Getting the bed converted goes faster this time; Merrin and Dalthem have a rhythm established for it. And Kalorm actually tolerates the rotation better this time; his heart rate still does weird stuff, but his oxygenation and blood pressure hold steady. 

...He does immediately drip a bunch of saliva onto the floor. 

Merrin makes a face, but drops a towel on the floor and then suctions Kalorm's mouth and wipes his face. "There. You're getting used to this, yeah? You're doing really well. We'll have to see what Treatment Planning says, but I have a good feeling about this afternoon." 

Dalthem is already pulling up the scan imaging and the multiple screens of Diagnostic and Treatment Planning commentary! He'll draw another set of labs, too, it's nearly 1:15 so they're slightly late on it. 

(It's been a really long five hours. Dalthem is getting pretty tired. He has no idea how Merrin is so chipper when she's been here longer than him and also, like, slept in the corner and didn't even get a full night's sleep.) 

(It's mostly the caffeine! But Kalorm improving is also helping a lot with Merrin's mood and earlier crankiness.) 

The scan imagery is mostly pretty reassuring! 

They're definitely seeing substantially more white blood cell uptake, basically everywhere - including a concentration around Kalorm's lungs and chest lymph nodes - but that's partly just the interval, and it's actually a good sign that Kalorm's body is mustering a response to the infection. His lungs are, of course, much worse than they were 24 hours ago, and his weakened, dilated heart means that there's less room for them to expand. (Possibly another reason why he does better lying facedown, with his heart at least not squashing the lung tissue behind it.) But it looks better than any of the bedside CT imagery from the last twelve hours. 

And his gut looks much better off! The submucosal tissue of his small bowel lining is still swollen, and there's now a pocket of free fluid in the peritoneum - probably thanks to a mix of ongoing fluid overload, local inflammation, and increased capillary permeability, because they definitely don't see any sign of bowel perforation - but it looks like they've cleared out nearly all of the stagnant contents, and there's less gas as well. (Partly because there are fewer actively multiplying gut bacteria to generate it.) It looks like his colon is pretty active at this point, and draining the liquid stool rather than letting it reflux through his forced-open ileocecal valve.

Better yet, although there's still some radioisotope-tagged red blood cells in his small bowel, they didn't see any sign of ongoing bleeding sites. 

His bloodwork comes back pretty good as well. Stable hemoglobin, and his mature neutrophils, though still definitely well below normal parameters, are a little bit higher, so it looks like maybe, possibly, his bone marrow is responding to the drug they gave yesterday. Lactate still in normal range. Electrolytes fine. Urea and creatinine are substantially down after the diuretic. Inflammatory markers are the same or decreased for everything, including lung-injury-specific. 

Kalorm is taking his time about improving back to the point he was at before they made him lie supine and flat for the scan, but he is improving again. His hemodynamics are responding faster than his oxygenation; within twenty minutes, Dalthem is back down to below 50% of the max dose on vasopressors, but still only down to 85% oxygen. 

He looks pretty good, though. His capillary refill is almost normal. 

Treatment Planning wants to get him down to below 50% oxygen on the ventilator before they consider reducing the paralytic. But his cardiac output and blood pressure are good enough that they can probably risk a larger dose of the diuretic; they'll try double the previous dose, but infused at the same rate as before, so run over a full hour, and with another dose of albumin first. (It's sort of unclear where he's putting all the albumin they keep giving him; his measured blood protein levels are still in normal range. Probably it's leaking out in areas of microvascular dysfunction with increased capillary permeability to the point of not holding in even large molecules, and then ending up in his lymphatic system.) 

They also want to trial taking out the ileocecal valve, now that his ileum has reasonable peristalsis, and seeing if the reflex arc is working better and his ileum is willing to empty itself spontaneously. 

After Treatment Planning sends in one of the GI surgeons to do the fiddly and delicate part of "unlocking" and collapsing the valve device so it can be removed, Merrin lets Dalthem take the lead on that, while she holds Kalorm's hammock-suspended hand and talks to him about what they're doing. 

Overall, it goes more smoothly than placing it did. Dalthem is being very, very careful and gentle, because Kalorm won't be able to warn them if something is hurting him, but also he conveniently has less sphincter tone and isn't moving, and it does totally help that his buttocks are facing up. Dalthem even manages not to make a mess.

It's nearly 2 pm by the time they finish, and Dalthem is SO ready to go back to his hospital suite, collapse, and not move for another 18 hours. 

Yeahhhhhh Personnel is aware that they are working all the staff on Kalorm's case unreasonably hard. It's okay if Dalthem needs a day off tomorrow; they can have Tharrim cover the morning. 

...For this afternoon, though, they don't have someone rested lined up. Given that Merrin is here in a Kalorm Support Person role, and Kalorm isn't even awake, they're planning to just rotate in some of the other Default ICU staff – filtered to be people Merrin has met before, but not especially filtered to be Kalorm-compatible or interested in working longer than a 2-3 hour shift. 

