State health authorities investigating radiology group's handling of fatal MRI incident

Tennessee health authorities are investigating the circumstances surrounding the death of a man who was undergoing an MRI at an outpatient imaging facility. 

The incident occurred at Premier Radiology in Brentwood, Tennessee, on July 11. According to media accounts shared Wednesday, the patient had both a pacemaker and implantable cardiac defibrillator at the time of his exam and was not feeling well beforehand. He reportedly was having difficulty breathing prior to the procedure but signaled to technologists during the exam he was OK.

“The patient seemed red-faced and I could tell I need to finish this pretty quick,” one of the technologists said in their account of the incident, according to the state.

By the time the scan was over, the patient was unresponsive. The moments that followed proved to be detrimental. Staff called 911 when they discovered the patient was unresponsive. They informed the dispatch worker that the man was “turning blue” and did not have a pulse, according to an investigation by the State Health Facilities Commission.

Logs from that same call suggest that staff struggled to operate automated external defibrillator equipment in the exam room. They could not locate the connection port for the pads, delaying lifesaving care for the patient. 

“The clinic failed to ensure staff were adequately trained on the use of emergency medical equipment,” state investigators claimed. 

The issues with the AED, however, are not to blame for what triggered the patient’s deterioration. The state’s report also revealed that his pacemaker and defibrillator—both of which can malfunction under a magnetic field if precautions are not taken—might not have been in MRI-safe mode prior to the exam. Investigators suggested that the devices were not switched over until 37 minutes after then 911 call was made, though the clinic has refuted these claims, pinning the timestamp on a discrepancy owed to daylight saving time. 

Tobias Gilk, an MRI safety specialist, filed a complaint with Tennessee authorities to gain more information on the incident. Gilk’s interpretation of the resulting report is that it uncovered “alarming inconsistencies” with the accounts of the incident. He described the entire ordeal as “a complete train wreck of information.” 

The investigation remains ongoing. 

Read more here.