Failure to Remove Patient's Oxygen Mask Causes Severe Burns

Article posted on:11/01/2007

In Detroit, Michigan last week, Valerija Milosevic, 75, was recovering from a heart attack in the ICU at Henry Ford Macomb Hospital in Clinton Township. While attempting to get of her hospital, Milosevic fell, breaking her nose and gashing her forehead. Medical staff began treating those injuries, including a cut above her eyebrow that required 20 stitches. The medical staff, however, failed to remove Milosevic's oxygen mask prior to attempting to cauterize the cuts. As a result, a "fire burst" occurred, severely burning Milosevic's face. Milosevic has not yet regained consciousness since the fire. Medical professionals inside the room during the procedure also suffered minor injuries. As reported in the Detroit News, a hospital spokeswoman expressed apologies to the family and noted that the hospital was "assuming all accountability for the incident."

Tragically, fires in hospitals and, in particular, the operating room are an all too common occurrence, often resulting in severe burns or even death.  Recent studies indicate that upwards of 650 operating room fires occur each year.  Perhaps the saddest part of each of these instances is that these types of fires are usually entirely preventable.  Surgical fires these days are often caused by the use of electro-cautery devices, instruments that reach several hundred degrees.  Other types of devices include lasers, overhead and fiber optic light sources, drills and burrs.  Lasers in particular have been known to create small areas of intense heat that burn through anything in their path and ignite things such as surgical tubes, clothing, patient hair and swabs.  These devices form part of a trifecta of elements needed for a flash fire:  oxygen, alcohol prep and an ignition source (the electro-cautery device).   The fire hazard has been heightened by the increased use of things such as disposable drapes, antiseptic  skin agents and cloth/paper drapes.  These fires can be prevented through a number of means such as:  using the lowest possible inspired oxygen concentration that still ensures adequate oxygen saturation or administering oxygen along with a nonflammable gas such as helium or nitrogen.  

There are also a variety of less obvious substances that can cause fires as well including the dermatome glue used in harvesting of skin grafts and gastrointestinal gases.  Hydrogen and methane gases are also extremely flammable gases produced by bacteria in the intestinal tract.  When these areas are operated upon and the gases released, an increased risk of a surgical fire increases, especially in the oxygen rich environment of an operating room.  

Several guidelines have been put forth by various entities to curb the risk of surgical fires.  These guidelines include keeping the tip of any electrocautery device in its holster while not in use; use adequately protected endotracheal tubes when operating near the trachea; use air or air and oxygen mixtures in anesthetic gases; avoid tenting of surgical drapes in a manner that allows for accumulation of oxygen and use fire retardant materials and drapes whenever possible. 


If you or a loved one has been injured as a result of a hospital or operating room fire, contact the attorneys at Silverman, Thompson, Slutkin & White at 410-385-2225.