Ann Arbor VA Nurse

Bizarre Ann Arbor VA Nurse Error Investigated After Veteran Death

Ann Arbor VA Nurse
Photo of Ann Arbor VA from Patrick Record, The Ann Arbor News

A sick veteran died after he stopped breathing because an Ann Arbor VA nurse mistakenly said he had do not resuscitate (DNAR) status.

After open-heart surgery, the veteran suffered a heart attack and stopped breathing. Rather than resuscitate, the veteran was allowed to die. No one performed CPR or related lifesaving procedures because of the nurse told numerous staff the veteran did not want to be saved.

RELATED: Voc Rehab Counselors Push Vets Out Of Program Early

In a VA OIG report, investigators concluded the veteran did not receive the normal lifesaving services he otherwise would have received had the nurse not made her mistake. The team also failed to place the veteran on a heart monitor while recovering from open-heart surgery. Disturbingly, facility administrators were aware of the problem for over a year but chose not to take action.

VA investigators found that, “Since all team members were under the mistaken belief that the patient’s code status was DNAR, no CPR was initiated per protocol. The patient was pronounced dead at 1:35 p.m.”

RELATED: VA Testing New PTSD Treatment

Like many investigations, VA OIG stopped short of concluding the failure to provide lifesaving services would have prevented the veteran’s death, though it seems probable that a combination of no heart monitor and no CPR certainly did not help save the veteran.

Shortcomings like VA OIG failing to connect the dots are not an insurmountable problem. Most medical malpractice attorneys familiar with malpractice at VA medical centers should be able to pull in experts to opine if the failure did likely result in the veteran’s premature death.

VA Secretary Shulkin On Medical Malpractice

“These are serious allegations, and we are looking immediately into taking appropriate personnel actions against those named in the report,” according to a statement released by the Ann Arbor VA. “Secretary (David) Shulkin has made clear that VA will hold employees accountable when they fail to live up to the high standards taxpayers expect from us. And that’s exactly what we’re doing in this case.”

RELATED: VA Busted Falsifying Mental Health Numbers

Ann Arbor VA OIG Investigation Report Excerpt About VA Nurse

According to the VA OIG investigation report summary:

The VA Ann Arbor Healthcare System’s Cardiopulmonary Resuscitation and Do Not Attempt Resuscitation policies were not consistent in identifying the staff responsible for determining a patient’s resuscitation status prior to initiating resuscitative efforts. Do Not Attempt Resuscitation orders were not linked to the Clinical Warnings, Allergies, and Directives tab in patients’ electronic health records. We identified a misperception among physician staff that all patients on a telemetry unit were monitored via telemetry (continuous monitoring of heart rate and rhythm from a remote location), regardless of whether a telemetry order had been entered. Also, electronic health record documentation did not comply with requirements for resident supervision, medical decision-making, and resident physician to attending physician discussion of care during an emergency situation. 

RELATED: VA Scheme Deprives Veterans Of Appeals Rights

About Ann Arbor VA

Ann Arbor VA has provided health care to veterans since 1953. More than 65,000 veterans receive health care from the facility. The facility has 109 acute care best and 40 Community Living Center beds.


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  1. Military friend of mine, not using VA medical side asked, why are Union people taking care Veterans? He said that there are no incentives to produce, they get the same paycheck at the end of the day, less creativity in the workplace, and no accountability. – – – Nutter.

    1. It shouldn’t matter to a health professional who has a moral compass . They are in a field to care for people. They should provide the best care possible under any circumstances! And if you are with a Veteran who is having a problem and your shift ends, you STAY to provide continuity to that Veteran’s care without thinking or caring about being reimbursed. It’s what marks a professional in a health care position. That was drilled into me years ago when I was in college to become a nurse. And No one should go into nursing so they can get a job. You go into nursing because you like caring for people, nothing less. Again, BIG problem with employee practices.

      1. Laura,
        Want to know what VHA employees “feel like” towards the end of the day?
        Go sit in a parking lot at any VHA clinic or hospital. Especially at a small clinic!
        Don’t be surprised IF the “stampede” starts BEFORE quitting time! The doors are usually locked, at least a half hour before they’re supposed to be! That’s HOW they are!
        A small clinic down here in Central Florida has been caught numerous times!

