Wow he's doing such a good job!!!

Merrin pats Kalorm on the arm approvingly (and very gently) and murmurs something reassuring - it's a habit trained on patients who at least might be able to actually hear her, but she hasn't bothered trying to un-train the habit in situations where it's pointless-but-also-harmless. 

Shifts in the various odds of outcomes on the Diagnostic prediction markets, based on how he the patient tolerated the setup procedures:

Minor brain damage 85% –> 82%

Moderate brain damage 62% –> 52%

Severe brain damage 38% –> 34%

Major complication pre-hospital 45% –> 35%

Survival to hospital 95% –> 98%

Survival through rewarming protocol 93% –> 96%

And he looks...pretty good? His skin, while definitely still cool to the touch, feels less clammy, and the texture under her fingers has much less of the sunken-doughy consistency she associates with dehydration. The mottling characteristic of dubious local circulation is now just in his hands and feet, mostly cleared from the upper arm area. 

(He's still probably more hemo-concentrated than he should be, based on much much pre-diluant fluid Merrin is having to run before the filter on the hemodialysis circuit just to keep the filter pressure down to something reasonable. They're not using any systemic anticoagulants; the filter membrane has an impregnated anticoagulant coating, as well as just imitating real epithelial biomembranes as closely as possible, but hypothermia causes enough weird problems with blood clotting function, they really don't need more problems. Probably Merrin can make this circuit last through the travel and the rewarming period.) 

...His temperature is also about to exceed 24 C. 

Merrin toggles the temperature controls on the ECMO circuit and lowers the bed temperature from 21 C to 18 C.

As soon as her hands and eyes are next free, she flips through screens of sensor data, looks at estimates of oxygen consumption and CO2 production - 

[He's producing more metabolic heat than I would've expected] she subvocalizes into her microphone, toggling it so Vellis and Illtham will also hear but the rest of her team, busy handing over patients, won't be distracted. [Going to need active cooling for transport. ETA on takeoff?]

....Actually they want to delay takeoff for some stabilization protocol updates, which are taking into account the last twenty minutes of data on the patient, and should better optimize his odds of an acceptable neurological outcome. 

Well. Key decision-relevant question for Merrin, first: they had initially decided not to have her prioritize the liver replacement machine. The hemodialysis is more critical, and handling both at once - plus ECMO and cardiac support and the basic lung-protective ventilator settings and the vasodilator-constrictor for regulating carotid bloodflow, plus some random peripherals like the cooling on the bed - is considered near or at the limit of Merrin's abilities. They judged that the patient had enough residual metabolic function in his liver, in the 24 C range, to avoid causing any life-threatening disasters within the next 90 minutes; once they're in the transport plane, it'll be a lot safer to place the circuit, probably actually safer than it is on the swaying boat. 

But. Can she interoperate six machines, for four hours, if one of them is the liver module? 

.....Merrin takes thirty seconds to actually, properly, consider this. 

It's - definitely a doomy proposition, in the abstract? She would not feel comfortable doing it on a more fragile patient, not for that length of time and while in transit without access to much backup. But she has been working on various six-machine sims this year, and even in really mean sims, she can usually keep the patient alive and maintain the pace for 4-6 hours.

And, uh, presumably once they reach Default Hospital, she'll have all the backup she could possibly want, and will be handing over the most annoying part of the task to the Complicated Liver Replacement Module team. Merrin does not think she could hold that pace for sixteen hours, but it sounds like she shouldn't have to unless something goes really weirdly and unexpectedly wrong. 

Plus this patient is bizarrely tolerant of minor fumbles. (Merrin thinks, privately, that her last really serious secret market hypothermia-near-drowning case spent the entire time slowly deteriorating on her, whereas Kalorm still, actually, seems to be improving.)

That might change, of course, but she...is much more willing to gamble on her ability to handle the proposed protocol modification. 

Presumably they think this is better for some reason but she honestly has no idea why? Are they suddenly worried about maintaining near-perfect liver function being a major input to the patient's neurological outcomes? 

