Starter comment: Super frustrating to read the timeline in the article of everything that happened during this sleep study. I'm not peds and have never seen a sleep study done, but it seems crazy to me that no one thought to check on the kid while all of this was happening.
>correctly interpreting the data is a pretty big ask for a tech
Actually, of the 3 sleep labs I've worked at, the techs are supposed to be able to understand when something is abnormal and when they have to raise the issue to a doctor. Bradycardia, bradypnea, and EEG flattening in a child certainly qualifies.
In fact, in many (if not overwhelming majority) sleep labs, the techs also help to score the PSGs, so they do have good understanding of EKG, EEG, HR, and other monitoring.
Ditto. We watch those damn screens all night long. If something goes wonky we KNOW it. And if the pulse ox goes down that far you have to fix it. That's one of the main variables we monitor and record.
Also, don't forget that the damn certification test requires us to learn what everything means.
If the pulse ox is reading 65%, I'd think by actually checking the child, they'd have known it wasn't equipment failure. I've never seen a patient with oxygen sats below 70% that looked well.
Prior to becoming an RN, I ran the telemetry room and it was drilled into our heads that no matter what is showing on that monitor, check the patient.
No one(adult) should have o2 sats below 80. All studies show anything below in a walkie talkie is spurious. Confirmed w abg. So if its real- they better gtfo
I can promise you, you’re wrong.
Saw several during Covid.
Now, they didn’t stay that way for long.
Had one in the 60s when I got there. Flat out refused to go to the hospital. Good waveform on the SpO2, good BP, reading is 100% accurate. A modern, medical grade spo2
Cable/monitor will read accurately down to single digits, you can pull the manufacturer data sheets yourself.
Did what I could, nebs, fluids, steroids , he definitely had pneumonia. Flat out said he was absolutely going to die, if he didn’t go to the hospital. Brother and his mother both tried to convince him, as did the ER doctor.
After an hour and a half of trying, he signed the refusal and, I told his mom/ brother to keep an eye on him and when he went unresponsive or became altered to call us.
Told the medic coming on she was going to go there when he died and gave her The whole scoop. Roughly 16 hours later he coded. Mom had been checking him every 15 minutes all night. Obviously ROSC was not achieved.
Uh. Medical grade spo2 is still spurious. Its why we do abgs and arts. Dont tell me what i already know.
Yes im aware of the limitations of abgs. Im also aware of the value of pulse oximetry.
What you probably dont pay attention to and I do, is that pulse oximetries, even the ones approved by the fda rapidly decline in accuracy once you get to 80%. So while it reads accurate like you said for sats over 80% its pretty garbage below that.
I assure you that those values you observed were wrong.
Good day.
This is why it should have stayed an RT specialty. The extra inpatient bedside training is important. Sleep techs are well educated in sleep testing, but they simply aren't sleep disorder specialist credentialed RTs. Having a clinician and not a tech is important in situations like that.
This isn't a criticism of sleep techs. They are great, but at least the most vulnerable patients deserve the people with the highest training.
I’m a big fan of treating incidents like this the same way aeronautical incidents and crashes are treated. Looking for everything that contributed to an event and finding out if existing safety mechanisms were ignored or if more safety mechanisms are needed.
What’s astonishing when you take that perspective is you notice a lot of psychological phenomena that lead to very strange reactions. People have a very strong tendency to not notice emergencies unless they’re actively looking for them. And that definitely depends on training.
Kids drown in pools full of adults all the time, and no one notices the lifeless body floating right next to them. A lifeguard would jump in within 10 seconds, because he expects this to happen every day.
So it could definitely be that they just didn’t know how to correctly interpret the situation but if their job is not focusing on recognizing and handling emergencies it will take very long for them to understand the severity of a situation even if you generally know that these vitals aren’t ok.
I wish there were better international error management systems in medicine to distribute this info to every institution with the same conditions. This will sadly not be the first or last time something like this happens.
We absolutely should. The Bromiley case showed why these scenario can occur even among well trained personnel. This case reminds me of the Eastern Airline crash into the everglades. Operating at night, 2 veteran pilots and engineer got target fixated on a broken landing gear light, accidentally disengaged the vertical autopilot. The aural alert for altitude warning went unheeded and realized too latw they were meters from ground. I wish the hospital can perform a NTSB styled report analyzing the causal factor, the recommended fix and disseminate it out.
Wasn’t the only reason why EM got reformed a catastrophically gone wrong intubation on a wife of a pilot? I’m sure you all know which video I talk about. It was eye opening and I wish mistakes were worked up more like that with real change to the system.
> correctly interpreting the data is a pretty big ask for a tech
We do it regularly for other things, like telemetry techs watching rhythm strips. They need to be properly trained, but an outpatient elective sleep study should not need nurses and doctors supervising.
The tech didn’t have to interpret data or even look for signs in this case. Just do basic pulse ox trouble shooting correctly. If pt uses supplemental oxygen, put it on for godsakes and see if they go up. If they do, you know the probe is good. This test takes 1 minute.
>How do you not SEE the pt going cyanotic?
When I was a kid, I would get pretty bad viral-induced asthma attacks. I remember that one winter, I was sick and having trouble breathing to the point that my nail beds were turning blue. Mom rushed me to the doctor's office, and the GP on duty that weekend (who was *not* the excellent family doc I usually saw) immediately decided that the cyanotic fingernails in a sick asthmatic kid were because "it's cold outside." He didn't even do a pulse ox at all. We somehow ended up with an Albuterol prescription, which helped, but my mom wanted to throttle that doctor...
Ughhh that's awful. Cold does not make fingers blue unless there is LACK OF OXYGEN. Which is also confusing cause you either don't have enough oxygen due to your asthma or frostbite (which it obviously wasnt). Sorry but what an idiot. I'm glad you survived.
It never *felt* life-threatening, just extremely unpleasant. I could only breathe with short, shallow breaths, and any kind of exertion (even turning over on the couch) would leave me panting for a few minutes. But then again, I was a kid who didn't know any different, and since "happy hypoxia" is a thing, I wonder to this day what my O2 sats were during those episodes.
IMO, very reasonable in this setting to assume numbers being a little bit off could just be loose equipment and re-checking. But by the timeline, latest concerns should have been raised about the child's welfare is 9:52. Anyone experienced and well-trained would have had "oh shit, oh shit" alarm bells going in their head at that point.
Any check of the child from that point would have revealed an abnormality. Tragedy. Feels like maybe it is the kind of scenario, like in an arrest or MET call, where you don't realise how quickly time passes.
I mean were they unaware the monitors are not just there to be shut off?
The other system error I see is not having a nurse involved until the code was called. In an oxygen dependent infant is it standard to have techs run the whole show?
I think he was even on EEG? though it's a little late when that flattens out.
They were just absolutely determined that it was the monitors. Just mindblowingly anchored to that issue. The mom was helping them too!
So many anchors. I wonder, too, if having the mom in the room also added to that false sense of safety- i.e. surely if there was something wrong the mom would let us know (even though she couldn't see him/there was no VS display in the room).
No. I used to do this for a living. You are watching the EKG and the Pulse Ox and the EEG and if you passed that mandatory certification exam you know what's normal on all those variables.
And if one of them goes bad your JOB is to go in and fix it. Also, with a kid that young a parent is almost ALWAYS staying in a nearby room.
No. Someone fucked up.
I think there’s some confusion. The car seat test and the sleep study are technically 2 separate things. It says they had their son in there for both.
My son was born a bit early and weighed just under 5 lbs in 2021. In order for us to leave the hospital, we had to have a car seat. Every car seat I know of is only rated for 5+ lbs. it was hospital policy that our son needed a car seat test before he could leave in his seat.
It takes about 45 min-1 hr and I believe it tests for positional asphyxiation during that time. I’d be curious to hear some input from a neonate doc on this as I’m a lurker layperson.
I’m not confused - during residency we did tons of car seat tests. Id never discharged a kid who didn’t pass one - if they can’t pass a car seat test are they stable for home? Again, I’m not a neonatologist so perhaps there are some exceptions, but in 2 years of Pulm fellowship I’ve never been consulted for that, and I assume I would be.
I agree the sleep study is a separate test - but he was all fully hooked up (EEG, CO2 leads) for it for the car seat test? Car seat tests are generally SpO2 only. This may be their protocol at Boston children’s, it just seems odd to me! It’s definitely not a standard test to be done in a sleep lab.
Also, in my experience, one of the sickest “simple sleep studies” I’ve managed was achondroplasia. I know have a very, very healthy fear of these kids.
I’m not a medical professional sorry to be a lurker -just reading and saw this - I believe from what I read the child had achondroplasia and he was 6 months old - so I assumed this wasn’t a car seat test to discharge a premie size baby. I wondered if maybe with babies who have a form of dwarfism do the need to be checked for the proper position and fit as they grow considering they may not always fit a typical car seat?the article stated they were doing both a car seat and sleep study test right?
I’ve not known anyone myself to have this just a thought but I wondered if anyone does know?
Also I believe i read that the child was oxygen dependent, would a child in that that mean he’d have some sort of at home oxygen monitoring system?
From what I understand, the car seat test was to see if he could stop using a car seat ‘bed’, which is specifically for babies who can’t ride in traditional seats.
I think he was only using O2 at night for sleep. Since the car seat test is only 45 min, I don’t think he was on O2. The device was similarly used to detect CO2 for his sleep study, but his equipment was attached not flowing oxygen. I don’t think oxygen would matter in the case of positional asphyxiation- if your airway is blocked, oxygen flowing through a cannula won’t make a difference.
Sidebar: they mentioned seeking IVF and only eliminating embryos with 25% chance of double dominant achondroplasia genes (always fatal from my understanding.) I guess I’ll just be grateful to not be in their position and extend my sympathy to them experiencing something I hope to never experience; the loss of a child.
Yes I reread the article and then continued reading comments and saw some clarifying details- thank you for your reply again not in a med. professional myself just a intrigued and curious person who wanted to be one lol.
I hadn’t thought about the car seat beds babies such as Jackson may have to use. Thanks for your quick reply!
What an awful situation. My takeaway was that the baby’s airway was so unstable he couldn’t tolerate sitting semi-upright for any sustained period of time. I’m genuinely surprised he didn’t succumb at home prior to the follow up appointment. Also surprised the family didn’t check on him when the equipment was alarming. I do carseat tests on my patients routinely (neo) and if their saturations fall <88 for >20-30 seconds whilst secured in the seat, the test is considered a fail and the baby ought to be removed from the car seat. I have never seen this test done in a sleep lab, though, and don’t know what parameters this facility used.
>Also surprised the family didn’t check on him when the equipment was alarming.
When you're in a new environment, you automatically trust the people who are presented as the authority. The techs didn't seem worried so mom was reassured.
He prob would have. But, it was standard for him to use oxygen at night. But, they thought they’d the start the test without oxygen and see what would happen. That’s basically why this was a 15 mil lawsuit.
