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Surgical Endoscopy (2018) 32:3439–3449 https://doi.org/10.1007/s00464-018-6063-x

Immersive virtual reality-based training improves response in a simulated operating room fire scenario

Ganesh Sankaranarayanan1  · Lizzy Wooley1 · Deborah Hogg2 · Denis Dorozhkin3 · Jaisa Olasky4 · Sanket Chauhan1 · James W. Fleshman1 · Suvranu De3 · Daniel Scott2 · Daniel B. Jones5

Received: 15 November 2017 / Accepted: 11 January 2018 / Published online: 25 January 2018 © Springer Science+Business Media, LLC, part of Springer Nature 2018

AbstractBackground SAGES FUSE curriculum provides didactic knowledge on OR fire prevention. The objective of this study is to evaluate the impact of an immersive virtual reality (VR)-based OR fire training simulation system in combination with FUSE didactics.Methods The study compared a control with a simulation group. After a pre-test questionnaire that assessed the baseline knowledge, both groups were given didactic material that consists of a 10-min presentation and reading materials about precautions and stopping an OR fire from the FUSE manual. The simulation group practiced on the OR fire simulation for one session that consisted of five trials within a week from the pre-test. One week later, both groups were reassessed using a questionnaire. A week after the post-test both groups also participated in a simulated OR fire scenario while their perfor-mance was videotaped for assessment.Results A total of 20 subjects (ten per group) participated in this IRB approved study. Median test scores for the control group increased from 5.5 to 9.00 (p = 0.011) and for the simulation group it increased from 5.0 to 8.5 (p = 0.005). Both groups started at the same baseline (pre-test, p = 0.529) and reached similar level in cognitive knowledge (post-test, p = 0.853). However, when tested in the mock OR fire scenario, 70% of the simulation group subjects were able to perform the correct sequence of steps in extinguishing the simulated fire whereas only 20% subjects in the control group were able to do so (p = 0.003). The simulation group was better than control group in correctly identifying the oxidizer (p = 0.03) and ignition source (p = 0.014).Conclusions Interactive VR-based hands-on training was found to be a relatively inexpensive and effective mode for teaching OR fire prevention and management scenarios.

Keywords Immersive VR · VR training · Simulation training · OR fire management

Operating room fire have existed from the time when wide-spread use of combustible anesthetic gases was common. In an investigation of 230 cases by the American Society of Anesthetists published in 1941, 36 deaths had been attributed to operating room (OR) fire at that time [1]. Even though the incidence of OR fire events has decreased over time, there are still about 550–650 cases reported each year, of which 20–30 cases have caused serious injury to the patients including death. The number of cases is simi-lar to that of wrong site surgery and generally preventable. In an analysis of the American Society of Anesthesiolo-gists closed claims database from 1985 to 2009, there were 103 reported cases of OR fire [2]. Several national organi-zations have recognized the importance of this sentinel event and have issued responses. The American Society

and Other Interventional Techniques

Presented as a poster at the SAGES 2017 annual meeting.

Electronic supplementary material The online version of this article (https ://doi.org/10.1007/s0046 4-018-6063-x) contains supplementary material, which is available to authorized users.

* Ganesh Sankaranarayanan ganesh.sankaranarayanan@bswhealth.org

1 Baylor University Medical Center, 3500 Gaston Ave. 1st Floor Roberts Hospital, Dallas, TX 75246, USA

2 UT Southwestern Medical Center, Dallas, TX, USA3 Rensselaer Polytechnic Institute, Troy, NY, USA4 Mt Auburn Hospital, Cambridge, MA, USA5 Beth Israel Deaconess Medical Center, Boston, MA, USA

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of Anesthesiologists (ASA) issued a practice advisory for the prevention and management of operating room fires [3] which includes an updated OR fire algorithm. The Joint Commission and the US Food and Drug Administration issued a sentinel event alert on prevention of OR fires [4, 5]. The Anesthesia Patient Safety Foundation created an 18-min video on OR fire prevention [6] and a fire algorithm [7]. The Society for American Gastrointestinal and Endoscopic Surgeons (SAGES) developed the Fundamental Use of Sur-gical Energy (FUSE), a curriculum-based program with an interactive online didactic module on safe usage of energy-based devices, including OR fire prevention and safety [8].