Actually, it's because they want to drop the goal temperature range on the protocol by about five degrees, to 17-19 C (ideally as tightly centered on 18 C as she can manage.) 

They want her to do what. 

The decision is not without controversy! Several hundred medical experts have been quietyelling at each other on a dozen different conference calls in the background, and it took them the entire past ten minutes to make a call. 

It will, in fact, hurt the patient's odds of surviving the flight to Default, even taking into account the updates made about his cardiovascular health and overall physical resilience. The last update had been 95% odds of surviving through the end of the rewarming period, and the market branch premised on using this protocol thinks that deliberately inducing more profound hypothermia will, unsurprisingly, increase the risk of complications en route (and rewarming-related physiological complications later on) substantially, and drop his near-term survival odds by 5 points, to 90%. 

But. 

9-in-10 odds is still pretty good? Also, some people have spent the last twenty minutes having a longer and more in-depth conversation with Khemeth, the patient's older brother who is also a psychological modeling expert and thus actually quite advantaged at predicting what the patient would have requested if he had bothered to fill out his advance directives more fully.

Kalorm is probably actually less bothered than population median by mild cognitive dysfunction - he has a diagnosed cognitive disability around visual-verbal processing, and Khemeth thinks he wasn't especially unhappy about this as an adult. Kalorm is also probably willing to deal with a lengthy recovery period and substantial discomfort, if it's temporary.

He would, however, predictably be really deeply miserable if his final recovered state is still "permanently too disabled to function independently." Khemeth is not certain that he would truicide over that, but it seems more likely than not. 

The really frustrating thing is that if, according to the market with the hypothetical premise where they can start the full neuroprotective protocol NOW, the patient has a less than 10% chance of severe brain damage, and only a 20% chance of moderate "can walk and talk, but likely to need permanent live-in support" level damage. That leaves an 80% chance of nothing worse than minor cognitive deficits, ones that at least won't be a dealbreaker for piloting a boat with his friends. Four in five odds. Worth fighting very hard for. 

- Of course, that premise is an impossible hypothetical. But huge amounts of thought have, over the last twenty minutes, how to bring their actual situation as close to that hypothetical as possible - to wrangle it so they can start the rewarming protocol with the patient in approximately his current state, with minimal new accumulated damage, minimal progression in the cell-death cascade. They cannot actually put everything on pause, but they can throw every single intervention available at slowing the deterioration. 

Khemeth and other family members - apparently he has six siblings, and his younger sister Ranthir is a highly successful market trading expert who runs her own trading company - have some additional non-public information on Kalorm's health, which can be summarized by "he keeps doing things you would totally expect to kill someone, and nonetheless made it to age 25 without dying yet." And while 'weirdly hard to kill' is not actually a medical diagnosis, it is some kind of information, and makes them considerably more willing to gamble and try actually dangerous interventions to minimize brain damage.

...The visible EEG activity is actually a good sign, and is a major factor in why the predicted odds of the worst-case scenario (that isn't literally a permanent coma), of an irreversible minimally-conscious state, with some subjective awareness preserved but approximately no ability to make sense of his surroundings, communicate his needs at all, or carry out any goal-oriented behavior, is now down to less than 5%. This is good because it's the one scenario where - if it looked like enough of a sure thing that no further recovery was going to happen - Khemeth is very confident that Kalorm would prefer True Death over that "life".

(And Khemeth and other family members would have to make that decision on Kalorm’s behalf, since he would be far past the point at which he could make decisions about anything at all.)

That being said, ongoing metabolic activity is exactly what they don't want. They were already going to put him under deep anesthesia as soon as Merrin had everything set up and his vitals stably within parameters (they were holding off because even very carefully designed and studied anesthetics don't just have effects on the central nervous system, and she previously had a lot less wiggle room if it ended up tanking his blood pressure.) This will slow the cellular metabolism by shutting down most actual synaptic electrical activity, but it won't actually halt the metabolic cascade already in progress. 

