Chain Chain Chain...

 

 

Notice the above.
What do they have in common? They're all patient ventilators.
What else do they have in common? Not very effing much.
They're all designed to deliver oxygen and room air, under pressure, to a (usually) intubated patient.

And they make a lot of noise.
Any similarity to other machines in the sub-genre pretty much ends there.

Who cares, right?

In one of the regular features on his excellent blog, WeaponsMan includes one detailing the various ways non-firearms and an assortment of sources can conspire to end your oxygen addiction, and move you over to the Darwin Awards website, given half a chance.

Today's example was batteries, in this case, the failed ones on a ventilator in the excremental limey National Health Service (which is to actual health care as Dr. Mengele and Dr. Kevorkian are to actual physicians).

The story notes,

Despite several loud alarms designed to warn staff about the failing power supply, Jacqueline Scott passed away after the ventilator keeping her breathing shut down.
An inquest heard a nurse did not recognise the warning sound because no ventilator had ever ran out of power before.
A jury inquest at the Royal Courts of Justice heard Mrs Scott was on a ventilator plugged into a wall socket.
But the circuit providing the power had blown, meaning it was running on batteries – which eventually ran out, with several alarms ringing out before the power cut out.

Some in the succeeding comments basically took shots at the nurse involved.

My response:

Equal time for opposing views.

Caveat: I am not a nurse in the UK, I am a nurse in the USA. So policy and procedure are probably somewhat different there, as well as duties and responsibilities.

That said, the following:

1) Ventilators do, in fact, put out a cacophony of sounds. Respiratory therapists, on this side of the pond, are the ducks who are extensively trained in understanding them, and maintaining the function of said machines. Not nurses, except accidentally, ever.

2) Most of the time, a patient on a vent is attached to a machine making more noise than R2-D2 on the electronic version of crack, for any one of dozens of reasons. It occurs virtually every minute the patient is attached, to the point far beyond sensory overload.

3) The display of information varies among every machine, from every maker, to the point that without intensive and specific training, anyone not a respiratory therapist would not readily grasp, nor be able to prioritize, what each note in the cacophony is intended to convey. Absent an actual trained member of the respiratory therapy department, the nearest equivalent is installing a pipe organ in the room, and assigning a capuchin monkey tethered to said organ to prance about the keys to the point of exhaustion. It isn't, for example, as if the machine would helpfully have been standardized among any number of makers, models, or what have you, or that knowing a bit about one machine, you could easily take the time to try and troubleshoot any other of the breed.

4) Respiratory therapists are eternally in short supply, everywhere and at all times, in every hospital I've ever been in, seen, or heard of, even under a medical care system here and not as thoroughly socialized (yet) as the abortion of care known as the UK National Health Service.

So in aviation terms, you had a device that looked about as intuitive as the engineer's panel on a B-29,

except labeled in Greek, with no such engineer anywhere handy, and with all the lights and bells sounding constantly, and thus conveying essentially zero useful information, to a person neither trained nor experienced in rapidly troubleshooting any of the plethora of alarms and noises.

And the ground power to said panel, which normally did not, failed, and the batteries, which normally did not, also failed, followed by which the patient asphyxiated.

If the nurse, doctor, nor anyone else handy didn't also have the patient on telemetry, didn't know nor notice, amidst the endless calliope of the ventilator's death throes, that the actual patient - the point of the exercise - was breathing less frequently, and also getting concurrently less oxygen in their bloodstream than what is normally found when everything's operating normally, then you could make a case that they should have noticed that - if the patient was attached to the requisite telemetry, if there was the equipment there to manually bag-ventilate the patient and deliver supplemental oxygen, and if the nurse wasn't simultaneously assigned care of a number of actually "sicker" patients whose care she could temporarily abandon to step in and non-stop do the work of the failed ventilator, to breathe for the patient, while waiting for an RT with a fresh machine, if either said technician and equipment was, in fact, readily available.

But I don't know what patient:staff ratios are or might have been at the incident or department of the hospital in question, or any of the other answers, and absent that information, trying to make this sound like nurse error is Stevie Wonder leading a backpacking trip through the Grand Canyon. Fun to watch, but joining, not so much.

