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.

Click here for Tobias’ Twitter Profile

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.

Click here for Tobias’ Twitter Profile

This is just one example of a laundry-list of serious projectile accidents that occurred in 2009.

I should note that the above isn’t a real X-ray of this injury, but hopefully it was ‘real enough’ to at least get you to swallow hard at the thought.

In this incident occurred when a technologist was positioning the patient on the table for the MRI exam. At that moment, the person who brought the patient to the MRI department entered the room with a pair of ferromagnetic scissors. The rest, as they say, is history.

But what about this one event makes it worth holding out as an example?

It, like the many other serious projectile injuries of last year, was completely avoidable. And the same is true for the burn injuries, and those that occurred as a result of incomplete clinical screening. These three causes are responsible for over 90% of the serious injuries in MRI.

Often these occur because the only accident protection in place is the vigilance of the technologist on duty (which, increasingly often, is only a single individual). When everything depends on that one, fallible, individual, the process will break down.

Effective clinical screening depends, in part, on the appropriate prescription of MR studies by primary care clinicians (more than half of which, according to a recent study, were unaware that medical implants were a contraindication for MRI exams). A review of the patient’s accurate medical records, effective pre-screening by scheduling staff, careful review of the patient’s screening form, all of which should be done to reduce the burden on the Technologist.

For burns, patients should be transported to MR without any extraneous monitors, equipment or devices. Upon arriving, they should be switched to MR Conditional monitoring equipment, as needed. The site should provide ample insulating and positioning pads to properly situate the patient for the exam. As with the preliminary screening steps, these will also reduce the burden on the Tech’s unblinking vigilance to prevent these types of accidents.

For projectiles, it isn’t realistic to keep a metal-free MRI suite. This means that the objects which can hurt patients or staff, and damage million-dollar scanners, are littered, like time-bombs, throughout our day. Changing patients, educating key support staff, implementing rigorous access controls, and using ferromagnetic detection can dramatically cut the risks associated with projectile accidents.

These preventative steps, above, have two things in common. First, their almost universally accepted as industry best practice. Second, they are universally omitted from any patient safety requirements! That’s right, no regulatory or accreditation body has objective standard requirements for screening, positioning, or projectile protection!

As long as these instances of head-piercing scissors, or leg-crushing gurney rides, or brain-damaging flying carts, or face-whalloping monitor panels, or any of the others, are viewed as just text descriptions of statistical aberrations, instead of easily-preventable human tragedies, we’ll stay stuck with ineffectual recommendations and scores of stupid, stupid injuries.

Click here for Tobias’ Twitter Profile

A number of the MRI accident reports, when the narratives weren’t appearing, were little more than the name and mailing address of the MRI manufacturer. Today, if you want to read about the MR Technologist who had a pair of scissors magnetically-impelled into his forehead, you can do so.

MAUDE report of MRI + scissors vs. Tech.

Though I must admit to indulging sinister fantasies that the FDA was trying to ‘cover up’ some of these accidents, so I requested the information that wasn’t being displayed through the online MAUDE database through a good-old-fashioned Freedom of Information request. The result is that I have PDF copies of many stunning, alarming, and disconcerting accidents. And if you’re so inclined, you can download PDF copies of them, too…

• Rolling cart seriously injures Siemens Apps Specialist (facial fractures & brain trauma)

• Flat-screen monitor hits research subject (facial fractures & surgery)

• Patient on gurney gets more of a ride than planned (foot, ankle, leg fractures)

• IV cart nearly strikes patient (near-miss)

• Knife slices patient (laceration requiring stitches)

• ‘Sand’ bag injures patient (brain hemorrhage, tongue laceration and facial injuries)

• Scissors seriously injures tech (embedded in forehead, surgical removal required)

• Bed tray-table (ambiguous injuries, including facial lacerations)

And the above accidents only represent a proportion of the collected number of accidents for little more than half of 2009!

The above list should not scare anyone out of getting an MRI exam. It is meant to illustrate just how far we have yet to go to eliminate the ‘pilot error’ types of accidents which continue to jeopardize patients, staff, and millions of dollars of MRI equipment.

Sometime in February or March, we should have access to the complete 2009 MAUDE data. Early indications already suggest that we’re on track for a dismal year-end report, with a 20% (or more) growth in accident numbers.

Continue to stay tuned for the latest information on MRI accidents and – more importantly – the tools and protocols that can help reduce the risks.

Link

Every so often there is an MRI accident description that is so stunning that it sends a jolt through me, reminding me why I do what I do. This is the entry that I came across just two weeks ago…

“Event Type Injury   Patient Outcome Life Threatening; Hospitalization Required Intervention”

‘Wait a minute… that may border on interesting (and I’m being very generous there), but that’s hardly a ‘jolt.’ What gives?’

Well, two weeks ago that exact same incident report described an accident in which an MR technologist had to be rushed to surgery to extract the pair of scissors from their forehead! Turns out that the tech was between the magnet and another staff person who had brought a pair of ferromagnetic scissors into the magnet room. The magnet ‘grabbed’ the scissors and started drawing them into the bore, but for the fact that the technologist’s head was in the way!

My longstanding complaint with the FDA and their MAUDE data has been that they seem completely disinterested in actually collecting it with regard to MRI accidents. The overwhelming majority of MRI accidents are a product of the inherent risks, and not a result of equipment malfunction and it seems to me as if the very existence of the MAUDE database is NOT as a patient safety tool, but as a CYA tool to validate that the approval of a medical device was warranted.

Now the hobbled MAUDE data (built on the FDA’s Medwatch program) has gone mute and the actual substance of an accident report is no longer there. Today there’s more information about the postal address of the company that manufactured the MRI than there is about the accident that is being reported, at least that’s the contemporary reality via the online database.

So I implore the FDA to please restore the narratives associated with MRI accidents. Removing this information does a grave disservice to patients and those who advocate for MRI patient safety.