In a full remote operation situation, we need to deconstruct and rebuild our policies and workflows for safety in the MRI environment. In my opinion, FRO only works if we have an elevated MR radiographer-aide. Historically this position hasn’t existed, so it needs to be clearly created and defined in order for us all to feel like there is a clear ‘handover’ of safety responsibilities, without duties being left unaccounted for.

A quench is defined as a loss of magnet superconductivity due to its temperature being raised and a sudden boil-off of liquid helium. A quench can be done in a planned manner, for instance during the decommissioning of a scanner, but it can also happen without warning. In theory, if the quench pipe is properly designed and maintained, the helium gas that is released should be safely vented away from the facility. However, in most reported circumstances, some cryogens usually escape into the magnet room and even into the surrounding areas, filling the area with a mist.

It is a requirement to have a means of monitoring helium loss via an oxygen sensor that detects the percentage of oxygen present, therefore one would hope to be given some warning of a quench by the oxygen alarm. Sometimes, the only warning of an impending quench is a mild hissing sound, followed by a roar as the great quantities of gaseous helium are released. Large clouds of gas would be vented via the quench pipe. (Typically, 1 litre of helium liquid produces 800 litres of gas, and the typical superconducting magnet contains 150 litres of helium.) Any gas produced is lighter than air and will float to the ceiling. It is very cold, with the risk of thermal injuries to eyes or skin and asphyxiation, therefore patients and staff must be evacuated from the magnet room immediately.

As above (oxygen sensor alarm) and a loud hissing / roar followed by the escape of a large amount of helium gas and the loss of the static magnetic field.

In my own experience this once happened overnight, and we came into work the following morning to discover no magnetic field on the MRI!  This was caused by an equipment fault.

In our clinical practice, the first person is usually an MRI radiographer who is authorised to work and supervise others within the MRI environment. The second person can be a radiographer, RDA, physicist or, more rarely, a radiologist, but all must be MRI safety-trained and trained to assist during an emergency.

Many units have seven-day working and can accommodate urgent patients within their normal working hours. Scanning emergency patients out of hours requires the on-call MRI radiographer to be totally supported by clear SOPs, and competent in controlling access to the magnet room (MR Environment). MRI radiographers working on call may find that the second person, if available, is a member of hospital staff completely unaware of the risks. MRI on call staff should have the necessary support to ensure that patients can be removed easily and quickly from the magnet if an emergency occurs (e.g. via detachable tables), with at least mandatory MRI safety training for emergency / incident teams. Anyone else in attendance should be at least MRI safety aware and cleared as MRI safe. Even then, anyone or anything going into the MR environment is at the discretion of the MRI radiographer.

According to the SCoR’s Safety in Magnetic Resonance Imaging, section 3.1, Safety of patients and staff, patient safety is paramount. There are particular safety issues associated with MRI: strong magnetic fields, time-varying magnetic fields and radio-frequency pulses. Staffing levels and competencies should be such that there are no compromises with regard to patient safety. Staffing levels should take account of the fact that MR operators must maintain visual and audio contact with the patient throughout the scan and should not leave the control room during the scan unless it is to enter the scan room.

We are on 3 sites with differing scanner numbers and staffing levels, but we book sessions for a minimum of 60 minutes every 3 to 6 months.

The drills themselves do not take very long at all, and we aim to get the person out of the scanning room as quickly as possible - we time this and it is usually under 60 seconds. The session itself however is 30 - 60 minutes in order to discuss scenarios and practise them.

The Superintendent (Responsible Person) or senior radiographers lead the drill session. We are fortunate to have the physics team on site, so they also need to be trained and able to assist in an emergency situation, as they are often scanning alongside our radiographers when doing volunteer studies for clinical development or undertaking research scans. Physicists also walk staff through the safety features of the MRI unit, in particular how to cut the power to the scanner in an emergency, how to deal with an oxygen alarm that may indicate a helium leak, and discussing when it would be appropriate to initiate a quench, and how.

Thank you for your question. Even MR-Conditional gurneys, wheelchairs and docking tables are fairly magnetic, just not enough to be projectiles. So they will trigger FMDs with or without hidden objects beneath the sheets - rendering it a pointless exercise. The only way FMDs can be used in these situations is if the transfer equipment is swapped out for "zero magnetic" versions. Wheelchairs and gurneys are available that won't trigger FMDs, so the hidden objects can be found with regular FMDs. However, it is expensive to replace such equipment. At this time, FMDs cannot distinguish hazard items on regular MR conditional equipment. May I bring your attention to a useful process advocated by the ACR? If you look at the ACR Manual on MRI Safety 2024 chapter 6, they recommend a "Full Stop/Final Check" process. In practice, this means a short stop outside the MRI door and inspecting all labels and equipment (including visual inspection under the sheets) and asking the patient if they have picked anything up since screening. Once the responsible person has done this, they proceed into the MRI room. As far as I can see, this is not mirrored in the MHRA guidance. However, I recommend this step is considered for UK hospitals.

