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How one ED mobilized his department during a mass casualty incident (2017)
- deleted 2y ago[deleted]
- Loughla 2y ago[flagged]
- mp2 2y agovery insightful, please continue posting
- ro_bit 2y agoDoes "crumped" in this context mean a sudden deterioration? (ie. crumpled)
- RandomCitizen12 2y agoWiktionary says crump means "(intransitive, US, medical slang) (of one's health) to decline rapidly (but not as rapidly as crash)."
- tptacek 2y agoThere 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 2y agomy understanding is "crump" as in crumple, fast but not immediate deterioration. I believe you can crash at the end of your crump.
- ghufran_syed 2y agoI often use them interchangeably, but “crashing” implies it’s a bit faster (and therefore more obvious), whereas “crump” implies it can be a bit slower. So a “crashing” patient implies you have to run in the room and do something immediately, but a patient who “crumps” might gradually get worse over several hours, have to be put on a ventilator, require pressors, but with much less drama maybe? 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”.
- FireBeyond 2y agoParamedic: Yes, it does.
- tptacek 2y agoMy understanding is that it's deterioration to the point where your patient is, in a figurative sense, actively trying to die.
- biofox 2y agoThe 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 2y agoSome of this can be applied to normal day-to-day running, outside of a crisis.
- sseagull 2y agoThis is the overall takeaway in “Turn the Ship Around!” by David Marquet (although there is lots more to it)
- RandomCitizen12 2y agoI 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.
- btach 2y agoUnrestricted access doesn't mean unmonitored access. Narcs are counted at every single access and records of who pulled what are kept and audited.
- hatthew 2y agoDepends how you define the job. A different interpretation is that the job of a medical professional is to improve the health of their patients as much as they can. Normally this is done by frequently having someone/something more specialized ensure perfect care for the task at hand, but on this night that might take too long, so the best way to improve the health of the patients was to abandon protocol and do the best they can as fast as they can.
- FireBeyond 2y agoDr 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 2y agoI’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 2y agoCould 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?
- lostlogin 2y agoFor sure. 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.
- alwa 2y agoI 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 2y agoI 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.)
- dinobones 2y agoDo 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 2y agoCan'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 2y agoThis is common in the US, and I would assume in every other modern healthcare system.
- ro_bit 2y agoThe 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 2y agoNot every hospital is a trauma center, according to the article this hospital only dealt with GSW victims
- bb611 2y agoYes 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-publications/news-and-articles/bulletin/2018/03/southern-nevada-trauma-system-uses-proven-techniques-to-save-lives-after-1-october-shooting/ 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 2y agoInteresting 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 2y agoThere 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 2y agoYeah it seemed very hands on , running around finding issues, getting people on them etc.
- dalben 2y agoEvents 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.
- mewse-hn 2y agoWith respect from Canada, I doubt you are seeing many incidents with 200+ gunshot victims in Belgium
- stereo 2y agohttps://en.wikipedia.org/wiki/2016_Brussels_bombings https://en.wikipedia.org/wiki/2016_Brussels_bombings
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- acedTrex 2y agoWhat a great read, i love times where competent people make shit happen. Crisis leadership is a rare skill.
- bell-cot 2y agoOn HN back in 2017, with 71 comments - https://news.ycombinator.com/item?id=15688900 https://news.ycombinator.com/item?id=15688900
- CrispyKerosene 2y agoThanks. 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 2y agoYou can also just click "past" under the post header.
- andrei-akopian 2y agoThat doesn't work. It plugs the title into hn.algolia.com which only returns the same thread. 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/ https://linkcleaner.app/ or something? I know the parameters are sometimes relevant but still...
- js2 2y agoThis site doesn't get many submissions so you can search for it by site (domain address): https://news.ycombinator.com/from?site=epmonthly.com https://news.ycombinator.com/from?site=epmonthly.com
- Bartkusa 2y ago> 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-access-to-ventilators-as-coronavirus-peaks/ https://www.vice.com/en/article/this-risky-hack-could-double...
- DowagerDave 2y agoyeah - I recognized that too. Seems like such an obvious thing in hindsight but real genius.
- halgir 2y agoThat part immediately made me think of a particular scene from Silicon Valley.
- rolph 2y agotriage tags for MCE https://www.ncbi.nlm.nih.gov/books/NBK459369/ https://www.ncbi.nlm.nih.gov/books/NBK459369/ https://www.nj.gov/health/ems/documents/ems-task-force/disaster_tag_presentation.pdf https://www.nj.gov/health/ems/documents/ems-task-force/disas... [PDF] https://en.wikipedia.org/wiki/Triage_tag https://en.wikipedia.org/wiki/Triage_tag https://www.boundtree.com/triage-tags/c/269?srsltid=AfmBOoq-EyDCxLql1-yV24AWZo_tk6rptv3xvDojRw_t-_gE-SoT2y2i https://www.boundtree.com/triage-tags/c/269?srsltid=AfmBOoq-... [ARTICLE FOR SALE]
- ianso 2y agoDoes anyone else think this should be made into a movie? Massive respect to this ED.
- jerlam 2y ago"ER slammed with patients, doctors improvise solutions and everyone is saved" is a common episode plot for TV medical dramas.
- kragen 2y agoa fictional account by filk star leslie fish, 'the day it fell apart' https://youtu.be/4aYVbt5ZwTc?si=ee4y8BZjgKOf3-5T 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
- BarbaryCoast 2y ago[flagged]
- rurban 2y agoAnd most of our OS' and stdlib's are riddled with blocking IO, where only the OS does the work-stealing. Beam is an incredibly slow VM, but in situations where everybody is waiting on IO, Beam is king.
- SheinhardtWigCo 2y ago> 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.
- vasco 2y ago> 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.
- cheekibreeki2 2y ago[flagged]
- bgroat 2y agoI'm not an Orson Scott Card fan generally, but I LOVED his Shadow Series (the world of Ender's Game from the perspective of Bean). 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
- more_corn 2y agoWhat a fantastic story. I’m humbled by the tireless efforts of the medical workers in this story, even the people working the phones. This is the story of hope, pride and excellence I want to see.
- amonon 2y agoIf you are interested in disaster psychology and planning like this, you might also enjoy "The Unthinkable" by Amanda Ripley. It covers several notable disasters and the environment that shaped them. It gives advice on the psychology of victims of a disaster, how to prepare for one as an individual, and how to prepare for one as a community. 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.
- stuff4ben 2y agoSo I'm not the only one who thinks about and pre-plans solutions to disaster situations in their head to pass the time. Not coincidentally I like to peruse prepper-type forums/subreddits. It's for those "you never know" and "someday this might be useful" type of events. FWIW, I'm not a guns and ammo prepper either (not that they're not important, but it's way down the list).