A Flash Under the Drapes

In practice

The patient is having a lesion removed from the upper chest under sedation, with oxygen flowing through a nasal tube. At the time out, the circulating nurse calls it a high fire-risk case: an ignition source will be used near the oxygen supply. The anesthesia provider agrees to use the lowest oxygen the patient needs and to stop it briefly before the electrosurgical pencil is used. The skin was prepared with an alcohol-based solution, and the team waited the full drying time on the label, longer than usual because of chest hair. The scrub person, Kai, has a basin of saline and wet sponges on the Mayo stand. Midway through, the surgeon, focused on bleeding, activates the pencil without warning. Oxygen has pooled under the drapes near the chin, and a small flame flickers at the edge of a drape. Kai says fire out loud. The anesthesia provider stops the oxygen at once. The surgeon pulls the burning drape away, and Kai pours saline over the area and the drape. The flame is out in seconds. The circulating nurse checks the patient's skin with the anesthesia provider; there is no burn. The case pauses while the drapes are replaced, then continues with oxygen stopped before each activation and spoken warnings each time. Afterward the event is reported, as the facility requires.