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everything could stay the same or we could change it all
marian's life continues to get weirder
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Tadesse is no longer especially tracking his surroundings. Hasn't been for a while. The water no longer even feels cold, and Ekunde hasn't bothered to say anything in a long time, possibly because there isn't really room for both of them to cling to consciousness, right now. 

He's too weak to do any magic, now, which means it's already over. They're hundreds if not thousands of miles from shore, clinging to wreckage. It's over and he's going to die and start over, again, repeating the same loop over and over and right now it feels so pointless and he's - not, actually, sure why he hasn't already let go so he can get on with it. 

 

 

Maybe because, even in the darkest moments, on a reflexive level he still doesn't want to die. Even though he's so tired. 

 

 

...eventually, despite his best efforts, his arms no longer have the strength to grip, and the next wave shakes him loose, and there must still be a surface, somewhere, but it's a moonless night and he can no longer distinguish up from down. 

And even then, he tries to swim, almost involuntarily, and he finds air half by accident, and from there, nothing exists except the endless timeless struggle for the breath after that, and a mantra only half in words, never to die never to give up never to walk away not until it's done not until - 

- until - 

 

 

When the change happens, he's no longer processing his sensory input enough to even notice confusion.

Though he does notice, vaguely, distantly, that even the folded-up silent presence of Ekunde is gone, and he's alone. 

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When Ma'ar has been on the unit for a week, the staff quarantine is officially lifted, and Marian goes HOME for the first time. 

At which point she immediately discovers that she failed to take out her compost bucket before the unexpected absence, and her apartment now has the worst fruit fly infestation she has ever seen. 

Compost bucket goes out on the snow-covered back porch. At this point she's inclined to let it wait until spring to deal with. 

She takes a SHOWER and luxuriates in checking Facebook on her laptop rather than her phone, and makes it an entire three hours before she calls Nellie, on night shift, to check in on how Ma'ar is doing. 

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(She's not expecting any major change, and indeed there isn't one. Their resident alien wizard is heavily sedated; it's now been an entire four days since they last needed to paralyze him in order to get adequate oxygenation but they're certainly not risking letting him wake up and get agitated, yet. He's off all the pressors except a low-dose dobutamine drip, and the last time he spiked a fever was two days ago.) 

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Marian takes her entire four days off, despite getting calls every single day asking about overtime, and by the time she's back in, Ma'ar is tolerating having the sedation weaned. He's still not capable of telepathy - he was on a lot of midazolam, which has a long half-life, it's going to be a while for it to clear his system - but he opens his eyes to speech he presumably can't understand, and makes eye contact with her, and when she squeezes his hand he squeezes back. 

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At around the two-week mark for his hospitalization, Ma'ar is able to make carefully supervised use of the picture board to convey that he's thirsty. 

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Marian does not read any of the news about the quarantine or the alien. During the first week, the charge nurse or nurse administrator for ER and ICU, or Bert, were the ones to field all the phone calls. Several reporters managed to somehow get Marian's personal cell phone, but since that was during Nightmare Week while she was sleeping on the floor of some manager's office and showering in an unused patient bathroom on the 5th floor and mostly living off Tim Hortons muffins, Marian hung up immediately each time and then blocked the numbers in question. 

On her next block of days off, nobody calls to bother her at all. Except for Nellie, who has scheduled time off plus some traded shifts, and is about to fly to Texas to see her family. 

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She promises that the unit is actually really quiet! "Oh, and you've got a great lineup tomorrow. Rick and Pascal are back on days, and management finally approved the extra staffing budget so there'll be seven nurses on. Want me to scheme for you to get Ma'ar again? We really need to try to get him off the vent, soon, it's coming on three weeks." 

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Marian is on her laptop in bed, headphones plugged into her phone so she can keep absently scrolling Tumblr. "Uh, is he still iso?" 

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"He's not! We fiiiinally got results back on all those tests that had to go to special labs and stuff, everything was negative except for the flu test and he's been on Tamiflu long enough." 

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"Woo! Yeah, sure, I'd like to have him back then, if that works out assignment wise. Who's got him tonight?" 

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"Isobel." 

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"Hey, taking a report from her isn't nearly as bad as giving her a report!" 

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"Yeah, but what if she's back tomorrow night?"

Marian grits her teeth. Takes a deep breath. "I can manage." 

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"Marian, you've just got to quit letting her get to you–" A muffled phone ringing. "Oh jeez. Uh, sorry, gotta take this." 

Pause. 

"- Gotta go, we're getting an admit. See you in ten hours!" 

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...Well, if she's getting Ma'ar tomorrow and also needs to take report from fucking Isobel Gagnon, Marian is going to go to BED EARLY like a reasonable adult. 

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The unit has had substantial turnover since Hell Week. 

Pneumonia lady in 201 was extubated and transferred out; the room is empty now. COPD poopful guy in 200 was extubated, went to the floor, had more respiratory issues, and came back on BiPAP, though he's now in 198, since the asthma girl recovered and was transferred; 200 instead has a sweet, lovely, pleasantly confused 98-year-old lady being treated for sepsis from a bad UTI. 199 is STILL the 61-year-old post-ulcer-repair lady, now with trach; she's being weaned off the ventilator and can handle up to an entire 4h at a time just on oxygen, now, but her kidney function is declining. 

197 is still the important businessman who made questionable choices regarding his flu problem. He's off dialysis and off the vent and still in the ICU because his kidneys aren't in amazing shape and his fluid and electrolyte status need a lot of troubleshooting, and on top of that he's both incredibly deconditioned, and has bad enough peripheral weakness and numbness that they're suspecting Guillain-BarrĂ© syndrome. He's also taking phone calls from his company every hour. Nellie does NOT envy his nurse. 

196 is empty. For now. 

Down Syndrome guy in 195 was extubated and went home. The room now hosts a 37-year-old man post cooling protocol after his cardiac arrest from a heroin overdose. He's not brain-dead but he's definitely brain-something'd, rather thoroughly. And just for additional drama, he broke his parole conditions or something and so is now technically under arrest? And thus handcuffed to the bed with a police offer extremely pointlessly guarding him. 

Patrick Stewart in 194 eventually got a permanent pacemaker and went home, apparently with no longer-term effects of his adventures. In his place is a 74-year-old frequent flyer, a lady whose COPD and CHF, exacerbated by her poorly-controlled chronic hypertension, make for a bad combination. The funniest thing about her is that she looks great; she could easily pass for 60, she's not even slightly overweight, and her silver hair is always perfectly coiffed even when she's on BiPAP and so unable to keep up with her traditional tasteful lipstick. 

192 is still open abdomen guy, though his intestines are no longer in plastic wrap; he went back to the OR to have the wound closed properly five days ago. He's had a trach for a week and he's been mostly off sedation except for pain medications for almost that long. Probably the reason he's still so out of it is because midazolam, in addition to its long half-life, is fat soluble and known to accumulate in adipose tissue. Of which he has...plenty. 

190 is still the Crohn's patient. She's trached as well, down to minimal doses of phenylephrine, starting to respond to her husband and children when they visit. She's on parenteral feeds, which are playing hell with her liver, but her poor abused GI tract continues not to tolerate tube feeds at ALL; they've fallen back on trickle feeds at 10ccs an hour, and her gastric residue is still often more than 400ccs even though it's very unclear where this can possibly be coming from. 

Stroke guy in 188 was transferred out directly to rehab a while ago; the room has, since then, hosted several patients including most recently a temporarily-unidentified homeless man brought in with alcohol poisoning. For the obvious reasons, related to their recent experiences, the unit staff spent several days wondering if he too would turn out to be a lost wizard. He didn't, though. 188 is now, also, empty. 

 

That makes 3/12 empty rooms, 9 patients for 7 nurses. A gloriously quiet night. Though this is guaranteed not to last for long. 

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Mayumi is quietly prepping 196. 

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"Heard there's an admit," Nellie says, sidling in and checking drawers to see how well they're stocked. The answer is pretty well, actually; they've had enough quiet nights this week for the care aide to get caught up. "What is it?" 

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"Chantal took report - swimming pool near-drowning, they're suspecting drugs were involved. Male, early twenties. I don't know more." 

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"Fun stuff. Are they actually at the ER yet, or was it a report from the paramedics en route?" 

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"Paramedics, I think. Chantal said I would have time to prep the room and finish my eight o'clocks for '97 first." 

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"Ah. Well, I should have time to swing by the ER if they want someone to pick him up. I've got 195 and 198, nothing complicated, and our cop buddy for the night is a sweetheart, he helped me turn him." 

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"I would appreciate that. Our poor man in 97 is so - I don't want to say anxious, quite, but - high-strung? Every five minutes he needs his phone or his iPad or his laptop or his headphones or his palm-pilot..." 

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"A real type A personality, huh?" That does go a long way toward explaining how he ended up not doing anything about the flu until he passed out on his office floor. "Don't worry, I got you covered. Where's Chantal? I want a run-down on this admit if I'm going to be picking him up for you." 

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"I think I saw her go to help Esther get 194 up on the commode." 

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That's mildly awkward timing, but eh, Nellie's not in a rush. She'll hang around nearby at the nursing station, watching monitors and reading her patients' charts more thoroughly until Chantal reappears. 

"Hey! Can I get a report from you on the admit? Gonna go get him for Mayumi when the ER calls - by the way, an ETA on that would be great?" 

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Chantal squints absently at her sheet of paper. "Drowning, swimming pool, mid-twenties. They think they got to him quickly - bystander saw him struggling and then slipping under - wasn't breathing when they pulled him out but still a pulse, the lifeguard had him breathing on his own within a minute or two. Very decreased level of consciousness on the scene, though, even on oxygen, he was never following commands. So they're suspecting drugs were involved. He did vomit, and probably aspirated, he was satting at 70% on oxygen when the paramedics got there. They were going to intubate him on site, get him stabilized, and then head out, they were guessing half an hour." 

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"Great. ...Chlorine or saltwater pool?" 

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"I– what? I have no idea, does it matter?" 

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"It might. Different physiological effects. Though saltwater pools are a lot less salty than ocean water, probably still rounds to freshwater drowning." 

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"Oh. Huh. Presumably the paramedics know what pool they responded to. I didn't ask." 

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Sigh. "I'd need to look it up again, anyway, s'been a while. Freshwater causes damage faster, and really fucks with electrolytes if they've swallowed a lot, saltwater's more likely to cause godawful pulmonary edema like you've never seen before. ...Either way, we should plan on everything going to hell at, oh, say, midnight, and take our breaks accordingly." 

