Fire in the Operating Room

When an unwanted fire breaks out anywhere it can be terrifying, but can you even imagine what might happen if it occurred in an operating room? Many people have never heard of a surgical fire, yet there are approximately 550 to 650 fires each year, resulting in up to 20 serious injuries and one or two patient deaths annually. Almost all operating room fires ignite either on or within the patient, resulting in little damage to equipment but causing considerable -often disfiguring-injury to the patient, and taking an unexpected staff totally by surprise. These numbers seem striking, but when balanced against nearly 50 million in- and outpatient surgeries each year and 80 to 90 percent of the fires are minor with no injuries, surgical fires are still deemed to be rare.

Mark Bruley, vice president of accident and forensic investigation, ECRI Institute, said that fire in the operating room (OR) is one of three-preventable-occurrences that should never happen to a patient; the other two are operating on the wrong surgery site and leaving an instrument or other materials in the patient. Medical errors, mostly preventable, are the eighth leading cause of death among Americans, exceeding those from motor vehicle accidents, breast cancer or AIDS.

Most people are aware of what it takes to make a fire; heat, fuel and an oxidizer are combined to form what is known as the fire triangle. When these components come together in the right proportions a fire is bound to occur-diminish or remove any one element of the triangle and the fire can be prevented or easily extinguished. The oxygen-enriched atmosphere in the OR contributes to 74 percent of all operating room cases; head and neck surgery carry the highest risk to the patient because the source of oxygen and the source of ignition are in such close proximity.

All three components are commonly found in the OR and each member of the surgical team controls one specific side of the triangle: Surgeon controls the heat source, nurse controls the fuels, and anesthesiologist controls the oxidizers. Since anesthesiologists are providing oxygen in nearly every surgery, all it takes is a simple spark to bring the three sides of the fire triangle together. Although operating rooms are saturated with high levels of oxygen the normal concentration in the air is 20.9 percent, and anything above this vastly increases the flammability of nearly all materials. Understanding and managing the components of the fire triangle can help surgical teams prevent fires in the OR.

Fuels can be anything and almost everything that comes in contact with the patient, including the patient themselves. The frightening thing is that the patient is asleep, unaware, and unable to communicate any thing their might feel to the surgical staff.

Fuels Commonly Encountered in Surgery:
On or in person:
Hair (face, scalp, body)
GI tract gases (mostly methane)

Prepping Agents:
Degreasers (ether, acetone)
Aerosol adhesives
Alcohol (also in suture packets)
Tinctures (Hibitane, Merthiolate, DuraPrep)

Linens:
Drapes (woven, nonwoven, adherent)
Gowns (reusable, disposable)
Masks
Hoods and caps
Shoe covers
Instrument and equipment drapes and covers
Egg-crate mattresses
Mattresses and pillows
Blankets

Dressings:
Gauze
Sponges
Adhesive tape (cloth, plastic, paper)
Ace bandages
Stockinettes
Collodion (mixture of pyroxylin, ether, and alcohol)
Ointments
Petrolatum (petroleum jelly)
Tincture of Benzoin (74% to 80% alcohol)
Aerosols (e.g., Aeroplast)
Paraffin
White wax

There are many tools used in the OR that can cause ignition of built up vapors: Lasers, drills, overhead lights, defibrillators, fiber optic light sources and cables and cutting and cautery equipment. Lasers produce temperatures form several hundred to several thousand degrees and can ignite a fuel source from a few centimeters to several meters away.

Because health officials aren't required to report surgery fires, many sources feel that these fires are on the rise, with more surgeons using lasers and electric tools, but perhaps it is just that patients who have fallen victim to these fires are receiving more publicity and making the public more aware of the danger of being burnt in the operation room.

Ironically it is common place in industrial settings to monitor the air for oxygen enrichment, but not so common in the health care environment. Proposed guidelines include lowering the oxygen level in the room when surgical tools that could produce ignition are in use, redesigning drapes to minimize oxygen buildup and finding better ways to remove excess oxygen from the surgery site. There are many things that could go a long way to reduce or eliminate surgical fires, but the ultimate responsibility lies within the operating room and its staff.