Story of an extraordinary death: How MRI machines work, and can (in rare cases) kill; Story of an extraordinary death: How MRI machines work, and can (in rare cases) kill Two doctors, two staffers at Mumbai’s BYL Nair Hospital have been charged with causing by negligence the death of a man in the hospital’s Radiology unit. Following this process for the rest of the logic tree resulted in the summary of root causes outlined previously. In total we reviewed 112 MRI related injuries. Westchester Medical Center announces that 6-year-old boy was killed during magnetic resonance imaging test; metal oxygen tank about size of fire … Get population and demographic information about the country, individual states, and more: View the latest QuickFacts statistics and estimates for the most popular topics. B. 25-year-old female patient with known chronic renal failure, status post renal transplant. Typically they can recount only three or four superficial facts about the accident: Sadly, the patent truth in each of these statements might equip each of us for a trivia contest but does not help us to understand—and more importantly, prevent—adverse events such as the Colombini accident. In the summer of 2001, the radiology world was shocked to learn of an accident at Westchester Medical Center in New York state in which 6-year-old Michael Colombini was killed while being prepared for an MRI exam. We looked closer at each of these incidents and evaluated whether best practice recommendations – taken from the ACR Guidance Document on MR Safe Practices (2013)* – could have helped prevent them. The major discrepancy rate between cause of death identified by radiology and autopsy was 32% (95% CI 26–40) for CT, 43% (36–50) for MRI, and 30% (24–37) for the consensus radiology report; 10% (3–17) lower for CT than for MRI. weight. Check out our new podcast for insight and analysis about the latest patient safety and quality issues! Having an MRI scan is a painless procedure. It is here where we start to hypothesize and ask, “How could the events in the previous block have occurred?”  We seek to move backwards, in short increments of time, to unfold the sequence of events and to use collected evidence to support or refute the hypotheses. When the oxygen tank was brought into the MRI scanner room, the profound magnetic strength of the MRI scanner drew it out of the anesthesiologist’s hands and into the scanner, where it struck and killed the young boy. Neither incident was reported to the hospital administration, nor to state or federal officials. Participants were asked if they had tried to obtain an appointment with an NHS dentist and, if … PACE. Search for publications, education brochures, statistics on admission rates, waiting times, bed occupancy rates, diseases and more. Our logic tree starts with an Event (E). OBJECTIVE: To demonstrate the magnetic resonance imaging (MRI) appearance of the brain in patients with clinical brain death. Specifically, this includes hospital or site administration, physician, security, and other non-MR personnel. Magnetic resonance imaging (MRI) uses a large magnet and radio waves to look at organs and structures inside your body. 1. d. In case of cardiac or respiratory arrest or other medical emergency within Zone IV for which emergent medical intervention or resuscitation is required, appropriately trained and certified MR personnel should immediately initiate basic life support or CPR as required by the situation while the patient is being emergently removed from Zone IV to a predetermined, magnetically safe location. Available at. Sudden cardiac death (SCD) secondary to arrhythmia remains a risk in those with dilated cardiomyopathy (DCM), an implantable cardiac defibrillator (ICD) is an effective strategy to prevent SCD. Current guidelines recommend selection for ICD based on ejection fraction (EF) less than 35%, however, most SCD occurs in those with EF>35%. Current guidelines recommend selection for ICD based on ejection fraction (EF) less than 35%, however, most SCD occurs in those with EF>35%. October 25, 2019 — A radiology nurse was seriously injured Oct. 23 at Sunderby Hospital in Luleå, located in northern Sweden, when caught in the strong magnetic field of the magnetic resonance imaging (MRI) scanner and pulled against it. The MRI technologists at UIMA were neither required to have. male. Magnetic resonance imaging (MRI) is a type of scan that is often used to diagnose health conditions that affect organs, tissue and bone. 106 of these were categorized as being burns, hearing damage or injuries caused by projectiles. Case contributed by Dr Shekhar Kalia. This is the degree of confidence we have in the supporting evidence. Changing trends in mortality in England and Wales An expansion of previous analysis of recent changes in the trends of mortality rates in England and Wales from 1990 to 2018 (Experimental Statistics). Available at http://www.acr.org/SecondaryMainMenuCategories/quality_safety/MRSafety/safe_mr07.aspx, The Joint Commission. A man with Down's