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Chantal surveys the monitors, silences a beeping alarm. "Ma'ar took his sat probe off again, I'll go fix that. Why midnight?" 

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"Oh, just, every near-drowning patient I've seen started tanking hard after a few hours, even if they were stable at first. Guess our guy might not be stable at first, I can't tell from that report. ...It's Dr Beckett again tonight, right? Where is she?" 

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"Went up to the fifth floor for something," Chantal calls back over her shoulder, heading 202-ward. 

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Nellie sighs, sits down in front of the monitors, props her feet up, and gets out her cell phone to text Dr Beckett. 

[Admission incoming] 

[20s M drowning, ~drug OD?? ↓ LOCs sats 70% on O2]

[coming intubated ETA 30min] 

[be prepared for a shitshow later] 

[like seriously though] 

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She gets a response several minutes later.

[thx for warning]

[busy rn, txt me & I'll meet you in ER] 

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Ma'ar is groggily hunting for something in the dark. Unfortunately he can't remember what it is. Also he can't seem to move his hands very far before something gets stuck? He remembers vaguely that this is supposed to be the case and he shouldn't fight it or else bad things will happen.

He wishes he could remember why it was important. 

He wishes he could remember what he's lost, so he could look for it better. 

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Isobel is stuck in 199 with the care aide for the foreseeable future, changing a bedsore dressing - it's nobody's fault, really, it's just impossible to prevent 350-lb people from getting bedsores if they're bedridden for weeks and also desat every time you turn them. 

Chantal turns on only the dimmest light, by the sink, and then hunts for the sat probe. Oh, there, it's just dangling over the bedrail. 

"Ma'ar? You awake?" He looks kind of squirmy. She slides the probe back onto his finger. "Please try to keep it on? For me?" 

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Ma'ar only gets half of that because he doesn't try to read minds unless the person is touching him. (He thinks that voice belongs to one of the people who's okay with mindreading in general even though she's not his main nurse? It's very confusing to keep track of who is and who isn't.) 

:Not that: he manages. :Something else: 

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Oh no, is he confused again. Chantal hates it when he's confused. "I'm sorry, Ma'ar, I don't know what you mean?" 

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:I lost something else: 

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"Oh. Uh, was it your picture board? That's right here. On the bedside table. Do you want it in your hand so you know where it is? ...No? Hmm. Suction's here, but you mustn't try to do that yourself, you need to use the call bell and get our attention. Did you lose your call bell– not that either? Um, I don't know. You can try to point at it on the picture board?" 

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Ma'ar really doubts that he can try to point at it on the picture board, but he tries to peruse it long enough to remind himself of his options. 

...Something does hurt. But it's not his body. He hurts because of the thing that he lost, only, it's too big to hold onto when he's so tired... He gives up and shakes his head and closes his eyes again. 

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Chantal pats his shoulder. "I'm sorry. Call if you need anything, 'kay?" And she heads back out to see what the rest of the unit needs. 

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Ma'ar still feels like there's something important that he should be remembering to do? But it's so hard to hold onto, and also people keep telling him that it's very important that he rest, and so it - probably makes sense to do that?

This feels as though it's probably a rationalization of some kind, because going back to sleep is easier than figuring out the other very important thing, but Ma'ar has no energy for that, so he is apparently going to go back to sleep anyway. 

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Nellie is still at the nursing station with her feet up, having briefly detoured to bring COPD/CHF guy in 198 his urinal and empty it. (He's very independent for almost everything; he knows the drill, and he only calls for help when he needs to do something that might risk messing with his BiPAP mask. He's got Lasix at midnight and six, but he repositions himself in bed and might not need literally anything else, he's already had a bowel movement on day shift.) 

"- How's Ma'ar doing? I haven't seen him properly, he was asleep when I got in." 

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Shrug. "Seemed a bit confused again. At least he wasn't too sedated to do the telepathy this time." 

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"I thought we were supposed to be weaning him off sedation period, wasn't that the plan?" 

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"It's all well and good to plan that, until he has one of those awful nightmares of his! Apparently he scared the crap out of Krystal on day shift by starting a fire, and Dr Prissan gave him five mg of olanzapine and then he was conked out for the entire afternoon." 

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"Jesus. How...big...a fire–"

The phone starts ringing. 

"- Oh, s'the ER, that's probably me." Nellie grabs it. "ICU-Nellie-speaking," she barks as though it's all one word.  

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"This is Nat - any way you can come over and help us with the drug OD admit?" 

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"Sure, I got you, fam." Nellie's already on her feet. "You're sure it's drugs, then?" 

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A sound of slight confusion. "Uh, yeah, pretty sure?" 

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"Well, hang in there, I'll be right over." 

She texts Emmy on her way to very quickly pee before her mission.

[Admit here. Confirmed drug OD] 

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[On my way] 

 

 

And, indeed, by the time Nellie reaches the ER, Dr Beckett is already there. She is currently occupied by having a very confused conversation with the ER charge nurse. 

"–had said it was a near-drowning?" she's saying. "Also, male?" 

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"Huh, what? No, this is a 20-year-old female, took Ecstasy at a rave -" 

     "To clarify," the very exasperated-looking paramedic by the gurney mutters, "she took 'Ecstasy'," (finger quotes are provided), "and then when it didn't kick in fast enough for her liking, she went back and got more from her, uh, friend. 'Friend.' And then she ended up taking...what did the other girl say, six, seven tabs?" 

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The blonde girl lying supine on the stretcher is, in fact, very clearly NOT an early-twenties male victim of a swimming pool near-drowning. She's wearing a scoop-necked, sparkly sequined spaghetti-strap minidress, and still has her glittery purple stiletto heels on. She has glowstick bracelets on both arms. Her eyeshadow is almost painfully sparkly. She's on oxygen by nasal prongs and is currently staring blankly at the ceiling as though captivated by it, blinking occasionally. 

 

 

"This," Nellie says eventually, "is definitely not the patient I got report on!" 

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"- and then some creepy guys were following them?" the paramedic is saying. "Although I honestly don't know if that was, like, relevant to the OD, it's just really hard to get a history out of someone's college friend who was also at a rave with them." 

     "Wait, she's not?" Nat looks nonplussed. "Philip! You called report to the ICU, right?" 

A blond nurse across the aisle turns around. "I got Ellen to do it." 

     "Ellen?" Nat calls. "Ellen, did you call the report over for Philip?" 

Ellen sticks her head over from the nursing station, scowling. "You don't have to yell! To the ICU, right? No, because I'd already transferred the paramedics directly to the charge nurse over there." 

     "...."

"What?" 

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"It's....sounding like we maybe dropped some balls here? Nat, can I confirm that you've got two patients both of whom are probably ICU-bound, and only one of them is here so far?" 

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"- What? Do we have two - who's the other one?" 

     "Drowning kid from the university free swim night?" 

"Oh, right, I overheard the radio on that one - they thought probably also some dumbass college kid on too many drugs." 

---

Nat lifts a hand. "Hey. Everyone. Shh one sec. Right. So - yes, it sounds like you've got two admits headed your way. Do you have two rooms available?" 

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"I think there were three beds available - Nellie?" 

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"Mmm-hmm. We've got - hmm, options are 201 or 188, neither's great. Loren could admit in 201, she's got 200, but she's just off orientation, I don't love the idea of giving her someone really sick. I should call Chantal and figure something out." 

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"Can we do a swap, give Loren 202 and then Isobel can take the admit?" 

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"I'd love if Isobel could take the admit - either of them, honestly, they both seem likely to be dumpster fires tonight - but 202 is Ma'ar."

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"Hmm, and?" 

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"He uses mindreading to understand us?" Still getting a blank look. Jeez, is Emmy going to be so oblivious that she has to say this out loud. "...Loren's wonderful, but she's still a baby new grad and she's going to be feeling unsure of herself most of the time, even if it doesn't show. Ma'ar gets really freaked out if he can pick up that the person responsible for keeping him alive possibly doesn't know what they're doing." 

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"Hmm, yeah, suppose so." Emmy is now distracted, scowling at the monitor. "- Has she been running tachy like that the whole time?" 

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"Pretty tachy, yeah– Christ! Not at 200 bpm before!" 

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"IV access? Any fluids given? - Let's get a 1L bolus in stat, she took MDMA at a rave - who the hell goes to a rave at eight-thirty pm in the evening on a Wednesday - she'll be dehydrated. Get a 12-lead ECG and print me a monitor strip now, she's going so fast I can't tell if it's SVT or not." 

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Nellie can't tell either! In any case, she's going to focus on sorting out their admission situation. 

Her portable hospital phone rings six times before Chantal picks up at her extension. 

     "What." 

"Nellie, at the ER. There was a miscommunication. We've got two admits. Swimming pool guy, and another young drug OD - this one pretty confirmed, she took way too much Ecstasy at a rave. She's satting fine on O2 by nasal prongs but she's not super responsive and she's running tachy at 200, they - appear to be working on IV access right now? I don't think Loren's up for this one. Wondering if she can swap with Isobel and we can put the new one in 201?" 

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"I - wait, sorry, which one is Mayumi taking and which is the new one?" 

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Pause. "....You know, I dunno that it matters? Mayumi barely got a report on pool drugs guy. Do we wanna put pool drugs guy in 201 and rave drugs girl in 196?" 

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"....Sorry, I'm still not managing to keep who's who straight. Who's going to give us more trouble?" 

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"I'll have a better guess once I've actually seen pool guy? Must still be en route– oh fuck are you fucking kidding me what now -" The alarm is screaming again, and it's not the heart rate of 200, she saw Nat changing the settings on that. "- Okay rave girl's in...V-tach? Or something? On reflection let's put her in 196, I am doubting pool guy can be worse than this anyway I gotta go bye." 

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Back at the unit, Chantal sticks her head into 199. "Isobel? You're getting an admit." 

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"Oh, am I? What is it." 

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"...Actually, take your pick. We've got a 20-year-old female, overdose on Ecstasy, currently in the ER and just went into V-tach. Or early 20s male, near-drowning in the university pool public swim, probably also on drugs but we have no idea yet, he hasn't arrived in the ER yet." 

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"I'll take the one that's arriving later, I'm sort of busy right now. Am I swapping 202 or 199 and who's taking them." 

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"Plan was to give 199 to Loren." 

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"Honestly I'd rather hand off 202." 

