"...I don't love that. How much midazolam did he end up getting, total– You gave him three doses? I guess that'd explain a bit of respiratory depression. ...Oh, and that BP's not filling me with delight either." The monitor is claiming 85/57, which is technically fine by ICU standards but probably not this guy's normal range.

He's mostly stable, she thinks, he's just...not bouncing back as fast as she feels that a young, apparently-healthy man, apparently not on any drugs at all, should be. "What am I missing..." 

She runs down the list of complications-from-hypothermia in her memory. And then admits that she should probably consult Google, and pulls up a US National Library of Medicine paper, watching Patricia unspool the tubing for nasal cannula and hook them into the patient's nose. 

"...Cold diuresis, right. Uh, we - should probably be monitoring urine output, we're putting a lot of fluids in. And he'll be losing electrolytes. Let's give him another litre of fluids, but switch it to lactated ringer's - and make sure it's warm. Three minutes in the microwave– actually, I'll just do it myself and, uh, probably I can check the temperature of it somehow...? And I want a Foley catheter." 

"Are you kidding? You want me to drop a catheter in mister 'I have a black belt in judo and will punch you in the face'?" 

"...We can't just not treat him. I guess maybe that's less urgent and possibly it could wait until day shift has an interpreter. Unless he drops his BP again, if that happens I want it done ASAP."

She vaguely recalls that the ICU stocks those neat catheters with temp probes, which would kill two birds with one stone, but also it's all the way over there. And she's pretty sure they cost three times as much. The patient is concerning her some, but he's not that sick. Yet she is not going to tempt fate here. 

She clicks around the chart. Labs: a whole slew of them pending, sent about thirty minutes ago. The only ones that are back yet are the blood counts; hematocrit is at the high end of the reference range, whether because he's an active male or from hemoconcentration because they weren't keeping up with fluids, she can't say. White count a touch elevated.

Arterial blood gas from hours ago: back, PaO2 low end of normal, PaCO2 the same, pH slightly acidotic, bicarb below the reference range but not marked as a critical result. Metabolic acidosis, which Doctor Google informs her is to be expected. 

...And then, inevitably, she's pulled away by a ringing monitor next door, before she can finish her mental checklist of what she might have missed.

She only realizes several minutes later that she told Patricia she would prep the warmed fluids, and she has absolutely not done that, and also Patricia is nowhere to be seen.

"Matt! Hey, I'm sorry, could you microwave some Ringer's for bed one?" 

The charge nurse shakes his head. "I still can't believe you can do that. Sure." 

"And a blood sugar while you're over there?" Emmy adds thirty seconds later, calling out so he'll hear her at the nursing station. "I'm not sure we ever followed up after we treated the low sugar that the paramedics got." 

Matt sighs, but doesn't frown where Dr Beckett can see. "Sure, of course." 

He passes her again a few minutes later. "Fluids are running. Sugar was 81, he's fine. I grabbed another temp for you, too, he's up to 31.2. Oh, and I bumped his O2 up to 3 litres, his sats were dipping a little." 

"Thanks for the head's up." That's a little worrying? She's not sure how worrying. Probably it's just that Patricia, well, got overenthusiastic about the midazolam order. It'll wear off soon, it's not that long-acting a drug... 

She makes a mental note that they'll want another blood gas, and returns her attention to the other patient. 

Ma'ar drifts through confused nightmares, voices and lights and other miscellaneous sounds of an understaffed ER at six-thirty am reaching him from a great distance, blending with memory of battle and fire and a child's flight through a violent country. 

Eventually he sinks into deeper sleep, where there are no dreams at all. 

His blood pressure rises briefly after the fluids go in, but creeps back down to a systolic in the 80s. His heart rate is consistently between 45 and 50, now - that one degree of body heat made a difference - but it's more irregular than before, the ugly wide-complex ventricular beats coming more often and sometimes joining up into couplets. 

His breathing is still unlabored, and not that much slower than normal - 10 breaths a minute, sometimes 9 or 8 - but it's less regular than before, and his chest only rises a little. 

