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Generated: Oct 27, 2022 4:05 AM
Post last updated: Sep 22, 2022 6:45 PM
for no laid course prepare
how Merrin came to the attention of Exception Handling
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Merrin does not, as a general rule, take days off. 

Oh, she doesn’t work a shift every day; she’s not sure they would let her and she’s never asked. And the official trainings on various emergency protocols are offered in standard one-hour or two-hour sessions, or rare special endurance four-hour sessions. She usually can’t line up two on the same day. She’s been at the hospital for a little over a year now, so she’s now at the point where some of the sessions are repeats, to keep her certifications active. 

Harkanam is not a Quiet City, but it is a quiet city in the normal sense: a population of around 65,536, with only a small regional hospital. Merrin used to dream of someday making it to one of the big hospital centers in Default, but she’s trying to be realistic about her prospects these days. Just the basic education to work as a nurse took her a year longer than usual, and she still didn’t pass all of her theory tests on the first try. But she is determined that her hospital will be better off for having her on staff. She can get there; it just takes a lot more stubborn effort than most people would consider reasonable (or even sane). 

As a minor regional center, the hospital is required, in addition to the several hundred standard protocols with thousands of subsections, to have a minimum of two nurses trained on each of a few dozen rare protocols – relevant for emergencies that will happen only rarely in such a small city, but if they do, the hospital will be ready to stabilize a patient long enough to transfer them somewhere else. Merrin, doing her best to make up for her other shortcomings, is at least able to make that easier for everyone else; she maintains certifications for everything on the list. 

Her standard shift is six hours. Most people do two or four, but Merrin hated that; even now, it takes her longer than most of her colleagues to assimilate new information, and two hours in she’s just barely hitting her groove. She pushed it up to twelve hours once, when an unusual emergency came up midway through and she was the nurse already on-site with qualifications for the relevant equipment. The warm glow of accomplishment, of being useful, stayed with her for a week. 

When Merrin isn’t working, or in training, or sitting in her room with a training program and studying for a cert, she’s usually found in the simulation room. There’s a minimum requirement to review certain simulated emergency scenarios regularly, but it turns out there are thousands of canned scenarios available; Merrin, with approval from her supervisor, can get access to ones that won’t ever come up in their little hospital, ones involving equipment or expertise they just don’t have on hand. It is arguably not the best use of her time, to train for things that aren’t going to apply to her, but - who knows, someday they might. Besides, it’s fun, and she figures that once she’s already putting in at least twenty hours a week of routine sim time, she’s allowed some fun. 

She still struggles with a lot of things. Everyone else around her can read faster, track more numbers and more complicated models in their heads; when she started out, even fully qualified on all the basics, she just couldn’t keep up, couldn’t take in information and hold enough of it in working memory and process it quickly enough to make all the decisions that needed making. 

(Which was fine, and expected, complicated patients - and that’s most of them, in the intensive care unit - are always seen by multiple nurses - but it hurt, that Merrin needed backup even on the relatively simple cases.) 

To keep up, she has to drill and drill and drill, until she has enough of those mental motions down to the level of instinct. In the sims, she likes to fiddle with her alarm thresholds, setting them vastly more sensitive than the usual defaults. Alarm fatigue may be real, and you’re not really supposed to work in purely-reactive mode. But when each of half a dozen sensors has a different audio tune, playing at a higher or lower pitch for out-of-range values in either direction (and standard flashing lights, faster or slower), and you spend twenty hours a week hanging out with those tunes and lights around you, eventually it gets down to the level of muscle memory, and you - if you’re Merrin, at least - can respond without conscious thought. She needs her conscious thought for everything else

She’s improving, she thinks. Eighteen to twenty-four hours a week of regular shifts - sometimes more, but the other nurses notice and give her weird looks if she goes above thirty hours, and Merrin hates weird looks, when all she’s ever wanted is to be normal, to be good enough. Then eight to sixteen hours of formal training with expert instructors (which costs money, but of course it's less than the hospital bonus for maintaining all those certs), twenty hours in the simulator, downtime with her spaced-rep program. It doesn’t leave a lot of time for a social life, or anything else, but that’s fine. Merrin lives in a little housemodule attached to the hospital itself - she'd have to move her module if the hospital ran out of live-in-patient housemodule capacity, but that's unlikely - and everyone knows to page her for weird emergencies even if she’s not certified on them, because she’s always happy to observe, and be a pair of arms if they need someone reasonably athletic. She wears her hair short so it doesn’t take much maintenance. Merrin has not especially figured out the whole romance thing anyway - well, mostly the sex thing - and she’s not sure what anyone would see in her, but she doesn’t really miss it. She watches televised Exception Handling scenarios when she’s too tired to think anymore.

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Every once in a while, though, her fellow nurses coax her into a real day off. Today, she exercises as usual and then only does one of the quick twenty-minute sims, nothing like some adrenaline to get herself properly awake, and then she prepares for the local Alien Trade Con. (Unlike the Alien Invasion Rehearsal Festival, these are fun and friendly aliens.) Merrin is one of the aliens - they’re doing Sparashki, a widely-popular standard-conventional-alien-species for LARPing, easily costumable and with unnoticeably cheap licensing thanks to economies of scale.  Merrin is green from head to toe, with some amount of visible forehead scaling, and glaring red eyes courtesy of synthetic-protein eyedrops. She will be at the underwater part of the con; all she’s wearing is a bathing suit, though it’s a one-piece with decent skin coverage. Dressed and ready, fed and rested, she treks out to the emergency-triage section to meet her friend, who should be finishing up her two-hour morning shift any minute now. 

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Meanwhile and not far away, somebody out on a stroll spots a human body floating down a river.

It's a lot less horrifying than some 'suddenly see a body' scenarios.  It's winter in Harkanam, and a body in very cold water is with high-probability not Dead For Real, if their head otherwise looks intact.  "You're not dead until you're warm and dead", goes the saying.

Regardless, she delays not a moment in calling it in on her cellular texter; and then, she runs ahead of the water's flow, to try and find some clever way to block the river or catch the body.  Even weighting all sapient lives equally, the risk-benefit doesn't favor her jumping into deadly cold water to try to fish out the body herself.

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From the moment they got the emergency alert, the rescuers did everything right. Still, the unidentified man had been trapped in the icy water for some unknown length of time, but at least ten minutes. His hands were badly abraded, maybe from a frantic attempt to save himself, and the retinal scanner was at the hospital. Until then, he would remain unidentified. 

Even before they had him tucked into the medicopter, they call ahead to the only possible short-term destination – it’s a couple of miles, several hundred to the next-closest regional hospital which is even smaller, or even further to the nearest large specialist center. 

Their monitoring equipment is more limited than what even a small ICU has access to, but they have the basics set up within under a minute, not that the basics are informative. No detectable pulse, no measurable heart activity (electrical or mechanical as seen on an ultrasound image). A body temperature that would translate to 20 degrees centigrade. It takes a couple of minutes – by which point the medicopter is already in the air – for their blood sample thrown onto the instant-test chip to come back with an oxygen reading. It’s actually not nearly as bad as it could be; maybe the man was struggling at the surface for a while and still getting some air, probably not a long while in conditions like these, but still enough that the cold shut down his cellular metabolism before his body had a chance to burn through all of the oxygen reserves in his blood. 

They’re not picking up any electrical activity on an EEG, which is unsurprising and not that meaningful at this temperature. 

They spend the trip getting a few more measurements sent ahead to the hospital, performing CPR to maintain some circulation, placing a breathing tube and pumping some oxygen into the man’s lungs – not very effectively, it turns out, his lungs are badly damaged by the water he inhaled. They don’t bother with defibrillation, but they do perform a quick, minimally invasive surgical procedure, sliding a few wires in between the man’s ribs to rest directly on his heart. They’re not even very surprised that the muscle is too shut down for it to work, and the direct stimulation doesn’t produce so much as a twitch, but the next option will have to wait until they’re at the hospital. They don’t have good options for controlled internal rewarming – the heated blankets and wraps, and the warmed IV fluids, are enough for less severe hypothermia but, for this, riskier than holding off. Even if they had the equipment, being rewarmed potentially deals brain damage – as oxygen reaches the brain and the neurons come back online, cells send out damage signals, setting off cascades of inflammation and swelling that directly cuts off the remaining blood supply – and the patient's medical testaments may call for him to be directly cryopreserved instead.

They’re small-town EMTs who’ve never dealt with a situation this severe, but they’re well trained in every component of it, and their reports ahead are concise and calm. They’re in the air for less than five minutes, despite somewhat rough weather. Touching down and unpacking their patient to race toward the intake bay takes a minute or two longer, but end to end, they reach the hospital exactly seventeen minutes after the call was made. 

They’ve been sending real-time progress updates, including on their location; the hospital knows exactly when to expect them. Various emergency-response protocols should already have been going into effect. 

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Some of the readings on this patient are odd, even considering his other circumstances.  Besides being a rewarming emergency, there may be other emergency protocols required.

The second-in-command at this hospital is its personnel-coordinator, whose job is to know everything that all the employees at this hospital can do, including in some cases their hobbies.  Besides readying the Complicated Patient Intake Room abutting the intensive care unit, she'll also dispatch orders to grab Merrin if she's on-shift within the hospital and reallocable, and call her at her home number if she's not.  Merrin is the most likely person to have a random emergency cert not known to the hospital in advance, and there's efficiency gains from having one on-scene medic knowing multiple required protocols simultaneously.

(This does not, at this point, take the form of putting any explicit bets on the treatment results if Merrin rather than somebody else is the medic on-scene.  Prediction markets are just starting to spin up for this patient; and they're based on guesses rather than knowledge about the patient's medical insurance, and what his insurance will pay to subsidize prediction markets, or how much his insurance will pay out per QALY saved (as determines the maximum expenditure on expensive treatment options).  The hospital is obviously proceeding anyways on the assumption that he has at least standard insurance, pending identification; but it's also possible that his medical testament says to take zero chances on brain damage, and just suspend him straightaways.  It's not easy to figure out how much you want to bet, in that sort of market, and it's mostly bots trading right now.  So the admin just orders Merrin called in, if possible, without betting on that as her own treatment subplan; nobody's really going to bet against her on that anyways.)

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Merrin is maybe going to take a moment to answer; her costume lacks pockets, so her cellular texter (which can take calls, though a lot of people block those or set the notifications to silent when they have plans) is in her bag. She is, however, right there, albeit green-skinned and red-eyed and forehead-scaled, and digging for her texter but also looking around in case the call is coming from here. It's not like anyone except the hospital ever calls her. 

"- I'm over here!" she offers helpfully. 

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The person who just poked his head into Emergency to yell if anybody knew where to find Merrin... isn't even embarrassed about this, you can't possibly expect him to recognize Merrin when she's GREEN and wearing an UNFAMILIAR SWIMSUIT.  Her own mother probably wouldn't recognize her like that.

Anyways!  There's an emergency case coming in, looks like it might be a complicated one.  Patient is alive, but spent a lot of time tumbling through a winter-cold river.  Hands messed up, medicopter couldn't get good fingerprints, they're waiting on retinal ID to decide treatment plans and whether to even try rewarming.  If they do it's possibly going to be a Complicated Emergency and require the execution of at least two different emergency protocols simultaneously.  Admin is betting on Merrin - metaphorically, prediction markets don't have much liquidity yet when they don't know the patient's insurance or testament.

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Oh oh oh she is absolutely available for that! Does she have time to really quickly text her friend and apologizing for being late for the con?

Merrin is, at this point, assuming she's not going to miss the con entirely - this might be a four-hour shift, or even six, but she's not going to plead to stay longer than they need her, and presumably in that time they'll either have rendered the patient, if not entirely stable yet, at least un-Complicated, or else settled on immediate cryo - which might actually be less complicated if the guy spent a while in an icy river, he's already cold.

(Well, for some definition of 'less complicated'. There’s got to be a written protocol for it somewhere but Merrin is only officially trained on the one that starts at 28 C, and she doesn’t have the various sensor data up yet but she sort of guesses this patient is colder than that. The standard protocols, overlearned to the extent that Merrin can probably do them in her sleep (or, more realistically, while multitasking) are ‘starting from normal body temperature, patient’s heart is still beating’ and ‘starting from normal body temperature, patient’s heart is not still beating.’ Merrin is also trained on handling various traumatic injuries including serious head injuries (kind of a nightmare scenario) and ‘patient no longer has appreciable quantities of blood in their body’, which she doesn’t think apply here. But at the very least, starting colder is going to have fewer discrete steps.) 

Anyway do they have vital signs, anything firmed up on the treatment plan yet, what do they need here in the triage area while the Complicated Patient Intake Room is being prepped? (Though she knows that shouldn't take long, it's kept in a state of generic readiness and will just need the addition of equipment for cold-related emergencies). And when are the EMTs landing, is she most useful if she runs out to meet them rather than preparing materials in an area of the hospital she's less totally familiar with? Merrin is pretty sure she shouldn't try to sprint back to the ICU, if she meets the EMTs here then she'll have a minute or two of extra time to get a verbal handover. 

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Landing in a hundred seconds!  He'll follow her to the receiving bay while he goes on updating her.

They've got vital signs.  They're at least going to want him stable while they ID him.  Treatment plans are being human-dictated with the markets this thin.  The other nurse who's practiced in extreme cold protocols is setting up the room.  The meta-plan now that Merrin has been found is that Merrin takes the handoff, and sees if the patient looks like an emergency she already knows how to stabilize from one or possibly several of her trainings... pending onboarding of a Diagnostician and Treatment Planner, and getting more readings on the patient, and some idea about his insurance and testament and medical history, so the actual markets start clearing.

He's happy to text her friend with a way more detailed update than Merrin herself should take time for, he just needs the friend's cognomen.

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Of course, she'll pass on that info for her friend (though she quickly indicates it's not the top priority, if patient-related tasks are competing). 

Which means she - just barely - has time to pull up the patient’s data stream on one of the big screens in the receiving bay and have a peek; there’s no point in sprinting out to the medicopter landing pad when they’re still sixty seconds away and the outdoor temperature is below zero. 

Merrin…is dubious of the claim that they have vital signs. That sure seems like an absence of many of the vital signs! Blood oxygen is low but not as low as you would usually expect in someone found with a complete absence of circulation, that’s a good sign, and it’s slightly up since the first measurement. It looks like right now they’re maintaining a rather minimal blood pressure by applying external mechanical force*, their attempt to place an internal pacemaker having failed because the patient’s temperature is TWENTY DEGREES. They’ll need to place internal mechanical cardiac support, then – which is only a slightly more invasive surgical procedure, she can extend the same incisions they used to place the wires. 

Merrin is trained on that procedure, and the triage bay has everything she needs for it, if she relays a message for someone to go grab the instrument itself. She might as well do it there rather than waiting another ninety seconds to reach the ICU. It’ll give the other nurses more time to set up and read the incoming data before she throws a distraction in their midst, and she’s less worried than usual about complications; she’s good enough to have a vanishingly low chance of puncturing a major artery, a low risk to begin with since none of what she’s inserting into the patient’s chest is sharp, and normally she might worry about disrupting the remaining electrical activity but the current patient does not have anything to disrupt. 

She’s going to be operating in a void for a little bit, without any of the constantly-updating recommendations from smarter people than herself that she likes to have, but there really aren’t any decisions here – other than whether to do the procedure here or in the ICU with more backup, and given her cert, it’s within her remit to make that call. 

She texts a message on to the ICU, and spends ten seconds considering whether she’s missing anything obvious, and then the timer runs out and she dashes out to meet the EMTs. 

*Dath ilan uses a powered mechanical device that fits around the patient’s chest and performs compressions, with variable speed and force based on the blood pressure readouts. No one wants to use their hands to perform CPR when they could be doing other, less easily automated tasks with them.

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The fact that they don't have ID on this patient yet means that various decisions usually dependent on standard cost-benefit calculations need to be improvised; there's a lot of people who could improvise them sensibly, but the one person with the job is the hospital's chief investment/risk-management officer.  They snap off some financial figures that seem obvious and good-enough, and double-check with the tech setting up Complicated Patient Intake to make sure that the retinal ID machine is being moved there and IDing the patient will be treated as a priority.

Personnel doublechecks to verify their memory that Merrin actually does have certs on immediate stabilization, or emergency rewarming if that's the treatment plan.  (Obviously Merrin could also point this out, if there was an error, but Personnel is the one person whose job that is.)  If the plan shifts to doing cryo from this starting temperature, that's going to take protocol that nobody here has memorized, but Merrin still looks probably best-qualified to implement whatever treatment plan the conditional-policy-prediction-markets say has the best chance of a good cryo outcome; it'll be a variation on cryo-from-28C which Merrin does have practiced.


(A hospital, conceptually speaking, is a vertically integrated corporation that both invests in patient treatments and carries out patient treatments, and gets paid for patient outcomes.  Or much more usually, gets paid by financial intermediaries that buy up the right to be paid later for long-term outcomes by the patient's insurance.  The hospital isn't worried that nobody will pay for this patient's outcomes - that's incredibly improbable in real life.  If somehow the patient escaped from the Last Resort and ended up in Harkanam, they could recoup the cost of treatment by selling story rights to the hospital's part in it.  The reason everything here is structurally-uncertain-risk-capital, is that the hospital doesn't know yet which patient outcomes they'll get paid for: successful rewarming with minimal organ damage and brain damage, or a successful cryopreservation.)

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The EMTs are already unloading the patient gurney by the time Merrin reaches them. (It’s fully mechanized; no one needs to apply more than 20 lbs of muscular force to the problem.) 

The patient is mostly dried off, but only covered with a light sheet, since they didn’t start any external rewarming protocols. His head is already shaved. In addition to the mechanical compressions vest and the currently-useless internal pacing device hooked to wires that vanish through tiny incisions between his ribs, he’s arrayed with a dozen different monitoring devices. All of them are wireless, fully compatible with all the hospital systems, and currently transmitting to both the medicopter display screens and (thanks to Merrin’s work earlier) the receiving bay. Merrin will note with satisfaction that they’re secured firmly in place against the choppy acceleration. 

The EMTs have some hasty and preliminary monitoring results (their equipment is good, but not quite as sensitive as what they’ll have in the ICU, and motion artifact from the helicopter is a real problem for some of it.) They confirm a measured core temperature of 20.6C, no spontaneous cardiac or respiratory activity but the external mechanical pump is maintaining a ‘heart rate’ of 110 and, with these settings for force delivered to the chest wall, a ‘blood pressure’ - indirect measurement from the radial artery, but using a simple algorithm to estimate equivalent blood pressure to the vessels supplying the brain - varying between 40/25 and 35/15, rounded because the motion artifact from acceleration renders any finer measurements unreliable. They could apply more force, but are going carefully because the onboard instruments they’ve had time to use during their brief choppy flight aren’t sensitive enough to confirm the presence or lack of broken ribs or other internal injuries, and also that should be well within the bounds of ‘tolerable, not making anything worse’ given the rate of cellular metabolism at this body temperature. 

They’re mechanically ventilating the patient using a standard field protocol for ‘low body temperature’ and ‘assumed lung damage’: rapid ventilation rate to clear as much CO2 as possible, but low lung volumes and an oxygen concentration only a little higher than standard (40%, right now), to avoid worsening the damage. 

Between the poor circulation and motion, they are mostly not getting a measurement on the finger pulse oximeter; they have a few spot checks on blood gas measurements from the radial artery, which (again using a simple correction to account for a temperature that’s a couple of degrees outside the technically-rated range of their standard field equipment) is probably equivalent to 45% oxygen saturation. They have preliminary results on other bloodwork: most of it looks reasonable, so far. Sodium is a touch low, but within the bounds predicted when you add the ‘freshwater drowning’ correction factor to the predicted values. More important, hemoglobin and hematocrit are normal; the patient is unlikely to have lost much blood. 

They’re still not picking up any brain activity on the EEG. Their lower-fidelity portable ultrasound doesn’t show any structural changes to the brain, either bleeding or swelling, but it’s not especially sensitive.

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This is, in any objective sense, extremely concerning!

But it’s not really an update, except for the fact that Merrin did not explicitly notice that they needed a continuous central blood gas measurement – they’re going to want to place a sensor for continuous and maybe separately an internal pulse oximeter (placed through the skin as a soft clip around the artery) on the carotid artery feeding the brain. 

Merrin is, conveniently, trained on both of those, though the first one is standard. She starts to reach for her cellular texter– wrongthought, this is a real emergency not a simulated one - looks up and there is, in fact, an on-scene observer already relaying information to the ICU (and recording it for once the prediction markets get going). So she can just explain out loud that she needs the ICU to make sure they’ve got someone, not her, ready to place a central probe with sensors for all the common blood measurements. 

(Merrin is trained on this, obviously, but it’s a standard procedure, that doesn’t have a lot of dependencies on other pieces that she’ll be running herself, so it’s not her comparative advantage to focus on it. Besides which, it’s fiddly, and Merrin is new enough to this to still find ‘going near the arterial blood supply with sharp things’ unreasonably stressful– it’s not that she can’t do it safely, she does have the cert, but staying within the safety margin will take her 50% longer than someone with decades of practice, and also be emotionally exhausting, which she does not need right now.) 

They’re going to want to detour past the CT room on the way to the ICU. (There are portable units, but the maximum sensitivity sensor suite, which lets them get very detailed imagery without excessive radiation exposure, is pretty much room-sized, it won’t take long, and the hospital layout is deliberately such that it’s on their way.) 

They’re probably not going to want to detour to the MRI suite on their way; too much setup time, they need to replace all the metallic components on the standard field sensors, and even the most powerful magnets don’t let you get a highly detailed image that fast. (Which may mean that a MRI adventure is in Merrin’s future, if the treatment plan ends up settling on something other than ‘immediate cryo’ and they get the patient stabilized enough to attempt it. That’s fine. It’s stressful, but the sims go pretty heavily on stressful things.) 

…Wow, she is not actually very confident in the second decision. Usually she would record her observations and default recommendation, and throw it at the group intelligence of the prediction markets, but she’s painfully aware that she doesn’t have that yet. Ten minutes from now, sure, but it takes time to onboard a remote Treatment Planner and Diagnostician, and with an unidentified patient, the prediction markets are running on wild guesses. Which leaves Merrin flying blind. She…will just quietly make a mental note that apparently this is differently stressful when it happens in real life and not a training sim, and then move on and carry out the motions she does, actually, know how to do on her own. 

(Merrin is, as a deliberate choice, almost entirely focused on the here-and-now; her planning loop extends 30 seconds ahead, with a brief nod at the next 5 minutes, and not further. It doesn’t make sense for her to be spending any of her limited attention on long-term strategic planning for this patient. To the extent she’s thinking ahead, it’s entirely on pre-learned processes.)

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Some of administration is looking in on this case, since it's an anomaly and nothing more exciting is happening inside the hospital right now.  Aside from the unknown patient ID and the delay in spinning up prediction markets, the actual orders going out from Merrin look routine and there's no blips in execution being reported on the other end; there's only one retinal scanner in the hospital, but it's en route.

(There's a near-unnoticeable collective wince when Merrin orders the CT instead of the MRI.  It's almost-certainly the correct decision, you can't get arbitrarily faster MRIs just by amping up the magnetic field arbitrarily, and the emergency at hand is an urgent one.  But the small statistical probability of eventual cancer associated with a low-intensity CT scan will come out of the hospital's expected payoff from its patient-outcome rebuyers, if the patient's medical testament doesn't just call for cryo; and 'how often does this hospital manage to avoid ordering CT scans' is still one of those things that patients look at if they have a chance to choose a hospital.)

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Merrin is aware that her decisions and reasoning are now being relayed to the relevant places, and probably a lot more places than that. (She, too, has looked in on cases that were not per se her responsibility, but weren't conflicting with her work and were the most interesting thing going on at the time.) So! Even without the full prediction markets online, someone is going to notice if she's doing something blatantly stupid because she failed to retain something from one of the classes she found so painfully hard. 

In the meantime, she'll focus on doing her job. 

Pause in the receiving bay first, to perform some minor surgery and place an internal mechanical device to manually pump the patient's heart, under real-time ultrasound guidance (now without medicopter motion artifact!) 

Nothing goes wrong. (Merrin would be making some serious updates if something had gone wrong; she's trained in this, she's also done it many extra times in simulations, and she's not that far below median in picking up procedural skills as long as they're not too reliant on fine motor skills.) 

Another three minutes, after the two minutes it took them to reach the triage bay. Twenty-two minutes since the emergency call. 

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The internal pump is more effective that the vest setup; the patient's measured blood pressure is now stabilizing at 55/40. 

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Is that sufficient? Does she want to toggle the settings and get it higher?? ...Does she want to keep it lower, they're still looking at potential cryo in which case she really doesn't want to kick off neural cellular metabolism any more - and the measured O2 sats are still below 50%, which means maybe it won't matter and maybe it'll make things worse–

- but probably not much of either, at 20C body temperature. Merrin is aware that this is well below the goal temperature for cooling patients to avoid brain damage during potentially risky and circulation-disrupting surgeries, where the aim is 'four minutes before you even have to worry about lack of oxygen to the cells', and ten minutes before you worry about actual anoxic brain damage. 

She wants her flaming prediction markets already, and of course the fastest way to achieve that is to get to the ICU already and ID the patient. 

She...probably cannot get them through the CT unit and over to the ICU in four minutes, but she can definitely do it in less than ten. 

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The CT suite calls for setting customization. 

Merrin is fully trained to make this call on her own. Merrin would not usually have to make this call on her own, but that's the whole point of emergency sims, isn't it. 

She feels only a moment of agonizing stress before addressing the CT tech. "Protocol suspected-anoxic-brain-damage*, modifier: hypothermia, radiation setting, uhh, four." 

*In Baseline specialist medical jargon, this is two syllables. 

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(The patient is not especially participating in these proceedings, but his vital signs, nearly all of them currently maintained by machines, do not change.) 

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Aaaaaaaaand now she gets to run down the hall to her nice well-equipped Complicated Patient Intake Room with all her familiar equipment and colleagues? Right?? 

(Merrin is trained to read CT imagery, but not to a very high standard, and in particular, not fast. A 5-second glance at the wall screen reassures her that the patient's problem is not 'massive brain bleed', which she was already suspecting from the lack of visible injury to his conveniently shaved head - he could have fallen into the river as a result of an unexpected hemorrhagic stroke, but that is very low priors and the sort of blatant plot device that even medical fiction tries to avoid. She is not going to wait around to look closer. Once the patient is ID'd, an actual expert can look at the CT scans, and also everything else.) 

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She's home!!!! 

By which Merrin means: she has now reached the Complicated Patient Intake Room! Her report on their progress to date should already be in the chart - a glance at the wall display confirms it is - the mechanical cardiac support is still working, the monitoring devices are still in place, and the other ICU staff already have a plan for getting a continuous bloodwork probe in place. A plan which does not involve her, so for a few precious seconds she can just...think. 

(- Someone other than her is handling the retinal ID scan, right?) 

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An equipment tech is carrying the machine into the room right now.  Hopefully it works on the first try!  It's actually near the end of the testing cycle on this machine and it hasn't been used on any unconscious-patients-with-no-ID-and-unusable-fingerprints since the start of that testing cycle.

The machine plugs in, turns on, and... doesn't connect to the hospital's wireless network.

This is actually fine.  Everything is fine.  There's a backup wired portal on the machine.  Give the tech a second to grab an SD chip, and they can scan the patient's eyes, get the scan to the chip, get the chip to a terminal, and get a hospital programmer-generalist to manually dispatch the data to Person Identification.  They'll run.


In other news, prediction markets and treatment policy markets are coming up on one of the many LCD displays covering the walls of the hospital room!  They say the patient has a 90% chance of staying alive if rewarmed, 10% chance of no significant brain damage if revived via the best treatment plan in the policy market, and bid-ask spreads are wide enough that you could drive the fifth planet through them without being careful not to bump the moons.

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Well! In that case Merrin is going to keep running on the emergency-sim assumption that she is the best-informed decisionmaker here, and keep following her training and engrained instincts. It's not as though she's running out of next actions. 

First thought: they should monitor the patient's sodium closely, on the assumption that (given premise: freshwater drowning) he swallowed and inhaled a lot of fresh (e.g. very hypotonic) water, which is probably still being absorbed. Low blood sodium equals a larger differential between cells and bloodstream equals more water entering cells equals BRAIN SWELLING which is, you know, absolutely the last thing they need right now. 

...They can place a specialized probe directly in the carotid artery, to measure the electrolyte concentrations actually reaching the brain? It's an obscure procedure but Merrin is, in fact, certified for it. 

 

(She is also obsessively checking the prediction market displays; she saw her colleague do the retinal scan, surely any minute now they'll have more certainty and backup...) 

(- though in the meantime she is not using all of her working memory right now, and she has a deeply-engrained habit to, when she notices that, take a mental step back and plan ahead. Which lands her on 'high probability of going straight to cryopreservation' - and if they don't, it's going to be because of something weird, so she's not going to invest too much advance-thinking in that - and honestly even if they do it won't be a standard protocol, but she can make some wild guesses at the nonstandard protocol, at least in terms of what cryopreservants she'll need to access and in what order....) 

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The tech is AWARE of how many administrators are watching all this!  This bothers a lot of dath ilani less than it would bother, say, Merrin, but all tasks are still being executed with alacrity.  Run back in with chip, get the data onto the chip (the retinal scanner automatically copies its most recent data onto a chip when you insert the chip and press the most obvious button for that), run back out, get chip to terminal!


