Tomograph incidents

Why you need to remove metal things before MRI

2023

American woman showed up for MRI with gun and he accidentally shot her buttocks during exam

In early December 2023, it became known that in one of the medical institutions the USA patient received a gunshot wound from her own pistol, which she secretly carried into the office. The woman magnetic resonance imaging (MRI) required further medical attention in connection with the incident.

MRI machines use powerful sources of magnetic field. Therefore, before undergoing the procedure, it is mandatory to remove all metal objects. For the same reason, scanning is contraindicated in patients with installed pacemakers, ferromagnetic or electronic implants, etc.

According to the website of the US Food and Drug Administration (FDA), before performing the MRI procedure, the injured 57-year-old woman, whose name has not been disclosed, underwent a standard questionnaire, saying that she did not have metal objects with her. After that, she carried the weapon into the MRI room, where the gun, under the influence of a powerful magnetic field, was drawn to the device. As a result, a single shot occurred, and the bullet hit the patient's right buttock.

The wound was minor. The bullet went right through the soft subcutaneous tissues, leaving a small inlet and outlet. Nevertheless, the woman was promptly taken to the first aid department. She subsequently reported that the wound was healing without complications.

It is noted that a similar incident occurred in February 2023, when a man from Brazil secretly carried a gun into an MRI office. Under the influence of a strong magnetic field, the weapon spontaneously fired a shot, and the bullet hit the man's stomach. The wound turned out to be very serious, and the doctors failed to save the victim.^[1]

Gun carried into MRI room fired on its own and killed Brazilian

On February 6, 2023, information appeared that a man was mortally injured in Brazil, approaching a magnetic resonance imaging apparatus with a loaded pistol. Read more here.

2021: MRI machine sucks oxygen tank and kills patient during examination

As a result of the accident, a 60-year-old patient from South Korea died after being hit on the head with a 60 kg oxygen cylinder, which was sucked into a magnetic resonance imaging (MRI) device. The incident occurred on the evening of Thursday October 20, 2021 in the southern city of Kimhe, when a man, whose name has not been released, was taken to the hospital's MRI department in critical condition. According to doctors, the man suffered from convulsive seizures.

We are figuring out why the oxygen tank was brought into the room, "police superintendent Choi Tae-young told Hong Kong news outlet the South China Morning Post, adding that" the built-in oxygen supply system could have malfunctioned. "We are thoroughly investigating the incident to determine if there were human errors in it."

The patient died due to a powerful blow to the head with an oxygen cylinder, which was sucked into the device due to its strong magnetic force.

MRI machine sucked oxygen tank causing patient to die during examination

According to authorities, "there are usually no metal objects around him due to the strong magnetic force" and "the hospital was also aware of this, but explained that the patient was in critical condition at the time and the oxygen tank could not be removed." As Tobias Gilk, Senior Vice President of Radiology Planning, founder of Gilk Radiology Consultants, noted, such clinical incidents in MRI simply should not occur.

Even though it "never happens," magnetic MRI projectile accidents still continue to occur quite regularly, he said. "The fact is that almost nowhere in the world is there specific explicit rules or requirements to follow long-established best practices that would help prevent just this kind of accident," he added.

The death in South Korea comes 20 years after six-year-old Michael Colombini was killed when a hospital employee brought a portable oxygen cylinder to an MRI room; the balloon got into an MRI scan and hit the child in the head. The death of Colombini marked the beginning of many years of efforts to prevent such events.

Given that 2021 marks the 20th anniversary of Michael Colombini's accident, we should be deeply embarrassed to see that scanner accidents continue to occur decades later, "Gilk said. "We know better - or at least we should know better.[2]

2019: Hospital to pay $14K for patient's death in MRI scanner

At the end of November 2019, the Bombay High Court ordered the Bombay city government to pay temporary compensation in the amount of 1 million rupees (about $14,000) to the family of a man who died in an MRI accident.

