[HN Gopher] Alarms in medical equipment
___________________________________________________________________
Alarms in medical equipment
Author : gaudat
Score : 174 points
Date : 2024-06-07 18:45 UTC (1 days ago)
(HTM) web link (th.id.au)
(TXT) w3m dump (th.id.au)
| odiroot wrote:
| I was looking for some good notification sounds for my ESP Home's
| buzzer. These are a great inspiration.
| bouvin wrote:
| Fascinating. Interesting to hear the differentiation in severity
| in the same class of error.
|
| Though a bit disappointing that there is no machine that goes
| PING! [1]
|
| [1] https://youtu.be/VQPIdZvoV4g?si=Ov4AuyKgeKtmYmz9
| LorenPechtel wrote:
| And how about the fact that there are simply too many of them!
|
| 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??
| jandrese wrote:
| False positives are definitely a problem. When you read
| industrial accident reports one extremely common theme is some
| sensor that was notifying the controller of the problem, but
| that sensor had a history of false positives so it was
| disregarded. Companies that don't take false positives
| seriously are inherently dangerous.
| teeray wrote:
| Many of those companies fall into the trap of "well, we'd
| rather a noisy alarm that catches the problem than a silent
| one that doesn't." Both are problems. The former just makes
| management feel like a problem would be caught be the on-
| call.
| throwaway173738 wrote:
| The ventilator company I worked for tried very hard to
| avoid false positives because we were very concerned about
| alarm fatigue. We also tried to ride the line on false
| negatives. It's really hard.
|
| 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.
| LorenPechtel wrote:
| The day I encountered it I have no idea of what
| sensitivity controls might have existed but the problem
| was unquestionably the system failing to recognize that
| what had just transpired was a beat. The trace on the
| screen looked like a beat to me, but not always to it.
|
| 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.
| makeitdouble wrote:
| Management could be the most relevant part. A silent alarm
| is management's fault, a wrongly ignored noisy alarm can be
| pushed as staff's fault.
| heavenlyblue wrote:
| Pretty certain management have 0 control over which
| alarms can be disabled on the equipment. And I would bet
| that the equipment from other brands have the same issue.
| kelnos wrote:
| > _Companies that don 't take false positives seriously are
| inherently dangerous._
|
| 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.
| pjerem wrote:
| I think GP was talking about the people who don't try to
| reduce false positives (by actively searching for solutions
| to reduce them), not the ones ignoring them because they
| are used to.
| nradov wrote:
| Please propose a design for better hardware then. You'll
| make a fortune and do a lot of good in the process.
|
| 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.
| kmoser wrote:
| It's hard to solve the problem of false positives when the
| decision to sound an alarm is reliant on a single sensor that
| may start to become detached (e.g. glue/tape failure). If you
| think the solution is multiple sensors, well, what happens
| when one sensor indicates an alarm condition and the other
| doesn't? Now you have _another_ potential false positive. Not
| to mention it 's untenable to connect _twice_ as many leads
| to a patient.
| bee_rider wrote:
| If they'd use three sensors, they could vote. If one sensor
| often votes differently from the other two, it could be
| marked as defective and replaced or re-seated.
|
| Three times as many leads would be pretty annoying, though.
| lostlogin wrote:
| You've hit the nail on the head. It's often tedious
| getting one to work.
| LorenPechtel wrote:
| That could partially be addressed by making the sensor
| include the concept of not working. Run a small electric
| current across the sensor, if that current fails the sensor
| knows that it's not monitoring and can report it as a loose
| sensor rather than as a failure of whatever it's supposed
| to be sensing.
| krisoft wrote:
| > When you read industrial accident reports one extremely
| common theme is some sensor that was notifying the controller
| of the problem, but ...
|
| 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.)
| Johnny555 wrote:
| _they were playing whack-a-mole with all the alarms caused
| by the flood_
|
| 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.
| ler_ wrote:
| Knowing how to trend the patient's health is probably more
| useful than relying on all the alarms. People hardly
| deteriorate from one second to the next if you know what to
| expect from their baseline. At least that's what I did when
| working as a nurse. However, I never worked in some place like
| the ICU, so the approach might be different in that case.
| btach wrote:
| Anecdote: At an ED I used to work at, our cardiac monitors got
| "upgraded" to another manufacturer. Silencing false alarms was
| a black hole of a game of whack-a-mole. You could never silence
| them all, another would just pop up to spite you. Anyway, one
| night, it was continuing to alarm and being ignored (with a
| glance occasionally to make sure). Except somebody was in
| v-tach and the person who noticed was a medic bringing a
| patient in. Thank goodness they noticed amid the noise! (We had
| as good of outcome as could be expected with that patient, and
| they went to the cath lab and lived).
