The inspector general of the U.S. Department of Veterans Affairs has found the Hampton VA Medical Center at fault after a doctor there failed to diagnose a Chesapeake veteran's stroke, leaving him permanently disabled.
The investigation also found that the vet's medical record contained lab results from another patient and that the medical center staff turned a deaf ear to his repeated complaints in the weeks afterward.
The veteran's complaints and the ensuing investigation prompted a series of corrective measures at the Hampton center, which serves a population of more than 200,000 veterans in eastern Virginia and northeastern North Carolina.
John Morgan, 53, a Marine veteran, was in the process of moving from Roanoke to Chesapeake in November when he began suffering slurred speech and weakness in his left leg. A volunteer paramedic, he had had a previous stroke in 1991 and thought he recognized the symptoms.
Morgan said in an interview that he went to the Hampton VA emergency room and told the attendant, "I'm having a stroke. Please help me."
Despite what the inspector general called "fairly classic stroke symptoms," the VA doctor failed to follow American Heart Association treatment guidelines, the investigation found. He sent Morgan home without ordering a CAT scan or consulting a neurologist.
The next day, Morgan's wife took him to Sentara Norfolk General Hospital, where he was found to have suffered a stroke and was hospitalized for six days.
In addition to missing his stroke, Morgan said, the VA doctor told him his lab results were "good" when in fact his blood glucose level was high. The investigation found a major documentation error that would explain that discrepancy: Another patient's lab results had been placed in Morgan's electronic medical record.
Finally, the investigation found that Morgan's repeated complaints about his treatment in Hampton - first to a patient advocate and later to the director of the medical center - went unanswered.
In response to the investigation, the Hampton center has developed new clinical guidelines for recognizing stroke symptoms, trained its staff in how to avoid misdirecting lab results and placed its patient advocates under the director's supervision.
The employment contract of the doctor who treated Morgan was not renewed.
Morgan, meanwhile, has since had another stroke and continues to suffer from slurred speech and problems with coordination and walking. He is unable to work.
A stroke occurs when a blood vessel that carries oxygen and nutrients to the brain bursts or is blocked by a clot. It is the third-leading cause of death in the United States and the No. 1 cause of permanent disability.
"It's very important that patients are diagnosed quickly when they've had a stroke because the neurons of the brain cells die very quickly after they're deprived of blood and oxygen," said Dr. Richard Zweifler, chief of neurology for Sentara Healthcare and a professor of neurology at Eastern Virginia Medical School.
Clot-dissolving drugs can significantly reduce the odds of permanent disability, but they must be administered within a three-hour window from the onset of symptoms to work best, Zweifler said. Once that window closes, he said, the damage is irreversible.
"I could have recovered," Morgan said. "But now I'm left with nothing."
Nevertheless, he said he is pleased with the care he is getting now at the Hampton center - an improvement that he attributes to the arrival of a new director, Deanne Seekins, in July.
"I have seen a change in attitude," he said. "She has turned that place around."
In a statement Friday, Seekins said she and her staff have reviewed the inspector general's report.
"We have instituted new training and procedures which directly address each recommendation," she said. "We will continue to strive for excellence and do all we can to build trust with all our patients."
Bill Sizemore, (757) 446-2276, bill.sizemore@pilotonline.com
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VETERAN WHO DID NOT RETIRE
It would be splendid if I had retired, but due to an act from Congress I was denied my right to complete my 20 years. You can say all you want about the VA Hospital for those who have service connect disabilities it is the only way they can receive health care without paying an arm and leg to get treated.
All medical facilities can have problems just like this. When the doctors are being paid lower than normal pay unfortunately you are not going to get the best that is available.
I had my issues with the VA Hospital but they have been taken care of by using patient advocacy, organizations like DAV or other veteran organizations.
You can whine all you want about is this what you expect if the government has a national medical plan or not. The main thing is the VA hospital is the only place a VET can go to that will understand some of their problems. I can't count how many times I was thanked for my service. Can you get that through Tricare?
This is a tragic event that occurred but not all of the VA hospital is that way. Quit your whining and thank a Vet for their service.
Don't put yourself at risk...go Tricare Standard
Whenever we read these horror stories, we constantly shake our heads and wonder why anybody opts for what is clearly substandard care when retiree's do have another option. We, as retired Navy, use Tricare Standard and always have. We love it. We go where we want, we see who we want within the medical community. The yearly deductible and cost share payments are a drop in the bucket. We're treated as consumers and there's accountability on the part of the medical professionals we see. And even though we have the option of using medical benefits through our jobs, we don't because Tricare Standard is inexpensive and extremely flexible in comparison. We've used it since we first became an active duty family over 20 years ago and wouldn't want our health coverage any other way. You ought to give it a look...it really is a good deal.
Don't put yourself at risk...go Tricare Standard
Thank you for your comments...I did not retire from the USMC.
Semper Fi...
John Morgan
VA Facility Care - Mistreatment - Misdiagnosis`
This is NOT an isolated incident by any means, it's rampant throughout the VA Medical care system.
And nothing will ever change until Veterans and their families all realize the "Veteran Service Organizations" who sit back and collect their monthly or annual membership dues and stockpile millions of dollars in membership and donations will NEVER step up and do what they're mission statements clearly say they will do and begin to take matters into their own hands.
Call, write, E-Mail, fax all your Elected members of Congress and tell them how angry, upset, and mad you are about not being able to get proper benefits, medical care, or have to go to run down improperly equipped facilities, only to be sent home and told you're fine, nothing is wrong.
Or to continually have your VA Benefits claims denied over and over.
