This report originally appeared in the August 2009 issue of DOTmed Business News

While surgeons must minimize distractions, patients face a complex assortment of fears and anxieties. The operating room is no place to yell "fire". Yet, with ever-advancing, power-hungry new technologies entering the operating room, it's possible that the incidence of devastating fires is showing a discomfiting rise. One problem is though there's a sense afoot that this is a growing threat, for numerous reasons O/R fires are not being fully reported. There isn't a national system for such reporting in place, admits Robert Caplan, M.D., chair of the American Society of Anesthesiologists (ASA) Task Force on Operating Room Fires. His group has suggested that the number exceeds 50 annually, and may go as high as 100. An independent advocacy group, the Pennsylvania Patient Safety Reporting System cites studies that say the number across the United States is closer to 650, with perhaps four times as many near misses. According to the most conservative estimates available, at least 20 patients are critically injured in OR fires annually, at least two of whom do not survive.

The reason anesthesiologists are at the forefront of the effort to get a handle on O/R fires is simple: the tools they use and the materials they work with, such as pressurized oxygen and nitrous oxide, put them at risk. Oxidizers make up one leg of what's called the "fire triad", found commonly in operating rooms everywhere. The other two parts of the triad are fuels, which include tracheal tubes, sponges, prepping agents like alcohol and acetone, and linens and drapes; and an ignition source, such as lasers, drills and electrosurgical devices. The latter, in particular, are becoming more prevalent due to their promise of accelerated healing time, which speeds recovery, and just as important these days, reduces hospital stays.

There is no question that the present health care environment presents new challenges and opportunities for disaster with which the medical community is only recently learning to contend. Accordingly, the ASA has taken the lead in raising awareness of the omnipresent danger of O/R fires, and has begun to set measures in place to address it. Last spring the organization's journal, Anesthesiology, published a white paper on the subject, a "Practice Advisory for the Prevention and Management of Operating Room Fires". The advisory breaks down the essential preventative approaches according to the key measures of education, preparation, prevention, and management. Each comes with its own set of standardized practices and a checklist of items and issues medical professionals are encouraged to reacquaint themselves with. The document is available free on-line at [http://tinyurl.com/mlgeh4 ].

The thrust of such advocacy on the part of practitioners and environmental safety experts is fourfold. The conditions that result in fire must first be vividly identified with appropriate preventative measures then put into place. Ways must be investigated to reduce the damage associated with such fires if they do occur and finally, the elements of an effective fire response must be identified, with an eye on procedures that can be seamlessly integrated into existing operating room practices.

The 40-year old non-profit ECRI Institute, an organization devoted to the use of applied scientific research in the investigation of optimal medical procedures, devices, drugs, and processes, has been keenly engaged with the problem of operating room fires for some time. The organization has published its own guide, "The Patient is on Fire! A Surgical Fires Primer," which cites, in extensive detail, specific features of the operating room environment that represent potential fire hazards, and offers a system for addressing them. Again, the key is standardization, and to that end ECRI has published a printable poster outlining simple prevention procedures to be followed on site. The poster, titled "Only You Can Prevent Surgical Fires" is available for download here: [http://tinyurl.com/pw3x5t ].

Patients call for help!

The other side of the O/R fire equation is the patient, for whom the risks are even higher. The patient is the least empowered presence in the room, and yet statistics show that almost all operating room fires ignite in or on the patient. The layperson is hardly in a position to mediate on behalf of O/R safety, particularly at the very moment that survival and healing are their sole concerns.

A Maryland woman learned this lesson in the most devastating way and today serves as an advocate for O/R fire safety. In late 2002 Cathy Lake's mother, Catherine Reuter, underwent surgery for a non-life threatening condition. Within two years she was dead, having succumbed to ongoing infections, kidney failure, and other complications resulting from the surgical fire that marred an otherwise routine tracheotomy. An electric cauterization device had ignited a topical solution on Ms. Reuter's face, delivering second- and third-degree burns to her face, shoulder, and deep into her respiratory tract. Ms. Lake established a web site, [www.surgicalfire.org] that offers patient advocacy, and at the same time provides an exhaustive set of resource links, articles, advisories and first-hand testimony, all in stark illustration of the axiom that O/R fires are an entirely preventable tragedy. She advocates speaking frankly with physicians before surgical procedures are performed. Offering advice, data and support resources to compensate for the average patient's lack of expertise, Ms. Lake insists that merely inquiring of the physician whether he or she has been trained in surgical fire prevention procedures is both warranted and ethical. "If what happened to my mom can happen and we learn nothing from it," Ms. Lake says, "what a waste of a life."

