Thread by @tobiasgilk

For those who don't know why this week, MRI Safety Week ⚠️ always includes July 27th, the date of the most infamous MRI accident (in 2001) in which a young boy died when an oxygen tank was brought into the MRI scanner room. This weeks seeks to build safety from tragedy.
(1/16)

Nineteen years ago a six-year old boy tripped on the playground, and struck his head. Worried about a concussion, his mother took him to the ER, where they performed a CT on young Michael Colombini.
(2/16)

The CT showed no skull fracture, but it *did* reveal a brain tumor, and he was transferred from the small hospital to the large county hospital for an immediate surgery to remove it. The boy actually had a pre-op MRI before his surgery without incident.
(3/16)

By all accounts, the surgery went very well, and the boy's prognosis was good. His early recovery was going well, and 19 years ago today he was scheduled to be released from the hospital... they only needed a baseline MRI before he left the hospital.
(4/16)

As you might imagine of a young boy, he was *done* with hospitals, doctors, and exams, and just wanted to go home. They sedated him for his MR study, but he pushed through the sedative, so the anesthesiologist gave him a 2nd dose.
(5/16)

Putting the top of the head-coil over the boy's face triggered another anxious / angry reaction from the boy, whereupon the anesthesiologist administered a third dose of sedative. The anesthesiologist and the tech finished positioning the boy and put the pulse-ox on him.
(6/16)

The pulse-ox reading starting dropping, quickly, as soon as they got it on him. The anesthesiologist (who may have never worked in this hospital's MR unit before) set up a nasal canula and connected it to the oxygen outlet in the room, but the readings kept falling.
(7/16)

The anesthesiologist discovered that -no matter how far he opened the O2 valve- no oxygen was flowing out of the wall outlet. The boy's pulse-ox continued to fall and he yelled to the technologist to fix the oxygen supply.
(8/16)

The hospital, when they built their MRI addition, didn't put it on their central piped medical gasses, so the oxygen that fed the MRI room came from a large cylinder in the equipment room. The scanning tech (who was relatively new) didn't know how to change the cylinder.
(9/16)

So the (junior) scanning tech asked the more senior tech to change the tank, and the senior tech took this as an opportunity to show the junior tech how to do this. The pair of them entered the equipment room and were acoustically cut-off from the rest of the suite.
(10/16)

All the while, the young boy's O2 levels are dropping, and the anesthesiologist is getting more and more anxious. He's yelling towards the open MRI room door for someone to get him oxygen.
(11/16)

At that same moment, a nurse who had left something in the MRI unit when she came with a patient earlier in the day walked back into what today we'd call the Zone III area and hears the anesthesiologist yelling for oxygen. She remembered having seen tanks earlier.
(12/16)

She goes to the induction alcove and -sure enough- comes across a couple O2 cylinders. She meets the anesthesiologist at the door to the magnet room and hands him one of the cylinders she located.
(13/16)

The anesthesiologist, grateful beyond words, turns and takes a couple steps back into the room and the MRI scanner rips the cylinder from his arms, and in flies into the MRI bore, striking the boy in the face and head.
(14/16)

As we recognize MRI Safety Week, let us not forget the cost paid when the safety of MRI patients is not a priority.
(15/16)

Let us take this opportunity to rededicate ourselves to the knowledge, practices, and standards that help protect all MRI patients, and that can prevent future injuries and fatalities, if we're only willing to engage.
(16/16)

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