I didn�t think I was supposed to notice anything until around zap 12 but I feel a bit fried with a slight headache.

I arrived about a half hour early today and there was a different Tech at the helm of the Tomo machine (or maybe I was the wrong patient!).

The mask felt different, didn�t seem to be crushing my Larynx like yesterday and actually seemed a bit roomier (Maybe it was the wrong mask!).

He buckled me down, then in and out the donut for the CT phase. It seemed like it took forever between the CT and Zap phase � like maybe the CT and Plan Program were not lining up? (Maybe not my Plan -eek).

Then he came over and changed something so the laser crosshairs seemed to move from being center across my nose to dissecting my right eyeball! Then back down the donut �.

Like yesterday, the machine roared around my head like a freight train and when it finally rolled me out I seemed disoriented, somewhat off balance, and couldn�t find my way back to the dressing room. The place is a maze and every turn I made there was another room with another alien zap machine! Sci-Fi nightmare!

I finally managed to find my way back to my Tomo machine. It looked hungry and menacing, but the Tech was still there and he led me back to the dressing room - I think he called me by the wrong name

Can�t help but wonder if that freight train thing running around inside that Tomo machine jumped the track and zapped a few of my brain cells!

I managed to stumble out of the Cancer Center to the mall across the street and find solace at a Starbucks in Mocha Latt�.

One thing about Tomo phobia is for at least a while; it totally took my mind off my PEG

What a way to forget about your peg. You had a rough day Don. I never heqrd about your reactions and never had them either. Maybe that train did jump the tracks.

You know, you are real early in the process to be having this kind of disorientation if people get it at all. You will feel your mask get looser as treatment progresses because you are losing weight, but that is also further down the road. I would speak to the radiation oncologist that is your doctor and see if he concurs that your experience is normal or abnormal. You listed several things that all seem like warning flags to me. What are the odds that the tech got all this stuff wrong vs. you just feeling that he did. Calling you the wrong name was the straw that breaks it for me. I would want the doctor to review your last session which is a matter of record before you go into the machine again. You may not be crazy. Hospitals are not perfect. Techs are radiating people for lots of things besides oral cancers in people's heads, all who use a mask, and several brain cancer patients I have talked with get disoriented after treatment. I have never seen a post on here about this happening to people getting their necks and mouths nuked. I don't want to spook you, but just to be on the safe side make the call to the doctor.

Hi Don,

I've just finished my 25th treatment and nothing like this has ever happened to me. I always have two techicians in the room positioning me and cross checking information - one of the cross checks is that I have to provide them with my name and date of birth. This is usually just before I put my bite bit in - and then they put the mask over and clip it in place.

My mask does feel different some days because sometimes my neck and face are more swollen than usual. But as Brian pointed out you should not have lost significant weight or even retained fluid at this point.

I would follow this up if I was you and also be querying their procedures if they are not confirming and cross checking patient information before commencing treatments.

Good Luck!

Sue

Make that Three down - thirty two to go

Well after a disconcerting start, today�s session certainly end a lot better than yesterday�s. The session went well and afterwards I felt fine, but as to the start�.

The same Tech came to the waiting room and motioned me to follow him into the Tomo Room. As he was beginning to position me on the bed of the Tomo, I notice a small LCD screen on the Tomo displaying a digital picture of a different patient. Pointing to the display I said �that�s not me � he is still in the waiting room�. The Tech looked perplexed and told me to return to the waiting room.

That other patient had been in the waiting room holding his head. He was perhaps similar in appearance, age, height but rather slim (I am not heavy, but certainly not that slim � yet) and he didn�t have a PEG since he was wearing a tee shirt (Unlike me, he was not required to change into a gown).

Perhaps this is just coincidental, but it makes me all that more concerned as to what happened yesterday.

At least now I know to check the Tomo and see if it is showing my �Name� and my �Picture�. Perhaps the Tomo isn�t such an alien and menacing machine after all � just the tech!

I am to see my RO next Tuesday. As Sue mentioned, I am going to ask why the Tech doesn�t make me confirm my name and if it is possible to zap the wrong patient.

It may be a silly question but do you think they would admit to possibly zapping the wrong patient..I think not!

Yikes! Sounds like you've had quite the drama with your first few treatments. I hope you get it sorted out soon! Keep checking that screen for your picture! I have a card that my tech scans every morning and it pulls up all my information, but they know who I am now since I am the first patient every morning. Also, I look at my picture on the screen before I lay down most times as well, but that may be me just being vain! (HA! they took my picture on my tenth day in the hospital, I got out the next, I was all swollen and hadn't washed my hair, except with that leave in shampoo stuff, so the picture is just a gentle reminder of how bad I actually looked!)

