Thursday, June 13, 2013

Nuclear Death

A very sad tale from the Wall Street Journal:

Equipment Collapses, Killing Patient


By TAMER EL-GHOBASHY and CHRISTOPHER WEAVERA patient at a veteran's hospital in the Bronx was killed Wednesday when a large piece of diagnostic equipment fell on him in what experts called a rare accident.

The 66-year-old victim was undergoing a procedure using a gamma camera at the James J. Peters VA Medical Center when the apparatus apparently collapsed and crushed him, officials said.

In a statement, a spokesman for the medical center said the camera was installed in 2006 and was maintained by its manufacturer. "This is a very tragic and unusual event and the details are still unfolding," said Jim Connell, a hospital spokesman.

He declined to identify the patient, citing privacy laws.

According to the New York Fire Department, a 911 call for an ambulance came from the hospital on West Kingsbridge Road at about 12:30 p.m. on Wednesday, but was quickly called off. A spokeswoman for the New York City Medical Examiner said an autopsy hadn't yet been completed and that the victim hasn't been formally identified by next of kin.

An official with knowledge of the matter said the camera was a Infinia Hawkeye 4 model, manufactured by General Electric Co. The Hawkeye line is one of the largest on the market and can weigh more than 5,000 pounds.

Mr. Connell said the camera had been used in diagnostic procedures "without incident."

"Our first concern is for our veteran patient and for their family," Mr. Connell said in the statement. " We are in the midst of conducting an investigation and when we have a conclusive report, we will provide more information."

GE Healthcare learned of the incident from the VA, and a company "team has responded and is supporting the ongoing investigation," said Benjamin Fox, a GE spokesman. He didn't respond to questions about whether the company had seen similar failures elsewhere.

Nuclear-medicine physicians use gamma cameras to scan organs such as the lungs and kidneys, and other tissue deep in the body. Doctors inject patients with radioactive fluids; the gamma camera tracks the location of those drugs within the anatomy by collecting radiation they emit from inside the body. By contrast, X-rays fire radiation at the body from the outside to create images. Virtually all major hospitals use gamma cameras, which are a staple of nuclear medicine departments, said Jamie Dildy, an analyst for MD Buyline, a health-care equipment and technology research firm. New models, manufactured by the health-care units of Siemens AG, General Electric and Philips Electronics NV, typically cost between $300,000 and $800,000, she said.

Gamma cameras, which have been in use since the 1960s, consist of large panels of crystal that convert the rays to light. The rest of the device takes a digital picture of the light, not unlike a traditional camera.

The panels, which are often designed to rotate around a prone patient, are generally insulated with thick layers of lead that focus the gamma rays. They weigh "hundreds and hundreds of pounds," said William Spies, a professor of radiology at Northwestern University Feinberg School of Medicine.

But accidents are unusual. "I've been doing nuclear medicine since 1974," Dr. Spies said. "I remember one other incident where a gamma camera fell on a patient." Even that was a long time ago, he said.
I certainly send my condolences to the family of the victim.

I haven't seen any photos of the actual accident site, but here is GE's stock photo of the Infinia Hawkeye 4:

I'm wondering just what they mean by "collapsed"...did one of the acquisition heads work loose from its mountings and fall? Was there undue fatigue in some of the fastening hardware? Did the whole darn gantry tip over?

I can't help but be reminded of the on-line argument I had over emergency CD-ROM's and viruses. It was stated (not by me): "If it were to infect an unprotected computer in a nuclear medicine camera gantry, it could lead to crushing and killing a patient, so you should think long and hard before you boldly insert any outside data into your workstation." I certainly DO NOT think this is what happened here.

I guess we will have to wait for more information.

In the meantime, it might be wise to kick the side of any similar device before getting into it.

ADDENDUM

My good friend Hussein from Kuwait found the FDA recall notice:

 http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfres/res.cfm?id=116030

Product:  GE Healthcare Quasar Nuclear Medicine System, Hawkeye Option and Hawkeye 4 Option for Dual-Head Variable Angle Gamma Camera. Nuclear Medicine imaging systems. Recall includes all Infinia systems, all configurations.

Reason for Recall: Accelerated fatigue of the lateral axis motion subsystem of the Infinia Computed Emission Tomography System could result in mechanical failure causing the detector to slide; may impact patient and operators.
Sounds like this is a pretty wide recall. Time for new cameras all around!

ADDENDUM 2

It was pointed out to me by the editors of AuntMinnie that the date of the recall was:
 
Date PostedApril 10, 2013
 
Uh oh......

4 comments:

Stacey Gordon said...

Heard of similar incident and discovered it was initiated by getting tangled up in stretcher that was left in the room, too close to scanner.

Anonymous said...

The man was a relative and still do not know the details. Such a tragedy and should never happen again. Two accidents are one too many. I certainly hope that the VA and GE move quickly on this issue.

Do not forget as time goes by until they let us know.

Q8PACS said...

I think this is the FDA recall related to this incident

http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfres/res.cfm?id=116030

In fact, I came to know that the GE distributor in Kuwait is planning to remove this machine and replace it with a new one. Not sure if it's the same reason.

Anonymous said...

A more recent FDA recall notice letter from GE seems to alude to loose head mounting bolts which in turn caused catastrophic failure of the head mount on the Bronx camera. GE is now apparently conducting inspections of all the recalled cameras. These inspections apparently take about several hours per camera.