Rita Talbert’s operation was supposed to be a simple thyroid surgery, three hours, in and out.
Instead, the Stafford Virginia woman woke up a week later in an ICU, in agonizing pain and horrified at the face she saw in the mirror.
“I didn’t know it was me,” said Talbert, now 62.
Her chin was gone; her nose was deformed. Her mouth was virtually melted – so damaged that after a dozen reconstructive operations, she still has trouble eating, drinking and breathing.
“There’s been an accident,” the doctors explained. An electrosurgical tool had ignited oxygen inside a mask under surgery drapes, sparking flames that left second- and third-degree burns from Talbert’s chest to the top of her head.
“It just caught fire,” she said, still incredulous at the idea. “They didn’t even know it had caught on fire.”
Experts told her that a surgical flash fire was a rare occurrence, a freak medical error that affected perhaps 100 people in the U.S. each year.
Not even close to being true.
Surgical fires are at least five times as common as once thought, affecting between 550 and 650 patients a year. Some are seriously disfigured. Some die.
Data collected by the Pennsylvania Patient Safety Reporting System, have helped quantify the problem, said Mark Bruley, vice president of Accident and Forensic Investigations at the ECRI Institute, a patient safety advocacy agency.
In Pennsylvania – a state where hospitals are required to report medical errors – fires occur in one in every 87,000 operations, or 28 patient fires a year in Pennsylvania alone.
Although surgical fires are a small fraction of the 50,000,000 operations performed each year, Bruley said, it shouldn’t take a body count to draw attention to a medical error that is nearly always preventable.
“We don’t need more information to know that we shouldn’t be setting people on fire,” he said.
Instead, the nation’s surgeons, doctors, nurses and aides need to be trained in basic steps to keep fires from happening and they need to hold surgical fire drills to make sure the training takes. Right now, Bruley estimates that fewer than half of the hospitals in the country conduct operating room drills to prevent and control fires.
Regular drills are one of several recommendations included in a new practice advisory published this spring by the American Society of Anesthesiologists.
The Fire Triangle: heat, air, fuel
Chief focus should be on communication between the surgeon and the anesthesiologist, Bruley said, because they control two of three primary elements needed to ignite a fire in an operating room or anywhere else: heat, air and fuel.
“If a surgeon is getting ready to use an electrosurgical pencil and he has not been informed that oxygen is flowing under the drapes, the result could be a fire,” Bruley said. “Oxygen concentrations of 50% and higher create a flash fire.”
About 65% of the fires occur on the upper body; another 25% occur elsewhere on the body and 10 % inside the body cavity, Bruley said. About 70% are ignited by electrosurgical tools known as Bovies, devices that use electric current to cut tissue or stop bleeding. 20% of fires are sparked by hot wires, light sources, burrs or defibrillators. About 10% are touched off by lasers.
Whatever the source, the head and neck region is grimly suited to hosting fires, especially in a high-oxygen atmosphere, Bruley noted, saying he has been trying for decades to get surgeons to advise when they start up a surgical tool and for anesthesiologists to monitor patients’ specific oxygen needs and to lower the levels to avoid fire danger.
That galls Talbert, who sued the surgeon, the anesthesiologist and Inova Alexandria, the hospital where her burns occurred.
“I don’t think they’re going to do anything to prevent it,” she said, adding later. “When they told my family, they said it was a ‘minor incident.’”
Talbert reached confidential settlements with the hospital. But the surgeon, Dr. Debra A. Hutchins, refused to settle and the case went to trial. Jurors awarded Talbert $4,000,000. However, Virginia caps such awards at $1.75 million.
Inova officials report that they have taken steps to prevent fires, including discontinuing use of oxygen face masks, lowering oxygen levels and requiring staff to implement a checklist of prevention steps before procedures.
Catherine Reuter, 74, was hurt after a cauterizing tool ignited a topical cleanser that was not allowed to properly dry.The burns led to multiple infections, kidney failure and long-term sedation for terrible pain. Two years later, Reuter, a former nun and kindergarten teacher, died in another hospital, having never fully recovered.
Talbert, the Reuter family and other victims of surgical fires want to see a mandatory national system that tracks the incidents, instead of inconsistent reports to the federal Food and Drug Administration or the Joint Commission, the national accrediting agency for hospitals.
“I don’t think they’re getting reported as diligently as they could be,” said Lake, who has heard from hundreds of victims and their families and friends. “They tell me their kids have been burned during tonsillectomies; women tell me they’ve been burned during vaginal surgeries.”
Concern over surgical fires declined after the 1970s, when safer anesthetics replaced highly flammable products such as ether. The worry has resumed in recent years with increased use of electrosurgical devices and the replacement of cloth hospital drapes with disposable synthetic fabric products. Although both are flammable, the thinner disposable drapes may burn faster.
Still, Bruley said he doesn’t see a need for a national reporting requirement. Several national groups, including the American Society of Anesthesiologists, the American Academy of Surgeons, the American Academy of Otolaryngology — Head and Neck Surgery, and the Association of PeriOperative Registered Nurses have adopted new recommendations or expanded education programs.
Bruley is working now on a Web-based training program that will bring the basics of fire prevention to even the most remote hospitals and care centers.
“When you have specific recommendations on a specific hazard, people listen,” he said.
Education is a start, said Talbert, who continues to adjust to the scars on her face. She suspects, however, that it will take much more awareness and effort to make any real difference in hospital procedures. Like other shocking medical errors, such as objects left behind after surgery or operations on the wrong body part, surgical fires are regarded as a rare problem, she said.
But, she added, they’re devastating if you’re the one affected.
(We thank JoNel Aleccia for her excellent reporting on patient safety matters)
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