MRI Accident Rate May Be on the Rise

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.”