`I'm On Fire. . .'
Blazes sparked in surgery are on the rise
Melanie Allen sleeps in fits and starts these days, consumed by a recurring nightmare of her head being seared by a white-hot flame. Even when she's awake, she can't shake the nauseous feeling or the fear.
In June, Allen walked into the Montclair Baptist Medical Center in Birmingham, Ala., to have several benign tumors removed from her head and back. The operation was relatively simple: Electro-surgical instruments were used to cut away tumors and cauterize blood vessels. Allen, 40, should have been ready to return to her job as a grocery checker the next day. Instead, she says she woke up in the intensive care unit, with first- and second-degree burns to her face, neck, and chest.
Allen was the victim of a flash fire during surgery. The fire apparently was caused when an electro-cauterizing instrument ignited her surgical covers in the oxygen-rich environment. "My lips were cooked, and my sinuses burnt up," Allen says. She remembers being jolted awake by severe pain in her head, then screaming, "I'm on fire, I'm on fire!" She says she still can't smell or taste and faces months of reconstructive surgery. Montclair Baptist declines comment.
Medical experts say such fires are a bizarre and persistent problem that often isn't reported by hospitals and may be growing because of increasing use of new technologies. Since June 1, ECRI, an independent healthcare research organization, has counted six fires alone that caused serious harm. The fires appear to be rare--only about 100 are reported, with about 20 patients injured and two or three killed each year. Despite this, "certainly, we are hearing about more of them," says Mark Bruley, an ECRI investigator. Experts say that most fires are caused by errors in the operating room.
Perhaps most disturbing are recent reports of fires involving children. In June, a newborn was burned during surgery at North Carolina's Duke University Hospital. In mid-April, an 8-year-old boy's mouth, throat, and lungs were burned when his breathing tube ignited during a tonsillectomy at the San Jose Medical Center in Northern California. Both hospitals have increased training. Investigations at both Duke and San Jose cleared the hospitals of wrongdoing.
Medical organizations are beginning to pay close attention to the problem. In June, the Joint Commission on Accreditation of Healthcare Organizations, which accredits nearly 17,000 healthcare providers, took the unusual step of publishing a safety alert. "Such fires," the commission said, "are significantly under-reported and are preventable."
Still, many states don't track flash fires. Only California, Tennessee, and Washington require reporting of all such fires, but the data are not always searchable. Six others require reports only in cases of major service disruption or serious patient harm. The Food and Drug Administration logs fires only when equipment failure of a device is suspected. "And it's almost never caused by a device failure," says Gerald Wolf, professor of anesthesiology at City University of New York.
Until the 1970s, surgical fires "were a known and a feared risk to surgery" because flammable gases were used for anesthesia, says Bruley. But over the last three decades, as safer gases and new drugs were developed, training about the dangers of fire fell off. There is still little training, although the risk of fire has again grown because of the heavy use of electro-surgical tools in oxygen-enriched environments, says Jerome Thompson, an ear, nose, and throat specialist at the University of Tennessee School of Medicine in Memphis. Thompson began studying flash fires after experiencing a few in surgery. "They didn't injure my patients but frightened me with how easily they can occur and how devastating the potential is," he says. In the vast majority of fires, he adds, "there is no injury, so there will be no report."
Better training is the way to avoid most fires. Experts say materials used in surgery must also be made more fire resistant. "What shakes me up is that in 1985 I wrote up a fire during a tonsillectomy, then in 2003 saw the exact same fire occur," says Wolf. "We have not gotten very far on this issue."
This story appears in the August 18, 2003 print edition of U.S. News & World Report.
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