Patient Catches on Fire, Highlights Need for Prevention

On Thanksgiving Day 2022, Kathy Stark watched as her husband of 35 years, Bobby Ray Stark, caught fire at a Nashville hospital. According to Clint Kelly, Kathy Stark’s attorney, the hospital staff was performing cardioversion to restore Bobby Ray’s heart rhythm when a spark ignited the oxygen and set the patient aflame.

Stark, 64, died of “a combination of cardiovascular disease and thermal burns,” according to a local news report. In May, Kathy Stark filed a malpractice lawsuit in US District Court. Kelly hopes that the lawsuit will help improve patient safety. Meanwhile, Kathy Stark “goes to bed at night and sees her husband on fire,” Kelly says. A similar incident occurred last December in the operating room at Oregon Health & Science University, resulting in minor injuries to a patient.

Surgical fires happen rarely, but they can pose serious threats to patients and result in litigation against physicians and hospitals.

Underreported, but Likely Dropping

Reliable data on the incidence of surgical fires is lacking because incidents may go unreported over litigation fears, says Jeffrey Feldman, MD, MSE, anesthesiologist at Children’s Hospital of Philadelphia and chair of the Anesthesia Patient Safety Foundation’s (APSF) Committee on Technology.

However, the Pennsylvania Patient Safety Authority has been tracking surgical fires for decades, and experts have used the agency’s data to extrapolate how often they occur in the United States.

In 2005, nationwide incidence was estimated to be somewhere in the neighborhood of 550-600 fires annually, says Barbara G. Malanga, BSEE, acting director of healthcare incident investigation and technology consulting at ECRI (formerly the Emergency Care Research Institute). By 2011, that number appeared to have dropped to 200-240 incidents per year.

A similar analysis in 2018 found the incidence may now be as low as 88-105 a year. The drop is likely a result of increased awareness due to educational efforts on the part of the ECRI and the APSF, including a widely disseminated video on fire safety.

The decline of surgical fires “sounds great,” says Feldman, “except that it’s a 100% preventable complication, and they’re still happening.”

Accidents Waiting to Happen

How do these fires happen? It comes down to the ‘fire triangle’ often taught in grade school. Fire requires three things: an ignition source, fuel, and oxygen or an oxidizing agent. Ignition sources are plentiful in a surgical suite, including any of a variety of electrical devices commonly used in surgical procedures, including defibrillators. Gowns, gauze, drapes, sponges, oxygen masks, nasal cannulae, a patient’s hair or their clothing — all provide the necessary fuel.

But the key factor for surgical fire risk is the presence of high concentrations of oxygen.

Safety Protocols

The best and most obvious way to mitigate risk is to reduce the amount of supplemental oxygen, explains Feldman.

“Many patients do not require a high concentration of oxygen during sedation,” he says.

When a patient does require a higher concentration for their safety, the APSF and ECRI recommend placing an endotracheal tube or supraglottic airway rather than using an oxygen mask or a nasal cannula. “You want to deliver the oxygen in such a way that high concentration doesn’t exist in the surgical field,” Feldman says. In cases where supplemental oxygen is necessary, ECRI and the APSF recommend reducing the oxygen concentration to less than 30%.

In addition, safety protocols include giving flammable prep solutions time to dry before applying towels or drapes and beginning the procedure. These precautions to ensure the safety of patients take just a moment, says Chester H. Lake Jr, MD, MS, assistant professor of anesthesiology at the University of Mississippi Medical Center.

Making Fire Safety Part of the Preop Routine

These safety protocols are straightforward but not always observed, experts say. Part of the reason is a matter of culture. Both anesthesiologists and surgeons have absorbed the attitude that placing an airway escalates the procedure beyond what the patient needs, says Feldman. And indeed, according to a 2013 analysis of the American Society of Anesthesiologists closed claims database, 85% of surgical fires occur in outpatient settings where airways are less likely to be placed, and 81% of those claims were for procedures that used monitored anesthesia care.

In an article on prevention of surgical fires, Lake and colleagues recommend in-house education on preventing and responding to fires at least once a year. But it shouldn’t stop there. Because these fires — horrific as they are — are fairly rare, it’s important to maintain awareness. Making fire safety a regular part of the surgical ‘time-out’ can help further reduce incidents, he says. ECRI and the APSF have teamed up to create a poster that can help surgical teams make fire safety a regular part of their routines.

Although the national decline in surgical fires is encouraging, the problem remains serious. “You can classify these incidents as low, but it’s not low if it happens to you or a family member,” says Lake. “One is too many.”

ECRI’s Malanga agrees. “I do like to emphasize that it’s rare,” she says. “But I’d like to see us reduce this until it’s zero.”

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