It's doing that at all? Not incredibly effectively, especially when she has Kalorm propped in a position where the terminal ileum - which points downward - has gravity on its side, and the ascending colon has gravity working against it. But it's enough that the cecum isn't worryingly distended, even though at a guess his small bowel just dumped at least 500 mls of contents over three minutes or so, and only 200 mls of that is the bowel prep solution that Merrin squirted in. 

The cramps seem to be easing off? Kalorm lifts his head to look at Merrin. "Feels - hurts but - not, not - other ways - bad." 

That is not the easiest to parse but Merrin smiles at him. "Do you just mean, you weren't feeling nauseated or lightheaded or too hot, or any of those symptoms?" 

Ambivalent wiggly hand. "Little bit. Nausea. Just. Not bad." 

She smiles at him. "That actually is reassuring to me. But we should still get a scan. Are you ready to go now or do you need a couple minutes to rest?" 

He gives her a suspicious look. "Don't wanna. Poop. In MRI." 

Merrin will NOT LAUGH at him, but she kind of has to press her lips together to avoid it. "You shouldn't have to worry about it, that's what the drainage tube is for! Once I get the probe out it should be forming a nice seal. ...How are you feeling other than that? Achy, cold, weak or tired...?" 

Eyeroll. "M'tired. You keep. Doing things." 

"Yeah, I know. I'm sorry." It would be EASIER not to laugh at Kalorm if he didn't keep saying things that were incredibly funny! At least to Merrin's brain right now, which is starting to feel slightly tired, she's already been here for more than six hours. "But I think the next things shouldn't require any participation from you. You can get some sleep." 

"Mmkay." Kalorm closes his eyes. 

Diagnostic updates: that was on the optimistic end of hoped-for responses to the ileocecal valve. It won't automatically help with the deep middle section of the small bowel, where the situation is worst, but it removes one of the obstacles. Updated to a 40% chance that the situation will be Mostly Solved within 4-6 hours (well, a little less than that now, it's been 30 minutes since that timeline was given.) 

They are, of course, not sure if that will be enough. However, Kalorm seems stable on his current dose of vasopressors right now, so Merrin is cleared to head over and get more scans. 

They're planning a different kind of radioisotope labeling, to track Kalorm's white blood cells with a different isotope signature than the bleeding tracking. (There should be enough of the first radioisotope left in his body that the very sensitive CT scanner can get a few more serial images, at least enough to rule out major GI bleeding.) 

Huh. Neat. Merrin had genuinely not known that was a thing. 

She summons some other medtechs to accompany her for the scary hallway transit. They head out. 

She is pretty stressed that Kalorm is going to STOP being stable at a point when he is IN THE MRI SCANNER and this will be horrible. Especially since he's clearly really tired, and may not wake up enough to notice and tell her if he feels worse before his vital signs start changing.

...She'd like to send more lab work right before they start. Yeah, she's aware it hasn't even been a whole hour yet. STILL. 

(Treatment Planning signs off on this. It's not a sustainable rate to keep stealing Kalorm's blood, but - the situation should clarify one way or another in not that many hours.) 

They inject a new specialized radioisotope mixture (Merrin is just going to trust Treatment Planning on this, she does not have the energy to look up a new protocol in depth, and there are specialist imaging techs on site to supervise it.) It's going to take 30-45 minutes to reach and mark the relevant cells, so in the meantime they'll get a CT check tuned on the earlier radioisotope - in case the abdominal tenderness was downstream of a larger GI bleed - and then a quicker round of MRI imagery, focused on the problem areas that they want sequential comparisons on. They're expecting it to be about an hour total, finishing around 7 pm.

This is, of course, assuming that Kalorm remains stable enough for it - and that they don't see anything that prompts an immediate change of plan. 

Kalorm, again, seems to have no trouble sleeping through a MRI as long as they give him the good noise-cancelling headphones. 

