Training Bolus: Ruby's Case
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Access – ce – 2015 03 rubys case This is a short case presentation on the tragic death of Ruby Chen, and the development of "Ruby's Rule"
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Training Bolus: Ruby's Case
- 1. Training Bolus “It’s The Little Things That Kill…” ACCESS – CE – 2015 03 “RUBYS CASE”
- 2. What is a Training Bolus?
- 3. 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.
- 4. Ruby Chen
- 5. Transfer to higher level of care…
- 6. 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.
- 7. 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.
- 9. 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’….”
- 10. 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.
- 12. 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
- 15. Attributions • Attributions: • Petzierides, Elia. "Ruby." <i>GraveLessonscom</i>. Wordpress.com, 11 Jan. 2015. Web. 5 Mar. 2015. <http://gravelessons.com/2015/01/12/ruby/>. • O'Connell, David. <i>Findings of Inquest: Ruby Chen</i>. OFFICE OF THE STATE CORONER, 14 Dec. 2012. Web. 5 Mar. 2015. <http://www.courts.qld.gov.au/__data/assets/pdf_file/0003/335 064/cif-chen-ry-20141212.pdf>. • 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
- 16. 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
Editor's Notes
- Ruby Chen was a 3 year old little girl who was being treated at a rural community health clinic /hospital (blackwater Hospital) in Queensland Australia in August 9, 2012. This community is small with a population of approx 5100 (2011 numbers) , mostly mining industry and a nearby national park provide the majority of the industry. Ruby was a tall/large child. Ruby’s bare weight at autopsy was 32kg. The Coroner informed me that the pathologist described Ruby as a 104cm tall, well-nourished 32kg child.
- When the helicopter paramedics arrived at Blackwater Hospital Ruby had been given 850mL of a one litre IV fluid bag. The paramedics requested the IV line to be taken down as the line could only be used with the IV fluid pump which was deemed to be too large to take into the helicopter. A new IV line was given to the paramedics by a nurse and this line was inserted into the original IV fluid bag which had 150mL remaining. The process of inserting a new IV line into an already used or ‘spiked’ IV fluid bag is known as ‘re-spiking’. This new line was primed (flushed with IV fluid to remove the air from within the tubing) by the lead paramedic at the helicopter and a small amount of fluid was spilt on the ground outside the helicopter. The volume of fluid remaining in the IV fluid bag was estimated to now be 115mL. Why was the line taken down? Online posts report that in this healthcare system, “pump sets” (called “Giving sets” in the local vernacular) do not permit gravity flow when not on a pump. And , even though this is a national health service, the hospitals are reluctant to let go of their equipment for transports. The HEMS was not equipped with IV pumps (not sure why, this was 2012). The Lead paramedic elected to swap out the IV administration set. He elected to use a hospital set that would allow gravity feed, instead of using their own supplies “to maintain operational readiness”. Above is a picture of the service aircraft, though it is unclear which aircraft they actually used.
- From the coroners inquest: The mechanism by which the air entered Ruby’s system is identified as a combination of the re-spiked IV fluid bag, through which the process of respiking has allowed air to enter the bag, and then that bag being placed inside an opaque pressure bag which forced the contents of the bag, the saline fluid and air, into the cannula in the back of Ruby’s hand. Dr McCaffrey identified that if an infusion pump had been used then once it detected air in the line it would have immediately sounded an audible alarm and shutdown delivery of fluid to the patient. If the saline bag had simply been ‘gravity fed’ into the patient then once that fluid reached a distance on the giving set just a few centimetres before the patient, then the patient’s own venous pressure would have prevented the last amount of fluid from entering the circulatory system. It was only the introduction of the pressure bag, required to be used in the confined space, particularly as to restricted cabin height in a helicopter, which caused the contents of the bag, being both saline fluid and air, to be forced down the giving set, such that when the fluid was exhausted air was pushed by the pressure bag into Ruby’s system. 42. Dr McCaffrey described it as an unusual combination of circumstances which he had not encountered before in practice, and he did not consider that any of his fellow clinicians whether experienced, or inexperienced, would have ever witnessed or considered such a situation, but when it was all laid out it all made perfect, logical sense.