Diel cannot figure out what language this is, or even what language group this is. She gets impatient after not really very long. "I'm going to call in an expert," she declares vaguely despite not knowing who'd be an expert in that. Not her, anyway.

"Yeah, that makes sense." Pascal is distracted. He wonders vaguely if Marian knows a linguistics expert; Marian knows a surprisingly wide range of people on the Internet. It's a Friday morning, though. Marian won't be back until 3:30, and counting on being able to solve this problem between 3:30 and 5 pm on a Friday afternoon sounds doomed, even aside from how it would be kind of a dick move to drop another thing back on Marian's plate. Maybe there's actually a system for this and Diel will make a phone call and solve it? ...Pascal is not incredibly hopeful about that but maybe. 

The fancily-dressed person is impatient with her?? This is actually pretty stressful, on top of all the other...everything...but it doesn't feel like it would help for Tsashi to look upset about it so she tries not to. 

(It turns out that she hates feeling helpless. She isn't used to it, which is in some sense a very strange thing to notice when the village and its surroundings are so much more dangerous than this place seems to be, but - it's a danger she understands. It's a place where she knows how to think like Lionstar thinks and make plans, not as well as Lionstar obviously but she still knows how things work. It's upsetting to have everything depending on strangers who she can't talk to, especially when they seem kind of irritated about her existence. It's not that confusing why – this probably is a bizarre messy problem for them, probably not very many people manage to get here at all from the storm-changed lands, when most people aren't mages and most mages don't know to Gate and the mages who do know how know why it's nearly always a bad idea. It's probably not surprising that the people here are confused and don't seem to know what to do about her. 

Lionstar would know what to do. But Lionstar isn't here, not really, and Tsashi is trying very hard to be brave about that but it's not getting easier.)  

...If the fancily-dressed person isn't talking to her anymore then she's going to eat more of the food. (Still with her hands.) 

It's now 9:35 and there's movement in the hallway! The rounds team is approaching, pushing computers-on-wheels like some kind of large mobile creature. It's a a particularly big-crowd day – there are two med student hangers-on, and the respiratory therapist and dietician each have a new trainee shadowing. 

Dr Sharma looks harried and incredibly tired. She sticks her head into the room. "Everything all right? Can we start rounds?" 

"Uh. Yeah, I think so." Nervous glance at Lionstar's blood pressure, which seems to be behaving for the moment but Pascal does NOT TRUST IT. He smiles at Tsashi and slips out into the hallway. 

That's so many people!!! Tsashi gives Diel a worried look and tries to wiggle herself and the chair a bit closer to Lionstar, but the lure of food keeps her where she is. 

Dr Sharma clears her throat. 

"Right. Uh. 202 is our John Doe admit from last night. Age estimated between 40 and 50, no info on medical history. Current diagnosis is, uh, wound necrosis and probably-cholinergic toxicity from something venomous pathology results pending." She rubs her eyes. Clears her throat. "Main events overnight, he arrived in respiratory failure with decreased level of consciousness. He was showing classic symptoms of cholinergic toxicity - difficult to ventilate with unmanageable bronchial secretions, bronchospasm, severe bradycardia and hypotension with cardiac conduction abnormalities. Also diarrhea and vomiting, I guess. Barely any response to epi, he improved a little with standard atropine dosing. We didn't know the wound was an issue at that point so the ER doc got it stapled and dressed. Once we had him stable enough for transport to the ICU, I called poison control and got their atropine dosing advice for suspected cholinergic toxicity. We doubled the dose every five minutes until we saw a significant improvement, which was after about 45 mg total." 

The pharmacist whistles. "It's a wack dosing protocol, isn't it? ...Pretty much confirms the toxicity diagnosis, I think. Pretty sure normal people are dead after that much atropine." 

Well that's morbid and upsetting! ...Pascal doesn't say anything. People are allowed to be morbid and upsetting at rounds, it's sort of unavoidable working here. 

Dr Sharma clears her throat.

"Yeah. Anyway. Initial lab results were pretty concerning - significant electrolyte imbalance, critically low mag, potassium at 2.8, and his initial blood glucose was 39 mg/dL. Severe metabolic and respiratory acidosis, unsurprisingly, we've been firefighting his pH all night. Hypoglycemia was surprisingly recurrent as well, we're not really sure what the deal is with that, it's not an expected side effect of - well, this probably isn't organophosphate toxicity after all but we're sort of using that as an approximation. We've really been chasing after his potassium too, but that's less surprising given GI losses– ...I'm skipping ahead. Other overnight events. We had a couple hours of peace and quiet where he seemed to be coping okay on atropine and pralidoxime, and then around 2 am it got to be really obvious the wound was a problem and we took him to the OR for debridement. He was very unstable under anesthesia and lost a lot of blood - 1700 ml estimated - but we removed 700g of dead tissue and managed to get him back here. He has a wound vac dressing to closely monitor drainage and encourage healing, so far - fingers crossed - everything looks okay and we're hoping we got all the nasty stuff out." 

Dr Sita has been sitting in a wheely chair with his feet up on the computer desk. "Well, as long as the demonic goat doesn't come back to finish him off. Keep an eye out, folks." 

One of the med students makes a sputtering sound, but puts a hand over her mouth and doesn't interrupt. 

