How one ED mobilized his department during a mass casualty incident (2017)(epmonthly.com)
epmonthly.com
How one ED mobilized his department during a mass casualty incident (2017)
https://epmonthly.com/article/not-heroes-wear-capes-one-las-vegas-ed-saved-hundreds-lives-worst-mass-shooting-u-s-history/
115 comments
The author's key takeaway is "flow is king", but what stuck me most was giving people freedom to do their job -- e.g., giving the nurses unrestricted access to the medication, letting the CT tech focus on their job, roaming ER doctors, delegating triage to a nurse, etc. -- the success here came from giving people responsibility and trusting them.
I think a key here is recognizing when the expected result is catastrophe and acting accordingly.
There's a whole lot of procedures in the hospital that are designed for normal times and are _good_ in normal times(*) - they enforce people double-checking their results, they give radiologists time to make the right call, they make sure the right drugs are going into the right people, they make sure patients are prepped correctly for a procedure. All of that takes time, but it moves your expected outcomes from, say, 95% to 99%.
In the case described, the expected outcome is 0% - it's a fucking catastrophe, there's 250 people on their way, and everyone who comes in is a corpse waiting to happen. At that point, absolutely, flow is king - hitting an expected outcome of even 50% (looks like they got somewhere around 65%) is a massive upgrade, so yeah, shove as many people through the CT scan bay as you can, let your radiologist flip a coin, and if the nurse gives the wrong drug, fuck it, that's probably not what killed the patient - move on and hope you do better next time.
I think the real takeaway here is recognizing what the stakes of your situation are and acting accordingly - what are the outcomes that matter, and what's the set of activities that get you closer to your desired ones. Sometimes that's care and caution, and sometimes that's taking your best guess, committing to it, and accepting the outcomes.
Huge kudos to the author and to whoever set up the system that enabled them to act as needed and supported them in doing so, though - I'm sure they broke every regulation in the book over the course of those six hours. Plenty of other disasters have been made much worse by the lack of flexibility in a system to recognize extreme circumstances and act accordingly.
(* take "good" with all the caveats you want here. I get it.)
There's a whole lot of procedures in the hospital that are designed for normal times and are _good_ in normal times(*) - they enforce people double-checking their results, they give radiologists time to make the right call, they make sure the right drugs are going into the right people, they make sure patients are prepped correctly for a procedure. All of that takes time, but it moves your expected outcomes from, say, 95% to 99%.
In the case described, the expected outcome is 0% - it's a fucking catastrophe, there's 250 people on their way, and everyone who comes in is a corpse waiting to happen. At that point, absolutely, flow is king - hitting an expected outcome of even 50% (looks like they got somewhere around 65%) is a massive upgrade, so yeah, shove as many people through the CT scan bay as you can, let your radiologist flip a coin, and if the nurse gives the wrong drug, fuck it, that's probably not what killed the patient - move on and hope you do better next time.
I think the real takeaway here is recognizing what the stakes of your situation are and acting accordingly - what are the outcomes that matter, and what's the set of activities that get you closer to your desired ones. Sometimes that's care and caution, and sometimes that's taking your best guess, committing to it, and accepting the outcomes.
Huge kudos to the author and to whoever set up the system that enabled them to act as needed and supported them in doing so, though - I'm sure they broke every regulation in the book over the course of those six hours. Plenty of other disasters have been made much worse by the lack of flexibility in a system to recognize extreme circumstances and act accordingly.
(* take "good" with all the caveats you want here. I get it.)
"Move fast and break things" is absolutely the right method in some scenarios. The trick is, as you say, identifying if you're in one.
“It depends” is certainly the answer more often than people want to believe.
It’s not so much freedom to do their job as getting them out of the trained pathways that work well in the nominal case and _then_ letting them use their judgement.
Requiring people to double check that someone gets the right meds is super important 99% of the time. Having a radiologist review x rays asynchronously is more throughput efficient 90% of the time. Having the person with the most experience do triage is normally the best use of his time and saves lives.
All of these are based on assumptions that cease to be true in a mass casualty event.
Requiring people to double check that someone gets the right meds is super important 99% of the time. Having a radiologist review x rays asynchronously is more throughput efficient 90% of the time. Having the person with the most experience do triage is normally the best use of his time and saves lives.
All of these are based on assumptions that cease to be true in a mass casualty event.
An irritatingly overlooked issue is the tension between procedure and results. Obviously, a well-refined procedure learns from past issues and evolves, growing ever more adaptable and useful, the way that aircraft rules are "writ in blood." Still, every one of the adaptations was prompted by an event that was Not in the Script.
I think, for my next job, one of those questions I will ask when the time comes to ask if I have anything I am curious about in the interview is the choice, when a choice must be made, between procedure and results ... which am I expected to prioritize?
Probably won't win me any callbacks.
I think, for my next job, one of those questions I will ask when the time comes to ask if I have anything I am curious about in the interview is the choice, when a choice must be made, between procedure and results ... which am I expected to prioritize?
Probably won't win me any callbacks.
There’s not really a clear tension though. Procedures exist with an intent to get results. Airlines have lots of procedures that are carefully followed and the result is “the plane always arrives safely”. If you asked a pilot the question to “make a choice between procedures and results” they’d think you were crazy.
Obviously there can be misguided procedures, but any decision made or operation done can be misguided.
Obviously there can be misguided procedures, but any decision made or operation done can be misguided.
Again, and continuing with the flight safety, all of it was an iterative process, learned the hard way. Flight safety rules did not emerge whole and unchanged with the Wright brothers. Every change was prompted by one or more incidents during which the current procedure was not appropriate.
What then?
Consider the current thread on the whole "toaster in the dishwasher" topic, during which someone related an incident wherein an entire server site was immersed in water but still functioning (https://news.ycombinator.com/item?id=41251234). The site manager followed procedure (wait a while, not cut the power, perform risk assessment) and it resulted in total loss, but the poster wanted to "cut the power, pump the water out of the bunker ASAP and immediately clean the whole lot with pure water." Here we have a tension between procedure and results. Procedure ended up causing total site loss, which was completely avoidable.
