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POLITICS: PennAve

Treatment at a Veterans Affairs hospital nearly killed an agency whistleblower

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Photo - As a physician’s assistant at a VA hospital in Tennessee, Valerie Hoermann saw one of her patients, a friend and Vietnam veteran, die because of what she considered inadequate medical care. As a whistleblower, she endured retaliation after complaining about it to the agency’s inspector general. (Photo by Pat Casey Daley)
As a physician’s assistant at a VA hospital in Tennessee, Valerie Hoermann saw one of her patients, a friend and Vietnam veteran, die because of what she considered inadequate medical care. As a whistleblower, she endured retaliation after complaining about it to the agency’s inspector general. (Photo by Pat Casey Daley)
Watchdog,Mark Flatten,Veterans Affairs,Tennessee,Health Care,PennAve,Whistleblowers,Accountability,Minusextra,Veterans,Nashville,Scandals

Fourth in a five-part series.

Valerie Hoermann lived through the scandals now plaguing the Department of Veterans Affairs.

Barely.

As a physician’s assistant at a VA hospital in Tennessee, Hoermann saw one of her patients, a friend and Vietnam veteran, die because of what she considered inadequate medical care.

Faces of Delay

A five-part series by the Washington Examiner on some of the individual veterans who have suffered from poor care and long delays by the Department of Veterans Affairs.

Part One: Delays, denials by VA deliver 'death sentence' to cancer victim

Part Two: A fatal level of trust in VA care

Part Three: Korean War veteran dies after VA hospital ignored his medical history, daughter says

Today: Treatment at a VA hospital nearly killed an agency whistleblower

Part Five: Missed leukemia diagnosis by VA leaves vet who put his trust in doctors living 'day to day'

Click here to see a summary of the series and find more resources

As a whistleblower, she endured retaliation after complaining about it to the agency’s inspector general.

As an emergency patient in a VA hospital, she spent hours without medical treatment as her life burned away. She survived only after staggering out of the VA's facility to a university teaching hospital next door.

What hurts most now is the realization that all of her efforts to get veterans better care amounted to nothing, she said.

“I realized that nothing I went through had changed a thing,” said Hoermann, a former Army Reserve captain and Operation Iraqi Freedom veteran. “It broke my heart.

“People are still dying now and people are still being punished for trying to get patients care,” she said. “There are some really good people in the VA. There are some people that believe they are serving their country. Some of them stand up and tell the truth and they get in trouble.”

Hoermann joined the Army Reserve in 1998. In 2003, she was placed on active duty and deployed to the Iraq-Kuwait border, where she provided routine health monitoring and emergency treatment of battlefield injuries.

She returned home a year later and left the Reserve in 2007.

By then she was working at Veterans Affairs, seeing patients as a physician’s assistant at the Alvin C. York VA Medical Center in Murfreesboro, Tenn.

There were frequent run-ins with doctors and hospital administrators over patient care issues, said Hoermann, who recently married and went by the last name Blackwell at the time.

“I was making trouble if I questioned, and my only questions were about patient care and can we get them help,” Hoermann said. “The poor veteran is not being taken care of. They are being re-traumatized all over again.”

Hoermann went from troublemaker to whistleblower after one of her patients died in 2008.

The man was a friend who had not sought medical care since serving in Vietnam. He had no health insurance, but complained of what he thought was arthritic pain in his back and hips.

Hoermann convinced him to see a private doctor, a mutual friend they knew through a faith-based missionary organization where they all volunteered.

That doctor recommended the veteran enroll for VA coverage, and on June 20, 2008, Hoermann performed an initial examination on her friend.

Because of the man’s age, potential exposure to Agent Orange in Vietnam and his lack of medical exams for decades, Hoermann had concerns about colon cancer, as did the private doctor the veteran had seen earlier.

She ordered a battery of tests after the visit, including a colonoscopy.

But no appointments for colonoscopies were available the following week, so the test did not get done, Hoermann said.

There are some really good people in the VA. ... Some of them stand up and tell the truth, and they get in trouble.
 

A week later, the man was in the Murfreesboro VA emergency room with abdominal pain.

When Hoermann visited him that Friday evening, the veteran had received no treatment, not even insertion of an intravenous line, she said.

The man “looked like he was nine months pregnant,” even though he was emaciated, she said.

Emergency room doctors ordered an abdominal ultrasound before admitting the man. It wasn’t done.

When Hoermann called the radiology department to find out why, she was told the staff had gone home for the day.

Hoermann spoke by phone with the veteran several times over the weekend, and when she visited him in the hospital Sunday night he had still not received any diagnosis or treatment, only pain killers, she said.

Hoermann tracked down the on-duty doctor and complained. A colonoscopy performed the next morning showed the veteran had advanced rectal cancer.

He was transferred to the VA hospital in Nashville, where surgery was performed to remove the tumor. Six weeks later, Hoermann’s friend was dead.

