In testimony before an administrative law judge, the boy’s father, who during the scans was standing at the foot of the CT table to calm his son, recalled his growing concern as the scanning stretched on. “I said, ‘Stop this!’ ” Padre Roth recalled, noting that Knickerbocker finally stopped the scan only after he became angry.

Within a few hours, the child developed a bright red ring around his head from the massive overdose of radiation. Photographs of the left side of the boy’s face show a clear line extending from the infraorbital ridge backward through the ear and nape of the neck; a similar line extends from the infraorbital ridge through the ear on the right side.

In off-the-record comments, some state officials called it the worst case of radiation overdose of a child in the U.S.

How could something like this happen? Apparently the tech involved pressed the scan button 151 times, averaging 25 seconds between each press. Afterward, she could give no satisfactory explanation for the event. She gave various excuses including motion of the patient, mechanical failure and distraction by the parents. None of these are any excuse for intentionally irradiating a patient that many times. Her supervisor could only describe it as a “rogue act of insanity”.

The consequences were dire.

A report by the hospital’s medical physicist calculated that the boy’s absorbed radiation dose was 2.8 Gy (2,800 mSv) and possibly as high as 11 Gy (11,000 mSv). The dose the boy received compares to a range of 1.5-4.0 mSv for a normal pediatric CT study of the entire spine, according to pediatric imaging experts.

Using relevant material from the article “Estimated Risks of Radiation-Induced Fatal Cancer from Pediatric CT,” published in the American Journal of Roentgenology (February 2001, Vol. 176:2, pp. 289-296), a report by the hospital’s medical physicist concluded the child had a lifetime increased risk of a fatal cancer of 39%.

Hopefully the hearing will shed more light into what exactly went wrong. There should be a written procedure in place on how to respond to instances where the CT scanner behaves incorrectly. Often, however, scans like this are seen to be too routine to worry with a formal procedure. Technicians are expected to be able to adapt to unexpected events. If the technician does not have the necessary understanding of the system, though, the consequences can be catastrophic. In his book The Human Factor, Kim Vicente describes how a lack of understanding caused the Chernobyl accident.

The problem was that the plant designers hadn’t paid enough attention to the human factor – the operators were trained but the complexity of the reactor and the control panels nevertheless outstripped their ability to grasp what they were seeing. [The reactor operator] didn’t completely understand the effects his actions were going to have until it was too late – with devastating consequences.

As a friend of mine once told me, “the secret to life is being smarter than the machines you work with.”

Undoubtedly, the technician in this case will have her license revoked, and rightfully so. The fact that a scan that should have taken a few minutes instead took more than an hour was a warning sign that any reasonable person should have heeded. However, that won’t make the problem go away. If the CT console software is too complex for a trained technician to understand, then the software needs to be simplified or there need to be hard and fast guidelines as to when someone with a greater understanding needs to be called in.

What about the people who are cutting granite into counter shaped pieces, though? That is a different question altogether. One of the hazards of cutting any kind of material is dust inhalation. If the material is radioactive, it makes sense that the hazard could be significantly multiplied. The radon given off from a piece of granite might have a low enough concentration that not much of it is inhaled. However if the granite is in your lung already, the concentration would obviously be higher. Now one researcher claims that the risk from cutting granite is, in fact, significantly higher.

Craftsmen who cut granite for kitchen countertops can be at risk of radiation exposure thousands of times above the federal safety limit, according to new research.

The danger results from inhaling the airborne granite dust, which sometimes contains significant quantities of uranium and other dangerous isotopes, scientists say.

“What we found scared the daylights out of us,” said co-author Linda Kincaid, an industrial hygienist in Saratoga, Calif.

The study, “Implications of Granite Counter Top Construction and Uses,” raises concerns that the stone dust could be exposing America’s estimated 24,000 granite fabricators to elevated cancer risks, according to Kincaid. People living in homes with granite countertops face no health concerns from the dust, which is generated when the stone is cut.

Obviously, this research needs to be replicated and confirmed. It hasn’t been peer reviewed and published, only presented as a poster at a meeting of the Health Physics Society. It seems at least somewhat plausible. I would guess, though, that the hazard of breathing in the dust itself is higher than any risk from the radiation, and workshops already take measures to keep the amount of dust in the air down. The linked article states that most fabricators use water cutting techniques that minimize the amount of dust generated. Whether the radiation hazard is real or not, it looks like a good idea for all fabricators to adopt those techniques.

