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5-Year-Old Girl Dies During MRI In Sri Lanka

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A mother pleaded Monday with a Sri Lankan magistrate not to let “the money power” obstruct an investigation into the death of her 5-year-old daughter during an MRI procedure.

The woman, Indumathi Ekanayake of Heiyantuduwa, Sri Lanka, said she took her daughter on January 31 to the Nawaloka Hospital in Colombo, Sri Lanka, because the girl, Buddhini Ratnayake, was suffering from a possible epileptic fit. Ekanayake said a doctor recommended three blood tests and an MRI scan. She said her daughter was anesthetized and put into the scanner. After 30 minutes, she said, she heard a sound.

The Daily Mirror, an English-language newspaper in Colombo, quoted Ekanayake as testifying:

I heard the doctor shouting that the balloon had exploded and nobody was there to assist him. I pushed off a ward attendant towards the room because there was nobody inside the room to help the doctor. When my daughter was pulled out from the machine, I saw she had turned blue and the belly had become swollen.

The Daily Mirror quotes Ekanayake as saying that the girl was admitted to the intensive care unit and “put on a vacuum machine”—apparently a reference to a ventilator. Ekanayake said the child was kept on the ventilator for four days, even though she had already died. “On the fourth day,” Ekanayake said, “I saw ants entering her nose.”

The newspaper said Ekanayake testified that a doctor told her the death was not the hospital’s fault and that hospital management declared that the girl had died four days after the MRI scan. The hospital is part of a large business group in Sri Lanka, which may be the source of Ekanayake’s worry about “the money power.”

DOTmed News cites a different report saying the mother heard the doctor screaming, “The oxygen pipes have burst.” DOTmed says postmortem reports found that the child died of oxygen deprivation.

DOTmed consulted Tobias Gilk, president and MRI safety director of Mednovus, an MRI safety company. Gilk speculated that the fatality resulted from a quench—cryogen gas escaping into the room and displacing oxygen.

“I could easily see how a sedated child with s suppressed respiratory system in a room where the oxygen is being displaced might die as a result of that condition,” he said.

Gilk said an estimated 10,000 MRI accidents occur each year in the United States alone, although none have been fatal since 2001. That year, 6-year-old Michael Colombini was struck and killed by a loose metal oxygen tank that flew across the room, drawn by the MRI magnet.

“If there was a high-profile accident today, God forbid, there would be a lot of really uncomfortable people having to answer questions about how we let protective measures sit on the shelf,” Gilk said. He has an obvious financial interest in promoting MRI safety measures. However, his warning is still worth taking to heart.

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Related seminar: Pediatric Radiology—Clinical and Radiology Perspectives

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