EZ SLIDE

Description of Event or Problem

DURING A SURGICAL PROCEDURE WITH THE PATIENT POSITIONED IN CRANIAL PINS ON A SKYTRON SLIDER BED, AN UNEXPECTED MECHANICAL MALFUNCTION OCCURRED. AFTER THE PROCEDURE HAD BEGUN AND PHYSICIAN OBSERVED THAT THE HEAD OF THE BED WAS SPONTANEOUSLY ELEVATING. HE INQUIRED IF THE ANESTHESIOLOGIST WAS ACTIVATING THE BED REMOTE, TO WHICH ANESTHESIOLOGIST RESPONDED THAT HE WAS NOT. THE SPONTANEOUS ELEVATION OCCURRED A SECOND TIME, PROMOTING THE SURGICAL TEAM TO PAUSE THE PROCEDURE. ATTEMPTS WERE MADE TO RETURN THE HEAD OF THE BED TO NEUTRAL POSITION; HOWEVER, THE REMOTE WAS UNRESPONSIVE. EQUIPMENT TECHNICIANS RESPONDED TO THE ROOM AND ASSESSED THE ISSUE. ATTEMPTS TO CONTROL THE BED USING THE MANUAL BUTTONS AT THE BASE ALSO FAILED. THE BED WAS IN A STEEP REVERSE TRENDELENBURG POSITION. IT WAS NOTED THAT THE BED WAS PRESSING DOWN ON THE SCD [SEQUENTIAL COMPRESSION DEVICE] MACHINE, WHICH WAS POSITIONED UNDERNEATH THE FOOT OF THE BED. THE PRESSURE APPEARED TO BE SIGNIFICANT, AND IT WAS OBSERVED THAT THE SCD MACHINE WAS ACTING AS A BARRIER, PREVENTING THE BED FROM MOVING INTO AN EVEN STEEPER ANGLE. EVENTUALLY, THE BED EXERTED ENOUGH FORCE TO BREAK THROUGH THE TOP CASING OF THE SCD MACHINE. THE BED WAS UNPLUGGED AND RECONNECTED TO POWER, WHICH TEMPORARILY RESTORED FUNCTION TO THE BASE CONTROLS BUT NOT THE REMOTE. THE TEAM WAS ABLE FLATTEN THE PATIENT MOMENTARILY, BUT THE BED AGAIN BEGAN TO MOVE ON ITS OWN INTO REVERSE TRENDELENBURG POSITION, WITH THE FOOT SECTION OF THE BED ELEVATING TO A 90-DEGREE ANGLE. THE MOVEMENT CAUSED THE PATIENT'S RIGHT FOOT TO BECOME FORCIBLY INVERTED AND COMPRESSED, WITH THE ENTIRE FOOT AND TOES COMPRESSED. THE SURGICAL TEAM GATHERED PILLOWS AND OTHER PADDING TO SUPPORT THE PATIENT'S RIGHT LEG AND ALLEVIATE COMPRESSION WHILE NEUROSURGEON BEGAN CLOSURE OF THE SURGICAL SITE. ONCE THE INCISION WAS CLOSED, THE PATIENT WAS REMOVED FROM CRANIAL PINS AND TRANSFERRED TO A NEW STRYKER BED. AFTER THE TRANSFER, ORTHOPEDIC TRAUMA WAS CONSULTED AND IMAGING PROVIDED THAT DID NOT FIND EVIDENCE OF FRACTURE AT THIS TIME, DEEMING IT SAFE TO PROCEED WITH SURGERY. THE PATIENT WAS REPOSITIONED IN CRANIAL PINS ON THE NEW BED; THE SURGICAL FIELD WAS RE-PREPPED AND THE PROCEDURE RESUMED. AT THE CONCLUSION OF THE CASE, THE PATIENT'S RIGHT ANKLE WAS WRAPPED WITH AN ACE BANDAGE PER ORTHO TRAUMA TEAM'S REQUEST.