"Yes. I had a couple similar cases down in Texas, it was key." Only one of them survived. She keeps that to herself for now. "I'll go discuss it with Pascal and start prepping it." 

She has an explanation for him that doesn't make it sound at all like she thinks he or the resident missed something, and instead leans on mentioning this one brilliant intensivist she knew in Texas. 

She ends up being stuck in the room for the next half-hour, prepping the insulin bag herself - the pharmacy here CLOSES at night, which is bullshit in her opinion - and printing off the protocol and checking the resident's orders and then holding Pascal's hand through getting everything set up. 

...And then, inevitably, Mayumi's poor asthma girl is desatting and Mayumi was just about to clean up a giant oil slick of black tarry post-bleed poop from her ulcer-repair lady in 200, and she's calling for help with one of these things because she can't be two places at once. 

Nellie has minimal context on the asthma girl, but she'll step in and help the night care aide with poop. 

Which, of course, makes it inevitable that something is going to go wrong. 

Chantal interrupts her when she's elbow-deep in scrubbing the lady's butt cheeks. "Nellie? Your guy in 202 got anything for nausea?" 

"- Yeah, I made sure to get orders in. And I did just progress him to juice, I meant to check on him more often, shit. Is he vomiting?" 

"Not yet unless he hid the evidence, but I answered the call bell and he was hanging onto his barf bag and looked miserable - you know the face people make."

This is the worst timing. "He can have Benadryl IV. Tell him I'm coming as soon as I finish my, uh, current task. ...And get a blood sugar. He might be low." 

Cleaning up after something like this can't be rushed, but at least Mayumi is free again a few minutes in, and Nellie ruthlessly informs her that she can take over now. 

When she catches up to the room, Ma'ar is scrunched halfway down the bed, curled up on his side, holding the bag with one hand while he presses a coldpack to the back of his neck with the other - it's a trick that works bizarrely well for nausea. He looks so miserable. 

Chantal is checking his blood sugar from the art line. "I just pushed the Benadryl." The glucometer beeps. "Hmm. He's not low-low but 71 is pretty on the edge." 

"And we're clearly not going to be fixing that with juice. Go inform the resident that he seems to do better when his glucose is above ninety and I'd like to give him more D50 - I'd ask to run D5 for his fluids but his sodium's low. Can you bring me an amp of it if he agrees to that?" 

     "If you like." Chantal shakes her head but leaves. 

Nellie turns back to Ma'ar, and touches his shoulder. "I'm sorry I didn't come right away when you called. You're still feeling sick to your stomach?" 

:Yes: He is also, it looks like, starting to feel at least the drowsiness effects of the Benadryl; his eyelids are drooping. 

"- Well, you know, sometimes the best cure for nausea is just to go ahead and get the throwing up over with. Or you might just need a good burp and if you stop fighting it and let her rip you'll feel fine. C'mon, let's get you sitting up - I said up, here..." 

She hip-checks the bedside table fully out of the way, and grabs the pad under him, scooting him higher in the bed. "There. Now lean forward and try to burp. It's okay, I've got you." She holds the bag steady. "Sometimes the pain meds make people throw up, or who knows, maybe you're allergic to fake grape flavour. Also your blood sugar's a little low. We're going to sort that out. But for now, don't fight it, just let your body do what it needs to do." 

Ma'ar gags and coughs for long enough that Nellie's arm is getting tired, and eventually manages a couple of gurgling burps. 

:Feel better: he admits. :Tired: 

"I bet you are. The nausea drug does that. Here, you can lie back again - once Chantal comes back we'll get you straightened out in bed, and then you can sleep, 'kay? I'm sorry you're feeling like this, it's no fun. You should probably give your stomach a break and back off to just ice chips again." 

Ma'ar is way too sleepy to care much. And he's still queasy, just below the threshold where it takes an ongoing effort of will not to heave up everything in his stomach. He just nods and keeps his eyes closed. 

Poor guy. This is among Nellie's least favourite parts of nursing - having patients who are past the worst of their critical illness, who are basically stable, but still sick enough that they feel like shit and there's not even that much Nellie can do about it. 

Chantal fiiiiiinally shows up again, with an amp of D50 and apologies, and they get Ma'ar reasonably position in the bed. She convinces him to lie on his other side for a while. He's clearly exhausted and barely even tries to wake up for it. 

Nellie resolves that, after this, she's going to leave him alone for as long as she can possibly get away with it. It's 9:40 now. She should get some followup blood sugars, and sneak a quick listen to his lungs at midnight but she doesn't need to wake him up all the way unless he's desatting - and, honestly, even then she would be a little tempted to sneak his O2 higher, maybe sneakily extract a blood gas from his art line just to check he's not retaining CO2. This guy so badly needs some uninterrupted sleep. 

Her CHF patient in 199 is hypertensive enough to need some drugs about it, and is also due for a turn. 

...And, inevitably, his pad is soiled. Not a lot of stool, she didn't see it until she turned him, but it's liquid and it smells foul. 

Ugh. 

She gets it cleaned up and then thinks to check the record of the last few days. Huh. He's been getting stool softeners every day, and tube feeds with fibre – and he's documented as having pooped a few times, but all of them are charted as 'small' and 'liquid'. And his belly is pretty distended; on reflection, it doesn't seem like it's just the tissue edema. 

Hmmm. She is forming a SUSPICION that this poor man is, perhaps, leaking around a rather large impacted hunk of shit. And might have some more room for his poor lungs if they could deal with that situation - which at this point calls for an enema or worse, since he's sedated and they can't plop him on the commode for an hour. 

Day shift is not going to be happy if she leaves them with that project. 

The official pharmacy might be closed at night, but X-ray isn't, since the ER runs all night long. 

She looks for the resident. He is, unsurprisingly, parked by 192. 

"Oy. Can I get an abdo X-ray on 199? Suspect he's pretty backed up and stool softeners aren't cutting it, I wanna confirm if I should try an enema." 

Dr Agarwal scrambles after his notes. "Who is he again?" 

"COPD, CHF, respiratory distress, intubated and getting Lasix." 

"Uh, sure, if you want." 

Past him, Pascal sees her and waves. "Nellie, could you come when you have a chance and, uh," he makes a vague gesture, "I don't know, if you've got any advice?" 

"'Course, I'll be right over. Hang in there." 

She orders an X-ray - not stat, 'needs to take a good shit' is not (yet) a medical emergency, but she calls radiology and very politely asks them to send someone over for a portable abdo if they have any downtime later tonight. 

And then it's back to helping the new grad survive what might well end up being his sickest patient yet. 

Her first guess was bang-on; the patient's temperature is down to 39.1, still a fever but at least a sane quantity of fever, and his heart rate is at 130. 

His blood pressure isn't doing well, though. He's maintaining an adequate mean arterial pressure, barely, on a maxed-out norepinephrine drip and a medium dose of phenylephrine as well, but he's got a very narrow pulse pressure, hanging out around 80/55. And he's breathing above the vent rate, at 28 breaths a minute, even snowed on midazolam. And he just, in general, looks like shit.

Pascal wants to talk through the insulin protocol some more and whether they're getting his blood sugar down fast enough. 

"...I think maybe we've got bigger problems. Dr Agarwal! We should get a lactate and a blood gas. He looks acidotic to me. And maybe repeat electrolytes, if they were last done at seven. And - holy mother of Jesus did you see what's coming out of his OG that's genuinely disgusting." It's nearly filled the suction canister and is a concerning shade of almost-neon yellowish green.