The Philadelphia VA Hospital has had some problems with
brachytherapy (implantation of small radioactive pellets for prostate cancer) recently. Multiple procedures were bungled, including wrong placement and incorrect dosages.
... The hospital suspended the brachytherapy program on June 11 last year. By then, 45 substandard implants had been found.
Two days later, the Joint Commission, which helps set standards in the hospital industry, surveyed the Philadelphia V.A. and on the next day accredited the hospital. “This organization is in full compliance with applicable standards,” the Joint Commission said.
The commission said that it had no indications of the problems in the brachytherapy program when it arrived at the hospital and that its surveys are not detailed enough to have uncovered the flawed implants. [Or, apparently, flawed computers - ed.]
Soon after, the N.R.C. sent its own inspectors to Philadelphia. And the more the inspectors looked, the more they found. All told, 57 of the implants delivered too little radiation to the prostate, either because the seeds missed the prostate or were not distributed properly inside the prostate. Thirty-five other cases involved overdoses to other parts of the body. An unspecified number of patients were both underdosed in the prostate and overdosed elsewhere.
From December 2006 to November 2007, the nuclear commission found, 16 patients received seed implants in Philadelphia even though computer interface problems prevented medical personnel from determining whether those treatments had been successful. The V.A.’s radiation officials knew of the problem but took no action, the nuclear commission charges.
I am uncertain how "computer interface problems" (in the
Philadelphia Inquirer, they were referred to as "glitches") prevented medical personnel from determining treatment success over several years. I would be most interested in hearing more about these "interface problems."
Here are some questions:
- Did these problems involve the VistA system?
- What was interfaced to what, exactly?
- Who did the interfacing?
- What regulatory authorities validated the interfaces and systems?
- If no regulatory agency was involved, why not?
I have some familiarity with odd events at the Philadelphia VA Hospital. (Not including the fact that I spent a few months there as a medical intern in the early 1980's). In the mid 1990's I took my father there for evaluation for increased service-related disability. He had been treated for skin lesions in the Army in WW2 and after by the VA with
Fowler's solution (an arsenical) and as a consequence of this (even then-outdated and dangerous) treatment, had developed widespread basal cell carcinomatosis over a major portion of his body, with chronic bleeding and discomfort. I accompanied my father to the exam but did not identify myself as an MD, only as his son.
My father was seen in an evaluation by several physicians and students (rare case) in my presence, and he was then handed his (paper) chart to take with him back to the main desk. I told my dad I wanted to look at the note. The note by a physician who'd seen him stated (paraphrasing):
"Mr. Silverstein said he'd taken more than the prescribed dose of arsenic for years, and even shared it with his wife."
My father and I were shocked and dumbfounded. He'd said no such thing, and being a retired pharmacist of 40+ years, thought anyone making such a statement would have had to have been insane. (My mother had even harsher words when she heard about this.)
Needless to say, I was upset. I confronted the physician who wrote the note, but that physician would not change it, bizarrely claiming that they remembered my father telling that story in a visit several years prior. Needless to say, such a claim violated all the precepts of medical information integrity of which I was familiar.
In an initial attempt to counteract this disability exam sabotage, I actually crossed out the statement in the chart, writing "this is untrue" or words to that effect and signed my own name.
The head of the Philadelphia VA Hospital would not return my calls on this matter.
That is, until
Jesse Brown, then Secretary of the Department of Veterans' Affairs, inquired directly a few days later. Unknown to the VA examiners, my father had been sent for the disability exam after reporting problems to Sen. Jay Rockefeller's office about delays in having his case heard. Sen. Rockefeller's staff was rather upset at the story I reported upon my return to New Haven, after my father's VA exam, and apparently relayed the story up the chain of command, as it were.
After that, the head of the Philadelphia VA Hospital really, really wanted to speak to me and called me at Yale several times. He wanted to set up a phone conference between me, himself, and the doctors who's seen my father. I told his administrative assistant that there was "nothing to talk about", and that the false statement in my father's chart would be removed. Period.
I think it was. My father's increased disability was granted in the end, but what was going on here with disability exams was never fully investigated to my knowledge (having done disability exams myself years prior for the regional transit authority, police, fire etc. in Philadelphia, I suspected an "incentive" program to deny vets a disability determination). If I had not examined my father's chart, we might have never known a reason for his being turned down.
A culture of honesty and accountability seemed lacking then, and seems lacking now.
Let's hope the investigation of these brachytherapy failures and "computer interface problems" is a bit more thorough than in my father's situation.
-- SS