Episode 1 - The Colombini Incident

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[00:00] [Music]

[00:18] Hello. My name is James Whittaker and I’d like to ask you to remove all the ferrous objects from about your person before I welcome you to this, the first episode of ‘Conditional 1’ an occasional podcast focusing on all aspects of MRI Safety.

[00:35] Before we go any further I’d like to take just a moment to further introduce myself. I originally trained in Diagnostic Radiography in the UK, graduating from Cardiff University in 1996. I started working at the Royal Marsden Hospital in 1999, the NHS’s flagship Cancer treatment centre in London. It was there that I trained in MRI, taught not only by knowledgeable MRI Technologists but by physicists, biochemists and other scientists working at the Marsden for the Institute of Cancer Research.

[01:12] From there I moved to a more senior role at the Royal Surrey Hospital performing cardiac and stroke imaging before taking a leap into the unknown and emigrating to New Zealand in 2007. It was here that I undertook further study, receiving my Postgraduate diploma in MRI in 2009. I have since worked in a number of Imaging roles, public and private and I received my MRSO qualification in Melbourne Australia in 2019. I’ve always had a keen interest in MRI safety and was taught early to have respect for the unique environment and risks we encounter as MRI Technologists.

[01:52] This episode, I’m going to be talking about what is probably the single most defining moment in the history of MRI safety, something that many of you will be aware of to some degree or another. It’s especially fitting at the moment, as this year marks the 20th anniversary of the disastrous event that inspired a paradigm shift in how we approach MRI safety.

[02:17] As Shellock & Crues said in the American Journal of Roentgenology in June 2002 “The topic of safety in the MR environment has long merited attention. Unfortunately, it took the tragic loss of a child’s life in a New York hospital to bring the topic of MR safety the current notoriety that it rightfully deserves.”

[02:40] I am of course, talking about the tragic death of Michael Colombini. Now, many of you listening will know the name, and probably know at least that his was the first MRI death caused by a projectile. But what actually happened to Michael Colombini?

[02:58] To answer that we need to go back 20 years, to a summer day in Croton-on-Hudson, a small village of just over 7 and a half thousand people in southern New York state. Monday, the 23rd of July 2001 dawned with the promise of clear skies and good weather. As the day wore on it became hot and humid with little breeze to clear the air.

[03:22] Making the most of the warmth of the day, 6-year-old Michael Colombini, by all accounts a happy and healthy young boy, was playing outside in his school playground. Unfortunately, though he took a tumble and banged his head, setting in motion the train of events that would lead to his unfortunate death 6 days later.

[03:43] It wasn’t a bad head injury, as these things go. Documents that I’ve read state that he wasn’t even knocked out. However it was obviously serious enough that his parents decided it was better to be safe than sorry.

[03:59] Michael was taken to the emergency room at Phelps Hospital in neighbouring Sleepy Hollow, about 7 miles away. After being examined by an Emergency Physician, Michael was referred for a CT scan of his head to rule out skull fractures or other injuries following his fall.

[04:17] It was at this point that young Michael’s life began to irrevocably change. The CT scan showed a cystic lesion in the right parietal lobe of Michael’s brain.

[04:30] This devastating and unexpected diagnosis led to Michael being transferred from Phelps Hospital on Tuesday the 24th July. His destination was Westchester Medical Centre in nearby Valhalla New York for further investigation and intervention. Michael was admitted and Doctors scheduled an MRI for the next morning with surgery planned for Wednesday afternoon.

[04:58] Michael’s MRI on the morning of Wednesday 25th July went smoothly and later that day neurosurgeons performed a craniotomy and resected the tumor, which the pathologist later identified as an astrocytoma.

[05:14] Following the successful surgery Michael was transferred to the pediatric intensive care unit to recover and for monitoring. He remained there until Thursday evening when he was transferred to the pediatric ward. Michael was apparently doing well and was being kept nil by mouth for an MRI the next morning.

[05:35] On the morning of Friday 27th July between 11:00 and 11:30 AM Michael was taken from the pediatric Ward to MRI by a hospital orderly. He had family with him but according to the Westchester incident review he was anxious and upset.

[05:53] It’s at this point that three further actors join the cast in the second act of this horrible tragedy. First is Dr Jian Hou, the anesthetist responsible for sedating Michael and monitoring him throughout the MRI examination. Next is Patricia Lauria, the MRI Technologist who would be performing Michael’s scan and finally comes Paul Daniels, the chief MRI technologist, who was catching up on some post-processing and filming of the previous case while Patricia helped Dr Hou get Michael ready for his scan.

