Training Bolus“It’s The Little Things That Kill…”

ACCESS – CE – 2015 03 “RUBYS CASE”

What is a Training Bolus?

Learning Outcomes

• Review the tragic circumstances of Ruby Chen’s Death

• Discuss the contributing factors as they pertain to EMS scope of practice.

• Apply those lessons to our own practice as paramedics.

Ruby Chen

Transfer to higher level of care…

So what happened?

• Report was received, patient assessed, Yada Yada Yada.

• It was determined that the IV pump that the patient was on was unsuitable for the air medical transfer, and was removed.

• As a result the Paramedic wanted to use a new line for the transfer.

• In this system. IV “pump sets” will not “free flow” or allow “gravity flow”.

• Used administration set from the hospital.

Transport

• Transport stated uneventfully. Expected to last 40-50 minutes.

• 7 minutes from estimated arrival, Ruby began to have a seizure, and subsequently went into cardiac arrest.

• Landing was expedited, and the code was continued on the way to the hospital.

• Ultimately resuscitation efforts were futile after about 40 minutes of resuscitation.

Oooops….

• Medical examiner found:

• 70 mL +/- 10mL of air in the right atria and right ventricle.

• Air was present in the aorta and superior vena cava

• Air was present in the surface vessels of the brain.

• “Microbiology testing returned a positive result to influenza A, which simply confirmed earlier diagnosis by the general practitioners that Ruby was suffering from the effects of a simple case of ‘the flu’….”

Key points in the “Perfect Storm”

• Respiking the bag with a new line allowed up to 450 cc of air to enter the bag.

• It is unclear if using an unfamilier drip set contributed significantly, but is worth discussing.

• Not using an IV pump (which typically have air in line alarms).

• Opaque Pressure Bag prevented visual monitoring of the IV fluid.

• Cabin lay out and the bag being laid down on the patient likely prevented visual monitoring of the IV fluid

• The pressure bag laying flat forced more air in the line than would have been typical in a gravity fed line.

• Mother and Paramedic rode in back with Ruby, with other Paramedic riding in front with Pilot.

• This eliminated the possibility of the other paramedic catching the air bolus in time to prevent the death of Ruby Chen.

So, how do I keep this from happening to me?• Avoid re-spiking bags

• Burp/purge air from the bag if reusing the bag is absolutely required.

• If you use a pressure bag, keep the net side facing you so you can monitor IV Flow

• When possible, hang all your bags

• gravity will keep any air at the top, and fluid at the bottom

• If you are unfamiliar with the equipment from a hospital, ask questions or don’t use it.

• Double check your partners work

• We are our brothers (and sisters) keepers

Attributions

• Attributions:• Petzierides, Elia. "Ruby." <i>GraveLessonscom</i>. Wordpress.com,

11 Jan. 2015. Web. 5 Mar. 2015. &lt;http://gravelessons.com/2015/01/12/ruby/&gt;.

• O'Connell, David. <i>Findings of Inquest: Ruby Chen</i>. OFFICE OF THE STATE CORONER, 14 Dec. 2012. Web. 5 Mar. 2015. &lt;http://www.courts.qld.gov.au/__data/assets/pdf_file/0003/335064/cif-chen-ry-20141212.pdf&gt;.

• Petzierides, Elia. "Ruby's Rule." Ruby's Rule. YouTube, 13 Jan. 2015. Web. 5 Mar. 2015. <https://www.youtube.com/watch?v=g3KC-wzeNS8>.

• Meme’s made at www.memegenerator.net

Wrapping Up

Resources• Coroners Report

• Local News Coverage

• Case discussion from GraveLessons.com

Special Thanks• Elia Petzierides

• Gravelessons.com

• Ruby Chen’s Parents for letting her story be shared