Dr Hulka will briefly interrupt at this point. "Can we check that?"

     "Yeah, one sec - shit he went down to 2.1, that's - that explains a lot - uh, as of 4:07 he'd gotten almost 30 mEQ IV and was at...2.8. - looks like he's still getting the last bag though -" 

Dr Hulka scowls. "I don't think that's going to cut it. Marian, is there any way he could tolerate it enterally? We don't think he had any bowel injuries, right." 

"...Uh, seems worth trying? He has a gastric tube, he's just - on a lot of pressors and in shock, I don't know if we should start feeds, and it's even more likely to make him nauseous if we don't. But, yeah, I was thinking that earlier, it'd definitely be faster if he can tolerate it." 

"Right, let's do 20 mEQ of the oral elixir, see if he copes. - I'm sorry, I interrupted you, go on." 

This isn't actually the first time Marian has heard Dr Hulka utter an apology, or anything, but it still makes her feel weirdly self-conscious - did she look like she was bothered and needed one?? She wasn't bothered! 

"Uh. He's been maintaining a tolerable BP most of the time when he wasn't in V-tach - ejection fraction was," fuck she doesn't remember the number, "- bad, but he's responding to pressors. Troponin was only a bit elevated." And probably they're not missing anything wrong with his heart? There are pretty obvious explanations for all the problems. 

"GI - uh, yeah, no obvious sign of trauma there, bowel sounds are hypoactive but present. - he did have persistent hypoglycemia, I have no idea what's up with that actually. It - maybe seems to happen at the same time as the hypokalemia?" 

"I got nothing." Dr Hulka looks over at the dietician. "Nutritional deficiency?" 

     The dietician has been on her phone, and startles slightly. "- Huh? Oh, right - hmm. That would make sense of his initial results but not the drops later? I'll have to think about it." 

"Implications for starting him on feeds?" 

     "....I'll have to think about it." 

..Seems like Marian should keep going then? 

"Right. GU, he's - I'm not sure what I think about his fluid status, actually. I think the kidney function indicators are still fine, but he's gotten a few boluses and his urine output still isn't amazing." 

...She's now at the end of her mental checklist, she's probably still missing stuff but she doubts she's going to recall it spontaneously. 

(She doesn't really have any urgent asks for her patient, which is - most of what comes up on rounds other than the standard various-organ-systems review stuff? He has all the lines he needs, he's at high infection risk but he got routine antibiotics in the OR and he hasn't popped a fever yet - he's honestly probably not on enough pain control but he explicitly didn't want more - no one is expecting him to poop today or tomorrow...) 

Dr Hulka looks like someone who still has a couple of patients to round on even though it's already past 5 pm. 

"Let's try the enteral potassium supplement. Keep going with the q4h labs and run them sooner if something seems off. Please keep weaning him off the epi, I really don't love that he's still on it - if he's still on it in two hours, let me know and I'll do another echo, he might benefit more from dobutamine. Let's get a chest X-ray now, I agree his resp status is worse. We'll hold off on feeds for now." 

Glance over at Alison. "He should be 1:1 tonight, please." 

Oh good, that is in fact what Marian wanted.

(She nonetheless very briefly feels like it means she Did Something Wrong, by not getting him stable on her shift somehow, but - that's stupid, actually, and she - even on reflection doesn't think she did anything obviously wrong except for not trying to explain to him about the call bell? And, like, she's not even sure that was a mistake where she should have known better, given how most patients would super not have been capable of trying to problem-solve going into V-tach by self-extubating so they could yell for help.

...Anyway, she does actually think she's done a pretty good job, today, even if she spent a ton of time on drawing pictures. She didn't go into the whole "was probably almost kidnapped and is understandably traumatized about it" part in rounds, but - he trusts her, she thinks, and it does actually feel like that was a priority?) 

- she should go check on her patient. It's been a bit and he presumably followed exactly none of that given the language barrier. 

