Staff in Renown's ER had seen a lot over the years, but nothing quite like this. The glowing portal deposited the unconscious teenager onto their floor with a splash, then winked out of existence behind him. For a moment everyone froze, staring in disbelief.
A nurse was the first to break the spell, rushing over to check for a pulse and breathing. "We've got a hypothermia case here! And possible drowning!" The flurry of activity exploded around the strange arrival. They cut away soaked clothes, wrapped him in blankets, started warm IV fluids and oxygen. His pulse was thready, body temperature dangerously low, but as they worked his eyelashes fluttered and he sputtered, expelling seawater from his lungs.
The ER physician took over, barking orders. "Let's get him stabilized and up to ICU. I want bloodwork, chest x-rays, the works. Somebody find out who this kid is and how the hell he ended up here!"
Tadesse had wanted to explore new worlds, but this was not quite what he'd had in mind. As the medical team fought to save his life, he drifted in and out of a fitful unconsciousness filled with fractured memories of his long-ago human life, dreams of drowning in an endless sea, and glimpses of unfamiliar faces and strange surroundings. The future, for the moment, remained as uncertain as the fate of his crippled magical talent.

The young man is, for the moment, surprisingly stable with just supplementary oxygen, and he even seems to be somewhat conscious now, though not cooperative; he fights them, weakly and ineffectually, as the staff cut away his clothes and place a non-rebreather mask running 100% oxygen. 

His heart rate and breathing are both worryingly low, though. His breathing is labored, and it's hard to get a reliable oxygen saturation reading on the pulse oximeter; his fingers are cold and mottled blue, his peripheral circulation nearly shut down by hypothermia. And they can't get a temperature reading at all on the ordinary ER thermometer, which means his body temperature is below 28 centigrade. The ICU probably has a low-temperature thermometer; they should get him there as fast as possible, for multiple reasons, he's still breathing on his own for the moment but drowning-related lung damage can worsen rapidly. 

- where is he -?

Tadesse manages, briefly, to open his eyes. Unfamiliar rectangles of strange, harsh white light blur together over his head as the ER team, crowded around his gurney, rush him toward the ICU. 

The world is spinning and it feels like he's falling into a pit. Tadesse clamps his eyes shut again, and tries to roll over before he vomits a large quantity of seawater into his oxygen mask and all over the gurney. 

The ER staff react quickly as the boy begins to retch, rolling him onto his side. Dark seawater gushes from his mouth, but his oxygen mask stays in place, providing vital air between spasms.
"His sats are dropping - we need to intubate, now!" The physician hastily threads an endotracheal tube down the boy's throat, securing it in place while nurses suction the vomit away. His body shudders with the violence of continued retching for several minutes before going limp once more.
They arrive in the ICU, transferring the boy to advanced life support equipment. An IV pump begins warming fluid to slowly raise his temperature. X-rays show water in the lungs; they connect him to a ventilator to breathe for him. His pulse remains slow, body chilled nearly beyond measure.
A nurse hooks ECG leads to his chest, frowning at the display. "Doctor, look at this. I'm not sure...his heart rhythm looks strange. And his blood pressure is very low, even for hypothermia." She glances at the mysterious patient with concern. His strange arrival and unknown medical history leave too many questions unanswered.
The physician studies the displays and examines the boy again, finding mottled skin and sluggish pupils. He turns to the team with a grave expression. "Severe hypothermia, acute lung injury, and...there may be signs of an underlying heart condition. We'll need to closely monitor his condition. For now, continue rewarming and life support. Let's do everything we can - his survival may depend on it."

Nellie likes interesting patients! This is...perhaps more interesting than she would prefer. They don't know the patient's name, or age more than approximately, and she is...confused and concerned...about claims that several of the ER staff had the same hallucination when they found him. 

