Yes, I’m talking about the ACR…

Before I launch into what they do that makes me crazy, it is only fair that I acknowledge what they do for which I am tremendously proud. The ACR has released the industry standard set of safety practices to address virtually every element of MRI safety. These practice standards could virtually eliminate all MR and MR-related adverse events, they’re that comprehensive and well developed. Three editions of these safe practice guidelines have already been published, and a fourth is in the final pre-publication steps as I write this. For one of these, the ACR deserves the industry’s thanks. For an ongoing effort that is about to produce the fourth iteration of this document, the ACR deserves praise and accolades. I wish that’s where this story stopped, but it isn’t.

While the ACR has gone to significant lengths to develop and keep current their MR safe practice guidelines, they don’t actually require them for their own accreditation clients (this despite an explicit request to do so from their MR safety committee, and even public promises that they would do so in 2009). That fact, however, hasn’t stopped the organization from promoting itself as the standard-bearer for MRI safety. Below is a screen capture of the press release that comes in the ACR’s ‘congratulations, you’ve been awarded MR accreditation’ package for all newly (re-)accredited sites.

Standard ACR Press Release For MRI Accreditation

For those who can’t read ‘microscopic’, you can click on the image to see it larger. The key phrase is in the lead sentence of the 2nd paragraph, which reads:

“The ACR gold seal of accreditation represents the highest level of image quality and patient safety.”

Click here to download the Word document template that the ACR provides on its website (which, as of December, 2011, reads exactly as the image above). Click here to see a Google search for items with exactly that sentence (will only show a couple of months of news items).

Grouping an assurance of image quality (for which the ACR does have some of the most exacting standards in the industry) with MR safety is erroneous, at best, if not outright deceit.

In order to obtain ACR accreditation for MRI, a site needs to go through rigorous image quality testing and validation. Highly specific imaging sequences must be recorded, both on quality-control phantoms (special test objects which, when scanned, can reveal several quality measures of images) and patients. A long series of images must be submitted for review, and regular followup must be done to assure that the MRI system sustains high levels of image quality.

In order to obtain ACR accreditation for the MRI physical safety criteria… well… just promise to do a safe job. That’s it!

• No requirement to have or use table pads / positioning aids (to prevent burns).
• No requirement to screen patients for clinical or physical contraindications.
• No requirement to provide patients with hearing protection.
• No requirement to label unsafe items kept in the controlled access areas of the suite.
• Heck, there’s not even a requirement to have a controlled access area of the suite!

It dumbfounds me that the ACR can put image quality and safety in the same sentence that extolls the value of their MRI accreditation program. Is it just their PR people running amok?

The ACR has been remarkably busy in the last couple of years. I mean they’ve been busy lobbying congress to require their accreditation services of all advanced imaging modalities (see the ACR’s own press release here). They might not be aware of the MRI safety situation and the constructive role that their own optional accreditation standard could have… except that it was presented to them at their Quality and Safety forum over a year ago (see the video recording here).

Personally, I find it unfathomable (and morally indefensible) to promote ACR accreditation as a safety advantage when the accreditation criteria don’t actually respond to the systemic (and preventable) accidents and injuries.

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One can only presume that this is the commentary that US States and radiology accreditation agencies have to offer on the contemporary state of MRI safety. After all, there’s been nothing more than navel-gazing when it comes to measurable changes in standards for MRI providers. Let’s break it down…

This first installment will look specifically at MRI safety standards as implemented by the American College of Radiology (ACR). By tackling them, first, I don’t mean to suggest that they’re the only concern with respect to MRI safety. In fact, in a weird, schizophrenic way, ACR has simultaneously advanced and held back MRI safety. More on that towards the end of this piece.

MRI Accident Rate Slide from ACR Quality & Safety Forum 2010

The American College of Radiology has distinguished itself with the premier industry best practice publication on MR safety, the Guidance Document for Safe MR Practices. Originally named the White Paper on MR Safety (published in 2002), its name switched to the Guidance Document with a 2004 update. I was fortunate enough to be a part of the ACR’s MR Safety Committee (the authoring body) for what became the 2007 edition.

