Patient Safety Day in our Brave New World: Medical radiation

In a scene in Aldous Huxley's classic, Brave New World, a technician becomes distracted by a visitor, causing her to fail to inject a vaccine, later setting up someone's death from a rare tropical disease. In that world, technology is wondrously powerful, though errors continue to occur.

One of our most wondrous technologies is medical radiation. Radiation has long been used to create images of body structures, tumors, etc. The use of radiation as a treatment in itself, via implanted radioactive seeds, IMRT, stereotactic or fixed beam, proton particles, etc., is much newer. These treatments are complex, powerful, and poorly understood, so that errors are difficult to prevent and detect. Medical radiation may be the epitome of much of medical care, whose drugs and other procedures are also complex, powerful, and poorly understood. That makes it an apt topic for Patient Safety Day.

That also makes it error-prone. The ECRI Institute put radiotherapy overdoses at the top of its list of the top ten technology health hazards. Such overdoses had caused the death of Scott Jerome-Parks, Alexandra Jn-Charles, and perhaps others we don't know about. Today, Dr. William Hendee, one of the most eminent medical physicists, presented a talk on the safety of medical radiation at a meeting of the Massachusetts Coalition for the Prevention of Medical Errors. He discussed both the use of medical radiation as a treatment itself, and in the use of diagnostic imaging (in CT scans, X-rays, etc).

Dr. Hendee's advice for people considering medical radiation treatment:
Ask a lot of questions of your radiation oncologist: Is this the best way to treat my condition? What are the alternatives? Once you've chosen, you should ask questions about the facility: Is it accredited by the American College of Radiology (ACR) and the American Society for Radiation Oncology (ASTRO)? What level of audits are done? Are the medical physicist and radiation therapist certified, accredited by the American Board of Radiation Oncology, and the American Society of Radiologic Technologists (ASRT)?

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.