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)

"When you set fire to the forest," he noted, "you don't blame the pack of matches."

In two weeks, Lake will fly to Colorado from her home in Boonsboro, Md., to lend her perspective to a training program started by the nurses association.

The particulars of her mother's surgery come from federal court records. A lawsuit filed on Reuter's behalf was settled before trial in 2004 and constrains both sides from discussing it publicly. Reuter died a month after the settlement, following a series of medical errors in several facilities. She had been hospitalized more than two years.

She was in poor health -- overweight and diabetic -- when she entered Washington Hospital Center in December 2002 for a coronary artery bypass and valve replacement. That ended without complications, but Reuter later had trouble breathing on her own. Doctors recommended a breathing tube be inserted into her trachea. The operation was scheduled for New Year's Eve.

It quickly went awry as the surgeon began opening the incision. According to a hospital report, "we heard an air leak and anesthesia found a fire on the right side of the patient's face." The lawsuit alleged that a tube supplying oxygen to Reuter was leaking, and an antiseptic scrub that contained more than 72 percent alcohol had been applied improperly.

Legal filings suggested that the electric current of the surgical device provided the ignition.

The hospital denied culpability.

In an interview, vice president and chief medical officer Janis Orlowski talked of the changes since this "tragic and rare occurrence."

"We've had much more safeguards put into place," she said, from strengthened education and annual training about the dangers -- with required attendance for all surgical staff -- to more comprehensive analysis of the products used in numerous settings. The antiseptic solution used on Reuter was discontinued in the operating room. "Absolutely," Orlowski emphasized.

In more than 250,000 surgeries over two decades, she said, records show that the medical center has had three surgical fires, with one patient injury. She has never seen a surgical fire -- "and I thank God for that," she added.

The hospital's actions are some consolation to Lake, 34. Her plan is to keep pushing for patient safety and advocacy within medical systems. She wants mandatory reporting of surgical fires and full disclosure to families of hospitals' investigations and subsequent actions. "If there are 100 [fires] a year, there are nearly nine a month, and if this is the type of devastation they can cause, that's nine too many," Lake said.

She thinks often about her mother, who immigrated to the United States as a young woman, was a nun for 22 years and then became a kindergarten teacher.

"My mother dedicated her life to teaching others and working hard to . . . help those in need," Lake reflected. "She wanted me to make sure nobody else was injured like her. I had no idea what a tall request that would be, and how difficult and slow change would be."