Pump malfunction causes death?!?-- 27 year old Steven Krueger

[lark 27]

I just came across this letter to the editor related to the death of Steven Krueger due to his MM pump priming the entire cartridge of insulin during his sleep: Insulin pumps can be faulty (http://www2.canada.com/windsorstar/news/letters/story.html?id=69abe737-e48e-402c-a517-2992886999f6) Wow! Talk about a scary article. I've been trying to fact check this some, but have not really found anything other than posts on various blogs.

The last thing I want to do is to be needlessly sensationalistic and scare people from the pump needlessly because I have seen such great progress since I've been using the pump, but I thought I would post with the hope that someone can add some knowledge here about how I shouldn't be frightened by this.

Any thoughts from my trusted diabetes forum community?

[Gordonm]

Yea and you could fall down and break your neck tomorrow. The law of averages is still on your side. There are always these scare stories around. Maybe they are true maybe not. Any machine can malfunction. I'll take my chances with the pump.

[JediSkipdogg]

I love how the article talks about three other cases of deaths with pumps and numerous cases of low blood sugars on pumps. I guess since I'm on a pump I should never go low? Gosh, when did I not get this memo? My brother has had to extreme lows that he can't remember anything in the past two months and he's not on the pump. The doctor thinks it was his activity level.

I just want to know how they can say it was a pump failure for sure unless they looked at the prime log and saw it all primed in at once. And even then, can you for sure rule out pump failure and not suicide? Just a sad thought to think about.

Seems very hard to prove it was a pump error unless you can surely replicate the error by a pump just sitting there and it automatically giving all the insulin in the cartridge at once.

[notme]

I tend to agree with this assesment, Jedi. Unfortunately, the 511 is a pretty old pump and correct me if I am wrong, but one of the first in the paradigm series. My pump has a safety that will not let it deliver more than 10 units (or whatever is set). Don't know if that is available on the 511.

I guess my point is that I don't think this one article should stop anyone considering the pump. The benefits FAR out way the risks.

[telizas]

"The pumps were never returned to the manufacturer."

WHY? Why were they never returned? Tested at an independent lab? If I thought a medical device killed my child, I'd be at their door camping out until I had some answers!

This is anecdotal and while I feel for these people, there is no way to conclude it was the fault of the pump.

[statdeac]

The article is lacking detail, for sure.

[AngelKitty]

I guess my point is that I don't think this one article should stop anyone considering the pump. The benefits FAR out way the risks.

I completely agree with you Nancy.

Besides all machines are capable of malfunction, heck people malfunction all the time!

[butterflykisses]

I have read this same story all over the internet, but can not find anything other than a parroting of this story. Its possible that it's true that the pump malfunctioned, but you would think there would be a recall or at least some mention about it OTHER than a "letter" to a paper??? I'm with telizas, if my child was killed by a malfunctioning medical device I would be shouting from rooftops making sure the world knew about it, not just writing a letter to one paper! I don't get it.

[lark 27]

Honestly, I feel somewhat guilty for wasting anyone's time (mine included) with this thread. I agree that the veracity of all of this is questionable and that even if a one-time pump failure occurred I would still consider the law of averages and continue pumping, but I sure would like to see some official statement from Minimed or something. I had to call yesterday for something else so I asked if they had any statements on this or other concerns and was just told to go to fda.gov and run a search which proved totally fruitless. I just tested my pump which I have a max dose set on, and when I entered prime mode and primed over that amount it definitely kept going. Alas, I guess I'll just move on...

[Subby]

Please don't feel guilty. I guess in the end it's something one needs to consider at face value as well as one can - because that's all we really get. That doesn't make it the wrong thing to post in the least! I guess I am also thinking of myself a bit, as I like to draw attention to things even if they are not all that I first thought, but that I think are worth a look by a few sets of eyes - and that's exactly what you did. Thanks for posting it.

[butterflykisses]

Honestly, I feel somewhat guilty for wasting anyone's time (mine included) with this thread. I agree that the veracity of all of this is questionable and that even if a one-time pump failure occurred I would still consider the law of averages and continue pumping, but I sure would like to see some official statement from Minimed or something. I had to call yesterday for something else so I asked if they had any statements on this or other concerns and was just told to go to fda.gov and run a search which proved totally fruitless. I just tested my pump which I have a max dose set on, and when I entered prime mode and primed over that amount it definitely kept going. Alas, I guess I'll just move on...

I have never tried that before. But then I would not expect the limits placed on boluses and basals to have an effect on how much of a prime can be given. I know that my Ping will only allow a 1 unit cannula prime. I have no idea about the tubing prime? I'm trying to remember what the Cozmo had? I know that when priming the tubing that it would prime to a certain amount, and if you went over that, it would stop and ask whether to continue the prime or not.

My Ping delivers a bolus fast and it can sting! So I tend to extend them if they're over a unit. I forgot to do that this morning and YIKES! :eek: It made me think about how it would feel to have a whole cartridge injected at once!

[fgummett]

I agree that there is little to prove this story and have been unable to find anything other than other sites restating the same claims... often word for word.

The letter form the parents seems pretty philosophical. I doubt I would write in such matter-of-fact terms if it were my son who had died.

I guess I'm sceptical that something as thoroughly tested as an Insulin Pump would allow such an action. I write and test software as part of my job and it seems to me a no-brainer that anyone designing pump software would consider how to avoid an overdose... and as mentioned above it would have to be a significant sub-q injection of insulin... but then again...

[telizas]

Actually, thinking about it as a prime, I suppose it is possible. You roll over in your sleep and the buttons start scrolling, it stops on Prime. You *can* scroll up on a Ping to just prime, it asks if you are disconnected, you press ok, and then it says "Go Prime" and you hold the button until you see a few drops. If you're laying on the pump and its in that "mode" if you will, it is possible to prime the whole amount into yourself. There are a LOT of variables and things would have to happen *just so*.

NOW, that said, this is NOT a malfunction of the pump, rather an unfortunate accident, and a "user error" for lack of a better term. Locking the pump would have prevented this, had this person's pump had that feature. How would you change a pump to limit a prime? An alarm *as* you prime, perhaps, so that if a button gets stuck or you are priming more than a few units, you stop? If you're laying on the pump it will alarm and vibrate as you prime, to wake you in this (very, extremely rare) circumstance? :cool:

I don't know. Put its not going to stop me from pumping. I keep my pump locked, because I have a small, button-obsessed child, who will crawl into bed with me without my awareness. It would be extremely easy for her to give me a normal bolus while I was asleep.