“Each time we have a bed, compressed gas cylinder, wheelchair, or floor polisher go flying into an MRI scanner there’s this collective wish to explain the event as some sort of freakish aberration. But how many of these freakish aberrations do we need to see before we come to terms with the fact that -to date- the radiology profession has proven unwilling to require the changes that we know would be effective in reducing these accidents?”
Tobias Gilk, MRSO, MRSE, MRI Safety Expert
Well, it has happened again. Twice actually. Two recent news stories highlighted the fact that we’ve sent another object flying into an MRI scanner with disastrous and, in one case, fatal results.
The first case reported in numerous news stories was about a Brazilian man killed by his own handgun while accompanying his mother for her MRI. On Jan. 16, lawyer Leandro Mathias de Novaes was wearing a registered firearm on his waistband while assisting his mother in the MRI suite when the scanner’s powerful magnet pulled the gun away from his body. The gun subsequently discharged and shot the 40-year-old lawyer in his stomach, landing him in an intensive care unit until Feb. 6, when he passed away.
The facts as we understand them – The site didn’t have a policy against companions going into the MRI scanner room, and they didn’t require people to change out of their street clothes. They did have a policy that people were to sign attestations that they didn’t have any metal (an attestation that the man purportedly signed but didn’t comply with). The man had a concealed pistol which, when he got close to the MRI scanner, the powerful magnetic energy of the MRI pulled from him and helped cause the gun to fire. The gunshot hit the man in the abdomen, and he died of the injuries several days later. As Professor Gilk (my go-to resource for all things MRI safety-related) outlines in his LinkedIn post:
“We’ve all heard (and probably repeated) tropes about the MRI technologist having ultimate responsibility for MRI safety. Those arise from the incredibly-long list of stories of techs whose training and observational skills have stopped off-duty police officer with a firearm, or transport with the wrong wheelchair, or anesthesia with a steel oxygen cylinder, or the patient with the lifelike prosthesis, just before the door into the MRI scanner. These ‘good catch’ happy accidents are so well known in our profession we’ve built de facto practices around the unblinking vigilance of MRI techs (often in lieu of system-level MRI safety practices).”
Tobias Gilk, MRSO, MRSE
The second example was reported just this week and happened in a hospital in the United States. In this case, the object was a hospital bed/gurney with multiple injuries.
The facts as we understand them –
• A senior MR tech was on duty but not immediately in the magnet room.
• The MRI’s undockable table was out of the magnet room to allow the transfer of the bed-bound patient.
• A nurse and tech aide brought patient-on-gurney into the magnet room.
• Patient was thrown off the gurney as it was drawn to and struck the MRI scanner (patient relatively unharmed).
• Nurse was struck by the gurney, and is reported to have suffered a broken femur and fractured pelvis.
The prevailing opinion shared extensively in most public relations campaigns is that MRI is the “safe modality. As Professor Gilk points out:
“To be clear, MRI injury accidents have been, and remain, rare, but in nearly every case of MRI injury accident there was an existing, well known and widely promulgated best practice prevention that wasn’t used. In other words, we could -if we so chose- prevent nearly every MRI injury accident that occurs… we just choose not to.
Tobias Gilk, MRSO, MRSE
To support his statement, Professor Gilk has created a chart that depicts the current state of MRI safety by looking at MRI accident rates.
The red line represents growth in MRI adverse events, and the blue line represents growth in MRI exam volume. If you apply ‘best fit’ slopes to each of these two datasets, you learn that reported MRI adverse events are growing at rates between 2x and 4x the rate of growth of MRI procedure volume (depending on the weighting given to the 2008 – 2012 ‘hump’ of MRI adverse events in the data). To quote Professor Gilk:
“Put simply, this data indicates that MRI adverse events are both greater in number, and represent a greater proportion of MRI exams, than twenty years ago. An MRI patient, today, appears to have a greater likelihood of an adverse event than an MRI patient in 2001. Despite more experience and more knowledge, we’re producing more MRI adverse events… Facts that shouldn’t coexist.”
Tobias Gilk, MRSO, MRSE
So what should be done to correct this problem? The industry, and each MRI provider, need to take long hard looks at their practices and identify ways in which their assumptions and ‘the way we’ve always done things’ might contribute to our national growth in MRI adverse events. Professor Gilk has studied how effective existing, established best practice standards can be at preventing MRI projectile accident injuries. In the most recent study for Metrasens, the more current data found that -for the two years studied- these same three existing best practice protections would have prevented 100% of the patient injuries from MRI projectiles.
In addition to the nine steps highlighted in the Metrasens study cited above, I always recommend the following to imaging providers:
- Appoint an MRI Safety Officer for your organization – That person is charged with reviewing, revising, and communicating all MRI safety protocols throughout the organization. Recommended responsibilities for management of MR safety guidelines can be found here: https://www.ismrm.org/smrt/safety_page/Recommended_Responsibilities_for_Management_of_MR_Safety_JMRI2016.pdf
- Review your MRI safety protocols annually and whenever equipment changes are made – This is an important step often glossed over by many organizations. It is critically important to do an extensive review if a new scanner is purchased.
- Conduct regular MRI safety training for all staff involved with patient care, including transport, nursing, etc. Training is available through AppliedRadiology.com. Programs for MR personnel include: “Introduction to MRI Safety,” “Basic MRI Safety Training,” and “Advanced MRI Safety Training For Healthcare Professionals.” Please visit appliedradiology.org/MRISafety/. Videos Available on IMRSER include MRI Safety Training Programs for Levels 1 and 2 MR Personnel, What to Expect During Your MRI, Projectile/Missile Effect videos, and Superconducting magnet quenching shown from both inside and outside the MR system room. Visit: IMRSER Videos.
- Keep a continuously updated list of MRI-safe implants and devices – A sample list can be found here: http://www.mrisafety.com/TMDL_list.php
- Ensure you have implemented the 4-Zone MRI safety system linking screening/supervision.
Until we take the well-known steps which prevent those injury accidents, we’re going to continue to experience these head-scratching moments every time another missile-effect injury (or worse, death) is reported.
Additional resources:
- Gilk Radiology Consultants website – https://gilkradiologyconsultants.com/blog/the-mri-accident-chart-2000-2020/
- MRI Safety website – http://www.mrisafety.com
- Applied Radiology MRI safety training courses – https://www.appliedradiology.org/MRISafety/default.aspx
- Institute for MRI Safety, Education and Research videos – http://www.imrser.org/genpg.asp?pgname=VideoList
- American College of Radiology MRI Safety Manual – https://www.acr.org/-/media/ACR/Files/Radiology-Safety/MR-Safety/Manual-on-MR-Safety.pdf
- American Board of Magnetic Resonance Safety website – https://abmrs.org
- MRI Zones: A Guide for Radiology Technologists – https://www.medical-professionals.com/en/mri-zones-guide/
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