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Merrin working in Exception Handling
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"You're not feeling nauseated right now?" 

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Headshake. Kalorm closes his eyes again. 

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Ughhhhhhhhhhhhhhhhhh STREEEEESSS but Merrin is not going to argue with him any more than this, she is NOT, it won't even HELP, Kalorm is capable of being a reasonable person (if he's not delirious) and she'll notice if he becomes delirious and has pre-established agreement with him that they're putting him back on the ventilator if his neurological status deteriorates, and so she is going to be PATIENT and WAIT even though this is possibly one of the most agonizing things she's ever done. 

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Bloodwork is back. Lung inflammatory and cell injury markers are up a bit, but not sky-high like you would expect if a damage cascade bad enough to cause his current symptoms was in motion right now. So it's probably mostly pulmonary edema, which is sort of embarrassing for the Diagnostics experts whose bets contributed to that being at 10% priors. 

His white blood cell differential is even more out of whack. His hemoglobin and hematocrit are lower but that's probably still mostly hemodilution, given that his gut is actually improving and the copious drainage from the rectal tube doesn't look like its digested-blood content is that high a fraction of the total. His electrolytes are basically fine. 

His lactate has done a big jump, though, up to almost double the maximum normal level. Which means that whether or not his measured blood pressure is technically adequate, his circulation isn't, at least not everywhere. It's not that surprising; his hands and feet are now both mottled and cold. 

The repeat blood gas is okay. Not better than okay, but...okay. 

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It's been another couple of minutes. 

"Kalorm? Hanging on there?" 

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Calm. Stay calm. She doesn't need to panic yet, he was hard to wake up last time too. The EEG thinks he's at most in light sleep. 

"KALORM! WAKE UP!" She pinches his nail. Then does it again, harder. 

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Kalorm can hear her. For a moment, he tries to wake up, to find his way to the surface of an ocean that's gluey and bottomless and so, so cold. But he's so tired, and something feels incredibly hard, waking up and answering questions on top of that is just unfair. ...Breathing. That's the thing that feels hard. Probably because he's underwater? He should stop that. 

The surface is such a long way away. 

He just wants to sleep. 

He...was supposed to tell Merrin if he was tired and wanted to sleep? But that sounds hard. She's not even asking him a yes or no question, she's just shouting at him. He wishes she would stop that. It's rude and it hurts his head and he still can't find his way to the surface to answer her. 

...Maybe if he just. Doesn't try to wake up. Then Merrin will figure out that he doesn't want to. And then she'll know. And he won't have to tell her. 

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Merrin gives it seven seconds exactly of escalating attempts to get a response. At which point she really barely has to escalate it officially, she is making a LOT OF NOISE and if Treatment Planning is paying the slightest bit of attention they'll already be sending the backup people in - but you always trust and then verify anyway, so she snaps, out loud, "escalate to intubation right now!" and then - she needs more control of his airway than she can get with the stupid positive pressure mask covering his entire face, and it doesn't even seem like it was helping that much - vital signs are okay, aside from his heart rate which is 140 for some reason - she flicks off the positive pressure setting and releases the attachment point and in about five seconds has the regular mask with the moveable panel for convenient suction access back in place, set to 100% concentration and maximum flow, and she turns Kalorm's head to the side and checks his mouth with the suction just in case - 

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He may not be awake enough to interact with questions, but he's apparently just barely awake enough to try to turn his head away and bite the suction catheter at the same time. 

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"Kalorm, please try not to do that," Merrin says, in the sweet dulcet tones of someone cajoling a reluctant child to take off their muddy shoes before running around indoors. "You're okay, I've got you, just try to relax and breathe - we're going to give you some sedation and put the tube in as soon as that's ready but for now I need you to just focus on breathing. If you're awake, can you try to squeeze my hand?" 

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Merrin is talking??? She sounds calm and almost cheerful. Probably everything is fine. Kalorm has no idea what Merrin is actually saying because he's very deep underwater and words aren't a thing down here. 

He does relax and stop fighting her. This doesn't entirely feel like a choice, making decisions is also not really a thing down here, but it's okay, Merrin won't let anything horrible happen to him. 

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It's really unclear exactly where he is on the spectrum from 'aware of his surroundings and just too confused to parse words' to 'basically totally unconscious.' Merrin is just going to keep talking to him as though he can hear her, though; mostly she just narrates exactly what's happening around her and reads out loud from the live-updating Treatment Planning screen. If they need her to do more complicated teamwork tasks than "talk to Kalorm and be responsible for his airway until they have a tube in it" then someone is going to have to tell her or, like, flag something with her name in flashing bright colors. 