| dmurray wrote:
| What would have happened if the medic didn't notice and the
| patient died? Would you have got the blame for ignoring it,
| or management for creating a situation where you had no
| choice but to ignore some alarms because of false positives,
| or the manufacturer, or would it have been swept under the
| rug as "the patient was having heart failure and
| unfortunately even our state-of-the-art medical care couldn't
| save him"?
|
| 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?
| btach wrote:
| There would definitely be an investigation, as all sentinel
| events are investigated. Management would do their RCA and
| I'm sure the issue with alarm fatigue would be ignored or
| underplayed (Something bad happen? make sure an alarm
| sounded. If staff ignored it, it must be the fault of the
| staff). I doubt any one person would be in trouble as it
| was a collective/systemic failure, but I don't know exactly
| what would have come of it. Likely a policy change or daily
| reminders for the next few weeks about not ignoring the
| monitors even if it has been going off nonstop for hours.
| Maybe extra charting or peer audits. It's a lot less
| expensive and effort to put pressure on staff than it is to
| change technology (even if it is as little as setting
| different, more sane, defaults). Depending on what was
| recorded from the monitor to the chart, if it looked like
| there wasn't a delay in resuscitation/cardioversion (like
| if the lethal rhythm wasn't recorded initially), it may
| have been just put down as clinical course for the patient,
| like you suggested. My perspective of that place is a bit
| jaded (and therefore biased), that place was a toxic burn-
| out factory. BTW, "post mortem"? Thanks, the morbid humor
| made me laugh!
| LorenPechtel wrote:
| They will try as hard as they can to pin system failures
| on the unfortunate person who was in charge of the
| system.
|
| 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.)
| UniverseHacker wrote:
| Hospitals have a sort of manic "New York Stock Exchange" energy
| and environment to them... The entire environment of a modern
| hospital seems brutally incompatible with the type of peaceful
| relaxing environment you'd want to reduce stress and improve
| patient outcomes. Bright lights, constant noise, loud
| electronics, preventing patients from sleeping based on
| whatever schedule is convenient to medical staff, etc.
|
| 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.
| Aeolun wrote:
| Don't think it's so unrealistic to make a sterile green
| environment with fake plants. Fairly certain it doesn't
| matter too much.
| nradov wrote:
| You're not wrong. ICU delirium is a serious problem.
|
| 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?
| matheusmoreira wrote:
| Hospitals are not "peaceful relaxing environments". They are
| large scale industrial operations designed to process as many
| people as possible. There simply aren't enough resources to
| afford every single person a "relaxing environment". You do
| the best you can for as many as you can. All this
| "relaxation" stuff will quickly be converted into spare
| capacity the second large numbers of severely wounded people
| start showing up at the emergency room.
|
| 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.
| LorenPechtel wrote:
| I suspect the patients would fare better if active noise
| cancelling headphones were issued to every patient.
| gravescale wrote:
| I honestly believe that a pair or noise cancelling headphones
| and an eye mask would have statistically noticable effects on
| outcomes. The bright, noisy environment of a hospital makes
| good, natural sleep basically impossible and that is brutal
| on even healthy people.
|
| 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.
| Buttons840 wrote:
| There will always be false positives and false negatives, they
| have to be balanced.
|
| 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.
| LorenPechtel wrote:
| You have it backwards.
|
| 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.
| takinola wrote:
| I used to work as a field engineer on oilfields and rigs. We
| had panels of equipment, each with their own alarms and beeps.
| Once the rig manager (the client) remarked that we were
| ignoring the alarms, snidely insinuating that we should pay
| more attention given the possibility of things going wrong.
|
| 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.
| KennyBlanken wrote:
| Nope. Alarm fatigue is a well documented problem in the
| medical field.
|
| 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.
| hiAndrewQuinn wrote:
| "They just didn't care enough" is an argument which can
| explain everything about how 1 person operates, half of a
| 10 person group, and roughly 0% of an entire profession.
| It's a question of the economic incentives at play far more
| than doctors universally deciding not to give a shit.
|
| 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.
| nabusman wrote:
| Pure deregulation can lead to a bit of anarchy, but a
| more measured approach that ensures that the regulation
| doesn't act as a way to decrease supply and increase
| profits for the industry would make sense. Probably
| something for Lina Khan to look into.