syndrome wasn't fed for 19 days in hospital and died having been neglected, an inquest has found. male. The concealment of these accidents from the State of New York violated the Department of Health statutes, and the failure to communicate prior accidents within the institution (including a prior accident that involved ferromagnetic oxygen tanks, and the remediation step, which included using only non-ferromagnetic oxygen tanks within the MRI suite) contributed to the Colombini accident. The most effective and engaging way for clinicians to learn, improve their practice, and prepare for board exams. The oxygen cylinder was introduced to the MRI suite by a nurse or anesthesiologist. indicator of whether participant is male (0=female, 1=male). HSDQ, and Robert J. Latino. Both MRI technologists on duty at the time of the accident had been employed at UIMA for about 6 months prior to the accident. We will continue to provide daily patient safety and quality news and analysis on our website, as well as provide insight via various innovative formats such as podcasts, webinars, and virtual events. Furthermore, TJC has disavowed that its own SEAs should be required elements of an accredited hospital’s Environment of Care risk assessment (providing a risk assessment of the services and environment is a requirement of Joint Commission accreditation). A heart MRI (magnetic resonance imaging) uses magnets and radio waves to create an image of your heart and nearby blood vessels, without a surgical incision. Following Michael Colombini’s death in 2001, civil suits were filed and litigation proceeded until a settlement was reached near the end of 2009. Learn more about Institutional Access, Christopher Landrigan, M.D., M.P.H.Children's Hospital, Boston, MA 02115 [email protected]tch.harvard.edu, September 27, 2001N Engl J Med 2001; 345:1000-1001 Sign in. The hospital subcontracted the management and operation of the MRI service to University Imaging Medical Associates (UIMA), which employed the MRI clinical and technical staff. The accident involved an oxygen cylinder drawn into the MRI scanner. A Surge in CT and MRI Scans Has Not Boosted Diagnosis Rates. GP Patient Survey Dental Statistics; January to March 2020, England In January to March 2020, 2.3 million adults were asked about their views on NHS dentistry as part of the GP Patient Survey. Death rate: 867.8 deaths per 100,000 population; Source: National Vital Statistics System – Mortality Data (2018) via CDC WONDER Upon hearing the anesthesiologist’s calls for oxygen, the nurse noticed portable cylinders in a patient preparation alcove, directly across from the entrance to the MRI scanner room. Includes death counts, cause-specific mortality ratios and odds ratios to identify differential risks of COVID-19-related deaths. http://www.acr.org/SecondaryMainMenuCategories/quality_safety/MRSafety/safe_mr07.aspx, http://www.jointcommission.org/assets/1/18/SEA_38.PDF. Anesthesiologist did not remove child from MRI scanner room in code situation. 2005.2 Magnetica Ltd. Todays MRI market. Latino may be contacted at blatino@reliability.com.ReferencesKanal, E., Barkovich, A. J., Bell, C., Borgstede, J. P., Bradley, W. G., Froelich, J. W., Gilk, T., et al. A. Purchase this article ACR guidance document for safe MR practices: 2007. These individuals shall be referred to henceforth as MR personnel. In the 10 years following this infamous accident, the professional accreditation bodies with the greatest capacity to mitigate these incidents have not taken a stand that would compel their members to implement these protections. 21-01 What is the Organ Distribution of MRI Studies? The persistent down-stream effect has been (and continues to be) that avoidable serious injuries to patients and caregivers not only continue but are growing at an alarming rate. MRI provides real-time, three-dimensional views of body organs with good soft tissue contrast, making visualization of brain, spine, muscles, joints and other structures excellent. The MRI technologist (#1) who was to have administered the exam came to the MRI scanner room door, which the anesthesiologist had opened to speak with her. Given the lack of response from regulatory, licensure, and accreditation bodies to the known risks (and published protections) for MRI, one might conclude that individual providers have been left to determine for themselves what MRI safety efforts are appropriate because the current system has been proven effective at managing MRI adverse events. The value in this RCA lies in exposing the “Russian doll” nature of this one accident, revealing both the immediate decisions and the persistent, underlying latent causes that led to the tragic outcome. Prepare to become a physician, build your knowledge, lead a health care organization, and advance your career with NEJM Group information and services. Preventing accidents and injuries in the MRI suite. MRIs are very useful for examining the brain and spinal cord. Author information: (1)Department of Diagnostic Radiology and Nuclear Medicine, University Hospital, London, Ont. The Joint Commission (TJC) has published articles for its members and, most importantly, a Sentinel Event Alert, the Commission’s highest patient safety warning, about MRI accidents and injuries. 