File uploaded, now it's over to the in-house-programmer who's hopefully been told about this already, right, and is ready to send that data to the same Network socket that the hospital machine itself would've used -

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In programming terms this is a totally unexceptional problem, obviously all the APIs here are standard ones, except for the part where identifying somebody's retinas against Civilization's database is something that not just anybody is supposed to be able to do, if you're not a hospital.  Which means that the retinal scanner in question has a cryptographic cert that is not actually supposed to leave that machine.

This is actually fine.  Everything is fine.  He called in that problem as soon as it became obvious, and somebody in admin should be talking to low-level Exception Handling about approving the request he's about to make into the person-identification API -

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Yeah, they're on it, shouldn't be but a minute, obviously hospitals have cryptographic certs for identifying themselves as such to 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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Merrin can definitely keep this up for thirty minutes.  Her emergency sims run a lot longer than that.  But she is concentrating and shouldn't be interrupted.

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Okay then.  That works.  Thirty minutes is enough time to fly in a rank-two Keeper special-trained in simultaneous task tracking, who also has some medical training, to take over the simultaneous performance being designed after Merrin gets tired.

 

Are they sure the monitors shouldn't display info for Merrin on her performance incentive here?

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Yes.  Merrin can deduce that some sort of large performance bonus exists if she wants to think about that, and should otherwise not be forced to think about that, it'll distract her.

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A number of people who need to bid on the success probability of all these procedures have questions about who this 'Merrin' person is, exactly.  Please transmit full records on her.


Also, why does she look like a Sparashki entering the aquatic phase?

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Exception Handling should know better than to ask questions like that last one.  They'll be told if they need to know.

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Oh NO she has to run the temporary manual liver machine. Merrin HATES the temporary manual liver machine. ...Or hated it, at least, until she practiced it into submission via about fifty accumulated hours of sim time over the last six months. 

(This is, in some sense, the double-temporary liver machine; the full version requires room-sized controls and about twelve trained personnel on site. Merrin is not trained in it - well, okay, she maybe ran a sim involving it once, and immediately killed the fake patient and slunk away in shame - and her little minor local hospital does not have the equipment or the personnel for it.) 

The version she can use covers about a dozen of the most important liver functions, and is, in fact, beautifully designed. Since even non-Merrin people at least find it kind of tiring and inconvenient to track that many variables simultaneously, it comes with a library of preset ratios, where you can pick a subset of the liver enzyme processes it replaces, and set others based on varyingly-complex functions of those. 

Merrin can run six of them with presets for the rest, which is the cert requirement, and about what it takes to stabilize a patient who is currently dying of liver failure and needs their body to stop poisoning itself so they can survive a medicopter transfer to a better-equipped hospital. 

This is not the source of Merrin's grudge. The source of her grudge is that you can, it turns out, play multi-role sims by yourself, if you are, say, playing them when all of your friends are tired after their shifts - and that running the liver machine along with three others is - if you are, like Merrin is, kind of slow at things - an exhausting attentional nightmare. She eventually figured out how to bounce around between using different sets of three variables, with the rest tied to those, and got to the point that she could keep her liver-failure simulated patients alive solo long enough for the rescue team to arrive. 

Fortunately! This patient is not even in liver failure! (Which presumably whoever is setting this protocol knows, when they decided whether it was even possible for one person to juggle all of these pieces.) All the patient's current values are fine; she just needs to adjust her manual liver to keep them that way. Also, his metabolism is running incredibly slowly, which buys her a vastly longer response loop. 

Great. Fine. She can do this. Bring it on. 

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Most of the machines require setup, which Merrin is currently the only person onsite qualified to do, and she's way less happy about splitting her attention for that, but basic maintenance for two minutes on a patient whose entire body is going veeeery sloooowly is probably something she can briefly hand off? 

If not that's fine she'll just set her alarm settings to max sensitivity and let them warn her, just, it'd be nice if someone was comfortable watching the parameters for her instead? 

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...this isn't actually a sim.  Merrin has Full Support at this point.

 

Dath ilani hospitals are organizationally designed with enough slack capacity to have a shot at handling an area-wide emergency, with remote support from the rest of Civilization to teleoperate those machines that can be teleoperated at a reasonable efficiency loss; or, not during emergencies, such that there are enough people around to do all the tasks that need doing without strain, insofar as those tasks can be performed by people with a myopic view of their own task.

Sims require you to handle emergencies all on your own, or with scripted help calls that you're supposed to make with scripted results, because they can't afford real support personnel for you during sims.  Actual emergencies like this one -


At current QALY prices on this patient, Merrin can name any skill this hospital has, and a person with that skill can be in the room within one minute if they're on-duty.

If they're off-duty, she could have them brought in by helicopter.

If she needs coffee from a particular nearby coffeeshop for maximum efficiency, that could be brought in by helicopter.

If the hospital runs out of helicopters to meet her demands they can start renting police helicopters.

...If the treatment protocol being developed says the patient needs an organ transplant that isn't in stock, it's possible that Exception Handling will start posting bids in Quiet Cities; there's a standard thing that sad people do, when they're otherwise thinking of giving up and going into cryo, which is to enter into a pact with another person where they both get put under, one of them quantum-randomly goes into cryo and has their organs harvested, and the other one wakes up with a lot of money with which to take a second shot at enjoying life.  (This being among the reasons why dath ilani in need of liver transplants, and with sufficiently expensive insurance, have good-enough survival prospects to motivate the existence of complicated liver-replacement machines in the first place.)


The point being, Merrin has nearly infinite money-power that can cause things to happen, if there's any particular chains of causality she'd like to initiate.

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....Right, Merrin should probably have remembered that.

(She would have, almost certainly, if she weren't busy aiming approximately all of her working memory and metacognition at keeping this patient ""stable"" under conditions that are well outside the usual operating tolerances for a human body.) 

In that case, Merrin will not feel bad at all about pulling in whoever she has to, however inconvenient for them, to babysit a machine for her while she does the setup procedure for the next one. There are non-her people available for most of them individually, after all; the problem is that for longer than a two-minute interval, they all interact, and her process for managing that is running mostly on the level of instinct. 

...There are efficiency losses. Merrin had hoped to get everything set up and going within ten minutes, and it takes closer to fifteen, because she has to pause a couple of times and make sure that the increasingly complex system is working together rather than falling apart. 

It's actually a lot easier than sims; the sims have treatment prediction markets, but canned-response ones, that don't respond quickly or cleverly if you do something outside the set parameters. Right now, she can apparently get actual liver-function experts (probably not the best in the world given the bizarre secrecy constraints?? but - among the world-class experts in general, probably, given the sheer amount of liquidity in their markets - and it's not hard to be a lot better than her) working on slightly smarter ratio-control algorithms than the preset ones?? This is kind of amazing. As long as she doesn't think too hard about it. 

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She is not even slightly tired at the thirty-minute mark. It's exhilarating, actually; it would be fun, if it were a sim, and not a real person who will actually for real go into cryo if she screws this up.

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...okay so the Sparashki's performance has noticeably improved between the 15-minute and 30-minute mark.  Who knew that Sparashki had such vigor when entering their aquatic phase?

Somewhat shockingly, the prediction markets say that they should keep running with Merrin, instead of the second-rank Keeper who's now arriving.  Merrin's performance here is a known quantity, she's apparently adequate, there's no obvious qualitative bonuses in reach for doing better.  The Keeper would have slightly better mechanical dexterity on the machines and faster naked reaction times; but she has not actually logged the same number of sim-hours on these machines, or their interactions, as Merrin.

Why is somebody like this working at a small regional hospital, at a small regional hospital salary, instead of, say, a much larger hospital for a much larger salary?

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Merrin's not actually all that bright.

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Well what does that make their second-rank Keeper, then?

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No, seriously, Merrin took a year longer at med training and bulled through on sheer determination, took longer to reach adequate performance levels on sim training, her school records show that she didn't learn to program a computer until age eight.  Merrin is a stamina monster, basically.  She exploited her stamina and determination to run lots and lots of sims, and get lots and lots of training, until she was carrying half of the hospital's emergency-cert load by herself.  But Merrin doesn't meet the minimum recommended intelligence to train for Exception Handling, or for care operations-coordinator at a major hospital -

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Part of the point of the intelligence threshold is your prospective capability to pick up lots of skills so you can do that job.  If instead you bulldoze the problem by running twenty times as much training, and end up with all the skills, you have achieved the actual endpoint which the prospective test was meant to measure your future ability to achieve later and never mind your having actually already -


You know, never mind, the Very Serious People can fight about this later.

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...look, some of these thoughts have ever occurred to the Chief of Personnel at this hospital - she's sometimes fantasized about whapping Merrin with a banana and telling her to be more ambitious - but Merrin seemed happy where she was, and there's such a thing as being reluctant to disturb that while you personally go replan somebody else's life in a way that you think is cooler.

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That medical venture capitalist who had the requisite clearances, who was willing to risk the most capital and make the most daring credible promises, is now taking primary point on developing the actual treatment plan.  Or rather, causing its development.

This plan is going to need, like, around 100 custom proteins, only 80 of which actually exist in the literature.

Is this matter urgent enough that Exception Handling could possibly... you know... happen to find those other 20 necessary protein designs in a forgotten filing cabinet somewhere?

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Exception Handling will ask, for the record, why he thinks Exception Handling can even do that.

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Because the people he put on contacting the researchers who allegedly delivered the most relevant existing protein designs all ran into suspicious preliminary stonewalls; which suggests to him that possibly most of the artificial protein design on the planet is actually being done by a secret Governance project rather than those supposed researchers.


Of course, it would have taken him longer to arrive at that guess if he'd had lower priors on it.

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Superheated lovely.  This shit gets harder to keep up literally every year.


Can there be a plausible story for the other people in his organization about how somebody who wasn't Governance found the extra 20 protein designs in a dusty filing cabinet somewhere.

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Naturally.  He's arranged all of the previous steps in this procedure with that eventuality in mind.

So long as they're talking about this sort of stuff anyway, why is the chief operator-coordinator on this patient a Sparashki?

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Exception Handling asked for the best, not the best human.

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It takes Merrin an embarrassing-in-hindsight length of time (about twenty minutes, from the point after she has everything set up and running smoothly enough that she theoretically has some free metacognition) to notice that her decision-making right now is…definitely sub-optimal. 

It’s not that she isn’t asking for help. She is delegating literally everything that she reasonably can. Of course, the bounds of ‘reasonable’ here are very different from the usual ones. It would never, under normal circumstances, occur to Merrin to ask someone else to go pull the internal blood temperature-monitoring lead back a centimeter for her because she’s paranoidly worried (despite having no conscious logical reason for it) that the vasoconstriction/vasodilation mechanism is interfering, and also she doesn’t feel like standing up. Merrin did, in fact, remember that under THESE conditions, her physical energy and stamina, which has never before in her life been an important limiting factor on shift length, is perhaps a more limited and critical resource than usual. 

She’s even been making copious use of her assigned personal assistant and transcriber, who listens to everything she subvocalizes into her throat microphone (to avoid noise clutter in the room) and, on request, puts up whatever she wants on the big display screens. 

…She failed to remember that, in addition to the support of the colleagues she knows and feels at least vaguely asking for advice from, AND the unusual but within-the-space-of-her-preconceptions external resource of a highly trained specialist medical assistant, she can also ask for other expertise. 

When, for example, she keeps repeatedly noticing that she’s starting to grab at the edges of a pattern, one she’s pretty sure the treatment recommendation markets haven’t picked up on it yet, she’s…doing the same cycle of adjustments over and over on her stupid manual vasodilation-constriction control (which is supposed to be a backup) to deal with O2 fluctuations, and something is interfering with getting a stable control state but she can’t hold enough of the pieces in her head at once to figure out what -

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Merrin knows exactly what she wants to ask for - not exactly who she wants to ask to do it, she’s not up to date on programmer-specialist jargon, but surely someone can figure that out. It is still really uncomfortable - not the least because if the markets, with world-class treatment experts betting on them, aren’t pointing out a solution, maybe she’s just imagining it?? But she’s aware that this is a cognitive error, and also that wasting any more of her limited attention on feeling awkward is just adding to the problem where she’s allocating resources stupidly like a stupid person. 

Right. She wants a visualization of…whatever type is good for visualizing this sort of data?? someone else should make that decision?? of the fluctuations in O2 and her manual corrections to brain bloodflow, graphed against literally everything else she’s doing. Presumably in separate graphs for each different intervention, because maybe smart people can make sense of visual projections of high-dimensional spaces but Merrin is not a smart person and she cannot do that. She’s just pretty sure that something is going on here and the treatment markets haven’t settled on a way to make it stop happening.

Also maybe someone who’s really good at making sense of high-dimensional-space graphs should look at it?

But Merrin kind of wants to see it herself too, just, if she can get the pattern in her head visually then she can probably react a bit faster. 

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…Oh, and, can she, ummm, maybe, possibly, get a programmer on the task of looking over the last ten minutes of just her vasodilation-constriction manual changes, and automating the response-pattern? She’s not sure she can tell them when to trigger it, because she’s…apparently doing it instinctively enough that she has no idea and her first two ideas for triggers are wrong–

(This is embarrassing, she should be able to make her thoughts legible, she probably even could if she had slightly more room to think after all the adjusting machines -)

…But she definitely keeps doing the same pattern of three adjustments in a row and then sometimes a fourth if that doesn’t stabilize it, so maybe they can figure that out, and if she can just toggle the machine once to set off that response pattern, it’ll free up way more attention to focus on the liver machine. Which is actually fine right now but she’s expecting it to get problematic in a couple of hours, on the assumption that everything takes four times as long to spiral out of control for this patient – and four times as long to fix so she needs to be ready to stay on top of it. 

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ALSO, this is especially ridiculous and if it’s not a priority people should feel free to put it off? But she has four different remote-consoles at her workstation right now, even though one of her consoles theoretically has the capacity to control five different mechanisms, its default programming doesn’t cover the weird ones like the vasodilator-constrictor. Can…someone…maybe grab another of the standard consoles on the unit and…reprogram it? So that she can tie all of the machines that she’s controlling personally to one piece of hardware?

(She hasn’t actually dropped any of her remote-consoles on the floor yet but she keeps feeling like she’s going to, and the CAMERAS ARE ON, there are Very Serious People watching her.) 

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OH NO Merrin has just managed to remember that she is green. And red-eyed. And wearing a bathing suit. AAAAAAAAAH.

She has already decided that she has limited mental space available and 'agonizing embarrassment' does not get to take up any of it. It's weirdly easy to just...do that mental motion...when the stakes are so obviously stratospheric. Merrin wonders vaguely if that trick generalizes. 

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     "So the image our hospital is presenting to all these Very Serious People is that our top opper is a Sparashki in a swimsuit.  Now that things have quieted down slightly, I just thought I should take a moment and say that."

"Uh huh.  And?"

     "Are we comfortable with that?"

"Why wouldn't we be comfortable with it?"

     "I mean, I'm fine with our sentience-embracing employment practices, I think it's a great image, myself -"


"Okay, good, because for a second there I thought you were about to go all speciesist on me.  If our best employee for the job is a Sparashki, a Sparashki gets the job."


     "Look, I'm just trying to establish common knowledge about whether we are all, in fact, fine with this."


"I literally can't think of a single valid reason why we shouldn't be."


    "Combine it with the secrecy requirement, and Merrin's apparently superhuman endurance, and there could be people in those secret markets wondering if Sparashki are real and the whole standard-alien business is a smokescreen to hide any who go out in public."


"Almost certainly not.  But if anybody is actually wondering that, what part of that would not be unutterably awesome?"

     "Fair point.  It's just -"


"Just what?"


     "Why is Merrin an aquatic-stage Sparashki today?"


"I'm sure if we were cleared to know that, Exception Handling would have told us already."

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It goes wholly without saying, at this point, that anyone at the hospital who knows about Merrin's aborted friend-date - or even the fact there's an Alien Trade Con today - is saying absolutely nothing about this fact to anyone who doesn't already know.

All of her fellow employees are vigorously maintaining to anybody outside the hospital itself, should the question arise, that Merrin has always cosplayed as a Sparashki while on duty, in fact nobody's ever seen her out of costume; sure it's a little odd, but lots of people are a little odd.

(This is not considered a lie, in that it would be universally understood and expected that no one in this social circumstance would tell the truth.)

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Their patient is definitely making Merrin - and dozens of other people on site, not to mention thousands off site - work very hard for those precious hours. 

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The human body is, in many ways, a pinnacle of engineering, an exhibit of how blind evolution can, eventually, surpass the abilities of even the best dath ilani engineers working together with the power of prediction markets. Second by second, hour by hour, hundreds of thousands of proteins (even dath ilan doesn't have a precise count) are expressed, in varying ratios depending on the cell type (of which there are around two hundred), and the surrounding tissue and, on a larger scale, organ. And an endless, fractally complex orchestra of signals, hormones in the blood, electrical signals echoing through neurons and muscle tissue, minute gradients in electrolyte concentration, and even more close-in, signalling molecules interacting in and around the complex organ-like structures found in every. single. cell. 

(The human body is, as per the usual design style of evolution, a spectacularly messy kludge of spaghetti code.) 

Put all of that together, and the result is a system that - with lower power consumption than a bright incandescent lightbulb - maintains a highly ordered internal state against the forces of entropy, corrects for perturbances, with interlocking control systems far beyond the capabilities of even the Basement's computing tech. 

And while thousands of different measures, from core body temperature to the exact potassium concentration in the blood, are usually maintained within absurdly narrow parameters, the human body actually has rather wide tolerances on what it can handle and recover from. A person starting out in good health can survive a complete lack of water intake for at least three days, or zero salt intake for - at least that long, possibly up to a month. With the first tiny flicker in sodium levels, still undetectable to the most sensitive medical equipment, and half a dozen internal alarms go off, the hypothalamus and pituitary gland react, and the kidneys do their work to hold the system stable as long as possible. The human body can adapt to outside temperatures of well above 45 C, as long as the humidity is low enough for sweating to shed heat. It can lose up to 40% of blood volume, and the heart will beat harder, the blood vessels will contract to raise blood pressure, and the patient will certainly be having a bad day, but if they have the cardiovascular reserve and aren't simultaneously facing too many other perturbances, will probably survive until the EMTs arrive. A patient with a body temperature as low as 30 C will be drowsy and confused, but probably still conscious, and able to regulate back to a normal body temperature with no treatment more invasive than warm blankets. The human body has an absurd degree of redundancy. One kidney, if it's healthy, is more than sufficient to meet the body's needs. 

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The compensation mechanisms that come into play in abnormal situations aren't without side effects – high fevers do help the body fight infection, and are also not very good for brain cells – and when one system starts to fail, it taxes others, eventually exceeding their tolerance thresholds, and damage accumulates in a cascade through that intricate interlocking web. 

High blood pressure deals small but cumulative damage to blood vessels, hardening and scarring them, and after long enough, inflammation attracts plaque and clots, weak spots in major arteries bulge and stretch, kidneys gunk up and gradually lose the ability to compensate for a high-potassium meal, and sooner or later a coronary artery blocks off or a blood vessel bursts in the brain.

Eat one sugary meal, and a healthy pancreas will groan but put out a flood of insulin; eat a high-sugar diet above the maintenance calorie needs every day for a decade, and the cells will gradually respond with less vigor, even as the overtaxed pancreas starts to fall behind, and fat deposits (fat is far from inert - it's an endocrine organ of its own, in a way) secretes its own hormones, and baseline blood sugar creeps up and up – and, again, inflames the lining of blood vessels, gunks up and eventually cuts off circulation to extremities, gradually damages peripheral nerves, and makes a very tempting meal for any bacterial infection that starts to sneak in, ignored by an immune system unable to reach it through those sticky damaged capillaries. 

The power to regenerate organs is a mixed blessing; every time a cell divides, however high-fidelity the DNA copying, and however thorough and paranoid the cellular machinery for error-checking and error-correcting, there's still an opportunity for a new mutation. Most mutations do nothing, or just kill the cell, but some instead leave it deaf to the instructions from the rest of the coordination-symphony of biochemical signals, and the cell sets off on its own rogue mission. The immune-system police are paranoid and careful, and very few of these cellular criminals make it past their watchful eyes and ears, but with two trillion cell divisions happening daily, eventually something slips through the cracks. Despite everything they've thrown at reducing cancer risk, about thirty percentage of dath ilanis will be diagnosed with cancer during their lifetime (though usually caught early enough for treatment), and likely many more people die of something else before the rogue enclaves are big enough to show up on a scan. 

Because, of course, the body has a limited operating lifespan. Eventually, even if nothing specific goes wrong, the awesome regenerative powers start to fail one by one. Most people don't wait around for that gruesome slow-motion breakdown to reach its natural conclusion; the brain deteriorates along with other organs, and besides, it's unpleasant to experience. 

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And that's only what it looks like when the control-system symphony breaks down slowly

It can happen very fast, from a single catastrophic disturbance, if the tolerances are exceeded drastically enough or affect enough systems at once. Drop even a tiny wandering clot in the wrong place, and the finely-tuned electrical orders conveyed across the heart will fall apart into chaos in seconds.

 

 

The healthiest adult can still bleed to death in less than five minutes – and even if the EMTs are on-scene in time to pour replacement blood into them, very little has to go wrong to set off a different failure cascade. If blood gases get out of whack, too-high CO2 leaves the blood acidic, with all sorts of nasty downstream effects. Confused clotting signals, aware that there's an injury somewhere but too rushed to coordinate properly, can spark a distributed clotting process everywhere at once, denying circulation to gunked-up capillaries and, more relevantly, instantly using up all of the body's reserve of clotting power. The stabilizers used in stored blood can even accumulate to toxic levels. 

 

 

It may take days to die of dehydration just from not having water, but one bad enough case of gastroenteritis, out of range of prompt medical help, and the fluid and electrolyte losses can hit critical levels in hours. Even with treatment, it's easy for the acid-base imbalance or low potassium to get out of hand.

 

 

An infection hits the bloodstream, and the immune system kicks into gear, marshaling its armies and supplies for a pitched battle - but a response that works very nicely at the local level can be actively unhelpful once it spreads too widely. With chemical orders flying left and right, coordination breaks down, immune-cell battalions overwhelmed by the confusion start attacking tissues indiscriminately, and the feedback loop of emergency alarms explodes out of control. Fevers can spike high enough to start denaturing proteins. Tissues everywhere send out chemical-radio alerts begging for aid workers, blood vessels helpfully dilate to open a quicker path, and oops, now the systemic blood pressure is 50/30. The heart tries to make up the difference, beating faster, but inflammatory cytokine messengers actually weaken the contractions of the heart muscle cells, and each beat accomplishes less and less. Inflammation and random friendly-fire damage to lung tissue leaves the endothelial cells more permeable, leaking fluid and blocking gas perfusion at the interface, and now the rest of the body, already burning energy at emergency levels, is facing a dropping O2 saturation in their blood supply. 

Trying to make up the energy shortfall, the endocrine system hears the inflammatory alert and responds by cranking up blood sugar - which maybe does some good somewhere, but also multiples the production of oxygen free radicals, and the oxidative stress on cells results in another round of inflammatory signals (yes, this is what is generally known as a positive feedback loop.) In desperation, energy-starved cells resort to less-efficient anaerobic metabolism, dumping lactic acid left and right, which adds on to the reduced CO2 clearance and sends the blood pH into a nosedive. Clotting factors respond to the generalized alarm of Something Wrong Somewhere and see if clotting it off is a helpful contribution to the war effort (spoiler: it really isn't, but they're trying their best.) Soon the kidneys and liver, overwhelmed and under-resourced, start to fail, adding accumulating waste toxins to the mix - and since the all-purpose-factory-extraordinaire liver is responsible for a huge fraction of the signaling hormones that coordinate all these immune forces, the chances of getting any of this back on the rails are dropping fast. 

Meanwhile, the central nervous system is having a bad time. On top of a protein-mangling fever, wildly outside-of-tolerance blood acidity, and a rapidly collapsing supply chain for oxygen delivery and CO2 collection, the inflammatory signals directly futz with neurotransmitter expression. Delirium, seizures, coma, and (if it continues for long) permanent brain damage are the inevitable result. 

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These are some of the conditions under which the normally-resilient homeostasis control mechanisms of the human body are no longer particularly in control. 

 

These situations are still potentially survivable - survivable without brain damage, even - because a prepared medical team has a lot of options for taking manual control. Fevers can be lowered. Failing hearts can be supported with drugs, replacement electrical pacing, and, in extreme situations, mechanical force. Loose blood vessels can be sent loud, unmistakeable chemical signals to quit that right now, putting peripheral tissues on strict rations and prioritizing vital organs. (With the cost that if you push it too far in the other direction, the heart has to labor against more resistance, and also this is not necessarily good for fingers and toes.) Clotting signals can be regulated from outside, while used-up platelets and clotting-factor proteins are replaced. Insulin can be administered to keep blood sugar in a reasonable range. Kidneys can be replaced with dialysis, degraded liver function propped up via a massively inconvenient team effort.  

It's critical to intervene early, and fast, before the cascade of system failures gets very far. The levers available for manual control are a lot clumsier than the systems they're trying to replace, and reversing a system failure, while dancing the delicate dance of avoiding harmful side effects, is an enormously harder problem. 

This makes it especially important to predict when a patient is on track to deteriorate, before it actually happens. Fortunately, this is something that prediction markets, and a supply of experts around the world, are very good at covering. 

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Of the factors that are currently making Merrin's job easier: 

- They are intervening pretty early. The patient may be in some degree of organ failure for just about every organ system, but they got the manual levers in place before anything could spiral very far out of control. 

- They're likely to see a new complication coming in advance, thanks to the insane liquidity on the diagnostic prediction markets. 

- The conditions for making the right judgement call on when and how to apply known treatment protocols are almost ideal, thanks to the liquidity and update frequency on the treatment planning prediction markets. 

- They have almost unlimited resources to throw at the problem, up to and including 'invent a new treatment protocol on the spot.' 

- The patient is cold. Which is of course causing all sorts of exciting problems by itself, but it does buy them a little longer to correct a mistake before the consequences spiral out of control. 

- They have explicit permission to attempt treatments with high risks of serious side effects - even potentially fatal ones - as long as the treatment planners and the markets think that it increases the likelihood of survival-with-brain-intact. They're even willing to risk minor permanent damage as long as it's not impairing, and major complications can be addressed later, once they know the outcome. If the guy needs a heart transplant after this, it's worth it. 

(Though Merrin is very, very badly hoping it doesn't end up being her call on whether to use a treatment protocol that ends with an organ being needed. She knows where the organ might come from, and she knows that the people who make that decision are making it for a reason, but it's not a reason that has ever made sense to her, and she doesn't like it.) 

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Also on their side: before he fell in a river, the patient was in good physical condition. (Now that he's been ID'd, they have a medical history in the chart; it's heavily redacted on details, but they have the basics on his last decade of health screenings.) 

His non-brain organs have reserve to spare. Which is good, because while they're trying to match oxygenation and perfusion needs to the tissue metabolic rate, a blood pressure of 50/30 reaching the brain - which they don't want to exceed - isn't enough to get much circulation to his extremities, especially given that they're dealing with a complete lack of vascular smooth muscle tone, and resulting tendency for blood to just hang out permanently in his feet, by giving potent vasoconstricting drugs, and their ability to differentially address blood pressure in different parts of the body is very limited. The risk of major tissue death is small, but he could lose toes, and cumulative peripheral nerve damage is likely. Losing a bit of sensation in his feet is probably acceptable. His visceral organs are getting more bloodflow and oxygen, but also need more, and will take more damage from stretching this out for many hours. 

He might need a heart transplant. The mechanical-assist device gets blood pumped through the heart, and they can increase that if necessary, but it comes with the downside of applying compression to the coronary arteries right as the systolic pressure is rising. They're already detecting a flicker of elevated troponin, byproduct of damaged or dying heart cells. It's also entirely possible that his electrical activity just...won't come back...when they start rewarming him. They won't know until they get there. 

His kidneys are...actually sort of working? The basic concept is just a filter; as long as some circulation is happening, some urine will come out. Absolutely no regulation is happening; a lot of that is neurologically-controlled, and even if his kidneys were getting the appropriate signals, the cells are going to be very sluggish at responding. They are very carefully monitoring exact quantity and electrolyte concentration, and trying to replace whatever is coming out. Meanwhile, there's already detectable protein in the urine, indicating cell damage. There is an ongoing debate and updating prediction market on whether to administer the usual kidney-protective drugs, or whether the unpredictable response at this temperature - and delayed breakdown, for anything not covered by one of the liver functions Merrin is providing manually - means an unknown benefit and unknown risks and they should wait. 

He's definitely going to lose the entirety of his gut lining after this. Those are fast-dividing cells, and fast-dividing cells don't respond well to multiple hours of hypoxia. Fortunately, they're not cells that particularly matter. It's a risk taken as a matter of course with chemotherapy patients, and it's not much fun for anyone involved, but it does grow back. He'll need a few weeks of IV-only nutrition, which is a much smaller risk than it would have been a few decades ago; the latest generation of IV nutrition is very thoroughly optimized to provide everything the body needs, customized to a particular patient and responsive to changes in their condition, and it's only slightly harder on the liver than regular tube feeds. Besides, if they have to, they can get him a new liver. 

