I work in the pediatric ED of a level 1 trauma center - case that stands out the most to me from my three years in this ED was a 9 month old male, history of repaired Tetralogy of Fallot, came in via car to the triage desk for difficulty breathing. The triage RN made him a level 1 and rushed him to one of us our resuscitation rooms because he was satting in the 80s and had a respiratory rate in the 70s. At that time, his heart rate was only slightly elevated. However, six minutes into his stay, he crashed and went asystolic and apneic. I was doing compressions, we had PICU and cardiology attendings down there at this point all yelling for various meds and protocols, the mother was laying on the floor in the doorway screaming her son's name over and over, when one of our cardiology docs screamed out the door that he wanted ECMO. We have never, in the 5 years we've had a dedicated pediatric ED, initiated ECMO in the ED and never while CPR was being performed but the ECMO team came and ECMO was started right there in the room. I was still compressing during the procedure. They then took him up to the PICU. Four months later, the same cardiologist came down for another infant code and afterwards was talking with me and said off-handedly how the ECMO baby (that's how we all referred to him after that) had not only survived after 45 minutes of CPR in the ED before ECMO was running, he was actually off ECMO and seemed to be doing fine - it turned out, one of his heart grafts had failed and lead to his crash. He had another heart surgery, but he was alive, seemed cognitively appropriate for his age, and was going to be (probably) alright. I will never forget the absolute terror I felt doing compressions on his tiny lifeless body as they sutured the tubes into his carotid and jugular, but it's worth it to me now knowing he made it.