Tsashi has a knife and she's competent at fighting with it, but she also isn't stupid. The goat things are bigger than she is. She's pretty sure Lionstar is going to get hurt, and she can't shield him so really the best she can do here is not have both of them be hurt. 

(She knows they might both be about to die. That's kind of the risk you take when you go out to investigate Problems. It's just that if nobody does that then it's not like the Problems go away, eventually they come find you at home. 

Besides, Lionstar has been about to die a lot of times and he's not dead yet.) 

This time might be different, though, since Lionstar is finding out the hard way that the horns are unnaturally magically as well as physically sharp, and with the power he's putting into the shield over Tsashi, plus the levinbolts he's flinging, he wasn't reinforcing his own personal shields enough to hold off a magically-boosted attack. He manages to deflect the horn-thrust enough that it doesn't gore him right through, but it still leaves a deep gouge across his lower ribs and stomach. 

There's pain, briefly, and then numbness. There's a lot of blood. The Changegoatthings seem to be able to smell it; they're even more frenzied now. He flings three of them back with burst of barely-shaped force - not a good tactical move, the thought comes to him slow and glassy a second too late, it's a waste of mage-energies he could have harnessed more efficiently if he had time to think - 

That's a lot of blood! Tsashi is alarmed and scared. 

- and she thinks can guess what Lionstar is thinking. Or what he would be thinking if he weren't distracted, maybe, because he seems kind of distracted and off-balance, which is almost scarier than the blood. But - 

(there's a way her thoughts go when the world is moving very fast, and there isn't time to think in the words you would use to tell someone else what you thought you ought to do, just - everything broken into simple pieces, like the wooden puzzle Lionstar made for her when she was very small. She thinks Lionstar taught her how to think like this, too, even though she was never able to explain it to the other children. Maybe because it's necessarily something you can't say in words -) 

Lionstar would have been thinking that it was better to fight than try to Gate, because a lot of small spells are less likely to go very badly than one big spell, and Gates can go wrong in worse ways than exploding (not that exploding is even that much of a problem when it would be convenient if the Changecreatures got exploded.) But that calculation was when he wasn't injured, and could expect to keep fighting until he ran out of reserves, which might be long enough to disable all the creatures enough for them to run away. 

She doesn't think he has very long now. He's losing blood and the horns look like they're poisonous. 

Which doesn't make Gating a better idea; it makes it a worse idea, really, because now he's distracted. But it makes staying and fighting a worse idea by a way bigger amount - it makes staying and fighting doomed - and so it's not very complicated, actually.

(Just bad. The world is allowed to be just bad. Tsashi always thinks that phrase in Lionstar's tired voice.) 

"GATE!" she screams at him. She doesn't have Mindspeech, and probably the goat-things didn't get smarter when they got more magical and it won't give away what they're doing. 

Lionstar had just been reaching the same conclusion; his thoughts are slow and muddy, but he can do this on instinct. 

He can't spare the energy to throw the Changecreatures back again, which wouldn't even buy them more than a second or two. The shield will just have to cover both of them for long enough. Lionstar is very fast at Gates when he's not exhausted bleeding and very dizzy. 

- the threads of magic twist, he tries to wrestle them straight but he's so tired - he's really not sure where this Gate is going to land but, well, nearly all places are going to be better than here - 

The Gate is....opaque? Gates are not normally opaque! That's a really concerning Gate!

The Changegoats are more concerning, though, so Tsashi shoves Lionstar through and dives after him. 

The Gate goes down behind them in a shower of disintegrating mage-energies.

The other side of the Gate is very very cold. It's...snowing? It's also windy. And dark, but it's a weird sort of orangey dark. There are strange noises that don't really sound like storm-noises. 

This is very baffling, but 'somewhere in the far north' seems like a better place to be than where they were a few seconds ago, so that's something. 

Tsashi is worried about Lionstar. He's unconscious in a heap in the snow, and still bleeding, and she doesn't have anything to help keep him warm or use as bandages (unless she takes off her shirt, which the mental voice of Lionstar is snapping at her is a terrible idea in a snowstorm.)

She thinks quickly, in simple pieces. If there are people around, the people might not be friendly. But the people almost certainly already know that someone is here, Gates aren't subtle. If they're not friendly, hiding isn't a good solution. If there's going to be a fight then it's probably going to go badly either way, but less badly if it's sooner, because Tsashi is going to get cold very fast, but probably people who live here have warmer clothes. And - one reason they might not be running to help even if they are friendly, is if they don't know whether Tsashi and Lionstar are here to fight them, and they're scared and might be less scared if they know Lionstar is hurt. 

She starts yelling for help.

(It's not until a little while later that it occurs to her that people very far north might speak a different language. She doesn't usually have much reason to think about people speaking different languages far away, but she does know that they do, she knows Lionstar had to learn when he came here.) 

The Montfort Hospital is having a bad day. The ICU in particular has been having a truly spectacularly terrible entire week. 

Marian is about six and a half hours into the worst kind of 16h shift; she was on the schedule for an eight-hour evening, 15:30 until 23:30, and in a moment of adrenaline-comedown-addled letting her guard down, was talked into tacking on the rest of the overnight until 07:30, at which point she'll have exactly eight hours - probably less, given charting overruns - until she has to be back for the next evening. 

It's just after 10 pm. The unit is briefly quiet, for the sole and incredibly depressing reason that 188, 196, and 202 all managed to die since the last shift change, the latter two in the last hour. 202 was Marian's and wasn't particularly a surprise - they made her DNR on Wednesday and she was spiralling for a couple of days now - but does mean that Marian now has an opening, or will as soon as the stat room clean actually happens. It would have been polite of her to hang on until 4 am or so, at which point Marian could probably have gotten through the rest of the shift without taking an admission.

She's sitting in front of the desk, charting on 201 and somewhat-guiltily savoring the lack of constant dialysis filter alarms from 188. That one was a nasty code. Marian had just been starting to get over her mild trauma about coding patients attached to dialysis machines. 

Something start beeping. The other staff nearby are apparently just as fried as Marian, since it takes a good ten seconds for anyone to click that it's the code blue pager, currently abandoned by Sylvie and in search of a good home on the central nursing station desk. 

Nellie scrambles up and almost kicks over a chair. "Jesus! I swear to God, I'm losing my mind -" 

"I can take it, I'm not busy." Wait why did she just say that. "Where -" 

The intercom beats her to it. Code bleu, l'Urgence...

...Well, Nellie is more behind than Marian, for once, and it would be embarrassing to change her mind now. Besides, Marian is already having a sufficiently bad day that "social anxiety about which doctor is on tonight" isn't really computing. Reasonable odds it's a false alarm, anyway, though lower given it's the ER, they don't tend to panic and call outright false alarms like 5th floor med/surg sometimes does. 

She heads off at a trot. Unhappily. 

The ER trauma bay contains:

In bed 1, a tiny elderly woman with a full face of makeup and a puff of white hair like a dandelion gone to seed, sitting up against the raised head of the gurney, apparently completely undisturbed by the heart monitor reading a slow irregular atrial flutter averaging to around 30 bpm with frequent longer conduction pauses. (Her last blood pressure is at 136/92. She must have arteries like copper pipes.) She’s watching the bed next door with curiosity and looking mildly perturbed, as though spectating an unexpectedly violent hockey match.

In bed 2: the curtains are wide open, giving bed 1 an excellent view of the drama, and probably a dozen ER staff are crowded around. The patient appears to be a man of indeterminate age; Marian can't see that much of him, there's an ambulance blanket flung haphazardly over the lower half of his body, but she glimpses deeply-tanned bronze skin and a shock of black hair. The monitor is a mess of CPR artifact. 

"Back off!" the ER attending snaps a moment later, "I think we've–" The monitor switches to...some kind of rhythm. Widened, distorted complexes, almost swoopy, but surprisingly regular; it's only a few seconds before the monitor decides on a heart rate of 37. "Do we have a -" 

    "I'm getting a femoral pulse," one of the nurses is saying. "Uh. Ish." 

"Great. Please tell me we have access -"

    "I'm working on it!" 

"I've got the epi ready to go -" 

    "Get a bolus under pressure ready - is the bleeding controlled - more pressure than that, please -" 

On the one hand, this looks more interesting than the average ER code. On the other hand, there are way too many people here already and Marian is perhaps slightly tempted to back away quietly rather than attempting to find something useful to do with herself. 

There's also a...kid? Gender somewhat indeterminate under all the dirt, but probably a girl? She's also wearing a ambulance blanket, wrapped tightly around her shoulders, and she's standing back and watching the proceedings with an alert, wary, but surprisingly controlled expression. She looks about twelve. 

(The place is very strange! Tsashi thought at first that it was somehow daylight inside the building, despite being dark outside, and that maybe they had gone through a very weird sort of Gate? She doesn't think so, though, later on they passed a window and the outside was still dark. There are so many incomprehensible objects. Maybe that's what magic artifacts are like? She's never seen a magical artifact, they don't work anymore, but Lionstar told her that they used to exist and someday he'll be able to make them again. Maybe if you go far enough north, far far away from the storms, then magic works again? Or...maybe they went to the future, somehow, only she thinks Gates probably can't do that even with storm-magic messing with them. 

She's very worried about Lionstar, but panicking won't help. She thinks the people are trying to help him, though it's not entirely obvious. If she decides they're actually hurting him, well, she did manage to hide her knife, and all the people are adults and much bigger than her but she would have the element of surprise.) 

No one else seems to be paying attention to the kid. Probably someone should be, like, reassuring her, or trying to explain what's going on? ...Which sounds much more agonizing than attempting to place an IV in a crashing patient, but. Marian is a grown adult and capable of doing things. 

She sidles over and makes eye contact with the kid. "Hi. Are you okay?" 

That earns her a hard-to-read but plausibly grateful look, and a sentence - probably a sentence? - in a language that Marian doesn't even slightly recognize. 

AWKWARD. She'll try in French anyway, but without much hope of communication resulting.

(The girl does not seem to understand French any more than English.) 

She tries to smile reassuringly, which doesn't depend on a shared language but, unfortunately, does depend on being able to do reassuring facial expressions on purpose, which Marian doesn't feel very on top of right now. 

"No idea what language she speaks," someone says in a low voice next to Marian's ear– oh, that's one of the paramedics. "Any chance you can take a report and let us get out of here?" 

Weeeeeell, that does sort of commit her to staying here until she can manage to convey her report to someone else. On the other hand, she's genuinely pretty curious. "Uh, yeah, I can." 

"It'll be quick, we haven't got much. Truck driver called it in, found them on the shoulder out on Innes Road - the industrial park area, nowhere near anything residential. No ID on him and we couldn't get any personal details off the kid, poor girl. She's a smart cookie, though - she was directing the trucker to stop the bleeding even before we got there. Tried to mime an explanation of what happened to him, which was pretty hard to follow but we think she saw someone attack him, which checks out, he's got a nasty laceration all across his trunk. Lots of blood and he'll need stitches for sure, but it's actually pretty shallow, nothing perforating the abdominal wall. Drugs might be involved, too, she seemed to be acting out him getting woozy and collapsing, and he was pretty out of it when we arrived. Initial vitals were tolerable and he was protecting his airway. No sign of a head injury, pupils reactive, but he deteriorated fast during the ride over. GCS dropped from 6 to 3, started tanking his BP, desatting and decreasing respiratory effort - I placed an oral airway and was bagging him, but didn't have a great airway and couldn't get IV access - we were like a minute away by then so we just booked it. We lost his pulse around when we were transferring him off our stretcher. Really great timing, that. Probably a hypoxic PEA arrest, he came back pretty quick once they got him intubated - or, well," vague hand gesture at the monitor, which is now displaying the same weird wide-complex rhythm at 41 bpm and a blood pressure of 37/19 with a question mark. "Questions?" 

The kid is watching both of them with a very intent focused expression, brow slightly furrowed, as though she might be able to extract some meaning from the words by staring a hole in the paramedic's skull. 

(Lionstar would be able to solve the different-language problem with Thoughsensing. It's really frustrating that Tsashi is left with trying to see if she can get anything off their expressions and gestures, which she mostly can't. The new woman seems worried and stressed, and Tsashi is fairly sure that she's worried in a wants-to-help-Lionstar way, but that's all she can guess.) 

It miiiiiiiight have been a good idea to bring pen and paper with her. Marian feels discombobulated.

She tries to make a mental checklist. Side of the road, laceration, maybe drugs, semi-stable at first but his condition deteriorated fast - but probably not from massive blood loss, it sounds like it happened after they had the bleeding mostly controlled - 

"Temperature?" It's really the obvious question to ask, for a suspected drug overdose found collapsed in a snowbank.

Shrug. "He's almost certainly hypothermic. Couldn't get an axillary reading with our machine." 

Which would make perfect sense. And gives Marian something useful to do, even, since mid-February is peak seasons for hypothermic drug OD patients showing up in the ER, which means she's pretty sure she remembers exactly where the low-temp thermometer is from the last two times this came up.

She smiles tightly at the paramedic. "Thanks. If you don't have ID on him, I, uh, guess that's probably everything we need from you?" 

     (A grateful paramedic starts packing up.) 

Okay. Focus. She's going to...smile reassuringly at the poor kid, who's probably having the most traumatic night of her life so far, and then head for the nursing station to look in the charge nurse's secret drawer. 

The kid glances at Lionstar, frowns thoughtfully at the people around him, and then shrugs and trots after Marian, looking everywhere at her surroundings. 

...Um. Okay then. Marian has apparently acquired a duckling??? She's not, uh, going to object to the scared traumatized kid following her, even if she feels kind of weird about it. 

She finds the low-temperature thermometer without difficulty and quick-marches back toward the trauma bay. 

The crowd of people around the patient is now down to only eight or so. Someone seems to have succeeded at getting an IV, and there's a 1L bolus hanging in a pressure bag. The rhythm on the monitor still looks bizarre, with wide ventricular complexes and no sign of P waves, but the rate is up to 49 bpm. The SpO2 reading on the monitor is showing a bumpy line that isn't particularly a waveform, and reading 62% with a question mark. The blood pressure cuff is cycling again. 

The attending doctor has the ultrasound machine, and seems to be attempting a quick bedside echo. 

A few seconds later, the blood pressure reading appears, this time settling with more confidence at 62/44. The nurse standing by the patient's head makes a face and whacks the monitor to cycle it again. 

That looks like probably they gave him epi and it's doing something and not doing nearly as much as you would hope. Hopefully it was like thirty seconds ago and is still kicking in? 

And the guy's cardiac conduction seems pretty fucked. Are there street drugs that do that? Cocaine and stuff can cause rapid arrhythmias but this looks like something different. 

There's a window of space beside the patient's head on the other side of the gurney. Rather than interrupting anyone out loud, Marian is just going to quietly sidle in and try to get an oral temperature. 

The low-temperature thermometer tends to take nearly a minute to pop up a reading. There's a new blood pressure, now up to 67/49, well before Marian gets a reading. The patient's heart rate is actually dropping again, now at 46. The SpO2 reading is still extremely dubious, and still in the 60s. 

Ughhhhhhh. Marian would usually assume the low reading was just fake, given that it's clearly not picking up on a pulse waveform, but this guy looks awful and she's not, actually, feeling very confident that just because he's intubated and the RT is bagging him with 100% oxygen means he's getting enough air. 