[06:27] Now I feel that this is the right time for me to provide a little bit of context into the events that followed. The MRI scan room at Westchester Medical Centre was not supplied with oxygen via piped supply but instead via two H class cylinders located in the plant room that were then piped into the scan room via waveguide where flow rates could be controlled using the flowmeter.

[06:52] H class cylinders are among the largest commercially available for medical gases and they’re many things, but portable isn’t one of them. They’re exceedingly heavy, weighing 50 kilos when empty and hold over 7000 litres of oxygen under huge pressure, 2200 psi. At the standard 2 litres per minute delivered via nasal prongs it would take almost sixty hours to empty one of these cylinders, and even at high flow rates of 15 litres per minute an H class cylinder would last nearly 8 hours. According to the Incident review undertaken later, the oxygen cylinder should be changed when the pressure dropped below 500 psi, an indication that the cylinder had about 22% of its contents remaining. With two of these in the plant room, oxygen supply should not realistically have been an issue.

[07:47] According to court documents from the Westchester County Supreme Court Patricia Lauria testified that she hadn’t checked the contents of the fixed oxygen cylinders in the plant room on the morning of 27th July but that she thought Paul Daniels would have, though she admitted she didn’t know for certain that he had done so. Several times that morning, Dr Hou had told Patricia that he would need oxygen to be available during Michael’s scan, and she informed him that it was all set.

[08:18] Michael was met by Dr Hou in the patient care area of MRI just outside and across the corridor from the scan room. Once he had been prepared for his scan Michael was given some sedation via the IV line in his arm. Michael was then transferred onto what is described as an MRI compatible stretcher and Dr Hou then moved with Michael into the MRI room. Once there, the wall mounted oxygen flowmeter was switched on so that Michael could receive oxygen through nasal prongs. A pulse oximeter was attached so that Dr Hou could monitor Michael during his scan and he settled in to watch over Michael while Patricia positioned Michael in the bore before leaving the scan room to start the scan.

[09:02] Just as Patricia was starting the scan Dr Hou adjusted the oxygen flow meter to increase the flow of oxygen as Michael’s sats were dropping. He soon noticed though that no oxygen was actually reaching Michael and he knocked on the scan room window to attract Patricia’s attention. Patricia left the control room and opened the scan room door. Dr Hou told her that Michael wasn’t receiving any oxygen, so Patricia went back into the control room and through into the plant room where the oxygen cylinders were located.

[09:36] Unfortunately, she didn’t know how to change the cylinders so she went to ask Paul who had changed the oxygen before and he offered to show her how to change over from one cylinder to another. Both MRI Technologists entered the plant room, leaving them with no view of the Scan room door.

[09:55] It was at this point that Mary Nadler a nurse who was leaving the MRI unit after attending with a previous patient heard Dr Hou shouting for oxygen in the MRI room through the open scan room door.

[10:09] Across from the scan room, in the patient prep area where Michael had been sedated only a few minutes earlier, Mary saw two oxygen cylinders in a trolley. These weren’t the big H class cylinders mentioned before – Mary would never have been able to carry one. Instead these were the smaller E class cylinders regularly used for patient transfers and short term provision of oxygen. 3.5 kilos in weight when empty, these cylinders hold 680 litres when full, enough for 5 ½ hours at 2 litres per minute, or 45 minutes at the highest flow rate of 15 litres per minute.

[10:46] Mary recalled that one was empty but the other was 3/4 full and she picked this one up by the regulator to give to the anaesthetist.

[10:55] Now at this point the story told by Dr Hou and by Mary diverges. Mary stated that the anaesthetist took the oxygen cylinder from her in the hallway outside before he took it back into the scan room however Dr Hou said that it was Mary who brought the cylinder into the MRI room.

[11:16] In the aftermath another hospital worker who was in the MRI unit revealed that she too had heard the anaesthetist and was walking down the Hall towards MRI when she saw Mary pick up the oxygen cylinder and make her way towards the scan room door. This witness says that she saw Mary hand the oxygen cylinder to Dr Hou and while she was certain that Mary was in the hallway and didn’t enter the scan room she couldn’t say with any certainty where Dr Hou was when he took the oxygen cylinder from Mary.