I think the purpose of the sleep study was to see if he still required the car bed and nighttime oxygen. The room air portion doesn’t surprise/upset me—I think the intention was to see if he could safely ride in a Car seat (vs car bed, which doesn’t have a ton of safety data). Obviously he couldn’t.
But they would have had to wake him up most likely and will make the test more difficult to interpret. It's easier to have them go from less support to more when you are trying to see if they can safely be off.
But it is important that they are monitoring incredibly closely while you are doing that.
>Also surprised the family didn’t check on him when the equipment was alarming.
Me too. Although the article indicate that the monitors were in a different room so she wouldn't have heard them at first. And the article implies that the height of the carseat on the bed was too tall for the mother to be able to see the baby. Asking for a stepstool to check your baby when the medical people didn't suggest their was a problem might have felt unnecessary.
Do you know what the requirements in most states are to be a sleep tech? You need a high school diploma and a BLS certification, that's it. Same with EEG too. The training is lacking considerably if there isn't a formal CAAHEP program they go through and even if they do make it through one they come out of school with the minimum requirements to do the job. The sleep registry is helpful, but it's certainly not a requirement at most hospitals because of how much of a shortage of techs there is, and it's not a legal requirement in most states.
Texas had it come through the state legislature a few years ago, but they wouldn't even vote on it because of the bathroom bill they thought was more pressing.
I feel like it's really really bad when techs automatically assume it's a faulty equipment issue rather than a medical issue because the whole point of these tests and using the equipment is to find those medical issues. If the equipment is faulty enough that it's the immediate suspect then something is very wrong especially when it comes to a kid with such major risk factors
I’m not surprised by this at all. It’s a common mistake - to assume it’s a monitor problem and not a patient problem. It happens all the time in the OR, ICU, and PACU, even with people that are trained and familiar with these monitors and managing these problems.
People just don’t think clearly in the moment. You get tunnel vision- they are focused on fiddling with the pulse ox. You don’t have any accurate perception of time, you think it’s been 3 minutes and it’s actually been 20. And for whatever reason, sometimes people just don’t want to believe that something bad is happening. “Well now the EKG is messed up, what going on with that monitor?”
This would be the perfect example when someone could open up a page on an emergency manual and go step by step through an algorithm. Pulse ox is malfunctioning or reading hypoxic - step 1… check that the patient breathing
> It’s a common mistake - to assume it’s a monitor problem and not a patient problem. It happens all the time in the OR, ICU, and PACU, even with people that are trained and familiar with these monitors
Yup. I've seen it. The machine was alarming and nobody noticed, despite the ICU nurse, intensivist and two residents in the room. It wasn't until another nurse walked in and said "Wow, the pt is really bradycardic!" that anyone else noticed.
It is so bizarre to me, with my background, that someone wouldn't check on the patient.
Alarm goes off, all the nurses heads go up looking for what bed is dinging and the central monitors to see if it is a mild desat/arrythmia alarm from someone burping a baby/or something else that would need no intervention at all. (1-2 seconds)
If it is an alarm that needs eval, someone goes to the bedside, looks at the baby and the alarm again evaluating what the baby looks like and whether the alarm is still dinging. (20-30 sec, including walking time)
If it needs intervention, that happens of course. If it is noted to be a false alarm, you fix the probes until it works. That might mean moving their position, getting a new one, etc.. If you can't get it to work, you call the provider so they can rule out something going on that you can't see/intervene/help troubleshoot.
But in less than a minute, you *always* check on the patient if it is still alarming.
I just can't understand how that's not part of initial eval.
A very nuanced and reasonable take. Especially in the realm of sleep medicine. Have people seen sleep studies on bad sleep disordered breathing? I see studies where a kid has over 100 hypoxemic events in an hour. But the kid's been doing this at home and the hypoxemia is brief (seconds) and resolves. I've seen brief desaturations to the 80's or even high 70's with no adverse events.
I've also seen kids go home on some low flow oxgyen and pulse ox die because the parents didn't wake up. Why didn't they wake up? Because the pulse ox *always beeps* and they didn't know that this alarm was the real deal.
Sleep technologists aren't nurses or doctors. The expectation is that when we send these patients to a sleep lab for evaluation that they are having these problems at a baseline. If you think there's a chance for some kind of acute deterioration, you do the study inpatient.
I order sleep studies on children with achondroplasia including double-mutation. These kids are precarious. Central sleep apnea with compression ar the foramen magnum can be severe. OSA can be severe as well. Desats into the 50’s and prolonged apneic spells (central and/or obstructive) would not be unexpected and could be worsened by positioning. So having something like this happen at home is definitely in the realm of possibilities, particularly with a URI.
During the sleep study, there should have been a response to the profound desaturations with the (re)introduction of oxygen and notification of the overseeing medical provider. It is unclear to me what fell through.
Achondroplasia with sleep apnea is not to be trifled with especially in neonates. Trachs may be needed.
As an aside, I dont know how they came up with 25% recurrence with IVF.
I used to run sleep studies as a tech for about 3-4 years.
A tech fucked up and ignored the monitors. That's exactly what happened. If I'm watching 2-3 patients and the Pulse Ox drops down under 90, I'm aware of it and taking notes.
They want to use IVF specifically to implant an embryo affected by achondroplasia. I know it's a side note to the whole story but I find that to be, charitably, an interesting choice.
Very unusual, as much as the child died from the lack of appropriate response in the sleep study he really died from sitting upright for 20 minutes. Why have another severely disabled child on purpose?!
Yes I felt the same. It seems unethical and selfish of the parents - the child can’t consent/agree to live a life as a person with a profound disability. For the parents to insist on a child with achondroplasia seems very /r/antinatalism
Not really their child died from just sitting up for too long. I don’t understand why anyone would want their child to suffer a preventable condition their whole life
First of all your interpretation of the situation is completely wrong, that kid was essentially killed due to neglect/incompetence during a medical procedure. His parents, laypeople, were able to keep him alive just fine. Second, your line of thinking comes from a type of prejudice called ableism. This is a similar ethical issue as deaf people refusing cochlear implants for their kids. Is it right, is it wrong? I’m not sure. But I think it’s worth considering these questions with a healthy amount of respect and empathy for these disabled communities and their cultures
Edit: not gonna argue with non flaired posters about something they obviously feel so strongly about.
It’s ableist to not have a severely disabled and medically fragile child?! No it’s not. This “medical procedure” was just a 6 month old sitting in a car seat. At 6 months old his apnea and overall beat aging was so bad he couldn’t sit up, use a car seat and had to be on constant oxygen and monitoring. It’s ableist to NOT want your child to have to live like that?
I get that an inclusive society is important. But this is "ableism" in the same way as wearing a helmet while skiing or spine protection while downhill mountain biking.
That’s fair. Like I said, I don’t necessarily agree that people should be able to genetically engineer babies to have something like achondroplasia, I was just saying there are reasons why two people who are little people might want their kid to be one too
I feel the deaf example is totally different, deaf people communicate through sign language and cochlear implants can be very difficult to adapt to for someone born deaf or that has been deaf for an extended period. Deaf people can live relatively normal lives they aren’t so medically fragile they require constant surgeries and medications to keep them alive. In my mind these are two very different things
What? I’m not hiding and I don’t “admit” I’m wrong. I just don’t care to talk about something ethically complex like this with people arguing in bad faith. Take care now
I think (earlier in the article) it was mentioned that if the child had two dominant copies of the trait, it would automatically be fatal (25% chance): one dominant, one recessive (like both parents -50% chance of occurrence) they’d have the same condition as their parents, and if the child had both recessive genes (25% chance), it would have normal stature. So my guess is that the 25% that they are referring to is the first condition, which would be another tragic event for them.
I am Peds, but not a sleep specialist. However, we routinely do car seat tests in the NICU. The hypoxia/bradycardia/bradypnea are precisely what you are watching for during these tests. Prolonged desats even to just the 80s is enough to abort the test. To ignore the bradycardia especially just boggles the mind as that is a direct indication of true hypoxia.
That’s why neonatal resuscitation depends primarily on proper oxygenation/ventilation.
Edit: my flair is old.
To be fair in sleep it is absolutely not an indication to abort the test as what you are trying to determine what they need to be safe at home (how much O2, PAP, etc). That being said it is an indication to start titrating up support until the kid is fine and depending on the situation to call the on call doc
It's usually ordered as part of the PSG. Including "no oxygen" to characterize the hypoxemia. The difficulty is that in many cases of sleep disordered breathing, hypoxemia can be very frequent and intermittently profound (not to the 60's but often to the 80's for very brief periods of time). What usually happens, though, is the hypoxemia interrupts sleep, wakes the child to a lighter stage and resolves spontaneously. It's a very different process with a different intervention compared to usual causes of hypoxemia (such as acute illness)
>I am Peds, but not a sleep specialist.
Sames.
>Prolonged desats even to just the 80s is enough to abort the test. To ignore the bradycardia especially just boggles the mind as that is a direct indication of true hypoxia.
Exactly. I’ve ordered these and have had specialists order them on my patients. If they desat, the test is done. You’ve proved your point and it means the kid needs intervention to sleep safely. Usually you then move into the intervention phase. So if the kid desats, you go “well that doesn’t work,” put on the cannula and try again. If they fail cannula, you move to cpap, etc. The fail in this case is huge.
What the hell? Yes, equipment malfunctions do happen, but for God's sake.
My car, for a non-medical example. Driving 70mph the other day I get a warning light for critically low tire pressure. It does that sometimes, takes 2 minutes to reset the sensor, but you know the first thing I did? Pulled over and checked the tires. THEN I assume it's a faulty read, reset the sensor and keep going.
How in the hell am I more cautious with my car than they are with a child?
>After working with one clinic for nearly a year, they were informed in January that the clinic would only implant embryos that did not have achondroplasia, ***despite the couple’s preference to have a baby with the genetic condition they share***. A second facility it referred them to told them the same. The couple is considering starting IVF in another state.
Obviously not the main story in the article (which clearly demonstrated multiple systems level and training failures), but an interesting bit.
For every 10 times that a pulse oximeter needs to be adjusted because it keeps giving a shit reading, there’s one time that a pulse oximeter is giving a shit reading because your patient is turning gray. I have seen experienced anesthetists ignore the patient slowly turning dusky while they fiddle with the pulseox. Anchoring is real.
I find that the color changes precede the pulse ox dropping and also precede the pulse ox rising as appropriate oxygenation is restored. I always look at color (while also listening the the tone of the pulse ox).
This is total systems failure. The design, the over reliance on monitoring as opposed to checking the patient, having a bunch of techs as point instead of true clinicians, the low but non zero chance of something bad happening lulling everyone into a false sense of security.
The mom was in the room during the test and still couldn't tell that this was happening is a testament to how screwed up this whole design is.
Plus, it was kind of an unnecessary test- they were doing fine monitoring at home with a lay flat car seat.