...Have they drawn blood yet for electrolyte levels? The poor kid clearly swallowed a ridiculous amount of...uh, apparently seawater, which makes no sense but it sure smells like the sea in here now...and if he’s this cold, he was probably in the, uh, sea, for a WHILE. Which might have really wreaked havoc with his electrolytes, and that all by itself could cause arrhythmias, even setting aside the low temperature. 

The kid also looks spectacularly dehydrated, and very thin - almost emaciated, actually, like he’s been on a starvation diet for weeks. She’s going to grab a blood sugar reading, normally blood sugar goes up with severe hypothermia but his body can’t possibly have much to work with right now.

The ICU team dispersed to gather further equipment and supplies for their mysterious patient. His unexplained arrival and precarious condition left much work to be done.
In the relative quiet, Nellie stepped closer to check the IV lines and monitors herself. His pallor concerned her, as did his shallow, uneven breathing. She placed two fingers against his throat, frowning when she felt how slowly his pulse beat.
A nurse returned with a tray of syringes and tubes. "Here's what we need for blood samples and a chem panel." She held out an alcohol wipe.
Nellie took it and swabbed the back of the boy's hand. His skin felt terribly cold against her own. As she slid the needle into a vein, dark blood flowed sluggishly into the first tube.
The nurse peered at it. "His blood looks...strange. Almost too dark."
"Poor circulation and dehydration." Nellie changed tubes, troubled by the boy's condition. "We'll know more once the tests are run. For now keep monitoring him closely. Any changes, call the doctor right away."
With care, she placed a pulse ox clip on his finger and secured other wires to his chest, starting additional monitors to track heart rate, breathing, and temperature. An IV of warmed saline fluid ran into the back of his hand, to begin restoring what the sea had stolen away. She gave the displays a final check, quiet beeps and lines the only signs of life in a patient who teetered precariously between this world and the next. His fate rested in their hands now - and whatever mysteries had brought him here, only time might reveal.

The patient remains completely unresponsive, though the only sedation he's on is the bolus given for the emergency intubation. His lanky, too-thin limbs are disturbingly limp, with no muscle tone present at all. 

The nurses finally get a real temperature reading: 26 centigrade, a whole ten degrees too low, in the range where even rewarming him too fast risks causing lethal arrhythmias. He's also not shivering at all, which is actually a bad sign. 

The pulse ox is still having a hard time, showing a question mark half the time rather than a number at all, but the bedside arterial blood gas result comes back fairly concerning: his oxygenation is only a little low, but he's currently mechanically ventilated with 100% oxygen; the only way to support his breathing more, without resorting to more invasive forms of ventilation or other intervention, is to go up on the pressure support, which risks damaging the delicate lung tissue even more. 

More worryingly, his CO2 is very high. So his his lactic acid, hinting that he's in shock and his tissues, not getting enough oxygen or bloodflow, are resorting to anaerobic metabolism. Between those two facts, his blood pH is far more acidic than it should be, which risks causing entirely new problems if not corrected immediately. 

They still don't have electrolyte lab results back, or any of the other very broad panel of bloodwork they sent, but his blood sugar reading is back with the bedside glucometer and it's at 47 mg/dL, which is appallingly low and calls for immediate intervention. The nurses will hurry to call the doctor over. 

