[00:20] 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 the second episode of ‘Conditional 1’ my occasional podcast focussing on all aspects of MRI Safety.
[00:38] In my twenty years in MRI I have been involved in one way or another in the training of I don’t know how many students and the situation was one that I am sure many of you listening to this will be familiar with – there is usually a huge amount of pressure for a new trainee or staff member to be productive as soon as possible as most Radiology departments or Imaging providers have a reactive rather than proactive strategy to training new staff.
[01:05] In my experience among the first tasks given to new MRI Techs is the safety checking of patients attending for MRI examinations. The process is usually explained to them with a brief explanation of why each question is relevant and they watch their supervisor or another Tech run through the safety checks a few times before they run the safety checks themselves for the first time. I always observed trainees for their first few patients, stepping in where necessary before leaving them to their own devices when they seemed to have developed a spiel of their own.
[01:37] Spiel – any MRI Tech listening knows what I mean – that way of running through the questions in the same way again and again until we’ve developed such a mental muscle memory that we can do it almost in our sleep. In fact if you’ve ever worked nights or provided on-call scanning you possibly have.
[01:55] We all have our own way of doing it, that personalisation of the dry list of dry questions and check boxes. We have those canned responses to those patients who think they’re being unique and funny with an answer we’ve heard a million times before and this episode I’m going to talk about how I approach Safety checklists.
[02:15] Now, I’m not saying that my way is better than anyone else’s – that’s not the point of this exercise. After all, every Hospital, every clinic, every company has their own safety checklist. Most of the questions are similar though the order is often very different. The order I run through my spiel would be very different to how you run yours.
[02:38] My point is, for many of us, apart from those early days of our practice, our workplaces are too busy for us to listen to our colleagues running their spiel. We find our groove and we stick with it and rarely get the chance for it to evolve.
[02:53] At the practice I work at I’m fortunate that safety checklists are usually filled out by the patient in advance, giving me the opportunity to have a look through for any potential pain points on the checklist. Have they had an MRI before? Are they claustrophobic? Have they messed things up, crossed things out or generally seem uncertain about what they’ve written? Have they not filled it in at all? Having spent nearly 15 years working in areas with relatively poor literacy rates it’s not uncommon to find patients who can’t read the form, at least not well enough to fill it out. It’s not always apparent either – “Oh I’ve forgotten my glasses,” or “I’ve just finished work & my hands are dirty”. Sometimes those statements can be taken at face value, sometimes not.
[03:41] Having done that I head out to greet my patient. First impressions are hugely important so no matter how bad a day it might be, or how busy things are, make sure the patient knows that they are the single most important thing to you right now. Smile, eye contact. You know the drill. Sorry if a lot of this is beyond basic for the Techs listening, but I got a lot of feedback from non-Techs after episode 1 and I wanted to try and make this as inclusive as possible. Not only that, Episode 1 was downloaded by listeners all over the world, and I have no idea exactly where to pitch this, so if it’s useful please email me and let me know. If it’s not? Email me and let me know.
[04:27] The first part of my patient interaction usually goes something like this.
[04:32] “Hello, Mr Smith. How are you today? How was your drive up / down / across? Weather is lovely / awful today, isn’t it? My name is James and I’ll be the Tech doing your scan today.” Once I’ve introduced myself I’ll try to ensure maximum privacy by walking them to a cubicle or by pulling the curtain round the bed bay – again this will be very much dependent on the work environment you find yourself in. In an ideal world safety checking should take place before the patient enters Zone 3.
[05:03] Now, I’ve just realised I’ve made an assumption that everyone listening to this will be familiar with the Zone model when it comes to MRI suites. Here in New Zealand Radiology is governed by RANZCR, the Royal Australian and New Zealand College of Radiologists, and they have followed the American College of Radiology in instituting a system of four safety zones around each MRI Scanner.
[05:28] Zone 4 is the room in which the MRI scanner is situated. There are always warning signs at the entrance to the room and a large and imposing door that usually gives first time patients a slight pause. If there is a patient inside Zone 4 there must be at least 1 member of MRI personnel directly supervising them.
[05:48] Zone 3 is the controlled area around the scan room. All access to this area must be supervised by MRI personnel and the doors should be kept closed and secured. Again, all doors must have signage highlighting the risks associated with entering. Anyone coming in here, patient or staff must be safety checked prior to entry.
[06:11] Zone 2 is a little bit more relaxed. This is the reception and waiting area, along with changing room and basically refers to the rest of the MRI suite. Members of the public can enter and leave freely but they will be supervised by members of the wider team – nursing, admin or MRI Techs dependent on your site.
[06:30] And Zone 1 is well…everywhere else. I honestly don’t know if the zone system has been adopted worldwide so if anyone is listening from somewhere that has a different system I would love to hear from you.
