Casualties of care

Casualties of care

In February 2012, Dr. Katherine Mitchell warned the new Phoenix VA Medical Center director that the hospital’s emergency room was so dangerous it should be closed unless there was an immediate increase in staffing and triage-nurse training.

By then, Mitchell had been voicing concerns over delays in treating heart attacks, infections, blood pressure problems and other medical issues in the emergency room for more than two years.

“There were hundreds of cases of near misses or bad outcomes,” she says. “We needed more staffing and more triage-nurse training, but there wasn’t any money.”
Absent changes, patients would die, she argued.

Mitchell’s impromptu meeting with now-dismissed director Sharon Helman touched off 18 months of reprisals that included Mitchell being forced to take a job in a small outpatient clinic. She was then placed on administrative leave in September 2013 and told she was under investigation after filing what she thought was a confidential complaint with the VA inspector general. Her concerns remained buried until Phoenix became ground zero in the VA scandal last spring – concerns she doubts will ever be addressed.

Mitchell’s experience illuminates a crisis that goes far beyond secret patient waiting lists and VA administrators falsifying records. Her story bolstered a litany of what were called “preventable deaths” at VA facilities, caused by a surge in patient demand, mismanagement, unsanitary conditions, understaffing, a lack of accountability and a culture of retribution.

“It’s a two-pronged issue,” Mitchell says. “There’s a lack of funding for medical providers and ancillary resources. And when physicians or providers bring up issues, they are retaliated against.”

As former Pittsburgh VA physician Victor Yu puts it, “When there is a problem at the VA, there is little effort to correct it. And huge effort to minimize it.”
Casualties are everywhere. Army veteran Barry Coates is dying of cancer because the Columbia, S.C., VA failed to perform a routine colonoscopy until it was too late. Similar VA errors caused the deaths of six other South Carolina veterans. Three preventable deaths came to light in the Memphis, Tenn., VA emergency room, including a patient’s lethal allergic reaction to a drug his medical chart clearly indicated he should never receive.

A suicide and two overdose deaths at the Atlanta VA were caused in part by failures in management, leadership and oversight, the VA inspector general concluded. A Legionella outbreak in Pittsburgh VA was blamed for killing at least six veterans and infecting as many as two dozen others.

A Korean War veteran suffered a stroke and later died at the Dallas VA Medical Center as a result of botched surgeries to remove a lump from his neck. A Navy veteran who had threatened to commit suicide hanged himself with his own belt hours after being admitted to the Buffalo, N.Y., VA Medical Center. All of this is in addition to claims from Sam Foote, a former VA doctor, that some 40 veterans died waiting for care in Phoenix.

The total number of veterans who needlessly died at VA hospitals in recent years will never be known. But VA paid $200 million in wrongful death settlements to the families of nearly 1,000 veterans in the decade following 9/11, according to the Center for Investigative Reporting. And despite scores of investigations, congressional hearings and whistleblower complaints, many VA executives focused their resources on hiding problems rather than fixing them, which ultimately led to the resignation of former VA Secretary Eric Shinseki.

“I was too trusting,” Shinseki said before stepping down in May. “We now know that VA has a systemic and totally unacceptable lack of integrity within some of our veterans health facilities.”

“Patient deaths are tragic – preventable deaths are unacceptable,” then-American Legion National Commander Dan Dellinger said as Mitchell, Foote and other VA physicians went public with their concerns. “But failure to disclose safety information – or worse, to cover up mistakes – is unforgivable.”

Short staffed Mitchell encountered problems soon after she went to work as a nurse at the Phoenix VA Medical Center in 1989. She recalls VA refusing to provide nutritional assistance for low-income patients with feeding tubes when they were sent home on weekend passes. So Mitchell and other nurses acquired liquid meal supplements from other parts of the hospital that the patients could use during their furloughs. In addition, “we were always short-handed,” she says.

Nevertheless, Mitchell – who comes from a family of soldiers and Marines – so enjoyed working with veterans that she went to medical school and returned to the Phoenix VA as an emergency room doctor in 2003.

The emergency room was so short-handed that medical staff had to answer phones, transport patients to radiology for X-rays, wash stretchers and perform other duties that aides would traditionally handle. Those shortages were exacerbated by low pay – an experienced VA doctor earns about the same as a new non-VA physician – and slow hiring procedures, Mitchell says. The Phoenix VA never had a full complement of emergency room physicians because candidates, weary of the process, gave up and pursued other jobs, she adds.

Lab wars Shortsighted management also appears to have created prime conditions for the Legionella resurgence that killed Maureen Ciarolla’s father and at least five other veterans. In 2006, Pittsburgh VA Healthcare System Director Michael Moreland closed the Special Pathogens Lab, which analyzed Legionella specimens from hospitals all over the United States, and told lab director Yu and renowned microbiologist Dr. Janet Stout that their pioneering infectious-disease work was no longer needed. “Mr. Moreland said we were using resources, and we were really unnecessary,” says Yu, a professor of medicine at the University of Pittsburgh. “It’s extraordinary and tragic.”

