Oh good! 

Merrin is going to go sit next door and, yawning, read Treatment Planning updates while cramming food into her mouth. (She ordered a more superstimulus-y meal than what she usually goes for, because she's very tired and eating felt unappealing despite her complaining stomach.) 

Fed and watered and topped up with a bit more caffeine - it's late in the day for it, she does want to sleep tonight, but Merrin is sort of past caring about being "responsible" with her "sleep cycle" right now - she's back at Kalorm's bedside by 6:45 pm. 

He's doing really well! He's only on 40% oxygen on the ventilator now - though still requiring the weird low-volume high-rate mode, Treatment Planning tentatively tried to decrease the rate to 40 and his O2 saturation held up but his CO2 rapidly rose outside parameters. But the biomarkers that would hint at new or ongoing lung tissue injury are dropping, and his ultrasound imagery is showing reasonable lung recruitment in the non-gravity-squished areas. It even looks like the pulmonary edema is, finally, slightly better than it was when they made the call to intubate him (rather than considerably worse, as it's been most of last night and today.) 

Treatment Planning will give the go-ahead to wean him off the paralytics, if Merrin is comfortable with that? 

Why do people keep thinking that MERRIN of all people is the most qualified to make decisions here Yeah, she's comfortable with it. Kalorm looks really good right now. 

....Well. Relatively speaking.

Objectively speaking, Kalorm still looks pretty awful! He's slightly less of a water balloon, but probably still carrying 3 or 4 liters of totally unnecessary excess fluid in his tissues; his face in particular is almost unrecognizably puffy, lying facedown is not helping with that, and despite regular repositioning, the soft straps supporting his chin and forehead have left welts in his skin. And restarting the epinephrine pinched off the circulation to his extremities a bit; his capillary refill is delayed to 4 seconds again, and despite the flushed, blotchy, sticky warmth of his back and trunk - he's still running a fever of 38.3 - his hands and feet are cool to the touch. 

But! For someone who, 24 hours ago, came very very close to dying - and who spent pretty much the entire night one or two additional complications away from irretrievable deterioration - Kalorm looks great! 

Merrin nods to the other medtech, whose nametag is blocked by the bed and whose name she's completely forgotten.

She fiddles a bit, readjusting Kalorm's arm hammocks so his arms are up at his sides. She mostly hasn't been putting them like that, because she is pretty sure Kalorm would think it looked really stupid or something, and he just looks more comfortable with his elbows hanging down freely and his forearms supported, like he's doing a plank position on his elbows. But having his hands lower than his heart is really not helping with the puffiness. 

She squeezes his clammy hand. "Kalorm, you're doing so well. We think your lungs are recovering enough that you don't need to be paralyzed to help your body get enough oxygen. If your oxygenation gets worse or if it makes you fight the ventilator - you're on a weird ventilation mode that probably isn't how your body wants to try to breathe - then we'll keep them for another twelve hours or something before we try again. Either way I think the earliest I see us reducing the sedation at all is tomorrow morning. But this is a big step forward, and I think you're ready for it." 

She sets the IV pump running the paralytic drugs to slowly decrease the infusion rate, over fifteen minutes, to nothing. 

They wait. 

Nothing happens right away! It takes longer than that for Kalorm's body to catch up on metabolizing and clearing out the drug. 

Twenty-five minutes after Merrin started the decrease, though, the muscle-activity-measuring electrodes on the inside of Kalorm's forearm start picking up a noticeable twitch in response to mild electrical stimulation. His heart rate rises a little, to around 100, hinting at higher metabolic activity. His oxygenation is unchanged, though, 95% on 40% oxygen. 

Thirty-two minutes in, he starts noticeably shivering. Within another five minutes, his temperature has spiked from 38.3 to 38.9, and his heart rate is up to 110. His body clearly very badly wants to be running a higher fever. 

(His oxygenation is down to 93% at 40% O2 concentration, which is still tolerable.) 