(She's not really much less worried about him. Her worry is more clearly localized, and she has some useful orders for what to try next, but she still doesn't know what to expect on his weirdest problem. Also she, uh, needs to try to explain to him that she's going to give him something that miiight make him feel like throwing up and he needs to try really hard to not do that.)

Is he still awake? 

Well, he had a large group of strangers having an important conversation within his Empathy range, so definitely yes.  (He had also been trying to pick out some of his handful of newly learned words out of the audible conversation, but hasn't had any luck with that.  It should be easier when someone's trying to talk to him, though.)  It wasn't very informative, it seemed like just - Healers doing their job and making slow progress at it without either significant realizations or significant worries.  Something is still wrong and they mostly still don't know what but they might be able to find out.  Also Marian was anxious because some of these people are more important than her and might think she did something wrong, but they didn't, so he doesn't have to feel annoyed with any of them. 

His eyes were closed, but he opens them when she comes back, looking tired but not like someone just waking up.  He looks at her expectantly, since there are clearly some new things they're supposed to be doing.

She squeezes his hand and tries to smile reassuringly, and then gets out the clipboard. 

...Right, okay. She's going to go track down the bit of paper where she drew the explanation about the lab tubes and testing things related to his heart. She draws a smiling face but with a slightly frowny face next to it - it's better, but it's not as much better as they wanted? 

She finds the paper with the anatomical gastric tube drawing again, points at it, and draws a - cup, sure, aiming to look more like 'medicine' than 'soup' - and an arrow to the tube and another arrow to his stomach. She points at the cup and - hmm - draws a tube of blood beside it and a smiling face, and then goes back to point at the blood-heart drawing? The reason they’re doing it is because it should help more and faster with that. (And with his lingering weakness, but Marian doesn’t feel like adding more complexity to the drawing right now. Hopefully he remembers that those are related?)

- and then there's the part where maybe it won't go well and will make him puke. Uh. She gets another piece of paper and draws a box and a line maybe 3/4 of the way down the box to divide it. The bigger half gets a sketch of him in bed smiling. The smaller half gets a sketch with a sad face and - hmm it's maybe easier to just act out 'someone feeling sick and trying not to throw up'? 

Awww!  He appreciates the physical contact and smiles back at her.

His first association with the slightly frowny face is that he did something wrong again, but she clearly doesn't mean that.  His heart or the related things-in-tubes are doing something mostly better but still slightly wrong?  Yes, fair enough, he's sure they are.  She's going to give him medicine through the tube and that will make things better?  Sounds like a normal healer thing, good, he hopes it works.

... Apparently it's more complicated.  Most of the time he'll feel better and some of the time he'll want to throw up?  Or one or the other might happen?  That also sounds like a normal healer thing, to be honest.  He shrugs a little and nods understandingly.  It's good to have the warning, so he doesn't think some new wrong thing is happening.

Marian thinks he followed that? As usual he's somehow conveying a vibe of having understood her through, like, eyebrows alone or something, it's really impressive how he can do that. But hopefully it won’t come totally out of the blue for him if he does get really nauseous.

- she’s tempted to do that right now, but she should also explain about the chest X-ray and it might be harder to do that if he’s feeling terrible.

Right. She flips the paper over (ugh she really needs to get a stack more paper, they’re going through a lot of it) and draws a quick version of the today-timeline with the sun going up and down, and then draws several instances of the quick lung diagram. The first one - mid-morning, around when he first woke up, and she'll find and point back at the old crowded timeline page to make sure he knows she doesn't mean when they first found him - gets a moderate frowny face, and she tries to act out someone a bit short of breath. 

The remaining sketches of lungs can get progressively slightly frownier faces and - actually she'll add a sketch of the monitor box drawing and a frowny face there, since the main thing she was noticing was his sats, not him looking more short of breath or complaining of it.

But - questioning look? She's not actually sure if it feels to him like something is worse with his breathing than it was this morning? 

They really do have so much paper to refer to.  It takes him a moment to figure out what combination of things she means this time - all this is getting tiring, not that he's about to complain, when she'll be going away soon - but he does get there.