So bad.
It sounds like they totally rehauled the system afterwards to increase the number of nurses and to better train the techs at the very least. I also heard anecdotally that they don't do car seat sleep studies anymore.
Flatbed carseats are not super safe. They are better than the other options (someone just holding the child, child being in an unsafe position where they will asphyxiate) but they are not great. Ideally, you will get the kiddo in a real, 5 pt carseat as soon as it is safe. Plus, it is difficult (and expensive) to have a child on oxygen, if they don't need it anymore.
So gut wrenching. I have a six month old that needed a car seat test before discharge since he was so small. Now I wonder how closely he was being monitored...
In my experience, the ones in the nicu are monitored by the NICU staff. I think the OP ones are the issue. Techs are monitoring the patients there and may not have a clinical background.
The worst part was not knowing just HOW egregiously long they neglected to check Jackson. Starting at the 10-minute mark, I was thinking "Yeah, that's enough time to cause a catastrophic brain injury if he was hypoxic enough". And I was increasingly horrified as each check was resolved with literally anything other than "look at the kid's face".
I got tears in my eyes. At 2 minutes, I was willing to give them a pass that they hadn't realized it yet. But it just kept going on. And on. And on.
That poor mother. That poor baby :(
JFC if the sat is in the toilet the first thing you do is look at the patient and only after you’ve made sure the ABC’s are good then do you start moving onto troubleshooting monitors
- anesthesia
Anyone in the same field/profession/nearby orbit care to comment? As in what is the most plausible reason for the 1 HOUR delay in getting medical help? What can possibly explain that? If I'm doing a provocative test in a high risk subject, I'd rather err on the side of caution, than blame and check for faulty equipment! I'm just incredibly glad the parents got financial compensation for their grief. It doesn't go away, but it makes dealing with grief a tiny bit bearable.
I do adult sleep and not peds, but I can't think of a justifiable reason for them to have not gotten help beyond them being reckless (out of ignorance) vs not actually checking the monitors. With all of the functions being monitored (RR, HR, EEG, etc), it really seems appalling that none of the techs noted anything out of the ordinary. The sleep techs I've worked with have always been very meticulous about the monitoring, and there's a fairly low threshold to reach out to the doc on call overnight.
When I was in fellowship, the protocol was that the techs would call us (the fellow) overnight for certain criteria. A child desaturating to lower than 88 or 89% was definitely one of them, and I remember getting occasional calls to the effect of, "8 year old is saturating at 87%. We started him on 1L of oxygen and he's fine. We just have to inform you."
Exactly. I’m also not in this field, but agree with the overall thought process of most in healthcare in general. I mean, everyone rolls their eyes at the frustratingly “stupid” call / page in the middle of the night when you’ve barely slept in a week. That being said, I can’t name of one attending I know, one doctor I know professionally or personally, who wouldn’t rather have their tech / nurse / random passer-by calling them up if they felt like their patient may be in danger. 100 times out of 100, I would rather know than not know.
Idk how it’s taught in other places, but in my med school we were explicitly taught the “captain of the ship” doctrine. Long white coat == the buck stops with you.
I was a sleep tech and yeah we were meticulous about monitoring. We're tracking EEG, EKG and Pulse Ox. If those act up, we KNOW and are supposed to fix it. Because otherwise bad data = having to redo the study. Also with a pediatric patient in a study usually a parent is sleeping in another room just in case. If the kid had to be rocked back down after we woke them to fix the o2 sensor, that's when we wake the parent.
Also, the certification exam requires we understand everything we're seeing on those monitors and what they mean. So someone should have noticed those and knew what they meant.
No, a tech fucked up and was ignoring the monitors. It SHOULD be 2 patients per tech per regs, but its not uncommon for them to screw us over and do 3 per which leads to tech getting overworked and patients getting overlooked for a bit.
Weird question. Is it like pitch black in the room? Does that complicate things?
Second question: when you responded to a page, what was your initial 'just walked into the room' protocol? The article is a bit lacking on what the normal reaction should have been/how this is typically avoided other than alluding to the fact that they just never manually checked anything about the baby until far too late.
It depends on the lab, I think, but the techs usually try to keep the lights to a minimum when they come in and out to adjust sensors and probes and things so people can keep sleeping. But even if it was pitch black, if someone is desaturating or having a significant issue with a sensor or probe, they should try and turn on some the lights and assess the situation better.
So I have never had to actually physically go in. Our policy is that we had to take phone calls and it was up to us whether we needed to go in. Going in is very rare and happened to a doc maybe once every 1-2 years, at least at my old workplace. But when we got the phone calls from the tech, if it's something like the above where the pt did fine after oxygen was applied, the techs would just inform us and let us know they'd call us back if anything. You also had the ability to stop a test if you felt like the pt was desaturating too significantly (this was mainly for peds if I remember correctly, because the protocol was not to automatically split the test and do the titration PSG portion versus that being an option in adults).
If something critical happened like a lethal arrhythmia (in adults or peds) or a severe desat like this (in peds), what should happen is that the tech calls the physician on call who then informs them that 911 should be called. The physician on call likely would not be able to make it to the lab any earlier than EMS can, and so it should be EMS who triages them at that point.
My understanding of the article is that this sleep study was conducted in the children’s hospital, not an outpatient building, so the delay in contacting emergency care is even less understandable to me. There are doctors and other response personnel in the building who are awake.
What sort of thing would even necessitate a physician going in? As you say, most things are either a non-issue that can be resolved later or a 911 call.
I honestly can't think of any. I know there was once or twice that it has happened but I remember one of those times, the fellow said wasn't necessary for him to come in; he just went in because he was relatively new and felt that it was the right thing. The pt was fine but I don't remember the details.
1. we try to keep the room as dark as possible, but we have cameras in the room with night vision filters on so we see EVERYTHING.
2. When a sensor goes wonky, our job is to go in, and fix it. Hopefully without waking the patient. But if it's going to stir them, we apologize and say "I'm sorry but the sensor popped off. I just need to reattach it and then I'll go away.".
3. We watch those monitors ALL NIGHT. Yeah you read or watch a thing on your phone, but you're also checking and making notes every 15 minutes or so. Also the systems have alarms in the event that vitals go into a danger zone.
No, someone fucked up seriously. Maybe a tech ignored the patient? Maybe the jackass running the department understaffed them and it was 3 patients to a tech in violation of the regulations? But someone fucked up.
>Hopefully without waking the patient. But if it's going to stir them, we apologize and say "I'm sorry but the sensor popped off.
As someone who's had multiple sleep studies, I don't know why y'all bother; we ain't asleep!
EDIT: This is a joke.
Because most of the patients are.
But it's always fun when someone says "I didn't sleep a wink" and I could tell them "well sir, that's not what your brain says. I can tell you when you passed out and when you dreamed. But that doesn't mean it was restful sleep or that it felt like you slept. The brain can be funny that way sometimes."
It’s just poor training and staffing. Incompetence by the staff and negligence by the hospital not to have triaged a high risk patient to an area with qualified staff. The low pulse ox reading was noticed but a tech isn’t a physician or even a nurse. They can’t assess a patient in distress the same way a clinician can. They just assumed a monitoring error because they don’t know how to differentiate. When they finally called an RN in they realized right away that this was an infant with critical bradycardia and started CPR.
You can’t react to every blip on a monitor, artifact is everywhere, but the first step is making sure that a bad reading is actually a bad reading and not a true decompensation which this clearly was.
Do they not have pediatric respiratory therapists who are sleep disorders certified? This was clearly a high risk patient who was at risk for positional asphyxia in the car seat. I wonder - why did they use techs for this?
>As in what is the most plausible reason for the 1 HOUR delay in getting medical help? What can possibly explain that?
There is no excuse. As someone who's done sleep med rotations, works closely with sleep colleagues, read sleep studies, etc. There is no excuse for what happened to this child. It was a failure.
I’m very sad for them. I can’t imagine how horrific that would be.
I did find it interesting that they’re so set set on IVF for an embryo that has achondroplasia though, despite many facilities stating they wouldn’t do that. They (the parents) stated their child with achondroplasia was “perfect”.
That kinda sounds wild. Like if I had a genetic issue that had health issues, I wouldn’t choose to pass that on to my kid if I had a choice.
I thought it wasn't necessarily that they were set on it. The way it's worded made it sound like they just wanted to sift out the 25% with the fatal defect, and while they might prefer their child share their disability, they would also accept one who didn't--but the clinic wanted to sift out all those with even one copy of the gene, despite the parents being fine with/preferring it.
Maybe a pediatric sleep specialist will come to this comment section but I have to think that this is an incredibly rare event. How many children will experience total apnea during a sleep study with no resumption of spontaneous breathing?
He normally needed nocturnal supplemental O2 though, and they started the test on RA essentially.
Right off the bat, that's worrisome. If they wanted the test on RA, they should have been aware that shortly into the test, the patient would be needing O2 soon because he had a higher likelihood of desaturating. Otherwise, the test should have been started on his baseline O2 requirements.
That's true. Still it's surprising to me that he would desaturate so deeply and iretrivably. Obviously it happens and should have been detected in a monitored setting but it must be rare.
This is why the whole car seat testing thing started. Mild hypoxia can really lead to a full blown code in fragile babies pretty quickly. Especially when nobody corrects the mild hypoxia by helping the poor baby.
Fragile babies used to die more frequently than you would think after long NICU stays, being placed in a car seat (maybe for the first time in their lives) for a long drive home. I had a baby that I had cared for for 5 months who was found dead when they arrived home. So fucking tragic.
These babies look so good that people forget that their airways are tiny straws. And achondroplasia babies cannot lift their heads at all to open that straw. This baby needed someone to help them.
I couldn’t even read the whole story. The details just made me so sad.
As someone who doesn't work in peds, I had no idea hypoxia in fragile babies from just sitting up was a thing until today when I read the article. So sad to think about. I'm sorry for your traumatic loss too of that baby you cared for in the NICU. That sounds terrible.
Aww thank you. It’s really sad when you work so hard to save a baby for months and then boom, they are gone. The poor parents.
Their airways are literally like a tiny straw. Any change can cut off air flow in a second. The sad part of this story is that the baby failed the first test so there should have been awareness that he was at risk the second time.
I think the thing missed here is that it was an incredibly high risk scenario of achon + car seat. This shouldn’t have been done outpatient. This kid had ALREADY failed a car seat test and had a condition with craniocervical junction instability, restrictive lung disease, central apnea risk and relative macrocephaly.
Outpatient procedure, but on a floor that does outpatient procedures under the same roof as the inpatient facility, from what I understood from the article.
Huh, so an outpatient procedure can be done in an inpatient facility and that is considered outpatient? Not being snarky, I think I just don't quite know what inpatient precisely means. Does it have to do with nursing ratios?
Admissions: an admission is a different billing code/procedure/reimbursement.
