"I'm really sorry. You can sleep in the scanner if you want - the MRI is really loud, but there's as much soundproofing on the scanner bed as we can do, and I'll give you noise-cancelling headphones."

(MRIs are very loud. Even patients who aren't desperate for a nap or having sensory processing difficulties hate it! Also, the standard noise-cancelling headphones contain electronics, which are contraindicated inside an MRI tube. But since this is an issue that comes up very regularly, the room has a dedicated MRI-safe noise-cancelling-headphones setup, with the part that goes inside based on fiber optic technology and totally metal-free, and sterile disposable earpieces that can be swapped out for each patient.) 

"I'm going to put your pain meds button in this hand," she folds his palm around it, "and - can you use the hand on your broken arm for the call button? It's easy to trigger, it's a sensitive bulb you squeeze, and then we can talk back and forth with you via the headphones. If you start feeling nauseated again, we'll stop the test until we handle that, because it's too much of a risk if you vomit where I can't help you. We can adjust other medications from out here. It should take about forty-five minutes - it's interspersed with faster CT runs to get serial images of where your radioisotope injection is ending up. If we get an ambiguous result on whether there's a hole or leak, we may want to place a long nasogastric tube that goes a little ways into your small bowel, so we can give contrast via that route, but that's only if we can't distinguish it otherwise, and the MRI gives us really good resolution. Questions?" 

Kalorm is TOO SLEEPY for questions! He can probably manage to squeeze a rubber bulb even with his less functional hand, if he feels sick in there. 

He's going to fall asleep again within about twenty seconds though. 

If there were less urgency, Diagnostics might be pushing for a whole body scan; they're here anyway, and there are lots of organs where an MRI is the best structural assessment. But a full-body MRI at the resolution they want would take like an hour, and they have no specific concerns about his heart or lungs.

If the abdominal imaging isn't worrying and the patient is calm and tolerating the scanner, they might try to get a brain MRI, because it's more sensitive for detecting subtle damage than a CT. It's not really actionable diagnostic information, though; they know Kalorm is awake and talking, they know he has some deficits, whether and how fast those deficits might improve is variable between patients and an MRI won't give them much more detailed predictive information. 

Market predictions are unchanged: 20% likelihood on something blatantly concerning, which will be obvious within the first 10-15 minutes, and then a 40% likelihood of less catastrophic but still ambiguously concerning findings becoming clear over the remaining time. 40% likelihood that the imaging doesn't turn up any new findings, indicating that the problem - which undeniably exists - is more functional than structural, dysfunction caused by inflammation, and the tissue damage is mostly limited to the microscopic level of villi and microvilli. 

STRESS

- there is nothing incredibly concerning! No major immediately-obvious bleed. No pervasive peritonitis or obvious perforations. 

(Kalorm's vital signs hold steady. He needs another dose of atropine at one point. Maybe just because he's still pretty deeply asleep, with less sympathetic activity to balance out the parasympathetic signals from an irritated vagus nerve, and his blood pressure is clearly sensitive to the anti-nausea drug, which has a long half-life and will be in his system for hours. Maybe something more concerning than that. But Merrin is gradually coming down on the vasopressor infusion.) 

Lab results come back! Inflammatory markers, especially gut-specific, are even higher. (This isn't really surprising but it's not great.) Lactate is also really high, a sign of shock, though they did take it when he was having a serious episode of hypotension on top of a lot of recent exertion. Hemoglobin and hematocrit are down a touch, though this could just be hemodilution, it was drawn right after he got some saline fluid boluses. His white blood cell count is slightly low. Blood gas isn't amazing; the oxygen partial pressure is actually non-terrible, but with lactic acidosis on top of moderately elevated CO2 levels, the pH is down to 7.19. 

They grabbed another serial set of labs right before wheeling him out for the trip, when his vital signs had been more stable for a bit. It'll be back in ten or fifteen minutes. 

Merrin relaxes SLIGHTLY when the Diagnostic screen updates, confirming that none of the experts saw anything bad enough to call off the scan right now and rush their patient to the operating room. 

She's still pretty worried! She doesn't have direct line of sight on Kalorm, and it makes her antsy; there's a camera feed on the inside of the scanner bed, but that's never the same. His blood pressure is still pretty labile, and lower than it feels like it should be given his heart rate, which as usual flew up to 120 when he got the atropine. She does NOT like that lactate level even if it's theoretically fully explained by an involuntary intense ab workout followed by tanking blood pressure. 

The Diagnostic market on 'immediate surgery needed' closes. 

The market on 'further investigation justified' is bouncing around as a dozen radiology experts remotely pore over the incoming images and fill the side chat window with discussion. 

It's...not overall updating in the good direction, though. 

