Having spent some time in the pharmaceutical industry and having a lot of doctor friends -- and, not a few lawyer friends -- Crusader AXE is not surprised when a hospital screws up. However, I am surprised when they either are not caught, since the accreditation process and peer reviews combined with the fear of malpractice suits tend to weed out the worst. Yes, there are good old boys clubs covering up some things, but for the most part, hospitals are kind of stuck with self-regulation to prevent slamming and loss of accreditation and careers...except for the VA.
I used to joke that VA doctors were rejects from pathology boards, because they lacked the requisite bedside manner. Well, I was obviously wrong...some of them are worse .
The article and associated graphic are kind of frightening. However, Look at the numbers -- a baseball player who whiffed 92/116 times would be headed out the door, hitting a roaring .206. While I love baseball, I can't equate cancer treatment to slapping a single to left. And granted, this was one unit, in Philadelphia. However, that doesn't make me feel any less outrage. And granted, this was in Philadelphia...why does that not make me feel better?
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...The team continued implants for a year even though the equipment that measured whether patients received the proper radiation dose was broken. The radiation safety committee at the Veterans Affairs hospital knew of this problem but took no action, records show.
Radiology is something of an exact science. However, if you need an instrument to monitor a procedure, and the instrument is broken, you really don't have a lot of options. You stop the procedure. As for allowing the doctor in question to rewrite his surgical plan, well, HOLYSHIT!
Before you think, well, someplace the AXE has mentioned being a disabled veteran, so he's not exactly disinterested here, I have been in a VA hospital three times; once to have an initial screening, once to have the pathologist, err, doc evaluate the screening, x-rays, and MRIs and once to have them re-evaluate the arthritis, bone spurs, degenerative disc issues, stenosis, etc, etc, etc. I have my Army coverage, and I pay extra to use it as a HMO. I have secondary insurance. Screw the VA...but, I'm not a hero or a rebel here. I knew the program was underfunded to the point of insanity, and did the cost benefit analysis and decided my other options were better.
Options. I had options. A lot of folks in the VA system do not have options. While it's comforting to lay the blame on Bush, the only thing his administration added to the evolving mess of underfunding and neglect that characterizes so much of our government's infrastructure is to stress the system by adding to the pile of problems. Veterans who get decent care that they paid for with blood, pain and loss of body parts get to live longer. The hospitals are old, the pay isn't great, and on and and on. Things get worse, and then you pump lots of new patients with new issues into the system.
Still, this one is pretty egregious. Now, it is a fact that most men die with prostrate cancer not from it. But, any guy who reads the article and has the self-awareness of their body equal to a mollask has grabbed their balls (psychicly, psychologically, or actually! Or, all three; excuse me for a second..."guys, I'm not going to let them get you!") and winced.
One patient was the Rev. Ricardo Flippin, a 21-year veteran of the Air Force. “I couldn’t walk and I couldn’t stand,” he said, citing rectal pain so severe that he had to remain in bed for six months, losing his church job and his income.Pastor Flippin first learned of what his doctors called a radiation injury not from the V.A., but from an Ohio hospital where he underwent rectal surgery in 2006 to treat the damage. “There are times when I don’t have control over my bowels,” he said one recent Sunday, after excusing himself during a service at a church in West Virginia where he now preaches.
No, not exactly reassuring. Now, General Shinseki has a lot of challenges, and I wish him luck. But, malfeasance, misfeasance and general coverups of really bad procedures indicates how severe the challenges are. In government and in bureaucracies everywhere, beware the truth-tellers and kill them. Problem is probably far, far greater than we can imagine.
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