| matheusmoreira wrote:
| > deregulate the medical personnel industry and allow
| supply to increase
|
| 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.
| hiAndrewQuinn wrote:
| Plummeting salaries for doctors means better average
| healthcare at all price points for the rest of us.
|
| 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!
| matheusmoreira wrote:
| Negotiate? Just quit. At some point you're better off
| doing literally anything else with your limited time on
| this earth. Way too much time and effort for too little
| reward. Who's looking forward to doing a decade of hard
| training only to end up with some 9-5 job and salary?
| That's just absolute nonsense.
|
| 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.
| hiAndrewQuinn wrote:
| Your profile indicates this is Brasil... Let me do a
| quick Google search.
|
| "[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.
| nradov wrote:
| The easiest way to increase the supply of physicians
| would be to increase Medicare funding for residency
| programs. We already have a surplus of smart and good
| people who would love to become doctors. Every year some
| of them graduate from medical school with an MD/DO degree
| but are unable to practice medicine because they don't
| get matched to a residency slot (some of them do get
| matched the following year).
|
| https://savegme.org/
|
| 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.
| LorenPechtel wrote:
| Alarm fatigue is very real. And the lack of sleep is very
| real.
|
| 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.
| deanresin wrote:
| My Mom recently had brain surgery and was recovering. Her
| machine would go off all the time and it took forever for a
| nurse to come buy and fiddle with it. I would joke to my Mom
| that it probably meant she was dying. Those beeps were so
| annoying. If anything, they should be beeping in the nurse's
| control area. It seems ridiculous it has to beep loud enough
| for a nurse down the hallway to hear it when it never seemed to
| be anything urgent or dangerous. Certainly, no one came
| running.
| tux3 wrote:
| Trying to figure out which melody was which in an emergency
| doesn't seem like the most human-friendly.
|
| 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)
| sebmellen wrote:
| GPWS warnings should be the gold standard for any sort of
| urgent audio alarm.
|
| Examples: https://www.youtube.com/watch?v=W5Z-d1Zx02o
| imglorp wrote:
| At :42 I think the buzzing sound is the "stick shaker" stall
| warning. It literally shakes the pilot's control yoke. So not
| only is it an alarm, it's also reminding the pilot of the
| correction needed: to push the control forward.
| varjag wrote:
| Wouldn't that be pull backward?
| seabass-labrax wrote:
| Not in this case, because the 'stick shaker' activates
| when the aircraft is stalling or close to stalling. The
| only sensible option in this scenario is to lower the
| angle of attack, that is, pitch forward. If you have both
| the GPWS 'terrain, pull up' warning and the stick shaker
| warning simultaneously then you are in a sticky situation
| indeed.
| krisoft wrote:
| > If you have both the GPWS 'terrain, pull up' warning
| and the stick shaker warning simultaneously then you are
| in a sticky situation indeed.
|
| 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.
| krisoft wrote:
| What i heard is that it is designed to imitate the stick
| sensation smaller airplanes have as the wind buffets the
| controll surfaces when a stall develops.
|
| And pilots from an early stage in their flying training
| conditioned to push the stick forward when that happens.
| Lammy wrote:
| Making this my PagerDuty alert sound
| https://youtu.be/fbfVGIBcD8c?t=77
| flemhans wrote:
| I used to have pull up as my ringtone, freaked my uncle out
| (who's a commercial pilot) when he was over for dinners. Or
| at least he pretended to be :P
| krisoft wrote:
| I was half-asleep travelling on a train when a kid blew a
| wistle near me which sounded exactly like the stall warning
| horn of the Cessna-150 i was learning to fly around that
| time. It jolted me awake right away. I had this clear
| clarity in my mind that i have to push the controls forward
| until i realised that I am nowhere near an airplane.
| masto wrote:
| Now I have this.
|
| https://looptube.io/?videoId=W5Z-d1Zx02o&start=77.1286764705.
| ..
| yread wrote:
| They also have their share of cavalry charges and buzzers. Plus
| the plane sometimes calls you a retard
| kmoser wrote:
| At least chimes are language-agnostic. Verbal warnings like
| "pull up" are only good if you have a reasonable grasp of
| English.
| graypegg wrote:
| At the very end, there's some examples of more literal
| sounds. It says there hasn't been a study, but I would bet
| they're a lot more clear with out having to resort of the
| aviation standard of "just learn basic english".
|
| _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!
| turrican wrote:
| True, but professional pilots from all countries are expected
| to be fluent in Aviation English.
