Marian escapes with great relief.

She has so much charting to do, but first things first: detour by the break room for her wallet, line up to collect some coffees for the unit. And a muffin. Today is NOT shaping up to be the sort of day that includes a lunch break. 

It’s already past 8:30, which seems like it should be illegal.

The OR calls back at 9:20 am, which is long enough that she’s caught up on charting, but in Marian’s opinion not nearly long enough to be ready for dealing with Fifty-Seven, Red again.

”Procedure went fine. Drained 1800ccs from the pleural space, the doc tied off the bleeder, bedside chest X-Ray already shows improvement. Though lots of patchiness appearing - did he aspirate?”

“They pulled him out of the river. Near-drowning.” And the river is gross enough that she wouldn’t want it anywhere near her patient’s lungs. “Did he get antibiotics yet?”

“We gave a dose of pip-taz, so he’ll be due in six hours for the next one.”

(Piperacillin with tazobactam, the standard extremely-broad-spectrum treatment for “we have no idea what infection this patient has and don’t feel like waiting two days for cultures to find out.) 

“He got three liters of fluids and a unit of blood - O-negative, he’s got some weird blood type - he may need more on your side.”

“Oh good. Orders in? And vital signs right now?”

“Heart rate hanging in at 110 - blood pressure’s a beautiful 120/70 right now but he’s maxed on the norepi. Vent settings - he’s still paralyzed, so set resp rate of twenty, he’s on...one sec...looks like 60% O2, sats are 94% but don’t lay him flat too long or it drops. Drips, we’ve got him on fentanyl and a touch of Versed, you can go up to 10 ccs an hour on that if you have to.”

“Any chance you got a central line in?” Marian asks hopefully. “He really needs one.”

“No, sorry, Dr Millinger said he’d have a resident do it on the unit, so you should get set up. Arterial line yes. Chest tube on suction, left side.”

"Great, sounds good - do you guys have enough people to help bring him over–" Fortunately it's not far, the trauma ICU is conveniently arranged to be very nearby the OR; however, Marian is developing some very paranoid feelings about being left alone with this particular patient in a hallway without any of her equipment. 

"Sure, I'll send the resident - can you come now, though, we've got to clear the room for the next case." 

"'Course, I'm coming." Marian stands up. On reflection she holds onto her coffee. "Elaine, sorry, I'll help you turn your guy after. Oh, and can you prep a central line kit outside the room, apparently we're doing that." Which will be EXCELLENT and a huge relief, having more reliable intravenous access for this patient who keeps determinedly trying to DIE on her, but also it's another task and she's feeling a bit overwhelmed by the pileup of tasks ahead. 

Her patient is looking somewhat better! That is indeed an absolutely gorgeous blood pressure waveform; in fact, it's hanging out at around 125/90, which is higher than strictly necessary and she can turn down the pressors and buy herself some leeway for later.

He's not restrained, which is annoying and the OR does that all the time, though it's not an urgent issue since he has the limp floppiness of someone recently given paralytics. She cranks his sedation drip up; she won't know if he wakes up still paralyzed, and doing that to a patient by accident is honestly one of her worst nightmares.

The chest tube drainage box must have been just emptied, but it's already got another - hmm she peers at it - two hundred ccs of bloody fluid in the receptable. Which is significantly more than the amount of pee in the hourly-measurement-bucket section of the catheter bag. His O2 sats are creeping down, though, and at a quick listen his lungs sound like a washing machine, though at least there are sounds at all on both sides. 

Also he's drooling all over the pillow. 

Marian is a nurse. She can handle the sight of blood. And the smell of it. And having it all over her scrubs. Same with poop - of any texture and consistency - and pee, and being vomited on. In fact, pretty much any bodily fluid is fine. 

With the exception of mucus, snot especially but lung gunk is almost as bad. And saliva. For some inexplicable reason, saliva is the WORST THING.

Blech. 

She grits her teeth and goes in with the suction catheter. 

Her patient is, inconveniently, too thoroughly paralyzed to cough about it, but she gets some gunk out; his O2 sats drop briefly while she's in the middle of attacking his lungs with suction tubing, but lifting the head of the bed more gets them to pop back up to the mid-90s. 

