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Apply Here: Discord: https://discord.gg/vPqyu9dPJ7
(WHITELIST APPLICATION TAKES LESS THAN 3 MINUTES)
**SEASON 9 - OPEN FOR ONE MONTH SO FAR.
**
ABOUT US
TotallyNotSuspicious is an established SMP community created in 2018 centered around semi-vanilla gameplay. Our main priority is fostering interaction and creativity within the community. We build together on the server, host Discord game nights, chat, and more. We have server members from around the globe; we maintain open arms for anyone wishing to join an active and friendly community.
Find out more about us below!
FEATURES
We have datapacks that maintain the vanilla feel of the game. Most of the datapacks utilized are used by Hermitcraft. On the other hand, our custom datapacks are intended to enhance and protect the multiplayer experience.

• Guilds (NOT FACTIONS, just a way for friends to group together and work on community projects and live together!)
  
• Non-plugin functioning economy Custom made minigames, inbetween season events, and mini-seasons!
  
• Custom Staff & Player Events
  
• Server Performance Optimization
  
• Version: 1.19.3
  

Previous Season Images: [https://imgur.com/gallery/0PEiH5n
](https://imgur.com/gallery/0PEiH5n)
NOTE: Staff are not permitted creative mode or any command that can provide them with an advantage while playing survival. Staff are restricted and remain on the same level of any other player.
COMMUNICATION
Our community uses Discord for communication. Announcements and information are sent out regarding server events & changes. Joining the Discord is required in order to be whitelisted on the server. Applying is simple and easy. The application process is completed within the Discord Server.

• Do not steal. Taking anything of anyone else’s without their consent is considered stealing; has zero tolerance.
  
• Do not grief in any way. Ruining any sort of building without the other player’s consent is considered griefing.
  
• Do not hack or duplicate items in any way. Any sort of hacking client, hacking texture packs, and duplication methods are considered a violation.
  
• Do not advertise other servers, other Discord Servers, or post invites.
  

Apply Here: Discord: https://discord.gg/vPqyu9dPJ7
(WHITELIST APPLICATION TAKES LESS THAN 3 MINUTES)
**SEASON 9 - OPEN FOR ONE MONTH SO FAR.
**
ABOUT US
TotallyNotSuspicious is an established SMP community created in 2018 centered around semi-vanilla gameplay. Our main priority is fostering interaction and creativity within the community. We build together on the server, host Discord game nights, chat, and more. We have server members from around the globe; we maintain open arms for anyone wishing to join an active and friendly community.
Find out more about us below!
FEATURES
We have datapacks that maintain the vanilla feel of the game. Most of the datapacks utilized are used by Hermitcraft. On the other hand, our custom datapacks are intended to enhance and protect the multiplayer experience.

• Guilds (NOT FACTIONS, just a way for friends to group together and work on community projects and live together!)
  
• Non-plugin functioning economy Custom made minigames, inbetween season events, and mini-seasons!
  
• Custom Staff & Player Events
  
• Server Performance Optimization
  
• Version: 1.19.3
  

Previous Season Images: [https://imgur.com/gallery/0PEiH5n
](https://imgur.com/gallery/0PEiH5n)
NOTE: Staff are not permitted creative mode or any command that can provide them with an advantage while playing survival. Staff are restricted and remain on the same level of any other player.
COMMUNICATION
Our community uses Discord for communication. Announcements and information are sent out regarding server events & changes. Joining the Discord is required in order to be whitelisted on the server. Applying is simple and easy. The application process is completed within the Discord Server.

• Do not steal. Taking anything of anyone else’s without their consent is considered stealing; has zero tolerance.
  
• Do not grief in any way. Ruining any sort of building without the other player’s consent is considered griefing.
  
• Do not hack or duplicate items in any way. Any sort of hacking client, hacking texture packs, and duplication methods are considered a violation.
  
• Do not advertise other servers, other Discord Servers, or post invites.
  

Shadow-Verse
The moans of the zombies seem to draw Blaze into sleep as he looks at Larissa.
A voice in the darkness speaks to him... "It's time." It says.
Suddenly he is falling and images of colorful world's and places flash in the darkness, some clearly, others blurred or missing pieces...
A different feeling envelopes him and everything goes black again...
Then there's light and noise as his memory plays out in the dreamscape.

 Non Hostile Invasion ... ... Heavy footsteps pound the dirt.... "Run... Keep going!" 

Dark energy rips through the air and punches through dead trees.
A female voice answers. "I can't!"
Several blasts rock the petrified forest as a steady drone of demons grows louder and louder by they second.
A younger male voice yells. "They are geTTING CLOSER!"
"WE CAN MAKE IT, DON'T GIVE UP!"
A large flaming demon rumbles by overhead and impacts the ground.
"IT'S GONNA BE OK! JUST DON'T!......"
....
....
Earlier that Day...
A week after Velzix is defeated by Shadow things in Hell are almost back to the usual. Mihrab smiles at her King as he kisses her cheek and laughs.
Velzix walks in at the same time. "Is that happy laughter I hear? My king I am disappointed." He says.
Shadow looks at him. "You wanna fighta bout it? Loser has to shut up and not complain anymore." Says Shadow.
Velzix declines as he continues with his report then leaves.
Looking at Mihrab, Shadow says. "Lets go for a walk around the lost zone of Purgatory."
She hugs him. "Its been awhile since we have been there." She says.
Mihrab nods. They both grab their weapons and head out into the woods.
After walking for about an hour they reach the edge of the area where souls are sent when they become corrupted enough to become a demon or monster.
One of the many unknown changes due to Shadow neglecting his duty long ago and not creating new demons on top of other things, eventually losing the full control of the ability as the new system was put in place by God's angels and was acceptable as an alternative. The energy to create being directed more to the Lost planes.
Tho Shadow did recently create a cute little fun loving demon fox named Spark and Mihrab Created the equally adorable and fun loving Ember.
As they walk through the Lost Zone Shadow sees many young demons aimlessly wandering around and some fight as they walk past.
Shadow looks over at a wolf like demon that's smaller than most of the others and stops in his tracks.
"MELIODAR!" He says excitedly.
Meliodar turns to him and sees him but doesn't move.
"Meli-dar!" Mihrab Shouts.
He looks around, then smiles and runs towards them.
Shadow looks at Him. "Where have you been son?" He asks Meliodar.
He looks around and notices the other demons staring at him.
"What is it?" Meliodar asks them and they all look away.
Shadow rejoices over finding their son Meliodar and the demons move away.
Meliodar looks up at his father. "I've been here the whole time. I thought you guys didn't want me anymore so I stayed out here." He says.
Shadow is shocked at his words and looks around again to see the rest of the demons still looking in another direction.
"Why would you think that?" He asks him. "We love you and we missed you."
His son who was conceived on Earth with Mihrab looks up. "Velzix told me, you hated me and that you said to stay out here alone." He says crying.
"He lied! We never wanted to get rid of you. We sent every demon we could to find you. Velzix had this part of Hell to search! That ingrate." He says.
Shadow and Mihrab hug their son tightly. "You're home now." Shadow says to him.
He looks up at his parents and asks. "Is that true? Did you send everyone to look for me?"
Shadow smiles. "Yes, we did. But we couldn't find you." He answers.
Meliodar looks at his mother and asks "Did you try to find me?"
She smiles at him. "We did. I'm so happy we found you!" She says kissing his forehead.
He looks back at his dad. "But why did you hate me? Why did you say to leave?"
Shadow looks around. "I never said that. Velzix lied to you son, we never hated you..." He pauses. He looks down and says to himself. "Velzix will pay for this." ....
....
On the way back to the castle Shadow, Mihrab and their son play chasing each other through the petrified trees.
It takes Shadow a second to realize that Meliodar's behavior has changed and he is more tame and playful when he had not been before.
Shadow smiles and wonders what to do next as he thinks about Heaven and Earth...
Shadow looks at Mihrab. "Lets go try and live in Heaven... But lets do it without violence and see how it goes. Earth didn't go well last time. Maybe our luck will change in Heaven" He says.
Mihrab hugs her husband and kisses him on the cheek. "That sounds strange but lets try it." They both laugh.
The three of them are almost to their kingdom and are met with the sight of Velzix and his followers attacking the castle.
Shadow stops motioning for his family to go back the way they came as a demon turns and sees them.
Shadow charges forward cutting it in half and the demon's body falls to the ground as several more rush at him!
He continues fighting until he is completely surrounded. Meliodar swiftly appears and rips through them making a path to escape as the three of them run....
10 million of Velzix's supporters roar in the distance as hundreds follow closely on their heels. ....
The three of them arrive at the Leviathan pit and have no choice but to travel through it as more demons appear coming from all three sides.
Mihrab looks around for the other enter-dimensional barrier leading out the other side as the pursuing demons hesitate to enter the pit.
She locates the exit. "There! We can go through here!" She shouts.
Shadow runs towards it as he grabs Meliodar and leaps to the side avoiding a Leviathan as it slams into the dirt, the void in its mouth violently sucking in material as it turns toward them.
Shadow and Meliodar are about to be eaten when the Leviathan Lilly bursts from underground sending the other Leviathan flying as she fires a powerful beam of energy.
Looking down at Shadow, Mihrab and their son Meliodar. " You had best keep your promise to me Mihrab." Lilly says and then leaves as they exit the pit.
Looking around they don't see any demons but continue to run as their war cry gets louder and louder.
Then a group of demons appears to the left and begins firing energy beams and blasts at them as they push harder to reach the portal room within sight on the horizon a dead straight path through Hell itself. ...
Shadow's heavy footsteps pound the dirt.... "Run... Keep going!" He yells.
Dark energy rips through the air and punches through dead trees.
Mihrab stumbles in front of him. "I can't!"
Several blasts rock the petrified forest as the steady drone of demons grows louder and louder by the second.
Looking back Meliodar fires a blast."They are getting closer!"
Shadows helps Mihrab up. "WE CAN MAKE IT, DON'T GIVE UP!" He shouts above the masses.
A large flaming demon rumbles by overhead and impacts the ground.
"IT'S GONNA BE OK! JUST DON'T!......"
The massive shockwave of its impact decimates the area knocking Shadow and his family off their feet....
Shadows shakes his head. "What happened!?" He asks out loud confused as he scans the area in disbelief.
He sees a strange being standing on the horizon. It is tall, covered in black armor and has a long spear that it points at him.
Looking more intently he notices the crest from King Arthur. One of his black knights having been cast down into Hell where he turned into a demon and should be imprisoned due to his power and selling his soul.
"Guess he is a demon now." Shadow thinks as he looks nervously at the gateway to the portal room then back at the knight as it charges it's spear with energy.
The knight fires and Shadow throws himself to the side as the attack hurtles towards him blasting away the already broken and splintered dead trees as it rips up the ground.
Seeing the power of the blast Shadow and his family brace themselves as it passes with the force of an explosion and impacts nearby creating a massive mushroom cloud that rises miles into the sky and the shockwave batters the area.
Shadow looks up in horror at the crater and realizes the ground is still shaking from the impact of the attack.
He turns and sees a small figure running toward him, as he watches he is filled with relief. "Meliodar!" He cries as he sprints towards him pointing at a high ridge line that the Knight can't see behind.
Mihrab appears beside Shadow holding an injured arm as another blast hits on the far side of the ridge.
Tho the shockwave is lessened by the landmass it hits them hard. They brace themselves as Splinters of wood and crushed rock scream by and then are sucked back up into the rising cloud of the explosion.
The sound of millions of demons shakes the ground as Shadow pushes debris off himself and Meliodar. Mihrab crawls from under the shattered trunks of dead trees groaning in pain.
Shadow moves to help her up and puts out his hand as the demons come into view.
Meliodar raises his head as a glob of dark energy forms in front of his mouth.
Launching his attack a rapid fire stream of dense energy spikes streaks towards the masses of incoming demons taking out 100's as the horde moves like a wave engulfing everything.
Every demon fighting to be the first ones to kill the royal family.
Shadow looks at the demons as Mihrab and Meliodar take off towards the portal room.
"Its a good thing they don't actually work very well together and are not organized." He thinks following close beside his Family.
The Black Knight appears above, massive raven-like wings protrude from his back and a rain of laser like beams fall as he attacks.
Shadow grabs Mihrab and Meliodar as he makes a barrier with his dark energy. The beams hit exploding violently and Shadow's barrier fails from the onslaught... The attack stops suddenly and Shadow stumbles shaking his head as his body screams in agony.
Grabbing his arm Mihrab pulls him into a sprint for the portal room as their son runs along side them deflecting blasts and projectiles with his cloak of dark energy.
Reaching the doorway they dive inside as the knight strikes once more, the blast destroying the portal structure as they vanish through it closing the portal. ...
Sitting inside the portal room Shadow and his family lay sore and exhausted.
Looking at the dark portal arc Shadow knows it will be a few days before it is fixed giving them time to rest.
With his body aching he crawls over to Mihrab and Meliodar wrapping them in his arms.
Looking at her as he brushes her cheek. "Are you ok?" He asks worried.
"I'm fine but I think we should wait until we heal until traveling again." She replies as they all pass into sleep...
...
...
Shadow is the first to wake the next morning. Looking around he sees the portal that leads to the gates of Heaven.
Mihrab and Meliodar sleep a few more hours as Shadow thinks about the plan...
....
..
After waking up fully Shadow, Mihrab and their son Meliodar move through the portal leading to Heaven.
A portal only Lucifer and the angels are permitted to use.
They land on a grassy field surrounded by the most beautiful white buildings and walk to the nearest one.
Shadow looks around and sees the building is a church. He scans the area finding no sign of anyone as they are all inside giving praise for the day.
Shadow covers his ears hearing them all and even dulling his own sense of hearing has no effect on how it stings his mind.
Tho Meliodar and Mihrab seem fine.
Suddenly the pain stops and Shadow feels a presence he knows from meeting only once when he was created and assigned a place.
He starts to turn to look.... A powerful voice calmly tells him. " Do not look upon me yet for thee shall surly perish....." It says and Shadow freezes obeying.
There is a noticeable shift in energies and then the voice says. "You may now turn around safely and state your business here. It better be good for it is unspeakable for a demon to enter this place uninvited." The voice says calmly.
"My name is Shadow. This is my wife Mihrab. We have come to speak with you God." He says and there is a slight pause. "We seek to live in Heaven by just asking you without violence so we can finally live in peace where our Love isn't hated."
God chuckles amused. "You know what? Why don't you go ahead and do that and see if I am willing to let you have it after doing that?"
Shadow looks at God. "Will you surrender peacefully to us and give us life in Heaven?" He asks God.
God laughs. "What kind of question is that? Of course I'll surrender to you!" He yells happily.
Shadow looks at him in confusion. "But why would you?"
"The reason is because you are a Demon. Demons are evil creatures that hate all life." God laughs. "I have been watching you for some time Shadow Seed. I find this turn of events amusing and you haven't heard my terms yet.... Somehow you seek to have it and try non violence. As well as claiming to Love another demon. I will say I am surprised by things you do but they are also not unexpected. For me to give you Heaven. You first have to be one of my protectors of the universes. All three of you will become half human half demon beings. You will keep your powers but you will lose a significant amount of it to hide you from demons as you go about this Path to Redemption." He pauses...
"You will also be given a secondary energy as well that will be weak in you but as you learn to us it, it's power will grow as well... You will also not die of old age, hunger or human illness, only sever damage can kill you and if you do die you will be reborn or remade at your choosing. You three will become Eturnals and in time you will fight to protect the humans you have conquered on numerous occasions..... I will call upon you later to Protect my human creations from the demons of Hell and other evil in the universe. And be warned that the demons of Hell are looking for you, stay hidden and work in secret avoiding the demons till you are strong enough to rival them." He says.
Shadow is speechless. He looks at his wife who is smiling at him.
He looks back at God and sees him laughing. "So what's the verdict? Do you accept my terms of surrender?"
Shadow genuinely smiles as he says."Yes I do and I surrender as well!"
Mihrab chimes in. "I accept this as well!"
Meliodar looks at his father Shadow who nods. Turning back to God Meliodar also agrees happily.
"Good, now one more thing, here is a sword that can kill anything. It is called an Eturnal Blade and I custom make each one." He says handing a blade to each of them.
"Thank you." They say together.
God then says. "One more thing being reborn you have a very high chance of... Forgetting past lives and who you really are due to the new brain that is different. Tho it will grow used to your soul and spirit bringing the memories back as they sync over time. The same is true for being made at an adult age, tho the memories come back significantly faster than when you are born."
He then raises his hand and transforms the three of them as he said he would. "Do you want to be born or to be created at the age of 35 and 20 for Meliodar?" He asks them.
They all agree to be born and Meliodar with spend time in a lower form of Heaven to learn a few things till his parents mature and bring him into the world.
"Very good! Now this is going to be very different to you... I almost forgot... Don't listen to the darkness within and if you hear it, refuse anything it offers you. This is unknown territory so heed my warning." God says and then there is a bright flash and everything goes dark for three of them.
God turns to the many angels watching. "Lets see if they can do it. If they can, who knows maybe there could be others as well." He says to them as some seem unsure.
....
....
Blaze wakes feeling as if he is full of energy and looks over at Larissa who is looking at him smiling. "I know that look. It's about time you remembered something.
Blaze nods. "We were king and queen of hell and even had a true son. Then we're made part human." He says.
Larissa flinches as suddenly the room is filled with light.

