2nd Potential Alarm Fatigue Death in 4 Years in Boston Area Hospitals

‘Alarm fatigue’ a factor in 2d death

by Liz Kowalczyk

The second patient death in four years involving “alarm fatigue’’ at UMass Memorial Medical Center has pushed the hospital to intensify efforts to prevent nurses from tuning out monitor warning alarms.

Nurses exposed to a cacophony of beeps may no longer hear them or begin to ignore them, and that’s what appears to have happened in the latest case: A 60-year-old man died in an intensive care unit after alarms signaling a fast heart rate and potential breathing problems went unanswered for nearly an hour, according to state investigators who reviewed records at the hospital.

The death occurred in August 2010 but was not reported to the state Department of Public Health until this spring. The state cited various violations by the hospital, including not responding to alarms “in a timely manner.’’

The fatality was remarkably similar to another at the Worcester teaching hospital four years ago, when nurses didn’t hear or ignored alarms indicating that the battery on an elderly woman’s monitor needed to be replaced. After the battery failed, 77-year-old Madeline Warner suffered cardiac arrest and the alarm didn’t sound.

Warner’s death in 2007 led the hospital to adopt aggressive measures to improve nurses’ responses and tackle alarm fatigue, which can occur when nurses hear alarms – many of them false – all day long. But the new death shows the problem continues, as it does at hospitals nationwide. It has led to at least 200 patient deaths since 2005 and likely hundreds more, according to a Globe investigation published earlier this year.

“I don’t think any hospital has fully solved this problem,’’ said Maria Cvach, an assistant director of nursing at Johns Hopkins Hospital in Baltimore and a specialists on alarm fatigue. At Hopkins, which is known for its intense focus on reducing false alarms and alarm fatigue, Cvach said she still sees nurses “not hearing or not answering alarms’’ because “they go off all the time.’’

Executives at UMass Memorial declined to comment about the latest death. The Globe obtained the Department of Public Health report on the case through a freedom of information request. The document does not say who disclosed the death to the state or provide a reason for the reporting delay, but the Globe’s stories on alarm fatigue, which included an account of Warner’s death, appeared several weeks before the health department was called.

The state inspectors’ report, which omits the patient’s name and other identifying details, indicates that the patient also was the apparent victim of a medication error. It does not make clear the extent to which that error or alarm fatigue contributed to the patient’s death.

The patient had been cutting down a tree and was struck in the head with a large branch in July 2010, breaking bones in his face and causing bleeding in his brain. After surgery at UMass Memorial, the patient was often restless and agitated. He kept removing a monitor that measured whether his blood had enough oxygen, triggering an alarm to sound much of one day – which could have been a factor in desensitizing nurses.

Read the entire article at Boston.com

What to Expect as a New Remote Viewing Student – Assistance and Resources Available

Remote viewing is a tool you can use to improve your life.  It is a tool that must be earned on a regular basis with practice and fine-tuned by honorable use.  It is not glamorous, not a particularly exciting process to go through, not something to pick up when the rare mood strikes you, or a useless star-streaked ride through wondrous astral planes.  Perception based remote viewing is an attention management skill.

Remote viewing can be used to find out just about anything.  The most practical way to spend your time in session is to discover information that will help improve your life, and perhaps the lives of others.  Sure you could attempt to find out if you should keep seeing some guy, or when the next big earthquake is going to occur, but you could also find out your next best employment opportunity; or what you should be doing to obtain optimum health; perhaps even work with others to find missing children and assist in their recovery; or discover the method to develop the next bestselling widget to help improve the quality of a sick person’s life half way around the world.

People have all kinds of wild ideas about what a session might look like.  It is not meant to appear “artistic” or feel “other worldly” but is more a data gathering function that results in a simple diagram with simple shapes and words that help describe what is going on.  Most people that start out only have simple lines, angles, circles, rectangles and motion indicators, and some basic words that help describe what they are seeing (and that’s the way it should be when you first get started.)

You spend roughly 45 minutes sitting still in a chair, recording your perceptions in a very orderly way.  It’s quite boring to watch and most serious remote viewers want to be alone while they do this to avoid distractions showing up in session (except for those that use a monitor as is the case with some CRV based methods).

There is a wealth of information hidden in simplicity. I have known quite a number of non-remote viewers who seem put off by the S.T. (site template) of a session, the final result of the data gathered.  It may not look like much, or just come off as a jumble of simple drawings surrounded by words with nothing immediately standing out as anything of interest.  Once you have learned the basics of remote viewing, it becomes quite easy to read and have an idea of what is being portrayed, just as an electrician or architect can immediately make sense of blueprints.

It takes months or years of steady practice to walk into session day in and day out, able to draw and describe something in such great and accurate detail that anyone looking at an S.T., including the viewer, is almost always able to name it and explain what is going on or what is the significance of that object.

