The Merrin-maintained blood pressure on the display drops...

...but not to zero. It steadies out at 65/40.

And his ECG looks - mostly normal? Slightly delayed conduction of the atrial impulse, a longer-than-usual pause between the little bump and the full spike, and the repolarization wave afterward is stretched a little as well, but the ventricular complex is approximately normal width. His heart rate is slightly irregular but averaging around 80, which is actually sort of reasonable. 

(Despite the number, to Merrin's eyes Kalorm actually looks a little better than he did earlier, when he was technically running a systolic blood pressure above 90.) 

Halthis checks for a carotid pulse. Nods and smiles slightly. 

Merrin should probably be...relieved? Or something? Instead she mostly just seems to have lost the ability to have emotions at all. 

[Can we do a quarter dose of epinephrine] she says. [And, like, slowly?] 

...That seems reasonable. Treatment Planning approves 0.25 mg of epinephrine over a minute, watch the response, stop immediately if he's throwing ectopic beats. If there's some improvement but not enough after one minute, try another 0.25 mg this time over two minutes. 

come on Kalorm you can do it, it's okay it's not scary everything's going to be fine 

Merrin can't take that line of thought as anything other than pointless motivated cognition, even in the privacy of her own mind, but she's still having it. 

It takes Kalorm thirty seconds to start responding in any way at all. 

- and then his heart rate rises, slowly over the next 30 seconds and up to around 95. More to the point, the ultrasound shows that his left ventricular contractions are stronger, the dysfunction is still pretty noticeable but he's squeezing out maybe 25% of the contents with each beat, which is still low but a third of normal rather than a tenth. 

His blood pressure takes longer to respond, but this isn't surprising, and by the time a minute is up, he's at 75/50. 

...Proposal: drop the rate to to 0.1 mg per minute, decrease by 50% if his systolic blood pressure hits 90, follow this protocol for 10 minutes and reassess, unless Merrin objects. 

Merrin is NOT THE LEAD OPPER HERE why are they asking HER Given the 30-second delay on their response loop in terms of blood pressure, she would've gone with "drop by 25% if he hits 85 systolic" or - maybe drop by 50% if his blood pressure rises by more than 5 points in less than 15 seconds? And drop by 25% if his heart rate goes above...uhhh 110 is where she would start to be worried but Treatment Planning should consider any number stated by Merrin to be very made up, right now, she's tired. 

...They want to set the heart rate cutoff at 105. His current blood pressure is, like, fine for the next few minutes, he's getting perfusion, it's not worth the risk of more arrhythmias. Otherwise, approved. 

Kalorm's blood pressure does indeed keep rising, even after the change. His heart rate hits 100, and then steadies out there, while his blood pressure is still on the way up.

...78/50...

...81/53...

...83/56...

...86/61...

It's taken him nearly four minutes to get there. Merrin lifts a hand, and waits another twenty seconds, and then nods to Halthis. [Drop by 25%] 

The next half-hour manages to be a combination of VERY stressful and also VERY tedious. 

Kalorm's body is dealing with SO MANY drugs in his bloodstream, all with different half-lives and metabolic breakdown pathways, half of them with effects that directly oppose some of the effects of the others. The single-dose drugs are slowly wearing off, and getting the continuous infusions into an acceptable equilibrium is a complicated and fraught dance. Treatment Planning has some more finalized recommendations for drugs that directly address the cardiomyopathy associated with raging sepsis, but they don't really want to perturb the system any more until it settles into slightly more of a stable equilibrium than this one. 

They're able to get the epinephrine infusion rate down reasonably fast: starting from a significant fraction of a cardiac arrest dose, in less than 10 minutes they're down to around 0.04 mg per minute, only a little above the usual range when used as a standard vasopressor. 

