Nobody is dying when she gets back to the ICU! 

Oh good. She can thank Louis-Philipe and then...sit down. Look at the chart. Remember to document the third IV she placed. Remember that she hasn't charted anything for urine output since Nellie put the catheter in (she put a roughly-estimated 400 ml in the input/output flowsheet at 23:30), go in and flip the measuring-box again and chart another 125 ml. ...And 460 ml of gastric contents in the suction catheter. He's still theoretically positive several liters on fluids but there are a lot of fluid losses not being successfully measured, he's probably losing a nontrivial amount literally to saliva. 

Maintenance drugs are running. ...Albumin's done, she should go pull a hemoglobin. And do a ABG on the iSTAT at the same time. That involves standing up. She's going to do that any second now, definitely. 

It takes kind of a while to find the iSTAT machine (Jean has it in 190) but she does, on her travels searching for it, find two not-in-use IV pumps to steal! 

Her patient appears to be resting comfortably when she gets to his room at 01:09. Heart rate 92, blood pressure 107/62, temperature 34.4 C, sats 99%. There is a very drowsy-looking child in the chair bedside him. 

...He is noticeably more responsive. Gently untucking his arm from under the Bair Hugger blanket shouldn't be causing him any particular discomfort, but he makes a face - not so much a pained face, just some kind of reaction - and seems to be trying to lift his head off the pillow, though not with any particular success. His eyes aren't open but his eyelids twitch in a way that looks like he might be trying. 

Awwwww Marian is so pleased and proud of him for responding to stimuli! 

...She is going to be a spectacularly mean horrible person, and pinch his nailbed hard to see how much response that gets. 

Lionstar is very unhappy about that! His face twists into a grimace and he takes a much deeper breath than usual and then coughs.

He's not really managing to pull away from the unpleasant stimulus, but his muscles tense enough that his arm twitches a little; he seems to be trying, and just not sufficiently competent at moving his limbs to get anywhere. His eyes still aren't quite opening. 

"I'm so sorry." Marian stops cruelly causing him pain and gently pats his hand instead. "I need to see how awake you are, is all. You're getting there." 

She draws blood, which shouldn't hurt him at all. Art lines are great. 

He doesn't seem completely happy until she has him thoroughly covered up by the Bair Hugger again. Maybe he's cold. 

That would be super reasonable of him! His body temperature is still below 35 C! 

Marian puts the little blood collector dingy in the iSTAT machine and leaves it on the bedside table while she dashes out to send the hemoglobin tube to the lab. 

Which means the results will be up by the time she's back! Arterial PaO2 is 78 mmHg, juuust barely squeaking above the cutoff for normal range. PaCO2 is 44 mgHg, in normal range. Bicarb 15.9 mEq/L, still low but less drastically so, and pH 7.18, still below the normal-threshold cutoff of 7.35.  

Some of that is probably his lactate, which will slowly return to normal as his liver finishes clearing it, but...on reflection he probably lost some bicarbonate ions in the diarrhea, stool is normally alkaline. (The gastric secretions in vomit are normally acidic, and heavy vomiting - or prolonged gastric tube drainage - can result in a metabolic alkalosis, so that's going to be partially cancelling out, but there was, like, really quite a lot of liquid stool.) 

It doesn't seem urgent enough to bother Dr Sharma. Marian documents the result and cleans the iSTAT machine and returns it to its charging dock in the med room like a good citizen, and then goes back to SITTING.

...Several minutes into her lovely relaxing sitting, which she spends poking around the chart filling in neglected areas like the patient's skin condition (no bedsores, no jaundice, no notable abrasions or bruises, there is not actually a box to chart 'completely filthy' but she should deal with that at some point), Marian remembers that she is PRETTY SURE Dr Sharma said something about doing the rest of the admission bloodwork set. 

Also wrist restraints. 

Also they're supposed to be starting the other antidote drug? Proxidime, no, praloxime, no, not that either, it's more syllables than that but she's not 100% where the syllables go– ...yep, the order is in the chart, good on Dr Sharma. No one has come to tell her about a pharmacy delivery but they honestly might not have, it's that kind of night. 

She's going to put in verbal orders for the admission labs they haven't yet checked off (mainly liver enzymes and clotting factors) and then UNSIT and go obtain wrist restraints and correct blood tubes and hunt for a possible medication delivery. 

There's a medication delivery! It's ended up half buried in what must have been an extremely delayed drift of routine restocking. She has a nicely pharmacy-labeled baggie with one 100ml bag of saline apparently containing 2g of pralidoxime, to be given over 30 minutes, and then two plump 250ml bags of 5% dextrose solution mixed at a concentration of 10 mcg/ml, to be administered at a rate of 8 mg/kg/hour. 

FUCK what does her patient weigh. Marian is really bad at estimating people's weight visually, as she learned dramatically last year when she eyeballed a short by heavyset woman and guessed "oh probably 70kg" and turned out to be underestimating it by nearly 25 kg. She should probably get a proper bed weight, hopefully the bed was actually zeroed, but that involves stripping all non-patient things off the bed and stealing the Bair Hugger is going to make Lionstar sad. 

She'll prime tubing - the 250ml bag can go in the main line and the little initial infusion in piggyback, presumably, the same drug is definitely compatible with itself - and make sure all of that is ready, and check that the bed is in fact zeroed (it is) before exposing him to the elements. 

He's so unhappy about it! He apparently still can't really move to express his unhappiness, but he can definitely tense up and make an agonized expression about it. 

63.2 kg. Plus or minus a hospital gown, she's not going to strip him naked for this. 

Huh. He's a grown man, and not a short man - his feet aren't quite bumping into the footboard but he definitely stretches out over most of the bed's length - and he weighs only a tiny bit more than Marian does. That's got to be an 'underweight' BMI. 

