One of the first rules in overseeing junior people working is to make available someone to answer questions, immediately, and render support if needed. I have had the pleasure of training junior people in a myriad of tasks over the years. When I read this Department of Veterans Affairs – Office of Inspector General (VA-OIG) report, a plethora of questions arise, and I deeply question the professionalism and competence of the doctor overseeing the work of residents in a VA Hospital who are performing procedures.
- Ophthalmology Resident Supervision – Important to note, the patient did not experience any long-term loss of sight over this issue. Congratulations to the resident and the other ophthalmology doctors present! From the VA-OIG report we find the following:
“… The subject ophthalmologist failed to provide adequate resident supervision and entered inaccurate documentation related to supervision for a single patient case.” Essentially, the doctor charged with overseeing residents was AWOL, and then compounded his error by falsifying patient records. The VA-OIG report continues by claiming this falsification was the result of an oversight when using pre-recorded notes for patient files.
Draw your own conclusions. Personally, I think this doctor needs to be released of all duties where overseeing residents is concerned. I would also question his ethics and morals for falsifying patient records. You hold a double position of trust, first as a doctor, second as a teacher and leader of residents, and the behavior witnessed should come with steep repercussions professionally!
On the topic of professional duties, and steep repercussions, drug interactions killed a veteran at the Marion VAMC in Illinois. Before launching into the VA-OIG’s report, please allow me a moment of your attention. Drug interactions can arise due to vitamin usage, over-the-counter medications, and from illegal and legal but illicit drug use. Often, I have claimed that people are walking chemistry experiments, and even vaccines need to be carefully evaluated for drug interaction potential. Foods can cause drug interactions due to the chemicals in the food. Drug interactions are a growing problem and every medical professional I have spoken to admits drug interactions are becoming worse by the day. I do not say this lightly, but I do not hold the medical professionals as fully competent in fighting the drug interaction problem due to the amount of chemicals the average person interacts with daily. The problem is Big-Parma and the continual push towards more specialized medicines, we are going to see more drug interaction issues. Unfortunately, drug interaction issues come with the risk of death!
From the VA-OIG report we find the following:
“The VA-OIG substantiated that high cholesterol contributed to the patient’s death; however, the death certificate indicated that the primary cause of death was accidental acute multi-drug intoxication. The psychiatrist and staff failed to document providing the patient with education during a telephone encounter regarding potential side effects or adverse drug-drug interactions of medication changes. Contrary to clinical guidance, the psychiatrist prescribed long-term benzodiazepine use for a patient diagnosed with posttraumatic stress disorder. The psychiatrist also failed to address the patient’s two negative urine drug screens for a prescribed medication and failed to address a positive urine drug screen for cannabis. Due to COVID-19, the facility failed to launch the Psychotropic Drug Safety Initiative Phase Four Plan. The primary care provider did not comply with facility policy by failing to enter a return-to-clinic order following an appointment but could not determine if this affected the patient. Primary care and behavioral health staff did not comply with facility policy to telephone the patient or send a letter after the patient missed appointments” [emphasis mine].
The lack of staff to follow procedures and do their job, I will certainly hold them accountable for, especially since Cannabis is involved! Please do not believe that Cannabis is a non-toxic drug, especially when mixed with other drugs, it can be the fatal trigger in a multi-drug intoxication!
At 18, low those many years ago, I took the EMT-Basic class, but left for US Army Basic Training before I could certify. Since then, I have received certification as a combat medic and a Journeyman Firefighter (Any industry) which required a lot of hours studying emergency medicine. I am experienced in drawing blood, starting IVs in difficult circumstances, and handling a myriad of injuries. I am not a medical professional by any stretch of the imagination, I simply have a healthy desire to learn, and emergency medicine is a fascinating topic I regularly pursue. I am not a chemist; I rely upon peer reviewed resources and legal and medical websites to stay current on a host of topics. With this as my qualifier I am going to make several statements and you can judge their merit. Feel free to comment.
- The first rule of medicine is document everything! My first lesson, first day of EMT training, this point was driven home. If you do not write it down, it never happened! Yet, what does the VA-OIG find time after time in reviewing cases at the VHA, lack of documentation of steps taken! Can you say, “Asinine and abysmal behavior by credentialed professionals?” I know I can!
- Aspirin and Alcohol can cause a drug interaction that can be deadly. Both chemicals are readily available in the home and over the counter. Why is spray paint now requiring proper ID, because people are huffing the stuff and getting a multi-drug intoxication. Oven cleaner and spray pain can cause serious breathing issues and when mixed together can cause a cheap high, as well as a multi-chemical intoxication leading to breathing paralysis and death!
