"It's not approved for use in Ontario yet." Chantal rubs her neck. "OR has a heating-cooling mattress pad, I think. And we've got a brand new direct-bloodstream cooling thingy for the induced hypothermia protocol, but it's a bitch to set up. Also it requires a central line which is, like, this long." She gestures to the length of her forearm. "We have to get it specially and central supply is closed for the day." 

Working in a smaller generic ICU in Canada has completely different challenges from her previous job. Nellie sighs. 

"Would you mind grabbing it, then? I'll watch your peeps. And Pascal really needs backup with this guy." 

     "Sure." Chantal heads out. 

Pascal hasn't left the room yet, he's busy fiddling with the norepinephrine drip. The patient's monitor is alarming for a supposed blood pressure of 81/69, but Nellie isn't buying it, that's way too small a pulse pressure - gap between systolic and diastolic - and the peak of each wave is truncated rather than pointed.

Nellie sighs again. "Get a cuff BP on his leg. And flush and zero out his art line, I don't trust that curve." She logs into a computer without sitting down and puts in Tylenol suppository q6h PRN as a verbal order under the resident's name - he didn't say no when she suggested it, after all - and then goes to pull it from the Pyxis. 

Pascal gets a sanity-check blood pressure - it's indeed a little better, and more believable, 92/51 - and then fiddles with the art line until it looks the way it does in the textbook. Well, almost. It's not...spiky enough? 

"Nellie? Why isn't there the notch thing in the middle?" Marian would know, he's pretty sure, but if she ever quizzed him on it, he's forgotten. 

"The diacrotic notch? Uhh, aortic regurgitation and atherosclerosis can both cause that, I think, I'd have to pull up a reference article to be sure, but I think most of what's going on here is his cardiac output is shit. Lowering his heart rate will help, so let's get this guy his Tylenol." 

"Huh, isn't - wouldn't that be bad, his heart rate is compensating for the shock and low BP, no?" It's hanging out in the high 140s. 

"Partly, sure, but heart rate also tracks temperature - you must know it drops with hypothermia, well, the reverse holds too. I bet you five bucks or a free coffee that we'll see him drop by 10 bpm for each degree we lower his temp. And it might help his BP - he's not a fit guy and he's running fast enough that his heart won't be at its best function, not enough time to refill and squeeze."

Suppository and lube in hand, she dons gloves, joins Pascal on the other side of the bed, and starts lowering the patient's head. 

Alarms start screaming almost immediately. The ventilator first - peak airway pressures are maxing out, tidal volumes are dropping - and then the patient's sats drop below 90%, and ten seconds later his blood pressure is tanking as well. 

Nellie very calmly returns the patient's head to its former elevated angle. 

"On reflection, I only want to do this once. Let's wait for Chantal to be ready with the cooling mat." She turns. "Dr - Agarwal, right? I need some orders for my wizard in 202. Advance diet as tolerated, mobilize as tolerated, Tylenol and tramadol PRN for mild to moderate pain, and let's try - no, wait, Zofran's known to cause headaches - can I get Benadryl and Phenergan PRN for nausea?" 

     "...Phenergan?" 

"Oh, sorry, promethazine. If you don't stock it here then prochlorperazine should do fine. I'm going to put in PO or IV, so I won't have to bug you at 4 am if he's puking too much to keep oral meds down. Thanks!" 

She puts in her orders, singing to herself under her breath. 

Chantal is back a couple of minutes later and starts setting up the cooling mat. It goes under the patient, with a sheet to protect their skin, and looks like a very thin ribbed rubber air mattress. It hooks up to a box at the foot of the bed, which needs exactly 875 ml of distilled water poured into its reservoir tank, and then it chills this and pumps it around a circuit, humming loudly the whole time. 

"Okay. Guys, we gotta do this FAST and we gotta be ready for shit to hit the fan. I've had patients code from being turned before. Dr Agarwal? Can we pre-emptively order a second pressor? Phenylephrine, ideally, we don't want his heart rate going any higher. Pascal, I want it primed and hooked up and the pump on standby. And max the norepi before we lay him flat, we know what's we're in for - but this way if it's not enough then at least we've got backup. Hmm - I'll go put in and then hand-mix some phenyl for you while you're getting the sheets ready." 

Pascal looks a bit overwhelmed and goggle-eyed, but he's used to working with her by now. Within another five minutes, the backup pressor is hanging, Y-linked into the nest of tubing emerging from the central line, and all four of them are ready to go. 

