EJF Newsletter — What does any nation owe to those who serve - Part II


April 27, 2017

In the United States the standard for the care of veterans was set by President Abraham Lincoln after a disastrous civil war when he stated this nation is obligated:

To care for him who shall have borne the battle and for his widow and his orphan.

That set the stage for the formation of the present Department of Veterans Affairs, which is chartered to provide health care services, benefits programs, and access to national cemeteries to former military personnel and their dependents. The department carries out its duties through three main administrative divisions: Veterans Benefits Administration; Veterans Health Administration; and National Cemetery Administration.

To carry out these duties the department currently has a budget of ~$171 billion, of which apparently $57 billion goes to Veterans Health Administration.

For this extraordinary expense veterans should be entitled to reasonable health care while living. But the facts speak otherwise!

Hardly a day goes by that there is not a new scandal about VA healthcare and the facilities. But statistics and generalizations have lost their impact on our psyche simply through almost infinite repetition and we seldom hear a first-hand account of the impact on a veteran.

On April 2, 2016, the EJF published a letter by Mark Mosher (USMC Force Recon, MSgt., retired) describing his incredible experience following minor surgery to remove a lipoma in his back at the US Air Force Academy Hospital in Colorado Springs, Colorado. Publication of that newsletter resulted in various high-level Veterans Administration officials contacting MSgt. Mosher. But, as follows, the result was effluvium from more cow manure of the type used to dip the scalpel in that was used to operate on him.

 But MSgt. Mosher was far from the only victim of dirty and infected instruments at the USAFA hospital and six months later the Colorado Springs Gazette published the following story:



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Testing offered to VA, Air Force Academy patients at risk from dirty endoscopes


September 23, 2016

By: Tom Roeder, (719) 636-0240

Reproduced under the Fair Use exception of  17 USC § 107  for noncommercial, nonprofit, and educational use.

The 267 patients subjected to improperly cleaned endoscopes at the Air Force Academy's clinic are being offered tests for hepatitis and human immunodeficiency virus, officials said Thursday.

Endoscope procedures at the clinic, which is jointly run by the academy and the Department of Veterans Affairs, remained halted as workers there worked to reach more than 150 patients who still hadn't been notified of the problem, which was first announced Wednesday.

Col. Robert Rottschaffer, the academy's No. 2 doctor, said the problem began in June when a technician in charge of cleaning the scopes used to inspect the digestive tract decided to cut out a step of the hour long sterilizing process to save time.

“He had been skipping a step in the precleaning process before the scopes went in for high-level disinfection,” Rottschafer said.

The step involved washing out a check valve that is used to send air and fluids down the snakelike scopes, and could leave patients at risk for infections including hepatitis and HIV.Officials said the risk of infection is “ extremely low, ” but the agencies involved are offering doctor's visits and blood tests for all involved.

The technician, who VA officials earlier identified as an airman, is at the center of an investigation to determine why the step was skipped and why it took the clinic three months to notice the misstep.

A new civilian worker at the clinic spotted the problem September 9 th and alerted commanders to the airman's shortcut, academy officials said.

After the problem was discovered, the Air Force and the VA spent two weeks determining how many patients could be impacted and the level of danger those patients faced. It was determined that 61 veterans under VA care and 206 military members, retirees and dependents may have had procedures using the improperly cleaned scopes.

The airman's name hasn't been released, but officials said he's been suspended from clinical duties during the investigation. Leaders refused to answer questions about whether the shortcut could lead to criminal charges under military law.

“Prior to this incident in June, there had been no concerns with the performance of his duties,” said Lt. Col. Thomas Stamp, who commands the endoscope clinic.

The cleanliness of endoscopes have been the subject of repeated warnings from the Food and Drug Administration that started last year, telling doctors and technicians that every step in the meticulous cleaning process must be followed before the devices are inserted into another patient. [EJF comment: Endoscopes, apparently the same instruments, are shoved up a patients anus and then, supposedly after being thoroughly cleaned and sterilized shoved down a different patients throat.]

Cleaning the scopes is crucial because they are exposed to large amounts of bacteria and viruses when they are used to inspect the esophagus or colon.

Stamp said the scopes used at the academy are different from those at the center of a incident this year at the University of Colorado Hospital in Denver. There, dirty scopes are suspected in the infection of nine patients, including three who died.

Stamp said the eight technicians at the center, four from the Air Force and four from VA, were being retrained on how to clean the scopes and other Air Force bases were alerted to the incident so commanders there can recheck their cleaning procedures.

“Patient safety is something we take very seriously,” Rottschaffer said.



From various reports the USAFA hospital has cost on the order of $100 million to build and equip. We've further learned that the “hot” water used in the hospital currently comes from the central plant and isn't hot enough for hospital requirements. Apparently plans exist to build a separate hot water plant for the hospital probably this year. But simply a better source of “hot” water will not fix the problems if proper sterilization methods are not carefully and conscientiously followed.

