And subvocalized to Personnel:

[I really do need a full block of sleep today. But, uh, after that, if he's deteriorating or - otherwise having a bad time - I think I do actually just want to know? Even if I'm asleep? And if Khemeth or someone on the team thinks it would help for me to be in the room, I'll do that, as long as, um, I'm not actually the main person on medical duty if I'm significantly impaired] 

But Kalorm is HER PATIENT and her brain is kind of yelling about ABANDONING HIM, and...seems like it would consider "just being nearby and comforting" to be relevantly not-abandoning-him. Merrin doesn't really need her brain working to do that. 

Kalorm nods. ...And closes his eyes, because that was tiring. 

(Personnel thinks Merrin's request is...in some sense Probably A Bad Idea just on priors? It's awfully shaped like "Merrin being self-sacrificing." But it does make any difference that she asked for it, rather than failing to say no to a request. And the Treatment Planning markets are at least right now solidly on "with Merrin there, outcomes of a given situation will be Better Than Otherwise Expected". This may update over the course of the day, if it turns out that actually Kalorm's family was massively overemphasizing his tendency toward uncooperativeness and actually the other medtechs they pick out for him can build rapport just fine - but in that case Khemeth and/or the treatment team would just end up deciding that waking Merrin wasn't going to help the situation, and so her request wouldn't come into play at all.) 

Merrin will give a much more thorough verbal report than she really needs to, given that she already talked to Tharrim for like twenty minutes earlier, and the fact that Tharrim has now been observing for like an hour and is going to be basically fully up to speed on the treatment plan.

It's mostly for Kalorm's benefit, who is definitely awake per his EEG even if he's only accepting audio inputs right now. He won't necessarily know that Tharrim is almost as familiar with at least the explicit details of his case as Merrin. Also, it feels like it'll be easier if she can stretch out the transition a bit longer? Give Kalorm ten minutes of hearing both their voices. She focuses particularly on talking Tharrim through all the communication aids they've been using. 

...And she's going to get Tharrim's help to turn Kalorm, just to get him used to the idea that Tharrim is a person who will be touching him, which her illegible intuition claims is a bigger deal for Kalorm than for most patients. She doesn't super need help, the equipment they use for it can (somewhat ungracefully) be adapted to floor height, and for purposes of minimizing-sensory-overload for Kalorm, she's been doing it solo all night rather than calling in extra hands. 

(Thaaaaaat is possibly one of the inputs into why her lower back hurts - the ergonomics for using said lift equipment for routine turns rather than just "a patient fell and we need to fix this" are way worse at floor level. She should make different choices tomorrow whenever she actually works next.) 

Kalorm is vaguely exasperated but not uncooperative with this process. 

Merrin decides not to make a big production of leaving. 

Ten minutes later she is at her apartment module, collecting a momhug and requesting that Irris get the really good massage person back - or, uh, she could maybe try to filter for 'massage therapists who can do Massages Made Of Suffering for more than twenty minutes' if that's a thing - and then she collapses onto her sleeping furniture and is asleep within five minutes. 

Kalorm does not, in fact, have nearly as good a rapport with Tharrim.

The Personnel-planning prediction market consensus is that Merrin is benefiting from several non-replicable factors such as "an impressive resume of daring Exception Handling adventurous sims", "having been the one who initially rescued him", "being around the age of his younger sister", and, yes, possibly even "having beaten him in a wrestling match." With Tharrim - and his later replacement - Kalorm is at the very least in a much worse mood.

It means that he more often reaches a degree of frustration where he's overwhelmed enough to stop really processing sentences, or making even vaguely strategic plans on how to solve his most recent communication impasse. A lot of his endless frustrating attempts to communicate are about sort of trivial things - the lights are a bad color, he hates the particular nature scenery displayed on the LCD screens, his pillow is Wrong In Unspecified Ways - and his level of emotional investment in it is clearly more of a desperate attempt to feel in control of his situation than about a medical need. 

(They do manage to figure out that he objects to the side effects of the regular pain medication. They promptly cycle through, like, four alternatives, all of which Kalorm ALSO claims to hate. He eventually agrees that they can just use a small dose of the really short-acting sedative, which is not great for pain relief but at least prevents him from having panic attacks about it.) 

