[throwaway3306a]

While I appreciate the effect this kind of downtime can have, I just don't understand these stories.

Presumably it was planned in advance, so the patients know the time of their appointment and the doctor knows what was planned, and everything necessary to physically perform the treatment is already prepared at the hospital. What's stopping them from doing it without filling it into a digital system? Why is it impossible to make a paper record and fill it into the computer system later?

If somebody was literally dying, would they stand around the computer like confused characters in a The Sims game who can't find the door, instead of saving the life? And if not, why is this less urgent case different?

[dsclough]

A nurse was unable to give my wife medication while in labor because the barcode on the bag of drugs wouldn’t scan. Fortunately we just had to wait another 20 minutes to get a new bag from the pharmacy but I can easily imagine a world where doctors are unable to perform procedures they are physically capable of doing because of liability surrounding not using the computer systems as intended. Epic particularly has really done a number on the healthcare system.

[throwaway3306a]

I really, sincerely don't understand that. How does an unscannable barcode prevent a doctor/nurse from administering medicine they are holding in their hands?

[sigmoid10]

The other commenter already said it: Liability. What if the scan is part of a procedure that ensures that the right drug is given to the right patient? Giving someone the wrong drug or even the wrong dose can cause serious harm. Imagine they kill someone that way and then during the investigation it turns out the they didn't scan the meds. It doesn't matter why they didn't scan it (lazy, forgetful, computer problem), it is en enormous legal risk for every party involved. Thousands of people die each year because of medical errors, so trying to prevent doctors from killing people by using strict procedures is very important. Even if it means that in extreme situations like this the procedure can cause harm as well. Overall it will save many, many more people than it will kill.

[throwaway3306a]

What if it turns out they harmed the patient by insisting on following the standard procedure during a worldwide outage? Isn't that the same kind of liability risk, and is the regulation really going to protect them in this case? If so, isn't that a hugely problematic regulation?

[AlotOfReading]

In that case the nurse or doctor has a strong defense of "I was following policy" for their insurance and boss.

The people writing hospital policies or regulations aren't thinking about individual patient outcomes unless some notable news story came out recently, and even then it's maybe the third or fourth priority on a list a hundred items long.

[sigmoid10]

We don't know that this is what actually happened in OP's case. I was referring to the comment you replied to and there it is pretty obvious that the regulation is exists to prevent harm from being done. But even if there is a clear justification, you would expose yourself to a lawsuit and need argue all this in court. I can totally understand why people don't want that, especially in the US. So if anything, you should blame the legal system.

[staticman2]

I doubt refusing to treat patients when the computer is down insulates you from malpractice claims.

[FeepingCreature]

Yes, and yes. Welcome to our messed up society.

[freeAgent]

It probably also automates the chart entry and billing to insurance/patient, at least to an extent. I wouldn’t rest sole responsibility for this system on legal compliance or risk mitigation. Under normal circumstances, there’s also an efficiency improvement. The problem arises when there either is no workaround when the system doesn’t work, or workers aren’t trained well enough to know how to do things manually (or don’t have enough time under the less efficient mode of operating).

[shouldbeone]

It doesn't. We do this all this time in rapid responses and cardiac arrest scenarios, when we can't wait for an order in the EHR; someone keeps track of the medications, doses and rough times of administration, and it's entered into the EHR later.

[toldyouso2022]

Because the law doesn't want to do its job anymore, so it created useless bureaucracy to make their lives easier and human life hell

[lambdaone]

An awful lots of apparently useless bureaucracy exists because many people, left to themselves, are often very, very stupid.

Bureaucracy certainly stops smart people from doing the right thing, but more often, it stops stupid people from doing the wrong thing. Hack away at bureaucracy at your peril.

[newaccount74]

It also stops smart people from doing stupid things.

[ctxc]

Well said.

[tzs]

If the barcode wouldn't scan there it might also have not scanned correctly when that bag was being filled which could have led to it being filled incorrectly.

[simmerup]

Because they’re accepting the liability of it going wrong if they make an unusual choice to disregard the error

[advael]

I think a good remedy would be to completely remove "normal procedure" as a defense against liability. Our legal standard should defend people who break protocols if they know they will result in harm, and prosecute people who don't, or prosecute the people who make the protocols in those cases. Law should supercede corporate policy, not treat it as a form of law

[throwaway3306a]

So the problem really isn't CrowdStrike or any computer at all, but dumb policy or regulation?

[staticman2]

That's not how liability works. There is no "I followed some written procedure when it didn't make sense to do so" defense to malpractice claims.

[throwup238]

> What's stopping them from doing it without filling it into a digital system? Why is it impossible to make a paper record and fill it into the computer system later?

It’s not filling in new data that’s the problem - every person involved in treatment needs to be able to access the patient’s medical records to check for contraindications. Allergies and drug interactions are a quick way to kill someone when injecting drugs directly into their veins even if they’re already in a hospital.

