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Merrin working in Exception Handling
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Merrin's facial expression doesn't change, but her eyes are very intent on the monitor. Kalorm's heart rate is doing weird things now - there's a slowing, basically to the point of being a pause - close to two seconds of flatline between consecutive beats - and then it speeds up, and his breathing is shallow and rapid again. 

"Kalorm. Deep breaths. You're okay, just focus on breathing - I'm going to give you the backup nausea medication - do you feel like you're about to vomit–?" 

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Kalorm has no idea! His body seems to basically do whatever it wants at random! He feels really awful right now, though. He's lightheaded and dizzy and the wrongbadconfusing kind of too hot and there's a really unpleasant feeling in his stomach, like nausea but lower down, and he's slightly feeling like his body is trying to drown him in his own saliva. 

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"Kalorm, look at me. I'm giving you some drugs to raise your blood pressure." She triggers the two-minute program. It's only actually dropped by 5 points, but Merrin does not like the pattern she's seeing right now. Kalorm is going pale before her eyes, he's sweating and his heart rate is up at 125 and his eyes are squeezed shut. He's clearly trying to take deeper breaths, but he's breathing raggedly and noisily through his mouth, with a pause before exhaling, in the pattern of someone definitely working their way toward throwing up. 

She doesn't have enough hands right now! She wants to do an ultrasound to see if anything awful is happening in his gut (though she would be surprised, it was fine on her last check literally a minute ago, it's probably just a lot of parasympathetic stimulation at once from coughing while also having more pressure and irritation in his lower intestine) but she also really wants to be right there with the suction - actually, she should maybe do that right now, he's drooling on the pillow. 

"Kalorm, I'm sorry - I need to help you keep your airway clear, you seem pretty out of it. Can you look at me. Tharrim I need backup in here right now." She says all of this in a very calm level tone. 

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Yeah he can be in the room in five seconds. He goes straight for the ultrasound. 

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Kalorm really doesn't want to open his eyes right now. He tries anyway, because Merrin asked him to look at her, but he can't make them focus at all and everything is whirling and he closes them again. 

- here it comes, he's definitely about to throw up, he can taste bile and acid in the back of his throat heshouldwarnMerrinrightaway but that would involve talking which feels impossible.

He groans again, and then his stomach heaves, which is horrible, and it's not fair his stomach is supposed to be empty - and in fact nothing is coming up yet - but it feels full and he can't breathe because just about every muscle in his core feels like it's spasming, as though his stomach is a soggy towel and his body is trying to wring it out. 

He barely has time to gasp in some air before his stomach spasms again. 

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Merrin whips off the oxygen mask - it's not ideal, Kalorm's oxygen saturation is already down to 91%, probably because he's not managing to breathe very effectively and his body is throwing a lot of sudden muscle exertion at him - but it's in the way, and his airway is a more urgent problem. And it sure looks like the NG tube wasn't getting everything! She turns up the suction on it, and it's draining opaque greenish-brown liquid in bursts, but not quickly enough; the third heave gets a trickle of the same stomach contents from both his mouth and nose, and Kalorm is coughing and looks panicked

"Sorry sorry sorry–" She sticks the suction as far back as she can reach in his mouth, which predictably makes him gag again, but at least she catches the vomit. 

His oxygen saturation is down to 85%.

There's a tent-like oxygen fixture above the bed. Which is unfortunately not here, and Merrin can't leave him to grab it. 

"Command, we need more backup in here," she snaps. "Tharrim, any idea what–" 

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[Stand by, backup in fifteen seconds. Treatment recommendations pending same timeline] 

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"I'm not sure! His colon is a little more distended, and there's some peristalsis, but not a huge change. Watch out, though - something's triggering the vomiting reflex really hard, I'm seeing reverse peristalsis as far down as the jejunum."

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Great. Apparently Kalorm's digestive system is reacting to being irritated at the bottom end by trying to get rid of everything in the upper end! There might actually be partially digested food down there! Which Kalorm incredibly doesn't need in his lungs! 

- there are nasal cannula in reach, Merrin can at least yank those down and slip them into Kalorm's nose without getting in the way of her access with the suction, and run them at the highest safe rate. He's mostly mouth breathing but he'll get some of it - 

- the nasogastric tube isn't draining very effectively, possibly because there's some solid matter in the intestinal contents being ejected. Merrin snatches the tube-compatible syringe, fills it with sterile water, flushes 10 ml down, draws it back - ewwww - ok the suction is draining faster now at least, maybe part of the problem is that it's getting suction-cupped to his stomach lining, that's the downside of turning the suction power up and making it continuous rather than intermittent but Merrin doesn't exactly want to change that back right now - she'll use one hand to push water down in increments of 1 or 2 mls at a time, multitasking with loudly reassuring Kalorm and telling him to relax and breathe, and trying her best to keep his mouth clear - he's coughing again which means she probably didn't entirely succeed, but at least it also means his airway-protective reflexes are mostly intact - 

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Backup runs in! One medtech flicks on all the lights including the bright ones, and then runs to retrieve the oxygen tent device and haul it over; it's not very efficient, it sort of rests over Kalorm's head while leaving big windows on each side and pumping out a ton of oxygen, most of which just ends up in the room. 

The other medtech checks Treatment Planning for medical recommendations. 