Merrin is also getting pretty tired, actually. It's been a long morning. She's not super in a mood to be friendly or social with anyone, though it's nice that the medtech taking over from Dalthem for the next 3-hour block isn't a complete stranger.

She...is maybe mostly going to haul her floorchair over and sit under the bed again, and proactively deal with Kalorm's saliva if it looks like he's about to start dripping it on the floor again. It's cozy down here. She feels much less Observed. 

After all the endless eventfulness of the morning – and the even more eventful night before it – it continues to be a very long afternoon. 

Kalorm improves, slowly. He responds well to the diuretic, dumping nearly 2000 ml of urine over a 90 minute period; his blood pressure does drop a little, and he ends up back at 60% of the vasopressor maximum, but it's helping his oxygenation and his ultrasound lung imagery already looks less soggy, so Treatment Planning doesn't opt to stop the infusion early. 

At 3:38 pm, the medtech on duty notes some new ECG changes, with a delayed and lengthened repolarization interval after the ventricular complex spike. He sends a lab work panel 20 minutes early, marked for extra-high-priority processing; Kalorm is at risk of electrolyte imbalance after peeing that much, especially given his ongoing induced diarrhea and GI losses of electrolytes, but his last electrolyte panel at 3 pm was still fine, and it could be inflammatory - or even a new structural heart issue, though the ultrasound looks fine. It's risky to do any electrolyte-supplementation interventions without knowing the current levels. 

At 3:44, before the lab results are back, he does a very scary 8-second run of a fast ventricular arrhythmia - a rate of around 250, but slightly irregular, with variably-shaped complexes. He doesn't actually entirely lose his pulse - the arterial line pressure waveform is incredibly confused but still shows movement, albeit with a rapidly dropping blood pressure that hits 45/30 before he snaps out of it on his own. 

Merrin is somehow there before the other medtech, even though she's still been parked under the bed and manages to whack her head - fortunately on the bedframe structural support and not, like, on Kalorm's body - in her rush to extract herself. She is aboooooout to whack the controls for the defibrillator - along with very sweetly and politely repeating "Kalorm please stop that" when Kalorm, in fact, stops it on his own. 

"Okay thank you now please don't do that again we're going to fix the problem," she says very calmly. "I think your kidneys managed to get rid of too much potassium or magnesium - like, very efficiently, it was a forty minute interval since we last checked, that's actually sort of impressive even if it's super counterproductive right now– ugh I said don't do that again - okay thank you - Treatment Planning can we assume he's low and give him magnesium like right now–" 

Other medtech is on it! Also the lab is being informed that they need to expedite those results even more, but it should be only a minute or two anyway. If giving 2 g of magnesium as a bolus dose doesn't stop the problem, they can reduce the risk by increasing Kalorm's heart rate – he's been consistently running at 70 for a while now.

They're not going to flip him to supine position unless he does another run that doesn't end on its own within 10 seconds or that degrades into ventricular fibrillation – which is a real risk, but right now he's actually maintaining a pulse and blood pressure even during the runs of tachycardia, and both being moved and being on his back tend to drop his cardiac output and might make him handle it worse. 

Backup medtechs are on the way and will be there in 15 seconds. 

Kalorm's heart continues to be in an incredibly bad mood! Over the 60 seconds that he's getting the IV magnesium, he does four more interludes – but only for 3-4 seconds each time, and with the vasopressor infusion maxed again, his blood pressure is managing to mostly recover in between. And then the magnesium also seems to drop his blood pressure, and Merrin restarts the vasopressin infusion without actually being asked. 

Lab results are up on the screen another minute after that. His potassium is, indeed, down to 2.9 mmol/liter – a significant drop, he was at 3.8 mmol/L before, comfortably in normal range – and his magnesium is down to 0.5 mmol/liter, from 0.8 mmol/liter at 3 pm. Calcium and phosphorus are also low, though not as severely. 

Okay new policy, Kalorm does not get diuretics unless his electrolytes have just been checked and, if necessary, supplemented until he's near the top of the normal parameters – and then he gets a fresh electrolyte panel every half-hour until 30 minutes after the full diuretic dose is given. They'll start potassium supplementation now, though the maximum safe rate to give it intravenously isn't that fast, and they can't give it to him enterally at this point. And for magnesium specifically they're going to start him on a continuous infusion and target a level between 2-2.5 mmol/liter, above the usual parameters, because his heart is still clearly pretty irritable. 

(It probably doesn't help that, though the fluid boluses they gave him earlier were a carefully optimized electrolyte blend that shouldn't have altered his blood levels, the drug infusions are mostly being administered in saline, with just sodium chloride and no potassium or magnesium.) 

