Flagg's can (Part II): Reports of incidents involving accidental deaths

A junior anesthesiologist in the middle of a tonsillectomy operation broke the K.E.M. bottle which essentially was a modified Flagg’s can. He lost his cool; and put the delivery tube in the stock ether bottle. Luckily the size of the delivery tube was slightly smaller than the opening of the stock ether bottle. The patient after few episodes of hypoxia was able to come through the operation when the delivery tube was taken out from the ether bottle. The second patient managed to survive the operation but later lost his life when the anesthesiologist was doing the oropharyngeal toilet; the delivery tube went in the bottle and dipped in the liquid ether. As a result the patient, a child, aspirated liquid ether and had pulmonary oedema – leading to cardiac arrest – finally death
Another incident involved a case where the surgeon in a mofussil (non-urban) hospital induced a patient with open drop ether anaesthesia. The anesthesiologist looing for the modified Flagg’s can (KEM bottle) found out thta it was being used at another table. The anesthesiologis put the delivery tube directly to the ether stock bottle and asked the ward boy to look after the patient and went to wash up only to find the patient dead. Cause: There was no place for the air to enter the bottle.
In yet another incident, the Flagg’s can was used for an infant with cleft lip. Since the tidal volume is small, the patient kept breathing his exhaled air. The end of the patient terminated the surgery.