The ICU nurse hurries to the physician's side, explaining the boy's dire test results in hushed tones. His expression turns grave. "We're losing him. Start a central line for IV access, increase ventilator pressure to maximum, and push bicarb for the acidosis. Start a dopamine drip for shock, and get glucagon on board now!"
The team springs into action. A doctor slides a large-bore needle into the boy's neck, threading a central catheter into his jugular vein. Another turns a dial to increase ventilation. A nurse plunges a syringe of sodium bicarb into his central line, then hooks up bags of medication to infuse.
His oxygen level rises slightly, but his blood pressure stubbornly remains low. The team watches the displays anxiously, hoping for signs their interventions are reversing the cascading damage. Time ticks slowly away, measured in the boy's labored, artificial breaths and faint, thready pulse.
After an hour with no response or improvement, the physician's shoulders slump. They had tried everything medicine allowed to salvage a life that seemed destined to slip away. As the boy's monitor alarms blare a dire warning, a nurse reaches to silence them -
but stops, staring in disbelief. On the screen, his heart rate and blood pressure have begun to climb. Oxygenation improves, temperature rises a degree.
They glance at the still, pale form on the bed, hardly daring to hope - but find his skin just a shade less icy, limbs less limp. Some spark kindled within threatens to ignite, fueling a battle for survival not yet lost. The team gazes at one another in exhausted wonder, sensing a long night ahead before knowing if that flame might blaze to life at last.

Nellie parks her chair outside the mysterious patient's room and drags a hand over her face, sipping from her third coffee of the night. Right now it doesn't feel like there's enough coffee in the world for this. 

"I think we need to try more aggressive rewarming measures," she says finally. "I know it's a risk to rewarm him too fast, but - we're barely making progress at all, it's been hours and he's still not above 28 C."

It's weird. As though the boy's body is trying to stabilize, but all of his body's resources are drained, leaving no energy for things like 'producing body heat'... 

" ...And I want us to push more IV dextrose," she says after a moment. "I know his last sugar was tolerable, but - he looks like he's starving - we don't know what happened to him but it might help." 

The ICU staff confer to determine the best approach with their strange patient's delicate condition. Despite their best efforts, he remains in critical condition - yet some spark of life still lingers. The physician considers the nurses' suggestions and finds wisdom in them.
"Aggressive rewarming is risky, but at this point we have little to lose. Increase the temperature on his warm IV fluids, use external warming blankets, and prepare an intravascular cooling device in case his temperature rises too quickly." He surveys the still form and adds quietly, "We'll need to watch him closely through the night. His survival still hangs by a thread."
The team moves to follow his orders with care. A nurse turns a dial to slowly increase the temperature of IV fluids entering the patient's veins. Another carefully tucks heating blankets and pads around and under him, watching displays to ensure his temperature does not climb too fast. All through the long night they take turns at his bedside, monitoring for any sign of change while the mystery of how he came to arrive here - and whether he might remain at all - weighs heavily upon their minds.
As slowly the hours pass and dawn breaks over the distant mountains, a glimmer of hope emerges at last. The boy's temperature rises by small measures, oxygen levels improve, IV medications reduce their support. Though still unconscious, the pallor of his skin seems less deathly; rising warmth brings faint color to cheeks drained near white before. The physician allows a weary smile at the displays and notes chroncling their long fight, sensing the patient who brought mystery to their midst may yet remain to solve it. The flame within, though dim, now burns steady - and where there is life, always hope remains.

Marian Daly, a travel nurse from Canada who's been working on the unit for three months now, arrives at 6:45 am for her assignment and shift report. 

...Ooh, teenager, near-drowning and hypothermia? That's different, at least. 

- uh. Marian is reading this chart and she is so confused. What is this about hallucinating staff and portals??? ...Also 'group hallucination' does NOT explain the fact that all of his test results fit with 'saltwater near-drowning' and there is no ocean anywhere near Nevada. What. 

She grabs her stethoscope and heads for the nursing station to hear more about the patient's night and the treatment plan for today. 

The day shift nurse sits Marian down and briefs her on the night's events. "This kid is a mystery. No ID, and he just appeared out of nowhere. The ER staff claim he came through some kind of glowing portal, if you can believe it." She shakes her head.
Marian blinks, nonplussed. That made no sense. "What's his condition now?"
"Still critical. Severe hypothermia, near drowning, dehydration. They've been rewarming him aggressively and he's up to 30 C, but he's not stabilizing as fast as they'd like. Bloodwork shows metabolic acidosis, electrolyte imbalance. He's on a vent, dopamine for low BP."
Marian absorbs this with a frown. The severity of the boy's condition was worrying, his mysterious circumstances aside. "No diagnoses yet for what caused this?"
"Not yet. The ER doc noted possible signs of an underlying heart condition, but hard to determine in his state. For now, continue supportive care and close monitoring. They want to start waking him once he's rewarmed and stabilized."
Marian nods, mind already reviewing the challenges ahead. "I'll get up to speed on his chart and start my assessment." She stands, glancing at the closed blinds of the patient's room with a mix of curiosity and concern at the long day to come.

