Deep resiliency and the ability to handle outlier events is not efficient from a bottom line perspective of a single entity with profit as its primary focus. Training people to effectively use uncommon gear and uncommon procedures is expensive especially as training decays and people need refresher training. This can lead to multiple years of refresher training with no major events, and no reimbursement for those trainings, it just is not efficient and kills the bottom line as removing a nurse from the floor for a day could cost $500 without a corresponding revenue stream.
We’ve been optimizing for efficiency with minimal required resiliency against expected shocks. This mindset leads to MBAs looking at a balance sheet and seeing preparations for very low probability events as being an easy cut to boost profits over the next three quarters (these MBAs are long term thinkers, I tell you). The public counterbalancing of providing funds to subsidize insurance against low probability events has been cut in half over the past fifteen years as that is BIG GOVERNMENT and tax cuts will solve all our problems. So we get hospitals that don’t know how to follow their own procedures and state governments that are in over their heads while knowledgable experts are not allowed to issue orders until asked.
To top this off, we have a national political/media freak out on what at this point is no more than a Friday night’s toll along the drunken back roads of any state….
OODA loop fail.
SP
Not that all of these situations will obtain, but this is like a convergence of all failures of conservative government and economics:
-Person presents with disease, treatment/diagnosis is deprioritized because he lacks insurance;
-Government support for training has been cut, leading to lack of training for response
-Unions at health care institutions are powerless to demand effective safety guidelines for employees
-Basic research reduced, no programs developing a vaccine or treatment
-Government regulation reduced, guidelines on travel restrictions and quarantine, not effective
-Lack of sick days, infected low-income food service worker can’t afford to stay home & infects customers
I’m not religious but if I did believe in a sky person I’d think he/she was giving a big omnipotent middle finger to conservative politicians and voters.
SP
Oh, and if you like, add foreign policy, intergovernmental orgs/coordination, etc…
Belafon
Now, how am I supposed to be scared if you won’t mention Ebola directly. Beating around the bush won’t get any news coverage.
Mnemosyne
I went to a presentation by Dr. Kate Hutton recently (for non-Californians, she’s a seismologist with Cal Tech) and she pointed out that, thanks to Just-In-Time inventory systems being adopted by our local grocery stores, we will all be screwed when the San Andreas fault decides to spit out its next 7+ earthquake. When Northridge happened in 1994, grocery stores all had huge warehouses of food on this side of the fault, so they were able to keep supplies coming. Now, they truck everything in over the state line every day as needed, over the fault. Which means we’ll be fucked, because the daily trucks won’t be able to get over the broken bridges and highways.
Time to add a little extra food to the earthquake kit …
gene108
Speaking of preparedness, does anyone have any news on the military units we sent to West Africa and if they have helped the West Africans?
The really fucking frustrating thing about this Ebola outbreak is, if the international community actually gave a damn, we could contain it in West Africa, without a problem.
Unfortunately, we’ve done more than most countries and we have done scant little it seems.
Belafon
@gene108: I saw something yesterday that said the UN has been trying to set up a $1B fund to help fight it in Africa, and so far, the only contribution has been $100K from Colombia.
aimai
I heard an interesting thing on NPR which is that one of the biggest problems with an illness like Ebola is that if moves out of its original locations when people go as migrant workers. So if the epidemic isn’t ended before the migrant worker season begins the men in these countries start trekking out to get work. The amount they are getting paid is something that, by western standards, is derisory: 5 dollars a day. If the world were capable of thinking rationally about it they would pay able bodied men to stay in their home villages and cities and work on infrastructure projects locally, train them do do health care work and simultaneously stop the flood of potentially unwittingly sick migrants and pump money into the local economies.
Someguy
@gene108: Speaking of preparedness, does anyone have any news on the military units we sent to West Africa and if they have helped the West Africans?
