Timothy is a 53yo with a history of HTN, DM II, previously healthy male involved in a motor vehicle collision in which he sustained fractures and ligamentous injury of C4 and C5 with a spinal cord contusion and spinal epidural hematoma, and some mild respiratory failure. He had significant autonomic dysfunction with bradycardia and vasodilatory shock, which were stabilized with a norepinephrine infusion. Neurologically he was a C4-5 quadriplegic, with some shoulder and a little hand movement. Three days after his injury he underwent surgical stabilization with internal fixation through an anterior approach via a right anterior cervical incision. Following the surgery he developed progressive worsening of his gas exchange and CXR, with concerns for aspiration versus late ARDS from the trauma and resuscitation. He required increasing levels of ventilatory support with sedation and paralysis. He still has a cervical collar in place and could not be safely put in the prone position. The neurosurgical team estimates that with his injury and last physical exam, he has about a 20% chance of recovering full spinal cord function, assuming the epidural hematoma does not enlarge. By POD#4, his gas exchange has still not improved with attempts at diuresis, and he has started requiring additional pressors. At this point he is fairly warm and well perfused, but has developed moderate anasarca. The neuro-intensive care team calls you requesting consideration for VV ECMO support.