The patient previously in room 192 is rushed out to the telemetry floor just in time for housekeeping to do a stat cleaning, and the bleach isn't even dry on the floor when the transfer patient is rushed in past Marian, an obese man whose enormous belly is trying to ooze over the edges of the paramedics' stretcher as they race down the hall, ventilating him with an ambu bag. 

...Well, that looks dramatic. 

Marian hammers in her final set of pee-numbers, then slips into Ma'ar's room and taps his shoulder. "Hey. Can you wake up a little?" She waits until he opens his eyes and blearily focuses on her. "I'm so sorry to keep bothering you, just - I want to go help my colleague, only I'll be out of earshot from you. I want to give you, uh, a button to press that'll make an alarm go off at the nursing station if you need anything - does that make sense?" 

He thinks so. :And then you come?: 

"Mmm-hmm, exactly. Here." She slips it under the warming blanket and into his hand. His temp is 37.6 now. "Uh, are you getting too warm again?" 

(Headshake.) 

"Okaaaay. You can keep the warm blanket for now but the night nurse might make you switch to the regular blankets if your temp keeps going up, 'kay?" 

Nod. :Can I sleep now: 

Marian is nonzero worried about how lethargic he seems to be, but also, SHINY ADMIT. She'll just have to make sure to tell Nellie not to give him any more morphine until he can stay awake for longer than ten consecutive seconds. 

"I'll see you at shift change," she says, and bolts. 

New admit is sick as hell! Marian finagles her way to attempting to draw blood while the paramedics give a verbal report. She may be meh at execution on IVs but, for whatever reason - probably patience, persistence, and the willingness to abuse instant heat packs and also draw from a crouching position on the floor so she can use gravity - she can almost always get blood. 

He's a 45-year-old man, who looks at least 15 years older. History of type II diabetes diagnosed when he was twenty-nine, high blood pressure, atherosclerosis, early-stage kidney disease as a result of all three of those. Oh, and morbid obesity, though he's not actually nearly as fat as he looked at a glance. His hands and forearms only have a moderate layer of protective blubber hiding his veins. It's mostly belly, because he is ridiculously bloated. 

He presented to the tiny community hospital in Almonte two days ago, with abdominal pain, constipation, nausea and vomiting. Acute bowel obstruction was ruled out, though an ileus - basically just decreased movement of the gut - is still suspected. Diagnosis is severe pancreatitis. It came out that he averages six to 10 drinks a day, which cannot possibly be good for ANY of his other health problems.

Yesterday he started requiring oxygen. Just a little bit at first, but by 7 am today he was at the max nasal cannula rate of 6 L/min, and by noon he was on 100%. For some inexplicable reason the floor nurse in Almonte...thought this was fine...even as he spiked a high fever and became increasingly anxious and restless, his heart rate and respiratory rate climbing. It wasn't until his blood pressure started tanking hard at 3 pm that the rapid response team was called, by which point he was lethargic, entirely disoriented, and running a fever of 40 C. They're assuming sepsis, his white blood cell count is through the roof. He got four litres of saline during the 45-min ambulance ride over, and even with that his blood pressure is lurking around 82/40, as though trying to hide under a table from someone who might shout at it. 

This is way longer than Marian had intended to spend trapped in this room, but Ma'ar has his call bell and her other lady is stable as a rock and, practically sitting under the guy's bed with his arm dangling off the side into her lap while she gives him a heat pack massage, she's finally spotting some veins. Ooh, that forearm vein actually looks good for an IV, too, straight and smooth, neither too superficial and roll-y nor too deep. 

"Amélie, what's our IV access? I can probably get one here." 

"I might kiss you! We've got one sketchy 22G. Here." Supplies are tossed at her head. 

Okay. Focus. It's game time. 

Marian wedges her penlight between her teeth so she can get some extra light. After a moment's consideration, she does the sketchy-but-incredibly-useful move that her original precepter taught her, and snaps off just the veeeery end of her glove's index finger, then scrubs the fingertip thoroughly with chlorhexidine. It's not like getting a droplet of the dude's blood on him will kill her - even if he had HIV it wouldn't, she doesn't have open wounds and she'll wash her hands REALLY well after. And it means she can actually feel directly what the hell she's doing. 

Light. Swab the skin - and she uses one of her other tricks, leaving the square swab in place a little above the target vein, turned diagonally so the corner serves as a guiding arrow. Extension tubing with prepped saline flush is ready, propped on her knee, tegaderm dressing beside it... 

Moment of truth. 

She takes a deep breath, wills her hands not to shake even a little bit, and pokes. 

The guardian angel of ICU nurses everywhere must be watching over her today, because she gets blood flashing up the needle almost immediately, and after a moment of initial resistance, the plastic catheter slides riiiight in. 

