02 March 2010

Cacophony

File this under something that is not at all surprising:
MGH Death Spurs review of patient monitors
A Massachusetts General Hospital patient died last month after the alarm on a heart monitor was inadvertently left off, delaying the response of nurses and doctors to the patient’s medical crisis.

Anybody who's ever set foot in an ER knows what I am talking about.  There's a big bank of monitors in the nursing station, at least half of which are flashing or chiming at any given time.   Throw in the chirping of the SpectraLink phones we all carry for in-department communications, pagers, the medic phone ringing, then maybe a few IV pumps in the hall pinging, and you've got a bona fide digital orchestra playing all the time.

The monitors are the worst, though.  Every patient in the main ER is usually monitored, either out of necessity in our high-acuity ER or out of habit (I once recall a girl with a threatened abortion who was put on a monitor just by reflex).  They bleep and they blare and they wail.  Sometimes it actually means something, but most of the time it means a lead fell off or the patient is wiggly or sweaty or that a doctor is playing with the leads to annoy the nurses.  Not me, mind you.  Some other doctor.  Occasionally you get a patient who for some physiologic reason (beta blockers and meth being the most common causes for us) is persistently bradycardic (slow) or tachycardic (fast) and the monitor for that room will alarm incessantly.  If only they had a feature where we could average out the heart rates of the meth-heads and the beta-blocked grannies and we'd be fine.  But eventually either someone deactivates the alarm or resets the limits so that it's not continually bothering us.

Which is how you get into trouble.

The "bad things" alarms usually never get turned off (meaning the alarm for VT or VFib) and they are designed to have a piercing sound which cuts through the acoustic clutter -- and a hearty well-done to the "human factors" engineers of the designers for it -- but those seem to represent a minority of the bad things that happen in the ER.  "Asystole" and "Bradycardia" for example, seem to be more common modes of patients suddenly dying on us.  But since "Aystole" kinda resembles "The leads fell off" and "Bradycardia" kinda resembles "granny on beta blockers" those alarms are more likely to be silenced/ignored.

In just the last couple of years I can remember no fewer than four "events" which involved a delayed/unrecognized arrest in the ED in which monitors were a factor.  (Though my spotty recollection hints that some them involved patients not being put back on the monitor after coming back from a test -- a chronic problem.)  Truly, cardiac monitors are a double-edged sword.

I don't have a solution to this, but for your entertainment I offer this story of how a colleague and I reacted when a code was called in the ER and we had to run it.

1 comment:

Jen said...

It never ceases to amaze me (a non-medical person) how medical staff seem to know which alarms to ignore, and which to pay attention to. My kids have been in hospital many times (preemies, RSV, loads of pneumonia, and cancer), and I used to jump out of my skin every time I heard an alarm go off, even when I learned to distinguish some of the 'scary' ones from the 'normal' ones.

Bradys were very scary for us as parents of preemies- we knew to reach into the isolette and shake a foot, wake the kid up, do the face wash etc., but they were very, very scary to see. Not to mention that the NICU always sounded like a very high-pitched marching band 24 hours a day.

I don't know what the solution would be either, but it's always impressed me how few deaths there seem to be because of ignored/mistaken alarms.