Surgical fires are a fairly rare complication in operating rooms. In fact, in the United States, only an estimated 90-100 surgical fires occur each year. So, while infrequent, these devasting incidents can still happen, and they often result in severe, catastrophic injuries. In this blog, we provide a deep dive into the case Ignelzi v. MAK Anesthesia and Sheel Todd, MD. We’ll explore the mechanics of surgical fires, their prevention, and how the Ignelzi family navigated a case in pursuit of justice for a young girl.
The Case: A Routine Procedure Turned Tragic
In September 2019, 10-year-old Anorah Ignelzi underwent a routine outpatient procedure at Marietta Eye Clinic in Cobb County to remove a tiny benign lesion from her eyelid. The procedure required the use of pure oxygen–however, the anesthesiologist, Dr. Sheel Todd, failed to reduce and clear the oxygen-rich air in the surgical field.
When the surgeon turned on the Bovie, an electric cautery to stop the bleeding, a spark from the device ignited the oxygen and caused a fireball to erupt around Anorah’s face. As a result, she suffered second degree burns on her head, face, and neck, which required skin graft surgery, therapy for PTSD and additional surgeries.
Surgical fires occur when three key elements—oxidizer, fuel, and an ignition source—combine in an operating room. This “fire triad” includes:
- Oxidizers: Oxygen or nitrous oxide used in anesthesia.
- Fuels: Flammable materials like drapes, gauze, or alcohol-based antiseptics.
- Ignition Sources: High-heat equipment such as electrosurgical units (ESUs) or lasers.
These fires are most common in oxygen-enriched environments, where even materials that don’t usually ignite in ambient air can burn intensely. For instance, a small spark from an ESU can ignite surgical drapes soaked in oxygen, resulting in flames that spread rapidly.
MAK Anesthesia Negligence: A Failure of Communication and Safety Protocols
The negligence in the Ignelzi case revolves around failures by the surgical team to prevent a catastrophic operating room fire during a routine outpatient procedure.
Anesthesiologists, such as Dr. Todd in this case, are tasked with maintaining safety standards, including communicating potential risks, particularly when oxygen-rich air and ignition sources like the Bovie are used.
Dr. Todd failed to warn the surgical team of her plan to introduce concentrated oxygen into the surgical field and neglected to inquire about the potential use of a Bovie during preoperative discussions. Despite clear opportunities to issue warnings—such as during preoperative communications, the procedure’s timeout, and even when the surgeon requested the Bovie—Dr. Todd remained silent, permitting the dangerous convergence of concentrated oxygen and the ignition source.
This failure to meet the standard of care directly caused a surgical fire, resulting in severe physical injuries, psychological trauma, and pain for Anorah.
How to Prevent Surgical Fires
When a fire in the operating room occurs, the medical outcomes are often catastrophic for the injured patient, with severe legal and economic consequences for the surgical team and the facility. Most OR fires are preventable with proper protocols like risk assessment, effective communication among surgical team members, and taking preventive measures based on risk level.
The most important fire-prevention measure is communication among surgical team members regarding potential fire risks and plans to manage risks. A breakdown or failure in communication is a key factor in most OR fires – like what we see in the Ignelzi case.
As a patient, you can start discussions with your healthcare team before surgery. You might consider asking the following questions to ensure safety measures are in place:
- Emergency Preparedness: Ask your doctor if they are familiar with the emergency protocols, including specific plans for managing surgical fires.
- Risk Awareness: If your surgeon or healthcare provider hasn’t mentioned the risk of surgical fires, bring it up to ensure the topic is addressed.
- Prevention Procedures: Inquire about the steps the surgical team takes to minimize fire risks.
These conversations can help build confidence in your care and ensure all safety precautions are met.
At Bell Law Firm, we continue to fight to bring our clients the justice they deserve. Anorah’s story and case settlement help bring awareness and adherence to safety protocols in all surgical settings. By prioritizing patient safety, healthcare providers can prevent such tragedies and ensure better outcomes for all.
To view the full complaint on the case, click here.