“The Patient Is On Fire!” is an article published by the ECRI in its journal Health Devices (Vol. 21, No. 1, January, 1992, p. 3). Fires on the actual operating table almost always corm as a complete surprise to the OR team. In one described case, an operating laser used during brain tumor surgery mistakenly activated by the surgeon ignited the surgical drapes. The smoke was heavy enough to form evacuation of the OR while the drapes and patient burned. Such incidents are comparatively rare but very dramatic and do occur often enough to cause significant concern.
ECRI (previously known as the “Emergency Care Research Institute”) is the world’s largest independent, nonprofit evaluator of medical devices and has been in existence for more than 20 years. In some senses, it might be considered analogous to a “Consumers Union” type organization for the medical equipment field. ECRI is also involved in accident investigation for hospitals and risk management consultation. Health Devices is the ECRI journal covering its equipment evaluation work as well as relevant general news.
ECRI authors Albert L. de Richemond and Mark Bruley describe in detail the components and implications of OR fires. They point out in “The Patient Is On Fire” that in each operating room, the basic elements of a fire are ever present, creating a constant danger.
For a fire to occur, three components of the “fire triangle” must be present:
- The heat source e.g. laser, electrocautery, or fiberoptic light cord. (The most common scenario involves unintentional activation of the electrosurgical unit foot or hand switch and a consequent spark.)
- An oxidizer 02 or N20 How to support and accelerate combustion.
- Fuel surgical drapes, sponges, egg crate foam mattresses, alcohol or acetone-based solutions, GI tract gas, shoe covers, or anything else that will bum readily.
The products of combustion of the fuel component include oxides, carbon dioxide, nitrogen dioxide, carbon monoxide, and unburned carbon. Plastics, always present in the OR environment, will usually not bum in room air but bum vigorously in an oxidizer-rich (usually oxygen enriched) environment and produce the most toxic products of combustion. Burning plastic emits hydrogen chloride, hydrogen fluoride, cyanide, mustard gas, phenol, and poisonous complex hydrocarbons.
Fire prevention begins by understanding the fire triangle and how to keep its component parts from coming together in the operating room. The anesthesia provider must be aware of the danger of creating an oxygen-rich environment near a he-at source. This could easily happen, for example, during a case involving MAC including supplemental oxygen insufflation for surgery on the head or neck. This is a set-up for a fire and the use of an electrosurgical unit or laser in such a situation must be given extraordinarily careful thought prior to the case. If such instruments must be used, it is advisable to put saline-soaked sponges all around the surgical field to minimize the potential source of fuel for combustion (dry drapes or sponges).
A specific plan to deal with a fire emergency, especially one involving a patient, and regular practice of that plan are critical adjuncts to good prevention efforts. In-service educational sessions on fire safety for all involved, especially anesthesia providers, are essential.
Stopping a fire in the operating room requires a sequence of steps, starting with the disruption of the fire triangle.
- Stop the flow of oxygen and/or anesthetic gases to the patient. If this does not put out the fire, cool the fire with nonflammable liquid (e.g. saline from a basin on the scrub table) or, from an extinguisher, carbon dioxide. Halon from a fire extinguisher cools and chemically disrupts the combustion reaction. (It may be wise to have a small two or five pounds halon extinguisher in each OR at all times.) A small flame on a drape may be simply patted out with a gloved hand. Smothering a small flame with a wet towel is also very effective.
- Remove the burning/burned material.
- Support the patient appropriately.
Information and guidance from local fire departments concerning fire drills and the proper techniques and equipment for extinguishing operating room fire can aid hospitals in establishing a protocol for controlling such occurrences and mines any injuries. Relevant literature from the National Fire Protection Association and the American Society for Testing and Materials should be provided to OR personnel.
Vigilance, knowledge of fire, and quick action will aid in the prevention of fire and fire-related injuries. If a fire occurs, educated operating room personnel should be able to keep damage to a minimum. Fire extinguisher location, type, and proper use must be covered repeatedly in the drills. All personnel must know where the oxygen shutoff for the whole room is and how to use it because in a large fire, this may be life-saving for both patient and personnel. Drills should include explicit information about immediate notification of hospital and fire officials and how to get help quickly.
Publication of this thorough discussion in Health Devices (Circulation Department, ECRI, 5200 Butler Pike, Plymouth Meeting, PA 19462; 215-825-6000) of the unusual but severe hazard of OR fires should prompt all anesthesia providers to take the necessary steps in the prevention and management of OR fires, and, thus, help insure a maximally safe experience for our patients.
Abstracted by: Chester H. Lake, Jr., M.D., Assistant Professor, Department of Anesthesiology, University of Mississippi, Jackson