"His MAP's okay but should I be trying to get his systolic higher?" Pascal says, anxiously. "It seems like it's still really low. Should I go up on the phenylephrine?" 

"Um. ...Dr Agarwal, what d'you think of giving him a 500cc bolus under pressure? Dump it in fast, just to see if it touches his BP or his urine output. Which is in a tailspin, by the way. The sepsis is crapping out his kidneys."

She lowers her voice, addressing just the new grad. "Pascal, are you flipping and charting it hourly? I know most of the time we can get away with slacking off and averaging it later, but with this guy we need to know right away if he stops pissing." 

"Uh. Right. I charted it at nine, it's... How's it ten already, man, tonight is nonstop. We've got... Yikes. Fifteen ccs." 

"I'm not surprised. Dr Agarwal, you on board with trying that bolus? Oh and it might be worth getting a central venous pressure set up on him too, it'll cost us a port of the central line but we'll know more about his fluid status." 

One thing leads to another, and Nellie is still in the room almost an hour later, when Chantal sticks her head in and informs her that radiology just called, they've got a lull and is now a good time to send a tech over for a portable abdo X-ray? 

"Sure, be right over." It's nearly eleven; she can sneak in a turn and her 'midnight' assessment at the same time. She casts an eye at Ma'ar's monitor; vitals are good, sats at 94%, his only IV is saline, he'll be fine if she leaves him alone until after midnight. 

The X-ray tech is Pat, a chatty, bubbly Latino gay man - well, he's never explicitly talked about his romantic life with her but you can tell - with a bleached mullet, who at 5'4" is shorter than Nellie is. 

"Pedro!" She likes him. "How's the ER tonight?" 

He laughs. "Not bad! And your night over here, hon?" He calls all women under fifty 'hon', as far as she can tell. 

"Could be better. But, you know what? Sure could be a lot worse. Knock on wood." They both turn in sync and rap the doorframes. "Right, let's get 'er done." 

Her patient is a round man, but a short one, and Pedro is stronger than he looks. They roll him side to side, get the board under his belly, and Nellie slips out while radiation is flying. 

Nellie pulls up the image herself on the portable X-ray machine and skims it. "...Well then. I'm not a radiologist but sure does look like he's full of shit." She enjoys Pedro's chuckle, nabs him for a minute to reposition the patient properly while they're removing the board, and then tries to decide if she feels like opening the spigot on the shit faucet just yet. 

Maybe she'd better wait for the 3 am lull. If they get one of those tonight at all. 

Chantal is at the nursing station reassuring Isobel. "Rick's coming in for 11:30 after all, the storm cleared up and he managed to get on a later flight. He'll take over with Tommy for you, so you'll be 1:1 for real from then on, and he'll get his pick of 201 or 188." 

...And, of COURSE, this is the moment when things go terribly wrong. 

They piece it together quickly afterward. Pascal's somewhat-neglected patient, the Patrick Stewart lookalike guy, was hunting for his glasses in the dark - while possibly a little confused after his nightly sleeping pill - and managed to, instead of grabbing his glasses, grab the wire from his transvenous pacemaker. 

And pull it out. 

Not the central line itself, that would be even worse, and the wire isn't even fully disconnected - but it needs to be pushed a very precise distance in, where the tip can hang out just past the point where the vena cava rejoins the heart. 

It's now at least ten centimetres too far out, and its steady electrical tick tick tick is pointlessly shocking a vein, while the guy's heart rate instantly drops into the 30s. 

Nellie gets there a split-second before Chantal does, and realizes in about 3 seconds what must have happened.

Priorities: airway, breathing, circulation. Patient is on room air, she can see his chest moving - she whacks the blood pressure cycle button and reaches to check a pulse. "Sir! Can you hear me? How're you feeling?" 

He gives her an annoyed look; Chantal just flicked all the lights in the room on. "I'm not deaf, you know. All you youngsters are bloody rude sometimes." 

Well, that part's a good sign. 

"Any chest pain, Mister..." she reads the top of his monitor, "Norbert? Palpitations, shortness of breath?" 

"You'll damn well give me palpitations if you go turning all the lights on after my bedtime, young lady!" 