She has two spare NICU sat probes in her pocket, which work fine on adult earlobes and have better luck than the finger probes for patients in severe shock. It's been that kind of week in the ICU. She can prop the thermometer in place with her forearm and try to fiddle one of them onto the patient while she waits for the temperature reading. 

"Let's try 1 mg atropine," the attending doctor says absently, focused on the ultrasound screen. "See if that gets a better response than the epi. We noted pinpoint pupils, right – did he get Narcan in the ambulance...?" 

No one else is answering?? Oh right that's probably because Marian is the one who actually talked to the paramedic. She clears her throat. "They didn't mention it in the report."

"Right. Let's try that, then." To the respiratory therapist, "- you mentioned a lot of airway resistance, do we figure he aspirated?" 

     "...Maybe. Heavy secretions on suctioning, but it looked clear. I'll have another go -" 

"Atropine 1mg, going in now -" 

The thermometer finally settles on a reading of 33.1 C. Low but not disastrously so. 

Unsurprisingly, the sat probe does have an easier time of things on the patient's ear than on his finger. It's picking up on a straggly waveform matching the ECG heart rate. A few seconds after that, it settles on a reading of 79%. 

The respiratory therapist notices the new reading and nods in acknowledgement to Marian, then catches the doctor's eye and makes an unhappy shrugging motion without using her hands, both of which are occupied. "He's pretty hard to bag. Copious secretions, but still clear. Watery. He's hard to suction too. Honestly, it feels like bronchospasm, not so much aspiration." 

     Frowning. "Huh. Well, the epi should start to help, and the atropine might once it hits him. - let's get a stat chest X-ray, we'll need that anyway for tube placement. And might as well try some albuterol nebs when you have a chance." 

Probably a normal sane person would be more upset about the patient's abnormal vital signs than the saliva disaster. It's just that the saliva disaster is pretty salient to Marian, who had to interact with the patient's mouth to get a temperature. It's really not the top priority, right now, it's just that it's still bothering her. 

...The guy doesn't have much of a cough or gag reflex, she thinks vaguely, he barely twitched when he was being suctioned. She knows what the RT means about patients with bronchospasm being hard to suction, they've had two young people with asthma exacerbations in the ICU since Christmas, but usually they cough like crazy. 

The guy is pretty sweaty, too, which is a thing for patients in shock but it really can't be helping with his low body temperature. ...Which isn't on the monitor, right. She should probably...say something...about it. 

Marian clears her throat. "Uh, he's hypothermic. 33 C." 

"Mmm." The doctor does not sound like he really considers this his top priority. "Warming blanket, I guess. And the next bolus should probably be warmed." 

"I can get that." Marian peers at the pressure bag. It looks like the first liter of fluids are mostly in, but she can't actually see the label on the bag. "Uh, normal saline or Ringer's?" 

Shrug. "Saline's fine." To one of the other nurses, "tox screen's sent? Someone make sure it's not sitting at the nursing station, please, I want to know what the hell this man took. And let's get a blood gas, please. On the iSTAT, I'd rather not wait to know if he needs bicarb -" 

All of which is interesting and none of which is Marian's job right now. She doesn't really want to put the low-temp thermometer back without, uh, cleaning it, and they'll probably need it again anyway; she'll stick it on the least bedside table, all three seem to be nearby. And then head for the utility room to see if the ER actually has one of the Bair Hugger machines in stock right now or if she'll have to trek back to the ICU for it. 

She glances back to smile at the kid, who seemed like she might find it less upsetting and traumatic to follow Marian around like a duckling rather than standing there staring at her...father? uncle? they don't look incredibly alike, she isn't sure...who currently looks like he's several minutes away from dying. At least to Marian. She's not sure how obvious things like that are to smart but presumably not-medically-trained twelve-year-olds. 

...Yeah, she'll follow and try to learn more about where they are. It seems important and more useful than hovering while foreign Healers do things. Lionstar would want to be oriented if he wasn't so badly hurt. He's obviously in bad shape right now, but he's very very tough and the foreign Healers clearly have all sorts of advanced magic and Tsashi is actually less scared for him than she was before. And maybe they aren't friendly - Lionstar would definitely be paranoid - but Lionstar is honestly too paranoid about whether people are friendly, he even admits it sometimes. And it would be pretty weird of them to pretend to want to help until Tsashi turns her back. Since Tsashi is half their size and they don't know she has a weapon. 

Great! They can go on a hurried tour around the ER, then, and end up in the brightly-lit utility room, where to Marian's relief one of the Bair Hugger machines is tucked in a corner. 

There's so much stuff! Tsashi has never seen so much stuff in one place and wouldn't have been able to imagine it before today! There's an entire shelf full of...bags of water? Tsashi stares at them curiously and then pokes one to see what it feels like. 

It would prooooobably be better if the kid didn't touch things, but given that she can't just politely ask, Marian is not actually sure how to convey that without seeming angry, which wouldn't be fair to the kid. She'll just collect one of the disposable warming blankets in its plastic sheath and hustle the Bair Hugger machine toward the door as fast as possible. ...and dart back to grab a 1L bag of saline, right. 

The kid is enthralled by the microwave! She stares at it in abject fascination, but does seem to get the gist of Marian's frantic awkward hand gestures, and doesn't try to poke it while it's microwaving the bag of saline. 

Awww. The mysterious non-English-speaking kid is cute. And...kind of looks like she's never seen a microwave before? Where is she from? 

Marian gives the bag a good shake to make sure it's evenly mixed before gauging the temperature against her wrist and judging that it's probably in the general vicinity of 37 C. She wonders if the ear thermometer would work on it. Probably it doesn't matter that much, it's not going to burn the patient. 

She sticks the saline bag in the front pocket of her scrubs - ooh, that feels really soothing actually, like a hot-water bottle - and manages to free up enough hands to wrestle the Bair Hugger through the nursing station and back to the trauma bay. 

The patient looks...a little better, actually! Not just his vital signs - heart rate up to 58 and more regular, latest blood pressure an entire 82/60 - but the gestalt sense Marian gets from him. His color isn't good, but it's much less several-minutes-from-dying. 

The SpO2 reading is still only at 83%. The respiratory therapist seems to be having an effortful time bagging him. 

What is UP with this patient. Marian's brain is at this point screaming at her that they're missing something. Maybe he's having an anaphylactic reaction to drugs? Only in that case you'd really think that epinephrine would have more of an effect. And anaphylaxis doesn't cause delayed conduction, or whatever it is he has going on, his rhythm on the monitor still looks ventricular even though it's now an almost-normal heart rate. 

...Focus. He has circulation right now and sats of 83% aren't great but aren't "imminently about to code" low, and probably the RT is on top of that. Marian's current task is to get the new IV bag hung and the Bair Hugger set up. 

Tsashi watches with rapt fascination, her eyes following the clear soft string going from the strange clear waterskin to Lionstar's arm. It's...hollow, she thinks? And they're using it to put water into his body? That's so clever! She wouldn't really have expected it to work but it's brilliant if it does. Tsashi isn't one of the children who Lionstar taught much about Healing, but she knows that people who were injured and bleeding need to eat and drink to regain their strength. 

She's worried about the Changegoat poison. Tsashi has no idea what you do about poisons; that's more advanced Healing lore than Lionstar taught her. In practice, in the village, usually the answer is that you make sure the person rests and drinks enough water, and hope for the best. And usually they die. But maybe Healers with powerful magic from before the Cataclysm can do things? 

She looks at the bright boxes again. She's pretty sure they have writing on them, in a different language. And...pictures, of some kind, but she doesn't know what they're pictures of. Maybe this is how Healing-Sight works? She stares intently at the wavy line, wondering what it's a picture of. 

The doctor frowns at the monitor. Then at his beeping pager. "...Let's bump him with another 2mg atropine, he did respond a little. If that helps you can repeat it q30minutes. I need to go answer this. Call me."

His eyes focus briefly on Marian. "ICU, right? Find out if there's a bed available." 

There's definitely a bed available, in 202. Maybe 188 or 196 too, if they haven't already been assigned to a different admission.

Marian...kind of wants this patient to be her admit? Which is probably committing herself to an intensely exhausting night, but - well, she's going to get an admit one way or another for sure, and at least she already has context here. And the kid is sweet. 

The crowd of people who assembled for the code has dispersed even more by now; they're down to two nurses, one of them now hurrying to pull atropine properly from the Pyxis rather than taking two more of the premixed 1mg syringes from the crash cart, plus the RT still bagging the patient. 

Marian shuffles her feet. The kid being cute and sad and apparently now Marian's duckling is not a reason she can justify hovering here for the next who-knows-how-long until admission orders actually happen. The patient still being unstable might be, but he's at least less unstable than earlier, and taking an admission will be less of a disaster if she can grab the narrow window to get caught up with her patient in 201 first. Maaaaybe she'll stay until they find out if the atropine actually helps? 

She fidgets. "I...should probably get back to the ICU soon and check we're ready for the admit. Uh, should I help with anything else while I'm here - do you need me to pull nebs for you, you look kind of busy -?" And Marian does know how to prep the nebulized bronchodilator treatment herself. 

Her help would be appreciated! It doesn't seem feasible to move the patient onto the ventilator when he's still satting at 85%, but bagging him is a two-handed job. 

With Marian's help, though, he can get nebulized albuterol hooked into the ventilator tubing! 

It...maybe does something. The atropine does more; a minute after it goes in, his heart rate is up in the 80s. Something still looks wonky with conduction, but at least some of the complexes have P waves. The next blood pressure reading is 101/68, which is entirely tolerable. And, maybe just because his lungs are perfusing better along with the rest of him, the SpO2 reading finally makes it above 90%. 

Despite the warming blanket and heated fluids, though, the next temperature Marian checks is actually down to 32.7 C. 

That's not ideal. It's not that surprising, though, probably they're just getting a bunch of cold blood returning from his extremities as his circulation improves. He's not that cold - they cool patients to that range on purpose for the therapeutic hypothermia protocol - and he should start warming up soon. 

(Marian still has a nagging niggling feeling that she's missing something, but 'something' is pretty likely to be a result on the pending tox screen, meaning she can't do anything about it by standing here staring at the patient.)  

"Uh, call the ICU if you get admit orders," she says. "We can probably send someone over for transport." And she smiles as reassuringly as she can at the kid and does her best to gesture 'stay here', it would be kind of awkward for her duckling to follow her all the way to the ICU and hover in her other patient's vicinity. 

She goes. 

Tsashi watches her go with mild wistfulness - it is, in fact, reassuring to have an adult look at her and smile at her and seem to be trying to tell her without words that Lionstar will be okay - but she's definitely being told not to follow this time.

She turns her eyes back to Lionstar, this time to investigate the thing in his mouth. She isn't sure what that's supposed to be doing. It takes another minute and a lot of repetitions before she pieces together that the woman doing something to the...whatever it even is...matches up with Lionstar's chest rising. 

That's so clever! It's sort of uncanny as well. Normally if someone is badly hurt or sick enough to struggle to breathe, they aren't going to survive - 

(She mostly isn't thinking about what happens if Lionstar dies. She probably should be. Lionstar would say that it's stupid not to plan for bad things that could happen. It's just...still hard to make her thoughts actually go there.) 

Somewhat unbelievably, it's only 10:25 pm when Marian gets back to the ICU. It felt like way more things than that happened. 

She finds Chantal at the nursing station. This would be awkward if she wasn't on the other side of embarrassment. "Uh, the code from the ER needs a bed here, probably. Dunno how long, the doctor sort of ran off for a page as soon as he was kind of stable. I can take him in 202, uh, if that's okay, I got report already." 

Chantal nods tersely. "Figured you would take the code if they needed a bed. It's either that or a transfer, but I can put the transfer in 196. - hmm, iso status?" 

Marian's brain briefly skips like a damaged CD. "...Uh. None that I know? He came in with lacerations and probable OD, hypothermic, I don't think there's any reason he needs isolation..." 

"Good," Chantal says, without explaining why she bothered to ask. "Annie can take the transfer, then." She's clearly busy, and spins her chair back around to the computer when Marian doesn't immediately say anything else. 

Okay. Right. Marian needs to get caught up on 201. And check the room, but cleaners are currently there, so. 201 first. That means she should...do things...that are not sitting in her chair staring into space and wondering what on earth is wrong with the John Doe admit and what country he and his maybe-daughter are from. 

Charting feels completely impossible so - stand up. 201 is isolation, droplet (pneumonia) and contact (known MRSA carrier.) She has a pile of midnight meds, which Marian can get a head start on prepping those before she commits to going into the room, and she can do an (early) assessment and turn (ideally with help but she has enough pillows to manage without, 201 isn't a huge lady), and that will probably take her to 11 pm and it's within-range to give q6h meds an hour early...

201 is intubated and sedated, rousable enough on a propofol drip to open her eyes and squeeze a hand but drowsy enough that she's unlikely to feel awkward if Marian doesn't bother with small talk the rest of the time. Which is a relief. Marian's brain is tired. 

By the time Marian makes it out of 201 at around 10:58 pm (she decided 10:52 was close enough to 11 pm to give meds early), her computer workstation has been taken over by the on-call resident, who smiles tiredly at Marian and rolls her chair back from the desk. 

"I picked you up a coffee," she says cheerfully. "Saw you're here all night. Tell me about your guy? There's not much in the chart." 

"Thank you." Marian finishes wadding up her disposable iso gown into the trash and detours to wash her hands at the corner sink before darting over to nab the coffee. She's almost embarrassingly glad to see Dr Sharma, and only about 30% because of the thoughtful delivery of caffeine. Dr Sharma is a third-year resident, and she's only been on ICU rotation for a few weeks but she really knows her stuff. 

"Right. Uh. There wouldn't be, we know, like, two facts about this guy and neither one is his name. We think he was assaulted - um, he definitely came in injured and bleeding, and there's a kid with him who doesn't speak any English or French but was, like, Charades-ing stuff for the EMTs. Suspect he also OD'd on something but that's a guess on symptoms and Charades-interpreting, so." Shrug. "They were both on the side of a road or something, so he's hypothermic from lying in a snowbank, the temp I got was like 33 C. Altered mental status when the ambulance arrived and he deteriorated from there and coded right when they got to the ER - uh, briefly, they basically had a pulse back by the time I even got there. He was in this weird slow ventricular-ish rhythm and epi barely did anything but he seemed to respond okay to atropine. He was also pretty hypoxic and hard to ventilate even once they intubated him, he might've aspirated and definitely had some sort of bronchospasm thing going on. They were waiting on tox screen results when I left. Plus everything else. Are his labs back yet?" 

"Only a really terrible iSTAT blood gas. I think the lab is still backed up. You'd hope putting the orders in stat would help, but." She shoves the chair back and stands. "I'd better go see. Is the room ready, if I think he needs to come over right away?" 

Dr Sharma is so efficient. Marian normally appreciates that, but right now she feels outpaced. "Um. I'm sure I can have the room ready by the time you get back." 

The room is clean and has a bed it in and everything! The bed has sheets! It still has a stolen extra bedside table from Marian's previous room setup. 

The cleaners have unsurprisingly not restocked anything except for basic linens. There are two clean gowns and plenty of towels and the soap dispenser is full, but most of the supply drawers are thoroughly depleted, and none of the wall suction hookups have canisters or tubing. 

