Marian starts another liter of saline. "...I'm checking his blood sugar again just in case, he had the weird hypoglycemia problem again and it didn't go up as much as you'd expect." 

72 mg/dL. 

Technically still within normal range! It's very borderline and making Marian nervous but she doesn't see how it could possibly be causing whatever problem he's having. 

She watches his vital signs closely and refreshes the computer repeatedly for labs. 

His heart rate does come down a little, to around 125, and his blood pressure is a more comfortable 110/60. His sats are holding up fine, still at 96%, and his breathing looks slow and steady and fairly unlabored.

He's if anything doing even more irregular beats, though. 

(Leareth has gone back to mostly trying not to be aware of their body; there's nothing he can do, so feeling worse in some way isn't decision-relevant, and trying to drift somewhere far away makes it easier not to be stressed, which is important, he needs to be calm so Karal can be calm...) 

Also he looks like crap, for someone whose vital signs are technically fine. 

Marian should probably go check with Dr Hulka if, given his current heart rate and BP, she wants to do anything else while they wait for the labs? 

One of the premature heartbeats lands at exactly the wrong moment, and the monitor switches from still mostly reading sinus tachycardia, to a very fast wide-complex ventricular pattern. 

- for about three seconds before breaking out of it, but there are only a handful of normal beats before it happens again. The blood pressure waveform almost instantly dropped to below 70 systolic, and doesn't have time to recover in between. 

Marian is at the nursing station, waiting for Dr Hulka to be off the phone. 

Someone's alarm is going off. She should see who has– WAIT SHIT 

"I need help in 104!" she yells, and runs. 

They're... doing things but none of it feels like it's helping... do they know that... Marian seems to know, good, he can stay calm if someone knows what to do... Leareth is doing the right thing in not being there, Karal is definitely better at being helpless and still and not trying to do any things...

Marian is going somewhere, clearly for good reason given how worried she is (he's relying on Empathy more and more as worrying and confusing things keep happening without a good opportunity for communication) and Karal will not protest but he is starting to feel less happy about being left alone like this...

--a sudden spike of pain and wrongness, he can't breathe and he thinks he really is dying, somehow, for no reason-- what happened-- 

--Marian's not here, he tries to find her with Empathy but he can't, it's like the whole world is shrinking around him, he can barely see anything-- (he's projecting distress in all directions, but his range is shrinking fast enough that it may not have anyone in it)

--he needs help, he needs to breathe, he has no idea what's wrong but if he pulls the tube out he can shout for help, and if he doesn't he may be dead before anyone knows what's happening--

He's incredibly weak (because he's dying) but he does still manage that.  It does not let him breathe.

(He manages to - briefly - hit the patient next door, who’s less than fifteen feet away on the other side of a thin wall, and who is actually conscious - and now very confused! Did someone just - yell for help -? …He’s going to hit his call bell, which is unfortunately a much lower priority for anyone to answer than the multiple alarms already screaming next door.)

Marian reaches the room and

WHAT

HOW

That’s not fair she was gone for less than a minute and he said he wouldn’t pull any tubes out if they left him unrestrained

She's going to be in so much trouble 

- focus. Airway/breathing/circulation and then she can have feelings.

He’s - still conscious, somehow, and at least making a valiant attempt to breathe unassisted, despite being in rapid V-tach on the monitor with a systolic blood pressure in the 50s - though at least there’s a waveform at all - his color is greyish and either he's lost the sat probe or it's failing to get a reading because his peripheral circulation is no longer happening. 

Marian whacks the code button - he appears to technically still have a pulse but she's unconvinced that's going to last much longer - and drops the head of the bed to flat, which won't make it any easier for him to breathe but his blood pressure feels like the bigger problem right now - she'll dive for the non-rebreather oxygen mask tucked behind the head of the bed, turn the flow up all the way and desperately hope he's not going to fight her about it because he's disoriented and terrified, or at least that if he does he's not strong enough to put up actual resistance - 

(At some point during that, the patient snaps out of the fifteen-second run of V-tach and back into an unsteady sinus rhythm. His blood pressure recovers slightly.)

Leareth is - still there, but honestly significantly less conscious than Karal at this point; there's less of him that can run on physical reflexes alone, and it feels like there's maybe not enough energy left in their body for both of them to be awake. He's confused and distressed and not incredibly aware of what's happening, but he does, on some level, just barely remember that he shouldn't be fighting Karal for control of the body... 

Karal makes a faint unhappy noise at the sudden drop but doesn't fight Marian about anything - she's here, that's really all he wanted - and she's upset with him, oh no, he's sorry for almost dying whatever it was and he will definitely not do any more things!

also doing things would be so hard right now, it's so much better that she's here and he doesn't have to

(He is still using what Empathy he can manage - after so long it feels like just another sense he has, more than something he's deliberately doing, so it never occurred to him to stop.)

Dr Hulka reaches the room within another twenty seconds, looking harassed, at around the same time as Marian's podmate arrives with the crash cart. "Okay, what's happening here - did he just self-extubate, why wasn't he -"  

     "He has PTSD about being restrained," Dr Cabat jumps in helpfully. "Uh, he did seem calm before." 

This is POSSIBLY THE WORST SHIFT OF MARIAN'S ENTIRE LIFE and she wants to disappear through the floor. "I wasn't restraining him because it made him really panicky and combative, and he was basically calm and cooperative otherwise - I think he must have felt it when he went into V-tach, that was the monitor alarm, and got scared -" She's trying to find the stupid sat probe. "He's conscious and - I think he's trying to be cooperative.” 