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"Noted, but we're juggling a lot here. Is he giving you trouble?" 

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Shrug. "I mean, he's chill on five of midaz, but day shift gets pissy about upping the sedation on nights, and we're not supposed to knock out his respiratory drive so he never breathes above the backup rate, which rules out propofol, and on just fentanyl he has a panic attack every hour. He's not complicated other than that, Loren would be fine." 

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Sigh. Isobel isn't, in fact, the best personality fit for a patient like Ma'ar, and 199 is, in fact, a pretty complicated patient for Loren. But Isobel's had him for half a dozen shifts, in total. 

"I don't want to switch up continuity of care for him. And 199 will be educational for Loren. Sorry." 

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"Fine, but you're on answering his call bell if I'm trapped in 201–" Sigh. She glances over. "Including right now, I've got to prep the room." 

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"Yeah, sure." Chantal will go see what Ma'ar needs this time. 

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Ma'ar is clearly awake, and equally clearly is working very very hard to achieve this feat. His eyes start to flicker shut every three or four seconds until he valiantly wrenches them open. The light by the sink is still on, and the light in the bathroom with the door half-closed. 

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She crosses the room to him, makes sure he's seen her first before she touches him, and then takes his hand. "Hey. You look really tired. Do you want the lights off?" 

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:No: 

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"Do you need something right now?"

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:I need - something to write on... Need to think. Forgot - thing I need to do. Important: 

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Oh no, he's in this mood again. Marian is very good at sitting with him and talking it through until he calms down, and her advice to Chantal was 'he needs to feel oriented and he needs to remind himself that nothing is the kind of emergency he can fix right now anyway.' 

"Ma'ar, it's getting late at night and I think that you'll be more able to figure that out in the morning, okay? ...Do you remember where you are right now?" 

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Ma'ar considers this intently for a while, eyes slitted half-closed. :Hospital. Montford. On Earth: 

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"Yeah. That's right." 

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:I...forget sometimes: 

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"Mmm. That makes sense - you were very sick and we're still needing to give you medicine to keep you comfortable with the breathing tube." She squeezes his hand again. "You - think you're back fighting the war, sometimes?" 

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:Sometimes I - forget - think it is not too late...Urtho...: 

He starts crying. And then coughing, because the ventilator is very unhappy with this. 

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- she is kind of starting to see Isobel's point about it being incredibly frustrating to try to wean his sedation! Poor guy. Also she can't remember who Urtho is. 

"Yeah. I'm so sorry. But - right now you need to focus on resting, because it's nighttime. Do you think you need more of the medicine to help you be less anxious about it?" 

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:No. Worse if I cannot think: 

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"Yeah, okay. Should I - is there anything that would help you remember where you are?" 

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Ma'ar considers this. :More lights: 

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"If you're sure about that, I can– shit. Sorry!" The intercom beep feels very loud in here. "I need to find out what that is -" 

She doesn't have to wait long, though; it's informing her loudly that CODE BLUE EMERGENCY ROOM TRAUMA BAY ONE. Oh, phew, that's probably just drug rave girl again. Well, not phew exactly, but it's not something ELSE. Probably. 

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Ma'ar, startled more by her surface thoughts than the noise per se, twitches against his wrist restraints. (Which he is very tired of. Marian at least would take them off during the day if she was in the room with him.) :Emergency???: 

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"Not one you need to worry about." Will he please just go to sleep. "I do have to go, though." Probably a good idea to go check exactly what's going on, over there. And make sure that Nat doesn't try to send them both patients at the exact same time. 

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Sequined minidress girl is, in fact, in trauma bay bed TWO. 

Bed one is not technically occupied, yet, because as soon as the yawning night shift care aide helped the newly-arriving paramedics turn the patient to get the slidey board under him, he dropped his heart rate into the 20s and then full-on flatlined for - Nellie actually has no idea how many seconds. At least one entire screen-width on the portable monitor, which is not a sight she was particularly hoping to see tonight. 

And then, of course, about point five seconds after someone actually made it as far as the code blue button, the rhythm came back. Still very slow, in the 30s, but - 

"Yep, I've got a pulse." 

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All of that happened fast enough that Emmy didn't manage to disentangle herself from the whole situation in bed two before it was, apparently, over. "Nellie? What the hell?" 

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"I don't know what the hell either! He just did like a ten-second pause. Didn't like being turned." To the paramedics, "- has that happened before?" 

     "No?" The young man looks as baffled as she feels. "Or, well, he went brady down into the 20s when we gave him propofol for intubation, but his sats were shit at the time." 

"Well, let's get this over with and at the very least we'll have help if he does it again - three two one and go–" 

They slide the patient across, one of the paramedics supporting his head. 

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He's rag-doll limp under the scratchy ambulance blanket and, on the monitor, does another pause, but this one is at most five seconds and the previous spike hasn't quite scrolled off the screen when the next beat comes. 

He looks...honestly incredibly terrible, for someone who was supposedly pulled out of the water seconds after someone noticed he was in distress and never lost his pulse. He's floppy, skin cold to the touch, his lips grey-blue. His hair is still wet. 

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"...Jesus. Okay." The report she got was clearly missing something relevant because this is INCREDIBLY YIKES and she was expecting only mild levels of yikes.

Nellie's hands are already working to swap over the monitor, even as half the ER staff pour into the room. "Dr Beckett, are you sorted over there?" 

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"I'm not sure I would go far enough to say that!" Emmy calls back. Rave girl was shocked out of V-tach after two minutes of CPR, and they've got a bag of amiodarone going, but the kid keeps hopping in and out of the probably-SVT extremely fast heart rate, and even when she's not doing that she's running at 160 to 170 bpm despite being, at this point, intubated and on propofol. And her blood pressure is currently reading at 208/125. Emmy is very glad she went with her first instinct of NOT giving epinephrine to someone whose entire problem is overdosing on recreational drugs with stimulant action. 

"...Uh, right. Get atropine ready but hold unless he does another pause longer than five seconds. Let's get all the ICU admission bloodwork plus the full tox screen. Other vital signs?" 

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"Swapping to our monitor now - last BP was 91/57, sats are...91%. How much O2 is that on?" she adds to the paramedic closest to her. 

     "Uh, he's been on 100% the whole time. The portable vent is crap, though, let's get him on yours ASAP." 

"I'll second that. You been getting anything when you suction him?" 

     "Yeah, lots of junk in there. Frothy white secretions, mostly. Not much of a cough reflex right now so it's hard to tell." 

Nellie makes a face. "How much propofol did you give him, anyway?" 

     "I think -" glance at his colleague, "maybe we gave the whole 100mg in the end - thought it'd take less, he was just lying there, but then he got really combative when we tried it after 50mg." 

"Huh.Yeah, I guess that'd tank his hemodynamics real good. Anyway, he sure doesn't need anything more right now. Oy, you in the pink scrubs, can we get warm blankets over here?" She lifts the horrible ambulance blanket, and then snorts. "Jeez. I was expecting a bathing suit. Not surprise full frontal nudity." 

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"Nellie! Hold off on suctioning him until we've got a set of vitals and atropine at the bedside - could be vagal stimulation that's setting off the bradycardic episodes." 

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"Huh, yeah, I guess?" Nellie is holding ventilator tubing for the RT and glancing between the two monitors. "...Seriously, if we could just take the average of these guys' vitals, we'd have a perfectly healthy patient."

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Emmy giggles and tries to swallow it. "Don't you wish that worked?" 

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Nellie isn't listening anymore, because she's glaring at the monitor for Pool Guy, which is now yelling an alarm. "...I don't buy that," she says after a moment. "Monitor thinks he's satting at 69% but the waveform is really dubious, reckon he's just peripherally shut down - oy, you in pink again, can you get me one of the neonatal sat probes for his ear? - Oh, hi, Chantal, s'up?" 

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"Just came to see how you were getting along over here. I - wait, sorry, which one of them was the...?" 

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"Believe it or not, this fucking dude. Dunno what's going on but Jesus was our report missing something. He's not tolerating being moved at all, which - uh, normally I'd say get him stabilized here first before we bring him down the hall, but I'm a little worried that'll take all night." If it happens at all. To the paramedics, "- oy, did we get a temp on him?" 

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"Axillary wasn't picking up, but he's wet." 

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That is not a good excuse and Nellie is feeling seriously ticked off. It's never helpful to indulge herself in that, though, so she smiles tightly at them. "Right. Hey, you - orange scrubs, sorry - can you get me the low-temperature thermometer, please. Chantal, how ready are we to ship him over like, right fucking now." 

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"Isobel's prepping the room but she was hoping it could wait, she wanted to finish up some stuff first - I'd been assuming we wanted to get miss party girl over first? I think Loren's ready." 

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Sigh. Glance over at bed one. "- Yeah, fair, I don't think we want to wait too long on her either. If I get your help we can probably bring both of them down at once?" 

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Chantal folds her arms. "Which is exactly what I came over here to tell you not to do. If you can chill out here and hold the fort, we can probably handle him in half an hour?" 

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Great. Half an hour stuck in the ER. Exactly what her night needs right now. "Fine. Whatever. If you hear a code over here please send someone, though." 

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"Uh, sure, we'll do our best," Chantal mutters distractedly over her shoulder. "Dr Beckett, you're coming with?" 

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"Dr Beckett do NOT LEAVE until you've given me orders!"

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

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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. 

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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. 

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"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." 

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"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 -" 

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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. 

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The machine thinks about this for a rather long time. 

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That is NOT REASSURING. 

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

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YIKES.

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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." 

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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." 

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"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?

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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. 

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"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...

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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. 

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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. 

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

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"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. 

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"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?" 

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"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 -?" 

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"...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." 

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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?" 

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"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." 

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"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 don't have time to go do a literature review right this second." 

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"Oh. Right. I...should maybe call the on-call attending about that? ...It's Dr Dalrymple, he'll come in if it's looking bad. Though honestly Dr Zee seems a lot more likely to know and she might not mind if I text her even when she's not on call, it's not like it's super late or anything yet." 

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"Oh, she wouldn't, wouldn't she! - She did say weeks ago to text me 'anytime' if something 'interesting' happened, which, I mean, was probably meant to be about Ma'ar specifically but you can't deny the intrigue here. How in the name of Beezlebub did he get that hypothermic in an indoor swimming pool? Without being in any visible distress before it got to that point? It's a medical mystery!"  