He is also a lot more obnoxious about refusing random care. Nothing critically important, at first, but he declines to let Tharrim do any mouth care other than giving him swabs. And then flat-out refuses help to change position for an entire four hours, which is not great for bedsore risk especially when he is on a THIN MAT ON THE FLOOR. Eventually then he declares adamantly that he only wants to change position in order to lie on his right side, despite Tharrim predicting (as matter-of-factly as he can manage, given how doomy he feels about this) that Kalorm will have trouble breathing. 

...Kalorm has less trouble than anticipated, which is actually useful information that his worse-affected right lung is recovering, but there's evidently some sort of ventilation-perfusion mismatch going on, because his per-minute volumes of air moved are okay but his oxygenation is substantially worse. Kalorm nonetheless insists that he doesn't feel short of breath and is FINE, flat-out refuses to let them do any diagnostic tests about it, and only reluctantly and grumpily concedes that he cannot actually STOP Tharrim from turning up the ventilator O2 concentration. 

(He does agree to be turned back after the requisite interval, and they're able to go back down on the O2, though not quite to the point it was at before. This is Mildly Worrying, but he's still only on 45%, and on lower inspiratory pressure support than when Tharrim took over. Given that the change is relatively minor, it's probably just that he lost some alveolar recruitment while that lung was being squished, and nobody has a suggested angle on convincing him of the importance of diagnostic tests to rule out more worrying complications. Treatment Planning agrees that if he suddenly takes a turn for the worse, they'll at least have new evidence to bring, and if Kalorm is noticing symptoms then maybe Merrin's suggested approach of "just say what you're going to do and ask what he needs to make it tolerable" will actually work rather than completely backfiring.) 

Kalorm puts up with exactly 45 minutes of dialysis before conveying via frustrated mime and pointing that the machine is making a Bad Noise and if they don't make it go away NOW then he WILL yank out his dialysis line and MAKE THEM. This is not great, his electrolytes still aren't all the way normalized, but they got enough fluid off that, combined with a slightly improved urine output, he's roughly neutral on fluid intake-output since they took him off the continuous dialysis yesterday. And the machine does, to be fair, make a humming noise, and Kalorm is known to be having trouble with sensory processing and may genuinely be finding it distressing. They...will consider better sound-isolation solutions for the next try?

(...Honestly everyone on the team is hoping they can somehow make the next try happen once Merrin is back, or at least once Khemeth is around to smooth it over.) 

That was the longest six hour shift of Tharrim's entire career. He has managed to mostly keep his emotional state on the side of "sympathetic toward Kalorm's understandable frustration and anxiety" but this is not easy. 

His replacement is much less experienced, because they are testing the hypothesis that Kalorm feels less ??threatened?? or something with women who look younger than him, and approximately nobody in that category has anywhere close to Merrin's level of experience. But Halthis is pretty smart, and does have basic ICU experience for a patient of Kalorm's current complexity level. Not the certs she would need if Kalorm seriously deteriorates, she's only worked in a less specialized lower acuity regional facility, but they have backup for that, and if Kalorm is having a medical emergency then they WILL pull Merrin in if at all possible, she'll probably be awake sometime soonish. Halthis is also a 'face recognizer' and high on several other psychometric measures that they hope will correlate vaguely at all with being in some sense personality-compatible with Kalorm. And she can work a six-hour shift, at least as long as she's outsourcing a lot of the minute-to-minute medical decisionmaking to people not actually in the room. 

(They had to look a pretty long way for her and then pay her kind of a lot of money to fly out for this, but Khemeth left them a really generous fund for staffing, and Nerdel is now awake and signed off on it.) 

Kalorm is either in a somewhat better mood with her, or else just out of ideas for new exciting ways to be contrary.

...Honestly, Kalorm is tired. And intensely frustrated, but in a way where he can vaguely recognize that he's frustrated with the situation and not, specifically, his medtechs. Everyone is being as considerate as they possibly could be, and this does not change the fact that everything about being in the hospital is horrible.

He's been pushing for minimum-ventilator-setting trials whenever he has the energy, but Merrin was right, it takes a lot out of him. He's really frustrated with how much his chest hurts and especially how every option for addressing it makes other things worse; he prefers pain to nausea, but he doesn't really like either. And he's already in a constant background state of - not quite actually nauseated, but with the promise that it's right there waiting to surprise him from behind a corner. Relevant corners include 'when he gags on the breathing tube', which is happening more and more when he tries to mouth words. It's unfair to have another disincentive to communicating, on top of the fact that the mental act of planning it is weirdly aversive.

