When he's awake and restless for the sixth time, though, at 1:30 am, she recognizes the frustrated, despairing expression of someone who would currently consider paying their entire net worth in exchange for just one entire night of actual restful uninterrupted sleep. 

Sigh. A disrupted night of sleep is ALSO not going to be great for Kalorm's recovery. Sleep deprivation is bad for the immune system, which is the last thing Kalorm needs right now, and it's a major risk factor for delirium. Hospitals take that really seriously, because even when handled optimally, it correlates with lower thinkoomph measurements even years later. Hospital-acquired delirium is one of the outcome metrics tracked and publicly posted for a given hospital. 

Once she's reassured Kalorm and asked if he needs more pain medication (he says no) and persuaded him to at least let her rearrange pillows a bit to shift the position of his limbs, she checks to see if Treatment Planning has any suggestions here. 

Dath ilan hospitals also try pretty hard to avoid leaning on sedatives as sleep aids; they do make patients sleep, but it's lower-quality sleep, and most of the drugs are actually an independent risk factor for delirium, not to mention other side effects. With Kalorm so recently off the ventilator, and already facing a number of risk factors for various complications, Treatment Planning doesn't want to go there yet. The first-line interventions are usually the obvious environmental ones. This is a lot easier when patients aren't averse to having their problems solved sleep masks and highly optimized hospital beds. 

(It is possible that some of the experts contributing to Treatment Planning markets are getting kind of fed up with Kalorm's attitude here.) 

Second-line interventions are to treat pain and anxiety, again with non-drug interventions as possible; lots of painkillers also have weird effects on sleep. If that's still insufficient, they'll move to circadian-rhythm-resetting drugs. Many of those aren't available by default in IV formulation, or are contraindicated for Kalorm because of one of his various organ dysfunctions, but it's not as though it's the first time they've ever had a patient with insomnia who couldn't take medications orally. 

Current recommendation: she can try a melatonin sublingual spray, and a timed-release skin patch of another sleep-encouraging hormone. And they should prioritize reducing Kalorm's stress levels. Khemeth is off-duty now, but he previously left some notes on this, and – yeah, he strongly registered that giving Kalorm space and privacy is pretty key. Ideally they would avoid going in at all except at his request. That doesn't seem like a good idea yet, but if Kerrin feels comfortable with it, they do think that fully dimming the lights and screens, and monitoring him from outside the room, is potentially justified. She can turn him on his left side to minimize the risk of aspiration if he vomits suddenly enough that he can't call her first. They can switch the video feed to the low-light ceiling camera; it won't give amazing resolution, and even with image-correction it's not great for color resolution, but it'll let her see if he's restless, or vomiting. They can give him a call button, and place a microphone on his oxygen mask to pick up if he tries to say something. And she should actually go into the room and check on him at least every 90 minutes, regardless of whether he calls her, but - unless there seems to be an actual emergency - using night-vision goggles rather than switching on even the dim red nighttime-use lights. 

He's probably going to wake up at least a few times and ask to change position, but if not, they actually think it's probably worth tanking the bedsore risk of not turning him. (Normally, if he were in an ACTUAL BED, they could put it on the gentle-weight-shift setting, which generally doesn't wake patients up.) He's not in the highest-risk reference class, given his age and the fact that his mobility is likely to improve fairly soon – and he is at a pretty high risk of delirium, given the neurological sequelae of his ocean misadventure. In addition to this being important to avoid in order to get him the best possible eventual cognitive outcomes, there's also the fact that nobody expects a delirious Kalorm to be very much fun. 

Is she comfortable with that?

...That seems probably safe? Hopefully she can persuade him to let her use all the fancy pillows and gel padding, if she promises in exchange to stop bothering him. She's slightly worried that he'll eventually start oxygenating worse if he doesn't change position all night, but - yeah, she agrees that he's probably going to end up requesting it. She's been at least partially repositioning him like every half-hour since Merrin left. 

Note, they should maybe do it at shift handover rather than now? She wouldn't feel super comfortable taking over on a patient without actually properly seeing them (and seeing them through night-vision goggles doesn't count, you really can't assess skin color that way.) 

Actually, she's also curious enough now to pull up the chart and see who they have slotted to take over. 

Personnel had kind of a hard time arranging to cover this shift! The constraint isn't just finding someone who can work a 6 hour shift; it has to be someone Kalorm won't hate, someone with enough acute ICU experience to react quickly if something does go wrong, and someone who's willing to potentially commit to a week or more of working a six hour shift every 24 hours if it turns out they're a good fit. 

They considered options as creative as "a rank-two Keeper with some medical training, who thinks she can model Merrin's thing well enough to imitate it", but that would get very expensive for a week, and also Kalorm apparently really, really hates Keepers.

