[...Registering that I'm vaguely stressed about that but I'm not sure why]

She'll do it, though, and draw and send blood, and then PACE and WORRY. 

Message to Merrin: she came in earlier than originally planned today and it's been an unexpectedly intense shift. Does she need someone to relieve her at six, or can she manage until eight pm when Halthis was originally scheduled to come in? 

She doesn't want to leave until Kalorm is OKAY that's really not a plan that will...work, here...but she'll be fine until eight. Without stimulants, even. 

Bloodwork comes back. It's mostly not that different or worse, but Kalorm's white blood cell count is down, now notably below the usual lower limit. His lactate, which had eventually returned to normal after his  is veeeeery slightly elevated. His liver enzymes and damage markers are worse. 

Merrin does NOT LIKE THAT! 

...She's going to click in to see the full breakdown on white blood cell counts. 

The abnormalities are still, at this point, mostly fairly subtle. 

Eosinophils, which mainly respond to parasitic infections, allergic reactions, and cancer, are skimming the bottom end of the normal reference range; basophils, also an allergy-response subtype, are also at the low end of normal. Monocytes, the precursor to macrophages - the cellular workers that clean up dead cell debris, as well as bacteria from an infection - are actually high. Natural killer cells are present as well, indicating damaged cells, which is in no way a surprise. Lymphocytes are, again, technically within the reference window but barely clinging to the lower end of it; there are also trace quantities of lymphoid progenitor cells. 

Neutrophils - the main cells that respond to a bacterial infection - are markedly low. Not low enough that Merrin would normally panic about it, though, if she were just looking at an immunocompromised patient and trying to judge their generic level of vulnerability to infection. 

However, Kalorm is a lot more than just "generically vulnerable" to infection; there's a giant reservoir of bacteria sitting in his gut and, despite their best efforts, refusing to go anywhere just yet, and they've already confirmed that some of those bacteria have made it into his circulatory system. 

And there are significantly more than trace quantities of myeloblasts – immature cells yet to specialize into neutrophils or their cousins – and a measurable presence of the even less mature common myeloid progenitor cells. Which indicates, roughly, that his body is trying to muster its resources to respond to an infection, and his bone marrow, damaged and struggling to keep up, is making a move of desperation and sending out immature cells, metaphorical children, to do their best to bolster the insufficient mature neutrophils. 

AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAHHHHHHHHH

Okay, Treatment Planning has seen this, right? Because this is really concerning, even if it's still pretty early stages of really concerning and Kalorm is still not all that unstable. Yet. Merrin has the DOOMIEST FEELING. She isn't sure what they can or should do about but an itchy feeling in the back of her head is yelling with increasing volume that they need to do something RIGHT NOW. 

Treatment Planning is aware! They've been aware for the same length of time Merrin has, e.g. less than thirty seconds, but the discussion window already split up into about fifteen different topic threads and they're escalating it to Finnar and Khemeth's attention to see if they want to throw more labor-hours at subsidizing the relevant markets. 

They've already started the most powerful antibiotics they have available. They're in a position to provide supportive care immediately if and when Kalorm needs it, because they agree that, antibiotics or not, Kalorm's condition is likely to deteriorate before it turns around. If it does. Early sepsis in an immunocompromised patient could get very bad, very fast. 

...It's not great for him, it's going to risk chewing up his liver function, but they're going to start him on antifungal drugs as well. Less because they suspect one now, and more because Kalorm is scarily close to running out of slack for surviving any more complications. They also want to escalate to more obtrusive powered leg-compression sleeves to minimize the risk of deep vein thrombosis, because at this point they can't safely give him even the small, purely preventative, doses of anticoagulants that they started after he was fully rewarmed, and treating a blood clot causing problems would be fraught for the same reason. They want to do preventative respiratory therapy as much as Kalorm will tolerate it; even with antibiotics, if his body is sufficiently overwhelmed, he's at higher risk of picking up additional infections, and they're already dealing with one bacterial reservoir and can't risk another one brewing in his lungs. 

The priority is dealing with his gut, before larger numbers of bacteria translocate; the inflammation response is going to be making the gut-blood barrier even more permeable. They're worried about two things: ileocecal valve dysfunction preventing his small bowel from draining into his large intestine even now that his colon is clear and no longer backed up, and the paralytic ileus further up meaning that the contents don't even get that far. They're moderately hopeful about his current response to the enteral bowel prep solution and motility-increasing drugs, but it's clearly going to take a while for the solution to trickle all the way down, and it's not at all clear that they have that time. 

