# IO (Intraosseous Access)
IO (intraosseous access)
An approach to delivering fluids or medication through bone rather than a vein.
The principle is straightforward.
Despite how it looks, bone is hollow on the inside and directly connected to the venous system.
Therefore, when IV fluid is injected into the interior of bone, the medication flows through the bone and into the veins.
Any drug suitable for intravenous use can generally be administered via IO as well — and unlike the narrow, threadlike veins, bone is large, making it an approach with a very low failure rate.
But once you've heard all that, a rather natural question arises.
— "If it's easier to access than a vein and has no drug-related side effects, why not just go through bone for everything?"
The reason is simple.
"Ugh...! Aaah—!"
"Gregor! Hold her down!"
"Aaaaaah!"
"Bear with it! You must endure!"
It hurts like absolute hell.
From the moment the needle goes in, all the way through the drug administration.
Enough to snap a mother who had been drifting on the edge of death from puerperal fever straight back into the waking world.
It was a needle going into bone, after all. Of course it was going to hurt.
"Lord Saint... are you certain this is alright?"
Gregor, pressing down on the mother's shin, looked up at me with a worried expression.
He was keeping the thrashing patient pinned down — skillfully, carefully, so she wouldn't injure herself.
"Yes. You're doing well."
Saying this, I connected the needle that had gone into the bone to the IV line.
Then I looked to Erpen.
"Lord Erpen. Would you mind continuously pumping the fluid?"
"Won't it flow in too quickly and rupture the vessel?"
"That would be the case if we were putting it into a vein. But where we're putting this fluid right now is bone."
The interior of bone is hollow, but filled with marrow.
Marrow, unlike a vein, does not flow — and it is also under considerable pressure.
Simply holding the IV bag high would not be enough to drive fluid into the bone.
That was why IO had to be pumped manually.
"How many times does it need to be repeated?"
"Prontosil must maintain a certain blood concentration for a sustained period before its antibacterial effect can be expected. Since it needs to be administered continuously, we'll need to keep it going until the patient is back on her feet."
Then, suddenly recalling Erpen's title, I corrected myself.
"You may have one of the low-rank healers do it."
"No, no. I rather like this — feels like returning to my roots."
The Director, smiling as he pumped the fluid.
A low-rank healer fussed anxiously at his side.
"It's been a long time since I felt this sense of awe in learning."
Three hundred years, I'd wager.
I swallowed the words that had risen to the tip of my tongue and turned my attention back to the patient.
The mother, still struggling in Gregor's grip.
Erpen looked down at her with concern and offered a suggestion.
"Isn't the injection causing her too much pain? It might help to administer a little anesthetic..."
"It wouldn't help."
I rejected that flatly.
The pain of an intraosseous injection is not so much from the needle going in — it's the pain of the fluid filling the inside of the bone that is far worse.
When liquid fills a space that is supposed to be empty, the bone is pressed from the inside — a slow, grinding torment that ravages the patient.
A local anesthetic does very little against that kind of pain.
General anesthesia carries the risk of respiratory depression in a sepsis patient, so it was out of the question.
In the end, this patient's pain was hers alone to endure.
"This level of pain won't kill her."
"Mmmmph...!"
"Gregor. Get her gagged."
"Understood."
"Mmmgh...!"
The Marchioness's dignity was in tatters, but it couldn't be helped.
Dignity was something you could afford to think about only when you were still alive to have it.
Several minutes of struggling with the patient later —
"The time has elapsed. The antibiotic should have spread throughout her system by now."
"Understood. I'll cast Heal immediately."
Erpen, who had been pumping the fluid, deployed his runic formula.
However —
Clink!
"It misfired. It seems I miscalculated the concentration in the bodily fluids."
Perhaps he wasn't yet accustomed to perceiving the antibiotic and germs within blood — the spell failed once.
"I'll try again. It seems that going through bone requires slightly different adjustments compared to a vein."
[Heal]
This time, a warm light seeped successfully into the mother.