Treatment Planning would kiiiiiind of prefer he not go above 39 C! Also it's not ideal for him to be burning that much energy on shivering, or running a heart rate above 100. 

It's not by itself a reason to keep him paralyzed, though. They'll switch the bed to cooling - Kalorm is still sedated enough not to be uncomfortable about this, at least - and give him an opioid pain medication that also damps down the shivering response. 

It's not completely effective, but combined with the cooling, they're able to stabilize his temperature at a tolerable 38.5. His heart rate is still at 105, but he's keeping his O2 sats above 92% without any changes to the ventilator settings. 

7 pm bloodwork comes back: potassium is finally up to 4.6 mmol/liter! His kidneys still hate the high magnesium and are trying really very hard to counteract their efforts to keep it high, but it's within the goal parameters! They are cleared to start a diuretic infusion - at a low dose, waiting 30 minutes and checking bloodwork again before increasing it. 

Also Kalorm's hemoglobin is slightly low again; he's not bleeding, so this is probably a mix of hemodilution, failing bone marrow production, and the sheer quantity and frequency of blood tests they've been running lately. They'll wait on recommending a blood transfusion until they see if the hemoconcentration of getting some of the excess fluid out of his system helps. 

His inflammatory markers are slowly but surely ticking downward, the gut-specific markers especially. His mature neutrophils count is another tiny increment higher. 

Kalorm is doing SO INCREDIBLY WELL and should get a cookie added to his tally.

(Though also Merrin is getting really quite impatient for the point when she'll get to see his eyes open again. She is going to award Kalorm another cookie just for the first time he does his tired-eyeroll expression in response to her suggesting something he doesn't like.) 

Despite the caffeine boost, she's pretty tired, and lets the other medtech take the lead on initiating drug infusions. 

Kalorm's kidneys are pretty eager to respond to even a very low continuous dose of the diuretic! When the medtech sends another electrolyte panel 30 minutes in, at 7:50, he's already put out 300 ml of urine, which would put him on track for 600 in the hour – not quite the goal, but it seems like it won't take a lot to get him there. 

His magnesium is still within goal parameters, with the continuous infusion rate unchanged; apparently adding more encouragement for his kidneys doesn't make them get rid of magnesium much faster than they were already doing. Potassium is down to 4.2 mmol/liter, though. They start a potassium infusion, at half the previous rate, and then inch the diuretic infusion up by 50%. 

At 8:20, Kalorm's total urine output for the 30-minute block is 400 ml, which extrapolated for an hour is close to what they want. They leave everything where it is. 

At 9:00 pm - when the 8:50 check comes back - his potassium is somehow down to 3.9 mmol/liter. They increase the potassium infusion by 50%. His urine output between 8 and 9 pm was around 800 ml. 

Merrin is both really tired and way too keyed up to sleep. She paces, and does probably-unnecessary random care, properly brushing Kalorm's teeth - which is very inconvenient when he's suspended facedown and the most obvious place for her to, like, sit to do it is one where he will leak toothpaste on her. She uses a damp cloth sprayed with no-rinse gentle skin cleanser to wipe the sweat from his back and limbs - and his other body areas when she does a round of removing panels to check his skin - before giving him his routine antiseptic wipe-down and timed exposure to the skin-safe UV lights to minimize skin bacteria colonization.

She does insist on turning off the cameras for the part where he's naked. 

(They were skipping that part when Kalorm was awake, and just using the milder-UV sunlight-imitating lights during daytime when he was awake – the full lights, that have an actual substantial effect on surface bacteria, are pretty obtrusive, a lot of patients find it unpleasant, and also Kalorm was absolutely not going to go for being stripped temporarily naked to get more skin exposure – but infection control is especially important right now, Kalorm won't mind, and it's also good for vitamin D production.)