There's definitely radioisotope accumulation in the inner lumen of his small bowel, where it shouldn't be. It's not fast, a slow ooze that looks like it's coming from tiny veins or even capillaries, but it's also not tightly localized; there are at least a dozen potential hot spots, spread over a couple of meters of deep and hard-to-access small bowel. It's not a great sign; it means that the mucosal integrity is affected over a large area, and there are multiple potential routes for bacteria to be slipping into Kalorm's bloodstream. He's not running a fever or showing other obvious signs of septicemia, but he's definitely having a major systemic inflammatory reaction of some kind, and he's immunocompromised, which would suppress some early symptoms. 

And, of course, it means he's losing blood. Probably some of those bleeding spots are recent, as tissue finishes dying and breaking down and the gas and bacteria buildup in his stagnant bowel loops puts more pressure on increasingly inflamed and fragile mucous membranes. Maybe it was even triggered by the irritation of the enema; if he had been losing blood at the estimated rate for three days, it would have added up to a noticeable drop in hemoglobin, one that they didn't observe. He's going to lose at least several hundred ml of blood over a 24 hour period if this keeps up, though, and it may still be getting worse.

There's clear fluid and gas buildup in those middle sections, stretching and distending the diameter of bowel loops; the upper duodenum area is both regaining peristalsis sooner and also recently tried to empty its contents via an alternate route, and looks better off. The submucosal layer of connective tissue is thickened with inflammation and swelling, sometimes to more than 5 mm. There's also some amount of inflammation in the mesentery tissue, especially the gut lymphatic system. There's a tiny quantity of free fluid in the peritoneal cavity. 

On the bright side: circulation in the mesenteric arteries looks great! Assuming the microcirculation is also intact, Kalorm's gut is now getting all the bloodflow it needs to eventually heal, even if some of that blood is instead ending up outside his circulatory system. The smooth muscle wall of the bowel looks generally intact, albeit not doing its job very well right now. The outer slippery serous membrane might be slightly inflamed, part and parcel of that whole cascade, but it's not adhering to itself. The large intestine looks less affected; the connective tissue is swollen and irritated, but it's nice and empty and should have a chance to rest now, and there's no sign of ulceration or bleeding. 

Kalorm :( :( :( :( :( :( 

They're going to finish the full MRI - they do want imagery of his other abdominal organs, just in case he has more than one kind of problem going on - and, assuming Kalorm stays asleep and calm in there, they'll get the brain imagery and maybe even some lung imagery. That's a lot of inflammation, and the body is an interconnected system. Usually the greatest risk of toxic byproducts from the gut sneaking into the systemic circulation and injuring other organs is in the 4-12 hours after an ischemic injury – but Kalorm's inflammatory response was delayed by the long period of profound hypothermia, the resulting immunosuppression, and the fact that they kept him at 32 C for another 24 hours. Merrin's first note of concern was actually mainly a neurological observation that he seemed unexpectedly tired and out of sorts - and his breathing is fine overall, but his oxygenation dropped fast during the incident earlier. If they notice early inflammatory injury in his lungs or brain, that might actually have Treatment Planning relevance. 

It'll end up taking an hour total, but that also lets them grab a few more timeslices on the radioisotope scan and narrow down the uncertainty on how fast he's losing blood. 

This is entirely reasonable and also STRESS!!!!

Treatment Planning discussion proceeds! 

They'll in fact take him straight to the interventional radiology-equipped OR suite after this. They want to avoid doing even a laparoscopic investigation if possible; they're not especially worried about a perforation or frank peritonitis, poking and handling his inflamed gut - or even just inflating his abdomen with gas so they can see what they're doing - will only shock it more, and post-surgical pain will confuse whether his underlying issue is getting worse. But they'll draw a sample of peritoneal fluid, and they can use a very thin carefully-placed needle to get a few blood samples from the mesenteric veins before it joins the systemic circulation, and try their cultures and genetic-sample-amplification testing, especially once they have some initial sequencing results on his actual gut bacteria population and can cross-reference it. They'll also schlorp some samples of lymphatic fluid to check concentrations there of various inflammatory markers and potentially toxic cell death and bacterial-metabolism byproducts. 

Even that part is pretty fiddly; they would strongly prefer to do it with Kalorm under anesthesia, just so they can be sure he'll hold still. They also want to do a scope exploration from both ends, upper and lower; an upper GI endoscopy in particular definitely risks making an awake Kalorm vomit, not to mention it's spectacularly unpleasant on any safe level of conscious sedation. The lower GI scope is going to really hurt, and pain is itself can directly stimulate the parasympathetic nervous system. And then they want to do a guided placement of a long nasogastric tube, and start administering the bowel washout  solution while they can watch under high quality imaging whether this is actually flowing like it should or just hanging out and distending his small bowel even more. 

