Ruby

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“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.

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106 thoughts on “Ruby”

  1. Such a sad, heart wrenching piece of information. I take my hat off to you for going one step further than you already do as a paramedic and vow to creating awareness so that these errors don’t cost more lives. Our kids are precious and in times of need, we hand over their care to amazing trained staff. We know you guys do your best every step of the way. But as they say “what you don’t know might kill you”… so knowing can make that difference. Thanks E.

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    • Considering all the eventualities why not just eliminate hanging fluids for any stable aeromedical patients and place a saline or heparin lock perhaps even a petcock?

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    • Thanks for your comment Jessie and I commend you on your interest in this issue. In his statement the lead paramedic stated he estimated there was still approximately 300mL of fluid remaining in the IV bag on his arrival. As for why the bag wasn’t changed I haven’t been able to locate any explanation in the Inquest notes. I can only speculate (and it is only my speculation) that re-spiking was seen to be a seemingly harmless shortcut.

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      • im picking they didn’t want to use a new bag so they wouldn’t run the risk of pushing more fluid into her without a pump (although surely you could have used a smaller new bag,.. hindsight is great). The flight seemed relatively short though and given the amount of fluid she had already had I wonder why they didn’t just stop it for the duration.

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      • And it actually is a harmless shortcut UNLESS of course you force it out. Gravity and IV pumps would have worked with it. What a pointless way to die.

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  4. yes even I thought ‘why’ were they re-spiking for the contamination risk, but I hadn’t thought ‘air’ ,thank you for sharing and my re-thinking, I too will be following Ruby’s Rule in memory of her, and protection of others, poor little angel.

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    • That was also my first thought!! I am surprised by the volume of air that entered the respiked bag. Thankfully (in my experience) this is not a common practice but will now be forever aware of the dangers associated. Thank you for enlightening us

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    • I thought the same thing, however on re-reading there is no info on how long the 850ml took to be infused. Was it 2hrs, or 8hrs- if the latter then the last 100ml over 30mins doesn’t seem too drastic.

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    • No, you aren’t. It seems like there should have been no reason to run fluids at that rate. Even using the 4-2-1 rule, it would seem difficult to arrive at a rate of 250ml/hr.

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      • My thought was this child was going to be on fluid over load at this rate. A three year old could be re-hydrated pretty quick but at that rate….Questions on the whole situation.

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    • If she was in a hypotensive state, which in her case would be systolic blood pressure below 76mmHg (70+ (2x Age in years)) then a fluid bolus of 20ml/kg over 5-10 minutes would be indicated. If she weighed 14 kg (about the 50th percentile for her age) then she would need a 280mL fluid bolus given over 5-10 minutes. Given over the slower end of that range (10 minutes), that would be a rate of 1680 mL/hour. Pediatric patients in shock can require fluid rates that would give MOST people a moment of pause. Most IV pumps run at 999mL/hour max, so hypotensive (shock) pediatric patients may even require the IV tubing be removed from the pump so the fluids can be given faster than the pump is capable. 250 sounds like a lot of fluid from the perspective of daily fluid maintenance, but certainly not surprising for someone in hypotensive shock. Remember, the pediatric patient in hypotensive shock is MINUTES away from cardiac arrest. The only reason we would want to see that bolus rate slowed down is if the shock is suspected to be cardiac in origin.

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  7. In the veterinary world it is extremely common to re-spike bags of fluids (patients often chew out/damage their IV lines). It is also well known that air will enter the bag, unless you use a haemostat to clamp the bag before removing the first spike. Sad our human counterparts haven’t worked this one out.

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    • I am an rn of 30+ years! I trained before all IVT was administered via a pump, we had to manually set the drip rate and re-spiking was not uncommon. As you say, clamping the bag was the correct protocol and awareness that having any air in the bag was potentially life threatening to the patient was common knowledge. As is often the case, with the introduction of safety equipment (in this case, the infusion pumps) the collective memory of previous practice is forgotten and when safety equipment is not available the risks are greatly increased.

