This week's case is a 67-year old woman who presented for an outpatient EGD. Post-procedurally she became hypoxic, so was brought to the ICU for monitoring and NIPPV. She was initially hemodynamically stable; however, over the next 6 hours she became profoundly hypotensive requiring very high doses of multiple vasoactive agents. She had a PMHx significant for severe COPD and HFpEF, with an Echo from earlier this year showing an EF of 50%. Below are her the clips taken upon arrival of the POCUS team the next morning. What do you think is causing her shock based on these images? You might want to make yourself comfortable, cause this week's case is a doozy and has a lot to unpack. *Note: given her marked hyperinflation she had no obtainable traditional parasternal or apical windows, so all views were obtained from a modified subxiphoid position (hence the unconventional axis). These scans are a good lesson, however, that you can still get lots of important information even when your views aren't perfect!