Marian can do that. It involves MULTIPLE STEPS including logging onto the computer and manually finding the patient's John Doe record and checking the medication history, which takes long enough for the blood pressure to come up at 54/35. 

At which point a lot of residents would snap at the nurse to hurry, but Dr Sharma is pretty sure that Marian is already hurrying. 

She investigates the IV pumps instead. "He's on a norepinephrine drip too, I can go up on– ...he's got a dopamine infusion too? I don't know who– nevermind. Marian, can you see if there's a note on which one we should titrate up first?" 

Tsashi is pretty unsure what's happening, but she can pick up that, one, Lionstar looks worse again, and two, both of the foreign Healers look surprised about it. The combination is stressful! She wants to ask what's wrong and she can't and it's very frustrating. She hovers close to Lionstar instead. 

Marian would prefer to do one thing at a time but she scrolls up to the continuous IV medication section. "I don't see a note." She's also confused about why you would have a patient on both a medium-dose norepinephrine drip and an equally mid-range dopamine drip, but it's really not the weirdest way they do things in the ER. "Uh, I think dopamine increases heart rate more, right?" 

Back to atropine dosing... 1-3mg q30min as needed for a heart rate below 40 or significant bronchospasm, last dose was at 22:47, it's now 23:16, good enough. She leaves the computer logged on and makes a run for the Pyxis. 

When she gets back with a syringe prepped, Dr Sharma is busy examining the patient's pupils with her penlight. (And being watched by a curious twelve-year-old.)

"This looks like cholinergic toxicity," she says thoughtfully. "Sweating, increased salivation and secretions, bronchospasm, bradycardia, pinpoint pupils – even the diarrhea, he hits everything on the list. And he's responding to atropine, but it seems to take a large dose. Did you prep the full 3 mg?" 

Ohhhhhhh. Marian feels incredibly stupid for failing to put that together...except that she's pretty sure she hasn't had cause to review those symptoms since nursing school, and actually she's still blanking on what drugs are associated with it. Altzeimers' medications, maybe? That seems...implausible, in this case. 

She digs out an alcohol swab to clean the IV port before plugging her syringe into it, trying to remember how slowly you're supposed to push atropine. Over thirty seconds is probably fine, right, she really doesn't feel like taking forever about it.

"...What could be causing that?" she says, when another ten seconds fails to produce any answer in her brain. 

"Organophosphate insecticide poisoning is common in India. People use it for suicide attempts." Shrug. "Nerve gas has the same effects. And muscarinic mushrooms. The tox screen won't check for any of those."

Are you fucking kidding, if her patient got nerve gassed then Marian is– actually she's not sure what reaction is appropriate to that. What the fuck. Probably a suicide attempt is more likely than that, except she has no idea how to fit it together with the kid's explanation of what happened. Maybe the paramedics completely misinterpreted her Charades and actually the patient cut himself? ...She has no idea and it's probably not productive to stand here wildly speculating. 

She gives the full syringe of atropine, slowly, and flushes it with two syringes of saline to make sure it's really definitely in, and bumps the monitor for another blood pressure. 

The patient is back to looking pretty awful! He's soaked in sweat again, practically dripping with it, his color an unpleasant blend of ashen and blotchy. The ventilator is getting better volumes now that he's flat again, but still only around 400ml per breath - not a lot for an adult man - and his sats are now at 82%, on 100% oxygen and moderately high ventilator support. 

Blood pressure comes back at 77/54. His heart rate is back up to 52 and reasonably regular, and there are P waves, but the complexes almost look weirder than before. It's hard to tell if the QRS spike is as drastically widened as it looks or if there's just something going on with the QT interval. 

Both of those would be concerning! Prolonged QT interval means he's at risk of randomly going into ventricular tachycardia, which is the last thing Marian needs in her life right now. And it's not just that it's too long, it's– ohhh yep that's an inverted T wave, a downward swoop instead of a neat upward bump. Which Marian's brain has tagged as possibly related to some kind of toxicity, so maybe it's that? 

She hits the blood pressure button again. Poor man's arm is getting squeezed off, not that he's anywhere near conscious enough to care. "- Should we get an art line if he's going to keep doing this?" she says to Dr Sharma. 

"He needs a central line too, we're running pressors peripherally." Dr Sharma grins briefly. One of the few upsides of a week like this one is so many opportunities to practice line placement. "I'd rather do both in the unit. And I want to call poison control, find out what tests we can run and if there are supportive treatments it's worth adding before we have confirmation." 

