Americans are worried about their safety when it comes to medical errors, and they very well should be.
In 1999, the Institute of Medicine published the famous “To Err Is Human” report, which concluded that: 98,000 people a year die because of hospital mistakes in the United States. Since that sentinel study, the situation has only become worse. Recently, the Centers for Disease Control (CDC) published a study estimating that Preventable Medical Errors are the 3rd leading cause of death in the United States.
One type of preventable medical error that should never happen is a surgical fire. Yet, it has been estimated that surgical fires, wherein the patient is caught on fire in the operating room occur upwards of 500 times per year in the United States and this figure is likely underestimated because there is no mandatory reporting requirement for surgical fires.
A Tonsillectomy Turned Tragic
Fires that ignite in the operating room and seriously injure patients occur more than you might think. I once handled a tragic surgical fire case where my client’s son was scheduled to undergo a minor surgical procedure to remove his tonsils.
Of course, his mother worried like any mother does when their child is going through any type of surgical procedure, but she was confident the doctor knew what he was doing. She knew that he had performed this type of surgery hundreds of times. However, when the doctor returned to the waiting room after a long time in the operating room (OR) to let her know how the surgery went, she got alarming news.
The doctor explained that there was a complication in the operating room and that her son had been badly burned. He had been sedated and was being sent to a special burn hospital for emergency treatment due to facial and inhalation burns he suffered as a result of a surgical fire. She was horrified and shocked, as anybody would be.
How can this happen? How does a simple tonsillectomy operation turn into a child fighting for his life?
In another surgical fire case I handled,my client was an older patient who needed a pacemaker. A fire erupted on her in the operating room. The operating room team extinguished the fire as quickly as possible, but the fire left serious, painful and disfiguring scars for this patient to recover from.
The Scope of Surgical Fires
Surgical fires occur in, on, or around a patient who is undergoing a medical or surgical procedure. Surgical fires can occur any time all three elements of the “Fire Triangle” (ignition source, fuel source, and oxygen) are present. Most people are aware of how dangerous these three elements combined can be. Surgical fires are significantly underreported and they happen entirely too often, resulting in disaster for the patient.
Surgical fires are undoubtedly one of the most frightening and devastating experience a patient and their family can experience. Because these fires are underreported, the exact number of serious injuries and deaths is difficult to determine.
According to the Council of Surgical Perioperative Safety (CSPS), An estimated 550 to 650 surgical fires occur in the United States per year, some causing serious injury, disfigurement, and even death. Despite the fact that the root causes of surgical fires are well-understood, surgical fires still occur.
Surgical fires are referred to by medical professional as Hospital Acquired Conditions (HACs) and “never events” because, theoretically, they should never happen. They do happen, though, and, according to the American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNW), as much as one-fourth of the nearly 350 otolaryngologists surveyed had witnessed at least one fire, and in some cases more than one fire, in the operating room (OR) during their careers.
How Do Surgical Fires Happen?
ECRI’s recent analysis of case reports showed that the most common ignition sources are:
- Electrosurgical equipment (68%)
- Lasers (13%)
An oxygen enriched environment is a contributing factor in at least 74% of all surgical fire cases. Each member of a surgical team controls a certain aspect of this triangle:
- The surgeon controls the heat source
- The nurses control the fuel.
- The anesthesiologist controls the oxidizer.
If surgical teams are educated and aware of how to properly manage these components, fires are prevented. Though many teams are aware and do take necessary precautions, there are still medical staff who are completely unprepared, in too much of a hurry or are ignorant of the true risks involved.
The ignition source is anything in the OR that can spark or start a fire when oxygen and a fuel source are present. Resting an ignition source on the drapes around a patient in the OR, for example, would most definitely ignite a fire. The surgeon usually supplies the ignition source when he uses a cautery device, but a number of other things can also spark a fire:
- overhead surgical lights
- electrosurgical or electrocautery units (ESUs, ECUs)
- heated probes
- drills and burs
- argon beam coagulators
- fiber-optic light sources and cables
- lasers used with the free-beam method or with contact tips or fibers
- MRI machines
- Overheated IV solution bags
- Blankets warmed in heating cabinets
When sparks are given off by these sources and they produce temperatures that are from several hundred to a few thousand degrees, enough to ignite most fuel sources in an oxygen enriched environment. Surgical teams can ensure that fires are prevented by making sure that heat sources are not directed towards or don’t come into contact with fuels. According to the ECRI Institute, a well-respected patient safety advocacy group dedicated to medical research,
- 70 percent of surgical fires are ignited by electrocautery devices
- 20 percent are started because of light sources, wires, and defibrillators
- 10 percent are sparked by lasers
A fuel source is anything that is flammable, including almost everything that comes into contact with patients in the OR. Even the patient is considered a fuel source. In an oxygen-enriched environment, even things that are not considered to be flammable can ignite and burn.
Fuel Sources Abound in the OR
Nurses generally control fuel sources. Almost anything in the OR will burn, including the following: preparation solutions, sponges, drapes, towels, hoods, masks, anesthesia circuits, dressings, and ointments.
