We propose that POCUS guided assessments of pulmonary arterial pressures via tricuspid regurgitation jet velocities can serve as a real-time hemodynamic tool to direct serial exchange transfusions thereby preventing right heart failure and mortality in severe acute chest syndrome.<h4>Case presentation</h4>A 20-year-old male patient with HbSS (baseline HbS 28.7%, on hydroxyurea) presented with shortness of breath, severe hip/back pain and acute hemolysis (Hb 8.3 g/dL, bilirubin 7.4 mg/dL, LDH 484 U/L). The gene discussed is GSTM1; the disease is acute chest syndrome.