Thread by @MrYearof

Welcome to MRI Safety Week!

All this week we're highlighting various 'why' elements of MRI Safety Week and the Year of MRI Safety.

Today's 🧵: The accident that started contemporary MRI safety

#MRI #MRIsafety #MRIsafetyweek

20 years ago -almost to the minute- a young boy was being taken to the MRI of the county hospital.

A few days prior he had an accident on the playground and a CT scan of his skull revealed a brain tumor that would likely have killed him, had it not been found.

The boy was transferred from the community hospital to the larger county hospital, where the tumor was confirmed, and brain surgery was planned.

The surgery was a success, and all indications were that the tumor was fully removed and the boy would have a full recovery.

But before the boy gets discharged, the hospital needs a baseline post-op MRI. He'll need MRIs every 6 months for the next several years just to verify that the tumor is, in fact, fully gone.

But he's six. He only wants to go home. He is *not* happy about this MRI.

The anesthesiologist (this might be his first time in the hospital's MRI department) gives the boy a sedative. As the doc and MRI tech move the boy to the MRI tabletop, he starts becoming agitated, so the doc gives a touch more sedative.

The hook the boy up with a nasal canula for oxygen, and a pulse oximeter. Then, as the MRI tech begins to place the head coil over the boy's head, he again starts getting agitated... and again the anesthesiologist gives a touch more sedative.

The tech leaves the MRI scanner room to get ready to start the scan while the anesthesiologist programs the propofol pump that will keep the boy immobile during the MRI exam.

While the tech is preparing, the doc sees the boy's oxygen saturation levels start to fall, so he goes to the wall outlet to 'turn up' the flow of oxygen going to the boy in the MRI. Except that -whichever way he turns it- there's no oxygen flowing from the valve to the boy.

The anesthesiologist taps on the window to the control room and motions for the tech to meet him at the door (there was no intercom).

When they meet, the doc says 'there's no oxygen coming from the wall outlet. Fix it quickly!'

Contrary to the building standards, when the hospital built this MRI addition, they didn't extend the piped-in medical gases. Instead, the oxygen in the MRI room was fed from a short pipe into the adjacent equipment room where there was a large bulk cylinder attached.

The tech, who knew there was something weird about the oxygen situation, went to the other -more senior- tech to ask him to fix the cylinder. The senior tech indicated 'this is something you should know how to do. Let's go together and I'll show you.'

So both techs go into the equipment room which is effectively sound-proofed. Once inside the equipment room, they can't hear anything that transpires in the MRI suite until they come out again.

The anesthesiologist continues to watch the O2 saturation levels fall for the young boy. He's getting anxious about his patient, and angry that, despite calling out to the techs about the urgency, the techs aren't responding to him.

At this moment, a nurse lets herself into the MRI suite. She hears the doc shouting out for oxygen. She remembers having seen portable O2 tanks, and she retrieves one.

She calls to the doc, 'if you need oxygen, I have some here!'

The doc meets her at the MRI room doorway, takes the tank from her, turns around and takes another step or two into the room when the MRI's magnetic field rips the tank from his arms and draws it into the 'tube' where the boy was positioned for his MRI.

The flying tank strikes the boy -who just had brain surgery- in the face and head.

Twenty years ago, almost to the very minute.

That's why this week is MRI Safety Week.

That's why this year is the Year of MRI Safety.

This date, July 27th, is a powerful reminder of the vital nature of MRI safety, and an appropriate time to reflect on MRI safety improvements made, and those that are still needed.

As always, we invite you to 'like' and 'RT' our tweets to help share them with your own personal twitterverse.

We also invite you to follow us for daily dose of MRI safety best practices.