It's a perfectly uneventful half-hour! They get Kalorm down to 45% oxygen again. Tharrim is even able to ease the vasopressor infusion down to 50% of the maximum. Treatment Planning approves adding some amino acids to his pre-tube-feeds. 

Second half of the bath is also uneventful. It's actually more like a third of a bath, since the time-consuming work on his hands and feet is all done. They soak off kind of a lot of accumulated dead skin; he's overall spent more time with weight on his back, and had it less frequently and thoroughly wiped down. There's some faint redness around the bony protuberances of his shoulder blades, but it blanches easily. Merrin puts gel stickies on them anyway. 

He tolerates the amino acid addition fine, which isn't surprising, it's a pretty trivial total quantity. (Not even enough to justify decreasing his IV amino acid infusion at all, especially since they don't know whether he's absorbing it much.) 

At 2 pm, with Kalorm's heart rate rock-solid at 75, Treatment Planning finally signs off on starting to decrease the inotrope alongside the anti-arrhythmic infusion. His cardiac output holds up well enough, and the overall effect on his blood pressure is very positive. (Tharrim also heads out, handing off to another Random Medtech who Merrin has met in passing).

By 3 pm, they're down to only 30% of the maximum on the vasopressor infusion. 

...In that case they'd like to leave it there and switch to tentatively weaning the methylene blue instead. 

And, in preparation to ease back on the sedation if Kalorm continues to do well in a few hours, they'll switch him to a pressure-controlled rather than volume-controlled ventilator mode. Once they have settings that work, they can transition to an adaptive mode that will accommodate patient-initiated breaths and coughing better. The current, very tentative thought is that they'll try one more round of albumin and diuresis at 5 pm - gently, going back to a half-dose of the diuretic, and dealing with electrolytes beforehand - then do another supine period at 6 pm. If Kalorm can handle that for 30 minutes without needing more than 50% oxygen concentration, then once he's settled in prone position and they've started the trickle-rate tube feed formula, they can start slowly decreasing the sedative dose. Very slowly. They'll aim to, over a 2-4 hour period, get him down to around half the current dose. The prediction is that Kalorm definitely won't be awake at that level of sedation; he's likely to end up somewhere around 'responds purposely to painful stimuli', and probably not able to respond to verbal instructions. They don't actually want him awake just yet, just to minimize drugs and to get his body used to being slightly less thoroughly unconscious. 

(Also, it'll help with his blood pressure and weaning him off the methylene blue infusion.) 

Wherever he ends up, the plan is to keep him there overnight, and mostly in prone position but starting to add in more frequent and longer periods supine, and more regular range of motion and stretching exercises. If, by tomorrow morning, he's demonstrated the ability to lie on his back for a full hour without becoming unstable, then they'll slowly decrease the sedation and try to get him to a level where he's still mostly asleep, but can be woken with some stimulation and is able to respond to verbal instructions. For obvious reasons, they want Merrin around for that. 

This is a pretty ambitious timeline! It definitely relies on Kalorm not having any serious complications. But they're, like, 80% confident that they can get there? 

Merrin BELIEVES IN KALORM because he is VERY GOOD and he will earn SEVERAL cookies if he can do all of those things. Hmm. She thinks he should get a cookie for peeing if he responds well to the diuretic and doesn't have weird problems, and he should get a cookie for tolerating tube feeds even if it's, like, only a token quantity of feeds, and another cookie if he manages to handle being on his back without needing too much oxygen at 6 pm, and if he manages to get down to half his current sedation without getting too combative or having a different weird problem, and he should DEFINITELY get a cookie if and when he handles being on his back for a whole hour and meets the criteria for WAKING UP even if it's only a little bit waking up for now.

Merrin just wants to see him open his eyes and squeeze her hand when she asks him to. That's all. She's not asking him to be alert enough that he feels comfortable with her going home. She just wants to feel like the actual Kalorm is there in the room with her again. 

...She's tired. It's not a physical tiredness - she's been sitting down plenty - or even really a lack-of-sleep tiredness, it's just a nebulous pervasive desire to be, instead of here, flopped in her bed where nobody is Observing her. But she promised. So she's staying. 

Kalorm, so far, seems inclined to cooperate with this plan?

