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Surgical Fires Pose A Danger To Patients

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(credit: KTVT/KTXA) Ginger Allen
Ginger is the Senior Investigative Reporter of the CB...
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DENISON (CBSDFW.COM) – Keller mother Teresa Velasquez remembers the day her son checked in to the operating room to get his tonsils removed. The 7-year-old was as all smiles before the procedure.

A tonsillectomy seemed routine to their family. Andre’s older brother and sister had the same surgery with no problems.

“He was excited because he could eat popsicles after the surgery,” said Robert Velasquez, Andre’s dad.

But Teresa and Robert Velasquez will never forget sitting and waiting in a room as other parents continued to be called back to see their children.

The wait got longer and longer. Finally, the doctor came and got them and took them back to a small room.

“She said something has gone terribly wrong,” Teresa Velazquez said cringing.

The surgeon said their son had “caught on fire” in the operating room.

“Fifteen minutes later they took us back to the emergency room to be with him. He was on a breathing machine in an induced coma,” Teresa said, looking at pictures of what her son looked like when they saw him for the first time.

The boy appeared to be asleep in a hospital bed. His small body was covered in blankets and tubes shot out in all directions. The boy was in a coma.

He was on a breathing machine and the white tape holding it to his nose and mouth nearly covered his entire face. “It’s hard to see a child lying motionless and helpless like that,” Andre’s dad said.

Seven days later, doctors pulled Andre out of the coma. He woke up to family surrounding him. They’d flown in from all over the country to support the Velasquezes.

It would be another week before Andre got to go home. Finally, his parents walked out the hospital with him along with a breathing machine, a feeding tube, and the knowledge that more surgeries would follow.

Andre fought respiratory problems for three more years, until he was in the fourth grade. His mom says she remembers the breathing treatments daily.

The fire started in a flash. And it could happen inside any operating room when three elements come together: Heat, fuel and oxygen.

In an operating room, the surgeon provides the heat with lights, probes, drills, or lasers. The nurse controls the fuel. Fuel can be anything from prepping agents like alcohol to linens, gauze, or hair. And, the anesthesiologist provides the oxygen.

In Andre’s case, the flames that shot down his throat were so intense they blackened his tracheal tube, which is normally clear. Attorney Kay Van Wey showed pictures of the black tube, which is almost unrecognizable.

“This should not and will not happen if everyone is doing the thing they are supposed to do,” Van Wey said. She sued the hospital for gross negligence. She is able to talk about the danger, but is not able to name the hospital as part of a confidentiality agreement.

Andre’s surgery was in 2001. And his family said it spoke to CBS 11 because it’s a mission to spread their story in hopes of alerting others. “We wanted people to know what happened to Andre because it could happen again,” says Teresa Velasquez.

But it has happened again. Much more recently.

“I walked in and I didn’t recognize my own mom, “ said Steve Schulze with a sadness and hopelessness in his voice. He flipped through pictures of his mom before and after what was supposed to be a routine pacemaker procedure in 2009 at Texoma Medical Center in Denison.

“Who would have thought an 82-year old woman, that woman being my mom, would go in for what they classified as a simple procedure and they’d burn her like that?”

Selah Schulze suffered burns to her scalp, face, neck, chest and right breast. She was transferned to Parkland Hospital and eventually underwent several more surgeries.

She spent the next year in and out of the hospital.

Her family often visited her and videotaped the struggle she faced. In one clip, after Ms. Schulze had undergone reconstructive surgery, she talks about one night she vividly remembers just two weeks after the burn.

She’d gone home but her family rushed her back to the hospital because she says the pain was unbearable. Sitting on a couch, she stared into the home video camera.

“They even suggested to somebody I have a living will. It was the most horrible pain,” Selah looked down and then wiped away tears behind her glasses. She looked back up at the camera and said, “I thought ‘I wish I could be home to die.’”

