By Scott Fontaine - Staff writer
Air Force Times
Posted : Saturday Oct 15, 2011 8:36:23 EDT

Surgeons are back to work at Nellis Air Force Base, Nev., after a daylong safety standdown to review a string of medical mistakes, including the death of a patient after a routine gallbladder operation.

Col. John DeGoes of the 99th Medical Group ordered the Sept. 19 standdown at Mike O’Callaghan Federal Hospital so medical staff members could discuss several preventable incidents that occurred in the past few months.

The hospital, run jointly by the Air Force and Veterans Affairs Department, performed almost 4,300 surgeries last year, about two-thirds of them on airmen and their family members. The number of patients totaled more than 260,000.

DeGoes did not publicly announce the standdown, which canceled elective surgeries and nonlife-threatening procedures; details of the review came from Jacob Hafter, a lawyer representing a civilian physician at the hospital concerned with the level of care.
About three-quarters of the hospital’s more than 2,000 workers are airmen or Air Force civilians, and the rest are VA employees.

Hafter alleged a “plethora of preventable injuries” at the hospital, including:
• An anesthesiologist blocked the wrong site on a patient in April.
• An orthopedist made an incision on the wrong forearm bone in June.
• A doctor lacerated the portal vein during surgery to remove a patient’s gallbladder in June. The patient bled to death.
• The wrong surgery site was marked during two procedures in August, but both were caught before surgery began.
• An otolaryngologist implanted a device in the wrong ear of a patient in September.

Hospital officials also discussed miscommunications, a lack of accountability and paperwork errors, according to notes from Hafter’s client.
DeGoes declined to be interviewed, citing concerns over patient privacy. In a statement, however, DeGoes said the standdown helped medical staff members “meet our safety objectives.”

“Our medical staff took time in an open and honest discussion forum in order to continue to improve the quality of care we provide, and to further build on the patient safety culture we highly value,” the statement read. “We took an unflinching look at our procedures and processes, both to identify areas we can do better and reinforce those we do well by ensuring our medical protocols continue to be followed.”

Later, Nellis spokesman Todd Lane provided written responses to questions from Air Force Times.

DeGoes scheduled the standdown almost three weeks in advance, issuing the order Sept. 1, according to the information from Lane. Several “good catches and two specific events that caused no permanent patient harm” prompted the standdown, according to the statement.

Other mistakes — aside from the death — were caught in time or resulted in no physical harm, he told Air Force Times.
Hafter, though, doubts DeGoes.

“When you have a standdown day, when you close your operating department because you need to practice safe medicine, that’s scary,” he said.

The hospital did not release the number of preventable deaths or “sentinel events,” errors that result in death or serious injury. Both statistics are protected by federal law “to ensure full cooperation by all involved in the investigation and ensure integrity of our quality assurance programs,” according to the information from Lane.

In the statement, the Air Force surgeon general reaffirmed the service’s commitment to patient safety.

“Patient safety is central to everything we do,” Lt. Gen. Bruce Green said. “By learning from mistakes and sharing information, we continually strive to enhance the quality of our care.”

Wrong-site surgeries — a term that includes surgeries on the wrong side of the patient’s body, on the wrong place on the patient’s body, the wrong procedure performed or surgery performed on the wrong patient — are rare. A 2008 study commissioned by the National Institutes of Health estimated as few as 1 in 112,994 surgeries were performed on the wrong site, although the report’s authors said as little as 10 percent of wrong-site surgeries are reported.

John Bright, of the Veterans Affairs Southern Nevada Healthcare System, defended the hospital to the Las Vegas Review-Journal by pointing to several patient safety awards, including best in the Air Force in 2008, best in the Defense Department in 2008 and best in Air Combat Command in 2010.

“Out of 4,000 to 5,000 surgeries [per year] I’ll put our safety record up against anybody, anywhere,” Bright told the newspaper. “I’ve been here 10 years, and in that 10 years, there has been one surgical complication of that [sentinel] event magnitude that I’m aware of. That’s a pretty damn good record when you consider the complexity of the patients we treat.”

