More bad news

[SuperScout]

Investigators flagged 19 deaths over the past two years at a Department of Veterans Affairs hospital in southern Illinois as possibly linked to substandard care, an angry VA official said Monday as he apologized to affected families and pledged reform.
The hospital in Marion, Ill., undertook many surgeries that its staffing or lack of proper surgical expertise made it ill-equipped to handle and hospital administrators were too slow to respond once problems surfaced, said Dr. Michael Kussman, U.S. veterans affairs undersecretary for health.
"I can't tell you how angry we all are and how frustrated we all are. Nothing angers me more than when we don't do the right thing," Kussman told reporters during a conference call after releasing findings of the VA's investigation and summarizing a separate Inspector General's probe.
Still, Kussman insisted, "what happened in Marion is an exception to what otherwise is a truly quality health care system" across the VA.
The VA will help affected families seek compensation, either through claims against the U.S. government or with the VA's disability compensation program, officials said.
The VA investigation found that at least nine deaths between October 2006 and March of last year were "directly attributable" to substandard care at the Marion hospital, which serves veterans from southern Illinois, southwestern Indiana and western Kentucky.

Kussman declined to identify those cases by patient or doctor, though Rep. Jerry Costello, a Democrat from Belleville, Ill., said those nine deaths were linked to two surgeons he did not name.
Of an additional 34 cases the VA investigated, 10 patients died as the result of questionable care that complicated their health, Kussman said. Investigators could not determine if the care actually caused the deaths.
The VA's investigation cited by Kussman covered a two-year span, the VA said.
The inspector general's office blamed three deaths on substandard care at the Marion site, but that review covered only the past fiscal year that ended in October, Costello said. That report was not immediately available Monday.
Telephone calls on Monday seeking comment from the Marion VA were directed to spokespeople with the agency's Washington headquarters.
Inpatient surgeries will remain suspended indefinitely at the Marion hospital, Kussman said. They have not been performed at the facility since problems first became public last August.
The next month, the VA installed interim administrators to replace the Marion VA's director, chief of staff, chief of surgery and an anesthesiologist, moving them to other positions or placing them on leave, Kussman said. The anesthesiologist has since quit, Kussman said.
"The previous leadership will not return" to their former jobs, he said.
Neither Kussman nor the VA investigation's 41 pages of findings named surgeons involved in the deaths, though Kussman acknowledged that much of the criticism has focused on Dr. Jose Veizaga-Mendez.
Veizaga-Mendez — identified in Monday's report as "Surgeon A" — resigned from the hospital on Aug. 13, three days after a patient from Kentucky bled to death after gallbladder surgery. All inpatient surgeries stopped a short time later.
Sen. Dick Durbin, an Illinois Democrat, has said Veizaga-Mendez is linked to 10 patients' deaths at the Marion site, about 120 miles southeast of St. Louis. Kussman declined to discuss it Monday, saying he didn't want to influence additional internal investigations of six of the site's surgeons he said had "at least one episode of substandard care."
Veizaga-Mendez and another surgeon no longer practice at the Marion VA. The remaining four surgeons remain on staff but are "only doing minor cases at this time," Kussman said.
"We don't think the physicians killed the patients," he said. "We think the physicians were trying to care for the patients and did so in an inadequate way."
Costello and fellow Rep. John Shimkus, a Republican from Collinsville, Ill., called Monday's findings "shocking." Durbin said the reports "confirm what many of us in Illinois feared" — that the Marion VA's medical care was substandard and protocol for protecting patients was ignored.
"As the inspectors who reviewed the Marion hospital put it, the quality of care at Marion was `horrible,"' Durbin said.
Veizaga-Mendez's whereabouts are unclear. He has no listed telephone number and has been unreachable for comment.
The Marion VA hired Veizaga-Mendez in January 2006 after he practiced in Massachusetts, where he was under investigation for substandard care in 2004 and 2005. The claims include allegations that he botched seven cases, two ending in deaths.
Veizaga-Mendez was permanently barred from practicing medicine in Massachusetts last November — a disciplinary move that also requires him to resign other state medical licenses he may hold and withdraw pending license applications. He has also made payouts in two Massachusetts malpractice lawsuits.
The trouble at the Marion VA caught Congress' attention last November, when Durbin and other federal lawmakers from Illinois introduced measures they said would tighten protocols for hiring doctors and bolster quality control across the nation's VA system.
In pledging reforms, Kussman said the VA has launched an administrative investigatory board to review care issues and matters raised by employee groups.