However, each 1 C decrease in body temperature will cut the cerebral metabolism by another 5%, down to 18-20 C, at which point the relationship starts to break down because the remaining cellular activity is so minimal; nearly all remaining energy usage is "structural", the basic maintenance of cell membranes and ion gradients, rather than active protein synthesis necessary for the metabolic pathways in the inflammatory cascade.

If the patient can in fact tolerate another 5 C drop (which seems plausible, it's actually a rather safe procedure if done in a controlled environment in preparation for major surgery), that will buy them a 20-25% drop in metabolic rate, and it won't entirely suspend the cell-damage cascade but it should, at least, slow it very substantially. They'll know more about how well it's working once they have the patient cooled. 

IF Merrin thinks she can do this. (The prediction markets on Merrin's performance think she can do it, but it actually separately matters if Merrin herself has enough confidence in her abilities, and she hasn't, in fact, done this exact thing or even anything that closely analogous in sims.) 

Ummmmmmmmmmm that reasoning all makes sense and Merrin...needs to think. Interoperating the six machines is going to be substantially harder if they push the patient's body even further outside the usual design specs, and however healthy he is, she's expecting him to be a lot more fragile at that temperature. 

- though it will also buy her more time to correct mistakes, so there is that. 

(The performance incentive that the patient’s family is offering Merrin literally just for agreeing to attempt it at all, not even conditional on final outcome - not even conditional on delivering a living patient to Default - is absolutely superheated wild. It's more money than Personnel has made in his entire career to date. It's honestly kind of frustrating that he can't tell her, but it soooooooooooooooooo won't help.) 

Personnel does want to reassure Merrin that they're aware this is an absurdly difficult ask. No one is going to think it reflects badly on her or her skills if she doesn't feel comfortable trying it. In fact, since Merrin is the opper on the scene and the one with trained intuitions and also the most direct context on the patient, Merrin's comfort level here is a key input on whether they should be trying this. 

Merrin is THINKING. 

The rest of the team is now making it back to the medicopter! Patients were successfully transferred to the ship; they're now trying a few last-ditch heroic measures to save the head-injury patient, which the markets think have only a 10% chance of working, but which aren't expected to hurt his odds of an acceptable cryopreservation outcome as long as they don't take too long about it.

The medtechs who had been focused on other patients until now are getting reoriented to this patient, scanning the treatment plan, the sensor log, and all the active medical markets. 

Who just dropped like another 500,000 labor-hours of liquidity on the markets????? This is now, like, literally the most generously subsidized market they've ever seen for an individual patient's case! 

(There have also been a few more contributions to the payment pot on offer for saving the patient's life. It's now above ten million labor-hours, which is maybe not literally unheard of but it's definitely the biggest number they've seen on a patient they were personally treating.) 

Personnel is a step ahead of them. 

Why is a worldwide celebrity dropping a million labor-hours on questionable-choices-boat-guy's outcomes??? Personnel's daughter goes to Mallor's concerts! This is super surreal! 

Also some third person (a Finnar?) is now directing funding Merrin's ridiculous performance incentive, presumably oblivious to the fact that she is in no way going to see it and be convinced to try the suggested protocol. 

...it does not actually take more than two screen navigations to determine that these are other family members! Finnar is the father, is an inventor-entrepreneur, and he and his third-youngest child, a son named Kurthin who is barely eighteen, have had some obscure but very financially lucrative successes. Mallor is an older sister.

Ranthir, the trading expert, is a younger sister - very young, twenty-two, to have a successful startup - and she's not directly contributing her personal cash to funding the liquidity pool, but is apparently offering really large performance incentives to her employees for them to join the trading even though, one, they're not mainly a medical trading company and they usually focus on shipping logistics (though one might point out that this particular medical emergency involves more complicated shipping logistics than usual), and two, it's currently the middle of the night for most of them. 