Having a lot of slightly gluey saliva hanging out near the back of his tongue also sets it off, but also even the thought of having the suction catheter in his mouth makes him preemptively nauseated. (He didn't so much mind Merrin doing it, for some reason, maybe partly because early in her shift he was still more out of it and by later on he sort of trusted her not to be excessively horrible about it, and– no, actually, it somehow did help how visibly she was grossed out about it. It's like the thing where Ranthir as a child just could not cope with the existence of sand anywhere in her environment, and Kalorm - never a child who especially avoided climbing things and getting sand all over himself - still carefully de-sanded himself before going in her room because he wasn't going to be mean about it even if her preferences were weird and stupid.) 

The stupid constant thirst is also not improving matters. Nerdel is patiently supplying him with ice-dipped mouth swabs whenever he looks hopefully at her, and that kind of helps, but also his mouth now permanently tastes like fake cucumber flavor (the most tolerable of the range available) and that is apparently its own nausea trigger. 

He doesn't quite have a headache per se but his head feels stuffy, like someone tried to inflate a balloon in there. And he's constantly dizzy despite the drugs that were supposed to help with that. Having a cold damp cloth over his forehead and eyes helps more, but then it doesn't stay cold for very long and also he can't see. Changing position - well, particularly having other people change his position for him - is genuinely very unpleasant, especially as the sedation fully clears his system and he's closer to fully alert during his waking periods. Merrin was really benefiting a lot from the fact that she got a rhythm established before he was with it enough to even properly form an intention to object let alone communicate it. 

His feet still feel Wrong In Some Unspecified Way and he wants to rub them or something to figure out what's going on but they're, like, all the way over there. Somehow he never realized before how far away feet are from hands when one is lying down and cannot really move from the lying-down position. 

On the one hand he would sort of prefer to be less conscious than this? On the other hand, then all the decisions would be made by PREDICTION MARKETS trying to optimize for his recovery without Kalorm getting any say in the matter. 

Halthis, who found out about the case this morning and landed in Default two hours ago, is already having a DAY and is only expecting it to get weirder from here!

When you are a 24-year-old rank four medtech at a regional facility in Alkan, population 530,450, you do not really expect a phone call from Exception Handling offering you more money than you usually make in a year to come to Default and be involved in a spectacularly bizarre patient case. Justifications for her performance incentive include 'there is a low but not trivially low chance that the patient will try to physically fight you', 'patient is currently insisting on lying on the FLOOR', and 'patient's father previously got into a bizarre altercation with the lead opper during an active medical emergency.' 

Halthis then spent her flight over reading Merrin's file and being, honestly, pretty intimidated.

Merrin is a year younger than her, and that's despite her relatively late start in the profession. Halthis was a qualified medtech at 14; Merrin didn't get there until 16, and then Merrin took four years in non-ICU positions whereas Halthis only needed two. And yet, at TWENTY-ONE she apparently had a longer list of weird emergency certs than Halthis does NOW, despite the fact that it apparently even now takes her 2-3 times as many sim-hours to reach adequate performance for a given cert. 

Halthis does in fact have more wall-clock hours of non-sim ICU time than Merrin. She's been doing it for eight years, and she usually works 24-hour weeks. She...somehow still has fewer hours logged of non-sim emergency case time, because apparently Merrin is some sort of weird alien who will immediately try to drop whatever she's doing and pounce on a complicated emergency case, and then be the lead opper on it for 12+ hours.

Well. Merrin is a weird alien in like eight different ways, given how there is ALSO a note on her file saying that it's disrecommended to tell her she's unusually good at things. Which is perhaps one of the most ????????!!!!! things that Halthis has ever read in her entire life. 

Anyway. Merrin isn't here. She's still asleep after working a total of 31 of the previous 55 hours, which Halthis is pretty sure is superheated insane even by Exception Handling endurance personnel standards. There's a note on Kalorm's file that as soon as they have confirmation that Merrin is awake, she will be available as a backup resource if Kalorm's condition deteriorates, which is NOT THAT UNLIKELY since apparently he keeps REFUSING TREATMENTS. 

Medically speaking, her patient is not any more complicated than the sort of case she's dealt with a hundred times. 

