But this is apparently the 1 in 20 scenario (...1 in 32, actually, per the initial odds she actually saw) where enough things went wrong in a row and enough safety precautions did fail that Merrin is INCREDIBLY glad she was within range! 

Because! Now Merrin is in fact frantically swimming through a storm-tossed ocean! at local time past midnight! trying to follow the stupid location-transponder signal through her earbuds and hone in on the one (1) final person from the capsized boat that she hasn't yet tracked down and pulled to safety! 

Merrin has at this point been working for Exception Handling for about 2.5 years. She is vastly better at, well, almost everything, than she was back when they recruited her! Superheated toilet paper, she was so bad at things then.

Fortunately, Exception Handling also has access to the best training sims - seriously, they're incredible - and they're investing in her, which means that she gets a lot of support for particular areas she struggles with? ...Like math. It's always math. 

Conveniently, swimming through a stormy ocean looking for a drowning person does not require ANY math! It mostly just requires being really good at swimming, and Merrin has had that one covered since she was ten! Though of course the powered wetsuit is helping a lot, as is all the navigation assistance.

(She's not in any particular personal danger. There are no obstacles nearby to whack her in the head, she has a sealed helmet with an independent oxygen supply, and she's thoroughly protected from the cold - though it's not even that cold, the local ocean temperature is 11 C and Merrin has, in fact, totally trained swimming without a wetsuit in water that cold. Maybe mostly just to prove she could.) 

....Locator-signal is clarifying and it's that way! Less than 150m! Clearly the casualty is not, like they're supposed to be, still tethered to the boat like everyone else was, but she can stop worrying about the (extremely unlikely) contingency where they somehow got separated from their flotation device, or the transponder failed entirely, and she has to resort to finding them visually or using the sonar system in her helmet. 

(There is clearly some other problem, because the signal is coming from an angle that is partly down, which means the flotation device is not, well, floating.)

At least four separate contingencies already didn't work as planned in order for Merrin to end up here at all, but at least she is not now in the 1-in-10,000,000 failure mode world. That really should only happen in sims. (It's happened before in the history of Civilization, of course, and it's planned for.)

Some unusually high-risk decisions were made leading up to anything going wrong at all. Very unusually high risk. Merrin has questions about this! Taking a personal boat, a small personal boat (one that unlike most cargo, transport, or research vessels in regulated shipping-lane areas, hadn't pre-registered a route or even been following a very predictable route) out in a STORM like THIS is superheated insane by the standards of normal dath ilanis. And their personal equipment is apparently on the older side; the latest-generation flotation device transmitters are a lot more robust to electrical-storm interference and Merrin wouldn't have needed to spend fifteen seconds getting a clear enough signal to follow. 

(People do sometimes make risky choices, of course, because people vary in what risks they personally consider acceptable, and Civilization is not generally in the business of telling people - well, adults, at least - that it's illegal to make fully-informed decisions that only put themselves at risk. Civilization doesn't want people wandering around in the wilderness completely unwatched, where they might bioengineer a viral pandemic or truekill people, but the options for causing harm while out in the deep ocean forty miles from the nearest human being are limited, and a location transponder is enough surveillance to go on.)

On her way here, she was expecting to find five people tethered to their capsized boat, hypothermic and possibly with traumatic injuries, but probably still conscious, and if not at least still at the surface thanks to their safety equipment; it takes longer than that to die of exposure, even in water this cold. And the initial report claimed 70% odds of getting their boat right side up and bailed out before help got there, if nothing else went wrong. 

Clearly something else, more likely several somethings, went very very wrong, because what she actually found on arrival was the smashed wreckage of a boat, one unconscious person still safely at the surface and with their flotation device keeping their face out of the water, three people technically conscious, staying calm and doing all the right things, but already hypothermic enough to be pretty out of it, and the extremely unpleasant revelation of one additional person MISSING. This is the point - actually, seven minutes earlier, when one of the other casualties managed to get out a VERY VERY PANICKED radio update - when the priority level and resource investment rose sharply. There is a lot of backup on its way, if Merrin can't figure this out on her own, but Merrin and her team, having been on route already, were closest - it's exactly the sort of situation she's specced for - and backup is not here yet.

The other four casualties are now safely in the medicopter with the other medtechs. All of whom have the basic water-rescue training and wetsuits and could safely join Merrin in the water - you don't send people out for a water rescue without that - and will come after her, if she needs help, but they don't have the fancy high-tech powered wetsuit and wouldn't be able to keep up now that she apparently has to go on a CHASE for one of the casualties. 

Fortunately, in her specialized wetsuit, Merrin can move so fast. 

...Going underwater, along with this degree of nearby electrical storm, might result in losing comms signal to the medicopter that should still be - somewhere nearby, Merrin super does not have visual contact right now. It probably won't, their systems on both sides are very over-engineered, and also they basically predict exactly what Merrin is going to do next, but she'll still warn them. 

Signal located (they'll know that, of course, they have a receiver as well) but close, attempted retrieval sub-100 seconds - pickup same location, she subvocalizes into her microphone. 

Backup is on its way. (Unlike in a lot of the sims Merrin does, where backup might not be on its way - though Exception Handling makes sure to arrange enough actually-realistic-levels-of-backup sims that she has the right habits for those.) They're not actually at risk of just losing someone in the ocean, even in a situation this far outside the normal, that would be a True Death - there's a diverted submarine on its way, with a far more powerful sensor suite to pick up the locator transmission as well as active scanning capabilities. But there's a lot of ocean, and last update the submarine was twenty minutes away. It's probably hurrying now that Merrin's team has flagged the change in circumstances, but it could also be delayed by the storm - and there's a huge difference between seven minutes and twenty-seven minutes. The latter is almost certainly immediate cryo.

She swims. 

Down is somehow EVEN DARKER than the surface, where it was already really dark! 

To be clear, this is not bothering Merrin because she isn't comfortable swimming in the dark. She swims in the dark for fun. It's bothering her because, from her current distance, the locator-signal is only precise to 1-2m when dealing with the interference of '10m underwater' on top of 'electrical storm', and she doesn't really want to keep swimming a repetitive search-pattern until she bumps into the person by accident. 

(She has a timer running. 90 seconds left on it. If she doesn't surface by then, it doesn't mean she personally is in trouble - that's unlikely - but it will be taken and understood as a signal that they should really strongly prioritize getting someone else in with her. No one else on her medicopter is fitted for a powered wetsuit - they're customized to the person - or trained on it, but there's probably someone on the way already, another storm-safe helicopter was dispatched to borrow on of the medtechs from a ship ten miles away who at least has the more basic water-rescue training, so that's now...five minutes out, probably?)  

She has a really bright headlamp mounted on the protective helmet that goes with her wetsuit. Usually Merrin doesn't like it - in most water scenarios, the water is cloudy or silty and extra light makes it glow even more confusingly - but right now, in the deep ocean and when she's looking for 'body, Y/N' rather than trying to do something fiddly with underwater equipment, it's straightforwardly useful. 

(She makes sure to aim it downward. If she pointed it upward, in theory she would have to flicker it in a specific pattern to signal that she is personally in danger and needs help, but Merrin does not super trust storm-tossed-ocean diffraction patterns, and if she accidentally summons help when she doesn't need it, it'll be a waste of resources. And also mortifying.) 

She aims the headlamp down, and flicks it on. 

Oh good there he is! The water is choppy enough that Merrin can't make out any detail, but there's definitely a roughly person-sized dark spot. 

Also that sure is a current! Fortunately Merrin is faster than currents! ZOOOOOOOOOOOOOM this is great Merrin loves her job she would be having so much fun if this were a sim.

(She is on some level having fun anyway and only feels slightly bad about it.) 

...When she gets closer, it's immediately obvious what went wrong. He's still tethered to part of the boat - a large chunk of the deck, it looks like, jostled loose by hours of crashing force - and the metal, torn loose from the foam filling that keeps even a capsized and water-filled hull at the surface, is sinking. Not fast, the personal flotation devices have a lot of buoyancy, but sinking. 

Merrin's wetsuit has more than enough propulsive power to compensate for the extra weight, but she makes a rapid judgement call that she doesn't actually have a good reason to want to haul along some boat wreckage. The utility would be mostly just 'the boat manufacturer can examine how it came loose and adjust their manufacturing processes to prevent that' but they can just try to replicate the accident instead. Merrin is not going to try to get a piece of metal almost as big as she is up to the medicopter just for manufacturing quality-control data. 

She stabilizes herself relative to the patient - twenty meters down, the waves are knocking her around much less - and flips out her knife from its wrist sheath, and, with some significant effort (they do not make tethers that can snap by accident even under a lot of force) saws through the cord. 

[Got him] she subvocalizes to her microphone. [Ascending now]

The super-bright directional light setting is no longer the one she wants; Merrin toggles it to the omnidirectional flashing green pattern that means 'no unanticipated problems, objective successful, please come pick me up now'. She gets a firm grip on the unconscious man (trying not to jostle him any more than necessary in case of injuries but she does have to move fast, and if he has a really serious spinal injury it's almost certainly going to be cryo next anyway), covers his mouth and nose with one hand so she won't get any more water into his lungs than is already there, and orients toward the surface entirely on proprioception, because she certainly can't determine visually which way is up. 

Wow these waves are terrible! It's a good thing Merrin's helmet means that she doesn't actually need her face above water to breathe, because with both of her arms occupied in securing the man, she is basically entirely underwater.

[Pickup incoming?] she mutters into her microphone. [Time-elapsed?]

By which she means 'that the patient was suspected to be underwater'. 

[Eleven minutes] The voice belongs to Vellis, who sounds really distracted, and maybe distressed. [Harness dropping now. Patient status?] 

[...Pulse absent - I think, hard to tell, stupid flaming waves! No obvious bleeding. Tethered to sinking wreckage twenty meters down. ....Something wrong?]

There is a carefully-timed pause, while Vellis tries to decide how much to tell Merrin about the incredibly unsuspected advance directive information that came up as soon as they had, by process of elimination, figured out which name went with this casualty, and then only after putting in a situation update - it hadn't come up at all before then - received some extremely unexpected information on the patient's medical advance directive - and, separately, insurance situation.

On the one hand, Merrin might appreciate some warning; on the other hand, it isn't actually going to change any of her priorities for the next ninety seconds, and she doesn't need the distraction. 

[...Special conditions] he settles on. [Just get up here] 

Oh great! Perfect!!! What additional incredibly-unlikely factor is about to show up in her life?! 

Despite his flotation device providing buoyancy, Merrin is having a time keeping the patient in a stable face-up position at the surface while also being able to see anything whatsoever, but the descending harness, also flashing green, is hard to miss. The harness fastener is magnetic and should latch directly onto her suit if she lines herself up right, and there are straps to secure the patient, which Merrin is going to take the time to use even though with the powered suit she should be able to hold onto him for a less-than-25m ascent. There's a lot of crosswind, and it would be so embarrassing, not to mention really bad for the patient's odds of surviving this, if she dropped him and had to go down again. 

The waves are throwing her around enough that it takes almost twenty seconds to actually align herself with the magnetic clip. (It would be easier five meters down, with less chop, but she is absolutely not letting go of the patient or pulling him under with her just to save ten seconds. 

Straps on. (Another forty-five seconds.) 

[Go] 

They reel her up. It's very windy. The helicopter has quite a lot of stabilization tech, but it's still going to be a turbulent ride until they get higher or out of the intensely stormy region. 

This would probably have stressed Merrin out if she hadn't done, like, 20 sims in vaguely similar conditions, including in much colder arctic-circle-region waters.

(If the patient were conscious, and thus unlikely to go straight for cryo by default but likely to care about the debilitating injuries, they would have gotten him on a backboard for the ascent to avoid the additional jostling. Given that he's not, the delay wasn't judged worth it.) 

It's another thirty seconds to the medicopter, and then she's through into the small receiving-bay area and two of the other techs are there to offer their helping arms and mechanical patient-lifting equipment, and wow something is really wrong they look so upset. 

Merrin doesn't bother to flip back her helmet facepiece; her hands are busy, anyway. [What?] she says into the microphone. 

Nobody answers right away; now that the floor-hatch is closed, cutting off the roar of wind, they're getting the patient secured and unhooking her harness. 

[Just come see] Vellis says after a moment. It would be a really awkward time for Merrin to wonder if they were trolling her with the claim. 

....Wow. Okay then. Merrin is already making the predictable update that she's going to absolutely hate it, whatever 'it' is. 

Aaaaaaand through the automatic door into the main area of the medicopter, where the two level-4 medtechs are treating the unconscious patient and the third is with the other three, who are now heated-electric-blanket burritos with facemasks dispensing oxygen heated to 43 C, but otherwise all look okay.

They've got the Complicated Patient Area (it's not actually its own room, though the interior of the medicopter can be divvied up into cubicles with plastic sheets that unreel from ceiling slots) prepped for her, and the screens are on. 

Okay. So what exactly are the special conditions, this is the most obvious reason for everyone to look so stressed. 

Patient's insurance status: Not insured. (This is rare but not completely unheard of, it comes up in sims sometimes, and it's sort of less surprising for someone who cannot possibly get reasonably-priced insurance thanks to their risky boat-related life choices.) 

...Except that in this case, the prediction markets are privately funded (????) and Merrin has seem numbers that high exactly once. 

Aaaaaaaaaaah? 

Medical advance directive: very sparse, does not explicitly offer an opinion on what recovery outcomes he would find acceptable, does not express an opinion on what treatments he would or wouldn't want if he were incapacitated and unable to provide consent at the time. 

Except for one specification: the patient DOES NOT CONSENT TO CRYOPRESERVATION. Definitely not under any circumstances. Don't even think about it. 

AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAHHH!!!!!!!!!!!!!????????????

You know that completely explains why everyone looks so upset!!!!!!!!!! 

Also. What??? What the superheated nuclear waste, why??????? WHO DOES THAT???? Especially who does that and also personally drops like a million labor-hours on his medical outcomes????? Honestly that part is really confusing by itself! How does this guy have that kind of money and also spend his time in a tiny not-necessarily-well-maintained personal boat way out in the middle of nowhere??? There is a series of life choices here that makes no sense! Individually make no sense and especially don't make sense in combination! 

This is actually a really bad time to be having a complete internal meltdown! 

Merrin is having a hard time not doing that because, for once, a thing is happening to her in real life that hasn't ever been thrown at her even in sims. 

(Medical Exception Handling does cover this sort of situation in sims. But it's not something they would usually throw at a 23-year-old level-5 medtech with less than three years of Exception Handling experience. And while they've definitely pushed the limits of Merrin's physical and cognitive endurance, they're being a lot more careful about testing the limits of her emotional resilience. It would lose some investors quite a lot of money, at this point, if Merrin decided to leave the job, and she's enough of a psychological outlier that it's harder to predict how much that would take.) 

(There are probably going to be some words exchanged on this topic later.) 

Merrin sure does seem kind of frozen. They cannot blame her at all; it's sort of on them, for letting her find out like this.

Merrin has some relevant certs that no one else here does, and at least ten times as much sim time on a number of the basic ones.

Her team is selected for endurance in the sense that they can all reliably manage six hours before hitting substantial performance degradation, if they're starting out well-rested, and they won't literally fall over if they have to keep doing basic support tasks for longer than that. But Merrin can do sixteen hours of anything that's sufficiently within her comfort zone, and a lot more things are within her comfort zone than was the case when she was recruited. The usual setup is for her to be the lead opper on whatever's the most complicated, weird, or likeliest to be a long-haul situation, and everyone else is there for support and to take the less complicated casualties in multi-casualty events like this one. 

They're pretty sure Merrin will pull herself together once a treatment plan comes up, especially if it's a blatantly her-requiring plan, and maybe sooner. She doesn't freeze very often. In the meantime, they can get basic supportive treatments set up and start dumping sensor data back to home base, in hopes of getting some sort of plan sooner. 

Merrin's initial guess was right, unsurprisingly; no spontaneous pulse, though there are still flickers of electrical activity on the ECG reading. 

THE KEEPER PROMISED HER THIS WOULDN'T HAPPEN all right fine Rittaen made a prediction that in expectation that her decision on whether or not to leave Harkanam would not be counterfactually responsible for preventing a True Death or not. Which is, you know, not even ruled out by this bizarre event that SHE TOO WOULD NOT HAVE PREDICTED, since someone else could have been here in her place - 

(- it's genuinely less likely, though, probably - not just because Merrin works in a small team, but because long periods on-call don't burn her out much at all, if nothing had happened here but something else had come up in 300 miles ten hours from now she would still have been ready to go, and the only way they got here maybe even sort of possibly in time is because she was already in range -) 

Aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaahokay she's fine she can do this she is entirely capable of doing whatever is needed here - the hypothetical possibility of not being prepared for this is much more a SCREAMING PIT OF HORROR than usual but it doesn't matter because she is prepared - 

Well. What do they have so far on the patient. 

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. 

OKAY GREAT THEN. 

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 is...at 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– ....you 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. 

They agree this is going to cause a lot of random ripples, which they are asking Merrin to handle, but they're very confident she can manage that, and also within thirty minutes she's going to have vastly finer levers for staying on top of the situation. 

...That's actually a lot of the justification.

Is this potentially going to cause some inconvenient dysregulation of other vital signs and electrolytes on the scale of an hour or two? Yes. Is the electrolyte imbalance - still evolving unpredictably as the patient’s gut regains circulation and more of the seawater contents hanging out there and in the local-circulation vicinity are fully absorbed into the systemic circulation - at least as much of a problem on the scale of four hours, let alone the full 12-16 hours before they’re actually done with the weird stuff? Also yes.

But - the experts and the markets think - it's going to significantly boost the efficiency of Merrin's later levers for fixing that.

The basic problem is blood viscosity. Hypothermia by itself already changes how the blood behaves on a chemical level, making it thicker - and thus harder to shove through an external filter circuit.

And they don’t just need the ECMO to work for at least four hours without clotting off or putting intractable load on a struggling heart - the interim-stabilization protocol taking shape also calls for the state-of-the-art dialysis system, not because the patient is in kidney failure, but because it’s a direct rather than indirect lever for Merrin to regulate the patient’s electrolyte balance to within a narrow set of parameters.

The narrow parameters are partly about survival, minimizing the chance that the patient deteriorates too far to reverse before they reach the real hospital facility at all, but really they’re mostly about optimizing the eventual neurological outcome.

(Markets are currently calling 80% odds of some degree of brain damage, and (on the hypothetical where they use the public version of the neuroprotective protocol, since while like a third of the experts involved know about the secret one, these are in fact still public markets) 55% odds of enough damage that the patient won’t recover enough to live independently, and 35% odds that he won’t even be walking or speaking after this.)

Anyway, they think they’re trading a ~3% increase in short-term risk of death in transit (and a ~10% chance of enough deterioration that the patient’s brain takes significant more irreversible damage before they can start the neuroprotective protocol), for…a less certain but much larger 15-25% decrease in the risk of moderate-to-severe brain damage overall. 

Based on their current best (though still rather sketchy) extrapolation of the patient’s preferences-over-outcomes-involving-tradeoffs, this is a tradeoff he would choose. And the markets really do have a lot of faith in Merrin’s ability to do damage-mitigating troubleshooting even if something does go seriously wrong.

Updated market predictions:

- Survival to hospital: down by well under a percentage point, still at 94%.

- Odds of a major pre-hospital-arrival complication causing significant additional brain damage: up to 33%

- Final-prognosis prediction on, controlling for 'patients survives rewarming and recovers', at least mild brain damage: down to 72%.

- Prediction on moderate brain damage: down to 44%

- On severe brain damage: down to 27%.

(This takes well under 30 seconds to express in Baseline.)

Ugh. Okay. Those are sufficiently better odds that it's worth the enormous hassle. People having a lot of faith in her to do really hard things well is SO SCARY but Merrin will absolutely do her best? 

5 minutes to go! 1350 ml of IV fluids now have the correct electrolyte concentration - the medicopter comes with a machine for prepping that, they're not doing it by hand - and it should be at the exact right temperature and ready to administer in another minute or two. 

