About Tobias Gilk, Editor

This blog is written, edited and maintained by Tobias Gilk, a certified MR Safety Officer (MRSO).

Tobias offers a vendor-neutral consulting service for radiology / imaging providers, providing guidance with respect to safety, operations, best practices, and accreditation standards (such as those from the Joint Commission and the American College of Radiology).

Additionally, Tobias is a Board member and officer of the American Board of Magnetic Resonance Safety (ABMRS), serves as Senior Vice President of RADIOLOGY-Planning (a company that designs radiology, nuclear medicine and radiation therapy facilities for healthcare providers), and was the former President and MRI Safety Director for Mednovus (a manufacturer of ferromagnetic detection products). Tobias is a prior member of the ACR’s MR Safety Committee (chaired by MRI safety expert, Emanuel Kanal, MD) and one of the co-authors of the ACR’s Guidance Document for Safe MR Practices: 2007, is a former member of the Corporate Advisory Board for the Institute for Magnetic Resonance Safety, Education and Research (founded by Frank Shellock, Ph.D.), and has written or contributed to a combined total of hundreds of articles, presentations and best-practice standards documents on MRI safety.

Tobias’ articles are published widely, and he is a highly regarded speaker and consultant on MRI safety issues, having been invited to present at national and international conferences and meetings.

This blog represents Tobias’ individual professional musings and are not necessarily those of any of the organizations or companies with which he is associated.

Want to contact Tobias? You can reach him via the contact information at the bottom of each of his posts on this blog, or contact him through Facebook by clicking the link below…

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Or contact him through Twitter via his profile there…

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32 thoughts on “About Tobias Gilk, Editor

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  8. Matt Woods

    Tobias I work at a Hospital that just recently moved our MRI from a trailer parked on the lot to inside the Hospital. My boss and I are trying to revamp our Safety manual as there are a few more people with access now. We do all the normal screening and questions but would like to have a video to share with new hires and all personel not associated with the radiology department. I was wondering if you could give me a website and or place to purchase a video and any tips on making a easy to understand mri safety protocol. We have never had a problem with MRI safety yet and are trying to be proactive. Thanks for any help you can give me. Matt Woods Rt(R)(MR)

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  11. kim Greco

    Ryan,
    Do you have any tips on how to handle these situations? I am currently working in an MRI clinic. We have 2 MRI Technologists: hours 730-430. We have no PSA/Clerical support. Technologists are required to protocol/schedule/mail apt letters/answer phone/ screen pts/gather implant information/medical surgical reports and eventually scan the patient. As you can imagine there are many daily distractions. The technologists are concerned for patient safety/privacy.
    All scheduling is done in zone 3 which is a huge concern.(privacy) We also have a backlog of 5 weeks in scheduling due to these insufficiencies. Management was alerted.
    The technologists made suggestions to management:
    1 Technologist will work 3- 12 hour shifts to open up 3 nights per week( 430-8 pm )
    1 CT Technologist to cross train in MRI to work on the 2 days the 12 hour technologist is not here.
    *A requirement of 2 technologists in the MRI area is mandatory by policy , except for emergencies. (This happens frequently-sick, vacation etc. )
    Also a tech aid was hired to work with the 12 hour Technologist for the 3 evening shifts.
    Our concern still is the scheduling and lack of PSA/Clerical support.
    Can you imagine arriving at your doctor’s office with no one at the front desk?
    The only support is a CT PSA that calls MRI to tell them a patient is here-however that PSA is out on leave frequently or not at the desk. This is a huge problem for us.
    Can you make any suggestions to help these deficiencies? Could you provide me with a model/data to prove PSA/Clerical help is needed in this area?
    Kimberly Greco
    Kimberly.greco@va.gov

    How would I research information that states how to staff for an MRI Clinic?

