then we can both focus entirely on the sick patient.” but it doesn’t work like that - instead, that patient will be just sick enough that it is incredibly hard to save them.

Each and every card in the game has a descriptive correlate that helps health professions learners understand more about the disease state. These cards also contain relations and linkages to each other which becomes rapidly apparent as you play the game! For example, if your patient is dealing with a Complication of Ascites, a Paracentesis Therapy Card would remove Ascites! But taking that link one step further, if you want to mitigate getting a Complication from your procedure, playing Point of Care Ultrasound (POCUS) before using Paracentesis will prevent you from drawing Complication cards!

Invasive procedures carry an inherent risk of complications. In the game, these cards carry risk too. For example, they may require you to draw Complications the moment you play the card; as noted above, these Complications may be irrelevant if the patient doesn’t have the relevant underlying injury, but they could also be significant and, indeed, lead to losing the game on that very turn. This changes the experience of playing one of these cards - often more powerful than other therapy cards - from a simple card play to a serious consideration of the risks vs benefits… just as we consider in real life!

Critical Care intentionally surfaces topics about social justice starting with recognizing “social determinants of health” (SDOH). SDOH such as food insecurity or the experience of racism leave patients more vulnerable from the outset, just like they do in real life. Other topics come through Pager Alerts, random moments that introduce critical thought and tension. Pagers feel a bit like real life - you don’t know when it goes off, it is almost always bad news in some way, and it acutely focuses your attention despite the overwhelming, non-stop nature of the hospital. We took some liberties in exactly what we did with that attention, bringing up issues like bias, gun violence, burnout, issues with our medical records system and challenges with health insurance. We are able to introduce these issues without compromising the game's light, fast, and enjoyable nature - striking a delicate balance between addressing serious topics and becoming engrossed in the game play.