...Turbulence is kind of bad right now. 

[meta complaint to be deleted later that there is NO DISCORD ACCESS ON THIS FLIGHT WIFI it's terrible]

Someone else placed a peripheral IV in the patient's arm while Merrin was doing...something...there's a few minutes in the middle there that are sort of a blur. Merrin really wants central line access, but putting sharp things near major veins is risky when one is subject to frequent sudden acceleration forces in random directions. While Merrin is technically, certed for it even in 'non-ideal conditions', and the training sims for that involved conditions less ideal than these, it's still not her favorite sort of adventure - and the way to do it safely, or at least more safely, is to go slowly, which means two minutes even if literally everything goes perfectly.

...She makes the call herself to just go ahead and start the fluids now, taking the risk that they'll hit the patient's core circulation more slowly and less predictably, but at least they'll have most of the initial fluid bolus in by the time she's starting her next procedures. 

She watches the patient's vital signs like a hawk. 

Her guess - and the market predictions - were right; the patient's temperature is still dropping, he's down to 22.5 now. 

But, for all that, he looks surprisingly okay. Well. Objectively speaking he looks awful, but taking into account the sequence of events before they picked him up, he looks less worrying than she would have expected. Despite a numerical blood pressure reading that is, one, all over the place, and two, still consistently under 60 systolic, if she looks at just his face and neck, the waxy bloodless look is clearing away and he looks much less like a dead or dying person, and more like someone who is admittedly very cold and very much in shock but is getting bloodflow. 

Also Vellis is now shaving his head to finish placing the EEG electrodes and he has SO MUCH HAIR. There's a little handheld vacuum for the purpose of things like 'not getting hair in your sterile field' but there's SO MUCH of it, and Vellis is trying to solo the sensor setup plus cleanup, because Nettir is busy getting another arterial blood gas sample. The vibration and turbulence are not helping, and his unusual pale hair color means it's kind of hard to see, but there sure is hair everywhere now. 

Well, when they LAND and the medtechs from the ship team run in to collect their patients, maybe Merrin can STEAL one of them and make them CLEAN UP THE HAIR, because she wants Vellis on placing a central line while Merris does the more complicated setup. 

Merrin is registering a strong mental prediction that his perfusion, at least to core organs, is actually improving. To the point that she sort of wonders if they're having a sensor calibration issue - the equipment and the setup protocol are supposed to avoid that but they did set it up really fast under far from ideal condition - or if maybe the software that adjusts from radial-artery pressure to calculate brain perfusion pressure is getting borked by all the motion artifact and the noise-smoothing is actually filtering out some of the real signal. 

- you know what she's going to go ahead and register that out loud as an observation. Along with her observation that this patient at least looks less worrying than her generic sense of what-to-expect-given-these-circumstances.

She wonders (out loud, or rather subvocalizing into her microphone to avoid distracting her team) if, in addition to his age and health, it's relevant that he's more physically fit than the patients usually modeled in sims, and that's the source of her ongoing background feeling of pleasant-surprise here? Like, it's just definitely the case that if someone regularly does very intense physical exercise, pushing their cardiovascular system to its limits on a daily basis, then the compensatory mechanisms there have more reserve.

Also temperature-acclimatization is a thing - regularly exposing a given physiological system to not-actually-dangerous stressors will shift the baseline state of the control system, up-regulating or down-regulating various responses to adverse conditions, and it sounds like this guy hasn't just been on a boat today, but for weeks or months, and maybe that means regularly getting soaked in cold water, and so the current situation, on a physiological and even biochemical level, is at least less far outside the parameters his body is accustomed to. 

(Also she's going to get a manual cuff-inflating blood pressure from his other arm, it's simple and low-tech but sometimes, and now seems like one of those times, that's exactly what you want.) 

Merrin is not in fact the first person to consider this hypothesis, but her independently confirming it - especially given that she's inferring it mostly from direct sense-observations of the patient plus years of trained intuition, rather than via a more abstract model of the system - is informative. 

And the physiological indicators that they hoped would improve with some rapid IV fluid administration are, in fact, improving, to a degree that's on the higher end of the predicted range. 

Diagnostic prediction markets are updating that the patient's odds of surviving transport-and-rewarming, on the current protocol that involves not rewarming him as soon as they can, did briefly dip after they made the call to treat the dehydration fast rather than carefully, but they're now back up, and settling at 94%.  

Could be a lot worse! Merrin will take that. 

(She is also, now that she's had a few minutes to absorb the situation - and, honestly, it also helps that she's had some positive updates - feeling significantly calmer about the whole superheated insane medical directive situation.

As in: it's bizarre and upsetting (and really confusing, in a way that leaves her with an itchy open-mental-loop of feeling like she's missing some sort of key context on the patient or the broader situation and that might matter), but it is not, in fact, the terrifying black-and-white scenario her mind immediately jumped to, where– where whether she, personally, is Good Enough will end up causally responsible for the patient's survival versus True Death.

She has no context on why he made the decision to refuse cryo (and is mostly not thinking about that because, whatever the potential answers, they're probably ALSO upsetting and she does not need to be wasting any of her limited metacognition on not-immediately-relevant questions with predictably upsetting answers) - but people don't make that decision lightly. Meaning that, even if he survives this, she shouldn't actually expect he would change his mind. He...might, in some weird edge cases, though her brain is annoyingly doing the thing where it FLAILS at her rather than answering when she tries to query it for an actual numerical probability estimate. But. Low??? 

Her counterfactual impact on this situation...was already, always, a narrow slice of this pie. Both because she's one person in a huge team effort mostly made up of people WAY SMARTER AND COOLER than her, where her only real advantage is being the one physically here first and with lots of sim time on the work that will buy the Very Serious People time to figure out clever solutions - and because, obviously, if she weren't available then Exception Handling would just have sent someone else. They sent her because she seemed like the best person to bet on given what they knew at the time, but the next-best person isn't actually much worse. (Honestly, performance-wise they might be better, and a lot of the reasoning is about the cost; Exception Handling knows that Merrin won't need as much recovery time as usual after a scenario like this.) 

And her counterfactual impact isn't actually on a True Death, because...absent some weird edge-case scenario, that was going to happen anyway, in forty or fifty years, and it's STILL really weird that Kalorm apparently prefers PERMANENTLY CEASING TO EXIST over...whatever he even thinks is bad about cryopreservation??? ...but it's his life and his choice and he, presumably, had endorsed reasons for it. 

So. By her efforts, here, she can buy him a higher chance of those fifty years. Which - is real, and important, and Merrin is still really very motivated by it - but it doesn't make sense to panic over it. Not that it made sense to panic before either, but it's helpful to draw those lines around what her actual, realistic influence is, here. 

(The ridiculously well-funded prediction markets are freaking her out in a different way, which is less amenable to calming down with that whole line of thought, but Merrin at least has practice on handling that.) 

90 seconds to landing. They were flying higher to avoid some of the turbulence, so expect more of that on the descent. 

Patient status: 

...Yeah there's something going on with either the sensor calibration/data-analysis-software, or maybe differential blood pressure in the lower vs upper arm, or it could literally be a difference between the two sides of the patient's body, you get that sometimes for reasons that are rarely explicable. Manual reading is 68/42. 

Latest blood gas result is up! (They still don't have an at-all-reliable continuous O2 sat reading, even though, when Merrin absentmindedly checks, there is now a faintly palpable radial pulse; under non-moving-helicopter conditions they could probably get a reading, on an earlobe if not a finger, but the sensor is trying to pick up a very weak signal against the backdrop of rather a lot of noise, and it's trying its best to give them numbers anyway but nobody is actually putting any trust in them.) 

Anyway. Latest results are almost not horrifying! This is actually really impressive given just how horrifying the initial readings were! 

(The normal range for the subparts of this test are: 10.5-13.5 kilopascal (kPa) for the arterial partial pressure of oxygen, 5.1-5.6 kPa for carbon dioxide, 22-28 milliequivalents per liter (mEq/L) for bicarbonate, the main acid-base buffer involved in the kidney-metabolic-side regulation of blood pH. Because the respiratory CO2-concentration and metabolic bicarbonate-concentration sides of the pH equation can compensate for each other, as long as only one side of the equation is affected by a given medical problem, the body usually succeeds at staying within an impressively tight pH range, centered on a pH of 7.4, with only a 0.02% range of variation in either direction.

The patient's initial blood pH of 6.95 was an entire 6% outside those delicately-maintained parameters, because both sides of the equation were severely affected; lactic acid is, as the name hints, an acid, and the large quantities of it dumped into the patient's bloodstream after those long minutes of desperate anaerobic metabolism were enough to exhaust and exceed the existing bicarbonate-buffer; the measured bicarb level from the first blood draw was down to 3.9 mEq/L. And meanwhile his blood CO2 was up to almost 18 kPa, triple the usual upper limit.

Oxygenation doesn't directly affect pH (though the indirect effect, via cells deprived of their primary fuel source and falling back on anaerobic metabolism, is one that happens fast enough) but it's still one of the most important metrics here, and his initial reading was 3.5 kPA, a third of the usual value.)

Anyway. The sky-high lactate is taking longer to clear - that requires metabolic work, much of it done by the liver - but, since they knew they couldn't afford to wait for that, the patient received some IV bicarbonate solution almost immediately once they had IV access and test results (this was a sufficiently predictable side-task that Merrin was neither consulted nor noticed it happening, because she assumed it would). And the blood CO2 concentration is now down to only about 10 kPa, which is still abnormal but it's not even double the limit. His measured bicarbonate is now 10 and his blood pH is now back above 7.2, still abnormal but back within the 'generally considered compatible with life' range; since blood pH affects approximately all metabolic pathways, this is kind of important. 

Partial pressure of O2 is up to 6.3 kPa. The temporary semi-stabilization protocol now being set, customized to all the details calls for a slightly-but-not-extremely lower range than the normal range at a normal body temperature, aiming for (roughly, they're actually calibrating mainly on measured O2 saturation on the assumption that they will AT SOME POINT have this as a continuous measurement) between 5.5 and 6.5 kPa, so...they're actually pretty much there? 

(Though of course the eventual protocol will be led from more direct brain-perfusion sensor data that they do not currently have, due to the inadvisability of poking sharp things near important organs while in a moving helicopter in a storm; all the current results are at best an estimate of that, and a lossier one than usual given how far outside usual-parameters the patient's body is currently operating.) 

Eeeeeeeeeeeeee!!!! Things continue to improve faster than Merrin's (intuitive) median estimate and this is the sort of thing that makes a Merrin really happy! 

(She has a very pointless urge to hug the patient about it, which would neither help nor be noticed or appreciated by him in any way.) 

Aaaaaaaaaaaaaaand touchdown on the helipad on the ship!

As soon as they're firmly secured down - ship staff are stationed nearby ready to manage the equipment for that - which should be in about sixty seconds, they'll open the side door and there will be a briefly stressful 5-10 min period of, like, eight additional people inside their not-actually-that-large medicopter, but soon after that, the other four patients will be elsewhere and there will be BREATHING SPACE to set up all the fancy additional equipment that will, hopefully, let them keep the patient from deteriorating any further before they reach Default. 

That being said, it would - if this seems realistic and the personnel actually on the scene don't predict that the distraction will impede their performance - be really appreciated if they start that setup process right away rather than waiting for the transfer to be done. Especially the more invasive sensors. 

(It is possible that a large number of people betting on the Diagnostic and Treatment Planning markets are currently very frustrated about the limited suite of sensor data coming in for their statistical models to chew on.) 

- yeah Merrin is also feeling that way and she's already kicked out everyone except Vellis and told them to drop the plastic-sheet 'room' separator, so that the instant the medicopter is confirmed secured against unexpected sliding around on a wet ship deck, she can start - carefully, not rushing, but definitely efficiently - placing the handful of invasive sensors that will hang out in the venous sinuses of the patient's brain and tell her how bad the damage looks right now.

(Everything else keeps going slightly-but-noticeable better than she was expecting, but the helpful factors she was speculating about - youth, excellent cardiovascular fitness, even being physiologically accustomed to random cold-water dunks - are not actually going to be protective against anoxic brain damage. Merrin is in SUSPENSE over here.) 

Even the large oceangoing ship is...not incredibly like being on solid ground? There are vibrations conveyed even through the medicopter's internal gyroscopic stabilization system, and there's definitely an ongoing rhythmic swinging-swaying motion from the waves. 

Rhythmic motion is fine, Merrin has trained for this and she can compensate for it on a basic motor-memory level. Vibrations are inconvenient mainly because they interfere (not a lot, but some) with the internal accelerometer sensors she's using to have any idea where the probes she's inserting have gotten to, and add some visually annoying static to the real-time ultrasound imagery that Vellis is getting for her. 

It's fine. Everything is fine. She will just go about 20% slower and make sure to time anything delicate to the moment in the sway-back-and-forth motion when they're moving the least, but she's done this like sixty times in sims and honestly most of them were meaner than this. 

It takes them about four minutes, and another minute after that for the sensors to calibrate and start filling an entire additional screen with readings. 

....Wow those are not great readings, though. 

They're not!!! Merrin doesn't like it!!!!! Those are badwronggross numbers!!!!

There are a lot of abnormal cell-damage readings, some of them ones specific to reperfusion damage, and the ones that have a normal reading of 'approximately None, definitely undetectable' are not just reading as 'barely above the detection threshold'. Some of them are, like, four times higher than it. 

It's in many ways not-exactly-comparable to the situation that Merrin faced two and a half years ago. For one, it's a redesigned and significantly better sensor, one that is both more sensitive and measures a lot more cell-damage factors. Last time, they were guessing and - maybe to some extent - hoping for the best. This time, they'll know a lot more of it from the beginning. 

Inconveniently, if unsurprisingly, there isn't a lot of human trial data on what the 'abnormal' sensor readings mean. 

It was (eventually, once involved parties found a way to introduce the new advance in medical tech without it looking suspicious or leaking any information about a still-secret medical case) a genuinely important step forward. Making it public took a while, but universal adoption happened almost immediately after that, and the basic sensor use-case went from 'obscure experimental lab tech' to available in most hospitals on the planet within a month.

However. It's nearly always been used to better inform the medical prediction markets on whether and when to shift from a lifesaving-recovery focused treatment plan to cryopreservation (or, occasionally, the reverse). This is incredibly valuable, but: most patients are not in the situation that this patient is, and most patients have advance directives that lean pretty conservative on risking irreversible brain damage.

Not everyone, people do vary, but it just hasn't been very long, and while there are now a few hundred at-least-vaguely-relevant case studies to refer to, they are mostly not actually very analogous. On average, dath ilani are rather unlikely to end up suffering this sort of mishap (the case Merrin dealt with in Harkanam was itself a rare and surprising event even leaving out the patient's identity and importance to Civilization.)

A large fraction of the documented use-cases for the sensor and related protocols were for stroke patients: usually elderly, usually aware that their bodies were headed toward the slow but inevitable cascade of gradually failing physiological control systems, and thus likely to have updated their medical advance directives accordingly. However, the local damage of a stroke, and resulting dysfunctional-physiological-compensation-cascade, is actually a pretty different situation from the widespread diffuse damage of global anoxic brain injury. 

A much smaller cohort of patients involves traumatic brain injuries - because accidents do, sometimes, happen, even when most people are being very careful. That patient population tends younger and healthier, and correspondingly tends to have a higher-functioning baseline they could return to with a full recovery (and medical directives that take this into account, and insurance that will pay out higher prices per QALY saved). But major head trauma doesn't tend to happen in isolation, and additional traumatic injuries or major blood loss add new confounders; also, even in controlled rat studies, the cascades that happen as the body tries to respond to the injury are actually pretty different. 

There is some data on patients who suffered an (also usually age-related) heart attack with cardiac arrest and suspected anoxic brain damage - somewhat more comparable to the current patient - but this is rare to begin with, hearts are a much better-understood organ with correspondingly better preventative medicine, and most patients at risk of a major heart attack either go for cryo anyway, or have a pacemaker and closer monitoring. 

In terms of near-drowning incidents, involving at least some degree of hypothermia, where the sensor and protocol were used and good documentation exists, it's mostly a tiny and really upsetting dataset of young kids. (Even in dath ilan, kids are the most likely demographic to end up in water-related incidents.) Most of those don't also involve this degree of hypothermia. The best and most comparable data on the protocol is from this source, and - it looks fairly positive, actually, in that population? But young children are in many ways a unique population. Cellular regeneration mechanisms just work better, neuroplasticity is far higher, and of course the cardiovascular system is nearly always in excellent shape. And of course it's harder to know what the counterfactual looks like, for a three-year-old after a 'full recovery' from a near-drowning-related potential brain injury. Three-year-olds' cognitive test scores are already imperfectly predictive of adult results to begin with, and besides, this entire setup has only been in testing for like a year. 

And even aside from the dearth of endpoint measures on patients who displayed concerning early signs – since those are exactly the patients who, even if their testaments hadn't just called for cryo in any case with that degree of uncertainty and risk of a bad outcome, very often would request that given specific reasons to update toward a poor prognosis – but even apart from that, none of those are the current patient's situation. 

There are just not very many adult near-drownings period. This is, of course, a good thing. It means that the water-safety training taught to all children is mostly adequate, and people are following it. But it also means that there are exactly three examples from the entire last 14 months that are even vaguely analogous. The data is better than nothing, but it approximately informs them that submersion time of 4 or 7 minutes respectively, at age 21 or 17 respectively, followed by immediate medical treatment at a specialist hospital, is a good sign. Being trapped under the ice on a frozen lake for forty-three minutes, while also living in a Quiet City a long trip from the nearest large hospital, and also being almost fifty, is not so much a good sign. It is pretty unclear how to interpolate from this to whatever territory lies in the middle between those extremes. 

All of the other, more prevalent use cases show a different pattern of damage-signals than other cases. They're the closest vaguely-comparable scenarios, but of course, as it is said, Reality can be such a huge asshole about what counts as having tested your code inside a domain that's close enough. 

There are lots of studies in rats, of course. 

They have the advantage that the question-being-asked was chosen in advance, and the conditions selected so that the observations made would be as relevant as possible to that question, while minimizing the involvement of any other factors that weren't directly part of the cluster-of-tightly-related-factors that the scientists were actually trying to measure. They also have the advantage of scale; thousands of rats, across multiple experiments, were sacrificed toward the cause of greater understanding of biological processes. 

They have the major disadvantage that rats are not humans - and, in fact, the differences between rats and humans are most extreme in the brain. 

(Not all of the animal experiments were on rats specifically. A small handful even involved primates - but the cost-benefit analysis is very different, for more intelligent mammals like monkeys, and so the vast majority of the recent data is in rats or rat-equivalent-intelligence mammal test subjects.) 

This doesn't mean that the expert Treatment Planners or the medical prediction markets have nothing to go on!

Sure, they have less to go on than they would for a more common medical event, one that might occur millions of times every year. Especially anything where the relevant sensors have existed for years or decades, where they can feed historical datasets containing tens or hundreds of millions of cases to their models, and - given how statistical distributions work - expect that any given patient will fall within rather than outside of the range within which the resulting model outputs useful rather than garbage predictions. 

In that type of situation, the Diagnostic prediction markets can take in sensor data on a patient and, usually, confidently predict the prognosis, and response to a range of different treatments, to within a fairly narrow range. 

This is not one of those cases. This is a case where the data is limited, and the patient is legitimately outside the distribution within which their models can be expected to produce vaguely sane outputs. This is legitimately really inconvenient! Especially given the stakes, everyone involved here would prefer if, instead, they were in a situation where they did have really comprehensive data and actually-thoroughly-tested predictive models! Instead, they are stuck cobbling together disparate datasets, each one non-analogous to this case in a different way, and combining them via models that have literally never been tested under realistic conditions. 

But the Diagnostic system of experts and prediction markets isn't trying to get a good grade on a test. They're not trying to find a defensible Right Answer to this question, and then defend it. 

