Kalorm makes a face again. "Feel foggy. Hard - to think..." 

"I know. It makes sense. I need you to try really hard to stay awake and pay attention for a bit, though, okay? So I can tell you what the other options are, either if you don't respond to the conservative treatment or if your condition gets worse and we decide we can't afford to wait. We would probably take you to the operating room, because if you need surgery and you're still getting sicker, it's important for us to do it as soon as possible before you're too unstable to risk it. If your bowel looks okay and like it's all getting circulation with no ischemic spots, we would probably try setting up a whole pacemaker system surgically, it works a lot better than the internal version and it's overall safer, just obviously more invasive. Then I think we'd want to keep you there for an hour to see if it was working well enough. If it wasn't, or if we saw any dead bowel, we would basically have to resort to an ileostomy. That's when we bring your small intestine to an incision in your skin, so it can drain from wherever the backed-up area is. We would try pretty hard to do what's called a "loop" ileostomy, where we don't cut out anything and leave the small bowel attached, just with an extra hole to drain. That kind is temporary, it'd just be until everything is healed up in there, and we can reverse it easily. If we have to cut out dead parts, though, I think it's to risky to try to link up the ends and sew them together, you're not going to be healing very well until you're doing better. So we'd leave it cut and with the lower end just sort of sewn off and blind. We can still reverse that, eventually, but it's a bigger deal and you would have more scar tissue from it." 

Kalorm listens to this with kind of remarkable calm. 

"Is it - how bad -" He stops. Clearly tries to lay out the words in advance. "...Would I. Die. If I. Said I. Didn't want that." 

Oh nooooooooooooo. Merrin kind of wants to cry. She blinks hard. 

"I - your chances would be worse. Treatment Planning right now thinks you have a 99% chance of surviving this and leaving the hospital, but - that's based on how sick you are right now, and on the assumption that we'll be doing absolutely everything we can to prevent you from getting too much sicker. If it were just the paralyzed gut, I...think you'd recover, survive, but it feels pretty likely the infection would get a lot worse before we were on top of it, and you would probably end up in septic shock. We're pretty good at getting people through that, but - not without damage. It might cause permanent kidney damage, or heart damage. It wouldn't be good for your brain." 

She squeezes his hand. Takes a deep breath. "If some of your bowel dies, and you've expressed that you're refusing major surgery no matter what, then - I think you might not survive that. That's just. Something where throwing antibiotics at it isn't going to be enough." 

(And Khemeth might, in that case, actually override Kalorm's expressed wishes, given that Kalorm is - arguably not entirely with it right now. Merrin is definitely not going to say that out loud.) 

Kalorm clutches at her hand, tightly enough to hurt. 

"I want..." His voice is thick, hard to understand, but it seems to be more with emotion than any medical problem. "I want. Not. This." 

Great now she is almost crying!!!! 

"I know. Trust me, I know. We - all along we've been trying to give you as little as possible of this. I'm not sure we made a mistake in expectation, even, given - all the factors - I wish I'd stayed and done the enema last night but I'm not sure that would've been right either, you were so tired..." Shrug. 

Kalorm makes SUCH a face at her. "Wouldn't - been - fair to you. Either." 

help Kalorm is too good and it's not fair for bad things to happen to him 

She blinks against the stupid pointless tears. "Kalorm, we aren't going to jump to surgery unless it really, really looks like your condition is deteriorating and we're out of options. There's a reason we've been conservative about escalating to more invasive treatments, even if - I wish - that'd gone better for you..." Helpless shrug. "It'll delay your recovery, which is worth it to save your life but not necessarily worth it to turn a 5% risk into a 1% risk. And surgery always has risks, and it's especially risky for you right now - we had to give you a lot of drugs to maintain your blood pressure for the procedure earlier, and you're in worse shape now, the infection is further along - and this is a much bigger surgery and will affect your vital signs harder. If we end up waiting too long and you're already a lot sicker than this when we take you to the operating room, Diagnostics thinks a 10% chance that your heart will stop at some point - and we'd almost certainly get you back, but it might take long enough that your brain would be deprived of oxygen again, and it'd significantly increase the risk of complications later. Anyway, that means we're going to avoid it if we possibly can, even if you're really sick, as long as it looks like the specific problem where your gut isn't moving looks like it's on a good trend. Okay?" 

Kalorm is trying INCREDIBLY HARD to focus and that was still so many words. It feels very unfair. His head hurts. It is completely unreasonable that he should have to make DECISIONS when he feels this terrible. Except that the whole thing is that he feels terrible because he is maybe dying of stupid intestine bacteria because he's incompetent at the completely routine act of pooping, and he has to decide, now, how many more horrible things he's willing to have done to him if the alternative is dying. 

"How - danger - if sooner?" he manages to squeeze out. 