UGH Marian should do something about that. It seems like a lot of effort, especially the drawers, she doesn't actually have a complete mental inventory of what's supposed to go where. If it could have waited until midnight then the night shift personal support worker could do this room first on their restocking run, but, unfortunately. 

Suction supplies first, because the patient is probably going to show up with an ongoing saliva disaster, and once that's done she can spend some time staring at the clean utility room shelves and figure out what she most desperately wants to have on hand for tonight... 

Chantal sticks her head into the room five minutes later, while Marian is shoving prefilled saline syringes into a drawer. "Sharma just called. Wants to know if you'll meet her at l'urgence." 

Oh no. That's not reassuring. "I can go. Did she say why?"

...Clearly not. Marian is going to run. 

It's not obvious from the scene greeting her whether it's, in fact, an emergency? The kid is still hovering. Dr Sharma is in the process of donning gloves; she doesn't look particularly stressed, but she tends not to show it even in active emergencies. 

The patient's vital signs look...vaguely tolerable, at least. He's on the ventilator now and the volumes it's getting for each breath look low, but his O2 saturation is hanging on at 90%, heart rate in the low fifties, and the last blood pressure up is an acceptable 94/55. 

Dr Sharma spots Marian. "Oh good, thanks for coming. I want to give him activated charcoal, in case he ingested something toxic. - that's not what I need you for, Pat is getting it. He had a watery bowel movement and I don't want to transport him lying in it. Can you help me get him on clean linens?" 

"- Yeah, of course." Marian appreciates Dr Sharma so much. She can count on one hand the number of residents who'll jump in themselves to help clean a patient up. 

She brings over an armful of linens. Smiles at the kid, then frowns as Dr Sharma folds the Bair Hugger blanket out of the way. "...Wow, okay, that's a lot. I'm just, uh, going to put some towels down before we try turning him..." Marian isn't particularly grossed out by diarrhea, but someone did a really nice job of the abdominal dressing and it would be tragic if it immediately got soiled when they rolled the patient into his own shit. 

(She feels surprisingly self-conscious about the twelve-year-old intently watching their every move. It feels like kids really do not need to see their...parents? uncles? whatever...in this particular situation.) 

She lowers the bedrail out of the way. "Want to turn and I'll wipe?" She's wondering if diarrhea is a known side effect of some particular drug. It's not leaping to mind. GI side effects are pretty non-specific. 

Dr Sharma is less used to moving patients than most nurses, and Marian has to awkwardly dive in and straighten out the IV tubing before she accidentally yanks on it. 

Which means it takes her a couple of seconds longer than it might otherwise to notice that the patient is, apparently, NOT a fan of being turned on his side. The ventilator high pressure alarm goes off, the breath volumes on the display immediately dropping to a minuscule 200 ml, and a few seconds after that the monitor alarm starts going.

It's not actually his sats, which haven't started dropping yet. His heart rate is abruptly dropping into the 30s. 

"Shit!" Marian's brain is not really coming up with a more coherent response than that.

"Hmm?" Dr Sharma glances at the monitor, then frowns and gently releases the patient onto his back again. "That looks like a parasympathetic response, maybe? I think he had a standing order for atropine, can you check when he last got it and pull some if it's been long enough?" 

She leans in to tap the monitor control and cycle the blood pressure reading. 

Marian can do that. It involves MULTIPLE STEPS including logging onto the computer and manually finding the patient's John Doe record and checking the medication history, which takes long enough for the blood pressure to come up at 54/35. 

At which point a lot of residents would snap at the nurse to hurry, but Dr Sharma is pretty sure that Marian is already hurrying. 

She investigates the IV pumps instead. "He's on a norepinephrine drip too, I can go up on– ...he's got a dopamine infusion too? I don't know who– nevermind. Marian, can you see if there's a note on which one we should titrate up first?" 

Tsashi is pretty unsure what's happening, but she can pick up that, one, Lionstar looks worse again, and two, both of the foreign Healers look surprised about it. The combination is stressful! She wants to ask what's wrong and she can't and it's very frustrating. She hovers close to Lionstar instead. 

Marian would prefer to do one thing at a time but she scrolls up to the continuous IV medication section. "I don't see a note." She's also confused about why you would have a patient on both a medium-dose norepinephrine drip and an equally mid-range dopamine drip, but it's really not the weirdest way they do things in the ER. "Uh, I think dopamine increases heart rate more, right?" 

Back to atropine dosing... 1-3mg q30min as needed for a heart rate below 40 or significant bronchospasm, last dose was at 22:47, it's now 23:16, good enough. She leaves the computer logged on and makes a run for the Pyxis. 

When she gets back with a syringe prepped, Dr Sharma is busy examining the patient's pupils with her penlight. (And being watched by a curious twelve-year-old.)

"This looks like cholinergic toxicity," she says thoughtfully. "Sweating, increased salivation and secretions, bronchospasm, bradycardia, pinpoint pupils – even the diarrhea, he hits everything on the list. And he's responding to atropine, but it seems to take a large dose. Did you prep the full 3 mg?" 

Ohhhhhhh. Marian feels incredibly stupid for failing to put that together...except that she's pretty sure she hasn't had cause to review those symptoms since nursing school, and actually she's still blanking on what drugs are associated with it. Altzeimers' medications, maybe? That seems...implausible, in this case. 

She digs out an alcohol swab to clean the IV port before plugging her syringe into it, trying to remember how slowly you're supposed to push atropine. Over thirty seconds is probably fine, right, she really doesn't feel like taking forever about it.

"...What could be causing that?" she says, when another ten seconds fails to produce any answer in her brain. 

"Organophosphate insecticide poisoning is common in India. People use it for suicide attempts." Shrug. "Nerve gas has the same effects. And muscarinic mushrooms. The tox screen won't check for any of those."

Are you fucking kidding, if her patient got nerve gassed then Marian is– actually she's not sure what reaction is appropriate to that. What the fuck. Probably a suicide attempt is more likely than that, except she has no idea how to fit it together with the kid's explanation of what happened. Maybe the paramedics completely misinterpreted her Charades and actually the patient cut himself? ...She has no idea and it's probably not productive to stand here wildly speculating. 

She gives the full syringe of atropine, slowly, and flushes it with two syringes of saline to make sure it's really definitely in, and bumps the monitor for another blood pressure. 

The patient is back to looking pretty awful! He's soaked in sweat again, practically dripping with it, his color an unpleasant blend of ashen and blotchy. The ventilator is getting better volumes now that he's flat again, but still only around 400ml per breath - not a lot for an adult man - and his sats are now at 82%, on 100% oxygen and moderately high ventilator support. 

Blood pressure comes back at 77/54. His heart rate is back up to 52 and reasonably regular, and there are P waves, but the complexes almost look weirder than before. It's hard to tell if the QRS spike is as drastically widened as it looks or if there's just something going on with the QT interval. 

Both of those would be concerning! Prolonged QT interval means he's at risk of randomly going into ventricular tachycardia, which is the last thing Marian needs in her life right now. And it's not just that it's too long, it's– ohhh yep that's an inverted T wave, a downward swoop instead of a neat upward bump. Which Marian's brain has tagged as possibly related to some kind of toxicity, so maybe it's that? 

She hits the blood pressure button again. Poor man's arm is getting squeezed off, not that he's anywhere near conscious enough to care. "- Should we get an art line if he's going to keep doing this?" she says to Dr Sharma. 

"He needs a central line too, we're running pressors peripherally." Dr Sharma grins briefly. One of the few upsides of a week like this one is so many opportunities to practice line placement. "I'd rather do both in the unit. And I want to call poison control, find out what tests we can run and if there are supportive treatments it's worth adding before we have confirmation." 

The patient's blood pressure pressure back at 93/67. His sats...still aren't really rising. 83%. 

"He's probably full of secretions." Dr Sharma reaches for the suction tubing. 

She's not wrong. The suction is making the worst sound in the world, and the patient is leaking saliva all down onto the pillow. WHY is there apparently a kind of poisoning that CAUSES saliva disasters??? Arghhh. And there isn't actually a second set of suction tubing hooked up, so she can't have a go at it in parallel. She settles for wiping up what she can with a towel. 

The patient still doesn't have much of a cough reflex. His heart rate dips again while being suctioned, but briefly and less terrifyingly, and clearing out some of the secretions does seem to help. The O2 sat reading starts creeping up again. 

Dr Sharma waits until it hits 90%, and the new blood pressure reading is above 100 systolic, before sighing and donning a new pair of gloves. "I think we can risk turning him. Maybe have a pile of towels ready, if he doesn't tolerate it then mop up what you can and put a dry towel down. He's pretty fragile, I don't want to push it." 

Marian is so in agreement with that! 

The patient tolerates it a lot better this time, though. Marian is in a hurry and doesn't try that hard to get him completely 100% clean – which is a job that would call for proper soap and water, now that she's paying close attention she's noticing that he's very grimy. Not really homeless-person grimy, though she's not sure what feels different about it exactly? More, like, vaguely reminiscent of her childhood and the kind of grimy you get four days into a camping trip? 

- she can wash her patient properly LATER, once they know what's wrong with him and can be sure he's actually stable. For now he gets a hasty wipe-down before she wads up the soiled sheet as far under him as she can reach, pads it with several towels so it won't leak on the new sheet and incontinence pad, and then puts those down and helps Dr Sharma turn him the other way. 

They're just finishing up when the ER nurse finally gets back with a squeeze bottle of activated charcoal and a gastric tube. "Hey. Did you still want this?" 

Dr Sharma is looking increasingly antsy. "- We'll do it in the ICU. Can you find RT and help transport? I'd like to go ASAP. - Marian, can you see if any labs are back while we're waiting for RT?" 
 

Marian can wash her hands hurriedly and then do that. 

The kid follows her and peers over her shoulder, staring curiously at the computer screen. 

The kid is so sweet and interested, and Marian is all out of reassuring smiles right now. She does her best, and manages not to growl at the computer for having logged her out in the last five minutes, and hammers her password in again to look up the patient. 

...Hematology is back. Hemoglobin and hematocrit are a bit low - well, he did lose some blood - and everything else is in normal range. It'll probably look worse on repeat labs, Marian thinks, trying to reconstruct the timeline in her head - this would've been drawn before they got IV access and fluid resuscitation started. The blood gas is listed earlier, and is indeed VERY AWFUL: critically low PaO2, and both high CO2 and low bicarb causing a combined metabolic and respiratory acidosis and a blood pH below 7. Not very surprising, though, it was drawn shortly after the dude coded. 

Electrolytes and lactate and urea/creatinine and tox screen are coming up on the screen, but still displaying as PENDING.

She heads back over to rejoin Dr Sharma at bed 2. "Hemoglobin's lowish, that's all that's back." 

"Hmm. I'll want a repeat in a bit, he really needs the oxygen capacity. But let's wait until he's topped up on fluids, I think he'd benefit from another bolus." 

The respiratory therapist sticks her head in the door. Dr Sharma waves. "Let's go!" 

The ventilator and IV pumps add some unwieldiness to transporting the patient, but four people is enough to manage it and steer out into the hallway without too much trouble. Marian catches the kid's eye to smile reassuring - well, hopefully reassuringly, she's not entirely sure what her face is up to right now - and gesture for her to follow them. 

They're going somewhere else?? Tsashi has no idea why they're going somewhere else in the huge daylight-building, and whether it's a good thing or a bad thing. She's really quite sure at this point that the people here are Healers and trying to help, but she's never been in a huge daylight-building for Healers with powerful magic and has no context on why they might go to a different part of the building. Maybe it means Lionstar is doing better, but maybe it means he's doing worse.

The novelty of all the powerful magic around her is starting to wear off, and it's increasingly frustrating and stressful that she can't understand anything anyone is saying and can't ask Lionstar to use Mindspeech and has no idea when - if - she'll be able to ask Lionstar for anything. Tsashi is not going to cry, because she isn't little anymore and it won't help, but she slightly wants to. 

She follows the Healer. 

The kid looks pretty overwhelmed. ...Marian should really try to figure out the kid's name at some point. And, like, get her a nicer blanket and some juice or something. Really what she should do is try...drawing, or something...to find out if the kid knows contact information for any other adult who knows the patient, ideally an adult who speaks English, but that sounds like an incredibly frustrating process and it miiiiight just be easier to wait until morning when the phone interpreter line opens. 

She buzzes them through the ICU doors. Louis-Philipe, sitting at the computer workstation outside 206, spins his chair around to look. 

"Admit," Marian explains. "Could use help." 

Nellie, as usual, has a sixth sense for exactly when an admit is about to arrive, and is already hovering outside 202. "That took a while. How unstable is he?" 

"Suspected organophosphate toxicity," Dr Sharma says tightly, maneuvering the IV pump through the open glass doors. "Or something cholinergic, it's not confirmed. So he's not doing great. He got atropine ten minutes ago, hoping that'll hold him for a few more minutes. - Marian, have that ready to go on the half-hour. I want to confirm dosing with poison control -" 

"Jesus on a stick," Nellie says, heartfelt. "What's he had total so far? Over how long?" 

"Two followup doses, and it's 3 mg per, so...9 mg total?" Wow that's a lot. In, like, one hour. 

"- Bet he'll need a lot more. Patient I had in Texas needed, like, fifty mg before he stabilized. And we'll want pralidoxime but I don't remember the dosing protocol. We should draw labs before we start that, the usual test is for plasma or RBC acetylcholinesterase activity but I don't actually know if our lab even does that..." 

Dr Sharma is staring at Nellie with an expression of abject gratitude. "- I should go call now. Marian, have the atropine ready and - probably give it right away if he goes brady again, I guess? We'll need a Foley and gastric tube, if I'm not back come get me to confirm placement once you have the X-ray. I'll be in the conference room. Tell me if any other labs come back abnormal." 

She hurries off. 

...Marian feels slightly abandoned now. Which is stupid. She's a grown adult who is capable of doing reasonable things without a resident babysitting her, even if something is very unreasonably wrong with her patient. 

They should probably get him transferred to the ICU bed ASAP before he decides to get unstable again. 

The patient does manage to desat down to 78% during the thirty seconds it takes them to get the slidey mat under him and haul him onto the bed, but avoids doing any scary heart rate shenanigans. 

Great, okay, ventilator plugged back in - portable monitor cassette transferred to the main monitor - cycle a blood pressure for what feels like the hundredth time today just on this patient - and then Marian is VERY PREPARED and has suction right there, both to hook to the in-line endotracheal tube suction circuit and one with a yankauer oral suction catheter already attached. The ventilator volumes don't look awful, so maybe she can even properly deal with the saliva first. 

(There's also a towel on top of the clean pillow, because Marian was expecting this.) 

There is a truly unreasonable quantity of saliva. And, if possible, somehow an even more unreasonable quantity of lung secretions. Not particularly gross lung secretions, they're white to clear and slide up the suction tubing without difficulty, but it keeps going. 

Euuuuuuuughhhhhh. 

And then Nellie is nudging Marian's shoulder. 

"Hey. I'll get him settled from here, do the gastric tube and Foley. You focus on the kid for a couple minutes, 'kay? She's having the worst day of her life and she keeps looking at you. Go show her the bathroom, get her a blanket from the warmer and some juice, and– oy! Louis-Philipe! Find a recliner chair for her!" 