Similarly, a current thread on an ER doctor not following the usual procedures during a mass casualty event was lauded. A choice had to be made. Here, results won.
I just like to know this sort of thing about a work culture in advance. Letter of the law versus the spirit of the law, and so on.
What then?
Consider the current thread on the whole "toaster in the dishwasher" topic, during which someone related an incident wherein an entire server site was immersed in water but still functioning (https://news.ycombinator.com/item?id=41251234). The site manager followed procedure (wait a while, not cut the power, perform risk assessment) and it resulted in total loss, but the poster wanted to "cut the power, pump the water out of the bunker ASAP and immediately clean the whole lot with pure water." Here we have a tension between procedure and results. Procedure ended up causing total site loss, which was completely avoidable.
Similarly, a current thread on an ER doctor not following the usual procedures during a mass casualty event was lauded. A choice had to be made. Here, results won.
I just like to know this sort of thing about a work culture in advance. Letter of the law versus the spirit of the law, and so on.
How would you know? How would they know? Okay, sure you will have a hunch based on the answer, but it seems something that only experience can tell. (Okay, you can ask them about their experience.. and who know how forthcoming and honest and relevant their answer will be, right?)
Pilots aren’t limited by experience, they know a great deal about aircraft systems and the mechanics of flight. Procedure is incapable of handling every single edge case because the possibilities are endless.
So when do you deviate from procedure? When the edge case you’re in is well outside the scope of exit procedures which requires detailed understanding of the procedures and their justifications.
So when do you deviate from procedure? When the edge case you’re in is well outside the scope of exit procedures which requires detailed understanding of the procedures and their justifications.
Pilots are also allowed to deviate from any procedure and even violate federal regs in the event of an emergency.
14 CFR § 91.3(b) In an in-flight emergency requiring immediate action, the pilot in command may deviate from any rule of this part to the extent required to meet that emergency.
14 CFR § 91.3(b) In an in-flight emergency requiring immediate action, the pilot in command may deviate from any rule of this part to the extent required to meet that emergency.
What's the result of the completely useless flight safety mantra? People will not leave their belongings! The mantra should tell them that they will be compensated if they make it out alive but they will be put down like a mad dog if they hinder others with their packing and packages...
Also people do charge all the fucking time, and don't put their phone into airplane mode. :|
Also people do charge all the fucking time, and don't put their phone into airplane mode. :|
I would say it works incredibly well. Everyone knows what it is. Everyone knows what they are supposed to do in an emergency. Everyone knows there are emergency exits. Everyone knows there are life jackets. Everyone knows they are supposed to wear a seatbelt. At least some people will get it right.
Do not underestimate how even minimal training can be extremely effective at scale. I know from experience that I am a person who does not freeze, I focus. When shit happens, I act but I can act without thinking. Because of that mantra, I have a plan to follow and I will act correctly.
Also don't underestimate the effect of priming. It reminds you there is a plan. When pilots prepare for takeoff, they briefly review how to handle emergencies during takeoff. Not because they don't know, but to bring those procedures to attention and have them ready in their mind.
For the mantra to work, all it has to do is remind you those procedures you vaguely know exist.
Do not underestimate how even minimal training can be extremely effective at scale. I know from experience that I am a person who does not freeze, I focus. When shit happens, I act but I can act without thinking. Because of that mantra, I have a plan to follow and I will act correctly.
Also don't underestimate the effect of priming. It reminds you there is a plan. When pilots prepare for takeoff, they briefly review how to handle emergencies during takeoff. Not because they don't know, but to bring those procedures to attention and have them ready in their mind.
For the mantra to work, all it has to do is remind you those procedures you vaguely know exist.
I believe this is not a question that can be asked.
Recently I pushed a change straight to production by myself with no approval and violated many rules but it saved us and carried us for weeks. Worse case if it broke, rollback would happen under in under 30 seconds.
I did it because not only did I triple check, I’ve kept mental track of the number of regressions and issues that have been logged against all of my work throughout my career. I’m good at determining risk and I know my bug rate is very low (I git blame every bug to find out who and why caused it. I don’t tell my coworkers but it does play a role in who gets what kind of tickets.) I did what I did because frankly I know it was going to work and no one was going to complain. And truthfully, I’ve done this at different companies several times. Of course, it’s still never a light decision and I rarely ever do it.
But if someone asks me if they could do the same thing, I would not be able to tell them. They would have to keep track of the same details and to be honest, if someone is asking if they can break rules, they probably shouldn’t.
This is the “tension.”
Recently I pushed a change straight to production by myself with no approval and violated many rules but it saved us and carried us for weeks. Worse case if it broke, rollback would happen under in under 30 seconds.
I did it because not only did I triple check, I’ve kept mental track of the number of regressions and issues that have been logged against all of my work throughout my career. I’m good at determining risk and I know my bug rate is very low (I git blame every bug to find out who and why caused it. I don’t tell my coworkers but it does play a role in who gets what kind of tickets.) I did what I did because frankly I know it was going to work and no one was going to complain. And truthfully, I’ve done this at different companies several times. Of course, it’s still never a light decision and I rarely ever do it.
But if someone asks me if they could do the same thing, I would not be able to tell them. They would have to keep track of the same details and to be honest, if someone is asking if they can break rules, they probably shouldn’t.
This is the “tension.”
I once had an engineer push changes directly to production because they were confident that they would do it correctly.
In fact, they were completely misguided about their own accuracy because they had systematically ignored or not understood the errors that they had made in the past.
The challenge as a tech lead or manager is telling the difference between you and them. Or even telling whether you are them. My own tendency would be to fire both of you.
In fact, they were completely misguided about their own accuracy because they had systematically ignored or not understood the errors that they had made in the past.
The challenge as a tech lead or manager is telling the difference between you and them. Or even telling whether you are them. My own tendency would be to fire both of you.
Your tendency may be that but the reality is my past companies want to ask me to contract for them after I leave, even 7 years later.
I uphold a certain quality of work and I expect my peers to do the same. Everyone makes mistakes but even mistakes can be modeled.
I uphold a certain quality of work and I expect my peers to do the same. Everyone makes mistakes but even mistakes can be modeled.
