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Dec 02, 2022 12:34 AM
Merrin working in Exception Handling
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Merrin is pretty sure this is going to be FINE but also aaaaaaaaaaaaaaaaaaaaaaah. Stress!!!!!

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Kalorm's blood pressure responds very enthusiastically to the vasopressin! Within twenty seconds he's at 125/85. Increasing the ventilator pressure drops it a little, but his heart rate stays solidly at 95. 

It takes thirty seconds at the higher pressures and 100% oxygen, but he does get up to an O2 saturation of 97%. 

 

They turn him. 

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STRESS

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come on Kalorm you can do this it's weird but it's not actually scary and you're not going to fall or anything and you'll be comfy and fine once it's done

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It...in fact goes basically fine? 

Kalorm's body clearly dislikes something about the forces and weight shifts of being swung around; his heart rate goes all over the place, spiking and then scarily dropping to 65 for a few seconds and then slowly rising to around 85. But his blood pressure is actually less affected, and never goes below 100/50. 

There are indeed a few messed-up tiny breaths while he's mid-turn in a weird position. Even with their careful preparation, Kalorm doesn't have a lot of oxygen reserve, and drops as low as 86%. 

But then he's turned, and they tilt his head higher than his feet again, and he stops dropping. Within 30 seconds, he's at 93%. 

Within two minutes, 98%. 

 

His blood pressure...if anything seems better? It's of course hard to tell how much of it is because he still has a lot of extra vasopressin in his system, but he's parked at 120/70 - and with a heart rate comfortably at 80. 

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They're going to keep him fully cocooned, so they can turn him over again on a moment's notice, for a full five minutes, in case he changes his mind about liking this position better. But it definitely seems like it's going well so far. 

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Merrin is so proud of Kalorm!!! He's very good!!! 

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At five minutes, his heart rate is still 80, his blood pressure is 115/65, and his oxygen saturation is solidly at 100%. 

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Having her patient doing well because she was riiiiiiiiiight that this would help is BETTER than caffeine! ....Merrin still kind of wants more caffeine. She feels self-conscious about it, though, and she forgot to actually put on her earbuds and subvocalization microphone when she was doing her abbreviated "morning routine." She...will awkwardly get out her cellular texter and send a message to Personnel. 

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This request was anticipated! Merrin can have more coffee in like thirty seconds. 

(Personnel is slightly concerned about her caffeine intake, but, like, this is an objectively insane shift schedule, and probably Merrin will be sensible about things as soon as she's no longer doing an insane shift schedule?) 

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Treatment Planning wants to start by cautiously decreasing the oxygen concentration on the ventilator; if Kalorm is still doing fine at 80%, which seems like a reasonable target for now, they'll start decreasing pressures as well, but for now having a slightly higher pressure support will help fully recruit the newly non-squished lung areas, and his blood pressure is not having any trouble with it at all.

In ten minutes they'll start considering weaning vasopressors further; right now it might still be residual effects from the extra bolus. 

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Kalorm tolerates 80% oxygen fine! Actually 75% is also fine! They can't get any lower than that, just yet, but he also lets them drop the ventilator pressures, so overall this seems like a solid improvement from where he was at right before. 

His blood pressure is actually higher ten minutes later, up at 125/80 again, and his heart rate is actually down to 75; something is working better, in terms of intrathoracic pressure differentials. (Or plausibly his venous return is just much better, now that his vena cava isn't sitting under the weight of all his swollen abdominal organs; they can't easily check with ultrasound until they un-cocoon him.) His feet are accessible, though, and they appear to be getting better perfusion. For the first time in many many hours, his toes are pink.

Treatment Planning proposes that they keep cautiously decreasing the vasopressin and the standard catecholamine mix, and keep the methylene blue where it is. Kalorm's body seems to be on board with this plan. 

 

Respiratory-wise, he's still worse than where he was at eight hours ago, despite their heroic and deeply inconvenient positioning efforts. He's almost certainly picked up some significant additional lung injury - whether from the systemic inflammatory response or from the high levels of oxygen is hard to tell - and they haven't actually been able to treat his pulmonary edema, and in fact have been giving him even more fluids and probably making it worse, because his heart function and blood pressure were the bigger concern.

