By Ray Reynolds and Keith Brower
As firefighters, we know smoking is the leading cause of civilian fire deaths and injuries in the United States. For decades, the fire service has been focused on the general hazards of smoking. A new awareness of a subset of smoking fires, those involving home oxygen therapy (HOT) equipment, is provoking the need for action, in the domains of community risk reduction (CRR) and firefighter risk reduction (FRR), and in the healthcare regulatory world.
In Nevada, Iowa, there were two recent HOT fires related to smoking within a year. The fires caused two civilian fatalities, and two others were severely burned. The ripple effect resulted in over $1.4 million from property loss and medical care. This scenario is playing out across the country.
- Ventilation-Limited Fires and the Influence of Oxygen
- How You Will Have Your Oxygen: Gaseous, Liquid or Solid State
It is estimated that HOT fires are the cause of one civilian fire death every four days. Dr. Clifford Sheckter, assistant professor of surgery and director of the Santa Clara Valley Medical Center, estimates the 10-year cost of treating burn patients at $175.11 million, with property loss at $430.89 million. These figures do not include the costs associated with firefighting. HOT fires present a significant risk to firefighters, as it is estimated that two firefighters die annually from HOT fires, and many more are injured. On June 6, 2023, five Tacoma (WA) firefighters were injured when a ceiling collapsed on them during a large apartment building fire caused by smoking and oxygen use.
At 9:14 pm, last night, firefighters were dispatched to a 2-Alarm apartment fire in the 7600 blk of Pacific Ave. The first arriving companies reported heavy smoke and flames showing from a second-floor unit. Two occupants were transported from the scene in stable condition. pic.twitter.com/5nIwTwBxW3
— Tacoma Fire (@TacomaFire) June 6, 2023
(1) A Tacoma (WA) apartment HOT fire at 7611 Pacific Avenue injured five firefighters and two residents.
Mechanics of HOT Fires
Home oxygen therapy is designed to help people with chronic lung disease, emphysema, sleep apnea, and other breathing problems to live. Low blood oxygen levels, or hypoxemia, will damage organs and can lead to death. HOT patients may also develop other medical conditions which render them partly or fully immobile. Therapy equipment normally consists of an oxygen supply source (pressurized metal cylinder); a regulating device, designed to meter the prescriptive flow of oxygen; and tubing to convey oxygen to the patient. While oxygen flows to the patient, the air around the patient’s face is enriched with oxygen.
When a patient smokes while using home oxygen, the process can lead to a flash fire on the patient’s face, which can spread quickly to clothing and nearby combustibles. In a panic, patients are often not able to shut off the tank, and the fire, now fully oxygen-fed, grows to rapidly involve the structure.
It is not just smoking that causes these tragedies. Any exposure to open flame while using home oxygen can result in an explosive fire. The source could be an open flame from a stove top burner, a candle, or flame from a fireplace. The American Burn Association recognized the increased severity and mortality of home oxygen burns long before the fire service. Dr. Lucy Wibbenmeyer, burn director at the University of Iowa hospitals and clinics, has been advocating to end these needless fires. “What got me is how preventable this injury was and how unnecessary the cost of life associated with it was,” says Dr. Wibbenmeyer. “Individuals incurring burns while using oxygen are more likely to die than similar burns.”
If your fire department has had a home oxygen therapy fire, scan this QR code to help collect the data needed to bring attention to HOT fires.
The International Association of Fire Chiefs (IAFC) Fire and Life Safety Section noticed a disturbing trend with HOT fires in the U.S. around 2020. The HOT working group was formed in May 2023 to be a national voice to reduce these fires. More than 35 agencies, including the fire service, burn centers and associations, as well as healthcare equipment suppliers, have aligned for this effort. Since inception, this group has focused on reducing HOT fires. Among the strategies, educating firefighters and including this component in a community’s risk assessment (CRA) are paramount. Additionally, improving data collection for residential fires will help to better demonstrate this problem. Smoking fire data must be refined to isolate oxygen use as a contributing factor. For better “real-time” reporting, the working group has developed this survey link to assist in this effort.
HOT Engineering Solution
There is an engineering solution, known as the “thermal fuse.” The thermal fuse (Cannula RES1107FS) is a bi-directional valve that is inserted in the oxygen supply tube line just prior to the tubing at the patient’s face, which shuts off the flow of oxygen when exposed to fire. The cost for a pair of fuses is less than $8.00 dollars. Over nine million thermal fuses have been installed worldwide. The United Kingdom (UK) tracked thermal fuse use from 2013-2017 and reported 63 serious incidents, with only one fatality reported.
For more information, click here or view the video below with Chief Reynolds.
Why Aren’t Thermal Fuses Used More?
The U.S. Census data estimates that over one-third of the nation’s insured population is covered by Medicare and Medicaid. The Centers for Medicare and Medicaid Services (CMS) has been approached to create a national reimbursement code for thermal fuse devices. This would allow the fuses to be included as a component of durable medical equipment (DME) along with other oxygen therapy equipment and thus proliferate their use. This effort has resulted in many meetings with CMS, but has not yet been successful, despite the UK data and the fact that the U.S. Veteran’s Administration (VA) has required these devices for oxygen therapy equipment since 2018. It is hoped that further research into the VA experience and improved reporting will yield data to convince CMS to create this national reimbursement code.
Absent a federal mandate, states must act to approve reimbursement. Five states—Iowa, North Dakota, Washington, Missouri, and Kansas—have done so. Hopefully, Ohio will approve of this soon. The end game, however, is a national reimbursement model. The fire service, and the allied professions which support us, must take an active role in data collection, public education, and overall advocacy if thermal fuse technology is to be maximized. Only then will the risk to the public and firefighters be minimized.
KBYG Note from Jack Murphy
This HOT fire incident article is a national example of how a local CRR program can address a life safety issue and seek an FRR solution to a response challenge. To read about how a local fire department can get more involved in codes and standards, read the Fire Engineering article “Codes and Standards: A Matter of Firefighter Risk Reduction and Community Life Safety.” (January 2025)
Ray Reynolds, from Nevada, Iowa, is a fire chief who oversees a volunteer department of forty-five members. He also works part-time on the job as a fire lieutenant/paramedic for the city of Bondurant, Iowa. He previously served as the 13th State Fire Marshal from 2010-2013. He is a member of the IAFC Fire and Life Safety Section and chairs the HOT working group. rreynolds@cityofnevadaiowa.org
W. Keith Brower Jr., is a special projects contractor with the National Fallen Firefighters Foundation (NFFF). He retired in 2018 from the Loudoun County (VA) Combined Fire and Rescue System, where he served for 45 years, notably as the chief fire marshal and fire chief. He primarily represents the NFFF on the Vision 20/20 Project but is also active in community and firefighter risk reduction projects with the IAFC, IAFF, and NASFM. kbrower@firehero.org
