MORE PROGRESS NEEDED Surgical fires are becoming less common, says Mark E. Bruley, CCE, but misunderstandings still pervade.

Mark E. Bruley, CCE, investigates medical mishaps of all kinds for the ECRI Institute in suburban Philadelphia, but he's known the world over as an expert in surgical fires — both what causes them and how to prevent them. We caught up with Mr. Bruley for an update.

Q Are there common misconceptions about surgical fires?
Mark Bruley: What's largely unappreciated is how much of a hazard the buildup of oxygen presents when it's coming from an open source, like a nasal cannula or mask — how easy it is to ignite cotton surgical towels, drapes and patient hair. At least 70% of surgical fires involve oxygen-rich concentrations that are under the drapes, and in and around the head and neck area.

Another big misconception is the notion that there are fire-retardant surgical drapes. The technology simply doesn't exist. The reason? It's all about the oxygen. The world of oxygen-enriched ignition and flame spread is unlike anything people experience with candles, campfires or gas stoves. It's a totally different world and a frightening world. In fact, the chemicals used to make fabrics fire-retardant in room air literally add fuel to the fire in an OR, because in an oxygen-enriched environment, they burn.

Q Is time pressure a factor that might lead to inadequate drying time being allotted to alcohol-based preps?
MB: Only about 5% of surgical fires involve alcohol-based skin preps that were still wet when the patient was draped. Alcohol gets much more attention because everyone knows it's flammable. It's easy to understand. But the more important issue is oxygen and how easily it allows things to catch fire and burn faster and hotter. Alcohol's role is overrated. Oxygen's is underrated.

Q Has there always been limited recognition of the role oxygen plays, and is recognition growing?
MB: Historically, because oxygen was so freely available, if providers wanted to give patients fresh gas under the drapes for an ostensibly "minor" procedure, they would just put an oxygen mask on and turn it to 3 or 4 liters per minute. It was being given at 100% without any consideration as to what the patient actually needed. We would never do that with any other drug or medication. Well, the real hazards happen when you get up above about a 40% or 50% concentration. And it was that type of minor surgery that often resulted in disastrous, disfiguring fires on the face, head and neck. The current guidance is that when a patient needs supplemental oxygen, he should have a tracheostomy tube or a laryngeal mask to prevent oxygen from building up around the surgical site. That's a big change.

A DAUGHTER'S STORY
When Fire Reality Hits Home

BEFORE AND AFTER Catherine Reuter spent 8 weeks in a medically induced coma after being burned, and never made it home again.

It was New Year's Eve 2002. Catherine Reuter, MHA, was waiting nervously for an update on her mother's aortic valve replacement when the surgeon summoned her. As the door closed behind her, she was sure she knew what was coming. "They took me into the death room," she says. "Because every time they took somebody in there, they came out crying. I figured it was my turn. I expected them to tell me that my mom had died."

Her mother was alive, but the news was devastating. "He told me they'd had an 'event' in the operating room and that she was burned," says Ms. Reuter. "When he said it was a fire, I looked at him like he was crazy. 'You had a fire in your operating room?' He said, 'We had a fire on your mother.' I was flabbergasted."

Her mother, also named Catherine, would survive for another 2 years, but would never make it home again.

"When the doctor introduced the cautery," says Ms. Reuter, "he kept hearing a popping sound. That popping sound was a fire starting around her face." Runoff from an alcohol-based skin prep had pooled underneath Ms. Reuter, and the rising vapors were burning. The former nun and retired kindergarten teacher suffered disfiguring second- and third-degree burns on the right side of her face.

"They kept warning me that it looked like a bad sunburn, and they were right," says Ms. Reuter. "But nothing prepares you for the days ahead, because unlike anything else, burns get worse first. Over the days, her face swelled and oozed and dissipated. She didn't even look like herself."

The next 2 years were a nightmare, starting with an 8-week-long induced coma. "As a direct result of the burn, her kidneys failed, so she was in dialysis 3 times a week. The trach in her neck could never come out because her airway was damaged. And she had so many infections — MRSA, VRE, C. diff — that, in turn, really hindered her care," says Ms. Reuter. "You have a diabetic who's a cardiac patient who's now a burn patient and who now has all these infections."

