...on the plus side, if the resulting insane treatment plan suddenly spotlighted as a great idea by the market prices, had been plausible enough to fool human experts, it really could have been a lot worse.

Merrin isn't watching the treatment-planning updates all that closely. She's in a fairly calm patch right now, so she's flipping past that screen for a few seconds every two minutes or so, but most of it doesn't directly concern her, and other people are tracking it. 

She does, however, have a whole lot of alarms set to unusually sensitive parameters. Most of them are ones she doesn't expect to go off very frequently, and when they do, she can afford the interruption - her entire working style means that dropping whatever's in her mental stack and reacting to an alarm is vastly cheaper, attention-wise, than watching the trends as they evolve and catching it that way when something seems off. 

The treatment-planning market is suddenly updating and recommending these three drugs! They're not commonly used - two of them are latest-generation biologicals - but they have a broad enough range of indications that Merrin has encountered all of them before. In sims. 

Merrin doesn't notice this immediately, of course, because it's on a screen that is not currently the one on her display. It's not instantly flagged as weird enough to be a probable error, either - but but Merrin has an alarm set to trigger for unusually high bids on any of the prediction markets, with the reasoning that this will warn her a few seconds in advance that she should free up her attention and get ready to do something new. (It happens in sims a lot.) When the algorithm, unopposed, doubles and then quadruples down on its bid, that sets off an alarm that Merrin notices. 

She's not doing anything more important than flipping absentmindedly through sensor-data history while toggling between three different modes on the liver machine every time the readings start to wander outside parameters (it's been a pretty repetitive pattern for a while, but not quite enough to justify trying to automate the response pattern, given that it's varying in some way she hasn't pinned down yet and it's also not really requiring any conscious thought.) 

Oooh! Some sort of treatment plan update incoming maybe! Shiny!  

Merrin hasn't consciously been listening for that particular alarm, but she is, on some level, waiting expectantly for updates and has been for a while. She flips to the relevant screen right away to see if the unusually high bid is related to dealing with the stupid ventilator problem (brief ignored pang of dread about high-frequency ventilation aaaugh), or if someone has a new backup cryo plan starting at 20 C so she can get a head start memorizing it in 30-second increments - or, maybe, possibly, an update on the timeline for those custom proteins -

It is super not any of those things! 

Merrin would almost certainly be reacting more slowly if she were running a more sophisticated mental model of the patient's state than 'X go up, Y go down'. Or, in this case, 'assume as an approximation that at 20 C, drugs with an immediate action on receptors will have reduced but maybe nonzero effect, and drugs with a complicated mechanism of action that involves modulating processes upstream of the intended result are going to do exactly nothing, or maybe do something weird and unexpected in half an hour once you've forgotten about it.' 

It makes no sense to give this patient weird obscure ??immunomodulators?? that she's seen, like, all of four times in sims, none of them in circumstances that even slightly resembled this one.

(Merrin is relatively slow at learning new material in general, by dath ilan standards, but she has a pretty good memory for 'that drug she gave that one time with the sim patient in those circumstances', especially if the circumstances were weird, and she loves finding the weirdest possible sims to run repeatedly until she manages not to kill the simulated patient.) 

Merrin also has a trained-to-the-level of instinct response to this! 

...It is, embarrassingly, apparently one that is trained for sims, because her response is to - well, apparently it starts with a not-especially-coherent, and also not especially quiet, mumbled exclamation of something like "superheated what that no," followed by, more coherently, "yeah yeah, market failure -" 

At the same time she's reaching for her cellular texter to indicate it to the sim system. Before she catches herself and remembers that this isn't a sim and, while the simulated prediction markets in sims throw weird errors a lot, this one shouldn't - so probably she's wrong and she definitely just flagged a stupid false alarm out loud in front of cameras and, like, half the top experts in various obscure domains of medicine on the planet, which is a level of embarrassing mistake that's going to be replaying in her head at inopportune moments for the next year - 

- except that recommendation really doesn't make sense??? She has her full attention on it now and she still can't see how it possibly fits. 

Merrin is now absolutely mortified, additionally filled with dawning horror that maybe the prediction market is failing now of all times and that's terrifying, and also she can't shake the feeling that she's in a sim, because this is weird - this is several levels of weird - and weird things happen in sims and, as a general rule, not during her actual shifts. 