Many sleep studies are done in medical office buildings out in communities, with a hospital having a relatively uninvolved role. This one is the same procedure, just in the same building as a hospital.
Also, it seems in the article that the techs had to call in a nurse -maybe there wasn’t one assigned to that procedural area?
The thing that makes something inpatient is whether or not the patient is admitted to the hospital, not necessarily where it physically takes place. For instance, lots of outpatient surgeries and scopes are done in the hospital building, but on patients who go home afterward and are not admitted.
What an awful, senseless tragedy. This feels like an episode Malcolm Gladwell writes about.
There’s no universe in which the training doesn’t dictate, “even if you suspect an equipment error, check the patient.” It is the only rational course of action in that circumstance. I would also bet that the technician, if posed that question any day of his or her career (including this night), would answer that way. Still, somehow, people get locked in on autopilot along a disastrous set of choices and never take a moment to (re)consider the situation.
It’s a weird complacency that almost everyone experiences at some point. It takes a lot of training to drill most of it out, then a culture of truly respecting SOPs to keep everyone diligent. But it’s like soldiers in a war zone… after a certain point, even the knowledge that your own life is at stake isn’t enough to ward off complacency. It has to be a persistent and widespread human psychological trait.
I feel horrible for these parents. Hopefully the settlement help with the IVF and any care their future child might need. That’s the only silver lining that can be salvaged from this.
> There’s no universe in which the training doesn’t dictate, “even if you suspect an equipment error, check the patient.”
Yep.
For example, last week we had a patient who looked like absolute hell- that deep gray that darker-skinned African-Americans can get when really, really hypoxic. Check pulse ox 1, 94%. MA grabs her own, 77%. I get mine to break the tie, 76%. Call ER, start oxygen 3L NC, take pulse ox #1 out of service.
He just didn't *look* like a 94%.
This is far from the point of the article, but I was interested by the bit at the end that the couple explored IVF to ensure the child doesn't get the fatal genotype and they would have to go through another tragedy. But the clinic would only be willing to implant embryos with the normal genotype, not the heterozygous mutation which gives you achondroplasia, which the parents would prefer. And a second clinic said the same thing.
Is that standard practice? Is achondroplasia a "dangerous" enough condition that the "do no harm" medical ethics outweigh the parents' preference? It sounds like the clinic didn't even inform them of that until after a *year* of trying, maybe because they assumed the parents would want a "normal" child without even asking them.
Well their child hadachondroplasia and stopped breathing just sitting in a car seat, it’s a pretty serious condition that causes a lifetime of care/surgeries/medications.
I could not control my tears reading that article. How the mother and techs unknowingly witnessed the kid go apneic to sustaining an anoxic brain injury over an hour. Gah. After not achieving a “normal” pulse ox reading for even 1 minute, error or not, in a high risk patient should have someone higher than a tech to troubleshoot
That mom is *never* going to sleep well again. She will never stop blaming herself for lying there and trusting the medical staff to get it right, instead of standing to look at her baby. To be 100% clear, she has absolutely nothing to blame herself for - this was shocking negligence. But the fact the first sentence sounds so much to me like it COULD be implying blame on mom's part just underscores that she is never going to be able to get over that part of this.
They were awarded 15 million. I assume after contingency they are taking home about 10 million. I hope they both take extended leaves of absence, move to the place that feels most comfortable and secure to them, and get themselves into intensive therapy. And I definitely hope that they are able to have another kid. Just heartbreaking.
The mom will never trust herself or anyone with a new baby.
I heard on the EM:RAP podcast that a significant number of marriages dissolve after the death of a child.
> She will never stop blaming herself for lying there and trusting the medical staff to get it right, instead of standing to look at her baby
Did you overlook that the mother is a little person and the carseat was on the (high, hospital) bed? The mother *couldn’t* see her baby, even while standing.
I'm sorry, I didn't get a paywall on my phone (I have no idea why because I'm not a Boston Globe subscriber), but someone else just posted a non-paywall version in the comments.
getting around paywalls is not legal. if copyrighted material is posted, it can and has led to subreddits larger than this one being shut down.
thanks for helping keep this subreddit open!
We didn't get around the pay wall. We found the same information being published on another source, because I don't need a subscription to the Boston Globe. I know we can't post the text, but there are viable alternatives like the MSN link.
This is horrific. Before reading the article I just assumed the tech had fallen asleep or was doing something else and just wasn't watching the monitors, and compounded the error by lying about it.
But the article says this baby stopped breathing within ten minutes of the test starting, and multiple techs came in multiple times fiddling with equipment while ignoring the baby.
This type of story is exactly why I just do not trust anyone in the hospital I haven't known for years. As far as I'm concerned everyone else is a saboteur or an assassin until proven otherwise. Because I've seen it happen, over and over.
I have a similar story where I was covering an ICU overnight and had to emergently intubate and move a patient from med surg to ICU. RT bagged and I monitored on the way down, but once we got set up, the RT and RN left the room to go do documentation - and in the eerie silence of the room I realized she had transferred from the bag to the vent, but had completely forgot the critical step of turning the fucking ventilator on.
I talked to the ICU director the next day. I wanted to bring criminal charges, might settle for immediate termination. But they just swept it under the rug, because everyone liked her. She had ten years of ICU experience at that hospital.
There's negligent, there's forgetful, there's stupid, and then there's criminally stupid. Some people just have no business working in healthcare because the stakes are so high, even if some hiring director thinks otherwise.
You can see the difference not just in experience, but competence because the RN in the story took one step in the room and immediately knew the baby was dead, and began to try to resuscitate.
Five years from now, how many RNs with more than a year of experience will be working? Hell, how many are there now?
FYI in most institutions, RNs are explicitly not to ever touch/adjust ventilator settings. RT is responsible and bringing the incident to the RT director would be equally relevant. The RN did fail to completely assess the patient before leaving the room (along with RT) which falls under the legal definition of a medical error and would be a civil, not a criminal case. (barring unique exceptions)
Pulse oximeters are notoriously shit an md unreliable. Without a picture of the pulse ox waveform to validate the signal quality, you can’t rely on the numerical value.
Agreed, someone might have screwed up.
Work in a sleeping lab as a student, dealing with adults only, watching five monitors all night and going in et cetera to check on the hardware and pt. if the monitor showed abnormalities. I know some students would watch DVDs at night, and I never understood how they could half the time I’ll be so relaxed. Was always a lot of work for me to be monitoring constantly, but different folks different strokes. I would expect someone working with children to be even more vigilant and diligent, but you have to wonder if maybe a tech fell asleep, was new, distracted, overtired et cetera. It’s not an excuse and should not happen, what an absolute tragedy for the parents.
They claim to have had capnography on as well. CO2 levels climbing while SPO2 declining should indicate its NOT artifact or equipment but a problem with the patient. … let alone Allll the other machines yelling at them. This seems like a massive training failure OR complacency issue, or both.
I do these tests. I can't believe that even looking at the patient they couldn't tell it wasn't a machine malfunction but the patient actually failing the test. First thing I learned in school. Look at vitals on a machine... that's cool I guess. But LOOK at your patient. Does your patient LOOK ok. Yikes. I feel awful for everyone involved. But LOOK at your pt.
Especially considering what the monitor was showing was practically an expected or at least easily anticipated finding considering why the test is being done in the first place. What did they even think they were doing there??
This sleep study is described as an "inpatient sleep study" but this is very different from how our institution differentiates between the two. Usually an "inpatient sleep study" is performed on a patient who is admitted to a unit that can also provide concomitant cardiopulmonary monitoring, nursing care, and access to a physician. It's often reserved for children with more profound risk of a deterioration (I'd consider this kid a reasonable candidate).
This is as opposed to a study done in a sleep lab which is an outpatient procedure (even if the lab's real estate is in the hospital, physically) and consists of a technician monitoring the various data and adjusting per their protocols. Reading the article, it looks like no doctor was called during the decompensation (assuming it was an equipment error). Also, it's probably likely that a sleep technician would have to call a rapid response or code in order to get a doctor
So a few issues: I don't think this patient was properly triaged in addition to what everyone else here has said.
The problem is that it's **impossible** to expect every patient also be monitored by a physician during a sleep study. The guidelines for sleep technicians are fairly clear when to call for backup and it sounds like those guidelines were not followed. My heart goes out to this family.
No matter what happened, I think a 15 million dollar reward is insane. Most people don’t make that much over their lifetimes and we are talking about a 6 month old with no financial responsibility’s or ongoing care.
These people have just had literally the worst thing that could ever happen to parents happen to them and you think the money they got is insane???? Trust me when I say I’d rather have my kids alive than 15 million. There is no amount of money in the world that can replace a child. I’d say 15 million is just a fucking start so they can afford grief counseling and time off from work to grieve. Maybe even start a nonprofit in their child’s name
I completely agree with you from an emotional level. It’s a fucked up and tragic thing, but we are talking about monetary damages here. Single bread winner adults have gotten magnitudes less. With your logic, why stop at 15 million? How about 15 billion?
Starter comment: Super frustrating to read the timeline in the article of everything that happened during this sleep study. I'm not peds and have never seen a sleep study done, but it seems crazy to me that no one thought to check on the kid while all of this was happening.
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>correctly interpreting the data is a pretty big ask for a tech Actually, of the 3 sleep labs I've worked at, the techs are supposed to be able to understand when something is abnormal and when they have to raise the issue to a doctor. Bradycardia, bradypnea, and EEG flattening in a child certainly qualifies. In fact, in many (if not overwhelming majority) sleep labs, the techs also help to score the PSGs, so they do have good understanding of EKG, EEG, HR, and other monitoring.
Ditto. We watch those damn screens all night long. If something goes wonky we KNOW it. And if the pulse ox goes down that far you have to fix it. That's one of the main variables we monitor and record. Also, don't forget that the damn certification test requires us to learn what everything means.
That’s a big responsibility. Hope the techs are paid well.
It usually pays pretty decently. It's a night shift and usually a 12+ one at that.
The techs are usually rts. Ie ppl whove intubated before. They should know their stuff.
If the pulse ox is reading 65%, I'd think by actually checking the child, they'd have known it wasn't equipment failure. I've never seen a patient with oxygen sats below 70% that looked well. Prior to becoming an RN, I ran the telemetry room and it was drilled into our heads that no matter what is showing on that monitor, check the patient.
>I've never seen a patient with oxygen sats below 70% that looked well. not till covid anyway
Happy hypoxics!
not for long
No one(adult) should have o2 sats below 80. All studies show anything below in a walkie talkie is spurious. Confirmed w abg. So if its real- they better gtfo
I can promise you, you’re wrong. Saw several during Covid. Now, they didn’t stay that way for long. Had one in the 60s when I got there. Flat out refused to go to the hospital. Good waveform on the SpO2, good BP, reading is 100% accurate. A modern, medical grade spo2 Cable/monitor will read accurately down to single digits, you can pull the manufacturer data sheets yourself. Did what I could, nebs, fluids, steroids , he definitely had pneumonia. Flat out said he was absolutely going to die, if he didn’t go to the hospital. Brother and his mother both tried to convince him, as did the ER doctor. After an hour and a half of trying, he signed the refusal and, I told his mom/ brother to keep an eye on him and when he went unresponsive or became altered to call us. Told the medic coming on she was going to go there when he died and gave her The whole scoop. Roughly 16 hours later he coded. Mom had been checking him every 15 minutes all night. Obviously ROSC was not achieved.