He does not have any arrhythmias. His left ventricular ejection fraction drops a little when they get below 50% of the current dose on the inotrope, but something else must be compensating, because they don't see a corresponding drop in his blood pressure. He puts up with the methylene blue being decreased down to 70% of its previous maximum; after that, they can't decrease it further without correspondingly increasing the other vasopressors, so Treatment Planning ops to leave it there, and get it stopped fully once it's actually been 48 hours. He continues peeing aaaaalmost enough to cancel out his fluid intake, only accumulating an additional 100 ml or so per hour; if they could straightforwardly assume his rectal tube drainage and GI fluid losses were coming from the same general reservoir of fluids, he would actually be slightly negative. 

At 5 pm, they wait for lab results before trying the diuretic. His potassium is still at 4.3 mmol/liter; his magnesium is down to 0.9, within normal range but not above it. He'll get a modest supplement of both and another check in 30 minutes. 

His hemoglobin and hematocrit are, indeed, back within normal range now that they've un-diluted his blood a bit. His neutrophils are back up another notch, edging bit by bit toward the lower cutoff for normal range. His inflammatory markers have nearly all dropped since the last check.

GOOD WORK KALORM Merrin thinks he deserves a cookie just for the improving neutrophil count! Even if it wasn't a big increase and he's still well below normal parameters. His body worked HARD for that increase, and - in the end, having a functional immune system is the only thing that will keep him safe against other later complications, and it's one of the physiological functions they can support and encourage, but not replace. She's so happy with Kalorm for making progress on it! 

He will get ANOTHER cookie if his electrolytes 30 minutes into the diuretic infusion - it's the smaller dose, but run at half-speed over a full hour - are still acceptable, and if he doesn't start dropping his blood pressure and making them cut the dose short. 

He manages both of these okay! His heart rate is up slightly but his blood pressure is tolerable. His potassium and magnesium both stay within safe parameters. And his lungs do like it! He's still not letting them sneak below 45% oxygen concentration - if they try to drop to 40%, his O2 saturations hang out at 89%, which Treatment Planning was willing to tolerate on the first night when he was very unstable, but they can now do better. Still, he's doing great in terms of per-minute ventilation, on pressure-controlled mode with baseline pressure another notch lower. He puts out about 900 ml of urine during the hour, which is - at the slightly lower rate of continuous infusions he's getting now - about 500 ml of total fluid loss. 

At 6 pm, his heart rate is still a little fussy about being flipped over, but he steadies out quickly. His breath volumes drop, and he wants a slightly higher pressure support, but his oxygenation holds up pretty okay! He stays at 92% O2 saturation on 50% oxygen for the entire 30 minutes.

Everything drops a bit when they turn him back to prone, of course, but he stabilizes in less than five minutes. 

Kalorm definitely isn't looking ready to be awake awake, but - probably safe to start cautiously decreasing the very deep sedation he's under right now? A Kalorm lightly sedated enough to respond visibly to pain or discomfort has the advantage that his medtechs will notice if he's in distress. He'll start putting in some of his own respiratory effort, maybe even to the point that they can decrease the ventilator support further and take even more strain off his heart. (And, of course, the anesthetic-level dose of sedation he's getting right now has other physiological side effects. Despite having been specifically optimized to minimize cardiovascular side effects, at this dose it's probably still causing some vasodilation and weakened cardiac contractility all by itself.) 

They'll go gently, though, and program the IV infusion pump to decrement the dose at 15-minute intervals, such that within three hours (around 9:45 pm) they'll have him down to 50% of his previous dose. And then they'll see. 

Merrin is so proud of how well Kalorm is doing! He gets another cookie on his cookie tally for coping so well with his interlude in supine position, it's so impressive he can do that now, and he'll get more if he tolerates being less deeply sedated. 

...Also Merrin is exhausted and she is maaaaybe going to just sit here under his bed and not talk to anyone. 

By 90 minutes in, around 8:15 pm, it's becoming obvious that one of their big problems is going to be Kalorm's intense desire to be running a high fever right now, which apparently the level of sedation was helping keep under control. They can't really increase the opioids any more; his blood pressure is even more sensitive to that. 

This is in some sense a good sign! Kalorm's body is trying to mount a strong immune response, and has the resources necessary for it.

They...would still kind of rather he not, though. Treatment Planning has been holding off on giving him any fever-reducing drugs, on the general principle that there are already way too many drugs in his system, and that even the narrowest-mechanism-of-action fever-lowering drugs they have available might cause some immune downregulation. Buuuut at this point it's probably worth it. 

This does work to bring Kalorm's temperature back down to around 38 C. 

