"- What - no, I'm fine. Uh. A lot happened pretty fast, though - that was right when the security guard was being a creep, I think, and he was scaring me - I was distracted for a moment, I must've looked away, and I didn't actually see him get out of the water? He was definitely awake and struggling in the water, and then I looked around and he was collapsed. Could be syncope." 

She...has a suspicion that it wasn't. But she also feels like she's losing her mind, so she's not sure where to go with said suspicion. 

"Hmm. Well, we'll get the echo and go from there. Beckett, put in a social work consult. Pharmacy? Anything to say?" 

     "- What? Oh." The pharmacist on duty puts down her iPhone on the desk of her computer-on-wheels. "Why the midazolam for sedation? It'll take much longer to clear his system once he's ready for extubation - in fact, with the hypothermia he may well have been metabolizing it more slowly." 

She said that already and the pharmacist just missed it because she was on Facebook. "We started him on midaz because he was hemodynamically unstable, and had a major blood pressure drop after he got propofol for intubation. I'd meant to ask you about switching him over, but I'm not sure I feel good about it just yet, he's still requiring blood pressure support." 

The pharmacist frowns. "Let's aim to get his phosphate levels high-normal, then. That's actually the standard rec for induced hypothermia, so I can't see it'll hurt in his case. We know low phosphate can reduce cardiac output pretty drastically." 

(Marian hadn't known that, actually, or maybe did at one point and forgot. Neat. She writes it down to look up later.) 

"Right. That's the same mechanism as the muscular and neurological effects? Checks out. Did you have any opinion on how often we should be doing serial labs for his electrolytes? He - I think from my reading that he's going to have some shift between intracellular and extracellular compartments as his temp comes up." ...Unfortunately she is completely blanking on the direction of the shift, and whether it'll make their job easier or harder. 

"Maybe. I'd suggest another check at - noon, let's say. Looks like someone," she side-eyes Dr Prissan, "decided to double the rate on those replacement bags that're running. Give me a call when you get those results, all right? I'm thinking we want him on the higher end for phos and mag both, neither is especially risky for that. Also, be careful about giving him too much free water, his sodium's low and still trending down. No more half-normal saline and please don't give him dextrose in water." 

     Dr Prissan pinches the bridge of his nose. "Should we give him some 3% saline to correct that? I'd hate to give him brain swelling." 

Ack. Is that a thing. Did she at some point know that was a thing. Marian bites her lip and makes a note and feels incredibly terrible that she was basically ignoring the sodium being flagged as low, since as far as she knows that doesn't cause lethal arrhythmias. It...does make sense, physiologically, it's one of the main ions in plasma, and hypo-osmolarity would mean water would leave the bloodstream and enter cells, swelling them... What was his last sodium, she didn't even write it down, because she's terrible. 

The pharmacist squints at her computer screen. "Hmm, he was at 128, compared to 131 on the earlier set. But it does look like he's gotten some normal saline since then. My recommendation would be that if the number hasn't increased by noon, we start him on some maintenance fluids, run normal saline at 100ml an hour. If he drops to 125 or lower or if you start seeing any neurological signs, we can give a bolus of 3% saline, 100 mls, but run it slowly, over at least an hour." 

Emmy nods. "That's...good to know. About the free water. I'd been thinking of putting him on D5 in water for maintenance fluids, since he keeps trending weirdly hypoglycemic and seems to respond really well to getting more sugar, but it sounds like I really shouldn't do that. Uh, is giving him amps of D50% going to be okay?" 

The pharmacist makes a face. "You're sure your glucose measurements are accurate? We'd expect to see his sugars sky-high, cooling protocol always does that." 

"I know! It's weird. I...guess we can send a proper blood sample to the lab for another check, just in case the glucometer's screwy." 

"He does respond well to the D50," Marian dares to add in. "I was paying attention and he just - looks better. Better colour, his BP comes up, his temp starts coming up faster, everything." 

Dr Prissan rolls his eyes skyward. "Well, he may just have to stay our little medical mystery of the day. As long as he's improving, that's really all I care about. Though we don't want to rewarm him too fast." 

"I am not worried about that, two degrees an hour is definitely safe and we've been going much slower than that - when we transferred him and had to lose the Bair Hugger for, like, fifteen minutes, he actually dropped. Though...ooh, nice, look at that! Up to 34.2." 

Dr Prissan is tapping his foot. "We're getting off topic. Have we covered everything?" 

"Can we get a dietician consult too? I don't know what tests we ought to be running if we're suspecting he had nutritional deficiencies before all this, and we need a decision on tube feeds." 

"Sure, do whatever you want." 

