R.H. was discharged to the main entrance in a wheelchair, like many other patients, on many other days. He was briefly hospitalized on this particular visit, but was a well-known patient to the HVI team because of his LVAD. He was to meet his wife at the main entrance- she was bringing the car around. Upon arrival to the car, R.H. was assisted into the front seat, but it quickly became evident something was not right- that R.H. had become unresponsive. The transporter grabbed a door aide who called a code. This quick action at nearly 6 pm at night brought all the resources necessary to the main entrance to attempt to save this man's life. Two men (unidentified- bystanders?) quickly assisted in getting R.H. from the ground to the sidewalk. House managers, NRCs, ED responders, and physicians - all arrive and spring into action. Compressions are started immediately, right there on the sidewalk- on their knees, in freezing temperatures. The VAD was constant with alarms- low flows as one would expect- but this creates a distinct tone that seems to innately focus the participants on the task at hand. The code cart arrives. The NRCs each placed a 10. Medications given are quickly given. The Zoll monitor is placed. R.H. is intubated right there on the sidewalk by anesthesia providers. Documentation is started by other MDs on their phones. Everyone is working in concert. The patient is moved as soon as possible onto a backboard, and transferred to an ED litter. They start moving in the direction of the ED. HVI Charge Jasmine becomes instrumental as the conversation pivots to the overwhelmingly high census and multi­ traumas that are simultaneously occurring in the ED. With rapid consensus and support of the HM, R.H. is moved directly to HVI. Although unorthodox, it was where, at this exact moment, he could receive the care he needed for the best chance at survival. Upon arrival to HVI, more participants arrived and continued with resuscitation, including further evaluation of the LVAD. MDs used a TEE probe to assess heart function during the resuscitation which unfortunately revealed very little remaining function.

ECMO was not an option. Resuscitation continues for 1hr and 10 minutes with all involved giving their very best. Tragically, R.H. did not survive.

Despite the unfortunate outcome, the great lengths and extraordinary circumstances under which this team performed was inspiring. Teamwork was clearly evident, especially given the rare initial location, recognizing that each second counts. It highlights the importance of just how many people were involved in this patient's specialized care up to this day, and what each person contributed to collectively provide resuscitation and ultimately supportive efforts on his final day. The team saw no barriers, only options, and acted expertly and swiftly without losing sight of his humanity. They heroically made decisions that were difficult from the first minute to the seventieth minute but made them with the best intent and highest integrity. R.H.'s wife was also cared for. She was involved in the decisions and supported during this emotionally unexpected and extremely difficult situation. After this event, R.H.'s wife wrote a letter to Dakota, R.H.'s discharging nurse. She wrote, "For a brief moment, you came into R.H.'s and my life. We were truly blessed." Dakota and this entire team had a meaningful impact on this patient and his wife. They should be recognized for embodying what we are all here to do. Many cases can be unique, but these people made it special.