Dr Sharma jumps back, startled. 

....Watches for a couple of seconds, frown growing. "- Marian? Is this new?" She reaches in, a bit tentatively, to lift the patient's eyelid and shine a penlight in his eyes. "I - think he might be seizing? Has he done something like this before with you?" 

Marian was ALSO startled and now her heart rate is unpleasantly elevated. "No! He definitely hasn't done that before!" 

"Okay. I can't tell - maybe he's just really freaked out -" She's going to back off and watch for a few more seconds to see if the patient stops whatever-that-is on his own. 

He does not! His face is still twitching in a way that really doesn't look like his previous grimace-responses to discomfort, and - it's not so much that he's fighting the ventilator, that would imply more purposefulness than he's showing, it's more that his chest muscles are tightly clenched and thus squeezing air out every time the ventilator wants to push air in. He's desatting fast. 

"Shit. This - isn't great. ...Marian, give him two of midazolam and call RT - I'm going to try bagging him until they get here -" 

Nellie didn't stay in the room after they were done with the dressing change, but expressed an intent to stay at the nursing station and be easily findable in case Marian needed her again. Marian sticks her head out. "NELLIE! We need RT, he's - maybe having a seizure or something -" 

And she has a bag of midazolam right there, because she's very prepared. It's not as good for giving an exact bolus dose when it's not already running, but it's faster than running to the med room. She doesn't have any unused IVs to run it in, but it should be compatible with atropine - ugh, except she still doesn't have a stopcock setup so there are like two feet of daisy-chained tubing mostly of things that aren't even running (paused norepinephrine and dopamine) before the first open Y-port - and she has no idea if it's even compatible with pralidoxime, which is running by itself in the third IV - she'll very briefly pause the atropine pump and unhook everything and plug the midazolam in directly and program a 2ml bolus at 99 ml/h - and then saline-flush it from the Y site to make sure that the 0.2ml or whatever in the tubing and IV catheter is definitely in the patient - and then hook up the atropine to that Y-junction, she's pretty sure those two are compatible... 

It does not have any noticeable effect. Lionstar's O2 saturation is down to 84%. His heart rate is up at 125 and his blood pressure actually seems to be dropping. 

Dr Sharma is trying to bag him one-handed while attempting to figure out which button will put the disconnected ventilator on standby and stop it from both screaming at them and trying to blast heated humidified air at the pillow. "Nothing? Give him 5 mg, we'll give another 5 in two minutes if he hasn't snapped out of it by then -" 

Nellie reaches the room at a run, looks around, and standby's the ventilator. "Vanessa's coming but she was in 196. What happened?" 

Marian is carefully programming in another 5ml fake-piggyback bolus on the midazolam pump. "We were trying to get a neuro assessment and instead of waking up when Dr Sharma sternum-rubbed him he did this." Her voice sounds surprising calm and level to her own ears. 

"Bizarre." Nellie exchanges a look with Dr Sharma and, without actually saying anything out loud, smoothly takes over on trying to force air into Lionstar's uncooperative lungs. "...I mean, decreased seizure threshold makes sense, that's just a weird trigger for it. What've you given him so far." 

"Uh, about to be 7mg of midaz." The IV pump is whirring. The kid...looks completely terrified, which is so understandable, but smiling reassuringly at her right now feels like lying and Marian honestly does not have a huge amount of brainspace available right now for tracking the "scared kid" element of this situation as opposed to her patient's vital signs. She...should probably at some point try to convey that they're going to take Lionstar out of the room to go to the OR, because Sashy definitely can't go with and is probably going to be pretty freaked out, but conveying it via mime feels complicated and Marian cannot think about that right now. 

The larger dose of midazolam, when it kicks in, does seem to have a stronger effect. The muscle twitches gradually slow and weaken, the clenched tightness in his chest starting to loosen, until about a minute later he abruptly goes entirely limp and Nellie has a much easier time squeezing air into his lungs. 

His sats are down to 78%. His heart rate, which made it as high as 140, is now slowly settling down – and his blood pressure is dropping fast, already down to 84/47 on the arterial line tracing. 

Arghhhhh she JUST got him off pressors and was PROUD of that accomplishment but the blood pressure is, in fact, a solvable problem, at least once she untangles the frantically-rearranged tubing and reattaches the norepinephrine line to her daisy-chain along with the midazolam and atropine. 