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  8. Just learnt something new. .From, http://rehydrate.org/diarrhoea/tmsdd/5med.htm ….for SEVERE dehydration, ” Infants should be given IV fluid at a rate of 30 ml/kg in the first hour, followed by 70 ml/kg in the next 5 hours, thus providing a total of 100 ml/kg in 6 hours. Older children and adults should be given IV fluid at a rate of 30 ml/kg within 30 minutes, followed by 70 ml/kg in the next 2.5 hours, thus providing a total of 100 ml/kg in 3 hours Assuming the child was 20kg (being Asian that’s my rough guestimate for a 3yo), she should have had 600ml in the first 30/60, then 1400ml in next 5 hours (or 280ml/hour). Of note, this is the rule for severe dehydration where she would have lost >10% of her body weight…obviously not a minor illness in her case.

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  11. Sadly, the issue here appears to be a lack of appreciation of the risks of using pressure bags to infuse fluid. “Ensure no air in the system”, from whatever cause, is the golden rule. The re-spiking per se was not the error, and placing a clamp on fluid bags prior to “de-spiking” is common practice elsewhere, to prevent entrainment of air. That said, when transferring a patient, I would be reaching for a fresh bag of fluid, however much was left.

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    • Well good for you. As a nurse of 27 years I have never been taught not to respike and have never seen clamping a bag prior to respiking so I for one am very appreciative of this piece.

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      • I also appreciated this piece very much, and believe it exemplifies the ‘Swiss-cheese model’ of critical incidents – if any one of several factors had been avoided, the crisis would not have occurred (and we would be none-the-wiser). Like you, I have never been taught not to re-spike, which is thought-provoking, as others have clearly been taught it’s not best practice. I should consider changing my (institution’s) practice. ‘Instead’, I was given the mantra “pressure bags = no air in the system”.

        This discussion reminds me of a critical incident where a pump was set to deliver more than the fluid volume left in the bag, relying on the pump to alarm – but the pump’s air alarm failed, resulting in an air embolism (happily, with no patient harm). I learnt that alarms are our back-up safety-net, and shouldn’t be relied upon as the primary defence.

        These incidents allow us to review our own practice and ensure we are providing the safest care possible using the best evidence, every day.

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  12. I have just finished my nursing degree. On internship on an acute surgical ward, it was common to respike bags on patients that had just come from surgery as they used different lines from theatre. The bags were always mostly full and would then be run through a pump. What are peoples thoughts on this?

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    • Hi Alice – this is a Quality assurance issue – why are the lines in the OR different from the lines in the ward? This is really inefficient as well as being potentially dangerous. I hope you do something about this.

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      • I can answer your question Sue. Having been a Peri-Operative Nurse for nigh on 40 years, we find that the internal lumen of giving sets suitable for use in infusion pumps are not conducive to high flow rates as required in the O.R. For most patients having surgery, an IV line is set up to facilitate the anaesthetic drug regimen and for replacing fluid lost due to the pre-operative fasting time and any other clinical indications evident. It may be that a patient needs a large bolus of fluid to compensate for a hypotensive episode or haemorrhage and the infusion pumps and their matching giving sets are just not up to the task of delivering 500 to 1000+ mL in the matter of just a few minutes. Thus we prefer larger bore giving sets and the ward staff change them to pump sets post-op.

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    • The pump alarms when there is air in the line so there’s no risk. It was the use of no pump plus the use of a manual pressure device which forced the contents of the bag into her veins.

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      • why oh why would one pressure infuse so little fluid over such a short period of time and not be able to see the amount of fluid in the bag or drip chamber or the line itself. respiking the bag is not the problem nor is not having a pump. just plain inattentiveness to the patient and lack of common sense. if you have time to change bags then you have time to change the tubing.

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    • Whilst the pump will alarm if there is air in the line, it won’t protect against the break infection control that occurs with respiking. Many hospitals recommend not respiking because of the introduction of pathogens alone.

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  13. As soon as I started reading this story, it wasn’t hard to pick that the error was re-spiking the bag creating an air embolism. I see re-spiking happening all the time though. Such a tragic error.

