Man dies in India MR mishap

January 30, 2018
by Thomas Dworetzky, Contributing Reporter
Another MR tragedy has taken a life.

This time a 32-year-old man perished at BYL Nair Municipal Hospital in Mumbai, when he was holding his elderly relative's oxygen tank as he accompanied her into the room for a scan.

Three people were arrested in the incident for causing “death by negligence,” according to the Indian Express. These included Dr. Saurabh Lanjekar, and hospital workers Vitthal Chavan and Sunita Surve.

Rajesh Maruti Maru, age 31, had helped his sisters's mother-in-law, Laxmibai Solanki, into the room for a test when the tank he was holding pinned him by the hand and trapped him in the device.

“Magnetic force of the machine sucked him in. We are not sure how he went so close. An inquiry is on,” said Dr Ramesh Bharmal, Dean of Nair Hospital, told the paper.

Apparently the machine snapped the tank's valve off and led to Maru inhaling too much oxygen.

Maru’s family recounted that he was instructed not to leave the tank outside, and hospital staff had him help position the elderly patient in the MR. “The ward boy asked him to help. They said it was okay. He went close to the machine and instead got pulled along with the oxygen cylinder inside the machine. Instead of taking responsibility, the hospital workers scolded us for Rajesh having gone close to the MR machine with the cylinder in his hand,” said Maru’s sister Priyanka Solanki, who was also present in the room.

"When we told him that metallic things aren't allowed inside an MR room, he [the hospital worker] said 'sab chalta hai, hamara roz ka kaam hai' (it's fine, we do it every day). He also said that the machine was switched off. The doctor as well as the technician didn't say anything," Solanki told NDTV.

A postmortem at J J Hospital showed that the cause of death was pneumothorax, in which excessive air enters the lung. “An excessive quantity of oxygen entered his body from the cylinder, which is also harmful. He seemed to have died instantly because of that. Apart from that there were injury marks on both his hands,” a forensic doctor said.

At this point, reported the Indian publication, the investigation continues. Senior Police Inspector Savalaram Agawane told the paper that “relatives should ideally not be allowed inside the MR room. The ward boy or doctor should have also told the family not to take the oxygen cylinder close to the machine.”

The report is far from the first such accident with an MR.

When Uttar Pradesh Minister Satyadev Pachauri was rushed to Ram Manohar Lohia Institute of Medical Sciences in Lucknow, India, for an emergency MR scan in June 2016, for example, his security guard brought his gun into the room.

The gun was sucked into the machine. Damage was extensive and costly.

The medical superintendent of the hospital, Dr. Subrat Chadra told NDTV at the time, "I will put up big notices everywhere in the hospital that people should not enter restricted areas without permission. I am not sure how the security officer managed to go in, we have launched an enquiry into it. The machine itself will take over 15 days to come back to action."

The pistol was loaded at the time, but fortunately did not go off.

A similar incident took place in January, 2016, when a U.S. veteran allegedly walked into an MR room in Indianapolis at Richard L. Roudebush Veterans Affairs Medical Center packing a .45 pistol, and it got sucked against the magnet and went off.

Fortunately his wound was not life-threatening.

Another mishap in India, in 2014, saw a patient and tech trapped in an MR for four hours, one with a broken arm, when a charged scanner launched an O2 bottle from the wheelchair in which the patient was being transported. In February, 2017, Indian MR technologist Swami Ramaiah received a settlement of nearly $150,000, after he was left temporarily paralyzed from the waist down by the accident at a Tata Memorial Hospital-run treatment and research center in Navi, Mumbai.

In December, 2016, at an RSNA session in Chicago, experts weighed in on the issue of adverse MR events. There has been an almost 500 percent increase from 2000 to 2009 in the face of only a 114 percent increase in volume growth, according to Armen Kocharian, Ph.D., senior imaging physicist, Houston Methodist Hospital. And he suspects there were many more that went unreported.