When the Committee met at the ACR headquarters in the late summer of 2006, to review drafts and collectively decide on the final revisions, it was noted that the ACR’s contemporary MR accreditation program didn’t actually require any of the safety provisions found in the (then twice published) Guidance Document. In that meeting, five years ago, the MR Safety Committee unanimously voted to formally request that the ACR incorporate safety provisions found in the Guidance Document in the MR accreditation program (this was frightfully easy since the representatives of the College were there in the room with us).

Surrounding that Committee meeting in 2006, Nephrogenic Systemic Fibrosis (NSF) was the hot topic in MR safety. The radiology community and trade press were trading speculation, recrimination, and early analyses. The 2006 Guidance Document was held until it could be published with the collected best available information regarding NSF, which meant that it wasn’t released until early 2007.

Perhaps the ACR was waiting for the new Guidance Document to be released, I thought, so they didn’t implement any of the safety requirements in their MR accreditation program prior to the new version’s publication. So the rest of 2006 came and went, as did all of 2007, without so much as a hint that the MR Accreditation program would include the Guidance Document‘s safety standards. Nearly all of 2008 passed the same way, with no indication that the ACR intended to include it’s own MRI safety standards in its accreditation requirements. But things showed promise of moving forward at the 2008 RSNA meeting.

I learned that the ACR’s MR accreditation committee was entertaining the notion of including some elements of the Guidance Document’s safety standards and that they had asked one of their physicists (not anyone from the MR Safety Committee) to draft a checklist set of safety standards. Purportedly, at that 2008 RSNA meeting, it was proposed that the 30+ page Guidance Document be distilled to about a half-dozen check-box question. One could argue that ‘something was better than nothing’, but the notion that these questions actually captured the essential safety elements of the Guidance Document was laughable. It didn’t fly. Back to square one.

Fast forward about a year, to summer 2009, when, at the AHRA annual meeting, representatives from ACR were giving a status update about accreditation standards. It was a packed meeting as the writing was on the wall about CMS requiring modality accreditation through the new MIPPA law. In that presentation, the ACR representatives stated that ACR would be incorporating elements of the Guidance Document‘s safety principles in the MR Accreditation program. Precisely how this was to happen was yet to be determined, but it would happen.

In early 2010 CMS announced that the ACR would be one of three approved accreditation bodies to accredit imaging providers’ CT, PET, and MRI scanners to qualify for reimbursement under the MIPPA law.

I was tremendously optimistic that this new requirement status would help to remove the concern within the ACR that implementing safety standards, unilaterally, would make other accreditation programs comparatively easier, and therefore more appealing to MRI providers. Now providers would be required to get accreditation, and ACR was clearly the front-runner in modality accreditation of the three named agencies. I called the ACR and spoke with a senior person within the organization about the safety standards. That person quickly burst my bubble…

Despite the public promise to incorporate elements of the Guidance Document from the prior year, in 2010 the ACR representative told me there would be no such plan going forward because they were now an approved accrediting body under the MIPPA law. According to this person, it was determined that it would be far too ‘bureaucratically burdensome’ to have to go through CMS (a step which would be required for any change to the accreditation structure, now that it was CMS sanctioned) to update it’s standards to include the safety elements in the Guidance Document. The irony of a federal law mandating quality and safety standards being the reason that an accrediting agency claimed it couldn’t enact safety standards wasn’t lost on me. Fortunately, I was just about to get the chance to talk with the principal radiology quality and safety person at CMS to let her know what I thought of their safety-inhibiting bureaucracy.

In the summer of 2010, I was a participant in a joint presentation on MRI safety between the FDA and CMS.  One of the CMS representatives in that presentation was Jeannie Miller, Deputy Director of the Clinical Standards Group. After that presentation, I followed up with Ms. Miller and asked her about the ACR contention that it was now too ‘burdensome’, because of their new role with CMS, to add safety standards to their existing MR Accreditation program. In a word, Ms. Miller was incredulous.

