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Dec 02, 2022 1:30 AM
Merrin working in Exception Handling
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This comment suddenly makes Merrin like Dalthem about 500% more. "I know, right! I would vaguely prefer to do it once he's at least awake enough to interact with yes-or-no questions - I think he'll agree to it - but if it looks like that's going to take longer than him being physiologically stable enough for that much repositioning, I'd be willing to do it later today. ...With the cameras off. If I have to tell Kalorm later that I bathed him while he was too unconscious to object, I want to at least be able to promise that it was just me there." 

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Dalthem looks thoughtfully at her while they coordinate to temporarily remove one of the chest panels so he can check Kalorm's edema-swollen skin for creases and pressure marks. 

(It looks okay. The slight texture of the foam lining has definitely left its impression on Kalorm's skin, but there's no sign of redness or irritation.) 

"...You really are good at that," he says after a few moments. 

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Merrin was slightly zoned out, focused on Kalorm, and she has no idea what he's talking about! "Hmm?" 

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"Just, I mean, treating his preferences like they're real and matter? Instead of like something inconvenient to be worked around? I mean, it seems like you do look for clever workarounds, I'm not implying you don't, just - it's different." 

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Wow. That makes Merrin really grumpy for some reason!

"I don't feel like that's hard," she says acidly, and turns back to focus on re-attaching the cocoon segment. 

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Oops. Apparently he - didn't actually manage to convey the thing he meant to convey? Did Merrin think he was saying that Kalorm's preferences for his treatment are stupid? Dalthem was not trying to say that! He was trying to say that, completely ignoring the question of whether or not Kalorm's preferences make any logical sense, it's neat how Merrin can just - take them on, represent them on his behalf – and, more impressively, apparently do this in a way that's legible to Kalorm. Which is super impressive, because Kalorm seems to relate to 'being legible' in an intensely neurodivergent way, and while Merrin is also pretty neurodivergent, he wouldn't have said a priori that her neurodivergence is similar or even in the same rough direction as Kalorm's? 

 

He does want to try again, because he wants to actually be able to have a conversation about this! It seems important to get down a more transmissible explanation of how to work with Kalorm as a patient, rather than relying on Merrin intuiting it from nothing and everyone else having to watch multiple hours of Merrin-care footage and try to blindly imitate it! But it seems like maybe not something to try when he's multitasking, since it's apparently a fraught topic for Merrin. 

He...should still probably say something to acknowledge that there was a miscommunication, and he didn't mean to be frustrating? 

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Oh no she was so rude. This is so embarrassing. Why did she snap at the lead opper! This is not going to help with anything! The fact that she's mildly underslept (and also, at this point, definitely over-caffeinated) is beside the point, it doesn't matter if there's a separate very reasonable explanation for why she's irritable and emotionally reactive, it still won't help Kalorm get better care. 

...She is apparently also too - something, the thing isn't exactly 'tired' - to figure out how to non-awkwardly apologize. 

 

She finishes refastening the left-side pectoral area cocoon panel and goes to open up the right one. 

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Dalthem helps her. After a few seconds he clears his throat. "I infer that what you understood from my words is possibly a different thing from what I meant to convey [apologetic]*."

 

*Three syllables, with 'apologetic' suffix. 

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"...Yeah. Uh, sorry, I'm– I didn't quite get a full night's sleep and I'm predictably going to be snappier than usual." She supports Kalorm's shoulder with her hand to avoid shifting too much weight onto the other panels. "...Skin looks fine over here." 

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They work together for a few minutes mostly in silence, occasionally exchanging observations about Kalorm. 

Merrin will note that Dalthem is very conscientious about making sure Kalorm is positioned comfortably, with no excessive pressure on his skin. He sticks gentle-adhesive gel pads over Kalorm's hipbones and kneecaps for better pressure distribution; he unwinds the alternately inflating leg-massagers on Kalorm's calves to prevent blood clots, makes a face about the deep impressions they've left, and then slathers Kalorm's creased skin with moisturizer and puts on slippery, friction-preventing stockingette tubes before replacing the leg-massagers. He rotates or repositions and then re-secures all of the various tubes that might be putting pressure on Kalorm's skin. 

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Kalorm is a silent non-participant in all of this. (Well, silent aside from the ventilator, which is still set to a respiratory rate of 60 and sort of makes it sound like he's hyperventilating in panic.) 

