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.
Monday, May 10, 2010
Flagg's can (Part I)- Reports of incidents involving accidental deaths.
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.
