Isobel: is in many ways a much better ICU nurse than Pascal (or Marian herself.) Also. Also. If Marian has to give report to her after this 16h shift, she will almost certainly literally cry. 

"- I think Pascal would be good." 

Nod. "Rick is charge, I'll tell him to make sure he's keeping an eye out for anything they need. - he'll have an assignment, unfortunately, I can't make two 1:1s work otherwise. I'm giving him 201, so he'll be right there – and he'll have to take the admit if we get one in 188, but we haven't heard a peep so far, might get through the whole shift without needing it." 

Thaaaat seems like rather a lot to gamble on, but Rick is in fact really on top of his shit. And knows how to be pushy with bed control; if it's a really bad time for an admission, he'll make the ER hold onto them for another half-hour until it's less of a bad time. 

She pokes at the chart a bit more - refreshes the lab results page, the lab is at least on top of things enough to have received the samples and put them in as PENDING but they're unsurprisingly not actually back yet - and then wanders over to look at the assignment board for day shift. 

There are 11 patients currently in the ICU and six non-charge nursing staff assigned for day shift; Rick, as charge, is the seventh.

Mayumi is assigned to 190 and 192. Marian isn't actually sure what the deal is with 190, he appeared while she was off and she hasn't done more than glance at the room while hurrying past; she knows he's intubated and a large dude and looks surprisingly young for an ICU patient, 30s or maybe early 40s. 192 is Nellie's abdo surgery lady with the awesome hair. 

Adele, a fellow recent grad who was in Marian's training cohort but actually studied in Quebec, has 194, their cardiac guy, and 197, who Marian did have last week – she's a sweet lady in her early 60s with bad kidneys - not quite at the point of needing dialysis, but she's on a 800 ml/day fluid restriction and strict low-sodium and low-potassium diet - and a catastrophic case of COPD. She's been in the ICU a few times in previous winters, for upper respiratory infections and respiratory distress requiring BiPAP, but this time they weren't able to stave off intubation, and from there the progression to a trach was almost inevitable. The really remarkable thing about her is that, unlike most patients with her comorbidities, she looks mid-50s at most, and still works part-time as a chartered accountant. Her mother, who visits daily and helps out with a lot of her care, is 90 and could pass for 75.

Isobel has 196, 1:1. Marian knows rather little about the patient, aside from that she's a recent transfer, intubated, on airborne precautions, on double strength epinephrine, and definitely looked like she had some kind of horrifying skin infection. She's apparently 57 years old. Based on the symbol marked beside the room number, they're starting her on CRRT, so also kidney failure? Marian's main impression is that she does not envy Isobel in the SLIGHTEST right now. 

Gianna has 198 and 199. 198 is a 22-year-old woman, type I diabetic, and apparently has a long history with the more senior ICU staff – Chantal greeted her like a long-lost friend. And then was very exasperated, because it sounds like she's made some dubious life choices in college, including getting into hard drugs. And combining hard drugs. Her official admission diagnosis is diabetic ketoacidosis, as usual, but with a large side helping of "took MDMA, cocaine, and ketamine at the same rave" and implicit addition of "like a dumbass." (The amusing - in the right light - other fact is that she doesn't drink at all, she claims because alcohol throws off her blood sugar.) 

199 is another newish admit, from during Marian's last shift – an obese woman in her 70s originally admitted for a knee replacement, she was a rapid response call for respiratory distress, a couple of days after the initial rapid response call from the orthopedic surgery floor for new-onset rapid atrial fibrillation resulted in a transfer from med/surg to telemetry. The current diagnosis is pulmonary embolism and she's on high-dose anticoagulants and high-flow oxygen. 

Rick has 201! Pneumonia, intubated, isolation, stable. (Rick's name is also next to the empty 188.)

Pascal, like they just discussed, is 1:1 with 202. 