They are trying to - well, a lot of the individual players here are optimizing for making money on the prediction markets, as per the design - but the overall system is aimed at maximizing the patient’s chance of survival-without-brain-damage. The entire goal of the Diagnostic predictions markets is to, on an ongoing basis as new information comes in, maintain a best-guess model of the underlying biological reality, and then simplify that down to something that can be conveyed to the Treatment Planners and the on-site oppers, so that better decisions can be made in real time, in order to achieve better-in-expectation outcomes. 

(Under this degree of uncertainty, the experts and the markets are far more likely to make mistakes - mistakes that would be theoretically avoidable in a hypothetical world where somehow they had 100x as much high-quality data on this particular medical problem. No one disagrees with this. No one is going to blame the decision-makers in this situation if they make their best judgment call, and get it wrong. If anything, the default expectation is that they’re going to get quite a lot of things wrong under conditions like these. There will be acerbic rants, later, but not blame. Anyway, debriefs on the better processes they should have had are not the priority NOW.)

There is a lot of guesswork, and frantic repurposing of maybe-possibly-relevant models from obscure research projects, and quietyelling on conference calls. These are conditions under which even the best and brightest of dath ilan are likely to make mistakes, and the medical prediction market system is aware of that. 

At the end of it, though, there are numbers up on the screens that Merrin can see, and the numbers mean something, even if they aren’t quite as reliable as what she might expect in a more standard, well-understood, boring case. 

Merrin is expecting some updates on the Diagnostic prediction markets! She is expecting them to be negative updates! 

But the shift in probability estimates for survival and for various sub-outcomes – without brain damage, with only minimal brain damage, with moderate or severe brain damage, etc – are going to be in response to the exact same input that she just spent five seconds mentally freaking out about.

If she expected the markets to land on something worse - or better - than her current vague-gestalt sense, then she would already be making that emotional update. In fact (and as things should be) she has no idea which direction the additional expert knowledge will push things in. 

Anyway, Merrin isn't actually looking at the screens at all, because she's busy setting everything! Honestly, her top priority is the extracorporeal membrane oxygenation circuit, but she should probably set up the internal mechanical cardiac support first, even though for right now the external compressions-vest seems to be managing a surprisingly reasonable blood pressure. 

- actually Merrin (while not pausing at all in her setup) wants to explicitly flag for the Treatment Planners that she is currently feeling weirdly confused and uncertain about the correct prioritization here!

Not really on that one specific question - she should set up the cardiac support before the ECMO, given that the patient does not currently have a spontaneous heartbeat - but on a broader level. She...feels like she's been noticing some observations that feel in conflict? 

Updated diagnostic predictions over outcomes over outcomes:

- Estimated likelihood that the patient will survive until they reach the hospital: down, but only a little, back to 93%. 

- At least minor brain damage: up again by 18% from previous, new odds are 85%.

- Moderate brain damage: up from previous by 40%, new odds are 62%. 

- Severe brain damage: also up by 40%, new odds are 38%. 

- Some sort of complication happening in transit that causes additional anoxic injury or sets off an uncontrolled reperfusion-injury spiral before they have the ability to do anything about that: 45%. Rises to a near-certainty if they have to resort to rewarming the patient aggressively. 

(Which is still an option on the table, if he's otherwise imminently dying - they might still be able to keep the damage to the 'moderate' range, and get an outcome where the patient is significantly disabled but can at least make a meaningfully-informed decision on what to do about that. If he doesn't recover enough to make even basic medical decisions for himself at all, they'll...deal with that when they come to it.)  

Merrin is, as usual, not the first person to point this out, and in fact she is pointing it out - if she's even pointing at the same thing - in a less useful way than many other, more verbally fluent experts advising on this situation. 

(If she were the first person to raise a concern, the non-specificity of her comment would be more of be an issue. But Merrin - who despite all her other advantages is operating at -1 SD thinkoomph from the population median - is approximately never the fastest at raise an issue. Her low verbal fluency, and related difficulties with explaining her reasoning in a legible way, are known and documented in her dossier.) 

In an emergency, it's generally not useful or justified to keep bothering the on-site opper and asking them to unpack their reasoning any further than whatever they provided on their own. They don't need additional distraction, and would obviously have already said everything that was obvious to them. 

Backchannel: Merrin can handle the distraction, and probably can and will unpack more detail on her observations if someone explicitly asks! It is costly for her, sure, but mostly she just has a psychological block around thinking to provide that detail at all, because she thinks of herself as stupid and so doesn't expect anyone to find her more detailed opinions and analyses useful.

Anyone who was previously operating on the assumption that Merrin was a normal dath ilani medtech, should update on the fact that Merrin is neurodivergent, and in particular, Merrin will sometimes only dedicate explicit reasoning to a problem if someone asks her for the answer. 

...That being said, it is still costly for her, so they should only ask her to verbally unpack her confusion for them if, in fact, this will be decision-relevant information. 

(There is, obviously, a monetary bid being placed in the most-relevant policy market, by Personnel and people who know Merrin, to convey their sense of how costly vs how worthwhile it is to interrupt Merrin right now and ask her to try to unpack her illegible intuitions.) 

- nobody is bidding for interrupting Merrin to hear more of her reasoning, at least not in this specific case. (There is quite a lot of debate going on behind the scenes, but nothing Merrin should be bothered with.)

Merrin's main reference screen will display (in Baseline medical-jargon shorthand): they have received and acknowledged her report, it matches other expert opinions and is being taken into account as semi-independent confirmation of said opinions, and they are updating and acting on it accordingly. Her report is potentially decision-relevant for determining the medium-term protocol, but for now - as in the next ten minutes - her protocol is unchanged. 

??????

Merrin honestly has no idea how they seem to have apparently decided that her incoherent verbal report was meaningful! What do they even think she meant?? She personally wasn't sure at the point when she was saying it! Honestly she still isn't sure!! 

...She's not even actually busy right now, at least not mentally? They told her the protocol and priorities were unchanged, and so her hands are now following the incredibly deeply engrained motions of doing some ultrasound-guided minor surgery to place the internal mechanical cardiac pump. This genuinely does not require almost any of her conscious attention; she had already put in dozens of hours of sims on it before she was recruited to Exception Handling at all. 

The patient continues to look objectively terrible, but significantly less terrible than one might expect, at her! 

Merrin has to pause the external chest compressions vest for this procedure, which makes it much more obvious that the residual electrical activity they were previously detecting in the patient's heart is, one, definitely real and not a signal-noise artifact, and two, definitely still being propagated across the heart muscle!

The electrical pacemaker systems within his heart seem to be pretty definitively settled on ventricular fibrillation as the thing they want to do right now. Which is not at all useful for actually pushing blood around, but it's still very obvious to Merrin. The 'coarse' (higher-voltage and wider variation) signal on the briefly un-interfered with ECG might have seemed implausible, likely just a sensor error, if not for the fact that Merrin, while performing the procedure, can literally feel his heart muscle wriggling, weakly yet determinedly, like a fistful of tired-but-desperate earthworms. 

....did she somehow hallucinate a totally wrong number for his core body temperature??? Because Merrin definitely thought the most recent value for that was under 23 C and she was not expecting this level of cardiac-muscle enthusiasm at that temperature! 

(She did not hallucinate the number! Though he's now up to 22.8 C.)

Huh. Interesting and - actually kind of impressive? Both the fact that his temperature increased (if only a little) without their active intervention, and the degree of functional metabolic activity implied by muscle contractions she can literally feel. 

She still sort of wishes he wouldn't, it's messing with her sensors which is rude.

It is! And it might normally make the mechanical pump less effective, but they do not actually seem to be having any trouble with this. They now have a direct pressure-waveform transducer just after the left carotid artery branches off the aorta - the right carotid is taken for internal O2-sat-clip placement - and the patient's blood pressure almost immediately shoots up to 95/40. 

Presumably because this is also increasing perfusion to his lungs, his O2 sats are now climbing. 

Merrin does not even need the urgent warning from Treatment Planning to dial the settings way down! While it's a good sign that they can attain basically-normal vital signs at all, it's not actually the goal at this point! 

Protocol calls for systolic blood pressure below 60 and goal mean arterial pressure of 40-45, goal O2 sat between 70-80%, and very tight parameters on blood pH and CO2 concentrations (once they get those to within normal range at all). This would be way harder to juggle with just ventilator settings, but fortunately Merrin will have much more direct control once ECMO is in position. 

...For right now, it looks like dropping the O2 concentration on the ventilator to like 30% is enough to stop the climb, and get his sats back down to the mid-70s. Unfortunately she doesn't have the newer and fancier version of the vasodilator-constrictor device for controlling brain bloodflow more directly, so the patient's blood pressure does spend an entire 15 seconds very out of range - actually spiking to above 100 systolic - until the change in settings takes effect. 

Getting that device in position seems like the next priority then! Fortunately Vellis is certed in it and can do it while Merrin takes care of the other next priority and inserts a large-bore catheter into the patient's femoral vein for hookup to the continuous hemodialysis setup. She has a super precise protocol to follow on trying to gradually decrease the patient's sodium, which is currently ABSURDLY high and still rising on each test, he's now at like 185 mEq/L which is more than 25% out of parameters from the upper end of normal range.

This is actually much less of a disaster than it would be if the patient were out of range by that degree on the lower end - a drop in sodium levels below 100 mEq/L, especially if sudden, can very quickly result in more water entering cells - including brain cells - causing seizures, coma, and often irreversible fatal brain damage. If this had been a freshwater drowning, the patient's chances would be significantly worse. 

High sodium has the opposite effect; at the level the patient is at now, it does have severe neurological effects, by "dehydrating" the patient's cells. Levels above 160 mEq/L are often fatal without prompt, high quality treatment. Even without the anoxic damage, a level this high is enough to sometimes cause seizures and coma. The tail-risk danger is of a subcortical or subarachnoid hemorrhage, from actively-shrinking brain tissue straining and rupturing blood vessels. 

Correcting high sodium is also fraught, because the brain is actually very good at adjusting to out-of-parameters sodium levels - but the compensation mechanisms don't immediately return to their previous equilibrium, especially if the patient's sodium has been elevated for a long time, and returning to a "normal" plasma sodium concentration at a rate that outstrips the re-adjustment can cause many of the same risks that actual objectively-low sodium levels do. 

In this case, it was probably an acute steep increase, unless this guy is just chronically dehydrated - he's in fact more dehydrated than the other patients, and the most coherent of them did report that their boat has been low on fresh water supplies since the storm really got into gear, and Kalorm has a tendency to make sure other people are fed and watered before him. There's no way his level was this high before the near-drowning incident, but he might have been outside normal parameters all day.

Anyway. They do want to get him under 160 mEq/L - and correct the dehydration and fluid balance fully - before initiating the rewarming protocol, because they super have not tested whether the set of proteins used for it even work with physiological parameters that far outside the usual zone.

So! Very careful continuous hemodialysis, during which Merrin needs to delicately control a gradual shift in these dozen different electrolytes and other blood solutes – and keep a super close eye on the brain-damage-byproducts sensor, EEG reading, and regular brain ultrasound and CT scan data, and adjust the dialysate solute concentrations and thus the filtration rate as necessary if they think damage is occurring. 

The policy markets think this protocol should let them decrease the patient's sodium to below 160 mEq/L over the next four and a half hours, but they're actually only 70% confident of that; if the patient tolerates changes worse than expected, they're a) going to accumulate some additional cell damage in the process of learning that, and b) be left having to run the neuroprotective rewarming protocol with a much higher risk of something going badly wrong. 

Also, while Merrin does have fifty-plus hours of sim time on managing the controls simultaneously with 3-4 other machines, it's still going to be a LOT to track. 

And setup is obnoxious; she has to connect the tubes and filter and temperature-control box, and outflow for the waste "urine" produced after filtration, and inputs for administering extra fluids directly to the patient's bloodstream either before or after the filter - and all of that needs to be secured very thoroughly against acceleration. 

It takes her long enough that Vellis is ready to hand her the controls on the patient's carotid blood pressure by the time she's ready to actually hook things up. This is now three - no, four counting the ventilator - different machines she has to interoperate to keep the patient within basic vital-sign parameters. 

His blood pressure does briefly plummet when the circuit starts pulling blood from his body and returning only plasma, but Merrin has a lot of room to go up on the mechanical cardiac pump settings - which of course results in a few minutes of correcting-for-overcorrections before she has basic vital signs staying within parameters without constantly making adjustments, and can move on to focusing on ECMO setup. 

Diagnostic models are guessing that Kalorm's heart and its electrical control system are especially irritable, not just because of the cold and the still-out-normal-range acidity of his blood, but directly because of the out-of-range sodium and other electrolyte levels. Correcting this may actually have a significant effect.

They're considering directly administering a paralytic drug to the heart muscle, just to keep its oxygen needs down, but that has nonzero risks, and they may actually get a spontaneous organized rhythm back at some point. Market is putting 8% odds this will happen within the next 4h with just electrolyte correction and no other intervention, rising to 13% if they use the internal defibrillator system on the mechanical pump once his sodium is below 160 mEq/L, and 17% that using the electrical pacing system along with the pump would get them enough of a response to be worth trying. 

They do want Merrin to administer a very short-acting muscle relaxant (not intravenously, but via diffusion directly onto the surface of the patient's heart; the mechanical pump system comes equipped with a port for that) and see if this calms down the desperate worms and gets them a bit less sensor interference (and of course lower oxygen needs for the heart muscle, which is at risk of taking some damage over the hours they'll need to use the mechanical pump.) 

Yeah okay done, and now she can get the ECMO set up, and with it the levers she needs to shove the stupid blood CO2 levels actually within parameters. Also his lactic acid levels are clearing, but started so high that the latest result is STILL, like, above 8. Frustrating!

The hemodialysis will help clear them faster but she can't actually do it as fast as she wants, it's not a fully independent lever from the sodium and other electrolyte control, which means they're going to have to keep administering bicarbonate - in the form of sodium bicarbonate - to correct the patient's pH. Of course, once she gets the ECMO circuit set up, the CO2 should be resolved much, much faster. 

It's taking a weirdly long time to correct the patient's CO2 the normal way via his lungs? Like, Merrin feels vaguely confused, it feels like it's a harder battle than the lactate. 

She flags that confusion for the Diagnostic experts and markets while she gets set up again. 

...Yes, this was noted already, Merrin's intuition matches their bio models. 

The obvious explanation is that more metabolic activity is happening than they expected, even with all the direct observations of things like cardiac muscle activity and the surprisingly not-totally-absent EEG activity. The patient is just...slightly more metabolically functional than would usually be predicted by a body temperature of 22 C. It may be just part of the same cluster of observations Merrin made earlier, hinting at the patient - who did not, after all, come in with a particularly thorough medical chart - having been healthier at baseline than their generic bio-models are taking into account. 

Combining this with various other now-incoming sensor data is interesting, and changes some of the tradeoffs here. Merrin should anticipate some updates to the stabilization protocol. 

Well, she'll finish setting up her life-support equipment while they think about it. 

The ECMO circuit connection requires another incision in the patient's chest, a mildly nervewracking ultrasound-guided probe adventure around the heart to the vena cava, and placement of two even larger-bore shunts - and, once they're in place and the circuit is running, a clip to pinch off the vena cava between them, to mostly prevent oxygenated and de-oxygenated blood mixing. That's normally fine, actually, but in this case they want a lower and carefully controlled O2 sat in the blood entering the patient's left-sided heart and proceeding to the systemic circulation, most importantly the brain. 

It's really stressful to carry out in a gently-rocking medicopter, but Merrin totally does not slip and poke a hole in the largest vein in the patient's body! 

The patient's heart is especially not a fan of the ten-second interlude when blood is leaving his body before reaching the heart, but before any of it is re-entering from the circuit. (They didn't try to start it circulating with transfusion blood on an organ-transport machine, like with a particular previous case; it's fiddly and tricky enough to pull that off in a well-equipped ICU on totally stationary land, and they're prioritizing speed.)

Venous return to his heart drops rapidly to almost nothing, the sensors on Merrin's cardiac pump are so confused, and ramming up the settings - which Merrin does pre-emptively - doesn't even especially help, because the next four heartbeats have barely any blood to squeeze out, and the real time blood-pressure waveform from the carotid artery dives off a cliff. 

...As predicted, though, as soon as the oxygenated blood starts re-entering at the other end of the circuit and filling the patient's heart between beats, the stroke volume rises almost instantly back to its previous baseline. The actual measured blood pressure is less instantly resolved - the waveform almost looks like 3-4 seconds of asystole, a long "diastolic" slide down and down, bottoming out at a reading of 16 mmHg before the next pulse-waveform bump. 

On a more fragile patient, this would be enough of a perturbation to the system that Merrin would probably be spending the next hour using ever single tool at her disposal to keep the patient's circulation going at all. (If this patient had been in similar predicted-condition to the guy she treated in Harkanam, they would absolutely have taken elaborate extra steps to prevent that temporary drop, because it might not have been one his body could recover from at all.) 

On this patient, though - as was predicted with >95% confidence by the Diagnostic markets - it only takes around ten mechanically-pumped heartbeats, with the pump settings maxed, to bump the curve up and up, and within twelve seconds of when his blood pressure nosedived, the systolic is back above 50. 

Which isn't the same thing as being back in a stable equilibrium! Merrin is definitely working pretty hard for the next five minutes, staying on top of O2 sats and whatever superheated anomaly is going on with his pH right now. 

Apparently they're getting away with it! Merrin is only actually outside parameters for blood pressure for that one twelve-second period, which never even dropped to zero perfusion pressure, and twelve seconds in an awake patient isn't even long enough to cause a loss of consciousness. 

This patient's already-stunned cells could have been more fragile, but apparently they aren't; the cellular-damage indicators on the sensor have been dropping gradually, as the waste byproducts accumulated during his cardiac arrest are flushed out, and minimal ongoing damage is occurring to generate more of them. There's not even a blip on that trend. 

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. 

"Hey, stop it," Merrin says mildly at her thoroughly unconscious patient. "That's rude." She absently toggles controls on three different machines at once and then goes back to securing all the loose tubing down very firmly with skin tape. 

Her overall affect is simultaneously calm and - not tense, exactly, but in a baseline state of intense hypervigilance. She is very, very focused on the patient, taking in relevant data and ignoring nearly everything else, her moment-to-moment emotional reactions tied intimately to subtle changes in her patient's condition. Things going worse-than-median-predictions make her wince and sometimes swear out loud at the equipment. 

Sometimes, though, things go well, better-than-expected even, and then Merrin beams proudly at her patient and says out loud that he's doing really well, and in this case she was checking peripheral circulation, and gently squeezes his limp hand for a moment before returning her hands to the control console. 

Merrin is fascinating to watch, and to have a little shoulder-model of in his head. 

(Khemeth, to be clear, finds basically all humans fascinating. But Merrin is neurodivergent in such an unusual way, and it's always rewarding to see someone repeatedly exceeding expectations.) 

....It's also incredibly endearing - and, honestly, kind of emotional - to watch her interacting with his little brother in a way that makes it so incredibly vastly obvious how invested she is, how strongly she already cares about a person whose specific existence she wasn't even aware of an hour ago, who she's been interacting with directly for thirty minutes and has in fact arguably not 'met' per se. It's interesting. Khemeth likes people, and also gets invested much faster than average, but for him it usually at least involves a conversation. 

[Suggestion: raise bid to keep her on the case] he sends to the group chat, and half-tunes back in to the Venture Capitalists' videoconference.

There is some sort of intense debate happening over whether they can, by throwing more money at the problem, get some of the specialty supplies over to the Exception Handling medtech team on the fast transport plane, do an aerial rendezvous and transfer to the patient transport plane in time to start the early stages of the neuroprotective protocol while still en route to Default. 

Patient now secured, vital signs re-stabilized after the most recent procedure and transition, and with Merrin having given the go-ahead, the medicopter takes off. They were on the ship for less than thirty minutes. It's been around fifty minutes, total, since the patient was pulled out of the water. 

