He would really like to set it on fire. It'll make him feel better. 

No. 

It won't even cost that much money. 

Still no! What is WRONG with his family, why are they LIKE this.

NEVERMIND THEN Finnar will DO IT HIMSELF!! Even though, you will note, Finnar is the one actually working directly on their problem and his time is significantly more valuable right now!!!

(Khemeth at age fourteen might have argued with this assessment. Khemeth at thirty-one accepted a long time ago that his father has some stubborn metacognitive blind spots. Really, doesn't everyone? Everyone other than Keepers, at least, and Keepers are doing very strange things to their heads and there's a good reason neither he nor his father are one. Anyway. Finnar's blind spots include a persistent low assessment of the value of Khemeth's particular comparative advantage, and even though you would think that being very rich would call for an update on that, Khemeth is not really expecting it to change at this point. He is, however, irritable and generally off-balance enough that he'll say things in the private family groupchat that he might not otherwise make explicit for reasons of 'saying them also won't help.')

Seriously, why is Finnar such a walking boat-related disaster! This isn't even the first time he's tried to convince Khemeth to set fire to a boat! And it wasn't going to help that time either! 

Finnar does not deign to answer because he's currently trying to find someone who will take his money and deliver him a boat. 

Merrin is focused and calm-but-tense and in the process of cooling her patient another 2.5 C over five minutes while working very, very hard to prevent this from breaking anything else. 

Profound hypothermia affects nearly every cellular process, and thus nearly everything Merrin is currently handling on manual. Previously, it had actually felt like she was only sort of doing that, because Kalorm was carrying a bunch of that load on his own, but they're now pushing his body into an even more unnatural state. 

Merrin is going to spend the entire time fighting with his systemic blood pressure - vasopressor drugs barely work at that temperature and his blood wants to pool in cold-paralyzed capillaries and she really desperately needs enough venous return to his heart for there to be anything to pump - while trying to keep his carotid blood pressure below a gradually-dropping as per the stabilization protocol ceiling. (At 18 C, they're aiming for a carotid systolic blood pressure of like 30, with an allowed range of TWO POINTS in either direction, which Merrin thinks is just mean and unfair to expect from both of them – but especially Kalorm, who is clearly, of the two of them, having the worse time right now. She gets it. She is not judging him at all.) 

His electrolytes and pH and CO2 are all over the place. His lactate is trying to rise again, probably because there's enough microcirculatory dysfunction going on in his extremities, enough areas where depleted blood pools and new oxygenated blood takes a long time to arrive, that even the metabolically-slowed cells, bunkered down to survive, are getting hungry enough to metaphorically eat their horses, resorting to anaerobic metabolism. 

Blood viscosity and increasing hematocrit are a real problem for the three extracorporeal filter circuits Merrin is trying to wrangle; the high-pressure alarms are going off constantly. She can dilute the blood in the circuits with carefully-calibrated electrolyte solution, but then she has to put more load on the final filter stage of the hemodialysis circuit to remove most of that water, since they cannot in fact afford to pump multiple liters per hour of fluids into him. And they definitely can't use anticoagulants, because the patient is - despite the "thicker" blood - already at very high risk of bleeding right now, as platelets are locked away in his spleen and liver, and the enzymes involved in clotting-factor pathways work more and more sluggishly. He has enough internal injuries, and enough artificial holes cut in his body, that bleeding is by far one of the most likely complications.

(25% chance on some non-trivial bleeding happening in the next 3h, the market thinks, though even if he does start bleeding, it won't be fast - not at that blood pressure - and they have lots of options to keep it semi-controlled until they're at an actual hospital facility. If he does start bleeding, call it a 20% chance, 4:1 odds, that they can keep it under control without compromising the cooling protocol.) 

His sodium and potassium and blood sugar and a dozen other biochemical factors are also going nuts. Merrin is actually having a lot of trouble with blood sugar, which tends to increase in hypothermia, and which she has a hard ceiling on, because too much sugar will set off the next phase of some inflammatory cascades that they very much don't want - even if the rest of the cascade won't happen until they rewarm him, they'll have lost the opportunity to block it closest to the source. 

This would be incredibly stressful, if Merrin had literally any metacognition to spare! She is not, in the moment, even trying to assess whether it's going worse or better than expected; she is completely in flow, immersed in the second-to-second reactions, tracking ahead but mostly only on the level of instinct - as his temperature drops another degree, she expects this and this and this, and will pre-emptively troubleshoot this.... 

She is also, mostly without even being consciously aware of it, telling Kalorm over and over that he's doing SO well and they're ALMOST there.

