Kalorm’s O2 saturation is back up to 100% within like fifteen seconds. His exhaled-CO2 is taking longer to normalize, unsurprisingly, and he’s still breathing fast, but deeper. He looks less distressed; the painkillers are taking effect.

“Better?” Merrin says brightly, letting go of his shoulder - he doesn’t seem inclined to struggle right now - but still holding his hand. “You did really well, honestly. That was almost nine minutes. I think it’s still a good idea to at least reserve the option of sitting you up quickly, when we move you - I know sleeping propped up is weird when you’re used to not that, but it can really help when you’re feeling short of breath. Seem reasonable?”

She does kind of have a point, and Kalorm is too busy catching his breath to really object anyway. Nod.

Merrin smiles at him. “I’ll let you know what the market estimates are on when we’ll be able to get you off the ventilator, but I expect that will shift it earlier. Anyway. We can still arrange to move you onto the floor, if that’s your preference, we’ll prop you against an adjustable wedge and we can play around with the lowest angle your lungs can tolerate.”

Lying flatter than a 30-degree elevation is also not ideal for possible vomiting and aspiration risk even with the breathing tube protecting his airway, but if Kalorm wants it that way, fair enough, Merrin has tested this herself and it is really weird trying to sleep with your head elevated even to that angle. 

Vague sleepy nod. Kalorm can tell that she gave him painkillers again and he appreciates it, taking deep breaths does in fact really hurt, but now he feels floaty and drowsy.

“I think you need to cough up some,” lung snot, “secretions again - that will happen, you inhaled a lot of water and you have a nasty pneumonia - so I’d like to suction you again. It’s going to hurt and be stressful, but I predict you’ll have an easier time afterward. Is your pain control good enough for that right now?”

Mmmmwhat that was a question…?

…Yeah, he must be exhausted after that nine-minute workout and the drugs are hitting him hard.

“I’m going to suction you, okay?” Merrin repeats loudly.

Kalorm cracks an eyelid open and manages a very sleepy irritated eye-roll, but doesn’t object.

She can do this one-handed and keep holding his hand. Merrin recognizes the look when a patient is starting to trust her enough that her presence is actually comforting. (Coming from Kalorm, it’s…really touching, actually.) 

Kalorm is CONFUSEDLY MISERABLE ABOUT THIS EXPERIENCE but not actually in agonizing pain. He coughs and sort of hangs onto Merrin’s hand. 

Cute???? 

Merrin manages to go in for three very thorough suction passes before his oxygen saturations start to drop. He has a lot of bronchial secretions, but they’re actually looking less gross? Looser, easier to dislodge, and more yellowish-white than tan. 

Still disgusting but not as bad as SALIVA which is now ALSO EVERYWHERE drool is not an emergency just because Merrin has a personal grudge against it. She can wait for Kalorm to be alert enough again that she can meaningfully ask his permission to clean out his mouth. He can have a flavored swab dipped in ice water as a treat afterward. 

Kalorm makes a face about this but allows it. It’s exactly like having an overly enthusiastic little sister.

…It is much easier to breathe now, actually. Kalorm falls asleep almost the instant they leave him alone.

Merrin gently pats his arm and looks very pleased with herself. 

“I think that went about as well as it could have,” she tells the others, cheerfully. “Nerdel, want to sit with him while I look up the markets and put together a summary? And we can get the supplies together to move him onto the floor when he wakes up, if he’s still determined to do that, but I’m not going to poke him awake for it.”

It’s nearly 1 am and Nerdel is kind of fading and having trouble staying awake, but she can do that.

Diagnostic market predictions on Kalorm getting off the ventilator, 20% / 50% / 80%: 6 hours, 20 hours, 54 hours.

(The former is mostly based on “Kalorm demands this, whether or not it’s medically speaking a good idea” and includes a 55% likelihood estimate that he ends up back on some form of assisted ventilation within 12 hours. The latter is premised on “some sort of complication”, which isn’t incredibly likely but is certainly likelier with a patient who insists on SLEEPING ON THE FLOOR and is not necessarily forthcoming with his medtechs about how he’s feeling.)

