Surgical Smoke Nearly Killed Me

This article originally appeared in Outpatient Surgery Magazine.

After years of inhaling surgical plume, orthopedic surgeon Anthony Hedley, MD, FACS, of the Hedley Orthpaedic Institute in Phoenix, Ariz., was diagnosed with idiopathic pulmonary fibrosis and underwent a life-saving double lung transplant.

You wouldn't want your surgeons to sit in the OR and smoke a pack-and-a-half of cigarettes while operating on their patients, but many are doing nearly the equivalent by creating surgical smoke and refusing to evacuate it.

I would know. Just over 3 years ago, at age 70, I underwent a life-saving double lung transplant, something I believe was a result of a danger that is lurking in ORs across the country: surgical smoke, one of the largest unaddressed health hazards facing operating room staff today.

After taking a walk alongside a river bank and noticing I was short of breath, I went to my doctor to find out what was going on. They took a look and in 2013, I was diagnosed with idiopathic pulmonary fibrosis. The disease causes lung tissue to become thick and stiff, making it hard for the body to circulate oxygen properly. The disease has no cure and many patients live only 3 to 5 years after diagnosis if they don't undergo a lung transplant.

Fortunately, I was placed on the transplant list. While I waited for a donor, the disease progressed fairly rapidly. I was on oxygen 24/7, could hardly move and felt like I was dying. Eventually in 2014, I underwent the double lung transplant and slowly got my life back.

Still, I was stumped. Environmental pollutants are often attributed to idiopathic pulmonary fibrosis, and being a smoker can increase your risk of getting the disease. But I hadn't smoked cigarettes in more than 40 years, and though I spent time in the military when I was younger, I was never exposed to agent orange or other similar materials. It was an open-ended question. But the more I thought about it, the more I fixated on Bovie smoke.

Surgical smoke dangers

Surgical smoke includes roughly 150 chemicals, including 16 EPA priority pollutants, toxic and carcinogenic substances, viruses and bacteria. I carry a list that contains the dozens of toxic chemicals that are contained in the smoke. They include formaldehyde, benzene, hydrogen cyanide and more. When you ablate tissue, the organisms found within that tissue are also ablated and carried by the smoke. That's why there have been reported cases where gynecologists develop warts in their throat and nose after years of breathing in the smoke created during laser ablation of warts. Many groups, including AORN, note that the average plume created in a single day in the OR is equivalent to smoking as many as 30 unfiltered cigarettes.

Some smoke evacuation pencils attach to your electrocautery device and remove smoke at the point of contact.

Before my diagnosis, I had performed more than 11,000 joint replacement surgeries and spent more than 30,000 hours in the operating room. In other words, I created a lot of Bovie smoke in my time. And I was breathing this same smoke that contains these bad actors and toxins day in and day out without any protection. The more I thought about it, the more I became convinced that this was the origin of my deadly diagnosis.

I'm not the only one who is noticing how surgical smoke impacts the health of healthcare workers. The National Institute for Occupational Safety and Health notes that "exposure to surgical smoke can cause both acute and chronic health effects, ranging from emphysema, asthma or chronic bronchitis." Despite this, in the United States there are no regulations requiring facilities to evacuate surgical smoke created during procedures. And while the Occupational Safety and Health Association (OSHA) notes that an estimated 500,000 workers, including surgeons, nurses, anesthesiologists and surgical technologists, are exposed to laser or electrosurgical smoke, they stop short of requiring surgical smoke evacuators, instead simply noting that "employers should be aware of this emerging problem."

Scary Smoke

Below is a list of chemicals contained in surgical smoke that Anthony Hedley, MD, FACS, keeps in his office as a reminder of its hidden dangers

  • Acetonitrile
  • Acetylene
  • Acroloin
  • Acrylonitre
  • Alkyl benzene
  • Benzaldehyde
  • Benzene
  • Benzonitrile
  • Butadiene
  • Butene
  • Carbon monoxide
  • Creosol
  • 2,3-Dihydro indene (hydrocarbon)
  • Ethane
  • Ethene
  • Ethylene
  • Ethyl benzene
  • Ethynyl benzene
  • Formaldehyde
  • Furfural (aldehyde)
  • Hexadecanoic acid
  • Hydrogen cyanide
  • Indole (amine)
  • Isobutene
  • Methane
  • 3-Methyl butenal (aldehyde)
  • 6-Methyl indole (amine)
  • 4-Methyl phenol
  • 2-Methyl propanol (aldehyde)
  • Methyl pyrazine
  • Phenol
  • Propene
  • 2-Propylene nitrile
  • Pyridine
  • Pyrrole (amine)
  • Styrene
  • Toluene (hydrocarbon)
  • 1-Undecene (hydrocarbon)
  • Xylene

Protecting the OR

But that's not good enough. I have been on a mission to warn my colleagues about these dangers. People who are using these electrocautery and laser devices need to understand that there is a potential hazard that comes with it.

While the danger is great, there is a fairly simple solution: smoke evacuation. For me, that means that whenever I'm performing a procedure that creates smoke, I will always use a surgical smoke evacuation pencil that attaches to my electrocautery device and removes smoke plume directly at the source. I want others to do the same.

Still, some hesitate to use the devices. A 2011 study from NIOSH found that less than half of healthcare workers surveyed reported using local exhaust ventilation during laser surgery and only 15% reported local exhaust ventilation was used during electrosurgery.

I remain optimistic. I believe that with more attention being paid to the dangers of surgical smoke, more facilities are getting on board with recommendations to use a smoke evacuator. There are several new technologies available that are immensely better than the loud and bulky evacuators of the past. The latest ones are smaller, easy to use and less disruptive. The pencil I use is only a half-inch in diameter and connects to my electrosurgical device to get rid of smoke at the point of contact. Though it makes the handpiece a little awkward, it's not enough to outweigh its enormous benefits.

The benefits aren't just for your surgeons. Trust me, the use of an evacuator makes the OR more pleasant overall for all of your staff members and it helps to protect your patient on the table. You will never hear an anesthesiologist or surgical technician complaining about the use of an evacuator. In fact, most OR team members will choose a smoke-free OR over a smoke-filled one any day of the week. Having a mandatory smoke evacuation policy can not only help the health of your staff, but also your recruitment efforts and retention rates. (Editor's note: There are no mandatory smoke evacuation regulations in the United States. California and Rhode Island failed to pass bills.)

The average plume created in one day in the OR is equivalent to smoking as many as 30 unfiltered cigarettes.

As for any lingering naysayers, education is key. If surgeons remain resistant to using evacuators during surgery, then you need to create doubt about the safety of the unfiltered air they are breathing day in and out. Show them the studies and stories (maybe even mine!), and they will likely come on board. Another way to get around stubborn surgeons is to ask them to commit to using the evacuator for just 1 week. Many think of evacuators as big and bulky like the ones of past generations, and will likely be pleasantly surprised to see how much easier the new technologies are to use. Plus, after they see how much clearer the air is without those noxious fumes in the OR, it's usually not difficult to convince them to use the evacuator all the time.