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Death by Tube

If you have to be hospitalized chances are reasonably high that at least one tube will soon be sticking out of your body. We’re thinking, “Does it have the right stuff in it?” “Is it the right strength?” “The right flow rate?” Few of us probably fret about whether the appropriate tube was being threaded into the right place.

Turns out that’s what we should be worrying about.

Gardiner Harris contributed a terrifying story to the New York Times about tube mix-ups in hospitals.

Tubes intended to inflate blood-pressure cuffs have been connected to intravenous lines, leading to deadly air embolisms. Intravenous fluids have been connected to tubes intended to deliver oxygen, leading to suffocation. And in 2006 Julie Thao, a nurse at St. Mary’s Hospital in Madison, Wis., mistakenly put a spinal anesthetic into a vein, killing 16-year-old Jasmine Gant, who was giving birth.

Nurse Thao had worked two consecutive shifts the previous day, and exhaustion could have played a role. But the problem is more straightforward. Tubes for different functions should be made incompatible—but they aren’t, leading to many documented mix-ups (and many more suspected as this kind of error rarely gets reported).

Harris notes that groups have tried to fix the problem for more than 15 years, but guess what stands in the way? You guessed it—the companies that make medical devices. Making changes to protect patients would be difficult—and costly. It would require cooperation among companies. Red tape and drawn-out FDA procedures don’t help any.

A color coding scheme seems like a good short term answer, but it turns out that different companies use different colors that can make things even more confusing.

In the meantime, it probably wouldn’t hurt to ask the staffer to carefully explain those tubes before they get stuck into your innards.

  • arabella trefoil

    I already have a degree in Biology, but it’s “old” so have had to take some prerequisites for a BSN (Bachelors in Nursing) again. I am applying for a ”Combined Degree Program.” This is a two year course of study that grants a BSN and MSN in nursing. A graduate of such a program is qualified to be a Nurse Practioner. I am only applying to two Universities, and the admission process is extremely competitive. (Hence the need for the GRE – it’s a graduate program.)

    The training I’ve had so far has been extemely rigorous. If I want to practice as a nurse or a nurse practioner in New York State I need the degree(s). Supposedly, RN’s are being given a four year grace period to get a BSN. Now a days, patients in the hospital are “sicker” than they were 20 years ago. Lots of procedures that used to require days of hospitalization are now handled as out patient procedures. (Thanks in part to laproscopic surgery.)

    I have seen many, far too many instances of health care aides, CNA’s etc. taking short cuts, failing to observe important patient changes and doing things wrong. It is crucial to have well trained staff. The problem is, education  is expensive and many jobs that require a lot of hard work pay very little.

    I admire and envy the older nurse who learned the “old school way” where they were focused on patient care. They did not require college degrees. These older nurses are absolute treasures. They think these young nurses with BSN’s think their shit doesn’t stink. Sorry to say, they are right.

    I am filling out my applications, but undergoing a crisis of conscience. Am I doing the right thing? I want to help people, alleviate suffering and comfort familiies. Ironically, I could do more of this kind of thing as a CNA. But I can’t afford to be a CNA. An experienced CNA makes $20.00 and hour.

    I pray for guidance. I hope I am making the right choices. My teachers all tell me I will be wonderful nurse, and that I have special talents that the world needs. I don’t see that myself. Lately I’m just depressed about it. But hopefully in the end I will wind up on the right path.

  • Helen

    What’s even scarier is that my local University Medical School has a no-medical-student-left-behind policy.  Once you are in they pull out all the stops to get you through – tutoring etc.  That’s OK if at some point they pull the plug on the student.  I’ve heard doctors in confidential conversations report an intern or resident who was making poor judgments.  RNs always saved the day in those cases and were the ones who brought terrible errors to someone’s attention.  Medical institutions need checks and balances and enough people to see that it gets done.

  • Puma.for.Life

    I volunteered in a hospital for several months and I pray I never have to go to one as a patient ever.  I am sorry, but those places are scary. 

    For one thing, yes, if you have someone who can stay with you 24 hours a day you have a better chance of survival than someone who is there alone with no one to represent them and care for them. 

