Surgical Tool Cited in Fatal Fire at UCLA

A 26-year-old patient who died in a UCLA operating room in May was the second Los Angeles victim in less than two years to perish in a flash fire caused by a spark-producing surgical tool, the Los Angeles Fire Department said Tuesday.

The Fire Department, the UCLA Medical Center and three other agencies released results of a four-month investigation into the death of Angela Hernandez, who was being treated for massive heart and liver damage she had suffered in a traffic accident when material draped over her body caught fire.

The announcement was made by arson investigation officials during a news conference that included statements from hospital officials, representatives from the company that manufactures the cauterizing instrument that sparked the blaze, county health services officials and representatives of the state fire marshal’s office.

The agencies concurred in the Fire Department’s finding that the blaze was accidental.

In October, 1988, a cauterizing device sparked a fire that caused the death of a 15-day-old infant at Cedars-Sinai Medical Center. Surgeons using the instrument accidentally ignited gauze that covered the infant as he underwent heart surgery.

The pen-sized tool, common in operating rooms since the 1920s, uses an electric current to emit a constant stream of sparks that sear shut blood vessels and lessen bleeding during surgery. In an oxygen-rich operating room, the sparks can easily ignite cloth materials, investigators said.

In the UCLA fire, the cauterizing tool was not in use when the fire began, said Fire Department Battalion Chief William Burmester, who oversaw an investigation into the fire’s cause. The cauterizing instrument, which was connected to a power source through a cord, dangled from the instrument tray as nurses and doctors maneuvered around the operating table.

According to surgery room procedure, once an instrument falls out of the physicians’ field of vision, it is considered contaminated and is disregarded. After the cauterizing tool was dislodged from its holster and rendered contaminated, one member of the operating staff “probably brushed or depressed the tool against the leg of the (instrument) tray,” triggering sparks, Burmester said.

Fire Department and hospital officials declined to identify the individuals responsible for dislodging or triggering the instrument.

“We found no negligence,” Burmester said. “The instrument was not in a wrong or illegal place. . . . It was just there.”

The department issued a list of recommendations for establishing state safety requirements for operating rooms where “high-energy” surgical equipment is used.

UCLA officials also said that Hernandez suffered from “what were probably three fatal injuries,” and that her chances of survival before the fire were uncertain.