  2. Republican establishment blocks veterans’ access to medical marijuana
    Mike Adams

    In the latest insult to America’s veterans by the corrupt GOP establishment, the U.S. House voted to deny veterans’ access to medical marijuana.

    This, of course, is a betrayal of our men and women in uniform, and it will force veterans onto more deadly opioids that enrich the drug cartels while killing the innocent.

    1. @Oldmarine – – – This makes Veterans a Second Class Citizenry of their own State in which they reside. Hmm, makes me think? Oh I know, then how come that I have to trust that a VA Physician is vetted enough to help in protecting my rights to receive good medical care? The VA wants to have it their way with everything. I’m tired of being controlled by a bunch of Politicians just because I’m a Veteran. If anything, we Veterans should receive the fucking BEST OF CARE. And WE’RE NOT. This is a legal force of I’m telling Veterans what they can’t do, while the other Citizenry are CLEARLY ABLE TO CHOOSE AS THEY PLEASE. Arguments will continue on this issue, mark my word. Per me, Fed and States need to be more concerned about the costs in lives, and property damages via intoxication of what is already legal (booze). – – – Nutter.

  3. Seymore,
    Have you seen this from;
    “Girls Just Wanna Have Guns” with Regis Giles, via “Army Times”

    “Poll: Should Bergdahl Receive $300,000 in Back Pay Benefits?”

    Posted on November 9, 2017.
    When I took the poll, only one person said “yes”!
    It seems Gen. Abrams will be making this, and other, decisions in a short time!

    1. I think Bergdahl should now worry only about the ‘arrears’ that will be of ‘Bubba’s’ front & center interest when new meat arrives.

      1. namnibor,
        According to ALL reports, he’s NOT going to spend one second inside a prison cell!
        In my opinion, he should be facing a firing squad. The last one to be executed, by firing squad, was in WWII! All that guy did was get lost, parachuting in, on D-Day!
        I think his name was something like “Rybeck”????? (Not sure though!)

      2. Got shot because he got lost????? The other side should’ve been executed after Eddie Slovik was killed. IMHO. – – – Nutter.

      3. Yep, because he got lost! He did find his way to another unit, (by accident)! Told them his story. They turned him in! It went downhill from there!

        It was Eisenhower who ordered the execution! It is speculated his execution was political. Because this was right after Gen. Patton had been relieved of duty (for beating Montgomery into some town in Sicily!) Remember, Patton was returned to England and was placed in charge of a “dummy air field”! (And for “slapping a soldier!”)

      4. From what I read on Wikipedia about him, it is true he got lost, but according to the entry there, he didn’t want to be assigned to a rifle company. After getting lost, he and a buddy spent 6 weeks with another unit before going to his own. When he got to his unit, he told his commander he would desert if he was assigned to a rifle company. His commander assigned him anyway. At some point, Slovik wrote down that he would desert if assigned to a rifle company. Also at some point, he did desert, and his buddy caught up to him and tried to convince him to return.

        He was caught at some point and he presented his letter saying he would desert if he was assigned to a rifle company. He was given a chance to tear up his letter, but he refused demanding the court martial believing he would only get jail time like thousands of others who had deserted. Ultimately he was given three chances to tear up his letter, and he refused each. I believe one chance was after his court martial. After that third refusal, he was told to write on the back of the letter that he understood what refusing a 3rd time meant. After that, he was executed.

      5. 91Veteran,
        That’s what “The official records” states! There’s a few “flaws” in the “official Army Records”!
        I met a retired Sargent Major, in 1964, outside Ft, Bragg, who “claimed” the records were, quote: “BULLSHIT!” unquote! That Sloviks’ trial was political in nature. That it was to “motivate the troops!”
        One has to remember, for a few months AFTER “D-Day”, June 1944, our Army was bogged down! It wasn’t moving fast enough to defeat the enemy! The Army was tired after losing many men and lots of equipment! This was one of the reasons why Patton was brought back on active duty in Western Europe! To take back control of the 3rd Army! Then move towards Germany!
        Gen. Abrams wrote about it in his book! Which the Sargent Major suggested for me to read!

      6. Not surprised at that Crazy Elf.

        Further into the same wiki entry, it states Slovik appealed his sentence to Eisenhower, who upheld it to discourage further desertions. I missed that last night when I read it.

