Little Oversight, Botched Procedures Alleged at Philadelphia VA

Philadelphia, PAReverend. Ricardo Flippin is a 21-year veteran of the Air Force. So it's hardly surprising that when he was diagnosed with prostate cancer in 2004 he chose to have his treatment carried out at the VA hospital in Philadelphia, which has since been linked to allegedly medical malpractice --botched procedures in its cancer unit. Radioactive seeds were to be implanted in the prostate to fight his cancer.

However, according to a June 20th report in the New York Times the radioactive seeds, which are about the size of a grain of rice, did not wind up in Flippin's prostate. Instead, they migrated to Flippin's rectum, causing a radiation injury (radiation burn) that was finally corrected by surgery in 2006.

Prior to the surgery, Rev. Flippin told the New York Times that he was in so much pain he couldn't walk, couldn't sit. He had to leave his job with the church. Following surgery he is back with another church, but he does not have consistent control of his bowels, forcing the thoughtful and articulate Air Force veteran to wear protective undergarments.

The error alleged to have taken place at the Philadelphia VA appears to form a pattern of lax procedure and oversight in the cancer unit of the hospital, according to public records and interviews conducted with government officials and investigators.

According to the Times article an investigation into the procedures of the Philadelphia VA cancer unit has uncovered 92 botched cancer treatments out of 116 over a 6-year period without revealing the oversights. It has been alleged that the unit operated with virtually no outside scrutiny or peer review.

The cancer team at the Philadelphia VA was found to continue implants for as long as a year even though equipment used to measure and determine if the patient did, indeed receive the proper dosage of radiation, was inoperable.

In one procedure, most of the 40 radioactive seeds that were intended for the prostate landed in the patient's healthy bladder. The incident was investigated, according to federal statutes. However, according to the New York Times report, investigators allowed the doctor who performed the initial procedure to rewrite his surgical plan to reflect the number of seeds in the prostate, essentially erasing his error.

For the patient, that meant a second procedure to implant more seeds. But it is alleged to have gone wrong too, with an unintended dose of radioactive seeds landing in the rectum.

According to the Times article, that oversight was never reported at all.

In 2005 the doctor who performed the botched procedures noted above revised a surgical plan yet again to reflect the implantation of half the radioactive seeds in the wrong organ.

Regulators were found to have filed no objection to the revision.

The New York Times reports in its expose that the prostate unit at the Philadelphia VA was closed last year and has yet to reopen. Veterans Affairs has also suspended brachytherapy implants in Jackson, Mississippi and Cincinatti—although it was noted that problems there pale in comparison to what is alleged to have happened in Philadelphia.

The New York Times investigation revealed that virtually none of the substandard implants carried out in Philadelphia were reported to the nuclear commission. That suggests that errors would not have been investigated for weeks, or even years—during which time patients would not have known that their cancer treatments were flawed.

So far, no one is believed to have died from a botched implant. However many, like Reverend Flippin, have been made to suffer.