In the rarest complication, a flash fire broke out inside the exposed chest cavity of a 60-year-old man who was undergoing emergency heart surgery in Australia.
The incident, which happened in August 2018, was presented over the weekend at the Euroanaesthesia Congress in Vienna, reported the EurekAlert.
Dr. Ruth Shaylor and his colleagues from Austin Hospital in Melbourne, where the fire incident happened, warned that dry surgical packs in the oxygen-rich environment of operating theatres where electrosurgical devices are being used present a fire risk.
The man in which the fire broke out had a history of chronic obstructive pulmonary disease (COPD) and had already undergone surgery just a year earlier. He had arrived at the hospital needing emergency surgery for a rupture in the inner wall of his aorta.
But during the surgery, a large blister in one of the man’s lung, related to the COPD, got punctured, releasing fluid into his chest cavity.
Patient catches fire during emergency cardiac surgery! This is why all perioperative staff need to be aware of fire prevention and management in the operating theatre: https://t.co/Xhkmk459Ju #surgicalfires #patientsafety @SaferSurgeryUK
— Daniel Rodger (@philosowhal) June 3, 2019
Fearing that the patient would suffer respiratory distress, doctors decided to give him more anesthesia and 100 percent oxygen.
They then used an electric cauterization tool to seal off bleeding tissue. That’s when a spark from the electrocautery device ignited the dry surgical pack that was placed near the man’s exposed chest cavity.
Doctors immediately took control of the situation and put out the fire with no injury to the patient, and the rest of the surgery was completed without a hassle.
“While there are only a few documented cases of chest cavity fires—three involving thoracic surgery and three involving coronary bypass grafting—all have involved the presence of dry surgical packs, electrocautery, increased inspired oxygen concentrations, and patients with COPD or pre-existing lung disease,” Dr. Shaylor said at the meeting.
— Brian Longo (@atomic811) June 3, 2019
Dr. Shalor said the case highlights the need for training in intervention procedures for such cases.
“This case highlights the continued need for fire training and prevention strategies and quick intervention to prevent injury whenever electrocautery is used in oxygen-enriched environments.
“In particular, surgeons and anaesthetists need to be aware that fires can occur in the chest cavity if a lung is damaged or there is an air leak for any reason, and that patients with COPD are at increased risk,” he said.
— Live Science (@LiveScience) June 3, 2019
Deaths from medical errors do occur quite commonly. According to a report on Van Wey, Presby and Williams, 98,000 people die every year in the United States due to preventable medical errors.
That makes them the third leading cause of death in the country.
New from @maggiemahar Taking Note: When a Fire Breaks Out In the Operating Room http://bit.ly/cTKNwz
— The Century Foundation (@TCFdotorg) June 1, 2010
According to report, between 550-650 surgical fires, where a patient catches fire on the operating table, happen in the country every year.
“Surgical fires can occur any time all three elements of the “Fire Triangle” (ignition source, fuel source, and oxygen) are present. Most people are aware of how dangerous these three elements combined can be,” said the report.
An oxygen-rich environment is the leading cause of these fires in 74 percent of the cases.