Letter from Hospital CEO about Accidental Fire

In a letter to Duke University Hospital staff, Dr. William Fulkerson talks about a fire in the Pediatric Intensive Care Unit that burned a baby on 5 percent of its body

June 4, 2003

Duke University Hospital officials are investigating the cause of a fire on Monday (June 2) in the pediatric intensive care unit (PICU). The fire occurred at approximately 1 p.m. as the medical team prepared to connect a critically ill child to ECMO equipment. ECMO (extracorporeal membrane oxygenation) is a treatment that involves the use of a machine that takes over the work of the heart and/or lungs until the organs are capable of functioning on their own. Before a child can be hooked up to the machine, a surgical procedure is undertaken to insert cannulas, or tubes, into large blood vessels. With ECMO, unoxygenated blood is taken out of a child and pumped through an artificial lung for oxygenation. The blood is then warmed and filtered before being returned to the child. The procedure and treatment are typically performed in the PICU.

When the medical staff saw the fire, they immediately responded by dousing it with sterile saline solution. The fire was extinguished within seconds. The care team was able to immediately continue the surgical procedure and successfully connected the patient to the ECMO. The fire burned a paper sterile drape, which was over the incision site, in addition to some fabric bedding and a blanket. Burns were sustained by the patient but are not life-threatening. The patient is responding well to the treatment. No one on the medical team or any of the other patients in the unit sustained injuries.

The child's family was informed and provided with full details.

All affected equipment has been removed and is being evaluated to determine the cause of the fire. The equipment has been tested and is functioning properly. All preventive maintenance on the involved equipment was up to date at the time of the incident and no prior history of problems had been reported.

We have reported the incident to the state Division of Facilities Services (DFS) and the Joint Commission on Accreditation of Healthcare Organizations.

Our concerns and attention are being directed to serving the medical needs of the patient, and we are working to support the family. The family will not be responsible for any medical costs associated with the incident.

We have received an inquiry from the media about the fire. At the same time the patient's parents have explicitly said they do not wish to have information about their child released to the media. We will respect the wishes of the family and not release any protected health information to media.