At a major hospital there’s too many patients coming through and the data changes too frequently to keep paper backups.

[moralestapia]

>Her children’s appointments were cancelled, the first they would miss in five years.

They've been going every two weeks for the last five years. I doubt they wouldn't know what to do ...

[throwup238]

It’s a large children’s hospital with thousands of employees treating tens of thousands of kids a year, not some rural family doctor with a list of patients that can fit on a single sheet of A4. They’re not going to get the same staff every time and the staff isn’t going to memorize the charts of every patient.

[colechristensen]

It’s not clear to me that this case is actually life threatening. They have a regular procedure which even in the article they say they have wiggle room for timing.

If all of your computers go down your throughput is going to go down because other kinds of organization are going to be slower to do ad hoc… so you triage.

[j-bos]

See some of the comments from affected medical staff on the main outage story, but the tldr is, tightly coupled systems.

[zdragnar]

I can get stories like call centers, but I absolutely don't understand how life critical systems aren't air gapped and rigidly controlled.

Fail safe is the only acceptable failure mode for any critical system. Crowdstrike failed here, but they're not the only thing that can go wrong with computers. Where is the redundancy?

[TeMPOraL]

Life-critical systems are air-gapped. Just no one considered systems running Epic to be life-critical. It turns out they are, probably more so than most.

Also, air-gapping helps only so much when network dies and hospitals can't exchange patient information or send images from MRIs and X-rays to radiologists.

[Rinzler89]

>and hospitals can't exchange patient information or send images from MRIs and X-rays to radiologists

My dentist literally took a photo of my x-ray with his phone and sent it to to my orthodontist via Whatsapp and everything went quick and smooth, much faster than the official channels. Solutions to get a job done quickly and efficiently in case of emergency always exist, they're just not "by the book".

[czl]

Imagine a news story about a dentist that violated HIPPA (or equivalent) laws because they used Whatsapp / Facebook to share medical records. Will this news story be about a hero vs someone who got into trouble?

[Rinzler89]

How would he get in trouble?

Hippa doesn't apply in Europe but GDPR, and I don't see how that would be in violation since my information was exchanged only between the two parties with my consent, on an encrypted channel.

They would only get into trouble if that info would leak in an identifiable way to unauthorized third parties and would cause damages (here there's no punitive damages like in the US). And people here tend to guard their WhatsApp chats pretty well since it's what everyone uses and it also contains their private chats so in a sense it can even be more secure than the official medical channels which are just more burocratic but offer no actual guarantee of more data security.

[throwaway3306a]

I get that, my point is, why is it absolutely necessary to use the computer system? Why don't they just knock on the door, go grab the medicine and tools, apply it, then fill it into the system later?

I understand they would just postpone whatever can be postponed to save the headache, I don't get the stories about life/health threatening situations.

[j-bos]

Have you ever worked a job that requires high degree of physical world logistics? In times where the primary coordination mechanism is down, any action becomes much slower to implement and often at a direct cost to implementing other actions.

With regard to this case, I don't know any specifics, but I can imagine tools require digital calibration, inventories not tracked outside digital systems, certain meds behind digital access control, and emergency response striained to the point where complicated non emergency procedures would be more risk than benefit.

[throwaway3306a]

I have managed IT departments that managed hundreds of locations and thousands of computers running Windows XP and Windows Server 2003, no cloud at all. And I went through several similar outages (similar in impact on our operations, not cause or impact on others). Our first priority was to get the critical computers that operated machinery running - we did that hours (1-2) after the problem started. Then we played around with the servers and network for few weeks - but critical stuff was operable, albeit with lesser capacity and efficiency.

And we were managing forests and waterways, not hospitals and human lives.

[TeMPOraL]

That's all fine, but this time, no one could get those computers back up in the first few hours, since they were stuck in a boot loop. Plus, systems like hospitals had to be running all that time. Plus, at the scale this outage is reported to be - banks, stores, factories, phones, emergency services, CNC machines, networking, aircon - I imagine everyone was confused and trying to figure out if anything works.

I'm happy nothing significant was hit over here in Poland; reading the main HN thread on the outage feels like reading war reports.

[throwaway3306a]

If it's stuck in a boot loop, the first thing I do is call the local admins and tell them to take a fresh SSD and a Windows installation USB drive with them. Plug the new SSD, reinstall the OS and copy the files from the old one. Computer running in less than an hour.

That's literally what we did to restart our forest logging machinery. Are human lives less critical than that?

[MostlyStable]

I can imagine that for something like this procedure, which is an infusion of medication into the brain it sounds like?, that the "tools" to perform the procedure themselves are computer based or computer dependent. It might not be as simple as injecting a drug into an IV line.

