Archive February 2017 XVIII, No. 2

Did Skin Prep Fuel This Fire?

Alcohol-based skin preps cause only 4% of OR fires, but you must still exercise care when applying these flammable agents.

Daniel Cook

Daniel Cook, Executive Editor


Jeanne Holden SCARRED Jeanne Holden, 86, was disfigured after flames erupted in an Oregon surgery center.

That's a difficult image to look at, isn't it? It's the charred face of 86-year-old Jeanne Holden, who went to the Oregon Outpatient Surgery Center in Tigard, Ore., on Sept. 16, 2016, for a left temporal artery biopsy, but left burned and blistered inside her mouth, down her throat, up her nose, in her ear, neck and down part of her back. A $1 million lawsuit filed on Ms. Holden's behalf last month says she was breathing supplemental oxygen through a mask during cauterization of the incision when a low blue flame ignited on her face. Ms. Holden's nose and left eye are so badly disfigured that she can no longer wear her eyeglasses, says her daughter.

The lawsuit seems to implicate her alcohol-based skin prep as the cause of the fire, but that's far from certain. The language in the complaint is confusing, in several instances seemingly mistaking "antiseptic" for "anesthetic" when describing the cause of the flash burns. "A local liquid anesthetic was applied to plaintiff's left face and as [the surgeon] attempted to use an electrocautery unit, plaintiff's face, head and neck caught fire," reads the suit.

Regardless of the cause of Ms. Holden's fire, you must still exercise care when applying flammable prepping agents. Here are a few questions to test your prepping knowledge.

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