Kalorm considers this unhappily. 

He tries to moisten his lips again. "Hurts." 

"- Can you point at where it hurts?" 

Not very specifically! It's, like, somewhere vaguely in the torso area. 

Nod. "I think that's not very surprising. Your entire digestive system isn't in great shape right now, and - well, it's now been more than three days since your accident, and you haven't had a bowel movement during that time, because the whole system is basically stunned and semi-paralyzed after everything you went through. It's potentially dangerous, which is the main reason why we need to deal with it, but it's also going to be incredibly uncomfortable. But I do need to get a serial scan, in case it's become a worse problem than just that - there's a risk that you're bleeding in there, or have an infection - or even a perforation in your bowel wall, though you would probably look and feel worse than this if it were that." It feels slightly incorrect and bad not to be giving him the market odds, but there are pretty clear notes that Kalorm probably doesn't find this help and does find it more overwhelming to process. 

What had Merrin said? That it worked for her to just matter-of-factly tell Kalorm what she was going to do, and offer him a choice about setup or medications? And there's a more recent note that he finds it reassuring when people are experienced with a procedure, and especially with making it less uncomfortable. 

"I've done this hundreds of times," he says. "Usually with patients who are in pain - often a lot more than you, if they've had abdominal surgery - so I'm used to taking it gently. If you're very uncomfortable, though, we can give you an extra dose of the fast-acting pain medication, or a light sedative or muscle relaxant to help you stay calm and relaxed for it." 

"Pain," Kalorm manages to push out. (He feels a tiny note of satisfaction; his voice is sort of audible today, though very hoarse and he can't manage much volume.) "Maybe. Relax. Not sedative." A two-word sentence! He didn't even have to stop for a breath in the middle of it! 

"Okay. I'll give you the painkiller now, and I need to see what Treatment Planning recommends for a muscle relaxant. And I'll have to get the equipment set up. If the ultrasound gel texture bothers you, I can probably get away with only using some inside the probe sleeve, so it's not directly touching you? And it might be more comfortable warmed to body temperature."

More to the point, cold gel on someone's stomach is a great way to get them to tense up, which, one, is inconvenient for the imaging, and two, seems like something that might set off Kalorm's weird parasympathetic activation thing, which is currently one of the worst downstream effects of this whole problem. 

The pharmacy team will drop something down the pneumatic chute to him in about a minute and a half, selected to be short-acting and known to have minimal effects on blood pressure. 

...That feels weirdly good, actually? Maybe he was tense and hadn't noticed it? Though also it's making Kalorm aware that he is, at this point, actually pretty uncomfortable on his left side. His bottom foot keeps falling asleep, and his back is achy and stiff-feeling. 

Conveniently for this, Tharrim apparently has plans to change that! 

"Kalorm, I want to shift you more onto your back for this, okay? It'll be easier to reach and probably more comfortable for you." 

(Kalorm rolls his eyes but does not object.) 

Tharrim does it on his own; it's not complicated and he usually uses the lift equipment rather than call someone in. He unfastens just the lower torso panel of Kalorm's pajamas, so that he's otherwise still covered. 

(Kalorm really could use a proper bed floor bath at some point. They would have been careful about moving him much during the 24 hour period at 32 C - they might have quickly wiped him down with gentle-on-skin antiseptic as part of the standard infection precautions, but wouldn't have done a real soap-and-water bath - and then they went straight to waking him up, and clearly no one since has managed to persuade him that being clean is a high priority. Which it's not, really, but it's something Tharrim focuses on, because a lot of patients are just in a better mood if they don't feel faintly grimy.) 

"All right. This is going to take about five minutes to do properly, or ten if I see something weird. Please flag right away if you feel worse - especially nausea or lightheadedness - or if it's too uncomfortable to tolerate." 

...It's not even actually all that uncomfortable. The warm gel helps, and so does the fact that it's not directly on his skin. Random Medtech whatever-his-name-is turns out to be pretty good at telegraphing all of his movements so it doesn't end up being ticklish, though Kalorm needs to keep his eyes open in order to benefit from that, and he's tired. 