Also she mentally blanked out the increasingly strident alarms on two of her other machines for the past fifteen seconds and they're now spiraling well outside parameters and actually she should fix that probably, except her concentration is kind of a mess for so many reasons.

Merrin isn't the first or third person to notice, she's not even the first person to say 'possibly that's a market failure and doesn't look like an urgent treatment if there is a reason, put that recommendation on hold', but the latency on deciding to bypass the entire system and then actually bypassing it is long enough that somebody has time to say on the overhead speaker "Possible market failure on prediction Thi-73" a few long long seconds before - since evidently this pseudo-market is borked in some unknown way with unknown-many consequences that could be corrupting everything - the prediction markets get blanked out of the monitors entirely.

Aaaaaaaaughhhhh actually the only thing worse than flagging an obviously stupid false alarm in front of a large fraction of the world-class medical experts on the planet is being RIGHT because now her SCREENS are BLANK and this is the worst thing that could possibly happen - 

Wrongthought. Probably, like, six wrongthoughts in there. This happens in sims, Merrin has fallback instincts, which right now are to check on all of her machines. At which point she fairly quickly retrieves the mental context that she had been working on making up for her last attention lapse - she had almost gotten the misbehaving ones sorted out, at least to 'within parameters' if not a stable equilibrium with everything else, and she's only lost a bit of ground. She's going to deal with that, first priority, and then (in fifteen seconds or thereabouts) tab back to the sensor-data screens, toggling to her preset 'in order of most critical for vital functions' rather than the order she was using before which was sorted by relevance to the machines she's running and the bodily functions they're replacing, and she is going to IGNORE whatever is going on with the prediction markets until someone better placed to figure it out makes the announcement. 

(The patient is fine. Or, well, as fine as he can possibly be given all of the extenuating circumstances. The sensor error was an error, none of the underlying processes are changing fast, the erroneously recommended treatment didn't actually get implemented and probably wouldn't have done anything even if it did, and 30-45 seconds of Merrin being distracted isn't actually enough to break anything.) 

Exception Handling, it seems, has utterly failed to prepare a failover version of their secret medical market with weaker medical trading algorithms that only use human-legible statistical methods.

But Exception Handling, contrary to what some angry voices are already saying, is not made up of complete incompetents!  Just moderate incompetents!  It's not the first time that any secret prediction market has failed for any reason, and Exception Handling does have a pretested secret version of the failover software and protocol that regular hospitals use, when some (rather less liquid) regular open prediction market seems to be failing for whatever reason, but the hospital still has Network access and the case still has interested human participants.

It involves human experts producing the same judgments and other human experts integrating those to arrive at final recommendations in place of machine algorithms.  It's not particularly complicated.  When a complicated machine system just failed, it is a great time to failover to a simple human system.  They aren't missing the software for that.  Failure on that level really would get people fired, and not just in Exception Handling's branch of Governance either.

It's going to take five seconds for the failover manual protocol to start booting up on the monitors, and twenty seconds after that to actually get the human expert judgments routed to a human integrator, and the first non-market recommendations to start appearing on the monitors.  Though, obviously, they're going to have a few more seconds latency compared to when algorithms were doing half of this work.

Oh, and standard protocol in these failover cases - developed for markets that are usually a lot less liquid when they fail - does of course state, simply and robustly and uncomplicatedly, that the current chief operator in the patient theatre is the one person responsible for making the final call on which expert recommendations if any should be followed.  Just like in the sims!

Everything is fine it's fine the sensor-log isn't trending worse there's already another alarm going off - liver machine this time - but she's on it - 

The failover software has a very recognizable look. Everyone on staff has trained on it in sims at least a few times. Merrin has run sims with it probably fifty times. She isn't confused, when it flips over, and in the first half-second she just feels relieved, higher-latency updates are better than AWFUL BLANKNESS. She has the final say, but that's standard, that's how it works in sims - 

...The fact that she still has the nagging feeling of being in a sim is probably why it takes her another ten seconds to draw the rest of that inference. Which is that she is SOMEHOW the chief operator in a BIZARRE and TERRIFYING scenario which is not a sim it is REAL LIFE and if she screws up then a real person ends up in cryo and - presumably, based on the shocking quantities of money and resources being invested in not that - other?? bad things?? happen??? Really major bad things, on the scale of one person's true death or a whole planet's inconvenience, because that price-per-QALY number is, while not actually infinite, large enough that her internal number-sense is having trouble parsing it as a real finite number. 

