> 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.
How one ED mobilized his department during a mass casualty incident (2017)
81–90 of 116 posts
Re: How one ED mobilized his department during a mass casualty incident (2017)
#82Earlier quoted context omitted.
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 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.”
Re: How one ED mobilized his department during a mass casualty incident (2017)
#83> 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.
Re: How one ED mobilized his department during a mass casualty incident (2017)
#84Interesting 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, ...
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.
Re: How one ED mobilized his department during a mass casualty incident (2017)
#85Interesting 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, ...
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.
Re: How one ED mobilized his department during a mass casualty incident (2017)
#86Earlier quoted context omitted.
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…
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.
Re: How one ED mobilized his department during a mass casualty incident (2017)
#87The 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.
This is a weird take. Giving nurses unrestricted access to medication is giving them responsibilities OUTSIDE of their job.
Re: How one ED mobilized his department during a mass casualty incident (2017)
#88Earlier quoted context omitted.
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…
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.
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.
Re: How one ED mobilized his department during a mass casualty incident (2017)
#89The 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.
This is a weird take. Giving nurses unrestricted access to medication is giving them responsibilities OUTSIDE of their job.
Or redefining their roles and responsibilities under a new (temporary) set of conditions.
Re: How one ED mobilized his department during a mass casualty incident (2017)
#90> 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…
That part immediately made me think of a particular scene from Silicon Valley.