Thank you for your question. Hip replacements are rarely made from ferromagnetic material and are therefore unlikely to be detected by FMDs. A minority are weakly magnetic and may give a weak detection. For ferromagnetic items (implants or otherwise) well-spaced apart, patient screening FMDs can resolve both but if they are within 20-30 cm they may show as a single detection.

Thank you for your question. Even MR-Conditional gurneys, wheelchairs and docking tables are fairly magnetic, just not enough to become projectiles. So they will trigger FMDs with or without hidden loose ferromagnetic objects present. One way to resolve this is to get a "zero magnetic" chair. Wheelchairs and gurneys are available that won't trigger FMDs, so hazardous hidden objects can be found with your Metrasens device. However, it is expensive to replace such equipment. Alternatively, you can use your regular MR Conditional chair and use the inevitable FMD alert to prompt a "Full Stop/Final Check" process before proceeding. If you look at the ACR Manual on MRI Safety 2024 chapter 6, they recommend a "Full Stop/Final Check" process. In practice, this means a short stop outside the MRI door and inspecting all labels and equipment (including visual inspection under the sheets) and asking the patient if they have picked anything up since screening. Once the responsible person has done this, they proceed into the MRI room. As far as I can see, this is not mirrored in the MHRA guidance. However, I recommend this step is considered for UK hospitals. Remember, the FMD is doing its job correctly in alerting you to ferromagnetic material entering the MRI room. It is the responsible person's job to always check the situation is safe before proceeding once alerted.

I have not seen reported any evidence for CGMs failing in MRI but that does not mean they won't. They are MR-Unsafe by way of not having been tested rather than being found to be unsafe. Research needs to be done.   

Consider booking patients with glucose monitors for their exam towards the end of the use of their device and that patients are informed about this by the pre-appointment information sent to them prior to their scan. This prepares them for the safe process to be followed and to bring their new device for replacing it after their scan. Removal of any pump is a must.

The prices of FMDs vary according to the manufacturer and the number needed and additional services. As a guide, patient screeners are typically in the £10k-£14k bracket and entry control in the £14k-£17k bracket.

Our band 7s do not have protected time for this. I often do my safety work during my reporting session as a way to break up the day. My other colleagues have to do them in the control room. We are working on a way to try and release every band 7 once a week to have dedicated protected time.

Blackpool radiographers do not go on image interpretation courses. They are provided in-house by our MRSE.

Recent would be considered since their last update to the cardiac device/cardiac surgery. Our procedures state, "Is a chest x-ray or other suitable imaging available since the last cardiology surgical intervention?" If yes then proceed and check that image, if not request a new x-ray.

No admin time, unfortunately, and band 7s are clinical as well.

All conditional CIED patients receive pulse ox monitoring. When patients are being prepared for their MRI scan or waiting, they are sat with a cardiac physiologist who monitors them. During the scan the patient is monitored by the radiographer (external patient monitor (Iradimed)).

Radiographers are trained in intermediate life support (ILS). Patient monitoring training is delivered during ILS training that is delivered by the Trust. The cardiac physiologist is outside the control room in the department with a reprogramming device. For non-conditional CIEDs, it depends on the risk assessment that our MRSE provides and if the cardiologist has any input. Most of the time we ask the cardiac physiologist to be present in the control room and apply the external patient monitoring ECG.

This scenario we consider and coin to be e-MR C (the device is considered effectively MR Conditional. The pulse generator is MR Conditional but other components may not be); the MRSE would advise on any additional measures to be followed, although typically we would just follow the MR Conditions for the generator as if it were implanted in the correct location.

We monitor the same, pulse ox. Staff are encouraged to discuss what the cardiac physiologist has done to the device i.e. turned off or put into asynchronous at 60 beats per minute, etc., so that they are aware when monitoring the patient.

Sometimes the referrer does put it on the request card. However, we require all ward cards to be sent down to the control room with a completed safety questionnaire. If not, it is returned. Often these safety questionnaires will say on them if they have no next of kin (NOK) or no capacity.

When we can’t contact or ask the patient’s immediate closest relative, or an individual deemed to have the best knowledge of the patient's medical history, then we follow the procedure that I spoke about in my presentation at the Safety Update Day.

We do have a lot of band 7s at Blackpool! 8! 2 of us report and 2 of the others are advanced practitioners. The others have other roles such as cardiac stresses, rota managers, etc. I mainly do the lion’s share of the work and to be very honest I am unsure of the number of hours it takes up. It’s maybe something we should audit! To make a guess, I would say it would probably take up a full day's work over the week.

See the answer above. Also, it is hard to say, as MR Conditional pacemaker checks can be done quickly. Once the information has come from pacing, which is usually the same day, the actual check can take less than 5 minutes.

No, there is room on the referral card to select if they have a pacemaker, clips, etc. but otherwise we don't deal with referrers or GPs that much.

They certainly could, as all the processes for checking certain implants are documented in our policies and procedures, which are provided by the MRSE. It is something we have thought about but not yet explored. Our band 6 radiographers are often scanning all the time. The band 7 is often coordinating so has moments to investigate.