It would seem safe, however, to assume that there are, or were more problems with sterilization and sanitary procedures at the hospital than just one airman and endoscopes, as MSgt. Mosher's story bears witness to.

And what has happened to MSgt. Mosher in the past year?


After Action Report from Veterans Administration Medical Appointment


April 26, 2017

Mark Mosher

MSgt. USMC (Ret.)

On 24 February 2016 I was operated on for the removal of a lipoma at the U.S. Air Force Academy Hospital. Within days of the procedure I became seriously ill. To date, I have not been afforded any after care by the Veterans Administration (VA) for what happened to me post-surgery over a year ago.

Twice since my initial statement concerning this incident I have been hospitalized with what I know were after effects of the infection I experienced from the VA's surgery on me.

Recently, March 17, 2017, I finally had an appointment set with, supposedly, a new PAC Team at the VA clinic in Colorado Springs, CO. That was not true, I was only reassigned to another nurse practitioner in the same team.

It seemed she was aware of the official complaints I made post-surgery a year ago.  During my appointment she was extremely unprofessional and displayed a level of disdain, arrogance, and disregard I found highly undesirable for a so-called health professional. This occurred within the first five minutes of my appointment.

Her opening statement to me was “I have an extremely loaded schedule today. What do we need to talk about?” At that moment, as if in a Saturday Night Live skit, she was interrupted by a support staffer from my intake declaring there was an urgent phone call she had to take. When she returned; approximately 10 minutes later, the dynamics and tone of the conversation had changed dramatically. She became pointed and contradictory regarding my health concerns and complaints concerning the aftermath of the surgery a year earlier.

She argued that I had not experienced an infection regardless of the fact I had a thoroughly diagnosed and treated infection evaluated at a civilian hospital a year earlier. She also stated that  we weren't going to talk about “old things.” That statement initiated an argumentative exchange in which I stated her team's post-surgery neglect put me in the hospital. She continued to argue as if scripted, and began to attempt to debunk my experience versus her years as a nurse. She also attempted to guide and frame the discussion toward my prescribed needs; Motrin, attempting to conclude the appointment.

I then suggested I should get a second opinion. Without hesitation, she spun her chair from her computer to grab a “transfer request” as if I meant to transfer yet again to another PAC Team. That would mean I'd have to wait another year to be seen in this non-permissive environment and continue to be stonewalled by irresponsible VA employees. 

 When she realized that was not what I meant, she began asking if VA was my primary healthcare provider. I reverted back into the original argument, i.e., no post-surgery after care and the fact I have had to absorb the financial cost of the VA's neglect in order to stabilize my health. The nurse practitioner then attempted to frame my health concern as strictly an administrative issue and suggested I should go see the patient advocate. At this point I began to question exactly who this person is and why was she so opposed to giving me any care that day? And of all days, my birthday...

Nothing happened in support of my health needs that day. I continue to have negative side effects from the surgery the VA performed a year ago. Maladies such as unexplained fevers, itching and throbbing of the incision site, periodic intestinal pain that puts me in a fetal position. I just endure it and it eventually passes. Those conditions were not present before the lipoma was removed. I was actually much healthier albeit uncomfortable with it in.

In recent months I had also attempted direct contact with a VA Patient Advocate for assistance with the financial costs associated with my repeated hospitalizations. There has been no acceptable outcome supported by the VA Patient Advocates office. They flat out refuse to communicate.

On more than one occasion I have been stonewalled at the front reception desk at the Colorado Springs VAMC. Once, I was actually confronted by a “work-study” student telling me I could not see the patient advocate. I simply told this individual to go get his boss. Now this individual was in my personal space telling me “No.” I then told him that his VA career was about to go down in flames. He walked away behind the counter, sat down and called his boss, a female volunteer. Once I established rapport with the female volunteer I was told the patient advocate wasn't even onsite that day. The day my wife and I were at the Colorado Springs VAMC, March 14, 2016, when I was in distress, as noted in my previous statement the patient advocate was not onsite then either.  I sense this is either a scripted excuse or there are federal employees getting a pay check they aren't earning.

 Further, this type “layering” of unofficial people does nothing for real assistance whatsoever and nothing describes the medical attention I've received following what turned into a very serious infection with continuing after effects.

 Note that I served in the United States Marine Corps honorably from 1979-2007 as an infantryman, reconnaissance man, force reconnaissance operator, and foreign service adviser. I survived combat and hostile environmental conditions. I expected the Abraham Lincoln motto: “To care for him who shall have borne the battle and for his widow and his orphan” to be honored by the Veteran Administration in the same manner as I honored my oath during my years of service. After retiring from the USMC I've served as a Disabled American Veterans Service Officer and founder of the Thumos Project in support of my fellow veterans; especially those disabled by combat injuries. I never expected to be a victim of the Veterans Administration as so many others have. I was simply asking for the care required to treat disabilities caused by long-term devotion to duty to my country.


 In Part III we will look at practices and conditions at other VA hospitals and how other veterans have been treated. 


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Issues The Equal Justice Foundation Deals With

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