Title: Riding Without Protection: The Dangers of Motorcycle Accidents
Hey Reddit community, as an attorney at Pacific Injury Law Firm in Portland, Oregon, I wanted to share some alarming statistics with you regarding motorcycle accidents. According to the National Highway Traffic Safety Administration (NHTSA), over 5,000 motorcyclists were killed in crashes in 2020 alone. This is a major public health concern that affects thousands of individuals and families each year.
One major factor contributing to these accidents is the lack of protective barriers between riders and the road. Motorcycles simply do not have enclosing structures, seat belts, or airbags like cars and trucks do. This leaves riders more vulnerable to injuries when involved in a crash.
Head injuries are one of the most common types of injuries suffered by motorcyclists. In 2020, over 1,500 motorcyclists were killed in crashes involving a head injury—accounting for almost 60% of all motorcycle fatalities. Other common injuries include road rash (abrasions from contact with pavement), back and spinal cord injuries—over 1,000 fatalities were recorded last year due to these injuries.
Alcohol and drug use also play a significant role in motorcycle accident rates; NHTSA data shows that 28% of motorcyclists killed in crashes had blood alcohol concentrations above the legal limit.
To address this issue effectively, helmets are considered one of the most effective interventions available. In fact, helmets saved over 800 lives in 2020 alone! Furthermore, they reduce head injury risk by up to an astonishing 37%.
Increasing public awareness about motorcycle riding risks is another important step towards reducing accident rates; educating people on helmet use and other protective gear while dispelling misinformation on alcohol/drug use while riding can lead us towards safer roads for everyone!
If you're interested in learning more about this topic or need assistance after being involved in a motorcycle accident, you can reach us at (971) 277-3811 or visit our website: https://pacificinjurylawfirm.com
Feel free to read our blog post on this topic here: https://pacificinjurylawfirm.com/blog/riding-without-protection-the-dangers-of-motorcycle-accidents
Stay safe out there. #PacificInjuryLawFirm

I moved to this city almost a year ago and it's got to be the most toxic place in the whole damn country. The culture is just so awful- if you're ugly enough in somebody's eyes, they will either stop in their tracks and make a scene out of you, pull out their phone, start recording and stick it as close to you as possible, or simply insult you out loud as if they expect people to chime in. And sometimes people do! What the fuck??? I've never had to go through this before coming here in my entire life. I'd never even heard of it.
I get stared at almost anywhere I go. I can't order at a fast-food restaurant without customers already inside looking at me in disgust. Some even leave while looking at me to make sure I know I'm the reason why. If I line up behind someone, they always look back at me as if I'm about to do something. And if I'm waiting for my order, anyone waiting before me would often become super protective of their order and rush to get it when theirs got called. It's so stupid.
Supermarkets are the same- I almost always feel eyes on me when I walk through the door, and when I look to see who it is, the security guard is almost always included, and I say included because they are never the only one. I remember once I asked one where to get a basket and they looked like they were holding in their anger when they responded to me. I don't wear anything offensive, except maybe the colour green? I genuinely don't understand to this day how these people get so mad over the presence of someone they don't even know, because this is a recurring thing throughout the entire city.
I've had run ins with stores I planned to visit keep them locked up if I showed up before their opening time- This was absolutely baffling to me because this is so blatantly discriminatory and punishable, but they do it anyway! I've also been refused service, which is just completely unheard of to me outside of Japan, and many places I've been to openly express their reluctance to have me as a customer. This isn't just me reading into it, even- you could evidently see the change of their expression on their face when I become the next in line, ranging from serious with dead silence or outright hostile with a fucking cough!
Speaking of coughs, this drives me fucking nuts! I don't know the specific criteria for this anymore, but I've subject to so much violent coughing whenever I go anywhere, it's fucking insane to me that people do not react to it at all. I guess they're used to it? How could you be so okay with something so plainly aggressive? They do this until I either leave, look away, or just don't react at all because I'm too fucking tired to bother because of all the other shit these people put me through. Why the fuck is this normal here???
I can't sit on a bus without people watching me, and if I sit somewhere I'm not really visible, people will move to get a better view of me, or to record because apparently the sight of me is that much of a novelty. With that said, people even slow me to gawk at me on the road if I happen to be walking on the sidewalk, many of which are recording for some god damn reason even though I'm not doing anything. Speaking of cars, a lot of the time when I walk past one, I'll hear its lock go off to let me know they think I'm planning to steal it. Some people even go so far as to play their fucking panic buttons, as if it's fucking necessary when I'm not even on the same side of it in some cases. There's even an undercover cop in the neighbourhood that briefly sounds their siren when I walk by theirs, just for the fucking fun of it I guess. It's fucking ridiculous.
People have even made attempts to make turns into me while I'm walking across the street, it's so fucking dumb because they obviously want to make it look accidental, and when they mess up they either just stop right after or just laugh because they get a kick out of letting someone know they want them dead. And the people around me either don't care or laugh with them- it's clearly part of their fucking culture to terrorize people here and it's so despicable.
And I can't even forget the most important part, where these people literally have my schedule down and wait for me to turn up so they can either laugh- I don't even understand what for- and record it too- who the fuck is this even for??? I've been called ugly in the past and even bullied for it, but going through the trouble of following me everywhere I go to make a mockery of me or just insult me with that stupid coughing shit everybody fucking loves doing here, this is a fucking first. I literally just can't deal with this fucking place and I just hate it so much, but I'm bound to my lease and I can't leave without monetary fines I can't afford, but my entire reputation is ruined because of whatever it is these shitheads do with all this recording they fucking do and I cannot fathom how that even resulted in people expressing pure, unbridled hatred towards my presence anywhere in this fucking place and I'm just so done. If I ever forget to lock my door and I take a shower, I will come back out from it to find my door left ajar because they're apparently always watching. They even messed with it once in a way that stopped me from locking it properly, that it broke my key and I had to leave it unlocked to get a new copy, which they took as an opportunity to attempt to break into my fucking laptop.
Speaking of which, they also did while my apartment building had plumbers come in and go for lunch though the plumbers themselves also put me through even more shit. We needed to clear out our closets so they could still out a crawlspace, but since my unit doesn't have another one I had to leave my clothes across my dining table. These fuckers apparently took it as a queue to steal my fucking food, damage some of my property, leave shit all over my floors and my walls and even have the nerve to leave my fucking curtains open every time they come in as if they're just fucking forgetting. I remember once, they asked the landlord for more time in December, but it was fucking -30 and I wasn't staying outside so I went back to my place like usual and found they were leaving their dirty ass gear all over my fucking stuff. Is this a regular thing with plumbers? Their company is rated 4.7 out of 5- this is the best this city has to offer???
I can go on and on with all the dogshit that goes on in this place but I've so tired of being mad about how much these asshats have ruined my damn life and I'm just so furious because I'm pretty sure that aside from lucking out getting an apartment over 2 other candidates who submitted applications, it's because of my skin colour- I've tried changing outfits, my hairstyle, even tried different deodorants and I still get the same shit from these people every day. I'm so fucking done with this place and I hate how I can't get it off of my mind and how I probably never well since I have a sneaking suspicion theyre going to follow me wherever I go in this country and the police are just not going to do anything to help me, since I've already tried to get to help of this city's, only to be treated like a schizophrenic when they of all people should know about discrimination being a regular thing in this goddamn place. Fuck.
Everyone who hears of this just dismisses me, and I get how unbelievable it probably sounds, so just in theory, if it was all true, am I right in saying this place is just goddamn hell and I need to get out? I can't stand knowing I'd need to wait another 2 months and it feels like almost literally everyone is against me and no one even tells me why, they just want to keep laughing at me. Have I just been lucky my whole life and haven't known that this has always been normal? Because it's so fucking stupid

