When Radiation Therapy Kills Case S

When Radiation Therapy Kills Case Study

When new expensive medical therapies come along, promising to cure people of illness, one would think that the manufacturers, doctors, and technicians, along with the hospitals and state oversight agencies, would take extreme caution in their application and use. Often this is not the case. Contemporary radiation therapy offers a good example of society failing to anticipate and control the negative impacts of a technology powerful enough to kill people. For individuals and their families suffering through a battle with cancer, technical advancements in radiation treatment represent hope and a chance for a healthy, cancer-free life. But when these highly complex machines used to treat cancers go awry or when medical technicians and doctors fail to follow proper safety procedures, it results in suffering worse than the ailments radiation aims to cure. A litany of horror stories underscores the consequences when hospitals fail to provide safe radiation treatment to cancer patients. In many of these horror stories, poor software design, poor human-machine interfaces, and lack of proper training are root causes of the problems. The deaths of Scott Jerome-Parks and Alexandra Jn-Charles, both patients of New York City hospitals, are prime examples of radiation treatments going awry. Jerome-Parks worked in southern Manhattan near the site of the World Trade Center attacks, and suspected that the tongue cancer he developed later was related to toxic dust that he came in contact with after the attacks. His prognosis was uncertain at first, but he had some reason to be optimistic, given the quality of the treatment provided by state-of-the-art linear accelerators at St. Vincent’s Hospital, which he selected for his treatment. But after receiving erroneous dosages of radiation several times, his condition drastically worsened. For the most part, state-of-the-art linear accelerators do in fact provide effective and safe care for cancer patients, and Americans safely receive an increasing amount of medical radiation each year. Radiation helps to diagnose and treat all sorts of cancers, saving many patients’ lives in the process, and is administered safely to over half of all cancer patients. Whereas older machines were only capable of imaging a tumor in two dimensions and projecting straight beams of radiation, newer linear accelerators are capable of modeling cancerous tumors in three dimensions and shaping beams of radiation to conform to those shapes. One of the most common issues with radiation therapy is finding ways to destroy cancerous cells while preserving healthy cells. Using this beamshaping technique, radiation doesn’t pass through as much healthy tissue to reach the cancerous areas. Hospitals advertised their new accelerators as being able to treat previously untreatable cancers because of the precision of the beam-shaping method. Using older machinery, cancers that were too close to important bodily structures were considered too dangerous to treat with radiation due to the imprecision of the equipment. How, then, are radiation-related accidents increasing in frequency, given the advances in linear acceleration technology? In the cases of Jerome-Parks and Jn-Charles, a combination of machine malfunctions and user error led to these frightening mistakes. Jerome-Parks’s brain stem and neck were exposed to excessive dosages of radiation on three separate occasions because of a computer error. The linear accelerator used to treat Jerome-Parks is known as a multi-leaf collimator, a newer, more powerful model that uses over a hundred metal “leaves” to adjust the shape and strength of the beam. The St. Vincent’s hospital collimator was made by Varian Medical Systems, a leading supplier of radiation equipment. Dr. Anthony M. Berson, St. Vincent’s chief radiation oncologist, reworked Mr. Jerome Parks’s radiation treatment plan to give more protection to his teeth. Nina Kalach, the medical physicist in charge of implementing Jerome-Parks’s radiation treatment plan, used Varian software to revise the plan. State records show that as Ms. Kalach was trying to save her work, the computer began seizing up, displaying an error message. The error message asked if Ms. Kalach wanted to save her changes before the program aborted and she responded that she did. Dr. Berson approved the plan. Six minutes after another computer crash, the first of several radioactive beams was turned on, followed by several additional rounds of radiation the next few days. After the third treatment, Ms. Kalach ran a test to verify that the treatment plan was carried out as prescribed, and found that the multileaf collimator, which was supposed to focus the beam precisely on Mr. Jerome Parks’s tumor, was wide open. The patient’s entire neck had been exposed and Mr. Jerome-Parks had seven times the prescribed dose of radiation. As a result of the radiation overdose, Mr. Jerome-Parks’s experienced deafness a

