Awwwwwwwwwwwwwwwwwwwww. That's adorable. (Dalthem's face does not show this. A lot of kids also hate when adults react that way to things they thought were perfectly serious, especially when they're already in prickly or fragile moods because they're in a strange bed somewhere and feel sick.) 

"We...can ask?" he says. "She was here until almost 11 pm with you last night, so I think she might not be awake yet at eight. If you want, I can send Personnel a note and they'll check with Merrin once she is up? Maybe she can come in at 11 am or noon, rather than 2 pm. And we can let you sleep through shift report, if you don't need anything, and maybe Tharrim can avoid irritating you too badly if it's only for three hours?" 

...Wow, time is really confusing right now. It does seem mean to make Merrin wake up early. Waking up early is also horrible, as Kalorm is CURRENTLY EXPERIENCING; he's not going to do that to Merrin too. 

He nods. 

Okay! Great! That could have gone a lot worse! 

...Hopefully the bloodwork isn't terrible, and he can in fact let Kalorm sleep through. He ducks out to dispatch it and then check market updates. 

Diagnostics super wants that abdominal ultrasound. They had already wanted to do a scheduled interval-check set of imaging between 5 and 6 am, and with some reluctance made the call to put it off so that Kalorm could get some quality sleep. Obviously they aren't going to do it without patient consent, but it would be great to get patient consent as soon as possible. 

Without that, they'll test for a detailed panel of inflammatory markers related to the gut in particular, and compare the change there. Really what they need is a colonoscopy (and maybe endoscopy from the top end of things too) for direct imaging, measurements of muscle electrical activity, and samples – but they can't do that until all the stool parked in his colon is dealt with. They could still miss a bleed in the small intestine, the region that can't be accessed even by a very flexible computer-controlled scope. Under normal conditions, there would use a capsule that patients can swallow, that has a tiny camera attachment and travels all the way through the gut until it can be retrieved and plugged in to download the data. Even with healthy patients it's a 24-48 hour turnaround, though, and they're not sure that would even work with Kalorm. It might not be safe; he doesn't have enough gut motility to definitely move the capsule along. 

If they have reason to suspect a serious problem – if his hemoglobin drops, say, or his white blood cell count rises – and they're not sure enough of his intestinal wall integrity to even want to risk an enema, then they can haul him off to the MRI-and-other-imaging suite, and get more inconvenient images, possibly including by injecting him with some radioactive isotopes to trace any bleeding - and if that looks potentially bad, then their remaining option is exploratory surgery. Which is really not what Kalorm needs at this point in his recovery, and he's at particularly high risk of complications, so hopefully it won't come to that. 

Ugh. Yes, he knows it's important. He's also pretty sure that trying to push the matter right now will do the opposite of help; he feels like he's built at least a tiny thread of fragile trust with Kalorm, but leaning on it too hard too soon will break it. If Kalorm is still cranky about it when he wakes up next, then...hopefully Merrin will wake up on the earlier side of things and be up for a weirdly timed middle-of-day shift? Dalthem has the sense that Kalorm is much more okay with being touched by Merrin; that she no longer feels like a stranger to him. 

(This is something that comes up for kids, too, especially two-year-olds.) 

What are the updated outcome predictions on various measures? 

Updated 20% / 50% / 80% spread on getting Kalorm off the strong painkillers: 3 hours / 4.5 hours / 8 hours. He's only on a moderate dose, at this point, and it doesn't seem like pain is his top source of distress. The drug may actually be making his gut function worse. At this point they're mainly waiting for him to be awake for the day, so that they can do some education on using a patient-controlled analgesia setup (and so that he doesn't fail to give himself any doses for hours until he wakes up in agony). 

GI recovery: continuing to update in a not-great direction! Tolerating unrestricted clear fluids is now 5 days / 8 days / 12 days. (The upper end starts to account for cases where they end up needing to do exploratory abdominal surgery.) Tolerating liquid nutrition, 7 days / 12 days / 18 days. He's definitely not likely to be getting his cookies for a while. 

Starting rehab exercises: 7 hours / 14 hours / 30 hours. The spread actually widened, here: they're basically not going to try this until he's had an enema and scope done, and only if it goes well. For one, he's incredibly not tolerating exertion at this point. Decompressing his gut somewhat could help a lot, if the issue is parasympathetic irritation, and washing out the stagnant and plausibly overgrowing gut bacteria will help if there's some local bacterial translocation going on. And of course if they find a minor slow bleed they can patch it. The hopeful 7 hour estimate is one where Kalorm is miraculously in a better mood when he wakes up next, or Merrin comes in on the early side, and they get all of that done before noon, and a much better-feeling Kalorm as a result. The pessimistic predictions are mostly of worlds where they need to do some more invasive interventions, up to and including surgery. 