Join an advocacy group, most are no charge and provide the tools needed to speak out as a group and make your voices heard and tell Congress enough is enough! http://groups.yahoo.com/group/VETERANS-FOR-CHANGE/
How can the government want a health care system when they can't even manage the VA Health Care System? There is no oversight, there is no true mana
VA Facility Care - Mistreatment - Misdiagnosis`
So very true...Thanks for the info.
Semper Fi...
John Morgan
Gov't healthcareless
And here is yet another case that shows clearly the gov't cannot take care of their own, yet they want to have a gov't health care for everyone but themselves.
The employment contract of the doctor ..............
Ok, good news for the VA possibly, but can someone tell us where this doctor might try to gain employment in the future so we can watch out for him? This should be news that makes the rounds. I wouldn't trust him as a vet for a gerbil. He knew the protocol and what he should be doing but chose to ignore his responsibilities. He should go back to selling cars or something.
VA Nonsensse
I have a doctor that lies in my record saying he has done a physical evaluation each time i have seen him has not touched me. Tells me the medication was sitting waiting for a refill i just don't know how to use the system even thought the pharmacy says it was expired and not renewed yet and i have used the electronic system for over a year with no problems. Had to stretch a weekly injection only sent a one month supply at a time to 2 months till i called patient advocacy and got them involved. I have now requested a new doctor 4 times in the last month and the person in charge can't seem to be bothered calling me back or do any work to process my request. With the exception of a few departments and a couple of good caring doctors the place is a joke and noone wants to help the patients. You can't even call the clinics you need you have to the call center who then transfer you to the telenurse who transfers you back to the call center instead of giving you the number to the clinic you need and making the receptionists actually do what they are paid to do. This place needs a major overhaul and real doctors who care and want to help their patients not hurt them.
I have a doctor that lies in my record
Hello JLG,
Try this:
Send the director a letter. Also attach a distribution list to send copies. I quickly found that the letter helped, however, the results came from who might get a copy!
Contact your congress person...They will contact the VA on your behalf.
Contact your local newspaper, they may want to let readers know about your concerns.
Remember, they work for the veteran. There would be no VA if it wasn"t for the vet!
Good Luck,
John Morgan
VA CARE
My dad had a massive heart attack on Wednesday, 100% blockage of Artery in heart.
ONE month ago, he had chest pains and went to the VA hospital. They told him he was healthy, no problems with his heart and sent him home with NO EKG, NO MRI, NO MEDS, NO Holter monitor...NOTHING.
He could have died. He may have damage now to his heart that he wouldn't have had if he had been treated.
VA care SUCKS and there is NOTHING you can do about it. Government run care will be the same. YOU CAN'T SUE THEM WHEN THEY KILL YOUR FAMILY MEMBERS or MALPRACTICE.
VA Care
Angelak,
You can SUE the VA under the "Tork Act." With that said, many lawyers won't handle a "Tork" case because there is a cap on the amount of money they can charge!
Also remember, that many VA Emergency room Doctor's are CONTRACTED to the hospital. In my case, the VA did not re-new his contract.
Also, I would send a letter to the Inspector's General Team. If they take the case, it will take a while to hear from them.
Good Luck
John Morgan
The Hampton VA Center
I've had too many friends who, for some 'GREAT UNKNOWN', have literally ended up in the Hampton VA Center. Many of those have still praised their care-givers there, while most would not speak well of the system that seemed to promise so much in their beginnings of service. When they had met their 'obligation', they were unfortunate recipients of a poorly maintained, shabby and all too often, incompetent system which failed to meet the original promises.
Not The First
This man is not the first the government has killed or crippled and he won't be the last. As a matter of fact, if we allow the entire medical system to be run by the government, people will drop like flies and, guess what, there is nothing you can do about it. If a government doctor commits malpractice, there are laws to protect Him---NOT YOU!
They won't be dropping...
...they'll be pushed. Remember the VA "Death Book"? The only reason it was removed from the web was bad publicity. They're just waiting for things to quiet down to bring it back. Nothing stops them from giving the same advice - or quietly killing patients - without the book, or without the patients' or families' permission. The only - YES, only - resource listed was the pro-euthanasia group that used to be called The Hemlock Society." (they had to change their name from bad publicity too)
What about all those vets who got AIDS from improperly sterilized equipment? A slow painful death, but see how quickly the furor died down? How soon will we forget this one? How soon till it's you?
None of these issues are new...I was a patient there in the 70's. Same old, same old. VA patients go there because they HAVE to. Why improve for a captive audience? Hey US public - gonna learn before it's too late?
Government run health care
And we want the government to run all of our health care?
Not the same thing
I have tricare standard, a government administered health insurance plan, and never ever have a problem getting claims processed. However I DO NOT go to military doctors - they are two separate issues
I agree wholeheartedly.
I agree wholeheartedly.
VA healthcare needs major boost in funding
For decades our government has done a very good job of saving taxpayers’ money with inadequate Veterans Affairs funding.
The tiny fuse of overmedication that has kept this whole VA system operational for 30-some years now desperately needs to be replaced with major re-wiring.
This young generation of veterans should not have to experience the palliative treatment of health care most veterans using the VA have experienced for decades. It would be great to see the VA step into the 21st century as the leader in world-class health care.
But after decades of under-funding, this proposed new VA budget is not enough. For our new leadership to achieve its full potential along with world-class VA health care, a one-time, additional funding of $20 billion for a ‘21st century investment in VA healthcare’ is desperately needed.
The VA has many good doctors working there who will feel much relief to actually have the opportunity to treat their patients instead of just medicating their symptoms.
Run like a third world government?????
How about run like our government??
VA healthcare
You mean over bloated with un-necessary people who probably have no idea how to do stuff? Sorta like Bushe's "Heck of a good job Brownie"?? I have seen so much good done there and it isn't until we get to the level of bureaucrats that the problems arise..more money for our vets and less for stupid stuff like $1100 chairs..