Convinced the veteran received inadequate treatment at the Murfreesboro hospital, Hoermann filed a complaint with the VA inspector general in July 2008, weeks before the man died.

The complaint was supposed to be confidential, but Hoermann’s name was disclosed during the IG’s on-site investigation in November 2008, so hospital officials knew she was making trouble.

A month later, she was stripped of her duties and prohibited from seeing patients. Initially she was assigned to a windowless room in a basement and not allowed to do anything, but eventually she was moved to the pharmacy to help fill orders.

Hoermann joined the Army Reserve in 1998. In 2003, she was placed on active duty and deployed
to the Iraq-Kuwait border, where she provided routine health monitoring and emergency treatment of
battlefield injuries. She returned home a year later and left the Reserve in 2007. (Courtesy photo)

The only explanation she got during the 159 days she was prohibited from seeing patients was that the action was because of the ongoing IG investigation.

Hoermann sought help from the U.S. Office of Special Counsel, which investigates complaints of retaliation against whistleblowers. The OSC dismissed the complaint as resulting from a legitimate disagreement with the doctors over the patient’s treatment.

The IG released its report to hospital administrators, but not to Hoermann, in December 2008. It concluded the doctors at the Murfreesboro VA did nothing wrong in their treatment of Hoermann’s friend, but did fault her for not doing more during the initial office visit.

The IG based its findings on patient records and interviews with other medical staff.

The accuracy of VA records has been called into question by recent revelations of “systemic” falsification of appointment wait-lists and other tricks used at veterans medical facilities nationwide to hide inadequate care and long waits for treatment.

The IG’s 2008 investigation also failed to expose bigger problems at the Murfreesboro VA hospital.

In December 2008, an incident in the colonoscopy department revealed equipment failures and unsanitary procedures had potentially infected thousands of veterans with diseases including HIV and hepatitis.

That triggered a nationwide review, and eventually more than 10,000 patients, most of them from Murfreesboro, were notified that they were potentially infected because of sloppy colonoscopy procedures.

Within a year, six of those veterans tested positive for HIV and 47 had hepatitis.

The incident that exposed the unsanitary procedures in the colonoscopy department occurred one month after the IG was on site figuring out whether a veteran with colorectal cancer was properly treated.

In August 2009, Hoermann was notified that the agency intended to fire her based on the IG’s findings that no one except her did anything wrong in treating her friend.

She hired a lawyer and challenged the action, insisting her treatment was consistent with agency directives, and that the colonoscopy she ordered was not done because no appointments were available.

VA backed down a month later and reinstated Hoermann without any explanation, allowing her to see patients again.

Valerie Hoermann resigned from VA in October 2010, disillusioned with the agency and fearful that her supervisors would sabotage her medical license when it came up for renewal if she stayed. (Photo by Pat Casey Daley)

Then she got sick.

In June 2010, Hoermann developed Rocky Mountain spotted fever, a potentially deadly infection. After days of fevers, and not trusting the doctors at Murfreesboro where she worked, she drove to the VA hospital in nearby Nashville.

Hoermann was running a high fever, bleeding internally and nearly comatose when she arrived at the emergency room, she said. Doctors started an IV for hydration, ordered a series of tests, and admitted her into the facility.

The IV drip was disconnected when Hoermann was moved to a patient room shortly after noon, she said. She was no longer receiving fluids. No one, aside from a couple of medical students and an orderly who brought her a meal, checked on her.

“I was asking for water and a blanket, slowly going into shock,” Hoermann said. “Not one nurse darkened my door. I knew I was going to die if I didn't get out of there. I almost did.”

After four hours without treatment, Hoermann pulled herself out of bed and staggered into the hallway, blood dripping down her arm from the IV that was no longer attached to anything. No one tried to stop her as she stumbled past the nurses' station and toward the elevator.

"I recall very vividly thinking that ‘If I stay here I am going to die,'" Hoermann said. “I thought it would prove absolutely nothing. No one would care.”

In a daze, she made it into the parking lot and collapsed. Two security guards from the adjacent Vanderbilt University Medical Center found her and rushed her into that hospital’s emergency room.

Doctors at Vanderbilt worked on Hoermann all night, pumping antibiotics into her to fight the infection. She spent a week in the hospital, and credits Vanderbilt with saving her life.

Later she found a message on her phone from the VA hospital asking where she was. It was left two hours after she stumbled out the front door.

Hoermann resigned from VA in October 2010, disillusioned with the agency and fearful that her supervisors would sabotage her medical license when it came up for renewal if she stayed.

After what she has been through, Hoermann said she is not surprised by recent scandals involving poor patient care and retaliation against whistleblowers at VA.

Despite the publicity, she is skeptical things will change.

“For things to change, they are just going to have to get rid of that culture,” Hoermann said. “They are going to have to fire a bunch of people, and I don’t know how realistic that is because they already are entrenched.”

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