how Merrin came to the attention of Exception Handling
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Oh good. 

 

Merrin is mostly not going to disagree with any of the recommendations being listed. The lag does mean that she's going to do more proactively asking for someone to look at something. 

And time passes. 

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Somebody notices that the computer-based portion of the new market system has started mainly deferring to Merrin, because the algorithm noticed that her most recent action is usually the best predictor of what will later be judged as a correct move.  (Not surprising when Merrin's action-output is the final summary of that much advice!)

There's a thing you do, in a case like this, to allow a trading algorithm to treat its own past final prices as data-about-history without relying on it as a followable indicator in a way that doublecounts evidence or creates circularity; but the whole system is hacked-together, and fixing that will take a few minutes once they notice.

Merrin will thus be warned at some point that the trading algorithms started relying too much on her own judgment as a followable indicator, because she's right too often, and she needs to trust market prices less as validation of her own judgment; they're not actually independent and won't be for another few minutes.

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Um???????????????????

 

...You know what this is not worth having feelings about. Pretend it's a sim. This would be fine in a sim. (...She's not sure this specific thing has ever been thrown at her in a sim, actually, but it would be fine if it was.) 

Merrin is maybe very slightly worried that she sure is doing a weird mental contortion here. She isn't sure if it's the sort of weird mental contortion that will compromise her clinical judgement, since in fact the entire point of sims is to make the right judgement calls. 

What's different? It's...not exactly that the stakes are high. She can take the pressure when it just comes to fighting for a good outcome for this patient, even if that's really really really hard. It's really mostly about the number of people watching her– no, not even that, it's about the number of people, smart capable experienced people, who nonetheless think she's the right person to run this. 

Why is that so awful

–you know what this is not helpful to try to debug right now she is going to keep doing the weird mental contortion. 

Merrin bites her hand to try to get her concentration back and then remembers the cameras and looks utterly mortified again, but it does help get her out of the stupid loop of agonizing about the result of someone else's decision to keep her at this. They're probably just being really risk-averse about changing anything up?

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Not everyone who works in Exception Handling, or even every Keeper, is read in on every one of Civilization's secrets.  Not everyone in the loop on this medical emergency is watching Merrin on the video feed all of the time.  Also there are some non-masochists in the world who apply pain to themselves to refocus their concentration, though it's not common.

This particular hand grenade isn't going to explode until a few years later.

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The patient's status:

The blood-levels sensor in the patient's brain is still reading close-to-undetectable on the various indicators of neuron and other cellular damage. They are, by vast effort, keeping everything within the incredibly narrow parameters set by the treatment protocol, and they seem to be the right parameters, probably - at least, there's nothing to indicate they're the wrong parameters. They're getting regular ultrasound imagery and his circulation is steady, no tissue swelling, no patches of irregular perfusion. 

(They're flying in an experimental CT scan setup from a lab somewhere, on the grounds that they really, really can't get this patient stable enough to risk half an hour trapped in the MRI suite with half the sensors missing - the ones that don't have metal-free replacements - and much more limited recourse if anything goes wrong, which is not a risk worth taking for the limited diagnostic benefits.) 

They're maintaining the holding pattern, at the cost of almost everything else - but as a result, everywhere else they're losing ground. Not fast, or on anything that really matters for the next 8-12 hours, but they probably can't stretch this out to 24 hours and expect the patient to recover in good physical condition, even if his brain is 100% intact. 

Ultimately, they have a limited number of levers they can push, and a lot of the variables they can affect are correlated. And the internal dance of coordination that would usually take care of keeping the patient's blood pressure tolerable in his brain and his toes is offline - the human body can send local signals to constrict or dilate capillaries, but they only have the one. Small random fluctuations spiral into bigger ones, everywhere that they're not focused on. 

Sensors placed against the gastric mucosa, down the patient's throat and in his rectum, can confirm that the circulation there is close to zero. Tissue damage is accumulating - slowly, but the signs of vandalism will be there whenever they revive the patient fully, and their careful hundred-custom-protein treatment plan is focused on the brain tissue, which is idiosyncratic in a number of ways. 

The patient's lungs are in awful shape. The manual cardiac pump does let Merrin tweak it somewhat to keep the lung-side circulation, from the right side of the heart, in nominal limits while still keeping the systemic circulation under their max, but you can only pull them apart so much. They're considering other options but every invasive procedure is another infection risk, and this is a weird problem to be trying to solve, there's no existing equipment or protocol for it. Anyway, the lung tissue is accumulating damage, not just from the water, but from an ongoing ventilation-perfusion mismatch that they cannot seem to balance out with the tools they currently have. Also it's probably really bad for the right side of his heart muscle. 