        2,864 were tried for desertion, 49 convicted and sentenced to death, only Slovik was put to death.

  4. You know, and especially upon watching the PBS documentary, ‘The Human Cost of War’, the VA’s mantra is that without the VA no one would have the knowledge, skill, and/or experience to give veterans proper treatment…and, say goodbye to innovation.

    Sorry, I don’t believe that. I believe in Capitalism and when the medical industry (by giving veterans their own choice of medical provider – not the Choice progam where still the government limits choices) see the market for veterans needing specialized care, that will result in innovation, customer service, and competition for veterans’ business.

    The VA is full of hacks who could not practice in the private industry and who use their status as government employees to shield themselves from liability.

    In sum, the government cannot manage healthcare for anyone, including veterans and the VA needs to be abolished.

  5. Introduced today is legislation to force the Dept of VA to report disciplinary actions against medical providers to a national database designed to prevent them from crossing state lines to escape their pasts & keep practicing.

    Thomas Franchini injured 88 veterans & now has a private practice is featured in the video.

    VA conceals shoddy care and health workers’ mistakes @

    1. @NiteWish – – – As you’re most likely aware, the MD-MO runners need to be banned from practicing in the VA system. I hope it passed through to become law in all the land. – – – Nutter.

    2. Verbal Band-Aids (VBA), nothing more. You have a greater chance at yelling at a can of canned salmon and it swimming upstream again…in it’s can, than the VA to actually abide by the regs already in place, let alone the scabs of Band-Aids covering past scabs of Band-Aids. (presently cooking canned salmon…can removed)

      1. Another accurate analogy. Nam, I’ve been appreciating you works of expressions since being on this blog. If my body don’t wiggle from laughing, at least my mind would then be shaking of thoughts in my skull case. Then when the shaking subsides, thoughts of stability will then arise. Why can’t these dumb asses get it? – – – Nutter.

    3. Who cares about more legislation!!!! What is the point of legislation if no one will enforce it!!!

      FBI and DOJ can go after these criminals without this legislation. But they won’t and this legislation won’t change a thing!!!

      1. I get your point, but the legislation says FORCE, and yes, its not the first time legislating this issue. FBI and DOJ have investigative powers, monies, and for the public’s trust factor, a need and win for the Federal’s BIG SWAMP CLEANING. Bottom line, hopefully better Veteran care. – – – Nutter.

  6. Everybody involved in this particular veterans demise now know what it feels like to have blood on their hands, provided they haven’t been involved in similar situations in the past…

  7. This should have been forwarded to the Justice Department for prosecution of neglect or murder. What’s the difference from a nurse shooting air into a veteran and killing them or just letting them die.

    Again the VA is acting as part of our Judiciary system and they are not trained to prosecute anyone. Shulkin says some employees will be held accountable ? How transferred to another unit or placed into an administrative position, or payed to quit.

    The VA wants Nurses to be able to treat veterans in stead of a real doctor and many nurses keep stating they are very qualified to do this. Well this Nurse just let a veteran die.

    Any employee caught doing wrong should have the federal authorities look into the situation and charge these employees with neglect and force them to tell it to a Judge and Jury.

    Who is speaking up for this veteran, Beside Ben.

    Again our Justice Department must take control or these deaths will just continue and these employees will do it again and again. Screw you veterans ! mess with me and we or I will kill you. Whos going to stop me, hell I know if I kill one of you, I will be given an administrative position or just transferred !

    Crimes against Veterans.

    1. The term manslaughter comes to mind. Both voluntary and involuntary manslaughter are crimes.

    2. Agreed. FBI and DOJ have jurisdiction to investigate and prosecute federal employees – but are wasting our taxpayers dollars on investigations on Russian collusion

      1. FBI and DOJ are purposely turning their heads away from the cries for help of Veterans, to help protect them from an Agency that is responsible to help to assist, care, and get as much as the Veteran’s previous life back for our sanity, and to make sure that our love ones and service animals are properly cared for. That’s if the VA cared for us so much as they brag about.

        Come on you Politicians, and the Protectors of the People’s and their Properties (FBI, DOJ). How many more articles are you waiting to be published?

        Do something for positive movement towards Veterans getting TREATED w RESPECT. Let me give you an already known fact, that if initiated, will become an investigative field day? Investigate the VA. The Secretary of the VA, Shulkin, has already admitted that the VA has been adversarial against Veterans. Words mean things.