Candi (who sometimes introduces herself by disclaiming that, yes, she knows her parents gave her a stripper name) has the hallway module, 204 and 206. 204, a 52-year-old man, is off isolation now that they've ruled out tuberculosis as a cause for his enormous lung abscess (they're now...unsure...what caused the enormous lung abscess, the biopsy was negative for cancer too) and is intubated and more or less stable. 

206 is a 41-year-old man post suicide attempt by hanging, and was actually Marian's admit originally, a week or so ago. He's...somewhat remarkably...probably going to be okay? Well. Mostly okay. His roommate found him and performed CPR while the paramedics were en route, and they're not sure how long he was down but given his age, lack of comorbidities, and the fact that the paramedics were able to restore spontaneous circulation on the scene, he qualified for the 48h therapeutic hypothermia protocol. He probably has some neurological deficits but they're genuinely unsure whether he was just always like that. Part of the "like that" is that he cannot seem to restrain himself, now that he's off the ventilator, from making extremely awkward off-color jokes at the female nurses, which is why he's been relegated to the room furthest from anything. And possibly why, on a shift with a dearth of male nurses, he's been assigned to Candi, who (maybe as a personality trait she developed to cope with her name) thinks this is hilarious. 

That's a reassuring lineup, actually!

Gianna is one of the most experienced nurses on the unit. She probably won't step in to help with 202 unless there's an emergency - she and Mayumi have the "old-school" work style that involves less asking for help but also less bouncing around the unit offering it - but if there is an emergency, she'll be there, and she's right next door. It's usually the case that a nurse assigned to 204-206 should be assumed less available to help the rest of the unit even if their patients are stable, but Candi is one of the more extroverted staff; Marian is usually content to chart in the corner, when she has hallway patients, and has to coax herself back to the nursing station, but Candi will get lonely and come chart where she can see everyone. And, of course, Adele was in the training cohort with Pascal as well as Marian, and there's a longstanding informal agreement that they'll help each other out. 

Marian is going to be a polite shift report buddy for Pascal, and make sure all of his drug infusions have extra bags prepped and hung behind the currently-running bags, except the fentanyl and midazolam, which are controlled substances and in any case running at a really slow rate that should let the current bags last all day. 

(Sheeeeee also remembers at this point that she stashed a fentanyl syringe in the drawer, and swings by Nellie's rooms to show it to her before dramatically tossing it in a sharps container.) 

The lab seems to be less backed up, now, and the full stat set of labs are back at 6:43 am! Which Marian finds out by repeatedly refreshing, rather than via a phone call, because nothing is actually abnormal enough to fall into the critical range! 

Hematology: white count is now more dramatically elevated, at 18 (normal cutoff is below 11.) Hemoglobin is down to 8.1 g/dL, low but not in the critical "transfusion immediately" range. His platelets are now a touch low as well. 

Electrolytes: potassium at 3.0 mmol/L! Not a lot of progress, but no longer quiiiiiite low enough to trigger the phone call. Phosphate is back in normal range, magnesium is at the upper end of normal range. His sodium is for some reason down to 129 mmol/L, which hints at some pretty shocking salt losses and/or free water retention, given that Marian checked and he got, like, four amps of (sodium!) bicarbonate in the OR. Kidney function, measured with urea and creatinine, is still apparently normal. 

Liver enzyme panel: a couple of the tests are now mildly off. Nothing drastic. (Yet). 

Clotting factors: mildly but systematically off, which is new. Dr Sita also added a troponin, to check for cardiac muscle damage. It's very slightly elevated - in context, probably not particularly indicative of a blockage in his coronary arteries, and more to do with the repeated v-tach episodes and general increased load on his heart, especially during periods of low O2 sats.

C-reactive protein, measuring inflammation, is markedly high. Creatine kinase is quite high, hinting at extensive muscle damage, but apparently it's either not critical or this test doesn't have a "critical" threshold. 

Lactate 3.5, which is still technically abnormal but barely counts as ICU standards. 

Those are not great labs and Marian is not delighted about it. She is especially undelighted by all the things which are abnormal now when they weren't before. There's not a ton to be done about it, but she's going to go tell Dr Sita anyway.