Infection risk is a bigger deal, and they won't even notice it until they start rewarming. Data on patients cooled to 28 C for 24-48 hours shows a serious immunosuppressant effect; the extrapolated models currently being generated have a wide range of uncertainty, and there isn't enough time to do any new animal testing, but it's possible the patient has no immune activity right now. Fortunately, a bacterial infection will be slowed down as well, and plausibly a lot of the organisms adapted to be nastiest in the human body, at normal human body temperatures, won't actually have cell division happening at 20 C. 

Hospital-acquired infections just don't happen, as a general rule, with the standard precautions, but this case is different, and they can't fall back on 'minimize invasive procedures' because they...sort of need them. They're pumping him full of prophylactic antibiotics and antivirals, and a team somewhere is working out a cost-benefit analysis for kicking the UV sterilization up to double the usual setting. They're considering doing something to kick his gut bacteria, since bacterial translocation from a damaged intestinal lining is a risky potential source of infection, but adding any more procedures right now is a risk, and this call isn't urgent on the scale of minutes, so no decision has been made yet. 

His lungs are a mess, and probably the next biggest problem other than the low body temperature. They can at least put off worrying about a local inflammatory cascade leading to acute respiratory distress syndrome - the immune dysfunction works in their favor, here - but this also makes it pretty hard to get a feedback loop on whether what they're trying is having any effect, positive or negative. It's not great, though. They suctioned out as much of the lake water as they could, went in with an endoscope and rinsed everything with saline to clean out all the river-silt, but that wasn't the first priority on arrival - given the low O2 sat goal, lungs full of gunk weren't actually a threat on the level of minutes - so it waited on all the key monitoring equipment was in place, and wasn't done until forty-five minutes in. Long enough for the fresh water to have some fascinating impacts on the delicate mucusa lining of the bronchioles and the even more delicate alveolae. The bedside chest X-ray was horrifying, and only a little bit because Merrin snapped at them not to even THINK of repositioning him for it (X-rays are usually done with the torso as vertical as possible.)

It's still....actually fine for oxygenation? With 45% O2, only a minimal increase since what the EMTs set, they're easily meeting the goal set for the interim treatment plan. But CO2 is getting to be a problem. There are a few different things they can change: peak pressure to force air in, lowest pressure (to keep alveolae from collapsing), volume, or rate. The last one has the lowest risk of causing additional damage, and low-volume-high-rate is recommended, so they're now up to, like, fifty breaths a minute. 

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Merrin is fine. This is fine. They're coming up on 150 minutes in (two and a half hours) and she's...getting the hang of this? It's objectively harder but it feels easier, as she's able to better chunk the pieces of it and get repeating subroutines automated by world-class programmers. 

(She has a library of her own, though most of the little automation scripts she wrote for situations involving five machine at once have never seen the light of day outside simulations, and also Merrin is objectively a terrible programmer. Her code is hideous and full of bizarre workarounds, though it's at least conscientiously well-documented. She....does eventually scrape together the dignity to ask if someone can look through a subset of them anyway and make sure they're safe to use for real and will behave the way she wants even in edge cases, or, uhhhhh, maybe it's....easier at that point....for someone who isn't stupid to just start from scratch and give her a non-stupid version?) 

To a random observer, it might be utterly mysterious what Merrin is even doing with her brain and how, but to a rank-two Keeper with explicit training in attention-splitting, who is watching her closely with the aim of replacing her as smoothly as possible once she's exhausted, it's probably not hard to figure out. Merrin talks to herself a lot anyway (or subvocalizes, at least) and given that she has an admin transcribing notes for her and taking requests, she's trying to actually be coherent in her narration. 

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Merrin doesn't have attention-splitting training, and certainly doesn't have the raw thinkoomph to split her attention five ways, so she's not even trying. 

One key part is that she's not trying to hold very much state in her head - if anything, she's trying less than she would in a sim, because she trusts her backup, and trusts that everything is being documented in detail and a dozen experts are checking over and analyzing every decision she makes. (If she frames it right, this is reassuring instead of mortifying.) She focuses on tracking a gestalt sense of how things are going - better or worse than expected - and is ongoingly making mental notes when something isn't working the way she expected it to. It helps a lot that, in this case, she doesn't have to task-switch to make those actual notes, she can just subvocalize everything that goes through her head - and intermittently, when she has a minute or two of breathing room, check in with her admin to get fed back the list of accumulated notes, and hopefully some commentary from the observers. 

Everything else is purely reactive, stimulus-response, over and over and over again. For any individual machine, she's spent dozens of hours drilling in sims; she's intimately familiar with the alarm tones, the patterns they form, what those patterns mean - and the link from 'hear alarm' to 'adjust controls on console' is down on the level of motor memory. For 80% of the adjustments she makes, it never even reaches the level of conscious attention, any more than someone carrying a box up a hill would have to stop and use explicit planning to lift their foot high enough to clear an obstacle while re-balancing the box in their arms. For alarms or alarm-patterns that call for a slightly more complicated response - one that involves pre-emptively toggling another machine, for example - she has the OODA loop down to less than five seconds, and once she's done it, she drops it from her mental stack entirely. 

Besides alarms, she has her screen set to notify her with a (distinct) audio tone for non-urgent Treatment Planner updates for her protocols or targets, and a different tone for urgent updates. 

Even with the alarms set to peak sensitivity and narrow parameters - and it's a lot more than five of them, she's watching the direct sensor data for the machines she's managing herself, but also a lot of other sensor data, and changing machine settings for all the other supportive devices that are going to impact with hers - but even then, she's not constantly reacting. She often has fifteen-second pauses, and every so often she lands in a nice settled equilibrium and gets an entire five minutes before some underlying process changes and starts rippling, or - more likely - someone ELSE decided to tweak their settings. 

The downside is that it takes her much longer to notice trends, if they're not linear and obvious, especially if she's in the middle of a bad run of "overcorrecting for previous overcorrections". To actively flag her attention, it has to reach the level where it's standing out in her vague gestalt sense. She makes the most of her moments of breathing space, though, and a lot of that is instinctive stimulus-response as well, and her internal process might be described like so: IF no interruption for ten seconds, flip through set of last-thirty-minutes-history screens for all her machines, IF obvious problem then troubleshoot ELSE refresh updated diagnostic predictions, refresh updated treatment plan - 

She usually doesn't get all the way through her cached list of Things To Orient To, but when she does, she stops and takes a deep breath and Thinks Ahead. It's very obvious when she's doing that: she goes quiet, often closes her eyes to help clear her mental cache of all the cruft, and relies on the alarms to interrupt her if she's run out of time. Merrin may be slower at thinking, and certainly much less able to track complexity, but she's actually around average at task-switching

She doesn't get a lot of longer-than-two-minute blocks to Think Ahead, but she makes the best use of them that she can, and these are generally the times that she notices she could ask for outside support on something. Or, like, a sugary drink. 

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Merrin also has some odd but charming habits, mostly developed during sim time when no one was watching her. She wants to disappear into the floor the first time she calls her vasodilator-constrictor a FLAMING NUCLEAR TURD, out loud rather than subvocalized, but regardless of how many Very Serious People are watching her from afar right now, it's honestly not worth trying to rewrite a bunch of random habits closely-adjacent to the ones she's leaning on so hard. She'll just...try to keep the actual noise pollution down.

The real problem is that, while she has a lot of sim hours with the vasodilator-constrictor machine controls, she's using it to hit a nonstandard target, and so it's flagging her attention a lot more often. ...Of course, an hour later, having sort of gotten the hang of some reactions and gotten the stupid repeating pattern automated, she's patting it and calling it a good girl. 

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To expert eyes - especially to the eyes of a world-class expert in the particular organ system and interactions she's running, sometimes the person who designed the current-generation equipment - it's pretty obvious that Merrin's performance is imperfect, and not just because her reflexes is slower.

She actively makes mistakes. She overrides-and-ignores alarms if she's in the middle of something else, and sometimes forgets to come back to them until the two-minute silence override runs out or until someone actually interrupts to remind her. She occasionally tries the same thing three times in a row, accumulating frustration about how it's not working, before her conscious attention comes in and points out that it wasn't even what she meant to do.

Based on the responses she picks out from her repertoire of standard ones (because she's basically never thinking that through in real time), even the ones she spends ten seconds choosing, her mental model of the underlying territory is massively simplified. In any given case, she's not doing much reasoning more sophisticated than 'if X go up, Y go down'. Every so often, she loses focus for a second, or just tries to make an adjustment without looking down at the controls because her eyes are busy on the screen, and toggles something in the wrong direction. (She invariably catches herself ten or fifteen seconds later, and squeaks 'sorry!' to the room at large while she fixes it.)

But her performance kept gradually improving, rather than degrading, for the first ninety minutes, and then leveled off - mostly because her rate of noticing and actually having the attentional capacity to implement her minor iterative process improvements was now having to keep pace with a slightly higher rate of unrelated problems, like sensors failing or her vasodilator-constrictor controls deciding to freeze on her for two minutes. (It's not really specced to be used almost-continuously for two hours.) Her reaction times start to slow if she's been in react-only mode for ten minutes straight, and her rate of making obviously-incorrect adjustments climbs, but two minutes of breathing room is enough to reset it. 

And, of course, she is just slower - not to mention less able to step back and see larger patterns, or think ahead and improvise a better set of next steps than her memorized set provides - than the counterfactual Merrin with +2 SD thinkoomph and the same accumulated hours of sim practice. But counterfactual Merrin isn't exactly waiting to take over. The rank-two Keeper with even twelve hours of intensive sims could probably improve on Merrin's performance on real-time management while vastly outperforming her on planning ahead, but they - unlike Merrin - definitely can't do twelve hours of sims in a single day at all, let alone keep going after. As of right now, the benefit if any isn't clear, handover costs are clear, and 'planning ahead' isn't centrally Merrin's role anyway, given that this isn't a sim and they have huge quantities of human capital going into the planning process. 

The markets - and the hospital administrator - are still not seeing any reason to replace her until she asks to be relieved or her performance noticeably deteriorates. 

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They're edging up toward three hours in. Merrin is obsessively refreshing the treatment plan dashboard in hopes of a new and better plan on what to do about the patient's disaster lungs, because the current state of affairs is giving her Creeping Unease, but she's also kind of desperately hoping they don't go for high-frequency ventilation. Not even for a good reason - it's a reasonable next step, balancing risk and invasiveness with benefit - but she HATES the noise it makes. 300 breaths a minute (delivered via an oscillating membrane in a control chamber) sounds like– not like anything else does, really, but it sets her teeth on edge, the vibration will throw off other sensors, and also it's just DISTRACTING. 

And maybe there will even be an updated timeline on their 100-custom-proteins so she can plan whether to ask for a bathroom break or push through it. She doesn't have to go very badly yet or anything, and asking is mildly awkward, and she's worried that whoever covers for her on the liver machine will mess up the nice stable equilibrium she's been in for the last half-hour. 

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A note on the heroic and innovative treatment plan now being improvised in real time, with venture-capitalist funding and the support of most of the secrecy-cleared relevant domain experts on the plan: 

As with everything else, the problem has to do with cascades, and the exact sequence of multiplying and self-reinforcing problems that ensue when a brain is briefly deprived of oxygen and then circulation is restored. 

The brain is metabolically hungry, has minimal local energy stores, and has very limited capacity for anaerobic metabolism even as an interim measure. It takes about fifteen seconds of interrupted circulation for a person to lose consciousness. Almost immediately, a number of changes result. Synapses depolarize early, coordinated internal regulation of various chemical gradients fails. Cells, almost immediately depleted of their main energy source, start to lose ground on the ongoing active work of keeping sodium, potassium, and other ions in the right places against osmotic gradients. The shifting balance in electrolyte concentration between cells and the fluid around them results, very quickly, in water entering the cells, causing them to swell. 

Eventually, a cell runs out of all its last-resort options to compensate, and dies. But cells are sturdy little factories, and killing them takes much longer - minutes, not seconds - and even longer than that in a cold brain. It's plausible that most of the neurons in their patient's brain are, currently, damaged but not destroyed. 

The problem is that the signs of damage are in the blood and extracellular fluid all around them. Nothing happens immediately, because any biochemical response to a perceived injury is one that takes energy. If you don't start to provide some energy to the struggling cellular factories (and your patient is still at room temperature rather than stored at -200 C), then damage is still accumulating. But if you do restore circulation and oxygenation, it's a little like a family coming home, turning the lights on, and only then realizing that some miscreant has vandalized it in their absence. You can imagine a reasonable response to this, the one an actual dath ilani family would have - 'stay calm, everyone, let's get everything back to normal first and then plan our next steps' - but the human body does not have dath ilani rationality training. The response is an immediate, forceful, panic-driven overreaction.

Oxygen is highly reactive - one of the reasons it's such a useful player in energy-generating cellular respiration - and this has its downsides, especially when the situation is already unstable. Chasing and fighting the vandal who trashed your house is rarely good for you or the surrounding infrastructure, especially if every other house in the city has also been vandalized and your neighbors are running around shouting and adding to the general confusion. Intensely reactive oxygen "free radicals" - about as indiscriminately violent as the name sounds, if the usual firm control and disposal mechanisms aren't yet up to speed - are generated everywhere, and go around breaking more things, setting off a cascade of even more cellular incident reports. Glutamate is released into the extracellular fluid, where it makes the neurons irritable and excitable, exactly at the time when they don't need to be messily burning more oxygen and pissing out waste products into a street where the maintenance workers aren't yet back on the job. 

All local and higher-level coordination is failing, lost in a cacophony of random signals. The usual inflammatory response to injury ramps up and up, every incoming piece of information convincing the cells that they SHOULD be panicking. 

...And a mechanism that plays a key role in the very low rate of new cancers comes into play. Immune-cell police are already on high alert, tracking down damaged offenders and destroying them before they can wreck the whole neighborhood, but cells have their own internal code of honor. Damage, especially DNA damage from oxygen free radicals and all the other nasty things flying around, makes them a risk. It's possible that most of the neuron deaths are cells following a deeply-programmed protocol to shut themselves down. 

At which point, of course, every dead cell dumps its waste contents in the public street, and the situation is not about to start improving anytime soon. In the worst-case scenario, the tissue swells enough to block off the recently-restored circulation, and it's game over. But even survivable outcomes are not generally going to be good

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They're in a better-than-usual situation for reperfusion, because of various factors but mostly the 'freezing river' component. With high quality medical treatment available, the cascade will probably stabilize before playing out to its gruesome final conclusion. 90% estimated odds of survival. 

The odds of a full recovery - of a cascade that stops before the damage exceeds the brain's ability to repair damage later and compensate for the odd dead neuron here or there - were initially estimated at 10%. The space in the middle is wide and varied, there are better and worse intermediate outcomes, but that doesn't actually matter. They know what the patient wants. A full recovery, neurologically intact, at whatever cost (whether denominated in money, favors called in, or awkward but temporary gastrointestinal adventures) - or, if every recourse fails, to go into the cold, and wait for a future time when, hopefully, Civilization will know how to fix it. 

(From here, they have a theoretically straightforward path to immediate cryosuspension if they run out of options, and hopefully an actual protocol will be finalized before and if it comes up.) 

10% obviously isn't good enough, but it's too late to interrupt the earliest stages of the cascade, because they happened before the patient even reached the hospital. 

So interrupt the later steps, then, right? Seems straightforward enough? It's exactly the same principle as basically everything else they've been doing so far. The issue is that here the tolerances are tiny, and it's not good enough to seize manual control of three or four levers, or even a dozen like the liver machine. 

The relevant knowledge exists, in bits and pieces, spread between dozens or hundreds of early-stage research programs. It would have been obvious before today that pulling it off on a human patient, with current research and available tech, will cost way more than most people's insurance would pay, and it might not even work. (The prediction market on the likelihood that this particular plan will work is still settling; they don't have a lot to go on, given that the plan mostly doesn't exist yet and is being written in real time.) 

Civilization would love to have solved this already, to have a protocol ready to go. But sometimes problems are just really hard, and their existing system of efficient market incentives to coordinate experts' effort hasn't, yet, solved this one except in fragments. Most patients won't choose the same stark risk-benefit analysis that this patient asked for, and certainly most patients don't have that much capital being thrown at their specific case.

They're about to find out if urgency and money are enough to pull together all those existing fragments, and make something work in time. 

Thus: a hundred custom proteins, and a team of some of the top world specialists, and a plan - that doesn't exist yet, but it will by the time the proteins do, hopefully - of what to infuse, in what order, to preemptively prepare all the walking-wounded cells to keep calm and carry on when the relief effort arrives, rather than, like everything always does in human biology, instead making everything worse

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In the meantime, they're in a holding pattern, because they can't afford to restore full circulation and oxygenation but they definitely can't afford to let any more damage accumulate, and so they're going to navigate a careful and maybe-impossible balance. Just enough energy to keep up with the most basic cellular maintenance, stringing damaged-but-not-dead cells along a little longer, but not enough for the cell-home security alarms to go off, or for the cellular neighborhood police to start reporting for duty. 

The single most important sensor result - displayed on the main wall screen in bold, big enough to take in at a glance - is from a tiny, very expensive sensor. It's hanging out in the patient's dural venous sinuses, where venous blood from the brain, and only from the brain, collects before returning to the heart. Choosing to place it was a real risk, given the patient's immunocompromised status and the very bad things that happen when infections reach the brain, but it's essential for the plan - or, perhaps more specifically, for the decision on whether to keep following the current best plan at all, or abort and frantically try something different.

Like with damaged heart muscle, there are chemical byproducts specific to damaged neurons and neural support cells. A few dozen of them are known; the continuous-measurement sensor suite that could be flown over on short notice from the nearest specialist lab can measure nine of them. It's not quite as sensitive or accurate as the full laboratory suite in the hospital, but there's a limit to how often they can draw blood and send it, and they can make up for some of the deficit by placing it where the concentration should be highest, as-yet undiluted by mixing with the rest of the circulating blood. 

There was, to no one's surprise, a period of measurable but gradually dropping levels on three of the indicators. Exactly what the markets predicted from the known cellular and metabolic changes that happen during a period of interrupted circulation. Slower, in a cold brain, but they don't actually know how long the patient was in the water; the models run on 'assuming normal body temperature, time required for the relevant heat loss' are guessing 15 to 30 minutes.

Then, for a few minutes, there was a just-above-the-minimum-detection-threshold level of a few byproducts specific to reperfusion injury, but the consensus is that this doesn't, yet, indicate any kind of irreversible damage. The brain does still have considerable capacity to heal. 

There's also an ultrasound skullcap for regular checks of circulation and signs of swelling in the brain - lower-accuracy than either a CT or MRI, but it skips the radiation risk and the incredibly inconvenient need to remove all the metal on the patient and haul him off to the MRI suite for a half-hour adventure, and running it frequently helps account for any noise in the measurement. They may want to risk getting a baseline MRI at some point, but it's going to call for things being Actually Under Control for at least the last half-hour, and this hasn't happened yet. 

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There's a saying in Civilization:  "There are three hard problems in system design:  Robustness against intelligent optimization, generalizing 100% correctly to a never-previously-tested problem on the first try, and maintaining the consistency of a Network-distributed data structure."  The joke/warning being that the third problem is allegedly that hard; the difficulty of the first two problems is considered obvious.

Hard problems are hard, often, because they have subtleties; gotchas that zap you when you wouldn't first-order expect them.

Of the first hard problem, a gotcha is that things blow up in the face of intelligent optimization even when those intelligences are not adversaries.  When you run a prediction market, the trading parties aren't adversaries, per se, but they want money out of your system and will take weird execution paths to get it, if any such execution path is available.  Even the programs the traders run, if they're executing simple means-end searches for maximum extractible value, can be considered as a kind of intelligence within the system against which the system must be robust.

Of the second hard problem, correctly generalizing out-of-distribution with 100% accuracy on a first try, a famous subtlety is that Reality has been known to be really ridiculously strict about what counts as a 'new and untested domain'.  Reality will kick you over the cliffside without hesitation even if you think you're in a domain very similar to a past domain, if you didn't test exactly that set of conditions.

And of course while it's sometimes hard to generalize correctly to a new domain at all, it's often a lot easier to do it right the second time, or if it's okay to get a few outputs wrong here and there.

Civilization has a lot of medical prediction markets.  It has a lot a lot of medical prediction markets.  Most medical markets don't experience this kind of attention, sure, but some do; it's not unprecedented for a rich patient to bid a million labor-hours on their outcomes.  Civilization has run thousands of medical prediction markets that saw higher bids than Merrin's patient, more trading, or more complicated and weirder medical problems.  If it was just that, the problem would be as 'inside of a previously tested domain' as any unprecedented complex event inside reality ever gets.

Few of Civilization's medical prediction markets are secret prediction markets, however.  There are routine secret prediction markets, some with a lot of liquidity, but those routinely secret markets are not medical markets for complicated medical conditions with lots of liquidity and traffic.


The case with Merrin's patient is, in fact, the very first time that a secret market operated by Exception Handling, in the medical domain, has dealt with a case that had this much liquidity, this much trading, these many medical complications... and, now, a particular malfunctioning sensor.

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The programs underlying Exception Handling's secret medical prediction market have unit tests, function tests, they've been tested on vast amounts of simulated data, they've been run over live data from nonsecret medical cases.  Just because you can't test exactly the future domain you're concerned about, doesn't mean you can't deliberately get as close to that as possible, under special training conditions meant to try to materialize any obvious kinds of anomalies that might turn up later.  That's just common sense.

The problem is hard anyways because Reality can be such a huge asshole about what counts as having tested your code inside a domain that's close enough.

There's a number of medical experts participating in the prediction market on Merrin's patient.  They're not expert market traders, though, they're medical experts; almost nobody has enough time to become world-class at both of those domains simultaneously.  The way medical experts participate in markets is that they have a deal with a professional market-trading entity that takes in the medical professional's expression of their opinion: its felt confidence, their guess as to how much evidence supports it, how much they'd shift their opinion if another medical professional said the opposite, a half-dozen human outputs that closely match the native format in which a human medical expert's brain generates its felt sense of the problem.

It's then the trading entity's job to run an algorithm that takes in that advice, weighs it against the bidding history of other trading entities, integrates those human opinions against algorithm-calculated statistical advice derived from a huge database of patient histories, and finally places a buy or sell order.

The human experts on this problem behave essentially the same individually as they would in a larger open market; that component isn't being run out-of-distribution in any way that'll turn out to be significant.  The human experts are fewer by a factor of around 32, compared to total market liquidity, than the number who'd be participating in a corresponding open market on the same patient; but individually they're behaving almost exactly the same way as they would for any other patient. 

But there are fewer separate codebases for the final bidding entities, fewer distinct algorithms being used by the actual traders and market participants, than there'd be in a corresponding open market.  Only three distinct codebases, in fact, because it's expensive to develop the software and algorithms and database to be a full-fledged medical trading entity, except that it operates on a secret subNetwork only and doesn't consult public feeds.  Exception Handling did not have infinite subsidy available for producing expensive secret infrastructure to use on secret medical problems.  Even so you obviously wouldn't want just one codebase used by all the trading entities, that would be insane; three such codebases gives you something like a majority vote in case one of them fails.

All of that secret infrastructure gets extensively tested against the routine open markets, of course.  It loses money, because it hasn't been optimized for nothing but open medical trading; but so long as it only loses a little money, the system is proving itself almost-correct.

But Reality can be ridiculously strict: those three algorithms trading in open nonsecret markets, are being tested under noticeably different conditions than those three algorithms alone trading in secret markets.  In particular, the secret trading algorithms being tested in open markets are seeing many more external buy-sell orders than they'd see inside a secret market.  You can program the secret trading algorithms to ignore that info, for purposes of a test run, but then they really do get eaten alive by open traders who can see the larger market history.

The three trading codebases cleared for secret medical prediction markets (each with several distinct instances, owned and operated by different professional traders, separately integrating the advice from subsets of the human experts) were of course requested by Exception Handling to be written separately from each other.  There's no redundancy if the programmers just copy each other's code.

But even then, sometimes there's a pretty obvious solution, such that three programming shops working separately will all pick that solution.  K-nearest-neighbor, for example, or lasso linear regression, or considering 3081 ratios between 79 measurements.

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One of the sensors included in the suite of continuous blood-test measurements, inserted a few hours ago into the patient’s vena cava, has malfunctioned and started showing high levels of a particular cell-damage indicator, one specific to the connective tissue involved in the lymphatic system.  The reading would make a lot more sense in a patient who wasn't being kept at 20C with minimal to no immune-system activity, and hence doesn't immediately trigger the first-pass garbage-data detection checks.  Worse, this individual sensor is part of a sensor complex producing enough distinct individual readings that humans are usually looking at summaries rather than every byte of data.  Only the machine algorithms are looking at every byte of data.

This sensor error doesn't set off the local anomaly-detector program, because that individual reading would be reasonable for a patient at standard body temperature.  The sensor error doesn't set off global anomaly detection, because those warnings have mostly been shut off and filtered; a patient at 20C is already chock full of unusual readings and ratios, already in a far strange corner of the state space.  So there's no simple way of noticing the anomaly, when the readings on the patient shift into a different far strange corner of the state space; a strange corner which, unfortunately, bears a nearest-neighbor resemblance to a totally different class of weird cases in the historical dataset, and sends a straightforward linear regression over quantities and ratios of measurements into bold new territory.  The complicated anomaly detectors have been shut off hours earlier, because they were just ringing all the time.  The entire system, in fact, is operating in something of a jury-rigged state of 'stop complaining about everything that's weird because the patient is at 20C, while still complaining about anything that looks weird given that'; this jury-rig is not perfect.

No human has eyes on this particular subelement of a wide stream of raw data.

An open market would be wide enough to have trading entities that specialize in noticing complicated algorithmic anomalies produced by sensor errors, but this market is too narrow for that.

And finally: in the underlying dataset, the resulting weird ratios between sensor outputs, produced by the sensor failure and run through a linear regression to yield other predictive factors, happen to be nearest-neighbor in the resulting metric to some cases of post-infectious autoimmune syndromes, in which the human-expert inputs often missed a treatment retrospectively deemed prudent.  This is a good occasion to 'correct' those disagreeing human-expert-opinion inputs! according to the algorithm anyways.

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This sort of algorithmic error is a kind of hiccup that happens all the time, inside trading entities in the bigger open markets.  It's just that in those cases, there's a lot of diverse other trading activity you can look at and suspect that your own algorithm's weird prediction is mistaken.  Traders in real markets get more practice, and have a larger budget to spend on proprietary patches to their algorithms, to try to avoid losing money over things like this.  The result of a few players' local hiccups is just that their trading entities will lose some money before somebody there notices the anomaly, leaves the market temporarily, and returns with a patched system the next day.

In this smaller, secret market - the trading algorithm would have been less confident if other trading programs had seemed to disagree.  But since nobody counterbids its bid, and indeed some competitors soon start to bid similarly, the trading algorithm rapidly doubles and quadruples down.

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Really, you could be impressed with how the thinner secret market got as far as it did, before breaking down.  The secret market processed tens of thousands of bids, thousands of prices, before outputting a gross error in one particular treatment-planning policy market.

It's just that, sometimes, 99.9% correct isn't good enough, and you also can't just leave the market and come back a day later.

Of which it's therefore sometimes said that there are three hard problems in system design:  Robustness in the face of optimization, consistency of distributed systems, and generalizing 100% correctly to a not-exactly-identically-tested new domain on the first try.

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A lot of secret people with secret jobs are going to be secretly very upset, after the exact origin of this problem has been tracked down.  They won't just be annoyed that the secret market failed, but that it failed in such an obvious, straightforward way.

And annoyed worse, that when the system did fail, the alternatives immediately available to fall back on were so paltry.  Why didn't Exception Handling just request for the system to have a comprehensible-reasons-only operating mode that the trading software could fall back to, if the complicated statistical stuff started producing obviously bad outputs?  Shouldn't you obviously do that, if you're a Governance project only pretending to be a real market using a tiny handful of custom-written codebases, when broken software can't just leave and come back later?  Somebody just coded up a system in blind imitation of a real illegible medical market, when those systems should have at least had a legible failsafe fallback mode that could immediately kick in!  Obviously!  There should've been a legible system like that checking all the illegible 'market' results, considering how the secret 'market' was ultimately a fake one that lacked the pseudo-adversarial inexploitability of a real market!

They will feel that this failure lacked dignity.  One of the sharper comments will be that if there actually had been a Sparashki present, Civilization would have embarrassed itself in front of aliens by failing like this.

Dath ilan lacks some context.

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...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.

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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. 

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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. 

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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 -

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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.

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(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.) 

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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. 

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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. 

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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.

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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.

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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. 

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(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.) 

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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!

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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????

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...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.) 

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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.

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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.

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(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?

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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.

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...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?

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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.

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

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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?

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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.) 

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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!

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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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Merrin doesn't actually know what backup would do that she isn't already doing! Can she get the latest estimates on whether adding higher doses of various vasopressors is even going to do anything - she doesn't want to do that, because once they're in the systemic circulation they will get into the patient's brain and hang out doing weird capillary-pressure interactions in a location where she doesn't have direct sensor data. But it would be nice to know what her options are. 