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Okay, Merrin likes Dalthem. He is forgiven for talking about Kalorm's unusualness in a weird awkward way. 

...Ugh at least he's not on actual high-frequency ventilation, this is not as bad, but ugh. It makes Merrin want to sympathetically hyperventilate along with him. 

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It continues to be...a pretty calm morning? 

Kalorm continues to tolerate being facedown. He's still putting out more urine than his hourly fluid intake, though only with a difference of around 100 ml, at which rate it would take him weeks to shed all of his excess fluid. (It's hard to judge the urine color exactly because, thanks to the methylene blue, it's now a sort of translucent dark green no matter what.) His blood pressure, while very acceptable, is still incredibly sensitive to even tiny decreases in the vasopressor rate; he's down to around 60% of the maximum rate he was on earlier, but he is super not letting them lower it any further yet. It's not surprising – he's improving, but the systemic inflammatory response (and resulting vasodilation signaling) is still going strong – but Treatment Planning is going to hold off on recommending diuretics until he's down to less than 50% of the max rate and, ideally, not reacting to the tiniest change as though someone is trying to murder him. 

At 9:30 am, when he's been stable in prone position for around 3 hours, Treatment Planning wants to add a side-to-side rotation, to help get better lung drainage and recruitment; they'll start with, like, a 15 degree rotation to each side, on a five-minute cycle, increasing to 30 degree side-to-side if he's handling it okay. 

He handles it okay! There's usually a little drop in oxygen saturation when he's first tilted to one side, as different lung areas are compressed by gravity before the newly-released ones actually re-expand, but overall he's still making progress. By 10 am they're down to just 60% oxygen, and it's taking much lower peak airway pressures to meet the ventilator's breath volume goal.

At 10:30, after reviewing the latest ultrasound scans of his lungs – definitely much better and more uniform aeration, despite the fact that the ventral sides of his lungs, now facing downward, are pretty compressed – Treatment Planning even makes the call to drop the post-exhalation ventilator pressure a notch. Which has predictable positive effects on Kalorm's cardiac output; the ultrasound of his heart shows an immediate improvement, and within a few minutes his blood pressure shoots up to 130/90. Dalthem is able to get the vasopressor mix all the way down to 45% of the max rate before Kalorm's body announces that this is enough. 

At 11:15, when he's still stable on all the same settings, Treatment Planning approves giving him another ampoule of concentrated albumin, to help his bloodstream hold onto its fluids, and then modest dose of a much stronger diuretic. Run over half an hour rather than the usual 5-10 minutes, though, so they can pause it if his blood pressure starts dropping again and Dalthem has to go above 50%-of-the-maximum on the vasopressors again. 

 

His blood pressure does drop a little, but recovers to an acceptable 95/55 without needing to go up on the vasopressor support. And his kidneys respond with great enthusiasm! In 45 minutes, he puts out 900 ml of urine. Faint wrinkles start to appear on the backs of his hands and the bottoms of his feet, as the tissue edema subsides just a little. 

By noon, 4 hours into Dalthem's shift, they get down to 50% oxygen on the ventilator. 

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(Dalthem doesn't try to restart the Conversation with Merrin. He's actually really busy! There are constant new updates on Treatment Planning and Diagnostics, and he doesn't read that fast for a dath ilani.) 

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All right. Kalorm has been in prone position for nearly six hours, he's more stable, and it's been a full 24 hours since his white-blood-cell-tagging radioisotope injection. Treatment Planning would like them to try turning him to supine again. They'll give it a full fifteen minutes before un-cocooning him and converting the bed to a form that will let them transport him; they're expecting an initial deterioration, and they have wiggle room to accommodate that, but they want to have time to see if there's an ongoing negative trend before they commit to taking him out of the ICU and sticking him in a scanner bed for half an hour. 

(If it looks like this isn't going to work, there are options for transporting him in prone position and using just the passive radiation detectors - which are mobile - to get an impression of where Kalorm's white blood cells are congregating. But it's a lot harder to interpret without the overlaid CT/MRI imaging, especially since Kalorm has put on at least five kilograms of water weight since the last scan – and they do actually want to get high quality structural imaging of both his gut and lungs.) 