In order for a fire to start in an operating room, all ele-ments of the fire triad (fuel, oxidizer, and ignition source) need to be present [9]. Elimination of one of these fire tri-angle elements removes the potential risk. It is important for all team members in the OR to be knowledgeable about the fire triangle elements. In addition, they must know how to reduce the risk of a fire and be able to manage and protect the patient in the case of a fire. The Association of Perio-perative Registered Nurses (AORN) has introduced a fire safety toolkit that has information on fire prevention, a risk assessment checklist, and instructions on how to put out a fire [10, 11]. AORN’s recommendation includes perform-ing a fire risk assessment before the start of the procedure, communicating the assessment to team members during the time-out process, and documenting the assessment in the patient’s record [11].

Since the occurrence of an OR fire event is relatively uncommon, simulation plays a key role in training the OR team for preparedness. Fire drills are one method for the entire surgical team to improve their response to a fire [12]. Adding a hands-on benchtop training component in addition to didactic materials has been shown to improve the learning and retention of knowledge of the SAGES FUSE curriculum [13]. Simulation training has also been shown to transfer skills to real-world setting in surgery [14–16].

Experiential learning as described by Kolb involves a cyclic process with four important components, namely, concrete experience, reflective observation, abstract con-ceptualization, and active experimentation [17]. This is par-ticularly applicable in healthcare setting where knowledge learned in a classroom needs to be practiced in an actual hospital setting. Serious games are gaming platform used as learning environments with clear learning objectives and provides opportunities to safely interact and learn in a com-pelling and real-life-like situations [18]. Experiential learn-ing combined with serious game has been used extensively in nursing education [19–25].

The Virtual Electrosurgery Skills Trainer (VEST)-OR fire module was developed as part of the virtual reality simula-tor to train surgeons in safe usage of electrosurgical energy with funding from the National Institutes of Health. This

fully immersive module combines a game-like environment with tasks designed to teach the fire triangle and appropri-ate sequence of steps needed to be taken in case of fire. The effectiveness of the VEST-OR fire module was evaluated by the participants.

Materials and methods

VEST OR fire module

The Virtual Electrosurgery Skills Trainer—Operating Room Fire Module (VEST-OR) is an interactive immersive vir-tual reality (VR) simulator that is designed to train operat-ing room professionals in OR fire prevention and control. It consists of a virtual operating room with an anesthesia unit, a laparoscopic tower, an electrosurgery unit, and a virtual patient model. The user wears an Oculus Rift head mounted display (HMD) system to be immersed in this vir-tual operating room scenario and uses a hand held trigger switch (X-keys inc.) with position and orientation tracked by Ascension Trakstar Magnetic Tracking System (Ascen-sion Inc.) to interact with the environment. The simulator currently supports single user interaction within this virtual operating room environment [26].

The VEST-OR fire module has an option of providing cues which can be used in the learning phase and without cues during the testing phase. The simulator enables the user to identify the elements of the fire triangle and also the proper sequence of actions that needs to be taken if the patient is on fire. The simulator is driven by self-paced inter-active menus as shown in Fig. 1 where the users familiarize themselves within the environment.

After the familiarization phase, the users are asked to identify the elements of the fire triangle by selecting the elements in the virtual environment (Fig. 2).

Once the fire triangles elements are identified, the users are led through a sequence of steps which cause an OR fire event due to gas enrichment area under the surgical drapes, which they are then asked to manage. The correct sequence of actions namely, removal of the anesthesia mask, turning off the gases, removal of the surgical drape, and then using the fire extinguisher to extinguish the fire are performed by selecting appropriate objects within the scene (Fig. 3 a–c).

Successful extinction of fire marks the completion of the simulation. Figure 4 shows a participant using the VEST-OR fire module during training with clicker interface and the HMD. The view on the computer monitor is used by the experimenter to track the progress of the participants.

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Study design

The study was a mixed within and between subjects design with two groups—control and simulation. Both groups took a pre-test (see “Appendix”) that tested their knowledge in OR fire and its prevention. After pre-test, both groups were given a 15-min lecture about OR fire and safety by a research team member. Additionally, they were also provided with an excerpt from the SAGES FUSE manual that covers OR fire as didactic material. The sub-jects in the simulation group were given an additional hands-on experience within seven days of the lecture ses-sion using the VEST-OR fire simulator. The simulation group practiced five times on the simulator. One week from the day of the lecture session, a post-test, identical to the pre-test, was administered to the subjects from both groups. One week after the post-test, both groups partici-pated in a mock OR fire scenario, simulated in a mock OR room set up in the Baylor Operative Skills Laboratory (BOSS) lab at Baylor University Medical Center (BUMC). In this scenario, subjects were asked to identify the com-ponents of the fire triangle and were also asked to act as

if a real patient is on fire in an OR. The transfer study was videotaped for assessment by two independent raters.