Tharrim explains what he's doing as he works, though trying to remember to be very non-technical about it.

"- There are actually some positive signs here. You have a little bit of peristalsis - movement - coming back in the upper region of the small intestine, that means your body is starting to respond to the drugs we were giving you to promote that. The lining is very irritated, though, so any movement in there probably does hurt, but it's important for it to be happening. You've got a lot of trapped gas in there, though, could be from bacterial overgrowth and fermentation." He moves the probe further down. "Some new thickening of the bowel wall, especially in the distal small intestine and in your large intestine. There's a lot of fecal mass in there and it looks fairly solid; normally the contents of the cecum, that's the sort of pouch where your small and large intestine connect, should be liquid, but they've been sitting there a while drying out. Mucus production is probably also disrupted, so there's less to lubricate it. Merrin is going to help your body out by administering hypertonic fluid and drugs that will loosen that and hopefully stimulate muscle contractions - it's not going to be incredibly comfortable at the time, but I predict you'll feel massively better after, and it cuts the risk of ending up with a serious infection. The good news is that your circulation everywhere looks good. The tissues aren't oxygen-deprived at this point, so they should be able to heal over time. And none of the smooth muscle wall looks structurally compromised. There's likely some nerve damage as well as inflammation involved in your body not sending or receiving the normal signals for muscle contractions, but it should heal entirely over the next month or two.”

(Which, unfortunately, is going to herald some very un-fun times for Kalorm - possibly weeks of painful cramps and diarrhea, as the dead cells of his gut lining slough off and leave behind still-living but very tender and irritated underlying tissue. He...thinks he'll let Merrin explain that.) 

It's probably good to know what ridiculous thing his body is doing THIS time, but that was so many words. Kalorm's attention is definitely drifting by the end. 

Fortunately, Tharrim is done! He doesn't even have a mess to clean up; he can just re-fasten Kalorm's pajamas and re-drape his blanket. 

"Is there anything else I can do to help you be more comfortable? Different pillows or blankets, a fan for airflow, to wash your face, mouth care - oh, and you should be safe to suck on an ice chip now if you want to try that." 

...Okay, Random Medtech is occasionally kind of cool! 

"Ice chip," he squeezes out. "...Fan? And...stretching...?" He attempts to gesture at his feet. 

"Of course! There's a note from Halthis that you were appreciate the passive range of motion exercises. It's good - it'll help get your muscles ready for more active exercise. - All right if I turn on the full lights? I can do only the lights behind you, so it's indirect and not right in your face, but it'll be good for resettling your circadian rhythm." 

With lights on (not full brightness, Kalorm was wincing about it and is clearly at least slightly light-sensitive right now) Tharrin will set him up with a fan, bring over an insulated vacuum flask with some ice in it and spoon out exactly one small ice chip for Kalorm to start with, and then stretch his feet and legs a bit. ...And his hands, he's clearly still struggling a lot with stretch and coordination, and hands-not-working is in many ways more disabling than legs-not-working. 

"...You know," he says lightly, "I'm not sure this will count enough as physical therapy for me to make any money off that market, but you can have a squeeze ball if you want, start working on getting some strength back. Think you're up for it?" 

...He's really tired, actually, but he's not going to back down from a challenge. "Yes," Kalorm says, rather than nodding, because being able to talk actually makes him feel a lot less helpless and stuck. "Can I - go -?" No that wasn't clear at all. Talking is powerful but words are so hard. "Alone?" 

"I won't be far, but - sure, if you're feeling okay right now, I can step out to the other room. ...By the way, we've now completely stopped your continuous pain medication infusion. Would you rather have a console of your own to control giving yourself doses - it's programmed with a maximum, you can't accidentally overdose - or call for me if you're in pain?" 

OBVIOUSLY he wants the one he can control, even if it's stupid that they don't trust him with it and put stupid rules on it. (And even if it, in fact, sounds like another Thing to have to do and there are already way too many Things.) "Console," Kalorm says emphatically. 

