The case of Betty Cummings
Betty Cummings was 17 years old when she came to Children's Hospital Oakland in November 2014. The girl, who has what her family describes as a mild developmental delay, was suffering from unexplained stomach pain.
After a series of tests including an EKG, a lawsuit alleges, hospital technicians placed Cummings inside an MRI machine, "failing to remove the metal EKG leads from her chest and abdomen."
"I just felt a lot of burning and... I knew something was wrong," said Cummings.
Despite her cries for help, Cummings says no one came to her aid for more than 40 minutes.
"I was just thinking about my family and I wanted to get out," said Cummings.
Her mother, Venice Block, told 2 Investigates a nurse later described how she discovered the problem.
"She ran across Betty, smoke coming out of the MRI machine," said Block.
While hospital records described the injuries as only "superficial burns," Cummings and her family disagree and have hired an attorney. They say Cummings has since been diagnosed with Post Traumatic Stress Disorder (PTSD) related to the incident.
"I shake a lot," said Cummings. "I still have flashbacks."
Children's Hospital Oakland declined KTVU's request for an on camera interview, but issued the following statement from Senior Vice President and Chief Medical Officer, Dr. David Durand:
"MRI's are an increasingly used and effective diagnostic tool - performed routinely at both pediatric and adult hospitals because they provide detailed images without radiation. Last year, we safely and successfully performed over 6,000 MRI's at our hospital and outpatient centers."
Children's Hospital has denied liability in the lawsuit and the case is now in the discovery process.
Cummings' family isn't satisfied.
"Betty slipped through the cracks. There's no excuse," said family attorney Markus Willoughby.
While several online videos demonstrate the magnetic power of MRI machines, experts say Cummings' burns were caused by radio frequency energy also used in MRI tests.
Tobias Gilk, a member of the American Board of MR Safety, has studied design of MRI facilities for more than ten years. Gilk says burns are among the most common type of injuries associated with MRI tests and the accident involving Cummings was not an isolated incident.
"MRI accidents are increasing," said Gilk. "They have been increasing for years and years."
Gilk estimates there are now more than 7,000 MRI accidents in the U.S. every year, an increase of 500 percent since 2000, according to federal data. While those accidents still represent a tiny fraction of the estimated 30 million MRI tests performed every year, Gilk says a greater focus on safety is needed across the industry.
"We found that 85 percent of the MRI injury accidents would've been prevented if people had just followed existing best practice guidance," said Gilk.
Other medical experts dispute Gilk's research. They say the FDA's Manufacturer and User Facility Device Experience (MAUDE) database often contains incomplete or duplicated injury reports. Gilk agrees the data is flawed, but insists MRI accidents are vastly under-reported.
"It is a 'fox guarding the hen house' situation in many respects. It's not in the hospital's best interest to report it. It's not in the medical device manufacturer's best interest to report it," said Gilk.
Children's Hospital Oakland told KTVU it reported the incident involving Cummings to the California Department of Public Health in a "timely manner." But in a review requested by 2 Investigates, CDPH said it couldn't find a single "adverse event" report involving MRI machinery from any Bay Area hospital since 2010.
"That strains any concept of what's possible," said Gilk.
Managers at UC Berkeley's Henry H. Wheeler Jr. Brain Imaging Center allowed 2 Investigates to visit their MRI suite to see the safety precautions taken at that facility.
In the control room adjacent to the MRI machine, every magnetic item, down to a stapler, comes with a warning label. The swinging doors into the exam room are shaped like a giant stop sign, providing one last warning to remove all metal.
The American Board of MR Safety is also now offering accreditation and credentialing to medical professionals specifically related to MRI safety.
"If we choose to, if we want to focus on MRI prevention, we can nearly eliminate MRI accidents and injuries," said Gilk. "The question is, do we choose to?"
Gilk also offers the following advice to patients:
- Identify what information your MRI provider for screening as early as possible.
- Ask questions about your upcoming exam as early as possible.
- Ask your facility about specific safety measures and staff training.
- Don't give up control -- if something doesn't feel right, speak up.