Neurologically speaking, he's pretty cognitively impaired right now, and it's hard to fully assess how much because he has a pre-existing disability that makes communication a lot harder, but he's basically oriented to the location if not the date, and can follow verbal instructions if they're delivered slowly (and he's in the mood for it.) He's having a lot of pain, which in itself doesn't indicate a worrying update - he did have his chest sawed open for bypass less than 48 hours ago - but could cover up the early signs of other discomfort-causing complications, so they need to be aware of that. 

He's very motivated to get off the ventilator, and made significant progress overnight and slightly-slower progress over the last six hours. He actively requests suctioning when he needs it and is clearing his lung secretions well, and the most recent try he managed almost 40 minutes on minimum ventilator settings, though the second half was clearly hard work and he was exhausted afterward. Predictions on when he'll be ready for extubation, 20% / 50% / 80%, are now 6 hours / 13 hours / 36 hours.

(The 80% one is higher than it was at the start of Tharrim's shift, because he was requiring, like, 80% O2 concentration on the ventilator when he insisted on sleeping on his bad side for 90 minutes. He was clearing CO2 adequately and denied feeling short of breath, but there was clearly some kind of ventilation-perfusion mismatch going on; if he develops sudden-onset worsening shortness of breath at rest while not doing a minimum-settings trial, the likelihood estimate that he's developing an embolism will jump up to >50%. They have a hard directive not to subject him to diagnostic testing he doesn't consent to if he's still conscious and responsive, but that is a point at which, if Kalorm didn't consent to a scan, they would probably drag his brother - or even potentially Merrin - out of bed to try to talk to him, however costly that will predictably be for their longer-run personnel coverage.) 

His cardiovascular system is in pretty good shape, despite everything it recently went through; he is still young and very fit, and his cardiac muscle contractility is almost back to normal. He tolerated dialysis fine from a blood-pressure perspective. The main worry there is that he refused to complete his full dialysis treatment for unrelated reasons, and now his potassium is riiiiiiight near the top of the normal range and his magnesium is well above it. He's probably losing significant potassium via gastric fluids being drained, which might explain why it's not rising fast despite dubious kidney function. If he starts throwing arrhythmias or showing increased blood pressure variability, it's probably an electrolytes issue. 

His gastrointestinal system is not in great shape. They're pretty sure he had a lot of tissue death in the superficial layers of his gut lining, but - unlike in previous similar cases Halthis has dealt with, usually post-chemotherapy patients having some sort of serious complication - his gut motility, pretty stunned after the cardiac arrest and prolonged absurd ""stabilization"" protocol they put him through, is still very shut down. He's complained repeatedly of abdominal discomfort and tenderness and is not, so far, even passing gas. This is fine nutritionally speaking - he's getting complete IV nutrition and tolerating it well - and they're waiting to see if he springs a GI bleed on them before intervening more aggressively. 

His urine output is improving, even if his kidneys aren't regulating electrolyte levels very well yet; he's consistently putting out 40-50 mls/hour, which is only about half his hourly fluid intake once you take into account the painkillers and IV nutrition and other IV medications, but he's losing some fluids through the nasogastric tube as well, and fluid overload isn't a major concern. 

At a superficial glance, he doesn't look worrying. Just really uncomfortable. 

Well, yeah! He's at the stage of his recovery where most of the things wrong with his body aren't even potentially life-threatening, but nearly all of them are even more unpleasant to experience than the sorts of complications that are life-threatening. 

Neurotypical patients usually express a preference to mostly sleep through this part, even if they haven't already specified that in their medical directives. There...are actually some neat advantages to having a patient who stubbornly insists on being conscious? She's way more likely to quickly notice any neurological deterioration, which means they can skip the cancer risk of regular CT scans. Assuming no complications, he's going to make much faster progress at getting off the ventilator, which is in Halthis' mind a straightforwardly good thing. She may even be able to get some cooperation in taking him through some range-of-motion exercises in bed. 

...She is not even going to try asking about that while he still looks so clearly miserable. 

Kalorm kind of would prefer to be asleep, honestly. (Just not to be involuntarily asleep due to drugs.) He's so tired. He keeps feeling randomly too hot, which is NOT helping with the threatening-to-become-nausea. He doesn't quite have a headache but somehow has all of the associated symptoms that would usually accompany a headache: moving his head is bad, sounds are bad, thinking is bad. 

