Wednesday, August 31, 2016

Exclusive: Did Short-Staffing at Minneapolis Veterans Affairs Hospital Result in Near-Death of Decorated Vietnam Veteran Craig Brewster?

Craig Brewster, a former high school football star and decorated Vietnam-era veteran, is described by his family and friends as a winner in life.

A member of an elite Army team during the Vietnam War who worked on top-secret spy missions and had high-level security clearance, and a member of the the Army Gunners football team, Brewster came home after his service mostly intact. He had no serious physical or emotional issues and a bright future ahead.

After receiving his BA in accounting, he went into mechanical sales, which took him throughout the Midwest, then entered the security business, where he ran operations for such high-profile clients as the Minnesota Vikings, the University of Minnesota, the Final Four and the Super Bowl. 

An active member of the community, Brewster coached his three children in football and baseball and volunteered at his church. More recently, he was enjoying his retirement and was still very active, playing baseball, golf, hiking and biking regularly.

But two years ago, after checking in to the Minneapolis VA Health Care System for the first time in his life for what he thought would be a short stay, Brewster’s life changed forever. And not for the better.

Admitted on April 13, 2014 with flu-like symptoms, he underwent several tests. It was determined that he needed heart surgery. A triple bypass was performed on April 19, 2014 by Dr. Herbert Ward, a prominent physician in Minneapolis who is contracted with VA but not a VA employee.

After the surgery was completed and Brewster regained consciousness, he and his wife, Jean Brewster, thought all was well and hoped he would return to his happy retirement. But that’s when the nightmare for the Brewster family began.

Four days after the surgery, Craig had a massive stroke that multiple medical experts interviewed for this story say could and should have been prevented by VA staff.

By the time he was released from the VA hospital six months later, Brewster could barely walk or talk, even after months of physical therapy in the hospital.

“The VA ruined my life,” said Brewster, who has trouble speaking now but sat for an exclusive interview with The Reno Dispatch. “No attending doctor at the VA hospital evaluated me for four days after my surgery, despite the fact that I had serious complications.”

Since the stroke and all the complications which he said were caused by the VA, Brewster said he has lived with extreme and chronic pain, has nightmares about his experience at the VA, has anger and emotional outbursts, is no longer able to work, can no longer type on a computer, cannot talk on the phone or carry on a decent conversation, and can no longer play sports.

Brewster said he had "never been to the VA" hospital before because he had always had private insurance. “I was nervous when we went to the VA,” he said. “My wife Jean and I argued about me staying there. I wanted to leave before the surgery.”

After Brewster was admitted, an angiogram foreshadowed what was to come. “When I said they were hurting me they told me to be quiet, to shut up," he said. "After that, I told Jean get me the heck out of here. She thought this was the best place for me to be. This is supposed to be where they take care of our veterans.”

Did VA Neglect Lead to Stroke?

Craig and Jean Brewster before his stroke
Brewster’s attorney, Benjamin Krause, a Gulf War veteran who’s helped many disabled veterans with their VA disability claims, said the Minneapolis VA understaffed its facility over that Easter weekend. 

The lack of supervision of the hospital staff, he said, contributed to the failure to assess Brewster for stroke risk and failure to use the right medication.

“Instead of using the standard-of-care anticoagulants for patients at high risk of stroke post-atrial fibrillation, they used subcutaneous Heparin for lower leg blood clot prevention due to immobility in bed," Krause said. "This treatment had nothing to do with proper assessment and prevention of the stroke risk presented by Mr. Brewster after his near death two days post-op. Mr. Brewster was not on any proper anticoagulant to protect against cardioembolic stroke."

According to Krause, “The medications they used were improper. Subcutaneous Heparin is well known to be insufficient. He was no where near the proper dose nor route of administration for stroke prevention after his respiratory failure, atrial fibrillation and 4 cardioversions.”

Krause added that the VA would "like the public to think they did the right thing because the treatment they used has the name ‘Heparin.’ They hope to fool us with this bait-and-switch shell game. But the treatments are dramatically different and treat totally different things.”

Medical Sources Confirm Brewster's Charges

Multiple medical sources interviewed for this story reviewed Brewster’s case and corroborated Krause’s assessment.

Dr. Lisa Nee, a Chicago-area interventional cardiologist who worked at VA for two years and reportedly left with a clean record after blowing the whistle on unethical practices in Chicago, told The Reno Dispatch, “Physicians and others bring me hundreds of cases on which to consult, and in most cases that are non-VA, I side with the physician. But the Brewster case is completely outrageous. They would have been sued instantly in the private sector for millions of dollars. What happened here is horrific, it’s outrageous.”

According to Nee, the VA gave Brewster substandard doses of Heparin in the wrong route of administration.

