Putting Things Into Their Proper Perspective
A surgical fire, appropriate OR attire and UnitedHealth's empire.
T
he more we looked into the case of Jeanne Holden, the 86-year-
old surgical fire burn victim on the cover, the more confused
we got. This much we know: Ms. Holden is suing an Oregon sur-
gical center for $1 million, alleging that her face caught fire during a
temporal artery biopsy.
We first reported online that the fire was due to a wet surgical skin
prep, even though the lawsuit blamed it on an "anesthetic" (perhaps
mistaken for "antiseptic?"). When we called Ms. Holden's legal team, a
representative told us that the OR team didn't let the chlorhexidine glu-
conate skin prep that had been applied to her face dry before they
closed the incision with an electrosurgical cauterizing probe.
But when we followed up again to get more details for "Did Skin Prep
Fuel This Fire?" on page 22, Ms. Holden's lawyer told us "there's a level of
uncertainty" as to what caused the fire and could not confirm that the skin
prep was involved. Ms. Holden's family and a national expert who has
researched the causes and prevention of surgical fires for more than 40
years strongly suspect that the fire was caused by supplemental oxygen.
"You never, ever cauterize an incision with oxygen on for obvious
reasons," says Katrina Staigle, Ms. Holden's daughter.
Whatever the reason, you have a wholly preventable surgical fire from
which to learn. Even though only a fraction of surgical fires involve alco-
hol-based skin preps, Michael Barts, CRNA, of Havre, Mont., was around
to witness one early in his career (not his case, he says). In 1983, a
Canton, Ill., surgeon was removing skin tags with a cautery pencil.
"The circulator told the surgeon no, but the surgeon did his own skin
prep and plugged the cautery stick back into the machine," he says. "A
low blue flame consumed the paper drapes. The fire department
responded in turnout gear dragging a charged hose."
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Editor's Page
Dan O'Connor
