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.

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Techniques of Anesthesia-Using Ether

Some important points with regards to using Ether:

• Always use anaesthetic grade ether. Never ever use solvent ether. Pulmonary oedema can occur due to impurities.
  
• With the change in brand, smell the ether any doubt compare with solvent ether.
  
• The simple test is to dip a blue litmus strip. Discard if it turns red. It indicates presence of sulphurous acid, which is a manufacturing impurity. If available do the aldehyde test or peroxide test.
  
• Store ether in a dark cool place in amber coloured bottle
  
• Do not overfill the bottle. The boiling point is 35º C and if overfilled a little rise in temperature the bottle will burst increasing the fire hazard. That is why we find that ether bottles are never completely full.
  
• Ether evaporates very fast and hence if there is any gap in the bottle cap (cracked or loose fitting or plastic cap missing or torn) the ether vapour escapes easily and one finds the bottle empty after few days.
  
• 2% ether vapour cannot change the biochemical parameters like blood sugar, serum creatinine or blood urea. It is perfectly safe in practice even though you may have been frightened by your teachers.
  
• Use of trifluperazine prevents nausea and vomiting of ether. For an adult do not give more than 5 mg. (½ cc) during anaesthesia and 1-2 mg. in children. The infants and small children tolerate ether and do not require any anti emetic.
  
• Sequil should not be given in bigger closes before and after anaesthesia as it causes hypotension and oculogyric crisis.

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