How one ED mobilized his department during a mass casualty incident (2017) (opens in new tab)

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.

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.”

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

  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"

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.

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.

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.

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.

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.)

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.

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.

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.

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.

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.