The tragedy took place at Nair Hospital on January 28, 2018. It was then that 32-year-old Rajesh Maruti Maru accompanied his mother-in-law to the hospital to undergo an MRI scan. With him, Maru brought an oxygen cylinder intended for an elderly relative. According to the rules, during the operation of the MRI scanner, metal products cannot be carried into the room. During the operation of the tomograph, a strong magnetic field is generated, therefore, it is forbidden to enter the room where the procedure is carried out with metal objects.

Nevertheless, as Rajesh Maru's brother-in-law said later, an employee of the medical institution allowed him to take the cylinder with him, assuring him that everything was in order and the scanner had already been turned off. The uncle of the deceased claims that one of the orderlies himself asked Mara to bring an oxygen cylinder into the office, assuring that the device was turned off.

The orderly, who was supposed to prevent such incidents, told my relative to go into the office with a working tomograph. We are shocked and devastated, "Jitendra Maru told AFP.

The tomograph operator and the doctor did not respond to this statement in any way. As a result, when Maru entered the room, he was instantly sucked inside the device. The device turned on and pulled the man with a powerful magnetic field. Rajesh Maru suffered injuries incompatible with life and died in intensive care ten minutes later from severe blood loss.

Man dragged by magnetic field into MRI machine dies

In an interview with the agency, a law enforcement official said that the cause of the man's death, according to preliminary data, was poisoning with liquid oxygen, which leaked from a cylinder damaged by a strong blow to a tomograph.

A doctor and a junior medical officer involved in the incident have been arrested. They are charged with causing death by negligence, said Deepak Deoraj, Mumbai police public relations officer.

Hospital management said an investigation was underway into the incident and that CCTV footage had been released to police.

The authorities of the state of Maharashtra, whose capital is Mumbai, at the end of January 2018 announced the payment of compensation to the family of the deceased in the amount of 500 thousand rupees ($7870).^[3]

Bombay high court orders Bombay city government to pay temporary $14,000 compensation who died in MRI accident

The family presented a lawsuit against Bombay Municipality, which operated Nair Hospital. Two judges ruled the death was caused by the negligence of hospital staff. The evidence presented led the court to conclude that the accident would not have occurred without the negligent attitude of the hospital employee to potentially dangerous devices. Bombay municipality was dissatisfied with the decision of the court, which decided to pay compensation by November 22, 2019, and filed a petition with the Supreme Court.

The important thing is that, according to the employer, his employees were negligent in the performance of their duties, the Bombay High Court remained with its opinion. - Thus, the municipality cannot avoid the responsibility to pay compensation to the family of the deceased.

2018

Patient suffered facial burns on masked MRI

In early December 2020, it became known that one of the patients in the United States undergoing MRI in a protective mask received facial burns. Medical workers did not pay attention to the metal fasteners of the mask, which heated up during the study and caused severe injury. The U.S. Food and Drug Administration (FDA) has issued memoranda to patients and health care providers that remind MRIs prohibit the wearing of metal items for any purpose.

We remind patients and medical professionals that face masks (surgical or non-surgical masks and respirators) with metal elements and coatings can lead to injuries to the patient during MRI, the memorandum says.

US patient suffers face burns in protective mask MRI scan

During a pandemic, patients are forced to wear masks everywhere, which is why the problem has grown sharply on a scale. Earlier, the FDA issued a decree according to which it is advisable for patients to wear protective face masks even during MRI to reduce the risk of transmission of COVID-19. But some masks contain metal parts, such as steel nose mounts, silver nanoparticles or a copper antimicrobial coating. Before starting an MRI, health care providers performing the procedure should ensure that the patient's mask does not contain metal.

Given the widespread use of masks during the COVID-19 pandemic, the FDA reminds patients and medical professionals of the potential risk of face burns associated with the use of protective masks during MRI scans. Metal parts... [protective masks] can warm up and cause burns to the patient's face during an MRI scan.

