The MRI Safety Myth: “No Radiation” Doesn’t Mean No Risk with Tobias Gilk

Speaker A: So we have all of these incidents where we have very significant safety issues in mri, and yet we run around and recite the bumper sticker slogan, mri is the safe imaging option without any meaningful protections for patients or even healthcare workers who work in these environments.

Speaker B: We're here because we're curious about medical imaging or have a hunger to learn more. What can we learn from each other and how should we prepare to tackle the challenges ahead? I'm Chris St. John and join me today as we Rethink Imaging, a podcast by imlogix.

Speaker C: Welcome to the show.

Speaker B: Today on Rethink Imaging, we are joined by Tobias Gilk, founder of Gilk Radiology Consultants and one of the leading voices on MRI safety in the country. Toby is an architect by background. In fact, he continues to practice with an appropriately named firm, Radiology Planning. But he's spent the last two decades focused on MRI safety, from how suites are designed and built to how workflows are structured, to how patients and staff are are protected once the magnet is on. He served twice on the ACR's MRI safety committee, co authored three editions of their Mr. Safety guidance documents, and helped found the American Board of Magnetic Resident Safety. He's a recognized expert witness in state and federal courts. He consults with hospitals and imaging centers on MRI safety operations, and he currently co hosts the Invisible Force, an investigative podcast on the ANT Mini Podcast Network.

Speaker C: Toby, it's so great to have you today.

Speaker A: Thank you so much. I'm so thrilled to be here with you.

Speaker C: So before we start getting into all of the nuance of MRI safety, uh, I want to talk a little bit about you and let our listeners get to know you as well. So do you mind talking me through your pathway through architecture and into MRI a little bit?

Speaker A: Whole bunch of unplanned left hand turns in my career. So when I was doing my undergraduate, I was actually working at the theater that a bunch of traveling shows came through. The university concert series would be Monday night, Tuesday night would be student film. Wednesday night would be a lecture. Thursday night would be a dance recital. Friday night would be the film series or something. Like we were constantly like turning over this theater building. And for somebody working in that space, you become kind of intimately aware of what about the design of that building doesn't really work or doesn't really support the intended function. So I actually went to architecture school because I was like, forget this theater design and production stuff. I'm going to design theaters. Probably should have done a little bit of homework before then realizing that in the United States we don't really build live theaters anymore, so career opportunities for an architect. So I pretty much shelved that as some sort of grand plan. Went to architecture school, came out of, got my master's in architecture, came out and worked for small firm in a small college town. And that firm had done essentially zero healthcare before I got there. But they had been bugging the county hospital's director of design and construction. You know, hey, give us a shot, give us a small project, we'll prove our worth, yada, yada, yada. Coincidentally, right when I got there, the county hospital's director of design and construction, I guess they wore him down and he was like, okay, fine, I'll give you guys a little project you can prove yourself. And the owners of the firm looked around and they were like, oh, crap, we've already got all of our architects assigned on other projects. We can't pull one of them off. We'll give them the new kid. And so they essentially, they gifted me to the hospital and said, whatever you need him to do, he will do. So I converted a large storeroom into an office for the director of surgical services. And that, I guess went fairly well because next thing I was, um, doing the very exciting design work to install a pneumatic tube station in the hospital's icu. And I guess that went well. And I was making friends, uh, over at the hospital. And they wound up giving us this just ridiculously fast paced MRI project at the end of the year. I guess they felt like they could work with me, work with the firm. And so I am less than six months out of grad school and I am managing the installation design. Installation of a new MRI M suite. One of the things I didn't realize at the time was that architects develop a set of skills where they figure out what they don't need to know about their client's business. Not only did I not have those skills, I didn't even recognize that that was a skill set that an architect develops. So when they told me I was doing an MRI project, I was like, I have to learn everything there is to know about mri. And I just kind of threw myself in the deep end trying to figure everything out about this technology. And I was hooked. I mean, I've always been kind of a science geeky kind of person. And MRIs are the closest thing that human beings have ever created. Closest to magic of anything that human beings have ever created. So I was hooked on MRIs. But this was 1997. This was before there was any real awareness of MRI safety. Fast forward to 2002. Same hospital is now adding the one that we did before was their second magnet. Now they need to add a third one because they keep growing this service, and they bring me back again. In 2002, the ACR published what was then the first white paper on Mr. Safety, the very first document in the United States that says, here's how we should do MRI more safely. It was published in response to a horrific accident that happened the year prior. And the head MRI technologist hands this to me and says, you know, hey, whatever it says, do. Well, I had a panic attack moment because I was like, nobody told me I had to pay attention to any of the safety requirements when I did the one five years prior. What all did I miss? I didn't look at the state requirements for all of this. And after a day or two of panic and frantically looking up what the safety requirements were for MRI suites, I discovered there are none. And so from that moment, I said, well, this is dumb. We should have some sort of minimum safety standards from an architectural design and construction standpoint. And that was really sort of the snowball being pushed down the top of the very mountain. Very top of the mountain, and began to kind of collect momentum and mass. Um, and that beginning of focusing on the bricks and mortar part of MRI safety just metastasized over the years, and I became interested in all aspects of MRI safety.

