Fire in the Operating Room

DEMOGRAPHICS Case Title: Fire in the Operating Room Patient Name: Mr. Smith Scenario Name: Fire in the Operating Room Simulation Developers: Marcia Corvetto, MD; Gene Hobbs, CHT; Jeffrey Taekman, MD Simulator: Laerdal SimMan Date of Development: August 2004 to June 2010 Appropriate for following learning groups: Residents: Postgraduate years 2, 3, and 4 Specialties: Anesthesiology Nurse Anesthesia Students: 1 and 2 CURRICULAR INFORMATION Educational Rationale Fire in the operating room (OR) is a rare but critical event. According to the Anesthesia Patient Safety Foundation, hundreds of fires occur in the United States yearly.1 The majority of fires occur during head and neck surgery due to the presence of oxygen and the extensive use of lasers.2 Surgical fires can be prevented by educating staff about risk and prevention strategies. Prevention depends on understanding how the elements of the fire triad interact, recognizing how standard operating room equipment can initiate a fire, and vigilance monitoring for the circumstances that increase the likelihood of fire.3 Education on fire prevention and mitigation should be a part of all undergraduate medical, nursing, and other allied health profession education.4 Using a case report from Barker and Polson5 as our inspiration, we designed this scenario to have learners reflect on preventing and effectively managing an OR fire.6 Learning Objectives Learners will be assessed on the following Accreditation Council for Graduate Medical Education general competencies: Medical knowledge: Recite the fire triangle concept (heat, fuel, and oxidizer). Demonstrate appropriate management of a fire in the OR. Patient care: Recite three fire prevention strategies. Demonstrate the early detection and proper management of an intraoperative fire. Practice-based learning and improvement: Discuss the hospital fire alarm system and how it works. Interpersonal and communication skills: Demonstrate proper management and crisis resource management skills. Professionalism: Demonstrate appropriate teamwork and communication. Systems-based practice: Contact Risk Management and report the surgical fire. Guided Study Questions What is the fire triad? What are common heat and ignition sources in the perioperative environment? What commonly used agents can add to combustion in the OR? What is the proper patient prepping technique? What are the ways to prevent surgical fires? How should you be prepared for fires or how can you develop a fire prevention plan? What should you consider and in what order if the patient is on fire? Is it necessary to evacuate the patient from the OR with an intraoperative fire? How and to whom? How and to who should we report a surgical fire? What postoperative care should be given? Didactics Guidance for surgical fire prevention and management is available at https://www.ecri.org/Products/Pages/Surgical_Fires.aspx. PREPARATION Roles Two residents (learners) Surgeon (a member of the simulation center plays as a confederate) Monitors Required Noninvasive blood pressure cuff Five-lead electrocardiogram Pulse oximeter Capnograph Other Equipment Required Anesthesia machine Surgical drape clips Gurney Dry ice Bucket and tubing Two surgical drapes (paper, water resistant) Fire extinguisher (empty and labeled for simulation purposes only) Duration Setup: 5 minutes Preparation: 5 minutes Simulation: 15 minutes Debrief: 35 minutes CASE STEM Mr. Smith is a 73-year-old Caucasian male scheduled for bilateral parietal burr holes to evacuate a subdural hematoma. The patient has severe Parkinson disease treated with Sinemet and postviral cardiomyopathy with a measured ejection fraction of <20%. Monitored anesthesia care was chosen as the preferred technique because of the underlying cardiac disease (Table 1).TABLE 1: Simulation FlowBackground and Briefing Information for Facilitator/Coordinator's Eyes Only In this simulation case, the patient is in the OR, with routine monitoring equipment applied and peripheral venous access initiated. The table will be rotated 90 or 180 degrees. A member of the simulation center staff plays the surgeon. The surgeon will place the surgical drapes, prep the patient, and start the surgery. The preparation solution, the supplemental oxygen supply, the closed tent of surgical drapes, and the electrocautery ignition source are all the required ingredients to produce a fire. Just after the procedure begins, a fire starts in the OR. Method for Replicating Fire A sealed bucket with a hole cut on top of the lid, a long tubing (ventilator tubing strung together works fine), and dry ice are required to replicate fire. The hose is connected at one end to the bucket (in the control room). The other end is fed up under the drapes, travels longitudinally