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"Yeah. I have no idea. Maybe there's some kind of bizarre metabolic issue that causes it? When we were debriefing after the whole Ma'ar thing, Dr Zee told me about a woman she saw once over at Civic who came in with a blood sugar of, uhhh, like twenty or something absurd like that - and also a temp of like 32, and they figure it's because she was profoundly hypoglycemic for a while and not - producing normal metabolic body heat? And was also collapsed on her floor in her nightgown and didn't have great heating in her apartment, but that wouldn't normally give a person hypothermia. Dr Zee said if she'd been on, she'd have considered something like that in the differential diagnosis for Ma'ar, though his sugars weren't really low enough for it to seem plausible. But I wonder if something metabolic like that could be going on?" 

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"Huh. ....I should get a blood glucose on him, shouldn't I." 

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"- Yes, right, please do that." 

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"And a chest X-ray, assuming that positioning him for it doesn't make him code on us. I think we'll want to do a repeat in, like - two hours? And again in four? ARDS takes a while to kick in." 

 

*Acute Respiratory Distress Syndrome, or roughly "your lungs are incredibly fucked up". 

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"Right, of course. You can put in the order for–" 

A muffled and distant loud pinging sound. 

"- Sorry I have to go!" 

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Ugh. Does NOT bode well for it being a good idea to show up with this guy at the ICU in ten minutes. Then again, it's not as though it's really a good idea to be hanging out with him here

She heads over to get the glucometer, finds that none of them are at the usual charging station, considers heading for the nursing station, and then remembers that she left several items pending delegation when she started this phone call. She's been watching Pool (Maybe Not) Drugs Kid's monitor from the corner of her eye, and he's hovering at a heart rate between 38 and 42 which is honestly super impressive for someone whose body temperature is FUCKING TWENTY SEVEN DEGREES CENTIGRADE but she hasn't actually observed if they managed to get a blood pressure reading or, better yet, an O2 sat. 

She turns to investigate this first. 

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Her patient is still alive! Someone has even very thoughtfully gone and grabbed like ten of the chemical instant heat packs and is currently putting them in strategic locations. Someone else is trying for a less sketchy IV. At one point one of the staff must have found a pressure bag for the heated saline bolus, because it's now most of the way in. There's a peds sat probe on his ear and a very very shaky waveform, but it's vaguely timed to his actual heartbeats and is currently reading 96% and a question mark. 

The blood pressure reading is still displaying as ???/??, and one of the staff - Grey Scrubs this time - is trying to get a blood pressure with a manual cuff and stethoscope. 

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Wow! Competence! Nellie loves competence! She wonders if this is just a luckier than usual staffing arrangement, or if the ER staff got a pointed lecture after the Ma'ar debacle and it hasn't worn off yet. 

"Dr Beckett wants a portable chest X-ray and a blood glucose on him," she says cheerfully. "I'll put the orders in and call X-ray if someone else can hunt down a glucometer for me, they've all gone and escaped on us." And probably the staff who actually work here have a better sense of where they tend to end up. Also there's a computer right there and a phone and she can do orders-entering and calls without actually taking her eyes off the kid for more than five seconds at a stretch. 

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He does not do anything especially new and alarming while she's doing this. 

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"Uh," says the nurse currently trying to get a blood pressure. He is presumably old enough to have graduated school, given his RN badge, but he looks about eighteen. "I'm getting I think like eighty over forty, but the monitor isn't picking it up." 

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"- Sorry, one sec," Nellie mutters to the X-ray tech who picked up five seconds ago. "Makes sense, his heart rate is irregular and that throws it off. We'll get an art line over in the ICU but I don't want to stick around here for it. We should start him on pressors, though - I mean, honestly, that blood pressure might be fine at his current body temperature, reduced metabolic demand, and I'm not sure norepinephrine even works if you're under 28 degrees, but we should do it anyway. Start it at 5 and see?" 

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"Ummm. Five...of what? - Sorry, I'm not really trained for, uh, this, I just came 'cuz it seemed you needed hands over here." 

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Jesus. Perfect. "Start it at 20 ccs an hour, I think that gets us about the right amount for the standard concentration - you'd normally start lower but I'm anticipating his body will respond to it less. Do that and try for another manual BP in five minutes, we'll see if it did literally anything." 

And to the X-ray tech, "- I'm sorry about that, but can you come in five? Portable chest X-ray, stat– yes the order's in the system, did you even check..." 

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Someone arrives with one of the wayward glucometers, and goes to check the patient's blood sugar, and then looks confused and restarts the machine to try a second time. 

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Nellie does not notice this immediately because she was trying to get literally any charting done, and is now pointlessly refreshing the page with all the PENDING lab results. 

She notices eventually, though. "- Hey. What's up?" 

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"Ummm, I think maybe I did something wrong? I got a reading of 42 but that can't be right." 

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It might be! Nellie swears under her breath. In hindsight, it would have been an excellent idea to get STANDING ORDERS for this eventuality. 

 

- you know what, Dr Beckett is definitely not going to be mad, and will probably be grateful, if she puts in a verbal order for it right now. Her hands are already moving to do it. 

"Yeah, no, I could buy it. I don't know what's going on with him or why - and it could be a little off, he's hecking peripherally vasoconstricted from the whole being a human popsicle thing, but it won't be that off. Do another from the other hand anyway, might as well - and we'll grab one from the art line as soon as that exists - but I'm giving him two amps of D50 anyway." 

Orders in. She goes to do that. 

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The intercom yells a long loud beep. 

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Nellie jumps a foot in the air, which is honestly pretty embarrassing. 

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After what subjectively feels like at least a minute of suspense (it's like ten seconds) the intercom announces a code blue in the ICU. Room 196. 

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ARE YOU FUCKING KIDDING.

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(These are Nellie's personal notes sheet on the current patient assignments.)

202: Ma'ar the fucking wizard. Trying to wean sedation. Keeps setting shit on fire. 

201: [empty] pool drugs guy?? 

200: 98-year-old female, urosepsis, not intubated. Boring af. 

199: 61-year-old female human disaster, ?? weeks post-bleeding ulcer. Obese. Trach, kidney failure. 

198: COPD dude, BiPAP.

197: Flu CEO. Guillaine-BarrĂ©? anxious, abuses call bell for work phone calls. 

196: [empty] rave drugs girl?? 

195: Heroine OD, cooked his brain. Technically under arrest. Handcuffed to bed, family is the literal worst, do NOT let mom and GF in the room same time.

194: 74yo frequent flyer, COPD CHF hypertension. Still looks like a TV anchor in Midwest. A sweetie. 

192: open abdo guy, closed now tho. Trach, off sedation, still not awake but consider: midaz fat-soluble & no shortage of fat. 

190: Crohn's mom w questionable NG tube refusal & sepsis. Improving slowly, off sedations, mostly off pressors. Can't tolerate tube feeds, parenteral nutrition destroying her liver. Responds to family members now. 

188: [empty]

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Nellie technically has 195 and 198 tonight and has even managed to lay eyes on them and give 198 his 8pm meds early. 198 doesn't have any scheduled meds until midnight. Both are stable, 198's monitor settings will warn anyone if bad things are happening and 195 is used to this whole circus and perfectly capable of using her call bell. 

Still. Nellie had not expected to be trapped in the ER for - jeez, it's looking like it'll end up being a whole hour. And this guy isn't even technically her admit, she was just being helpful. 

(Shows how far that will get you.) 

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The patient continues to lie there, doing nothing more dramatic than setting off the yellow alarm by dropping his heart rate to 34. 

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"Uhhh, second blood sugar was 39?" Grey Scrubs says uncertainly. "Should I be - trying to get another blood pressure -?" 

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Yes, right, job to do. It's not even 10 pm and Nellie already feels like she desperately needs some Red Bull, possibly via central line, but she can do this. 

"Please." And she looks down, notices the two boxes with the syringes of 50% dextrose, and goes to ram those in FIRST - should totally be compatible with norepinephrine if she pushes it in fast and flushes, right - and she can deal with anything else LATER. 

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Grey Scrubs looks up at her. "I got 90 over 30? Is that even a real blood pressure number?" 

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The child who looks too young to even be a nurse yet is possibly not the best at manual blood pressure readings but even Nellie isn't going to say that out loud. 

"Look, kid, who the fuck knows. See if the monitor can get something–" 

The monitor is currently having unrelated complaints, and singing the song of its people about them. 

"- Okay I can't remember the exact thing I put in for atropine dosing but it's been more than five minutes for sure and I hate that number."

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The patient's heart rate has just dropped to the mid-20s. 

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"Yeah, okay, I'm not waiting a minute to see if he keeps this up. Where's the fucking atropine vial gotten to. Oh there. Go on and cycle the BP on the monitor again, though, might as well try." 

She's only halfway through the second ampoule of dextrose - it's thick, it doesn't push fast - but he's presumably been having bizarre blood sugar problems for a WHILE and it seems more urgent that he continue to have a pulse. 

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This doesn't do that much but it gets his heart rate back above 30 and more regular? 

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The monitor is still ruminating on its attempt at a blood pressure reading when the care aide runs into the room, triumphantly holding a large box in one hand and hefting two enormous bags of saline in the other. 

"I got it! The bladder irrigation stuff you wanted from uro-surgery, right?" 

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"I could kiss you!" Nellie says fervently. "Don't worry, I won't actually. Go stick one of those bags in the microwave for me please. For, uh," how to math this, "- try five minutes and then slosh it a bunch and check it with your wrist like you'd do with a baby bottle?" 

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The aide looks dubiously at her. 

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"Look, this dumbass kid has a body temperature that usually kills people and we're trying to fix that. Just get it to, like, bath temperature. Please." 

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The monitor bings plaintively, having finally made up its mind on a blood pressure reading of 86/39. 

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Well, you know, that's not a blood pressure of 'dead'. Nellie's going to bop the norepinephrine drip higher just in case -

 

- though plausibly they should consider switching to a pure inotrope like dopamine, from her vague background knowledge Nellie thinks that hypothermia generally messes with cardiac function but tends to cause vasoconstriction by itself, which sure looks like what's happening based on the kid's mottled grey-blue hands and feet - she really shouldn't put that in as a verbal order without asking Dr Beckett though - honestly she wants Dr Zee's input here, but clearly no one has had time to even consider texting her - 

 

"We should put in a large bore gastric tube before X-ray gets here," she says to Grey Scrubs, very calmly. "I assume you're comfortable with that? Go find the biggest one you can, please." 

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He gives her a skittish look and then hurries off to check the shelving full of supplies. 