Depending on your MR vendor, there should be a breath-hold quantitative T2* sequence for iron overload. This will give you multi-echo data that will show haemorrhage as well as a R2* map, where R2* = 1/T2*, so things with short T2* look brighter rather than darker. It might be that the sequence is ECG triggered, in which case you can see if the system can simulate an ECG or you will need a simple ECG simulator to trigger the sequence.

ZTE sequences are field strength independent.

In short, no, although a reasonable question.

This paper Yin, M & Venkatesh, SK. Ultrasound or MR elastography of liver: which one shall I use? Abdom Radiol (NY). 2018 Jul;43(7):1546–1551. doi: 10.1007/s00261-017-1340-z provides an excellent comparison of the two methods and explains why they give different results – in short (from the paper using their references) “Ultrasound elastography systems use polychromatic (range of frequency) transient vibrations that generate complicated nonplanar shear wave fields. Wave diffraction and dispersion are inevitable. This leads to big variations between machines and observers [25–28]. Liver MRE uses monochromatic (single frequency) steady-state vibration for the shear wave generation, which gives a uniform wave field exactly at 60 Hz. Assuming that most people can hold their breath well for the duration of the MRE exam, and no biases from wave diffraction, dispersion, and sampling errors are observed, MRE can provide a more accurate shear stiffness measurement throughout the liver than that of ultrasound systems [29, 30].”

See Figure 1 in this recent paper Imajo, K et al. Direct Comparison of US and MR Elastography for Staging Liver Fibrosis in Patients With Nonalcoholic Fatty Liver Disease. Clinical Gastroenterology and Hepatology Volume 20, Issue 4, April 2022, Pages 908-917.e11. You will see there are group differences between the reported values of stiffness between the three methods of magnetic resonance elastography (MRE), vibration-controlled transient elastography (VCTE), and two-dimensional shear wave elastography (2D-SWE). In summary, they found “MRE, VCTE, and 2D-SWE demonstrated excellent diagnostic accuracy in detecting liver fibrosis in patients with NAFLD. MRE demonstrated the highest diagnostic accuracy for stage 4 detection and intra- and inter-observer reproducibility.”

While Jonathan answered the question on the recording, he wanted to provide a clearer explanation:

We wanted to keep a tight remit on the inclusions for the GISPs and to target what would be the lion’s share of MRI systems across the UK (i.e. 1.5T, 3T closed bore Hydrogen). Furthermore, the expertise across the "expert group" was primarily with these systems and hence voting may have been difficult if we asked questions regarding the implant outside of these common MRI systems. It's not that we necessarily expect there would be any additional risk for other nuclei, it is purely that a lack of knowledge means we didn't want to make any statements.

Are sites concerned about the China IUD and do they include this as a question on their screening form?

You can find out more in this link: https://www.mymri.org/my-mri-buddy

In the same way natural language processing can be used to simplify medical reports, it could also be used to tailor screening questionnaires to different levels of patient understanding. Perhaps in the future, we could have several patient-friendly versions of the same screening questionnaire, with the same aim but more customisable, to make it overall more effective and suited to the patient using it.

We put together the simulation training using a standardised approach, considering regulatory standards such as MHRA guidelines, resuscitation guidelines, etc., therefore the training was used as an opportunity to inform their existing SOPs, rather than a means to test their SOPs (which we understood were diverse). We were thus able to bring about a unified approach in the handling of emergencies such as quench, anaphylaxis, etc. Minor variations were always present, such as different exit routes, style of patient transfer, numbers to dial, etc., which were given due consideration. However, the heart of the training remained unchanged in terms of interventions, algorithms, etc.

The NCL Imaging Academies training is currently available for purchasable booking to external customers (private and other NHS Trusts). You can request a course brochure with fee by e-mailing an expression of interest to us at: uclh.ncl-imagingacademy@nhs.net

eLfH content is available to non-NHS staff. It can be accessed through eIntegrity for a small fee.

The module will be released when NHS England have completed their legal requirements. Unfortunately, there isn't a set date at the moment, but when it is released, we will be promoting it through Synergy magazine and social media.

Does the module offer any safety advice?

Where can I find the program? 

When I've looked at x-rays, it's not just things inside people that you can see. Does it also show things found outside of the body?

Systematic review of MRI safety literature in relation to radiofrequency thermal injury prevention

Wearing scrubs does not reduce the risks of flesh loop burns. Appropriate padding, as guided by the scanner manufacturer, is required as well as appropriate patient positioning etc. Changing patients into pocketless MR Safe clothing such as a gown or scrubs, however, will help to remove the risks of anything metal on, or in, the patient’s ‘street clothes’ being taken into the scan room by mistake. If the patient wears appropriate MR Safe scrub trousers it may also potentially help with patient dignity issues or potentially make the placement of padding more comfortable.

The discount code (MRISM091124) is available until the 1st of January 2025 at Class Professional Publishing. Please note that the publisher can only deliver to a UK address.