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Thursday, October 29, 2015

A Rogue Act of Insanity: Jacoby Roth and the Mad River Hospital Radiation Overdose

sᴇᴄᴏɴᴅ ᴘᴏsᴛ ɪɴ ᴛʜᴇ ʀᴀᴅɪᴀᴛɪᴏɴ sᴇʀɪᴇs.

 “Well, that radiation thing was sort of creepy,” you might say, “but Brazil is far away.  And I won’t be scavenging any scrap metal from a junkyard.  And I’m pretty sure that if a bunch of people were rubbing some glowing shit on their skin, I would ask some questions about it first.”

Such as, "What drugs are you on?" and "Can I have some?"

“So I’m feeling pretty safe, at least on the being-exposed-to-unnecessarily-dangerous-amounts-of-radiation front.” 


Enter Jacoby Roth, a happy two-and-a-half-year old boy who lives in Arcata, California, a small town 290 miles north of San Francisco.  On January 23, 2008, Jacoby’s parents, Carrie and Padre, took him to the ER at Mad River Community Hospital after he complained of neck pain after he fell out of his bed the night before.  A CT scan was ordered to check Jacoby’s cervical spine. 

Normally, the actual CT scan only lasts for a couple of minutes, with around 25 pictures being taken.

Jacoby’s test only ended after Padre Roth became concerned that it was taking too long, and yelled at the technician to stop the machine.  For inexplicable reasons, Jacoby had been scanned 151 times in the same area, and the test had taken 68 minutes.

It was not immediately clear what had occurred; but within a few hours, Jacoby’s face began turning red.  His parents insisted that pictures be taken.

"There were red marks all the way around his head, like a severe sunburn," said the attorney for the Roths, Don L. Stockett.  Later, state investigators would record that the pictures showed “a clear line” on Jacoby’s face, “consistent with the anatomical region that received the excessive radiation.”   The line extends “from the infraorbital ridge backward through the ear and nape of the neck; a similar line extends from the infraorbital ridge through the ear on the right side.”

Just how much radiation the toddler was exposed to is difficult to say.

 A report by the hospital's medical physicist calculated that the boy's absorbed radiation dose was 2.8 Gy (2,800 mSv) and possibly as high as 11 Gy (11,000 mSv). The dose the boy received compares to a range of 1.5-4.0 mSv for a normal pediatric CT study of the entire spine, according to pediatric imaging experts.

Using relevant material from the article "Estimated Risks of Radiation-Induced Fatal Cancer from Pediatric CT," published in the American Journal of Roentgenology (February 2001, Vol. 176:2, pp. 289-296), a report by the hospital's medical physicist concluded the child had a lifetime increased risk of a fatal cancer of 39%.

What the fuck?

It’s difficult to say why this happened.

This is Raven Knickerbocker, the technician in question.  

Scanner records show an average interval of 25 seconds between the 151 scans, which started at 8:29 a.m. on January 23, 2008, and ended at 9:37 a.m. The CT scanner used was a single-slice Picker PQ-5000 manufactured in 1998, which needed about 25 seconds for the tubes to cool between scans. It was replaced a month after the incident, but hospital officials said the replacement had been planned long before and was unrelated.

To top it all off, the scans taken by Knickberbocker were blurry and couldn’t be used.

 A second CT scan by radiologic technologist Susan Sampson took only two minutes and included 25 axial slices. Sampson remembered being "a little shocked" when she heard that Knickerbocker had done 151 scans in the same area at the base of the boy's skull. "That's a lot more time than it usually takes for an exam," she testified, estimating it should have taken less than 10 minutes.

 Knickerbocker was certified was a licensed radiological technologist in December of 2000.  She left the hospital two weeks after this incident, and her state license was suspended on September 30th by the California Department of Public Health, which was investigating the incident at the time this article was published. 

Knickerbocker does not have much to say for herself.

Ms. Knickerbocker said in an interview that she did not remember pushing the scan button 151 times. “I pushed the button like four to six times,” she said. “It’s frustrating because I don’t know what happened. I never intended it to happen.”

She said the machine must have malfunctioned. “I’ve been a technologist for more than 10 years,” she said. “Never had any kind of problems, never been written up.”

As the mother of a young daughter, Ms. Knickerbocker said she could understand what the Roth family was going through. “I’m human and if I did make an error, I’d be the first to admit it,” she said. “And I’m not afraid to ask for help when I need it. And unfortunately, that day, the help wasn’t there.”

According to state records, Ms. Knickerbocker told investigators that after suspecting the machine was malfunctioning, she summoned help but none came.

A state investigator concluded that even if the machine had malfunctioned, she should have stopped the test.

Knickerbocker has actually changed her story several times.

Bruce Fleck, the hospital's former radiology manager, testified that Knickerbocker subsequently gave many explanations for the incident, such as the boy's parents distracted her, the scanning table wouldn't move incrementally, and the boy's father was leaning on the table. But he noted that an experienced operator like Knickerbocker should have known to stop after a couple of images if the scanner wasn't operating properly.

When asked if the scanner could somehow take images automatically, he replied that the images showed the machine was in manual axial mode. "She had to hit the button each time," Fleck observed.
He also noted that Sampson had no problems when she used the machine. It was checked later and no malfunctions were found.

Knickerbocker could not provide a "valid explanation" of why she took 151 images of the same location, Fleck said. "I think it was just a rogue act of insanity," he told a stunned court.
Interestingly,a commenter on this story writes,
I know this family...the tech was talking incessantly while dosing this baby.

Since then, thankfully, Jacoby has shown no ill effects.  "He bounces around like a normal two-year-old," Don Stockett, the Roth’s attorney, said. "You wouldn't know anything was wrong with him at all."

A cytogeneticist who analyzed the boy's blood found substantial chromosomal damage, and one radiation expert predicts that Jacoby will develop cataracts in three to five years.  But no one really knows if Jacoby will suffer any ill effects – or what those effects will be.  No one is sure if Jacoby will develop cancer, because medical literature on radiation-induced cancers in children only looks at full-body exposures, such as those suffered at Nagasaki and Hiroshima.  This overdose was focused only in one specific area.

I think this quote sums up the entire situation perfectly:

“The problem with this case is that the parents are subjected to worry for the rest of their lives,” Mr. Stockett said. “They’re always going to have to worry for years — forever — because every time the child sniffles they instantly start thinking maybe this is the start of something really bad.”

Knickerbocker was fired shortly after the incident, and the Roths rightfully filed suit against her.   A settlement was reached, but the terms were kept secret. The hospital was fined $25,000 for this case, but those fines were dismissed on appeal, possibly because the California authorities found that this instance was due to operator error, not any negligence by the hospital itself.

Rogue act of insanity, indeed.

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