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

SyMRI Software Receives FDA Clearance for Use With Siemens MRI Systems
Technology | Magnetic Resonance Imaging (MRI) | June 14, 2019
SyntheticMR announced U.S. Food and Drug Administration (FDA) clearance for clinical use of its SyMRI Image and SyMRI...
Sponsored Content | Videos | Radiology Imaging | June 13, 2019
In an interview with itnTV, Henry Izawa, vice president, modality solutions and clinical affairs, Fujifilm Medical Sy
A static image drawn from a stack of brain MR images may illustrate the results of a study. But a GIF (or MP4 movie), created by the Cinebot plug-in, can scroll through that stack, providing teaching moments for residents and fellows at Georgetown University

A static image drawn from a stack of brain MR images may illustrate the results of a study. But a GIF (or MP4 movie), created by the Cinebot plug-in, can scroll through that stack, providing teaching moments for residents and fellows at Georgetown University. Image courtesy of MedStar Georgetown University Hospital

Feature | Information Technology | June 13, 2019 | By Greg Freiherr
Editor’s note: This article is the third in a content series by Greg Freiherr covering the Society for Imaging In
A high-fidelity 3-D tractography of the left ventricle heart muscle fibers of a mouse

Figure 1. A high-fidelity 3-D tractography of the left ventricle heart muscle fibers of a mouse from Amsterdam Ph.D. researcher Gustav Strijkers.

News | Magnetic Resonance Imaging (MRI) | June 07, 2019
The Amsterdam University Medical Center has won MR Solutions’ Image of the Year 2019 award for the best molecular...
Study Identifies MRI-Guided Radiation Therapy as Growing Market Segment
News | Image Guided Radiation Therapy (IGRT) | June 06, 2019
Revenues from the magnetic resonance imaging (MRI)-guided radiation therapy systems market exceeded $220 million in...
Ann Arbor Startup Launches Augmented Reality MRI Simulator
Technology | Virtual and Augmented Reality | June 04, 2019
SpellBound, an Ann Arbor startup specializing in augmented reality (AR) tools for children in hospitals, has officially...
At ACC 2019, Siemens unveiled a version of its go.Top CT optimized for cardiovascular imaging. The newly packaged scanner can generate data needed to do  CT-based FFR (fractional flow reserve).

At ACC 2019, Siemens unveiled a version of its go.Top CT optimized for cardiovascular imaging. The newly packaged scanner can generate data needed to do
CT-based FFR (fractional flow reserve).

Feature | Cardiac Imaging | May 31, 2019 | By Greg Freiherr
The fingerprints of value-added medicine were all over products and works-in-progress on the exhibit floor of the ann

Photo courtesy of Philips Healthcare

Feature | Radiology Business | May 31, 2019 | By Arjen Radder
Change is a consistent theme in our world today, no matter where you look.
Einstein Healthcare Network found that use of automated power injectors reduced CT contrast extravasation rates over a 30-month period.

Einstein Healthcare Network found that use of automated power injectors reduced CT contrast extravasation rates over a 30-month period.

Feature | Computed Tomography (CT) | May 30, 2019 | By Jeff Zagoudis
As of 2015, approximately 79 million computed tomography (CT) scans were performed each year in the U.S.
Sponsored Content | Webinar | Computed Tomography (CT) | May 30, 2019
This webinar will explain technical considerations when performing cardiac CT angiography in pediatric patients.