Organic Matter: MRI tragedy an alert

A magnetic resonance imaging (MRI) exam is a diagnostic tool often used by physicians in diagnosing brain tumors, heart disease, spinal disorders and other diseases and conditions.

The exam gives far more detailed information than standard X-rays and is considered safe, usually.

But a terrible accident during an MRI killed a 6-year-old boy in Valhalla, N.Y.

on July 27.

Michael Colombini had undergone an operation a week earlier to remove a benign brain tumor discovered following a fall at home.

The boy was sedated and having an MRI done to check on his progress.

For unexplained reasons, an oxygen tank about the size of a fire extinguisher was introduced into the room while the 10-ton electromagnet was in operation.

The tank was immediately magnetized and pulled into the center of the machine, striking the boy and causing head trauma.

Michael died of blunt force trauma, a fractured skull and bruised brain, the county medical examiner's office determined.

A spokeswoman for Westchester Medical Center would not say who took the oxygen tank into the MRI room or why.

Hospital president Edward Stolzenberg said in a statement the hospital assumes full responsibility for the horrific accident.

The reaction of Jenny Anson, a neighbor of the Colombini family, may reflect what most people think.

"What can you say? It's every parent's worst nightmare," Anson said.

"Especially in a place where you expect them to be cared for."

Separate investigations into the tragedy are being conducted by the Westchester District Attorney's Office and the hospital.

Kingman Regional Medical Center has a 13-ton MRI machine.

Bill Crome, director of imaging services, said the potential for an accident here will always exist.

"We have non-ferrous oxygen tanks so they could go into the (MRI) room, if necessary," he said.

"But you always have to keep your guard up.

"We do safety training with our housekeeping personnel.

They can't take buffers into the room or carts because they'll go right to the magnet, and maintenance guys can't go into the room with tools on their belts."

A lapse in screening procedures must have contributed to the fatal accident in Valhalla, Crome said.

Last year, there was another incident involving an MRI machine in Rochester, N.Y.

An MRI magnet yanked a .45-caliber gun out of the hand of a police officer and the gun discharged a round that lodged in a wall.

The Associated Press reported that workers dismantling an MRI machine recently at the University Of Texas found numerous pens, paper clips, keys and other metal objects inside.

Each had sailed through the air as a projectile and been drawn to the magnet that powers the MRI's medical scanner.

Some deaths have been reported in the past when an MRI machine's magnet disrupted metal aneurysm clips or cardiac pacemakers inside the bodies of patients.

On one occasion, a patient was blinded when a piece of metal, long embedded in one eye, moved during the machine's operation.

Results of a records study of nearly 138,000 MRI scans done over 15 years by Dr.

Gregory Chaljub of the University of Texas medical branch in Galveston were published in June in the American Journal of Roentgenology.


Chaljub found five cases in which tanks mistakenly brought into an MRI room immediately were pulled toward the magnet.

In a 1987 case, an oxygen tank struck a patient in the head and caused facial injuries.

He has suggested all oxygen tanks be made of aluminum that are used in hospitals, but added the cost would be much greater than other metal tanks.

"My bottom line is this kind of accident is preventable and MRIs are safe," Dr.

Chaljub said.

"The tragedy in Westchester shouldn't scare people.

It should alert people."

Terry Organ is the Miner's education, health and weather reporter.