    Also, if the nurses don’t like you, you don’t get as good as care. I guess that is only human but it is not reassuring.  I witnessed one poor man who was finally rescued by a CNA with a heart….she must have been an angel.  All the nurses did was complain about how he was making problems for them and hard to deal with.  The man was unable to communicate, I don’t know, he might have had a stroke.  They had a catheter up his urethea and no one had bothered to check it for quite some time and that was the problem.  He was completely backed up.  Thank god for this CNA, who had just figured it out, cleaned him up, and he was sitting  peaceably and calmly in a chair next to his bed. 

    I pray I stay healthy until the day I drop dead.

  • Diana L. C. Hazelut Nut Thin Cracker

    I don’t teach nursing, but I did teach.  I DO know the pressure to pass students who should not pass.  It’s mindboggling if they’re doing that in nursing.  No Nursing Student Left Behind–very frightening.

  • Katmoon

    Sorry late to the article, Thank You Pat, it is an important look into something we can easily overlook. Excluding children,the other part of the problem can be not being with a family, say a person who has no one local, to look out for them, as well as the patients who may not seem interested in what is happening to their body. Patient honesty, responsibility and feedback is incredibly important in providing good care. IMHO. I am vigilant with my records, and every bit of my treatment, but I am also a former Nursing Student in a BSN program, with quite a few clinicals and employment in the medical field under my belt, I know what to watch out for. I found most errors are just mistakes, but sometimes there are people who have no business being in the medical field, just like any other job. If you do not like your care, or are having a reaction which seems not “right”, speak up, and insist. As was mentioned upthread, switiching providers, or hospitals, or Physicians is recommended when the care is lacking. Also I wonder what the influx of third world students into the American Medical system, has done to the level of care. Our standards are different and I have seen first hand, poor treatment by nurses who came from third world countries. 

  • Katmoon

    Pat, I also believe the 12 hour shifts, and very few real breaks are killing the competence of even the best medical staff. I know I am worthless after 8-9 hours of work. We need to see the 3 shifts back, instead of these 2 gruelling long shifts.

  • Katmoon

    Surgery Rev Amy? How soon is soon? Dang, keep us informed(not being nosy, just concerned). We do need you, and love you too. I sure don’t like hearing this.

  • Cooney

    Thank you for posting this Pat.  I am a Professor of Nursing and reading the article nearly made me ill.  I have had students who are capable of such agregious errors.  No one in higher education understands why so many nursing students fail out, they can’t comprehend that something so simple as a tube attachment could be fatal.  Like all educators today, we are pressured to pass people, and many do as you can see from the number of horrible errors that go on in hospitals every day.  For us in the trenchs, it looks bad when so many students fail.  It is very hard to tell a student who has spent 3 or 4 years getting in a nursing program they can’t make it because they can’t be careful enough, and even harder to tell an administrator you just failed a student because she could not hook up a tube correctly. 

  • don x

    Electronic medical records certainly have the drawbacks many of you mention.  However, a bigger problem is that hardly anybody can read the scribbles of many doctors and other staff.  I worked for years in a hospital setting with access to and writing in medical records and  progress notes.  A lot of errors come from inability to read the writing of hospital employees who write in the records, many using shorthand and abbreviations unfamiliar to others.  There is a lot of guess work and often it is impossible to find the person whose records you can’t read in order to check on what you think they wrote.  Sometimes the doctors can’t read their own writing.

  • Peggy Sue

    Yikes.  I’m glad I was somewhat unaware of danger with these tubes when my son was injured.  I recall being stunned by all the tubing, how the tubes and lines snaked everywhere.  In fact, I had a nurse jokingly say: welcome to modern medicine, a tube for every orifice and when we run out of them we make new holes.  Gallows humor, I guess.  But in all fairness, the staff did explain every single tube and procedure, and they were very attentive. My husband and I were also on site round the clock.

    I wonder how much fatigue enters into this equation.  I understand many nursing staffs are seriously understaffed these days, so I suspect multiple, back-to-back shifts are more common than they were 10 years ago.  And the young doctors, the residents, always looked like dead men walking.

    We were lucky.  Good info, Pat. 

  • Diana L. C. Hazelut Nut Thin Cracker

    Cont.

    I watch those TV commercials for drugs and always after the speed talking spokesperson mentions the possible side effects  I say to myself–cross that one off the list as something I’ll never take.  My favorite so far for a side effect is “asthma related death.”

