There are apparently some missed messages from Dr Zee. 

[Is Dalrymple there] 

[Did 201 get his methylprednisolone] 

FUCK

[no and no] 

[not sure where dr beckett is either] 

[pulling meds for rave drug girl but ill go give the steroids for 201 right away after] 

Her phone buzzes again ten seconds later. 

[coming in now] 

This is an imminently reasonable response and yet nonetheless Nellie has slightly hurt feelings about it and keeps defensively wanting to message back that it's not her fault there kept being things more urgent than figuring out the order for 201's methylprednisolone. What was it again, actually? ...5mg per kg. But was that per day or per dose...? She thinks it was per day but she didn't actually get it in writing... 

Damn it she's going to have to google for medical studies and try to double-check this, isn't she. 

Before doing that, she logs into a computer by the bank of monitors and checks what the midnight labs are for Isobel's rave drugs girl in 196. 

Repeat electrolytes, repeat liver panel, repeat urea and creatinine. 

Liver panel? Huh. She remembers hearing something about possible dialysis, but not about liver issues. 

She pops over to the lab results page to check previous liver panel results. 

ALT 646 U/L  [reference range 7 to 55 U/L]
AST 306 U/L [reference range 8 to 48 U/L]
ALP 799 U/L [reference range 40 to 129 U/L]
GGT 259 [reference range 8 to 61 U/L]

Great. Wonderful. What in the name of the Trinity has this kid managed to do to her liver. 

The chart has no answers for her but it does have the color of tube she needs for the midnight bloodwork. 

Nellie gathers a couple of tubes (plus a hastily collected styrofoam cup of the various accoutrements for bloodwork that a nurse less incessantly organized than Isobel would need, and which even Isobel might benefit from on a night like tonight) and brings them to 196 along with a plump neatly labeled bag of phenylephrine.

"Here you go! Sorry, gotta run - I should check on my wizard. And my other potential wizard." 

Isobel is currently immersed in fiddling with IV pumps and acknowledges her only with a raised hand and a mutter. "You can leave them on the side desk." 

Nellie does that. 

...She's going to obsessively stalk this kid's lab results all night. This is just definitely what is going to happen. 

Nellie heads back to the nursing station, where she can log into a computer and put in a verbal order for 201's methylprednisolone while also watching the central bank of monitors. It gives her an itchy feeling in her spine when she knows no one is doing that. 

The bank of monitors tells her that 201's temp is up to 29.5 and his sats are holding steady at 93%. 

Ma'ar's vital signs continue to be perfect. 

She's going to use 60kg for the dumbass kid's weight, because this makes the math prettier and also if you're talking "ideal" weight, he clearly needs to put on at least two kilos. 

Cool. That gets her 300mg per 24h. Divided by 6 is 50mg. 

That is super inconvenient! It turns out the standard vials for reconstitution and IV administration are 40mg or 125 mg! Frustrating! 

...Nellie does some more math. 

Fortunately it sounds like methylprednisolone is stable once mixed for over eight hours! Meaning that she can mix two bags at once! 

The 125mg vial is supposed to be reconstituted with 10ml of saline. And it's one of the very fine fast-dissolving drug powders that doesn't add much to the original fluid volume, so it should end up pretty close to 12.5 mg per ml final concentration. At which point Nellie can splooge 4ml into one 50ml bag of saline, and another 4ml into a second bag, and then if the remainder is noticeably more than 2ml she can eyeball it and split it half and half between her two bags. 

(It's maybe a smidge over.) 

You know, whatever, the weight she put in for him was a smidge high as well. Also this is already well over the usual dosing they give for sepsis patients. Which is not weight-based and most of them are, like, twice this guy's size. It's probably fine. 

She labels the bags, less meticulously than she did with the ones for Isobel's patient, and then speedwalks down the hall to check on Ma'ar before hanging them. 

He's not currently moving, and his heart rate is steady at 62 bpm, but he's now twisted the other way and has one arm half-shoved through the gap in the bedrail, and his other foot propped up on the footboard of the bed. 

Nellie continues to be mystified about how he even does that, but he's not currently in distress and her other patient is at risk of dying before morning, so she knows what her priorities here are. She heads back to 201 and re-dons all of her isolation gear and - pauses - she's not sure if you can hang methylprednisolone with a dextrose drip and she doesn't super want to pause his drip, so she should get a saline (half-saline?) primary line to run a piggyback on. ...And also lab tubes. It's well past 11pm and she was supposed to check electrolytes again now. 

She's not contaminated yet, but still pops off her mask to avoid looking like she's left an iso room without de-gearing, and trots off to collect that equipment. 

Kid's temp is 29.7 by the time Nellie hangs his steroids, putting them in the peripheral IV line because the femoral central line, for all its impressive length, is only single-lumen and she's not sure if methylprednisolone is compatible with dopamine, which is already running into the same line as the midazolam. 

His blood pressure is down, though, hovering at 92/42.

Ughhhhh. It's probably the midazolam boluses she gave him. Nellie sighs and bumps up the dopamine drip, even though she's not loving the frequency of ectopic ventricular beats. 

...She should theoretically be able to pull labs from the central line, but unlike a triple-lumen - which would let her get away with just pausing the drugs running in the other lumens she wasn't pulling from - for this she would have to stop everything, unhook everything, and then waste an entire 10ccs of blood just to make sure she'd gotten all the infusing drugs out of the very very long lumen. She has so little desire to do that even just with his sedation, let alone for a pressor. She'll stick him peripherally. 

The patient disapproves! Even less purposely than the last time, though - he doesn't even try to pull away from her, exactly, just goes rigid and sets off the ventilator alarm. 

It's inconvenient, but some patients just don't get very deep sedation from midazolam. He seems totally out as long as she's not stabbing him with needles, so Nellie isn't especially worried that he's going to wake up and cause problems while she's out of the room. 

She thinks to take a blood sugar while she's here anyway, she can't remember whether one is due or not but she might not make it back in before midnight. 

96.