’WPC… `. <»įĪ F|/-¦x.C4†ŹÕ¼½ļ`o0YÅĄĻō!F|&¢$Aq5eśmźüE³V”­Tp”~Ć-÷ˆ€’<"~_W‰^žMs·­ĻÓæda öeŠiy÷Ć 7½@Æ¢Īø­:³€¾L4aL˜#ųĘŚ`(ĶŠiBŒõč·Š0Ģ'Š[—Rž¶ŅĄ€śģ“ĮR=č\„uāÉhhfÖ4ƒ2'ŠRšŃ+Ŗģ‹–cčµI[›gjaµEĪ …—G+gŠ¼Gqą†(¹š_ņoi|ƒö²U8õ¾-éŸ5S')oMģĢ$ńµ°€'”4Ās©Ÿą^ķöŪŖ߈,Ā_ ćš"_Ķ4œńAøĖū,ł©Ōʌž¬F/7Uf䋇B €‰nŁpy晣›ōį÷E¾qĘ#‘ō¤· ģ¶cĖ© ›ĮošÜ5Ēm‚į^õBåcčy{3J8R„ l8Kč ·ĶSsĪ’éģm•Mōƒŗ0R|H‹f_SCū³0‚øŹĒŒy`¦‰7Ņ~`g!ęMWW,.ĻWēÜUPFnŹĻ¤ž\’€«HķƉ©D°4LrŲo*ćtFBu®˜n¢„L‘±7e~€VEįõ8MZ<¾h‘D™ #ɶU N %Ķ 0:Ó^ w41@ mBYo˜Canon MF5700 Series (FAX)ģīģīīģģī0(ÖĆ9 Z‹6Times New Roman RegularX(üœ$””ŌUSUS.,Ō&id7ó ć])7ź:i¢×+003|x’U‹’ĄĄĄ Ń e Ń Ń ° ŃŻ ƒüœ!ŻŌUSUS.,ŌŻ  ŻŌ_ŌŌ€č^æēXXŌŌ‡X&įXēč^æŌÓ  ÓŃ  ŃŃ€ ļOŃŃ€ OYŃĢĢĢĢĢŌ#†č^æēXX&į\#ŌĢĢĢĢĢĢĢĢĢĢPresentation€before€the€Presidentššs€Commission€onŠ œģ ŠWounded€WarriorsŠ (x ŠĢMay€14ņņthóó€,€2007Š @ ŠĢJoseph€Olimpio€Boggi€D.O.Š X Ø ŠInternal€MedicineŠ ä!4 ŠĢĢŌ‡X&įXēč^æŌĢĢĢĢĢĢĢĢŠ Ø-ų(  Š‡Ō_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌŌ_ŌInŌ_Ō€the€first€few€days€as€chief€of€Internal€Medicine€I€encountered€three€poorly€treated€patients.€TheŠ ° Šhandwritten€notes€came€out€of€my€green€notebook.€In€quick€succession€I€found€a€patient€on€the€wardŠ ”ä Šwho€had€a€Potassium€of€7.5.€In€terms€of€severity€that€is€a€ten€on€a€scale€of€ten.€You€would€not€expectŠ xČ Što€find€a€patient€alive€with€a€Potassium€that€high.€Dr.€Sreekumar€had€changed€medication€and€notŠ \¬ Šmonitored€the€Potassium.€Things€had€been€out€of€sorts€in€that€way€for€a€couple€of€days.€Later€anŠ @ Šoutside€reviewer,€Dr.€Ripple€did€counsel€Dr.€Sreekumar€for€her€inattention€to€this€patient.€It€was€aŠ $ t Šslap€on€the€wrist.€Š  X ŠĢNext€came€a€patient€with€multiple€medical€problems.€Dr.€Sreekumar€encountered€a€hypotensiveŠ Š  Špatient€in€Atrial€Fibrillation.€There€is€one€thing€to€do€in€that€setting,€and€it€is€cardiovert€the€patient.Š “   ŠIn€other€words€you€shock€the€patient€as€the€first€step.€In€this€case€you€could€have€added€CalciumŠ ˜ č  Šbecause€the€ER€physician€had€inappropriately€treated€the€hypotensive€A€Fib€patient€with€Verapamil.Š |Ģ  ŠDr.€Sreekumar€presented€the€case.€My€notes€document€her€words.€The€patient€was€uncomfortableŠ `°  Šand€so€I€had€them€gradually€sit€him€up.€Indeed€the€patient€had€water€on€his€lungs€and€wasŠ D”  Šhypotensive.€On€a€scale€of€one€to€ten,€this€one€is€a€wrong€on€a€scale€of€ten€multiple€times.€YouŠ (x  Šwould€treat€the€atrial€fibrillation€with€cardioversion,€and€possibly€calcium.€Agents€to€increase€theŠ  \  Šblood€pressure€would€be€appropriate€if€that€did€not€work,€along€with€other€measures.€The€patientŠ š@ Šruled€in€for€a€heart€attack€and€should€have€been€transferred€to€Walter€Reed.€When€I€encountered€theŠ Ō$ Špatient€he€had€been€in€Congestive€Heart€failure,€in€our€ICU€bed,€and€not€properly€treated€for€aŠ ø Šcouple€of€days.€There€is€no€way€this€complicated€patient€should€have€stayed€in€our€ICU.€This€patientŠ œģ Šdid€expire.€Š €Š ŠĢThe€next€patient€was€admitted€to€the€ICU€with€a€severe€blood€infection.€Another€Internist€had€put€aŠ H˜ Špressure€monitor€in€the€heart€of€this€patient€to€help€guide€the€treatment€of€this€patient.€I€was€in€theŠ ,| ŠICU€doing€my€chores€when€I€witnessed€Dr.€Sreekumar€running€away.€At€the€time€I€thought€that€sheŠ ` Šhad€an€ER€case.€However,€I€quickly€learned€that€Dr.€Sreekumar€had€run€away€from€the€nurse,€ChrisŠ ōD ŠSamisch.€Chris€had€presented€Dr.€Sreekumar€with€the€pressure€data.€Dr.€Sreekumar€had€trained€as€aŠ Ų( Šcardiologist,€in€addition€to€Internal€Medicine.€However€she€was€unable€to€treat€the€hemodynamicŠ ¼  Šstate€of€this€extremely€ill€patient.€The€primary€Internist€called€and€adjusted€the€therapy€for€thisŠ  š Špatient€based€on€the€data.€The€Internist,€Don€Lazas,€asked€me€the€next€morning€to€keep€Dr.Š „Ō ŠSreekumar€on€the€call€schedule€since€without€her€we€would€just€have€three€on€call€doctors.€It€wasŠ hø Šclear€to€the€nurse€and€to€us€as€the€days€went€by€that€this€doctor€had€no€clue.€Š L œ ŠĢA€procedural€note,€there€are€several€inches€of€documents€to€present€to€the€Commission.€I€wentŠ "d! Šthrough€and€essentially€translated€each€document€into€patient€speak.€Initially,€I€was€going€to€briefŠ ų"H" Šyou.€Then€at€the€last€minute€I€was€told€that€I€would€have€five€minutes.€My€submission€is€puttingŠ Ü#,# Šeach€of€these€cases€on€to€the€official€record€of€the€commission.€Š Ą$ $ ŠĢAt€the€end€of€this€write€up,€I€have€some€recommendations€and€conclusions.€Once€I€was€forced€to€goŠ ˆ&Ų!& Šoutside€the€hospital€in€order€to€fix€this,€those€reviewers€avoided€talking€to€me.€That€is€a€critical€error.Š l'¼"' ŠSome€of€these€cases€were€never€reviewed€by€the€outside€reviewers€as€a€result.€On€many€other€casesŠ P( #( Šthey€just€rationalized€apparently€because€of€the€wishes€of€the€command.€One€reviewer€actuallyŠ 4)„$) Šblamed€ME€in€writing€for€the€poor€care€of€this€doctor.€Before€I€left€the€army,€I€sent€copies€of€all€ofŠ *h%* Šthis€material€to€the€Surgeon€General,€Ō_ŌPerscomŌ_Ō,€and€Ō_ŌHSCŌ_Ō.€I€personally€placed€the€boxes€in€Ō_ŌPerscomŌ_ŌŠ ü*L&+ Šand€the€Surgeon€Generalššs€office.€Š ą+0', ŠĢŠ Ø-ų(. Š‡ĢAt€this€point,€I€met€with€Dr.€Sreekumar.€My€note€reflects€my€immediate€fears€about€this€case.€Dr.Š ”ä ŠSreekumar€immediately€claimed€discrimination.€She€went€on€to€make€an€empty€assertion€noting€thatŠ xČ ŠI€was€using€incorrect€data.€This€person€was€extremely€well€practiced.€There€was€no€ability€to€have€aŠ \¬ Šdiscussion€with€her.€Š @ ŠĢAt€this€point,€I€went€to€Dr.€Dunn,€the€deputy€Commander€for€Clinical€affairs€at€Kimbrough€ArmyŠ  X Šhospital.€He€told€me€that€I€could€not€use€these€cases€to€counsel€Dr.€Sreekumar.€That€was€incorrect.Š ģ < ŠThey€had€occurred€just€recently,€and€in€a€normal€world,€this€problem€could€have€stopped€right€here.Š Š  ŠI€did€get€permission€to€fire€the€doctor.€Š “   ŠĢI€reviewed€the€Credentials€chart€of€Dr.€Sreekumar.€She€had€just€come€from€Fort€Belvoir.€There€sheŠ |Ģ  Šwas€specifically€prohibited€from€working€in€the€Internal€Medicine€clinic€or€the€inpatient€portion€ofŠ `°  Šthe€hospital.€It€was€clear€that€she€did€have€Internal€Medicine€privileges.€That€was€no€doubt€a€legalŠ D”  Šcompromise€of€sorts.€€Review€of€her€training€saw€a€year€of€training€here€and€there,€that€included€aŠ (x  Šyear€(€at€least€)€of€Cardiology€training.€She€did€not€finish€training€at€any€one€hospital€and€was€notŠ  \  Šboard€certified.€Š š@ ŠĢĢĢThe€next€patient€died€a€witnessed€respiratory€death.€The€nurse,€again€Chris€Samisch,€stood€by€Dr.Š €Š ŠSreekumar€at€the€bedside.€The€monitor€and€the€clinical€circumstances€supported€the€narrative€of€theŠ d“ Šnurse,€Dr.€Sreekumar€did€not€intubate€this€patient€in€a€timely€manner€and€that€led€to€the€demise€ofŠ H˜ Šthe€patient.€Š ,| ŠĢĢper€DOD€instructions,€you€do€monthly€QA€reviews.€My€note€dated€3€September€notes€that€only€2€ofŠ Ų( Šseven€charts€were€acceptable.€At€this€point,€I€did€not€save€the€supporting€data.€I€forwarded€it.€IŠ ¼  Šshould€note,€that€my€criteria€for€a€deficient€chart€were€clear.€If€the€problem€on€the€chart€could€kill€aŠ  š Špatient€that€was€unacceptable.€In€real€terms€it€is€hard€to€get€charts€that€bad.€Š „Ō ŠĢĢĢOn€€the€same€day,€3€September,€I€decided€to€have€Dr.€Sreekumar€call€me€for€all€ICU€admissions.€InŠ "d! Šterms€of€practicality,€and€in€retrospect,€this€was€a€sign€of€a€young€guy€trying€to€do€too€much.€I€hadŠ ų"H" Šnothing€else€to€do.€Š Ü#,# ŠĢI€had€contacted€Len€Wartofsky,€the€Chief€of€Medicine€at€WRAMC.€There€were€no€replacements€forŠ ¤%ō % ŠDr.€Sreekumar.€It€was€physically€impossible€to€cover€an€ER€with€three€on€call€physicians€for€anŠ ˆ&Ų!& Šextended€period€of€time.€If€I€had€to€do€it€again,€I€would€have€closed€the€ER€permanently€at€thatŠ l'¼"' Špoint.€The€army€was€choosing€not€to€support€us,€and€that€should€have€been€that.€I€was€a€youngŠ P( #( Šmajor,€in€my€first€supervisory€position.€The€position€of€chief€was€slotted€for€an€O„6€and€wasŠ 4)„$) Štypically€given€to€an€O„5.€Š *h%* ŠĢIn€short€order,€I€learned€of€our€ghost€employee,€Dr.€Melissa€Loughney.€She€was€on€MY€books€butŠ ą+0', Šworking€at€Walter€Reed€as€an€Endocrine€Fellow.