Fatal Misadventure

At Cumberland Hospital in Brooklyn, the operating room hummed with the efficient bustle of surgeons and nurses. On the table, her face covered by the anesthetic mask, Mrs. Raffelinia Manfra, 30, lay unconscious under .cyclopropane gas. She had just given birth by Caesarean section to a 5 Ib. 10 oz. baby girl. Then, without warning, came the flash and blast of an explosion in the anesthetic machine. The explosion knocked one of the doctors to the floor. But Mrs. Manfra took the worst of it. The blast seared through the anesthetic tube into her lungs. Within the hour she was dead.

It was the second fatal explosion in three months in a U.S. hospital (TIME, Feb. 18). As before, no one knew immediately just what touched off the gas, though static electricity at some point near the anesthetic circuit was accepted as the general cause. City hospital officials began a thorough investigation last week, but one fact was established immediately: though Cumberland had taken careful precautions (cotton gowns for the surgeons, metal chains on the anesthetic machine), its operating-room floor was tile, and lacked a grounded grid of conductive material, e.g., copper, to drain off static electricity. The U.S. Bureau of Mines and the National Board of Fire Underwriters recommend that operating-room floors be grounded in some such way. But there is no uniform code, and doctors disagree about what is safest.

The American Society of Anesthesiologists has been working on a standard set of rules for ten years. The work has gone slowly. There has not been enough money for research. In the meantime, the hospitals make their own rules on conductive v. nonconductive floors. And about once in 75,000 operations a patient is killed or injured by what is known as anesthetic "misadventure."

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