Breathing Life Into Surgical Smoke Safety


A nurse's devastating lung cancer diagnosis inspired an impassioned plea for evacuation legislation.

The persistent pain above her ribcage made sleeping at night nearly impossible. "My primary care physician dismissed it as a muscular injury that would correct itself," says Angela Hohn, RN, BSN, BS, CNOR, FCN, a perioperative nurse in the Atlanta VA Health Care System. "So did I."

In February 2020, after months of agony, Ms. Hohn finally went to the ER, where a CT scan revealed a lesion on her right lung. The next day, a pulmonologist identified the growth as a tumor and suggested it was malignant. A biopsy confirmed stage 4 non-small cell lung cancer.

Lung cancer? Impossible.

Ms. Hohn was an avid runner who had always taken preventative medicine seriously. She'd never smoked, nor lived with anyone who did. "I was very active, vibrant and health-conscious, doing all the right things," says Ms. Hohn. "When I got the diagnosis, I simply didn't believe it."

She was so blindsided by the news that she thought her results had been confused with those of another patient. Devastated, she checked in with her primary care physician. "She said, 'Something's not right here," recalls Ms. Hohn. "'You're on top of your health and you live a clean life. Have you ever considered that your cancer was caused by exposure to smoke at work?'"

The conversation caused Ms. Hohn to reflect on her career. She'd been an OR nurse since 1979, starting in England and working in Jamaica in the early 1980s until she arrived in the U.S. in 1985. She reentered the OR in the early 1990s and continued working in surgery for the next two decades. All along, she had a vague notion of the harmfulness of surgical smoke, but the issue had never been a priority.

It still wasn't when Ms. Hohn began the fight for her life at the start of the pandemic. All she wanted to do was get better. "That was a difficult time," she says. "I was immunocompromised, and family members were a threat to my well-being, so they stayed away. I was alone and petrified."

HEALTH HAZARD The Georgia Smoke Busters printed cards and T-shirts with this attention-grabbing logo.

One night before bed, she said a brief prayer and laid down ready to die. "I had given up," she recalls. "I didn't have the will to go on."

When she awoke the next morning, she decided God had other plans for her. In constant pain and suffering shortness of breath, she started chemotherapy, immunotherapy and other treatments. During this time of great personal suffering, Ms. Hohn found the strength to embark on a quest to understand how surgical smoke may have affected her health, and how she could protect other surgical professionals from suffering a similar fate.

Smoke evacuators were installed in every OR at the Atlanta VA a couple of years ago. "But every time we'd attempt to hook one up, the surgeon would say it was too cumbersome, and it would slow them down," says Ms. Hohn. "When something is rejected time and again, you offer it less."

Worse, she and other concerned colleagues had no organizational support. "Smoke evacuation wasn't mandatory, so it wasn't enforced," she says.

Ms. Hohn was convinced there was truth in the idea that breathing in surgical smoke day after day over a long career had caused her lung cancer, but didn't know how to act on the hunch. She soon received emails about surgical smoke safety from AORN and the International Council on Surgical Plume (ICSP). She got more involved and energized, and considered how she could contribute to the smoke evacuation movement. "I didn't have a clue about where to begin," she says, "but knew I wanted to make a difference."

Before her illness, Ms. Hohn was so busy that she rarely had time to attend local AORN branch meetings. However, she'd become aware of fellow member Brenda Ulmer, MN, RN, CNOR, past president of AORN, who had been investigating and advocating for smoke safety since the mid-1990s. She reached out to Ms. Ulmer, who lived close by in suburban Atlanta. It was the connection Ms. Hohn needed to advance her newfound advocacy.

For Ms. Ulmer, Ms. Hohn was another reminder of the importance of her efforts to remove surgical smoke from ORs. She graduated from nursing school in 1975 and had worked various positions in ORs around Atlanta since. While serving on AORN's board of directors in the mid-1990s, she became interested in surgical smoke, chairing roundtable discussions on the topic. Since then, she's written articles, book chapters and self-study guides on surgical smoke safety. She was part of the group that developed AORN's first smoke toolkit, as well as its smoke position statement, which morphed into guidelines in 2017.

"I don't know how many programs I've done all over the world on surgical smoke," says Ms. Ulmer.

Having access to a worldwide expert on smoke safety was a blessing for Ms. Hohn, especially when she discovered what Ms. Ulmer and the Georgia Council of Perioperative Nurses Legislative Committee were trying to accomplish: getting a state law passed that would require healthcare facilities to install and use surgical smoke evacuation systems. At the time, Ms. Hohn had no idea she'd play a starring role in that effort.

POWERFUL ALLY Brenda Ulmer (right) and her team worked extensively with Georgia State Sen. Gloria Butler (left).

Ms. Ulmer's initial lobbying for surgical smoke safety began in the 1990s on the national level. She spent significant time in Washington working on language with OSHA representatives for a bill that would have required the evacuation of surgical smoke in ORs across the country. The legislation was introduced, but ultimately died in Congress. Two decades later, a national ban on surgical smoke is no closer to becoming reality. The good news, says Ms. Ulmer, is that local legislation can be just as effective.

"Nurses and technicians have grown tired of nothing happening, which is why you're seeing so much activity at the state level," she says.

Smoke safety is a personal issue for Ms. Ulmer as well. After she joined AORN's board in the 1990s, she'd work in the OR only once per month. "After one day of high-smoke-producing cases, my nose burned, my throat hurt, my chest was tight and I felt nauseous," says Ms. Ulmer.

She felt fine the next day, but experienced the same symptoms a month later after a full day spent in the OR. "I made the connection that when I'm away from the smoke, my body starts to feel normal again," says Ms. Ulmer. "I decided then that surgical smoke was really bad for your health, and that's what started me on this journey."

When Ms. Ulmer stopped working in ORs full-time in 2012, her primary care doctor said she had a "90-day cough," and an allergist diagnosed her with adult-onset asthma. "I had a lot of respiratory issues," she says.

Ms. Ulmer knew her story wasn't unique, as the unusually high rate of perioperative nurses with respiratory illnesses had been well-documented. Her own health history, the reported problems of fellow nurses and smoke evacuation legislation passed in Rhode Island and Colorado inspired Ms. Ulmer to begin working toward getting a similar law passed in Georgia. After proposing the initiative to Georgia Council Chair Pat Thornton in 2019, she was asked to chair the council's legislative committee. She and a small core group started contacting local legislators to seek support for smoke legislation. Their persistent efforts eventually resulted in gaining the support of Senator Gloria Butler. However, it would take a serendipitous encounter to make it happen.

Senator Butler's annual fish fry was scheduled to take place in October 2019, and Ms. Ulmer made it a point to attend. She had been calling the senator's office so often to discuss smoke evacuation legislation that her staff knew her by name. Still, her calls went unreturned.

At the fish fry, Ms. Ulmer walked right up to Senator Butler. "I held out my hand and said, 'I'm Brenda Ulmer,' and she said, 'I know about you!' So she had gotten my messages!"

Ms. Ulmer gave Senator Butler materials from AORN about smoke evacuation, which she held in her hand as she addressed the crowd. After the fish fry, though, Ms. Ulmer didn't hear from the senator, so she and the legislative committee continued contacting and meeting with other legislators in the Georgia Senate and House. The legislative committee traveled to AORN chapters around the state to talk about smoke and build a statewide coalition, which they called the Smoke Busters.

On New Year's Eve 2019, Ms. Ulmer's phone rang at 10 p.m. It was Senator Butler calling to say she would sponsor a smoke evacuation bill. Ms. Ulmer hung up the phone, stunned by the senator's out-of-the-blue support. With Senator Butler now on board, the Georgia Smoke Busters were about to get a crash course in lobbying and lawmaking.

A few months later, a smoke evacuation bill began to take shape in the Georgia General Assembly. A hearing was held, but then the pandemic shut down the legislature. When lawmakers reconvened in the summer, Senator Butler introduced and helped pass a resolution that required the Senate to convene a smoke study committee, which held meetings each month in the fall. Senator Butler included Ms. Ulmer and the legislative committee in developing the agendas aimed at educating the legislators on the hazards of surgical smoke.

Ms. Ulmer says she was working 30 to 40 hours a week on the legislation effort throughout 2020. She and legislative committee members traveled to AORN chapters around the state to drum up support and encourage perioperative nurses to contact their local legislators. It was during that massive networking effort that Ms. Hohn's story came to light.

Jennifer Pennock, AORN's senior director of government affairs, was working with the Georgia team on their lobbying efforts. She asked Ms. Hohn to testify before the senate committee by writing a letter that could be read to its members. "I wrote what I thought was my first draft, and video-called with the smoke evacuation team to read it," says Ms. Hohn. "Afterward, everybody was silent. Then one person finally said, 'You're incredibly brave. Don't change anything. We want you to be the first presenter to the committee because your message is so powerful.'"

SEEING IS BELIEVING During Senate committee meetings, Ms. Ulmer and colleagues activated an electrosurgery pencil in this plastic box to show how much smoke it produced.

Some of the smoke team members were shocked that Ms. Hohn, who was struggling in the midst of her cancer battle, was up to presenting. "I wanted to make a difference," she says. "I didn't think I was going to live, and didn't want to die without being heard." Says Ms. Ulmer, "It was unbelievable to hear what she went through, and that her doctor said she was sick because she breathed in surgical smoke for all those years. It had a huge impact on us."

A week later, Ms. Hohn videoconferenced into the Senate committee hearing to read her letter, which contained many powerful messages. An excerpt: I got a call that rocked my world. My deepest fears were confirmed — I had lung cancer. I was so unprepared for this devastation that it felt like a death sentence, a nightmare I couldn't wake up from. How could this happen to me?

When she finished, the committee members remained silent. Finally, Senator Butler looked up and said, "I don't know what to say. Is there anything we can do for you? If there is, please reach out to my office."


The State(s) of Smoke Evacuation Legislation
The State(s) of Smoke Evacuation Legislation ?Perioperative Pros Team Up to Get Mandatory Usage Bills Passed
TEAMING UP Supportive Georgia legislators and smoke evacuation advocates come together at the Georgia Senate's October Smoke Study Committee meeting.   |  Pamela Bevelhymer, RN, BSN, CNOR

When COVID-19 upended business as usual in state capitols across the country, surgical smoke evacuation legislation efforts were put on hold. This year, AORN, state associations and individuals have been working hard to reestablish their surgical smoke evacuation lobbying efforts. Here's a snapshot of the current status of legislation around the country, according to AORN Senior Director of Government Affairs Jennifer Pennock.

— Joe Paone

Cal/OSHA has not yet released its final surgical smoke evacuation regulations.

A bill signed into law in March 2019 will go into effect in May 2021.

Two bills were introduced for the 2021 legislative session: HB 5024 and HB 5997. Both have been referred to the Joint Committee on Public Health.

Senator Gloria Butler introduced SB 19 on Jan. 14. The bill was read and referred to the Senate Health and Human Services Committee, where it awaits a hearing.

Introduced on Jan. 14 by Representative Bobby Kaufmann, HSB 59 was approved unanimously by the members of a state subcommittee on Feb. 8.

Senator Julie Raque Adams reintroduced legislation in early 2021, and SB 38 passed in the Senate unanimously on Feb. 3. The bill awaits a hearing in the House Health and Family Services Committee.

New Jersey
AB 3982, reintroduced in May 2020, carried over into 2021. The legislation has not yet been posted to the Assembly Health Committee for consideration.

HB 2622, introduced on Jan. 11 by Representative Sheri Schouten, had a virtual public hearing before the House Health Care Committee on Feb. 2. A vote on the bill was expected from the committee later in February.

Rhode Island
Law went into effect in January 2019.

On Jan. 25, Senator Borris Miles filed SB 429, which will require state facilities to implement policies for surgical smoke evacuation by Jan. 1, 2022.

Note: Updates to failed 2020 bids in Illinois, Tennessee and Utah are not currently on the dockets.

Ms. Hohn's testimony had a significant impact on the committee, but the smoke evacuation team also assembled supportive testimonials from other nurses, doctors and a scrub tech, as well as Richard Lamphier, president of the board of directors of the Georgia Nurses Association. Through a friend in Arizona, Ms. Ulmer facilitated prerecorded video testimony from Anthony Hedley, MD, FACS, a Phoenix-based orthopedic surgeon profiled in Outpatient Surgery's February 2018 issue ( Dr. Hedley required a double lung transplant due to idiopathic pulmonary fibrosis, which he believes was caused by decades-long exposure to surgical smoke. "Dr. Hedley was wonderful," says Ms. Ulmer. "He feels the same way Angela does — he wants to do everything he can to eliminate surgical smoke."

Senator Butler introduced SB 19 in January before it was referred to the Senate Health and Human Services Committee, which will likely call another round of hearings. Ms. Ulmer, though, feels the bill is well-positioned to succeed, partly because Senator Butler just became the Minority Leader of the Georgia Senate — the first woman to do so in either party. She gave the televised Democratic response to Republican Governor Brian Kemp's annual State of the State address. Before doing so, she texted Ms. Ulmer and told her to watch. Toward the end of her 15-minute speech, Senator Butler said she would introduce legislation to address the nursing shortage, expand telemedicine and ... require proper ventilation in operating rooms.

Ms. Ulmer was overjoyed by the mention. "Senator Butler has been an angel for us," she says. "Everything we've been able to accomplish in Georgia is because of her." Ms. Hohn will testify again in support of SB 19 if she's called. In the meantime, her battle against cancer is going well. "I'm doing much better," she says. "The tumor has shrunk significantly, and I can walk up stairs without having to sit at the top to take a breath. I've come a long way."

Ms. Hohn and Ms. Ulmer warn OR professionals that the harmful effects of surgical smoke exposure are cumulative. The two nurses are somewhat stunned that many still don't realize the risks posed by the smoke they breathe in the OR. "When you smoke cigarettes, you're smoking processed tobacco," says Ms. Ulmer. "Surgical smoke contains blood, tissue and bacteria."

Ms. Ulmer hopes to help push the latest Georgia bill over the finish line and wants similar laws passed in other states. "We're committed to helping nurses across the country," she says. "I hope we can make a difference." OSM

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