| https://en.wikipedia.org/wiki/Aviation_English
| kmoser wrote:
| Yes, but in a high-stress environment, your ability to
| process words--especially those not in your native language
| --goes down the tubes quickly. Even if you were to _tune
| out_ sounds to the same degree that you tune out words, at
| least the sounds would still have a relatively universal
| meaning, e.g. loud klaxon for big problem, soft chime for
| minor notification.
| flemhans wrote:
| Another good thing is that they allow for talking over them
| better. The same way you may sing along to an instrumental-
| only music track using whichever lyrics you prefer.
| graypegg wrote:
| I wonder how much information any 1 medical device with an
| alert knows though. GPWS has the benefit of being part of 1
| system, where (I think, no experience here) hospitals seem to
| treat equipment as singular items that do 1 thing or are meant
| for a specific area of responsibility in an operation. Like a
| vitals monitor might not know what the drug pump is doing.
|
| I could imagine ventilation?
| arrhyth-*C-chord*-ARRHYTHMIA! CHECK PUMP! HEART RATE!
|
| coming from different devices to be pretty distracting.
|
| 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.
| HeyLaughingBoy wrote:
| That's really the problem many here are describing. 60601
| mandates what alarms shall be active, but it spans a single
| device. If you have, e.g., 10 ventilators in a room that are
| alarming, you can't silence them all with a single button
| press.
| graypegg wrote:
| I can kind of understand why it ended up that way. There's
| some benefit to just assuming, nothing works together. It's
| at least a consistent state of affairs. You can just wheel
| in any heart rate monitor, and you only need to understand
| that heart rate monitor.
|
| 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.
| HeyLaughingBoy wrote:
| Interoperability is definitely a problem. I've been in
| the industry for quite some time, and at one job we got
| to shadow med lab techs, since they were the operators of
| the machines that we built. Their workload is _insane_
| and after an hour watching them work, I could identify a
| number of new products that would help them. I brought it
| up to my management and learned that "marketing is aware
| of those problems and we're devising solutions." No idea
| if those solutions ever hit the market -- this was over
| 10 years ago.
|
| 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.
| fhsm wrote:
| Inter op has a lot of different standards but support for
| all those standards is limited. Here's an example:
|
| 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:
|
| https://www.iso.org/standard/72026.html
| unsignedint wrote:
| One significant difference between verbal warning systems in
| airplanes and those in medical environments, such as hospitals,
| is the level of environmental control. In an airplane, the
| environment is highly controlled, with a single set of systems
| specific to that aircraft. In contrast, hospitals often have
| multiple systems operating simultaneously in the same room or
| nearby. This can lead to cognitive overload when multiple
| systems issue verbal warnings simultaneously. In such
| scenarios, tone alarms might be easier to manage and
| differentiate than multiple overlapping verbal warnings.
| akira2501 wrote:
| > In an airplane, the environment is highly controlled
|
| 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.
| Dalewyn wrote:
| >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.
|
| 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.
|
| [1]: https://en.wikipedia.org/wiki/Alarm_fatigue
| akira2501 wrote:
| Yea, I kinda got myself there in a roundabout way in the
| end.
|
| 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.
| g15jv2dp wrote:
| What's not clear from this webpage is whether these are actually
| used anywhere. Are they? I couldn't tell.
| thomasthorpe wrote:
| Yes, well, some. To gain certification, often something
| customers require, medical devices must comply with standards
| such as ISO60601 (hardware) ISO62304 (software) and ISO13485
| (process, quality management).
|
| 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]
| HeyLaughingBoy wrote:
| > often something customers require
|
| 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.
| davidw wrote:
| It gives me anxiety just looking at this. Add this to the list of
| things I don't want to work on.
| HeyLaughingBoy wrote:
| On the producing or consuming side? FWIW, I found the article
| interesting as I'm starting a new Oxygenator project so I'm
| probably about to become even more familiar with IEC60601 :-(
| davidw wrote:
| I don't want to work on software where bugs might cost
| someone their life.
| HeyLaughingBoy wrote:
| I get that, but it's very unlikely to happen. The benefit
| of your code vastly outweighs the potential downside. As
| engineers, we're used to only hearing about the problems.
| It's really gratifying when you hear from someone who says,
| "tell your engineers that they saved my life."
