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.
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.
I uphold a certain quality of work and I expect my peers to do the same. Everyone makes mistakes but even mistakes can be modeled.
Obviously there can be misguided procedures, but any decision made or operation done can be misguided.
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.
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.
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.
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.
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.
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.
that's both a big "If" and a very ambiguous ask - what's does a "reliable AI" mean?
Taking medical advice from ChatGPT over what your doctor says, what could go wrong?