Shavri is so tired. 

She Mindspeaks Dr Harrison and Dr Chadra as well as Marian and Samora. :I think you'd be better off letting him wake himself up slowly. Keep reducing the drugs, slowly, and don't bother him. If the first experience he has is of being under attack, it's not going to go well. ...If you can give him any drugs for pain and nausea specifically, he's probably going to wake up calmer if he feels less like he's dying horribly.:

To Samora, she adds, :- save the Calm Emotions spell. It'll do the most good when he has a chance of staying alert and lucid without it. He's not even processing that I exist, yet, if we calm him down he'll immediately pass out again so we might as well do it with the drugs.: 

Marian kiiind of feels like this is the sort of situation where there simply does not exist a dose of meds that will succeed at relieving Leareth's symptoms without by itself making him so drowsy that they can't get a good neuro assessment anyway. 

"- You had a spell prepared that helps with nausea, right?" she asks Samora. "It's just that we were planning to use it as a Cure instead? - being nauseous is so bad, I'm not surprised he's kind of freaking out about feeling terrible." 

"Yes, I have two and they'll last an hour each. I can do one right before the Calm Emotions, but not right after because I have to keep concentrating on the Calm Emotions the whole time it's running. Being nauseous is harder to think through than pain, in some ways; I expect suppressing it will help."

“- And all our really good painkillers tend to cause nausea as a side effect, but if we’ve got a magic solution we can maybe manage a high enough dose to control his pain without just making the nausea even worse. I’ll ask the doctor.”

She goes and asks Dr Harrison.

“Pain control? Sure, whatever, start him on fentanyl at 25, feel free to titrate up as you wean the propofol, you can do boluses of 12.5 if our telepath says he’s feeling it. I’d like Dr Chen’s input on medication options for nausea, I don’t love sacrificing a Cure spell backup when we’ve got twelve hours to go until dawn. - Oy, Healer, how fast are we losing ground?”

Shavri rubs her eyes. :- Not as fast as I’d feared, but - steadily - and he’s losing ground on Endurance again, he’ll get less out of Cures or channels closer to morning. I think he can get by on two more, in - let’s say four more hours, and then five-ish hours after that - but it’d be a big gamble to use up everything and be left with nothing except Stabilize for the last few hours of the night.:

“- Samora, you have three channels left, right? So we’d still have two channels for emergency backup closer to morning, if we use a Remove Sickness for the nausea and then the other for a Cure later, he’ll need a channel at like - five am or something - and if he’s stable at six-thirty we can maybe afford to send you to run and use the two channels on other units that have, like, post-op patients. …I’m more stressed about you not being interruptible for a whole hour if we need Stabilize but I think there’s no helping that.”

Dr Harrison is writing up an email.

Subject: RE: Radiation case - I need more information

Dr Chen,

I'll be straight with you but you'll have to be patient for the full run-down, I don't have time for an essay. 

Our healer: "Samora", cleric of a goddess from another world ("Golarion", either a different planet or alternate dimension, but medically she seems human). Her abilities resemble D&D mechanics, per my resident who plays, but not a perfect match. Showed up 36 hours ago via unexplained magical transport, unconscious with mysterious injuries, admitted overnight. Made a full recovery first thing today once her spells renewed, cast a translation spell on one of the nurses to fill us in. 

Our current patient: "Leareth", 40s male and some kind of powerful wizard from a DIFFERENT other world (called "Velgarth"), key ability: can do portals for transport. The radiation exposure occurred when a god blew up a country to, we're theorizing, blast him with a giant gamma death laser. He arrived also via unexplained magical transport, approximately 9:45 AM this morning, about 30 minutes after teh exposure and in cardiac arrest. Accompanied by "Shavri", who's a telepath with different witchy healing powers. She's our diagnostician, her powers come with "Healing Sight" - can see anatomical structures, physiological processes in action, and cellular-scale damage. We've been using her assessments as a guide; so far, no significant discrepancy with labs or clinical findings and we're treating her as reliable. 

