It's a very smooth intubation. They're a practiced team and Kalorm isn't exactly difficult and within less than twenty seconds they have confirmed air entry by ultrasound and lung sounds, and exhaled CO2 by sensor. 

Kalorm's oxygen saturation STILL manages to drop as far as 91% during this brief interlude before beginning a laborious rise. His heart rate drops to a low point of the mid-70s before the epinephrine properly hits, 30 seconds later, and it starts climbing fast. 

His blood pressure lags behind both on the drop and the increase. It's only down to 85/45 when his heart rate first shows a reaction to the epinephrine. But it's still dropping. Another thirty seconds later, heart rate is at 130 again, and his blood pressure is down to 70/30. 

Time for Merrin to DIE of STRESS. She shouldn't even be that exhausted right now but she's not thinking of anything, just sort of staring upsetly at Kalorm and feeling like she definitely make a mistake of some kind, somewhere, at some point, but she isn't actually sure what. 

His blood pressure plateaus at 65/30 and finally, slowly, starts to climb, and makes it back up to 85/50 before, apparently, deciding that this is good enough for now. His heart rate is still 160 and shows no sign of dropping. 

Halthis looks uncertainly at him. [He's not bleeding, I don't think - it was fine five minutes ago - but I'm going to check, he's not reacting to this how I expected] 

Merrin picks up Kalorm's limp hand. It's cold to under her gloved fingers, and damp, almost wet with sweat. He's not shivering, right now - sedation knocks that out - but his skin is goosepimpled. His face is slack and white around the tube. 

[...I don't think we should give him more epinephrine. He's - this is really high sympathetic activation and it's not helping. Treatment Planning, do you have any other ideas] 

They're considering several different exotic vasopressor-adjacent drugs that are supposed to directly counter some of the effects of sepsis-induced cardiomyopathy. They want an updated ultrasound of his heart now - not at the cost of Halthis checking for bleeding, there's another ultrasound probe in the equipment room, someone - not Merrin - should get it and they should run. They need visualization of his vena cava and other large vessels to get an estimate of central venous pressure and whether he's fluid-overloaded or whether it looks like they could give him more fluids - measuring it from the main central line will require pausing all the drugs they're infusing, which is a terrible idea, it's kind of sketchy to check from his dialysis line but Merrin is certed on that, can Merrin in fact handle that right now. 

Yes. It doesn't require having a functional brain, just functional hands, and Merrin is entirely capable of keeping her hands from shaking even when she's simultaneously panicking and incapable of experiencing normal human emotions

She's not going to rush but she doesn't take quite as long to definitely avoid any possible hint of making even a non-dangerous mistake on camera, either. 

Kalorm's heart is really not liking something about his current physiological state! They can get a best-guess estimate of pressures, though if he continues to be this unstable they may want to risk invasive monitoring, it's an infection risk but it's not like they aren't already covering him with every possible antibiotic treatment. Anyway, the preload - the blood returning to his heart, on both sides but especially the systemic circulation returning to the right atrium - is definitely substantially down, which is to be expected with positive pressure invasive ventilation, especially when they're running a fairly high post-exhalation baseline pressure to gently squeeze fluid out of his lung tissue and back to where it belongs.

This should in some sense be decreasing the strain on his heart, but it's combining very badly with an elevated heart rate - in addition to the pressure discrepancy, his heart barely has any time to fill with blood between contractions - and severely depressed left ventricular function and thus fraction of blood in the ventricle actually ejected per beat. His stroke volume - the amount of blood pumped per beat - is almost nothing. It's sort of remarkable, and a testament to how well the rest of his body is managing to respond to the epinephrine despite the lure of toxins and chemical signals swimming through his blood and telling his capillaries to dilate dilate dilate, that he's still maintaining a blood pressure even this tolerable. 

