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Boy Killed in Freak MRI Accident

Flying oxygen canister crushes his skull

TUESDAY, July 31, 2001 (HealthDayNews) -- A 6-year-old cancer patient in New York was killed during a routine brain scan when the machine's massive magnet turned a nearby oxygen tank into a ballistic missile.

The boy died two days ago from head injuries and brain trauma after being struck June 27 by a oxygen canister that was sucked into a magnetic resonance imaging (MRI) machine by its 10-ton magnet. He was being treated at the Westchester Medical Center in Valhalla for a brain tumor and was undergoing the scanning procedure to measure his progress, according to officials who just released details of the incident.

Experts say the incident, while tragic, shouldn't frighten patients away from the potentially lifesaving test. While accidents do occur, they're quite rare, given that millions of MRIs have been performed.

Moriel NessAiver, an expert in MRI physics at the University of Maryland Medical School, says the New York incident is the first death, or even serious injury, he's heard of involving objects flying into the machines.

"It's the kind of thing we all fear will happen, but we try very hard to prevent," he says.

Hospital officials say the oxygen tank was "introduced" into the exam room while the machine's magnet was on.

In a statement, Edward Stolzenberg, president and chief executive officer of Westchester Medical Center, calls the death a "horrific accident," and says the hospital is taking "full responsibility" for it.

"The Medical Center will do anything it can to ease the family's grief," the statement says.

The hospital and several county agencies, including the health department, the medical examiner and the Westchester County district attorney are investigating the boy's death. But Det. William Rehm, a county police spokesman, says the department hasn't been asked to step in yet, which it would should the inquiry involve possible criminal charges.

The so-called "missile effect" of MRIs is well known, and clinics have explicit warnings about the possible dangers of iron-containing objects around the machines. Although harmless to human tissue, the magnetic field an MRI generates is 30,000 times stronger than that of the earth, capable of accelerating an object the size of an oxygen canister to dozens of feet per second.

A spokesperson for the Food and Drug Administration also calls the "missile effect" a "well-known phenomenon in the medical community and in the textbooks, and it's treated in the labeling for MR devices." The agency recommends that the imagers be used in restricted areas with controlled access.

NessAiver has a Web site on which he collects pictures of MRI mishaps around the world, including chairs, toys, floor polishers and even a welding tank that have hurtled into the tunnels.

Gas canisters are among the more common projectiles, he says, since they're ubiquitous in hospitals.

"Every technician, every nurse is taught not to bring these things [into the imaging suite], but you have so many people who are involved with patient transportation that every now and then somebody sees a door open and walks right in," he says.

What To Do

To learn more about MRIs, try How Stuff Works or the Food and Drug Administration.

For more on the accidents that happen with these machines, visit NessAiver's site, SimplyPhysics.

SOURCES: Interviews with Det. William Rehm, spokesman, Westchester County police department, Hawthorne, N.Y.; Moriel NessAiver, Ph.D., assistant professor of radiology, University of Maryland Medical School, Baltimore; July 30, 2001, statement from Westchester Medical Center, Valhalla, N.Y.; U.S. Food and Drug Administration
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