Copyright 2000 St. Louis Post-Dispatch, Inc. St. Louis Post-Dispatch (Missouri)
May 28, 2000, Sunday, FIVE STAR LIFT EDITION
SECTION: NEWS, Pg. A13
LENGTH: 1318 words
HEADLINE: FIRES THAT BREAK OUT DURING SURGERY ARE DUE TO IGNORANCE OR CARELESSNESS,; EXPERTS SAY; EXACT NUMBERS AREN'T KNOWN; LAW DOESN'T REQUIRE HOSPITALS TO REPORT THEM
BYLINE: Andrew A. Skolnick; Special To The Post-Dispatch
BODY: The first thing you should know about fires that happen during surgery is that they are rare.
nonprofit agency that investigates incidents involving medical devices
estimates that about 100 of the more than 27 million surgical
procedures done in the United States each year involve a fire.
Ten to 20 of those fires cause serious injury, with one or two a year resulting in a patient's death.
second thing that you -- and more importantly your doctor -- need to
know is that virtually all surgical fires are preventable, because
nearly all are caused by ignorance, carelessness or both, said Mark E.
Bruley, a vice president and investigator for the Emergency Care
Research Institute in Plymouth Meeting, Pa. Bruley has been studying
and publishing articles on the causes and prevention of surgical fires
for 22 years.
There are no laws
requiring the reporting of surgical fires, so an exact accounting isn't
available. In some cases, hospitals may be reluctant to make reports
out of fear of lawsuits or bad publicity.
Fires require three things: something to burn, an ignition source and sufficient oxygen.
oxygen is given to patients during surgery, high concentrations can
build up under surgical drapes, especially around the patient's head
and neck. Anyone who has seen a piece of paper or even steel wool burn
explosively when dropped in a jar of pure oxygen can understand the
danger of using an ignition source near oxygen.
that's what surgeons often do during surgery. Various surgical
instruments -- especially laser knives and electrocautery devices like
the one involved in a fire during surgery at SouthPointe Hospital that
ended Eleanor Diehn's life -- can set fire to surgical drapes, surgical
tubes, the patient's hair or other flammable material.
electrocautery device also ignited a fire that nearly killed Wallace
Beene, 75, a retired University of Arizona journalism professor in
Tucson. Two years ago, while undergoing brain surgery to remove a blood
clot, Beene's head, neck and shoulders caught fire.
with many patients undergoing brain, eye or other surgery of the head
and neck, Beene had been under local anesthesia and awake at the time.
As he struggled to get off the operating table, a quick-thinking nurse
dowsed the flames with water.
doesn't remember much of anything from the first two months after the
fire. His wife, Geraldine, who is a registered nurse, must recount
Wallace Beene spent nine
weeks in the hospital's intensive-care unit and four more weeks in the
hospital. After that, he spent 10 days in a rehabilitation facility
before he was able to return home to recuperate.
first- and second-degree burns he suffered led to a series of
infections. The powerful antibiotics needed to control those infections
caused serious side effects, including damage to his kidneys.
Beene keeps an office at the university. He is still recovering, though
there is little scarring left. He also is $ 1 million richer, having
received a settlement in a lawsuit against the hospital.
to Geraldine Beene, the fire started when an electrocautery device
ignited the alcohol-based solution that had been used to prep her
husband's head for surgery. In an oxygen-enriched atmosphere, the
solution burns like rocket fuel, which is why its manufacturer warns
against using it for head and neck surgery, she said.
Beene blames the accident on a failure to educate doctors and other
health care providers about the dangers of surgical fires and how to
"I taught nursing students
about the need to educate patients who are on oxygen about the serious
danger of fire, but never in any nursing textbook have I ever seen
information about the danger of setting patients on fire during
surgery," she said.
Bruley, of the
Emergency Care Research Institute, said the incidence of surgical fires
has increased in the United States during the past 15 years or so,
despite efforts by the institute to educate physicians.
makes no difference how experienced the surgeon is, he said. Even a
surgeon who operated on a recent president has set a patient on fire,
Bruley said. He declined to provide more details.
increase has been caused in part by the introduction of much better
ways to monitor a patient's blood-oxygen level, he said. This has led
to the "preventive medicine" practice of keeping the patient's
blood-oxygen level at maximum -- which is not always necessary. By
increasing the flow of pure oxygen to the patient when an ignition
source is being used, you increase the risk of surgical fire.
of articles have been published in medical journals during the past 20
years that warn of the dangers of surgical fires during head or neck
surgery. In 1989, researchers at the Eastern Virginia Medical School in
Norfolk published a study in the journal Ophthalmic Surgery
recommending the use of compressed air instead of oxygen to reduce the
risk of fire during eye surgery.
said that when oxygen must be used, better communication and
coordination between the surgeon and anesthesiologist is needed. The
concentration of oxygen should be reduced about a minute before the
surgeon uses any possible source of ignition.
steps also can reduce fire risk, he said. Flammable preparations should
not be used to prepare the skin for surgery. Also, the patient's
eyebrows, mustaches and other hair should be coated with K-Y Jelly or
similar water-based ointment.
especially the almost invisible ones that cover our skin, burns in a
flash in the presence of concentrated oxygen. A tiny spark landing on
these hairs can erupt in a sheet of flame that spreads to surgical
drapes. That's exactly what happened to a 2-week-old baby at
Cedar-Sinai Medical Center in Los Angeles in 1988. The fire lasted just
six seconds. The baby died two hours later.
fire, like almost every other one Bruley has investigated over the past
two decades, could have been avoided if medical personnel had been
better educated about surgical fires, he said.
"Every surgeon I've talked to who set their patient on fire never makes the same mistake twice," Bruley said.
Some high-profile fires
catching on fire during surgery happens on average about twice a week
in the United States, according to experts. The fires can be
devastating, sometimes fatal, but don't often get publicized. Here are
some that did:
* July 1998: Journalism
professor Wallace Beene enters University Medical Center in Tucson,
Ariz., to remove blood clots in his brain. During the operation, an
electrocauterizing device sparks a flash fire that burns his face and
* July 1996: Joyce Levine, a
high school teacher, goes into Jewish General Hospital in Quebec to
have breast-reduction surgery and some moles reduced from her groin. A
spark from the surgeon's cauterizing gun ignites antiseptic solution
under her legs. She suffers second- and third-degree burns on her legs.
November 1993: Douglas Parker, 23, undergoes surgery at Seton Medical
Center in Austin, Texas, to remove some benign throat tumors that were
making him hoarse. The surgeon's laser ignites a plastic endotracheal
tube in his throat, causing an oxygen-induced flash fire in his
airways. He dies two months later.
1990: While doctors at UCLA Medical Center in Los Angeles are
performing surgery on auto-accident victim Angela Hernandez, 26, sheets
covering the patient catch fire. The operating room fills with smoke so
thick the medical staff cannot put out the flames and must leave the
room. Hernandez dies.
* October 1988:
Doctors using an electrocauterizer to seal a blood vessel during
surgery on a premature infant at Cedar-Sinai Medical Center in Los
Angeles spark a flash fire that kills the baby.