She gets the probe back on his finger; his blood pressure is struggling its way back to 70 systolic, which might be enough to get a reading on his finger, though also she thinks the crash cart should have some of the neonatal ones that work on an earlobe…

84%.

"Well, that could be worse," Dr Hulka says matter-of-factly. "We'll have to reintubate but I reckon he'll tough it out a few minutes while we stabilize his rhythm. - get the defib pads on him, please, let's do front and back rather than yank off more dressings - run amiodarone 150mg over ten minutes - and let's prep an epi drip in case his BP doesn't recover or the amio drops him more - we sent labs, right, do we have those back, what were his last lytes -?" 

     Dr Cabat is pulling up the chart on the computer. "Uh, last K was back up to 3.6. Most recent set is still marked pending." 

"Show me the ECG again - this looks like it could be hypokalemia, but I can't think what would drop him that fast - he definitely didn't get diuretics, right?" 

     "No..." Dr Cabat looks speculative. "He does have that weird recurrent hypoglycemia thing - uh can someone check his sugar again? - right, anyway, I know giving insulin and D50 is a firstline treatment for hyperkalemia - if whatever's going on with him has a similar mechanism, could it be doing the same thing, pulling too much K into the cells and dropping his serum levels..." 

"That's certainly a theory. - okay, I want his BP up faster than this, let's start the epi -" 

Marian is trying to half-listen to everything going on but most of her attention is on making eye contact with her patient and keeping him calm while they mess a bit with his dressings again to make enough room to attach a defibrillator pad - some of it's going to be over blistered skin but she can at least manage to avoid the third-degree burns - and then they also have to roll him all the way onto his side to stick the other pad on his back, both of which have to hurt like hell. He keeps doing little runs of V-tach but at least nothing that lasts more than two or three seconds, and with enough time in between for his blood pressure to straggle back up again. 

(Her affect is actually significantly less alarmed and upset now; she's stressed but focused. Her team is in the room with her and it feels at least more like whatever happens they'll be able to wrestle the situation back under control.)

Marian is very good.  All these people are doing so many strange and uncomfortable things, but he knows he's supposed to let them, and it's easy to remember that when she keeps looking at him and thinking calming thoughts.  His chest hurts whenever they do anything, but it's surface pain, it's fine, they can do that-- he still feels faint and just generally horrible, but... maybe a little less so?...  He tenses up whenever his heart does the Wrong Thing again, but he tries to relax and wait it out and it keeps not killing him, so maybe it's not as bad as he thought--

And he can breathe now - it takes so much effort but it's good to have something he can usefully apply effort to, and Marian clearly wants him to keep trying, so that's not one of the things he shouldn't be doing.  He focuses on keeping it up for as long as he can manage, looks at her, and tries to let these people keep him alive. 

(He thought it wasn't that important to be alive, but Leareth was so scared, and he thinks Marian would be upset...)

He's doing so well! Marian is so proud of him! He's managing to maintain his sats at 90%, which is really impressive given the broken ribs and lung damage and obvious muscle weakness. It's also actually pretty reassuring that he looks alarmed again every time he does another short run of V-tach, it means he's with it enough to notice. 

"Dr Hulka, uh, his blood sugar is, like, fifty-nine -" 

      "Seriously, again? Let's deal with that - labs still aren't back? This really feels like something is up with his lytes. ...I think let's run another 10 mmol of potassium without waiting, even if I'm on the wrong track it shouldn't send him high. - repeat lytes again first, if something is going on with that it's worse than it was an hour ago -" 

"I'm going up to 0.2 on the epi - amio's half done, I can't tell if it's helping but -"

     "Well, he hasn't actually coded, that's something -" 

It seems like he's going to keep not coding! The amiodarone bolus finishes after ten minutes and it's clearly not fixing the underlying problem but it does maybe seem to be helping, he's now mostly back to sinus tachycardia with a lot of ventricular beats and is only occasionally doing short runs of V-tach. It also clearly would be tanking his blood pressure, but the epinephrine drip is managing to keep up with that. 

And Dr Hulka is now prepping an intubation tray, which is such a reasonable plan - he's clearly going to exhaust himself soon - but they'll have to give him sedation and Marian feels really bad about just - doing that without indicating it to him in any way. 

She takes his hand and tries to get his attention, then - points at him, mimes closing her eyes and letting her head flop in a way she hopes looks more like "drugs to fall asleep" than "deciding to go to sleep on purpose", and then gestures to try to convey "the tube will go back in." 

Does it look like he's following any of that? Does he seem upset about it? 

He doesn't look happy about it, but seems oriented in an exhausted way.  He nods - Marian is probably right that he can't keep breathing this hard for very long, especially if he ever wants to sleep, and in any case she knows better than he would. 

He's not entirely clear on how the falling-asleep is supposed to happen, or whether that gesture even means falling asleep and not just relaxing and trying not to think about what's happening (which would be a very reasonable way to go about having the unpleasant tube put in! and might be what they mean if they expect it to happen very soon, which it looks like they do?), and he will in fact close his eyes and try to relax once she's done talking to him.

Oh good. Marian isn't sure if she thinks he understood, but she feels better for having tried. 

And someone is handing her a syringe of propofol, so she'll find an available bit of IV tubing going into the central line - the one just running IV fluids, you're not really supposed to mix propofol with most things - and squeeze her patient's hand reassuringly while she waits for Dr Hulka to indicate that they're ready. 

A minute or so later, she gets a nod and pushes in 50mg of propofol (at which point Karal will feel an overwhelming wave of sleepiness for several seconds, followed by feeling the world spinning - a little like being very drunk - and then nothing.)