Experts recommend that health workers offer patients recyclable disposable masks to replace their own for the duration of MRI.^[4]

Massive iPhone outage due to helium leak in MRI scanner test

On October 8, 2018, at the Morris Hospital private medical clinic from Illinois, USA, after testing a new MRI device, a massive malfunction of the iPhone and Apple Watch of the medical facility staff occurred. Initially, electromagnetic radiation emanating from the MRI apparatus was considered the cause of the breakdown. However, as it turned out, neither gadgets from other manufacturers nor other electronic devices in the building stopped working. As a result of the investigation, it turned out that the cause of the "death" of smartphones and smartwatches was liquid helium, which is actively used to cool the components of the MRI apparatus.

According to Eric Wooldridge, system administrator at Morris Hospital, on that day, employees of one of the departments began to launch a newly installed magnetic resonance imaging scanner from GE Healthcare. At the end of the day, employees turned to the IT department of the clinic, whose gadgets suddenly stopped working.

{{Quote 'The devices behaved rather strangely. Most of them became completely inoperable. I put the affected devices on charge, but they did not react. Other devices began to experience problems connecting to cellular operators, although the Wi-Fi connection remained stable and fast, Wooldridge said. ^[5]

In total, about 40 users were injured as a result of the incident, mainly owners of iPhone 6 and higher models, as well as Apple Watch Series 0 and later versions. It is noteworthy that in the building at the time of the launch of the tomograph there was a person with an iPhone 5, but nothing ordinary happened to his gadget.

The system administrator first suggested that the electromagnetic pulse from the tomograph could damage the components of the devices. However, after making sure that Apple's gadgets were affected exclusively, he turned to the technical support of the tomograph manufacturer. They put forward their own version that the reason for such a strange behavior of smartphones could be the interaction of helium with electronics components. At that time, the version seemed implausible to Wooldridge, moreover, it did not explain the selectivity of the problems that affected only the iPhone and Apple Watch. As a result, the Morris Hospital sysadmin decided to seek help from Reddit users.

One member of the "r/sysadmin" community explained to Wooldridge that it was most likely all about MEMS generators, used for several years by Apple to calculate time in its devices instead of conventional quartz generators. In particular, it is known that the company installs a silicon generator SiT1532 manufactured by SiTime in the iPhone, iPad, Apple Watch and even the Apple Pencil stylus. As with conventional quartz generators, its function is to continuously create oscillations at a given frequency (usually 32 kilohertz) to allow time intervals to be counted. Such generators are quite inexpensive and, moreover, take up much less space in smartphones.

Because the vibrations of the mechanical resonator are affected by the environment, chip manufacturers place it in a chamber isolated from the outside atmosphere. In the vast majority of cases, that protection really works. However, the chip maker admits on its website that for gases with small atom sizes, such as helium and hydrogen, this protection is not intended because in a normal atmosphere their concentration is at only five particles per million by volume (ppmv). These gases, due to the small size of the atoms, can penetrate through the protective wall of the isolated chamber, increase the pressure in it and change the characteristics of the sensor. Since the operation of the clock directly depends on the operation of the central processor, a strong deviation from normal mode can lead to incorrect operation of the entire device.

In a user guide, Apple also notes that "if the iPhone is in conditions with a high concentration of industrial chemicals, including near vaporized liquefied gases such as helium, damage to the iPhone or a violation of its functionality is possible." The company recommends leaving the affected iPhone alone for a while, in which the smartphone should finally ventilate and start working again.

The clinic's system administrator decided to find out where helium came from in the hospital in a volume sufficient to disable smartphones. It turned out that during the tomograph testing, experts poured liquid helium into it. This is the standard procedure required to keep the superconducting magnets in the tomograph in a cooled state. At the same time, the office with a tomograph was not isolated from the rest of the building and connected to the general ventilation system. Apparently, a significant part of 120 liters of liquid helium, the atoms of which, when evaporated, occupied hundreds of times the volume, fell into other offices, and then into the MEMS generators of the devices.

