VA Hospital Slip-Up Infects 4 Patients With HIV

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BILL POOVEY | April 24, 2009 07:52 PM EST | AP

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CHATTANOOGA, Tenn. — Thousands of veterans were at first shocked to learn they should get blood tests for HIV and hepatitis because three hospitals might have treated them with unsterile equipment. Now, just a couple of months after the Department of Veterans Affairs issued the dire warnings, veterans are growing frustrated by the lack of information from the tightlipped federal agency.

Nearly 11,000 former sailors, soldiers, airmen and Marines could have been exposed to infectious diseases because three VA hospitals in the Southeast did not properly clean endoscopic equipment between patients. On Friday, the VA revealed that another patient had tested positive for HIV, bringing the total to four such cases among patients who got endoscope procedures at hospitals in Miami, Murfreesboro, Tenn., and Augusta, Ga.

The agency also said a new hepatitis case had been discovered, increasing the number of positive tests to 26. More than 4,270 veterans still have yet to get test results.

Beyond those skimpy facts, the VA has said little else, citing an ongoing investigation.

It hasn't answered questions from The Associated Press about why problems with cleaning the equipment _ and possibly co-mingling infectious body fluids _ went on for five years at the Miami and Murfreesboro hospitals and about a year in Augusta. The VA also refuses to say if it found similar problems at its other 150 hospitals or if more patients should get blood tests.

The VA has stressed that the positive tests are "not necessarily linked" to medical treatment at its hospitals, and infections don't always cause symptoms and can go undetected for years.

Still, veterans are calling on the agency to release more information.

"This effort must involve continual updates on what the VA is learning about the extent of this situation," Vietnam Veterans of America President John Rowan said in a statement Thursday.

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More facts are little comfort, though, to those who are already infected _ and those that don't know.

A 60-year-old Navy veteran who had a colonoscopy at a VA hospital last year got an unimaginable phone call recently _ a blood test showed he had HIV. A second test by the VA was negative, and now, the Tennessee man doesn't know what to think.

"I screamed out loud, `No' and went over and held my wife and told her what happened," said the veteran, who spoke to The Associated Press on the condition of anonymity because he was afraid of repercussions against himself and his employer. "We had a nice, good cry. The things that go through your mind. You think your whole world is going to end. Her world could end, too."

It was not clear whether the Tennessee man was counted as a positive HIV test by the VA.

The VA said the problems with the endoscopic equipment had gone on for years, but were discovered in December when it learned the Murfreesboro facility wasn't following cleaning procedures the manufacturer recommended. It issued an internal alert for hospitals to check their procedures, and the problem at Augusta was discovered in January.

On Feb. 9, the VA announced a nationwide safety check of endoscopic equipment used in colonoscopies and ear, nose and throat treatments. The procedure involves a narrow, flexible tube fitted with a fiber-optic device such as a telescope or magnifying lens that is inserted into the body.

Some veterans were warned in February to get tested, and more were alerted in March when the Miami hospital backtracked on its previous conclusion that it didn't have a problem.

The day after the first HIV infection became public April 6, the VA announced that its top medical official, Dr. Michael Kussman, was retiring. Kussman still works at the VA but could not be reached for comment. VA spokeswoman Katie Roberts said there was "no connection whatsoever."

The endoscopic equipment is made by Center Valley, Pa.-based Olympus American Inc., and the company has said its recommended cleaning procedures are clear.

The VA and its inspector general have started investigations, and congressional members of the Veterans Affairs Committee have asked for a hearing in late May to discuss how the VA has been handling the problem.

U.S. Rep. Steve Buyer, R-Ind. and ranking member of the committee, said in a statement he and his staff have been briefed weekly by senior VA officials. His office declined to release more information.

Private hospitals have also spread infectious diseases with unsterile equipment, but requirements to report such problems vary by state and there's no national regulation requiring disclosure, according to Barbara Rudolph, director of The Leapfrog Group, which advocates for quality health care.

The VA is providing a hot line for veterans and their families and posts the information it is releasing on its Web site. Because the VA hasn't ruled out other hospitals having had problems, some veterans are wondering if its more widespread.

In Cedar Rapids, Iowa, former Marine Allen Lusk had several colonoscopies at the VA hospital in Iowa City and tested positive for hepatitis B in December.

"I never had it till I started going to the VA," said Lusk, 51.

He started using the VA in 2006 after he was injured when a car fell on him and he didn't have health insurance. After seeing news reports about the contaminated equipment problems elsewhere, Lusk went to his county health department for an HIV test. He tested negative.