They don't see a massive GI bleed! There might or might not be an increased overall rate of local oozing, but it's getting hard to judge at this point, multiple hours after the red blood cell-labeling radioisotope was injected. Either way, though, it's not a surgical emergency. They can keep going. 

No cardiac arrhythmias. His heart rate is higher than you would ideally like in someone who is to all appearances comfortably asleep - it's hovering around 95, and the vasopressor mix he's on shouldn't directly be increasing it. His blood pressure holds steady enough - some dips, but given other physiological indicators, Treatment Planning had been thinking he would benefit from more fluids, especially given the hard-to-measure GI losses. This does seem to boost his blood pressure, and overall his vasopressor needs aren't increasing. (Yet.) 

(It's pretty hard to assess mental status, since, you know, he's asleep and also entombed in a scanner bed.) 

Lab panel comes back. Electrolytes are fine; urea is actually down, though that could be partly dilution effects from all the fluids. Lactate is still creeping up, but slowly, and it's by no means scarily high yet. Hemoglobin is lower - they should probably give him another blood transfusion even though it's not quite below the normal range - but they did also just give him another liter of IV fluids to offset GI losses. The abnormalities in his white blood cell differential are worse, but they're not getting worse fast, and he does still have enough mature neutrophils remaining that, absent a massive overwhelming internal source of infection - which they are working REALLY HARD on dealing with - he should have enough immune function to work alongside the powerful antibiotics and fight off the bacteria already in his bloodstream. Inflammatory markers of multiple kinds are appallingly high - not just gut-specific, at this point, the inflammation is hitting his liver too, unsurprising since the liver is the direct recipient of all the blood draining from the gut. But they're not picking up anything specific to his brain, at least. 

The MRI imagery shows no sign of peritonitis, or perforation of his small bowel. His intestines are definitely very swollen, and a lot of that is tissue edema and not just bowel contents that should hopefully be on their way out, but that's kind of to be expected with the sheer degree of inflammatory response going on. The distal (lower) half of his ileum is noticeably cleared out, now, along with the proximal (higher) half of his jejunum. The remaining backed-up area is pretty much just in the middle, though that's still enough to affect over a meter of small intestine. 

...On the bright side, if they do end up resorting to an ileostomy, they now know exactly where to put it. Also, even in the lying-flat-on-his-back position optimized for MRI imagery as opposed to anything else, his colon is making some headway. There's another 200 ccs in the drainage bag by the time the MRI part is over. 

His oxygen saturation is starting to drop a little. Not by a lot - he hasn't yet gone below 94% and is still only on 30% oxygen - and this is plausibly because he's both lying flat and asleep. But he managed fine during the last set of scans. 

CONCERN it's probably fine but CONCERN. 

...Merrin clears her throat. Addresses the command center (out loud, since she's hardly going to be disturbing Kalorm, stuck inside a loud MRI and with noise-cancelling headphones). "I, uh, can we - pause briefly before the next stage? I, um, I think we're actually still earlier than the specified stop point, and I - I'd feel better if I can talk to him and do some deep breathing exercises and see if that fixes the oxygenation." 

Approved.

(Treatment Planning is overall making positive updates from this, or at least ruling out many of the worst-case scenarios. They are updating less than they might otherwise on Merrin's current anxiety, because Merrin has been under significant stress for a long time, and is probably very highly sensitized to even small changes in Kalorm's condition, that may or may not end up being significant.) 

They slide Kalorm out from the scanner. 

This is enough to get him to at least sort of wake up. Kalorm makes a very tired halfhearted attempt to look around. 

"Hey. Sorry. We're not quite done, I just wanted to see how you were feeling. And I want you to do some deep breathing and see if you need to cough anything up, okay? You're doing fine overall but your oxygen levels went down a little bit." 

The way Kalorm is feeling is mostly ANNOYED to have been WOKEN UP. He'll consider it, though, while he tries taking some deep breaths and coughing. 