2. During preparation for the MRI, Michael was given sedative several times in an attempt to calm him for the exam. Ten years after this tragedy, it is appropriate to measure what we know about it, how that knowledge has reshaped MRI safety, and how improvements in MRI safety measure up. UIMA’s president was also the chair of radiology for WMC. While it is unclear what the expectation will be for TJC accredited providers, we expect increased attention to MRI safety concerns to be part of upcoming surveys. participant's weight at time of MRI … We determined whether changes in integrated [18F]-fluoro-2-deoxy-D-glucose positron emission tomography/MRI (18F-FDG PET/MRI) parameters after the first 2 weeks of antiprogrammed death-1 antibody nivolumab therapy could predict the response of patients with non-small cell lung cancer … ACR guidance document for safe MR practices: 2007. What can we learn from the accident that killed Michael Colombini? 2014. In a period of five years, we witnessed growth of nearly five-fold in the number of MRI accidents. The mri are a fictional alien species in the Faded Sun Trilogy of C. J. Cherryh's Alliance-Union universe.Their culture appears to be drawn upon those of the Apache, Berbers (especially Tuaregs), and Japanese samurai.Their name means simply "the people," and they refer to all other races as "tsi-mri," which literally means not people He died two days later.1 Undetected or misplaced metal objects have caused numerous injuries during MRI. All Statistics. So the questioning and validation process continues as we progress backwards in time and re-create the path of failure. The RCA of this one accident does not provide us a window into the full range of contemporary MRI risks, or even all MRI hazards of 2001. Samuel Osborne @SamuelOsborne93. requires its safety provisions for facility or MRI-specific accreditation (this despite the explicit request of the ACR’s own MRI safety committee in 2006). It does, however, plainly illustrate that elements foundational to effective safety programs beyond MRI (training, appropriate facility design, comprehensive and up-to-date policies and procedures, clear lines of communication and authority) are equally relevant to MRI. Gilk may be contacted at Tobias.Gilk@Mednovus.com or TGilk@RAD-Planning.com. race. She picked up one of the cylinders and handed it to the anesthesiologist who turned to take it to the boy in the scanner. Brain and spine studies make up more than 50% of all stu­dies, breast, heart and interventional studies less than 5%. This is essentially our evidence log that captures the verification method used, the outcome, any file links to support the hypothesis, the person responsible for collecting the data, and the date by which the verification data would be collected. any MRI safety training as a part of their duties. Magnetic Resonance Imaging (MRI) and Spectroscopy (MRS) in Breast Cancer Uma Sharma, Rani Gupta Sah and Naranamangalam R. Jagannathan Department of NMR and MRI Facility, All India Institute of Medical Sciences, New Delhi—110029, India. Background The early response to treatment with immune-checkpoint inhibitors is difficult to evaluate. While it is unclear what the expectation will be for TJC accredited providers, we expect increased attention to MRI safety concerns to be part of upcoming surveys. Of course this is only one leg of the logic tree but it shows how systemic causes (Latent Roots [LR]) influence our decision-making processes.From these causes, a provider could identify a specific set of operational protections. In total we reviewed 112 MRI related injuries. The Joint Commission. (212) 419-8286 Employees of UIMA were unclear which organization they worked for or which supervisors had responsibility for safety issues. that result from these MR safe practice guidelines are implemented and adhered to at all times by all of the site’s personnel. Each site will name an MR medical director whose responsibilities will include ensuring that MR safe practice guidelines are established and maintained as current and appropriate for the site. MRI Safety 10 Years Later By Tobias Gilk, M.Arch. race. Beyond the SymptomsIt deserves to be said that it is often very difficult to glean “lessons learned” from medical errors that wind up in litigation or are otherwise subject to strict confidentiality. Statistics on Claustrophobia. age. For a narrated tour of the complete logic tree, please visit www.reliability.com/mri/. The National Vital Statistics System analyzes ~2.8 million records each year to produce timely and accurate information on death and its causes in the United States. Ten years after this tragedy, it is appropriate to measure what we know about it, how that knowledge has reshaped MRI safety, and how improvements in MRI safety measure