WHERE DID THIS FAMILY COME FROM AND WHY ARE THEY LIKE THIS??? It feels like the plot of a convoluted mystery novel that probably involves a supervillain. 

The performance incentives being offered to the rest of the team aren't as big as Merrin's - she is, after all, the lead opper and the single most critical person for pulling this plan off - but they're pretty big! Especially considering that they're not even conditional on outcomes! 

(There are, in fact, financial activities in motion to add higher compensation for a good outcome, but even within dath ilan's very efficient financial system, that much money doesn't change hands instantly.) 

Merrin is not looking at the market screens. All the screen real estate she can manage to parse is taken up by her current array of sensor data - because she is still, in fact, managing five machines, though the patient is not giving her an especially hard time right now - and then the proposed stabilization protocol, which is intimidatingly complicated and has super narrow parameters on some of the numbers. 

She's mostly not even looking at those screens right this second, though; she's got the alarms set to max sensitivity and is letting the audio tones guide her, while she focuses all of her available attention on the patient. 

...What does her gut think, when she queries herself on whether this is a plan that's going to work? 

The patient lies very still, with a dozen invasive tubes entering and leaving his body, surrounded by machines, blinking lights and screens of scrolling numbers and graphs, audio tones singing a quiet song in Merrin's earpiece. His chest rises and falls, slowly and very shallowly - she set the tidal volume to like 100 ml - but with mechanical regularity. 

He's sedated and paralyzed, probably redundantly - he's too cold to shiver, too deeply unconscious to fight them, his basic brainstem reflexes had remained totally absent even before they sedated him - but they really don't want him moving at all or burning any unnecessary oxygen. He's still covered in bruises and scratches, mostly ignored; they've steri-stripped and covered a couple of the deeper lacerations, but haven't even bothered to stitch the wounds. The recent crop of bruises are darkening, with circulation now restored including to broken capillaries. 

To Merrin's eyes, used to noting a thousand tiny observations and instantly parsing it in terms of the underlying biological processes, he still looks visibly dehydrated and hypovolemic, and generally shocky - he's pale, still with a greyish tint, the skin sunken around his eyes and mouth - but the mucous membranes of his mouth are a reasonable, non-hypoxemic-looking pink.

He looks like someone who does not necessarily get enough calories all of the time, but he doesn't look starving; his skin lies over compact, wiry muscles. His extremities are mottled, but less blue now; his hands and feet are still faintly wrinkled from hours spent in the water. When she reaches to lift his eyelid - his pupils are constricted, an anesthesia side effect, and react almost-imperceptibly to a bright enough light - his flesh is cool and dry to her touch. 

With this much sedation, his EEG is an almost-perfectly-flat isoelectric line, only occasional bursts of electrical activity making it past the suppression of deep anesthesia. The ECG reading is a confusing blend of coarse v-fib and the sawtooth-y spike you get from the mechanical pump. Various blood pressure readings form tidy waveforms, adequate within parameters even with a pump rate set to 65 bpm and the force on a rather gentle setting. The sensors placed against the mucus membranes of his gut - at both ends - are picking up limited but present bloodflow; the continuous audio sensor on his belly is very occasionally detecting a faint rumble of gut peristalsis, which is pretty impressive given everything. When she pinches a fingernail, the color fades back in after only three or four seconds. 

There's a tiny trickle of dark-colored urine in his drainage bag; the filtrate draining from the hemodialysis circuit is significantly more the color that pee is supposed to be. 

He certainly doesn't look healthy. But he doesn't look like he's dying, either. 

Less than thirty minutes ago, he was with his terrified friends, clinging to a capsized boat in a storm hundreds of miles from the nearest port - but staying calm, reassuring them that help was on the way, promising that everything was going to be okay. 

Merrin wants to help him keep that promise. 

(Also, weirdly, she really wants to meet him. Like, as a person, not a mostly inanimate body stretched out on a bed and pierced by machines. There's probably a story behind his boat adventure, and she wants to get to hear it.) 

