One of the most advanced features of Massachusetts General Hospital’s new Lunder Building is a fourth-floor surgical suite with a powerful magnetic resonance imaging (MRI) device mounted on a ceiling track. The movable MRI allows surgeons in two operating rooms to perform delicate procedures, such as the removal of brain tumors, with unprecedented accuracy, safety and efficiency.
Another remarkable aspect about the MRI suite is that it wasn’t on the building’s original construction plans. The elaborate research and planning that went into adding the MRI helps make the 530,000-square-foot building a fitting symbol of MGH’s third century.
At Mass General, “state of the art” has never meant the same thing for very long. Founded before the advent of anesthesia, antiseptics and other medical advances now taken for granted, the hospital has a history of relentlessly seeking new techniques, technologies and treatments to improve patient care. In many cases, such advances have come from MGH’s own researchers. In others, they have involved investigating and adapting innovations originated elsewhere.
Along with the MRI suite, the Lunder Building features Intraoperative Computerized Tomography equipment that can move across a procedure room floor and other sophisticated imaging devices designed to pinpoint a disease’s location, minimize invasive surgery and shorten hospital stays.
Planning for the Unknown
By the time the initial plans for the Lunder Building were drawn up, Mass General leaders had defined the pressing needs the new structure had to fulfill. They included new surgery and procedural rooms, a streamlined and expanded Emergency Department and additional space for Radiation Oncology.
But deciding how to equip those new facilities could only go so far. From the start, Mass General leaders wanted to allow for medical technology that was likely to change dramatically both during construction and after the Lunder Building opened. “We designed the whole building so that it would be flexible for technology that we know now and technology that we don’t know about that will be here in 10 years when the building is still there,” says Jean Elrick, MD, Mass General’s senior vice president for Administration.
Maintaining such flexibility was no simple task. With the Lunder Building surrounded by other MGH structures, space was at a premium. Disruption of the hospital’s ongoing operations during construction had to be minimized. And in a 14-story building laced with intricate mechanical and electronic connections involving everything from elevators to heart monitors, modification in one space could mean design repercussions elsewhere.
The Threat of Flying Surgical Tools
All of those factors came into play in determining how to accommodate a moving, ceiling-mounted MRI device that weighs 18,000 pounds and, if used incorrectly, is powerful enough to transform common surgical tools into dangerous projectiles. “Architecturally, the impact was significant,” says Mass General’s Joanne Ferguson, RN, project specialist for the Lunder Building.
MRI is only a few decades old as a diagnostic tool. The technique involves exposing a patient to an electromagnetic field to produce thin-section pictures of the human body’s internal parts. Those images can be pivotal in determining how to treat diseased organs, tumors and other conditions. The sharpness and precision of the images depends in large part upon the strength of the MRI magnet.
Through the years, MRI makers have introduced increasingly powerful magnets but, for doctors and surgeons, when and how to best use them has always been something of a dilemma. One issue is whether MRIs should be used inside the operating room itself and, if so, how to accommodate the powerful electromagnetic fields they create.
To avoid related problems, most MRIs are installed in specially-prepared rooms of their own. To avoid moving patients during an operation, surgeries are typically conducted based on images taken before they begin.
A Penetrating New View for Surgeons
But in many situations, surgeons think they could benefit by having real-time MRI images to guide them while they work. During surgery to remove a brain tumor, for instance, the brain often collapses in on itself as it fills the space where the tumor once was. That movement could reveal additional problem tissue not visible on the original image but the operating surgeon can’t always see that with the naked eye. As it stands, detecting it frequently requires a post-operative MRI. For the patient, a negative result could mean the discomfort, recovery time and cost of a second operation.
With an MRI available for use inside the operating room, surgeons can obtain those additional images before the first procedure is over. “This allows you to do it in a much more refined and accurate fashion, that’s the bottom line,” says Robert Martuza, MD, chief of Mass General’s Neurosurgical Service, who was deeply involved in planning the Lunder Building’s MRI suite.
But the Mass General team working on the issue quickly discovered that providing for such an “intraoperative” MRI involved sorting through a tangle of options, tradeoffs and decisions. “One of the biggest issues is how do you make it the safest but get the most utility out of it?” says Peter Dunn, MD, MGH executive medical director, Perioperative Administration and co-chair of planning for peri-operative services for the Lunder Building.
Of course, Mass General has used MRI technology for years and, prior to the Lunder Building’s construction, it had a semi-portable device that could be used directly in the operating room. But that MRI could be cumbersome to maneuver and, because its magnet was relatively small, many surgeons weren’t satisfied with the images produced. “People didn’t use it effectively,” says Dr. Dunn.
Learning What Not To Do
The initial plans for the Lunder Building’s fourth floor called for installing an MRI 10 times more powerful than the semi-portable device in a room adjacent to one operating room. By having the MRI in a separate room lined with special shielding, operating room monitors and tools would not be impacted by its strong magnet and vice-versa.
But MGH caregivers were never totally satisfied with that placement since using it could involve transporting a patient with an open cranium during the course of an operation. “None of us were really comfortable with moving the patient if we didn’t have to,” says Ms. Ferguson.
While construction planning for the Lunder Building was under way, more advanced MRIs came on the market and a handful of hospitals elsewhere began implementing their own strategies to provide for their use while operations were in progress. To see what might be adaptable for the Lunder Building, MGH doctors, nurses, radiologists and architects visited hospitals in Houston, Phoenix, St. Louis, Rochester, Minn., and other cities.
