"...Bad enough, but we've got time. His organs should still be perfusing some,  it's just going to be tanking his venous blood return, it's crushing his inferior vena cava but good. And the kidney hit, of course. ...This is actually promising, kind of? If his kidneys were tanking this bad from just sepsis, it wouldn't be so easy to fix. I bet if we can decompress him in there, all his numbers will start improving." 

"That's...something, I guess," the resident says, sounding unsure of this. "Er, is there anything we can do before the surgeon gets here." 

"Finish reading that NCBI writeup you've got, I bet it has suggestions. ...And, oh. Consider paralyzing him. It'll relax the abdominal muscles, maybe give him another inch or two of stretch in there. And - hmm, it might affect choice of pressors but I'm not sure how. Look it up. You've got time, he's not dying yet. ...If we've got a two-hour wait for the OR to be ready it might make sense to ultrasound him for ascites and consider draining that, but run that by the surgeon." 

She looks to Pascal. "You good here? I'm overdue for...something, in 199." She cannot for the life of her remember what.

"Uh, sure. You'll stay around...?" he adds pleadingly. 

It turns out that she is, in fact, just over two hours late on a midnight Lasix dose and antibiotic. 

Whoops. That's a little awkward. She's been in there since then, even, it was just so long after midnight by then that she wasn't prompted by 'midnight tasks'. They're Q6H, though, and it looks like the evening doses were given closer to 7pm than 6pm anyway. 

She takes care of that, and then - because the unit has that strained-to-the-brink feel that almost never happens on nights, and Chantal is now thoroughly occupying calling up on-call OR support staff to come in urgently for overtime - slips almost without noticing it into the charge nurse habits of mind. She does a pass through the unit, checking in, is anyone behind on meds or turns or labs that she can help with... 

She draws a repeat troponin on their resident pacemaker-yanking Patrick Stewart lookalike, and changes propofol tubing for just about every patient on the unit who's on it - it's a lipid suspension, it needs to be changed every 12 hours to avoid gumming up and growing shit in there - and she pulls and signs off on a new fentanyl bag for ulcer lady, and she helps Mayumi do a turn and a hasty bath on her asthma girl. 

She makes it by Ma'ar's room to check a 3 am blood sugar. 84, slowly dropping but still in normal range. He's theoretically due for a turn but he's still satting fine, at 93%, and he's probably strong enough to shift position a little on his own if he's uncomfortable, that cuts the risk of bedsores a lot. He needs his sleep. She leaves him be. 

She hovers nearby while the GI surgeon and Dr Prissan discuss outside 192's room, but they seem to be handling it fine. 

The unit is...busy, but settling back into a steadier, less frantic rhythm. Pascal is prepping his patient to transport to the OR. They've got lots of hands. 

"If you don't mind," Nellie says to Chantal, "I'd like to take 45 min now and have a break. I can cover you after. My people don't need anything, just keep an eye on the monitors. ...If Ma'ar starts screaming again you - well, you probably won't have to get me, I think the entire unit heard it. Don't go in the room if he's asleep and yelling, he yells telepathically too and it sucks ass. Just turn the lights on from the door."

Some nurses don't nap on night shift. Nellie's never understood it. She naps on all her shifts, even if just for ten minutes. Usually on nights you can nab longer breaks, but thirty minutes will help a lot. 

Approved to leave, she slips off to the conference room - the clean utility and its reclining chair is already claimed by Isobel while Rick covers her CRRT patient, and besides, who needs beds when it's three in the morning. Nellie sets an alarm for 3:55 am on her phone, stretches out one flannel blanket on the floor under the table, lies on it with her borrowed pillow and another blanket over her, and relaxes. Within about 90 seconds she's asleep. 

At 3:47 am the code blue wakes her.

Not even the intercom beep; when it's on your unit, it rings at the nursing station, like a call bell except higher-pitched and five times as fast. 

She's on her feet and at the door in a couple of seconds while still only semi-awake, and she's halfway down the hall to Ma'ar's room before her brain catches up and notes that the running footsteps were going the other way. 

...Oh fuck a duck it's Patrick Stewart isn't it. 

Yep she was right. Rick is in there already, pounding the patient and his wayward transvenous pacer into the bed, and Chantal is wrestling the crash cart around the corner of the nursing station, and Dr Agarwal is standing there looking petrified. 

At least 192's room is empty, presumably because the guy is still in the OR. That's one small mercy. 

Rick lifts his head and sees her. "CPR board please?" he says, in a deceptively mild voice, as though asking how she likes the weather today. 

She's seen Rick do this before and she wouldn't miss it for anything. She grabs the rigid board off the back of the cart and wedges past Dr Agarwal and drops both bedrails on her side. "Ready?" 

Rick nods, grips both of the patient's arms just below the shoulders; the patient is a tall man, but skinny, and Rick's large hands reach far enough to support under his shoulder blades as well. 

And he lifts. Just lifts the guy's entire torso right up like he's a pillow. 

Nellie supports the patient's loosely-flopping head with one hand and shoves the board into place with the other. 

"What happened?" During the pause in CPR she can at least see the rhythm, and check for a pulse as Rick sets the guy down.