Samora has limited daily spells that recharge at dawn after an hour of prayer. From now until tomorrow morning we're down to:

- 2 spells that suppress nausea for ~1 hour, OR can be converted to Cure spells 

- 1 spell that cures disease or infection, not perfectly reliable 

- 3 "channels" - heals everyone in a radius, otherwise behaves mostly like the Cure spell

- Unlimited use of a spell that stabilizes someone dying, but not a guarantee, she couldn't land it on him until his pH was normalizing on ECMO

Cure spells work dramatically well on trauma, and they do reset some of our guy's acute tissue damage, fortunately including the complications of cerebrovascular syndrome, but not the DNA damage, so the cells keep dying and the injuries show up again. They don't correct metabolic derangements or organ damage not strictly from injury. 

Earlier we used a powerful spell that fixes "ability damage", my resident says to google STR/DEX/CON/INT/WIS/CHA, we targeted CON which seems to be vital organ function. Didn't help with muscle damage, nerve damage, or the signs of brain dysfunction we're worried about on the CT. None left until tomorrow. Requires diamond dust, that was the delay. 

Current status: weaning sedation for neuro assessment. On 30 mcg/kg/min of propofol, he's rousable to pain but very agitated, not obeying commands, telepath said no awareness of surroundings and trying to portal himself out. Settled with a propofol bolus but I'm not sure where to go from here, we need him awake and able to do a portal to Golarion. Telepathic healer reports he's in pain and severely nauseated, could be exacerbating the agitation and confusion.

QUESTIONS:

What's your recommended regimen for radiation-induced nausea this severe? He's on TPN only, gastric tube to suction. Haven't given anything yet, I'd like to avoid exacerbating the drowsiness or confusion.  
- Remove Sickness vs saving Cure spells: Should we burn a Remove Sickness spell (1 hour guaranteed full nausea relief) to assess his neuro status, or save it for a backup Cure later? Our telepathic healer thinks he'll last until morning with a Cure and a channel, and we'd still have 2 more channels for backup, but we'd get more oomph if we can save them to hit a few dozen people each up on med/surg. 
- Complications to watch for next 12 hours: What should we be monitoring for? Respiratory deterioration? Worsening neuro? GI bleed? We have almost no treatment options until dawn.
- Sedation strategy: Need him awake enough to assess cognition but calm enough not to panic and portal out. Guy has insane PTSD or something, gets pretty fighty. Suggestions?

Look for your ride at baggage claim, he'll have a sign.

---

James Harrison, MD
Department of Critical Care Medicine
Renown Regional Medical Center
1155 Mill Street
Reno, NV 89502
Direct: (775) 982-xxxx
Pager: (775) 770-xxxx

It’s maybe fifteen minutes before they get a reply.

Leareth is still more-or-less asleep, now on 20 mcg/min of propofol and 75 mcg/min of fentanyl. His blood pressure is handling it fine, and he’s now often breathing above the set rate on the ventilator. He occasionally grimaces and tries to shift his weight a little, without much success, and sometimes he coughs and looks actively distressed for a few seconds before drifting off again. 

Ugh he could probably really use suctioning, it's been like an hour, but now is the worst time to subject him to that. His sats are fine, it's not an emergency. 

...He's also been in the exact same position for...god, like ten hours. He's probably uncomfortable just from having his weight on the same pressure points. Marian...is a little nervous about whether she can reposition him without startling the fuck out of him and getting punched, given how he's apparently already in a lot of pain just lying there, but maybe if she gives him a small propofol bolus and a fentanyl bolus first and then does it fast? 

"Hey, Samora, wanna help me slide him up a bit in the bed and turn him a bit in case he's comfier that way?" It's somehow ended up just being her, Dr Chadra, Dr Harrison, and Shavri; she's not actually sure if she's supposed to be giving report at some point, but maybe Clarice came to the same conclusion she did, which is that Marian has to be here anyway because she's the only one who can talk to Samora. 

Subject: RE: Radiation case - I need more information

Harrison,

Will have to see it to believe it but I've already committed at this point. 

NAUSEA MANAGEMENT:
Standard radiation nausea protocol: 5-HT3 antagonist (ondansetron 8mg IV q8h, or 4mg bolus) + NK1 antagonist (aprepitant 125mg if you can get it on formulary, probably not at this hour) + dexamethasone 10mg IV (anti-inflammatory bonus for radiation injury). Olanzapine 5mg surprisingly effective for refractory cases and won't sedate as much as you'd think. Avoid metoclopramide, no benefit from prokinetic if gut mucosa is already sloughing. Check gastric tube drainage regularly, if no recent output irrigate to rule out blockage. 