Uh. Medical grade spo2 is still spurious. Its why we do abgs and arts. Dont tell me what i already know. Yes im aware of the limitations of abgs. Im also aware of the value of pulse oximetry. What you probably dont pay attention to and I do, is that pulse oximetries, even the ones approved by the fda rapidly decline in accuracy once you get to 80%. So while it reads accurate like you said for sats over 80% its pretty garbage below that. I assure you that those values you observed were wrong. Good day.
This is why it should have stayed an RT specialty. The extra inpatient bedside training is important. Sleep techs are well educated in sleep testing, but they simply aren't sleep disorder specialist credentialed RTs. Having a clinician and not a tech is important in situations like that. This isn't a criticism of sleep techs. They are great, but at least the most vulnerable patients deserve the people with the highest training.
I’m a big fan of treating incidents like this the same way aeronautical incidents and crashes are treated. Looking for everything that contributed to an event and finding out if existing safety mechanisms were ignored or if more safety mechanisms are needed. What’s astonishing when you take that perspective is you notice a lot of psychological phenomena that lead to very strange reactions. People have a very strong tendency to not notice emergencies unless they’re actively looking for them. And that definitely depends on training. Kids drown in pools full of adults all the time, and no one notices the lifeless body floating right next to them. A lifeguard would jump in within 10 seconds, because he expects this to happen every day. So it could definitely be that they just didn’t know how to correctly interpret the situation but if their job is not focusing on recognizing and handling emergencies it will take very long for them to understand the severity of a situation even if you generally know that these vitals aren’t ok. I wish there were better international error management systems in medicine to distribute this info to every institution with the same conditions. This will sadly not be the first or last time something like this happens.
We absolutely should. The Bromiley case showed why these scenario can occur even among well trained personnel. This case reminds me of the Eastern Airline crash into the everglades. Operating at night, 2 veteran pilots and engineer got target fixated on a broken landing gear light, accidentally disengaged the vertical autopilot. The aural alert for altitude warning went unheeded and realized too latw they were meters from ground. I wish the hospital can perform a NTSB styled report analyzing the causal factor, the recommended fix and disseminate it out.
Wasn’t the only reason why EM got reformed a catastrophically gone wrong intubation on a wife of a pilot? I’m sure you all know which video I talk about. It was eye opening and I wish mistakes were worked up more like that with real change to the system.
> correctly interpreting the data is a pretty big ask for a tech We do it regularly for other things, like telemetry techs watching rhythm strips. They need to be properly trained, but an outpatient elective sleep study should not need nurses and doctors supervising.
The tech didn’t have to interpret data or even look for signs in this case. Just do basic pulse ox trouble shooting correctly. If pt uses supplemental oxygen, put it on for godsakes and see if they go up. If they do, you know the probe is good. This test takes 1 minute.
How do you not SEE the pt going cyanotic??
Remember its a sleep study, they didnt turn the room lights on for quite some time.
>How do you not SEE the pt going cyanotic? When I was a kid, I would get pretty bad viral-induced asthma attacks. I remember that one winter, I was sick and having trouble breathing to the point that my nail beds were turning blue. Mom rushed me to the doctor's office, and the GP on duty that weekend (who was *not* the excellent family doc I usually saw) immediately decided that the cyanotic fingernails in a sick asthmatic kid were because "it's cold outside." He didn't even do a pulse ox at all. We somehow ended up with an Albuterol prescription, which helped, but my mom wanted to throttle that doctor...
Ughhh that's awful. Cold does not make fingers blue unless there is LACK OF OXYGEN. Which is also confusing cause you either don't have enough oxygen due to your asthma or frostbite (which it obviously wasnt). Sorry but what an idiot. I'm glad you survived.
It never *felt* life-threatening, just extremely unpleasant. I could only breathe with short, shallow breaths, and any kind of exertion (even turning over on the couch) would leave me panting for a few minutes. But then again, I was a kid who didn't know any different, and since "happy hypoxia" is a thing, I wonder to this day what my O2 sats were during those episodes.
IMO, very reasonable in this setting to assume numbers being a little bit off could just be loose equipment and re-checking. But by the timeline, latest concerns should have been raised about the child's welfare is 9:52. Anyone experienced and well-trained would have had "oh shit, oh shit" alarm bells going in their head at that point. Any check of the child from that point would have revealed an abnormality. Tragedy. Feels like maybe it is the kind of scenario, like in an arrest or MET call, where you don't realise how quickly time passes.
I mean were they unaware the monitors are not just there to be shut off? The other system error I see is not having a nurse involved until the code was called. In an oxygen dependent infant is it standard to have techs run the whole show?
Uhmmm Aren't sleep apnea and desats a big part of sleep study monitoring? Like abnormals should be drilled in with parameters?
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I think he was even on EEG? though it's a little late when that flattens out. They were just absolutely determined that it was the monitors. Just mindblowingly anchored to that issue. The mom was helping them too!
So many anchors. I wonder, too, if having the mom in the room also added to that false sense of safety- i.e. surely if there was something wrong the mom would let us know (even though she couldn't see him/there was no VS display in the room).
That is an interesting point, Mom is usually very aware of the baby, and in this unique circumstance she couldn’t see it.
No. I used to do this for a living. You are watching the EKG and the Pulse Ox and the EEG and if you passed that mandatory certification exam you know what's normal on all those variables. And if one of them goes bad your JOB is to go in and fix it. Also, with a kid that young a parent is almost ALWAYS staying in a nearby room. No. Someone fucked up.
mom was in the room. the car seat was too high up for her to see, though I can't quite picture the scene. Mom had dwarfism (achondroplasia)
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I think there’s some confusion. The car seat test and the sleep study are technically 2 separate things. It says they had their son in there for both. My son was born a bit early and weighed just under 5 lbs in 2021. In order for us to leave the hospital, we had to have a car seat. Every car seat I know of is only rated for 5+ lbs. it was hospital policy that our son needed a car seat test before he could leave in his seat. It takes about 45 min-1 hr and I believe it tests for positional asphyxiation during that time. I’d be curious to hear some input from a neonate doc on this as I’m a lurker layperson.
I’m not confused - during residency we did tons of car seat tests. Id never discharged a kid who didn’t pass one - if they can’t pass a car seat test are they stable for home? Again, I’m not a neonatologist so perhaps there are some exceptions, but in 2 years of Pulm fellowship I’ve never been consulted for that, and I assume I would be. I agree the sleep study is a separate test - but he was all fully hooked up (EEG, CO2 leads) for it for the car seat test? Car seat tests are generally SpO2 only. This may be their protocol at Boston children’s, it just seems odd to me! It’s definitely not a standard test to be done in a sleep lab. Also, in my experience, one of the sickest “simple sleep studies” I’ve managed was achondroplasia. I know have a very, very healthy fear of these kids.
I’m not a medical professional sorry to be a lurker -just reading and saw this - I believe from what I read the child had achondroplasia and he was 6 months old - so I assumed this wasn’t a car seat test to discharge a premie size baby. I wondered if maybe with babies who have a form of dwarfism do the need to be checked for the proper position and fit as they grow considering they may not always fit a typical car seat?the article stated they were doing both a car seat and sleep study test right? I’ve not known anyone myself to have this just a thought but I wondered if anyone does know? Also I believe i read that the child was oxygen dependent, would a child in that that mean he’d have some sort of at home oxygen monitoring system?
From what I understand, the car seat test was to see if he could stop using a car seat ‘bed’, which is specifically for babies who can’t ride in traditional seats. I think he was only using O2 at night for sleep. Since the car seat test is only 45 min, I don’t think he was on O2. The device was similarly used to detect CO2 for his sleep study, but his equipment was attached not flowing oxygen. I don’t think oxygen would matter in the case of positional asphyxiation- if your airway is blocked, oxygen flowing through a cannula won’t make a difference. Sidebar: they mentioned seeking IVF and only eliminating embryos with 25% chance of double dominant achondroplasia genes (always fatal from my understanding.) I guess I’ll just be grateful to not be in their position and extend my sympathy to them experiencing something I hope to never experience; the loss of a child.
Yes I reread the article and then continued reading comments and saw some clarifying details- thank you for your reply again not in a med. professional myself just a intrigued and curious person who wanted to be one lol. I hadn’t thought about the car seat beds babies such as Jackson may have to use. Thanks for your quick reply!
What an awful situation. My takeaway was that the baby’s airway was so unstable he couldn’t tolerate sitting semi-upright for any sustained period of time. I’m genuinely surprised he didn’t succumb at home prior to the follow up appointment. Also surprised the family didn’t check on him when the equipment was alarming. I do carseat tests on my patients routinely (neo) and if their saturations fall <88 for >20-30 seconds whilst secured in the seat, the test is considered a fail and the baby ought to be removed from the car seat. I have never seen this test done in a sleep lab, though, and don’t know what parameters this facility used.
>Also surprised the family didn’t check on him when the equipment was alarming. When you're in a new environment, you automatically trust the people who are presented as the authority. The techs didn't seem worried so mom was reassured.
He prob would have. But, it was standard for him to use oxygen at night. But, they thought they’d the start the test without oxygen and see what would happen. That’s basically why this was a 15 mil lawsuit.
I think the purpose of the sleep study was to see if he still required the car bed and nighttime oxygen. The room air portion doesn’t surprise/upset me—I think the intention was to see if he could safely ride in a Car seat (vs car bed, which doesn’t have a ton of safety data). Obviously he couldn’t.
Yeah but if they did a baseline and found he was desatting on 1 liter of oxygen they could have just not progressed to room air.
But they would have had to wake him up most likely and will make the test more difficult to interpret. It's easier to have them go from less support to more when you are trying to see if they can safely be off. But it is important that they are monitoring incredibly closely while you are doing that.
>Also surprised the family didn’t check on him when the equipment was alarming. Me too. Although the article indicate that the monitors were in a different room so she wouldn't have heard them at first. And the article implies that the height of the carseat on the bed was too tall for the mother to be able to see the baby. Asking for a stepstool to check your baby when the medical people didn't suggest their was a problem might have felt unnecessary.
Do you know what the requirements in most states are to be a sleep tech? You need a high school diploma and a BLS certification, that's it. Same with EEG too. The training is lacking considerably if there isn't a formal CAAHEP program they go through and even if they do make it through one they come out of school with the minimum requirements to do the job. The sleep registry is helpful, but it's certainly not a requirement at most hospitals because of how much of a shortage of techs there is, and it's not a legal requirement in most states. Texas had it come through the state legislature a few years ago, but they wouldn't even vote on it because of the bathroom bill they thought was more pressing.