There is a protocol in place at every hospital to prevent this kind of thing happening. What you are not getting - is that radiation to unneeded parts of your anatomy is damaging, harmful, not targeting your disease, and a lawsuit in the making. This is serious stuff, and you should not take it so lightly. The doctor should be made aware of this and their protocols and that technician brought into the spotlight and put in question. There is supposed to be a log of doses etc. each time the machine is turned on and a patient number assigned to that log, so a record of what took place legally exists. Gary on the boards knows lots about this from a regulatory affairs standpoint, and I hope he will chime in. You have possibly been hurt by a couple days of mistakes. Do not let this slide!!!

Clearly, being incorrectly radiated is considered a patient injury by the FDA and you can report the incident to Medwatch.

The FDA is so strict on this that if the institution loses a CT scan and have to repeat the study that is considered a patient injury due to receiving double the amount of radiation.

There was another incident, a fews years back, where a female patient had her "prostate" irradiated because the patient before her was a "no show" and the techs didn't update the treatment plan.

Unfortunately they run people through LINACS like cattle - many institutions in my area run 2 shifts now.

ALWAYS check the monitor in the treatment room to insure that your name is on it. 1.8-2 gy of radiation probably won't cause permanent long term harm but I would still report it. The tech should be reprimanded. Hospitals are required to do multiple checks to insure that a patient is receiving the correct treatment, wrist bands, answering certain questions, etc.

Your mask should also have your name on it and if it doesn't feel right then they may be using the wrong neck rest or have it positioned backwards.

See: http://www.fda.gov/medwatch/ for how to report the incident

...get this checked out first thing tomorrow! You will not only be helping yourself, but think about the other patients that follow you. If they have a "no show" and don't update their records, then they could indeed radiate the remainder of the patients for that day!

While our hospitals are doing wonders each/every day, humans are still running them and they do indeed make mistakes!

Good Luck!

You need to let the Staff know about this problem, at the Norris Cotton Cancer Center I had a card that I put in a machine apon arrival (works similar to wn ATM) this then told the secretary and the Techs that I was present. The secretary receives a call from the Tech for the patient, you give your name and date of birth and proceed to a waiting area.Next a Tech comes and revarifies your name and date of birth and escorts you to the radiation room where another Tech joins in and verifies the name and date of birth on the neck brace, mask and mouth guard then a 3rd Tehn joins in and reverifies everything again before snapping the mask down. Before starting the machine they (all three techs) would verify that the machine was set for me and not someone else!This seemed like alot at the time, but the Techs explained that they did not want to make a mistake with the radiation theropy. So listen to everyone and complain to your Doctors ASAP! Bob

Don . . . I also had a card to check in and I never had any techs that I didn't reconize or visa versa. One comment on the mask, mine was so tight initially that I had them cut ( RO okayed ) a small rectangle around the adam's apple area so I could swallow without discomfort. Best of luck.

I can't believe you haven't reported this the the doctors, especially since it almost happened a second time. Do not wait any longer. Print off you posts so you don't forget any of the details and see the RO tomorrow, not sometime next week. This guy could do someone a lot of harm.

Take care,
Eileen

now Four Down Thirty One to go

Today was about the same routine, same Tech, motioned me to follow him. But once in the Tomo room there was a second Tech.

Unfortunately he turned out to be a trainee
Neither asked me to confirm my ID.

I made sure to keep my glasses on so I could clearly see that it was my image being displayed on the Tomo machine. It was, so I politely handed the Tech my glasses and laid down... session went fine.

Tomorrow, after my Tomo session I have an appointment with my RO and will asked about protocol and if it is possible to zap the wrong patient.

Over the week-end I combed the TomoTherpay web site to see if it had any info on safeguards that might be built into the system -- didn't find anything. So I went through the American College of Surgeons site since this Cancer Center is accredited by them. Their site has a lot on protocols to be followed, but nothing related to the actual zapping.

Tomorrow, I will approach the issue delicately. I don't want to piss anyone off since this is the only Cancer Center in San Diego with a Helical TomoTherapy Hi Art IGRT/IMRT system and I have been told for Head and Neck it is my best treatment option.

Now Six down Twenty Nine to go

It turned out I was wrong about having an appointment with my RO this past Tuesday. We do exchange hello�s most days at the Cancer Center, so when I asked he said not until next week unless I was having a problem.

I figured discussing the zap protocol in the hall was inappropriate and could wait a week.
Also this week I have had different Techs.

Yesterday the Tech was Debra. She did my first zap -- so I asked her. She said it couldn�t happen because everyone has a unique plan and the CT Scan wouldn�t match.

Of note Debra did call me by my name, but I noticed when I walk into the vault that my picture was not showing on those little displays built into the Tomo. But, my name was showing on a nearby computer display. So now I figure if I don�t seem my picture on the Tomo to check that display.

Today a different Tech named Julie called me by name, and then Debra joined her. I think the girls are really good, but Danny and his trainee still bother me. I guess now having two Techs is also an improvement since most of my zaps have been by just one.

Well with that I will probable end this thread, but at an appropriate time mention it to my RO just to confirm that they really can�t zap the wrong guy

Hi Don,

It's up to you what you do and you certainly need to be comfortable with the people who are working with you while in treatment. That said I do think that your centre seems to be lacking in consistency with their protocols and cross checks. This is a problem that may have affected not only you but also the guy who may have missed out on his brain zaps.