What struck me was how the author was able to identify choke points and make decisions to deviate from procedure to fix them. In many organizations, adherence to procedure is more important than getting good results. It is interesting to see that at least in this hospital at this time, that wasn't true.
Ironically to some degree things worked well because he had a procedure in mind already even though he didn’t tell everyone.
Obviously the improvised fixes weren’t planned in advance, but it still speaks to having some process/plan being helpful.
Obviously the improvised fixes weren’t planned in advance, but it still speaks to having some process/plan being helpful.
Eisenhower: “Plans are worthless, but planning is everything.”
He mentions that the CEO of his hospital was there and accepted his suggestion to reorganize the CT scan flow. That shows a level of trust and flexibility that's not common in large organizations.
This struck me too—especially the way he seems to have kept one eye on the big picture even while he was facing a flood of individual patients depending urgently on his task-level attention.
Having people bleed out in the waiting room is quite an unpopular outcome. When you have the luxury of time it's less excusable to make a misdiagnosis or to rush a treatment.
While that’s true, I worry about glorifying too much the desperation of the whole situation.
If the same patients had arrived at a pace consistent with normal operations, wouldn’t you expect the outcomes to have been better?
Normally cross-checking medications and dosages saves lives by reducing medical errors. Normally I’d rather not be operated on by a surgeon so strung out that, like the author describes, his mind can’t make sense of words on a page.
There are times when the problem vastly outmatches the resources you have to bring to bear. Where getting things done at all is more important than making sure they’re done absolutely perfectly. But to me the lesson is in deciding which compromises will save the most lives.
Which has to weigh even heavier on the mind of somebody like the doctor here, who understands that “the very best we could with what we had” is far short of “the best medical care we’re capable of.”
If the same patients had arrived at a pace consistent with normal operations, wouldn’t you expect the outcomes to have been better?
Normally cross-checking medications and dosages saves lives by reducing medical errors. Normally I’d rather not be operated on by a surgeon so strung out that, like the author describes, his mind can’t make sense of words on a page.
There are times when the problem vastly outmatches the resources you have to bring to bear. Where getting things done at all is more important than making sure they’re done absolutely perfectly. But to me the lesson is in deciding which compromises will save the most lives.
Which has to weigh even heavier on the mind of somebody like the doctor here, who understands that “the very best we could with what we had” is far short of “the best medical care we’re capable of.”
"Normally I’d rather not be operated on by a surgeon so strung out that"
Normally no one wants to be part of a "mass casualty event" but if one ends up in one, I would be glad if competent people do the best they can and not stop on arbitary regulations meant for normal times.
Normally no one wants to be part of a "mass casualty event" but if one ends up in one, I would be glad if competent people do the best they can and not stop on arbitary regulations meant for normal times.
Absolutely, and I hope that I didn’t give the impression otherwise. In times of crisis I’m immensely grateful that most everyone will step up beyond their normal responsibilities.
I’m even more grateful that leaders like the author have spent their careers developing the experience, instinct, discernment, credibility, and fortitude to make the right adaptations under pressure.
I’d even agree with the original comment that a good leader trusts their people and gets out of their way. I just think that manifests differently in steady-state operations than during crisis.
I’m even more grateful that leaders like the author have spent their careers developing the experience, instinct, discernment, credibility, and fortitude to make the right adaptations under pressure.
I’d even agree with the original comment that a good leader trusts their people and gets out of their way. I just think that manifests differently in steady-state operations than during crisis.
The CT scan reminds me of someone that was trying to optimize welders.
They said they were at their maximum, but welders would move parts and plates and then weld.
Efficiency expert realize that welding was maximized if the welders were welding the entire time.
Other people could bring them the metal parts that needed to be welded.
So the normal process where the CT person wouldn't move the person in and out of the CT scan in between CTS was a classic example of that.
The CT tech and the CT machine needed to be running as much as possible. Other people without the skills he's juggling the patients
They said they were at their maximum, but welders would move parts and plates and then weld.
Efficiency expert realize that welding was maximized if the welders were welding the entire time.
Other people could bring them the metal parts that needed to be welded.
So the normal process where the CT person wouldn't move the person in and out of the CT scan in between CTS was a classic example of that.
The CT tech and the CT machine needed to be running as much as possible. Other people without the skills he's juggling the patients
The balance here is what I think is really impressive. They both built assembly lines AND rely on deep, adhoc experience & skill in applicable places. Efficiency in narrower, skill-specialized areas and an "artisanal" approach to initial triage.
Makes me think of the apocryphal story that the genius behind Sears Roebuck & co, the thing that enabled them to change from being "just another mail order company" to "The mail order company" was to invert the fulfillment process. this changed the cost of assembling an order from n to log(n)
I don't think it was Mr Sears or Mr Roebuck that came up with the idea, One of their warehouse managers I expect. I always sort of wonder why Sears did not become what amazon is, They already had the infrastructure for it. my best guess, unable to shift mediums fast enough?
While looking for sources to this story(I could not find any, sorry) I did find a claim that bezos was pivotal for a 1992 ruling that no sales tax was due for orders that originated outside the state. and this was critical for amazons early success. I worked for a mail-order company when that ruling was overturned. And it was a mess, I was not in accounting so I have no idea what it did financially, but all of a sudden all the software went from having to handle (in state collect tax, out of state no tax) to (every state, county, city and their dog charges a different tax and now you have to try to figure out what this is and collect it).
I don't think it was Mr Sears or Mr Roebuck that came up with the idea, One of their warehouse managers I expect. I always sort of wonder why Sears did not become what amazon is, They already had the infrastructure for it. my best guess, unable to shift mediums fast enough?
While looking for sources to this story(I could not find any, sorry) I did find a claim that bezos was pivotal for a 1992 ruling that no sales tax was due for orders that originated outside the state. and this was critical for amazons early success. I worked for a mail-order company when that ruling was overturned. And it was a mess, I was not in accounting so I have no idea what it did financially, but all of a sudden all the software went from having to handle (in state collect tax, out of state no tax) to (every state, county, city and their dog charges a different tax and now you have to try to figure out what this is and collect it).
I thought that law only required you to collect state tax, if you were out of state, local taxes were still exempt unless you had an actual business in that state.