If you are in search of an unknown, as is often the case with a cue (like a question, a set of words) based remote viewing assignment, you may feel lost at first when trying to make sense of the final product. Greater understanding often is gleaned by providing yourself with feedback:  by viewing the photo or reading the cue.  It is then that two and two make four.  Even with simple photos provided after the completion of a practice session, there are often a number of “aha” moments.  It’s these moments that help us to improve.

For group projects only certain data is relied upon: that which repeats itself over at least 2 remote viewer’s sessions for the same assignment.  Through trials it has been shown that information gathered in this way approaches 100% accuracy.  If you complete a session twice, (preferably blind to the fact that you are completing the same session an additional time) you can usually take the data that repeats and rely on that to help you make decisions.  Of course, common sense should always prevail.

There are simple techniques you can use when setting up your “blind assignment basket” so that you can complete a session on the same assignment twice and not know that you are doing so.  This is a slower way of gathering information, but also results in the ability to keep an important project private as well as knowing which information gathered is most reliable.

There are many misconceptions about what remote viewing is and what it is related to in application, form and function.  Perception remote viewing is not channeling or meditation or happens as a result of emptying your mind or relaxing or listening to sound, nor is it dowsing or astral projection.  No amount of supplements, mantras or subliminal tapes are going to make you able to RV or cause you to have a spontaneous “RV experience” or improve the quality of your work.  Only practice, observation and following protocol will cause you to improve. In terms of practicality, it is worlds away from the value astrology reports or tarot card readings can provide (I used to be paid to do both, but have completely quit them).

On a side note… I was very “oh look a squirrel” before I began and would want to scrap sessions left and right for the first six months because I was realizing I had so much brain chatter it was hard to focus. I worked through it and just kept practicing. Now it’s easier for me to focus even when I’m not in session.

I have posted a sample remote viewing practice session to give you a taste of what to expect should you be interested in learning remote viewing.

Remote viewing requires a commitment to yourself.  You must also know why, deep down inside you want to learn and why you want to have this skill at your disposal.  You don’t have to have romantic notions of changing the world, but you have to believe yourself and have a strong conviction that keeps you going when times get tough.The easiest part of remote viewing is learning the basic rules.  If you are not sure yet if remote viewing is right for you, I suggest just jumping in and learn the basics, while letting yourself know it’s fine if you want to pull back after your initial training to evaluate if this is something you want to be a part of your life, to integrate into your own being, like any other skill or hobby.   That time after someone learns to go through the motions and can stumble through a complete session is when a large majority of people either decide they love it or can leave it.  The water’s warm, so pull up your skivvies and take the plunge.  You won’t melt, I promise.

If you have questions, want to learn more about the subject in general or would like help getting started I do offer some free training and provide free practice photo assignments.  I also extend confidential assistance with blind pools, cuing, basic project management and analysis for the novice and experienced remote viewer.  We are all here to help each other,  just email via the contact form on about.me.

Reaching Beyond Self – Sending a Soldier a Care Package from Home

There are many American soldiers scattered throughout the world who would like nothing more than a piece of home, whether that be much needed gear, bed linens, their favorite snack or just a few kind words in a short letter from a stranger.

Sending a care package from home to a complete stranger might not be your first thought when seeking self-development, but these small acts of charity (the more accurate translation of the word commonly referred to as “love” found in 1 Corinthians 13 in many newer versions of the Bible) help to take our mind off our own daily issues and to be thankful for the small things in life we take for granted.

Finding a soldier is easier than you might think.  Shipping is not expensive and they are only a few basic guidelines you need to follow.  The website Any Soldier makes it easy to put a smile on the face of a hardworking soldier.

From the Any Soldier website:

It was March 26th, 2003. Army Sergeant Brian Horn, one of 1,000 soldiers, parachuted into enemy territory in Northern Iraq. Five months later, Brian Horn was able to call his parents. Marty and Sue Horn had been sending their son an average of six care packages per week. So when Brian asked his parents to send more, “my wife and I thought he was kidding!” Marty Horn told me. “But Brian said, ‘no — its for the soldiers that don’t get any.’”

Both Marty and Sue Horn had spent their careers in the Military, so they immediately understood what Brian was saying. Millions of men and women serving overseas never receive any mail. Besides often lacking basic necessities, these men and women have to cope with the harsh conditions of serving overseas without signs of support from friends and family back home.

Any Soldier is a website that lets you find a soldier to send letters or packages to. Some are better off than others but all of them are missing something or another from home. Some of them would like nothing better than a letter.

Brian Horn’s regiment spent nearly a year finding places to sleep on the ground or on their vehicles while behind enemy lines in Northern Iraq. From Life in Iraq, Stars and Stripes special report on morale. October, 2003, Jon R. Anderson, Stars and Stripes.

Why would you want to do this? You may want to consider this act a reminder to be thankful for what you might take for granted, or to remember others before you start to worry about trivial matters in  your life.  Keep in mind this action is in no way a political statement. Whether or not you believe in the reason the government put those soldiers in various places around the world has nothing to do with the individual Americans that are far from home.