Their first and overall-least-invasive option is to manually force the ileocecal valve open. This is normally not a great idea, but the risk is mostly of stool backing up from his colon, carrying bacteria that don't belong in the higher gut. If they're carefully making sure to keep his colon drained – and giving enough drugs to ensure that what comes out is easy-to-evacuate liquid stool – then it's probably their best option to at least prevent that part of the problem. The terminal ileum is less distended than the deep middle sections of the jejunum and proximal ileum, but there's enough there that, given the empty cecum just below it, it should be triggering the reflex arc to open the valve. The fact that it's not is suspicious for more serious nerve damage than they had realized.

Anyway, they have very good imagery of the area, both on scans and direct visualization during the colonoscopy; they can 3D print a carefully shaped tube that will stay in place without causing any further tissue damage. And they're going to consider the risks and benefits of placing pacemaker electrodes via that route, versus taking him back to the OR to cut tiny incisions in the connective-tissue membrane covering his small intestine and place a fuller set directly on the muscle layer. The latter is more effective, and less likely to cause further damage to his gut lining, but it's involved – another procedure needing general anesthesia, which is pretty stressful on a potentially-deteriorating patient – and it presents an additional infection risk as long as it's in place. 

If they go that route, they would likely want to keep him under and in the OR for at least an hour, observing his response, because if it's not good enough, the next, last-ditch option is an ileostomy – picking a place just below the point of worst distention, pulling a loop of his small intestine to the skin, and surgically opening it to drain directly. The "loop" ileostomy is a simpler procedure (and much easier to reverse) than an "end" ileostomy that involves cutting the intestine entirely and pulling the upper cut end to the skin, but it's only doable if there's no tissue death. It didn't look like there was any non-viable bowel tissue earlier, but the situation is evolving fast. Merrin's ultrasound imaging can only capture the flow in vessels large enough to see, and can't directly visualize the tissue to judge its perfusion.

With the inflammation going wild, Kalorm is at moderate risk of developing multiple microvascular clots and blockages, killing off whatever local section of tissue those vessels supply. This is hard to do anything about, since they can't anticoagulate him, and can't use catheterization techniques to directly clear blockages in vessels that small. But even small patches of ischemia mean a risk of gangrene in the dead tissue, bowel perforation, and massive peritonitis, which Kalorm is unlikely to survive let alone recover from without major, permanent organ damage. If they operate and see any splotches of dead bowel, they'll have no choice but to remove those sections and go with an end ileostomy for whatever's left – and hope that they can preserve enough viable bowel to eventually stitch back together that Kalorm will be able to survive on a specialized oral diet rather than being permanently dependent on IV nutrition. 

The markets on outcomes modulo various treatment options are still pretty preliminary but there will be actual numbers on it soon. 

AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAHHHHHHHHH yeah ok she knew this was bad but this is too many spiders. put some of the spiders back. this is not an acceptable way for the world to be because Kalorm is very good and he has to be okay and he is definitely definitely not allowed to die

All right. Focus. Kalorm is NOT ALLOWED TO DIE or to get disastrously sick enough that the septic shock causes more brain damage, but right now he needs Merrin's help with that, which means that Merrin needs to be CALM and FOCUSED and do all the right things. 

She still has to take a couple of deep breaths before she can make herself look at the updating predictions. 

The Diagnostic experts think there's a 20% chance that Kalorm's gut situation will resolve with the current treatment plan in motion, within 4-6 hours and without any deterioration in his condition that would prompt them to escalate. If they add the ileocecal valve device, that rises to 35% – if they include placing a couple of electrodes to stimulate the terminal ileum (and hope that the nerve plexus is intact enough that this will result in some signals making it further up and informing the stagnant area that it's fine to move along now), then 40%. 

This isn't a great number! And Kalorm's odds of a good outcome, especially if they end up resorting to major abdominal surgery, are definitely worse if they wait until he's already rapidly deteriorating. 

