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
>
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