Marian wants to go over all of the lab results and X-rays and other test records, since it's not like they know anything else about the patient other than the results of his tests. But she's going to try to get a look at him, first. 

Wow. He looks really terrible. Pale and cold, his closed eyes sunken in their sockets; he still looks dehydrated even though the chart claims he's had nearly five litres of replacement IV fluids at this point - 0.45% "half" saline, because his sodium is unsurprisingly ridiculously high and he does not need more salt in his body right now. His initial hematocrit was absurdly high, his blood 'thick' with dehydration, and that's improved but not yet normal. Hypothermia can directly cause diuresis and water loss, she remembers. 

...On top of the obvious, he looks like he's had kind of a terrible life. 

He's finally shivering a little, though, an indication that his body is putting more effort toward producing heat and raising his temperature. Maybe they'll make more progress over her shift. Though she's worried about his breathing. His blood pressure is improving a little as his temperature rises, but his oxygen needs are actually going to go up, his metabolic rate increasing with a higher body temperature, and his lungs are in bad shape. She saw in the chart that they administered a dose of steroids overnight, to try to get on top of the inflammatory lung damage, but based on the last chest X-ray she's not sure it's working. 

She listens to his lungs - which sound terrible, unsurprisingly - and checks the settings on all the machines, and checks his pupils with a penlight. And then she pinches his nailbed firmly with her pen, checking for any response. 

The physician makes his way to the patient's room, checking the latest test results and vital signs with a critical eye. Despite hours of intensive treatment, the boy's condition remains precarious. He arrives to find Marian in the midst of her assessment, watching as she checks the teen's pupils and tests his nail beds for a response.
At her frown, he joins her beside the bed. "What have you found?"
Marian shakes her head, troubled. "Minimal responses so far. His breathing sounds worse, I'm concerned about his oxygenation. The steroids don't seem to be helping." She indicates the latest chest film, pneumonia apparent despite their efforts.
The doctor studies the X-ray, then examines the oxygen flow and ventilator settings. The teen's lungs strain with each breath, sickness ravaging weakened body and broken talent both. "Increase his pressure support and FiO2. Start a broad-spectrum antibiotic, and schedule another chest CT to check for effusions."
He pauses, gazing down at their mysterious patient. So young, clinging to life by the slenderest thread - yet something in the cast of thin features suggests a spirit tempered by far more years. "There's a fighter in there. But his lungs won't heal overnight, and may worsen before improving. We'll need to keep a close eye for any complications."
Marian nods, adjusting vent settings before preparing to hang new medications. The doctor squeezes her shoulder, a brief gesture of support, as the slow battle to mend what the sea had shattered begins anew. Step by step through the long hours ahead, they strive to solve the riddle of a life delivered into their hands from worlds away.

It's a relentless next few hours, for Marian. 

She's making progress, slow and hard-won. He's still somehow managing to look hypovolemic - probably because his kidneys, reacting to the low body temperature, are dumping out kind of a lot of dilute urine - and he gets another two litres of half-saline, which finally makes a noticeable difference in how he looks to Marian. She has to give him two more ampoules of 50% IV dextrose, and is honestly really unsure where he's putting all of that blood sugar - unless it's into shivering, which he's finally doing in earnest, to the point that the doctor orders some sedation just to calm him down and decrease his oxygen needs. 