Previous First Next
Even almost a week later, Yegel was still soaring on the hope from that day. A weight on his eyes that he'd never even noticed had been lifted, leaving him more alert and awake, the whole world more vibrant and colorful.
Of course, the morning after had brought clarity- and an additional helping of stress. Having had the time to calm down and examine it, he was realizing that the fact he now saw humans as people was dangerous- especially with such an important and dangerous screening coming up. If he accidentally sympathized too much in one place, or had a reaction that he would never have had before...
...He still couldn't bring himself to regret it though. Even the fading of his emotional high hadn't erased what felt like an important revelation- that he no longer thought of humans as predators with interesting quirks, but as real, actual people, with true empathy and sapience. They were still predators, still alien in ways he couldn't understand- but now, that didn't feel like the same kind of impenetrable barrier that it used to be.
Still, now he had to be even more careful going forward- regardless of it being the truth, nobody else would believe him about a predator species being fully sapient and civilized. If anything, trying to convince anyone would get him institutionalized- and he was already fighting far too hard to keep himself out of those nightmare-makers for as long as he could manage. At least with humanity being extinct, the topic was unlikely to come up, but he hadn't made it this far in life without preparing for even the unlikely.
Caution was still warranted though, and so he'd been spending his time preparing and watching the manifests for incoming ships- so when he saw a group of scowling figures approaching him from behind at lunchtime, it was less of a shock and more the realization of inevitability.
Exterminators. Just what he needed to deal with today.
Sighing quietly, he fought down the rising panic and instinctive urge to run, and instead pretended not to notice the approaching officers- running never did any good, and trying to fight back or protest would lead to... retaliation.
Their timing was just the worst though- he'd been looking forward to having lunch with his friends, and taking a chance to decompress and relax. He'd been meticulous so far this week at maintaining his stress- other than his newfound indulgence in forbidden predator media- so it wasn't like he was scrambling to calm down. However, he really could use every bit of patience and composure he could get.
The grasping hands roughly pulling him out of the lunch-line, however, clearly didn't care about that, immediately starting to goosestep him through the cafeteria, regardless of the whispers and stares now coming their way.
"Lieutenant Yegel," a vaguely-familiar voice barked harshly as he was shoved forward, "your presence is required immediately. You are coming with us."
A bit late to give him a warning, wasn't it? Especially since he wasn't resisting in the first place. It was just theater to them- reciting something because they were supposed to, despite the outcome having already been determined. It was better to just not antagonize them-
"You know," he couldn't stop himself from saying, "If you wanted a date, you could have just a-"
A massive fist slammed into him, burying itself beneath his ribcage. The words died in his throat as all his air was forcefully expelled, his talons leaving the ground as he bent double over the grey three-toed paw.
"Quiet, predator," the Takkan ground out, slowly removing his forelimb from where it had been buried in Yegel's gut. "you'll only talk if our boss deigns to let filth like you waste our air, got it?"
Wheezing in reply, Yegel fought to try and recover the air that had been forcefully driven out of him, the exterminators yanking him by his wings and dragging him onwards. Perhaps it was good that he hadn't eaten yet- nothing there to have upchucked other than the vile spittle now burning at his tongue.
Guess he must be a new transfer, Yegel thought offhandedly, glancing up to see them approaching a familiar eating area. That would be a useful distraction from the main threat. Fighting down the pain through bitter familiarity, Yegel did his best to relax his feathers and his mind- he'd need all of it for this next mental sparring match.
Ornate doors covered in intricate patterns were thoughtlessly slammed open as the Exterminators dragged him into the private eating area, the shift between industrial flooring and soft, luxurious padding making his dragging talons catch on the delicate textiles. Vibrantly detailed paintings hung amidst sprawling vines imported from Nishtal, cast in cool, fluorescent light that made their rich colorings shimmer as he was dragged by. Even the tables and chairs were carved in the old Krakotl fashions, padding clearly intended for nesting rather than the utilitarian perching of the seats in the mess-hall.
It wasn't perfect though- spots of dull gray industrial walls poked through gaps between the wood, and the carpet was peeling in places, revealing the dirty standard flooring beneath. Despite the valiant attempts, any further inspection made it clear that this was all inserted after this area had already been built- a veneer of elegance plastered over a crude, utilitarian base.
Unfortunately, he did not get the chance to indulge in the comfortable seating, instead receiving a sharp blow between his wings that pushed him to the ground, heavy feet planting themselves on his back and neck to pin him to the ground. Iron grips continued holding his wings, pulling them painfully above his back, where they felt moments away from getting dislocated. Dragging in a rasping breath, his eyes roved to the two exterminators now aiming their flamethrowers at him, a young krakotl female whose adult patterns hadn't even fully come in yet, and a grim-eyed Gojid with distinct scarring, who at least looked somewhat professional as opposed to his partner's obvious anger and twitching trigger.
"Oh, fer Intala's sake," a familiar wheezing voice groaned in exasperation. "Can't trust you Grucknut-heads with anything, can I?"
The Krakotl tottering into the room was puffing what rough, stringy feathers he had left in irritation, a walking cane thunking on the floor as he hobbled over to a table decorated in a carving of two krakotl in flight- though from this angle, it looked more like they were plummeting to the ground. The skin around the geezer's eyes was wrinkled and gathered into such heavy bags that he seemed to be squinting at all the world around him- though Yegel certainly didn't miss the cold, calculating glint buried deep within his eyes.
"Off!" He barked, clacking his way over to where Yegel was pinned, angrily thumping his cane against the very confused Exterminators pinning him down. "Off him, you nut-skulled lunks! Bad enough you can't remember simple instructions, now you make me correct your messes meself? Off I say!"
In the face of the irate elder, the befuddled Exterminator's grips on Yegel loosened, finally letting his wings fall slack enough to make his chest stop feeling like it was stuck in an industrial compressor. Gratefully sucking in air as his rapidly-bruising side twinged, he looked up to find the his crotchety savior kneeling next to him, one wing resting on his cane as he creakily settled into a crouch.
"Sorry about the fuss," he wheezed, flicking his tail angrily at the young krakotl who had been moving forward indignantly. "Ask them to invite somebody to mealtime, and they go and pull this." A shaking wing reached out, offering it's grip to Yegel. "Up you come, boy. I'll not have you eating off the floor like some animal."
Yegel eyed the shaking hand, before planting his wings on the ground, fighting through the pain until he'd pushed himself onto his talons through his own strength. A glimmer of something oily flashed behind the old man's squinting eyes as he watched the display, snorting in amusement when Yegel reached out and pulled the Elder to his feet instead.
"Wasn't much of a request," he commented, carefully ignoring the angry shuffling of the people he knew had flamethrowers trained on him. "I don't suppose you're just wanting to make another sales pitch, are you Geezil?"
"Hah!" the old man barked, toddling over to a cushioned seat, "Always so blunt, Yegel. Straight to business, every time!" The younger krakotl female stepped forward, gently helping the grumbling man into his seat, where he sighed and immediately settled back into the cushions. "Ah, don't worry, got more to say than the usual this time- but first, got a special something for our meal."
With a flick of his wing, he signaled several servers to quietly enter the room, carrying a wide array of dishes and platters that were quickly and efficiently distributed to the relevant tables- both for the old man and Yegel, and even for the other exterminators, who glanced warily between the food, Yegel, and the officer watching everything with a hawkish stare. None of them seemed brave enough to decide what to do- or to stop Yegel as he began moving forward.
Yegel carefully pulled out his own perch, keeping his own movements slow as he settled into the admittedly-luxurious seating. Commander Geezil, the one in charge of the base's Exterminators- and probably one of the oldest individuals still serving within that institution's ranks. He'd heard the rumors about this being an unofficial forced retirement- storing him someplace out of the way when they couldn't make him quit- but he'd come to know the old man too well to believe it. He'd chosen this post himself- and Yegel still couldn't figure out why.
"Sir," the young krakotl started, giving Yegel the stink-eye from across the table, "I must ask what you are doing- you are well aware that he's-"
"Accused, girl," the codger interrupted, frilling his feathers derisively, "by a bitter fleet commander with a record of incidents from his troops longer than his crew-lists- and a penchant for lashing out at those he thinks insulted him." Seeing her shrink back at his harsh tone, his tattered feathers smoothed back down, a shaking wing reaching out and gently patting her shoulder. "Ah, it's politics, grand-daughter- a vile game of inflated egos and pointless posturing. It's like a courtship dance with a Duerten- unpleasant, filled with angry words, with a result that's unpleasant regardless of success or failure- but if you try to skip out, you're liable to lose an eye or worse, hehe."
"Still," she insisted, though much more hesitantly now, her eyes not quite as harsh as they flicked over at him, "with a list of incidents this long, however justified, you must admit it is a clear sign of a violent, unstable nature. If he were to suddenly lash out..."
"I've personally reviewed each incident," the commander snorted, swirling an eating utensil through the bowl in front of him. "Didn't find a single one where he were in the wrong. Besides, were we really concerned about his mind, we got a perfectly good doctor right on-base." His gimlet eyes turned to Yegel, the corners of his beak turned up in a smirk. "You're familiar with her, of course?"
"Indeed," Yegel admitted, keeping his wings at his side despite the tightening of his stomach as the smells of the meal assaulted him. Everything the old man was saying was already known between them- and while it might be simply for the benefit of his new underling, Yegel knew better than to assume there wasn't a different, less obvious purpose. "I've been screened by her multiple times- just like the doctors back on Nishtal, got clear marks across the board."
Her expression was twisted, clearly unwilling to accept that but unable to think of an adequate rebuke for it. "All the same," she started, shifting her wings to roll the fuel tank for her flamethrower from side to side, "I'm uncomfortable with this- it's dangerous to be eating with a predator, especially alone. Just because we're in the room doesn't mean we'll be able to react in time."
The old man's features wrinkled as he scowled, beak half-open, when Yegel jumped on the opportunity. "Actually, I agree," he stated, taking a bit of mischievous glee in the way their expressions popped in shock. "I would feel much safer if someone was sitting with us, to keep me safe."
Beak dropping open, her gaping expression twisted between shock and indignation as she choked at such blatant disrespect- but whatever retribution she thought to unleash was cut short as the old krakotl burst into loud, wheezing laughter, his bony wings thumping against the table as he howled in glee, making the dishes rattle dangerously. His laughter echoed through the room, to the visible discomfort of every other exterminator, half of them sinking back down from where they'd half-risen from their seats.
"Cheeky to the last, you are!" he barked, clutching his chest as he giggled dry, crackling chortles. "Ah, you have a point- best you sit with us, my dear- get introduced with- with this handsome young fella. Yegel, this is Lialu, daughter of my firstborn, and as you can see, the unfortunate inheritor of the branch up his bum." Kalina squawked indignantly, raising a wing as if to smack his shoulder in retribution, but her eyes flicked to Yegel as she paused, slowly settling back into a tense at-ease stance. "You might be working together someday- and if things go well, maybe a little more than that, hehe!" The sour twisting of her cheeks showed exactly what she thought of that idea.
"I'm flattered," Yegel droned dryly, "but I think if she hasn't even gotten her adult patterns, then that's far too dangerous for me."
"As if I'd be interested in such a disgraceful troublemaker in the first place!" she snapped right back, wings half-raised in a gesture of disgust. "tarnishing my career so early would be pointless- and I have no interest in such distractions anyways!"
"Bah, you're fourteen already, better that you start looking for a partner now," the geezer griped, ignoring the way she rolled her eyes uncomfortably. "This work's dangerous, girl- you can't plan for the future as if it's guaranteed, or else you'll find you've missed out." His eyes went a bit glassy and unfocused, staring off into the walls in an melancholic reminiscence. "Regret's a heavy thing to bear, and the years are never kind..."
The two younger krakotl shifted uncomfortably as silence fell, glancing between each other uncomfortably as he lapsed into old memories only he could see. Yegel was silently thankful for the break- these gaps in the old man's train of thought were the only thing that made these conversations manageable.
Unfortunately, Yegel's stomach decided to interject by gurgling it's frustration at being empty, snapping the greying elder out of his thoughts as his gaze snapped across the table. Yegel fought back the urge to flinch, if only barely- and even that was enough for the old man's eye to sparkle with something that made Yegel's skin crawl beneath his feathers.
"Ah, I've been distracting you with my yammering, haven't I?" the Head Exterminator apologized, gesturing grandly towards the array of filled dishes. "Go on, eat up boy- you've got a busy day ahead of you after all!" His wrinkled wing-hand receded from gesturing, and patted the young female on the shoulder. "You too, grand-daughter- gotta keep your calorie intake up to maintain those muscles- gear's heavy, and always getting heavier!"
Whatever his tone and attitude might have suggested, Yegel already knew that it wasn't a request. Gritting his beak, he delicately scooped up a bowl of thick, viscous algae, and methodically poured some into his beak.
Silty and clinging to his tongue, Yegel knew intellectually that this was a high-quality blend- that the consistency and density of the meal spoke of great care taken in the growing, filtering, and preparation of this dish- completely unlike the usual clumpy, soil-tainted slop served in the cafeteria. It was the sort of dish that must be incredibly expensive, even ignoring how far they were from anywhere of any importance- a culinary treat most on the base would have fought fiercely for a chance to try.
Yet as he consciously swallowed it down and discreetly clinked the bowl down on the table, all his tongue could taste was ash and flamethrower-fuel.
"Good, isn't it?" Geezil prompted as his grand-daughter also set her own bowl back down. "Straight from Nishtal, that is, grown properly in the pools, instead of them techno-vats they got on this here base. Reminds me of when I met Laila, you know- or rather, when I first worked up the gumption to ask for her time..." The old man chuckled to himself, his eyes staring off into the distance once again. "Stars, she was beautiful- and me a strapping young lad, straight from academy- big-headed from training, yet a fumbling mess with the other sex. Took me far too long to even make a pass, and longer still to make it official- kept finding excuses, when I really was just scared she'd say no!"
Yegel suppressed the urge to sigh, and found himself sharing a commiserating look with the exterminator who clearly had been through this rambling story almost as often as he had. Maybe he'd entertain the idea of bonding with her over it, if only he wasn't painfully aware of how strongly she and her friends wanted to reduce him to a pile of charred carbon. At least he wasn't suffering alone.
"You know, we got some side-eyes because of our difference in age- I was a fresh recruit, and she had been in the service for twelve years," Geezil confided absentmindedly, a dreamy expression on his face even as his granddaughter blanched and leaned away. "Ah, but we made it fine, found our happiness- and you should too!" he shifted, refocusing on his two unwilling guests. "Ten years made no difference, and you've a difference of what, five years? Not even that!"
Yegel inhaled deeply, letting his chest fully expand as he held back the surge of emotion that would certainly have worn through the elder's patience if let loose. Releasing the air in a deep sigh, he wrangled himself back into a restrained, controlled frame of mind. "Is trying to play matchmaker with your grand-daughter the only reason you arranged this meeting, sir? Because I stand by my utter lack of interest in her."
"Ah, you know it's not, you stiffneck," the old man grumbled, shifting around in his seat as he picked through his own spread of food. "You're a perfect fit for the corps, and we both know it. You got enough fire in you to want to fix the rot in society when you see it, and a good head on your neck as well- just gotta give you the training to aim it right, if you know what I'm saying." His cane reached out and tapped Yegel on the side jovially- and Yegel winced as his bruised ribs ignited in fiery pain, unable to stop a strained hiss from escaping his beak as he bent in place from the automatic tightening of his muscles.
Immediately, the entire room fell deathly still. Where once the silence had been uncomfortable but tolerable and interspersed with the inane sounds of clinking dishes, now it was an oppressive, choking claw squeezing around everyone's neck, unbroken by even a single breath of air.
