East Naples man among hundreds who catch fire each year in operating rooms

Frank Komorowski

Frank Komorowski

Submitted photo 
 Frank Komorowski awoke from a "twilight" anesthesia and found himself on fire after nurses allegedly told a surgeon he could operate, although an alcohol solution wasn't dry. That caused an electrical cauterizing device to ignite.

Submitted photo Frank Komorowski awoke from a "twilight" anesthesia and found himself on fire after nurses allegedly told a surgeon he could operate, although an alcohol solution wasn't dry. That caused an electrical cauterizing device to ignite.

— Frank Komorowski of East Naples was lying in a Naples operating room, under the sleepy twilight of anesthesia, when he heard a nurse yelling.

"Oh, my God! He's on fire!" Komorowski testified, recounting her screams, in his deposition. "And the next thing I remember is … smelling my skin burning."

Komorowski, then 68, suffered second-degree burns to his shoulder, chest and neck, and his hair was singed after he underwent surgery on March 19, 2008, to insert a pacemaker at NCH Downtown Naples Hospital.

Operating room fires are rare, but they can be devastating, causing severe burns, gross facial disfigurement, even death. Hospital employees also live with the memories and trauma — and expensive equipment can be damaged.

On Tuesday, the federal Food and Drug Administration will hold a webinar to help stop surgical fires, which it calls a well-understood, but persistent problem. FDA officials say they're preventable if a surgical team works together to reduce the risk.

Komorowski's case in Collier County is among 550 to 650 surgical fires that occur yearly, according to the FDA Safety Initiative, which began a push to educate health-care professionals in October.

"The bottom line is they set the man on fire," Komorowski's attorney, Mark Weinstein of Weston, argued during a Collier Circuit Court hearing last week. "It is universally acknowledged this does not happen in the absence of negligence."

NCH attorney Ashley Withers of Naples maintained NCH wasn't negligent because the surgeon, who isn't a hospital employee, caused it. NCH's expert believes oxygen under the surgical drape caused it to ignite.

Citing the depositions of the nurses, none of whom took responsibility, and the surgeon, Weinstein said they all agreed an alcohol-based antiseptic, DuraPrep, hadn't dried before nurses told the surgeon he could operate, which caused an electrical cauterizing device to ignite.

Another nurse said the burns occurred where alcohol was applied and pooled around his neck.

Collier Circuit Judge Hugh D. Hayes on the bench in a 2009 case.  Michel Fortier/Staff

Photo by MICHEL FORTIER

Collier Circuit Judge Hugh D. Hayes on the bench in a 2009 case. Michel Fortier/Staff

Collier Circuit Judge Hugh Hayes ruled there was adequate evidence to prove the hospital was liable no matter what caused it.

"The patient is in the defendant's custody and control," Hayes said. "The patient is sedated — in essence, out of this world."

The ruling means a jury only needs to determine how much money Komorowski and his wife, Elizabeth Szyymczak, should be compensated, including for pain and suffering.

* * * * *

Like a medical detective, Mark Bruley is often called by a hospital to investigate accidents and medical device problems, including why a fire occurred, and recommend preventative measures.

Bruley, vice president of Accident and Forensic Investigations at Pennsylvania-based ECRI, is known as a world expert in surgical fires. He's spent 37 years at the former Emergency Care Research Institute, an independent, nonprofit group that tests medical devices and researches how to improve patient care.

"In most of these cases, it's about oxygen," said Bruley, who has investigated four patient burning cases this year, all caused by oxygen. "The question is why are you using oxygen and not air?"

News reports show oxygen was to blame in three recent cases that made headlines:

■ In November, a 29-year-old Florida woman was having surgery to remove three cysts on her head when her face erupted in flames at an Okaloosa County hospital. The cauterizing tool erupted in flames after being fueled by her oxygen mask.

■ In June 2011, a surgeon was performing a tracheotomy at a New York hospital when his electronic scalpel, which sparks, set off the oxygen supply and prompted a minor explosion that caused severe burns on a 52-year-old patient's neck and chest.

