"- Right. Sorry. I can't imagine it would be an issue to prepare more, if you'll definitely use it within 12 hours." Dr Sharma drags a hand over her hair. "I need to finish filling out the paperwork requisition for the test, courier should be here by 1 am. I called the pharmacy to bother them about pralidoxime, the orders are in. ...Am I forgetting anything you still need?" 

"Um." Marian checks her paper. "...Right, we're still waiting on labs for whether to supplement phos. Um. I don't think so. I'll keep checking for the labs and come find you when they're back?" 

"Sounds good. I think you'll probably find me in 196, she's pretty unstable." 

Oh no Marian did not manage to help at all with Annie's admission and now she feels bad about it. 

...Priorities. She needs to - go pull a huge pile of atropine, 10mg for another push dose and - hmm, 50 mg in 250 ml saline would still be 0.2mg per ml, and she can probably just do that with a 200ml bag rather than fuss around removing 50 ml from a 250 ml bag...that's going to take a while to mix, she should give the poor man his push dose first...

The poor man's lungs do seem to appreciate it! His heart rate jumps again, unsurprisingly, but it's only above 120 for a few seconds, and settles back to around 110. 

Temperature 33.9 C. 

Which is STILL HYPOTHERMIC but they're making progress! Slowly! Time to set herself up with a syringe and filter needle at the bedside table station and methodically break open 10 ampoules of 5mg/5ml atropine to inject them into a bag of saline! 

Tsashi creeps out of her chair to watch this process with utter absorbed fascination. 

Awwwww. It's really too bad they don't share a language, it would be neat if Marian could explain to the clearly smart and inquisitive twelve-year-old what exactly they're doing to support Lionstar's body while he recovers. She seems like such a cool kid. Marian settles for smiling at her a lot. 

Chantal interrupts her around halfway through prepping the bag. "Marian! Lab for you. Line 4." 

Great. Perfect. Marian pats her pockets to make sure she has her paper and pen there, and then abandons her half-mixed drugs and darts out to pick up the phone. "Yes?" 

They have results for her! Critical results! 

Lactate: still 4.2. It's coming down, but slowly. 

Venous blood gas: his pCO2 is a touch high (53 mmHg), though it's not as informative in venous blood. His pH is all the way down at 7.01. Bicarb 12.9 mmol/L, well below the normal venous blood range of 23-29. 

Electrolytes: potassium still critically low, at 2.9 mmol/L. Magnesium at 1.5 mg/dL, still low but no longer critically so. Phosphate still critically low - actually, very slightly lower than before - at 1.1 mg/dL.

Sodium now also slightly low, at 132 mmol/L (normal 135 to 145). Albumin now significantly lower; the test doesn't give critical results, but it's at 2.8 g/dL (normal 3.4 to 5.4). 

WELL ISN'T THAT JUST GREAT.

None of it is new and an emergency. His potassium is at least not lower than before they started trying to keep up at supplementing it? 3.0 is usually the cutoff when it counts as low-but-not-critical and they're nearly there. She already has an order to do something about his albumin; the lower result isn't shocking, his blood is way more diluted now, though it does hint that she should maybe make rechecking his hemoglobin a priority. The sodium drop is...probably diarrheal losses? Ugh, despite the fact that they've given him three liters of normal saline. She should probably bother Dr Sharma about the pH, find out whether they want to give him an amp of bicarbonate for it or confirm with an iSTAT arterial blood gas now that they can do that easily. 

...Marian is just going to go finish mixing and labeling the atropine before she forgets where she was on that. And actually start the albumin, and - 

- she runs aground on the fact that she's currently using every single one of the five IV pump in the room. Well, not using-using, the dopamine is on standby and she hasn't started running the midazolam, but the norepi and potassium and magnesium pumps are definitely in use, and she doesn't want to overwrite the programming for the ones she might need again any minute. 

This is not a good week for finding pumps; nearly every patient on the unit is sick enough to be on half a dozen IV infusions. Marian will grumpily go look in the clean utility, find one pump - that can be atropine - and then grumpily decide that a heart rate of 108 and BP of 113/52 means she probably won't need the dopamine again in the next hour, and that one can be stolen to run albumin.

She's also pretty short on IV lines. And the drawer did not end up stocked with stopcocks for adding more usable saline-lock ports. She ends up daisy chaining the albumin in a Y-site with the electrolytes, and atropine with the norepinephrine and now-finished saline bolus. She'll make a mental note to canvas the unit for unused pumps in patient rooms that can be stolen, and then go looking for Dr Sharma. 

Annie does not look like she's having the best night. The room is on airborne isolation, door firmly shut and plastered with warning placards, but leaving enough of the window uncovered for Marian to observe a room full of the detritus that accumulates after more than thirty minutes straight of uninterrupted emergency. The patient appears to be a short, very obese lady; Marie can't see her face, Annie is standing in the way, but her exposed lower legs look alarmingly blotchy and mottled. The monitor shows rapid irregular atrial fibrillation at 170 bpm and a cuff BP of 79/50. 