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  14. Im just so sad to hear about this. As a parent I would like to pass on my condolences to rubys family. As s nurse I would like to think I dont become complacent. When you take a stable child or any person into your care, you still need to think “in a worst case scenario, I would do….” easy to say. But I really think alarms should have been going off for those ambo’s. A rate of 250mls/hr for a 3 year old child is huge. Alarm 1. An almost empty bag of fluid in transit Alarm 2 respiking can i troduce infection to the circut alarm 3 and saftey over being nice… they where the clinicians resposible for ruby they should both have been in the back with her! Swiss cheese or custer f##k! Either way that should never have happened and I think the coroner shoukd have been tougher on the ambo’s.

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    • I just want to add i love your ‘swiss cheese or cluster F##’ comment. As a student nurse, the ‘swiss cheese’ (sans ‘cluster f##’) has been heavily drummed into us… at one hole, it is hoped potential error would be stopped at the next level.

      Incredibly sad story.

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  15. Forgive me for my confusion…Certainly there are multiple practice issues, but I can’t see how re-spiking is the main one here. The overwhelming error seems to be using a pressure bag (and no infusion pump) to deliver fluid in a paediatric. I’ve never heard of this before either in PICU floor nursing or retrieval. The only scenario in which pressure bags in paeds seems appropriate is peri-arrest when fluid boluses needed to be drawn up hurriedly (3 way tap, 50mL syringe, transducer bag with saline so repeat boluses could be drawn up rapidly, in succession). Even in this scenario, a clinician is always taking note of what/how much exactly is going IV.

    Using a transducer bag means you can’t visualise your fluid, you can’t monitor the infusion rate (not many modern nurses/medics are guns at drip-count infusion, myself certainly included) and generally nurses/medics are taught to use burette in paediatric fluid administration- dialling up the required fluid hour by hour (or at least 2nd hourly)- to ensure we are constantly reassessing our patient’s fluid status, vigilant for errors, and status of the infusion bag/line/cannula. (Also, ~18mLs/kg/hr is an almighty fluid prescription for a mildly paed, who’s already received 60mL/kg of fluid?).

    Departing for transport with a nearly dry bag is an unusual practice for retrieval…but even if the IV bag wasn’t “respiked” it still would have meant this child would have been inundated with fluid (425mLs in 24 minutes?) rather than air (also very potentially lethal in a 14kg child).

    Certainly, “respiking’s” biggest hazard is infection control…but air entrainment is ALWAYS an issue in fluid admin. IV pumps with hr by hr dialling up should be gold standard.

    But of course, medical errors are completely heartbreaking to everyone involved. I hope the family is well compensated, and the staff are looked after by their colleagues/management and have some constructive education and emotional support.

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  16. The error is clearly respiking of the IV bag. As an ICU nurse of 10 years and having worked for Queensland Retrieval Services there is simply not enough room in these particular assets for IV pumps. Although all fluids should be ran through a pump with a burrette for a paediatric patient sometimes this just isnt possible. The child may have been able to go without fluids in the short term to facilitate the transfer as the fly time from Blackwater to Rocky is not that far. The QAS officer would have been in contact with not only an ED MO/paediatrician in Rocky but also the QCC doctor regarding the amount of fluid to give the child so to say that the Coroner should have been tougher on the ambo’s is being somewhat nieve about the situation considering they would not have nor are able to make such judgment calls (regarding the fluid rate) on their own in such a retrieval. This is an extremely sad set of circumstances and a child has untimatley lost her life. I am sure this is not an isolated incident but hanging people out to dry does not change things in the world of healthcare!

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  17. Why would you not have EVERYTHING new when transferring any patient. Nothing should run out. Confused as to the amount of fluid a small child received. Sad story, for all concerned

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  18. as a mother I send my condolences to the family and friends, such a tragic lost. I’m Adult nurse but I have seen people respike in my practice and is a bad habit , thank you for the awareness also I’m not to clued up with paediatrics but 250/mls seems a lot for a 3 yr ?? And I would have just kept the same equipment in place rather than stop change and delay treatment but hindsight !! A lesson warned …

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  19. i have flown over 200 AME’s as a Paramedic. My golden rule for accepting a patient is full bags before transfer as changing a bag in flight can be difficult so the least procedures I need to do in flight the better. My heart fell when I heard that they did this to save about 100ml of IV fluid. A new bag should of been put up which would of lasted an additional 4 hours, ample for the among of time for the transfer, instead of an amount for under 30mins. QAS need to change their procedure to this to prevent it in the first place.

