A tragic and bizarre accident occurred last Saturday at Doernbecher Children’s Hospital in Portland, Oregon. Ireland Lane, 11, ran from her room in flames and investigators believe that static electricity may have ignited flammable hand sanitizer on the cancer survivor.
Ireland will now need skin grafts — a truly horrific burden for a child who has already faced so much in her short life.
Her father Stephen Lane, 34, was sleeping in her room overnight when he was awakened by her screaming. She suffered third-degree burns from just above her belly button to her chin as well as parts of her arms and the bottom of her earlobes. Her hair also caught on fire. The last thing that she recalled was using sanitizer to clean the table that rolled over her bed, where she had painted a wooden box as a gift for her nurses. She had also been playing with the static electricity on the sheets of her bed. There have been a number of cases involving fires with hand sanitizer in hospitals.
Doernbecher uses the sanitizer Avagard D, produced by 3M that is 61 percent ethyl alcohol and warns of a fire danger. Notably, 3M spokesperson Donna Fleming Runyon insisted that “When used as directed, it is entirely safe.”
However, that does not answer the tort question. First, even if directed to be used in specific conditions, 3M would be liable for “foreseeable misuse.” A manufacturer is liable for the foreseeable use of their product and use around static electricity on beds would clearly fall within that definition. Second, there is the question of a design defect in the high use of alcohol and whether there is an alternative chemical composition. Third, there is the question of a warning defect if static electricity — a ubiquitous factor in homes and hospitals — is a danger.
There is also a question of liability for the hospital in the use of alcohol-based sanitizer as well as sheets with a high static electricity characteristic. This would be a case that both parties should want to settle quickly and quietly. I fail to see any plaintiffs’ conduct issues since a little girl playing with sheets is hardly an act of negligence or assumption.
Source: Oregon
“Why did the girl not read and understand the instructions that came with the hand sanitizer? Why did her dad not read and understand those instructions and caution her to use the sanitizer only in accord with the instructions? Why is it not obvious to a typical eleven-year-old that ethyl alcohol spread on a hard surface will tend to evaporate and form a flammable to explosive vapor?”—————–Harris
Ridiculous question!
The father and the child were grappling with cancer. The staff should know to caution the child and to put such sanitizers out of the reach of children.
Your claimed prescience is not available to our children. Or have you produced one? Have not read farther than the quote above.
Whatever your reality is, ours include anticipating things and reacting to avoid accidents. If all were as you then we would be like you. But we are not. And I prefer our anticipatory approach.
Why is everybody not like you.? Because they are not. It is for now a statistically proven existential bla bla. 🙂
Cordiallity above all.
No more for now.
“All actually avoidable accidents are all actually avoided, such that they never happen, and no one knows or understands what they were because they never were. All accidents (and mistakes) which actually happen are actually unavoidable in the exact situational context in which they actually happen, which is why they happen.”————Harris.
Someone once quoted to me that “reality” is the only word that has any meaning in all languages, if it is enclosed by quotation marks.
Sometimes, Harris makes me wonder if he sees another reality than we do.
But then how could he put up with OUR reality, or with the delusioned population, as we could “actually” be???
interesting, I don’t think I’ve ever encountered static in bed clothes. we do have cotton sheets but also polyesters in duvets & blankets. Probably it’s just that the house is cool and relatively damp! also we have only a few area rugs, no “carpeting” AT ALL in the modern sense. it gets too filthy & moldy/mildewy for our allergies (we’ve taken it out of every house or apt we’ve ever lived in, it is ALWAYS totally disgusting on the underside & padding-stuff)
I still believe that they have a case. A PhD or autism is not necessary for consumers of hospital care.
That is a matter for the staff, so the defendant may have to be the hospital.
Here, no static electricity floor coverings, only cotton sheets, and no nurses in clothing which cause static discharges.
Believe me, it is not by chance. And not by solely flaming hair, or burnt children either. This was carefully studied over the years, and clinically tried before it was step by step put in effect on closed wards visited by patient’s friends and family. Outpatient care somewhat less rigorous.
Wrote at length on the justification and the myriad other hygienic measures to stop the disabling of smitten personnel at the hospitals, not forgetting protecting the patients. Here ”vinterkräksjuka” winter vomiting sickness, virus caused, could before force the closing of whole wards. No staff to man, and no place not infected to care for them in.
This is not the first assault, before we had yellow staph MRSA.