She told me that, just a few weeks prior to our conversation, the ACR had submitted their breast MR accreditation program to CMS for their approval. How long did the ‘burdensome’ CMS bureaucratic review take for this new and unprecedented MR accreditation program? Less than two weeks! Ms. Miller was dumbfounded at the suggestion that CMS would make it anything but easy for a quality and safety standard to enhance its safety components. So, if CMS ‘burdensome bureaucracy’ is just a smoke screen, what’s the real reason ACR is unwilling to heed the recommendation of their own MR Safety Committee, and honor the promise they made two years ago, to incorporate substantive safety requirements in their MR Accreditation program? Could it be money?

Though ACR is one of the accrediting bodies from which CMS mandates that outpatient participants must obtain accreditation, it’s still one of three. While ACR is seeking to ‘make the pie bigger’ by advocating for mandatory accreditation of more modalities than just CT, MRI, and PET and for accreditation of hospital-based imaging, nuclear medicine and radiation therapy, they’re also looking at their proportional slice of that pie. Were they to unilaterally decide on MR safety enhancements to their accreditation program, it might make providers looking for the lowest-threshold CMS accreditation steer clear of ACR. I suspect that the ACR’s thinking goes that, by enacting MR safety standards, they’re likely to lose prospective members and the revenue that their participation in the ACR’s accreditation program provides.

So we’re left with this profound contradiction presented by the ACR. One one hand, they have produced the industry’s best MRI safety best-practice document. On the other hand, they’re playing ‘see no evil, hear no evil, speak no evil’ when it comes to implementing the real-world safety benefits that their own Guidance Document.

And it’s not as if the ACR has any doubts about the value of the Guidance Document… as a safety tool. They have brought together many of the best minds on MR safety, four times now (the 4th release of the Guidance Document is likely to come out in the 2nd half of 2011). The MR Safety Committee lead the charge in disseminating best practice standards relative to NSF screening. And at the ACR’s own radiology quality and safety forum, last year, they were presented with a paper jointly authored by their own MR Safety Committee chair, Dr. Emanuel Kanal, and me, which showed that the explicit provisions in the Guidance Document could mitigate at least 80% of the clinical MRI accidents (see the video of that presentation, here).

So, ACR, you’ve been asked to implement the Guidance Document in your MR Accreditation standards. You’ve said that you would do so. Then you reneged on that promise with an excuse that’s been shown to be tissue-thin. At the same time, representatives have testified before Congress that in the interest of safety, there should be more accreditation of imaging and therapy devices in more healthcare settings.

Explain to me one more time why it is that you can’t honor your promise to include MRI safety standards in your MR Accreditation program?

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PS: Tune back in for the next installment, which will be taking a close look at the Joint Commission’s role in MRI safety.

Revo MRI Sure Scan Pacemaker by Medtronic

You see, up until the Revo, pacemakers were considered a very potent contraindication to MRI exams. Interference from the MRI acting on the pacemaker could turn the pacer off, turn it into a fairly benign ‘asynchronous mode’, start pacing your heart as if it were a hummingbird’s at 100′s of beats per minute, burn cardiac muscle, or drain the pacer’s battery precipitating an earlier-than-planned replacement.

Some pacemaker patients could still get MRI exams, but you had to be the right kind of pacemaker patient, with the right kind of pacing device, needing the right kind of MRI on the right kind of scanner. Even then, you ought to have had the cardiologist and a code team (to resuscitate you if the MRI and your pacer decided to not cooperate), plus someone to de-program and re-program your pacer. Even with those protections, some insurance companies simply forbid coverage of MRI exams for any pacemaker patient.

Along comes the Medtronic Revo pacemaker. This is the first FDA-approved biostimulation implant that has been specifically designed, from the ground up, to permit MR examinations (though it won’t be the last). It is not, however, carte blanche for MRI examinations. There are important limitations, or conditions, for its safe use.

There are three designations, each with very specific critera, that an object or medical device can obtain to describe its relative safety in the MR environment, ‘MR Safe’, ‘MR Conditional’, and ‘MR Unsafe’. Given the fact that I just described the Revo as having important limitations, or conditions for safe use, which of these three designations do you think the Revo has earned?