along the body of the simulator, and its end is positioned at the simulator's shoulder. “Fire” is simulated by dropping dry ice into the bucket filled with water and closing the lid. “Smoke” will flow to the end of the hose, coming out adjacent to the patient's head. Experience and Tips for Running the Scenario The surgeon will place the surgical drapes (tamp them down if the learner tries to tent), will prep the patient, and start the surgery, without enough drying time after solution application. All these actions will be done by the surgeon, who is a confederate, so students would not be able to take precautions. The surgeon needs to act a little rude or push to get the case started. Second, have the case set up before the students come in for their first case. Once we have run another scenario, they do not think about the extra 22-mm hose that is coming into the room. Finally, if the learner asks for a blender or other means to reduce the delivered FiO2, we tell them that we do not have one or that is coming from another OR. The surgeon should start the surgery besides the absence of the blender. The confederate is really important in this case. PATIENT DATA BACKGROUND AND BASELINE STATE Patient History Mr. Smith is a 72-year-old male who has a subdural hematoma. He was scheduled for an elective bilateral parietal burr holes for evacuation. Hemodynamic and neurologic status is stable. The anesthesiologist's interview revealed that the patient is a male with a medical history significant with Parkinson disease and postviral cardiomyopathy. Monitored anesthesia care was chosen as the preferred technique because of the underlying cardiac disease. Medical History Parkinson disease and postviral cardiomyopathy. Surgical History No surgical history. Review of Systems Central nervous system: alert and oriented, severe Parkinson disease treated with Sinemet (carbidopa and levodopa). Cardiovascular: postviral cardiomyopathy, in routine monitoring in cardiology, no coronary artery disease, last echocardiogram 2 months ago with impairment of left ventricular function (eyection fraction 20%). Pulmonary: negative. Renal/hepatic: negative. Endocrine: negative. Heme/coag: negative. Current Medications and Allergies Sinemet 25–100 (25 mg of carbidopa and 100 mg of levodopa), one tablet three times a day. Coumadin discontinued. No known drug allergies. Physical Examination Vital signs: blood pressure 100/50; heart rate 75; respiratory rate 12. General: well-nourished male in no apparent distress, Glasgow Coma Scale 15. Weight: 90 kg; height: 160 cm. Airway: Mallampati class 2, dentition intact. Lungs: clear to auscultation. Heart: regular rate and rhythm, no murmur, gallops, or rubs. DEBRIEFING The main objective of this case is to discuss about prevention and management of OR fires. The surgeon confederate may stay for the debriefing to help with opinions from his point of view. Essential teaching points to be reviewed during the debriefing: Discuss about the fire triangle concept (heat, fuel, and oxidizer) and how to disrupt it.7,8 Identify OR contents capable of acting as heat, fuel, and oxidizer sources. Discuss the mechanisms of injury from fire. Discuss about prevention strategies of a surgical fire.1,3,9 Teaching points to include: Control of oxygen delivery during surgery of the head, face, neck, and upper chest; practice of open delivery of 100% oxygen should be discontinued. Techniques for controlling oxygen concentration in an open system (Anesthesia Breathing Circuit, Venturi System, and Air/Oxygen Blender).10 If an oxygen concentration >30% is required, the airway should be secured through intubation or a laryngeal mask airway. Discuss about management of OR fires, actions to take in response, importance of a quick response to prevent injury. Identify the location of fire extinguishers. Talk about crisis management in anesthesiology.11 Talk about airway management in a burned patient.12 We expect just a simple airway management to finish the scenario. Again, the idea is to talk about fire prevention and management and if you have enough time, you can talk about the airway management in a burned patient. Additional suggestions to facilitators: The facilitator teaching this issue needs to become knowledgeable about this type of event. A good way is to see the new Anesthesia Patient Safety Foundation Fire Safety Video.1 The facilitators should emphasize the current thinking on prevention. It is very easy to have learners talking about management, but prevention is even more important, so we need to guide the discussion to emphasize prevention issues. The facilitators should be familiar with the local fire evacuation protocol and fire alarm. The facilitators should be familiar with the location of fire extinguishers (laminated floor plan).