But that...might not be true anymore? They're definitely getting indications that the systemic inflammatory cascade has peaked and is now starting to recede. The bacterial reservoir in his gut is significantly decreased. His immune system seems to be haltingly stepping up to the challenge. A lot of his current cardiac dysfunction is actual cellular injury – not irreversible, it can and will heal once the infection is fully resolved, but on the scale of weeks – but some of it is a direct result of dysfunctional panic signals from elsewhere. That should improve as soon as his body is panicking slightly less, and it's starting to look like that is indeed what's happening. 

It's not going to instantly fix everything. But lower oxygen concentration and pressures mean less risk of causing more damage - and if Kalorm's cardiac output continues to be better in this position, then they can wean down the vasopressors, and maybe even try giving him stronger diuretics to clear out some of the accumulated excess fluid. 

It promises to be a very long day. But...maybe...a better day than yesterday? 

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...Okay, twenty minutes in and it looks very unlikely that they'll suddenly and with no warning need him in a normal bed position again. Treatment Planning approves removing the mattress section over his back, leaving him just suspended in the form-fitting foam panels and various body-part-hammocks. 

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Merrin is RIGHT THERE with the back half of a set of hospital pajamas, to get him instantly covered up so it at least sort of looks like he's dressed! 

...Then she'll find a position out of everyone's way. It turned out that squatting on the floor under the cocoon, level with Kalorm's head, is not in anyone's way right now! She rearranges the soft molded straps supporting his forehead and chin in a way that looks more comfortable to her, and suctions in his mouth because if he has a saliva disaster he will drool on the floor which is horrible, and absentmindedly shifts his arm hammocks around until his arms are in a position that her model of Kalorm doesn't think is stupid. 

(She still really wants to give him a baaaaaath. He's sweaty and grimy– okay not actually, hospitals are extremely clean, she just feeeeeels like he is because her brain is insisting that he's covered in like eight layers of antiseptic-wipes residue by now. However, one: she can't get at most of him easily, and two: Kalorm absolutely does not want to be bathed with eight people in the room and a bunch of pulmonology and cardiology experts watching the video footage and filling their discussion channel with thousands of words of commentary on how their treatment plan is going. It can wait.) 

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It's now nearly 7:00 am. Twelve hours, give or take, since Kalorm started his rapid deterioration (though of course Merrin had been very worried about him for a while before that.) 

His blood pressure is definitely headed in a positive direction! Kerrin will decrease one of the drugs, he'll drop to 105/60 but rarely lower, and then over the next 5-10 minutes he'll usually go back up to more like 115/70, at which point Kerrin swaps to decreasing the other drug, and the pattern repeats. His heart rate actually drops all the way to 70, at which point Treatment Planning suggests decreasing the anti-arrhythmic drug by another 25% - which sends his heart rate up again, but only to 85, and his blood pressure starts rising even faster. 

By 7:30 it's pretty clear that the vasopressin is doing less than the standard vasopressor mix; decreasing it barely drops his blood pressure at all, whereas at this point, even decreasing the other drug by a cautious 10% tends to drop his blood pressure back to 95/50, at which point it does eventually rise but it takes a while. Kerrin switches to just decreasing the vasopressin. By 7:50 he's off it entirely. 

His body is apparently noticing that it's now allowed to PEE! He puts out almost 40 ml of urine just in the next five minutes. Combined with the fact that he's now getting a bit less fluid intake per hour, with some of the drug infusions stopped, he may actually manage to start getting rid of fluids faster than he's receiving more of them. 

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Tharrim was kind of tired after two shifts in a row, and expressed concern about not having up-to-date certs on everything that might come up with an unstable septic patient now being ventilated in prone position, so Dalthem is back for the 8 am shift change! He is going to act totally normal around Merrin. Definitely. Merrin is probably tired and cranky and definitely doesn't want to be interrogated about sims. He will be so normal and not act at all like he's meeting someone INCREDIBLY COOL who can both, like, fish a patient out of the ocean in the middle of a violent storm, and somehow get on that patient's good side, AND intuit the right call on later treatment well before Treatment Planning got there. 

 

 

...He's kind of sad that his patient, who he handed off to Tharrim 24 hours ago after a pretty good night where goals were achieved – well, the goal of Kalorm getting any sleep was achieved, at least – and this did not result in Merrin having a good shift! Instead it sounds like Merrin had a really very horrible shift! Maybe less horrible for her, since she likes emergencies in the abstract (though he is pretty sure that she didn't at all like the fact that it was happening to Kalorm, who now has a harder and more miserable recovery ahead of him.)