They really need to reduce the irritability of his heart muscle - it's probably oversensitized and overreactive even to the endogenous panic signals his own body is producing - but they also can't afford to do that when his blood pressure is this low, it may increase his ejection volume per beat eventually but in the meantime they risk losing his blood pressure entirely. 

They'll try another 250 mls of albumin and then another liter of IV fluids, and they're preparing one of the drugs to stimulate contractility that has relatively less of an effect on heart rate, and they're working on the exotic drug blend to try to block the dysfunctional pathway in a very heart-specific way but it's not fast, it's something that will stabilize him over hours and not minutes. 

That is...pretty much everything they can do, right now, plus be ready to respond instantly if he does manage to just go into cardiac arrest first – in which case they should not follow the protocol that involves giving him more epinephrine. They can try vasopressin but if he slips into a pulseless but non-shockable rhythm and a few minutes of manual chest compressions don't help – and there's no obvious and easily correctable structural or metabolic problem - it doesn't look like a cardiac tamponade, fluid buildup in the membrane sac around the heart, it just looks like a weakened left ventricle ballooned out to the point of near-uselessness, trying to contract and not getting purchase – anyway if they don't see anything they can fix in less than another five minutes, they should make a call fairly early to put the internal cardiac pump back in, it's not great but it can buy them a few hours for other treatments to work. 

They would consider just putting him on heart-lung bypass but his lungs are in tolerable shape and should recover soon, and patients in severe sepsis are a nightmare with external filter circuits. They really don't need to increase Kalorm's risk of a clotting cascade careening out of control and falling into disseminated intravascular coagulation. 

Halthis catches a bag of fluids tossed by one of the other medtechs, sets it up. "We've got defib pads connected, right, if we get a shockable arrhythmia? ...Wondering if we should just get the compressions vest on him now but I kind of don't want to move him, everything feels really fragile right now." 

Merrin rolls her shoulders. "...If we need to then I'll just do compressions the hard way. It'll be easier not to hurt him if I can feel what I'm doing." Shrug. "I can usually manage five minutes, if it goes longer we'll need a change of strategy anyway - someone else needs to place the pump, I don't think I can do that right away after." 

Halthis is giving her some sort of Look. It's hard to tell if it's an impressed look or a horrified one. "You can do five minutes straight? How, when did you even try that, when would it come up– oh right Exception Handling." Her eyebrows are definitely impressed. "That's mean." 

It's really by far not the meanest thing they've done to her in sims, and also Merrin doesn't really want to be having this conversation right now, it's distracting and weird. 

Halthis refreshes screens, more as a fidget than because she expects them to have any new brilliant answers for them. She switches back to subvocalizing, because a group of the other backup medtechs are coordinating on cardiac arrest protocols. [He's not bleeding. Gut looks - actually better, somewhere in the middle of all that he dumped another 300 ml in the rectal tube.] She looks unhappy. [I think our problem is just the sepsis, and he's immunocompromised, which is unfortunately way harder to fix. ...We should get a repeat lactate. It's definitely going to be ugly but we're going to need to track if it's improving or worsening from this point.] 

That's good? ...Oh no it's bad. Probably. It's hard to tell since everything is already bad and Merrin's entire brain is kind of a nonstop chant of DOOM and it's probably going to be okay Kalorm's chances of surviving to hospital discharge are still pretty good no matter what happens here, today, but it doesn't feel okay it feels NOT ALLOWED and her mind doesn't want to put numbers on anything it's all a wordless wall of refusal or just pointless mental flailing and she wants to be somewhere else she wants a different thing to be happening and it's TERRIBLE it's the WORST THING that she can't just try harder and have been better and done more sims and somehow make everything safe.  

Fluids go in. Recommended inotropes to coax his tired heart to beat harder arrive, with a rather cautious on-ramp-dosing protocol. They're even more cautiously going to try a drug that's supposed to decrease heart rate without having any effect on contractility; it's not thoroughly tested in combination with the other drugs, in theory it should cancel out the unwanted side effects but it might just not work.

