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Dec 02, 2022 2:02 AM
Merrin working in Exception Handling
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Kerrin is also going to tentatively try easing his head up to 45 degrees. Maybe his heart rate will tolerate it better this time? 

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...Better, sure, but still not great; he pops back up to 105 almost instantly. His blood pressure is okay, though, and it does help with oxygenation - more than the ventilator changes did - though it takes a while. Five minutes later, though, he's hovering at 92% O2 saturation. 

5:30 am. 

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Kerrin is trying very hard not to pace. It feels like she's been here so much longer than 3.5 hours. 

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At 5:45 am, unprompted by anything in particular, Merrin wakes with a start. Disoriented, she sits up, and immediately bangs her forehead on the fortunately-padded top of her pod. 

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Kerrin feels sort of bad that her immediate emotional reaction to that obvious thump is MASSIVE RELIEF. 

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That was indeed not a full night of sleep for a Merrin! She is, however, now definitely wide awake. 

Right. She's not at home. She is instead in...Kalorm's room? Aaaaaaaaaah. Merrin is going to have to get out of her sleeping pod in front of PEOPLE and CAMERAS. What if she has bedhead. 

 

...she has no idea why something feels wrong, outside is calm and quiet, but - well, maybe it's just that she hasn't laid eyes on Kalorm all night. Presumably there were no emergencies, or they would have woken her, but she really badly wants to have a look at him and his recent test results. 

She takes a deep breath, grits her teeth, and pops open the pod so she can get out. 

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Kerrin nods to her and does not bother with any casual conversation. "Want a handover report, or, uh, caffeine or something first?" 

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"...Report." Merrin DOES want caffeine, and also really has to pee, but there is no way she's leaving the room until she knows what's going on. And she's going to place herself right next to Kalorm's bed and listen from where she can SEE him. 

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(Personnel is going to discreetly send someone in with Merrin's favorite kind of coffee.) 

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Right! Kerrin will give Merrin the quick-version summary of the (really rather eventful) last seven hours or so. It's a lot of things, once you lay out the whole timeline of it!

Summary of Halthis' shift: Kalorm was off epinephrine by around 11:30, not that long after Merrin went to sleep. Low hemoglobin result from - it looks like the 11 pm standard checks - decision made to administer a blood transfusion over an hour– ah, it looks like this was the second he'd gotten tonight. Kalorm's lungs didn't approve: 45 minutes in, this would have been 11:55 pm, rapidly dropping O2 sats. Treatment Planning responded with bronchodilators (not very effective, bad for heart rate) and they increased the ventilator pressure, which did improve oxygenation but dropped his blood pressure. Treatment Planning chose to decrease the anti-arrhythmics infusion rather than restart epinephrine; this was actually very good for his blood pressure. But with that combined with the bronchodilators, Kalorm had an episode of rapid a-fib a little before 12:30 am. They attempted electrical cardioversion rather than anti-arrhythmic drugs that would affect his blood pressure, and were successful after three shocks and presumably a lot of stress on everyone's part. Around 1 am his blood pressure was consistently good enough that they started easing down on the angiotensin II, and were able to cut it by 50%. Kalorm's urine output immediately improved, and this may or may not have helped out his lungs. At shift change his oxygen saturation was finally consistently above 90%. 

Kerrin's shift! With normal hemoglobin levels, Kalorm's lactate finally normalized. By around 3 am he was running a low-grade fever, which bumped up his heart rate again but was taken as a very positive sign on immune function, and wasn't treated. His oxygenation was still tolerable but not great - mostly above 90%, basically never above 92%, and he wouldn't tolerate lying flat; raising his head helped but also increased his heart rate for some reason (despite not touching his blood pressure). They decided not to prioritize a repeat scan, since it's not like they're running out on a short time window, the infection-tracking radioisotope-labeled white blood cells will actually form a clearer picture once it's been 24 hours since the injection.

Treatment Planning is worried about his lungs. Kalorm is looking pretty fluid-overloaded, and picking up an extra liter of net fluid every 3 hours. They try a small dose of a diuretic, run slowly and continuously rather than given as a bolus. This helps a little bit with urine output but doesn't fix the oxygenation problem. They're suspicious of oxygen toxicity causing cellular injury and inflammation, and absorption-related alveolar collapse. They're not quite ready to try putting him in prone position, so they decide to chemically paralyze him and switch to a lung-protective small volume rapid rate ventilator protocol – not specialized high frequency ventilation, just swapping around settings on the normal ventilator with a rate of 50 breaths/minute. (The specialized high-frequency-ventilation equipment does, like, 300 breaths a minute.) This helps somewhat, for a while, but with lower ventilator pressures to avoid lung damage from that, they're starting to lose the dependent, gravity-squeezed areas of Kalorm's lungs.

