Man catches Home Nurse's tragic mistake - page 5

by EmergencyNrse 14,116 Views | 49 Comments

LONDON (Oct. 26) -- A shocking video captures the moment that an undertrained home health care nurse mistakenly turns off her quadriplegic patient's life-support machine. That disastrous action, and a succession of further... Read More


  1. 0
    Quote from tothepointelvn
    there is something very odd about this video. she turns the vent off alarms go off then when asked by the caregiver she says "i turned it off" was she trying to "help" him

    why didn't she just turn the vent back on. even if it rebooted to the wrong settings it will have still helped.
    this is my gut reaction entirely. you turn it off and it stops working, then turn it back on.or you start trying to find the turn on button but the video doesn't show her or the other lady even looking. (i did notice someone comes up behind the nurse in the video, why could these 2 not figure out how to turn it back on?) something seems a little off and i cannot put my finger on it.

    it is horrid for this gentleman, but i think there is more to all of it than meets the eye or he would not have had reservations in the first place.
  2. 0
    Quote from cheyfire
    this is my gut reaction entirely. you turn it off and it stops working, then turn it back on.or you start trying to find the turn on button but the video doesn't show her or the other lady even looking. (i did notice someone comes up behind the nurse in the video, why could these 2 not figure out how to turn it back on?) something seems a little off and i cannot put my finger on it.

    it is horrid for this gentleman, but i think there is more to all of it than meets the eye or he would not have had reservations in the first place.
    right! i'm thinking "undo what you did, undo what you did!" i've been working with ventilator dependent people pretty much my whole nursing career off and on and i couldn't imagine turning a vent off on a ventilator dependent patient without having ambu bag in hand first. why didn't the caregiver or the nurse turn the vent back on??? it was the patient's sister, correct? so isn't it safe to assume she knew basic vent knowledge? i know here in the states a family member has to be trained on the vent as a backup in case a nurse has an emergency or doesn't show up. what is missing? what is wrong with this story? 14 minutes without oxygen and no one knew how to turn the vent back on, put him on a backup vent, or bag him appropriately? no one knew?!
  3. 1
    Quote from kiyasmom
    RIGHT! I'm thinking "undo what you did, undo what you did!" I've been working with ventilator dependent people pretty much my whole nursing career off and on and I couldn't imagine turning a vent off on a ventilator dependent patient without having ambu bag IN HAND first. WHY DIDN'T THE CAREGIVER OR THE NURSE TURN THE VENT BACK ON??? It was the patient's sister, correct? So isn't it safe to assume she knew basic vent knowledge? I know here in the States a family member has to be trained on the vent as a backup in case a nurse has an emergency or doesn't show up. What is missing? What is wrong with this story? 14 minutes without oxygen and NO ONE knew how to turn the vent back on, put him on a backup vent, or bag him appropriately? No one knew?!

    I think neither of them knew how to use the ventilator equipment. It would be the only logical explanation as to why she did not know how to proceed. Even in the video the paramedic asks her if she has been trained on it and she replies "no."
    It is absolutely scary and really sad for this man and his family.

    I tried working for a health agency as a new grad and they placed me on a few floors within hospitals and it didn't take me long to figure out the dangers of not being trained. I found out that this agency, and i'm sure others do not care about the nurse, her/his license, or sometimes even the patients if they are willing to risk putting people with no experience onto the field. I never received any orientation and this scared me to death. Once they refused to train me, I quit and I am so happy to say I would never ever risk a patient's life for money. It is not worth any type of suffering on either end. It is also the nurses responsibility to recognize her competency level and speak out in regards to what she can an cannot do.
    Not_A_Hat_Person likes this.
  4. 0
    Quote from chrisj74
    I don't know the first thing about vents but why would you turn it off? ever????