It's still higher than is ideal for longer than a half-hour period, and he's still just barely maintaining a systolic blood pressure between 80 and 85, though the mean arterial pressure - usually a decent estimate of actual perfusion reaching the brain - is still usually managing to be above 60. At this point they start cautiously tweaking other parameters: another 50 ml of concentrated albumin, increasing the methylene blue by 50%, creeping back up on the inotrope over another ten minutes of wary observation. This lets them get down to only 0.02 mg/minute of epinephrine – which is still double the rate at which you start to really worry about gut and extremity perfusion if it's going to be longer than 30 minutes, and it's been twenty already. 

His heart rate is pretty steady at 90. They start very cautiously trying to ease off on the continuous antiarrhythmic infusion, which is at a high enough dose to be interfering with contractility. 

(They've been tolerating any oxygen saturation above 90%, in the interest of minimizing oxygen toxicity to lung tissue and high ventilator pressures that will screw up his cardiac output again. At the end of the half-hour, he's sitting right at 90%, occasionally dropping to 88% or 89% and recovering, but they've managed to ease the oxygen concentration on the ventilator all the way down to 75%.) 

...Another ten minutes and they're down to 0.01 mg per minute of epinephrine, which is, like, probably about as good as they're going to get right now. 

Question for Merrin: where is her doom sense at right now? 

...Honestly Merrin is sort of worried that she managed to break her doomsense, because despite the fact that Kalorm's vital signs are mostly worse and he's requiring way more drugs to hold his cardiovascular system together, when she actually looks at him she doesn't feel nearly as stressed? His color isn't great, and his extremities are still mottled, but she's not looking at him and feeling dubious that the numerical blood pressure reading is someone trolling her in a really insensitive way. 

If she had to guess, it's going to be a horrible agonizing stressful night and there will probably be some setbacks to panic about, but if Kalorm can manage not to have any more catastrophic setbacks for the next twelve hours then...probably...she feels like he might start improving? 

They should really not trust her doomsense very far right now though. Merrin thinks she maybe just completely messed up her calibration because of all the escalating doom earlier. 

They'll keep everything how it is now for a few minutes, then, and wait for another full panel of lab results before trying to introduce any more drugs. 

...One piece of good news here is that - controlling for actual measured outcomes like "time spent with blood pressure below parameters" but not for total vasopressor needs - sepsis with cardiomyopathy doesn't actually have a lower survival rate than sepsis without that. Of course, if not for that Kalorm might not have had a cardiac arrest, which is associated with worse outcomes - from this point, in the abstract looking at the broader reference class, a 2% chance of fatal complications before hospital discharge - but Treatment Planning is trying to take into account more factors, and most of them are positive. It didn't take very long to get spontaneous circulation back (5 minutes) and they were able to maintain minimal perfusion throughout. It was primarily an arrhythmia, not a normal electrical rhythm failing to produce any actual muscle contraction, which is associated with worse outcomes and a higher risk of repeated arrests. He responded well to anti-arrhythmics and it's probably a temporary inflammation-associated irritability, not an underlying permanent issue with his heart's electrical wiring. 

The next twenty minutes continue the same pattern: everyone is tense, and Kalorm's measured vital signs are juuuuuust this side of 'barely tolerable' - except for his heart rate, which is rock solid at 90 - but nothing deteriorates. 

Lab results come back. His lactate, unsurprisingly, is still markedly high, but it's dropped by half since the spectacularly terrible result immediately after the arrest, and with all the bicarbonate they've given him, his pH is only slightly outside parameters. His hemoglobin is stabilized. Sodium is high - a lot of drugs are most stable in saline - but not very high. Potassium is actually low, almost certainly GI losses; he's drained nearly a liter from the rectal tube over the past hour, through all of the excitement.

His urea and creatinine are both actually down a little, though it might be dilution more than anything; his urine output is adequate but nothing spectacular, certainly not enough to offset all the fluids. 

Hemoglobin is stable. His mature neutrophil count is still well below the usual lower bound, but it hasn't actually dropped further, though his immature myeloblasts are up some more. 

For the first time in the last day or more, his generalized inflammatory and tissue-damage markers haven't risen. They haven't dropped either, but it looks like they might be leveling out. 

