Philadelphia VA Hospital radiation errors blamed on offline computer

The medical blog Health Care Renewal with doctors being the primary writers, had this article submitted that noted the Philadelphia VA Hospital Cancer Radiation Therapy Debacle: For The Want of One Competent and Industrious IT Person.

It was posted by a Medical Informatics MD who wrote that this story should perhaps be subtitled "The Theatre of the Absurd."

An extract of comments made in that article follows in the comments section after this update from the Philadelphia Inquirer.

Robert L. Hanafin
Veterans Advocacy Editor
Major, U.S. Air Force-Retired
VT News Network &
Our Troops News Ladder

      Vietnam Veteran James Armstrong had no way to know that his prostate-cancer treatment had gone dangerously awry as he recovered from the brief procedure at the Philadelphia VA Medical Center in August 2007. Doctors for the war veteran from West Philadelphia, however, should have known, federal investigators concluded. The dozens of tiny radioactive seeds they had implanted in Armstrong’s prostate gland were delivering only about a quarter of the radiation called for in his treatment plan – too little by established standards to wipe out his cancer. Armstrong’s doctors, led by University of Pennsylvania radiation oncologist Gary Kao, didn’t recognize their error because they hadn’t done the crucial last step of the brachytherapy procedure – calculating the actual radiation dosage administered to their patient – investigators found.

For a year, starting in November 2006, the computer workstation with the software used to calculate the post-implant dosages was unplugged from the hospital’s network. All that time, no one took steps to plug it back in, work around it, or tell patient-safety officials, investigators found. As a result, post-implant calculations weren’t performed during that period for Armstrong and 15 other patients, according to the U.S. Nuclear Regulatory Commission, which oversees medical use of radiation. Even after the computer was finally reconnected to the network, investigators discovered, post-implant calculations continued to be omitted for an additional seven patients.

The unplugged computer was symbolic of the management disconnection and disregard that investigators say pervaded the brachytherapy program at the Philadelphia VA. Between February 2002, when the program opened, and June 2008, when it was shut down, 92 of 114 prostate-cancer patients received too little radiation or too much.
A congressional panel held hearings in Washington to question Kao and other key individuals from the VA, Penn and the NRC because, "The VA abdicated its responsibility . . . by allowing this program to operate without adequate safeguards or supervision," said U.S. Rep. John Adler (D., N.J.), who has pushed for a congressional investigation.

Viewed as essential

There are no laws or federal regulations requiring that radiation doses be calculated after a radiation isotope implant. However, professional radiology organizations say it is essential for good practice.

[NOTE for readers ‘like me’ with a high school GED, Brachytherapy does not use drugs per se in the treatment of certain cancers but are implanted solid gold Au-198 and iridium Ir-192 seed implants of well radiation. Simply put it is nuclear medicine or radiation therapy. VT, ed.]

The Acting Chief of radiation oncology at Cooper University Hospital in Camden, New Jersey said an implant at their hospital would have been canceled or postponed rather than go without post-implant analysis. It is not surprising, then, that NRC and VA investigators spent considerable [buying] time delving into why the calculations weren’t done for more than a year at the Philadelphia VA.

Their investigative reports blamed a "computer interface problem" – the same terminology Dr. Kao used during his testimony last month at a congressional hearing. The implication was that some intractable technology breakdown was behind the lapse in care. WRONG!

In fact, technology had little to do with the breakdown, as James Bagian a Philadelphia-born physician and former astronaut who is now the VA’s national patient-safety director, discovered when he led a recent inquiry at the Philadelphia VA and the veterans’ health system’s 12 other brachytherapy programs. His investigation discovered that the "interface problem" was nothing more than the disconnected computer.
Here’s what else his inquiry found:

The computer was initially unplugged so that another medical device could use the network port. Then, various departments dithered and ducked a request for an additional network port, which was finally installed – after a year. Some doctors, physicists, and other professionals at the VA acknowledged it was "clinically inappropriate" to omit the post-implant calculations. Some said they had informed their "chain of command."

[Pay special attention to how some doctors, physicists, and other professional at the VA informed their "chain of command," that what they were doing was "clinically inappropriate". The smart questions anyone should have asked these medical professional is exactly who in their chain of command are they talking about administrative management, medical management or both? They sure as hell did not inform the hospital’s patient-safety officer. VT, Ed.]

When asked why they didn’t tell the hospital’s patient-safety officer, they said "it had not occurred to them to do so."

VA National Press Secretary Katie Roberts said that the department had shut down the Philadelphia program after the problem was discovered last spring and since that time had worked to inform and treat all the affected veterans.

"VA deeply regrets this unfortunate occurrence," Roberts said in a statement. "VA is actively using this experience to implement stricter protocols of accountability and transparency throughout the department."

[Note: Katie Roberts is the VA’s top talking dog, when the VA gets into trouble she barks. Seriously, she is a political appointee from the spoils system, the former Communications Director for Governor Bill Richardson’s unsuccessful run on the White House. Very interesting, but so much for credibility representing what’s best for America’s Veterans that is unless Ms. Roberts is a Veteran that I highly doubt. The VA just doesn’t hire Veterans for such influential posts. This is but another case where change of political regimes at VA upper and middle management really doesn’t change a damn thing. VT, Ed.]

