Fire in the Operating Room

balt3/sih-sih/sih-sih/sih00111/sih0287-11z xppws Sⴝ1 2/3/11 17:21 Art: SIH200306 Input-sm Case Report/Simulation Scenario AQ: A Fire in the Operating Room Marcia A. Corvetto, MD; Gene W. Hobbs; Jeffrey M. Taekman, MD AQ:B-C AQ: D 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 AQ: N From the Department of Anesthesiology (M.A.C.), Pontificia Universidad Catolica de Chile, Santiago, Chile; and Human Simulation and Patient Safety Center and Department of Anesthesiology (M.A.C.), Duke University Medical Center, Durham, NC. AQ: O ●●●. AQ: P Reprints: Marcia A. Corvetto, MD, Department of Anesthesiology, Pontificia Universidad Catolica de Chile, Marcoleta 367, Santiago 833-0024, Chile (e-mail: mcorvett@med.puc.cl). Copyright © 2011 Society for Simulation in Healthcare DOI: 10.1097/SIH.0b013e31820dff18 Learning Objectives Learners will be assessed on the following Accreditation Council for Graduate Medical Education general competencies: 1. Medical knowledge: • Recite the fire triangle concept (heat, fuel, and oxidizer). • Demonstrate appropriate management of a fire in the OR. 2. Patient care: • Recite three fire prevention strategies. • Demonstrate the early detection and proper management of an intraoperative fire. 3. Practice-based learning and improvement: • Discuss the hospital fire alarm system and how it works. 4. Interpersonal and communication skills: • Demonstrate proper management and crisis resource management skills. 5. Professionalism: • Demonstrate appropriate teamwork and communication. 6. Systems-based practice: • Contacts 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. Vol. 6, No. 1, February 2011 <article-id pub-id-typeⴝⴖdoiⴖ>10.1097/SIH.0b013e31820dff18</article-id> ● <fpage></fpage> ● <lpage></lpage> 1 AQ: E AQ: F balt3/sih-sih/sih-sih/sih00111/sih0287-11z xppws Sⴝ1 2/3/11 17:21 Art: SIH200306 Input-sm 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 T1,AQ:G 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). Background 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 2 Fire in the Operating Room 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 (EF 20%). • Pulmonary: negative. • Renal/hepatic: negative. • Endocrine: negative. • Heme/coag: negative. AQ: H 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; HR 75; RR 12. • General: well-nourished male in no apparent distress, Glasgow Coma Scale 15. • Weight: 90 kg; height: 160 cm. Simulation in Healthcare AQ: I AQ: J balt3/sih-sih/sih-sih/sih00111/sih0287-11z xppws Sⴝ1 2/3/11 17:21 Art: SIH200306 Input-sm TABLE 1. Simulation Flow State Patient Status Student Learning Outcomes or Actions Desired and Trigger to Move to Next State 1. Baseline Awake, oriented BP, 100/50 HR, 75 O2 sat 96% RR, 12 Learner actions Introduces self Adequate history Explains procedure Place monitors 2. Sedation started Patient stable BP, 100/50 HR, 75 O2 sat 96% RR, 12 Learner actions Attaches oxygen source Starts sedation medication Titrates medication to respiratory rate 3. Sedated and prep Patient sedated BP, 90/48 HR, 70 O2 sat 95% RR, 10 Learner actions Ask about bed/patient positioning Titrates sedation to RR of 8-12 Adjusts medication with incision 4. Fire Patient stable and surgery starts BP, 140/90 HR, 120 O2 sat 92% RR, 20 Learner actions Looks for source of fire (checks drapes, equipment) When fire found, tells surgeon to remove drapes and extinguish fire Turns off O2 source Evaluates etiology, unplugs equipment if in question When unsuccessful smothering, calls for help and activates hospital fire alarm Removes burning material from patient Considers evacuation plan and informing rest of OR suite Informs OR control of fire Assigns tasks to different personnel 5. Hypoxia Patient becomes unresponsive BP, 150/90 HR, 130 O2 sat 80% RR, 0 Learner actions Turns bed in anticipation of intubation Assesses patient injury Checks airway for signs of burns Induces anesthesia 6. Airway control Patient unstable BP, 160/90 HR, 100 O2 sat 95% Learner actions Intubate the patient Remembers to ventilate and sedate patient 7. End of scenario Patient stable BP, 120/80 HR, 100 O2 sat 96% Learner actions Arranges for ICU bed Handoff to ICU team Operator Announce patient arrival in OR Make sure to have patient ask about informing spouse Teaching points Use the appropriate monitoring Risks and benefits of MAC Trigger: Manual Operator Allow learner to choose any agent Maintain oxygen saturation above 95% Teaching points Anesthetic considerations of Parkinson disease Invasive monitors