...Right. That's a good suggestion. She's pretty sure they're going to end up ignoring the kid for kind of a lot of the night, if it keeps going the way it has been so far, and if it were her in that situation - in a foreign country or something, in unfamiliar surroundings, with her parent-or-relative-or-whatever incapacitated and maybe dying - she would, well, for one she would not be coping nearly so gracefully, but also it feels like a few minutes of someone paying attention to her might go a long way. 

Tsashi isn't getting upset, but it's been an increasingly difficult not-getting-upset. There are so many things happening and she doesn't know how to read the Healing-Sight magic and can't tell whether it's good or bad, which is stressful. The Healers keep doing things to Lionstar that look like they should hurt a lot and he's not moving or resisting or even showing signs that he feels it, which is actually even scarier than if he were fighting them. 

They're a long way from home, though, and right now Lionstar needs her to learn things about this place. She controls her expression and goes with the Healer. 

Marian stops in the hallway, still in sight of the patient. She smiles again, then slowly and obviously points at her own chest. "Marian." 

Oh! That one isn't too hard to figure out! 

Tsashi nods solemnly. "Merr-rayn?" she tries. 

Close enough! Marian beams at her. 

It's good to know one person's name. 

Tsashi points at herself. "Tsashi." She pronounces it clearly and carefully. 

"Sashy?" That's an interesting name. Marian wonders vaguely what ethnicity it is. 

Eager nodding.

...Tsashi hesitates, then points back into the room. "Lionstar." If she were a Healer she thinks it would bother her, not knowing the name of someone she was trying to help. 

That one is slightly more of a mouthful. Marian tries to wrap her tongue around the foreign syllables. "Lionstar?" 

Nodding! 

Tsashi wants to ask if he's going to be all right. Maybe she could even convey that question just by pointing at him and saying him name again and gesturing. It's probably a pretty obvious question for her to have. But she still doesn't speak the language and it's not as though she would understand the answer. 

Marian really wishes she could explain! But she's not actually sure what the patient's prognosis is, her memories of nursing school are failing to dig up anything on whether, with supportive treatment, it's closer to 'full recovery after an unpleasant few days' or 'permanent organ damage.' And the physiological problems he's currently having and the treatments they're trying would be complicated to explain to a kid even if they spoke perfectly fine English or French. 

She'll take "Sashy" down the hall instead and show her where the bathroom is. 

Tsashi had been wondering if they were trying to shoo her to a different place to wait, the village sort-of-Healer doesn't like hangers-on, but she would have expected them to put all the unhurt people in one place to wait; there are definitely lots of other people here being Healed, maybe even dozens of them, it's a big Healing house. 

This room is very small and she's not sure what it's for? It has a strange uncomfortable-looking sort of stool and an equally strange artifact sticking out of the wall and not much else. Tsashi would investigate but she's gotten the feeling that the Healers would rather she touch fewer things, which is sort of reasonable, when she was little her mother would always slap her for touching the loom or poking at things when she was cooking. 

...Sashy is definitely acting like someone who's never seen a bathroom before. Huh. Even if she's literally from a third world country, Marian isn't sure how you could be in Canada for more than a few hours without using a toilet. Maybe if she and her probably-relative-of-some-kind lived in their car or something? 

She'll lead Sashy over to the sink and show her how to run the tap. 

Tsashi jumps in surprise, then lights up. The big building doesn't just have daylight inside, it has a tiny magic river that goes and stops for you! Magic from before the Cataclysm is wonderful! Why did Lionstar never tell her– ...that's a stupid question, of course it would make him sad to talk about it. 

...She's actually very thirsty. She isn't sure if she's supposed to touch the river, but she'll move slowly so that Merrayne can stop her if it's dangerous. She cautiously sticks both hands in the river and, when this doesn't get her slapped or pulled away, cups her hands to fill them and then bends over to drink. 

Oh nooooooo Marian feels terrible now for not offering her something to drink sooner! ...Also Sashy's hands are filthy. The blanket is now sliding half off her shoulders to reveal a...short dress? Long shirt? of some noticeably coarse-threaded weave, and also deeply impregnated with dust. 

"No, no." She turns the tap off. "Sorry. I'll get you water." She tries to mime holding the shape of a cup. "Here -" She pulls down wads of paper towel and shows Sashy how to dry her hands. Really it seems like a good idea to get her to wash them properly, if she's going to be wandering around 'Lionstar's' hospital room touching things, but that can wait until after Sashy is hydrated. And doesn't actually have to be in the bathroom, the ICU rooms have sinks, though she should probably detour back here anyway to show Sashy how to use a toilet. Oh god is she going to have to demonstrate peeing on it. Conveniently she does have to pee kind of badly at this point

Once Sashy's hands are dry, and hopefully at least slightly cleaner, Marian ushers her out of the bathroom and around the corner to the little patient kitchen, which has a stack of paper cups and a water and ice dispenser. 

Tsashi did not at all follow why she's supposed to drink out of this magic river instead of that magic river, but she makes a note of it anyway! Cups make sense, at least, though it's mysterious what these ones are made of. She gulps down a cup of water and copies Marian to refill it and gulps it down again. 

And from there it's another five minutes or so of awkward puttering back and forth, to show Sashy how to use a toilet (she looks awed at the concept, and then pees in front of Marian with zero self-consciousness) and how to use soap to wash her hands (she stares at the foam like it's literal magic) and then over to the clean utility room to get a fresh blanket out of the warmer. (Sashy seems reluctant to let go of her old blanket, and instead folds it up neatly and carries it with her, which Marian is fine with.) 

It would be nice to get her washed up more thoroughly and wearing something cleaner - maybe some of the smallest-size OR scrubs would do in a pinch - but that sounds like a longer project, and Marian is antsy about leaving Nellie to do all the work with her patient for too long. They'll do a final stop at the kitchen so she can show Sashy the contents of the fridge and offer her some graham crackers and, on consideration, a cup of the Resource 2.0 liquid meal supplement. Marian got a slightly better look at her while they were switching blankets, and it seems likely she could really use the calories. 

Aaaaaand back to the room, where hopefully someone else has caused a comfortable reclining chair station to exist? 

Someone has! 

Nellie also immediately turns to fix a beady gaze on Marian. She points at the monitor, which now has a temperature tracing, because Nellie thought ahead and used the Foley catheter with an indwelling core temperature probe. 

"Did you know your patient's temp was 31.9 C?" 

"Gah! I - no - I mean, yeah, he was hypothermic when he came in, but we had the Bair Hugger on him, I can't believe he dropped nearly an entire degree!" ...Where did the Bair Hugger go. Oops, it definitely looks like they took it off him to deal with the soiled linens and then left it behind in the ER. 

"Ah. Well, he's got no body fat and he's not shivering - OP toxicity causes muscle weakness, he might be partially paralyzed - so he can't be producing much body heat. Oy! Louis-Philipe! Grab us a Bair Hugger, would you? I think there's still one more in the clean utility, if someone else took it since I last looked then I guess go steal it from the ER..." 

There are raised voices! Tsashi is pretty sure they aren't being raised at her but if anything it's more alarming for them to be raised about, presumably, Lionstar's injuries. 

Tsashi will just try to stay very out of the way? 

Oh no she scared the kid. Reassuring smile reassuring smile probably that's not very reassuring ugh. There are too many things wrong with this patient and it feels unfair. 

"Dr Sharma thought he probably needed more fluids." Marian peers at the urine in the collection bag. There's already 400 ccs in it, pale straw-color. Cold diuresis, maybe...does cholinergic stimulation increase urine output, something feels familiar about that... "Uh, we can give that heated once she orders it -" 

Louis-Philipe shoves the ICU Bair Hugger machine, fresh blanket balanced on top, the rest of the way to the door. "Lab's calling for you, Marian. Line 6. Critical results." 

Of fucking course. "Uh, thanks - Nellie, I should go take that -" 

What are these critical results spoken of? 

Critically low magnesium at 1.0 mg/dL (normal range 1.8 to 2.6). Critically low phosphate at 1.2 mg/dL (normal range 2.5 to 4.5). Critically low potassium at 2.8 mmol/L (normal range 3.5 to 5.2). 

Critically high lactate at 9.2 mmol/L (normal range less than 2), though this isn't all that surprising, it was drawn when they were practically in the middle of coding him. 

Critically, terrifyingly low venous blood glucose, all the way down at 39 mg/dL (normal range of 72 to 108.) 

Moderately but not critically low albumin. Maybe he's a bit protein-deficient. 

Everything else is within normal parameters! 

Yikes! So much yikes! This patient has way too many serious problems and should share some of them with the rest of the unit

...For one, Marian has no idea what's up with the glucose. If it was an expected consequence of the poisoning then Nellie would have said something. Two, the diarrhea and sweating and general exodus of bodily fluids would explain some electrolyte imbalance, but surely not this bad this fast. ...The lactate is genuinely probably a lot better now that he's had a tolerable blood pressure for the last while, they should redo that. 

The glucose might be an error somehow. Probably not, Marian has a feeling it's real, but it's quick to check. She thanks the lab tech and hangs up the phone and runs for the med room to grab a glucometer. 

"Nellie! Check his blood sugar - lab called said it was 39 - I'm gonna go tell Dr Sharma and get dextrose -" 

Conference room, right. She runs. 

The shouting and running is really alarming! Tsashi wants to know what's happening, but it seems like it would be a bad time to ask even if she knew how and could understand the answer. 

She doesn't want to touch Lionstar in case it messes something up or gets her yelled at, but she glues herself as close to the magical artifact supporting his body as she can. 

Dr Sharma is perched on a chair on the conference room, legs tucked under her, cell phone cupped to her ear and apparently listening to someone on the other end of the line; she's scribbling furiously on a legal pad. 

She sees Marian, makes a 'wait one second' hand gesture, writes another note, then cups her hand over the phone. "Hmm?" 

"Um. Labs are back. Critical results on potassium, mag, and phos – uh, low, I didn't write down exactly what, but really low. Lactate high but that's not weird. Blood sugar is really scary low, Nellie's rechecking it but on the labs it was, like, under 40?" 

"One sec." Dr Sharma brings the phone to her ear again. "Hey - sorry, I'll be right with you in a minute - we got some results back, electrolyte imbalance - yeah, K is low - one sec -" To Marian again, "- was it under 3?" 

She should have written things doooooooooown. "Um. I think so–" come on Marian's brain, you heard the number less than a minute ago "- yeah, it was 2.8." 

"Shit. Okay. That's a bad sign, we'll want to supplement ASAP - it sounds like there's not much benefited to giving the activated charcoal, and he isn't vomiting, so let's try 40 mEQ by gastric tube, that's faster. If he vomits we'll try IV. And we want his magnesium high, let's give him 4mg over an hour and reassess from there." 

Pause. 

"...You said low sugar? Bizarre, that's not– eh. If the bedside glucometer confirms it, give him an amp of D50 and recheck. I'll be over in five minutes, I need to finish here." 

...Nod. "Um, I think we're still waiting on X-ray for the tube, and then we'll need you to confirm it -" 

"Yeah. I'll be over really soon. - oh, you can go ahead and try 6 mg atropine now. Nellie's right, we're not going high enough, we want to be reassessing every 5-10 minutes and doubling the dose if it's not effective yet." 

"Uh, okay." That is NOT HOW DRUG DOSING WORKS. Marian wonders if the Pyxis even lets you take that much out at once. "We'll do that." It won't add anything to say please hurry up and come see him, so she doesn't. "So - start magnesium 4mg, recheck sugar and treat if it's low, atropine, wait on you for the gastric tube?" 

She waits for the confirming nod, and then heads for the med room at a jog. 

The Pyxis wants Marian to confirm several times that she does, in fact, for real, want to take out two (2) 5mg ampoules of atropine, but it lets her override and do this. In contrast, nabbing a premixed 4mg bag of magnesium and 40 mEQ oral potassium elixir are straightforward. The 50ml giant syringes of 50% dextrose can be nabbed off a shelf. 

She's going to grab a bag of IV potassium too, it's not like the guy isn't already having GI symptoms. It feels to her like it's a thing for very sick patients to have a hard time with enteral potassium even if they weren't vomiting before they got it. 

What else - ugh she didn't get an order for more fluids, she really should have asked about that - she'll grab a new bag of saline anyway for later microwaving in the patient kitchen. Syringes and needles for mixing should be in the room, she had time to refill that drawer. She stuffs her scrub pockets with a handful of IV tubing - mag could go in a piggyback on the saline, except no nevermind it's on gravity tubing, they'll want another IV pump...

She heads back to the room rather than detour to the clean utility for IV pumps, and drops her hoard on one of the bedside tables. "Nellie, we need to give him mag and 6mg atropine. And I've got D50 if he's really low–" 

"Down to 36, yeah, give that here." Nellie snatches the D50 box and rips it open. Pauses very briefly to frown at the pile of drugs on the table. "We're doing oral potassium? I bet you a coffee he's going to barf. Poison control said don't bother on the activated charcoal?" 

"Not taking that bet." Marian sticks her head behind the pillar. Oh, good, there's still a tree of IV pumps hiding back there. She pulls it out. "Uh, shit, we could use more IV access - maybe I should try for another peripheral, I don't know when Dr Sharma will actually have a chance to do a central line..." 

The patient's skin is notably clammy to the touch, but he makes it surprisingly feasible to find a vein, for someone with a systolic blood pressure currently in the low 90s and a body temperature below 32 C. He's really not carrying much subcutaneous fat, but he's clearly very fit, with wiry muscles. Marian is able to get a 20G IV in his wrist without too much trouble, and prime a new saline primary line to hook up the magnesium to in piggyback. 

(This is around the point when Louis-Philipe finally arrives with the Bair Hugger.) 

The patient responds a little more to a 6mg dose of atropine. His heart rate jumps to nearly 80, and the next blood pressure reading is 112/81. 

Nellie, having given the dextrose and atropine, is now pausing briefly to listen to the patient's lungs. "...God, he's still drowning in secretions. He's on other pressors? ...Why is he on dopamine and norepi, weird. I'm going down on the dopamine, think we're going to have to give him a lot more atropine to get his lungs under control and I don't want to overstimulate his heart." 

Magnesium is running, good. Still waiting for the X-ray tech to show up... Marian will take another blood sugar. 

53 mg/dL. 

At least it's headed in the right direction? Probably she doesn't strictly speaking need to bother Dr Sharma for a repeat order and can just...give him another amp of D50... 

By the time Dr Sharma actually makes it to the room another five minutes later, the X-ray tech has come and gone, and Nellie has the raw image up on the computer screen (where the kid is peering curiously at it.) 

It takes her about four seconds to confirm that the tube is in the right place. "Go ahead with potassium. How's he doing?"

O2 sats at 94%, which isn't incredibly impressive on 100% oxygen but is at least tolerable. Heart rate at 86, last blood pressure 108/79. 

Marian is rechecking his blood pressure yet again. "I, uh, ended up giving him three amps of D50. Repeat sugars were 53 and 66. I don't know where he's putting it all but I think it's helping." The patient's color is a little better, and it's early to say - and hard to know how much is the Bair Hugger - but he might be managing to produce more body heat. He's now back up to 32.2 C. 

"Heart rate's improving but he's still pretty wheezy and wet. Try a higher dose of atropine?" 

"It's been more than five minutes? Yeah, let's try 10 mg next – and grab enough to step up to 20 in another five minutes if he's still wet, we're apparently supposed to just keep going up until his respiratory status improves."