"Barum." Geezil's flat, quiet statement whipped out through the stillness, a single cracking note that made the Takkan flinch in his seat. There was no waver in the old bird's voice now, only a cold, hard surety that made Yegel's feathers itch. "I was very explicit in my instructions. Was I not?"
"The- the predator resisted!" Barum tried to protest- though the waver in his voice clearly made it more of a plea. "With how dangerous he's proved to be, I had to-"
"Dangerous?" the drawled interruption made the hulking, thick-skinned exterminator flinch back from the dull-feathered bird barely half his size. "I see no injuries on any of you. There has never been an injury from officers bringing him in to me. I... was quite clear about wanting him brought here unharrassed." A single beady eye bored into the towering gray alien, making him shrink into himself under it's heat. "Do I lie?"
"S-sir please!" Sweat glistened on the Takkan's thick grey hide as he cowered back, his seat clattering to the floor as he stumbled. "It- I apologize, I swear I thought it was necessary! It won't happen again, sir! Please!"
Yegel knew what was coming next- the tightening of Geezil's beak and raising of the feathers on his back were a sure sign of how furious the old man was. All he had to do was sit back quietly and let it play out, and it would be both a distraction that bought him time, and retribution for the unnecessary blow he had taken- and was probably going to need to see the doctor for after this- if he was in a position to visit her, of course. Geezil's eyes were hard and cold, focused on his subordinate- getting between him and the subject of his ire would only earn him trouble... and yet, as Geezil's beak opened, he simply couldn't stop himself.
"While this is all quite engaging," Yegel interjected, refusing to flinch back as every eye in the room snapped towards him, Kalina's expression one of open shock while Geezil's screwed up in barely-contained fury, "but you said there was more to this meeting than making another recruitment pitch to me, yet all you've actually given besides that was an attempt to get me to go out with your grand-daughter." His confidence faltered as wrinkled eyes tightened, glaring holes into him, but he rallied himself and carefully considered his next words. "While your... repeated offers are actually quite flattering, I am quite happy with what I have managed to make for myself, without accepting favors or handouts- from anyone."
Geezil hummed to himself, maintaining his glare as the silent room held it's breath, before his jaw twitched upwards into a satisfied smirk, his eyes glinting as the granite in them faded into a smug satisfaction of having found what he was looking for. The entire room relaxed as he leaned backwards in his perch, Barum falling to the floor and trying to muffle the sounds of his heaving for breath. The gentle clinking of dishes and silverware once more filled the room in a very deliberate attempt at making noise, covering up the previous tension with artificial ease. Kalina was giving Yegel a look- not the pure disgust from earlier, but something confused, as if he were a particularly perplexing puzzle-game, or a problem that had suddenly reached an unexpected solution.
"You really can't help yourself, can you," Geezil noted approvingly, glancing over at his grand-daughter's reaction before nodding at Yegel- and making a jerking motion at Barum, who gulped and pulled himself off the floor, quietly hurrying his way out of the room. "So, I uh..." the light in his eyes faded, his beak clacking shut as he rapped his talons against his perch. "I, uh, huh... hmmm. There was, actually something else... Bother me, where were we? I can't remember..."
"I believe," Yegel commented dryly, fighting to keep his own breathing even, "That I was once again saying how content I am with my current position, and that even this doctor being imported just for me isn't enough for me to leave everything behind and run into the Exterminator Corps."
"Ah, right, right," he nodded, snagging on to the lead Yegel had thrown him, before pausing and looking out over the room. "I do respect what you've managed on your own," he finally admitted, setting his bowl to the side, "But this time... this doctor, he's not exactly playing fair. This is politics, the nasty sort- where he's going to do everything he can to make you disappear. Unless, of course..." reaching into his own pouch, he shakily produces a holopad that he slides over to Yegel, displaying a series of documents- and a prominent line for signatures. "You take an alternative. Sign up, and it'll be our own docs who do your eval- and you'll clear their tests just fine, I think. Might not be your ideal career path- but I'm loathe to let such a promising young man get screwed by Old-Molts with thin egos and sharp talons."
Yegel's first instinct was to push the pad away, to reject it like he usually did- but now, he paused, expression screwed up in conflict. A part of him was tempted- severely tempted- to accept- the part of him that was still terrified of the looming threat, that wanted to run somewhere-anywhere- and hide until this whole twisted situation just went away.
Was he being selfish, rejecting an offer like this? Wouldn't the right thing to do be to accept and guarantee he stayed alive, like Jelliba and Kallik so desperately wanted? Why take the risk, when safety was right here, just a signature away- something that would guarantee him the chance to see what Jelliba's final design would look like, to see Kallik climb through the ranks like Yegel knew he someday would? Was it pride that stayed his talons, or was he simply afraid of change?
"Seriously?!" his granddaughter hissed, clearly taken aback, unaware of Yegel's silent internal debate as she rounded on her grandfather angrily. "That's why he's here? So we can just ignore his entire history of warning signs, just because you like him? With a record like his-"
"-He'd fit right in," he finished for her, eyes narrowed in a disappointed glare that had her beak snapping closed as she shrunk back into her perch. "I know you ain't seen most of it, Lialu, but most of our recruits aren't exactly got glistening feathers. Heck, lots of our older recruits got worse on their record! It's half the point of the training regimen, to file down the burrs in their talons, make something useful from them."
File down the burrs... Was he really willing to accept what that entailed? What parts of himself would he need to sacrifice, if he went down this road? What would he become, on the other side of whatever training they had in store for him?
Would he still be Yegel?
Inhaling deeply through his beak, Yegel grasped the pad, which felt far heavier than it should... and gently slid it back over to Geezil.
"If I accepted now, that would practically be an admission of being sick," Yegel breathed, his heart pounding heavily within his chest. "I... am going to see this through- I will pass this evaluation, no matter what he throws at me- and then!" Finally, he looked Geezil in the eye, firming his own resolve as he squared his shoulders. "Then, and only then, will I consider your offer."
Geezil watched on, the burning tongues of some dark flame flickering behind his ancient eyes. When Yegel stood strong, his feathers crinkled into an amused display, even as he shook his head in mock disappointment. "Ah, you really are a fine young lad," he sighed mournfully, rapping his cane against the table. "Are you sure? The doctor arrived only an hour ago in port- this is your last chance, before we have to take you to your evaluation. And without anyone having requested the extra security of one of my officers, why, this might be the last time we see each other!"
Ah. So that was the old geezer's game. Yegel pushed down the rising surge of fear, quivering in his perch as he forced himself to meet the elder's gaze. "Then I'll go ahead and invite you myself- I'm more than happy to have an audience to me proving my innocence."
The old bird's beak twisted into an ugly grin. "I am sure you do. Lialu, go ahead- consider this a learning experience for the future, hmn? Now, I won't waste any more of your time- so off you go!"
The scraping of seats being pushed out was all the warning Yegel got before he was grabbed and pulled from his seat. "Hey, hey, gentle with him, you hard-headed brutes!" Scoffing, Geezil pushed himself back in his seat, glaring at his Exterminators as Yegel was unceremoniously dropped.
"So, you planned this all out in advance, didn't you?" Yegel guessed, pushing himself to his feet- and wincing as his side twinged in pain, reminding him of the rapidly-swelling bruise.
"Dunno what you mean," Geezil denied in faux apology, as his granddaughter gaped between the two of them, clearly lost on what was happening. "Figured you needed a chance to make the right choice- or failing that, a decent last meal." Waving his wing in disappointment, he gestured towards the door- which Yegel found himself getting rapidly pushed towards. "Good luck, lad- I hope to see you again someday!"
"Don't worry, sir," Yegel snapped back, shouldering away from his escorts and refusing to look back. "I'll be back sooner than you think."
The doors slammed shut behind his escorts, reflecting the young female's confused, conflicted gaze as she strode alongside him- Yegel felt a moment of pity for the young girl, who the geezer had clearly thrown into the deep end on purpose. Hopefully she caught onto the game soon, otherwise she'd end up as somebody's tool- though maybe it was already too late for that.
Stomach roiling at the thought of what lay ahead, Yegel couldn't help the feeling of regret for not taking the escape offered to him- sure it wouldn't be ideal, but he owed it to the people most important to him to make sure he stuck around a little longer. Why he'd rejected it... he couldn't quite put it into words, only a feeling that it would have been... wrong, somehow.
The cafeteria murmured again as he was led through the mealtime crowd, catching the panicked gazes of his friends across the room. Kallik was halfway out of his seat before Yegel carefully gestured back, tapping his wing against his throat- and watching his friend slowly settle back down, Kallik's eyes growing focused as he turned and strode towards a different exit, vanishing into the distance as Yegel was dragged through a set of doors out into a cold, grey hallway.
Clenching his gullet, he carefully felt out around Kallik's gift- safely stored within his throat. The creeping tendrils of terror within his mind were growing stronger, but he chose to have faith in his friend- and resolved to make sure his efforts were not wasted.
He'd find a way through- he just had to keep moving forward.
///
one week earlier...
Once he'd had the chance to compose himself, Yegel returned to his viewing- he wanted to see what happened next, after such a massive shift in the struggle now that Eren had actually earned them a victory.
Despite that, Armin's narration pointed out that too many lives had been lost for any celebrations to be in order- a sentiment that Yegel understood, but... well, he wasn't as surprised to to see it from the humans anymore. Imagine, it wasn't long ago that he'd have been expecting them to revel in the carnage like other predators, uncaring of the toll in lives- yet here they were, deeply affected by the loss of so many friends and comrades, and instead of being baffled by it, Yegel completely understood their response.
Oh, and they'd taken advantage of their unique situation to even capture two of the smaller titans, presumably for study- which, given Eren's sudden new powers, was probably something that needed more study than initially presumed. Thankfully the restraints seems pretty extensive, so hopefully they could keep the monsters contained- but still, imagine being the poor soul tasked with keeping them locked down! Hopefully it wouldn't take long for them to get what they needed and dispose of the creatures.
Of course, with victory came the morbid task of cleaning up the aftermath- and not in the way anyone else in the Federation would believe if he told them. Gathering up bodies as respectfully as they could, instead of devouring them on the spot? He'd be hard-pressed to convince anyone he was telling the truth!
Wait... Marco?!
When did Marco die?! Yegel thought he'd gotten away after saving Jean! Maybe it was in the push to get Eren to the gate? Geez, and Jean was the one to find him- Marco had been so supportive of him, despite Jean's fear and self-doubts, always willing to give a word of encouragement and affirm Jean's place as leader... and now he was gone, with Jean being forced to help the cleanup crew's by giving Marco's details...
The female doctor brought up something Yegel hadn't considered- that the reason for the urgency of their cleanup was because of the risk of an epidemic breaking out. The dead had been left too long, and now there was a risk of a secondary disaster if the humans didn't hurry. Yegel had never really considered something like that- meat was meat to predators, wasn't it? The Arxur never seemed to mind eating bodies they stumbled across, so he'd somehow assumed that diseases like that weren't a concern for predators.
Just another area where the humans proved their difference from the greys, he supposed.
Thankfully, the camera hadn't focused on Marco's corpse for too long, so Yegel was able to contain his urge to gag, focusing in on Jean and his emotional response- and how expressive human faces were, even when covered by face-masks to protect themselves from germs and contamination. Of course that was when the scene shifted to Sasha and Connie, helping to clean up a massive ball of... flesh... that apparently titans upchuck when they're too full, since they don't actually have a digestive track... and a closeup showed a human mouth inside, still opened in a silent scream...
Yes, hello wastebin, been a moment since we last met, how have you been? Don't mind me, just emptying my stomach again!
...Yegel didn't like Sasha- she was clearly the most "predatory" of the humans- but at least here, the disgust and horror on her face showed that there were lines even she wouldn't cross.
Even Annie, the stoic female who never seemed to show emotion, was shaken- standing over a body, apologizing over and over again, before Reiner pointed out that contrition did the dead no good, and that they needed a proper burial. So the humans buried their dead? That was kind of similar to Gojid traditions for honoring the dead, burying them in vast family crypts.
But, why did the scene shift to a fire burning? What were they-
Oh.
So that's what those grey flakes that had been falling everywhere were. Yegel had kind of been wondering about that.
So, they didn't even have time to give proper burials to everyone.
That...
Yegel forced himself to take a deep breath, rubbing the sides of his head as he exhaled. He'd say it was similar to Krakotl death rites, purifying the body to drift through the divine winds of Nishtal, to be carried away to Intala's realm, but... in this context, it clearly must have been desperation and urgency rather than a matter of respect.
...Intala, please watch over them.
...Thankfully, the perspective then shifted back to Eren- who was now locked up in a cell deep underground, and chained to a bed. Understandable precautions- his powers were clearly still volatile, and the last thing the humans needed to deal with was a rogue titan wandering around.
Commander Erwin and Captain Levi were outside his cell, watching him. Erwin asked if he had any questions- which, well, Yegel obviously had several, but Eren was still disoriented from waking up. Which made sense, given how much using his power seemed to take out of him- he must have been exhausted after carrying that boulder for so long.
Erwin proceeded to ask about the key that had held such importance- and the secret that was apparently hidden beneath Eren's house. Eren confirmed, and Levi scoffed about how it must suck to have your dad and your memories MIA at the same time- unless it was just a cover story. Which- was a reasonable concern, but... was that what Yegel sounded like to other people?
At least Erwin confirmed that they knew Eren had no reason to lie- and proceeded to ask Eren what he wanted- what his intentions were. After all, to reach the cellar, they'd need to seal the breach in the other wall like they'd done in Trost- which required Eren's special power. Apparently they'd even conjectured that the Colossal and Armored titan must be like Eren- titans piloted by people?! Which did make sense- the Bad Humans probably had an easier time developing and using titan powers, since they weren't trying to fight or resist their predator instincts. That also would explain their motive- killing all the good humans would mean the bad humans would win, and be able to rule as dominant predators like the Arxur did.
...Was there a group of good Arxur once, that lost their own fight with the Arxur Yegel knew?
NO. No, that was impossible- there was no way the greys had ever had anything good within them- they were monsters through and through! Good Arxur? Ridiculous- just because humans were an insane enigma that broke every rule as if they were intentionally trying to didn't mean the same applied to other predators!
Unless of course, the good Arxur had all been killed-
No. NO. Yegel was not going down that path of madness! He was not!
...
...Erwin expanded on his statement, saying that was why he asked Eren's intentions- because Eren could save "us," presumably meaning the good humans. Eren initially said he didn't know- but then his past, his memories, all flooded through his head- his inner voice angrily declaring that he would stop this with his bare hands! When Levi pressed for an answer, Eren looked up with a downright deranged grin- and declared that he wanted to kill all the titans- every last one.
So that's how Eren turned out different- he'd aimed his instincts towards the monsters, and become obsessed with wiping out the titans, instead of wanting to consume humans like every other titan did. That said something about Eren's mental fortitude- and why he still had difficulties with his power. Actively twisting your instincts like that must cross a few wires, leaving him needing to actively learn things instead of simply doing what came naturally.
Levi seemed to like that answer, a gleam entering his eyes as he approached Eren's cell and announced that he'd take responsibility for him. Not that he implicitly trusted him, but that he trusted his abilities to kill Eren if necessary. He offered Eren congratulations, officially welcoming him as a new member of the Scouting Corps- and told Erwin to let the higher-ups know.
And then announced that, despite this meeting, Eren wasn't out of the woods yet- as he was going to stand trial, where they'd need to argue against him simply being killed.
Because of course it couldn't be that simple.

