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Friday, November 14, 2014

A failed quench circuit?

UPDATE: 23rd Feb 2015, courtesy of Tobias Gilk on Twitter

An article in Diagnostic Imaging claims to cover "everything you need to know about the GE MRI recall." Not sure about that, but it's a step in the right direction.

UPDATE: 19th Feb 2015, courtesy of Tobias Gilk on Twitter

The FDA has just ordered a recall of over 10,000 GE superconducting MRI systems worldwide. Some news articles here and here. Based on a quick read of the early reports it does look as if the Mumbai event precipitated the recall.

UPDATE: 20th Nov 2014, courtesy of Greg Brown on Twitter

It is being reported that the quench button was disabled by GE Healthcare engineers to the point that it was only usable by authorized personnel, presumably thus requiring a specific piece of kit that neither the hospital staff nor the first GE engineers to arrive on-site either possessed or perhaps even knew about. This story is set to run and run....


No doubt you've seen this news doing the rounds:

Two stuck to MRI machine for 4 hours

There was, of course, a huge procedural failure that allowed a large, magnetic oxygen cylinder into the MRI facility in the first place. No doubt the investigation will find ample blame to spread around. But the solution to the problem is rather simple: education/training coupled with standard operating procedures to nix the threat. As procedures go it's not especially difficult. (By comparison, over 34,000 people manage to get themselves killed on US roads every single year. Clearly, we can't drive for shit. Our procedures are severely wanting in this department.) And if you're ever in doubt as to whether an item can be brought safely into the MRI suite there is always - always! - someone you can go to for an expert opinion. In my facility no equipment is allowed through the door without that expert opinion being cast.

So let's shift to the part of this fiasco that really got my attention: the claim that the magnet quench circuit malfunctioned. From the second article, above:
"At a press conference on Wednesday, a day after this newspaper broke the story, senior officials of Tata Memorial-run Advance Centre or Treatment Research and Education in Cancer (ACTREC) in Khargar said that because a switch to disable the machine's magnetic field malfunctioned, it took engineers four hours to disengage the two employees - a ward boy and a technician -- stuck to the machine, when it should not have taken more than 30 seconds."