Why aren't respiratory machines and their displays as standard as a car's dash panel?
Why are there eleventy-six noises and alarms, none of which can be shut off, to prioritize critical information from routine?
Where was the requisite expert in the operation and interpretation of such specialized machinery?
Was there any telemetry delivering basic patient information attached?
Why was a plug failed, with no one capable of fixing it, or red-tagging it until such was done, and no one aware of that condition?
Why did the back-up batteries fail?
Those are just the first six most obvious culprits here.

As in most aviation accidents, hospital deaths frequently involve a lengthy chain of errors and mistakes, and blaming the last person standing closest, in this case the nurse, is about like blaming all aviation disasters on "pilot error":
easy, convenient, self-serving for everyone but the accused, and generally a monumental load of horse cobblers.

If it were in my power, everything in my world that honks, squawks, beeps, clangs, and whistles, to include family members, would be cheerfully beaten to death at the first moment they offended my ears, every shift, and the person(s) who inflicted and designed them, after a proper crotch-punching. I would love to be able to prioritize the things that make noise to the one to three things that actually matter, so that if they did go off, I'd know
a) what it was, and
b) that it was important, and then be able to set about fixing it.

Unfortunately, no one, from the assholes who mis-design the offending hardware, to hospital purchasers of such horseshit, the administrators and clinical co-ordinators that implement it, nor anyone else, ever asks, let alone listens, to any input from end-users. Not once, ever, in a career.

So you and yours are taken care of by entirely non-standardized machines, that emit an ongoing cacophony of worthless sensory overload, delivered in an under-staffed care model, with safe levels of both enough and the right skills sets of the requisite personnel purely a forlorn fantasy, in an increasingly mechanized system, and then the entire thing falls on its ass, and your granny dies.

And to top it off, granny probably had ten bodily systems failing or in severe decline, had a chance in the single percentiles of ever having anything like recovery with any quality of life, but was being maintained on life support so that the long-neglectful family could feel better about the years of neglect of granny prior to that time, ignorance of the seriousness of her health conditions, and the utter futility of further care, and total denial of her probable end-state, despite the medical technology of the society she lived in. But that's just an anecdotal guess, based solely on 98% of the ventilated patients I've seen over two decades here. YMMV.

And then cared for in a failed socialist health care model by insufficient and overwhelmed staff, just for the cherry on top of the frosting.

So maybe the nurse was to blame.

Or maybe the health care system, the hospital, the staffing plan, the engineering department, the machine's designers and manufacturers, the family, and the actual patient, had some wee bit of the blame to chug down as well...?

Just saying.

Flail away.

Hognose's point was that dead batteries were the culprit, and the rest of the article noted that in fact

Dr. Renate Wendler, who led an investigation into the death, told the jury it was "not realistic" to expect nurses in the ward to know when power would have been interrupted to the plug sockets.
In front of the jury of six men and three women, she said: "The machine made a loud screeching alarm that no nurse had previously heard.
"This noise must have been the final battery warning.
"A lot of alarms had sounded on the machine.
"They were high priority alarms."

 Consultant anaesthetist Dr Wendler said the best nurses were looking after Mrs Scott, but that they reviewed the design of the machine and felt it was "not intuitive".
She said: "I do not think the delay in calling for help had anything to do with the outcome of Mrs Scott's case.

And finally

She added: "We looked at Mrs Scott's health and we found she was very sick and probably a pre-terminal patient when she came to the hospital.
"We found evidence of good practice and care.
"Usually if an incident happens, it is a result of a lot of factors, no single factor.
"Nurses were very busy looking after her in all sorts of ways."

 I read the details after my reply above, and lo and behold, they're just about the exact same thing (minus the gratuitous swipe at NHS, which is the rhetorical equivalent of shooting fish, in a barrel, with a Barrett M82A1).

Health care, even bad health care, is not magic nor miracle work. Handicapping caregivers with shitty equipment, let alone a shitty system, to care for a "pre-terminal patient", is a poor recipe for success, as we normally define the term.

Especially when you saddle them with a cacophony of worthless alarms, to the point that doing your job is the nightly equivalent of what Stephen Coonts described in Flight Of The Intruder, where you spend an inordinate amount of time turning the worthless clanging, dinging, buzzing, flashing, squeaking, squawking shit off, so you can get down to focusing and concentrating on doing the important parts of the job.

So as Paul Harvey always said, now you know the rest of the story...