Dr Sharma coughs politely. "Aaaaanyway. Most recent labs from 6 am - mag and phos back in normal range, potassium up to 3.0 but still a ways to go, sodium was down to 129, we're minimizing free water intake and monitoring. Hematology isn't great, white count is up to 18 and hemoglobin down to 8. Some new abnormalities started appearing – platelets and clotting factors both a bit low, troponin is positive, liver enzymes are up. C-reactive protein is really high, he's clearly having a massive inflammatory reaction - too early to tell yet if it's just the wound and being cut open or if there's an infectious process too -" 

She consults her notes and goes methodically through Lionstar's current vital signs - tolerable only with a lot of support - and ventilator settings. Backtracks to mention the seizure incident, though she adds hopefully that it hasn't happened again. "Neurologically, he's clearly altered - he's been on minimal sedation the entire time, except when he was getting anesthesia, and his GCS is maaaaybe 6 or 7 - but he is responding a little, which is a good sign."  

Dr Sita gets up. Somewhat to Pascal's surprise, he smiles reassuringly at the line of nervous-looking med students. "Don't worry, I'm going to leave out the pop quiz on his treatment plan, that would be cruel and unusual for this guy. As I'm sure you've picked up on, this is a disturbing case and our biggest problem here is that we have no idea what the fucking hell happened. But! We've stumbled our way to supportive treatment that seems to be keeping him tolerably stable while we figure the rest out. This is an important teaching moment - no, really, it will happen that you admit someone and have no idea what the fuck is wrong with them, and it's okay, you just focus on the basics and hope to get them stable enough to buy time to figure the rest out. Which, right now, means we're waiting on pathology to hopefully tell us what the fuck. - and my understanding is that social work is working on getting an interpreter for the kid, who can hopefully give us a less baffling rundown on the history here once she can use her words. Yeah?" 

...There are nods. Nervous ones. 

Brisk nod. "And, in the meantime, we dot all the i's and cross all the t's we can. Pharmacy? It's been a wild night, please do fill us in on any basics we missed."

The pharmacist consults the computer screen. "...No home meds but nothing we can do about that. We've got nothing for DVT prophylaxis, but it sounds like it's contraindicated to anticoagulate him? I'll put in an order for compression stockings, that should be safe. I don't see any bowel protocol orders, but it sounded like we'd rather he pass less stool - I can look into whether Imodium as-needed would be safe to combine with his other meds?"

She scrolls down further. "Nothing for ulcer prophylaxis, and that I think we should be covering. ...IV pantoprazole daily is associated with a higher risk of MI and his troponin came back positive, but the current consensus on the mechanism of risk is that it reduces efficacy of common cardiac meds. He's not on any. Thoughts?" 

Dr Sita rubs beside his nose. "He's not. And he's a young guy, I don't think we have any reason to suspect coronary disease. Navya skimmed over some of our adventures last night – he coded in the OR and was down for seven minutes, I think that and all the repeated episodes of V-tach are more than enough to explain the troponin. And he's got to be at increased ulcer risk, cholinergic toxicity causes excess gastric secretions along with every other type of secretion he really doesn't need. I'm comfortable starting him on pantoprazole daily." 

Dr Sharma shuffles her notes. "I would feel a lot more comfortable if we could do more to minimize his risk of arrhythmias, or at least have a PRN on hand if he starts popping a lot of ectopic beats again. It's at the point where the nursing staff are avoiding moving him and that's obviously not sustainable. Poison control recommended pushing his mag to the high end of normal while his potassium was uncorrected, and he got amiodarone in the OR, but I'm not sure he's in good shape to get more of either, it really tanked his BP and he's still nearly maxed on norepi right now. Uh. Any ideas for something he might tolerate better?" 

The pharmacist looks uncertain. "...Honestly, I'm not sure. I want to minimize the risk of drug interactions, he's got enough going on already, but I see your concern. I can quickly look into our options?" 

"Sounds good to me. Anything else on the drug regimen?" 

"...I'll review the chart in more detail after rounds, I, er, haven't had a lot of time to catch up. ...Is his pain control adequate? Might be worth putting in a consult for the pain management team now, try to at least get some standing orders before the weekend." 

Before the– oh right it's a Friday. Pascal had honestly completely forgotten both the day of the week and that it had any significance whatsoever. He has to be back tomorrow same as usual. 

"Go ahead." Dr Sita swings his feet down and spins the chair around, lacing his hands between his head. "...I'm wondering if he'd tolerate continuous dialysis, if we weren't trying to take fluid off. There was an article that thought it might be beneficial in some poisoning cases, aaaaaand it's definitely on my mind that we don't know what he's got in his system and for all we know it's slowly dissolving his organs from the inside." 

Aaaaaaaaaaaaaaah!!!! Pascal did not need that mental image right now. Also Pascal is technically trained on dialysis and technically already 1:1 but aaaaaaaaaaaaah he really doesn't feel like he needs another THING requiring constant management. ALSO it'll definitely freak out Sashi. ALSO ALSO Dr Sharma is looking at him aaaaaaaaaaaaah. 

"I'm - not sure?" he says uncertainly. "His BP is pretty soft and he's nearly maxed on norepi, and Marian was worried the dopamine makes him more prone to arrhythmias..." 

"Hmm. Thing is, I'm concerned we should be seeing more neurological improvement with the pralidoxime and I'm not sure we've seen any. ...We'll come back to it." He turns to the dietician. "Any thoughts? We're not feeding him, and I'm not sure we should start while he's still got this much stuff going on, but I think it's fair to say we've got concerns about his nutritional status. - The kid too but she's not your patient and it looks like she got some breakfast." Smile and wave at Tsashi.