Huh. That's got to be a good sign. ...Also he's not on any sedation whatsoever and they should plausibly at least have something ready to go. And bother to put some wrist restraints on him just in case. They would have serious problems if he pulled out his ET tube now. 

Marian doesn't really think he's conscious enough to hear her, and who knows if he speaks any English, but she reaches for his hand anyway. "Hey," ugh damn it how did Sashy pronounce his name again, "- hey, Lionstar. You're in the hospital. My name is Marian and I'm your nurse. Can you open your eyes?" 

Nope. No further reaction of any kind. 

Well, that's not spectacularly surprising. Marian will finish cleaning his face, and suction his mouth again, and then the clock hits 23:39 and it's time to slowly push an entire 20 mg of atropine into him. She does it into the bolus line, so it'll be automatically diluted, and over an entire minute. 

His heart rate, which fell back to the 90s after Nellie stopped the dopamine, immediately shoots up to almost 140, though only for a few seconds before it starts slowly settling back down. His color is almost instantly more normal. 

For the first time, he seems to notice the blood pressure cuff inflating. He's not reacting purposefully, or moving his limbs at all, but he grimaces slightly again and he takes a breath early, before the ventilator set rate would kick in, and then very weakly coughs. 

(Clear-white foamy secretions bubble up in the endotracheal tube.) 

Blood pressure 147/102. 

Wow! Marian is very proud of him and also he does not need to be 75% of the max rate of norepinephrine. She'll drop it by a decent increment and watch his blood pressure. The new bag of fluids is about halfway done (though it really does feel like that's barely keeping up with the amount he's leaking in saliva and lung goop) and he's already gotten nearly a quarter of the 4g bag of magnesium running in the pump. 

His sats are at a glorious 98%. Better yet, he only drops briefly and to 94% when she suctions him. 

Marian turns to grin at the kid. She can't help it. "He's doing great," she says even though Sashy won't understand her. 

Tsashi is getting the idea! She smiles back. Healing magic looks surprisingly complicated and effortful, they keep bringing in more bizarre artifacts, but it's clearly helping. 

Nellie gets back with fresh sheets and two cartons of heated wipes, just as Marian is dropping the norepinephrine drip again by a smaller increment. (Lionstar's blood pressure is now at 119/83, which is a totally normal BP but higher than it strictly needs to be for adequate perfusion.) His sats are, finally, solidly at 100%. 

Nellie grins as well. "Look at him go! Let's get him clean before it wears off. The atropine should start to calm down his GI tract at some point..." 

"I really hope so." It's awkward having to repeatedly clean him up in front of the twelve-year-old (but it feels even more awkward, and probably upsetting for the poor kid, to kick her out of the room for it), and Marian is kind of worried about how much of the potassium they just got into the guy is now coming out the other end. 

She carefully turns Lionstar toward her, trying to arrange the Bair Hugger so it's still covering at least some of him. 

He tolerates being moved about 500% better than the last time they had to do this; his heart rate barely budges from 120, and his sats dip a little but stabilize at 95%. 

When Nellie bends and lifts his upper leg to clean him, though, he coughs weakly again and then vomits on Marian's arm. 

Auuuuuughhhhhhhh! 

(Marian is, to be clear, not at all bothered for her own sake. It's not even particularly gross puke, it's mostly clear liquid, and his airway is protected. She's upset because that was the POTASSIUM that he was supposed to be DIGESTING and now they'll have to give it IV at a max rate of 100 mEQ/hour and it'll take, like, the next four or five hours to get him up to normal range, or maybe MORE than that if he keeps LOSING BODILY FLUIDS.) 

She make a frustrated noise and grabs for the oral suction. 

Nellie grunts, unsurprised. "...At least he held it in for, like, fifteen minutes. Maybe he got some of it." She wads up the soiled sheet under a pile of towels and darts over to the wall to grab a handful of sani-wipes to use on the waterproof mattress surface. 