[Packo]

This is nothing new as you well know. When I finally had my first hip replacement in 86' it was done in the Washington DC VAMC. It was the most horrible place I'd ever been in....other than Vietnam of course. I've talked about it many times but the point is, I don't think Marion is an anomaly. You would think the VAMC Charleston SC would be a nice hospital. Nope....more like Marion. I was lucky to escape both of those places with my life. The operation, that I did not need, caused me more pain afterward than I had getting wounded in the first place. Imagine a hospital with no hot water for a shower. That's just one of the minor things.....but unreal, no hot friggin' water. A buddy of mine who was a VA Doctor chose to practice with the VA because he was a veteran, did not come from a rich family, so he could not just jump into private practice due to student loans. He was appalled by the doctors he found at Martinsburg VAMC. The head of "internal medicine" was not even board certified in IM. My buddy was. The "Chief of Staff" had been sued so many times that he literally lived on the hospital site, for free. The original site was an Army Hospital completed right at the end of WWII. It wasn't needed so given to the VA, therfore they had some houses. He went to his house for dinner and his wife served Hamburger Helper and they sat on basically lawn furniture. He said that the guy was the dumbest Doc head ever met and said it was scary he was in the position he was. When the VA found out my buddy was a veteran, upset with the hospital, and was also doing C&P exams, they forbid him from doing any more C&P'S stating that as a veteran he would be prejudiced in his decisions. He had to eventually transfer to another VAMC due to the harassment he started getting for rocking the boat. I could go on...forever, but I'm getting pissed as we speak. This is no new problem.....it's been going on for at least 45 years.

I have a MRI today at VAMC Charleston. If you don't hear from me again.....they probably killed me. These kind of things are the only thing I really allow the VA to do after the last operation. I am eligible for all care including dental....but have to maintain Blue Cross/Blue Shield because the VA will never touch me again for anything other than minor tests and taking care of my blood pressue, pain meds for my hip, and I love my VA shrink at the Beaufort VAOPC. What a shame that a fully entitled combat wounded veteran is afraid to use the system set up for him/us.

Pack

[Gimpy]

but one that COULD have been avoided!

If only the actual "promises" made more than seven years ago by GW Bush were kept!

This latest story is nothing new, it's the culmination nearly TWO (2) YEARS of neglect and misconduct within the highest levels of the VA, not just the inept and unqulaified doctors at the VA marion facility. The blame for this bullshit lies directly at the feet of the current Bush administration for allowing the conditions to floriish and worsen these past seven years (hiring practices, hiring "feeezes", lax or non-existent QC & safety procedues) and inadequate FUNDING that exacerabted an already cripled and suffering VAMC.

Former VA Secretary Jim Nicholson and now medical Director Michael Kussman were aware of these conditions as early as October 2006. What did they do???????

Not much, for sure.............It took Democratic Senators Dick Durbin and Barack Obama and their persistence in solving this problem to bring it to the forefront and get the wheels of justice spinning to get the necessary attention and action in place to get this mess cleaned up!

Innocence Lost: A chronological look at VA Medical Center woes

BY JOHN D. HOMAN
THE SOUTHERN


MARION - What started out as a significant but not horrendous story has evolved into the latter. The Southern was first to break the news on Sept. 7 that inpatient surgeries at the VA Medical Center in Marion had been suspended after an internal investigation.


Since that first story, much more has come to light. More than two months later, the VAMC remains under investigation by multiple sources. One former surgeon has lost his license to practice medicine in Illinois. The number of patient deaths is climbing as related to care administered by specific physicians.


Employees, past and present, are speaking out about other perceived atrocities from within the center.


Legislators, namely U.S. Sens. Dick Durbin and Barack Obama and their staffs, have devoted countless hours of research into queries and complaints lodged by constituents on a daily basis. There will be many more details to report in the weeks ahead.


Following is a chronological look at a series of events to date involving the VAMC at Marion:

l January 2006: January 2006: Dr. Jose Veizaga-Mendez was hired by Marion VAMC.


l October 2006-March 2007: October 2006-March 2007: Suspicious spike in deaths at VA Medical Center in Marion is noted (nine deaths vs. expected average of two deaths for that period).


l August 2007: August 2007: A patient of Veizaga-Mendez at Marion dies the day after a routine surgery. The patient's family files a notice of intent to sue for malpractice.


l August 2007: August 2007: Veizaga-Mendez resigns from Marion.


l Aug. 10: Aug. 10: VA headquarters in Washington, D.C. receives information about the spike in deaths at Marion.


l Aug. 29: Aug. 29: National Surgeon Quality Improvement Program investigation team sent to Marion.


l Aug. 31: Aug. 31: Inpatient surgeries at Marion VAMC suspended.


l Sept. 4: Sept. 4: VA Medical Inspector team sent to Marion.

