Tilted Forum Project Discussion Community - I think you could call this a rude awakening.

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Quote:

Patient's `face ignited' in surgery

06/26/03

DAVE PARKS
News staff writer

Melanie Allen recalls emerging from anesthesia two weeks ago in an operating room at Montclair Baptist Medical Center with her head ablaze.

"I remember waking up and yelling, `I'm burning; I'm on fire,'" said the 40-year-old grocery store clerk from Sylacauga. "My face just ignited."

Allen is at home recovering from the painful ordeal a surgical fire. Her experience was rare, but authorities say it occurs too often in an environment that has all the ingredients for a blazing disaster: oxygen, flammable material and the increasing use of electrical instruments.

Wednesday, the Joint Commission on Accreditation of Healthcare Organizations issued a bulletin warning hospitals and surgery centers to reduce the risk of fires in operating rooms through training and awareness. A spokeswoman said the warning was prompted by data that showed a pattern of problems.

The commission, one the most powerful organizations in health care, said operating room fires were significantly underreported and preventable. It estimated that 100 operating room fires occur annually out of 50 million inpatient and outpatient surgeries.

The fires cause one or two deaths and 20 serious injuries, the commission said.

"Though they are considered rare ... surgical fires are certainly one of the most frightening and devastating experiences for everyone involved," the commission's bulletin said.

Allen can attest to that.

"It's terrifying," she said.

Allen said she checked into Baptist Montclair on June 10 to have a fatty tumor removed from her back and a cyst taken off her forehead.

"I'm just expecting one-day surgery ... and then end up like this," she said.

The anesthesiologist told her she would be sedated throughout the procedure, and everything seemed OK until she was shocked into consciousness by a burning sensation and flames. She yelled for help and lost consciousness again, Allen said.

Allen vaguely remembers being shifted to another bed and taken to a recovery room. She didn't realize how badly she had been injured, Allen said.

``They never told me nothing," she said.

She was transferred to an intensive care unit, and the staff refused to allow a visit from her stepdaughter, who had accompanied Allen to Birmingham for the operation.

Allen said a doctor came in with a mirror. He told Allen he wanted her to see what happened before anybody else did. She took one look and was aghast. The fire had burned her face and apparently followed the oxygen tube into her nose and sinuses.

"I said, `What the hell happened to me.'"

She said a doctor told her the blaze ignited like a gasoline fire when he was using an electric instrument to cauterize a blood vessel on her forehead.

Dressings on her face caught fire, and the doctor had to remove them to extinguish the blaze, she said.

The joint commission said the most likely ignition sources of operating room fires are electric instruments used in surgery. A patient's head, face and airway are common locations for these fires, which are often fed by an oxygen-rich atmosphere, alcohol-based prepping agents and surgical dressings.

Allen spent two extra days in the hospital. She's now going to a plastic surgeon every week for her facial scars and a specialist for her nose and sinuses. Her lips and chin still hurt, and her left sinus cavity has been burned out. She can neither smell nor taste, Allen said.

"I still hurt real bad with it," she said.

Officials at Baptist Montclair declined comment, citing patient confidentiality and legal restrictions about releasing information about quality-improvement issues, but Allen said the hospital is paying for her treatment. Officials have told her they are investigating the accident, but haven't told her exactly what happened, she said.

She hasn't returned to work yet and is shaky.

"I got bad nerves now," she said. "I still wake up dreaming about that fire."

Every 3.65 days, someone catches fire during surgery.