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(The Garden Island)   Family gets $1.5 million settlement due to software glitch. Of course, it was the software that determined how much radiation an accelerator beamed into their late relative. 2.5x dose doesn't cure you 2.5x better   (thegardenisland.com) divider line 41
    More: Scary, radiation treatments, doses, cure, mobile apps, Michael Tateishi  
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3904 clicks; posted to Main » on 10 Sep 2013 at 7:18 AM (32 weeks ago)   |  Favorite    |   share:  Share on Twitter share via Email Share on Facebook   more»



41 Comments   (+0 »)
   
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2013-09-10 07:21:00 AM
Well, just a second there, professor. We, uh, we fixed the *glitch*. So he won't be receiving radiation anymore, so it'll just work itself out naturally.
 
2013-09-10 07:22:02 AM
 
2013-09-10 07:24:47 AM
I am a medical physicist and I use the eclipse software.  Things like this should never happen because you always check the plan with a third party software and run it through quality assurance.  Takes a whole 20 minutes.  I am sure Varian is at fault, but I would guarantee the cancer center has some faults too.
 
2013-09-10 07:25:01 AM
10x the settlement makes the headline 10x more correct.
 
2013-09-10 07:28:00 AM
I'm going to go out on a limb here and say that if 2.5x the dose didn't kill the cancer cells, that the normal dose probably wouldn't have done it either.
 
2013-09-10 07:31:37 AM
Again for those biatching about medical settlements have nothing to do with inflated medical care this is the reason why that's just wrong. Yeah the guy died but lung cancer only has in the neighborhood of 17% survival rate the first 5 years.

If the subbys original headline was correct I would have no problem with it but $15 million? F*ck that, the guy wasn't going to have a high quality of life anyways, sucks but its the truth.
 
2013-09-10 07:33:23 AM

SwiftFox: I'm going to go out on a limb here and say that if 2.5x the dose didn't kill the cancer cells, that the normal dose probably wouldn't have done it either.


Radiotherapy is a biatch... you want to kill the cancer cells without doing too much harm to the healthy ones.  Do lots of harm to the healthy ones, and you can't get any more treatments until you're strong enough to handle it again.

Or:  2.5x the dose doesn't make you 2.5x better.
 
2013-09-10 07:46:00 AM
Wrong, subby, it works the same way as cooking food. 300 degrees for 2 hours is the same as 600 degrees for 1 hour.

As a fat guy who wants an acetylene welder, I can confirm this.
 
2013-09-10 07:46:33 AM

Mister Peejay: Radiotherapy is a biatch... you want to kill the cancer cells without doing too much harm to the healthy ones.


My dad once aptly described cancer treatment as "Civil War medicine".  We don't know how to treat it, but we know where it is, so we're just going to hack it off and hope that takes care of the problem.

Killing cancer with radiation is like resolving a hostage situation with a hand grenade.  Yeah, odds are he's the only one standing up so if your aim is good enough that the grenade literally blows up inches from the bad guy's face then statistically you'll only kill the bad guy and everyone else in the room will live to recover.  In reality you're attempting surgical precision (pun intended) using an indiscriminate killer for lack of options that make a lick of sense.  There's absolutely no guarantee it'll get the objective done and plenty of times it'll do tons of undesired damage.

That's not to belittle those who are working on cancer cures; if anything it just goes to show how much of an asshole cancer is.  But the reality is that for all the money and hours spent, cancer still so thoroughly kicks our asses that the most prevalent forms of treatment still use 19th century "hack it off" principles.

/ Dad wasn't a doctor, but he was a pretty smart dude
 
2013-09-10 07:48:28 AM

steamingpile: Again for those biatching about medical settlements have nothing to do with inflated medical care this is the reason why that's just wrong. Yeah the guy died but lung cancer only has in the neighborhood of 17% survival rate the first 5 years.


The logic is weak with this one... For those who claim medical settlements have nothing to do with inflated medical care, the argument usually ends with Texas. Which does not have cheap medical care but does have a constitutional limit on medical settlements. A $15 million settlement is rare enough that it doesn't even register on the $2,600,000 million spent each year on medical. Math, how the fark does it work?
 