Tharrim can get that set up! And then give Kalorm (mostly an illusion of) privacy. He wants to catch up on market updates, and also it's nearly ten o'clock; possibly they have an ETA on Merrin at this point? 

Merrin is not, per se, out of bed yet. She's catching up on Kalorm's chart, though! Personnel yesterday was lovely and got her set up with temporary personal access to the system from her room. Merrin isn't sure if this is a good work-life balance habit to have in general, but for right now, it's exactly what she wants. 

The Diagnostic market on whether Kalorm will have Some Sort Of Complication isn't technically closed yet, but it's at 94%, and up to 19% that it ends up being medically serious. It's almost certainly downstream of something going wrong in his gut but they don't, actually, know that for sure and it could be something else they've missed entirely (market says less than 5% odds of a serious non-gut problem, though).

He now admits to having abdominal pain, and he's woken up a couple of times with serious nausea, the second time coinciding with a parasympathetic-activation-looking blood pressure drop. He hasn't actually vomited, and his nasogastric tube is draining slightly less, with analysis showing a little less bile reflux; the upper duodenum is starting to pick up a tiny bit of movement. (This is a good sign that he'll respond to enterally-administered motility drugs; they're bumping up the priority level on discussing a nasoduodenal tube placement with him. Minimizing pain medication also a priority but obviously not if the alternative is the patient being in severe uncontrolled pain.) 

In the meantime, though, they really do need to clear out his lower gut. They don't actually know when he last had a bowel movement before the accident – but storm began nearly 4 days ago, and if he was dehydrated or low on rations already at that point, he might have already been constipated going into the accident. His colon is certainly packed full, and given the reduced peristalsis, that's not going to resolve on its own and needs to be dealt with as a matter of significant urgency. 

They'll need to send a sample for analysis of his current gut flora, because that's probably all out of whack: there are thousands of known species of gut bacteria and a given individual has hundreds, but some will have been more sensitive to the period of hypothermia, and also he's been getting broad-spectrum antibiotics – though they're being given intravenously, and likely aren't getting very good penetration into the actual contents of his gut, especially given that the cells of the epithelial lining are likely mostly dead. If they can convince Kalorm to go along with a endoscopy at the same time as the nasoduodenal feeding tube placement, they can get some samples from higher up too; the duodenum should normally have only a sparse flora, but the ultrasound looked suspicious for overgrowth. 

...Unfortunately, Kalorm is very likely having some metabolic dysfunction downstream of this whole problem.

The gut flora actually play an essential role in the metabolism of a number of drugs – even ones given IV, if they're partially broken down by the liver and then sent out in the bile to be further processed by various bacterial enzymes – and then sometimes reabsorbed for a second round in the liver. But, right now, Kalorm's liver is not working at full capacity, and his gut bacteria are probably running around in circles screaming in confusion, AND his damaged intestinal lining isn't going to be absorbing any of the resulting byproducts very well. They're running mathematical models of how this is likely to be affecting Kalorm's metabolism of the drugs they're actually giving him, but there are a lot of hidden variables there. They can account for it by regularly checking actual blood levels of drugs and by giving him very expensive and carefully-developed maximally bioavailable forms of all the micronutrients his body needs, but getting a biopsy sample and culture will let them feed a lot more informed data into that modeling. 

Part of the problem is that the intestine isn't just a hollow tube. Despite its length – 7 meters on average, a bit more than that on a tall male like Kalorm, and with an internal diameter of about 2.5 cm, making for a total internal surface area of over 5 square meters – that's not enough mucosal surface area to absorb enough nutrients. To increase it, the inside of the tube contains rippled accordion-like folds of tissue - increasing the effective surface area 3-fold - which are covered in tiny finger-like projections called villi, forming a dense velvety carpet with 10-40 villi per square millimetre of tissue, and another 10-fold increase in surface area. Each of these projections contains a tiny artery and vein, a strand of smooth muscle tissue, and a lymphatic capillary that eventually drains back to the gut-specific lymph nodes, and among other things helps make sure that bacteria don't sneak into the central circulation. 