If surgical drapes are placed in such a way that allows oxygen to pool under them, they can very easily ignite as well. Various prepping agents and some ointments used in the OR are extremely flammable. Liquid alcohol from a wet, dripping prep can pool under the patient and generate vapors that can easily ignite.
Preparation solutions, such as alcohol-based sterilizers, are especially likely to catch fire when they have not been given sufficient time to dry. To the contrary, water-based lubricants, like K-Y Jelly, are mostly water and they will not burn. These types of lubricants should be used to coat the patient’s hair, making it fire resistant.
The final component of the fire triangle, the oxidizer, is supplied by the anesthesiologist who monitors the amount of oxygen given to the patient. The amount of oxygen to be delivered to the patient is especially important. Anesthesiologists should try to minimize the amount of oxygen they use, but if the patient needs more oxygen, the airway should be secured and a mask should be placed over the airway to prevent oxygen from venting under surgical drapes.
When the concentration of oxygen in the room is greater than the ordinary room air, conditions are set for a fire to occur.
The majority of surgical fires arise in oxygen-enriched environments in which oxygen and nitrous oxide have accumulated under the drapes and near the patient’s airway. However, oxygen is not the only oxidizer. Ambient air and even atmospheres that contain less than 21 percent oxygen can support combustion of fuels.
Surgical fires most often occur in surgeries performed on the head, neck, and chest, because the electrosurgical equipment, or the ignition source, comes within a close proximity of the oxygen being given to the patient. Injuries from these fires often occur on the head, face, and chest.
Lack of Appreciation for OR Fire Dangers
image source: hpnonline.com
The three elements of the fire triangle combined exist in almost every surgical situation. This becomes a problem only when it is combined with a lack of appreciation for the potential dangers that are present.
Procedures that carry the highest risk for a surgical fire include ENT surgical procedures, due to the presence of exposed supplemental oxygen around flammable materials. These include the following:
- Removal of laryngeal papilloma
- Skin surgeries of the head and neck
Other procedures that put patients at risk for catching on fire in the OR include procedures as simple as an excision of a skin lesion, which are often performed in an office based environment. Since these surgeries tend to take less time and are far less complex than those performed in a traditional OR, the risks posed may not be taken as seriously.
Additionally, in these types of procedures, anesthesiologists may have a tendency to give their patients more oxygen than necessary, because they want the patient to maintain a good oxygen saturation rate.
When surgical fires occur, healthcare providers will often suggest that some type of equipment failure caused the fire. BUT THIS IS MISLEADING.
The ECRI Institute, in its 20 years of research and analysis of surgical fires, has found that surgical fires are typically caused by misuse of the equipment rather than malfunctioning electrosurgical devices. In other words:
Disaster = human complacency + fuel + oxygen + heat
Surgical fires are preventable given proper coordination and communication between nurses, the anesthesiologist, and the surgical team. Lack of communication among the members of the surgical team is a frequent cause of surgical fires.
Why Surgical Fires are so Dangerous
We all have an innate, healthy fear of fire and the destruction it can cause. When a surgical fire is sparked in the operating room, the patient sometimes suffers life-changing, serious, significant injuries.
The dangers of a surgical fire are especially high when the setting is considered. Patients who may already be weakened from some underlying condition are anesthetized, or drugged, so they will not be aware of the procedure taking place. These patients are immobile from the drugs and may even be secured to the operating table so that they won’t move during the operation.
Commonly, the patient is provided with additional oxygen, which has the unfortunate side effect of increasing the risk of fire and making a fire burn hotter once ignited. If a fire does occur, the unconscious and restrained patient cannot protect himself or even move out of the path of the fire.
Unfortunately, many surgical fires occur during surgery performed on the head, neck, and chest, so the flames are located in the body’s most delicate area.
In mere seconds, an open flame can blind, scar, or even critically injure a patient. In a case we once handled, a flash fire started during a pacemaker implantation surgery, engulfing the patient’s face, neck, and breast. The patient had to be airlifted to a burn specialty hospital for critical care. She had deep burns to her face that required plastic surgery and skin grafts.
Following the fire and numerous surgeries to replace the burned skin, she had tremendous difficulty even using her dentures because her mouth would no longer stretch enough for the dentures to fit. The doctors feared that the flames she inhaled had damaged her throat and lungs. The victim of this fire reported such discomfort when the skin on her face began to heal that she was taken again to the hospital, where she thought she might die due to the intense pain.
About 65 percent of all surgical fires occur in the most dangerous places: the upper body and inside the patient’s airways. A vivid imagination is not needed to see how dangerous these types of fires can be, but the ramifications of such events are nearly unimaginable. Surgical fires often leave patients with long-lasting, life-changing injuries like the following:
- Infections in the parts of their body damaged by the fire
- Difficulty breathing through their nose due to scar tissue buildup
- Pain from multiple plastic surgeries
- Difficulty chewing because of the lack of elasticity around the mouth
- Long-lasting physical and emotional scars
- inhalation injuries from inhaling flames or smoke
- Burns to skin
Reducing Surgical Fire Occurrences
Thankfully, awareness about the frequency and dangers of surgical fires is growing as medical professionals begin to recognize the need to educate healthcare providers on how to prevent these events. The American Society of Anesthesiologists (ASA), the Association of Perioperative Registered Nurses (AORN), and the American College of Surgeons have all developed training manuals and recommendations aimed at reducing the risk of fires through education. There is no reason for a surgical team of medical professional to be unaware of the risk of a fire.