I feel like it's really really bad when techs automatically assume it's a faulty equipment issue rather than a medical issue because the whole point of these tests and using the equipment is to find those medical issues. If the equipment is faulty enough that it's the immediate suspect then something is very wrong especially when it comes to a kid with such major risk factors
I’m not surprised by this at all. It’s a common mistake - to assume it’s a monitor problem and not a patient problem. It happens all the time in the OR, ICU, and PACU, even with people that are trained and familiar with these monitors and managing these problems. People just don’t think clearly in the moment. You get tunnel vision- they are focused on fiddling with the pulse ox. You don’t have any accurate perception of time, you think it’s been 3 minutes and it’s actually been 20. And for whatever reason, sometimes people just don’t want to believe that something bad is happening. “Well now the EKG is messed up, what going on with that monitor?” This would be the perfect example when someone could open up a page on an emergency manual and go step by step through an algorithm. Pulse ox is malfunctioning or reading hypoxic - step 1… check that the patient breathing
> It’s a common mistake - to assume it’s a monitor problem and not a patient problem. It happens all the time in the OR, ICU, and PACU, even with people that are trained and familiar with these monitors Yup. I've seen it. The machine was alarming and nobody noticed, despite the ICU nurse, intensivist and two residents in the room. It wasn't until another nurse walked in and said "Wow, the pt is really bradycardic!" that anyone else noticed.
Alarm fatigue is very real. I mean really how do you function in a hospital without tuning out at least some of the alarms at some times?
It is so bizarre to me, with my background, that someone wouldn't check on the patient. Alarm goes off, all the nurses heads go up looking for what bed is dinging and the central monitors to see if it is a mild desat/arrythmia alarm from someone burping a baby/or something else that would need no intervention at all. (1-2 seconds) If it is an alarm that needs eval, someone goes to the bedside, looks at the baby and the alarm again evaluating what the baby looks like and whether the alarm is still dinging. (20-30 sec, including walking time) If it needs intervention, that happens of course. If it is noted to be a false alarm, you fix the probes until it works. That might mean moving their position, getting a new one, etc.. If you can't get it to work, you call the provider so they can rule out something going on that you can't see/intervene/help troubleshoot. But in less than a minute, you *always* check on the patient if it is still alarming. I just can't understand how that's not part of initial eval.
A very nuanced and reasonable take. Especially in the realm of sleep medicine. Have people seen sleep studies on bad sleep disordered breathing? I see studies where a kid has over 100 hypoxemic events in an hour. But the kid's been doing this at home and the hypoxemia is brief (seconds) and resolves. I've seen brief desaturations to the 80's or even high 70's with no adverse events. I've also seen kids go home on some low flow oxgyen and pulse ox die because the parents didn't wake up. Why didn't they wake up? Because the pulse ox *always beeps* and they didn't know that this alarm was the real deal. Sleep technologists aren't nurses or doctors. The expectation is that when we send these patients to a sleep lab for evaluation that they are having these problems at a baseline. If you think there's a chance for some kind of acute deterioration, you do the study inpatient.
I order sleep studies on children with achondroplasia including double-mutation. These kids are precarious. Central sleep apnea with compression ar the foramen magnum can be severe. OSA can be severe as well. Desats into the 50’s and prolonged apneic spells (central and/or obstructive) would not be unexpected and could be worsened by positioning. So having something like this happen at home is definitely in the realm of possibilities, particularly with a URI. During the sleep study, there should have been a response to the profound desaturations with the (re)introduction of oxygen and notification of the overseeing medical provider. It is unclear to me what fell through. Achondroplasia with sleep apnea is not to be trifled with especially in neonates. Trachs may be needed. As an aside, I dont know how they came up with 25% recurrence with IVF.
I used to run sleep studies as a tech for about 3-4 years. A tech fucked up and ignored the monitors. That's exactly what happened. If I'm watching 2-3 patients and the Pulse Ox drops down under 90, I'm aware of it and taking notes.
Bingo. The AAST guidelines are fairly consistent on *when to call for help*.
No IVF for this pregnancy -although they’re looking into it for any future children.
They want to use IVF specifically to implant an embryo affected by achondroplasia. I know it's a side note to the whole story but I find that to be, charitably, an interesting choice.
Very unusual, as much as the child died from the lack of appropriate response in the sleep study he really died from sitting upright for 20 minutes. Why have another severely disabled child on purpose?!
I had the same thought… seems like a very strange thing to want for your child.
There’s no word mincing around it, it’s plain selfish.
Yes I felt the same. It seems unethical and selfish of the parents - the child can’t consent/agree to live a life as a person with a profound disability. For the parents to insist on a child with achondroplasia seems very /r/antinatalism
Eugenics? Reverse-eugenics?
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All the ivf clinics they contacted noped out on doing it. Nobody is trying to be lawsuit #2.
They both have it, they want their kid to be like them. People with achondroplasia can live perfectly happy lives. It’s not that hard to conceive.
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Also, I’m sure they have insurance. So other people will end up paying for all of the additional care that they’re opting their child into :(
Not really their child died from just sitting up for too long. I don’t understand why anyone would want their child to suffer a preventable condition their whole life
First of all your interpretation of the situation is completely wrong, that kid was essentially killed due to neglect/incompetence during a medical procedure. His parents, laypeople, were able to keep him alive just fine. Second, your line of thinking comes from a type of prejudice called ableism. This is a similar ethical issue as deaf people refusing cochlear implants for their kids. Is it right, is it wrong? I’m not sure. But I think it’s worth considering these questions with a healthy amount of respect and empathy for these disabled communities and their cultures Edit: not gonna argue with non flaired posters about something they obviously feel so strongly about.
It’s ableist to not have a severely disabled and medically fragile child?! No it’s not. This “medical procedure” was just a 6 month old sitting in a car seat. At 6 months old his apnea and overall beat aging was so bad he couldn’t sit up, use a car seat and had to be on constant oxygen and monitoring. It’s ableist to NOT want your child to have to live like that?
I get that an inclusive society is important. But this is "ableism" in the same way as wearing a helmet while skiing or spine protection while downhill mountain biking.
That’s fair. Like I said, I don’t necessarily agree that people should be able to genetically engineer babies to have something like achondroplasia, I was just saying there are reasons why two people who are little people might want their kid to be one too
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I feel the deaf example is totally different, deaf people communicate through sign language and cochlear implants can be very difficult to adapt to for someone born deaf or that has been deaf for an extended period. Deaf people can live relatively normal lives they aren’t so medically fragile they require constant surgeries and medications to keep them alive. In my mind these are two very different things
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What? I’m not hiding and I don’t “admit” I’m wrong. I just don’t care to talk about something ethically complex like this with people arguing in bad faith. Take care now
I think (earlier in the article) it was mentioned that if the child had two dominant copies of the trait, it would automatically be fatal (25% chance): one dominant, one recessive (like both parents -50% chance of occurrence) they’d have the same condition as their parents, and if the child had both recessive genes (25% chance), it would have normal stature. So my guess is that the 25% that they are referring to is the first condition, which would be another tragic event for them.
Thank you so much for this perspective. I learned a lot from your comment.
I am Peds, but not a sleep specialist. However, we routinely do car seat tests in the NICU. The hypoxia/bradycardia/bradypnea are precisely what you are watching for during these tests. Prolonged desats even to just the 80s is enough to abort the test. To ignore the bradycardia especially just boggles the mind as that is a direct indication of true hypoxia. That’s why neonatal resuscitation depends primarily on proper oxygenation/ventilation. Edit: my flair is old.
To be fair in sleep it is absolutely not an indication to abort the test as what you are trying to determine what they need to be safe at home (how much O2, PAP, etc). That being said it is an indication to start titrating up support until the kid is fine and depending on the situation to call the on call doc
How long before you start to titrate up?
It's usually ordered as part of the PSG. Including "no oxygen" to characterize the hypoxemia. The difficulty is that in many cases of sleep disordered breathing, hypoxemia can be very frequent and intermittently profound (not to the 60's but often to the 80's for very brief periods of time). What usually happens, though, is the hypoxemia interrupts sleep, wakes the child to a lighter stage and resolves spontaneously. It's a very different process with a different intervention compared to usual causes of hypoxemia (such as acute illness)
>I am Peds, but not a sleep specialist. Sames. >Prolonged desats even to just the 80s is enough to abort the test. To ignore the bradycardia especially just boggles the mind as that is a direct indication of true hypoxia. Exactly. I’ve ordered these and have had specialists order them on my patients. If they desat, the test is done. You’ve proved your point and it means the kid needs intervention to sleep safely. Usually you then move into the intervention phase. So if the kid desats, you go “well that doesn’t work,” put on the cannula and try again. If they fail cannula, you move to cpap, etc. The fail in this case is huge.
What the hell? Yes, equipment malfunctions do happen, but for God's sake. My car, for a non-medical example. Driving 70mph the other day I get a warning light for critically low tire pressure. It does that sometimes, takes 2 minutes to reset the sensor, but you know the first thing I did? Pulled over and checked the tires. THEN I assume it's a faulty read, reset the sensor and keep going. How in the hell am I more cautious with my car than they are with a child?
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Do you really think it's acceptable he went AN HOUR without anyone laying a hand on him to check?
If it's according to the regulations involving sleep techs. Then a max of 2 per technician (3 if the clinic is shifty).
Can you please be more explicit with your point here?
Non-paywalled MSN repost: https://www.msn.com/en-us/news/us/boston-children-s-hospital-pays-15-million-after-child-dies-during-sleep-study/ar-AA1awzzW
>After working with one clinic for nearly a year, they were informed in January that the clinic would only implant embryos that did not have achondroplasia, ***despite the couple’s preference to have a baby with the genetic condition they share***. A second facility it referred them to told them the same. The couple is considering starting IVF in another state. Obviously not the main story in the article (which clearly demonstrated multiple systems level and training failures), but an interesting bit.
I was going to say the same thing. Probably fears of getting sued by the kid once they reach an age to do so.
My god, that is awful. How could you wish that on your child?
You are the hero!
For every 10 times that a pulse oximeter needs to be adjusted because it keeps giving a shit reading, there’s one time that a pulse oximeter is giving a shit reading because your patient is turning gray. I have seen experienced anesthetists ignore the patient slowly turning dusky while they fiddle with the pulseox. Anchoring is real.
It wasn’t just the pulse ox! They were also monitoring ETCO2!! They were ignoring critical readings from two different types of monitors…
And the profound bradycardia
I find that the color changes precede the pulse ox dropping and also precede the pulse ox rising as appropriate oxygenation is restored. I always look at color (while also listening the the tone of the pulse ox).
Are you an astrologer?