By 9:45, when they hit the goal rate on sedation, they're making substantial progress on getting him off other drugs as well! He's entirely off the anti-arrhythmic infusion with no obvious problems, he's down to a token 20% of his previous dose on the inotrope, and he's at around 40% of the maximum dose on the methylene blue. He's still not triggering any breaths above the set ventilator rate, but he is on a set rate of 25, so this isn't very surprising. 

He's still pretty solidly out when they leave him alone, but he grimaces and ineffectually tries to pull away when Merrin pinches his nailbed, and he's back to trying to bite the oral suction catheter when they put it in his mouth. 

This seems like a pretty good stopping point for the night. 

Merrin, despite her desperate impatience to see Kalorm's eyes open, kind of agrees. She's exhausted. Kalorm can get another cookie added to his tally and then she will go to SLEEP. 

It is another fairly uneventful night. 

Kalorm's gut doesn't seem to react badly to the slow-trickled tube feeds. It's hard to tell if he's getting much nutrition from them, but by 2 am they're fairly sure that he's at least not dumping them entirely undigested out the other end. His rectal tube drainage decreases gradually, as the remaining bowel prep solution is excreted, and eventually steadies out at around 50-100 ml per hour. 

He doesn't let them just decrease the methylene blue, but responds reasonably to decreasing it while carefully increasing the other vasopressor infusion; by midnight, he's off it entirely, albeit back up to 60%-of-maximum-dose on the regular vasopressor mix. 

As hoped, he's tolerating longer periods on his back, and his heart seems to be having an easier time with the transition. By 6 am, he manages a full hour. 

(Personnel decided not to go with Halthis and Kerrin on the overnight, since Kalorm is far from awake enough to know or care which medtech is taking care of him, and at this point the team has a handle on the basics 'don'ts' of what Kalorm wouldn't want happening when he's unconscious and Merrin isn't there. Well. Merrin is there, just not awake. Anyway. They want to reserve the roster of known people for once Kalorm is actually awake enough to interact with them.) 

Halthis, having taken the relevant drugs yesterday afternoon to rotate her circadian rhythm by 12 hours, is reasonably well-slept and can come in for 8 am! 

Merrin has actually been awake for a bit. She is not up, per se; she's been procrastinating on leaving her cozy sleeping pod, because while she feels reasonably well slept, her social energy is in the negative digits, and she really doesn't want to be Observed just yet. 

...Ooh, that's Halthis' voice though. Halthis is a known person and not stressful to be around, and also her arrival means it's plausibly time to start waking Kalorm up? 

(She's been checking his chart updates on her tablet, and it doesn't look like any overnight events are going to get in the way of letting him gently and tentatively wake up some more.) 

Kalorm has now been hospitalized for six days. Nearly a week. 

His hemoglobin is stable. His electrolytes have been fine all night. His kidneys are in pretty good shape; the underlying damage isn't going to be entirely repaired for months, but he's back to the point of having more than enough redundancy there; unprompted, he's maintaining an almost-exactly-neutral fluid balance - slightly positive, but that could be entirely explained by evaporative fluid loss to the air, he's going to be losing more that way thanks to the fever. His immature myeloblast count is finally dropping, a hopeful indication that his bone marrow is no longer in panic mode and is producing enough mature neutrophils to deploy those instead; his neutrophil count is almost back up to the bottom end of normal range. (Which is, of course, still abnormal for a patient who's fighting an infection and keeps trying to run high fevers like clockwork every 4 hours when his previous dose of fever-reducing drug starts to run out. But his other inflammatory markers are still trending downward, and it seems likely that the antibiotics have the systemic infection suppressed enough that his body can afford to take its time in tracking down and destroying the remaining bacterial colonies. 

(He's still at some risk of other end-organ complications and damage. But the microcirculatory dysfunction seems to be resolving, which helps a lot, and at this point the only really serious local organ complication would be if the remaining bacteria lurking under cover in his body manage to sneak into his central nervous system and cause meningitis or encephalitis. The Diagnostic market is only putting a 4% chance on that now.) 

His gut isn't working very well, but it is working. Gas production is up somewhat now that they're putting (a small quantity of) actual calories in, and the gaps between antibiotic doses are probably long enough to let local gut bacteria multiply a little. His abdomen overall seems less distended, though; with less fluid overload and tightened-up capillaries, his body has managed to stop leaking fluid into his peritoneal cavity, and the bowel wall thickening that indicates local submucosal edema and inflammation is even starting to decrease a little on his last bedside CT scan. He's probably going to be substantially more comfortable when he wakes up. 