[11:46] Regardless of how exactly the cylinder entered the room it was almost immediately captured by the strong magnetic field and was pulled into the bore. Dr Hou reported that he tried to catch the cylinder as it was pulled in…but he couldn’t.

[12:03] The oxygen bottle plunged into the bore and struck Michael a number of times, fracturing his skull and causing severe facial injuries as it ricocheted within the confined space before finally coming to rest.

[12:18] The next part of the timeline is a little confused as to which events happened in which order. Michael was pulled from the bore and carried by Dr Hou out of the scan room into the prep area across the corridor as Patricia and Paul returned from the plant room to report that they had successfully restored the oxygen supply.

[12:38] The Crash Team was called and quickly attended, and Michael was rapidly intubated by Dr Hou and ventilated until he could be transferred to the Emergency Department for treatment of his critical injuries.

[12:51] The trauma team rushed Michael to CT where an emergency head CT was performed. Michael had sustained right temporal and parietal skull fractures, along with a left sided subarachnoid hemorrhage. The CT also demonstrated diffuse cerebral oedema and resolving pneumocephalus.

[13:13] Later in that afternoon of Friday 27th July, Michael was transferred from the Emergency Department to the paediatric ICU where they fought for the next two days to keep him alive.

[13:27] Alas, their struggles were ultimately in vain and 6-year-old Michael Colombini was pronounced dead at 5.40pm on Sunday 29th July 2001.

[13:50] [Music]

[13:59] Edward Stolzenberg, the hospital’s president and CEO, made a statement on Tuesday 31st July. “The medical center assumes full responsibility for the accident. Our sorrow is immeasurable and our prayers and our thoughts are with the child’s family,” The hospital issued statements that investigations were ongoing and medical and law enforcement authorities refused to be drawn into discussion about who may be at fault. At Westchester Medical Centre, staff held a prayer vigil for Michael.

[14:34] Michael was buried on Wednesday August 1st. Press and television reporters descended on Croton to share the aftermath of this human tragedy with the general public. This was the first such MRI-related death and shockwaves were rippling out from the small New York town within the field of Radiology as well as wider society.

[14:56] While reporters were asked not to speak to hospital staff, David Chen of the New York Times found a visiting medical professional who was willing to comment – Gloria Wiley, a nursing assistant from Staten Island, who was visiting a friend at the hospital. ”If I needed an M.R.I., I wouldn’t want to get one here,” Gloria said. ”This was pure carelessness. Why did they have an oxygen tank in there anyway? This procedure has been done many times before. Whoever brought it in should have known what to bring in the room and what to leave out.”

[15:33] Having admitted responsibility, the hospital faced fines for their safety violations, though the maximum fine of $2000 per violation provoked a strong reaction from members of the State assembly. After the state health department investigation concluded, Westchester Medical Centre was fined a total of $22000, though the Colombini family were initiating their own legal action.

[16:00] Michael’s parents, John and Barbara brought a $20 million lawsuit against Westchester Medical Center and its parent company, Westchester County Health Care Corporation (or WCHCC). Also named in the suit were Dr. Terence Matalon, who was the center’s chief radiologist in July 2001 but who was not present when the accident occurred; Patricia Lauria & Paul Daniels, the two MRI Technologists working that day; Dr Jian Hou the anesthetist and Mary Nadler the registered nurse. GE Healthcare as manufacturer of the MRI system was also included in the lawsuit, but removed in a pre-trial motion.

[16:46] There were many twists and turns in the case of Colombini versus Westchester County Healthcare Corporation. In 2004 Dr Hou, Patricia Lauria, Paul Daniels and Mary Nadler were removed from the part of the lawsuit relating to punitive damages in a summary judgement on the basis that the WCHCC as their employer was the proper defendant. That was later overturned by the New York Supreme Court in 2005 for Lauria, Daniels & Nadler but sustained for Dr Hou.

[17:21] Despite admitting responsibility for the accident almost immediately and offering 1 million dollars to settle the case, it was only in October 2009 that Westchester County Health Care of Valhalla, New York reached a settlement with John & Barbara Colombini for $2.9 million. Papers filed with the Westchester County Clerk in January 2010 showed that Michael’s parents received 2 million, with 900,000 dollars going to the family’s lawyers.

[17:53] In the wake of Michael Colombini’s death, Westchester County Health Care Corporation performed an incident review that found a range of failings had combined to create the unfortunate cascade of events resulting in Michael’s death.