        By investigating the VA, you’ll hopefully save hundreds of Veterans life’s per month. No offense, but I’m VERY SUSPICOUS of YOU for NOT ACTING on the VA’s PEYTON PLACE SCANDALS.

        And, I’m not shocked that the Main Stream Media (MSM), again has dropped the ball by not probing Shulkin with deeper questions of; “what exactly his understanding was of using the word *adversarial* to describe how the VA Claims Side of things, has been treating Veterans.” – – – Nutter.

    1. Maybe the guy didn’t completely fill in the oval with a number two pencil? That is the second leading cause of death in most VA surgical accidents. The leading cause of death of course would be the stray marks outside of the oval.

      1. I notice how that directly correlates to Milton Bradley’s ‘Operation Game, you got the malpractice red light buzzer if you went outside of the oval and it alerts the new VA Command Center Under Mt. Malfeasance(VACCUM).

  8. The articles being written that are reporting on the actions of the VA nurse that cost a Veteran his life are being reported two different ways.

    1.) Some articles are based on The Office of the Inspector General for the Department of Veterans Affairs report. Which reports that the Veteran died following a relatively simple non-life-threatening surgery on his leg. The surgery was to clear a blocked artery. Also, that the nurse was male and had a history of being sanctioned for causing major problems in several other Veteran’s care prior to this Veterans death.

    Source Full OIG report at: “”

    2.) The second type of articles are the ones that rely on the words of the VA spokespersons for their reporting. These wrongly state that the Veteran was recovering from open heart surgery and indicate that the nurse is female. An example is the article that Ben linked at the bottom of his article.

    At: “”


    On a side note Professor Roberto Kampfner from the University of Michigan Dearborn was interviewed by Channel 7 ABC WXYZ-TV Detroit. Clearly English is not his first language and he truly has not mastered speaking english.

    Interview of Roberto Kampfner at: Man dies at Ann Arbor VA hospital; nurse wrong about resuscitation”, WXYZ-TV Detroit | Channel 7

    1. Another example of disinformation being spread by the VA is the recent reporting on Agent Orange and Shulkin’s decision.

      An article based on and stating the facts:

      “After study, VA delays Agent Orange additions”, Tom Philpott, Military UpdatePublished 12:27 p.m. PT Nov. 3, 2017

      “After 18 months of review by his department, VA Secretary David J. Shulkin awkwardly announced Wednesday that he plans to “further explore” adding ailments to the list of compensable conditions VA presumes were caused by exposure to Agent Orange and other herbicides used during the Vietnam War.

      The decision to punt long-anticipated decisions on Agent Orange-related ailments will disappointment thousands of aging veterans with bladder cancer, hypothyroidism, Parkinson-like tremors and hypertension (high blood pressure).”


      An article based on VA disinformation:

      “Secretary of Veterans Affairs considers 14 conditions linked to Agent Orange exposure”, Carol Robidoux, November 1, 2017 

      “WASHINGTON, D.C. – U.S. Secretary of Veterans Affairs Dr. David J. Shulkin on Wednesday announced that he is considering possible new presumptive conditions that may qualify for disability compensation for veterans related to Agent Orange exposure.

      “After thoroughly reviewing the National Academy of Medicine (NAM)’s latest report regarding Veterans and Agent Orange, and associated data and recommendations from the NAM Task Force, I have made a decision to further explore new presumptive conditions for service connection that may ultimately qualify for disability compensation,” Secretary Shulkin said. “I appreciate NAM’s work and the commitment and expertise of VA’s NAM Task Force, and look forward to working with the Administration on the next steps in the process.””

      1. On a possibly brighter note as it stands now after a lot of bad press on shulkin punting the decision down the road on new additions of conditions connect to Agent Orange.

        Secretary Shulkin was forced to change his stance on punting the decision and stated at the National Press Club that the decision has now been made and they are adding to the list.

        “VA May Expand List of Ailments for Agent Orange Coverage: Shulkin”
        “ | 7 Nov 2017 | by Richard Sisk”

        “Veterans Affairs Secretary Dr. David Shulkin said Monday he’s decided to expand the list of “presumptive” ailments for Agent Orange compensation subject to approval by the Trump administration.

