inforMED
DeathCBF

PERRY HYPERBARIC CHAMBER

Received Jun 12, 2002 · Event occurred Jun 4, 2002

Report 1036464-2002-00001 · MDR key 399680

Device

Generic name

Hyperbaric Chamber

Model number

SIGMA II-4

Catalog number

NA

Lot number

NA

Product problems

  • Break
  • Misassembled

Patient

19 YR

  • Death
  • Other (for use when an appropriate patient code cannot be identified)

Narrative

Description of Event or Problem

EVENTHOUGH THE CHAMBER WAS NOT PRESSURIZED AND IN OPERATION AND THE DOCTOR DOES NOT FEEL THE INCIDENT IS RELATED TO THE COMPANY'S DEVICE, THE COMPANY FEELS IT IS APPROPRIATE TO FILE THIS REPORT AS REPORTED TO THE COMPANY: CAR ACCIDENT PATIENT WAS DIRECTLY TRANSFERRED FROM THE EMERGENCY ROOM TO THE HYPERBARIC CHAMBER ROOM. PATIENT WAS ON ENDOTRACHEAL TUBE. A DOCTOR CONNECTED THE O2 GAS SUPPLY FROM THE CHAMBER WITH A FLOW RATE OF 30 1PM, TO EXHAUST CONNECTOR OF THE AMBU (MANUAL RESUSCITATOR). "WITHIN A FEW SECONDS THE PATIENT'S LUNG EXPLODED AND THE ENDOTRACHEAL TUBE BROKE." WHEN THIS INCIDENT OCCURRED THE CHAMBER DOOR WAS NOT CLOSED AND NO CHAMBER PRESSURE WAS USED. DOCTOR WAS PRESENT WITH THE PATIENT.