Dr Sita is PROFOUNDLY UNSURPRISED. He'll put in orders for four more 10 mmol bags of potassium and another electrolytes panel in fourish hours once those are done. They should try to minimize free water intake at this point, but most of the guy's drugs are in saline, he really should be getting plenty of sodium and 129 isn't low enough yet to justify supplementing it separately. He'll put in a standing order to repeat the troponin if the patient does any more episodes of ventricular tachycardia or other arrhythmias. 

...He'd like Marian to check a ferritin level. If that's normal, they'll make a decision at rounds on whether to transfuse another unit, but one explanation for the electrolyte imbalance and low sugars is if the guy had a generally inadequate diet, and Dr Sita wants to be more aggressive about transfusing him if his iron reserves are low. 

That makes a lot of sense. It won't be back on her shift but Marian can send it now and make sure to include the reasoning in her report. 

Aaaaand then it's 6:55 am. Time to do a final pee measurement in both rooms and empty the catheter bags, do a final review to make sure she actually hit all her charting, and then wait for day shift to trickle in! 

At 7:03 am, a startled shriek from the direction of the nursing station summons most of the people currently ambient on the unit, including Marian. 

...Someone has APPARENTLY taped up the cursed goat drawing beside the little pharmacy cubby for 202, where it's not visible from outside the med room but anyone walking into the med room will come unexpectedly and directly face to face with it. 

Gianna is displeased about this! "What is that thing? Why is it -?" 

"If certain allegations are to be believed, the thing nearly killed a man," Dr Sita says, completely deadpan. "You'd better keep an eye out unless you too would like a pound of flesh debrided from your horrifying wounds in the OR." 

"What?" 

....Presumably Dr Sita is making a joke out of this? Marian is, uh, abruptly feeling kind of unsure exactly to what extent Dr Sita is joking.

Her brain is way too out of brain juice to deal with the ambiguity. She's...just going to edge quietly away from the nursing station and over to her desk outside 201 and 202. 

Pascal is there at 7:07 am, looking very freshly-showered. (He works out at the gym most mornings before his day shifts.) He swings past the assignment whiteboard, frowns unhappily at it, then stops by Marian's desk-station before dropping his bag and coat off in the staff room. He peers into the dim-lit interior of 202. 

"- Oh, wait, that's not the lady from yesterday. That's a relief–" Pause. "Should that be a relief?" 

Wait huh what oh right Marian did start her shift with a totally different patient in 202, her brain has just apparently managed to completely flush that information over the last eight hours. 

"Overall I guess he's probably less doomed?" Ugh did she actually just say that out loud. "Young guy. He's - complicated, though. Want a head start on report? Um, after you drop off your stuff, sorry." Usually the full-unit brief standup report is at 7:15 and the nurses disburse to take individual reports after that, but she has a feeling that a full and complete report on Lionstar is going to take...a while...and she wants to go home. 

"...Yeah, okay."

And he'll be back three minutes later, pulling over a second wheely chair. As usual he's carrying his fancy clipboard/binder, the kind where you can pin a sheet to the front and have the inside full of reference material. Unlike Marian, who just grabs blank printer paper and populates it according to a vaguely standardized schema, he uses photocopies of a daily worksheet from one of their nursing clinical rotations, and prints one of the patient name-date-medical-record-number stickers to label it. 

"All right, I'm ready." 

Pascal gets stressed out by reports that don't go in the Standard Order they learned in school, or at least with everything neatlygrouped into categories that match up to the ones on his sheet. He doesn't complain, of course, but getting a chaotic report slows him down because he needs to spend half an hour in the chart filling his paper out properly, and Marian doesn't want to do that to him. (Or to Lionstar.) 

Uuuuunfortunately her report is going to be kind of nonstandard from the start, given how nothing about this situation is normal. 

