Effect Measure

I’ve seen surgeons blow up in the operating room but never saw an operating room blow up. But according to the Wall Street Journal, it’s not that rare for them to catch fire and sometimes worse. Operating rooms are full of flammable gases and materials and oxygen. Moreover it isn’t just a matter of taking a fire extinguisher off the wall or dumping a pail of water on the patient. There is the little matter of sterile procedures. So I was quite taken aback by a figure given in the article of 650 surgical suite fires each year in the US and maybe four times that number of “almost” fires (e.g., smoldering surgical drapes immediately extinguished). Apparently people are paying attention:

Patient-safety groups and medical specialty organizations are stepping up efforts to raise awareness of risks and provide guidelines for prevention. Hospitals are conducting operating-room fire drills that teach how to fight fires that break out on the drapes, gowns or skin of surgical patients and extinguish flames inside a patient’s airway or tracheal tube. They’re also developing training programs to educate staffers on the dangers of burns from medical equipment and procedures. (Laura Landro, WSJ)

I haven’t been in an operating room for a long time (excepting the birth of my daughter and my own kidney stones), but I when I was scrubbing regularly I don’t remember anyone mentioning what to do if there was a fire and certainly no training. Now a lot of surgery is being done as day surgery in outpatient surgical facilities. The way to enforce attention to safety is through reimbursement and a new federal law will require safety plans and reporting or suffer a reduction in Medicare reimbursement. The reduction is so small (2%) and levels of reimbursement also ridiculously inadequate I’m not sure how effective this will be, but it’s the right idea. The objective is to reduce scalding, fire, chemical, radiation and electrical burns from warmers, prep solutions and various instruments like lasers and electrical cauterizers.

While the use of flammable anesthetic gases like ether are no longer much of a problem, there are a whole host of new hazards to take their place: all sorts of coils, sensors, magnets, fiber-optic light sources, electric blankets, etc. The results can be terrible:

ECRI [a safety advocacy group] earlier this month recommended the removal of a series of infant warmers after an investigation showed that a baby caught fire in a bassinet at Mercy Hospital in Coon Rapids, Minn., most likely because a hot particle fell from the warmer’s assembly into the area near the baby’s head where oxygen was being delivered. Though nurses quickly extinguished the fire, the baby sustained burns. The warmers in question were last manufactured in 1998 but are still in use in some hospitals, and ECRI says several other models with similar heater assemblies may present the same risk.

Interaction of different kinds of new medical devices and treatments are another difficult problem. I learned in the article that nicotine or fentanyl patches (for pain) used by many patients can heat up in an MRI and burn the patient. Some tattoos have iron in them and can heat up. Surgery is done by teams, and often one person (the surgeon) will employ the heat source while others are working with anesthetics or oxygen or disinfectants. If they aren’t coordinated, bad things can happen.

Because each member of the team may be focusing on his own role in a procedure, “the No. 1 cause of fires is lousy communication” says Patricia Seifert, editor-in-chief of AORN Journal, the monthly publication of the Association of periOperative Registered Nurses. AORN developed a fire-safety tool kit that it sent to 13,000 operating-room directors and managers around the country, and it is now offering the kit free to its 42,000 members.

Fire in the OR is like (or worse) than fire aboard a ship. You want to avoid it at all costs, and strict training, regulation and sanctions for infractions are the best way. It’s not the job of the patient, despite what M. Christine Stock, head of anesthesiology services at Northwestern University’s medical school suggests: Before surgery, ask what fire-prevention strategies are in use.

Sure. Just what I want to do before being rolled into the OR. Ask if they have made sure the place won’t blow up while I’m lying there unconscious or a fire won’t flash down into my lungs through the endotracheal tube keeping me breathing. And what if they say, “Gee, we don’t have a plan”?

Or more likely, “Don’t worry. Everything will be fine. Now count backwards from ten.”

Comments

#1 M. Randolph Kruger
February 22, 2009

Now this is something I have a little personal experience with. 1979…AK round to the chest from a LONG way away else this conversation wouldnt be taking place. Hit my chest and stove in the body armor and they thought my sternum was cracked.. It hurt like a bitch.

Anyway some dummy somehow managed to arc some sort of equipment about six feet from a guy who was in an oxygen tent and even though the procedures apparently had been followed, the sparks ignited the linoleum floor because of the oxygen content. Then those drapes they use to separate the areas went up. Fortunately the sprinkers had a manual kick handle around the corner and the personnel set them off. Kept the fire down until the fire dept rolled in and someone did have the presence of mind to kill the oxygen. They rolled him out. Me, I rolled off that gurney like a rocket. Never saw a fire get so out of control so fast.

After that the USAF hospitals were required to have high oxygen content rooms instead of having patients in proximity to hydrocarbons that only need a spark to get them rolling. Apparently this stuff pools in higher concentrations in some cases.

I am sure thought that Revere could expound upon the virtues of nitrous and a spark.

Works real good in drag racing.
#2 Eadwacer
February 22, 2009

Kindof like a fire in a spacecraft.
#3 Art
February 22, 2009

A few ideas on a simple engineering problem:

You could reduce the fires to around zero using the same method Russians weld titanium sub hulls. Perform the operation in a room, essentially an empty swimming pool, that has been flooded with CO2. Welders, in this case the operating room staff and patient, are lowered down into the CO2 atmosphere in modified diving suits. In a saturated CO2 atmosphere fire, or oxygen embrittlement of welds, is not a problem.

