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.)

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.

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.

Obviously there can be misguided procedures, but any decision made or operation done can be misguided.

Also people do charge all the fucking time, and don't put their phone into airplane mode. :|

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.

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.

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.

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.

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.”

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.

Obviously the improvised fixes weren’t planned in advance, but it still speaks to having some process/plan being helpful.

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 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.

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.

  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.

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

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).

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.

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.

Taking medical advice from ChatGPT over what your doctor says, what could go wrong?

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...

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.

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.

However, a shooting is just one type of mass casualty event.

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

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 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.)

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Beam is an incredibly slow VM, but in situations where everybody is waiting on IO, Beam is king.

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.

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.

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 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”.

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

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.

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...