The installations varied widely. One institution used a sort of trolley to transfer the patient from the operating table into an MRI in an adjacent room. At another, the operating table was mounted on a pivot so that it could be turned and inserted into the MRI during surgery.
Dawn Tenney, RN, MSN, recalls being taken aback by what they saw at a third hospital. There, as a safety measure, operating room furniture was tethered to the walls with chords. “We came away from there saying, ‘Wow, I’m not sure we want to do that,’” says Ms. Tenney, associate chief nurse, Patient Care Services and co-chair of planning for perioperative services for the new building.
The Utility of a “Doghouse”
In the end, MGH team members found the option closest to what they wanted in their own backyard. A new installation at Children’s Hospital Boston featured a state-of-the-art MRI that could be moved on a ceiling track into an operating room when it was needed and, afterward, put in an adjacent, garage-like storage area that could be sealed off.
The Mass General planners decided that if Children’s could make such an installation work, so could they. To increase the availability and utilization of the expensive device, they decided to extend the ceiling track so that it could serve two operating rooms, one on either side of MRI storage area, which came to be known as the “doghouse.” Moreover, amid advances in technology, they opted to use an MRI twice as powerful as the one originally planned and with a larger opening.
The challenge of fitting the more complex three-room configuration into the space originally designed for two fell to Sarah Markovitz, the project’s lead planner and a principal at NBBJ, a leading healthcare architecture and design firm. “We had some real complexities,” she recalls.
One of the trickiest tasks was providing for the intraoperative MRI’s magnetic field, which will be as much as 60,000 times more powerful than the Earth’s magnetic pull. The original plans called for a much smaller MRI to be permanently installed in a separate, specially shielded room. Moving the new MRI in and out of the two operating rooms meant that they, too, would need to be shielded.
Steering Clear of Elevator Shafts
Meanwhile, the MRI’s path of movement couldn’t come too close to nearby elevators shafts, steel columns and beams or any other large pieces of heavy metal. That included large electrical transformers on the floor above. They could interfere with the quality of the MRI’s images. Operating tools and other small items made of ferrous metal could be drawn to the powerful magnet if not kept at a proper distance.
With construction already under way, major structural changes elsewhere would mean unacceptable disruptions and delays. And as for the fourth floor’s design, “there was no way to be able to get a magnet in between two operating rooms that did not start to disrupt the way we had been thinking,” says Ms. Markovitz who, in the end, had to make some design tradeoffs.
One of the stand-alone operating rooms already planned for the fourth floor was incorporated into the intraoperative MRI suite. A restroom and some storage space were relocated to another part of the floor. A corridor was closed off, reducing the amount of natural light that would reach into one portion of the floor’s interior as well as the view of the outside world.
In preparation for overall construction of the Lunder Building, architects and planners had erected detailed working mock-ups of patient rooms in a Mass General parking garage. Environmental services employees were asked how to make the job of cleaning the rooms more efficient. Former cancer patients stretched out on beds to assess the aesthetics of the rooms around them.
For the MRI suite, Ms. Markovitz used chalk to mark up a full scale replication of the floor plan under a sprawling tent erected in front of the Bulfinch Building. Using a stretcher as a proxy for the operating table, doctors and nurses went through the paces of various types of operations to see whether they had ample elbow room and tools were in reach.
A Carefully Choreographed Array of High-Tech Machines
Their input helped decide the precise installation and positioning of instrument carts, video monitors and lights. The details of that job, along with the task of ensuring that devices, machinery and software from various vendors worked in tandem, were overseen on a daily basis by Samantha Lukacs, another NBBJ architect.
When the arms of some lighting booms were only available shorter than expected, for instance, she had to adjust the positioning of its ceiling mount to ensure that the boom could still be pushed out of the way when the MRI was moved into the operating room. “I don’t even think of them as problems,” Ms. Lukacs says of such tasks. “It’s just part of the process.”
The resulting operating suite is a carefully choreographed array of high-tech machines and mechanical devices. High-definition monitors on the walls will allow surgeons and nurses to check vital signs, review an operation’s progress and confer with colleagues elsewhere. Ceiling booms with long arms allow mounted lights and equipment trays to be moved out of the way when an MRI scan is required. For safety, concentric ovals of flooring, each a different color, mark the levels of the magnet’s pull.
Painted and tiled in white, the suite’s walls are pleasant and seemingly simple, but they are merely the outer covering of a thick shield designed to contain the MRI’s magnetic power and keep out radio frequencies that might interfere with its operation. Nonmagnetic screws attach the wallboard to a stud system which is fastened to thin layers of silicon steel and gleaming copper, all painstakingly welded at the seams.
Hoisting the Massive Magnet
At about 3 a.m. on Dec. 16, 2010, a semi delivered the MRI’s massive donut-shaped magnet to a parking area behind the Lunder Building. After hours of preparation and positioning, it was early evening before a crane hoisted the magnet up to a fourth-floor opening in the building’s outer wall. Inside, workers in hard hats pushed and pulled the mammoth machine down a 170-foot corridor — in some places working with just a few inches of clearance — to the suite.
Although the new MRI has only been in operation for a relatively short time, Lunder Building planners have already laid the groundwork for the day when the relentless march of medical technology makes it obsolete.
The long hallway the MRI came down is supported with larger beams and more reinforced steel. The exterior wall at one end of the corridor was built in modular fashion so that it can be readily removed. The same goes for one interior wall of the MRI suite. “We were trying to build for the future with the current users in mind,” says Dr. Dunn, who helped plan the installation. “When the next phase of technology needs to be put in, it’s ready.”
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