Joshua is a 20yo 56kg male unrestrained passenger thrown from the back of a pick-up truck during car crash who intubated in the field with a GCS of 3 and airlifted into your trauma center. He was found to have rib fractures, a small pneumothorax, pulmonary contusions, and fractures of T2 and T3. There was fluid, presumed to be blood, in the right mastoid sinus, right middle ear, and bilateral sphenoid sinuses. His head CT demonstrated temporal, sphenoid, mastoid, and occipital skull fractures, with subarachnoid blood, and multiple bilateral punctate brain hemorrhages, most predominant in the frontal lobes, “worrisome for diffuse axonal injury”. Other than abrasions, he had no abdominal or extremity injuries. He was taken to the trauma ICU and paralyzed and sedated, and then underwent placement of an intracranial pressure (ICP) monitor (“bolt”). He was placed in a pentobarbital coma due to his elevated ICP of 20-30 and rising, and subsequently had a ventriculotomy drain placed. He remained hemodynamically stable, but gradually developed worsening ARDS over the next 10 days requiring increased ventilator support, with particular difficulty correcting his respiratory acidosis, which was making his ICP more difficult to control. He has not been transported for a more recent head CT because of the instability of his ICP. You are called to discuss the possibility of ECMO support to manage his worrisome hypercarbia and hypoxemia to decrease his ICP.