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  20. $2 bag of fluids cost poor Ruby her life!

    As a senior clinician this breaks my heart!

    I hope this never happens again as QAS merges with QLD health and hopefully uses standardised consumables & equipment across both care delivery settings.

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  21. As with many stories such as this one, there usually is a comedy of errors that all contribute in different ways to the disastrous outcome.

    The decision to use the existing fluid bag and not a new one was the first error.
    The subsequent decision to change the giving set leading to re-spiking the old fluid bag was the second one.
    Not purging the air from the bag before inserting the new spike was the next one. This is the most critical one and I don’t need to be a coroner to work this one out.

    Many have criticised the re-spiking thing. Some have mentioned the infection control risk. Both of these issues fade into insignificance because the risk is so small relative to the child’s hydration status. I have re-spiked many bags over the decades of my practice. Re-spiking can be done without contaminating the spike point. Sadly this is a nursing technique no longer taught in Nursing Schools. Hence their irrelevance. I will say again, the first major mistake was not purging the air prior to re-spiking.
    Had the air been purged, then all of the subsequent practices of questionable nature by QAS staff would have amounted to diddly squat as no harm would have come to the patient.
    The issue of whether or not to have an IV pump in the helicopter, whether or not the patient is a child or not, whether an opaque or transparent pressure bag was used are all inconsequential issues that added to the comedy but were not significant in and of themselves.

    On another matter. I am very concerned about the calibre of the ‘Independent Medical Expert’ advising the Coroner.

    Elia writes, “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.”
    Where did this guy come from. To say that these circumstances are so rare… This comedy of errors is so predictable and can so easily happen if medical, nursing and paramedic performance is not up to scratch. There, but for the diligent practice of some healthcare professionals, could be so many more of this type of case presenting to coroners all around the country.

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  22. As an ICU nurse who also does helicopter retrieval a, I must say that this disturbs me for several reasons. First off, it is important to remember that there is no such thing as a “routine” helicopter transfer. Any time a medical crew is sent to retrieve someone to a tertiary hospital it is for those who will not survive without more specialised treatment. I have been nursing for 15 years and in that time, re spiking a bag of fluids has never been best practice. If I am prepping a person for transport, I always use a blood pump line with a fresh litre bag of fluids. If I am transporting a child I always use a volumetric pump. The pumps we currently use in NSW weigh 2.5 kilos, and can be attached to the bridge of the helicopter stretcher. Surely this could have been done in this case. Finally, in our helicopter we have room for 1 parent to travel with a child in the adjacent jump seat, alongside the flight nurse and the Dr at the head of the patient. Having this configuration would not have saved Ruby’s life, but at least they could have worked in tandem to perform CPR and attempt to save her life.

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  23. Really cannot fathom why a pressure bag would be needed for simple IV fluids.Very unusual for retrieval to not use a new bag of fluids for the transfer as the old would not be enough.

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    • Pressure infusers are required in aircraft as you usually don’t have enough height to allow the fluid to flow using gravity alone. That said, a bag on a pressure infuser should be limited to simple procedures like TKVO, flushing bolus meds, or if a fast bolus of fluid is required (many pumps can’t keep up with the fluid required for say, a profoundly septic patient during initial resus, or a bolus for a massive hemorrhage, a severe anaphylaxis, or fast administration during a PEA arrest.)

      Can’t think of how the air ambulance service can be excused for not providing an IV pump for the aircraft. That’s a head scratcher. The aero-medical environment is the most difficult one to practice in: if you’re not going to provide the proper equipment, don’t fly patients.