She covers him up again, and programs one of her nice new unused pumps - piggyback over 30 min, then main infusion with the MANUAL DRUG setting and details entered, the rate comes to almost exactly 50 ml/h - and hooks it into the nice new unused IV, and starts it.

And then has to spend thirty seconds retrieving everything else in her stack. Bloodwork, right, and restraints. 

Lionstar really doesn't seem to like the restraints. Marian is being very gentle, and reaching under the Bair Hugger blanket rather than lifting it to avoid making him feel cold, and he still grimaces and twitches and seems like he would absolutely be fighting her about it if he had any muscle strength to speak of. 

Huh. Marian apologizes instinctively, of course, and then - can he open his eyes to a loud firm verbal request? (Or try to squeeze her hand, but she's less hopeful about that, he seems to have some serious neuromuscular Problems going on. She should really go look up the side effects of organophosphate poisoning, just so she knows which things are definitely because of that and which things are still weird and notable.) 

He doesn't particularly react to her voice at all, let alone take actions on request. 

Huh. So...not really awake, she's not even sure she would call that 'localizes pain' or 'purposeful movement', he's not opening his eyes even to painful stimuli, he just...really hates restraints?

Actually, Marian is starting to wonder if he's just generally in pain, given how much he's reacting to things that shouldn't in themselves be painful. It wouldn't be that surprising, he has a giant laceration with staples in it, and it seems plausible some of the poisoning symptoms are directly painful. It seems reasonable not to sedate him too hard, given that they want to be able to assess neuro changes, but maybe she can at least ask about giving him something for pain. 

For now, it's nearly 1:30 am, and she's going to dim the lights and leave him (and the kid) alone to rest while she goes and sends bloodwork, and then comes back and sits at the computer desk repeatedly refreshing the lab work screen. 

The lab doesn't call, but eventually the hematology comes back. The patient's white count is now slightly elevated - maybe a sign of generic inflammation, maybe because all the secretions gave some bacteria a chance to start something in his lungs. His hemoglobin is in fact reading lower now, at 9.2 g/dl, but clearly not low enough to prompt a call from the lab. 

Urghhh, even if he didn't aspirate before he was intubated, he's probably at super high risk of hospital-acquired pneumonia, given the lakes of lung secretions. Nothing worth bothering Dr Sharma about yet, though. He's probably pretty due to be suctioned but she just finished making him uncomfortable and it would be polite to give him a few minutes to actually just sleep. 

...After ten more minutes of poking at both her patients' charts, filling in gaps she forgot to document and reassuring herself that she's probably not forgetting any pending tasks, Marian has to admit that she's more or less caught up. It's 01:37. Six hours to go. ...Six hours is so long and she is, now that she's stopped moving, pretty impressively exhausted. The cafe is closed, obviously, but this maybe calls for making herself a 3x-strength instant coffee packets concoction in the patient kitchen. 

She'll drink that, and then wander around the unit seeing if anyone else needs help, because she is not doing great tonight on her personal quota for helping other people at least as much as she's getting help with her own patients. 

Nellie has 192 and 194. She's charting, but spins in her chair when she sees Marian. "Looking for tasks? I'm overdue to turn my peeps, I'll help with yours after if you help with mine." 

"Sure! 201's good for a while but, yeah, 202's been on his back forever." She gulps down the remaining dregs of coffee. "Let's do it." 

Nellie's patient in 192 is a woman in her late forties with a bleached mohawk and an elaborate cyberpunk sleeve tattoo, who looks like she might have, at one point before getting sick, been a professional bodybuilder. She's intubated, but awake; Nellie addresses her, somewhat incongruously, as Dory.

Dory is recently post-op for some kind of complicated abdominal surgery; she has a colostomy bag, an enormous midline incision leaking through a heavy gauze dressing, and two bulb-suction drains hanging from slim rubber tubes sutured to her abdomen, both full of pinkish-yellow drainage; Nellie scowls at them and then empties them with a long-suffering expression. Dory has both an epidural hooked up to continuous pump, and a patient-controlled analgesic button which she stoically presses before they prepare to turn her. In spite of it, she's cooperative but clearly in enormous pain. She gamely exchanges a fist bump with Nellie and accepts a mouth swab, and they head to the next room. 

194 has been here for 10 days, and is something of a frequent flyer in general; Marian knows him. He's a gaunt, dignified black man in his late eighties with an Oxford accent, and one of the worst hearts of anyone Marian's ever treated, once you add the filter "and they went home from the hospital alive, to live mostly independently in their bungalow, more than once."

He's had three heart attacks and two bypass surgeries. He has a pacemaker and an implanted defibrillator and his left ventricular ejection fraction is in the vicinity of 10% on a good day. He ends up in the ICU a couple of times a year with some new and exciting cardiac or probably-cardiac misbehavior - this time, several fainting episodes at home, which you would think a pacemaker would stop but the cardiologist suspects that some kind of autonomic blood pressure regulation issue is combining badly with his chronically abysmal cardiac output.

...At home, he somehow lives more or less independently, perfectly compliant with his ever-rotating roster of a dozen-plus cardiac medications, with nitroglycerine spray to control his angina and occasional use of home oxygen "when he feels like he needs it." He's been Dr Fauckensteir's cardiology patient for fifteen years. He's not even pre-diabetic, his lungs are fine despite a lifetime's cigar-smoking habit, and his kidneys are pristine. Bets have been exchanged on whether he's going to make it another fifteen and top age 100. 

He's unfailingly polite, even when being nudged awake at nearly 2 am to be scooted up in bed and tucked in on his other side. He asks Marian how her mother's fabric art business is going. (They ended up making conversation about that on his last admission six months ago.)