Weighing-in on Ruby’s fluid management
By Elia Petzierides
Yesterday, following a groundswell of comments about the amount of fluid administered to Ruby Chen as described in our recent article about her preventable death, I contacted the Queensland Coroner’s Court. I stated the concerns raised regarding the amount of fluid administered to Ruby throughout the duration of her care.
Today, while I was resting before my night shift, Coroner David O’Connell – Ruby’s Coroner – called me to discuss these concerns. He spoke with the predictably serious, flat-toned voice you would expect of a Coroner on a television show.
I explained the usual care for a child requiring fluid resuscitation (according to this Clinical Practice Guideline) which involves two 20mL per kg fluid boluses followed by inotropes (drugs that increase the strength of contraction of the heart) if required. Given Ruby’s weight was not documented in the Coronial Inquest notes, using what I thought was a generous estimated weight of 16kg for a 4-year-old child (Ruby was months away from her 4th birthday) I estimated a volume of 320mL for each fluid bolus. This means after 640mL of intravenous fluid, if perfusion remains inadequate, the next course of action should be inotropic support, not more fluid. Therefore, the approximately 840mL of fluid administered at the hospital seems to be excessive, as does the 250mL per hour of fluid prescribed for the helicopter flight.
As the Coroner shuffled through his records he advised me there were no signs of fluid overload at autopsy. I responded by stating the absence of fluid overload at autopsy is not proof that Ruby’s fluid management was in accordance with best practice. I asked if the independent medical expert who assessed Ruby’s management had specialist qualifications in paediatrics. I was advised he certainly did – Dr McCaffery is a consultant in paediatric intensive care – and he was satisfied with Ruby’s fluid management.
Something was not adding up, the fluid still seemed excessive. The Coroner stopped me mid sentence – Ruby’s bare weight at autopsy was 32kg. The silence pause that followed the Coroner’s statement was broken by my question, “Are you sure? That’s double the estimated weight for a 4-year-old?” The Coroner informed me that the pathologist described Ruby as a 104cm tall, well-nourished 32kg child. His tone of voice remained unchanged as the basis of the query was quashed and the integrity of the Inquest upheld.
I had always suspected this case had taken a toll on Ruby’s family and the healthcare professionals involved, and comments which will remain off the record confirmed my suspicions. Needless to say, the ripple effects of such a tragedy are far-reaching and long-lasting. It was with this in mind that the Coroner expressed his gratitude for raising awareness about Ruby Chen’s preventable death. Everyone who has shared the lessons learnt from this tragic case is deserving of this praise.
Our conversation then digressed to the Coroner’s job-satisfaction for the role he has held for the last four years. With his tone of voice lifting he confessed, “I look forward to going to work everyday,” then he quipped, “Maybe I should see a psychologist.” We both laughed.
There is no doubting the dedication of Coroner O’Connell. The passion he has for his job, his willingness to spend half an hour on the telephone with a stranger thousands of kilometers away, and the concentration with which he actively listened to the concerns raised left me reassured. The integrity and transparency of the Coronial process in our society is alive and well. And from this, we all benefit.
The author Elia Petzierides is a Victorian based Advanced Life Support Paramedic and a Registered Nurse with a Graduate Diploma in Advanced Clinical Nursing.