Patient  seen and evaluated by PA-C. with myself.  We agreed on the clinical findings and implemented our plan together.  Please see PA's note for details.  All relevant procedures supervised. Patient arrived to the emergency department due to respiratory symptoms, hypoxic, reported that Wednesday he received his 2nd dose of COVID vaccine.  His initial workup was concern for NSTEMI with elevated troponin and peaked T-waves,  his chest x-ray concerning for COVID/pneumonia.  Patient initially tolerated oxygen by nasal cannula and sepsis protocol was started including IV fluid resuscitation that was done cautiously due to the concern of COVID with respiratory failure.  The biotics were given.  PA-C readdressed code status with patient who confirmed that his DNR DNI, she so contacted his daughter.   Patient had multiorgan failure including acute kidney injury, and pneumonia with respiratory failure +/- respiratory failure.  Due to the concern of NSTEMI patient was initially going to be transfer to was hospital and transfer was started.  Patient respiratory status started deteriorating and his blood pressure dropped slightly but improved after 500 cubic centimeters of IV fluid and he was also placed on a NIPPV. Around 6:00 p.m. patient has significantly desaturation and he discontinued himself NIPPV.   Due to inability to intubate patient, he was ventilated with BVM, patient is slowly improved saturation levels and was opening his eyes, he was placed on a non-rebreather.  At this point there is high concern of ARDS and due to inability to intubate or give for the respiratory support His daughter was at bedside and updated of current medical status and poor prognosis.  Patient continued deteriorating and at this point he had agonal breathing.   His daughter was at bedside and she was made aware of the futile prognosis of patient due to his respiratory failure.   Patient rapidly became bradycardic and went into cardiac arrest.   No CPR was done due to the DNI DNR status of the patient.    Critical Care Procedure Note Authorized and Performed by: MD  Total critical care time: Approximately 30 minutes Due to a high probability of clinically significant, life threatening deterioration, the patient required my highest level of preparedness to intervene emergently and I personally spent this critical care time directly and personally managing the patient. This critical care time included obtaining a history; examining the patient; pulse oximetry; ordering and review of studies; arranging urgent treatment with development of a management plan; evaluation of patient's response to treatment; frequent reassessment; and, discussions with other providers. This critical care time was performed to assess and manage the high probability of imminent, life-threatening deterioration that could result in multi-organ failure. It was exclusive of separately billable procedures and treating other patients and teaching time. Please see MDM section and the rest of the note for further information on patient assessment and treatment.   PE:   VITAL SIGNS:   BP: 126/75   Pulse: (!) 122   Resp: (!) 40   SpO2: (!) 82 %   Temp: 98.1 °F (36.7 °C)   Height: 5' 8" (172.7 cm)   Weight: 152 lb (68.9 kg) General:  Alert, nontoxic, in no acute distress. Lungs:  Clear to auscultation bilaterally.   CLINICAL IMPRESSION:  1. Sepsis with acute hypoxic respiratory failure and septic shock, due to unspecified organism (HCC)  2. Suspected COVID-19 virus infection  3. NSTEMI (non-ST elevated myocardial infarction) (HCC)  4. Multifocal pneumonia  5. ARDS (adult respiratory distress syndrome) (HCC)  6. Acute kidney injury (HCC)      Further care and disposition otherwise as outlined by PA.             ED on 2/14/2021   Revision & Routing History   Detailed Report  Note filed date Mon Feb 15, 2021  8:46 AM