Surgical fires spark review
‘ TRAUMA’ FOR THOSE BURNED ON OPERATING TABLE
The surgery to “de- bulk” or shrink the mass of a tumour inside the woman’s trachea began uneventfully enough, until the surgeon switched on the laser. A sudden flashback, and then a burst of flames inside her windpipe. The surgeon’s laser had hit the inflatable cuff around the breathing tube delivering anesthetic gases and oxygen. The cuff deflated, gases leaked and the laser ignited the oxygen.
The woman, who spent three weeks in intensive care, sued for malpractice — one of dozens of Canadians who went into surgery in recent years and who, in some cases, were literally set on fire.
Surgical fires are rare. However, pa- tient safety groups have deemed them “never events,” meaning they should never happen.
A new review of 54 cases of surgical fires and burns by the body that defends doctors accused of malpractice found many people were left with “scarring, disfigurement and psychological trauma.”
One-third involved fires in the operating room. Others involved burns from surgical equipment or chemicals used during surgery, according to the review by the Canadian Medical Protective Association.
In the case of the woman who suffered an “i ntratracheal fire,” experts who reviewed the case said the injuries likely resulted at least in part by the anesthesiologist’s use of 100 per cent oxygen, instead of the lowest possible concentration — between 30 and 40 per cent — “to prevent OR fires in this scenario,” according to the summary.
For a fire to occur, “the three elements of the fire triangle must be present: ignition (heat), fuel and oxygen,” the CMPA says (the body publishes regular articles for doctors on how to avoid errors.)
Fuels abound in the OR, especially alcohol- based antiseptics used to clean and prep the skin before an incision. In some cases, the solutions were not given sufficient time to dry before the person was draped; in others, the solutions were allowed to pool under the patient, instead of being soaked up.
The prep agents remain flammable until completely dry. If too much is put on and it pools, alcohol vapours can form that can be easily ignited by the heat or spark from a cauterizing tool or other instrument, said Dr. Douglas Bell, the CMPA’s associate executive director.
In other cases, lasers ignited dry gauzes or sponges placed inside the incision site that should have been wet down.
Burns not caused by fires were due to equipment “issues,” according to the review — including using the wrong type of device, equipment malfunctions or lasers with the power level set too high.
Half the fires occurred when the oxygen concentration wasn’t decreased to the lowest possible level during laser surgery on the head, neck or upper chest, according to the review.
Among other problems, experts who reviewed the cases cited communication breakdowns and members of the surgical team not sharing “critical information” during surgery. There were also delays in diagnosing burns.
The 54 cases involved legal actions and complaints to doctors’ licensing colleges between 2012 and 2016. The bulk of them, Bell said, were settled.
Patient safety experts say that, if 54 cases made it to litigation at the CMPA, there were at least 10 times as many cases nationally, perhaps more.
“If you want to hold the hospital or medical system accountable, you better have deep pockets,” said Darrel Horn, a former patient safety investigator with the Winnipeg Regional Health Authority.
The CMPA has vast funds at its disposal to defend MDs accused of negligence. Those of other nations dwarf the number of malpractice lawsuits filed by Canadians.
“Because these injuries are seldom fatal or, in the long term, life altering, they don’t get a lot of attention,” Horn said.
The vast majority also would not be reported or collated by any central body, he added. ( In some of the CMPA cases, the “burn event” wasn’t properly documented.)
Errors often come down to human factors, Horn said. “It’s human interaction and demands on time over thoroughness and efficiency. These are the things that need to change — we have a system that is just too busy. There is no system that can operate at 100 per cent and not fail.”
In the U. S, as many as 650 operating room fires are reported in each year, but the true number is likely higher because half of the states don’t have mandatory reporting.
“What can you say to a patient having a skin lesion excised under monitored anesthesia care ( MAC) who suffers severe burns to the neck and face from a surgical-site fire caused by unnecessary supplemental nasal cannula oxygen leaking under drapes and towels into the surgical field where electrocautery was used? ‘ Oops!’ is clearly insufficient,” Dr. John Eichhorn, of the University of Kentucky College of Medicine and Medical Center wrote in 2013 in an editorial in the journal Anesthesiology.
Two years ago, a Seattle woman was awarded $ 30 million in damages when, similar to the Canadian case, an endotracheal tube caught fire inside her throat during surgery for polyps on her vocal cords. She’s now unable to speak or breathe on her own.
In 2011, t he U. S Food and Drug Administration launched a surgical fire prevention i nitiative, citing specific cases that included flash fires of an eyelid, a bowel explosion, throat fires and drape and gown fires.
“Most fires in the OR will be either on or in the patient,” the FDA cautioned in their document, “The Patient is on Fire! A Surgical Fires Primer. While a burning drape or gown can be quickly patted out by hand, “fires inside the patient are typically small but can be deadly.”
In the case highlighted in the CMPA review, the fire in the woman’s trachea “was put out very quickly,” Bell said. Saline was flushed into her airway. The woman suffered burns to her tracheobronchial tree, the airways of the lungs.
There were no deaths among t he 54 cases reviewed. However, five per cent involved “major, permanent” injuries.