She puts a gel dressing over his femoral dialysis line, and a little gel pad under the ports, because his body weight is pressing them into his skin hard enough to leave a deep welt in the surrounding edema. She fantasizes about Kalorm being recovered enough to wheel into the shower, or even take a proper bath in a tub. A proper soap and water bed bath will be a good start - tomorrow, she promises herself, if he's stable - but sometimes you just need to sit in hot water and soak. 

(They can't do full immersion in water while he has the dialysis line; there are temporary waterproof dressings they can use to make his invasive lines shower-safe, and the central line is in his upper chest and would be compatible with most of him being properly immersed, but the dialysis line is especially high risk for infection. In addition to the location, it's a much larger-bore catheter, and goes directly into the large femoral vein, whereas the standard subclavian central line is usually "tunneled" under the skin for a couple of centimeters, which keeps it more thoroughly secured against wiggling, reduces the risk of bleeding or oozing at the site, and more importantly means that hopeful bacteria need to make it along two centimeters of bacteriostatic catheter - with the immune cells in the patient's subcutaneous tissue on the lookout - before actually reaching the bloodstream. He probably doesn't need it for much longer, though; if he's stable tomorrow morning and showing no sign of new acute kidney injury from the sepsis, Treatment Planning will probably consider that the risk/benefit tradeoff points in favor of removing it.) 

Between 9 and 10 pm, Kalorm somehow manages to dump out 950 ml of urine! This is apparently too much; his blood pressure drops, requiring them to go up to 0.02 mg/minute of epinephrine, and his magnesium comes back all the way down to 1.6 mmol/liter – not low, in fact it's still above the "normal" range interval, but well below their arrhythmia-preventing goal. 

They'll up the magnesium infusion, decrease the diuretic back to its starting rate, and Kalorm can have more albumin to help make sure that the water he's peeing out is coming from the reservoir in his swollen arms and legs, and not his bloodstream. 

The albumin helps (though of course it's also adding more fluid back into the system, and Kalorm is already getting over 100 ml/hour just from electrolyte supplementation). They're able to get back down on the epinephrine. 

He is noticeably less of a water balloon! There are deep, raisin-like creases along his ankles and the tops of his feet, where subcutaneous tissue swelling is decreasing and the stretched skin is taking longer to return to normal. The taut shininess of his lower legs is nearly gone. His face is still puffy enough to not look like him at all, but his neck is a lot more neck-shaped and he no longer has a water-filled double chin. 

His lungs are also happier! He's not letting them decrease the oxygen concentration on the ventilator any further, but the ventilator is having a very easy time delivering the set volume, and his next blood gas shows a CO2 level that's actually slightly low. Treatment Planning recommends increasing the goal volume to 350 - with less water in his alveolae, he should tolerate it without further lung injury - but decreasing the rate in increments, hopefully all the way down to 35. Still faster than a normal respiratory rate, but much closer to something that a slightly awake patient would find tolerable. 

It's 10:30, medtech #3 of the night is nearly ready to hand off, and Merrin is a sleeeeeeeeepy Merrin. She is going to BED. After reminding the current medtech to pass on at shift report that if they do anything that involves an unclothed Kalorm they should have the CAMERAS OFF. 

All things considered, and especially compared to the last 36 hours, it's an uneventful night. 

Kalorm keeps running low blood pressures and needing more epinephrine, even with repeated doses of albumin, so Treatment Planning decreases the diuretic infusion goal parameters for a net fluid loss of only 150 ml per hour, which helps. He continues to have electrolyte fluctuations that require correction - his calcium drops very low at one point - but they're monitoring him very closely and nothing gets far enough out of whack to cause heart problems again. 