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Merrin feels slightly hesitant about this, but not really because she expects it to go disastrously. It's just going to be an enormous hassle, and laying Kalorm nearly flat in the scanner bed will probably lose them some of the progress they've been making. But it will be decision-relevant diagnostic information, at this point; Treatment Planning isn't going to want to make a call on phasing out the chemical paralysis and reducing Kalorm's sedation until they know how the infection is progressing and how his lungs actually look. 

With Dalthem there, she's mostly been too self-conscious to talk to Kalorm out loud, but it...feels important...for this part, even if it's kind of mortifying. So she talks to him, narrating and explaining what's happening. 

"Kalorm, we're going to turn you onto your back again, to see if your breathing is okay like that. We're just putting back the mattress components that you're going to end up lying on, it's going to be a bit of weight and pressure on your back but it won't hurt you - uh, sorry, we do need to take off your pajamas, they'll get wrinkled under you and you're very swollen from all the fluids and it's bad for your skin to lie on creases. ...Your skin is looking good right now, though, I think it was a nice break for your poor tailbone."

(Though, with all the edema, his buttocks kind of have the visual texture of orange peel. Merrin does not narrate that. She makes sure to arrange a thin memory-foam pillow under the small of his back and another one under his knees, so that there won't be too much pressure on that area when he's cocooned on his back.) 

"Nearly done. We're just going to make sure your head will be comfy, because we won't be able to move you a lot while we're waiting to see if you keep doing well on your back. You're doing so well right now, I'm really happy. I think you should get more cookies for it. Command Center, can someone add a cookie to his cookie total?"

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His cookie total?????? ....Okay you know what nevermind, Dalthem will ask someone else later

 

They gently rotate Kalorm onto his back. 

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He's not incredibly enthused about it! His heart rate spikes-and-drops-and-recovers again. Even with the bed re-tilted so his head is raised at an angle, his cardiac output starts dropping immediately - Dalthem has to go up several times on the vasopressors, to 70% of the maximum dose. His oxygen saturation falls to 70%, and only re-stabilizes at 65% oxygen on the ventilator and a higher baseline pressure, which necessitates increasing the vasopressors again to 75% of the maximum. 

 

But over the next three, five, ten minutes, his vital signs actually improve a little rather than deteriorating further. Treatment Planning wants to leave all the settings as-is, rather than trying to wean oxygen concentration or vasopressors, but after ten minutes of that, Kalorm's O2 saturation is at 96% and his blood pressure is at 110/70. 

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This is better than they were expecting. They'll convert the bed back to its standard form and take him to the scanner! They realize this is a ton of logistical overhead, especially since they almost certainly want to put him back in prone position for another session afterward, but after this - assuming they see the expected improvements and not something awful on the scan - they'll be willing to wait another 24 hours before repeating it. 

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Okay. Fine. Merrin will support this plan even though it is VERY ANNOYING and also VERY STRESSFUL. 

On the VERY STRESSFUL trip over, once they get the bed converted and the bedrails in place again, she'll say lots of encouraging things to Kalorm about how she gets that this is hard but it's going to help them decide whether they can start reducing any of the drugs he's on or let him wake up a little. 

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Kalorm, who continues to be in no way awake, does not respond to this. 

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It's really interesting watching how Merrin interacts with Kalorm while he's completely out of it. Dalthem...suspects it's important to whatever thing she's doing that works so well for him as a patient? Something something maintaining a mental attitude that they're working together on this, even when Kalorm isn't actually meaningfully participating in his care? 

He doesn't interrupt her, and even adds his own quiet narration when he helps slide Kalorm's mattress off its base rails and into the scanner bed. 

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Being on his back and nearly flat for 45 minutes is clearly not great for Kalorm. Over the course of the scan, they need to inch up on his oxygen concentration and vasopressor dose several times; by the end he's maxed out on the vasopressors again, and back up to 85% oxygen. But his heart rate holds steady, no sign of any arrhythmias or ectopic beats, and Treatment Planning discusses at various points whether to cut the scan short, but doesn't end up making that call. 

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Merrin still kind of wants to hurry back to the ICU! Turning him to prone again if he's already unstable will be really awful! 

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Treatment Planning wants the same preparation for it as before – dose of vasopressin (a smaller dose, though, since they're hoping to get more fluid off later) and 100% oxygen, wait for his blood pressure and O2 saturation to be really good before turning him. 

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