Medicine Gone Horribly Wrong: Therac 25

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imp

Senior Member
Our Canadian members may recall something about this, as these machines were Canadian-designed and built. I do not recall seeing coverage here in the States, though a number of them were sold and used here. Here is a quick synopsis of what happened. Extensive study followed use of these therapy machines, and they were ultimately scrapped. I came upon the topic quite by accident, and having technical interest in things of this nature, as well as understanding of the horrible consequences of exposure to high radiation dosage resulting in "radiation poisoning" and death, took it upon myself to learn more. In case the reader chooses to limit reading further: I recall these details: One patient in terror tore loose the restraining straps, bounded away from the machine, and began pounding on the door of the enclosure in which the technician was operating the machine from. The "inter-com" allowing conversation between operator and patient had BROKEN DOWN, and was not repaired! Another patient, who died of the radiation overdose, was found at autopsy to have had her entire hip destroyed. The machines continued in operation, even after significant accidents had occurred, the Canadian concern backing them continuing to claim the machines were not at fault!

This is a horror story demanding attention and concern. imp


"The Therac-25 was a radiation therapy machine produced by Atomic Energy of Canada Limited (AECL) after the Therac-6 and Therac-20 units (the earlier units had been produced in partnership with CGR of France).
It was involved in at least six accidents between 1985 and 1987, in which patients were given massive overdoses of radiation.[SUP][1][/SUP][SUP]:425[/SUP] Because of concurrent programming errors, it sometimes gave its patients radiation doses that were thousands of times greater than normal, resulting in death or serious injury.[SUP][2][/SUP] These accidents highlighted the dangers of software control of safety-critical systems, and they have become a standard case study in health informatics and software engineering."

"The machine offered two modes of radiation therapy:

An Engineering Disaster:
Therac-25
In a period where computers have become part of everyday living, the technology has been increasing at an alarming rate. And with this rate of innovation, human mistakes are bound to occur. Between the period of 1985-1987, such an error did occur, costing six innocent people their lives. Six people too many. This mistake was known as Therac-25; the name of the machine used in radiation therapy for cancer patients. It is the biggest and most disastrous case of human error relating computer controlled radiation and human death to date.

Excerpted from the most revealing study I have found: http://www.bowdoin.edu/~allen/courses/cs260/readings/therac.pdf
 

I thought by posting this story, surely some among us have in their advanced age undergone radiation therapy. It was for them that my OP was intended.
 
IMP
You are talking to a deaf group that think if the medical system used it it has to be OK. All radiation causes damage in some cases cancer but that dose not stop them from using it.
IMP thanks for the information.
 

"You are talking to a deaf group"

Ahhh, well......benefit of doubt, lots of us old farts are deaf anyway. It's just that my lifelong experiences with medical practice have so often encountered exactly that- "practice". At 19 a Charlatan Oral Surgeon convinced my Mother & I that a Caldwell-Luc Radical Maxillary Operation was needed immediately, as the abscess in my tooth was a "tumor". My Dad, upon hearing this news, called it off. Our regular dentist pulled the tooth, I revealed nothing to him about the proposed surgery until my next 6 months check-up, by which time the extraction had healed just fine. He took down a big Dental Surgery text, showed me pics of the Caldwell-Luc. Absolutely horrifying! He said that it was done only as a last resort cure for serious jawbone infection. If anyone cares I'll reveal more about this story. imp
 
d0ug said:
IMP
You are talking to a deaf group that think if the medical system used it it has to be OK.
Click to expand...

What deaf group are you talking about Doug? You shouldn't paint everyone with a broad brush like that. I for one, do not think that if the medical system uses it or used it, it has to be okay.

imp said:
"You are talking to a deaf group"

Ahhh, well......benefit of doubt, lots of us old farts are deaf anyway. It's just that my lifelong experiences with medical practice have so often encountered exactly that- "practice". At 19 a Charlatan Oral Surgeon convinced my Mother & I that a Caldwell-Luc Radical Maxillary Operation was needed immediately, as the abscess in my tooth was a "tumor". My Dad, upon hearing this news, called it off. Our regular dentist pulled the tooth, I revealed nothing to him about the proposed surgery until my next 6 months check-up, by which time the extraction had healed just fine. He took down a big Dental Surgery text, showed me pics of the Caldwell-Luc. Absolutely horrifying! He said that it was done only as a last resort cure for serious jawbone infection. If anyone cares I'll reveal more about this story. imp
Click to expand...