And step by step hygiene has been increased. And hand sanitizers are an essential part of it practically from floor to ceiling and all in between.
Long list written, but that got dumped by pushing a wrong key combo.
Would my quickly finding the URL for the Material Safety Data Sheet convey to anyone some sort of Internet research competence on my part?
The URL is:
http://multimedia.3m.com/mws/mediawebserver?mwsId=SSSSSuUn_zu8l00xlY_SP8mv4v70k17zHvu9lxtD7SSSSSS–
The flash point is given as 68.9 degrees Fahrenheit.
The LEL is given as 3.28 volume %
The UEL is given as 19 volume %
And, in section 7.1 it states, “Keep away from heat, sparks, open flame, pilot lights and other sources of ignition.”
So, the MSDS properly warns against sparks, and sparks includes electrical plasma arcs (the temperature of which is presumably the range of thousands of degrees Fahrenheit).
That the girl and her dad did not, I am guessing, read, study, and understand the readily available MSDS properly accords to them significant contributory neglegence? 3M did, it appears to me, provide proper information to anyone, such as me, willing and able to look for, and find, it.
Is ignorance a basic human fault, or is ignorance among the greatest of gifts given to humanity? If ignorance is a great gift, could the greatness of that gift be found in all that remains yet for humans to learn?
How can tomorrow actually precede yesterday, such that what becomes foreseeable only tomorrow was truthfully foreseeable yesterday?
If foreseeability is real, why did not the adversarial system and its adherents foresee me and my research methodology, and its findings?
I work, not to damage or destroy law, but to help make the law more truthfully honest in its nature, intent, and implementation, doing so by helping to identify aspects of the form and function of law which require what is prohibited as the exercise of learning what effective and decent law can become, such that the law raises every person up, because every person is above, not beneath, the law.
When the burden of law is above everyone, such that no one is above the law, how can the law fail to crush those beneath it, particularly when the law has become so complex that no person, and no combination of persons, can actually, fully understand the law?
If the law is fully understood by the U.S. Supreme Court Justices, how is it possible for other than unanimous decisions to ever be made?
J. Brian Harris, Ph.D., P.E.
I ate your first post, rapidly skimmed, as an appetizer.
WÃll eat the rest later.
Just wanted to say welcome back and don’t know where to begin my praise.
I particularly enjoyed this:
==========
“The news of the day is simply that the hypothesis of the actual happening of an actually avoidable accident (or mistake) is, from a process or procedural view, the hypothetical actual happening of an actual impossibility. Also, to me, as an autistic person who never learned the ways of effective lying in accord with adversarial socialization tradition, without actual exception or the actual possibility of of actual exception, whatever does not actually happen, when it does not actually happen, is, when it does not actually happen, existentially actually impossible.”
========
If eaten slowly it is capable of being enjoyed by an ordinary person.
Mike,
If you leve one of these containers in your vehicle…. And it’s hot…. You get the rumination s of vodka spilt …. Bad smell…
Scientific ignorance is apparently abundant.
Looking in our medicine cabinet, I found a larger plastic bottle-dispenser of hand sanitizer, “Wakgreeb Instant Hand Sanitizer with Vitamin E” (UPC 49022-42873).
On the label, I find:
“Warnings”
“For external use only-hands.”
“Flammable. Keep away from heat and flame.”
As for “sheets” and “static electricity,” am I almost alone on earth in understanding that the electrical arcing of “static electricity” is a plasma, and am I almost alone in understanding that the temperature of such plasma arcs is well above the flash point of explosive concentrations of alcohol vapors in room air?
I wrote about my sense of the adversarial approach to the structure of human society back in 2003, thus:
ODE to Autism, or ODE to The Authentic, Essential Self
A clattering cacophony of sounds cascading into the pit,
Burying me deeply wherever I sit–
Sounds that form daggers piercing me through.
What in the world am I to do?
When at society I sneak a peek
I meet with a stench, a putrid reek,
The children’s unheard anguished cries
Protesting culture’s dastardly lies.
How long must it take
Children’s hearts burned at the stake…
Reduce the heat to a simmer
perhaps then we may see a gilmmer.
Of the unmitigated truth
known only to intact youth —
The best that yet can be
is just what we may see.
The hellfire is near —
Why is not not clear, why not fear
The heat of the lies
In which everyone fries.
What shall it takew
for humanity’s saKE?
How much unrequited gruel?
How much unrequited cruel?
