Los Angeles Times: Child Dies in MRI Machine

http://latimes.com/news/nationworld/nation/wire/sns-ap-mri-death0730jul30.story?coll=sns%2Dap%2Dnation%2Dheadlines

Child Dies in MRI Machine
By JIM FITZGERALD
Associated Press Writer

July 30 2001

VALHALLA, N.Y. -- A 6-year-old boy undergoing an MRI exam was killed when the
machine's powerful magnet pulled a metal oxygen tank through the air, fracturing
his skull.

Officials at the Westchester Medical Center said the tank had been brought into
the exam room accidentally Friday morning after the boy, Michael Colombini, of
Croton-on-Hudson, was already in the magnetic imaging machine and the 10-ton
electromagnet was switched on.

The oxygen tank was "immediately magnetized and drawn to the center of the
machine, causing head trauma to the child," the medical center said in a news
release.

The county medical examiner's office said Colombini died Sunday of blunt force
trauma, a fractured skull and bruised brain.

The boy, who had undergone surgery before the MRI exam, was sedated when he was
struck, the hospital said. The nature of his surgery was not being released out
of sensitivity for his family, medical center officials said.

"The trauma was due to what can only be described as a horrific accident and the
entire medical center is grieving," said Edward Stolzenberg, president and chief
executive officer of the medical center.

He said the hospital assumes full responsibility and "will do anything it can to
ease the family's grief."

The medical center and state Health Department were investigating. A Health
Department team was at the hospital on Monday, checking records and interviewing
staffers to see if there were any violations, department spokesman Robert Kenny
said.

Medical center officials would not say who brought the oxygen tank into the MRI
area.

An MRI generates images of the body using an electromagnet, radio waves and a
computer. It is used in the diagnosis of many diseases, including brain tumors,
spinal disorders and heart disease. It is considered nearly risk-free.

The Westchester Medical Center, with four hospitals and six other centers 15
miles north of New York City, is a major transplant center and has recently
ventured into robot surgery.

On The Net:

Westchester Medical Center: http://www.wcmc.com
Copyright 2001 Associated Press

They are fortunate the valve on the oxygen bottle didn't get broken off in the process.  It would have been REAL interesting in that room then.

This truly is a sad incident ... things get sucked into MR machine's all the time though - unfortunately, this time there was a patient in the magnet.  I'm pretty sure this was a superconducting magnet, which means the magnetic field is ALWAYS on.

Here are some pics of things that can get stuck in magnets, though not from the hospital I work in (I have some of an IV pole in our magnet somewhere).

[img]http://www.simplyphysics.com/flying_objects/chair.jpg[/img]

[img]http://www.simplyphysics.com/flying_objects/Buffer_In_Bore2.jpg[/img]

[img]http://www.simplyphysics.com/flying_objects/WeldTank2.jpg[/img]

Where are the calls for Federal Legislation?

.  waiting periods
.  Federal Inspectors to clear the room
.  MRI locks

Hey, a child died!  Do it for the children!

Children have too much access to medical equipment.

No more high capacity mag(net)s

www.mricontrolinc.com

I want to know who was the dumb ass that bought in a METAL oxygen canister into the room? You never ever place paramagnetic objects (things that can attract a magnet for you non-quantum physics people out there) next to a MRI machine. When there are terminally ill patients or those on respirators, you're supposed to only use CAT scans, which uses X-Rays. Hell, newer fourth and fifth generation CAT scanners are just as good if not better than most MRI machines out there. I don't know if they have diamagnetic oxygen bottles out there, does any one know?

themao [chainsawkill]

BAN MRIs NOW!!!!!!!!!!!!!!!!!
SAVE THE CHILDREN!!!!!!!!!!!!

I never knew how powerful these machines were until 2 weeks ago...

I had to have an MRI done on my knee prior to surgery.(Torn cartilidge)

Before they did the MRI, they X-rayed my head and eyes, to look for any metal particles...