| blackeyeblitzar wrote:
| I absolutely hate the poor design of medical equipment found in
| hospitals. The worst thing by far is the constant beeping and
| noises in the room, which totally disrupts rest and hurts
| recovery. It is SO obvious that this hurts patients (and
| visitors), that I cannot believe the entire medical industry
| (nurses, doctors, hospital administrators, equipment makers,
| insurance companies) have failed to do anything about it. It also
| makes it hard to know if some sound is expected or if it is a
| signal that something is wrong. In addition to this, I've seen
| nurses make mistakes several times because the equipment is too
| confusing. Once, I had to page the nurse myself because the IV
| they thought they set up was not functioning and I was able to
| discern that from the screen on the IV machine (which said one
| particular drug was not active) but they had not noticed,
| essentially administering an imbalanced cocktail of drugs for a
| period of time.
|
| 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.
| atahanacar wrote:
| >I've seen nurses make mistakes several times because the
| equipment is too confusing. Once, I had to page the nurse
| myself because the IV they thought they set up was not
| functioning and I was able to discern that from the screen on
| the IV machine (which said one particular drug was not active)
| but they had not noticed
|
| This doesn't sound like the equipment's fault.
| blackeyeblitzar wrote:
| Technically no, but watching them debug it and configure it
| made me think it's too complicated. They basically had to
| figure out the right sequence of buttons to hit.
| mschuster91 wrote:
| It's a necessity, a side-product of not having anywhere near
| enough nurses, assistant staff and doctors in hospitals.
| They're juggling alarms constantly (which have to blare in a
| cacophony) and speed from one patient to the next.
|
| _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...
| ler_ wrote:
| Thank you for bringing that up, understaffing affects
| everything and harms patients. No set of alarms will ever
| replace the benefit of having enough people working.
| blackeyeblitzar wrote:
| I don't disagree but I'm not sure how to make the costs of
| healthcare work with those ratios
| mschuster91 wrote:
| Get rid of bureaucratic bullshit and you'd get > 250
| billion $ a year [1]. Get rid of insurances and other
| middlemen and you'd get _another_ 450 billion $ a year by
| going for single-payer [2]. Then, get the homeless enrolled
| in insurance as well - even if the government pays the
| premium, _every single homeless person_ costs > 18k a year
| in ER visits [3], a lot of which could be prevented if
| these people could go to a doctor before they'd be sick
| enough to incur serious ER costs. And finally, get as many
| homeless drug addicts back into some sort of stable
| housing. A lot of drug usage "on the streets" is self-
| medication to cope with the immense stress that comes from
| being homeless. Yes, there will always be a certain
| percentage of hardcore voluntary homeless people, but
| that's way better manageable than the status quo.
|
| 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...
| dmd wrote:
| About 15 years ago I worked for a medical usability firm. We
| did a review of the Baxter Large Volume Infusion Pump. Among
| dozens of other issues[1] we found, the absolute mother of them
| all was the stop button, which had been _overloaded_ to have
| multiple functionalities:
|
| 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.
|
| [0] https://archive.is/s1wEU
|
| [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.
| blackeyeblitzar wrote:
| > 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.
|
| Wow this sounds so dangerous and so easy to predict.
| nradov wrote:
| If you want to feed observation data into Epic for charting
| that is quite easy. It supports inbound interfaces using HL7 V2
| Messaging and FHIR standards for things like medical device
| waveforms, aggregated device data, vital signs, etc. Other
| major inpatient EHRs have similar functionality.
|
| 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...
| ano-ther wrote:
| I seem to remember that some of these sounds (perhaps the one
| with syllables) were originally part of a joke paper and that the
| author was quite astonished how they became part of a standard.
|
| Unfortunately, I cannot find the article anymore.
| tverbeure wrote:
| A friend of mine used to have a small side business selling
| loudspeakers for medical equipment. She order them in Asia and
| had her own little certification lab at home: heat chamber,
| impedance testing, that kind of stuff. Every so often, she'd
| receive an order of a few hundred speaker, and test them one by
| one.
|
| 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.
| roughly wrote:
| The cardiac alarm tone is unexpectedly jaunty.
| graypegg wrote:
| Out of all of them, it's definitely the most "washing machine
| is done"
| strnisa wrote:
| The standardization of medical alarms was important when
| introduced, providing consistent and clear communication across
| devices and countries. However, with modern technology, these
| standards may now limit innovation.
|
| 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.
| ncallaway wrote:
| I don't know, I kinda think if you're going to have verbal
| warnings you kinda need a centralized system that processes all
| alarms to triage them like in an airplane.
|
| 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.
| Aeolun wrote:
| If two of these tones sound at the same time, I'm fairly
| certain I couldn't distinguish them.
