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Merrin working in Exception Handling
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Well, Halthis is ready to step in at 8 pm. She's arranging to catch up on the chart and get a verbal handover from one of the other read-in medtechs, Merrin doesn't need the distraction right now. 

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Merrin does NOT need the distraction right now! The last thing she needs is to worry about sounding really stupid to someone. 

"Kalorm, I'll stop bothering you soon, but I want to try a different position - I can get you a heating pillow to lie behind your back, too, that might help you feel a little more comfortable - and I do need to grab an ultrasound of your abdomen, I predict it's going to look better because you just managed to evacuate another, like, 300 ml in the tube, that's really good. And then you can rest for a little while, but - I'm sorry, I am worried about you and that means I'm going to want to check on you properly more often. And please, please tell me right away if you're having trouble breathing or feel really lightheaded or anything else." 

Do the fluids seem to be helping with his heart rate or blood pressure at all

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Again, it's not really touching his blood pressure per se, but his heart rate is down a bit, to 102, and the blood pressure waveform is at least less straggling-up-and-down with the pattern of his breath. 

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Merrin very gently rolls Kalorm onto his left side, arranging him comfortably, but turned far enough that she can quickly flip him the rest of the way into recovery position if he starts vomiting. She's hoping he won't, and mostly expects it to be fine - the nasogastric tube is draining without issue but not all that much, compared to before - but he's getting close to the point of being sufficiently out of it that she wouldn't be sure he could either warn her or protect his airway. 

She apologizes again, and does a quick check with the ultrasound, arranging to reach under the blanket with the probe rather than uncover him fully. 

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It's improved! The bowel wall is still noticeably thickened in a lot of places, but even at a quick glance, she can actually start to see a difference in the overall fluid-and-gas distention, and no sign of blockage in the mesenteric circulation. 

(The audio sensors for his bowel sounds are now picking up pretty substantial gurgling sounds.) 

The different position does seem to help with this! The rectal tube almost immediately dumps out another 200 ml, and then keeps up a steady trickle. 

It...maybe helps a little with his blood pressure? His heart rate is still trying to creep up - it's maybe not helping that Merrin has finally gotten his core temperature back up to a pretty reasonable 36.6 - but he's running a blood pressure closer to 100/60, which isn't enough to feel comfortable going down on the vasopressors but at least buys some wiggle room. 

 

...It's really not helping with his oxygenation. His O2 saturation drops to 85% almost immediately once he falls asleep again. 

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AAAAAAAAAAAAAAAH this is definitely not looking like just a drowsiness issue! 

[Bad feeling] she tells the command center, and then turns up his oxygen to 50%. 

 

 

Frowns critically at him. 

 

 

...Tries to not-quite-shake but definitely not very gently prod him awake. "KALORM." 

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Mrrrrgghhhhhhhhhh Kalorm feels weirdly like he's underwater, and it's cold water, even though he can tell that actually he's in warm blankets. Waking up is so hard. Everything is so hard. 

He doesn't even try to drag his eyes open. "Mwhat." 

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"Kalorm, are you having any trouble breathing? Your oxygenation is getting a bit worse and it's worrying me." And she sort of feels like his mental status is deteriorating by the minute, though she's not sure how much that's an objective observations versus a hypervigilance-generated one, and also when he's clearly worn out she usually lets him actually sleep for longer than five minutes. 

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Kalorm tries to take a deeper breath. Coughs, but it's clearly not a productive cough; the problem apparently isn't, or isn't mostly, that he's too sleepy to clear his lung secretions. 

"...S'hard," he manages. 

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She tunes his lung-sound sensors to her earbuds. Diagnostics hasn't flagged anything to her attention, but they might not have, if it were a minor change and she hadn't brought up a change on the clinical observation side. 

...Huh. No coarse crackles or wheezing - a little bit of fine crackles at the bases, which is vaguely normal for him if he's been asleep a while, though less normal if she literally just woke him and yelled at him to cough - mostly just...quieter? Decreased air-moving sounds, sort of throughout. 