Rapid ventricular tachycardia. Great. No pulse. 

"What you see is about it," Rick says, just as level as before even as he resumes compressions. "One second he was fine, sitting there reading his damned Carl Sagan book, last BP was perfect, and then - bam. He was unconscious by the time I got here." 

"Rude." She reaches for the ambu bag, checks it's hooked up to the oxygen, turns the flow up to its max. "Isobel's back? You were covering -" 

"Damn. Blanked on that, someone should get her." He says it in the same tone of mild annoyance that one might use if they'd missed their bus and had to wait for the next one in ten minutes. "Pacer pads are on him just in case, where's the defib? Can just hook it up." 

Another reason she gets on well with Rick; he always takes the time to set up precautions like that, 99 times of 100 it doesn't matter but on the 100th time it saves you ten seconds and that's worth it. 

She finds the trailing wires, holds them up, sees a hand that looks like Mayumi's pick them up, and goes back to ventilating the patient. "Who's prepping the intubation kit?" she says to the room at large. 

"On it." Chantal. "I'll wake Isobel. Kaysi's gone down the street for shawarma at that place, reckon I should text her and tell her to book it?" 

Nellie does a speedy mental headcount. "...Think we got enough hands on deck. Who's watching the desk?" Given that just about the entire staff of the unit is stuck in here for the foreseeable future, someone needs to watch monitors and call bells. 

Pascal, being the least experienced with codes and conveniently short a patient, volunteers himself. Nellie makes a mental note to swap him in if the CPR rotation goes on long enough. 

"Dr Agarwal did you page the attending? ...Good, just checking. Push epi first or shock him?" 

"Defib ready?" 

Mayumi confirms that it is. Everyone back off. Really all you need is 'not literally touching the bed' but most people prefer getting at least two feet away. Nellie included. Rick, apparently, doesn't feel the need to even stop leaning on the bedrail. 

It's plastic and non-conductive, as is the mattress, and honestly it wouldn't be that out of character if Rick turned out to be immune to electricity somehow. 

"Everyone clear? Charging..." Dr Agarwal's deer-in-headlights expression is, Nellie thinks, priceless. "Shocking," he squeaks, and presses the button with what clearly requires a lot of willpower-override. 

Nellie isn't going to tease him, she remembers feeling that way herself. ...Okay fine she might tease him a little bit. Later. Once he's less new and it's been long enough that it's funny. 

"- Oh great, here." The respiratory therapist - shared between the ER and ICU on nights, but on call for codes - just reached the room. Nellie shoves the ambu bag at her. "I'll pull meds. Chantal, are you charting?" 

She checks the patient's femoral pulse at the same time, and given the zigzag waves on the monitor, is unsurprised not to find one. She keeps her fingers there a few seconds longer, though, just for the satisfaction of feeling how effective Rick's compressions are. 

"Who's timing?" She's going to tell Rick to switch off after the next two minutes. If nobody tells him to then he just...never does. Apparently he did ten minutes straight once. Nellie, who works out regularly and considers herself in good shape, is regularly a puddle after two minutes. 

Mayumi helpfully turns the drawer side of the crash cart to her and she digs for meds. Makes eye contact with Dr Agarwal, shows him the syringe of epinephrine, gets his nod, and rams it into the single lumen on the transvenous pacer like, which very conveniently can also be used as an actual central line. 

Another minute passes. Rick continues to be some sort of absurd superhuman monster who is not only breathing normally like he's just taking a pleasant stroll, but also doesn't even look like he's trying. (It's a lot easier when you weigh 280 lbs and all of it is muscle.) 

Dr Prissan strides in. "- Oh, so that's what all the fuss is." 

Dr Agarwal explains in a stressed whisper what they've done so far. 

"Two minutes," Chantal says tonelessly.

Still V-tach. Nellie's had her finger on the guy's groin for the last fifteen seconds and she feels the pulse stop. 

"Who's swapping in on compressions?" Mayumi is the least occupied but she also weighs about as much as a feather. 

"I can -" Rick starts, but several people frown at him. 

Dr Agarwal steps forward, clearly happy for an opportunity to do something that doesn't require having any clever ideas. "I'll do it - Dr Prissan, you're taking over leading it?" 

Dr Prissan rolls his eyes ceilingward. "Am I? ...Sure. No pulse? Let's shock him again." 

Mayumi does it this time; most of the nurses on the unit are trained for it, and Dr Prissan clearly isn't interested in doing it himself. 

Everyone leans in. 

"...That looks like a rhythm change?" Dr Agarwal says hopefully. "What is that?" 

It's very slow, the monitor isn't even deigning a number yet, and the peaks don't look much like heartbeats at all, so much as little mountains, or maybe the swoopy bits on top of meringues. 

"Idioventricular. Agonal rhythm. ...And no pulse so it's PEA anyway - compressions?" 

Dr Agarwal dives to start this. He does it with a lot of enthusiasm and somewhat less effect than Rick, probably because a strong gust of wind would blow him away. Nellie can still feel the faint throb of a pulse by thirty seconds in, though, once he's built up enough blood pressure in there.