        Shulkin didn’t disclose the expanded list — “I’m protecting the sanctity of the process” — but stressed, “I have made a decision. I have passed that on in the process that we follow in the federal government.”

        A VA official later said Shulkin’s recommendations on Agent Orange compensation expansion would go to the White House Office of Management and Budget and other agencies for approval and analysis of the costs. Shulkin said he expected approval “in a matter of a few months.”

        Shulkin’s remarks on Agent Orange on Monday at the National Press Club were in contrast to the statement put out last week by the VA suggesting that decisions on expanding the list had been delayed yet again.”

        The VA faced its own deadline of Nov. 1 for deciding on whether to include bladder cancer, hypothyroidism, Parkinson-like tremors and other ailments to the list for Agent Orange compensation based on a report from the National Academy of Medicine that had been sitting at the VA for 18 months.

        After reviewing the academy report, Shulkin said in his statement last week, “I have made a decision to further explore new presumptive conditions for service connection that may ultimately qualify for disability compensation.”

        Shulkin readily acknowledged the confusion on what transpired last week in regards to expanding the list. “I’m glad to clarify this situation, since I think that it may be a little bit murky,” he said.

        The VA had received the NAM’s report in early 2016 and had been required to approve or disapprove of its recommendations within 60 days. The VA failed to meet the initial deadline in another “example of the VA not performing at an acceptable level,” Shulkin said.

        Rather than committing last week to “further explore” an expansion, he had actually decided to expand the list, Shulkin said. “I made made a decision,” he said. “I’m not announcing it,” he said, but “my intention is to do what’s right for veterans.”

      2. Again, in summary, Shulkin punted on a decision they should have made in 2016, got called on it and he claims confusion.

      3. Key words here, “considering” and “explore”….which is typical politician talking in circles.

        Same thing like Shulkin grand announcement of the VA’s process being adversarial.

        Shulkin is a politician, lots of talk and no realistic actions.

        I was watching the CBS interview he had yesterday and he flat out lied that delays in scheduling is an isolated issue and not a systemic on. How many VA facilities have been caught with accusations, investigations ane persecution of whistleblowers like Dr. Klein who exposed phantom waiting lists?

        Shulkin is a liar and is a calm as a cucmber (eye contact and all) when he spits his spew and no reporter will call him on his poop.

      4. I fully agree with you that Shulkin is a walking talking Colostomy Bag that leaks every time he opens his mouth. Nothing but poo all over the place every time he speaks.

      5. So, in summary, some unqualified bureaucrats are going to second-guess an organization with people much more qualified than any they employ, to see what steps they should then take?

        Why not just say they are going to delay anything until more vets are dead?

      6. 91Veteran you got it. Only he past it off to the bean counters to make the decision so he can’t get blamed. That is instead of doing his job and making the determination based on the report from the National Science Foundation.

      7. I guess if I were a vet affected by Agent Orange, I would be trying damn hard to get my hands on that report, and what they recommend.

        …and see what Shulkin eventually pulls out of his ass for recommendations.

      8. Good point 91Veteran!

        For anyone wishing to access a copy of the full report and recommendations of the National Academies of Science, Engineering and Medicine you can access the full report at:


        A summary of the report and findings are included in my next post.

      9. From 1962 to 1971, US military sprayed herbicides over Vietnam. Congress passed the Agent Orange Act of 1991 to address whether exposure to these herbicides contributed to long term health effects in Vietnam veterans. The legislation directed the Secretary of Veterans Affairs to request the IOM to perform a comprehensive evaluation of scientific and medical information regarding possible health effects of exposure to Agent Orange and other herbicides used in Vietnam or to TCDD and other chemicals in those herbicides. Veterans and Agent Orange: Update 2014 is the tenth and last congressionally mandated biennial update. The current update presents this committee’s review of peer-reviewed scientific reports relevant to this question that were published between October 1, 2012, and September 30, 2014, and its integration with the previously established evidence database.

