Review of unusual patient care experiences is a cornerstone of medical education. Each month, the AQI-AIRS Steering Committee abstracts a patient history submitted to the Anesthesia Incident Reporting System (AIRS) and authors a discussion of the safety and human factors challenges involved. Real-life case histories often include multiple clinical decisions, only some of which can be discussed in the space available. Absence of commentary should not be construed as agreement with the clinical decisions described. Feedback regarding this article can be sent by email to the AIRS Committee: airs@asahq.org. Report incidents or download the AIRS mobile app at www.aqiairs.org.

A healthy adult patient was scheduled for an MRI of his brain under general anesthesia in a 3 Tesla scanner. The resident was standing next to patient’s head at the scanner’s bore and was getting ready to extubate...

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