That's...better than the alternative? It's not good but they're not going to get "good", not tonight. 

...Also how is it 9:30 pm. Merrin has been here for ten hours without any stimulants. No wonder her brain is in the middle stages of shutting down. 

[I think I - should be off duty now] she manages to Halthis. [I'm staying - I promised Kalorm - but I probably shouldn't be doing medtech things] 

She goes to sit down. 

Aaaaaaaaaaaand she's going to make questionable life decisions, and refresh all the Diagnostic markets on outcomes to see how much ground they've lost. 

It's not actually as negative an update as it might have been, but a lot of their hope is conditional on Kalorm making it through the next 12 hours without any further deterioration (and ideally with some slow improvement.) They think it's about 70% likely. 30% odds of another serious complication in that interval (50% odds for more complications in general), but that will drop with every hour that passes. 

They've lost ground on the odds of permanent cognitive deficits, up to 60%. They're definitely hoping that the five minutes of cardiac arrest and ensuing minutes of settling for a less-than-ideal blood pressure won't have caused any additional damage - and it's very unlikely to have caused severe or even moderate levels of damage - but it's not great, and neither is another day or two of heavy sedation. 

They're also definitely behind on their optimistic hopes for physical rehab, because they can't do anything with Kalorm this unstable, and because the heart issue will almost certainly resolve on its own once the sepsis does, but not for a week or two. The 20% / 50% / 80% for even bed-based rehab exercises is now 24 hours / 60 hours / 5 days, and they're only that optimistic on the 24 hours because the signs of system inflammation are showing signs of plateauing and because Merrin has a relatively good feeling. They're making good progress with his gut; if that keeps up, even just for another 3 or 4 hours, they'll have the bacterial reservoir cleared out and powerful antibiotics taking care of the rest. This still may or may not be enough to get Kalorm stable in 24 hours, and almost certainly won't be enough for them to be comfortable extubating him, but he seems like someone who, even groggy and still on a ventilator, will probably be enthusiastic to start moving his body to the extent he can. 

But walking looks like a long way off. They're guessing 72 hours / 7 days / 14 days for assisted walking short distances, and 6 days / 10 days / 25 days for making it 50 meters unassisted. 

He's not going to be off oxygen on the timeline they'd hoped. The spread for getting him off the ventilator at all is 36 hours / 4 days / 7 days, because at this point they're going to want to play it very conservatively, and Kalorm did give his advance consent for that as long as Merrin was around. But rapid-onset pulmonary edema doesn't necessarily indicate damage that will persist once the fluids clear out, so if he doesn't pick up any additional lung problems in the meantime, it's possible that once he's stable enough at all for them to be comfortable extubating him, his lungs will be mostly fine? The spread on timelines for getting him off oxygen entirely is 48 hours / 7 days / 12 days. 

The spread on when he'll be able to eat or drink hasn't gotten more optimistic, exactly, but it has narrowed, because he's now past the point of highest danger for picking up more serious gut-related complications. Predictions on Kalorm tolerating unrestricted clear fluids are now mainly bottlenecked on him being otherwise stable (off the ventilator, off vasopressors, alert, tolerating enteral tube feeding at a low rate, and no nausea or vomiting with his nasogastric tube clamped and not draining, for at least 24 hours). Modulo that, it's a good idea to start him on it as soon as they can, to give his stomach something to do and help promote healing. The spread for clear fluids sitting at 4 days / 6 days / 9 days. Tolerating liquid nutrition, 7 days / 10 days / 13 days. He might even be moving on to solid food in less than a month! 

....Okay this is the stupidest why is she crying now. That's a genuine question! Merrin has no idea! She can't even really tell what emotion she's experiencing! 

This is so awkward!!!! And kind of distracting!!!! Especially since, in addition to herself and Merrin, there are like three other medtechs who Merrin presumably doesn't know at all! (Eight people physically in the room was kind of excessive once the immediate emergency was over, and the room does feel crowded at that point; the other three medtechs are next door, ready to be there on five seconds' notice. 

