Description of Event or Problem · 1
DURING A BRONCHOSCOPY WITH YAG LASER PROCEDURE, A FIRE STARTED INSIDE THE ENDOTRACHEAL TUBE DURING LASER ABLATION OF A CARINAL TUMOR. THE TIP OF THE LASER FIBER WAS BURNED OFF AND APPARENTLY LOST IN THE PATIENT. A PORTION OF THE ENDOTRACHEAL TUBE BURNED AND MELTED BOTH THE BRONCHOSCOPE AND THE END OF THE FIBER. BRONCHOSCOPY FOLLOWING THE FIRE DIFFICULT TO ASSESS, AS THERE HAD BEEN EXTENSIVE LASER TREATMENT/FULGURATION PRIOR TO THE FIRE. THE FIRE WAS QUICKLY EXTINGUISHED AND THERE APPEARS TO BE ONLY MINOR INJURY TO THE PATIENT. IT IS NOT CLEAR IF THE FIBER FAILED FIRST AND CAUGHT THE ET TUBE ON FIRE OR IF THE FIRE STARTED FIRST AND MELTED THE FIBER. LASER POWER WAS SET AT 15W AND 0.5 SEC DURATION. LASER IS 1064NM WAVELENGTH. LASER MACHINE WAS TESTED FOLLOWING THE INCIDENT AND POWER OUTPUT WAS FOUND TO BE WITHIN ALLOWABLE TOLERANCE. THE DISTAL END OF THE DAMAGED FIBER APPEARS TO BE FRACTURED, BUT IT IS NOT KNOWN AT WHAT POINT THIS HAPPENED. THE FIBER USED IS A CONTACT TYPE THAT USES A SAPPHIRE OR RUBY TIP AND AIR COOLING. WE HAVE HAD SEVERAL FAILURES IN THE PAST WHERE THE TIPS BURN OFF AND GET LOST.WHAT WAS THE ORIGINAL INTENDED PROCEDURE?DIAGNOSTIC BRONCHOSCOPY / RESECTION OF CARINAL TUMOR.DEVICE #1IS THIS A LABORATORY DEVICE OR LABORATORY TEST?NO.DEVICE #3IS THIS A LABORATORY DEVICE OR LABORATORY TEST?NO.DEVICE #4IS THIS A LABORATORY DEVICE OR LABORATORY TEST?NO.