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Surgical tool believed to cause OR fire

Hospital Safety Connection, March 31, 2004

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A hot surgical tool was the likely source of an operating-room fire that seriously injured a 78-year-old patient at Wilson Memorial Regional Medical Center in Johnson City, NY, two weeks ago, the Binghamton, NY, Press & Sun-Bulletin reports.

Village Fire Marshal Robert Blakeslee officially ruled the cause accidental, but hospital officials continue their investigation.

Wilma Baker of Union Center was undergoing a surgical test on the side of her head March 16 when she suffered second-degree burns to her face and neck. The surgeon was using a cauterizing tool, which uses heat to close wounds, when a flame erupted.

The cauterizing tool likely ignited cloth surgical draping in the presence of oxygen near the patient's face. No other medical gases were used during the operation.

Witnesses on the surgical team described a frantic scene in which surgeon Mark Brennan, DO, initially fought the fire with his hands, Blakeslee told the paper. The flame burned Baker's face, the blue drape, bedding, and even the oxygen tube in her nose.

The surgeon performed an emergency tracheotomy so she could breathe after she was burned. After spending six days in a Syracuse burn unit, Baker is recovering at home from the burns and the tracheotomy, her lawyers said. When the fire started, Baker was undergoing a common biopsy for temporal arteritis, or an inflammation inside blood vessels.

An inspection of the cauterizing tool revealed no particular problems with the device. Witnesses said oxygen did not appear to be leaking from the oxygen tube.

Although the fire was extinguished in a few seconds, fire officials criticized the hospital staff for waiting about 90 minutes to call the fire department.

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