Abstract: At approximately 6:30 p.m. on March 1, 1991, a contractor employee left a 2-quart, plastic cylindrical container on a desk at Bethesda Hospital. A note attached to the lid of the container stated "used agent please dispose." Several inches of a mixture of three anesthetic liquids (halothane, ethrone, and isoflurone) had been placed into the container by the contractor. Bethesda Hospital Employee #1 was found at 8:20 p.m., slumped over the desk with his face centered upon and resting on the upper rim of the container. He was sitting in a chair at the desk with his left foot resting on the lower left desk drawer. It appears that he lost consciousness while voluntarily inhaling the anesthetic vapors. All attempts to revive Employee #1 failed.