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Dec 02, 2022 1:27 AM
Merrin working in Exception Handling
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The other techs have basic life support set up. They super cannot get a regular O2 saturation reading but the arterial blood gas results are reading on the instant test kit.

Tentative readings on core body temperature: 23.8 C, but even the tentative, still-settling diagnostic predictions are that it's likely to drop further unless they respond with aggressive rewarming now. It actually takes a surprisingly long time for the core body temperature to drop, for a conscious casualty in cold-but-not-freezing water, especially if they stay calm and follow the best advice for conserving heat – but the body compensates with massive vasoconstriction, keeping warm blood away from the skin and extremities. This fails at a certain point, as the body shuts down and control mechanisms cease to function. Now that they're re-establishing circulation, a lot of cold blood is about to be dumped back into the patient's systemic circulation. 

There are actually still occasional twitches of cardiac activity visible on the ultrasound, before they get the external compressions-vest on and promptly can no longer pick out any muscle-generated motion from the motion it's causing. That's a good sign; it means that while he may have been without air for the eleven minutes they know he was trapped underwater, the remaining oxygenated blood in his body was likely still circulating for a while. 

(It can take a long time, even once a casualty is unconscious from hypoxia, for the heart to actually stop beating.) 

On the less bright side, the test results are in and he's very hypoxic. 


Basic demographic information: his name is Kalorm, he's apparently 25 years old – only a little older than Merrin herself – and he has literally no documented medical history in the last five years. 



Merrin...seems to be doing things? Her hands are now occupied on optimizing ventilator settings. She isn't sure she decided to do that, it's just sort of happening. Everything feels very far away, in the way that normally only happens on hour seventeen or eighteen of a really unfair sim (they do, sometimes, keep her going even after the point at which her performance on complex tasks is noticeably falling apart, because it's not impossible that someday a situation will come up when her ability to stay conscious and on her feet and keep doing very basic tasks for upward of 24 hours is important.) 


There was already a lot of attention on this situation even before the point at which it exploded - it was the most unusual thing happening on this side of the planet, and it's possible that a lot of people like watching Merrin work, not that they could see much in this case while she was in the water - and that was now twelve minutes ago. Unlike a certain incident in Merrin's past, this is not a secret case, and the market is very well-funded. They're quickly approaching having every domain expert on the planet who is currently awake watching. 

The medicopter has a dedicated satellite signal to stay in contact with the mainland; despite the storm, the signal lag is only a few seconds longer than it would be from a hospital on land. Getting updates in both directions, and quick turnaround on market recommendations, isn't going to be too much of an issue.


The bigger issue is that the medicopter is currently a couple hundred miles from the nearest point of land, and the nearest point of land is not the right direction to head for the closest major specialist hospitals. Default is fifteen hundred miles away, mostly over water. The copter has limited equipment. More to the point, it has limited personnel. Six, in fact, counting Merrin and not counting the pilot, who isn't a medical specialist. For five patients.

The medicopter is engineered for fuel efficiency - it has to be able to make long trips without refueling - fine control, and minimizing the effects of turbulence on the personnel and patients inside it, not to mention being able to fly safely in a storm. It's not optimized for speed; it can manage 200 mph, maybe, with a significant fuel efficiency loss. Also it's been in the air for hours; it has enough fuel to reach Default, but only at its lower efficiency-optimized speed of 100 mph.

The nearest hospital center period - actual hospital, not just a small emergency depot - is five hundred miles away, and would be deeply non-ideal. They would have to fly in personnel and equipment from elsewhere. Ideally, they really do want Default Hospital.

Also, fifteen hours to get there is not acceptable. 


Yeah no if they make her deal with this with only field equipment, in a moving helicopter, for fifteen hours, then Merrin is definitely going to end up yelling some ill-advised things at anyone in earshot. 


No one is considering making Merrin do that. 

The fastest plane available for Exception Handling medical evacuation, with the facilities and equipment they need to stabilize the patient and smooth enough flight for delicate procedures to actually be safe, can reach six hundred miles an hour, and can be ready to take off in fifteen minutes.