They also decrease the rate of the bowel prep solution and motility-increasing drugs; his small bowel is getting to the point of looking almost hyperactive on ultrasound, and it's still coming out almost clear at the other end. Treatment Planning wants to do a quick upper endoscopy tomorrow morning to assess the epithelial integrity of his duodenum and upper jejunum, but if that looks acceptable, they might even be able to stop the bowel-washout solution entirely and switch to intermittent doses of antibiotics and motility drugs (and they probably only want another 24 hours of enteral antibiotics anyway, because at some point they need to start letting his gut flora recover. If he tolerates that, they can even initiate a slow trickled rate of enteral tube feeds. Not enough to get significant calories from, and Kalorm probably won't be absorbing it that well anyway – they'll use a special formula that doesn't ferment or break down into anything weird if it goes all the way through basically undigested – but it'll help him slowly make his way toward normal gut function. 

At midnight Kalorm is tolerating ventilator volumes of 400, with a set rate of 30, and maintaining perfect CO2 levels and a decent O2 saturation of 94% on 40% oxygen. His lungs look noticeably less wet on the ultrasound imagery.

Treatment Planning recommends rolling him back to supine for 30-45 minutes, to do a more thorough assessment and give his skin a break (and the fronts of his lungs a chance to maybe re-expand a little.) Kalorm is not a huge fan, and requires 60% to 70% oxygen the entire time despite having his head elevated at a 30 degree angle - and, even very deeply sedated, is apparently capable of having a coughing fit during the turn back to prone, which drops his O2 saturation into the 60s for a few very stressful seconds - but by 1:30 am, once he's been comfortably prone for 45 minutes, he's back to doing fine breathing 40% oxygen, and tolerating breath volumes of 450 with a rate of 25. 

At 2:30 am he makes another, more enthusiastic and persistent attempt to spike a high fever; this time, the metabolic activity of shivering does raise his oxygen needs enough that the medtech on duty has to go up to 55% on the ventilator, and it takes three doses of opioids to stop him, by which point he's managed to hit a core temperature of 39.2 despite the cooling blanket draped over him, and his heart rate is at 125. (The lightweight custom cocoon panels do not come with inbuilt heating/cooling ability.) Still not a reason to re-paralyze him if he's otherwise stable, though, so they start an opioid infusion. It takes him a while to get back down below 38.5, and they're never able to get the ventilator O2 concentration below 45% - which is fine, it's the sort of up-and-down variation that just happens sometimes. 

By 3:45 am it's pretty obvious that he's no longer tolerating any more net fluid loss, despite having received kind of a lot of albumin. He's still puffy around the face and hands and ankles, but his lungs are probably about as dried out as they're going to get given the inflammatory injury, and his circulatory volume is definitely no longer overloaded; his central venous pressure is actually measuring as low. He's on such a tiny dose of the diuretic at this point that Treatment Planning opts to just stop it, and let his kidneys decide what fluid balance they want to go for; this leaves him positive around 100 ml/hour on fluids, which is vaguely tolerable for now, and they'll hopefully be able to get his mandatory hourly fluid intake down as he needs fewer drugs to hold his physiological control systems together. 

Merrin wakes up at 4:15 am from a STUPID NIGHTMARE where she's back in the ocean, in the storm, and she can see Kalorm deep underwater but her wetsuit isn't working and her radio isn't working and she just. can't. get to him. and he's sinking faster than she can swim. She practically flies out of her capsule, and it takes her five minutes of looking at Kalorm, peacefully unconscious and breathing at an almost-normal rate - albeit with no contribution of his own efforts - before her emotions believe that he's alive and recovering and okay, and not lost forever at the bottom of the ocean because she wasn't good enough. 

Possibly being here literally all of the time - coming on 48 hours now - is getting to her. 

She spends a while lying on the floor under Kalorm's cocoon, wiping and suctioning saliva every so often before it drips on her. She watches the sunrise. Eventually, at around 5:30, she attempts to go back to bed. 