"To be honest, I'd like to see them come out and be honest about how big this really is," he said. "It might be embarrassing, but in the long run it might be better for them."

CHATTANOOGA, Tenn. — Thousands of veterans were at first shocked to learn they should get blood tests for HIV and hepatitis because three hospitals might have treated them with unsterile equipme...
CHATTANOOGA, Tenn. — Thousands of veterans were at first shocked to learn they should get blood tests for HIV and hepatitis because three hospitals might have treated them with unsterile equipme...
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and again we leave our good men and women behind like useless stem and seeds

    Favorite    Flag as abusive Posted 10:00 AM on 04/26/2009
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Ah the Veterans Administration.... Before the republicans were in charge (for those 8 years) I was medically discharged from the Army (couple of blown out discs in my lower back) After fattening my army med records with MRI's and HEAVY narcotics I was finally out. So of to the VA right? visit # 1 was a 6 hour wait to be screened.

#2 was to be told that "although the Army had me under the care of one of the best Neurosurgeons they had (who would not operated do to the risk in my case) and a year of Army Pain Clinic treatment (epidererals and meds)" That I now needed to see a GP doctor (in 2 weeks) who could refer me to a Ortho doctor (wait time 9 or 10 months) the Ortho Doctor would be the one who could THEN refer me to a Neurosurgeon (waiting list time unknown)

Those of you on board for nationalized health care.... let this be a lesson in what you get mixing GOV and Medicine.

    Favorite    Flag as abusive Posted 12:19 AM on 04/26/2009

nasty. where can i buy my own tube?

    Favorite    Flag as abusive Posted 09:10 PM on 04/25/2009
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"... there's no national regulation requiring disclosure,"

After 12 years of Republican rule, should we be surprised?

    Favorite    Flag as abusive Posted 07:46 PM on 04/25/2009

It always amuses me when people rail against the VA and have no idea what they are talking about. for the most part the employees of the VA are dedicated to taking care of veteran with an ever shrinking budget and even less manpower. VA employees are being asked to do more with less constantily, it is no wonder things like this occur. So if you are outraged by this maybe you should take the time to write your congressmen and senators to properly fund the VA and give us vets the proper care we deserve.

    Favorite    Flag as abusive Posted 04:16 PM on 04/25/2009
- TeeLolly I'm a Fan of TeeLolly 47 fans permalink

Our vets (in fact, all citizens in this country) deserve better. With some people earning millions and millions of dollars a year for questionable performance and paying only a tiny percentage in taxes, it's not a matter of the country being unable to afford decent treatment for everyone. We need to establish some priority other than propping up huge pay packages and cutting taxes for the wealthy.

    Favorite    Flag as abusive Posted 01:04 AM on 04/26/2009
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Here, here. My uncle is an othro surgeon at the VA in Ann Arbor and he has overextended himself to the point that his eyes literally cross and he was forced on to medical leave because he can't focus during surgery. His dad was a vet, as were all of his uncles--he works for the VA, and works with a passion, to show his honor and respect for those who serve the country as military personnel. But the meager resources allocated to the VA and the bureaucracy that bogs it down is not only cheating vets out of the QUALITY healthcare they deserve but also strait jacketing VA personnel who really want to aid vets. If it's frustrating for us to hear about it must be maddening for skilled care givers who wish they could help MORE.

    Favorite    Flag as abusive Posted 02:48 AM on 04/26/2009
- TJCole I'm a Fan of TJCole 160 fans permalink
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Thank God we finally have Tammy Duckworth as head of Veterans Affairs, and hopefully an end to the Republicans repeated abuse and degradation of our Troops and veterans as we saw these last 8 disgraceful years..!

    Favorite    Flag as abusive Posted 03:20 PM on 04/25/2009
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I could not agree more.

    Favorite    Flag as abusive Posted 04:50 PM on 04/25/2009
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All of the Repugs that apposed the nomination of Ms. Duckworth are cowards.

Not a one of them ever served their country they should resign.

    Favorite    Flag as abusive Posted 05:10 PM on 04/25/2009
- ibfuddled I'm a Fan of ibfuddled 4 fans permalink

Sad, but the Murfreesboro hospital is like a medical resort compared to the Chattanooga clinic. Any weekday morning, you will see 50 - 120 veterans in the waiting room with canes, wheelchairs, walkers, prosthetic legs and arms. Waiting, waiting, waiting. And the docs tell us we are the lucky ones and should feel like we have a sweet deal compared to the really sick ones. There is something terribly wrong with this picture. After 150 airborne combat missions in the Mig's gunsights, and 50 nights in the bunkers during mortar storms, I cannot get an MRI for undiagnosed spinal destruction for over two years. But I can get all the drugs I need and don't need, and I can get plenty of toys. Just cannot get to see a doctor. And once I do, I cannot get them to do what they say needs to be done.