Power analysis

A power analysis using the G*Power software was per-formed with two groups mixed design. With an assumption of effect size of 0.25 between the two groups, a total of 20 subjects (ten per group) are needed for this study.

Statistical analysis

The performance of each subject on the pre and post-tests as well as the transfer test on a mock OR was analyzed using the IBM SPSS 23 statistics software (IBM Inc). Wilcoxon Signed-Rank test was used to assess differences in pre- and post-test scores within each group and Mann–Whitney U test was used to assess the differences between the groups. For transfer test rating, Cronbach’s Alpha and Intraclass Correla-tion Coefficient (ICC) were computed to assess the reliabil-ity and consistency of ratings by the two independent raters.

Fig. 1 Familiarizing phase with the virtual operating room in VEST-OR fire module. Users are asked to select the fire extin-guisher (circled in red), the fiber optic light (circled in yellow), and the surgical drape (the blue cover on top of the patient). (Color figure online)

Fig. 2 Identification of fire triangle task ignition source electrosurgery device and fiber optic cable circled in red and yellow, respectively. (Color figure online)

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Mock OR fire setup

A mock OR was set up at the Baylor operative skills (BOSS) lab at the Baylor University Medical Center. The overall set up is shown in Fig. 5. It consists of a height adjustable plat-form to act as an operating room table and OR lights with adjustable arms. A fully draped SimMan 3G (Laerdal Inc.) mannequin was used as the simulated patient. A nonworking anesthesia machine with attached airway connection with oxygen mask was connected to the SimMan. A fully work-ing video endoscope station with fiber optic light source was also placed next to the table. A monopolar electrosur-gery tool connect to an electrosurgical unite (ESU) was also placed inside a plastic holder next to the SimMan. A fire extinguisher with signs marked in big red printout was also placed on the wall (not visible in the picture) and readily accessible to the participants. Due to hospital regulations, neither a real fire nor smoke can be generated within the lab and hence a humidifier placed on the floor and connected through a ling tube and attached to the chest of the SimMan was used for simulating smoke. The experimenter controlled the activation by switching on the device. A fire alarm audio was played in loop on an iPod (Apple Inc.), which was also activated by the experimenter. The Mock OR setup was care-fully designed to test the subjects’ knowledge. Table 1 shows the elements of the fire triangle that was present in our mock OR fire setup.

Results

Demographics

A total of 20 subjects (n = 20) participated in this study. Ten of the subjects were General Surgery residents and the rest were OBGYN residents. The subject population consisted of 11 females and nine males (OBGYN—nine females, one male, GS—two females, eight males).

Pre‑ and post‑test performance

For the control group, the median test scores increased from 5.5 (IQR 2) to 9.00 (IQR 2) (p = 0.011) between pre- and post-tests (Fig. 6). For the simulation group, the median test scores increased from 5.0 (IQR 3) to 8.5 (IQR 1) (p = 0.005) between pre- and post-tests (Fig. 7).

No significant differences were found in the total score between the control and the simulation group for both the pre-test (p = 0.529) and post-test (p = 0.853) indicating, both groups started at a same baseline and gained knowledge to a similar level at the end of the study as assessed by multiple choice questionnaire.

Transfer test performance

The ratings of the two independent raters in assessing how many of the fuel, ignition, and oxidizer sources that were correctly identified and whether correct sequence of opera-tion was performed in the simulated fire scenario were ana-lyzed for interrater reliability and the results are shown for individual measures in Table 2. There was high agreement between the raters for fuel, ignition source identification and order of operation and moderate agreement for oxidizer source agreement. All measures showed high reliability with Cronbach’s alpha > 0.8.

