Yup, she's gotten closer to room temperature. It doesn't seem to be having any consequences other than blueness yet.

Well, it could be related to the drop in her heart rate! Also, huh, it’s a surprisingly large drop in half an hour. They’ll get a warming blanket on her, and any further fluids and blood products should go into her warm.

- on reflection, given that they can’t take her to the OR anyway while her clotting problem is undealt with, maybe they do want to send her for a scan? If she’s bleeding internally as well as through all the dressings, it would be much better if that didn’t come as a surprise to the surgical team. 

On the other hand, she’s not that stable. He’ll wait and see if the dopamine infusion will do anything about her heart rate, and whether this is enough to scrape them up to a blood pressure of 80 systolic.

Her heart rate and blood pressure pop up a bit once she's warm, but not very much. The donated blood products are doing a lot better at staying in her body than the original flavor was, which also helps.

Okay. Maybe it's not quite a good idea to risk it. For one thing, the rapid infuser that they're now using to deliver warmed blood products (which shouldn't just be popped in the microwave) doesn't have enough battery life to haul to Radiology with them. 

They'll just - wait for lab results. And watch to see if the apparent decrease in bleeding holds up, though it's a bit hard to tell since they don't want to remove the original layer of dressings and disturb any clots that miiiiiight be trying to form. 

...They get a call from the lab. 

It's not for anything related to the clotting panel. The extended electrolytes panel is back and it's mostly totally fine, except for her venous blood glucose, which is incidentally included with the other tests and which, apparently, is a horrifyingly low 37 mg/dL. 

This is bizarre enough that the trauma bay nurse is going to just immediately do a fingerstick to check capillary blood glucose as redundancy, in case there was somehow something wrong with the sample.  

Her current blood glucose is not 37 mg/dL! 

It's 34 mg/dL.

...Which is actually even worse than it looks, capillary blood glucose is normally slightly higher, since venous blood glucose is after the tissues have extracted whatever sugar they need to burn for fuel. This is baffling - did she OD on insulin on top of everything else wrong with her??? - but it does, at least, sort of explain how rapidly her body temp dropped, and why she isn't responding better to the pressors. Her body is running on empty and it's lucky she hasn't started having seizures yet. 

The attending doctor is back at the nursing station trying to answer questions about three other patients, all of whom are less critical but also you can’t just put the whole ER on pause while waiting for test results on your sickest patient. However, this is more than worth interrupting for.

- or sending someone else to do that, actually, she's not going to wait for orders is just going to start giving IV dextrose immediately. 

She gives three amps (75 cc) in a row, and only then pauses briefly to glance at the patient's vital signs and take another blood sugar reading. 

That helps a lot! Her heart rate goes up to 155, her blood pressure just barely hits 80/50, and she looks less like death warmed over. The second finger stick comes back at 56.

That definitely makes it look like they’ve identified one of the things wrong with her! Maybe she is just diabetic on top of being a cosplayer with a bleeding disorder and who was ???attacked by coyotes??? in central Reno??

- not important to make wild guesses at the exact history right now. She’ll give another amp of D50 and then wait for actual orders.

Actual orders are to keep rechecking and giving more dextrose until she’s in normal range, and then continue checking every 5 minutes to make sure she stays there. If she’s diabetic and on long-acting insulin - and, one could guess, running into problems because she’s normally an athletic young person who eats a lot, and right now she’s instead busy losing significant fractions of her blood and doing the cardiovascular equivalent of running a marathon just to maintain her blood pressure - then they shouldn’t assume the problem is fixed for good once she’s above 70 mg/dL.

…Yeah, that checks out. Where is the patient at another three minutes later after her fourth sugar top-up? 

When there was last anything it was like to be Samora, things were going so totally to the dogs that she was expecting to wake up in heaven. That's bad--she had a job--but not worth freaking out over.

As her consciousness starts to pull itself together and it becomes clear that she feels way too awful to be in heaven, she starts thinking Tris and Marshall must have gotten her out somehow. Or possibly brought her back? She's far too groggy to figure out whether that would be a smart decision. 

Then she gets a bit more of her senses online and realizes that she's on some kind of table, with a device sticking down her throat and piercing both arms.

She's not with Tris and Marshall. The necromancer got her, maybe got all of them, and she's in some kind of horrible fiendish contraption like that poor dwarf from upstairs.

To the Abyss with that!

The third finger stick is interrupted by the patient attempting to leap upright (which fails, because her legs are still hamburger) while ripping her IVs out (much more effectively).

Yikes! That was really unexpected! It's not that unexpected for a patient to wake up confused even if they have very serious injuries, and they haven't given her anything for sedation since the 50mg of propofol to intubate her 45 minutes ago, but normally people show some sign of it before the point that they try to get up and rip out all their IVs. 

- the patient did somehow get all three of her IVs yanked out - bad like that they were all in use and thus had tubing connected - which is actually a pretty bad problem, because, one, she needs those, and two, it's going to be pretty fucking hard to put any new lines in place while she's actively panicking like this and they can't give her anything for sedation due to the lack of an IV line to give it in. 

The nurse will try to pin her patient's arms so she can't also go for the endotracheal tube, yell that she needs some help in here RIGHT NOW, and then - are the young woman's eyes open at all? - if so she can try to make eye contact and smile reassuringly and repeat that she's in the hospital and badly hurt and needs to hold still - 

She doesn't speak that language! Her eyes (she has silver irises) are open and working on getting focused, and the clearly-alive human face and lack of detectable Evil are a little reassuring. The attempt to restrain her is NOT reassuring and neither is the absence of her party and her sword. The unfamiliar surroundings are kind of a mixed bag, because it doesn't look like a dungeon but it doesn't look like anywhere normal either.

