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Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.

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1 0 2 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • N O V E M B E R 2 0 1 7 I n the 40 years I've been studying surgical fires, I've investigated hundreds of them on behalf of hospitals and surgery centers try- ing to piece together the chain of events that led to the fire. It usually takes me about 20 seconds to retrace the lines of the fire triangle: the oxidizer, the fuel and the ignition source. But one case took me about 20 minutes to reconstruct. A patient's face caught fire during a gynecologic laparoscopic surgery. Yes, I know what you're thinking: How in the world did that happen? I took a cross-country red eye from Philadelphia and arrived at the hospital at 2 a.m. As soon as I got there, one thing was obvious: the ignition source was the disconnected fiber optic light cable that the surgeon had rested on the drapes (fuel) near the patient's left clavicle. Those light cables can cause charring, but they don't usually cause a flaming fire unless there's excess oxygen (oxidizer) present. 3 Fire Prevention Tips Mark E. Bruley, BS, CCE Plymouth Meeting, Pa. Your OR team can minimize the chance of a surgical fire. • FIRE RISK Many fires start when the surgeon activates the electrosurgical device in the presence of an oxygen- enriched environment or in the presence of an alcohol-based prepping solution that has not been allowed to dry. SURGICAL ERRORS

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