"We're getting more people in the room to help and we're giving you lots of extra oxygen. If you feel something on your chest, that's because Halthis is getting another ultrasound picture of your lungs and heart. We're going to give you a small dose of painkillers now and - looks like the really powerful anti-nausea drug because it would be an incredibly inconvenient moment for you to throw up, and the sedation and painkillers can cause that, your stomach should be empty - someone's checking the tube, it looks fine - but still. You're doing great. Just relax and keep breathing for like fifteen more seconds, okay?" 

Subvocalized: [I have a bad feeling I realize his blood pressure is reading as acceptable right now but it's borderline and he looks really bad, can we max the vasopressors or maybe push some epinephrine before we give the sedation and ruin everything? - nevermind that's a bad idea. Kalorm why is your heart rate 150 that's so unnecessary right now. Can we give him, like, an inotrope or something first. But like now I don't want to wait on it] 

(A drug that strengthen the contractility of his heart without necessarily increasing the rate, though inconveniently most of them do increase the rate and the others have different risk profiles that aren't appealing either.) 

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Kalorm is - less responsive, in some way that Merrin can't actually name or describe since it's not like he was responsive before. He's shivering. His oxygenation is reading fine and his blood pressure is still at 90/40 even after a small dose of painkillers and a much larger dose of anti-nausea drug, but his skin color is not reassuring at all

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Treatment Planning doesn't think an inotrope will take effect fast enough. They'll max the vasopressors and give another 500 ml of fluids – his lungs won't like it but once he's on a ventilator his lungs aren't going to be the scariest problem and it won't hit right away, and fluids seem to be the only thing his heart rate really responds to - and wait no more than 30 seconds to see if this does anything, and if not they'll push, like, a quarter of the epinephrine dose you would give for someone actually in cardiac arrest, and give the sedation and try to be fast, and if his blood pressure drops by more than 10 points anyway - or if Merrin has an illegible doomy feeling - they'll push a full dose of epinephrine, he'll tolerate a few minutes of a rapid heart rate a lot better than if they wait too long and lose his pulse entirely. 

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Merrin's brain feels like it has maxed out her internal doom sense and she's not sure she would, like, notice if her doomfeelings got stronger than this? She is, reluctantly, ready. 

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30 seconds of the conservative option does something? Kalorm's blood pressure creeps up a tiny bit, to 95/50. 

His oxygen saturation is down to 98%, though, even on literally the maximum flow and concentration of oxygen they can give him. 97%. He's relaxed, his breathing more regular, but with the added drugs he's clearly not breathing enough

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Halthis exchanges a look and a nod with Merrin. "Go now." 

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Merrin squeezes Kalorm's limp hand one last time. "We're giving you the sedative and you're going to go to sleep now," she says, even though she's about 80% sure he can't hear her at all. 

She waits until literally the last second to yank out the pillow and flip him all the way onto his back. 

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Kalorm's body relaxes into bonelessness. 

He doesn't take another breath. 

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There is not actually any particular need for verbal coordination; this is a sim scenario they've all done at least a hundred times, Merrin has probably done it a thousand times, everyone has been in a similar situation at least a few times in real life. (Usually because of less than ideal external circumstances and NOT because a patient was extremely stubborn.) This is why they gave him a few minutes of 100% oxygen. 

Merrin does one last pass to suction saliva from his mouth, Halthis clamps a different mask to his face and squeezes four breaths' worth of 100% oxygen into his lungs, and then two of the other medtechs move in. 

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Kalorm's heart rate reacts sooner and faster than anything other visible sign, by almost immediately dropping from above 150 to 120. 

110. 

 

His blood pressure is only just starting to dip but it didn't actually go up very much in the first place. 

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WOW WHO KNEW IT TURNS OUT HER DOOM SENSE GOES TO HIGHER NUMBERS THAN THAT 

"Can we do the thing now," Merrin says, out loud and not exactly being very specific. She's too tired for this, or too emotionally engaged, or something; not all of her brain that should be online right now is. 

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"Yeah." Halthis whacks the control to give him a full milligram of epinephrine. 

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STRESS there is not really anything Merrin can usefully do right now but STRESS

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