Like a handful of these consults, this one is extremely complex and ridded with risks, and no one would fault you if you turned the patient down. A frank discussion with Timothy’s family was undertaken and we elected to offer him support. He had a recent right neck incision and deep dissection for the anterior repair of his spine, so that was ruled out for access. Although there have been some successful reports using DL cannulas in the left IJ and left subclavian, we did not want a large cannula in his SVC because of theoretical partial obstruction and high venous pressures in his neck, and perhaps on his cord. We elected to use a 25 Fr drainage cannula in the right femoral vein, and a 21 French arterial cannula placed into the left subclavian vein (see CXR below). Prior to cannulation, a baseline TEG with LY-30 had been obtained, and then he received a bolus of heparin, a bolus of Amicar, and then was started on infusions of both. He had an immediate bronchoscopy once on support, which showed severe mucosal edema, with some thickened secretions, but no frank purulence,. BAL cultures were obtained. The TEG with LY-30 was followed to monitor for fibrinolysis, and the Amicar adjusted accordingly. With rest settings and aggressive diuresis his lungs cleared over several days, and his compliance improved greatly with a bolus of steroids, so he was continued on a full course. He woke up and was appropriate once the sedation was stopped. After neurosurgery was satisfied with the cervical wound healing, he underwent a tracheostomy. He was weaned and decannulated after 10 days of ECMO. A follow-up MRI showed no expansion of the cervical spinal epidural hematoma. After 2 weeks he was weaned off the ventilator to trach collar, and later transferred to a long term care facility. Unfortunately, he had only minimal neurologic improvement, and expired about 18 months later of septic complications of his paralysis.