Still asleep. The yellow alarm on the monitor is going off; his sats are at 89%. 

Dislike! 

Lisa draws a blood gas first, sticks it on the iStat machine on the bedside table, tells her podmate to please get one of the RTs over here, and then nudges her patient awake. 

He wakes up a little slowly.  The first thing he notices is that his breathing does feel worse, she was right that something's wrong with it-- at least the machine lets him breathe harder if he wants to, does that help?  ...It may help a little but it's also... really harder than it should be...

He's not otherwise feeling weak or backlashy or vaguely miserable, his heart isn't doing any wrong things, probably this is a new different problem?...  Why is something wrong with his lungs, they didn't get stabbed or burned or anything...

He's projecting a bit of upset confusion, but looking at her like he recognizes her and hopes she'll make things better, and definitely not doing anything he shouldn't be.

Yeah his PaO2 on the blood gas is low.

...His CO2 is actually also slightly low. It definitely doesn't look like they're under-ventilating him at this point.

Lisa needs to lay him flat but, uh, he's clearly already in some distress and that's not going to make things easier for him. Instead she's going to bump the bed controls to raise his head, give him a couple of minutes of 100% oxygen until his sats are actually better, and then suction him, which at this point clearly isn't addressing his underlying problem but might make things easier for a few minutes. 

He expects suctioning to help but it... doesn't seem to be working right?...  He's trying to cough so hard and there's still something in there he can't get out and he still can't breathe right, and all the effort makes it feel even worse.

But he can tell that Lisa wants to do more things, and presumably some of them will help, so he'll try to be calm and not distract her with questions about what's happening.

...She hits the 100% oxygen button again (where the fuck is RT??) and keeps him sitting up for a couple of minutes until he's caught his breath. She did get a lot of watery secretions again, but it doesn't seem like it decreased his work of breathing at all.

She takes the time to swap his pressors to his peripheral IV, which is still in place and not being used for anything. It's not great to run norepi peripherally but it'll only be for a couple of minutes. 

- and, very apologetically, she tries to explain via mime that she needs him to lie flat and hold still and relax for - she's not sure how to convey "about a minute" and it might be longer - until she says he can sit up again? 

And going by her apologetic emotions this will be a lot worse than it sounds...  Not that it matters, particularly.  He nods. 

He is fairly sure he can lie flat and hold still while unspecified unpleasant things happen, especially when it seems like it won't be that long.

(He makes sure all the Gifts are under his control, in case this is going to be the sort of thing that makes Leareth panic, although it seems like he's learned not to.  He hopes Leareth is drifting far away somewhere and experiencing as little of this as possible.)

(Leareth is aware that something is happening, but - no, it doesn't seem like being engaged is going to help. If Karal wants to ask him a question then Karal can let him know.) 

Lisa gets the pressure tubing attached and transducer set up and connected to the monitor and everything in place before she lowers the head of the bed to flat. 

- it almost immediately feels like he can't breathe. Or - no, not quite, it's not the same as the previous bad thing - the tube is still helping, and it's a lot more effortful to take deep breaths but Karal can manage to inhale and exhale, he can tell that air is moving in and out of his body, it just -  somehow feels like it's not working like air should, he still feels like he's suffocating - 

He wants to struggle and he's not going to, Lisa said he should relax and be still... he reminds himself that she's right here and has all the measurements about whether he's dying, if anything is worse than she was expecting she can tell and he should just not... try to make any decisions about it...

Every time he takes a breath he wants to tense up and fight to inhale harder because it's clearly not enough--  so he just stops, lets the tube do the breathing in its alien regular way, it's not his job to breathe it's his job to stay still--

(It would be so much easier if this just hurt.  He knows he can stay still through that.  He's not sure he can stay still until he passes out from lack of air.  He wonders how long it would take, to do that.  If he goes unconscious the people here will... do something reasonable about it, he's very sure of that, it's fine it's just miserable but it's supposed to help and it's very important to get better... He wants to go outside in this different world, he wants to let Leareth do things again, he wants to breathe)

Lisa waited until he had been on 100% oxygen for a while and his sats were actually up to 98%, and he's dropping but not instantly. She’s still not going to dawdle; he looks pretty freaked out.

Fortunately, with everything set up it takes her like twenty seconds to zero and calibrate the pressure sensor, and another thirty seconds is long enough to be reasonable confident in the reading making sense. It probably felt like a lot longer to him, but he’s actually still satting at 91% when she starts cranking the head of the bed back up.

