This case follows fictional Baby Girl Jones, born with a life-threatening condition: cyanotic heart disease (not enough oxygen in the blood). Her initial evaluation revealed transposition of the great arteries, a condition in which the two main arteries carrying blood away from the heart are reversed. The doctors also realized that the baby’s heart had a hole between the pumping chambers. The baby’s condition worsened and the doctors decided to perform an emergency balloon septostomy, but it had been years since they had done the procedure and it did not go well. Students must consider how this situation could have been avoided, and what could be done to prevent this in the future.