If you have a side-effect-free alternative: USE IT!!! Nausea severely impairs cognition and attention even in healthy people. If he's already in distress from severe nausea while on 30 of propogol, you can't meaningfully assess neuro function, and you need a clean assessment to establish baseline. It sounds like you're already coming to that conclusion yourself? 

COMPLICATIONS - NEXT 12 HOURS:
Watch for in order of likelihood:

Cerebral edema - watch neuro status, any change in mentation beyond what sedation explains, this is why a baseline now is critical. I'll assume you know as much as I do on how to treat.
Pneumonitis/ARDS - radiation lung injury, usually takes weeks to manifest but everything about this case is accelerated. Watch O2 requirements, lung compliance. If FiO2 creeping up or airway pressures/PEEP requirements increasing, you're in trouble. Bad mix with pneumonia, would be a reason to move forward on curing his infections even if you're not worried about sepsis. 
Cardiac arrhythmias - patchy myocardial damage creates unstable electrical substrate. 
GI bleed - mucosal sloughing, probably already happening if he's this nauseated. Monitor NG output, serial Hgb. 
Sepsis - obviously, he's neutropenic and his epithelial barriers are breaking down everywhere. Monitor temp, lactate, BP. Stay ahead of it.

SEDATION STRATEGY:
I think you may just be asking for the impossible here? I'll tell you the obvious. Optimize pain control first, preferentially fentanyl if he tolerates it. You can try low-dose dexmedetomidine, I guess? Minimize benzos and anything long-acting. Be aware that his drug clearance rate could be swinging back and forth, if his organ function is deteriorating between healing treatments. Your basic nursing care will be critical: you want your nursing staff doing everything they can for non-medication comfort measures, and doing their best to establish some rapport and trust. You've got mindreading to figure out what's bothering him, apparently, so use that. The man's from some sort of fantasy planet; be aware that the same degree of underlying delirium can look a lot worse with a complete lack of familiarity cues. Maybe your telepath has some ideas for what might make the environment look less like he's been kidnapped by aliens? 

If he's still too agitated to assess even with pain and nausea controlled: consider this is delirium from the injury itself. I'm not sure what else to tell you. Find the best tradeoff you can between avoiding deep sedation and torturing the patient.

Tried to google the acronyms. I’m sorry, I cannot make medical decisions off arguments on Reddit and wiki pages that won’t load properly on airline Wi-Fi. Send me a description if it’s relevant. I’d probably consult neurology if what you’re looking for is a cognitive assessment that maps to Dungeons and Dragons character traits.

- RC

Samora is happy to help shift Leareth around. "In case it ends up mattering, I can be interrupted during prayer if you need a Stabilize immediately, but then I won't be able to prepare anything other than what I already have by that point. So the closer it gets to the end of the hour, the less costly it will be for other patients if you need me to stop. There's also a spell called Delay Pain, but it's second circle instead of first and I've heard all the pain comes back when it wears off even if the underlying cause is fixed, so if it isn't fixed I'd worry about him getting twice as much. I guess if we're going to knock him out again we could have him knocked out for that part, but it's still probably not worth losing a Lesser Restoration."

“- Yeah, I can’t see it being worth it unless he’s able to tell us before morning that he thinks he can get a Gate to Golarion if he has six hours of not being distracted. And we can only really plan on knocking him out again if we’re keeping him on the breathing machine the whole time - I guess we could put the tube back if jt’s worth it for some reason - eh, it can go on the list to ask the expert who’s getting here at midnight.”

Time to give Leareth his tiny boluses of extra drugs and then be so careful and gentle. They can manage it mostly without touching him directly at all and just pulling on the linens under him. Marian can occasionally produce strong opinions about exactly how patients should be propped in their nest of pillows, and this is one of those times. 

Leareth does not try to fight her! He makes a face like it's hurting him, and he tries not-very-purposefully to pull away when she picks up his arm to position a pillow. 

He does look significantly more comfortable in the new position; his heart rate had crept up to nearly 110, and it drops back to 95. 

Oh good– oh and there's another email!!! Marian hurries over to read it. That was fast. 