Hello Apple,
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There are completely free widgets of each category, no annoying ad pop ups or full screen ad and the best part is that it doesn't require a subscription, compared to many other apps in this category.The app is usable without purchasing the premium widgets.If you like to, you can unlock Premium to get access additional widgets. Widgets cost from $0.99 to $3.99. NO SUBSCRIPTION, NO HIDDEN COSTS.
💡 Feedback appreciated
As Apple is full of Apple enthusiast I am curious what you think about my app. Any feedback is much appreciated! What do you like or what do you think needs improvement? Doesn’t matter if it’s about the design, content, or bugs. Do you have ideas for widgets I could add? Looking forward to your feedback!
📲 Download Now
So, why not give it a try and lighten up your day with our cute cat widgets!
Download Cat Widget on the App Store: https://apps.apple.com/app/cat-widget-world-of-cats/id1598647610

For those of you unaware or not American. A funny little gimmick of the US is that the national debt limit must be approved and expanded once every 2 years. This is sometimes said to be a way to ensure that the government stays responsible to its debt. However considering national debt is a farce and often used as a excuse to prevent spending on “non-essential” tasks. Such as feeding and housing people.
This gimmick also means that if say, a fascist party is in power, they can hold the debt limit hostage as to force concessions in both government and in government policy.
Well after weeks of touting the evilness of the Republican Party’s cuts and how they will mean destruction of the way of life for millions of Americans the Democratic Party acquiesced and agreed to the deal
Which would raise the work requirement to qualify for the paltry amount of benefits available to disenfranchised workers. Most of which work for Americas major corporations or their key industries.
This single change is expected to throw roughly 1 in 4 Americans on food stamps off the program and roughly 1 million older adults will find themselves unable to afford food in the coming year.
As the GOP hail this achievement, the details of which we will find out later today, the Democrats are remarkably (but not surprisingly) okay with it all including the agreement not to touch military spending until at least 2030.
Guaranteeing that more Americans then ever will struggle to survive as the US military continues to taken for a fool with American tax payers in tow.
We here have long argued that the notion of fighting the system from without is both highly unlikely and prone to pointless bloodshed as the bourgeoisie state fears not killing in the name of the protection of capital.
But days like today that future seems grimmer and more impossible then ever as the democrats bare their ugly faces once again to tell us that the stock market, it’s military and it’s subsidies to kulaks (small time, but wealthy landowners) are all more important then helping people acquire the most basic of life needs.
That bombing innocent people in Afghanistan and Syria, or Africa. Or that harassing China off its territorial waters somehow helps people more then giving them food and shelter.
When I say that we need to take hold of institutions I don’t mean we simply vote once a election and throw our hands up. But rather im calling for every one of you to enlist in the fight that is closest to you. Join you’re city council. Get hired as a staffer if that’s the best you can do. Infiltrate these institutions and take control of them from the inside. Everything from your local political party memberships and caucus for change. All the way to taking control of institutions such as the police and military positioning yourself in a way that can help others take control of this runway nation. All runaway states.
Because change is coming. Not the gradual Revolution of new ideas and new beliefs. But days like this it feels like a sudden change towards fascism is closer and closer. And if that happens it will take nothing less then my suggestion above to prevent the massacre of people and the falling into a pit too dark to ever climb out of. We can’t trust the democrats. We must take control of our institutions and society.