She could try to draw blood from here before she flushes it, but on reflection it seems like this guy really needs a non-sketchy IV access right fucking now, and she doesn't want to fiddle and risk losing it.

She screws the little loop of extension tubing on, pulls back - yep, easy blood return - then flushes in all of the saline, holds the arrangement in place with one hand, and dressing's it in place. 

"IV access!" she crows delightedly. 

"Great, we've got a norepi drip ready - Dr Prissan, can we run it peripherally? It's a new IV." 

     "- Is it as dubious as the old IV?" 

"Marian?" 

"It's not dubious at all! Not even a little bit!" Marian is so pleased with herself she's practically giddy. "Here!" She levers herself up and presents the patient's arm. "20G, gets blood return, flushes great." 

"Good. This guy does not need any more fucking fluids. His lungs sound like my toddler jumping up and down on bubble wrap. ...Don't bother with peripheral blood, buddy needs an art line stat and who cares if we get a repeat lactate five minutes later. Can I get the kit at the bedside now please." His voice drops to a gentler tone. "Dr Agarwal, you done any art lines before?" 

The resident makes another small squeaking sound. 

Poor tiny baby. (He's almost certainly older than Marian is, to be in residency already, but it's Traditional for ICU nurses to think that about babydoctors. Even if they, themselves, are babynurses or at least not out of toddlernursinghood.) 

"I'll get a kit," Marian promises, "be right back." 

She doesn't stop on the way to the supply room, except for a very brief detour to glance at the central monitor display, but she does kind of do a happy dance while in motion. She got an IV she got an IV she got an IV! On a really septic patient! She's so delighted. 

The rest of the shift is...okay, it cannot exactly be said to be uneventful, given their dumpster fire of an admit. And of course, inevitably, this is when urosepsis code lady in 196 jumps back into rapid a-fib AND Anne-Marie's sweet lovely 89-year-old lady waiting for a pacemaker starts her evening 'sundowning' delirium - while Anne-Marie is busy pulling amiodarone for 196 - and does her best to swan dive out the side of her bed. The waist-belt restraint, which the patient's non-delirious daytime self consented to wear after a Serious Conversation this morning, stops her from literally faceplanting, but nobody here is having a fun time. 

Marian dashes down the hall twice during this to check on her folks and satisfy herself that Ma'ar is still cozily asleep and satting adequately, and her other lady is still restrained and sedated and in possession of all her tubes. She volunteers for the dubious assignment of trying to stick a Foley catheter in dumpster fire admit guy, and then discovers that after receiving all those fluid boluses, his junk is approximately the size, shape, and consistency of a large water balloon. Nobody seems to have the faintest idea when he last peed, so it's unclear whether the 240 ccs of amber urine she eventually lets out is good or terrible. 

She makes it out to the nursing station just in time for the 7:15 quick group huddle, where Amélie gives a quick summary of each patient to everyone - for Ma'ar she keeps it to 'hypothermia, admitted very unstable in am, extubated this afternoon, doing well, complicated personal situation see notes on door before going in.'

She gives Chantal a quick and easy report on 201, and then it's time to hand off Ma'ar. 

Nellie comes down the hall to join her after getting caught up on her patient in 199. As usual, she's wearing stylish, well-fitting scrubs, dark maroon with magenta trim today, over one of those spandex-looking long sleeved undershirts, her dyed bright-red hair sort of halfheartedly scraped back from her eyes with bobby pins. 

She snags an office chair and kicks off a wall, gliding over. "So. Sounds like you got someone interesting for me tonight?" 

"You, uh, could say that. Yes. ...You're going to think I'm crazy." 

"Don't worry, Amélie told me I'd think you'd gone totally crackers and I'd be wrong. I'll hear you out." 

"Uh, right." Nellie can be - a lot, sometimes, but right now it's just kind of relaxing. "So. ...Oh, you've got to hear the first part, it's epic. I was out late at a party last night, like, really late - I know, I was being an idiot, don't say it - and I saw this guy sleeping on a bench by the Rideau River. Wearing a bathrobe..." 

She recounts the whole tale up until the arrival at the hospital. 

Nellie listens, looking appropriately intrigued. She scribbles a couple of notes. "...I'm guessing this isn't either the interesting part or the part that'll make me think you're wacko?" 

"...No." Shit, it's really hard to stay on topic and not ramble, she's not sleepy exactly but she can feel her brain shutting down piece by piece from sheer exhaustion. "Uh, in the ER they gave him a fuckton of Haldol because he wouldn't hold still, and eventually figured out he wasn't ETOH, tox screen negative for everything, but his temp was twenty-nine something."