Going flat-out with warm gastric lavage and direct intravascular warming, the patient's temperature creeps up to 31 C in just half an hour. 32 C by an hour into her shift. His heart rate is up to 65 now, with the aid of the dopamine. His blood pressure is still very borderline, and starts swinging wildly as clamped-down capillaries start to relax and dump de-oxygenated and acidic blood back into his circulation, but with very careful vasopressor titration, Marian can keep it mostly within reasonable bounds. His color is finally improving, his lips pink rather than greyish, and the mottling is now only in his hands and feet. 

...His lungs and oxygenation are not improving. By two hours (and a perhaps-unwise four cups of coffee) into Marian's shift, he's on the maximum ventilator settings and the pulse ox reading is still dropping below 90%. She's suctioning a lot of pinkish, frothy liquid secretions from his lungs, but even that isn't helping. 

Dr Patel, the attending on today, is very behind on rounds, but when the patient's oxygen saturation has been 86% for an entire two minutes, Marian grits her teeth and goes to interrupt him. "Uh, I'm sorry, it's my patient in 109. The near-drowning kid. He's - we need to try something else, I can't keep his oxygenation up." 

Dr. Patel hurried into the room, alerted by Marian's concern. His frown deepened as he checked the displays - oxygen saturations falling despite maximum ventilator support, with fluid still filling damaged lungs.
"His pneumonia is worsening rapidly. We need to drain fluid from his chest immediately and start high-dose steroids." He grabbed two nurses on his way out, barking orders to gather thoracentesis supplies and IV medications. A chest tube, though invasive, might provide the only chance to save a life that now hung in the balance.
They worked quickly to sterilize the site on his chest, preparing needles and tubing. "On three -" With care Dr. Patel slid a needle between ribs, frowning at the rush of fluid that began flowing through connected tubing into a container. 500 ml, then 750 - the level slowly dropped, easing pressure that had made each breath a struggle.
After a few tense minutes the flow slowed, his oxygen levels stabilizing for now. But the chest x-ray showed stubborn shadows that remained - a long fight ahead before battered lungs might heal. Dr. Patel sighed, stripping off gloves. "We've bought some time. Start methylprednisolone, and keep draining fluid as needed. I'll check back shortly."
As the doctor left, Marian began infusing steroids to combat the infection wracking the boy's lungs. She checked IV lines and vent settings yet again, ensuring maximum support as his body struggled simply to survive each tenuous breath. The mystery of his arrival aside, seeing life fade before her eyes stirred an ache within - a calling to save those who wandered into her care, no matter where the path might lead. Step by step, they would walk the road ahead together, until at last he found the way home.

Marian is so worried. Everything else seems to be improving - the patient's temperature is up to 34 C, nearly normal, and she's actually able to decrease the dopamine infusion, though he still needs a lot of vasopressor support. She glares at the foamy straw-colored fluid still draining from the chest tube, and then squeezes the patient's hand, even though he's sedated and almost certainly can't hear her. "Hey. You're doing great. Just keep breathing." 

...Even with the heavy sedation, he's still visibly tense, and the desperate hunger for air is making him fight the ventilator and is actually counterproductive. Marian, finally caught up enough that she has two minutes to stand still, spends it at the foot of the patient's bed, watching the numbers on the various screens as he breathes. 

His lungs are still getting worse, she thinks, the combination of serious damage from the seawater and his young, healthy immune system setting off catastrophic inflammation. If they can get him through the next couple of days, he can probably make a full recovery, but right now it feels far from guaranteed that they can. 

It's nearly her turn for actual morning rounds, finally, but first she's going to pull aside one of the residents on this week's rotation and anxiously list off every idea she's ever heard of, to make sure it's on the list to be discussed. They could paralyze him to keep him from fighting the ventilator; they could try high-frequency low-volume ventilation to minimize the damage from high ventilator pressures; they could get him onto a Rotaprone bed to put him in prone position, which she's never done but it apparently often helps; they could even maybe consider extracorporeal membrane oxygenation, if the hospital has the equipment for it or can get the equipment on short notice, though Marian definitely isn't qualified to run that herself.

