“The preventable death of three year old Ruby Chen”

By Elia Petzierides

The recent media coverage of the Queensland Coroner’s Inquest into the death of three year old Ruby Chen has left me perplexed. As a Registered Nurse working in paediatric critical care and a paramedic with over ten years experience this case unsettles me – how could something as simple and common as administering a bag of fluid go so catastrophically wrong? And as the parent of a three year old this case frightens me to the bone – how can a child with a seemingly minor and common illness be pronounced deceased shortly after a routine aeromedical transfer?
In an attempt to find answers to my questions I decided to read every detail of the Coroner’s Inquest and write this summary for like-minded nurses, paramedics and parents.

What happened?

During August 2012 when Ruby’s mother took her to see their local doctor for the second time in three days it was decided that Ruby should be admitted to the local Blackwater Hospital for observation and management of her dehydration and fever. While in Blackwater Hospital Ruby was given intravenous (IV) fluid via an IV fluid pump which delivers fluid at a precise rate with the added safety of being able to detect even the slightest amount of air in the IV fluid line. The staff at Blackwater Hospital in consultation with staff at the larger Rockhampton Base Hospital decided the level of care required by Ruby was best delivered at Rockhampton Base Hospital and a helicopter aero-medical transfer was organised.

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.

Due to limited space in the helicopter and a desire to keep Ruby close to her mother, one of the paramedics sat in the cockpit next to the pilot and the lead paramedic sat next to Ruby and her mother in the cabin.

Prior to take off the lead paramedic consulted with the Queensland Emergency Medicine Retrieval Coordination Centre. The administration of IV fluid at a rate of 250mL per hour was ordered and the lead paramedic commenced this soon after departure using the partially used IV fluid bag from the hospital with the new giving set, also from the hospital. The IV fluid bag was placed inside an opaque pressure bag to squeeze the contents of the bag through the IV line into Ruby’s vein. Twenty four minutes after the IV fluid was commenced in the helicopter Ruby had a seizure then rapidly went into cardiac arrest. The lead paramedic requested the pilot to land immediately and the pilot determined it was safest and most expedient to proceed to the planned landing site which was seven minutes away. The pilot changed flying style to accommodate for Ruby’s time critical condition. Ruby was immediately conveyed to Rockhampton Base Hospital where futile resuscitation attempts were ceased and she was declared deceased.

The medical staff at Rockhampton Base Hospital were (presumably) so perplexed by Ruby’s sudden and inexplicable death that they performed a chest X-ray following her death and another the following morning.

What went wrong?

The chest X-Rays taken by the medical staff at Rockhampton Base Hospital revealed air in the chambers of Ruby’s heart and blood vessels and provided the first clue of what would later be concluded by autopsy as Ruby’s cause of death – massive air embolism or air in Ruby’s circulatory system. Approximately 70mL of air was found replacing the blood in Ruby’s heart (right atrium and ventricle), air was also found inside Ruby’s major blood vessels (aorta and superior vena cava) and many of the superficial veins covering the surface of her brain. Most unusually, air was also found inside the internal jugular vein. So where did all of the air in Ruby’s circulatory system come from?

Before identifying the source of the air it is important to note that the Coroner’s Inquest concluded there was no evidence that Ruby’s death was the result of malice and that no referral was made by the Coroner against any person or entity.

It was not immediately known by the independent medical expert acting for the Coroner where the air in Ruby’s circulatory system came from until just prior to the commencement of the inquest in September 2014. By process of elimination and armed with the belief that the air must have come from the IV line the independent medical expert concluded the air came from the partially used IV fluid bag. Further investigation revealed the air entered the used IV fluid bag prior to re-spiking. It should be noted that IV fluid bags do not contain more than a trace amount of air and it was the process of re-spiking that trapped a lethal amount of air in the IV fluid bag. (The author replicated the scenario and found a total of 452mL of air in the IV fluid bag after re-spiking.) The air trapped in the IV fluid bag entered Ruby’s circulatory system via the IV fluid line after the remaining 115mL of fluid ran out. This occurred twenty four minutes after IV fluids were commenced in the helicopter. Due to the pressure cuff’s opaque appearance the paramedic was unable to easily recognise when the fluid in the IV fluid bag ran out and the air was squeezed through by the pressure cuff.

