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ACR MRI burn complaint letter.

Back in November 2016 I filed a complaint against  the Imaging facility where I was burned with the ACR (American College of Radiology). 6 months later I had heard nothing back so I followed up in June 2017. The ACR is the body responsible for accrediting an Imaging facility. There are supposedly strict requirements a facility must pass to be awarded the ‘prestigious’ ACR accreditation. Today, July 20th I finally received a response to my complaint. Here is what it said :

Now this seemed a little weak for me so I called the director. I asked what exactly they had investigated. I wanted to know what procedures they had followed to determine whether their ‘accredited’ facility had contravened any rules or safety protocol’s. The response I got was ‘Our investigation is private and confidential and we are not at liberty to discuss it with you’. I said but I’m the victim here. I’m the one who actually filed the grievance. Don’t I have a right to know what procedures you followed even if you don’t tell me specifics about the results. ‘No, it’s confidential’, she said. I asked- how do I know you didn’t just tell your secretary to call the facility and as long as they said everything was good on that day you would mark the case ‘resolved’. I asked if she had seen the photographs I submitted along with my complaint. I asked if they had sent anyone out to the site to investigate the environment that existed on the day I was burned or to review MRI machine logs. ‘It’s confidential’ she said. Are you kidding me ? I asked if the fact that the facility had not even so much as acknowledged one of the certified complaint letters send to them contravened any of their ‘accreditation’ requirements. When she said the facility must respond to patient complaints, I asked why? You say they ‘must’, but who is enforcing that? Certainly not ACR. Its a meaningless comment. She had no answer. I know for a fact that very little if anything was done as part of this investigation because there were at least half a dozen safety violations in effect during my MRI scan – I was not put in a robe, no padding was used around my body, I was not told to put my arms down by my side instead of crossed at my chest etc. Apart from the real cause of the MRI burn which I believe to be related to either operator error or machine malfunction, these simple things would at least have been discovered if a proper investigation was performed.

Slightly annoyed about the comment in the letter (above) about following up with my primary care physician, I let her know that this was obvious and completely redundant. I asked her if she actually believed that after nearly 8 months of an horrendous MRI burn injury it would never have occurred to me to go and seek medical advice. Huh ?

So here’s the interesting moral to this story. The American College of Radiologists is a self formed non-profit organization with no government oversight. They have taken it upon themselves to create an accreditation program that Radiology Clinics can elect to participate in, in order to receive an accreditation certificate. The general public is then led to believe that this certification provides them an extra level of safety when they see the logo. This obviously wasn’t the case with me. In my opinion the fact that the ACR is self regulating deflates the  validity of the certification. Keep in mind – It is NOT in the ACR’s best interests to acknowledge that an adverse event such as mine occurred at one of their ‘accredited’ institutions. This would cast a shadow on their accreditation process and put the safety of the general public into question. Much easier to say they conducted an investigation, that everything was in order and hope the complainant just disappears.

Guess what, that’s not going to happen.

On Saturday 11/19/16

The next day I went to see my family doctor who also happens to specialize in dermatology. She said she was unfamiliar with MRI related burn injuries but after looking at me felt it had been caused by some type of thermal exposure and advised use of cooling gels and lotions. She consulted with an MRI physicist about the problem and was told :  “Regarding the burn: I’d definitely recommend the pt to be checked out by a Dermatologist. MR burns typically starts at subcutaneous fat (no pain receptors) and moves up to epidermis. If the pt was not sedated during the scan and ended up with a burn, there is a clear chance that the patient has damage under the skin that is not visible. After researching this issue myself I discover articles that describe RF related burns from high power MRI machines. In fact burn injuries are seemingly the highest reported type of MRI related injury. Apparently during MRI, if RF power is not deposited uniformly into the patient’s body blood flow redistributes this energy, resulting in non-uniform in vivo temperatures. Because certain in vivo regions become hotter than the rest, temperatures go beyond a safe value and RF burns occur. I believe this is what has happened to me.

Monday 11/21/16 and I am still feeling the burning prickling feeling on my skin. I decided to schedule another doctor’s visit to discuss if there are any other tests that should be done to rule out deeper tissue injury since I don’t know how deep the heat penetration was. (blood work etc.). I also decide to start reaching out to subject matter experts in MRI to try to find out what may have happened. MRI physicists, safety experts, anyone who knows anything about MRI technology. My first contact is to a renowned MRI safety expert and Professor of Radiology at USC. After looking at my account and reviewing pictures his his initial reaction is that this is RF radiation burn and that I needed to be checked out ASAP by a dermatologist.

Getting scared …

 

MRI BURN INJURY – DAY ONE

On Thursday 11/17/16 I was burned on a 3Tesla MRI machine at a local MRI facility in Scottsdale, AZ during a routine CSpine/Thoracic scan.

My neurologist had ordered the MRI to check the status of an old neck injury (which happened in April 2011). He was concerned about upper cervical instability and possible brain stem compression, but that’s another story. My MRI was to be cervical thoracic spine procedures done back to back. I’d had many MRI’s before of my cervical spine without incident but never a thoracic.

My appointment was for 1.15pm but when I arrived the facility was backed up and staff was trying to get patients in and out as soon as possible. I waited for a while and was then hurried into the MRI room (probably around 1:45) and placed on the MRI machine bed (still warm from the previous patient). I was given special boxer shorts to wear but not a full gown and was wearing a plain cotton T-shirt. I was given headphone apparatus but not earplugs. I was positioned lying on my back and entered head first. There was no padding used during the study but no part of my body touched the walls of the machine. I held the ‘panic’ button in my right hand and my hands came together just below my sternum in a typical ‘praying’ position so my arms rested on my upper abdomen as opposed to down by my sides. The procedure was started immediately. No communication with technicians. About 10 minutes in I felt the noise level was too high so I pressed the button and asked if I could be given some earplugs as well as the headset. I was given these, shunted back in and the procedure continued.

For the first 15 minutes or so (during the cervical scan) everything seemed to be going fine. Then about 10 minutes into the 2^nd procedure (thoracic) I started to feel a sort of prickly vibrating heat hitting my skin. It felt like a kind of rippling wave and I started to feel quite warm. It even seemed to vibrate my T-shirt and penetrate through. It was accompanied by a loud hum which I could hear over and above the typical clicking sound. I had never felt or heard anything like this on previous MRI procedures. The sensation wasn’t excruciatingly painful like you would expect from a contact burn and since I was half way through the 2^nd procedure I just decided I would just see it through. This decision would probably turn out to be one of the worst of my life. The combined CSpine/Thoracic procedure took approximately 30-40 minutes and I felt this sensation for about the last 10.

When I got off the table I felt hot, like I had been ‘cooked’ and mentioned it to the technician. She said it was normal to feel a bit warm when the machine had been running for a while. As the day wore on my skin got redder and redder. It’s hard to remember it hour by hour but by the time my wife arrived home from work around 5.30 I was pretty red and felt and looked like I had a bad sunburn. I started applying Aloe Vera gels and lotions. By the next morning I was very red and sore.  I was pretty concerned and worried there may be deeper tissue damage. I decided to call the office manager at the clinic and explained the problem. She was non-committal and told me that they had had no other similar complaints from the same day. When I asked her whether they had ever had any complaints like mine she was a bit hesitant and said she thought they had had a few but not for at least 6 months or so. She said the sunburn feeling would go away after a few days. I was again dubious and I told her if it hadn’t gone within a few days I would go and see my doctor.

Little did I know what was to come!