Operating Room Surgical Fires

"What can you say to a patient having a skin lesion excised under monitored anesthesia care [MAC] who suffers severe burns to the neck and face from a surgical-site fire caused by unnecessary supplemental nasal cannula oxygen leaking under drapes and towels into the surgical field where electrocautery was used?"
'Oops!' is clearly insufficient."
Dr. John Eichhorn, University of Kentucky College of Medicine and Medical Center 

"If you want to hold the hospital or medical system accountable, you better have deep pockets."
"Because these injuries are seldom fatal or, in the long term, life altering, they don't get a lot of attention."
"It's human interaction and demands on time over thoroughness and efficiency. These are the things that need to change -- we have a system that is just too busy. There is no system that can operate at 100 percent and not fail."
Darrel Horn, former patient safety investigator, Winnipeg Regional Health Authority

"[For a fire to occur], the three elements of the fire triangle must be present: ignition [heat], fuel and oxygen."
Canadian Medical Protective Association

The last thing anyone would expect when they go into surgery is to catch fire. While rare, surgical fires causing injuries and burns occur in Canada, a new review reports.  Astoria.foto

Undergoing surgery to shrink a tumour mass inside a woman's trachea, the operation went extremely awry when the laser switched on by the operating surgeon caused a sudden flashback and a burst of flames where the laser had lit the inflatable cuff around the breathing tube where anesthetic gases and oxygen inside the windpipe were being delivered, from causing the cuff to deflate, gases to leak and the oxygen to be ignited. This resulted in a rare (for Canada) lawsuit when the patient sued for malpractise.

This was an untowardly dangerous event that should never have happened, but it did. The professional body that defends doctors accused of malpractise, in reviewing 54 cases of surgical fires and burns concluded that many patients came out of this type of unexpected complication during surgery with "scarring, disfigurement and psychological trauma". Some burns were occasioned by surgical equipment or chemicals during surgery.

The woman who suffered an "intratracheal fire" might not be comforted to learn through the inspection by experts that the injuries she sustained partially resulted in all likelihood by the anesthesiologist using 100 percent oxygen rather than the recommended lowest possible concentration, between 30 and 40 percent "to prevent OR fires in this scenario".

Alcohol-based antiseptics used to clean and prepare skin before an incision represent the most flammable of solutions which should be given sufficient drying time before any procedure is commenced. In some scenario the solutions, allowed to pool under the patient rather than being wiped up, present another opportunity for fire to erupt. Until completely dry, prep agents are highly flammable. Alcohol vapours can form, readily ignited by heat or a spark from a cauterizing tool. Alternately, lasers were known to have ignited dry gauzes or sponges placed within the incision site.

Malfunction of lasers, the power level too high or the use of an incorrect type of device represent other issues leading to fire, but half of the fires studied occurred when oxygen concentration was not diluted to the lowest possible level during laser surgery on a patient's head, neck or upper chest. As well -- it was pointed out by experts reviewing the cases -- communication breakdowns during surgery were cited along with delays in diagnosing burns.

The 54 cases all occasioned legal actions and the receipt of complaints to licensing colleges. According to patient safety experts, at least ten times as many additional cases would have occurred nationally. Problems such as these are of magnitudes higher elsewhere around the world and particularly in the United States malpractice lawsuits are infinitely more plentiful. In the U.S., up to 650 operating room fires annually are reported, with the true number much higher, reflecting the lack of mandatory reporting in half of the states.

A patient in Seattle had been awarded $30-million in damages two years ago when an endotracheal tube caught fire inside her throat during surgery to remove polyps on her vocal cords. Post-surgery and fire, she no longer is able to speak or breathe on her own. The U.S. Food and Drug Administration launched a surgical fire prevention initiative in 2011, citing cases including flash fires of an eyelid, a bowel explosion, throat fires and drape and gown fires.

In their document, 'The Patient is on Fire! A Surgical Fires Primer', it was noted that "Most fires in the OR will be either on or in the patient. Fires inside the patient are typically small but can be deadly." Among the 54 cases reviewed in Canada, there were no deaths resulting from the events, but five percent did involve "major, permanent" injuries.