The night - well, early morning, at this point - continues, uneventfully. At 6 am, Kalorm tolerates another 30 minutes on his back, this time only requiring 55% oxygen to maintain an O2 saturation at 92%. (At rest back in prone position, he quickly recovers to 96% on 40% O2). He's losing less magnesium, and lowering the continuous rate also helps with his blood pressure. By 7:30 am, after hours of careful effort, he's finally off epinephrine, though still maxed out on the first-line vasopressor mix and the methylene blue. His heart function on ultrasound is tolerable; the vasopressor needs seem to be mostly about minimizing vasodilation. He's definitely accumulating a little bit of extra fluid, but it doesn't look like it's going near his lungs. 

Tharrim will come in for the morning shift. He's feeling pretty caught up on rest, and no longer nearly as worried about stuff coming up that he's not adequately certed for. 

(The plan is to cover the afternoon with temporary medtechs again, and then have Halthis and Kerrin, both having had an entire night off to rest, work the same shifts they did two nights ago. Kalorm may be stable enough that they can let him wake up a little, and it seems especially important to have people he knows around if Merrin is going to be asleep.) 

He checks the Diagnostic market updates! They're probably not great! 

They are, indeed, not great! 

It's coming on 36 hours since the round of updates after Kalorm's intubation and cardiac arrest. They've already ruled out the most optimistic worlds, because while Kalorm didn't have any really catastrophic complications on that first night, it was definitely very touch-and-go and, up until his cardiovascular system was stable enough to try prone position, his lungs were actually deteriorating. But he is, almost certainly past the worst of it now? It's clearly going to be a long and difficult struggle to wean the ventilator support, wean the vasopressors, and get him stable enough for extubation. But the markets are only putting 5% odds that he has another major complication or deterioration before they get to that point. He's responding to the antibiotics, his immune function is picking up a little, and his actually-dangerous gut problems are approximately resolved. The 20% / 50% / 80% spread on when he'll be stable enough to start decreasing the sedation to a level where he's responsive - if not alert, they do want him sedated enough to stay calm and not be bothered by the tube - is now 6 hours / 14 hours / 28 hours. 

Only being stable in prone position is kiiiind of a barrier to bed-based physical therapy, as are his currently still-high vasopressor needs. The spread on Kalorm being all of awake and cooperative enough, breathing comfortably enough, and hemodynamically stable enough to participate in that is now 18 hours / 30 hours / 3 days. 

Walking is a harder ask. Some patients do get to the point of walking while still intubated, but those are cases where the only problem is lung-related, not cases like Kalorm's with muscle damage and problems in basically every organ system. (At this point, the range for getting him off the ventilator is 48 hours / 72 hours / 5 days, and the shorter range assumes that Kalorm ends up being entirely stable except for the lung injury, and prefers being off the ventilator but with 'rest' periods of noninvasive positive pressure ventilation.) 

Kalorm has been hospitalized for five days, and has at no point been up for anything more than passive range-of-motion stretches; in addition to the initial rhabdomyolysis, he's going to be losing muscle strength and conditioning fast, and all of that will be a struggle to regain, especially when he's still reliant on IV nutrition. The new estimates aren't overall more optimistic, but they are narrower, because both the best and worst-case worlds have now been approximately ruled out. The current range is 4 days / 6 days / 10 days for short-distance assisted walking, and 7 days / 11 days / 18 days for making it 50 meters unassisted. 

The estimates for weaning him entirely off oxygen are more pessimistic; the pulmonary edema was straightforward to fix, and in fact should be mostly resolved, but the effects of oxygen toxicity and inflammatory injury will take longer to heal. They're thinking 4 days / 8 days / 14 days. 

His gut is doing really well, though! They're down to only 50 mls an hour of gastric drainage, and it looks basically normal (except for now containing some methylene blue); his pyloric sphincter is functioning well enough that he would almost certainly be fine if they clamped the tube and left it for his body to deal with its natural stomach secretions the usual way. They're not going to - it's separately not great for his stomach to be sitting around empty with all that acid, and his duodenum may not be at top functioning in terms of neutralizing the acid to avoid damage - but he probably wouldn't start vomiting uncontrollably or anything. Most of the criteria for cautiously working toward a clear fluid 'diet' are already met; the only one missing is that Kalorm is intubated and sedated and can't swallow liquids. But the current spread on getting there is 72 hours / 4 days / 7 days – and for meeting a decent fraction of his nutritional needs, 5 days / 8 days / 10 days. 

