September 2000
Volume 64 |
Number 9
|
| |
|
| Fires and Explosions |
Kim E. Turner, M.D.
From the beginning, the hazard of fires and explosions related
to the administration of anesthesia has been an area of concern
to ASA. Fires and explosions were relatively uncommon events,
but as Philip D. Woodbridge, M.D.,* stated: "Although statistically
their importance is minute, they are of great emotional importance.
The dramatic nature of the accident and of the death that may
occur leads to publicity. The noise, the dramatic suddenness and
the publicity all tend to produce a wave of fear and under the
emotional tension of fear it is felt that something must be done,
and done quickly." 1
The ignition of vapors by static sparks had been demonstrated
as early as 1745. 2 Reports of fires
related to the administration of inhalational anesthesia began
soon after William T.G. Morton's demonstration in 1846.3
These early descriptions were often dramatic, as in the ignition
of ether by a candle during a dental extraction reported in 1866.3
The author wrote, "When I beheld the flames gushing forth
from his mouth, I almost believed it was a veritable fire-demon
sitting before me." When the patient was later asked how
he felt, it was noted that "a rather ghastly smile illumin(ated)
his pale countenance his only answer was what a wonderful occurrence."
The patient's toothache did not return.
Reports of explosions became more frequent as anesthesia techniques
evolved to include the use of inspired oxygen. The sources of
ignition were no longer open flames but cautery, electrical equipment
and static electricity. A representative medicolegal report in
1924 documented an incident involving a nitrous oxide oxygen anesthetic.
The cautery was utilized distant to the head and neck, or "zone
of danger," where the concentration of anesthetic gases was
greatest. The ensuing explosion during this urethral procedure
resulted in burns to the patient's face and injury to her eyes.4
The agents employed were themselves flammable. Acetylene, as
amazing as it may seem, entered the armamentarium of the anesthesiologist
in 1924. Its explosive capacity, as one would expect, resulted
in its discontinuation as an anesthetic the following year. Ethylene
was also introduced in 1924. Initial laboratory studies suggested
that the likelihood of explosion from ethylene entering the operating
room air during its administration was "only in the remote
realms of possibility."5 This
prediction was proven inaccurate a few months later during hemorrhoid
surgery utilizing cautery.6 The resulting
explosion burned the face and shoulder of the patient and singed
the eyebrows of the assistant. The following year, Isabella Herb,
M.D., reported five ethylene-oxygen explosions that had occurred
in her hospital as well as two explosions with nitrous oxide-oxygen,
which the doctors had substituted for ethylene as a result of
their concerns.7 No injury resulted
from these incidents. Dr. Herb made a series of recommendations
for the control of electrostatic conditions, but the situation
worsened.
In November 1927, an ethylene-oxygen mixture was being administered
to a 16-year-old for analgesia during labor. 8
The explosion was heard throughout the four-story building. The
patient and her child died despite resuscitative efforts. Among
the autopsy findings were lacerations of her trachea and massive
pulmonary hemorrhages. The source of ignition was static electricity.
In January 1929, an anesthetist was manipulating the valve on
a tank of gas that exploded. The force of the explosion, as reported
in The Evansville Courier, hurled the physician's body through
a six-inch wall. There were further detailed descriptions of the
physicians’ fate that do not bear repeating. The hospital officials,
assuming the tank to be ethylene, immediately discontinued its
use. 9 The investigation of this fatal
incident revealed no ethylene tank in the room. It was postulated
that the nitrous oxide tank that had exploded was contaminated
with ethylene while attached to an "old-time anesthetic machine"
that allowed flow between tanks.10
In 1930, the American Medical Association (AMA) Council on Physical
Therapy, in its examination of the "Explosion Hazard in Anesthesia,"
made the statement that "a certain carelessness regarding
this matter has developed."11
This contrasted with the statement made later in the same year
by the AMA Committee on Anesthesia Accidents that "care does
not now completely forestall this hazard." 12
This report discussed the necessity of weighing the potential
advantages and disadvantages of each anesthetic technique. The
risk of death from postoperative pneumonia, the "chief general
hazard of anesthesia and major surgery," was quoted as between
1:2 and 1:300 versus that of explosions estimated at 1:100,000.