“They did not give him a proper dose of Heparin to prevent against strokes caused by clots that originate in the heart," she said. "They gave him the wrong dosage of Heparin administered in the wrong route, subcutaneous instead of intravenous, and in no way addressed his unique risk of stroke after atrial fibrillation, cardioversion and respiratory failure. Such an assessment is standard and required per the standard of care, but VA was apparently asleep at the wheel that Easter weekend with no staff physicians available to Brewster.”

For clarification, Nee added, subcutaneous administration is an injection into the fat under the skin. The required method for Brewster should have been intravenous administration, which goes directly into the blood stream, and at a much higher dose.

From the records she reviewed, Nee concluded, “It indicates that four days went by without an attending or staff physician seeing this man. It took place over the entire Easter holiday from Thursday through Monday. No staff-level physician saw him even after his life was at risk. That is not quality care.”

Nee said there are “multiple levels of malpractice” in this case that include deviating from Medicare rules.

“According to the standards on how doctors practice medicine, if you are in the hospital, there has to be a note from an attending doctor every 24 hours, per Medicare rules,” said Nee, who now works as a national medical consultant with private health industry to improve transparency. 

“Policy at most hospitals and VA is that if there is a change in status, from floor to intensive care unit, the patients have to be seen by an staff physician,” she said. “None of that occurred. This is a cut-and-dried case of malpractice. If this had happened in a private practice setting, there would be a multi-million dollar lawsuit.”

Craig Brewster in his Vietnam-era Army years
Nee said Brewster has a “great shot at winning this case because the facts are on his side.”

One VA specialist agreed about the standard of care and reached a similar conclusion as Nee.

Dr. Jesse E. McGee, a cardiologist on staff at Memphis VA Medical Center, wrote in his opinion that the “standard of care for cardiology was not met” due to lack of adequate anticoagulant dosage. McGee has practiced for 20 years after receiving his medical degree from the University of Iowa.

According to Krause, the VA quickly replaced McGee on the agency’s list of experts, but not before an agency paralegal provided Krause with an excerpt of his opinion, which was then shared with The Reno Dispatch.

Krause said the “VA practice of using residents to augment staffing shortages is putting veterans’ lives at risk, and VA understaffing on weekends, which results in patient abandonment, is a scenario right out of ‘Lord of the Flies’. And the failure to use adequate anticoagulants is a major problem at VA.”

Krause said the VA failed to adhere to the minimum standard of care for stroke prevention per the American Heart Association’s guidelines for atrial fibrillation treatment post-bypass, and “rigged its experts to evade accountability” when it removed McGee from its reviewing experts for this case.

Regarding the lack of appropriate anticoagulation to protect against Brewster having a stroke after atrial fibrillation, Krause said, “VA did not even consider it until many days after Mr. Brewster’s stroke. A staff physician did not weigh in on using adequate anticoagulants until almost one week later.”

Craig Rushed to Intensive Care

On Saturday, two days after Craig's surgery, Jean Brewster said she was with her husband on the medical floor most of the day.

“He had trouble breathing since the surgery,” she said. “On Saturday he refused to lie down, saying he could not breathe lying down. He continued to have shortness of breath and had told the nurses he could not lie down, but they laid him down anyway. Why? And at approximately 4:30 he stopped breathing.”

Craig said VA staff laid him down and then left the room. “When someone came back to his room, he was not breathing,” Jean noted. “They were not able to obtain vital signs.  A code was called and he was intubated; which, Craig added, “broke two of my front teeth in the process,” and he was rushed to intensive care (ICU).

As a result of not breathing, Craig developed an erratic heart rate, which the chart states “could have resulted from inadequate sedation.”

Jean Brewster said no one at the hospital called her to inform her that Craig had “coded” and was back in ICU.

“I found out that Craig was back in ICU from friends who came to visit and found he was no longer on the same floor and that he was now in ICU,” she said. “I arrived about 6:30 pm and when I asked for details the cardiologist was very brief and short with me. Meanwhile, my husband was in critical condition and fighting for his life. He coded and I was not even notified. I felt like no one wanted me to know what had really happened.”

Two days later, Jean was with Craig at the ICU until approximately 5 PM.

“I received a call at approximately 6:30 pm that my husband had a stroke,” she said. “He was intubated now for the third time, his whole right side was paralyzed. I rushed back to ICU, not believing this was really happening. I was told that Craig was in critical condition and that nothing could be done to prevent the effects of the stroke due to the recent heart surgery. What is says in his chart is that the ‘embolism that caused the stroke was most likely due to the afib’ that was experienced with the respiratory failure’.”

Craig remained in ICU in critical condition for several days. He was then transferred to a medical floor to begin months of rehabilitation.