Established in 1979, the lab developed the premier tools to identify and fight Legionella bacteria, which is transmitted via inhaled water droplets and causes a virulent pneumonia. Yu and Stout also proved the effectiveness of a new water disinfection system – copper-silver ionization – that helped prevent Legionella infections at the Pittsburgh VA for more than a decade. They published more than 100 research articles on Legionella control, treatment and prevention. Stout’s request for a raise, after 20 years, drew the ire of VA administrators who instead decided to close the lab. She and Yu came to work one Monday in July 2006 to find the lab doors locked and police standing guard. “I was shocked – and shocked at the way it was done,” she says.

The American Federation of Government Employees stopped VA’s attempt to fire Stout. But she resigned after VA closed the lab and demoted her. Yu was fired for continuing to analyze Legionella specimens while he appealed the decision to close the lab. As he was leaving the Pittsburgh VA he received a letter thanking him for that 11th-hour work, which helped stop an outbreak that had contaminated drinking water at a VA medical center in the Southwest.

Stout had arranged to transfer the lab’s specimen collection – invaluable for infectious-disease research and prevention – to the University of Pittsburgh. The Pittsburgh VA instead destroyed it. “It was gut-wrenching,” she says.

The American Legion, along with University of Pittsburgh medical school faculty and some members of Congress, protested the lab’s closure. Five years later, Ciarolla’s father contracted Legionella and died after a lengthy stay at the hospital. An investigation by the CDC revealed that 32 cases of Legionella were detected at the Pittsburgh VA between January 2011 and October 2012. That micro-pandemic was inevitable given VA’s decision to close the lab, Ciarolla told Congress last fall. “And veterans paid the price.”

Not only did Pittsburgh VA administrators hide the most recent outbreak until it was leaked to a local newspaper, but they have also hidden Legionella cases dating back to the lab’s closure, Yu says. “The real date for the beginning of the outbreak is 2007.”

Moreland went on to become VA regional director for Pennsylvania and surrounding states. He received a $63,000 bonus after the VA inspector general criticized the Pittsburgh hospital’s handling of the outbreak. He subsequently retired from VA.

Suicide watch A rash of suicides has also plagued VA. Cheryl Placek’s son sought VA’s help with a painkiller addiction he developed after he injured his back. The Navy veteran had attempted to get treatment at three private hospitals before landing at the Buffalo VA Medical Center in January 2012. Daniel Placek was despondent, threatening suicide and in a drug-induced psychosis, his mother says. “VA knew he was in serious trouble ... knew he was talking like he didn’t want to live. We had to beg for three weeks to get him in.”

Less than 12 hours after Daniel was admitted to the Buffalo VA inpatient substance abuse program, Placek got the call that her son had hung himself in a hospital bathroom. “He’s our only child,” she says, her voice breaking.

Brandie Petit’s brother went to the Atlanta VA for counseling in November 2012 during a long struggle with debilitating knee injuries that had ended his Army career 20 years earlier. VA lost track of Joseph Petit soon after he saw his psychiatrist. They found his body in a hospital bathroom the next day, after his mother and sister called the Atlanta VA to check on him.

Strung out on a 30-pill-a-day regimen VA doctors had prescribed, Joseph was worried he was going to hurt someone, his sister says. “Instead, he took his own life. He should have never had the opportunity.”

VA watchdog VA’s preventable deaths have received sustained scrutiny from House Veterans’ Affairs Committee Chairman Jeff Miller, R-Fla., who has conducted hearings, subpoenaed agency records, and called on VA officials to demonstrate they are serious about changing the culture. “The single most important mission of VA is to provide the highest quality of care for the men and women who have served, and support for their families,” Miller says.

That would go a long way toward addressing VA’s preventable-deaths problem, John Daigh Jr., assistant inspector general for health-care inspections, said during a congressional hearing in April. “The unexpected deaths that the (OIG) continues to report on at VA facilities could be avoided if VA would focus first on its core mission to deliver high-quality health care.”

Acknowledging the agency’s failures, VA Robert McDonald has raised physician salaries, visited troubled VA hospitals, fired employees and administrators. He told CBS’ “60 Minutes” that he has a list of 1,000 additional employees who may face disciplinary action. McDonald has also warned VA administrators not to punish whistleblowers. Current and former medical staff are skeptical.

“The top echelon of the VA is essentially a huge web where the people are all protected by each other,” Yu says. “The tragedy is (that) VA can be a good place. The physicians and nurses are more dedicated than the medical staffs in other hospitals.”

Mitchell and her colleagues, too, say they have more fear than hope. “The feeling is that this is only a temporary change, a lull in the malevolent administrative storm, which will end as soon as the cameras are turned off,” she says. “When the storm resumes, so will the retaliation against anyone who brought issues to the attention of the OIG or the public. I feel like a canary just waiting for the cat to pounce.”

Ken Olsen is a frequent contributor to The American Legion Magazine.