He is in the conflicting position of desperately wanting to be LEFT ALONE, and also feeling sick and helpless enough that not having someone within a meter of him and ready to help is terrifying. Merrin was weirdly good at...not counting as a person to the part of his brain that wants No People? Nerdel also doesn't count in that sense, but has no medical qualifications and is correspondingly deferent to the medtechs on literally anything of substance - or not of substance, he's pretty sure that she's looking to them for approval before giving Kalorm mouth swabs. Khemeth would be an almost-acceptable Merrin substitute except for the part where Khemeth may or may not at any moment try to give him a weird lecture while Kalorm can't do anything about it, and also he's pretty clearly freaked out about a lot of the medical equipment and has no idea what to do with it. 

It would be nice to do something about this, but he's spent all morning trying to take actions at the situation to make it slightly less horrible, it feels like things are still just as horrible ANYWAY, and Kalorm's emotions sort of no longer buy that this will work. Whatever the cause, 'doing things on purpose' doesn't currently feel like a process under Kalorm's conscious control, and right now it doesn't seem to be happening. 

Halthis is not super expecting her patient to be in any shape to problem-solve! Inconveniently, Kalorm is also known to hate it when other people try to problem-solve on his behalf, which is just such a bizarre and irritating constraint. 

Okay. She's unlikely to make any more progress than Merrin or Tharrim on directly addressing symptoms. They've already tried all the obvious things, and Merrin, going by the recordings of her Kalorm interactions that Halthis watched while on the plane over, had managed to establish enough rapport that she had Kalorm's actual cooperation. Merrin is very neurodivergent and Halthis cannot be Merrin here, even if they weren't attributing at least half of Kalorm's trust in her to the fact that she was there when he woke up and proceeded to be around for the next 10+ hours. 

(It's going to be so annoying if it turns out that the main factor needed to get along with Kalorm is literally just "be in his presence for a single 10+ hour stretch".) 

Whatever. Halthis is also not, actually, particularly experienced at collaboratively working with patients to address symptoms directly, because most of her patients operating under Kalorm's current set of constraints - tired, brainfogged, in pain, with limited communicative channels, and not medically qualified in any way - don't want that. They want their highly qualified medtechs plus a team of world-class experts betting on prediction markets to figure out the optimal course of action and make it happen for them. But Kalorm wants to be the one making decisions for himself, despite a set of cognitive deficits that mean he is really disadvantaged at doing that. 

Merrin somehow made it work anyway, and it's really frustrating that Halthis can't figure out what Merrin was actually doing differently aside from "being incredibly superheated impressive as a person", and she can't ask because Merrin is deservedly resting right now...

...Hmm. On the surface it's hard to find any way to relate to Kalorm's clearly expressed desires here as a valid preference set rather than an inexplicable obstacle, because it's so bizarrely alien. But Merrin clearly deeply empathized with Kalorm's current state, to the extent that it apparently seemed totally reasonable to her on an emotional level, and that can't just be a Merrin-is-neurodivergent thing, because Merrin herself is clearly fine with smarter, better-positioned experts optimizing on her behalf, and would be a lovely patient. It has to be some other angle, some perspective-taking motion that Merrin did automatically, and she was able to onboard Tharrim to the strategies it generated but maybe not the underlying perspective... 

What was the perspective that Merrin was able to flip to, almost certainly at a pre-conscious level but enough to reshape all of her emotional reactions? How does reality need to be arranged such that Kalorm's feelings and decisions make sense? 

(Merrin doesn't think of herself as good at things, doesn't see her skills as rare and important - she's calibrated on what level of patient complexity she can or can't safely take on, clearly, but somehow she doesn't frame being a top Exception Handling endurance opper as special - is that even relevant, it feels like it might be...) 

...Somehow, what Halthis lands on is "how would she feel, if she were an ICU patient and her medical decisions were being made by a team of which no individual member had even a tenth of her domain expertise?"

She would be frustrated and terrified, obviously! She would feel strongly motivated to stay conscious enough to follow what was going on and advocate for her treatment needs, even if this was incredibly unpleasant. On an emotional level, she wouldn't trust the medtechs; even if she didn't expect them to screw up on a particular care item, she would want to be running that check, and in an exhausted and low-executive-function state (most easily emulated as "if it were happening immediately after one of her rare, horrible 8 hour shifts") she can easily see herself just refusing care rather than trying to wrestle her brain through that motion. 