I do a lot of welding and metal fabricating, and they asked this in particular, during my pre-MRI interview.

They said if there was any tiny metal particles in my eyes or brain, it could create MAJOR problems...

Imagine that...

I definately did NOT like the experience in the machine...
It was identical to the one pictured above...
It was very claustrophobic and LOUD!!!...
VERY LOUD !!!
It felt like the whole goddamn room was shaking.
Imagine laying in a tube next to a racing engine at full throttle.
Only it didn't sound sweet like an engine...
It sounded like it was going to take-off or explode...
lasted about 20 minutes...
Next time I will ask to be sedated...

Just saw that on the news.  The talking head mentioned that last year in Rochester NY, an MRI pulled a Glock .45 out of the hand of a cop in the room.  I'd always heard this was just one of the latest urban legends.  Anybody hear anything more definite?

They must have X-rayed him & didn't see that "invisible" Glock.   [:)]

Norm

...jesus...all I hope is that it was not a mistake by one of my fellow RTs!!! Most of the industry has moved into lightweight spun aluminum o2 cylinders, and away from the metal o2 cylinders (alum is stronger and lighter) the aviation industry has moved into spun alum. and carbon fiber cylinders. The metal relics are still around and most likely will continue to be around for a long time. The regulators are made of a variety of metal compositions i.e. metal, brass, and aluminum...so even if the tank was aluminum the regulator could have been the culprit....then there was the cart it WAS restrained in...jeezzz.....

p.s. it's a VENTILATOR not a RESPIRATOR...and yes there is a BIG difference (sorry, my professional pet peeve!)

- rigid the flying RT

[img]http://www.finalfront.com/hosting/users/geepgeep/lifestar_ani.gif[/img]

YOW!  How do you get those things off of the MRI machine.  I see that the chair is blocking the entrance to this particular machine if the machine is always on?

Maybe if it's very old. it depends upon what your looking for.
Certainly not anywhere near as good as the latest MRI produced by Siemens,Phillips,GE.

This accident took place a 1/2 hour from where I live.
I don't know the whole story but will add this.
There are people coming and going through these facilities such as EMT's, Patient transporters.
They may be too focused on the patient and unaware of the things attached to or on top of a stretcher/wheelchair. The MRI technicians do their best to screen everyone before allowing entry to the MRI room. Some visitors don't pay attention or give short shrift to the warnings.
That's the cause of 99% of the accidents.
It's unfortunate it had to take the life of a 6yr old to get everyone's attention.
Now, hopefully, people will be aware of the dangers associated with these powerful machines.

Engineer......what make is that MRI in your photo's?

themao.....yes, there are non-ferreous oxygen bottles specifically for use around MRI unit's

There are plenty of horror stories involving these magnets, due to people that weren't paying attention to what they were doing.

My heart goes out to the family [:(]

Carpenter had nails in shirt pocket. Entered MRI room. Nails flew and pierced the superconducting magnet. Magnet exploded.

Floor buffers, wheelchairs, handtools etc. If it's metal and it's in the same room it's going to eat it.

To top it off it costs big bucks to restart one of those puppies after a repair. You have to charge the machine with a LOT of voltage for it to work.

I don't know what the machines are in the bottom two photos, but the top machine is from Picker which up until recently was known as Marconi Medical Systems, but was recently bought out by Philips for $1.1 billion earlier this month.



I don't know about the chair, but when we had to pull the IV pole out, it took ALOT of guys and rope to secure it.  Luckily it didn't wind up in the bore but kind of stuck itself on the face of the machine.  It just takes alot of hands - or a winch - to pull it away (on a shielded magnet the field falls off pretty quickly)

El_Kabong makes a good point ... don't talk to the service engineers after they're called in to ramp up and shim a magnet - they tend to be a bit moody.

This tragic incident even made the news here in Australia.

A while back had an MRI on a shoulder injury, and they asked if I welded alot, I said why, and they said becauses of metal particles in the eyes. Now I know the reason for their question.