"He's in the system as John Doe, we don't have an ID, but his name is - uh, I have no idea how to spell this, sorry, but the kid who arrived with him and might be his daughter pronounces it 'Lionstar.' She goes by Sashy." She'll give Pascal a second to write down some kind of transliteration of that; his printout does actually have a box for 'patient's preferred nickname'. "Age is down as 50 in the system but that's presumably a wild guess and I think it might actually be high." Especially if the kid is in fact his daughter. "Medical history is - we've got basically nothing, sorry. Demographic history - there's a good chance he doesn't speak much or any English or French, the kid doesn't seem to know a word of either. He hasn't been conscious enough yet to tell." 

Pascal nods. He writes "Sashi, ?daughter" in the 'family members' box. "Admission diagnosis?" 

Unfortunately DEEPLY UNCLEAR. "Uh, originally it was suspected organophosphate toxicity, I think, but it's - complicated. Abdominal wound and suspected toxicity from some unknown horrible substance with, uh, cholinergic and also necrotizing properties." 

Pascal looks pretty unnerved but writes all of that down very carefully!

"...I feel like I should have questions but I don't know what questions yet, sorry." 

"Yeah it's, uh, kind of messy. He was brought into the ER last night around 22h00, a trucker found him collapsed and bleeding from a laceration on his torso, out on some industrial park road, and the kid yelling for help. He was semiconscious with stable vital signs when they first picked him up, apparently, but deteriorated to GCS 3 en route, hypotension and respiratory distress, and then coded - uh, briefly - pretty much right as they got to the OR."

Glance down at her sheet, not that the part she's recounting is even written down there.

"I went over for the code - they intubated him and got spontaneous circulation back but he was pretty bradycardic, and hard to ventilate, pretty severe bronchospasm. Also hypothermic at like 33 C. Uh, I helped out for a while and then went to check with Chantal if 202 was ready to admit him, and went back a bit later with Dr Sharma. He was having, like, massive diarrhea, and went really brady again when we tried to turn him, atropine helped a bit. They were still having trouble with sats, he was really tight and full of secretions, and Dr Sharma looked at that plus the bradycardia and diarrhea, and flagged that it fit with cholinergic toxicity. I think her top guess at the time was that he'd ingested organophosphate insecticide, maybe deliberately. We tried giving more atropine, that helped a bit more, and then moved him over. - uh, the ER doctor also cleaned and stapled the laceration, dressing was clean and stuff at the time." 

Pascal gives her a suspicious look. "...You're saying that like it's some sort of clue and I don't like it." 

"...Sorry. Uh, anyway, things were pretty hectic for a while - Dr Sharma called poison control for advice and they suggested huge doses of atropine, the protocol is literally 'give double the previous dose every five minutes until it kicks in' - we got up to a bolus dose of like 20mg before it helped much with the secretions, and he'd have had nearly 50mg in total over the last hour and a bit by then. We had to send a weird diagnostic test to the General by courier - uh, let me look that up, it was for plasma cholinesterase activity, I don't have anything on a timeline for it but I'm guessing they'll call? We started an antidote called pralidoxime - uh, it's running at 8 mg/kg/hour for a weight of 63kg, we can check it together - and we were running continuous atropine at 10mg/h. He got a few boluses - um, I need to check this - uh, three liters total by then, he's had like seven liters of boluses by now." 

Marian is starting to wish she had gone back in the charting and made a timeline, her memory of what happened in what order is starting to get iffy. "Uh, at some point around then the initial labs from the ER came back with a bunch of critical results - phos, mag, potassium, were all critically low, and his glucose was at like 39 - 37 on a bedside check - which was bizarre, it took like three amps of D50 to bring it back up. We started electrolyte replacement but he barfed up the potassium elixir so had to switch to IV." 

Pascal has flipped over to the blank back of his paper and is frantically writing bullet points. “How do you spell the antidote drug?”

“P-R-A-L-I-D-O-X-I-M-E.” Marian fiiiinally has that properly in her head. “Uh, I’m trying to remember if anything else - I might be totally forgetting a thing, sorry. I know I had him off norepi entirely at one point and that was before stuff happened…”