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"Man is least himself when he talks in his own person. Give him a mask, and he will tell you the truth." Oscar Wilde
Wednesday, August 23, 2017
Bladder catheter + oxygen supply tubing = death
You may not be aware that I blog twice a month for the Physician's Weekly website. My latest post is called "Bladder catheter + oxygen supply tubing = death" and it can be read by clicking here.
This x-ray shows what happened to an elderly man whose oxygen tubing somehow became connected to his bladder catheter.
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17 comments:
I believe it. Patient and nurses can do some silly things. This year I had a trach fall out of a patient who was on trach collar. The nurse didn't replace the trach with another, but instead put the blunt trach intruducer into his trachea, then placed gauze and tape over it. Luckily he could breath around it and it didn't fall into his bronchus. Imagine my surprise when I showed up and I removed the dressing to place a new trach.
If it can be accomplished, it will happen!
Great story. I just can't imagine how a nurse could do such a thing. But then...
"I just can't imagine how a nurse could do such a thing"
It shouldn't be *possible* to do such a thing. It does not make any sense for the two connections to fit in this way. People will make mistakes and systems need to be designed to stop them.
The ends of the two tubes do not even remotely fit together. Someone found a connector and rigged it so both tubes could mate. A determine person with no common sense who doesn't know to ask for help can defeat most systems.
Experience has taught me that both physicians and nurses can do silly things. I was acutely aware that any foreign body episodes in the OR would result in my immediate firing as a scrub nurse.
Surgeons always made up an excuse. I was scrubbed on a case when the ENT surgeon excised a patient's uvala and told the family he did not need it and that it just gets in the way. He was half right. It sure enough got in the way of a tonsil snare.
Old Fool is correct. I had a patient that had a colostomy, performed after a colonoscopy. He said they "found" a perforation during the scope, and had to take care of it.
Old, good story. I laughed. Artiger, also a good story. Both were very creative by the surgeons involved.
I just love x-rays with helpful arrows and added markers to aid interpretation.
Back in the day we used to mark entrance and exit GSWs with paper clips on the STAT preop X-rays. Sometimes to give students or novices something to think about. I would exclaim, "Look at that X-ray. What kind of new gun shoots paperclips."
We did that too but I never thought of saying what you said. We would have worked well together.
I read somewhere that the pressure from the wall driving oxygen in a hospital system amounts to 55 psi. It would have to be something like that to rupture a bladder. I would think that there would be an alarm set to go off if the oxygen tubing was obstructed (?kinked) to inform the nurse that the patient was not getting the prescribed oxygen.Perhaps a valve close to the flow meter that would make a noise if the pressure got high enough to generate a force to cause the alarm to sound.?
Your idea would probably work, but hooking oxygen to a bladder catheter is an exceedingly rare event. Would it be cost-effective to install alarms everywhere?
Most oxygen tubings will make a noise if completely occluded. The small plastic adaptors that are used to lengthen the oxygen tubing so that the patient can ambulate around the room are usually harmless, unless disconnected. I have never heard of anything like this bizarre accident. The safest solution is to use longer cannulas that don't require extra connectors. These are also the most expensive,so they are not widely used in the hospital, mostly at home.
Tracye, thanks for the comment. I agree that the fewer connections there are, the less likely a problem will occur. I would bet that there were originally two oxygen tubes connected in series in this case.
It has been said most anything can be made foolproof. Nothing can be made dammed foolproof.
I agree completely.
There is an old saying, 'Foolproof systems never fully account for the ingenuity of fools.
As to OldFoolRN's comment about surgeon's making things up, the only case I was ever involved with that had a retained lap sponge, the scrub and circulator reported the count was correct. (The case was a long case in residency that had 3 different first assistants (I was one.). I had no clue about what sponges were packed where, as I wasn't there when they were packed in.
The counts are almost always correct when something is left in a patient. If they were incorrect, the object would have been looked for with an x-ray.
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