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Image: Surgical fires
ECRI Institute
Growing use of electrosurgical devices and paper hospital drapes have contributed to fires in the operating room.
Image: JoNel Aleccia
By JoNel Aleccia Health writer
msnbc.com
updated 9/25/2008 8:27:32 AM ET 2008-09-25T12:27:32

Rita Talbert's operation was supposed to be a simple thyroid surgery, three hours, in and out, in the spring of 2005.

Instead, the Stafford, Va., woman woke up a week later in intensive care, in agonizing pain and horrified at the face she saw in the mirror.

“I didn’t know it was me,” said Talbert, now 62.

Her chin was gone; her nose was deformed. Her mouth was virtually melted, so damaged that after a dozen reconstructive operations, she still has trouble eating, drinking and breathing.

There’d been an accident, the doctors explained. An electrosurgical tool had ignited oxygen inside a mask under surgery drapes during the operation, sparking flames that left second- and third-degree burns from Talbert’s chest to the top of her head.

"It just caught fire," she said, still incredulous at the idea. "They didn't even know it had caught on fire."

Image: Rita Talbert, surgical fire victim, before and after
Courtesy of Rita Talbert
Rita Talbert of Stafford, Va., suffered burns to her face, neck and chest during a routine surgery in 2005. These photos show Talbert, now 62, before the fire and after a dozen reconstructive operations.
Back then, experts told her that the flash fire was a rare occurrence, a freak medical error that affected perhaps 100 people in the U.S. each year. It turns out, however, that surgical fires are at least five times as common as once thought, affecting between 550 and 650 patients a year, including 20 to 30 who suffer serious, disfiguring burns. Every year, one or two people die this way.

The first-ever specific figures, based on data collected from the Pennsylvania Patient Safety Reporting System, have helped quantify the problem, said Mark Bruley, vice president of accident and forensic investigations at the ECRI Institute, a patient safety advocacy agency.

In Pennsylvania, a state in which hospitals are required to report medical errors, fires occur in one in every 87,646 operations, according to the latest 2007 data. That amounts to 28 fires a year in Pennsylvania alone and allows researchers to estimate with greater certainty the incidents in the rest of the country.

Surgical fires are still a tiny fraction of the 50 million surgeries performed each year, Bruley emphasized. But, he said, it shouldn’t take a body count to draw attention to a medical error that is nearly always preventable.

“We don’t need more information to know that we shouldn’t be setting people on fire,” he said.

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Instead, the nation’s surgeons, doctors, nurses and aides need to be trained in basic steps to keep fires from happening and they need to hold surgical fire drills to make sure the training takes. Right now, Bruley estimates that fewer than half of the hospitals in the country conduct operating room drills to prevent and control fires.

Regular drills are one of several recommendations included in a new practice advisory published this spring by the American Society of Anesthesiologists.

Fire triangle: heat, air, fuel
Chief focus should be on communication between the surgeon and the anesthesiologist, Bruley said, because they control two of three primary elements needed to ignite a fire in an operating room or anywhere else: heat, air and fuel.

“If a surgeon is getting ready to use an electrosurgical pencil and he has not been informed that oxygen is flowing under the drapes, the result could be a fire,” Bruley said. “Oxygen concentrations of 50 percent and higher will create a flash fire.”

About 65 percent of surgical fires occur on the upper body or inside a patient's airway, another quarter occur elsewhere on the body and less than 10 percent actually occur inside the body cavity, Bruley said. About 70 percent are ignited by electrosurgical tools commonly known as Bovies, devicesthat use a high-frequency electric current to cut tissue or stop bleeding. Twenty percent of fires are sparked by hot wires, light sources, burrs or defibrillators. About 10 percent are touched off by lasers.

Whatever the source, the head and neck region is grimly suited to hosting fires, especially in a high-oxygen atmosphere, Bruley noted.

“There’s the vellus, the peach fuzz on your face and head,” Bruley explained. “Each tiny hair burns like a tiny sparkler and propagates a ripple of flame across the face.”

