Tharrim has been trying with great persistence to wean the vasopressors! Kalorm is not really being very cooperative with this, but he's managed to get down to 85% of the maximum on the vasopressor blend. 

(They want to start weaning the methylene blue by tonight; it'll have been 48 hours, which is the point at which research indicates patients will have gotten most of the benefit for mitigating sepsis-induced cardiomyopathy, and the dye has more side effects in awake patients and some metabolites that aren't great in the long run – not to mention making it hard to assess the underlying color of Kalorm's various bodily excretions, and potentially masking changes.) 

Merrin ended up requesting a non-caffeine stimulant for today, even though basically nothing else works as well with as few annoying side effects. She's just definitely had caffeine for enough consecutive days that she's feeling the tolerance buildup. Which is really irritating, it'll take her months of being very good about avoiding it to get back to her previous baseline. 

She's in a reasonably good mood, though. "Hey! I kind of wanted to give him a bed bath today, he's gross. Do we have time for that on your shift?" 

It's almost 10:30 am. Tharrim checks the Treatment Planning screens. 

"We need to get a bedside CT at noonish. I think it makes sense to combine with giving him a break from prone position, it'll be way easier supine. I'd rather not move him too much before that – I'm trying to get the vasopressors down a little more, and we're testing how well he absorbs an enteral glucose solution, so I want to give him the best chance at that. But we can maybe do the bath after? Wash his front if he's still tolerating supine after the scan – he handled a half-hour fine last time – then we can swap in a clean foam lining, he's about due for that anyway, and flip him and do his back once he's settled?" 

"Sure. ...I do want to turn off all the cameras for anything where he's naked. I don't know if he'd even be upset about it if he were awake, he might be chill, but I think he'd definitely be upset about strangers in another city watching him naked while he's unconscious and we can't even check. I've just been putting half a pajama over the relevant half of him when we don't need full access." 

Tharrim looks faintly dubious, but nods. 

Kalorm continues to do pretty okay! Any continuing improvement is very slow and gradual, but with great effort, Tharrim is able to get him down to 75% of the max vasopressor dose by noon. 

Also his repolarization time on the ECG is totally normal and he hasn't shown any indication that he wants to do arrhythmias! Treatment Planning thinks they can stop maintaining a high magnesium, and let him bring himself back to normal range (though they'll definitely still pre-supplement him with that and potassium if they want to give him any more diuretics.) They want to try pausing the magnesium infusion while he's supine, because at this point his cardiac function seems to handle the position change without much trouble, and if he does turn out to still be prone to arrhythmias without it, it'll be slightly better to find that out when he's in a better position for emergency treatment. 

If that goes well, later this afternoon they want to start cautiously decreasing the inotrope he's still on, and the anti-arrhythmic infusion. They probably want to decrement both in synchrony, since they're to some extent cancelling out each other's side effects. Mainly, Kalorm is on a LOT of drugs, and while all of them were absolutely necessary to get him through the period of critical illness, now that he's more stable they want to start minimizing that, and avoiding the risk of complicated drug interactions causing new and exciting problems. 

Also he's due for his antibiotic! It's going to be one of the higher fluid-intake hours, even with the magnesium stopped. It'll be good to see whether Kalorm's kidneys are now autoregulating better around that, though. Over the morning he's consistently been peeing about 50-100 ml less than his fluid intake the hour before, despite said fluid intake varying. 

Tharrim hangs the antibiotic for infusion, and then they replace the mattress components, get everything firmly secured, and rotate Kalorm onto his back. 

His heart rate is now reacting to this with less confusion! Still a jump, but without the scary drop. His blood pressure stays pretty constant; his O2 saturation does drop, as usual, but recovers nicely with 60 seconds of 100% oxygen and then Tharrim keeping the setting at 50%. 

(As soon as they're ready to remove the front cocoon panels, Merrin whips out a clean pajama front and gets Kalorm covered up in an approximation of clothedness.) 

They half-rebuild the bed - just enough that he won't fall out - and position him for the CT, which takes about five minutes. 

Kalorm does not give them any trouble with this! 

The low-sensitivity radioisotope scan is showing...maybe 50% or 60% uptake on the glucose? There's definitely still a noticeable cluster in his belly area, but there's also a desner cloud around his liver - indicating that it at least made it that far - and the rest is disseminated throughout his body, concentrated around the higher-metabolism areas of his brain and heart. 

Acceptable! They'll start the amino acid enteral solution once he's back in prone position and settled and they've finished doing things with him. 

...Merrin is cleared to switch off cameras for a bath, though Treatment Planning is not delighted about this and they would like her to get him covered up and turn the cameras back on immediately if his vital signs deteriorate in any way. 

Merrin will do that if it comes up. (She's always very conscientiousness about keeping patients mostly draped with a sheet or towels except for the part she's actively washing; even patients who don't have any self-consciousness about nudity in front of medical experts still, like, get cold.) 

Merrin may not have anywhere close to Halthis' detailed opinions about specialty pillows, but she sure has opinions about bed baths! (One of her opinions is that it's really nice to get to do a proper, unhurried one. It's one of the things she misses most from regular ICU work, now that most of her day to day is weird emergency sims where bathing is approximately never the priority.) She brings over a portable table and a self-warming water pan, with the temperature set to exactly 37 C. She has three different textures of washcloth; the very soft ones are good for delicate skin areas, the thicker more textured ones are good for tough areas like the feet, and the intermediate ones are for everything else. She has a portable towel warmer for the bigger super-absorbent drying towels. She has four different soaps in little squirt bottles, arranged in escalating order of "more irritating and less good to get in your mucous membranes but also better at dealing with dirt and oil"; the gentlest one, for his face, is technically fine to leave on the skin without rinsing, but she's not going to leave it.