(Also at some point they are going to run out of room to keep increasing the oxygen concentration, and won't be able to stay above even the very low O2 saturation and partial pressure O2 blood gas goals. That now seems pretty likely to happen before 8h is up, and of course it's going to be a much more serious problem once they want to bring the patient back up to a normal body temperature and normal oxygen saturations. They're going to want extracorporeal membrane oxygenation to replace the patient's lung function entirely by that point, and arguably sooner, but the standard equipment needs a lot of tweaking for what they want to do with it, the usual settings don't go that low and the remaining way to regulate it, slowing the flow somehow, will probably just make the filter clot faster.) 

Also his minimal liver function - it did come back a little once they had consistent if low circulation - is now nosediving again, a combination of slow-motion cell death and the fact that stores of various enzymes are running out and the energy cost for the relevant secretory cells to make more is much higher. 

Merrin is doing her best, but her simplified liver machine is not going to cut it for another 8-12 hours. 

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They're working on clever solutions for stupid problems, there are other venture capitalists in this loop and all of them like a challenge, they can't regain ground lost but there's people working on not losing more of it.

 

complicated Liver Replacement Module has now been flown in by special aircraft, and docked with the hospital's foundation and initialized.  But they're going to have to move the patient's room, to get it adjacent to the Complicated Liver Replacement Module.  Is this a good time to move the patient's room?

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Aaaaaaaaaaaaaaaaah does she HAVE to that's almost as bad as an MRI It's not, in fact, nearly as bad. The room module moves with the patient in it. Everything needs to be secured for some acceleration, but they won't have to reposition any of the machines or anything. 

Merrin will put it this way: it's unlikely to miraculously become a better time for it any time soon? Can they please try to keep it really gentle though, no sudden stops, especially not in the direction which is to the patient's left, there's something weird going on with his lung on that side and she has an uneasy feeling about jostling it any more. 

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Not the first time a situation like that has arisen, they've got software for minimizing acceleration and jerk, and they'll obviously put human programmers on monitoring the software.

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Then this will go basically fine!

Merrin is still on edge the whole time but that's half about the upcoming handover on the liver stuff. It's going to be great once it's done but she is so incredibly not looking forward to the process. The time duration is probably fine, but it will take like half an hour for the new team to get set up properly, during which time they'll be trying to gradually take control from her, but inevitably there's going to be interference and imperfect coordination and it's going to mess up everything else. ALSO the Complicated Liver Replacement Module takes about triple the amount of blood in its circuit - still not that much blood, about 100 mls, and the treatment planning is recommending priming it with plasma instead of saline, but they need to start it circulating fairly quickly to avoid clotting and it's going to throw off her nice comfortable rhythm of manually controlling this guy's blood pressure so badly. 

Which will mean that she has to spend the first five minutes stabilizing that and not sparing much attention for the liver machine - oh, she can ask someone to cover for her, they'll lose coordination but it's probably better than her trying and ending up completely ignoring it or doing really stupid things because she has no cognitive bandwidth for it. 

She will ask for that. 

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She can get temporary support! They've had assigned temporary spotters for a while, who are trained on a given piece of equipment (just not all the machines), and the nurse covering for her has been watching her for a while and has the hang of her particular process, so can stick as closely to that as possible. (Even if this is theoretically suboptimal, because someone focusing all of their attention on it can make faster and more sophisticated judgement calls than Merrin task-switching, it's worth it to keep it predictable for her while she's juggling unpredictability elsewhere.) 

The team for the Complicated liver machine will, of course, keep theirs on standby and wait until Merrin has the patient re-stabilized to start the actual handover. 

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Larger-gauge catheters are placed in the patient's femoral vein and femoral artery. The machine starts up. Plasma goes in, blood goes, out, and -

 

- yeah the patient's body really really does not like that! 

It's especially destabilizing to Merrin's delicate balance because it's on one side of his body (they could have gone for the abdominal aorta or something, but it's a lot harder to get at, it would require a laparoscopic approach with a camera, and of course it's a much larger risk if someone's hand slips.) The bloodflow here is less than what the actual liver gets (under normal conditions which are not these conditions) but sufficient for their needs. 

For whatever reason, the immediate effect is to tank the right-sided cardiac output, maybe just because Merrin is pushing the limits of her equipment more for that. 

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Merrin was not per se expecting that to be the thing that happened!!!!! She was mainly worried about a drop in his systemic blood pressure, not lung perfusion. 

Fortunately, she THOUGHT AHEAD, and has someone with an ultrasound probe getting real-time imagery of the patient's heart. (They're not doing that continuously because the ultrasonic vibrations screw up some of her sensors.) Her manual cardiac pump machine also picks up on something and sings a tune of concern into her earpiece, but she silences it without even looking, it's not like it's telling her anything she doesn't already know. 

Weirdly, a complication that she saw coming is when Merrin is least likely to resort to expletives, and most likely to calmly and politely complain in the patient's general direction. "I would rather you didn't do that," she says out loud, and dives for her console. 

