Alarms in medical equipment(th.id.au) |
Alarms in medical equipment(th.id.au) |
The nurses obviously couldn’t respond to it each time, but nor could they switch it off altogether, and it didn’t reset after any period of time.
My siblings and I took turns to gently hold his arm down on the side of the bed… which became just holding his hand, which I still miss.
The use of these alarms is not something imposed by the manufacturers, but by the standards, eg 60601, 62304 etc. For devices involved in diagnostic, or more importantly interventional care, you are required to have alarms within certain auditory and visual thresholds, and a lot of them have mandated silence times (in a life critical system, you can only silence a true alarm for 120 seconds at a time).
Then again, "ALARM" as dictated by the standards means something truly emergent, though the wording can feel a bit fuzzy at times. Trust me, alarm fatigue is a known phenomenon to these manufacturers, and theres been a recent trend (with, eg, the Dexcom G7) of giving users more control over delaying alarms, silencing them until you can respond etc etc, which has its benefits, especially as quality of life is concerned.
You'll have a hard time convincing the FDA of this for critical devices like those found in hospitals though.
Props to Airbus for proper UX and information prioritization.
I was once in the recovery room with my wife. For some reason the sensor was having a very hard time reading her pulse. The normal bips would frequently fail. Too many failures in a row and the alarm would start it's EEEEEE scream we've all seen from Hollywood. It would shut up as soon as it managed to pick up a beat.
Hers was definitely not the only one in the room occasionally screaming. The nurses were completely ignoring it. Quite understandably so as it was obviously doing false alarms. But in a flood of false alarms like that are the real ones going to be noticed??
Contrast with the GPWS warnings in aviation, which tells you what the problem is (TERRAIN TERRAIN) and what to do (PULL UP) in a progressively more alarmed voice as things get worse.
(Well.. Sometimes you hear of some particularly bright individuals who think the bank angle warning is a checklist item, but it's generally hard to get these wrong, compared to many other beeping warnings)
My take - the medical industry has too many barriers to competition, and it is too difficult for people who work with these things to do anything about it as well. It’s unclear who the buyers are at a hospital or how a startup could reach them. It’s also unclear what sort of interoperability (for example with Epic for charting) is needed. Regulations also make it difficult to get devices approved and investors are less likely to support a startup in this space.
It’s a low volume but high margin business. Some of the issues were the constant fight against the factory not following design requirements to cut costs, knockoffs etc.
It seems to me that clear verbal alerts like "BLOOD PRESSURE VERY HIGH" could be more immediately understandable than tones. A hybrid system combining verbal alerts with alarm tones might be a good compromise for clarity and international usability.
If even 2 verbal alarms are going at the same time, it’s going to create a chaotic environment.
In a decentralized system, I think tones have less of an overlapping problem.
Unfortunately, I cannot find the article anymore.
Though a bit disappointing that there is no machine that goes PING! [1]
The alarm waveforms described are within the scope of the hardware standard guidelines, sufficiently common that application notes such as this exist. https://www.ti.com/lit/pdf/slaaec3 [ti.com]
A bit more than that. Certification is required in order to put your product on the market. Whether or not customers require it is irrelevant.
The reality was we knew what was going on just by listening to the alarms. I could predict which alarm was going to go off before it did and so I could safely (appear to) ignore them. I would only panic if an unexpected alarm went off (or happened in an unexpected sequence). It is possible the same situation was going on in the hospital.
Like residents who are getting a few hours of sleep over days worth of high-stress / high-stakes work, poor hand-washing between patients, and not clearly printing one's handwriting on prescription forms - all things that kill patients - doctors and hospital administrators just don't care enough.
For a profession that is supposedly so pure morality-wise - do no harm, patient privacy, etc - doctors are remarkably careless.
