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June 2002
Volume 66 |
Number 6
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WHAT'S NEW IN…
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| Operating Room
Fires: Still a Problem? |
David E. Lees, M.D.
Committee on Equipment and Facilities
Most, if not all, anesthesiologists begin their clinical day
knowing the location of the nearest defibrillator, but how many
can say they checked for the location and types of the nearest
fire extinguishers? In 1988, John Bruner, M.D., led a joint study
by ASA and the National Fire Protection Association (NFPA) that
examined operating room fires. ASA and NFPA have worked together
for more than 50 years to lessen the risk of fire in our nation's
health care facilities while assuring dependable medical gas services
for our patients.1 The Bruner study determined
that, while rare, operating room fires have devastating consequences,
cause severe patient injury or death, precipitate legal actions
and take a great psychological toll on the patients, family, the
operating room team and the institution itself. Fourteen years
later, those observations are still true. Operating room fires
receive publicity that is echoed and magnified many times over
in the popular press.
Experts believe there are less than 100 incidents per year involving
patient injury. Of these, between two and 10 per year involve
serious injury or death and make the national media. The fact
that decades-old episodes are still used as illustrations of the
problem is testament to how rare and yet how indelible an occurrence
can be in the public memory. Exact figures are difficult to come
by for several reasons. Unless a municipal fire department is
summoned, there will be no public record. Patient injury is quickly
cloaked by hospital counsel to minimize adverse publicity; the
facts then only become public with litigation. No state specifically
requires reporting operating room fires. The Safe Medical Devices
Act of 1990 requires reports to the Food and Drug Administration
only when one can directly or indirectly attribute the cause of
the fire to a specific device malfunction or operator error due
to faulty design.
Some critics postulate that there has been an increase in operating
room fires that correlates with the introduction of the pulse
oximeter. Pulse oximeters supposedly encouraged the liberal use
of oxygen to prevent heretofore-unrecognized hypoxemia, but there
is doubt whether modern anesthesiologists are any more cavalier
with oxygen than their colleagues of two decades ago. Given the
lack of reliable data collected by a central source, it is difficult
to say whether the incidence of operating room fires is on the
increase, waning or unchanged. There is no doubt, however, as
to the danger of an oxygen-enriched atmosphere where a small spark
can trigger a conflagration. ASA Patient Safety Videotape No.
20, "Fire in the Operating Room," contains a dramatic
and vivid demonstration of the effect of just 23 percent oxygen
on the ignition of a disposable drape with an electrosurgical
unit (ESU).
What Are the Contributing Factors?
The three elements of the classic "fire triangle" are
present in almost every operating room:
- Fuel
- Ignition source
- Oxygen
The ignition source implicated most often is the ESU, with lasers
ranking second. Plastic and rubber anesthesia supplies, disposable
and woven drapes, preparation solutions and patient hair provide
the fuel. Surgical procedures about the head and neck are most
often implicated – more specifically, it is usually a laser-
or ESU-induced surgical fire in the oropharynx or a facial burn
due to the combination of electrosurgical units and an oxygen-enriched
atmosphere about the head and neck.
Reducing the Chances Experts may disagree whether it is possible
to prevent all surgical fires, but it is possible to anticipate
the likelihood in certain cases. Oxygen is under the control of
the anesthesiologist, who should prevent the development of an
oxygen-enriched atmosphere. Drapes should be tented to vent oxygen
from under the drapes to the floor. Active gas scavenging also
should be considered. Oxygen should be used sparingly, especially
during monitored anesthesia care procedures about the head and
neck; use no more than is necessary to maintain an adequate SaO2.2
Surgeons should use clear adhesive "incise" drapes
at the wound site to block the diffusion of oxygen into the operative
field. Facial and scalp hair should be wetted with a water-soluble
surgical lubricant. ESUs should be set to the lowest intensities
practicable and care exercised to holster the "pencil"
when not in use. A contaminated pencil should always be disconnected
and not left to hang down on the drapes, nor should the cord be
clamped to the drapes. Nursing can do much to reduce the combustible
load in the room by removing the disposable paper wrappers and
covers before the start of the case. Not only does this reduce
the fuel in the room, but it also reduces the waste that must
be disposed of as "red bag" waste with its higher disposal
costs.
What to Do When a Fire Occurs
Every member of the operating room team – anesthesiologist,
surgeon, nurse and technician – should know what to do in
the event of an operating room fire. All personnel should know:
- Immediate bedside measures for fire suppression
- Location and type of fire alarms and the extinguishers in
the operating room
- Location of oxygen zone shut-off valves and who is authorized
to close them in the event of a fire
- Evacuation plans in the event that the operating room or
suite must be abandoned
Remember that fire extinguishers are not all alike! They vary
in fire rating, capacity and chemical make-up. Learn the indications
and location of each type in your operating room suite. Those
found in most hospitals are rated for one or more categories:
A – Ordinary combustibles (e.g., paper and wood)
B – Flammable liquids
C – Electrical fires
Education and fire drills are essential, but communication among
the members of the operating room team before starting a procedure
with a high fire risk is equally important. Teamwork in fire prevention
and suppression may well determine whether a minor surgical fire
is extinguished promptly without harm or whether it becomes an
operating room tragedy amplified by the national media.
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Junior Editors Sought
for First Time for In-Training Exam
The ABA/ASA Joint Council on In-Training Examinations is
seeking 40 junior editors. The commitment for a junior editor
is to accept training and feedback in question writing from
senior editors, Joint Council members and the National Board
of Medical Examiners and to prepare 15 questions per year
from assigned sections of the Content Outline. Junior editors
would serve four-year terms, an activity that would be acknowledged
with certificates and be eligible for promotion to one of
25 senior editors and nomination for one of 14 members of
the Joint Council with responsibility for the yearly In-Training
Examination.
This request reflects a change in how questions are obtained
for the In-Training Examination and how individuals are
nominated to become oral board examiners. In the past, questions
for the examination originated from individuals "waiting
in line" to become oral examiners and from oral examiners
themselves. The American Board of Anesthesiology and the
ABA/ASA Joint Council now desire to separate the two activities
of question writing and oral examining and make them independent
of each other. In the new system, questions will originate
from the junior and senior editors, not from oral examiners.
Individuals may be involved in both activities; i.e., being
a junior or senior editor does not preclude one from being
an oral examiner, but the nomination processes and activities
are separate (the first through the ABA/ASA Joint Council
and the second through the ABA).
If you are interested, please send your curriculum vitae
to Raymond C. Roy, M.D., Ph.D., Chair of the In-Training
Council, by mail to the ASA Executive Office; fax to (336)
716-3394 or (336) 716-8190; or e-mail to < rroy@wfubmc.edu
>. The decisions will be made by autumn 2002 with training
to occur in 2002-2003.
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References:
1. National Fire Protection Association. NFPA
99: Standard for Health Care Facilities, 2002 Edition. 2002.
2. Emergency Care Research Institute. Eye on
Medical Errors: Health Devices. 2002; 31(4):125.
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David
E. Lees, M.D., is Professor and Chair, Department of Anesthesia,
Georgetown University Medical Center, Washington, D.C. |
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