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Friday, May 18, 2012

MRI injuries: Because children use it too frequently


Darla Stuart's story:
The U.S. Food and Drug Administration (FDA) reported in 2011 that MRI accidents in the US have risen over 500% from 2000 to 2009. The overwhelming majority of reported injuries fell into one of three categories: burns, projectiles and hearing damage.  However, these injuries are not accidents: they are directly related to the failure to assure proper safety standards.

 In 2008, our, then, fifteen year old daughter walked into a children's hospital to have an MRI.  More than a half-hour behind schedule the technician rushed her through the screening as it was late, the last appointment of the day.  Precautions like a two way audio system, safe and inspected equipment and a panic button, which were advertised on the hospital’s website, were non-existent.  Thirty minutes later our daughter crawled out of the MRI machine of her own accord: alone, traumatized and injured. 

The video goggles that were offered by the hospital to help her relax during the procedure were faulty.  They had been recently returned to service after being repaired by the hospital’s own Biomedical Department.  A plastic casing, part of the video goggle manufacturer’s original design, meant to cover the metallic webbing of the video goggles, had been removed and not replaced during the most recent repair.  So, at the moment the MRI started, a piece of tungsten metal from the video goggles, acting like a magnetized projectile,  soldered to our daughter’s eyelid and burned like an ember during three MRI cycles while she laid in there asking, begging, crying for help:  help that never came.  The attending technician had turned the patient microphone down because the noise of the MRI was disturbing to other radiology staff.   

The hospital knew within hours that: the goggles had been improperly repaired by their biomedical department; the microphone had been turned down too low by their staff to hear our daughter’s cries; and the panic button, meant to be an additional safety procedure, was not installed.  They knew that her injuries were not a result of an accident, but caused by their systemic failure to assure proper safety standards. Ironically, though, they blamed her for their negligence and treated her with cold indifference. 

Our daughter’s injury was much deeper than the multiple lacerations on her eyelid, her innocence was lost and her trust of others was shattered.  As the wounds on her eyelid healed and scarred, the wounds in her soul festered.  She found herself waiting for the next bad thing to happen, preparing herself for what she would do if she had to save herself, living in fear every day.  Ultimately, she felt like the fear she lived with every day was too much and she considered suicide.  She has received therapy to help overcome her post traumatic stress reaction, and will likely never be free of the heightened anxiety she experiences as a direct result of this life-changing incident.

On May 16, 2012, four plus years after our daughter’s injury, a jury in Adams County, Colorado found the hospital guilty of medical negligence.  That verdict not only publicly confirmed to our daughter that she was indeed a victim of their negligence, but it gave us the freedom to speak about that negligence as substantiated through a public record. At trial it was admitted into evidence via a staff member’s testimony that the panic button that was to have been mandatorily placed into service was often removed because children use it too frequently.  Further it was stated that the safety manual, which was allegedly written after our daughter’s incident to retrain staff on MRI safety, hadn’t been instituted and staff weren’t even aware that it existed.  

Our daughter’s injury could and should have been avoided.  Her injuries were not caused by an accident or a device malfunction; they were directly caused by the failure to assure and implement common and highly recommended safety standards. Safety standards that remain, as of today, inconsistently applied to children who use that hospital's MRI equipment.

Industry leaders agree that there should be safety standards that provide regulated oversight for MRI safety.  Colorado does not regulate or inspect MRI equipment or associated items used in MRI’s.  Additionally, Colorado doesn’t require that MRI technicians be licensed. Essentially, each facility that offers an MRI service is allowed to independently regulate how they oversee their equipment and determine staff credentials.  Tragically in our experience that independent oversight was absent.

Statistics indicate that with a 500% increase in reported accidents it is highly probable that another child will be a victim of this type of negligence. We can’t turn back time and change what happened to our daughter. 

Darla's Advice:  We can insist regulations are created and government oversight provided. We can warn parents to do what this hospital as of May 16 refused to do:  require staff perform an parent observed inspection of the MRI and associated equipment; assure that the two-way audio system is tested  with their child; make sure there is a panic button is working and tested.  We can speak publicly about our experience, and perhaps with the support of others we can make a stand and insist that no other child be a victim of this type of avoidable negligence.

Read another kind of MRI error story, and see Darla's blog.  Thanks to Darla for sharing her daughter's story.


3 comments:

Anonymous said...

Dear Darla,
I am truly sorry to hear what has happened to your daughter and family. I, too, am frustrated with the lack of oversight in our profession and mandates for standards in safety, technologist education and training and equipment safety.
I would suggest to you and to others to contact their representatives in Congress to support a bill in Washington that would mandate education and credentialing standards across the country for all imaging personnel. I am from California and it is not required to be licensed to do MR and Ultrasound. we are covered in radiation based imaging but could do better in that in some regards as well. HR 2104 is the CARE bill and we are lobbying for that to be passed so that all patients and families can be assured that their care will be performed by a competent individual, no matter what the imaging exam or state. Lorenza Clausen, RT(R)(CT)(MR) President CSRT

Greg Bailey said...

Dear Darla,
This was truly an unfortunate circumstance. I, too, live in a state that does not require technologist to be licensed in MRI. I believe that all medical professionals should be required to have a formal education in what they do. Administrators and managers also need to be educated in the process of these exams and allow their staff the time to perform these exams and not be overwhelmed with clerical duties which may distract from attending to the patient. I would suggest to anyone having an MRI to inquire as to the credentials of the technologist and if they are registered in that specific modality.

Greg Bailey said...

Dear Darla,
This was truly an unfortunate circumstance. I, too, live in a state that does not require technologist to be licensed in MRI. I believe that all medical professionals should be required to have a formal education in what they do. Administrators and managers also need to be educated in the process of these exams and allow their staff the time to perform these exams and not be overwhelmed with clerical duties which may distract from attending to the patient. I would suggest to anyone having an MRI to inquire as to the credentials of the technologist and if they are registered in that specific modality.