Most healthcare professionals regard surgical fires as rare, almost freakish incidents that hardly ever occur. But the elements of surgical fires - ignition source, oxidizer and fuel - are present in almost any procedure, and they can come together under even the most controlled circumstances, with devastating results (see "Surgical Fire Victim Dies" on page 14).

Let's examine the details of three fires. Although all of them could have been avoided, the quick thinking of the healthcare team prevented them from becoming much worse.

Endotracheal tube catches fire during a tonsillectomy
What happened: During a tonsillectomy on a pediatric patient, the surgeon was using electrocautery to control bleeding when the polyvinyl chloride endotracheal tube ignited. Staff disconnected the anesthesia machine to stop the flow of oxygen, pulled out the endotracheal tube and extinguished the fire with saline. The patient, transferred to intensive care, recovered fully.

How it might have been prevented: All the elements of the "fire triangle" - the ignition source (the electrosurgical unit), oxidizing gases (nitrous oxide and oxygen) and the fuel (the endotracheal tube) - were present and in congruence, says surgical fire expert and anesthesiologist Gerald Wolf, MD. While all of those elements were vital to surgery, this fire was preventable, says Dr. Wolf.

• Reduce the oxidizer-enriched atmosphere. Using a lower oxygen concentration and avoiding nitrous oxide could have made the tube less prone to ignition and combustion, says Dr. Wolf, who recommends reducing the flow of oxygen at the surgical site when using cautery. "This requires that the anesthesiologist and the surgeon are constantly communicating - the surgeon needs to know when the oxygen concentration is high, and the anesthesiologist needs to know when the cautery is on," he notes.
• Use a cuffed endotracheal tube. This may have prevented retrograde gases from coming back from the lungs and creating the oxidizer-enriched atmosphere at the surgical site.

Although not an issue in this case, alcohol-based prep solutions can also provide fuel for a fire, says Dr. Wolf. Don't let prepping solutions pool around the surgical site and give alcohol vapors a chance to dissipate before starting a procedure.

Patient catches fire during a bilateral blepharoplasty
What happened: During a bilateral blepharoplasty, a patient was receiving oxygen through a nasal cannula. The surgical team had used a U-shaped drape that tented over the patient's face and opened at the chest. They had placed dry gauze on the patient's chest to dab away blood.

As the surgeon activated the cautery device, the corner of the drape, the sponges and the patient's eyebrow caught fire. The surgeon first tried to pat out the flames, which only fanned them further. He pulled the drapes from the patient's face. The anesthesia provider shut off the oxygen and disconnected the nasal cannula, and a scrub nurse extinguished the flames with a bowl of saline. The patient suffered second- and third-degree facial burns.

How it might have been prevented: Here's how the team might have reduced the risk and extinguished the fire more effectively, says Scott Aronson, Esq., a principal at Russell Phillips & Associates, LLC, a law firm that specializes in fire safety.

• Proper draping: Surgical drapes can often trap oxygen and nitrous oxide, which support combustion. The greatest hazard leading to surgical fires is an oxygen-enriched atmosphere under the drapes, says ECRI, a healthcare research firm in Plymouth Meeting, Pa.

In this case, the team realized that the adhesive at the corner of the drape had come loose, causing the oxygen that had been venting from the patient to pool around the eye socket instead of dissipating. Make sure that the drapes don't cover the patient's face, if possible, and arrange them so that the oxygen flows away from the surgical site. For this type of case, use incise drapes that adhere to the skin and prevent oxygen from entering the surgical site. A gas-scavenging system under the drapes can help remove trapped gases.

• Reducing oxygen concentration. As in the first case, the anesthesia provider could have reduced the level of oxygen, particularly when cautery was being used. "Even though it adds time to the procedure, it's advisable to wait one minute after shutting off the oxygen to allow it to dissipate before engaging the cautery device," says Mr. Aronson. Other options include intubating the patient for a closed delivery system or using the breathing circuit to titrate down to a concentration that keeps the blood well saturated with oxygen.
• Using moistened sponges. Surgeons generally prefer dry sponges, because they absorb more blood. In this case, however, the dry sponges provided additional fuel for the fire, and they should have been moistened, says Mr. Aronson.
• Using water-soluble jelly on the patient's facial hair. Coating the patient's eyebrows and mustache would have helped eliminate the facial hair as a potential fuel source.
• Better communication and fire prevention knowledge. The two biggest mistakes the team made once the fire started were trying to pat down the flames (which, in the oxygen-enriched atmosphere, only fanned them) and communicating to shut off the oxygen immediately, says Mr. Aronson. "The first simultaneous steps should have been to pull the drapes away from the face, throw saline on the flames and shut off the oxygen," he says.

Mr. Aronson pointed out that the team was fortunate that a bowl of saline was close at hand: "In longer cases, the saline isn't always replenished throughout the case. Make sure you have saline or sterile water available at all times."

Getting trained in fire prevention and safety could have helped as well, he says. Discarded cautery probes ignite fire

Discarded cautery probes ignite fire
What happened: When an electrocautery probe manufacturer notified a surgery center that a box of battery-operated cautery probes was defective, it provided detailed instructions on how to dispose of the devices. The box sat unnoticed for a while, until a non-clinical employee decided to discard them herself. But she failed to follow the instructions for completely disengaging the devices before discarding them in a waste can in an empty OR. Over the next hour, as more waste was piled into the can, it pressed on the ignition buttons, causing one or more of the devices to engage. Soon, the entire garbage can went up in flames, setting off the smoke alarm.

While a nurse and anesthesiologist extinguished the flames, another turned off all the surgical gases, and the rest of the 20 employees got their patients and themselves out of the building. "Within minutes, everyone was out," says Erica Riffert, the surgery center's director.

Although the fire didn't spread, the OR sustained extensive smoke damage. The fire department also broke a hole in the wall to ensure that the insulation was not on fire. In the following weeks, Ms. Riffert worked with the insurance company, the state department of public health, biomedical equipment companies, and cleaning and restoration firms to assess and repair the damage. Some of the tasks included

• extensive cleaning and repainting of the OR, plus wall repair and complete replacement of the floor;
• air duct cleaning and air sampling;
• biomedical checks of all equipment; and
• replacement of supplies, such as sharps containers, which had melted in the heat.

Although they had to shut down for six working days, by the seventh day, everything was back to normal, says Ms. Riffert.

How it might have been prevented: The employee who disposed of the devices should never have taken on that task, even though she meant well, says Ms. Riffert. "A clinical employee would have known how to completely disengage the devices and dispose of them properly," she says.

Only you can prevent fires
While surgical fires are rare (50 to 100 occur each year), they do happen, as these real-life cases show. Reducing the risk of surgical fires is a new 2005 National Patient Safety Goal for ambulatory facilities (not hospitals) accredited by the Joint Commission on Accreditation of Healthcare Organizations. The goal has two elements:

• educating the staff, including surgeons and anesthesia providers, about controlling heat sources and fuels; and
• establishing guidelines to minimize oxygen concentration under the drapes.