I think the DoD employee who threw up on the commuter bus at the Pentagon this morning may have been part of the advance team to Sierra Leone. Fortunately, they located the bus on Capitol Hill and got it out of service within a few hours. Total overreaction, probably the flu, but hey, D.C. loves a good panic. No big deal; more people die from obesity every month than have died, ever, from ebola.
wenchacha
Thank you, Richard Mayhew. The JIT mentality saves money right up until there is a crisis. Then, the costs can become enormous. Our government can’t run like a business; we should always be prepared for some previously unheard of calamity. And emergency preparation doesn’t always require armored tanks on the shopping list.
This short-term/bottom-line thinking will be the death of us.
srv
Boyd is overrated
Mnemosyne
@wenchacha:
To be fair, JIT makes perfect sense for the industries it was originally created for, like car manufacturing. It’s when it’s seen as a magical efficiency engine that can be applied to every aspect of life that it grows into a Frankensteinian monster.
jl
@Mnemosyne: Not sure that is JIT itself, or Nevada warehouse tax policy. NV has an intentional fiscal policy to tax arbitrage CA on warehousing. State competition to win fiscal race to the bottom, so NV can set up a string of low pay warehouse and trucking jobs around Reno, Carson City and Las Vegas, just over state line. Then NV pols can crow about jobs, while state education and infrastructure investment starved.
Tree With Water
Cause and effect: An engineer once explained to me that the reason most huge skyscrapers have such lousy locking dock facilities (which serve as a building’s main artery) is because architects usually treat it as an afterthought, as something to be squeezed in.
Privatization zealots have always treat vital services that promote the general welfare with similar disregard. The hell of it is, since 1980 their screwball and cancerous beliefs have been a north star for all of one party, and a large percentage of the other.
The democratic party’s rank and file deserve better. Gratuitous shot: they won’t get it with Hillary Clinton, either.
Roger Moore
@Belafon:
But this kind of thing applies to all kinds of low-probability events, not just Ebola. There are all kinds of expensive mandates for hospitals that only apply during rare disasters, but we see them as worthwhile because the middle of a disaster is when it’s most important for a hospital to remain functioning. For example, here in California, we updated our building codes after the Northridge earthquake in a way that effectively mandated that every hospital built in a high quake risk zone- which means all the big cities- be replaced. We also require those hospitals to run regular disaster drills that cover all kinds of disasters that are quite unlikely. There’s no way the MBAs would put up with it without state mandates backed up by serious penalties for non-compliance.
japa21
A lot of places have special response teams, including hospitals. By training a select group of nurses, Drs, and ancillary staff in procedures with monthly drills, if a situation comes up, that staff is immediately called in to care for the patient. It would be a little bigger than what immediate needs would be to account for staff on vacation, ill, etc.
It reduces the cost of training and supplying gear for everyone in the hospital and increases compliance with all procedures.
Yes, there is a cost factor, but it wouoldn’t be so prohibitive as to serve as a negative when compared to the potential positive.
Wait a minute, since, forsome hospitals, every penney saved is a plus, maybe it would be after all.
Roger Moore
@Mnemosyne:
That’s Caltech, dammit!
Mnemosyne
@jl:
Dr. Kate seemed to indicate that it was due to JIT, but she’s a seismologist, not an economist.
Mnemosyne
@Roger Moore:
;-p
jl
I think RM gives the US health care system too much credit. Maybe he can chime in on the TPM story about the Presbyterian Hospital Dallas (which I believe is non-profit affiliated with the church) odd decision wrt to personal protection protocols and gear.
Dallas Hospital Waited Three Days to Use Hazmat Suits
” there was apparently a critical two and one half days after Duncan was admitted to the hospital with a suspected case of Ebola but before his definitive diagnosis when hospital workers continued to operate without hazardous materials protective gear. ”
” But workers at Texas Health Presbyterian Hospital Dallas did not abandon their gowns and scrubs for hazmat suits until tests came back positive for Ebola about 2 p.m. on Sept. 30, according to details of the records released by AP.”
http://talkingpointsmemo.com/edblog/dallas-hospital-waited-three-days-to-use-hazmat-suits
From my reading of Nigerian doctor’s story of her own infection linked to on this blog in comments a week or so ago, there are a lot of fairly specific signs and symptoms for Ebloa infection that can be seen by naked eye from several feet away. The patient was sick with a high fever, vomiting and diarrhea for three days. Was he an atypical case, which no specific easily seen signs and symptoms, like the ‘Ebola tongue’ and characteristic rashes with unusual under color and distinctive patient smell that I read about in the Nigerian doctor’s story? I would think the docs and nurses would be on the phone to get info about this.
