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Merrin working in Exception Handling
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"Last thing! Your stomach and gut are starting to heal, and you might be almost ready to start drinking clear fluids. Except obviously you can't swallow them yet. Treatment Planning wanted to try giving you some sugar water – about 150 ml, so, uh, one and a half times what fits in this syringe." She shows him the enteral-drug-administering syringe that goes with the feeding tube.

"We've been giving you tube feeds already, but not to your stomach, we're giving them through the feeding tube that goes all the way down into your small intestine, and using this tube to keep your stomach empty, because you were feeling nauseated a lot and we were worried that you would vomit. But everything down there is a lot less irritated now, and if we try this now and it goes well, then we can start giving you clear fluids to drink, like, as soon as you have the tube out and can swallow safely. Does that make sense?" 

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...All right, fine, Kalorm is glad she brought it up even if it's SO MANY THINGS and he just wants to practice breathing right now. He nods. 

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Tharrim steps over. "I'm going to give that to you now. Over three minutes, so it's not all at once but it's about as fast as your stomach would get it if you were sipping it slowly from a cup. I want you to tell me right away if you have stomach pain or nausea. You probably won't, but the chance isn't that low." 

He switches off and clamps the suction, and instead hooks a tube-feed-infuser to the relevant port, plugs in the pharmacy-provided bottle of 10% glucose in water (it also has some electrolytes in it) and programs it accordingly. 

Diagnostics is now putting about a 25% chance that Kalorm experiences immediate discomfort. Which doesn't necessarily mean this endeavor is doomed, just that they'll need to abort, re-drain his stomach, and then try again slowly - 10 ml an hour and increase from there, not 150 ml in three minutes. If he tolerates it fine, they want to check the residual amount of liquid in his stomach 90 minutes later. In a healthy person, that quantity would be long gone and in the process of being absorbed by their small intestine. Kalorm's stomach is almost certainly going to be working less efficiently than that, but as long as he has less than 75 ml of fluid left in his stomach (some amount of which will consist of gastric secretions) they're comfortable advancing to clear fluid oral intake as soon as he's off the ventilator. They think he has a 50% chance of meeting that bar. 

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Challenge accepted! 

 

Kalorm...actually has no idea how to apply effort and willpower to the problem of making his stomach work better! (And he's not going to just not tell them if he's nauseated. Ignoring pain is one thing, but nausea is AWFUL.) 

He pays kind of a lot of attention to his stomach. 

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And??? 

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Kalorm feels fine! He's not sure he can even tell at all that there's anything going into his stomach. 

He points, even more impatiently, at the ventilator. 

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Yeah, of course! He can give it a try! 

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...By ten minutes in, it's obvious both to Kalorm and Merrin that he is, in fact, working pretty hard to breathe. He can do it, he's not exhausted yet and the visualizations of his parameters are very motivating and he can stare at them and figure out the exact minimum effort he has to put in to keep the lines where they're supposed to be. But it's kind of a lot of effort. 

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Awwww. Merrin had been excited about Kalorm coming off the ventilator now! In a way that isn't stressful for everyone and somewhat medically ill-advised! 

He's very good and trying very hard, though, and Merrin does want to see how well he can still do. She stays close and holds his hand and says reassuring things. She promises another cookie if he can stay within parameters for an hour – and to eat her own cookie right away behind a plastic divider where he can see her. 

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This is also pretty motivating, if only because it's hilarious. 

Kalorm sucks in air and pushes it out and tries to stay calm, to keep his breathing slow and deep and even. By 30 minutes in, it's getting really hard. He's keeping everything within parameters - his minute ventilation sliding average is occasionally dropping below the line but then it flashes yellow at him and he digs his fingers into the blanket and tries EVEN HARDER and it comes up again. 

But the muscles in his chest sort of hurt, and he is starting to feel slightly queasy now – not so much like he's actually sick to his stomach, more like he did vigorous exercise too soon after eating, which he supposes is sort of what he's doing now. 

And...apparently he has some kind of bad associations with the feeling of struggling to breathe? He's starting to feel vaguely panicky, and - stupidly - like he wants to cry. 

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His heart rate and blood pressure are both up, and he's not quite exceeding his 25/minute respiratory rate limit but he's been at 24 for a while. He's flushed and sweating and his eyes are fixed straight ahead. 

Merrin reaches for Kalorm's shoulder. "Are you okay?" 

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Kalorm tries to nod, but - no, he's not okay, actually, and it's awful and he's so frustrated and angry with himself for being incompetent at breathing, and he's scared, and all of that is making it even HARDER to breathe and now he does kind of feel like he's suffocating. 

 

His face crumples and he tries to curl up, not very effectively. 

