Yes, that’s right, a recent news story from the NBC television affiliate station in Jacksonville, Florida, provides an account of how an off-duty police officer’s pistol wound up stuck to their MRI scanner, and cost the provider something in the neighborhood of $150,000 to remove!

You pretty much have to ignore the completely unintelligible explanation as to how MRI’s work or what would have caused the gun to be attracted to the MRI, but the underlying story of a police officer’s pistol getting stuck to the magnet (and pinning her hand to the scanner) again demonstrates the seriousness and frequency of MRI accidents.

And it’s not as though this is the first time. There are other, similar accounts, including this one in which the magnet caused the pistol to fire, despite the fact that the safety was engaged.

Perhaps, since the industry hasn’t taken any formal steps to improve patient screening with standard procedures or tools, we may have needed a reminder about the pervasiveness of screening accidents on the local newscast.

Screening lapses are nothing new. Time and time again we demonstrate that an exclusive dependence upon the vigilance of MR Technologists is not the most effective way to prevent these accidents. Patient safety, and the protection of millions of dollars of MRI equipment should come from layers of protection.

Additional layers of protection, such as ferromagnetic detection, aren’t an indictment of our Technologists, they’re necessary supports to help ease the burden on Techs and provide the greatest protection possible to patients, visitors, and millions of dollars of MRI equipment.

PS: Though this isn’t a picture of the account in this story, the image below is of a gun, or more precisely a pistol, drawn into an MRI scanner. Between the photo, below, the newscast from Jacksonville, and the journal article linked above, clearly these pistol-versus-MRI accidents aren’t unheard of.

The Technologist, Laura Price, claims that her former employer, Horizon Diagnostic Center in Orange Park, FL, ignored repeated requests from Ms. Price and other Technologists to repair the coils on the MRI, and that the image quality was so poor as to compromise the clinical value of the scans. She was purportedly fired for insisting that the coils be repaired. She is suing for wrongful termination and has taken her efforts public in an interview with a local television news station.

What is particularly interesting (to me at least) is that there is not currently any claim of injury or misdiagnosis based on the claimed failure to keep the MRI equipment in operational condition. Therefore, this is strictly a claim against the practices of the provider and their adherence to standards of care and best practices.

Though the MRI fatality case has yet to go to trial (having been postponed ad nasuem for years, now), the Technologists are named defendants in that suit, suggesting at least that Techs have a legal obligation for safety and the standard of care.

This Florida suit is intriguing because it puts operations squarely in the legal crosshairs. When legal liability is tied only to injury, it fosters an ‘ends justify the means’ culture of safety. Something akin to, “if we haven’t hurt anybody, it proves that we’re doing things right.”

Many patient safety experts decry this sort of ‘negative proof’ of safety. Getting all the way across the freeway unscathed, on foot, blindfolded, is not proof that walking blindfolded across the freeway is a safe practice, yet this is the logic that prevades MR safety at many locations.

Whatever you may think of this one case, or the Technologist who is bringing it, I am very interested simply because it does put safety practices in the spotlight. I’m also very interested in what you may think of this, so please share your comments, below.

That’s right, a guy getting an MRI in Colorado had a nail, purportedly stuck in his nasal cavity for approximately 30 years, wriggled loose and he coughed it up shortly after the exam! Follow the link below to view the video (after a short, but annoying commercial):

News video on MRI’s and nails in noses!

Ferromagnetic detection systems have caught a variety of unusual and unsuspected magnetic objects before they entered the room with the giant MRI magnet, but at the time I write this, no ferromagnetic detection system has been approved for finding things internal to the body of a person… even nails.

Would it have been possible for a ferromagnetic detection instrument to find an inch-long nail at a distance of an inch or two, say buried inside a beef roast? Yes, but it would depend greatly on the instrument and the conditions in which it was operated.

I don’t recommend sticking ferromagnetic materials in orifices just to test the sensitivity of your detector (a friend of mine did this with a BB in his ear… took several days to get it out). If you have questions about your instrument, ask the manufacturer.

And whatever you do, don’t go putting nails (or anything else, for that matter) up your nose!

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.