I had to have surgery in the second week of my treatment and missed two days of radiotherapy because of that. I then had to make up those days by attending on consecutive Saturdays. My RO said it was vital that I received the full radiotherapy treatment and that even missing two could compromise the outcome. I guess my point is that if you have missed even 1 prescibed dose it is important to follow it up and get the extra treatment is there has been an error.

I know that it may be uncomfortable but you may be compromising both yours and someone else's treatment by not following this up.

Good luck with the rest of your treatments and please keep us updated with your progress!

Sue

I used to ask my RO questions whereever I saw him and he would quit what he was doing and listen then give me his thoughts. He is still the same way. just approach him and he will take the time to help.

I believe that if there is any doubt about recieving the correct treatment that you should ask the question now. Ask the RO and make sure he/she checks the treatment plan and reviews the records of the treatment that you have already recieved. You have to be your own advocate at times. Protocols for radiation, as Brian and Gary have eluded to are to be "EXACTLY as prescribed" and only altered by the doctors. We all know mistakes happen and unfortunatly too often in my own opinion. Check it out, it will only benefit you and if all is right it will certainly take at least one stress off your shoulders.
All the best,
Cheers.
Mike

DonB - While it is not my place to tell you what to do, I am a little surprised by your willingness to let this ride, continuing to get more treatments from a tech that may have made more than one mistake on you, and live within the doctor's schedule/timetable to discuss it. That level of trust may not be justified, and makes me feel that you do not fully appreciate the seriousness of the issue. I will not say any more about this, as this (OCF) is a place to come safely to talk without being pushed in one direction or another.

Thanks to so many for being concerned, but I am pretty confident now that I was not zapped using another patients treatment plan.

I am sure it was just newbie anxiety, but I will bring it up with my RO at our appointment next Tuesday.

I went over this again with Julie. Of note, both Debra and Julie have always called me by name.

Julie is the by far the best RT Tech I have had and like Debra, she said "It can't happen".

She said she thinks she always calls patient in by their name, but confirmed they could and some might rely solely on the photo displays which she showed me was also on their control console.

She said she didn't see how Danny could have ever gotten past the setup phase without detecting he had the wrong patient.

But, she said even if he were to the Tomo has to be able to register the Treatment Plan with the daily CT Scan and recalibrate or it will abort.

She said "the shift would be to great".

I am pleased that you have explored this to your satisfaction.

Take a look at the number of patient radiated with the wrong program at the ONE hospital

Govt urged to ensure no repeat of hospital radiation bungle

Posted Sat Jul 26, 2008 6:49pm AEST
720 cancer patients at the hospital have potentially received an incorrect dosage of radiation treatment (ABC News)

Map: Adelaide 5000
Related Story: Radiation bungle poses little risk to cancer patients: AMA
The chairman of a South Australian cancer support group says he hopes the radiation treatment bungle at the Royal Adelaide hospital will not scare people off of getting treatment.

Cancer Voices SA chairman Ashleigh Moore was diagnosed with head and neck cancer and was potentially one of the hospital's 720 cancer patients to have received an incorrect dosage of radiation treatment over a two-year period.

He says the State Government needs to make assurances this does not happen again.

"In my situation I needed to have maximum dose radiotherapy to get rid of the cancer, so I'm certainly hoping none of my treatment has been compromised and I'm concerned for the other people who were not so lucky," he said.

Thanks Brian,
Found this artical as well..It is really scary.
Have not seen anyone from Adelaide in South Australia here only people from the other states of New South Wales, Victoria and Queensland.

Cancer patient demands answers over radiation bungle
July 27, 2008, 7:45 am


A former Royal Adelaide Hospital cancer patient has demanded answers as to why he may have been incorrectly treated.

One of four radiotherapy machines at the hospital was found to have given patients lower doses of radiation between July 2004 and July 2006.

Ashleigh Moore suffered from head and neck cancer and is potentially one of the hospital's 720 cancer patients to have received an incorrect dosage of radiation.

Mr Moore, who is also the chairman of Cancer Voices SA, says the bungle highlights a terrible flaw in the State's health system.

"From a safety and quality perspective I suppose and as far as the health care system in South Australia [goes], it seems as though there's something terribly wrong," he said.

"When it takes two years for a problem like this to be corrected and then it takes another two years for something to be done about it - that's just not acceptable."

But he says he hopes the incident does not put cancer patients off having radiotherapy.

"Cancer is a terrible experience and people get through all the fears associated with their treatment and the things that could possibly go wrong," he said.

"And then to suffer it again, several years later, to have all those fears resurface, it does nothing to help people get over the cancer."

Mr Moore says preventative measures must now be taken to make sure this does not happen again.

"We'd like reassurances from the Minister that something will happen to ensure that this problem doesn't happen again, that there are systems in place to prevent errors, and that there's a system in place to ensure that errors are picked up before they become catastrophes and affect the health and safety of patients."