That...sure does seem like it predicts Kalorm's current behavior. Kalorm isn't a medical expert, of course, but - it's not at all a stretch to say that he's the expert on Kalorm. (Halthis does not, actually, particularly think of herself as the top world expert on Halthis, but she's not that far from neurotypical, whereas the story of Kalorm's life that she's pieced together from his basic chart is one where he was reminded over and over and over again that Civilization isn't built for people like him.) 

...And Merrin doesn't think of herself as an expert and, on reflection, obviously that means having to make less of an emotional leap to see Kalorm as the expert on himself, and herself as - what - 'as Kalorm's employee' doesn't feel entirely right but it's closer... 

Or, you know, maybe Halthis is completely making that up by trying to find patterns where patterns may or may not exist! Maybe the strategy Merrin was using so successfully was based on completely different premises! 

But it's at least an angle that makes it easier for her to feel sympathetic rather than inconvenienced. Kalorm, reasonably-according-to-his-priors, doesn't trust the medical team as an overall system to understand let alone look out for his interests - Kalorm is clearly not very inclined to put his trust in systems in full generality - and trying to advocate for himself must be incredibly frustrating given his current condition and limited communication ability. And as soon as he starts to figure out some calibrated personal trust in a specific individual, they have to rotate off to get some sleep! No wonder he's in a bad mood. 

And, yeah, Halthis can't solve this for him, because she is not the world expert on Kalorm. And isn't going to get there in a shift, given how it just took her like ten minutes of furious metacognition to socially model Merrin in enough detail to generate her current best understanding, which is still awfully sparse. 

Probably the best she can do here is...try to buy Kalorm a bit more slack? Which honestly calls for most of the same actions that she would have taken if her goal were "optimize for Kalorm's recovery directly" but maybe the alternate framing is actually relevant. She's not going to make any decisions for him, just - figure out what the high-leverage decisions are, and condense down the important factors into something he can make sense of while under a heavy cognitive load. Basically exactly what the Emergency Admin Liaison does for the on-site oppers, summarizing and conveying the content of rapidly updating medical prediction markets and Treatment Planning recommendations during a fast-paced patient admission. 

(And this is one thing that Halthis can plausibly do better than Merrin! She has +1.75 SD of thinkoomph on Merrin, and isn't already multiple hours into her second >12 hour shift in two days.) 

Right. Patient still stable: check. Time to go skim literally all of the Diagnostic and Treatment Planning discussion and updates from the last 18 hours! 

The markets have substantially less bidding activity than they did during the initial rewarming period, but there's still a lot of liquidity, and plenty of material. Way too much to skim while multitasking watching an ICU patient! 

Both Merrin and Tharrim had defaults set for the summary-screen and initial further-detail screens, focused mainly on the probability spreads for outcome metrics, plus updating predictions on physiological processes likely to feed into those. 

(This is no longer an active emergency, but given the funding available, Halthis still has Full Support if she wants it. In fact, she was specifically promised that they would have more experienced high-acuity-ICU and emergency medtechs on hand in the command center, plus they have the full suite of admin personnel. If she wants a different summary, she can and should just ask them to make that exist.) 

....Yeah. Seems like a good time to try a different strategy! Halthis would like her support team to reformat the summary to focus on extrapolating their models of Kalorm's physiological processes and predicting Kalorm's current symptoms rather than future course, and get her a list of subjective symptoms ordered by a weighted multiplication of likelihood and experiential unpleasantness. And their best proposed treatment plans for addressing the top few symptoms on that list while minimizing any aggravating effects to other symptoms.

Particular focus on highlighting the full physiological causal chain behind any and all factors that might be contributing to brainfog, executive dysfunction, and whatever sensory processing issue he's been having. 

This only takes a few minutes! The information already exists, and in fact was being fed into Treatment Planning recommendations for e.g. which painkillers to try. 

The projected symptom list that comes up isn't all that surprising; there's a note that the ordering is uncertain because 'experiential unpleasantness' varies between individuals and Kalorm is neurodivergent, which is a major factor in why they've been deferring to Kalorm's self-reported symptoms. 

But here's a tentative ranked list! 