If an object receives the ‘MR Safe’ designation, it means that that object would be safe under any allowable MRI conditions. Field strength? Doesn’t matter. Magnetic spatial gradient? Who cares. Time-varying gradient? No worries, mate. RF deposition? Don’t worry your pretty little old head. In short, to receive the ‘MR Safe’ designation there can not be any restrictions on its use.

So here we are, with a pacemaker that isn’t ‘MR Safe’, but is being touted in nearly every medical media (or mass media with a health reporter) as the “MRI Safe pacemaker”.

[We'll ignore, for this entry, the fact that a company has already copyrighted the phrase "MRI Safe", as well as the fact that this company uses the copyrighted name to describe products that aren't classified as 'MR Safe'.]

For the lay person, my hair-splitting must seem awfully pedantic. The problem is that the technologist who will administer a patient’s MRI exam gets the bulk of the information about the patient’s medical history from the patient, himself. If the patient doesn’t remember the brand-name of the pacemaker (and so many of them seem to forget — or at least fail to disclose — that they even have the device, I think remembering the model and manufacturer is very unlikely), they’re probably likely to remember that this particular one was “MRI safe”. Now the technologist, charged with vetting the patient for MRI safety, is being given misleading information about the safety of scanning that patient.

So, my call to healthcare media and reporters is to please… PLEASE stop calling the Revo the “MRI Safe” pacemaker. Call it what it is, the first pacer designed to allow MRI scanning, or the first MR Conditional pacemaker, or even Medtronic’s towering achievement (which it is).

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If you accept the notion that an expert is defined as a person who has survived in their industry despite having made nearly every mistake there is to be made, then I’m an MRI suite design expert. I don’t stand in an ivory-tower of self-aggrandizement, rather I offer what I’ve learned, more often than not, the hard way.

So I stumble across designs for an MRI suite that are to be built soon. The building has sprinklers, fire-exits, and presumably conforms to all requisite codes, but the MRI suite… well…

[segue] My bedroom is quite large. It’s big enough that there should be a half-dozen different ways to lay it out with the furniture that I have… except for reading lamps. Despite the size of the room (which suggests a great deal of flexibility), there is only one possible configuration (which doesn’t involve extension cords) that provides an outlet at the bedside table on each side of the bed. This seemingly simple design element constrains the function of this room. [/segue]

If my bedroom and this MRI facility are each compliant with the applicable codes, does that mean that they’re well designed? No, in both cases.

A poorly-designed MRI facility can handicap patient safety (e.g. failure to provide lines of sight to patients in the scanner or entrances to the scanner room), can degrade image quality (e.g. ferromagnetic content in construction, including magnetic shielding, approaching shim tolerances), can impair clinical utilization (e.g. inadequate space or ineffectual layout for anesthesia or biopsy patients), and, when combined, can accelerate the replacement need for equipment ($$$) or facility renovations ($$).

So last week I came across such a design. There were no apparent code violations, but the design ran counter to a very large number of design best practices for MRI. The project manager (working on behalf of the client) and the project architect, who I contacted, were largely dismissive of these concerns. After all, no mandatory codes were violated…

Should I have even stuck my nose in a project that was outwardly none of my business? Rebuffed though I was, should I have taken my concerns further up the food-chain? Or did I strike an appropriate balance of bringing concerns to their attention without evangelizing?

I think that these questions are ‘blog-worthy’ in part because situations like this occur fairly regularly. Sometimes I’m asked, and sometimes I just stumble into situations where I see MRI suite designs that would benefit from a major rework. My firm belief is that these design changes will benefit patients and building owners, but may come at the expense of someone else’s ‘rightness’ or authority. In each instance I find myself coming back to the same questions of how should I best handle the situation.

Tonight, as I’m nodding off to sleep, I’ll try and imagine what it would be like with the bed on the opposite wall, instead of imagining this MRI suite with an efficient and functional layout.

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“Why — now — ten years later would you post these documents?”

Excellent question! Here’s why I didn’t publish these long ago…

I didn’t have them.