It was South Dakota v. Wayfair, Inc. I was a sysadmin so only tangentially involved, but the programmers were having a hard time because the situation was basically unknowable, That is, there was no primary source of information, I think they ended up buying a service that specialized in keeping track of what address charged what taxes.
https://en.wikipedia.org/wiki/South_Dakota_v._Wayfair%2C_Inc.
The basic idea is that some localities charge a use tax, which is a sales tax applied to items bought outside their jurisdiction. The citizens if the jurisdiction are required to self report and pay this tax. The problem(or beneficent depending of what side of the transaction you were on) is that this is very nearly unenforceable, just too large an attack surface. The standard way to enforce tax payment is to move it a rung up the ladder. The store collects collects the sales tax before you get the item, your employer collects the income tax before you see the money etc. now there are exponentially fewer collection points. the collection points are hidden, out of the voter base and each point has far more to loose if they rebel keeping them in line.
https://en.wikipedia.org/wiki/South_Dakota_v._Wayfair%2C_Inc.
The basic idea is that some localities charge a use tax, which is a sales tax applied to items bought outside their jurisdiction. The citizens if the jurisdiction are required to self report and pay this tax. The problem(or beneficent depending of what side of the transaction you were on) is that this is very nearly unenforceable, just too large an attack surface. The standard way to enforce tax payment is to move it a rung up the ladder. The store collects collects the sales tax before you get the item, your employer collects the income tax before you see the money etc. now there are exponentially fewer collection points. the collection points are hidden, out of the voter base and each point has far more to loose if they rebel keeping them in line.
What do you mean by "invert the fulfillment process"?
I think it is that instead of sending a boy around the store to assemble the stationary order, the assembler stays still, only responsible for what is in reach and the order moves on conveyor between assemblers.
I don't think giving nurses unrestricted access to narcotics is giving them 'freedom to do their job' because a valid part of a nurse's job is controlling access to narcotics. It's not a medical need, but it's an operational and societal need. Same with whatever a CT tech would do away from the controls. I think this is more accurately a descoping of the job to improve throughput.
Depends how you define the job. A different interpretation is that the job of a medical professional is to improve the health of their patients as much as they can. Normally this is done by frequently having someone/something more specialized ensure perfect care for the task at hand, but on this night that might take too long, so the best way to improve the health of the patients was to abandon protocol and do the best they can as fast as they can.
Unrestricted access doesn't mean unmonitored access. Narcs are counted at every single access and records of who pulled what are kept and audited.
These are core principles that are taught to Emergency Managers in the Swarm Leadership method [0].
Unity of mission – it was for these leaders, Save Lives!
Generosity of spirit and action – these leaders and people across the community were willing and eager to help one another.
Stay in your lanes, doing your job, and help others to succeed in theirs. How can I make you a success?
No ego – no blame. No one took credit for their success together. No one pointed fingers when problems arose.
A foundation of trusting relations – these leaders knew and had confidence in one another.
> The author's key takeaway is "flow is king"
Yep - can't discharge the patient taking up a room because they've been waiting three hours on a CT read.
Giving people freedom to do their jobs is how we got the Crowdstrike incident. Those rules and restrictions at a hospital are in place precisely because there are enough people who cannot be trusted with the freedom to do their jobs to make them unavoidable.
Your premise is highly debatable; I don't know anyone who determined Crowdstrike was the result of "freedom to do your job", but regardless the hospital rules are for regular operation, not black swan events like this.
This could be a really cool use for AI. We have so many rules and systems in place to protect normal people from professionals that we have to blindly trust. If I had a reliable AI in my pocket I could be in charge of my own safety again.
I did this a month or so ago when a Dr. recommended a cortisone injection behind my ankle. I asked GPT about it, it said consensus recommends against it because it can weaken the Achilles. The doctor hated it but I am really glad I didn’t just blindly trust him.
I guess I like it because it is enabling instead of replacing humans.
I did this a month or so ago when a Dr. recommended a cortisone injection behind my ankle. I asked GPT about it, it said consensus recommends against it because it can weaken the Achilles. The doctor hated it but I am really glad I didn’t just blindly trust him.
I guess I like it because it is enabling instead of replacing humans.
> did this a month or so ago when a Dr. recommended a cortisone injection behind my ankle. I asked GPT about it, it said consensus recommends against it because it can weaken the Achilles. The doctor hated it but I am really glad I didn’t just blindly trust him.
Taking medical advice from ChatGPT over what your doctor says, what could go wrong?
Taking medical advice from ChatGPT over what your doctor says, what could go wrong?
>> If I had a reliable AI in my pocket
that's both a big "If" and a very ambiguous ask - what's does a "reliable AI" mean?
that's both a big "If" and a very ambiguous ask - what's does a "reliable AI" mean?
A cursory glance suggests that a reliable AI is one that generates max revenue for shareholders whilst data mining the user reliably.
Someday, but I think we're still a way off.
Regarding your interaction with the doctor, I completely understand both sides, and I can guarantee he was well aware of the small risk of tendon weakening.
People usually want their physician to do "something", otherwise what's the point of going? This puts them in a no-win scenario. A single cortisone injection provides immediate relief, with a very small chance of side effects. If he doesn't offer it, people will complain about him being useless. If he does, some patients will think he's incompetent.
I'd find it exhausting having to second guess every interaction.
Regarding your interaction with the doctor, I completely understand both sides, and I can guarantee he was well aware of the small risk of tendon weakening.
People usually want their physician to do "something", otherwise what's the point of going? This puts them in a no-win scenario. A single cortisone injection provides immediate relief, with a very small chance of side effects. If he doesn't offer it, people will complain about him being useless. If he does, some patients will think he's incompetent.
I'd find it exhausting having to second guess every interaction.
Every single doc knows about steroids + tendons. Did you ask why steroids were offered ?
> Dr. Greg Neyman, a resident a year ahead of me in residency, had done a study on the use of ventilators in a mass casualty situation. What he came up with was that if you have two people who are roughly the same size and tidal volume, you can just double the tidal volume and stick them on Y tubing on one ventilator.