Post-surgical and trauma-related pain (causal factors: bypass incision, injuries including broken arm and cracked ribs with manual chest compressions x 10 minutes, frequent coughing and need for suctioning, patient refusing pain medication)

Mental fatigue and brainfog (causal factors: post-anoxic-injury brain damage, high doses of painkillers, electrolyte disturbances) 

Generalized muscle/joint/bone pain (causal factors: rhabdomyolysis, continued immobility, LYING ON THE FLOOR) 

Dizziness (causal factors: approximately same as for brainfog)

Physical fatigue and weakness (causal factors: approximately same as for generalized pain, plus electrolyte disturbances especially high magnesium, plus exhaustion from repeated minimum-ventilator-settings trials spaced way more frequently than the recommended rest interval) 

Nausea (causal factors: a ton of them! including gut stasis, painkiller side effects, direct symptom of brain injury, electrolyte imbalance, high blood urea, intubated with inadequate sedation, uncontrolled pain, patient refusing proper mouth care) 

Abdominal pain (causal factors: gut stasis and resulting constipation, gut lining damage, cramping from high doses of motility-increasing drugs to prevent nausea) 

Thirst (causal factors: on a ventilator, fluid restriction, refusing proper mouth care) 

Itchiness (causal factors: high blood urea, healing abrasions, immobility) 

Peripheral numbness/tingling (causal factors: local neuropathy, immobility) 

(It keeps going after that for a while. There are a lot of possible symptoms.) 

Halthis is actually kind of close to overdue on turning Kalorm. (Normally you could give this more leeway but he is LYING ON THE FLOOR rather than on a high quality weight-distribution mattress.) 

Kalorm finally seems to have actually fallen asleep, though, and she wants to spend a bit long staring at this, trying on her Kalorm-perspective-taking and figuring out if there are one or two legible, straightforward interventions she can suggest that might help with multiple symptoms at once and give Kalorm a bit more cope for the rest, and where the causal chain for how and why they might help will be something he can parse. 

'Painkiller side effects' are a suspected part of the causal chain for a bunch of other symptoms, but at Kalorm's current pain levels, plus the fact that they do really want to get him off the ventilator and so are reluctant to try an epidural or a more thorough local nerve block, it's hard to know how to avoid that; they've already trialed basically all of the painkillers strong enough to work on "recently had his chest sawed open" pain levels and also not contraindicated by his poor kidney function or likely immunosuppression. 

What other factors can Halthis maybe actually do something about... 

'Electrolyte disturbances' sure are appearing a lot! ...she'll tab through to look at the further-details on that... 

Yeah. His high magnesium level, in particular, comes up a lot higher on the "likely to cause brainfog and/or experientially unpleasant symptoms" list than it did on the "likely to delay his recovery or contribute to serious complications" list. (If anything, high magnesium is protective against the cardiac side effects of out-of-range potassium.) 

...Also if she tabs to just the causal flowchart of how "high magnesium" affects everything else in the system being modeled, it's a lot of things! Including at least one potential positive feedback loop, because high magnesium can contribute to constipation and gut stasis, which then - in theory, though mainly studied in patients who are, like, eating by mouth - contributes to lower magnesium excretion and higher blood levels. 

Going back to painkiller side effects: there's actually an uncertainty-flag on ranking pain first as the most distracting/distressing symptom. This is generally true - pain is bad! human bodies and brains were subject to very strong selection pressures to find pain aversive! - and also it's the one most strongly associated with Kalorm being visibly in distress. But there may be an observer bias there, since "facial expressions of pain" are very easy to parse even in a semiconscious patient, whereas "facial expressions of being itchy" are not so much. They're leaning a lot on assuming Kalorm would have definitely indicated it to them if itchiness were causing him more distress than his chest incision. But...there is potential reason to think that painkiller side effects are at least sometimes more aversive for him than untreated pain, since he refuses the drugs. (Though, you know, they're also putting significant weight on "Kalorm just refuses some treatments for weird Kalorm reasons.") 

(Halthis doing perspective-taking to empathize with Kalorm thinks that is an irritating framing. Fair enough if Kalorm prefers to minimize total number of individual medical interventions he's subjected to or something! She's of course extrapolating wildly to arrive at that guess for his motive, but whether it's that or something else, she trusts that Kalorm has a reason, one made of gears, that he could explain if he were able to actually communicate and it must be so frustrating the extent to which his communication channels consist of "medtechs who don't know him guessing what yes-or-no questions to ask" and a pictorial vocabulary of less than fifty "words".) 

