Greg Freiherr, Industry Consultant
Greg Freiherr, Industry Consultant

Greg Freiherr has reported on developments in radiology since 1983. He runs the consulting service, The Freiherr Group.

Blog | Greg Freiherr, Industry Consultant | Magnetic Resonance Imaging (MRI)| March 06, 2018

What The MR Accident in India Says About Us

While the imaging community may never have consciously put patients second, putting patients first is more than a numerical ranking.

Moral ambiguities don’t often come into play in medical imaging. Forget what Dr. House says ad nauseam on the syndicated doctor show. Nobody does exploratory surgery anymore. Seeing inside the body noninvasively is … duh!

But the digital revolution in imaging has created some issues, among them patient safety in computed tomography (CT) and magnetic resonance imaging (MRI). Concerns about the latter bounded to the front of the line with the story about a man in India who died in an MR accident (“Mumbai: Man dies after being sucked into MRI machine; doctor, ward boy arrested,” Indian Express, Jan. 29, 2018). The accident involved a medical oxygen tank brought into the magnetic field of a scanner.

In response to this report, we might bask smugly in reports about the safety of MR exams in this country, where medical oxygen tanks are typically made of nonferrous metal like aluminum and hospital staff are wise to the dangers of powerful magnetic fields. Neither is true in India.

The MR accident that killed Rajesh Maru was the second reported there in the last few years. Two staff were injured — but neither killed — when they were pulled into an MR in November 2014, according to a story published by the Mumbai Mirror. (“Two Stuck To MRI Machine For 4 Hrs,” Mumbai Mirror, Nov. 11, 2014.)

 

Why Accidents Happen

The tragic death in India highlights an unfortunate aspect of human nature, one that can turn a positive into a negative anywhere in the world. The Indian Express quoted Maru’s sister Priyanka Solanki, who saw the accident happen, as saying “instead of taking responsibility, the hospital workers scolded us for Rajesh having gone close to the MRI machine with the cylinder in his hand.”

Rajesh Maru was not a hospital employee. He was just trying to help. He was assisting his sister’s mother-in-law, the person who was to have been scanned. A hospital staffer had asked him to carry the tank into the suite.

Who was responsible for this accident? It’s easy to point to the hospital staff, as the Maru family did. It is also easy for the hospital to point to the family, which the hospital did. Someone familiar with the operation of MR scanners might instead point to ignorance by the hospital staff. But each misses the point.

It’s not about what was done, but what should have been done.

While accidents involving MR scanners are rare in the U.S., they do occur. And they happen regardless of the smarts or knowledge of staff. One example happened in 2014 at a hospital in Oakland, Calif., when a patient was apparently burned by the radiofrequency (RF) energy emitted by an MR scanner.

Electrical leads attached to the patient for an electrocardiogram (ECG) test done before the MR scan may have channeled the RF energy to the skin of the patient. The leads should have been removed when the ECG was done — long before the patient got on the table of the scanner. But the leads weren’t removed. (“Girl injured during MRI: experts say accidents rising,” Fox News 2 KTVU, Apr 28, 2015.)

At the time, the hospital denied liability, instead issuing a statement about its record for safety: “Last year, we safely and successfully performed over 6,000 MRIs at our hospital and outpatient centers.” The patient’s family attorney stated, according to KTVU, that the patient “slipped through the cracks.” The TV station went on to quote a member of the American Board of MR Safety as saying MR accidents were increasing and have been “for years and years.”

About the same time as this accident was happening, patients at Cedars Sinai Medical Center in Los Angeles were being routinely overexposed to CT radiation. During an 18-month span, 206 people were overexposed to ionizing radiation. The serial overexposures came to light only when a patient complained of hair loss following a CT exam.

Rather than point their collective finger at staff, hospital authorities blamed a “misunderstanding” due to an incorrectly programmed CT scanner. (See “Doctors ‘Shocked’ by Radiation Overexposure at Cedars-Sinai,” ABC News, Oct. 13, 2009.)

 

What Must Be Done

Accidents will happen until patients are put ahead of everything else.

Five years ago the Radiological Society of North America (RSNA) decked the McCormick Center during its annual meeting with banners proclaiming “Patients First.” While the imaging community may never have consciously put patients second, putting patients first is more than a numerical ranking.

Digital imaging has improved the detection of disease. It is indisputably better than exploratory surgery. But modern imaging only provides the tools to help patients. These tools can harm as well as help.

What people do with them determines which happens.

Related Content

Videos | Magnetic Resonance Imaging (MRI) | August 13, 2018
Haojie Wang, M.D., director of advanced cardiovascular MRI and a member of the heart valve clinic at Baylor Scott Whi
ACR LI-RADS Steering Committee Releases New Version of CT/MRI LI-RADS
News | Clinical Decision Support | August 13, 2018
August 13, 2018 — The American College of Radiology Liver Imaging Reporting and Data System (LI-RADS) steering commit
Indiana Hospital Installs First Vantage Titan/Zen Edition 1.5T MRI in U.S.
News | Magnetic Resonance Imaging (MRI) | August 10, 2018
Patients in Pulaski County, Ind., now have access to quiet, comfortable magnetic resonance (MR) exams thanks to the...
Videos | Radiomics | August 09, 2018
A discussion with Martin Vallieres, Ph.D., post-doctoral fellow at McGill University, Montreal, Canada.
3T MRI Installed at The London Clinic Through Hospital Roof

Image courtesy of The London Clinic

News | Magnetic Resonance Imaging (MRI) | August 08, 2018
Patients at The London Clinic, a private hospital and charity, will be the first in the United Kingdom to access the...
Gary D. Luker Named Editor of Radiology: Imaging Cancer

Image courtesy of University of Michigan Medical School

News | Oncology Diagnostics | August 06, 2018
The Board of Directors of the Radiological Society of North America (RSNA) announced that Gary D. Luker, M.D., will...
Videos | Contrast Media | August 03, 2018
Lawrence Tanenbaum, M.D., FACR, vice president and director of advanced imaging at RadNet, discusses the latest resea
Videos | Digital Radiography (DR) | August 03, 2018
Sheila Sferrella, president of Regents Health Resources and Bill Finerfrock, president of Capitol Associates, discuss
Videos | AAPM | August 03, 2018
Ehsan Samei, Ph.D., DABR, FAAPM, FSPIE, director of the Duke Un...
New Regulatory Approvals Driving Research and Development Dollars in Medical Imaging Artificial Intelligence
News | Artificial Intelligence | August 01, 2018
Medical imaging has become the bellwether for the application of artificial intelligence (AI) technologies, especially...
Overlay Init