The National Council on Aging just released a study which details these alarming numbers. The matter-of-fact language of their release did nothing to diminish my welling fear as the study went on to detail chronic failures in our healthcare system to educate, alert, and prevent the dangers inherent in MR imaging of medical implant patients. Here are a few of the particulars:

• Medical implant patients over age 65 have between a 50% and 75% chance of requiring imaging during the useful life of their implant.
• While 90% of physicians knew of MRI risks for some pacemakers, over half of doctors say that they aren’t informed about imaging limitations when a patient is implanted.
• Nearly a third of patients who receive medical implants are not informed of MRI restrictions.
• After exposed to the MRI risks to their implant, nearly 20% of these device patients experience some sort of problem or malfunction with their implant.

Example of a Pacemaker Pulse-Generator Which Could Present Dangerous Contraindications For MRI Exams

The near universal opinion (98%) of healthcare providers is that they require additional information and training on these MRI safety risks.

Let’s hope that regulatory (FDA and States) and accreditation (JCAHO, ACR, and IC) bodies for MR imaging look at ways that they can take a more active role in promoting education and protecting these patients.

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But then, typically after I’ve lost all hope of seeing anything that approaches reality, something plausible and even downright real is shown on one of these programs…

OK, so there are probably 100 unreal aspects to the above clip (like MD’s, even though they’re residents, bringing the patient to the MR to run the scan themselves). But the main message, the patient bed being drawn to the MR, is a concern. And the concern is not theoretical, but is in fact quite real.

Beyond the above photo, an anecdote was shared with me by a trusted source of an accident somewhat similar to the video clip above.

In the story, an end-stage AIDS patient in a hospital is brought down for an MRI and, like in the video, is transported into the MRI scanner room on a conventional hospital bed. As in the video, the magnet attracts the bed which rolls across the floor until it strikes face of the MRI machine. The impact of the front end of the bed (where the patient’s feet are) against the machine causes the back end of the bed (where the patient’s head is) to lift up off the ground momentarily. The magnetic field of the MRI is pulling on the back end of the bed, however, and essentially catapults the back end of the bed over the front end, smashing the patient’s face and upper-body against the outside of the MRI scanner.

According to my source, the patient died a couple days later and the official cause of death was identified as ‘complications from AIDS’ and there was no explanation offered for the severe facial contusions and fractures that were present at the time of death.

Now, I wouldn’t suggest that you take every fish-story you hear at face value, but the more I learn about the breadth and breathtaking frequency of MRI projectile accidents, the less skeptical I’ve become about the relative ‘impossibility’ of the anecdotes I’ve heard. Some of the most outlandish and improbable have proven to be true.

Per the aphorism, “as soon as you make something foolproof, they come out with a better fool,” there is no way to 100% prevent projectile accidents in the MRI suite. However, the fact that we can’t make a safety solution ‘foolproof’ is no reason to reject the healthy improvement that we can make with improvements to process and technology.

Appropriate staffing levels, regular MR staff training, access controls tied to screening protocols, and ferromagnetic detection systems all help to reduce the risks of projectile accidents in the MRI suite. The first three of these four options have been well known elements of MRI safety for years, and yet projectile accidents keep occurring and the overall rates of MRI accidents appears to be climbing… alarmingly.

Simply put, we have the ability to make these sorts of accidents largely fictional, left to ER and House, but we haven’t done so. And when prime-time television is more honest about MRI accidents than the industry is (even if their honesty is purely coincidental), we’ve all got a way to go.