■ In May 2011, a Pennsylvania jury found a nurse anesthetist negligent and liable for $250,000 in damages for injuries to a 72-year-old woman who suffered second-degree burns to her face and chest, and burns to her larynx, trachea and lungs, in September 2006. Testimony showed he administered extra oxygen but didn't tell the surgeon, who activated an electrocautery device that ignited the surgical drapes and prompted a flash fire at a Pennsylvania hospital.

According to the Anesthesia Patient Safety Foundation, 65 percent of burns involve the head, face, neck and upper body and the rest occur elsewhere on, or in, the body. If it occurs in an airway, it can be fatal.

For a surgical fire to occur, the FDA says three factors must be present: an oxidizer, such as oxygen and nitrous oxide; an ignition source, including lasers, drills, cauterizing devices; and a fuel, such as tracheal tubes, sponges and drapes.

Operating rooms have a heavy oxygen concentration, which increases if oxygen is used during surgery.

"The high oxygen concentration can cause that fine body hair to be extremely flammable — a ripple of flames that spreads across the skin, traveling at 10 feet per second," Bruley said. "Oxygen makes other things a fuel."

"The high oxygen concentration can cause that fine body hair to be extremely flammable — a ripple of flames that spreads across the skin, traveling at 10 feet per second," said Mark Bruley, a world expert in surgical fires. "Oxygen makes other things a fuel."

Many blame alcohol because it's flammable, but Bruley said it causes only about 4 percent of fires — and those shouldn't occur if the alcohol solution is left to dry for three minutes, as manufacturers recommend. If wet, a red, green or blue stain is left on surgical drapes or tape.

Alcohol was to blame when a Syracuse University professor undergoing a C-section two years ago suffered third-degree burns. News reports say DuraPrep was ignited by a cauterizing device.

An alcohol-based antiseptic that wasn't given time to dry caused 72-year-old Catherine Reuter to suffer second- and third-degree burns to her upper airway, chest, throat, face, and ear, during a tracheal operation in Washington, D.C., in December 2002. She was sedated for seven weeks due to pain and suffered multiple infections until she died two years later, never returning home. Her story and photos are featured on her daughter's site, surgicalfire.org, which she created to raise awareness.

"Every time I hear these stories, it breaks my heart because they are 100 percent preventable," Catherine Reuter Lake of Maryland told the Daily News. "I'm not out there to demonize hospitals, but they need to be held accountable.

"I was so horrified over the last images I had of my mom," she said, adding that the retired kindergarten teacher wasn't angry, but wanted her daughter to raise awareness. "She said they just weren't educated ... She said if it could happen to me, it could happen to other people ... That's the only thing you can do for me so more don't suffer."

© 2012 Naples Daily News. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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Comments » 23

sunburnt writes:

NCH - Never Come Home

osamaisdead writes:

in response to sunburnt:

NCH - Never Come Home

Or, as the Mexican patients say "No cash here"

scubatenor writes:

It's simple. Ban all flammable liquids from the Operating room (especially in the proximity of cauterizing scalpels) as there are other alternatives to these items. Or the question should be, why were the cheaper (and flammable) sterilization products still being used?

glennhamilton writes:

in response to sunburnt:

NCH - Never Come Home

good one!

nightranger writes:

NCH = No Chance Hospital

cozyboy writes:

NCH ...NOT Coming Home

greathornedlizard writes:

thanks, God for the anesthesia!

Iamman0318 writes:

Hahaha. You people are so funny. Never come home. Find something new to talk about. That is so old and just dumb now. Gees what about all the people who do come home. It's a hospital that's what happens people sometimes die its apart of life!!!!

Bramble writes:

Dr. Smokey says, "Only you can prevent OR fires."

Hospital and staff all say it wasn't their responsibility. That's scary. Always trying ways to be unaccountable, until it's time for patient to pay up.

garyOfTheGulf writes:

Don't eat Beans before surgery!!

Spock_is_logical writes:

Live long and put out that joint before you operate doc.

youwilltapout writes:

You are going to get MRSA if you go to NCH and now you have to worry about becoming a crispy critter?