The medical transport airplane took off uneventfully 20 minutes ago, just about on schedule, and is already 200 miles closer. If everything goes smoothly, the medicopter will reach the plane for rendezvous in around 70 minutes, transition should be complete within 20 minutes, and at that point they'll be about 1300 miles from Default - call it 130 minutes airtime.

Just over three and a half hours, and they'll be in a real medical facility with full backup. 

Merrin is cleared to begin cooling the patient as soon she feels in control of the situation! 

...The markets are not incredibly confident that this will work. The conditions are far from ideal; the patient will be less stable at a colder temperature, they don't know by how much or how well Merrin will be able to compensate by juggling her six-machines puzzle, and being in a moving helicopter in a storm is not great for that. This is roughly why, while the patient's predicted odds did improve when Merrin agreed to run the new stabilization protocol, they are still not nearly as good as the hypothetical where rewarming-with-neuroprotective-protocol starts now. Updates were roughly:

Minor damage: 82% -> 65%

Moderate damage: 52% ->32%

Severe damage: 34% -> 18%

The odds improved a little in response to the absence of anything going horribly wrong or worse-than-expected while Merrin was performing the final procedure, and are now:

Minor damage 62%

Moderate damage 28%

Severe damage 14%

They're about to narrow the uncertainty a little, though, when they learn whether or not they can realistically hit 18 C while still in the medicopter. Because if the patient tolerates cooling poorly (which is, you know, pretty reasonable of him, human bodies are really not meant to exist while that cold) the odds of a fatal complication start to be uncomfortably high even, within their rather ruthless cost-benefit framework. 

A major issue - of course, one they are planning for in advance - is the actual midair transfer from the medicopter to the medevac plane. It's inevitably going to involve some jostling and some g-forces as the two aircraft match velocities and line themselves up while still in a storm region. And then about 100 seconds during which the patient will be inside a protective transport pod while being reeled up to the underbelly hatch of the plane - and Merrin will be nearby, with her basic control console, but without visual contact on the patient and with far more limited screen real estate to keep an eye on sensor data. The plan is for her to do what she does best: work in purely reactive stimulus-and-response, and if she doesn't have a muscle-memory-instinct reaction in her repertoire, and would have to pause and think about it, instead call it out as an Exception to the remote support team and then ignore it and focus on the rest of her interlocking six-part control system, and someone else on her team will implement whatever the Treatment Planning team can come up with in ten seconds. (Which is a serious efficiency loss, since they won't be fully loaded-up with all the context that Merrin is tracking mostly on an implicit and instinctive level, but it should suffice to make sure the patient at least keeps having a blood pressure.) 

If the patient tolerates cooling well, and is stable (or as "stable" as anyone nearly 20 degrees below normal body temperature can possibly be) at the point of transfer, the markets are actually giving it 98% odds that any problems caused will be resolvable, and the patient will reach Default alive, albeit maybe with a lot of extra stress and hassle for Merrin and her team. At that point, given the sheer quantity of advanced life-support equipment and backup they have at their fingertips, the patient's chances of straight-up biological death during rewarming are negligible.

If the patient tolerates cooling very badly - if he's fragile enough at 18 C that Merrin is already working flat-out just to keep his basic bodily functions going - then Merrin cannot be expected to have much slack for the inevitable perturbations of giving that delicate system a hard shove. It's way too likely that she won't be able to stay on top of everything. They'll of course be throwing all the remote support they can at her, but there is far too high a chance - 30%, maybe - of one of Merrin's variables - electrolytes, or pH, or some weird cell-damage detritus that the liver should be clearing - spiraling wildly out of control. Which isn't a guaranteed failure, but in maybe 50% of those cases (15% overall) the patient is either basically dead on arrival, or else accumulates enough additional cell damage that the neuroprotective protocol will be coming far too late. 

They do not want to be in that world, and so if it looks like they're headed there, when Merrin starts cooling the patient, the plan is to stick with keeping the patient at 22-24 C, and if that means losing ground on neurological outcomes, letting the inflammatory cell-death cascade get further before they can interrupt it, then - well, if they kill Kalorm before even reaching Default, they aren't going to have a chance to put the neuroprotective profile into action at all, are they. 

...And, of course, it's most likely that they'll end up somewhere in between those two extremes.

If the markets were expecting one outcome more than another, they would already be updating on that. If there is anything about the patient's underlying condition that makes success or failure more likely, and they can measure that, it's already been taken into account in the current predictions over outcomes.

There are, of course, things they can't measure - but from the point of view of the medical prediction markets and the Treatment Planners, operating under uncertainty, the upcoming turning points are going to feel pretty much analogous to a certain dath ilani children's game involving using quantum randomness generators to simulate efficiently functioning markets. 

First up! Merrin is going to start cooling the patient by about 1 C per five minutes (he's currently at 22.9 C, about 5 degrees from the new goal) - and briefly pause around halfway to the goal temperature, call it around 20.5 C, to wait on the results of some blood tests that aren't included on the continuous sensors, or where the continuous-sensor readings at such a low temperature are imperfectly reliable. 

The market does not think that the patient is going to crash before this point; it's the second half that's going to be especially fraught. Call it a 10% chance, 1:9 odds, that the patient destabilizes enough that Merrin has to abort and re-stabilize him before they reach the 20.5 mark. If the patient copes okay with the cooling, it's a modest but far from definitive good sign, one that mostly impacts the odds on the worst outcomes. 

Call it a 1% drop in the probability of minor damage, a 2% drop for moderate damage, and a 3% drop for severe damage. This is pretty likely! 90% likely, in fact! 

Of course, this necessarily means that in the 10% case, the odds of the bad outcomes will increase much more steeply: by 9% (62% -> 71%) for minor damage, 18% (28 -> 46%) for moderate damage, and 27% (14% -> 41%) for severe damage. 

Is Merrin ready to find out which world they're in? 

Aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaahstressstressstress! 

(Well, the previous improvement in the patient's odds was entirely based on Merrin being willing to try this moderately risky new stabilization protocol! The patient's odds are strictly better if she starts cooling - it's just that they're going to find out sooner if the patient's underlying condition is worse-than-expected, but it's not that they're causing that; they would have found out one way or another eventually anyway.) 

See, but Merrin has secret information about Kalorm that the markets don't, which is that Kalorm is very good and so he has to be okay Well, if Merrin really did think she had information the markets didn't, she really ought to point this out. But she usually shouldn't be more right than the markets - sure, she's the one on-site, but there are more experts and traders, they're smarter, and she's already conveyed the fact that Kalorm keeps doing better than she was expecting.

Sheeeeeeee does not think that even her illegible intuitions actually disagree with "10% chance this won't go well". It's just that her motivation system feels like this should not be allowed. This is not actually how probabilities work. 

Controlled cooling (or warming) is a little harder than it would be if she had the patient on a full heart-lung bypass circuit, but 0.2 C per minute is totally doable even in a moving helicopter while juggling six different life-support machines. 

And??????????

It seems to go basically fine! 

The transition time is obviously more stressful. His blood pressure is confused about what Merrin is doing to it, his CO2 - now actually within the stupidly narrow parameters they handed her - is trying to drop below them, as his metabolism slows a few ticks further and less is produced. 

But he responds to Merrin's interventions and tweaks, and once she's gotten him leveled off at 20.5C, fifteen minutes in - 55 minutes to go before the midair transfer - it's not much harder to maintain the whole system than it was at 23 C. 

Additional bloodwork comes in within vaguely acceptable bounds. 

The markets update! 

Likelihood patient will survive through the end of the rewarming protocol: 93%

Likelihood of at least minor brain damage: 61%

(Corresponding likelihood of no long-term cognitive deficit: 39%) 

Likelihood of at least moderate brain damage: 26%

Likelihood of worst-outcome severe brain damage: 11%

Odds of an unexpected complication en route and change of plan: 35%

Also, they're not done yet. Is Merrin comfortable proceeding, and cooling the patient to 18 C? They'll go a little faster, this time, since nothing disastrous happened and the disastrous outcomes were, if they happened at all, very likely to start happening by now. Is Merrin comfortable cooling by 0.5 C per minute, so they'll be at the goal in 5 min? It took another 5 min to obtain and analyze all the interim lab results, so the rendezvous is now in 50 minutes, and they want Merrin to have enough time to get really very comfortable with the patient's stabilization needs at 18 C, since she'll have to keep doing it under extremely non-ideal conditions during what may be the single highest-stakes 100 seconds of the entire evacuation. 

Merrin is mildly relieved, but not surprised, that the first bit went well. Yeah, she can manage 0.5 C per minute cooling. Probably. Presumably if something goes super awry she'll slow down and switch to a more conservative cooling protocol, so she can actually stay on top of wildly fluctuating vital signs and other bodily functions. 

Yep, they'll tell her if she needs to slow down, though Merrin should of course also use her judgement if she needs to, instead, switch to a very conservative 0.1 C per minute cooling protocol (which will take 25 minutes, leaving Merrin only 20 minutes to get settled in a new rhythm with a patient who will, if they need to resort to that at all, in expectation be a lot more fragile.) 

They think this is relatively unlikely to happen, but more likely than before; they're putting a 25% probability on it. 1 in 4 odds.

If the patient tolerates the further cooling, that's actually a substantial good sign, one that has the largest impact on the moderate-brain-damage odds (the predicted odds on severe damage are already low, and most of the remaining probability mass on it is in worlds where that degree of damage was already done, not worlds where it hasn't yet happened but might or might not happen in the next 3 hours depending on whether they do everything exactly right.) '

The markets are not always right about how far they'll move, but currently are looking at 3:1 odds of a 3% decrease in the probability of mild damage – to 58%, which is actually getting kind of close to even odds of no permanent cognitive deficit at all. 

(It's not under debate that there is currently damage; the sensor readings are enough to confirm that. But now that they've dealt with the worst of the dehydration and Merrin is successfully bringing his sodium steadily down, the patient's brain does, in fact, look basically structurally normal to blinded experts examining his CT scans. Under optimistic models - partly based on their tiny dataset on near-drowning in young children, which wouldn't normally be comparable to a 25-year-old with less neuroplasticity but may, for a bizarrely resilient 25-year-old, be closer to comparable than looking at post-cardiac-arrest outcomes in 50-year-olds with heart disease. The initial damage dealt by those 11 minutes without oxygen, and some-smaller-number-of-minutes without circulation and with CO2 and anoxic-cell-damage byproducts accumulating, may still be within the brain's capacity to heal from and repair, and with high-quality supportive care and eventual rehab - which they can take for granted he'll have access to - the patient could eventually return to his cognitive baseline.) 

The likelihood of moderate damage will be the most affected; the market is expecting to drop by 6%, landing at 20%. (The hypothetical market branch on "immediate access to neuroprotective protocol" actually updated in an optimistic direction after some of those case studies, plus a larger though less-directly-applicable dataset of stroke patients, were reviewed in more detail, and landed on 17%; 20%, 1 in 5, is about as close as they're likely to get conditioning on having to wait 3 hours.)

Severe damage is already looking relatively unlikely, but the market anticipates another 2% drop, to 9%. 

...Of course, in 1 of 4 worlds, they're going to get bad news. If the patient is unstable at 18 C, then either they have to return to a less-ideal higher temperature, or if not they're still risking additional damage accumulating just because Merrin won't be able to as consistently stay within the really-quite-unreasonably-tight parameters on the protocol. (The markets have not yet settled on which of those is better; behind the scenes, there is a very contentious debate going on about it.) 

So, with 1:3 odds, they're instead going to be looking at a 9% increase in likelihood of minor deficits (to 70%), an 18% increase in moderate damage (to 44%), and a 6% increase in severe damage (to 17%).

(Probably! But they are, still, reasoning under massive uncertainty. The patient's brain could be in better or worse shape than they're aware of, and whether his other organs tolerate cooling to 18 C is not directly informative about that. It's possible the patient's actual chances are different than the ones the market has the information to show.) 

Merrin takes a deep breath, and for a precious ten seconds, takes her eyes off the screens, takes one of her hands off the control console, and squeezes Kalorm's hand. "Listen. You're doing really well and I'm so impressed and I need you to keep it up. I know it's hard. It won't be for that long. Just - hang on for me, okay?" 

(Does Merrin expect this to have any effect whatsoever on how the patient's body reacts? Absolutely not. His EEG is a flat isoelectric line; there's no information-processing happening there. But she knows from sims that it does, actually, have a small positive effect on her performance if, when she's about to attempt something high-stakes and very very hard, she takes a moment to– it's not obvious even to her what she's doing, actually, or why this helps, but she's a little calmer and a little more focused.) 

It's more obvious to Khemeth, actually, who is currently running his best attempt at a Merrin-copy in his head. Merrin benefits from - no, stronger than that, she needs to feel that she and her patient are fighting for the same side. 

It's easy, when you're a medtech handling a complicated protocol with a critically ill patient, wrestling dozens of metabolic processes that really are not designed to work under these conditions and keep trying to run off in incredibly inconvenient directions, and you've just signed yourself up for twice as much stress and hassle to buy your patient a few more percentage points of a good outcome, and also you expect to be doing this for up to sixteen hours - it's easy, under those conditions, for the human mind to start feeling like the battle they're fighting has to involve an enemy. It's easy to end up frustrated with the patient for making you work so hard, especially if things end up going not the way you hoped. 

Merrin needs to feel like she and her patient are a team, and the enemy they're fighting is - the vagaries of biology, the forces of entropy, and of course the horror of True Death. Merrin isn't increasing the odds that Kalorm will tolerate being cooled another 2.5 C, but she is, genuinely, improving her own chances of coping gracefully if he doesn't. She won't blame him, because he isn't her enemy, Death is. 

...Also, Khemeth is running a Kalorm in his head, still, because one of his five text chat windows is with the Exception Handling Assistant Financial Coordinator on the case. In the absence of explicit written medical advance directives, and given the fact that Kalorm is a bizarre psychological alien by dath ilan standards and she's still incredibly confused about his preferences, she feels more comfortable if she can sort of just consult the Kalorm Expert every time something comes up. 

(Under different circumstances, there might be a prediction market on this. Khemeth is in fact considering setting up a small secret market, just so he can stop doing this extremely exhausting and emotionally destabilizing mental modeling, but he's only going to do that if he decides that his family members are coping and are not going to set anything on metaphorical-or-maybe-literal fire, and if Kalorm's friends on the boat – the conscious ones, because the unconscious one is now going to emergency cryosuspension, no he's not having feelings about that – recover enough over the next couple of hours to be up for participating in it during the actual rewarming.

But! Guess what! Khemeth has a very good idea of exactly how radioactively furious his brother would be about his internal preferences on whether to live or die being subject to debate by strangers and (even worse) trading experts. And he's not sure it would even help - he's genuinely not sure that people who are neither family members nor close friends of Kalorm's even have useful inputs here. So. No prediction market.) 

Anyway. It turns out that running a mental model of Kalorm, while watching Kalorm's rather skilled, given her age, and very very very dedicated Exception Handling medtech give some quiet encouragement to Kalorm's unconscious body before she embarks on a truly heroic effort to try to save his life–

(and this in the context of having spent the last hour terrified of Kalorm gone forever or, maybe even worse, Kalorm helpless in a hospital bed, probably in pain, certainly confused and scared, not really himself, not really there, but not really gone either, and being the one who has to make the final call on whether to let that remnant of his brother go the rest of the way)

- it turns out that these are conditions under which Khemeth, who has not had an unendorsed emotional reaction in front of anyone save his boyfriend since he was twelve, has to switch off his video and audio for the Venture Capitalists conference call because he is now crying. 

This does not actually interfere with pinging Ranthir in the family group chat to check if she finds the 3:1 odds of Kalorm tolerating 18 C convincing, or if she's also looking at them with a dubious expression and remembering a particular childhood adventure on an in-hindsight-ill-advised family skiing vacation when eight-year-old Kalorm decided to run away, made it like four miles on foot, fell off a 15 meter cliff, and had to be rescued by Exception Handling after Nerdel convinced Finnar that no it was not safe for them to mount a family rescue expedition with no backup. And then was somehow uninjured and completely fine after like twelve hours in -10 C winter conditions.

Khemeth has no idea if this is medically comparable enough to be genuine new information that isn't screened off by the EMTs already knowing literally everything about Kalorm's physiology that can be measured by a sensor, but he is still sort of frowning at that 3:1. 

Ranthir does not very clearly remember that incident. She was five at the time. But, yeah, she's absolutely betting against the markets on those odds. The markets are definitely wrong. Kalorm's actual odds have got to be at least 9:1.  

....okay, some of that is in fact a rationalization from the fact that Kalorm is not allowed to die, and the odds given by thousands of actual medical experts do mean something and should shift her prior. (You get very good at immediately catching that, when you have Ranthir's career.) 

She still thinks the markets are wrong in that direction, though, and will absolutely bid on 4:1. 

Finnar is in his basement workshop - not the secret basement workshop a level below it, just the normal basement - and currently has the full-wall projector screen displaying the View Three vast tangled multicolored visualization of the 5-dimensional structure representing every metabolic pathway and upstream gene-expression pathway known to dath ilan. The other wall display has the full-detail diagram of the metabolic pathways touched by the neuroprotective protocol. The full, secret version of the protocol, that is. 

(Finnar is not really supposed to know about that. He wasn't involved in the Harkanam case, and Khemeth swore a grade-three secrecy oath about it, and neither of them would ever expect Khemeth to violate that even under these circumstances. But Finnar is the sort of person who guesses about the secret project in the Basement of the World at age thirteen, and is fortunately quietly approached by a Keeper before he does anything ill-advised like "tell everyone", and Finnar very grumpily agreed to a secrecy oath, and has also never broken it. His son Kurthin does know, but not because Finnar told him; Kurthin is just enough like his father to have also deduced it, though not until he was fifteen. Finnar tries not to be too disappointed. Not everyone can be expected to keep up with him. In fact, in his experience, almost nobody can keep up with him and the people who can are all working on secret Governance projects.

Anyway. Finnar does not work in the Basement, because that calls for a higher level of legible trustworthiness than anyone has ever assessed him as having. He's not bitter about it, no really. However, once you know about the Basement at all, have not been told per se but have some hypotheses about what the Basement can do with custom protein synthesis, and then spend three minutes reading up on the history of the non-secret protocol that suddenly emerged onto the scene a couple of years ago, it's pretty obvious. He had to do a lot of quietyelling to get access to it, and swear a grade of secrecy oath which he is kind of bitter about, and then right as he was ramping up for a very satisfying argument, it turned out that somehow Khemeth of all people was already read-in on the situation and handling it. But, of course, the important thing here is that it's being handled. Kalorm has to be okay. Kalorm will be okay, even if Finnar has to personally become an expert in neurochemistry and figure out a protocol that fixes brain damage after the fact.) 

He's not an expert in medicine or biochemistry. Not even a little bit. Most of his domain knowledge is in advanced physics and computer hardware. But he is very, very smart, +3 SD thinkoomph from the dath ilan median and more like +3.5 SD on visual-spatial specifically, and he is absolutely not going to let a lack of any domain experience stop him. He will be confidently wrong repeatedly until he manages to be confidently right! This strategy has never failed him! 

Though he'll take five seconds to message Khemeth, who is of course not working on anything nearly as important to saving Kalorm's life, but does have a lot of connections and a lot of money.

He tells Khemeth to pay for a retrieval mission to get the wreckage of Kalorm's boat brought back to Default. 

Khemeth would like to register that he is, in fact, really busy. Why in the superheated depths of the Deep Ocean Trench is retrieving Kalorm's boat a priority here. 

He would really like to set it on fire. It'll make him feel better. 

No. 

It won't even cost that much money. 

Still no! What is WRONG with his family, why are they LIKE this.

NEVERMIND THEN Finnar will DO IT HIMSELF!! Even though, you will note, Finnar is the one actually working directly on their problem and his time is significantly more valuable right now!!!