up. Inexplicably, however, TJC did not select any of the performance criteria from. Neither MRI technologists, nor anesthesiologist were provided with MRI safety training. Health Data and Statistics The Georgia Department of Public Health has two ways to access Georgia’s public health data: The Online Analytical Statistical Information System (OASIS) is a web-based tool that will allow you to access publicly available health data and statistics for the state of Georgia. Further evidence of this communication gulf was demonstrated when two prior MRI projectile accidents (neither resulted in injury) were discovered to have happened at the same facility in the months and years prior to the Colombini accident. A heart MRI (magnetic resonance imaging) ... (CHD) is the leading cause of death among adults in the United States. We assessed 182 unselected cases. Sentinel Event Alert, 38. Eagle Farm, QLD, Australia, Magnetica Ltd. 11-12-2014.3 Kalin R, Stanton MS. Current Clinical Issues for MRI Scanning of Pacemake (2008, February 14). Resources & Statistics. 1. c. Zone III regions should be physically restricted from general public access by, for example, key locks, passkey locking systems, or any other reliable, physically restricting method that can differentiate between MR personnel and non-MR personnel. This degree of confidence will come from the Verification Log. To the Editor: In July, a six-year-old child undergoing magnetic resonance imaging (MRI) in New York suffered a skull fracture and intracranial hemorrhage after an oxygen tank that had been brought into the room was pulled into the machine at high speed. The Joint Commission (TJC) has published articles for its members and, most importantly, a Sentinel Event Alert, the Commission’s highest patient safety warning, about MRI accidents and injuries. Thank you for your continued interest. Until the cause of the deaths was established, all MRI scans using contrast agents, except in emergencies, had been suspended in public hospitals of Campinas, they added. MRI is an imaging technique designed to visualise internal structures of the body using magnetic and electromagnetic fields which induce a resonance effect of hydrogen atoms. it is possible to trace the outcomes of this accident to more than 50 contributory root causes. RR570 - Assessment of electromagnetic fields around magnetic resonance imaging (MRI) equipment. Register for 2 FREE subscriber-only articles each month. DOI: 10.1056/NEJM200109273451316. B. The Event is the last effect in a chain of cause-and-effect relationships. And MRI scans are sought after in such high quantities for good reason as their results can make the difference between life and death for millions of people around the world. Sadly, the patent truth in each of these statements might equip each of us for a trivia contest but does not help us to understand. Health Data and Statistics The Georgia Department of Public Health has two ways to access Georgia’s public health data: The Online Analytical Statistical Information System (OASIS) is a web-based tool that will allow you to access publicly available health data and statistics for the state of Georgia. Death statistics for Infant Death: The following are statistics from various sources about deaths and Infant Death: Infant (1 year) death rate 0.706% or 1-in-141 (highest in the first 28 days) [CDC NVSR 2001] 0.188% or 1-in-531 death rate for infant ( 1 year) but after the first 28 days [CDC NVSR 2001] he spectrum of clinical MR examinations has hardly changed during the last decade. Beyond these common foundational elements, there are safety needs unique to MRI, such as access restrictions, non-magnetic equipment, ferromagnetic screening, specific hazard warning signage, all of which would help to prevent a recurrence of just this sort of accident. Magnetic resonance imaging (MRI) units Magnetic Resonance Imaging (MRI) is an imaging technique designed to visualise internal structures of the body using magnetic and electromagnetic fields which induce a resonance effect of hydrogen atoms. By asking, “How could the ferrous O2 canister have been drawn into the MRI tunnel?” we hypothesize that either the canisters were left in the MRI room prior to the scan or the canisters were introduced into the MRI room during the scan (Figure 2). Image Interpretation and Statistics. Now that we have hypotheses, we need to validate which are true and which are not. A Reflection on MRI Safety 10 Years LaterThe American College of Radiology’s MR Safe Practice Guidance Document was initially published in 2002 following an investigation of the Colombini fatality by the committee’s appointed chair, Dr. Emanuel Kanal. participant age at time of MRI, in years. The conflict in the roles and responsibilities is illuminated in the deposition transcripts, which show that the MRI technologists were unclear on both the immediate responsibility for checking the MRI’s bulk oxygen cylinder and the larger issues of whether maintenance and upkeep of the MRI oxygen supply was the