Welcome!
This is a series I am going to be working on where I endeavour to cover various topics in physiology intermixed with clinical pearls to impart some knowledge that doctors of most specialties and grades will hopefully find useful when looking after acutely unwell patients. Join me as we dredge through the depths of anaesthetic exam revision to answer important questions like "why do CT ask for a pink cannula", "why frusemide is okay to give in AKI", "why is hypoxic drive a bunch of horse manure" and many more. Pick up some of this material and you'll be well on your way to becoming a pernickety anaesthetist, whether you like it or not!
Questions, comments, feedback, and suggestions are both encouraged and welcome.

Previous installments:

• IV access, resuscitation, fluids, and the cardiovascular system
  
• The physiology of ageing and illness, and its impact on critical care decision making
  
• Respiratory failure, oxygen therapy, and gas exchange
  
• Reduced consciousness, intracranial events, and the central nervous system
  

Kidney function, acute kidney injury, and acid-base disorders

Next stop along our systems review are the mighty kidneys. I won't talk to you about Lupus nephritis or renal tubular acidosis, however I will try my best to cover some more typical things you might encounter like acute kidney injury (AKI) and drug dosing in renal impairment while trying to avoid embarrassing myself as a non-renal doctor.

What do the kidneys do?

An obvious question, they allow us to get rid of waste substances in urine. They are so much more than that however, they:

• Regulate electrolyte concentrations, water balance and plasma volume, plasma osmolality
• Regulate red blood cell production
• Regulate blood pressure via RAA system influencing vascular resistance
• Maintain acid-base homeostasis
• Control Vitamin D production
• Produce glucose from proteins and triglycerides (gluconeogenesis)

We will focus on only a few of these in this post, but the kidney's multiple roles and complex biochemical signalling deserves as mention as it can make diagnosing and understanding disease states difficult. It can also make us forget what other consequences there might be for patients in these disease states.

How do we measure kidney function?

In some respects knowing the heart or the brain aren't working is easy. Low blood pressure and infection? Septic shock. Low blood pressure + STEMI? Cardiogenic shock. Unconsciounsess or coma? Well whatever it is, it ain't working. So what about the kidneys, well we have creatinine, right? WRONG.
Although the kidney has many functions as we noted before, the easiest methods to quantify function look at the obvious: waste production. Its function is the sum of filtration through all the glomeruli in the kidneys, the glomerular filtration rate (GFR). When a substance is freely filtered through the kidneys and is neither secreted nor reabsorbed (which occur in the tubules rather than the glomeruli), the rate at which that substance is removed or cleared from the plasma can be used to measure GFR (in mL/min).
This substance is inulin and not creatinine. Because inulin isn't naturally present in our bodies, it has to be infused and then its concentration and the rate of decay measured. This is impractical clinically, so creatinine was selected as a practical alternative. The correlation between serum creatinine and measured GFR was researched and various formulas like MDRD and CKD-EPI were developed to estimate GFR (eGFR). This is why labs report eGFR as opposed to GFR. (There are also other methods to determine GFR like radionuclide scintigraphy...)

What's the problem?

The estimation of the GFR relies on assumptions that are not without problems. This review covers the topic at length, however the main points are:

• Creatinine is secreted, unlike inulin. As mentioned this occurs in the tubules, so changes in secretion will affect serum creatinine level despite a static filtration rate. As renal diseases progress, more and more creatinine is secreted, making serum concentrations less reflective of actual filtration.
  
• To truly reflect instrinsic renal function creatinine has to be in a steady state with stable generation and serum concentration. Creatinine is produced as a waste product of protein breakdown mainly from muscles. Therefore anything affecting catabolism, muscle activity, dietary protein intake, can alter this steady state. Frail sarcopenic patients will have artificially low creatinines and may not get as significant of a rise as a young muscular person in AKI.
  
• There has to be adequate delivery of creatinine to the glomeruli. The kidneys receive ~20% of the cardiac output, so the heart has to be pumping out effectively with healthy blood vessels, good volume and blood flow. A hypovolaemic patient with an MI may have a high creatinine despite working kidneys, they're just not being adequately perfused. Chronic diseases like hypertension, diabetes, heart failure, lead to upset of autoregulation of normal afferent (entering) arterioles, whereas ACE inhibitors and ARBs block AT-II from causing vasoconstriction of efferent (outgoing) arterioles, an imbalance can lead to renal impairment if perfusion isn't maintained, or improved blood flow and urine output if it is.
  
• The studies from which eGFR formulas are derived were conducted in mostly European and North American populations with elderly, black and CKD patients being significantly underrepresented. They only measured GFR a few times a year. With increasingly older, frailer, sicker patients, leading more sedentary industrialized diets and lifestyles, will the accuracy of these formulas hold up with time?
  
• eGFR correlates loosely with important indicators like proteinuria, fluid status, blood pressure, acidosis, anaemia, bone disease, iron deficiency, tubular function, etc. In the absence of those indicators, the elderly often have decreased GFR without increases in morbidity and mortality.
  

The takeaway is that creatinine and eGFR are tools developed from the assessment and monitoring of long term renal function. It is not designed for use in patients with acute fluctuations or those with zero kidney function (eg, anuric dialysis dependent).

What else we can monitor?

The example of the heart earlier was misleading. Blood pressure is influenced by many factors. Septic shock is actually a high cardiac output state with low systemic vascular resistance (SVR). Patients with heart failure can have normal blood pressures despite severe systolic dysfunction and poor exercise tolerance. Blood pressure is an easy surrogate marker because determining cardiac output and SVR is invasive and complex (of course we have focused echocardiography to help us these days).
A surrogate marker we can use for the kidneys is urine output (UO). After all the end product of glomerular filtration is the ultrafiltrate which will become the urine. If there is adequate urine output despite raised or increasing creatinine levels, we can be reasonably satisfied the kidneys are actually receiving enough blood flow to get rid of waste and perform its other functions.

Acute Kidney Injury

This leads us into one of the most commonly encountered entities in hospitalised patients: AKI. Let's look at the KDIGO criteria seen in the table below.

AKI Stage	Serum creatinine criteria	Urine output criteria
1	SeCr increase ≥26 umol/L <48hrs or SeCr increase ≥1.5 - 2x from baseline	<0.5mL/kg/hr for ≥6hrs
2	SeCr increase ≥2-3x from baseline	<0.5mL/kg/hr for ≥12hrs
3	SeCr increase ≥354 umol/L <48hrs or SeCr increase ≥3x from baseline or started on renal replacement therapy (any stage)	<0.3mL/kg/hr for ≥24hrs or anuria for ≥12hrs

^{Note: UO <0.5mL/kg/hr is the definition of oliguria.}
Definining by creatinine is a more practical screening test in most situations, allowing earlier diagnosis and intervention. UO can be monitored during the course of the day to identify patients who are borderline or not responding to treatment, may need re-evaluation of the cause, or escalation of care. This way a combination of the two can help offset the limitations of each method.
NICE guidance already exists on the diagnosis and management of AKI, most hospitals will have care bundles or even 'AKI nurses', so I'll run over a few important points.

• Pre-renal - This only means the cause lies outside the kidneys, and in at least in the early stages there is no histological change in the kidneys. In many cases like sepsis, diarrhoea, haemorrhage, there can be a relative or absolute fluid deficit and IV fluids are generally indicated. However excessive fluids can result in interstitial oedema in the kidneys, reducing the glomerular pressure gradient and so also reducing filtration. Similarly in poor cardiac output states where there is venous congestion there is a problem with the outflow of blood from the kidneys, so this is not a cause to reflexively withhold diuretics.
  
• Intrinsic - Here there are structural histological changes in the kidney, caused by many intrinsic renal diseases or nephrotoxic agents like aminoglycosides, vancomycin, NSAIDs, etc. If this is suspected, stopping the offending agent generally resolves AKI without needing a biopsy. Furosemide is not mentioned here as it is not inherently nephrotoxic. Acute tubular necrosis is often mentioned as a specific clinical entity, either due to nephrotoxic agents or sustained hypoperfusion from pre-renal causes. It is not a very helpful term since histological tubular damage has rarely been proven in studies, nor does it help with treatment.
  
• Post-renal - Obstruction may be incomplete, acute on chronic, with a normal ultrasound, no oligo/anuria, and may be associated with other pathologies like a kidney stone with pyelonephritis or sepsis. Catheters can get blocked too so don't forget a bladder scan if anuric, and obstruction can rarely be external such as by tumours or abdominal compartment syndrome.
  