...The patient does not code. Nellie is fast and ruthless about suppositories, and can do it one-handed while she tucks the old sheet as far under the patient's ponderous behind as she can and lets the rolled-up sheet and mat assembly unroll halfway. They flip the patient back, she rolls him toward her to complete the bedding change, they roll him flat - Nellie suggests just one thin pillow behind his back, under the cooling mat so it won't break contact - and then she's elevating his head again. His sats are 80% and his blood pressure is jumping around like a startled cat but he's alive. 

"Nice work, Pascal." She gives the kid a high five; he needs the encouragement. "Come back down on the norepi if you can but don't push it. Don't forget the ice packs and towels - oh, and if he's still not using it at midnight I'll steal back Ma'ar's Bair Hugger, it's not great at cooling but if you keep him wet under there and put it on the LO setting we'll get some evaporative-cooling effect. If you don't mind, I've got patients to assess now, but I'll be back in a bit, 'kay?" 

She leaves. 

Ma'ar is sleeping again, and Nellie manages to get a blood sugar reading - 72 - and splooge crushed Tylenol and Tramadol down his NG. (Her old hospital tended to use the pediatric syrup for tube administration, but she never liked that, the stuff is sticky and hard to flush in properly). 

She wakes him gently, patting his hand until he opens his eyes. "Hey there. I've given you pain meds, they'll kick in fully within an hour. Water's going down okay? Here's some juice. Apple, orange, grape, mixed berry punch - pick your favourite." She pops in all the straws for him. "And this is Jello. I thought you might approve of the orange or the lemon-lime." 

Ma'ar tries a sip of a randomly selected drink-box. It's very sweet and slightly astringent and he could believe that it's intended to taste like grapes.

It tastes good. It's the first even slightly foodlike thing he's consumed in an entire day if not more. 

"Very good! I'll leave you to it." It's somehow almost 8:45. "Why don't I drop by in an hour or so, see how the pain meds are working, maybe get you settled for bed? But call me if you need anything before that. Okay? Don't be shy." 

Ma'ar is finding it hard to judge the passing of time, right now, and kind of wants to ask about timekeeping devices here, but Mindspeaking is too much effort. He nods agreement. Drinking juice and eating whatever-that-is seems about the right level of challenging for him, right now, and after that he can sleep again. 

Nellie sighs, checks on 199 again on her way past - BP up a bit, he's got PRN Hydralazine injections for that but only if his systolic goes above 160, she'll keep an eye on it. For the moment she ups his propofol a little. And then back to Pascal's room. 

"Have you even seen your other patient yet?" she asks him. 

"Uh. No. If you have time to go give him his 8 pm meds...?" 

"How about you go and I'll babysit this guy? You know 194, I don't." 

After a little more persuasion, Pascal departs, and Nellie immediately embarks on a full assessment. She feels bad doing it in front of new grads - it embarrasses them, makes them feel like she doesn't trust them. Which she doesn't, really, but all nurses were new grads once. She remembers what it was like and she's not inclined to make it worse for him. 

The patient is conked the hell out on 8 mg of midazolam, barely twitching when she sternum-rubs him. He's got adequate air entry in the upper lobes of his lungs and just about nothing lower down. 

Bowel sounds are...well, she listens for a full minute, and there's maybe a faint gurgle or two, but not much. Extremities are cold, despite the fact that his temp is still 40.1. The fresh urine in his Foley bag, since whenever it was last flipped, is about 40ccs, and amber. 

Nellie is not delighted. The guy looks like a three-day-old dog turd. She pulls out her spare piece of paper and makes a couple of notes, she'll have to ask Pascal if he's flipped the urine receptable into the rest of the bag since he took over. If not, then it probably hasn't been done since the Foley was placed, which must have been 7 pm or so. Maybe earlier. 20ccs an hour is...concerning. 

She logs into the chart, looks up the patient, and checks his blood sugar history. 

Most recent is 225. Pascal gave 4 units of insulin for it, per the patient's sliding scale and then halving the dose because he's not eating. Any earlier history is presumably in the paper chart, and/or dropped by the vagaries of lossy handovers. 

Nellie scowls and takes another reading. She is not at ALL surprised when it comes up at 231, actually higher than before. 

"Dr Agarwal?" The resident is at the nursing station, talking to Isobel, but Nellie interrupts. "I think the admit needs an insulin drip. And repeat lytes and blood gas. He's having a massive inflammatory response and his pancreas is crapping out, his sugars are going to be through the roof." 

The resident is clearly still wet behind the ears, enough to be scared of insulin drips. "You think so?"