I felt like the title of this story was almost certainly going to generate threads from people reacting to the headline without reading it, which would suck, because this is from start to finish an amazing story about incident response and improvisation. So I synthesized a title from the intro paragraph.
A bunch of the terms used in this piece (like "crumping", which apparently means dying without doctor permission) are emergency medical jargon, all easy to look up.
Wow, lots of impressive thinking ahead of time. I’m heading up our incident management team at work and this is definitely going in my presentations.
A few things that jumped out:
- Thinking ahead to how he was going to handle an MCA probably saved dozens if not hundreds, even if he made some choices that he shouldn’t have if you’re sitting in our present armchairs.
- This is great demonstration of why the incident commander needs good oversight of the whole situation, and why not everyone makes a good incident commander. The three doctors in Station 1 should have felt empowered to solve the bottlenecks, but they did not... they just kept working within established procedure. That’s ok. You need good operators. But the good leaders in incidents are the people who know how and when to establish and communicate new standard procedures.
- Getting ahead of and staying ahead of a cascade failure is a difficult thing to manage, one that we don’t often accomplish in operations/sre incidents. I know I’ve had one or two incidents like that, mostly DDoS or other attack types. This story shows the value again of staying frosty and planning to handle your next problem before it snowballs and hits you from behind.
> This story shows the value again of staying frosty and planning to handle your next problem before it snowballs and hits you from behind.
My experience in emergency services is my greatest asset in ops work. So, half the datacenter has crashed, and the other half is about to buckle under the load. Is anyone literally going to die in the next 5 minutes? Ok, cool, then let's just sort this out and get on with our lives.
I was pretty astonished by this article. I work in the medical field in Australia and I can’t imagine any hospital here responding and coping in this manner. Our trauma is generally from car crashes and only rarely from guns. I think the victims of this incident were very lucky that this guy was running the show that night.
What I would like to know is how well they coped with record keeping and infection control. These are the things that I find tend to get deprioritised in a crisis.
Generally there is an "MCI kit", which has a form that can be attached to the patient (an elastic band around the wrist or ankle, generally). That form will contain whatever information we know about the patient, interventions thus far, etc. It stays with them throughout the process (in the triage and treatment areas, to the OR, etc). That being said, documentation is often a tertiary concern at best in large scale events like this.
As far as infection control goes, the OR is obviously using standard sterile procedures. In the ER, infection control is mostly "changing your gloves a lot" (be sure to put on two pairs, any only change the top pair, as your hands are going to get really sweating, and putting a new pair of gloves on your bare hands is going to be impossible).
While I doubt anywhere but the US or a military battlefield will get hundreds of bullet wound patients at once, it's quite possible to get dozens of patients in one go at any hospital. One memorable story I have been told is a tour bus that overturned on a tight hairpin mountain road. Most tour buses do not have seatbelts. The only hospital within reasonable driving distance got 40 elderly patients with head trauma, multiple broken bones, and exposure. Gunshot wounds are not the only Mass Casualty Incidents that can happen. Think about a riot at an Aussie Rules Football game, for instance...
The article doesn't go into detail about your two areas of concern but does mention two items: Infection control was mostly glove changes. Record keeping was on the triage tags from the MCI; cards are attached to patients and travel with the patient. Yes, both of these are a "bare minimum" effort and may not have been used, but when the priority becomes throughput of a system many features of a system can get dropped and picked up again after the crisis is over.
I once hung out for half a day at a hospital in Bakersfield, CA to watch a surgery and they had several gunshot victims come in. So in the US it seems they are highly experienced with this kind of injury unfortunately.
Let me preface this by saying I am in no way trying to "Monday morning quarterback" this incident. This doctor's decisive actions saved dozens of lives.
To facilitate discussion though, I'd like to highlight this section:
"By textbook standards, some of these first arrivals should have been black tags, but I sent them to the red tag area anyway. 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."
There is a reason the "textbook" calls for a black tag. The simplest definition of a "mass casualty incident" is when you need more resources than you have. Sending those dead patients to the treatment area was a waste of the most critical resource they had (the time and attention of medical providers). It is likely some outcomes were worsened by that waste of resources.
