News broke the other day of a nurse in England who was in agony for three months following a routine surgery during which her gall-bladder was removed. Fearing an infection, she was sent for an MRI. Unfortunately, the MRI could not be completed as the magnetic field began torquing the 7-inch pair of forceps that had been left inside her abdomen during the surgery, causing excruciating pain!
According to the news accounts, her concerns about something having been left in her from the surgery were laughed-off: “The times of leaving instruments inside you are long gone.”
Returning to her own hospital, she got an X-ray which showed just how wrong that statement is…
X-ray Image Showing Forceps. Image From www.thesun.co.uk
While retained surgical instruments (or fragments of instruments damaged during a procedure) are certainly a rare event, the fact that they occur illustrates just how vital a thorough and comprehensive pre-MRI screening is. Often patients are unaware of the risks to their own safety that they bring with or on them (or, in this case, ‘in’ them).
Nothing is foolproof, but our historical MRI pre-screening methodologies, alone, let far too many dangerous items through. As indicated in the new Guidelines building code for healthcare facilities, ferromagnetic detection is an important new adjunct that can help reduce projectile risks in the MRI environment.
As of this writing, no ferromagnetic detection (FMD) system has been approved by the FDA as a clinical device for finding ferromagnetic materials within the body of the patient, so this is not an evangelistic call for using these tools for looking for retained surgical instruments. I only mean to illustrate how many different ways that people (patients and staff alike) can unwittingly bring dangerous ferromagnetic materials into the MRI suite.
Perhaps FMD systems wouldn’t have been helpful in this case (though there are many accounts of incidental findings of ferromagnetic objects within the bodies of patients with these tools), but for every pair of retained forceps that make it into the MRI, how many gurneys, wheelchairs and floor polishers do? And we know that FMD systems can and do help to find these!
Tobias Gilk, President & MRI Safety Director Mednovus, Inc. Tobias.Gilk@Mednovus.com www.MEDNOVUS.com