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      • Re-spiking does not concern me nearly as much as using an opaque pressure bag in a situation where it is almost impossible to monitor what is going in to the patient. “Simple procedures like TKVO” worries me greatly, as TKVO implies low volumes/low rates often with minimal supervision. This kid had had a decent volume to start with, was still a bit dehydrated, but unlikely to die if the drip had been bunged off for the helicopter ride. Monitoring a pressure pump can be quite demanding in an operating theatre, let alone in a chopper!

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  25. 1. Um, re-spiking is common? It just reeks of risk of contamination, nevermind air embolism. Didn’t know anyone ever did this. That’s just sloppy.

    2. When prepping for transport, the minimum I start with is 1.5 times the amount to be infused in an hour. That allows vehicles to break down, and backup crews/vehicles to intercept.

    I think the crew is lucky the Coroner didn’t make any findings against them. The whole case reeks of lazy, dirty practice.

    Advanced Care Paramedic
    Canada

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  27. Tragedy for sure. I agree with above comments. 250ml per hour for a 3 year old would also ring alarm bells. Plus I also thought pediatric patients shouldn’t be given 0.9%saline but rather 0.45%. I feel for the poor paramedics involved.

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  28. I work in a regional hospital in WA where re-spiking is common practice as the pumps used in the private and public hospitals are different therefore a new line is required when transferring patients between hospitals. This has raised concerns with myself and this common practice. Pumps and giving sets should be universal across all institutions or the practice should be that all Iv bags are changed upon transfer, if the pumps and giving sets are different. I will be bringing this to the attention of my manager to implement a change of practice to prevent this from occurring even in adults. This sort of incidents break my heart. We as healthcare professionals learn from such tragic situations to prevent this from happening again.

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  29. Sad story but interesting and informative. Respiking is common practice in Anaesthetics when adding different IV administered medications. Another consideration when using a pressure bag while flying is that the pressure in the cuff increases the greater the altitude thus affecting the flow rate. I have worked where patients with fractured limbs had pneumatic splints (similar to a pressure cuff on IV fluids) applied and these had to be deflated a little the higher the altitude so as not to restrict blood flow. I don’t know at what altitude the helicopter flew and it may well not be considered.

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  30. So tragic, condolensences to family, friends and healthcare wrker involved. I have only respiked when needing to between peri operative areas and wards when SPPS, haemocel, intralipids and they were always clamped or could not have air enter due to airways in the bottles [ trained in mid 80’s…]. I cannot help thinking that the small amount of fluid left in the bag was oversight on the hospital, as we always give the air retrievals/medivac teams an extra bag. Maybe it came down to something as PAINFULLYsimple AND HEARTBREAKINGas they were on the helipad and a nurse said something like “oh I forgot to get a new bag”,” easygoing accomodating paramedic said, oh thanks but don’t go back down to the ward now, we have to go- time pressure who has not experienced that!!!” Lets face these things happen all the time in our dynamic area of work and handovers/transfers where ETA;s are always changing by medivacs and RFDS through no fault of their own, is just the nature of emergency retrieval serviceand as space is VERY LIMITED for an imprest. Will pass this on to all my colleagues in SA.

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  31. I have been a Registered Nurse for over 30 years, working both in the public and private sector with experience in OR, E.D ,ICU,CCU,Radiology,Agiography and Midwifery .
    Re-spiking IV bags is poor practice, it is well known air will enter the bag! To then apply a pressure cuff is asking for disaster!
    Always use a new line and new IV bag when T/F a patient from one department to another, or one health facility to another, especially if it is not compatible with the environment, additional equipment to be used or familiar to the user.
    The individual or team taking over the care of a patient is totally responsible for that person as well as all the equipment in use and treatment given.
    We are not infallible and we do make mistakes.
    Take a moment to… Stop and Think ….about what you are doing. In every circumstance a moment to analyse a situation and maintain best practice will have a better outcome for you and the patient.
    A tragic loss of life occurred because of poor clinical judgement.The reason for this could be due to many circumstances.(inexperience,deficient education,poor peer support,time pressure,lack of sleep,emotional stress or even laziness etc)
    We all feel for the professional in these circumstances, but as the previous posts suggest the warning bells went off for many, and for others their questioning went down a different path. We learn from mistakes made by ourselves and others but sometimes the cost is too high.

