A fix for dan­ger­ous CT scans

Los Angeles Times - - OP-ED - Michael Heuser Michael Heuser has worked in the film busi­ness as a dis­trib­u­tor of films in­ter­na­tion­ally and as an ex­ec­u­tive pro­ducer for 25 years.

On July 4, 2009, my life changed for­ever. While the rest of the nation cel­e­brated In­de­pen­dence Day, my world tilted on its axis. The right side of my body be­gan an ac­cel­er­ated jour­ney to­ward paral­y­sis, and my words wouldn’t come out.

I was rushed to Cedars-Si­nai Med­i­cal Cen­ter, where a CT brain per­fu­sion scan re­vealed I’d had a stroke.

I vividly re­call en­ter­ing the CT ma­chine that first day, slid­ing on a nar­row ta­ble un­der the big halo of mod­ern med­i­cal technology. Its so­phis­ti­cated elec­tron­ics whirled, a tsunami of ra­di­a­tion pen­e­trat­ing my head to pro­duce im­ages of my brain. Over the course of a twoweek hos­pi­tal­iza­tion, Cedars physi­cians had me un­dergo two more CT brain per­fu­sion scans as well as a num­ber of ad­di­tional CT scans.

But as it turned out, the ma­chine that was meant to di­ag­nose me and guide my treat­ment was also ex­pos­ing me to ex­ces­sive lev­els of ra­di­a­tion ca­pa­ble of caus­ing lethal harm.

Ap­par­ently, the scan­ner had been set im­prop­erly, so each CT brain per­fu­sion scan bom­barded my head with at least eight times the al­low­able dose of ra­di­a­tion. Within days of my fi­nal scan at Cedars — af­ter I had been trans­ferred to a rehabilitation cen­ter to fo­cus on my re­cov­ery — my hair be­gan fall­ing out in a bizarre, donut­shaped band from tem­ple to tem­ple. It matched the CT’s tar­get zone.

Shocked and fright­ened, I called my doc­tors, but no one could ex­plain what was hap­pen­ing to me.

This be­gan a trou­bling and emo­tion­ally tax­ing quest for the truth. As the first pa­tient to re­port side ef­fects from this mas­sive ra­di­a­tion over­dose, the Cal­i­for­nia Depart­ment of Health re­ferred to me as “Pa­tient 1.” My com­plaints helped bring a ma­jor hos­pi­tal and med­i­cal de­vice prob­lem to light and launch sev­eral lo­cal, state and fed­eral in­ves­ti­ga­tions.

I soon learned I was not alone. The var­i­ous in­ves­ti­ga­tions de­ter­mined that more than 330 pa­tients at Cedars-Si­nai and sev­eral other Cal­i­for­nia hos­pi­tals had also suf­fered ra­di­a­tion over­doses from CT brain per­fu­sion scans.

Since then I have pro­vided tes­ti­mony to the U.S. Congress, and I have made re­peated trips to the state Capi­tol to speak on be­half of SB 1237, a bill by state Sen. Alex Padilla (D-Pa­coima) that could set a na­tional prece­dent and act as an im­por­tant de­ter­rent against fu­ture CT ra­di­a­tion mishaps.

Cur­rently, there are no safety pro­to­cols in place to mea­sure and record the ra­di­a­tion doses be­ing ad­min­is­tered to pa­tients who re­ceive CT scans. SB 1237 re­quires that doses be recorded in a pa­tient’s med­i­cal records, so that mis­takes will be more eas­ily de­tected and ad­dressed. The bill also re­quires that hos­pi­tals in­form pa­tients and their doc­tors when they are sub­ject to ra­di­a­tion over­doses.

I was kept in the dark for weeks about the true na­ture of my ra­di­a­tion over­dos­ing, and it took months to get my full med­i­cal records. I learned more about what hap­pened to me by read­ing the Los An­ge­les Times than from Cedars — hardly the level of care and com­mu­ni­ca­tion one ex­pects from a world-class hos­pi­tal.

Con­ser­va­tive es­ti­mates are that I suf­fered the equiv­a­lent of more than 50,000 chest X-rays to my brain. I shud­der to think what that means for my long-term health, and I live with the con­stant fear that with ev­ery headache, ev­ery in­stance of blurry vi­sion or any time I stum­ble and lose my bal­ance, I have de­vel­oped a brain tu­mor or some other form of can­cer caused by mas­sive ra­di­a­tion ex­po­sure.

No one should have to go through this. My hope is that Gov. Arnold Sch­warzeneg­ger, who has not taken a po­si­tion on SB 1237, will do the right thing and sign it into law. Though it is too late to ben­e­fit me and the other pa­tients who were reck­lessly over­dosed, the gover­nor can make pro­tect­ing peo­ple from care­less med­i­cal ra­di­a­tion over­doses part of his legacy.

Even if Sch­warzeneg­ger does take ac­tion, there is still more that should be done. CT scan­ners are man­u­fac­tured by rec­og­niz­able multi­na­tional cor­po­ra­tions, yet they lack safety pro­to­cols and sys­tems to shut them down if the ra­di­a­tion doses get too high. It is fright­en­ing and un­con­scionable to me that my car, which beeps if a bumper gets too close to the curb or an­other car, has a more so­phis­ti­cated warn­ing sys­tem than a ma­chine ca­pa­ble of pro­duc­ing po­ten­tially lethal lev­els of ra­di­a­tion.

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