The Sarasota Herald Tribune is reporting that testing by three agencies, the Florida Department of Health, the U.S. Environmental Protection Agency and the Consumer Product Safety Commission, on drywall manufactured in China has found no traces of radioactivity. Why was it being tested in the first place? Apparently, there have been quite a few problems with Chinese drywall: foul smells, metal corrosion and even illnesses reported in people living in houses with it. A radioactive material called phosphogypsum was considered as a possible contaminant in the drywall, but the testing ruled this out.

Phosphogypsum is a byproduct left over from the process that creates fertilizer from phosphate ore. Phosphate ore contains trace amounts of uranium, and therefore its daughter product radium. When phosphate ore is chemically treated with sulfuric acid to create fertilizer, the radium is separated out with the phosphogypsum. As a Health Physics Society “Ask the Expert” answer makes clear, phosphate ore produced by marine deposits has a higher concentration of uranium, and therefore the phosphogypsum produced is too radioactive to use in construction materials. Since it cannot be used, the fertilizer industry has resorted to piling it into stacks. The wikipedia article states that there are 1 billion tons of radioactive phosphogypsum in stacks in Florida and that 30 million more tons are produced each year.

Chinese industries are not prohibited from using phosphogypsum, though. Was it reasonable to suspect that imported drywall laced with phosphogypsum was the culprit? An article in July from the Los Angeles Times found some evidence that phosphogypsum use was widespread in China. The radioactive La-Z-Boy story shows that radioactively contaminated materials can be imported into the US without discovery. However, in that case, the contamination was fairly low level. In order to corrode metal and cause acute illness in humans, a much higher level of radioactivity would be required.

In the United States, phosphogypsum cannot be used if its activity is greater than 370 becquerels/kg. Exposure to phosphogypsum with this activity is estimated to give a dose of 1 mSv/year. However, acute symptoms of radiation poisoning require a dose of around 500 mSv. Considering, that phosphogypsum has a maximum activity of around 1,300 becquerels/kg, even pure phosphogypsum would not come close to that. Of course, cancer can be induced at a much lower dose and therefore the drywall could still pose a significant health hazard. Therefore, it is reasonable to check the safety of the drywall even if the specific complaints listed above are unlikely to be caused by radiation.

In any event, the radioactivity in the drywall was found to be at background levels, and the more likely culprit might be sulfur compounds (which would explain the rotten egg smell described by some residents). But could other household objects be slowly killing you? Stay tuned for a special report that could save your life! (Well, not really. I just always wanted to say that.)

Despite my fears about this turning into a referendum on national health care, there were few comments in that direction. Sen. Specter asked a question relating to the need for a standards enforcement scheme in relation to health care reform. Rep. Fattah defended Dr. Kao and the Philadelphia VA in what seemed like an attempt to defend against the argument that this failing was indicative of government run health care. All in all, though, the direction of the hearing was productive. I still have my fears about the upcoming hearing in Washington, though.

At least one comment seemed to indicate that the Philadelphia VA was accredited by the ACR while these errors were occurring. A visit to the ACR accredited facilities web site shows the hospital having their accreditation under review. If it is true that the hospital was accredited, that basically blows my entire argument that ACR accreditation is the answer out of the water. It seems odd that the ACR would miss something as easy to find as a failure to perform post-implant dosimetry, unless they visited during the period after the CT transfer problems were worked out.

There were two misconceptions that I hope will be worked out before the next hearing. The first is the definition of a medical event. A medical event is very clearly defined, but there were a few questions asking if one seed placed in an organ other than the prostate is a medical event. What constitutes a medical event is the amount of dose given to the prostate and other organs. A single seed in the rectum will probably not give enough dose to rise to the level of a medical event. This misconception allowed Dr. Kao to make the argument that medical events are commonplace, but go unreported.

The second misconception is, as I wrote above, the idea that because prostate brachytherapy is “evolving”, that placing 40 seeds in the wrong organ is any kind of a common or expected event. If it is true that Dr. Kao refused to use to fluoroscopy during his procedures, that is a serious break with the standard of care in these procedures. The failure to perform post implant dosimetry is also contrary to standard practice. A report of the American Association of Medical Physicists (Task Group 64) states, “A quantitative dose analysis must be carried out for each patient postimplantation” (emphasis theirs). This is not a program that is being singled out unfairly. Their clinical practice was outside the norm.