2013-09-10 07:50:39 AM
We fixed the glitch.
 
2013-09-10 07:56:09 AM
Came to ensure the glitch was fixed

Leaving satisfied...
 
2013-09-10 07:59:46 AM
OMG 2.5x is OP. Nerf 2.5x!
 
2013-09-10 08:00:18 AM
FTFH:  Family gets $1.5 million settlement due to software glitch

[iseewhatyoudidthere.jpg]
 
2013-09-10 08:00:35 AM
Buy one dose, get 1.5 dozes free. Offer ends when you die.
 
2013-09-10 08:00:57 AM

Snarcoleptic_Hoosier: 300 degrees for 2 hours is the same as 600 degrees for 1 hour.


Fowl blasphemy. Foul as well. Stay the hell out of my kitchen. You know those community pot luck picnics? Yeah -- just bring chips and dip, that'll be fine.
 
2013-09-10 08:02:24 AM

Ambitwistor: Therac-25


Worse then that.

January 23, 2008- A licensed Radiologic Technologist, Raven Knickerbocker, at Mad River Community Hospital in Arcata, California performed 151 CT scan slices on a single 3mm level on the head of a 23 month-old child over a 65-minute period. The child suffered radiation burns (skin erythema) to a small strip of his face and head. In one report, an independent investigation of the child's blood was said to have found "substantial chromosomal damage"[64] but subsequent reports reported no lasting harm.[65] The technologist was fired, and her license was permanently revoked on March 16, 2011 by the state of California, citing "gross negligence".[64] The hospital's radiology manager, Bruce Fleck, testified that Knickerbocker's conduct was "a rogue act of insanity".


I once heard an IT horror story that I think this accident is about.

So these CT scanners outputs are piped to a computer right? Something was wrong with the computer, and the images didn't pop up on the screen. So the tech kept clicking the scan button, figuring the machine hadn't done the scan. Over, and over, and over.

Well, the machine was working fine, but whatever program that was supposed to open the images got broken.

Like a user who thinks that clicking the print button 200 times will fix a  paper, jam, the tech scanned the person over and over.

I went looking for evidence of this story being true, and this is the only story I could find at all close to the anecdote.
 
2013-09-10 08:04:04 AM
Dammit, I always make some small mistake.


i1180.photobucket.com
 
2013-09-10 08:06:41 AM

Surpheon: steamingpile: Again for those biatching about medical settlements have nothing to do with inflated medical care this is the reason why that's just wrong. Yeah the guy died but lung cancer only has in the neighborhood of 17% survival rate the first 5 years.

The logic is weak with this one... For those who claim medical settlements have nothing to do with inflated medical care, the argument usually ends with Texas. Which does not have cheap medical care but does have a constitutional limit on medical settlements. A $15 million settlement is rare enough that it doesn't even register on the $2,600,000 million spent each year on medical. Math, how the fark does it work?


States with caps are rare and those that do have caps usually have medical centers located there.

If someone was killed as negligence then I can see it but that wasn't the case here at all.
 
2013-09-10 08:13:31 AM
Between having a father receiving radiation treatments for lung cancer and knowing several radiation technicians I am both frightened and unsurprised.

Snarcoleptic_Hoosier: Wrong, subby, it works the same way as cooking food. 300 degrees for 2 hours is the same as 600 degrees for 1 hour.

As a fat guy who wants an acetylene welder, I can confirm this.


You're the guy with that fried ice cube recipe right?
 
2013-09-10 08:16:03 AM
dragonchild: Mister Peejay: Radiotherapy is a biatch... you want to kill the cancer cells without doing too much harm to the healthy ones.

My dad once aptly described cancer treatment as "Civil War medicine".  We don't know how to treat it, but we know where it is, so we're just going to hack it off and hope that takes care of the problem.