The fastest cargo transport plane available to Exception Handling can break the sound barrier - they'll have to pay quite a lot in compensation to everyone in the cities it flies over, but that would be clearly justified. The straight-line distance from Default to the hospital Merrin and team can reach fastest - though even tanking the higher fuel-burn rate it'll take them two and a half hours - is almost two thousand miles, since it's in approximately the opposite direction.

In terms of flight time alone, the supersonic transport can definitely beat them there; the issue is that there's a lot of equipment they're going to want, much of it weird and obscure. It'll need to be loaded, which adds...thirty minutes, maybe an hour. And then setup time on the other end. They can probably have the patient safely in an actual hospital unit in three hours, but there's certainly room for something in the timeline to go wrong. 

(There is some quietyelling about this fact and about how incredibly unacceptable three entire hours is for a situation this serious.) 


If the closest ready-for-takeoff fast medevac plane flies out to meet the medicopter, it can intercept them in ninety minutes. Merrin isn't very trained in midair transfers but she is, technically, sim-trained in it, as are her crew. The transfer - and turning around - will cost them some time, call it 30 minutes pessimistically; at that point they'll be three hundred miles closer to Default, 1200 miles left to go, two hours. Four hours total, an hour longer than if they go for the closer option, but it's just solidly better to be in Default for a situation this complicated. 


....Honestly, a major consideration here - at least, one that the Personnel currently speaking on behalf of Merrin is loudly flagging - is which option will minimize Merrin's stress levels. 

The treatment recommendations haven't settled yet, but the range of options isn't huge, since they can't fall back on cryo – APPARENTLY, which he ALSO THINKS should have been RAISED EARLIER so it wasn't a COMPLETE SURPRISE. They're going to have to make the best trade they can between 'patient survives at all' and 'patient does not suffer unacceptable brain damage'. Since the patient has registered approximately nothing about his preferences aside from the bizarre refusal to consider cryo, there are currently some frantic conversations happening with family members, but the only real decision for right now is whether to start aggressively rewarming the patient during transit, or stabilize him at this body temperature.

Once they reach whichever destination they select, they're almost certainly going to be using the current best version of the protocol developed on the spot two and a half years ago. Exception Handling does not like to be caught flatfooted like that, and the event was actually rather informative as to the current state of the science. They invested heavily in learning from their mistakes. 

(The slightly complicated part is that the actually-sort-of-decent version of the protocol is secret, because it relies rather heavily on now about forty custom proteins that are not really supposed to exist. The current case is very much not secret. Making it secret at this point - or, ideally, at the point when they actually reach a hospital, because in the meantime Merrin needs every edge they can buy her - will itself leak some information, if not details. Also, while they do have a better solution to avoid the market failure catastrophe from the last time, it's still going to cut out half the experts currently providing advice. Also, the Exception Handling case coordinator is currently reviewing a dossier on the patient's family members, and their collective attitude toward secrecy oaths is not entirely reassuring.) 

...Anyway, Merrin is trained on the secret version of the protocol. She isn't the only person who is, but she's certainly the only person who can carry it for the 8-12 hours or so it's likely to take once they begin. Pushing the possible total shift length to 16 hours, if they head for Default. 

Merrin can do it. She'll have all the support they can possibly get her, since - helpfully - money is not a limiting factor here. She's done sims that long, and even sims that long and also complicated. 

She hasn't been tested on how well she can cope with the stakes potentially involving a True Death. Probably she can cope well enough that it won't compromise her performance, but that's only a 'probably'–




–and unfortunately their Merrin-modeling intelligence is currently limited by the REALLY INCONVENIENT FACT that one of the top-world experts in psychological modeling, who also has some experience with Merrin in particular, turns out to be RELATED TO THE PATIENT. Seriously. Why. 

