(Not) Too Late For MRI Safety…

I apologize for my unusually long hiatus from posting. I’d love to tell you that I haven’t written because I’ve been so extraordinarily busy putting the final touches on a set of meaningful standards which will effectively protect the 30,000,000 (that’s million) annual MRI patients in the U.S. from the most frequent preventable MRI injuries. I’d love to tell you that, but it’d be a lie…

Not that I haven’t been working on MRI safety issues, but I don’t have nearly as much to show for this effort as I’d like. I think that’s part of the reason why I stopped writing here for a while. I was dispirited at my inability to land a killing blow on any one of my target windmills, and cataloging your failures in print isn’t always cathartic. So it took something to grab me by the figurative lapels and shake me, and that something came the other day in the form of a phone call from a dear friend. My friend went for an MRI and something that happened during that exam spurred him to call me afterwards.

As the ‘MRI guy’, I am used to getting calls or emails from friends who have been prescribed MRIs – or their loved ones have – and they’re looking for assurances that everything will be OK. I’ve also been on the receiving end of calls of friends who’ve just had an MRI, wanting to know if ‘it was supposed to be that loud?’ or ‘what did it mean that they said I was moving too much?’ This time, however, the call was a long distance admission of guilt.

My friend went for his MRI straight from work. He’s a normally fit and healthy adult and the MRI exam was scheduled at a pretty prestigious teaching hospital in his area. He walked in, gave the perfunctory ‘yeses’ to all of the screening questions. He emptied his pockets, went into the magnet room, hopped on the MRI scanner patient table, and was slid, head first, into the scanner. A moment later, he felt something moving at his thigh.

Turns out he hadn’t emptied all of his pockets. He had one of those folding multi-tools tucked in a pocket that he hadn’t checked, and he could feel it being pulled towards the magnet. Next thing he knew, it slid from his pocket and struck him on the elbow, right on the funny bone. Fortunately, he wasn’t injured, but he said that it hurt like hell for a while after. He knew what was happening, as it was happening, and instantly chastised himself (as he thought I would), for not checking and double-checking before his MRI.

Multi-tool

Example of a multi-tool, opened up.

His call to me to recount his story shook me out of my hiatus.

We think of MRI accidents as being that which happens to ‘someone else’. We like to think that these accidents happen to patients who don’t understand why MRI screening is important, not good friends of MRI safety experts. We like to think that these accidents happen at disreputable MRI providers, not major academic medical centers. We like to think that these accidents only happen with under-qualified techs at the helm, and not well educated and credentialed technologists.

In the past 12 months I’ve had two friends tell me stories of their own MRI personal MRI mishaps. One was a failed screening which (by dumb luck and not because of anyone’s intentional actions) turned out to be a minor threat, and this past week’s story which could easily have resulted in a very serious injury. I have no expectation that I will ever see either of these events in a public reports of MRI accidents. They won’t be part of the quantified record of MRI accidents, and yet they occurred, as do thousands of others every year.

These preventable accidents are endemic to MRI in the U.S., and that’s inexcusable. We know what the root-causes are of nearly every MRI burn, projectile, and hearing injury. We know what the preventative steps are. And I won’t rest until it is an explicit part of the mission of every MRI provider to implement the protections that will prevent these types of accidents and injuries.

I hope I’m not too late.

Tobias Gilk,
 
President & MRI Safety Director — Mednovus, Inc.
Tobias.Gilk@Mednovus.com
www.MEDNOVUS.com
 
Sr. Vice President — RAD-Planning.com
TGilk@RAD-Planning.com
www.RAD-Planning.com
 

Click for Tobias Gilk's Twitter PageClick here for Tobias’ Twitter Profile

4 thoughts on “(Not) Too Late For MRI Safety…

  1. Stephanie

    I was wondering if you had a source for the pic above of a bed in a scanner. I am trying to discover if this is a real or staged picture as I see it a lot. I can’t tell where the table for the scanner is in the picture which is why I am suspicious of it.

  2. Tobias Gilk Post author

    Stephanie,

    I wish I did have a source for this image. This one, like virtually all circulating MRI accident pictures, are ‘orphans.’ Someone who took the picture (or to whom it was given) decided to share it, but didn’t want the location identified.

    The most important element of learning from these other accidents is how they occur (and how to prevent them), and not the name of the facility at which it happened.

    Tobias

  3. Tim

    That is a real photo from a site in Boston that wants to remain nameless.

    I think your article misses the point that all of these incidents are due to human error. You can hope to prevent them by using multiple strategies from the Manufacturer, Provider and Technologists but there are always ways that humans will fail to follow them.

  4. Tobias Gilk Post author

    Tim,

    The overwhelming majority of MRI injury accidents are a direct result of human error, that is true. But both errors and the negative outcomes of errors can be reduced when we look at the factors involved and seek to create conditions that promote the more favorable outcomes. Look at automobiles, for example. We can reduce the number of accidents through more effective roadway design (lane width, lines of sight, signage, lighting, traffic-calming mechanisms, etc…), and we can reduce the risk of injury (door rails, crumple-zones, shoulder belts, airbags, etc…). Ultimately, the ability of the driver is central to any question of automobile accidents and injuries, but there are so many things that can be done (and have been done) to reduce the risk environment by both reducing the potential for accidents and the likelihood of injury from those accidents that do occur.

    Contrasting MRI accidents with automobile accidents, we – as an industry – have done a comparatively poor job identifying the ways in which accidents occur, how to effectively and consistently prevent them, and how to reduce the potential for harm when those accidents do occur.

    I hope this is helpful.

Leave a Reply

Your email address will not be published. Required fields are marked *

CAPTCHA
Change the CAPTCHA codeSpeak the CAPTCHA code