In our last post, we talked about a Pennsylvania woman who suffered severe burns to her face, chest, larynx, trachea and lungs after a surgical fire. The nurse anesthetist was found negligent, and the woman was awarded $250,000. The settlement was a victory for the woman, but she should never have been placed in that situation. Even so, the woman’s case is among 550 to 650 surgical fires each year.

But what surgical errors lead to surgical fires? Typically, there are three factors that must be present for a fire to erupt during surgery. In order for a surgical fire to start, there must be:

• An oxidizer, such as oxygen or nitrous oxide
• An ignition source, such as lasers, drills or cauterizing devices
• A fuel, such as tracheal tubes, sponges or drapes

One man who works with the Pennsylvania-based ECRI Institute — a group that tests medical devices and researches ways to improve patient care — is an expert in surgical fires. He has investigated four patient burning cases so far this year, and he said oxygen is a common cause of fires. Operating rooms typically have a heavy oxygen concentration, and that concentration level increases if oxygen is used during surgery.

The high oxygen concentration makes many things become more flammable. The expert on surgical fires said, “The high oxygen concentration can cause that fine body hair to be extremely flammable — a ripple of flames that spreads across the skin, traveling at 10 feet per second.”

In many situations, a nurse or surgeon can make a small change that has drastic results. Administering extra oxygen or failing to allow alcohol to dry can quickly cause a patient to erupt in flames. The results are horrifying, and they’re far more common than they should be.

Source: kypost.com, “FDA focusing on patients catching fire in operating rooms,” Aisling Swift, Scripps Howard News Service, June 12, 2012