(Merrin hasn't actually been poking at what bad things someone somewhere with a lot of resources is worried about, or who cares so much about the outcome here and why - you don't mess around with level-3 secrecy oaths, this is an Exception Handling situation, she doesn't need to know -) 

...But she's been so narrowly focused for so long, and it's a little like waking up from a dream, except for how she has the feeling that she's still dreaming. Fine, sure, she was the only one in their tiny hospital with the necessary certs, but it's been three hours and Merrin is suddenly so confused about how she's still the chief operator here. This does not seem like the sort of thing that should happen????

...This is also a really bad time to freeze up and have an internal meltdown about terrifying situations which she is not qualified for in any way, no matter what certs she has. Merrin is not the person responsible for deciding whether to replace herself. Even if they've suddenly made her responsible for everything else, she still isn't, because for one she doesn't have the slightest idea what their alternatives are although surely by now they could have flown someone in with all the same certs but smarter than her and with more extensive hospital experience not limited to a tiny unspecialized regional hospital Merrin is not the most informed person on their constraints and it doesn't make sense for her to waste time getting more informed. Her role here is to convey any information that she has and other people don't, and then concentrate on the patient. 

"I, um," and she's sort of having trouble keeping her voice level, which hasn't happened since she was eight, "I'm - this is probably not new information, but, I don't think, I'm very qualified for this... Um. I'm not tired, I - can do this for a while - ummm if it's going to be more than another three hours I maybe need someone to cover me so I can go to the bathroom at some point. Not urgent though. An hour from now is fine." 

Aaaaaaaand now she is going to FOCUS and only slightly melt into a puddle of embarrassment on the inside. 

(The embarrassment doesn't actually last very long. The everything-else is very absorbing and Merrin is....maybe just going to sort of half-pretend she's in a sim, for a while, until she has a better handle on being terrified.) 

There's all kinds of background discussions going on about this issue right now, needless to say.

Most of those discussions have started with somebody firing a query to Hospital Administration that goes "I assume she was being understandably sarcastic about the additional three hours, right?  I can't infer back what she meant in terms of her actual stamina constraints past the humor" and Hospital Administration firing back "No Merrin was being perfectly serious and did not mistake this for a joking situation."

The second-rank Keeper brought on site as Merrin's backup has by now been set up with a sim room hastily reprogrammed to mirror what Merrin is getting.  Since the prediction market blanked she has resumed trying to shadow Merrin's responses to those, albeit with some irretrievable latency from extra steps in mirroring the output.

After watching them both for a minute, the consensus is that Merrin is still doing at least as well as the Keeper would.  Possibly due to Merrin having roughly 20X as much emergency medical sim wall-clock time; possibly due to Merrin having tracked every aspect of this patient for the previous three hours.  Without, apparently, her getting tired.

The other experts on this issue have not actually been trying to read off everything that Merrin has seen over the last three hours.  Even the second-rank Keeper who specializes in attention-splitting hasn't been doing that, because then she'd already be tired by now.  Keepers can decide to proceed past being tired, they can even decide not to be unhappy about that or distracted by that, but they can't decide to not have their reaction times degrade with expended stamina.

Also Personnel from Administration, who might possibly feel a bit protective about Merrin, is currently quietyelling at Exception Handling about whether the next step is going to be dropping Merrin in a forest with only a flint knife to do surgery on her patient, while the function of a prediction market is provided by inferred-pre-Screening-conditions hunter-gatherer elders watching and betting coconuts against each other.

(Exception Handling has in fact started to have thoughts along those lines, about Merrin; but that's for later, rather than in the current case.)

Anyways!  Exception Handling knows that it has screwed up and Exception Handling will dutifully accept being yelled at later.  But right now, considering the increasing weirdness of the present situation, Exception Handling would like to know everything there is to know about Merrin in vastly greater detail.  So would a lot of other market participants, actually, particularly all the ones betting on whether or not to replace Merrin with the Keeper.  Where are they on the Merrin dossier?

Exception Handling now has their hands on a summary of Merrin’s school history, psychometric results at various ages, family and major childhood events. 

The tests for thinkoomph are about what you’d expect. -1 SD overall, weakest on numerical, some deficits of abstract reasoning, strong executive function and attentional-control - above average on that, in fact - incredible biographical memory, plus she's also a 'face recognizer' - all of which is potentially confounded by the various ways in which she’s an extreme psychological outlier. 

