Joseph is a 33yo 255kg (560#) male with a history of HTN, tobacco use, and suspected sleep apnea, who initially presented with a 10% TBSA 2nd and 3rd degree scald burns. In the burn unit he began having desaturations into the 70% range when sedated with narcotics for his dressing changes. He showed some improvement with Narcan with saturations up to 90%, but then failed BiPAP and was subsequently intubated. Over the subsequent days he developed worsening hypercapnic respiratory failure with the development of probable pneumonia. This progressed to what appeared to be septic shock with acute renal failure and ARDS, although he had no positive cultures at that point. He was noted to have some ST elevation concerning for an MI, but also possibly from a PE or Pulmonary HTN. His cardiac enzymes were borderline. Because of his size, he was unable to get a CT Scan, cardiac catheterization or pulmonary angiography, and so was treated with thrombolytics to potentially treat both an MI and a PE. A technically difficult transthoracic echo suggested adequate LV function, but suspected a distended RV with moderate to severe dysfunction, possibly from PHTN, although they were unable to visualize a TR jet to estimate his PA Pressures. Because of continued deterioration, he was referred for possible ECMO support.