They're probably not in incredible shape right now - in particular, the lymphatic immune system around the gut is at high risk of dysfunction, and he almost certainly has some slow capillary bleeding across huge numbers of damaged villi - but the biggest problem is that the 30-fold increase in surface area isn't enough. Each of the villi is normally covered in a membrane of epithelial cells, and they also have fingerlike projections called microvilli, which add another 20-fold increase in surface area.

Except that right now, even Kalorm's epithelial cells are dead or dying. He's lost nearly all the benefit of that 20-fold increase, and it's going to take weeks for the epithelial lining to regenerate itself – weeks during which the bacterial-metabolism byproducts are just going to hang out, being absorbed very slowly if at all, while a significantly altered and outside-parameters bacterial population, deprived of their usual diet, make due by munching on sloughing dead cells (and plausibly hemoglobin from small local bleeding), and try to sneak into the bloodstream in search of richer pickings. 

The still-tentative plan, once the bottom end of things is cleared out, is to flush much of the small intestine's contents as possible, with hyperosmolar bowel prep solution that draws water into the gut, drugs to directly stimulate smooth muscle contraction, and potentially an electrical stimulation 'pacemaker' if that's not sufficient. Which will cause its own set of metabolic-dysfunction problems, but more predictable problems, and one less likely to spiral into systemic sepsis. And then they can get samples for a fecal transplant from his family members and hopefully his boat friends - this is a very personalized microbiome, with enormous variation between people, but genetic relatives and people in close contact eating the same food both tend to have more similar gut-flora composition - and reset his microbiome once the tissue is healed enough to benefit from it. 

(And, no, flushing the contents of his entire digestive system out the bottom end isn't going to be much fun for Kalorm either.) 

None of this is surprising, really, but poor Kalorm. 

Merrin is now sort of internally wincing at how much of this is probably directly downstream of those four hours she spent keeping his body temperature at 18 C. Her emotional associations on this are probably not entirely trustworthy, but certainly the thing she vividly remembers after the fact is that he was...surprisingly okay at 22 C? In particular they had the invasive sensors in his esophagus and rectum, still detecting bloodflow and activity. And then she screwed up his body on purpose, and it's - probably worth it, it was worth it in expectation, for the improved neurological outcomes it hopefully bought them. 

But it's one thing to make that sort of ruthless tradeoff in an emergency, and another thing entirely to stay for the duration of the aftermath, with a patient who's fully a person to her, who she knows, who matters to her – and who's now facing weeks of undignified misery. 

It's probably really stupid to feel guilty about this! In particular it's not helping her get together the impetus to drag herself out of bed! And Kalorm needs her.

(Also, for once, she's not actually performing in front of a camera feed, visible to world-class medical experts and probably Keepers. She can bite her hand really hard until her brain stops doing that. It's not entirely satisfying and it feels like maybe there's an adjacent thing that would be better, but she at least feels less like she's teetering above an abyss.) 

She messages Personnel to say that she can be ready to come in in an hour, and then gets up and takes an incredibly hot shower. 

Update for the on-site opper: Merrin is awake and says she’ll be there in an hour, so 11:10 am. She only just got up, though, so their current 20% / 50% / 80% probability spread is 45 minutes / 70 minutes / 90 minutes. 

Kalorm’s eyes are closed on the video feed, but the EEG claims he’s awake, soooo it does seem worth ducking in to let him know. 

Oh good. ...Mostly good. Apparently Merrin has to DO STUFF to him. He's really not looking forward to that, even if they're right that part of the reason he feels gross right now is because he hasn't pooped in days. What an incredibly stupid problem for bodies to have. Also some of Tharrim's descriptions were uncomfortably vivid and now he keeps trying to pay attention to how his abdominal area feels. Which is 'bad'. It's not the most painful part of his body right now - his sternum area still hurts more, overall - but it's somehow disproportionately a distressing kind of uncomfortableness.