(Khemeth at age fourteen might have argued with this assessment. Khemeth at thirty-one accepted a long time ago that his father has some stubborn metacognitive blind spots. Really, doesn't everyone? Everyone other than Keepers, at least, and Keepers are doing very strange things to their heads and there's a good reason neither he nor his father are one. Anyway. Finnar's blind spots include a persistent low assessment of the value of Khemeth's particular comparative advantage, and even though you would think that being very rich would call for an update on that, Khemeth is not really expecting it to change at this point. He is, however, irritable and generally off-balance enough that he'll say things in the private family groupchat that he might not otherwise make explicit for reasons of 'saying them also won't help.')

Seriously, why is Finnar such a walking boat-related disaster! This isn't even the first time he's tried to convince Khemeth to set fire to a boat! And it wasn't going to help that time either! 

Finnar does not deign to answer because he's currently trying to find someone who will take his money and deliver him a boat. 

Merrin is focused and calm-but-tense and in the process of cooling her patient another 2.5 C over five minutes while working very, very hard to prevent this from breaking anything else. 

Profound hypothermia affects nearly every cellular process, and thus nearly everything Merrin is currently handling on manual. Previously, it had actually felt like she was only sort of doing that, because Kalorm was carrying a bunch of that load on his own, but they're now pushing his body into an even more unnatural state. 

Merrin is going to spend the entire time fighting with his systemic blood pressure - vasopressor drugs barely work at that temperature and his blood wants to pool in cold-paralyzed capillaries and she really desperately needs enough venous return to his heart for there to be anything to pump - while trying to keep his carotid blood pressure below a gradually-dropping as per the stabilization protocol ceiling. (At 18 C, they're aiming for a carotid systolic blood pressure of like 30, with an allowed range of TWO POINTS in either direction, which Merrin thinks is just mean and unfair to expect from both of them – but especially Kalorm, who is clearly, of the two of them, having the worse time right now. She gets it. She is not judging him at all.) 

His electrolytes and pH and CO2 are all over the place. His lactate is trying to rise again, probably because there's enough microcirculatory dysfunction going on in his extremities, enough areas where depleted blood pools and new oxygenated blood takes a long time to arrive, that even the metabolically-slowed cells, bunkered down to survive, are getting hungry enough to metaphorically eat their horses, resorting to anaerobic metabolism. 

Blood viscosity and increasing hematocrit are a real problem for the three extracorporeal filter circuits Merrin is trying to wrangle; the high-pressure alarms are going off constantly. She can dilute the blood in the circuits with carefully-calibrated electrolyte solution, but then she has to put more load on the final filter stage of the hemodialysis circuit to remove most of that water, since they cannot in fact afford to pump multiple liters per hour of fluids into him. And they definitely can't use anticoagulants, because the patient is - despite the "thicker" blood - already at very high risk of bleeding right now, as platelets are locked away in his spleen and liver, and the enzymes involved in clotting-factor pathways work more and more sluggishly. He has enough internal injuries, and enough artificial holes cut in his body, that bleeding is by far one of the most likely complications.

(25% chance on some non-trivial bleeding happening in the next 3h, the market thinks, though even if he does start bleeding, it won't be fast - not at that blood pressure - and they have lots of options to keep it semi-controlled until they're at an actual hospital facility. If he does start bleeding, call it a 20% chance, 4:1 odds, that they can keep it under control without compromising the cooling protocol.) 

His sodium and potassium and blood sugar and a dozen other biochemical factors are also going nuts. Merrin is actually having a lot of trouble with blood sugar, which tends to increase in hypothermia, and which she has a hard ceiling on, because too much sugar will set off the next phase of some inflammatory cascades that they very much don't want - even if the rest of the cascade won't happen until they rewarm him, they'll have lost the opportunity to block it closest to the source. 

This would be incredibly stressful, if Merrin had literally any metacognition to spare! She is not, in the moment, even trying to assess whether it's going worse or better than expected; she is completely in flow, immersed in the second-to-second reactions, tracking ahead but mostly only on the level of instinct - as his temperature drops another degree, she expects this and this and this, and will pre-emptively troubleshoot this.... 

She is also, mostly without even being consciously aware of it, telling Kalorm over and over that he's doing SO well and they're ALMOST there.

(Merrin used to have trouble multitasking on 'reassure patient' in sims with conscious or semi-conscious patients, and so she trained her verbal loop to run a Reassurance Script basically by itself while the rest of the Merrin is entirely occupied with life-saving treatments. She normally doesn't actually do it in real life with unconscious patients, or she catches herself and is embarrassed, but real-life situations are almost never as hard or as absorbing as her hardest sims. Merrin is not even sufficiently aware she's speaking out loud to think to be embarrassed about it.) 

She does keep having to flag things for her team, who are also pretty busy - there is significantly more to do than just dialing settings up and down on machines (plus they've divided up which one of them is very closely tracking one of Merrin's machines, in case she calls out that she needs to be spotted on that for a while, which is an efficiency loss but better than Merrin being on her own and overwhelmed.) They've worked together for a long time, though, and she can mostly manage it with hand signals. 

Speaking out loud is generally frowned upon in a situation like this one, for noise-pollution reasons. Her support team is not going to point it out, though. They can subvocalize for their own communications, and if they point it out then Merrin will die of embarrassment, and this is really not a great time to distract her. 

Besides which, it's adorable. 

Aaaaaaaaaaaaaand 18 C! 

....17.9 C.

....17.7 C.

Superheated plasma cannon why is it doing that her equipment is being rude to Merrin personally and also doesn't it know Kalorm is very good and deserves better shut up Merrin's brain. This is not even actually hard to fix. 

...17.9 C. 

...18.2 C flaming pie hole - 

...18.1 C

...18.0 C

- aaaaaaaaaaaaand okay she thinks she is no longer overcorrecting-for-overcorrections. How's her patient. 

Kalorm at roughly 18 C looks terrible, actually!!!

His extremities are dusky grey-purple, mottled nearly all the way up to his torso. There's almost no color in his face; his skin seems practically translucent - and feels cold to Merrin's touch, not just cool. On the ECG, his heart has finally given up on fibrillating and fallen into limp quietude, perturbed only by the sawtooth-bump of the mechanical pump's action. His pupils are once again fixed and dilated. The sensors detecting bloodflow to his gut are now picking up pretty much nothing at all. 

But! For all that, his basic vital signs are not actually that hard to maintain within allowed limits. 

(Said allowed limits - systolic carotid blood pressure between 28-32 with a mean pressure of 20-25, adjusted O2 sat of 35-40% - would not, normally, be very compatible with life. That's sort of the point. They want his neurons and their supporting cells to be just barely maintaining their membrane integrity and ion gradients, and ideally literally nothing else.) 

....Oh, and on the brain-damage-byproducts sensor, just about all the readings have dropped to 'undetectable'. 

Spot-check bloodwork panel, when she gets it, is super abnormal on hematocrit and platelets, moderately low potassium, everything else is basically within the limits it should be in. 

The cooling itself took five minutes; the stabilization and reassessment after took another five. 40 minutes to rendezvous.  

The markets are updating, but the medical experts betting on both the Diagnostic and Treatment Planning sides want to know Merrin's gut feeling on whether she can keep this patient semi-stable and maintain everything within allowed parameters for 40 minutes in these conditions, and then manage a transfer where she temporarily won't have eyes on him. 

....Yeah, Merrin can do it. 

Really, it's Kalorm who can do it, believing in Kalorm is so much easier than believing in herself

Then they'll proceed. 

Updated market predictions: likelihood of the patient surviving to rewarming are still at 93%. Chances of mild, moderate, and severe brain damage are respectively 58%, 20%, 9%. Updated risk of major complications en route, 30%. 

And they fly onward. 

It goes pretty smoothly for a while. Merrin can get into a pretty comfortable rhythm. Not a lot of spontaneous metabolic function is happening, but that same fact is buying Merrin lots of wiggle room.

The team thinks it's safe for her to lower the patient's sodium a lot faster, too, since his low body temperature is in itself protective against brain swelling. She gets it down to 165, which is almost out of the 'critical range' into the 'high but not, like, panic-level high' range. 

...At some point, though, she's going to find herself upping the settings on the mechanical cardiac pump for the third time in the past three minutes. She's been bumping it up and down sort of constantly, of course, but three times in the same direction is enough to stand out. 

Uhhhhhhhhhhhhhh. 

[Something's wrong] Merrin subvocalizes to the admin note-taking and relaying messages for her - it's an entire team, actually. [Cardiac output issue]

     Vellis is already getting ultrasound imagery of the patient's heart (they're checking it often but not constantly, since it does slightly interfere with sensors.) [...Nothing structurally wrong. Just - drop in venous return - anything to explain that?] 

Merrin surveys her numbers. 

....There isn't, really. Not that she can see. 

[Full body scan right flaming now] she tells Vellis, very calmly. 

(It's okay. It'll be okay. This is literally the soonest moment she could have noticed it, and she still has a ton of wiggle room on the cardiac pump - he's probably bleeding, that's the single most likely complication, right, 5:1 odds, the others possible culprits are weirder and might be harder to diagnose let alone treat, but are still much less likely...) 

Yup! He's totally bleeding internally! 

He already was, probably - one of his ribs is cracked badly enough, from the initial trauma plus ten minutes of having his circulation maintained via external force on his torso, to have splintered a little bit, and the splinter doesn't appear to have actually pierced his lung but, for all their efforts to keep him secured and not jostled, there have been a lot of vibrations and g-forces, and at some point that splinter definitely tore something. 

Not a major artery, or they would have noticed this way sooner. Before now, the leaking relatively-minor artery had at least formed a minimum-viable clot to pinch the main bleeding off before the blood loss - or pressure on other organs in his chest - could cause any visible problems, or show up on the CT scan as something more obviously than "bruised tissue maybe" which describes like half of his body. 

Platelets are not working very well at this temperature. There are now way fewer of them than there should be, as his body responds to the cold by tucking them away in his liver and spleen. The continuation of the clotting cascade leading to a tighter-woven fibrin cap never properly happened, at the temperature they were keeping him at, and now the clotting factor activity is very sluggish, and must not have been enough to keep up when a particularly violent gust of wind shook the patient and jostled just the wrong thing in his chest. 

He is now bleeding into his chest cavity, though it looks not the space between the pleural membranes of the lung, which would be worse - still not panic-level bad, he's not super relying on his lungs for oxygenation right now, but a lot more delicate to fix in a moving helicopter. 

Even a torn artery isn't bleeding fast at his current blood pressure, and he hasn't lost a lot of blood, yet. Maybe 100 mls, enough to be visible as a little pocket of fluid where there shouldn't be fluid. Not enough to even inconvenience a healthy person; blood donations regularly take more than that. 

Kalorm is, of course, not currently being kept in a very healthy state. It's not clear if the cause is the blood loss, or (more likely) the slight shift in intrathoracic pressure, but the blood return to his heart, and thus the quantity to squeeze out on each beat, is dropping. 

It's not very surprising when outcomes which are 25% likely to happen end up happening! Kalorm's odds of making it to Default and through the end of the rewarming protocol alive have dropped, but not by a lot, they're still giving him an 89% chance of making it.

It'll probably jump back up to - not quite as high as before, one bleeding incident downstream of his existing traumatic injuries does predict others, but say 92%, a 3% increase. 

(The odds on other outcome endpoints are updating too, but not very much, yet, and mostly downstream of the 4% lower chance that the patient survives to be rewarmed. If Merrin can stay in control with him at 18 C, and his vital signs never go outside parameters, bleeding in his chest is not actually predictive of a worsened cognitive outcome. ...Maybe. It's perhaps more the case that there is a RAGING ARGUMENT going on about this, right now, and the numbers haven't settled.) 

The markets are now actually pretty optimistic on Merrin-and-team's chances of stopping this! Merrin's performance level so far has been high, her focus better than anticipated. They could have gotten luckier and caught the bleeding earlier, maybe - it would have been visible on a CT scan ten minutes ago, probably, but the last CT scan was fifteen minutes ago - but they could also have caught it later. It's from a traumatic injury, which actually indicates less in the way of clotting dysfunction and general physical deterioration than, say, a GI bleed would, and it's probably the highest-risk of his traumatic injuries.  and it's conveniently located for a simple percutaneous go-in-and-cauterize procedure. Quick and dirty, but they'll fix it up later in the real hospital.

The experts still think Merrin and her team have a 5:1 odds of getting the bleeding under control before it's bad enough that they make a call to rewarm the patient. She should definitely hurry, though. Rendezvous is only in twenty minutes and delaying to stabilize the patient will mean delaying their arrival at Default Hospital. 

It's a simple procedure. If they can't stop the bleeding, or if the attempt causes more bleeding, that's really not a great sign, and the markets expect to react with a 15 percentage-point drop in the survival-through-rewarming odds, all the way down to 74%. 

Merrin actually wants Vellis to do this, because Vellis will do it just about as well as she will, and Merrin is planning to instead focus on keeping Kalorm's vital signs super optimal. 

Vellis is on it. 

The markets are watching!  

If Vellis doesn't succeed at stopping the bleeding, this could just imply operator error - especially since Merrin, reasonably given what else she's doing, doesn't want to do it herself, and Merrin is the one with by far the most sim time, especially sim time under moving-helicopter conditions. But probably not. They're a good team.

There is, however, an underlying complication that would predict both 'bleeding' and 'bleeding that is more difficult to stop than it should' be – and also predicts, soon after that, lots of hard-to-stop bleeding everywhere else. Injured patients on three different extracorporeal filter circuits, who have been through a whole lot of other weird medical interventions, are at some risk of disseminated intravascular coagulation - of the platelets and clotting factors responding to an imaginary injury, everywhere, in the process exhausting all the resources they need to (especially in this case) prevent bleeding in a dozen different bruised or torn tissues, or from the various holes they've cut in him. 

The prior is low, but if Vellis fails at this procedure, it's suddenly the top explanation, call it 9:1 odds. And it's a pretty bad sign. A survivable one in the short term, if they do everything right and don't get more unlucky, but a bad sign for the eventual prognosis. 

Aaaaaaaand Vellis is trying it! Very very carefully. So carefully. 

This is indeed an extremely stressful thing to attempt in a moving helicopter! It takes like five minutes before she has a sufficient moment of calm to risk shoving a sharp thing between Kalorm's ribs and cauterizing the leaking artery, during which time he's still bleeding into his chest cavity. 

Buuuuuuuuuut - 

- once she has it cauterized, the bleeding does stop! And appears to stay stopped!

(And still no sign that he's oozing blood from all his orifices, natural and not.) 

The markets breathe a collective sigh of relief; the patient is (at least very likely) no longer having a potentially lethal in transit complication. His survival-through-rewarming odds bounce up to 92%. 

...However, he did just lose an estimated 250 ml of blood, into his chest cavity where it's probably at least somewhat messing with intrathoracic pressure. Vellis is trying to suction some of it out, but most of it has started forming a gelatinous semi-clot that doesn't really want to come up through her soft plastic suction tubing, and they're being very gentle, they don't want to jog that splinter and poke a hole in something else. 

Most of the worry about a complication en route, especially pre-midair-transfer, wasn't about cases as bad as DIC. Just that they don't have a lot of slack on this particular protocol, and Kalorm is in a fragile enough state that any complication on this level of severity, even if by itself it doesn't predict damage, is still a perturbation to a system being maintained in a rather delicate balance. 

During the active bleeding, Merrin has been having to work her butt off to keep his vital signs within parameters. Rendezvous is in less than fifteen minutes. If Merrin's team can't get him a lot more stable than this before that point, then - well, they're going to do the transfer anyway, they do not actually have better options. But they're expecting to spend almost the entire time with the patient randomly outside some number of the narrow parameters, with the predictable result that - even at his current temperature - probably some cell damage, or factors upstream of later cell damage, with accumulate. It'll be really not great. Plus there will be some time on either side of it when Merrin is more distracted.

And then Merrin will still have to try to keep him stable for just over two hours, and her chances of being able to do that at all, if he was unstable going into the transfer and semi-controlled crashing during it, are not great at 18 C. He's still fairly unlikely to die in transport, but they'll lose ground on the stabilization protocol, and may have to abort entirely and bring him back up a higher temperature if it looks like too much for Merrin to handle, or too big a risk of a sudden deteriorating running into a situation that already has no slack. 

The market...is pretty balanced on whether Kalorm will or won't stabilize before transport, which is the strongest predictor of whether Merrin can keep him that way during transport. 40% that he does, 60% that he doesn't. 

- if he does stabilize before the transfer and then tolerates it without crashing, that's actually a modest positive update about his underlying health, and the market thinks it would land on outcome predictions a little better than they were before the bleed. They are expecting that, if that happens, it'll be a 3% increase to 95% chance of surviving-through-rewarming, a 6% decrease to a 55% chance of minor damage, a 3% decrease to 18% chance of moderate damage, and a 1.5% decrease to 8% chance of severe damage. 

('Stable at point of transfer' doesn't guarantee also stable at point of arrival. The shifts will be bigger after that.) 

If he's unstable at the point of transfer, well, there are still a lot of additional things that have to go wrong before they really start losing ground. It increases the odds of those things going wrong, but by less. Call it a 2% decrease in survival odds, back down to 89%, a 4% increase in minor damage to 65%, a 2% increase in moderate damage to 23%, and just a 1% increase for the worst outcome, up to 10.5%. 

Go Merrin! Personnel is rooting for her! 

(Personnel is not saying anything to Merrin because this never helps.) 

(Ranthir might bet against those 40-60 odds, if she were currently looking at that market, which she isn't because there are, like, eight thousand things to look at, and she's also having a raging family argument with her father and little brother via videoconference over the matter of a certain entrepreneur who does not think he can realistically do the thing Finnar wants within two hours.) 

Come on, Kalorm. You can do this. Merrin believes in you. 

Please?? What if Merrin believes in you even harder than that??

.....Kalorm is not super stable, no. 

He's not getting worse. Merrin is, in fact, maintaining his vital signs within the limits given. But he still has a cupful of blood parked against his lung, and they gave him a blood transfusion of the exact quantity they think he lost and then some more plasma when his heart still wasn't really filling with enough blood, but now he seems to maybe be fluid-overloaded. His lactate keeps trying to rise and they're having to give him bicarbonate again to keep his pH in line, and sodium bicarbonate is the safest, metabolically speaking in general, but she's sure having to work super hard not to let his sodium levels creep up again. 

She can do it. It's not even the single hardest thing she's done before. But it would be rough to maintain for two hours, and maybe impossible while in a separate transfer pod swinging in the wind, operating his machines purely by remote control, without even having a good screen setup for visual sensor data. 

It's okay, Merrin isn't mad, she knows he's trying and honestly he could be doing a lot worse, she's doing her part but he's doing his too and she couldn't do this on her own...

Well, it was a lot to ask. Updated predictions: 89% survival through rewarming, 65% on minor damage, 23% on moderate, 10.50% on major. 

The next part is what's really going to matter. 

The markets...do not really expect Merrin to pull this off. Nothing against Merrin, it's just really really hard. A lot of very smart people having been poring over her complete sim-performance record, and she's never done anything comparable to this. It would normally be insane to expect a 23-year-old to do - well, most of what she's doing, but especially what they're about to ask of her. (Merrin in some sense has more clock-time experience than many 50-year-olds, but sim time isn't the only kind of experience that matters, and the fact that she's 23 and actually looks younger is, perhaps, affecting some priors here.) Also, this isn't a sim, the stakes are even higher than usual for a real-life rescue, and it would be totally understandable for Merrin to be operating at slightly less than peak performance. 

They think Merrin has maybe a 25% chance of pulling this off, 1:3 odds. 

If she can't - well, 100 seconds isn't that long, the damage will be limited by the fact that the patient is at 18 C, and they'll have a chance to regain control of the situation for the rest of the flight. The medevac crew - remarkably - includes an Exception Handling medtech certed for all of the machines and reliably able to interoperate 4 of them, so Merrin will be able to get some breathing room. It isn't going to be the single factor that wrecks the patient's odds going forward. It's not great, but it mostly hits the odds of mild-to-moderate damage.

