"No kidding. He weighs 63 kg? I'd like to measure him for his height, to start, and have a peek, but with that plus the low albumin on admit - and I saw you ran a ferritin and that's low - and the recurrent hypoglycemia, I'm definitely worried he came in undernourished and might be deficient in all sorts of things. I agree we'd better hold off on starting feeds until he's a bit more stable, but I'd like to run a lab panel for other micronutrient deficiencies, we can at least supplement anything we do find. And I'd like to order an iron infusion now, unless pharmacy thinks that's contraindicated?" 

     The pharmacist clears her throat. "I don't think so, but I'd like a minute to check, I'm - we don't see a lot of organophosphate poisoning here, and whatever he's got going on is more complicated than that anyway." 

"No worries. It's not incredibly urgent." Glance at Dr Sita. "Sounds like he lost a lot of blood in the OR. Did he get any transfusions?" 

"Couple units, yeah. I've been going back and forth on ordering another bag, we wouldn't normally transfuse for a hemoglobin of 8 but - you know what, on further thought I think I will. See if it gets his BP up enough to feel comfortable trying him on CRRT, and maybe we can at least dilute the amount of blood in him that's full of demons. Lab panel for weird deficiencies sounds good, I'm fine to run an iron infusion if pharmacy okays it, anything else?" 

     The dietician does not have anything else at the moment. 

"Respiratory therapy? Anything we need to change?" 

Pascal is now feeling awkward about not having spotted the ferritin result coming back - apparently lab didn't call for it so it can't have been that low? - and also SHIT did he do a blood sugar at 9, he's pretty sure he didn't and now he's 45 minutes overdue AGAIN. The glucometer is...somehow still on the counter, maybe the other nurses are being generous to him because they know his patient is 1:1 and critical. If so he really appreciates that! He will try to sidle into the room and pull a teeny bit of blood from the art line in a 1ml syringe to discreetly check. 

He's able to do this without disturbing Lionstar. The blood sugar comes back at 87 mg/dL. 

The respiratory therapist looks unhappy. "He's hard to ventilate. We managed to wean him down to 75% O2 over the last few hours. He's on pressure-control mode with a set rate of 20, inspiratory support pressure of 22, end-expiratory pressure of 14. I think it's working better than volume-control, peak airway pressures are lower and he's usually hitting tidal volumes of 500ml, but," shrug, "he's not tolerating suctioning incredibly well and we were told to minimize stimulating him - and we're not moving him, which is what would help with recruiting more lung fields - so that's really our main problem here. I think we're right on the edge of underventilating him, and he'd be better off if we could push his CO2 lower, but he's been on high vent pressures all night and he's already at risk of barotrauma. We've been fiddling with the inspiratory-expiratory times and can probably get that a little more optimized, but it's not really solving our underlying problem." 

Nod. "Why doesn't he tolerate suctioning?" 

Another shrug. "He's under-sedated for it, I think? He's too weak to get really combative but he's definitely feeling it. And he desats fast even if we boost him to 100% first. His lungs are still irritable, poking them seems to worsen the bronchospasm and airway compliance. And the night RT told me to be careful of setting off arrhythmias." 

"Checks out. I'm hoping we can afford to be less cautious about disturbing him once his K is up to normal range, we should know before noon." Glance at the pharmacist again. "Any ideas on sedation? One thing we're worried about is his seizure threshold, and I know the recommendation for organophosphate poisoning is to control seizures with benzos rather than anticonvulsants, but he hates midaz." 

"Hmm. He might tolerate Valium better? Tends to cause a bit less cardiovascular depression. We don't normally give it here what with the long half-life, but could try a small dose, see if his BP handles it." 

Brisk nod. "Let's do it. We can start with, hmm, 1 mg IV, we don't want him snowed for the next two days." Dr Sita glances around, somewhat impatiently, and then stands up. "Great. Navya, let's go have a look at him." 

He sanitizes his hands at the door, grabs gloves from the wall dispenser, and forges into the room, nodding tersely to Diel and managing an actual smile at Tsashi, before going in to pull back the Bair Hugger blanket. 

Lionstar's temperature is at 36.8 C but he's still not at all all a fan of having the warm blanket taken away! He grimaces forcefully and seems to be trying to lift his head off the pillow, his neck muscles tensing fruitlessly. 

He's even more unhappy about it when Dr Sita pokes at the dressing site. 

"Sorry, buddy." Dr Sita whistles. "Don't think I commented before but that's one hell of a farmer's tan. Wonder if he does manual labor." Frown. "- And just came up with the kid from South America or someplace it's not the middle of winter. Poor guy. - dressing site looks fine, at least, that's a good sign." He peers at the fresh drainage in the wound vac canisters. "Stuff coming out doesn't look full of demons." 

He turns around to address Diel, and his eyes land on Tsashi's eyeball drawing, pushed to one side of the table while she eats.

Tsashi is licking scrambled eggs off her fingers and watching him with wide eyes. 

"What the heck." Dr Sita picks up the drawing and glares at it. "Eyeballs. Why. The last thing this case needs is eyeballs." 

One of the med students is hovering. "Is it meant to be one of those biblically accurate angels?" 

"One of those what?" Dr Sita scowls and puts the drawing down. "I don't know and I'm not sure I want to know. What's it going to be next, space aliens, I do not need this today." 

He smiles at the kid again, who seems kind of alarmed by all the scowling, and then actually looks over at Diel. "Thanks for coming out, we really do appreciate it. Sorry it's all so," vague handwave, "like this. Any updates? What's the plan for the kid? Also it really would be great if she could tell us more about what happened to him, any progress on sorting out an interpreter?"