Some patients present with profound life-threatening hypoxemia or severe shock with no history of known pre-existing conditions and no diagnosis. In the absence of an obvious contraindication like some end-stage disease, advanced malignancy or far advanced age, one can make an ethical argument that we have an ethical obligation to provide ECMO support for “bridge to decision”.

Thomas was taken to the OR for fluoroscopic guided placement of a 31Fr DL cannula for VV ECMO, and support was initiated. He then had a flexible bronchoscopy which showed minimal mucosal edema, no inflammation and no secretions. Bilateral BAL for cultures were obtained. He then had a right anterolateral mini-thoracotomy. There was no pleural fluid, and the parietal pleura appeared normal. There was some visceral pleural inflammation and neovascularization on the surface of the right lower lobe. A biopsy was obtained with a stapler device from clearly abnormal lung.

The lung biopsy had findings consistent with the proliferative phase of acute lung injury, and changes consistent with organizing pneumonia, with negative stains for AFB, GMS and Gram stain to ID microorganisms. There was no viral cytopathic effect noted. However, the BAL cultures later grew MRSA and treatment was adjusted appropriately. His kidney issues progressed and he was placed on CVVHD, although he continued to make some urine. He did require a re-exploration of the right chest for some collected blood, but otherwise progressed nicely. He was decannulated on ECMO Day #6, and successfully extubated 5 days later. He was transferred to Rehab for a couple of weeks before heading home.