I remember an accident report. It was about a container ship which had a bad flooding incident in their engineering spaces. One thing the report pointed out that the engineers had ways to fight the flooding, but they were not doing them because they were playing whack-a-mole with all the alarms caused by the flood. If i recall correctly the engineers kept ignoring the waist deep and rising water and prioritised silencing the alarms. (And not because they were stupid, but just because the many independent blaring alarms task-saturated them.)
Alarms with incessant false positives are inherently dangerous. Sure, there's some threshold of false positives, under which we should still expect people to investigate all alarms. But above that threshold, how can we continue to blame the people involved? The hardware is at fault.
If the cost of a actual negative is 100 and the cost of an actual positive is 1. You'd expect there to be approximately 100 times more false negatives, because we want to be 100 times more sensitive to the costly negative condition.
I'm this sense, the alarms in hospitals make sense. Actual negative are very costly.
But this is a cold mathematical analysis that doesn't consider alarm fatigue and the cost of people learning to ignore the alarm. I wonder how to best model human nature in this calculation?
An optimal solution would require considering all alarms, and modeling the fact that every alarm given is another alarm ignored (assuming the hospital is operating at capacity, if it's below capacity the solution is easy, just manually check all alarms). This system might realize that the 4th "no pulse" alarm of the night for Alice would detract from the 1st "no pulse" alarm for Bob, and that Bob's is more likely to need attention. I'd be terrified to program such a system though, and from what I've seen in corporate programming environments, I'm not confident any company could get this right.
They really do not want false negatives because that gets them sued. Thus the system will be set up to err on the side of false positives--the current liability climate does not blame them for alarm fatigue.
Consider a local case (although it's possible it was overturned on appeal): Yes, the doctor was unquestionably playing loose with standard safety precautions. His behavior transmitted blood-borne infections. He died in prison which was well deserved.
However, the lawyers went hunting for some deep pockets. The manufacturer of the drug involved in the cross contamination. They made various size vials, including some that were bigger than would be used on one patient. This permitted the doctor to contaminate between patients and got them hit with a $250M verdict. (Never mind that had they truly only used clean needles with them like they should have there never would have been an issue. They used a new needle but the old syringe.)
That's the sort of insane legal pressure driving the garbage.
All of those sound superficially plausible to me, although I have my ideas on which are more likely... Would you even do an, um, incident post mortem for something like that or would it just be a statistic?
I think they could substantially improve patient outcomes by taking some tips from the best modern birthing centers, and make a quiet, relaxing, dimly lit, and peaceful environment at hospitals. I'd also say add some plants, natural (wood) surfaces and natural light, but realize that might make it hard to keep things sterile and private. It would make sense to create a rough schedule for each patient also with a consistent "left alone unless there is an emergency" time for sleep, etc.
I would imagine a calm and quiet physical environment would also reduce stress, fatigue, and improve performance of the medical staff themselves.
https://www.statnews.com/2016/10/14/icu-delirium-hospitals/
But it's tough to make improvements. Regular hospital design is (roughly) optimized for staff productivity. They need to be able to treat and monitor many patients simultaneously which requires clear sight lines, good lighting, and a high level of automation. A more humane hospital design would also require more staff at a time when we already have a severe shortage. Where would the funding come from?
My ward even managed to have the (networked digitally controlled, and do presumably very expensive) lighting set up so the night lighting was inside the curtains and shining directly into the bed spaces, and the main ward lights would come up if you touched the wrong thing (even the nurses weren't quite sure exactly what the proximal causes of lighting changes was). With the pumps alarming the whole time (about once per night, per patient, up to 20 minutes until resolution each time) plus all the other regular medical checks preventing any extended quiet time, it was absolutely exhausting at a very deep level.
If you're a multibillionaire then obviously you can just hire and equip your own private medical team that will focus 100% of their attention and care exclusively on you and your needs. The vast majority of the humans will never have that luxury. Normal people enter the system and are processed like everyone else.
Aircraft systems are developed independently and added as options to planes. Which means they get swapped out, there are variants in capabilities, and multiple manufacturers involved.
