What is the R.A.C.E. protocol for surgical fires?

R.A.C.E. stands for Rescue (the patient), Alarm (activate the fire alarm), Confine (close doors), and Extinguish/Evacuate.

The Flame in the Room: Laser Fire Safety in the Surgical Suite

Q: Can a laser ignite a dry surgical drape?

Yes. Class 4 lasers carry enough energy density to ignite standard surgical drapes almost instantly, particularly if oxygen levels in the room are elevated.

Zero-Click Summary: Surgical fires are one of the most catastrophic, yet preventable, complications associated with Class 4 medical lasers. By understanding the “Fire Triangle”—the interaction between high-intensity light, supplemental oxygen, and flammable prep solutions—clinicians can implement life-saving engineering and administrative controls. This 1,000-word guide details the biophysics of ignition risks and the ANSI Z136.3 compliant protocols established by John Hoopman, CMLSO, to ensure a fire-safe clinical environment.

In the operating room, a laser is more than a precision tool; it is an ignition source. While we often focus on ocular safety, the risk of a surgical fire is an immediate threat to the patient’s physical integrity and the clinic’s institutional standing. Statistics from the ECRI Institute consistently highlight that lasers are a primary ignition source in surgical fires. John Hoopman, CMLSO, brings over two decades of experience in surgical oversight to help clinics move beyond “luck-based” safety into a rigorous, physics-driven fire prevention framework. This post explores the mechanics of ignition and how to mitigate the risks of the surgical fire triangle.

The Surgical Fire Triangle: A Physics Perspective

To understand fire prevention, one must understand the three components required for a fire to exist: an ignition source, an oxidizer, and fuel. In a laser procedure, all three are frequently present in high concentrations.

The Ignition Source (The Laser): A Class 4 laser beam carries enough energy density to ignite almost any flammable material instantly upon contact. The danger is not just from the direct beam, but from specular reflections off surgical instruments.
The Oxidizer (Oxygen and Nitrous Oxide): Many patients receive supplemental oxygen via nasal cannula or mask. An oxygen-enriched atmosphere (OEA) significantly lowers the ignition temperature of surrounding materials and increases the speed of the flame spread.
The Fuel (Preps, Drapes, and Hair): Alcohol-based skin preps, surgical drapes, dry gauze, and even the patient’s hair or intestinal gases (during perianal procedures) act as high-energy fuel sources.

Managing Oxygen-Enriched Atmospheres (OEA)

The management of the oxidizer is the most critical step in preventing surgical fires, especially during head and neck procedures. Physics dictates that oxygen is heavier than air; it “pools” in the drapes and around the patient’s face. If a laser is fired into this pooled oxygen, the result is often a flash fire.

ANSI Z136.3 protocols require that:

Supplemental oxygen be titrated to the lowest clinically necessary concentration (usually below 30%).
Oxygen delivery be stopped at least one minute before the laser is fired in the head and neck region to allow for “washout.”
The surgical site be properly vented with air or a scavenger system to prevent oxygen accumulation under the drapes.

The Danger of Alcohol-Based Preps

Modern surgical preps (like ChloraPrep or Betadine) are often alcohol-based for superior antisepsis. However, alcohol is highly volatile. If the prep solution has not completely dried, or if it has pooled in the umbilicus or skin folds, the laser can ignite the invisible vapors. This leads to a transparent flame that may go unnoticed by the surgical team until significant tissue damage has occurred.

Fire-safe protocols mandated by an LSO include a “Dry Time” policy where the laser is not introduced to the field until the prep is visibly dry and vapors have dissipated. Furthermore, surgical drapes should be fire-retardant and positioned to allow for adequate ventilation of the surgical site.

Clinical Controls: Wet Gauze and Fire Extinguishers

Administrative and engineering controls are the primary lines of defense. For example, any gauze used near the laser impact site must be moistened with sterile water or saline. Wet gauze will absorb the laser energy and dissipate the heat through evaporation, preventing the cotton fibers from reaching their ignition point.

Additionally, the room must be equipped with the correct fire suppression tools. A standard “dry chemical” extinguisher can be corrosive to expensive laser optics. Many surgical suites utilize specialized Halotron or Water Mist extinguishers that are effective without destroying the medical technology. The LSO is responsible for ensuring these tools are accessible and the staff is trained in the **R.A.C.E.** (Rescue, Alarm, Confine, Extinguish) and **P.A.S.S.** (Pull, Aim, Squeeze, Sweep) protocols.

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Establishing a Culture of Vigilance

Fire safety is not a “set it and forget it” task. It requires a “Time Out” before every laser procedure. During this time out, the surgical team should verbally verify the oxygen concentration, the dryness of the prep, and the presence of wet gauze and fire-safe water. By making fire safety a standard part of the clinical workflow, you protect your patients from devastating injury and your practice from catastrophic liability.

Laser Fire Safety Questions & Answers

Can a laser ignite a dry surgical drape?
Yes. Class 4 lasers can ignite standard surgical drapes in less than a second, especially in an oxygen-enriched atmosphere.

Why is “pooled” oxygen dangerous?
Oxygen is heavier than air and can collect under surgical drapes or in skin folds, creating a highly flammable environment that significantly increases fire intensity.

What should I do if a fire starts?
Immediately stop the laser, remove the drapes or the ignition source, and use sterile saline or water to extinguish the flame. Follow the R.A.C.E. protocol.

Is an LSO responsible for fire safety?
Yes. The Laser Safety Officer is responsible for developing fire safety SOPs and ensuring the staff is trained in fire prevention and response.

What is the best way to protect a patient’s hair during a laser procedure?
Hair near the treatment site should be covered with wet gauze or water-soluble lubricant to prevent ignition.

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John Hoopman

John began his clinical career at The University of Texas Southwestern Medical Center in Dallas in 1998, managing a 225-laser program that served multiple surgical and medical specialties for more than two decades. Nationally recognized for patient safety and laser education, he continues to research, publish, and teach through his work with ANSI, ASLMS, ASAPS, and the Laser Institute of America.