You should have grown
before you could yearn?
You should have known
before you could learn?
Or so with sincerity they say
to this very timorous day.
Yet such consensus confabulations are never true.
How much yet remains for us to rue?
Would our lives have been better
Had we seen the way to unfetter
Our minds from the delusional fiction
That causes so much unbearable friction?
Second-guessing any newborn child
makes the gift of life defiled.
When will we have sufficiently striven
That we first fathom what we have been given?
A clattering cacophony of sounds cascading into the pit,
Burying us deeply wherever we sit–
Sounds that form daggers piercing us through.
What in the world are we to do?
copyright (c) 2003, J. Brian Harris, used with permission. (Note: ODE = Ordinary Differential Equation)
What, I sometimes wonder, could ever distinguish hindsight bias from absolutely unmitigated pure evil?
In a way, I find myself rather astonished at the lack of any useful grasp of basic scientific principles among what I guess might be labeled, “most people.”
That it would be deemed better that hundreds to thousands of people get sick and/ or die from contagious diseases that hand sanitizer can prevent would be preferable to the risk of scientifically ignorant people doing tragically stupid things for want of decent science education is of the nature of a travesty to me.
I wrote my first comment when there were only two replies, and find it useful to add to what I already wrote.
Among my friends and acquaintances was the late Harvey Echols, Ph.D. (who was a Chemistry Professor at Chicago State University, as I recall). He described having been an expert witness in a tort liability court case in which a person had been seriously burned while adding windshield washer fluid to the washer fluid reservoir in an automobile.
Yes, the alcohol in windshield washer fluid makes it dangerously flammable under some, fortunately rather uncommon, circumstances.
I mentioned this blog thread to my wife, whose curiosity was piqued thereby.
I got out a flame-proof ceramic coffee cup saucer, and placed a dollop, about a quarter m:L, of hand sanitizer near the center of the saucer. Then I took a wooden match, lit it, and laid the lit match across the dollop of sanitizer. The match appeared to burn, and burn out, and my wife did not see any flame. However, the center of the match, atop the dollop of sanitizer, had not burned.
I asked my wife if she could see the flame, and she said that the flame had gone out. She was mistaken. A small alcohol flame, in a normally lit room is not visible to the insufficiently informed and aware. So, when she was sure that there was no flame, I put a small piece of flammable paper, a couple square centimeters or so in area, a couple inches above the match and slowly disappearing dollop of sanitizer, and the paper immediately burst into flame.
There is a trade-off between people being harmed or dying from contagious diseases that hand sanitizer can prevent and people being harmed or dying from not reading and understanding carefully written instructions for hand sanitizer.
The essence of my present bioengineering work in forensic engineering is demonstrating that the entire notion of torts is grounded in a misunderstanding of the nature of procedural learning as a neurological process, that misunderstanding being the mistaken belief that tort liability can ever actually exist.
Yes, I have a sense that I am as though asserting not only that the emperor has no new suit (remember Hans Christian Andersen?), but also that the emperor is a delusional figment of traumatized imagination.
The nifty thing, to me, about valid science and valid scientific research is that neither the science, nor the work, nor the scientific findings, depend in any way whatsoever on personal authority, or on group consensus authority, or on any other form of authoritarianism.
And, as a father, I know about a child being badly burned and taken to hospital. My wife and I adopted a “neglected” eleven-year-old boy in 1979. One day, he was visiting a neighbor family where the dad had obtained illegal fireworks from out of state, something my son had not told me. Something happened, and my son came back home, screaming in pain. At the hospital emergency room, it was determined that outpatient care would be adequate, and, with a bandaged hand and wrist, our son came back home.
I understood the risk of such illegal fireworks to our son, our neighbors evidently did not.
I attribute much of human indifference to scientifically foreseeable harm to the learned helplessness that necessarily accompanies the dissociative trauma intrinsic to the traditional infant-child transition, a transition and resulting traumatic insensitivity to harm that my infancy with my scientifically-trained parents enabled me to avoid.
In what may indeed be stark contrast with the view of a majority of humans, I have never been coerced or otherwise induced into believing that any event which actually happened could, having actually happened, have actually happened other than as it actually happened.
The a-priori probability of any event is necessarily greater than zero and less than unity. The a-posteriori probability of every event is identically unity. There is no a-posteriori probability for any event that did not happen because the event never was; the a-posteriori probability of a non-event is not zero, because neither the event nor its a-posteriori probability ever existed.