This technique was later applied during the COVID-19 pandemic, when ventilators were in high demand and short supply.
https://www.vice.com/en/article/this-risky-hack-could-double...
This technique was later applied during the COVID-19 pandemic, when ventilators were in high demand and short supply.
https://www.vice.com/en/article/this-risky-hack-could-double...
That part immediately made me think of a particular scene from Silicon Valley.
yeah - I recognized that too. Seems like such an obvious thing in hindsight but real genius.
Interesting that he had to do so much thinking and improvising. I'm an EMT in Belgium, and every hospital here has to have plans for mass casualty events. Ambulance bays are built to be transformed into a triage ward, spare beds are kept close, often there's a dedicated command room, ...
At the Luton airport they have these big "mass casualty event" supply boxes on the walls. Presumably full of supplies to provide efficient first aid after such an event on the spot.
As I was writing this comment I learned that they were inspired by a bombing which happened in Brussels: https://www.shponline.co.uk/fire-safety-and-emergency/mascal...
One of those things you hope will never need to be used. But if it is ever needed it will be very handy.
As I was writing this comment I learned that they were inspired by a bombing which happened in Brussels: https://www.shponline.co.uk/fire-safety-and-emergency/mascal...
One of those things you hope will never need to be used. But if it is ever needed it will be very handy.
There is a rather large difference to having plans and dealing with an actual incident. Not to bicker, but a dedicated command room sounds like a fun plan but the opposite of what was needed in the incident described in this story.
Events like this are much more common than you may think, though rarely as severe as this shooting. From fires at retirement homes and even at an ED once, bus crashes, WWII bombs surfacing during construction, floods… it almost becomes routine. I can assure you the plans are not built not academics but are refined through experience. And in a weird way, disaster response almost becomes routine.
Yeah it seemed very hands on , running around finding issues, getting people on them etc.
With respect from Canada, I doubt you are seeing many incidents with 200+ gunshot victims in Belgium
We do not! The US is a loved destination for training placements and exchanges because you can see so many stabbings and shootings in one shift.
However, a shooting is just one type of mass casualty event.
However, a shooting is just one type of mass casualty event.
As Eisenhower put it: "Peace-time plans are of no particular value, but peace-time planning is indispensable."
In other words, the act of planning means you're better prepared for specific contingencies, so you'll hopefully be better prepared for whatever actually happens, but some improvisation will always be necessary.
In other words, the act of planning means you're better prepared for specific contingencies, so you'll hopefully be better prepared for whatever actually happens, but some improvisation will always be necessary.
100%. As another wise man once said, "everybody has a plan until they get punched in the mouth."
The planning may be directly applicable in whole, is almost certainly applicable in part but in my opinion the main thing is that it provides a template for thinking about what things are important and which are expendable when you're operating in an environment with a greater tolerance for risk.
The planning may be directly applicable in whole, is almost certainly applicable in part but in my opinion the main thing is that it provides a template for thinking about what things are important and which are expendable when you're operating in an environment with a greater tolerance for risk.
> I'm an EMT in Belgium
It always happens eventually in discussions like this. "I'm from <country in Europe> and I don't get why y'all are so stupid, unlike us."
The US healthcare system is worthy of critique for many things, most of all cost, but the quality of care is just as good as every other western nation. Doctors are quite skilled, just like they are in Belgium I assume. And of course hospitals plan for mass casualty events. All of them, I bet, if they have an ER.
It always happens eventually in discussions like this. "I'm from <country in Europe> and I don't get why y'all are so stupid, unlike us."
The US healthcare system is worthy of critique for many things, most of all cost, but the quality of care is just as good as every other western nation. Doctors are quite skilled, just like they are in Belgium I assume. And of course hospitals plan for mass casualty events. All of them, I bet, if they have an ER.
Dr Joshua Corso was the Senior Resident on duty the night of the Pulse Nightclub shooting in Orlando, and had a photo of his trainers covered in blood go viral.
I saw him do a talk at an EMS conference a few years back that was both profoundly touching and deeply insightful, and talked about all the things you might not think of (at one point, there was a lot of banging from something nearby the ED, that made people think there was more shooting, and so they had locked it down further, which made some of the efforts more difficult (moving people from ED to theater, for example).
I saw him do a talk at an EMS conference a few years back that was both profoundly touching and deeply insightful, and talked about all the things you might not think of (at one point, there was a lot of banging from something nearby the ED, that made people think there was more shooting, and so they had locked it down further, which made some of the efforts more difficult (moving people from ED to theater, for example).
I'm not an Orson Scott Card fan generally, but I LOVED his Shadow Series (the world of Ender's Game from the perspective of Bean).
In one of the books in the Shadow Series Bean explains his leadership style as:
"I will always explain why something is important, and why we're doing it this particular way... The reason for this is that if we ever find ourselves in a situation where I CAN'T give orders you know what I prioritize and how I might think of something... furthermore, if we're in a situation where I CAN give orders but DON'T explain you will understand that it's simply because I do not have time, but presumably have good reasons, and will proceed to immediately execute said orders"
It appears this emergency room operated in a similar capacity
In one of the books in the Shadow Series Bean explains his leadership style as:
"I will always explain why something is important, and why we're doing it this particular way... The reason for this is that if we ever find ourselves in a situation where I CAN'T give orders you know what I prioritize and how I might think of something... furthermore, if we're in a situation where I CAN give orders but DON'T explain you will understand that it's simply because I do not have time, but presumably have good reasons, and will proceed to immediately execute said orders"
It appears this emergency room operated in a similar capacity
I’m surprised reports were generated quicker when the radiologist worked with the X-ray tech.
Back when I did x-rays, a quick radiologist could report a set of films in about a minute.
I could X-ray 6 patients per hour (whilst doing data entry, billing, walking them to the room etc as well). I doubt I’d have been much more than twice as fast if the admin was skipped.
Back when I did x-rays, a quick radiologist could report a set of films in about a minute.
I could X-ray 6 patients per hour (whilst doing data entry, billing, walking them to the room etc as well). I doubt I’d have been much more than twice as fast if the admin was skipped.