[06:44] Anyway…back on track. Once I’ve got to a point that is as private as it’s able to be I get straight to the point and ask the single question that helps to reduce patient risk more than any other – I ask them to identify themselves. Full name, date of birth and address. It protects you and it protects the patient. Studies in the USA have found that the risk of false matching decreases dramatically from a 2-in-3 chance to a 1-in-3500 chance if you ask first & last name, address and date-of-birth, compared to using last name only. If the patient is wearing an identity wristband feel free to use it to check their details but ALWAYS ask the patient who they are. After all, the wristbands aren’t always right.
[07:35] Remember, if you have the wrong person everything you know about them goes out of the window.
[07:42] This is one of those errors where I was very lucky to learn from someone’ else’s mistake. Many years ago, before I even thought of working in MRI I was working in a radiology department in one of the nicer parts of London. You know the layout, reception area that feeds multiple x-ray rooms doing multiple examinations. Chest xrays to the right, general and dental x-rays just to the left, and fluoroscopy rooms round to the side.
[08:10] The unwitting hero of this story was a gentleman with a suspected chest infection. No appointment, walked in for a chest xray as requested by his family doctor. Booked in, took a seat and began to wait, not particularly patiently. Now at this point I should say that only the chest x-ray room was first come first served, and as you’d expect quite busy. All the other rooms were running scheduled appointments, so our patient saw other patients arrive after him getting called through before him. After stewing in the injustice of it all for a little while, perhaps 20 or 30 minutes, he resolved to stand up when the next patient was called, regardless of what name they called or from which corridor the member of staff happened to come from.
[08:57] A Tech entered stage left and our patient took his chance, jumping up almost before the Tech had started speaking. “That’s me” he said and the tech took him off round to the side, where if you’ll remember the fluoroscopy rooms were located. Now the Tech dropped the ball and believed that our patient was the patient she was looking for – I have no idea where the actual patient was while this was taking place, but it was only when he was lying on the fluoro table about to be introduced to the barium enema tube that our gentleman spoke up “This is a bit much for a chest infection.”
[09:30] Mistakes like this happen all the time, staff and management meetings often include reports of which patients had the wrong examinations, but that doesn’t make them any less serious. Always identify your patient.
[09:46] Another thing that you might want to check with your patient before you get too involved with the process is what do THEY think they are having scanned? If it’s something they have more than one of, which one? Many Doctors suffer from left-right confusion.
[10:01] After that, my next few sentences are always the same. If the patient has had MRI before, was it the same body part? Or something different? Was it done here, or by another provider? Previous exams are vital for comparison if they’re available. That said, while its really tempting to just gloss over the safety check if the patient says they’ve had an MRI before, don’t give in to temptation.
[10:26] Firstly, just because they had an MRI before without issue doesn’t mean that things haven’t changed. They may have had new surgery or implants, or some other treatment. Hilary from Auckland contacted me about a case where a hospital patient had an MRI of her brain one afternoon and needed to be brought back the next day for some follow-up imaging with contrast.
[10:48] “Sorry but I just need to go through the checklist again with you. Anything implanted over night?” “Well I’m not sure what this is they put in last night” The patient pulled down the neck of her gown to show a wee lump, right where a pacemaker would go. Needless to say, the patient was sent back to the ward while this new information was added to the mix.
[11:10] Secondly, often patients have no idea what examinations they’ve had before. They know the difference between an x-ray and an ultrasound, because hopefully no-one has covered them in jelly for an x-ray but to most patients an MRI and say a CT or PET scan is pretty much one and the same.
[11:31] If a patient hasn’t had an MRI before, or if they’re not sure or it was a long time ago, I find the best strategy is to draw everything together and explain things as if they’ve never had an MRI before. It usually goes something like this.
[11:46] “So, I’ll start with the good news. MRI doesn’t use x-rays, it uses magnets and radio waves. Because there are no x-rays MRI is safe for almost everyone. I say almost everyone because the magnets we use are very strong which is why we ask all these questions about metal things” At this point I point to the safety checklist just to make sure they understand what I’m talking about.
[12:11] “MRI is a very noisy process, so I’ll be giving you earplugs and headphones. The earplugs will block out the worst of the noise and the headphones mean I’ll be able to talk to you during the examination and play you some music if you like.”
[12:26] At this point, patients that have had MRI before will generally start to remember the process a bit more, and those that that thought they have but haven’t will begin to understand that whatever scan they had before definitely didn’t involve earplugs or music.
[12:42] After all this preamble I move onto the safety checklist itself.