Maybe their store is always running out of soap or they can’t get their favorite gum or candy where they are. Maybe they are in short supply of socks or proper boots or need sheets. Maybe they are bored and just want a new video game to take their mind off more serious things in their off time. If you are a die-hard gamer you can understand this plight. The items and reasons are endlessly varied.

There are thousands of names to choose from and usually it is best to choose someone that is newly listed because they don’t have as many people sending them packages. Each soldier will state how many people they have contact with on a regular basis and separate them into male and female. I chose a female soldier because I figured I’d have a better grasp of what she would want or need.

If you want to help, do what you can, even if it is just a letter. I’ve read time and time again letters are much appreciated. This would also be a good project for a classroom or church. A soldier could be chosen that has an appropriate amount of contacts (say one for each student or one per classroom). A list could be made public of all their wants and needs. Small donations could be asked for the shipping and packaging supplies. Boxes could be sent off as they become full and the money is raised for shipping.

You can click on a link on the solider info page that will tell you what the shipping rules are. Also you will need to read the details about shipping. Basically you only pay for shipping to a few points around the United States, so you might want to pick someone that has a zip code close by to keep your shipping costs to a minimum. The average sized box shouldn’t cost more than 10 dollars or so to ship.

For security reasons you have to request an email containing the soldier’s address, and can only ask for a few at a time. They are usually prompt in emailing you the information, just be patient and check your junk mail. Also, before sending additional packages, check back and see if there is a notice that the address has changed. Usually it doesn’t because units move together, but if the individual is a floater of sorts or if a unit embeds itself into bigger units then there may be an address change.

If you decide to send anything, just follow the rules. Depending on where you send something the rules may change. Often you cannot send pork products, fresh vegetables, or money and I’m pretty sure you can never send anything overly violent or sexual, even if they don’t know any better or do know and ask. You are still responsible for what you send in the mail.

Although you may ship to a specific soldier, in spirit the packages can be given to anyone who might need what’s inside, but only if you write a specific line in the shipping address. If you want, you may write “ATTENTION: ANY SOLDIER” (in all capitals to adhere to U.S.P.S. guidelines) below the soldier’s name. This will help ensure that your package will be given to someone else who can appreciate your effort and not end up a “Return to Sender” waste of time and money.

I’ve had arguments with a few postal workers about the use of the line “ATTENTION: ANY SOLDIER” even though there is a name above it. This particular line without a name is not acceptable, but the official rule as I understand it, is that it is fine as long as there is a name above it. Try telling that to some of the postal workers and you’ll end up in an argument and won’t get anything sent.

There is however a simple solution to this. After writing the line, cross it off with a single pen stroke. Then there is no argument because if you are given a hard time by a well-meaning but misguided employee you can say: “Yes I know, so I crossed it off.” A scowl might be thrown your way but they can’t do anything about it.  The addition of this simple line in the address helps the soldier understand the meaning of the package.

The rule of thumb for shipping is, if the box is shaken and you can hear stuff move around you haven’t stuffed enough peanuts in. I hold the box closed and give it a gentle and then rougher shake. Once I get the box so there’s no more sounds of shifting, I then pack a few extra in, squeeze it shut and tape it up very well. The reason I do this is because peanuts do settle a bit in shipment.

Put as many layers of sealed plastic as you can between things. If you send something such as soap and candy in the same box, wrap them up individually in several layers of small unscented trash bags or sandwich bags or even larger food storage bags. (These kind of bags can be reused and might come in handy.) I can ensure you, the candy will taste like soap after being locked up in a box for a good deal of time, even if they are both in their own package. This also helps if something comes out of its package and leaks. Even if it makes it way out of its own plastic bag, it won’t get on everything else. Whatever you do, never send anything like soda or aerosol cans like shaving cream or bug spray. Buy squirt bottles instead. It’s a good idea to tape removable lids in place.

Oh and don’t expect a reply. They are busy doing a dangerous job. It is usually easier to give them an email, but even then, sometimes they just don’t have time or don’t have access to a computer on a regular basis. Some of them don’t have access to reliable electricity!

The best way to keep up with what is going on with them is to check back on the website, as they have to check in every 50 or so days so the owners of Any Soldier know they are still available to take packages and letters. Some of them seem to give weekly updates with lots of pictures. Others aren’t so social or wordy and just let you know they received your packages and they are thankful and give an update on things such as “no more books we have a library now!” or “we still need socks and shampoo.”

Check out the Any Soldier website and become familiar with it. Click on some names and read what these soldiers have to say. Pick one, check the shipping rules for their particular address, and put a smile on the face of a hard working soldier!

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1 Corinthians 13:11-13

When I was a child, I spake as a child, I understood as a child, I thought as a child: but when I became a man, I put away childish things.

For now we see through a glass, darkly; but then face to face: now I know in part; but then shall I know even as also I am known.

And now abideth faith, hope, charity, these three; but the greatest of these is charity.