The main complication that would prompt them to escalate faster is sudden worsening hemodynamic instability; the markets think there's a 20% chance of this within 2 hours and a 60% chance within six hours (assuming they haven't yet escalated the treatment). Kalorm is arguably already hemodynamically unstable, already in the early stages of shock, because he's requiring vasopressor support, even off sedation and with lots of fluids. His lactate is rising, hinting that not all of his tissues are getting enough circulation for comfort. He's hanging on for now, but barely; if his blood pressure crashes enough that they need to restart the epinephrine, this is a very bad sign, especially because it will reduce circulation to the gut and dramatically increase the risk both of microvascular blockages and ischemia, and more bacteria slipping through an undersupplied epithelial barrier. It would at that point be reasonable to go straight to the OR – but anesthesia on a patient already requiring that much vasopressor support even without sedation is not a reassuring prospect. Even if he makes it through, they're risking long periods of profound hypotension, which won't do his organs any good – and that includes his brain, so they're not just risking a longer and more grueling recovery, but much worse permanent deficits. The markets think that if they wait until Kalorm is deteriorating before trying a last-ditch surgical intervention, there's a 20% chance that he crashes while in the OR, a 10% chance of cardiac arrest, and a 5% chance of significant and prolonged enough oxygen deprivation to pull him over into the "moderate" brain damage category.

(The odds that, in the short run, they wouldn't be able to resuscitate him after a cardiac arrest are low, probably less than 1 in 500 - at worst they'll just put him back on the full cardiopulmonary bypass - but it would drastically worsen his outcomes, and increase the risk that he doesn't survive to hospital discharge, up to maybe as high as 10%. Assuming they can avoid letting it get that far, the median fatality rate for "sepsis in immunocompromised patients" is around 5% - but most of those patients are pretty sick going into it; they often have cancer and received chemotherapy, or are on immunosuppressants for an autoimmune condition, or have a genetic immune deficiency that tends to come along with other health problems. With Kalorm in particular, given that he's still, at this point, not looking terrible, and they have a good idea of what precisely went wrong and have already started antibiotics - they think that his baseline risk of dying from this is around 1%. One in 100. Still not a very happy number, but...better.) 

They should definitely avoid this! The problem is that even an uneventful and successful surgery will have a number of negative effects for Kalorm's recovery and long-term prognosis. Going in and handling his intestines will only make the motility issues worse and slower to resolve, he's simultaneously at risk of bleeding AND of developing clots, and it will escalate the systemic inflammatory response even further. The antibiotics are hopefully going to get the infection under control, but they can't count on that doing anything to halt the inflammatory cascade once it's already gotten this far. 

Other potential complications:

- Significant respiratory deterioration. This could be because of a missed deep vein thrombosis ending up in his lungs (though despite his skyrocketing risk for clotting dysfunction, the markets put less than 5% odds on this happening in the next 6 hours and 1% in two hours), or - more likely - downstream of systemic inflammation making his capillaries leaky, and sending toxic cell-death and bacterial-metabolism compounds to damage lung tissue, which they think is about 30% likely to happen at all within six hours badly enough to require much higher oxygen (15% within two hours) and 15% likely to result in needing to be reintubated for purely respiratory reasons (only 3% within two hours, he has a lot of reserve). If he requires a lot more fluids to maintain his blood pressure, that's also a risk factor for pulmonary edema - only 10% likely, his heart is still in relatively good shape, but independently from the others. 

- Deteriorating mental status, to the point of needing reintubation just for airway protection. This is a lot more likely if he's also having other physiological deterioration - 70% if he becomes significantly hemodynamically unstable - but it could happen in isolation, just as a result of cascading inflammation and neurotoxic compounds in his blood. They think that's 10% likely in isolation over the next 2 hours and 20% over the next six, but it bodes especially poorly for his recovery. Increasing confusion or delirium is even more likely, call it 40% in the next six hours. 

- Deteriorating kidney function from the sepsis. Prolonged low blood pressure makes this almost certain, but even if they can maintain his hemodynamics, the inflammatory cascade alone is about 15% likely to cause this to happen within 6 hours (and 30% likely within 24 hours, but at that point they'll have made a decision on treatment, one way or another). It's not an immediate medical emergency, unlike some of the other complications, but it's not great for his long term prognosis.

- Cardiac arrhythmias. This isn't that likely if they keep his electrolytes in parameters, but they're still calling a 10% chance that his heart becomes irritable enough to start throwing potentially dangerous arrhythmias within 6 hours (though only 3% within two hours.)  

- Massive GI bleed. Call it a 2% chance within two hours, but a 15% chance within six hours IF they haven't decided to escalate yet despite a not-very-effective response to the conservative treatment. 

Adding up all of those dice rolls gives a pretty not-great overall risk! But Treatment Planning thinks it's probably an acceptable risk to take for two hours - by which point they'll have at least a preliminary sense of how quickly peristalsis is increasing along how much of Kalorm's gut. They are, needless to say, going to monitor him SO closely, and think hard about which other diagnostic tests would be informative and worth the risk. 

This is pretty worrying! Merrin is worried! 