In addition to his heart still not working quite right, his lungs are getting worse?  That's troubling...  He supposes there obviously is something pretty wrong with his lungs or else he wouldn't need the tube, but the presence of the tube made him assume they had whatever it is under control and he didn't need to worry about it.  In retrospect that doesn't really make much sense, he's just not used to... being expected to do any of his own thinking about anything that's clearly someone else's area of competence.  In his experience people mostly don't like that.  But it's useful to have the information, and he's sure Leareth will appreciate it.

He... spends a moment trying to tell whether something feels like it's worse.  He has again been very much not paying attention to his breathing or anything related to it, and when he deliberately tries to, most of what he notices is that there's a tube down his throat.  Going beyond that... yes, something feels bad, but he has no idea whether it was better or worse in the morning.  He shrugs, makes an uncertain gesture, points at the tube and grimaces a bit.

He can try to keep better track of how his breathing seems, but he's not sure how well he can do at that given how weird everything feels either way.  He mimes pulling out the tube, breathing hard for a little while, and putting it back in?  If it's important to get useful opinions from him, she might have to do that.

No, that's not what she meant! Marian shakes her head and looks immediately apologetic. She should probably have gone ahead and drawn the next bit without trying to bother him (though, like, she does want him to be aware that there might be a problem and try to tell someone if it gets worse overnight). 

X-rays aren't actually that hard to draw - she can draw a stick figure sitting up against a board, and an eye. They can look at his lungs, like they're looking at his blood, and tell if they look worse. (And hopefully what's worse, which will give some better idea of what to do about it to help, but Marian is less sure how to draw that.) 

He nods, points at the button on a wire - if something feels obviously bad he can tell people about it, and otherwise he'll go back to not paying much attention, since it's hard to do that and it sounds like it's not really worth it.

Yes, what the next step is was going to be his next question, and it's definitely more important than trying to get more detailed opinions out of him!  Oh good, there's something they can do about this. 

He doesn't... have any idea what that is...  He points at the eye and at his chest with a confused frown, but after a moment shrugs and waves his hand.  It's obviously something else he has no background to understand, and maybe it'll make more sense once he sees it happening (or maybe it won't), but in any case he understands what the purpose is and he believes Marian that it'll be useful.

He considers asking more questions, but... he really is tired, and probably he should just let her do the new things before he gets to the point of having trouble staying awake for them.  He nods and half-closes his eyes.  (Communication is great, but he really hopes that sometime soon they'll get to the point of being able to communicate what the problem is, instead of how they're going to do new confusing things to try to figure it out.  All this would be so much easier if there were fewer things.  Marian is very impressive for keeping track of them all, and Karal definitely can't do it.)

...Oops, apparently X-rays aren't that easy to draw. Though her main goal there was less to explain how it works and more to make sure he wouldn’t be surprised and confused when the X-ray tech shows up and doesn’t want to wait for her to draw pictures to her patient.

(Possibly she’s trying too hard to explain things, he looks kind of overwhelmed? But she’s concerned he would just be differently overwhelmed by things like X-rays happening to him when he doesn’t know why.)

Anyway, that's probably all the urgent stuff? (She's also supposed to keep trying to get him off the epinephrine drip and if she can't then there'll be more things, but hopefully she can.) It's okay for him to sleep, and she tries to convey this by miming putting her head down on her hands and closing her eyes, then smiling reassuringly. 

She'll go get the oral potassium. 

One of the residents spots her and flags her down. "- Dr Hulka says to check the chart for orders, RT and dietary were going to follow up."

…Sure, she can do that.

Great, q1h blood sugar checks plus a new order for 5% dextrose in normal saline as maintenance fluids. (Does this guy actually need more fluid, he’s already getting something like 150 cc/h just from all the continuous drug infusions he’s on - which is way more than he’s peeing - well, he does seem like he needs the sugar, and she can just keep a close eye on whether he starts to seem fluid overloaded.) 

