Patrick,
Thank you for your interesting (and amusing) account.
Harry
Date sent: Mon, 21 Apr 2003 23:57:48 +0200
Send reply to: British Medical Laser Association <[log in to unmask]>
From: Patrick Brouwer <[log in to unmask]>
Subject: Re: Laser Accidents
To: [log in to unmask]
> Dear Harry,
>
> I do have a case that is not that impressive but it shows the problems
> involved with laser safety in the hospital.
>
> One day I was teaching a colleague of mine how to treat a patient for a disc
> herniation with a 804 nm diode laser. The initial powersetting was 25 Watts
> which is normally decreased to 15 W as soon as vaporisation is noticed in
> the disc. Since in this patient no vaporisation was observed I decided he
> should try to carbonise the tip (since then abandonned) by short firing on a
> gauze with iodine. He didn't fire a short but a longer pulse. Doing this,
> the gauze caught fire and so did his gloves. He swiftly threw the gauze
> away, which in turn fell on to the drapes covering the patient. I managed to
> put out the fire with sterile saline. So far little harm was done. Ofcourse
> there was a nasty smell of burning for which we explained the patient what
> had happened. We proceeded with the treatment. But then, out of the blue:
> Five minutes later the hospitals' firemen came running through the 3
> separate doors (with signs that said laser in operation) without taking any
> precautions and stood there in the sterile theater because the smoke alarm
> went off.
>
> 1/ When teaching someone a new trick, make sure that you show the trick the
> first time and let the other do it afterwards. (see one, do one, teach one)
> 2/ Make sure that the unforeseen (like fire in this instance) can be solved
> easily by having the proper materials at hand (for example saline, drapes
> etc.)
> 3/ Make sure that no one can enter the room unasked. If even three doors
> with proper signs won't hold them, what more can you do than explain the
> signs to all involved (even the firebrigade, ER-perssonnel etc.). Let
> ER-nurses, assistants etc. guard the final entrance.
> 4/ Solving the problem (in this case the fire) might not be all you need to
> do, give notice to the fire-desk of what has happened and the current
> status.
> 5/ Fill out a near accidents form afterwards otherwise your colleagues won't
> learn from you experiences.
>
> I hope you can use some of this as a demonstration of how complicated signs,
> accidents and teaching can be. I have no problem with you using my name in
> this case.
>
> Regards, and see you soon in Amsterdam,
>
> Patrick Brouwer
>
> --------------------------------------------------------
> P.A. Brouwer MD(hon), (neuro-)interventional radiologist
> President of the NMLA
> Vice-president of the ELA
>
> Radiology dept.
> Leiden University Medical Center
> Albinusdreef 2, Leiden
> The Netherlands
>
> 071-5269111 beeper 8857
> [log in to unmask]
> -------------------------------------------------------
>
>
>
>
> On 17-04-2003 17:21, "Harry Moseley" <[log in to unmask]> wrote:
>
> > Dear list member,
> >
> > During the Joint International Laser Conference in Edinburgh on 21-
> > 23 September 2003, there will be a course on Laser Safety
> > (Faculty: David Sliney, Roy Henderson, Penny Smalley and Harry
> > Moseley). As part of this we will present cases of laser-induced
> > accidents (and near-misses). You are invited to participate in this
> > by sharing some of the incidents that you are aware of. Your
> > contribution will be acknowledged unless you wish to remain
> > annonymous. We are already hearing of some very interesting
> > cases. We don't think that anything on this scale has been done
> > before. So, don't be backward in coming forward. We want to hear
> > from you.
> >
> > To help, we have compiled a data collection form (attached).
> > Please use this as many times over as you wish.
> >
> > Also, for your information, information on all of the courses on offer
> > is attached. Places are limited. So do not delay in booking your
> > place(s).
> >
> > And finally, a flyer is enclosed (in Adobe Acrobat). Please note that
> > abstracts for the laser safety session are welcome. Many of you
> > have something you could present at this session. So, take your
> > chance.
> >
> > Regards
> >
> > Dr Harry Moseley
> > Consultant Medical Physicist
> > The Photobiology Unit
> > University of Dundee
> > Ninewells Hospital & Medical School
> > Dundee DD1 9SY
> > United Kingdom
> >
> > Tel. (0)1382 632240
> > Fax. (0)1382 646047
> >
> > The following section of this message contains a file attachment
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> > If you cannot, please ask your system administrator for assistance.
> >
> > ---- File information -----------
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> > Date: 17 Apr 2003, 14:58
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> >
> > ---- File information -----------
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> > Date: 25 Mar 2003, 15:48
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> >
> > ---- File information -----------
> > File: Lasers ad 24 Feb mark 3.pdf
> > Date: 25 Feb 2003, 17:30
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> >
Dr Harry Moseley
Consultant Medical Physicist
The Photobiology Unit
University of Dundee
Ninewells Hospital & Medical School
Dundee DD1 9SY
United Kingdom
Tel. (0)1382 632240
Fax. (0)1382 646047
|
