Description of Event or Problem · 0
DARE MEDFLIGHT WAS REQUESTED TO (B)(6) HOSPITAL FOR A TRANSFER TO (B)(6) MEDICAL CENTER. THE REGISTERED NURSE'S PHONE REPORT INDICATES THE PATIENT IS A 62-YEAR-OLD FEMALE WHO CONSUMED AN ENTIRE BAG OF THC GUMMIES. SHE WAS BROUGHT TO OBH VIA POV (PRIVATELY OWNED VEHICLE) IN AN UNRESPONSIVE STATE AND SUBSEQUENTLY EXHIBITED SIGNS OF RESPIRATORY FAILURE. THE PATIENT WAS INTUBATED, PLACED ON SEDATION, AND STARTED ON PRESSOR INFUSIONS. SHE IS NOW BEING TRANSFERRED TO SAMC ICU FOR FURTHER CARE UPON THEIR ARRIVAL, PARAMEDIC ANDERSON REMAINED AT THE NURSING STATION TO HANDLE REPORT AND PAPERWORK, WHILE (B)(6) PROCEEDED TO THE PATIENT'S BEDSIDE. ONCE THERE, (B)(6) IMMEDIATELY BEGAN THE ASSESSMENT AND TRANSFER OF EQUIPMENT. ROWE FOCUSED ON THE LEVOPHED INFUSION WHILE I PREPARED THE CARDIAC MONITORING EQUIPMENT (THE PATIENT WAS STILL ON OBH EQUIPMENT AT THIS TIME). DUE TO THE NEED FOR NEW TUBING, THE LEVOPHED INFUSION HAD TO BE STOPPED, RE-SPIKED, PRIMED, AND THEN PLACED ON OUR INFUSION PUMP. ROWE HAD THE CALCULATIONS READY IN THE PUMP, BUT WHEN THE INFUSION STARTED, WE RECEIVED A 'CASSETTE JAMMED' ERROR. THEY ATTEMPTED TO TROUBLESHOOT BY REMOVING AND REINSTALLING THE CASSETTE MULTIPLE TIMES ACROSS DIFFERENT CHANNELS (A & B), BUT THE ERROR PERSISTED. THEY DECIDED TO REPLACE IT WITH TUBING FROM THE AIRCRAFT, WHICH WAS THE ORIGINAL MANUFACTURER PUMP TUBING USED PRIOR TO THE RECENT SHORTAGE. I RETRIEVED THE ORIGINAL MANUFACTURER TUBING FROM THE AIRCRAFT, AND UPON RETURNING TO THE ROOM, NOTED THAT THE PATIENT HAD BECOME SIGNIFICANTLY HYPOTENSIVE. ANDERSON AND ROWE WERE WORKING TO TRANSFER THE SEDATION INFUSIONS, BUT QUICKLY FOCUSED ON REESTABLISHING THE LEVOPHED INFUSION. DURING THIS TIME, THE PATIENT EXPERIENCED SIGNIFICANT HYPOTENSION AND EPISODES OF BRADYCARDIA (HR (HEART RATE) DROPPED FROM THE 50S TO THE UPPER 30S, STILL ON OBH'S CARDIAC MONITOR). ONCE THE LEVOPHED INFUSION WAS RESTORED, ANDERSON INCREASED THE RATE TO STABILIZE THE PATIENT'S BLOOD PRESSURE, AND UPON ACHIEVING NORMOTENSIVE PRESSURES, THE LEVOPHED WAS RETURNED TO ITS INITIAL STARTING DOSE. THE TWO REMAINING INFUSIONS, VERSED AND FENTANYL, ALSO PRESENTED CHALLENGES, RESULTING IN ERRORS SUCH AS 'CASSETTE JAM' OR 'FLUID SIDE.' AFTER SOME TROUBLESHOOTING, WE WERE ABLE TO RESOLVE THESE ISSUES WITHOUT FURTHER ADVERSE EFFECTS. THE FENTANYL INFUSION ENCOUNTERED ONLY MINOR ISSUES (AIR SENSOR) THAT WERE EASILY ADDRESSED. HOWEVER, THE VERSED INFUSION CONTINUED TO DISPLAY A 'CASSETTE JAM' ERROR. AT THIS POINT, THEY HAD EXHAUSTED OUR SUPPLY OF 'ORIGINAL TUBING' AND HAD TO REVERT TO THE NEWEST TUBING PRODUCED BY ENVIHS. (B)(6) EVENTUALLY MANAGED TO GET THE INFUSION RUNNING WITH THE NEW TUBING, BUT IT REPEATEDLY DISPLAYED A 'CHANNEL SERVICE' ERROR AND WOULD STOP INFUSING EVERY 2-4 MINUTES. THEY MANAGED TO WORK AROUND THIS BY SELECTING THE CHANNEL, PRESSING THE 'RETRY' BUTTON, AND RESTARTING THE INFUSION. HOWEVER, UPON THEIR ARRIVAL AT (B)(6), THE CHANNEL COMPLETELY LOCKED OUT, INDICATING 'SERVICE,' AND WOULD NO LONGER INFUSE. WHILE THERE WERE NO ADVERSE REACTIONS OR OUTCOMES DUE TO THESE INFUSION PUMP AND TUBING ISSUES, THE SITUATION COULD HAVE BEEN CATASTROPHIC. THROUGHOUT THIS PROCESS, IT IS ESTIMATED THAT THE PATIENT WAS OFF THE LEVOPHED INFUSION FOR APPROXIMATELY 10 MINUTES. HOWEVER, THE TOTAL DELAY ON SCENE DUE TO PUMP AND TUBING MALFUNCTIONS WAS SIGNIFICANTLY LONGER, ESTIMATED TO BE AROUND 35-40 MINUTES. WE UTILIZE THE ALARIS MED SYSTEM 3 AND PUMP TUBING FROM ENVI HEALTH SOLUTIONS. REF REPORT: MW5158592.