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(Merrin has also been trying to figure out how she guessed right. The most explicit explanation she can come up to verbalize her gut feeling - which she's suspicious of on general principle, since she didn't try to generate it at the time and is now doing it with the benefit of hindsight - is a very stupid oversimplified model that, roughly, it's weird for Kalorm to have heart problems and they resolve sooner than you expect? But it's not very weird for him to have lung problems and they usually take longer to improve than Merrin was hoping. Which...predicts that Kalorm would end up being hemodynamically stable enough to risk placing him in prone position, at a point when his lungs were still in bad enough shape to make it an appealing thing to try. Which is in fact what happened.

...Though also Merrin is pretty sure that, last night, she had a feeling that it wouldn't mess up Kalorm's hemodynamics more than temporarily, and that in fact he would be one of the patients whose cardiac output improved. Which is also in fact what happened! Merrin just has absolutely no idea why she was so confident of this! Diagnostics is chewing on the most recent ultrasound data and trying to figure out why and if they could have more confidently predicted it beforehand, and they're throwing around hypotheses to do with venous return and abdominal distention causing pressure on the diaphragm and thoracic structures, but Merrin definitely wasn't thinking about any of that last night. The most she can regenerate - and it's way too embarrassing to say out loud - is that her intuitions...thought that Kalorm, if he were awake, would find this position more comfortable? Which is completely besides the point, since he's not awake, and also not even the same thing as whether it improves his oxygenation! 

 

She really hopes that Kalorm manages to offload some fluids once the sepsis starts to subside, and that the glove-balloon hands lose some of their puffiness before he wakes up. She is very sure that awake Kalorm would think that his hands look really stupid like this, and be mad about it. This is also kind of a pointless observation, but it's what she's thinking. 

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It's been SUCH an eventful 24 hours and Kerrin has so many things to summarize! ...Actually she'll maybe tap Merrin to summarize the roughly 12-hour period that she was there for yesterday, since Kerrin wasn't around for it. 

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Does she HAVE to come out from under the bed Merrin is a grown adult and a trained medtech and she is entirely capable of giving a report even if there are cameras on. She's done this hundreds of times. It's kind of mortifying how much she's having to cajole herself into it lately. 

"So, uh, Tharrim said he had what looked like a pretty nasty parasympathetic activation episode at...nine-ish? Yesterday? Blood pressure drop, nausea, pallor, feeling terrible. He wasn't entirely happy to be awake, but Treatment Planning thought that getting his gut cleared out was becoming really urgent, so I came in at 11 am. - Oh, and he had a dialysis run yesterday, finished around 11:30. I got him set up for the enema. Administering it seemed to go okay, but afterward he– I think it was coughing that set it off, he had a really intense parasympathetic reaction and a lot of nausea. He started vomiting even though I'd given him, like, everything we had approved for nausea, and then he reacted horribly to the extra-powerful nausea drug that Treatment Planning added. Maybe, it might've been something else but it looked like that timing-wise. He went really bradycardic and dropped his systolic blood pressure into the 50s and lost consciousness for about a minute." 

Aaaaaaaah and now she's remembering that and for some reason feeling really embarrassed???? 

"We were pretty conservative about responding to it, mostly because of, uh, Kalorm's specific preferences - we tried to hold off on intubating him for airway protection, gave it a little bit to see if he'd wake up with atropine - he was breathing spontaneously and responding to pain and had a cough reflex at that point - so I just had him on the floor in recovery position and the suction right there. Atropine by itself wasn't quite enough, we gave him a liter of fluids and started an epinephrine infusion, he woke up pretty much instantly. Wasn't very happy about things - we had to irrigate and drain his colon directly, it wasn't working fast enough on its own - but I talked him through everything and he agreed to go for a scan to figure out what was going on. Oh, and Treatment Planning was worried about early sepsis - so was I - so we started him on the last-resort broad spectrum antibiotics around then. We were able to rule out a surgical emergency but we did the radioisotope labeling to track bleeding and he had a bunch of oozing spots in his deep small bowel. Also a lot of bowel wall thickening and gas and fluid distention. He agreed to have exploratory scopes from the top and bottom done under general anesthesia, and Treatment Planning held off on a full exploratory laparoscopy but they did go in percutaneously and take some abdominal samples. We also put in an epidural for pain control, the abdominal stuff was clearly causing him a lot of distress. Anyway, all of that went basically fine, but he needed a lot of vasopressors including epinephrine to keep his blood pressure up with the anesthesia. His small bowel definitely looked gnarly but we didn't find anything really awful. His colon was better off, but nothing was coming out the rectal tube right away, even though we did a bunch of irrigation in the ileum with motility-increasing drugs." 