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Nellie rams in the rest of the dextrose and bumps the norepi drip up to 10 micrograms per minute - about half of the standard max dose, her old hospital did it weight-based and she thinks the local way is much worse for obese patients but this kid really, really isn't - and then she heads to the desk with the phone. 

And dials Staffing. 

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She gets an automated voicemail, saying that the department closed at 9 pm. 

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Hoooooooowwwww is it already after 9 pm. Shit on a pickle. 

 

After another ninety seconds of FRUSTRATION - which she spends mostly fuming about how she COULD be using this time to put a three-way Foley catheter in and get ready to provide internal rewarming to this dumbass kid as soon as the stupid aide gets back from the microwave mission - she has the on-call night shift manager on the phone. 

 

"Hi. Nellie from the ICU here. - Yes, I know I'm calling from the ER." Scowl. Pause. "I'm calling because you need to find us someone else to come in on nights. ....Yeah, no, I don't give a crap." Pause. "- I don't know what the acuity metrics at 7 pm have to do with anything, we just got two admits who almost tried to code at the same time and I'd be surprised if they don't throw that at us before tomorrow morning." 

She listens for a while. 

Looks pleased with herself. 

"- Thank you. 'preciate it. ...Uh, bless you too." 

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The patient does not do anything exciting while supplies are being assembled. His heart rate goes irregular again while Nellie is putting in the three-way Foley catheter, but doesn't actually drop below 30.

 

 

 

...He does, however, do a nine-second pause while Grey Scrubs is in the middle of fiddling with trying to place an NG tube. 

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Oh, right, that's probably a vagal stimulation thing. For fuck's sake. It hasn't been five minutes probably but Nellie still has the rest of the 1mg vial of atropine in her pocket along with a syringe and she can have that in his bloodstream within thirty seconds, by which point the excitement is clearly over. 

 

 

Grey Scrubs is still standing there looking sort of paralyzed. 

 

"- Hey," Nellie says quietly. "S'fine. I'll do it. He's fine, he's just being obnoxious. Why don't you go find me one of those Kangaroo gravity bags for tube feeds, and then go microwave a bucket of water. Tap water's fine." 

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He gives her a very overwhelmed look. "Umm. Microwave it in what? I think the graduated measurement thingies might have BPA in them." 

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Sigh. "Look, I don't care? Maybe it'll make him trans or whatever next year but it won't kill him, unlike the hypothermia, and also it's going to be in his stomach for like thirty seconds, that's the point. If you really wanted I guess you could steal the clinical educator's 'Best Mom' mug, that's at least 500 ccs and her office is unlocked." 

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He scurries off. 

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Nellie gets an orogastric tube down in about fifteen seconds, without causing any problems, though it presumably helps that she just gave the patient drugs that block parasympathetic nerve activity from affecting his heart. She's even pretty sure it's in the right place, because WOW it looks like this dumbass kid swallowed a lot of water. Probably should have done this sooner, actually, just to decompress his stomach and minimize the risk that he vomits again when they do anything to him.

She's going to hook the tube to one of the suction canisters for now - sure, she's about to pour a Best Mom mug's full of hot water down there but it'll work even better if it's not just mixing with gross swimming pool water. 

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Why does the syringe she just squirted out into the nearest garbage can kind of smell like the beach. No beaches were involved. 

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Eh, whatever, she can worry about that later. Tube goes to suction canister. 

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By the time the X-ray technician arrives, there are 300 ccs of cloudy stomach contents in the suction canister, and a 3L bag of approximately-warm-bath-temperature saline hanging precariously from an IV pole and hooked up to one lumen of the patient's fancy catheter, which is draining into the special enormous floppy extra-capacity catheter bag that comes with the kit. There is also, perhaps inexplicably from their perspective, an enormous, faintly steaming ceramic coffee mug with 'Best Mom' next to a picture of a unicorn and a rainbow, sitting on the bedside table alongside a pile of miscellaneous supplies. 

 

...Whatever, it's hardly the weirdest thing he's ever seen on night shift. "X-ray?" 

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"Yep!" Grumpy squint at the monitor, which is back to a heart rate of 32 and seems to have fallen into a pattern of two or three regular beats, a wide-complex ventricular beat, and then a two-second pause. "....Wait one sec though, gotta give this guy some atropine first. He does screwy shit when we move him. Or do anything to him." 

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Perhaps due to the proactive premedication, their patient does not do anything exciting while they reposition him mostly sitting up for the X-ray and get the board in place behind his back, stuffing some pillows to stop him from toppling sideways. 

 

 

In fact, he doesn't do anything exciting until afterward, when they're pulling the board out, and the X-ray tech misjudges the manual controls on the ancient gurney and drops him from 45-degrees to flat with a thump. 

The patient startles visibly, tenses, and starts reaching for his breathing tube. There are restraints on his wrists, but not actually fastened to anything. 

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ARE YOU SERIOUS???? 

 

Nellie lunges for him, and fortunately he's not very competent at moving his arms; he mostly manages to bang one elbow into the rail. 

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Now that he's done being startled, he goes limp again, apparently lapsing back into unconsciousness. 

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Kid's temp is TWENTY FUCKING SEVEN DEGREES how is his brain capable of functioning at all!!! Fine, the propofol he got on the scene with the paramedics was probably an hour ago and he's not on any ongoing sedation, but STILL! 

 

...On consideration, she hasn't actually been re-checking his temperature. Because - why - right, because she looked around for fifteen seconds and didn't see a cable to hook the stupid rectal probe to the monitor and then completely forgot. She will go look right now. 

- scratch that, she will tie the restraints down and start some midazolam - just at 1 mg/h, it's not like he's agitated at baseline - and then she will worry about finding the right cables. And calling Dr Beckett to get official go-ahead for the OG tube, though she's pretty sure from her own glance at the screen and also all the stuff they got out of it that it's in the right place. 

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The patient does not do anything else concerning while she's working on this. 

The monitor eventually declares that his core temperature is up to a whopping 28.2 degrees centigrade. 

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That is ALMOST A WHOLE DEGREE Nellie is DELIGHTED. 

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There's a long way to go, of course, and the next few hours are the riskiest - and with their luck, they'll get him through that only for him to slowly die over the next week as his lungs stop working. But if they can get him through the acute ARDS, this degree of hypothermia is - maybe actually good for his eventual prognosis? Even with some hypoxia, the cold and reduced metabolism would have protected his brain. 

She's about to call Dr Beckett when the phone rings. 

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It's Chantal. 

"Is Nellie still there? Need to talk to her." 

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"It's me. I hope you're calling to say I can head over!" 

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"...The room's ready. But I'm calling you because we've got some issues and I need to reshuffle the assignments." 

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Sigh. "What - oh, is it that you don't want to give Loren the shitshow rave girl? Fair enough, I guess. I...don't really want to give Loren this guy either, though." 

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"Isobel's willing to take her if she can be 1:1, it's looking from initial labs like we may need to start her on dialysis before the am, she's threatening some multi-system organ failure on us. But I just got a call from the manager and Rick's willing to come in at 11:30. ...On the downside I think we may be getting a third admit. Do you think there's any possible way you could hand off your patients - I can take one, Loren can take the other since she's not getting 196 after all - and then take your guy in the ER and also Ma'ar?" 

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Nellie's first, absurd thought is that Marian will be so relieved she doesn't have to take report from Isobel. "Hmm? Yeah, sure, of course. I know Ma'ar, that's totally fine. I'm glad staffing listened to me, I called and had an argument about it." 

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"You did? Wasn't sure if it was just because I had updated the acuity scoring. It did seem more proactive than they usually are!" 

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"You're welcome. Honestly, this dumbass kid should maybe be 1:1 but I think I'm just going to text Dr Zee for advice, I have standing permission to do that." And she should actually DO it before it's past a sane person's bedtime. It's just that things keep happening. 

 

- in fact, another thing is happening now. The phone is ringing on the other line. It says LABORAT– (the screen size generally cuts off the second half of long words). 

"Is that all? Gotta go, might be critical results on my patient calling." 

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"Yes, of course. Try to get over here soon so we can do the handoffs and switching around." 

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Great. Trekking to the ICU was a better proposition when it didn't mean she also had to take over responsibility for Ma'ar. Damn, she should really have asked Chantal about getting him an overnight sitter. She can and will drug him to the gills if that's what she needs to do to keep him safe while she handles dumbass kid here, but Marian will be so sad if she comes in (Marian is definitely getting Ma'ar back, Nellie will make sure of that) and it takes him half the day to wake up. 

She answers the phone. 

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They sure do have some abnormal lab results for her! 

Sodium: 156, critically high. 

Chloride: 121, critically high. 

Potassium: 2.9, low though not critical. 

Phosphate: 2.1, low but not quite critical. 

Magnesium: 1.3, also low but not critical. 

Lactate: 6.1, extremely alarming. 

Blood gas, venous: PvO2 25, PvCO2 65, bicarbonate 15, pH 6.98. 

 

Oh and also his hematocrit is really high, which would usually indicate dehydration; they don't actually have a 'critical' top range because this is never really an issue, but it's, like, pretty damned high. 

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What in the name of the Father the Son and the Holy Ghost - 

 

 

Maybe if - 

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....Nope, she's got nothing actually. 

 

Nellie thanks the lab tech and then sits at the computer and refreshes the screen until the new lab results pop up, in case staring at them will make any more sense of it. It doesn't. 

 

She takes a photo on her smartphone and texts it to Dr Zee. 

[Near-drowning. Supposedly campus swimming pool]

[Looks sick as hell. Temp under 28 C. Keeps bradying down to 20s & 10 sec pauses. Latest labs here] 

[Also randomly hypoglycemic???] 

[Please tell me something here makes sense to you] 

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The little "typing" dots pop up instantly. 

 

They do this for a while

 

 

[Logging into chart remotely]

[Name & room?]

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[Still trapped in Resus] 

[Entered as a John Doe] 

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This time, there's a longer pause before the answer. 

 

[Looks like saltwater drowning not fresh] 

[Very prolonged exposure] 

[Like shipwreck-style long exposure] 

[Looking at case studies now to compare] 

[Yeah still have that impression] 

[What are you doing for him] 

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[Mostly really aggressive rewarming] 

[OG & Foley warm water lavage set up here] 

[Gonna hook up the CoolGard on heating mode once we're on the unit]

[Wanted to plan ahead for the ARDS tho] 

[Last patient I had tanked 4h post admission]

[So we're looking around midnight] 

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[Hmm so if it's real saltwater drowning that's a good prognosis for ARDS] 

[He should be proned but your unit doesn't have a rotaprone bed in stock] 

[Maybe better to transfer out, checking] 

...