She has non-greasy fast-absorbing moisturizing lotion for delicate areas, and heavier-duty cream for dry areas. She would have even more things if she had to wash Kalorm's hair, but - although, five and a half days after she pulled him out of the ocean, Kalorm has almost 2 mm of pale blond stubble, barely visible but fuzzy to the touch - he does not exactly have enough hair to be worth washing. 

(Tharrim happens to also have a lot of patient-bathing opinions and systems! Which don't entirely match Merrin's! He prefers a different stronger-soap-option, he doesn't like the textured towels period and prefers to use a special exfoliating sponge if patients have a lot of dry skin, and rather than rub-in moisturizer after washing, he tends to use a mix that is technically meant as hair conditioner, and leave it as a sort of mask on a patient's skin that he then comes back to and wipes off. But he's happy to go along with Merrin's system for this.) 

Merrin gets to work. "I'll do his face - want to get his hands and arms?" 

She's going to get Kalorm's face so clean. She soaks off sweat and oil and replaces it with a thin layer of the super-light instantly-absorbing lotion. She dissolves and wipes away the eye gunk at the corners of his eyes without even slightly having to pick at his swollen skin. She gets the residue of probably-dried-saliva-or-something around the corners of his mouth, and the weird dry crusty dead-skin stuff behind his ears. She washes around his neck and under his chin until he's not even a little bit sticky. She puts in eyedrops and balms his lips and clears out earwax with cotton swabs. (Also she takes the opportunity to properly brush his teeth while he's in a non-terrible position for it.) 

It takes her, like, five minutes; she doesn't have time to be this thorough on everything, Kalorm won't tolerate being on his back for an hour so she can go over every inch of skin with this much care. But, in Merrin's opinion, having their face be really genuinely clean is especially key for patients not feeling weird and gross. 

Kalorm continues to kind of disprefer lying on his back, even with his head raised. By the time Merrin is drying his neck and moving on to his chest (and Tharrim has gotten both arms and hands very clean, including carefully trimming Kalorm's nails, filing them evenly, and cleaning under them with a brush and antiseptic, and is now thoroughly scrubbing Kalorm's armpits with the strongest soap), his O2 saturation is down to 90%. 

Also, despite Merrin's best efforts to keep him warm, his temperature is already down to 37.9. 

Ugh. Merrin turns the ventilator up to 55% oxygen concentration, and - okay, 37.9 isn't hypothermic, if anything it's still technically a low-grade fever, but she really doesn't want to cause too many perturbations to the fragile system which is Kalorm's physiology right now. Fortunately, he's currently on the normal mattress! Which has a heating mode! She puts it to the lowest warming setting, and also drapes the heating blanket back over his legs while they're waiting to get to them. 

Kalorm tolerates the rest of the bath (well, front-half-bath), with some reluctance - it's not clear if it's just the duration, or the fact that they're moving and stimulating him, or the modest temperature drop, but Merrin has to go up to 65% oxygen - and 85% of the vasopressor maximum on the infusion - before they finish. He's so clean, though. Tharrim had time to trim and clean under his toenails. Merrin included an antiseptic phase in the washing, but before the final rinse; Kalorm is certified sticky-residue-free, at least until his next routine wipe-down. And his temperature hasn't dropped further; he's at 38.0. 

(The custom cocoon front panels have, in the interim, been taken out and the plastic components thoroughly sterilized, before the foam lining was replaced with fresh confirmed-sterile - and also unsquished - new foam. They're ready to go.) 

Merrin's last step is to replace all of Kalorm's gel stickies for protecting sensitive or bony places. He gets them on his collarbones and pubic bone and hipbones and over the dialysis line - and little ones over his nipples, because the custom-fitted cocoon is not supposed to let patients' skin slide and chafe while they're being rotated but Merrin does not entirely BELIEVE that claim. It can't be that perfectly custom-fitted, Kalorm's body weight has varied by multiple kilograms over periods of hours thanks to his water balloon phase. 

He's substantially less of a water balloon at this point! His hands and feet are still puffy, but the pitting edema is nearly gone from his trunk and upper arms and legs, and lying on his back even just for 40 minutes noticeably helped redistribute some fluid away from his eyelids. It looks like he could maybe actually open his eyes comfortably now, if he were awake, which he is not. (It does make it easier to check his pupils without worrying about hurting him.) 

They get him re-packaged to turn him back over. (Tharrim is, perhaps, slightly hurrying. Kalorm is doing vastly better than he was 12 hours ago but he is still not incredibly stable.)  

His heart rate reacts a lot harder to this transition; he does the weird spike-and-drop pattern again, and Tharrim has to max out the vasopressor infusion again.

But his oxygenation starts improving almost immediately, and once he's been solidly at 99% O2 saturation for a couple of minutes, his blood pressure starts coming up as well. And up some more. And improving further. Tharrim is able to get down to 60% of the max vasopressor rate before he levels out and refuses to let it be eased down any further. 

Treatment Planning approves un-cocooning his back and getting him properly settled for the afternoon. They're going to hold off for half an hour on changing any of his IV infusions, and on switching to the amino-acid enteral solution. They would prefer Merrin also wait half an hour before doing anything that requires no cameras. 

....Yeah okay Merrin is content to SIT DOWN for half an hour. Maybe duck out and get herself some lunch.