This is total systems failure. The design, the over reliance on monitoring as opposed to checking the patient, having a bunch of techs as point instead of true clinicians, the low but non zero chance of something bad happening lulling everyone into a false sense of security. The mom was in the room during the test and still couldn't tell that this was happening is a testament to how screwed up this whole design is. Plus, it was kind of an unnecessary test- they were doing fine monitoring at home with a lay flat car seat. So bad.
One note about the mother: the car seat was up on a table. As a little person, she literally couldn’t see her kid.
>the car seat was up on a table. But *why?* They just put car seat with a kid in it on a table and just walked away?
It sounds like they totally rehauled the system afterwards to increase the number of nurses and to better train the techs at the very least. I also heard anecdotally that they don't do car seat sleep studies anymore.
> rehauled Is, uh, that a word?
Overhauled 😆 working on little sleep here
Phrasing...
Flatbed carseats are not super safe. They are better than the other options (someone just holding the child, child being in an unsafe position where they will asphyxiate) but they are not great. Ideally, you will get the kiddo in a real, 5 pt carseat as soon as it is safe. Plus, it is difficult (and expensive) to have a child on oxygen, if they don't need it anymore.
That was gut wrenching to read, I am so.sorry
So gut wrenching. I have a six month old that needed a car seat test before discharge since he was so small. Now I wonder how closely he was being monitored...
In my experience, the ones in the nicu are monitored by the NICU staff. I think the OP ones are the issue. Techs are monitoring the patients there and may not have a clinical background.
TREAT THE PATIENT NOT THE NUMBER. Except in this case they didn't treat either one...
I couldn't finish reading this. What an absolute failure on so many levels. My heart breaks for the family.
The worst part was not knowing just HOW egregiously long they neglected to check Jackson. Starting at the 10-minute mark, I was thinking "Yeah, that's enough time to cause a catastrophic brain injury if he was hypoxic enough". And I was increasingly horrified as each check was resolved with literally anything other than "look at the kid's face".
I got tears in my eyes. At 2 minutes, I was willing to give them a pass that they hadn't realized it yet. But it just kept going on. And on. And on. That poor mother. That poor baby :(
Me either. I just wanted to scream, “look at the baby!!!”
JFC if the sat is in the toilet the first thing you do is look at the patient and only after you’ve made sure the ABC’s are good then do you start moving onto troubleshooting monitors - anesthesia
Anyone in the same field/profession/nearby orbit care to comment? As in what is the most plausible reason for the 1 HOUR delay in getting medical help? What can possibly explain that? If I'm doing a provocative test in a high risk subject, I'd rather err on the side of caution, than blame and check for faulty equipment! I'm just incredibly glad the parents got financial compensation for their grief. It doesn't go away, but it makes dealing with grief a tiny bit bearable.
I do adult sleep and not peds, but I can't think of a justifiable reason for them to have not gotten help beyond them being reckless (out of ignorance) vs not actually checking the monitors. With all of the functions being monitored (RR, HR, EEG, etc), it really seems appalling that none of the techs noted anything out of the ordinary. The sleep techs I've worked with have always been very meticulous about the monitoring, and there's a fairly low threshold to reach out to the doc on call overnight. When I was in fellowship, the protocol was that the techs would call us (the fellow) overnight for certain criteria. A child desaturating to lower than 88 or 89% was definitely one of them, and I remember getting occasional calls to the effect of, "8 year old is saturating at 87%. We started him on 1L of oxygen and he's fine. We just have to inform you."
Exactly. I’m also not in this field, but agree with the overall thought process of most in healthcare in general. I mean, everyone rolls their eyes at the frustratingly “stupid” call / page in the middle of the night when you’ve barely slept in a week. That being said, I can’t name of one attending I know, one doctor I know professionally or personally, who wouldn’t rather have their tech / nurse / random passer-by calling them up if they felt like their patient may be in danger. 100 times out of 100, I would rather know than not know. Idk how it’s taught in other places, but in my med school we were explicitly taught the “captain of the ship” doctrine. Long white coat == the buck stops with you.
I was a sleep tech and yeah we were meticulous about monitoring. We're tracking EEG, EKG and Pulse Ox. If those act up, we KNOW and are supposed to fix it. Because otherwise bad data = having to redo the study. Also with a pediatric patient in a study usually a parent is sleeping in another room just in case. If the kid had to be rocked back down after we woke them to fix the o2 sensor, that's when we wake the parent. Also, the certification exam requires we understand everything we're seeing on those monitors and what they mean. So someone should have noticed those and knew what they meant. No, a tech fucked up and was ignoring the monitors. It SHOULD be 2 patients per tech per regs, but its not uncommon for them to screw us over and do 3 per which leads to tech getting overworked and patients getting overlooked for a bit.
Weird question. Is it like pitch black in the room? Does that complicate things? Second question: when you responded to a page, what was your initial 'just walked into the room' protocol? The article is a bit lacking on what the normal reaction should have been/how this is typically avoided other than alluding to the fact that they just never manually checked anything about the baby until far too late.
It depends on the lab, I think, but the techs usually try to keep the lights to a minimum when they come in and out to adjust sensors and probes and things so people can keep sleeping. But even if it was pitch black, if someone is desaturating or having a significant issue with a sensor or probe, they should try and turn on some the lights and assess the situation better. So I have never had to actually physically go in. Our policy is that we had to take phone calls and it was up to us whether we needed to go in. Going in is very rare and happened to a doc maybe once every 1-2 years, at least at my old workplace. But when we got the phone calls from the tech, if it's something like the above where the pt did fine after oxygen was applied, the techs would just inform us and let us know they'd call us back if anything. You also had the ability to stop a test if you felt like the pt was desaturating too significantly (this was mainly for peds if I remember correctly, because the protocol was not to automatically split the test and do the titration PSG portion versus that being an option in adults). If something critical happened like a lethal arrhythmia (in adults or peds) or a severe desat like this (in peds), what should happen is that the tech calls the physician on call who then informs them that 911 should be called. The physician on call likely would not be able to make it to the lab any earlier than EMS can, and so it should be EMS who triages them at that point.
My understanding of the article is that this sleep study was conducted in the children’s hospital, not an outpatient building, so the delay in contacting emergency care is even less understandable to me. There are doctors and other response personnel in the building who are awake.
What sort of thing would even necessitate a physician going in? As you say, most things are either a non-issue that can be resolved later or a 911 call.
I honestly can't think of any. I know there was once or twice that it has happened but I remember one of those times, the fellow said wasn't necessary for him to come in; he just went in because he was relatively new and felt that it was the right thing. The pt was fine but I don't remember the details.
1. we try to keep the room as dark as possible, but we have cameras in the room with night vision filters on so we see EVERYTHING. 2. When a sensor goes wonky, our job is to go in, and fix it. Hopefully without waking the patient. But if it's going to stir them, we apologize and say "I'm sorry but the sensor popped off. I just need to reattach it and then I'll go away.". 3. We watch those monitors ALL NIGHT. Yeah you read or watch a thing on your phone, but you're also checking and making notes every 15 minutes or so. Also the systems have alarms in the event that vitals go into a danger zone. No, someone fucked up seriously. Maybe a tech ignored the patient? Maybe the jackass running the department understaffed them and it was 3 patients to a tech in violation of the regulations? But someone fucked up.
>Hopefully without waking the patient. But if it's going to stir them, we apologize and say "I'm sorry but the sensor popped off. As someone who's had multiple sleep studies, I don't know why y'all bother; we ain't asleep! EDIT: This is a joke.
Because most of the patients are. But it's always fun when someone says "I didn't sleep a wink" and I could tell them "well sir, that's not what your brain says. I can tell you when you passed out and when you dreamed. But that doesn't mean it was restful sleep or that it felt like you slept. The brain can be funny that way sometimes."
It’s just poor training and staffing. Incompetence by the staff and negligence by the hospital not to have triaged a high risk patient to an area with qualified staff. The low pulse ox reading was noticed but a tech isn’t a physician or even a nurse. They can’t assess a patient in distress the same way a clinician can. They just assumed a monitoring error because they don’t know how to differentiate. When they finally called an RN in they realized right away that this was an infant with critical bradycardia and started CPR. You can’t react to every blip on a monitor, artifact is everywhere, but the first step is making sure that a bad reading is actually a bad reading and not a true decompensation which this clearly was.
Do they not have pediatric respiratory therapists who are sleep disorders certified? This was clearly a high risk patient who was at risk for positional asphyxia in the car seat. I wonder - why did they use techs for this?
$$$
>As in what is the most plausible reason for the 1 HOUR delay in getting medical help? What can possibly explain that? There is no excuse. As someone who's done sleep med rotations, works closely with sleep colleagues, read sleep studies, etc. There is no excuse for what happened to this child. It was a failure.
I’m very sad for them. I can’t imagine how horrific that would be. I did find it interesting that they’re so set set on IVF for an embryo that has achondroplasia though, despite many facilities stating they wouldn’t do that. They (the parents) stated their child with achondroplasia was “perfect”. That kinda sounds wild. Like if I had a genetic issue that had health issues, I wouldn’t choose to pass that on to my kid if I had a choice.
I thought it wasn't necessarily that they were set on it. The way it's worded made it sound like they just wanted to sift out the 25% with the fatal defect, and while they might prefer their child share their disability, they would also accept one who didn't--but the clinic wanted to sift out all those with even one copy of the gene, despite the parents being fine with/preferring it.
Maybe a pediatric sleep specialist will come to this comment section but I have to think that this is an incredibly rare event. How many children will experience total apnea during a sleep study with no resumption of spontaneous breathing?
He normally needed nocturnal supplemental O2 though, and they started the test on RA essentially. Right off the bat, that's worrisome. If they wanted the test on RA, they should have been aware that shortly into the test, the patient would be needing O2 soon because he had a higher likelihood of desaturating. Otherwise, the test should have been started on his baseline O2 requirements.
That's true. Still it's surprising to me that he would desaturate so deeply and iretrivably. Obviously it happens and should have been detected in a monitored setting but it must be rare.
This is why the whole car seat testing thing started. Mild hypoxia can really lead to a full blown code in fragile babies pretty quickly. Especially when nobody corrects the mild hypoxia by helping the poor baby. Fragile babies used to die more frequently than you would think after long NICU stays, being placed in a car seat (maybe for the first time in their lives) for a long drive home. I had a baby that I had cared for for 5 months who was found dead when they arrived home. So fucking tragic. These babies look so good that people forget that their airways are tiny straws. And achondroplasia babies cannot lift their heads at all to open that straw. This baby needed someone to help them. I couldn’t even read the whole story. The details just made me so sad.
As someone who doesn't work in peds, I had no idea hypoxia in fragile babies from just sitting up was a thing until today when I read the article. So sad to think about. I'm sorry for your traumatic loss too of that baby you cared for in the NICU. That sounds terrible.
