Flagg's can (Part I)- Reports of incidents involving accidental deaths.

When things go wrong...The new ward boy in the operating theatre was asked to fill ether- full in amber drop bottles and half in Flagg’s can. He did exactly the reverse. The patient was induced with ethyl chloride and ether and when relaxed he was intubated and connected to the full Flagg’s can. The patient aspirated pure liquid ether developed pulmonary oedema and developed cardiac arrest.
Another patient- a child undergoing mastoidectomy with Flagg’s can was kept secured in a doughnut. The surgeon adjusted the position of the head; tilted the Flagg’s can resulting in aspiration of liquid ether. The patient developed pulmonary oedema was immediately bronchoscoped aspirated and lavaged with dilute solution of soda bicarbonate. The patient expired the next day.
On a winter morning when the temperature was really cold, ether was used in Flagg’s can and to prevent the cooling of the bottle it was kept in a water bowl. After the tonsillectomy was over, the anesthesiologist had to attend a telephone call. He left the patient disconnecting the Flagg’s can and instructed the house surgeon to remove the E.T. and do adenoidectomy. During the adenoidectomy it was observed that the blood was very dark. The patient could not be resuscitated.
Cause: The delivery tube was disconnected at the Flagg’s can end which was dipping in the water bath. When the anesthesiologist left, the child aspirated water from the water bath and drowned. Death due to drowning in fresh water.