- The Washington Times - Saturday, May 26, 2007

Rita Talbert had been putting off having a minor thyroid operation for more than a year, but the 60-year-old said her anxiety eased when a doctor called the procedure “routine.”

“I’d be in and out of there in three hours; nothing to worry about except a small, little stitch,” Mrs. Talbert recalled being told.

On April 25, 2005, Mrs. Talbert’s husband, Francis, a truck driver, and her son and daughter-in-law drove her to Inova Alexandria Hospital from the family’s home in Stafford, Va., with plans to return sometime early in the afternoon. Four days later, however, Mrs. Talbert awoke in excruciating pain in intensive care in a D.C. hospital.

Early during Mrs. Talbert’s surgery at Inova, the unthinkable happened — a flash fire ignited, leaving second- and third-degree burns on her face and neck. Her chin was burned off, and surgeons later found soot in her throat, she said.

During her 13 days in the intensive-care unit, Mrs. Talbert’s family hung a poster-sized card over the bathroom mirror. The card included encouraging get-well messages from fellow church members, but it also kept Mrs. Talbert from looking at her face.

However, on a walk in the hospital corridor, she stopped to use a restroom, washed her hands and, by habit, looked in the mirror. She collapsed on the floor, sobbing.

“What I saw wasn’t me,” said Mrs. Talbert, who has since undergone eight reconstructive surgeries. “At that point, I understood I had been badly burned, but I didn’t understand why.”

Surgical fires are extremely rare and usually preventable, but those that occur can be disfiguring and even deadly.

Out of 50 million surgeries nationwide annually, operating-room fires are reported in about 100 procedures, according to the Joint Commission, which accredits hospitals and other healthcare facilities across the country.

The Pennsylvania nonprofit research group ECRI Institute said such fires are among a group of rare but high-profile “incidents of misadventure in healthcare.” Others include wrong-site surgery and retained instruments.

There is no formal reporting to track surgical fires, but Mark Bruley, vice president of Accident and Forensic Investigation for the institute, said that about 10 percent of about 100 fires a year are serious and one or two of them are fatal.

Most of these fires, he said, can easily be prevented. They usually occur in an oxygen-rich environment beneath the surgical drapes or in a person’s airway. The combination of heat from electro- or laser-surgery devices, gases and alcohol-based surgical-prep solutions can start a fire, Mr. Bruley said.

An authority on surgical fires, Dr. Gerald Wolf, a professor of anesthesiology at the State University of New York’s Health Science Center in Brooklyn, said, in a 2001 study, that as many as 200 surgical fires occur each year in the United States, with surgical drapes the most common fuel.

Dr. James Cottrell, past president of the American Society of Anesthesiologists, who worked with the now-deceased Dr. Wolf, said the lack of a central clearinghouse for data on surgical fires makes it hard to track their frequency.

“It’s not a very high number, but obviously, this is a very serious thing when it does occur,” he said. The fires occur most frequently during head and neck surgeries. Sometimes, gases in the airway can be ignited, burning a patient from the inside.

“That’s the most devastating,” Dr. Cottrell said.

Another common cause is when alcohol-prep solutions do not dry completely before surgery, sometimes pooling in the neck area, before they are ignited by heat from a laser tool or other surgical instrument.

Based on the medical records, early indications suggest something similar went wrong in Mrs. Talbert’s surgery.

A surgeon’s postoperative report showed nothing unusual about the first stages of the operation: Mrs. Talbert was sedated, taken to the operating room, then her neck was prepped with an antiseptic.

The surgeon made a 3-centimeter incision on her neck. Next, she started using a Bovie, an electrosurgical device to open muscle tissue.

“A flash ensued,” the surgeon wrote in the report. “I removed the drapes to find some hair and plastic burning.”

“In retrospect, my suspicion was that this involved the pooling of oxygen under the mask … certainly a sight I have never witnessed before,” the surgeon wrote.

Mrs. Talbert said she never heard from the hospital after she returned home from the burn center, except for a phone call from one of the nurses.

“She said she heard I was out and wanted to see how I was doing,” Mrs. Talbert recalled. “I said I was fine, except you all lit me on fire.”

Mrs. Talbert eventually sued Inova, the surgeon, anesthesiologist and anesthesiology practice, among others. Her attorney, Kenneth Berman, of the law firm of Berman, Sobin & Gross, said the defendants have denied liability. Inova has declined to discuss the lawsuit.

Inova spokesman Che Parker has said the hospital “fully regrets” what happened and that officials want to resolve the matter fairly.

Inova never reported the fire to Virginia hospital regulators or the Joint Commission, which accredits healthcare programs, or to Alexandria’s fire department, according to a Freedom of Information Act request. But such notifications are voluntary, officials said.

Christopher Durrer, director of licensure and certification for the state’s Department of Health, said regulators plan to question hospital officials about the fire.

“We will inquire about it,” he said.

Mr. Parker said the fire was an “isolated incident, and Inova Alexandria has taken numerous steps to prevent a recurrence.”

Inova no longer uses oxygen masks during surgery, instead using small, thin nasal tubes to keep oxygen from pooling, he said.

In addition, surgical teams minimize the use of flammable gases, such as oxygen, and now participate in a pre-procedure checklist before each surgery to address fire-safety issues, he said.

“The hospital routinely monitors and inspects operating rooms to ensure safety measures are being followed,” Mr. Parker said.

Some say Mrs. Talbert’s case shows there should be more stringent reporting requirements for alerting regulators about operating-room fires.

Cathy Lake, of Frederick, Md., started an advocacy group after her mother was badly burned at a hospital in the District in 2002. A lawsuit was filed and later settled out of court under an agreement that prevents either side from discussing the case.

“I don’t care if they put the fire out. It still should be reported,” Miss Lake said.

Mrs. Talbert said she’d never heard of surgical fires until she was burned.

“I’d heard of instruments being left in a person, that kind of thing, but I never heard of somebody catching on fire,” she said. “I’ve always questioned why this happened to me, of all people, and some day, I hope to have an answer.”

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