Shift change is approaching and most of the nurses are doing their very best to catch up on a night's neglected charting, even as the first dribs and drabs of the morning rush start. Patricia is stuck in an isolation room helping clean up a, well, mess, which would be very embarrassing to leave to the arriving nurses. 

One of the others at the nursing station notices the monitor pinging sadly on the central display, glares at it for thirty seconds to see if the sat reading will come up by itself, and then groans and briefly interrupts her charting to go increase the patient's oxygen. Might as well go to 6L and let day shift sort it out later. 

6:35 am. 

Ma'ar's sats pop up above 92% again, but the reprieve is short-lived. By the time Patricia extracts herself, washes her hands thoroughly, and heads back over, he's slowly dropping through the mid-80s. 

He looks calm at least. She taps his shoulder. "Hey, man, take a couple deep breaths for me? Through your nose." 

No response. The alarm shifts to a faster, shriller ringing as the number slides down past 85%. 

"Jesus. Why now." It's 6:45 am. Staff huddle and shift report is at 7:15. 

Patricia squeezes his shoulder harder, repeats the instructions much louder, then winces and rubs her knuckles up and down on his sternum. When this doesn't get a noticeable response beyond, maybe, a faint frown-line appearing on his forehead, she starts to genuinely worry. 

"Matt! Lila, get Matt here now - find the resident, I need her ASAP - uh, call the lab, see if they can move on results." She whacks the button for a blood pressure. 

76/41. 

Sats down to 84%. 

Ma'ar's features are slack, his expression almost peaceful for the first time. His skin feels clammy to the touch as Patricia wrestles an oxygen facemask into place, turning it up all the way - better to overreact and correct later.

By the time Emmy Beckett arrives at a jog with Matt, he's maintaining his sats at a fairly cheerful 95% - but it's a less cheerful sign that that's on 100% oxygen. His blood pressure is back up to borderline-acceptable, probably because Patricia keeps repeatedly causing him pain. She can get some response - an eyelid flicker, a faint tensing of his limbs - but not more than that. 

Emmy stands at the foot of the bed. "Shit. What's up with him. Matt? Anything obvious we're missing here? ...Labs, right, his electrolytes could be whacky and they're not back yet–" 

"Lila's calling the lab. Sorry, if I'd expected," vague handwave, "this, I would've put them down stat in the first place. Anyway, right now I'm worried about his BP." 

A terse nod. "I don't want to dump more fluids in him til we've seen that bloodwork and I know I'm not making anything worse. Can you prep some norepinephrine? I don't love running it peripherally, but it is what it is - if he doesn't stabilize we can do a central line. Maybe we should prep for one anyway. He seems fragile."

At which point she actually turns her attention on the patient and looks at his face, rather than the monitor. "...God. I do not like how he's looking right now."

It's hard to put into words. She remembers her first attending saying something like that, 'I can't say why I'm worried except she just looks sick'. 

"- Right. Let's prep to intubate him as soon as we've got some support for his BP. Matt, call the ICU and make sure they've got a room for us? If we can get him stable enough for transport before day shift..."

6:48 am. 

Marian feels a lot better than she expected to, even with the interruption to her few hours of sleep. The pre-shift-change bustle and lights being switched on in the hallway woke her, and she emerges, yawning, and heads for the end of the hallway, there's an empty patient room there and it's a way nicer bathroom than the staff one. She stole a mini deodorant and one of the disposable patient toothbrushes from the clean supply room; the mini tubes of toothpaste are awful, but at least she can make herself very slightly more human before 7:00 am. Which is when the Tim Hortons in the front lobby opens. 

Chantal's desk is empty. Judging by the lights being on, she's in the closer patient room in this side hall. 

The phone at her desk rings. Rings again. 

After the third ring, Marian grumbles under her breath, sets down her filched toiletries, and picks it up. "Soins intensifs, c'est Marian?" 

She listens for a while.

When the ER night charge nurse gets to the patient details on their requested admit, her stomach seems to drop out the bottom of her feet. 

"...Oui, je penses qu'on a une chambre libre? On peut envoyer quelqu'un pour aider. ...Non, je suis jours, j'ai...arrivé tôt. Je m'en viens, deux minutes..." 