The report concluded with the statement, "Explosion is statistically
today the least of the hazards of anesthesia." This was similar
to the opinion of Harold Griffith, M.D., one year later: "Respiratory
complications and shock from improperly administered anesthetics
cause a hundred times more deaths than all the explosions."
13
Then came cyclopropane. George Lucas, M.D., and Vilyien Henderson,
M.D., of Toronto, Ontario, Canada, discovered cyclopropane's anesthetic
and explosive properties in 1929.14
Unable to proceed with cyclopropane's development, Professor Henderson
encouraged Ralph Waters, M.D., from Wisconsin, to experiment and
use the drug clinically. 15 Dr. Waters
began experimentation in 1930. Cyclopropane was very expensive
and the Great Depression hampered its further development, or
so most have thought. Betty Bamforth, M.D., in her review of Dr.
Waters correspondences, noted that there may have been other reasons.16
In a letter written to Professor Henderson several years later,
Dr. Waters related that he had delayed experimentation on cyclopropane
in hope of the discovery of an agent without the added hazard
of fire. The existing hazard of fires and explosions therefore
may have delayed the introduction of cyclopropane, which most
modern anesthesiologists would consider synonymous with explosions.
In 1937, ASA appointed a subcommittee to study the hazards of
fires and explosions. The February 1938 scientific session of
the Society's regular meeting was occupied entirely by a symposium
on "fire and explosion hazards with anesthetic agents and
techniques." Dr. Ruth concluded the meeting with the statement
that "two factors stand out: one, the tremendous work ahead
for our Research Committee, and, the other, the possibility of
interesting future meetings." 17
Dr. Ruth's prediction was correct. At the meeting that followed
on October 20, 1938, the reports of the Subcommittee on Fires
and Explosions again occupied the entire scientific session. Dr.
Tyler reviewed the reports that had been submitted by members.
This was followed by a lengthy and enlightening presentation by
Mr. G. W. Jones, a chemist from the Explosion Division of the
Bureau of Mines. In his demonstration, Mr. Jones illustrated the
combustion of varying concentrations of ether with and without
oxygen. The results in the Society's minutes are recorded variously
as: "small explosion and flare," "very loud report"
and "a violent explosion," followed by the applause
of the members present. 18
Just 11 days later, a 44-year-old woman died as a result of a
cyclopropane explosion while undergoing breast surgery at the
Lahey Clinic in Boston. 19 The source
of ignition was static electricity. Dr. Lahey asked Phillip Woodbridge,
M.D., to coordinate an investigation by experts of this tragic
event. Dr. Woodbridge conducted a survey of 100 anesthetists who
he knew were using cyclopropane in the United States and Canada.
Dr. Woodbridge reported at the April 14, 1939, regular meeting
of ASA that those surveyed, recognizing the potential advantages
of cyclopropane, were almost unanimously in favor of continuing
its use.20
The ASA subcommittee's report of the clinical investigation
of 230 fires and explosions involving anesthetic agents appeared
in Volume Two of Anesthesiology, March 1941. 21
This review revealed that "at least 152 (70 percent) of the
explosions and 23 (60 percent) of the deaths were due to causes
about which effective prophylactic information has long been available
and repeated cautions have been urged." The report concluded
with the optimistic statement that "our present-day knowledge
of the etiology and prophylaxis of all anesthetic fires and explosions
is sufficient to prevent all further anesthetic combustions."
This was accompanied by the report from Professor Horton, Massachusetts
Institute of Technology, titled "Present Status of the Problem
of Preventing Anesthetic Explosions" that included detailed
explanation of recommended practices. 22
Professor Horton's concluding statement remains applicable today:
"The chief value in adequate physical equipment is not that
it makes eternal vigilance unnecessary, but that it makes eternal
vigilance effective."
ASA was represented in the formulation of the recommended Safe
Practice for the Use of Combustible Anesthetics in Hospital Operating
Rooms, sponsored by the National Fire Protection Association,
that appeared in Anesthesiology in September and October 1941.
