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Fatal MRI Accident Is First of Its Kind

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WebMD Health News

Aug. 1, 2001 -- Despite the horrific MRI accident that caused the death of 6-year-old Michael Colombini earlier this week in Valhalla, N.Y., many medical experts reiterate that the use of the imaging test is safe when used appropriately.

Colombini was undergoing an MRI, or magnetic resonance imaging, at Westchester County Medical Center last Friday when an oxygen canister was turned into a guided missile by the powerful MRI magnet. The canister was drawn into the magnet core while the boy was in the machine. The result was a fatal blow to the child's head. He died on Sunday.

Frank Shellock, MD, an MRI safety expert who has been tracking MRI-related accidents for 16 years tells WebMD that this is the first death caused by an MRI projectile, and that any kind of MRI accident is "relatively rare."

MRIs have been used regularly by doctors since "1982, and it is estimated that about 10 million MRI imaging studies are done in the United States each year," says Shellock, who is a clinical professor of radiology at the University of Southern California.

The imaging machines are very popular because they use powerful electromagnets -- not radiation -- plus computers and radiowaves to create clear and detailed images of the brain and other organs. While accidents involving the magnetized machines are rare, they do happen.

Gregory Chaljub, MD, an associate professor of radiology at the University of Texas Medical Branch in Galveston, says that he and his colleagues know of five instances in which oxygen canisters became dangerous projectiles in MRIs. "If we found [the accidents] in these two institutions, I have to guess that accidents happen elsewhere, too," Chaljub tells WebMD.

In only one of those incidents, all of which are described in a study published in the July issue of the American Journal of Roentgenology, one patient was injured. That patient, a 60-year-old man, sustained fractures to his face when an oxygen canister became wedged in the machine pressing against his head. The man later sued the hospital and was awarded $100,000 in damages.

Chaljub says that MRI suites typically post large warning signs telling of the dangers of metal objects near the machine. The powerful magnets used by MRIs "are on all the time so it is not a question of flipping the magnet on and off. Anytime an object comes into the magnet's field it can become dangerous."

The nurse who carried the oxygen canister into the room where Colombini was being scanned mistakenly believed the canister was made of a nonmagnetic material, like aluminum. Chaljub says that accidents often happen when nonmagnetic and magnetic canisters get mixed up, and he recommends putting special markings on aluminum canisters to indicate that they are safe. He also recommends the use of security entrance systems -- such as the use of special computer codes to unlock the doors to MRI suites.

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