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Merrin working in Exception Handling
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(Kalorm promptly falls asleep as soon as he's undisturbed, even though getting an initial sequence on this particular scan is only a ten-minute process. His blood pressure dips again - not incredibly low, he's still above 90 systolic, but his heart rate is still creeping higher, it's at 105 now, and Treatment Planning orders another 500 mls of IV fluids.) 

It is, unfortunately but not very surprisingly, showing up pretty much everywhere! Distributed throughout his bloodstream, though maybe relatively less in his brain - that's good, it means his blood-brain barrier is still functioning as normal - and also less visible in his lungs and spleen, though that's more a matter of slower physiological uptake and will give a more accurate result in 24 hours. (For this particular test, the isotope apparently stays in his body up to 72 hours, so they'll be able to get serial followups and see how well he's responding to treatment.) 

On the bright side, his rectal tube is draining in occasionally spurts, and puts out another 100 ml over a ten-minute period. 

 

...When they slide him out of the scanner, 65 minutes after they started, his body temperature is 35.8. Possibly giving him all these room-temperature IV fluids, while he doesn't have the electric warming blanket because it isn't MRI compatible, has some downsides. 

When Merrin checks his hands, they're cold to the touch, with markedly delayed capillary refill. His feet are slightly mottled. 

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On the bright side, Merrin has a good feeling about the process they're making on clearing out his gut! Maybe the ileocecal valve device plus some intermittent scopes and irrigation will really be enough to solve the underlying cause of their problem here! 

 

...On the less bright side, solving the root cause is not actually going to get rid of the problem, at this point, and Merrin has some concerns about how Kalorm looks right now. And the only thing she can really do is get him back to the ICU and WARM ENOUGH and...hope that the next 12 hours don't tailspin into as much of a disaster as she's worried they will. 

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They make it back to the ICU without anything disastrous going wrong yet. Kalorm opens his eyes and even manages a weak, sleepy smile when Merrin gets him tucked in with the warming blanket again. 

...He's still managing to look kind of dehydrated. Nothing glaringly obvious, but his arterial line blood pressure tracing straggles up and down whenever he takes an especially deep breath, and his heart rate is up to 110 despite the lowish body temperature. 

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Treatment Planning is pretty sure that he's third-spacing fluid - the massive widespread inflammatory response isn't just trying to make his capillaries dilate everywhere and drop his blood pressure, it's also making them leaky, and fluids given into his bloodstream are less likely to stay put there. It's not that externally visible yet - he's very long and thin - but his ankles are already very slightly puffy.

This is not great but it's predictable, and (unless it starts backing up into his lungs) it's not directly harmful if they keep replacing those fluids. And they need to try to minimize his vasopressor dose as long as possible, because - guess what - deliberately giving drugs to cause vasoconstriction will reduce circulation to the vasoconstricted areas. One of which includes his gut. 

They'd like to give him some albumin first, though, in hopes of maybe pulling some of that lost fluid back. If that doesn't bring his heart rate below 100, then another liter of fluids – this time WARMED fluids, please. 

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Merrin may be tired and stressed and not that smart but she's not actually a COMPLETE IDIOT yes of course she's on that now. 

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250 mls of 5% albumin helps; it gets his heart rate down to almost exactly 100, which Treatment Planning declares acceptable for now.

 

...This lasts for, like, twenty minutes. His blood pressure is hanging on at 90/50, which is at least tolerable, but his heart rate is creeping up again. 

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FINE she will give him MORE FLUIDS even though his wrists and ankles and even his eyelids are noticeably puffy now. 

...Merrin is also going to nudge him awake to get him to cough again, because he's breathing shallowly and his oxygen saturation is down to 92%. Also she's tempted to see if he's somehow more stable in a different position? It would be concerning if his blood pressure were positional, that doesn't indicate reassuring things about his heart function, but in that case she doesn't want to fail to notice by not checking and also she still, like, wants him in whatever position his body is happiest in. (And repositioning him regularly is probably going to help a bunch with decompressing his bowel, and she has an itchy feeling about checking his level of consciousness often.) 

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...Kalorm is harder to wake up, this time. He doesn't respond at all to her saying his name at normal conversational volume; when she practically shouts at him, he moans and halfheartedly tries to turn his head away, but it takes a few more repetitions before he drags his eyes open and glares at her. 

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Oh no she's worried. 

"Kalorm, hey, I'm really sorry but I need you to take a couple of deep breaths and cough for me again, and I think you should change position." 

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"No. Go'way." He closes his eyes again. 

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Aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaah. 

"Kalorm. I said I'm sorry, but that is NOT the response that's going to get me to leave you alone. Remember I told you that you need to tell me right away if you're feeling worse in any way? It really looks like you're feeling more tired or something right now! If you're just mad at me I need you to confirm that to me in words!" 

 

...That is perhaps not the most thoughtful way she could have phrased it. Oops. 

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Kalorm glowers without, actually, opening his eyes, but he seems to consider the question. It takes him a while.

"...Yeah," he admits finally. "M'tired. Bit - dizzy. Feel - cold - hurts..." 

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...He's sounding more out of breath again, Merrin notes internally, quietly in the back of her thoughts and with a surprising degree of calm. He's pausing more between words. "Kalorm, this is important. Where does it hurt? Your belly?" 

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"...No." A breath. "Can't...feel...anything." 

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Is that less concerning or MORE concerning?????? Merrin is genuinely unsure! 

"Okay. One moment– Kalorm, stay awake." She darts across the room and fills a baggy with ice from the dispenser, then back to his side, to fold back his blanket and start opening the torso panel of his pajamas. 

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"Hey." Kalorm tries, not very effectively, to fend her off. "Cold." 

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"I know, you said. I'm really sorry. I'll be fast." She presses the ice to one side of his belly, level with his navel. "Does that feel cold, or just like pressure?" 

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Kalorm gives her a puzzled, irritated look and makes a face. Shakes his head. 

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"I...am interpreting that to mean that it doesn't feel cold, which means I think your epidural is too strong and I'm going to turn down the drug infusion in it, okay? So you need to tell me if it's hurting more later. Where else specifically does it hurt?" 

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Kalorm is giving her SUCH an affronted look. "...Head. Back. Just...achy..." 

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Merrin gets him covered up again. Squeezes his hand, under the blanket. "Yeah. You're really sick. I know it's unpleasant. Uh, do you think you're having more trouble breathing? You sound a bit short of breath." 

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"Maybe." He closes his eyes again. "Wan'sleep." 

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Merrin takes a deep breath. 

To the command center: [I'm really worried. How far away is backup if I need it - how many people are read in and can step in on short notice without a report–]

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Two people right outside the room and following along in real time. Another five people can be there within 3-5 minutes if it's an eight-people-in-the-room scale emergency. They have a bunch of extra funding approved for prediction market liquidity until the situation is resolved, and Khemeth is actively participating and is ready to fully step in as Kalorm's substitute decisionmaker if Kalorm deteriorates enough to be unable to speak for himself; they're putting 80% odds that this will happen at some point tonight. 

 

Important question: how is Merrin doing on stamina? They realize she agreed to stay with Kalorm until he's stable, but it's now well past 7 pm and she's been here for over eight hours. Does she want someone ready to take over as the lead opper for 8 pm? 

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Merrin winces. 

[That's...probably a good idea. I. I can - keep functioning for a while. I'm...probably not going to be at my best if it's a whole overnight, though, and he - deserves someone at their best] 

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