Yes, the civil suit had been underway for years. Yes, individual documents had been filed and made public during the course of the civil litigation, but the civil suit was only resolved a year ago and it took several months for the last of the documents to be made public through the Westchester County Clerk’s Office (who, by the way, were profoundly helpful in accessing these public records).

Here’s why I am publishing them now… Despite the fact that this is the watershed event in MR safety, the degree to which the industry has really dissected this event and identified the causative factors has been wanting. Desperately wanting.

I’m currently working with a colleague on a root-cause-analysis of this event, drilling down through the simple (don’t have ferrous oxygen tanks in the MR suite) to get at more meaningful elements of this accident that we can work to prevent similar accidents. It promises to be unlike anything you’ve learned about why this accident happened.

Given the trajectory of MR accidents and adverse events, this sort of analysis appears to be desperately needed.

So, what are the documents? They are transcripts of the depositions of many of the key people involved in the accident and couple of ‘official’ reviews. These are the source materials. The news accounts you’ve previously read are all synthesized from these (or from others’  interpretations of these). If you’re so inclined, you can download and read these for yourself.

The essential elements of the sequence of events for the accident are these:

• Michael Colombini, a young boy, was injured from a playground accident
• The ER had a head CT run, which revealed an unknown / asymptomatic brain tumor
• The boy had surgery very shortly thereafter to remove the tumor
• Prior to discharge, the boy was sent for a baseline MRI as a reference for future monitoring
• The boy was sedated prior to the exam and placed in the MR with a cannula to deliver oxygen
• Before the exam began, the anesthesiologist observed a decline in O2 saturation, and realized that the oxygen from the wall outlet was not flowing, despite his attempts to turn it up
• The anesthesiologist called the technologist who was to administer the exam to the door of the MR room, instructing her to find and fix the source of the problem with the oxygen flow
• This technologist was not familiar with the oxygen supply system, which — in apparent violation of codes — was fed to only the MR exam room from a bulk cylinder without any pressure or flow alarms
• The technologist sought her colleague who she believed knew the oxygen system and together they entered the MR equipment room to try and fix the supply problem
• The anesthesiologist cried out for help, though the technologists in the MR equipment room could not hear this
• A nurse (who had accompanied an earlier patient to the MR suite was returning to retrieve an item she had left) heard the anesthesiologist’s cries for help and handed him a portable cylinder near the door to the MR exam room
• The anesthesiologist turned to approach the boy with the oxygen tank when the magnetic attractive force of the MRI pulled the cylinder from the doctor’s grasp
• The tank flew into the MRI where it struck the boy in the face and head, inflicting fatal wounds

The following PDF documents vary in size from 1 MB to 25 MB, and will take a few minutes to download, depending on your connection speed.

Deposition of Patricia Lauria, technologist who was to have administered the Colombini scan
Deposition of Paul Daniels, other technologist on duty who assisted in the repair of the oxygen supply
Deposition of Jian Hou, MD, anesthesiologist who sedated / monitored Colombini for the MR exam
Deposition of Terrence Matalon, MD, Radiologist who was simultaneously the hospital’s Director of Radiology and president of the private company subcontracted by the hospital to provide operations for the MRI service
New York State Department of Health incident report
Westchester Medical Center incident review

As you might suspect, these documents are but the tip of the iceberg of the body of the court filings in this civil suit. However, for those interested in what happened and why (as opposed to the legal maneuvering), these documents are the most illuminating.

In the months ahead, the 10th anniversary of the 2001 Colombini fatality will include a deeper look into this accident and the changes that have taken place (and those that are still needed if we wish to avoid repeating this accident). This has begun, slowly, with the new building code requirements that are being adopted by various US states and the Joint Commission, but may pick up steam with federal government intervention.

Please check back periodically for the latest information on MRI safety… both as it relates to specific preventions, such as ferromagnetic detection systems, and broader awareness such as knowledge of the factors in the Colombini fatality.

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Damn! I’m impressed, particularly since the abstract also states that this meeting was hastily called in response to articles appearing, starting in January of this year, in the New York Times on radiology and radiation therapy accidents. Such a coordinated response by the professional societies. Such representation from the professional community at a time when conference and professional development budgets are being slashed. How does this compare with MRI?

