Reader response

Myron Yaster MD

From Bishr Haydar, MD, CS Mott Children's Hospital / University of Michigan / Michigan Medicine Re: Thursday 5/22/2025 "Straight Line Scoring (SLS)"

Excellent piece. I agree completely with the final thought of having a cadre of well trained evaluators. Most departments probably already have this, to some degree. I can think of a handful of my colleagues who always have deep insights into individual trainee and student performance.

These outstanding evaluators deserve some kind of award/recognition, additional time to do this important task, financial incentives, or ideally all three. Rewarding them can help encourage further skill development, which would benefit everyone in the department. We rely on their discerning eyes to help trainees grow and to guide faculty hiring and/or trainee remediation.

We can start today. It's not hard for program directors or other leaders to start giving commendations for "excellence in evaluation" to those who already do the lion's share of this work. Many departments already give teaching awards; this is also very important.

Separately, perhaps further research and technology can help here. We can identify markers of meaningful evaluations, so that we can weigh them more heavily than empty SLS / "good job" evaluations.

From Jeffrey Feldman, MD, MSE, FASA Commentary on High flow nasal oxygen and airway fires

The PAAD of May 15, 2025 on High flow nasal oxygen and airway fires does not emphasize the key consideration that FIRES ON OR IN THE PATIENT SHOULD BE A NEVER EVENT. Videos and other materials produced by the Anesthesia Patient Safety Foundation (APSF) on OR fires specifically focus primarily on prevention, rather than management, in an effort to focus on practices that will make OR fires a never event. (1). One can see from the table published in the BJA article listing fires while using HFNO that 100% oxygen was common to every case.(2) We have known the role of oxygen in serious OR fires for more than 25 years, yet practitioners continue to follow an anesthetic plan that includes administering a high concentration of oxygen during procedures on the upper part of the body when a heat source is present.

An oxidizer is an essential component of the fire triad which also includes heat and a fuel. Oxygen is the most prevalent oxidizer and prone to misuse since a source of 100% oxygen is readily available in the operating room, and commonly administered, whether that concentration is needed to prevent hypoxemia or not. We know that 100% oxygen causes fires to burn hotter and faster than when the oxygen concentration is limited, and also, materials common in the OR, like PVC, only become fuels for supporting fire in the presence of an enriched oxygen concentration. A recent publication, based upon decades of work by ECRI, reviews the rationale for recommending that delivered oxygen concentration be less than 30% as a key strategy for preventing fires. (3) An important principle emphasized in that article is “surface fiber flame propagation” which occurs in the presence of high concentrations of oxygen. This phenomenon is depicted in a video attached to the article demonstrating how fire spreads rapidly from the ignition source in the presence of enriched oxygen. Patients have the potential for a burn injury when any heat source is used, but serious injury from fire is always related to the presence of an enriched oxygen concentration.

While it may be useful to understand the principles of OR fire management since lets face it, shithappens, education on prevention should be the primary focus combined with intentional practices that identify high-risk fire scenarios to the entire team, and providing clinical care in those scenarios that either limits the delivered oxygen concentration to less than 30%, or isolates the enriched oxygen concentration from a potential heat source by controlling the airway.

Given the devastating consequences of death or permanent disfigurement that results from OR fires in the presence of enriched oxygen, it is virtually impossible to imagine a scenario where the benefit of administering a high concentration of oxygen in a procedure at high risk for fire outweighs the attendant fire risk. HFNO has the potential to be a valuable clinical tool and the authors of the BJA article are correct that there is much to learn. Fortunately, commercial HFNO systems have oxygen blenders that make it possible to adjust the delivered oxygen concentration. Many patients can be managed with oxygen concentrations of 30% or less without the risk of life-threatening hypoxemia. HFNO may even make it easier to use lower oxygen concentrations by reducing the upper airway obstruction associated with anesthesia, becoming a valuable tool for managing patients when there is a high risk for fire. HFNO systems are quite likely to become increasingly available in the operating room making it possible to do research and refine practice.

Let me reiterate this: Serious surgical fires should be a never event. Prevention requires that the concentration of oxygen delivered in high-risk scenarios be less than 30%, or the airway should be controlled to isolate the oxygen from the heat source.

PS from Myron: as I wrote in the original PAAD: For those of you who work with trainees thinking fire risk thru and practicing with the Pedi Crisis app should be a routine teaching moment whenever you do a T&A or use HFNO during procedures.

References

1. SURGICAL AND OPERATING ROOM (OR) FIRES – A PREVENTABLE PROBLEM. APSF website. https://www.apsf.org/videos/preventing-surgical-fires/. Accessed May 21, 2025.

2. Lyons C, Jonsson Fagerlund M. Airway fires during use of high-flow nasal oxygen: a cause for concern. Br J Anaesth. 2025 Apr;134(4):893-897. doi: 10.1016/j.bja.2024.12.021. Epub 2025 Feb 21. PMID: 40118580; PMCID: PMC11947558.

3. Bruley ME, Feldman JM. Assessing Fire Risk in Surgery: Why Limit Open Oxygen Delivery to 30%. APSF Newsletter 2025;40:22. https://www.apsf.org/article/assessing-fire-risk-in-surgery-why-limit-open-oxygen-delivery-to-30/.

From Myron: follow up on Feb 25, 2025 PAAD

On May 13, 2025, the U.S. Centers for Disease Control and Prevention (CDC) issued a nationwide alert about bloodstream infections traced back to contaminated, non-sterile, multi-use ultrasound gel, a real-world safety breach that puts everyday procedures at risk. (https://www.cdc.gov/healthcare-associated-infections/bulletins/outbreak-ultrasound-gel.html )

As we discussed in the previous PAAD, while sterile gel addresses one contamination source, it doesn’t address 2 other major vectors: the ultrasound transducer itself and your hands. Probes easily transfer pathogens from one patient to the next or back to the operator’s hands. Unfortunately, we know that adherence to using probe covers remains variable, and clinicians continue to improvise with transparent dressings like Tegaderm®. These are not approved as probe covers, and as discussed in our review of the ASRA guidelines, ASRA insists on sterile one time use probe covers. Further, Tegaderm may leave residue on the probe, which can even damage the probe over time.