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RE: medical misadventures
At 04:48 PM 9/10/01 -0400, Yusko, James wrote:
>In the medical field, physicians are prescribing radiation either to
>diagnose or to treat a disease in a human patient. Yet there have been many
>instances where something went wrong, and patients have suffered from it. A
>misadministration where too little radiation is delivered results either in
>the disease/condition worsening, leading possibly to a patient dying, or the
>disease/condition recurs. If too much radiation is delivered, the patients
>may die, either singly or in groups. Most Nuclear Medicine overdoses have
>not been fatal, although some have (e.g., mCi delivered instead of
>microcuries). There have also been therapeutic misadministrations,
>exemplified by instances in the US (Ohio, 1975), Spain (1990), Costa Rica
>(1996) and Panama (2001) where calculational errors occurred and patients
>died. There have also been equipment malfunctions, also leading to patient
>deaths. There have also been at least two instances in the US where
>brachytherapy sources were left inside the patients, resulting in their
>eventual deaths, too. For several of the therapy misadministrations, these
>were not discovered promptly, and deaths were ascribed to the evolution of
>the patients' disease. Needless to say, this doesn't correct the
>mistakes...
>
>(this is my opinion only, and does not represent the official policy of my
>employer).
>
>J. G. Yusko, CHP
>
>
>
>
>
>PA Watershed Conference
>October 5-6, More Info. at
>http://www.pawatersheds.org/2001wsconf
>
>
>-----Original Message-----
>From: carol marcus [mailto:csmarcus@ucla.edu]
>Sent: Monday, September 10, 2001 2:21 PM
>To: Jack Earley; Vernig, Peter G.; 'Perrero, Daren';
>radsafe@list.vanderbilt.edu
>Subject: Re: medical misadventures
>
>
>At 10:26 AM 9/10/01 -0500, Jack Earley wrote:
>>>Another difference between power plant health physics and NM HP is that
>>> radioactive materials and radiation is deliberately applied to humans in
>>NM
>>> which is not the case in power plants. When there is a monumental
>>mistake,
>>> or rather series of mistakes, you get a Three Mile Island. In NM when
>>there
>>> is a big enough mistake in therapeutic use you get a death. These have
>>been
>>> relatively rare.
>>
>>Good point, here. There were no deaths from TMI.
>>
>>Jack Earley
>>Radiological Engineer
>>
>>Enercon Services, Inc.
>>6525 N. Meridian, Suite 503
>>OKC, OK 73116
>>phone: 405-722-7693
>>fax: 405-722-7694
>>jearley@enercon.com
>>
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>
>
>
>Dear Radsafers:
>
>I think that the statement that radiation deaths from nuclear medicine
>mistakes are "relatively rare" is somewhat misleading. In the entire
>history of nuclear medicine, beginning in 1936, there has been ONE probable
>radiation death due to a nuclear medicine mistake. This occurred with an
>administration of Au-198 colloid for a liver scan, in which millicuries were
>administered instead of microcuries. The patient died of liver failure, but
>had underlying liver disease as well. This occurred, I believe, in the
>1950's. On the other hand, there have been, very roughly, about 350,000,000
>administrations of radiopharmaceuticals to patients from 1936 to the
>present. That's not a bad track record.
>
>There is no regulation to prevent this even now. It was human error. We
>have had a few of these "micro-milli" mistakes, but none of the others have
>killed anyone. The only thing that minimizes human error is (1) solid
>education of those involved in the practice (physicians, technologists,
>nuclear pharmacists), and (2) having adequate resources with which to
>practice the profession carefully (something very difficult to do with
>today's low reimbursement rates and the high costs of compliance with
>meaningless paperwork that is called "radiation protection" but actually
>only provides paper for inspectors to inspect).
>
>Current NRC and Agreement State requirements for education of Authorized
>Users are pathetic, and appear to be optimized for User Fee collection, not
>the assurance of competence. Only about half the States require nuclear
>medicine technologists to be certified. Nuclear pharmacist education is
>actually rather good, fortunately. The "new" Part 35, if it ever goes
>through, will cost about a billion dollars the first year, including
>licensing requirements that now, for the first time, have achieved the
>status of de facto regulation.
>
>It would seem that the regulators themselves are doing everything possible
>to subvert the two factors that DECREASE human error. Why do you suppose
>that is?
>
>Ciao, Carol
>
>Carol S. Marcus, Ph.D., M.D.
>Prof. of Radiological Sciences and of Radiation Oncology, UCLA
><csmarcus@ucla.edu>
>
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>
Dear Mr. Yusko:
I think perhaps you are confusing two distinctly different medical
specialties, nuclear medicine and radiation oncology. Nuclear medicine is
the specialty that utilizes radiopharmaceuticals, and radiation oncology
uses machine-produced therapeutic radiation or therapeutic radiation from
sealed sources of radioactive material. Big difference. Different
residency programs, different levels of administered radiation absorbed dose
(nuclear medicine is 99.5% diagnostic), different levels of malpractice
insurance, different dosimetry considerations, etc.
Lumping them together is like lumping submarines and aircraft carriers
because they are both boats.
Ciao, Carol
Carol S. Marcus, Ph.D., M.D.
<csmarcus@ucla.edu>
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