He clung to this wish: Fatal radiation overdose

Scott Jerome-Parks was raised in a conservative family in Gulfport, Mississippi, later moving to Toronto, and then New York City. There, he met his Canadian-born wife Carmen, a dancer, singer and aspiring actress. He took a job as a computer and systems analyst, at the southern tip of Manhattan.

Haunted by the deaths he saw up-close on September 11, 2001, he volunteered to work with the Red Cross near "the Pile." He developed what he initially thought was a nagging sinus infection, diagnosed two months later as tongue cancer. His doctor believes there was a link between his tongue cancer and the toxic dust from the collapsed towers, though the cause of his cancer was never proven.

Scott approached his illness as any careful consumer would, evaluating the treatment options before choosing a hospital. He chose a hospital that provided Intensity Modulated Radiation Therapy (IMRT), which it advertised as more precisely targeted, and so having fewer serious side effects, than conventional radiation therapy.

The first four radiation treatments were provided as prescribed. The medical physicist revised the treatment plan for the fifth session to better protect Scott's teeth from radiation damage, at the suggestion of Scott's doctor. Such a revision of the treatment plan is a time-consuming task. As the medical physicist tried to save the computer program containing the revised treatment, late in the morning of March 14, 2005, the system crashed, after appearing to save the changes first. An hour later, Scott's doctor approved the new plan. Half an hour later, the computer crashed again. Six minutes later, staff administered the first of several radioactive beams. They administered another round the next day.

Two friends – a layman and a nurse – noticed something wrong because of Scott's intense pain, and swelling throughout his head and neck, and asked the hospital to check on Scott. The hospital sent a psychiatrist. Scott received another round the next day. Several hours later, the medical physicist ran a test to see whether the radiation had been provided appropriately. Then she tested again, and tested a third time. A frightful mistake had been made: Scott's entire neck had been exposed, causing a large overdose of radiation. The damaged cells were not reparable.

Scott died in early 2007 at age 43.

The New York City hospital treating him for tongue cancer had 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.

In a recent exceptionally thorough data analysis, the New York Times found that the complexity of this new technology has created new avenues for error – through software flaws, faulty programming, poor safety procedures, or inadequate staffing or training.

As he lay dying, he clung to this wish: that his fatal radiation overdose – which left him deaf, struggling to see, unable to swallow, burned, with his teeth falling out, with ulcers in his mouth and throat, nauseated, in severe pain and finally unable to breathe – be studied and talked about publicly so that others might not have to live his nightmare.

Read a happier radiation story. Thanks to Walt Bogdanich for the source story in the New York Times of Jan. 24.

Advice to patient advocates for patients undergoing radiation: Insist on a test by the medical physicist before radiation is used. The test is customary but is sometimes skipped, as it was here.

The FDA had violated its own policy: Adverse drug reactions from defective heparin

Baxter International announced recently that it is recalling virtually all its heparin products. Baxter makes and sells more than 500,000 multi-dose vials of heparin in the U.S. each month. Heparin is used to prevent blood from clotting during dialysis and some common forms of heart surgery.

More than 400 adverse reactions have already been reported in the US from the use of heparin, including up to 21 deaths. Investigators are trying to identify the root cause, which seems related to the practices of small Chinese suppliers of crude heparin.

To make heparin, workers collect and cook the mucous membrane from the intestines of slaughtered pigs, producing crude heparin. Major producers refine that and sell it to Baxter and others, which make the finished product for use in hospitals.

Blue ear pig disease has swept through China, depleting stocks, and leading some farmers to sell sick pigs. This led companies to switch to using small, often unsanitary and unregulated village workshops as less expensive suppliers. As much as 70% of China’s crude heparin now comes from such small factories in poor villages.

The FDA had admitted this month that it had violated its own policy by failing to inspect Changzhou SPL, located west of Shanghai, before the factory began shipping crude heparin, an ingredient of the medicine heparin, in 2004. The Chinese government does not inspect such factories.

Advice to heart surgery and dialysis patients: Ascertain, or ask your patient advocate to ascertain, the source of the heparin you will receive. A sufficient supply is available from safer suppliers.

Browse for related stories in the index at the very bottom of this page.

Thanks to Walt Bogdanich and David Barboza for the two source articles in last week's NY Times.