The first note isn’t even one of the standard tests, but an observation made by various adults who interacted with her as a child. On the dimension that might be called ‘diachronic versus episodic sense of self’, and basic consistency of traits demonstrated over time in different situations, Merrin is off the charts toward episodic. In short, Merrin’s personality is unusually malleable, her psychological profile at age 4 bizarrely non-predictive of the later measures at age 14. This wasn’t flagged as soon as it might have been, because – and this is also unusual – Merrin had lived in five different cities by the time she was seven. 

The age-4 notes do look predictive of someone ending up in the medical field, though Merrin may have had a mild developmental delay – she was testing at -1.5 SD at age 4 and uninterested in learning math, which seems even more incongruous with her current performance. Otherwise: extreme agreeableness, high conscientiousness, excellent emotional regulation for her age, and a lot of persistence. Four-year-olds are not usually tested on stamina, but Merrin just didn’t seem to get bored the way other kids did. Despite overall high emotional stability, it was noted that she had low confidence in herself and was often anxious - more specifically, she constantly worried about whether other people were upset with each other or with her. She was deeply reluctant to ever contradict an authority figure, and had a tendency to go along with other people and agree with their claims even if she knew they were wrong. But ‘eagerness to make the teacher happy’ worked as a motivator for lessons, even if apparently ‘wanting to prove she was right’ didn’t. 

There is probably a full report somewhere on everything that went wrong next. It’s not in the current packet, but you can read some of it between the lines. Her parents also tested around the same intelligence, which wouldn’t normally be an indication for a child subsidy, but a subsidy is what’s on record - looking at Merrin, the justification of ‘cognitive diversity’ does look justified in retrospect. The subsidy isn't that high; at least one of the parents must have badly wanted kids. 

It’s not hard to guess which one. Merrin’s mother, Irris, taught art for toddlers - and was very good at it, apparently - but dedicated the next fifteen years of her life to raising three children. Merrin’s father worked ‘miscellaneous jobs’, presumably the reason for all the moving around, and…when she was seven, opted for early cryopreservation. This is really not normally something that the parent of a seven-year-old and two younger children does. It’s not further explained, but there’s a whole tragic story told in that handful of lines. (One of the tiny costs of the huge benefit of Civilization-wide cryopreservation; Merrin's father probably wouldn't have truicided if truicide had been his only option.) 

One final move later, Merrin arrived at a new school in Harkanam, and the initial notes could have been about a different child entirely. Merrin in Harkanam was quiet, withdrawn, and abruptly uninterested in any kind of social connection with her classmates or teachers. Her mother accessed some of the available support resources, but not really for Merrin, who ‘was fine at home’ – despite the fact that, based on the sketchy school notes, it would be four years before she had another friend. It’s generally not considered a good idea to keep pushing kids who aren’t engaged, and risk burnout - in hindsight, this might have been actively counterproductive for Merrin, but she was certainly disengaged, and ended up around three years behind educational milestones for the median child her age. 

Skip ahead to Merrin aged eleven, when the latest set of assessments includes an instructor’s note, that starts with ‘learning potential not well represented by formal test scores’, and the rather bold decision to assign Merrin intensive tutoring for a summer of catch-up and then jump her ahead by two years’ worth of curriculum. The fact that it worked would have been baffling to anyone who didn’t already know that Merrin was apparently willing and able to regularly pull eight-hour sessions of drilling sims. 

By thirteen, Merrin had caught up to her peers overall, though she was still very behind on mathematics and probably always would be. ‘Merrin learns best with realistic live examples rather than abstract description’, a teacher noted. She had apparently been set on training as a nurse for years, and as per usual spent some time in the hospital as an unskilled care aide, shadowing the trained nurses. Despite still apparently being very emotionally sensitive to whether anyone was annoyed with her, she was good at it. The face-recognition maybe helped, and likely her high agreeableness - at least now that it was tempered by a few more years of training in when to notice that authority figures were actually wrong and say something - but mostly it was the fact that she could do it for six or even eight hours at a stretch.

She didn’t meet all the entry requirements for further nursing training, though - economics and statistics, mostly, she was actually above average on bio knowledge - so she spent another year grinding through remedial tutoring, then took took two years to get through what was usually a one-year program if not less. Her theoretical and conceptual understanding of areas like advanced biochemistry was never anything more than mediocre. Good enough to get by, in the end, if just barely, and a sympathetic instructor might have made the in-hindsight-reasonable judgment call to let her consistently subpar performance on real-time mathematical reasoning slide. 