And just getting his magnesium up will help even if it takes a while to correct the potassium - and he hasn't done any arrhythmias yet - the monitor tracing actually looks a lot more normal now, though the T waves are still inverted and generally weird-looking. Probably they should do a proper 12-lead ECG at some point? Marian doesn't think that they actually, uh, got around to that at any point. 

She helps Nellie turn the patient back over onto his clean sheets and finish making the bed. 

He's still not noticeably shivering, but he's warming up! Finally back up to 33.0 C, so, well, nearly caught up to the temperature he was when Marian first checked it in the ER. He's taking lovely deep breaths, getting volumes of over 700 mls on the ventilator, and once they get him on his back again with the head of the bed slightly raised, his sats leap back to 100%. His blood pressure is a perfectly respectable 108/67 on only 25% of the max dose of norepinephrine. 

Nellie helps tuck the Bair Hugger Blanket up to his chin. "Great. ...I should really get back to my folks, but I'll do a walkabout to see if I can track down Dr Sharma. She might've gotten waylaid by Annie's transfer." 

"Mmhmm, thanks." Marian feels like she's forgetting something... oh! right! "Ask her about orders for sedation! I don't think we need it yet but I'd feel more comfortable with something prepped and ready to go, he was starting to react a tiny bit and I don't want him to wake up fighty." 

"Great plan." Nellie shoots finger-guns at Marian and then bounces over to the sink to wash her hands before heading out. 

It's 23:48. Nearly midnight. Midnight in Marian's head is deeply associated with Tasks Due but she's not...actually...sure what if anything she has to do on this patient? There are a lot of floating pending items, they were supposed to do some kind of diagnostic blood test that has to be sent to a bigger hospital to process but she needs, like, several additional pieces of information before she can do that... 

She should probably do literally any charting but that sounds like it would require having an attention span, which Marian thinks she can muster if she actually gets a full ten minutes uninterrupted to sit down and pour more caffeine into her face but she's not hopeful about getting that soon. She'll...putter, and tidy up the various mess that managed to accrue on surfaces in the room during the last half-hour. 

Nellie swings by again five minutes later. "You can do midaz for sedation if he needs it, 1-5 mg per hour. I put the order in, I'll cosign a bag with you." She holds it up. "Dr Sharma mentioned he's at some risk of seizures, if he starts seizing you can push 2mg midaz as a standing order. You'll need to start an atropine maintenance infusion now that we've hit the therapeutic dose for him. Dr Sharma's going to put it in, she wanted to double-check the poison control recommendations. - oh, and repeat lytes at midnight, was the other thing. Dr Sharma pointed out the last set was done, like, two hours ago. She thinks she'll be busy for the next bit so you can draw that and a lactate and venous blood gas peripherally. I put the orders in for you." 

"Nellie, I love you."

Marian can cosign a bag of midazolam with her. And put it in her second-to-last available pump, programmed and on standby so it's right there if she needs it. There's a trick she learned from Annie where you can program a bolus in the "piggyback" programming, and if there's no actual piggyback line attached it'll just run the main infusion at the piggyback rate until the volume elapses - she can use that with a rate of 999 ml/h and a volume of 2 ml to give a seizure-halting "push" dose, without having to actually leave the room and frantically pull one of the smaller vials from the Pyxis. 

...Aaand now it's midnight and she has to go dig up bloodwork supplies and draw blood. A venous blood gas won't tell them much about oxygenation but it'll give them information on bicarb and pH, which is presumably what Dr Sharma wants to know. 

She definitely has a feeling she's forgetting something but it's not coming to her.

The patient does not enlighten her! He's lying still under the Bair Hugger blanket. The monitor shows that his temperature is up to 33.2 C. Last blood pressure 103/59. Heart rate 97. Sats at 98%. 

Bloodwork!