For well over half a century, the law of the United States has recognized the right of citizens to seek compensation for injury resulting from negligent government health care.  If you believe that you or a loved one have suffered an avoidable injury due to errors or omissions in military or VA medical care, the experienced attorneys at Rawls, McNelis and Mitchell are standing by to evaluate your case at no expense, and to help you obtain compensation.  

Call us toll free at (877) 838-4838, or click "Tell us about your case" at the top or bottom of this page.  
 

The veteran filed his own administrative Federal Tort Claim.  VA officials eventually responded by explaining that the veteran had “received appropriate medical care for (his) melanoma”, but it offered a nominal settlement because of the “communications difficulties” associated with his case.  This was how the VA chose to characterize the four year delay in treating the patient for a life threatening and eventually incurable disease.

At this point, the veteran and his companion of some twenty years contacted our firm.  In our discussions, VA officials made clear their belief that, once the veteran died, his life companion would be unable to bring a successful wrongful death claim because the couple had never married.  As matters developed, the veteran and his devoted friend decided to marry, after which he survived three months before passing away due to his incurable cancer. 

Following the veteran’s death, we filed an administrative wrongful death claim against the VA on behalf of his (newly-married) widow and estate.   VA officials were clearly aware of their error in allowing their patient’s potentially deadly cancer to fall between the cracks.  Nonetheless, the agency refused to increase their minimal settlement offer. 

As soon as allowed by law, we filed suit on behalf of the widow and the veteran’s estate.   Unable to defend the care provided to the deceased veteran, the government nonetheless demanded a ruling that our client was barred from recovering damages for her personal loss.  They argued that applicable state law did not allow her to profit by “marrying the existing injury.”   John McChesney of our firm prepared a forceful and eloquent brief opposing that motion, and persuaded the Court that the law did not allow the government to escape liability.  The government’s motion was denied, and the path was opened for a prompt and fair settlement of the case.

This was a case where there was a clear error in the care provided to this gentleman.  The government did not contest that.  It never even tried to do so.  Yet, it fought this case for a long time, unfortunately adding to the hard times already being faced by a dying veteran and his widow.     Of course, these good folks wanted compensation for the loss, but they also wanted to send a message to the VA that continuity of care is important.  Veterans, those men and women who have served our country faithfully, deserve quality care.   In the end, the courage and persistence  of this couple was doubly rewarded; not only by reminding VA health care providers of the critical importance of providing reasonable care, but by helping to make new law protecting the rights of other survivors to appropriate compensation.

It was our honor to serve them.   It was a pity, however, that they ever had to get to the point of needing our services.

 

Over the years, my veteran client did his best to comply with these instructions, and he returned his samples as directed. All were evaluated and found to be negative for the presence of blood (which would signal the possible presence of a cancerous lesion). Meanwhile, he was busy dying from a relentlessly advancing colon cancer.

His disease was finally diagnosed when he reached age 65 and became eligible for Medicare. At that point he switched his primary care to the doc in his local neighborhood. In light of his age, his new doctor saw that he had never received a screening colonoscopy and ordered one immediately. That exam disclosed the presence of an advanced colon cancer which had obviously been present and undetected for several years. It eventually took his life.

Before he died, and after the VA had denied his administrative tort claim, we filed suit on this veteran’s behalf. Eventually it came time to hold a settlement conference. I recall being in a room at the Federal Courthouse with a lawyer from the VA, one from the Justice Department, the Federal Magistrate Judge, and my client. All of us present were males over age 50. As discussions progressed, it turned out that the only person there who had not been more or less automatically referred for colon cancer screening by colonoscopy was the dying veteran seated at my side. In due course we were able to obtain a substantial settlement.

For most of my own life I’ve been blessed with good health. For the first eight years after retiring from the Navy I don’t believe I visited my (private) doctor more than twice – and then for routine matters like flu or back ache. When I reached 50 years of age, however, I dutifully made an appointment for a comprehensive exam – thinking it was ‘the thing to do.’ My doctor noted my age and, among many other matters, asked about my family history for colon cancer. I told him there was none so far as I knew, but he still recommended that I schedule a colonoscopy for screening purposes. I did.