        Based on the entire body of evidence, the committee Update 2014 changed the categories of association with exposure to the herbicides sprayed in Vietnam for three health effects. Bladder cancer and hypothyroidism were moved from “inadequate or insufficient” evidence of association up to “limited or suggestive” evidence of association, while the birth defect spina bifida in the offspring of Vietnam veterans was demoted from “limited/suggestive” down to “inadequate/insufficient.” The committee clarified that Vietnam veterans with “Parkinson-like symptoms,” but without a formal diagnosis of Parkinson disease, should be considered eligible under the presumption that Parkinson’s disease and the veterans’ service are connected. For this last volume in the Veterans and Agent Orange series of reports, the committee distilled “lessons learned” into recommendations for the continued monitoring of the health of Vietnam veterans. The committee also set up procedures that will ensure military personnel are followed from the time they are deployed in order to anticipate the possibility of increased risk of health problems that arise later in life and could be associated with the exposures experienced during their service.

  9. Off-Topic Rant: I have to ask since Veteran’s Day is almost upon us: Who The Fuck rushes to buy furniture for the plethora of “Veteran’s Day Sales”? This will be stretched for two weeks AFTER VD…much like venereal disease…it just grates my nerves the deflection used via consumerism & marketing yet meanwhile back at the VA ranch, Veterans are dying and VA keeps on lying!
    Stage Prop Rant Out!

    1. Personally, we wait for the annual going out of business or the semi-annual or quarterly going out of business sales from the furniture stores in our area. Of Course they never seem to actually go out of business and it really doesn’t seem like the prices are really marked down to a sales price.

      But notably in our area all the businesses, not just furniture stores, release their Black Friday ads right after their Veterans Day Sales.

      1. The State of Michigan closed it’s offices today on 11-10 for veterans day. I must wonder why government employees with the majority of them do not know right shoulder arms for order arms need or even qualify to take the day before “US” day off.

        By the way HAPPY “US” day all

  10. As “Shithead Shulkin” says, “After every scandal, money is thrown at [VA]!”
    Well, here’s another scandal, Shulkin! How much of the taxpayers monies are you wanting NOW? Your more than likely going to need it. To pay off the family of the veteran YOUR nurse helped MURDER!

    Here’s a question:
    During that PBS special on the VA a few nights ago. The wife seemed to remember something about how, in the early 1950’s, VA Hospitals were built next to Medical Universities. So students could “practice” on veterans!
    More specifically though,
    1. Weren’t the universities supposed to pay the VA for that privilege? Or, was it the other way around?

    2. Out of ALL the students who graduated, HOW many actually had a great “Grade”? (Say, a 3.8 to 4.0 grade level!) How many ended up working for VA?

    3. While these students are “practicing” on veterans, IS there a “licensed physician” in the operating room? When something like this occurs, shouldn’t it have been the physician to verify anything, not a nurse?

    Looks like the OIG, is still NOT letting anyone to know the full story on what’s really happening to veterans.

    1. VA Response: They will spend oodles of $$$ on printing up DNR pamphlets in Arabic and all the Hindi Dialects so the hacks will have them handy in their native hut lingo. Will spare absolutely no expense. Separate budget from the Travel Pay Fraud Warning Poster Funds.

    2. I watched that video last night. Yes it was infuriating for the first 20 minutes, but the first time McDonald was shown, my view changed quite a bit. It went downhill from there.

      After watching the whole video, if you see what several were saying, you can only conclude it is nothing more than an advertisement in favor of the VA. They mentioned a few times about how the VA started, and how about 70% of today’s doctors were trained at the VA with their association with med schools.

      They then got into how much research the VA did, how bad it would be if the VA were privatized, and how short staffed they were. All that was missing was an AFGE logo at the end.

      1. 70% were trained at the VA. Read between the lines, meaning on the job training for the losers who get employed. They can’t find any of the good ones because they simply don’t want to practice at a VA and not because of the Veterans. I’m sure there are a few exceptions, but they’re far and few between, and the good ones don’t last.

    3. Uh, that’s why we can’t get rid of the VA because where else are practicing doctors going to get human test subjects from?