And, you know what? Merrin believes in Kalorm! She and her team may be doing a lot of work here, but his body still has to tolerate it - and, right now, she actually feels good about that. She has faith in Kalorm's body. They are going to be very mean to Kalorm's body for the next little while, but she thinks he can do it! 

"I'm in favor of this plan," she says, out loud - the rest of her team is there, watching her, listening. "Let's move." 

Thousands of miles away, in Default - less than five miles from Default Hospital, in fact, though there's no point in traveling there this far in advance of the planned arrival - a man sits in front of a dozen LCD screens.

Khemeth has like five realtime text conversation windows open - one of them is an enormous groupchat with his entire family that is currently generating about 1000 words of content per minute. Khemeth can read very fast even for a dath ilani, but even he can't keep up with his father and his little brother going full speed ahead on an intellectual problem.

There is now also a private backchannel conversation with Nerdel, his mother, who is trying to make sure he's okay.

Khemeth is not super okay right now, actually. In fact, he's intensely miserable. A little bit about the situation itself - he's known since they were kids that something like this was inevitably going to happen, eventually, but 'eventually' could have been ten years from now, and anyway he absolutely hates being right - but, also, he just spent twenty minutes running a high-fidelity mental model of his little brother to try to get the medical team more information on Kalorm's preferences, since his actual little brother is currently not available for comment, and the last time Khemeth tried to have a conversation with him about it, a decade ago, Kalorm did not answer the question at all and instead told him to stuff his stupid advance directives down a radioactive hole.

Anyway, it turns out that convincing his brain to be Kalorm, and then modeling Kalorm's feelings about a wide range of potential outcomes all of which are HORRIFYING AND UPSETTING, is....in fact kind of a traumatic experience. However, he's really very busy, and mostly dealing with his feelings by LARPing being a person who instead has different feelings that are less distracting. Everyone ELSE is having ENOUGH feelings, and Khemeth is expecting to have to do a lot of management and steering especially once the medical team arrives in Default and his family has the opportunity to make themselves obnoxious to Exception Handling medical personnel. Finnar is difficult to work with at the best of times.

If his mother is worried about Khemeth and trying to intervene about it, then that's yet another social variable to track, it makes Khemeth's feelings - which are, at this point, pretty causally isolated from his actions, he's very skilled at LARPing a non-upset person - an active variable in the complicated emotional system he's trying to juggle, and then you get recursion and feedback loops and it's just so much more cognitive overhead. 

Khemeth is not someone who habitually lies (even though he would be very, very good at it.) This is dath ilan. Khemeth has sworn secrecy oaths, and you generally don't get cleared to swear secrecy oaths if you are someone who goes around defecting against the equilibrium where words can be treated as meaning something. Whether he had deliberately lied to people since age fourteen was in fact one of the questions he was asked. However, Civilization considers it to be a legitimately different situation if, as Khemeth in fact did at age nine and again at age fourteen, someone explicitly warns about future cases where they would lie. The complicated emotional feedback loops in the family aren't a new thing, and small Khemeth was already getting very tired of navigating the recursive element, so he told his parents to stop asking him about his emotional state, and that if they kept asking him, he would not consider it defecting to lie.

Then, predictably, his parents sometimes asked anyway. He's been able to successfully lie to his father about his emotional state since the first time he tried this at all, Finnar is not exactly observant in that way. His mother is more perceptive, but still knows better than to dig, and Khemeth does not strictly have to say how he knew what Kalorm would want in this situation; for all Nerdel knows, he in fact managed to have a productive conversation about it once. So Khemeth is, technically, lying, and assuring Nerdel that while of course all of them are very stressed, and there's a lot to do, he's managing okay and she should focus on supporting Finnar (whose feelings are not going to be causally isolated from his actions, and who might manage to make something explode.) 