National, military and state organizations have likewise developed or adopted recommendations to reduce the risk of fire. Additionally, AORN has developed a Fire Safety Tool Kit that is being distributed across the country and is being offered to its members free of cost. As early as 2003, the Joint Commission, a U.S.-based non-profit hospital accreditation organization, published a document entitled “Preventing Surgical Fires,” which explains the risk of surgical fires as well as effective preventative measures that can be taken to prevent them.
Through its National Patient Safety Goals Program, the Joint Commission stresses the importance of educating healthcare providers on ways in which they can reduce the risk of surgical fires. Topics covered range from minimizing oxygen concentrations to controlling ignition sources. Hospitals who have a culture of patient safety are doing these things, while others are not, thereby putting their patients at risk. Hospitals are responsible for working with teams who work in the OR and training them on the importance of teamwork, communication, and individual roles to be fulfilled.
The Key is Communication and Education
It seems obvious that the key to preventing surgical fires is the proper management of the interaction of the three main components of the Triangle of Fire: the ignition source, the fuel and the oxidization.
Medical personnel should always be aware of the possibility of a fire can break out at any time, and they should be ready to protect their patients from harm. COMMUNICATION IS KEY! Hospitals have a legal responsibility to hire and train competent staff and ensure they know appropriate fire safety principles and are following them.
Preventative Perioperative Measures
- Surgical drapes should be arranged so that oxygen does not accumulate under them or near the area where the cauterizing tool will be used.
- In preparing the patient for surgery, especially head, neck, face, or chest surgery, the patient’s hair should be coated in water-based jelly to make it nonflammable.
- During surgery, the surgical team should ensure that alcohol-based or other flammable skin prep solutions they will be using are dried before the patient is draped.
- Any gauze or sponges used near an ignition source should be moistened, and oxygen should be turned off, if possible, to allow it to dissipate before an ignition source is used.
- An additional bottle of saline can and should be kept in the OR to put a fire out and that bottle should be replenished before every surgery.
Perhaps most importantly, each member of the surgical team needs to collaborate with each other and with the anesthesiologist who is controlling the flow of oxygen.
In the event that a fire does occur, surgical teams need to know how to extinguish the fire as quickly as possibly to try and minimize the harm to the patient. The ECRI Institute is the leading authority on how to deal with and prevent surgical fires and they clearly provide the guidelines and procedures for extinguishing a surgical fire.
According to them, Where a fire occurs on the patient, all airway gasses should be stopped immediately, and all burning materials should be removed from the patient and extinguished. A fire extinguisher may be used on the patient, but only if needed. If the drapes start to burn, all of the drapes should be removed and checked for flames that may have been underneath the drapes. The patient should then be cared for by controlling any bleeding, evacuating the patient if necessary, and examining the patient for injuries.
Oxygen should be resumed only when the team determines it is safe to do so. If the fire is not extinguished, a fire alarm should be activated, and the patient and the surgical team should be evacuated from the OR, according to the facility’s emergency response plan. The emergency response plan should also include a system to alert other staff members that a fire has occurred.
Where an airway fire occurs, the surgical staff needs to immediately remove the tracheal tube before stopping the flow of gasses to the airway. Once this is done, saline should be poured into the airway, and the patient should be cared for by reestablishing the airway and resuming ventilation to ensure nothing is left in the airway.
Only when a staff member determines that there is nothing burning in the airway should oxygen use be resumed. The elements required for a fire to occur are well-known, and the procedures needed to diminish the risk are well understood. Generally, the steps to achieve fire safety are simple, and unlike many things in modern medicine, are relatively inexpensive. Because of this, a surgical fire should never happen.
What You can Do to Protect Yourself
Patients are the most vulnerable to surgical fires, but can protect themselves by asking certain questions of their surgeon before going under the knife. Make sure that your doctor is aware of the emergency plans and procedures by asking him what he would do in the event of a fire during surgery.
If your doctor does not explain the risk of fire to you, do not be afraid to ask. In most states, doctors have an affirmative legal duty to explain all risks of surgery to you before you consent to the surgery. Also, ask what the doctor’s procedure is for preventing a fire. If he does not know, you might want to find another surgeon who is well-versed on procedures to prevent and deal with fires in the OR.
Another thing you, the patient, can do is to really know your doctor. With any surgery, the patient should choose the doctor and hospital that are most familiar with the procedure to be performed—meaning they have performed the procedure often and have had success in performing it. The sad reality is that as patients we aren’t always in control.
We are vulnerable. We must be able to rely on our healthcare team to be aware of the risk of surgical fire and take the steps that are known to prevent them.
By: Kay Van Wey | August 23rd, 2016