Six Year Old Killed During MRI
August 15, 2001
Outside of the X-ray, perhaps no other
medical examination is as well known or as safe as the magnetic
resonance imaging test, which is conducted eight million times
a year in the United States on patients ranging from people
with brain tumors to famous athletes with knee injuries.
But today, officials at the Westchester
Medical Center announced that something went horribly wrong
on Friday with an MRI test on a boy, 6, who had just undergone
Even though no metal objects are supposed
to be in the testing area, because they will be pulled toward
the 10- ton machine by its powerful electromagnet, a
metal oxygen tank somehow made it into the examination room.
The tank, about the size of a fire extinguisher,
became magnetized, then flew through the air at 20 to 30 feet
per second and fractured the boy's skull.
The boy died on Sunday. And today, an
autopsy conducted by the Westchester County Medical Examiner's
office confirmed that he had died of blunt force trauma, severe
hemorrhaging and a contusion to the brain.
The hospital and the State Department
of Health are investigating, and the Westchester District
Attorney's office is also reviewing the case.
An MRI generates images of the body using
strong magnetic fields and a computer. And since its introduction
on a widespread scale within the last two decades, it has
generally been considered very safe, according
to Dr. Emanuel Kanal, a professor of radiology and neuroradiology
at the University of Pittsburgh Medical Center.
Still, there have been several MRI accidents,
some of them fatal, involving metal objects as small as paper
clips, Dr. Kanal said. One woman who underwent an MRI died
because of an implanted aneurysm clip in her brain.
Another who forgot to pull a hairpin out
of her hair required a procedure to extract the hairpin after
the pin traveled up her nose and lodged in her pharynx. And
in Rochester last year, an MRI magnet pulled a .45-caliber
gun out of the hand of a police officer and the gun shot a
round that lodged in a wall.
The accident in Westchester also comes
on the heels of a recent article in The American Journal of
Roentgenology about the potential dangers of oxygen tanks
being brought into MRI testing areas.
In that study, researchers found that
there had been five such
accidents in 15 years, including four in the last
three years, mostly involving patients on life support who
have been wheeled into an examination room with an oxygen
"MRI is safe, but if
something goes wrong, it can go very wrong,"
said Dr. Gregory Chaljub, a radiologist at the University
of Texas Medical Branch in Galveston and the study's primary
Indeed, the power of the MRI Is so strong
that in one case, a janitor who was buffing the floor of the
examination floor suffered a wrist fracture because of the
magnetic pull on the cleaning equipment, Dr. Chaljub said.
On Friday morning, the boy, sedated,
was placed inside the MRI - a General Electric Signa machine
- with his head in the center of the machine. At some point,
the tank was "introduced into the exam room" and,
magnetized, was drawn to the center of the room, striking
the boy, according to a hospital news release.
New York Times
July 31, 2001