Finally, the testimony of Rev. Ricardo C. Flippin was incredibly powerful and a reminder that is not some bureaucratic turf war. There are real lives at stake here.

It’s easy to see why this series of accidents has attracted so much more notice than other recent mishaps, such as the overdoses at Tampa’s Moffitt Cancer Center. Right now, the US is in the middle of a debate on the future of our health care system. This is too “sexy”, to borrow Lisa Raitt’s term, an issue to pass up both for advocates and opponents of more government involvement in health care. Opponents are already pointing to the mistakes as a warning against “government health care.” Advocates are blaming the outsourcing of the procedures to private physicians.

Both viewpoints are incorrect. These failures were not a product of too much or too little government control over medicine. They can (and do) happen in for profit hospitals, non-profit hospitals, and public hospitals throughout the world. The problem was a failure to mandate department wide peer review by a team of radiation therapy experts. It’s sad really, because I hoped that at least something good could be salvaged from these awful events. I hoped that finally our health care system would see the need to enforce minimum standards for accreditation of radiation oncology programs. I hope I’m wrong, but right now I’m afraid that all we will get is cheap political theater.

It is important that the seeds be placed in the correct position. Critical
structures surrounding the prostate include the rectum, the bladder and the
urethra. The seeds are typically placed around the periphery of the
prostate, avoiding the urethra and keeping them safely away from the rectum
and bladder. Typically, two imaging modalities are used to verify the
placement of the seeds. While the needles are being inserted, their position
is monitored by an ultrasound probe. An x-ray technique known as fluoroscopy
is used to watch the seed insertion in real time to make sure that the seeds
do not migrate to a different part of the body.

In these procedures, the number of seeds used depends on the volume of the
prostate. About a week before the implant date, the patient undergoes a
procedure called a volume study in which the volume of the prostate is
measured using ultrasound. The physicist and radiation oncologist then
determine the number of seeds needed based on clinical guidelines.

Usually, the number of seeds ordered is increased by about 20% to account
for lost seeds or changes in the prostate volume. The number of seeds
depends on the technique used, but usually is in the neighborhood of sixty
to eighty. The seeds are shipped to the hospital where the medical physicist
measures their radioactivity to ensure that they will deliver the correct
dose of radiation.

In at least two of the procedures performed by Dr. Gary D. Kao at the
Philadelphia V.A. hospital, more than half of the seeds used ended up in the
bladder instead of the prostate. Rarely, during these procedures, one or two seeds
will migrate to the bladder. This is typically no big deal; the urologist
uses an instrument called a cystoscope to look through the urethra into the
bladder and retrieve any seeds he finds. I assisted on a number of these
procedures when I was going through my clinical training, and I remember at
least once when a seed had to be retrieved via cystoscopy. In one of the
procedures at the V.A., however, approximately 40 seeds ended up in the
bladder. The seeds were all removed, but could not be reused. This exceeded
the number of extra seeds available and therefore the planned distribution
of seeds could not be delivered.

The incident was reported to the V.A.’s Radiation Safety Committee, who
reported it to the Nuclear Regulatory Commission (NRC). The V.A. argued that
Dr. Kao had adapted his treatment plan in the operating room to fit the
number of seeds available, and that there was therefore no error. The NRC
agreed in this case, and also in a second case of Dr. Kao’s in which the
same error occurred.

Other mistakes also occurred. One patient, who was interviewed for the
article, had a painful radiation burn in his anal canal that required
surgery to correct. The article states,

All told, 57 of the implants delivered too little radiation to the prostate,
either because the seeds missed the prostate or were not distributed
properly inside the prostate. Thirty-five other cases involved overdoses to
other parts of the body. An unspecified number of patients were both
underdosed in the prostate and overdosed elsewhere.

The NRC also found that from December 2006 to November 2007, 16 patients
received seed implants in Philadelphia even though computer interface
problems prevented medical personnel from determining whether those
treatments had been successful. The V.A.’s radiation officials knew of the
problem but took no action, the nuclear commission charges.

