Woman dies in ambulance when oxygen runs out

[Just Plain Ruff]

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.

Why do we continue to rely on technology to provide the most important of all patient care tasks.

We rely on an electronic system that keeps the oxygen flowing on a ambulance. There are no fail safes in that electronic equipment. If it dies, then so may the patient.

The most important piece (one of them at least) is the oxygen delivery system, and to rely on a electronic system without a failsafe which some ambulances still have is just tantamount to stupidity in the making.

But the more and more that we rely on technology like this, the more and more we become hooked to it. Just look at cell phones and laptops.

But anyway, in the end, it will more than likely be borne out that human error, rather than equipment error was the cause. Seriously, if you can't recognize that your patient is hitting the crapper then I don't know what to expect. But we are of course armchairing this, we don't know what truly happened. I suggest waiting until we hear more abou this.

Unfortunately, in the end Road Rescue will bear the brunt of the blame.

[Chief1C]

Of course, we know what we'll be dealing with, and the possibility of time delays in getting to a hospital. So, the ambulances have a few portable set ups, and two spares for each portable.

[Just Plain Ruff]

Of course, we know what we'll be dealing with, and the possibility of time delays in getting to a hospital. So, the ambulances have a few portable set ups, and two spares for each portable.

And those should have been used prior to trying to reset the oxygen system.

[FireMedic65]

I just wrote an essay for school about "advances in technology". Part of my argument had to do with medical devices, a vent being one of them. My main point was even though these devices take a great amount of work load off of us and "thinking" we should never fully rely on them. I explained briefly how a vent works. Relying on such devices can land us in a lot of trouble. They are not "turn on and forget". You have to constantly monitor the devices and THE PATIENT! These devices are only tools to help us get what needs to be done, done.

As for this situation, it boggles my mind of how it could have happened. Don't vents have alarms and stuff that go off? What was the medic doing? Why didn't they bag the patient with a BVM? Was there no portable o2 cylinder?

I can understand how the system would fail, shit happens. There are backups though, such as YOUR BASIC AIRWAY MANAGEMENT, you know... the BVM. Although, this system failed 2 times, even after it was "repaired". Maybe the repair was poor, or the problem was more complicated? Still doesn't explain why the medic didn't revert back to the basics...

[JPINFV]

If it was a vent dependent patient on an interfacility transport, why were they using an oxygen powered ventilator anyways? If the ventilator isn't oxygen powered, then you don't need oxygen to run it and, while there would be a lower FiO2, the consequences aren't quite so grave when the on board oxygen system shuts off.

[Don1977]

Very true Ruff and HERBIE

[Chief1C]

Just to clarify, I'm not justifying the oxygen system. The best device to carry, when you rely on oxygen for machines, is a yoked dual set up with a quick connect on a pig tail. Either E or Jumbo D's on the yoke. Just put a handle on it and you're golden.

Edited June 14, 2010 by 4c6

[emtannie]

"... a paramedic discovered the outage and restarted the system. But Hall had died."

Like others have questioned, was this medic not monitoring this patient at all? No SpO2? No EtCO2? It sounds like the medic only noticed AFTER the patient was dead...

If this is in fact true, I hope the investigation proves negligence.

How did they explain this to the family of the deceased? "I'm sorry, the vent quit, we didn't notice, she died... "

[chbare]

It's so much worse:

http://wcco.com/health/oxygen.system.failure.2.1729569.html

If we are to believe the reporting, it is conceivable that this went on for up to eight minutes before any steps were take to rectify the problem let alone help the patient out.

Regarding monitoring pulse oximetry, it is quite possible to go several minutes without desaturation, and pulse oximetry would be one of the least useful tools we can use to ensure a properly functioning ventilator. However, many other techniques such as looking at the patient and noting chest rise and assessing waveform capongraphy would be far better techniques to use. I can only guess as to why it took eight minutes to realise, but a host of factors including a significant portion of human elements are the most likely root causes.

Regarding technology; I would be very hesitant to claim we are addicted and rely too heavily on it. In fact, when it comes to ventilators, I think the opposite is true. We are not educated enough in the field of positive pressure ventilation. I am currently learning how to identify auto PEEP by simply looking at the baseline of the flow, time waveform. I am learning to assess the effectiveness of bronchodilator therapy using the flow, time wave form as well. I can look at other waveforms to appreciate leaks and other problems. In addition, I am learning how to identify numerous problems such as overdistention, obstruction and restriction utilising various loop assessment techniques. This is all by simply looking at a waveform on the graphics package and correlating the finding to the patient's clinical assessment. In the EMS environment, we have all sorts of issues that can limit our ability to assess the patient properly, yet how many of us can use the technology of the ventilator to actually assess and appreciate these problems?

I will have to disagree with the argument that technology is bad or a crutch. The real problem is we simply do not know how to properly, safely and effectively use that technology. Big difference IMHO.

Take care,

chbare.

[robert gift]

Anyone watching the pt?

Or both riding in front?