The market expects another 1% drop in survival odds, a 5% increase in minor damage, a 2% increase in moderate, and a 1% increase in major. 

...If they do get lucky, though - well, it won't mostly be luck, and it will make their odds of pulling off this plan look substantially better. 3% improvement in survival, 15% drop for minor damage, 6% drop for moderate, and an entire 3% drop for severe.

(Based on some more careful analysis of case studies compared against Kalorm's early sensor readings, they're more sure that he doesn't yet have that much damage, and that it would take several different failures at halting the cascade for it to get that out of control. There are some tweaks being made to the eventual neuroprotective rewarming protocol in Default that should, at least slightly, improve their odds, if they can deliver a patient who still has sufficiently minimal reperfusion injury. It's not totally original research, that would be almost impossible in the time they have, but they're comparing different versions of the non-secret protocol that have been tested in different cases actually in humans and have a large enough sample size to count for something, and asking themselves how they can tweak the secret protocol - which has gotten less attention and less direct research effort in humans - to work as well as possible for Kalorm, who is apparently in many ways not a median adult male. It's not clear if the changes will be ready to go in two hours, but it helps a lot, for this situation, that the research is happening in Default and not a tiny regional hospital.) 

...Oof. You don't tell Merrin that she would have to be very special in order to succeed at something important! Personnel recognizes that they didn't literally say this, but Merrin is absolutely capable of reading between the lines, and Personnel is worried that she's now even less likely to succeed. 

If other people also think this, they superheated thankfully don't have time to actually bet against Merrin before her departure. 

Time to go.

Well. Not quite. The helicopter is matching speeds with the plane, but Merrin-and-team need to load their patient into the transport pod, without disrupting any of his life support equipment or making him start bleeding again. (Vellis did, eventually, sigh and settle on squirting some biodegradable gel around the site of the bone splinter, after judging it was completely not safe to try to extract it while the helicopter was being knocked around by the storm. It'll put a bit of pressure on any other torn vessels and cushion the surrounding tissues against further damage while the patient is being tossed around in the wind as they reel him up fifty meters on a winch. Normally you could do air transfers closer in, but it would be really very bad if either the medicopter or plane were damaged, and they're not actually out of the storm yet. 

Kalorm does not super like being moved! (They're sliding his force-distributing gel mattress and its supporting base on rails into the pod, not taking him off the mattress; they'll be able to do that for the arrival in the plane too, and probably the arrival in Default; it's not quite as good for preventing bedsores in totally immobile patients as the ones they'll have available there, but it would be convenient to avoid moving him any more than necessary until some of those tubes are no longer attached.) 

"I know, I know, I'm sorry - I know this is going to be superheated awful but I know you can do it, it's not for long -" 

She squeezes his hand one last time, and then they seal the pod, and Merrin is (much less carefully) flinging herself into her own pod, Vellis is fastening the straps for her, and then she's sealed in as well and the world goes away. She can't even hear the sound of the storm, which has been a constant throughout. 

She has a thirty-by-thirty centimeters of LCD screen real estate, awkwardly close to her face, and her console, which she can handle basically by feel, and this is going to suck so much but - mostly on Kalorm's side of things, really, she isn't the one with broken ribs. 

She isn't, in fact, the main character of this story at all. Right? Kalorm is the one fighting for his life. She's just here to be encouraging. Kalorm is the one who's weirdly good at that. Merrin is just here to be a supporting character for this particular interlude of his life. 

This is, perhaps, a point at which the market is betting on incomplete information. 

Khemeth would have caught it, if he were fully paying attention. The relevant pieces were starting to come together in his mental model of Merrin, and if he had seen her face when she was packing Kalorm up for transfer and then climbing into her own pod, it would have shifted some of those pieces, and he would have placed some rather large bets that Merrin was about to outperform those odds, and would have made some money (though not all that much money compared to what he's been spending, today.) 

Khemeth is instead trying to convince his father to let him talk to the head of a research lab who may or may not be willing to do something personally inconvenient for them in exchange for a lot of money, while both only saying true things (he doesn't lie to his parents, or anyone, about important things, just his emotions, which aren't) – and while also not once implying that it's because Finnar has a tendency to, well, offend people, especially when he's convinced a problem is the single most important problem in the world and only stupid people would disagree. 

This is why Khemeth isn't going to notice, and make his bets and recommendations, until after the transfer. 

Here are some facts about Merrin: 

Merrin is stubborn, and high-conscientiousness, and may not be that smart, certainly not in terms of raw processing speed or mathematical ability, but she retains information well, and retains procedural skills better than that. Merrin can and does work twelve-hour shifts regularly, and has ten thousand hours of emergency sim time under her belt, which is ridiculous for someone her age (though of course the first several thousand hours weren't on situations like this; that's just what it took her to catch up to her peers.) 

Merrin is also deeply neuroatypical, sometimes in ways that help - nearly everyone likes working with her, even people who are often cantankerous - but often in ways that are ongoingly costly to her. It's not just that thinking about being unusually good at something - especially if it's in a way explicitly represented by numbers - has a tendency to send her entire brain into a panicky spiral. That, just about everyone who works with her has been willing to accommodate. It's not even just about the chronic imposter syndrome, which no one has even pushed her on that much because of the panic spiral, and because she's psychologically unusual enough that it's sort of unclear what would happen. 

(A couple of instructors tried, and the thing that happens at least sometimes is that Merrin starts crying, which seems, you know, pretty bad? And like they should super not keep doing that thing?) 

It's also that, compared to most dath ilani, rather a lot of Merrin's mind is specifically attuned to social threats, and it's really hard for her to turn that off. She does vaguely know this is a problem when it actually makes her lose focus at a particularly bad time, but often it's not very salient to her, and she certainly doesn't go around thinking that other people don't have a constant background internal monologue running on how other people are perceiving them. She's gotten better at not letting it distract her, but as long as she's being watched, it's pretty hard to tune out. 

...Another fact about Merrin is that her relationship to tests is, well, weird. Particularly in sims, she's especially aware of being watched – and not just watched, but judged on her performance. This is, after all, part of the point. Merrin can cope with it - Merrin can even sort of cope with the fact that way more people are going back and assessing her sim performance, as long as she mostly avoids thinking about that too hard - but it's still distracting. It means that unless she is literally too busy to have thoughts, her mind is running an ongoing thread of commentary, not just on how she thinks she did, but on what the imaginary shoulder-version of her instructor thinks. 

(Merrin is not like Khemeth. She does somewhat more social modeling than median, but not especially well. There's a vast gulf to cross, when it comes to really understanding and accurately predicting the minds around her, and Merrin's social instincts often makes unjustified assumptions. Usually that someone is judging her in a particular way. Merrin's conscious mind knows this, of course, and with enough years of catching herself in the act, she might mostly stop. But it's hard, in a world where it's very salient to Merrin that she is constantly worse at some things than the people around her.) 

Anyway. Roughly, what this means is that while Merrin's performance in sims does improve, by about the rate one might expect based on her general intelligence and other psychometrics, her performance in sims is not a perfect correlate of her performance in real-life situations, which are not tests – and where, very saliently in this particular real-life situation, she is currently in a sealed pod swinging from a cable in a stormy void, and no one is watching her. 

(Well. A lot of people are certainly watching every patient-oriented action she takes. To Merrin's brain, right now, this doesn't count. Kalorm is the main character, and everyone including her is quite reasonably watching Kalorm, and so of course that includes what happens to the settings on his life-support machines.) 

Another Merrin fact is that she assimilates information pretty slowly, by dath ilani standards - especially in Exception Handling, where most people are above median thinkoomph - and particularly dense numerical information. She did flip past those screens, shortly before embarking into her pod, but she completely missed any commentary that might have been about her, and honestly she only half-parsed the numerical probabilities given, seriously, she had like eight other numbers in her working memory, she was sort of instantly dumping numbers that were not ones she could directly change by poking her console. 

This is not normally an advantage, but right now it's plausibly decreasing Merrin's anxiety. 

Also, Merrin is filling basically the entirely of her social-modeling-slot with Kalorm and Kalorm only, because (yeah, okay, fine, after the fact she will admit that she was doing a weird anthropomorphizing thing where she attributed volition to a system when that was not meaningfully present, but it worked okay.) 

(And even Merrin's social instincts are not insane enough to think that Kalorm is judging her right now.)

Merrin's mind feels quiet and spacious and the world feels very small and it's all so simple, really - it's hard, it's a lot, but it's not complicated, not the way everything else is complicated.

There are just a handful of numbers that matter (and a much larger list of numbers that also matter, but, like, less, she can just straight-up ignore his flaming sodium levels for 100 seconds) and the alarms sing to her and she reacts and in one way it's like there's no Merrin at all, because there's nothing at the center of her but shifting numbers, certainly no Merrin that is aware of her own existence why would she bother using any cognitive capacity on that - and in another sense she's never been more alive - 

Fifteen seconds in, it could just be luck. Thirty seconds in, though, the markets start to update on the fact that this is very clearly going better than expected. 

In the Exception Handling control room, there is a discussion happening. It's not heated so much as confused. 

"...And she's only a level-5 medtech?" 

     "She's twenty-three! Were you a level-5 medtech at twenty-three?" 

"She's an endurance EMT. Have you seen her sim records?" 

     "- This is NOT just about endurance! Thellis can do sixteen hours but she doesn't do it for fun – honestly sometimes I wonder if Merrin just enjoys suffering–" 

     "...She really hasn't done this before, though? Even in sims? Just. She's doing 30% better than her extrapolated performance and I thought we were extrapolating in generously." 

"No, we have not made her manage six machine controls, three of which are extracorporeal circuits, while both her and the patient were subject to storm-level random g-forces. Until this happened I would have said that wouldn't possibly come up." 

     "I don't think she's actually carrying all six, not to sim standards - she's simplifying it, see, she's - I think she literally just put the ventilator on standby mode - and she's temp-silenced alarms on the sensor values for the hemodialysis and liver module, see, she's only responding to filter pressure alarms..." 

     Gesture at the screen showing the patient's vital signs. "I mean. Is it or is it not working?" 

Snort. "She should get paid more." 

     "Oh, she doesn't check how much she gets paid. - I mean, I'm not denying she should get paid more, it just won't meaningfully incentivize her performance." 

"......" 

     "WHY does she work horrible sims if not for the performance incentive? I'm serious - have you seen this sim they made her do–" 

"She asked for that. I think it's a competitiveness thing." 

     "She doesn't even like competitions!" 

The update on the Diagnostic markets is enough to get Khemeth's attention. 

He looks at it. 

....He pulls up the last ten minutes of recorded camera footage from the medicopter. Skips to Merrin while she's packing up for transfer. Replays the ten-second loop of her sealing Kalorm's pod and hopping into her own, watching her expression closely...

- he tells Ranthir to place some bids on the markets, and then he sends an urgent recommendation to be forwarded to the medevac-plane crew and the coordinating team that might communicate with Merrin directly. No one should congratulate her on this. They can say it went smoothly and the patient did fine, since that is indeed what happened, but if they have to look impressed, they should do it about Kalorm. Poooossibly they should imply to Merrin that the main update here is how her patient is superhumanly tough. It might even be sort of true! There is some level of patient instability that Merrin couldn't have coped with; he doubts she could have kept a sixty-year-old nearly as stable through that! Anyway, they should mostly be matter-of-fact about the whole thing. 

(And someone should quite possibly talk to Merrin, plausibly him, but...not now. Not when she's trying to save his brother's life, and he really, really wants her to keep performing as well as she just did, and is not even particularly bothered if this means they have to sort of deceive her about how impressive she is.) 

....Personnel is super not going to argue with that. 

At some point, all the bouncing around stops and there's a final thump and rattle and then everything is very still. There's the faint vibration of engines below her, but they're very smooth engines. 

A message flashes on Merrin's screen: transfer complete, patient did fine, given that he's not actively deteriorating and is currently super well secured against acceleration, they're going to leave him in the transport pod while they turn the plane around and get enough altitude to fully clear the storm turbulence, objections? 

Objection, there is something on her screen that isn't a blood pressure, what is Merrin supposed to do with that  Seems fine. Merrin will just stay right here and get back on top of his sodium. 

It's about ten minutes. 

It's so quiet and peaceful in her little pod. Merrin is definitely getting itchy about laying eyes on her patient again, but she diligently deals with all the values that slid off in random directions while she was ignoring them. None of them slid very far, which is why she ignored them.

She flags that the patient's lactate is up again? It's fine, she suspects he just got a bunch of sudden venous return from his extremities, something was sure going on with that, and she can compensate for now by keeping his CO2 right at the bottom of the allowed range, but he's going to need another dose of bicarbonate as soon as they can physically access him. 

And then they crack open Merrin's pod! 

(The others on her team rode up on more normal personnel harnesses, so they could supervise the pods. They're all pretty wet.) 

A level-6 medtech greets her. He nods to Merrin, in a friendly but terse way that implies he does not find Merrin all that interesting. "Decent work. The patient handled it very well. I mean, I know you're watching his vitals, but we've done a repeat scan in the pod - no new bleeding, no worrying changes at all. We're about ready to transfer him to our Complicated Patient Area -" 

"Oh good!" Merrin scrambles up. "Uh, here, let me - some of the machines are really fussy when he's this cold..." 

(Something that happens with human brains, not unique to Merrin - but which does seem to happen especially to Merrin, who works so heavily from pattern-recognition, and whose thoughts are often only legible even to her if she's prompted to stop and think about it - is that, after coming on two hours of very closely watching a lot of correlated signals and trying to tease out the patterns, you start to develop what one might call SUPERSTITIONS. Usually a dozen of them are completely spurious for every one that's real, but you don't know which one.) 

Merrin is kind of desperate to see her patient with her actual eyes again. 

Kalorm looks....mostly fine? 

- well. In fact he looks super awful! Just. Not worse than he did when they put him into the pod, and better than he has any right to at his current body temperature, blood pressure, and general level of metabolic function. 

They get him transferred properly into the Complicated Patient Area. This is a delicate procedure but Merrin is feeling GOOD about THINGS right now. Her faith in Kalorm was justified!

"Want us to spot you for ten minutes so you can have a break?" Altham, the level-6 medtech, asks her.

(He's about forty-five, nearly as old as anyone gets as an Exception Handling medtech - it's an exhausting job that pays well enough to retire at a sensible age - and he does, actually, have more sim experience than Merrin overall, though perhaps less tilted towards the really intense sims that are made of suffering. He also has way less patient context than Merrin, and he can't cover this complicated a protocol for two hours. He's on the flight team mainly because he was nearby enough to make the takeoff deadline, and because after that many years, there are some obscure procedures he's certed for that Merrin doesn't know, and a lot more that she's only ever done in sims and he's seen half a dozen times with real patients.) 

"I was mirroring your sensors and controls from here for the last while, so can spot you on the cardiac pump and extracorporeal circuits, and one of our team is up to speed on the rest and can cover it without much efficiency loss." 

She glances down at herself. "I...guess I could change out of this wetsuit? And I do have to pee." 

Merrin comes back no longer a Sparashki and now wearing scrubs! It's not going to take her more than three minutes, and she doesn't want a longer break than that, she is feeling sort of possessive of her patient. What if Altham didn't notice the thing where if you let one of the liver functions slip too much then the filter pressure alarm starts going on the ECMO circuit for UNKNOWN AND MYSTERIOUS REASONS. 

Markets are now updated and settled again! 

They're feeling optimistic. Survival likelihood is up more than they'd predicted, all the way to 95%. (The general feeling is that the worst is over, and if Merrin can handle that she can almost certainly handle more random complications as long as they happen in a nice mostly-stationary not-terribly-equipped medevac setup.) 

Prediction for minor brain damage: 50%, which means 50% on 'no permanent damage at all'.

(Though there are very likely to be temporary deficits, and the awkward thing is that the damage markers detected during rewarming don't...seem to be especially predictive of whether those temporary deficits are going to resolve? The sample data is mostly patients with localized strokes, and - some of them were fully back to baseline in 3-6 months, some weren't, the difference is probably something about the brain that isn't directly about the total cell damage. Kalorm's odds are currently judged to be much better than one would predict based on how those patients did - there, it was more like 20% who fully recovered to baseline - because 25 is probably a better age for it than 50, and because 'something about the brain that predicts recovery' is maaaaaaaybe the same sort of thing as Kalorm's general physical resilience.)  

Moderate: 19%. Not as big a drop as hoped, because despite Merrin doing a very impressive job on keeping the patient approximately stable, there was a small spike in damage markers, most likely indicating new concussion-type damage from the forces involved. It wouldn't be a big deal for a patient at a healthy baseline - they can confirm that the patient's brain still looks structurally normal to CT - but the cascade is cumulative.

Severe: ...actually, all the way down to 6%. This wasn't just about Merrin's performance. There are hopeful updates to the timeline on getting access to some particularly obscure proteins and other biomolecules needed for the customized-to-Kalorm version of the rewarming protocol, and there's also, maybe, a soon-incoming update to the interim stabilization protocol that will help them get ahead on things. 

...Also, they did the transfer more efficiently than hoped, and think they can make up some time in the air. ETA to Default is almost exactly two hours. 

They fly. 

This is fine it's fine Merrin is definitely fine, Merrin is not the one having a bad day, but - wow, she hopes poor Kalorm is going to have an easier time of it once they're safely in Default and don't have to keep him so cold. 

Keeping his basic vital signs within parameters is actually mostly going okay. They're not even having to use the backup vasoconstrictor-dilator much. 

Dialysis is getting less effective as time passes, though, mostly because the blood viscosity at this temperature is really hard on the filter, but also it was janky after the transfer and never quite got back to normal. They super do not want to try to swap out the filter in flight and risk perturbing everything else; it's adequate for now, Merrin can keep gradually decreasing his sodium and should have it down to 155, which is where they want her to pause it anyway, by the time they reach Default. Keeping the other electrolytes in line is easier. Mostly, it just means less wiggle room on taking fluid off, so she has to be very careful about managing filter pressure in the other two circuits via dilution. 

His native liver function is failing - slowly, gradually, but with a noticeable trend. They're probably going to have to switch him to the full-size liver machine once they reach the hospital, even though they think there won't be permanent organ damage; some of the waste products that they can measure on blood panels, but that Merrin cannot correct with the limited version, are going to be pretty bad for his neurons once they start rewarming. 

His hands and feet look awful. There are no detectable pulses, and it's questionable whether even capillary refill is present. 

30 minutes in. 90 minutes to go! 

Treatment Planning has some new recommendations for them!

They have also rejected really quite a large number of proposals for being sufficiently "experimental" that they were judged about as likely to kill the patient as to help. They don't want to do that! The patient has decent odds right now! Not, like, amazing, but 95% that he'll be alive at the end of the rewarming protocol.

(After that point, there is some lesser probability of a fatal complication, but mostly the True Death outcomes are ones where the patient, or his decision-making representative, choose truiicide over the outcome they got on the first try.) 

Anyway, apparently the patient's father is an AMATEUR BIOCHEMIST, and while he is fact surprisingly good, given that his field of expertise is something TOTALLY DIFFERENT, the Exception Handling liaison who has been tasked with hearing his suggestions is very tired. 

(Merrin does not need to know about any of this, to be clear, they are just COMPLAINING.) 

Actual recommendation: they want Merrin to try infusing low-dose magnesium sulfate directly into the brain circulation. It's unlikely to do much harm since it's present in the body all the time, they can stop right away if that seems not to be the case, and it does in fact have metabolism-suppressing effects, well studied in rats even. If it works, they can raise the ceiling on the blood pressure and O2 sat limits and cut the risk of other end-organ damage. 