€My€concern€was€the€call,€in€real€terms,€if€they€hadŠ Ä,(- Šsplit€up€the€call€amongst€the€hundreds€of€doctors€at€WRAMC€it€would€have€amounted€to€about€twoŠ Ø-ų(. Šcalls€per€year.€Nevertheless,€in€his€first€blatantly€incorrect€action,€Dr.€Wartofsky€abandoned€theŠ ° Špatients.€There€is€no€other€word€for€it.€The€imperious€nature€of€this€decision€in€retrospect€is€justŠ ”ä Šnauseating.€It€should€be€noted€that€in€August,€we€ALSO€had€a€physician€go€out€on€medical€leave.Š xČ ŠShe€was€out€for€a€year.€Š \¬ ŠĢĢWhen€I€wrote€this€memo,€withdrawing€my€support€for€the€hospital€Privileges€of€Dr.€Sreekumar,€Dr.Š  X ŠDunn€met€me€angrily€and€asked€me€what€I€was€doing.€He€was€upset€about€the€prospect€of€gettingŠ ģ < Šsued.€Š Š  ŠĢĢThe€next€memo€is€self€explanatory.€It€was€October€and€an€anemia€picked€up€in€July€was€notŠ |Ģ  Šfollowed€up.€Š `°  ŠĢĢOct€28€Š  \  ŠNine€out€of€ten€outpatient€charts€did€not€pass€the€review.€Since€I€thought€that€we€were€workingŠ š@ Štogether,€I€did€not€keep€a€copy€of€the€details€of€the€initial€reviews.€They€disappeared.€Š Ō$ ŠĢOct€28€Š œģ ŠĢI€counseled€Dr.€Sreekumar€about€the€chart€review.€Dr.€Burchenal€was€in€attendance.€I€can€still€seeŠ d“ Šthe€face€of€Dr.€Sreekumar.€She€would€not€stop€talking,€attacking€me€verbally.€She€had€bared€herŠ H˜ Šteeth.€It€was€quite€a€sight.€I€am€quite€sure€that€no€communication€occurred.€In€the€real€world,€IŠ ,| Šwould€have€fired€Dr.€Sreekumar€just€for€being€so€terribly€offensive.€Again,€she€was€practiced.€€Š ` ŠĢOctober€28Š Ų( ŠĢI€noted€to€the€command€that€the€chart€review€was€done€using€the€forms€that€existed€before€myŠ  š Šarrival.€They€were€pretty€standard€forms.€Š „Ō ŠĢThis€memo€notes€another€physician.€He€was€a€new€hire,€by€my€immediate€predecessor.€As€such€heŠ L œ Šwas€on€probation.€This€doctorššs€problem€was€that€patientššs€would€complain€about€his€manner.€HisŠ 0!€  Šcharts€were€not€up€to€par,€but€they€did€not€rise€to€the€level€of€Dr.€Sreekumar.€Since€the€problemsŠ "d! Šwith€the€second€doctor€came€through€the€patient€advocate€the€DCCS,€Dr.€Dunn€was€usually€on€theŠ ų"H" Šcase€before€me.€That€said,€this€doctor€was€not€hurting€people,€and€just€upsetting€patients.€My€priorityŠ Ü#,# Šwas€the€health€of€the€patients.€The€second€doctor€was€eventually€fired€by€the€DCCS€Dr.€Dunn.€WhyŠ Ą$ $ Šhe€saw€this€emergency€was€beyond€me.€It€sapped€the€currency€that€I€needed€in€building€a€caseŠ ¤%ō % Šagainst€Dr.€Sreekumar.€The€second€doctor€sued€and€a€settlement€was€made.€This€presented€an€evenŠ ˆ&Ų!& Šlarger€barrier€to€dealing€with€the€main€problem.€Š l'¼"' ŠĢI€should€set€the€scene€at€this€point.€It€should€be€clear€that€there€were€serious€problems€with€patientŠ 4)„$) Šcare,€and€patients,€two€of€them,€had€already€died€before€I€had€gotten€my€feet€on€the€ground.€The€firstŠ *h%* Šletters€of€counsel€involved€what€I€was€told€were€the€first€opportunities€to€counsel€Dr.€Sreekumar.Š ü*L&+ ŠThat€was€not€correct.€I€sought€advice€from€all€sources.€I€had€just€come€from€three€years€in€theŠ ą+0', ŠEmergency€department€at€WRAMC.€Before€that,€I€did€my€residency€at€WRAMC€in€InternalŠ Ä,(- ŠMedicine.€Dr.€Hunt€had€sent€me€to€be€chief€of€Internal€Medicine€and€then€left€the€army.€Dr.€HuntššsŠ Ø-ų(. Šreplacement€as€Chief€of€Medicine,€Dr.€Wartofsky€had€already€left€us€in€the€lurch.€The€chief€ofŠ ° ŠMedicine€at€Fort€Meade€was€one€Patricia€Burden.€This€is€a€key€point,€she€was€a€dermatologist.€InŠ ”ä Šthe€army,€you€have€to€wait€around€for€Dermatology€residencies.€While€you€are€waiting€you€usuallyŠ xČ Šworked€at€minor€illness€clinics€at€the€time.€You€did€no€inpatient€work.€The€waiting€for€residency€Š \¬ Šmeans€that€you€usually€wind€up€staying€in€the€army€longer€than€a€bunch€of€other€doctors.€That€givesŠ @ Šyou€seniority.€In€that€regard€this€is€a€poor€system.€It€should€go€without€saying€that€you€need€to€knowŠ $ t ŠMedicine€in€detail€in€order€to€be€chief.€Seniority€should€not€matter.€A€š šspecialist,šš€who€does€notŠ  X Šknow€the€craft€of€her€fellow€doctors€cannot€be€Chief€of€Medicine.€This€particular€dermatologist,€Dr.Š ģ < ŠBurden€came€with€her€own€particular€set€of€problems.€Š Š  ŠĢ€Dr.€Burden€made€a€pass€at€me.€We€were€at€a€conference.€She€put€her€hand€on€my€wallet€actually.Š ˜ č  ŠShe€told€me€that€it€was€hard.€She€went€on€to€say€that€my€evaluation€would€depend€on€myŠ |Ģ  Šperformance.€Š `°  ŠThe€command€did€not€believe€me€even€though€she€noted€that€she€may€have€winked€at€me,€which€wasŠ D”  Ša€non€denial€Ō_ŌdenialŌ_Ō.€€Š (x  ŠAfter€that€day,€I€always€had€someone€else€present€when€I€met€with€Dr.€Burden.€Control€being€a€tenetŠ  \  Šof€sexual€harassment,€that€which€ensued€is€not€terribly€surprising.€Š š@ ŠĢOf€note€as€well€was€the€Pediatrics€department.€Before€the€arrival€of€Dr.€Burden,€I€was€acting€chief€ofŠ ø ŠMedicine.€I€was€charged€with€figuring€out€the€problem€in€Pediatrics.€Due€to€time€I€was€just€able€toŠ œģ Šlearn€that€everyone€was€unanimous,€the€chief€of€Pediatrics€did€not€know€what€he€was€doing.€I€passedŠ €Š Šthis€on€to€Dr.€Burden.€Š d“ ŠĢI€note€this€because€Dr.€Burden€did€one€thing,€she€had€the€Pediatrics€department€fawn€all€over€theŠ ,| Šchief€of€Pediatrics.€She€made€it€clear€that€there€was€not€problem,€and€so€it€was€gone.€You€have€toŠ ` Špicture€this€fawning.€It€was€a€visible€thing.€I€would€often€walk€to€the€wards€and€encounter€the€gaggleŠ ōD Šof€Pediatricians€walking€in€a€gaggle€to€the€wards,€fawning€over€Dr.€Park.€Really.€I€really€do€notŠ Ų( Šknow€the€details€of€the€Pediatrics€issues,€except€to€say€that€this€was€another€doctor€who€hadŠ ¼  Šdeliberately€stayed€in€the€army€to€benefit€from€the€privileges€rank€brought€to€him.€You€usually€doŠ  š Šnot€get€people€to€talk€openly€about€another€doctor.€That€was€not€the€case€with€the€employees,Š „Ō Šmilitary€and€civilian€of€Dr.€Park.€Š hø ŠĢĢYou€can€see€why€this€was€a€key€point.€Patients€were€being€injured€and€two€patients€had€died.€I€wasŠ "d! Šnot€about€to€bury€this€problem.€Frankly,€I€thought€about€this€incessantly.€At€the€time,€I€went€aroundŠ ų"H" Šsaying€that€the€only€problem€with€being€a€martyr€was€that€you€were€dead.€Š Ü#,# ŠĢJust€after€the€conference,€we€had€a€visit€from€the€Health€Services€Command€Quality€AssuranceŠ ¤%ō % ŠConsultant.€The€fellow,€who€drove€a€rented€Lincoln€Continental,€looked€me€right€in€the€eye€and€toldŠ ˆ&Ų!& Šme€that€we€were€no€longer€targeting€individuals€with€QA.€In€other€words,€the€command€was€lookingŠ l'¼"' Šat€meeting€standards.€I€kid€you€not.€As€long€as€the€standards€were€met,€according€to€the€words€of€thisŠ P( #( Šconsultant,€things€were€fine.€Since€I€am€talking€to€civilians,€this€meant€to€me€that€if€you€had€threeŠ 4)„$) Šdoctors€who€were€really€good,€and€one€really€bad€doctor€you€could€have€a€quiet€department.€Š *h%* ŠĢIn€the€fall€of€1991,€Dr.€Dunn€was€in€the€process€of€getting€me€a€position€at€Madigan€Army€MedicalŠ ą+0', ŠCenter€as€a€teaching€Internist.€I€wound€up€interviewing€with€the€fellow€in€charge€of€sending€peopleŠ Ä,(- Šaround€the€country,€Dr.€Claypool.€He€came€up€the€day€I€received€an€award€for€the€code€blue€system.Š Ø-ų(. ŠI€mention€this€because,€on€one€hand€š šIšš€was€causing€controversy,€and€getting€clear€messages€that€IŠ ° Šshould€not€be€making€waves,€and€on€the€other€Dr.€Dunn€was€helping€my€career.€I€took€this€to€meanŠ ”ä Šthat€I€still€had€a€mandate€to€fire€Dr.€Sreekumar.€I€was€not€one€to€pass€on€a€problem,€and€well€I€thinkŠ xČ Šthat€you€get€the€general€idea.€Š \¬ ŠĢI€should€note€that€about€a€year€later,€Roy€Leatherberry€the€IG€at€WRAMC€told€me€of€Dr.€DunnššsŠ $ t Šnickname€while€he€was€a€practicing€physician€in€Europe.€They€had€called€him€Dr.€Death.€Great.€Š  X ŠĢDr.€Dunnššs€immediate€supervisor€was€Dr.€Robert€McMeekin.€Commander€of€KACH.€Dr.Š Š  ŠMcMeekin€honored€me€with€the€privilege€of€being€his€doctor.€This€was€the€second€doctor€on€myŠ “   Španel.€I€could€barely€speak€when€these€things€happened.€Dr.€McMeekin€was€also€a€lifetime€FAAŠ ˜ č  Šemployee€by€report.€This€was€his€first€command,€and€it€was€said€that€he€was€coming€here€on€his€wayŠ |Ģ  Što€getting€a€star.€In€other€words,€he€was€putting€in€the€time€in€various€jobs€in€preparation€ofŠ `°  Šbecoming€a€General.