Speaker C: It's so funny. I, like, I identify with this story a lot. I took a lot of architecture classes in college myself, actually, and my senior thesis while it was installation, but it was, uh. I called it a choreography of a space. And, like, about how we view art in a gallery setting. Right. Like, how we move in a gallery setting, how we. And what you were talking about in terms of, like, designing a better theater, I think that all translates very, very clearly into the design of an MRI space. Thinking about intention, thinking about best practices, thinking about safety, it all translates. It feels like a very smooth transition to me, in fact.

Speaker A: Yeah. If you stop and you ask somebody, what does a live production theater and an MRI suite, what do those things have in common? I mean, you probably could not pick two more different spaces. But I look at it very much the way you just described, and it's. I'm doing exactly the thing that was my intention when I decided to go to architecture school. I just changed the building that I'm doing this for. No longer doing it for theater buildings, but I'm doing it for radiology departments.

Speaker C: So here you are. You're discovering, um, that there are no safety requirements for these MRI suites. Let's bring in some of your public discourse. Right. You have said, I think of it as kind of like your tagline, right?

Speaker B: Like, MRI is not the safe modality

Speaker C: when compared to CT or X ray. I think a lot of people would gut instinct, say, like, of course it is, but would you mind just expanding on that and explaining what you mean?

Speaker A: So I think in radiology, we are victims of our own PR relative to MRI and our messages about MRI safety. I think everybody who has sort of a passing familiarity with radiology has heard and probably internalized to some level, MRI is the safe imaging option. Uh, we've all heard that, we all understand that ionizing radiation has some inherent risks. And if we could choose an imaging option that doesn't have the same inherent risks, well, that seems to be the logic choice. What that bumper sticker slogan for MRI doesn't really convey is that, yes, MRI doesn't have the ionizing radiation risks, but it has its own unique, peculiar risks just within mri. And it appears to me that the conversation when MRI first came upon the scene was something along the lines of, hi, we're mri, we'd like to get official approval to be able to sell our equipment. And the regulatory world was like, yeah, we're really worried about ionizing radiation. Tell us how much ionizing radiation the patient gets with an exam in your new machine. Well, none. Oh, okay. In which case you're approved. Right? And that there was never the follow on conversation of, well, if you don't have those sets of risks, what risks do you have? It's almost like somebody looked around and said, oh, my goodness, 10,000 people die in car crashes in the United States every year. If we want to eliminate deaths by automobile accident, the thing that we should do is outlaw, uh, cars and just have everybody parachute to work. Jump out of a plane with a parachute on, and car crash deaths will go to zero. And while that's true, that ignores the fact that there are different unique risks associated with skydiving. Now, I'm not trying to equate the greater risk of skydiving with some greater risk in mri. That's not really the case. But we need to acknowledge that there are different sorts of risks and we need to respond to the different sorts of risks in different ways. In I think it was 2008, there was like a toddler who got a CT scan at a facility in Mad River, California. And the CT tech, um, little two year old squirmy kid and was not holding still, not cooperating for the head ct. And so the CT tech just hit the scan button over and over and over and over again, more than 100 times. This incident was so egregious in the world of radiation safety that it was all over the news. The pictures of the kid, you could see what were essentially sunburns, radiation burns around the circumference of the kid's entire head. And that was the worst accident. There was identified chromosomal damage within this kid. I do not mean to make light of this. I don't mean to minimize that in any way, shape, or form. That was 2006, and to be honest with you, I have not heard of a single other radiation exposure incident that has made the press since 2006. So we're 20 years on. I haven't heard of a single one that has made the press. We're really good at hiding our dirty laundry. Um, so I don't mean to suggest that nothing has happened since then, but in that intervening time period in mri, we saw a man with an aneurysm clip die in a hospital in Southern California. We saw, a few years ago, the nurse essentially get crushed by an ICU bet an MRI scanner Last year in the state of New York, we saw the man get killed, um, by the chain around his neck. Same timeframe last year. There was a pacemaker, ah, ICD patient who died in an outpatient imaging center in Tennessee a couple of years before. There was a patient who was essentially hit by a flying wheelchair. And the patient was knocked off of the MRI table as the wheelchair went flying. At the magnet, there was another patient who had an esophageal geal temperature probe. Essentially, you swallow this probe, and it monitors your body temperature from inside you. But there's a wire that comes out of the mouth, and this patient underwent an mri, and the wire heated up and essentially gave the patient burns in their throat, tongue, mouth, and lips. So we have all of these incidents where we have very significant safety issues in mri, and yet we run around and recite the bumper sticker slogan, MRI is the safe imaging option, without any meaningful protections for patients or even healthcare workers who work in these environments.