I think he was talking about the first few car loads, while he knew there were a bunch of doctors inside with nothing else to do, he was not doing this the whole night?
This triage system is pretty standard, you can see the same triage armbands in this RNLI medical kit in the bottom right corner[0] (I couldn't find a standard UK ambulance kit image), but I am told that it takes a huge amount of mental discipline to follow this training to the letter in real life. It probably took a few people going through the system for him to get into the swing of it.
I can't imagine having to do this, this guy will be going back over the decisions he made that night for the rest of his life. I hope that in writing this article he has felt validated in himself because it sounds like he and his colleagues did an incredible job.
'The simplest definition of a "mass casualty incident" is when you need more resources than you have.'
This definition is an example of the logical fallacy called begging the question. Nobody would deny that an incident that brings 250 gunshot victims to one center is a "mass casualty." The brilliance of Dr. Menes's approach is that he did not immediately assume insufficient resources. He didn't say this, but it appears to me that he proceeded under the thought that with careful planning and ingenuity, they might have just enough resources. This redefines triage from a rigid algorithm to something like "the optimal deployment of available resources to maximize the utility for as many as possible."
> It is likely some outcomes were worsened by that waste of resources
I think the more interesting concept is the second look. Doctors are trained to be sensitive, then specific. Perhaps it would be easier to black tag people if you knew the next thing that would happen is they would go the red tag area for a second call of "black tag".
Here in our county (that includes Tampa), we have an annual mass casualty drill. The larger hospitals actually get mock patients (high school students, some in makeup) transported and practice triage. Every capable facility in the county, even little surgical centers in strip malls, practice communicating with emergency dispatch and "tabletop" how they would handle trauma patient overflow. Fire rescue practices coordinating patient transport to send more minor cases to the more remote facilities. They rotate where they actually do the drill so they get experience working in the different sports arenas, airport, etc.
When I was in the military, between boot camp and going to our first school, we were en masse "volunteered" to be patients in a mass casualty drill at a hospital in Chicago. I'm not sure if it was really worth the trouble. Most of the triage staff rolled their eyes and looked annoyed when we showed up. It was a lot of effort - probably 20 busses full of 19-25 year olds staged in McCormick place all day, trained, made up to look wounded - I can't imagine what it cost to put on, and it seemed to only piss off the staff.
Reminder to donate blood, this is what allows medical professionals to save lives, be it in dramatic incidents such as this one, or in more mundane settings.
It can be worth checking if a regional health provider has their own donation network. The Red Cross does blood drives here but there is also a location in one of the local clinics that makes appointments. Much more convenient than a blood drive.
The Red Cross has every day donation centers in larger cities, just not in as many places as health providers.
Learned some pretty interesting concept on this one with the notion of "Golden Hour":
In emergency medicine, the golden hour (also known as golden time) refers to a time period lasting for one hour, or less, following traumatic injury being sustained by a casualty or medical emergency, during which there is the highest likelihood that prompt medical treatment will prevent death.
https://en.wikipedia.org/wiki/Golden_hour_(medicine)
Another interesting thing is the Golden Hour suggests that nearly any patient far from help (e.g. wilderness) who is still alive by the time you get there, is probably going to make it.
Interestingly, there was a recent study that indicated for penetrating trauma the patient had a much higher survival rate if they were taken to the ER by private car compared with waiting for EMS transport. Presumably because you are less likely to waste that golden hour.
I was looking for an interview I heard with someone from this hospital and could not find it, but I did come across this piece with quotes from many of the staff (it's complementary to the submission):
Even on this, the useful idiots are out trying to claim the vegas murders were fake...
> FB
> Dr. Anson,
> Did the bullet wounds you saw match the caliber of weapon used in the shooting? I ask because wounds would have been more severe than what is being reported. Thanks.
====
> Dr Menes: There were single bullet-pass through-multiple extremity wounds, entrance/exit through narrow torso, and entrance only through dense torso consistent with 5.56 ballistics.
* Plan - have a plan in place in advance
* Flow - recognise and shift bottlenecks + understand the impact to the system
* Prioritise - rank what is critical, urgent, or standard - and be ruthless
* Process - simplify the processes to make it more effective and efficient
* Shift - innovate and adapt in the face of changing circumstances.
