"Ummmm. There was...kind of a lot that I didn't, uh. Get a chance to measure. Since I put the catheter in, it's...two hundred ccs? Very pale." 

"And that's in less than an hour, right?" Emmy slips back into the room, frowning at the straggling blood pressure waveform. 

What is time even. Normally Marian is so much better than this at writing times down. Lately she's barely had enough attention to spare to look at the clock. 

"...Half an hour ish, we didn't get here until after 7:15. I probably got a hundred ccs out right away, though, it's not all new." 

Emmy rubs her hands together. "Cold diuresis, right. Low body temperatures affect the kidneys' ability to concentrate urine, so he's losing more water and salt than he should, and I bet he was already dehydrated when he came in. Hmm. I might want to give him some albumin, just in the hopes that'll stay put in his circulation." 

"Huh. Right, I think I read about that... Is that why the low mag and phos, you think? Because he's peeing it all out and the fluids we gave him were just saline?" 

"...And diluted him even more on the other electrolytes. That's way too plausible. He's been hypothermic this whole time, he'll have been cold-diuresing and we've been pushing him lower and had no idea... Shit, that would explain the deterioration." She rubs her chin. "Although I - don't see how that gets a phos of point fucking nine. He has to have been low already." 

"Uhhh. Nutritional deficiency?" The guy doesn't look starving - he's carrying some solid muscle mass, physically he looks like someone who takes care of himself - but someone whose wardrobe consists of a Salvation Army bathrobe plausibly can't afford a reasonable balanced diet. 

"Not impossible, but it's pretty hard to get that deficient in phosphorus! Mag I could see." She rubs her arms. "I'm going to be so pissed if he turns out to have some one-in-a-million rare genetic disorder." 

"...Is there a genetic disorder that would cause low phos and mag, and, uh, worse cardiac function?" 

"No idea, I'm not a specialist in rare metabolic diseases."

Emmy sighs. "...Well, I don't know what to do differently, aside from supportive treatment which we've already got covered, and watching him like a hawk. Shit, how is he still not back up to the temp he was at before?" 

"I don't know! I did notice he's not shivering that much? If I were that cold my teeth would be rattling." 

"...Could be the low phosphate. It can cause muscle weakness and 'neurological dysfunction' which...who knows, maybe that includes shivering response? And, uh. Hypothermia by itself should increase blood sugar," according to Doctor Google an hour ago, she did NOT know this off the top of her head but it's neat to sound like she did, "but since we suspect he's doing something screwy, metabolically, possibly we should have him on q1h glucose checks?" 

"Cool, can do. Uh, the blanket doesn't go any hotter but I can...heat pack his armpits?" She's never done that before but she's done the opposite, to bring down fevers, she can't see why it wouldn't work.

"Given how unstable he is, we should maybe be thinking about active internal rewarming, not just the blanket. If he needs fluids anyway we can heat them, but I don't want to overload him - once there's a line in we can get a central venous pressure... I need to do some research." Also where the fuck is the attending doctor, Emmy would swear she asked someone to page him, it's almost eight. 

Emmy runs to the supply room and fills the front of her oversized scrub top with instant heat packs and runs back. She cracks a few of them, puts them in pillowcases just to make sure she won't burn the guy, and then tucks them into his armpits and groin. 

This is a weird enough sensation that it wakes him - well, mostly the brief gust of colder air when Marian has to flip back the Bair Hugger blanket wakes him, and then Ma'ar is vaguely bemused. It's not uncomfortable, though. He's very cold and it's actually kind of pleasant. 

Marian retrieves a glucometer and takes his blood sugar. With a drop of blood pulled from the art line, because why not, it'll be more accurate than capillary blood when he's so peripherally vasoconstricted, and it means not having to stab his finger. 

"...Uh? Dr Beckett, you still there?" 

     (Murmured affirmative.) 

"Well, he's not critically low but he's at 64." 

"...Weird. I gave him two litres of half-D5 plus the bolus, where's he putting all of it. Push another amp of D50, I guess?" 

Marian does this. 

...and, of her own accord, watches really closely for any change. 

...His colour actually looks noticeably better within five minutes? His heart rate is steadier, with fewer arrhythmic beats. His blood pressure is still variable, but the MAP is steadying at a much higher number. 

Huh. Fascinating. 

Marian relays this to Dr Beckett. 

"...Weird. Wonder if he's got some sort of liver issue where he's not using glycogen stores. This is so weird, but - well, he does look better." She takes another breath. "Um. Check again in fifteen minutes, if he's still below - hmm - if he's still below 90, push another amp, we might as well try keeping him at the upper end of normal and see if that helps him out." 

She is completely making this up on the spot and it's basically the opposite of all the standard advice for hypothermic patients, but the standard isn't working here. 

"Sure, I'll do that at...8:15. Uh. After I chart that I did this one." The big ampules of D50 are just available in the medroom; the order is neither placed nor charted as given in the computer. "By the way I'm going down a bit on the norepi, his MAP's at eighty. And uh can you watch him for five minutes I really really really need the bathroom." 

"- Nah, go ahead. You slept here last night, right, and then we grabbed you early - I'm sure you could use a few minutes to freshen up." Her lips twitch. "Fun night out?" 

"Uh."