The infant-child transition teaches people to confuse a-priori with a-posteriori probability, and this confusion (time confusion in the work of Erik H. Erikson) is the result no less than the cause of the delusion that an accident that actually happened could ever have actually been avoidable.
Darren, thanks for the research.
Not very long ago, I was visiting a person who was undergoing post-surgical rehabilitation in an intermediate care nursing facility. Something contagious and infectious got into a couple units at that facility,and ethyl alcohol based hand sanitizer was abundantly available. I used it, as did the staff, when entering and leaving a unit where contagious infection had presented itself. One patient on that unit died during the period of quarantine control of infection spreading, even though use of hand sanitizer was intensive and extensive.
For the safety of patients in that nursing facility, I bought a small (about 60 mL) bottle of about 2/3 ethyl alcohol hand sanitizer, to use prior to entering the nursing facility. Printed on the bottle label is a clear flammability warning. Yes, I read it.
Is there an alternative form of hand sanitizer that can control infection spreading in patient care medical facilities as well as typical ethyl alcohol based hand sanitizer in terms of overall efficacy and effectiveness for the hospital patient and staff population as a whole? I genuinely doubt it.
As for liability, well, that is a curious social phenomenon at best. Yes, we can ban hand sanitizer from medical facilities. However, would vastly more injuries and deaths result from the lack of use of such hand sanitizer than from its use?
Would it be ethical, or even possible, to conduct a large-scale double-blind test to discern the differential injury and death rates from using ethyl alcohol based hand sanitizer in medical care facilities and from avoiding its use in such facilities?
What proportion of people are so insensate to the odor of ethyl alcohol that such that any genuine double-blind test is even remotely achievable?
If foreseeability is the criterion for determination of after-the-fact probabilities, I have long foreseen that the conventional standard of tort liability is fraught with its on foreseeability conundrum. Why has not the legal community foreseen that a sufficiently autistic bioengineer might be capable of effectively blowing the whistle on the abuses of the biologically false doctrine of the foreseeability of the actually unforeseeable?
There is one, intractably and inextricably biologically grounded principle of valid law that I find necessarily frames and delimits all other valid principles of law, to wit, “Impossibilium nulla oblagatio est.” (In English, from Black’s Ninth, page 1835, “There is no obligation to perform impossible things.”)
How do I, as a professional engineer, accurately identify what is impossible? It is so simple, that I understood it well before I learned any words. Eliminating self-contradictory, and therefore nonsense, hypotheticals from my life, I find that whatever did not actually happen when actually it did not happen did not happen when it did not happen because it actually was impossible when it did not actually happen.
I can concoct a hypothetical fruit fly (drosophila melanogaster) that terraformed Mars ten seconds ago, traveling at more than a googolplexion times the speed of light, such that earth-based telescopes will discover that Mars is completely ready for human habitation later today.
I am rather confident that no such discovery will happen, because I am rather confident that my hypothetical fruit fly and its work are of the form and function of an impossibility.
However, I also am rather confident that the probability of such a fruit fly and such terraforming of Mars is of a vastly more than an immense order of magnitude greater a-priori probability than is the actual happening of one actually-avoidable accident.
The news of the day is simply that the hypothesis of the actual happening of an actually avoidable accident (or mistake) is, from a process or procedural view, the hypothetical actual happening of an actual impossibility. Also, to me, as an autistic person who never learned the ways of effective lying in accord with adversarial socialization tradition, without actual exception or the actual possibility of of actual exception, whatever does not actually happen, when it does not actually happen, is, when it does not actually happen, existentially actually impossible.
I do not live with a divided will and the associated necessary duality of personality that would allow me to interchange tangibly actual, directly observable objective reality with existentially paradoxical process-nonsense hypothetical beliefs in the form of biologically blatant delusions, such as the actual happening of actual impossibilities.
All actually avoidable accidents are all actually avoided, such that they never happen, and no one knows or understands what they were because they never were. All accidents (and mistakes) which actually happen are actually unavoidable in the exact situational context in which they actually happen, which is why they happen.
Except, to me, as the most viciously contagious and atrociously addictive delusion of which I have yet become sentiently aware, the notion of the hypothetical avoidable accident is the best candidate for the core essence of profoundly tragic child abuse that has ever strayed into my consciousness.
I find that the actual demonstration of so much as one actually avoidable accident ever happening is an absolute existential impossibility.