Kalorm...improves a little? The fluids seem to be doing most of it; they're definitely not helping his lungs, Halthis has to go up to 80% oxygen concentration because she really doesn't want to mess with pressure changes right now, but they should have more leeway on that soon, and if they fix the cardiac issue then the pulmonary edema should resolve fairly well. But his oxygenation is acceptable and his heart rate drops to 135. Starting the recommended drug infusions doesn't decrease it, but doesn't increase it either, and his left ventricle does seem to be ejecting its blood with a little bit more force and enthusiasm, even on the cautious starting rate. He doesn't really look any better but they get his blood pressure up to 95/60. 

They can really carefully try a little bit higher on the inotrope. 

Cardiac-specific anti-inflammatory possibilities are being considered, but one seems obvious to try, even though it has various non-ideal risks including reducing circulation to the gut (but, like, so do approximately all vasopressors). Because biology is superheated insane, it's also a bright blue dye. The IV bag that arrives looks kind of disturbing. 

The also-very-cautious starting dose doesn't have much visible effect, but increasing the inotrope does. Kalorm's blood pressure is up to 110/70! They can afford to ease down on the other vasopressor! 

His heart rate is also creeping up again, though, and increasing the heart-rate-slowing drug doesn't seem to do anything at this point. 

A heart rate of 140 to 145 seems acceptable for a few minutes? It's better than 160? At least he's getting circulation, which will buy them a lot - more oxygen to all his tissues, including his heart muscle, and flushing out some of his in-fact-absurdly-high lactate - they should give him some bicarbonate, actually, his CO2 is in normal range but his lungs can't currently regulate to lower it and get his pH to something normal in the meantime - 

Those irritable extra beats on the ECG tracing are maybe less acceptable! 

Aaaaaaaaah DOOOOOOOOOOOM and time to try to wildly guess which of the numerous things they just did is causing this! Or it could be his body temperature, they didn't change anything and the warming blanket is still blasting him but he's somehow back down almost a full degree to 35.6. Or maybe his pH! Or something else is wrong! 

He definitely doesn't look like someone with a perfectly respectable blood pressure of 105/55 now on only 75% of his previous dose of normal vasopressors! 

[I'm registering a bad feeling] Merrin says, and then stops, because her doomsense is not producing anything specific about, like, what they should consider doing more of or less of. 

It's...most likely to be the inotropes? Unfortunately Kalorm's blood pressure is responding well to them and they don't really want to stop and lose that. They can ease off by, like, 10% on the current dose, and if that doesn't resolve it they'll probably have to put him on an anti-arrhythmic to calm down his irritable heart muscle, at least until all the other physiological parameters are normalized. 

Halthis does this instantly. 

...She toggles her subvocalization microphone to Merrin privately. [Merrin, do you - think this is enough? Or are you still feeling worried - do you think we need to more drastically rethink what we're doing...?] 

Why is Halthis asking Merrin???? Who is stupid at the best of times and currently feeling emotionally and mentally drained and not successfully having any complete thoughts other than an unending refrain of I don't know I don't know something is doomwrongbad but I don't know what and– no, stop, she's done - not this sim specifically, not with the part where if Kalorm dies then he's gone forever, but she is an Exception Handling medtech and they invested very hard in drilling this skillset into her however much extra work it took on everyone's part. She can make her brain stop screaming and start thinking. 

[...I'm not sure but I'm - worried about how many things we're doing at once? It's not just side effects, there's interactions to think about. ...Think maybe we should decrease the what's-it-called, the one that's supposed to lower heart rate, at least back to the starting dose, and maybe stop it entirely, it didn't seem to help and it's another variable here. I...feel really nervous about the inotrope causing irritability but I don't actually know if we have much of a choice, we need the positive effect, just -] She shrugs helplessly. [Guess all we can do is hope he hangs on for this bit]