For identification of fuel source within the mock OR, the number of correctly identified fuel sources ranged from 1 to 3 out of possible 4. All subjects correctly identified drape as a fuel source but only one subject from the control group identified personal protection equipment as a fuel source (see Fig. 8). The box plot of the sum of correctly identified fuel sources is shown in Fig. 9. The median number of cor-rect identifications for both groups was 2.0 and was found to be not significant (p = 0.398). For identification of the two oxidizer sources, Fig. 10 shows the number of correct identifications for both the groups. The simulation group could correctly identify oxidizer sources more than the con-trol group. The box plot of the sum of correct identifications for both groups is shown in Fig. 11. The median for both groups was 1. There was a significant difference between the two groups (p = 0.03). For identification of the two ignition sources, Fig. 12 shows the number of correct identifications for both the groups. Both groups identified the electrosur-gery tool easily whereas for the fiber optic light source, 90% of the simulation group identified it correctly whereas only 40% of the control group could do so. The box plot of the sum of correct identifications for both the group is shown in Fig. 13. The median number of correctly identified sources for the control group was 1 and it was 2 for the simulation group. There was a significant difference between the two groups (p = 0.014). For the assessment of the correct order of operation, the median for the control and the simulation group was 0 and 1 respectively (see Fig. 14). Only two out of 10 subjects (20%) in the control group were able to exe-cute the proper sequence of action, whereas seven out of 10 (70%) of the subjects in the simulation group were able to do all the steps correctly to put out the mock OR fire. The effect was significant between the groups (p = 0.006).

Fig. 3 A Fire caused by a gas enrichment area under the surgical drape. B Simulation scene in the middle of managing OR fire with oxygen mask removed and the gas supply switched off as well as the burning materials removed from the patient. C Fire extinguisher is used to completely put out the fire on the burning materials

◂

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Discussion

An operating room fire is a preventable event that can be devastating to both the patient and the healthcare workers [11]. In order for a fire to begin and be sustained, there must be an oxidizer, an ignition source, and fuel; these three items are also known as the fire triad or triangle. Disruption in any one these elements will make it difficult for fire to occur.

An oxidizer lowers the temperature at which ignition can occur. In the operating room, the oxygen saturation can increase beyond the room level (20–30%) as well as in the presence of nitrous oxide. The mixture of oxygen and nitrous oxide presents an oxygen enriched environment and it can be present in a patient’s airway or it can be pooled under drapes in certain configurations [27]. Ignition sources present in an operating room are the electrosurgical devices, fiber optic cables, lasers, argon beam coagulators, defibrillator pads, drills, and burrs. Many items can serve as fuel for a fire, including personal protection equipment (PPE), drapes, sponges, oxygen mask, alcohol prep solution, and gastroin-testinal gases. The OR fire itself can occur on the patient or elsewhere inside the operating room. In reported incidents, 44% of cases occurred during face, head, neck, or upper chest procedures; 21% occurred in airway surgery; 26% occurred elsewhere in the body, and 8% occurred in other locations in the body [28]. For these reasons, face, head, and neck procedures are considered high-risk procedures.

The ASA practice advisory recommendation starts with fire safety education, which is left up to the individual

Fig. 4 A participant undergoing training in the VEST OR fire module

Fig. 5 Mock OR fire Setup

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institution to plan. It also recommends OR fire drills, [3]. The SAGES FUSE didactic materials developed as part of safe usage of energy based devices has a significant section devoted to OR fire in Chap. 3—Fundamentals of Electro-surgery part II. The manual is a great resource for educa-tion material but it does not have any hands on training or a testing component. It has been shown that fire drills

improve staff response to fire [12]. Though a previous study has shown usefulness of structured benchtop mod-els for learning and retention of knowledge in FUSE topics [13], it did not cover OR fires, in part because simulating a fire in a physical environment is costly and challenging due to the presence of fire and smoke. The VEST OR fire module was developed as a completely immersive virtual reality simulator to overcome the logistical problems and the lack of realism associated with traditional mock OR fire drills.

Simulation-based training in surgery has been shown to be effective in transferring skills to a real procedure [29]. Moreover, guided deliberate practice has been shown to be very effective in improvement of performance [15, 16, 30]. OR fire is a “never event” that involves the entire OR team. This never event has to be prevented from happening and in situations when it does happen, it needs to be handled in an effective manner within a shortest possible time. This requires the ability of the team or individual members of the team to repeatedly go through the scenario and perform actions, which enables them to exercise the knowledge, reflect on their mistakes and strengthen the preparedness through an experiential learning process [17]. Virtual real-ity-based serious games have been found to be effective in many areas including healthcare [18, 31]. So it is anticipated that the VEST OR fire module training should provide expe-riential learning for participants in the simulation group.