Well, MRI accidents haven’t been the focus of a string of national news articles, and I certainly wouldn’t begrudge safety-minded professionals within radiation oncology from seizing upon the public attention to address longstanding safety issues… but how do the raw numbers compare? Fortunately, we have an excellent resource for raw numbers and we don’t have to idly wonder.

The FDA’s medical device adverse event database, MAUDE, is much maligned (much of the maligning is by me), but its one redeeming value is that it gives us a snapshot, over time, of medical-device related adverse events.

I searched MAUDE, and from 1999 – 2009, three ‘radiation therapy’ product codes (JAI, LHN, IWB) accounted for 165 total adverse event reports. Some of those included things like pinched fingers while the couch was moving, but some were also the more serious adverse events, such as incorrect dose administration.

During the same 10 year period, the MAUDE database revealed that MRI (product code LNH) has 838 adverse event reports! That’s 5 times as many as radiation therapy! Similar to the radiation therapy reports, there were also adverse event accounts that were spurious, at best, but mixed in were accounts of broken bones, penetrating wounds, and even death, related to MRI hazards.

At the risk of being repetitive, I do not begrudge or belittle the current efforts at making radiation therapy safer for all who administer and receive it. Everywhere there is error in healthcare delivery, we have a duty to work to squeeze it out of existence, and nowhere is that mission more important than in the highly technical arenas of radiology, nuclear medicine and radiation therapy. My frustration, however, lies in the fact that larger safety issues, and safety issues that clearly have a dangerous trajectory, are being ignored.

I would love to see a collaborative forum of 14 organizations, MR manufacturers, and regulatory agencies from multiple countries gather to speak to the alarming growth of MR accidents. I’d love to see 400 professionals convene for a conference dedicated to practical, actionable and direct solutions to our contemporary MR safety needs. Unfortunately, many organizations that have similar duties to the MR community are ‘just too busy’ to look at MR safety right now.

I’ve said it before (and will say it again despite the fact that I hope I am completely and utterly wrong), it may take another high-profile MRI fatality to shake-off the professional indifference to MR safety issues.

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I was invited to present a paper at the American College of Radiology’s meeting on quality and safety held October 22 – 23 in Phoenix, Arizona. Actually, the invitation came in response to an abstract of a paper that hadn’t been written yet [not to self, don't promise papers you've not yet written again].

While the FDA’s adverse event data was clearly never intended to be useful to the outside world (we eliminated over 50% of the events from consideration, primarily because of too little narrative), it did provide a great snapshot of the diversity of accidents. We wound up with 104 useful event reports from an 18 month period of reporting.

We then compared each of these 104 events against the criteria in both the ACR Guidance Document and the Joint Commission Sentinel Event Alert #38. What we found gave us tremendous encouragement… encouragement tempered with some very unpleasant contemporary realities.

Stunning: Our review found that the ACR Guidance Document for Safe MR Practices: 2007 had explicit, actionable criteria that could have interdicted 80% of the 104 tested adverse events! And that doesn’t even include the general provisions for safety such as technologist training, or situational awareness.

The TJC Sentinel Event Alert (SEA) #38 fared somewhat less well, with a 49% effectiveness, though preventing half of the MRI adverse events that are occurring is certainly nothing to scoff at!

Frustrating: Neither the ACR nor the Joint Commission currently have any… ANY… explicit standards for MRI safety, despite the fact that each organization has published best-practice standards that promise to be 80% and 49% effective (respectively) in mitigating MR specific hazards in the MRI suite!

So the conclusion of the presentation offers a challenge to the ACR, the Joint Commission, DNV, and the IAC, to adopt explicit MRI safety standards as a requisite element of accreditation.

If you would like to view the presentation, please see the video (below).

http://www.youtube.com/watch?v=O4zsQ1Yh15A

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Also, make no mistake that I find the highly publicized flock of radiation exposure accidents abhorrent oversights. Whether it was equipment calibration, record errors, or simple human foul-ups, each of these violates the simple truth of the special obligation to patient safety that imaging has. But I think we have to look at these accidents squarely, and assess what went wrong, what the adverse outcomes were, and the appropriate preventative and mitigating steps are before we promote knee-jerk responses.