They're now considering prone position, but wanted Merrin's input. So? 

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See, she was riiiiiiiight shut up, Merrin's brain. 

Well. How does Kalorm look? 

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Uncomfortably like an overfilled water balloon! The tissue edema is most noticeable around his hands, feet, and face, but nearly everywhere on his body, pressing down with a finger will leave a visible slowly-receding pit. Kalorm's normal shape, at baseline, is that of a very long, very skinny guy; the difference is extremely noticeable. 

It's also somehow SUPER obvious at a glance that he's chemically paralyzed. Merrin isn't sure why it's so obvious, but it feels like there's a limp emptiness in his face that reminds her unpleasantly of the middle hours of the rewarming protocol. When she gently picks up his arm, it feels boneless, no muscle tone at all. 

He's propped up with his head pretty high, with the ventilator set to 100% oxygen and a rate of sixty, and fairly if not shockingly high ventilator pressures. His oxygen saturation is still just barely at 92%. Heart rate around 100, temperature at 37.7; his body is clearly trying to maintain a fever, but having trouble because he is banned from literally any muscle activity. 

But his blood pressure is so much better! He's off epinephrine, off angiotensin II, and the infusion rates of the catecholamine mix and the vasopressin are both down to around 80% of their previous maximum rate. His blood pressure is at 95/60. 

His hands may sort of look like someone inflated a latex glove into a balloon, but they're not mottled at all, and they almost feel warm to the touch. His face is actually slightly flushed, rather than grayish-pale. 

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Merrin squeezes his hand. (It leaves finger marks.) 

"Yeah. I think we should prone him. I assume Treatment Planning has a suggested protocol for trying to keep him stable during the transition, and, uh, parameters for when to abort if it doesn't go well? ...And wow he's going to pee so much once his body figures itself out. He's got to have, like, five extra liters of fluid he doesn't need in there. At least." 

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Treatment Planning indeed has that up! They're pretty much ready to go; there are backup medtechs who will come in for it. 

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...Kerrin is going to gently suggest that Merrin should, uh, take ten minutes for her morning routine before she commits herself to a pretty involved and long-lasting procedure. 

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OH RIGHT okay yeah she super has to pee. She will....go do that. 

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Kalorm does not misbehave in any new and exciting ways while Merrin is doing that. 

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When she gets back, there are four backup medtechs with Kerrin in the room! (Another two are lurking in the adjacent room, watching monitor screens.) 

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Treatment Planning has worked very hard on optimizing their transition plan! 

The bed needs to not be bent when they start transitioning it to the rotate-able cocoon mode, but that doesn't mean it needs to be flat. Kalorm won't tolerate flat, so they'll just have the whole thing tilted at an angle, right until the last second. (And then they plausibly want his head higher than his feet even once he's prone, but he does need to be actually flat for them to do the rotation part; that's not the time-consuming aspect, though, it takes fifteen seconds.) 

It's plausible his heart rate or blood pressure will be grumpy about this, especially since they want to go up on the ventilator pressure for the transition period. They plan is to give an IV bolus dose of vasopressin, which should boost his blood pressure without increasing heart rate. They have the option of restarting a low rate of epinephrine if they need to; he was starting off a lot less hemodynamically stable than this the previous time when he reacted badly to it, and he tolerated the moderate infusion rate way better than bolus doses, so now they know that. But his heart seems much less irritable now than it was ten hours ago; even with the fever and the heart rate variations, he hasn't been doing ectopic beats at all in hours. 

If he becomes hemodynamically unstable when prone, they'll roll him back to supine. If his blood pressure is maintaining, though, then they'll give it at least ten minutes to observe the trend with his lungs, even if his oxygenation is initially worse (as long as it's above, like, 80%.) They're expecting an initial drop, just as an effect of moving him around. But if their model is right, then within ten minutes he ought to have recovered from that, and if he's going to improve from his current baseline, the trend should be visible. 

