Archive November 2017 XVIII, No. 11

3 Fire Prevention Tips

Your OR team can minimize the chance of a surgical fire.

Mark Bruley

Mark Bruley, BS, CCE


surgical fires FIRE RISK Many fires start when the surgeon activates the electrosurgical device in the presence of an oxygen-enriched environment or in the presence of an alcohol-based prepping solution that has not been allowed to dry.

In the 40 years I've been studying surgical fires, I've investigated hundreds of them on behalf of hospitals and surgery centers trying to piece together the chain of events that led to the fire. It usually takes me about 20 seconds to retrace the lines of the fire triangle: the oxidizer, the fuel and the ignition source. But one case took me about 20 minutes to reconstruct. A patient's face caught fire during a gynecologic laparoscopic surgery. Yes, I know what you're thinking: How in the world did that happen?

I took a cross-country red eye from Philadelphia and arrived at the hospital at 2 a.m. As soon as I got there, one thing was obvious: the ignition source was the disconnected fiber optic light cable that the surgeon had rested on the drapes (fuel) near the patient's left clavicle. Those light cables can cause charring, but they don't usually cause a flaming fire unless there's excess oxygen (oxidizer) present.

So where'd the oxygen come from? The cuff on the patient's anesthesia endotracheal tube was inflated. The heat from the disconnected light cable melted the inflation tube. Once the tube melted, the cuff deflated, which caused oxygen to leak past the cuff and build up under the drapes around the patient's head. Right then I knew that somewhere on the floor, there had to be a Luer connector that had come loose from the inflation tube when it melted. I started looking around for the luer like a contact lens, and sure enough, found it. Case closed.

Could this fire have been prevented? Yes, had the OR team placed the light source in standby when the surgeon disconnected the light cable. For most outpatient surgeries, these 3 preventative measures will help minimize the risk of a surgical fire.

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