versus routine monitors Trigger: Manual Operator Bed turned 90 to 180 degrees Surgeon preps and drapes (tamp them down if the learner tries to tent) Teaching points Contingency, planning for loss of airway Drugs titration Trigger: Manual Operator The surgeon notice a “smell” in the room Visible wisps of smoke coming from drapes Pinhole burn in drapes causing under drape to catch fire If students still don’t notice it, surgeon might yell “fire” Patient is screaming in pain Teaching points RACE (rescue, activate, contain, extinguish) PASS (pull pin, aim at base of fire, squeeze handle, sweep) Management of fire in the OR (source, evacuation, isolate source) Isolation (close doors, turn off ventilation, O2 source, air conditioning) Crisis management Trigger: Manual Operator Progressive decrease of oxygen saturation until 80% LMA may be attempted but still unable to ventilate Announce that patient has upper airway edema Teaching points Signs of airway burn Timing of intubation Succinylcholine and burns-proper timing Trigger: Manual Operator Announce that airway appears red and edematous with some ash in airway Assuming intubation performed properly, ETCO 2 should be present Teaching points Airway management Trigger: Manual Operator Return to normal if the airway is controlled Announce that ICU team is waiting for transfer Teaching points Contacts Risk Management and reporting Trigger: End of simulation, move to debrief BP indicates blood pressure; HR, ●●●; RR, ●●●; ICU, intensive care unit. Vol. 6, No. 1, February 2011 © 2011 Society for Simulation in Healthcare 3 balt3/sih-sih/sih-sih/sih00111/sih0287-11z xppws Sⴝ1 2/3/11 17:21 Art: SIH200306 Input-sm • Airway: Mallampati class 2, dentition intact. • Lungs: clear to auscultation. • Heart: RRR, 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. 4 Fire in the Operating Room 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). REFERENCES 1. Available at: http://www.apsf.org/resources_video_watch.php. AQ: K 2. Yardley IE, Donaldson LJ. Surgical fires, a clear and present danger. Surgeon 2010;8:87–92. 3. Rinder CS. Fire safety in the operating room. Curr Opin Anaesthesiol 2008;21:790 –795. 4. Lypson ML, Stephens S, Colletti L. Preventing surgical fires: who needs to be educated? Jt Comm J Qual Patient Saf 2005;31:522–527. 5. Barker SJ, Polson JS. Fire in the operating room: a case report and laboratory study. Anesth Analg 2001;93:960 –965. 6. American Society of Anesthesiologists Task Force on Operating Room Fires, Caplan RA, Barker SJ, Connis RT, et al. Practice advisory for the prevention and management of operating room fires. Anesthesiology 2008;108:786 – 801. AQ: L 7. Hamza M, Loeb RG. Fire in the operating room. J Clin Monit Comput 2000;16:317–320. 8. Available at: http://www.mdsr.ecri.org/summary/detail.aspx?doc_ id⫽8197. 9. Surgical fire prevention guide. Health Dev 2009;38:314 –322. 10. Available at: http://www.apsf.org/resources_video_commentary.php? id⫽1. 11. Gaba DM, Fish KJ, Howard SK. Crisis Management in Anesthesiology. New York, NY: Churchill Livingstone; 1994. 12. Schmitz BU, Koch SM, Parks DH. Airway management in burn patients. In: Carin AH, ed. Benumof’s Airway Management. 2nd ed. Philadelphia, PA: Mosby; 2007:997–1008. Simulation in Healthcare AQ: M JOBNAME: AUTHOR QUERIES PAGE: 1 SESS: 1 OUTPUT: Thu Feb 3 17:21:40 2011 /balt3/sih⫺sih/sih⫺sih/sih00111/sih0287⫺11z AUTHOR QUERIES AUTHOR PLEASE ANSWER ALL QUERIES 1 A—Please check whether the short title is OK as given. B—Please check whether the author byline is OK as given. C—Please provide degrees/educational qualifications for the second author. D—Please check whether section heads and subheads have been set as intended. E—Kindly check whether the point “Contacts Risk Management and report the surgical fire” is OK as given. F—Kindly check whether the sentence “Guidance for surgical fire. . . ” is OK as given. G—Please check whether the citation of Table 1 is appropriate. Also, check whether Table 1 is OK as typeset. H—Please spell out EF. I—Please spell out HR, RR, and RRR. J—Please check whether the change of “Glasgow” to “Glasgow Coma Scale” is appropriate. K—Please provide accessed date for Refs. 1, 8, and 10. L—Please check whether Refs. 6 and 12 are OK as typeset. M—Please provide author names (if any) for Ref. 9. N—Please provide affiliations for the second and third authors. Also, check whether the affiliation is OK as given. O—Please provide disclosure information. P—Please check whether the correspondence information is OK as given.