But the patient never lost her caring nature and sense of purpose. "When she was told what had happened, the first thing she asked was whether everyone in the OR was OK," her daughter recalls. "She always put everybody else before herself.

"I wanted to do something for her. I said, name it, I'll make it happen, what can I do to make the quality of your life better? She said there were 2 things. One, she wanted to go outside. The hospital helped me make that happen. The second was, she said: 'I'm going to die, I know this, but I want others to learn from this.'"

Her daughter took the request to heart, altering the course of her life to make sure her mother's request was answered. An administrative assistant for a commercial lender at the time, Ms. Reuter started a website (surgicalfire.org) to tell her story and promote safety and awareness. "We have so much technology," she says, "but technology isn't going to solve this problem. This is a problem of human error, a problem of common sense, of what's flammable and what's not."

— Jim Burger

Q What about when patients need supplemental oxygen?
MB: It's ironic. Every surgery has a pulse oximetry probe on the patient — technology that can monitor almost in real time how much oxygen is needed for that patient. But what I've seen many, many times are cases where patients were being given 100% oxygen, then a fire broke out, and then, while treating the burn, still in a perioperative situation, the patient was given nothing but air. And yet the pulse oximetry levels stayed the same throughout — 98 before and 98 after. We recommend that in the exceptional cases in which patients need supplemental oxygen from an open source, that you start with 30%. At that level, you're still providing extra oxygen, but the hazard of a flash oxygen-enriched fire isn't present.

Q A flash oxygen-enriched fire?
MB: Flash fires are fires that occur when fine body hairs or fuzz on towels catch on fire. They spread a ripple of flame across your skin at a rate of about 10 feet a second. In other words, they go from head to toe in less than one second.

Q What fire-related questions should surgical teams ask or address during time outs?
MB: First, is there a risk for surgical fire in this case? The answer depends on whether you're using open oxygen or a skin prep that contains alcohol. If you're using an alcohol-based skin prep, the question is, how are we going to prevent pooling and how are we going to make sure that it's dry before we drape? The third question is, are we using supplemental oxygen from an open source on this patient? And more fundamentally, if the answer is yes, is it needed, or can this patient be safely maintained with fresh air delivered from the anesthesia machine?

The questions are detailed in a really nice flowchart with a succinct list of questions provided by the Anesthesia Patient Safety Foundation (APSF) (tinyurl.com/l5lz4ky). ECRI Institute's free surgical-fire-prevention posters (ecri.org/surgical_fires) also address these issues.

Q Are anesthesia providers being adequately trained to reduce supplemental oxygen administration to the lowest levels needed?
MB: The excellent work of the APSF is going a long way toward pushing out the needed training and resources to that community of healthcare professionals. If anesthesia providers are exposed to the information, they have adequate training. Implementing the training is up to each provider.

Q How do surgical fires change OR staff who've experienced them?
MB: The majority take the unfortunate experience to heart as a learning experience. They get training and move on. But they absolutely devastate others. I know of one case where a member of the OR team committed suicide after being involved in a fatal operating room fire. Some OR staff have been so upset that during the lectures I frequently give in hospitals after an incident, where I show a recreation of a surgical fire from the anesthesia patient safety video, they have to leave the room and come back in after the video's over. They just can't deal with it. Even though most surgical fires last only about 4 or 5 seconds, they change lives.

Another common theme from surgeons, nurses and anesthesiologists has been: I've done 5,000 of these surgeries. What happened in this case that caused my patient's throat to catch fire during a tonsillectomy, or caused a fire on the face or the upper chest. What was different? I tell them that all 3 things that can cause easy ignition came together here — fuel, oxygen, ignition source — and that the real issue is that it's all about the oxygen.

Q Estimates vary as to how many OR fires occur annually. Do you have reason to believe the numbers are going down?
MB: In 2007, we estimated that nationwide there were 550 to 600 surgical fires per year. Two years ago, we published updated data, and now our estimate is 200 to 240 a year. What I feel reasonably confident in saying is that since 2007, the increased attention to this hazard has dropped the numbers of fires. But the incidence of serious fires — which is around 20 or 30 a year — we don't think has gone down.