Radiation Offers New Cures, and Ways to Do Harm
By WALT BOGDANICH
I HAVE INCLUDED THE LINK FOR THE WHOLE INVESTIGATION WHICH IS LENGTHY BUT THESE CLIPS SHOULD GIVE YOU THE GUTS OF WHAT WAS FOUND....
As Scott Jerome-Parks 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
A 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.
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.
Yet 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.
......The Times has pieced together this account of what happened to Mr. Jerome-Parks largely from interviews with doctors who had been consulted on the case, six friends who cared for and comforted him, contemporaneous e-mail messages and Internet postings, and previously sealed government records. His wife declined to be interviewed about the case, as did Ms. Kalach, the medical physicist, and representatives of Aptium, Varian and St. Vincent’s.
In a statement, the hospital called the case an “unfortunate event” that “occurred as a result of a unique and unanticipated combination of issues.”
On the afternoon of March 16, several hours after Mr. Jerome-Parks received his third treatment under the modified plan, Ms. Kalach decided to see if he
was being radiated correctly.
So at 6:29 p.m., she ran a test to verify that the treatment plan was carried out as prescribed. What she saw was horrifying: the multileaf collimator, which was supposed to focus the beam precisely on his tumor, was wide open.
A little more than a half-hour later, she tried again. Same result.
Finally, at 8:15 p.m., Ms. Kalach ran a third test. It was consistent with the first two. A frightful mistake had been made: the patient’s entire neck, from the base of his skull to his larynx, had been exposed.
Early the next afternoon, as Mr. Jerome-Parks and his wife were waiting with friends for his fourth modified treatment, Dr. Berson unexpectedly appeared in the hospital room. There was something he had to tell them. For privacy, he took Mr. Jerome-Parks and his wife to a lounge on the 16th floor, where he explained that there would be no more radiation.
Mr. Jerome-Parks had been seriously overdosed, they were told, and because of the mistake, his prognosis was dire.
Stunned and distraught, Ms. Jerome-Parks left the hospital and went to their church, a few blocks away. “She didn’t know where else to go,” recalled Ms. Leonard, their friend.
nytimes.com |