These sound like no brainers, but reading the story you get a sense of how one individual pushing these forward in a tough situation had an incredibly powerful impact.
How could we apply these powerful lessons more widely?
I am surprised from the article that all hospitals don't have plans in place for major incidents and its only his experience with the SWAT team that led him to devise the plan before time.
Also I know in the UK they do role-play major incidents out using the police and emergency services to test there plans.
BTW this guy and his team deserve an honour of some sort
> For years I had been planning how I would handle a MCI, but I rarely shared it because people might think I was crazy.
I should state up front I'm ex-military and volunteer for a disaster response organisation.
I find this to be incredible. Who in their right mind would ostracise a trauma professional for conducting such planning? In fact, who who dare not support such a professional to plan for such eventualities?
I actually can't quite believe the implication here, that there is a systemic reluctance to plan for such events. Maybe things are different in my country (UK) but this 'worry' the doctor has seems frankly absurd!
> The first thing I did was tell the secretaries I needed every operating room open. I needed every scrub tech, every nurse, every perfusionist, every anesthesiologist, every surgeon—they all need to get here right away.
I thought I'd misread the article, maybe I still have, but this sentence seems to back up the claim no MCI plan was already in place.
It may be a product of our troubled history and extensive threat of terrorism (including the Irish dissident threat) but here in the UK Major Incident Response planning is practised extensively, and not just for medical emergencies. Planning is in place at almost every level to deal with such incidents. Almost every large institution, let alone just hospitals/emergency services, will deliver a 'Major Incident Response plan' (just Google 'Major Incident Response Plan UK' and you'll get many many examples), which will almost universally include a Mass Casualty Response Plan.
Indeed, there is even an NHS Tactical Command Framework in place to deal with Mass Casualty Incidents that will usually span several local health trusts and setup a coordinated response framework dedicated to responding to incidents like these.
Equally, all local governments departments have well rehearsed responses, integrating tightly into the UK's Gold/Silver/Bronze Command response coordination structure. Usually our emergency services, military and hospitals will have physically practised inter-operability via joint exercise and will utilise other joint working practices like JESIP and the METHANE reporting system.
I know for a fact the US follows the very well planned ICS system which links into both FEMA and local/state level emergency planning. I find it absolutely unfathomable that no well rehearsed and fully scoped plan of similar thoroughness to the UK was ready to go and instead this doctor simply made it up on the hoof.
Despite my own disbelief, it seems this Dr. actually did have to make it up as he went along - what an amazing, stunning personal achievement, and what a devastating systemic failure.
Only tangential related: But the quality improvements in ER has saved countless potential "murder" victimes over the last two decades. The problems these victims phase, after they have been patched up are severe. Chronic pain, disabilitys and hardships.
But they are not murders, so its not so bad in the city of <place-name-here>.
We should write into the news how bad the victims future prospects are limited. Not just a "wounded", but "wounded, with future limitations on autarc living"
It's not uncommon for a given piece to be submitted a number of times before it "takes" (if it does at all). Also, it looks like both times this has been submitted the article title has been different. It might get more visibility if it's submitted by a well-known HN member, but overall, I wouldn't read too much into it.
[+] [-] tptacek|8 years ago|reply
A bunch of the terms used in this piece (like "crumping", which apparently means dying without doctor permission) are emergency medical jargon, all easy to look up.
[+] [-] unknown|8 years ago|reply
[deleted]
[+] [-] karlkatzke|8 years ago|reply
A few things that jumped out:
- Thinking ahead to how he was going to handle an MCA probably saved dozens if not hundreds, even if he made some choices that he shouldn’t have if you’re sitting in our present armchairs.
- This is great demonstration of why the incident commander needs good oversight of the whole situation, and why not everyone makes a good incident commander. The three doctors in Station 1 should have felt empowered to solve the bottlenecks, but they did not... they just kept working within established procedure. That’s ok. You need good operators. But the good leaders in incidents are the people who know how and when to establish and communicate new standard procedures.
- Getting ahead of and staying ahead of a cascade failure is a difficult thing to manage, one that we don’t often accomplish in operations/sre incidents. I know I’ve had one or two incidents like that, mostly DDoS or other attack types. This story shows the value again of staying frosty and planning to handle your next problem before it snowballs and hits you from behind.