As a layman I find the decision to basically do nothing for almost three days until an ‘official’ lab test came back very odd. This is not waiting for a test on a culture to come back on a person with sore throat to see if strep before Rx for antibiotics.
I don’t see a dilemma here at all. Maybe sloppy US medical care system, consistently with highest reports of errors among high income industrial counties.Maybe toxic management slave labor attitude towards workers of all kinds in both for and non-profit institutions.
Some international docs I’ve talked with have accused US medical professionals of being very excessively lab test driven and unable to make good decisions based on anything else, either evidence based standards of care or clinical judgment from signs and symptoms.
It is not even an issue of taking nurses and techs off the floor for training. Those workers were trained enough to know that proper equipment was not provided in a timely way with a likely Ebola patient. Considering the costs and benefits of different types of error in this case, as a layman, I find waiting for a definitive lab test a very odd decision.
Maybe just deeply ingrained FU cheapskate attitude of any US revenue based business management: “I don’t spend a damn penny or lift a finger until i am damn well forced to, I don’t give a rat’s ass about the consequences unless I know for sure it will hit my bottom line right now.”
Maybe a doc or an epidemiologist or RM can explain that decision to me, as a layman who can read, I don’t get it.
gene108
@Roger Moore:
I think human nature is somewhat similar to the atoms that make up our body.
We tend to gravitate towards the lowest energy state, where we can rest comfortably.
If the state did not mandate safety, few of us would think “OMG! What could possibly go wrong? I don’t need reinforce that/ take a back-up / fix it, etc.”
I bet there’d be plenty of doctors and nurses, like in any profession, who do not feel a burning need to get another set of protocols dumped on them, which are not routinely necessary.
They won’t get it until the crop of media chuckle heads dies in a fire. Between the Second Gulf War and this current Ebola scare, the media is a powerful tool, currently in the hands of morons, at best, and vicious evil fucking liars, at worst, who don’t give a damn about anything other than their ratings / salaries.
Kathleen
Based on what I’ve read and heard from my brother, who lives in Dallas and has followed stories about this particular hospital in the past, poor management at the facility is the root cause of why Duncan died and two nurses became infected.
1. Duncan was not treated properly when he came to the ER, most likely because he did not have insurance. My brother said that hospital has been investigated a few times over the years due to its treatment of the uninsured.
2. It sounds as if basic 101 precautions for any disease were not taken.
3. Doctors refused to listen to the nurses when they raised concerns.
Of course no one can say for sure that Duncan would have survived and the nurses would not have been infected even if the above conditions hadn’t existed. But it’s possible if Duncan had been admitted and treated properly the outcomes may have been different. I’m not criticizing medical personnel but I am criticizing the management. The long term mistreatment of the uninsured is a clue that the management is the problem.
Davis X. Machina
@jl:
The US belief in a generalized ‘science’ of ‘management’ guarantees that whether the hospital is non-profit or not, or whether the affected institution is a hospital or not, you’re going to see the same stupid replicated, right across the culture. Look at the schools… and school ‘management’.
aimai
Just heard a story from a doctor I know about a local hospital here where a patient presented in the ER and was told to “drive in his own car” to a better treatment facility (i.e. another hospital). I don’t think this can have been a real case of Ebola–there are no reports–but the triage nurse who saw the guy seems to have overreacted and independently decided to prevent the contamination of the ambulance by just shifting the patient and the responsibility to another ER and telling the patient to just go there on his own.
