December 2011: A 29-year-old woman is undergoing minor facial surgery at an outpatient center in Florida when a flash fire erupts. She sustains burns to the face and neck and is airlifted to a burn center.
October 2011: A 68-year-old California woman’s oxygen tube catches fire while a surgeon is cauterizing a wound in her neck. Five months later, she’s still recovering.
September 2009: A woman from Illinois, age 65, dies six days after being severely burned in a flash fire during a biopsy. The hospital subsequently revises its safety policies and puts mandatory training in place for all surgery staff.
Of all the things that can go wrong in patient care, surgical fires are among the most horrifying – so much so that the U.S. Food and Drug Administration recently launched a prevention initiative to educate health care organizations about the causes of surgical fires and provide them with risk reduction strategies. The initiative includes a number of prominent partners: the Anesthesia Patient Safety Foundation, the Institute for Safe Medication Practices, the Joint Commission, the Veterans Affairs National Center for Patient Safety, the American Academy of Orthopaedic Surgeons, the American Society of Anesthesiologists and the American Society of Nurse Anesthetists, among others.
Surgical fires are thought to be rare. Some estimates put the number of surgical fires at 600 to 650 a year out of millions of surgical procedures performed in the U.S. Other studies have suggested they’re much less common, citing fewer than 100 a year. But because many states don’t require hospitals and surgery centers to report them, the true incidence is unknown, and surgical fires in the U.S. likely are significantly underreported.
What’s more, most patients and families are unaware of the risk. Ann Grice, the mother of the Florida woman whose face was burned last December, told the Crestview (Fla.) News Bulletin in an interview shortly afterwards, “I am in shock. This is not what happens with a routine outpatient surgery.”
After the death of her mother in 2004 following a surgical fire and subsequent severe complications, Cathy Reuter Lake founded SurgicalFire.org, a nonprofit organization dedicated to raising awareness and providing information about this underrecognized risk.
“While many people have never heard of a surgical fire inside a patient, it happens more frequently than you might think,” Lake writes on her website. “Exact statistics are hard to uncover due to under-reporting and efforts to cover up surgical fires for fear of malpractice suits.”
Regardless of how often they occur, fires that break out in operating rooms are frightening, both for staff and for the patient – the more so since the consequences can be so deadly. Surgical fires also can injure the staff in the OR, damage or destroy expensive equipment and put a surgery suite out of commission due to smoke or water damage or worse.
ORs present a uniquely hazardous environment for triggering flash fires. They contain numerous instruments capable of touching off a fire: surgical lasers, electrocautery units, heated probes, fiberoptic light sources, drills, defibrillators and so on. They contain fuels such as surgical drapes, sheets, mattresses, bandages, alcohol skin preps and breathing circuits. Finally, they’re typically rich in oxygen, which makes it easier for a fire to break out and causes the flames to spread faster and burn hotter.
Based on data collected and analyzed by the FDA, the Joint Commission and the ECRI private research group, the majority of surgical fires have several things in common. Electrosurgical equipment and lasers account for the most frequent ignition sources, and an oxygen-enriched atmosphere was a contributing factor in nearly three-fourths of the cases that were studied. Burns to the patient were most likely to involve the airway, head or face.
The most critical conclusion: With proper precautions, surgical fires are almost 100 percent preventable.
One of the outcomes of the FDA initiative has been the development of a series of recommendations to reduce the risk of surgical fire. Surgery teams are advised to be judicious in their use of supplemental oxygen and to avoid allowing oxygen to accumulate around the surgery site. After alcohol-based skin preparations are applied, the patient’s skin should be allowed to dry before being draped and starting the procedure. Surgery teams should exercise caution in how they wield electrocautery devices, lasers and other tools and how they place them when not in use. Finally, the OR should have a plan for what to do if a surgical fire does break out.
None of this might be very reassuring to patients – and indeed, it’s exceedingly difficult to patients to advocate for safety in the OR when they’re under anesthesia. Nevertheless, there are a handful of things patients can do ahead of time, starting with awareness of the risks and the knowledge that these types of fires are almost entirely preventable.
The Empowered Patient Coalition suggests asking questions: Is the OR team at the hospital or surgery center trained in preventing, recognizing and putting out surgical fires? What precautions do they use to protect patients? Are water and carbon dioxide fire extinguishers readily available in the OR? Vague or unsatisfactory answers may mean the patient is better off choosing somewhere else to go for surgery.