At VA Hospital A Rogue Cancer Unit

[WannaJumpMyScooter]

Source: New York Times

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.

Dr. Gary D. Kao is responsible for most of the errors, investigators say.

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.

Read more: http://www.nytimes.com/2009/06/21/health/21radiation.html?src=twt&twt=nytimes

---

And, for this, we risked all.

[MADem]

1. It was a "lucky break" that revealed the disaster, too......

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.

“Every once in a while you’re going to have a medical event because the seed will migrate, but when you see more than one or two at one place, we’re like: ‘What’s going on? Is this a pervasive problem?’ ” said Mr. Reynolds, the nuclear commission official.

The hospital suspended the brachytherapy program on June 11 last year. By then, 45 substandard implants had been found.

[RandomThoughts]

2. This article sounds like something else to me.

you could easily see this article itself as the exact same thing as spoken of in the article.

Sounds like someone is trying to move particles put in to cure, because they don't care if a cure occurs. It gives them no personal reward to see a cure, and it might cost them money if suddenly cures occured.

Might this article be missing the point? Might the article be bad medicine? Might it have a different motive?


Although it was stopped last year, so maybe things are going to the correct places now. That could be the point of the year old contriversy spoken of in the article.

[DeltaLitProf]

3. This is part of the Right's attack on "government health care" too

You'll see a lot of Right-wing politicians on the House and Senate floor use these incidents to say the government can't be trusted to run health care. Never mind that private hospitals are not bound by public record laws and their mistakes are often covered up in their legal settlements. Private hospitals always demand non-disclosure agreements with plaintiffs as a condition of collecting the settlement money.

[Lagomorph]

5. I think people with cancer would rather...

be given the proper care, regardless of their political leanings. If there is a problem, it needs to be corrected before we turn them loose on the public.

Hopefully, my Democratic Senators will make an issue of substandard treatment and not let the Republicans get away with playing politics with the issue.

[quidam56]

7. I support HR 676 after seeing what is called quality health care in

East Tennessee and southwest Virginia. http://www.wisecountyissues.com/P=62 Clearly profit care is more important than patient care. It took the health care system three years to prove their own advertising was false and misleading.

[cindyperry]

4. It is mistakes such as this that made me understand

that the one time I saught treatment at the VA and was told I couldn't be helped was the last time I went. I was written a specfic prescription by the dr. and was given the wrong thing by the pharmacy. Those hospitals are incompetent. Never went back.

[Delphinus]

6. I regret to hear of your experience.

The VA is the only place one of my family members can receive care and, thankfully, it's been good. I hope you will find an alternative place for your care.

Welcome to DU.

[DollyM]

8. More than one bad experience with VA health care . . .

Our VA hospital surgical unit was shut down after a series of patients died. The Dr was fold to have had his license already suspended in another state but VA hired him and didn't know or didn't bother to check. Other serious problems in care were found in all other areas of the hospital too. Just an overall lack of quality. I had to constantly stay on top of my husband's care due to the shoddy way it was handled. They wouldn't order tests he needed and prescriptions he needed and I spent my time arguing with VA doctors over such. My Dad died as a result of this shoddy care from VA, my husband nearly lost his foot after VA preferred to hospitalize him five times in the same year for the same infection rather than pay to have him see a specialist outside the VA hospital. The VA system is based upon saving money and they know the Veterans won't complain. It is a good thing they have spouses that will.

[tabasco]

15. I've received excellent service from the VA hospital.

Thanks to President Obama increasing the VA budget by more than in 30 years, it will only get better.

[UpInArms]

9. kickin' this back up

sorry about duping your thread, WJMS!

:blush:

[UpInArms]

10. At V.A. Hospital, a Rogue Cancer Unit (astounding in its failure)

Source: New York Times

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.

<snip>

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.

Had the government responded more aggressively, it might have uncovered a rogue cancer unit at the hospital, one that operated with virtually no outside scrutiny and botched 92 of 116 cancer treatments over a span of more than six years — and then kept quiet about it, according to interviews with investigators, government officials and public records.

Read more: http://www.nytimes.com/2009/06/21/health/21radiation.html?em=&pagewanted=all

---

unbelievable in its cruelty

[lindisfarne]

11. duplicate

http://www.democraticunderground.com/discuss/duboard.php?az=view_all&address=102x3932510

[jwirr]

12. This kind of story is what scares people when it comes to the government

running our health care system but there is a difference. The single payer plan is actually a kind of health insurance system run by the government who pay doctors and care providers from the private sector to take care of patients. In the VA system the doctors are government doctors.

[hedgehog]

13. The difference is that doctors in VA hospitals are subject to review, that's

how these mistakes were found. Doctors in private practice are subject to limited review. If no one complains or sues, nothing is done to ensure good practice.

[jwirr]

14. Yes, except that I learned long ago in dealing with institutions for the

developmentally disabled that the worst kind of review is an internal review where everyone works for the same entity. My daughter was abuse 6 times before anyone even notified me. They were just protecting their turf.

[tabasco]

16. LOL. Yep, I never heard a horror story from the private medical sector.

Nope, it's perfect!

[DollyM]

17. the private Dr. along with a medical card worked great for us . . .

That is the system we need, a medical card that allows us to go to any doctor that accepts it (most do) and allows us to get the prescriptions we need when we need them. After my husband nearly lost his foot due to VA ineptitude, we were able to get medical cards and my husband went to a private physician who treated his infection aggressively, got it under control and he has had very little problems since. We have also not used VA since (about 2 years). Good medical care is preventative care, it saves money down the line. How VA could justify putting my husband in the hospital five times for the same problem rather that having him see a specialist, is totally beyond me.

[panzerfaust]

18. "Think Blue"

Is the current VA management slogan.

No, no one at the VA knows what it means either - although I am sure that someone received a large payment for developing it.

Taken as a whole, the VA is the most uncaring, unaccountable, inefficient, and toxic organization that can be imagined. Veterans receive healthcare in spite of, not because of, VA administrators and regulations.

I do not want to get started, or to paint with too broad a brush. There are a few, a very few, VA administrators who are something other than drones, who try to accomplish something beyond the creation of another rule or form: but they are too few to make an impact on the culture of the VA, and they generally do not last very long.

The true function of the VA is to provide secure, if completely meaningless, employment for those who run the system. Any healthcare that gets provided is purely incidental. My observation is that a typical private sector employee could replace 3-5 VA employees and would still accomplish more.

The VA system has no overreaching principal, except to not be accountable. They are careful to push to meet any administrative metric of patient care (internal, or external) without understanding that it is about patient care, not about checking a box on a form.

There are good physicians at some VAs, usually those VAs associated with medical schools, there are even a few good physicians who are directly employed by the VA, but many VA physicians are those who cannot work anywhere else. Certainly, it is difficult to imagine Dr. Kao setting up a successful practice where he would be dependent upon his skills for patient referrals. More likely, outside of the VA, he would have ended up losing his medical license.

Even for those VA hospitals associated with a teaching institution, the VA has the last say in patient care, and that care is generally not up to standard of care.

Nothing is too good for our vets ...