      1. The perception some of you have about the medical students who do rotations at the
        VA are incorrect, at least with major university medical schools. I can’t speak to areas that don’t have access. Medical students are under close supervision by the medical school and are accountable. The best care a Vet could get would be from medical students or residents who have already graduating and spending another 3 to 5. years specializing in a particular area. These are the cream of the crop. How many would get jobs at a VA? Personally, I never knew of one over a 9 year period when my husband spent 4 years in med school, another year as a chief resident, 3 years specializing in Interna medicine, and another 3 years subspecializing. in pulmonary medicine. They are certainly not “practicing ” on patients under VA doctors. Unfortunately, the VA medical care is laughed at and not even considered! In that report which included University of Michigan being somehow connected, that sounds like name dropping, to counter the truth. Look up the credentials needed to get in that med school. This is the top of the top. I would doubt ANY Graduate from University of Michigan Medic School would seek employment at the VA. Sad but true. So who gets employed? Not the cream of the crop, someone who can get away with a whole lot, or maybe the most minimal credentials. I personally know one very credentialed, excellent Dr. my son had. I know what I’m talking about since I am from a medical family. My father, father-in-law, husband. I know the differences in admission requirements of schools which give a good idea how smart someone is. So pray you get the residents and Docs. affiliated with the major University Medical. Schools when you need that surgery! When my son was returned from Germany after surgery, he had a pulmonary embolism, then needed more surgery, then more surgery for another problem. Did he go to th VA? Absolutely not! Family paid out of pocket! But how many Vets could do that! This substandard care for our Vets has to stop. I am ashamed of these health “professionals”, and embarrassed to have these losers give a bad name to those of us in that field!

      2. Laura, my first experience with a med school student at a VA was in Houston in the mid 1990s. I was in the VA hospital there for tests, which was a joke in itself.

        I don’t recall what specialty he was training in, it may have been neurology. The appointment consisted of him coming to my room at about 9pm, standing in the door and asking me questions for about 5 minutes.

        He had nobody with him, and I never saw him again, but his 5 minutes in my door counted as being seen in that clinic.

    4. Elf, a nurse should absolutely know that immediately, the status of a DNR! These are nurses that just don’t care or just dumb. That’s one of the first things tat a qualified nurse would look for when reviewing the chart to provide the essential care for any patients assigned to his/her care. Absolutely appalling! I hope that nurse was canned and his license removed. That would happen in the private sector. No excuses!

      1. Laura,
        Yes, a qualified nurse would/should have known that about a patient. This one screwed up!
        As far as the nurse being fired in the private sector. That’s more or less a given. On the other hand, we’re talking about the VA healthcare here.
        What will more than likely happen is, the nurse will be transferred to another VHA somewhere else!
        That’s the “modus operandi” of the VA! We’ve seen it occur many times in the past!

  11. 1) The Do Not Resuscitate info was indecipherable due to English not native language of engorged purple team member…or…
    2) …a clear example of antagonistic and adversarial behavior by indifferent assholes?
    3) All of the Above?

      1. Namnibor,

        Speaking about the VA Whack-A-Mole Transfer Game. Remember Ben’s article from Nov. 1st. About the Two Memphis VA Leaders being fired For ‘Failure To Lead And Act’

        One of the Malpractice Cases that occurred that led to their firing was for A veteran who wound up having his leg amputated at a VA hospital after a previous procedure left plastic tubing in his artery.

        A diabetic veteran wound up with 10 inches of plastic tubing embedded in an artery in his leg after VA doctors apparently failed to remove the protective cover from a catheter before inserting it. Surgeons found the tubing more than three weeks later when they amputated the leg, according to the article.

        Just so happens this patient that died at Ann Arbor VAMC was having the same surgery and was also diabetic.

        Makes a person think that maybe this death may have something to do with a failed surgery possibly by the same doctor in the Whack-A-Mole Transfer game.

        The nurse just did everything he could to cover up the doctors mistake.

  12. I had a experience at the VA where I had sinus surgery but I live alone and on a C-PAP machine so the Doc said I had to spend the night there because I needed to be monitored, the next day on my ride home I thought about the procedure and said WTF they never put a monitor on me. Nobody reads anything at the VA…….Asheville NC VA where the vet’s walk around with frowns on their faces and the STAPH never looks at you…..No wonder they have to push the old saying of good southern Hospitality…
    And the only reason I live here is I can get away from EVERYBODY……And here is a simple way to see if the VA is any good just take a walk around and look at the cars vets are driving if they are all old..That means the claims are denied…..RUN…LOL

  13. …let me summarize…

    In a statement today regarding the untimely death of a veteran who sought out surgery at a VA medical facility to save his own life, the VA has concluded that the qualified and vetted VA nurse present on the surgical team had not been properly informed that the veteran intended to live through the procedure so took no action to save his life when that jiggly thing in his chest stopped wiggling.

