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

Blog | 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.

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