The last thing a patient would expect while undergoing surgery is for the area to catch fire – yet it is a very real risk that can happen, and often does.
A recent review by non-profit medical malpractice insurer Canadian Medical Protective Association (CMPA) reminded physicians that surgical fires – fires that erupt while a patient is undergoing a surgical operation – remain a relevant risk.
The review found that between 2012 and 2016, the insurer had handled 54 cases of litigation related to surgical fires. A third of the cases involved fires in the operating room, while others involved burns from surgical equipment or chemicals used during the procedure.
CMPA found that many of the victims of surgical fires were left with “scarring, disfigurement and psychological trauma.”
In one case, a woman was undergoing surgery to shrink the mass of a tumor inside her trachea. When the operating surgeon switched on the laser for the procedure, the laser hit the inflatable cuff around the breathing tube delivering anaesthetic gases and oxygen. This deflated the cuff, and ignited the flammable gasses.
The woman survived the ordeal, spending three weeks in intensive care. She later sued the surgeon for malpractice.
Although a rare risk, surgical fires have been classified as “never events” by patient safety groups – they should never happen, provided surgeons take the necessary precautions.
For a surgical fire to occur, “the three elements of the fire triangle must be present: ignition (heat), fuel and oxygen,” CMPA said in its review, outlining how doctors can avoid the risk.
CMPA associate executive director Dr. Douglas Bell told
National Post that most of the 54 cases of surgical fire it had handled recently were settled.
Patient safety experts commented that if 54 cases made it to litigation at the CMPA in the last five years, there could possibly be 10 times that number that have gone unrecorded.
“If you want to hold the hospital or medical system accountable, you better have deep pockets,” said former Winnipeg Regional Health Authority patient safety investigator Darrel Horn.
Horn explained that the CMPA has enough funds to protect MDs accused of negligence.
“Because these injuries are seldom fatal or, in the long term, life altering, they don’t get a lot of attention,” he added.
He also told
National Post that the vast majority of surgical fires would not be reported or collated by any central body. In some of the cases recorded by CMPA, he said, the “burn event” was not properly documented.
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