"Well, then, consider the anesthesia a free nap?" Merrin pats his shoulder. "You've put up with a lot today. Ready to go, so we can get this next bit over with?" 

Sigh. Nod. 

Kalorm stays awake for the transfer-on-rails back to the main bed chassis and then his second hallway transit of the day. He even tries to look around, but it's clearly taking a lot of effort. 

Aaaaand they're there! Merrin always relaxes a bit when they get to a destination and are no longer in a HALLWAY where she has like HALF HER USUAL EQUIPMENT. 

(Tharrim, she notices, is also looking pretty worn out.) 

"- You can go after this, I think?" she says. "They've got a whole on-site team, I'm not sure I'll even have much to do, and your shift was ending at 2 pm anyway. See you tomorrow, maybe? Unless there's enough people in the rotation that you get a day off, I feel like you've maybe earned a day off." 

They slide Kalorm over onto the OR table base, and half a dozen medtechs swarm in to get set up. Merrin is not especially trained on this. (She's done sims where she had to do surgical procedures alone in sketchy circumstances without backup, but it's not really the same skillset.) She mostly hangs close to Kalorm and tries to narrate everything that's happening. 

They modify the bed settings (the mattress folds up narrower to give easier access to a patient). Since Kalorm seems both calm and cooperative, they'll do the epidural placement while he's still awake, though with a mild sedative. They redo all the infection precautions - swap sheets for sterile ones, wipe down his whole body with (warmed) antiseptic cloths, then plop eye-protective goggles on him and bathe him in UV-C light, relatively safe for skin but reasonably effective at neutralizing microbes. They'll do much more thorough local sterilization of his abdominal wall, but not until he's out. 

Epidurals are bad as a concept, but apparently also MAGIC, because Kalorm can no longer feel the ongoing stomachache and pervasive wrongbadness at all. It's such a relief. 

(It drops his blood pressure some, they need to go back up on vasopressors, but - honestly less than they were worried about? It's plausibly helping tamp down some of the random parasympathetic noise flying around, even as it directly reduces his sympathetic nervous system activity.) 

Merrin squeezes his shoulder. "Ready for the anesthesia?" 

What's he going to do, say no? And - at least Merrin is here. He trusts her, if she says that he'll wake up in two or three hours. (Unless there's an emergency, but, well, in that case it's really sort of on him for having a medical emergency in the first place. He should just instead not do that.) 

- he's apparently going to stubbornly try to stay awake as long as possible, though.

...Yeah, no, that does not super work. He's out in 10 seconds. 

The team is super efficient. They have a breathing tube in and the ventilator hooked up within 15 seconds, without his oxygen saturation ever dropping below 98%. They gradually increase the anesthesia (and vasopressor compensation for it) until the EEG shifts from a pattern vaguely like EXTRA-deep sleep to a flattened line with occasionally bursts and ripples. They start running the new ultra-powerful antibiotic - might as well do it now when he won't notice side effects - and hook up a blood transfusion, because his hemoglobin is on the lowish end of normal and it really won't hurt to bump it up to the high end of normal instead.

(They have like eight more bags of blood, if he catches them by surprise with a sudden massive bleed, but that seems unlikely.) 

They're going to prep for the upper GI scope first - but as an initial step, they want to swap the current nasogastric tube for the lead opper's favorite model! It's slightly less comfortable, despite being made of softer plastic, because in addition to the main suction lumen, it has two side components, one passively open to the air - to prevent suction-cupping to the stomach wall - and one for irrigating with fluids. It has a slippery nonadhesive coating inside to make drainage easier, and a 15 cm flexible silicone coil at the end with over a dozen different drainage holes, making it safe to use for long periods with continuous and more powerful suction. 

...Yeah, Merrin's helicopter did not have an entire cabinet with twenty-eight different kinds of gastric tube. That's so cool! Merrin would perhaps normally be really bored, since she has approximately nothing to do except obsessively refresh screens now that her patient is unconscious and no longer in need of reassurance, but it helps that she's not at all tired yet - it's been like two hours! - and this is fascinating. 