She makes a face. "We really shouldn't be running pressors in a peripheral, but I'm pretty nervous about dropping a line in him before we've corrected his lytes. I'll do an art line, and - hmm, maybe if we're lucky the atropine will let us wean him off the pressors..." 

Marian is just going to hurry off and see if the Pyxis lets her take out six ampoules of atropine without throwing a fit about what the hell she's thinking– oh, right, she should ask about fluids. "Uh, did we want to give him another bolus? He's still pretty cold, we can do it heated -"  

"Yes, definitely, thanks for reminding me." Dr Sharma turns back to Nellie. "You're right, we'll want to start pralidoxime - only once we've hit adequate dosing for atropine, or it can make things worse, but we'll want it ready to go. Protocol is a 2g loading dose over 30 min and then 1g/hour for at least the next 24h and reassess, but probably keep it up for a full 48h. And I need to call the General, our lab doesn't do the diagnostic test we want to confirm it, but you're right that we need to draw that before we start the pralidoxime..." 

Tsashi is wishing desperately that she could understand what anyone was saying! The Healers are definitely doing lots of things in a hurry. They seem calmer, though, there are no more raised voices and the expressions are stressed but not surprised. Her guess is that something was wrong with Lionstar that they weren't expecting, but now they're deciding what to do to help him, and nothing more surprising happened? Which seems...good, probably...but she wishes she knew for sure. 

She slips her hand into Lionstar's. She's a bit worried that he's going to wake up and be very confused and upset. 

Marian comes back a couple of minutes later with pockets full of atropine and a freshly warmed bag of saline to slap into the pressure bag. Awww, the kid is being cute. ...Which is actually weirdly upsetting to watch, probably because it's nearly midnight all of a sudden and Marian is tired and undercaffeinated and hasn't sat down or eaten in way too long. 

The higher dose of atropine almost-instantly spikes the patient's heart rate to 120. The effect on his lungs is less marked and slower to kick in, but it does look like the breath volumes on the ventilator are rising. His sats creep up to 96%. 

Nellie puts the dopamine pump on standby. "I think we can get him off pressors. I'll have another go at suctioning him, maybe now he'll tolerate it long enough to actually get him cleaned out." 

...Oh right Marian was supposed to be checking a repeat blood sugar. She forgot to actually look at the glucometer and now the screen is turned off. Maybe if she pokes it, it'll turn back rather than resetting entirely...? 

- yep, good, 81 mg/dL. "Uh, Dr Sharma, his sugar is back up but it's not, like, super high? I kind of want to recheck hourly," until they have some idea WHY it was so low, she's still at a loss. 

"Yeah, sure," Dr Sharma says distractedly, leaning in to examine the lung secretions now emerging from the suction tubing. "...Wow, he really is wet. I want to have a listen once you're ready to give him a break -?" 

Pause. Nellie silences the ventilator alarm again, checks the sats on the monitor - down to 91% - and goes in for another pass. "Euuggh. ...That might be a bit less, we're making some progress." 

Once Nellie finally does give the patient a break - less because she thinks his lungs are cleared out and more because his sats are still dropping and down to 87% - Dr Sharma swings down her stethoscope to listen to his lungs.

"We're getting better air volumes and lower peak pressures, I think that's a good sign on the bronchospasm? But he's still sounding pretty tight. Marian, go ahead and prep 20 to give in, hmmm, three minutes. And I want some repeat labs, ABG and lactate, but we need the art line anyway, it can wait for that." She glances between them. "...You both look busy. I'll prep the tray." 

Nellie sniffs the air, scowls, and lifts the edge of the Bair Hugger blanket. "- Definitely busy. Dr Sharma, do you want maintenance fluids? Poor guy's losing a bunch of fluids out the back end. - Marian, I'll go get stuff to clean him up, we'll want to do it after he's atropine'd." 

Which leaves Marian abruptly alone with the kid in her patient's room, with two minutes to go until she's supposed to push the syringe of drugs in her hand. 

...He's still sticky with sweat, and drooling, making an unpleasant mix with all the grime around his face and neck. Marian puts her syringe down on the bedside table beside the four empty ampoules, and gets out a small washcloth from the conveniently stocked drawer to wet at the sink and wipe him down a bit. 

The patient hasn't shown any visible sign of responsiveness to anything up until this point, at least not in front of Marian, but apparently having his face washed is particularly stimulating! He grimaces faintly, his forehead scrunching. 

Huh. That's got to be a good sign. ...Also he's not on any sedation whatsoever and they should plausibly at least have something ready to go. And bother to put some wrist restraints on him just in case. They would have serious problems if he pulled out his ET tube now. 

Marian doesn't really think he's conscious enough to hear her, and who knows if he speaks any English, but she reaches for his hand anyway. "Hey," ugh damn it how did Sashy pronounce his name again, "- hey, Lionstar. You're in the hospital. My name is Marian and I'm your nurse. Can you open your eyes?" 

Nope. No further reaction of any kind. 

Well, that's not spectacularly surprising. Marian will finish cleaning his face, and suction his mouth again, and then the clock hits 23:39 and it's time to slowly push an entire 20 mg of atropine into him. She does it into the bolus line, so it'll be automatically diluted, and over an entire minute. 

His heart rate, which fell back to the 90s after Nellie stopped the dopamine, immediately shoots up to almost 140, though only for a few seconds before it starts slowly settling back down. His color is almost instantly more normal. 

For the first time, he seems to notice the blood pressure cuff inflating. He's not reacting purposefully, or moving his limbs at all, but he grimaces slightly again and he takes a breath early, before the ventilator set rate would kick in, and then very weakly coughs. 

(Clear-white foamy secretions bubble up in the endotracheal tube.) 

Blood pressure 147/102. 

Wow! Marian is very proud of him and also he does not need to be 75% of the max rate of norepinephrine. She'll drop it by a decent increment and watch his blood pressure. The new bag of fluids is about halfway done (though it really does feel like that's barely keeping up with the amount he's leaking in saliva and lung goop) and he's already gotten nearly a quarter of the 4g bag of magnesium running in the pump. 

His sats are at a glorious 98%. Better yet, he only drops briefly and to 94% when she suctions him. 

Marian turns to grin at the kid. She can't help it. "He's doing great," she says even though Sashy won't understand her. 

Tsashi is getting the idea! She smiles back. Healing magic looks surprisingly complicated and effortful, they keep bringing in more bizarre artifacts, but it's clearly helping. 

Nellie gets back with fresh sheets and two cartons of heated wipes, just as Marian is dropping the norepinephrine drip again by a smaller increment. (Lionstar's blood pressure is now at 119/83, which is a totally normal BP but higher than it strictly needs to be for adequate perfusion.) His sats are, finally, solidly at 100%. 

Nellie grins as well. "Look at him go! Let's get him clean before it wears off. The atropine should start to calm down his GI tract at some point..." 

"I really hope so." It's awkward having to repeatedly clean him up in front of the twelve-year-old (but it feels even more awkward, and probably upsetting for the poor kid, to kick her out of the room for it), and Marian is kind of worried about how much of the potassium they just got into the guy is now coming out the other end. 

She carefully turns Lionstar toward her, trying to arrange the Bair Hugger so it's still covering at least some of him. 

He tolerates being moved about 500% better than the last time they had to do this; his heart rate barely budges from 120, and his sats dip a little but stabilize at 95%. 

When Nellie bends and lifts his upper leg to clean him, though, he coughs weakly again and then vomits on Marian's arm. 

Auuuuuughhhhhhhh! 

(Marian is, to be clear, not at all bothered for her own sake. It's not even particularly gross puke, it's mostly clear liquid, and his airway is protected. She's upset because that was the POTASSIUM that he was supposed to be DIGESTING and now they'll have to give it IV at a max rate of 100 mEQ/hour and it'll take, like, the next four or five hours to get him up to normal range, or maybe MORE than that if he keeps LOSING BODILY FLUIDS.) 

She make a frustrated noise and grabs for the oral suction. 

Nellie grunts, unsurprised. "...At least he held it in for, like, fifteen minutes. Maybe he got some of it." She wads up the soiled sheet under a pile of towels and darts over to the wall to grab a handful of sani-wipes to use on the waterproof mattress surface. 

And just getting his magnesium up will help even if it takes a while to correct the potassium - and he hasn't done any arrhythmias yet - the monitor tracing actually looks a lot more normal now, though the T waves are still inverted and generally weird-looking. Probably they should do a proper 12-lead ECG at some point? Marian doesn't think that they actually, uh, got around to that at any point. 

She helps Nellie turn the patient back over onto his clean sheets and finish making the bed. 

He's still not noticeably shivering, but he's warming up! Finally back up to 33.0 C, so, well, nearly caught up to the temperature he was when Marian first checked it in the ER. He's taking lovely deep breaths, getting volumes of over 700 mls on the ventilator, and once they get him on his back again with the head of the bed slightly raised, his sats leap back to 100%. His blood pressure is a perfectly respectable 108/67 on only 25% of the max dose of norepinephrine. 

Nellie helps tuck the Bair Hugger Blanket up to his chin. "Great. ...I should really get back to my folks, but I'll do a walkabout to see if I can track down Dr Sharma. She might've gotten waylaid by Annie's transfer." 

"Mmhmm, thanks." Marian feels like she's forgetting something... oh! right! "Ask her about orders for sedation! I don't think we need it yet but I'd feel more comfortable with something prepped and ready to go, he was starting to react a tiny bit and I don't want him to wake up fighty." 

"Great plan." Nellie shoots finger-guns at Marian and then bounces over to the sink to wash her hands before heading out. 

It's 23:48. Nearly midnight. Midnight in Marian's head is deeply associated with Tasks Due but she's not...actually...sure what if anything she has to do on this patient? There are a lot of floating pending items, they were supposed to do some kind of diagnostic blood test that has to be sent to a bigger hospital to process but she needs, like, several additional pieces of information before she can do that... 

She should probably do literally any charting but that sounds like it would require having an attention span, which Marian thinks she can muster if she actually gets a full ten minutes uninterrupted to sit down and pour more caffeine into her face but she's not hopeful about getting that soon. She'll...putter, and tidy up the various mess that managed to accrue on surfaces in the room during the last half-hour. 

Nellie swings by again five minutes later. "You can do midaz for sedation if he needs it, 1-5 mg per hour. I put the order in, I'll cosign a bag with you." She holds it up. "Dr Sharma mentioned he's at some risk of seizures, if he starts seizing you can push 2mg midaz as a standing order. You'll need to start an atropine maintenance infusion now that we've hit the therapeutic dose for him. Dr Sharma's going to put it in, she wanted to double-check the poison control recommendations. - oh, and repeat lytes at midnight, was the other thing. Dr Sharma pointed out the last set was done, like, two hours ago. She thinks she'll be busy for the next bit so you can draw that and a lactate and venous blood gas peripherally. I put the orders in for you." 

"Nellie, I love you."

Marian can cosign a bag of midazolam with her. And put it in her second-to-last available pump, programmed and on standby so it's right there if she needs it. There's a trick she learned from Annie where you can program a bolus in the "piggyback" programming, and if there's no actual piggyback line attached it'll just run the main infusion at the piggyback rate until the volume elapses - she can use that with a rate of 999 ml/h and a volume of 2 ml to give a seizure-halting "push" dose, without having to actually leave the room and frantically pull one of the smaller vials from the Pyxis. 

...Aaand now it's midnight and she has to go dig up bloodwork supplies and draw blood. A venous blood gas won't tell them much about oxygenation but it'll give them information on bicarb and pH, which is presumably what Dr Sharma wants to know. 

She definitely has a feeling she's forgetting something but it's not coming to her.

The patient does not enlighten her! He's lying still under the Bair Hugger blanket. The monitor shows that his temperature is up to 33.2 C. Last blood pressure 103/59. Heart rate 97. Sats at 98%. 

Bloodwork!

...It's not until Marian is dropping the labeled bag of lab tubes for electrolytes, lactate, and a venous blood gas in the nursing station pneumatic tube that she remembers she had also been slightly worried about his hemoglobin. That's - probably not spectacularly urgent? It was barely low before - 11.9 g/dL, if she's remembering it correctly. Normal range for men is 13.5 to 17.5 but for an ICU patient, 11.9 is barely low at all. He's probably dropped a bit more due to hemodilution, after all those fluid boluses, but they don't normally transfuse until hemoglobin falls before 7.5 g/dL. He doesn't look catastrophically anemic. 

Forgetting it is definitely a sign that she's not as on top of everything as she likes to be, though. Which is how things are in emergencies, but the emergency seems to be at least temporarily over, and she should probably sit down at the computer workstation with a piece of paper and review the guy's chart to make an actual todo list, rather than bouncing from task to task as they occur to her like some kind of demented butterfly.

(And then inevitably get interrupted when Dr Sharma comes back to place the art line, but that's how it goes, it's not an excuse not to try to get on top of her shit in the meantime.) 

Marian grabs paper from the printer, heads back to the room, and smiles at Sashy before settling herself at the computer desk between 201 and 202. 

The patient's chart is, unsurprisingly, quite sparse. Name down as 'John Doe', age presumably wildly estimated at 50, nothing under medical history. There are vital signs charted from the ER, but almost no drug administration – right, it's probably all on the paper flowchart since a bunch of it happened during a code, for a generous definition of "during." The temperatures Marian took in the ER aren't charted and nothing is synced yet from the monitor. Marian can fix that quickly. Blood sugar readings also aren't charted and neither is the order to recheck every hour. Marian....can drag some of the results out of her brain, with a bit of guesswork and more guesswork applied to what time she took them, and put those in the chart. She'll recheck at 00:30. 

Lines: Nellie does seem to have documented the gastric tube and Foley. The single IV he arrived with from the ER is listed, but not the second IV Marian placed. She can fix that too. 

Wounds and dressings: the laceration was apparently cleaned and stapled and has an absorbent gauze and Mepilex adhesive dressing. Fine. Marian should, like, look at it at some point, but at the very least it hasn't bled right through the gauze or anything. 

Urine output: nothing charted. Bowel movements: nothing charted. Marian can fix that. 

Medications: Atropine doses are charted; no orders yet for maintenance dosing, that's waiting on Dr Sharma but Marian can make a note on her paper to follow up on it as well as on the diagnostic test and the...god what was it called, she'll put down "pyroxime???".

2 1L saline boluses are charted. Marian can add the third one. Dopamine and norepinephrine infusions are in the chart; Nellie must have noted when she stopped the dopamine, but the norepinephrine is still showing as running at the higher rate. Marian can at least estimate when she titrated it, based on atropine dose history, and retroactively chart that. 

Magnesium is running and will be done around 00:30. Oral potassium 40 mEQ is documented as having been administered a little after 23:30. 

Marian has a mental note that the potassium administration did not work out as hoped and they're going to need to go to IV and oh shit fuck that is definitely not, like, in any way done. She did grab a bag of 10 mEQ potassium in 100ml, but it's still in her scrub pants pocket. 

...Proooooobably she doesn't actually need to track down Dr Sharma again? They did, like, discuss this. She puts in a verbal order and - damn it magnesium is still running - she goes to the med room to get another little saline bag and primary tubing set and secondary tubing set, and jogs back to 202 to get all of that primed and set up in her last remaining pump and hook it up to the same IV line as the magnesium. And chart it. 

