“Stuff?” Pascal says, in a deeply unhappy tone of voice. 

“Sorry, I’m not trying to be mysterious and ominous on purpose! It’s just - been that kind of night. Um. Around 2 am I went to turn him with Nellie and she noticed something smelled weird. And checked the abdo dressing. And it was. Um. Leaking. So we checked under it and the wound looked really horrifying and Dr Sharma called Dr Sita in so they could get an OR consult.”

“Yeesh? Uh, is that where the ‘necrotizing’ bit comes in?”

"Yeah. I'll get to that. ...Maybe after the team huddle." People are definitely congregating at the nursing station now and they should probably not be antisocial and should go join it. 

A suspicious fraction of the arriving day shift team is huddled specifically near the med room, but they meander over as the clock hits 7:15. 

Team report considers mostly of Chantal giving a two-sentence summary of everyone's patients, particularly focused on upcoming Events like tests, surgeries, or possibilities of discharge. She'll flag the patient's night nurse for a longer rundown if they were admitted during the immediately-previous shift.

The guy in 190 is 34 and apparently has GANGRENE in his SCROTUM, which honestly leaves Marian with more questions than she started out with.

192 is post surgical resection of a bowel tumor and scheduled for a PICC line today, she needs total parenteral nutrition while her bowels heal.

194 is their cardiac guy and he's ON STRICT BED REST, NO ACTUALLY, no matter how nicely he asks to get up to use the commode.

196 was transferred in from Carleton Place for respiratory distress and sepsis. Contact and airborne isolation, continuous dialysis, 1:1. Annie's addition: she's in multi-organ failure, and was just started on systemic antifungals because they suspect her lung infection, skin infection and sepsis are actually being caused by FUNGUS or possibly YEAST. She may need high-frequency ventilation. 

197, trach, doing short trials off the ventilator. Physiotherapy scheduled today, they'd like to get her up and walking. 

198 is "our friend Kelly", apparently meriting introduction on a first-name basis. Insulin drip, Q1h blood sugars, alert and oriented x3, on a clear liquid diet but this does, in fact, include sugar-free Red Bull, she won the argument with Dr Sita yesterday and they're not having it again. 

199 is yesterday's rapid response for pulmonary embolism. She's  v e r y  close to requiring intubation but given  they're holding off with two (2) 100% oxygens, via high-flow nasal cannula with a non-rebreather mask on top, and yes she desats with only one of them. Very anxious, pain control is iffy, needs a lot of reassurance. 

201 is intubated for pneumonia, stable. Contact iso for MRSA+ status, but should actually be coming off droplet iso today, she's been on antibiotics long enough. Minimal vent settings trial planned but she's probably not ready for extubation. 

202! New admit from ER, no ID, extremely cursed, does Marian care to briefly fill the team in. 

Marian would prefer to pass on that, actually Marian is a grown adult and can do this. She takes a deep breath. 

"Came in with an abdominal wound and suspected poisoning, we're not sure with what, it seems to have cholinergic effects and cause massive tissue necrosis. Intubated for respiratory distress and decreased level of consciousness. OR overnight for wound debridement and wound vac placement. He's on continuous IV atropine 18mg/hour yes that's the actual dose. Had a seizure overnight and did a lot of V-tach. Uh, pending - kind of a lot of tests, especially pathology on the wound. I don't think anything else is specifically planned."

It has not so much been a 'making plans for the future' kind of night. 

Adele clears her throat. "Where does the demonic goat come in." 

"The what?" 

CAN THEY NOT TALK ABOUT THE GOAT. Oh no everyone is looking at her. 

"He came in with a preteen girl who doesn't speak English, maybe his daughter. I tried to explain with drawings that we had to take him to the OR. She wanted the pen and paper and drew that and communicated with gestures that it's how he was injured."

Wow. Okay. Apparently she's exhausted and emotionally drained enough that any sense of self-consciousness has gone out the window and she can just. Say all of that out loud. 

Pascal is giving Marian a LOOK indicating that he has AS MANY AS SEVERAL QUESTIONS.

...There's a brief silence and then Chantal is going to wrap up the team huddle. 204 and 206 are normal! 204 is their lung abscess guy, he's stable, intubated, might or might not go for another biopsy today. 206 is their post cooling protocol suicide attempt, being seen by speech therapy today for a swallow evaluation and they should really try to get the man out of bed. That's it! 

And they can go continue their report now? 

Pascal doesn't sit down again. He stands in front of 202, fidgeting with his clipboard. 

"Marian? Is the cursed goat, like, for real?" 

.....Marian puts her head down on the desk. "Pascal, I am too tired to talk about the goat." 

Pascal looks even more unnerved! "What's that supposed to mean! That was really not as reassuring as a 'no'!" 

...Marian drags herself into a sitting position and drags a hand over her face. "Sorry. It means I've been here for sixteen hours and I can't think. Um. Where we were, we'd gotten up to the necrotizing wound and the OR– no, wait, sorry, before that -"

"You're going to explain more about the seizure and V-tach, right? Not just drop that there and leave it?" 

