Why anyone would bring a metal tank anywhere near an MR scanner is hard to fathom. But it happens, sometimes with horrific results, as in the case of the six-year-old boy killed at Westchester Medical Center in New York. Michael Colombini of
Why anyone would bring a metal tank anywhere near an MR scanner is hard to fathom. But it happens, sometimes with horrific results, as in the case of the six-year-old boy killed at Westchester Medical Center in New York. Michael Colombini of Croton-on-Hudson, was in the scanner’s bore on July 27 when an oxygen tank was mistakenly brought into the exam room. The national media reported the tragedy in the context of MRI’s extraordinary safety record. But, in reality, these accidents happen much too often.
The July issue of the American Journal of Roentgenology described five accidents involving tanks of compressed gas pulled into MR scanners-four in the last three years. The accidents, none of them fatal, occurred at two institutions within the University of Texas (UT).
But the problem is far more pervasive. About half the imaging centers responding to a survey about MR safety from UT researchers mentioned airborne objects. The projectiles pulled into MR equipment included a defibrillator, a wheelchair, a respirator, ankle weights, an IV pole, a toolbox, sandbags containing metal filings, a vacuum cleaner, and mop buckets.
What were these people thinking? This question is especially relevant in the death of Colombini. Because oxygen is piped into the MR suite, there was absolutely no reason for an oxygen tank to be brought into the room.
Another disturbing question is how many incidents like this are unreported because a patient or worker escapes serious injury. The UT researchers believe such accidents are underreported.
But there is a simple solution-the installation of metal detectors. These devices are everywhere: airports, stadiums, museums, even schools. The volume of sales has made them surprisingly affordable. A top-of-the-line model lists for $5000; a lower cost model, capable of detecting a .22 derringer, goes for $3000. Positioned at the entrance to MR suites, they could prevent the kind of senseless accidents that have happened in the past and that could occur with increasing frequency.
While radiology staff are acutely aware of the dangers inherent in MRI equipment, others are not. As cardiologists and neurologists begin managing their own machines and MRI becomes a routine interventional tool, the chance of more tragedies caused by airborne objects will grow. We have the technology to keep this from happening. Why not use it?