responsibility of the hospital or the MRI center. The value in this RCA lies in exposing the “Russian doll” nature of this one accident, revealing both the immediate decisions and the persistent, underlying latent causes that led to the tragic outcome. are aware of this most infamous MRI accident: the 2001 death of Michael Colombini. In a study involving an MRI diagnosis and claustrophobia, up to 13% of patients receiving an MRI reported having a … Non-MR personnel are not to be provided with independent Zone III access until such time as they undergo the proper education and training to become MR personnel themselves. Abstract: Breast cancer is a major health problem in women and early detection is of prime importance. Ferromagnetic material stored next to MRI scanner room. The numbers in the lower left hand corner of each block is a Confidence Factor. The anesthesiologist was reported to have been yelling to inquire about the status of the oxygen supply, alarmed by the deteriorating condition of the patient in the MRI scanner. all categories. Upon checking the output rate of the piped-in oxygen at the wall outlet, the anesthesiologist observed that no oxygen was flowing. indicator of whether participant is male (0=female, 1=male). In Figure 4, we show the next level of questioning and the resulting six paths of simultaneous contribution to the overall incident. Presentation. Preventing accidents and injuries in the MRI suite. MRI machine death 00:45. We looked closer at each of these incidents and evaluated whether best practice recommendations – taken from the ACR Guidance Document on MR Safe Practices (2013)* – could have helped prevent them. The MRI has a magnetic field, an invisible force that surround's the patient's body during a scan. mortem MRI have mainly focused on natural causes of death [4, 5]. . Effective immediately, PSQH will no longer publish print magazine issues due to a number of factors. B. At this point we ask “How did the event occur?”  The answer is labeled M for ‘Mode.’ (Figure 1). Figure 4: The Next Level of ‘How Could’ Questioning. Of course this is only one leg of the logic tree but it shows how systemic causes (Latent Roots [LR]) influence our decision-making processes. MRI staff training on the operation of the medical gas system, including zone valves. Bob Latino is an internationally recognized expert in the field of root cause analysis (RCA) and CEO of Reliability Center, Inc. (www.reliability.com), a consulting firm specializing in improving equipment, process and human reliability. The study found that, among 30-day survivors, the risk of death by the twentieth year mark was highest for ischemic stroke patients, at 26.8 percent, with TIA sufferers close behind at 24.9 percent. Information and tools for librarians about site license offerings. Up to 5% of the US general population may suffer from claustrophobia in some form, including mild versions of this phobia. While that is frequently the case, it is not so with the Colombini civil litigation. the date on which the participant underwent MRI scan in MMDDYY format. Stay connected to what's important in medical research and clinical practice, Subscribe to the most trusted and influential source ofmedical knowledge, This article is available to subscribers. Death statistics for Infant Death: The following are statistics from various sources about deaths and Infant Death: Infant (1 year) death rate 0.706% or 1-in-141 (highest in the first 28 days) [CDC NVSR 2001] 0.188% or 1-in-531 death rate for infant ( 1 year) but after the first 28 days [CDC NVSR 2001] MRI findings in brain death. 28, 326-328. What statistics can I get from the census? Government Leaders and Prioritization of SARS-CoV-2 Vaccines, Vaccinating Children against Covid-19 — The Lessons of Measles, Case 2-2021: A 26-Year-Old Pregnant Woman with Ventricular Tachycardia and Shock, Polypill with or without Aspirin in Persons without Cardiovascular Disease, Post-Transcriptional Genetic Silencing of. After speaking with the anesthesiologist, the technologist sought out her colleague, technologist #2, who was preparing films from a prior examination. Already have an account? The other involved technologist #1, who was to have administered Michael Colombini’s MRI scan, who brought a ferromagnetic wheelchair into the MRI scanner room. Patient's relative 'dies after being sucked into MRI machine' Rajesh Maru's family accuse hospital of negligence as member's of staff arrested. Established responses for pressure/flow failures of medical gas service, including support from engineering. indicator of participant's race (1=white, 2=black, 3=Asian, 4=other). Too often, the industry focuses on capriciously selected “symptomatic” details and not on true root causes involving systemic deficiencies that impact our decision-making. The X-ray nurse is currently being treated at the intensive care unit at the hospital. All individuals working within at least Zone III of the MR environment should be documented as having successfully completed at least one of