International Academy of Cosmetic Dermatology

FIRE IN THE OPERATING ROOM!

I.   Introduction

People start fires, and people can prevent them.  Surgical fires can occur in any setting where invasive procedures are performed, including ORs, ambulatory surgery centers, and even physicians’ offices.  Due to the lack of awareness among surgery team members, the risk of surgical fire is often not considered.  When they do occur, they can cause devastating consequences for the patient and usually result in a lawsuit for considerable damages.

Statistics show more than 23 million inpatient surgeries and 27 million outpatient surgeries are performed each year(1).  The JCAHO estimates that approximately 100-200 surgical fires occur each year.  This estimate, however, is considered to show only a small percentage of the actual fires that occur annually due to the lack of a mandatory reporting mechanism.

Studies by the ECRI (Emergency Care Research Institute) show that the vast majority of surgical fires occur during surgical procedures for the head and neck.  The injuries to the patient are devastating, leaving horrific scars and permanent disfigurement.

II.   How to Build a Fire in the OR

The title of this section is outrageous for a reason.  It is intended to remind the captain of the surgical team or the solo surgeon about the principles of combustion often overlooked in the surgery. 

Fires occur in any setting where the three elements that form the “fire triangle” come together.  These components are considered safe when they are apart, but they become a blazing hazard when they unite.  The three components of the fire triangle are:
1. fuel, 2. oxygen, and 3. heat.

• Fuel is anything that can burn.  The operating room contains abundant fuel sources, such as material (e.g., dressings, fabric, and paper drapes), plastics and rubber (e.g., anesthesia circuits, endotracheal tubes, gloves, gowns, covers, or tourniquets), solutions and ointments (e.g., petroleum based ointments, prep solutions), and the patient (e.g., head, face, and body hair, gastrointestinal methane gas, hair spray and perfume).

• Supplemental oxygen is used in the operating room.  It is often used prophylactically and many times, unnecessarily.  Items that would not normally burn in room air, 21% oxygen, will burn in an oxygen-enriched atmosphere.  Less energy is required to ignite materials in the presence of higher oxygen concentration, and once ignited, these fires burn hotter, burn faster, and are more difficult to extinguish.

• Heat is the last component of the fire triangle.  Without an ignition source, there can be no fire.  High-energy ignition sources are plentiful in today’s operating suites and come in many forms, including electrosurgical units, lasers, and fiber optic light cords.  These sources provide temperatures from several hundred to several thousand degrees Fahrenheit.

These elements are entirely safe independently and alone.  It is only when they are brought together that they present a serious risk to the patient.  Therefore, “human complacency” is the only remaining element that once brought to the center of the fire triangle, ignites in a blaze of horror for the patient – and the physician.  Human complacency is the sine qua non to starting a fire in the operating room.  An equation to remember: Disaster = Human complacency + fuel + oxygen + heat
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III.  Preventing Fire in the OR

Surgical fires are preventable.  ECRI’s analysis of case reports show that the most common ignition sources are electrosurgical instruments (68%) and lasers (13%); and the most common fire location is the airway (34%), head or face (28%), and elsewhere on or inside the patient (38%).  An oxygen-enriched atmosphere was a contributing factor in 74% of all cases.(2)

Each member of the surgical team plays an integral role and has a responsibility to control the three elements.  Each member of the surgical team (i.e., surgeon, anesthesiologist, and nurse) should know his or her role and responsibility with regard to preventing surgical fires.  Each controls a specific side of the triangle.  By properly managing the technique and with appropriate communication among the team members, surgical fires can be absolutely avoided.

The ECRI offers a free poster entitled Only You Can Prevent Surgical Fires that summarizes preventative recommendations based on the organization’s more than 25 years of research and publication on surgical fires.  The poster is available at: http://www.mdsr.ecri.org/asp/dyndoc.asp?id=195&nbr=413558.

