1. SILENT DANGER!
THE INTERTWINED STORIES OF AMANDA ABBIEHL AND
CONTINUOUS ELECTRONIC MONITORING!

2. Told by Sean Power, Physician-Patient Alliance for Health and Safety.
Adapted from Martha Vockley’s “Silent Danger: PCA Pumps and the Case for
Continuous Monitoring”, published in Biomedical Instrumentation & Technology,
November/December 2013. pp. 454-465.
Biomedical Instrumentation & Technology is produced by the
Association for the Advancement of Medical Instrumentation.

3. “WITHOUT EXCEPTION.”
Experts interviewed by the AAMI said they would want continuous electronic
monitoring for themselves or their family receiving PCA treatment.

4. “IF IT WAS YOUR KID, WHAT WOULD YOU DO?”
Eighteen year-old Amanda Abbiehl was
hooked up to a PCA pump on Friday
evening.

5. “SHE WAS A SPITFIRE.”
The next morning, she was found dead in bed.

6. “WELL-DOCUMENTED RISK.”
Amanda’s father, Brian, says he will never be
able to say with certainty what led to his
daughter’s death.
But right now he and his wife, Cindy, believe
that the most likely cause of her death was
respiratory depression.

7. “WE’RE NOT TRYING TO PLACE BLAME.”
At least as far back as the 1990s, the risk of respiratory depression has been associated
with PCA pumps.

8. “FOR MOST PATIENTS, PCA PUMPS SAFELY AND
QUICKLY EASE PAIN.”
The Promise to Amanda Foundation (www.promisetoamanda.org) raises awareness
about the risk of respiratory depression with PCA pumps.

9. “UNINTENDED CONSEQUENCES.”
Dr. Peter Pronovost, John Hopkins Medicine, says we haven’t been mindful enough of
the unintended consequences of PCA.

10. “SPOT CHECKS EVERY TWO TO FOUR HOURS.”
Spot checks did not detect that Amanda was in trouble.

11. “WE OUGHT TO MONITOR EVERYBODY ON PCA.”
“We ought to monitor everybody on PCA.”
-Peter Pronovost, MD, John Hopkins
Medicine

12. “THE HAZARD OF RESPIRATORY DEPRESSION.”
Risk factors include
− obesity
− low body weight
− sleep apnea
− chronic obstructive pulmonary disease
− asthma
− advanced age, and
− the use of other medications that produce sedative effects.

13. “NOBODY CONSIDERED HER A HIGH RISK.”
Amanda’s story illustrates the shortcomings of these approaches.

14. “STANDARD OF CARE IS LONG OVERDUE.”
Pulse oximetry measures oxygen saturation. Capnography measures respiratory rate
and the concentration of exhaled carbon dioxide.

15. “EVIDENCE IS MOUNTING.”
Monitoring both oxygen and carbon
dioxide levels yields the best patient
outcomes.

16. “ADOPTION IS HAPPENING.”
Mr. Greg Spratt, director of clinical marketing at Covidien, wishes adoption was
happening faster.

17. “FROM BUTTERFLY KISSES, TO ZERBITS ON THE
CHEEKS.”
“You don’t have any idea what I would give for one of those from her.”
-Cindy Abbiehl, A Promise to Amanda Foundation
(May 10, 2013)

18. MAKE A #PROMISE TO AMANDA TODAY.
Promise to do everything you can to make it mandatory at your hospital for all patients
on PCA pumps to be continuously electronically monitored with capnography and pulse
oximetry.

19. WHAT NURSES, PHYSICIANS, AND RESPIRATORY
THERAPISTS CAN DO:
1. Encourage patients and families to share their experiences with respiratory
monitoring equipment.
2. Promise to talk to decision makers about capnography every chance you get.
3. Use the PCA Safety Checklist before, during, and after initiating PCA treatment.

20. WHAT HOSPITAL ADMINISTRATORS CAN DO:
1. Build redundancies into the system. Mistakes are going to be made but adverse
events are preventable. Monitor every patient and save lives.
2. Tell us if your hospital monitors patients with capnography while they are
connected to patient-controlled analgesia pumps.

21. WHAT PATIENTS AND FAMILIES CAN DO:
1. Come forward to share your story about capnography.
2. Write, phone, or email your local congressperson about making zero preventable
deaths a policy priority.

22. FIND OUT:
Some experts recommend that patients find out if their hospitals offer continuous
electronic monitoring with PCA before they schedule medical procedures.

23. HOSPITALS THAT MONITOR WITH CAPNOGRAPHY IN
THE UNITED STATES!

24. PLEASE SHARE WIDELY!
FACEBOOK.COM/PPAHS!
@MIKEPPAHS!
PPAHS.ORG!