[12:47] “Have you ever had any heart surgery?” There are a huge number of operations that patients can undergo so I find it easier to separate them for ease of questioning and hopefully minimises the amount of time I spend talking to people about their haemorrhoids. Coronary stents are the most common positive answer, followed by Cabbages or coronary artery bypass grafts, and valve replacements.
[13:11] “Do you have a pacemaker?” The vast majority of patients will give one of two answers, either “No”, or “what’s a pacemaker?” to which my answer is “It’s a metal box in your chest that keeps your heart beating. As a rule of thumb if you don’t know what it is, you haven’t got one.”
[13:30] The patients that cause me the most aggravation are those who say yes. It means they’ve either got a pacemaker that their referrer forgot to tell me about, or they’re trying (and failing) to be funny. I have zero sense of humour when it comes to this stuff, and I’ve read the riot act on more than one occasion to patients who think they’re comedians. If I can’t trust what they have told me about something this important, how can I trust anything else they tell me?
[13:57] The best story along these lines was recently told to me by a good friend and colleague when I told him I was basing an episode of my podcast on safety checking.
[14:06] “Have you ever had any operations?” he asked of his female patient. “No,” she said. “Ok, so no pacemaker or anything then?”
[14:14] “Oh, I’ve got a pacemaker,” she responded. Somewhat confused his next question was, “How did you have a pacemaker inserted if you’ve never had any operations.”
[14:24] “Oh,” said the patient, “that wasn’t an operation, it was only a procedure.”
[14:33] When he told me this story, (Thanks again Gene, if you’re listening), it brought to mind all the patients leaving the Emergency department in plaster who immediately call their families “No, the Doctor said it wasn’t broken…. it’s only fractured.” Every time I hear that I roll my eyes so hard I get a headache.
[14:49] In addition to pacemakers, an increasing number of patients are having ICDs or implantable cardioverter / defibrillators implanted. Whereas a pacemaker constantly provides electrical stimulus to maintain a cardiac rhythm an ICD only provides a shock if it senses an arrythmia. Similar but different, patients often get the two confused.
[15:12] Not only that, but I recently found out that pacemakers can be used to treat several other conditions. They can be implanted to treat paralysis of the vocal cords, diaphragm and even the stomach.
[15:24] Now, back when I started doing MRI pacemakers were an absolute no-no for MRI and it’s only in the past few years that matters have improved. And it isn’t because the process of MRI has hugely changed, it’s because the manufacturers have realised that many of the patients that require a pacemaker are likely to need MRI at some point in the future and they’ve altered their designs to allow them to be scanned under certain conditions.
[15:50] Now at this point I’ll pause and discuss exactly how we should be asking these questions. It’s really important not to lead the witness, I mean patient “You don’t have a pacemaker, do you?” is a good example. It gives the patient an impression of the answer that you are seeking, and in times of stress people can be hugely suggestible and will seek guidance from those they see as being in authority. It is also easier for a patient to give you the answer they think you want to hear if you ask them a leading question, I’d be very interested in hearing people’s thoughts on this and anything else in this episode so please email me or contact me via the website.
[16:34] “Have you ever had any brain surgery?” If I got a dollar for every patient who laughed and said something along the lines of “Nah, they can’t find one” I probably wouldn’t be retired yet, but I would definitely be driving a nicer car.
[16:49] I then follow that up more specifically. “Have you ever had an aneurysm clipped or coiled?” Almost all aneurysm clips inserted today are non-ferrous and can be scanned safely at 1.5T, but that has not always been the case and determining what type of clip is in your patient can vary from very easy to extraordinarily hard dependent on the whens, wheres and who’s of its insertion.
[17:14] “Have you ever had a neurostimulator attached to your brain or spine?” Like pacemakers and ICDs, neurostimulators are electronic implants designed to improve function through the application of electric current. Note the phrasing. “Have you ever had…” Patients can have these devices replaced, removed, or partially removed once they stop working or are no longer required. To be fair, the same can be said for pacemakers, where the generator can be removed while leaving the pacing wires in situ. Orphaned wires are their own separate issue and are often more problematic than the devices they were once attached to but that’s a subject for another episode or two.
[17:57] Speaking of which, I think this is as good a place as any to call it a day for Part 1. In Part 2 I’ll continue running through my spiel as well as discussing some of the weird and wonderful answers patients give to what seem on the face of it to be very straightforward safety questions.
[18:14] If you have any questions about the content of this podcast, or safety checking stories of your own, good, bad or ugly, please email me. The email address is podcast @ conditional1.com. You can also message me on the website www.conditional1.com. Thank you once again to Purpleplanet.com for the use of their music.
[18:40] And remember, if anyone ever tells you that being an MRI Technologist isn’t Rocket Science, tell them No, but it is Nuclear Physics.