...Okay. Back to the computer. Marian's feet are kind of distractingly sore at this point, and she's even more distractingly hungry, but she really needs to figure out if she's forgetting anything else. 

The set of labs drawn shortly after 22:00 continue to show low phosphorus levels and medium-low albumin. 

That's...confusing? Why is that confusing. Because "organophosphates" has the word 'phosphate' it in. 

Marian...is on reflection totally unsure if that's, like, relevant. Dr Sharma didn't give her any orders to supplement phos but honestly that could easily be that she forgot or missed it, there was kind of a lot going on. It's at least much less panic-inducing than the potassium and magnesium results. She's...going to write it down on her list of things to ask Dr Sharma about. 

Dr Sharma reappears around 00:15, pushing yet another bedside table with a sterile line kit on it. "Marian, I am so sorry about that. How is he?" 

Marian scrambles up. "Uh. Vitals are still decent, though I'm wondering if he's still a bit dry? He's running a bit tachycardic for his body temp and his BP is, like, okay, but that's still with some norepi. Uh, and we still wanted to recheck his hemoglobin, I think. ...I put in a verbal order for the IV potassium and started a bag, he vomited when we were cleaning him up. And I remembered his phos is low, too. And kinda low albumin." 

Frown. "Good thought on the K. He'll probably need more than the one bag, right, but I think we can see where it comes back on the repeat labs. We can give him 250ml of 5% albumin instead of another bolus, and then run another hematology after that's in. Maybe with the rest of the admission lab set, we don't have the clotting panel or liver panel on him. ...I'm not sure about the phos, I think the phosphate in organophosphates isn't - bioavailable as elemental phosphorus - but I'm not very sure of that. Let's see how it looks on the followup, I guess." 

She starts setting up the sterile tray next to Lionstar's bed. "I put in the orders for pralidoxime but the pharmacy needs to prepare it, we don't stock it on the unit. Serum cholinesterase needs a paper requisition and to be courier'd to the General, I'm working on arranging that. I need to call poison control back to clarify the maintenance atropine dosing, UptoDate thinks we should start at 0.02 mg/kg per hour but that seems low, poison control had said an hourly rate of 10% to 20% the total effective dose and we know we gave him nearly fifty mg. My guess is that we'll want to run it at around 5mg/hour." 

She washes her hands thoroughly at the sink and then starts carefully donning the sterile procedure gown.

...Right. The thing Marian is doing right now is helping with an art line. 

Sashy should really not be touching anything for this. Marian will smile at her, and then maybe try to encourage her via gestures to have a seat in the reclining chair that someone brought over? 

Tsashi is very curious about what they're about to do! But also capable of taking hints and not being in the way. She sits down and watches. 

The patient, while still not exactly awake, does seem to notice his arm being taken out from under the warm blanket. His fingers twitch ineffectually, and he grimaces and coughs. 

Marian pats his shoulder. "I know, I know, you're cold. You can have the warm blanket back really soon. - Dr Sharma, should I start something for sedation?" 

"Hmmmmmm. I - think I'd rather not? He doesn't seem agitated, and I want to see if his neuro status improves once we start the pralidoxime. We'd be expecting mental status changes, but poison control was surprised that he was GCS 3 even after atropine." 

She slips on sterile gloves. 

Marian is going to hold down Lionstar's arm very firmly. Just in case. 

His brow furrows again when the needle actually goes in, and it seems like he might be trying and failing to bend his arm or pull it away; the muscles in his bicep are maybe tensing slightly. He's not anywhere near strong enough to actually resist Marian's grip. 

Poor guy. Marian murmurs probably-pointless reassurances while Dr Sharma puts two stitches in to hold the art line in place, hooks up the waiting primed pressure tubing, and then puts a dressing over the site. 

Dr Sharma will even hook it up to the monitor and zero the line for Marian! In her mind, it's good practice to at least be comfortable doing the things that nurses would usually do, and the nurses will appreciate you so much for doing something objectively very easy. 

Marian DOES appreciate Dr Sharma! She focuses on getting Lionstar comfortably ensconced under the blanket again. She should really remember to track down some extra pillows at some point to keep his arms nicely supported, the room-cleaning staff seem to have (quite reasonably) returned the enormous stash she had in here for the previous patient to the utility room. 

Lionstar's blood pressure reads a little higher on the art line, which isn't uncommon; he's at a comfortable 109/57 with a comfortable mean arterial pressure of 69. His heart rate is at 103. Temperature 33.7 C. 

...Sats creeping back down to 94%, and he's losing ground on lung volumes on the ventilator. 

And a quick listen with her stethoscope confirms that he's sounding both wheezy and full of secretions. UGH. Doesn't atropine have a longer half-life than that? 

"I think we should probably hurry up and start whatever his maintenance dose is," Marian says, and goes in to suction him. 

Lionstar does NOT LIKE THIS! He still doesn't seem sufficiently capable of moving his limbs to resist or even squirm very much, but he coughs more forcefully, gagging on the tube, and his face scrunches in discomfort. Tears are leaking from under his clenched eyelids.

The secretions coming up are a bit less watery than before, more creamy-white than clear, but still copious. His airways are tight enough that he's noticeably a bit difficult to suction, which Marian has only ever noticed once or twice before in patients with severe asthma. 

He's also leaking saliva from the corners of his mouth– ...no, he's in fact vomiting again, not very forcefully but there are traces of bile in it. 

"Sorry sorry sorry!" Marian turns his head to the side and tries to clean out his mouth with the oral suction before he can make any more of a mess. "No, don't bite it - sorry -" 

Dr Sharma comes over to look. 

"It's probably worth putting the OG tube to suction. Cholinergic agents increase gastric secretions, vomiting isn't surprising." She picks up the endotracheal suction tubing to examine its contents. "...I almost think his lungs could use another atropine loading dose, but I'm worried about overstimulating his heart, I don't know if it's safe to give him anything to control his rate. I need to call poison control back." 

Oh, right, putting the gastric tube on suction is a good idea that Marian had not even slightly thought of. And will let them measure how much fluid he's losing via that route, which might do something to ease Marian's anxiety about his potassium losses, not that there's really anything they can DO about it if it turns out he's losing potassium in bodily fluids faster than they can give it IV. Ugh. 

She hooks the OG tube up to the third prepped suction canister, because she is SO PREPARED, and then focuses on cleaning Lionstar's face again and replacing the towel over his pillow with a clean one. 

Lionstar makes a face again when she lifts his head, his neck muscles tightening. 

Marian tucks the pillow gently under his head. "I'm glad you're starting to wake up a little bit. That's really good. ...Can you squeeze my hand?" 

(Either he cannot do that or he doesn't understand the request.)

Not surprising. Marian will leave him alone. ...Actually, she's going to check the drawers for a set of wrist restraints, fail to find one, and make a mental note to get some from the clean utility when she next has to leave the room, just in case. 

The patient calms down as soon as she stops bothering him and does not try to make a grab for any tubes. His sats are slightly better after being suctioned, but he's still getting unimpressive volumes on the ventilator and, when Marian checks, he sounds less crackly but if anything more wheezy. 

...An entire 350 mls of gastric fluids come out of the OG tube into the suction canister over the next 5 minutes. 

And then it's 00:30 and time to take another blood sugar! It comes back at 67 mg/dL. 

Marian is very glad she thought to get the hourly checks order, because thaaaaaaat is borderline low AGAIN. Where is he putting it. She also doesn't have a standing order to treat low sugars, but she's inclined to take that as a given, put it in as a verbal order and let Dr Sharma know afterward. 

She does that. 

Dr Sharma comes back just as she's disposing of the empty syringe of 50% dextrose. "...Low glucose again? I'm so confused about that - I brought it up with poison control again and apparently this is supposed to cause high sugars if anything. Anyway. We're going to push another 10mg now, because I think we got a bit behind over the last half-hour, and I'll show you the order I put in, one moment..." 

Marian follows her out to the hall computer. 

"It's kind of involved, sorry. Start him at 10 mg/h atropine - they suggest diluting it in saline, take 10ml out of a 50ml bag of saline and add your 10mg of atropine so it's a total of 10 mg in 50 ml, 0.2 mg per ml. Titrate up by 2mg/h for bradycardia below 60 bpm or bronchospasm or copious secretions, titrate down by 2mg/h for systolic BP above 140 or tachycardia above 120 - sustained longer than 5 minutes, it's not worrying if he's up there briefly. Pause the infusion and call me for tachycardia above 150. Does that make sense?" 

It's definitely involved but it's all there in the order notes. Marian nods. "...Can I prepare more than 50ml at once? Uh, I don't know if it's not stable for hours or something, but I would be running through a bag every hour if I do 50ml at a time." 

"- Right. Sorry. I can't imagine it would be an issue to prepare more, if you'll definitely use it within 12 hours." Dr Sharma drags a hand over her hair. "I need to finish filling out the paperwork requisition for the test, courier should be here by 1 am. I called the pharmacy to bother them about pralidoxime, the orders are in. ...Am I forgetting anything you still need?" 

"Um." Marian checks her paper. "...Right, we're still waiting on labs for whether to supplement phos. Um. I don't think so. I'll keep checking for the labs and come find you when they're back?" 

"Sounds good. I think you'll probably find me in 196, she's pretty unstable." 

Oh no Marian did not manage to help at all with Annie's admission and now she feels bad about it. 

...Priorities. She needs to - go pull a huge pile of atropine, 10mg for another push dose and - hmm, 50 mg in 250 ml saline would still be 0.2mg per ml, and she can probably just do that with a 200ml bag rather than fuss around removing 50 ml from a 250 ml bag...that's going to take a while to mix, she should give the poor man his push dose first...

The poor man's lungs do seem to appreciate it! His heart rate jumps again, unsurprisingly, but it's only above 120 for a few seconds, and settles back to around 110. 

Temperature 33.9 C. 

Which is STILL HYPOTHERMIC but they're making progress! Slowly! Time to set herself up with a syringe and filter needle at the bedside table station and methodically break open 10 ampoules of 5mg/5ml atropine to inject them into a bag of saline! 

Tsashi creeps out of her chair to watch this process with utter absorbed fascination. 

Awwwww. It's really too bad they don't share a language, it would be neat if Marian could explain to the clearly smart and inquisitive twelve-year-old what exactly they're doing to support Lionstar's body while he recovers. She seems like such a cool kid. Marian settles for smiling at her a lot. 

Chantal interrupts her around halfway through prepping the bag. "Marian! Lab for you. Line 4." 

Great. Perfect. Marian pats her pockets to make sure she has her paper and pen there, and then abandons her half-mixed drugs and darts out to pick up the phone. "Yes?" 

They have results for her! Critical results! 

Lactate: still 4.2. It's coming down, but slowly. 

Venous blood gas: his pCO2 is a touch high (53 mmHg), though it's not as informative in venous blood. His pH is all the way down at 7.01. Bicarb 12.9 mmol/L, well below the normal venous blood range of 23-29. 

Electrolytes: potassium still critically low, at 2.9 mmol/L. Magnesium at 1.5 mg/dL, still low but no longer critically so. Phosphate still critically low - actually, very slightly lower than before - at 1.1 mg/dL.

Sodium now also slightly low, at 132 mmol/L (normal 135 to 145). Albumin now significantly lower; the test doesn't give critical results, but it's at 2.8 g/dL (normal 3.4 to 5.4). 

WELL ISN'T THAT JUST GREAT.

None of it is new and an emergency. His potassium is at least not lower than before they started trying to keep up at supplementing it? 3.0 is usually the cutoff when it counts as low-but-not-critical and they're nearly there. She already has an order to do something about his albumin; the lower result isn't shocking, his blood is way more diluted now, though it does hint that she should maybe make rechecking his hemoglobin a priority. The sodium drop is...probably diarrheal losses? Ugh, despite the fact that they've given him three liters of normal saline. She should probably bother Dr Sharma about the pH, find out whether they want to give him an amp of bicarbonate for it or confirm with an iSTAT arterial blood gas now that they can do that easily. 

...Marian is just going to go finish mixing and labeling the atropine before she forgets where she was on that. And actually start the albumin, and - 

- she runs aground on the fact that she's currently using every single one of the five IV pump in the room. Well, not using-using, the dopamine is on standby and she hasn't started running the midazolam, but the norepi and potassium and magnesium pumps are definitely in use, and she doesn't want to overwrite the programming for the ones she might need again any minute. 

This is not a good week for finding pumps; nearly every patient on the unit is sick enough to be on half a dozen IV infusions. Marian will grumpily go look in the clean utility, find one pump - that can be atropine - and then grumpily decide that a heart rate of 108 and BP of 113/52 means she probably won't need the dopamine again in the next hour, and that one can be stolen to run albumin.

She's also pretty short on IV lines. And the drawer did not end up stocked with stopcocks for adding more usable saline-lock ports. She ends up daisy chaining the albumin in a Y-site with the electrolytes, and atropine with the norepinephrine and now-finished saline bolus. She'll make a mental note to canvas the unit for unused pumps in patient rooms that can be stolen, and then go looking for Dr Sharma. 

Annie does not look like she's having the best night. The room is on airborne isolation, door firmly shut and plastered with warning placards, but leaving enough of the window uncovered for Marian to observe a room full of the detritus that accumulates after more than thirty minutes straight of uninterrupted emergency. The patient appears to be a short, very obese lady; Marie can't see her face, Annie is standing in the way, but her exposed lower legs look alarmingly blotchy and mottled. The monitor shows rapid irregular atrial fibrillation at 170 bpm and a cuff BP of 79/50. 

There's a crash cart in the room. There's also a Dr Sharma, apparently setting up to place a central line. 

Ughhhhhhh Marian does not really want to put on a gown and N95 mask and faceshield just to walk in for 30 seconds and ask Dr Sharma a question. 

...She thinks briefly, then darts back to the nursing station for a pad of paper and Sharpie. She writes in large block letters. 202 VENOUS PH 7. GIVE BICARB (1) OR REPEAT ON ABG (2)? 

She returns to the window, holds up her makeshift sign, and taps it until Annie looks over. 

Annie gets Dr Sharma's attention, and Dr Sharma comes over to the window and squints at the sign. She shrugs and holds up 1 finger, then mouths...something...that Marian cannot entirely make out but that probably refers to repeating an ABG later. 

It's 00:41. She'll....urghhhh, bicarbonate is incompatible with tons of things...she'll PLACE ANOTHER IV LINE, Lionstar has decent veins and should be better-hydrated now, she'll do that and give an amp of bicarb and check it along with hemoglobin once the albumin is done. Wait, she's forgetting bloodwork...isn't there a courier coming at 1 am...? That's in nineteen minutes and she does NOT have a paper requisition form from Dr Sharma and, in fact, has no idea what color tube to use. Hopefully Dr Sharma hasn't forgotten and will do that once she's finished the line in 196...

It's tempting to rush to get her patient's bicarb given and then go help Annie, but the voice of common sense is very firm that she should not do that right now. Marian sighs and goes to grab a syringe of bicarb from the med room.  

The patient has not gotten worse during her brief absence! The albumin (running over 15 min) might already be helping improve his intravascular volume status; his heart rate is down to 96 and his blood pressure is up at 117/56, mean arterial pressure 76. His O2 saturation is at 99%. 