  12. Tobias Gilk Post author

    Hello Kim,
    First, as a general resource, I might suggest that you look at RBMA (Radiology Business Management Association). They might have resources specific to MR staffing that would be helpful to you.
    It sounds to me as though your MR techs are being asked to do too much that isn’t scanning the patients. If you’re running with weeks of backlog, I think that there are a few things that warrant attention.

    1. before adding hours of operation, I think it would be more beneficial to have someone look at operational efficiency, from patient scheduling / screening, down to the protocols / sequences used for standard MR exams. Shaving 5 minutes off each exam can make a huge difference when evaluated over weeks / months.

    2. make better use of resources I bet you already have. I suspect that your facility has a centralized scheduling function, and I would suggest seeing if you can get them to schedule and pre-screen your patients. I would not count on this pre-screen to be thorough, so I would have the MR staff do the follow-up, appointment confirmation call in which your staff reviews the screening information with the patient, but regular schedulers should at least be able to weed-out (or red-flag) pacemaker or shrapnel patients for you.

    I hope these suggestions help, at least a bit.

    Tobias

  13. Tobias Gilk Post author

    Kim,

    Often times it is hugely beneficial to have someone from the outside come in to help streamline operations. If you ever need it, I’d be happy to recommend some people who might be able to make a huge difference for you.

    Tobias

  14. Betty M.

    My husband is scheduled for an MRI in the next week or so for some back pain. He has worked as a metal fabricator/welder for 30+ years and has been exposed to metals (steel, aluminum, etc.) for the entire time, including the inhalation of (metal) fumes. Should he have any safety concerns with how an MRI device might react during the MRI procedure? Is it possible that his body could have some lingering metal in it due to this continuous daily exposure? Any advice is appreciated. Thank you.

  15. Tobias Gilk Post author

    Betty, I’m sorry to be slow in replying to your questions. I trust that – by now – your husband’s MRI is over, and that it went smoothly. But even so, let me tackle your questions.
    Metals can be a safety risk, and an image-quality risk. I’m not aware of any reported issues with the inhalation of fumes containing metal. Interesting, but not something that I’m aware of having any safety implications.
    Any electrically-conductive material (which is pretty much all metals) can potentially be at risk of heating, but they generally have to be fairly long, and not a ‘splinter’ or a ‘bb’. Ferromagnetic materials can be risks because of the way that the MRI scanner likes to pull and twist on those types of metals.
    If your husband has any known retained metal within his body, it is extremely important to let the MRI provider know about it, in advance. Most of the time it turns out to not be a major safety concern, but we want to make sure that the radiologist who is going to be responsible for the safety of the exam helps to make that call.
    I hope this helps, even if it is a bit late.

  16. Alice Price

    I was diagnosed with a meningioma in November 2012 and have been having MRIs regularly since then. In the last 3 months, my left ankle sets off the airport metal detector. It has happened 4 times. Is it possible the metal in the contrast is accumulating in my body?
    Thank you.

  17. Tobias Gilk Post author

    A very interesting question…

    There is very recent research in the radiology journals that demonstrate that some patients (and we don’t yet know how many or why) appear to retain measurable amounts of some of the gadolinium contrast agents (linear structured agents, not any of the macrocyclics, as of yet). The amounts / concentrations of the retained contrast is very small, and I would be surprised if an airport-style metal detector would be capable of either the quantity (very small) or a diffuse distribution of contrast (if it were throughout the body). And since gadolinium contrast is typically injected into an MRI patient’s bloodstream when used, that it would accumulate in one ankle, of all the places in the body, seems to me to be very unlikely.

    I’m not sure what may be causing the metal detectors to alarm on your ankle, but in my opinion it is extraordinarily unlikely that it relates to MRI contrast. If you have any questions about this, however, I recommend that you speak with the radiologist who has read one of your recent MRI scans.

    I hope this helps.