...It's not until Marian is dropping the labeled bag of lab tubes for electrolytes, lactate, and a venous blood gas in the nursing station pneumatic tube that she remembers she had also been slightly worried about his hemoglobin. That's - probably not spectacularly urgent? It was barely low before - 11.9 g/dL, if she's remembering it correctly. Normal range for men is 13.5 to 17.5 but for an ICU patient, 11.9 is barely low at all. He's probably dropped a bit more due to hemodilution, after all those fluid boluses, but they don't normally transfuse until hemoglobin falls before 7.5 g/dL. He doesn't look catastrophically anemic. 

Forgetting it is definitely a sign that she's not as on top of everything as she likes to be, though. Which is how things are in emergencies, but the emergency seems to be at least temporarily over, and she should probably sit down at the computer workstation with a piece of paper and review the guy's chart to make an actual todo list, rather than bouncing from task to task as they occur to her like some kind of demented butterfly.

(And then inevitably get interrupted when Dr Sharma comes back to place the art line, but that's how it goes, it's not an excuse not to try to get on top of her shit in the meantime.) 

Marian grabs paper from the printer, heads back to the room, and smiles at Sashy before settling herself at the computer desk between 201 and 202. 

The patient's chart is, unsurprisingly, quite sparse. Name down as 'John Doe', age presumably wildly estimated at 50, nothing under medical history. There are vital signs charted from the ER, but almost no drug administration – right, it's probably all on the paper flowchart since a bunch of it happened during a code, for a generous definition of "during." The temperatures Marian took in the ER aren't charted and nothing is synced yet from the monitor. Marian can fix that quickly. Blood sugar readings also aren't charted and neither is the order to recheck every hour. Marian....can drag some of the results out of her brain, with a bit of guesswork and more guesswork applied to what time she took them, and put those in the chart. She'll recheck at 00:30. 

Lines: Nellie does seem to have documented the gastric tube and Foley. The single IV he arrived with from the ER is listed, but not the second IV Marian placed. She can fix that too. 

Wounds and dressings: the laceration was apparently cleaned and stapled and has an absorbent gauze and Mepilex adhesive dressing. Fine. Marian should, like, look at it at some point, but at the very least it hasn't bled right through the gauze or anything. 

Urine output: nothing charted. Bowel movements: nothing charted. Marian can fix that. 

Medications: Atropine doses are charted; no orders yet for maintenance dosing, that's waiting on Dr Sharma but Marian can make a note on her paper to follow up on it as well as on the diagnostic test and the...god what was it called, she'll put down "pyroxime???".

2 1L saline boluses are charted. Marian can add the third one. Dopamine and norepinephrine infusions are in the chart; Nellie must have noted when she stopped the dopamine, but the norepinephrine is still showing as running at the higher rate. Marian can at least estimate when she titrated it, based on atropine dose history, and retroactively chart that. 

Magnesium is running and will be done around 00:30. Oral potassium 40 mEQ is documented as having been administered a little after 23:30. 

Marian has a mental note that the potassium administration did not work out as hoped and they're going to need to go to IV and oh shit fuck that is definitely not, like, in any way done. She did grab a bag of 10 mEQ potassium in 100ml, but it's still in her scrub pants pocket. 

...Proooooobably she doesn't actually need to track down Dr Sharma again? They did, like, discuss this. She puts in a verbal order and - damn it magnesium is still running - she goes to the med room to get another little saline bag and primary tubing set and secondary tubing set, and jogs back to 202 to get all of that primed and set up in her last remaining pump and hook it up to the same IV line as the magnesium. And chart it. 

...Okay. Back to the computer. Marian's feet are kind of distractingly sore at this point, and she's even more distractingly hungry, but she really needs to figure out if she's forgetting anything else. 

The set of labs drawn shortly after 22:00 continue to show low phosphorus levels and medium-low albumin. 

That's...confusing? Why is that confusing. Because "organophosphates" has the word 'phosphate' it in. 

Marian...is on reflection totally unsure if that's, like, relevant. Dr Sharma didn't give her any orders to supplement phos but honestly that could easily be that she forgot or missed it, there was kind of a lot going on. It's at least much less panic-inducing than the potassium and magnesium results. She's...going to write it down on her list of things to ask Dr Sharma about.