Thomas is a 57yo male with a history of HTN, Bipolar disorder and alcohol abuse who presented to his local hospital with a one-week history of worsening SOB without associated cough or sputum production. His CXR showed bilateral pulmonary infiltrates and he was found to be hypoxemia and have acute kidney injury. His CRP was 1.15, C3 was 188, LDH was 316. ANCA was negative, and Anti GBM was negative. An echo showed normal LV function, no effusion and only mild left atrial enlargement. He was treated with Levaquin for presumed pneumonia without improvement and was started on BiPAP with plans for a VATS lung biopsy. Prior to the procedure he developed worsening hypoxemia and was intubated and transferred to your center for a higher level of care. He arrived sedated with propofol, and supported with epinephrine and neosynephrine for hypotension. In your MICU he was tried on multiple different modes of ventilation without much improvement in his blood gases. At one point he became significantly bradycardic requiring a dose of atropine, and was then paralyzed and sedated with fentanyl and versed drips and his pressors changed to norepinephrine alone. His WBC returned at 37.9. New cultures were sent and he was started on Methylprednisolone 125mg IV q8h and arrangements were made for CT of the Chest and flexible bronchoscopy. However because of more instability during the night and gradually worsening hypoxemia not responding to ventilator maneuvers, you are consulted to evaluate him for VV ECMO.