At the baseline evaluation, it is not surprising that both groups’ performance was low as they had not received any previous information on OR fire safety. Their scores at median level of 50% are similar to baseline assessment performance of subjects in principles of electrosurgery [13]. After the lecture session and studying the didactic materials, both groups improved their performance in the post-test. There were no significant differences between the control and the simulation groups indicating both groups obtained knowledge by reading the FUSE OR fire chapter as well as listening to the didactic lecture. The lack of difference between the groups could be due to focus on a single topic on OR fire unlike broader range of topics that was covered in [13], where the simulation group showed better performance in the post-test based on a multiple choice questionnaire.

The key factors for fire prevention are the ability to clearly identify the elements of the fire triangle and proper sequence of steps that need to be taken in the case of fire. The ASA practice advisory recommendation in the event of a fire in OR in the case of airway fire is to remove the endotracheal tube, stopping all airway gasses, removing all burning mate-rials from the patient, dousing any remaining fire on the patient with saline solution and extinguish remaining fire on the removed burning materials using a fire extinguisher. For fire elsewhere in the body, the procedure is similar except the endotracheal tube is not removed. It has been shown that

Table 1 List of Fire Triangle Elements in the Mock OR

Oxidizer Ignition Fuel

OxygenNitrous oxide

Electrosurgery toolFiber optic cable

DrapePersonal protection equipmentSurgical prep solutionOxygen

Fig. 6 Pre- and post-tests total scores for the control group

Fig. 7 Pre- and post-tests total scores for the simulation group

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removal of all flammable and burning materials and drapes vastly reduced patient injury [32].

Though these concepts are included in the FUSE chapter as well as in the lecture, the simulation group had an oppor-tunity to immerse themselves in a virtual OR module and was asked to identify all fire triangle elements correctly and put out a simulated fire. When a wrong choice was made, the simulator provided instant feedback by displaying in

red-colored bold text their incorrect choices and did not let them move to next phase until the correct choice was made. The subjects were able to reflect on their choice and enabled them learn in an experiential learning environment. When tested in a mock OR fire scenario, clearly 70% (seven out of 10) of the simulation group subjects were able to perform the correct sequence of steps whereas only 20% (two out of

Table 2 Interrater reliability of transfer test measures

Rated measure Cronbach’s alpha Intraclass correlation coefficient

Intraclass cor-relation

Confidence interval Significance

Fuel 0.826 0.703 0.388–0.871 p < 0.0001Oxidizer 0.8 0.667 0.329–0.853 p < 0.0001Ignition 0.946 0.898 0.762–0.959 p < 0.0001Order of operation 0.949 0.903 0.771–0.960 p < 0.0001

Fig. 8 Number of individual Fuel sources correctly identified by the subjects

Fig. 9 Number of fuel sources correctly identified by the subjects

Fig. 10 Number of individual oxidizer sources correctly identified by the subjects

Fig. 11 Number of oxidizer sources correctly identified by the sub-jects

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10) subjects in the control group were able to do so, which clearly shows the effectiveness of the VR fire simulation.

The simulation group subjects were able to recollect cor-rectly most of the oxidizer and ignition elements of the fire triangle when compared to the control group. No benefits were seen in identifying the fuel sources between the two groups, which could be due to subjects’ previous knowl-edge in fuel sources some of which are very obvious such as drapes and sponges. The most common mistakes that the control group made in the mock OR fire scenario were not completely removing the drape of the patient and using the extinguisher directly on the patient. The ASA practice advi-sory recommends using fire extinguisher on patients as a last resort when it cannot be put out by removing the drape nor quenching using a saline solution. The fire scenario on the mock OR mimicked the fire on the virtual patient which may have provided some advantage to the simulation group but in the mock OR, the subjects were asked to proceed with what they would do on a real patient except that the seal on the fire extinguisher was kept intact for compliance purposes.

Conclusion

Training in an immersive VR environment improves per-formance when tested in a mock OR fire scenario. The self-paced immersive, interactive environment with instant feedback has provided an experiential learning environment for the users that reinforces what they learn from didactic material.