Usually if someone is visibly upset, the thing to do is - ask them gently if they want to leave. However. Merrin can't leave because she made a commitment not to. (Kalorm won't know, of course, but it's not even slightly occurring to Halthis that this means they can send Merrin to recover at home for a few hours.) Short of that, Halthis has no idea whether the most helpful thing to do here is 'ignore the crying and pretend it's not distracting her at all' (it iiiiiiiiiiiiiis though) or...pull some of the others back in to cover her position and talk to Merrin??? 

It seems like a bit too much to hope for that their advising social modeling expert on Merrin has advice, given that he must ALSO be pretty upset right now, but she's still going to hopefully check. 

Khemeth is indeed not having one of his better days! 

He is...coping better than he would have expected. A full actual night of sleep in his boyfriend's arms helped. (He has some sort of emotion about the fact that, as far as he can tell, his father didn't even notice that he was mysteriously gone from their Family Room for twelve hours.) Dekan even sneakily turned off all the notifications on his devices, and everything that would display the time in the room, and then, when Khemeth drifted awake a few times, didn't lie to him about what time it was but definitely implied that it was Early and Not Time To Get Up. 

Anyway, Khemeth got thirteen hours of sleep, and Dekan didn't wake him until Merrin was actually arriving for her late-morning shift. At which point, of course, things started going wrong rather promptly, and Khemeth spent several frustrated hours feeling behind and confused on his model of Kalorm, and much more focused on that than on Merrin. 

(And, of course, worried, though at this point he's mostly not trying to track the medical details of the case beyond the top-level summary on each page – and what Merrin explains to Kalorm, which is more helpful. Merrin was worried, though, and that was more than enough to have Khemeth very much on edge.) 

It's now been more than ten hours, and Khemeth is tired. Dekan has been enforcing regular breaks, though, including by pointing out that while Kalorm was in surgery, he was asleep and Merrin was supernumerary and there was therefore not much useful context for him to offer. He slightly regrets letting himself be talked into it, because it feels like he did manage to miss something relevant to Merrin's current state. But Dekan is right that he cannot, really, work effectively for ten hours. 

It's been a gut-wrenching last 90 minutes. Watching Kalorm's rapid deterioration on a screen, wishing he could be in the room and knowing he would be worse than useless, but seeing his brother helpless and scared and less and less able to engage with anything except trusting Merrin. And - at least he had that much, at least Khemeth bet right on something here, because he puts 95% odds that if Merrin hadn't been there with him - there and clearly sharp and on top of things - then Kalorm would have landed on reflexively refusing any proposed treatment he couldn't make sense of. (Which would have left Khemeth with the awful choice of whether to betray his brother's trust and override his stated preferences, on the grounds that Kalorm was barely able to orient to his surroundings and understand language let alone make reasoned decisions. He's pretty sure he would have, but - it's the sort of thing you can't ever take back.) 

The five minutes that Kalorm spent in cardiac arrest were an experience he never wants to repeat. In a way, it was less upsetting than he had expected; he mostly felt blank, numb, his mind full of formless noise rather than internal screaming. He couldn't really manage to track Merrin's state at all, save to notice, distantly, that doing something very physically unpleasant seemed - not soothing, not calming exactly, but - grounding? 

He's spent the time since then trying to reorient, and he can probably figure out what's going on with Merrin, but definitely not in the next ten seconds? He posts a message to the relevant subchat on the case discussion board, saying that he needs two minutes. 

Interim recommendation from Personnel, who does at least know Merrin in general: ...probably don't try to talk to Merrin right now. There are interactions that would help her, almost certainly, but also a lot of ways to just make her feel more self-conscious and guilty for being a distraction, and - it's not an emergency? Merrin cries sometimes - more times than most people - and in this case it's probably just as much a delayed physical stress reaction as it is a reflection of deep emotional distress. Some people, as soon as an immediate emergency is over and they have time to think and process what happened, have to immediately run to the bathroom, or get shaky hands, or urgently need a snack. Merrin sometimes cries. Merrin has, in fact, cried before in the middle of a sim while continuing to perform excellently. Personnel understands that it's distracting but, like, maybe knowing that will make it somewhat less so? 