She feels kind of stupid, and like maybe the resident will get mad at her for acting like she has all the answers, just...she really wants this kid to have the best possible chance. 

The resident listened carefully as Marian described her suggestions, concern evident on his face. Some were drastic measures not undertaken lightly, but with the boy's condition deteriorating despite their best efforts, no option could be ignored.
"You're right, we need to consider everything possible here. I'll discuss your ideas with Dr. Patel - high-frequency ventilation and prone positioning may provide the most immediate help if his lungs worsen further." He studied thelatest chest film, pneumonia's shadows ominously spread. "If those fail, ECMO is a last resort...but we have a unit here, should it prove necessary."
His pager sounded, summoning him away to emergencies across the ward. But he turned back briefly with a nod of thanks for Marian's care and quick thinking under pressure. "Keep monitoring closely. Any changes, don't hesitate to call."
Alone once more, Marian resumed her vigil at the boy's bedside, watching the slow rise and fall of his chest with the vent's rhythm. Each breath might mark one step closer to recovery - or the last, without warning, stealing away a life delivered into their hands from distant shores. The battle ahead would push her skill and stamina to their limits, a test of devotion to her calling through long days and nights to come.

Marian is at this point mostly out of things to do other than monitor him. His temperature is finally up to 35 C. She's having to go up again on the dopamine drip for some reason; possibly the lung damage is now bad enough to be putting significant strain on his heart all by itself. She's got a lot of wiggle room there, though, so she isn't incredibly worried yet. 

...he's doing a few ectopic beats on the heart monitor, which is enough to get Marian to abuse her standing orders and send some stat labwork for an electrolyte panel, it might just be the extra strain on his heart but it also might be out-of-whack potassium or magnesium. His blood sugar is somehow low again, when she checks; it always seems to briefly help, when she pushes IV dextrose, for a couple of minutes his color improves and his heart rate steadies out. Marian has no idea why that's working but she'll take what she can get. 

At rounds she worriedly presents her report. Oxygen saturation at 89% for the last ten minutes, still on maximum settings for everything, and his last blood gas showed that he's retaining CO2 as well, meaning that his lungs aren't ventilating well and the entire gas exchange process is, in a single word that she's normally too professional to use in her report at rounds, fucked. ...His blood pressure is tolerable but he's having some irregular heart rhythms, the electrolytes should be back any minute for the doctor to check. He's still unresponsive. His body temperature, at least, is finally normal. 

Dr. Patel studied the latest test results and vital signs, concern etched on his face. Despite aggressive treatment, the boy's pneumonia raged out of control, sapping strength from his battered form with each faltering breath. His heart struggled under the strain, irregular rhythms a warning of collapse if the tide could not be turned.
"We're losing ground. Start dobutamine for his heart, and prepare to prone his position - we need to drain secretions and improve ventilation." The team moved quickly to carry out his orders, hanging a new IV bag and carefully turning the boy to lie face down, monitoring lines and tubes with each shift of his limbs.
Freed at last from the smothering weight of fluid-filled lungs, his oxygen levels rose over the next hour, steadying heartbeat following. But shadows still clouded the x-ray - a lingering threat that demanded ceaseless vigilance through the trials yet to come. The physician allowed a flicker of hope, sensing life grasped tight where before it slipped away.
"Good work. Keep up the steroids and broad-spectrum antibiotics. Check blood gases every 30 minutes; if he stabilizes we'll need to wake him to check neuro status." One long breath at a time, the boy was mending - though the path ahead remained twisting, and fraught with peril at each turn. Step by step the doctor and his team would forge a way ahead, through a forest of fading shadows toward sunrise at the far side. For in the delicate flame restored, a riddle still lingered to be solved.

