Thursday, May 30, 2013

"Backlog of disability claims not only problem facing this agency."

Part VI of a series
by Nicholas J. Vocca

U.S. District Judge Adalberto Jordan ruled in favor of Air force veteran Robert Metzler and his wife by awarding them $1.25-million on Wednesday, November 12, 2012, as compensation in their medical malpractice suit against the U.S. government after Mister Metzler had become infected with Hepatitis C when personnel at the Miami, Florida VA Hospital failed to properly clean colonoscopy equipment prior to performing that procedure on him.

According to the Veterans Affairs own Administrative Review Board, Metzler was one of more than 11,000 veterans who had received colonoscopies with improperly cleaned equipment between 2004 and 2009 at VA Hospitals in Miami, Florida, Mufreesboro, Tennessee, and Augusta, Georgia.

Metzler, who received his colonoscopy in 2007, had tested negative for Hepatitis C the year before.  Then, in 2009, he tested positive for the virus two days after receiving a letter from the VA warning him of being a "potential risk" related to the equipment used in his procedure.

The U.S. Attorney's office defending the VA acknowledged the Miami VA Hospital had "breached" a "duty of reasonable care," but denied the equipment caused any health problems.  If this were so, and there were no risks of any health problems related to the colonoscopy equipment used, why then did the VA send out warning letters?

In his testimony, Doctor David Nelson, a board-certified doctor in internal medicine, said that there was a "less than 0% chance" that Metzler contacted Hepatitis C through his colonoscopy, according to court records.

Despite acknowledging that the records from the Veterans Affairs "strongly suggest" that Metzler couldn't have been infected by the colonoscopy, Judge Jordan said that the veteran had no other risks associated with contracting the virus.

"I realize that the chances of acquiring Hepatitis C under these circumstances are slight.  But I find that there is nothing to preclude Mister Metzler from being one of those two persons in a trillion or billion who do get the virus," Jordan wrote.

On the website, it was reported on April 2, 2009, that the Miami VA was "warned by the Department of Veterans Affairs about potential problems with the colonoscopy equipment," and asserted that "the hospital checked its equipment and reported everything fine...that is, until a more extensive review later found problems."

The potential problem was first brought to the fore on December 22, 2008, when the VA issued a patient safety alert to every VA medical center and clinic, warning them of possible contamination problems with colonoscopy equipment based on reported incidents at the VA Hospital in Murfreesboro, Tennessee, where it was discovered that subject equipment was being cleaned at the end of the day, instead of after each procedure.

In January, 2009, the Miami VA Hospital once again reported that everything was fine.

Over a three-day period starting February 10, 2009, a total of 7,500 veterans in Augusta, Georgia and the Alvin C. York VA Hospital in Murfeesboro, Tennessee were sent warning letters.  According to records, those from the Murfreesboro VA received letters informing them that "improperly assembled equipment" might have exposed them to cross-contamination between April 23, 2003, and December 1, 2008. 

In February, 2009, the Augusta VA warned 1,100 patients that they may been exposed to the Hepatitis B, Hepatitis C, and even HIV, during endoscopic procedures at its ear, nose, and throat clinic between January and November of 2008.

Between March 8 and 14 of this year, the U.S. department of Veterans Affairs issued updated alerts to all hospitals and clinics directing them to check again for improper procedures and establish new training protocols.

During the course of a second inspection at the Miami VA, more problems were found...2-months after that hospital had issued an "all clear" statement.

On March 23, Miami sent letters to 3,260 more veterans with regard to possible infectious diseases from colonoscopy procedures.

While it has been reported that the 16 veterans who tested positive for the hepatitis virus between the Murfreesboro and Augusta VA Hospitals have yet to be proven as being directly linked to the colonoscopy and endoscopy debacle, the fact remains that 16 out of 11,000 have been infected, and this ratio of infected individuals is much worse than the previously reported odds.

No veteran has tested for HIV, so far.  However, Hepatitis B represents a serious infection, and Hepatitis C can be fatal.

At the Murfreesboro VA, four veterans have tested positive for Hepatitis B, and 6 for the deadly Hepatitis C. 

Though VA spokeswoman Katie Roberts stated that "We take full accountability" in putting these veterans at risk, she did not say whether the VA would be willing to pay for treatment.  Neither did she reveal if the VA would be prepared to pay compensation damages.

In its editorial on this issue, the Miami Herald called the oversight "stunning and completely unacceptable.  Putting lives at risk through carelessness is inexcusable."

Meanwhile, veterans and their families are incensed at how the mere act of attempting to be proactive about one's health has potentially put them at risk, and further fumed about how it took the both the Department of Veterans Affairs and individual VA Hospitals several years to detect this life-threatening problem.

"Veterans who attend VA clinics and hospitals as a way of being proactive about their health should not be exposed to potentially life-threatening diseases because of the carelessness and negligence of VA personnel to adhere to sound medical and sterilizations procedures," wrote one angry veteran.

Another veteran says that these "disturbing incidents" certainly give "new meaning to how the VA has long shoved it up the rear of our nation's men and women who served it."

We agree.

Is there verbal, physical, and emotional abuse in our nation's VA Hospitals, and have VA employees dealt drugs to veterans?  We shall see in our next part of the series.

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