Assisted walking at least 5 m: 60 hours / 5 days / 12 days. Again, the most pessimistic worries here are predicated on a serious gut-related complication delaying everything. Other than that, though, his lungs are in good shape and his chest incision seems to be healing well; if they can stabilize his gut issue and get the nausea under control, he's going to be SO motivated to get up and walk.  

Unassisted walking at least 50m: 5 days / 9 days / 20 days.

Off supplementary oxygen for a contiguous 24 hour period (time interval counted as the start of this 24 hour block, though the market of course won't close until it's over and confirmed) is one of the few spreads that's straightforwardly improved, to 36 hours / 4 days / 7 days. 

Likelihood of a moderate complication, not necessarily medically dangerous but enough to delay his recovery: well, he is definitely starting to drop hints that he might already have a complication like that, the hope is just that they can get it under control before it negatively affects anything else. 75%. 

Likelihood of a serious complication: up to 16%. 

Likelihood of permanent (mild) cognitive deficits: slightly up again, to 49%.

Sighhhhhhhhhh. 

Kalorm is already solidly asleep again, going by the EEG. He looks comfortable. He's doing more frequent blood pressure dives, but his baseline is still high enough that it's not dropping to concerning levels. 

Lab results come back (not all at the same time) and are pored over. 

...The improvement in his kidney function has maybe leveled off; his urea and creatinine are still rising. His magnesium is now above normal range, which could be contributing to blood pressure issues, but nothing is dangerously (as opposed to unpleasantly) outside parameters yet. They'll leave him be, and someone can have that conversation with him once he's awake. It would definitely be convenient if he agrees to it on the early side, so they can get it done before Merrin has to give him an enema, something that will predictably cause parasympathetic stimulation and related problems in itself. 

Hematology is unchanged: if he's bleeding in his gut, he's not yet losing significant blood that way. His various subtypes of white blood cell count are also unchanged (a few of them are abnormal for expected reasons to do with his ongoing immunosuppression). In a patient like Kalorm, this doesn't necessarily mean an absence of infection; his body might just be failing to respond to it via the usual channels. 

Liver enzymes, and liver-specific damage factors: still steadily rising, as ischemic and inflammatory damage marches along, but not spiking in the way that would hint at a new dysfunction. 

Neurological-specific damage factors: most of them are unmeasurable, which is good, though of course systemic blood draws aren't as sensitive a test. A few are still present in measurable quantities, but low, and still dropping. 

Skeletal muscle damage: not worse, still on a trend of gradual improvement. 

General inflammatory response factors: so high, pretty much across the board, except for a few which are abnormally low and indicate subtypes of immune dysfunction. This isn't great - and probably explains Dalthem's observation that Kalorm looked sort of like he should have a fever - but also isn't really surprising. 

Gut-specific damage and inflammation: yep, pretty significant spike since the last panel. Not to an extent that would indicate new tissue ischemia or death, so probably his circulation is still functioning fine and it's just the gut lining that is suffering, but it's suffering pretty badly. They really need that followup ultrasound. 

Is that a bid for Dalthem to go in and wake Kalorm and try to coax him into it? Because, uh, he'll try if they think it's critically important to do this on his shift, but Dalthem is kind of worried that it might actively backfire, and result in Kalorm settling on a stubborn general policy of refusing the test and possibly not even changing his mind for Merrin. 

...Well, if he doesn't expect an attempt at persuasion to work, then he shouldn't do something that won't help and might do the opposite? Just. It's in fact important. (There is some degree of quietyelling going on, behind the scenes, about patients who refuse treatment for no reason.) 

...He'll see if Kalorm wakes up before his shift change. It does seem possible that if he has another bad nausea episode, he might be more amenable to figuring out how to better treat that. 

Kalorm sleeps right through, though. 

Tharrim is not incredibly looking forward to this shift, but - well, it's pretty exciting that Kalorm is off the ventilator! Communication should be much lower friction! He's way better at building rapport with patients who can talk. And it sounds like today is mostly a holding pattern, for him, unless Kalorm's mood swings around to 'good' once he's slept. There's of course a possibility that Kalorm has a major medical complication on his watch, but despite rising concerns, the markets think there's less than a 15% chance of that over the next six hours, and down to 6% if he ends up only here for 3 hours. 

(Kalorm might also literally sleep through Tharrim's shift, since they're apparently avoiding disturbing him except when he calls them, and Merrin apparently might be in by 11 am.) 

Anyway, he mostly wants to figure out the building blocks of working with Kalorm, so that once Kalorm is ready to start rehab, they already get along. Physical rehab is one of the areas where Tharrim has vastly more expertise and certs than Merrin, who really only has the bare-bones basics and is plausibly going to end up having a very educational week or two. Anyway, Tharrim is actively looking forward to that! But he's not intending to push Kalorm especially hard on anything today. Maybe do some deep breathing and coughing exercises with him if he's awake and seems open to it. 