Engineer.....LMAO! So you've noticed that about us!

Actually the ramping up of a magnet after a "quench" (depending on the reason for it) isn't to bad. Just time consuming, but a great source of easy over time.

Shimming a High-Field magnet (0.5t to 1.5t) is a royal pain in the a$$! Only those that have tried/done this can appreciate trying to take a piece of metal and put it exactly where it's needed. On one magnet that I worked on,it took 4 weeks of 14 hour day's to get the damn thing in specification.

Los Angeles Times: MRI Accident Rate May Be on the Rise

http://latimes.com/news/nationworld/nation/la-000062565aug01.story?coll=la%2Dheadlines%2Dnation

MRI Accident Rate May Be on the Rise
Medicine: A boy's death in N.Y. is a freakish case. But a study shows an
increase in possibly life-threatening incidents with magnetic machines.
From Associated Press

August 1 2001

WHITE PLAINS, N.Y. -- When workers dismantled an MRI machine recently at the
University of Texas, they discovered dozens of pens, paper clips, keys and other
metal objects clustered inside.

Each had sailed through the air from a pocket or a folder, drawn to the huge
magnet that powers the MRI's medical scanner. Much less common is the kind of
accident that killed 6-year-old Michael Colombini last weekend.

Experts believe it was the first death caused by an outside object in a magnetic
resonance imaging machine room, although a recent study suggests that similar
accidents may be on the rise. The machines are used across the country for more
than 1 million scans each year. An oxygen tank the size of a fire extinguisher
became a magnet-seeking missile, killing Michael in the MRI machine at
Westchester Medical Center in Valhalla.

Services were held Tuesday for the boy at a temple in Croton-on-Hudson, where he
lived, and at the hospital chapel, where staffers gathered for what spokeswoman
Carin Grossman called a "healing service."

"You have to be so very careful," said Dr. Michael Rubin, attending radiologist
at Sound Shore Medical Center and director of MRI at New Rochelle Radiology
Associates.

"MRI's are safe machines, as long as you follow certain rules and don't bring
metal into the room," he said.

Deaths have been reported before when an MRI machine's magnetic power disrupted
metal aneurysm clips or cardiac pacemakers inside patients' bodies. At least
once, a patient was blinded when a piece of metal, long embedded in his eye,
moved in response to the machine.

Regulations to prevent accidents are strict. Operators insist that metal objects
be kept out of the MRI room.

Pockets are emptied; watches, earrings and eyeglasses are removed; patients are
stripped and quizzed about implants, shrapnel and bullets in their bodies. Some
patients are deemed ineligible for MRI.

There are MRI-compatible gurneys, wheelchairs and oxygen tanks, made of
aluminum.

Still, accidents may be occurring more often than ever. Dr. Gregory Chaljub of
the University of Texas medical branch in Galveston studied records covering 15
years and nearly 138,000 MRI scans for an article that was published last month
in the American Journal of Roentgenology.

He found five cases in which tanks were mistakenly brought into MRI rooms and
immediately headed toward the magnet. In one 1987 case, the oxygen tank hit the
patient in the head and caused facial fractures.

The other cases did not cause injuries but were troubling for another reason.
They all occurred in 1997 or later, leading him to suggest such incidents are on
the increase.

"I think the reason accidents are going to occur more often are twofold," he
said Tuesday. "There are magnets all over now; we're putting them up in shopping
centers. And we're imaging sicker and sicker patients who have more life-support
equipment with them--and not everything is MRI-compatible."

Chaljub noted that in all the cases he studied, the accidents could have been
avoided if existing rules were followed.

He suggested that all of the tanks used in a hospital be made of aluminum, but
noted they cost much more than other metal tanks.

"My bottom line is this kind of accident is preventable and MRI's are safe," he
said.

The tragedy in Westchester, he said, "shouldn't scare people. It should alert
people."

Copyright 2001, Los Angeles Times