*snip*

That's not to belittle those who are working on cancer cures; if anything it just goes to show how much of an asshole cancer is.  But the reality is that for all the money and hours spent, cancer still so thoroughly kicks our asses that the most prevalent forms of treatment still use 19th century "hack it off" principles.
/ Dad wasn't a doctor, but he was a pretty smart dude


The American Cancer Society, celebrating 100 years of failure to solve the disease and 100 years of successfully cashing your check.
What balls it takes to "Celebrate" 100 years of failure.
To say I was outraged to receive a mailer inviting me to attend a formal social function in "celebration" is the understatement of the year.
 
2013-09-10 08:30:21 AM

SwiftFox: I'm going to go out on a limb here and say that if 2.5x the dose didn't kill the cancer cells, that the normal dose probably wouldn't have done it either.


Subby didn't say it wouldn't kill the cells, he said it wouldn't cure you. Important distinction.
 
2013-09-10 08:43:51 AM
But it didn't turn their relative into a hulking green superhuman?
 
2013-09-10 08:46:19 AM
 This was used as a case study in my c++ class as to why it's important to control the size of your arrays. Apparently the programmer who farked this up  had flaky credentials and was unable to be located after he left the company.
 
2013-09-10 08:47:58 AM
There's been a CURE for All cancers since the mid sixties but it costs less than $100 and has MINIMAL side effects so don't expect any pharmaceutical company to use it .
 
2013-09-10 08:55:40 AM

cajunns: There's been a CURE for All cancers since the mid sixties but it costs less than $100 and has MINIMAL side effects so don't expect any pharmaceutical company to use it .


Cure? No, just makes suffering less severe.
 
2013-09-10 08:55:59 AM

cajunns: There's been a CURE for All cancers since the mid sixties but it costs less than $100 and has MINIMAL side effects so don't expect any pharmaceutical company to use it .


Can I come live with you?
 
2013-09-10 08:57:27 AM
Are those real x-rays?

GOOD question we'll check into that. Meanwhile x-ray machine to full power!
 
2013-09-10 08:57:50 AM
If you learn just two things from this article it should be:

1. You should have "Seattle-based Luvera, Barnett, Brindley, Beninger & Cunningham, a law firm with experience in medical device litigation" written on your insurance card with a Sharpie and engraved on a "medical malpractice alert bracelet"; and

2. That it's seldom the "prescription" that injures the patient, but rather someone or something's interpretation/administration of the prescription that will injure. As they said: "We found that in every other case, the prescription was absolutely correct."

Yes, of course, the prescriptions were correct: it was the administration OF the prescription that was wrong.

And anyone that thinks this is problem unique to radiation therapy has never worked in the medical/ medical device business.
There are plenty of examples of surgical/therapeutic devices that fail during use because of deficient design. And although software validation is particularly challenging, I'd say the weakest link is nearly always the operator. And as patients are living longer, their (multi) disease states and often re-configured anatomies are only becoming more difficult to treat.
 
2013-09-10 09:00:15 AM
Oh I don't know, they're disease free now, right?

/dnrtfa
 
ZAZ [TotalFark]
2013-09-10 09:02:43 AM
The Therac-25 is literally a textbook example of how not to do software and user interface design. One of MIT's software engineering course books had a chapter devoted to it.
I almost wrote "...design and testing" but lack of testing was part of the problem.
 
2013-09-10 09:07:31 AM

cajunns: There's been a CURE for All cancers since the mid sixties but it costs less than $100 and has MINIMAL side effects so don't expect any pharmaceutical company to use it .


Was it just one wierd trick discovered by a school teacher mom who lives close to my area and pharmaceutical companies don't want me to know about it?
 
2013-09-10 10:02:46 AM

MythDragon: cajunns: There's been a CURE for All cancers since the mid sixties but it costs less than $100 and has MINIMAL side effects so don't expect any pharmaceutical company to use it .

Was it just one wierd trick discovered by a school teacher mom who lives close to my area and pharmaceutical companies don't want me to know about it?


I think it was the one wierd trick discovered by a college dropout.

