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    Mid 40s obese AA F only hx of asthma, 2 lifetime intubations. No tobacco, no drugs, no etoh. No allergies.

    Fails BiPAP during first night in ICU, tubed. Insanely hard to ventilate, but P/F is staying normal. Attempt PRVC, APRV, epi, ketamine, in addition to usual care. Still, vent volumes dropping to 100-200cc, PIP 60+. CO2 >100 and pH <7.0 mixed acidosis.

    Decision to go to VV ECMO via Avalon catheter. Unable to confirm cannula placement with TEE, eyeball it with CXR. Circuit looks good, no apparent mixing. Overnight, 2-3 liters of fluid removed via CRRT for AKI with obvious fluid overload. Vitals looking good all night. Suddenly crashes at morning shift change. NSR PEA arrest, BP just gone suddenly. Long long CPR with refractory VF, many shocks, but no sustained ROSC.

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