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  32. I didn’t read all of the comments so someone may have pointed this out already; why wasn’t the air squeezed from the bag when the new tubing was attached? It is simple to do. I don’t understand how am experienced paramedic or nurse could not see the danger of air in the bag. Any time gravity tubing is used, which is the majority of the time in the emergency department, the air in the bag is removed during spiking. In the event we subsequently have to change from gravity to pressure, it is safer to already have removed the air. This appears negligent on the part of the caregiver. This little girl should not have died. It was easily preventable. So sad for her family.

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  33. I think what everyone is focusing on is the danger of re-spiking. That is not the issue. The issue is the negligence on the part of the paramedic that cost this child her life. There is no excuse or justification for this. Why was there not a nurse on board to assume the responsibility for keeping this child out of harms way? Regardless of the intent or the circumstance the paramedic was guilty of an act of comics ion that resulted in a death.

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    • And a nurse has never made an error that resulted in a death? And if I recall it was the nurse at the hospital that re-spiked the bag and didn’t remove the air. Not absolving any of the responsibility that the paramedic had in this case, but your comment wreaks of arrogance.

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  35. I am sorry to say but as medical expert, i can see, there are so many MISTAKES that should have been made clear with appropriate consequences for these people doing such untrained and naive things. I also find medical expert’s opinion not so ‘expert’ as he is saying its rare set up. The comment should have been its a ‘wrong set up’. It is a mistake as trained and sensible paramedic would not do so. Last but not the least, i do not want to guess but compelled to think that if there was a ‘foreign’ paramedic, they would be punished straight away. Gentler approach has been used for a reason here.

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  36. My heart breaks for the family’s loss of a little Angel taken so unfairly . I pray that Rubys rule always be aplied . And now as Ruby watches over all of us . We never forget her rule .

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  38. I’ve been in Anaesthesia (AT) for 35 years and have been involved in many Patient Transfers and one of my Golden Rules – ALWAYS CHECK THE IV LINE to see if it’s still infusing, nearing empty, air in the tubing etc – Regardless whether it’s a new bag or the original bag!!! I’m always scanning the the scene/surrounding/Patient – “Left to Right” …minute by minute Vigilance!! You do not want a Medical Emergency in an enclosed space. If the Lead Paramedic was the only one looking after Ruby, then vigilance is prudent (After-all the IV Fluid is under pressure) The other paramedic who is in front with the pilot would then be doing the paperwork etc, etc.
    For whats it’s worth…Pressure bags are commonly used in:
    1. The OR/A&E/ICU scenario where rapid fluid/blood replacement regime is required (and there is a dedicated experienced individual keeping an eye on this high-pressure infusion system) … obviously this wasn’t possible in the Helicopter due to space constraints.
    2. When using an Arterial line/CVL pressure monitoring transducer (it only infuses 3mls/hr)
    Pressure Bags should not be used in Paediatric Patient Transfers – using a 20ml Syringe with a 3-way-tap and an extension is another option instead.
    This is a sad unfortunate and unavoidable incident that we can all learn from. Condolences to Ruby’s Family and having just lost my 3 week old Grand-daughter to SUID, I understand what they went through. May Ruby’s Family be Comforted.

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  40. 2 thoughts;
    We can wait hours (even days) for Retrievals for non emergency transfers, in This case waiting even another 1/2hr would have allowed 125 more mls through and the bag would probably have been deemed “close to empty” and discarded.

    2nd thought;
    maybe the reason the last 250mls in the bag was re spiked was because the paramedics wanted to fulfil the original fluid order and did not have time to chase up a new fluid order for the transfer?
    I Feel for the paramedic, how could you ever get over this…… We are always in such a hurry,we need to slow down and THINK.