'Healers really are mages, in the end. To work something like that out on the spot.'
It wasn't a feat I was capable of.
Calculating the ratio of bad energy to good energy flowing through a person's body and incorporating that into the formula on the fly — there was no way an ordinary person like me could manage such a thing.
'Determining the clinical concentration for the antibiotic will have to be left to the healers.'
My role ended here.
Develop the drug, confirm that it works — and the rest belongs to the healers.
It was also the limitation of a healer in this world who stood apart from everyone else: one who could not use divine magic.
As I sat with those thoughts, the patient's fever began to drop rapidly.
"Hah...hah..."
I brought the stethoscope to the chest of the mother breathing in ragged gasps.
Crackles from the lungs.
'Pulmonary edema.'
A complication that could readily appear in puerperal fever worsened by sepsis.
Fortunately, there happened to be someone in this room capable of addressing pulmonary edema.
"Lord Erpen."
"Speak."
"One last thing — I'd like to ask you to perform bloodletting."
"You said bloodletting was meaningless against sepsis, did you not?"
"It would be meaningless if the germs were still multiplying."
Saying this, I beckoned the elderly elf over and held out the stethoscope.
Erpen focused on the sound of the mother's breathing.
"This sound is..."
"Her lungs have filled with fluid."
The germs had disrupted the body's osmotic pressure, and the fluid from her blood had flooded her lungs.
Now, a question.
If fluid has filled the lungs, what is the fastest way to drain it?
"It is time for bloodletting."
"Correct."
To be precise, what was needed was emergency dialysis, not bloodletting.
To explain in greater detail: for pulmonary edema accompanying sepsis, a diuretic is the first line of treatment.
You drain the fluid through urine.
And if the diuretic isn't doing its job adequately, you move on to emergency dialysis.
But since there was no diuretic here, I would leave it to our high-performance bloodletting machine — Erpen.
"So whenever dyspnea is observed in a sepsis patient, I should perform bloodletting?"
"Mm... I'll explain the details later."
"Understood!"
Erpen, positively delighted, immediately set about preparing to bleed the mother.
I watched him draw a precise incision along the inner thigh with practiced ease, and felt a quiet admiration stir within me.
'Oh — the femoral vein? He really is a genuine authority on bloodletting, I'll give him that.'
There is an order of priority for the veins used in bloodletting — or rather, dialysis.
First priority: the jugular vein.
Second priority: the femoral vein.
In this patient's case, her veins were barely visible, so he was going with the femoral vein, which had a comparatively lower failure rate.
After that, Erpen inserted a tube into the vein, cast Heal, and began exchanging the old blood for new.
The elf healer watched the blood filling the bucket with gleaming eyes.
"I've found a new bloodletting method. Thank you, Lord Saint."
"..."
Why on earth was he so obsessed with bloodletting, of all things.
I wanted to ask, but held back.
I had no desire to hear the sprawling, epic saga of bloodletting stretching three hundred years into the past and all the way to the present.
And so I left the patient in Erpen's hands — when a healer drew close and murmured something in my ear.
Whisper, whisper.
The moment I heard it, I turned my back on the ward.
Gregor followed as I walked out.
"Lord Saint, where are you heading in such a hurry?"
"To the Lafavre Sect Infirmary."
"What brings you there...?"
"Word just came regarding the Lafavre Sect's disposal."
"Their...disposal, you say?"
"Yes."
A few days prior.
The very day after the Lafavre Sect announced they would not support germ theory, I had begun deliberating on what to do with them.
However precious their own survival was to them, their rejection of germ theory was no different from evading responsibility.
And so, while I was weighing their fate —
"Today's events confirmed it for me. At the very least, those people were doing their utmost within their own domain."
The moment they judged the patient was beyond their ability to save, they sent her here without hesitation. That told me everything I needed to know.
That they, at minimum, deserved a chance.
