Halthis is of course going to take this very seriously and immediately run it by Treatment Planning and then drop the heart-rate-lowering drug back to its tiny baby dose starting rate. 

This, perhaps predictably, does not have any effect on Kalorm's heart rate. It does seem to correlate with an improvement in his blood pressure over the next couple of minutes, which is the exact opposite of what is supposed to happen, though of course it's hard to untangle from the methylene blue that they just started. 

Kalorm hangs on. Acceptable if not stellar oxygen saturation, totally respectable blood pressure in numerical terms even if he still doesn't look like a patient with a systolic blood pressure over 100, heart rate steady at 140 with occasional ectopic beats but at least not couplets of them. 

Merrin fidgets. [Trying to think if it's actually worth decreasing the post-exhalation ventilator pressure] she adds to Halthis, still privately. [We'd probably have to go to 100% on the oxygen concentration for a while, but it would maybe help with the preload issue and get a better stroke volume, and if we can get enough it might successfully get the signal through to downregulate his heart rate...] 

It's...worth trying. They definitely can't afford to drop it by a lot, they keep giving him fluids and are really leaning on the ventilator positive pressure to keep him from spiraling into intractable respiratory failure before his heart function picks up. Halthis will, again, run it by Treatment Planning, since for some weird reason Merrin seems to prefer this private conversation thing over just telling them herself. 

Treatment Planning approves a one-increment drop. 

...The good news is that his oxygenation holds up through it, and they actually only need to go up to 85% oxygen. The less good news is that it doesn't really help much. Maybe a few points of blood pressure increase, not enough to risk decreasing any of the other drugs. 

He does a run of three ectopic beats. 

Merrin doesn't even think she just dives for the console and drops the rate of the inotrope mix by 50%. "Where are we on anti-arrhythmics?" she snaps to the room at large, out loud, and then only slightly internally dies of mortification. 

...They don't have a consensus that the experts are happy with on what's the best tradeoff between efficacy (for the intended purpose) and safety, including safety in the sense of not cancelling out the limited progress they've made so far. If Merrin is expressing concern, though, especially in that tone of voice, they'll expedite sending over the one they're not entirely happy or in consensus on. It'll be in the pharmacy chute in 30-60 seconds can it wait that long. 

Merrin doesn't see a BETTER OPTION so she'll just sit here QUIETLY PANICKING. 

A few more abnormal heartbeats land in pairs. 

(They're already losing ground on the blood pressure improvements.) 

A run of four, before Kalorm's heart rhythm straggles its way back into sinus tachycardia at 135. 

...A run of - Merrin has already lost count it's running at least 300 bpm if you can count them as beats and it's three...four...five seconds - 

[Sustained ventricular tachycardia] Halthis subvocalizes with the channel open to everyone not in privacy mode (which should not include anyone in the room), [is everyone - Merrin get clear -] 

Shock. 

For about three seconds it looks like this is maybe going to work - the electrical complexes on the screen aren't exactly normal but they're at least not running at 300 bpm anymore -

- and then the electrical rhythm decays into random fibrillation. 

"Eeep." 

(Merrin manages to make only a Small Upset Noise even though internally she is SCREAMING IN DESPAIR AND FRUSTRATION.) 

This isn't. It isn't even the problem she was expecting they would have. She was expecting pulseless electrical activity, not a shockable rhythm, though it didn't work on the first try and they should not just keep shocking him hopefully and should wait until they have anti-arrhythmics in him to make his heart CALM DOWN even though yeah at this point she's worried that this will wreck any chance they have of Kalorm maintaining spontaneous circulation for the next few hours. 

It's fine. Someone else will figure that out. Merrin has one job here. 

[Bed] she snaps out to Halthis, because any other medtech will know exactly what she means, and Halthis toggles the bed to fully-rigid mode and drops the head fully flat again - wow that is not going to be good for Kalorm's oxygenation but she so has other priorities right now. 

She has to remind herself very very hard not to try to be gentle. It's going to hurt him. She has a better chance than a machine of calibrating it so she gets any circulation going without seriously disrupting his healing sternum incision, but it's going to hurt him no matter what, he's going to wake up in pain again - it's fine, it doesn't feel fine but it is, Kalorm did not refuse to consent to this and wants to be alive and the only important thing is that he does wake up. 

It is, in fact, exhausting. Within thirty seconds her back and shoulders hurt and she's overheated - they're keeping the room at a Kalorm-friendly temperature which is NOT a friendly temperature for a Merrin doing intense physical exertion - and out of breath. There's a relief and clarity in it, though. She's mostly not having any thoughts but it feels like she could, if she wanted, if that were the strategically right thing for her to be doing, which it's not. 

Kalorm does not object to this. 

Bad! Terrible! This is the WRONG way for things to be and Kalorm should be glaring at her and trying to hit her for this. 

(It's weird how much more upsetting and awful this is than the last time! Or, well, it wasn't not awful, she definitely wasted a few seconds on freaking out about the no-cryo thing, but it wasn't personal, it was an abstract internal screaming, she wasn't imagining Khemeth's face and having to tell him that his brother is gone forever. And normally she wouldn't think about that right now, it's clearly distracting and pointless, but she isn't the lead opper on this and she's not doing anything that requires complex thoughts or doing math and she's tired of wrestling her brain toward productive reasoning and numbers.) 