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Yeah, he's well outside respiratory-rate parameters now, and his per-breath volume is dropping. Heart rate isn't one of the official parameters, but he's running at 150 now, which does not indicate a happy or healthy Kalorm. 

[Tharrim, back to normal settings and maybe boost the O2 for two minutes] she subvocalizes, and then she moves in closer and takes both of Kalorm's hands, squeezing tightly.

"Kalorm. Hey. Look at me. Your oxygen levels are fine, we're going back to normal settings so you can catch your breath and rest. I know it's frustrating. You will get there. It's okay for it to take more time. The ventilator is going to be helping you more, so just breathe, okay?" 

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Aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaah

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[Tharrim, he's having a panic attack or something - I think he got freaked out by feeling short of breath, he probably remembers the previous times and it going badly - I think we should give him the beta blockers, he's been off vasopressors awhile and his blood pressure is high now–] 

And Merrin is pretty sure she knows what will help him CALM DOWN but she wouldn't normally– but she is actually recently showered, this time, and Kalorm's white blood cell count is basically back in normal range, they don't have to be quite so paranoid about infection risk, and he's on a ventilator so he won't be breathing in right next to where she's breathing out... And it's not hard-line against policies, it's just against the usual Merrin heuristics. 

 

She drops the bedrail and eases herself down on the mattress next to Kalorm and hugs him. 

"Kalorm, you're fine. I think you're having a panic attack right now, because you felt short of breath, and it makes sense that that's stressful but we put the ventilator settings back up and your oxygen saturation is 100%. Just breathe out. Good. And breathe in. Good. You're okay." 

[Tharrim, get him the weighted blanket? We should have one here somewhere. And, uh, his vital signs aren't actually unstable, can we...maybe have the cameras off...?] 

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Kalorm is trying really hard to calm down.

 

Eventually (it's only 30 seconds or so but from Kalorm's point of view it feels like so long) he feels less like he's dying! Instead he's just exhausted. So exhausted. He wants to fall asleep on Merrin's shoulder. He wants his mother

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He's slowly relaxing, his heart rate finally dropping back below 100. 

"There, see, you're fine," Merrin says gently. "You can have a nap now and then we'll try a different exercise, and we'll do a minimum settings trial again tonight if you feel ready then." 

She tries to ease herself off the bed. 

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No! Clinging! 

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Awwwwwwwwwwwwwww (and neat that he's actually effectively grabbing her, his upper body strength is noticeably better since yesterday and his motor planning must be better as well, he reacted pretty quickly rather than needing fifteen seconds to figure out how arms work) but also this is so awkward!!! 

 

Merrin's brain is apparently kind of upset about touching a patient this much and is insisting that she needs to go shower, like, right now, which is kind of rude of her brain really. But she's not going to leave when Kalorm only just got calmed down and is clearly still pretty upset. 

"Okay. It's okay. I'll stay until you fall asleep, yeah?" 

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This is not going to take Kalorm very long. 

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Then it will not be very long before Merrin can, very very carefully, slip free and sneak off to SHOWER, because her brain is yelling very loudly that she BROKE a RULE and is now CONTAMINATED. 

She feels kind of bad about how that went, but she's not sure what she could have said differently to prepare Kalorm better for it? Sometimes he's just...stubborn. Usually this is a good thing. It might even still be a good thing in this case! He got nearly 35 minutes of respiratory muscles exercise. 

She should possibly, like, talk to him about the fact that it's pretty normal and expected for him to be somewhat traumatized about things. Being in the ICU is a traumatic experience! Nobody comes out of it thinking 'that was a nice time, I should go back someday'! Kalorm is probably going to think this is really stupid and if he's having trauma-related reactions to things then it's his own fault for being dumb, and Merrin isn't sure how to approach that, but she at least shouldn't ignore it. 

She heads off to shower. 

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Kalorm sleeps. With the ventilator settings back to where they were before, his oxygen saturation is fine. 

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90 minutes after they gave Kalorm the sugar water down his gastric tube, Kalorm goes back with a 200 ml enteral-tube-compatible syringe and checks how much fluid is hanging out in there. 

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Kind of a lot! Around 120 ml, mostly clear but faintly pinkish. 

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...Well, that's not the best sign, but Kalorm did just have a workout and then a panic attack or something, which isn't ideal for digestion. Treatment Planning thinks he should put it back and check again at noon. (If he still has a high gastric residual at noon, they should actually put the tube back to suction, because he gets his potent antibiotic then and it's known to cause nausea as a side effect, and during the day they avoid giving him the most effective anti-nausea drug because it's so sedating.) 

It's about 9:50 am. They wait. 

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