It's not that unexpected for the ER to ask for help, for an unstable ICU-bound patient this close to their shift change. Marian...would probably have volunteered to go anyway, she's here and might as well, but it does make a difference that it's her dude. 

She pauses outside the isolation room, yells an update across to Chantal, runs back to the clean utility to retrieve some entirely different medical supplies, and then books it down the hall. 

Emmy is glowering at the thermometer. "What the fuck do you mean his temp's gone down?" Not a lot, 30.9, and it's not impossible that the high-flow oxygen mask messed up getting an oral temperature, but STILL. 

...The patient isn't shivering. He was before, she's pretty sure. Now he's very, very limp.

She lifts his arm. Clammy skin, his nailbeds are dusky purple - no wonder the O2 probe is having trouble getting a good signal - and completely floppy, no muscle tone to speak of. 

She doesn't think this could be just from giving the guy too much midazolam hours ago. Well, that may not have helped, but something else is wrong - what is she still missing... 

"Where're we at with that norepi? Matt, can you get us another peripheral IV line, we've got a lot to do and I'd rather ship him to the unit and then fuss with a central line if he's still needing it." She looks around. "Damn it, guys, we need more hands in here." 

     "ICU's sending someone over to help out," Matt offers. "Day shift, too, starting early." 

"Excellent. We could use someone fresh." Emmy's forehead is aching from the combined exhaustion and tension. She massages her temples. "Well. Get me that IV - we'll need meds for intubation - oh you know what I can pull those myself." Another thing that Emmy considers it important not to be too proud to do. 

Matt is having a hard time with this stupid IV. The patient is hypotensive, and peripherally shut down, his hands purplish-grey and cold to the touch despite the blanket blasting him with warm air. You would THINK that three litres of fluids dumped into his veins would help, but in fact it's mostly made his hands and forearms slightly puffy, apparently without plumping up the veins much at all. 

Matt is an experienced ER nurse who has placed, at the very least, over a thousand IVs. He does not normally have to stoop to digging around for a vein that might if he's lucky be there. 

After the second poke fails to get even a speck of blood return, he resorts to digging. 

Ma'ar drifts below a dark quiet sea. Something keeps intermittently hurting, somewhere above the surface, but it's not exactly him, and it's hard to care. He feels very, very tired. 

- until the STABBING PAIN yanks him closer to the light and air, close enough to his body that he notices he feels incredibly dizzy and sick and he can't move he can't even pull away from the agony, let alone fight back, he barely has the strength to curl his fingers slightly and he's not actually sure whether or not he's succeeding. His feet are entirely outside his range to control. 

He manages to get his eyes open and slightly turn his head, though. And immediately regrets it. His head hurts and the gently spinning blur of too-bright lights is making him motion-sick. 

Something makes a whimpering sound. Maybe it's him. Then his body starts trying very hard to vomit, a process he has approximately no control over. 

"- Jesus Christ, could he have picked literally any other time?" Patricia snarls, dropping the trailing IV line that she was about to connect and grabbing the patient's shoulders to roll him towards her instead. 

Marian arrives at a breathless run, temperature-probe-Foley-catheter package in hand. "What is it?" 

"Get the suction tubing - the last thing we need is for him to aspirate on us - oh, hey, Marian!" A brief and harried smile. Marian is...well, a kid, really, less than nine months out of school, and it shows, but she's a decent kid, at least. And she has ICU discipline. "Matt, buddy, maybe torture our patient after he's sedated." 

The suction tubing is not hooked up to the wall, because SOMEONE didn't do their ROOM PREP, but Marian keeps the grumbles in her head and rushes to plug everything together and pass it to the nurse. "Here." The leg of her scrubs catches on something– oh, tubing, trailed over the gurney railing. "...This meant to be running?" 

"Yes. Start it at two, please." 

More than half of the patients she's ever had were on blood pressure-increasing drips. Marian has the ccs per hour to actual dose conversion memorized. She makes a mental note to program the pump properly anyway. Later.