Even with that, they're pretty worried about post-procedure pain! They're considering placing an epidural; it wasn't really an option for controlling chest pain from his sternal incision without taking way too high a risk of respiratory suppression, but they can do an upper-lumbar-spine site that covers most of the abdominal area and definitely doesn't go near the diaphragm. It does have risks? Any invasive line is an infection risk, and the epidural drugs can also cause low blood pressure. But, ultimately, getting Kalorm through the next few days without making it a horrifically traumatic experience is ALSO a priority. 

(And there are real advantages to Kalorm's bizarre alien determination to be awake and participating in all of this? Most dath ilanis, facing down days of misery, would prefer to instead not do that, let alone take the nontrivial risk of choking on their own vomit and ending up with much worse medical problems. But it means that Kalorm is already building some strength, and maybe more importantly, exercising his cognitive faculties early. It's certainly getting them a lot of data on his cognitive status. And it means he can communicate symptoms, and 'subjective feeling of something wrong' is often going to come earlier than obviously abnormal vital signs or other measurable results.) 

- oh, also, before they do that, they want to start him on two more broad-spectrum antibiotics, one IV and one trickled down the nasoduodenal tube. They're the kind of last-ditch-or-only-for-REAL-emergencies antibiotics that are almost never prescribed, to make sure that on the occasions that they ARE prescribed, they are really definitely going to work. Combined, they'll cover just about anything plausibly in his gut, unless he picked up some kind of obscure ocean archaobacteria that that can somehow infect humans. For all that he was pretty stable before this, Kalorm is exactly the sort of patient that protocol is for. He's making progress, but his defenses and physiological slack are massively reduced, and he has some degree of damage to nearly every organ system in his body. Even with the broad-spectrum antibiotic he's already been getting since before reaching the hospital, the Diagnostic markets were guessing a 25% chance of systemic infection during the next week (20% of that gut-derived, 5% Something Else). And septic shock, if it gets that far (call it 30% odds, they're normally very good at catching infections but Kalorm is a tricky case) would be catastrophic for him. There's a 50% chance he would end up accumulating enough organ damage that he wouldn't ever recover fully, even physically let alone mentally. 

So. Antibiotics. INCONVENIENTLY they both cause nausea! The IV one is only every 12 hours and the nausea tends to last 30 minutes at most, so at worst they can just give him the final-backup sedating drug in advance. For the enteral one, they...can give a preparatory enteral nausea treatment beforehand, if he tolerates it poorly without that? Though it's usually given every 4 hours for 48 hours so that's inconvenient.

The hope is that preparing his duodenum with a gentle rinse of water (isotonic, to avoid having to account for dehydrating him by pulling water into his gut, and containing: drugs to stimulate muscle contractions, a drug with anti-foaming effects that reduces the surface tension of air bubbles and breaks up gas accumulations, and oily and soapy compounds to keep everything moving without friction against the fragile and sore mucosal walls) will reduce his nausea a lot and help his stomach actually stay empty. They'll start that process with him asleep, because they need to judge the rate and concentration of different components based on imaging showing how he responds, and going too high on rate or motility-stimulation will predictable cause a lot of discomfort. 

That's so many things! 

It's fine. Merrin is fine. All the things are reasonable. Just. Poor Kalorm. They're doing so many things to him. 

She flags in a message to the Treatment Planning team that she wants to talk to him once the scan is done, and get his agreement - or at least non-disagreement - to head to the OR. 

Of course. This isn't emergent surgery for a life-threatening issue; it's almost entirely diagnostic. It will inconvenience the OR specialist team less if Merrin can give a timeline? Is ten minutes enough? 

Of course. Ten minutes should be plenty. 

Merrin fidgets and FRETS, and catches herself biting her hand and then sits on her hands instead. 

She should check the Diagnostic outcome prediction updates but she doesn't waaaaaaaaaaaaaanna. They're going to be bad numbers with spiders in them. 

- that is an obviously stupid thought process. Merrin grits her teeth and checks the numbers. 

The market on getting Kalorm off continuous strong painkillers CLOSED, with a result on the optimistic side, but there's now of course a consideration of putting him back on them. 

Tolerating clear fluids (by mouth): 6 days / 10 days / 20 days. The 80% interval is mostly in worlds where Kalorm ends up getting emergency abdominal surgery. Getting significant calories from nutritious liquids (not counting tube feeds given far enough down that it shouldn't risk vomiting as much): 10 days / 16 days / 28 days. Timeline on being able to start giving him literally any fat or protein via his normal digestive system, even by jejunal tube feeds at 5 mls an hour: 5 days / 11 days / 19 days.