Khemeth is, at the same time, on a conference call with half a dozen of the top medical venture capitalists in the world who are considered trustworthy by Exception Handling and are willing to take a grade-three secrecy oath. Several of them are quietyelling at each other. Khemeth is approximately only tracking the social dynamic, not the content; he is not himself a medical expert or a market trading expert and he has literally no idea what they're talking about right now. Finnar is listening in (with his sound and camera off, probably because he's non-quietly yelling at someone else in the room). Khemeth is mostly here to glean whatever he can from the social dynamics. 

He is also watching the situation currently taking place in a helicopter bolted to the deck of a storm-tossed cargo ship, about as closely as one can watch it from another continent. He has the basic medical sensor-data displaying directly to one of the monitors, but isn't actually well versed enough in medicine to make useful sense of the less basic data. There's a lot of it. 

Mostly, his eyes are on Merrin. 

Khemeth is a world-class expert in 'psychological modeling', but first and foremost he's himself an extreme psychological outlier, intensely neurodivergent for dath ilan.

He's very intelligent, if not quite the +3 SD thinkoomph of his father - but on psychometric tests, his subscores are very skewed, coming apart far more than usual. He's not, actually, particularly outstanding at math. His verbal fluency is high, but not enough to explain his performance in one very specific domain. 

Khemeth does not have Keeper training, and the way he models people is completely different from how Keepers can step outside of normal social reasoning and form a highly accurate predictive model of a person by analyzing their mind as machinery, as a complex cognitive system. 

Khemeth just does 'normal' intuitive social reasoning. Constant, rapid, incredibly sophisticated social reasoning, with a degree of perceptiveness and accurate prediction that is probably +5 SD above the dath ilani median (to the extent that there even exists a scale that can measure this.) 

When he watches a young woman in a Sparashki wetsuit - Merrin has flipped back the faceplate on the helmet and stripped off the gloves, but not actually taken a break to remove it - he is understanding Merrin by putting himself in her shoes, by building a smaller Merrin emulation in his own mind and holding it up alongside what he observes her saying and doing, what microexpressions he can read in her face, what subtle shifts in body language speak to him more clearly than words. 

Merrin is leaning in over her patient's bed, knees braced against the handhold-foothold struts arranged around the gurney for holding oneself steady during acceleration maneuvers, still wearing the harness meant to prevent her from getting flung across the room in case of really extreme unexpected acceleration. She's gritting her teeth a little in concentration, eyes narrowed and intent and darting between the sensor-data screens and the liver machine console and the written (simplified for quick reading) protocol. 

It's pretty obvious when an alarm is going off, some parameter exceeding the stupidly sensitive limits she sets for herself; her whole body goes still for a fraction of a second, her eyes dart to the patient and the spot where the relevant machine and the patient meet, and then she - at this point, because her hands are fully occupied - snaps a terse parameter-change instruction to one of her colleagues. 

With the veno-venous shunt in place and firmly secured with adhesive, she swings the primed tubing over by bumping it with her shoulder and catching it in a practiced motion, mutters a single syllable that prompts Vellis to re-sterilize the venous line site with a burst of UV light from the handheld UV flashlight, slips off the cap covering the sterile end of the inflow tubing -

(She's connecting it first, starting the circuit with a secondary reservoir hooked up to it and transfusion-ready blood, which is an inconvenient extra preparation step and will mean wasting whatever blood is left behind in said reservoir, but it should mean there won't be any drop in venous return to disrupt the patient's blood pressure. It would almost certainly be recoverable, quickly even, if she did get another drop, but troubleshooting that will mean taking longer to get her now-six-part system into an equilibrium.) 

- twist and pop into place, it's an easy-connect-easy-remove setup that, since they don't need to be safe for MRI, includes magnets, and will let Merrin really quickly abort and disconnect if, for some reason, she has to do that - she's already starting the inflow - connect the outflow and unclamp the line and slowly, slowly ramp up the outflow controls, keeping the inflow constant by dialing down the flow from the transfusion bag secondary line... 

This is sufficient to avoid any significant blood pressure drop!

Instead, something weird starts going on with the patient's blood CO2 and pH.