Ms. Schulze survived that night. She lived almost another year. When she passed away in May 2010, her children and grandchildren said she had never been the same since the fire.

Selah Schulz’s children are suing Texoma Medical Center and the Dallas doctors who operated on their mother. Kay Van Wey filed this case also.

“I was really surprised when the Schulze family contacted me. I thought medical knowledge had advanced further…When the Velasquez family contacted me in 2001 it was already considered to be a completely preventable experience. Since 2001, there’s been more and more written about it in all the journals and continuing education seminars.”

Van Wey filed the lawsuit last month. The Schulze family says Ms. Schulze suffered scarring, loss of mobility in her mouth area and nose and enormous pain.

Van Wey alleges the nurses did not control the fuel sources or the fire would not have occurred. They suspect the nurses did not allow the prepping solution to dry before they draped Ms.Schulze.

Van Wey alleges the anesthesiologist did not control and minimize the oxidizer. And, they believe the cardiologist also used unnecessarily high settings on the electrosurgical unit which caused an arc of electrical current.

“Most of the cases I reviewed are largely preventable, “ said Dr. Charles Cowles of MD Anderson Hospital in Houston.

Cowles is a former firefighter turned anesthesiologist who’s made it his mission to stop this fires. He is also the Assistant Professor of the Department of Anesthesiology and Perioperative Medicine and an advisor to Anesthesia Patient Safety Foundation.

“If we can’t make it safer, we can communicate better,” he said. “This is a high risk.”

Cowles believes some surgical teams do not know enough about how to prevent this danger.

He is involved in several educational inititatives led by professional societies working to bring surgical teams up to speed on how to prevent fires. “When I go to national and state meetings, folks will say , you know, I never thought about this, I never thought this oculd happen, “ Cowles said.

“It’s simple chemistry and physics. If you remove one of the elements of that fire triangle you learn about, it removes the risk and the fire will go away.”

Cowles also says hospitals are part of the problem;Keeping the public, and even their surgical teams, in the dark.

“We, as far as standardized reporting, in the medical community, are not where we need to be,” Dr. Cowles say Texas, like most states, makes it difficult to track the fires. While a handful of states have some type of adverse event reporting systems, only the state of Pennsylvania requires mandatory reporting of these incidents in a database that is accessible by patients.

CBS 11 has learned some incident reporting may soon change in Texas. A spokesperson with the Texas Department of Health says recently passed legislation will require reporting of preventable adverse events.

House Bill 1 of the 82nd Legislature appropriated almost $1.8 million for TDH to implement a system for the collection of preventable adverse event data. TDH is now working towards making the data accessible to consumers.

Senate Bill 203 of the 81st Legislature added the requirement for preventable adverse event data collection from hospitals and ambulatory surgical centers, but there was no funding available for that specific effort.

ECRI Institute is an independent nonprofit organization that focuses on researching ways to improve safety and quality of patient care. It has complied the only available statistics on the number of operating fires that occur.

By compiling Pennsylvania’s data and then using a number of formulas to relate it to surgeries and populations in all other states, ECRI estimates that 550-to-650 surgical fires occur each year in the United States. It estimates 20 to  30 of those result in injuries and disfigurement. ECRI says one or two surgical fires result in fatalities.

Dr. Cowles says patients have a right to ask these questions:

  • Am I having the type of surgery that puts me at risk for surgical fires?
  • If so, what are you doing to prevent it from happening?
  • If I am getting oxygen, is it absolutely needed?
  • What is the safest place to perform my procedure…office or operating room?
  • What risks are involved in this procedure?

The hospital and medical team are denying any negligence in court documents filed last month. So did doctors did in the Andre Velesquez’ case a decade ago.

Today, Andre is a healthy high school senior whose parents cannot believe another family is facing the same fight. “A family should not have to go through what we all went through,” Teresa Velezsquez said.

Texoma Medical Center did not comment on the Schulze accusations because of pending litigation.

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