23,24 These were
the earliest formal recommendations relating to the safe conduct
of anesthesia to appear in Anesthesiology. The hazard of fires
and explosions in the operating room continued to be an area of
great concern until the introduction and acceptance of the first
nonflammable agent, halothane. The reminders of our explosive
history endure in the form of the conductive flooring in some
operating rooms and the occasional drag chain on an old stretcher.
The danger of fires and explosions associated with anesthesia,
though much less than that which confronted our past colleagues,
requires our continued vigilance whenever an increased oxygen
concentration is employed in the presence of a source of ignition.
Kim E. Turner, M.D., is Assistant
Professor, Department of Anaesthesiology, Queens University, Kingston,
Ontario, Canada. She was a 1999 Paul M. Wood Fellow of the Wood
Library-Museum.
References
1. Woodbridge PD. Incidence of anesthetic explosions.
JAMA. 1939; 113:2308-2310.
2. MacIntosh A, Mushin WW, Epstein H. In: Physics
for the Anaesthetist. 2nd ed. Oxford, England: Blackwell Scientific
Publications; 1958: 412.
3. MacDonald G. A short history of fires and
explosions caused by anaesthetic agents. Br J Anaesth. 1994; 72:710-722.
4. Medicolegal. Injury to patient from explosion
of machine used in anesthetizing. JAMA. 1924; 82:329.
5. Brown WE. Explosibility of ethylene mixtures.
JAMA. 1924; 82:1039-1040.
6. Davis CH. Explosibility of ethylene. JAMA.
1924; 82:1607.
7. Herb IC. Explosions of anesthetic gases. A
method for the control of electrostatic conditions. JAMA. 1925;
85;1788-1790.
8. Peterson R. Report of an explosion of ethylene
gas resulting in the death of a maternity patient and her child.
Am J Obstet Gynecol. 1929; 18:659-664.
9. Laboratory blast kills physician. The Evansville
Courier. 1929; 83:1-2.
10. An anesthetic accident [editorial]. JAMA.
1929; 70: 476.
11. William HB. The explosion hazard in anesthesia.
JAMA. 1930; 94:918-920.
12. Henderson Y. The hazard of explosion of
anesthetics. JAMA. 1930; 94:1491-1498.
13. Griffith HR. Operating room explosions.
Anesth Analg. 1931; 10:281.
14. Lucas GHW, Henderson VE. A new anesthetic
gas: Cyclopropane. Can Med Assoc J. 1929; 21:173-175.
15. Lucas GHW. The discovery of cyclopropane.
Anesth Analg. 1961; 40:15-27.
16. Bamforth BJ. Cyclopropane anesthesia: Its
introduction at Wisconsin. In: Rupreht J, van Lieburg MJ, Lee
JA, et al., eds. Anaesthesia - Essays on Its History. Springer-Verlag;
1985:271-275.
17. Proceedings Regular Meeting of the American
Society of Anesthetists, Inc. February 9, 1938. Squibb Auditorium,
New York City.
18. Proceedings Regular Meeting of the American
Society of Anesthetists, Inc. October 20, 1938. Squibb Auditorium,
New York City.
19. Zeitlin GL. The Lahey Explosion. In: Schulte
am Esch, Goerig M, eds. Proceedings - The Fourth International
Symposium on the History of Anaesthesia. Berlag Drager Druck Lübeck.
1998:209-211.
20. Proceedings Regular Meeting of the American
Society of Anesthetists, Inc. April 14, 1949. Squibb Auditorium,
New York City.
21. Greene BA. The hazard of fire and explosion
in anesthesia: Report of a clinical investigation of 230 cases.
Anesthesiology. 1941; 2:145-160.
22. Horton JW. Present status of the problem
of preventing anesthetic explosions. Anesthesiology. 1941; 2:121-137.
23. Current Comment. Recommended safe practice
for the use of combustible anesthetics in hospital operating rooms.
Anesthesiology. 1941; 2:581-586.
24. Current Comment. Recommended safe practice
for the use of combustible anesthetics in hospital operating rooms.
Anesthesiology. 1941; 2:689-694.
return to top
|