These recommendations include:

• Staff should question the need for 100% oxygen for open delivery during facial surgery and as a general policy, use air or FIO2 at less than 30% for open delivery (consistent with patient needs).
• Do not drape the patient until all flammable preps have fully dried.
• Tent drapes so that supplemental oxygen does not pool and accumulate beneath the drapes or migrate into the surgical field.
• During oropharyngeal surgery:  Soak gauze or sponges used with uncuffed tracheal tubes to minimize leakage of oxygen into the oropharynx, and keep them wet; and moisten sponges, gauze, and pledgets (and their strings) so that they will resist igniting.
• When performing electrosurgery, electrocautery, or laser surgery:  Place electrosurgical electrodes in a holster or another location off the patient when not in active use; and place the lasers in STANDBY when not in active use.

ECRI is a great resource for additional information on the incidence and prevention of surgical fires setting forth the standard of care required of the surgical team members.  ECRI offers a clinical website called “Medical Device Safety Reports” where published articles and educational posters on surgical fires are available free of charge.  Go to http://www.mdsr.ecri.org/ and enter “fires” into the Search Terms line.

IV.          The Standard of Care and Avoiding Malpractice

Operating room fire cases are indefensible in this author’s opinion.  Patients do not expect to be set on fire by their healthcare providers.  When the surgeon introduces himself to the patient and explains the procedure, he or she does not say, “Hello, I’m Dr. ‘X’.  I’ll be doing the cauterizing.  My assistant here will put out any fires.”

These cases are fiercely defended and posturing by liability insurance carriers necessitate the filing of a public lawsuit when good judgment would seem to dictate these cases be settled out of court confidentially.  Unfortunately, because the fire triangle necessarily involves three different specialties in medical care, i.e., surgery, anesthesia, and nursing, and a common reluctance for any one of them to accept sole responsibility for the fire, all three usually find themselves joined as defendants.

When fire breaks out in the OR, it could be the result of an equipment malfunction, but it usually results from a simple failure to communicate among team members.  The standard of care to which every surgical patient is entitled requires the surgical team to communicate with each other so that each member knows the other is controlling his or her side of the fire triangle.  For example, during head and neck surgery, the surgeon tells anesthesia when he or she is going to engage the cautery.  Anesthesia stops the flow of supplemental oxygen and advises the surgeon to wait for at least one minute to allow any excess build-up of oxygen beneath the surgical drapes or about the surgical field to dissipate.  Before surgery ever begins, the nurses communicate with both the surgeon and anesthesia to learn whether cautery will be used and whether there is a need for supplemental oxygen so that the patient can be properly and safely draped to prevent an excessive accumulation of oxygen.

V.    Case Study

A 34 year-old woman is admitted for cosmetic removal of keloids from her earlobes The electrosurgical unit (ESU) will be used during the procedure.  The patient is prepped and pre-oxygenated with a mask placed on her chest blowing 10 liters per minute.  The surgeon injects a local anesthetic and an anesthesia physician’s assistant administers drugs for conscious sedation.  The physician’s assistant turns to complete the medical chart.  Meanwhile, the surgeon and the nurse place a drape over the patient’s body from her neck down to her feet and cover the oxygen circuit laying on her chest.  The draping process is completed and surgery begins.  The left earlobe is completed without incident.  The surgeon turns the patient’s head and causes a gap to open in the drape at the patient’s neck.  The surgeon engages the ESU to cauterize a bleeder.  The ESU sparks and a few moments later, the patient, who is consciously sedated, announces that she is on fire.  The surgeon and nurse pull back the body drape and expose the flames.  The fire is extinguished with sterile water, and the oxygen circuit is observed to be melted to the patient’s chest.  The patient subsequently undergoes 14 additional cosmetic procedures by burn specialists.  Despite their best efforts, she remains horribly disfigured with additional keloids that are now painful  on her neck, chest, and breasts.  The keloids on her earlobes were successfully removed without any residual scarring.