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Transitioning the bed mode is a lot of work! They need to remove the detachable sides of the mattress - very carefully, one at a time, with equipment and people in place to make sure Kalorm doesn't, like, fall out that side - and replace them with a memory-foam-lined set of custom-printed front panels that will wrap over Kalorm's shoulders and torso and legs, to support him and distribute his weight evenly when he's rotated over facedown. (At which point they can separate the now-redundant central mattress down the middle and fold it out to access Kalorm's back and perform skin care.) His head goes in a sort of padded supporting harness, that won't be too much in the way of performing basic care. His arms get little arm hammocks; they're moveable, because some patients get better breath volumes or oxygenation if their arms are in weird positions. Once he's turned over, the front panels can be taken out one at a time to check his skin. 

(As part of the preparations, they remove Kalorm's hospital pajamas. He'll be covered with a sheet and his warming blanket once he's turned, but the weight-distributing foam works best against bare skin, and it's not like Kalorm is conscious to mind.) 

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Mental note they need to DEFINITELY REMEMBER to put CLOTHES on him before they reduce the sedation, because awake Kalorm will absolutely hate being naked except for a blanket! She feels sort of bad about it even now. Not bad enough to make a bid that they shouldn't - it's inconvenient enough to check his skin - but maybe they can, like, drape the back panels of a set of pajamas over him once he's turned. It feels sort of silly to care about it so hard but she does.

....Also, oof, he needs a BATH. Like, a proper one. He's been sweaty for a bunch of the past day, and he's been getting quick wipe-downs with the antiseptic wipes but after enough of that with no real soap-and-water bath they start to leave a residue - or at least Merrin feels like they do - and now he's sticky and smells like sick person. Now is really incredibly not the time, and arguably it should wait until he's awake and can agree to it, even if that is predictably going to be a whole thing. 

She helps the other medtechs prepare. She doesn't take a lead role; she hasn't done this a huge number of times, and the last couple of sims where it came up were the limited-equipment kind where she was improvising the whole setup out of anything on hand, so not really the same as this at all. Also she's definitely feeling the lack of sleep, and needs more caffeine after this. 

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Kalorm tolerates having his legs lowered to straighten the mattress out, the whole bed still at a tilted angle; his blood pressure drops a little, but then steadies out without further intervention. There's a lot of picking up and moving his limbs, and tilting him very slightly from side to side to get everything firmly fastened. His heart rate still spikes in response to any pressure against his abdominal area, but other than that he handles this fine as well. 

(The support panels have a swappable lower-torso section with a stretchy hammock-style area around the middle of his abdomen, rather than the rigid-backed foam; it'll hold him comfortably in place, but hopefully help take even more of the pressure off his diaphragm, and once he's no longer paralyzed, it will give a little bit of room for his belly to expand as his diaphragm pushes downward to inhale.) 

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And then he is cocooned! You can't really see anything except the parts of his face that don't have padded harness straps around them! Merrin haaaaates this part. She doesn't really like the limited access of having patients in prone position at all, but she especially hates the part where they're, like, completely wrapped in bed and she can't touch most of them at all. 

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Kalorm is doing fine, though! Well, his oxygen saturation has been at 89% for a while, but that's not a new problem, and his hemodynamics continue to be fairly solid. 

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Treatment Planning proposes pushing the vasopressin, waiting 30 seconds or so for his blood pressure to start rising, then increasing the ventilator pressure (gradually over a 15-second transition period; they're going to switch back to a pressure-controlled rather than volume-controlled mode for the transfer, which will probably result in some weird tiny breaths when he's mid-turn but will at least avoid spiking his peak airway pressure scarily high.) If his blood pressure handles that, then they'll boost the oxygen concentration to 100%, wait until his oxygen saturation rises - ideally to at least 95% - and then tilt him back until he's parallel to the floor and flip him over. 

It's a very controlled flip. They'll pull out a bunch of the underlying bedframe, leaving only the two main column supports-and-feet at each end, and then do a controlled motorized rotation around the long axis. It takes about fifteen seconds.

In the unlikely possibility (the markets are putting less than 2%) that Kalorm, despite appearing pretty hemodynamically stable right now, decides to go into cardiac arrest while prone - and this happens suddenly enough that they don't catch the obvious warning signs and start turning him back over - they can flip him back, move the bedframe into position, yank and have Kalorm in a position where it's possible at all to perform awkward manual chest compressions in, like, thirty seconds. 

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