l Sept.10: Sept.10: VA Inspector General Office notified of problems at Marion. It's requested that a team be sent to Marion.


l Sept. 14: Sept. 14: Marion VAMC hospital director and chief of staff reassigned.


l Sept. 17: Sept. 17: First Durbin/Obama letter sent to VA Secretary Nicholson expressing concern about the spike in deaths at Marion and requesting additional information.


l Sept. 24: Sept. 24: Second Durbin/Obama letter sent to Secretary Nicholson after learning of Dr. Veizaga-Mendez. Expressed concern about patient care provided by Veizaga-Mendez and about overall quality of care at the facility.


l Oct. 3: Oct. 3: Meeting between Durbin and VA Undersecretary for Health, Michael Kussman and Deputy Undersecretary for Health, Gerald Cross.


l Oct. 4: Oct. 4: McBrady addresses the media, explaining hiring practice procedures.


l Oct. 10: Oct. 10: VAMC spokeswoman Rebecca Shinneman says 45 patients, who were scheduled for surgery at Marion, had been referred to other hospitals.


l Oct. 11: Oct. 11: Third Durbin/Obama letter sent to Acting Secretary Mansfield asking for clarification on oversight and background checks performed on Veizaga-Mendez and throughout VA system.


l Oct. 15: Oct. 15: Response from VA received for first two letters.


l Oct. 15: Oct. 15: A number of current and former employees at Marion VAMC relay concerns and allegations of wrongdoing to new managers at Marion.


l Oct. 16: Oct. 16: Durbin/Obama letter sent to Secretary Dean Martinez at Illinois Department of Financial and Professional Regulation concerning the state investigation of Veizaga-Mendez.


l Oct. 17: Oct. 17: The Illinois Department of Financial and Professional Regulation in Chicago indefinitely suspends the license of Dr. Jose Veizaga-Mendez to practice medicine in the state.


l Oct. 17: Oct. 17: Jimmy McGlawn is named the new associate director of operations at Marion.


l Oct. 18: Oct. 18: Fourth Durbin/Obama letter sent to VA Secretary asking for additional clarification in their response to the first two letters and questioning the overall quality of care at Marion.

l Oct. 18: Oct. 18: Durbin staff visits Marion. Operating room manager tells of her concern and action to report problems. She tells Durbin staff she is concerned about retribution.


l Oct. 24-31: Oct. 24-31: Three additional Marion VAMC staff interviewed. All tell of serious problems with management and quality of care at the hospital. All report concerns over retaliation if they come forward.


l Oct. 25: Oct. 25: Meeting between Durbin and Acting VA Secretary Gordon Mansfield and Deputy Undersecretary for Health Gerald Cross. VA tells Durbin that no one had reported problems at Marion VAMC.


l Nov. 1: Nov. 1: Three additional doctors at Marion have their privileges restricted. Names not yet released.


l Nov. 2: Nov. 2: Durbin letter/conversation with VA Acting Secretary Mansfield requesting protection from retribution for Marion VAMC whistleblowers.


l Nov. 2: Nov. 2: Feeling the concerns originally relayed on Oct. 15 were ignored by managers at Marion and following assurances that they were protected from retribution, group of former and current employees send letter to VA Inspector General and Senate offices alleging wrongdoing at Marion VAMC.


l Nov. 6: A former patient of the Marion facility and two other VA officials testify before the Senate Veterans Affairs Committee in Washington, D.C. The hearing dealt with hiring practices and quality control issues at VA medical facilities, including Marion.


l Nov. 6: It is announced that a third investigative team from the VA in Washington will travel to Marion within the next week in light of recent allegations made by hospital employees.


l Nov. 9: Nov. 9: Durbin and Obama send a letter asking the Massachusetts Board of Registration in Medicine to confirm the doctor's role in seven cases under investigation in Massachusetts, two of which ended in deaths.


December 2007 thru Jan. 2008: VA IOG Report completed



Gimp


PS----------And I agree with you in one respect Packo my brother. There ARE doctors within the VA health care system that should NOT be allowed on the premises, much LESS practice medicine there. But, by and large...........this is NOT the overwhelming majority of them. Since I have been treated by several doctors down here at the Tampa VA facility I have as YET to come in contact with ONE SINGLE doctor that I feel is more than qualified, dedicated and professionally competent to treat ME or any other patient......and I have spoken with and have testimony from countless other veterans and their family members who feel the same way.

Now, I couldn't say that about the Atlanta VA as I'm sure you're aware. That SOB of a quack that nearly killed me has long been replaced at that VA, but I'm not sure of their "hiring practices" either!

But here in Florida at the Tampa and Bay Pines (in St. Petersburg) the care and treatment is FIRST RATE!