| throw46365 wrote:
| I remember my Dad, in his last day conscious, with a fluid line
| in that kicked off some sort of pressure alert every time he
| raised his hand to his face... which he did compulsively because
| of his confusion on top of his dementia.
|
| 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.
| ijustlovemath wrote:
| We're building a life critical medical device, and I haven't seen
| this mentioned, so I thought it was worth contributing:
|
| 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.
| jimmySixDOF wrote:
| The airline industry went through this too and have moderated
| requirements to be more understanding of who it's consumers are
| and when. One of the big near miss cases was QF32 out of
| Singapore where they had over 50 alarms to deal with in
| addition the the emergency at hand. Alarm pollution is a real
| UI/UX dilemma.
| hejdufufjrj wrote:
| In an airplane at least all the alarms are integrated, but in
| a hospital room you'll have 15 devices from 7 manufacturers
| spanning 5 generations.
| amelius wrote:
| Maybe someone can train an AI to decide which alarms need
| immediate attention, given N staff members available.
| throwaway765123 wrote:
| Yikes I hope this is tongue-in-cheek, I definitely don't
| want a statistical process deciding whether to surface a
| life-critical alarm to healthcare staff
| amelius wrote:
| If it statistically saves lives?
|
| 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%.
| wolrah wrote:
| > Maybe someone can train an AI to decide which alarms need
| immediate attention, given N staff members available.
|
| 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.
| ijustlovemath wrote:
| The FDA would not let this fly. To get a device in the
| hospital, you have to enumerate EVERY failure mode that you
| can reasonably protect against, as well as the ones you
| can't. Some of these failures are crucial enough that they
| qualify to be _required_ to implement an alarm for.
|
| 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.
| hi-v-rocknroll wrote:
| 58 faults on the ECAM. Source: https://youtu.be/a-4FBN8OTkk
|
| Props to Airbus for proper UX and information prioritization.
| netsharc wrote:
| Huh, that title smells of tabloidization. I know about this
| incident, the "mid-air explosion" have to do with an
| uncontained disintegration of 1 turbine (with shrapnel
| flying that breached the wing, luckily not the fuselage),
| but the title makes it sound the whole plane exploded...
| hydrolox wrote:
| this is very true with diabetes equipment since there is
| constant alerts (for example from insulin pumps) of low
| battery, undelivered insulin, etc. I think it definitely helps
| to give users the right amount of control if it's non life
| critical like a CGM or for insulin delivery.
| ijustlovemath wrote:
| Insulin delivery is considered life critical by the FDA,
| because the failure modes of those devices can involve coma,
| brain damage, and even death. Some of those alarms will still
| be hardcoded, and for good reason!
| hydrolox wrote:
| I agree, but something like "incomplete bolus" doesn't
| really make sense to me and I think those types contribute
| to alarm fatigue. The key issue with T1 diabetes is
| hypoglycemia, which can cause acute damage and death, so in
| theory not having insulin on isn't as big of an issue
| (assuming the patient is actually trying to control their
| disease and checks blood sugar etc, in the alternate case
| the alarms probably don't help much). Of course, I agree
| something like a hypoglycemia alarm is important
| userbinator wrote:
| Some of them remind me of YouTuber Ashens' intro sound.
| jill4545 wrote:
| An amendment to IEC 60601-1-8 introduces the concept of acoustic
| icons. These are the alarms that mimic the sound of what the
| device does e.g. a ventilator would be a sighing/breathing sound
| as well as a pulse to indicate if its alarm with a priority. This
| directs the clinician to know immediately which device is
| alarming and how high the priority is as opposed to a plethora of
| beeps and pings all merging together. Could be a game changer.
| kioleanu wrote:
| Only very slightly tangential, I remember when my son had his
| surgery and had to be in the hospital, they would have these
| dosing machines for the medicine and they would start throwing a
| warning sign 3 minutes before the syringe was empty, every 30
| seconds and then a proper alarm when it was empty. Now, we were
| supposed to call a nurse to remove the syringe, and each nurse
| had their own preference on when to be called. Some said call us
| when the warning starts, some said call us a minute before and
| some said call us when the red alarm goes off. We found this
| strange until one of them explained it is simply related to the
| amount of chit chat they wanted to do with us, as the syringe
| always had to go out at the red alarm
| chess_buster wrote:
| There's a dissertation from a Professor of Health Care about
| Alarms in ICUs:
| https://uol.de/f/2/dept/informatik/download/Promotionen/Cobu...
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