"I, um, I think we should have enough extra that we can afford to waste one tube." Marian would kind of rather think about this in an hour, after she’s dealt with her stupid labs. “I guess if you’re actually not busy you could look at ways to test it sooner? - sorry I was about to go in, I need five billion labs -“

Everything is put in stat, and within twenty minutes or so they are all, once again, crowded around the computer. 

Shavri cannot read the numbers but she demands an immediate mental explanation of what they meaaaaaaaaaan.

Marian is unfortunately limited in being able to explain everything because she's not sure why they're checking a bunch of the new ones!

Cytokine panel is...inflammatory stuff? Marian is not really sure what to make of it because she mostly thinks of it as related to immune response to infection and Leareth does not, currently, have an immune system to speak of, so what gives? 

Going back to the top. Reticulocyte count is - wow this is making Marian feel like she's back in nursing school taking a quiz she forgot to study for - she thinks it's the...baby...red blood cells? She doesn't think she ever learned the reference range, but the lab is nice and provided one, and unsurprisingly given everything they know, Leareth is not making very many new red blood cells. Maybe none at all, those could be all that's left of the number that were in his blood right before this happened. 

Electrolytes are still abnormal but better, that's entirely the work of the dialysis but Marian still feels a quiet internal moment of pride toward her patient. Hemoglobin is fine! Like, technically a little low but by ICU standards that's more or less normal! ...Blood gas got worse again, she doesn't love that, it looks like it's just the lactate going up again by why his blood pressure is adequate he's satting at 100% what's wrong -

- well, his clotting panel is worse across the board, and a positive D-dimer, that's a sign that his body has been making clots, probably everywhere in his body - his vasculature is damaged on the inside throughout his body, there'll be rough spots and tiny "injuries", plus all the inflammation - that's disseminated intravascular coagulation and Marian is scared of it, though admittedly for Leareth it's, like, not even in the top three scariest things wrong with him and she's vaguely hopeful that it's the sort of thing a Restoration fixes. 

Liver enzymes are worse, that's not surprising, if anything they're not rising as scarily fast as Marian might expect - ammonia is high, that's something the liver should handle and isn't, it's not great for his brain especially if it keeps going up but it won't kill him. Cardiac markers are still rising, so there's damage that the latest Cure spell didn't get, but - again, it's not a catastrophic rate of increase. Elevated CK is from muscle breakdown, also not surprising but it's really going to mess with his kidneys, also not going to kill him especially when they've already got him on dialysis.  

LDH, Marian has no idea, what is that, her brain keeps autocorrecting to "the bad cholesterol" but that's LDL. Haptoglobin sounds like it's related to red blood cells but who knows what it means that it's low, except 'be worried'. Ferritin is...iron stores? Marian only knows what it means when it's low (iron deficiency anemia boo), high...is plausibly because his cells are breaking down and the iron formerly in their hemoglobin is loose now? Marian will go with that and look it up later. Procalcitonin is an infection marker! It's high but not 'fifty times the upper-normal cutoff' high, which makes sense, he's got a known infection in his lungs but it might not even make the top ten worst problems. 

Amylase and lipase are pancreas stuff! His pancreas is kind of dissolving or something, great, just what they needed. 

Central venous O2 saturation is...high...? Why are they even checking that, Marian's lost, but - well, maybe it's just high because his arterial blood oxygenation is high, does that make sense - that can't be all of it, it's saturation (of hemoglobin) not partial pressure (of directly dissolved gas), most people have a baseline hemoglobin-saturation near 100%, so you just can't go much higher than normal, and that's where nearly all the oxygen in the blood is. So Leareth's tissue must be using less? That seems related to the lactate rising - he's not burning oxygen even though it's there, his cells are going anaerobic instead - but the part she's not getting yet is why and what that means in context... 

Shavri will drink all of this in like a person dying of thirst in a desert who's just found an oasis, and then - because there are too many thoughts in her head again and she's got to spread the joy around or explode - rapid-fire it over to Samora with commentary. 

...It is interesting that his blood is full of vital air that his body can't use properly. There's a vague shadow everywhere (it's actually not entirely unreminiscent of Randi's wasting illness, just worse) - it feels like it's got to have something to do with the tiny libraries, maybe the cells need to refer to those instructions in order to do whatever it is they do with the vital component of air, and now some number of the cells are just failing to complete that process at all, or doing it with terrible inefficiency... 

Samora has no idea whether any of her spells can fix the tiny instructions because she didn't know they existed! Not being able to turn air and food into ability-to-do-things sounds like it's either an Endurance issue, which Restoration will fix, or some kind of weird one-off thing there's no magic for. She'd be a lot less worried it was the latter if he hadn't been personally attacked by a god, which is exactly the sort of thing that gets you damaged in weird ways there's no magic for. Can Shavri tell her anything about which god and why, and how strong the other cleric she's met was and which god they were a cleric of, and does she have any speculation about which god or what other mechanism might have sent them to Earth?

Shavri's mind is still very full of MEDICAL THOUGHTS and having trouble parsing why any of that is...important or relevant...but she can answer. 

