http://www.washtimes.com/specialreport/20070526-115729-9163r.htm

Though rare, surgical fires leave patients scarred for life
By Jim McElhatton
THE WASHINGTON TIMES
Published May 27, 2007

Rita Talbert had been putting off having a minor thyroid operation for
more than a year, but the 60-year-old said her anxiety eased when a
doctor called the procedure "routine."
   "I'd be in and out of there in three hours; nothing to worry about
except a small, little stitch," Mrs. Talbert recalled being told.
   On April 25, 2005, Mrs. Talbert's husband, Francis, a truck
driver, and her son and daughter-in-law drove her to Inova Alexandria
Hospital from the family's home in Stafford, Va., with plans to return
sometime early in the afternoon. Four days later, however, Mrs.
Talbert awoke in excruciating pain in intensive care in a D.C.
hospital.
   Early during Mrs. Talbert's surgery at Inova, the unthinkable
happened -- a flash fire ignited, leaving second- and third-degree
burns on her face and neck. Her chin was burned off, and surgeons
later found soot in her throat, she said.
   During her 13 days in the intensive-care unit, Mrs. Talbert's
family hung a poster-sized card over the bathroom mirror. The card
included encouraging get-well messages from fellow church members, but
it also kept Mrs. Talbert from looking at her face.
   However, on a walk in the hospital corridor, she stopped to use a
restroom, washed her hands and, by habit, looked in the mirror. She
collapsed on the floor, sobbing.
   "What I saw wasn't me," said Mrs. Talbert, who has since undergone
eight reconstructive surgeries. "At that point, I understood I had
been badly burned, but I didn't understand why."
   Surgical fires are extremely rare and usually preventable, but
those that occur can be disfiguring and even deadly.
   Out of 50 million surgeries nationwide annually, operating-room
fires are reported in about 100 procedures, according to the Joint
Commission, which accredits hospitals and other healthcare facilities
across the country.
   The Pennsylvania nonprofit research group ECRI Institute said such
fires are among a group of rare but high-profile "incidents of
misadventure in healthcare." Others include wrong-site surgery and
retained instruments.
   There is no formal reporting to track surgical fires, but Mark
Bruley, vice president of Accident and Forensic Investigation for the
institute, said that about 10 percent of about 100 fires a year are
serious and one or two of them are fatal.
   Most of these fires, he said, can easily be prevented. They
usually occur in an oxygen-rich environment beneath the surgical
drapes or in a person's airway. The combination of heat from electro-
or laser-surgery devices, gases and alcohol-based surgical-prep
solutions can start a fire, Mr. Bruley said.
   An authority on surgical fires, Dr. Gerald Wolf, a professor of
anesthesiology at the State University of New York's Health Science
Center in Brooklyn, said, in a 2001 study, that as many as 200
surgical fires occur each year in the United States, with surgical
drapes the most common fuel.
   Dr. James Cottrell, past president of the American Society of
Anesthesiologists, who worked with the now-deceased Dr. Wolf, said the
lack of a central clearinghouse for data on surgical fires makes it
hard to track their frequency.
   "It's not a very high number, but obviously, this is a very
serious thing when it does occur," he said. The fires occur most
frequently during head and neck surgeries. Sometimes, gases in the
airway can be ignited, burning a patient from the inside.
   "That's the most devastating," Dr. Cottrell said.
   Another common cause is when alcohol-prep solutions do not dry
completely before surgery, sometimes pooling in the neck area, before
they are ignited by heat from a laser tool or other surgical
instrument.
   Based on the medical records, early indications suggest something
similar went wrong in Mrs. Talbert's surgery.
   A surgeon's postoperative report showed nothing unusual about the
first stages of the operation: Mrs. Talbert was sedated, taken to the
operating room, then her neck was prepped with an antiseptic.
   The surgeon made a 3-centimeter incision on her neck. Next, she
started using a Bovie, an electrosurgical device to open muscle
tissue.
   "A flash ensued," the surgeon wrote in the report. "I removed the
drapes to find some hair and plastic burning."
   "In retrospect, my suspicion was that this involved the pooling of
oxygen under the mask ... certainly a sight I have never witnessed
before," the surgeon wrote.
   Mrs. Talbert said she never heard from the hospital after she
returned home from the burn center, except for a phone call from one
of the nurses.
   "She said she heard I was out and wanted to see how I was doing,"
Mrs. Talbert recalled. "I said I was fine, except you all lit me on
fire."
   Mrs. Talbert eventually sued Inova, the surgeon, anesthesiologist
and anesthesiology practice, among others. Her attorney, Kenneth
Berman, of the law firm of Berman, Sobin & Gross, said the defendants
have denied liability. Inova has declined to discuss the lawsuit.
   Inova spokesman Che Parker has said the hospital "fully regrets"
what happened and that officials want to resolve the matter fairly.
   Inova never reported the fire to Virginia hospital regulators or
the Joint Commission, which accredits healthcare programs, or to
Alexandria's fire department, according to a Freedom of Information
Act request. But such notifications are voluntary, officials said.
   Christopher Durrer, director of licensure and certification for
the state's Department of Health, said regulators plan to question
hospital officials about the fire.
   "We will inquire about it," he said.
   Mr. Parker said the fire was an "isolated incident, and Inova
Alexandria has taken numerous steps to prevent a recurrence."
   Inova no longer uses oxygen masks during surgery, instead using
small, thin nasal tubes to keep oxygen from pooling, he said.
   In addition, surgical teams minimize the use of flammable gases,
such as oxygen, and now participate in a pre-procedure checklist
before each surgery to address fire-safety issues, he said.
   "The hospital routinely monitors and inspects operating rooms to
ensure safety measures are being followed," Mr. Parker said.
   Some say Mrs. Talbert's case shows there should be more stringent
reporting requirements for alerting regulators about operating-room
fires.
   Cathy Lake, of Frederick, Md., started an advocacy group after her
mother was badly burned at a hospital in the District in 2002. A
lawsuit was filed and later settled out of court under an agreement
that prevents either side from discussing the case.
   "I don't care if they put the fire out. It still should be
reported," Miss Lake said.
   Mrs. Talbert said she'd never heard of surgical fires until she
was burned.
   "I'd heard of instruments being left in a person, that kind of
thing, but I never heard of somebody catching on fire," she said.
"I've always questioned why this happened to me, of all people, and
some day, I hope to have an answer."