Does anyone have a theory yet for what's going on more specific than 'when you perturb this system, the system really doesn't like it', which is where Merrin's currently at. 

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Top general-hypothesis for what caused this, if not exactly what is currently going wrong at a level of granularity that suggests solutions: they did dilute the patient's blood very slightly? 100 ml of plasma, compared to a total estimated blood volume of 5100 ml (they have not literally measured his blood volume, it's an estimate based on the patient's weight and a few other factors) is a pretty small fraction, and it shouldn't have affected the vasopressor dosing or anything, but it might have affected local concentrations before it mixed, and it may have subtly shifted his blood chemistry - not electrolytes, those are stable, they're throwing the full suite of continuous blood sensor data at some modeling software now but it's a lot of data and they have a lot of hypotheses. There is ongoing debate and nothing is standing out yet in the diagnostic prediction markets, so it's not worth distracting Merrin with it. 

(An 'ongoing debate': a number of Very Serious People are quietyelling at each other. Merrin probably does not need to hear this. Merrin could go check the diagnostic prediction markets herself but is probably not going to do this in the middle of everything that's happening right now.) 

They can get some formal lab reads in case there's a sensor error causing them to miss something, unless Merrin thinks drawing 2 ml of blood is a bad idea. 

How's the patient doing?

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Merrin is not checking ANYTHING right now except for TWO NUMBERS. (...Wrongthought, she's tracking at least eight different things when you include all her machine settings and the ultrasound imagery.) However, Merrin sure isn't paying attention to the diagnostic prediction markets, or the treatment-planning ones actually, someone needs to interrupt her if they think of something for her to try. 

2 ml of blood shouldn't have any appreciable effect but Merrin is really confused and wants to note that on an intuition-level she feels like she has no idea how this patient works anymore. It's probably worth it, this is probably the most dramatic thing that's going to happen this hour? 

(Lab testing can be done with very small quantities of blood - even moreso when using top-of-the-line lab equipment, which they now have on site - but it still adds up, so they're not being frivolous about it.) 

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The patient's blood pressure is 31/23. His O2 sat is 59%. 

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Why are her numbers bad and wrong in OPPOSITE DIRECTIONS oh wait that makes sense, the oxygen already in his blood is being taken up more slowly.  

Check on whether she should try to cut blood flow to his brain further until the O2 is back in range or if 'trying to make your bad and wrong numbers cancel each other out' is the opposite of a good idea - actually now that she's said it out loud she's pretty sure she should not do that, but check anyway - 

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Rapidly-consulted experts on relevant body systems also think Merrin should not do that. They are more confident of this although not entirely in agreement. 

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Well great then. 

Merrin is...her intuition is saying that she should briefly drop the ventilator O2 concentration to 80%, drop the programmed heart rate further and max out the mechanical force for - thirty seconds is probably not going to kill more heart cells - and see if that gets the blood pressure back in range, in case it's the sort of self-reinforcing low blood pressure problem where it's low because blood isn't getting back to the heart because it was low ten seconds ago. She is not entirely sure why this might work it just feels like the sort of thing that might work, and it'll only take thirty seconds, and if something else starts to jump up in the prediction markets before the thirty seconds is up they can interrupt her.

If it does work it's going to mean briefly being further outside parameters but it feels like the best way to only be outside parameters briefly? Sorry Merrin is really distracted right now and doesn't want to take thirty seconds to try to make her reasoning legible can she just get a go or no-go?

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It seems obvious to at least a couple of people why this might be a good idea? If venous return to the heart is low then a higher heart rate means less time for it to fill and a rapid drop in cardiac output per beat, which at a certain point outweighs the increase in per-minute bloodflow from more beats per minute - and with real-time ultrasound imagery they can watch as Merrin drops it slowly over ten seconds, throw the recording at some analysis software, and come back with a suggested rate that maxes this. Also if she can get systemic bloodflow circulating, meaning more oxygen uptake, it should make oxygen saturation changes in response to setting changes faster and smoother, which will help Merrin avoid the repeated overcorrections when the measured response lags further. Also it's not going to do his non-brain tissues much harm, and might help, but Merrin really definitely can't let the carotid blood pressure go above 50/30. 

...Also update the diagnostic prediction markets are getting closer to settling. One rising hypotheses is 'something to do with nitric oxide concentrations: it causes potent vasodilation, the mechanism is simple and direct enough that it likely works even on cells at 20 C, and their process for getting the blood plasma from frozen to exactly the same temperature as the patient involved, for simplicity, reheating it to 37 C with the standard equipment and then controlled cooling from there, and it's possible this resulted in it containing more nitric oxide than is usual for infused plasma. Other contenders involve a reaction with the citric acid used as a preservative, and a few others to do with more obscure plasma proteins that have some enzyme functions. 

Good news if it's the first one: nitric oxide is very short acting, they might already be mostly past the window of effect and just still recovering from the resulting perturbations.

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Merrin will do all of those things! She's kind of scared, but externally this mostly comes out as looking absolutely furious at all of her equipment. 

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As recorded at five-second increments, at the patient's radial artery for reference (R), carotid artery (C) with [a] indicating manual adjustment with vasoconstriction, and O2 sat (direct carotid measurement). Measurement begun when mechanical force to cardiac pump increased, after a 15-second gradual drop from a set heart rate of 100 to one of 70. 

T0: R 27/23, C 31/24, O2 60% 

T+5s: R 30/22, C 34/23, O2 61% 

T+10s: R 32/21, C 36/25, O2 59% 

T+15s: R 35/23, C 39/24, O2 58%

T+20s: R 38/22, C 42/29, O2 57% 

T+25s: R 41/24, C 42/29 [a], O2 57% 

T+30s: R 46/25, C 45/25 [a], O2 56% 

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Recommendation that Merrin gradually increase rate to 80 over 15 seconds without adjusting the force setting and while keeping carotid systolic blood pressure between 40-45 if this is at all possible, maintain settings until O2 sat consistently under 50% with stable ventilator settings, then decrease force until no longer requiring constant vasodilator-constrictor manual adjustment to maintain carotid blood pressure below radial blood pressure. 

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...Sure, Merrin doesn't know why 80 but presumably their model spat out something more accurate that what she can figure out with just her eyes on the screen. (That was really fast, wow, it's actually super cool working with world-class experts as long as she's not in the process of embarrassing herself.) The rest she was planning to do anyway. Though if it takes more than two minutes she's really worried about further heart damage. 

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It does not really seem avoidable right now. It won't affect their immediate treatment plan; they're making preliminary plans to quickly arrange a heart transplant if, once they have the patient rewarmed and otherwise stabilized, his heart function fails to recover. (Obviously they aren't going to finalize anything until it comes to that.) The rewarming protocol taking shape likely involves (market at 80% that this is the best option for balancing risk and benefit) first transferring the patient onto a full heart-lung replacement machine, for tighter control of everything during rewarming. So they'll have time to react, if they get that far. 

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Merrin is NOT going to think about pacts made in Quiet Cities involving early cryo and organ procurement. She is going to PRETEND THIS IS A SIM wow she's kind of off-balance right now it doesn't usually bother her that much. 

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She's going to finish carrying out the instructions before worrying about silly things like whether Exception Handling is aware that she isn't actually certed to set up a full heart-lung replacement machine although, like, she can run one. Obviously they know what she is and isn't certed for, and her brain is being ridiculous by worrying that somehow for some reason they're going to decide she's the best person to do it anyway

 

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T+40: R 51/27, C 46/24 [a], O2 55% 

T+45: R 53/29, C 45/25 [a], O2 54% 

T+50: R 55/30, C 45/27 [a], O2 53% 

T+55: R 58/35, C 45/29 [a], O2 51% 

T+60: R 61/39, C 45/29 [a], O2 49% 

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Merrin lets out an audible exclamation of joy, says 'good job!' at the patient - or maybe the machines, it's sort of hard to tell - and then immediately rams the O2 concentration back up to 85% because, impairments in abstract reasoning or not, she is perfectly capable of extrapolating trends if they are that straightforward

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49%...

48%...

49%...

50%...

50%...

49%...

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"Does that count as stabilized yet can I stop." The patient's blood pressure did not actually keep going up much past a systolic of 60, but it's the highest she's seen it and her brain, used to the previous baseline, is insisting on finding it - the word she keeps landing on is creepy, which doesn't make a ton of sense. Also she is sort of worried that using the vasodilator-constrictor on almost its maximum setting for a minute continuously is not within its design specs. 

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She can start to back off very slowly on the force-settings, one increment at a time and wait at least fifteen seconds for it to settle, but yes. 

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(Okay Merrin did not actually need to be told that, she isn't stupid she is kind of stupid but that's, like, really basic practice for handling settings-changes on multiple interacting pieces of equipment). 

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It takes another five minutes to get everything back to sort-of-equilibrium, by which point the diagnostic prediction markets still going on what just happened have settled on 80% for 'nitric oxide interaction from the rapid plasma administration' - the remainder of the probability mass is split between half a dozen conflicting theories, citric acid is mostly out because that wouldn't have stopped causing problems so quickly. The current treatment recommendation, at least for right now, is 'already moot' - it was a short-acting substance causing a self-limiting problem, at least given that they got on top of it so promptly.

Less than 90 seconds outside parameters, even less than that for time spent off on both blood pressure and O2. Unfortunately, the post-incident analysis is concluding that both deviations were in the worse direction, and they're going to tweak some of the protocols to try to avoid any more incidents where a high O2 sat coincides with a low blood pressure 

 

...Probably unsurprisingly, there's a tiny spike in neural-cell-damage factors associated with reperfusion injury. It clears and drops back to below the detection threshold in less than five minutes, though, which means the damage isn't ongoing. It's not, by itself, indicative of a degree of damage that compromises their objective.

And it's useful information, in a way, if only to reinforce that they set the parameters right and really do need to stay within that narrow, narrow line.

They definitely can't afford for this to happen every time they swap out equipment, which means they should minimize doing that. 

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Merrin spends five seconds feeling like the most terrible person in the world and then tells herself to stop that, and then remembers that biting herself in front of Exception Handling is undignified. She bites the inside of her lip instead, so that it won't be conspicuous, and concentrates on her actual job. 

 

Fortunately for the patient, and also Merrin's sanity, the actual handover process and getting the settings calibrated right on the Complicated Liver Replacement Machine is, while incredibly obnoxious and fiddly and time-consuming, mostly not interacting with the patient's main vital signs. 

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...They are maybe having a temperature problem?

 

Which is new. Up until now, it hasn't actually taken a lot of effort to keep their patient between 20 C and 20.5 C. The air temperature in the room is 18 C, and while the bed is set with a simple thermostat-control hooked to the temperature sensor - standard hospital mattresses come with warming or cooling functions, obviously - it was barely doing anything. Apparently 'enough to maintain a two-degree temperature differential' was about the amount of metabolic waste heat their patient is producing. 

He's now at 19.1. 

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Merrin would like to register a complaint, this sim is unfair It doesn't seem that mysterious - given the timing it's clearly related to the Complicated Liver Replacement Machine, which does take blood out of the body and run it past cooler air. Probably someone who isn't her has noticed - 

"–I'm adding the heating-cooling controls to my console," she hears herself say. Great, as soon as she manages to hand off one of her machines, she acquires a new one. It's a lot simpler, though. And now that it's done, the more thorough coverage does seem to be helping, as dozens of different metabolic factors that had been ignored and slowly drifting entropy-ward are now being corrected. There are fewer fluctuations for her to handle. 

"It would be a really good time for some mild stimulants now," she subvocalizes to her assistant, and then - after reviewing her settings and sits back and grants herself, not a break exactly, but a precious fifteen minutes of being a purely-reactive attentional butterfly, existing only in the moment, the input of her sends, her hands moving almost by themselves.

It's not quite as good as a nap but it's surprisingly close to being as good as a nap, and for that fifteen minutes, not one weird thing happens to interrupt her. Bliss. 

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Now that one of the pressing problems has been addressed, and the aftermath navigated, there are a few other pending problems - nothing immediately urgent, but definitely things that need to be sorted out before they start trying to rewarm the patient. 

Delaying is worth it to the extent it buys them more time to prepare - for cleverer solutions to be improvised, for better equipment to be flown in as they realize they need it, for the Diagnostic prediction markets to anticipate what might go wrong in response to a planned intervention, and the Treatment Planner and markets to come up with plans for preventing those complications or at least a repertoire of responses in advance. 

Delaying is costly to the extent that the patient's condition is worsening, albeit very slowly - and because if the Venture Capitalist somehow does come through on his timeline and they're ready to start the improvised treatment protocol in just over six hours, they don't at that point want to be delayed on 'the patient still needs to be placed on a heart-lung replacement machine.' 

The benefits of acting sooner – if they can be confident of carrying out an intervention safely, and have reached the point of diminishing marginal returns to further preparation in terms of increased chance of success and decreased risk of making anything worse – is that they can maybe slow that deterioration even more. 

But there are still costs, even if a procedure goes off perfectly. Invasive interventions bear a cumulative risk, not just one-time, and many have an anticipated 'lifespan'. For example, machines to replace lung function use a high-surface-area array of fine tubules formed of semi-permeable biosynthetic membranes floating in a hyper-oxygenated nutrient fluid, imperfectly imitating the lung capillaries that absorb oxygen from the alvaolae. Flow pattern are different, often including unpredictable turbulence that can damage red blood cells, and unlike with biological capillaries, the biosynthetic membrane is inert, incapable of constricting or dilating to manage the pressure inside the circuit, and the membrane doesn't regenerate itself. Older models, based on earlier manufacturing technology, also lacked the quality control to consistently match the smoothness of real epithelial membranes, and microscopic irregularities would eventually start accumulating clots; the circuit had a lifespan of around 24 hours if the patient was on anticoagulants. The latest generation is much better, and can last several days even without taking the risk - which they can't afford for this patient - of using systemic anticoagulant drugs. 

The problem is that this is at normal temperatures. Among the many, many other biochemical processes altered at lower temperatures, blood viscosity increases, with obvious challenges when it comes to forcing blood through a high-resistance circuit of narrow-diameter imitation capillaries which can't dilate to reduce internal pressure. They can reduce pressure by reducing total flow, but slower-moving blood is also more prone to clotting. The current best models on how long a filter circuit will last at 20 C have very wide error margins, but the lower end is 10-12 hours – and 'while in the early stages of their improvised experimental rewarming protocol' is among the worst times imaginable to have to swap out the entire circuit (and every filter change costs the patient somewhere between 100ml and, if they get really unlucky, 500 ml of equivalent blood volume.) The later they can leave it, the less clock time they'll be putting in with the system operating well outside its design specs. 

That's just for lung function; the full version of the heart-lung replacement machine obviously also includes a pump, or in modern models, two pumps with separate controls - drawing blood from the patient's returning venous circulation, actively pushing it across the filter, and then running it past a second pump. This gives the medical staff very fine, and partially independent, control of both the pressure and flow inside the "lung" circuit, and the systemic blood pressure; it's the closest they have to imitating the interlocking natural biological control system of the combined circulatory-respiratory system. But artificial pumps, even with the current top-of-the-line technology, have pockets of internal turbulence that, again, damage red blood cells and platelets. Current equipment has a setup to catch and strain out some of those ruptured cells before sending them through the "lung" circuit to deposit clots in the tiny tubules, and before dumping them back into the patient's body - but they can't entirely catch the chemical byproducts released, including potassium and free-floating hemoglobin, which are also not great for the patient's circulatory system. 

The pumps will probably still work at 20 C, especially if they can design a software control system that more cleverly adapts flow rate to blood viscosity; frantic research is being carried out both on that and on modified mechanical components. But the rate of platelet damage and hemolysis of red blood cells will be higher – and right at the time when they're also dealing with wild swings in blood chemistry and accumulated cell-damage byproducts as the patient's own metabolism responds to the rising temperature. 

The current best idea is to attach a plasmapheresis circuit after the "lung" circuit and second pump, to filter out the non-cellular liquid component of the blood and - via specialized chemical substrates still frantically being tested - to selectively remove the protein components they don't want to dump back into the patient. But coordinating flow is going to be a pain, and obviously removing the liquid component of the blood means leaving behind much more concentrated red blood cells - plasmapheresis would usually filter plasma from the patient's bloodstream directly, rather than from the final stages of an already-elaborate circuit.

Also, doing it this way means that the final piece of equipment will be both rather jury-rigged, and also not something that literally anyone in the world is trained on using. They could instead use a more standard heart-lung replacement setup with only the hypothermia-relevant mods, and place a standard-equipment plasmapheresis circuit separately, but that gives them much less fine control on the overall system behavior. 

 

 

These are just some of the constraints currently being balanced. 

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There is now a new minor distraction, almost certainly not important enough to claim the attention of someone important, but: Merrin's mother is calling Personnel! Her daughter was supposed to be at a con and didn't show and isn't answering her cellular texter?? Also there are, like, so many helicopters converging on the hospital and Merrin's mother is kind of worried about whatever's going on right now??? 

She wants to confirm whether her daughter is okay, whether she's likely to be working the entire day and missing family dinner tonight, and if so whether Irris should make her a nice homecooked lunch and bring it to the hospital again? 

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A rather unusual medical emergency has occurred and Merrin is the only person on staff who has all of the certs required to handle it.  Further details gated behind a secrecy oath, unfortunately, the sort where you've got to take a grade-one oath just in order to be told which grade it is.  Merrin is likely working the entire day, and... yeah, should probably be fed at some point.

Under the circumstances, they're going to want to have it be a commercial precut-for-easy-eating homecooked lunch that Merrin can eat one-handed.  Possibly even a commercial homecooked lunch blended to where Merrin can suck it out of a tube with her hands free.  Does Irris know anything about Merrin's food preferences that aren't on file?  It would potentially save asking Merrin at a time when Merrin shouldn't be distracted.

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Oh goodness is it that kind of day! Merrin sure has a tendency to get herself into Situations, doesn't she. (Irris says this with pride and fondness). In terms of normal non-blended-to-suck-out-of-a-tube food, Merrin isn't picky and will usually eat whatever you give her (unless it's eggplant cooked in anything but this one (1) way Irris knows, but don't give her commercially-cooked eggplant.) She tends to forget to ask for food if she's busy, though. Here is a list of the foods she is especially enthusiastic about. 

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Yeah, this is a good time for the hospital to be nice to Merrin.  Like, not that they're usually cruel to her, but, extra-niceness today.  They'll get a chef on that.


(Admin doesn't say which rank of chef they'll be putting on that.)

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Awwww that's good to hear. Irris will try not to worry too much. 

(She is pretty curious about exactly what situation Merrin has managed to get herself into, this is definitely some kind of personal record for weirdness, but secrecy oaths are not to be messed around with and she doesn't actually need to know.) 

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Merrin does tend to forget about the existence of food when she's this distracted, and is also definitely not going to fully appreciate the quality of the chef, but the combination of 'delicious' and 'low effort to eat' is definitely going to help with actually getting the requisite calorie intake. 

 

Six hours in, they manage to bring online a higher-grade prediction market system. Merrin now has access to more predictions, faster, but not ones she can trust to the same extent as a real, tested, open market system. 

...One of the experts involved in setting it up starts giving her the quick explanation of the limitations, in terms they probably think are extremely simplified and accessible to non-specialists, and she sort of snaps at then that she has literally no idea what they're saying and less than zero interest in being taught new math right now. This would, under normal circumstances, be really embarrassing. Merrin has been throwing her brain at making sense of stupid data visualizations on various cross-sections of her sensor data logs during every single minute of not-entirely-occupied-by-reacting-to-problems "downtime" she can scrounge; she is sort of past caring who does or doesn't think she's stupid. It's not like it isn't already obvious, when she keeps repeatedly asking the data-visualization experts to redo something simpler because she's staring at it going cross-eyed and failing to even make sense of what it's depicting, let alone get the pattern into her subconscious to help guide her reactions.

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(There's a certain mental state that Merrin gets into after enough hours of non-stop reacting. It's not exactly that she's tired, not in a reflex-slowing way, but it's as though some part of her gets emotionally depleted long before the point when she actually starts running low on stamina. The mental lever that produces embarrassment when whacked is gradually less and less responsive, and eventually - here, about six hours in - she reaches the point when she is what one might describe as "out of fucks to give."

It has some interesting effects. She's less inhibited, less polite, much more likely to respond with brief rudeness to being interrupted by a person. But she's also, in a way, less distracted. Her raw reaction times aren't faster, but the moments when she loses focus are rarer and briefer, and there's actually a small but measurable improvement in her performance. 

Tomorrow morning, she's going to wake up, remember all the times she was moderately rude to top world experts in obscure domains of medicine, and be mortified again, but she's hardly the only one occasionally engaged in some quietyelling in situations that, if they were under less prolonged stress, they would have been able to navigate a lot more gracefully.) 

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Seven hours in, the Treatment Planners have a plan for transitioning to extracorporeal membrane oxygenation! Both for a system that works in the weird conditions they're throwing at it and will maintain an O2 saturation under 50% while running on a blood pressure of less than 50 systolic, and with 90% estimated likelihood that the the modified filter setup will hold up for at least 12 hours; the markets are currently at >95% that the rewarming treatment module and the team to run it will be ready by then. 

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(Merrin did say out loud, two hours ago when they were discussing interim plans, that if they had to switch to high-frequency ventilation as a temporary measure, not only would it mean two incidents of having to re-juggle all her settings into a new equilibrium, she also has some sort of misophonia about it and it would be distracting for her. Apparently when you are the chief opper on a situation like this, your stupid preferences get taken seriously as an actual constraint? They had the equipment ready just in case, of course, but by very, very careful setting management, she's managed to eke out the last three hours without ever needing to bump the ventilator O2 concentration above 95%.) 

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Merrin will be running the system once it's in place - and they're going to keep ventilating the patient's lungs – without the constraint of needing to maintain systemic oxygenation with that alone, so they can drop to a non-toxic O2 concentration and gentler volumes and per-minute respiratory rate, but it's not actually good for lungs to stop doing their job entirely, and it's not a sure thing that the patient's lungs are too badly damaged to recover once any of the normal cellular regeneration mechanisms are back online. 

Merrin will not be doing the actual setup procedure herself. She's certed for it, but it would take her full attention by itself, and it makes more sense to leave her on keeping everything else going while someone with exceptional fine motor skills and reflexes plus decades of hospital experience does the actual procedure. Also, they're modifying the protocol to make it possible that, up to the last minute, the opper can swap in a full heart-lung machine, if it turns out that the higher circuit resistance means that the mechanical cardiac pump can no longer maintain an adequate blood pressure.

(Merrin is not unusually advantaged at learning a new protocol on the spot, and is rather too busy to practice. At this point, she isn't even the person on-site with the most combined sim time on her current set of machines - just the one who has that plus eight hours of context on this patient specifically, and who can plausibly keep going for more than another 2-3 hours.) 

Also, rather than priming the circuit the normal way and hooking it up directly, they're going to prime it and then start circulation not on the patient, but instead through a module improvised from the organ-transport circulation support systems used for organ transplants. The transition will be awkward, with much narrower tolerances around timing, but it'll mean that the system is already flowing, already full of compatible blood oxygenated to exactly the desired degree, and the overall impact on the patient's blood volume, chemistry, and oxygenation status at the moment the connection is attached should be very close to zero. And it means they can connect the returning circulation a moment before the outgoing circulation, the opposite of how it's normally done, but predicted with 80% odds to provide a smoother and lower-risk transition in this particular case. 

There are other fallbacks in place if various different things go wrong, and personnel on-site (though not in the room, it's crowded enough) and ready to leap into motion on ten seconds' notice if they need to adjust plans. 

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Merrin is still super on edge for this, but on the bright side, she has a protocol to follow in advance, bumping up the patient's systemic blood pressure just before the switchover. There's a planned ventilator-setting adjustment at the same time, but by default someone else will be doing that; Merrin will only take over if they have to deviate from the timing in the protocol suggested by Treatment Planning and start improvising. 

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....Probably because of all the planning invested in this, though, the procedure goes almost perfectly. 

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Now Merrin has a new, more detailed sensor suite and a new set of console controls! 

Which, of course, means that her process for wrangling all the machines is going to have to change a bit; the overall cognitive load and challenge of the next thirty minutes or so is significantly higher than it's been on average for the last two hours, and while not tired enough that she can't do it, Merrin is emotionally drained enough to find it frustrating

On the bright side, the extracorporeal membrane oxygenation console is great. It's a standard piece of equipment, not one that only shows up in weird obscure sims, so she has at least a hundred hours of sim time with it, with or without wrangling other systems at the same time. There are a lot more input variables to control than just the basic ventilator settings, but it's very intuitive for her by now, and the degree of fine control it gives her makes her feel like some sort of epic wizard. 

(Also, the ECMO setup has a temperature-control setting! It's not as effective as the full heart-lung setup will be - it would be pretty challenging to stick to the rewarming protocol with just that - but for keeping the patient at 20 C, it's a lot better than only being able to adjust the mattress temperature.)

She's still going to be pretty tunnel-visioned for the first thirty minutes or so of getting used to the new workflow. 

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It's noticeable to the observers that this is pushing her closer to her limits; she's missing more alarms, defaulting to less sophisticated responses, and she's mostly not even trying to track the bigger picture; she'll need to be interrupted by a human if something changes in the treatment recommendations or the sensor data not directly linked to her machines, but that still calls for a shift in her overall strategy. 

But her raw reaction times are still maintaining. And while the Keeper shadowing her was getting to the point of probably outperforming her on her previous workflow, this is a new workflow, and Merrin still has twenty times as much emergency-conditions sim time on the ECMO controls. 

(There was some discussion of at least spotting Merrin for a thirty-minute break so she could rest before taking over again for the switchover, but Personnel was concerned that if Merrin knew her shadow was a rank-two Keeper, she - could probably still be convinced that she was the most qualified person for the next part, but it would at the very least be incredibly distracting and confidence-shaking for her. It was pointed out that they could just not tell her, but there are other considerations; on the recommendations of the prediction markets now focused on Merrin, and particularly on the betting of one particular expert in psychological modeling called Khemeth, having too much time to stop and think might by itself throw off Merrin's confidence. Whatever mental state she's in right now is clearly working, but may not be that robust to any poking. Also, it's not obvious that she needs the rest badly enough to make up for the context-loss of having to pick up after missing the last thirty minutes of the evolving situation; the Keeper will be leaning heavily on Keeper-specific training to manage stepping in with no ramp-up time.) 

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Fortunately, by the time half an hour has passed, Merrin mostly has the hang of the new equilibrium. And still feels like an EPIC WIZARD. It's good for her mood. Probably so is the caffeine she requested. 

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Only Merrin could be almost eight hours into a shift - which has been an emergency that could at any minute spiral out of control basically the entire time - and still look like she's HAVING FUN. 

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(Merrin is mostly only having fun to the extent that she's pretending really really hard that this is a sim. She feels weird about having fun when it's a real patient.) 

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8 hours in. Markets are now at 20%/50%/80% that the treatment module will be ready in 3.5/4.5/5 hours. How's Merrin doing on fatigue? 

Keeping her on this for another 5h will bring the total to thirteen hours which is insane to ask of a single person. But if they can be sufficiently confident that she won't burn out in that time, the rank-two Keeper can shadow her for a while longer until she feels more confident attention-splitting with the more complicated control suite on the ECMO, run a few times through a sim programmed with their best model of how the transition will look once the treatment module and team arrives, and then rest long enough to be in, if not peak, at least pretty adequate condition to actually take over whenever that happens.

(In the meantime, they can be ready to swap in one of the waiting replacements from another hospital, someone with equivalent sim time on the relevant machines. They can even make sure that there's always someone on standby, who's been watching Merrin's sensor suite and consoles long enough to sub in with some context. But not eight hours of context - and if they have to do that now, they'll be committing to doing it again in 2-3 h, and quite possibly again after that before the treatment module is actually ready.) 

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Uh, honestly if things keep going this smoothly until the treatment starts, and they don't keep needing her to keep everything together while they do new and exciting things to the patient, she'll be fine? She could probably do another six hours; she's never done 14 hours straight, but she has done six-hour shifts followed by eight hours of sim time and not much of a break in the middle. She's never done sixteen hours in the same day and does not want to promise she can. 

(Emergency sims are way meaner than this, but they're often adversarial almost by design - they're meant to cram as much relevant troubleshooting practice into a 2-3h block as possible. Sims basically never give you six hours of everything being approximately under control, but this isn't a sim, and real life isn't actively out to get you in the same way.) 

Can she get some updated probability estimates on various complications that could happen before they start rewarming?

- Uhhh, she means can someone go interpret the markets for her and then explain it to her like she's literally an eight-year-old or something. She's not tired enough that her abstract reasoning is failing on that level, or anything, it's just that if it might be five more hours of this, she really wants to minimize cognitive load and avoid doing things that are hard for her.  

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The highest-estimated-probability complication is that neural-cell-damage indicators will start rising at some point before the treatment module is ready - the markets are giving it less than 10% odds if treatment is somehow ready in two hours, but up to 30% odds if it takes more than five hours. If that happens, they have a flowchart of parameter changes and then various other measures to try; Merrin can review it, here it is, and of course someone will prompt her if this comes up. 

Nothing else has a >5% prediction on sudden-onset complications. The highest estimate for complications period is a GI bleed - 12% that this would happen within the next 5 hours, up to 35% if they somehow need to keep this up for another 8 hours - but they would almost certainly catch it before significant blood loss could occur, and there are responses planned. Emergency blood transfusions will likely mean that Merrin has to do a lot of rebalancing to stay within parameters. 