Note that I am not a doctor and have absolutely no specific knowledge beyond what is in the original article, but I am guessing at potential explanations.

Additionally, the article states that there is some "wiffle [sic] room" around the timing of the infusions. So it may be that the delay is not quite as serious as the title makes it sound.

[throwaway3306a]

Presumably they would fix these computers first thing during the night from a backup? If not, is this really about CrowdStrike, and not about a hospital unable to keep their absolutely critical computers backed up and restored in a timely manner?

Again, I understand that restoring a complex net of servers is hard and takes time. But they surely have local hospital IT admins for these absolutely critical computers who are always available on site and can do it individually - it's not like there will be more than a hundred of these at a particular hospital? Hack it a little if you have to, disable the SSO etc - all that can be fixed later.

[advael]

The unfortunate fact of the matter is that centralizing IT systems around large corporate products, including the on-prem software and any cloud services, necessarily means less local control of what can go wrong and how it can be mitigated, and thus often problems that simply can't be fixed, even by competent on-prem staff. Even when it is possible, it's often highly illegal, and most organizations do a lot to beat risk-aversion into everyone on their staff, and of course I mean aversion to risk of breaking rules or protocols, not risk like "someone dying"

I think it's always a mistake to outsource control of a mission-critical system, but that is exactly what large tech companies have been encouraging every organization that will listen to them to do for decades now

[throwaway3306a]

I have trouble accepting that. Even if they had to unplug the computer from the network and disable SSO and antivirus in safe mode, it's possible to get the computer operational. Even if they had to reinstall the OS and the critical software from scratch. There are solutions, the question is - did they even try? If not, why? And is CrowdStrike really to blame if they didn't? I just don't think so.

[lambdaone]

Absolutely. The risk being managed is the risk to the CEO/CTO's jobs, not the risk to life.

[toast0]

Hospital IT sucks. Look at a news report about a ransomware or this and it can easily be a few weeks for them to get back in shape. This one is hopefully easier because reportedly CloudStrike can sometimes pull an update before it BSODs and most windows machines auto restart on BSOD, so just leaving things unattended may be enough.

Restore from backup or reimaging fresh often means you need a working backup or image server, which at a lot of these places is also a Windows server and is likely also running the same endpoint protection, and is likely also boot looping.

Restore from zero isn't something any IT wants to do, and many of them aren't prepared to do it either.

Like it or not, hospital care revolves around the electronic medical records systems, and while Kaiser Southern California in the 90s was using amber screens and some sort of mainframe, afaik, almost everyone is on EPIC now, which is a windows application with all the baggage that contains. Even before EPIC took over Kaiser, they were running terminal emulators on Windows.

IMHO, it would be better for them to put together a ground up desktop distribution with exactly what they need, but that has user training costs and development costs.

[nullindividual]

From having seen the infusion process myself, I take it that it requires precision measurements over an extended period of time. This would seem unreasonable requirement for staff to perform.

Again, from what I've seen, infusions are not just "throw it in an IV bag and wait".

[throwaway3306a]

If it requires a computer, why was that operationally critical computer not restored from a backup within hours after the problem started? This has nothing to do with CrowdStrike or other bugs - it could've simply failed hardware wise and the hospital should have been able to replace it immediately.

[nullindividual]

You have a naive view of how modern operations work, I must say. This shows when you suggest endpoints have backups. We're back to the mainframe/terminal times where all software is running on a web server or other centralized application server, which is also in a boot loop, somewhere else.

Failed hardware is different, but hospitals likely have very few computers just 'lying around'. Especially the highly regulated machines, such as those which are attached to MRIs and the like.

CFR 21 Part 11 was the bane of my existence. Software that can be installed and configured in a matter of minutes? That's a six month project, at least. Sure, backups are great, but then you've got a significant process to get it back up and running.

These aren't early-2000 logging operations.

I see you'll never be convinced, but this is how modern operations work. Being a hospital (or other industry with heavy government regulations) make operations that much worse.

[throwaway3306a]

You misunderstood me, I am easily convinced that this is the case - what I don't get is how they could let it be the case.

[ciabattabread]

Hotels have difficulty with paper and pen bookings when their computers are down. You expect a modern hospital to function in those circumstances?

[pasquinelli]

the hospital better function.

what you're saying is, if the less important service fails, of course the more important one will fail too.

[dopylitty]

Yes

[anotherhue]

It's because these computers are a means of corporate control. Policies and checks and procedures and whatever are all delivered through them.

It's preferable, from the corporate perspective, to have everything fail temporarily than to relinquish this level of workforce management.

If this is hard to imagine, just think of a Lyft driver from the perspective of Lyft Inc.

[renewiltord]

The truth is that many medical personnel are not agentic. They are human robots unable to act unless instructed to by a computer. The computer tells them when they can do something and they do it.