Patient received 2nd dose of COVID vaccine on 3/20/21, then tested positive for COVID on 8/12/21 & 8/19/21  Hospitalization Admit Date/Time: 8/19/2021  9:06 AM Discharge Date: 8/30/2021 Referring provider name and address:  No referring provider defined for this encounter.   Chief Concern, Brief History of Present Illness, and Hospital Course Patient is a 64 yo M with thalassemia and mechanical AV on warfarin who is presenting due to fatigue, cough, fever, and low oxygen saturation.  On 8/10, pt started with mild symptoms of cough and fatigue that was generally manageable at home. He tested + for COVID on 8/12. On 8/14, started having fever (Tmax 102-103F) managed supportively. On 8/19, the pt was noted to be in the 80s in his pulse oximeter. He denied having shortness of breath but with a worsened cough. Hypoxia prompted presentation to the ED.    Of note, pt is a generally healthy man except for a history of congenital AV disease warranting Ross procedure in 1998 and a mechanical AV replacement in 2018. He exercises regularly. Vaccinated with Pfizer 2/2021.  The patient had been managed on the medicine team with progressively worsening chest x-rays and hypoxia requiring HFNC at settings high enough to require ICU care.   Our service was consulted to evaluate the patient for ICU admission.    On exam, he is calm, conversant and ATO x 3.  ABG demonstrates profound hypoxia with a pO2 of 51 with a recheck of 53.  He is hemodynamically stable.  The remainder of his labs are relatively normal.  We discussed these findings and his wishes to proceed with intubation, be FULL CODE and consents to tracheostomy if this is required.  His wife was called with the above discussion as well and the patient conversed with her at length before intubation.         AHRF/ARDS d/t COVID-19 requiring MV c/b Air Leak - pt was vaccinated man with Pfizer vaccine 2/21 - Treated with Dexamethasone 08/19- 08/29 for total of 10 days, with PPI prophylaxis Completed remdisavir (08/19 - 23) - admitted to MICU on day 11 of hospitalization, pO2 53 prior to intubation, PF ration prior to intubation 51 with severe ARDS - received Vanc/Cef for HAP coverage started 8/28 - Dex ARDS for 3d - Diuresed for pulmonary toilet   Transaminitis - improving at time of death - likely d/t severe acute viral illness vs remdesivir   CHD w/ Mech AVR on AC (warfarin at home) - received heparin gtt while in MICU   Chronic Microcytic Anemia d/t Thalassemia  - monitored Hb  At approximately 5:30 p.m. on 08/30/2021 code blue was called on patient, high-quality compressions were initiated, nursing had reported that prior to cardiac arrest the patient developed tachyarrhythmia followed by precipitous drop in blood pressure followed by hypoxia, rhythm was consistently asystole, patient patient received approximately 17-18 rounds of compressions, doses of epinephrine every 3-5 minutes, bilateral chest tubes were placed due to concern for tension pneumothorax as patient had pre-existing pneumomediastinum with diffuse subcutaneous emphysema, hypoxia improved mildly after chest tubes were placed but return of spontaneous circulation was not achieved, patient also received multiple rounds bicarbonate, calcium, insulin and dextrose during the code, resuscitation was attempted for a total of 35 minutes when out of medical futility with overall poor neurologic prognosis the code was stopped, family had just arrived at the time of stopping resuscitation, patient's family was informed and they voiced understanding of what had happened and the patient had expired, family thank team for excellent care despite outcome, time of death 1805