Speaker C: I'd love to actually expand on those examples a little. It's my understanding that you and Dr. Emmanuel Kanal were doing some work with the FDA where you were exploring the different, uh, dangers of MRI. And I believe, uh, that y' all documented something like 95% of MRI injuries fall into those categories. Right? Burns, projectiles, hearing damage, 95% of the

Speaker A: ones that are cataloged as MRI accidents. So if, if an MRI causes a pacemaker or an insulin pump to malfunction and things go badly, those accidents, even though the MRI was the reason for the malfunction, just get cataloged today as malfunctions of a pacemaker, malfunctions of an insulin pump. So we actually have no good way to track interactions between the MRI scanner and implants and devices. So, yes, of the injury accidents that get cataloged under this was an MRI incident, uh, 95% of the injury accidents are burns, projectiles and hearing damage. And we have some really remarkable best practice standards, practices that can interrupt the way that those accidents happen. And yet nobody requires them. No states, no accreditation organizations, CMS doesn't require it as conditions of getting paid for Medicare, Medicaid patients. They just don't exist.

Speaker C: And why do you think that is?

Speaker A: I think it's a combination of reasons. I think it's partially inertia. If you go from state to state to state and between the various states and the federal government and you're looking at the radiation safety rules, right? They are remarkably consistent across all of the different states and between states and the feds. Did everybody come up with their own set of rules and they just happen to match almost perfectly across all the 50 states? No. What happened was when we became concerned about ionizing radiation exposure in diagnostic imaging, human beings are lazy. We went looking for where is there a standard that we can copy or adapt? And what they found was that the US Department of Energy developed a workplace safety standard for folks working on the Manhattan Project that limited the amount of radiation exposure and specific ways for measuring that and yada yada, yada. And so they were like, oh my goodness. Department of Energy did our homework for us. We're going to copy and paste the DOE workplace safety standards, and these are going to become our state's ionizing radiation standards. And that copy and paste essentially spread like wildfire. And that's why ionizing radiation standards are so uniform, in part because nobody had to do any work other than copying and pasting them. Fast forward to mri. There were no sort of predicate safety standards about exposure to high strength magnetic fields, were no predicate safety standards on oscillating or pulsed electromagnetic fields and the safety risks. So we're faced with sort of the challenge of the blank canvas, right? You know, do we start what's appropriate? Who has done work before to tell us if this is if we're going in the right direction or the wrong direction. And I think the intimidation factor of, uh, we're not exactly sure what it is that we're doing. We don't know if we're pointed in the right direction. I think that that plus regulatory inertia. Who wants more regulation? Right? And so everybody's like, look, until people start fussing about this, we're going to let sleeping dogs lie. Now, the consequence of that has been there were all of these preventable accidents, accidents that we know how the accident happens, accidents where we know what are effective interventions that would stop sort of the chain of causation. And yet from a regulatory and accreditation standpoint, we all collectively kind of throw up our hands and like, boy, man, I wish there was something we could do, ignoring the fact that there is, in fact a lot we can do.

Speaker C: I want to come back to that. But something you said, like when you were talking about the copying and pasting of safety standards, it triggered something for me because when we spoke previously, one of the things you mentioned was that a lot of MRI workflows were essentially like inherited from CT and never really updated. It's almost this like additional copy paste over. And I'm curious, just with that workflow kind of copy and paste over, can you just walk us through what that looks like in practice a little bit?