Brewster’s Life Before and After His VA Stay

Craig Brewster playing baseball before stroke
Before the stroke, Brewster worked part-time at Home Depot in the electrical department to keep active in his retirement, and enjoyed connecting with friends, playing baseball on two teams, golfing one or two times per week, fishing, biking and taking long walks.

He also enjoyed being a husband, father and grandfather, driving and enjoying independent living, having a sexual relationship with his wife, eating dinner out, attending sporting events, church activities, socializing, and travel.

But, said Brewster, “I can’t help now with housework, finances, shopping or meals. I have difficulty walking, I’ve lost most of the use of my right hand and arm, I have trouble swallowing because of the three intubations in the VA hospital, and I can't read more than a few sentences at a time. I just sit at home now.”

Dr. Herbert Ward

The Brewsters, their attorney and several doctors interviewed for this story all want to know what happened to Dr. Herbert Ward, the thoracic surgeon and professor at the University of Minnesota, who performed the procedure.

“He simply did not follow up with his patient,” said Krause. “Did Minneapolis VA contact him when Mr. Brewster suffered complications and almost died? Why didn’t VA call in a staff doctor while Ward was away?”

Dr. Ward did not respond to a request for an interview with The Reno Dispatch.

Was This a Case of Malpractice?

Krause said VA’s cardiology department missed the acute decompensated heart failure diagnosis prior to surgery, and that Ward then failed to properly calculate Craig’s risk levels pre-surgery for the triple bypass.

“Ward then disappeared over Easter weekend until after Craig experienced his stroke - Friday to Monday - during which time the patient experienced respiratory failure, a heart attack, atrial fibrillation, recitation, cardioversion and chemical cardioversion, continued decompensated heart failure, hypoxia, and then stroke,” Krause said.

After the atrial fibrillation but before the stroke, Krause said his expert witnesses say VA needed to assess for use of anticoagulants to protect against cardioembolic stroke that should have resulted in administration of IV Heparin.

“VA failed to conduct the assessment and failed to use adequate anti-coagulation strategies to include IV Heparin,” Krause said, adding that the VA failed to assess the veteran for risk of stroke using CHADS score, "which can help physicians estimate stroke risk in patients, until months after his stroke. They totally botched it. During that time, VA refused to tell Jean Brewster what was going on, sent her home, and failed to seek informed consent after changing the treatment plan.”

From April 19 to April 24, Krause added, “VA was knowingly operating without informed consent. According to the medical notes, no staff cardiologist or neurologist saw Craig during that period. They also stopped verifying the echo-cardiograms over Easter weekend, which would have alerted VA to bigger problems including a heart attack. VA failed to provide notice to the family that this was an ‘adverse event’ or at least a ‘near miss.’ They claim they did nothing wrong.”

Were Records Deleted and Altered?

Krause said the VA “deleted and altered” a record that discussed the anti-coagulation issue that was endorsed by Ward, who was the attending thoracic surgeon and is also in charge of the University of Minnesota Thoracic Surgery Fellowship Program. He is also a lead medical investigator for VA. 

Craig Brewster (front row #28) on Army Gunners football team
Brewster’s discharge summary that was signed by Ward on May 7, 2014, a copy of which was provided to The Reno Dispatch, was “deleted, moved, and then relabeled as a progress note on September 8, 2014 after the Brewsters informed Minneapolis VA that they intended to sue,” said Krause.

Five paragraphs from the note were permanently deleted from the primary record, Krause added. “I only noticed this because Jean Brewster got a copy of the record in August prior to the deletion,” he said.

“I requested a copy later, and realized the record was manipulated without any notations," Krause said. "I then requested a backup copy of all records deleted or altered from a VA database. That backup copy contained a blurred image of the deleted paragraphs and electronic signature. Anyone looking at the present medical record in VistA would have no idea what Dr. Ward said about why VA was tardy in administering the anticoagulant Warfarin or that the record was deleted, relabeled, and altered with five paragraphs missing – minus Dr. Ward’s signature.”

During Craig’s stay in the hospital, he said many other errors were made and that he was afraid to even go to sleep because a nurse might do something wrong with his meds, IV’s etc. Craig said the staff and doctors continued to try and convince him that nothing was done wrong.

Added Krause, “And three days after his discharge, they deleted that part of Mr. Brewster’s previous discharge summary that was endorsed by Dr. Ward.”

Comment from VA

While Ward did not respond to an interview request, Randall Noller, a spokesman for the VA, told The Reno Dispatch, “The Office of General Counsel confirmed that a tort claim has been filed and offers the following statement in response to this query, as well as responses to some of the reporter’s questions. VA will not provide comment regarding a claim which is currently in the administrative process under the Federal Tort Claims Act (FTCA).”