A few weeks later I reported to a local gastroenterology clinic for my colonoscopy. There was nothing to the exam itself (it felt like I blinked and missed it), although the stuff I had to drink as a bowel-prep beforehand tasted truly lousy. A week following the procedure, the doc who performed my exam called me and said that the three tiny polyps he had plucked out during the procedure had been identified by the lab as adenomas – and were potentially pre-cancerous. Not all adenomas grow into cancer, he explained, but enough of them do that I should be sure to undergo a repeat colonoscopy in three years. I did so, and since that second exam found no further polyps, I was told to get ‘scoped’ in future at five-year intervals. Ten years would have been the recommended interval for a repeat screening test if I had been clean as a whistle the first time around. Anyway, I’m about two years out from my next colonoscopy right now.

Most of the veterans I represent don’t have the option of private health care. In almost every case where I have filed claims on their behalf alleging negligent colon-cancer screening, they had been under the sole care of VA or military primary care clinics for a decade or more. None received colonoscopy, or were even offered it. Most received FOBT kits every so often, generally without much explanation as to their purpose, and with no idea of their limitations. In many cases the kits were simply handed out in an envelope or paper bag by the clinic receptionist on the way out of the office. Sort of like when we used to go to the barber shop as little kids and get a taffy on the way out if we behaved and didn’t fuss too much in the chair. In turn, my clients figured out how to sample and return their stools for analysis with varying degrees of success and compliance. When stool samples were returned they were sometimes lost or at least not evaluated and recorded by VA labs. Those samples which were returned were uniformly found to be “normal.” Meanwhile, all of these veterans were harboring developing cancers.

I look at their experience and I sometimes ask myself, if I had been in their shoes, and knowing that my local VA hospital would not have provided me with a screening colonoscopy at age 50, whether I would have gone on to become a victim of advanced colon cancer – but for the fortuitous removal of those polyps several years back. A voice in the back of my head tells me there’s a good chance I would not be alive to write this.

Medical authorities have long known that FOBT kits, while certainly better than no colon-cancer screening at all, are a poor substitute for colonoscopy. The reason for this is simple: FOBT kits are designed to detect traces of blood in one’s stool, but colon cancers don’t bleed continuously. Instead, the expectation (gamble, really) is that by taking three successive stool samples, and doing it every year, you are eventually going to show evidence of bleeding if cancer is indeed present in your GI tract.

Sadly, just as in the case of my client mentioned at the outset, pinning your life on that sort of random chance doesn’t always work out. Even in those cases where cancer is discovered as a result of a ‘positive’ fecal occult blood test (which should normally lead to colonoscopy if reasonable standards are observed), that discovery often comes too late to save the patient . This is true even though it is generally acknowledged to take as long as a decade for most colon cancers to progress from a tiny polyp to a life-threatening, metastatic mass.

Yes, colonoscopy can lead to serious complications in a tiny percentage of cases. Yes, colonoscopy is a lot more expensive than even several years’ worth of FOBT testing. If you put 1000 primary care doctors who have researched the subject in a ballroom and ask them whether FOBT alone is an acceptable means of colon cancer screening, a lot of them will raise their hands in agreement.

Still, I have never spoken to a doctor who was willing to swear that screening for colon cancer by means of FOBT alone was, objectively, a preferred option; or to one over age 50 who had not him/herself opted for cancer screening via colonoscopy. This is because at a personal level the good docs understand all too well that FOBT, while cheap and expedient, is so “non-specific” and random in its ability to catch cancer at an early, curable stage that it is only really effective when used in addition to periodic screening by colonoscopy.

Nonetheless, in the view of many health care organizations, screening for colon cancer by FOBT alone is a useful and acceptable practice since it has the potential to eventually discover the presence of cancer. What it doesn’t have is anything like the ability of colonoscopy to find many colon cancers at an early, curable stage – or like for me, in the pre-cancerous, no big deal stage.

Similarly, I have never found a VA or military service or Justice Department attorney willing to focus his expert witnesses’ testimony on the argument that government health care systems (such as the VA and military) shouldn’t be expected to provide the sort of ‘Cadillac care’ that folks with private insurance have come to expect, including colon cancer screening by colonoscopy. Government healthcare bean counters may think that, and the VA and military may shape their cancer screening guidelines accordingly, but their lawyers know not to stress that argument.

