By Susan Levine
Washington Post Staff Writer
Tuesday, July 18, 2006; B01
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.
"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."