By Gary Evans, Medical Writer

In what may be a tipping point in the long struggle to end surgical smoke exposures in the operating room, Rhode Island has become the first state to mandate that healthcare facilities take measures to protect healthcare workers (HCWs) from the hazardous plume.

Testifying before passage of the bill recently was Julie Greenhalgh, RN, an operating room nurse with 42 years of experience in Cranston, RI.

“As a young nurse, we were at the beginning of cauterization,” she said. “We knew that it smelled — a powerful, obnoxious odor — but we weren’t aware of the side effects.”

She attributes her chronic lung disease to decades of occupational exposure to surgical smoke.

“I have a constant cough, bronchitis, and asthma,” she said. “I have never smoked cigarettes and never had asthma as a child.”

Testifying at a Feb. 14, 2018, hearing on the bill, Greenhalgh held up a plastic bag of medications she uses to treat her lung disease.

“I have three inhalers that I use every day as well as some oral medications,” she said. “I have been trying to promote this for many years. Passing this bill will allow nurses to work to save patient lives without putting their own lives in danger.”

Effective Jan. 1, 2019, the Rhode Island law gives hospitals and surgical centers 90 days to submit a policy to state health officials detailing their plan for “evacuation of surgical smoke plume [as] required in operating rooms.”

Terri Plante, RN, an operating room nurse with 16 years’ experience, also testified in support of the bill, describing working in ORs with and without smoke evacuation equipment.

“If you are not using smoke evacuation, the smoke comes up from the surgical incision,” she said. “Your eyes burn, your throat burns, it’s in your hair, and your clothing smells. The smoke travels throughout the entire operating suite. It travels under the door and into the hallways.”

In contrast, use of equipment to remove the plume is “100% different,” she added. “You are not choking and coughing and there is no smell in the operating room.”

Some hospitals have the surgical evacuation equipment in use, but others use it only according to the surgeon’s preference. Echoing a common complaint about the situation, Plante said OR nurses are exposed for longer periods during multiple procedures by different surgeons.

“As nurses, we are there for 8-, 10-, and 12-hour shifts for three, four, and five days a week. [That is] a lot of exposure. It’s pretty bad,” she said.

Highlighting the toxic nature of surgical plume was Danielle Glover, MPA, associate director of government affairs at the Association of periOperative Registered Nurses (AORN). “There are 150 chemicals in physical plume,” she testified at the hearing. “[It contains] toxic gases such as carbon monoxide and hydrogen cyanide, carcinogenic and mutagenic substances.”

Will OR Nurses Leave Field?

Signed into law in June 2018, the legislation was originally introduced by RI State Rep. Joseph M. McNamara, who was convinced in part by the hazard data.

“I looked at the statistics related to the ascent of surgical plumes, especially data [for] nurses in the OR exposed to this for long periods of time — five or six hours,” he tells Hospital Employee Health. “It was the equivalent of smoking half a pack of cigarettes a day. It really has a cumulative detrimental health effect on these individuals.”

This contention has not been without controversy, as skeptics and critics claim the threat of surgical plume is being overstated to sell the evacuation equipment. (See related story in this issue.) However, no one testified in that regard at the Rhode Island hearing, with McNamara saying the primary pushback during discussions was the cost of purchasing and implementing the equipment.

“With these surgical teams and the level of training these individuals have, certainly any expense would be mitigated by them not being exposed to these plumes and surgical smoke,” McNamara says. “It is detrimental to their health, and therefore they don’t want to participate in this line of nursing. That is a real cost — highly trained people are leaving this profession because of the environment they have to work in. They know it is unhealthy.”

Having done some basic dissection work with scalpels in college, McNamara was impressed by the equipment when he tested it by cutting oranges.

“The devices I tried had the evacuation systems hooked up to them,” he tells HEH. “I was amazed at the precision of these instruments. It’s a small hose that is attached to the end of the instrument that is very light and swivels 360 degrees.

State by State?

Saying he hopes Rhode Island inspires other states to follow suit, McNamara argues the increasing use of technology like laser surgery and electronic scalpels underscores the need to address the issue.

AORN certainly sees the Rhode Island law as a model for other states, and also is concerned about nurses leaving the field, Glover says.