    Favorite    Flag as abusive Posted 03:08 PM on 04/25/2009
- larry278 I'm a Fan of larry278 47 fans permalink

Gen Shinseki, Secretary of VA, needs to hire more hard nosed people for the VA's IG office & send them to VA facilities to investigate the use of dirty instruments. Firing (removing from office) everybody involved in this breach of aseptic technique from the Medical Center Director on down to a GS 2 worker who was supposed to properly cleaning the instruments is an appropriate response. The IG's people can consult & use the table of penalties which the VA uses. If there was also criminal neglect involved, there are federal courts which can determine that. Federal prosecutors should work with the VA IG's who find the cause of the VA establishing & persisting in a pattern of using dirty instruments.
Veterans infected by the VA's dirty instruments & sub-standard medical techniques should recieve supplemental monetary compensation for the diseasess that the VA inflicted upon them by using dirty instruments, etc.

    Favorite    Flag as abusive Posted 02:54 PM on 04/25/2009
- normathumb I'm a Fan of normathumb 26 fans permalink

Get right with Jesus. There are no virus' in the bible.

    Favorite    Flag as abusive Posted 02:12 PM on 04/25/2009



No Fords or Chevys, either. There IS a burning bush, however. And I dearly love a burning bush ....

    Favorite    Flag as abusive Posted 05:09 PM on 04/25/2009

The same hospital in Tennessee diagnosed me with cancer, and the military told me they were going to operate whether I liked it or not (I had no idea if I had the authority to refuse or not). I was counseled about my will and whether my household was in order in case I died. I told them that I wanted a second opinion, and they would not cooperate or let me have my military medical records to have a civilian doctor check it out. I took my records anyway by convincing a nurse that the doctor needed them and I was going to take them to him. I took the records and went to a local cancer institute, where they found that I did not have cancer at all. It took a lot of fighting to prevent them from operating on me. Thank god I got a second opinion from a real doctor.

    Favorite    Flag as abusive Posted 11:15 AM on 04/25/2009

This is rediculous. Universal healthcare would help solve these problems in the states because our Armed forces would have access to regular civilian healthcare. Everyone involved with not properly sterilizing equipment should be fired. I would use VA healthcare only if death itself were my other option.

    Favorite    Flag as abusive Posted 11:07 AM on 04/25/2009
- TeeLolly I'm a Fan of TeeLolly 47 fans permalink

If we had truly universal healthcare, and members of Congress and multi-bazillionaire CEOs all went to the same hospitals as vets, none of this crap would be happening and everyone would get decent care.

    Favorite    Flag as abusive Posted 12:57 AM on 04/26/2009
- Diogenis I'm a Fan of Diogenis 65 fans permalink

"The Enemy Within"

    Favorite    Flag as abusive Posted 10:50 AM on 04/25/2009
- dadw5boys I'm a Fan of dadw5boys 278 fans permalink
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MANY WOMEN GET DISEASES FROM THEIR GYNO CHECK UP'S.

Doctors too cheap to have extra exam equipment spread Chlamydial and Endometrious.

Timimg of appointment is important 1st appointment in the morning or the 1st one after lunch.

So the instruments get sterlized at least 1 hour in autoclave.

.

    Favorite    Flag as abusive Posted 10:28 AM on 04/25/2009

Dear "dad":

Please read up on your subject before posting comments, please pay attention to the spellchecker here at Huffpo, and PLEASE read this:

http://en.wikipedia.org/wiki/Endometriosis#Potential_causes

You don't catch endometriosis; it's caused by a variety of environmen­tal/physic­al factors. And it's not chlamydial, it's chlamydia. I'm not saying that the VA is the only organization to pull something like this, it's just that when one point of your comment is so out-and-out wrong, it's hard to take anything you post seriously.

    Favorite    Flag as abusive Posted 03:17 AM on 04/26/2009
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More of that wonderful privatization at work.

    Favorite    Flag as abusive Posted 09:13 AM on 04/25/2009
- solarian I'm a Fan of solarian 15 fans permalink

the vets should sue the va if they get infected

    Favorite    Flag as abusive Posted 09:12 AM on 04/25/2009

And the doctors and administrators that caused this should be behind bars or injected with HIV as punishment.

    Favorite    Flag as abusive Posted 11:40 AM on 04/25/2009
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