(There’s a bit of a delay on the reading; he drops as far as 87% before turning around.)

Lisa makes eye contact and holds his hand and tries to look very calm and reassuring, because that probably sucked for him.

(She’s going to parse the actual reading she got later. He was bouncing around at 14-15 mmHg. Not terrible, she’s seen a lot worse, but it is kind of high, especially for a young fit non-obese guy, and this particular measurement shouldn’t be raised artificially by him panicking.)

It's really bizarre how just sitting up makes breathing feel like it's halfway working again!  But it does, and right now he will take that and not question it.  He squeezes her hand lightly, and does look reassured.  Of course it felt like a long time, but he can tell it wasn't, and could've been much worse.

He would... like to know what's happening... but he's not sure if she has the time to explain, and not sure if she can explain much, yet.  Probably he should wait until she's done all the figuring things out she can, and then ask.

(It makes perfect sense to Lisa that he can breathe better sitting up! It’s really common!)

And, no, she doesn’t super have time to draw pictures right now. She’s going to hit the 100% oxygen button on the ventilator again, smile reassuringly at him, and stick her head out the door to see where anyone is.

The respiratory therapist gets there at around the same time as Dr Hulka with the ultrasound machine.

     “Okay, what have we got?”

“He needs a higher FiO2,” Lisa says. “CO2 was actually low, we're ventilating him enough, he's just full of fluid. - Dr Hulka, can you do an echo with him sitting up? He really didn't cope with laying flat." 

     "I don't love that," Dr Hulka says drily. "I'll do my best. He can turn side to side?" 

"Should be able to, yeah, just mime what you need him to do. - CVP's highish by the way. 15." 

     "...Yeah. He’s really fluid-overloaded. I don’t think I’m going to like this echo.” Dr Hulka guides the ultrasound machine in close to the bed. “Can we move the defib pad for now, please, I don’t have a lot of access here.” 

Lisa nods, gives her patient a very apologetic look, and peels off the adhesive gel pad. Some chest hair comes off with it.

(Karal will recognize Dr Hulka as the busy-seeming older woman who was there during the day. It’s unclear whether she’s rested in the interim. She does seem tired, but not spectacularly impaired by it.)

The oxygen helps, and so does having done well at something difficult and being finished with it, so he shakes off his distress quickly.  Having all these good competent people trying to figure out what's wrong with him is very calming (and incidentally reminds him that he still hasn't figured out why they're going to all this effort for his sake).  He will make their work as easy as he can. 

He smiles at Lisa.  The apologetic looks are a useful warning that something's going to happen, but she really does worry too much.  He does not make any faces about the gel pad.

Dr Hulka, with the mostly-flat expression of someone who’s really too tired to do social warmth unless she has to and has judged that she doesn’t have to here, gestures impatiently for him to shift the position of his torso in various ways while she jams the ultrasound against his chest. (It’s actually pretty painful, with Karal’s injuries, but not the kind of pain that feels like damage.)

After several minutes she backs off and turns back to Lisa, scowling.

     “Looks like we’ve now got right-sided heart failure too, his right ventricle looks like a party balloon. I’m thinking that’s caused by the pulmonary hypertension he popped sometime in the last twelve hours - I’m not sure, can’t get an amazing view, but it fits with the evolution of his symptoms. Snuck up on us, he must have been working up to this half the day but he compensates really well.”

Well. That’s not great. “What’s our plan?” Lisa says quietly. 

     “We should get some fluid off him ASAP, but the real problem here is the pump.” A brief sigh. Dr Hulka turns to look at the resident, who's now hovering looking stressed.  “On the bright side, I doubt there’s any structural damage we didn’t already know about? My theory is his myocardium had a real bad day, his left ventricle started falling behind - probably while his rate was high and his lytes were screwed up - and he's been slowly backing up into his lungs ever since. - let's run another troponin, maybe I'm wrong and he just had an MI on us, but I'm hoping we can turn this around with an inotrope and taking some of the load off his heart. We'll start dobutamine, try to remind his heart to do its job here. We definitely need him off the phenylephrine - all that does is increase his systemic vascular resistance, which is just making his heart work even harder - if dobutamine isn't enough by itself, we'll switch him back to epi. We probably will need to if we're diuresing him - I'm inclined to start with something like spironolactone and see if it cuts it, we don't have a ton of wiggle room on his potassium..." 

