They can be ready! And also ready to take seriously that no really this patient needs her blood sugar checked every five minutes, she’s probably on long-acting insulin or something, and also anesthesia should be really careful about not letting her wake up and kick someone else in the ribs.

To the OR, then! (And there’s a bed ready for her in the ICU, assuming she survives the next hour.)

…How bad is it when they start removing the pressure dressings? 

Less bad than last time! Also her intestines have been leaking remarkably little ick into her abdominal cavity given how many places they've been sliced open in. Her last meal must have been clear liquids or a long time ago or both.

Surprising but convenient! For once something is going right! (...Also that miiiight explain the degree of hypoglycemia?) 

The surgeon focuses on finding and stopping all the sources of bleeding, first, and then on cutting out any non-viable bowel tissue and stitching the remainder back together. The damage is pretty bad; he’ll also find the furthest-down point where none of the bowel loops higher up were actually severed, and pull that through the skin to make a loop ileostomy. If she survives the next few hours and days, they’ll close it up later once the damaged bowel has had an opportunity to heal.

They very thoroughly wash out her abdominal cavity with sterile saline. She’s likely to still end up with an infection, but they’ll load her up with antibiotics as well, and hopefully it’ll be a survivable one.

How does their patient tolerate all of this?

Pretty well, if they keep the sugar coming as fast as she mysteriously disappears it! She doesn't reveal any additional problems or kick anyone in the ribs or start fountaining blood again.

How much fucking insulin did she fucking take. 

...She's alive, and closed up, and has a blood sugar reading above 70 with the heroic administration of, like, at least ten amps of D50. Onward to the ICU! 

Having not yet received a handover from the OR nursing team bringing the patient over, Marian has the following pieces of information about her patient, relayed via from the ER charge nurse via the ICU charge nurse: 

* Young woman, no ID, in the system as Eighty-One, Violet. 

* Found unconscious in the city, brought in with severe bleeding from traumatic injuries, the cause of which was unwitnessed but that looked like an animal attack (?) 

* In cosplay when they found her (??) Possessed of an actual literal sword, like, a sharp one (???!!) 

* Suspected diabetic with suspected overdose on long-acting insulin, and/or she took her normal dose but hasn't been eating? 

* Originally suspected to have hemophilia but it might actually be DIC (aaaaaah!!!) 

* Had been parked in the ER since like 10 am while they tried to stabilize her enough for the OR and figure out the hypoglycemia and clotting deficit; actually went to the OR two hours ago. 

* Blood type A positive. 

She discharged one of her patients this morning and managed to rush the transfer out of her other patient an hour ago when they needed to urgently free up a bed. Room 104 is ready! Marian is ready! 

She looks pretty good for how shredded she got! Completely out of it thanks to the anesthesia, but she's breathing well and her BP is starting to approach the low end of mildly concerning, and the general vibe is of someone who's more likely to get better than worse.

OR report: they dealt with a lot of bleeding (though fewer torn arteries than it looked like at first), lots of damage to the abdominal wall fascia and muscle, relatively minor lacerations to her liver and spleen, and quite a lot of shredded bowel, though surprisingly little of it was totally non-viable. She has an ileostomy, which isn't draining much because there (rather fortunately) didn't actually seem to be very much in her GI tract, and three surgical drains. She has all the usual lines and tubes: central line, arterial line placed in the OR for blood pressure monitoring, nasogastric tube to suction, Foley catheter (urine output has been pretty decent ever since they got her blood pressure to something at all reasonable.) She's intubated, on pretty minimal ventilator support and 30% oxygen, mostly not having any respiratory issues at this point. 

She's on norepinephrine at the maximum rate, dopamine at around 25% of the maximum rate and Marian should stop that first if she can manage it, midazolam at 2mg/h for ongoing sedation, and maintenance saline at 100 cc/h. She got, like, ten units of blood and fifteen units of plasma since her arrival in the ER, and Marian has a standing order to give two more units of blood if her next hemoglobin comes back below 7. Marian can also start a fentanyl drip for pain control if the patient seems to need it, with the following parameters. 

Marian has orders to do a new set of labs now and another set in four hours, so around 6 pm. She also has broad-spectrum antibiotics due at 6 pm. Other than that, there's - not that much actually on the schedule? Mostly just hoping nothing else goes horribly wrong - 

- oh and the blood sugar. They have never actually felt comfortable stopping checking it every five minutes, even if she was only actually needing top-ups every fifteen or twenty minutes more recently. Sorry about that. 