"I've finished speaking with the Board of Inspection. The Lafavre Sect will not be held accountable for any of their past mistakes."
"The...Board of Inspection?"
Gregor stared at me with wide eyes.
A pardon from the Board of Inspection was no different from an Imperial Pardon.
To ignore it and pursue punishment would be tantamount to disregarding the authority of the Imperial Court itself.
For an institution of that weight to grant the Lafavre Sect a pardon — his surprise was only natural.
"Might I ask what reason secured the pardon?"
"Ah, well..."
A dry laugh escaped from beneath the crow mask.
"It's a long story. I'll explain on the way, inside the car."
*
Several days after Prontosil had begun to be used in earnest at the Adamberta Infirmary —
The Lafavre Sect abruptly reversed their stance on germ theory.
— [This Sect also affirms its full support of germ theory, and hereby announces that, effective immediately, all midwives shall be employed as Honorary Healers of the Lafavre Sect.]
The primary reason for their sudden change in stance was the pardon from the Board of Inspection.
[This Board hereby declares, effective immediately, that imperial law shall not hold the Lafavre Sect accountable for any 'mistakes' they have committed to date, and shall permit no disadvantage of any kind to be directed against them in relation to these matters.]
The Board of Inspection's sudden endorsement of the Lafavre Sect.
Behind that endorsement lay three key factors.
And in the visiting room of the Imperial Eschenwald Academy —
Director Schun's holy knight, Gregor, sat across from a woman, and the two were discussing exactly that.
"What are those three things, Older Brother?"
"The first is Viagra."
Viagra.
The last refuge for the men of this age who had lost their virility — through spinal injury, drug addiction, heavy metal poisoning, the side effects of magical experimentation, the passage of time, and more besides.
Since this miraculous drug had appeared, it was no exaggeration to say that the Empire's childbearing age range had expanded dramatically.
"I hear even the head of Count Horn's family — the one who apparently took a concubine late in life — recently had a child."
"...Isn't he in his 50s?"
"I could hardly believe it when I heard it myself."
Gregor chuckled, his beard twitching with an expression of sheer disbelief.
"It's hardly limited to the count's family either. You hear this sort of news among couples of different races fairly often these days. So the number of children being born is growing by the day."
"The Lafavre Sect must be swamped."
"Indeed."
Three years since Viagra had come into the world.
Over that period, the number of births had risen by nearly twenty percent, by our estimates.
"And here, the second factor — the vaccine demands attention."
The vaccine.
The thing that guarded against the plague that had claimed the most children's lives in this world.
"Since the vaccine, child mortality has been dropping at an exponential rate."
It had begun with the smallpox vaccine — the pustule disease — but recently, other vaccines had begun to appear as well.
Only three kinds existed yet.
Even so, the number of children who had grown safely into adulthood had nearly doubled.
When you included the children spared from disability, the figure grew larger still.
"More children are being born, and unlike before, the chance of children contracting serious illness has also diminished. On top of that, Lord Saint recently created..."
Gregor trailed off and glanced around.
He looked about the room, then leaned in and spoke in a low voice just barely audible to the woman across from him.
"Don't breathe a word of this to anyone. Lord Saint has recently developed a medicine that kills germs. It will be made public in a few months, so until then — not a soul."
"Understood. But what does that have to do with the Lafavre Sect?"
"That medicine is the cure for postpartum fever."
"...Pardon?"
The woman murmured blankly.
"A cure...for postpartum fever?"
Postpartum fever.
The leading cause of death among women of this era.
And the most common reason so many children were left without their mothers.
Even the most accomplished high-rank healers had been unable to do anything about it.
And there was now a cure for that?
"Then if it had come just a little sooner...our mother might have..."
"..."
The two fell silent for a moment, heads lowered.
The woman broke that silence, making a deliberate effort to brighten the mood with a small joke.
"If there truly is a cure for postpartum fever now, the Beastkin population is going to surge enormously."
"I'd imagine so. The Beastkin in particular might double, I'd think."