(Merrin used to have trouble multitasking on 'reassure patient' in sims with conscious or semi-conscious patients, and so she trained her verbal loop to run a Reassurance Script basically by itself while the rest of the Merrin is entirely occupied with life-saving treatments. She normally doesn't actually do it in real life with unconscious patients, or she catches herself and is embarrassed, but real-life situations are almost never as hard or as absorbing as her hardest sims. Merrin is not even sufficiently aware she's speaking out loud to think to be embarrassed about it.) 

She does keep having to flag things for her team, who are also pretty busy - there is significantly more to do than just dialing settings up and down on machines (plus they've divided up which one of them is very closely tracking one of Merrin's machines, in case she calls out that she needs to be spotted on that for a while, which is an efficiency loss but better than Merrin being on her own and overwhelmed.) They've worked together for a long time, though, and she can mostly manage it with hand signals. 

Speaking out loud is generally frowned upon in a situation like this one, for noise-pollution reasons. Her support team is not going to point it out, though. They can subvocalize for their own communications, and if they point it out then Merrin will die of embarrassment, and this is really not a great time to distract her. 

Besides which, it's adorable. 

Aaaaaaaaaaaaaand 18 C! 

....17.9 C.

....17.7 C.

Superheated plasma cannon why is it doing that her equipment is being rude to Merrin personally and also doesn't it know Kalorm is very good and deserves better shut up Merrin's brain. This is not even actually hard to fix. 

...17.9 C. 

...18.2 C flaming pie hole - 

...18.1 C

...18.0 C

- aaaaaaaaaaaaand okay she thinks she is no longer overcorrecting-for-overcorrections. How's her patient. 

Kalorm at roughly 18 C looks terrible, actually!!!

His extremities are dusky grey-purple, mottled nearly all the way up to his torso. There's almost no color in his face; his skin seems practically translucent - and feels cold to Merrin's touch, not just cool. On the ECG, his heart has finally given up on fibrillating and fallen into limp quietude, perturbed only by the sawtooth-bump of the mechanical pump's action. His pupils are once again fixed and dilated. The sensors detecting bloodflow to his gut are now picking up pretty much nothing at all. 

But! For all that, his basic vital signs are not actually that hard to maintain within allowed limits. 

(Said allowed limits - systolic carotid blood pressure between 28-32 with a mean pressure of 20-25, adjusted O2 sat of 35-40% - would not, normally, be very compatible with life. That's sort of the point. They want his neurons and their supporting cells to be just barely maintaining their membrane integrity and ion gradients, and ideally literally nothing else.) 

....Oh, and on the brain-damage-byproducts sensor, just about all the readings have dropped to 'undetectable'. 

Spot-check bloodwork panel, when she gets it, is super abnormal on hematocrit and platelets, moderately low potassium, everything else is basically within the limits it should be in. 

The cooling itself took five minutes; the stabilization and reassessment after took another five. 40 minutes to rendezvous.  

The markets are updating, but the medical experts betting on both the Diagnostic and Treatment Planning sides want to know Merrin's gut feeling on whether she can keep this patient semi-stable and maintain everything within allowed parameters for 40 minutes in these conditions, and then manage a transfer where she temporarily won't have eyes on him. 

....Yeah, Merrin can do it. 

Really, it's Kalorm who can do it, believing in Kalorm is so much easier than believing in herself

Then they'll proceed. 

Updated market predictions: likelihood of the patient surviving to rewarming are still at 93%. Chances of mild, moderate, and severe brain damage are respectively 58%, 20%, 9%. Updated risk of major complications en route, 30%. 

And they fly onward. 

It goes pretty smoothly for a while. Merrin can get into a pretty comfortable rhythm. Not a lot of spontaneous metabolic function is happening, but that same fact is buying Merrin lots of wiggle room.

The team thinks it's safe for her to lower the patient's sodium a lot faster, too, since his low body temperature is in itself protective against brain swelling. She gets it down to 165, which is almost out of the 'critical range' into the 'high but not, like, panic-level high' range. 

...At some point, though, she's going to find herself upping the settings on the mechanical cardiac pump for the third time in the past three minutes. She's been bumping it up and down sort of constantly, of course, but three times in the same direction is enough to stand out. 

Uhhhhhhhhhhhhhh. 

[Something's wrong] Merrin subvocalizes to the admin note-taking and relaying messages for her - it's an entire team, actually. [Cardiac output issue]

     Vellis is already getting ultrasound imagery of the patient's heart (they're checking it often but not constantly, since it does slightly interfere with sensors.) [...Nothing structurally wrong. Just - drop in venous return - anything to explain that?] 