More practically we could take a clue from European gas nozzle design. Their gas nozzles have a coaxial vapor collection system at the outlet. While your pouring gasoline into your fuel tank a suction system held in proximity to the filler outlet on your vehicle is scavenging any vapors that escape.

It wouldn’t be difficult to set up an oxygen scavenging system that would suck up the vast majority of the excess oxygen discharges. If the oxygen line was putting out 10 liters of 100% oxygen a minute the scavenger held near the point of use, could be sucking up 20 liters a minute with the balance being made up with room air so there is a constant air movement toward the oxygen scavenger system. Removing the excess 100% oxygen should remove most of the fire hazard.

Interestingly welders use a similar wide-bore, high-volume, low-pressure exhaust systems to collect welding fumes and discharge them to the outside when welding in confined spaces.
#4 orac
February 22, 2009

You could reduce the fires to around zero using the same method Russians weld titanium sub hulls. Perform the operation in a room, essentially an empty swimming pool, that has been flooded with CO2. Welders, in this case the operating room staff and patient, are lowered down into the CO2 atmosphere in modified diving suits. In a saturated CO2 atmosphere fire, or oxygen embrittlement of welds, is not a problem.

Have you ever actually been in an operating room? Your “solution” to the problem strongly suggests to me that you have not and that you have no clue what is involved in a typical operation. Trust me, as a surgeon, I can’t do an operation in a “modified diving suit.”
#5 Lea
February 22, 2009

Better yet, have you ever been aboard a “ship”? A real ship, not some frakking cruise “ship”.

“Before surgery, ask what fire-prevention strategies are in use”. Among other idiotic questions we need to ask, which we shouldn’t even have to ask in the first place is; “MRSA, do you know what MRSA is and what is your hospital’s record on MRSA”?
#6 caia
February 23, 2009

Lea: Last time I had (minor) surgery, they asked if I had ever had MRSA or c. difficile (sp?).

And, recently visiting family in hospitals, I’ve seen they have both sinks with soap AND dispensers of hand sanitizer outside the rooms, which you see them rubbing into their hands all the time. Plus reminder sheets posted about hand-washing and speaking up if you think someone should use hand sanitizer.

A system is only as perfect as the people who use it, and humans aren’t perfect, but I find all this rather reassuring.
#7 Lea
February 23, 2009

The point was dear caia that we should NOT have to ask these type of questions in the first place.
And the point of the question dearest one, was to be told up front if MRSA was or was not a problem in the hospital to begin with.

I don’t find any of it reassuring, but then again I’m an older woman who has had far too many “experiences” this lifetime, IMO.
And yes, I’m a tad bit paranoid when it comes to trusting humans, let alone hospitals given their reputations.
#8 Art
February 23, 2009

Well, I’m real sorry my little brainstorming session didn’t immediately come up with the perfect solution in a fully formed and polished form that you would like.

Actually I worked in a hospital for years and often went into operating rooms. Mostly not during an operation but yes, I’m familiar with the setting. The claim (waaaa) ‘I can’t work in a diving suit’ is pretty much what surgeons claimed when gloves, gowns, surgical masks and sterile fields came into the practice.

Nothing personal here but Doctors are always the most backward and resistant to change of all professions. Docs can’t even get their own colleagues to wash their hands consistently. You would think that simple step would catch on after a few hundred years but the evidence is to the contrary. Change is always slow and hard for doctors.

The second bit, collection and exhaust of concentrated oxygen, was likely more practical than the first but even the first wouldn’t require much more than a modified form the full-face units neurosurgeons sometimes wear. They seem to get along pretty well in them.
#9 D. C. Sessions
February 23, 2009

a) Titanium burns very nicely in carbon dioxide. Also pure nitrogen. Argon is preferred for welding it.

b) Having the OR staff as well as the patient on external oxygen while in a nitrogen atmosphere (CO2 is toxic, remember) would be manageable; the hands etc. don’t need oxygen. However, you’re missing the “when (not if) things go wrong” aspect. Deaths from asphyxiation would be more of a threat than fire is now. Keep in mind that hypoxia is sneaky, and the first thing to go is judgment.

All in all, standards for non-flammable materials and equipment are a better bet. Yes, they cost more than paper and cotton. Take your pick.
#10 daedalus2u
February 24, 2009

Actually the external skin does get O2 from the external air. That is why the outer skin doesn’t have hemoglobin in it. I agree with Orac, operations can’t be done in a low O2 environment, not just because the surgeon can’t operate there, but the patient needs air-concentrations of O2 over their entire surface.

Pure O2 is extremely dangerous. Virtually everything that is organic will burn in pure O2, including living flesh. The water content isn’t high enough to keep it from burning vigorously in pure O2. Most metals will burn (iron, steel, even stainless steel), even in thick sections; the only exceptions being copper and nickel alloys. There are no plastics that won’t burn. Teflon and perfluorocarbons don’t burn well (and are quite difficult to ignite), but they will still burn (and make very toxic fumes).

I think there is too much use of high O2 atmospheres in medicine. I don’t think there has been enough evidence based analysis of the practice.