The setup used in this rare set of circumstances created the perfect storm for this catastrophic event. The confined space in the helicopter was listed as the reason an infusion pump was not used. Additionally, the limited height in the cabin meant gravity feeding IV fluid at the desired rate of 250mL per hour was not possible. Therefore the use of the pressure cuff on the partially used IV fluid bag was employed to squeeze the IV fluid in at the desired rate. The air in the partially used IV fluid bag was a catastrophic seed which germinated in the most unlikely sequence of events.

The independent medical expert further concluded that these circumstances were so rare that neither he nor any of his colleagues (irrespective of their level of experience) could have seen or predicted such an outcome.

It is here where three simple yet painful statements are made that make this such a difficult case to accept.
1. If a new IV fluid bag had been used Ruby would still be alive as the air would not have been present in the IV fluid bag.
2. If an infusion pump had been used Ruby would still be alive as the pump would have alarmed and ceased the infusion when air was detected in the line prior to it entering Ruby’s circulatory system.
3. If the IV fluid was gravity fed (without the pressure bag) Ruby would still be alive as Ruby’s venous pressure would have stopped the final few centimetres of IV fluid from entering her circulatory system, preventing any air from entering her circulatory system.

In short, a lethal amount of air had entered the used IV fluid bag which when re-spiked and administered with the pressure bag resulted in a fatal dose of air being squeezed into Ruby’s circulatory system after the IV fluid had run out.

Will it happen again?

While there was no evidence that Ruby’s death was the result of malice and no referral was made by the Coroner against any person or entity, the Coroner did find that one area of the paramedics’ treatment and care was not in accordance with best practice. Specifically the one area was the re-spiking of the used IV fluid bag. The Coroner did however take note of the independent medical expert’s conclusion that these circumstances were so rare that they could not be predicted and accordingly no referral was made against the paramedics.

In order to prevent a re-occurrence the Coroner did however make four recommendations and an observation.

1. That IV fluid bags are marked with “SINGLE SPIKE ONLY” in contrasting coloured lettering.
2. Education and prohibition of re-spiking IV fluid bags with the possibility this be referred to as “Ruby’s rule”.
3. That Queensland Ambulance Service (QAS) implement their new Clinical Practice Guideline for the priming of IV lines (which QAS have already done however attempts by the author to view this have been fruitless).
4. That aeromedical retrieval services attempt to eliminate the use of the opaque pressure cuffs and see if it is possible to trial IV infusion pumps to benefit from their alarms and safeguards.

The final observation of the Coroner was that paramedics should not restock or obtain equipment from hospitals. The rationale given by paramedics for doing this is to maintain a state of operational readiness and prevent the need for restocking upon return to their ambulance branch. The risk of obtaining equipment from hospitals is that slight differences in equipment pose a risk due to unfamiliarity and this is to be avoided if possible. The Coroner stopped short of banning the practice or making a formal recommendation to avoid it.

The short life and preventable sudden death of Ruby Chen is one that holds many lessons for paramedics, nurses and healthcare providers. While the recommendations and observations pertain to Queensland, Australia, it is essential for all health professionals to gain an awareness of this case. Furthermore, healthcare providers would benefit from auditing their IV fluid administration policies with a view to eliminating the risk of reoccurrence.

As I sit and watch my three year old daughter drift off to sleep I make myself a promise that in Ruby’s name I will do all that I can to prevent another similar catastrophe. I implore you to do the same. And just in case you missed it the first time, NEVER re-spike an IV fluid bag. EVER.

Elia Petzierides is a Victorian based Advanced Life Support Paramedic and Registered Nurse with a Graduate Diploma in Advanced Clinical Nursing.

More about Ruby Chen:

• Was Ruby given too much fluid?
• Commentary

More from GraveLessons.com

• GraveLessons about children here and here and here and here
• Hospital based misdiagnosis here and here
• A GraveLesson about Ultra Skinny Jeans

Like our Facebook page to catch our next Grave Lesson click here