"Good point. All right, fine, you can give him one mg of midazolam and...let's try 25 mcg of fentanyl, that should hopefully be enough to keep him chill - Marian, I do want a neuro check on him first, please." 

"Yeah. Right. Ma'ar! ...No response to verbal. He...withdraws to pain," or, like, twitches, at least, but it's not decorticate or decerebrate posturing, those are both very recognizable, "but no opening his eyes - pupils are reactive - can't assess verbal - I'm calling that a GCS six or seven probably." 

Nod. "We can max his norepi and give a little sniff of sedation, just to relax him a little. Let's get some phenylephrine prepped, please, and - hmm, put in an order for albumin 5%, 500ccs. And then - Marian, dim the lights for me?" She's squinting at the ultrasound screen again, which is indeed a little washed out by the glare of the overhead fluorescents. "Also, if anyone'd like to see an impressively crap echo - where's that resident gotten to, this is a great learning opportunity." 

"Hopefully covering the entire rest of this unit, this isn't our only active clusterfuck. I'll call him?" 

Marian gets the lights, and then winces. "Is it as bad as that time a few years ago -?" 

Crooked smile. "Not that disastrous, thank god. Severe systolic dysfunction, but I'm calling it an ejection fraction of...15%? We need a proper bedside echo, put in the order for that please." 

That's still very inexplicable! "Uh, is that a thing low phosphate or mag can cause...?" 

"Actually, my top guess right now is viral cardiomyopathy. Which bumps up my guess that this is influenza - it's an uncommon complication but it does happen, and it's more likely with this kind of full-on cytokine storm immune response." 

Aaaaaaaaaaaaaaaaaaah. "Does it, uh, get...better...?" 

"Yes, actually. Most previously healthy patients regain full systolic function in a couple of weeks, or at least that's what's coming to mind from the papers I've read." 

How does Dr Zee manage to have a perfect memory for every single paper she's ever read about some obscure disease process. It's absurd. (Two days ago Marian might have said 'it seems like magic', but having since encountered actual magic, it...doesn't really seem very similar.) 

"Hey, and check this out! O2 sats of an entire seventy fucking two percent! Joy!" 

Dr Zee is still scowling at the ultrasound screen. "I'm a little worried at how long he went without much oxygenation. I'd cooling protocol him except for all of the reasons why we're definitely not going to do that. Maybe if he stabilizes a bit within the next few hours, it'd still be worth trying." 

Marian is going to be SO UPSET if her wizard patient has anoxic brain damage from this! It feels like it almost definitely has to be somehow her fault, for missing something, except she's not sure what - well, obviously, if they'd caught him deteriorating earlier, on night shift, then maybe something could've been addressed sooner - but he was having so many problems at once... 

She will think about that later. Right now she will focus on the basics. One thing at a time. 

Eventually, the basics involve Bert, who is sitting at the nursing station looking utterly and incredibly exhausted, putting in orders for about a dozen swabs and blood draws and urine specimens and various other tests he wants to run for foreign pathogens. Half of the materials need to be couriered over from the Civic Hospital, but this happens, somehow. 

Marian really really wishes she could get someone ELSE to do that! Her feet really hurt! 

Nellie is hiding and sleeping in the administrator's office, though, and it's not like anyone on the rest of the unit has much spare time right now either. She has a hard enough time recruiting Esther to help turn Ma'ar - an incredibly stressful process! - so she can stick a swab up his butt because apparently Ottawa Public Health wants THAT. 

He's still not purposefully responsive at all, but he's tensing up when touched enough that she sedates the fuck out of him before attempting this, even though this means she has to max out both pressors for the next half-hour while his blood pressure recovers from that. 

He's also still running a fever, back up to 38.9 C, now and Dr Zee declares that while they're not going to cool him into actual hypothermia because once was bad enough, they need to keep his temp below 37 C. Which is going to call for a cooling blanket, ideally, except that they have ONE of those and it's in use already. 

Marian will strip him naked and cover him in cold wet towels while Amélie calls various other local hospitals and eventually gets someone at the Civic to send one of their care aides over in a taxi with their extra one. 

Ma'ar....is not fighting her, exactly, that would imply a lot more strategy than what he's displaying, but he's doing the tensing-up thing a lot, which usually makes him start coughing and fighting the ventilator, at which point his O2 sats instantly drop into the low 80s and his blood pressure dives. 

Wow she does not like that! Marian would prefer this was not happening and it makes her mildly panic each time. 

She doesn't really want to leave the room, right now, so she calls Amélie at the charge station. "Hey - where's Dr Zee, I've got an issue."

     "Huh? Doing rounds." 

"Rounds? Wait– oh." How is it possibly almost 11 am already? 

     "I'll poke the resident - what's going on?" 

"Uh, I think 202 needs more sedation or something, he's not really responsive but he's fighting the vent and then he desats and it keeps scaring the crap out of me." 

     "What's he got now?" 

"Uhh... Nothing. He got a teeny bit of midaz and fentanyl push but that must've been an hour ago." 

     "Oh." Marian can tell what that tone of voice means, because it's exactly what she's thinking - that it's not very meaningful, yet, but 'not especially responsive, on zero sedation' is not the world's most reassuring sign. "I'll send Dr Agarwal over to give you orders." 

The thing about being 1:1 with a patient in 202 at the very end of the hallway - especially on a day when the charge nurse has a double assignment and 201 is her easy patient - is that once there is slightly less of an active emergency, and Bert from Public Health has disappeared off to do administrative phone calls somewhere, and rounds are happening while constantly being interrupted by other disasters - 

- is that the rest of the unit seems to mostly forget that Marian exists. 

At 1:30 pm, Amélie treks toward 201 with an armful of incredibly overdue meds, and does a minor double-take at Marian half slumped over the desk, despondently dipping saltine crackers from the patient kitchen into a pudding cup likewise stolen from the fridge while she grumpily hits 'refresh' repeatedly to see if the last set of labs are back. 

Amélie does a mild double-take. "- Marian? Have you had a break?" 

Marian has NOT had a break. She at one point dared a five-minute run on the supply room and med room, at which point she filled two entire plastic washbasins with literally everything she could possibly think of that she would need during the next ten hours because it was increasingly unclear that she was going to get a second chance. She's made herself three cups of incredibly horrible instant coffee from the patient kitchen instant coffee packets, and the only reason she's been able to pee EVER is that she's been doing it in Ma'ar's attached bathroom. With the door open so she has line of sight. (It's not like he's going to mind.) 

She gives Amélie a look of flat exhaustion. "I have super not had a break. Are you offering? ....Uh, I need to call the echo tech again, they were supposed to come 45 minutes ago." 

Amélie sighs, glances at her watch, decides that being another ten minutes late on a pile of standard Old People Meds and a q6h blood sugar check for a patient on continuous tube feeds who needs 2 units of insulin every time like clockwork, and sets down her pile before plopping herself in a wheely office chair and kicking off down the hall to join Marian. 

"How's he doing?" 

"Uh. Better than this morning?" 

Amélie raises her eyebrows. "That's an incredibly low bar."