/no... wait... that's penis enlargement.
//I've been tempted to click one just to KNOW what they are
 
2013-09-10 10:18:09 AM
It was a GLITCH. It was a- a TECHNICAL MALFUNCTION. Why in hell won't anyone believe me?

/obviously didn't have the right stuff
 
2013-09-10 11:12:16 AM

dragonchild: Mister Peejay: Radiotherapy is a biatch... you want to kill the cancer cells without doing too much harm to the healthy ones.

My dad once aptly described cancer treatment as "Civil War medicine".  We don't know how to treat it, but we know where it is, so we're just going to hack it off and hope that takes care of the problem.

Killing cancer with radiation is like resolving a hostage situation with a hand grenade.  Yeah, odds are he's the only one standing up so if your aim is good enough that the grenade literally blows up inches from the bad guy's face then statistically you'll only kill the bad guy and everyone else in the room will live to recover.  In reality you're attempting surgical precision (pun intended) using an indiscriminate killer for lack of options that make a lick of sense.  There's absolutely no guarantee it'll get the objective done and plenty of times it'll do tons of undesired damage.

That's not to belittle those who are working on cancer cures; if anything it just goes to show how much of an asshole cancer is.  But the reality is that for all the money and hours spent, cancer still so thoroughly kicks our asses that the most prevalent forms of treatment still use 19th century "hack it off" principles.

/ Dad wasn't a doctor, but he was a pretty smart dude


Unfortunately, cancer seems to be adept at coming up with new ways to avoid treatment by other means.  I've heard retired Oncologists from the early days of radiation therapy say they  thought they'd only be using that barbaric technique for a few more years until pharma cranked a better treatment out.

We're still at it, just about every new biotech startup has a novel treatment for cancer, I think it in end it will be a highly specialized treatment that beats cancer, but it'll be different for each case.
 
2013-09-10 11:13:03 AM

stuhayes2010: I am a medical physicist and I use the eclipse software.  Things like this should never happen because you always check the plan with a third party software and run it through quality assurance.  Takes a whole 20 minutes.  I am sure Varian is at fault, but I would guarantee the cancer center has some faults too.


I worked for a startup that was trying to bring a faster, more accurate model of radiation absorption to market. We found problems with the test standard used by everyone to certify their results... and then the Great Recession hit, and money to prove the issue needed correction, along with money for our company to bring the product to market, dried up. :(  I'm confident there would be fewer deaths and disabilities from radiation treatments if the product had made it.

OTOH, Subby is wrong: 2.5x dose does cure you 2.5x better. It just damages you irrevocably 2.5x more. Collateral damage is the problem... as the article pointed out.
 
2013-09-10 12:09:47 PM
si0.twimg.com
 
2013-09-10 02:07:10 PM
ts3.mm.bing.net
 
2013-09-10 02:32:08 PM
How does a software glitch occur just once when it had been used dozens or hundreds of times?  How did they verify that the "prescription" was, in fact, the proper amount of radiation delivered?  Did they have some sort of meter that recorded the dosage delivered, and archived that info somewhere?

I suspect many others got high dosages, but didn't die from them (or their families suspected their cancers weren't affected by the radiation).

Also, $15M is way out of line.  A Ph.D. is supposed to earn something like $4M over a lifetime; what did this guy do to merit the life work for 4 Ph.D.s?
 
2013-09-10 02:50:26 PM
Reminds me of the Therac-25 incidents back in the 80s. Textbook example of piss poor assumptions and all around bad engineering. It's an interesting read.
 
2013-09-10 03:18:18 PM

fluffy2097: Like a user who thinks that clicking the print button 200 times will fix a  paper, jam, the tech scanned the person over and over.  I went looking for evidence of this story being true, and this is the only story I could find at all close to the anecdote.


Something like that happened with the Therac-25 incident, too.  Ray Cox got fried three times because the machine didn't give the tech feedback that it was delivering a dose; he finally jumped off the table and ran out of the room before getting another, but he'd already received a lethal dose.
 
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