Hacker News Board Hacker News, browsed like a classic message board
Live data from Hacker News

How one ED mobilized his department during a mass casualty incident (2017)

epmonthly.com

Post reply on HN
Print view View original

71–80 of 116 posts

Re: How one ED mobilized his department during a mass casualty incident (2017)

#71

Post by roughly »

biofox wrote: post #5

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.)

Re: How one ED mobilized his department during a mass casualty incident (2017)

#72

Post by jcims »

ooterness wrote: post #41
dalben wrote: post #15

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, ...

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.

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.

Re: How one ED mobilized his department during a mass casualty incident (2017)

#73

Post by roughly »

eapressoandcats wrote: post #25
aftbit wrote: post #17

Earlier quoted context omitted.

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.

Eisenhower: “Plans are worthless, but planning is everything.”

Re: How one ED mobilized his department during a mass casualty incident (2017)

#75

Post by jmcgough »

dotancohen wrote: post #54
biofox wrote: post #5

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.

> The author's key takeaway is "flow is king" Which usually doesn't exactly happen with ED.

Yep - can't discharge the patient taking up a room because they've been waiting three hours on a CT read.

Re: How one ED mobilized his department during a mass casualty incident (2017)

#76

Post by somat »

AtlasBarfed wrote: post #34
biofox wrote: post #5

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.

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 C…

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).

Re: How one ED mobilized his department during a mass casualty incident (2017)

#77

Post by intelVISA »

DowagerDave wrote: post #57
ericmcer wrote: post #46

Earlier quoted context omitted.

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 Ac…

>> 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?

A cursory glance suggests that a reliable AI is one that generates max revenue for shareholders whilst data mining the user reliably.

Re: How one ED mobilized his department during a mass casualty incident (2017)

#79

Post by at_a_remove »

eapressoandcats wrote: post #23
biofox wrote: post #5

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.

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 n…

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.

Re: How one ED mobilized his department during a mass casualty incident (2017)

#80

Post by trustinmenowpls »

somat wrote: post #76
AtlasBarfed wrote: post #34

Earlier quoted context omitted.

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 C…

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 sor…

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.
Post reply on HN