:The other cleric was of Iomedae, too: and how about she DOESN'T get into any of the complications right now, :and he had up to third circle spells. ...The god who attacked Leareth was Vkandis. Sun god, has a couple of countries run as theocracies, one has been protected by a magical shield-barrier for almost two thousand years and - that's what exploded. It's gone, there's a mile-wide strip of fire all around the border, there's - we hadn't begun to assess the collateral damage but - a lot of people died. A lot of His people. ...He and the Star-Eyed Goddess were both involved in earlier plots to murder Leareth, which he claimed They've been trying to do for a very, very long time. His theory is that they hate - change, including progress, things that make countries wealthier - and that's always been his goal so they hate him. ...I have no idea if what sent us here is related, or the same thing that brought our cleric to Velgarth or brought you here.: 

Probably two gods she's never heard of and not either of Sarenrae or Desna. :If two of the people it's happened to are clerics of Iomedae that suggests She might be involved somehow or at least not actively opposed. Also, you landed here in the hospital, not a mile away where there wouldn't have been help available. That suggests that Someone wants Leareth healed and thinks there's a chance we can do it. It's all speculation and not much to hang a theory on, but it seems more like reason to hope than reason not to.:

:Maybe. I hope so.: It would certainly be baffling for Iomedae to object to Leareth getting healed - or to Blai saving Valdemar from a war - but Blai also thought Iomedae wouldn't be able to intervene in their favor even if She wanted to, so Shavri isn't getting her hopes up. 

She is thinking, though. :I think your magic must be able to act on it, though? On the part that's reducing his Endurance, I mean, I don't know if it can fix the tiny libraries, it might just fix it temporarily but the problem will keep coming back. But - it was hard to see, before, with his life-force so dim, but I think even the Lesser Restorations helped a lot and the numbers they're measuring agree.: 

She'll wait to see if the doctors want her to check anything or do anything, now that they have more information on the problem. 

"That's mitochondrial dysfunction, check, cytokine storm, check," Dr Harrison says dryly. "Well, let's shoot all that over to Dr Chen's email and see what she has to tell us. And now we've got a baseline, we can repeat after the diamond dust spell and find out exactly what it can help us out with." 

Oh no what if the specialist doctor advises them to do more things. Marian is not up for doing any more things than this 

They get a reply within twenty minutes. Again, almost everyone not currently trapped in the room in isolation gear crowds around the computer while Dr Chadra reads particularly choice parts aloud. 

I've reviewed your labs multiple times and consulted with two colleagues. We are collectively baffled.

Your lactate of 14.5 with ScvO2 of 82% is actually pathognomonic for severe radiation injury. This is cytopathic hypoxia; the mitochondria are so damaged they can't utilize oxygen even when it's delivered. It's one of the few results that I can explain.

The cytokine storm (IL-6 of 950) is consistent with massive radiation-induced systemic inflammatory response. That tracks. The absolute lymphocyte count of 140 at ~4 hours post-exposure is compatible with >15-20 Gy exposure. Maybe higher.

Now, the things that don't make sense: His pH is 7.12. With the degree of cellular dysfunction you're describing, he should be much more acidotic. I would expect a pH below 7, which we saw on your earliest labs, followed by a sudden jump. Something is buffering him that shouldn't be possible.

His liver enzymes are very elevated but not astronomical. With this level of radiation plus the ischemic injury from the arrest, I'd expect AST >5,000. Where's the rest of the hepatocellular necrosis?

His hemoglobin is 11.4. At this point post-exposure with severe radiation injury, I'd expect more hemolysis. Your haptoglobin is appropriately low, but his H/H is holding up better than it should.  

Your "experimental cellular regeneration therapy" is doing something. I don't know what, and I'm not sure I want to know. (Do you have institutional ethics board approval for continued experimental therapy in a patient who cannot consent?)

Dr. Harrison, even with your experimental therapy, these labs show multi-organ failure that is incompatible with survival. Even with whatever you're doing, he's still deteriorating. His pH dropped from 7.18 to 7.12 in two hours. His lactate rose from 12 to 14.5. His liver enzymes are climbing. His ANC is in free fall. Whatever you did before is wearing off, and the underlying radiation damage is winning.

Dr Harrison rolls his eyes. "Yeah, yeah, skip ahead, what's she recommending we do?" 

There's a lot of email, especially for having been written in less than twenty minutes. Dr Chadra scrolls down. 

"She's suggesting tocilizumab for, uh, IL-6 blockade? ...Uh, that seems like a really bad idea, that's a biological immunosuppressive drug, right - okay, it says she's aware we're concerned about infection risk but that the cytokine response itself is life-threatening. She says he'll need cryoprecipitate for the DIC, yeah, okay. Consider stress-dose steroids, sure. She's recommending we start TPN now, that he needs calories and protein for cellular recovery, that does make sense... Says he should be on a continuous bicarb drip... Oh, look at this -"

If this is real (and I'm still not 100% convinced it's not an elaborate training scenario), you're attempting something that's never been done. I want to help, but I need to understand what I'm helping with. If you can provide more details about the therapy - even under NDA if necessary - I might be able to give better guidance. Also, for what it's worth: if you pull this off, this will be the case report of the century.

