Fires during surgeries a bigger risk than thought

Use of cleaners, pure oxygen adds to danger

Email|Print| Text size + By Liz Kowalczyk
Globe Staff / November 7, 2007

During gallbladder surgery at North Shore Medical Center four years ago, Antoinette DiPhillipo became a victim of a little-known medical hazard: A flash fire ignited on her midsection.

DiPhillipo's surgeon rubbed an alcohol-based cleaning solution on her abdomen after her surgery, wiped it clean, and then decided to remove a mole from her stomach with a hot cautery instrument. Blue flames immediately shot up from her midsection - "similar to a flambé," the surgeon told state public health investigators.

The surgeon and other operating room staff quickly patted down the flames and pulled off the sterile draping that also ignited, he said. But DiPhillipo suffered painful first- and second-degree burns, state investigators determined.

Operating room fires have received less attention than other potential hazards such as wrong-site surgery, but fires have seriously injured and even killed patients. And new data show that they are more common than previously believed.

Pennsylvania, which collects some of the most comprehensive statistics, has had 28 operating room fires a year for the past three years - 1 in about every 87,000 surgeries. The state's data, released in September, suggest that nationally there may be hundreds of such fires out of roughly 50 million inpatient and outpatient surgeries annually - not the 50 to 100 previously estimated by patient safety organizations.

"The numbers are higher than we expected," said Mark Bruley, vice president for accident and forensic investigation at the ECRI Institute in Pennsylvania, a nonprofit healthcare research organization that works with the state on its patient safety-reporting program. "It's a small risk, according to the statistics, however, having a fire on your face can be severely disfiguring and a horrendous experience. And with throat procedures, where these fires often occur, they can be fatal."

Massachusetts does not track operating room fires as closely as Pennsylvania, but health officials said hospitals in the Bay State have reported 18 fires or cases of smoke in operating rooms since 2005.

DiPhillipo filed a lawsuit against her surgeon, Dr. Hubert Johnson, who denied allegations of malpractice in court papers. Last month, DiPhillipo and her lawyer, Leonard A. Simon of Waltham, filed a lawsuit against the surgeon's malpractice insurer, Medical Liability Mutual Insurance Co.. Both Johnson and his lawyer, Stephen M. Fiore of Cambridge, said they could not comment on the case, as did Edward Amsler, Medical Liability vice president.

The hospital, which is not named in the lawsuit, said it disputes some of DiPhillipo's allegations about the fire and her treatment afterward, as well as some of the findings of health officials. But hospital executives acknowledge the fire occurred and said they reported it to the state Department of Public Health.

Several oversight groups, including the Department of Public Health and the Joint Commission, which inspects hospitals, have published warnings about surgical fires and recommended preventive measures since the early 2000s. In the past year, several professional organizations, including the American Academy of Otolaryngology - Head and Neck Surgery, the Association of periOperative Registered Nurses, and the American Society of Anesthesiologists, have also launched educational efforts. Bruley said these programs are beginning to decrease the number of accidents.

"People are becoming more and more aware of safety and quality issues in general," said Dr. David Roberson, an otolaryngologist at Children's Hospital Boston and a patient safety specialist. "There are a lot of things in medicine that are rare. The average head and neck surgeon would go through 10 careers and never have a fire. It's pretty easy not to be aware of these [risks]. We're trying to acknowledge that mistakes happen everywhere, and we want to learn from them."

Fires in operating rooms have a long history in medicine. Traditionally, anesthesiologists used highly flammable gases such as ether to put patients to sleep, and doctors and nurses were vigilant about preventing fires, Bruley said. But as doctors began using less flammable anesthetics in the 1980s, prevention efforts started to wane. At the same time, other fire hazards grew, including the use of 100 percent oxygen, which can leak into the air, increasing the combustibility of gauze and hair; alcohol-based skin cleansers; and advanced surgical tools such as lasers and electrocautery devices.

According to ECRI, 44 percent of operating room fires occur during head, face, neck, or chest surgery, when electrical surgical tools are closest to the oxygen the patient is breathing.

As with other types of surgical errors, such as wrong-site surgery, poor communication between surgeons, nurses, and anesthesiologists can be the root of the problem.

"This is a fairly unique hazard within healthcare because in order to prevent it you have to have awareness and collaboration of three different specialties," Bruley said. "Until each is empowered to question the actions of the other two, you can't have prevention."

Operating room safety specialists recommend that doctors use less than 100 percent oxygen during head and neck surgery, that surgeons store hot instruments off the operating table when they are not in use, and that doctors wait two or three minutes until alcohol-based products have evaporated from the skin before using cautery tools.

In DiPhillipo's case, Johnson told health investigators in 2003 that he applied an alcohol-based "skin prep" to her abdomen and chest before removing her gallbladder to help prevent postoperative infections. The substance is sticky, he said, so after he finished the operation, he applied an alcohol-based cleaner to remove it. He said he then remembered that he promised to remove a mole, so he grabbed the cautery device, and a flash fire occurred. A surgical scrub technician told health officials that he heard a sound similar to the lighting of a grill. The surgeon said the fire was extinguished in two to three seconds.

DiPhillipo, 35, who lives in Saugus, said in an interview that she was in pain from the burns when she awoke in her hospital room. She said neither the surgeon nor hospital nurses explained to her what had happened in the operating room - an assertion hospital executives dispute. And, she said, she did not give the surgeon consent to remove a mole.

"I just wanted to know what happened and for someone to talk to me," she said. "It would have been nice if I had gotten an apology."

DiPhillipo said that blisters and redness covered most of her abdominal area and took several weeks to heal and that she still has faded scars.

Dr. Mitchell Rein, chief medical officer for North Shore, however, said in an interview that the burns were small and minor and were well healed when DiPhillipo was discharged the day after surgery.

He did say the fire led to more aggressive prevention policies, some of which were already in the works before the incident. All surgeons, anesthesiologists, nurses, and other operating room staff members must now undergo mandatory training annually on how to prevent surgical fires.

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