There's a crash cart in the room. There's also a Dr Sharma, apparently setting up to place a central line. 

Ughhhhhhh Marian does not really want to put on a gown and N95 mask and faceshield just to walk in for 30 seconds and ask Dr Sharma a question. 

...She thinks briefly, then darts back to the nursing station for a pad of paper and Sharpie. She writes in large block letters. 202 VENOUS PH 7. GIVE BICARB (1) OR REPEAT ON ABG (2)? 

She returns to the window, holds up her makeshift sign, and taps it until Annie looks over. 

Annie gets Dr Sharma's attention, and Dr Sharma comes over to the window and squints at the sign. She shrugs and holds up 1 finger, then mouths...something...that Marian cannot entirely make out but that probably refers to repeating an ABG later. 

It's 00:41. She'll....urghhhh, bicarbonate is incompatible with tons of things...she'll PLACE ANOTHER IV LINE, Lionstar has decent veins and should be better-hydrated now, she'll do that and give an amp of bicarb and check it along with hemoglobin once the albumin is done. Wait, she's forgetting bloodwork...isn't there a courier coming at 1 am...? That's in nineteen minutes and she does NOT have a paper requisition form from Dr Sharma and, in fact, has no idea what color tube to use. Hopefully Dr Sharma hasn't forgotten and will do that once she's finished the line in 196...

It's tempting to rush to get her patient's bicarb given and then go help Annie, but the voice of common sense is very firm that she should not do that right now. Marian sighs and goes to grab a syringe of bicarb from the med room.  

The patient has not gotten worse during her brief absence! The albumin (running over 15 min) might already be helping improve his intravascular volume status; his heart rate is down to 96 and his blood pressure is up at 117/56, mean arterial pressure 76. His O2 saturation is at 99%. 

He's still getting 100% oxygen on the ventilator and pooossibly at some point she should get RT in here to assess whether he really needs to be, but...maybe not just yet, he was still dropping noticeably with suctioning and still needing that pretty often.

He can be on less norepinephrine, though! Marian is happy. She's now down to a pretty tiny dose and the trend looks promising for stopping it entirely. And he can get another 20G IV in his other forearm, and his pH fixed with a syringe of bicarbonate. 

It's 00:49. What is she forgetting... She should turn him at some point, but that's not spectacularly urgent, he's been technically "on his back" since he arrived around 10 but they've moved him a bunch in that period. Actually you know what she should do, is turn 201, who is by now solidly due. ...A glance around the hallway is not promising in terms of finding someone to help, but she can probably iso up and do it herself - at some risk of future back injuries that Marian is, honestly, not especially motivated to care about right now - and be out promptly to make sure Dr Sharma is going to get the bloodwork requisition in. 

Dr Sharma does apologetically rush over at 00:53 and leave a wad of paperwork and a lab tube on the desk outside the room. She briefly makes eye contact with Marian and points to it before rushing off to wherever she needs to be next. 

Tsashi is feeling kind of tired at this point. It felt like being scared for Lionstar would keep her awake forever, but apparently not. It feels very draining not understanding what's happening. She sort of wants her mother, which is such an unhelpful feeling to be having. 

No one is nearby. She looks around, then drags the reclining chair close to the mage-contraption holding Lionstar, and curls up in it with one arm reaching over the side of the box-thing to hold his hand. 

Marian tugs sheets and stuffs pillows and does very hurried mouth care and hurriedly apologizes to Ms Lebedev in 201 when she makes a face about the hasty mouth care, and then de-gowns and de-masks and washes her hands as fast as she can. She's back in 202 by 00:56. 

...Drawers do not have the adapter thingy to take blood from an art line, fuck. She's back from the clean utility with that by 00:57. Sashy is watching her from the reclining chair, looking sleepy-curious, awwww. Okay, great, handwritten label on the tube, sign her name on the paper rec, shove everything in a biohazard bag, now where is she supposed to go to get this to the courier...? 

Probably the charge nurse was at some point involved in helping arrange a courier. She goes to ask Chantal. 

Chantal looks very harried and has no idea. 

Okay. She really wants this blood to make it to its destination. Also to not get yelled at by some poor person doing courier runs at 1 am. The front reception desk is closed at night, so probably they're going to show up to the ER?

She asks Louis-Philipe to keep an eye on her people for five minutes, and then sprints down the hall to the ER. 

The ER charge nurse does know what she's talking about! "They called us twice. They're going to be twenty minutes late, but I can hold onto that for you - it's for the code earlier? How's he doing?" 

"Uh. Better. SorryIshouldreallygetback." 

She runs.