It's tragic how her patient can't understand any of this, Lisa thinks wryly. Dr Hulka is clearly having a glorious teaching moment with the resident. Lisa miiiight with enough banging her head on it manage to draw something about the sequence of what they think went wrong, but she's a liiiittle tempted to leave it to Marian - who's frankly better at that - and for once it's not, like, 2:30 in the morning. They're disrupting the poor guy's sleep enough already.

Also she's too busy for drawing right now, even after hauling in Kasey to get her some dobutamine and help mix a new ultra-concentrated bag of norepi. Also she is going to bother Dr Hulka about changing the whole maintenance-fluids situation out for alternatives that don't give him quite so much fluid per hour. 

...It still only gets him down to, like, 200ccs an hour, assuming no extra IV medications in that hour, which is like 150ccs more than he's usually been peeing in that length of time. Lisa really hopes he's going to respond well to diuretics. 

She tries to make time to offer her patient reassuring smiles. He's maintaining a pretty good O2 sat now, but that's with him awake and sitting up and on 70% oxygen on the ventilator. 

(Karal is in fact going to have trouble getting back to sleep for a while. All the ceiling lights are on, multiple people have been coming in and out of the room, and not very long later someone comes back with the big light-shining machine from earlier and the board to stick behind his back.

He can breathe, though! It's definitely not working like it should, but as long as he's sitting up, he doesn't feel like he's suffocating.) 

Not feeling like he's suffocating is good enough for him right now!  (Although he's also gotten to the point of - not looking forward to needing to lie down flat again, exactly, but thinking of it as a challenge rather than misery, if it does happen.  Everything's much easier the second time around, and he doesn't have a lot of other useful things to think about, when nobody can tell him anything about what's going on.)

He wouldn't try to sleep anyway, with a confusing new problem and with multiple people to look at with Empathy to try to get some idea of how solvable it is.  They're all so busy!  The impatient older woman seems like she has plenty of solutions in mind, for all her scowling.  (He likes her and her correct amount of unconcern for his discomfort.)  And he's so curious about all the machines - what is that light doing, and the earlier thing that needed to be poked at his chest all over for some reason...  Mm, he knows Lisa is busy, but if she'll give him paper he can write himself notes?  He has so many questions he'll probably forget some by the time he can ask them.

…Sure, he can have his pencil and paper back, if it keeps him awake and too distracted to get anxious that sounds like a GREAT deal to Lisa. He can have the bedside table to lean forward against, for the best possible breathing ergonomics. 

(After a while Karal’s heart does seem to be doing something weird again, but - not obviously bad? It just feels thumpier, mostly?

He doesn’t otherwise feel worse. He maaaaybe feels very slightly better?)

He will write himself some notes!  (And appreciate the breathing ergonomics. Breathing is great.)

The page accumulates, in not very practiced but still obviously foreign-looking Karsite letters:
- what's wrong and can they fix it?  (Not that he was going to forget to ask that one, but if he's making a list he's inclined not to skip obvious things)
- why do strange new things keep being wrong? nothing even happened to his lungs!
- what was lying down flat for?
- why does lying down flat feel so bad?
- what's the bright light and board artifact doing?
- what's the poking at his chest artifact doing?
- what's the impatient older woman's name?  (There are enough people here that he's not going to try for all of them, but he's seen her enough that he feels like he should know)
- why are all these people putting so much effort into helping him?

When he notices his heartbeat changing - which he does pretty immediately, he's not quite anxious but he's definitely paying a lot of attention to what his body is doing - he waits for Lisa to look less busy, and mimes lighter and then heavier thumps at her with a questioning look.  (He's not asking for a whole drawn explanation - mostly he just wants to know if it's bad or not, and maybe it'll tell her something.)

Wow this guy is remarkably perceptive of what's going on in his body! When he's, uh, trying. He also seems remarkably able to tune out pain when that's his goal.

Lisa is pretty sure nothing is wrong! They did just start dobutamine with the entire goal of making his heart beat harder. She nods and smiles reassuringly and gives him a thumbs-up.

(She's curious what he's writing - and also what language it's in, she has no idea what alphabet that is - but now isn't the time to ask and it's also, like, not obviously her business. She's glad it's giving him something to do, and it's not a bad way to get an incidental assessment of his strength and motor function – she doesn't think he could have written that much at the start of this shift.)