Monthly Archives: October 2011

8 Hours in an Emergency Room — Thoughts of Queueing

Yesterday morning I awoke to my girlfriend calling my name from three rooms away – “Jeff, Jeff… wake up Jeff. Jeff, I’m hurt!” Skip a lot of fast-moving details and we find ourselves in a room at the ER with the kind of real problem that gets you through triage in minutes… and in this case leaves you waiting unnecessary hours for your discharge. That we spent so much time in the room was a problem for the entire department as they were filling up the hallways with patients.

Emergency rooms known to those outside the medical profession for wait times. This is connected to the fact that you’re servicing the person who needs stitches or is running a high fever with the same resources that you’re servicing a person who came in from a helicopter on the roof with their arm falling off. That’s not enough of an explanation, however when the average wait just to be seen is 3 hours, 42 minutes.

Resource utilization and compartmentalized responsibility may be the biggest factors to address. In any system with a single lead, you have a clear setup. When multiple people are responsible for a process at multiple stages and with many who have similar authority involved, the system becomes too complex for the parts to work together on their own. If somebody doesn’t have an overview of the process, it can feel like trying to drive down a road with timed stoplights in the middle of the night. Failing to coordinate such a system can result in huge backups when there is traffic even though the number of vehicles per hour doesn’t change.

In a bustling emergency room that has multiple units, it may be the case that nobody is following the patient’s status throughout delivery of treatment to the same effect that as when nobody is coordinating stoplights. Triage bins patients according to priority and ensures that urgent cases are attended to first. Once they leave the waiting area, triage is uninvolved. Nurses prep patients, doctors attend to them, nurses carry out medication orders, and techs handle the more trivial issues such as monitoring blood pressure. Eventually the doctor will sign the patient over to another department or discharge them, but their attention is focused on medical issues, not on flow.

Consider the flow of customers and orders within restaurant. The host is aware of capacity and utilization; hosts seat people according to reservations and group size (triage).  Wait staff tend to guests determining their food orders (nurses). Some staff roam the restaurant filling up water glasses as needed (techs). Chefs prepare main dishes (doctors), and in a bustling operation many of them may work on a single dish (specialists). The trick is that all your food must come out quickly and at the same time. Wait staff can’t coordinate that because they’re tending to tables. Chefs need to focus on food itself (diagnosis / patients / complex interactions). The missing link is the expeditor. They manage all the kitchen queues and fire orders in a way that ensures everything is addressed at the proper time.

Hospitals generally lack a position that’s analogous to this. A non-medical individual who never interacts with patients and is in charge of movement probably boggles a few minds in the field. I was a bit boggled myself when I did some searching and realized that first good example of the idea forming in my head was implemented in an ER by a facilities cleaning company.

Queuing problems are not unique to hospitals in any way, and some great solutions for them come from outside. Besides the restaurant view, there are many other instances where an individual with overview of the holistic situation is a benefit. Being able to view an entire supply chain of parts can result in great increases in efficiency and improve reliability. Safety officers on fire grounds and hazmat scenes are an example where everybody is focused on safety and yet an individual not involved in fighting fire provides an overview to keep everybody safe because the interaction of various companies at once is complex. Police departments in growing numbers have civilians who determine resource allocation based on information from many officers and departments. Even the railroad I volunteer at benefits greatly from an outsider asking why all the rail isn’t pulled up at once and the idle backhoe used to grade everything instead of one section at a time.

Queuing is also a matter of consideration with a patient just sitting in a room. Whenever we needed attention, there was one button to push. Whether it was asking a trivial question that could wait 10 minutes or a spurting vein, there was only one button to push. While we always want that that big red button to be easily accessible for anybody, a patient who is capable of pressing smaller 5 or 10 minute request buttons, or even typing up their requests will appreciate not feeling demanding and will benefit the staff by allowing more efficient servicing of their requests.  A patient might alert us for medication when pain starts to increase rather than waiting for somebody to incidentally stop in or alerting only when it becomes seriously uncomfortable and requires immediate attention.

Having an overall view is needed to efficiently coordinate any complex systems with multiple pieces that all work together, whether it’s the traffic lights on the evening commute, different military units storming Normandy, or the person in your ER who reserves a CT scan ahead of time so that the contrast agent can be consumed just before an ultrasound and leave the patient absorbing their dye during an already needed test instead of waiting in a bed between tests.

The First One

The history of the world tells me that I first registered this domain in 2003. I filled it with random writings and a bit too much angst… but I did write my own SQL backend for it. The problem was the same as most blogs suffer — a limited audience with limited potential and temporal relevance. If I didn’t write regularly, it was valueless. The stuff that I wrote previously also lost value. While it’s amusing to look back on, I want something of lasting value.

These past years I’ve been been forced to learn to adapt in different ways. I’ve come to understand that there’s a useful limit to technical knowledge in the world. At a certain point, it matters less what you know and more how you can interact. Put another way, you eventually have to start trading on your name. For technology, I live in a pretty small city for that.

I’d say around June I decided to start fixing that. Stackoverflow.com was a useful site to me. It was mostly useful as a concept. While I’ve made my money in part by programming, I never felt it was my strongest calling (even if I did start enthusiastically looking at The Art of Computer Programming this week). A spinoff site, security.stackexchange.com really did do it for me, though. I like that feeling that pointing to my user account there is a way to say, “This is who I am, and I do know my stuff.”

I also found that writing outside that format was useful. I’ve been a contributor to the Security.SE blog for some time now, and plan to continue that. Yet, I think the things I learn and the traits I want to present extend beyond that. So, for an open forum where I can choose the topic, I give myself this goal: Write things with a technical focus that will individually and collectively be a useful reference to those who may read them.

Thus: for a reason to write, a place for my thoughts, and some good ‘ol shameless self-promotion, I have a real website.