Dr Sharma reappears around 00:15, pushing yet another bedside table with a sterile line kit on it. "Marian, I am so sorry about that. How is he?" 

Marian scrambles up. "Uh. Vitals are still decent, though I'm wondering if he's still a bit dry? He's running a bit tachycardic for his body temp and his BP is, like, okay, but that's still with some norepi. Uh, and we still wanted to recheck his hemoglobin, I think. ...I put in a verbal order for the IV potassium and started a bag, he vomited when we were cleaning him up. And I remembered his phos is low, too. And kinda low albumin." 

Frown. "Good thought on the K. He'll probably need more than the one bag, right, but I think we can see where it comes back on the repeat labs. We can give him 250ml of 5% albumin instead of another bolus, and then run another hematology after that's in. Maybe with the rest of the admission lab set, we don't have the clotting panel or liver panel on him. ...I'm not sure about the phos, I think the phosphate in organophosphates isn't - bioavailable as elemental phosphorus - but I'm not very sure of that. Let's see how it looks on the followup, I guess." 

She starts setting up the sterile tray next to Lionstar's bed. "I put in the orders for pralidoxime but the pharmacy needs to prepare it, we don't stock it on the unit. Serum cholinesterase needs a paper requisition and to be courier'd to the General, I'm working on arranging that. I need to call poison control back to clarify the maintenance atropine dosing, UptoDate thinks we should start at 0.02 mg/kg per hour but that seems low, poison control had said an hourly rate of 10% to 20% the total effective dose and we know we gave him nearly fifty mg. My guess is that we'll want to run it at around 5mg/hour." 

She washes her hands thoroughly at the sink and then starts carefully donning the sterile procedure gown.

...Right. The thing Marian is doing right now is helping with an art line. 

Sashy should really not be touching anything for this. Marian will smile at her, and then maybe try to encourage her via gestures to have a seat in the reclining chair that someone brought over? 

Tsashi is very curious about what they're about to do! But also capable of taking hints and not being in the way. She sits down and watches. 

The patient, while still not exactly awake, does seem to notice his arm being taken out from under the warm blanket. His fingers twitch ineffectually, and he grimaces and coughs. 

Marian pats his shoulder. "I know, I know, you're cold. You can have the warm blanket back really soon. - Dr Sharma, should I start something for sedation?" 

"Hmmmmmm. I - think I'd rather not? He doesn't seem agitated, and I want to see if his neuro status improves once we start the pralidoxime. We'd be expecting mental status changes, but poison control was surprised that he was GCS 3 even after atropine." 

She slips on sterile gloves. 

Marian is going to hold down Lionstar's arm very firmly. Just in case. 

His brow furrows again when the needle actually goes in, and it seems like he might be trying and failing to bend his arm or pull it away; the muscles in his bicep are maybe tensing slightly. He's not anywhere near strong enough to actually resist Marian's grip. 

Poor guy. Marian murmurs probably-pointless reassurances while Dr Sharma puts two stitches in to hold the art line in place, hooks up the waiting primed pressure tubing, and then puts a dressing over the site. 

Dr Sharma will even hook it up to the monitor and zero the line for Marian! In her mind, it's good practice to at least be comfortable doing the things that nurses would usually do, and the nurses will appreciate you so much for doing something objectively very easy. 

Marian DOES appreciate Dr Sharma! She focuses on getting Lionstar comfortably ensconced under the blanket again. She should really remember to track down some extra pillows at some point to keep his arms nicely supported, the room-cleaning staff seem to have (quite reasonably) returned the enormous stash she had in here for the previous patient to the utility room. 

Lionstar's blood pressure reads a little higher on the art line, which isn't uncommon; he's at a comfortable 109/57 with a comfortable mean arterial pressure of 69. His heart rate is at 103. Temperature 33.7 C. 

...Sats creeping back down to 94%, and he's losing ground on lung volumes on the ventilator. 

And a quick listen with her stethoscope confirms that he's sounding both wheezy and full of secretions. UGH. Doesn't atropine have a longer half-life than that? 