[18:07] Firstly, they found that the oxygen delivery and monitoring systems were poorly designed and had failed to ensure continuous delivery of oxygen when required. This failure meant that Dr Hou was not able to determine whether oxygen was available or switch to an alternative supply without assistance from other staff – in this case Patricia Lauria & Paul Daniels.

[18:32] The recommended solution to this was to remove the H class cylinders and replace them with individual non-ferrous E class cylinders. Upon the arrival of a patient requiring oxygen, MRI personnel would remove their ferrous cylinder and replace it with a non-ferrous cylinder. Those personnel would then monitor the oxygen levels every 15 minutes and replace the cylinder if the pressure dropped to 500 psi.

[18:59] Secondly, the review found that the failure to adequately identify and secure the restricted area around the MRI scanner contributed to the incident. The patient alcove opposite the MRI scanner should have been a restricted area with additional signage making it plain that this was the case. From the incident report it would appear that while certain risks had been recognized previously and specific policies written, no comprehensive risk assessment had been performed.

[19:29] In tandem with the expansion of the restricted area, the incident report strongly suggested that emergency responses be tailored more carefully to the specific MRI environment. The fire extinguishers closest to the scanner were all ferromagnetic, as was the crash cart in the patient care area next to the oxygen cylinders that Mary Nadler found that fateful day. Where possible the report suggested MRI conditional equipment be used though in an unfortunate conflation of the words non-ferrous and compatible the report states that non-compatible equipment be utilized where available.

[20:08] The review further found that issues with communication between Dr Hou and Patricia Lauria hampered Dr Hou’s efforts to adequately convey his concerns for Michael’s safety when the oxygen supply was found to be inadequate. Furthermore, there was no ability for him to keep track of their efforts to rectify the situation once they were out of sight and earshot. It was determined that the Westchester Medical Centre would assess MRI conditional communication devices to try and remedy this situation in future. In addition, part of the action plan was the removal of the door to the console room to (and I quote) “minimize obstacles in technologist response to patient care needs.”

[20:54] The Incident review also found that there was inadequate education of hospital staff regarding the very particular dangers associated with the permanent stationary field. The action plan stated that an orientation and in-service program for all staff who might need to enter the MRI restricted area should be developed in an effort to maintain a safe level of awareness.

[21:19] Finally, and possibly most shockingly, the incident review found that a prior incident had occurred in 1997 where an oxygen tank had entered the MRI scan room and been introduced to the permanent stationary field. Fortunately, there was no patient in the scanner on that occasion. At that time the MRI scanner was owned and operated by a private company and the Westchester Medical Centre was operating under the name of ‘the Department of Hospitals under the County of Westchester’. The review tersely stated that an investigation of this prior incident was still ongoing.

[22:00] My references for this podcast were many and varied with almost all of the information being freely available on the internet. My primary reference was the Incident Review performed by the Westchester County Health Care Corporation, along with the deposition of Patricia Lauria from 2004. I also searched court documents and media reports found online. These included the New York Times, New York Post, ABC News, Aunt Minnie, law websites & blogs as well as more esoteric websites such as Findagrave.com for details of Michael’s funeral and Wunderground.com to discover what the weather was like the day Michael first sustained his head injury. All references are available upon request.

[22:49] So, there you have it, the sad sad story of Michael Colombini. Well, almost. In June 2011, just weeks before the 10th anniversary of Michael’s death, a novelty Twitter account with the handle of @Mikecolombini was created. The account posted 128 tweets telling the story from Michael’s viewpoint in a sad and macabre memorial. It’s unclear who created the account or what their motivation was. But now, on the 20th anniversary of Michaels death perhaps they’ll tweet again. Who knows what they’ll say…

[23:36] Finally, while I’m not sure it’s appropriate to say I hope that you’ve enjoyed this podcast I do hope that you’ve found it interesting and informative and future episodes will be lighter…I promise.

[23:50] I’d like to say thank you to Purpleplanet.com for the use of their music, and also thank Jaenelle Whittaker for graphic design. If you have any questions about the content of this podcast, or ideas for future episodes of Conditional 1, please email me. My email address is podcast @ conditional1.com

[24:12] And remember, if anyone ever tells you that being an MRI Technologist isn’t Rocket Science, tell them No, but it is Nuclear Physics.

[24:30] Goodbye.

[24:32] [Music]