€He€was€a€full€Colonel€at€the€time.€Dr.€McMeekin€was€family€practice,€but€heŠ D”  Šdid€not€do€that.€He€did€FAA€work€for€his€entire€career.€Š (x  ŠĢI€relied€on€Dr.€Dunn€to€be€able€to€decipher€the€medicine€and€read€the€EKGššs€and€what€not€that€I€sentŠ š@ Šhim.€A€year€or€more€later€it€became€clear€to€me€that€I€should€not€have€done€that.€You€cannot€run€aŠ Ō$ Šhospital€that€way.€Again,€that€was€based€on€the€comment€of€the€IG,€Colonel€Roy€Leatherberry.Š ø ŠLooking€back,€the€first€qualified€Internist€in€my€chain€of€command€was€not€really€in€my€chain.€HeŠ œģ Šwas€Dr.€Len€Wartofsky€at€WRAMC.€He€was€the€fellow€who€had€already€abandoned€us.€As€aŠ €Š Špreview,€over€the€next€year€plus,€three€outside€reviewers€were€sent€to€KACH.€You€should€note€thatŠ d“ ŠDr.€Wartofsky€sent€all€those€folks€over€to€KACH.€In€a€word,€they€were€not€terribly€helpful.€TheŠ H˜ Šdetails€are€even€more€interesting.€Š ,| ŠĢIn€addition€I€had€two€supremely€qualified€Internists€working€for€me.€Don€Lazas€and€DaveŠ ōD ŠBurchenal.€Don€was€a€perfectionist€who€admittedly€almost€lost€it€when€he€was€not€appointed€ChiefŠ Ų( ŠResident.€If€he€did€not€get€a€100€on€the€test€or€score€100€on€the€Physical€training€test€he€was€upset.Š ¼  ŠThose€are€good€things,€however,€his€concern€for€himself€was€primary.€Š  š ŠĢDave€Burchenal€is€and€was€a€nice€guy€and€an€excellent€physician.€However,€even€when€presentedŠ hø Šwith€direct€harm€to€his€patients,€he€could€not€focus€on€disciplining€a€doctor€for€very€long.€Š L œ ŠĢIn€the€fall€I€was€already€working€without€a€net,€counseling€with€everyone€available,€and€not€gettingŠ "d! Šanywhere.€There€was€no€effective€help€for€this€situation.€Š ų"H" ŠĢĢĢĢĢĢĢĢĢĢĢŠ Ø-ų(. Š‡Ģ25€NovemberŠ ”ä ŠĢThe€monthly€review€showed€four€out€of€five€charts€to€be€deficient.€Of€note,€one€patient€had€a€changeŠ \¬ Šin€diuretic€does€and€potassium€dose€but€no€follow€up€lab€checks.€I€mention€this€because€there€areŠ @ Špatterns€of€neglect.€The€first€patient€had€an€increase€in€Potassium€without€a€lab€check€and€wound€upŠ $ t Šwith€a€potassium€of€7.5.€As€we€get€into€more€of€the€charts,€you€will€see€simple€patterns€emerge.€Š  X ŠĢĢĢĢAbout€this€time,€I€had€Don€Lazas€ask€Dr.€Sreekumar€questions€about€her€patients€in€Morning€report.Š |Ģ  ŠMorning€report€is€just€that.€You€inform€the€other€covering€doctors€about€the€patients€you€admitted.Š `°  ŠSince€we€always€taught€acting€Interns€we€made€the€morning€report€an€academic€exercise€as€much€asŠ D”  Špossible.€€The€pressure€from€Dr.€Sreekumar€was€relentless.€I€had€Don€ask€her€the€questions€inŠ (x  Šmorning€report€and€I€had€Dave€counsel€her€about€the€deficient€outpatient€charts.€€Š  \  ŠĢ26€DecŠ Ō$ ŠĢI€had€been€taking€Dr.€Sreekumarššs€calls.€On€this€date,€Dr.€Lazas€offered€to€share€the€calls€based€onŠ œģ Šongoing€problems.€I€appreciated€that.€Š €Š ŠĢThere€was€a€third€problem.€That€was€the€ER.€I€have€to€take€things€a€bit€out€of€order€and€go€back€toŠ H˜ ŠJuly€and€August.€Actually,€my€experience€with€the€EMSA€contractors€in€the€KACH€ER€wasŠ ,| Šextensive€since€I€had€been€in€the€WRAMC€ER€for€the€previous€three€years.€Š ` ŠĢFrom€WRAMC€we€saw€one€thing,€inadequate€work€ups,€and€attempts€to€send€patients€before€theyŠ Ų( Šhad€been€properly€worked€up€or€treated.€Š ¼  ŠĢOn€arrival€at€KACH,€the€problem€became€more€apparent.€This€is€what€was€happening.€If€a€sickŠ „Ō Špatient€came€in,€they€would€call€the€Internist.€At€that€time,€they€would€sign€out€the€patient€on€theŠ hø Šchart€and€do€no€further€work€up€or€care€of€the€patient.€I€am€not€kidding.€This€led€to€several€delays€inŠ L œ Šcare.€The€primary€problem€surrounded€the€level€of€training€in€the€ER€physicians.€None€were€ERŠ 0!€  Šphysicians€or€Internists.€They€were€all€family€practice€doctors.€You€canššt€have€that€and€maintainŠ "d! Šgood€care.€I€had€my€staff€write€up€several€cases.€One€was€the€second€patient€noted€who€was€treatedŠ ų"H" Šin€the€ER€with€Verapamil.€A€frequent€patient€was€an€asthma€patient€from€the€local€jail€in€Jessup.€HeŠ Ü#,# Šwould€come€in€frequently€and€need€emergent€care.€When€it€was€clear€that€he€was€very€ill€theŠ Ą$ $ ŠInternist€was€called€and€signed€out.€I€was€called€to€see€another€patient.€The€diagnosis€of€theŠ ¤%ō % Šphysician,€Wanda€Simmons€Clemons€was€as€follows.€MI€(€Heart€attack€)€versus€Urinary€tractŠ ˆ&Ų!& Šinfection.€As€noted,€she€said€that€the€patient€had€one€or€the€other.€Heart,€or€kidneys,€she€was€notŠ l'¼"' Šsure.€I€had€been€having€problems€with€this€doctor€and€so€in€front€of€her€boss,€the€chief,€Dr.€Murthy,€IŠ P( #( Šcalmly€said€that€I€was€going€to€be€more€strict€with€her.€That€resulted€in€a€complaint€by€Dr.€SimmonsŠ 4)„$) ŠClemons€against€me.€Indeed,€on€another€patient€the€same€doctor€ascribed€the€patients€dizziness€to€theŠ *h%* Šincorrect€source€and€demanded€admission.€She€was€also€involved€with€the€asthma€patient,€as€wereŠ ü*L&+ Šmost€doctors€in€the€ER€since€he€was€a€regular.€Š ą+0', ŠĢIn€all€there€was€an€inch€and€a€half€worth€of€cases€when€I€handed€them€to€Dr.€Dunn.€Dr.€McMeekinššsŠ Ø-ų(. Šsolution,€was€not€really€a€solution.€He€found€that€many€of€the€doctorššs€did€not€have€traumaŠ ° Šcertification€as€directed.€So€when€their€grace€period€for€obtaining€certification€ran€out,€those€doctorsŠ ”ä Šwere€let€go.€It€did€not€get€rid€of€all€of€the€poorly€functioning€doctors€in€the€ER.€They€still€signed€outŠ xČ Špatients€the€minute€they€called€you.€€That€practice€may€have€contributed€to€a€death€in€the€ER.€I€wasŠ \¬ Šhome€and€came€in€to€attend€to€a€severe€COPD€patient.€The€patient€had€been€sitting€there€withoutŠ @ Štreatment,€and€went€on€to€code€and€die.€When€patients€are€very€sick€like€that€you€never€know,Š $ t Šhowever,€there€was€never€a€reason€to€delay.€I€should€have€come€in€to€an€intubated€patient€instead€ofŠ  X Šhaving€to€attend€to€a€patient€in€extremis.€Š ģ < ŠĢĢSo,€just€after€I€wrote€up€the€ER,€and€the€doctors€who€did€not€have€certification€disappeared,€I€lost€myŠ ˜ č  Šprivileges€to€teach€Advanced€cardiac€life€saving.€Say€what,€well,€the€chief€of€the€ER€was€in€charge€ofŠ |Ģ  Šthe€advanced€cardiac€life€saving€teaching.€I€had€taught€ACLS€for€three€plus€years,€at€WRAMC€andŠ `°  ŠBethesda€Navy€Medical€Center,€€and€now€I€could€no€longer€do€that.€That€was€the€first€thing€that€IŠ D”  Šlost.€Š (x  ŠĢI€donššt€have€the€date€on€the€next€patient€but€I€remember€that€I€had€left€my€back€up€beeper€in€the€car,Š š@ Šit€was€a€weekend€day€around€Christmas.€Š Ō$ ŠĢThe€chief€of€the€ER,€Dr.€Diallo€and€the€DCCS€Dr.€Dunn€paged€me,€but€well,€no€one€can€be€on€callŠ œģ Š24/7.€I€was€volunteering€to€put€in€extra€back€up€call.€They€reached€Don€Lazas€at€home.€Dr.Š €Š ŠSreekumar€was€on€call.€She€could€not€place€a€pacemaker€in€the€patient.€All€three€of€those€doctorsŠ d“ Šmissed€the€primary€problem,€digoxin€toxicity.€They€focused€on€the€rhythm€and€not€the€underlyingŠ H˜ Šcause€of€the€rhythm.€Š ,| ŠĢMy€note€shows,€the€EKG€was€missed,€lethal€mistake.€Dr.€Sreekumar€would€repeat€her€inability€to€doŠ ōD Šprocedures€later€on.€Š Ų( ŠPlease€note€that€I€am€writing€this€for€a€lay€audience€of€the€Commission.€If€you€have€any€questionsŠ ¼  Šplease€contact€me.€I€pause,€still€shocked€that€I€am€writing€or€did€write€about€all€of€this.€I€want€toŠ  š Šnote€that€I€did€not€plan€on€writing€this€part€until€the€other€day.€There€are€no€physicians€on€yourŠ „Ō Šcommission.€So€I€have€to€translate€everything.€You€should€know€that€over€the€years,€when€someoneŠ hø Šelse€appeared€on€the€scene,€I€wrote€to€them.€No€one€ever€cared€enough€to€do€anything.€Š L œ ŠThe€last€time€I€wrote€was€the€fall€of€2006.€Š 0!€  ŠĢSo€I€have€talked€about€three€problems€that€affected€my€patients,€a€civilian€employee,€a€contract€withŠ ų"H" ŠEMSA€for€the€ER,€and€inexperienced€yet€senior€army€doctors.€Those€army€doctors€that€stay€aroundŠ Ü#,# Šneed€to€be€assigned€according€to€current€abilities€and€not€because€of€a€particular€rank,€and€time€inŠ Ą$ $ Šgrade.€Š ¤%ō % ŠĢWhen€you€get€permission€to€fire€a€doctor,€as€I€did€with€Dr.€Sreekumar,€I€would€think€that€the€boss,Š l'¼"' ŠDr.€McMeekin€would€have€to€check€with€the€CG€at€WRAMC.