Friday, August 12, 2005

I'm bored... I can't sleep... sighz... Nevermind, I'll just see what can I crap up now...
Hmm...
Oh yea, today in my Human Factors class, I heard 2 really disgusting stories. Now, it may seem trivial to some people but I don't want to cause any upset stomachs or traumatized minds. The stories are about the simple errors that people make, that sometimes lead to really, really bad results...
So, before I begin, any of you who think you can't be able digest it, please don't read the following paragraphs in red. I'm putting this warning because when my lecturer was telling them to us, I imagined every scene in my head and the last scene wasn't pretty >.<
Alright then... here we go:

Story 1: Medical human error...
Ray was a 32 year old man who has just been diagnosed with cancer in his left shoulder. So he had to undergo radioactive therapy. As he lay down in the machine, (I forgot what was it called) he thought of nothing much as this was his 9th time getting the treatment. The first 8 went fine. He got into position and waited for the treatment to begin.
In the control room, Mary-Beth was keying in the information into the computer so that the machine would be able to aim at Ray's tumor accurately. The machine has 2 functions, 1 was for X-ray and the other was an electron beam. To use the X-ray, the 'X' key is to be pressed while the electron beam is activated by the 'E' key. Pretty simple.
But Mary-Beth entered X on her first trial. But she noticed her mistake immediately and went back to the controls and pressed E. The computer screen now showed that Ray was to be aimed with the electron beam. So she presses 'Enter' to commence the treatment.
But little did she knew, the machine was never given a command of X then changing to E. This 'bug' or faulty command was never tested out by the designers or engineers of the machine. But this bug caused the machine to malfunction.
For both X-ray and electron beam, there is a metal plate which lessens the intensity of the beams before hitting the patient. But during the malfunction, the metal plate was retracted and there was nothing between the beam and Ray. An X-ray beam is alot more powerful than an electron beam (I've forgotten the exact numbers). And also during the malfunction, the beam was still for X-ray and not electron beam like it showed on Mary-Beth's computer screen.
There is a small video camera and a mic in the machine to enable communication between the control room and the machine room where the patient was in. But on that day, both were unplugged. Therefore, Mary-Beth could not communicate with ray and vice versa.
After Mary-Beth had pressed 'Enter', the screen showed the word 'Malfunction'. She thought it was just a bug, no big deal, she reseted the computer and entered Ray's treatment again. But the machine was still in a malfunctioning state, the X-ray beam was still used without the metal plate.
In the machine, Ray heard the machine working and he should recieve the treatment of an invisible ray which he could not have felt. But instead of that, he heard a frying sound and a searing pain through his shoulder.
When Mary-Beth entered the treatment again, the screen once again showed that there was a malfunction and she thought the treatment has not commenced. So she restarted the computer and entered the treatment again. The same thing happened. So she repeated the steps again, and again, and again, and again, and again...
By now, Ray has already recieved almost 25,000 times the amount of his supposed treatment. He called out to Mary-Beth "Hey, you're pressing the wrong button!" But Mary-Beth can't hear him. He lay there in pain.
Finally Mary-Beth gave up and told the nurses to wheel Ray out of the machine room. A few weeks after that, the same thing happened to another patient and Mary-Beth was also the controller of the machine.
By now, doctors were suspecting that Ray has been over-exposed to radiation. The engineers were called to the machine room and sure enough, they found the malfunction and alerted the company that designed the machine.
Ray's flesh around his shoulder and neck started to disinegrate and fall off. He died 4 months later.

Well, that was pretty shocking for me. And it was a true story... happened in the 80s. Kinda makes you wonder what could go wrong...

I was writting the 2nd story when I decided not to as it is bringing back really disgusting images in my head. So I'm not gonna write it...

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