"Hmm?" Emmy is very distracted. "Uh, what orders do you need?" 

She resists the temptation to snap back 'how am I supposed to know, I'm not the doctor here'. She is, in fact, apparently the person here who has the most context on this patient, even though you would really think that the paramedics who stabilized him on the scene and then spent an entire ambulance ride in his company would, perhaps, know MORE THINGS. 

"Uh, something for sedation - not propofol please, probably midaz is fine? - some standing order for a pressor, I want a max dose and frequency on the atropine if that comes up. And, hmm - something for active rewarming if I'm right and this dude is hella hypothermic."

Not that Nellie has any idea how he got that way in a SWIMMING POOL, but whatever, it's winter, maybe he was wandering around outside high on something and inexplicably decided the university swimming pool was a good place to get warm. Confusedly went for the pool instead of the hot tub? Whatever. 

Emmy really doesn't have a lot of brain to spare. "Yeah, sure, all of that sounds fine. Midaz, norepi, usual protocols. Atropine - I think it's 0.5 mg every five minutes, as needed, to a max of 3 mg, and - hmm, give it if he sustains a heart rate below 30 or does a pause longer than five seconds. Give him a 1L saline bolus to start and you can warm it." Convenient how she had all that fairly recent practice with treating hypothermia. 

"Ummm. I think we should get some stat labs, near-drowning fucks with electrolytes. ...Honestly, we should probably send everything stat, something about the story isn't adding up and I think we could be missing a complication." 

"Right. Do that. And a tox screen. Do the obvious rewarming things. And text or call me if something else comes up - sorry, we really should go -" 

Nellie is not delighted by this! Though she can't blame Dr Beckett for wanting to get Rave Drug Girl to the unit ASAP, it looks like that could get gnarly. 

She's even less delighted by the fact that several of the ER nurses were roped into transport. Orange scrubs is back now with the low-temp thermometer, at least, and Nellie can rapid-fire delegate the collection of bloodwork tubes and a butterfly blood-draw kit, and pulling some atropine to have prepped, and - jesus, she really doesn't like how the kid looks. 

She tries to get a temperature, orally. 

The machine thinks about this for a rather long time. 

That is NOT REASSURING. 

The thermometer eventually settles on displaying 26.9 C, but flashing and with a question mark. 

YIKES.

No fucking wonder the patient's heart rate is so low and he looks like something you would scrape off the bottom of your shoe. That temp is horrifying. 

It's...possibly not accurate. She should probably get a rectal to confirm. Unfortunately the patient does not so much tolerate things like "being turned", which suddenly makes WAY MORE SENSE now that she knows how profoundly hypothermic he is. 

It also makes way LESS sense with the history they were given? Below 28 C is unconscious. Maybe he's not on anything at all, the mental status changes are more than explained, what's unexplained is how in the name of Jesus Mary and Joseph he got himself into a swimming pool. 

"...Get Dr Beckett on the phone," she says to Orange Scrubs. "We're going to need internal rewarming and to get that set up as soon as possible before this guy decompensates any more. ICU has that fancy machine for cooling protocol that does heating too - I'll have to call ahead, get it set up over there - we can't just keep dumping saline in him until we know his electrolyte status but we could do gastric and bladder lavage with heated water, but I don't know where we stock the stuff for that, ugh. Surgical floor must have the stuff for continuous bladder irrigation, they do prostate surgeries... Is there literally anyone we could spare to send up and get us that? ...I guess I should confirm a rectal temp first, the thermometer wasn't very sure of itself, but I'm expecting it to match. He looks sick enough for it." 

Orange Scrubs is just sort of standing there blinking at her. 

"I...guess we can send the care aide upstairs? Need help getting the temp, I can turn him." 

"Yeah, uh, let's do that after we've got atropine ready to push. Uhhhh. I – should check out the paramedics' IV. I didn't get a report on that at all. I'm not even sure where it is." 

Hunt hunt hunt for an IV?

It's there! Left antecubital fossa. It's the horrible kind where the saline lock is plugged directly to the cannula, without any kind of extension tubing, and it's held in place with a couple of pieces of tape rather than the clear film dressing. 

"Well, technically we have IV access but it's sketchy as fuck and I do not want to have to fiddle around pushing directly, we need extension tubing. I'll prime some saline - ugh, but we can't give him cold fluids - I'll throw some saline in the microwave if you can stay here and keep an eye on him -"

Nellie is currently juggling about eight different urgent priorities in her head, what order to do things in so they can get all the ducks lined up as fast as humanly possible. Calling Dr Beckett back is pretty up there as a priority but she wants a more trustworthy temperature first...