You know what, while they're at it and since this isn't an emergency or anything, they're going to rinse out Kalorm's sinuses properly with saline and then an antibiotic solution. Since, you know, it wouldn't be any fun for him to end up with a sinus infection on top of everything else. 

(Note on the chart: the thicker tube diameter means that one, it should be gently rotated and re-taped at a different angle every so often to avoid pressure ulcers on the inside of the nose, and two, patients often cannot super breathe through that nostril. Kalorm will probably be coming back from this procedure with the full oxygen mask again anyway, to make sure his lungs get lots of humidity, and hopefully his oxygen needs will be lower by tomorrow.)

And with that done, and some irrigation fluid hooked up, they'll do an upper GI endoscopy! 

The anesthesiologist is good at her job. Kalorm, judging by his EEG and complete lack of even a frown or twitch, has no idea this is happening. 

COOOOOOOOOOOOL!!!!!! 

(Merrin has very basic certs for this. She can tell if someone has an ulcer or a similarly obvious problem. She isn't really sure how to interpret more subtle abnormalities, but the Diagnostic market screen side chat window is very helpful for figuring this out!) 

Observations: stomach lining is moderately swollen and irritated-looking, and the electrical and muscle activity is definitely abnormally reduced, but otherwise it actually looks okay? There's fresh mucus production and no ulcerations or discolored areas. 

Aaaand going in deeper! They slide the probe past the pyloric sphincter, which is still a lot easier than it should be, and then swap in the powered enteroscope attachment - it has a soft and slippery coating, but slightly grippy spiral ridges, that 'grip' the tissue folds and pull the head of the scope deeper when the motor rotates it. They'll need to be cautious on a patient like Kalorm, to go gently and avoid putting tension on the intestinal lining - and it's pretty risky to approach the section with the highest frequency of suspected bleeding spots - but they should be able to get at least 3 meters in. 

And????????????

It's pretty gnarly! The lining is reddened and discolored in patches, and in at least a few places the mucus lining looks loose over fluid-filled blisters. There's a lot of gas and...unrecognizable slimy stuff? 

Really cool and also disgusting! 

They'll irrigate and suction it as they go, which also gets a bunch of gas. It's probably a good thing the gas is going directly into a canister, since it almost certainly smells awful. 

They make it almost 280 cm in before the lead opper expresses discomfort at how friable the mucous membrane looks down here. They haven't found any active bleeding areas, but the slime they pulled back came back positive for containing hemoglobin, so it's likely that some of those discolored or blistered areas were previously bleeding. 

The very top of the small bowel has reasonable peristalsis, and - maybe more relevantly - responds to mild irritation with higher activity. This trails out pretty quickly in the later sections, though. They relieved a bunch of the gas pressure, and pulled out a lot of gas and slimy dark brown fluid, which they're sending for analysis but visually looks convincing as a mix of bile, bacterial overgrowth, sloughed-off dead epithelial cells, and digested blood. They also trickled some CT contrast medium in - not the best kind, but non-irritating and non-toxic even if some of it leaks through damaged membranes into Kalorm's bloodstream or lymphatic system - and all of it stayed where it was supposed to be rather than feathering out into the abdominal cavity. 

They collapse and pull back the enteroscope to about 30 cm deep in the small intestine, just past the junction between the initial duodenum and later jejunum. With a second camera unit slid down the probe in Kalorm's esophagus to directly view the stomach. With real-time imaging guidance as well, they slide a soft small-caliber feeding tube with a lightly weighted tip (non-metallic and MRI compatible) down through Kalorm's other nostril, guide it to the sphincter, and nudge it down until it meets the probe. 

Kalorm tolerates all of this with no reactions or opinions, given that he's unconscious. He's still requiring a lot of vasopressor support, but that's probably mostly the anesthetic, and his blood pressure is at least much less variable. 

Nearly an hour in. They're making good time; Kalorm is helping them out on that by not having any weird complications that need stabilizing. They're at least halfway done, maybe more. 

