Fire in the hole: An endotracheal tube fire

Abstract

The author, having recently served as an expert witness on the case described in this paper, is in an excellent position to share the details of the pre- and mid-operation decisions and actions that led to a catastrophic endotracheal (ET) tube fire. In preparation for trial, information was gathered from depositions of virtually all persons involved in this case. While concerns about the possibility of laser-induced penetration and ignition of an ET tube were first expressed in 1972, papers reporting such fires did not begin to appear until 1976. Following a brief overview of the history of the development of laser-safe airway surgical equipment and procedures, case details (sans names and location) will be presented. It will be clear that key decisions and the following actions by doctors and hospital staff were contrary to well-documented protocol presented in medical journals, physician training and ANSI Z136.3. Awareness of these protocol and the importance of adhering to them must be stressed (and evidently stressed again and again) to both physicians and other hospital staff.The author, having recently served as an expert witness on the case described in this paper, is in an excellent position to share the details of the pre- and mid-operation decisions and actions that led to a catastrophic endotracheal (ET) tube fire. In preparation for trial, information was gathered from depositions of virtually all persons involved in this case. While concerns about the possibility of laser-induced penetration and ignition of an ET tube were first expressed in 1972, papers reporting such fires did not begin to appear until 1976. Following a brief overview of the history of the development of laser-safe airway surgical equipment and procedures, case details (sans names and location) will be presented. It will be clear that key decisions and the following actions by doctors and hospital staff were contrary to well-documented protocol presented in medical journals, physician training and ANSI Z136.3. Awareness of these protocol and the importance of adhering to them must be stressed (and ev...