unbelievable, but sad reality

Radiation Offers New Cures, and Ways to Do Harm

By WALT BOGDANICH
(Read my response only after you’ve read at least the FIRST page of the article) Here’s an abridged version:

A New York City hospital treating [Scott Jerome-Parks] for tongue cancer failed to detect a computer error that directed a linear accelerator to blast his brain stem and neck with errant beams of radiation. Not once, but on three consecutive days.

Soon after the accident, at St. Vincent’s Hospital in Manhattan, state health officials cautioned hospitals to be extra careful with linear accelerators, machines that generate beams of high-energy radiation. But, on the day of the warning, at the State University of New York Downstate Medical Center in Brooklyn, a 32-year-old breast cancer patient named Alexandra Jn-Charles absorbed the first of 27 days of radiation overdoses, each three times the prescribed amount. A linear accelerator with a missing filter would burn a hole in her chest, leaving a gaping wound so painful that this mother of two young children considered suicide.

Ms. Jn-Charles and Mr. Jerome-Parks died a month apart. Both experienced the wonders and the brutality of radiation. It helped diagnose and treat their disease. It also inflicted unspeakable pain.
While Mr. Jerome-Parks had hoped that others might learn from his misfortune, the details of his case — and Ms. Jn-Charles’s — have until now been shielded from public view by the government, doctors and the hospital. […]

In June, The Times reported that a Philadelphia hospital gave the wrong radiation dose to more than 90 patients with prostate cancer — and then kept quiet about it. In 2005, a Florida hospital disclosed that 77 brain cancer patients had received 50 percent more radiation than prescribed because one of the most powerful — and supposedly precise — linear accelerators had been programmed incorrectly for nearly a year. […]
[New York State] records described 621 mistakes from 2001 to 2008…The Times found that on 133 occasions, devices used to shape or modulate radiation beams were left out, wrongly positioned or otherwise misused.

On 284 occasions, radiation missed all or part of its intended target or treated the wrong body part entirely. In one case, radioactive seeds intended for a man’s cancerous prostate were instead implanted in the base of his penis. Another patient with stomach cancer was treated for prostate cancer. Fifty patients received radiation intended for someone else, including one brain cancer patient who received radiation intended for breast cancer.

New York health officials became so alarmed about mistakes and the underreporting of accidents that they issued a special alert in December 2004, asking hospitals to be more vigilant.
[However, the mistake documented in this story occurred one year later.]

My Response:
What makes me the most outraged is how long it took for them to publish this story after the incident, and how no one seems to be taking it seriously. “Oh, it was an unfortunate misshap” or “Oh, it DOES carry a risk, but it can also help!” –are these people human?! Also, “oh, the computer just indicated an error, but we’ll just go through with the treatment anyways” or “oh, its not THAT important to double check treatments before they are administered, since I mean, only the patient’s LIFE is on the line” and “oh, we don’t have to WATCH the computer because its fine anyways! (ignores the fact that the WEDGE IS MISSING ON THE SCREEN)”
“Fines or license revocations are rarely used to enforce safety rules. ” !?!!
Something they said in the article was a great way of indicating why computers should never replace humans and the true root of the problem with radiation overdose (paraphrased) : “Why is there not a way programs can realize there is an error when a huge amount of radiation is being administered?!” To any bystander, there is clearly something wrong–the computer should not be allowed to administer that much radiation! Also, isn’t it just common sense to VERIFY THE DOSE before it is administered? These medical mishaps make me sick to the stomach, and yes, in the real world people are imperfect and impatient and make mistakes, but really? Is verification really that hard? If there is inadequate staffing that disallows proper monitoring of the treatment, that facility should NOT be allowed to administer, not to mention POSSESS, such an instrument.
I am amazed by how Mr. Jerome-Parks handled the situation, and how strong his mercy and faith were. If anything, that should make others even more outraged at the system and  DO SOMETHING ABOUT IT.
The sad thing is, everyone always thinks someone else will do something about it. Still, getting the issue out is the first step. As future physicians, the best thing we can do is promote vigilance, and be SERIOUS about it.
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