Breathing Life Into Surgical Smoke Safety

One night before bed, she said a brief prayer and laid down ready to die. "I had given up," she recalls. "I didn't have the will to go on."

When she awoke the next morning, she decided God had other plans for her. In constant pain and suffering shortness of breath, she started chemotherapy, immunotherapy and other treatments. During this time of great personal suffering, Ms. Hohn found the strength to embark on a quest to understand how surgical smoke may have affected her health, and how she could protect other surgical professionals from suffering a similar fate.

Smoke evacuators were installed in every OR at the Atlanta VA a couple of years ago. "But every time we'd attempt to hook one up, the surgeon would say it was too cumbersome, and it would slow them down," says Ms. Hohn. "When something is rejected time and again, you offer it less."

Worse, she and other concerned colleagues had no organizational support. "Smoke evacuation wasn't mandatory, so it wasn't enforced," she says.

Ms. Hohn was convinced there was truth in the idea that breathing in surgical smoke day after day over a long career had caused her lung cancer, but didn't know how to act on the hunch. She soon received emails about surgical smoke safety from AORN and the International Council on Surgical Plume (ICSP). She got more involved and energized, and considered how she could contribute to the smoke evacuation movement. "I didn't have a clue about where to begin," she says, "but knew I wanted to make a difference."

Before her illness, Ms. Hohn was so busy that she rarely had time to attend local AORN branch meetings. However, she'd become aware of fellow member Brenda Ulmer, MN, RN, CNOR, past president of AORN, who had been investigating and advocating for smoke safety since the mid-1990s. She reached out to Ms. Ulmer, who lived close by in suburban Atlanta. It was the connection Ms. Hohn needed to advance her newfound advocacy.

For Ms. Ulmer, Ms. Hohn was another reminder of the importance of her efforts to remove surgical smoke from ORs. She graduated from nursing school in 1975 and had worked various positions in ORs around Atlanta since. While serving on AORN's board of directors in the mid-1990s, she became interested in surgical smoke, chairing roundtable discussions on the topic. Since then, she's written articles, book chapters and self-study guides on surgical smoke safety. She was part of the group that developed AORN's first smoke toolkit, as well as its smoke position statement, which morphed into guidelines in 2017.

"I don't know how many programs I've done all over the world on surgical smoke," says Ms. Ulmer.

Having access to a worldwide expert on smoke safety was a blessing for Ms. Hohn, especially when she discovered what Ms. Ulmer and the Georgia Council of Perioperative Nurses Legislative Committee were trying to accomplish: getting a state law passed that would require healthcare facilities to install and use surgical smoke evacuation systems. At the time, Ms. Hohn had no idea she'd play a starring role in that effort.

Ms. Ulmer's initial lobbying for surgical smoke safety began in the 1990s on the national level. She spent significant time in Washington working on language with OSHA representatives for a bill that would have required the evacuation of surgical smoke in ORs across the country. The legislation was introduced, but ultimately died in Congress. Two decades later, a national ban on surgical smoke is no closer to becoming reality. The good news, says Ms. Ulmer, is that local legislation can be just as effective.

"Nurses and technicians have grown tired of nothing happening, which is why you're seeing so much activity at the state level," she says.

Smoke safety is a personal issue for Ms. Ulmer as well. After she joined AORN's board in the 1990s, she'd work in the OR only once per month. "After one day of high-smoke-producing cases, my nose burned, my throat hurt, my chest was tight and I felt nauseous," says Ms. Ulmer.

She felt fine the next day, but experienced the same symptoms a month later after a full day spent in the OR. "I made the connection that when I'm away from the smoke, my body starts to feel normal again," says Ms. Ulmer. "I decided then that surgical smoke was really bad for your health, and that's what started me on this journey."

When Ms. Ulmer stopped working in ORs full-time in 2012, her primary care doctor said she had a "90-day cough," and an allergist diagnosed her with adult-onset asthma. "I had a lot of respiratory issues," she says.

