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In July 2001, 6-year-old Michael Colombini was in the MRI suite for a follow-up scan after surgery to remove a benign brain tumor. He was sedated for the procedure. During the scan, the oxygen line in the MRI room malfunctioned, and Michael’s oxygen levels began to drop. The intercom was broken, metal was stored too close to the magnet, and the oxygen alarms weren’t tied into the hospital system. A nurse who wasn’t a regular staff member of the MRI department, heard the anesthesiologist urgently
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