  18. Lynds

    I need to contact Tobias Gilk ASAP. Time is of the essence. Please answer.
    Thank you,
    Lynda

  19. Rebeeca J. Reyes

    Had MRI of c spine on 5/14/14 in which tech inadvertently placed a lead apron with cable on my abdominal area. Thereafter, I felt pain in my back and shock sensations all over my body even up this day. Pain in back showed white patches and diagnosed as hypopigmentation of skin in back. Other dermatologists said it was due to severe dry skin. Also, bursting pain in head and later on MRI of head revealed 2 small lesions in brain of unknown tumors. Last Sept 6, 2016 a neurosurgeon in Chicago (I am from Las Vegas, Nv) told me that he couldn,t clear identify the lesions. They are neither epidermoid nor arachnoid cysts. Another neurosurgeon gave a conflicting opinion and advised that I see him in 6 months. I have had 3 MRIs of the brain and the lesions remain stable in size and nature. I felt pain everyday but it feels like more “shock” rather than a prolonged and lingering pain.

    None of the lawyers in Nevada would accept my case because they told me that it was hard to prove and that MRI is a very safe procedure. Other attys told me that they represent the provider in the past.
    I was also diagnosed with a small cyst in liver. The cable was close to my right abd. and the pain originated from that area. A surgeon took a small piece of tissue from lower abd. area knowing that the pain was from upper side of abdomen …… pathology report revealed lipoma.
    Right now, a lawyer friend is willing to represent me if I could have a provider/expert willing to provide an absolute causation or medical certainty that my condition was from the medical error during the MRI procedure. My PCP diagnosed me with shock and hypopigmentation of skin months after the MRI with metal. She, too, did not believe that I could have mishaps during MRI. Pls. help. I am concern of the lesions in my brain. Neurosurgeon suggested that I need MRI of brain every 6 months to evaluate if the lesions are growing.

  20. Tobias Gilk Post author

    Rebecca,

    It would be highly irregular for there to be a lead apron in MRI (lead is a frequent shielding material for ionizing radiation, such as X-rays, but has no practical use in MRI, which uses magnetism and radio frequency energies).

    It sounds as if you’re looking for a medical diagnosis, which I’m afraid I can’t give. I would encourage you to share any health concerns with your physician(s) (which it sounds as if you’re doing). I do wish you well.

    Respectfully,

    Tobias

  21. Frank Oliver

    I have 3 stents in my heart and a stapedectomy prosthesis in my ear. The first stent and the stapondicomy may be ferrous metal. They were done in the mid-1980s and so the hospital have long destroyed the records. How can I find out if they are indeed ferrous metal? I need an MRI for my prostate cancer.

  22. Tobias Gilk Post author

    Frank,

    I’m not aware of any coronary stent that was ever ferromagnetic. In my opinion, the risks -unless you were a part of a clinical trial or received a non-FDA approved device- are quite small with respect to a coronary stent being overtly ferromagnetic.

    Some stapes implants, on the other hand, have been made of ferromagnetic material. You may ask your ENT to help identify what are the likely manufacturers / models for that implant. That information may be very helpful to an MRI provider in trying to assess the relative risk of your specific implant.

    I hope this helps.

  23. Hannah

    Hi there Tobias, my name is Hannah. I am a student currently doing my clinical practicum for MRI in Alberta. I have a few questions about taking the United States MR exam, and my preceptor said that you would be the best individual to ask. First I was wondering if you knew that process of going about challenging the US exam (once I complete the CAMRT exam), who I should contact, and is there any other important information I would need? I am a dual citizen (US + Canadian) so that’s one less hurdle. Also, my preceptor said something about taking a specific safety course (I think it is more MRI?) that would help give me an extra leg-up as well, if you know of anything like that? Sorry if my questions are pretty vague, I have been web searching for some information but I couldn’t find anything! Any help would be greatly appreciated, and if you need more clarification, please let me know.

