Chen, Ruby Yan

3y · Female·massive air embolism

Ruby Chen, 3 years old, died from massive air embolism during aeromedical transfer from Blackwater to Rockhampton Hospital. The fatal sequence occurred when a paramedic re-spiked a partially-used IV saline bag (containing ~115 mL) with a new giving set, allowing air to enter the bag. The bag was placed in an opaque pressure cuff that forced both fluid and air through the IV line into the patient's circulation. At 250 mL/hour infusion rate, fluid exhausted after ~24 minutes, sending ~70-100 mL of air directly into her bloodstream. Clinical lesson: never re-spike IV bags; ensure single-use spike labeling; prohibit opaque pressure cuffs in aeromedical settings; use infusion pumps when feasible. The constellation of factors—re-spiking, priming with new set, opaque pressure bag, helicopter environment—was unusual and not previously encountered in practice, but entirely preventable.