Our VR simulator is compact and portable and unlike a mock OR, does not require large space or personnel. It allows highly realistic fire and smoke scenarios that cannot be safely created in a mock OR. Our VR platform allows for recording user performance with a high degree of granular-ity and providing instantaneous feedback and opportunities for repetitive deliberate practice without the logistical con-cerns of setting up mannequins and recording in a mock OR. Some limitations of our study include, testing on a single scenario of patient on fire. Even in this single user simu-lation environment, having the ability to simulate airway fire would be a valuable addition. An additional limitation is the single user platform. In the future, we plan to add a team training multi-user option in VEST-OR to be even more effective in training an OR team on how to prevent and control an OR fire.

Acknowledgements The authors acknowledge the valuable inputs from the SAGES FUSE committee during the various phases of the develop-ment of the VEST OR fire module, providing questionnaire to be used for the study and sharing power point presentation materials.

Funding This work was supported by funding from NIH/NIBIB R01 EB014305.

Fig. 12 Number of Ignition sources correctly identified by the sub-jects

Fig. 13 Number of ignition sources correctly identified by the sub-jects

Fig. 14 Number of subjects correctly followed the order of operation under simulated OR fire

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Compliance with ethical standards

Disclosures Dr. Jones is a consultant for Allurin, a Intragastric balloon company. Drs. Sankaranarayanan, Dorozhkin, Olasky, Chauhan, Flesh-man, Scott, De and Ms. Wooley and Hogg have no conflict of interest or financial ties to disclose.

Appendix

Test questionnaire

1. Which of the following is true:

a. Between 550 and 650 OR fires occur each yearb. Each year 20–30 OR fire-related injures result in

disfiguring or disabling outcomesc. One of 11 priority safety topics identified by

AORN Presidential Commission on Patient Safetyd. All of the above

2. Which of the following cannot contribute to an OR fire:

a. Nitrous oxide (N2O) sourceb. Surgical drapec. Argon (Ar) sourced. Fiber optic light

3. The ‘C’ in the RACE acronym stands for:

a. Coordinateb. Confinec. Coagulated. Clear

4. Which of the following should be avoided:

a. Placing electrosurgical electrodes in a holster when not in active use

b. Activating the ESU unit only when the active tip is in view

c. Making the surgeon aware of open O2 used. Placing rubber catheter sleeves over electrosurgi-

cal electrodes before use

5. Which of the following cannot contribute to a higher value of the Silverstein/Christiana Fire Risk Assess-ment Score:

a. Surgery above the xiphoidb. Alcohol based skin prepc. Available ignition source

d. Open oxygen delivery system

6. Which of the following is not true with regards to explosions in the operating rooms:

a. Reduced significantly from the era of ether and cyclopropane anesthesia prior to the 1970s

b. Can be caused by unprepped bowel and associated hydrogen-air-methane mix

c. Mannitol should be used for bowel preparation prior to surgery to reduce the methane production

d. Nitrous oxide usage enhances the risk for the forma-tion of potentially combustive combination of gases

7. Which of the following is not true for surgical drapes selection:

a. Oxygen Index (OI) is a measure of drape flam-mability

b. Woven cotton towels have low oxygen indexc. Drapes with high OI do not pose any fire hazardd. Polypropylene is a safer material option for surgi-

cal drapes

8. As a laparoscopic nephrectomy is beginning, the surgi-cal drapes catch fire from the fiber optic light cable that was turned on. The immediate next step is:

a. Pull the fire alarm and activate a code redb. Stop flow of all airway gases and remove the

endotracheal tubec. Extinguish the fire with the fire extinguisherd. Remove burning and burned materials from the

patient

9. Regarding fire safety in the operating room:

a. If possible, 100% oxygen should be avoided during head and neck procedures

b. During an open tracheostomy, electrosurgery should be used when entering the airway to mini-mize bleeding

c. The light source should be turned on before the fiber optic cable is connected to the laparoscope

d. The surgical drapes should be applied before the skin prep has dried

10. While performing an open tracheostomy with a monopolar device, there is a fire in the airway. What is the sequence of events that should subsequently follow:

a. III, II, IV, Ib. I, IV, III, II

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c. III, IV, II, Id. II, III, IV, I

i. Pull the fire alarm and activate a code red ii. Stop flow of all airway gases and remove the

endotracheal tube iii. Remove burning and burned materials from the

patient iv. Extinguish the fire with the fire extinguisher

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