Frederick Mother's Burning Inspires Daughter's Activism

Daughter Catherine Lake says fires during surgery are a persistent danger. (By Kevin Clark -- The Washington Post)

Catherine Lake realized her mother's surgery entailed risks. But she never imagined this one. There had been an "incident" in the operating room, the doctor at Washington Hospital Center was saying. Her mother had caught fire on the operating table.

The 73-year-old Frederick County woman had been undergoing a tracheostomy when smoke started rising around the incision. By then, hidden under surgical drapes, flames already had reached her face, right ear, neck and shoulder.

Catherine Reuter was left with severe burns that would take months to heal. More than three years later, her daughter remains haunted, and motivated, by the images.

They explain the "SurgicalFire.Org" sticker on Lake's minivan. People who go to her Web site learn that such fires, while rare, remain a persistent danger in this country. As many as 100 occur every year, in settings from strip-mall clinics to world-renowned medical complexes. Eighty percent cause little or no injury to patients or staff. The rest, however, result in serious harm.

Before Reuter died 18 months ago, she asked her daughter to help change things. That request is at the heart of Lake's growing activism, which has included testimony before state lawmakers and presentations in national forums.

"She would always say, 'I don't want to see people suffer like this,' " Lake remembers. " 'I don't want to see people get hurt.' "

Medical advances in recent decades have paradoxically increased and decreased the potential for surgical fires. No longer do operating rooms use flammable anesthetic gases. Yet much of the sophisticated equipment used in even routine operations, from electrocautery pencils to lasers, is a heat source that can ignite alcohol vapors, cloth or plastic materials in an oxygen-enriched environment.

The issue has been receiving renewed attention, in part because of several widely publicized cases. In 2000, an elderly woman died at a St. Louis hospital after her face caught fire during a minor operation on an eyelid. In 2003, a newborn suffered second- and third-degree burns during a procedure at Duke University Medical Center.

In the wake of those and other events, the influential Joint Commission on Accreditation of Healthcare Organizations put out an alert about the hazards of surgical fires. Last year, the commission declared better prevention a national patient safety goal.

Yet last month, a man in a Texas hospital was badly injured when an alcohol-based antiseptic solution used in preparation for throat surgery became fuel for a fire that spread to his beard. Though there is no mandatory reporting to the joint commission or federal officials, health industry experts say they continue to hear of one to three such events a week.

And with many procedures being performed in labs, clinics and physicians' offices, where fire safety might seem of lesser concern, "it just raises the risk," said Sharon Giarrizzo-Wilson, a nursing specialist with the Association of Perioperative Registered Nurses.

The association and industry groups are working together to improve doctors' and nurses' education. Human error, not equipment malfunction, is virtually always the source of surgical fires, said Mark Bruley, vice president of ECRI, a nonprofit research organization that tracks the safety of medical devices.