  24. Tobias Gilk Post author

    Hannah,

    I don’t know about taking the technologist registration exam here in the US (or at least not enough to be helpful about that). I am the Chair of the American Board of Magnetic Resonance Safety (ABMRS) and we do administer a certifying exam for the following roles, MRMD, MRSO, and MRSE. You can get more information about those exams here.

    There are training courses for MRMD and MRSO… I know of two providers who have regular courses on this material. One set of courses is offered by Dr. Emanuel Kanal through Northwest Imaging Forums (click here for details), and the other is a set of courses offered by Bill Faulkner (click here for details).

    I hope this is helpful.

  25. John

    MRI BURN INJURY

    I sustained burn injury during a routine MRI procedure November, 2016. The incident occurred on a 3Tesla MRI machine during a CSpine/Thoracic scan. I was positioned lying on my back and entered head first. There was no padding used during the study but no part of my body touched the walls of the machine. I held the ‘panic’ button in my right hand and my hands came together just below my sternum in a typical ‘praying’ position so my arms rested on my upper abdomen as opposed to down by my sides. The procedure was started immediately. About 10 minutes into the 2nd procedure (thoracic) I started to feel a sort of prickly vibrating heat hitting my skin. It felt like a kind of rippling wave and I started to feel quite warm. It even seemed to vibrate my T-shirt and penetrate through. It was accompanied by a loud hum which I could hear over and above the typical clicking sound. I had never felt or heard anything like this on previous MRI procedures. The sensation wasn’t excruciatingly painful like you would expect from a contact burn, so I decided I would just see it through. I believe the combined CSpine/Thoracic procedure took approximately 30-40 minutes and I felt this sensation for about the last 10-15.

    When I got off the table I felt hot and mentioned it to the technician. She said it was normal to feel a bit warm when the machine had been running for a while. As the day wore on my skin got redder. I felt and looked like I had a bad sunburn. I started applying Aloe Vera gels and lotions. By the next morning I was very red and sore. I was pretty concerned and worried there may be deeper tissue damage. The next day I went to see my doctor. She said she was unfamiliar with MRI related burn injuries but after looking at me felt it had been caused by some type of thermal exposure and advised use of cooling gels and lotions. She consulted with an MRI physicist about the problem and was told : “Regarding the burn: I’d definitely recommend the pt to be checked out by a Dermatologist. MR burns typically starts at subcutaneous fat (no pain receptors) and moves up to epidermis. If the pt was not sedated during the scan and ended up with a burn, there is a clear chance that the patient has damage under the skin that is not visible. I reached out to a Professor of Radiology at USC who looked at my story and pictures and told me this was an RF radiation burn and that I needed to be checked out by a dermatologist ASAP. This was the beginning of a nightmare that has now lasted over 6 months. I have consulted with numerous dermatologists, general practitioners and MRI specialists over this time as well as conducting my own research and have learned a lot about RF frequency injuries and SAR. One of the other MRI physicists I contacted recommended I look at the SAR readings for my tests. He said these are used as an indication of over-exposure and are usually less than 1.

    I was able to find these readings in the DICOM data on the disk (shown below). The overheating feeling I experienced started about 5-10 minutes into the Thoracic procedure which coincides exactly with the 4th thoracic sequence. I was between 2.5 and 2.72 SAR for about 7 minutes and this is when the burning occurred. These SAR reading are of course the machine estimates and not the actual SAR on my body. My belief is that sustained exposure to SAR above 2.5 was too much for my body to dissipate the heat and I burned. Having had many MRI’s in the past I wondered why I had never had any problems before, but when I looked back at the SAR readings for numerous previous exams I noticed it was never more than 1.5 and whenever a sequence showed a higher SAR it was followed by one with lower SAR etc.

    At 6 months post incident :

    Skin – My skin continues to hurt wherever the thermal rays hit it. Face, neck, arms, upper torso and some on upper thighs. Erythema still present on face, neck and upper chest. I have a little temporary relief with lidocaine based topicals and anti inflammatories. Skin continues to atrophy and now shows marked deterioration and scarring. Dermatology consultations refer to skin corrosion consistent with a thermal burn injury and talk about protracted recovery times, and sometimes permanent damage.