How could so many implants be performed incorrectly? Another article in the Philadelphia Inquirer, quotes an NRC staffer named Darrel Wiedeman saying “He refused to use fluoroscopy; said he didn’t need it.” Without being able to see where the seeds were placed in real time, it’s no wonder that so many ended up in the wrong position.

I first heard about this case in October of last year, when the V.A. shut
down the brachytherapy programs in Philadelphia and two other hospitals.
This article was posted on the medical physics listserv. Details, as usual
for cases that might lead to litigation, were sketchy; although many
speculated as to what the cause could be. With this new information, it
seems obvious that the problem was that the team was inexperienced and was
not subject to sufficient oversight. The article blames the NRC and the V.A.
radiation safety committee for not providing peer review. They also blame
the Joint Commission, which is responsible for accrediting hospitals. I
believe that misses the mark.

It is true that peer review is one of the strongest tools we can employ to
ensure the quality of our patient’s treatments. However, the NRC and the
Joint Commission are not equipped to provide that peer review. The mandate
of the NRC is to enforce regulations regarding the handling of radioactive
material. Steven A. Reynolds, director of nuclear materials safety for the
NRC is quoted in the article as saying “The N.R.C. isn’t in the business of
practicing medicine”. They do not have the authority to second guess the
decision of a doctor. The Joint Commission does a great job in enforcing
standards of patient care in many departments of a hospital. However, in all
of the Joint Commission inspections I have been through, I have never spoken
to a medical physicist or a radiation oncologist. The inspectors are often
nurses or doctors in a different specialty, but they do not have the
experience with radiation therapy necessary to know what a medical physicist
or radiation oncologist even does, much less if they are doing it correctly.

I agree that peer review is necessary, but the article does not mention the
body that has done the most work in developing an accreditation process to
ensure quality treatments in radiation oncology and radiology. The American College of Radiology has teams of radiation oncologists and medical
physicists who make site visits to a clinic and conduct a review of every
aspect of its medical and technical operation. These people are experts in
their field and would have quickly discovered errors such as the ones that
occurred in the Philadelphia V.A. Currently, this accreditation process is
costly and has no benefit besides public relations. On the radiology side,
however, Medicare has required that freestanding (not hospital) clinics with
CT or MRI must be accredited by the ACR to receive payment for imaging
services rendered. Other insurers are expected to follow suit, making ACR
accreditation a de facto requirement for a clinic to operate.

In my opinion, errors like this will continue to occur until radiation
therapy clinics are subject to the proper oversight. The ACR accreditation
process has been shown to work for diagnostic imaging clinics, and can work
for radiation therapy clinics. There is a push within the radiation therapy
community to mandate certain clinical standards (e.g., ACR accreditation and
the CARE bill, which has languished in Congress since 1999) Hopefully, with
the new focus on cost effectiveness in health care, ensuring the minimum
quality of treatments will become a priority.

As if there weren’t enough side effects from radiation to worry about, a new one has been discovered by the Denver police: tire slashing.

A man who admits he slashed the tires on at least 46 vehicles in Boulder blames his mom, speeding police cars, radiation from Rocky Flats and being forced to wear braces on his teeth.

Boulder police arrested Alexander Kabelis, 31, Thursday night, after he slashed a tire on a police Suburban parked outside a police substation on University Hill.

…

Kabelis also told investigators that his desire to slash tires may stem from wearing braces in the late 1990s “or the radiation poisoning he suffered as a result of his proximity to the Rocky Flats nuclear production facility .

I haven’t noticed a rash of tire slashings outside of our clinic, but we did have someone crash into our building with a car. We thought it was just due to driver inattention, but now I wonder.

The radiation safety community is still coming to terms with the results of that study. The general consensus that is forming is that while the risk from diagnostic scans like CT is low, there is still some toxicity associated with it. Therefore, scans should only be ordered when medically necessary. There is an ongoing effort to educate physicians and the public to the risks of medical scans, which are often overprescribed as a result of defensive medicine. Because children can be most sensitive to the effects of radiation, a campaign called Image Gently has been formed. That being said, there is no doubt that CT imaging is of immense value in the diagnosis of patient disease and trauma, and the risks for most scans are well outweighed by the benefits, which can be literally life saving.

Hopefully, patients can use the information from X-Ray Risks to understand that the risk from a medically indicated scan is low compared to the benefits, and physicians can use it to determine whether the risk to the patient from a scan is justified.