DO THEY HAVE ANY IDEA WHAT MAGNESIUM SULFATE DOES TO BLOOD PRESSURE BECAUSE THE THING IT DOES IS NOT INCREASE IT 

....It's okay Merrin is okay she is just maybe a little bit stressed and the constant high-filter-pressure alarms on her THREE extracorporeal circuits are maybe kind of getting to her.

(She has been reluctant to make the alarm limits less sensitive, because not intervening until a much higher threshold would be fine for another 90 minutes but she has to budget for 8-12 more hours after that, and guess what Merrin does NOT feel like doing in the middle of a complicated and stressful rewarming protocol. If you guessed 'swap out extracorporeal filter circuits without getting blood everywhere', you were correct!) 

It's...probably tolerable if they're targeting the brain directly? Then it can be actually low-dose, and also she can manually filter it out of the systemic circulation on the dialysis-circuit side and not, like, completely wreck the point of administering it at all. 

Merrin would kind of prefer if Altham inserted the drug-administration line. She doesn't want to multitask any more things right now it wouldn't be fair to Kalorm, the deal was that she does her part as long as he holding up his end of things, which he IS she's so proud of him

The markets are not super sure this is going to work! The main reason to try it is that it's unlikely to be a disaster. 

Call it 30% that it works, 70% that it doesn't. It's judged to mainly impact the mild and moderate damage categories; if it works, markets are guessing a 7% and a 3.5% reduction in those outcomes, respectively. 

If it doesn't work, they're mostly where they started, but a bit worse off: it's not zero risk, and it's time wasted, and weak evidence that similar interventions also won't work. Call it a 3% and a 1.5% increase. 

(There is nonzero risk of the procedure for them to directly access the bloodflow to the brain in order to inject things into it itself being a disaster, but it's not much above zero. Altham has the cert, has a lot of experience, and they're now well out of the storm and cruising smoothly in a quiet peaceful still-dark sky.) 

STRESS

The procedure goes fine! 

...There is no reason to think that the very-low-dose magnesium sulfate is doing literally anything, at least not based on a few very approximate proxies, like CO2 readings from the venous blood directly draining from the brain versus everywhere else. 

His blood pressure is fine though. 

They could try - 

No! That is back to sounding like an uncomfortably high risk of killing the patient! Who is currently 95% (96%, actually, updated based on the fact that they're barely an hour away from Default now) likely to still be alive at the end of the rewarming treatment, and honestly it's going to be pretty hard to push any lower on the brain-damage outcome predictions, they're at the point now when most of the probability mass there is from damage that already happened.

(That happened before Merrin even got to him, in fact, and the Exception Handling liaison is being so good about not pointing out how the best way to avoid that would have been if Kalorm had radioed for help right away instead of an hour later. It does not seem likely to help.) 

Anyway. ....Still no on that suggestion too, they're not - seriously that research was done on frogs– 

FINE then, Finnar will go back to his original Plan A, which was to figure out a way to FIX BRAIN DAMAGE. Which, you know an actually competent Civilization should ALREADY HAVE SOLVED, surely, nobody is denying this is a really important problem! But how much can you expect of people, really. 

To the family groupchat: plane is an hour out, time to start thinking about relocating to the hospital. 

Do they all have to be there? Hospitals smell weird. And they're so intense about ""noise pollution"" so she can't sing. Mallor does not feel like it is in any way her comparative advantage to hang out in a hospital while Kalorm is, like, definitively unconscious for at least the next 12 hours. 

Technically they are going to be keeping Kalorm in a medically-induced coma for probably a lot longer than that! Finnar did not know this three hours ago but now he has read all of the usual protocols. Kalorm will 99%+ not be conscious within the next 24 hours! Even if he does super well and they want to reduce the sedation earlier than usual, it's currently around 4 am local time in Default, and they're going to prefer trying to wake him up when they have daytime personnel on hand, there are studies showing that medical personnel working night shifts in their local timezone have mildly reduced performance even if you reduce their shift length by 25%. (Yes, Finnar also found and read all of those studies within the last 3h. He's a fast reader.) But anyway it'll probably be more like 48-72 hours given Kalorm's injuries from the boat incident and ensuing near-drowning, they're going to lean toward keeping him under sedation until he's medically stable. 

(Finnar has learned so much about critical care medicine in the last few hours. It turns out it's really fascinating! He is maybe going to have to invent some new medical equipment after this because he keeps thinking of ideas.)

Anyway, sure, Kalorm will in fact not give a superheated pool of feces whether Mallor is there this morning. 

Though has Mallor considered coming and just singing anyway? Finnar doesn't mind, nobody in the family minds, probably a lot of people won't mind as long as she doesn't do it literally in Kalorm's room or the on-site command center while they're in the middle of high-stakes procedures, and they can just compensate anyone who does mind.

If the weird smell is a dealbreaker by itself they can find a scented product that isn't banned in hospitals, or just pay a lot of money to break the rule where a lot of scented products are banned in hospitals because sometimes people are allergic to them.

(Finnar sort of wants a full show of family solidarity, here. It feels important even if Kalorm won't know until later. And, on some level, he wants to have his other children where he can see them.) 

...It's perhaps not so much a smell per se as just a general indefinable way-that-hospitals-feel. Mallor thinks this is mostly about the fact that hospitals have a lot of sick people in them, even if they're behind closed doors she still knows they're there. Mallor is really not sure if that is the kind of thing you can fix even with a lot of money. 

She'll come, though. 

Nerdel, three hours ago, was faced with the major logistical-planning question of: when one is bringing together one's entire very large, very stressed-out family to camp out at a hospital for an unknown length of time, what does one pack? 

(Besides the obvious course of having their nearest family-vacation-house-module transported over to dock with the hospital. That's actually a pretty good step-one plan - but also she has seven children, some of whom haven't joined in on a family vacation in multiple years, and so this isn't a complete solution. What if Ranthir no longer likes the same model of pillow? What then?) 

She did the obvious thing, and funded some prediction markets about it. 

She also called ahead and was promptly put through to the Medical Crisis Liaison department at the hospital, to discuss in advance some of their family's circumstances and support needs. 

You don't actually have to call ahead! Dath ilan does not necessarily expect people who just received unexpected and terrifying news about the medical condition of a family member or close friend, and are now frantically rushing to the hospital, to have time or be in a good emotional state to make their needs and preferences legible. (Also, it's not uncommon for people to just straight-up document what support they would benefit from, if they end up in a hospital not as a patient but as a friend or family member of a patient.)

Hospitals are mostly focused on patient outcomes, of course, but Civilization broadly prefers for things to be better rather than worse, even if the thing in question is not the primary goal of an institution. Having a loved one experiencing a medical crisis is an awful situation to be in, and dath ilan does not want any of that awfulness to be avoidable awfulness. And it's generally understood that, given the stress and also the likely accumulated exhaustion of being in an emotionally vigilant state for many hours or days, people are going to be in a weird corner of their psychological state-space, and might find apparently very random things upsetting and have unusually little emotional slack to cope with that. If you think that you'll feel a little bit safer and calmer in a room that has the exact vibe of a particular scene from an obscure amateur-TV-show-of-a-fanfic-of-a-popular-TV-show, and also does not contain a hint of the color yellow, providing this is really very cheap compared to the heroic medical interventions happening a few rooms over.

Also! Keeping the patient's support people updated - and hearing their responses - is sometimes genuinely relevant to optimizing for patient-QALYs! People close to a patient have a lot of private information about them, which the medical prediction markets cannot be assumed to have. Most of it isn't medically relevant information, but sometimes it is. The Medical Crisis Liaison caseworker assigned to a case has extensive training in communicating about the complexities of biochemical models justifying a diagnosis or treatment, updating prediction market probabilities, and cost-benefit analyses to people who may be all over the cognitive-ability spectrum and who are also having the worst day of their lives. 

If they don't have explicit directives, either verbal or written in advance, they still have public information to go on, and will spin up some policy prediction markets on their end to inform how to set up the Family Room (sometimes on literally ten minutes' notice, but the hospital has a wide variety of quickly-customizable furniture and decor in stock, that's also cheap compared to actual medical treatment) and to assign a caseworker. All of the Medical Crisis Liaison caseworkers have a minimum set of qualifications and experience, but they don't all have the same background, and different families-or-friends have different communication preferences. If they do have private information to go on, they'll usually still run prediction markets during a case, for anything that lets them avoid bothering or interrupting people who are in a strange place, probably tired, plausibly very cognitively overloaded and decision-fatigued, and definitely dealing with more than enough emotional challenges. 

It's honestly really helpful in this case to have more to go on, because dear superheated geysers this family dynamic is complicated. 

Agreed! Also, several aspects other than just the family dynamic are pretty complicated! Exception Handling is going to provide their own team. 

(All of whom have sworn high-grade secrecy oaths, and are cleared to know certain facts about this family that even most of Exception Handling isn't aware of, but saying that would itself be leaking information.) 

The assigned Exception Handling Medical Crisis Liaison is named Dathim (and will introduce herself by name if anyone seems to care, but otherwise defaults to letting them call her by her role). She is highly qualified, has over a decade of experience, and is secrecy-oath-cleared. 

She immediately reviews all publicly-available data on the patient and (even more importantly given her role) the patient's family. On the one hand, it's fascinating reading, but on the other hand she is already feeling very tired.

One of Khemeth's open text-conversation windows is with his boyfriend. He...has honestly been prioritizing it below almost all of the other realtime text conversations. Mostly because, one, Dekan trusts him and Dekan is also a sane and well-adjusted person who can handle himself and so this piece of the complex emotional puzzle is unlikely to fall apart no matter what he does -

- and two, because Dekan is going to want to interact with Khemeth's emotions.

Khemeth is currently LARPing being a person who is not having any emotions, because he can't manage to dig up any that are useful. He feels like this is sustainable at least in the short term, which is what matters in an emergency. He would prefer that his emotions continue to not be anyone's priority. He is pretty sure that he can handle this for the next 12-24 hours, and it won't be easier if he suddenly also has to navigate Dekan being sad because Khemeth is sad. 

(He has also been multitasking a number of conversations to a ridiculous extent for a while, now, and while that in itself is in his wheelhouse, he's ALSO having to actually read the dense technical medical papers that Finnar keeps sending him, which is NOT.) 

Dekan is not confused about any of Khemeth's recent behavior, which mostly means that it doesn't hurt. 

He would prefer if things were going differently, of course. He would prefer the hypothetical world where he could go join his boyfriend at the hospital, and maybe make some useful contributions, but if not, at least be there while Khemeth was repeatedly making agonizing cost-benefit-analysis judgement calls on behalf of someone who he loves (and who has given him so little to work with.) 

Instead, they are living in the world where Dekan shouldn't even try to be in the room, however much this would help Khemeth make critical decisions more effectively and at a lower emotional cost – because, thanks to decades of complicated emotional history, it would be net-negative-in-expectation.

Dekan is pretty sure Khemeth would also prefer that different events were happening, and that different events had happened in the past, but - given the actual history, and recent events, and the problem they now have to solve, and the resources available to solve it, and the fact that Khemeth is very much himself - well, Dekan knows his boyfriend very well, and he understands. 

He knows better than to interrupt and bother Khemeth by asking about what he needs. He is still pretty worried. 

Khemeth packs up his office. (This doesn't take long. Most of what he needs on the scale of 12-24 hours is computer-based, and he's sent that data ahead to Default Hospital. Nerdel will have handled anything else.) 

[headed to hospital now] he messages Dekan.

A pause. 

[wish you could be here]

It is vaguely tempting to retort with "well who's stopping me from being there" but Dekan does not say this, even in private text chat, because it would not help. 

[will be here and receptive next 24h if you need anything, flag any needs where I have comparative advantage to help*] he answers. 

*I am pretty sure this requires fewer syllables in Baseline but I am not sure which ones.

[noted] 

Finnar would like to check whether they can bring his wall-display-projector to the hospital? He's using it for important work. 

....Yes, Khemeth did think of that. The room being prepared for them should include an identical model. 

What if they calibrated the display settings wrong. 

Khemeth did check that and he's pretty sure it'll be fine and if not they will fix it. 

(...It hasn't even been four hours and he's already so tired.) 

30 minutes to go before landing! 

Not that Merrin's work will end there!  Just. During this particular interlude, she keeps having to be MEAN to Kalorm! For example by keeping him really cold at 18 C! And then shoving him into a tiny transfer capsule and subjecting him to the full winds of a storm!

She is super looking forward to landing in Default! Both because she will have way more backup so she can stop worrying about killing her patient because she's stupid, and because once the have everything in place for the neuroprotective rewarming protocol, she can instead be NICE to Kalorm, by letting him rewarm to a less insane temperature. 

(Merrin is having to juggle a lot of factors right now, and she can do it, she can keep up, but it's frustrating and stressful and emotionally draining. She is trying really hard not to let that slide into being mad at her patient about how he cannot flaming stop doing weird stuff with his electrolytes that forces her to run the dialysis harder, which means upping the dilutant fluid at the top of the circuit, which means that to keep overall fluid-input-to-the-system at an allowable level she has less wiggle room for dilutant in her other two circuits, which means the high pressure alarms going off CONSTANTLY and she wants to PUNCH the machines producing them for being INCONSIDERATE of her FEELINGS.) 

(Yes, Merrin is on some level aware that she is attributing agency and volition and social goals to a system which absolutely does not have them. Her brain is going to insist on doing that about something anyway, it's better than being socially anxious about all the people watching her.) 

Public announcement on treatment planning: they have everything ready on site to start phase one of the protocol as soon as they land in Default.  Some details of the treatment protocol have been blocked from the public feed at the family's request, to make use of proprietary research to be published soon. 

(This is obviously not ideal, in terms of the medical experts contributing to the prediction markets being fully informed, but it's not unheard of. The trading entities have strategies to account for that uncertainty, and it lets them keep the public markets up.) 

Separate announcement from Exception Handling, to only the people cleared for grade-three secrecy and higher (which includes everyone on the medevac plane, and at least a solid fraction of the experts betting on the markets): they're using a more complex experimental protocol that includes elements which are not published yet for reasons. 

Here is the full updated version to familiarize themselves with before landing. 

Merrin cannot currently assimilate complex novel information very well, since she can only look at screens that are not her main sensor data or machine settings in fifteen-second chunks before an alarm starts screaming. Can someone review it and then explain to her like she's eight what the differences are from the version she's drilled in sims. ...Maybe starting with just the differences in phase one, there is no way she's going to retain details for six hours. 

Of course! It was predicted that Merrin was going to want this. There is a simplified flowchart that just highlights the differences, and someone will go over it verbally with her as well. 

They're going with slower rewarming - twelve hours, not eight. Justifications: they have more degrees of total rewarming to cover since they're starting from a lower temperature, they think the patient can tolerate it, and the prediction markets on Merrin have faith in her ability to stay on her feet and maintain consistently adequate performance for that length of time, if she has the support she needs, which she will. They're moving these three peptides from phase two to phase one, and adding this custom protein. (It's possible that additional custom proteins will be added in phase two and three, but that depends on whether they can synthesize them and test them in vitro before the relevant timepoint.) They've tweaked a lot of the dose and rate ranges, based on a genetic analysis and models of how Kalorm will respond, but the computers will handle those calculations and they have people double-checking them, Merrin doesn't have to worry about getting one wrong out of inattention or something, just be aware of it as an aspect of the system she's managing. 

Okay. She can do this Kalorm can do this. The hard part is all on him. Merrin just has to be a helpful sidekick and tough it out with him for the duration, and she can do that, staying on her feet and functional for sixteen hours really just takes willpower and pushing through suffering. 

(...This is not really true. In moments when she has more metacognition online, Merrin knows this isn't true. But when faced with a situation this daunting, framing it that way eases the strain on some part of her that she has a hard time looking at directly.) 

Seen from the air, an hour or so before dawn, Default City is beautiful. (Especially the region around the hospital, which has lighting even at night.) And finally, years after Merrin left Harkanam, it feels like coming home. 

Fanthim is the Support Worker assigned to the family – separate from the Medical Crisis Liaison, whose attention will be mainly on staying up to date with the medical case, her full attention will be on the family. If Kalorm survives rewarming, he's likely to be here for weeks recovering, and while the Medical Crisis Liaison will be reassigned once the situation is no longer actively a crisis, Fanthim will stay on the case through to its conclusion. Whatever that ends up being. 

She is, like Merrin, an outlier on stamina – not to the extent that she could do something as cognitively taxing as Merrin's current role for sixteen hours, but she can be on duty through the end of the rewarming period and a little longer. She works for Exception Handling, is considered highly legibly trustworthy and cleared to make a very high grade of secrecy oath, and she is currently reviewing the full dossier of non-public information on Finnar and his children. 

Aaaaaaaaaaaaaaaaaaaaaaaaaaaahhh!!!???

The basics: 

Finnar's parents, like many couples, had prediction markets on whether they ought to have children. They were both highly intelligent, talented people. It was predicted that the child they would have if they combined their genes would be very very smart, neurodivergent in a potentially-valuable-to-Civilization way, and not at incredibly high risk of a lower-than-average happiness setpoint. 

It was also predicted that their child was likely to be challenging to parent, and that, combined with his mother Mirrell's other risk factors, it was likely that having a child would make her unhappy, and the odds were high that this would spiral into untreatable depression. The overall policy recommendation came out solidly on the side of not taking that risk. 

Mirrell wanted a child, and she knew that her partner wanted to be a father, and she was very stubborn. She ignored the prediction market recommendations. 

The markets, unsurprisingly, weren't wrong. After her child was born, Mirrell was in fact miserable, and this didn't resolve over time – in fact, it was getting worse as years passed. She was likely suffering from some sort of post-partum chronic fatigue syndrome that made her depression harder to address. Mirrell's depression was making her partner, Firrin, unhappy as well. Living with two deeply unhappy parents was not considered a great childhood environment. 

Mirrell expressed wishing she could die for years, but didn't want to leave the other affected people in the situation worse off. At some point, though, prediction markets concluded that if Mirrell were no longer in the picture, and Firran remarried another woman, they would be compatible partners and he would eventually be significantly happier than he was while co-raising a child with a suicidally depressed coparent. 

Mirrell didn't want to be cryopreserved. She said that she saw no particular reason to expect the Future to be any better than this. 

Firrin convinced her to talk to a Keeper about it before making a decision. She did. The relatively shallow conversation - its contents confidential, of course, but likely mostly about Mirrell's preferences and whether her reasoning included a flawed premise, and perhaps some vague details about the Keeper's information on the Future - did not change her mind. 

In another world, if Mirrell had been a somewhat different person, perhaps they would have been able to give her the option of swearing a high-level secrecy oath, and learning more specific details about the work being done in the Basement. But this was a very high bar, and Mirrell - especially at this point of her life - was not considered legibly reliable enough to make that oath. 

Finnar's mother truicided when he was six years old. 

AAAAAAAAAAAAAAHHHH it's a good thing Fanthim had some warning and can read this in advance and get her own emotional reactions under control and tucked away where she won't be making this poor family deal with that as well. (It's okay for them to be emotional in front of her, she fully opted into that by having this job at all, but the reverse is very rarely helpful.) 

This was, of course, an Exception of enormous magnitude and stakes, and after it happened, Civilization did direct quite a lot of its resources and collective intelligence toward managing the fallout and mitigating the damage. But there was only so much that could be done. Possibly the whole tragic series of events had been almost-guaranteed to play out like this from the point at which Mirrell decided to make a choice with predictable, and predicted, consequences. 

(It's genuinely hard to know whether Civilization should have had a different policy of what to do, of how much to step in and meddle in the lives and decisions of two fully-informed adults. It's clear that Mirrell, making that decision, valued something a lot more than her own happiness, and maybe got it; she did express, strongly, that she had never regretted choosing to have Finnar, that she was grateful to have been a mother and glad that Finnar, specifically, existed, however much suffering those six years had brought her. And although it's not true that her choice harmed no one but herself and her equally-consenting-to-this-risk partner, because Finnar was very much harmed, it's still true that in the counterfactual, Finnar never existed – and though the actual Finnar who did exist was of course devastated and furious, it wasn't obviously the case that his existence was net-negative from his own perspective. Besides, while 'Mirrell is unhappy' was something the prediction markets saw coming, the resulting outcome was a lot worse than the median prediction.) 