Bruley said he’s been trying for decades, with mixed success, to get doctors to announce when they start up a surgical tool and for anesthesiologists to monitor patients’ specific oxygen needs and to lower the levels to avoid fire danger.

That galls Talbert, who sued the surgeon, the anesthesiologist and Inova Alexandria, the hospital where her burns occurred.

“I don’t think they’re going to do anything to prevent it,” she said, adding later. “When they told my family, they said it was a ‘minor incident.’”

Talbert reached confidential settlements with the hospital and the anesthesiologist. But the surgeon, Dr. Debra A. Hutchins, refused to settle and the case went to trial in March. Jurors awarded Talbert $4 million. However, Virginia caps such awards at $1.75 million, her lawyer said, and Talbert is still responsible for legal fees and about $500,000 in medical expenses.

Inova officials said in an e-mail that they have taken steps to prevent fires, including discontinuing use of oxygen face masks, lowering oxygen levels and requiring staff to implement a checklist of prevention steps before procedures.

Image: Surgical fire victim
Courtesy of Cathy Lake
Cathy Lake's mother, Catherine Reuter, 74, suffered second- and third-degree burns in 2002 after a cauterizing tool ignited a topical solution that wasn't allowed to dry properly. She died two years later, having never fully recovered from her wounds.

‘Spontaneous combustion’
Those steps are commendable, but not enough, said Cathy Lake, a Maryland homemaker and activist who created a Web site, www.surgicalfire.org, after her mother suffered second- and third-degree burns on her face and head during a 2002 operation

“If you go into the hospital without burns and come out with burns, that’s not right,” she said. “In my mother’s medical chart, they wrote, ‘spontaneous combustion.’”

Lake's mother, Catherine Reuter, 74, was hurt after a cauterizing tool ignited a topical cleanser that was not allowed to properly dry, Lake said. The burns led to multiple drug-resistant infections, kidney failure and long-term sedation for terrible pain. Two years later, Reuter, a former nun and kindergarten teacher, died in another hospital, having never fully recovered.

Lake sued the hospital and received a settlement. Terms of the agreement prevent her from discussing the amount or the hospital, identified in press reports as Washington Hospital Center in Washington, D.C. Hospital officials there did not respond to questions about the case.

“It’s been ‘resolved,’ that’s the term I can use,” Lake said. “What price is your mother’s face worth?”

Lake, Talbert and other victims of surgical fires want to see a mandatory national system that tracks the incidents, instead of inconsistent reports to the federal Food and Drug Administration or the Joint Commission, the national accrediting agency for hospitals.

“I don’t think they’re getting reported as diligently as they could be,” said Lake, who has heard from hundreds of victims and their families and friends. “They tell me their kids have been burned during tonsillectomies; women tell me they’ve been burned during vaginal surgeries.”

Concern over surgical fires declined after the 1970s, when safer anesthetics replaced highly flammable products such as ether. The worry has resumed in recent years with increased use of electrosurgical devices and the replacement of cloth hospital drapes with disposable synthetic fabric products. Although both are flammable, the thinner disposable drapes may burn faster.

Medical groups back changes
Still, Bruley said he doesn’t see a need for a national reporting requirement. Several national groups, including the American Society of Anesthesiologists, the American Academy of Surgeons, the American Academy of Otolaryngology — Head and Neck Surgery, and the Association of PeriOperative Registered Nurses have adopted new recommendations or expanded education programs.  

Bruley is working now on a Web-based training program that will bring the basics of fire prevention to even the most remote hospitals and care centers.

“When you have specific recommendations on a specific hazard, people listen,” he said.

Education is a start, said Talbert, who continues to adjust to the scars on her face. She suspects, however, that it will take much more awareness and effort to make any real difference in hospital procedures. Like other shocking medical errors, such as objects left behind after surgery or operations on the wrong body part, surgical fires are regarded as a rare problem, she said.

But, she added, they’re devastating if you’re the one affected.

“People who don’t know me, they do still stare,” Talbert said. “I try not to let it bother me, but I still have problems and I think I always will.”

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