Oh. Also she should probably be careful with letting sedation wear off, the patient kicked a nurse in the ribs and managed to yank out all of her IVs earlier in the ER. 

Okay. That's - actually not too bad. Marian can do this. 

Labs first, then she'll check all her patient's lines and tubes, then - does she respond at all to a cautious painful stimulus like having her nailbed pinched? (Marian is in fact pretty cautious about this. She doesn't mind getting kicked that much per se but she's feeling really protective of her patient's recent OR repair job and all her lines.) 

Nope. Twitching is a free action but she's not even getting those this round. 

Okay. It doesn't seem like she needs fentanyl for pain control yet, but Marian is absolutely going to be keeping an eye on her to gauge if she starts showing signs of feeling pain even if she's not awake yet. Waking up in a ton of pain and not knowing why is a really understandable reason for someone to freak out.

- fuck it's been more than five minutes since she got in from the OR and presumably there was any transit time involved, Marian needs to find a glucometer right now and check her blood sugar. Is her blood sugar okay. 

67 mg/dL. Previous check was 73.

Which the chart confirms was shortly after receiving D50, her last dose if it was in fact right about fifteen minutes ago. Where is she putting it.

Marian runs to get some - no, actually, she'll get, like, five boxes of it - and tops her up again. ...This poor lady's fingers. Marian is actually going to grab a bunch of 1 cc syringes and start using teeny art line samples instead, it's a pretty negligible amount of blood and in any case if they take too much of this patient's blood, Marian already has standing orders to fix that

How are her heart rate and blood pressure doing? Aaaaaany chance Marian can try to gently ease down her dopamine dose? 

Her blood pressure would get a "how are you walking around" if someone was discovered walking around with it, but it's back over 80 systolic and her heart rate is fine. Backing off on the dopamine a tad doesn't cause any problems.

Marian would leave it alone except for how she kind of feels like the dopamine isn't helping that much? Her heart rate and contractility don’t seem like the main issue. And the patient’s blood pressure does seem like it’s getting adequate circulation to her fingers and toes - her peripheral pulses are reasonable, capillary refill is delayed but not that horribly, and the sat probe on her finger is picking up a perfect waveform. If easing it down in tiny increments isn’t making the numbers worse, Marian is inclined to keep at it.

- and check blood sugar. every. five. fucking. minutes -

- and refresh the chart unreasonably often, the latest hemoglobin (and other blood counts) should be back aaaaaaany miiiiinute now… 

Reducing the dopamine continues to work and her numbers don't get worse. Her blood sugar keeps doing the same weird but manageable thing it's been doing. Eventually the blood count comes back with a hemoglobin of 8.5 and a WBC of 13.

Wow, neat, she doesn’t even need another transfusion yet! (8.5 is still technically significantly below normal but honestly by ICU standards it barely counts.) Her platelets also haven’t gotten lower, which is something. (The clotting factors panel is still pending because of course it is, even stat it takes soooo long.)

If all the patient’s numbers are fine, and she still looks comfortable and doesn’t start freaking out when Marian pinches her nailbed again, then maybe Marian will be an overachiever and pull in her pod neighbor (Kristy, today) to help her tilt the patient onto her side and tuck her in with a cozy nest of pillows. She’s been flat on her back for, like, four and a half hours now, a bunch of than on the OR table.

….If that goes fine then Marian doesn’t actually have anything spectacularly urgent on her plate? And maybe she’ll be incredibly proactive and on top of things, and have a peek inside the bag of blood-soaked clothes labeled “patient belongings”. (Minus, apparently, her sword and a shield, which are…somewhere else…Marian should follow up on that but she’s honestly deeply relieved not to have a sword of all things in her ICU room. Where would you put it. She doesn’t think the drawers or cabinets are deep enough.) Anyway, probably nothing is very salvageable what with having been bled on, ripped up by whatever actually caused her injuries, and then hastily cut off by paramedics, but if Marian had a nice cosplay outfit she would want someone to check? Also she’s definitely heard of the ER staff missing a patient’s ID, if it wasn’t in a wallet findable by a quick pat-down of pockets, and it would be cool to know her patient’s actual first name, you know? 