Commendably, it seems that at least some VA healthcare centers have recently started to provide colon cancer screening by colonoscopy for low-moderate risk patients, but the waiting list for those exams is long. The decision to undergo colon cancer screening by colonoscopy should be the product of an informed decision by the patient, based on reasonable (and candid) information from their primary care provider about the risks and benefits of various screening methods. If you are a low-to-moderate risk patient (which basically includes everybody age 50 and over with no family history for colon cancer) and conclude that you are in need of colon cancer screening by colonoscopy, there is no harm in asking that your VA health care provider refer you for a prompt screening colonoscopy. If they won’t, sound off. Let your VA medical center ombudsman, the chief of that facility’s medical staff, and your congressperson hear about it. The same goes double if you are a high-risk candidate for screening (blood relatives with colon cancer, or a personal history of colon polyps).

Finally, if you detect signs of rectal bleeding on toilet paper or in your stool, let your primary health care provider know about it ASAP, and ask them whether you should receive prompt colonoscopy for diagnostic (not screening) purposes in order to rule-out the presence of cancer.

Joe Callahan

At least 13,000 U.S. veterans have been warned in the past two years that their blood should be tested for potentially fatal infections after possible exposures by improper hygiene practices at five VA hospitals in Tennessee, Ohio, Florida, Georgia and Missouri.
Channel 4 News first uncovered problems at the Murfreesboro, Tenn., VA hospital back in 2009. After the investigation aired, notices went out to thousands of veterans about mistakes the York V.A. hospital had made cleaning its equipment.

Herman Williams was one of those veterans getting the warning about his visit to a VA facility in Ohio. Williams came home safely after fighting in the jungles of Vietnam as a Marine. He was shocked to learn four decades later that his military service had again placed him in jeopardy -- this time, because he got a tooth pulled.

This Memorial Day finds the Department of Veterans Affairs under political fire and numerous veterans upset after enduring fear and uncertainty over their health.

"I was scared to death," Williams said. One afternoon this winter, Williams received a letter warning that he could have been infected during tooth extraction and other procedures in the dental clinic at the Dayton VA Medical Center. A VA investigation found that a dentist who practiced there for decades repeatedly violated safety measures such as failing to sterilize equipment or change soiled latex gloves, potentially exposing patients to HIV, hepatitis, or other blood-borne diseases.

For two anxious weeks, the 60-year-old Springfield, Ohio, man wondered and worried about himself and his family's health. "HIV ... that's something to be afraid of. AIDS is no joke. If you're positive, then your wife, everybody around you, needs to be tested. "I didn't know what was going to happen." As with the vast majority of veterans tested, Williams' results were negative.

So far, VA officials say, tests on nearly 12,000 patients have found eight HIV-positive results and 61 confirmed cases of hepatitis B or C, including three hepatitis cases at Dayton. It's not known how many of the positives resulted from treatment at VA hospitals or from unrelated causes -- officials say testing may not be able to determine the origin of the infections. Infections related to medical treatment are a problem at public and private hospitals nationwide. The VA, as a government entity, must report infections publicly but most public and private hospitals do not.

The Veterans Affairs system that serves about 6 million vets a year in more than 1,000 medical facilities has been praised by medical authorities for its successful efforts to reduce antibiotic-resistant staph infections from treatment, a common problem in U.S. hospitals. A study published last month in The New England Journal of Medicine reported VA hospitals reduced such infections by 60 percent in intensive care units around the country after three years of emphasizing hygiene education and sanitizer availability in its facilities.

Diane Pinakiewicz, president of the advocacy group National Patient Safety Foundation, agreed that VA health care has done exceptionally well on the problem of health care-associated infections, which the U.S. Centers for Disease Control and Prevention estimates afflict 1.7 million patients nationally, killing 99,000 people and costing up to $34 billion a year. Many hospitals have balked at pushes for greater transparency about infections, citing issues ranging from inconsistent reporting standards to patient privacy. "It's not a small problem," she said. "It's something patients should be aware of and very concerned about."

VA officials say their overall record of providing care for veterans is strong, and that critics shouldn't generalize about VA care from the series of hospital infection cases in the last two years. The Disabled American Veterans, which represents some 1.2 million veterans, rallied to the VA's defense as criticism grew. "VA health care is clearly the best anywhere and has been so deemed by numerous private entities," Wallace Tyson, the group's national commander, said in a statement late last year. But subjecting those who had put their lives on the line for their country years ago to such alarming potential harm infuriates VA critics.