I recently accompanied a patient through an imaging lab. It was a room full of maybe 10 pieces of expensive equipment, and there was a big line of patients in a waiting room. There was one single technician, who handled one patient at a time, kept disappearing, and even when the technician was there, they spent more time convincing the machines to send the images to EMR than actually taking images.
I estimated that they could have gotten at least 4x the throughput (and 4x the utilization of expensive equipment!) if the process was streamlined. For this single patient, at least 45 minutes and probably more was wasted doing what boiled down to nothing of value.
While actually fixing this seems complex, in an emergency situation, I can easily imagine that skipping all the EMR integration and paperwork and just taking the pictures and having someone stand in the room and read the images would have gotten that 4x throughput improvement, even if the person reading the images would personally have lower throughput than if they were in their office.
(Maybe make the 4x into 8x if there could have been two technicians sharing one radiologist.)
I estimated that they could have gotten at least 4x the throughput (and 4x the utilization of expensive equipment!) if the process was streamlined. For this single patient, at least 45 minutes and probably more was wasted doing what boiled down to nothing of value.
While actually fixing this seems complex, in an emergency situation, I can easily imagine that skipping all the EMR integration and paperwork and just taking the pictures and having someone stand in the room and read the images would have gotten that 4x throughput improvement, even if the person reading the images would personally have lower throughput than if they were in their office.
(Maybe make the 4x into 8x if there could have been two technicians sharing one radiologist.)
>I can easily imagine that skipping all the EMR integration and paperwork and just taking the pictures and having someone stand in the room and read the images would have gotten that 4x throughput improvement
Yes. But 45 minutes later when someone wants to see the images ‘on that guy with the broken leg’ it becomes a nightmare. You need some labelling and a documentation system, and a unique identifier for each patient is a bare minimum. Using the RIS and creating an order isn’t that slow, and quickly becomes a time saver once you’ve got several patients.
Yes. But 45 minutes later when someone wants to see the images ‘on that guy with the broken leg’ it becomes a nightmare. You need some labelling and a documentation system, and a unique identifier for each patient is a bare minimum. Using the RIS and creating an order isn’t that slow, and quickly becomes a time saver once you’ve got several patients.
>Yes. But 45 minutes later
45 minutes later that person (or someone else) could be dead because paperwork created a choke point.
The trade off here, again, is reducing overall efficiency (bandwidth) to get the results that are needed now ASAP (latency).
Once the mayhem is over, those patients can have new X-Rays done the next day, the records can be sorted out the next week, etc.
How would you even justify it?
I'm sorry, ma'am, I understand you're in pain and dying after being shot, but waiting a few minutes NOW will really save us some time filing paperwork going forward.
Note that it's not just about the patients getting the X-Rays; with 250+ people arriving at the same time, any delay propagates with cascading effects and delays care for everyone.
Even non-critical patients waiting for their turn creates an issue, since space is limited.
45 minutes later that person (or someone else) could be dead because paperwork created a choke point.
The trade off here, again, is reducing overall efficiency (bandwidth) to get the results that are needed now ASAP (latency).
Once the mayhem is over, those patients can have new X-Rays done the next day, the records can be sorted out the next week, etc.
How would you even justify it?
I'm sorry, ma'am, I understand you're in pain and dying after being shot, but waiting a few minutes NOW will really save us some time filing paperwork going forward.
Note that it's not just about the patients getting the X-Rays; with 250+ people arriving at the same time, any delay propagates with cascading effects and delays care for everyone.
Even non-critical patients waiting for their turn creates an issue, since space is limited.
I read this to suggest that it was a flow thing more than a quantity thing.
By doing the readout on the spot, they could decide what was next for the patient before they even made it out of the machine, and the patient would roll directly off to get whatever attention the scan indicated.
I also thought I picked up an insinuation that they saved time by short circuiting all the convoluted EMR and billing kinds of systems, too. He mentions the radiologist reading the images directly off the “small screen” on the machine itself.
By doing the readout on the spot, they could decide what was next for the patient before they even made it out of the machine, and the patient would roll directly off to get whatever attention the scan indicated.
I also thought I picked up an insinuation that they saved time by short circuiting all the convoluted EMR and billing kinds of systems, too. He mentions the radiologist reading the images directly off the “small screen” on the machine itself.
Digital x-ray has changed everything so much. Slap the Wi-Fi enabled plate under someone, click click, image already up on the screen and doc's reading it.
I (almost) broke my ankle and had to go to the ER to have it looked at and it was during a system downtime -- the doc did just that alongside the radiology tech from the machine's console instead of from a PACS workstation.
In a masscal event on one of these systems there's typically an 'emergency entry' option that lets you just input patients manually into the system and start shooting, so instead of the normal paperwork process they'll just image first and reconcile later.
I (almost) broke my ankle and had to go to the ER to have it looked at and it was during a system downtime -- the doc did just that alongside the radiology tech from the machine's console instead of from a PACS workstation.
In a masscal event on one of these systems there's typically an 'emergency entry' option that lets you just input patients manually into the system and start shooting, so instead of the normal paperwork process they'll just image first and reconcile later.
It does get better when digital, but there is more to it than one might think when a good tech does it all in a few seconds and a couple of clicks. Positioning and adapting exposures isn’t always straightforward.
In terms of tracking imaging, you have to be able to track images back to a patient, and something identifying images needs to relate back. It’s a disaster otherwise and a complete waste of time. That ‘emergency patient’ function isn’t that helpful when it’s completely anonymous and there are several cases.
I’ve been a PACS admin for a brief time, and have seen enough to get twitchy.
In terms of tracking imaging, you have to be able to track images back to a patient, and something identifying images needs to relate back. It’s a disaster otherwise and a complete waste of time. That ‘emergency patient’ function isn’t that helpful when it’s completely anonymous and there are several cases.
I’ve been a PACS admin for a brief time, and have seen enough to get twitchy.
> In terms of tracking imaging, you have to be able to track images back to a patient, and something identifying images needs to relate back
The worst incident I have been on as a paramedic involved transporting 73 people from a train derailment. One of the simpler, but crude, methods we had as a fallback, was a sharpie and writing a number on foreheads, etc...
But we had MCI tags, which all have a unique number, would serve as a pseudo-MRN.