"Yes, I'm getting to it! ...The seizure was before the OR, actually. He'd been on zero sedation the whole time, and he was still definitely very altered but he seemed a bit more responsive and pretty uncomfortable, so I was pushing for some sedation and Dr Sharma wanted to get a baseline neuro assessment first. I don't know if it was in reaction to the painful stimulus or what, but she sternum-rubbed him pretty aggressively and he woke up a bit more, opened his eyes – and then, yeah, bam, seizure. It took like seven mg of midaz to break him out of it, which was rough on his blood pressure, and he really tanked his sats, so he was, uh, kind of unstable already when we went to the OR." 

Pascal looks horrified and upset! "What am I supposed to do for neuro assessments? Does he do that every time?" 

"I have no idea, we've been trying to give him peace and quiet. He's not on much sedation, he might start to wake up again at some point? Try to be aggressive about pain control - you can go up to 150 on the fentanyl - and definitely skip that part of the neuro assessment, they thought in the OR he was having some sort of fucked-up autonomic dysfunction and dropping his BP when they were hurting him." 

Pascal is now looking very stressed and trying to flip back to the front of his paper to make a note in the 'IV drips' box on his worksheet. "I - sorry - can we go in order -?" 

"Yeah, sorry." Marian is for once not managing to actually feel bad about it, because apparently her feelings are mostly offline. It's almost a relief. 

She can give a more-or-less coherent recounting of the OR – started off strong with a 7-minute code after trying to place a central line sent him into V-tach, they eventually got him sort-of-stabilized and decided to tolerate pretty objectively crappy vital signs during the procedure in order to get it over with. They debrided 700g of dead tissue, estimated 1700ml blood loss, he got two units of blood and 3L in fluid boluses. There were more V-tach episodes, one requiring a defib shock but otherwise non-sustained. He came back with a wound vac, instructions are to closely monitor drainage and call Dr Sita immediately if he's losing a lot of blood or especially if the drainage is malodorous and, for lack of a better term, you know, cursed-looking. So far it looks fine! They should check it together at the bedside but, having now caught up on the sequence of events overnight, they can do that after Marian goes through the full head-to-toe assessment, lines and tubes, and medications in order. She's so tired but Pascal and her patient both deserve it. 

Pascal does in fact seem to find this significantly calming after the goat incident! He fills in his sheet. 

Marian is also finding it weirdly reassuring. Maybe because she's been so intensely focused on the things that are wrong with the patient, and - well, spent a lot of the night caught up in the emotional state of not knowing what was going on, not to mention constantly feeling behind and off-balance and like she was caught in a loop of belatedly remembering things she had dropped earlier. 

But there are actually several things that are surprisingly not-wrong with him! His kidney function is fine! His temp is now up to 36.5 C. He hasn't had diarrhea since well before the OR, and the gastric tube is still draining but barely 50ccs between when she marked the line at 6 am and now. She was freaked out about the newly abnormal labs, but they're honestly not very abnormal, and it was a full eight hours after the initial...events...that happened to him. If the poison were causing serious liver toxicity directly, she would have expected something to show up on the first set of labs; in context, this looks more like "his organs, predictably, did not love spending most of an hour with a systolic BP in the 60s." The clotting abnormalities and rising white count could be part of a worrying trend, but they'll see at noon - well, Pascal will see - if the trend actually continues. In the meantime, their patient has tolerable vital signs and they've got to be making progress on his abnormal potassium. Also he has three lovely IVs and a central line, which Pascal looks quite reasonably pleased about. 

Even the things that are abnormal aren't, like, entirely unreassuring, from the right angle? It seems like everything wrong with his lungs and circulatory system is a straight-up direct result of cholinergic toxicity, which means it's likely to be temporary - Marian did have a chance to look it up, and it sounds like organophosphate toxicity can sometimes cause permanent neurological damage (aaaaah!), but that's more likely to be associated with hours of uncontrolled seizures, and there's no particular concern that it causes permanent lung or heart damage. Dr Sharma seemed very concerned about the combination of toxicity and low potassium, and it definitely hasn't been great, but he seems to have made it through the worst of it with only survivable arrhythmias? The OR trip was rough but he survived it, and is doing better now.

Even his neuro status, while definitely worrying, could...be worse...? He was responding to painful stimuli like someone heavily sedated or otherwise out of it (and with muscle weakness, which is an expected temporary effect of the toxicity), not with decerebrate or decorticate posturing that would indicate more severe brain damage. He was sitting there for over an hour with both un-antidoted poison in his system AND untreated catastrophically low blood sugar, and didn't have seizures at that point, it really did seem like later it mostly happened when they caused him a lot of pain while he had zero sedation in his system. Which is bizarre but, like, they can definitely avoid doing that? 

Once Marian has covered everything for Pascal's benefit, and Pascal's sheet is fully populated with his neat square handwriting, they can go in and actually see the patient! And Sashy. Marian definitely wants to make sure that Sashy gets an introduction and has any idea why this new random person is suddenly there instead of her. 

Tsashi had in fact been fast asleep in the recliner, her head buried under the flannel hospital blanket, but she stirs when Marian turns on the sink light, and then drowsily uncovers her face when Marian cautiously taps her shoulder. 

“What is it?” she starts to say, before remembering that no one speaks her language. 

Marian smiles at her. She thinks she manages to make it an actual genuinely reassuring smile, too.

She points at herself, points out the door, and makes walking motions, then mimes putting her head down on her folded hands and closing her eyes. Then she points at Pascal, says, “Pascal,” and makes an expansive gesture at the room.