"...Uh. I didn't actually see that on the main screen, since the plan isn't to go right now, the cost-benefit analysis is overall that the ileocecal valve device - sorry, the one that will help your small intestine actually empty at the end - is that it's worth waiting a couple of hours. - Though I do need to do a scan of your belly with the ultrasound, and I want to do it pretty frequently - sorry - so that I notice right away if the bowel prep solution we're giving you is blocked at some point and just making your bowel dangerously stretched, because I'm pretty worried about that as a big risk of our strategy right now, and it'd put you at higher risk of your bowel getting circulation cut off and dying, or getting a hole ripped in it and dumping a bunch of stool and bacteria everywhere." 

That is a HORRIBLE mental image why did Merrin have to say that out loud presumably because she cares about Kalorm having the information he needs to make a decision. 

If his gut is sufficiently incompetent that THAT could happen, Kalorm definitely wants Merrin to notice before something happens that might cause him to die. He nods emphatically. 

She squeezes his hand. "Okay. I know it's annoying and you'd probably love to get some sleep, but I'm hoping that checking really often will help give me a better idea of whether you're on a trend toward improving - if you are, I'm going to push harder on recommending we stick it out even if you're on more vasopressors or needing a lot of fluids, but if it's looking worse, I think we should go to the OR even if you're stable." 

She unfastens the abdominal-area panel on his pajamas. It's mildly more annoying; he's still in the MRI-safe ones, since MRIs may still be in his future, and Velcro just isn't nearly as convenient as the miniature magnets. 

...Stares at his abdominal area, trying to judge if it's more distended than earlier. The difference from when she pulled him out of the water is quite noticeable; one wouldn't quite describe him as looking potbellied, and on someone else it might not even stand out, but he's thin, and when his gut wasn't a disaster, his belly area actually had almost a concave hollowness to it. The subtle roundedness below his ribcage is a VERY stark difference. 

"Kalorm, tell me right away if this hurts, okay?" She gently palpates the area, trying to gauge firmness, but keeping the actual pressure minimal; with the epidural, he might not feel it in time if she's causing him actual damage. 

Kalorm isn't sure if it hurts or not but it's really unpleasant!!! He tenses up and grimaces visibly. 

Merrin stops immediately, looking very worried. "Kalorm, are you okay? What did that feel like?" 

The generic unpleasantness almost immediately fades back - though it doesn't subside entirely, and is now resolving into a VERY UNWELCOME but at least describable sensation. "Nausea," Kalorm manages. Talking is hard. 

"Okay. Can you tell me if it was just bad when I was pressing, or was there any unpleasant feeling that got worse when I let go?" She's not as sure as she would like that Kalorm is currently able to parse pain as that. 

Kalorm gives her a confused look. "When you. Touched me. Less bad now." 

"Okay. That's not as bad a sign but I'm still pretty worried and I think we maybe need to take you off for another scan, at least, sooner than two hours from now. I'll see if I - or the Diagnostic experts, they're way better at this than me - can pick up anything on just the ultrasound, and if we can then that's really worrying, but if I don't see anything that does not actually entirely reassure me about there not being a problem." 

She has a look (trying to avoid putting any pressure on Kalorm's abdomen, which is actually really frustrating when attempting to get high quality ultrasound images.) 

It's not obviously worse? It does look like the waves and ripples of peristalsis, while still not as frequent or strong as they should be - Merrin has to spend a while looking - have made their way a little further along the jejunum, and the most distended bowel loops are now a little further along. 

This would be WAY MORE REASSURING if Merrin could TELL what that fluid was - regular bowel contents versus BLOOD - and if she could see more in general, and if Kalorm hadn't looked abjectly miserable when she put fairly light pressure on his belly. 

"Do you have any of the other symptoms you had earlier?" she asks. "Lightheadedness or dizziness, feeling too hot, that sort of thing?" 

Tired headshake. "You - worried -?" Kalorm would like Merrin to STOP looking so worried!!! It's alarming!!! And also he kind of feels bad for making her sad!!! 

"I'm pretty worried, but I don't think we should necessarily escalate to the OR based on it, just - try to get more information. Probably after we place the valve device, I think it's being 3D printed now." 

Tired eyeroll. 

This should not be funny and yet. Merrin can't help snorting before she manages to stifle it. Of course Kalorm isn't a fan of 3D printers. They're probably way too Civilization-flavored for his tastes. 

"I'll check the markets and let you know what the odds are on taking you to the OR when you're still mostly stable." 

Pause. Refresh. 

"...Looks like still a 15% chance that you'll deteriorate significantly when we induce anesthesia or during the operation, I think that's mostly - we know you're pretty sick, and anesthesia will knock out a lot of the compensation mechanisms your body is leaning on. But it's down to a 2% chance that we lose control enough that your heart stops, and - likely to be a lot easier to get you stabilized, so they think only a 1 in 200 chance of additional brain damage." 

Kalorm gives her a desperately pleading look. "Should we - safer - just go - now?" His eyes are wide and visibly terrified. "Don't - want - but - scared -"