“You don’t know what you don’t know.”
This phrase isn’t meant to make anyone feel small. It doesn’t mean “you should know,” or “everybody else knows this,” or even that “the guy writing this knows.” This phrase is very democratic… it applies to each of us (particularly the guy writing this).
What it means is that, if our brains are libraries, even big ones, there’s only so much information that can fit inside. We may know the next 10, 100 or 1,000 books we want to add to our mental Alexandria, but we can’t want (or even hate) the book that we don’t know exists. The same is true of MRI safety.
We think that MRI accidents come from a limited menu; burns, projectiles, screening misses. The fact is that the contributing factors to any one accident often include a combination of operational, training, clinical and physical considerations.
Perhaps the most dangerous response to the potential of any MRI accident is, “oh, that can’t happen here because we’ve done ________,” as if any one factor is enough to eliminate the risk of accidents. The fact is that all protections fail.
“What about a suite with two trained Technologists and an MD immediately available? Surely we can rule out staff problems, right?”
“For our anesthesia cases, we have medical gasses piped into the room, so that risk goes away, right?”
“We don’t share the MRI suite with other modalities, so access from unscreened or unauthorized personnel isn’t a risk, right?”
Would you be surprised to learn that the suite where the most infamous MRI fatality occurred had two on-duty Techs, an MD in the suite, piped-in medical gasses, and a dedicated MRI suite?
Each of these are partial protections, and each of these can fail. What happens if your staff isn’t effectively trained (not what they can recount on a ‘quiz’, but the behaviour they would exhibit in an emergent situation)? What if the oxygen supply stops? What happens if an unscreened / unauthorized person enters the suite?
It’s ‘Murphy’s Law’… everything breaks down and the thing you depend on most will break down when you need it the most. The same applies to your MR suite safety features, which is why one is never enough for any risk factor.
Some decry layers of protection as redundant. I mean, do we really need 4-zones? What about ferromagnetic detection?
Have you played the ‘what if’ game? What if there are holes in your MRI safety net? What if transport circulates the door access code? What if engineering responds to a faulty smoke detector alarm at 4 am? What if the new guy in housekeeping wants to make a good impression by buffing the magnet room floor, even though nobody asked him to? What if a patient codes while one tech is taking a bathroom break? What if you find a pacemaker on a scout scan?
We don’t need reinforced frames, seatbelts, or airbags in order for our cars to take us from point a to point b. Similarly, in the strict sense we don’t really need MRI safety in order to have MRI imaging.
But just as if we stripped our cars of the safety glass, crumple-zones and eliminated crash-tests, we would imperil MRI imaging if we didn’t protect our providers and patients with fundamentals such as access controls, comprehensive screening and ferromagnetic detection.
Just because you don’t know what you don’t know, doesn’t mean you can’t learn it.
Tobias Gilk, President & MRI Safety Director Mednovus, Inc. Tobias.Gilk@Mednovus.com www.MEDNOVUS.com