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Uhhhhh Merrin cannot promise she has more than one more block of frantic troubleshooting left in her today? She's pretty sure she can handle it once, even if it's in four and a half hours, and keep up until they get back to something vaguely stable - but if it happens in ten minutes, she may actually be tired enough afterward for her reflexes to start going. 

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...They can probably work with that. Probability estimates on an emergency troubleshooting level response being required from Merrin in the next hour are very low. 

(At this point it seems worth it to have the Keeper run sims and be fatigued for a few hours; if they do have an episode of patient deteriorating to resolve before the treatment module is ready - and Merrin is even right that her stamina will run out after that, the Merrin-related prediction markets seem to have more faith in her than she does - they'll tank the efficiency loss of subbing in a non-Keeper nurse for the remaining time.) 

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Sure. 

Can she get a caffeinated drink please. And maybe a cookie?

(What Merrin actually kind of wants right now is a hug and for someone to tell her explicitly that she's doing a good job and not being an idiot and nobody is judging her for not being any good at prediction-market math, but she isn't about to ask for that out loud.) 

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(There is in fact a prediction market on what will happen if various possible personnel go in and give Merrin a hug, and it's mostly predicted to be beneficial, but the expected benefit is small and the downside risk is large.)

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After all the work they've put in, they now have control of enough levers for the patient's various bodily processes that nothing is going to go too wrong in the next few hours. 

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Somewhere in the background, while all this is going on, a minor horde of high-ranking programmers and prediction market experts are frantically scurrying around, trying to get out ahead of testing the new untested prediction-market trading backend, turning up bugs before they explode - now with 70% less statistical learning, but still enough statistical learning that advice propagates in three seconds instead of ten seconds.

Among the acerbic comments being exchanged on backend, where nobody in the operating theatre can hear, are comments to the effect that statistical learning is sort of like summoning a deranged nonreductionist alien-spirit into your system: it will serve you faithfully until it stabs you in the back.  And the entire invention of statistical learning was a bad idea with bad brain-incentives, because it often initially seems to work great and your brain is happy about that.

They're sad about how miserable their fates as programmers are, that they have to get involved with these statistical learning methods that are not always perfectly legible and sometimes produce bugs that are hard to understand even when you're looking directly at their causal antecedents.

They, too, lack context.

Actually in this case, three-quarters of the people on this team have context; but everyone who has context is trying to act exactly like someone who doesn't.

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The previous Personnel has now gone off-shift - temporarily, she's left instructions that she's to be called back into the office once this is over or Merrin gets rotated out, even if she's asleep then, because she wants to be the one to congratulate Merrin and also she wants to see the look on Merrin's face about a lot of things.  The new Personnel is named Villar, doesn't know Merrin quite as well, and has been left with a lot of extremely detailed instructions about Merrin-related contingencies; many of them counterarguments Villar is to use if anybody suggests rotating Merrin out before Merrin herself says she's feeling tired or actual performance degradation has been measured.

(The previous Personnel doesn't have a name she uses in-hospital besides "Personnel".  She's an adherent of that subculture which holds that people in real life ought to go by names that correspond tightly to what they are in a social context, like LARPs where everyone is named 'Acerbic Cook' or 'Frustrated Ruler's Daughter' so that players can actually hold all the identities in their head instead of dropping them while they try to associate names to unfamiliar people.  Or as she puts it for hospital purposes:  New employees are going to have a hard enough time remembering new coworkers without asking them to remember that Personnel is called anything except Personnel.)

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The Venture Capitalist - whose personal name would be Ashre, if he was asking anybody in this social context already juggling complicated problems to remember him as anything except The Venture Capitalist - has done a lot of organizing and quietyelling and spent really a lot of money, for a plan that prediction markets currently give only a 20% chance of working.

He got his initial set of 20 custom proteins hours ago.  And then his people sacrificed a number of rats, testing the new protocol on them and checking results in lethal detail.  After which they asked for 8 of the custom proteins and 7 more of the off-the-shelf proteins to get replaced - this being when the patient's survival probability dropped from 30% to 20% - and now they've tried the second round on rats and a few precious monkeys.

The basic story seems to be that whether you get a flood of damaged-neuron cell signals (followed in fact by actual brain damage) depends on how much the monkey got cold-damaged beforehand, and it's hard to tell in advance how much damage happened beforehand.  They have debugged every bug about this protocol that is scrutable on a few hours of work by very smart people, and which Exception Handling's mysterious protein-design capabilities think they can possibly fix in hours rather than weeks.

It is obviously not the best possible protocol.  It is not even a very good protocol.  But the patient is not incredibly stable, right now, and doing another design-observation iteration on the protocol would add another 4 hours to timeline and probably not be worth it, all of which is playing out pretty much as the prediction markets expected.  The entire research timeline, at this point, looked like cooling and rewarming some rats while applying 80 proteins and peptides and a handful of lesser chemicals already known in the literature, the rats getting brain damage, writing back for 20 more proteins, getting those, new round of testing, asking to fix remaining errors if possible; there is an old saying in dath ilan that what you can't solve by killing two groups of rats you are unlikely to solve by killing three.  It's usually taken as a metaphor for correcting first-order errors and then correcting second-order errors, but it's also often literally true.

They've killed two rounds of rats and observed half of a third group end up with unacceptable levels of brain damage, they've already run out all their most promising nitwit-ideas and improved-nitwit-ideas on the first two rounds, it's time to roll.

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It's not a very good protocol, but it's possible at all because it leans heavily on decades worth of rats sacrificed to narrow in on many - though certainly not all - of the links in the cascade that they're already too late to block at the source, and need to fall back on interrupting at every possible point. 

Reviving patients from temperatures as low as 18 C is actually fairly safe, IF the cooling process is done under controlled conditions - for example, to perform a complicated and risky surgical repair on an aortic aneurism, with an initially stable patient. This is no longer the standard process, since there are now simpler and safer bypass methods to avoid having to disrupt circulation at all, but originally, a patient would be placed on a heart-lung bypass machine while at a normal temperature, and rapidly cooled - with fully- supported circulation and oxygenation throughout, controlled to a high level of precision - until their heart stopped beating, all electrical activity in the brain ceased, and the patient's circulation could be paused for up to an hour, the oxygen already in their blood sufficient to cover any minimal remaining metabolic activity. The survival rate for the procedure itself was 95%, and this was in patients already badly off enough to need major surgery. (Infection risk in the days afterward, due to the suppressed immune activity on top of multiple invasive procedures, was the main motive for figuring out systems that only required cooling to 28 C, if that.) 

Using the exact same rewarming procedure on patients brought in with accidental profound hypothermia to the point of cardiac arrest had, at the time, a survival rate of around 25%. (And those who had dealt with a lack of oxygen or disrupted circulation before they were cold enough for circulation to spontaneously cease still faced a high likelihood of brain damage.) The raw survival rates were predicted to be much higher now, largely because of new techniques that gave finer control of all the other affected variables - electrolytes, liver function, clotting, etc, but this was an estimate based on very few case studies, because most people's medical testaments preferred not to take the risk of further irreversible damage. 

The rats in recent experiments analogous to the patient's history now had decent chances! In a dozen different studies (all repeated by separate research teams using their own methods to check the findings), around 95% survived - even after 10-15 minutes of submersion in ice water before treatment was initiated, and 50% had no measurable signs of brain damage - but, of course, it would be far harder to detect any subtle cognitive deterioration in 'recovered' rats.

None of the individual studies addressed more than fifteen of the pathways now being targeted, and many had been intended to isolate a single enzyme path and measure the effects in isolation of either blocking or amplifying it. The interactions and side effects involved in combining them were as-yet unmeasured and unstudied.  And rats weren't humans. Their small size and resulting high surface-area-to-volume ratio meant that their internal organs, including the brain, would cool much faster than those of a much larger human, and the metabolic suspension likely kicked in before their blood oxygen was depleted.

The team designing the current process was leaning rather hard on the premise that combining a dozen different protocols that had worked okay, in rats not humans, would block a wider range of the cascade, while not interfering with the effect. This premise had never been tested at all, let alone confirmed to a reasonable standard of proof. 

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These treatments have never been combined. Fifty-three of the custom proteins have never been administered experimentally to mammals, though sixteen of those have been tried on nematodes.

(C. elegans, with its fully-mapped proteome and conveniently deterministic arrangement of exactly 302 neurons, is an excellent case study for fundamental research - and a surprising number of the metabolic pathways that play out in a human brain are ancient, shared by approximately all animals that have nervous systems. But for all the shared pathways, the nervous system of a millimeter-long invertebrate worm faces a very different set of constraints; biomolecules may be passed on and reused for billions of years, but that doesn't mean that their exact usage stays the same.) 

And, of course, twenty of the proteins had never been synthesized before today; they're for the cases where a given metabolic feedback loop is described in the literature (usually in gene-knockout studies with mice showing how overexpressing or underexpressing a particular enzyme pathway rendered them more or less susceptible to anoxic brain damage.) They were rapidly tested in vitro on a neural cell culture, before the actual rat trials, but there was never going to be enough time to unpack the details of how they behaved differently in a rat brain. 

(The sacrificed rat brains weren't thrown away, of course; some are frozen, some are being plasticized in resin to section and examine under a microscope, and there's more information to be gleaned in future weeks and months - it's just that even with every lab in the world willing to work under a grade three secrecy oath, you can't do that in six hours.) 

Some of the proteins are ones normally expressed in the human body, like the family of superoxide dismutases that break down the highly reactive superoxide radical; an O2 molecule with an extra electron, roughly; back to O2 and a hydrogen peroxide – which is still not a substance one wants in one's brain, and is in turn processed by the ancient catalase pathway into oxygen and water. 

(So many of the biological pathways in all oxygen-metabolizing organisms all the way back to aerobic bacteria are focused on mitigating the damage from the various inevitable byproducts of using oxygen's chemical reactivity for fuel. You start to wonder sometimes if the whole oxygen-breathing evolutionary track was a mistake.) 

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And it doesn't stop with oxygen. Nitrogen also likes to form highly reactive radicals, calling for an entirely different set of antioxidant enzymes. These radicals damage lipid cell membranes, dumping an entirely new metabolically-reactive class of peroxidized fatty acid bits, which float in the bloodstream and scream out their own inflammatory alarm.

The RNA-to-protein transcription of proteases (protein-digesting enzymes, which is sort of like cannibalism if you think about it) is upregulated, for some reason that the cellular code leaves entirely undocumented, and start eating the carefully-arranged tight junctions and cellular "feet" that form the blood-brain barrier, letting panicked immune-system cells from the bloodstream ooze through and, in their desperation at the vandalized state of the city, overreact drastically. This process is complicated enough that no one is sure which steps are actually critical bottlenecks – the metabolism likes to have eight different ways to accomplish the same thing, and often, like with anaerobic metabolism of glucose, the fallback ones are even lossier and messier – so they're throwing a dozen wrenches into those cogs, putting rather a lot of hope in 'it didn't kill a C elegans in one study ten years ago.' 

Caspases, sometimes called “Executioner” molecules for their key role in noticing damaged cells and convincing them to commit seppuku, are a very robust pathway - the body is under strong selection pressures to catch DNA-damaged cells before they go rogue and found a tumor colony, and...rather less selection pressure to be conservative about preserving neurons that can only probably recover with further heroic interventions. 

Thirty of the proteins aren't human proteins at all (six were isolated from a single species of hibernating frog.) None of them seem to be actually toxic to rats, but that's about all that's known. 

(Presumably this, as well as the CT scans, is going to end up significantly increasing the patient's later cancer risk, but requiring more frequent and thorough cancer screening for the rest of his life is a relatively tolerable price to pay.) 

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Surprisingly quickly in the reperfusion process, it's known that (in rats, at least) the changes ripple up to the level of directly altering gene expression. Among many, many changes, cluster of genes known mainly for their tumor-suppressing effects are upregulated - an excellent idea in theory, but more appropriate in the context of organs that have more redundancy and regeneration ability than the central nervous system. Directly regulating gene expression is a science in its early stages, even in dath ilan, but according to the simplified biochemical simulations, they need to at least try to block it that far upstream to prevent the system, noticing that its usual response is being suppressed, from desperately exploring other side pathways to compensate. 

(The proteins used for this aim are likely to do all sorts of other poorly-understood things, because there is nothing biology loves more than to reuse bits and pieces of four-billion-year-old code in new and creative ways.) 

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Most of the uncertainty on success vs failure is already determined, not the result of the team performing worse or better. In the world where the patient was without circulation for ten minutes or less, the success estimate on “no brain damage” rises to 50%, and the remaining probability mass is on outcomes that wouldn’t be acceptable for this patient specifically, but would still include leaving the hospital walking and talking. 

On the other hand, if the interval was more than 30 minutes, the predicted success probability drops to less than 10%. 

They don’t know which world they’re in, yet - in fact, they aren’t likely to find out, unless the investigation into how this happened turns up an exact time for when the patient fell into the river. The outcome of the treatment will give them some evidence, maybe, but not conclusively.

The plan is to have very extensive monitoring in place, including via actual brain surgery, to add a far more thorough suite of sensors across the entire brain. (Some regions, especially the cortex, are a lot more vulnerable to anoxic and reperfusion damage than others, and they want every chance lined up to notice failure as soon as possible.)

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From Merrin's perspective, though, this whole desperate Plan of Proteins is going to infringe on her personal reality in the form of an overhead voice waiting until the next time Merrin has a half-minute free, and then telling Merrin to prep for shift handoff to her replacement.  Rewarming protocol is incoming, Merrin's performance has started to degrade a little as they approach the 12-hour mark, rewarming is a new regime that'll take a while... in other words, this is Merrin's best chance to escape.

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On the one hand: finally!!! Merrin is definitely starting to feel— not exactly tired, but definitely mentally slower, emotionally out of energy, and frazzled enough that she’s been building up more and more quiet dread at the possibility of anything else going wrong before she manages to hand off. Now seems like an excellent time to escape, and she can even feel like she’s handing over a reasonably stable patient.

On the downside, she’s definitely going to be handing off to someone five times as qualified as herself, and she’s worked for this long before but never given a report on something this complicated while already this low on mental and emotional energy. What if they think she’s stupid.

 

- Eh, they wouldn’t be wrong, but Merrin still feels pretty good about how this went overall. She signals back that she’s ready. 

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The woman who comes in to take over looks to be in her early thirties, as is plausibly where you'd find the optimal combination of stamina, reflexes, and having done a whole lot of weird sims plus a large chunk of actual weird medical experience.


(Avarris, rank six medtech at Default Hospital.  Merrin is unlikely to recognize her from Exception Handling scenario TV; Avarris sticks to real patients for the most part.  Merrin might recognize her if Merrin is familiar with the most famous medical oppers on the planet as such.)

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It’s probably a good thing for Merrin’s state of mind that she isn’t, at this point in her life, familiar with the most famous non-TV-scenario medical oppers. (She is going to look up Avarris and freak out AFTER.)

…She does catch herself four seconds into the usual “dropped by surprise on a pile of steaming superheated nuclear waste” sim report with all the background context and scene-setting, before remembering that this continues not to be a sim, and obviously Avarris has been watching the proceedings and will be up to speed on everything she can follow from outside the room.

The remaining handover mostly concerns Merrin trying to convey as much as possible of the procedural information involved in handling the machines.

This unfortunately is embarrassing, because Merrin is notably worse than most dath ilanis at converting her intuitions into a legible-to-others verbal explanation at the best of times, and mental fatigue hits her verbal fluency significantly sooner and harder than her ability to keep reacting intuitively. Fortunately she’s had them in a fairly predictable state for a couple of hours, so can at least hold everything else together while Avarris has a chance to incrementally take over one machine at a time and get used to it.


….Wow she is actually pretty exhausted. It was less noticeable when she had been in a half-trance flow state doing the exact same things for five hours, but Merrin is so ready to be done.

Though not to go home. She’s too wired to be sleepy and too emotionally invested to walk away before she finds out what happens next.

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Avarris will do very well, very quickly; and only do a few things, while operating an increasing number of machines, that strike Merrin as clearly not what she'd do for this patient.

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Wow! That’s impressive. Merrin wants to be that cool when she grows up which is never going to happen, a lot of it has to be raw thinkoomph, that’s so fast. Being sad about that is a waste of mental bandwidth she doesn’t have.

- Well, maybe the thing Avarrisdid instead is a totally reasonable thing to do and Merrin is just missing the reasoning for why! Merrin totally does not do anything mortifying like try to slap her hand away from the console, even though she is very tempted and apparently less inhibited than usual! She will politely point this out while immediately tabbing across all her sensor-data screens to make sure that didn’t break anything else.

They at least manage not to cause any new and exciting deterioration while doing the handover.

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And now Merrin can sneak out and find a quiet corner somewhere else on the unit to sit down and watch the next proceedings? 

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When Merrin leaves the operating room, she'll find somebody in the (overt) uniform of Exception Handling, waiting for her.

He can call her a helicopter straight home, accompany her home and give her updates, accompany her to a massage parlour and give her updates while somebody works on her muscles, or she can head over to the hospital command center as has been commandeered by Very Serious People to watch how the final rewarming ends.

(She's also got a fairly unlimited number of other options, like getting flown by private jet to Nandville on a comped ticket.  Like, one hears secondhand reports that Merrin personally is unlikely to go for that.  But she should be aware that this, and many other things, are among her options if she wishes.  Merrin has worked hard today, and Civilization recognizes that.)

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Merrin is sufficiently nonplussed by this unexpected attention that she just stares blankly at him for ten seconds.

“…I’d like to watch from the command center,” she says, sort of shyly because aaaaaaaaaah Exception Handling is important and scary and she feels unusually stupid even for her. “I. Um. If there’s space and I won’t be in the way or distracting anyone?”

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"I expect you'll validly distract some people who would on reflection endorse their desire to pay attention to you," he says, heading off in almost the right direction inside the hospital.  "Oh, one quick word though - don't say or do anything that would contradict the theory that you're a real Sparashki entering her aquatic phase.  We passed word to the Fake Conspiracy section of Exception Handling, and they've spent the last few hours quickly planting evidence consistent with how Civilization should look if the Sparashki are real.  The notion being that their apparent fictional status and licensing is just a cover, so Sparashki can walk around if they have to and just get compliments on their incredible cosplay.  Since this event is medium-secret, the CEO of Yattel's Less Expensive Tunneling Machines has been photographed by surprise through a window, looking like a Sparashki, to explain why conspiracy-theoretic research is suddenly focusing there and turning up the evidence we've planted."

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People are going to pay attention to her???? Why this??????? Merrin wants NOT THAT. Unless maybe the attention is a hug. From her mom specifically. If someone from Exception Handling tries to hug her she has no idea how she would react but she might cry. 

“I, um, oka…ay,” she manages. It’s fine. Everything’s fine. She’s not even that much of an expert on fictional Sparashki, mostly her friend convinced her to pick that cosplay as an excuse to show off her swimming skills. Merrin is terrible at bluffing (by dath ilan standards) under normal circumstances. Maybe she just won’t talk???

Also who even had time to go plant a fake conspiracy in the last twelve hours? Sure, it’s useful cognitive training for someone somewhere probably, but weren’t people BUSY? Were they somehow still bored despite the absurd level of THINGS HAPPENING and needed to add in even more fictional complications to keep themselves amused? Sometimes Merrin feels like she does live among people of a different species, and this is one of those times. 

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She will follow the Exception Handling person and try not to look as socially uncomfortable as she feels.

(She doesn’t really succeed at that, but it’s notable that even now, she doesn’t look physically especially tired. It was actually an unusually light shift for physical exertion, and she’s so caffeinated.)

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Correctly reading that Merrin looks more fried by her twelve-hour medical emergency than like she's following along with all this, he'll mention that it's not important for Merrin to execute her Sparashki masquerade perfectly.  Exception Handling didn't do all that for a reason.  It's just that, if Exception Handling only did things that made sense, it would then be far too easy to infer the true states of affairs in Civilization by looking at Exception Handling's actions and asking what background truths would make their actions sensible ones.

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…Sure. That makes sense. Merrin can at least avoid denying being a Sparashki, though if someone straight-up asks her to her face, she will probably react by bursting out laughing and then possibly having to flee the room before she cries (wow this was way more emotionally and socially intense and draining than anything she’s done before, huh. Merrin feels sort of vaguely capable of going to the sim room, but definitely not of having a normal conversation with anyone smart and famous aaaaaaah.)

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This person happens to be unusually good at reading people and has been briefed on Merrin in particular.

So before they get to the command center (once he's correctly figured out how to get there inside the hospital, if Merrin doesn't correct him earlier), he'll ask Merrin to wait a quarter-minute, and duck in ahead of her.

Then he'll inform everybody present (physically or remotely) that he infers medium-confidence that Merrin is pretty fried from her twelve-hour emergency shift, and possibly nobody should talk to Merrin directly for a few minutes unless she initiates conversation.

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Very understandable!

Governance's Chief of Medical Oversight will get out of one of the comfier chairs, in case Merrin happens to want to sit down once she comes in.

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Back!  Sorry, he was just checking and optimizing a thing.  Merrin can head in now.

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(Merrin vaguely notices they’re headed in slightly the wrong direction, but it takes her long enough that bringing it up feels weird, and maybe it’s on purpose and actually makes sense. She doesn’t interject.)

She stands sort of blankly outside while he goes in.

The first place her eyes go is to the LCD wall screens - there are even more of them in the command center, and she’s now had her eyes off the patient for, like, an entire five minutes. It seems very unlikely that anything will have changed yet - the operating team is still getting set up for the pile of initial procedures, which need to happen before they start manipulating the patient’s core temperature at all. Still, it’s giving her an itchy feeling. 

There are actually a number of banks of extra screens that were brought in, for the people flown in and now sitting on the chairs brought in, and also for the people not brought in on-site but currently participating via videoconference. 

There are not going to be any quiet corners for Merrin to hide out of sight - 

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Merrin is a face recognizer, and the Chief of Medical Oversight - not to mention probably a lot of the other involved parties - do, unlike Avarris, ever appear on TV.

Merrin, who is quite looking forward to sitting down again actually, notices the available chair first and only then notices who’s sitting NEXT to it. 

It’s probably too late to quietly slink out of this terrifying room that Merrin so incredibly doesn’t belong in??? Running away after everyone already saw her is not any less mortifying than…this…and she can’t even hide under any desks, they’re all in use. Plus she wouldn’t be able to see the lovely array of screens, then, would she. The chair is actually a pretty great placement, in addition to looking like one of Merrin’s preferred chair models.

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This is now actually surreal enough again that, combined with Merrin’s sheer emotional exhaustion, she’s sliding back toward being incapable of caring. Also everything feels fake. This is a scene from a TV show, surely, not Merrin’s actual life.

She smiles nervously at the Chief of Medical Oversight, because that’s just polite, and sits down, and without particularly making a decision, logs herself into the computer console and goes to look up Avarris’ file. She has the evidence of her own eyes that HER PATIENT (Merrin gets protective) is in good hands, but confirmation will still be reassuring, right? 

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This weird surreal TV show sure is making some interesting casting choices. 

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People present that a face-recognizer like Merrin should easily identify:

The hospital's Fat-Tailed-Risk+One-Responsible-Person (chief of financial risk management), who is glowering at the hospital's central financial viewscreen; while getting a shoulder massage from one of the hospital's more ambitious sex workers, who's trying not to look like she's plotting any sudden career moves.

The actual CEO of the hospital.

Villar the on-duty Personnel.

The off-duty Personnel who just goes by Personnel, looking rather sleepy.

 

Others present in the room, who may be identifiable if Merrin watches enough news, or if Merrin is at an angle to read the large nametags clearly showing name/title/affiliation because this is serious business and nobody has time to try to remember that stuff:

The second-rank Keeper who was understudy if Merrin suddenly fell over during her first few hours.  She's wearing medical scrubs rather than standard Keeper-wear, but still bears a rank insignia in her hair.

A fourth-rank Keeper who would have taken over if Merrin had faltered during later hours and before shift handoff.  Ditto on medical scrubs, rank insignia as circlet.

A very-long-serving Representative who sometimes concerns herself with Exception Handling and with Civilization's operations excellence generally.  It's widely acknowledged by everyone including herself that she chose the wrong career track and should have gone to work for the Bureaucracy directly, but the executive branch of government is forbidden to hire anyone who's ever been in politics for obvious reasons so too late now.

The grandmother-gendertroped woman who originally spotted a body in an icy river.  She's here out of curiosity, out of compassion, and of course because her final bounty is going to depend on the final outcome.  She's already sold most of her expected gains as a bond, outcome variance here being very high; but Civilization's generally good financial practices mean that almost nobody will buy an entire risk from anyone.  It's suspicious when somebody wants to end up with zero skin in the game they're selling you.

An information-security expert from Exception Handling, to be the one person present whose job it is to keep track of all the secrecy and related practices.

One actual soldier / military police; there's enough concentrated value in this room that Civilization will actually bother to defend it against the very remote case that some criminal decides to make a move or somebody suddenly goes insane.  The fourth-rank Keeper would be a more powerful military factor, if it came to sudden conflict, but it's not his one job nor his comparative advantage.

 

Standout figures among the viewscreens:

Someone wearing an insignia recognizable as belonging to the Fourth Legislator of Civilization.  Her brightly sparkling hat of many-colored sequins marks her as probably the Legislator's Chief of Staff.

The Sparashki ambassador.

A dark, shadowy silhouette with a broad-brimmed hat, seated before a dark-gray monolith with red glowing letters reading "03".

A man dressed only in a bathrobe, colored in the solid purple shade of a Chronicler of History, bearing a dispassionately skeptical expression beneath massive purple-dyed eyebrows; his listening-ears have been done up as fluffy cat ears of the highest quality.

 

 

To be clear, this should all strike you as perfectly normal if you grew up in dath ilan, because high-ranking people are just like that.  They haven't come all this way to not be themselves.

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(There's also an ordinary fruit bowl, oranges and bananas and grapes and the like; no apples, since those would require peeling to be eaten.  Uncomplicated nutrition-bars are scattered beside.  This minitable of Healthy Snacks is accompanied by a small purple dinosaur figurine; which is very humorous and ironical if you grew up inside of dath ilan, but which nobody there would even try to explain to aliens unless they'd run out a whole lot of better things to do with an alien's time.)

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Weirdly, having like FIFTEEN scary important people (also Keepers in scrubs? why are there Keepers in scrubs?? more importantly where were they the entire last twelve hours???) is less intimidating than having ONE scary important person. Merrin’s brain is doing some sort of overflow error. 

It’s bizarrely reassuring having the Sparashki ambassador there even though Merrin is not, in fact, actually an alien.

She has the pointless, half-hysterical thought that they could just give her all the apple peels; Merrin has been the designated apple-peel-eater of her entire family since she was little, she always thought throwing them away was a waste, they have a fun chewy texture. She gets up and collects herself some grapes once it feels less like everyone is probably LOOKING at her. (As far as she can tell, everyone is busy and quite reasonably looking at their screens instead of her.)

She’s kind of jealous of the bathrobe. It takes her an embarrassing length of time before the mental voice of Mom points out that it would be completely reasonable to ask someone to get her a bathrobe, she’s earned it. Also it feels sort of rude to still be in a swimsuit. At least her cosplay, intended to last through a morning in the water, seems to have held up okay.

She’s almost not embarrassed about asking, even.

Also she should really text her mom but she has no idea what to say. Maybe she’ll just text Personnel (the regular Personnel who she knows) and ask if someone can figure that out for her. Asking out loud in a room full of busy people for someone to text your mom is a step too far even for exhausted Merrin.

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A bathrobe appears very quickly, correctly ornamented for an eminent Sparashki female of Merrin's status.  This was a predictable request and people were just waiting on it; markets worried that asking Merrin if she wanted a bathrobe might make her self-conscious of her previous swimsuited status.

Information security expert has precleared asking Merrin's mom if she wants to swear grade-three secrecy about a subset of the facts, assuming Merrin wants her looped in.  Else there's a neat menu of true things that Merrin is allowed to say to Irris without looping her.

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Bathrobe! Much better. Also, wow, someone is having fun with the Sparashki theme.

Merrin would rather decide whether to ask Irris about the secrecy oath later. (The fact that everything feels kind of fake is making it hard to judge whether it’s a good idea or what her mom would prefer.) She’ll go with some of the pre-selected true things in the meantime, feeling deep gratitude to whoever thought ahead and made this so seamless for her.

And then she wraps herself in the bathrobe, takes off her shoes - they’re annoying her and it won’t even stand out terribly - and tuck her feet under her in the chair, watching the screens of sensor data and the camera footage of the operating theatre being set up for the upcoming treatments.

(It’s probably a good thing for Merrin’s mental state that she isn’t actually enough of a hardcore Sparashki aficionado to know off the top of her head exactly what status markers they’re assigning her.)

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Avarris was brought in at the optimal balance time between "get some feel for the patient under the previous semi-equilibrium state being maintained, before starting complicated new processes" and "preserve stamina for operating the new protocol".  She's still maintaining essentially Merrin's equilibrium, and isn't making large mistakes that Merrin can spot while monitoring at this remove.

