Friday, June 3, 2016

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...


B said...

Where do you get faulty batteries?

They apparently kewpt the machine operating for significant time frame before finally failing.

THe nurse ignored "strange and odd" noises coming from the machine.

Why did she ignore them and not call someone?

Likely because she didn't care (or was too stupid to ask why the machine was making odd noises "she had never heard before".

Perhaps a failure on many levels, but still a failure on the nurse's part. One that caused a patient, however sick or terminal, to die.

I can easily point the blame for the final failure at the nurse. there may have been other failures, but the nurse did the final fail.

Aesop said...

You're still not getting it: the nurse was likely neither trained nor expected to maintain nor troubleshoot specialized respiratory gear, which is precisely what a patient ventilator is. Period. Precisely why the examining doctor after the fact didn't see any reason to hold her responsible for not fixing something she was not responsible for, nor for troubleshooting the system when it began to fail.

There is no reason to think she ignored the alarms, based on available information.
So it takes a monumental amount of prejudging, based on facts not in evidence, to assume she either "didn't care" or "was too stupid to ask" anything. Your bias there is hanging out of your underpants.

There's absolutely no information either way regarding whether or not those trained to do so were summoned, or even available. If they aren't available, "notifying" them is vaporware, and not notifying imaginary technicians is a null in the blame column.

Customarily, an RT should have responded to the machine's alarms, sorted out the problem, and solved the trouble. As that manifestly did NOT happen, it's far likelier that there was no such technician available, rather than making wild assumptions that that the person caring for the patient was either stupid and/or negligent. William of Ockham says "Hi".

The simple point is that NHS, exactly like American health care, relies on machinery for which it is unwilling to staff adequately, and expects untrained personnel to pull non-existent specialized expertise out of their ass when formerly reliable machinery goes bonk.

Lo and behold, that kills people.

You may as well blame airline pilots when their engines fall off; it's not their job to inspect or maintain them, and unlike basketball, just because they touched it last doesn't pass on vicarious fault when the ball goes out of bounds.

The short story is a terminal patient died in intensive care.
That's what terminal patients do.

Try reading the linked source article, and then lay out a chain of blame based on actually available facts. You can question any number of things for which there are no available answers. But what you absolutely can't do logically is to blame the nurse, without wild irrational leaps of illogic.

If instead you just want to spaz and spew, because butthurt or whatever, you've simply picked the wrong venue.

Able said...

OK former former forces (military RM X and E Sqdrns) and then trained as a nurse here. Years (decades) working A&E, HDU and ITU (as well as experience at Lane Fox, St. Thomas' the last former polio ward in the UK with negative pressure 'iron lung' ventilators – the patients from the 60's outbreak if you're interested, as well as all those nice new 'immigrant' cases).

My opinion? Aesop nailed it.

RT's here, like physios work mon-fri 9-5 hours so the chances are (it doesn't state when it occurred) there simply wasn't one available except as 'on-call' (most likely from home miles away at best).

Staffing? Think money, they've reduced qualified staffing levels across the board, even in such specialised high dependency areas (because they have to be able to afford all those extra managers, administrators and clerical staff, and all their secretaries somehow – seriously there are more than four times as many non-clinical staff as clinical in 'every' NHS hospital now. When I started as a newly qualified Staff Nurse I had two layers of management above me (Sister, Matron), when I left, as a ward manager, I had eight (and the numbers at each level boggle the mind)). So one, probably very junior nurse (one years general experience only is needed) per (one, two, or occasionally three) patient(s) and one relatively junior nurse in charge (two plus years plus specialist general ITU course), whilst the senior (five plus years experience and hopefully knowledge of all the varied machinery foibles) will be somewhere on site (doing paperwork, and unlike the good old days promotion is not now, nor has it been for a while, the best, brightest but usually a complete battleaxe, it's those who have the most PC credentials, 'people skills' (otherwise known as a brown-noses) and can use the correct buzzwords in the seminars).

