Death Puts Surgical Fires In The SpotlightSep 18, 2009 | Parker Waichman LLP surgical flash fire caused the death of a woman last week at Marion, Illinois’ Heartland Regional Medical Center. The Associated Press (AP) reported that the woman was seriously burned in a fire that occurred during surgery, dying six days later at the Vanderbilt University Medical Center in Tennessee.
The reason for the surgery has not been released; however, the state medical examiner in Tennessee said the woman, whose death was ruled accidental, died from thermal burn complications, said the AP. According to a Heartland statement, "There was an accidental flash fire in one of the hospital's operating rooms," quoted the AP, which noted that a patient was injured just before the fire was put out; the hospital did not explain how the fire started.
KFVS, citing the ECRI Institute—a group that tracks surgical fires—approximately 550-650 surgical are reported annually, with 20-30 deemed serious, and one or two deemed deadly. ECRI accident and forensic investigator, Mark Bruley, who has studied surgical fires for some 30 years, said that most—about 75 percent—occur when high oxygen levels are found under “surgical sheets or drapes,” which can cause the material to ignite, reported KFVS. Another common flash fire occurs when surgical staff use alcohol-based cleaners and do not permit the alcohol to fully dry before setting up electronic scalpels, said KFVS, which can cause vapor ignition.
According to Bruley, the fires are “100 percent preventable.”
"Let me put it this way, there's not a whole lot the patient can do to prevent a surgical fire if anything…. An informed health care community with the surgeons and anesthesiologists and OR nurses being informed on how to prevent the fires is the real critical issue," said Bruley, quoted KFVS.
The AP noted that concern about surgical fires has increased in recent years with the advent of electrosurgical tools—such as scalpels and cauterizers—and the use of less flame retardant, disposable synthetic fabrics, which have replaced cloth hospital drapes. The ECRI, said the AP, recommends anesthesiologists stop using 100 percent oxygen, giving the patient only what he/she requires and diluting the oxygen content with room air when electrosurgical tools are in use.
"What we've been advocating for years is that the open delivery of oxygen under the drapes essentially has to stop," said Bruley, quoted the AP, with noted that there are needed exceptions, for instance in operations involving cardiac pacemakers or a neck artery. Bruley also noted, said KFVS, that many of these accidents, such as the recent death involving 65-year-old Janice McCall of Energy, Illinois, result in legal action.
The medical community is not unaware of the issue with surgical fires. According to MD Publishing, a trade publication, it recently wrote that “The OR is a complex setting, with high-tech demands and team members with varying competencies working on cases that are often emergent or urgent. These factors make the OR prone to errors, which are more likely to occur during periods of procedural confusion and deviation from protocol.” The article listed an array of adverse events possible in the operating room under such circumstances, stating that surgical fires are among the high-risk outcomes.