(...It's perhaps less of an implausible coincidence once you notice that both of them are extreme psychological outliers for dath ilan, albeit with presentations that look rather different on the surface - but apparently the ENTIRE FAMILY is like that, and Personnel is not delighted about having an entire cohort of very neurodivergent, very upset family members hovering in the vicinity of a situation which is already complicated enough. But they could particularly use Khemeth's input right now, and cannot rely on having it.) 


The current consensus is that being in Default, a familiar hospital where Merrin has trained and worked - and the city she lives in, when she's actually home - is going to be at least a minor element of reassurance for her, buying them a less stressed-out Merrin at the cost of one additional hour of travel time. 

The downside is that if they don't rewarm the patient until arrival - which gets them a slightly higher chance of the neuroprotective protocol working - they are going to be trying to stabilize him in an inherently unstable physiological state, while airborne, with very little affordance to bring in emergency equipment or, more importantly, people

The market is giving 98% odds of at least near-term survival (next 48 hours) if they they aggressively rewarm the patient starting now. That drops to 92% if they delay on any rewarming until they reach a proper facility. Which would be a much less scream-inducing number if not for the fact that, one, that is an 8% chance - one in twelve - of the patient PERMANENTLY DYING, and also the fact that this is premised on past team performance when they weren't splitting six people across five patients. 

The limited number of on-site personnel is a real problem. They're a good team, but there are also six of them for five patients. And even the conscious patients, while their prognosis overall is good, have a fairly high chance of deteriorating if they don't receive ongoing 1:1 medical attention (or ideally ongoing way-more-than-1:1 attention). Right now, one of the medtechs is trying to treat all three, and while she's capable at all of the attention-splitting, and also theoretically capable of a six-hour shift without falling over, the markets are not actually optimistic that she can do both at once.

Meanwhile, the fourth patient has serious intracranial bleeding and this is not exactly the type of situation you want to be dealing with in a moving helicopter, during a storm, with only two pairs of hands. (The other two techs are with Merrin, and the sixth is their team coordinator, and currently busy coordinating.) 

Intracranial bleeding patient is not an inexplicable denier of the entire concept of cryopreservation, which is good, because the Treatment Planners are really quite close to calling it now before the existing damage gets any worse. The issue is that emergency cryo in a helicopter usually calls for four techs. 


Merrin can do it by herself. Merrin has run that sim, like, four hundred times; she's not quite as reliable solo as she is with her full team, but she's actually better than, say, the average small-town hospital staff. 

Personnel is concerned that Merrin is going to be pretty distracted by the ongoing superheated nuclear disaster in the bed over - she's been mainly focused on him so far, reasonably, and she gets emotionally invested. It might be quite bad for her emotional state to make her switch anyway, especially when they'll presumably need her to switch back. 

Do they have literally any other options that don't require pulling four of the other techs onto that, leaving one person with the other three patients and Merrin by herself with the patient who is going to be GONE FOREVER if they don't do everything exactly right. Because this ALSO seems VERY BAD for Merrin. 


...Treatment plan comes up. 


It is, at this point, primarily a logistical plan. Step one: proceed to the cargo ship thirty miles away - ten minutes, at top speed - which is equipped with a helipad, and also has its own in-house medical team. Not Exception Handling calibre, but they can handle emergency cryo, and they can definitely handle the more stable patients. They will immediately offload those four patients and take over. 

(This isn't just out of consideration for the medical team, or for their patient's survival. Three of the casualties they're leaving are conscious, and nobody really wants to leave them with a 1 in 12 chance of personally witnessing the True Death of a close friend.) 

Meanwhile, as soon as they're on the– well, not ground, but a somewhat more stable surface, Merrin and team will initiate this stabilization protocol with Kalorm: goal range for core temperature: 22-24 C core range, this set of parameters for other vital signs. They'll need a fairly comprehensive suite of sensors and life-support machinery, and while Merrin is certed to handle most of the relevant procedures in flight, the setup is still safer if they don't have to contend with unexpected turbulence. Also they really do need the cell-damage sensor, and inserting things into the blood supply of someone's brain while subject to unpredictable turbulence is really not a safe idea and Merrin is not actually certed for it.

