3/14 Getting slammed

Looking at the  Italian doctors interview about his ICU getting slammed and trying not to be overwhelmed by the surge.


A lot of the stuff we talk about in general is evident in his experiences.  It also parallels our study of a mass casualty response – the clinicians adapt to somehow make up a response that gets everyone through; the planning and plans contribute very little to the front lines. 

Analyses are using the #s (estimates based on current experience) to show what overload looks like.  Note the critical # – length of stay in hospital until sufficient recovery – it’s a bigger than normal #.  This is part of knowing how recovery processes happen after hospitalization.  The Italian physician’s account of their adaptations to treat the growing need shows how front line clinical work adapts as the need they directly face grows.  These are very local and an open question is how well are these processes/lessons being shared and set up by hospital systems not yet loaded with COVID-19 patients. 

The care issue shifts from a standard of care centered on each patient to a standard of care centered on handling the patient load — a set — while doing the best available for all patients (given the response resources mobilized)  note how the Italian physician said this in effect. Simple example:  in a standard of care centered on each patient, each patient gets a physician from the appropriate medical specialty while in a potential overload situation, physicians from other specialties are recruited in and work with the specialists – so that expertise is deployed to cover patient needs in new ways.

We see a strange loop effect in this case, as well as in the IT infrastructure/DevOps incidents –  providing care undermines the ability to provide care as the clinicians needed for care are themselves quarantined or get the disease, increasing cases, transmission risks, and reducing the ability to meet care needs, as is happening in northern Italy.

The US is providing an extraordinary contrast:  the incoherent non-system in US provides a variety of pathways for the virus to spread and as that happens the potential for overload is scary.  Cross level coordination is the only way to generate new capacity  ahead of need (this coordination also facilitates varies forms of horizontal sharing). 

There is no way to know what is sufficient effort to generate new readiness to respond. This means, if enough capacity is generated given the actual experienced load, afterwards there will be the perception of inefficiency or unnecessary or wasteful or overreaction – exactly what I wrote about the sacrifice judgement in the 2006 Essentials chapter, though with examples at a very different scale.

Interview with WHO head on lessons from past outbreaks, Ebola.


Highlights how timing matters and need to act aggressively early — shows anticipation paradox.  Also how the standard framing of decision making leaves out time; even he is caught in this framing, when he is supporting the fundamental reframing of naturalistic decision making – time (time pressure, tempo, keeping pace) always matters. 

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