the MR safety live lectures or prerecorded presentations approved by the MR medical director. Epilepsy is a disorder caused by unusual nerve cell activity in the brain. Well prior to the accident, lines of authority and responsibility among the UIMA employees and between the on-site employees and either UIMA or WMC management were unclear, at best. The “always on” magnetic field of the MRI scanner pulled the oxygen cylinder from the grasp of the anesthesiologist, and it flew into the center bore of the MRI machine, where it struck the boy, who died two days later from the injuries. Information, resources, and support needed to approach rotations - and life as a resident. Deaths from heart disease including heart attacks and those related to complications of high blood pressure increased by 11% and 17%, respectively, compared to 2019, the study showed. In 2010, after the last of the civil suit documents were filed with the Westchester County Clerk’s Office, we were able to undertake a comprehensive assessment. Axial Tomography (CT Scan, 0.40 million) and Magnetic Resonance Imaging (MRI, 0.28 million). The content of this site is intended for health care professionals. Background and purpose: Lung cancer is the most common cause of cancer related death among both men and women worldwide. A Surge in CT and MRI Scans Has Not Boosted Diagnosis Rates. In a positive development, Michael Kulczycki, executive director of The Joint Commission’s Ambulatory Care Accreditation Program, has stated that the organization will soon be providing extensive MRI safety training to its hospital surveyor corps, a first for the organization. Infectious Disease Statistics Singapore Health Facts Healthcare Institution Statistics. Too often, the industry focuses on capriciously selected “symptomatic” details and not on true root causes involving systemic deficiencies that impact our decision-making. The oxygen cylinder struck and killed the boy, who was in the MRI scanner. Peer-reviewed journal featuring in-depth articles to accelerate the transformation of health care delivery. With these facts, we can drill-down in a root-cause analysis (RCA) to a set of practical lessons based on the construction of a “logic tree.”  A logic tree is a graphical representation of cause-and-effect relationships that led to an undesirable outcome. To our knowledge, there has been no systematic evaluation of the use of postmortem whole-body MRI in traumatic causes of death. Fire/Smoke Inhalation Deaths: 3,275. That would make sense if the time frame from 2004 to 2009 did not record a 472% growth in the incidence of FDA-reported MRI adverse events. He also is a former member of the American College of Radiology’s MRI Safety Committee. Establish, implement, and maintain current MR safety policies and procedures. Available at http://www.jointcommission.org/assets/1/18/SEA_38.PDF. The reader is invited to view the full product of the analysis, available online at, Kanal, E., Barkovich, A. J., Bell, C., Borgstede, J. P., Bradley, W. G., Froelich, J. W., Gilk, T., et al. An Indian man died after being sucked into an MRI machine while visiting a relative at a hospital in Mumbai, police said Monday. the organization will soon be providing extensive MRI safety training to its hospital surveyor corps, a first for the organization. So, 10 years later, it appears that the knowledge of the risks and causes of MRI accidents has been captive in institutional ivory towers. By Tobias Gilk, M.Arch. Early detection is crucial for prognosis. (2007, June). Are you a member of an institution such as a university or hospital? (2007, June). The increases were greatest in areas that were the hardest hit by the pandemic: New York City saw a 139% spike in deaths due to heart disease and a 164% rise in deaths related to high blood pressure. Nearly all practitioners who have some responsibility for safety in MRI—risk managers, technologists, compliance officers, administrators, patient safety officers, and radiologists—are aware of this most infamous MRI accident: the 2001 death of Michael Colombini. The hospital where this occurred is located in New York. [27 Oddest Medical Cases] MRI imaging is quite safe for … In Figure 3 we can see a sample of the verification log for the hypothesis about the canisters being introduced into the MRI room during the scan. Activate your online access. By following the “Piped-In O2 Supply Depleted at Commencement of Scan” box we can conclude the string of logic depicted in Figure 5. Two people have been placed under arrest and multiple investigations are underway in India over a fatal accident that saw a … All rights reserved. The skeleton is the most common site of cancer metastasis. Diagnosis almost certain Diagnosis almost certain . One alarmingly similar incident involved an anesthesiologist who brought several ferrous oxygen cylinders into the MRI scanner room. After Michael was placed in the MRI scanner but preceding the beginning of the exam, the anesthesiologist observed the boy’s oxygen saturation levels falling.