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Shortly before the rewarming protocol is set to start, a new viewscreen lights with a figure that even most dath ilani could identify on sight: the Chief of Exception Handling, probably the third most famous supervillain-gendertroped person in Civilization, insofar as you can distinguish fine gradients of fame among people who everyone knows.

It's not that everyone could recognize his face, obviously, but that everyone would recognize that ominous spiked steel gauntlet he wears.  The prediction market on what, if anything, his gauntlet actually does, has over a million labor-hours bet on it; and isn't set to resolve-by-default until another hundred years have passed, by which point the truth ought to be fully declassified.

He is one of the only people in Civilization to own a cat.

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Aaaaaaaaaaaaah??!!

It’s probably fine and nothing to do with her at all but Merrin is having trouble shaking the feeling that she’s someone in trouble and about to get told off. Maybe about failing to smoothly handle the incident when they switched to the new liver machine? The ECMO setup went fine once they’d actually prepared for it. What if the literal Chief of Exception Handling is about to yell at her for falling short of Exception Handling standards for contingency planning???

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"Good evening," says Catchall in his usual doomvoice.  "I've come to share with you some of my opinions upon our general, collective performance."

(The Chief of Exception Handling is another fan of the general concept that people should be named after what they do; but the same philosophy holds that at Civilization's Chief-level it's okay to ask people to remember a 'cape name', as the fanon terminology goes, so long as that name is easy to derive mnemonically from someone's role rather than being a completely arbitrary fact.)

(Also it's not evening, either in the hospital or where Catchall happens to be.  But Catchall is in the habit of just always saying "Good evening" in that dark grim voice to everyone, as it obviates having to worry about what time zone he or anybody else is in.)

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AAAAHH it turns out Merrin is not going to get to find out if the patent survives because the Chief of Exception Handling is about to villain-monologue in front of literally the entire room about all of her (to be fair, numerous) shortcomings as a person and then demand what the hospital could possibly have been thinking keeping her on the case. And then she is going to die of embarrassment. 

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"It is of course the appropriate time for such a review," Catchall continues, in the low, rough-edged, ominous voice that has occasionally given rise to mild speculation about exotic forms of asthma or lung damage, since he literally never seems to break character about it.  "Prediction markets give our patient a 20% chance of survival.  Hard-won as that chance was, it might be in poor taste to share some of my frank thoughts after he is suspended.  And if we hit on our one chance in five, the subsequent atmosphere of cheerfulness might conflict with some of what I have to say."

"It is a truism that you do not know what a system really does while it is being fed only a narrow range of inputs.  If you only ever feed two and two into a binaryfunction whose output always seems to be four, you don't know if it's performing addition, multiplication, exponentiation, or some other and entirely nonstandard operation."

"The actual correctness of Civilization's code, I would say, is only really tested when Civilization encounters some relatively unaccustomed circumstance."

"Today, Civilization encountered a slightly unusual - very slightly unusual - set of circumstances.  Somebody valuable fell into cold water."

"And I can characterize Civilization's overall performance and response, to this microscopic digression from the ordinary, in two words, if you'll pardon the otherwise incomplete sentence fragment."

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"Miserable.  Failure."

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Ouch???????!!!!

 

 

…On the one hand, like, it’s not false. Merrin is already very aware of her various failures spread over those twelve hours, not to mention how slow and stupid she felt compared to Avarris?

On the other hand, Merrin is feeling kind of defensive now! She’s not actually sure what she could realistically have done differently in advance, once you exclude totally non-actionable options like “be smarter” or “have passed the ICU certs sooner so she had more non-sim experience.” She could have done somewhat more sims if she spent less time flopped in bed watching medical TV, but she couldn’t have done twice as much. 

Honestly, she almost feels like Catchall is being unfairly harsh right now.

 

(Merrin is trying not to react visibility, and doesn’t make a sound, but does look noticeably miserable.)

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"This episode began when somebody spotted a body in the river, fifteen minutes before that body would have reached an outflow bottleneck with a sensor that would have otherwise had even a chance of spotting that anomaly.  Setting up the first notes of today's grand, overarching theme where the only reason we now have the slightest chance of succeeding is due to randomly fortunate events and contributions from individual heroes that we, as a Civilization, did not earn by anything remotely resembling any slight form of advance planning."

"We then go on to the next step of ambulance response, where, despite the oddity of the unidentifiable patient and the abraded fingers, nobody calls Exception Handling and tells them about that.  No, we don't want the citizens of Civilization to conceptualize themselves as unable to handle any anomalies without Exception Handling, we don't want Exception Handling becoming the parents of children who can't handle any exceptional circumstances on their own.  But we could maybe at least be the excited little sister who gets told about interesting anomalies like this, without it automatically becoming our responsibility?  Is Civilization fundamentally unable to strike a compromise this simple?  Yes.  Yes it is."

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…None of that is actually yelling at her, but oddly Merrin finds herself almost more defensive at someone being hard on other people she knows. What were they supposed to do, carpet the riverbed in sensors? Is he aware the river in winter is full of ICE?

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"And then... we encounter the event of the hospital's retinal machine failing to connect to the network when plugged in.  As was in fact the actual reason why Exception Handling was first notified of this event at all."

"Usually, as I understand it, one identifies unconscious patients through their fingerprints and their electronic devices.  What that means, my fellow citizens of Civilization, is that a retinal scanner at a hospital is itself a kind of exception handler.  A hospital retinal scanner gets invoked when circumstances are anomalous, ordinary means have failed.  This means that when you plug it in and turn it on, it should work correctly on the first try, absolutely shitting period.  When a program tries to throw an exception inside an exception, the correct compiler behavior is to immediately dump memory and quit the program with a message saying that the programmer was an idiot and ought to be fired."

"It didn't have to be like that, is the thing.  If you'll pardon something of an angry sub-rant, so long as I'm ranting anyways about these fascinating events that I will not be allowed to write up in a newspaper.  Hospitals could leave emergency machines like that plugged in to a row of outlets, and have them turn themselves on and run self-tests every day.  Maybe then there'd be a reasonable chance that they'd work the first time, when people tried to use them during ongoing exceptions."

"So why did we build the system this way?  To save on electricity, instead of building an additional three percent of a nuclear power plant to serve all the self-testing hospital devices on the planet?"

"No.  We did it that way because somebody thought for fifteen seconds about how the system ought to work and then decided that a policy of turning on the device once a month and testing it had taken care of the part of the system labeled 'testing'.  Somebody actually thought that and, apparently, the rest of Civilization just nodded along and thought it was a great idea."

"Why is our planet like this?  Why do we choose to live like this?  Isn't the whole design aim of a democracy to end up with a society that's smarter than its median voter?  Isn't that the point of having a voting system more complicated than selecting one random voter to be dictator?  Have we just given up on that important social goal?  Every part of dath ilan reads like it was built by some person of strictly average intelligence who'd read about education in a book but never actually gone to school, who spent ten minutes designing all our civilizational systems via a series of fifteen-second casual decisions about how things intuitively 'ought to work' that they made without ever seeing the consequences in action.  We have the illusion that Civilization works only because it's not on fire most of the time, and mostly doesn't kill us, and we think deep in our limbic system that this must mean that everything is fine.  The entirety of dath ilan is one gigantic failure fractal."

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Okay but how much monologue about the entire entity of Civilization's various flaws is he planning to cover before he tells her how she specifically screwed up, the suspense is killing her here

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"So, in Exception Handling, we finally find out what's going on, at this point, and we start coming up with a treatment plan.  We don't already HAVE a treatment plan, or so I am informed, for this exact circumstance.  And this, you know, this really bothers me, people.  It's a common misconception that being Chief of Exception Handling means you're supposed to think of every possible and probable contingency in advance.  In fact my job isn't to do that, it's to ride herd on the people who are supposed to do that, which, given their general fractiousness and wild-ranging creative imaginations, is a full time job that leaves me very little time to imagine events myself.  Which is to say, I had ONE JOB, and today it became apparent that I must have FAILED at that one job over an EXTENDED PERIOD and in a very wide-ranging way.  Because while my employees had devised over 144 advance plans for different kinds of alien invasions, on the excuse that rehearsing those would 'increase general robustness', they were so busy 'increasing general robustness' that we had zero advance-tested plans or advance development work for the case of 'what if somebody with a really valuable brain falls into cold water'."

"I try, generally speaking, to be pessimistic enough that I am ever pleasantly surprised, and sometimes I am, so I cannot say with confidence that I am still ill-calibrated on how bad things really are in Civilization.  But I was nonetheless, on an emotional level, deeply and unpleasantly shocked by the STAGGERING lack of advance work I found, that had NOT been done by Civilization generally and Exception Handling specifically, on the case of averting anything more than the bare level of brain damage from rewarming an ischemic patient.  Which, you might have thought, you might PREDICTABLY encounter as a problem across a wide variety of imaginable cases, if for some reason you wanted to save someone even THOUGH - this being a level of weirdness apparently beyond our tiny intellects to envision - we would USUALLY have put that person straight into cryo.  Which we did not want to just do here, due to other conditions being NOT TOTALLY PERFECTLY NORMAL, but who would ever think of THAT possibility in advance of it ACTUALLY HAPPENING?  Not us, apparently."

"But we at least had, apparently, some general contingencies for what would happen if there came about a medical case of very high value to Civilization under conditions of mild secrecy.  We spun up those social connections and those pseudo-markets - as would seem to work at least TEMPORARILY - and obtained an initial stabilization plan that was at least a tenth as good as an actual market could have provided.  And we staggered on ahead, usurping the target hospital's computer systems - which worked unexceptionally, you'll note, because THAT part had been envisioned in advance and ACTUALLY THOROUGHLY TESTED - and transmitting our treatment plan, including fallback contingencies for if their emergency certs were not in sufficient order."

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...You know, that's kind of a good point about the lack of any existing protocol. This does seem like a problem that will sometimes, predictably, come up! And sometimes even come up in circumstances where you want to try to revive the patient! 

Oh no was there drama about emergency certs. Merrin missed it if so? She's pretty sure they were fine on them, though, she checks regularly if new weird ones got added. 

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"And here, of course, another random unearned heroic saviour begins to become important to this story, because the local hospital has someone who possesses the exact five certs needed for five different emergency protocols to be implemented simultaneously.  Sheer improbability?  Meddling aliens?  No, it just turns out that she has all of the emergency certs.  Why, it's hardly improbable at all, when you look at it from that perspective!  And she's done roughly twenty times as much emergency sim time as her general career cohort and can interoperate all five protocols adequately from the moment those are called in."

"There's two problems with this, people.  The first problem of course is that we could not possibly have relied on this happening, as part of any ACTUAL PLAN, which means that no part of this performance can be properly credited to Exception Handling as such, and our earned performance on this scenario is whatever the patient's survival probability would have been without that quality of medical care being delivered immediately.  Which a counterfactual market-grounded-nonmarket-prediction places at 15%.  One quarter of our total success probability was delivered by this one stroke of sheer, unearned luck."

"The second problem is that this particular bit of good luck should actively not have happened because somebody like that should not be working at a small regional hospital.  It should have reliably been the case that this hospital had nobody like that, because they should not have found it profitable to spend the amount of money it should take to afford that level of talent and put it to that particular use.  I am not an expert on labor markets, people, but I know what they are supposed to do.  Labor markets are supposed to offer people financial incentives to go work where their work will be most valuable, such as, say, Default Hospital, where they on a weekly basis encounter strange patients who could benefit from somebody simultaneously versed in all protocols, practiced in synergies of their simultaneous operation; who could benefit further from someone able to do the work of five people for six consecutive shifts, at an emergency tempo, accumulating additional facts and practices and procedural skills about the particular patient."

"Does Harkanam regional hospital pay to employ second-rank Keepers as medical personnel?  No?  Because my understanding is that by the time we had our second-rank Keeper medtech in place to replace Merrin, she was doing adequately enough and was enough of a known quantity of adequate performance that policy-prediction-markets declared it a bad idea to replace her, especially after taking into account that the second-rank Keeper in question in fact had less total emergency sim time.  People you can't replace with second-rank Keepers should not, as a general rule, be paid the same amount as tier-three hospital medtechs."

"I am not an expert on labor markets, people, but I have read theorems about them.  I know what sort of equilibria correctly functioning labor markets are supposed to have.  In a functioning labor market in equilibrium, you should not be able to trivially predictably generate a massive profit by moving labor from one use to another.  So, while I don't know what to call whatever Civilization has instead of a labor market, we apparently don't have one.  We simply do not have a labor market, people.  We are not actually paying people according to their opportunity costs and the marginal value they generate, but paying them according to some entirely other mysterious principle.  Somebody who acquires several dozen emergency certs should not be paid for emergency-cert maintenance a quantity that is linear per emergency cert, because their value is not, in fact, LINEAR.  If that DOES happen and furthermore the way in which it came about is that somebody did twenty times as much emergency sim time as the rest of her cohort, including multiple runs of consecutive hours at emergency tempo on a practically daily basis, you would think there would be some sort of VENTURE CAPITALIST who would see a misplaced labor source and try to MOVE HER SOMEWHERE MORE PROFITABLE in exchange for MONEY.  But this did not happen because of a MISSING REQUISITE detected by the software, a requisite for the supposed fluid intelligence levels to easily acquire the crystallized skills she ALREADY HAD."

"Civilization did not simply profit from Merrin happening to be present, today, it profited from Merrin being present somewhere she was underpaid.  We profited at Merrin's own expense, and that's just entirely unacceptable."

"Why did nobody notice the entire stamina monster affair?  It's valuable generally and in medicine specifically.  We know extended endurance is valuable in medicine.  Default Hospital bids more for their tier-five and tier-six operators who have that property.  So why don't we measure that capability, run competitions about it, and award status for it?  If it's valuable to society, why doesn't society try to detect it and reward it somehow?  Are we just hoping that we'll get nice things for free?  There should be, I don't know, Endurance Medical Technician rankings, if that's a useful property worth competing on, and that way society can actually notice excess talent there and move it where it can generate the most value."

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What.

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Merrin is aware - on some level, not necessarily the level that most of her conscious mind is attending to - that Catchall is saying nice things about her. 

Normally, she would have some sort of emotion about that. Probably. Right now she mostly just feels like swerving to calling people 'random unearned heroic saviours' is a weird tonal shift, she thought this was supposed to be the villain monologue section of the weird TV show. It's just a bizarre narrative choice. 

(The grandmother-gendertrope lady who spotted their patient in the river deserves it, though. Merrin sort of wants to give her a hug at some point. It would have been scary for her and she's seen way more bodies.) 

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IS THAT WHY THE KEEPERS ARE WEARING SCRUBS???

 

HOW DID THEY POSSIBLY THINK IT WAS A GOOD CALL TO USE MERRIN INSTEAD?????

 

PREDICTION MARKETS ARE SUPPOSED TO BE RIGHT ABOUT THINGS AND NOT LUDICROUSLY WRONG???????? You know, just, maybe someone could have noticed that and flagged the whole secret pseudomarket setup as dubious way earlier if they had put together how little sense that conclusion makes? 

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(Merrin is vaguely background aware that there's some sort of wrongthought in there, the part of her that flags that is still working, just...not the part of her that goes on to do anything about it and try to have correct thoughts instead.) 

 

 

...Oh phew here comes the criticism, he...thinks she should have gone to work somewhere else? Great! Now she feels bad about not having done that years ago! And somehow simultaneously very aaaaaaaaaah about the prospect of having to do it now. Convincing people to hire you is stressful! She knows everyone here! She had sort of expected she would keep working this job for, like, at least a decade. 

Now apparently she needs to move to Default because that's where Civilization can make the most use of her talents??? Aaaaaaaaaaaaaaaah that feels so fake and also badwrong but what is she going to do, ignore the Chief of Exception Handling? 

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- ok definitely wrongthought, Merrin is pretty sure that's not what he means. It's usually not what people mean. 

That being said, if a venture capitalist shows up to try to recruit her after this she might actually cry. She so incredibly does not have the emotional bandwidth for this level of weirdness right now. 

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None of the rest is really emotionally registering compared to the part where, not just Hospital Administration, but also the absurdly well-funded prediction markets and top world experts, decided she was going to outperform a second-rank Keeper. 

Merrin is staring woodenly ahead, sort of half trying to disappear into her bathrobe, and would be turning bright red, but conveniently she's already green and maybe no one can tell. It's tempting to hide under the table but there continues not to be very many available under-table spots and it won't help anyway. 

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(Personnel is frantically trying to text Catchall and tell him to stop saying things that imply Merrin is special but in fact it's not actually that easy for a random dath ilani citizen to text Catchall directly.  It's not that hard for many high-ranking people, but Catchall specifically is the one whose address gets frantic texts from people who just went schizophrenic, so it's a bit harder to contact him directly than usual.  Catchall isn't going to get Personnel's advice until thirty seconds after it's too late for him to benefit.)

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"Merrin was a hero, and anybody who thinks that puts Civilization in a good light ought to be flung out the nearest window before they drag down the average sanity in the room any further.  Correctly designed social systems do not rely on individual heroes.  Especially heroes who, on a planet that actually had a labor market, would not be working as tier-3 medtechs in the middle of nowhere.  Merrin wasn't there because Civilization has a great hospital system and educational system, she was there because our labor allocation system is a flaming fragrant failure fart.  We had no right to that piece of luck, and we gained it at the expense of Merrin being severely underemployed for a quarter of her life."

"We turn now to a bright spot that was, I suppose, slightly more earned, if you count it as skill that we contacted a large group of people one of whom was the right person; the venture capitalist Ashre, who did a quite impressive job of frantically improvising around Exception Handling's total failure to have done the right research or even gathered the right information more than five minutes in advance.  I won't call him a hero, because he was doing his actual job and was approximately where Civilization thinks somebody like that should be, but he was, beyond reasonable doubt, the most valuable player of this entire affair, above even Merrin..."

(This next section is about complicated proteins and possibly of less direct personal interest to Merrin.)

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Oh, good, he's done ??using her as a character in some sort of parable to make Hospital Administration and the rest of Exception Handling feel bad about their lack of preparation?? Which is sort of valid, they were unprepared, not that Merrin herself would have thought of those contingencies ahead of time even if she had a million years of it being her only job.

Merrin would have preferred not to be used as an example in a villain monologue but it's fine, she's fine. 

Normally she might be interested in complicated proteins, but it's not of direct personal relevance to her right now, and her brain is tired. She half-listens, but goes back to watching the various patient screens, flicking through to hunt for any change in vital signs or various other sensor data. 

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He'll get noticeably louder when he talks about the CATASTROPHIC FAILURE OF THEIR PREDICTION MARKET SOFTWARE and how he is not TOO UPSET because HUMAN BEINGS FLATLY CAN'T PROGRAM COMPUTERS and this state of affairs does reflect a deliberate, considered choice by Civilization not to go too far into genetic engineering or even systematically breed their best current programmers together, but it is still ANNOYING.

The lack of any FAILOVER system he is likewise not blaming on HUMAN BEINGS PER SE because this state of affairs was presumably brought about by INTELLIGENT MICE who'd somehow TAKEN OVER THAT SECTION OF EXCEPTION HANDLING and were running it to Civilization's subtle detriment.

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Whatever he thinks counts as 'flatly can't program computers', Merrin is vastly less capable than that, and has been for her entire life, which is apparently enough to not feel like this is a criticism of her personally. She doesn't have any opinions on the prediction market failure aside from how it was really stressful and she hopes it never happens again.  

Oh no she asked people to review her code what if he saw it almost certainly the Chief of Exception Handling had better uses for his time than looking at her horrible sim-practice automation scripts. 

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They're getting on towards initiation of the actual rewarming protocol, so Catchall will wind down and finish up, here.

"...really, the whole concept of 'exception handling' is an element of creeping fridge horror as a design pattern in computer programming.  It normalizes the idea that your ordinary code is not actually correct in general, only correct by coincidence for specific inputs, and sometimes needs to 'throw exceptions' when it reaches conditions under which the code's underlying incorrectness would be made manifest."

"Nothing in Civilization works in general, it breaks as soon as it encounters slightly unusual challenges, no organizational structure within all Civilization is actually generally correct and known to be correct.  Our approach to this as a society has been to slap Exception Handling on top of it as a patch."

"For this to be even slightly okay, it requires that at least Exception Handling work."

"And then it doesn't work."

"If we came across a computer program as poorly designed as Civilization, we'd throw the entire thing in the trash and start over and not hire anyone who'd caught a glimpse of the previous code."

"They say it's a famously hard problem to predict what the Aliens will be like, when we finally meet them, some billion years hence.  After today, I think I will dare to venture a prediction as to how specifically the Aliens might differ from us, and I'm not entirely joking either."

"When we meet the Others, they will, during their corresponding historical period insofar as their history can be aligned with ours, have had better healthcare that was more robust to out-of-distribution inputs."

"Thank you for listening to this rant, since I cannot actually rant about it on television in this particular case.  We don't have long before the rewarming protocol will be initiated, now, but I have courteously made certain to reserve at least a hundred seconds for questions, objections, and comments.  Are there any such?"

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(This really is supervillain behavior, reserving so little time for objections at the end.)

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Merrin does not have questions. That would requite saying words with her actual mouth, for one, and she doesn't have anything coherent, just...she's vaguely mentally poking at whether she actually expects Aliens to have better health care relative to other Civilizational infrastructure. Also what if he asks her to her face if she's a Sparashki. Merrin is too tired to ad-lib anything. 

Anyway, she is so eagerly watching the screens for the actual rewarming protocol, though she's a little curious if anyone else has questions or objections. 

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There's a brief exchange of glances, and then the fourth-rank Keeper lists the top five things that Catchall said that were probably not valid inferences given current knowledge.  'The Others will have had better healthcare during their corresponding historical period' is on the list.  Nice things Catchall said about Merrin are not.

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Merrin does not actually think to update from the inexplicable failure of anyone who actually knows her to point out that saying she should have been working in one of the top-worldwide ICUs in the world in Default Hospital is obviously absurd. That would require her to still be thinking about the absurdity.

She is definitely going to look very apologetically at the second-rank Keeper if at any point she can catch the woman's eye. Merrin isn't sure what she owes an apology for but it's definitely something.  

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Second-rank Keeper actually has her eyes closed, at this point.  Trying to keep up with all of Merrin's data inputs for a few hours, without actually being her or actually controlling the systems, is mentally exhausting; and she's been trading off shifts with the fourth-rank Keeper and a third-rank Keeper at staying fully up-to-date on what Merrin was doing.  (That third-rank Keeper is currently busy tracking the current medtech in case she falls over.)  She's not asleep, but she's accepting audio inputs only, right now.

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And the rewarming protocol goes into action, with Avarris orchestrating.

Patient ok-outcome probability drops to 18% shortly after it begins.

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Oh no did the smart people now in the room just notice a stupid mistake she made in one of the earlier treatments that no one else caught from outside the room itself

You know what? Even if they did, Merrin is past caring. This is a weirdly paced TV show, and – well, would she be judging a fictional TV character in her position, with her previous established backstory, for failing to plan out a perfect response to all the cases where the patient started deteriorating on her watch? No. She would not. She definitely wouldn't judge, say, her colleague Lethan, who with six weird-emergency certs (and at least a standard deviation of thinkoomph on Merrin, and about her age but with four years rather than one in direct ICU experience), was probably next-most-likely to end up in charge here. 

...Huh. Now that she's actually picturing this in its specifics, it's obvious that Lethan couldn't have handled all five machines like Merrin did. Lethan could have handled two or three machines with a lot more skill and forward planning, of course, but...not for twelve hours. Come to think of it, Merrin isn't sure if anyone on staff would have been able or willing to tough out twelve hours of that. 

Merrin is under no illusions that she was the only option; the hospital should have had enough people with the relevant certs, who were adequately rested and hadn't just come off-shift, to cover the machines until they could bring in someone like Avarris. But coordinating within a group of multiple people all handling complicatedly-interacting functions is stressful, and handovers are stressful, and - yep, checking the prediction markets on when Avarris will need replacing, they're expecting it to be a lot sooner than twelve hours. 

Maybe - at least in this one bizarre edge-case scenario that really has no right to happen outside of a weird surreal TV show - there really is something to be said for being able to perform badly for twelve hours. The imaginary mental voice of Merrin's mom is telling her she should feel good about it. Merrin is not quite there, right now, but it feels a little more plausible that the hospital really was lucky to have her in particular on staff, not that this feels very predictable in advance. 

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Does Default Hospital really get patients this interesting on a weekly basis?

(In the immediate aftermath, Merrin would, if asked outright, have said that she never wanted to deal with a shift like this EVER AGAIN, but even just twenty minutes later, she's emotionally recovered enough to start reconsidering.) 

Just, wow, in a way - a very hypothetical way that she can't actually think about as though it's a real decision without internal screaming - it might actually be pretty neat to regularly get to do stuff this intense outside of sims? By which Merrin mostly means 'it would be horribly stressful but after a year of it she would be better at things'. Maybe that's how you get to be as cool as Avarris. Hypothetically. Thinking that she could be as cool as Avarris is definitely not the sort of thought that Merrin lets herself think without flagging it as not something she can ever reasonably expect to achieve. 

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...Actually, Merrin is still too off-balance for any of this to be productive to think about right now.

She leans forward in her seat and flips through screens of sensor data, including from sensors that she's never seen even in sims, and she feels weirdly empty and floaty, and at the same time she can't seem to stop fidgeting and there's a tight knot of something in her chest. It's hard to tell what emotion that is. Maybe that's just all the caffeine.

Bits and pieces of Catchall's speech keep replaying in her head, unwanted. 

- there's a restless itchy feeling behind her shoulder blades, and she wants to go to the sim room and stay up all night angrily playing the same stupid sim over and over again until she can do it right, she wants to go to the pool and swim and swim until everything hurts, she wants a hug, she wants her mother, she wants the patient to be okay so badly and it's out of her hands and was maybe never in her control at all but 18% odds aren't good enough that's not acceptable it shouldn't be allowed - 

- and it's all tangled together in her head: if Civilization were better, if they'd been more prepared, if she were smarter if she had worked harder if she were braver if she had ever really cared enough if she were a better person not the sort of person who's scared of everything all the time...

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Merrin is on some level aware that she's an unhelpful degree of emotionally engaged, but she doesn't actually want to disengage, that feels like an impossible mental motion right now, and it doesn't really matter if it makes her less functional, since she's not doing anything important. The worst that happens is she cries in front of the Chief of Exception Handling on vidscreen and maybe this will convince everyone she's not cut out to work in Default Hospital

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She's definitely going to ask Irris to swear a secrecy oath, though. And maybe invite herself over to her childhood home tonight so she can get hugs while she unloads everything. She considers texting her mother to ask about that and decides this is still too much multitasking when she cannot get herself to take her eyes off the screens. 

 

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Prediction markets do not shift in response to what happens; prediction markets shift in response to what becomes known, possibilities as they are eliminated by observation.  The initial drop from 20% to 18% wasn't in response to any unexpected medical event occurring; it was in response to everything going as initially expected.

On one side, people were working hard on this, pursuing profit, Exception Handling was playing some unusual cards not all of which might be visible; it could have been the case that the protocol would be mysteriously polished and smooth and everything would go great right from the start, and Exception Handling would say 'wow what a coincidence'.  Some of the bettors in the market have noticed the improbable emergency medic guised as a Sparashki, which could be a distraction from any number of realities, and her 12-hour shift; Exception Handling claims that this was a total coincidence, but they're saying it under social circumstances where it's known and understood that they might lie.

And on the other side, the patient was fairly stabilized going in, and might've just continued being that stable as rewarming started.  It wasn't the most likely event to observe, but it was a going possibility.

Nothing really amazing happened when the human-untested protocol went into play, as the market traders did still mostly expect; and the patient responded as modally expected and not in any way showing that they were healthier or more robust than that; and so the market dropped from 20% to 18%.

It's not just the impact of the momentary event being observed, it's traders following the trend of all the future observations that you could guess would go the same way, the moment you got the first hints.  Maybe they'll have to walk back some of those guesses later.  That's not embarrassing, that's how things should be; if you never had to walk back a leap, you wouldn't be leaping far enough.

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(It has absolutely not occurred to Merrin that market participants might have been betting based on her improbable existence and stamina being one Weird Thing that might correlate with or suggest other potential helpful surprises in the future. Merrin is still mostly not processing the fact that her presence here was weird or surprising period.) 

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A little while later, the predicted odds fluctuate a bit and settle back at 20%. 

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!!!!!!!! 

Tragically Merrin is no longer in the room, which makes it much weirder to do a happy dance and say 'good job!' at the patient, who is after all not really involved in this as an individual making decisions. She does a small happy wiggle in her chair instead and then pokes at the screens. 

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This update is actually also a matter of things going as expected - but in a case where there was some probability mass on things going noticeably worse than expected even at this early stage, which would indicate they were in a world where the invisible accumulated damage to the patient's body and tissues was in one of the worst-probable-case scenarios.  

But the patient's core temperature is slowly and unproblematically starting a controlled climb, his blood chemistry is holding steady (with a lot of effort going toward maintaining that, of course, but that might not have been enough), and the sensor metrics for peripheral and gut perfusion are rising as they slowly, cautiously, bring his blood pressure and oxygen saturation up toward the parameters for the next stage of the protocol. Which are still deliberately lower than the normal range for a healthy person at 37 C, of course; his cellular metabolism is going to be lower, which is actually how they want to keep it. The default plan, if they make it that far without running into a complications (unlikely), is to re-stabilize him at 28 C and do a more thorough assessment. 