[Damn Civic is full] 

[Flu season] 

[Calling the General] 

...

[They can't take him but they can deliver a bed by tomorrow morning] 

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See this is why Dr Zee is one of her favorite people in the entire world. She gets nerdsniped and then she gets emotionally invested and then you literally can't keep her away. 

Nellie busies herself hooking up the warm water OG "feeds" - too bad it doesn't come with separate lumens for intake and suction, her old hospital stocked those but Montfort doesn't - and the tube placement isn't technically confirmed by a doctor but it's clearly pulling stomach juices along with all the water, there's like 500 ccs of it and yep when she lifts the suction lid it sure does smell like the seaside. 

(She is not about to taste it.) 

She charts atropine pushes and ""verbal"" orders and checks blood glucose again - it's 68 - and she gives another amp of D50 and charts that and finally her phone buzzes again. 

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[Rotaprone bed incoming 6 am] 

[This things costs as much as a new Ferrari so don't break it] 

[Should I come in] 

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[I mean you're not even on call & probably Dalrymple should just come in already] 

[But he might appreciate the backup] 

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[I'll call Dalrymple] 

[texting Beckett that I'm putting orders in] 

[do NOT give any more saline] 

[next bolus try half-NS 1L] 

[& get him to the goddamned ICU] 

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This is going to be easier said than done because all of a sudden she has loads of things on IV poles! Which is kind of exactly what Nellie wanted to avoid here! 

She requests the accompaniment of the care aide and a respiratory therapist if they can track one down, and gets a microwaved back of 0.45% saline going (half the salt concentration of 0.9% "normal saline") - that can go on the built-in pole with the gurney - she's going to pause the hot water "tube feeds" and clamp that and give the OG a couple of minutes on suction because it would be especially inconvenient if the kid pukes mid-hallway. The 3L bag hooked to the Foley catheter is already swaying precariously, so she sighs and clamps that and just sticks it between the patient's legs. 

And they're off! 

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Mayumi is outside 201. "I think tonight is too exciting! Marika has a triple assignment until Rick gets here! I have the machine ready for you and a sterile tray for the central line but Dr Beckett needs to finish an art line in 196 before she can come place it. Also I heard we're going to be proning him? On one of the fancy beds meant for that? I've never used one before! Have you?" 

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"Oh, yeah. Couple times. Helped other nurses more times. What...do you guys normally do if you have to prone someone?" 

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"One time we tried to put a lady just facedown on the normal bed but this did not work very well." 

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"Jesus on a stick. I'm not surprised!" And she should really stop being surprised that this understaffed under-resourced hospital resorts to things that sound incredibly sketchy to her. 

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"She was very doomed! She had decided to take all of her colchicine for some reason." Mayumi peers at the portable monitor brick, which is pinging anxiously. ".....Does your patient normally do that?" she says mildly. 

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"God why would you do that– sorry what? I can't see from here?" Nellie is trying to maneuver the stretcher right up next to the nicely made clean bed. 

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"He did a pause. I think three or four seconds? And heart rate at twenty now." 

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"Oh, yeah, he does that. One sec, I've got a syringe of atropine in my pocket. Can we get some more hands in here to help transfer him? Best time to move him will be right after I give it, he seems to handle anything and everything we to do him by doing that." 

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"Yes, of course." Mayumi hits the 'nurse assist' button on the wall, which rings faster and more urgently than a patient call bell, and then starts absently checking for pedal pulses. "....I can't find any pulses. Did he have them before?" 

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"Doubt it." Nellie pushes the atropine. "Do we have a glucometer in here? On top of all the other crap, he's doing some wacky hypoglycemia." 

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Mayumi pauses. ".....Really? That sounds a little bit like Ma'ar." 

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"I guess, but he can't be a–" 

She stops. 

"........You know. Now that I think about it, another thing he has in common with Ma'ar is that the history is baffling. Everything looks like a saltwater near-drowning with prolonged exposure to cold water but they found him in a blasted swimming pool." 

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Mayumi hooks up the monitor bring and starts unscrewing and transferring the norepinephrine and midazolam pumps from the gurney pole to the IV pole already in the room, with a triple-bank of pumps already on it and ready to go. "If he's a wizard too, maybe he did a portal there?" 

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"You know, personally, if I was drowning in the ocean, I wouldn't do a portal to somewhere else where I'd keep drowning. But tastes could vary on that one, I guess." 

The care aide arrives and they slide the patient over onto the ICU bed. 

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The patient startles again when moved, but this time Nellie is ready for it and has a hold on the trailing end of his restraints, and again his movements really aren't very purposeful or competent. 

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"What's the range on portals, anyway. I guess I can ask Ma'ar when I go in for my assessment. Wonder if he can tell whether or not someone's a wizard?" 

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Mayumi shrugs and whips down a stethoscope to listen to the patient's lungs. 

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Nellie should probably be figuring out what her PLAN is here. It's somehow 10:25 pm. Rick is getting in at 11:30; until then, the unit is stretched to the limit and she can't count on much help in here, and should prioritize only the most time-sensitive treatments. She'll start the warmed fluids in various holes running again, and then check a repeat blood sugar - 

 

Her phone buzzes in her pocket while she's waiting for the glucometer to think up a reading. She digs it out one-handed. 

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Ten seconds later the glucometer makes up its mind on a blood sugar of 79. 

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It's Dr Zee again. 

[Put some orders in the system] 

[Urgent: start D5W at 200cc/h, hourly glucose, decrease to 100cc/h if over 140mg/dl]

[Repeat lytes at 11pm then q2h] 

[Will give 2g mag & 1g phos over 4h] 

[No intervention for K+ for now, might come up with rewarming, see replacement protocol for repeat lytes once temp above 30C] 

[Looks like you're near max atropine doses, should switch to dopamine as main pressor] 

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See! She was RIGHT! 

[on it] Nellie texts back, and darts for the doorway to log into the nearest computer and check. 

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Mayumi shoots her a worried look. "Is there a reason I shouldn't suction him? He sounds very wet and I think we could get his sats higher." 

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"Uhhh, can you hold off for five? This might be dumb but he keeps doing pauses whenever we do - stuff - and that's stuff and I'm getting kind of superstitious here. Dr Zee wants us to switch to dopamine as a first-line pressor, can it wait till I've grabbed that?" 

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"If you say so. I can go prepare that for you? Dr Beckett might be here any minute for the line." 

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"Good point. Thanks! While you're at it can you grab me a litre of the 5% dextrose and - damn it it's not going to stay warm is it - whatever, nevermind. I'm gonna need a top-up on warm water soon." 

 

 

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By the time Emmy makes her way down the hall, looking exhausted and already kind of frazzled, dextrose is running and the care aide for the ICU has been successfully dispatched with one of the linen carts, emptied of its usual fare, to go load up on literally all of the 3L saline bags in stock for bladder irrigation on the 5th floor. 

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Switched to dopamine, the patient is in fact maintaining his blood pressure on a much lower equivalent dose, and his heart rate is consistently above 40.

However, he seems to have replaced the pattern of, when stimulated, dropping his heart rate into the 20s or doing 5-second pauses, with instead throwing random ventricular beats. Nothing sustained, so far, but Nellie doesn't like it.

His sats are holding, but barely, hovering between 93-95%. This would be a lot more reassuring if he weren't already ventilated and on 100% oxygen. 

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Emmy frowns at the monitor. "Did he get steroids yet?" 

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"Shit. No. Uhhh, Dr Zee might've put in the order but if so I didn't see it." 

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"I'll text her, she'll know if we should do something nonstandard and I don't." Emmy makes a face at the hanging back of 5% dextrose. "...What was his last glucose?" 

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"Like 79?" 

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"That's normal, though? So, uh, why...?" 

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Oh. Right. This is kind of awkward now. "....Sorry. I completely forgot to say anything but I put in some verbal orders under you before I texted Dr Zee. Initial glucose was, like, forty? This is after three amps of D50." 

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"I know! It's weird as balls! Sorry, this was right after we talked on the phone and I went to check his sugar." 

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Emmy, busy donning sterile gloves, tries to itch her nose by rubbing it on the shoulder of her scrubs. "So - huh - I wonder if he actually is a type I diabetic and just fucked up his insulin? And then, I don't know, got confused and ended up in the pool...?" 

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"Yeah, wouldn't explain his fucking sodium though. Unless he separately got confused and, I don't know, ate six packets of ramen sauce without the noodles. Something's really weird here." 

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"....I mean, have we considered that he might have Ma'ar's problem." 

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"What, the being a wizard problem? It's - I mean, at that point it's not really answering any questions without giving us even more questions! And until he's awake I don't know there's anything we can do to check, or if it affects the medical management here." 

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"We should consider putting him in isolation now? I know Ma'ar didn't come back positive for any alien diseases but that might've been luck. I - probably we can't justify shutting down the entire hospital again without confirmation, but - iso, send off some tests, I'll ask Dr Zee if it makes sense to warn the paramedics who picked him up, she's the one with contacts at Public Health anyway..." 

Sigh. "Let's get the line in first, though." It's not an aerosol-generating procedure, but she already has a surgical mask on anyway, just to minimize infection risk to the patient

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Nellie sighs and dons a mask as well. She needs to be on-hand for troubleshooting any weird vital sign fuckery, and bringing supplies as needed so Emmy doesn't have to contaminate her sterile field. Fortunately, the giantass central line, complete with a circulating system of balloons that can have hot or cold water pumped through them while hanging out directly in the patient's vena cava, has to be inserted femorally - because it's over a foot long - and thus the guidewire insertion is less likely to cause horrible arrhythmias. Nellie is very glad of this. She does not at all trust this patient to stop having horrible arrhythmias if they set one off. 

In the meantime, though, her hands aren't urgently needed. She texts Dr Zee. 

[thinking whether the low sugar is bc he has Ma'ar's thing] 

[can't confirm now but should we iso him just in case]

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The typing-dots aren't there for very long, this time. 

[Yes] 

[I'll email bert at public health] 

[but probably wait and see before we do more] 

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[got it] 

 

Is their patient behaving? 

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Well, his heart rate is still at 41 and he's throwing ventricular beats ever 4-5 normal beats, sometimes in couplets, and his blood pressure is just barely tolerable on a medium rate of dopamine. The temperature reading on the monitor is up to 28.9 though. 