A fast plane is already prepping to take off from Default; there will be a tricky midair transfer, but once that's accomplished, they'll have much better facilities and a smoother flight in case they need to do any more emergency procedures to keep the patient alive that long. In less than five hours, they'll be set up in one of the Complicated Patient Rooms in Default Hospital, with literally everything ready for them to start the neuroprotective rewarming protocol. 


(Personnel wishes to check that absolutely everyone on the case knows not to mention anything about Merrin's performance incentive, right? Obviously her direct colleagues know, but this situation is by far the most high-profile that Merrin has been involved in on his watch - expert Diagnosticians and Treatment Planners who don't know Merrin may end up interacting directly with her - and Merrin's set of weird neuroses around seeing the value of her work denominated in labor-hours is really weird and unusual.) 

And actually relayed to Merrin directly: is she comfortable with this plan? Are there any obvious problems? 


Merrin's internal reaction is that there are 57623 obvious problems with EVERYTHING about the ENTIRE SITUATION, but taking that as given, the plan seems basically reasonable. She can handle the initial procedures and the stabilization protocol looks doable with the resources and people they have.

(She doesn't love abandoning the other casualties for reasons that boil down to 'resource constraints', but she does work for Exception Handling. She's run sims under much steeper resource constraints than this. It's not as though they're denying anyone treatment - in fact, in a closely adjacent world where Exception Handling hadn't already sent her team to hang out in the general area on the basis of a 1 in 32 chance they would be needed, the medical team on the ship would have been the first-line rescuers anyway. They're certed for it. They'll have the same access to expert backup that Merrin and her team would have. They may not be trained to quite as high a standard, but the benefit of not being in a moving helicopter is probably actually just enough to cancel that out. Also, she really doesn't have time right now to have feelings about the other patients' outcomes. Honestly, she doesn't have time to have feelings about anything, but not having feelings about their primary case seems to be an unrealistic expectation for herself right now.) 


ETA to the ship: 9 minutes. Their goal for Kalorm in the meantime is mostly just to keep maintaining basic oxygenation and circulation support, until they're in position to set up the internal cardiac pump and various other support machines.

(The recommendation is to go ahead and place an extracorporeal membrane oxygenation circuit from the outset. Merrin is certed for it, and while they don't actually badly need it at this point - the lung damage is still early-stage and probably won't interfere with oxygenating him to whatever parameters are selected by the time they're ready to execute on them - having to urgently place it in a moving medicopter if the patient starts unexpectedly deteriorating on them is not something anyone wants to risk.) 

Other than that, the main task for the medical team is data collection, from every sensor they can safely get into place while in the air.

Also, specific request coming in for Merrin to report her gestalt sense of how doomy she feels about the patient?

(They're also requesting the same info from the rest of the team, given separately of course so they don't just anchor on each other, but Merrin is the one with literally more than ten thousand hours logged of, not just medical sims period, but emergency conditions sims. There are Exception Handling medtechs who've been doing it for thirty years and still only have half that much sim time. While the performance of those experienced medtechs, their ability to explicitly analyze all the sensor data and react quickly and correctly to problems, is still better than Merrin's - because Merrin is using sim-endurance to compensate for learning things way more slowly, needing way more repetitions, than would usually be required to work in Exception Handling at all - it's also already been noted that Merrin is getting bizarrely good at having illegible intuitions that often turn out to be correct and useful.) 


(Merrin...has not actually been paying the kind of full attention to her sense-observations that she needs to have a useful gut reaction, oops, she's definitely both been distracted by all the aaaaaaaaaaah, and also sort of metaphorically only looking at the situation sideways out of the corner of her eye.) 

She'll think about it and get back to them on that in 30-60 seconds? 