> This can lead to cognitive overload when multiple systems issue verbal warnings simultaneously.
This is a known phenomenon on flights as well. There is some speculation it played a part in Air France 447. The plane technically _was_ telling the pilots the _precise_ problem they faced, but in the sea of other warnings they were entirely lost.
> tone alarms might be easier to manage and differentiate than multiple overlapping verbal warnings.
If you're a nurse, is the fact you have a ventilation alarm in one room and a temperature alarm in a different room that can be discerned without visual confirmation a useful feature in a health care setting?
I think the big difference is your flight has 2 people responsible for hundreds of lives. In the hospital you would hope the ratio would be more favorable.
I could imagine
ventilation? arrhyth-*C-chord*-ARRHYTHMIA! CHECK PUMP! HEART RATE!
I think GPWS can set windows of cases where an alert is given. Like, a terrain warning isn't much help when landing. Maybe there's something like that already for medicine, but a device who's job is to consume information from other devices, and only provide alerts based on rules the staff can configure before an operation, could be a thing that's useful.
https://looptube.io/?videoId=W5Z-d1Zx02o&start=77.1286764705...
buh-bump is cardiac stuff. wiSShhh... wooosSH is respiratory stuff.
Only thing is, I bet you can hear sounds similar to those in a hospital. The "beep beep" they put over it might not be enough. Still a really interesting research topic!
If you push the button once, it would stop infusing drug into the patient.
If you push the button twice, it would EMPTY THE SYSTEM - as in, run the pump continuously, infusing all remaining drug into the system, at high speed.
We ran usability tests where we'd say to the nurse "wrong drug! stop! you're giving the patient the wrong drug!"
90+ percent of them did what any human would do - jab STOP over and over. Whoops, patient's dead.
In part because of our report Baxter was forced to recall[0] hundreds of thousands of the pumps and pay for their replacements with competitors' products. The stock dropped by 30% in a day. Sadly I didn't short it, or I'd be [checks notes] in jail.
[1] like drug libraries where sometimes the units were displayed, sometimes they weren't, and sometimes they were displayed in your "preferred" units even though the number being shown was in a DIFFERENT unit and the system didn't translate it, just showed the wrong value.
Wow this sounds so dangerous and so easy to predict.
Ideally you'd have a 1:1 (or better!) assignment between a single patient to a single nurse in critical care, 1:3 for patients that can't move around on their own (and thus need more assistance, even if it's just helping them to eat or go to the loo), and 1:5 to 1:10 for everyone else. The sad reality is that even in Germany, you have care home staff calling in the fire department to assist because there were just three staff in a night shift, having to deal with 170 patients.
[1] https://www.morgenpost.de/berlin/article242110812/Kurioser-G...
https://open.epic.com/Interface/
The FDA has a whole program office to assist startups with medical device innovation. They can help you a lot if you engage with them early in the development process and explain what you're trying to accomplish. Think of them as partners, not obstacles.
https://www.fda.gov/about-fda/cdrh-innovation/activities-sup...
This doesn't sound like the equipment's fault.
That's common in computer monitoring systems, at my last job when we had a serious outage, we'd get dozens of pager alerts, it was hard to figure out the root cause because so many alerts fired that were caused by the root cause. I.e. like if the root cause was a root volume was out of disk space, the "unable to log in" alert was superfluous and not helpful. Eventually we moved to a better system that had a betrer sense of hierarchy for alerts as well as a way to easily silence them.
There's a reason everyone is so loud in the hospital, it's because we have to be to be there in the first place.
The words you've used could hypothetically mean some future artificial general intelligence that does not currently exist and there is no guarantee will ever exist, especially within the lifetimes of those participating in this thread. That could obviously be quite good.
"AI" as currently defined by marketing and pop culture to mean machine learning, large language models, etc. should never be allowed to make a medically important decision. We've already seen beyond any reasonable doubt how risky it is to even treat them as a natural language search engine, the idea of handing over life-or-death decisions to them is literally insane.
