[HN Gopher] How one ED mobilized his department during a mass ca...
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How one ED mobilized his department during a mass casualty incident
(2017)
Author : CrispyKerosene
Score : 136 points
Date : 2024-08-14 16:22 UTC (6 hours ago)
(HTM) web link (epmonthly.com)
(TXT) w3m dump (epmonthly.com)
| Loughla wrote:
| Wow. Honestly. Just wow.
| mp2 wrote:
| very insightful, please continue posting
| ro_bit wrote:
| Does "crumped" in this context mean a sudden deterioration? (ie.
| crumpled)
| RandomCitizen12 wrote:
| Wiktionary says crump means "(intransitive, US, medical slang)
| (of one's health) to decline rapidly (but not as rapidly as
| crash)."
| tptacek wrote:
| 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.
| DowagerDave wrote:
| my understanding is "crump" as in crumple, fast but not
| immediate deterioration. I believe you can crash at the end
| of your crump.
| FireBeyond wrote:
| Paramedic: Yes, it does.
| tptacek wrote:
| My understanding is that it's deterioration to the point where
| your patient is, in a figurative sense, actively trying to die.
| biofox wrote:
| 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.
| lostlogin wrote:
| Some of this can be applied to normal day-to-day running,
| outside of a crisis.
| sseagull wrote:
| This is the overall takeaway in "Turn the Ship Around!" by
| David Marquet (although there is lots more to it)
| RandomCitizen12 wrote:
| 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.
| aftbit wrote:
| 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.
| eapressoandcats wrote:
| 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.
| jeffrallen wrote:
| 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.
| alwa wrote:
| 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.
| hinkley wrote:
| 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.
| eapressoandcats wrote:
| 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.
| alwa wrote:
| 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."
| lukan wrote:
| "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.
| alwa wrote:
| 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.
| AtlasBarfed wrote:
| 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
| DowagerDave wrote:
| 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.
| ericmcer wrote:
| 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.
| biofox wrote:
| 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.
| DowagerDave wrote:
| >> 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?
| ThrowawayR2 wrote:
| 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.
| DowagerDave wrote:
| 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.
| dotancohen wrote:
| > The author's key takeaway is "flow is king"
|
| Which usually doesn't exactly happen with ED.
| FireBeyond wrote:
| 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).
| lostlogin wrote:
| 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.
| aftbit wrote:
| 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?
| alwa wrote:
| 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.
| amluto wrote:
| 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.)
| kotaKat wrote:
| 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.
| dinobones wrote:
| 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.
| dalben wrote:
| 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.
| rootusrootus wrote:
| This is common in the US, and I would assume in every other
| modern healthcare system.
| ro_bit wrote:
| 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.
| biftek wrote:
| Not every hospital is a trauma center, according to the article
| this hospital only dealt with GSW victims
| bb611 wrote:
| 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.
| dalben wrote:
| 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, ...
| lbwtaylor wrote:
| 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.
| lawlessone wrote:
| Yeah it seemed very hands on , running around finding issues,
| getting people on them etc.
| mewse-hn wrote:
| With respect from Canada, I doubt you are seeing many incidents
| with 200+ gunshot victims in Belgium
| stereo wrote:
| https://en.wikipedia.org/wiki/2016_Brussels_bombings
| mewse-hn wrote:
| I stand corrected
| ooterness wrote:
| 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.
| rootusrootus wrote:
| > 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.
| acedTrex wrote:
| What a great read, i love times where competent people make shit
| happen. Crisis leadership is a rare skill.
| bell-cot wrote:
| On HN back in 2017, with 71 comments -
|
| https://news.ycombinator.com/item?id=15688900
| CrispyKerosene wrote:
| 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.
| anamexis wrote:
| You can also just click "past" under the post header.
| Bartkusa wrote:
| > _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...
| DowagerDave wrote:
| yeah - I recognized that too. Seems like such an obvious thing
| in hindsight but real genius.
| rolph wrote:
| triage tags for MCE
|
| https://www.ncbi.nlm.nih.gov/books/NBK459369/
|
| https://www.nj.gov/health/ems/documents/ems-task-force/disas...
| [PDF]
|
| https://en.wikipedia.org/wiki/Triage_tag
|
| https://www.boundtree.com/triage-tags/c/269?srsltid=AfmBOoq-...
| [ARTICLE FOR SALE]
| ianso wrote:
| Does anyone else think this should be made into a movie?
|
| Massive respect to this ED.
| jerlam wrote:
| "ER slammed with patients, doctors improvise solutions and
| everyone is saved" is a common episode plot for TV medical
| dramas.
| kragen wrote:
| a fictional account by filk star leslie fish, 'the day it fell
| apart'
|
| 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 fire
|
| ...
|
| 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
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