When do I refer to renal or ICU?

Local protocols aside, advice should be sought when the patient does not appear to be responding to medical management and there may be a need for renal replacement therapy (RRT). This is often in the form of intermittent haemodialysis (iHD) on renal wards, and continuous venovenous haemodiafiltration (CVVHDF) in ICU. There are small differences in mechanism, efficacy, and indications of the many forms of RRT, the details of which aren't important for most non specialists. Generally accepted indications for RRT include:

• Symptomatic uraemia - Encephalopathy, neuropathy, pericarditis. Elevated urea on its own is not generally an indication.
  
• Hyperkalaemia - Persistent hyperkalaemia (>6.5) despite insulin/dextrose. Severe hyperkalaemia (>8 ) with arrhythmias, requiring pacing or isoprenaline. This can occur even without anuria and should be escalated as it obviously can be life threatening.
  
• Severe metabolic acidosis, pH <7.1 - This will depend upon the cause and patient's condition. Patients with DKA and pH <7 can almost always quickly be turned around with insulin and fluids. Severely septic patients may not be able to tolerate medical management long enough to improve without RRT.
  
• Toxins or overdose - Some medications and toxins may be removed by RRT (eg, lithium, vancomycin), with specific type of RRT better for some drugs than others. This is uncommon and decisions will depend on the input from renal, clinical state of the patient, and advice from toxbase or national poisons service. A drug may not be removed by RRT but if it leads to another entity such as acidosis it may still warrant RRT.
  
• Fluid overload or pulmonary oedema refractory to diuretics - If patient is anuric despite diuretics then it's more likely they'll end up requiring RRT. In contrast pulmonary oedema in decompensated heart failure with worsening renal function is not helped more by RRT than by adequate diuresis.
  

Absent from above include oligo/anuria or specific values of urea and creatinine. This doesn't exclude them as considerations, however the whole picture should be taken together to make decisions on an individualised basis. It might be that the patient improves despite a creatinine of 700, it might be they become acidotic and hyperkalaemic with a creatinine of 400. Even on the ICU we still don't know when the right time is to start RRT.
This is a reason why renal and ICU often advise the generic "monitor I/O" rather than taking over care. We do appreciate accurate monitoring is unrealistic on the wards, but we also don't have the ability to admit everyone when few will need a specific intervention like RRT. An adequate UO to aim for is above 0.5mL/kg/hr. As AKI resolves some patients enter a polyuric phase, this will resolve but watch that they don't become hypovolaemic in the process, it may require further fluids matching what is lost.

Renal vs ICU referral

This will depend on local arrangements and acuity. Refer to renal if:

• Single organ kidney failure - Normotensive haemodynamically stable patients, not septic or comorbid with poor cardiac function. The principal reason haemodialysis is intermittent because fluid is more rapidly removed therefore borderline hypotensive patients may not tolerate large volumes of blood and fluid being rapidly withdrawn from their intravascular space. I have seen patients arrest from starting dialysis!
  
• Unclear cause of AKI - ICU can offer RRT as a bridge, but the underlying cause has to be treated, if the cause is unclear or there is persistent renal dysfunction, this will require renal input. We refer for this from the ICU too.
  
• Diagnosis requiring specialist treatment - Immunosuppressive therapy for vasculitis.
  
• Renal transplant patients - Even with a clear cause and response to treatment, the precarious nature of immunosuppression, renal impairment and graft function mean these usually merit a call to transplant renal physicians.
  

Refer to ICU if:

• Multiorgan failure - Borderline blood pressure, high oxygen requirements, fluctuating consciousness level, coagulopathy, these patients are unlikely to tolerate iHD, but more importantly it suggests they are critically ill and may need rapid escalation of care (if appropriate) beyond what renal can provide (intubation, vasopressors, etc).
  
• No on-site dialysis service - In hours there may be arrangements to transfer to partnetertiary hospital particularly for complex patients. However hospitalised dialysis patients known to the renal team may require more urgent RRT than this allows. Some ICUs have the plumbing to offer dialysis (this will need a dialysis nurse however).
  
• Patient in extremis - ICU may be able to offer more timely input in patients needing urgent intervention especially if prior to surgery. A patient with bowel perforation and severe AKI will usually be septic and in multiorgan failure anyway, but a 70 year old with obstructive pathology may benefit from being close to theatre to offer RRT while awaiting a nephrostomy (or exchange). If it's reversible and there is somebody willing to operate, I would even dialyse a patient with a DNACPR we wouldn't otherwise admit.
  

Specific considerations

• AKI in heart failure
  
  • The heart-kidney interaction is complex and works both ways (see this review). Volume status and cardiac function needs to be carefully evaluated. Seeing CCF documented in the notes is meaningless. What does their most recent echo show? What did they present with? Stable HF with reasonable ventricular function and sepsis with no signs of overload can receive fluids. Acute cardiogenic pulmonary oedema with severe ventricular dysfunction probably has AKI rooted in the decompensation of heart failure (type 1 cardio-renal syndrome) and would benefit from diuresis.
  • Acute decompensated HF is usually a hypervolaemic state. Elevated right atrial pressures reduce the arteriovenous pressure gradient in the kidney leading to venous congestion, poor outflow. Inflow is also limited adding to the poor cardiac output so glomerular filtration is reduced, leading to a vicious cycle. Aggressive diuresis with furosemide reduces this congestion, improves glomerular pressure gradient and increasing filtration (as long as the patient does not become hypovolaemic). Furosemide's initial beneficial effects in venous congestion is preceded by its diuretic action and is thought to be due to it causing venodilation, reducing preload. The addition of acetazolamide may improve decongestion further.
  • Creatinine rising is not an indication to stop diuresis, it may in fact signify adequate decongestion with improved patient outcomes.
• AKI in liver disease
  
  • Like in heart failure this is a complicated topic (see this recent review). AKI is very common, occuring in up to 50% of hospitalised patients with cirrhosis. While we hear things like hepatorenal syndrome thrown around, common things being common we have to look at all the usual causes we've discussed first (so don't just throw terlipressin at everyone!)
  • Pre-renal causes are most common: Discontinue nephrotoxic drugs. Look for and cover for infections and spontaneous bacterial peritonitis. Hypovolaemia from diuretics or GI bleeds, resuscitate with crystalloids and blood as needed until euvolaemic (careful to avoid overload). Albumin has been found to improve survival in patients with SBP and can be considered if worsening renal function despite resuscitation (or following paracetensis for large volume >5L ascites). Hypervolaemia from congestion (cirrhotic cardiomyopathy leading to right heart failure can benefit from diuretics, abdominal compartment syndrome from tense ascites should be drained).
  • Intrinsic leaves us with tubulointerstitial causes and hepatorenal syndrome (HRS). Low fractional excretion of sodium and urine microscopy can help confirm HRS which offers a grim prognosis. Terlipressin may improve renal function at the cost of significant pulmonary oedema so regular volume assessment and avoidance of overload is paramount. RRT would only expected to be offered if waiting, or under consideration, for liver transplantation. If not, palliation will be the most likely alternative course.
• Drug dosing
  
  • I would avoid using the BNF in renal impairment. Many of its recommendations are different than common guidelines and frankly weird. Do talk to your pharmacist (also microbiologist where appropriate), they'll often refer to The Renal Drug Handbook which is a good resource and covers scenarios like RRT. Most drugs will be dosed based on creatinine clearance not eGFR so arm yourself with an app or calculator.
• Sodium bicarbonate
  
  • Bicarbonate infusions offer temporary extra buffering capacity, mopping up excess hydrogen ions resulting in a higher pH. This is beneficial in hyperkalaemia as a higher pH favours potassium moving intracellularly (for this reason saline is more harmful and Hartmann's more beneficial in hyperkalaemia). It also has accepted roles in tricyclic antidepressant overdose with adverse ECG findings (QRS, QT prolongation), urinary alkalinization (in salicylate poisonining, poor evidence in rhabdomyolysis), and normal anion gap metabolic acidosis (there is high cloride to replace loss of bicarbonate, see later).
  • Its use outside these indications is contentious. There is no evidence of benefit in DKA over conventional fluids even if normal saline's tendancy for acidosis may slow resolution of the acidaemia in DKA. It may be actively harmful in lactic acidosis and respiratory failure as the increased pH shifts the O2Hb dissociation curve to the left, causing reduced oxygen offloading. It also results in net CO₂ production (HCO₃⁻ + H⁺ → H₂CO₃ → H₂O + CO₂) which will have to be blown off with excess minute ventilation.
  • So why do ICU and renal advise it or use it themselves even with a lack of solid indications? Well, essentially it's a temporising measure. Severe acidaemia contributes to myocardial dysfunction, arrhythmias, and catecholamine resistance. In the critically ill it can be useful as a delay while you insert lines or in the hope it will avoid the need for RRT. The BICAR-ICU trial did find it delays the need for RRT and may even possibly reduce the need. I'm not entirely sold on the latter, but it can be reasonable to try if there are positive indicators like good UO.
  • How? Usually available in concentrated (8.4% with 1000mmol/L of each ion) or dilute (1.26% with 150mmol/L) forms. Due to the high tonicity of the former, 1.26% is generally preferrable especially if you can or want to give larger volumes. 8.4% should be reserved for fluid restricted states and should be given slowly via a central line except in an emergency. Slow infusions help combat significant CO₂ rises and hypernatraemia (especially with 8.4%). Dosing is 1 mmol/kg which is 1mL/kg of 8.4% or 6-7mL/kg of 1.26%. For real simplicity most patients can take a 50mL vial of 8.4% or 500mL bag of 1.26%.
• Iodinated contrast
  
  • The entity contrast induced nephropathy, better termed contrast associated acute kidney injury, is a contentious topic. There are many good reviews already on this topic.
  • The evidence is from old studies using high osmolality agents during PCI. Fluctuations in creatinine may not be indicative of actual renal function and may simply reflect the underlying illness requiring a scan rather than the contrast itself. Patients are not more likely to need long term RRT.
  • IV contrast with modern low osmolality agents isn't associated with AKI in patients who aren't and even those who are critically ill. There was no association in patients even with pre-existing AKI. Prophylaxis with intravenous saline nor sodium bicarbonate have been found to make a difference even in CKD patients with eGFR >30.
  • The tl;dr is unless you're in cath lab or IR suite bolusing large quantities of dye arterially it is probably irrelevant. The benefit of a quality contrast enhanced scan in diagnosing and treating the patient are likely to outweigh any miniscule risk. RCR guidelines mention appropriate consent and identification of patients at risk (eGFR <40) they do not exclude the use of contrast or require hydration, at any renal function. You are the doctor, it's up to you to discuss and determine need and benefit. (It's the radiographer's job to ask, don't @ them, but they shouldn't refuse either).