For all that the situation is somewhat of an emergency, Nellie can't help but smile a little. "I do apologize. There's an issue with your temporary pacemaker, it's not working anymore. Do you feel it at all?" 

He considers this. "My chest does feel a little funny." 

"No pain, though? How about heaviness?" 

"You folks sure are nosy, aren't you? Could call it heaviness, I reckon." He rubs his breastbone. "But I'm sure that nice doctor will set me right in no time." 

"I'm sure he will." She twinkles at the man. "You just sit tight for a minute, 'kay?" 

She turns back to Chantal. "Page Dr Prissan, please - he's still the attending on call for tonight, yeah? Oh, and if it's at all possible to swap assignments, I think this guy's going to be heavier than 195 or 188. I'd recommend we swap Pascal and give him one of those, whichever one he knows more about - he's pretty overwhelmed as it is. And Rick can take this guy." Rick is also a LOT more experienced, and might have ever interacted with a transvenous pacer before. 

The next 45 minutes pass in a blur. 

Dr Prissan doesn't want to come in at almost midnight for a stable patient, and - somehow - the guy's blood pressure is totally normal, right around 120/80. He feels fine, no chest pain or shortness of breath, only that it 'feels funny.' 

Dr Agarwal is coaxed via phone instructions into trying to nudge the pacing wire back down to its previously measured point. This doesn't work. Dr Prissan's response to this is very 'eh whatever.' He suggests they keep external pacer pads nearby, and promises to come in ASAP if the patient's vital signs become unstable, he develops symptoms, or his troponin - bloodwork indicating fresh heart damage, newly sent - comes back positive. 

Rick arrives and takes report. 

Pascal takes over the Down Syndrome man in 195, he's had him before, and then he goes back to obsessively checking his admit's drips and fretting about the urine output. 

Nellie is worried too. The bolus helped with blood pressure - briefly - but didn't touch the urine. 10-11 pm produced 15 ccs, exactly the same as the previous hour, about half the bare minimum they want to see. And the guy's lactate is frigging 7, still rising. 

She's not sure what else to do, though. It feels like she must be missing something but it's not coming to her. She politely suggests to Dr Agarwal that he do some reading up on necrotizing pancreatitis, 'so he'll have some clever things to say at rounds' (and maybe spot what she can't manage to retrieve from memory), and then she decides the best way to help is to answer the call bell for Pascal's new second patient. And then turn and clean him. It's easy work, doable by a single person; the guy is awake and cooperative and can roll himself obediently from side to side. 

She's just washing her hands afterward, still mulling over whether there's anything else they can do for the sick admit, when a bloodcurdling scream rips through the unit. 

Fuck. It's not the Screaming Harpy, wrong direction and wrong pitch. And there are only two people on this unit capable of screaming, right now, unless someone just self-extubated. 

Hands dripping soapy water, she sprints down the hall toward Ma'ar's room. 

He's in exactly the position she left him in, tucked in with a nest of pillows around him, head slightly elevated. He looks asleep, except for the part where his heart rate is spiking to 150 and he's screaming like someone who's being murdered. 

Shit. She takes a deep breath and approaches the bed, cautiously - 

- and, about four paces away, is suddenly hit by a gust of TERROR PAIN GRIEF GUILT– 

"Yeeeep!" she yelps, and jumps back, which - embarrassingly - results on tripping and falling on her ass, but at least gets her out of range of TELEPATHIC NIGHTMARE PROJECTION. She's shaking. That was - she was seeing what he must be experiencing right now, for a second there, though it wasn't very coherent - a flash of light on the horizon, certain knowledge he was about to die - knowing that someone he cared about very much was already dead, had died to destroy him - 

She scrambles to her feet and, at a loss for anything else to do, dives for the panel of light switches and flicks on every single light at once, including the spotlight directly above Ma'ar's head that they usually only use for bedside surgical procedures. 

He startles awake, trying to scramble up and getting tangled in blankets and ending up sort of sprawled half-sideways in the bed. The awful scream trails off into a whimper of pain. 

...The edge of his blanket where he tried to grip it is faintly blackened, sending up a wisp of smoke.