“This is definitely a concern that we hear,” she says. “Perioperative nurses are twice as likely as the general public to develop respiratory illnesses. When you are being exposed to smoke on a daily basis — all of the toxins and the mutagenic, carcinogenic substances in it — this is definitely something that we have heard from our nurses.”

AORN will be in touch with its members in Rhode Island to help them comply with the law.

“The law requires the adoption of policies that require the evacuation of surgical smoke,” Glover says. “What a hospital or an ASC policy says is not outlined in the legislation. They can do what works best for them. There is a lot of flexibility for facilities.”

AORN has resources available for facilities that want to go smoke-free, encouraging voluntary efforts while it continues to lobby for state laws.

“Colorado had legislation last year that was very like [RI], so more states are looking at this and considering it,” she says. “Part of it is about raising awareness of the issue and making sure that the education is out there.”

Half a Million Exposed

In that regard, the National Institute for Occupational Safety and Health (NIOSH) reports that almost 50% of workers who may come into contact with surgical smoke have never received any education about the mix of chemicals and biologicals found in the plume. “Each year, an estimated 500,000 healthcare workers, including surgeons, nurses, anesthesiologists, surgical technologists, and others, are exposed to laser or electrosurgical smoke,” NIOSH reports.1

Plume removal advocates in California pushed a bill that made it as far as the governor’s desk this year, but it was vetoed and rerouted through California’s Division of Occupational Safety and Health.

“They are looking at going through the regulatory route,” Glover says.

The Rhode Island law is not tied to state or federal OSHA, which has no specific regulation on the issue and can only protect workers in the OR though its general duty clause.

“The general duty clause is insufficient because it is not specific about what exactly a safe workplace is and they don’t provide clear guidance on smoke evacuation or elimination,” Glover says. “That creates a lot of inconsistencies between facilities and systems. At this point, OSHA recognizes the dangers of surgical smoke, but there is no clear guidance [for evacuation].”

As a result, the protracted status quo finds many healthcare workers inhaling surgical smoke daily because there is little federal or state enforcement and their hospital leaves the decision to the preference of surgeons. While surgeons often are typecast as highly individualistic “cowboys,” more of them may gradually accept the equipment as early adopters like Christian DiPaola, MD, and normalize the practice.

“When I was a resident in an orthopedic surgery, nobody really used the smoke removal devices,” says DiPaola, an orthopedic surgeon specializing in spine procedures at the University of Massachusetts Medical School in Worcester. “It was something that always bothered me. It is annoying and noxious. Smoke is no good for you — that is obvious.”

Nurses complained, but DiPaola says many of his surgeon colleagues said the plume did not bother them. Given NIOSH reports of the toxins and carcinogens in the smoke, he compares the current situation to having employees X-ray patients without taking the well-established measures to prevent occupational radiation exposures.

“If people didn’t pay any attention to that, heads would be rolling,” he said.

DiPaola started looking into surgical smoke removal after his fellowship in a hospital that used evacuation devices. He even tried to invent his own, eventually getting in touch with a manufacturer selling a design that suctions the smoke right as it is released from the scalpel, eliminating the need for handheld tubes that are sometimes used.

The hospital accepted his proposal to stock the disposal equipment, but did not force other surgeons to follow suit.

“The day I started using it, I never went back,” DiPaola says. “I won’t do a case without it. I even use it for very small cases, but in the big scoliosis cases that I do, you cauterize a lot.”

The nurse reaction was immediate and favorable, but other surgeons continued to work without plume removal.

“Ultimately, what goes on in the surgical field is the surgeon’s choice,” he says. “The nurses appreciated the air quality in the room and I thought, ‘This is something we are doing for everybody, not just for me.’ It didn’t add any complexity to my operations — it’s just a little piece of foam that sticks out.”

Within the hospital, the use of the evacuation device has grown slowly, as others are gradually exposed to the equipment and the difference in OR air quality.

“Almost invariably, the people that try it don’t stop and go back,” he says.


  1. Steege AL, Boiano JM, Sweeny MH. Secondhand Smoke in the Operating Room? Precautionary Practices Lacking for Surgical Smoke. Am J Ind Med 2016;59(11):1020–1031.