Merrin will stay RIGHT THERE and talk to Kalorm and - do they want to try restarting a very, very low-dose infusion of epinephrine again, rather than having her keep going up on vasopressin? She has a feeling his blood pressure will respond better to it now, and at this point it might actually be protective if it increases his heart rate a bit. 

Treatment Planning had also been discussing that, and will okay it. 

Even on 0.005 mg/minute of epinephrine, Kalorm's heart rate immediately rises from 65-70 to 90-95, but it also cancels out the magnesium side effects and increases his blood pressure way more effectively than the vasopressin had been. 

(And, despite all the resulting excitement and hassle, the diuretic was very helpful to his lungs. He's back down to 60% oxygen on the ventilator, and his O2 saturation is 100%, so Merrin can probably start easing that even lower.) 

He manages to avoid doing any more arrhythmias. 

By 5 pm, when the current medtech gives a handover report and swaps out for someone else Merrin has met twice ever, Merrin is  e x h a u s t e d  and so, so ready for a nap. She's not napping unless Kalorm seems more stable, though.

He mostly does! His potassium is up to 3.2 mmol/liter, still low but not scary low; it's apparently going to take a while of running a supplementary potassium infusion at the maximum safe rate before they can get him up to 4.5 mmol/liter, which is what Treatment Planning wants before they consider giving him any more diuretics. With a magnesium infusion calibrated to keep his levels above 2 mmol/liter, his blood pressure is definitely feeling it. Merrin was able to stop the vasopressin by bumping the epinephrine up to 0.01 mg/minute. He put out about 450 ml of urine over the last hour, almost but not quite enough to break even with all the drug and electrolyte infusions they're giving him. 

His lungs are doing really well, though. He's down to 45% oxygen. 

Treatment Planning would like to hold off a bit longer on stopping the paralytic drugs, since he's been less than totally stable this afternoon. But if Merrin wants to take 90 minutes for a nap, and Kalorm doesn't have any other setbacks during that period, they'll consider un-paralyzing him at 7 pm once she's back. 

Okay. Sure. 

It turns out to be really hard to nap during the day, even in her dark cozy pod where no one is observing her even a little bit. Merrin took a console and portable tablet screen in there, and she finds herself repeatedly checking on Kalorm's sensor data from a distance. 

She does, eventually, doze off for maybe half an hour, and wakes up at 6:15 with a sticky-feeling mouth and a growling stomach. 7 pm seems like a reasonable time to do things, but before that she does want to duck out of Kalorm's room so she can, without having to worry about infection control precautions, eat an actual hot meal. 

Though of course she has to check on Kalorm, first, she's definitely not leaving line of sight until she knows he's okay. 

Kalorm is...reasonably okay? Given everything going on? His blood pressure does NOT like having his magnesium maintained at an unnaturally high level, and his kidneys don't seem to approve either, and are trying to get rid of it as fast as possible; they're having to give him almost 3 g/hour to keep him in the goal range. He's up to 0.015 mg/minute of epinephrine now to maintain a tolerable blood pressure. It has, however, been very effective at preventing him from throwing any more electrolyte-imbalance-caused arrhythmias. And his 6 pm potassium check was up to 4.1 mmol/liter, so they're nearly at the point where they can safely try to get a bit more fluids out of his body. 

...In other good news, his ileocecal valve seems to be working! Maybe not perfectly, but he's still draining stool from the rectal tube. Or, well, sort-of-stool. At this point it's visually apparent that it's mostly just bowel prep fluid, cloudy with mucus and - based on lab analysis - sloughed-off dead epithelial cells. (And some of his blue dye vasopressor, diffusing from his bloodstream into the lumen of his small bowel; it's an entirely different kind of bizarre and unnerving color.) The highly sensitive genetic analysis is still identifying some gut bacteria, but under a microscope it looks like most of the ones being washed out now are dead. The samples are finally coming back negative for any hemoglobin content that would indicate ongoing bleeding. 

Treatment Planning is actually considering doing a continuous, titrable infusion, rather than intermittent doses; they could calibrate it to get 750 ml/hour of urine output, which will leave Kalorm negative about 250 ml once they subtract all the hourly fluid intake. He's getting 100 ml/hour just from diluted potassium; Treatment Planning is also considering making that a titratable continuous infusion, aiming to keep his potassium levels between 4-4.5 mmol/liter; they'll need to do frequent checks at first to calibrate it, but if they can get the whole system to a reasonable equilibrium, they might be able to drop back to hourly, with the corresponding benefit that they're not taking quite so much of Kalorm's blood.

And if they can get all of that set up by 8 pm, then by 8 am tomorrow he'll be negative almost 3 liters – a little less accounting for his antibiotic, which is due again at midnight and has to be diluted in 400 ml of saline and infused slowly to avoid various organ toxicities.