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There's a simple game you can play to simulate a correctly functioning prediction market:  Start with a number like 20%, and then, pick any possible balanced shift you like.  There could be a 1/3 chance of it going down by 4% and a 2/3 chance of it going up by 2%.  (Absolute shifts, additive shifts, not multipliers.)  Don't introduce any potential shifts that would go below 0% or above 100%.  If the number reaches 0% or 100% the game is over.

In dath ilan, playing a game like that, they'd use a quantum randomness generator, just to be sure to emphasize how it did go different ways in different worlds.

Let's try to pick up that 2/3 chance of a 2% upward shift, shall we?  It's probably going to happen.  Odds are probably going to look a bit better.  Or they could drop by 4% instead, but that probably won't happen.

Isn't it exciting?  You could almost imagine that, by picking the right balances, the right die-rolls to make, you could possibly shift the probability of the outcome in any way.  Little dath ilani children play the game until they realize that they can't.  It's their first introduction to predictive asset markets as random walks, which is how markets are experienced by anyone who doesn't know something that few or no others in the market know.

Let the dice roll.

22%.

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HAPPY WIGGLE yeah okay this is still objectively a really unacceptably low number and in theory Merrin is still mad at the world about that but that direction is a better direction! 

(Whatever caused the shift, it's something subtle, not immediately obvious to her from the screens she's already flipping through and can actually parse.) 

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Just a bad thing that could have happened but didn't.  A lot of this protocol is going to be like that.

Key juncture coming up.  1/5 chance of going down by 4%, 4/5 chance of going up by 1%.  Reality rolls its dice...

18%.  Well, it happens.

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OH NO RUDE! 

(Merrin has, to be clear, herself played this game before as a child. In fact, it's one of the areas where she wasn't noticeably slower-than-average at picking up the expected lesson. This was, however, perhaps mostly because Merrin is less driven to win than the median dath ilani. Which is...less true...right now. She does know intellectually how this works, just, she's really really exhausted and her emotions are much less under her control than usual.) 

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Among the likely reasons for this update, they've now hit 22 C, which is a point at which there might have started to be noticeable EEG activity, and...there isn't, yet. 

(They don't actually want the patient's brain cells to be very active for the next while, and are prepared to put him under deep anesthesia to suppress that as soon as they notice activity, but the presence or lack of said activity, and whether it's normal-for-relevant-temperature or additionally abnormal, is information, and the plan is to wait to get that information before they go ahead and mask it.) 

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How well will the patient respond to this series of relatively ordinary events happening next?  Most news is good news, an absence of bad things; the downward movements are sharper than the upward movements.

18%, 19%, 20%, 21%, 22%, 20%, 18%, 19%, 17%, 18%, 19%, 20%, 21%, 22%, 23%, 24%.

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By a few minutes in, Merrin has managed to properly internalize that she isn't taking actions about this situation anymore, and so it perhaps makes less sense to be so exhaustingly hyper-vigilant about any shifted in the predicted-outcome likelihoods.

It's sort of unsurprising, now that she thinks about it. After the past twelve hours, when the main numbers in front of her were vital signs rather than overall predicted likelihood-of-ok-outcome, her emotions and motivation system had gotten really used to responding to minor good or bad shifts in the patient's condition as though they were happening because of actions she took, since that had at the time been true: the primary numbers she was tracking were very directly responding to her settings manipulations, if not always the way she expected or preferred. 

Which means it keeps being tempting to hook up her emotions to updates in the predicted outcomes the same way, but it's also stupid, she's not even properly plugged into that feedback loop, and she can't do things, so it's just leaving her a constant pointless itchy desire to do something unspecified.

She will instead focus most of her attention on the screens of raw sensor data. 

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In a market this liquid, you can see probabilities on individual events coming in, conditional values for what will then be true about the Patient given that.  This won't be the first time or the 20th time that Merrin has tracked a prediction market to see how it plays out; but it might be the first time she's ever, outside of sims, maybe even in sims, had this much market information.  Enough to see the balanced shape of possible market movements before they happen.

There's now substantial biological activity in the brain's neurons, as they rewarm, and they're about to get the first readouts on post-rewarming-that-much signs of metabolic damage, neural cell death, as it becomes visible in blood leaving the brain.  They're using pretty sensitive readouts but even so they cannot afford to steal the patient's blood for tests that often.

Signs of neural cell death are what ought to be observed if the protocol is not really working all that great.  The market mostly expected the protocol to not really work all that great.  They're sticking a hundred fingers into a dam they believe to have a hundred holes, and while one or two holes untheorized or unplugged won't break that dam, 10% of the fingers failing will do it.

In terms of the market game, to simplify a complicated spread of possibilities... roughly, the dath ilani child is about to gamble on a 3/4 chance of dropping the odds from 24% to 11%, balanced by a 1/4 chance of raising them from 24% to 63%.  Or at least, that's what the market thinks the market will do.  Sometimes the market is wrong about that.

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...Yeah, the prediction markets in the sort of weird obscure emergency sims that Merrin likes to play are basically never this liquid. 

She cannot affect the events happening now. It might just be better for her odds of crying in front of the entire room if she didn't care about the outcome– no, wrongthought, but if she wasn't trying and wanting so hard for a particular future-world-state that might happen (with around 1 in 5 odds) and probably won't happen and either way it is no longer under her control.

Pretty much all she can do right now is...hope that she actually did a better job of minimizing tissue damage than what the markets are giving her credit for? (Which is, you know, obviously ridiculous? Since if anything it sure looked like the markets had too much faith in her.)

Anyway, it's not worth making emotional updates on anything else other than the final outcome. Given how much Merrin has eaten into her reserves of coping ability and emotional resilience, she is maybe going to have trouble executing on that, but she is at least going to try to be calm about this. 

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Reeeaaaady?  The information is allllmossst in.

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Merrin does not really think there's anything else she can do to be ready! Short of getting a hug from her mom but that's complicated. 

She is sort of squinting at the markets screen out of the corner of her eye, like someone with a spider phobia opening a file that might or might not contain horrifying spider images. 

(In the back of her mind she is thinking that she clearly needs more practice at...well, something related to this.) 

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12%!

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You know, she was expecting it to be spiders, and then it was indeed spiders, and really if human brains were better designed then probably this entirely unsurprising outcome would not suck nearly so much???? 

Of course, Merrin is already fully aware that nothing about biology - which is, after all, what her feelings are made of - is well designed, see: what she spent the last twelve hours of her life doing. 

It's not definitely over yet, 12% means 12% not 0%, presumably the protocol includes some fallback tweaking that might still help, but are still much less likely to work than the already-low odds of the original plan working. Merrin did not at any point have a chance to read through the contingencies in detail, it wasn't something she prioritized since she wasn't expecting to have to run it herself, and she's actually feeling very tired at this point. She would consider just leaving except for how getting to her room involves standing up, and also maybe looking like a coward in front of the Chief of Medical Oversight and also whoever else happens to be watching and she might make the Sparashki look bad 

She stays where she is. 

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12%, 13%, 14%, 15%, 16%, 17%.  A steady upward trend as more bad things fail to happen.

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Okay, the part Merrin perhaps did not entirely think through, when she decided to stick around for this, was how the rewarming protocol would take a while. It's now been, like, another hour and some, and she's still wired on caffeine and adrenaline but sitting here is not appreciably emotionally and socially less exhausting than what she was doing before. It might be worse; she's way more aware in-the-moment of how many important people are around her, and keeps randomly remembering fumbles from six hours ago and cringing in embarrassment at the thought that she was up on that screen where Avarris is now. 

Her brain keeps informing her that she wants her mom but she definitely can't ask Irris to come here. 

She...can get out her cellular texter and text her, though. 

[Still stuck at work. Want to come over after but might be really late] 

Pause. 

[can you think about whether you would swear a grade 3 secrecy oath, in case I'm sad and want to tell you why] 

 

(Merrin's mom is not glued to her cellular texter, even when her daughter has been in a known weird situation all day. The reply isn't immediate.) 

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Soon after the number is at 21%.

Here's the thing: even after that big Spiders disappointment, if the number is at 21%, that's a payment every bit as good as the 20% they had at the start!  1.05 times better multiplicatively speaking!  Around a 1 in 5 chance the patient makes it out!

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Irris eventually replies. 

[ETA home 20%/50%/80%?] 

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Oh noooo none of the prediction markets are about that. Can she ask for a prediction market on 'when Merrin goes home' so she doesn't have to use her actual brain to answer her mom that's stupid and Merrin is not going to ask for that right now. 

Uhhhhhhhhhhh. Well. At the very least, if this goes badly it'll be over faster. If not, then....probably the limiting factor is on how long it takes before Merrin is actually literally falling asleep in her chair. Which isn't going to be for a while. She's pulled all-nighters before - not doing shifts, that would be really irresponsible and unfair to her patients, but she miiiiiight have gone to her tutoring sessions before after a night shift, and she's definitely finished an especially stressful shift and then "decompressed" by spending the entire night watching Exception Handling TV. This is probably more similar to the second thing? 

[90 min/3h/8h] she sends after not actually very much thought. [low certainty. i'm tired] 

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A pause. 

[is there not a market on that] 

Another pause. 

[i'm going to call personnel and tell them i'll swear the oath if they let me come in now. i made cookies for you] 

 

(Shortly later, Irris is on the phone to Hospital Administration with this exact question. She is absolutely willing to swear whatever oaths they want if they let her come hug her daughter who sounds like she's having a really something day.) 

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The protocol comes in phases.  They're approaching the first blood test after the start of phase 3.

There's one particular form of cellular damage that seems to be standing out as the real problem.  They don't have any good way to interrupt it; phase 1 was meant to interrupt a precursor to it, and it didn't.  Three different molecules in phase 3 - plus a fourth molecule added at nearly the last minute, which is what the jump to 21% was about - are meant to interrupt that cascade anyways and without killing the patient.

If this part works, the patient is largely home safe, 91% victory probability.

Otherwise, the patient's chance of making it out drops to 7%; the damage, if continued, is enough to imply cryopreserving the patient, and there is not on paper a backup plan to interrupt it.  There will probably be, from there, a slow decline, as one last-minute surprise-salvation protocol adjustment after another... fails to suddenly be delivered by the Venture Capitalist or Exception Handling.  And instead things just go as expected, getting closer and closer to the borderline where they stop and cryopreserve the patient.

The market's odds of good news are, necessarily, 1:5, or a 1/6 probability.

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Irris has been pre-screened and... does not look super legibly reliable, in some ways?  Irris can't come into the command center, but she sure could come to the hallway just outside (the room is obviously soundproofed) (most rooms in hospitals are, for that matter) and Merrin could step outside to be hugged.

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...Honestly that's better than Irris expected? She has never in her life given any thought to whether she looked legibly reliable to Exception Handling, which means she almost certainly doesn't, you don't get to that by accident. 

She's on her way. She doesn't want to interrupt Merrin, who has not 100% clarified that she's, like, done with important responsibilities, just seems to have time to send her own messages again. But she'll come by the hallway outside and hug Merrin whenever it's a good time. 

[I'm coming over] she texts her daughter. 

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Merrin is not checking her messages right now because she is instead watching out of the corner of her eye for the presence or absence of METAPHORICAL EVEN BIGGER SPIDERS.

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6%.

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UNSURPRISING AND YET STILL TERRIBLE!!! 

 

 

 

 

as long as they still get a good predicted cryopreservation outcome then she hasn't completely failed 

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This is, usually, where one would suspend a patient.  Instead they're playing it out to the end and hoping that somebody in this process comes up with a last-minute miracle.

In terms of the children's game... you could model it, maybe, as a series of six quantum die-rolls, each with a 1/81 chance of bumping the number up by 80%.  And each time that doesn't happen, the number drops by another 1%.

In the children's game, of course, the worlds actually branch, and you know that some version of yourself, though with a very small amount of realityfluid, saw the number go up by 80%.  This isn't a quantum game, that way; if it was, the patient would pretty reliably experience waking up, albeit not embedded in reality quite as much as before, and if they went on playing games like that they'd find themselves somewhere else sooner or later.

Here, by and large, you'd expect everyone inside the universe as dath ilan knows it, to see pretty much the same outcome.  It's knowable to an ideal agent if not to mortals, the dice already rolled somewhere behind the screen; now it's just playing out.

5%.

4%.

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(It is ultimately okay.  He's not going to end up dead dead.  They're not flirting with Death, just death.)

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Well, Merrin is certainly not going to be coming up with a last-minute miracle. (According to the weird villain monologue she already did that once, but of course she knows she didn't, really.)

 

She's really scared, for some reason. She isn't sure of what. 

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3%, 2%, and somewhere not on a video screen, a sixth-rank Keeper makes the call.  The patient goes to cryo; it's over.

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Merrin honestly has no idea what emotion she's feeling, anymore.

 

Mostly she feels...very far away, and sort of lightheaded in a way that isn't exactly physical. 

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Irris arrives at the hospital, wearing a tie-dyed romper suit and carrying a container of homemade cookies. (A clear container, since this is a bizarre situation where the decisionmakers have no particular reason to trust her, and she doesn't want to alarm anyone unnecessarily.) 

She enters via the usual hospital entrance, and very gently and politely informs the nearest staff-uniformed person that she is Merrin's mother and is here on Merrin's request in order to give her a hug, while definitely staying outside the exclusion zone? 

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Merrin is gently informed - via a message to her cellular texter, based on the correct impression that she will be paying attention to it now that things are no longer happening and will be way more embarrassed if someone speaks to her out loud - that her mother is outside the room, in the hallway. 

 

 

This feels very fake but she will go outside. 

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Hug? 

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Hug!!! She's in the hallway, that means crying is allowed now right???

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Well, definitely no one is stopping Irris from hugging her daughter. Irris might have some things to say if they did attempt this. 

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Merrin is not cleared to tell her mom that much about the details of what just happened. 

 

In fact, she is explicitly not cleared to tell Irris any exact numbers on the prediction market liquidity. Which is superheated awful because, like, that's the most clear reason why this situation is so different from all the other times? It was HIGH STAKES and they were REAL STAKES and she thought she could handle this - and she did handle it, maybe, sort of - but it turns out it was really exhausting???

....She is allowed to say that she worked very, very hard on a very, very complicated problem. Which is true. It was a long shot, so they were probably going to lose. And then they lost, which was not an update on anything - probably including her general skill and worth as a person - but it's still really awful actually???

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Hugs. 

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...Oh, yeah, also she was a Sparashki the whole time! 

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She was what– oh right she missed the con today. Is Merrin saying she was already in cosplay before all of the...whatever it was...started happening? 

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Yes!! Exactly!!! And then, well, people went with it. Like they tend to do. 

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Presumably it wasn't funny at the time from Merrin's perspective but, uh, Irris sort of thinks it's funny now? By 'they went with it' does she mean 'there's some sort of Governance-approved conspiracy' because that sure sounds plausible.

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No comment. 

(Merrin loves her mom so much.) 

 

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....Uh, on a completely different note, she supposedly did the work of five people for six shifts??? Some, uhhhhh, some unspecified important people noticed her and. maybe. also. said things about her. Including that they think she should move to Default and work in Default Hospital???

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Oh. Fascinating. Well. Presumably they're offering her a lot of money for that? 

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.....Did Merrin not check what salary they're offering her to move to Default? 

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Ummmmmmm. No? Was she supposed to have had time to ask about that? She was, uh, sort of busy. 

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Hug hug hug. Irris is making an exasperated face but not where Merrin can see it. She manages not to make an exasperated noise. Has Merrin at least checked her performance incentive for whatever she just put herself through, it sounds like it was a lot and she almost certainly earned more recompense than she's giving herself credit for. 

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....It is possible that Merrin was overly focused on the hugs element, and forgot how her mom knows her and is going to make her ask the uncomfortable questions that she did not ask earlier because, well. Uncomfortable. 

 

 

No. She did not check that. She....can check it now? 

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Chances would have been 5% lower without Merrin, but they would have been lower subtracting a lot of other people too, like the Venture Capitalist or the woman who spotted a body in a river.  In the possible permuted orderings, call Merrin something like 15% responsible for saving 5% of the life of somebody who would then have had a 1/2 chance of doing something worth the lifetime incomes of 200 people to Civilization.  She would have gotten significantly more if he'd lived, less since he small-d died, because it's important to align the very last incentives of people who might know a little more than everything the prediction markets can observe.

Let's say it's about half as much money as Merrin was expecting to earn over the course of the rest of her life.

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Hug! 

"You shouldn't tell me anything yet, Exception Handling needs to finish deciding whether I'm trustworthy, but I'm so proud of you!" 

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"....What if I have to move to Default and work in the hospital there? I, I don't know if I want to do that....?" 

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Who said anything about having to do that? Did anyone literally say that, in words Merrin can quote back? As opposed to, like, assuming she would obviously want to get paid for all the value she can provide? 

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Irris hugs her daughter again. 

"Hey. It's okay. Listen, you definitely don't have to do anything that'll be bad for you, right? Even if the Chief Executive of Civilization tells you it's important, it's still your decision, to decide if it's worth it for you?" 

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....No, actually, Merrin is pretty sure she will always do the thing that's obviously correct even if, uh, it hurts her a lot. Because not doing that won't actually hurt less, at this point, when she already knows that - okay fine she doesn't really know anything yet -

(- she is holding some significant probability mass on 'the Chief of Exception Handling was trolling everyone' which isn't something she can actually tell Irris about - but she can't unsee that, uh, apparently it's....actually relevant and useful....that however stupid she is, she's at least capable of doing a thing stupidly for a lot of hours in a row? and this is sometimes important?) 

She can at least vaguely try to summarize the takeaway from that? 

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Wow. Irris loves her daughter very much, and also has no idea what to say right now! 

Hugs will have to do. Maybe she can....ask a Keeper to talk to Merrin about, well, stuff? Irris isn't sure what stuff. It seems well outside of her sphere of understanding. 

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Hug.

Merrin is remembering that she had sort of wanted to give the grandmother-gendertroped woman who found their patient in the river a hug. Probably she's left by now, though, like a reasonable person would have, and Merrin isn't sure how to ask Irris to look for her without saying anything she's not sure she's cleared to say. 

 

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Hug hug hug. 

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Merrin eventually disentangles herself. 

"I - sorry - I shouldn't be long but I, I want to make sure everyone else is okay..." 

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A narrow-eyed look. "90% odds less than an hour?" 

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That's probably fair but still. "90% odds less than twenty minutes, Mo-om!" 

And Merrin will leave her mother in the hallway for a little while and stick her head back into the command center to - well, first of all, look around and see if anyone, regardless of whether she actually knows them, looks like they might appreciate a hug? or at least Merrin walking past and maybe making eye contact? 

 

(If not, she's going to go log into a computer console and look properly at her performance incentive, without her mom right there staring over her shoulder, because she really does want more information on why they're paying her that much....) 

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A number of people have in fact cleared out; less is at stake, now, and the patient's fate is known.  The CEO and CFO and risk officer are clearing up some of the mess of the hospital having a sudden prospect of large income which then did not materialize - nobody staked life changes on that, obviously, it's just that the equity markets in which hospital shares trade are responding to the suspension of trading due to all the secrecy.  Night-shift Personnel is figuring out how how the impacts on various participants will affect the hospital over the next couple of days, if anybody needs to move shifts around.  (Mostly no; hospitals operate with a lot of slack when there's no area-wide emergencies going on.  But some people can shift schedules very easily and that will help to maintain the hospital's slack tomorrow, with other people going off-duty to rest.)

The morning-shift Personnel known as Personnel is here, actually specifically in case Merrin needs anything though she's not going to say that.  She'll totally make eye contact.

And the fourth-rank Keeper who works in the medical part of Exception Handling, because sometimes people find things easier to talk over with a Keeper.  It's not that Keepers aren't people, more like - they're reliably not the sort of people where they'll quietly judge you and then let that info leak out to their social network.  Keepers really will judge you less; there's a sense in which you are not their species, and not something close enough to their own psychology to be judged by their own standards.  Even to their friends, they're not likely to laugh about that thing you did wrong; of course non-Keepers do everything wrong, that's how things should be.  The universe is not so dark a place that everyone needs to become a Keeper to ensure the species's survival.  Just dark enough that some people ought to.  He'll make eye contact too, if Merrin looks his way.

The grandmother-gendertroped lady has gone home, to somebody she knows well enough to cry around them; she was old enough to have seen some sad things in her life, but she has not, in fact, been this close before to the sharp and bitter end of healthcare.

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Aww, okay, probably the lady who found the patient has gone home to the people who actually know her, this is unsurprising. 

Merrin spots Personnel, makes eye contact, doesn't smile because she isn't sure she's capable of producing a smile right now, and then lets her eyes move on. 

 

- aaaah that is definitely a Keeper making eye contact with her???

This is mildly terrifying, but - well, it would have been a lot more terrifying this morning. At this point, after everything else, Merrin is at least temporarily desensitized to social anxiety. And mostly the thing bothering her is that she's confused. And - maybe, probably - talking to a Keeper might help her feel less incredibly confused about what she, personally, is supposed to take away from all this? 

She will walk in the Keeper's direction. Slowly, and sort of mostly looking the other way, in case the eye contact didn't mean at all that he wanted to talk to her. 

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He'll wave in such fashion as to explicitly indicate that it's acceptable but not obligatory to talk to him.

(There's civilizations where you'd have to guess this fact entirely off of body language; this is not one of those.)

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Why is she doing this Merrin does, actually, want to resolve her confusion. It's really unfair how now she knows the final patient outcome, which should have been the last unresolved piece for her personally, but somehow the superheated villain monologue from the Chief of Exception Handling is still sort of echoing in her head, and she doesn't actually know how seriously she's supposed to take it? 

(Merrin would probably be able to get most of this just from body language, but it's a lot less stressful for her when she doesn't have to.) 

She shuffles over the rest of the way to meet him, and then.....has no idea what to say. 

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It's been told to him, by this point, and not least by Personnel, that he ought not to say 'hey hero' or anything of that sort.  Personnel has tentatively inferred: Merrin does not like thinking of herself as unusually good at things, and Personnel's best-found-strategy was acting like anything Merrin could do including running eight hours of emergency sims back-to-back was only normal and to be expected.

It's not unusually insane for a non-Keeper, really, just differently insane.

"Good work today," he says.

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Merrin ducks her head, and makes a face which might hopefully be interpreted as a smile. 

"I, um, I guess I still haven't thought of anything I could obviously have done better not-in-hindsight. For today, I mean."

Wow what an inane pointless thing to say.

"...The Chief of Exception Handling seemed to think it was bad that I hadn't already tried to apply to work at Default Hospital? Which, just - I don't think I could have gotten hired there before even if I tried, but, I, I'm not sure if I should have tried harder, if I - did something predictably wrong...?" 

(This is probably ALSO stupid in some way, Merrin is pretty sure there are wrongthoughts in there somewhere, but she's actually really tired at this point.) 

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"Depends what your goals are.  It's not wrong to want to work in the same city where your mother lives, for the rest of your life, if no one's true life is at stake.  It's not wrong to decide that being an ordinary tier-3 medtech is the happiest job in the world for you, and that matters more to you than anything else, if no one's true life is at stake.  And in fact it isn't, so far as I know, not in a predictable way."

"Some people will offer you more money to work somewhere that isn't here, doing something that isn't this.  There are two offers along those lines, that I am authorized to pass on to you, if you wish, or Personnel can do it.  But making you offers is the sum of what most everyone thinks anyone is allowed to say or do, to influence you.  You might save more lives, elsewhere, but you will not save more true lives in but the unlikeliest of cases.  Given that, the ordinary stance of ordinary morals is that people are allowed to offer you more money to do things that they prefer, and aside from that ought to shut up; and once you've been offered incentive, your life is your own, to do with as you wish, in the face of those choices.  We can increase how much an option pays out to somebody, if we want them to choose our way; we don't make choices for them."

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Somehow Merrin feels like that was missing the point of the question she was asking.

She's - not sure how, though, and also she maybe doesn't want to know. 

(Also WHAT two offers she's suddenly so curious...) 

 

She takes a deep breath. "- Actually I think my main question is whether the things that the Chief of Exception Handling said about me are, um, usefully true, as - information I should have, as opposed to - mainly things he said to make a point for other people who aren't me." 

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"There was indeed a formal market-anchored-nonmarket-counterfactual estimate that if 'adding in Merrin' came last in the permutation and after everyone else had already decided their contributions, the patient's survival logodds thereby went up by .4 bits.  In the end that was zero to zero, but in terms of probabilities before the fact it was 15% to 20%."

"A lot of the apparent-logodds-of-success that it was possible to seize at all lay at stake in those first 30 minutes of stabilization, before it was possible to get anyone else on scene who could have run all the emergency equipment simultaneously.  Having five differently-certed oppers trying to coordinate those machines would have in the market-grounded-counterfactual-model been a substantial expected loss.  That was most of your irreplaceability, but one person learning the patient's particular realtime-procedural-skill details for twelve hours straight wasn't negligible either."

"If the larger system of the world had worked out earlier that you could do that, you could have been at Default earlier and done that for other patients.  They'd have been less well-paying cases than today's, but your earnings prior to today would have been substantially greater, if that career offer had been made you and you had accepted it."

"The ominous supervillain lecture surrounding these relatively straightforward counterfacts is, shall we say, a choice of particular slant and emphasis to put on those counterfacts.  Not everyone would find Catchall's slant useful.  I didn't."

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Merrin still feels like maybe the main point here is that she could have been better at things by now if she had somehow ended up working in Default Hospital, which apparently has emergencies this interesting every week, a few years ago. But this seems like a hypothetical that's probably mostly only interesting to her. 

"...Right. I, um, what are the two offers you're authorized to tell me about?" 

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"You have the option of heading off to a slightly more private location before hearing them.  I don't mind either way, just mentioning the option."

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Oh no has she been bothering people by having this conversation in the command center? Merrin glances around quickly to get a sense of whether anyone else is still in earshot and looks like they might be bothered. 

"...Um, I - guess I would prefer to sit down somewhere if it's going to take a while to explain? And if you think it should be private I don't mind walking further." 

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"Do you want Personnel there too?  The markets think she's your friend."  (Said more quietly.)

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Merrin is so out of energy for making decisions on things like that, but– oh, huh. 

"...Yeah, I think that would be nice, if she doesn't mind? She looked tired before though, I don't want to, um..." 

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"High probability that she's still around specifically in case you turned out to want her there.  You worked intensely for a long time with high stakes, it's not surprising if someone who thinks she has advantage in Merrinology wants to be the one who hangs around and makes sure you're okay.  There obviously had to be someone."

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...Nod. 

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The Keeper collects Personnel and heads off to a nearby breakout room with seating for three.

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"How are you doing?" Personnel asks Merrin once they're out of earshot of anybody except the Keeper.  "I keep thinking thoughts along the lines that someone ought to wrap you in a blanket and feed you chocolate, but I don't actually know how one cares and feeds for a Merrin in this particular circumstance."

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Merrin is really not sure how to respond to that. 

"- I had a hug from my mom! ....Um, I - said I was going back to check on everyone else and that 90%-likelihood it'd be less than twenty minutes but I don't actually know how long this is going to take. She was just asking for likelihood it'd be over an hour so probably she won't worry unless it's more than that."

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She takes a deep breath.

"I...think I mostly want to close all the mental loops I still have open, which are - at this point not about the patient," because they know the outcome and great now she's having to try not to cry again, "and just the stupid villain speech." aaaaaaaaaaaah she did not entirely mean to say that out loud. 

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"Yeah, that was... an experience.  I'm pretty sure we were not the intended audience and were just collateral to him talking to the other Very Serious People involved.  If he meant to give you advice I'm sure he'd text it to you privately in accordance with incredibly fundamental basic advice-giving etiquette."

Personnel has elected not to say anything about her attempts to text Catchall to tell him not to do that around someone with Merrin's neurotype, nor about how it turns out you can't just text Catchall directly because other people are silly about trying to text him, nor about how she worked out roughly one minute after it was too late that she should've just poked one of the Keepers or any number of other people physically present who'd have Catchall's direct contact route.  Personnel is reasonably sure that she's not saying this because it would make Merrin feel uncomfortable, rather than because it would make Personnel look stupid.

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"...I did mostly figure that out after the fact." No need to mention the entire freakout in the middle. "But, um, I - apparently some people do want to offer me jobs somewhere else and I thought I should at least hear what the offers are." 

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She's not really expecting to get to keep Merrin, but it still feels a little sad, and maybe something of a sting in thinking that Catchall's spin is that they never should've had her in the first place and profited from their own failure to notice that.

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The breakout room has whiteboards, a vidscreen that isn't on, three chairs around a table positioned so that everyone could see everyone, and its own fruit bowl around half of which has been eaten.  (No small purple dinosaur figurine.)

The Keeper, slightly leading the way even if it's not his hospital because people just seem to expect that of Keepers, sees them both seated in the breakout room and then sits down beside them.

"The modal-case higher-earning offer is from Default Hospital," the Keeper begins.  "You'd come in as a tier-4 medtech there, and expect to make most of your money on occasional emergency cases that can benefit from somebody doing five oppers' worth of work for six shifts.  Replaceability-wise, once you were trained, the opper in Default Hospital who was previously worst at that sort of work while able to do it at all would go to Oceania Central hospital, and cause Oceania to have three people like that on staff instead of two.  Quickie estimate is that your counterfactual impact would be around a third of the direct work you'd do, save maybe a few hundred QALYs annually on the margins as your final share of group-effort impact."