Marian shares a quick eye-roll about this with Dr Beckett, and then is immediately embarrassed and worried about who saw that. 

"- Dr Prissan, one more thing. I did want to consider extubating him today if we get him rewarmed and his electrolytes normal? His lungs are fine, right, and he's following commands. Some commands. He has a pretty limited grasp of English or something." 

Sigh. "You can hassle me about that later, all right? I want him hemodynamically stable before I think about it. Minimize sedation and get him switched to propofol if you can, obviously - if we do decide to pull the tube, I don't want to do it past 4 pm." 

Marian nods, trying not to sigh audibly. She knows this is because Dr Prissan always tries to leave at 5 pm on the dot. It's kind of understandable. He's got small kids at home - they're cute, she's seen the pictures. Still. She really hopes the next on-call resident is any good. 

And they move on to her next patient. 

Rounds for her are very boring. Marian complains about the loose stools and gets Imodium ordered and the dietician to switch the tube feeds to the ones without fibre, which is clearly not needed right now.

The huddle moves on. 

Somehow it's already almost 10:45 am. 

Okay. What now. Labs at noon; she writes that down. She did not get an order on discontinuing the hourly blood glucose checks, but she'll bother Dr Beckett if the guy's sugars level out. Someone said something about sending a sample to the lab to get them to confirm the blood sugar? She did draw from the art line for the last one, and she's pretty sure the glucometer is accurate or someone else would've noticed on their patient, but she might as well put in the order and do that. 

...Maybe first she will catch up on charting. Nobody called her on it, but it's suddenly very embarrassing that the computer is claiming the patient is positive 4 litres of fluid and has had 0 urine output. Because IV fluids automatically get added from the med-administration record page, but urine output needs to be manually charted and she hasn't charted almost anything yet. 

At least the new monitor model has the vital signs ported directly over to the chart. She refreshes the page, and notices the red alert for new orders.

Oh, wow, that is a LOT of bloodwork. Oh, okay, less than it looks, only two different tubes even though it's got to be over a dozen tests, for...various vitamins and more-obscure minerals? Oh, right, probably that's a dietician order. Yup, it is. Cool. Maybe it'll turn out he's horrifically low on something incredibly random like vitamin A, and supplementing it will fix all his problems? That'd be neat. Probably won't be that easy but it's nice to imagine. 

She gets to work. 

Ma'ar drifts, rocking gently in an ocean of mist. He dozes, swimming through repetitive pointless half-dreams where he's checking wards or trap-spells. Sometimes voices in the distance reach him, foreign syllables rising and falling, and he finds himself pulled closer to the surface, not quite awake but not quite asleep either. 

He notices distantly that he's shivering, and that he keeps feeling like he has to sneeze but for some reason can't. And his throat still hurts. He's drowsy, though, and as long as he doesn't focus too hard on the discomfort, he can float below it and not mind too much. 

...Marian is there, he notices sleepily. She's not trying to wake him or talk to him, this time, she seems to be moving very carefully to avoid disturbing him. If he tried to wake up fully he could read her mind, but he doesn't think he's in danger right now, and he needs to rest. The best opportunity will be later, when he's stronger, and he needs to be ready then. 

Marian sends off the tubes for all the random-nutrient-deficiency tests plus the blood sugar. And then checks on the glucometer as well, with the last driblet of the blood she pulled from his arterial line. It's at 92. Seems fine. She'll check again at...noon. It seems like she doesn't have anything else to do before then, except creeping down on the norepi drip whenever she can. Down to 8ml/h now. Way better than before.

The current bag of potassium is just about empty, and in a moment of brilliance and time management, she thinks to pause and silence the pump and swap to the next bag now, so the alarm won't disturb him and she won't have to come back in here again. 

She goes to collect the new tube-feeds formula for next door, and pulls a dose of Imodium, and then is entirely unsurprised to find more diarrhea, though at least there's less of it? By the time that's dealt with, it's still really early for her noon assessment, but she does it anyway, including the blood sugar check, because then she can arguably get away with not coming back in here until 1:30 pm. Nothing's really changed. She's not surprised. 

At 11:30 she parks her butt in her chair, where she has a good angle to see both of her sleeping, sedated patients, and she CHARTS. It's the first time she's had a chance to really thoroughly go down all the flowsheets for various assessments and there are an awful lot of gaps. She catches herself doing some guesswork and extrapolation. Whatever, it's fine. 

Even with the huge backlog, by 11:50 she's done and at a loss. The steady lunchtime bustle in the more central part of the unit is a long way off. Probably people need help, but she could just...sit here...for five minutes. 

She sneaks out her phone and looks up meditation instructions and tries to sit with good posture and focus on the breath in her nostrils for the next ten minutes.