LGoldstein writes:

If operating room fires are well established why not have surgical patients wear a fireproof suit as some firefighters do? The suit could be modified with zippers to accommodate the particular operation. Also they could be sanitized and reused while costs transferred to private insurance and Medicare. This would save many lives and avoid future embarrassment of the medical profession.

TruePatriot writes:

For all the NCH haters, funny how you still show up at the front door for help or bring your family member there for them to save their life. Just Saying. Never Come Home? Original . Never heard that before.

InCognitogirl writes:

in response to Iamman0318:

Hahaha. You people are so funny. Never come home. Find something new to talk about. That is so old and just dumb now. Gees what about all the people who do come home. It's a hospital that's what happens people sometimes die its apart of life!!!!

They usually don't die of burns in the hospital, and it still means Never Come Home, old news or not. Hooray for the people who do go home. Dyi g in the hospital from fire is not a part of life,natural causes is more like it. Get real already

HAP writes:

The worst hospital.

Raminar_Dixon writes:

in response to LGoldstein:

If operating room fires are well established why not have surgical patients wear a fireproof suit as some firefighters do? The suit could be modified with zippers to accommodate the particular operation. Also they could be sanitized and reused while costs transferred to private insurance and Medicare. This would save many lives and avoid future embarrassment of the medical profession.

I'm at a loss for words of just how ignorant your idea is.

unfatcat writes:

in response to LGoldstein:

If operating room fires are well established why not have surgical patients wear a fireproof suit as some firefighters do? The suit could be modified with zippers to accommodate the particular operation. Also they could be sanitized and reused while costs transferred to private insurance and Medicare. This would save many lives and avoid future embarrassment of the medical profession.

How many lives would be saved by your modified-zipper suit? Perhaps this suit could qualify as a green manufacturer while saving lives (you say), along with skin, bed, curtains, and jobs.

If, in fact, you are not joking, when an aspirin costs $50 at the hospital, imagine how much a green modified-zipper suit would cost patients. Besides the medical world only knows how to work with the transparent nightshirt with matching slippers.

dizwiz21 writes:

Quote:

"NCH attorney Ashley Withers of Naples maintained NCH wasn't negligent because the surgeon, who isn't a hospital employee, caused it."

Wow! What a lawyer's way to 'pass-the-buck'. Im sure the surgeon works for a 'physician's group' of some sort.

If the hospital allows the surgeon to use the hospital's equipment, facilities and their other staff they are also liable. There is plenty of precedent showing so.

Maybe 'medical tourism' to places like cleveland make sense if the care here is so bad.

Win the lawsuit!

bana writes:

"Yeah, it was the patients fault,we did not see him light up the smokes he smuggled into the prep and operating rooms. It's not our fault."- Goldberg,Goldberg,Goldberg & O'Brien, O'Brien speaking.

nitestik writes:

"NCH attorney Ashley Withers of Naples maintained NCH wasn't negligent because the surgeon, who isn't a hospital employee, caused it."

Did Ashley ever actually attend law school? As regards an injured third person, it doesn't matter whether the doctor is or isn't a hospital employee.

bananas8187 writes:

in response to dizwiz21:

Quote:

"NCH attorney Ashley Withers of Naples maintained NCH wasn't negligent because the surgeon, who isn't a hospital employee, caused it."

Wow! What a lawyer's way to 'pass-the-buck'. Im sure the surgeon works for a 'physician's group' of some sort.

If the hospital allows the surgeon to use the hospital's equipment, facilities and their other staff they are also liable. There is plenty of precedent showing so.

Maybe 'medical tourism' to places like cleveland make sense if the care here is so bad.

Win the lawsuit!

I've done "medical tourism" and recommend it.

But, one doesn't have to travel all that far.

The Mayo Clinic in Jacksonville is light years better than anything within 100 miles of Naples. Seriously, the difference is remarkable.

mewillandale writes:

in response to HAP:

The worst hospital.

Negative Nellie,

Do you ever have anything good to say? Or is your soapbox just that small?

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