    But, as for electronic records—I’m all for them.  I keep mentioning that I am on Colorado’s Kaiser Permanente insurance.  ALL my records are electronic.  If I go to a specialist in a different KP office, that person sees all my history immediately.  I get emailed results almost as soon as my doctor gets them if, for instance, I have blood tested.  I can even use the KP system to make little charts for myself–say for instance if I want to see how the glucose reading changed or didn’t over all the blood tests I’ve taken in the system.  Because of the system, all my doctors in the hospital provided my regular physician all the information immediately.  When I broke a finger last summer and had an X-ray taken, I went from the trauma clinic to the x-ray lab in the same building and then walked back to the clinic to see my results and was out in less than an hour, with an appointment with a hand speicalist in the speicalist building a 20 minute drive away, where that specialist could immediately access my original x-ray.

    My son’s girlfriend recently was diagnosed with an ovarian cyst under her insurance system.  From the time she had the original diagnosis and the referrals to specialists who wanted new tests at a different facility, which requred that she wait for those text results to be mailed to the specialist, who then needed another test–etc., etc., etc.–it took her about three weeks to really know what she was dealing with.  Now all her records are scattered and kept in various offices–no one can easily access all the information on her.

    This was the first time since 1999 that I’ve been to a hospital (after I slipped and broke my thigh on a hotel parking lot that had a dust of snow covering it (couldn’t see the ice beneath).  I felt safe at that hospital also, but maybe I was lucky.  I was in a different insurance program at the time, so I know that if I ever need to access those records, I will have a heck of a time finding them and getting them.  That is why I feel I will stay with KP until I die. 

    When my mother died on the operating table–long story–it became clear that if the cardiologist had access at the time to all her records he would not have recommended the procedure he did.  She had been to so many doctors during her life.  She died at 58, and after her autopsy we FIRST learned of the fact that she had a birth defect that caused the problem on the table and that had been the root of many of her health problems.  But each of her doctors had started “cold,” so to speak and had never been with her long enough to figure it out.  Lifelong electronic records would have been such a good thing for her to have.

  • Diana L. C. Hazelut Nut Thin Cracker

    I am very late to the discussion on this thread, but feel compelled to comment. 

    Pat, your concern about this problem is a good thing.  I admire the medical profession every time I have to deal with someone in it regarding my own health. I can’t imagine taking on their responsibilities and dealing with everything they must deal with that could endanger lives–all while trying to save lives or make lives better. 

    I think however, you need to carry your suggestion a bit further.  For example in my recent hospitalization this last June, every single nurse or technician who came into my room DID explain what pills they were handing me and why or what they were doing in regard to the tubes they used on me.  However, I could look at those pills and ask, but how in the world would I know from the little cup they put them in to give them to me that they took them out of the right bottle?  I had to trust that they did give me what they were saying they gave me. I think, though, that because they spoke it to me, that alone made them conscious of the need to look at the pill and recognize it. 

    A terrible news story here in Colorado was about an operating room technicion who replaced a painkiller injection (I think) with water so she could take it herself, as she was addicted  She had Hepatitis.  Those needles were therefore contaminated and a large, large number of people were notified that they had to come in for the test after her behavior was discovered.  This person had been fired for similar behavior while working in an out-of-state facility, though somehow none of this information got to the hospital in CO.  (She’s now serving a jail sentence.) Good vigilant oversight of hospital workers IS important in this regard–and for goodness sake, don’t force or allow nurses to work two long back-to-back shifts..

    The real thing patients need to do  is one’s own research a bit to know about the medications and procedures–and it is a good idea if the patient is unable to do this for him/herself to have family members there as some suggested.  If I wasn’t really sure I wanted to take something or have them do something I made them explain about a pill they gave or about the thing they were going to do, I made them explain why it had been ordered and what the possible side effects would be.  I am a paranoid when it comes to medication, as I seem to be one of those people who get many of the reactions. 

  • lorac

    arabella, you mentioned that you were going to take the GRE, so I’m guessing that your nursing degree is part of a BA (BSN?) program.  But, as I’m sure you know, a person can become an RN without a 4 year program in college.  They can go to a technical school and become an RN in much less time.  I wonder if the people in the short programs get the same rigorous program that you have had….

  • oowawa

    Arabella, as I am writing this, my wife is hosting her semiannual get-together of nurses who used to work in a local hospital that is no longer there.  What are they doing?  (I am not allowed to enter the room)–Well, mostly mocking and laughing at the stupidity of doctors.  But other nurses get their attention too!  You’re going to be a great nurse, and god help any doctor who talks down to you like a subservient!