The worst incident I have been on as a paramedic involved transporting 73 people from a train derailment. One of the simpler, but crude, methods we had as a fallback, was a sharpie and writing a number on foreheads, etc...
But we had MCI tags, which all have a unique number, would serve as a pseudo-MRN.
Could you do more than one patient in ten minutes if they were lined up outside your door and shuffled on and off the machine by spare staff?
For sure.
And the most critical stuff is quick. I’m sure most techs could knock off a chest X-ray in 2 minutes, repeatedly.
As a student and doing all the paperwork correctly, I did 125 chest X-rays in a dedicated chest room in an 8 hour shift. That’s a 4 minute turn around.
However, all the patients were walking and talking. This makes a massive difference.
I failed the module on chest x-rays on first submission. I was supposed to log 120 over 3 years, showing progression.
Not enter 120+ from a single day. Resubmission was just paperwork, so not a big deal.
And the most critical stuff is quick. I’m sure most techs could knock off a chest X-ray in 2 minutes, repeatedly.
As a student and doing all the paperwork correctly, I did 125 chest X-rays in a dedicated chest room in an 8 hour shift. That’s a 4 minute turn around.
However, all the patients were walking and talking. This makes a massive difference.
I failed the module on chest x-rays on first submission. I was supposed to log 120 over 3 years, showing progression.
Not enter 120+ from a single day. Resubmission was just paperwork, so not a big deal.
It's latency vs. bandwidth.
Reduced patient wait time (lower latency) was prioritized over how many X-Rays were processed per hour.
E.g. it wouldn't matter how fast the X-Ray specialist was working if the results were getting back to the patients in big batches, sent once an hour, because the patients might not live long enough to get them.
Reduced patient wait time (lower latency) was prioritized over how many X-Rays were processed per hour.
E.g. it wouldn't matter how fast the X-Ray specialist was working if the results were getting back to the patients in big batches, sent once an hour, because the patients might not live long enough to get them.
What a great read, i love times where competent people make shit happen. Crisis leadership is a rare skill.
> For years I had been planning how I would handle a MCI, but I rarely shared it because people might think I was crazy.
This is such a huge problem.
This is such a huge problem.
If you are interested in disaster psychology and planning like this, you might also enjoy "The Unthinkable" by Amanda Ripley. It covers several notable disasters and the environment that shaped them. It gives advice on the psychology of victims of a disaster, how to prepare for one as an individual, and how to prepare for one as a community.
It was recommended to me by an EMT giving a TECC class. I found the book fascinating and am open to other recommendations in the same vein.
It was recommended to me by an EMT giving a TECC class. I found the book fascinating and am open to other recommendations in the same vein.
> I didn’t black tag a single one. We took everybody that came in—I pulled at least 10 people from cars that I knew were dead—and sent them straight back to Station 1 so that another doc could see them. If the two of us ended up thinking that this person was dead, then I knew that it was a legitimate black tag
If you don't pre-tag them, the second guy will be the only tag on them so there's no "double check". The second doctors opinion wins, since the first one is doing zero triage between black and red. Still commendable but it doesn't have the safety property he described.
If you don't pre-tag them, the second guy will be the only tag on them so there's no "double check". The second doctors opinion wins, since the first one is doing zero triage between black and red. Still commendable but it doesn't have the safety property he described.
So I'm not the only one who thinks about and pre-plans solutions to disaster situations in their head to pass the time. Not coincidentally I like to peruse prepper-type forums/subreddits. It's for those "you never know" and "someday this might be useful" type of events. FWIW, I'm not a guns and ammo prepper either (not that they're not important, but it's way down the list).
On HN back in 2017, with 71 comments -
https://news.ycombinator.com/item?id=15688900
https://news.ycombinator.com/item?id=15688900
Thanks. How do you check if something will be a repost?
Edit: Plugged the article URL into the search bar at the bottom of HN and it worked surprisingly well. Im not sure why, but i had no confidence in that actually working.
Edit: Plugged the article URL into the search bar at the bottom of HN and it worked surprisingly well. Im not sure why, but i had no confidence in that actually working.
You can also just click "past" under the post header.
That doesn't work. It plugs the title into hn.algolia.com which only returns the same thread.
Shouldn't it search for the URL instead?
Am I missing something?
Also, I noticed the tracking parameters are in the URL of the old thread. Shouldn't the mods remove them using https://linkcleaner.app/ or something? I know the parameters are sometimes relevant but still...
Shouldn't it search for the URL instead?
Am I missing something?
Also, I noticed the tracking parameters are in the URL of the old thread. Shouldn't the mods remove them using https://linkcleaner.app/ or something? I know the parameters are sometimes relevant but still...
This site doesn't get many submissions so you can search for it by site (domain address):
https://news.ycombinator.com/from?site=epmonthly.com
https://news.ycombinator.com/from?site=epmonthly.com
Do paramedics/ambulances shard across hospitals?
It looks like there’s 3 hospitals within 15 minutes of the Las Vegas strip, I’m curious if there’s any attempt to allocate patients equally so that no single hospital becomes overwhelemed.
It looks like there’s 3 hospitals within 15 minutes of the Las Vegas strip, I’m curious if there’s any attempt to allocate patients equally so that no single hospital becomes overwhelemed.
Can't say for Las Vegas, but we do here (in Belgium). There's a dedicated responsibility during mass casualties to distribute leaving ambulances over hospitals, also taking into account hospital specialties and facilities, such as a burn unit. The closest hospital is usually skipped because victims who self-transport will usually go there.
This is common in the US, and I would assume in every other modern healthcare system.
The graphic at the end of the article says the author's team only treated patients with gunshot wounds, and not tramples or sprains, so I imagine those lower priority injuries were diverted to other hospitals.
Not every hospital is a trauma center, according to the article this hospital only dealt with GSW victims
Yes to the extent they're able.
This article is a pretty good overview of the situation across Las Vegas that night: https://www.facs.org/for-medical-professionals/news-publicat...
In short, every hospital was overwhelmed, but Sunrise was the closest to the shooting so got the most overflow.
This article is a pretty good overview of the situation across Las Vegas that night: https://www.facs.org/for-medical-professionals/news-publicat...