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They're sending over the most powerful anti-nausea medication they have in stock. It's super sedating, especially given as a bolus instead of over 15 minutes, which is usually recommended but they need the results fast right now. It will probably drop his blood pressure but they can treat that, they should trigger the two-minute vasopressor program along with the bolus and stand by to restart a continuous infusion. And give him 400 ml of IV fluids at the fastest rate, mostly to see if he responds well. They want all of this emergency bloodwork. Someone should prep the large-bore irrigation-and-suction kit to try to urgently evacuate the enema contents and hopefully-loosened feces, he's really not coping with the delay.

And be on standby to intubate him for airway protection, if it looks like he aspirated, though Merrin was on that really fast and hopefully his lungs are okay. 

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Repeatedly flushing the nasogastric tube does seem to be helping it catch up; Kalorm is still retching occasionally, in between coughing fits and desperately trying to catch his breath, but he's not bringing anything up. His nose is running, though, which is probably not helping the oxygen nasal cannula get anything to him. Combined with the tent fixture, his oxygen saturation is no longer dropping. Though it's not rising either, and it's currently at 86%. 

His blood pressure is all over the place but mostly keeping a mean arterial pressure over 60. 

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Everyone else is working in silence, passing instructions and confirmations by subvocalizing to avoid noise-polluting the room.

Merrin is keeping up a continuous monologue, at Kalorm-parseable speed (and being conservative about it, because he's probably really distracted.) 

"Kalorm, it's okay, you're okay, just take slow deep breaths. Slower than that. Sorry about the lights and all the people - we just have to sort this out and get you stable again and then they'll leave. I said deep breaths. I'm sorry, this is going to be really un-fun, we need to go in and suck out all the stuff in your colon so it stops putting pressure on things down there, but it's only five minutes. You can do it. I'm right here. Breathe. Sorry about the suction I know it's uncomfortable but please don't bite it. You should feel better any second, we just gave you a really powerful drug to stop the vomiting. It'll make you sleepy for a few hours but we think that's worth it. I'm going to give you a dose of the pain medication, it's good that you're coughing and keeping your lungs safe but it must really hurt. ...Oh, they want us to give you a different muscle relaxant, too, make it easier for you to relax and settle down. I'm sorry, this is a lot of drugs, you're going to need a nap, but it'll be okay. I'll stay here." 

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The drugs they're giving all seem to hit him at once. Kalorm's body relaxes slightly. He manages to take a deep breath, and then another, without coughing. He looks like he's trying to open his eyes and completely failing. 

 

The nasogastric tube is still getting some drainage, but a more normal amount of it, not in spurts anymore. 

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[Stomach looks mostly decompressed] Tharrim confirms. He eyes the suction canister. [That was...400 mls? In less than five minutes? Wow.] 

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"There's some in his bed too," Merrin mutters. "Kalorm! Squeeze my hand." 

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"Kalorm? KALORM." Merrin pinches his nailbed. "Kalorm, if squeezing my hand is too hard, I need you to try to do something to show you can hear me." 

 

A faint crease of pain appears between Kalorm's eyebrows, but he doesn't otherwise respond to her. 

 

"- Guys. I have a bad feeling. Can someone hit the vasopressor protocol right now." 

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At the moment someone does this, Kalorm's blood pressure is actually fine. Or, well, tolerable, the wild variability had smoothed out when he stopped coughing, and it was hovering at 95/50.

But, of course, they had triggered the two-minute dosing schedule along with giving him the other drugs. Two minutes ago. 

 

 

Kalorm's color changes to ashy-pale a few seconds before his measured radial blood pressure starts falling off a cliff. 

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See!!!!! Merrin SAID she had a bad feeling!!!! Kalorm should have gotten more vasopressors already! And yet this is still happening! It's very unfair. 

 

"Escalate that," Merrin says -

- and she needs Kalorm flat, and the wedge only goes as flat as 20 degrees. It does not really feel like there's time to use the mechanical lift and get him into the bed. 

Merrin shrugs, leans in and gets her arms under his armpits and around him, like she's hugging him, and lifts his head and shoulders a few inches. It's an incredibly awkward position and her back hates her already.

"Tharrim get the wedge out," she snaps. "Grab that pillow - no not the vomit pillow, the other pillow - that one's too puffy, the thin one - can you hurry up before I drop him what's his blood pressure–" 

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(55/30. And he's having pretty profound bradycardia; his heart rate is in the 40s). 

He's breathing - Merrin can hear and feel that - but she had to temporarily dislodge the oxygen tent, and he's clearly not getting much air through his clogged nose. Oxygen saturation 74%. He's completely limp in her arms. 

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This is really not ideal and also Merrin's scrubs are now really gross. 

She gets him flat, though, rolls him into recovery position on his left side. She doesn't want to sternum-rub him right on his incision, so she gets her finger and thumb around the trapezius muscle between his shoulder and neck, and pinches it as hard as she can, yelling his name. 

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Kalorm's face scrunches in distress; he coughs weakly, moans, and tries, not very effectively, to flinch away from the source of pain. His heart rate briefly rises above 50 and his blood pressure recovers a few points.

60/35 is still not great. 

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URGENT from Treatment Planning: max out the continuous standard vasopressor infusion, another liter of IV fluids at the max rate (it's a precalculated Kalorm-standard electrolyte mix, incoming to the pharmacy chute) and give him a dose of atropine to block parasympathetic function. If no improvement to heart rate within 15 seconds they're starting an epinephrine infusion. 

They can wait one minute to see if he starts waking up a little; he's responding to pain and his airway seems clear. If any of his vital signs deteriorate rather than improving, though, they're intubating him for airway protection. 

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"Tharrim gimme a clean suction catheter. No the skinny flexible kind. For his nose, it's blocking his airflow and it's also disgusting and I'd better do it before he wakes up." 

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