The best bit? Any RT would 'not' be allowed to repair any such faulty equipment anyway (minor mods but not full-scale replacement/repair). Union dominance ensures that. They may monitor, report and then wait for six weeks whilst it sits in the shop, and then gets returned to the manufacturer (if they're still in business, some of the equipment I used was older than (Oh OK, like to pretend) I am) to repair the bodge they made of it ... and possibly even the original problem.

Know why I retired now? And you think 'you' have a poor opinion of the NHS!

Jennifer said...

Yes, the machines make a crapton of noise. But after babysitting them night after night, you get familiar with which of the squawks is urgent. And in our ICU/PCU, EVERY call light and vent alarm has to be attended to IMMEDIATELY. Waiting for the alarms to go into screaming panic mode is not even an option, no matter how many patients you have. Some nights you feel like human popcorn, jumping to answer the bells. To this day, electronic bleatings hit me like a cattle prod. I hate them.

I'm in a small hospital in BFE, but we generally have RTs wandering the floors giving breathing treatments; when we need one, they come pretty quickly. In the meantime, if they can't, the RTs showed us how to check and adjust the vent settings and equipment until they get there. Failing that, we also have BVM at the head of every bed. An RT (or two) circulates our ER pretty much all the time; the only times we've run short have been multiple overdoses and a CO mass casualty.

I hate the way admin always blames the nurses when things go to shit, but given the dire picture of the NHS painted by the Mail and the Telegraph and others, I really have to wonder about the nursing staff. You'd think SOMEBODY on the team would have checked the patient if the nurse was busy.

Anonymous said...

Here's a novel idea. Bit late for this sorry lass, though. How about engineering the machine to say, "Batteries Dying!" instead of beeping? If a fucking $50 mobile phone can talk to you, a multi thousand dollar machine sure as hell should be able to.

Aesop said...

@Hillbilly girl,

There's no indication that staff failed to check on the patient. Whether they had BVMs handy, let alone RT staff, is an open question.
But the reviewing anesthesiologist quoted pretty much noted that it's unreasonable to expect the nurse to pinch-hit for the RT staff with the equipment.
As I've hinted in comments, it sounds like if there's any culprit, it's either that the machine lacked a notification that the power to the plug was missing when initially plugged in or subsequently, and/or that the person who installed it and set it up missed that flag, if it existed.
I don't think they either neglected the patient, nor that they stood around the bed doing the Headless Clueless Chicken while the alarms went off. But I suspect that once the ventilator crapped out because it was powerless, their options were obviously not sufficient to maintain the patient's life.

@ Anonymous
Brilliant, that. But you're talking about someone
a) actually responding to the requests of practitioners who use it
(which has happened zero times in my entire healthcare career, for reference), if they ever even listened to them or solicited their input in the first place, and
b) NHS would have to pony up hard cash to buy it.

To give you an idea of how socialized medicine works (and spending money on patient care is counter-factual to their mission), at last look there are reportedly more MRI machines in the city of Minneapolis solely for their citizens, than are installed in the entirety of the nation of Canada.

And now we're on the same slippery slope here.

Unknown said...

UK "health care". Doctors, 1/100,000. Nurses 1/10,000. Janitors 1/500. RT's/ 1-O. This is what you get with rationed healthcare. DEAD.

Unknown said...

Bring out your dead! Bring out your dead!

Anonymous said...

I wouldn't expect a nurse to know an uninterruptible power source from an interruptible one, nor would I expect them to investigate every screeching alarm that goes off in their ward. I certainly don't expect them to ensure that the patient call button works either. Shit just happens sometimes, and everyone is going to die someday anyway. Good verdict.

ASM826 said...

So reprogram the gorram thing. Let's say things instead of chirping. A programmed menu of things like, "Not plugged in, running batteries, currently at 38 percent.", "Batteries now dangerously low, in seven minutes, pump will stop.", "Batteries drained, life support not functioning, check patient stat." and so on.