- Cannabis continues to be modified, changed, enhanced, and designed to trigger different chemical reactions in the body. Continuing work that began in earnest in the 1960s for the pot-smokers who wanted a more serious high. Guess what, cannabis and aspirin along with vitamins can cause multi-drug intoxication problems leading to death!
- Vitamin D and Vitamin C have both caused serious drug intoxications during COVID-19. People became frightened and took too many of both or just one and wound up in the ER with life-threatening health problems from toxicity of these vitamins. India has reported a spike in black mould that has caused serious long-term health problems for diabetics after recovering from COVID. It is currently presumed that the chemicals used to fight COVID allowed for a natural mould to grow in the body, and that became life-threatening.
The VA-OIG conducted another virtual comprehensive healthcare inspection, and found the same problems continue at another VAMC. Do you know how tired I am of reading these “comprehensive inspection” results and finding the same problems time after time? When will the VA actually start enforcing some of these VA-OIG recommendations to effect change? Better, when will the politicians who are charged with scrutinizing the government tire of seeing the same recommendations and not seeing any change? Bloody frustrating reading these reports and not seeing improvement!
Finally, we come to what I was hoping to be a great report, where the politician’s heads were going to explode at the inefficiencies, the detestable behavior, and the horrendous responses to legally mandated IT infrastructure changes, and why those changes are not happening at the VA. I was not disappointed; I was thoroughly disgusted that his report fell on plastic ears speaking plastic words from wax lips! Statement of Michael Bowman, Office of Inspector General, Department of Veterans Affairs, Director of IT and Security Audits Division, Before the Subcommittee on Technology Modernization, Committee on Veterans’ Affairs, U.S. House of Representatives, Hearing on Cybersecurity and Risk Management at VA: Addressing Ongoing Challenges and Moving Forward May 20, 2021. Notice something, the failures at the VA in the IT Department are being called “ongoing challenges.”
Let me remind you, FISMA was released on 29 April 2021, and I wrote about the abysmal findings of the VA-OIG. This report is the accountability statement to the Congressional representatives who should have skewered this bureaucrat and roasted him on a spit with onions and peppers, then served him up for public ridicule after firing him! For the Director of IT and Security Audits Division to make the following statement is flat out beyond comprehension, “The OIG’s conclusions in the FY 2020 FISMA audit are not new or revelatory—rather, they repeat many of the same concerns with VA’s IT security that the OIG has found for many years.” What incredible chutzpah to make this comment after that scathing report showed just how deplorable the leadership of the IT and Security Audits Division revealed! Director Bowman then goes on to downplay the band-aid solutions implemented while decrying the time for improvement is too short and there is not enough money. Do not forget, “Of the 26 recommendations, 21 have been included in every FISMA audit dating back to at least 2017.” With at least 15 of these recommendations dating back even further. Want a full list, as well as how old these recommendations are; you will not find it in the Director’s report to Congress! Is anybody incensed enough to demand a full accounting of just how old these IT recommendations are?
The gall of this director to continue to blame legacy systems that were legislated to have been scrapped between 2000 and 2010 continues to highlight the incompetence of the director in conducting business and holding people accountable for failed projects and overspending of taxpayer monies! The director went further and stated the following, at which time, every single Congressional Representative should have stood and demanded his head. The “VA does not properly manage and secure their IT investments.” Tell me director, why should you remain employed if the VA does not properly manage and secure their IT investments? Is the failure to manage and secure IT investments the root cause for veterans to continue to suffer identity theft from the VA losing their identity?
The director’s next statement puts his other outrageous comments to sleep. “Security failures also undermine the trust veterans put in VA to protect their sensitive information and can affect their engagement with programs and services” [emphasis mine]. Talk about such an obvious statement, it’s like the sun coming up on a cloudy day, you just cannot miss that sun rise; you also cannot miss the absurdity of making this statement! Did some intern write his speech? You are the director of IT Security and you make this type of comment, did you make this comment with a straight face? I cannot find the video-record of this Congressional hearing so I can only guess he delivered his lines with a straight face! Most detestable of all, he continued to make outrageous comments, his plan to move the IT security program at the VA forward is weak, lacking firm deadlines, and continues to allow him and his staff to escape accountability and responsibility.
America, with these bureaucrats in charge, why shouldn’t we be weeping and wailing, and gnashing our teeth in frustration? When will we, the owners of this atrocious government, finally scream ENOUGH and demand a full change of heads at the ballot box? For until the elected representatives are forced out, the bureaucrats abusing us, will only continue! The VA is sick, but the problem lies in the bureaucrats, administrators, and directors leading the VA at the Federal and VISN levels. So many other government agencies are just as sick, or worse, and the same problem arises, the leadership refuses to act, but still expects a big titanium parachute when they leave office! I say it is time to tell them NO!
© 2021 M. Dave Salisbury
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