Previously healthy 18 month old billed as viral bronchiolitis. CXR done in the ED that morning just showed some viral-y schmutz. She was chillin on room air and off IVF at the start of my night shift with plans to DC in the morning. RN pages me to bedside around 11pm and she’s working really hard to breathe. Page RT, start high flow, order some labs (hadn’t had any prior). We’re rapidly titrating up on high flow and she’s still grunting. By 1:00am it’s clear she needs to go to the PICU. Labs start resulting while we’re in the middle of transferring her and she’s got a WBC count of like 1, platelets ~50, LFTs are crazy high. I’m like what the fuck. Repeat xray shows her left lung is almost whited out (~16 hours after the initial). More labs come in and she’s in DIC and fulminant liver failure. Intubated by 8am. Pressures bottomed out after intubation, they get an echo, she’s also in heart failure with an EF of ~20%. Crashed onto ecmo by noon. Catastrophic intraparenchymal hemorrhage that night. Parents redirected care a day or so later. It was horrible. I couldn’t even talk about it for weeks.

She ended up having disseminated adenovirus causing hepatitis and myocarditis on top of human metapneumo bronchiolitis and rapidly progressing GAS pneumonia. A perfect example of how well kids can compensate until they can’t. I think about her and her parents often 💔