Radiation Overdose and Nobody Looking

I am flummoxed.

How did 207 people, over an 18 month period, receive, at Cedar-Sinai hospital, a CT brain perfusion scan, at 8 times the correct dose of radiation?

Apparently, there is a readout, each time a scan is done, that indicates the level of radiation. Maybe, I thought, the information panel for the CT scan is really complicated, and maybe the information on the dose is hidden in a corner. That would be stupid, but still possible. But no; one person said, “It’s right there in front of your face.”

So how did the technicians miss it; and how did the doctors who read the scans miss the level of radiation dosage printed on each scan.

Expert opinion proves not very helpful. One such expert says, “It’s pretty mystifying to me.”

Well, you bet, it’s mystifying and even a bit terrifying.

I could understand once or twice perhaps….maybe…but this happened 207 times over an 18 month period.

During this time, patients called to tell their doctors that, after the scan, their hair fell out.

Finally, somebody put two and two together–the scan and the hair falling out–and the flaw in the machine was finally noted and fixed.

One person tried to find a silver lining to the whole thing, saying that the people who received this scan were mostly old and in bad shape anyway and would probably die of something else before they died of a brain tumor produced by the excess radiation, since these are generally slow growing. I find this odd and slightly offensive reasoning. I would, were I one of the persons scanned, take small comfort in knowing I would die of something else before I died of brain tumor resulting from gross incompetence.


Is this another case of dependence on the machine? I don’t know and don’t want to be flip. I think this episode is worthy of some serious sociological research, and some soul searching on the part of the medical profession.