Noller added, “As a general rule, the FTCA provides coverage for medical injuries that result from any negligence of medical residents and students employed at VA and acting under the supervision of VA employees.”

Noller also stated, “The FTCA does not waive the government’s sovereign immunity for the acts or omissions of individuals who are not employees of the Federal government.”

Attorney Responds to VA Comments

Brewster’s attorney, Krause, said in response to the VA's comments, “There are certain instances where an agency is liable under FTCA for government contractors. It is a complicated review to evaluate the extent to which the agency has control over the contractor. Generally, it depends on the contract type and whether the government controls the details of their day-to-day activities. It is a very fact intensive review.”

In this instance, Krause noted, "I verified that Dr. Ward is a government contractor. VA pays the University of Minnesota Physicians’ cardiothoracic surgeon services department over $2 million per year. That contract allows physicians like Ward to teach his residents and fellows how to operate on veterans like Brewster. And, if what VA says is accurate, it allows VA to not be liable when veterans are injured from malpractice by those same surgeons.”

Krause said the VA has "made a practice of benefiting from cheap labor of residents and medical students under the supervision of university employee contractors while conveniently exculpating its own liability through the cost savings measure, depending on the facts and location of the incident.”

Krause noted that many veterans do not know the difference between VA employees and contractors, and VA does not inform veterans of the liability risks related to using contractors. Most veterans believe they are receiving care from VA employees the whole time. 

“In many states, due to the cost of bringing lawsuits and requirements for experts in advance of a suit, it is difficult to get justice for veterans harmed by a contractor,” he said. “Whereas, if the veteran is harmed by a VA employee, they may not need an expert to at least get some form of compensation for the injury due to negligence through the administrative process.”

The Brewster claim is now in the second part of the administrative process called reconsideration. 

"VA asserts it is not liable for Dr. Ward’s actions," Krause said, "but Dr. Ward was only a small part to the puzzle. VA clinicians failed to act after it was apparent that Brewster needed advanced life saving services to include treatment due to increased risk of stroke."

Krause said the issue in Craig's case is "to what extent does VA exercise control over the government contractor such that FTCA liability applies, and was Mr. Brewster harmed by the contractor or by VA employees? Brewster was under the care of numerous VA employees while Dr. Ward was away from the facility. During that period, Brewster was harmed by negligent VA employees. But VA is trying to hang this one on Dr. Ward.”

Legal Precedent

Krause said there is legal precedent in a case called Farley vs. US in which the veteran was awarded $21 million after VA prescribed aspirin instead of Coumadin, the well-known anticoagulant.

Michael Farley, 60, a Navy veteran, was reportedly awarded a $21 million malpractice verdict against the Veterans Administration Medical Center in Manchester, New Hampshire.

The New Hampshire Union Leader reported that the ruling by a judge in April, 2015  assailed the VA for "carelessly prescribing the wrong medication" and leaving the patient "medically abandoned."

Farley now has no voluntary muscle movement other than the very limited ability to move his eyes and his head, the newspaper reported. U.S. District Court Judge Landya McCafferty concluded that Farley’s condition could have been avoided if doctors at the Manchester VA had properly treated him after his first stroke in October 2010.

But according to the newspaper report, the judge said Farley’s doctors at the Manchester VA “carelessly prescribed him the wrong medication.” 

The judge cited medical studies and expert witnesses in stating that the anticoagulant Coumadin should have been prescribed after the first stroke. 

“The overwhelming weight of the expert testimony, coupled with the scientific studies, established that Coumadin more likely than not would have prevented Mr. Farley’s second stroke from occurring,” she wrote.

Coumadin, a lifesaving medication that I personally take every day for multiple blood clots that showed up in my lungs, is the commercial name for Warfarin, the mention of which was deleted from the medical records within Dr. Ward’s discharge note days after VA learned Brewster intended to sue.

Brewsters Want to Help Other Veterans

The Brewsters, who are claiming $25 million in damages for Craig Brewster and $5 million in loss of consortium for Jean, said they want to educate the public regarding their experience in hopes that no one else will experience what Craig went through and is still going through.

“We want Craig’s disability rating to increase from 10 percent to possibly to 100 percent,” Jean said. “This would validate the fact that errors were made by the VA that contributed to the stroke.”

She added that it is a “realistic possibility” that Craig Brewster will need extended care in the near future, which could result in cost ranging from $4-6,000 per month.

“This would exhaust very quickly every penny we have,” she said. “The VA is responsible for what happened to my husband. They were so short-staffed that they were not watching Craig closely, so he coded. Because of the code and the atrial fibrillation, he had a stroke. He is now debilitated for the rest of his life.”