(Honestly, a lot of the gestalt her colleagues are noticing is that this patient is young, previously-healthy, clearly extremely physically fit, and has super lucked out on the facial symmetry genetic lottery - he is very attractive and very much not currently faceblanded - which could be from all that time in the water, but you'd expect some traces to still be noticeable, and maybe someone who lives on a boat in the ocean just doesn't bother? Anyway. It's distracting. Fortunately, the consensus is that Merrin is unusually non-distracted by that sort of thing, and may or may not have even noticed.) 


He's tall, slim but reasonably well-muscled, with various visible tan lines that must be the result of spending nearly all of his time in a boat under the open sky. His hair is an unusual, very light-colored shade - it's unclear whether it's his natural hair color or dyed to be like that, but if it is dyed, it's done very well and looks plausibly natural. 

His hands are callused, and there are signs that he uses his body hard - old scars including some that must have been deep lacerations, more recent scabs of half-healed minor cuts and abrasions, and plenty of bruises that can't just be from the storm incident today, they look varying numbers of days old. On their initial whole-body CT scan for unseen injuries, there are multiple signs of once-broken bones, healed reasonably well but, at least in one case, crooked enough that he must have set the broken arm himself with a splint or cast, rather than the more common basic surgical intervention with pins. Maybe he's habitually clumsy or careless, or maybe operating a small boat in the deep ocean just entails that degree of physical risk.

(Merrin herself is one of the only people she knows who's kind of constantly going around her life with that many random bruises, and it's not that– okay, fine, it is also that she is not the most physically coordinated person she knows, has actively kind of bad fine-motor skills, and is definitely less careful than others. But it's mostly that her trainers keep throwing her sims that involve things like climbing trees. Or mountains. Or buildings. She's never gotten seriously hurt, Exception Handling obviously has very good safety protocols and she's conscientious about learning and following them, but sometimes you can just get to a place literally twice as fast if you're willing to risk bruises or scratching up your legs crawling under thorny bushes.) 

None of that is actually a problem, of course. In terms of recent injuries, he has a whole new layer of minor lacerations and still-forming bruises, plus a newly broken arm and a couple of cracked ribs, presumably from being tossed into the wreckage of the boat's hull repeatedly by the waves. (The other conscious patients have a similar range of non-life-threatening traumatic injuries.) He seems to have avoided hitting his head, at least not hard enough to cause anything more than some scalp bruising, and he doesn't have any ongoing internal or external bleeding. 

None of that is flagging Merrin's doom sense; if it were just that, he would be fine. 


Observations that do flag to her as doomy:

He has, unsurprisingly, been completely unresponsive since Merrin first scooped him from twenty meters under the ocean surface, with the limp boneless zero-muscle-tone floppiness of someone under deep anesthesia - or, in this case, just as deeply unconscious for other reasons, like the fact that they only started restoring any breathing or circulation like five minutes ago.

All basic spinal reflexes are still absent. His pupils are fixed and dilated. 

He is...not quite dead-person-colored, and there's already been a noticeable if slight change improvement, especially the mucous membranes of his mouth, and when she pulls back his eyelids to check his pupils. There's still the yellowish-grey tint you get in someone who hasn't had any circulation or oxygenation for the last ten minutes, which Merrin has mostly only seen in sims and in a few emergency-cryo cases, and she does NOT LIKE it, it is a VERY PANIC-INDUCING color.

With the external vest, they're still only reaching a blood pressure of 59/29 and can't get an O2 sat reading at all. It's probably adequate circulation at this temperature, and applying more force to already-cracked ribs seems non-ideal. (The ventilator is set for 50% O2 based on Merrin's opaque reflexive intuition, which was confirmed-as-vaguely-reasonable by the treatment planning markets like thirty seconds later, and, pending getting the internal carotid artery O2 sat clip placed for ongoing sensor measurements, they're waiting for a repeated arterial blood gas measurement.) The fact that the patient already looks notably less dead-colored is reassuring to Merrin on that front. 