Acid-base disturbances

Now it would seem we are forced to consider the fundamental concept of what acid-base physiology even is. You might have heard about strong ion difference and become lost in confusion. You're not alone. Put simply, there are two competing theories that try to explain how pH changes occur in the body: the traditional model that uses the Henderson-Hasselbalch equation to mathematically explain pH with bicarbonate, and the Stewart model that uses the concept of strong ion difference to explain why changes in bicarbonate occur. The bottom line is that these are detailed explorations of physiology more useful for bed time reading than the bedside. For the interested details can be read elsewhere.
More practically, we can work through a blood gas in a systematic fashion to help decipher the type of acid-base disturbance. Start with pH → PO₂ (always check oxygenation) → PCO₂ (respiratory component) → HCO₃⁻ (metabolic component). I've reproduced this in a simple but limited table below for reference, but this is a more intuitive flowchart to work through.

pH	PCO₂	HCO₃⁻	Disturbance
<7.35	>6	↔	Acute respiratory acidosis
		↑	Chronic respiratory acidosis
	↔ /↓	<22	Metabolic acidosis
>7.45	<4.5	↔	Acute respiratory alkalosis
		↓	Chronic respiratory alkalosis
	↔ /↑	>26	Metabolic alkalosis

^{Numbers indicate primary abnormalities, arrows indicate compensatory changes. Respiratory compensation by altering ventilation occurs quickly, while renal compensation by altering bicarbonate excretion is a much slower process.}

Respiratory

With the topic being the kidney, I won't discuss respiratory acidosis here (see this earlier physiology bite). Acute respiratory alkalosis is due to hyperventilation blowing off CO₂. This can be due to obvious things like pain or anxiety, a compensation for hypoxaemia (eg, high altitude climbing), pregnancy (increased minute ventilation stimulated by progesterone), or salicylate poisoning (direct stimulation of respiratory centre).

Metabolic

Dipping back into some physiology, we can consider two concepts that can give us more information: base excess and anion gap. The purpose of these concepts is help narrow our differential diagnosis, rather than serve as pathophysiological explanations of illness.

• Base excess (BE) - This idea comes from Danish physicians during the polio epidemic where patients often experienced chronic CO₂ retention. For a standardised numerical way of gauging the degree of disturbance Siggaard-Andersen proposed BE to represent the quantity of acid in a lab that needed to be added to a solution of blood to normalise it to a pH to 7.40 and PCO₂ of 5.3. Not because the plan was to literally add acid, but this way you could easily quantify the degree of disturbance. Rather than use this concept Americans appear obsessed with the more complicated Winter's formula instead. Most blood gas analysers will calculate BE for us, often reported as standardised base excess (SBE), with a normal range of +/- 3. A negative base excess is sometimes described as a base deficit, they're the same thing.
  
  • SBE <-3 - There is a metabolic acidosis, alone or as compensation for a respiratory alkalosis.
  • SBE >3 - There is a metabolic alkalosis, alone or as compensation for a respiratory acidosis.
  • Mild -4 to -9, moderate -10 to -14, and severe <-15 (same but positive values for alkalosis)
  • It is especially helpful with mixed disorders or causes. A lactate of 4 doesn't explain a BE of -12 alone, are there other contributors to the acidosis? A bicarb of 30 doesn't explain a BE of +10, what else can be causing alkalosis?
• Anion gap (AG) - I have a more detailed reply here explaining anion gap. It is a theoretical number that exploits the body's need to maintain electroneutrality: we have a bunch of positively charged ions (cations) that are evenly matched with negatively charged ions (anions), and we measure some of these. When we have an excess of some anions that we don't measure like lactate this calculated number rises because one of the measured anions (bicarbonate) drops to compensate to maintain electroneutrality. Like BE, most blood gas analysers will calculate AG for you.
  

There are far too many causes and detailed physiology to discuss here exhaustively. If you want to read about the Cori cycle, Type A and B lactic acidosis, helpful mnemonics and more, head to this review or this section on Deranged Physiology.

Metabolic acidosis

Symptoms are non-specific, with the most obvious being hyperventilation for compensation. In severely acidotic states (pH <7) seek early ICU help. Awake patients will hyperventilate sometimes down to PCO₂ <2 which can dramatically increase work of breathing. Initiating invasive ventilation in this stage or patient fatigue can be very dangerous if hyperventilation isn't maintained, the acidosis can worsen and precipitate cardiac arrest. Hypotension from vasodilation and reduced cardiac contractility can occur, as well as arrhythmias, confusion, delirium, coma.

• High anion gap metabolic acidosis - The presence of unmeasured anions including: lactate, ketones (diabetes, starvation, alcoholic), salicylates, formate (metabolite of methanol), oxalate and glycolate (metabolites of ethylene glycol), other toxins.
  
• Normal anion gap metabolic acidosis - Losses of base (bicarbonate loss in GI tract via high ouput ileostomy or diarrhoea, renal loss via acetazolamide) or excess of acid (renal tubular acidosis, hyperchloraemia, adrenal insufficiency).
  
• Pitfalls: Albumin is an unmeasured anion, so low albumin can mask a high anion gap. Albumin corrected formulas have been developed. Similarly excessively high unmeasured cations like magnesium, calcium, and even lithium, can also lower the gap.
  

Treatment is aimed at eliminating the underlying cause with specific therapies as required like insulin in DKA, fomepizole for ethylene glycol poisoning, folinic acid in methanol poisoning, etc.

Metabolic alkalosis

Despite metabolic acidosis being the usual focus, metabolic alkalosis is actually the more common abnormality of the two in hospitalised patients and is frequently seen as a mixed disorder (like as a response to prolonged CO2 retention as seen in mechanically ventilated patients). In severe states it can lead to delirium, seizures, obtundation, arrhythmias.
The 'opposite' of acidosis, here we see a gain of alkali or loss of acid, with impaired bicarbonate excretion required to maintain this (via chloride or potassium depletion, impaired renal function, or volume depletion).

• Gain of alkali - Iatrogenic from bicarbonate infusions, citrate in transfused blood.
  
• Loss of acid - From the kidneys via diuretic therapy, or mineralocorticoid excess, hypokalaemia. From the GI tract by vomiting especially with pyloric stenosis or obstruction as there is gastric acid loss (with chloride) only, laxative abuse diarrhoea.
  

Treating the underlying cause is important as always. Where there is low chloride and hypovolaemia, this usually responds well to fluid replacement with saline and potassium as required. Acetazolamide can be given if there is hypervolaemia although in practice this is rarely required unless continued diuresis with other diuretics is required. Alkalosis results in low ionised calcium that can cause paraesthesias, but as calcium is buffered by albumin this rarely requires treatment and resolves with correction of the alkalosis.

Conclusion

This is another large topic where there was plenty to talk about. I had to cut down the scope significantly as it rapidly spun out of control, however I thought the nuances deserved a detailed writeup. Nothing is ever absolute so don't take any of this as incontrovertible evidence of the incompetence of a hated colleague (or their brilliance)! It will hopefully have given you some ideas to think about and research further when you see patients with AKI yourself.
Until next time!

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This is a supplement to my other post about Chaos;Head Noah. Read that, too, if you want. I just thought this was interesting enough to merit its own post lol.
So, I've expressed my issue with Nanami in my first post about Chaos;Head.

And then we're onto Nanami. Her entire purpose is to be cute (so that you get attached), and then to get kidnapped. I'm not going to go on a feminist tirade here, but it's a textbook example of 'fridging', and, frankly, as well as being a disservice to her character, it's just boring.

And I don't think that's wrong, but I think a better way of expressing it is that, thoughout the story, Nanami lacks any real agency.
Almost every time Nanami shows up in the story, she's following instructions from other people. She checks on Takumi because her parents told her to. She tries to get him a phone for the same reason. Takumi makes her call the unknown number at school. She gets manipulated into walking onto the street. She gets kidnapped. She doesn't even get to take care of the original Takumi, because her memories are stolen from her, and when she gets those memories back, she's stuck in a supportive role before passing out. In Takumi's delusions, Nanami makes all sorts of decisions - pulling pranks, coming onto him for no reason - but given those are fake versions of her, they're actually decisions Takumi is making for her.
(Of course, she does make some minor decisions, like specific things to say, or when to storm out etc., but those basically don't matter to the plot.)
During the course of the story, the only decision Nanami actually makes for herself is taking the bangle that Takumi bought. And, even then, it turns into a sort of obsession that's weaponised by Norose to make her unable to think clearly and make rational decisions.
That was my problem with Nanami. Despite her assertive personality, she's not really a character, just a plot element to get Takumi a phone, to take a bangle from him, and then to get kidnapped and be rescued.
​
In Nanami's ending, Takumi doesn't realise he was sent Nanami's severed hand, and she shows up on his doorstep, naked. She sticks around for a bit, and the siblings take care of each other. It's wholesome, until it becomes incestuous. But then it's revealed that this is actually a delusional Nanami, and the real Nanami shows up, missing her hand, and tries to get Takumi to realise that he's been living a lie for the last couple weeks. Takumi, unable to deal with the outside world (despite Rimi's appearance), refuses to believe her, and decides to live together with his delusional Nanami, ignoring the fact that the real one and Rimi almost certainly died in the third melt.
I found this ending alternately boring and horrifying to read. I did like how wholesome bits of it were, but I never had much of an interest in Nanami, so the cute bits weren't all that great for me, and, as a dude with a younger sister, the incest stuff was just disgusting (even if it was tamer than I'd come to expect from this game). Even the mystery elements didn't interest me all that much.
The big exception was when the real Nanami shows up. This is the one and only time in the entire story that Nanami is a badass. She shows up and demands to be heard, demands Takumi listen to her. For only the second time in the story, she's actually shown some initiative and exerted her will.
And then, Takumi denies her.
​
Looking at this through the lens of "agency" I discussed above, what we see is Takumi, unable to deal with reality, inventing a version of Nanami who, despite the fact that he's protecting her, will be essentially his perfect companion - she cooks him breakfast, sleeps over because he asked, even takes the bandage off her wrist for no real reason other than because he wanted her to (despite the fact that she put it on to treat some pain), and any decisions she takes are unconsciously instrumented by Takumi in furtherance of his goals (as small as those are). And, when the real Nanami shows up and finally tries to exert her own will, she's denied it.
For me, this ending is a sort of commentary on Nanami's role in the overall plot of Chaos;Head. Its a reaffirmation that Nanami doesn't get agency, she doesn't get to make decisions, and when she does, she doesn't get to be heard. And, honestly, while I don't think it makes her role in the original story all that much better, I think that this sort of meta-commentary in her ending makes it the most interesting one.
​
We could honestly analyse the whole story as being about agency (among other things): Takumi's constantly being told what to do - by Rimi, by Shogun, by Suwa and Hazuki - and in the end, has to decide to take real charge; Kozue's stuck between different versions of herself and what they want to do; both she and Ayase have trouble communicating (one can't speak, the other can't be understood) and so can't do everything they'd like: Suwa and Hazuki are being made to do the bidding of the Committee: Rimi and Ayase awaken as Gigalomaniacs when they're trapped, unable to do literally anything; hell, the concept of exerting your delusions onto others by changing their perception of the world is literally taking their agency away from them - and that's what the villain's plan turns out to be, and it gets resolved by literally controlling his body; and the true ending song of Noah is even titled A Will.
But that would take a lot more work and a lot more patience with this story than I'm ready to give lol. I just thought that Nanami's ending was a really interesting aspect of it, and a good starting point into looking at Chaos;Head as a story about agency as a theme. Obviously, it's not the only theme, either (in my other post, I identified, uh, identity as a theme, too), but I think it's an important thing here.
As for whether it makes me like Nanami's character more... I'm unsure. I do think that this at least grants an explanation for why Nanami has so little agency throughout the story. But it doesn't inherently make her character any more interesting.
​
Anyway, just a thought I had.

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