If she had any spells left she'd prioritize healing herself, but if she had any spells left she wouldn't be in this situation, and anyway she couldn't cast anything because there's still something shoved in her mouth. She makes a valiant effort to cough it up or bite it in half, and only succeeds in making her vision start to grey out again.

Yup that seems like a confused and uncooperative patient! Fortunately, what with all the blood loss and ongoing hypoglycemia, she's not actually strong enough to meaningfully resist being held down. Though she is managing to drop her O2 saturation a bit, probably because she's coughing too much to breathe effectively while also struggling as hard as she can. 

The attending doctor is there again, good. "We've got a problem - we've lost all three lines," which is pretty embarrassing to admit it took like a second for the patient to yank them out, there really wasn't time to react to stop her, "- and she won't hold still -" 

Yup, that sure looks like the situation. "Let's give 5mg lorazepam IM, get her settled down enough to put in some new lines - I think her BP can handle it, last one looks a lot better - and then we'll want to start midazolam for ongoing sedation."

One of the other nurses will go prep an intramuscular injection of sedatives, while a couple of the other staff help restrain the patient. Does she actually stay conscious and fighting them for the next minute or two? 

She's in and out, but never out long enough that it seems like a good idea to let go of her. When they come at her with the needle she fights back like she's never seen a needle used for non-malevolent purposes before and manages to kick the nurse in the ribs and incidentally dislodge one of her bandages. But she's not strong enough or coordinated enough to stop them from getting the lorazepam in, and goes limp again shortly thereafter.

(To the extent she's tracking hypotheses at all, which isn't very much, she's guessing these people are enchanted or coerced, or her Detect Evil is incapacitated somehow.)

This is not the first time she's been kicked in the ribs by a confused fighty patient. It's fine. 

Does the patient stay out when they stick her finger again for another blood sugar? (It seems like a good test for whether she'll hold still enough to get a peripheral IV in. Really she needs a central line but that's a terrible idea unless she's sedated enough not to twitch.) 

- also what is her blood sugar, it seems plausible it came up high enough for her to start regaining consciousness, but also since then she's been fighting hard and probably burning a lot of energy. 

(Someone else is trying to get the pressure bandage back on her wound where she dislodged it, though this is also a decent opportunity to get a better look at how quickly it's bleeding.) 

They can take her blood sugar; she tries to pull away a little after the fact, but that's all. It's back down to 43.

The unbandaged wound is still bleeding more than it should, even given the bandage getting ripped off, but it's not the total clotting failure of earlier.

Okay. They'll get a bandage back over it, that's fine. 

...The blood sugar is less fine but not shocking, and fixable as soon as they have IV access again. The nurse is going to have one of her colleagues firmly hold the patient's arm down before she tries placing another IV, but hopefully she can then get one in without too much trouble? 

How are the patient's vital signs? She's not losing blood as quickly as before, but it's now been, like, almost five minutes of not getting any of the fluids or blood products that were running before, and maybe more importantly not getting the vasopressors that were running. Also the lorazepam is getting absorbed and hitting her bloodstream, where it's probably going to depress her cardiovascular function a bit, but really having to stop all the pressors seems like the bigger problem here. 

The IV can go in. She's fit and muscular and completely ran herself out of fight.

Her vitals signs have deteriorated about as expected. Maybe a little better than expected, actually. BP 65/47, heart rate still in the 150s.

Yeah, unsurprising, all of that it really wasn't good for her. They'll get all the pumps hooked up again - it's a bit dubious to run plasma through the rapid infuser into the same peripheral IV as the maxed-out norepinephrine and mostly-maxed dopamine drips, and then also immediately push two amps of D50, and hook up a bag of midazolam as soon as it's ready - but it's a better idea than not getting all the treatments she badly needs started as soon as possible. 

Does that help? And is she still sufficiently out once her blood sugar is up a bit for the doctor to feel comfortable messing around with major veins in her neck to place a central line? 

It does help! The D50 continues to not raise her blood sugar as much or fast as it ought to, but it does go up, and she doesn't put up anything worth calling a fight about the central line.

Oh good. It's sutured in, and the nurse will also tape the tubing running into it firmly in place so that it's not easily grabbable, just in case. 

- this is the point at which someone lets her know that the lab just called about more concerning results? This time it's the full coagulation panel. 

It doesn't look like hemophilia, actually? It's systematically off, but the patient isn't outright missing any clotting factors, just low on - most of them, really? Her prothrombin time is unsurprisingly very prolonged. Her fibrinogen is especially low. 

...All of this is potentially a direct consequence of the massive bleeding and transfusions, except that they hadn't actually transfused that much yet when the sample was taken? 

Also her D-dimer is positive, which in this context is a sign that clots are trying to form and either being broken down or just not being very effective at stopping the bleeding.  

Well shit. 

This is actually a lot worse than a specific and treatable deficiency would be! It doesn’t point at an obvious targeted treatment, and it does hint that the patient may well already have been suffering from disseminated intravascular coagulation (DIC) - her body freaking out in response to her injuries and trying to form microclots everywhere, simultaneously causing diffuse tissue and organ hypoxia by gunking up capillaries, thus the acidosis from elevated lactate, and also depleting the critical reserves of clotting factors that she badly needs to stop bleeding from the important spots.

….Or maybe it’s not that bad, it does seem - better than the alternative - that she’s improved somewhat since this sample was drawn, and in particular that the bleeding might actually be less of a problem.

It does probably mean that there’s no further benefit in waiting to take her to the OR; they’re not going to get more information that will improve her chances of surviving it, and in the meantime she’s now been sitting there for over an hour with a nasty gut wound probably leaking bacteria into her abdominal cavity. 

Is the OR ready for her?