In short, every hospital was overwhelmed, but Sunrise was the closest to the shooting so got the most overflow.
Yes, there was lots of sharding across hospitals (although it wasn't executed perfectly). Wikipedia has some good info. About 60 people died and almost 900 were injured, over 400 of whom had gunshot or shrapnel wounds.
https://en.wikipedia.org/wiki/2017_Las_Vegas_shooting#Victim...
> Approximately 867 people were injured, at least 413 of them with gunshot wounds or shrapnel injuries. In the aftermath, many victims were transported to area hospitals, which included University Medical Center of Southern Nevada, Sunrise Hospital & Medical Center, and at least one of the six hospitals of Valley Health System. Sunrise Hospital treated the largest portion of the wounded: 199 patients, 150 of whom arrived within about 40 minutes.[80] University Medical Center treated 104 patients. Additionally, six victims sought medical treatment in Southern California; UC Irvine Medical Center treated four and Loma Linda University Medical Center treated two. Many victims of the shooting required blood transfusions, which totaled 499 components in the first 24 hours of treatment. This blood was rapidly replaced by available blood from local and national blood banks.
>University Medical Center, the Level I trauma center in Las Vegas, was difficult to access for the more than 50 percent of patients transported by private vehicles because Interstate 15, the most direct route from the shooting location, was closed to the public. Also, an erroneous emergency services announcement made one hour after the shooting reported UMC had reached capacity and was on diversion. This confusion persisted for several hours and led to most patients being transported to Sunrise, a Level II trauma center.
https://en.wikipedia.org/wiki/2017_Las_Vegas_shooting#Victim...
> Approximately 867 people were injured, at least 413 of them with gunshot wounds or shrapnel injuries. In the aftermath, many victims were transported to area hospitals, which included University Medical Center of Southern Nevada, Sunrise Hospital & Medical Center, and at least one of the six hospitals of Valley Health System. Sunrise Hospital treated the largest portion of the wounded: 199 patients, 150 of whom arrived within about 40 minutes.[80] University Medical Center treated 104 patients. Additionally, six victims sought medical treatment in Southern California; UC Irvine Medical Center treated four and Loma Linda University Medical Center treated two. Many victims of the shooting required blood transfusions, which totaled 499 components in the first 24 hours of treatment. This blood was rapidly replaced by available blood from local and national blood banks.
>University Medical Center, the Level I trauma center in Las Vegas, was difficult to access for the more than 50 percent of patients transported by private vehicles because Interstate 15, the most direct route from the shooting location, was closed to the public. Also, an erroneous emergency services announcement made one hour after the shooting reported UMC had reached capacity and was on diversion. This confusion persisted for several hours and led to most patients being transported to Sunrise, a Level II trauma center.
And most of our OS' and stdlib's are riddled with blocking IO, where only the OS does the work-stealing.
Beam is an incredibly slow VM, but in situations where everybody is waiting on IO, Beam is king.
Beam is an incredibly slow VM, but in situations where everybody is waiting on IO, Beam is king.
[deleted]
Does "crumped" in this context mean a sudden deterioration? (ie. crumpled)
Wiktionary says crump means "(intransitive, US, medical slang) (of one's health) to decline rapidly (but not as rapidly as crash)."
There are several doctors here, one of them could pop in and tell us if crumping and crashing are interchangeable. I actually thought "crumping" was the more severe thing to say.
I often use them interchangeably, but “crashing” implies it’s a bit faster (and therefore more obvious), whereas “crump” implies it can be a bit slower. So a “crashing” patient implies you have to run in the room and do something immediately, but a patient who “crumps” might gradually get worse over several hours, have to be put on a ventilator, require pressors, but with much less drama maybe?
I think “crash” gets used more in the past tense, whereas “crump” gets used maybe equally in both future and past tense? e.g “that patient you signed out to me crumped a couple of hours later” , but also, say when leaving a shift, in the future tense, “the guy in bed 6 is admitted to medicine, but let me tell about him in case he crumps”.
I think “crash” gets used more in the past tense, whereas “crump” gets used maybe equally in both future and past tense? e.g “that patient you signed out to me crumped a couple of hours later” , but also, say when leaving a shift, in the future tense, “the guy in bed 6 is admitted to medicine, but let me tell about him in case he crumps”.
my understanding is "crump" as in crumple, fast but not immediate deterioration. I believe you can crash at the end of your crump.
My understanding is that it's deterioration to the point where your patient is, in a figurative sense, actively trying to die.
Paramedic: Yes, it does.
What a fantastic story. I’m humbled by the tireless efforts of the medical workers in this story, even the people working the phones. This is the story of hope, pride and excellence I want to see.
a fictional account by filk star leslie fish, 'the day it fell apart'
https://youtu.be/4aYVbt5ZwTc?si=ee4y8BZjgKOf3-5T
it gets more engaging from there
things like this have happened lots of times in real life, but the people who did them don't sing songs about them of course
https://youtu.be/4aYVbt5ZwTc?si=ee4y8BZjgKOf3-5T
just a little general hospital in a little factory town
the board put me in charge for mainly keeping prices down
i hadn't touched a patient since 1982
but the day of the explosion i remembered what to do
at 11 in the morning we all heard the factory blow
the blast took out the windows and the shrapnel fell like snow
we could get no help from out of town for half a day or more
we had near a thousand casualties and beds for 94.
and can you keep your head your backbone or your heart
we all found out the answer on the day it fell apart
it was worse than combat medicine
supplies were draining fast
bandages ran out and antiseptics wouldn't last
i took all the able-bodied i could catch inside the door
and made them help the doctors or go scrounge supplies and more
i invented laws to tell them saying, "in such emergency
forget your usual job and boss; your orders come from me!"
i sent the cops to commandeer anything in reach
food or disinfectant, cloth or alcohol or bleach
and can you keep your head your backbone or your heart
we all found out the answer on the day it fell apart
the janitor ran cleanup squad; the cook maintained supplies
the garbage man removed the ones who died before our eyes
the clerks burned all our papers to boil water on the fireit gets more engaging from there
things like this have happened lots of times in real life, but the people who did them don't sing songs about them of course
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