An Australian doctor is warning her peers about the danger of fires in the operating room after a patient’s chest cavity ignited during open-heart surgery.

Dr. Ruth Shaylor and her colleagues from Austin Health in Melbourne, Australia, presented their case study at the European Society of Anaesthesiology’s annual conference this week.

They told the story of a 60-year-old man who went to the hospital with a tear in the inner wall of his aorta. The man was suffering from chronic obstructive pulmonary disease (COPD) and had had coronary artery bypass grafting a year before.

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When doctors opened the man up to perform surgery on his aorta, they noticed that the man’s right lung was stuck to his sternum — and the COPD had caused bullae, or big air pockets in his lung. While they tried to detach the lung from the sternum, they accidentally punctured one of the bullae, causing a “substantial air leak.”

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So, they turned up the oxygen.

Unfortunately, they were also using an electric device to cauterize, or seal, the man’s wounds during the procedure. A spark from the device ignited a “dry surgical pack” — a bundle of sterilized equipment for the surgery, causing a “flash fire” in the man’s chest cavity.

The fire was quickly put out, and the man was uninjured. The rest of the operation proceeded as planned and the aortic repair was a success.

This isn’t the first time there has been a fire in the operating room, or even in someone’s chest cavity, according to Shaylor. In a press release, she said: “While there are only a few documented cases of chest cavity fires — three involving thoracic surgery and three involving coronary bypass grafting — all have involved the presence of dry surgical packs, electrocautery, increased inspired oxygen concentrations and patients with COPD or pre-existing lung disease.”

A 2018 article in the Canadian Medical Association Journal noted that while fires in the OR are relatively rare, the combination of oxygen, fuel (in this case the dry pack) and heat (the cauterizer) can cause them.

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The Canadian Medical Protective Association reviewed 54 cases of burns during surgical procedures between 2012 and 2016 and found that 15 per cent of patients experienced severe harm such as airway damage and serious burns. Others were left with scarring, disfigurement and psychological trauma.

One-third of those cases involved fires — the rest were burns from equipment or chemicals used during the surgery. In a few cases, alcohol that was applied as an antiseptic provided the fuel source for a fire. Sometimes, a surgical sponge or gauze ignited.

Around 550 to 650 surgical fires happen every year in U.S. operating rooms, according to an estimate from the ECRI Institute, an organization that evaluates medical products and processes.

“This case highlights the continued need for fire training and prevention strategies and quick intervention to prevent injury whenever electrocautery is used in oxygen-enriched environments,” said Shaylor. “In particular, surgeons and anesthetists need to be aware that fires can occur in the chest cavity if a lung is damaged or there is an air leak for any reason, and that patients with COPD are at increased risk.”