There are stories like those of Tom Sharp, 63, a Vietnam veteran from Springfield. He wasn't notified for testing -- the Dayton VA has contacted only the 535 patients who received invasive procedures such as extractions and root canals from the dentist from 1992 through last July 28. But Sharp has gotten his health and dental treatment at the center for nearly four decades, so he was worried after seeing TV reports of the dental clinic problems. "It tore me up. I was really nervous," Sharp said. "I go all my life, and then this. This is abhorrent, that any patient who entered a VA hospital would be placed at such risk," said Rep. Mike Turner, R-Dayton. "Our veterans deserve the quality of care they were promised."

In February, surgeries were halted temporarily at the Cochran VA Medical Center in St. Louis after potentially contaminated surgical equipment was discovered. Last year, improper equipment sterilization at the same center's dental clinics caused the VA to offer testing to 1,800 veterans who may have been exposed to blood-borne infections. "In my years in public service, this is one of the issues that has made me madder than anything I've ever seen," Rep. Russ Carnahan, D-Mo., said after the latest problems.

In 2009, about 10,000 veterans treated at hospitals in Augusta, Ga., Miami and Murfreesboro, Tenn., were informed they could have been exposed to infection during colonoscopies or endoscopic procedures because of improperly cleaned equipment. Surprise inspections at 128 VA facilities afterward found all were following proper procedures, the VA said. At the Dayton center, whose first patients were Union Army veterans of the Civil War, an employee complaint last July brought VA investigators, who learned that dental instruments weren't properly cleaned between patients and that sterilization of instruments was skipped entirely.

One dentist, the employees reported, sometimes left his gloves on between patients, answering his cell phone or drinking coffee -- routine behavior by him since at least 1992. Employees told investigators a supervisor had been notified but didn't respond. The investigation began in late July and the clinic was closed for nearly a month in August. "We were horrified and surprised," Dr. John Daigh, an assistant VA inspector general, said in a congressional hearing. The dentist has denied the allegations, blaming co-workers he said were out to get his boss. The VA won't confirm the dentist's identity, but Dr. Dwight Pemberton, 81, told the Dayton Daily News in an interview this month that he had put no patients at risk and had been falsely blamed. With administrative action against him pending, Pemberton retired this year after more than 30 years with the agency. The hospital's director was reassigned, and the newspaper reported Pemberton's supervisor was fired.Some in Congress say VA officials have been slow to make needed changes at the hospitals to prevent recurrences, and generally were reluctant to share information or cooperate with their fact-finding efforts.

"You neglect the basic issues of communication and accountability," Rep. Bob Filner, D-Calif., told VA officials in a recent Washington hearing. Sen. Sherrod Brown, D-Ohio, has questioned what he saw as a lack of urgency in responding to the Dayton issues, with six months passing before veterans were notified for testing. Turner and a local independent task force have urged broader testing of the clinic's patients and for reforms in the center's training and openness. The investigations have suggested that a culture of secrecy and fear of retribution contributed to the problems.

Daigh said he considered the Dayton VA dental clinic "an outlier," and not typical of VA operations. William Montague, a longtime VA hospital executive called out of retirement in March to lead the Dayton hospital, said officials have stepped up efforts to encourage problem reporting, from anonymous employee surveys to confidential face-to-face meetings with him.

The clinic adopted a "dental dashboard" system of checks on equipment and procedures and frequent drop-in inspections of the clinic rooms. Montague said this month that two hospital employees have been disciplined recently for not following hygiene procedures, although he declined to give details. Montague, who last headed the Cleveland VA hospital, has gone out to talk at American Legions, VFW halls and anywhere else he can find veterans to tell that problems in Dayton have been cleaned up. "We had a situation that was dealt with effectively, but slowly. And because we were slow, we appeared resistant or secretive. For that, I apologize. We should have been quicker. We should have been more transparent," he told The Associated Press.