Merrin surveys her numbers. 

....There isn't, really. Not that she can see. 

[Full body scan right flaming now] she tells Vellis, very calmly. 

(It's okay. It'll be okay. This is literally the soonest moment she could have noticed it, and she still has a ton of wiggle room on the cardiac pump - he's probably bleeding, that's the single most likely complication, right, 5:1 odds, the others possible culprits are weirder and might be harder to diagnose let alone treat, but are still much less likely...) 

Yup! He's totally bleeding internally! 

He already was, probably - one of his ribs is cracked badly enough, from the initial trauma plus ten minutes of having his circulation maintained via external force on his torso, to have splintered a little bit, and the splinter doesn't appear to have actually pierced his lung but, for all their efforts to keep him secured and not jostled, there have been a lot of vibrations and g-forces, and at some point that splinter definitely tore something. 

Not a major artery, or they would have noticed this way sooner. Before now, the leaking relatively-minor artery had at least formed a minimum-viable clot to pinch the main bleeding off before the blood loss - or pressure on other organs in his chest - could cause any visible problems, or show up on the CT scan as something more obviously than "bruised tissue maybe" which describes like half of his body. 

Platelets are not working very well at this temperature. There are now way fewer of them than there should be, as his body responds to the cold by tucking them away in his liver and spleen. The continuation of the clotting cascade leading to a tighter-woven fibrin cap never properly happened, at the temperature they were keeping him at, and now the clotting factor activity is very sluggish, and must not have been enough to keep up when a particularly violent gust of wind shook the patient and jostled just the wrong thing in his chest. 

He is now bleeding into his chest cavity, though it looks not the space between the pleural membranes of the lung, which would be worse - still not panic-level bad, he's not super relying on his lungs for oxygenation right now, but a lot more delicate to fix in a moving helicopter. 

Even a torn artery isn't bleeding fast at his current blood pressure, and he hasn't lost a lot of blood, yet. Maybe 100 mls, enough to be visible as a little pocket of fluid where there shouldn't be fluid. Not enough to even inconvenience a healthy person; blood donations regularly take more than that. 

Kalorm is, of course, not currently being kept in a very healthy state. It's not clear if the cause is the blood loss, or (more likely) the slight shift in intrathoracic pressure, but the blood return to his heart, and thus the quantity to squeeze out on each beat, is dropping. 

It's not very surprising when outcomes which are 25% likely to happen end up happening! Kalorm's odds of making it to Default and through the end of the rewarming protocol alive have dropped, but not by a lot, they're still giving him an 89% chance of making it.

It'll probably jump back up to - not quite as high as before, one bleeding incident downstream of his existing traumatic injuries does predict others, but say 92%, a 3% increase. 

(The odds on other outcome endpoints are updating too, but not very much, yet, and mostly downstream of the 4% lower chance that the patient survives to be rewarmed. If Merrin can stay in control with him at 18 C, and his vital signs never go outside parameters, bleeding in his chest is not actually predictive of a worsened cognitive outcome. ...Maybe. It's perhaps more the case that there is a RAGING ARGUMENT going on about this, right now, and the numbers haven't settled.) 

The markets are now actually pretty optimistic on Merrin-and-team's chances of stopping this! Merrin's performance level so far has been high, her focus better than anticipated. They could have gotten luckier and caught the bleeding earlier, maybe - it would have been visible on a CT scan ten minutes ago, probably, but the last CT scan was fifteen minutes ago - but they could also have caught it later. It's from a traumatic injury, which actually indicates less in the way of clotting dysfunction and general physical deterioration than, say, a GI bleed would, and it's probably the highest-risk of his traumatic injuries.  and it's conveniently located for a simple percutaneous go-in-and-cauterize procedure. Quick and dirty, but they'll fix it up later in the real hospital.

The experts still think Merrin and her team have a 5:1 odds of getting the bleeding under control before it's bad enough that they make a call to rewarm the patient. She should definitely hurry, though. Rendezvous is only in twenty minutes and delaying to stabilize the patient will mean delaying their arrival at Default Hospital. 

It's a simple procedure. If they can't stop the bleeding, or if the attempt causes more bleeding, that's really not a great sign, and the markets expect to react with a 15 percentage-point drop in the survival-through-rewarming odds, all the way down to 74%. 

Merrin actually wants Vellis to do this, because Vellis will do it just about as well as she will, and Merrin is planning to instead focus on keeping Kalorm's vital signs super optimal. 

Vellis is on it.