They'll start trickling bowel prep medium through the feeding tube now, laced with juuust enough of the extra-safe contrast that they can see it super clearly on image checks. It's plausible that some of the decreased movement in there is actually a direct result of general anesthetic shutting down the nervous system signals to the gut, but in that case it should still respond to local signals, and they can calibrate dosing. (They're using ultrasound to follow moment-to-moment movement and circulation, but for more detailed slices including any sign of bleeding - conveniently the radioisotope is still in his blood - or leaks, they're going ahead and using a low-powered CT protocol.) 

Lower GI scope! As expected, his large intestine is somewhat less concerning. The mucous membrane lining is irritated, but already looks slightly less swollen than before; relieving the pressure on it is helping. There's no discoloration and no sign of bleeding. 

They rinse everything out very thoroughly, and then - with enormous care - thread the thinnest and most flexible scope into the terminal ileum, where the last section of small intestine releases its contents. It's harder to safely get very far from this end; the gut doesn't like things going the wrong direction. But they can get it around 30 cm in, take a small biopsy of the bowel wall, and then irrigate and drain some of the contents from higher up by infusing the bowel prep solution while moving the patient through a series of position changes so that gravity will help them out. 

It'll take longer to get the full culture and gene-sequencing data on the bacterial contents, but they're also sending samples directly to the pathology lab for visual inspection under a powerful microscope. 

Kalorm doesn't really like all the repositioning! He's deeply unconscious and shouldn't be feeling it, but his blood pressure is swinging wildly. 

His gut is responding better than it might have to the solution they're dripping down his feeding tube, at least? There are more ripples of peristalsis, contents are moving, and overall it doesn't look like this new activity is setting off any bigger bleeds. 

It's not necessarily a sign of something badly wrong; the epidural could be contributing, and Kalorm is deeply sedated enough that his neurological control systems for functions like blood pressure are partially shut down. It's not delightful, though. Treatment Planning orders more albumin and a new backup vasopressor to have ready before they make the small incision in his abdomen to collect samples. 

They're going to very thoroughly re-sterilize everything first. Kalorm's main risk of infection is from the inside, but that doesn't mean they want to stack any more odds than necessary on top of that. 

They numb the skin with local anesthetic, even though Kalorm shouldn't be feeling anything right now, and then make an incision less than a centimeter long, carefully one layer at a time through the skin and what little subcutaneous fat Kalorm has, then through the fascia and muscle and peritoneal membrane. They instill a small and cautious quantity of humidified CO2, just enough to be able to move the probe and see what they're doing; it's warmed to 32 C to avoid irritating the delicate peritoneal membrane.

Kalorm's blood pressure HATES this. 

Well, they'll try to be efficient, and then be particularly thorough about removing the gas they put in there. They're going to need to restart the epinephrine infusion to get him through the next ten minutes, though.  

On visual inspection, the small bowel loops are definitely swollen with tissue edema and distended by their still-backed up contents, but the peritoneal membrane doesn't look inflamed, and there's less discoloration or visible signs of tissue damage on the outside of his bowel. They can visually see some areas of peristalsis. 

Drawing blood from the mesenteric veins in a few locations goes fine; they use very thin needles, and spray the withdrawal sites with an absorbable 'liquid bandage' to seal the damage and prevent bleeding. They take a sample of the small amount of free fluid hanging out in the pelvic area, and then irrigate the abdominal cavity with saline and suction it out again to get a more comprehensive sample. They draw fluid from a couple of swollen lymph nodes. 

Nothing aside from the blood pressure drop goes wrong. They need to shift his position around again to be sure of getting all the gas out, and Kalorm ALSO isn't particularly a fan of this, but they have a lot of wiggle room on the epinephrine rate and can prevent anything from getting disastrous. 

Less than ten minutes, and they're done and closing the tiny incision, covering it with a small dressing. 

RELIEF! Merrin is really impressed with this operative team but this was still really stressful to sit through!