Suit was initially filed against the surgeon as the captain of the surgical ship.  He denied liability and refused to accept any responsibility when his deposition was taken.  He did agree that his patient did not receive the standard of care she was entitled to receive and testified that the anesthesia physician’s assistant fell below the standard of care by failing to maintain control of his oxygen circuit.  The physician’s assistant accepted some responsibility in his deposition but testified that the surgeon and the nurse also fell below the standard of care for placing the drape over his oxygen circuit.  The complaint was amended adding the corporate entities legally responsible for the physician’s assistant and the nurse as defendants.

The experts retained in behalf of the patient all agreed this fire and the resulting injuries to the patient were absolutely preventable.  In addition, each member of the team fell below the standard of care in several ways.  A common criticism of each member was a failure of communication with the other members of team.  No one ever communicated at all about the need to avoid the combination of heat, fuel, and oxygen in this case.  The physician’s assistant did have a duty to maintain control of his oxygen circuit, but this did not relieve the surgeon and nurse from their duty to avoid creating a hazard by placing a drape over the oxygen circuit.  Before engaging the cautery, the surgeon had a duty to advise that the heat source would be engaged so the physician’s assistant could turn off the oxygen source.  At that moment, the physician’s assistant and the surgeon would have realized the circuit was buried beneath the drapes, permitting the accumulation of a significant amount of excess oxygen.

A cascade of errors presenting multiple opportunities to intervene and prevent the ultimate outcome brought about this catastrophe.

Consider the following questions that would likely be asked in some form to an expert witness at the trial of an operating room fire case:

• Is the patient entitled to a surgical team that communicates with one another to prevent the risk of fire in the operating room?
• Do you have an opinion as to whether each member of the surgical team owes a duty to the patient to communicate with the other members of the surgical team in such a manner to reduce the risk of fire during surgery?
• Who controlled the ignition source during this surgery?
• Who controlled the fuel?
• Who controlled the oxygen?
• Did each have a duty to advise the other members of the team of any actions taken with the oxygen?  The fuel? The ignition source?
• Would the failure on the part of a team member to keep the others advised be a departure from the standard of care [patient’s name] was entitled to expect?
• Do you have an opinion as to whether the nurses violated their duty to communicate to the surgical team when they failed to advise the surgeon and anesthesiologist that they placed the surgical drapes over the oxygen circuit laying on the patient’s chest?
• Do you have an opinion whether the anesthesiologist violated his duty to communicate to the surgical team when he failed to advise the surgeon and nurses that he had misplaced his oxygen circuit and that the ignition source should not be engaged until he found it?
• Do you have an opinion as to whether the surgeon violated his duty to communicate to the surgical team when he failed to inquire whether supplemental oxygen was being administered to his patient and whether the oxygen circuit had been turned off before he engaged his electrocautery device?
• Do you have an opinion as to whether these failures of communication on the part of each individual member of the surgical team in this case, resulted in this patient being set on fire?
• Please describe for the jury what communication should have occurred in this case to prevent this horrible fire.

VI.   Conclusions

The above case study reveals a vivid description of complacency in the operating room.  Not all operating room fires arise out of such glaring omissions.  Some surgeons work day in and day out with the same nurses and anesthesia personnel and have become so familiar with the practices of the other that communication as explicit as that which is recommended above would seem to be unnecessary.  There should always be some discussion regarding for fire prevention, even if it is nothing more than a short “time out” to raise awareness or serve as a reminder.

With a thorough understanding of how fires occur in the operating room, they can be prevented.  Each member of the surgical team is responsible for the patient and for communicating with the other members to minimize or eliminate the risk of combing the elements of the fire triangle. When heat, fuel, and oxygen are controlled and kept apart from the other, no physician (or patient) should ever experience the horror of a patient on fire.

Adam Malone, JD
Atlanta, GA

References:
1.  “Preventing Surgical Fires,” Sentinel Event Alert 29 (June 24, 2003).
2.  ECRI. A clinician’s guide to surgical fires:  how they occur, how to prevent them, how to put them out [guidance article].  Health Devices 2003; 32(1):5-24.  To purchase a copy, contact ECRI at (610) 825-6000, ext. 5888.