The surgery seemed routine. The 62-year-old patient was prepped and draped according to protocol. The hair around his soon-to-be tracheotomy incision was shaved. Duraprep surgical solution was applied and allowed to dry for at least three minutes. But when the electrocautery tool was activated, “there was an immediate, audible ‘whoosh,’” wrote Mark Wax, MD, professor of otolaryngology/head and neck surgery at Oregon Health and Sciences University in an article about a surgery gone awry (Head Neck. 2006;28(7):649-652).
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April 2012The flash fire was out almost as soon as it started, but the patient suffered first- and second-degree burns to his neck and shoulder, and Dr. Wax was motivated to “look back and try and define what were the events that led up to the fire,” he said.
Ultimately, Dr. Wax and his team concluded that the patient’s “very hairy body habitus” may have contributed to the fire by soaking up some of the Duraprep. In a 2006 Head and Neck article, he recommended increased pre-op shaving and/or the avoidance of Duraprep when working with particularly hairy patients (2006;28(7):649-652). But today, Dr. Wax stresses that “it’s never just one thing. In the majority of cases like this, physicians are following procedures, but there may be something that’s unaccounted for. Suddenly, one more grain of sand is added to the pile and the whole thing collapses.”
While surgical fires are exceedingly rare—the ECRI Institute estimates that 550 to 650 surgical fires occur annually—they can have devastating consequences. That’s why the U.S. Food and Drug Administration (FDA) and a coalition of health care providers recently launched an initiative to help physicians manage the risk of surgical fire.
The Preventing Surgical Fires Initiative is designed to “increase awareness of surgical fires, to disseminate surgical fire prevention tools and to promote the adoption of risk reduction practices through the healthcare community,” said Cindi Fitzpatrick, BSN, Safe Use Initiative Project Lead for Preventing Surgical Fires.
A High-Risk Field
The risk of a surgical fire is higher than normal during most head and neck surgeries, simply because the elements needed to start and sustain a fire are all within close proximity.
“As an otolaryngologist, you have to be particularly concerned because when you are working around the head and neck area, your oxidizer is very close by, you are using an ignition source and there are fuels all around,” said Soham Roy, MD, an associate professor of otorhinolaryngology and director of pediatric otolaryngology at the University of Texas Medical School at Houston, where he is also a member of the Preventing Surgical Fires Committee.