€For€sure,€Dr.€Wartofsky€wasŠ P( #( Šintimately€aware€of€our€problem.€I€had€talked€to€him€twice€a€week€for€the€first€three€months€of€so€inŠ 4)„$) Šregards€to€getting€another€doctor.€I€was€usually€frantic€in€my€requests€and€Dr.€Wartofsky€wasŠ *h%* Šunderstanding€but€not€helpful.€I€had€known€Dr.€Wartofsky€for€six€years.€He€had€never€known€me€toŠ ü*L&+ Šcomplain,€no€one€really€did.€I€should€say€that€things€changed€when€Dr.€Hunt€left.€Dr.€Wartofsky€wasŠ ą+0', Šand€is€an€elitist,€and€Dr.€Hunt€rewarded€those€who€did€well,€like€me.€If€you€called€up€Dr.€HuntŠ Ä,(- Štoday,€he€would€say,€š š€I€am€fond€of€Joe.šš€Politics€replaced€a€Ō_ŌmeritocratousŌ_Ō€environment€when€Dr.Š Ø-ų(. ŠHunt€left€the€army.€As€far€as€Dr.€Wartofsky€was€concerned,€the€world€stopped€at€the€door€of€theŠ ° ŠMecca,€WRAMC.€Š ”ä Š€Finally,€the€level€of€sick€patients€in€the€ER€at€KACH€was€probably€twice€as€acute€as€the€WRAMCŠ xČ ŠER,€that€had€to€do€with€the€retired€folks€who€lived€nearby.€Drššs€Lazas€and€Burchenal€and€myselfŠ \¬ Šwere€extremely€qualified€to€care€for€such€patients.€I€had€three€years€of€Emergency€Medicine€inŠ @ Šaddition€to€Residency€in€Internal€Medicine.€The€other€two€had€their€excellent€training€in€Residency.Š $ t ŠThe€patients€are€and€were€great€people,€they€also€get€sick.€I€miss€them.€It€was€a€new€year€and€I€hadŠ  X Šgotten€absolutely€no€where,€except€I€was€hoping€to€pack€for€Washington€State€and€Madigan€ArmyŠ ģ < ŠMedical€Center.€€Š Š  ŠĢThis€patientššs€EKG€is€provided.€Dr.€Sreekumar€diagnosed€a€Ō_ŌjunctionalŌ_Ō€rhythm€when€the€patientŠ ˜ č  Šactually€had€a€potentially€lethal€rhythm€problem€in€his€heart.€There€were€three€patients€presented€byŠ |Ģ  ŠDr.€Sreekumar€that€day.€Since€one€or€two€of€them€were€the€personal€patients€of€Dave€Burchenal,€heŠ `°  Štook€me€aside.€First€he€noted€that€I€thought€Dr.€Sreekumar€also€had€problems€with€outpatients,€andŠ D”  Šthen€he€offered€to€help€take€back€up€call€for€Dr.€Sreekumar.€Š (x  ŠĢIn€the€real€world€missing€complete€heart€block€would€get€you€immediate€walking€papers.€ThereŠ š@ Šwere€TWO€other€cases€that€day.€Š Ō$ ŠĢTwo€patients€are€on€this€one€piece€of€paper.€The€first€one€was€admitted€to€the€ward,€but€actually€hadŠ œģ ŠUnstable€angina.€He€was€moved€to€the€ICU€and€placed€on€appropriate€medicine.Š €Š ŠĢThe€second€patientššs€EKG€was€misread.€There€was€an€old€heart€attack€on€the€EKG.€Later€after€thisŠ H˜ Špatient€ruled€out,€Dr.€Sreekumar€was€informed€that€the€patientššs€symptoms€of€angina€at€rest€hadŠ ,| Šreturned.€I€was€in€the€ICU€when€that€happened.€Dr.€Sreekumar€asked€for€the€patient€to€come€downŠ ` Šfor€a€stress€test€anyway.€Frankly,€Dr.€Sreekumar€called€up€repeated€to€the€ICU€about€this€patient.€IŠ ōD Šwas€called€in€and€cancelled€the€order.€I€transferred€the€patient€to€WRAMC€cardiology€where€he€hadŠ Ų( Ša€procedure€to€relieve€his€chest€pain.€Exercising€someone€with€Unstable€angina€is€terribly€dangerous.€Š ¼  ŠĢThe€patient€information€that€follows€documents€multiple€mistakes.€First€of€all,€the€patient€had€anŠ „Ō Šacute€MI.€This€was€treated€properly€with€blood€clot€busters.€It€worked.€As€the€medicine€worked,€itŠ hø Šproduced€Ō_ŌrythymsŌ_Ō€that€signify€the€process€is€working.€These€are€not€treated€or€treated€with€medicine.Š L œ ŠThey€are€certainly€not€treated€with€a€Ō_ŌprecordialŌ_Ō€thump.€Š 0!€  ŠĢAfter€review€of€the€CXR,€the€patient€developed€water€on€his€lungs€as€a€result€of€pump€failure€afterŠ ų"H" Šthe€heart€attack.€In€the€face€of€that€acute€heart€failure€the€patient€was€treated€with€medicine€thatŠ Ü#,# Šwould€make€his€heart€pump€less€well.€Š Ą$ $ ŠĢIn€the€real€world,€this€would€have€not€just€landed€you€on€the€street,€it€would€have€gotten€you€thereŠ ˆ&Ų!& Šby€10€AM.€Š l'¼"' ŠAlso€Dr.€Sreekumar€failed€to€call€me€for€the€admission€to€the€ICU.Š P( #( ŠĢThe€patient€was€transferred€to€WRAMC€successfully.€Š *h%* ŠĢĢĢŠ Ø-ų(. Š‡The€performance€standards.€For€those€of€you€who€know,€you€must€have€been€wondering€where€theseŠ ° Šwere.€Well,€they€disappeared.€That€made€any€counseling€up€to€Jan€23ņņrdóó€1992€totally€useless.€ItŠ ”ä Šseems€that€without€performance€standards€you€cannot€counsel€someone.€In€late€November€or€earlyŠ xČ ŠDecember€I€made€emergent€moves€to€get€these€performance€standards€in€place.€The€weeks€went€by,Š \¬ Šand€instead€of€having€them€signed€before€the€holidays,€or€even€soon€after€the€holidays,€they€wereŠ @ Šsigned€officially€23€January€1992.€This€was€a€totally€inappropriate€delay€on€the€part€of€Dr.€Burden.€Š $ t ŠĢJust€a€few€days€later€I€was€on€vacation€skiing€in€British€Columbia.€I€called€back€to€Dr.€Claypool.€HeŠ ģ < Šwas€the€consultant€to€the€Surgeon€General€for€Medicine,€essentially€he€was€the€guy€who€sent€you€toŠ Š  ŠMadigan€or€wherever.€After€a€three€to€four€month€consideration€process,€and€a€personal€interview,Š “   ŠAND€from€literally€the€top€of€the€Mountain,€Dr.€Claypool€told€me€that€I€was€written€in€ink€for€aŠ ˜ č  Šposition€as€Washington€State.€Š |Ģ  ŠĢAs€you€will€see€soon,€Dr.€Burden€also€told€me€in€writing€to€stop€the€outpatient€charts€reviews.€ThatŠ D”  Šwas€against€DOD€regulations.€Š (x  ŠĢHaving€to€start€over€and€having€a€job€at€Madigan€Army€Medical€Center€in€hand€and€facingŠ š@ Šharassment€from€Dr.€Sreekumar€and€Dr.€Burden€and€Dr.€Dunn€all€about€Dr.€Sreekumar,€I€resignedŠ Ō$ Šas€chief€on€Valentineššs€day€1992.€We€went€to€Galileo€for€dinner€that€day.€I€appointed€Don€Lazas€asŠ ø Šchief€since€he€had€always€agreed€with€me.€I€wrote€a€letter€to€Dr.€Burden€that€stated€that€I€wasŠ œģ Šexhausted€dealing€with€her.€Š €Š Š€ĢŅe°ŅA€few€weeks€after€that,€or€seemingly€days,€I€lost€my€position€in€Washington€State.€I€was€now€just€aŠ H˜ Šworker€bee.€Dr.€Lazas€had€seen€what€they€had€done€to€me€and€even€though€he€knew€the€patients€wereŠ ,| Šgetting€injured,€he€refused€to€counsel€Dr.€Sreekumar.€Nurse€Samisch€and€I€counseled€with€him€onŠ ` Šseveral€occasions€to€no€avail.€While€I€would€not€recommend€resigning€in€protest,€resigning€with€aŠ ōD Šplace€to€go€is€perfectly€acceptable.€I€did€MORE€than€my€duty€in€dealing€with€the€command€and€Dr.Š Ų( ŠSreekumar.€Now€I€also€had€Don€Lazas€to€deal€with.€Š ¼  ŠĢĢSo,€I€was€starting€to€get€the€idea€that€I€would€not€see€the€chart€reviews€again€unless€I€copied€them.Š hø ŠThat€is€also€why€I€have€more€copies€of€the€inpatient€charts.€This€regards€an€outpatient€chart€review.€IŠ L œ Šhope€that€you€are€sitting€down.€You€can€read€some€of€the€critical€but€less€important€problems.€I€willŠ 0!€  Šgo€over€the€highlights.€€Again,€I€was€using€forms€that€predated€my€time€at€KACH.€They€were€typicalŠ "d! Šforms.€€Š ų"H" ŠĢ1.€A€patient€was€referred€from€the€general€outpatient€clinic€in€August€for€typical€chest€pain€thatŠ Ą$ $ Šresolved€with€nitroglycerin.€The€pretest€probability€of€a€positive€work€up€is€higher€than€70%.€It€isŠ ¤%ō % Šimportant€to€stratify€the€risk€of€the€patient€by€doing€a€work€up.€No€work€up€had€been€done,€at€all.€JustŠ ˆ&Ų!& ŠŌ_ŌNTGŌ_Ō.€About€three€months€had€passed.€Š l'¼"' ŠĢ2.€Pt€was€depressed€and€also€taking€Ō_ŌcatapressŌ_Ō€and€Ō_ŌlopressorŌ_Ō.€They€can€cause€depression.€There€was€noŠ 4)„$) Štreatment€of€the€depression.€While€a€critical€mistake,€it€is€not€a€life€threatening€mistake.€Š *h%* ŠĢ3.€K€5.5€on€the€chart.€That€is€TOO€HIGH.€The€patient€is€in€danger€of€death.€K€needs€recheck€Now.Š ą+0', ŠThis€is€the€third€patient€whose€Potassium€was€an€issue.€This€could€not€be€more€simple€to€address€andŠ Ä,(- Šcritical€if€not€addressed.€Š Ø-ų(. Š‡4.€Cough€and€infiltrate€needs€a€pulmonary€consult€since€about€six€weeks€prior€to€that€chart€review.Š ° ŠNo€plan€for€referral€on€the€chart.€€Š ”ä ŠĢ5.€No€Ō_ŌNeuroŌ_Ō€exam€but€patient€complains€of€incontinence.€Š \¬ ŠĢ6.€No€evaluation€for€leg€edema.€This€could€be€a€critical€error.€Š $ t ŠĢ7.€Please€call€patient€in.€NO€check€of€K€or€digoxin€level€since€September€with€changing€dosages.Š ģ < ŠValvular€disease€with€water€on€the€lungs,€needs€a€cardiologist,€TSH€on€the€chart€is€14.6€that€is€WAYŠ Š  Štoo€high€and€is€a€sign€that€you€are€not€getting€enough€thyroid.€That€can€contribute€to€a€dysfunctionalŠ “   Šheart€among€other€things.