He still has the waxy, ashen pallor of someone in deep shock, and his extremities are mottled bluish-grey - to Merrin that says cold, shock, hypoxia, or side effect of dumping blood-pressure-increasing drugs into him - all of which are expected, and not a new negative update, but still not things she likes seeing. When she pinches his nail and watches the nailbed blanch and then slowly return to its previous color as the capillaries refill, it takes forever – well, like ten seconds. Verdict: still nothing she didn't already know, but confirmation that the patient is, physically, in precarious condition right now. 

The ventilator is pushing air into his lungs against a little more resistance than usual, despite the fact that it should usually be less for someone this deeply unconscious, with no muscle tension to resist and with their airway-protective cough reflex offline. She can guess why even without properly listening to his lung sounds; there's a certain rattle-y vibration you get in the ventilator circuit from pushing air against accumulated fluid. 


Overall they should try to be gentle to his poor lungs, but ughhhhh wrongbad sound, and his actual lung sounds are almost completely absent except in the upper lobes, and sound like someone walking on bubble wrap. 

She goes in with the suction tubing, which also has some simple controls and a camera sensor at the end, so she can peek at his unsurprisingly inflamed bronchial lining. It looks pretty irritated and swollen! More extensive changes than she would have expected over fifteen minutes while unconscious with an absent cough reflex - her best guess is that, while getting tossed around in the storm, he was aspirating smaller quantities of seawater on and off over the last hour. Nothing really dangerous in itself - she's been there, not all of her sims in water involve having a sealed helmet and oxygen supply, and in a conscious person with airway-protective reflexes, the water won't get as far as the lower airways and alvaolae - but enough that he spent a lot of that time coughing to clear his airway. 

Aaaaaand then there's a bunch of fluid in there. Probably significantly more than what he aspirated in the first place, because seawater is hyperosmotic relative to body fluids, and will be drawing more plasma and extracellular body fluids into the airspaces. 

She suctions some of it out to have a look at it. 


Yup it's mostly just water. Pink and kind of foamy. 


GROSSWRONGBAD Merrin will try to get some of it out of there, but she doesn't try too hard. They're still getting some oxygen to the patient's blood, they're going to be replacing with ECMO soon anyway, and her recollection is that the lung repair and regulation systems are actually pretty robust to salt-water aspiration; if they can get him otherwise stabilized, his tissues will notice the problem, reabsorb the excess fluid, and eventually regulate mostly back to normal and heal the damage. Fresh water actually damages the membrane barrier of the epithelial lining a lot more. 

She does drop some of the sample into the instant test kit for protein and electrolyte concentrations, because why not. 


That'll take a couple of minutes, but the patient's blood serum electrolytes and other basic results on the lab panel are back, along with a repeat arterial blood gas from 60 seconds ago (3-4 minutes after they started ventilating him). 

The latter least moving in the correct direction? Oxygenation is still well below normal range, and the test result at his body temperature may be an unreliable estimate of true oxygen availability to tissues, because lower temperature changes the solubility of O2 in the blood, and shifts the oxygen-hemoglobin dissociation curve to the left, resulting in a lower partial pressure of O2 relative to the actual O2 saturation.

His CO2 levels are through the roof and taking longer to stabilize - the disrupted gas diffusion in lungs after a near-drowning incident often hits CO2 removal more than oxygenation per se, and his initial levels were really impressively high. Combined with a blood lactate of 18 mmol/liter (normal is below 2, so this is NINE TIMES too high), this has his blood pH below 7.

This is almost, in a way, a good thing. It hints that even exhausted, already severely hypothermic, and with a broken bone, he still actively struggled to free himself from the debris, for long enough that the muscle activity depleted all the oxygen still in his blood and dumped large quantities of lactic acid.  

The Diagnostic markets, running mathematical models based on known physiological factors and, as an input for comparison, the measured core temperatures of the still-conscious patients, are guessing that before the boat finally broke apart enough for his piece to come loose and sink, he was (just barely) maintaining a core temp around 27-28 C. 

