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» 20 October 2009
Software Vulnerability Hampers Brain Tumor Operation

The developers of a world-renowned radiation therapy appliance had recently created a fix for a programming glitch that can cause the device's emergency stop button to cease functioning (an undoubtedly dangerous risk) after a bone-chilling incident in a Cleveland hospital wherein employees were forced to physically haul a patient from the machine during treatment. The coding flaw affected the Gamma Knife—an apparatus that looks like a CT scan that focuses waves of radiation on an affected individual's brain tumor while leaving the neighboring cells and tissues intact.

Gamma Knife therapy is done via the following steps: First, the patient puts on a special helmet that's screwed into his skull to make sure that his head doesn't move around and expose the wrong part of his brain during the operation. Because the machine's tumor-destroying beams are immensely accurate, a mere inch of error can prove fatal to him. From there, he lies down on a moving couch that slides into a chamber where two-hundred-and-one emitters concentrate radiation on the designated treatment location from a variety of angles.

Positioning is a crucial factor for Gamma Knife treatment, so when the couch was slid out of position during a routine session at a Cleveland university hospital last year, staffers immediately hit the emergency stop button in order to automatically close the radiation shields and realign the setup properly. According to the account submitted to the Nuclear Regulatory Agency, the machine didn't respond. The available medical staff was forced to rescue the trapped patient by manually pulling the errant couch from the activated gadget. The report reassured that neither the workers nor the patient were injured by the incident because their radiation exposure was minimal at best.

After the hospital contacted Elekta AB, the company from Stockholm that manufactured the Gamma Knife, it was able to conclude that a "known software bug problem" was the culprit behind the hazardous event. Thomas Valentine—Elekta's quality assurance director in its American branch—emailed that the company was aware of the bug at the time of the mishap (December 2008), but their corrective measures for it could only be released in an impending patch. It should be noted that this was the only reported incident of the Gamma Knife malfunctioning in the midst of an operation, and it's presently used to treat about 500,000 patients all around the world.

 

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