California blamesoperator errorfor CT incident

January 1, 2009

The California Department of PublicHealth has determined that excessiveradiation exposure to a two-year-oldboy who was allegedly subjected to151 CT scans while in the machinefor 65 minutes, leaving him with radiationburns on his face and head, wasdue to “operator error” by the radiologictechnologist.

The California Department of Public Health has determined that excessive radiation exposure to a two-year-old boy who was allegedly subjected to 151 CT scans while in the machine for 65 minutes, leaving him with radiation burns on his face and head, was due to “operator error” by the radiologic technologist.

The child, Jacoby Roth, was taken to the Mad River Community Hospital in Arcata, a small town on the Northern California coast, on Jan. 23, 2008, by his parents to check for possible head injuries after the toddler fell out of bed the night before, according to a lawsuit filed by his parents.

The boy's parents, Padre and Carrie Roth, filed the suit against the hospital and radiologic technologist Raven Knickerbocker, claiming medical malpractice and battery.

Dr. David Brenner, director of Columbia University's Center for Radiological Research, said that, depending on the actual length of the boy's exposure, Jacoby faces a possible increased risk for cancer.

Although high doses of radiation can be fatal, intermediate doses can damage the gastrointestinal or hematological systems, with symptoms that would show up within a few weeks, Brenner said.

The boy should not have been scanned for more than two seconds, Brenner said, noting that the x-ray tubes in CT scanners would overheat if used for extended periods and have built-in safety measures that would automatically turn the machine off.

A cytogeneticist who analyzed the boy's blood found substantial chromosomal damage, according to attorney Don Stockett.

The child's parents are looking for an epidemiologist to conduct further examinations, Stockett said. Immediate symptoms were limited to skin inflammation with the appearance of sunburn on the boy's face.

Officials for the hospital, a 78-bed acute care medical facility, declined to comment on the case, citing pending litigation.

Knickerbocker, who was certified in December 2000, left the hospital two weeks after the incident, and her license was suspended Sept. 30 by the California Department of Public Health. She had no prior complaints, and none of the previous complaints that had been lodged against the hospital were substantiated, according to agency records.

She has appealed the suspension.