Predictions on Kalorm’s injuries healing enough or other pain control options working well enough that they can wean him off the sedating/cognitively-impairing high doses of strong painkillers, and get a less confounded assessment of his neurological status, 20% / 50% / 80%: 24 hours, 38 hours, 72 hours.

Predictions on Kalorm being medically stable and otherwise strong enough to properly start physical rehab: 32 hours, 60 hours, 96 hours. 

Predictions on when Kalorm’s digestive tract (and swallowing ability, which could be a bottleneck if his current lack of coordination is due to more than just being super sedated on painkillers) will be in good enough shape to try him with:

- clear fluids: 60 hours, 5 days, 9 days.

- nutritious liquids with much fat or protein content: 96 hours, 8 days, 14 days.

- solid food: there are numbers but flagged with high uncertainty since they’re premised so heavily on earlier events. Given how little gut motility he’s regained at this point, the complaint of a stomachache, and analysis of the backed-up gastric fluids they’re draining from the nasogastric tube, there was a bunch of tissue damage. 50% estimate is three weeks. 

Unfair, that is SO LONG to make Kalorm wait for his fairly-earned cookies 

Estimate on how long until Kalorm is up and walking (any amount of assistance, minimum distance 5m), 20% / 50% / 80%: 6 days, 12 days, 24 days. 

Estimate on how long until Kalorm is walking unassisted, distances >50m: 11 days, 21 days, 60 days. 

Estimate on when Kalorm will no longer require supplementary oxygen (defined as “for at least 24h” since he might still be at risk of later complications): 7 days, 12 days, 30 days. 

Estimate on hospital discharge: 12 days, 4 weeks, 10 weeks. (Low end is very much premised on “Kalorm demands to leave the hospital once he is physically capable of making it to the front door, regardless of whether it’s a good idea”, high end assumes either complications or Kalorm miraculously deciding he’s happy enough with the hospital to complete the full recommended course of rehab from here.) 

Likelihood that Kalorm will have a serious medically-dangerous complication down the line (aspiration pneumonia, blood clot, central line infection, etc): this would USUALLY be very low, precautions against in-hospital complications work well, but Kalorm seems unusually likely to be straight up non-compliant with any care he personally finds irritating or thinks is stupid. Estimate was 19% until recently, and then spiked all the way up to 31% after the WRESTLING incident and the REFUSING TO ADMIT TO RESPIRATORY DISTRESS incident, but - actually dropped a lot after Merrin's handling of that.

Now it looks like maaaaybe they can significantly improve his cooperation just by having Merrin stay on and tag-team his treatment with Khemeth (which is perhaps a dubious use of Merrin’s highly specialized skillset, but Khemeth is certainly willing to bid high enough on her time to indicate how much he values it, and it’s a higher number than anything except a really critical Exception Handling all-hands emergency, or something similar to the Kalorm rescue that could really use Merrin’s team in particular, in which case they can pull her off BRIEFLY.) New estimate 8%. 

Likelihood that Kalorm will impulsively do something that causes additional physical injury: 24%.

Likelihood that Kalorm will give himself an additional head injury with:

- No additional neurological injury (just an upsetting time for everyone): 10%

- Temporary neurological consequences: 6%

- Permanent neurological damage: 2% but everyone will be SO UPSET, that sort of thing approximately doesn’t happen unless you have a patient who is an INSANE ALIEN who does things like wrestle their medtech while basically fully oriented to their surroundings.

Merrin thinks the markets are being unfair to Kalorm, who is trying very hard and is very good 

Updated-though-not-final prediction on odds of eventual neurological outcomes: 

Persistent severe damage: rounds to 0%, since currently he wouldn't even close to meet the criteria for severe brain damage.