"I can assure people that dental is completely safe, as is the rest of the hospital," he said. "The Dayton VA is a first-class organization." Jerry Adams, a Vietnam vet who comes to the Dayton VA for diabetes treatment, said he's generally pleased with the care he receives there, but he's still disquieted by the dental clinic problems. The Sidney, Ohio, man, age 64, said he will continue relying on his wife's insurance for his dental care elsewhere. "I had been considering trying a dentist here, but not now," he said. "Not after this."
 

When the Virginia Board of Medicine reprimanded Dr. David Ostman in 2004 for posing a danger to the health and welfare of his patients, it included one reassuring note. He had closed his private practice and been hired by the Hampton VA Medical Center, where, the board noted, his work would be supervised and subject to strict quality assurance standards.

That was not, it turned out, enough to head off more trouble for Ostman.

A pending malpractice lawsuit against the Hampton veterans center alleges that the gynecologist negligently perforated a patient's large intestine and punctured her bladder during a hysterectomy in 2008. That required a repair procedure that left her with a temporary ileostomy, a surgical opening in the abdomen that allows body waste to be collected in a pouch. The lawsuit alleges that Ostman failed to properly identify the patient's anatomy or to consult a colleague with more surgical experience for assistance. He is alleged to have used a "blunt dissection," pulling the patient's organs apart with his hands rather than using scissors, resulting in the injuries to her intestine and bladder.

The plaintiff, Miriam Cenedese of Portsmouth, is seeking $1.875 million in damages. She filed the lawsuit in federal court after an administrative claim for compensation was denied by the U.S. Department of Veterans Affairs. The medical center has denied the allegations in court papers. No trial date has been set. The principals in the case declined to be interviewed for this report. Citing privacy policies, VA officials declined to say whether they knew Ostman was under investigation by the state Board of Medicine when he was hired in June 2003 as a staff physician. He is still on the medical staff at the Hampton center.

In an order filed in October 2004, the state board found that Ostman had violated a variety of laws and medical regulations from December 2001 until he closed his private practice in May 2003. During that time, the board found, he wrote 225 prescriptions for "Libido Lotion," a topical preparation containing testosterone, outside of a bona fide doctor-patient relationship. He took orders for the product through his website and sent the prescriptions to a pharmacy in St. Louis, where it was prepared and mailed to his customers.

Testosterone, while commonly thought of as a male hormone, has been shown to boost sex drive in some women. But it has not been approved for that purpose by the U.S. Food and Drug Administration. The Virginia board also found that Ostman sold or dispensed thousands of doses of various prescription medications - the appetite suppressant phentermine, the narcotic pain reliever hydrocodone, and anti-anxiety drugs sold under the trade names Xanax and Valium - without holding a pharmacist's license. In a drug audit of his office in May 2003, hundreds of doses of federally controlled drugs could not be accounted for.

The board also found that Ostman prescribed weight-loss drugs to five patients without performing appropriate physical examinations, recording a comprehensive medical history or documenting any diet or exercise program. Ostman admitted the truth of the board's findings. He was reprimanded, fined $2,500 and ordered to take a course in medical recordkeeping.

As a result of the Virginia action, medical boards in North Carolina and Georgia, where Ostman was also licensed, reprimanded him as well. In November 2005, the Virginia board found that Ostman had fulfilled the requirements of the 2004 order and restored his license to unrestricted status. VA officials declined to say when they became aware of Ostman's disciplinary record.

Jennifer Askey, a spokeswoman for the Hampton center, said the VA requires all of its doctors to have a full, current, unrestricted medical license. Licenses are verified with the licensing agency at the time of initial employment, at license renewal times, and during periodic reappraisals by the medical staff, which occur at least every two years, Askey said.

All state medical board sanctions of VA doctors are researched by the center's medical examining board, Askey said. State board reprimands, fines and continuing medical education requirements do not bar a doctor from VA employment, she said. Jim Strickland, a former Army medic and retired hospital administrator in Savannah, Ga., who runs the website VA Watchdog Today, said the Ostman case is not unusual.

"Doctors that have problems, that have had civilian issues, can get hooked up in VA hospitals," he said. "The real issue here, from my perspective, is that once they're entrenched, you can't get rid of them."

If the law is overturned, it could expose the federal government to billions of dollars in liability claims.