The patient was scheduled for a 3T MRI scan on UCLA’s highest-strength magnet. He had a fairly complex medical history. As Williams reviewed his record, she noticed he had an implantable cardioverter-defibrillator, a device used to detect and stop irregular heartbeats. According to the chart, it was later removed when the patient had a heart transplant.
Williams decided to examine the patient’s chart in greater detail. She searched for a prior chest X-ray. The X-ray revealed that something was still implanted in the patient. The radiologist from that time noted it was a stent.
Williams’ intuition told her to keep digging.
“As the person who actually scans the patient, the MRI tech is considered the last line of defense to clear the patient before the actual exam. It’s our responsibility to be 100% certain the patient is safe to go through with the exam, to ask the right questions and verify the history,” she says. “We have to be extremely diligent and thorough.”
Instincts and knowledge
What was in the patient’s upper chest? A leftover remnant of his defibrillator coil.
“The main concern with MRI is that any metallic objects, like the abandoned coil, could potentially heat up, resulting in internal burns to the area or dangerous movement of the fragment,” explains Williams.
She canceled the exam. Trauma to a blood vessel through the MRI could have been fatal.
UCLA Health recognized Williams through its Good Catch Program. This program calls out staff and faculty who have acted to prevent harm brought about by “close calls,” hazardous conditions or errors.
In radiology, techs are responsible for performing imaging exams. But they are also responsible for upholding high standards of patient care through awareness, transparency and adoption of best practices.
“Katelyn truly cares about each of her patients, and her diligence in this matter proves that. She’s amazing,” says Deborah LaBrie, director of MRI operations.
Patients who need an MRI go through a screening process. During this process, trained individuals ask important questions about each patient’s history and possible risk factors for metallic interference.
Still, in some cases, patients misremember or simply aren’t aware of materials present in their own bodies. Williams’ patient had no knowledge of the coil remnant.
“As MRI technologists, it is important for us to have good instincts as well as knowledge about potential medical procedures that could lead to contraindications for the MRI exam,” Williams says.
A further look
Education in the MRI suite is critical, and UCLA Health requires safety courses and annual screening exams.
Their goal is to promote awareness of MRI safety among all patients, physicians, nurses, technologists, escorts — anyone who could be in the magnet area or involved in scanning clinical patients and research subjects using MRI facilities across the UCLA Radiology enterprise.
“The MRI staff are trained to look below the surface, as in Katelyn’s incident, and always double check. Going above and beyond is part of every MRI technologist’s duty,” explains LaBrie. “A missed implant could cause a devastating outcome.
"All day, these techs review and search through charts just to find the one sentence that may mean the difference between life and death. This is an incredible team.”
Learn more about radiology services at UCLA Health.
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