He's still getting 100% oxygen on the ventilator and pooossibly at some point she should get RT in here to assess whether he really needs to be, but...maybe not just yet, he was still dropping noticeably with suctioning and still needing that pretty often.

He can be on less norepinephrine, though! Marian is happy. She's now down to a pretty tiny dose and the trend looks promising for stopping it entirely. And he can get another 20G IV in his other forearm, and his pH fixed with a syringe of bicarbonate. 

It's 00:49. What is she forgetting... She should turn him at some point, but that's not spectacularly urgent, he's been technically "on his back" since he arrived around 10 but they've moved him a bunch in that period. Actually you know what she should do, is turn 201, who is by now solidly due. ...A glance around the hallway is not promising in terms of finding someone to help, but she can probably iso up and do it herself - at some risk of future back injuries that Marian is, honestly, not especially motivated to care about right now - and be out promptly to make sure Dr Sharma is going to get the bloodwork requisition in. 

Dr Sharma does apologetically rush over at 00:53 and leave a wad of paperwork and a lab tube on the desk outside the room. She briefly makes eye contact with Marian and points to it before rushing off to wherever she needs to be next. 

Tsashi is feeling kind of tired at this point. It felt like being scared for Lionstar would keep her awake forever, but apparently not. It feels very draining not understanding what's happening. She sort of wants her mother, which is such an unhelpful feeling to be having. 

No one is nearby. She looks around, then drags the reclining chair close to the mage-contraption holding Lionstar, and curls up in it with one arm reaching over the side of the box-thing to hold his hand. 

Marian tugs sheets and stuffs pillows and does very hurried mouth care and hurriedly apologizes to Ms Lebedev in 201 when she makes a face about the hasty mouth care, and then de-gowns and de-masks and washes her hands as fast as she can. She's back in 202 by 00:56. 

...Drawers do not have the adapter thingy to take blood from an art line, fuck. She's back from the clean utility with that by 00:57. Sashy is watching her from the reclining chair, looking sleepy-curious, awwww. Okay, great, handwritten label on the tube, sign her name on the paper rec, shove everything in a biohazard bag, now where is she supposed to go to get this to the courier...? 

Probably the charge nurse was at some point involved in helping arrange a courier. She goes to ask Chantal. 

Chantal looks very harried and has no idea. 

Okay. She really wants this blood to make it to its destination. Also to not get yelled at by some poor person doing courier runs at 1 am. The front reception desk is closed at night, so probably they're going to show up to the ER?

She asks Louis-Philipe to keep an eye on her people for five minutes, and then sprints down the hall to the ER. 

The ER charge nurse does know what she's talking about! "They called us twice. They're going to be twenty minutes late, but I can hold onto that for you - it's for the code earlier? How's he doing?" 

"Uh. Better. SorryIshouldreallygetback." 

She runs. 

Nobody is dying when she gets back to the ICU! 

Oh good. She can thank Louis-Philipe and then...sit down. Look at the chart. Remember to document the third IV she placed. Remember that she hasn't charted anything for urine output since Nellie put the catheter in (she put a roughly-estimated 400 ml in the input/output flowsheet at 23:30), go in and flip the measuring-box again and chart another 125 ml. ...And 460 ml of gastric contents in the suction catheter. He's still theoretically positive several liters on fluids but there are a lot of fluid losses not being successfully measured, he's probably losing a nontrivial amount literally to saliva. 

Maintenance drugs are running. ...Albumin's done, she should go pull a hemoglobin. And do a ABG on the iSTAT at the same time. That involves standing up. She's going to do that any second now, definitely. 

It takes kind of a while to find the iSTAT machine (Jean has it in 190) but she does, on her travels searching for it, find two not-in-use IV pumps to steal! 

Her patient appears to be resting comfortably when she gets to his room at 01:09. Heart rate 92, blood pressure 107/62, temperature 34.4 C, sats 99%. There is a very drowsy-looking child in the chair bedside him. 

...He is noticeably more responsive. Gently untucking his arm from under the Bair Hugger blanket shouldn't be causing him any particular discomfort, but he makes a face - not so much a pained face, just some kind of reaction - and seems to be trying to lift his head off the pillow, though not with any particular success. His eyes aren't open but his eyelids twitch in a way that looks like he might be trying. 

Awwwww Marian is so pleased and proud of him for responding to stimuli! 

...She is going to be a spectacularly mean horrible person, and pinch his nailbed hard to see how much response that gets. 

Lionstar is very unhappy about that! His face twists into a grimace and he takes a much deeper breath than usual and then coughs.

He's not really managing to pull away from the unpleasant stimulus, but his muscles tense enough that his arm twitches a little; he seems to be trying, and just not sufficiently competent at moving his limbs to get anywhere. His eyes still aren't quite opening. 

"I'm so sorry." Marian stops cruelly causing him pain and gently pats his hand instead. "I need to see how awake you are, is all. You're getting there." 

She draws blood, which shouldn't hurt him at all. Art lines are great. 

He doesn't seem completely happy until she has him thoroughly covered up by the Bair Hugger again. Maybe he's cold. 

That would be super reasonable of him! His body temperature is still below 35 C! 

Marian puts the little blood collector dingy in the iSTAT machine and leaves it on the bedside table while she dashes out to send the hemoglobin tube to the lab. 

Which means the results will be up by the time she's back! Arterial PaO2 is 78 mmHg, juuust barely squeaking above the cutoff for normal range. PaCO2 is 44 mgHg, in normal range. Bicarb 15.9 mEq/L, still low but less drastically so, and pH 7.18, still below the normal-threshold cutoff of 7.35.  

Some of that is probably his lactate, which will slowly return to normal as his liver finishes clearing it, but...on reflection he probably lost some bicarbonate ions in the diarrhea, stool is normally alkaline. (The gastric secretions in vomit are normally acidic, and heavy vomiting - or prolonged gastric tube drainage - can result in a metabolic alkalosis, so that's going to be partially cancelling out, but there was, like, really quite a lot of liquid stool.) 

It doesn't seem urgent enough to bother Dr Sharma. Marian documents the result and cleans the iSTAT machine and returns it to its charging dock in the med room like a good citizen, and then goes back to SITTING.

...Several minutes into her lovely relaxing sitting, which she spends poking around the chart filling in neglected areas like the patient's skin condition (no bedsores, no jaundice, no notable abrasions or bruises, there is not actually a box to chart 'completely filthy' but she should deal with that at some point), Marian remembers that she is PRETTY SURE Dr Sharma said something about doing the rest of the admission bloodwork set. 

Also wrist restraints. 

Also they're supposed to be starting the other antidote drug? Proxidime, no, praloxime, no, not that either, it's more syllables than that but she's not 100% where the syllables go– ...yep, the order is in the chart, good on Dr Sharma. No one has come to tell her about a pharmacy delivery but they honestly might not have, it's that kind of night. 

She's going to put in verbal orders for the admission labs they haven't yet checked off (mainly liver enzymes and clotting factors) and then UNSIT and go obtain wrist restraints and correct blood tubes and hunt for a possible medication delivery. 

There's a medication delivery! It's ended up half buried in what must have been an extremely delayed drift of routine restocking. She has a nicely pharmacy-labeled baggie with one 100ml bag of saline apparently containing 2g of pralidoxime, to be given over 30 minutes, and then two plump 250ml bags of 5% dextrose solution mixed at a concentration of 10 mcg/ml, to be administered at a rate of 8 mg/kg/hour. 

FUCK what does her patient weigh. Marian is really bad at estimating people's weight visually, as she learned dramatically last year when she eyeballed a short by heavyset woman and guessed "oh probably 70kg" and turned out to be underestimating it by nearly 25 kg. She should probably get a proper bed weight, hopefully the bed was actually zeroed, but that involves stripping all non-patient things off the bed and stealing the Bair Hugger is going to make Lionstar sad. 

She'll prime tubing - the 250ml bag can go in the main line and the little initial infusion in piggyback, presumably, the same drug is definitely compatible with itself - and make sure all of that is ready, and check that the bed is in fact zeroed (it is) before exposing him to the elements. 

He's so unhappy about it! He apparently still can't really move to express his unhappiness, but he can definitely tense up and make an agonized expression about it. 

63.2 kg. Plus or minus a hospital gown, she's not going to strip him naked for this. 

Huh. He's a grown man, and not a short man - his feet aren't quite bumping into the footboard but he definitely stretches out over most of the bed's length - and he weighs only a tiny bit more than Marian does. That's got to be an 'underweight' BMI. 

She covers him up again, and programs one of her nice new unused pumps - piggyback over 30 min, then main infusion with the MANUAL DRUG setting and details entered, the rate comes to almost exactly 50 ml/h - and hooks it into the nice new unused IV, and starts it.

And then has to spend thirty seconds retrieving everything else in her stack. Bloodwork, right, and restraints. 

Lionstar really doesn't seem to like the restraints. Marian is being very gentle, and reaching under the Bair Hugger blanket rather than lifting it to avoid making him feel cold, and he still grimaces and twitches and seems like he would absolutely be fighting her about it if he had any muscle strength to speak of. 

Huh. Marian apologizes instinctively, of course, and then - can he open his eyes to a loud firm verbal request? (Or try to squeeze her hand, but she's less hopeful about that, he seems to have some serious neuromuscular Problems going on. She should really go look up the side effects of organophosphate poisoning, just so she knows which things are definitely because of that and which things are still weird and notable.) 

He doesn't particularly react to her voice at all, let alone take actions on request. 

Huh. So...not really awake, she's not even sure she would call that 'localizes pain' or 'purposeful movement', he's not opening his eyes even to painful stimuli, he just...really hates restraints?

Actually, Marian is starting to wonder if he's just generally in pain, given how much he's reacting to things that shouldn't in themselves be painful. It wouldn't be that surprising, he has a giant laceration with staples in it, and it seems plausible some of the poisoning symptoms are directly painful. It seems reasonable not to sedate him too hard, given that they want to be able to assess neuro changes, but maybe she can at least ask about giving him something for pain. 

For now, it's nearly 1:30 am, and she's going to dim the lights and leave him (and the kid) alone to rest while she goes and sends bloodwork, and then comes back and sits at the computer desk repeatedly refreshing the lab work screen. 

The lab doesn't call, but eventually the hematology comes back. The patient's white count is now slightly elevated - maybe a sign of generic inflammation, maybe because all the secretions gave some bacteria a chance to start something in his lungs. His hemoglobin is in fact reading lower now, at 9.2 g/dl, but clearly not low enough to prompt a call from the lab. 

Urghhh, even if he didn't aspirate before he was intubated, he's probably at super high risk of hospital-acquired pneumonia, given the lakes of lung secretions. Nothing worth bothering Dr Sharma about yet, though. He's probably pretty due to be suctioned but she just finished making him uncomfortable and it would be polite to give him a few minutes to actually just sleep. 

...After ten more minutes of poking at both her patients' charts, filling in gaps she forgot to document and reassuring herself that she's probably not forgetting any pending tasks, Marian has to admit that she's more or less caught up. It's 01:37. Six hours to go. ...Six hours is so long and she is, now that she's stopped moving, pretty impressively exhausted. The cafe is closed, obviously, but this maybe calls for making herself a 3x-strength instant coffee packets concoction in the patient kitchen. 

She'll drink that, and then wander around the unit seeing if anyone else needs help, because she is not doing great tonight on her personal quota for helping other people at least as much as she's getting help with her own patients. 

Nellie has 192 and 194. She's charting, but spins in her chair when she sees Marian. "Looking for tasks? I'm overdue to turn my peeps, I'll help with yours after if you help with mine." 

"Sure! 201's good for a while but, yeah, 202's been on his back forever." She gulps down the remaining dregs of coffee. "Let's do it." 

Nellie's patient in 192 is a woman in her late forties with a bleached mohawk and an elaborate cyberpunk sleeve tattoo, who looks like she might have, at one point before getting sick, been a professional bodybuilder. She's intubated, but awake; Nellie addresses her, somewhat incongruously, as Dory.

Dory is recently post-op for some kind of complicated abdominal surgery; she has a colostomy bag, an enormous midline incision leaking through a heavy gauze dressing, and two bulb-suction drains hanging from slim rubber tubes sutured to her abdomen, both full of pinkish-yellow drainage; Nellie scowls at them and then empties them with a long-suffering expression. Dory has both an epidural hooked up to continuous pump, and a patient-controlled analgesic button which she stoically presses before they prepare to turn her. In spite of it, she's cooperative but clearly in enormous pain. She gamely exchanges a fist bump with Nellie and accepts a mouth swab, and they head to the next room. 

194 has been here for 10 days, and is something of a frequent flyer in general; Marian knows him. He's a gaunt, dignified black man in his late eighties with an Oxford accent, and one of the worst hearts of anyone Marian's ever treated, once you add the filter "and they went home from the hospital alive, to live mostly independently in their bungalow, more than once."

He's had three heart attacks and two bypass surgeries. He has a pacemaker and an implanted defibrillator and his left ventricular ejection fraction is in the vicinity of 10% on a good day. He ends up in the ICU a couple of times a year with some new and exciting cardiac or probably-cardiac misbehavior - this time, several fainting episodes at home, which you would think a pacemaker would stop but the cardiologist suspects that some kind of autonomic blood pressure regulation issue is combining badly with his chronically abysmal cardiac output.

...At home, he somehow lives more or less independently, perfectly compliant with his ever-rotating roster of a dozen-plus cardiac medications, with nitroglycerine spray to control his angina and occasional use of home oxygen "when he feels like he needs it." He's been Dr Fauckensteir's cardiology patient for fifteen years. He's not even pre-diabetic, his lungs are fine despite a lifetime's cigar-smoking habit, and his kidneys are pristine. Bets have been exchanged on whether he's going to make it another fifteen and top age 100. 

He's unfailingly polite, even when being nudged awake at nearly 2 am to be scooted up in bed and tucked in on his other side. He asks Marian how her mother's fabric art business is going. (They ended up making conversation about that on his last admission six months ago.) 

Marian really enjoys seeing Nellie interact with her patients. It always feels like she's learning something. 

...Aaaand now it's just past 2 am and she's antsy to lay eyes on 202. 

Nothing terrible seems to have happened? His sats are creeping down again, now at 94%, probably because he's long-overdue for suctioning. Heart rate at 101, blood pressure 108/61, temperature finally up to 35.1 C.

Even at rest, his expression maybe looks slightly pained? 

It's taking him kind of a while to warm up all the way, Marian thinks. Maybe just because he has some kind of neuromuscular weakness thing going on and can't shiver effectively? ...Also shit she totally missed the 1:30 am hourly blood sugar check, though at least partly because on the half-hour is a counterintuitive time for Tasks to be due and it's actually convenient to shift that to the top of the hour. She'll make a REALLY VERY LOUD mental note and do it after Nellie leaves to avoid admitting to embarrassment and failure.

She frowns. "I think he might be having some discomfort - he wasn't awake-awake before, at all, but he was making a lot of faces, and he looks kinda..." Wiggly-hand gesture. "Uh, we should probably just turn him and then I'll go try to grab Dr Sharma–" Nellie is wearing an odd expression, "...what?"

"Something smells bad in here." Nellie starts lifting the edge of the Bair Hugger blanket to peer under it. 

Cue a grimacing unhappy patient! 