(Personnel is perhaps strategically emphasizing this. She is, in fact, worried about Merrin – but mostly because Merrin has declared that she isn't leaving this room until Kalorm is stable and awake enough to agree that she can, and this could end up being like a week, and it's really not a situation where you want to leave any other stressors unaddressed if they can at all possibly be resolved or mitigated.) 

To the Keeper just pulled in because Khemeth is very likely going to need backup - who is familiar with Merrin in general but hasn't actually interacted with her face to face - the rough basics of what's probably going on in her head right now seem fairly clear? 

Merrin ties her motivation system very tightly to the minute-to-minute flow of her work. It's one of her strengths; it's not clear if it's related to her physical and mental stamina, but it's almost certainly related to her unusual motivational stamina, the extent to which she can do things which are hard or unpleasant or even boring, over and over, hour after hour, and she does eventually run out of physical and cognitive reserves but she doesn't usually run out of caring or engaging. 

She's also been on the Kalorm case for what's actually a pretty unusually long time, compared to her usual work. It's an emotionally intense situation in multiple different ways. Merrin has been noticeably having trouble 'switching off' at the end of her shifts, which isn't actually a usual problem for her, it might have been once, but her Exception Handling training went pretty hard on teaching her how to rest efficiently, which means setting very clear divisions between work and off-duty. And now Merrin has basically agreed that she won't go off-duty for an indeterminate period of time. She may not be the lead opper 24/7 for a week, and arguably shouldn't be the lead opper period since these conditions are pretty likely to degrade her performance, but there's a motivational and emotional burden there that she's promised not to set down. 

And a bad thing just happened! Merrin has spent, at this point, nearly four days carving her mind into a shape where Kalorm and Kalorm's recovery and Kalorm's good outcomes are the most important thing in the universe, and what happened today was, while recoverable-from, definitely a huge setback. Even now, Kalorm still has somewhere between a 1% and 5% chance of not leaving the hospital alive. It's a real possibility that Merrin will try as hard as she can at the most important project in the universe, and fail. That, you know, seems like enough to explain being pretty upset as soon as she stops and thinks about it! 

It is also a fact about Merrin that her mind very easily jumps to hypotheses that something went wrong because she wasn't good enough. The fact that just about no one could have done better than her here, and most people - even the other handpicked medtechs on Kalorm's case! - would have done substantially worse, is irrelevant, because in a real sense Merrin doesn't know that. (The Keeper doesn't expect that Merrin is necessarily consciously looking for ways to blame herself for this, she's probably more just overwhelmed, but it's going to be there in the background.) 

...And she's coming down from an adrenaline high, and in a weird liminal state of half-off-duty where she has time to process but doesn't actually have the affordance to relax, and she's also just, like, been here for over ten hours? Without stimulants, since she was trying to engage in good habits for non-emergencies and wasn't actually expecting this to become an emergency to this extent, so she is just tired. These are all factors that predispose her to greater emotional reactivity than usual, and she's already pretty emotionally reactive relative to median. 

It's not entirely clear what to do about this? There's a decent chance that she'll calm herself down in a few minutes, be incredibly embarrassed (but she would have found a way to do that about something or other anyway), find something productive to focus on instead, and continue with her day. Merrin is almost certainly not going to feel slighted or hurt or unappreciated if no one shows up to try to comfort her right now. There are also ways they could give her some privacy; she promised not to leave Kalorm's room, but 'Kalorm's room' is at least slightly underspecified and doesn't only include the single space where Kalorm is right now. Presumably Merrin has not solemnly committed to avoid grabbing a snack or going to the bathroom. 

There's...probably a possible conversation with her that would actually help? The Keeper does not feel that he actually knows Merrin well enough to navigate that, and also a Keeper showing up to talk to her right now would in itself be really stressful.