[ RadSafe ] " -overradiated by CT scans"

Wed Feb 10 15:54:31 CST 2010

Once again, the ol' fashioned checklists are the key.  Pilots use them over and over again, even after many years of experience.  Things can get real exciting if they happen to forget something simple that most of us may take for granted. 

Jeffrey R. Johanning
Health Physicist V / RSO
Science Applications International Corp.
858-826-9725

-----Original Message-----
From: radsafe-bounces at radlab.nl [mailto:radsafe-bounces at radlab.nl] On Behalf Of HOWARD.LONG at comcast.net
Sent: Wednesday, February 10, 2010 11:28
To: Doug Aitken
Cc: Mike 'Brennan (DOH)'; radsafe at radlab.nl
Subject: Re: [ RadSafe ] " -overradiated by CT scans"

Doug and Mike are right on. 

'"Check List" is part of the name of a new book I saw reported on TV yesterday, as the most important way to reduce medical errors like this. 

A recent emergency illustrates. HPs must have similar routines. 

Sunday, I was called to stop a severe nosebleed, 

(after failure of emergency room "standard care", 

            dictated by  bills just passed by Congress). 

My check list was subconscious. I hadn't done this for years. 

         I just asked myself, "What might this patient need?" 

I, Lasix out (to lower high blood pressure, fast), 

2, Nasal speculum and head lamp ready 

3, Loaded syringe of lidocaine-epinephrine (to slow bleeding and anesthetize) 

4, "Coagulation" setting (on cautery machine). 

When the patient arrived, spitting and vomiting blood, I had her blow out the clots and daughter constantly  press on usual bleeding place -  lower septum . 

BP was very high, so I shot her with the ready Lasix, squirted the ready lido-epi into both nostrils, and waited 10 min. always with pressure on the septum. 

With ready speculum and light, I applied  ready cautery to still spurting bleeder and reapplied pressure 10 min. It worked. 

Check lists are essential to safe care - medical or health physics . 

Indeed, m anagement can provide info. , but operators must feel responsible for the people they protect. 

Howard Long 

----- Original Message ----- 
From: "Doug Aitken" <jdaitken at sugar-land.oilfield.slb.com> 
To: "Mike 'Brennan (DOH)'" <Mike.Brennan at DOH.WA.GOV>, radsafe at radlab.nl 
Sent: Wednesday, February 10, 2010 9:32:52 AM GMT -08:00 US/Canada Pacific 
Subject: RE: [ RadSafe ] " -overradiated by CT scans" 

What he said! 
Government oversight has its place, but the primary responsibility is with the users: 
Training and management control is where the effort needs to be made. 

My $0.02! 

Regards 
Doug 
___________________________________ 
Doug Aitken 
QHSE Advisor 
D&M Operations Support 
jdaitken at sugar-land.oilfield.slb.com 
Mail: c/o Therese Wigzell, 
Schlumberger, 
Drilling & Measurements HQ, 
300 Schlumberger Drive, MD15, 
Sugar Land, Texas 77478 

-----Original Message----- 
From: radsafe-bounces at radlab.nl [mailto:radsafe-bounces at radlab.nl] On Behalf Of Brennan, Mike (DOH) 
Sent: Wednesday, February 10, 2010 11:08 AM 
To: radsafe at radlab.nl 
Subject: RE: [ RadSafe ] " -overradiated by CT scans" 

Hi, Howard.   

You are, of course, completely correct that there are many, many, things where an 8x over recommended dose/amount/time could have deadly effects.  I also agree without reservation that radiophobia is a counterproductive attitude that has almost certainly cost more lives than it has saved, especially when it has been expanded to industrial and environmental policy.   

That being said, there is no excuse, none whatsoever, for patients to get the wrong exposure/medicine/treatment.  The fixes to prevent these are administrative and technical, with all the tech being well established and many easier to use than the current systems.  Much can be done with check lists, where people have to read and check each step (and no, it doesn't slow down the process, not when you factor in even the rare time that some step gets missed, and corrective action needs to be taken).  Another fix would be to include an RF tag in the patient ID bracelet, and use it to make sure that the right prescriptions, treatments, etc, go to the right patients.   

I consider this to be more of a medical industry failure than a radiation industry failure. 

-----Original Message----- 
From: radsafe-bounces at radlab.nl [mailto:radsafe-bounces at radlab.nl] On Behalf Of HOWARD.LONG at comcast.net 
Sent: Wednesday, February 10, 2010 8:35 AM 
To: Kyle Harness 
Cc: radsafe at radlab.nl 
Subject: [ RadSafe ] " -overradiated by CT scans" 

" NY Times -  more than 300 patients in four hospitals were overradiated by powerful CT scans used to detect strokes. The overdoses were first discovered last year at Cedars-Sinai Medical Center in Los Angeles, where patients received up to eight times as much radiation as intended. 

"The errors occurred over 18 months and were detected only after patients lost their hair." 

What would happen with 8x sunbath or UV tanning salon exposure or dose of coumadin (rat poison taken by millions to save thousands of lives from clots)? Smell burning skin or write obituaties, instead of hair loss! 

This radiophobia is pretext to expand larceny of government, which now increases salaries while private pay is cut! I believe those hospitals will suffer reputation harm far more safety-inducing than oppressive "oversight". 

How about the millions of people scared out of CTs in cancer-inhibiting doses that would detect unsuspected kidney cancer, dubious brain clots, etc. (10 to100 mSv)? 

Howard Long, family doctor, Pleasanton CA 
----- Original Message ----- 
From: "Kyle Harness" <kharness at ohmartvega.com> 
To: radsafe at radlab.nl 
Sent: Wednesday, February 10, 2010 6:55:39 AM GMT -08:00 US/Canada Pacific 
Subject: [ RadSafe ] (no subject) 

http://www.nytimes.com/2010/02/10/health/policy/10radiation.html 

Some food for thought for my fellow Radsafers.  Looks like the FDA is finally addressing all of the over-exposures that occur daily in this country. 

Kyle Harness 

Radiation Safety Officer 

Ohmart/VEGA Corp. 

4241 Allendorf Drive 

Cincinnati, Ohio 45209 USA 

[tel]  513.272.0524 ext. 211 

[cell]  513.432.4504 

[fax]  513.272.4390 

www <http://www.ohmartvega.com/> .ohmartvega.com 

KHarness at ohmartvega.com 

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