Eric Wooldridge decided to clearly demonstrate the effect of helium on the iPhone. He placed the gadet in an airtight transparent plastic bag with lightning and inflated it with helium. In the video, you can see that eight minutes later the same saome occurs with the smartphone, which happened during the launch of a tomograph in a clinic with other Apple devices: it "freezes." Perhaps the iPhones of other users also worked after the "freeze," but since their screen was turned off, users believed that their smartphones were turned off, the system administrator suggested.^[6]

Spandex and Lycra sportswear leads to MRI burns

In the United States, many medical centers have introduced a requirement instructing patients not to wear clothes from modern stretching tissues such as spandex and lycra for a magnetic resonance imaging procedure due to the risk of getting burns during an MRI scan. This became known from the MarketWatch article published on May 9, 2018.

The requirements were introduced after several incidents. So, in 2011, an 11-year-old girl who was examined for scoliosis received second-degree burns due to a T-shirt sewn from the so-called microfiber. As it turned out later, the material contained silver particles, although there were no warnings about this on the clothes, and checking with a metal detector showed nothing. The girl underwent the procedure under the influence of a sedative, so she did not wake up when the clothes on her were hot.

In the US, they ask not to wear sports clothes from spandex and Lycra on MRI due to the risk of burns

Another case that was widely publicized occurred in 2014. A patient named Jenn Marr, who wore leggings for yoga, felt a burning sensation during an MRI scan. After 15 minutes, the discomfort became so severe that the woman pressed the emergency stop button and interrupted the procedure. The patient was not seriously injured.

The thing is that modern materials, most often used for sewing sportswear or underwear, contain metallized fibers. For example, Canadian sportswear manufacturer Lululemon Athletica has developed "Silverescent" technology, which, by weaving silver-coated threads into the fabric, provides an antibacterial effect and prevents sweat from appearing in the clothing.

But no matter how comfortable and pleasant such a tissue seems to the body, being in it in a tomograph is fraught. The publication provides a photo of ads that can be found in the United States on the doors of MRI cabinets.

Many manufacturers, such as Lululemon Athletica, use metallized fibers in their athletic and stretching clothing. These tissues can cause you burns during MRI scans. If you have clothing (including underwear) made from similar materials, please let the employee know. We will provide you with other clothing for the procedure. We take care of your safety.[7]

Noxious gas emissions at New York airport

On February 10, 2018 , an emergency occurred at JFK Airport in New York: a damaged magnetic resonance imaging (MRI) scanner began releasing poisonous gases.

According to CBS Local, a team of liquidators of the consequences of man-made disasters with dangerous substances arrived at the airport after a report that a damaged MRI apparatus began to emit poisonous gases.   According to a police spokesman, the MRI scanner was in transit and was temporarily located in cargo terminal No. 23. Somehow equipped was damaged and began to emit dangerous gases, not reported. It is also unknown what type of gases began to come from medical equipment.

Firefighters and a rescue team arrived at the scene and responded quickly to the call. There were no casualties in the incident.^[8]

As a result of the incident, there was no delay in flights, unlike another emergency that occurred at the JFK airport in early 2018. Then the air harbor limited the reception of international flights due to a burst of water supply in one of the terminals.

2017

Blanket burned in MRI scan

In late August 2017, an incident involving the ignition of a blanket used to cover the patient during magnetic resonance or positron emission tomography became known.

When going for an MRI scan, you cannot wear clothes with metal fittings (lightning, rivets, etc.), watches, glasses, jewelry and piercings. It is not recommended to use cosmetics, since some of these products contain metal attracted by powerful magnets. In addition, there may be problems with some types of tattoos.

Consequences of burning a blanket that had copper threads in an MRI scan

The Radiology newspaper described a case that occurred in August 2016 with a 62-year-old woman while undergoing an MRI scan at the Pitie-Salpetriere Hospital in Paris. She was injected with fluorodeoxyglucose (a radioactive marker that clearly shows deviations in the body), after which the patient, covered with a blanket, was placed in the ward for 30 minutes. The coverlet was used to maintain body temperature because in the event of its fall, fluorodeoxyglucose can be deposited in the drilling adipose tissue.

