Sep 29, 2022 4:14 AM
how Merrin came to the attention of Exception Handling
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It's simpler to transmit the retinal data directly to Exception Handling, instead of them trying to override the standard hospital API.

 


(...Exception Handling is not totally uninterested in any situation this slightly unusual, actually...)

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Yes sure he can do that literally fifteen more seconds and they should have patient ID -

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Twenty seconds later, the prediction market prices disappear from the LCD monitors above Merrin's patient.


"Exception," sings a loud female voice on the overhead speaker, using a legally restricted prosody and melody.*  "Tick five."**


(*)  When this sort of thing happens in movies, for example, the actors use a slightly different but clearly distinguishable prosody and melody.  This preserves the ability for somebody to shout 'Exception, the movie theatre is on fire' and have that announcement be clearly distinguishable by sound from an in-movie event.

(**)  Meaning:  Everyone has five ticks to prepare themselves to hear the rest of this announcement.

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They took her decision-making information away that's NOT PLAYING FAIR  this isn't a sim. Besides, Merrin has delved well into the depths of weird extreme sims where more than one unexpected thing happens in a row. 

Merrin is allocating her full attention to– no, that's not true, she is still watching the screen currently set to display the various settings on the internal cardiac pump alongside the patient's blood pressure and O2 saturation, since she is in fact the only person in the room with a cert for that. Still, the majority of her attention is on waiting to hear the announcement, whatever it proves to be. 

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"This is Exception Handling.  We have ID on the patient and special conditions apply.  Everyone in this process needs to affirm a grade-three secrecy oath covering all further events and observations not specifically excluded, before further information exposure; else recuse themselves."

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Merrin is absolutely not going to recuse herself!! This is HER PATIENT!!

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…Except apparently these are special conditions? Unspecified special conditions?? Merrin is definitely not certed for special conditions! Especially not ones that involve Exception Handling!

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Wrongthought. Whatever’s happening right now, unless it turns out that the patient is literally an alien or something (this possibility is, perhaps, especially close to the surface for Merrin given her abandoned con plans for today, but it’s vanishingly unlikely) - but outside of vanishingly unlikely possibilities, the special conditions are going to be about who this person is to Civilization. Not the basic anatomy and physiology of their body, which she’s already been watching over. If she was the right person for this before it turned into a bizarre Exception Handling case, she’s…probably still the right person for it now? At least for the next thirty minutes until they pull in someone more qualified? 

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Anyway. Merrin doesn’t want to walk away, it turns out, even if this is suddenly and unexpectedly high-stakes. She’s played out high-stakes scenarios in her simulations, before, and of course that wasn’t the same but she’s not entirely incapable of generalizing skills practiced in one context over to another context. 

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Also, it’s causing her visceral, almost-physical discomfort to have the screens blanked out like that! 

 

 

So, yes, Merrin is going to affirm the grade-three secrecy oath.

(She doesn’t need to figure out the non-medical implications until the medical situation is over.)

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One of the equipment oppers has full-sharing marriage vows and grade three secrecy is above that - can somebody dual-op their position pending their replacement, ok great they're recusing themselves -

 

Everyone else is on board, apparently.

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"Special goal on patient.  Patient wants his brain in near-perfect working condition by any means necessary, even at risk of other injuries requiring cryo; else patient wants cryopreservation.  We'll go looking for success-probability bids on procedures for that.  Your interim goal is to keep him stable and in best condition for unspecified future procedure, wait duration unknown but assume multiple hours."

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The market screens come back online!  The bid-ask spreads have narrowed to points and are also actively moving by the second!

The combination of these two conditions implies a degree of liquidity and trading activity in this patient market that you'd ordinarily associate with, say, a top-1000 worldwide corporation during a CEO news conference.

 

Oh, and they've got a number on how much they should be willing to spend per patient-QALY!  It's not literally +INF or NaN but it might as well be.

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AAAAAAAAAAAAAH???

 



On the one hand this is terrifying and Merrin feels like she does not belong in this room at all! On the bright side, though, her screens are back up! With much faster updates! And it seems like she can assume extremely quick responses from world-class experts on treatment planning! This is a good sign. She is no longer flying solo. She is instead working in front of every currently-awake, available, and interested medical expert on this continent this is not a helpful target for any of her limited attention.

…The decision-relevant piece, at least for Merrin personally, is about the “multiple hours”. She would really like more information on how many hours that means! Is it three hours or 30 hours? Does she just need to worry about basic vital signs and electrolytes, or longer-term organ function (for organs that are not, currently, functioning at a body temperature of 20 C).

What do they mean by 'stable' - do they want her to get spontaneous cardiac electrical activity back online, that's going to require at least (quick mental estimate) four to six degrees of rewarming - do they want her to keep everything exactly the same as it is right now -

…What targets are the treatment planning screens actually showing her?

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Policy markets:  Current top success-probability is if they don't rewarm the patient at all, right now.  Explanation-summary: it preserves option-value if anybody digs up a further injury that'd potentially occur on unguarded rewarming of the patient's brain from 20C-cold to a more standard 28C-cold.

That policy's success probability dips suddenly even as Merrin watches, some unknown trading entity placing a more pessimistic bet, but doesn't drop to the point where it goes underneath the success probability if they start rewarming the patient to a higher cold temperature right now.

...the markets haven't actually updated yet with a protocol telling her how to semi-stabilize a patient at this temperature, but presumably that will be on the way very soon?

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....Okay, that gives her enough to go on, and the plan mostly makes sense. 