€The€elevated€TSH€dates€to€EIGHT€months€before€this€chart€review.€Š ˜ č  ŠĢI€did€not€write€up€all€11€deficient€charts.€First€of€all,€it€is€apparent€that€the€level€of€sickness€in€ourŠ `°  Špatients€is€high.€So€you€canššt€have€someone€waving€at€them€and€smiling€and€just€kind€of€being€nice,Š D”  Šwhich€is€what€Dr.€Sreekumar€did.€People€live€or€die€because€of€what€we€did€or€did€not€do€in€thatŠ (x  Šclinic.€€Š  \  ŠĢThis€is€just€one€months€chart€review.€I€was€serious€when€I€noted€previously€that€I€did€not€mark€downŠ Ō$ Ša€critical€mistake€unless€the€life€of€the€patient€could€be€in€danger.€I€am€sorry€that€I€did€not€copy€theŠ ø Šearlier€chart€reviews,€they€revealed€similar€problems.€Š œģ ŠĢSince€you€should€be€getting€the€hang€of€this€a€couple€of€pages€after€the€review€are€presented€withoutŠ d“ Šcomment.€Š H˜ ŠĢDr.€Sreekumar€admitted€an€overdose€patient.€She€presented€the€š šunknown€pills,šš€were€ingested.€If€IŠ ` Špresented€that€during€my€residency,€without€scouring€every€source€for€the€answer,€I€would€have€beenŠ ōD Štarred€and€feathered.€The€key€to€the€overdose€patient€is€finding€out€what€was€taken.€Š Ų( ŠĢOn€this€patient€Dr.€Sreekumar€overestimated€the€presence€of€illness.€In€general,€I€donššt€get€worked€upŠ  š Šover€things€like€that€too€much,€since€it€is€much€more€important€NOT€to€miss€the€sick€patients.€It€isŠ „Ō Šnoted.€Š hø ŠĢOn€that€same€page.€Dr.€Sreekumar€did€not€call€me€about€the€next€patientŠ 0!€  ŠĢThis€page€is€out€of€chronological€order€apparentlyŠ ų"H" ŠĢĢĢĢĢĢĢĢĢĢ€€Š Ä,(- ŠŠ Ø-ų(. Š‡Missed€the€old€heart€attack€on€the€EKG,€and€Ō_ŌHCTŌ_Ō€of€18.2€That€is€a€blood€count€that€is€too€high.€Š ° ŠĢĢDr.€Sreekumar€wanted€to€give€the€patient€Aspirin€and€Quinidine€for€the€patientššs€atrial€fibrillationŠ \¬ Šwithout€anticoagulation.€When€the€atrial€portion€of€your€heart€is€fibrillating,€a€clot€can€form€in€it.€IfŠ @ Šyou€heart€goes€back€to€regular€sinus€rhythm€without€anticoagulation€the€clot€can€go€to€your€brain€andŠ $ t Šcause€a€stroke.€Nowadays,€as€then€we€would€Ō_ŌanticoagulateŌ_Ō,€but€we€would€not€use€Quinidine.€Š  X ŠĢSuicide€attempt€patient€who€took€Tylenol€and€Ō_ŌBusparŌ_Ō.€There€was€no€Tylenol€level€ordered.€TylenolŠ Š  Šis€extremely€toxic€to€your€liver€in€large€amounts,€AND€the€prompt€treatment€of€an€overdose€is€relatedŠ “   Što€success.€Again,€you€would€normally€just€leave€the€office€if€you€did€this.€There€was€also€no€urineŠ ˜ č  Šdrug€screen€ordered.€Š |Ģ  ŠĢThe€report€is€that€the€Ō_ŌtylenolŌ_Ō€ingested€was€minimal.€Suicide€patients€are€the€last€patients€that€you€canŠ D”  Štrust.€Š (x  ŠĢHeld€the€blood€thinner€in€a€patient€with€an€artificial€heart€valve.€This€is€one€of€those€things€you€cameŠ š@ Što€expect,€but€just€would€never€even€think€that€someone€could€do€to€another€human€being.€Were€itŠ Ō$ Šnot€for€morning€report€fixing€these€things,€this€patient€would€have€clotted€off€his€artificial€valve.€Š ø ŠĢĢAt€the€time€we€used€1.5€to€2€times€control€as€the€standard€for€anticoagulation.€Nevertheless,€with€aŠ d“ Šnormal€anticoagulant€action,€the€anticoagulant€was€increased.€Š H˜ ŠĢOf€course,€there€are€the€ones€that€you€really€worry€about,€they€happened€as€well.€This€patient€sat€inŠ ` Šthe€ICU€with€Chest€pain,€and€EKG€changes€but€received€NO€treatment€for€his€MI.€Š ōD ŠĢBy€the€time€morning€report€rolled€around,€it€was€too€late€to€give€clot€busters.€Š ¼  ŠĢI€call€this€one,€by€the€grace€of€God.€Sorry,€I€started€naming€them,€what€else€was€there€to€do.€At€anyŠ „Ō Šrate,€we€used€to€give€Quinidine€to€make€Atrial€Fibrillation€go€away.€There€are€two€commonŠ hø Šproblems€with€Quinidine.€It€can€cause€diarrhea,€and€it€can€cause€low€platelet€counts.€If€you€have€aŠ L œ Štherapeutic€dose€of€Quinidine€and€get€recurrent€Atrial€Fibrillation,€you€have€proven€that€theŠ 0!€  ŠQuinidine€is€not€working.€That€is€when€you€stop€it€and€consider€something€else.€Š "d! ŠĢSo,€in€this€patient,€Dr.€Sreekumar€continued€the€Quinidine€despite€REPEATED€recurrent€AtrialŠ Ü#,# ŠFibrillation.€Moreover,€during€this€time,€she€was€encouraging€the€patient€to€tolerate€the€diarrhea€thatŠ Ą$ $ Šwas€caused€by€the€Quinidine.€In€addition€the€patient€had€low€Ō_ŌplateletsŌ_Ō.€This€was€also€a€result€of€theŠ ¤%ō % ŠQuinidine.€The€medical€community€knew€that€Quinidine€can€cause€sudden€death,€and€so€if€it€is€notŠ ˆ&Ų!& Šworking€you€stop€it.€Atypically,€Dr.€Sreekumar€was€actually€diligent€about€the€treatment€and€such€inŠ l'¼"' Šthis€patient.€She€was€just€misguided.€Š P( #( ŠĢĢĢĢĢŠ Ø-ų(. Š‡In€this€patient€the€doctor€correctly€noted€that€the€treadmill€stress€test€had€changes€consistent€withŠ ° Šinadequate€blood€flow€for€23€minutes€after€the€test€was€over.€That€is€a€patient€who€may€be€having€aŠ ”ä Šheart€attack.€That€patient€needs€to€be€admitted.€He€needs€to€have€his€blood€tests€monitored€for€heartŠ xČ Šdamage,€and€receive€further€expeditious€work€up.€This€patient€was€sent€home.€Š \¬ ŠŠ  @ Š3€Feb€1992Š ° ŠĢI€was€ordered€to€stop€doing€outpatient€chart€reviews.€This€was€counter€to€DOD€regulations.€Also€IŠ xČ Šasked€the€so€called€outside€reviewers€about€this.€There€was€NO€outside€reviewer,€that€assertion€wasŠ \¬ Šconcocted€to€make€this€problem€go€away.€Š @ ŠĢĢ10€Feb€1992Š ģ < ŠĢI€was€ordered€to€withdraw€a€set€of€counseling€statements.€It€was€apparent€to€me€that€some€pressureŠ “   Šfrom€someone,€more€than€likely€a€lawyer€for€Dr.€Sreekumar€prompted€this€action.€You€can€see€theŠ ˜ č  Štotal€disconnect€between€these€actions€by€the€command€and€the€EKGs€and€charts.€Š |Ģ  ŠĢThis€patient€was€admitted€but€most€of€his€medications€were€stopped,€for€unknown€reasons.€They€wereŠ D”  Šatrovent€for€breathing,€Azmacort€for€breathing,€Buspar€for€anxiety,€and€Procardia€and€Isordil€for€hisŠ (x  Šheart.€Š  \  ŠĢThis€patient€was€coding.€Chris€Samisch€attended€this€code€along€with€Dr.€S.€Dr.€S€ordered€Isuprel€forŠ Ō$ ŠV€Tach.€Chris€Samisch,€who€knew€ACLS€very€well,€disregarded€the€order.€The€nurse€cardiovertedŠ ø Šthe€patient€in€a€life€saving€maneuver.€By€this€time,€Don€Lazas€was€chief.€He€did€write€up€aŠ œģ Šcounseling€statement€on€this€case.€However€he€never€delivered€it.€Chris€and€I€counseled€with€DonŠ €Š Šabout€this.€However,€Don€declined€to€do€it€on€account€of€EEO.€He€noted€that€fear€to€both€myself€andŠ d“ ŠNurse€Samisch.€Š H˜ ŠĢOnce€again,€the€civilian€performance€standards€were€misplaced.€They€were€found,€but€still€noŠ ` Šcounseling€occurred.€This€was€Dr.€Lazas€first€dereliction€of€duty.€Š ōD ŠĢDr.€Sreekumarššs€inability€to€follow€ACLS€protocol€comes€up€later.€Š ¼  ŠĢA€patient€with€š š€a€heart€this€bigšš€was€admitted.€Š „Ō Š€ĢĢFor€some€reason€Dr.€Dunn€heard€about€this€through€the€nursing€staff.€He€ordered€an€outside€review.Š 0!€  ŠDr.€Chung€came€over€from€WRAMC.€Dr.€Chung,€an€ID€specialist€told€me€that€Dr.€Dunn€would€haveŠ "d! Šwhat€he€wanted€to€fire€Dr.€Sreekumar€as€a€result€of€his€report.€Š ų"H" ŠĢDr.€S€clearly€missed€yet€another€congestive€heart€failure,€this€time€relating€her€amazed€state€that€theŠ Ą$ $ Šheart€on€the€xray€was€so€big.€The€patient€had€recent€Urologic€surgery.€The€patient€had€a€acidic€phŠ ¤%ō % Šand€had€this€congestive€heart€failure,€otherwise€known€as€water€on€the€lungs.€No€treatment€wasŠ ˆ&Ų!& Šoffered€for€these€two€states.€For€some€reason€however,€in€the€middle€of€the€night€a€sleepingŠ l'¼"' Šmedication€was€given€to€this€patient.€By€the€next€Ō_ŌmoringŌ_Ō€the€ph€of€7.25€had€become€7.15.€The€patientŠ P( #( Šwas€found€to€be€hypoxic.€The€patient€was€presented€to€Dr.€Lazas,€who€was€now€chief€and€myself.Š 4)„$) ŠAnother€physician€came€to€care€for€this€patient.€He€was€eventually€discharged.€His€underlying€illnessŠ *h%* Ševentually€did€take€him€a€few€days€later.€This€episode€may€have€contributed€to€that,€however,€theŠ ü*L&+ Špatient€was€very€ill€in€the€first€place.€Š ą+0', ŠĢI€should€be€able€to€find€the€write€up€on€this€patient€and€put€it€in€the€queue.€Š Ø-ų(. ŠŃ OYŃā  āŃ°°Ńā  āŃ  ŃĢĢA€patient,€my€patient€actually,€had€ruled€out€for€MI.€However€she€started€having€symptoms€of€a€heartŠ xČ Šattack€in€the€hospital.€Dr.