1 0 2 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • N O V E M B E R 2 0 1 7
I
n the 40 years I've been studying surgical fires, I've investigated
hundreds of them on behalf of hospitals and surgery centers try-
ing to piece together the chain of events that led to the fire. It
usually takes me about 20 seconds to retrace the lines of the fire
triangle: the oxidizer, the fuel and the ignition source. But one
case took me about 20 minutes to reconstruct. A patient's face caught
fire during a gynecologic laparoscopic surgery. Yes, I know what
you're thinking: How in the world did that happen?
I took a cross-country red eye from Philadelphia and arrived at the
hospital at 2 a.m. As soon as I got there, one thing was obvious: the
ignition source was the disconnected fiber optic light cable that the
surgeon had rested on the drapes (fuel) near the patient's left clavicle.
Those light cables can cause charring, but they don't usually cause a
flaming fire unless there's excess oxygen (oxidizer) present.
3 Fire Prevention Tips
Mark E. Bruley, BS, CCE
Plymouth Meeting, Pa.
Your OR team can minimize the chance of a surgical fire.
• FIRE RISK Many fires start when the
surgeon activates the electrosurgical
device in the presence of an oxygen-
enriched environment or in the presence of
an alcohol-based prepping solution that
has not been allowed to dry.
SURGICAL
ERRORS