Also a curled-up twelve-year-old sleepily lifting her rumpled head. The Healers aren't speaking loudly, but there was something in the red-haired woman's voice making Tsashi's hindbrain feel like it's a good time to be fully alert. 

Oh no Marian's lack of a functional sense of smell is embarrassing her again (even if it's often convenient in this job.) "Uh, should I get supplies to clean him up again?" 

"Nnno, it's not stool." Nellie flips the blanket out of the way. "Sorry, hon," she says absently to Lionstar, "I know it's nippy.

 - Marian," she adds in the exact same tone of voice. "I'm assuming his gown wasn't soaked with something gross the last time you looked. How long ago was that?" 

"What? Uh. Not...that long before 1:30? I had to weigh him to start the pralidoxime - what is it -?" 

"I don't know, but I think I want gloves on to touch it." Nellie hurries to grab some from the box in the wall dispenser, then wrinkles her nose as she carefully folds back the patient's gown. 

"...Okay, well, that does look like a problem." 

No, not allowed, no more problems Marian hurries over to look. 

The lower half of the gauze dressing taped diagonally over the patient's torso is now saturated with...something. It's not bloody, or the usual yellow serous drainage; it's a thicker, darker brownish-green. 

That looks pretty alarmingly bad! Tsashi makes a tiny involuntary squeak and then holds very still out of the way. 

"I'm really not looking forward to this," Nellie says, and then peels back the gauze. "...Jesus on a cracker. Wow. What the fuck." 

Someone in the ER did a very hasty staple job, but that's not really the most visually obvious part. The lips of the ten-inch-long wound are swollen and discolored, the flesh purplish-gray and sometimes almost black, and the full length of it is crusty and oozing. Now Marian can smell it. 

Marian resists the horrible pointless urge to retort back with 'I thought the idea was Jesus was the cracker.' Shut up, brain. "I'm, uh, going to get Dr Sharma to come look." 

"Yeah. Do that." 

That does seem like kind of what you would expect after getting gored by a venomous Changecreature but it's stressful that the Healers seem to be so surprised and confused about it!!! Maybe Tsashi didn't manage to convey the part about the Changecreature very well. 

Dr Sharma is, unsurprisingly, at the desk outside 196, watching through the window while catching up on charting. Marian clears her throat. "Sorryit'sanemergency can you come see 202 with me right now please sorry -" 

Dr Sharma doesn't ask, just scrambles up and follows Marian at a brisk speedwalk back to the room. 

...She sucks in her breath. 

"Okay. I don't...know what could've caused - that. I, think I want to call Dr Sita," the ICU attending doctor on for this week, "and - maybe poison control would have ideas? But I don't - think - that organophosphates would cause this even if they were - introduced into the wound..." 

She takes a deep breath. "He needs to go to the OR. It's gotten this bad in - three, four hours? He needs to go soon. I need to - make some phone calls - just keep it clean and covered for now - tell me right away if his vitals change -" 

Marian clears her throat. "Can I give him anything for pain? He's," vague gesture at Lionstar, who still isn't moving much but whose face is scrunched in discomfort. 

Dr Sharma breathes out between her teeth. "I - hmm. I don't want to do too much, if he's going to be going under anesthesia soon, but - you can give 25 of fentanyl, see what that does." 

That will PROBABLY NOT DO MUCH but, fine, Dr Sharma has a point, it's not worth risking tanking his blood pressure or something. "Okay, thanks. - Nellie, I can go pull that and grab dressing supplies if you can do a cosign -?"

"Mmhm. Grab me a buncha the non-adhesive pads, and abdo pads, and - hmm a roll of that gentle-skin tape, if he's headed straight for the OR I'll just pin the corners down. - and a towel and a thing of saline, this thing is gunky -" 

Marian is not normally squeamish about wounds, but this one is kind of horrifying her. Mostly it's the suddenness of it, and the fact that Dr Sharma seemed just as baffled and thrown-off-balance about it as she feels. She's feeling an entirely uncharacteristic relief that dealing with it in the OR is going to be someone else's problem. 

She puts in a verbal order for fentanyl and pulls a 50 mcg ampoule from the Pyxis (they're technically supposed to waste the excess but she's inclined to pull it all up in a syringe and keep it in case 25 mcg does nothing and she can persuade Dr Sharma to let her give him the rest), and then heads for the clean utility and loads up her arms with the requested dressing supplies. 

Louis-Philipe seems to be collecting supplies for his own patient's dressing change, and steps out of her way. "Something going on?" 

Marian does not really feel like she has time to explain. "Yeah, kinda." She grabs a roll of paper tape - and sterile gloves and one of the dressing-change kits that comes with a sterile thingy to put saline in, Nellie didn't ask but it's probably not a bad idea - and is out the door again. 

Nellie, tongue between her teeth, is carefully trying to peel away the remainder of the adhesive holding the old dressing in place. "Mmm, thanks. ...Marian, chill, he's not actually any more unstable than he was ten minutes ago." 

Marian is NOT ACTUALLY SURE that logic particularly holds!! Ten minutes ago she thought they had, like, identified and more or less dealt with all of Lionstar's problems? And that the rest of the shift, and probably his next few days, would just be a grind of supportive care and juggling the atropine dosage while they waited for the poison to clear his system. And now it looks like there's something ELSE wrong with him that is PROBABLY NOT EXPLAINED by "he ate some pesticides" (whether accidentally or deliberately) and she has a bad feeling that the suddenly-elevated white count isn't his lungs brewing something after all, and might be getting worse even as they speak and it'll take, like, at least half an hour to actually get him to the OR and get rid of the horrifying damaged tissue before it gets worse... 

- she should probably chill anyway. At least half of her reaction is probably because she just consumed some extra-concentrated caffeine, and if she looks freaked out she's going to freak out the kid and no one needs that. She takes some deep breaths, and dumps everything she's holding on the bedside table so she can free up her hands to retrieve the fentanyl and syringe from her pocket and pull it up. 

Half a syringe of fentanyl does seem to help a little? Lionstar's resting expression is less tense, and he only winces faintly when Nellie dripples cold sterile saline from the bottle over his stomach. 

...With the blanket off, he's noticeably losing ground on body temperature. He's down to 34.8 C again. 

Poor guy, no wonder he's miserable about having the blanket stolen. (Nellie seems to have turned it off entirely, presumably because it's threatening to blow unsterile air at her dressing-change site.) Marian isn't really sure what to do about it right now – and she's a little worried he'll lose even more ground while he's in the ER, patients notoriously tend to come back from them chilly. 

Some instinct reminds her that she was due to check his blood sugar. It hasn't especially gotten less confusing that he keeps going low, but it would explain some of his difficulty with generating any body heat. 

She caps the leftover-fentanyl syringe, hastily tapes it to the empty ampoule in lieu of labeling it, and hides it in a drawer - it's not great practice to just leave them lying around on surfaces - and then looks for the glucometer. Perhaps unsurprisingly, it looks like one of the other nurses nabbed hers from the room while she was occupied elsewhere. She'll go hunt at the nursing station. 

Nellie is accumulating an entire pile of soiled gauzes, heaping them on a towel to one side of the patient. 

Lionstar makes a face when Marian sticks his finger for the blood sugar. The reading comes back at 73 mg/dL. 

Hmmmm. Normal range, but, like, barely. Marian is on an instinctive level tempted to give him more D50 anyway, just because it sort of feels like he could use it, but that is not actually how the standing order works. She'll...make a note to herself to make sure she includes his persistent low blood sugar problem in her report to the OR nurse. 

...How does her patient look, other than that? 

His heart rate is up a bit, at 111, maybe from discomfort. Blood pressure 104/67 with a MAP of 79; he probably doesn't need the norepinephrine running. He does look like he's quite overdue for suctioning; his sats are at 91%. 

Something about the gestalt of how he looks is leaving Marian uneasy, though it's hard to tell how much of that is because he's still visibly in some pain, or because the horrifying wound is VERY SALIENT. 

...Yeah. 

Suctioning him sounds like it might disrupt what Nellie is doing and Marian can't shake the irrational worry that the exertion of coughing will make his laceration burst open and the monster from Alien will crawl out that is not how anything works, and the wound didn't even penetrate his abdominal wall. 

She pulls down her stethoscope to listen to his lungs first, since she can do that without getting in Nellie's way. 

He actually sounds significantly less tight and wheezy than she remembers! Probably a mix of the atropine helping counteract the bronchospasm, and the fact that Marian hasn't irritated his bronchi by shoving a suction catheter down them in, like, over an hour. (He's also getting decent breath volumes on the ventilator, consistently above 600 ml.) 

He's absolutely full of coarse crackles, though. 

"Okay, you know what, I fucking give up. The surgeon's going to debride all of this anyway. ...Can you grab me, like, six more gauzes from the drawer to pat it dry, I used all of mine." 

Gauzes obtained, Nellie pats the wound dry - it's mostly de-crusted, but already leaking fresh greenish-black pus - and stacks non-adhesive pads over it before layering three of the extra-absorbent abdominal pads over that and stretching a few strips of tape over the whole thing to loosely pin it in place. 

It's so much less scary now that she can't see it Marian is not six and her brain should stop that. "Thank you," she says emphatically. "Uh, I guess he could use a clean gown..." There's still one in the room, fortunately, and then she'll put the Bair Hugger blanket back and switch the machine back on at the highest heat setting. And then she can suction Lionstar's lungs out. 

It's around 2:25 am by the time Dr Sharma trudges back to the room. She looks very tired. "Dr Sita is driving in. He was going to page Dr Norbin for gen surg, but he wants to see the patient first, and be on hand in the OR. It sounds like they'll be ready for him in 45 minutes." 

That's SO LONG what if Lionstar is being EATEN FROM THE INSIDE BY THE MONSTER FROM ALIENMarian's brain can stop that please. "Right. Um. Just a head's up that his sugar is still, like, borderline - I can check it again before they take him. Uh, and it would be neat if they could do something to keep him warm in the OR, he loses body heat really fast without the Bair Hugger." 

"Huh. That's a good thought, people always do come back cold and he's already so fragile. ...Dr Sita wants us to type-and-cross him and have matched blood ready, he doesn't have a lot of wiggle room for more blood loss. And we should try to push his magnesium up, Dr Sita actually wants him above normal range, so let's give him another 2g over half an hour. ...Is he otherwise more or less stable?" 

Lionstar is looking more comfortable with the blanket back in place, though his temperature is still only at 34.9 C. He's entirely off norepinephrine. Heart rate at 98, blood pressure 102/62, sats at 99%. 

"He's oxygenating fine when we leave him alone, but he still needs a lot of suctioning and he desats fast with it," Marian says. "He's still on 100% on the vent but I don't really want to go lower yet, given that. ...Um, I do kind of still feel like he could use something for sedation and pain control? I know we wanted to get an accurate neuro baseline, but if he's about to go under anesthesia in forty-five minutes anyway...I think he's, like, just awake enough to be really uncomfortable..." 

...Nod. "I suppose it's kind of mean to be suctioning him a lot if he's feeling it. Maybe it's not a bad idea to try to get a neuro baseline now and then start him on some midaz and fentanyl? I'm not surprised that wound is painful." 

She goes over to the bed, leans in close. "SIR! CAN YOU PLEASE OPEN YOUR EYES?" 

...Nope, but that's apparently loud enough for him to notice, and make a face about it. 

"I'm sorry about this," Dr Sharma says, and then pulls the top of the Bair Hugger blanket down and rubs her knuckles up and down his sternum, quite hard. 

That gets a reaction! The patient tenses noticeably, breathing out suddenly against the ventilator's rhythm and setting off the alarm. His face scrunches and his eyes actually make it partway open, unfocused. 

"Good! I need you to try to wake up as much as you can, just for a minute - can you squeeze my hand -?" Dr Sharma reaches under the blanket for his hand. ...And, when the patient's eyes instead start to slide shut again, sternum-rubs him again. 

...Something hurts, unexpectedly. Something else is loud and bright. Something is wrong. 

Lionstar can't - really - finish a thought, or even start one, but certain reflexes are very deeply engrained. He reacts instinctively. His instinct is to shield himself with magic. 

...It doesn't work. Something is wrong and bad and there's a blazing burst of some-kind-of-sensation, too intense to be pain, and - notsafeunderattack - Lionstar struggles against it, but it only makes it worse - 

There's an unexpected crackle of...static electricity? 

The patient goes rigid on the bed, at least to the extent he can when most of his muscles are clearly not accepting input right now. His eyes roll back, his breathing abruptly shallow and rapid (the ventilator loudly objects.) His facial muscles seem to be spasming, not in a very purposeful or expressive way. 

Dr Sharma jumps back, startled. 

....Watches for a couple of seconds, frown growing. "- Marian? Is this new?" She reaches in, a bit tentatively, to lift the patient's eyelid and shine a penlight in his eyes. "I - think he might be seizing? Has he done something like this before with you?" 

Marian was ALSO startled and now her heart rate is unpleasantly elevated. "No! He definitely hasn't done that before!" 

"Okay. I can't tell - maybe he's just really freaked out -" She's going to back off and watch for a few more seconds to see if the patient stops whatever-that-is on his own. 

He does not! His face is still twitching in a way that really doesn't look like his previous grimace-responses to discomfort, and - it's not so much that he's fighting the ventilator, that would imply more purposefulness than he's showing, it's more that his chest muscles are tightly clenched and thus squeezing air out every time the ventilator wants to push air in. He's desatting fast. 

"Shit. This - isn't great. ...Marian, give him two of midazolam and call RT - I'm going to try bagging him until they get here -" 

Nellie didn't stay in the room after they were done with the dressing change, but expressed an intent to stay at the nursing station and be easily findable in case Marian needed her again. Marian sticks her head out. "NELLIE! We need RT, he's - maybe having a seizure or something -" 

And she has a bag of midazolam right there, because she's very prepared. It's not as good for giving an exact bolus dose when it's not already running, but it's faster than running to the med room. She doesn't have any unused IVs to run it in, but it should be compatible with atropine - ugh, except she still doesn't have a stopcock setup so there are like two feet of daisy-chained tubing mostly of things that aren't even running (paused norepinephrine and dopamine) before the first open Y-port - and she has no idea if it's even compatible with pralidoxime, which is running by itself in the third IV - she'll very briefly pause the atropine pump and unhook everything and plug the midazolam in directly and program a 2ml bolus at 99 ml/h - and then saline-flush it from the Y site to make sure that the 0.2ml or whatever in the tubing and IV catheter is definitely in the patient - and then hook up the atropine to that Y-junction, she's pretty sure those two are compatible... 

It does not have any noticeable effect. Lionstar's O2 saturation is down to 84%. His heart rate is up at 125 and his blood pressure actually seems to be dropping. 

Dr Sharma is trying to bag him one-handed while attempting to figure out which button will put the disconnected ventilator on standby and stop it from both screaming at them and trying to blast heated humidified air at the pillow. "Nothing? Give him 5 mg, we'll give another 5 in two minutes if he hasn't snapped out of it by then -" 

Nellie reaches the room at a run, looks around, and standby's the ventilator. "Vanessa's coming but she was in 196. What happened?" 

Marian is carefully programming in another 5ml fake-piggyback bolus on the midazolam pump. "We were trying to get a neuro assessment and instead of waking up when Dr Sharma sternum-rubbed him he did this." Her voice sounds surprising calm and level to her own ears.