I will welcome the tangible demonstration of the actual happening of an actually avoidable accident (or mistake”. Such demonstration will effectively rebut and refute my bioengineering research.
If thousands upon thousands of hypothetically avoidable mistakes (the essence of the notion of tort liability?) have happened, why has no one ever been able to scientifically demonstrate the actual happening of even one actually avoidable accident or mistake?
For those whose education in statistics is entirely frequentist, and who, therefore, find my work to be utter and absolute nonsense, I offer the insight that frequentist statistical methodologies are designed with the prevention of learning as a core element, supposedly the better to avoid the errors of the past. Alas, frequentist statistical approaches are as adept at avoiding such truthfulness as has been found in the past as avoiding such falsehood as has been found in the past.
My approach is primarily Bayesian, and is so because ignorance of history prevents useful learning of the lessons of history.
Do I have a historical lesson in mind? Yes. What lesson? Adversarial methodologies are their own best adversaries.
Please, if you can, actually demonstrate that an actually avoidable accident can ever actually happen. I find that hypotheticals that are actual impossibilities never actually happen.
Show me, with a tangible, scientific demonstration, that I am mistaken, please, if you can…
Before I began kindergarten, at age 5, my parents had informed me of the danger of fire and of flammables, perhaps because they were able to foresee such danger because of their scientific-oriented college educations.
The label of the ethyl alcohol based hand sanitizer I have clearly states that it is flammable. However, I understood such before kindergarten, because my parents’ educations allowed them enough grasp of science to enable them to inform me of plausible dangers that people who were not given the benefit of education comparable to that of my parents may never have.
Is ignorance ever other than an indicator of possible learning opportunities?
The label on the little plastic bottle of ethyl alcohol based hand sanitizer I have informs me that it is for use only for sanitizing hands. That rules out its being used for sanitizing surfaces other than the skin of hands.
Why did the girl not read and understand the instructions that came with the hand sanitizer? Why did her dad not read and understand those instructions and caution her to use the sanitizer only in accord with the instructions? Why is it not obvious to a typical eleven-year-old that ethyl alcohol spread on a hard surface will tend to evaporate and form a flammable to explosive vapor?
What circumstances kept the girl and her dad from getting the quality of education my parents had and gave me well before I was eleven?
I started an electronics business early during sixth grade, in 1950, when I was eleven years of age. I worked with radios and TV receivers, and other electronic equipment that had lethal voltages and currents that would surely have electrocuted me had my parents not properly taught me how to live and work safely.
That electronics business has been continuously active ever since, and is active now, more than 62 years later. Along the way, my business expanded to include engineering and contracting and also into bioengineering research into public safety aspects of the structure(s) of human society, in the manner of forensic engineering.
It is my ongoing forensic engineering work, as a licensed professional engineer, that brings me, from time to time, to the Turley blog…
Truly sad for the girl.
I did a little research and found some links to the directions of the use of this product from 3M’s website. Nowhere in the directions did I see where it read to “Keep away from static electricity or electrical discharge” It only referred to flame. So I don’t see how their defense applies here.
Uses 1
Technical publication
They should sue. A law suit in this matter will serve to purposes. The first of course to compensate the victim and her family. The second to uncover the negligence of both the hospital and the manufacturers and makenitnpublic so that both entities would be force to correct the obvious problems with the product and its use.
I would urge the family not to sign a settlement that seals any documents or the settlemt papers themselves. Too often serious dangers are swept under the run when companies condition a settlement on making everything about the case secret. At a minimum, Sealed settlements should be outlawed to the extent they contain information that is relevant to health and safety. The public has a right to know.
Wow! My post transplant condition requires the frequent use of hand sanitizers. I would never have suspected that some were flammable. I think there are ample grounds for a Tort victory, but also that 3M should recall this product.
AY – exactly, the stuff is a fire waiting to happen. So sad that a child should have to go through so much.
On a adult ward, here, the plastic bottles are enclosed in a metal frame attached to a the bed frame assuring (?) static electricity discharge.
It alcohol (%) mixed with a sort of handcreme. How it is in a children’s ward I don’t know. This would NOT appear to be a likely first time incident.
Sue like h*ll IMHO.
OMG…. That stuff is made with alcohol… Between 70 to 90%….. I’m surprised there are not more reports….
I hope she has a full recovery and the hospital looks into this matter seriously so as to utterly avoid it in the future.