Persistent moderate damage: 1%. It's arguable whether he was impaired enough even immediately on awakening to meet those criteria, if you were ignoring the communication difficulties that directly resulted from having a tube down his throat plus a pre-existing text-processing disability, and a degree of physical weakness (and need for strong painkillers) that is almost certainly mostly due to his physical injuries. 

Persistent mild deficits: 47%.

It's a lot lower than before. 1 in 2, not 2 in 3. It's a good sign that Kalorm's mental status improved noticeably as he went from 'still very sedated' to 'only on painkillers, albeit a lot of them.' It's a good sign that he is showing any ability to follow incentives, if intermittently. He doesn't lose as many points as a neurotypical patient would for his instances of utterly ridiculous behavior, because apparently he's just like that as a person??? He can at least sometimes execute plans that require more than one step of inference, like "figuring out what elements he would have to draw to indicate his needs, and carrying out a frustrating ten-minute process to draw it." (There is, in fact, quite a lot of surprisingly complex implicit reasoning and theory-of-mind buried in that apparently-simple case of setting a communicative goal and doing goal-oriented planning for it; it's an area involving capabilities that humans have, that dolphins and apes have, but that even most relatively intelligent animals would fail.) He retains the ability to stick to a pre-decided plan even under unexpected duress, at least if you count "deciding it's a good idea not to tell anyone that he's having a hard time breathing", but that was a step toward achieving a later goal, at least in Kalorm's mind, and he did stay mostly calm for almost nine minutes, which is...demonstrating kind of a lot of willpower and emotional regulation, actually. 

And they can check off some negatives. No seizures. No observed spasticity or abnormal reflexes, even mostly off sedation. If he has visual-field loss, it's subtle, and they haven't definitely noticed any agnosias; he recognizes Merrin and he's now interacted with various objects and not appeared confused about what they were. He has a surprising degree of retrograde amnesia about the events of the accident - a modest negative update - but, since waking, seems to be forming at least some long-term memories. His motor planning is at least intact enough to draw a picture that his brother could parse, even if only 4% of the prediction market contributors had any idea what it was (though to be fair, the PRIORS on what he meant were LOW.) 

(There are other elements they can't clearly assess yet, and so can't rule out neurological impairment. His strength, coordination, and fine motor skills are terrible – but it's not clear if that's neurological in origin or just the inevitable result of two days in a deep medically-induced coma and currently being on a ton of painkillers, on top of a bad case of rhabdomyolysis. Overall, the markets are calling 60% odds that these resolve at the rate one would expect from a mostly-physical issue.) 

But. 

He clearly has pretty severe processing difficulties. Merrin and Khemeth are having to speak at, like, half of normal speed, and he still gets confused frequently if they include multiple pieces of information or complex clauses. His verbal processing is functioning at, like, the level of a 3-year-old, which indicates either an actual receptive language deficit, severe executive dysfunction and brainfog, or pretty serious sensory processing difficulties; most likely, some combination of the latter two. They have Kalorm's baseline psychometric results to refer to - well, from eleven years ago, he refused to be tested again after that - and this is not his baseline. Indications on his visual processing ability are even further below his baseline; a healthy Kalorm should find it trivial, and certainly not overwhelming, to scan a board of fifty simple images. A really unusually bad cognitive reaction to painkillers could explain most but not all of it. However, the Diagnostic markets are at 92% that at least 75% of the deficit is just...where Kalorm's current neurological function is at. 

It's not the worst update. These are very common short-term symptoms even in the case studies of patients who recovered fully. Sensory processing deficits respond moderately well to occupational rehabilitation, and are areas where every indication is that Kalorm was functioning at a high level previously; a lot of the negative update is in just how big a drop there was, but it does also mean that Kalorm could permanently lose 2 SD in visual processing ability and this would still leave him at basically-population-average. (Not that this means he would be happy with the outcome. He would be able to tell the difference.) 

Persistent executive dysfunction...doesn't respond well to rehab programs, and can be a very hard issue to treat, but at least it's likely to improve a lot once he's more fully awake. The degree of impairment hinted at right now is relatively common in severely ill patients even when nothing is wrong with their brain, just from sedation, pain, and sheer distractingness of the ICU environment. 