Verdict: he's still really tired! It's hard to tell if he's more tired - he might be, but he's maybe just overthinking it at this point, and it's just because he was very rudely woken up? He can take deep breaths, though, with only about the usual amount of pain and effort, and he doesn't actually seem to have that much stuff to cough up. 

He does feel sort of weak and achy and cold - not actually cold, the warming blanket is very much appreciated, but like he's almost cold? He has a headache, which isn't entirely new but it's maybe ambiguously worse now. Lots of random body parts hurt, including his back, for some reason. His feet continue to feel mysteriously weird-and-bad in half a dozen other ways he can't manage to figure out let alone describe in words, but it's not as though that's new. 

He's not especially nauseated or lightheaded or - feeling the thing that Merrin keeps describing as "too hot" but he's sort of just decided that this is FAKE and actually what she means is the confusingbad thing where he's too hot and cold at the same time. ...Though his skin sort of feels bad - not painful exactly, not itchy exactly, just some sort of badness that seems like maybe it fits in that same category. 

There is definitely some kind of general background stomach-and-lower-regions discomfort: it doesn't quite hurt, but he thinks they were giving him drugs to prevent that specifically? even if he can't remember how that works exactly? - anyway, while he still has the sense that nausea is maybe not that far off, it's...a less unpleasant kind of not-far-off than before? Possibly just not having a STUPID TUBE in his mouth helps a lot, actually. (He's really not happy about the prospect of ending up with one of those AGAIN for one of...he can't remember what but it was at least several...possible stupid reasons.) 

...Okay. Merrin asked a question. He should try to, like, actually answer it. 

"Feel - not worse? Tired. Cold. Skin - bad? ...But. Not worse." 

Merrin can recognize the sheer effort that went into that clearly-carefully-considered response, and tries her best to reward it by squeezing Kalorm's hand and smiling at him, even if she's both not entirely reassured and still having a bit of a hard time figuring out what he means. 

"That's good!" And his oxygen saturation did improve once he did some deliberate deep breathing and coughing, if not as much as she had maybe hoped - he's back up to 97%. "Uh. Is your skin feeling - itchy? Cold? Pressure somewhere? Or is it, like, the sort of tender uncomfortable thing you get when you have a fever?"

(He still doesn't have a fever. In fact, his temperature is apparently at 35.9. Merrin does NOT FIND THIS REASSURING.) 

That was sooooooooooooo many words. Or at least they were being said faster. Probably because Merrin is stressed. Kalorm doesn't LIKE Merrin being stressed. 

"...Maybe?" 

"Okay." She pats his arm. "It wouldn't be surprising at all, if you notice that - you don't have a fever right now, but you do have an infection, you just have enough other things going on that your body isn't responding to it in all the usual ways. ...I'm not worried."

(This is false, but she's at least not, on net, MORE worried, and that is what Kalorm is going to actually be taking away from her statement, and so Merrin does not feel like this is a lie.) 

"- Anyway, we do need to keep going with the last part of the test. Ready?" 

Kalorm manages to tiredly roll his eyes at her. "Why. Do we - have to -?" 

Oh no that's actually such a good sign because Kalorm is very good 

...Merrin takes a deep breath. "We don't have to. But it won't take very long - fifteen minutes - and it won't hurt or be uncomfortable. And we already put you through the main risk for it. Which was injecting you with, uh, a different sort of radioactive substance - sorry! I would've told you about that, but I think Treatment Planning hadn't fully decided on it before we left for the scan, and I'd said you could sleep–" 

Kalorm manages to lift one hand a little. He rolls his eyes. "Okay. S'fine." He closes his eyes again. 

It's weirdly reassuring for Kalorm to be sarcastic at her. Merrin isn't unworried but she is, in fact, substantially reassured. 

Time for the exotic superheated awesome scan that will show her where his white blood cells are currently trying to respond to infection!