The Triage Override

The ethics committee meets in a windowless room on the third floor, which Luana has always suspected is deliberate. Today's agenda has one item, printed in bold. It asks whether the hospital's triage ranking, which sorts the emergency department's waiting patients by predicted risk, may be overridden by a nurse's judgement and, if so, on what terms. Luana, the committee's lay member and a retired statistician, has read the validation report twice. She trusts the numbers. What she does not yet trust is the sentence "the system is correct in ninety-four per cent of cases".

伦理委员会在三楼一间没有窗的屋子里开会，卢安娜一直怀疑这是有意为之。今天的议程只有一项，用粗体印着。它问的是：医院的分诊排序，也就是按预测风险为急诊室里候诊的病人排队的那套系统，能否被护士的判断推翻，如果可以，又该以什么条件。卢安娜是委员会里的非医学委员，一位退休的统计学家，她把验证报告读了两遍。她相信那些数字。她还不相信的，是这句话：“该系统在百分之九十四的病例中是正确的。”

The case that has forced the issue is described by the chair in careful, non-graphic terms. Three weeks ago a man in his sixties arrived with a vague discomfort in his chest and normal first readings, and the system placed him fourth in the queue. Toril, a senior nurse with twenty-six years on the floor, moved him to first, writing only "doesn't look right" in the notes. Within the hour he was found to need urgent treatment, and he is now recovering at home.

促使这个问题摆上桌面的那个病例，由主席以谨慎、不带细节渲染的方式描述了出来。三个星期前，一位六十多岁的男士因胸口隐隐不适来就诊，最初的各项读数都正常，系统把他排在了第四位。托丽尔是一位在一线干了二十六年的资深护士，她把他挪到了第一位，在记录里只写了一句“看着不对”。一小时之内，他被发现需要紧急治疗，如今已在家中康复。

Toril has been invited to speak, and she does so without notes. She cannot say exactly what she saw, she admits; perhaps the greyness around his mouth, perhaps the way he kept apologising for taking up a chair. "If I had waited for the number to change, I would have been waiting for the wrong thing," she says. A young doctor objects, politely. Nurses have been wrong too, he points out, and the system exists precisely because tired people see patterns that are not there.

托丽尔受邀发言，她没有拿稿子。她承认，自己说不清当时到底看到了什么；也许是他嘴边那层灰白，也许是他总在为占了一把椅子而不停道歉的样子。“如果我等着那个数字变化，我等的就是错误的东西。”她说。一位年轻的医生客气地提出异议。他指出，护士也出过错，而这套系统之所以存在，恰恰是因为疲惫的人会看到并不存在的规律。

Luana asks for the override log. There have been eighty-one in two years, and what strikes her, turning the pages, is that the nurses were right far more often than not, and wrong in a pattern. The overrides that proved unnecessary cluster among patients who were articulate, calm and easy to like. Had the system been left unchallenged, the man with the chest discomfort would have waited; had the nurses never been checked, the people who are easy to like would always have been seen first.

卢安娜要来了推翻记录。两年里一共有八十一次，她一页页翻着，注意到的是：护士们对的时候远远多于错的时候，而且错有规律。那些后来证明并无必要的推翻，集中在那些表达清晰、情绪平静、讨人喜欢的病人身上。如果系统不受质疑，那位胸口不适的男士就会一直等下去；如果护士们从不受检验，讨人喜欢的人就会永远最先被接诊。

"Both of those are true," she hears herself say, to her own surprise, "and neither of them is an argument for choosing one."

“这两件事都是真的，”她听见自己说，连自己也觉得意外，“而且，它们都不是在两者之中选一个的理由。”

Not until two hours have passed does the committee reach an answer, and it is neither a victory nor a compromise in the usual sense. Any nurse may override a ranking at once, without asking permission, but she must record one line of reasoning. The system, for its part, will display its own uncertainty beside every rank instead of hiding it behind a single tidy number. Each month the overrides will be reviewed by pattern rather than by person, and the algorithm's misses will be audited in the same meeting, at the same table.

两个小时过去，委员会才得出答案，这个答案既不是通常意义上的胜利，也不是妥协。任何一位护士都可以立刻推翻某个排序，无须请示，但必须记下一句理由。至于系统，它将在每个排名旁边显示自己的不确定性，而不是把它藏在一个整齐的数字后面。每个月，推翻记录将按规律而不是按个人来复查，算法的漏判也将在同一场会议上、同一张桌子旁接受审计。

Toril reads the draft over Luana's shoulder. "One line of reasoning," she says. "I can do that. Most nights the reason is only a feeling."

托丽尔从卢安娜的肩后读着草案。“一句理由，”她说，“我可以。大多数夜里，理由不过是一种感觉。”

"Write it down anyway," Luana says. "Then we can find out what the feeling was made of."

“还是写下来吧，”卢安娜说，“这样我们才能弄清楚，那种感觉是由什么构成的。”

Toril nods slowly and asks whether there will be a place on the form for the nights she is wrong. Luana turns the page. There is already a box at the bottom, small and unremarkable, labelled "What I missed."

托丽尔慢慢点头，问表格上有没有地方，可以写她出错的那些夜晚。卢安娜翻过一页。底部已经有一个小小的、毫不起眼的方框，标签是：“我漏掉了什么。”