"I think we should probably hurry up and start whatever his maintenance dose is," Marian says, and goes in to suction him. 

Lionstar does NOT LIKE THIS! He still doesn't seem sufficiently capable of moving his limbs to resist or even squirm very much, but he coughs more forcefully, gagging on the tube, and his face scrunches in discomfort. Tears are leaking from under his clenched eyelids.

The secretions coming up are a bit less watery than before, more creamy-white than clear, but still copious. His airways are tight enough that he's noticeably a bit difficult to suction, which Marian has only ever noticed once or twice before in patients with severe asthma. 

He's also leaking saliva from the corners of his mouth– ...no, he's in fact vomiting again, not very forcefully but there are traces of bile in it. 

"Sorry sorry sorry!" Marian turns his head to the side and tries to clean out his mouth with the oral suction before he can make any more of a mess. "No, don't bite it - sorry -" 

Dr Sharma comes over to look. 

"It's probably worth putting the OG tube to suction. Cholinergic agents increase gastric secretions, vomiting isn't surprising." She picks up the endotracheal suction tubing to examine its contents. "...I almost think his lungs could use another atropine loading dose, but I'm worried about overstimulating his heart, I don't know if it's safe to give him anything to control his rate. I need to call poison control back." 

Oh, right, putting the gastric tube on suction is a good idea that Marian had not even slightly thought of. And will let them measure how much fluid he's losing via that route, which might do something to ease Marian's anxiety about his potassium losses, not that there's really anything they can DO about it if it turns out he's losing potassium in bodily fluids faster than they can give it IV. Ugh. 

She hooks the OG tube up to the third prepped suction canister, because she is SO PREPARED, and then focuses on cleaning Lionstar's face again and replacing the towel over his pillow with a clean one. 

Lionstar makes a face again when she lifts his head, his neck muscles tightening. 

Marian tucks the pillow gently under his head. "I'm glad you're starting to wake up a little bit. That's really good. ...Can you squeeze my hand?" 

(Either he cannot do that or he doesn't understand the request.)

Not surprising. Marian will leave him alone. ...Actually, she's going to check the drawers for a set of wrist restraints, fail to find one, and make a mental note to get some from the clean utility when she next has to leave the room, just in case. 

The patient calms down as soon as she stops bothering him and does not try to make a grab for any tubes. His sats are slightly better after being suctioned, but he's still getting unimpressive volumes on the ventilator and, when Marian checks, he sounds less crackly but if anything more wheezy. 

...An entire 350 mls of gastric fluids come out of the OG tube into the suction canister over the next 5 minutes. 

And then it's 00:30 and time to take another blood sugar! It comes back at 67 mg/dL. 

Marian is very glad she thought to get the hourly checks order, because thaaaaaaat is borderline low AGAIN. Where is he putting it. She also doesn't have a standing order to treat low sugars, but she's inclined to take that as a given, put it in as a verbal order and let Dr Sharma know afterward. 

She does that. 

Dr Sharma comes back just as she's disposing of the empty syringe of 50% dextrose. "...Low glucose again? I'm so confused about that - I brought it up with poison control again and apparently this is supposed to cause high sugars if anything. Anyway. We're going to push another 10mg now, because I think we got a bit behind over the last half-hour, and I'll show you the order I put in, one moment..." 

Marian follows her out to the hall computer. 

"It's kind of involved, sorry. Start him at 10 mg/h atropine - they suggest diluting it in saline, take 10ml out of a 50ml bag of saline and add your 10mg of atropine so it's a total of 10 mg in 50 ml, 0.2 mg per ml. Titrate up by 2mg/h for bradycardia below 60 bpm or bronchospasm or copious secretions, titrate down by 2mg/h for systolic BP above 140 or tachycardia above 120 - sustained longer than 5 minutes, it's not worrying if he's up there briefly. Pause the infusion and call me for tachycardia above 150. Does that make sense?" 

It's definitely involved but it's all there in the order notes. Marian nods. "...Can I prepare more than 50ml at once? Uh, I don't know if it's not stable for hours or something, but I would be running through a bag every hour if I do 50ml at a time."