Which implies a rather rapid drop, but they think it's possible; the body can compensate for cold water for a rather long time if its compensation mechanisms are working, but actually having to exert serious muscular effort is a risk factor rather than beneficial once a casualty is cold enough, as the muscles demand bloodflow and send their (cold) blood back to the heart. And then the vasoconstriction capillary control would have failed as his tissues ran out of fuel, and metabolic heat production ceased until - hopefully - now. 

27 C to 24 C is still a very large and rapid drop to happen over less than fifteen minutes - plausible, by the models, but a 1 C drop is equally plausible, and 1.8 C is the median predicted drop absent other information. But a major piece of evidence here is that the most coherent of his (colleagues? acquaintances? nobody is exactly sure what the relationship is between the group of young men who took a boat out during a storm) is confidently claiming that up until twenty minutes ago, Kalorm was still talking to them. Reassuring them, it sounds like, more than making plans; at that point, the group knew their only remaining chance was to wait for help, and that help was coming. 

(This is also the point at which they learned that the initial problem, when the boat capsized, was actually an entire hour before the group of them called for help. At which point, of course, Merrin and team were still lurking in their helicopter in the general vicinity of the storm, but they didn't know which of the many boats in this area for various reasons would end up having a problem, and the storm meant that no one could follow satellite imagery.) 


That's a bizarre choice on their part and Merrin might, at another time, be really annoyed about it, and might at a different time, thinking about it in more depth and from another angle, be really incredibly sad at...whatever history lies behind this boat, this day, a lonely ocean, a storm, a call for help not made until a time that might turn out to be too late. 

Instead of feeling any of that, it sort of slides off. Right now Merrin is having emotions about the color of the patient's skin and the numbers on the screens and an updating prediction market that just dropped from 92% to 91%. Anything that is not the next sixteen hours is out of scope for having feelings about. 

(The next 16 hours if everything goes right. But the most likely way for things to go wrong is that some catastrophe during the flight will mean that they don't even make it to Default, and they lose, and it won't be a 16h shift after all because there won't be anything left to do. And if that's the world they land on, then– know what, Merrin is not going to preemptively think about that, that is a baaaaaaad plan, she is instead going to do the thing that lets her function right now.) 


Other labwork is abnormal in basically the expected ways. Electrolytes are out of whack; in particular, the sodium and magnesium are sky-high, which is what predictably happens if you inhale and swallow large quantities of seawater. He's additionally quite badly dehydrated, as shown by elevated urea and creatinine, and his hematocrit - the ratio of the volume of red blood cells to the total volume of blood - is high as well, indicating loss of the fluid component, his blood more concentrated than it should be. 

There was still a lot of water in his stomach when they scooped him out; inserting a gastric tube to drain it before he gets even more completely unnecessary salt intake was one of the quickest and simplest interventions they've done so far. 


Urgent new treatment recommendation: they need to move on treating the dehydration now, ideally before they land. Here is the patient-customized volume and electrolyte concentration of IV fluids that their model spat out. 

(It's not very carefully calculated, since they took less than 90 seconds to make a decision on it.) 


Does she HAVE to Merrin is going to calmly and levelly flag her worry that this buys them speed at the cost of caution, and usually, with this many things simultaneously wrong and this many short and long-term tradeoffs to navigate, it's often preferable not to jump to focusing on ONE of the problems and solving it as fast as possible, since the solution is likely to have all sorts of effects on the other problems they're juggling, and significantly raise the risk of something unexpected spiraling out of control. 

(This takes way fewer words to say in Baseline.) 

She's assuming they have some reasoning to justify this. (She can guess at what their reasoning might include, and she predicts it's likely downstream of a different weighting on short-term stabilization versus long-term prognosis – because Merrin is predictably going to, in her own quick intuitive reasoning, emphasize the short-term effects that she's vividly personally observed across hundreds of simulated scenarios, with a mental penalty assigned to things that were stressful for her personally separate from whether they worsened the patient's eventual odds.) She also assumes their reasoning is legible and reflected in the treatment planning markets, but she would appreciate if someone can tell her the thirty-second version because she can't have her eyes on the screens and the patient at the same time. 

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