'Stable' is a relative term. The patient isn't medically stable, right now, by any reasonable definition: his heart isn't beating on its own, his critical organs are mostly not functioning. But in another sense, he's currently stable in that he isn't rapidly deteriorating. Because the approximately-suspended-animation of a body temperature that low means that every metabolic process - both the helpful and the actively unhelpful ones - are drastically slowed. 

She gets, instantly, why 28 C is different. There's a reason why that's the low-point cutoff for standard protocols: you can keep a patient stable at 28 C, with their metabolic processes still working - slower, but not paused

You would not normally try to do this. Usually, either the patient is recoverable via existing protocols, or they're not, and you go straight to cryo. But these aren't normal circumstances, because this person is IMPORTANT because they have absurdly huge numbers of labor-hours available to spend on any treatment that buys them an even marginally higher chance of more patient-QALYs. 

A treatment which doesn't exist yet. But someone thinks it's worth their while to come up with it, on the spot, while Merrin buys them a few more hours, by preventing the patient from getting any worse. 

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Well! Merrin is very slightly less confused!

This is going to be a fascinating and probably exhausting few hours (and she should at some point remember to text her friend delegate that, because there is no way she's going to be in an emotional state for a con after this) but she has her objectives, at least. 

The one she knows already is 'maintain body temperature at its current number'. She's already thinking ahead to what measurements are currently normal and are going to go awry over the next few minutes or hours, but in the meantime the market will hopefully suggest some parameters for blood pressure and O2 sats? Given that the current ones are kind of a random result of treatments applied by the EMTs and herself before they had any idea that THIS was the medium-term plan? 

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They don't, actually, have every treatment planner on the continent who's awake, watching this; only treatment-planners who already have extensible secrecy-oaths with Exception Handling, likewise the market participants.  They're well-capitalized, sure, but fewer than Merrin might have hoped.  Bid-ask spreads are that small in part because market participants are bidding closer to their true probabilities in exchange for subsidy.

They're rushing getting at least the consensus first steps on that ops-room monitor, even if it's not sufficiently formally specified to get traded and come with a probability attached; but, alas, things are not quite as fast as they'd be if this was an open commercial medical market.  Secrecy has costs, always; and secrecy has nonmonetary, financially irreducible costs, almost always.


Someone else is having a conversation with Hospital Administration about a purported plan now rapidly being sketched out which would involve five different pieces of equipment, half of which only get used in weird emergencies.  Is this tiny regional hospital actually up-to-date on its emergency certs, and do they actually have oppers corresponding to all of those five pieces of equipment on-call, and can all five of the requisite people actually be inside that room in the next seven minutes?  It's understandable if trying to press all five of those buttons makes one of those buttons fail, but if so, EH treatment planning needs to know that right now.

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Actually they've got somebody with all five of those certs and she's in the room already.


(It's possible that Hospital Administration may have snapped their fingers just before saying this.  Not where Exception Handling could hear it, if so.)

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...that's a clever hack for passing emergency certs, if they've got somebody who learns that fast - legitimately clever, it wouldn't usually be a bad thing - but in this case they need at least three different people with those certs, because one person isn't going to be able to supervise five different procedures -

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Nah, Merrin's got it covered.  She runs sims like that all the time.

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The monitors update with an interim stabilization plan, involving five different pieces of equipment all of which Merrin luckily happens to be certified on.

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Weird??? That is not the sort of thing that happens in real life?? 

Merrin has not, in fact, used exactly those five pieces of obscure equipment before in a sim. ....That she can explicitly remember, at least. She's run kind of a lot of sims. Sometimes fifteen of them in a row when she kept screwing up and 'killing' her sim-patient. 

Still. She's personally run five different pieces of equipment kind of a lot. It's fun. (Sometimes she pushes it to seven, but usually not for very long, because then she starts to consistently kill her simulated patients, which really kills the mood.) 

All right. Focus. 

She's got the internal cardiac pump set up already. They've now given her parameters for (mechanically-provided) heart rate, and for blood pressure. Separate for systemic and for carotid e.g. brain bloodflow - awesome. (Not awesome as in easy, but Merrin is always happier when she has a number to aim for.) 

They've given her a maximum O2 saturation, specifically based on a real-time pulse oximeter placed directly around the carotid artery (it's a soft clip, inserted through the skin under ultrasound; Merrin's trained on it and it's fiddly in a way but it doesn't involve sharps near major arteries). That's...something. It makes sense given the premise but it's not something she's had to wrangle before, and she cannot actually pull it off just by adjusting the mechanical ventilator settings.

Especially because they've given her a really narrow band for allowed blood CO2, and she (well, someone else most of the time, that's standard except when it starts interfering with her other procedures) is predictably going to be maxing out the allowed vent-setting variation just staying within that. 

For now, she can set up a different device and use it for...the opposite of its usual function, actually, normally it's used to prevent vasospasm (overly clenched and narrowed arteries) providing blood to the brain, and she's going to need to use it to induce that reduced bloodflow if her O2 is about to go out of allowed bounds, long enough for the vent settings to catch up. 

 

And meanwhile she's going to be adjusting minute variations in blood temperature to the brain, and running multiple other organ functions on manual mode. For an unknown number of hours. 

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...handling that many different processes is probably going to burn out the opper - "Merrin", apparently - pretty quickly.  But if she can control all five procedures simultaneously and integrate the results, there's expected efficiency gains from her doing that.

There's a lot of conversation going on behind the scenes right now, none of which Merrin should be bothered with.  The only thing worth interrupting her is explicit confirmation that Merrin thinks she can keep up this level of intensity for at least thirty minutes -

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