What is ventilator?
Ventilator is a mechanical equipment that helps patients with their breathing. Ventilator work by blowing air into the airways through a breathing tube. One end of the tube is inserted into the patient’s windpipe and the other end is attached to the ventilator. The breathing tube then serves as an airway by letting air from the ventilator flow in and out of the lungs.
In any case of a ventilator failure, it can be life threatening. This is because ventilator is considered a “life-critical system” which patients relied to complete the biological exchange of gases, such as oxygen and carbon dioxide. A failure in the ventilator would result in organ tissue damage and worse case scenario, led to death. This machine is used by people who have difficulties in breathing due to acute disease or chronic condition. Patients as well as elderly who have suffered a stroke, spinal cord injury, neuromuscular disorder or other illness also use this device.
There was one incident of ventilator failure that led to serious death. Although there are reports about malfunction of mechanical ventilators that lead to deaths, they have very few forensic autopsy records.
One case report with forensic autopsy records is an unexpected death of a ventilator-dependent amyotrophic lateral sclerosis (ALS) patient. The patient is a 69-year-old ALS female ventilator-dependent, trachostomised patient and she was found dead by her husband, with the ventilator in “stand-by” mode. The night before her death, her husband had checked both ventilator and enteral nutrition (EN) pump and had found nothing unusual. However, he was woken up by the alarm of the EN pump early in the morning. By the time he realized, his wife was not breathing and pulseless with the ventilator which was in “stand- by” mode. CITATION Mdi l 1033 (Paolo, Evangelisti, ; Ambrosino, n.d.)Description of the fault of the device:
Examination was done and the results showed that the patient died from acute asphyxia. The ventilator internal memory was analysed and tested to search the possible ways of malfunction. Analysis of the ventilator internal memory showed that during the night of death, there had been several voltage drops. Specific tests revealed that the cause of voltage drops was due to the malfunction of the internal battery. This malfunction of the battery is unable to provide the necessary voltage to the machine and hence, the ventilator was switched off, causing a stop in the ventilation.
The volume of the ventilator alarm was greatly reduced due to the battery malfunction. Hence, the caregiver did not hear any ventilator alarm. This caused the death of the patient who suffered from acute asphyxia. ALS patients lose their ability to speak, eat, move, and even breathe and hence the patient cannot inform the caregiver.
Lessons learnt from this incident:
Based on the case report, the failure of ventilator is caused by the malfunction of the internal battery. Ventilator is a medical device that has life support priority and preventive maintenance are done minimally twice a year. A possible cause of this incident may be due to the caregiver not sending the equipment for preventive maintenance. Hence, resulting to death of the patient. One important lesson that can be learnt from this incident is that preventive maintenance must be done regularly as the ventilator is a device with life support as its priority and failure of the machine can easily lead to death.
Another lesson learnt is that the caregiver should stay near to the ALS patient. ALS patient cannot inform the caregiver in case of any emergency as they loses their strength and the ability to speak, eat, move, and breathe hence, intensive care taking must be enforced by staying near to the patient. In this incident, the caregiver was probably too far away from the patient thus, he did not hear the alarm from the ventilator. The patient was unable to inform the caregiver when the alarm rang and as a result, the patient died from acute asphyxia.
In conclusion, the breakdown of medical device can be a very serious issue especially those devices with life support priority. However, there are ways to reduce malfunction of device. One solution that can be done is by doing preventive maintenance. The number of times a certain device need for preventive maintenance can be found in the equipment management code. In this case, a minimally of twice preventive maintenance must be done. Doing regularly maintenance can greatly reduce the chances of an equipment failure which in turn can lessen the number of death or serious injuries that can be caused.
BIBLIOGRAPHY IEEE GlobalSpec. (n.d.). Medical Ventilators Information. Retrieved from https://www.globalspec.com/learnmore/specialized_industrial_products/medical_equipment_supplies/medical_ventilators
IndiaMART InterMESH Ltd. (n.d.). Intensive Care Ventilator, Ambulance And Portable. Retrieved from https://www.indiamart.com/proddetail/intensive-care-ventilator-9829817673.html
National Heart, Lung, and Blood Institute. (n.d.). How Does a Ventilator Work? Retrieved from https://www.nhlbi.nih.gov/node/4453
National Institute of Neurological Disorders and Stroke. (n.d.). What is amyotrophic lateral sclerosis? Retrieved from https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Amyotrophic-Lateral-Sclerosis-ALS-Fact-Sheet
Paolo, M. d., Evangelisti, L., ; Ambrosino, N. (n.d.). Unexpected death of a ventilator-dependent amyotrophic lateral sclerosis patient. Retrieved from https://www.sciencedirect.com/science/article/pii/S0873215913000159