€Sreekumar€refused€to€attend€to€this€patient,€and€it€fell€to€the€medicalŠ \¬ Šstudent€to€transfer€the€patient€to€WRAMC.€Š @ ŠĢĢĢA€patient€began€to€Ō_ŌreinfarctŌ_Ō€in€the€ICU.€Dr.€Sreekumar€had€been€ordered€by€Dr.€Lazas€to€transfer€theŠ Š  Špatient.€Despite€the€fact€that€the€patient€had€a€blood€pressure€documented€to€be€well€over€220€systolicŠ “   Šand€with€acute€anterior€changes€on€EKG€and€CHF,€the€only€treatment€was€oral€Ō_ŌdiltiazemŌ_Ō.€That€isŠ ˜ č  Štotally€incorrect€and€more€than€likely€harmful.€This€is€the€one€piece€of€data€that€I€have€but€wasŠ |Ģ  Šunable€to€find€for€this€review.€I€have€this€EKG€in€my€files€should€it€be€needed€for€further€review.€Š `°  ŠĢĢThis€note€regards€treadmill€stress€tests.€I€did€a€review.€Three€out€of€11€in€this€review€were€misread.€Š  \  ŠĢThe€read€of€Dr.€S€and€the€correct€read€are€noted.€With€the€test€on€the€facing€page,€my€read€is€to€theŠ Ō$ Šleft.€That€is€opposite€of€the€first€two.€All€patients€required€follow€up€for€positive€tests,€but€did€notŠ ø Šreceive€it.€Essentially,€each€patientššs€test€was€Ō_ŌunderreadŌ_Ō.€Š œģ ŠĢI€did€a€larger€review.€Š d“ ŠĢOn€these€two€notes,€six€out€of€fifteen€treadmill€stress€tests€were€misread.€The€Ō_ŌTMSTŌ_Ō€QI€was€NEVERŠ ,| Šnoted€on€the€monthly€report€to€the€command.€That€is€a€violation€of€JCAHO€standards.€Š ` ŠĢĢThis€patient€had€a€positive€Ō_ŌTMSTŌ_Ō€and€symptoms.€No€follow€up€was€planned€by€Dr.€S.€Dr.€LazasŠ ¼  Šwound€up€admitting€this€patient€and€admonished€Dr.€S€in€morning€report€for€not€planning€any€followŠ  š Šup€for€this€patient.€The€patient€needed€expeditious€follow€up€in€cardiology€for€the€positive€test.€TheŠ „Ō Šonly€way€to€get€that€is€if€we€called.€Hence€the€protocol€required€the€testing€doctor€to€call€and€get€theŠ hø Šfollow€up.€Dr.€S€failed€to€do€that.€Š L œ ŠĢPulmonary€function€test€QI.€Š "d! ŠĢDon€Lazas€actually€signed€off€on€this€report.€It€shows€critical€reading€errors€on€the€part€of€Dr.€S.€ThisŠ Ü#,# Šreport€also€did€NOT€make€it€to€the€monthly€QA€report€to€the€command,€this€is€a€JCAHO€violation.€IŠ Ą$ $ Šcannot€know€who€did€not€include€this€report€and€the€Ō_ŌTMSTŌ_Ō€report,€I€believe€that€Dr.€Burden€hadŠ ¤%ō % Šsomething€to€do€with€that.€Š ˆ&Ų!& ŠĢAlso,€I€did€a€Ō_ŌHolterŌ_Ō€Monitor€report,€which€Dr.€S€also€failed.€This€report€disappeared€entirely,€and€didŠ P( #( Šnot€show€up€on€the€QA€report€to€the€command.€Š 4)„$) ŠĢI€have€the€pertinent€monthly€QA€reports.€I€did€not€include€them€in€this€packet.€Š ü*L&+ ŠĢĢŠ Ø-ų(. Š‡This€patient€had€symptoms€consistent€with€new€onset€water€on€the€lungs,€and€angina€but€was€notŠ ° Šadmitted.€She€treated€the€patient€with€just€two€days€of€Ō_ŌlasixŌ_Ō€as€an€outpatient.€There€was€no€K€orŠ ”ä Šelectrolyte€check,€or€EKG€check.€The€patient€had€been€referred€from€the€ER€for€Shortness€of€breathŠ xČ Šand€diaphoresis.€Š \¬ ŠĢWorked€up€the€anemia€in€this€patient.€Found€iron€deficiency€and€blood€in€the€stool,€but€there€was€noŠ $ t ŠGI€workup€done€Š  X ŠĢThe€patient€presented€with€Diarrhea€due€to€a€fistula.€When€I€saw€this€patient€in€Jan€93€I€decided€toŠ Š  Šsend€the€entire€mess€to€WRAMC€QA.€I€had€enough.€Š “   ŠĢThis€was€the€exact€repeat€of€another€case,€Colon€cancer€was€found€in€each€case.€€€Š |Ģ  ŠĢĢĢRather€persistent€BP€increases€ignored,€with€a€probable€complication€as€per€another€health€careŠ  \  Šprovider.€The€routine€things€get€ignored€as€well.€Š š@ ŠĢĢĢĢĢUntimely€intubation€of€patient€resulting€in€death.€This€was€reviewed€by€Dr.€Ripple.€He€cleared€thisŠ H˜ Šcase.€This€is€a€situation€where€you€have€to€take€the€history€from€the€attending€nurse,€who€once€againŠ ,| Šcomplained€that€the€patient€was€not€intubated€in€a€timely€manner.€Š ` ŠĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢŠ Ø-ų(. Š‡Reassurance€for€a€mildly€low€blood€count€diagnostic€of€a€mild€anemia.€There€was€no€further€workŠ ° Šup.€Motrin€and€Ō_ŌVistarilŌ_Ō€were€prescribed.€Š ”ä ŠĢĢĢThis€is€essentially€a€repeat€of€an€earlier€case.€The€patient€was€seen€twice€and€diagnosed€with€an€IronŠ $ t Šdeficiency€anemia.€The€doctor€even€treated€the€anemia€with€iron.€However,€when€you€find€an€ironŠ  X Šdeficiency€anemia,€as€even€you€probably€know,€you€have€to€look€for€blood€loss.€In€an€elderly€personŠ ģ < Šthat€is€a€colon€cancer€until€proven€otherwise.€Š Š  ŠĢĢ€I€put€this€sequence€of€reviews€at€the€back€to€keep€€them€together.€In€Feb€1993,€against€the€advice€ofŠ |Ģ  Šmy€advisors,€I€brought€this€issue€to€WRAMC.€I€wrote€up€all€the€cases€that€I€could€remember,€theŠ `°  Šbigger€ones€anyway,€and€waited€for€someone€to€come€and€talk€to€me.€That€never€happened.€In€MarchŠ D”  Šof€1993€I€thought€that€I€had€finally€gotten€through€to€the€command.€Dr.€Ripple€came€to€investigate.Š (x  ŠDuring€that€investigation€Dr.€Sreekumar€was€taken€out€of€the€care€of€patients.€I€was€overcome€withŠ  \  Šemotion,€but€it€was€short€lived.€Dr.€Ripple€never€talked€to€me.€When€I€later€talked€to€Dr.€Ripple€heŠ š@ Šindicated€that€he€had€not€talked€to€Dr.€Sreekumar€during€this€review.€The€letter€of€Dr.€Ripple€statesŠ Ō$ Šthat€it€was€my€fault€actually.€He€states€that€my€aggressive€pursuit€of€Dr.€Sreekumar€led€her€to€loseŠ ø Šconfidence.€Confidence€was€rarely€a€problem€(€except€where€noted€on€one€occasion€)€Dr.€SreekumarŠ œģ Šwould€act€arbitrarily€actually,€based€on€the€thought€of€the€moment,€and€that€thought€often€hadŠ €Š Šnothing€to€do€with€medicine.€The€report€goes€on€to€say€that€Dr.€Ripple€did€interview€staff.€I€do€notŠ d“ Šknow€who€that€was.€Dr.€Ripple€goes€on€to€clear€Dr.€Sreekumar€except€in€the€case€of€the€highŠ H˜ Špotassium.€He€ignores€the€EKGs€and€other€clear€evidence€of€a€non€functioning€doctor.€Of€note,€Dr.Š ,| ŠRipple€mentions€the€patient€who€prompted€the€referral,€saying€that€Dr.€Sreekumar€should€moreŠ ` Šaggressively€seek€document€and€treat€abnormal€findings.€Well,€that€is€true,€she€would€ignoreŠ ōD Šabnormal€findings€quite€often.€Dr.€Ripple€did€note€that€the€ICU€work€of€Dr.€Sreekumar€should€beŠ Ų( Šexamined€telephonically,€just€as€I€tried€to€do€in€real€time€to€make€sure€that€she€was€doing€OK.€YouŠ ¼  Šcan€read€the€rest€for€yourself.€When€Dr.€Sreekumar€was€returned€to€duty€with€no€consequences,€IŠ  š Šwrote€to€Dr.€Ripple€by€email.€That€is€enclosed.€€I€questioned€why€Dr.€Ripple€had€cleared€the€case€ofŠ „Ō Šthe€patient€with€the€Ō_ŌreinfarctionŌ_Ō€in€the€hospital.€This€was€the€patient€treated€with€oral€Ō_ŌdiltiazemŌ_Ō€for€aŠ hø Šseverely€elevated€blood€pressure,€EKGs€of€acute€MI,€and€water€on€her€lungs.€Š L œ ŠĢHe€said€the€following.€š šI€understand€that€you€disagree€with€the€way€others€practice€medicine,€butŠ "d! Šwhen€there€are€disagreements,€appropriate€reviews€are€undertaken.€He€accused€me€of€circumventingŠ ų"H" Šthe€system€and€dismissed€me.€Š Ü#,# ŠĢIndeed,€Dr.€Ripple€a€pulmonary€and€critical€care€specialist€from€WRAMC€had€abandoned€his€oath.Š ¤%ō % ŠHe€had€ignored€the€misread€EKGššs,€the€severity€of€the€poor€follow€ups,€and€did€not€see€me€in€order€toŠ ˆ&Ų!& Šget€the€entire€story,€which€I€present€to€you€here.€Dr.€Ripple€was€most€likely€acting€at€the€behest€of€Dr.Š l'¼"' ŠWartofsky€and€Ō_ŌBlanckŌ_Ō.€As€you€recall€about€a€year€ago,€Dr.€Chung€had€come€over€and€told€me€hisŠ P( #( Šreport€would€be€all€the€evidence€needed€to€discipline€Dr.€Sreekumar.€Š 4)„$) ŠĢĢĢĢŠ Ø-ų(. ŠIn€short€order,€I€sent€two€letters€to€Ō_ŌLTGŌ_Ō€Ō_ŌBlanckŌ_Ō.€You€can€read€these.€In€a€rare€document,€DR.€BlankŠ ° Šclaimed€that€he€had€personally€reviewed€all€of€the€materials.€He€went€on€to€chide€me€for€going€toŠ ”ä Šhim,€telling€me€to€work€through€the€folks€at€Ō_ŌKinbroughŌ_Ō.€I€wrote€him€two€more€letters.€While€I€haveŠ xČ Šwitnessed€many€people€give€up€their€integrity€for€fear€of€getting€sued€and€what€not,€I€have€neverŠ \¬ Šgotten€that€response€from€someone€up€so€high.€I€will€skip€topics€at€this€point,€but€note€that€my€nextŠ @ Šstop€was€CID.€After€that€it€was€the€DOD€IG.€I€still€believe€this€to€be€an€OPEN€case€for€CID,Š $ t Šconsidering€the€deaths€that€occurred,€and€want€to€prevail€upon€you,€the€Commission€to€get€someoneŠ  X Šin€here€who€has€some€integrity€to€fix€this€thing.€CID€is€the€Criminal€Investigation€Division.