I'm interested in the story of Caldwell-Luc, Imp. Sounds like your father was very wise not to have the Caldwell-Luc operation. Honestly I've never known about any of this, but I'm not a big fan of radiation treatments, I think a lot of people, including some in my family, died from the treatment more than the cancer itself. But, I'm not that knowledgeable in these things. I personally avoid even x-rays, don't take mammograms anymore and if I had to fly somewhere, I'd opt for the pat-down.
 
A long read, but explains how I became wary of Medicine as a young man. Week before Easter, I was 19, my jaw swelled up, obviously a molar involved, great pain. Day before Good Friday, my Mother called our reliable old Dentist, Dr. John Ott; he explained he would be off Friday through Sunday, he was Catholic. My sister recommended a young Dentist, a Dr. Musil, to whom I went on Friday. He took many X-rays, gave me an antibiotic to take, said he was referring me to a colleague, an Oral Surgeon, named Dr. Nicholas Choukas, set up the appointment for the following Tuesday. Over the weekend I had the worst pain ever experienced, up all night, nearly in tears, so bad it was. Sunday night, the abscess broke through beside my first molar (8-year molar), pus drained out, pain subsided. Tuesday afternoon my Mother accompanied me to the Specialist. He ordered complete skull X-rays, done in the same location, then explained in detail the procedure needed.

A half-dollar sized hole is cut through the facial skull structure above the molars, below the eye. That would allow removal of the "cyst" he claimed was present. Presence of the hole prevents normal breathing and speech, so afterwards a plastic "plug" is driven into the hole. We were shocked and frightened, as he made arrangements with a hospital to schedule this. At home, my Dad came from work, we described all this to him, and he was outraged, called Dr. Choukas, and demanded more information. The Dr. told him I had a "tumor" in my jawbone, whereupon my Dad cut him off, told him to just send us his bill. Our good old Dr. Ott was called, I went to his office two days later, he took one X-ray, and stated he was sorry, the tooth could not be saved; no mention of a cyst or tumor, a severe abscess had been present. He placed antibiotic into a drilled hole in the molar, extracted the tooth the following day. It came out quite easily, the bone having been softened by the infection. I went home, and the extraction healed normally. As I mentioned in earlier post, I told Dr. Ott the whole surgery story next check-up visit. He said, in any event, if a cyst were suspected, normal procedure would have been to pull the tooth, and see if healing occurs; Caldwell-Luc was a "last-ditch" procedure.

He explained that as the hole cut in the skull healed, every few months the "plug" must be removed, and a smaller one inserted. Gradually, the entire hole and gum tissue make a recovery, over several years' time. Two "kickers" now remain in the story: I had noted Dr. Musil's Dental Diploma on his wall: Northwestern University, 1955. I also looked at Dr. Choukas' in his office: Northwestern University, 1955! So, "referrals" in cahoots! Could this butcher be doing this sort of thing to folks routinely, I thought?

Second unreal fact: Many years later, jump ahead from 1961 to 1995. My sister lay dying in Chicago West Suburban Hospital, as I flew to Chicago from my home in Phoenix, to see her. A bronze plaque commemorating the hospital's heroes, listed Nicholas Choukas, Member of Board of Directors!

I may post separately an image of the Caldwell-Luc procedure. Do not view it if you are squeamish. imp
 
Wow, that's intense! Glad your dad didn't let you have that procedure for nothing! I'm sorry about your sister.
 
SB, in a lot of ways, I'm reluctant to share a lot of the background which has made me a negative kind of guy. I enjoy stuff to the limit, like anyone else, but was molded into the way I am by circumstance. A victim of circumstance? Victim, wrong word. Just a lot of skeletons still lurking within my closets. I am easily misunderstood in some of my forum work, but generally, find it rewarding when someone "sees" where I come from.


My sister, incidentally, literally smoked herself to death, took over 50 years for it to take effect. We were never close, she being 12 years older than I. imp
 
I don't think you're too negative Imp, I think we all have some skeletons in our closets, but if we learn from our mistakes and don't dwell on the past, it helps us move on with life in the moment. My sister was a smoker too, died from lung cancer at 42, and oddly enough same age difference. I was very close to her when I was young, but when older we lived in different states, so we grew apart.
 
Thank you kindly for sharing that, SeaBreeze. Your input is a strengthening factor, rather than many of the remarks belittling folks' personal status. imp
 

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