His odds of not surviving this hospitalization are now down to less than 1 in 1000. 

His odds of persistent brain damage are at 62%. 

...Well, for now he'll start working toward some of those goals, by fully pausing the bowel prep solution, waiting half an hour to get fresh ultrasound coverage and make sure his bowel doesn't immediately forget how to do peristalsis, and then getting that upper endoscopy to check on how things are coming along. 

Kalorm's small bowel is less hyperactive after half an hour of no new input. It's still a pretty normal level of active! The last stubborn pockets of gas in his ileum are finally being de-foamed and passed along, and his rectal tube is continuing to drain at nearly the same rate as before. (With all the tissue damage, dead cells that need to be shed, and resulting malabsorption, he's probably going to keep having diarrhea for a week even once they're no longer causing it on purpose.) 

The endoscopy looks pretty much fine? His stomach lining is pink and producing mucus and looks reasonably happy. His duodenal lining and upper jejunum are more irritated, but the discolored patches actually look better than they did on the last check. 

Treatment Planning approves switching to intermittent doses of the relevant enteral drugs. Antibiotics and motility-promoting drugs will each be every two hours, for now, but on alternate hours. They'll stop the antibiotics at midnight, and slowly decrease the frequency of motility drugs as tolerated until they hit the standard frequency of every 6 hours. 

The GI specialists and nutritionists don't think Kalorm is quite ready for tube feeds, even the specialized formula for patients with malabsorption and no gut flora. He's especially likely to have trouble absorbing fats, and even pre-broken-down amino acids in the right concentrations are likely to be poorly absorbed and hang around being food for surviving pockets of bacteria. They'll try him on a plain 5%-glucose-in-water solution for now, at 10 mls an hour; for the first four hours, they can actually give him a radioisotope-labeled version; they'll get a bedside CT at noon, which they want to do anyway to get higher fidelity imaging of his small bowel and make sure he's not building up gas and fluid again with the bowel prep stopped, and the bedside unit isn't great at detecting radioisotope output, it's nowhere near sensitive enough to get useful vascular imaging or even much on the labeled white blood cells, but whether the glucose ends up taken up into Kalorm's tissues and disseminated everywhere, versus staying in a local dense knot in his gut, won't be subtle. If it does look like he's absorbing most of it, they'll bump it to 15 ml an hour and add some amino acids. If that's well tolerated, they can try phasing in the specialized formula that also contains some fats at 6 pm; they expect him to tolerate it better diluted, so they'll do 10 ml of formula diluted 1:1 with sterile water, and run the mix at 20 ml/hour. It won't provide more than a tiny fraction of his nutritional needs, and he's unlikely to tolerate more than that for days, but it will stimulate cell division and replenishment, help remind his small bowel to keep up some maintenance peristalsis, and get him ready for a fecal transplant once they're ready to give him gut flora again. 

Radioactive sugar water coming right up! Yummy! 

It's still only 8:45. Tharrim checks Kalorm's skin, does the few passive limb stretches that are compatible with prone position and don't do weird things to Kalorm's oxygenation, and rubs quite a lot of moisturizer on various areas where the days of immobility and large shifts in fluid balance have left his skin thickened and dry. 

Merrin, after her disrupted sleep, doesn't wake up until nearly 9:45. Again, she's not immediately sure where she is, but this time she at least manages to avoid embarrassingly whacking her head on the roof of the pod. 

After checking on Kalorm, and confirming that he's definitely alive and all his recent sensor data is the same or better as before, she is maybe going to take the time for a shower before she emerges to be properly on duty, whatever 'properly on duty' even means during this extremely weird period.