 

 

[I want a bedside chest CT right now] she tells Treatment Planning. [I think it's worth the radiation exposure to get more detail than an ultrasound or a plain X-ray. I don't know what's going on but something is wrong. ...I'm sending a blood gas too] 

She does this. 

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The blood gas will need a few minutes and so will the full CT, but the low-dose-radiation CT protocol - she didn't figure that she needed really high-detail imagery - gives her a flat chest X-ray slide first. 

It doesn't look terrible at a glance, but - pulled up beside one from yesterday evening to compare - it's...foggy? Not the patchiness of infection and local mucus plugs, that's actually looking better, but a more evenly-distributed background haze.

Kalorm's oxygen saturation is better on 50% O2, it's up to 96%, but not to the 100% that Merrin would really have preferred to see. 

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Obviously a dozen experts who are way better at this are going to be doing their best to come up with potential interpretations and bet on them, but Merrin tosses some reference images up on another screen anyway, and refreshes the earlier predicted odds of various lung complications. 

...It doesn't especially look like a pulmonary embolism, that's a relief; she was doubting it anyway, the odds were low and it would probably come with some additional symptoms, chest pain or more of a cough, even coughing up blood. It's...maybe more like the reference image for pulmonary edema than for inflammatory lung injury triggered from a gut source - and pulmonary edema would be less bad even if it's inconvenient to treat since they can't exactly give him diuretics when he's barely maintaining a blood pressure - but the prior odds of straightforward pulmonary edema were lower by a factor of three, given his healthy heart. So Merrin's guess is that it's still more likely to be an acute lung injury. Which is NOT GREAT. 

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None of the options here are great! The Diagnostic markets odds on other deterioration, especially hemodynamic, are rapidly rising. Kalorm is still oxygenating tolerably and they have room to go up on his O2, but they're still updating to 70% odds that he'll end up back on the ventilator for some reason or combination of reasons before midnight. 

Urgent treatment recommendations: nebulized anti-inflammatory steroids and bronchodilators NOW, and get Kalorm on non-invasive positive pressure ventilation; they're getting the heavier-duty positive pressure ventilation facemask ready, but this one flipped to that mode will do for ten minutes. Prophylactic nausea drug because it would be much worse if he vomited in the positive pressure mask. Monitor Kalorm's mental status, ideally semi-constantly, at this point. They are not going to be able to risk giving him more fluids, in case it is pulmonary edema (35% odds on it on the current market, 60% on inflammatory lung injury, 5% on "a really weird presentation of pulmonary embolism and/or something we didn't think of".) So Merrin should be ready to go up on the vasopressors.

Also they want a bedside ultrasound of his heart right now, sepsis-induced cardiac dysfunction can come on pretty fast and it would nudge the odds toward pulmonary edema. And a full panel of additional bloodwork including a differential on lung inflammatory factors. And repeat ultrasound imagery of his lungs every ten minutes or with any clinical deterioration.

And flag IMMEDIATELY or ideally EVEN SOONER THAN THAT SOMEHOW if she has a new doomy feeling. If they could give Merrin a TIME MACHINE to travel back in time and warn them five minutes before she would otherwise have noticed that Kalorm was about to crash, they would probably do that. 

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Aaaaaaaaaaaaaaaaaah that's so many things! 

 

- okay. Deep breath. First thing is to get Kalorm more stable, so - give him the prophylactic nausea drug, switch to positive pressure setting– no, earlier step, TELL HIM that this is what she's doing - start nebulizers once those drugs actually arrive in the pharmacy chute, and then she can work about diagnostics. 

It's still a lot, though. She subvocalizes to the command center again. [Uh, I could actually use that nearby backup now, if we want the diagnostic tests immediately, I think I need to focus on explaining to him what's going on and, uh, making sure he's on board with it] 

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...If Kalorm isn't on board with any of the urgent interventions he needs to stabilize him, then probably Kalorm is not going to continue to be in any condition to make his own medical decisions for very long. Merrin is welcome to try talking to him, though, it does seem like she rarely makes things worse

It's only 7:45, but they'll send in Halthis, as well as the additional relief medtech. 

