The violence in Iran isn't the only horror story on today's NYT front page. Just below the fold is a story about what the Old Grey Lady describes as a "rogue" cancer unit at the Philadelphia VA hospital. According to a federal investigation, that hospital's brachytherapy (prostate cancer implant) unit botched a staggering 92 out of 116 procedures from 2002 to 2008, while operating with practically no oversight.
Peer review, a staple of every good hospital, in which colleagues examine one another’s work, did not exist in the unit. The V.A.’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 their inspections had been limited or they had not acted decisively upon finding problems.
In at least one case, the screwup was tragic. One patient nearly died as a result of a botched procedure in Philly, and still can't control his bowels. Fortunately, the unit was shut down in June 2008.
Most of the screwups were done by one doctor, Gary Kao. Kao was one of several outside contractors brought in from Penn's medical school. Back in 2003, Kao mistakenly put more than half the seeds in a patient's bladder. However, he simply rewrote his plan, with the approval of the VA and NRC. When the patient had to come in for a second procedure, Kao botched that one too--putting the seeds in his rectum. However, no one reported this snafu.
Two years later, Kao made his biggest screwup when he treated Ricardo Flippin, a 21-year Air Force veteran from West Virginia. He started having severe bowel pain 10 months later, and treatments at the VA hospital in Huntington, West Virginia didn't seem to make a dent in it. He dropped to 109 pounds and lost his job. He finally went to Ohio State in 2006, where doctors there discovered a radiation injury. It was 2008 before the VA told him he'd received a poor implant. Mercifully, Kao is no longer working at that hospital, and won't be allowed back. If I were Kao's malpractice lawyer, I'd start getting ready to negotiate a settlement, stat--based on the evidence against him, he's screwed eight ways to Sunday.
Incredibly, regulators only learned how serious the problem was by accident when a VA official ordered seeds that were too weak. Investigators didn't find this had happened before, but found several cases where implants had been put in the wrong places. A separate NRC investigation found that 57 implants didn't deliver enough radiation to the prostate, and 35 more sent too much radiation to other parts of the body. It also found that the hospital allowed the procedures to continue for much of 2006 and 2007 even though VA radiation officials knew a device that monitored whether patients got the proper dose wasn't working.
The incompetence displayed here is simply staggering. However, it's not entirely surprising, considering what happened at Walter Reed.