The woman was then taken to an MRI room and placed on a table in the position of her arms and legs pressed to the body. She was fixed to a medical device with a special 50-centimeter belt, and the same blanket was placed on top.

The scan was carried out according to the instructions for 20 minutes. However, when the doctor entered the part of the room where the MRI scanner was located, he felt a strong smell of combustion, and the smoke came from the covering. The doctor quickly removed a piece of tissue from the patient. For part, she managed to avoid burns partly due to the use of a fixing belt.

During the examination of the blanket, employees of the medical institution discovered copper threads, which, as it turned out later, remained in the edge after sewing at the factory. The hospital purchased blankets from one manufacturer for 15 years. It turned out that shortly before what happened, the production process was changed at the enterprise.^[9]

MRI burns

The 60-year-old patient suffered a burn during an MRI examination she was undergoing at a private clinic in the Indian city of Bhopal, the capital of Madhya Pradesh. The incident was reported in early August 2017 by the local Times of India.^[10]

Due to what happened in the medical center, confusion arose. Those accompanying the woman made a scandal, accusing the staff of negligence. The victim was immediately provided with the necessary assistance, and later her relatives took her to a neighboring hospital for examination.

Patient suffered burn during MRI examination

News of what happened quickly spread on social media. At first, the victim's relatives wrote that the woman was burned by a fire that broke out in the MRI installation. Then they began to say that a malfunction of the device led to the burn, and that now the patient herself blames the incident on the clinic.

Meanwhile, the staff of the diagnostic center complain that they were abused by the woman's relatives.

In an interview with the publication, the head of the clinic, Dr. Makesh Mehra, clarified the situation. According to the doctor, that day the woman was already 14 patients. During the procedure, she panicked, but instead of pressing the button and calling for the help of an employee, she began to stab on the MRI installation. As a result, a burn appeared in the patient's abdomen - redness about two millimeters in size. The doctor added that before that, his practice had never received an MRI burn.

Specialists from the Indian Center for Nuclear Research BARC (Bhabha Atomic Research Center) in Mumbai also say that they are not aware of cases of burns during an MRI examination.

Doctors at the clinic say the MRI setup in question has been in use for 8 years. At the same time, the average service life of a magnetic resonance tomograph is about 15 years.

MRI apparatus for $1 million disarmed a policeman

In Turkey, an MRI machine literally disarmed a retired police officer who did not pull out a gun before entering a magnetic resonance imaging office. The incident that caused panic in the state hospital of the city of Nazilli in the Turkish province of Aydin became known on June 20, 2017. The weapon magnetized to the installation was torn off only after a long effort, according to the Daily Sabah.^[11]

In Turkey, an MRI scanner literally disarmed a retired police officer who did not pull out a gun before entering a magnetic resonance imaging office.

57-year-old retired policeman Beyhan S. (Beyhan Ş.) Brought his 80-year-old father-in-law Necati K. (Necati K.) for an MRI examination and entered the office with him, forgetting that he had a gun behind his belt. Beyhan Sh. Helped an elderly person to settle in an MRI installation when a powerful magnetic field of the device was pulled by a weapon. The man tried to tear off the magnetized pistol, but despite all his efforts he could not move the weapon. The retired officer then noticed the pistol trigger cocked and had to report the incident to the facility's management. The employee who came to the rescue blocked the trigger to prevent the shot.

It was possible to tear off the magnetized weapon with great difficulty, after almost two hours. To do this, a copper wire five meters long had to be attached to the pistol, which was pulled by five people, notes the Turkish Internet resource Hürriyet.^[12]

After the gun was removed from the MRI unit, it turned out that there was no cartridge in the barrel. In connection with the incident, a complaint was filed against a retired policeman. The culprit of the incident took the gun and apologized for the oversight. Whether the device suffered as a result, the market value of which is $1 million, is not specified.

It is worth recalling that according to the rules, in the office where the MRI examination is carried out, it is not allowed to find metal and electronic objects, since they can affect the operation of the magnet.

Notes