Medical errors (iatrogenic events in doctor speak) are pretty common. But this type of errors is not often reported – fires and burns during surgery.
The tabloids had a real day last Dec 1. Here is just one of the headlines:
The incident concerned about a woman who “caught fire by accident” while undergoing a C-section at the Sheba Medical Centre in Tel HaShomer, near Tel Aviv. The accident happened because of a combination of 2 things: excessive alcohol used as disinfectant used on the patient and an electric medical device used by a doctor. The combination set the patient in flames and caused severe burns. Fortunately, she delivered a healthy baby boy despite her ordeal.
However, this incident is not isolated. In fact, fire in the OR is more common than we think (or than we hear about!).
The US FDA recently gave an estimate: at least 600 surgical fires occur each year in the US! And that is only what has been officially reported.
Many surgical fires cause minimal manage to hair, bed linens, and instruments, are easily and quickly put out – and soon forgotten. However, all these seemingly harmless minor accidents are actually potentially disastrous.
According to The Patient is on Fire! A Surgical Fires Primer of the Emergency Care Research Institute (ECRI):
“Virtually all operating room fires ignite on or in the patient, and about 10 surgical patient fires a year come to ECRI’s attention through various medical and legal communications. These fires typically result in little damage to equipment, cause considerable injury to patients, and are a complete surprise to the staff.”
The title of the some of ECRI’s emergency procedure brochures tells us what’s involved:
“Fighting Fires on the Surgical Patient”
“Extinguishing Airway Fires”
Sounds scary, huh?
No wonder the US FDA recently included Preventing Fires in the Operating Room in their safety alerts for health professionals.
The Anesthesia Patient Safety Foundation (APSF) together with ECRI also produced a video Prevention and Management of Operating Room Fires which they are distributing to health professionals for free.
APSF and ECRI explain about the so-called “Surgical Fire Triangle” – three things needed to cause fire: an ignition source, a fuel, and oxygen. Oxygen is in the air. There’s plenty of fuel around, especially alcohol and other flammable substances. Think about the ample amount of oxygen gas available to aid patients in breathing.
Another way that patients can get burned is during dental surgery. The US FDA has warned again and again about the danger of electric dental handpieces that overheat.
“Burns can occur if the electric handpiece is worn or clogged. If that happens, the motor sends increased power to the handpiece head to maintain performance, which generates heat at the head or the attachment. All of this can happen very quickly. And it can happen without warning, because the patient is anesthetized and may not be able to feel the heat, and the operator is protected from the heat by the handpiece housing.”
In some cases, patients suffered from third-degree burns usually in the facial area that required reconstructive surgery.
This post is not meant to scare you. Most surgeries are safe, with the benefits overwhelmingly outweighing the risks.