Her patient is doing so well! Marian is so proud of him! 

...She is, also, exhausted, and has been on her feet nonstop for the past six hours, and there's nothing in her stomach but black coffee. Once everything has been rearranged to her satisfaction around the RotaProne bed, and she's drawn the 2 pm blood gas and hung plump spare bags beside all of his current IV infusions, Marian will look around to see if any of the other nurses on the unit are up for covering her for a lunch break. 

The rush of the ICU continued around Marian as she took a much-needed break. The cafeteria was bustling with activity, staff fueling up for long shifts ahead and visitors fortifying themselves for hours keeping vigil at bedsides.
Marian found an empty table and sank into a chair, fatigue weighing heavily upon her as the buzz of adrenaline faded. Though her patient seemed to have turned a corner, the severity of his condition left no room for complacency. She picked at her meal, thoughts drifting back to the closed door of his room and the long hours of watching and waiting ahead.
A familiar voice startled her from her reverie. "Mind if I join you?" The resident who had listened to her suggestions that morning stood before her, tray in hand. At her nod he sat, gaze sobering as it fell upon her drawn features. "You look exhausted. How is our mystery patient doing?"
Marian described the improvements since prone positioning, hope and anxiety mingling in each word. "His oxygenation is better, but he's still so sick. I don't know if..." Her voice trailed off, fears left unspoken.
The resident offered a sympathetic smile. "You've done well. He wouldn't have made it this far without your quick thinking." His pager sounded, a summons back to the fray. But before leaving he added gently, "Call if you need anything. We'll get him through this, one day at a time."
Bolstered by his confidence, Marian finished her meal with renewed purpose. The battle was far from won, but with caring comrades at her side, despair held no place among them. Step by step they would forge ahead through trials untold, holding fast to fading embers kindled anew each dawn.

Marian takes her full lunch break, though she's tense the whole time, on edge for the crackle of an intercom announcement from the ICU. 

She buys another coffee at the cafeteria and brings it back with her. Does the nurse who was covering for her have any changes in the patient's condition or new test results to fill her in on? 

Marian returned to find the day nurse finishing up charting at the station outside their patient's room. At Marian's inquiry, the nurse shook her head. "No major changes. Blood gases were stable so we're still holding off on waking him. Fluid output is good and his heart rate has steadied." She nodded toward the closed blinds, adding, "Dr. Patel came by - he seemed pleased with the improvement but wants to keep a close eye, especially if we lighten sedation."

Marian spends a couple of minutes catching up on the chart before she goes in for another assessment. The blood gas results are in fact a little better, and the patient's O2 saturation has been above 90% for her entire lunch break - it seems like the steroids are finally making some headway with the inflammation - but the pneumonia is still hitting him hard. His lungs sound like walking on bubble wrap, when she listens with her stethoscope, practically rattling with thick secretions - and he's wheezing slightly now, irritated airways starting to spasm. 

She's going to go bother the poor overworked resident again. "Um, he's completely full of lung gunk," wow she just called it 'lung gunk' with her actual mouth, he probably thinks she's an idiot, "it's almost too thick to suction out. And he's wheezy, I think there's some bronchospasm going on. Do you have ideas?" 

(She would suggest a bronchoscopy to wash out some of the infected secretions, and then nebulized bronchodilators, but she doesn't want to sound like a know-it-all telling the doctor what to do.) 

The resident frowned as he listened to Marian's report, concerned by the wheezing and thick secretions filling the boy's lungs. His pneumonia raged on despite their best efforts, sapping strength with each rattling breath.
"A bronchoscopy sounds prudent. We need to clear out as much of the infected material as possible." He paged the respiratory therapist to bring nebulizers from available supplies "Salbutamol and budesonide should help reduce inflammation and open his airways. We'll have to watch closely for side effects, especially with his heart still weakened, but I don't see other options if his condition's worsening."