Anesthesia: The Lethal Ether

The operations performed on two successive days at the modern Pontiac Osteopathic Hospital in Michigan could not be considered dangerous. Nonetheless they turned into a nightmare of anesthetic error, and when the nightmare ended, three patients were dead.

The cause of the tragedy, by the hospital’s own admission, was an extraordinary catalogue of casual and careless actions by several doctors.

Violent Response. Unlike many hospitals, which make up a fresh batch of anesthetic for each patient, Pontiac Osteopathic practice was to mix Surital* in half-pint quantities, enough for at least ten patients. When Kimberly Ann Bruneel, 8, was wheeled into Operating Room No. 1 to have her appendix removed, Nurse-Anesthetist Joan Booth simply jabbed the needle of a syringe through the rubber seal on the “Surital” bottle, drew off some of the fluid, and put a, little into the patient’s arm through an intravenous drip tube. The child immediately went into bronchial spasms. Nurse Booth says she “never saw anything so violent.” She injected a muscle relaxant and called in a staff osteopathic surgeon, Dr. Paul W. Trimmer, to put a breathing tube down the girl’s windpipe. The child kept flailing the air, so Nurse Booth injected more fluid from the Surital bottle to quiet her. With no other anesthetic, but with oxygen given by machine, the doctors finished the appendectomy. Seventy minutes later, Kimberly Bruneel died.

That afternoon, Trimmer and a staff pathologist did an autopsy and noted an odor of ether in the child’s lungs. She was not known to have had ether, but the doctors did not mention the odor in their report. They listed “gross pulmonary edema” (waterlogging of the lungs) as the cause of death.

Grey, Then Blue. Nor did Dr. Trimmer mention ether the next morning, when he and Anesthesiologist Lloyd Goodwin were preparing Michael Ketchum, 12, for a hernia operation. Dr. Goodwin injected fluid from the same Surital bottle/and there was the same instant reaction of spasms and coughing. The boy complained that the injection burned, but Dr. Goodwin gave more of the same fluid, and the coughing ceased. The operation went smoothly, and the boy seemed to be doing well.

As the two doctors got ready to operate on Mrs. Lurea Covington, 24, a mother of two, Goodwin injected liquid from the same bottle and got the same cough-spasm reaction. Only now did he suspect that there might be something wrong with the analgesic mixture. He mixed a fresh batch, gave some to Mrs. Covington, and her’ operation continued with no other anesthetic. She went to the recovery room alongside Michael Ketchum. It was not long before the boy turned ashen grey, then blue, from insufficient oxygen in his blood. So did Mrs. Covington. Despite frantic attempts at resuscitation by a belatedly alerted hospital staff, both patients died.

Where to Put It? Dr. Trimmer took both the old and the new Surital bottles to the lab for analysis. But little analysis was needed. As soon as the older bottle was unstoppered, it reeked with the unmistakable odor of ether—something that had not happened when the cap had only been pierced by a syringe needle. Ether is almost always given by inhalation, and is used intravenously only in the rarest special cases (it inflames the lungs and depresses the heart and nervous system). So how had ether got into the Surital bottle?

In his investigation, Prosecutor S. Jerome Bronson pieced together the dismal answer. When another Pontiac anesthesiologist, Dr. Stanley E. Abrams, began work in O.R. No. 1 on the day before the first fatal operation, he had found ether in the gas-anesthesia machine. Dr. Abrams prefers other anesthetics and wanted to get rid of the ether. Sometimes, in similar situations, nurses say, Dr. Abrams has casually drained ether onto the floor and let it evaporate. This time, he spotted the almost empty Surital bottle and drained the ether into that. He intended to throw the bottle away when his own operations were over. But he forgot. The bottle stayed in the operating room, mislabeled and deadly.

Prosecutor Bronson foresaw civil rather than criminal action arising from his investigation. “It is impossible,” he said, “to assess major blame on one person.” Then he added: “What I’m concerned about is that the whole business was so damned sloppy.”

*A barbiturate used as a painkiller, especially as a preliminary to more potent, gaseous anesthetics.