She nodded at Gregor's words.
"I understand what you've said, Older Brother. But why does any of this relate to the Lafavre Sect's pardon?"
"Both the Church and the Empire are projecting that birth rates will increase by one and a half times — perhaps even double — going forward. And if the Lafavre Sect properly assists with deliveries, the population will grow explosively from here."
"So that is why the pardon was granted."
"Exactly."
Population is national power.
Overpopulation is not desirable, of course.
But for a humanity that could face annihilation at the hands of demonic beasts at any moment, more people is simply better, for now.
"That is also the reason for hiring midwives in large numbers."
Delivering babies doesn't particularly require a healer.
So the system they've devised is this: midwives handle the delivery, and healers manage whatever complications arise afterward.
"Then now that even the Lafavre Sect has acknowledged the existence of germs..."
"All that remains is the Mencia Sect."
The woman nodded.
"I thought as much. Lately, even my friends in the Department of Healing have been saying the Mencia Sect's days are numbered. So that was the reason."
"Yes."
"Thank you, Older Brother."
The woman rose from her seat.
"This helps me decide which sect to join."
"Good — glad to have been of help. But I have one question..."
"What is it?"
"Aren't you a first year in the Department of Healing right now?"
"I'll be a second year in a few months."
"Even so, you still have two years until graduation. And then you'll need at least four more years of training in the Academy Infirmary that Lord Saint is building for healers — so isn't that six years away?"
The woman looked at Gregor with an expression of mild exasperation.
"You're supposed to decide on your sect early and start building connections while you're still a student."
"Well, if you put it that way..."
Gregor conceded, albeit looking somewhat unconvinced.
Then, remembering something, he added a note of warning.
"Right — your father mentioned it as well, but you know the Academy Infirmary is opening next year, don't you?"
"I'm well aware, Older Brother."
"The Black Saint will be there, so you absolutely cannot issue a written challenge to him the way you've done to other healers. Understood?"
"I know."
"And not to the Saintess of the Lamp either!"
"I said I know."
The black-haired woman let Gregor's warnings go in one ear and out the other.
"What I'd rather is that you don't go stripping in the infirmary, Older Brother."
"What do you mean by that?"
Gregor flexed his forearms in his chair, striking an emphatic pose.
"A healthy mind dwells in a healthy body. Is it not the finest treatment I can offer the ailing — to show them this healthy physique and inspire within them a longing for muscle?"
"Goodness... Father told me you'd improved..."
The woman pressed her hands to her head.
As the woman prepared to leave the visiting room after their visit —
Gregor called out to her — to Jenny Raylick.
"Right. Jenny. There's something Father wanted to tell you."
"What is it, Older Brother?"
"He says to keep your gambling to a reasonable level."
Flinch.
"Just to ask — you're not gambling away your allowance and working as an infirmary assistant to make ends meet, are you?"
"I haven't been gambling...lately..."
"Horse racing?"
"..."
Jenny went silent.
Gregor's gaze sharpened.
"Have you been borrowing money from a friend...?"
"Ju-just a little from my r-roommate..."
"How much did you borrow?"
She held up three fingers.
"3 Copper?"
Shake, shake.
"3 Silver?"
Shake, shake.
"Don't tell me...3 Gold?"
Nnn...nod.
"..."
"..."
"...Please tell Father I said hello."
"I'm telling him exactly as it happened."
"No, you can't!"
Jenny grabbed onto Gregor's clerical robes and clung to him.
Gregor shook her off and cried out.
"Let go! Visiting hours are over! I have to get back to the capital!"
"I won't let go! At least don't tell him I borrowed from Charlotte!"
"Fine, fine!"
"And don't tell him I've been working as a divine power mule at the infirmary!"
"That I have to tell him. He sent you there to study and you're out here earning money to gamble."
"Nooo! It's practical training! It counts as practical training!"
"Enough of your nonsense!"
It was a full hour later when Gregor finally made it out of the visiting room.