€Š ģ < ŠĢĢĢĢI€should€note€that€in€January€1993€I€was€working€in€the€minor€illness€clinic.€I€had€been€taken€out€ofŠ `°  Šthe€Ō_ŌIMCŌ_Ō€the€previous€June.€I€was€treated€disparately€after€an€incident€with€an€MP.€I€spent€some€timeŠ D”  Šdoing€QA€reviews€and€then€went€to€the€Outpatient€clinic€in€the€early€fall.€I€remember€the€day€I€metŠ (x  Šwith€Dr.€Dunn€very€well.€Dr.€Dunn€and€I€talked€about€the€MP€incident.€However,€when€I€told€Dr.Š  \  ŠDunn€that€I€had€finally€gotten€Don€Lazas€to€sign€off€on€a€negative€QA€review,€and€that€I€had€justŠ š@ Šdone€a€Ō_ŌHolterŌ_Ō€monitor€review.€He€became€upset.€When€I€told€Dr.€Dunn€that€I€would€persist€inŠ Ō$ Šdocumenting€the€problems€of€Dr.€Sreekumar,€he€blew€up.€I€would€say€that€at€this€point,€Dr.€DunnŠ ø Šjust€had€no€clue,€in€retrospect€anyway.€He€had€been€sued€once,€and€was€not€about€to€be€sued€again.Š œģ ŠDr.€Burden€had€convinced€him€that€I€was€a€liar,€he€was€not€capable€of€making€independentŠ €Š Šjudgements€apparently,€and€things€continued€to€go€down€hill.€Dr.€Dunn€treated€me€terriblyŠ d“ Šdisparately.€I€was€suspended€for€a€time€and€then€reinstated.€That€effectively€ended€my€career€rightŠ H˜ Šthere.€€€€Sometime€in€the€fall,€we€had€met€with€the€Commander€of€the€hospital.€He€had€told€me€that€IŠ ,| Šwould€be€returned€to€the€Internal€Medicine€clinic€eventually€and€that€this€would€blow€over.€However,Š ` Šsubsequent€documents€note€that€was€a€lie€on€the€part€of€Dr.€McMeekin.€The€command€had€started€toŠ ōD Šseparate€me€from€the€army.€Š Ų( ŠĢI€didnššt€know€that€and€exasperated€by€the€presence€of€this€cancer€patient,€my€guilt€got€the€best€of€me.Š  š ŠI€had€seen€a€patient€who€had€an€anemia€that€was€not€attended€to.€The€patient€turned€out€to€haveŠ „Ō Šcancer.€I€got€on€the€email€to€WRAMC€and€broke€the€rules,€I€had€taken€the€matter€outside€of€theŠ hø Šhospital.€A€week€or€so€later,€I€was€informed€that€I€would€be€separated€from€the€army.€I€successfullyŠ L œ Šfought€that€by€showing€everyone€the€cases,€the€separation€was€cancelled.€Š 0!€  ŠĢWhile€these€investigations€were€going€on,€I€lost€my€doctor.€It€seems€that€first€the€command€hadŠ ų"H" Šdecided€to€medically€board€me.€Š Ü#,# ŠĢI€also€have€ADHD,€attention€Deficit€and€Hyperactivity€disorder.€I€can€say€that€this€has€neverŠ ¤%ō % Šinterfered€with€patient€care.€It€actually€enhances€my€patient€care€as€it€makes€me€much€more€sensitive.Š ˆ&Ų!& ŠCombined€with€my€intellect€and€my€social€skills€I€make€a€fine€physician.€I€am€the€one€who€goes€outŠ l'¼"' Šof€his€way€to€talk€to€the€patients.€I€will€admit,€that€my€ADHD€did€not€come€in€handy€when€dealingŠ P( #( Šwith€this€patient€care€problem.€I€donššt€know€if€anyone€can€handle€this€type€of€problem,€but€I€can€tellŠ 4)„$) Šyou€that€I€was€exhausted.€Š *h%* ŠĢĢĢŠ Ø-ų(. ŠI€pause€to€€note€that€I€lost€my€doctor.€He€was€actually€relieved€of€his€duty€by€Colonel€Joan€Ō_ŌZajthcukŌ_Ō€(Š ° ŠSp?€)€deputy€commander€of€WRAMC.€Dr.€Koshes€told€me€this.€He€was€told€to€put€the€correctŠ ”ä Šdiagnosis€on€my€chart.€When€he€declined€he€was€relieved.€€Of€course€this€was€done€with€the€fullŠ xČ Šknowledge€of€Ō_ŌLTGŌ_Ō€Ron€Ō_ŌBlanckŌ_Ō.€€There€is€one€word€for€this,€it€was€a€medieval€act.€Barbaric€in€everyŠ \¬ Šway,€and€perpetrated€by€someone€who€still€claims€to€be€at€the€top€of€Medicine€in€the€United€States€ofŠ @ ŠAmerica,€Ron€Ō_ŌBlanckŌ_Ō€D.O.Š $ t ŠĢHe€did€not€just€relieve€my€doctor,€Ron€Koshes€M.D.€He€also€relieved€Joe€Ō_ŌFaganŌ_Ō€M.D.€These€two€areŠ ģ < Šunblemished€heros€of€the€first€order.€I€demand€that€at€the€very€least€the€Commission€offer€themŠ Š  Šsomething,€and€start€with€an€apology.€Dr.€Koshes,€is€a€gifted€clinician€by€all€accounts€and€was€anŠ “   Šextremely€young€assistant€chief€of€inpatient€psychiatry€at€WRAMC€when€this€happened€to€him.€IŠ ˜ č  Šnever€met€Joe€Ō_ŌFaganŌ_Ō€M.D.€but€I€hope€to€one€day.€Š |Ģ  ŠĢĢAgain,€the€relief€of€these€doctors€€happened€as€I€was€engineering€these€investigations.€While€theŠ (x  Šattempt€at€medically€boarding€me€began€at€Kimbrough,€it€continued€at€WRAMC.€Another€doctorŠ  \  Šimplicated€in€this€scandal€is€Dr.€Ō_ŌFollansbeeŌ_Ō,€who€did€actually€concoct€a€second€diagnosis€for€me.€HeŠ š@ Šdid€this€to€facilitate€a€medical€board.€That€was€done€by€direction€of€the€command,€and€specificallyŠ Ō$ ŠDr.€Michael€Dunn€and€Robert€Mc€Ō_ŌMeekinŌ_Ō.€M.D.€I€still€get€goose€bumps€as€I€write.€Š ø ŠĢThe€level€of€abuse€of€command€on€the€part€of€these€so€called€physicians€is€alarming,€downright€scary,Š €Š Šand€something€that€the€Commission€cannot€pass€on€without€a€mark€on€the€record€of€these€people.€Š d“ ŠĢI€say€again,€Dr.€Koshes€and€Dr.€Ō_ŌFaganŌ_Ō€need€to€be€celebrated€as€heros.€Š ,| ŠĢI€went€to€CID.€They€were€given€the€report€of€Dr.€Ripple.€I€have€always€thought€that€Dr.€RippleŠ ōD Šblamed€me€for€the€problems€of€Dr.€Sreekumar€because€the€command€needed€that€to€happen.€SendingŠ Ų( Šthe€report€of€Dr.€Ripple€and€the€subsequent€report€of€Dr.€Pearson€to€CID€was€and€is€obstruction€ofŠ ¼  Šjustice.€The€WRAMC€command€is€directly€responsible€for€the€death€that€occurred€just€after€this€firstŠ  š Šinvestigation,€the€one€by€Dr.€Ripple.€€Š „Ō ŠĢEvery€effort€by€the€command€focused€on€minimizing€the€problem.€When€I€was€able€to€meet€with€anŠ L œ Šinvestigator€it€was€only€after€extreme€effort€on€my€part.€When€I€went€to€the€DOD€IG,€my€way€wasŠ 0!€  Šblocked.€My€schedule€was€altered€in€order€to€interfere€with€my€appointment€with€the€DOD€IG.€OnceŠ "d! ŠI€got€to€the€DOD€IG,€they€stuck€with€the€party€line€and€ignored€the€facts.€Now,€it€should€be€said€thatŠ ų"H" Šthey€have€no€doctors€at€the€DOD€IG,€and€so€the€investigation€came€down€to€those€who€had€alreadyŠ Ü#,# Šrelieved€people€and€what€not.€Also,.€at€one€point€the€badged€investigators€of€the€DOD€came€to€myŠ Ą$ $ Šhouse€to€intimidate€me.€That€episode€is€on€tape.€Š ¤%ō % ŠĢWhen€I€was€a€resident€Dr.€Clarence€Pearson€was€a€cardiology€fellow.€We€were€colleagues.€He€wasŠ l'¼"' Šfine.€So€I€expected€that€when€he€saw€the€EKGššs€he€would€make€the€right€decision.€He€never€saw€theŠ P( #( ŠEKGs€before€he€wrote€his€report.€After€figuratively€banging€on€the€door€of€the€IG€for€some€time,€IŠ 4)„$) Šwas€allowed€to€see€the€investigator.€I€showed€him€the€EKGs,€but€they€never€made€it€to€his€report,€as€itŠ *h%* Šhad€already€been€written.€As€an€aside,€Len€Wartofsky€sent€both€Dr.€Ripple€and€Dr.€Pearson€toŠ ü*L&+ ŠKimbrough.€€Š ą+0', ŠĢŠ Ø-ų(. ŠI€want€to€note€that€I€have€the€two€reports€because€they€were€forwarded€to€my€attorney€since€they€wereŠ ° Šgoing€to€be€used€by€the€command€in€order€to€separate€me€from€the€army.€I€am€quite€sure€that€hasŠ ”ä Šsomething€to€do€with€the€wording€of€the€reports.€Š xČ ŠĢI€persisted,€and€wound€up€getting€my€board€cancelled.€I€was€received€by€Colonel€Ō_ŌEsteyŌ_Ō€and€hisŠ @ Šassistant.€It€seems€that€Colonel€Ō_ŌEsteyŌ_Ō€and€the€WRAMC€IG€Colonel€Roy€Leatherberry€had€beenŠ $ t Štalking.€Colonel€Ō_ŌEsteyŌ_Ō€came€in€and€first€took€the€time€to€shake€my€hand.€I€went€over€the€cases€above,Š  X Šand€the€board€was€canceled.€When€I€prevailed€upon€Colonel€Ō_ŌEsteyŌ_Ō€to€pursue€those€who€had€brokenŠ ģ < Šthe€law€he€declined.€I€was€given€an€honorable€discharge€in€January€1994,€I€believe€it€was€the€third,€IŠ Š  Šwould€have€to€check.€Š “   ŠĢĢThe€previous€July€Ō_ŌNeyŌ_Ō€Gore€M.D.€came€in€and€reviewed€all€of€the€cases.€Dr.€Diallo€the€chief€of€theŠ `°  ŠER€was€moved€to€occupational€therapy.€I€was€reinstated,€and€two€other€doctors€were€reassigned.Š D”  ŠColonel€Leatherberry€had€a€lot€to€do€with€my€reinstatement.€Ō_ŌNeyŌ_Ō€got€it€right,€although€I€do€not€knowŠ (x  Šwhat€he€had€on€Dr.€Diallo.€Dr.€Diallo€did€manage€to€get€himself€reinstated.€I€served€in€InternalŠ  \  ŠMedicine€again,€and€Dr.€Sreekumar€was€taken€out€of€the€care€of€inpatients.€Tom€Loughney€does€getŠ š@ Šsome€credit€for€keeping€Dr.€Sreekumar€out€of€inpatient€medicine.€However,€he€failed€to€act€for€a€yearŠ Ō$ Šuntil€he€was€chief.€I€was€told€that€the€move€of€Dr.€Sreekumar€out€of€inpatient€medicine€€wasŠ ø Špermanent.€I€heard€a€rumor€that€Dr.€Sreekumar€declined€an€offer€of€retirement.