It's the same as allowing full self driving cars which on average are safer than human drivers but sometimes accidentally drive into a fire truck because they couldn't train an image classifier to more accuracy than 99%.
Seriously, what would motivate you to make a comment like that? Do you think medical device engineers and clinicians are unaware of the false alarm issue and haven't already tried a variety of improvements? There is an inherent trade-off between false alarms and missing a real problem. And devices need to be not only accurate but also affordable, durable, and cost effective. It's not easy to get this right.
That should be way more than enough to hire enough nurses.
[1] https://www.americanprogress.org/article/excess-administrati...
[2] https://ysph.yale.edu/news-article/yale-study-more-than-3350...
[3] https://www.newsweek.com/homeless-americans-are-costing-us-m...
Or, a local case, the nurses were complaining about shoddy supplies. Eventually the holes in the swiss cheese lined up and a baby died. The hospital tried to treat it as a murder by the nurse. (Claiming the line was cut, rather than it broke.)
Three times as many leads would be pretty annoying, though.
Sometimes the alarm limits are set incorrectly by the RT or aren’t forgiving enough to allow some motion. When you see an entire ward of nurses totally ignoring alarms it’s a management failure. Either there aren’t enough nurses available to manage the issue or there aren’t enough technicians to properly configure the equipment for each patient. If someone dies because of that then it’s ultimately the hospital’s fault.
I will not say it was a management failure because I don't know if management could have done anything about it. Given the total indifference of the nurses I strongly suspect they couldn't do anything.
He means there is only ever one aircraft (the one you're flying) and hundreds of patients in a hospital.
Imagine if you will, hundreds of GPWS alarms are blaring off all screaming TERRAIN PULL UP TERRAIN PULL UP PULL TERRAIN UP UPTERRAIN PULL TERRPULLAINUP UPULLPTERRAIN TERRPULLAINUP PULLRAIN TEUPR...
That's both alarm fatigue[1] and the alarms being wholly impractical to begin with. For starters, which GPWS wants to be pulled up again? You can't know, there's hundreds! And that's even assuming you can make out TERRAIN PULL UP in the maelstrom of noise.
In any case, if that's the environment, then it reminds me of our solutions for broadcast studio alarms. There was a combined master tone alarm in the engineering control room, and a set of annunciators for each station, with three levels of severity for each. You'd hear the tone, snap your head around to look at the board, and quickly be able to tell what you were dealing with and where the priority problems were.
Likewise, in the hallway leading up to the studios, there were colored flashing lights above each studio door that also displayed the alarm level for that studio. Those were completely silent, for obvious reasons, but their flashing pattern got your attention anyways. They were arranged vertically according to severity so even if you were color blind you could understand them at a distance.
Then inside the studios there were more detailed annunciators that would actually display which part of the air chain monitoring was causing the global alarm signal. These were also silent, but did not flash, and had a clock that would pause when the first error became displayed.
The economic recommendation is to deregulate the medical personnel industry and allow supply to increase. A great many smart and good people would love to become doctors but aren't in love with 5 years of residency and taking a quarter million dollars in debt to make less than their dropout cousin does at Netflix.
There has already been deregulation to an extent. The scope of practice for lower licenses such as Nurse Practitioners and Physician Assistants has been increased in many states such that they are now allowed to perform most primary care services. This is a great option for other smart and good people who don't want to spend 3 - 7+ years in residency and take on enormous student loans.
And salaries to plummet.
Who's gonna be the first to volunteer to spend about 14 hours of their day in some shithole hospital nearly every day sacrificing their own health and sanity for the sake of others, all while making a fraction of what people here make? Deny people their prosperity and suddenly going to medical school turns into a stupid and irrational decision and something only rich people will put up with for the status.