...Civilization does believe in causal attribution, whether or not it makes sense to frame it as blame. It has Official Experts and Standards about attributing causality (as plays a central role in impact markets). There was an answer, or at least a best available prediction, of "why did Mirrell truedie, and was anybody responsible for that even in the sense that they'd have been paid a bonus if that had been a good thing". Civilization also does not believe in concealing that information from involved parties, and there was a straightforward market-grounded-nonmarket-prediction of the counterfact that Miriel would've had a 30% chance of still being alive or in cryo if she hadn't given birth to Finnar.

That information was available to Finnar himself, if he chose to seek it out, which he did. 

(From a fault analysis perspective, the main actor in the situation who made a deliberate choice, and could have made a different choice, was Mirrell, though the counterfactual world where Mirrell placed more of her trust in the policy markets, and was more willing to let that override what she wanted and cared about, does sort of boil down to "if Mirrell had had different values". And from another angle, one might attribute fault to all of Civilization, for failing to offer Mirrell something worth sticking around for. Just about nobody would place any fault, even fault-not-in-the-sense-of-blame, on the small child, who hadn't chosen to be born and could not meaningfully have decided to, instead, be a different small child who was easier for Mirrell to parent.) 

From Finnar's perspective – a child more than smart enough to follow that causal analysis, but still with the emotional maturity and nuance of a six-year-old – it seemed pretty clear that his mother's death was his fault. 

But not only his fault! Mirrell had, after all, cared about the wellbeing of her partner and her son, and stuck around as long as she believed her departure would leave them worse off. Which meant, from Finnar's point of view, that another blameworthy actor was the woman willing to remarry his father after his first wife's True Death. Or at least this was probably his reasoning; the observable effect was that, from the very beginning, Finnar hated her with the fury of a thousand supernovas. 

(This was perhaps foreseeable in advance, if the right eyes had been on the situation before rather than after Mirrell's truicide. It's also unclear if it reflected a mistake in Civilization's priorities, that those eyes weren't on the situation until too late.) 

In any case, Firrin wasn't going to subject his kid to a stepparent he detested, and so Firrin was not going to pursue a relationship with Indis as long as he was still raising Finnar, despite the fact that he was grieving, deeply miserable and clearly struggling to parent his traumatized and also very neurodivergent child (who on some emotional level he probably did resent after what had happened with Mirrell), and the prediction markets thought that he would be happier if he remarried. 

Finnar was not oblivious to this, and was also very bitter and angry with his father. He was about nine when he started insisting that he would be FINE on his OWN and DIDN'T NEED A PARENT ANYWAY and everyone would really be better off if he MOVED OUT. Perhaps unsurprisingly given the sheer accumulated tangle of emotional history with his father, the policy markets agreed with this assessment. 

POOR TINY CHILD also this is so upsetting.

....And the current situation has to be one of Finnar's worst nightmares come true, for even more reasons than she had previously known. 

....Finnar was thirteen when he noticed some fishy inconsistencies in certain cover stories, made some inferences, and was getting dangerously close to straight-up guessing the existence and purpose of the Basement. Per policy, he was approached by a Keeper.

Civilization does not actually prefer to coerce traumatized young people into making secrecy oaths if they will predictably consider this to be a bad deal for them.

Finnar was not really considered reliable enough that anyone wanted to fully bring him in on all of the Basement's secrets and offer him a job there, and in any case, he wasn't interested. At this point, perhaps reasonably given the events of his childhood, he had very little trust that Civilization's values aligned with his own. The whole situation was somewhat irregular, but they were able to agree on an outcome that all parties considered preferable to the alternatives: in exchange for keeping the Basement's secrets, Finnar would get access to slightly faster computers and some of the existing alignment research, and could have his own independent go at solving the problem.

(They didn't particularly expect him to succeed, and of course disagreed on the matter of what values Civilization ought to impart to an AGI, but it wasn't ruled out. Finnar didn't love the clause that they would step in and intervene if it looked like he was about to do something very very dangerous to Civilization, but he grouchily agreed that if they warned him and he wasn't convinced and didn't stop voluntarily, from their point of view it wasn't totally unreasonable to stop him by force. And if it looked like he was going to solve it, knowably and verifiably, then of course he would be in a position to negotiate a cosmic-level reward about that.) 

(And this part is inferred, not directly observed, but: at this point, Finnar had a pretty good guess of exactly what the Keepers could have told Mirrell, that might have changed her decision, if she had been considered trustworthy enough. Finnar almost certainly blamed himself for not having guessed on his own much sooner, while his mother was still alive and while he was still unbound by a secrecy oath.) 

Related inference: while Finnar doesn't trust the Basement to build a Future that has space for himself and his children, he is, in fact, trying to get there on his own. His son Kurthin made some similar deductions and was similarly brought in on the secret; they now work together.

His son Khemeth is considered very legibly reliable, and was brought in on elements of the secret years ago. (One of the traits that goes into Khemeth's trustworthiness is of course that, when you tell him part of a secret and that he doesn't need to know the rest, he accepts this and doesn't keep digging.) Khemeth is part of the reason that the Basement is willing to let Finnar work on his project with the degree of autonomy he currently has. 

Three of Kalorm's close family members were possessed of information that might, maybe, have convinced him to revisit his medical advance directive and agree to be cryopreserved. All three of them were bound by oath not to tell him. (Kalorm is definitely not considered reliable enough to keep an oath, and also tends to categorically refuse to swear any to Civilization. Making an oath to his family would not be considered sufficient, not for this.) 

It hardly requires a genius level of insight to guess that right now there are probably some VERY STRONG FEELINGS about that. 

Fanthim is high-empathy, and also has a VERY high tolerance for empathizing with unpleasant and painful emotional states, for which she also has relevant training. 

There are still some things that she really doesn't want to even try to imagine. 

They fly over Default City, most of it still dark or lit only with dim red lights, but the hospital region, with work that goes on day and night, is in an area that never sleeps, and is lit. 

They descend. 

Merrin takes deep breaths, and promises Kalorm that they're so close now, and hopes quietly to herself that the pilot can manage a really, really smooth landing. 

Kalorm obviously doesn't respond to this in any way. 

Three hours and fifty minutes after Merrin pulled Kalorm out of the water over a thousand miles away, they land. 

The next part is going to be pretty stressful! Default Hospital is really big. A lot of optimization went into its layout, but the airstrip is not immediately adjacent to the ICU. Rather than transfer to a helicopter for a three-minutes flight, or set up in a room-module and then move the room-module (more like ten minutes), they're going to use one of the underground transport tunnels. They have fully equipped short-distance-transfer-ambulances, one is waiting for her with all the screens already mirroring the ones in the plane, and it'll be, like, four minutes of transport and then a straightforward transfer into the Complicated Patient Intake Room, already set up for the invasive procedures they need to carry out before they start rewarming. There won't be that much acceleration – if they were confident Kalorm could take it, they could be there in two minutes, but they're trading more time in transit for a gentler ride. 

It is still agonizingly stressful. Merrin is going to be so so so relieved when she's finally home in her nice well-equipped ICU room. 

The markets think there is about a 40% chance of something going wrong en route. Which will be okay, but the more stable the patient is for upcoming procedures, the more likely it is that he'll tolerate those without complications, and the better their overall success odds. 

STRESS come on Kalorm you can do this STRESS

They get lucky, this time. Merrin's stress is the worst thing that happens, and then they're there, sliding the mattress-and-supports from the transport ambulance gurney to the room gurney, and there's so much equipment and so many people waiting. 

Is Merrin ready to go RIGHT NOW on transferring the patient to full heart-lung bypass or does she need a minute to orient first. 

(Merrin isn't the one with the most experience at the procedure itself, and she'll have help with the surgical prep, with opening the patient's chest, and with pretty much every other aspect - someone already has the pump and filter primed with transfusion blood and circulating through an organ-transport module - but she has more than enough sim time to safely perform the actual cannulation of the patient's heart and aorta, and the timing for that is really delicate, since they need to put the mechanical cardiac pump on standby for each cannula placement. Merrin, with four hours of context on keeping the patient vaguely stable, has the best chance of wrangling that timing without hitting an issue of the type "the patient has no blood pressure for thirty seconds".) 

Yeah she's ready. 

(She is quietly explaining to Kalorm that she realizes this procedure looks really scary, but it's fine, they do it all the time, and it'll make the rewarming so much easier for him.) 

On-site personnel who have not actually worked with Merrin before think this is weird but adorable, not that they say anything about it out loud. 

It's not a complicated surgical procedure. But it's a lot more fraught than usual on a patient this cold, with limited homeostatic regulation functioning, clotting dysfunction, and existing injuries. They're going to do the whole thing under realtime CT guidance, with injected contrast to visualize blood vessels, so Merrin can see exactly what she's doing and how the patient's circulation is responding. (It's a small radiation exposure for the staff, but they'll be compensated for that tiny increased risk of cancer later, and with protective gear it really is a tiny risk.) 

First up: inject contrast. It's normally pretty safe, if the patient isn't allergic, and they know Kalorm isn't allergic to this kind of CT contrast. He had CT scans as a kid thanks to all the times he came in with suspected traumatic injuries after doing things like falling 15 meters out of a tree, and some of those scenarios being scary and urgent such that it was worth the faster imagery at the cost of the low cancer risk. 

It might do something weird at this body temperature, though! Data on that is really limited! The patient's blood chemistry is in a delicate enough balance that there's some chance a perturbation will push them outside the parameters until Merrin can address that, hopefully quickly. The markets think there's a 30% chance this will happen. 

It's not great if it does happen, both because of any direct damage that gets dealt while Merrin is frantically trying to get back on protocol, and because it's a general sign that Kalorm's state is more fragile than they hoped. It'll mainly affect the probability of mild damage; the market is expecting it would react with a 14% increase in that risk, and a 7% increase on the odds of moderate damage, to 27.5%. They don't expect it to affect the odds of severe damage very much. 

If it goes okay, they get a smaller improvement in the prognosis, a 6% and 3% decrease, because one thing going well is at least slightly predictive of the patient having more physiological slack, and other things continuing to go well. 

(There are going to be a lot of dice rolls like that over the next few minutes. No one thing they're doing has a very high chance of serious complications, but they need to do a lot of things very quickly and the patient is not incredibly stable to begin with.) 

.......And this time they got unlucky, because several blood chemistry parameters on the continuous sensor are thrown out of whack, and it's maybe interacting in some bizarre way with the filter pressure on the ECMO circuit, which they still really badly need for the next five minutes until they can get the new oxygenation circuit attached and running. 

Merrin has one more chance to try to get on top of it before it cascades to affect the patient's vital signs! It's a big ask to be that fast, though. Someone with faster processing speed and better raw reaction times than Merrin would have a higher chance, but that person does not also have the thousands of hours of sim time that Merrin is leaning on to do this at all, or the endurance to have already worked with Kalorm for four hours and still be at top performance. 

The markets think she has about a 20% chance of correcting the system before they're very far outside parameters on the really important variables. 

If she navigates this well, and the system is perturbed temporarily but the most critical factors (blood pressure and O2 saturation) don't or barely slip outside parameters, they mostly get back to the previous odds (predicted 12% and 6% decrease on the relevant predicted outcomes). If Merrin has to spend a while wrestling the patient back to stability, the market expects to update on the complication and then a little further, an additional 3% and 1.5% increase. 

Come on Kalorm be nice be helpful this would be a really good time for some teamwork–

That was probably too much to expect of him right now, wasn't it. 

Market updates: 

Prediction on mild damage: 70%. They lost a lot of ground just then, and thus probability mass on literally the best outcome, because as expected, while Merrin is fighting machines for the next ten minutes, for one it's adding delay and for another, there is the expected bump in cellular damage markers. 

Moderate damage: 29%. Closer to 1:3 than 1:4 odds, but still not that likely. 

Odds of severe damage: a very small jump to 7%. 

Merrin feels awful about this!!! Sorry Kalorm sorry sorry sorry – also now is not a good time to be upset, she has him vaguely approximately stable again and they have to keep moving. 

Sawing open a patient's chest! While they are really low on platelets and their clotting factors are not really functioning normally! Is sort of a fraught plan! They don't really have a choice but still! 

The markets don't think that massive bleeding is very likely – one in ten odds, maybe – and they're super ready to react appropriately if it does, it won't by itself be catastrophic. But given that Merrin just barely has the patient re-stabilized, it won't be great either, especially happening in such short succession. Call it a 4.5% increase in odds of minor damage, 9% increase in odds of moderate damage, maybe a 4.5% increase in severe damage too. 

(If it goes smoothly, the situation is mostly unchanged, but looks very slightly better, call it by 0.5% and 1% and 0.5% respectively.) 

STRESS 

No bleeding! 

Aaaaaaaaaaaaaand now Merrin has to do the hard part. (STRESS!) 

They think it's a little more likely than even odds – 60% probability – that Merrin can time it well enough that they don't lose any more ground. But the patient is still really quite fragile.

In the 40% of worlds where she loses his blood pressure, even very briefly, there are probably a lot of neurons and neural support cells that are just barely hanging on, just barely maintaining membrane integrity and ion gradients, and losing control of that again will push more of them over the edge – the markets are guessing it would send the likelihood of mild damage up by 12%, to 80.5%, and of moderate damage up by 9% to 37%, a little bit above 1 in 3 odds. Severe damage...still less affected, relatively speaking, but maybe a 3% increase there. 

If it goes smoothly, they're one step closer to starting the actual protocol, more of the risky parts behind them rather than ahead – the markets expect to react with an 8%, 6%, and 2% decrease respectively.

Merrin is only a LITTLE bit internally screaming because she does, in fact, super need to be focusing here. 

It goes about as smoothly as it could have! 

Merrin - finishes securing everything really well, first - and then does a little happy dance before she remembers that there are CAMERAS.

Merrin DESERVES a little happy dance! That was genuinely objectively very hard and impressive, and Personnel is so proud of Merrin, not that she’s going to say that. She probably can’t even say it later.

(Merrin feels that this was a TEAM EFFORT with Kalorm, actually, but he did so well and she can provide honest, if unheard-by-Kalorm, reassurance that that was the worst scariest part.)

Literally how is Merrin so adorable? Weird, and you want to bap her with a banana and tell her to have a higher opinion of herself and then you DO that and it doesn’t even WORK (…it is possible this story has been retold rather widely among the Exception Handling staff) - anyway she is a very confusing alien, but, like, an adorable one.

Kalorm's entire family is now in the Family Room prepared for them. (It's roughly just their summer vacation home including bedrooms, plus a room for Finnar set up with LCD screens to fully mirror all the displays in the main command center, plus another room for Finnar with the requested projectors and wall screens.)

Finnar is pacing between those two rooms and the living room where most of the family is huddled together, on the edge of their seats, watching just the basic camera footage of the room. The atmosphere is....tense. 

Kurthin and his father keep exchanging abjectly miserable looks. No one else is acknowledging this. 

Khemeth might or might not be able to do some steering to smooth over the tension (there is kind of a lot to be tense about!), if he weren't too busy having multiple simultaneous text conversations, while his mental Merrin is very very stressed and his mental Kalorm is veering around between a dozen different strong emotions, none of which are pleasant to have playing out in his head. 

He's impressed with Merrin, though. Not especially surprised, but a little surprised, that was really smoothly done for someone who is just definitely below-average on physical dexterity and reflexes. She's clearly using various strategies to compensate for that, but the fact that she has those strategies, and can execute them even under conditions of intense cognitive load, is a testament to just how many hours she's put into drilling this. It's not even just that most dath ilanis don't have the stamina to have put in that much sim time at her age. Most dath ilanis would get painfully bored after repeating variations on this procedure several hundred times.

(He looked it up. Merrin has done variations on heart-lung bypass setup in sims 384 times - and like a dozen times in real life, though never with a patient starting out this unstable or with stakes this high. It's only, like, a twenty-minute procedure, so it's not hard to work it into a wide range of sims. She's done it outdoors in 40 degree heat, in "earthquake wreckage", in a flooded hospital, in a cave with only the equipment she could carry on her. These are, comparatively speaking, almost optimal conditions.) 

You watch Merrin work, every part of her fully engaged with the task at hand, and - while it's clearly a draining emotional roller coaster for her - you end up feeling like maybe the thousandth patient case would feel just as important and real, even new, as the first. 

His mental Kalorm is grudgingly impressed, which is saying a lot, Kalorm is deeply unimpressed with most people. But he did always respect stubbornness. 

It's terrible how she doesn't have enough arms to hug all of her children and it's EVEN WORSE that she can't hug Kalorm at all, or even be in the same room - there are a lot of medical staff working on him, it's already crowded, and they really don't need the distraction of hovering emotional family members. 

Their Medical Crisis Liaison (who on request introduced herself by name to Khemeth, but absolutely does not expect anyone else to remember her name) can provide a running commentary. 

"What the opper said is right," she can confirm, when Merrin murmurs to Kalorm's unconscious body that the riskiest part is past. "It's– well, we're going to be getting a lot of information over the next few hours, about - how well we can expect this to work. But there's much less room for things to actively go wrong." 

On the screen, Merrin is unhooking the no-longer-necessary ECMO circuit, avoiding any blood pressure disruptions via the fact that she has, like, literally a dial for that on the bypass controls. Brain surgery is happening, other medtechs placing the sensor array that will tell them what they need for real-time protocol dosing adjustments. 

These are not nearly as high risk. The prediction markets place a pretty low probability on anything going wrong, and in fact nothing is going wrong. 

Nerdel wrings her hands. 

- and abruptly looks over at their Support Worker. "- Can we see him? I, just for a minute, just for ten seconds, it would - I don't know how to get through the next twelve hours otherwise..." 

She is sort of crying right now. Quietcrying. 

Finnar nods emphatically. "You should let us see him." 

"I - it's going to depend if they think he's stable enough right now - I'll send a message..." 

(Actually, Fanthim thinks it mostly depends on whether the lead opper is okay with crying family members! It seems like it might be really distracting! Also asking her the question seems pretty distracting in itself! Fanthim...is going to run this by Personnel first.) 

It would probably be a little distracting! But Merrin is juggling fewer total machines now, and is pretty much just keeping things in a holding pattern while they start what one might call phase 0 of the protocol, which mostly consists of administering some low dose immunomodulators while they calibrate all the new sensors and wait for results on an extremely thorough panel of lab tests, which will inform some final parameters. 

Also, Merrin will super understand this being important to the family, and Personnel actually models that she would be upset if she learned after the fact that the request was made and no one had even asked her for fear of distracting her. 

In that case, the question can be relayed to Merrin herself! Is now a good time for a very brief family visit to the room itself? If so, does she want special instructions conveyed to them? 

Oh. Um. ...Yes? Well. It's not going to be a better time at any later point, this is probably the least distracted and busy she'll be for a while, and it's very reasonable of them to want to visit - they're here at the hospital now? she didn't realize they were here? ...which is stupid in hindsight, obviously they came to the hospital.

Actually she is realizing that she knows so few facts about the family! She did not have time to read any of the extra dossiers. They should...not touch anything? If they're going to be upset about not touching the patient, they can maybe - pat him on the hand? Or something? Merrin has been doing that and while she has weird superstition paranoia that someone else will manage to do it wrong and hurt him, that is objectively speaking probably not very reasonable. 

Also, umm, what...are their names. Is there anything she would know if she'd had time to read up more on the patient, that will be super embarrassing for her not to know? 

Private text message, Fanthim to Personnel: presumably Merrin should not at this point be informed that the patient's grandmother also refused cryo and truicided? It informs some of the family dynamic here, but the family dynamic is not in fact Merrin's problem to handle, and seems like it would be distracting? 

(Merrin is obviously not herself cleared to know the rest of the factors that Fanthim is pretty sure are the explanation behind all of the anguished looks behind exchanged.)