In the end, they're going with Dalthem, a 27-year-old rank-three medtech whose experience is mostly in the pediatric ICU. He doesn't have as much clinical experience with adult cases as is really ideal, but he has some, and the hope is that he'll be able to communicate better with Kalorm – especially a tired, groggy, irritable nighttime Kalorm. It's actually pretty normal for cognitive function to vary based on circadian rhythm, in patients recovering from some kind of brain injury, with around 4 am being the low point. 

Dalthem is also pretty much exactly median thinkoomph, or maybe a bit lower. At this point, there are definitely some speculations that Merrin's native communication style is easier for Kalorm to interface with right now because of her lower-than-average cognitive abilities. 

Huh. Taking this case sure is a way to meet people she wouldn't meet in the normal course of things! 

...She should, like, actually check with Kalorm whether he even wants to do the space-and-privacy plan. 

"Kalorm, hey. We're doing a shift handover soon, the new medtech is called Dalthem, he'll be here in twenty minutes. Once we've done that, we were wondering if you'd find it easier to sleep if we turn off all the lights for you and aren't in the room. Dalthem would be next door, so he can be in the room in about five seconds if you call for help or we see a problem on the monitors. Do you feel comfortable with that plan, and do you think it would help?" 

Yeah. See, if she wasn't in the room, then she wouldn't be TALKING to him right now. Kalorm scowls, but nods. 

"Okay. The thing we're most worried about right now is that you've been having a lot of nausea, and you're still weak enough that if you do throw up you might choke on it. So I need you to call us right away if you start feeling nauseated - we'll give you a button you can press to call the medtech in, and a microphone so we'll be able to hear you from outside the room - and it's going to be safer if you're sleeping on your side. And we'll need to tiptoe in and check on you every so often. But if you're not having issues, we'll try really hard to let you sleep through the night. Okay?" 

Yeah, whatever, okay. 

Dalthem arrives slightly early. He's very short, and doesn't look 27 at all; he looks younger than Merrin. He also looks very energetic for someone awake at 2 am. 

"Hey," he says cheerfully to Kalorm. "I'm Dalthem. I'm new on your case, but if we get along, I'll be sticking around for the whole week. I'm looking forward to it - I expect you'll be making so much progress." He grins. "At some point I might even get to take a report from Merrin in person! That would be so cool. - Yes, Kerrin, I know, I will not say that to her face." 

Kalorm is SO confused right now. It doesn't seem worth the effort of figuring out words to say and then saying them, though. 

"You hopefully won't see too much of me tonight, though!" Dalthem adds cheerfully. "I have to be awake, but your job for now is to get a good night's sleep, so Merrin can have a good day with you tomorrow. And I predict you aren't feeling chatty at 2 am, so - Kerrin, let's get this report done and get him settled for the night?" 

It's a straightforward handover report, though Kerrin tries to be very thorough; given his lack of clinical experience with adults, and the fact that he probably can't assimilate information as quickly as she can, it seems important to make sure he knows everything up front. 

(Though once she's covered the basics, she gets Kalorm's permission to give him the circadian rhythm drugs - he makes such a face about the taste of the sublingual spray, but mostly cooperates with letting it sit under his tongue so the mucus membrane can absorb it. And then they can multitask it with getting Kalorm nicely positioned on his side, with the help of most of the pillows in Halthis' stash. She has to walk Dalthem through a lot of it; apparently small children have different positioning needs, and he's clearly not accustomed to the whole improvised floorbed setup, though he seems to be taking it in stride.) 

The drugs have a pretty noticeable effect! (It probably helps that Kerrin gave him a dose of the short-acting pain medication before turning him, and on Treatment Planning's recommendation, also gave him the stronger nausea drug that they tried before, since it seemed to work tolerably well and didn't have awful side effects.) By the time Kerrin puts the call button in his hand, Kalorm can barely keep his eyes open, and the only thing in the world that he wants right now is SILENCE. Dalthem is so chatty. (Merrin is chatty too, sort of, but it's different.) 

...And then the lights are off and he's in near-complete darkness, and it's QUIET. It's wonderful. Apparently he did have a headache, that he's only noticing now that it's easing. He's about as comfortable as he ever is, and he lets the drowsy floatiness of the drugs carry him into sleep. 

Kerrin reserved some of her report for once they were out of Kalorm's earshot. 

"Keep a close eye on him," she says. "I mean, as much as you can from out here. Merrin had a nonspecific bad feeling, and pretty soon after that he had the weird vasovagal episode. We did some basic diagnostic workup that didn't show any obvious new problems, just the expected problems, but he doesn't have a lot in reserve right now. Just - be alert, and don't be afraid of escalating it to Treatment Planning and getting recommendations for more tests to run, if he seems to be deteriorating in any way – hopefully he won't, and we can let him sleep, but not if it means missing a complication. I'm inclined to take Merrin's bad feelings seriously." 