[+] [-] JshWright|8 years ago|reply
My experience in emergency services is my greatest asset in ops work. So, half the datacenter has crashed, and the other half is about to buckle under the load. Is anyone literally going to die in the next 5 minutes? Ok, cool, then let's just sort this out and get on with our lives.
[+] [-] gizmonty|8 years ago|reply
[+] [-] JshWright|8 years ago|reply
Generally there is an "MCI kit", which has a form that can be attached to the patient (an elastic band around the wrist or ankle, generally). That form will contain whatever information we know about the patient, interventions thus far, etc. It stays with them throughout the process (in the triage and treatment areas, to the OR, etc). That being said, documentation is often a tertiary concern at best in large scale events like this.
As far as infection control goes, the OR is obviously using standard sterile procedures. In the ER, infection control is mostly "changing your gloves a lot" (be sure to put on two pairs, any only change the top pair, as your hands are going to get really sweating, and putting a new pair of gloves on your bare hands is going to be impossible).
[+] [-] karlkatzke|8 years ago|reply
The article doesn't go into detail about your two areas of concern but does mention two items: Infection control was mostly glove changes. Record keeping was on the triage tags from the MCI; cards are attached to patients and travel with the patient. Yes, both of these are a "bare minimum" effort and may not have been used, but when the priority becomes throughput of a system many features of a system can get dropped and picked up again after the crisis is over.
[+] [-] maxxxxx|8 years ago|reply
[+] [-] will_hughes|8 years ago|reply
It's obviously a completely different scale though, and they had some time to prepare before the patients started arriving.
[+] [-] JshWright|8 years ago|reply
To facilitate discussion though, I'd like to highlight this section:
"By textbook standards, some of these first arrivals should have been black tags, but I sent them to the red tag area anyway. 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."
There is a reason the "textbook" calls for a black tag. The simplest definition of a "mass casualty incident" is when you need more resources than you have. Sending those dead patients to the treatment area was a waste of the most critical resource they had (the time and attention of medical providers). It is likely some outcomes were worsened by that waste of resources.
[+] [-] willyt|8 years ago|reply
This triage system is pretty standard, you can see the same triage armbands in this RNLI medical kit in the bottom right corner[0] (I couldn't find a standard UK ambulance kit image), but I am told that it takes a huge amount of mental discipline to follow this training to the letter in real life. It probably took a few people going through the system for him to get into the swing of it.
I can't imagine having to do this, this guy will be going back over the decisions he made that night for the rest of his life. I hope that in writing this article he has felt validated in himself because it sounds like he and his colleagues did an incredible job.
[0]https://twitter.com/TowerRNLI/status/593180062565924865
[+] [-] mathgenius|8 years ago|reply
[+] [-] aladoc99|8 years ago|reply
This definition is an example of the logical fallacy called begging the question. Nobody would deny that an incident that brings 250 gunshot victims to one center is a "mass casualty." The brilliance of Dr. Menes's approach is that he did not immediately assume insufficient resources. He didn't say this, but it appears to me that he proceeded under the thought that with careful planning and ingenuity, they might have just enough resources. This redefines triage from a rigid algorithm to something like "the optimal deployment of available resources to maximize the utility for as many as possible."
[+] [-] killjoywashere|8 years ago|reply
I think the more interesting concept is the second look. Doctors are trained to be sensitive, then specific. Perhaps it would be easier to black tag people if you knew the next thing that would happen is they would go the red tag area for a second call of "black tag".
[+] [-] unknown|8 years ago|reply
[deleted]
[+] [-] ja27|8 years ago|reply
[+] [-] bbarn|8 years ago|reply
[+] [-] forg0t_username|8 years ago|reply
UK: https://my.blood.co.uk/
US: http://www.redcrossblood.org/donating-blood
[+] [-] maxerickson|8 years ago|reply
The Red Cross has every day donation centers in larger cities, just not in as many places as health providers.
[+] [-] unknown|8 years ago|reply
[deleted]
[+] [-] tehlike|8 years ago|reply
http://www.militaryblood.dod.mil/Donors/can_i_donate.aspx
Good thing is i don't have a rare blood type.