    Eyes – Eyes are also very susceptible to heat damage. I had an ophthalmology check a week after the injury. I am scheduled for a follow up 6 months after injury to check for cataract formation.

    Testes – After the burn there was dramatic impairment of sexual function and seminal fluid change. I was made aware that testicular tissue is very susceptible to heat related damage due to a lack of ability in this area to disperse heat (much like the eyes). Since I did suffer from some burning on my upper inner thighs, it’s possible there was heat build-up in this area. I’m working with an Urologist to determine the extent of damage and again hope it’s not permanent. Testosterone production and semen analysis is ongoing and I’ve been put on Clomid to see if function can be restored.

  26. John Bowler

    MRI BURN INJURY

    I sustained burn injury during a routine MRI procedure November, 2016. The incident occurred on a 3Tesla MRI machine during a CSpine/Thoracic scan. I was positioned lying on my back and entered head first. There was no padding used during the study but no part of my body touched the walls of the machine. I held the ‘panic’ button in my right hand and my hands came together just below my sternum in a typical ‘praying’ position so my arms rested on my upper abdomen as opposed to down by my sides. The procedure was started immediately. About 10 minutes into the 2nd procedure (thoracic) I started to feel a sort of prickly vibrating heat hitting my skin. It felt like a kind of rippling wave and I started to feel quite warm. It even seemed to vibrate my T-shirt and penetrate through. It was accompanied by a loud hum which I could hear over and above the typical clicking sound. I had never felt or heard anything like this on previous MRI procedures. The sensation wasn’t excruciatingly painful like you would expect from a contact burn, so I decided I would just see it through. I believe the combined CSpine/Thoracic procedure took approximately 30-40 minutes and I felt this sensation for about the last 10-15.

    When I got off the table I felt hot and mentioned it to the technician. She said it was normal to feel a bit warm when the machine had been running for a while. As the day wore on my skin got redder. I felt and looked like I had a bad sunburn. I started applying Aloe Vera gels and lotions. By the next morning I was very red and sore. I was pretty concerned and worried there may be deeper tissue damage. The next day I went to see my doctor. She said she was unfamiliar with MRI related burn injuries but after looking at me felt it had been caused by some type of thermal exposure and advised use of cooling gels and lotions. She consulted with an MRI physicist about the problem and was told : “Regarding the burn: I’d definitely recommend the pt to be checked out by a Dermatologist. MR burns typically starts at subcutaneous fat (no pain receptors) and moves up to epidermis. If the pt was not sedated during the scan and ended up with a burn, there is a clear chance that the patient has damage under the skin that is not visible. I reached out to a Professor of Radiology at USC who looked at my story and pictures and told me this was an RF radiation burn and that I needed to be checked out by a dermatologist ASAP. This was the beginning of a nightmare that has now lasted over 6 months. I have consulted with numerous dermatologists, general practitioners and MRI specialists over this time as well as conducting my own research and have learned a lot about RF frequency injuries and SAR. One of the other MRI physicists I contacted recommended I look at the SAR readings for my tests. He said these are used as an indication of over-exposure and are usually less than 1.

    I was able to find these readings in the DICOM data on the disk (shown below). The overheating feeling I experienced started about 5-10 minutes into the Thoracic procedure which coincides exactly with the 4th thoracic sequence. I was between 2.5 and 2.72 SAR for about 7 minutes and this is when the burning occurred. These SAR reading are of course the machine estimates and not the actual SAR on my body. My belief is that sustained exposure to SAR above 2.5 was too much for my body to dissipate the heat and I burned. Having had many MRI’s in the past I wondered why I had never had any problems before, but when I looked back at the SAR readings for numerous previous exams I noticed it was never more than 1.5 and whenever a sequence showed a higher SAR it was followed by one with lower SAR etc.

