An Illinois woman was left in a coma after receiving stereotactic radiosurgery (SRS). SRS is a highly complex form of intense radiation therapy that emits high, but concentrated doses of radiation to the brain to combat tiny tumors and other problems. The surgery was performed at Evanston hospital, which now, according to investigation, lacked the properly functioning equipment. Evanston hospital, along with other hospitals around the country, use linear accelerators modified to emit a smaller beam of radiation capable of performing the complicated surgery instead of a Gamma Knife machine. Some of the modifications apparently caused the device to malfunction. Other hospitals that used the malfunctioning devices reported instances of operator error in not adjusting the machine in order to properly reduce the amount of radiation emission. However, Varian is being accused of not installing the appropriate safety mechanisms in its product. The Food and Drug Administration (FDA) is responsible for monitoring the safety of the device, which does not actually use radioactive material in producing radiation. But some are saying that the FDA does not have the proper authority to investigate deeply enough into these incidents. Furthermore, there is no uniform system of data reporting that can shed light on how prevalent these errors are occurring. However, these are not small errors with small consequences. One Illinois woman is now incapacitated as a result of receiving a radiation dose 4 times stronger than it should have been during her SRS treatment. The 50 year old mother of 3 was receiving the surgery as a treatment for trigeminal neuralgia, a brain condition that causes facial pain. SRS surgery needs to be perfectly accurate in targeting the trigeminal nerve because of the large amount of radiation, unlike other forms of radiation treatment that are delivered in multiple, less potent doses. At first the woman had no symptoms of radiation overdose, but within 4 weeks quickly deteriorated to a vegetative state according to friends and family, and doctors say her likelihood of recovery is slim. Despite the tragedy of this incident, no investigation by any regulative body has been launched into why this radiation overdose occurred. Varian, the company that produced the modified linear accelerator, has also declined to respond to questions. Adjusting the linear accelerators to perform the SRS surgery required a technological complex system of data input into the hospital computer system that controlled patient treatment plans. However, instead of making sure there were systematic backstops to prevent this kind of error from occurring with their machine, Varian instead put only a warning decal on their device telling operators to be extra careful in adjusting the amount of radiation. Only after this accident did Varian develop software to prevent a similar glitch. However, there is still no way of knowing how many patients have received radiation overdoses from these devices, which could cause cancer or other harmful long-term effects.