All right. Plan. Halthis is going to consider that she gets a maximum of ten yes-or-no questions in a given interaction with Kalorm before the sensory-processing overwhelm for him starts to outweigh the information benefit for her. She is going to TRIAGE her questions. 

For this particular interaction: she knows he objects to something about the pain medication and Tharrim thought it was probably side-effects-related but did not manage enough communication to figure out WHICH side effects, which is unsurprising because Kalorm has limited stamina for being asked annoying questions by medtechs who keep bothering him. However, Halthis now has a LIST of symptoms that are likely to be bothering him and also could be exacerbated by painkillers, and unlike in many cases, Kalorm has been getting bolus doses and is awake enough to self-report whether he's more brainfoggy, dizzier, or more nauseated (if it's none of those, she'll ask about itchiness or other lower-down-on-the-list symptoms, but it's probably at least one of those.) 

Overall her suggested plan for him is going to be that he could maybe actually be on, like, half his current continuous-IV-infusion dose at rest, assuming her guess is right and he's finding the pain pretty tolerable then and other symptoms less so. If they do that then she does want to premedicate him for turns and suctioning, but he's already agreed that they can pre-medicate him with the quick-acting sedative, and if she combines that with literally the shortest-acting IV painkiller they have, the effect should overlap enough that he's basically asleep the whole time he would be dizzy or brainfoggy or nauseated or whatever - and the rest of the time he can maybe feel more like himself. 

Whether she gets into the Dialysis Conversation with him this round will depend on how the first conversation goes, and how overwhelmed or irritated he seems with her after that. It's not an urgent issue. But her plan is to go through all the symptoms that are likely being exacerbated by high magnesium levels, and ask if he thinks he can tough out another hour of [whatever is so terrible about the dialysis machine humming sound] on the chance that he might feel way better afterward. His cardiovascular system is in good enough shape that they can run the circuit at max settings and should be able to get his electrolytes totally normalized in less than an hour. Among the particularly-relevant-to-Kalorm pieces of information she can provide: high magnesium causes muscle weakness. Not usually severe weakness, at his current levels - only moderately out of the normal - but he has other risk factors, and for ideal muscle recovery they should really be keeping him right at the midpoint.

And he's been working really hard at his minimum-ventilator-settings trials – she's already had the thought that he must be about as much of a stamina monster as Merrin, most patients do that once a day and are pretty much done with anything challenging for the next eight hours – but obviously he's going to get tired faster if his respiratory muscles aren't working at top efficiency because too much magnesium is sloshing around in his bloodstream. 

Well. That's her planned angle to argue, anyway, and then she can mention that dizziness and nausea and brainfog are all possible side effects as well, and his actually-pretty-high blood urea levels aren't helping either. 

Enough of Halthis' past experience is with patients in mid-recovery that she is DISPLEASED about leaving his whole bowel issue alone for her entire shift. (Especially since she cannot help but notice that it's a whole additional risk factor for nausea! And unfortunately most of the stronger anti-nausea drugs they could try with him, if it does turn out that it's significantly bothering him, will make him drowsy and won't wear off in 5 minutes.) 

But Treatment Planning has some good points about why they shouldn't take it too fast, it's unlikely to be a big factor in his most disabling or obtrusive symptoms, and also the methods for addressing it more aggressively are...unpleasant, and undignified, and something even she would be grumpy about. Nobody likes enemas, especially from strangers. 

(Also, while they do really need to get it sorted out within 48 hours or else put him at significant risk of an actual bowel obstruction, the aftermath is not going to be more pleasant, for anyone but especially for Kalorm. He's probably going to lose most of his gut lining, like those poor post-chemo patients she's treated before. Halthis is fine leaving all of that for Merrin's next shift.) 

Kalorm predictably coughs himself awake when he's only 40 minutes overdue for repositioning. He looks around blearily without actually moving his head. 

...That sure looks like someone who's feeling dizzy or headachy and instinctively trying not to make it worse. 

"Hey," Halthis says, moving herself into his field of view. "It's 3 pm, you first woke up about 20 hours ago, it's been two and a half days since the boat accident. I'm Halthis." There's a note on the file that Kalorm prefers to be introduced to people by name, even though he's much less likely than Khemeth is to remember names. "I'm due to help you change position, and then I want to give you some updates on the treatment plan, but - do you need anything first?" 

Kalorm rolls his eyes in tired irritation, and then gestures vaguely at the suction tubing.