It ends up taking closer to ten minutes, by the time she's booked it back and forth from the staff room twice, squeezing in a blood draw in the three-minute wait; she goes in the other inner elbow, even though she would normally save that vein if possible, but he's so peripherally shut down. Even that vein flows slowly and sluggishly and it takes ages to get the half a dozen tubes she's sending for the full array of tests - and then of course the lactate and venous blood gas need to be on ice and sent promptly and the orders aren't even in the system yet and it turns out the PATIENT isn't properly in the system yet and it's just. one. thing. after. another. 

The patient does not code when they turn him. 

Measured rectally, his temperature comes back at 27.4, which matches - rectal is usually half a degree higher - damn it they desperately need a continuous temperature on him and usually Nellie is a fan of the catheter probes but they can't use that if they're using the continuous bladder irrigation setup - fucking FINE she will keep him turned on his side for thirty seconds longer even though it's intensely nervewracking, so Orange Scrubs has time to go grab a rectal temp probe - and for a few seconds, remembering previous events, she is absolutely expecting to get pasted with an elbow to the face, but this guy is much worse off than Ma'ar was at that point. He doesn't even twitch.  

He does decide to do a thirteen-second pause shortly after they finish laying him flat again. 

AAAAAAAAAAAAAAAH!!!

Nellie doesn't know it's exactly thirteen seconds right away, of course - that's only documented after the fact, when someone runs over from the nursing station with the strip they printed at the central monitor bank. In the moment, it's just way too bugfucking long, and by the time she's gotten the syringe of atropine hooked to the Y-junction on the saline tubing and rammed in half a mg and flushed it and is deciding whether to start CPR, there are spikes on the monitor again, and several seconds of hasty fumbling confirms a femoral pulse. 

Several people are asking her at once if she needs anything. Nellie fights the urge to snap back that she could've used extra hands ten minutes ago. "Someone get a blood pressure and start the norepi if he needs it - and sort out why we're not getting a sat reading - I need to call the resident. Can someone measure that strip and tell me how many seconds it was, she'll want to know."  

She digs out her personal cellphone and flips to Contacts and calls Dr Beckett. 

She gets an answer after seven rings. Dr Beckett sounds faintly muffed. "What is it? Problems?" 

"You could say that! Our pool drug guy's temp is fucking 27 degrees. At this point I'm half betting no drugs were even involved though we got the tox screen off. Also he did a pause of, um -" 

     Orange Scrubs is counting grid-lines. "Uhhh, ten - thirteen seconds!" 

"Thirteen seconds," Nellie relays. "He's brady at, shit, still only 25 bpm. I pushed atropine. We're getting a blood pressure, suspect we'll need to start the norepi too. Labs are all sent but he's going to need much more aggressive rewarming, the Bair Hugger won't cut it. I think we should put him on that machine that hooks to a central line - we need a line anyway - and start heated gastric and bladder lavage. We can probably use the continuous bladder irrigation kit from urology but I don't know how to make something non-janky for gastric lavage with the supplies you've got in stock, might just have to go with a syringe, or we could maaaaybe set up one of those refillable gravity tube-feed bags and alternate that with suction? Anyway none of that's going to be any fun to travel with so I'd rather get him to the unit, like, now, and get started." 

She pauses for breath. 

"Shit," Emmy says, with feeling. "This is– well, it's a good thing the rest of the unit isn't as heavy as it was a couple weeks ago. Um. I've - never treated someone that cold before. Sounds like you have?" 

"Once." Pause. "She didn't make it. But I reckon this kid has better chances. If we move. How soon can I bring him over - is there any reason why it can't be right now -?" 

"...It'd be a strain. We're kind of all running right now just dealing with the rave girl. But it sounds like it's not really any better over there, and you'd at least have the equipment closer at hand, even if we can't give you as much backup as would be ideal." 

Sigh. 

"Got it. I'll be over as soon as I can rustle up some hands over on this side to help me get him settled. Could you do me a solid and have someone drag the what's-it-called machine to the room? And check there's a bed and suction and all that?" 

"Will do. If you come in five or ten minutes we'll probably be able to send you someone to help out but that does depend on this girl not coding on us. If you think aggressive rewarming might save us from two simultaneous codes on the unit, I'm all for that." 

"Yeah, no, I'm still on team 'be ready for the shit to hit the fan at midnight' on this guy, when the pulmonary edema kicks in - hopefully he'll tolerate rewarming but the near-drowning is a whole other kettle of fish. ...We should throw some steroids at him. There's probably some kind of early-treatment protocols but his temp is a bigger issue and I don't have time to go do a literature review right this second."