"That'll do." She looks around hopefully for the promised resident to accompany her. There's a LOT more equipment around the bed now; she cannot wrangle all of this by herself at all. "All right, let's go." 

They reach the unit without further incident, except for Marian's sudden forehead-slapping realization that she didn't get an up-to-date temperature from the nurse, and it doesn't look like all his fluids were going in warmed at all. Patients always come back from the OR cold and she didn't think to warn them about the hypothermia. 

The piranhas are back the instant they cross the doors back into the unit, though there's less to do this time; they wheel his bed back into the room and replug all the monitor wires and charging cables, and Elaine cheerfully helps turn him a little, very carefully holding the dangling chest tube to avoid yanking it. They can finally manage to properly check his back in order to chart 'no bedsores on admission', and get a continuous rectal temperature probe which should definitely be reliable. 

Marian sneaks in and tucks a couple of pillows to keep him propped a quarter-turn onto his side. He's been flat on his back for hours - somehow it's almost ten, god, she's so late on morning meds for the patient in 114 who's theoretically hers now - and maybe having the bad lung up will help it finish re-expanding. 

Her feet hurt so much but it's time to help a baby resident put in a central line! For 'practice', which means she's going to spend the entire time watching anxiously and trying not to yell at them! Joy! 

Emma-the-resident seems to have fled back to the ED or maybe home to sleep, but there's a fresh-faced new baby doctor lining up to do this under Dr Millinger's watchful eyes! 

He gets the sterile field set up and only needs prompting twice, and then swabs her patient's neck with the sterilizing solution and starts poking around with the bedside ultrasound to find the jugular vein. 

Dr Millinger is in a teaching mood, apparently. "There! See, that's the carotid artery, with the pulse, and that's the vein right by it - look how easily it collapses when you press? He's still hypovolemic." 

     The resident blinks. "Didn't he get like four litres of fluids already? Should we start another–" 

"Saline won't expand circulatory volume as much as colloidal fluids, lots of it spreads out in the tissues - that's why our patients tend to end up with edema, right, you can already see how his hands are a little puffy. And he's not dehydrated, he's lost two litres of blood." To Marian: "What's our ETA on the next couple of units? And last hemoglobin?" 

Aaaaaaaaaaaa she was busy watching the resident to make sure he didn't break the sterile field and this is too many things. "I, uh, newest one from the OR isn't back yet - last one was six. Elaine!" she adds, raising her voice. "Anything from the blood bank?" 

"I'll call them!" Elaine shouts back from Leg Lift Lady's room. "Dr Millinger, do you want to order some plasma too?" 

     "- You know what, yes, two units please. And once we've got this line in, send another set of labs, check clotting factors too if we don't have a recent one. And a new blood gas in, hmm, half an hour, once he's had time to settle down - the last one was gnarly." 

Marian refrains from pointing out that the last arterial blood gas was both when her patient had one working lung and had just been moved and shoved around a lot for the scans, of course it wasn't great. Getting a new one will be almost trivially easy now, since he has a nice shiny new arterial line from the OR. Aside from the part where she has way too many things on her mental stack right now. 

She writes it down, and keeps watching the nervous resident as, with aaaaagonizing slooooowness, he gets his materials ready and starts trying to slip an ultrasound-guided needle into her patient's jugular vein. 

"You've got blood return - excellent!" Dr Millinger coaxes. 

(Whyyyy is he so much more patient and kind with his residents than with the nursing staff?? Or, come to to think of it, with the patients?)

"That's it - all right, slide the guidewire in, you've got it - there it goes...bit further..." 

The patient's heart monitor pings plaintively. 

"We're getting ectopic beats," Marian says levelly. "Careful, that's probably– fuck fuck stop that's V-tach!"

Her patient's heart, stressed and irritable from the heavy workload expected of it plus the stimulation of the norepinephrine drip, is reacting badly to being poked from the inside with a guidewire. In particular, he is just now slipping in and out of a life-threatening arrhythmia, though at least there's still a visible pulse on the arterial line tracing. His blood pressure is plummeting rapidly, though. 

"Pull back," Dr Millinger says, much more calmly. "About an inch - ah, there, he's coming out of it. Just hold there, and slip your catheter over the guidewire - no, make sure you hold it, do not push it further in again–"