This past weekend I was invited to present the findings of a study I did with my friend and colleague, Emanuel Kanal. Among his many accolades and credentials, Manny Kanal is the Chair of the ACR MR Safety Committee, a fellow of the ACR and ISMRM, and a neuroradiologist at the University of Pittsburgh Medical Center. The study had a two-part mission, first to review and categorize 18 months of the FDA’s MRI accident data, and second to compare each of these adverse events against existing best-practice standards for MRI safety. The results of the analysis were both stunning, and disheartening…
One of the most oft-cited rationalizations for not complying with contemporary best practices that call for using ferromagnetic detection (FMD) for MRI pre-screening is that ‘FMD doesn’t catch anything that existing screening protocols aren’t meant to catch.’ What you may find surprising about this statement is that I agree with it wholeheartedly… I would just change the inflection a bit. I would say it more like…
Ferromagnetic detection doesn’t catch anything that existing screening protocols aren’t meant to catch.
That inflection makes a world of difference, as you’ll see in just a moment…
I have a serial weakness for medical dramas. I get sucked-in and watch for a couple of seasons before the absurdity catches up with me. With respect to MRI, it seems that 99% of the time the shows are so wildly off-base that it seems that each must outdo its own crazy scenarios (and those of the other medical dramas) to come up with a new MRI-related plot gimmick.
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…
As mentioned in an earlier post, noted MR safety guru Dr. Emanuel Kanal gave a brilliant presentation at the 2008 annual meeting of the American Healthcare Radiology Administrators (AHRA). While his session, “MR Safety Update, 2008″ addressed several different MR safety issues, below is a video excerpt, which marries the audio recording with his presentation slides, showing information on ferromagnetic detection that Dr. Kanal presented.
Among the ACR Guidance Document on Safe MR Practices: 2007, the recent Joint Commission Sentinel Event Alert #38 on MRI Accidents and Injuries, and other standards and expert recommendations, it is abundantly clear that ferromagnetic detection is a potent part of an effective MR screening program.
A PDF transcript of the above video is available for download at http://MRImetaldetector.com/blog/wp-content/uploads/Transcript_of_Dr_Kanal_Edited_video.pdf.Tobias Gilk, President & MRI Safety Director Mednovus, Inc. Tobias.Gilk@Mednovus.com www.MEDNOVUS.com
You know, they’d be funny if they didn’t so often result in injuries to patients, Technologists, or housekeeping personnel. Yes, I’m talking about the plethora of MRI missile effect accident images that you can find scattered across the internet.
As everyone who’s spent more than an hour or two around an MRI knows, these super high-strength magnets have a reputation for ‘sucking-in’ ferromagnetic materials that are so prevalent in wheelchairs, gurneys, gas cylinders, fire extinguisher, and carts.
In the last few years, there’s been a spate of floor polishers that have found their way into MRI scanners across the country…
But while there’s a nearly universal urge to snicker at these images, it is important to realize two crucial things about each and every projectile accident.
First: Each and every MRI missile effect accident is theoretically 100% avoidable. By prospectively identifying the ferromagnetic nature of materials before they’re brought into the MRI suite, none of these need to happen. By following best practices including the ACR’s Guidance Document, or the Joint Commission Sentinel Event Alert, and deploying ferromagnetic detection screening of all people and materials approaching the MRI scanner, it is possible to prevent projectile accidents.
Second: Each and every ferromagnetic projectile incident has all the ingredients for injury. While there is only one official account of a projectile-related fatality, there are many, many reports of injury, a good number of which have been severe. And given the abysmal rates of MRI accident reporting, it’s entirely believable that other anecdotal accounts of MRI-projectile fatalities are more fact than fiction.
These projectile accidents are more commonplace, and more dangerous than many are aware. So what can you can do to avoid becoming a part of the MRI missile accident scrapbook? Start by reviewing all of your MRI safety protocols, and consider deploying ferromagnetic detection screening for each and every MRI.Tobias Gilk, President & MRI Safety Director Mednovus, Inc. Tobias.Gilk@Mednovus.com www.MEDNOVUS.com
PS: If you’d like to find more pictures, and even a video or two, on MRI accidents, I encourage you to check out www.SimplyPhysics.com/flying_objects.html
A new computer animation on MRI screening has been making the rounds in both the 3D animation realm and the MRI safety arena. The more interesting (to me at least) is the virtual MRI accident with a floor polisher…
The full video (from which the still above was taken) is available at the Imagylis website (http://www.patiencys.com/mri-safety/). The MRI patient screening video is also available at the same website, but on its own page (http://www.patiencys.com/mri/).
Maybe, with all of the recommendations for the use of ferromagnetic detection, they’ll recreate the accident video to demonstrate how how such an accident might be averted with the effective use of ferromagnetic detection.Tobias Gilk, President & MRI Safety Director Mednovus, Inc. Tobias.Gilk@Mednovus.com www.MEDNOVUS.com
The single accident that really galvanized the very existence of the MRI safety movement was an accident that occurred in 2001 at Westchester Medical Center in New York State. In that tragedy, a steel oxygen cylinder was brought into the MRI room while Michael Colombini, a six-year old boy, was receiving a post-operative MRI to confirm they doctors had successfully removed his brain tumor.
Click Here For The Rest Of This Story…
I mentioned in a prior post that projectile accidents, ones in which ferromagnetic objects get sucked to the extraordinarily powerful MRI magnets, are expensive. We’re not just talking cab fare here. Not even a fancy night out. We’re talking easily 6-figure price tags for repair and service, plus tens-of-thousands in lost revenue and operational expenses.
Here’s a perfect example that made the local news in Seattle a few years ago…
$200,000! And that was probably just the repair bill and didn’t count the ongoing expenses such as the scheduled staff’s salaries, the cost of the machine and the service contract (which, by the way, wouldn’t cover this type of accident), and the $1,000 per hour that the hospital failed to bring in by performing MRI scans.
“Uhh, Mr. Jones we could probably squeeze you in if you don’t mind if we cover your body in Crisco so that we can slide you past the floor polisher that’s wedged in the front of the opening to the MRI scanner.”
And at $10,000 – $15,000 per day in lost revenue (and probably something approaching that for ongoing operational expenses) the immediate indirect costs probably start to rival the direct repair costs. Then add on the fact that the accident made the evening news. How many patients over the next several days and weeks canceled their appointments (or worse, simply didn’t show up) out of a fear that the MRI at the hospital was unsafe??
The shocking truth is that these sorts of accidents occur all the time. MRI providers can be faced with up to a half-million dollars in costs just from one overzealous housekeeper with a floor polisher.
Why do floor polishers and oxygen cylinders (and a whole laundry list of other items) repeatedly get sucked into magnets and cause so much damage? It’s usually because people are either unaware of the fact that there is a risk from these super-strong magnets, or because they mistakenly think that the object that they’re carrying is safe in the MRI room. In either case, a ferromagnetic detector could provide the feedback needed to alert the patient, support staff or physician that they have something on their person that may prove to be a major threat to the MRI scanner.Tobias Gilk, President & MRI Safety Director Mednovus, Inc. Tobias.Gilk@Mednovus.com www.MEDNOVUS.com