[I'm really feeling most worried about the, like, five minute period after we give him an induction does of sedation - I want everyone here if we go to that - and if we get thirty minutes out and his oxygenation is solid then I'm a bit less worried. I don't know. I'd still put...15% that it looks like we're doing okay and then he randomly arrests at some point without much warning] 

And she needs to TALK to her PATIENT before he gives up on valiantly trying to stay conscious and listen to her because she asked him to nicely. Okay, fine, yelled at him to. Nicely, though. 

"Kalorm," she says, very levelly. "You're really tired, aren't you? - It's okay, don't try to talk, just focus on breathing, I'm going to stick with yes-or-no questions from here. But. It sounds like you're expecting staying awake to be really hard and you aren't sure if you can, is that right?" 

Kalorm nods, a slight but clear motion. And squeezes her hand unprompted, weak but also clear. 

She squeezes back. 

"I'm pretty worried about that. I think you're getting less alert, because you're very sick, this is something we knew could happen. But at this point I have a feeling it's going to get worse, and at some point you might not be able to stay conscious at all, and by then you sort of by definition can't warn me about it, right? Your breathing started to get worse really suddenly, so it's probably not done getting worse, and - the mask with positive pressure is only safe if you're awake enough, and honestly you're just barely awake enough now. Does that make sense?" 

...Uncertain nod.  

"Sorry, too many words." Merrin is a tense ball of STRESS and CONCERN but she deliberately forces herself to speak even more slowly. "You're more groggy and your breathing is worse. I'm worried the mask won't be enough to help you breathe and we'll need to put you back on the ventilator until you're more stable. Does that make sense." 

Mostly Kalorm looks like someone whose only remaining desire in the world is to be asleep. He nods, though. 

"I know you really didn't want that to happen, and it's awful when you can't communicate very well. But it wouldn't be forever, right? Maybe only for a day or two until the antibiotics start working." 

Maybe. Merrin is mostly, at this point, expecting it to be a LOT longer than that. But it wouldn't be the first time Kalorm has surprised all of them. 

"And you could sleep, right? You would be comfortable. We would have more options for keeping you stable without it being awful for you. And - I'll be here the whole time, until you communicate that it's okay for me to leave. I promise." 

Kalorm shakes his head, his lips moving but not quite forming a word. 

"You don't have to. It's important to know you're okay with it in an emergency, if you deteriorate fast, but it's not that scale of emergency yet. Just, I'm - more worried about you if we hold off as long as possible, even if it's because there's some chance you'll hang on long enough that your body starts making headway on the infection and we don't need to go there at all. Diagnostics was thinking only a 10% chance you can make it through the night without needing to go back on the ventilator - but I think there's a nearly 100% chance that you would have the worst night of your life. And in the 90% of worlds where we do have to do it as an emergency, with you already unstable - more unstable than this - then I'm really scared that you would get sick enough that your heart would stop. Which - you'd probably survive, just - more complications, more pain, longer recovery, and it's risking your brain which we just worked really really hard to protect. But if we do it now, while you're still only kind of unstable, I think that's - not completely safe. But safer." 

That was so many words. Was that a question. Kalorm can't figure out if any part of that was a question. He blinks at Merrin. Every time he blinks, though, his eyes try to just stay closed. 

Yeah, she keeps misjudging that, which is to be fair because Kalorm was MORE ALERT like half an hour ago. 

"I think we should put the breathing tube back in now," she says. "You'll almost certainly need it before morning and it's safer if we do it sooner. And that way you can sleep." She squeezes his hand. "What do you think? Yes or no?" 

Kalorm looks really overwhelmed, actually! He blinks at her some more, and doesn't manage to indicate a yes or a no. 

It's an overwhelming question! They should maybe have covered this ground earlier! 

"If you stop being able to nod yes or no to questions," Merrin says calmly, "we're going to give you sedatives and put the breathing tube in. If your blood pressure gets any worse, we're also going to put the breathing tube back before it gets even riskier. If your breathing gets worse, obviously we have to. Or if you think you can't stay awake any longer and you want to sleep, then we can do it. I'll keep asking you every couple of minutes. I promise to stay the entire time you're unconscious."

Pause.

"...And the better mask is here, so I'm going to switch to that and put it over your face. You won't be able to talk as easily but I don't want you to try to talk anyway, I want you to focus on breathing." 

Kalorm still looks overwhelmed and uncertain, but he is, at least, awake. He doesn't protest or resist when Merrin places the positive pressure mask over his face and seals it; he just makes a bit of a face. 

