Woman dies in ambulance when oxygen runs out

[OwleyMedic]

Woman dies in ambulance when oxygen runs out

RED WING, Minn. — The city of Red Wing is investigating after a 64-year-old woman died during an ambulance trip.

Janice Hall was being moved from a nursing home in Red Wing to one in Minneapolis on April 22. Hall was ventilator-dependent, according to the medical examiner, and the ambulance’s onboard oxygen system spontaneously shut down during the trip.

Red Wing Fire Chief Tom Schneider says a paramedic discovered the outage and restarted the system. But Hall had died.

The ambulance’s electronic components were replaced, but the same problem happened a month later. In that case the patient was not hurt.

Road Rescue of Marion, S.C., which built the ambulance, says it’s the only reported incident. The company says it’s testing a field remedy for all ambulances that use that system.

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How could this happen? How does an Oxygen system "spontaneously shut down"? Is this a case of attendant inattention? Negligence? Also "The ambulance’s electronic components were replaced, but the same problem happened a month later" what does the electrical system have to do with the oxygen system? Maybe the electrical system effected the ventilator, but again this should have been noticed by the medic attending the patient, in time to have prevented their death.

Just my 5 cents worth.

Edited June 14, 2010 by OwleyMedic

[Steve Owen]

How could this happen? How does an Oxygen system "spontaneously shut down"? Is this a case of attendant inattention? Negligence? Also "The ambulance's electronic components were replaced, but the same problem happened a month later" what does the electrical system have to do with the oxygen system? Maybe the electrical system effected the ventilator, but again this should have been noticed by the medic attending the patient, in time to have prevented their death.

Just my 5 cents worth.

The oxygen systems in those ambulances are controlled by an electronic oxygen control. That is what the electrical system has to do with the oxygen system.

Edited June 14, 2010 by Steve Owen

[akflightmedic]

The oxygen systems in those ambulances are controlled by an electronic oxygen control. That is what the electrical system has to do with the oxygen system.

So was she being ventilated with room air...doesn't sound like it. If I ran out of oxygen, a good old fashion BVM will do the trick along with a D cylinder from your airway bag.

This sounds like someone being extremely casual about a vent patient being moved from a nursing home and not being attentive when they should have.

To "notice" a patient has died after you restart the system sounds way too hokey...

[Timmy]

I agree, there are backup methods there... Do not blame the equipment when you have failed to provide basic care and assessment.

[Don1977]

So was she being ventilated with room air...doesn't sound like it. If I ran out of oxygen, a good old fashion BVM will do the trick along with a D cylinder from your airway bag.

This sounds like someone being extremely casual about a vent patient being moved from a nursing home and not being attentive when they should have.

To "notice" a patient has died after you restart the system sounds way too hokey...

The truck I had this morning/last night has the electric oxygen switch, but as AK said, D cylinder would have done the trick. Obviously the medic wasn't paying attention or didn't care.

[HERBIE1]

If the person was on a vent, why wasn't their O2 sats being monitored? Wouldn't they realize the person was "desatting"? The problem with the system is not the disturbing part of this- why didn't the provider monitor their patient?

[chbare]

Agreed:

Take care,

cbare.

[Just Plain Ruff]

Even with the electrical system Oxygen delivery there is a manual switch that you can turn to open the oxygen.

There are safeguards for exactly this type of thing.

We of course do not know all the particulars of this but I'm going to do something that I don't normally do here.

What the hell, Ventillator dependent patient, oxygen, pulse ox don't you check that stuff? What was the attendant doing? reading a book or sleeping?

I think that this needs to be laid down at the feet of the medic and no-one else. There should have been back-ups set up.

A ventillator patient is inherently dependent upon You the medic to make sure they Don't freaking die. Lose the oxygen, lose the patient.

He should not have been trying to re-start the system, you call for backup(your driver can do that), you take out the portable oxygen tank and attach the BVM and breathe for the patient. That's simple aint it

My suspicions are they ran out of oxygen, they used the month's old excuse that the system did it last month as a cover and theis patient died.

Don't blame road rescue for her death, you have backups in place until another ambulance gets there. Pathetic

Now disclaimer here. If it really happened like reported then I apologize to the medic in question but I'm going to be that this medic was covering his own ass and they are conveniently blaming road rescue.

[+medic]

Sounds like by blameing the road rescue they are trying to prevent a lawsuit or the medic was just no paying attention to his patient. If they facts are true I think the medic just was not paying attention.

As we all know there are many basic things you can do if the above happens then blame the fancy 02 machine for brakeing down.

[Chief1C]

I've had the "electric oxygen alarm" tripped by using CPAP from an on board port. Luckily we no longer have those type of devices, that drain the tank severely. It caused an error that shut off the electric oxygen valve, IMO, it was probably from the condensation. This was a feature in our Horton ambulances. In order for the oxygen to flow, you had to push a button on the control panel. The button opens a valve, that's what the "click" is when it's pushed. If you turn off the mod, or shut the vehicle off, there's a louder click, the valve closing. However, by KKKA1822E standards, if your ambulance has one of these, it also must have a bypass valve. The new SOP for CPAP use, on the remaining Horton, is that this bypass valve has to be open during use. So, even if we lose mod power, o2 will flow. Our new ambulances have no oxygen control, if the tank's on, o2 can flow. The only down side, is it has no electric oxygen level meter.