Eighty-one Violet's total worldly goods, with the very important exceptions of her sword and shield, consist of:

- a medallion with an image of a sunburst behind a sword, on a short chain (still on her neck)

- a nice brocaded headband (still on her head)

- a set of seriously torn and bloodstained clothes, apparently hand-sewn of handspun fabric 

- a breastplate and backplate 

- a nice tooled-leather belt (somehow not shredded, but very bloodstained)

- a cloak (likewise)

- leather boots 

- a dagger (found in the boots)

- a leather belt pouch, which is about six inches in each direction and doesn't weigh much, but turns out to be containing:

- a string of prayer beads with the same sunburst-and-sword symbol as her necklace 

- flint and steel

- quite a lot of rope

- a gilded chess set with folded-up board

- a bar of soap

- a packet of tea or incense or something 

- several pieces of weirdly crappy paper, mostly blank but also including a sketch of a person, a diagram of gears, and a half-written letter in an unfamiliar alphabet, plus pen and ink

- a bottle of blue liquid, corked

- a packet containing several steel caltrops 

- a coin pouch with several gold and silver coins, stamped in the mostly-competent manner of historical coins rather than with the perfection of the US Mint, with a guy's head on one side and some more of the unfamiliar writing on the other

And absolutely no driver's licence.

Marian is wearing gloves and put down one of the quilted incontinence pads on the counter to put everything on. She's trying pretty hard not to let anything touch areas not covered by her gloves (and dumped out the little bag rather than stick her hand in it, on the principle that given the surprise dagger in the boot, it might also contain surprise sharps.) 

This is, like, well beyond cosplay! And actually really cool? Is this young woman part of - shit what are they called again, the historical re-enactment people who make their own clothes using historical fibercraft methods and stuff - huh that might actually be a decent way to figure out who she is, if she can find, like, a website with contact info - though hmm maybe she had better leave that to social work or something, it's not incredibly Marian's job and as a travel nurse she doesn't, for example, actually have a hospital email address... 

Anyway, the clothes do not in fact look salvageable (which is sad, because it sure looks like a lot of craft work went into making them) but a lot of the other possessions seem okay, or like they would be okay with proper washing, which Marian isn't going to attempt because they aren't hers. Marian has questions about some of them but mostly of the variety "this person seems really cool and I want her to wake up and tell me about her hobbies." 

She doesn't try to put things back in the belt pouch; she was distracted when she emptied it onto the counter, and now she's staring at the little pile feeling kind of nonplussed about how the hell everything fit, that must have been such a careful packing job and there's no way Marian can replicate it. She...is going to organize the stuff in biohazard bags instead, not because she thinks the items are biohazardous - they're not actually covered in blood - but because those are the bags that are right there in the supply drawer, and also around the right size. 

Ughhhh it seems...really sketchy...to have an actual dagger stashed in a patient room. The problem is that Marian does not especially trust this hospital to have a system for safekeeping hazardous patient belongings that will definitely result in them not getting lost. She'll...carefully put it back into the boot for now, how about that, and put the boots in a patient belongings bag and stuff it in the bottom of the cabinet. 

It takes Marian, like, an hour to get through all of that, significantly because every five minutes she has to swap out to clean gloves and take a blood sugar and about 1/3 of the time she has to treat it with more D50. Does the patient stay basically stable through that whole period? 

Towards the end of that period she starts looking . . . kind of off, in some hard-to-define way. Also she shifts around in her sleep a bit and makes the one noise it's possible to make with a breathing tube in.

...Shit. 

The rest of the stuff does not have to go in the cabinet all nice and sorted, it can get wrapped in the counter incontinence pad and shoved in there to tidy up later.

Is there anything obviously newly wrong with the patient's vital signs, urine output, stuff coming out of her abdominal drains, et cetera? 

Her temperature is 99.8 where she had previously been a bit on the cool side, and there's . . . something grey-green . . . coming out of the abdominal drains.

Shiiiiiiit. 99.8 isn't a fever yet but it sure is warmer than she was running before - in fact, Marian can check the history and note that her temp is up nearly a degree in the last, like, ten or fifteen minutes. 

...Also WHAT THE FUCK is coming out of her drains. Seriously, what is that??? Bile?? That would already be super worrying, since it would mean that something opened up again in her gut or that they didn't successfully patch all the damage in the first place, but it's not even really a normal color for that. 

Marian sticks her head out the door. "Kristy! Hey! Can you, uh, go find a resident right now to come look at something?" - also, separately, the patient looks like she might be starting to wake up, or at least be uncomfortable? "Oh, and can you pull a bag of fentanyl for me and bring it to cosign?"

And then she’ll do a neuro assessment. She stands at the head of the bed and reaches to take the patient’s hand. “Hey! Can you open your eyes for me?”