He gets a report from Dalthem in the adjacent room. 

Dalthem is some combination of incredibly relieved to be handing over a patient who is overall still pretty stable, and feeling sort of bad about how the 80% intervals on a bunch of the outcome metrics are worse than when he started. He relates very seriously that Merrin had a Bad Feeling and Merrin's Bad Feelings are not to be taken lightly and, while they are in fact committed to respecting Kalorm's sleep time (which he's sure Merrin will appreciate, later, if she has a patient who isn't extremely cranky from sleep deprivation), he should watch him super closely and be ready to respond if there's a problem. 

Kalorm, for his part, is still fast asleep – though he's now spending much less time in slow wave sleep and longer in REM, a decent indication that he's clearing some of his sleep debt. 

8:30 am. Still asleep. 

9:00 am. Still asleep.

9:15 am. Blood pressure drop that lasts slightly longer than usual, nearly a full minute at 90/45 before it straggles back to his previous baseline. 

9:17 am. His predictable sleep pattern is breaking up a bit, going from slow wave sleep to what looks like increasingly light sleep without a REM interlude. 

9:18 am. Abrupt EEG transition to wakefulness, simultaneous with another blood pressure dive. They don't normally happen that close together. 

It's been a really boring hour and a half, and Tharrim can't remember the last time he was this thoroughly caught up on a patient's entire chart history. 

- the first time wasn't concerning enough to go in, just to flag to Diagnostics with a question mark, but for this he's not going to wait for Kalorm to call him. He heads in. He's not running, but he's definitely walking briskly, and he switches on the dim red light without asking first and then gets awkwardly down on his knees beside the floorbed rather than figure out a chair. 

"Kalorm. Are you okay? Your blood pressure did a little drop."

More than a little, actually, it's down from 102/55 to 85/40. [I'm giving him a push of the short-acting-vasopressor] he subvocalizes to Treatment Planning, already tapping it in on his portable console. 

where is he? why is everything red? why can't he move? why does he feel so terrible??? 

(Kalorm's eyes are open, but not really tracking Tharrim. He's breathing in short little pants. It's hard to see perfectly in the dim light, but he looks pale, and he's definitely drenched in sweat.) 

Yeah this is definitely kind of concerning! 

"I'm going to give you the drug for nausea," he tells Kalorm, because he really looks like someone who's about five seconds away from vomiting. "Try to slow down your breathing, okay? It'll help. ...You look like you might have been too warm, I'm taking your blanket off so you can get some air. You can ask for it back if you feel cold." 

His temperature is still totally normal, though. ...No, running a quick mental check against his previous values over the last 24 hours, 36.1 is actually running low for Kalorm. That's...not great. 

He gives the max dose of the main anti-nausea rescue drug, and then also the standard dose of the backup one they apparently started using yesterday, and giving both of those at once risks dropping Kalorm's blood pressure again so he taps the program for one of the other vasopressors, a slightly longer-acting one; the default is a set rate for a three-minute period, rather than all at once. 

Basics accomplished, he reaches for Kalorm's hand. "Can you squeeze my hand? I need to know if you can understand me right now." 

There's suddenly less terribleness? It's still kind of a lot of terribleness, though, and now on top of that he feels shaky and floaty and weird. 

He is not super tracking who the Random Person talking to him even is, but he can squeeze the Random Person's hand (with a five-second delay, after he manages to successfully parse words.) 

Okay. That's good. And his blood pressure is responding promptly, also good. 

[I'm inclined to pause the pain medication] he subvocalizes to the command center. [I think it's not helping with this, and we can switch to boluses as-needed] 

"Kalorm, are you feeling any better? Your vital signs are responding well but I don't know what's bothering you the most right now." 

Kalorm manages to nod. He was, in fact, intensely nauseated thirty seconds ago - which is the absolute worst way to wake up from a deep sleep, and he's quickly developing a deep and abiding hatred of the experience - and now he's at least significantly less so. He's also sort of half having an out-of-body experience, and his heart isn't actually beating unreasonably fast but feels unpleasantly thump-y n his chest. The room still feels like it's spinning, or at least gently rotating. 

"...That was a slightly awkward introduction. I'm Tharrim, I took over from Dalthem - he was the night shift medtech - about 90 minutes ago. It's around 9:30 am now. - Do you need the oral suction?" 

It probably wouldn't hurt. Kalorm is exhausted again, but he manages a tired nod. He's already forgotten Random Medtech's name. 

Tharrim makes sure to be very gentle and careful with the suction tip. 

"I expect that wasn't a very pleasant wakeup," he says. "You've had a pretty reasonable number of total hours of sleep, though, and at this point I think it's a good idea to figure out why you're having these symptoms. Can you tolerate the ultrasound scan of your abdomen now, do you think, if I try very hard to be gentle with it?"