I am enthralled by MRI. And while my life and livelihood are by no means tied exclusively to this one modality, I am certainly doing myself no worldly favor by suggesting that the ‘simple fix’ of moving more patients to the safe solution, MRI, is neither simple nor necessarily safe (or safer, which is really the object). Hear me out…

Medical radiation accidents, in most of the reported cases, involve over-exposure of the individual. While there are extreme examples of this that result in clear, severe and sometimes fatal outcomes, most these over-exposures are similar in incremental lifetime risk to that of having spent your teenage years sun-worshiping, instead of worshiping bottles SPF 30. The best estimations for many of these accidents are that they involve modest increases to lifetime risks of developing cancer… outcomes that will manifest themselves often 20 years or more after the exposure.

It should not be forgotten that MRI is not without its risks. While they aren’t insidious, clandestine biological risks like lifetime cancer probabilities, they are equally serious. Recent examples include burns (up to a severity requiring amputation) magnetically-induced projectiles breaking bones or crushing body parts, and earlier this year a woman who was struck, killed, and her corpse magnetically-pinned to the MRI scanner!

Because the negative effects of medical ionizing radiation exposure (from X-ray based modalities, radiopharmecuticals or beam therapies) often won’t be realized for decades, particular consideration should be paid to treating the young, those under 30. Whenever feasible and clinically appropriate, these patients should be considered for non-ionizing exams and therapies, such as MRI or ultrasound, in lieu of CT. But we shouldn’t simply redirect everyone who can name all three Jonas Brothers to MRI, certainly not with how well we’ve been managing those risks.

While it hasn’t made Walt Bogdanich’s New York Times series on radiology accidents, the last several years of MRI accident data show accidents and adverse events quadrupling over four years! MRI is currently still an extraordinarily safe imaging option, but the meteoric growth in accidents, and the continued acceleration of that growth, are each frightening.

I have a ten-year-old daughter, and we have (reluctantly) acceded to her having a fluoroscopic exam, and I would choose an MRI, hands-down, for anything for which it was equally diagnostic. But each year that I watch the accident-trend data, the calculus gets a little bit more difficult. The MRI grows less appealing, and this is egregious because it should be the irrefutably safe option.

You see, we know what causes MRI accidents, and we know how to prevent them. The fact of quadrupled MRI accidents isn’t because of sunspots, or statistical clusters, or global warming, or MRI voodoo dolls, or anything else similarly beyond our understanding or control. The fact of quadrupled MRI accidents is because we, individually and collectively, fail to act. We fail to follow industry best practices. We fail to even expect best practices of our providers!

We should directly confront the issues of radiology safety, and not just those that land on the pages of the NY Times. In imaging we have a particular obligation to protect our patients, including those going for MRI.

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PS: They’re Nick, Joe and Kevin (the Jonas Brothers). You could either think I’m under 30 (‘Ha’), or realize that I have a pre-teen daughter… Take your pick.

Wired UK Illustration by Lee Hasler. Click for Wired UK source.

The UK edition of Wired magazine just ran one of their ‘featurettes’ on this blog and picked their favorite (though, that’s a slightly squint word-choice for potentially deadly accidents) types of projectile accidents. Quote’s from — and a direct link to — the article follow.

Often when I renew my subscription to Wired (the US edition) I get the complimentary tote, or whatever other trinket they’re giving away. This time, however, apparently my renewed subscription coincided with a small feature in the UK edition for this blog! [Perhaps I should start subscriptions to Forbes or Yachting to see if there's content-related good fortune that rubs off from either of those!!]

Below are quotes from the article (the original version of which is just a click away on the article title, below) and some of my added links to related content that aren’t in the online edition of the article. Please do visit the Wired UK site (click on the quoted headline, below) because they have embedded links to other, very interesting related Wired articles.