(They'll try intermittently trickling diluted glucose in water down there as soon as he has motility in the middle small bowel sections, to prompt cellular activity and repair, but he's not going to be absorbing anything more complex than that very well. He probably isn't going to be able to absorb drugs very well; they'll give drugs for local effects that way, but IV (or sublingual or skin patches) is still much safer for anything they want to definitely reach his systemic circulation.) 

Starting active rehab exercises: ....yeah this did not go as hoped and they're really unlikely to risk it this afternoon, even if Kalorm is feeling up for it. 18 hours / 24 hours / 48 hours, but the bid-ask spreads are still pretty wide here. 

Assisted walking at least 5 m: well, he might still make rapid progress once he's safe to begin activities at all! It's actually pretty likely that he'll have more energy and fewer obtrusive symptoms once his gut is cleared out; the tail risk is mostly that he needs surgery and his recovery is slow. 72 hours / 6 days / 16 days.

Unassisted walking: 7 days / 11 days / 25 days.

Off oxygen for >24h: 24 hours / 60 hours / 10 days. 80% interval maybe assuming aspiration or toxic-bowel-cellular-byproduct-associated lung injury.

Likelihood of a moderate complication: closed, since, you know, that happened. 

Likelihood of a serious complication: 25% 

Likelihood of persistent cognitive deficits: ....actually down, for unclear reasons? 44% 

Merrin doesn't think that's weird! Kalorm has been VERY GOOD on her shift today. He's talking in sentences! He's forming hypotheses about his symptoms and what evidence this provides about his condition! 

And then, finally, they're done. 

Kalorm is still at least half-asleep, his EEG ambiguous between phase I and II light sleep but definitely not awake. His sleep pattern was pretty fragmented, bouncing between light sleep and near-awakening and shorter bursts of REM, but he hasn't been moving around in there. His blood pressure is bouncing around in a 20-point range but generally acceptable, and he's nearly off all the vasopressors. 

He opens his eyes when they slide him out of the dimmed scanner bed into the well-lit room, though, and looks around blearily, clearly trying to remember where he is and what he's doing in this weird room. 

Merrin nips in beside him and reaches for his hand. "We're still at the imaging suite but we just finished. Do you want to hear about the findings or do you need a minute? ....Also, uh, do you want lip balm. I think I've got some. Noticed you keep licking your lips and that's not going to help." 

Nod. "Can - tell me," Kalorm adds. 

She balms his lips for him. 

"Uh, so, the good news is that we ruled out the worst kinds of problems that would be a medical emergency. The sort of bad - but also actually sort of good? - other news is that we did see some stuff that explains your symptoms. Main thing is that you're bleeding - a bit, not a lot and not fast, it looks like surface damage to the mucus membrane and not deeper ulcers. But in multiple places, from which we can infer that your bowel tissue integrity is weakened over a wide area. It's still not that likely to escalate to an emergency problem, but Diagnostics does want to get a closer look, so after this the plan is to head to the interventional radiology OR suite and prep you for anesthesia. We probably won't be doing actual surgery unless the diagnostics turn up a much bigger problem than we expect, but they'll do a tiny incision to get some samples for culture and analysis, and also a GI scope exploration from both ends. It's really uncomfortable, and would almost certainly make you nauseated and at risk of vomiting if you were awake. Following so far?"

She waits for his nod.

"And we'll also put in a really long thin tube through your nose, that goes a ways down into your small bowel, so we can give drugs that way while still keeping your stomach empty. And probably place a rectal drainage tube by scope - it's not actually as uncomfortable as you'd expect, they're super well designed, but the drugs and bowel prep solution we're using to clear everything out before it causes more problems are going to give you constant diarrhea for, like, days. Sorry, I know it's horrible, but it's better than having your small intestine full of overenthusiastic bacteria that will make you really sick if they get into your bloodstream. And this way you shouldn't even have to think about it. Okay?" 

It's horrible to have to choose between 'having constant diarrhea in his bed' and 'having yet another tube shoved somewhere that tubes should not be'!  Kalorm is really mad about it! 

...It sounds really inconvenient for Merrin otherwise, though. On top of the unpleasantness, that would be mean to her. He nods. 

Merrin squeezes his hand. "It should only take, like, two hours? Maybe three hours? It's almost 1 pm now, and we'll need some time to get set up over there. But we should definitely be back to your room by 4 pm, and I'll definitely be here until at least 6 pm. And then in the evening I think it's Halthis, and middle of the night will be Kerrin, so both people you know. ...Oh, forgot to mention, we'll probably place an epidural, to help with the abdominal pain without having to give you high doses of systemic pain medications that make you sleepy. You will probably be tired for a while after the anesthesia, but it's been a big day, it's okay if the rest of it is naps." 

Kalorm makes a face. "Tired already."