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Kapan terapi radiasi membunuh studi kasusWhen new expensive medical therapies come along, promising to cure people of illness, one would think that the manufacturers, doctors, and technicians, along with the hospitals and state oversight agencies, would take extreme caution in their application and use. Often this is not the case. Contemporary radiation therapy offers a good example of society failing to anticipate and control the negative impacts of a technology powerful enough to kill people. For individuals and their families suffering through a battle with cancer, technical advancements in radiation treatment represent hope and a chance for a healthy, cancer-free life. But when these highly complex machines used to treat cancers go awry or when medical technicians and doctors fail to follow proper safety procedures, it results in suffering worse than the ailments radiation aims to cure. A litany of horror stories underscores the consequences when hospitals fail to provide safe radiation treatment to cancer patients. In many of these horror stories, poor software design, poor human-machine interfaces, and lack of proper training are root causes of the problems. The deaths of Scott Jerome-Parks and Alexandra Jn-Charles, both patients of New York City hospitals, are prime examples of radiation treatments going awry. Jerome-Parks worked in southern Manhattan near the site of the World Trade Center attacks, and suspected that the tongue cancer he developed later was related to toxic dust that he came in contact with after the attacks. His prognosis was uncertain at first, but he had some reason to be optimistic, given the quality of the treatment provided by state-of-the-art linear accelerators at St. Vincent’s Hospital, which he selected for his treatment. But after receiving erroneous dosages of radiation several times, his condition drastically worsened. For the most part, state-of-the-art linear accelerators do in fact provide effective and safe care for cancer patients, and Americans safely receive an increasing amount of medical radiation each year. Radiation helps to diagnose and treat all sorts of cancers, saving many patients’ lives in the process, and is administered safely to over half of all cancer patients. Whereas older machines were only capable of imaging a tumor in two dimensions and projecting straight beams of radiation, newer linear accelerators are capable of modeling cancerous tumors in three dimensions and shaping beams of radiation to conform to those shapes. One of the most common issues with radiation therapy is finding ways to destroy cancerous cells while preserving healthy cells. Using this beamshaping technique, radiation doesn’t pass through as much healthy tissue to reach the cancerous areas. Hospitals advertised their new accelerators as being able to treat previously untreatable cancers because of the precision of the beam-shaping method. Using older machinery, cancers that were too close to important bodily structures were considered too dangerous to treat with radiation due to the imprecision of the equipment. How, then, are radiation-related accidents increasing in frequency, given the advances in linear acceleration technology? In the cases of Jerome-Parks and Jn-Charles, a combination of machine malfunctions and user error led to these frightening mistakes. Jerome-Parks’s brain stem and neck were exposed to excessive dosages of radiation on three separate occasions because of a computer error. The linear accelerator used to treat Jerome-Parks is known as a multi-leaf collimator, a newer, more powerful model that uses over a hundred metal “leaves” to adjust the shape and strength of the beam. The St. Vincent’s hospital collimator was made by Varian Medical Systems, a leading supplier of radiation equipment. Dr. Anthony M. Berson, St. Vincent’s chief radiation oncologist, reworked Mr. Jerome Parks’s radiation treatment plan to give more protection to his teeth. Nina Kalach, the medical physicist in charge of implementing Jerome-Parks’s radiation treatment plan, used Varian software to revise the plan. State records show that as Ms. Kalach was trying to save her work, the computer began seizing up, displaying an error message. The error message asked if Ms. Kalach wanted to save her changes before the program aborted and she responded that she did. Dr. Berson approved the plan. Six minutes after another computer crash, the first of several radioactive beams was turned on, followed by several additional rounds of radiation the next few days. After the third treatment, Ms. Kalach ran a test to verify that the treatment plan was carried out as prescribed, and found that the multileaf collimator, which was supposed to focus the beam precisely on Mr. Jerome Parks’s tumor, was wide open. The patient’s entire neck had been exposed and Mr. Jerome-Parks had seven times the prescribed dose of radiation. As a result of the radiation overdose, Mr. Jerome-Parks’s experienced deafness a