She registers only a few things around her, crystal clear. 

Kalorm's face, grayish and empty but not quite dead-person-colored. 

The screen of readings, bright colored numbers that don't take any conscious thought to assess, she's somehow getting a blood pressure of 115/40 and wow Kalorm's heart wasn't working very effectively before this, usually manual chest compressions are much less effective than a spontaneously beating heart.

The main ECG reading is basically useless, just the jagged up-and-down spikes of artifact from Merrin's chest compressions, all it really tells her is that she's indeed managing a pretty consistent 120 bpm as per the recommendations. There's an attempt below it at software correction to take out the motion artifact, but the software correction is never very good, so at a guess he's probably still in ventricular fibrillation but they can't really see more until Merrin pauses. 

Kalorm's EEG tracing is...basically unchanged? It shows the slow, suppressed waves of deep sedation not quite at the level of full anesthesia, but there's still activity there, which is a good sign – if the bloodflow to his brain was interrupted, it wasn't for very long. 

Someone crosses her field of view with an IV bag and one of the ampoules for IV push, and slots both into the infuser. 

[Thirty seconds for anti-arrhythmics to circulate and we'll try shocking him again] Halthis relays to Merrin's earbud. [Back off on my go] 

Merrin is in pure stimulus-response mode right now but yes she can do that. 

Thirty seconds. 

She hops down from the bed. Tries to catch her breath as quietly as possible, to avoid distracting anyone else. 

(At which point it's clear that the ECG reading is definitely still ventricular fibrillation. It's the coarser kind, though, higher-magnitude ripples and spikes, 

Kalorm twitches on the bed, his arms contracting briefly up toward his chest. 

The ECG reading shows a massive spike, then...smooth...a longish pause, maybe a second and a half... 

- something that isn't quite a normal heartbeat electrical complex - it's missing the little initial bump that indicates normal atrial conduction pathways, and the main spike is wider than it should be - but it doesn't immediately degrade back into the previous rapid ventricular rhythm. Instead it's - slow, and irregular, but a rhythm that looks like it could be compatible with pushing blood around. 

(The blood pressure meeting dropped back to negligible almost immediately after Merrin backed off, and still isn't picking up even small bumps – but it's a radial arterial line, it'll take a while to catch up and propagate there even if Kalorm's heart is somehow working fine now, which seems very unlikely.) 

Halthis leans in. [...Not feeling a carotid pulse - ultrasound -?] 

Ultrasound imagery goes up on a wall screen all of them can see. There's something there? More of a halfhearted squirm than a proper contraction, though. 

Merrin doesn't need to be told to continue compressions. She scrambles back onto the bed. 

Within thirty seconds she can get back to a measured blood pressure of 100/40, but of course it's impossible to tell right now how much of that is Kalorm's doing. 

(They're just barely getting a pulse oximetry waveform, reading at 89%.) 

Treatment Planning recommendations happen around her.

They want to give him one more dose of albumin, this time the highly concentrated form, 50 mls of 25% concentration, in hopes of sucking some fluid back into his bloodstream. They're going to try one (1) dose of one of the higher-risk cardiac drugs – it's exactly what they need in a lot of ways, it has a powerful effect on contractility but should help regularize the heart rate, but it also has a very narrow therapeutic window, or range where it's effective-but-not-toxic. Kalorm's body is likely to be metabolizing things in unpredictable ways right now, so they'll have to do serial lab checks for his blood levels and make sure he's clearing it at a safe rate, and they really shouldn't keep using it.

They want to run a continuous IV infusion of a powerful anti-arrhythmic drug that at a dose that will definitely by itself weaken the contractility of his heart, but now that he's out of the initial arrhythmia it should significantly reduce the likelihood of it happening again. If another three minutes of all of this, plus the still-running methylene blue, doesn't get him back to maintaining a tenable blood pressure on his own, they want to risk trying again with a halved dose of epinephrine and then, if he responds well, a continuous infusion.

It's a risk, definitely, but they can't keep doing this forever; given the existing rib injuries and the incision, his risk of clotting dysfunction and bleeding is too high to keep pounding away on his chest. Given that, they'll tolerate a lower blood pressure than what one usually aims for; if Kalorm can manage 85/50 or better on his own, either in 3 minutes or later with epinephrine, that's good enough for now. 

If not: well, they really want to avoid falling back on more invasive circulatory assistance, because of the additional infection risk, but the new-albeit-controversial calculation is that cardiac bypass might actually be safer overall, if it's a six-hour period or less and they don't have to do a filter change. So the backup plan is to try to buy those six hours, and hope they can reverse enough of the cardiomyopathy before it runs out. 

Across all of these, they think there's a 96% chance that something will work – but that's still a 4% chance that it won't. 

Merrin is saving all her breath for the workout, so she's only talking to Kalorm in her head. But she thinks they're not giving him enough credit and he's very good at not dying and so this is going to be fine. 

...Three minutes. She pauses again, but stays perched awkwardly on the bed, one hand gripping the headboard for balance.