    No vent = no oxygen right? Even I know that!
    Well, my response to your question has nothing to do with the main topic of this thread. But as Lvn with home health experience, I can tell you that a patient may be able to sprint (breathe without a ventilator for a period of time) depending on the medical condition. Some patients use the ventilator only when sleeping at night. Some do sprint with the ventilator turned and disconnected from the trach during patient care in when they wake up in the morning. It's all stated in the Plan of Treatment (POT) that has already been signed by the physician and the registered nurse who is writing the specifics of the home nursing care. If the family of patient is competent to assume care, it is also stated in the POT. The POT also states what intervention the skilled nurse needs to initiate. For example: Call 911 if apical palse is below 50bpm or above 140bpm, sustained, and notify RN or MD etc. My advice to every nurse in home health is, "Know your limits, know which respiratory therapists to call for help from the ventilator company, know which of your fellow nurses to call when you are not sure about things. Above all, make sure that the patient and his/her family members can help you to learn". Because, many verbal trach patients have been on vent for years and they know the ins and outs of it. Always have knowledgeable resource person that you can contact. I did not know how to do everything right when I first started. But now I can teach others what I know. I wish you all the best.
  5. 2
    Quote from Ayeloflo
    I can tell you that a patient may be able to sprint (breathe without a ventilator for a period of time) depending on the medical condition. Some patients use the ventilator only when sleeping at night. Some do sprint with the ventilator turned and disconnected from the trach during patient care in when they wake up in the morning. It's all stated in the Plan of Treatment (POT) that has already been signed by the physician and the registered nurse who is writing the specifics of the home nursing care.
    That is very true. The care providers should also know the level of injury and what to expect especially when dealing with quads. I shudder to think of all the other procedures that could have been screwed up with this type of patient. You've got to do bowel programs, supra pubic catheter, quad coughing while not damaging the supra pubic catheter or feeding tube, trach care (hopefully he didn't have an inner cannula to change epecially a Shiley), cuff deflation for pressure release and secretion clearance above the trach, suctioning, mechanical lifts if he got into a chair, positioning to prevent pressure wounds, feeding tube, BP monitoring and autonomic dysreflexia issues which can lead to serious consequences quickly including death. And then there is the ventilator with a circuit which has lines that can be also disconnected or a trach that can be dislodged when turning. I can't imagine what this man went through on a daily basis knowing he life depended on health care providers who were sent by an agency ran by people who themselves may not know what it takes to care for severely disabled people in a home setting. Unfortunately some health care providers believe if a patient can be at home, "they're alright enough". We even have our own hospital CCT team, which includes an RRT, take patients who are ventilator dependent to their homes at discharge. The same for those ventricular assist devices.

    It appears from some of the articles this patient may have a high C-spine injury with complete tetraplegia at the C2 level. That means he was probably vent dependent totally 24/7. Christopher Reeve (Superman) was a C2 tetraplegic at least tolerated cuff deflation and a speaking valve (Passy Muir or similiar) placed in line with the ventilator. Not all can even tolerate cuff deflation to allow speech which at the C1 - C2 level can be very difficult. Any injury at C4 or above can be a great challenge for the patient and health care provider. Several years after his injury Mr. Reeve had a phrenic nerve or diaphragm pacer ($100, 000) placed in an attempt to breathe without the ventilaor. Mr. Reeve also had his share of mishaps such as a broken arm from being dropped by his assistants. Eventually he died from sepsis caused by a pressure wound. It just shows that even in a country with lots of expensive technology and access to well trained health care providers especially if you have a decent bank account, this type of patient is very fragile and requires extensive training for their care. We also start to get the primary care givers in the family involved in the patient's care as soon as possible with information and procedures repeated over and over during the patient's hospital and rehab stay. I have also found family members easier to train than some health care providers.
    Last edit by GreyGull on Dec 7, '10
    Not_A_Hat_Person and Ayeloflo like this.
  6. 0
    That is shocking. People need to be more careful.
  7. 0
    Good gracious why would you take a case if you did not know anything about the vent??? Horrible video to watch. She apparently doesn't know about trachs either?
  8. 0
    Quote from tyvin
    Ok; I think the person who made the comment about socialized medicine gets it.

    Anyway why is she not being criminally charged? When someone gets into an car accident and someone dies many times they are charged with manslaughter because there was a loss of life with no intent to murder; an accident. She should be charged with some type of criminal act IMO. It was a crime how she nonchalantly turned off the ventilator and walked away with the bell ringing. This makes us all look bad.

    I have seen it all and this only adds to the many horrible, shocking things I have witnessed nurses doing to patients in home health and the hospital. I will never understand why someone would do something they have no idea of how to do and do it anyway especially when it involves the life of a human being.

    When she walked into the house on assignment with this man and saw the vent she should have not taken report and called her boss. If she had no experience with vents why in the blazes did she take the shift? Very bad, very bad.
    jkeonelf e;d
  9. 0
    Quote from tyvin
    The relationship between this man and some of the nurses sounds tumultuous; therefore is it so outrageous to think she may have been exacting a little revenge. Perhaps she thought it would teach him a lesson to go without the vent for awhile not realizing the extent of her actions? Hmmm; thinking it would cause him some discomfort.

    She is far too calm when the alarm goes off, so that's where I came up with this theory on revenge. I mean really; who turns a button, hears alarms, then walks away as if nothing happened? I know one thing; I would've suspended her license stat. But is that going to happen?
    I don't think we know her motives. I don't know why she would have been turning the vent off, but I don't think we can even begin to think there is any evidence of malfeasance on her part. And I don't think she was inwardly calm. She might have been outwardly not flailing and fainting and screaming, but that doesn't prove an iota of what she was feeling inside.

    Let's give her the benefit of any doubt.

    Do we even know that she had cared for him previously?

    I do not see her walking away. She called for the aide to help her, she stayed and did what she could to try to help, erroneous though she was.
  10. 0
    That visor is indeed very difficult to watch. If that woman was really a nurse I dont understand how she got her license. even with zero hand on training with a vent, one can clearly see that it is connected to the trachea, hence providing ventilation. Plus the fact that that man is desperately trying to get her attention, how did she miss that? It was neglect. Plain and simple. And how do these nursing agencies get by without knowing what type of training an employee has? I just don't get it.


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