Fire prevention has become second nature to the surgeons, anesthesia providers and staff at our ENT center, where many procedures require the use of supplemental oxygen and electrocautery or a laser in the nasopharynx. To a certain extent, this is a good thing. But the delicate balance between routine procedure and surgical fire can tip disaster's way in an instant, and I don't want their deftness to become complacency. So I've instituted five strategies that keep us mindful that the ingredients for a surgical fire are ever present.

1 Control the heat sources
Light sources, lasers and the active electrodes can generate enough heat to ignite a fire in the airway or elsewhere on the patient, if the other conditions - presence of oxygen and fuel - are right.

• Light sources. Light cords should be attached to equipment on the field. When disconnected, light sources should be turned down or off entirely.
• Lasers. Put the laser in standby mode when it's not being pointed directly at the surgical site. The surgeon controls the laser via foot pedal. The nurse enables the beam by controlling both ready and standby modes. To keep the beam on target, you should use only non-reflective instrumentation at the laser impact area.
• Electrocautery and electrosurgery. Place ground pads or return electrodes as close to the surgical site as possible. If the patient has excess hair, consider removing it. Clean the tip of the handpiece as needed with wet gauze pads and, when not in use, place it in a protective holster to keep stray heat from being generated.

In all cases, keep plastic instruments away from target areas to prevent their melting. Have a fire extinguisher in the surgery suite at all times.

2 Manage fuels
During surgery, many materials are present that can catch fire and act as fuel: drapes, gowns, prepping agents, even the patient's own tissue. Keeping water or saline present on the field during electrocautery and laser cases will prepare you for the worst-case scenario, but that's only reactive action. You're better off taking proactive steps to manage the potential fuels.

First and foremost, don't use flammable prep solutions for procedures involving ignition sources. Similarly, lubricants should be water-based, such as K-Y Jelly. (Never use a petroleum-based lubricant when performing laser or electrosurgery.)

Some protocols call for a light scrub and a final prep with rubbing alcohol. If you do that, use the driest sponge possible; if betadine is your prep of choice, blot, then squeeze the sponges out well so that you can apply it only to the necessary area. Either way, the goal is to keep the solution from dripping onto - or, worse, under - the patient.

To prevent this, tuck towels and absorbent paper drapes around the patient before prepping, then remove them and visually inspect to ensure that solution hasn't pooled under the patient before you start the procedure. You have to be especially careful with preps for neck procedures, as the solution can easily run down the side of the neck and under the head. For procedures on extremities, solution can run up the arm or leg and under a tourniquet. Besides the flammability factor, preps can be very irritating and may blister the patient's skin. To prevent this, protect the leading edge of the tourniquet with an impervious drape. After the prep is finished, remove the drape and carefully inspect the area before continuing with the procedure.

It should go without saying that you must allow sufficient time for the prep to fully dry before draping, no matter how much of a hurry everyone's in. We always use flame-retardant drapes; cloth drapes are just too prone to burning. This is one area where manufacturers have helped standardize precautions: Most of the paper drapes on the market now are flame-retardant; it's just a built-in convenience.

While using the cautery or laser, protect tissue around the operative site by using wet towels or gauze, by avoiding the use of dry combustibles and by irrigating the laser site as directed by the physician to prevent carbonization of tissue.

3 Minimize gas concentrations
It's estimated that excess oxygen is behind three in four OR fires. It's especially dangerous in ENT procedures, as it tends to pool in the back of the throat. When you introduce the laser or active electrode, you could ignite it, and suddenly you have a flash fire in the sinuses.

It's best to use non-explosive anesthetic gases in conjunction with an anesthesia scavenger system. Vent anesthetic gases and oxygen, and direct them away from the surgical drapes so the gases don't build under them. Charge anesthesia with regular inspection and changing of the soda lime in the anesthesia machine; as it becomes desiccated, dangerous reactions can take place between volatile anesthetics and the substance, potentially sparking a fire that the patient could inhale into his airway.

4 Drill the action plan
I can't stress how important it is for everyone to know their roles in the event of a fire (see "How to Manage an Airway Fire" on page 49). All personnel should complete annual safety training - we hold a safety fair - that includes activation of the fire alarm system, use of fire extinguishers and evacuation techniques. Instruct new hires in your fire safety practices before they begin work.

In our facility, if a fire were in the OR, a surgical nurse (or the circulator, if no one else is available) would pull the fire alarm and unplug electrical equipment in close proximity to the fire. Nurses in pre-op and PACU would close the primary gas valves in their areas and unplug other equipment as a precautionary measure. They would also move their patients to a safe area until the all-clear is sounded. The anesthesia provider and surgeon would work as efficiently as possible to stabilize the patient. With ENT, this is a fairly quick process. But it's far more difficult for more invasive procedures. For example, in a hysterectomy, the patient is under general anesthesia with instrumentation in her abdomen - you can't just stop. Your surgical teams must know under what circumstances they continue working until they can move the patient.

It's up to the OR manager to determine the site and severity of the fire, and to coordinate the staff response until your facility's fire team or city fire marshal assumes responsibility. Use discretion and tact to minimize alarm and fear.

At least quarterly, I hold a fire drill. I have a construction paper mock-up of flames, and when we're done for the day, I just stick it somewhere: a wastebasket, oxygen tank or the nurses' station. I'll even take someone who's free and lay him on an OR bed and stick the flames on his chest. Then I'll wait for someone to spot the flames and watch for the staff to carry out the action plan as if there were a real fire. It's a great way to keep the staff on their toes - just be sure that there are no patients around, as you don't want to terrify them with a drill.

5 Maintain safety
The final piece of the puzzle is maintenance, both of equipment and knowledge. The St. John's system employs a person whose only job is to move from building to building, checking that fire extinguishers are in working order and that all fire doors and smoke seals are intact. He visits us monthly. If you don't have this luxury, you should check fire equipment and systems every six months. Biomed-ical services should inspect and re-certify all equipment in the surgery suite as safe for use regularly and after a facility or surgery suite fire.

Overkill? We don't think so
This probably seems like a lot to do and coordinate, but if there were ever an adverse event for which an ounce of prevention was desirable, this is it. We've never had an OR fire and, frankly, I'll do whatever I can to keep it that way.