Death from the Machine

After 2 1/2 hours of tense work in the operating room of St. Francis Hospital in Evanston, Ill., Surgeon Edson F. Fowler was just beginning to relax. He had removed part of the stomach of the Rev. James Cummings, 35, a Chicago priest, because of intractable ulcers. Everything had gone smoothly. But as Dr. Fowler was putting the last stitches in the patient's abdomen, there came a bang like that of a bursting tire, and a puff of smoke spewed out of the anesthesia machine. The explosion ripped open the anesthesia bag, and blew out the glass covers on the machine's flutter valves.

Dr. Fowler quickly examined his patient. Part of the hot blast had traveled along the anesthesia tube: bright red blood from broken vessels in the lungs was filling Patient Cummings' windpipe. The blood was drained off, and a mask was fitted to give artificial respiration. But little more than two hours later, Father Cummings was dead, the victim of the kind of accident every hospital dreads. Explosions of anesthetic gases (in this case, a mixture of nitrous oxide, ether and cyclopropane) happen about once in 75,000 operations, and are almost certain to cause serious injury to the patient, if not death.

As Father Cummings lay dying, the U.S. Bureau of Mines, by a coincidence, issued a set of recommendations to reduce the hazard. Wool blankets, plastic sheets and most synthetic fabrics should not be allowed near an anesthesia machine, the bureau said, because of the danger that they will generate static electricity and cause a spark. Cotton should be used instead. Doctors and nurses must not wear wool trousers, nylon gowns, or rubber-soled shoes. Tables, machines and stools should have non-insulating feet, to conduct static electricity to the floor.

Almost all of the bureau's requirements had been met in St. Francis' well-run operating room. The main exception was that the anesthesia machine itself had not been grounded, and on this, some experts violently disagree with the bureau: grounding the machine, they say, may make it behave like a lightning rod. There was nothing to suggest that the Evanston accident had been caused by a spark outside the machine. The explosion had been inside it, and the best evidence was that the spark originated there, too--probably in a valve.

This file is automatically generated by a robot program, so reader's discretion is required.