It's slightly comforting to have numbers on the badness of the situation, at least. There are too many spiders but at least she, like, has a spider count? Which is not 'infinity'? And the chances of Kalorm literally dying on her in the next two hours are still incredibly low. It had briefly not FELT to her brain that that number was very low. 

[I'm going to check with the ultrasound every fifteen minutes] she tells the command center. [And I think we should send more bloodwork right away if there's a significant change in his vital signs - or anything else, really. ...Is there a point when I should wake him and do a full neuro assessment? He'll be cranky but I'm worried about him, and I– if we leave it too late, we might not have a chance to explain to him what's happening and what might happen later] 

Treatment Planning...thinks Merrin should be the judge of that? They are, to be clear, planning to go with Khemeth as a spokesperson for Kalorm's preferences if Kalorm himself is unable to make medical decisions. All else being equal it seems good if Kalorm is involved in those decisions, but like, he might refuse treatments even if clearly informed that they give him the best chances of a good outcome. 

Merrin does NOT literally hiss at the cameras about how they are incapable of respecting Kalorm as a person. Instead, she takes a deep breath, and surveys his monitor data one more time before approaching the bed and reaching for his hand. 

"Kalorm. Hey. Sorry, it's time to wake up." 

Kalorm's eyes flutter open. Behind the oxygen mask, he clears his throat. "What...?" 

Mental checkmark: patient spontaneously saying words, which make approximate sense in context! The spiders could be worse than this! 

Merrin squeezes his hand. "It's about five-thirty pm. I want to check your belly again, because you're not doing incredibly well right now. We're worried from your bloodwork that you have an infection, from the bacteria in your gut, and it might already be systemic." 

Kalorm makes a visible effort to force his eyes open all the way. Licks his lips. "How...bad...?" 

"Stop that. I'll get you some lip balm." Merrin does this, briefly lifting the oxygen mask for it and then re-settling it.

Then she looks seriously at him. "It could be pretty bad. You're probably - almost certainly - going to survive it and be okay in the long run, but you could get very sick. Your immune system is in bad shape, probably because the hypothermia and the rewarming protocol was hard on your bone marrow and it's not able to make new cells as fast as possible. We're seeing immature white blood cells, which means that your body is trying to fight something, but doesn't have any fully matured cells in reserve to deploy. Which means that you're pretty immunocompromised in practice and your body is going to have a hard time fighting the infection, but it's still sending out a lot of panic signals that something is wrong, and those can set off a pretty nasty cascade of other effects. We're giving you a new really strong antibiotic that should definitely cover anything you could possibly have in your blood, but it's not going to be able to reach the reservoir of bacteria in your gut, and the antibiotic we're giving you down the feeding tube isn't getting to everywhere yet because you're still kind of blocked up in there. So we might have to take more drastic action about it, because it's going to be really hard to get on top of this as long as your gut might keep dumping more bacteria into the rest of you. Does that make sense?" 

Kalorm's eyes are definitely focused on her. He looks...pretty scared, actually. 

"What - treatment?" he manages. 

Merrin reaches out and squeezes his shoulder. 

"We're going to have to do another scope to place a sort of tube thingy in the spot where your small intestine drains into your colon, because it looks like the reflex for the valve there to open when there's stuff to drain and room in the colon isn't working. This should help with some of the problem. It's going to be fast to put in and - kind of uncomfortable during but it shouldn't be afterward, and the epidural will help. We might also slip a little wire up with electrodes to help stimulate the muscle in there to do more. And then I think we're going to wait two hours and see how it's going, unless you start getting much sicker – so you need to tell me right away if you feel worse in any way, okay? ...How are you feeling right now." 

Kalorm frowns. Considers this. 

"...Tired," he admits. "Feel weak. Achy. M'cold." 

Merrin nods. "Your body might be trying to give you a fever, which would make you feel cold, but - your body temperature is actually down, even though we're trying to keep you warm. Some of it could be from the anesthesia and from the surgery itself, but it looks like maybe your metabolism isn't working that well at producing heat. I can turn up the blankets, we don't want you to have a high fever but it's actually worse if you're hypothermic."

And he's not far off. 36.0, now. Merrin doesn't liiiiiiiiiike that. His hand isn't cold but it does feel cool to her touch. 

She squeezes his nailbed, not hard enough to hurt but enough that the flesh under blanches. She watches the capillary refill, and makes a face. 

Kalorm is watching her, and notices. "...What?" he manages. "Is - bad -?" 

Merrin puts both of her hands around his, as though sharing her body heat to warm them will fix the whole problem. "It's kind of bad, yeah. But you seem pretty alert, which is a good sign."