A routine operation, performed dozens of times before in the same room, with the same surgical team, turned into tragedy Thursday morning at Cedars-Sinai Medical Center when a flash fire engulfed a 15-day-old boy as he underwent a life-saving procedure.
Ripping away a flaming breathing tube, a doctor rushed the 2-pound baby, born 4 months premature, from the neonatal operating room to an incubator where physicians tried unsuccessfully for 90 minutes to revive the infant, officials said.
The fire, which was immediately extinguished, broke out after surgeons used a cauterizer--a pen-like electric instrument that emits a tiny spark--to stop the bleeding from the first incision.
One of the doctors present said that gauze underneath a surgical drape burst into flames, igniting the boy’s breathing tube.
Attending physician Arie Alkalay said: “The bed was on flame. I took the baby out of the flames.”
“Everyone is so puzzled,” medical center spokesman Ron Wise said. “Nothing was unusual. This is a group that knows every aspect of this procedure.”
The boy, identified by coroners only as Baby De Jesus, suffered second-degree burns over 60% of his body. No one on the seven-member surgical team was injured.
“We really aren’t sure what happened,” pediatric director David Rimoin said at a press conference on the steps of the West Los Angeles hospital.
The boy had gone into heart failure before the operation began at 8 a.m.
“How much the fire caused this (death) I can’t say,” Rimoin said.
Although doctors described the surgery as commonplace for premature infants, usually taking only 30 minutes, it was nevertheless a life-saving operation.
Before birth a small duct connects the aorta, the artery leaving the left side of the heart, and the pulmonary artery, which leaves the right side of the heart. When the duct fails to close after birth--a condition known as patent ductus arteriosus and common to about half of all premature infants--medication usually induces closure, doctors said. When it does not, surgery is necessary to stop blood from being pumped into the lungs.
If the operation had been successful, Wise said the boy would have still faced trouble because of his small size. But, he added, the neonatal ward has a good record, and such infants routinely survive.
The procedure has been performed about 50 times at Cedars-Sinai, Rimoin said. The boy might have lived for a matter of hours or days without the surgery, he added. An investigation is under way. Rimoin said “every piece of equipment” will be checked.
Officials said there are no plans to suspend the procedure.
“If it’s a life-saving measure, what do you do?” Wise asked.