Honolulu EMS Director Jim Ireland said the department has made changes to operating procedures in response.

The ambulance fire that killed a 91-year-old patient in Kailua last August erupted from an oxygen tank, though the “precise mechanism” that triggered it remains unknown, a third-party investigation found.

The fire has led Honolulu Emergency Medical Services to change its procedures when using oxygen in an ambulance, to make ambulances safer, director Jim Ireland said.

As the ambulance approached the Adventist Health Castle hospital Aug. 24, the paramedic inside was switching the patient’s oxygen source from the ambulance tank to a portable one, to transfer him to the emergency room.

The investigation showed the incinerated ambulance gurney compared to a functional gurney. (ECRI Investigation)

When the paramedic touched the oxygen device’s connector to the cylinder’s port, he heard a “pop,” saw a bright flash of light and fire, then the “noise of an activated propane blowtorch,” according to an investigation by ECRI, a medical consulting group, that Honolulu Emergency Medical Services released Wednesday.

The patient, Waimanalo resident Fred Kaneshiro, died in the blaze. The paramedic was severely burned. The fire kept reigniting and fire fighters spent 10 minutes trying to extinguish it.

The investigation offers two possible explanations for the event that could have arisen from unspecified contaminants — oil, grease, dirt or other materials — in the oxygen tank or its valve.

The first, known as adiabatic compression or the “gas hammer effect,” can occur when oxygen rushes into the regulator or hose, creating a momentary spike in pressure and heat.

The paramedic and his clothes were badly scorched in the blaze. (ECRI Investigation)

“These conditions can ignite contaminants within the system,” the report said.

The second, known as particle impact, can occur when oxygen exits its cylinder too quickly, forcing out contaminants and metallic flakes that collide into other surfaces.

“Aluminum O2 cylinders are particularly susceptible to this phenomenon because flakes from the interior body of the cylinder can burn at pressures much lower than within the system,” the investigators said.

Changes In Procedure

Now, paramedics are being instructed to open oxygen tanks slowly, to turn on an exhaust fan when using oxygen, and to switch a patient’s oxygen tanks only when the ambulance is parked and has its doors open, Ireland said.

The Kailua ambulance fire sparked from the oxygen tank regulator (right). A functional regulator is on the left. (ECRI Investigation)

“In the one-in-a-million chance this ever happened again, everybody would be able to get out of the ambulance, including the patient,” Ireland said in an interview. “Very sadly, the patient couldn’t get out of the ambulance, and no one could get him out because of the intensity of the fire. And the paramedic struggled to get out of the ambulance because he had to get the doors open,” Ireland said.

The standard practice had been to switch a patient’s oxygen source while the ambulance was moving, in order to quickly move them into the hospital upon arrival, Ireland said.

“We’re saying, Let’s take a pause,” he said.

“This affected all of us psychologically,” Ireland said. “But we are better after it, we have now these other procedures that I think make the ambulances safer.”

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