Dr Harrison waves his hand. "I'm not telling her we're doing this with literal divine faith healing magic out of a Dungeon and Dragons setting over the phone. - go call her, you can say we'll tell her everything if she flies out, see if she bites. But this is enough to be getting on with." He makes a shooing motion. "I need to put orders in." 

...Okay, in terms of additional Tasks to achieve, that could be a lot worse. 

Shavri gets caught up via bothering Dr Chadra over Mindspeech, and is almost bouncing as she updates Samora. 

:They can feed him! Even though his gut isn't working! They can - take what's in food and break it down into very very small pieces, so it dissolves completely in water, and they make it completely clean, and they can give it right into his veins, like with the drugs!: It's SO powerful. One of the worst hurdles for Healers is that some of the patients the most desperately in need of Healing can't safely eat, and Healing will rapidly exhaust them if they're not getting any nourishment. 

:That's really cool! Does it go from the blood to the stomach, or does it nourish him just from being in the blood?:

:It doesn’t need to go to his stomach at all! The stomach - well, the intestine mostly - would normally break the food down into tiny pieces so it can transfer into the blood, which takes it all over the body to the tissues that use it as fuel. But if someone’s stomach and intestine aren’t working, they can skip that step entirely!:

:Neat!: She wonders what happens differently when she eats versus when she doesn't and whether Shavri could tell whether she'd been eating recently. :So what was in that letter they were all reading together?:

Shavri catches part of the thought about Samora eating versus not eating and is...confused, because of course people's bodies look differently to Healing-Sight when they've just had a meal, compared to when it's been all night or whatnot, but it seems like Samora means something more drastic than that? Does she regularly fast for days or something? - she can ask later. 

:They talked to a famous doctor from a long way away, someone who's specialized in treating patients who have this kind of injury - she lives in a different city, hundreds of miles away, they can just do that! And then they sent all of the numbers in an instant-letter with their artifice, and she was giving her interpretation. She found it very confusing – it sounds like some of the measurements are very bad, in ways that she didn't find surprising, but some aren't nearly as bad as she would expect and that was more surprising? I think that has to be because the Lesser Restorations and Cure spells were helping, in ways they can’t replicate with artifice. She - I think she isn't sure whether to believe it's real or not, she thought it might be a - practice scenario to test their response systems, or something? But she's playing along. She wants them to give him a drug that will prevent his body from responding to the damage with inflammation, because his body is freaking out hard enough that the inflammation itself is life-threatening rather than helpful for healing. And she was the one who said we should start giving him some kind of nourishment as soon as possible, that it’s urgent because his body will need so much fuel for healing. …I think probably the Restoration spell doesn’t rely on that? But she isn’t wrong that natural healing and my kind of Healing-work both do.:

:That does sound like a good idea. Healing spells still work the same when someone is starving, but they also don't help with it. Is inflammation useful sometimes? What's it good for?;

:Mm-hmm! It's very helpful if there's a local injury or infection - if you break your leg, or have a wound that's starting to be infected - it's how the damaged part of the body communicates to all the rest that it needs extra resources to heal. The cells that are affected will - send messages, that tell the blood vessels nearby to relax and be wider so that more blood with its vital-air and nutrients will reach that spot, and that summon the cells in the blood that fight infections, and the blood vessels will get - leakier? - so that the defense-cells can get out and into the injured tissue, and then your broken leg or your infection will heal much faster. But if it's everywhere at once, like with blood-poisoning - or with Leareth right now, an injury in every part of his body at once - then there aren't enough of those resources to go around, so it's useless if everywhere is asking for them at the same time, and it just makes the blood pressure drop way too low - because there's not enough blood to fill the blood vessels when they're all relaxed at the same time, even if the person hasn't lost any blood, and because the fluid in the blood starts leaking out into the tissues rather than staying - and then even the organs that aren't badly injured will start panicking like they are, and not work very well. And they think that's a lot of why his blood can't clot properly - it's not just that his bones and liver can't make the parts of blood that form clots, it's that everywhere his body is shouting 'I'm injured! help me!' and the clotting-cells think there must be a wound that's bleeding and try to make clots everywhere at once, and actually all it does is gunk up the tiny blood vessels, so now his extremities aren't getting enough blood, and it uses up all the clotting-cells and clotting-substances and there are none left for if he does actually start bleeding from a wound.: 

Shavri looks thoughtful. :Marian said that's actually a problem for a lot of their patients, because their artifice can fix the underlying problem, but the patient's body doesn't know that and will panic about the problem anyway, even when all it's doing is making it worse. So they use drugs to tell the patient's body to stop doing those things, while the artifice handles it. They're nervous about doing that for Leareth because he's already going to have trouble fighting infection, but the expert doctor thought it was worth it and I kind of agree, I think? I think his body wouldn't even notice a true infection-alarm because there are so many spurious ones already.: 

:So it's like the body is an army, or a line of forts, and usually they're all cooperating and sharing resources sensibly, but now a bunch of them are overwhelmed and it's ruining morale across the whole front and also some of the officers are fools or cowards. So you've got to take over and impose some rules and fire some of the worst officers and install replacements.: