Drrzzzt. It was the faintest click, the slight sound of sparks flying. "I realized what was happening immediately," says the surgeon. "I said to myself, 'That sounded very electrical.'" As he pulled back the drapes from the patient's face, whoosh!, a bluish flame raced across the tip of the nasal cannula. He smushed the drapes to snuff the fire. It was out in seconds, but the damage was done: The man who came to the surgery center to have fat pads removed from his lower eyelids wound up at a burn center with first- and second-degree burns to the middle of his face and one nostril.

The patient, himself an anesthesiologist, filed a medical malpractice suit against the surgeon and the anesthesiologist. He asked the jury to award for the extreme pain and suffering he experienced due to his injuries and claimed $120,000 in lost earnings from his pain management practice. He'd also need surgery to repair scar tissue that was causing one nostril to collapse. Somewhat remarkably, he lost his case - the jury deciding unanimously that a surgical fire is a rare but well-recognized risk of surgery and that the clinicians didn't deviate from the standard of care.

"The jury was convinced it was nobody's fault. Of course, I was surprised," said the burn victim from his California pain management clinic.

Experts are fond of saying that surgical fires are exceedingly rare medical errors, a "never event" right up there with retained instruments and wrong-site surgery. They also say that surgical fires are one of the most frightening and devastating experiences for everyone involved. While exact numbers are unavailable, it's thought that there are about 100 surgical fires each year, resulting in up to 20 serious injuries and one or two patient deaths annually. The surgeon in this five-year-old case agreed to speak with us on the condition of anonymity.

Buildup of excess oxygen
When the fire ignited, the patient was receiving oxygen from a nasal cannula while he was receiving room air from an oral airway that was simultaneously blocking nasal-oxygen flow by pressing up on the soft palate, an odd situation that, in the surgeon's view, indirectly led to the fire.

Before the case, the anesthesiologist suggested a nasal cannula, arguing that the patient wouldn't be sedated enough to tolerate an oral airway. Efforts to reach the anesthesia provider for this article were unsuccessful. The surgeon agreed with the anesthesiologist because, he says, there was no reason to give this patient general anesthesia and extubating the endotracheal tube would have increased the risk of a periorbital hematoma.

"Patients often gag and buck and bear down on the endotracheal tube," he says. "That causes a ton of pressure to build up in the face - not what you want when you're doing an eyelid procedure."

But during the case, the patient began to snore so violently that his entire body was moving. "His head was moving up and down. So now I'm doing surgery on an eyelid that's a moving target. It was an unacceptable situation," says the surgeon. "At that point, I revisited the airway issue with the anesthesiologist. 'He's moving around. I can't do the surgery. Maybe an oral airway would make much more sense now because it would open up the airway and there'd be no more snoring.'"

Unbeknownst to the surgeon, when the anesthesiologist put the oral airway in, he also left the nasal cannula in. That's likely when trouble began.

"The point is that he left the nasal cannula in the patient's nose with oxygen still delivered to it," says the surgeon. "After placing the oral airway, he should have either removed the nasal cannula or at least shut the oxygen off if he was going to leave it in. Moving oxygen to the oral airway would have been helpful, but not absolutely necessary if the patient's oxygen saturations were adequate while breathing room air ... But I didn't see what he was doing," adds the surgeon. "He was fumbling under the drapes. When he was done, the snoring stopped and I continued surgery."

What was really happening, the surgeon contends, was that oxygen was still being delivered to the nose but most of the air was going in to the oral airway. The surgeon explains: "When you put an oral airway in, you divert most of the air going in and out of lungs to the mouth. The nasal cannula, which should be providing the oxygen, is not moving air of any kind because the oral airway is pushing the soft palate up and blocking off the nose."

With the oral airway in, the nasal cannula-delivered oxygen was simply going into the nose, meeting with resistance and exiting the nose. "It was like pushing air into a closed space," says the surgeon. "I was doing surgery right where the oxygen was being exhausted."

The perfect storm
Experts say that a fire will occur when an ignition source (heat, sparks and flares from electrosurgery are often ignition sources), an oxidizer (oxygen) and a fuel (drapes, virtually everything that comes in contact with the patient, and parts of the patient are all fuels) come together in the proper proportions and under the right conditions. Here, you had the perfect storm. Oxygen that was flowing into and out of the patient's nose pooled under the drapes, got trapped there because it wasn't adequately ventilated and was ignited by the electrosurgical pencil. The central question at the trial: Why was the nasal cannula left in after an oral airway was placed?

At trial, a defense expert testified that the surgeon was not the "captain of the ship" in this scenario because the oxygen was under the control of the anesthesiologist, not the surgeon. The anesthesiologist denied that he was in control of the oxygen, but testified that the circulating nurse, who was employed by the surgery center and wasn't a defendant, turned up the oxygen without his knowledge or consent, according to court records.

"Remember, oxygen doesn't catch on fire. Oxygen is just a catalyst. It lets something burn," says the surgeon, who continued with the surgery after consulting with a burn specialist to ensure the patient's safety - "It's bad enough we burned him; all we have to do is wake this guy up not having finished the surgery" - and thereafter accompanied the patient to a burn center for treatment.

The surgeon found a silver lining in this mishap. The oral airway prevented the fire from spreading to the patient's airway, which might have been deadly. "Because he wasn't inhaling oxygen into his throat, let alone his lungs, that probably saved his life," he says.

The Joint Commission last year issued a patient safety goal concerning surgical fires. The key points: Educate staff (including anesthesia providers) on how to control heat sources and manage fuels, and establish guidelines to minimize oxygen under drapes.