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Merrin is mostly bouncing off thinking about the numbers being quoted. The numbers part of her brain is especially worn out and also mostly full of patient-specific data and, uh, she is maybe mostly going to be going off social cues from Personnel on whether what she's being told makes sense? (And, of course, asking to give her final decision on this later once she's slept and can think again.) 

Except for making tier-4. That's good, right? It's good in a way she can personally make sense of, even! 

....She can sort of tell - or guess, at least - that Personnel is sad about this. Fair enough. She's sad too! She feels like she'll be letting Civilization down if she doesn't go elsewhere, and that's worse, but she'll still be letting down her hospital if she does leave, and that hurts. Probably a whole lot of that is wrongthought but Merrin is especially tired of stomping on wrongthoughts.

"...Mmm," she manages. "What's the other offer?" 

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"In all of dath ilan there aren't actually that many people who want to spend half their waking hours training every single emergency cert they're eligible for, to high fluency, at realistic stress levels.  Many of those don't want to go into medicine specifically."

"And not all of Exception Handling is movie-style needing to lightning-integrate twenty unprecedented weird observations into a shocking yet correct theory using sheer uncrystallized fluid intelligence and five different polymath backgrounds while alone in interstellar space.  Sometimes, even in the weird hypotheticals that Exception Handling tries to position itself to handle, it's more about having somebody who's trained in exactly the right five weird protocols because she's trained in everything; better yet, even, if she can do that for twelve hours straight given adequate prediction-market guidance.  Though you did not, actually, fall down or fail to notice when the markets steered you wrong, even while incredibly distracted."

"For you, as for everyone, working for the weird-hypothetical branch of Exception Handling means that, in most probable worlds, your life will have less impact than it would in most other occupations you're suited for - balanced by a tiny probability that you end up doing something incredibly incredibly important.  Clearly not everyone ought to do that, clearly someone has to do it, and so - as an obvious matter of conventional morality - the deciding factor can be whether you think it'd be fun."

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"....It seems really implausible that Exception Handling wants me?" Merrin says dully. "I - um - I think I don't meet the basic entrance requirements." 

 

(Sure, Catchall said something about that in his weird villain monologue, which in the abstract sort of makes sense, but Merrin was only half listening at that point, and also it was clearly a speech meant to make a point to someone who wasn't her, Personnel even confirmed that.) 

Though she hasn't actually failed to notice that all of today was deeply implausible. Or that, for some reason she can't quite pin down, working for Exception Handling feels less scary, or something - not exactly 'less scary', something else - than working for Default Hospital. 

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"Well, they've made you a job offer.  Whatever your prior was on that, it happened, so go ahead and update."

"Being fair, a number of computer systems apparently agreed with you about your sense of the implausible.  Their priors will be updated."

"It's a longstanding problem of Civilization to build a social system where guesses, heuristics, proxy measures don't ossify into, as you put it, requirements.  Especially requirements about people.  The social-system-builders try to not have it happen, and it happens anyways, especially when people have to delegate part of their judgment to other people who feel more comfortable working to rules.  Computers make it worse, and there isn't enough human attention-resource in Civilization to live without them."

"You do, in fact, fail to meet Exception Handling's entrance heuristics for candidacy, but that's fine because you meet Exception Handling's actual performance metrics for hiring.  So while it might become a problem if you want to apply as a candidate, it should be fine if you just directly start work." [Humor.]

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"...Okay." 

(Merrin is now kind of absurdly, and belatedly, distracted by having been specifically praised for noticing when the treatment-planning markets started proposing treatments that blatantly made no sense. Is that impressive?? It was really pretty obvious???) 

It probably WOULD be fun to spend more of her time training on weird hypotheticals like the ones on Exception Handling medical TV

"- I, um, should - probably think about it." And give other people, who might be even more tired than her right now, a chance to rethink their offers before it becomes even more weird and awkward to withdrawal them if it turns out to have been a bad decision. 

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"Yes, I'd have booped you if I noticed you trying to make a decision immediately.  Even you, at this point, are visibly tired."

"The people who approved the offer weren't tired, be it clear.  Same with the offer from Default Hospital.  Avarris made a recommendation after following along with your work, but she wasn't the final decider, she was busy trying to follow all of your sensor inputs and your responses."

"I am in fact tired myself, but not to the point where it would impair my judgment that the people offering you money are following an obvious course of thought in doing so.  The unusual challenge we faced today made it visible that you can do a kind of work that's valuable to either Default Hospital or to Exception Handling.  That part isn't controversial, nor a difficult-to-make barely-marginal call.  The Very Serious arguments are about how bad it is that we don't live in a Civilization which figures out everything like that about everyone, as soon as it becomes reasonably knowable to a very smart person staring at it, and then informs people about it right away."

"Have you other questions for me, or do you want to be alone, or with just Personnel?"

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Merrin tries to imagine how much more dubious and sheerly weirded out she would have been if someone from Default Hospital or Exception Handling had approached her out of the blue and tried to recruit her. She...would honestly have thought they were trolling her - where 'they' was some group that had very deeply misunderstood her own feelings on the subject and didn't know it would hurt. She would have, reasonably she thinks, been pretty mad about it. 

(Merrin did grow up in dath ilan. She is capable of enjoying and appreciating group conspiracy-pranks like the whole Sparashki adventure; now that it's safely after the fact, she can even faintly enjoy picturing how nonplussed all the elite traders on the market must have been. But it doesn't come naturally to her, and catching when she's being trolled doesn't either, especially because her mom is also an unusually straightforward person. Merrin has always been earnest, and she still remembers with humiliation some childhood incidents of wrongly taking people at face value.) 

She...doesn't place more than negligible probability mass that they're trolling her right now. After the day she just had, that would actually be mean, and this would be obvious to everyone. 

 

She shrugs a little. "I mean, didn't know I could do that until today. In real life, I mean. Sims are different." 

(...Sims are harder, sometimes, she remembers thinking that on multiple occasions. The reality of human biology in a state of crisis isn't on her side, but it's not actively out to get her either. And having the same patient for twelve hours of nonstop emotional roller coaster was...exhilarating, actually, at least after the fact, and somehow it still feels that way even though they lost this one. Merrin sort of feels like she was more alive, more all of herself, than she's maybe ever been before.) 

Honestly, the hardest part of today, relative to an especially nasty sim, was being watched by Very Serious People. Which is a stupid thing to have a problem with, so really, opportunities to practice it are good? Right? She made actual mistakes because she was distracted by socially panicking, and - in this case they probably didn't matter, in this case she probably did basically well enough not to cause more cumulative damage during the time the patient was hers to carry, and the conclusion - holding constant a treatment protocol that she didn't and couldn't have designed - was predetermined by the time he reached the hospital at all. Probably, in this case, it wouldn't have mattered if Merrin was ten years older with five times as much emergency sim time. 

She's been doing emergency sims for more than two years, of course, but - not at this level of difficulty. She couldn't have handled a patient like this even a year ago - even just six months ago, she was technically certed on the temporary liver replacement machine by then but hadn't yet sufficiently drilled it into submission that she could handle it alongside anything else complicated. So much of her first few years at the hospital were just making up ground, fighting with every hour she could stretch and snatch out of every day just to pull even with her peers, stubbornly submitting herself to the embarrassment of being bad at things in front of everyone over and over and over again. 

Really, so much of Merrin's entire life, since she was eleven and someone believed in her, has been spent on trying to catch up with a Civilization that outsmarts her at every corner. That isn't shaped for people like her, though of course it does its best to have room for everyone. She was determined to prove that her existence would be worthwhile anyway, that she wouldn't be one of the people left behind, in Quiet Cities or waiting in the cold for something, somehow, to be different. It might have taken years to grind her way all the certs for ICU, but she did it, and she was so happy here, and it was enough, it's - not really surprising, given how hard it was to reach this point at all, that she didn't hope for more. 

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(Merrin, to be clear, absolutely doesn't begrudge Civilization for being hard for her to keep up with. Can you imagine the alternative? A world where somehow like Merrin is unusually smart rather than unusually slow would be so awful.) 

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Merrin glances at Personnel.

"I - think it makes sense for it to have been an update for other people as well? And I don't– I didn't really want to leave, before."

And she isn't sure she wants to now, but...who is she kidding, she's going to. Not even because of the compensation, really. She already has a big enough pile of labor-hours that she has no idea what to do with it! But, while other people might not consider it a moral imperative for Merrin to leave behind a life she likes when no one's True Death is at stake, Merrin does, actually, care about whether she saves people from the temporary death of cryopreservation. It's not the same as living to go home, here, now, in this time and place, surrounded by the people they live and work and raise children with. And that's leaving aside the part where the predicted 97% chance of cryo working and the preserved people being revived is not the same as a probability of 1.

(Merrin suspects she's actually less upset than average about True Death, especially her own, it's not like it's any worse than the fact that she also didn't exist before she was born.) 

The value function is not up for grabs. Even a fourth-rank Keeper cannot, actually, tell Merrin that either choice here is equally good from Civilization's point of view and so it's up to her to do what makes her happier as though that matters more. (Though, honestly, there's no reason to think she won't be happier in Default, treating interesting patients all the time, once she gets used to it.) But the reason Merrin already knows that she's going to leave isn't that she thinks people will be angry or judge her otherwise. 

...Or because they'll be impressed with her for her achievements. They probably will, but this feels very uncomfortable - and that's weird, because Merrin does actually like doing things well and pleasing her colleagues, so why is it so superheated awful to remember Catchall talking about her like she was suddenly an impressive person instead of a decidedly mediocre one.... 

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- oh, right. 

"I, um, think I find this scary because it - feels like making a negative update on Civilization," she says, shakily. "If - there's anything I can do that most people can't do, it, it feels like that means the world is worse off than I thought. But - I guess that's thinking about it wrong." She giggles nervously, which aaaaaaaaaaaaah why is she like this. "Uh, the thing I mean is, it's so specific, the only thing I'm actually good at is working longer," being able to handle five machines is downstream of that, and other people can do it too, the normal way, by being actually smart, "anyway I already know what the world looks like, and nothing is actually on fire, definitely nothing is on fire because of me specifically not fixing it, it probably...shouldn't...feel like new information on - things that aren't me..." 

Merrin is aware that her throat is tight and she's pleading desperately for something and she cannot actually pin down what. But that is, after all, why she went to talk to a Keeper in the first place. 

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Not all Keepers and not even all medi-Keepers are psychiatrists; but every Keeper has to know at least the basics, because everyone on some very deep level seems to believe that Keepers are psychiatrists, so they have to be ready.  It does, in fact, help - in that particular regard, if not others - to have the ability to visualize how most people work, deep down.

It is in fact a sort of knowledge that has measured dangers to human beings, if not to ideal agents.  The brain is built to model others by sympathy, by putting itself into somebody else's shoes, to model other people by asking your own brain what it might be feeling inside if it had lived through their experiences.  To think of other people as complex cognitive machinery, if you've learned enough to do that and accurately, is not just to imagine other people in a format where your emotions don't natively bind to that representation.  It directly bypasses the underlying machinery of sympathy.

So, if you're a Keeper, you just don't do that all the time, and only do it when you choose, and then having done it you restore your previous state of emotional modeling with respect to that person and prevent the mechanical knowledge you gained from interfering with the emotional bindings there.  And since you can't do that perfectly, you also by an act of choice treat the person, and to some extent feel about the person, the same way you would as if you couldn't see those truths about them.  You know the theory, but you don't constantly see the very obvious implications of that knowledge all of the time, even though you've already practiced many times the mental motion of seeing those implications.

And that's how you learn to model people as machinery instead of people, without turning into an exceptionally dangerous psychopath.

Which is to say: there's a hazard to knowing how to model people as machines, but you can cancel out that hazard by learning other mental techniques, which you could also easily use to shoot yourself in the foot or the limbic system if you didn't use them exactly correctly; and once you learn those, you need to learn other hazard-bearing mental techniques to navigate around their downsides.

This, in the end, is why there is a distinguished cluster and profession of people called 'Keeper', rather than sociologically distinct groups that are Bearers of Secret One, Bearers of Secret Two.

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Rittaen, fourth-rank Keeper attached to Exception Handling, can tell, obviously enough, that there is something that Merrin desperately wants to be true, or desperately wants not to be true.

It's not in fact the function of Keepers to tell people what they want to hear.  It's not the function of Keepers to ward off people's internal stresses and crises.  Sometimes you would be hurting people, in the long run, if you steered them around an internal crisis.

If there's a point where a Keeper would definitely straightforwardly just tell you something, it's when your distress is being generated by a belief about something that's straightforwardly false, that was arrived at by local noise rather than global internal problems, and they can just tell you how reality actually is and be believed by you and then that actually solves your largest real problem.

This does not look like one of those cases.

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Rittaen has heard from Personnel (indirectly via the second-rank Keeper reporting to a sixth-rank Keeper and then back to himself, very strong links individually but he does not neglect to notice the chain) the hypothesis that Merrin doesn't want to be 'special', in some sense of specialness that Personnel doesn't know how to pin down exactly, and suspects of maybe possibly being not the sort of thing that has a straightforward truth condition on states of reality.

So Rittaen flips on his person-as-machine Sight, and considers Merrin and her fear.

...If you were to translate Rittaen's conclusions back into language that ordinary dath ilani understand, they would not be very exciting conclusions.  The hidden truths derived of secret knowledge usually are not, in fact, exciting, because it is usually the nature of correct conclusions that they end up merely real.  If you know that the Sun does not circle around dath ilan but rather dath ilan rotates - as is forbidden to tell young children before they work it out on their own - you don't thereby know that the day tomorrow will be twice as long as the child expects.  It all adds up to normality, and the question is just what is normal and how the adding-up occurs.

What does it mean, to Merrin, to be 'special', that is so very terrible?  The evidence doesn't suffice to pin it down precisely, but as is often the case, the multiple hypotheses consistent with past data about Merrin tend to all make pretty similar predictions about the future too.  Merrin's neurodivergence is known to include her being a face-recognizer, and that in turn often goes along with the condition of status-heaviness where the human sense of status takes on greater weight within the mind and becomes a reified order of the universe, such that disorder within it is directly painful; Merrin has a sense of how much status she is supposed to have, and for her to have more status than that is disorder and That's Terrible...

Only it isn't, of course, anything like that simple, real human beings are not that simple; it's more that there was that potential structure and instinct in Merrin, and then it attached to other thoughts and experiences.

People are built, not with an instinctive fear of snakes, but with neural structures that are ready to latch on to a class of stimuli that include snakes, and learn to fear things in that snakelike class much more rapidly.  If you raised children in a way where they were sometimes threatened with tentacles - not even hurt by them, maybe, just seeing other people scream and run away - then those tentacles might be, to them, snakes, in the sense that the snake-identifiers would have latched onto those.

Rittaen can guess, as one hypothesis among many non-mutually-exclusive ones, that Merrin has sometimes talked to people whose behavior and reactions struck Merrin as their expecting Merrin to be more verbally fluent, and being disappointed that Merrin wasn't.  Maybe some kids actually said that to her, as a kid, when Merrin wasn't in a selected cohort of other kids with similar subject fluencies and learning speeds.  Maybe Merrin just imagined the disappointment, the underlying potential structure and pseudo-prior of her brain prompting her to imagine that people were thinking that, imagine disappointment that they might or might not have really felt.  It'd be the same pain to smol!Merrin either way.  And that's one of many kinds of stimuli that this potential latent structure in Merrin - the recognizer of getting-above-your-place, as is more heavily powered in her than in the average dath ilani - might have latched onto, and said to Merrin over and over, "This pain, now, this is your punishment for other people thinking you had more status than you had."

Rittaen can also guess, based on Merrin's externally visible behavior within this very conversation, that Merrin also considers people of status to have duties; and that Merrin has in the past been compelled by a sense of obligation to perform what she sees as her duties, and made sacrifices for that, which other parts of herself resented; and this also was internally bound as a kind of pain that happened to her because she went above her place, swiftly learned as a fear; and so now the cluster of everything learned this way is partially opposed to Merrin's morality; which is turn is a kind of stress that diminishes to the extent that Merrin does not internally consider herself to be higher; and this reinforces a mental motion against that.

And that the higher Merrin is, the lower Civilization is relative to her, and that she has a sense of safety and wholeness and comfort in being surrounded by Civilization, that it is to her something like a parent but not a parent that let her down the same as some of her other parents.

(The rearing of an average child is heavily optimized to avoid predictable formations of tangled fears like these in average children.  But Merrin is neurodivergent, and human-attention is a sharply bounded resource in Civilization.  If there'd been Keepers following smol!Merrin around, thinking through every consequence of events around her, they could have prevented her from being tangled in a way that an average dath ilani wouldn't have been; but Civilization does not in fact have that kind of money.)

(And also to be clear, it's entirely possible, on this model-cluster of Merrin, that she'd have ended up with very similar scars if she'd been born at +3sd g instead of -1sd g.  The thing inside her that was hyperprimed to learn a certain fear quickly, might have just found something else, but similar, to latch onto - some other unpleasant experience that could match the neural criterion for 'this bad thing happened to you because you have an objective place and went above that'.  While people are ultimately shaped by their experiences, their brains are often very ready to be shaped in particular ways.)


...the point being that while Merrin may have started out as genetically neurodivergent in a simple way, her sense of not-wanting-to-be-special is now this enormous tangled cluster of past pains and fears learned too quickly, some based on false models of reality and some parts on true models too, that were all latched onto by the same neural structure that wanted to very quickly learn to avoid things like that.  The details are hard to guess exactly because her past behavior doesn't distinguish them, which means that all those different possibilities mostly imply similar future behaviors and can be mostly integrated out.

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What should Rittaen do about it?  Mostly nothing.  It's not his own place to meddle just because he knows Merrin better than Merrin does, even in the possible worlds where that's true and he hasn't made a critical mistake from not having true introspective access to Merrin's own thoughts.  It's more Rittaen's place to check that nothing really bad is about to happen to Merrin on account of this internal tangle; and so long as he's there, checking that, Merrin doesn't have to learn Keeper disciplines herself in order to prevent anything really bad from happening to her.  That's the point.

"For what it's worth," he answers, after a pause during which he chooses to appear to be somberly considering her words - "the way in which most of Civilization can't do what you can, should not, I think, cause you to update very drastically about Civilization.  There isn't something deeply wrong with a universe where most people don't want to run emergency sims all day, or at least, it seems not so to me, and that is what you are observing.  If you do go to work for Exception Handling, you'll learn in time that there is both more and less to Civilization than you thought.  I'm not sure but that you wouldn't learn the same in Default Hospital too, and maybe even if you stayed in Harkanam and had children and found that neither you nor Civilization could protect them from everything."

"The world is very large, in the end.  You should not fundamentally expect that you already know its workings.  And you are also very large; you should not expect that you already know yourself.  Today you learned that you were wrong about yourself and about Civilization and about which jobs you can have; and that's really a very small way to be wrong, compared to some I've seen.  The upshot is that instead of staying in Harkanam and learning more about how you were wrong about Harkanam, you have the option of learning about how you were wrong about Default Hospital, or going off to Exception Handling to be wrong about that.  But that's just an option, and you don't have to take it at the expense of being wrong about Harkanam."

"The world is too large to be mastered, and exactly for that reason, there's no point in you feeling that you have to chase after any single part of it.  Go where you want to be.  You'll learn some things you wish weren't so, but that will happen to you regardless and in time.  Eventually, everything that can be destroyed by the truth will be, in this life or the next."

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Merrin listens warily, with the expression of someone whose personal experience has not left her assuming that adults will tell her true things, and is trying to figure out where his incentives lie in this particular situation. (She doesn't expect an actual Keeper to lie, or to be trolling her in a serious situation like this, but she certainly has no expectation that he's particularly going to be saying everything, or conveying what he actually thinks.) 

She nods, though. Nothing he just said sounds false, and it also doesn't feel like he's - carefully padding the edges for her, leaving out the parts that he might think she isn't strong enough to hear. (People leaving out things that they think will upset her to hear is something Merrin hates, even when the things do, in fact, hurt and upset her a lot.) 

Civilization isn't perfect, and its resources are extensive but not infinite. She already knew that, and really it was the entire lesson of today. It was quite a memorable way to find out that Exception Handling doesn't quite have everything figured out, yet. Would she prefer to live in a different world instead, one where Exception Handling already had a protocol for this, and they saved the patient? Yes, a million times over. Is that one of the options on the table? No. She lives in the world she lives in, and she can either know that or refuse to look, and it's better to know. Not to know everything - there's a reason she isn't a Keeper - but to know the things that are relevant to her decisions. Which is a lot of things, because everything is intertangled, Merrin knew that as well. 

She's...still really scared, actually. But it's much more a familiar kind of scared. It's how she felt when she decided to go for her nursing certs, how she felt when she showed up for her first shift as an unskilled health care worker, how she felt over and over again when she decided to try something hard, something where she might fail - worse, where she might fail in front of people and let them down. 

And the world isn't going to end if she lets people down. It might feel like it will, but she's been there before, and it won't

She wants to meet their patient again in the Future (though inconveniently she doesn't actually know his name) and say that she tried really, really hard, and it wasn't enough that time, and she really is sorry about that, but that she kept trying, and someday, later, they saved the next patient thanks to what they had learned. Merrin may be a person who makes a lot of mistakes, but she does try really hard not to keep making the same mistakes over and over, and especially not to do that because she's too scared to look directly at reality. 

 

(Also, if she does fail to see reality as it is, because it hurts to accept it, that's not a permanent failure either. They have the whole Future for her to figure it out, eventually, and if there's one thing Merrin has already learned she's capable of, it's not giving up.

...Though it might really, really suck if it turns out she can't do something that someone was expecting of her, and she's never really and truly failed before, that is scary, she...might not be okay for a while...) 

 

"I...think that makes sense," she says finally, after making a lot of rather expressive faces. She glances over at Personnel. "Although, um - are things going to be okay here? I don't want to inconvenience everyone by leaving if that's going to mean you have a problem covering all the emergency certs?" Why does it have to be ONE OR THE OTHER, no matter what she decides here she's going to be letting someone down, it's terrible. 

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"I mean, people do sometimes change jobs, that's among the reasons why hospitals have two people with each emergency cert.  You'd leave a larger hole than usual, but we'd spike the bonuses for picking up certs, and be back in compliance a couple of months later."

Another note of that sting from Catchall's criticism.  People whose departures would leave large expensive holes in your organization are usually people you want to pay more, above and beyond payments linear in labor or numbers of certs; and maybe someone should've noticed that fact about Merrin, what with the general heuristic being a proverb.

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(This might have been easier to notice if Merrin had ever asked to be paid more for the truly ridiculous number of their emergency certs she was taking on, or, you know, if she had made a habit of even checking how much she was getting paid. She knows it's more than enough to cover her housing and other expenses, at which point she doesn't keep very close track of the excess.) 

"...I don't have to decide right away, right?" she asks Rittaen. "I can - make sure it's not going to be a problem here?"

(Though she's a little worried that if she stays, the surrealness of today will start to drift into the past, it'll go back to feeling like surely someone is trolling her, and she won't actually be able to bring herself to leave. She can probably sort that out in her head and do the correct thing anyway, but it's definitely always been easier for Merrin to push through scary things on adrenaline and momentum.) 

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"Yes.  Though your prospective employers would probably appreciate the courtesy of hearing a deadline by which you'd decide, sometime in the next two days."

It's meddling, but anybody could figure out that Merrin stood in that much danger and meddle; you don't have to be a Keeper.

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Aaaaaaaaaaaaaaaaaaaaah two DAYS??? ....Okay, fine, it's in fact reasonable for Default Hospital and Exception Handling to prefer not to be inconvenienced by her indecisiveness. 

"I can probably do that. Um. I maybe should talk to people who work with both, just to - get a better picture of what it would be like? But I don't need to do that tonight." In fact, her brain feels just about ready to melt and slide out her ears. "Anyway, I...think that's all my questions, I, um, sorry for taking up your time but I'm glad I asked you, it - helped." 

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"I mean that you should tell them your actual deadline in the next two days.  Not that your deadline should be two days from now.  Get some sleep and check things over with a friend before you make any large life decisions, Merrin, you're exhausted even if honorably so."

Rittaen rises.  People expect him to act with gravity, and it doesn't cost Keepers nearly as much sanity points to reconfigure themselves around other people's expectations; so he rises with great formality and departs in a terribly sober and serious fashion.


(Keepers are nearly the only people in all Civilization who will dress consistently somberly in public, and then not feel an irresistable urge to for example speak in a high squeaky voice just to show how much they shouldn't be taken too seriously.  Realistically this explains quite a lot of what's going on there culturally speaking.)

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Aaaaaaand now that Merrin no longer feels like she has to maintain some basic dignity in front of a fourth-rank Keeper, she flomps. 

"Aaaaugh," she says, heartfelt. "I still half feel like I'm going to wake up tomorrow and find out I hallucinated all of this. Thanks for staying for that. Um. I - should get back to my mom before she worries, but. I maybe want to go actually look at the offers. It's going to keep bothering me otherwise." 

Rudely, the computer terminal in the room is all the way over there. Terrible. Merrin wasn't feeling physically that tired before, but it's actually getting late according to her circadian rhythm now. 

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Personnel pauses with her hand halfway to a grape in the table's fruitbowl.  "So, the Keeper didn't explicitly say that you shouldn't look at the exact salary offers, because, you know, telling people not to learn true facts is... something Keepers try not to do unless they really have to, or so we're told.  But he also didn't actually tell you the salary and expected-bonus numbers, despite it being the first thing that most people would want to hear, and that sort of sounds like somebody who worried that he'd be at least slightly injuring you by telling you the numbers, which a Keeper would also try not to do."

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"Mom is going to ask me! It's literally the first thing she'll ask!" 

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"Just tell her that you got implicitly advised to think it through without knowing the numbers first?"

"Or I could tell her but not you, yet?  They did kinda authorize me to pass on the job offers myself, if you came over and asked me what was going on and if anything was meant seriously, so I actually do know the numbers too.  Well, and also because they wanted to give our hospital a chance to counterbid, though with this sort of look that said that there'd be questions about why we hadn't paid you more earlier, if you were generating that much value for us... but, like, not in a way where they wanted that to impede all the interested parties putting in bids on you, because that's in your interest too."

"My guess, for what it's worth, is that you're supposed to think it through knowing the part that the Keeper told you, that the higher modal-case monetary offer is from Default Hospital, but not knowing specifically how much modal-case money you'd pass up by spending whatever fraction of your time in Exception Handling.  Then once you know how you feel about that, you actually look at the amounts of money.  Then you go into a soundproof room and spend a while screaming to express your emotions about how you can't possibly provide that much economic value and are going to hugely disappoint these people who falsely believe in you way too much.  And then, you know, take the job, because they know better and it's not your job to correct them about that anyways."

"Though I guess you could also take the job and just never ever find out how much it pays, at all?  Just set up an agent who handles all your finances sight-unseen, and have an account somewhere which always gets refilled to at least ten thousand unskilled-labor-hours no matter how much you spend."

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"....I, um, I might appreciate it if you can tell my mom just so she won't nag me about it– I, um, wait. Can you do that? I mean the last thing - getting an agent to deal with all my finances - that would be great!" 

Merrin is pretty sure that she is supposed to be on top of her own finances but also literally all of the advice she can find on the Internet for her sort of financial situation is super hard to follow, and she sure seems to have self-selected into a colleague group of people smarter than her, which means that their advice consistently makes her feel stupid. And, like, she is at all capable of learning and then doing math? She doesn't mind doing math for her actual job! She does sort of mind having to do random extra math about her earnings and spending! 

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Oh wait. 

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Um. 

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....Okay so she just learned that Personnel knows the figure and thinks that Merrin will scream about it, and Personnel knows her really well, so - really this is enough information to know that she should already be screaming??? 

(She is not literally screaming out loud, but mostly only because she's tired and that would be so much work.) 

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"I had in fact meant that as a HUMOROUS ANTISUGGESTION.  And while it plausibly fits you unfortunately well, and I can't actually think of a psychologically better plan to substitute now that I'm focusing there, if you actually do it, I'm still putting you on my 'does not get humorously terrible advice because she might do it list' forever."

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Merrin would probably be really embarrassed about that if not for the INTERNAL SCREAMING. 

"....I. Um. I'm not sure if this was also meant as a humorous antisuggestion but. You know the monetary offer. And. You did sort of say. That if knew it I would have to go scream about it. So I am making the predictable update about that!" 

Also aaaaaaaaaaaaaaaaaaaah! Also she is, in fact, predictably going to take the job anyway??? ....This really does not reduce the aaaaaaaaaaah!!! 

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"Merrin?  You're probably leaving the hospital and so, while we'll maybe always be friends I hope, our actual relationship is probably going to be mostly winding down, and given that, there's something I've wanted to do with you - well, to you - and something I've wanted to say to you - for quite a while now."

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Slowly, ominously, maybe even tenderly, Personnel leans towards Merrin -

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- and her hand reaches out -

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- and takes a banana from the fruit bowl.

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"Be more ambitious!"

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- WHAP -