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MP900313990The surgical burn death of an elderly woman inspired her daughter to create a website addressing the subject for other potential and actual victims and government and private sector policymakers to reform emergency room procedures.

In December 2002, the deceased woman, Catherine Reuter, 74, who was in surgery for a tracheotomy, sustained second and third-degree burns to her face and upper airway after a cauterizing tool triggered a fire when it came in contact with the alcohol-based disinfectant meant to prepare her for the operation.

Ultimately, the event caused powerful infections, kidney failure and long-term sedation with painkillers and anesthesia. Reuter never truly survived the incident and died in hospital after two years.

Her daughter, Cathy Lake, a homemaker and now surgical burn activist, said that she believed her mother was the only person to undergo the tragedy and learned about common occurrences in other hospitals and medical facilities nationwide. Lake said that hospital administrators indicated that Reuter’s death was caused by “spontaneous combustion,” a misleading determination that downplayed the cause and gravity of the incident.

Lake said the fire started on her right shoulder and traveled to the right side of her face to her ear, her eyes, her mouth, her nose and her scalp. As a result, her mother informed her that she would not survive the event.

Reuter then developed infections such as MRSA, VRE and C-Diff.

MRSA stands for “methicillin-resistant staphylococcus aureus,” a form of bacteria causing infections in different parts of the body. This strain is harder to treat than most other forms of staph as it resists the most commonly-used antibiotics.

Symptoms of MRSA infection depend on the impacted part of the body. Most likely, it manifests itself as mild skin infections such as sores or boils. However it can also lead to more serious skin infections or infect wounds brought on by surgery, the bloodstream, the lungs or the urinary tract.

VRE stands for “vancomycin-resistant enterococci”. This, too, has grown resistant to several antibiotics, including vancomyin, which is used to treat it. This brand of bacteria reside in our intestines and skin without trouble. However, when resistant to antibiotics, they can lead to infections in any part of the body , including the intestines, the urinary tract and wounds, in individuals who are ill or weak.

The human digestive tract contains over 1,000 species of bacteria, some harmful and others helpful. However, an event inside the human body can increase the number of these microorganisms in the gut, lead them to grow out of control and make an person sick.

A prime example of such bacteria is clostridium difficile (C. difficile or C. diff). As they grow, the bacteria release poisons attacking the intestinal lining, causing a condition known as clostridium difficile colitis.

In fact, C. diff is one of the greatest causes of diarrhea in the country. They can range from mild to life-threatening. Mild symptoms can mean watery diarrhea, three or more times a day for days, with abdominal pain or tenderness. Severe forms include watery diarrhea up to 15 times a day, severe abdominal pain, loss of appetite, fever, blood or pus or weight loss.

The treatment of Reuter’s burns led to kidney failure and dialysis three times a week, her daughter Lake said. She added ventilation was needed because her mother was administered painkillers for seven weeks for the pain.

In February 2003, Lake’s mother was sent to a facility that had an acute pulmonary rehabilitation unit where she received higher quality care, she said. Lake added that mistakes were made there but the physician in question expressed sorrow and made an effort to correct them immediately.

By May 2004, Lake’s mother was placed in Western Maryland Hospital Center, a hospital for chronic illness, where she had a broken arm. After her arm was broken, Reuter was moved to another hospital because the critical illness hospital would not re-admit her.

On Dec. 17, 2004, her mother died at a Maryland hospital.  Lake said the hospital had her believe that Reuter died of natural causes but she later learned the truth. In reality, Reuter was removed from the dialysis unit and, when she returned, her nurse did not connect back to the wall oxygen. The oxygen tank no longer held oxygen and Reuter died hooked up to an empty tank with no call light to ask for help.

In the end, when Lake asked her mother what she could do to help, Reuter replied that there was nothing but made it her final wish that her daughter educate others about medical errors and surgical burns so that no one else would suffer as she did.

To carry out her mother’s wishes, Lake started the website, Surgicalfire.org, as a resource for medical error and surgical burn victims. Sharing her personal story and that of others, she said that hospitals and medical facilities must include the steps for surgical fire prevention as part of their operating room procedures.

Lake said, if such measures were in place at the time of her mother’s illness, she would have not suffered as she did. Her site cited such statistics as 40 percent of Americans and more than one-third doctors having undergone such mistakes.

The Food and Drug Administration reports that such surgical mishaps occur 550 to 600 times a year in hospitals and medical facilities across the country. More reliable figures are hard to discover with under-reporting by facilities and tendencies to cover up fires for fear of legal reprisals.

Burn experts say a problem starts during surgery when an electrical tool or laser ignites oxygen and such implements are used more in different types of medical procedures. There must also be a combustible source for an accident to take place, which usually means body tissue or paper hospital drapes serving as electrical current conductors and oxygen making an explosion.

Experts advise patients to talk about fire prevention with surgical staff as they are being prepared for an operation. Surgical team members tend to forget some measures as they are working or don’t pay attention. Lake agrees with these regulations, stating that she follows them herself as she has had surgeries since the death of her mother and would not allow anyone to operate on her without them.

(NOTE: As a regular feature, PharmPsych.com is offering up summaries of legal medical malpractice suits, especially in the field of pharmacy and other healthcare specialties. Each summary will detail the narrative for the suit, the reasons, outcomes, financial compensation and settlements involved. The summaries will also discuss the lessons learned by medical professionals.)

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Last updated October 2014