    At 6 months post incident :

    Skin – My skin continues to hurt wherever the thermal rays hit it. Face, neck, arms, upper torso and some on upper thighs. Erythema still present on face, neck and upper chest. I have a little temporary relief with lidocaine based topicals and anti inflammatories. Skin continues to atrophy and now shows marked deterioration and scarring. Dermatology consultations refer to skin corrosion consistent with a thermal burn injury and talk about protracted recovery times, and sometimes permanent damage.

    Eyes – Eyes are also very susceptible to heat damage. I had an ophthalmology check a week after the injury. I am scheduled for a follow up 6 months after injury to check for cataract formation.

    Testes – After the burn there was dramatic impairment of sexual function and seminal fluid change. I was made aware that testicular tissue is very susceptible to heat related damage due to a lack of ability in this area to disperse heat (much like the eyes). Since I did suffer from some burning on my upper inner thighs, it’s possible there was heat build-up in this area. I’m working with an Urologist to determine the extent of damage and again hope it’s not permanent. Testosterone production and semen analysis is ongoing and I’ve been put on Clomid to see if function can be restored.

    John

  27. Tobias Gilk Post author

    John,

    I am very sorry to learn of your situation. Please be aware that none of the following is medical advice, though it sounds like you are under the active care of physicians and I would encourage you to continue as needed / directed.

    You have been given – in my opinion – both good and bad information.

    Yes, the predominant theory for one type of MR burns is that it originates in or below the subdermal fat layer (I don’t know that this has been scientifically proven) where there are not temperature or pain sensors. Values for SAR, however, are NOT typically limited to below 1.0 W/kg for an MRI exam. There are different designations for the ranges that an MR scanner can operate in… ‘Normal Operating Mode’ (which is defined as having both RF and time-varying gradient power levels low enough that they’re 80% of the mean perception threshold), which limits RF power to no more than 2.0 W/kg, and ‘First Level Controlled Operating Mode’, which allows RF power of up to 4.0 W/kg. ‘First Level’ scans are presumed to potentially cause stimulation, but not harm, though there are reports of neuromuscular excitation from the time-varying gradients (which correlates with the noisy parts of the exam), and RF heating. Many sites regularly scan patients with ‘First Level’ settings for either / both RF and time-varying gradient power.

    To the best of my knowledge, while there are reports of both moderate diffuse erythema (1st degree burn, similar to sunburn) and even focal 2nd and 3rd degree burns, I am unaware of any incidents reported to the FDA or other regulatory bodies (who share these kinds of reports, publicly) in which an MRI patient had diffuse erythema-type thermal injuries that had such protracted recovery and the breadth of symptoms that you report.

    Thank you for sharing your account, and I wish you a full and fast recovery.

  28. John Bowler

    Tobias,

    Thanks for the feedback and the good wishes. Sorry for the duplicate post. You can remove one if you like. I will take the information you have given into account. Is there a way to tell from the metadata whether they used Normal operating mode or First Level controlled mode? They key is that the thermal injury coincided exactly with the jump to 2.56 SAR and then sustained levels above this for over 7 minutes. Couldn’t the sustained levels have been too much energy for my body to dissipate? I’ve had many, many MRI’s but never experienced anything like this before. Is machine malfunction a possibility? Since the machine does not measure actual patient body heat, isn’t it possible the local peak SAR was even higher but this wouldn’t be obvious ?

  29. John Bowler

    Just an FYI – The ‘sunburn type’ effect is simply a way to describe the initial appearance right after the incident and is not meant to imply that this injury is in any way similar to a sunburn. I have had many bad sunburns in my life and as everyone knows they recover after 2-3 weeks. I’m now into my 7th month with this horror and not confident it will ever heal completely. For all who are interested I have started a blog post where I will be chronicling this nightmare from beginning to end with photographs showing progress. ‘A picture speaks a thousand words’, as they say.

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