There is a major problem with the idea of the independent, stand alone, ER or hospital treating a communicable, contagious disease like Ebola or refusing to treat it. We have to start thinking about the entire health care system and treatment system for an entire community as a single organism or organization. We really need a good overall design for each community and hospital/clinic which prevents sick peopel from being bounced around–you can do that either by bypassing the insurance system altogether (a good first step) so that cost is not an issue for these patients or by having flying teams of trained medical professionals and freestanding units (if those are even possible) like contagion wards as trailers that get brought into communities that are starting to be affected. And/or you could ask people who think they may be sick to phone in and be visited by a flying medical team rather than teling them to go to the ER at all. Our ER based triage system may be a liability in a serious epidemic rather than a good way of handling possibly contagious patients.
Sir Nose'D
@srv: Boyd is Underrated.
PurpleGirl
Just got home from an appointment at Elnhurst Hospital (a City hospital). They now have large signs on stands by each entrance and in the main hall telling people that if they have recently come from three countries in West Africa with Ebola and they ahve a fever, to tell anyone at an information desk or reception area or nurse. The staff will then take over to help you.
Kathleen
@aimai: Yes, I agree. I am not anti Western medicine, but my prayer is that I never have to be hospitalized. Too much can go wrong, and the lack of communications and linkages between doctors and departments is scary.Then there is the culture issue, in which nurses don’t always feel free to speak up or question a doctor.
Bill Arnold
@Roger Moore:
My brother works in CA as a project manager for a very large construction company, and they did a LOT of hospital work.
JustRuss
In fairness to the MBAs, that’s what their customers–shareholders and CEOs–want. Unfortunately, when people talk about “running government like a business”, that’s exactly what we get: short-term thinking that benefits the 1% while driving the enterprise into the ground. Not a great way to run a railroad, and a horrible way to run a country.
Bill Arnold
@JustRuss:
What they want is to socialize the risks. Doesn’t work for governments.
Capri
@Kathleen: At least some places are striving to change the culture. My son is a freshman in medical school, and from Day1 he has been teamed with nursing students and given tasks that allow both RN and MD to appreciate what the other is doing. Their first assignment was to admit a medical error to a patient’s family.
d58826
Saw this article in intl. business times
hopefully the Czar will kick some butt on this. It won’t solve all of the panic but if a passenger gets sick on a plane at least every one will know in short order if it is Ebola. That alone should calm the nerves of the nervous nellies amoung us.
RaflW
If the political media would freak out about the slashed government funding, then maybe we could get somewhere.
I know, that would look too partisan. As opposed to deficit fetishism, which is oh la la centrist.
Sondra
Bravo.
Sorry I repeated what you said: I’d add that there are Governors out there like Bobby Jindal who think cutting funding for research into health issues like this is a good idea. They come up with crazy scenarios that scare the devil out of themselves and then ignore and/or deny what is right in front of their faces.
Sondra says:
October 19, 2014 at 11:01 am
.
@John Cole +0:
I say amen brother. It’s too tiresome to go into the details of the AIDS Epidemic scare back in the day, but the parallels are there.
Neither disease can be spread just by sitting next to someone who has the virus. But is would be foolish to try to treat these viruses carelessly.
By foolish I mean that someone within an organization like an enormous hospital, must be in charge of obtaining the proper equipment for the staff and in-training them in best practises. In the case of Ebola, best practices must extend to the life of the staff outside of the hospital: at least for the 21 days in which they might be vulnerable to the infection.
We all know this. The administration of the Hospital – at least the bean counters in the administration, must not be allowed to over-rule the doctors and nurses who need very specific equipment and training: on-going training, not just one class and you’re done,
They will cut corners wherever they can, and preparing for an outbreak of a dangerous virus seems to them so unlikely that it doesn’t warrant the funding. I’d be curious to know how many AIDS patients this hospital cares for. My guess is very few or none.
I’d also be curious if the ER staff gets sloppy about other best practices too: bad enough that they sent him home with a fever and an RX . I’m guessing they didn’t spend much time with an uninsured patient and either didn’t bother to get a history from him, or didn’t understand the implications of his return from Liberia.
Liberia! Dammit. Heads up people – too tired to think about that is the most foolish decision of all the foolish decisions made by the folks at that hospital.