A 46-year-old male with a past medical history of hypertension, type 2 diabetes, gout, gastroesophageal reflux disease (GERD), morbid obesity, obesity hypoventilation syndrome, and hepatic steatosis presented to the emergency department (ED) with altered mental status, generalized weakness, severe heartburn, chest tightness, and nausea. Physical exam was significant for agonal breathing; Glasgow coma scale was 3. Patient was immediately intubated and placed on mechanical ventilation for airway protection. Initial vitals showed tachycardia, tachypnea, low blood pressure, and low-grade fever. Labs revealed leukocytosis, elevated blood glucose, hyponatremia, hypocalcemia, low CO2, elevated creatinine, positive acetone, lactic acidosis, high lipase level, and elevated triglycerides (see Table 1). Severe metabolic acidosis was seen on arterial blood gas (ABG; see Table 1). Urinalysis showed leukocyte esterase, nitrite, ketones, and hyaline casts. Bibasilar infiltrates and atelectasis were seen on chest x ray. Computed tomography (CT) abdomen and pelvis revealed fatty changes of the liver. Computed tomography head was unremarkable. Electrocardiogram (EKG) showed sinus tachycardia and prolonged PR interval. Patient was diagnosed with severe DKA, high anion gap metabolic acidosis (HAGMA), acute pancreatitis secondary to hypertriglyceridemia, acute kidney injury (AKI), and septic shock secondary to urinary tract infection (UTI). He was started on DKA protocol, intravenous (IV) fluids, bicarb drip, pressors, and broad-spectrum antibiotics. Hemodialysis was initiated for severe acidosis and anuria. Despite some improvement (Figures 1 and 2), neurological status remained the same and patient could not be extubated. He was transferred to "in network" hospital for further care.