Numerous examples exist of such practical and actionable knowledge: where surgeries take place around the neck and head, as Ms. Reuter's did, patients are at disproportionately greater risk, because cutting tools will be used in close proximity to where oxygen is delivered. Even outside of the operating room per se, surgicalfire.org reminds visitors that preventable burns can easily occur and easily go unreported. For example, transdermal delivery vehicles, such as nicotine patches, may become hot enough to administer serious burns when exposed to MRI radiation. Training MRI technicians and alerting patients to be cognizant of such details is all part of the group's educational agenda.

New hardware, new strategies.

Congress seems to be responding to the popular groundswell over this subject. Changes to Medicare payment structures that have been in debate since 2005 will finally become law later this year. These changes mandate that health care facilities that produce data on a range of safety and patient care concerns showing an improvement in the quality of those services can be awarded a 2% increase in payments, while those at the other end of the spectrum will suffer a 2% reduction. It is hoped that the financial incentive will help spur greater attention to fire and patient safety recommendations.

Efforts like these point out the need for training and teamwork across disciplines. The typical O/R triumvirate is a mirror of the fire triad, with anaesthesiologists handling the oxidizers, nurses in charge of propellants such as disinfectants and ointments and surgeons providing the spark with lasers and electrosurgical tools.

The group AORN (Association of periOperative Registered Nurses) has developed a tool kit free to all members, and presently in the hands of at least 13,000 operating-room directors and managers nationwide that emphasizes the role of teamwork and the need for standard procedures that compel every member of the O/R team to think beyond his or her specific role in the surgical process. As Patricia Seifert, editor-in-chief of the monthly AORN Journal writes, "the number one cause of fires is lousy communication."

Across the nation operating-room staffers are undergoing quarterly briefings by their institutions, aimed at reinforcing fire-prevention techniques. These include such simple practices as proper hand-off of high-heat cauterization tools so as to avoid ignition of blankets, paper and dressings. Such practices should be second nature, but the surge in new and unfamiliar technologies requires that current practitioners be periodically reacquainted with hardware devices coming more commonly into use. Even warmed blankets present a problem. A nurse may not feel the internal temperature of a blanket just out of an electrical warmer, before spreading it over a patient. About half of the hundreds of O/R malpractice suits that cite patient burns are from devices intended to keep the patient warm. About a third center on electrical tools used for cauterization.

Hardware manufacturers are joining the effort as well. Earlier this year DOTmed News reported on Megadyne Corporation's announcement of a new line of electrodes featuring enhanced polytetrafluoroethylene (PTFE) insulation [https://www.dotmed.com/news/story/9467/ ]. When an electrode's insulation fails, it can peel back to expose the active device, presenting a burn hazard for the patient and the potential for ignition of ambient fuels. The enhanced PTFE insulation resists temperatures up to 700 degrees Fahrenheit, reducing insulation failure during operations.

The ArthroCare Corporation has built its entire enterprise around its patented Coblation technology, using a low-temperature plasma field to gently and precisely dissolve tissue, as opposed to traditional electrocautery devices, which burn tissue and are radio frequency-based. ArthroCare's Coblation devices provide benefits in facilitating more minimally-invasive procedures, as they also all but eliminate the risk of ignition, and therefore are becoming a tool of choice in performing head and neck surgeries.

Our research into operating room fires turned up a number of unwelcome surprises. The victims are many, but their stories, even the nature of their injuries are discouragingly consistent. If the problem were a series of diverse, one-off occurrences it would suggest that despite best efforts, professionals will always be plagued by anomalous emergencies. Instead, what the situation suggests is insufficient awareness of ongoing dangers. Also, we found that burn injuries are a problem not confined to the O/R. In addition to flame fires, scalds, chemical burns, and electrical or radiation burns caused by warming devices are occurring throughout hospitals. In one infamous case that took place at Mercy Hospital in Coon Rapids, MN, a baby's bassinet caught fire, probably due to the outmoded warming unit's arcing near an oxygen delivery site. In the present movement to reform and to streamline America's health care practices there is a phalanx of activists led by anaesthesiologists, nurses, patients and patient advocates and some conscientious and forward-thinking manufacturers. Their message is clear: no greater efficiency, no reduction in costs, no amount of freeing-up resources is worth the price of ignoring mortal threats that are completely within our ability as professionals to prevent.