Ms. Ulmer knew her story wasn't unique, as the unusually high rate of perioperative nurses with respiratory illnesses had been well-documented. Her own health history, the reported problems of fellow nurses and smoke evacuation legislation passed in Rhode Island and Colorado inspired Ms. Ulmer to begin working toward getting a similar law passed in Georgia. After proposing the initiative to Georgia Council Chair Pat Thornton in 2019, she was asked to chair the council's legislative committee. She and a small core group started contacting local legislators to seek support for smoke legislation. Their persistent efforts eventually resulted in gaining the support of Senator Gloria Butler. However, it would take a serendipitous encounter to make it happen.

Senator Butler's annual fish fry was scheduled to take place in October 2019, and Ms. Ulmer made it a point to attend. She had been calling the senator's office so often to discuss smoke evacuation legislation that her staff knew her by name. Still, her calls went unreturned.

At the fish fry, Ms. Ulmer walked right up to Senator Butler. "I held out my hand and said, 'I'm Brenda Ulmer,' and she said, 'I know about you!' So she had gotten my messages!"

Ms. Ulmer gave Senator Butler materials from AORN about smoke evacuation, which she held in her hand as she addressed the crowd. After the fish fry, though, Ms. Ulmer didn't hear from the senator, so she and the legislative committee continued contacting and meeting with other legislators in the Georgia Senate and House. The legislative committee traveled to AORN chapters around the state to talk about smoke and build a statewide coalition, which they called the Smoke Busters.

On New Year's Eve 2019, Ms. Ulmer's phone rang at 10 p.m. It was Senator Butler calling to say she would sponsor a smoke evacuation bill. Ms. Ulmer hung up the phone, stunned by the senator's out-of-the-blue support. With Senator Butler now on board, the Georgia Smoke Busters were about to get a crash course in lobbying and lawmaking.

A few months later, a smoke evacuation bill began to take shape in the Georgia General Assembly. A hearing was held, but then the pandemic shut down the legislature. When lawmakers reconvened in the summer, Senator Butler introduced and helped pass a resolution that required the Senate to convene a smoke study committee, which held meetings each month in the fall. Senator Butler included Ms. Ulmer and the legislative committee in developing the agendas aimed at educating the legislators on the hazards of surgical smoke.

Ms. Ulmer says she was working 30 to 40 hours a week on the legislation effort throughout 2020. She and legislative committee members traveled to AORN chapters around the state to drum up support and encourage perioperative nurses to contact their local legislators. It was during that massive networking effort that Ms. Hohn's story came to light.

Jennifer Pennock, AORN's senior director of government affairs, was working with the Georgia team on their lobbying efforts. She asked Ms. Hohn to testify before the senate committee by writing a letter that could be read to its members. "I wrote what I thought was my first draft, and video-called with the smoke evacuation team to read it," says Ms. Hohn. "Afterward, everybody was silent. Then one person finally said, 'You're incredibly brave. Don't change anything. We want you to be the first presenter to the committee because your message is so powerful.'"

Some of the smoke team members were shocked that Ms. Hohn, who was struggling in the midst of her cancer battle, was up to presenting. "I wanted to make a difference," she says. "I didn't think I was going to live, and didn't want to die without being heard." Says Ms. Ulmer, "It was unbelievable to hear what she went through, and that her doctor said she was sick because she breathed in surgical smoke for all those years. It had a huge impact on us."

A week later, Ms. Hohn videoconferenced into the Senate committee hearing to read her letter, which contained many powerful messages. An excerpt: I got a call that rocked my world. My deepest fears were confirmed — I had lung cancer. I was so unprepared for this devastation that it felt like a death sentence, a nightmare I couldn't wake up from. How could this happen to me?

When she finished, the committee members remained silent. Finally, Senator Butler looked up and said, "I don't know what to say. Is there anything we can do for you? If there is, please reach out to my office."