[+] [-] jxramos|8 years ago|reply
In emergency medicine, the golden hour (also known as golden time) refers to a time period lasting for one hour, or less, following traumatic injury being sustained by a casualty or medical emergency, during which there is the highest likelihood that prompt medical treatment will prevent death. https://en.wikipedia.org/wiki/Golden_hour_(medicine)
[+] [-] martinmunk|8 years ago|reply
Time is off course at a premium, but there seems to not be anything special about the 60 minute mark.
[+] [-] sliverstorm|8 years ago|reply
[+] [-] khed|8 years ago|reply
[+] [-] js2|8 years ago|reply
https://hcatodayblog.com/2017/10/06/sunrise-hospital-staff-s...
[+] [-] x0x0|8 years ago|reply
> FB
> Dr. Anson,
> Did the bullet wounds you saw match the caliber of weapon used in the shooting? I ask because wounds would have been more severe than what is being reported. Thanks.
====
> Dr Menes: There were single bullet-pass through-multiple extremity wounds, entrance/exit through narrow torso, and entrance only through dense torso consistent with 5.56 ballistics.
[+] [-] deepandmeaning|8 years ago|reply
The standout's for me were:
* Plan - have a plan in place in advance * Flow - recognise and shift bottlenecks + understand the impact to the system * Prioritise - rank what is critical, urgent, or standard - and be ruthless * Process - simplify the processes to make it more effective and efficient * Shift - innovate and adapt in the face of changing circumstances.
These sound like no brainers, but reading the story you get a sense of how one individual pushing these forward in a tough situation had an incredibly powerful impact.
How could we apply these powerful lessons more widely?
[+] [-] walshemj|8 years ago|reply
Also I know in the UK they do role-play major incidents out using the police and emergency services to test there plans.
BTW this guy and his team deserve an honour of some sort
[+] [-] razakel|8 years ago|reply
[+] [-] PuffinBlue|8 years ago|reply
I should state up front I'm ex-military and volunteer for a disaster response organisation.
I find this to be incredible. Who in their right mind would ostracise a trauma professional for conducting such planning? In fact, who who dare not support such a professional to plan for such eventualities?
I actually can't quite believe the implication here, that there is a systemic reluctance to plan for such events. Maybe things are different in my country (UK) but this 'worry' the doctor has seems frankly absurd!
> The first thing I did was tell the secretaries I needed every operating room open. I needed every scrub tech, every nurse, every perfusionist, every anesthesiologist, every surgeon—they all need to get here right away.
I thought I'd misread the article, maybe I still have, but this sentence seems to back up the claim no MCI plan was already in place.
It may be a product of our troubled history and extensive threat of terrorism (including the Irish dissident threat) but here in the UK Major Incident Response planning is practised extensively, and not just for medical emergencies. Planning is in place at almost every level to deal with such incidents. Almost every large institution, let alone just hospitals/emergency services, will deliver a 'Major Incident Response plan' (just Google 'Major Incident Response Plan UK' and you'll get many many examples), which will almost universally include a Mass Casualty Response Plan.
Indeed, there is even an NHS Tactical Command Framework in place to deal with Mass Casualty Incidents that will usually span several local health trusts and setup a coordinated response framework dedicated to responding to incidents like these.
Equally, all local governments departments have well rehearsed responses, integrating tightly into the UK's Gold/Silver/Bronze Command response coordination structure. Usually our emergency services, military and hospitals will have physically practised inter-operability via joint exercise and will utilise other joint working practices like JESIP and the METHANE reporting system.
I know for a fact the US follows the very well planned ICS system which links into both FEMA and local/state level emergency planning. I find it absolutely unfathomable that no well rehearsed and fully scoped plan of similar thoroughness to the UK was ready to go and instead this doctor simply made it up on the hoof.
Despite my own disbelief, it seems this Dr. actually did have to make it up as he went along - what an amazing, stunning personal achievement, and what a devastating systemic failure.
[+] [-] rb666|8 years ago|reply
[+] [-] WillReplyfFood|8 years ago|reply
[+] [-] jopsen|8 years ago|reply
[+] [-] aerovistae|8 years ago|reply
[+] [-] grzm|8 years ago|reply