They did not think to examine Merrin on her ability to pull off slightly subpar performance for six hours straight as a newly-qualified nurse, which makes sense because this is absolutely not one of the pass requirements. 

AND she continued to pick up some paid work as an unskilled care aide while she was studying??? The hospital schedule from two years ago shows her occasionally working night shifts - last-minute scheduling, maybe doing a favor for someone - and then attending courses the next day??? Who DOES that????? 

…She apparently didn’t draw on any income-sharing agreements to cover her living expenses during school, though she must have known this was an option. Her expenses wouldn’t have been high, it’s plausible she had enough in savings or parental support to cover it anyway, but it’s still at least a little unusual. 

Anyway, she reached the basic cert at sixteen, spent four years in lower-level positions at the same hospital while gradually adding to her certs in her spare time and has now, at age 21, been working in the ICU for about a year.

...that sure would sound underqualified if she didn't have literally twenty times as much emergency-sim wall-clock time as somebody like that ought to have.  Not sim time in general, there are people who play sims like they play games, but Merrin went specifically for emergency sims where she had to handle five simultaneous problems with unreasonably small amounts of backup like those were just video games, for hours at a time.

Right.  Should somebody tell her that she's still apparently outperforming the rank-two Keeper who'll take over once her performance actually starts to degrade?

Not phrased like THAT, definitely!  Merrin is a bit shy, and has some sort of mental block about being praised as special for things like being able to casually work eight-hour shifts or maintain dozens of emergency certs.

...for the record, has anybody already tried just whapping her on the head with a banana and telling her to be more ambitious?

Next time there's a pause when it won't distract Merrin too badly, she'll be told that she's still outperforming her current understudy trying to shadow her.  They'll keep the expert recs strong where unambiguous, but those experts are not actually on the scene watching all the machines and retrospective performance assessments are reflecting that.  The Venture Capitalist is aiming to start treatment in seven hours but prediction markets are calling it for 8/9.5/12 hours at 20%/50%/80% cumulative probability.  Can they share her extended dossier with market participants under grade-two confidentiality?

Oh NO now so many people are going to know exactly how terrible she is at math Merrin is going to tell them that yes of course that's absolutely fine. 

(It's really weirding her out that her mysterious understudy - probably someone from one of the really big hospitals that sees situations this complicated, if not regularly, at least ever outside of sims - isn't any better than her? Maybe it's just because of all the time she spent on the liver machine. She ran so many iterations of that sim - tweaked to play out differently each time, of course, otherwise it would just be memorization and not useful practice.)

For the record Merrin is pretty sure she can do another eight hours without substantial degradation (internally, she's thinking that yes she'll get a bit tired, but getting used to the task and iterating toward a better workflow more cancels that out - her performance in sims does start to degrade at seven or eight hours, but that's when she's running multiple blocks of two or three-hour sims with different patients, since for some reason the library of sims mostly doesn't include ones that last twelve hours. And even a fifteen-minute break helps a lot.) 

- it'll help if she has a steady supply of mild stimulants - uhhh, on that note, now would be a good time for that - actually on reflection this seems like the sort of situation where it's not a stupid borrowing-against-the-future idea to go for a less mild stimulant, this seems like exactly the case where it's worth it although someone should check her reasoning on that she's sort of metacognition-impaired by all the keeping track of five things at once. Caffeine works really well for her although she should maybe confirm they aren't going to need her for any more obscure procedures, it makes her hands shaky. 

She's never tried fifteen hours straight of something this hard and would not bet on herself and they should make other plans for that, although she's not going to collapse or anything. (She just starts getting really irritable and angry at the the equipment or the patient when they don't behave how she would like, but that's actually too embarrassing to say out loud.) 

It takes them twenty radioactive minutes but they do get an alternate prediction market mechanism back up, except that the algorithmic outputs aren't just simpler, they're being passed through human bettors.  There are such things as people who get pretty good at medicine and pretty good at betting, and some of those rare folk have now been sworn to grade-three secrecy and brought into the system.

This does mean the new system being rolled out is untested as a whole, so Merrin should please consider herself to be one of a dozen people charged with yelling if the predictions look slightly stinky.

But the recommendations now once again come with quantities-that-actually-mean-something attached to them!