Plus, play the tape forward. You're working 14 hour days and your pay has been halved in the last 5 years. What can you negotiate on? More pay probably isn't an option. How about working only 12 hour days for 6/7s the (already reduced) pay? That might be doable. In a decade, you might even be working a normal 9 to 5 again. The horror!
Where you go off the rails is with saying "don't care enough". This is a market problem, not a problem with individuals. "We don't overwork our people" isn't a selling point with insurance. The budget is pretty much fixed, a company that doesn't overwork their people ends up in the red.
But it seems like a space that's really ripe for improving. We have very reliable simple protocols you could hook these all into. Imagine it was law that every medical device had to emit the numbers it displays on something like an ODB2 port. Something that can be visually checked to be plugged in, be unplugged and replugged with no handshake, and handle daisy chaining so in the event the "network" breaks in two, or a device goes down, you still get information from the remaining network/it can reroute.
For such a highly regulated industry... you kind of wish they would regulate. I guess status quo is also a regulation.
At the time, the solution to interoperability was to buy all your lab equipment from one manufacturer, who would use their own (usually proprietary) protocols to tie things together. That way, at least even if they weren't actually interoperable, the UI's and workflows were mostly consistent.
A large part of the problem is that hospital IT is understandably hostile to anything connecting to their network, so all the stuff we were building at the time that talked to each other, had to use its own standalone network, or serial ports (ugh!).
Standards like IEC-60601 or 62304 (my daily bread) are easier to adopt because they address patient safety. I suspect it would be much harder to mandate an interoperability standard unless you could show that it improved safety instead of "just" making the healthcare provider's job easier. Or maybe it exists, but just never came up on my radar.
https://www.astm.org/f2761-09r13.html
As you point out the corporate network operators tend to have a different set of priorities but even there too standards exist. Here’s an example:
And pilots from an early stage in their flying training conditioned to push the stick forward when that happens.
Yeah. To quote the movie Wargames: “The only winning move is not to play.” That is a pilot should do their best to avoid getting into anywhere near that situation.
Becoming a doctor is quite simply a stupid decision if you're not gonna get rich off it. You're replying to a citizen of a country which implemented your idea and then some. Believe it when I say the "get into medical school and you're set for life" meme has worn off.
You haven't seen the damage that stupid indebted underpaid doctors are capable of causing. I'm actually afraid of getting sick. Killing patients? I've seen worse.
"[T]he Brazilian healthcare system has achieved significant success in improving population coverage, reducing infant mortality rates [a 4-fold drop!], and controlling infectious diseases." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10231901/
It sounds like doctors are actually doing a much better job there nowadays than they were 35 years ago. The facts I see simply don't match your outrage.
Let's rid ourselves of all these polite euphemisms though. Here's a likely incomplete list of all the things that you don't see.
What you don't see is the communist president of the worker's party who is literally quoted saying "we need to create a new generation of leftist doctors who accept working for less". Population needs doctors, and they vote, so give them what they want: more doctors. And when you want quantity, then obviously you also want cheap. Flood the market with doctors, open hundreds of new schools with ever more lax filters and bring in doctors from neighboring countries too even though they seem to be in even worse shape than us. Problem solved, look at all those happy voters.
The government's latest move was to remove doctors from the decision making positions that control residencies in an obvious preparation to flood the market with "specialists" by dumbing down the requirements and opening new residency programs, no doubt without any concern for quality. You might be skeptical about this claim but these are people who are stupid enough to believe a nurse with 10 years of job experience is equivalent in knowledge and skill to a doctor. At least one such "illustrious" politician can be directly quoted on that.
There's already a huge number of medics, they just happen to be concentrated in the major cities and capitals. The simple fact is nobody wants to live in some undeveloped shithole. Living in Brazil to begin with is punishment enough, there just aren't many maniacs around here who are willing to work and live in the literal amazon jungle. Even comically high salaries fail to attract doctors to areas like that. Partly because quality of life is abysmal and partly because those little villages are so poor they're actually likely to default on those payments anyway so there's no point. Those are the places where the government wants to ship doctors off to though. You'd think they'd develop the country instead so that people in general would want to move there but that's too difficult. Better to just destroy the profession of the "mercenary" doctors instead until they're so squeezed they have little choice.