Normally she would ram the O2 concentration on the ventilator up to 100% rather than waiting for the patient's oxygen saturation to start dropping - there's a delay, and a corresponding delay in increasing it - and she almost does that on instinct and catches herself. Over-oxygenating this patient even briefly is almost worse than responding slowly to a drop. 

She dials it up to 80%. 

She's - actually maxed out on the controls that let her increase right-sided cardiac output and not systemic output, apparently, that's really annoying. She doesn't want to increase his systemic cardiac output because then she'll have to spam the vasodilator-constrictor, and she knows exactly what she would do that would work on a muscle-memory level, at this point, but her hands are sort of busy and she doesn't think she can verbalize the pattern to anyone else. 

She dials the rate up instead, which isn't great but it should be okay for a couple of minutes. 

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The next couple of 'heartbeats' shown on the ultrasound screen are even worse, though hopefully this is the worst of it, the circuit is now fully primed. 

Merrin's O2 alarm is complaining - he's down to 43%. 

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Aaaaughhhhhhhh why is this her LIFE right now fine up to 85% on the ventilator - no, 90%, he's still dropping - and wow they're running out of wiggle room fast, she's already noticed that she can almost never wean the oxygen concentration back down, probably because ramming almost-pure, highly reactive oxygen at already-damaged cells, when the pathways for dealing with reactive oxygen species are mostly offline because 20 C is outside the design specs, is a great way to throw around lots of free radicals and break everything more. 

...Ugh and she hasn't seen an update on a clever solution to the stupid problem of 'our extracorporeal membrane oxygenation systems don't go this low and don't like it this cold', which means a swap to high-frequency ventilation might be in her future, and that's going to completely throw off the timing-rhythm she's intuitively absorbed on when in the respiratory cycle to tweak her cardiac pump settings for the best effect, AND it will make NOISE. 

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39% and the faster and higher-pitched urgent alarm is going off now. 

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Oh no now people with more reasonable alarm settings are probably going to notice and judge her  Merrin's brain can shut up. She goes up to 90% with one hand while dialing in Subroutine Number Four on the vasoconstrictor-dilator because, surprise surprise, the patient's blood pressure is responding to the increased heart rate and starting to rise outside parameters - fortunately not the hard upper limit on the treatment protocol, yet, just the limit Merrin set for herself so the alarm will yell at her in time to correct. 

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The patient stays at 39%. 

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WHY IS NOTHING WORKING his right-sided cardiac output is up again she can see that on the ultrasound, and her reference sensor is carotid artery not radial artery, it's right close to the heart (and his radial O2 sat is consistently 5 points lower), so...probably in, like, ten seconds his O2 sats will start rising again? Right?? That is how things work??? 

His blood pressure is still rising and she hits Subroutine Number Five, which should buy her ten seconds when she can take her eyes off that reading and instead focus on all the other readings.

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Ten seconds later: nope! 38%! 

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It's fine everything is fine it's been less than thirty seconds and she's not very far outside parameters and this should work - she bumps the ventilator to 100%, though - 

"I'm having all the expected problems but more of them," she says, in a voice that would sound almost cheerful if you weren't intimately familiar with how Merrin sounds when an expected emergency is suddenly going somewhat worse than she had predicted. 

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39%. 

Also his blood pressure is now dropping again for utterly mysterious reasons. 

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"Flaming toilet paper!" and she aborts Subroutine Five a few seconds early and - following some intuition opaque even to herself - slides the set heart rate on the manual pump down before upping the left-ventricular force applied and it looks like it should be working, she can see his heart up on the screen and it's squeezing harder, but his blood pressure is STILL DROPPING and she tries using the vasodilator-constrictor in the vasodilation direction - 

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This has no appreciable effect on the readings. The patient's blood pressure has sort of leveled out - at 33/25, just below the treatment protocol parameters.

His O2 sat is finally rising, though, up to 44% - 45%, officially within protocol again - 47%...

...nope, that was totally a fakeout on the 'blood pressure stabilizing' part, because it's abruptly 29/24 and that's way outside bounds. 

O2 sat 50%....51%...now outside bounds in the other direction–

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What is that number even. Merrin doesn't approve of it. Also that alarm can SHUT UP Merrin noticed - that one can shut up too she's ALREADY AWARE. 

She turned the ventilator O2 concentration back down to 95%. 

"Can someone please correlate my main sensor data with, uhhhh, stuff," she subvocalizes for her listening assistant, "and get me an estimate on how likely this is to be sensor error, versus something new and unwelcome is happening?" 

(Actually, Merrin is starting to feel a bit like whoever programmed this incredibly frustrating sim is now messing with her on purpose.) 

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That's going to take a couple of minutes, is this a 'can wait a couple of minutes' sort of issue at this point or does she need backup, like, right now. 

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