Either that or the nebulizer treatments are helping a little. His O2 saturation is up to 98%, still on 50% oxygen. His breathing is both rapid and noticeably labored, though, which is a lot less reassuring. 

Merrin will take her eyes off him for a maximum of FIVE SECONDS AT A TIME while she refreshes and checks screens. 

The CT scan is complete and Halthis is getting ultrasound imagery of various things! They've approximately ruled out a pulmonary embolism, and his pneumonia is actually a lot better; it doesn't look like an infection in the lung. Doing a bronchoscopy would get them more data but is unlikely to help all that much with Kalorm's oxygenation.

Diagnostics agrees that the imaging looks more like a typical presentation of pulmonary edema than of inflammatory lung injury. Which isn't conclusive on its own, but the cardiac ultrasound is clarifying, because it does look like Kalorm has - over a pretty short period of time - developed some significant cardiac dysfunction. His rhythm is fine, albeit constantly faster than they would like and now all the way up at 125 (though the sympathetic-nervous-system-stimulating bronchodilators he's inhaling cannot be helping); the effectiveness of each contraction is way less than it should be in a healthy young person.

But Kalorm wasn't starting out from a place of perfect health; his body was still recovering from the significant shock they put it through not very many days ago, including almost sixteen hours when his heart wasn't even beating on its own, and a lot longer than that of needing medication support of various kinds. 

Anyway, this basically evens out the prior probability on inflammatory lung injury versus more straightforward "water backing up in the lung thanks to a struggling left ventricle", and with the imaging, it's probably 50% more likely. Not quite enough to confirm a diagnosis, so they're going to keep throwing anti-inflammatories at Kalorm's lungs until the more sensitive lab work panel is back, but the levels of lung-specific inflammatory and damage indicators will be informative. And his response to positive pressure ventilation, one way or another; it should actually be fairly effective at reducing straightforward pulmonary edema, squeezing water out of tissues and shifting around the pressures in various chambers of the heart to reduce the circulatory congestion, but for inflammatory lung injury, more pressure on the tissue will actually worsen the damage. 

...This unfortunately assumes that Kalorm can last for an hour or so while staying alert enough to protect his airway, not crashing his blood pressure, and not running into a wall of exhaustion with his still visibly increased work of breathing. This is a point at which most dath ilanis would not find it a hard choice at all to opt for immediate intubation. Kalorm - is apparently still trying to figure out which side of things he disprefers harder. 

Aaaaaaaaaaaaaaaaah Merrin does NOT LIKE THAT ultrasound! She spends a couple of seconds staring between the screen and Kalorm, and trying to make her brain settle on whether her probability of straight-up cardiac arrest if she convinces Kalorm to go along with intubation right now should be updating upward a bit to 40% or all the way to, like, 60%. Mostly all she succeeds at wringing out of her brain is internal screaming. 

"Kalorm." She takes his hand. His eyes are closed but the EEG at least thinks he's drowsy-but-awake. "Kalorm, are you getting more tired? Would you rather be asleep and have more help breathing?" 

Gaaaaaah she wishes they could risk giving him something to slow his heart rate, he's at 130 right now and it's making her neeeeervous. There really aren't a lot of options that decrease heart rate without massively dropping cardiac output, though, and they really cannot afford that. 

Kalorm drags open sticky eyelids. Shakes his head, but not with very much oomph. 

"Okay. I'm worried it's getting closer to being an emergency, but your oxygen level is still okay and you're apparently still answering questions. Do you remember where you are?" 

He licks his lips behind the mask. Looks faintly puzzled, as well as bleary; apparently it's taking him some thought to dredge up. Eventually he mouths something that is probably 'Default Hospital'. Merrin can't really hear him. 

Merrin tries he best to smile reassuringly at him. It's probably the least reassuring attempt at a smile of the entire week. "How does your breathing feel - is it a bit easier?" 

Small nod. 

Merrin tries to decide if she believes him. He's still using a lot of accessory muscles that he shouldn't be having to use, but - he's plausibly clearing CO2 better and thus at least feels less short of breath overall? 

She squeezes his shoulder. "I'm not panicking about you yet. I'm worried about you, I'm especially worried because it looks like the infection in your blood isn't great for your heart right now, but it's your prerogative to stress out your medtechs if something is sufficiently disprefered for you. Just. You should have the information that I am here being very stressed." 

Nod. Scowl, clearly visible even behind the mask.