MRI’s fatal attraction

By Vaughan Bell|06 August 2010

Look out! It’s the dark side of the magnetic force

“It’s like Russian roulette, except that many don’t know that they’re even playing,” says Tobias Gilk, a California-based MRI safety consultant. MRI scanners have electromagnets so powerful that they can dislodge pacemakers, suck in beds from across the room and turn small metal objects into dangerous “ferromagnetic projectiles”. Gilk now collects data and reports of incidents at mrimetaldetector.com/blog.

[Well, maybe not dislodge pacemakers, but certainly disrupt them... sometimes with fatal results.]

Here are six of Wired’s favourite MRI metal menaces.

Floor polisher
This is so common that the internet has whole galleries of trapped cleaning machines. Floor polishers end up stuck in scanners when cleaners stroll into MRI facilities out of hours and only realise they’re in trouble when their equipment starts to gravitate towards the magnet.

[We could establish a very long gallery of floor polisher accident photos. In fact, in the 'Flying Objects' image collection of my friend Moriel Ness Aiver on his website, SimplyPhysics.com, there are quite a number of them to see! And while they don't show you the actual accident, here's a link to a Seattle news story on a floor-polisher meets MRI accident that occurred there.]

Metal gurney
A patient and a metal gurney were both lifted off the ground and pulled towards the magnet as they were accidentally wheeled into the MRI room. The scanner had to be shut down in order to free the bed, and the unlucky patient suffered from foot, ankle and leg fractures.

[Here's a link to the FDA accident report for this specific accident (the news account having been linked above). And here's a link to a popular image showing an ICU bed magnetically adhered to the face of an MRI scanner.]

Pistol
An MRI machine disarmed an off-duty US police officer. She forgot she was carrying her Glock pistol as she accompanied her mother, who was being scanned. The gun was pulled by the magnetic force, jamming her hand between the pistol and the machine and trapping the officer.

[Here's a link to my summary of the news story from that specific incident. There is also a peer-reviewed journal piece on a different, but similar, incident in which the handgun actually fired, despite the presence of two engaged safeties.]

Flat-screen
A member of the public who was inside the scanner solely for research purposes got badly injured when hospital staff walked a flat-screen monitor through the room. The magnetic field tried to put the screen and the participant in the same place; the next stop was casualty.

[Here's the link to the FDA accident report PDF for this one, too.]

Scissors
An MRI technician ended up with a pair of scissors embedded in his forehead as he prepared a patient. Someone entered the scanner room with the scissors in their pocket — they were pulled out by the magnet and collided arrowstyle with the technician’s head.

[There have been multiple accidents involving flying scissors in the MRI room. This one is among the most severe.]

Wheelchair
A wheelchair brought into the danger area shot across the room and pinned a radiographer to the scanner. The staff member was unharmed but a patient waiting for her scan was so frightened she fell off the bed and broke her leg.

[As with floor polishers, there have been many, many incidents of not-safe-for-MRI wheelchairs being brought to the MRI room. You can see a couple of these, as well as a sampling of other projectile objects here.]

Wired UK, September 2010

I am very flattered that the editorial staff at Wired UK included information on our humble little blog in their September, 2010 issue. I hope that this sort of attention raising opportunity is not lost on the audiences in the US and elsewhere.

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Well, in case your imaginations have only wrapped around the aftermath, and not the incident, I’ve just recently come across another visual aid that might just help you with the complete picture. Imagine a pair of scissors, an MRI, and a pumpkin…

MRI + scissors + pumkin = Do Not Try This!

Now, the screen shot, above, taken from the video doesn’t do the moving picture justice. I encourage you to take a look at it for yourself. But before you do it is vital to remember that this isn’t just a hypothetical. This accident and many, many other MRI projectile accidents – with, thankfully, less catastrophic outcomes -  occur all the time.

This isn’t simply a gee whiz scientific demonstration. This represents the real nature of projectile threats. It is at our (and our patients’) own peril that we relegate these to intellectual curiosities instead of cautionary tales.

So, with that prelude, you can find the video here.

I hope that every single MRI is adequately protected against similar sorts of accidents. This protection should include, in nearly every instance, ferromagnetic detection screening of patients, visitors, and equipment.

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