Speaker A: Sure. So for folks who haven't seen or aren't conjuring their minds, a picture of a CT scanner and a picture of an MRI scanner, and for that matter, the picture of a PET scanner. These are essentially almost identical appearing pieces of equipment. We have a big donut shaped scanner, and then there's a table that sticks out of it like a tongue. You get on the table, the table slides you into the middle of the donut, you get a scan. Um, so CT scanners, MRI scanners, PET scanners look remarkably similar. CT scanners were the first ones on the scene. And we realized, oh, uh, we want to make sure that the operator of the CT scanner is not being exposed to the radiation. We're going to build a separate sort of control room for them. And, oh, we've got all of this equipment that doesn't have to be in the room with the CT scanner, but it's necessary. So we'll build like a little equipment room associated with this. And then we'll get our patients ready and have a little subway area for them to kind of rest so that we can grab the next patient and bring them in. Some of the patients will probably need to have them change at least partially out of their clothes. Make sure there are no zippers or snaps or buttons in the field of view, um, so that we can get good, clean CT pictures. For those folks who are familiar with mri, um, they're kind of scratching their head right now going, why is he describing an MRI workflow? Because that is essentially when MRI came upon the scene after ct. We just looked at what we had invented before, um, and we said, you know what? That's probably going to work now. At the time, a CT scan was probably 20 minutes, and an MRI study was probably going to be an hour and a half. So we didn't even really need to worry too much about patient preparation and subweighting because MRI was such a slow process. There'd be lots of time to get people ready and that kind of thing. Well, MRI has sped up dramatically, and we're beginning to see how the workflows and the demands of getting people ready is very different in the MRI space. In ct, we can almost pretty much just sort of take you off the street, make sure that there's nothing that's going to interfere with the image that you're wearing or carrying, uh, you know, jewelry or whatever. And we can pretty much walk you right into the CT room, throw you on the table, scan you, and walk you out of the building in less time than it will take to get that MRI M patient to fill out a screening form. Because we need to identify, do you have an aneurysm clip? Do you have a pacemaker? Did you have a pacemaker? And they took part of it, most of it out, but left, you know, fragments of the leads in. We need to identify all of these things and then any one of those questions that's, yes, I do have that in me. Well, great. Now we have to go and look up your medical records. Now we have to figure out exactly what is that thing that's within you. So, and this is no exaggeration, it would not surprise me in certain circumstances if we get the easy CT patient and a difficult Mr. Patient, we could probably scan six CT patients in the time that it takes us to do the clearance activities for one MRI patient. So the clearance and the preparation for MRI takes a significant chunk of time. Now the scanners are accelerating. The scanners are being able to produce these exams in less time. So we need to actually focus more and more attention on patient screening, patient preparation. Are we gowning the patients? Where is that happening? You know, how are we doing the sub weights? And so we are seeing through the acceleration of MRI scans and greater emphasis and greater Complication in patient screening and preparation. We're seeing this emerging conflict within mri and it really requires, if we're going to tackle this smartly, that we rethink the entire workflow around mri. And it ought not be a copy and paste of ct because the demands are very different.

Speaker C: I'm curious, are you comfortable sharing some of your thoughts and opinions on, like, what an idealized Mr. M workflow could look like?

Speaker A: First off, it's gonna be very different if we're talking an outpatient imaging center versus a hospital, because outpatient imaging centers generally get to cherry pick the less complicated patients. But if we're looking at in a hospital setting, one of the things that really ought to happen is we ought to be pushing more of the patient screening. Patient preparation upstream had been the practice that, you know, other than being told when to show up for your mri, that was probably the one and only thing that you were told beforehand. You show up there, they describe what the exam is going to be, they hand you the screening form. We're doing all of this. We're checking you out in the 30 minutes prior to your scheduled exam or however that works. We need to be looking, because of the complexity of managing these patients, we need to be looking at how we institutionalize patient review, patient prep, those kinds of activities so that when the patient shows up, we already know what's in them or on them or with them. We've already had an opportunity to look that up. If there were questions or concerns, we've had the opportunity to resolve those. And when the patient shows up, none of that preparatory work other than getting them changed is really necessary. We want to diminish, reduce the amount of time at the point of care for all of that preparation, screening, activity work. So now we have patients there. And if our MRI studies are averaging 20, 25 minutes apiece, we need to be expecting how we are going to be efficiently moving the patient who's in there right now, how we're moving them out, how we're moving the next patient in, and how we're completing whatever preparation works are necessary for patient number three. And nobody likes feeling like they're on an assembly line. But we need to, from a workflow standpoint, we need to be thinking of it like an assembly line, like a machine. And there are lots of things that you can do to make people's experience of that assembly line, that machine feel much better. Just ask Disney World, how long do we stand in line for one of their rides? And every twist and turn in the line, you get to see something new so we can engineer not only the workflow, but we can engineer the patient experience so that it doesn't suck. But we need to be rethinking all of these things in terms of how are we going to maximize the available productivity of these machines that are faster and better? How do we get our money's worth out of those machines, and at the same time do that in a way where we're not pushing people through the preparatory process for MRI scans.

Speaker B: Frame by Frame Rethink Imaging is brought to you by imlogix. Here you'll find engaging interviews with thought leaders, experts, and patients sharing stories that showcase the transformative power of medical imaging. To discover how Imlogix is rethinking imaging in healthcare, visit Imlogix.com Be sure to subscribe to Frame by Frame Rethink Imaging on Apple Podcasts, Spotify, or wherever you listen. And from all of us here at imlogix, thanks for tuning in.