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.
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.
There are veterans who serve honorably for a term and go back to civilian life. Then there are those who make a career of the military, an honorable profession for most. But there are an elite among these who serve as special operators in the Army Special Forces, Navy Seals, and the Marine Corps Force Recon, where MSgt. Mosher served from 1979 to 2007.
One might expect that these iron men should receive at least basic medical care from the VA when needed. But as outlined in his letter below, beginning on February 9, 2016, when MSgt. Mosher needed surgery for a painful lipoma on his right side, that may not happen.
Before proceeding to his letter describing his near fatal surgery and treatment by local facilities it should be noted that a lipoma is a slow-growing, fatty lump that's most often situated between the skin and the underlying muscle layer. They are usually harmless but may become painful, as in MSgt. Mosher's case. Surgery to remove them is typically one of the most basic procedures in medicine, which makes the horror of what MSgt. Mosher underwent even more dreadful and inexcusable.
This statement is written as my testimony for the maltreatment I experienced post-surgery by several elements of the Veterans Administration (VA) Medical Center in Colorado Springs, Colorado on the morning of 14 March 2016.
Chronologically, this odyssey began on 9 February 2016 when I was assigned to a VA surgical team led by Dr. Clifford A. Porter for the pre-op assessment that was done at the PFC Floyd K. Lindstrom VA Clinic located at 3141 Centennial Blvd, Colorado Springs, CO 80907. The pre-op assessment followed a well organized protocol that resulted in the issuance of written instructions to be done by me in the days ahead including the day of surgery. Date assigned for surgery was 24 February 2016. Purpose of the surgery was to remove a large lipoma from my rib cage/right side that had become increasingly painful albeit benign.
On 24 February 2016 at 0615 I and my stepson, Coltan Stevens, arrived at the U.S. Air Force Academy (USAFA) 10thMedical Group Health Care Facility located at 4102 Pinion Drive, USAFA, CO 80840. We went to the assigned location and reported in via internal phone, given further instructions to proceed and located my point of contact in the surgical unit. All preparations went smoothly and before I knew it I was waking up in recovery and released to my stepson to safely drive me home. Prescription drugs I was assigned at discharge were Hydrocodone [for pain relief] and Docusate NA [a stool softener].
I returned to the VA Clinic on Centennial Blvd on 1 March 2016 at 1200 for follow up with Dr. Porter. Since the surgery, I had been experiencing increased pain along with other side effects that concerned me such as constant twitching in my RIGHT latissimus, severe cramping in the RIGHT abdominal region, deep bruising down into my RIGHT hip and decreased range of motion in my right leg at the hip. I also expressed my concern for the severe swelling, mild fever and possible infection at the incision site. I was told then to continue following the assigned protocol of heat applications and not to use ice to reduce swelling.
Over the course of the next week I began to experience health decline. Fever increased, I began having severe headaches and pneumonia-like symptoms that included severe coughing, blurred vision, earaches, weakness in limbs and respiratory issues. On the morning of Thursday 10 March 2016 I attended two appointments at the VAMC and attempted to "walk in" with Dr. Porter or someone from his team to report the health decline I was now experiencing. Dr. Porter was not in the VAMC according to his RN; name unknown. I asked if she would please briefly observe the incision site to get an idea of the distress I was experiencing. The nurse obtained a medical assistant to witness me open my shirt to show the incision site. Both women seemed a little mortified at what they saw. The incision site was now reddening and very hot and severely distended. The nurse told me there wasn't anything she could do but I could call the USAFA and leave a message for Dr. Porter. She wrote a phone number at the USAFA Surgical Unit for me. At that time I requested some kind of message be put into the VA messaging system to be sent to Dr. Porter. When I left the VAMC I know by my appearance alone I did not look well whatsoever and definitely needed immediate medical attention.
I did not leave a message for Dr. Porter via the USAFA phone number because I was more concerned about my own personal safety driving home from the VAMC. Once I was home, I was now feeling nauseated, dehydrated, had severe chills and felt like I was losing consciousness. I pushed fluids such as clean drinking water and diluted Gatorade. I also ate a bowl of organic vegetable soup. Throughout the night my wife kept asking me if I wanted to go to the emergency room due to the severity of the pain, coughing, and frequent passing out from the pain in my side and head. At around 0430 on 11 March 2016 I awoke suddenly, bolted to the bathroom and wretched for 15 minutes to the point of near unconsciousness. I had to physically crawl across the floor to get to my couch. I remained in this status the entire weekend as statement from my family will reveal.