Dalthem nods earnestly. "Of course!" He fidgets. "I don't like the inflammatory markers being that high." 

"I mean, we were basically expecting that. Treatment Planning was thinking about trying to block some of it, but it's tricky to balance that with supporting his immune function, and we really can't afford for that to be any more compromised. But - hmm, Merrin didn't feel like the thing she was picking up on was caused directly by neurological damage, but I don't know if she's right, and even if she is, whatever is going on could cascade and start affecting that. I know it's awkward to get neuro assessments at night, but if you think you've noticed any slide - even if it's plausibly just that he's sleepy - don't be shy about escalating that, okay? And maybe have a low bar for waking him to get a more thorough assessment, or getting diagnostic testing even if it's inconvenient." 

She shrugs. "Hopefully it's - well, it's not nothing, but hopefully Merrin was just noticing effects from the organ dysfunction we know about, and it'll get better rather than worse from here. I'm just concerned that he may not be able to notice and flag new symptoms very specifically for us, given that he's clearly having sensory processing issues, and - he feels like the sort of guy who physiologically compensates and looks mostly fine until five minutes before it's an emergency. If we miss subtle early warning signs, he could deteriorate fast from the point when the signs are non-subtle." 

Dalthem looks thoughtful. "Huh! Kids are like that. Including on not being very capable of accurately reporting symptoms. And compensating pretty convincingly until they suddenly crash. I guess maybe my pediatrics experience is more relevant than I thought. ...Anyway, I think I'm good from here, you look more than ready to go get some sleep." 

It's unclear if it's the reduced light pollution, the drugs telling Kalorm's probably-very-confused circadian rhythm that now is time for sleep, or the reduced stress from having some actual space to himself and at least the illusion of privacy. (Or maybe Kalorm is just a night owl, and 2 am is around when he would normally go to sleep.) But something they did seems to have worked, and Kalorm settles into a much deeper and more relaxed-looking sleep than before. 

His oxygenation holds up, staying above 95% even as his breathing slows to a sedate 12-14 breaths a minute. His heart rate is a gorgeous 55 beats per minute.

His blood pressure is on the low side, though, despite the reduced continuous dose of pain medication. And it's labile, mostly staying above 90/60 but sometimes dropping to a systolic in the low 80s for a thirty-second interval before recovering. Given the low-resolution footage on the room, it's hard to tell if this is associated with anything in particular. 

Uhhhhhhhh should he be concerned about that? Should he take any actions about it? Blood pressure variability during sleep is actually pretty common, and not abnormal in itself; Kalorm is never low for very long, and it doesn't seem to be negatively affecting perfusion too much; his O2 sat reading doesn't budge. But also Dalthem is just, like, sort of on edge about his patient.

The markets are putting less than 5% that this is the first warning sign of a new serious problem. Dalthem should intervene if it drops lower than a systolic of 80, or stays below a systolic of 90 for more than two minutes continuously, but for now they think it makes sense to be conservative about that intervention; he can start with gently stimulating the patient (not necessarily even fully waking him) and seeing if that brings him back up. 

...Okay. 

He really wishes MERRIN were here, SHE can handle emergencies, which are scary (Dalthem is entirely competent at handling emergencies. He has all the certs that are remotely likely to come up, and if something comes up that he can't handle on his own, there are like five other people briefed on the case who can be here in less than two minutes. But, unlike Merrin, he really doesn't like emergencies. Emergencies are stressful! And scary!) 

He will continue observing his patient from a distance. 

The blood pressure weirdness doesn't get worse. 

Kalorm spends almost 35 minutes in very deep slow-wave sleep; he clearly needed it. And this time he doesn't wake up after his REM period, but slides directly to phase II light sleep again.

His oxygen saturation is slightly lower, at 94%, but that's not actually worrying, especially when they still have a LOT of room to go up on the oxygen concentration that he's breathing. His lung sounds from the wireless sensors are decreased at the bases, but not even very crackly (he's been occasionally coughing without fully waking up.) 

Dalthem is nervous about this, but he will run by Treatment Planning whether he can maaaaaybe stretch the interval for checking on Kalorm directly to like 100 or 110 minutes, to time it for when Kalorm is in phase II deep sleep and less likely to be woken by the sound of someone opening the door and tiptoeing into his room. 

(Treatment Planning thinks this is fine.) 

Kalorm has, somewhat impressively, managed to move enough to kick one of his pillows off the floor mat entirely. He's squirmed himself into a slightly diagonal position on the hard foam wedge supporting his head and shoulders at an angle. He looks reasonably comfortable, though, and doesn't wake up when Dalthem very carefully checks his peripheral circulation and skin temperature, or even when he adjusts Kalorm's arm to rest more comfortably on a pillow. 

(His feet are cool, but they seem to always be colder than the rest of him, and the pulses are strong.)