The patient's blood pressure pressure back at 93/67. His sats...still aren't really rising. 83%. 

"He's probably full of secretions." Dr Sharma reaches for the suction tubing. 

She's not wrong. The suction is making the worst sound in the world, and the patient is leaking saliva all down onto the pillow. WHY is there apparently a kind of poisoning that CAUSES saliva disasters??? Arghhh. And there isn't actually a second set of suction tubing hooked up, so she can't have a go at it in parallel. She settles for wiping up what she can with a towel. 

The patient still doesn't have much of a cough reflex. His heart rate dips again while being suctioned, but briefly and less terrifyingly, and clearing out some of the secretions does seem to help. The O2 sat reading starts creeping up again. 

Dr Sharma waits until it hits 90%, and the new blood pressure reading is above 100 systolic, before sighing and donning a new pair of gloves. "I think we can risk turning him. Maybe have a pile of towels ready, if he doesn't tolerate it then mop up what you can and put a dry towel down. He's pretty fragile, I don't want to push it." 

Marian is so in agreement with that! 

The patient tolerates it a lot better this time, though. Marian is in a hurry and doesn't try that hard to get him completely 100% clean – which is a job that would call for proper soap and water, now that she's paying close attention she's noticing that he's very grimy. Not really homeless-person grimy, though she's not sure what feels different about it exactly? More, like, vaguely reminiscent of her childhood and the kind of grimy you get four days into a camping trip? 

- she can wash her patient properly LATER, once they know what's wrong with him and can be sure he's actually stable. For now he gets a hasty wipe-down before she wads up the soiled sheet as far under him as she can reach, pads it with several towels so it won't leak on the new sheet and incontinence pad, and then puts those down and helps Dr Sharma turn him the other way. 

They're just finishing up when the ER nurse finally gets back with a squeeze bottle of activated charcoal and a gastric tube. "Hey. Did you still want this?" 

Dr Sharma is looking increasingly antsy. "- We'll do it in the ICU. Can you find RT and help transport? I'd like to go ASAP. - Marian, can you see if any labs are back while we're waiting for RT?" 
 

Marian can wash her hands hurriedly and then do that. 

The kid follows her and peers over her shoulder, staring curiously at the computer screen. 

The kid is so sweet and interested, and Marian is all out of reassuring smiles right now. She does her best, and manages not to growl at the computer for having logged her out in the last five minutes, and hammers her password in again to look up the patient. 

...Hematology is back. Hemoglobin and hematocrit are a bit low - well, he did lose some blood - and everything else is in normal range. It'll probably look worse on repeat labs, Marian thinks, trying to reconstruct the timeline in her head - this would've been drawn before they got IV access and fluid resuscitation started. The blood gas is listed earlier, and is indeed VERY AWFUL: critically low PaO2, and both high CO2 and low bicarb causing a combined metabolic and respiratory acidosis and a blood pH below 7. Not very surprising, though, it was drawn shortly after the dude coded. 

Electrolytes and lactate and urea/creatinine and tox screen are coming up on the screen, but still displaying as PENDING.

She heads back over to rejoin Dr Sharma at bed 2. "Hemoglobin's lowish, that's all that's back." 

"Hmm. I'll want a repeat in a bit, he really needs the oxygen capacity. But let's wait until he's topped up on fluids, I think he'd benefit from another bolus." 

The respiratory therapist sticks her head in the door. Dr Sharma waves. "Let's go!" 

The ventilator and IV pumps add some unwieldiness to transporting the patient, but four people is enough to manage it and steer out into the hallway without too much trouble. Marian catches the kid's eye to smile reassuring - well, hopefully reassuringly, she's not entirely sure what her face is up to right now - and gesture for her to follow them. 

They're going somewhere else?? Tsashi has no idea why they're going somewhere else in the huge daylight-building, and whether it's a good thing or a bad thing. She's really quite sure at this point that the people here are Healers and trying to help, but she's never been in a huge daylight-building for Healers with powerful magic and has no context on why they might go to a different part of the building. Maybe it means Lionstar is doing better, but maybe it means he's doing worse.

The novelty of all the powerful magic around her is starting to wear off, and it's increasingly frustrating and stressful that she can't understand anything anyone is saying and can't ask Lionstar to use Mindspeech and has no idea when - if - she'll be able to ask Lionstar for anything. Tsashi is not going to cry, because she isn't little anymore and it won't help, but she slightly wants to. 

She follows the Healer.