At approximately 0330-0400 on 14 March 2016, I awoke covered in bloody fluid. The incision site had burst. I got up and cleaned myself, then made plans with my wife to go to the VAMC and check myself in because I thought there was an emergency crew on duty there. My rationale for this was to keep the responsibility loop closed. VA had done the surgery, they are responsible for my care. I did not want to go to a civilian emergency room requiring me to use my military retiree medical benefits to cover some other entities responsibilities.
My wife and I took two vehicles because she needed to be at work that morning by 0900 and I thought if VA could assist in stabilizing me this early, she could make it to work on time and I could drive myself home thereafter. Upon arrival at the backdoor of the VAMC (time now was approximately 0515), we realized the emergency service ended at 0430 as posted on the sign. We drove around to the front door to see if we could contact someone still on duty. Two people were present, the coffee shop worker and another unidentified woman who recommended going to Penrose Hospital a couple of miles away. We left the VAMC and drove over to the hospital. Once there I decided I would not check into this place, that the VA had the responsibility of providing me care for the health issues I was experiencing and would not break the chain of responsibility.
We returned to the VAMC at around 0730 and asked if there was someone who was responsible for walk in emergency triage. I was pointed toward the duty PACT who then sent me to my assigned team across the way. There was a young man on duty conducting intake. I showed him the incision had burst and I was still draining severely, I am in distress and need assistance now. I and my wife were told I couldn't be seen until 0800. I told him to get nurse now. He returned and told us the team nurse wasn't onsite. I walked over to another PACT and asked a woman if she was a nurse. She said yes, then immediately asked me if I had been assigned to a particular PACT. I responded by showing this woman my wound and tried to explain my circumstances. She then attempted to walk me back to my PACT. I told her that team's nurse was AWOL. She asked me "Well what do you want me to do?" I asked "are you the emergency triage team?" No response. I looked at my wife and said "OK, lets try the surgeon down stairs. These idiots are not going to take responsibility." I went to Dr. Porter's area, announced myself to a gentleman at the desk and showed him the bloody mess under my shirt and asked for Dr. Porter or his nurse. The nurse came out and immediately tried to put it on me for not calling the doctor. I countered with a question asking "did you bother putting a message into the system like I requested?" There was no answer. I told my wife to come on and lets go find the site Patient Advocate.
We went to the Information Desk to ask where the Patient Advocates office was. I was told that official "was not in today." A Monday morning at a packed clinic and no one responsible enough to make a simple decision outside their comfort zone. By this time I was furious with this maltreatment in not only poor medical care but the customer service aspect. No one at this facility would accept responsibility for my care that morning regardless of me continuously stating I was in emergency distress.
My wife now had to call in to her employer to let them know she had to take me to a hospital. I called a friend and fellow veteran to ask where he'd recommend going that was reasonably reliable and concerned about my health. He recommended Penrose St. Francis Hospital located at 6001 East Woodmen Road, Colorado Springs, CO 80923. We convoyed across town to this location and checked in at 0856. Within 15 minutes of completion of necessary entry forms, I was brought into an intake room, vitals taken, blood samples taken, then briefly moved into a waiting room. By 0945 I was taken to an examination room and placed on telemetry for monitoring. A nurse practitioner examined the burst incision and agreed there was definitely infection in the incision site and would need an antibiotic therapy applied before release. The incision site also needed to be lanced in order to open it for further drainage. I have pictures of this procedure.
Another specialist came in and conducted an ultrasound examination to determine if there were any internal issues. Once the doctor reviewed all collected information and examined me physically, I was then placed on an IV antibiotic therapy; Vancomycin, for approximately 2 hours. Once the IV was completed, the incision site was cleaned and dressed for discharge. I was prescribed Clyndamycin and Percocet and released.
During the emergency room procedure and up to 1600 that day, several calls from the VA took place. I made no effort to communicate with them directly after the fact. Since that day, 14 March 2016, no one from the VAMC nor the Denver VA Hospital Patient Advocates office have made any effort to call me directly to see what the problem was, let alone if I am still alive.
It is now 28 March 2016 and I am just now feeling somewhat normal. The incision site has normalized but is still swollen with periodic leakage. The severe headaches, extreme pain, nausea, fever, congestion and respiratory issues caused by the infection have subsided but are still periodically present. I am a 55 year old retired U.S. Marine Corps Force Recon man who was in outstanding health before this procedure. It is my opinion that had this happened to another veteran of less health or greater age, they might not be with us right now. I mean they'd be dead. I have heard the nightmare stories concerning the VA Health Care System but never thought I would be a victim of this system. I realize the volume of veterans using the system but this is no excuse for being disregarded, dismissed, and disrespected by the institution that is directed by law to be responsible for service disabled veterans requiring 1 st class care and treatment.