Commandos

Sally Rabinowitz sat in the windowless subbasement of the hospital, contemplating four computer screens stacked in pairs and feeling slightly overwhelmed. She was assessing the flow of patients into the hospital—local, national, and international transfers from other health care facilities, as well as admissions from the hospital's emergency department and outpatient clinic. At the same time, she was also tracking scheduled admissions for procedures and surgery and monitoring the number and location of available hospital beds. Sitting on one side of her was a representative of environmental services, who was determining which beds were clean versus those that were empty but dirty and prioritizing the cleaning activities of his staff. On her other side was a nurse from care management, tracking potential discharges and that vast array of unexpected delays, from procedural scheduling snafus to infection-related skilled nursing facility closures.

Across town, at the airport, Jonathon Begnem briefly glanced up from his monitors and gazed out at the wraparound windows overlooking the tarmac. It was a nice but momentary distraction. The sky was gray, and snow was on the way, but for now all was calm. He checked his stacked screens for the status of incoming flights, open gates, and delayed departures with an eye on the weather. Next to him sat a colleague gazing at his own array of monitors showing the status of baggage. He was monitoring handling, delays, and misplacements. On the other side sat a morose woman following the movement of flight crews and adjusting for delays, illness, and availability.

Joe Charleson was an unhappy patient. He'd been driving his 18-wheeler from San Jose to Chicago with a load of limes. He had developed chest pain somewhere in the middle of nowhere. It came on suddenly, like an airbag had spontaneously inflated against his chest. He felt short of breath. He was about to pull over when he spotted a sign for a hospital at the next exit. He pulled into the parking lot of the small facility but couldn't get out of the cab of his truck. He blasted his horn to get help. The next thing he knew, they were taking off his clothes, attaching pads to his chest, and putting an IV in his arm. The doctor was talking about dimers. What the heck was a dimer? It sound like drug slang. Then he started talking about thrombosis and “doe-acks,” which sounded even worse. Joe was lost in all the terminology. All of a sudden he was signing forms and being loaded into an ambulance. He should have been contemplating his own survival, but all he could do was think about his truckload of limes.

Charlotte Johnson was a disgruntled traveler. She swore she would skip her next work trip if at all possible. She was tired of second-class hotels, tasteless franchise food, and especially overcrowded airports. It wasn't the security lines, though she did find them annoying, or the unforgiving hard plastic seats. Her greatest frustration was delayed flights. Changes in itineraries really drove her to the brink, and now it was happening again. Bad weather on the East Coast meant she'd miss a connection and not make it home until tomorrow, and thus also miss her daughter's fifth birthday party. She'd promised she would be home. At the gate, a harried airline employee was trying to get an update under Charlotte's glaring gaze. She just had to get back to Savannah via Atlanta.

In the hospital subbasement, Sally took a quick look at the ambulance board and noted a patient en route from a critical access hospital. They had planned on an air transport, but with the encroaching weather had elected to go by ground. The ED was stacked up with patients, two who were boarding waiting for medical beds and three waiting for psychiatry placement, and the trauma bay was filled by a recent pile-up on the freeway. There was one open ICU bed currently, and the PACU had three patients waiting. The ambulance was 15 minutes out. The PACU and ED charge nurses were messaging for a bed, but Sally had to use the one free ICU spot for the incoming patient with a massive PE. The ED nurse was concerned about the throughput metrics, but the needs of the ambulance patient came first.

Jonathon looked at the darkening sky, then back to his monitor. The flight to Detroit had left the gate and was de-icing. He had to make sure it had taken off or was back at the gate with the passengers unloaded within three hours, or there would be major penalties for the airline. There were two planes waiting for the open gate, one that would be bound for Atlanta, the other for San Diego. He'd have to see which would lead to the least disruption. He had to balance the luggage, connections, and cost. The San Diego flight was full while the one to Atlanta was not completely booked and was on a smaller plane. But the Atlanta flight would lead to the highest number of missed connections if delayed further. He had to choose.

Planes and ambulances, patients and travelers—all create complex systems with many moving parts, varied needs, and intolerance of error. A command center is key for managing this thermodynamic level of complexity. Joe made it to an ICU bed and got thrombolysed. The limes he was driving went unshipped for several days and rotted. Charlotte made it home for her daughter's birthday, but sadly her luggage was never seen again.

Even with a center, not everything is under our command.