RT just put in a note that they're changing him to a volume-control rather than peak-pressure support mode. (The ventilator will keep pushing air into him up to a goal volume, rather than providing a certain level of support for him when he breathes in. It's usually better for patients who are having trouble moving enough air, at the cost of often being less comfortable - which Marian isn't sure how to warn him about, but she's at least glad that she tried to explain how they were worried about his breathing.) There's also an order for a followup blood gas in an hour.

- right, anyway, she should give him the potassium elixir and call X-ray. 

The respiratory therapist comes in while Marian is out of the room and quietly makes the settings change on the ventilator.

Once Marian is back a couple of minutes later and gives the potassium elixir, it does in fact make Karal nauseated! Not intolerably, or to the point that throwing up feels inevitable, but enough to be hard to sleep through.

(She is absolutely right that it's worth explaining things to him before they happen!  It's not at all her fault that there are so many things - in fact it's pretty much all Karal's fault in various ways - and Karal will give her a tired smile and project reassurance at her if he notices her worrying about it.  Before trying to sleep like she gestured for him to.)

He half opens his eyes at someone coming in - he wasn't deeply asleep yet, and he knew more things were expected to happen - but it's obvious to Empathy that they're another healer doing some routine thing, so he leaves them to it and manages to half fall asleep again.  Although his breathing feels...worse now, in some confusing way?... and it's making his ribs hurt... which he knows is supposed to happen, he's had broken ribs before and knows what they tell you about breathing deeply anyway... he's been trying to do that, when he remembered, but definitely not while he was sleeping, so he supposes this new thing makes sense, even if he doesn't like the way it feels even less under his control.

And then the nausea starts and he definitely can't sleep.  He makes an unhappy face at Marian, gesturing at his stomach and then less emphatically-- augh, he can't even mime breathing because the new thing makes it impossible to change anything about the process-- but probably his attempts and differently unhappy look are obvious enough anyway.  He does mostly relax once he's made his faces - he's trying to communicate discomfort, not an urgent complaint about any of the uncomfortable things.

Oh no poor guy. Marian would ask if he wanted more sedation, but she really doubts he does, and also she really appreciates him being awake enough to communicate. 

She starts the new fluids and then checks his blood sugar.

67 mmol/L.

(Leareth is appreciative of Marian’s explanations, and especially appreciates Karal’s persistence in trying to understand them. He’s a lot more relaxed with more information about what’s going on. He’s also very very tired, and - thinks they should both rest, but at the very least he’s going to do his best to drift for the next bit without pushing his mind too hard to do anything.)

The standing order says to give him a D50 top-up if he’s below 70, so Marian will do that, and then settle in to keep him company until he’s feeling better enough to relax and get some sleep. 

(Having his blood sugar pushed higher does make Karal feel better in some way that isn’t quite about the specific things bothering him, and over the next fifteen or twenty minutes the nausea slowly ebbs until it’s only a quiet background note, not entirely gone but ignorable. …And he is starting to feel a bit less weak, maybe? 

The ventilator mode does not really get less annoying but it does start to feel like he’s breathing enough without having to put active effort into it.) 

He does not try to get her to hold his hand while they both wait for him to feel better, but the thought feels so comforting that he has to resist the impulse.

(Oh good, he thinks blearily at Leareth's reaction, he knew there was another reason why it felt worth it to try so hard to understand what's going on instead of just taking in the list of things without really thinking about what they are.  He doesn't feel very good at understanding any of it, but it makes sense that even... treating everything as things that can be understood... is making it easier for Leareth to relax, to feel like he can rely on him a little.)

And he does, gradually, feel better.  He gives Marian a sleepy smile, and projects feeling-better instead of trying to draw it.  He's still very tired, but in a more normal way, that he can probably just fix by sleeping - and tired enough that he's pretty sure he can sleep despite the new breathing weirdness.

Or maybe he can't, some subconscious worry is keeping him from relaxing properly and for a moment he's not sure what it is...

... Oh, there was an important thing he forgot to ask about!  He will push himself more awake for that.  He looks around for the right piece of paper... that's so much effort, he can probably do without...  He points at Marian, mimes footsteps going away and then sleep, nods.  Mimes footsteps coming back - questioning look?