She shifts her weight and gulps some coffee. Hopefully she's not sounding incredibly stupid right now? 

"He came out of the anesthesia pretty uneventfully, we got him extubated and towed back to the ICU around, uh, I guess it would've been like 4 pm. He was still really drowsy at 5 pm when I did a followup ultrasound, and I...was worried. We sent more labs. His neutrophils were dropping and I think that's around when we started seeing immature myeloblasts, so it definitely looked like his body was responding to an infection - oh, and we did get a trace positive bacteremia on the direct blood samples from his mesenteric circulation. His small bowel still wasn't draining very effectively, it looked like a neurological reflex arc problem, so Treatment Planning recommended a specialized device to hold his ileocecal valve open. I had a long conversation with him at that point about how he was doing and what the treatment options were - that he might need surgery - and, uh, that's when he asked me to stay here." 

She rolls her shoulders. Just remembering last night is making her tense up. 

"Uh. I guess we took him back for a followup scan after that, around 6 pm? We did another radioisotope injection to tag his white blood cells and follow the immune response to the infection, confirmed it was pretty much everywhere. He looked pretty bad at that point, and we had to keep giving him more fluids, but he held on during the scan – he didn't start seriously deteriorating until we were back in the ICU, but it must've been pretty soon after we were back. Decreased level of consciousness and respiratory distress. We tried bronchodilators and noninvasive positive pressure ventilation first, but he was already kind of too drowsy for it, and, uh, in hindsight the bronchodilators probably weren't great for his heart. Ultrasound showed some new-onset severe left ventricular dysfunction. His level of consciousness decreased some more and we intubated him a little before 8 pm. It tanked his blood pressure, unsurprisingly, we gave him epi and it helped a little with his blood pressure but his heart rate was insanely high, like 160, and his heart was really irritable, he started throwing ventricular beats. We started methylene blue, since it's supposed to help with sepsis-induced cardiomyopathy. We - tried a few more things - but eventually he went into v-tach, degraded to v-fib when we shocked him. Five minutes total of chest compressions – uh, two minutes in we were able to shock him back to a more normal rhythm after he got anti-arrhythmics but still no pulse until the three-minute check afterward. His blood pressure was below 80 systolic for a while, five minutes or more. ...9 pm lab panel is probably the first time we got any good news, his inflammatory markers had stopped rising. That's, uh, around when I signed off for the night." PLEASE nobody mention the crying in a corner.

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That is a spectacular number of things in one shift! Dalthem is awed. He's going to be so calm and normal about it though! 

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And Kerrin repeats the just-as-eventful report she gave Merrin a few minutes ago, with an added update on the last two hours and how Kalorm tolerated being rotated to prone position (well!) 

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Dalthem had sort of figured! Since he's currently looking at a cocoon-suspended facedown Kalorm, and some numbers on the monitors that look vastly better than the ones he's hearing about from earlier. 

Once Kerrin leaves, he wants to do a full assessment - well, to the extent he can when Kalorm is in this position, but he wants to do his own checks that Kalorm's weight is evenly distributed and there are no areas of excessive pressure or chafing on his skin. He could use Merrin's help? 

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Of course! Merrin is here to be helpful! 

(It continues to be really weird to be here as Kalorm's dedicated medtech but not as the assigned lead opper.) 

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Kalorm's temperature is back up to 38.2. This seems to be pretty much the highest fever his body can manage when he can't shiver to generate heat, but he looks like someone with a higher fever than that. 

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Dalthem - who is carefully removing one area of draped-pajamas at a time to keep Kalorm mostly covered - touches the skin of Kalorm's exposed shoulder blade, and makes a face. "He's sticky. I really wish we could bathe him properly." 

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