TOO Many played key roles

Reviews by the VA and the NRC found that the brachytherapy program under dosed 57 veterans while 37 got excessive doses of radiation to nearby tissues. Dr. Kao, who did almost all the errant procedures, is the only person officials have publicly identified. But many others – including medical physicists, urologists, and radiation technologists from Penn, and VA employees – played key roles in the program. Penn, No one can say how many of the 92 veterans face a poor prognosis as a result of the treatment lapses, but for Armstrong, the damage is clear.

[The University of Pennsylvania trains young doctors at the hospital, contracts with the VA to provide a raft of medical services, including radiation oncology.]

Vietnam Veteran James Armstrong

Like the other men who received inferior VA care, James Armstrong learned of it last summer. Philadelphia VA officials asked the 62-year-old veteran to come in for a new CAT scan that would be used to review the quality of his implant. The VA’s review showed that his prostate had received only 27 percent of the prescribed radiation dose. And it appeared that his bladder and bowel received excessive radiation from errantly placed seeds. Armstrong now suffers from severe pain during urination. He also has trouble controlling his bladder and bowels.

Last October 2008, the VA flew Armstrong – and seven other veterans with suspected treatment failures – to the Puget Sound VA in Seattle, an internationally recognized leader in brachytherapy (radiation therapy). There, the men received corrective "touch-up" implants. Armstrong’s "original implant was grossly inadequate by current standards," radiation oncologist Kent Wallner, the VA expert who re-treated Armstrong, wrote in an Oct. 20, 2008, letter.

"The resulting complicated situation leaves him at considerable uncertainty regarding his chance for a cure," Wallner wrote. "He is also . . . at higher than usual risk for severe urinary or bowel complications due primarily to excess radiation."

Like Dr. Kao, Dr. Wallner inserted needles loaded with radioactive seeds [isotopes] into Armstrong’s prostate while watching ultrasound images of the organ. But Wallner was so exacting that after placing 40 seeds in Armstrong’s prostate; the doctor gauged the radiation dosage, and then added four more rice-grain-sized particles.

"We elected to add four more seeds to try to bring it up closer to 100" percent, Wallner wrote in his operative note.

For Armstrong, the aftershocks of his original care at the Philadelphia VA added to the fallout of fighting in Vietnam – namely, post traumatic stress syndrome [PTSD]. He also lives in fear the cancer will return, and of the tiny nuclear war inside him.
"I feel things in my body and think the worst," he wrote on the claim form he filed with the VA last summer. "I really don’t know when something is going to happen. I can’t get past it."

Of course James Armstrong will be filing a malpractice suit againt the VA.

As mentioned in a previous  VT article on this, VA scandals are long-term systemic problems not a few bad apples ,

During the recent Senate Veterans Affairs Committee hearing, several senators wondered how the Joint Commission could have given the Philly VAMC its accreditation given that circumstance. In response Robert Wise, vice president of standards and survey methods for the Joint Commission said, "We need to pull back and take a look at this."

We believe that pulling back and taking a look at this, whatever Robert Wise really meant to say IS NOT THE RIGHT ANSWER? It certainly did not respond to Senator’s questions regarding why the Joint Commission gave the Philadelphia VAMC its accreditation?

Below is a little background on the Joint Commission and we encourage anyone, patient, doctor, nurse, clerical employee working for the VA to contact the Joint Commission, and bombard them with both complaints and praise of the patient safety and care within our VA Hospitals, because there’s something very wrong at the Joint Commission when one of its Vice Presidents (a non-profit at that) tells members of Congress that when a VA Hospital harms or mistreats America’s Veterans, "We need to pull back and take a look at this." At least Mr. Wist should have explained what he really meant by that.

Robert L. Hanafin

Readers are more than welcome to use the articles I’ve posted on Veterans Today, I’ve had to take a break from VT as Veterans Issues and Peace Activism Editor and staff writer due to personal medical reasons in our military family that take away too much time needed to properly express future stories or respond to readers in a timely manner.

My association with VT since its founding in 2004 has been a very rewarding experience for me.

Retired from both the Air Force and Civil Service. Went in the regular Army at 17 during Vietnam (1968), stayed in the Army Reserve to complete my eight year commitment in 1976. Served in Air Defense Artillery, and a Mechanized Infantry Division (4MID) at Fort Carson, Co. Used the GI Bill to go to college, worked full time at the VA, and non-scholarship Air Force 2-Year ROTC program for prior service military. Commissioned in the Air Force in 1977. Served as a Military Intelligence Officer from 1977 to 1994. Upon retirement I entered retail drugstore management training with Safeway Drugs Stores in California. Retail Sales Management was not my cup of tea, so I applied my former U.S. Civil Service status with the VA to get my foot in the door at the Justice Department, and later Department of the Navy retiring with disability from the Civil Service in 2000.

I’ve been with Veterans Today since the site originated. I’m now on the Editorial Board. I was also on the Editorial Board of Our Troops News Ladder another progressive leaning Veterans and Military Family news clearing house.

I remain married for over 45 years. I am both a Vietnam Era and Gulf War Veteran. I served on Okinawa and Fort Carson, Colorado during Vietnam and in the Office of the Air Force Inspector General at Norton AFB, CA during Desert Storm. I retired from the Air Force in 1994 having worked on the Air Staff and Defense Intelligence Agency at the Pentagon.