Electrocution in the Operating Room

Abstract

The manner in which a patient sustained an electrical shock injury from improperly wired equipment during the course of an operation was described in order to acquaint others with a potentially hazardous situation. A patient requiring surgical treatment had the ground plate of an electrocautery unit placed under her buttocks and the electrodes of an EKG unit attached to her shoulders and her precordium. During the course of the operation, the EKG monitor was subject to electrical interference. In an effort to correct the problem, the surgeon instructed the nurse to unplug the monitor and reinsert the plug into a 2nd wall receptable. As the plug was reinserted, the physician suffered a minor shock and the patient experienced an intense shock. She became cyanotic and her pulse stopped. The patient was revived and later recovered completely. Inspection of the equipment revealed that the EKG's power plug was incorrectly wired. The chassis ground was connected to the neutral plug instead of the ground plug. Furthermore, the 2nd wall receptacle was wired with reversed polarity. When the plug was inserted into the 2nd receptacle, a 110 volt alternating current developed between the precoidal EKG lead and the ground plate. If the monitor had been plugged into the 2nd receptacle prior to the operation, the monitor would not have functioned. The technician probably would have assumed that the machine was not in working order and would have substitued another machine. In order to minimize electrical shocks, EKG leads should be applied only to the extremities and not to the precordium region.