The situation will almost certainly improve. In fact, in slightly more than half of worlds they expect to observe, three-months-from-now Kalorm will no longer experience subjective impairments, or exhibit any externally-obvious functional deficits; that he'll be back to normal, save probably a 0.3-0.5 SD drop in scores on a formal thinkoomph assessment, which they're unlikely to get data on given how Kalorm hasn't willingly taken a formal test since he was fourteen. Still, slightly less than half of possible futures are...varying degrees less happy than that. 

You know what? Merrin is going to focus on how the numbers are better than before and not how they are still objectively speaking pretty bad. 

And then focus on writing up a really clear simplified summary for Kalorm, with high-level bullet points and more detail to go into if it seems like he can both understand it and wants to know. 

...When Kalorm is still fast asleep at 2 am, Merrin catches herself yawning and feeling very tempted to find a desk surface to put her head down on, just for a minute. She's tired and she is, to be honest, also bored.

She does want to tough it out until morning with him, especially given how it looks like he won't be making it off the ventilator until then (if today at all). But supercooled superconductor this is going to be a LONG NIGHT. 

Merrin sighs and gets herself more caffeine. It's like her third of the night, a good indication that she should probably take more of a break after this before her next 12 hour shift. She always manages to forget how painful the 12 hour day -> 24 hours off -> 12 hour overnight blocks are. 

It would be better if no, she might be more alert and motivated right now if an emergency were happening, but it absolutely wouldn't be better. 

Kalorm spends the rest of Merrin's shift on the floor; he doesn't raise a complaint about the 5mm-thick gel mat, or the adjustable hard-foam wedge raised to a 30-degree angle.

He does not get off the ventilator on Merrin's shift. 

He doesn't push very hard for it. Or, well, he does bring it up via a by-now-easily-interpretable hopeful gesture every time he wakes up, approximately every ninety minutes. 

At which point Merrin cheerfully suggests that he try the minimum-support ventilator settings again?

Reminder that the goal is to do that for an hour and not be tired at the end. If he’s tired before an hour, then cutting off the option to get more help with breathing is likely to end in a stressful scary time, right? 

If he does start feeling really tired, she would appreciate hearing about this sooner rather than later, though she won't actually put him back to the regular settings unless one of the following: oxygen saturation below 90%, CO2 more than 10% above the 'normal' high cutoff, or respiratory rate above 20.

Unfortunately Kalorm cannot actually read numbers (according to Khemeth he usually can a little, with moderate disfluency, but he super cannot right now). She can do...three color-coded graphic charts, with lines to stay under? If that's motivationally helpful?  

Also she wants to preemptively suction him if he needs it (which he literally always does), since she would rather leave him alone while he's actively in the middle of a different challenge. 

(Merrin is honestly really in favor of Kalorm trying this! It seems good for him to notice if he's doing a little better each time, and it'll prevent his respiratory muscles from getting deconditioned by prolonged mechanical ventilation.) 

Kalorm is still not making it even close to an hour when the sun rises. He's trying very diligently, but his limiting factor is usually rising CO2 as he gets tired and his air-volume-moved-per-minute starts to drop.

The first time, he flags to Merrin after five minutes that he's feeling tired and breathing is more effortful, but he wants to keep going, and - with Merrin sitting beside him, talking to him reassuringly and explaining how to interpret his charts (which are indeed VERY motivational), he makes it to ten minutes before his metrics start dipping out of the allowed ranges, and even then he's able to respond to encouragement and coaching from Merrin. It takes nearly fifteen minutes before his exhaled CO2 levels rise and stay above the allowed range, and he is still, at this point, pretty calm and - with very deliberate concentration - keeping his respiratory rate at 18. 

At which point Merrin says "good try, that was impressive" and puts the settings back to where they were, and an exhausted Kalorm almost immediately falls asleep. This sets the pattern for the rest of her shift.