10/11/2022
October 31, 2022, marks the 25-year anniversary of one of the worst tragedies in the field of Hyperbaric Medicine. On that day, a fire broke out in the multiplace chamber at the Galeazzi Orthopedic Institute in Milan Italy.
This preventable incident cost the lives of 11 people (10 patients, 1 inside attendant) and led to a lengthy investigation and eventual prosecution of the medical director, safety representative, chamber operator, and the CEO of the hospital, among others.
The investigation revealed several deficiencies, to include:
• Failure to screen patients for prohibited items (cause of the fire: A liquid fuel-filled hand warmer)
• Poor or nonexistent maintenance
• Lack of water in the deluge tanks
• Lack of pressurization in the deluge system
• No interior fire suppression handlines
• The chamber operator was absent from the console at the time of the incident
• Staff training on equipment and emergency procedures was nonexistent
• The oxygen analyzer alarms were manipulated to avoid a nuisance
• Poorly fitting hoods and masks
• Patients were allowed to wear their street clothes into the chamber
• And much more*
*To read a detailed report of the investigation, click here: https://www.dropbox.com/s/a090hdkne0mkp5y/Technical%20advice%20conferred%20by%20the%20Ordinary%20Court%20of%20Milan.pdf?dl=0
Let us never forget the lives that were lost, and may we learn these lessons from this tragedy:
We must stay vigilant to stay safe. Always follow the guidelines and codes developed to protect hyperbaric practices. NFPA, ASME-PVHO, UHMS Facility Accreditation, Australian Standard 4774.2, and many other international hyperbaric standards like these.
The 11 souls who lost their lives on that day:
Inside Attendant: Massimiliano Felline
Patients: Ercole Alfieri, Franco Basei, Gino Bocchi, Angelo Nespoli, Agnese Orlandi, Maria Pisanò, Lauro Previato, Renzo Spinelli, Cesarina Turponi, Augusta Villa.