€I€never€wanted€toŠ œģ Šcheck€to€see€how€long€she€stayed€at€Kimbrough.€Š €Š ŠĢDr.€Sreekumar€was€allowed€to€do€the€treadmill€stress€tests€after€she€was€taken€out€of€the€care€ofŠ H˜ Šinpatients.€The€last€two€cases€show€that€she€was€not€able€to€do€that.€Š ,| ŠĢIn€summary,€the€folks€who€perpetrated€these€crimes€against€the€patients€have€gone€unpunished.€It€isŠ ōD Šway€past€time€for€these€people€to€be€punished.€For€myself€I€ask€only€for€a€letter€of€apology.€I€do€notŠ Ų( Šfeel€that€a€Ō_ŌwhistleblowerŌ_Ō€can€ask€for€more€and€maintain€his€credibility.€I€do€need€help€if€theŠ ¼  Šcommission€is€interested.€Š  š ŠĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢŠ Ø-ų(. Š‡Things€in€the€civilian€world€are€run€quite€a€bit€like€those€at€Walter€Reed.€Š ° ŠI€can€tell€you€that€Lee€Ō_ŌHallerŌ_Ō€M.D.€psychiatry,€subsequently€agreed€to€give€me€a€false€diagnosis.€HeŠ ”ä Štold€me€on€the€phone,€before€I€met€with€him€that€I€was€done.€I€requested€to€see€another€doctor.€ForŠ xČ Šsome€reason€that€request€is€marked€against€me€currently.€Š \¬ ŠĢI€can€tell€you€that€Ellen€Ō_ŌMcDanielŌ_Ō€M.D.€gave€me€a€diagnosis,€for€which€I€have€no€criteria.€Also,Š $ t Šalong€with€a€member€of€the€Maryland€board,€most€likely€Pam€Ō_ŌKromerŌ_Ō,€Dr.€Ō_ŌMcDanielŌ_Ō€put€in€my€chartŠ  X Šthat€I€told€Dr.€Ō_ŌMcDanielŌ_Ō€I€was€fired€by€a€subsequent€employer.€The€diagnosis,€and€the€assertion€that€IŠ ģ < Šhad€said€that€are€totally€false.€Š Š  ŠĢI€can€tell€you€that€in€my€attempts€to€be€reinstated,€Michael€Ō_ŌLlufrioŌ_Ō,€no€doubt€at€the€direct€request€ofŠ ˜ č  Šthe€Maryland€board,€called€Paul€Ō_ŌPrunierŌ_Ō€M.D.€in€order€to€have€Paul€Ō_ŌPrunierŌ_Ō€M.D.€change€the€goodŠ |Ģ  Šreport€that€he€gave€me.€Dr.€Ō_ŌPrunierŌ_Ō€can€and€will€tell€you€that€if€you€wish.€Š `°  ŠĢI€can€also€report€to€you€that€the€board€also€called€a€testing/retraining€center€in€a€so€far€successfulŠ (x  Šattempt€to€keep€them€from€retraining€me.€I€tested€out€more€than€fine€but€they€are€making€up€reasonsŠ  \  Šnot€to€retain€me€in€medicine.€I€have€been€folded,€spindled,€and€mutilated€so€to€speak.Š š@ ŠĢI€have€related€the€above€incidents€at€Kimbrough€Army€Hospital€and€Walter€Reed€Army€Hospital€toŠ ø Šthe€Maryland€board€on€too€numerous€to€count€occasions.€At€one€point,€I€went€up€to€the€board€withŠ œģ Šmy€brother,€Michael.€I€handed€the€chief€of€compliance,€Barbara€Ō_ŌVonaŌ_Ō,€the€documents€noted€above.Š €Š ŠShe€forcefully€handed€them€back€to€me.€I€have€had€Pam€Ō_ŌKromerŌ_Ō€also€an€investigator€for€the€board,Š d“ Šstand€just€an€inch€or€two€away€from€me€in€order€to€get€me€to€react€in€some€way€that€she€could€use.€ItŠ H˜ Šhas€been€one€thing€after€the€other.€Š ,| ŠĢI€am€a€good€doctor,€and€frankly€one€of€the€only€people€who€has€consistently€followed€the€rules.€NoŠ ōD Šclaim€of€harm€to€patients€is€on€my€record.€That€should€be€taken€into€account€strongly,€however.€€Š Ų( ŠĢI€have€a€long€still€have€a€bumpy€road€in€front€of€me€before€I€get€to€practice€medicine€again.€I€prayŠ  š Šthat€you€can€give€me€at€least€some€peace€and€write€out€a€letter€of€apology.€Actions€like€mine€Š „Ō Šsafeguard€the€patients.€They€need€to€be€encouraged.€€Š hø ŠĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢŠ Ø-ų(. Š‡ĢMedicine€TodayŠ ”ä ŠĢHarvard€(1)€tells€us€that€only€three€percent€of€the€malpractice€ever€comes€to€light.€That€means€that€ifŠ \¬ Šall€of€the€cases€were€paid,€we€would€have€to€pay€the€patients€for€the€privilege€of€practicing€medicine.€Ō#†č^æēXX&į×#ŌŌ‡X&įXēč^æŌŠ @ ŠĢRecently,€the€Institute€of€Medicine€(2)€noted€that€1.5€million€people€are€harmed€every€year,€just€fromŠ  X Šmedication€errors.€They€were€incorrect€in€calculating€the€cost€of€that.€If€each€of€those€people€filed€aŠ ģ < Šclaim,€the€cost€would€be€1.5€Trillion€dollars,€more€or€less.€That€is€almost€as€much€as€the€total€revenueŠ Š  Šfor€all€of€Medicine.€There€is€a€lot€that€needs€to€be€done€in€Medicine€in€America.€Ō#†č^æēXX&į”#ŌŌ‡X&įXēč^æŌŠ “   ŠĢAccording€to€Ō_ŌLeapeŌ_Ō,€in€the€Annals€of€Internal€Medicine€Jan€2006,€(3)€doing€what€I€did€at€KACH€Š |Ģ  Šmakes€you€a€problem€doctor,€in€and€of€itself.€According€to€Ō_ŌLeapeŌ_Ō€these€problem€doctors€are€subject€toŠ `°  Šdiscipline.€The€only€way€to€discipline€these€problem€doctors€is€to€make€up€a€psychiatric€diagnosis.Š D”  ŠThat€is€what€happened€to€me.€Ō#†č^æēXX&į²#ŌŌ‡X&įXēč^æŌŠ (x  ŠĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢĢŠ Ø-ų(. ŠFinal€RecommendationsŠ ° ŠĢThe€one€BIG€thing€that€I€would€do€is€take€the€money€given€to€utilization€review€people€in€hospitalsŠ xČ Šnationwide€and€give€that€to€the€JCAHO.€That€would€put€the€JCAHO€directly€in€the€hospitals€on€aŠ \¬ Šdaily€basis.€If€you€got€to€the€JCAHO€today€they€will€tell€you€that€you€are€not€a€protected€whistleŠ @ Šblower.€That€should€stop.€JCAHO€should€be€in€the€hospitals€everyday.€Š $ t ŠĢThe€next€thing€is€to€institute€airline€level€procedures€in€Medicine.€There€is€a€big€difference€betweenŠ ģ < Šairplanes€and€the€baggage€that€goes€in€them.€It€should€go€without€saying€that€the€airline€baggage€isŠ Š  Šsimilar€to€medicine€at€present.€Standards€are€much€too€low.€If€the€FAA€finds€problems€with€yourŠ “   Šairplane€maintenance€records€very€bad€things€happen€quickly.€That€is€not€the€case€with€people.€YouŠ ˜ č  Šhave€to€act€before€the€patients€are€harmed.€There€are€only€two€things€on€the€medical€side€of€the€houseŠ |Ģ  Šthat€almost€always€function,€the€administration€of€blood,€and€the€no€dumping€patients€rule.€Š `°  ŠĢIf€you€could€do€one€thing€for€medicine€in€the€US€army,€just€make€them€follow€their€rules€andŠ (x  Šregulations.€Walter€Reed€is€truly€a€great€hospital.€It€is€a€national€resource.€However,€I€remain€one€ofŠ  \  Šthe€very€few€members€of€my€chain€of€command€who€followed€all€of€the€rules,€save€an€incident€withŠ š@ Šthe€Ō_ŌMPsŌ_Ō€one€bad€night€for€which€I€have€been€treated€disparately.€Ō#†č^æēXX&įĢ#ŌŠ Ō$ ŠŌ€X&įXēč^æŌĢStandards€are€the€key.€In€this€case,€I€documented€problems€with€both€civilian€DOD€employees,€andŠ œģ Šindependent€contractors.€Everyone€is€afraid€of€getting€sued€apparently.€As€an€active€duty€army€guy,€IŠ €Š Šcould€never€sue€the€people€who€treated€me€disparately.€So,€the€messenger€was€killed.€Š d“ ŠĢMedical€Holding€company€is€asset.€It€provides€workers€and€while€working,€or€training,€the€membersŠ ,| Šof€medical€holding€company€inform€the€command€about€their€level€of€disability.€That€will€save€DODŠ ` Šbig€money€over€the€years.€If€the€army€has€enough€workers,€I€would€be€happy€to€give€my€packages€toŠ ōD Ša€Wounded€Warrior€working€at€the€Post€Office€and€so€on.€Competitions€between€crews€of€soldiers€toŠ Ų( Špaint€the€offices€at€WRAMC€and€what€not€can€serve€to€relax€all€concerned.€When€relaxed€and€happy,Š ¼  Šthe€true€level€of€disability€can€be€determined.€Overall,€it€is€important€to€keep€the€soldiers€busy,€treatŠ  š Šthem€to€zero€defects,€and€hopefully€get€their€board€scheduled€a€little€after€that€treatment€plateaus.€AtŠ „Ō Š400€plus€days,€the€scheduling€of€the€board€is€the€slow€part€of€the€process.€€That€is€done€at€the€DODŠ hø Šlevel.€With€the€help€of€three€regular€army€folks,€700€war€hardened€soldiers€can€organize€themselves.Š L œ ŠThe€focus€should€be€on€returning€the€time€between€discharge€from€the€hospital€and€the€final€boardŠ 0!€  Šaction€to€a€normal€interval.€€€€Š "d! ŠĢThe€Commission€has€to€realize€that€Psychiatric€evaluations€of€this€type€are€medico€legal€procedures.Š Ü#,# ŠAll€of€them€should€be€taped,€whether€they€are€in€the€army€or€in€the€civilian€sector.€That€will€save€youŠ Ą$ $ Šlots€of€money€down€the€line,€and€the€command€will€not€be€so€quick€to€try€and€have€psychiatristsŠ ¤%ō % Šdictate€diagnoses€for€people€like€me.€These€evaluations€are€what€they€are,€unless€they€are€not€taped,Š ˆ&Ų!& Šthen€they€can€be€described€in€ways€dictated€by€the€command.€Š l'¼"' ŠĢI€personally€blacked€out€the€names€of€the€patients€in€this€case.€I€have€the€charts€with€the€patientŠ 4)„$) Šnames,€and€I€expect€someone€to€come€and€properly€adjudicate€this€case.€I€have€the€names€of€all€theŠ *h%* Špeople€that€need€to€be€interviewed.€Most€of€them€are€in€this€writeup.€€Š ü*L&+ ŠĢĢŠ Ø-ų(. Š