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  41. When it comes to medical supplies don’t be afraid to throw something away and use items that are new, full, sterile, what have you. There’s no reason to “re-spike” a 1,000mL bag of IV fluid with only 150mL left. It won’t make a difference trying to save a few milliliters of fluid; just get a new bag! In the context of a field paramedic using gravity or a pressure infuser for administering, I wouldn’t let a bag get below 50-100mL before I changed it just to have a buffer between the drip chamber/tubing. One of the first things you learn in paramedic training, whether it be the hard way or not, is when using gravity or a pressure infuser, FREQUENTLY check the bag of IV fluid you’re using to give a drip/bolus so that you don’t fluid overload them or completely run out of fluid. They tell you little air bubbles won’t hurt and it takes a large amount of air to be harmful (that may be true for adults) but air in IV bags and tubing is not something to play with especially in a pediatric patient.

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  42. Pingback: LITFL Review #165 - LITFL

  43. tragic. but i guess i am wondering why they had to change tubing at all? we have used pump tubing before with out a pump. pretty easy actually. the only time we change tubing is if it’s incompatible with our pumps. so if they weren’t going to use a pump there was no need to change the tubing.

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  44. I have re-spiked before… but only with the bag upside down, after rolling the air out of it. Re-spiking does NOT need to introduce additional air unless you are just simply popping in the new line without paying attention to your air level. I spike any bag that is going to be on a pressure line this way, whether it is a re-spike or an initial spike, regardless of what I’m using that line for (bolus, art, CVP) just to make sure there is NO air in the line at all, not even the air that was already in the bag when it came out of the supply room brand new.

    There were multiple errors in this scenario. Re-spiking can cause problems but it does not have to. I have never seen pressure bags that I couldn’t tell a fluid level through, so I’m not getting how no one could see the fluid level. One side has been a solid white but the other has been mesh at all facilities I have worked at. Maybe pressure bags are different in the UK. That was also a lot of fluid for a child.

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  46. I know nothing of the services in other countries nor the exact circumstances here but I have ti ask one critical question. Why was this patient transported by air rather than ground? We all know air medical transport has many dangers unique to it. It seems that this patient was completely stable and in no immediate danger so why the need for a helicopter? Would it have made a difference in this case? Who knows just a thought! I really don’t understand why one would “re-spike” a bag anyway. I am quite sure that no one will punish those medics any worse than they are punishing themselves!

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  48. What kind of IV pump would be too big to be carried by a helicopter? Alaris GPs are less than 1cubic ft.. Just to say, I work in recovery and we always change IV lines before discharge to the ward.. What I do is I clamp the bag with a forcep and respike it with a regular IV line for ward use… Ergo, Just like everything else in Nursing, be mindful of what you’re doing.. Every little thing counts…

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  49. Re-spiking the proper way. I suspect that the IV line was re-spiked on a new set of IV bag with inflated pressure bag. Spiking on this new set of IV bag causes a strong pressure thus air in the IV line chamber mixes with the fluid and enters at the IV line simultaneously even when the IV line was closed prior to giving desired drips. If re-spiking be made, deflate first the pressure bag, close the IV line, check for the presence of air, pull spike out of the old IV bag, re-spike on the new correct IV bag, put the deflated pressure bag, check for any presence of air on the lines, open the IV line, inflate the pressure bag, check the gauge, check IV line site if secured, check drops per min…and that’s it.

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  50. Woah.. Why are they giving 250cc/hr to a child? Even 140 cc/hr is the max rate I know for adults… 250 is too big even if the kid’s malnourished.. Maybe a doctor can give 200cc as fast drip but not every hour because that’s just too much.. It causes pulmonary congestion.. The kid would be in respiratory distress… Actually, I don’t see the need of the pressure cuff, do they not know how to manually count the flow rate? Probably… and they should have anticipated that in 30minutes, the bag will be totally empty if it only had 115cc left.. Re-spiking? I have always done that but air was never introduced to the tubings.. You just have gotta clamp the tubing near the chamber first before re-clamping (I’m assigned in a poor hospital so we can’t just request for new sets that easily) I guess, they were not just that vigilant.. And also..why was there a need of air transport? When it was not an emergency case… This confuses me…

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