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That's still colder than Ma'ar was at any point, and he managed to have some serious difficulties about it - maybe wizards have more trouble? if it happens along with the magic-overuse low blood sugar thing? - but also Ma'ar did NOT get adequate early treatment in the ER, and nobody really knew what was going on with him for ages. Whereas this time Nellie at least has the hypothesis in mind. 

 

...Marian is going to feel a way about it if she comes in and finds out she has TWO wizard patients, Nellie thinks. 

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"Line's in!" Dr Beckett says cheerfully after a couple of minutes. "Just suturing it now - machine should be primed and programmed, you can hook him straight up." 

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"Oh goody." Nellie glances at the clock. "Christ. It's nearly eleven. Uh, has anyone checked on Ma'ar recently? I didn't especially get a report on him or anything." Or, come to think of it, give a report on the patients she was supposedly handing over to Loren and Chantal. 

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Dr Beckett is giving her a 'why would you expect me to know' sort of look. 

"Um, I think it was Isobel who had him before? - She's still in 196, probably." 

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Great. Wonderful. 

"Keep an eye on dumbass kid while I go get report from her?" 

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Nellie is already halfway down the hall. 

She pauses briefly at the nursing station bank of monitors. Glares at them. ...Both of her former patients who she failed to give report on appear to be alive with stable vital signs, thank the Virgin. She doesn't even know who the heck was supposed to end up with which one. 

- not her problem now - 

 

 

....Okay, fine, she will swing by 195's room and offer the police officer outside a sloppy salute. "Hey. Did he get turned anytime recently." 

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He blinks at her. "Not since the last time you got me to help?" 

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Nellie HATES HER LIFE. 

"Sorry, not his nurse anymore."

(When was that even. She left for the ER almost immediately after shift change - she had taken report and laid eyes on both her patients and called Marian, so it must have been before 8 pm - and she wouldn't have dived in to turn Coma Guy except that she had checked the charting and he was already hours overdue...) 

It's now nearly 11 pm.

"We're really busy tonight but I'll either send his new nurse over in the next ten minutes or I'll help turn him with you," she says, and escapes. 

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198's curtains are open and the lights are on. Loren is standing awkwardly next to the patient's bed, holding a toothbrush in one hand and a cup of water in the other. 

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Perfect. Everything looks under control and now she knows to look for fucking Chantal to turn fucking coma guy in fucking 195. 

...Chantal is charge nurse and Nellie can neither pass any judgement for her failure to turn coma guy, who is definitely not leaving this hospital alive, for an entire three (3) hours, nor feel okay dropping anything else on her plate for tonight. FINE. She will do the fastest turn ever on her way back around. 

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Loren spots her walking past and tries to catch her eye, hopefully lifting a hand. 

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NOPE. 

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All the lights are on in 196. The floor is spotless. 

The patient is now in a hospital gown. Her glittery makeup is still mostly in place. Her blonde hair is mostly coiled to one side of her head but fluffed in a halo around her face. Her heart rate on the monitor is racing past at 170 bpm. 

There is a CRRT* machine apparently primed and ready, stashed in the corner of the room. 

 

 

Isobel is standing by the bedside table, checking her phone. 



*continuous bedside dialysis, used for very sick patients who are too unstable to tolerate regular dialysis. 

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"Hey." 

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"What." 

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"Report on Ma'ar?" 

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Isobel rolls her eyes. Slightly. 

"He's fine. No real change. He was anxious when Elle answered the call bell an hour ago so I asked her to give him the PRN olanzapine, this is not a good night for him to be setting anything on fire." 

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Great. 

Nellie is not shouting which she personally feels is showing great restraint. 

"Anything else? Any changes with neuro status, vent settings, tube feeds, last bowel movement...?" 

(Nellie is in fact up to date on this because she skimmed Ma'ar's chart before calling Marian earlier, but it's not like Isobel knows that.) 

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Isobel sighs and flips over a couple of sheets on her clipboard and reads off a proper report, very fast. 

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"Thank you. When was he last turned?" 

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"I mean, he squirms constantly. I think Elle grabbed the care aide to fix him up in the bed, since as usual he was half fallen out of it, that would've been at - nine?" 

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"Ah. Thank you." 

Pause. 

"Do you need help with anything in here." 

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Isobel glances down at her clipboard. Frowns. "I'm going to run out of norepinephrine in twenty minutes and phenylephrine in thirty-five minutes. And I need to send more labs at midnight. Other than that I'm fine here." 

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It would be so much easier to hate Isobel as a person if she didn't always know exactly what was going on with her patients.

"Got it. I'll make sure we get that to you." 

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The comatose patient in 195 has only pooped a tiny bit and there's a spare pad on the counter so it barely takes longer to turn him. 

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Nellie still has the pending sense that she owes Isobel certain prepared bags of drugs and lab tubes at particular times, and she's really tempted to just give her the dumbass hypothermia kid's leftover bag of norepinephrine that will otherwise go to waste, but that is definitely against policy. And also dumbass kid might be a wizard and might have alien smallpox. She doesn't feel like the latter is very likely even if the former is true, it turned out fine in Ma'ar's case, but still. 

It won't come up for fifteen minutes, which should be long enough to book it back to her patients and actually lay eyes on Ma'ar. 

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Emmy has, in the interim, shut the main door, slapped one of the isolation warning posters from the vestibule on it, and turned on the negative pressure system. She's lurking in the vestibule, texting on her phone and frequently looking up worriedly at the patient's monitor. 

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The monitor is readable through the door, and it kind of looks like things are improving, actually! The kid's body temperature is up to 29.1. His heart rate is holding steady at 45 or so. Blood pressure a perfectly respectable 105/49. Sats at 92% on 100% oxygen but you can't have everything. 

She raps on the door to the vestibule. 

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Emmy twitches, glances up, and then hurriedly stuffs her phone away, Purells her hands, and exits. 

"- Sorry, I was– anyway." She was hiding but she isn't going to say that out loud. "He's seemed stable. I talked to Dr Zee and she wants him on methylprednisolone q4hours. Do we have a weight for him? The dosing in the study she was looking at was in mg per kg." 

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"I cannot claim I actually checked before but I did check the bed was zeroed. I'm going to guess sixty kilo, he's tall but he's scrawny. But I'll go get a weight if you really need one." 

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"I think I'd be more comfortable with that. Sorry. I know isolation is really convenient. Er, once you've done that, feel free to put in a verbal order for, one sec–" She digs out her phone again and fiddles her way to the text message app. "Dosing protocol is 5mg per kg of ideal body weight - that'll just be his actual weight, he's not fat or edematous - per 24 hours, then divide that into six equally spaced doses." 

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Cool. Great. She will GOWN UP and MASK UP and forge into the room. After checking the drawers in the vestibule and shoving a bunch of random items into a styrofoam cup that just happens to be sitting around and hopefully hasn't been drunk out of. There's no point going into an iso room just to do one thing

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Even with Nellie only putting a bit of effort into removing the excess weight of various tubes and wires and lines from the bed, the patient apparently weighs in at 58.6 kg. 

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"That has got to be a BMI in the underweight range," Nellie mutters under her breath, and starts attaching stickers with date-and-time labels to all his IV lines, before transferring them to the shiny new femoral central line. 

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The formerly-hot-water bag hooked to the patient's OG tube is now down to its last dregs. The extra-large catheter drainage bag, on the other hand, must have four or five liters in it, and looks almost ready to burst. 

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Nellie sighs, hunts for a receptable, finds nothing but the stupid potty-catcher hat for getting urine samples (why do they even have those in standard stock here, there isn't a single patient in the ICU right now who is capable of walking to their adjoining bathroom to pee), and grumpily makes eight trips back and forth to the toilet to empty the bag.

She hooks the OG tube to suction. Notes that the drainage is coming out mostly clear, now. 

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The patient's temperature is up to 29.4, which is a third of a degree in ten minutes (Nellie has to spend several seconds doing mental math to ensure this isn't exceeding the safe rewarming rate of 2 degrees per hour; it's not but it's right on the edge of that.) 

His O2 sats are less happy, though, now hovering around 90% and setting off the yellow alarm.

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Which Nellie DIDN'T NOTICE immediately because someone must have silenced the alarm from the nursing station before it could get her attention! Grrrrr! 

She...is kind of running low on immediate responses to this. And is really hoping this patient manages not to die on them before they get the fancy Rotaprone bed, now due in seven hours and counting. In the slightly longer term, giving him steroids might help his lungs from getting worse, but she's not sure whether to expect much short-term improvement? 

She can at least raise the head of his bed somewhat and suction him. 

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The patient does some concerning ventricular beats on the monitor when she moves him, but settles down quickly. 

When she suctions in his lungs, even more concerning-looking pinkish foam comes up the tubing. 

 

Also, the patient coughs and tenses all his muscles and then tugs ineffectively at his restraints. 

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GODDAMNIT. 

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Can she afford to give him any more drugs? His blood pressure is tolerable, she can probably get away with bumping up the midazolam. Though it's not fast-acting, and she really doesn't want him waking up - probably if he can tolerate a higher hourly rate, he can also tolerate a 1mg bolus right now? She'll do that, then. Put it in as a verbal order from Dr Beckett later. Dr Beckett (or Dr Zee) might even have given her an actual order for boluses, Nellie just failed to take any notes and is spectacularly behind on charting.

She does not have any midazolam boluses on her, but she pauses the pump, glances at the current remaining bag volume (94ccs, the concentration is 1:1 and he really hasn't gotten very much at the 1 mg/h rate), then goes in and edits the remaining volume to 1ml, and the hourly rate to 999, and restarts it. It's running into the same line as the dextrose, it should go in quick. 

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It does! The pump is beeping for ""empty bag"" seconds later. 

The patient gradually relaxes. Though he might have done that anyway, since she's now stopped doing horrible things to him. 

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Great.

She still needs to suction him more, though, she does not like whatever the fuck is going on in his lungs. She...kind of things he should be more thoroughly out, he's just going to get more awake as they rewarm him and he's probably going to start shivering soon and that will just result in burning more oxygen, which he cannot afford to do right now. 

(Also he might be a wizard, in which case he might or might not set things on fire if he wakes up too much.) 

She gives it another minute of puttering around the room and glaring at his O2 sats. 

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Which go down to 89%. The patient isn't moving, exactly, he's stopped pulling against his restraints, but the muscles around his neck and shoulders are still tensed. 