You don't see the hundreds of brazilian medical schools soaking up billions in government student loans while providing mediocre education. Student loans are very efficient at making school administrators very wealthy. They were devastating for academic integrity everywhere in the world including the US but this country always manages to make it worse by not even pretending to give a shit about quality. In the US medicine apparently escaped that fate due to stronger regulation. In Brazil? So many of these medical schools do not even have an actual hospital for medical students to practice on. How do you become a doctor without seeing patients? You don't.
You don't see the palpable pessimism in health care workers, as a class. What was once a profession that guaranteed prosperity turned into essentially a joke. Doctors generally do not recommend that their children follow in their footsteps. Why would they want their children to bust ass in medical school just to make six dollars a patient? That's just stupid. And those are the lucky ones. The family medicine workers of the study you cited usually make even less than that. This new generation of doctors is feeling the pressure, meanwhile older generations of doctors are taking the wealth they built up and bootstrapping actual businesses instead.
You don't see the 40 thousand newly minted doctors of dubious quality entering the job market every single year. That obviously brings about difficulties with job and residency availability, not to mention the massive and constant downward pressure on salaries. So how does the typical newly minted doctor react to this adversity? Charlatanism.
You don't see the rampant charlatanism on social media. Social media platforms are absolutely filled with them. "Professionals" promising miracle cures, promising results, just basically doing everything that medical ethics says they can't do. That includes passing themselves off as specialists while having a fraction of the education, or just straight up advertising "specialties" they just made up on the spot.
Hilariously, these charlatans are actually the ones who are making it in this distorted reality. They do things like charge people thousands for aminoacid injections that literally do nothing. Brazilian medicine regressed to literal "blow smoke up people's ass" charlatanism and these people are getting rich off it. Do you know what coffee enemas are good for? I haven't the slightest clue but you bet there are doctors doing that to patients literally right now. Things are so screwed up even non-doctors, people who have never stepped foot in a medical school let alone an operating room, have grown bold enough to do "simple procedures" on their customers.
Ever seen an unemployed doctor? Ever seen doctors become Uber drivers? Cashiers? I have. It used to be a meme. Then it actually started happening. Salary only ever decreases. We have emergency services paying the lowest and ever decreasing salaries. What kind of doctor do you think that's going to attract? The simple fact is there aren't enough hospitals in this country for all of them. Most of the ones we do have are in such disrepair that nobody sane would actually want to work there.
The decentralized public health care system familiy medicine situation is even more precarious. There are workplaces in this country that do not have a working sink for doctors to wash their hands with. You simply cannot exercise your profession with dignity under such conditions. The smarter, better doctors have better options and don't subject themselves to that. The ones manning the public health system are generally the desperate and indebted ones. The ones who weren't good enough to match into a good residency.
You don't see the criminally stupid doctors who fuck up so bad they end up on national television. Doctors working an ER who are so stupid they don't run a simple EKG on a patient with textbook myocardial infarction symptoms. Imagine being this fuckup's lawyer. And it's not an isolated case either, their numbers are increasing. The fact is in Brazil any moron can become a doctor these days and you better believe it shows. The problem with that is people's loved ones die in the process and there's no amount of damages that will bring them back. A few years ago I nearly died of appendicitis myself because they initially blamed my symptoms on COVID19. The doctors who saved my life were all older than the public health system the paper you googled talks about. They're becoming rare now, and knowing that makes me afraid of getting sick again.
I seriously hope you reconsider this "just increase supply" nonsense. I know HN hates doctors and it's kind of a tall order but I sincerely hope what I wrote here makes some impact. Simple solutions like that will not accomplish what you want. To put it mildly.