Taking from the pages of the VA
Murder Doc case out of Albany NY
here, get ready because here it
all comes out of VA Philadelphia
almost the same verbatum situation.

Yes I have passed this to the
House Veterans Affairs Committee
so not to worry. This isn't funny,
y'all !!





At VA hospital, a rogue cancer unit
Records show 92 of 116 treatments over a 6-year span were botched

By WALT BOGDANICH, New York Times


First published in print: Sunday, June 21, 2009



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.


Most of the seeds, 40 in all, wound up in the patient's healthy bladder, not the prostate.

It was a serious mistake, and under federal rules, regulators investigated. But 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 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, 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.

The team continued implants for a year even though the equipment that measured whether patients got 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.

One patient was the Rev. Ricardo Flippin, a 21-year veteran of the Air Force. "I couldn't walk and I couldn't stand," Flippin said, citing rectal pain so severe that he had to remain in bed for six months, losing his church job and his income.

Flippin first learned of what his doctors called a radiation injury not from the VA, but from an Ohio hospital where, records show, 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 where he now preaches.

The 92 implant errors resulted from a systemwide failure in which none of the safeguards that were supposed to protect veterans from poor medical care worked, an examination by The New York Times has found.

Peer review, a staple of every good hospital where colleagues examine one another's work, did not exist in the unit. The VA's radiation safety program; the Nuclear Regulatory Commission, which regulates the use of all nuclear materials; and the Joint Commission, a group that accredited the hospital, all failed to intervene, either because their inspections were limited or they did not act decisively upon finding problems.

Overall, the implant program lacked a "safety culture," the nuclear commission found. Kao and other members of his team, the commission said, were not properly supervised or trained in what constitutes a substandard implant and the need to report it. Kao declined to comment for this article.

Federal investigators are continuing to look into the flawed implants, known as brachytherapy, as well as implants at other VA hospitals. The Philadelphia prostate unit was closed after problems began to surface in mid-2008, and it has yet to reopen. The VA has also suspended brachytherapy at hospitals in Jackson, Miss., and Cincinnati, though neither had problems on a scale of Philadelphia.
Virtually none of the substandard implants in Philadelphia were reported to the nuclear commission, meaning errors went uninvestigated for weeks, months and sometimes years. During that time, many patients did not know that their cancer treatments were flawed.

The VA has yet to fully account for how these substandard implants affected veterans, though no one is believed to have died from them.

A lawyer for Kao, Jack L. Gruenstein, said The Times' account of the doctor's role was "false," but declined to elaborate.

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End of Times Union Release, Albany NY
from the New York Times