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Maybe they should chemically paralyze him or something? On the one hand that will make him even worse at clearing his lung secretions, but on the other hand he might stop doing that

 

(On the third deformed monstrosity hand, if he's a wizard and he wakes up while paralyzed he might set something on fire before anyone has the chance to notice something's wrong...) 

She suctions him again. 

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He's less actively fighting against his restraints this time? He's still coughing with every muscle in his body going rigid, and relatedly desatting fast. 

She gets a lot of secretions out. 

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Yeah okay she's going to check his blood pressure - in thirty seconds once he's slightly calmed down from having horribly uncomfortable medical procedures done to him - and if it's acceptable she'll give him another sneaky bolus of midazolam and then bump the rate up to five an hour. She's pretty sure five an hour is the max but, unfortunately, her patient is now in precautionary airborne isolation because he is maybe a WIZARD who might have CONTAGIOUS ALIEN SMALLPOX.

She really should bring a computer-on-wheels in here. And also get this kid his steroids so his immune system stops slowly destroying his lungs in its panic. Except that she also needs to bring Isobel backup meds - or delegate that but the question is delegate it to who - it's just after eleven and Nellie grits her teeth and reminds herself that Rick is arriving in half an hour and their night will get much better then. 

Ideally she will personally lay eyes on Ma'ar before 11:30, but also apparently she missed the opportunity to tell Isobel not to drug him, so probably he's fast asleep now? 

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Her current patient's next blood pressure is 115/56. 

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Yeah, neat, he's getting a 2mg sneaky bolus of midazolam then. Followed by Nellie actually remembering to increase the rate on the pump and restart it properly, with a remaining bag volume of 90 ccs which she's pretty sure is approximately right and shouldn't result in a line full of air bubbles when it runs dry. 

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By the time she's finished all of that fiddling, his sats are back up to 92%. 

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Nellie has to pee so badly and the nearest bathroom requires walking past the staff room and in line-of-sight from the nursing station, at which point someone will almost certainly accost her with some other urgent task. 

She is going to be a slightly terrible person about isolation precautions, and pee in dumbass kid's attached bathroom. She takes her gloves off first and washes her hands after and then dons new gloves. 

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The patient is sleeping peacefully. His sats are now up to 93%. His next blood pressure comes in at 109/51. 

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SEE she was RIGHT he just needed to be more sedated!

...Either that or needed to be suctioned. Or it's a straight-up coincidence. That's totally possible. 

Nellie checks that the blood pressure is set to every 5 minutes, reminds herself that he super needs an art line - she's pretty sure painful stimulation is bad for patients if you want to be carefully minimizing their oxygen consumption, even if they're sedated - but ideally that would wait until one of the other docs comes in. Where the fuck is Dalrymple. Wasn't he supposed to come in?

Nellie would really prefer Dr Zee onsite for a night like tonight, but it's not even Dr Zee's night on call so it feels very gauche to beg for it, even though arguably it's not begging if Dr Zee offered via text message, but still...

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She checks that all of the IV pumps are running and have at least an hour left, and then she slips out into the vestibule to de-gown and de-glove and de-mask and wash her hands even though all of this is probably pointless, and then she leaves the room and checks the time on her phone. 

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(It's now 17 minutes since Isobel asked her for norepinephrine in 20 minutes.) 

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She should definitely get a move on that! 

- probably she can spare fifteen seconds to stand outside Ma'ar's door and peek, and if anything looks obviously on fire then she can call the nursing station from here and if that fails she can call Emmy's cell phone and probably someone else will be able to deal. 

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Ma'ar is currently still, breathing steadily on the ventilator, vital signs all perfect. He's also kind of diagonal in the bed again with one foot dangling out past the lower bedrail. 

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How is Ma'ar this good at ending up in bizarre position in bed despite being restrained and attached to half a dozen tubes and lines??? Nellie will never understand it. Personally, if she were ever an ICU patient (god forbid) she's pretty sure she would be too scared to move. 

She does not especially feel like perturbing this situation any further right now, though. She heads for the nursing station at a jog, and goes to pull some norepinephrine vials from the meds machine and starts mixing, all the while glancing anxiously at the (apparently-deserted) nursing station and bank of monitors. 

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Nothing explodes, either metaphorically or literally. 

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Nellie brings the neatly labeled bag over to 196 (along with a spare IV tubing shoved in her pants pocket just in case that's needed, because she is perhaps slightly competitive around Isobel.) 

"Hey. Brought you the norepi you'd asked for?" 

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Isobel is perched on a wheely chair in front of a portable computer, glancing between the screen and her patient and her patient's monitor, but she whips around and jumps lightly up from the chair, smiling at Nellie. "Oh, good. Wondered if you'd forgotten." 

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"Ha. I never forget. Dumbass pool drowning kid in 201 is misbehaving so I nearly had to call in backup but I made it. Figure I'd better get you the phenylephrine top-up now before any other fires start. And lab tubes for midnight, right?" 

(Nellie has in fact completely forgotten what lab tubes were requested, but. It'll be searchable in the patient's chart. She is not going to admit to being disorganized in front of fucking Isobel.) 

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"You're a doll. - What's your kid doing? He's the one who's very hypothermic for no reason, no?" 

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"Also a ton of other very mysterious problems! Hypoglycemic like crazy, even though normally you'd expect the opposite, right - and his sodium's high - we were texting with Dr Zee and she thinks it looks like a saltwater near-drowning presentation, even though he was found in a pool -"

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"- I would bet money that he's another alien." 

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See! This is why it's hard to stay mad at Isobel even when she's continually a raging bitch to anyone who she can get away with it to! 

"Sorry, I would but I'm not gonna bet against you now, you're not the first person to bring it up. We put him in precautionary isolation just in case of the alien smallpox thing. Even though Ma'ar turned out not to be contagious with anything." 

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Isobel tosses her head, making her glossy ponytail bounce. "Well, good luck with that. Is he sufficiently sedated? If he might be a wizard you should make sure of that." 

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Yes. Nellie is aware that Isobel holds this opinion. Nellie is personally of the opinion that Ma'ar should be sedated less and is not actually an enormous threat to the entire unit. 

...Though she can't even disagree because she's pretty sure that even in the scenario where her dumbass half-drowned kid is not a wizard and there's somehow a perfectly mundane explanation for everything, she would want him to be thoroughly sedated and ideally paralyzed so he stops burning excess oxygen by freaking out. Or even just by shivering. 

"Yeah. I don't think he's as sedated as I'd like but he's also still very out of it, his temp is below thirty. I'm going to ask for more orders as soon as I've gotten you what you need and checked on Ma'ar. Which I'd better get started on." 

And she escapes. 

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The bank of monitors at the central station is still deserted and quiet. It's apparently 11:14 pm. 

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....She should give Loren a proper report at some point. Chantal will be fine, she's had 198 before. Also there are a thousand other things to do and she still has to prep Isobel's meds - she saw the monitor readouts in there, if she were in Isobel's position she wouldn't want to leave even to pee. (And it's one of the standard non-airborne-iso rooms that doesn't even have an en-suite bathroom...) 

Nellie sighs and heads back to the med room to pull ten vials of 10mg/1ml phenylephrine, because this stupid underfunded hospital has been out of stock on the 100mg vials for an entire fucking year

She mixes drugs. 

Gets bored halfway through and checks her phone. 

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There are apparently some missed messages from Dr Zee. 

[Is Dalrymple there] 

[Did 201 get his methylprednisolone] 

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FUCK

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[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] 

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Her phone buzzes again ten seconds later. 

[coming in now] 

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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. 

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

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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. 

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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]

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

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

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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." 

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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." 

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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. 

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

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

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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. 

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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. 

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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. 

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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. 

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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. 

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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.

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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. 

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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. 

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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. 

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96. 

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That's respectable. Is his blood pressure up on the higher rate of dopamine? 

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99/62. Heart rate is finally breaking 50, too. 

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Nellie still isn't delighted about his sats, which are just baaaaarely hanging at 92%. Maybe he would benefit from a higher pressure setting on the ventilator? ...In the short run he almost certainly would, but she's also very aware that higher pressures will actively exacerbate ARDS, and this patient's lungs are going to be fucked enough already. And sats at 88% or 90% won't harm him too much in the short run. 

She changes the 'low' limit on the O2 sat alarm to 90%, and leaves the room, hurriedly sanitizing her hands rather than washing them properly even though this is sort of bending the rules. 

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It's 11:20 pm when she drops off the bloodwork in the pneumatic tube system's departure cradle and keys in the code to send it to the lab.

Rick is at the nursing station, apparently taking report from Chantal. 

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"Hey. Thanks a million and a half for coming in. We would've been screwed. You're taking 195?"

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"Sounds like it, but I know the man. Chantal said he should be easy, so he'd be a good pair with this new mystery admit." 

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"- Yeah, if you have to be doubled he's one of the better choices. Family won't be in on nights, so you can just pretend that whole clusterfuck isn't a thing. He's not making it out of here, but he's stable. Definitely won't be on the call bell." 

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Snort. "Last turn, last bowel movement?" 

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"I turned him at - christ - uhhhh, probably nine or ten? Last real BM was who knows when. He had a smear when I turned him but I bet he's really backed up." 

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"In the unlikely event that I'm at any point bored tonight, does he have the standard enema orders?" 

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"Dunno. Probably not, he was admitted under Prissan who never does the admission standing order checklist. Dr Zee's coming in though." 

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"- I thought it was Dalrymple's week?" 

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"Yep! But my patient's a fascinating medical mystery and just miiiiight be another wizard, managed to reel her in that way. I hope Dalrymple eventually gets his pants on and comes in too, have a bad feeling that my admit and Isobel's are both in for a rough ride." 

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"Chantal said the General is shipping us a Rotaprone bed! Which one is that for?" 

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"Mine. Near-drowning. Though he's got to survive the hypothermia first. Isobel's just nuked her own kidneys and liver via questionable rave decisions. - I mean, I've made questionable rave decisions too but this is taking it to a new level." 

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"You, taking drugs? Never." Rick rolls his eyes. "Well, I hope the mystery admit is less exciting. You need anything right now?" 

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"Not desperately, but if you wanted to come help me turn Ma'ar in a few minutes...?" 

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"Sure, if nothing explodes I'll come do that." 

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Dr Beckett is hovering at the nursing station, watching the bank of monitors and occasionally darting in to refresh the screen on one of the computers.