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.