If you are a veteran you should read this, or if you have already dealt with the VA perhaps you shouldn’t. It will only raise your blood pressure and destroy any faith you might have had in the system.
This is from a story in the NYT – “At V.A. Hospital, a Rogue Cancer Unit:”
For patients with prostate cancer, it is a common surgical procedure: a doctor implants dozens of radioactive seeds to attack the disease. But when Dr. Gary D. Kao treated one patient at the veterans’ hospital in Philadelphia, his aim was more than a little off.
Most of the seeds, 40 in all, landed in the patient’s healthy bladder, not the prostate.
It was a serious mistake, and under federal rules, regulators investigated. But Dr. Kao, with their consent, made his mistake all but disappear.
He simply rewrote his surgical plan to match the number of seeds in the prostate, investigators said.
The revision may have made Dr. Kao look better, but it did nothing for the patient, who had to undergo a second implant. It failed, too, resulting in an unintended dose to the rectum. Regulators knew nothing of this second mistake because no one reported it.
Two years later, in 2005, Dr. Kao rewrote another surgical plan after putting half the seeds in the wrong organ. Once again, regulators did not object.
Out of 116 cancer treatments 92 were botched, investigators knew about the problem and helped cover it up. Nobody has been punished and aside from closing a couple of units the VA has taken no action.
After learning of Dr. Kao’s error, V.A. officials thought that because he had revised his surgical plan while still in the operating room, the mistake did not exist. The nuclear commission agreed, on the ground that doctors needed freedom to revise their surgical plan depending on what they found during surgery.
Yet this case did not involve a new diagnostic interpretation: it was an implant mistake, causing the patient to return for another procedure.
Dr. Charles M. Anderson, who heads the V.A.’s national radiation safety committee, said it was “not good medical practice” to have to redo surgery.
“not good medical practice” —A politically correct term for incompetence.
The substandard implants might never have been discovered were it not for a clerical error.
In the spring of 2008, a radiation safety official at the V.A. mistakenly ordered seeds of lower strength, and they were implanted.
After the error was discovered, according to the nuclear commission, the V.A.’s national radiation safety unit asked the hospital to examine 10 to 20 more cases to see if the problem had occurred before.
It had not. But investigators found something more troubling: four instances where seeds were implanted in the wrong places. As more cases were examined, more mistakes were found.
The investigators obviously didn’t care when they discovered this medical malfeasance. Instead it took a file clerk to point the way to the problem.
Susan Phillips, a senior executive at Penn’s medical school and health system, said Dr. Kao had voluntarily given up his clinical privileges there, though he continues to do research on campus. Dr. Kao did an unspecified number of brachytherapy procedures at the campus hospital with no apparent problems. A check of state and federal records over the last decade in Pennsylvania turned up no malpractice or disciplinary actions against Dr. Kao.
Back in West Virginia, Pastor Flippin said he continued to try to build up his small church while dealing with the side effects of his implant. After 21 years of serving his country, he had hoped for a better ending.
“It’s not fair,” he said. “Any veteran should expect more than what we’re getting.”
The Philadelphia prostate unit was closed after problems began to surface in mid-2008, and it has yet to reopen. The V.A. has also suspended the implants, known as brachytherapy, at hospitals in Jackson, Miss., and Cincinnati, though neither had problems on a scale of Philadelphia’s.
Let me repeat myself: Out of 116 cancer treatments 92 were botched, investigators knew about the problem and helped cover it up. Nobody has been punished and aside from closing a couple of units the VA has taken no action.
Dr. Kao’s lawyer says it’s not the doctor’s fault. –Then who? pray tell, did the procedures?
Dr. Kao and the other people who are responsible still continue to practice medicine and live their lives as if nothing happened while their victims continue to suffer.
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