(At this point, one of his individually-highest-risk complications, given the severe disruption to his native gut flora, is that a normally-harmless bacterial subtype, usually in equilibrium with the several hundred different species that make up Kalorm's healthy microbiome, will start dividing wildly and no longer be harmless. The chance of this happening is almost entirely in the worlds where Kalorm already hosted that bacterial species, because dath ilan has put vast quantities of optimization, creativity and cleverness, and investments of labor-hours into cutting the risk of in-hospital transmission to almost zero. Without the benefit of those past efforts, Kalorm would currently be at pretty high risk of ending up with a clostridium difficile infection and resulting colitis, and potentially even a new round of sepsis.

C. difficile is very difficult to eradicate from hospitals; its spores are tough, a handful will manage to survive any and all sterilization methods other than "literally burning and replacing all the materials in the patient room" – and, since staff cannot exactly be incinerated and replaced, all staff treating a C. diff-positive patient need to be in full isolation gear, single-use and carefully disposed of afterward to avoid the risk of moving spores around. And, outside the hospital, some people are unaffected, asymptomatic carriers, so that needs to be tracked as well. But, a decade or two ago, dath ilan felt that critically ill patients ending up with a C. diff infection, after the antibiotics to treat their first infection disrupted their gut flora, was a STUPID PROBLEM that ought to be MADE TO GO AWAY. As a result, they can be, not entirely, but pretty sure that Kalorm's hospital room and the equipment used with him - much of it single-use and disposable anyway - has never seen a C. diff spore, and none of the personnel allowed anywhere near him are carriers. Kalorm himself wasn't a carrier – of C. diff or of any of the other top ten problematic organisms – the last time he had routine testing done. Which was admittedly like a decade ago, but his initial stool samples also tested negative, and no one in his family has ever been a carrier. He is, with greater than 99% odds, safe from that in particular. Overgrowth of other gut bacteria that he does carry would be much less catastrophic, and much more possible to treat while still at an early stage; the markets are calling 10% odds that, in the interval between stopping the enteral antibiotics and giving him a family-sourced fecal transplant to replenish his microbiome, he ends up with enough of a bacterial imbalance issue to delay his gut recovery and ability to eat and drink again, but only 3% that it will end up being more medically serious than that.)

Kalorm's toes are warm and pink. 

Halthis greets Merrin warmly, finishes updating herself on all the Treatment Planning discussion and Diagnostic market predictions, checks Kalorm's skin - making pleased sounds about how clean he is, and doing another round of antiseptic wipes and UV light - and then, around 8:35 am, starts easing down the sedation. 

She leaves the opioid infusion; he could probably use it for pain control as well as shivering control, he did after all get five minutes of chest compressions directly on his half-healed sternum incision. 

Nothing happens for about 45 minutes. 

- and then, once she gets below 25% of the original deep-sedation infusion rate, Kalorm begins to show rapid and very emphatic signs of consciousness, or at least activity. He gags on the breathing tube and starts coughing, which wakes him up further; he struggles ineffectually against his arm hammocks, tosses his head from side to side in its supporting straps, and seems to be making a bid to extract his leg from the leg-supporting cocoon panel. 

Merrin is right there! She grabs both of his hands. "Kalorm Kalorm it's okay I'm right here - it's Merrin - you're still in the hospital everything is fine just relax - can you squeeze my hands - Halthis we should up it and turn him on his back and try again - Kalorm, did you hear that? I know this is a really weird position to wake up in and you're probably confused about it! We're going to help you go back to sleep for a little bit so we can put you in a less weird position and you can try this again." 

Kalorm's eyes are sort of halfheartedly open but he at no point seems to be making eye contact or tracking her, let alone purposefully squeezing her hands. He's mostly just flailing randomly. 

Ten seconds later he's limp and peaceful again. 

(One good sign is that his oxygenation hasn't dropped much; he went down to 91% while he was coughing, but after that he was actually breathing faster than the set rate, and sucking in bigger lung volumes.) 

Halthis is looking concerned. "That was...sixty hours? Of deep sedation. Not to mention all the inflammation and sepsis toxins flying around. He's at pretty high risk of delirium." 

"Or he was just uncomfortable and confused about it!" Merrin points out. "I think I'd be disoriented too if I woke up in that position with no idea how I got that way. Let's roll him to supine and we can try decreasing more slowly." And this time she'll talk to him continuously, so he can wake up to the sound of her voice even before he's quite alert enough to process language. 

On his back with his head at 45 degrees, Kalorm is still hemodynamically pretty stable! His O2 saturations are tolerable on 45% oxygen, and his heart rate is still up a little but his blood pressure is actually high.