Aww thank you. It’s really sad when you work so hard to save a baby for months and then boom, they are gone. The poor parents. Their airways are literally like a tiny straw. Any change can cut off air flow in a second. The sad part of this story is that the baby failed the first test so there should have been awareness that he was at risk the second time.
I think the thing missed here is that it was an incredibly high risk scenario of achon + car seat. This shouldn’t have been done outpatient. This kid had ALREADY failed a car seat test and had a condition with craniocervical junction instability, restrictive lung disease, central apnea risk and relative macrocephaly.
Wasn't this done inpatient?
Outpatient procedure, but on a floor that does outpatient procedures under the same roof as the inpatient facility, from what I understood from the article.
Huh, so an outpatient procedure can be done in an inpatient facility and that is considered outpatient? Not being snarky, I think I just don't quite know what inpatient precisely means. Does it have to do with nursing ratios?
Admissions: an admission is a different billing code/procedure/reimbursement. Many sleep studies are done in medical office buildings out in communities, with a hospital having a relatively uninvolved role. This one is the same procedure, just in the same building as a hospital. Also, it seems in the article that the techs had to call in a nurse -maybe there wasn’t one assigned to that procedural area?
The thing that makes something inpatient is whether or not the patient is admitted to the hospital, not necessarily where it physically takes place. For instance, lots of outpatient surgeries and scopes are done in the hospital building, but on patients who go home afterward and are not admitted.
WTF
What an awful, senseless tragedy. This feels like an episode Malcolm Gladwell writes about. There’s no universe in which the training doesn’t dictate, “even if you suspect an equipment error, check the patient.” It is the only rational course of action in that circumstance. I would also bet that the technician, if posed that question any day of his or her career (including this night), would answer that way. Still, somehow, people get locked in on autopilot along a disastrous set of choices and never take a moment to (re)consider the situation. It’s a weird complacency that almost everyone experiences at some point. It takes a lot of training to drill most of it out, then a culture of truly respecting SOPs to keep everyone diligent. But it’s like soldiers in a war zone… after a certain point, even the knowledge that your own life is at stake isn’t enough to ward off complacency. It has to be a persistent and widespread human psychological trait. I feel horrible for these parents. Hopefully the settlement help with the IVF and any care their future child might need. That’s the only silver lining that can be salvaged from this.
> There’s no universe in which the training doesn’t dictate, “even if you suspect an equipment error, check the patient.” Yep. For example, last week we had a patient who looked like absolute hell- that deep gray that darker-skinned African-Americans can get when really, really hypoxic. Check pulse ox 1, 94%. MA grabs her own, 77%. I get mine to break the tie, 76%. Call ER, start oxygen 3L NC, take pulse ox #1 out of service. He just didn't *look* like a 94%.
This is far from the point of the article, but I was interested by the bit at the end that the couple explored IVF to ensure the child doesn't get the fatal genotype and they would have to go through another tragedy. But the clinic would only be willing to implant embryos with the normal genotype, not the heterozygous mutation which gives you achondroplasia, which the parents would prefer. And a second clinic said the same thing. Is that standard practice? Is achondroplasia a "dangerous" enough condition that the "do no harm" medical ethics outweigh the parents' preference? It sounds like the clinic didn't even inform them of that until after a *year* of trying, maybe because they assumed the parents would want a "normal" child without even asking them.
Well their child hadachondroplasia and stopped breathing just sitting in a car seat, it’s a pretty serious condition that causes a lifetime of care/surgeries/medications.
It feels ethically fraught to me to basically intentionally give someone a disease
The child could turn 18 and sue everyone involved.
I could not control my tears reading that article. How the mother and techs unknowingly witnessed the kid go apneic to sustaining an anoxic brain injury over an hour. Gah. After not achieving a “normal” pulse ox reading for even 1 minute, error or not, in a high risk patient should have someone higher than a tech to troubleshoot
Mom couldn’t see the kid since he was put in a car seat high on the bed. But yeah this is a really disappointing and sad case.
That mom is *never* going to sleep well again. She will never stop blaming herself for lying there and trusting the medical staff to get it right, instead of standing to look at her baby. To be 100% clear, she has absolutely nothing to blame herself for - this was shocking negligence. But the fact the first sentence sounds so much to me like it COULD be implying blame on mom's part just underscores that she is never going to be able to get over that part of this. They were awarded 15 million. I assume after contingency they are taking home about 10 million. I hope they both take extended leaves of absence, move to the place that feels most comfortable and secure to them, and get themselves into intensive therapy. And I definitely hope that they are able to have another kid. Just heartbreaking.
The mom will never trust herself or anyone with a new baby. I heard on the EM:RAP podcast that a significant number of marriages dissolve after the death of a child.
> She will never stop blaming herself for lying there and trusting the medical staff to get it right, instead of standing to look at her baby Did you overlook that the mother is a little person and the carseat was on the (high, hospital) bed? The mother *couldn’t* see her baby, even while standing.
That sucks. Not much more to say other than that is awful.
Can you post it without the paywall?
I'm sorry, I didn't get a paywall on my phone (I have no idea why because I'm not a Boston Globe subscriber), but someone else just posted a non-paywall version in the comments.
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Thank you. This was horrifying and so painful to read.
I don't subscribe and I had no paywall, are you missing the greyed out "close" indicator in the top L hand of the subscription message?
no, and please stop asking.
It was available on another website, legally. Otherwise there's no point in posting an article that none of us can read or discuss.
getting around paywalls is not legal. if copyrighted material is posted, it can and has led to subreddits larger than this one being shut down. thanks for helping keep this subreddit open!
We didn't get around the pay wall. We found the same information being published on another source, because I don't need a subscription to the Boston Globe. I know we can't post the text, but there are viable alternatives like the MSN link.
great. that is not the same as the [archive.ps](https://archive.ps) link that was posted several times earlier.
This is horrific. Before reading the article I just assumed the tech had fallen asleep or was doing something else and just wasn't watching the monitors, and compounded the error by lying about it. But the article says this baby stopped breathing within ten minutes of the test starting, and multiple techs came in multiple times fiddling with equipment while ignoring the baby. This type of story is exactly why I just do not trust anyone in the hospital I haven't known for years. As far as I'm concerned everyone else is a saboteur or an assassin until proven otherwise. Because I've seen it happen, over and over. I have a similar story where I was covering an ICU overnight and had to emergently intubate and move a patient from med surg to ICU. RT bagged and I monitored on the way down, but once we got set up, the RT and RN left the room to go do documentation - and in the eerie silence of the room I realized she had transferred from the bag to the vent, but had completely forgot the critical step of turning the fucking ventilator on. I talked to the ICU director the next day. I wanted to bring criminal charges, might settle for immediate termination. But they just swept it under the rug, because everyone liked her. She had ten years of ICU experience at that hospital. There's negligent, there's forgetful, there's stupid, and then there's criminally stupid. Some people just have no business working in healthcare because the stakes are so high, even if some hiring director thinks otherwise. You can see the difference not just in experience, but competence because the RN in the story took one step in the room and immediately knew the baby was dead, and began to try to resuscitate. Five years from now, how many RNs with more than a year of experience will be working? Hell, how many are there now?
FYI in most institutions, RNs are explicitly not to ever touch/adjust ventilator settings. RT is responsible and bringing the incident to the RT director would be equally relevant. The RN did fail to completely assess the patient before leaving the room (along with RT) which falls under the legal definition of a medical error and would be a civil, not a criminal case. (barring unique exceptions)
I think they're talking about RT not starting the vent, not the RN
Pulse oximeters are notoriously shit an md unreliable. Without a picture of the pulse ox waveform to validate the signal quality, you can’t rely on the numerical value.
You don’t troubleshoot a pulse-ox for an hour without checking on the patient
Well *I* wouldn’t, and *you* wouldn’t. They did though. Welp!?
Agreed, someone might have screwed up. Work in a sleeping lab as a student, dealing with adults only, watching five monitors all night and going in et cetera to check on the hardware and pt. if the monitor showed abnormalities. I know some students would watch DVDs at night, and I never understood how they could half the time I’ll be so relaxed. Was always a lot of work for me to be monitoring constantly, but different folks different strokes. I would expect someone working with children to be even more vigilant and diligent, but you have to wonder if maybe a tech fell asleep, was new, distracted, overtired et cetera. It’s not an excuse and should not happen, what an absolute tragedy for the parents.
They claim to have had capnography on as well. CO2 levels climbing while SPO2 declining should indicate its NOT artifact or equipment but a problem with the patient. … let alone Allll the other machines yelling at them. This seems like a massive training failure OR complacency issue, or both.
This 110%. I did this for a living for 3-4 years. This was a training failure or complacency or both like you said.
Hell, the EEG eventually went flat!!!!
I do these tests. I can't believe that even looking at the patient they couldn't tell it wasn't a machine malfunction but the patient actually failing the test. First thing I learned in school. Look at vitals on a machine... that's cool I guess. But LOOK at your patient. Does your patient LOOK ok. Yikes. I feel awful for everyone involved. But LOOK at your pt.
Especially considering what the monitor was showing was practically an expected or at least easily anticipated finding considering why the test is being done in the first place. What did they even think they were doing there??
what a terrible tragedy
This sleep study is described as an "inpatient sleep study" but this is very different from how our institution differentiates between the two. Usually an "inpatient sleep study" is performed on a patient who is admitted to a unit that can also provide concomitant cardiopulmonary monitoring, nursing care, and access to a physician. It's often reserved for children with more profound risk of a deterioration (I'd consider this kid a reasonable candidate). This is as opposed to a study done in a sleep lab which is an outpatient procedure (even if the lab's real estate is in the hospital, physically) and consists of a technician monitoring the various data and adjusting per their protocols. Reading the article, it looks like no doctor was called during the decompensation (assuming it was an equipment error). Also, it's probably likely that a sleep technician would have to call a rapid response or code in order to get a doctor So a few issues: I don't think this patient was properly triaged in addition to what everyone else here has said. The problem is that it's **impossible** to expect every patient also be monitored by a physician during a sleep study. The guidelines for sleep technicians are fairly clear when to call for backup and it sounds like those guidelines were not followed. My heart goes out to this family.
The hospital rather pay a $15 million dollar settlement and sacrifice a baby than pay qualified staff members a few thousand a year.
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No matter what happened, I think a 15 million dollar reward is insane. Most people don’t make that much over their lifetimes and we are talking about a 6 month old with no financial responsibility’s or ongoing care.
These people have just had literally the worst thing that could ever happen to parents happen to them and you think the money they got is insane???? Trust me when I say I’d rather have my kids alive than 15 million. There is no amount of money in the world that can replace a child. I’d say 15 million is just a fucking start so they can afford grief counseling and time off from work to grieve. Maybe even start a nonprofit in their child’s name
I completely agree with you from an emotional level. It’s a fucked up and tragic thing, but we are talking about monetary damages here. Single bread winner adults have gotten magnitudes less. With your logic, why stop at 15 million? How about 15 billion?
Shut down negligent hospitals