Dr Sharma is looking mildly frazzled. "Let's get an ABG on the iSTAT - and I think we still need to send the tube for a type-and-cross, I put the order in stat -" 

Marian can go grab those. She doesn't spectacularly want to leave the room - for one thing, Sashy is looking at her plaintively - but Nellie is right there. 

Tsashi is very freaked out! She's trying not to show it but she doesn't think she's entirely succeeding. She doesn't understand why they were hurting Lionstar???? It wasn't the one whose name she knows is "Merr-rayn" (if anything she looked kind of unhappy about it too?), it was the other Healer who's only there sometimes. And then things after that were very confusing, and it at least seemed like the Healers were upset about it too but that's...not really entirely reassuring.

It doesn't really seem like it would make things better to get her knife out and try to stop anyone from touching Lionstar, which is the only idea occurring to her. 

Marian has to go on a bit of a treasure hunt for the iSTAT, but she's back in the room after a couple of minutes with that and one of the pink lab tubes for blood typing. 

She has extra blood in the syringe she pulled to use for the iSTAT sample, and the glucometer is still there. She's not sure what instinct is telling her that she should really check again, when she checked less than half an hour ago, but it's there. 

Lionstar's blood gas promises to be concerning, given that Nellie only has his sats back up to 82%. His heart rate is in the 60s, the lowest Marian has seen it since they started the higher-dose atropine, though at least the complexes are neat and regular with much less of the previous delayed-conduction weirdness. His blood pressure is a tolerable 93/49 (mean arterial pressure 64) but a glance at the thicket of IV pumps confirms that someone, either Nellie or Dr Sharma, bumped the norepinephrine up from Marian's medium starting dose to nearly the maximum rate. Temp 35.3; apparently the one single upside of several minutes of seizure activity is that it generated some body heat. 

The blood sugar reading comes back first. It's at 59 mg/dL. 

...Well, it's not shocking - he probably just burned some extra calories - but it can't be doing his brain any good, low sugars can trigger seizures by themselves. Marian will mutter something to Dr Sharma and go grab...possibly a handful of boxes of D50, actually, she can stash spares in a drawer.

The blood gas reading is back. PaO2 is 44 mmHg, unsurprisingly well below the normal range of 75-100. PaCO2 is moderately high, at 56 (normal range 35-45). Bicarb 16.4, below but not catastrophically below the 22 mmol/L normal cutoff, and pH 7.09. 

(It's probably already improved in the last three minutes; his sats are up to 86% now.) 

Dr Sharma leans in to see. "Let's push another amp of bicarb. Did the magnesium get started?" 

...The magnesium absolutely did not get started. Marian will run to pull that from the Pyxis and grab another box of the 50ml injectable sodium bicarbonate (plus spares to stash, Lionstar's low blood pH problem seems almost as recurring at this point as the blood sugar) and remember to drop off the lab baggie at the pneumatic tube station, and then run back to the room. She's starting to feel slightly like a chicken with its head cut off, still on her feet but not actually managing to think ahead or plan. 

Dr Sita gets in at 2:37 am.

Vanessa, the respiratory therapist on for the night, is fiddling with ventilator settings. Nellie is absently tidying the room. Dr Sharma is back outside at the computer workstation desk, on the phone. Marian is sort of at a loss of what to do. 

Presumably because Dr Sharma is clearly occupied, Dr Sita heads for Marian. "So what's the story?" 

Aaaaaaaah why does she have to answer questions it's too 3 am for that. 

"He was brought in by ambulance last night with a laceration on his torso and decreased level of consciousness. Uh, deteriorated in the ambulance, dropped to GCS 3 and started having respiratory distress. He coded pretty briefly in the ER and then was really bradycardic and hypoxic for a while. Epi barely did anything and atropine did, like, a bit, eventually Dr Sharma noticed his symptoms looked like cholinergic toxicity and guessed organophosphate poisoning and we did the diagnostic test for that and tried way higher doses of atropine and started the other antidote," which is not pradoxime...not pralixime either, damn it, "- uh, pralox– pralidoxime. ...Separately he had really low blood sugars, which I think isn't expected from organophosphate toxicity, and his lytes are surprisingly off, we've been trying to replace his mag and K. He seemed to be stabilizing with the atropine, but about half an hour ago we, uh, noticed the wound looks really awful and Dr Sharma called you. And then he had a seizure when we were trying to do a neuro assessment."