View full size

Kira Reed was woozy from local anesthesia for her cesarean-section delivery, but she knew something was wrong.

She was lying in the operating room at Crouse Hospital on March 12, 2010. Her doctor had made the incision.

“I could not come up with the word for what I was smelling,” Reed said in a recent interview. “It did not smell like anything recognizable.”

She figured it out and got out the words: “I smell something burning.” The doctor and nurses told her she had nothing to worry about, Reed said.

“I see the smoke,” said Reed’s mother, who was sitting beside her for emotional support. The obstetrician performing the operation, Dr. Stephen Brown, suddenly saw a small flame on Kira Reed’s left side.

“She’s right,” Brown said, according to Reed. He patted out the flame with his hand.

“What’s going on?” asked Reed, whose view was blocked by a curtain.

“Oh, there’s nothing to worry about,” Brown said, according to Reed. “There’s been a little fire.”

Reed worried about the baby inside her.

“I didn’t know where the fire was,” Reed said. “I didn’t know how close it was to her.”

Reed didn’t know until later that the fire was on Reed herself.

Brown continued with the operation, and Reed gave birth to a healthy daughter, Rayna. But Reed suffered a painful third-degree burn on her side, 7 inches long and 5 inches wide. A plastic surgeon described it as similar to those he’d seen on napalm victims.

Reed, 42, a business professor at Syracuse University, is suing Brown and Crouse for medical malpractice, claiming the doctor and nurses failed to follow the manufacturer's recommended procedures for using an alcohol-based antiseptic that was applied to her skin in preparation for surgery.

Four of the nurses and the anesthesiologist testified in depositions that before the incident they hadn't been trained in how to prevent surgical fires while using the commonly used antiseptic skin preparation DuraPrep.

“Before this, I didn’t realize fire was even an issue with DuraPrep,” one nurse testified.

Reed's lawsuit doesn't blame 3M Company, which makes DuraPrep. The company, under direction from the Food and Drug Administration, a month before Reed's C-section had issued a new warning to hospitals about the solution's flammability and gave instructions on how to prevent surgical fires.

After Reed’s injury, Crouse immediately looked into the cause of the fire, said Catherine Gale, a lawyer for the hospital. Crouse takes full responsibility for Reed’s injuries, but does not admit it was negligent, she said.

“The hospital was horrified,” Gale said. “This should not have happened. This lady came in to have a baby. She did not come in to have third-degree burns on her lower abdomen.”

Crouse has been using DuraPrep for 20 years, and Reed’s surgery was the first time it resulted in a fire, Gale said. The hospital temporarily stopped using the solution after the incident, but reinstituted it soon afterward, Gale said.

Gale wouldn’t disclose Crouse’s findings. But she said the hospital made changes to ensure it never happens again.

A woman at Brown’s practice, CNY Women’s Healthcare, hung up on a reporter seeking his comment. His lawyer, Mark Dunn, said that although Brown wasn’t involved in applying the skin preparation, he responded quickly to the fire and safely delivered Reed’s baby. Dunn would not comment further.

The warnings that 3M had issued should make the fire indefensible to Crouse, her plastic surgeon wrote in Reed’s medical records.

“I certainly cannot understand the rationale of defending it,” Dr. Bruce Shafiroff wrote in June 2011.

Reed still suffers discomfort. The area of the burn, which required plastic surgery, is numb and she often feels like it’s going to tear open, she said.

Crouse officials apologized to her shortly afterward, Reed said. But Brown has never offered an apology or an explanation, she said.

When the fire started, Brown was using a commonly used electrical cautery tool on Reed’s incision. A spark from the tool could have ignited fumes from the antiseptic, according to an expert.

But that can't happen if the skin preparation solution is allowed to dry, as the manufacturer's warning instructs, said Mark Bruley, a national expert in surgical fires for the past 35 years.

The solution can ignite if it soaks into the patient’s hospital gown or the paper surgery drapes, or if it pools somewhere on the patient, said Bruley, vice president of accident and forensic investigation for the ECRI Institute, an independent, nonprofit organization that researches the best approaches to improving patient care.

Surgical fires are extremely rare — between 400 and 600 of them on patients each year among the 50 million surgeries in the U.S., he said. And only 4 percent of those fires involve skin preparation solutions such as DuraPrep, he said.

Bruley said he knew of only a dozen surgical fires during C-sections over the past 20 years, and those were all emergencies where the medical workers were hurrying to save the baby. He said he didn’t recall a fire during a scheduled C-section.

View full size

The anesthesiologist in Reed’s C-section testified that she noticed Reed’s gown was wet after the fire with what could only have been DuraPrep. One of the nurses testified that she was unaware the solution shouldn’t be allowed to soak into the patient’s gown.

In his deposition for Reed’s lawsuit, Brown said he didn’t know what caused the fire. He said he was sure the DuraPrep had dried, and he saw no evidence that it had dripped down her side, he said.

Reed’s lawyer, Janet Izzo, asked Brown in the deposition if he thought fires were an accepted risk of surgery.

“I think unintended outcomes are unintended outcomes,” Brown testified. “There are inherent risks of surgery in the operating room. What they may be are wide and varied.”

The healthy baby girl born that day was Reed’s second child. Her older child, Declan, was 2 at the time. For months afterward, he watched nurses come to their home and change the dressings on Reed’s burn. She explained to him what had happened.

Reed got worried when she started seeing Declan playing make-believe, pretending he was saving people who were on fire.

“I thought, ‘Is that healthy?’” she said. “But then if he’s acting it out, he’s thinking people do survive. So I started thinking maybe it’s going to be OK.”

Contact John O'Brien at jobrien@syracuse.com or 470-2187.