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Merrin is going to give Halthis SUCH A MISERABLE LOOK before, drugs in hand, she goes to wake Kalorm again. 

...She is not very surprised but is definitely displeased when it takes even more stimulation to rouse him this time. 

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He eventually opens his eyes to fairly significant pressure on his nailbed, enough that it has to be very painful. Says a word that's probably 'what' but his speech is notably slurred. 

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Merrin arranges herself where she's directly in his field of view.

"Kalorm. Listen to me. Everything is going to be okay, but - remember I said you might get very sick before the antibiotics take effect? I'm worried that that's happening, and I think we're going to need to do some urgent interventions to get you stable. Does that make sense?" 

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Kalorm doesn't seem to be in the mood for talking right now. But he manages to keep his eyes open and at least in Merrin's vague direction, and he nods. 

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She squeezes his hand. "Something is wrong with your lungs. We don't know exactly what, but it's not the pneumonia, it's a new problem. Right now I'm going to give you some breathing treatments - you don't have to do anything, it's a mist you inhale - and I'm going to modify the oxygen mask setup so that it gives you a bit of extra help to push air into your lungs. If that's not enough we'e going to switch to a bigger mask that seals better. And I'm giving you the drug for nausea first - right now - because some people find that the positive pressure makes them feel nauseated, and because it'd be bad if you vomited with the mask sealed on. You need to get my attention if you feel sick. Which means it's really, really important that you stay awake, okay? I know it's hard, but - can you do that?" 

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Kalorm blinks at her. "...Dunno," he admits finally. "Can. Try." 

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Merrin takes a deep breath, and keeps her expression as calm and pleasant as she can. It's okay. Her hands are already moving to set up the nebulizer treatments. They sort of feel like they belong to someone else. 

....Well, it's not very okay, actually, but it's not - yet - an emergency on the order of seconds and maybe not even minutes. Kalorm's heart rate is - ugh, up at 120 somehow, but his blood pressure is still just barely tolerable, he's awake enough to say words and breathing on his own and even maintaining his O2 sats at 94% still on 50% oxygen. He just looks terrible, and it's pretty clear that all of those things are costing him significant effort, and she doesn't know how much more effort he has in him, right now. 

[Just to check] she subvocalizes, still very calmly, [when I said I have a bad feeling, did you make the update I intended, which is that I do not currently want eight people in this room but I am plausibly going to want eight people in this room on five seconds' notice at some point in the next five minutes and so can they please, please, please be five seconds away] 

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Yes. It's a pretty obvious update. It seemed like Merrin didn't need the crowding and resulting distraction or stress for Kalorm at this point, but they've got two people prepping the intubation kit who can be there in seconds if Merrin calls for them, the odds of needing that are now, well, higher than 70% and on a shorter timeline than 4 hours, though things are moving fast enough that the Diagnostic market odds haven't fully settled. 

 

- what would Merrin put as her own subjective prior on Kalorm having a cardiac arrest in the next: 10 minutes, 30 minutes, 90 minutes? Before she refreshes the screen so she's not biased and they can put it in as independent information. 

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Merrin's opinion is that they should NOT ASK HER FOR NUMBERS when she is BUSY and STRESSED and her brain is ALREADY TIRED is she a dath ilani or isn't she, though. 

The timepoints is an obnoxious format, though, Merrin's brain is not formatted that way right now. 

[Uhhhh. I don't... I think I'm most worried about when we decide to intubate him] because it really does not feel like an if to her at this point, even if right now Kalorm's eyes are somehow staying open and on her even though she's not talking to him out loud. [So - depends when we do that? And I...think it's doomier if we wait longer, sedation and the intrathoracic pressure shift will definitely tank his blood pressure and right now we have wiggle room on pressors and in two hours we might not. If we do it right now then, uh, 20%?] Critical look at Kalorm. [...30% unless we get his blood pressure up from where it is right now first. If we do it and he's already maxed on epi then like 75%.]

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Noted. Does she need anything else right now. 

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