"...The expert doctor thinks we should use the Remove Sickness for nausea," she relays to Samora. "That it's better than any drugs we have and won't have side effects - I assume it doesn't have side effects? Our drugs might make him sleepy - and she thinks that feeling really nauseous will actively impair his thinking and make it harder for him to engage with us." 

"And you," Dr Harrison says to Marian with someone unnerving cheeriness, "are on duty for some kickass nursing care tonight, all right?" He mouses over the email and highlights 'Your basic nursing care will be critical: you want your nursing staff doing everything they can for non-medication comfort measures, and doing their best to establish some rapport and trust'. "You're good at that shit, I'm sure you can get this guy to like you." 

Aaaaaaah?!! That's actually a pretty sweet and flattering thing for one of the trauma surgeons of all people to say, and, like, Marian tries to do that all the time? She thinks she's pretty decent at rapport with patients? And a 1:1 patient with a lot of extra hands in the room with her is ideal conditions for being extra attentive to his comfort, but also that's a lot of pressure and she feels so Observed and self-conscious about it aaaaaaa. Why her, why isn't he telling Shavri– oh it's probably that Shavri does not strictly speaking work for him and he doesn't feel like he can just order her around. Also Shavri, in fact, really shouldn't be on duty all night, she's already looking half-asleep in her chair again.

"Okay," she says.

And then translates the whole email properly for Samora, feeling weird and self-conscious the whole time for no good reason. 

"Remove Sickness doesn't have side effects. I'd really expect Restoration to fix heart damage and maybe Cures to do it as well, but it sounds like it's coming back faster than we can stay on top of it. Is there a way to stop the damage from coming back? If we keep him alive long enough will we outlast it without doing anything else? Do you want me to try to explain the three kinds of mental damage and enhancement?"

"The Cures definitely weren't getting all of it, I think he had - some that was like an injury, like burns to his heart directly, and some was maybe more like - when old people have bad hearts? Which I wouldn't expect a Cure to do anything for, but I think a Restoration would fix - and it did, his heart actually seems to be in great shape right now. We’re just worried the injuries and damage will come back because the," what had Shavri been calling it again, "the tiny-instruction libraries inside the cells are still garbled? …Also Dr Chen doesn’t know very much about your magic yet so she might be guessing off patients she treated who were affected much less severely but didn’t get any magic healing. I don’t…think we really know what’s going to happen with Leareth, she’s just trying to guess what might get worse overnight so we know what to watch for and aren’t caught off guard by it.”

Marian considers for a moment. “I…don’t think we can cure him just by keeping him alive until enough time passes? Maybe some problems will stop coming back if we fix them all the way, but I think at best he would just die of six kinds of cancer at once? I don't know, though, I think we're hoping Dr Chen will know more about his type of injury and have better ideas." 

Marian would definitely appreciate an explanation of the three kinds of mental damage and enhancement! She'll take notes, again in English so she can pass them to whoever. 

(She's watching Leareth closely for any sign that the random foreign-language conversation happening a meter away from him is starting to be enough to wake him up.) 

(Not yet.) 

Dr Chadra does sidle over to ask Shavri if Leareth is currently capable-of-having-experiences enough to be nauseous or if they should wait longer to get the most benefit out of the Remove Sickness duration. 

:...He's definitely feeling it. I think he'll start being able to try to pay attention to his outside surroundings a lot sooner without it.: 

Got it. 

"Marian, tell Samora we'd like to use the Remove Sickness now. We're going to hold off on using the calming spell until Shavri tells us it's a good time." 

Right got it Marian will relay that. 

The three kinds of magically changeable intelligence are Cunning, Wisdom, and Splendor. Cunning is good for math and remembering things you've read and holding complex images in your head. Wisdom is good for introspection and situational awareness and noticing which things are important and which aren't. Splendor is good for understanding other people and changing how you're perceived and also, for some reason nobody understands, how many channels per day clerics get. They can temporarily boost Leareth's Wisdom by putting Samora's headband on him, and it could well get him from "conscious but too confused to hold a conversation" to "able to talk about what's wrong with him", but that's not a good long-term solution because she'll get fewer spells if she leaves it off for more than an hour or two.

"Remove Sickness".