    Meanwhile, Sec. Shulkin contends that VA is sometimes adversarial with veterans in their affairs…

    1. Also stands to reason that if a Veteran has a will to live, do not rely on the will of VA hacks to honor, let alone understand what a living will or will to live even means, let along basic human/medical ethics.

  14. Ahhhh, the algorithms of ACLS. The ICUs in the VA are exactly what they are. I SEE YOU ARE DYING. The fake OIG and Secretary’s Office are actually ICU units as well. See no evil, hear no evil. “The more reason to close them bitches down” ( country accent)
    Sounds like something either to do with the recovery protocol as well. They do not have the best anesthiologist in these hell holes.
    Usually you will have a rapid response team, 6 to 8 people, with 33 staff in the way being lookey Lous.
    Fake Healthcare tgat will never compare to DOD medicine.
    Oh yeah, Fuck you VA!

  15. Here we go again. Hmm. Can’t stop thinking for some reason or another;

    “The Better the Evidence, the Sweeter the Deal. Something’s Got to Give?”

    There has to be a way to make the VA compliant. I don’t know what it is, and I may never come across, or discover something that helps to solve an issue. But, I’m responsible for the protection of my wife, and my not all the way trained service dog (thank you for interfering VA).

    The VA has my marching orders, and it’s not into playing their game, their way. After time, Veterans become very seasoned about the workings inside the VA. – – – Nutter.

  16. 11/08/2017

    Dear Benjamin Krause,

    This is sad, very sad for the Veterans Family, and for those who are trying to correct the VA System as a whole; my condolences to the family.

    The failures and the “honest mistakes” can only last so long.

    Signed up today for the Senate Seat, thought you might want to know.


    Don Karg

  17. The VA almost killed me a least 6x. This story made me remember this. I was very sick and stayed in bed 2-3 days, when couldn’t swallow anything including saliva built up inside my mouth I finally went in. Checked in the ER, just waiting. People that came after me were getting treatment, was left out in the waiting area almost 7 hours complaining telling the nurse it was an emergency. Well I guess the idiot nurse felt nothing was really wrong with me and without even checking a single thing, she just left me out there. So finally I go up yelling at with all nice words and a new nurse came on and promised she’d go back and see what was going on. Within 15 minutes I was in the ER, sat on a bed answering stupid questions. The doctor on the other side of the room seen me spitting into a cup and came right over. He asked why was spitting in cup and asked how long was I out there, 7 hours. Next thing I know was like TV all the nurses got me in room, hooked up the monitor and put IV in. Seem had an infection on my tonsils, forget what called? Put high dose of antibiotics and shit for pain. Once stabilized got a CT Scan. My throat closed up almost completely, another 15-20 minutes I would not been able to breath and died. Because a piece of garbage nurse decided I needed nothing. I had to be watched for next 6 hours while they pumped meds in to get infection under control. Procedure next day and 3 days in hospital. If that dirtbag would have had someone look, probably not a big thing, doctor said he’d get a piece of her ass. If stayed without complaining in corner, been dead. Because just one of many people who should not work there with union the first thing out of her big mouth. People always want to know why so angry with the VA, should write a book. I never had hate in me before the VA, now I tell them their garbage and should go elsewhere. Just like the stupid bitch that can’t read that kept telling people not to treat him. A waste of human flesh and my luck will run into so she can kill me too. They can’t figure out why i hat the VA

  18. Also from the full report:

    “This event was particularly disturbing as about a year prior to this event, system leaders identified a vulnerability in the process of confirming resuscitation status, especially during situations when a patient’s medical status was deteriorating. Although system managers assessed the concern, they failed to identify a solution due to difficulties in balancing patient safety and privacy concerns and took no actions to decrease this risk.”

    1. More about the VAMC or school practice grounds complete with Veterans for practice dummies.

      The system is a 149-bed (109 acute and 40 Community Living Center) tertiary care facility that offers a variety of primary and secondary levels of inpatient and surgical services. The system also provides outpatient and consultative care in medicine, surgery, and mental health (MH), and oversees outpatient clinics in Flint and Jackson, MI, as well as Toledo, OH.

      The system has active medical school affiliations with the University of Michigan Medical School and the University of Toledo College of Medicine. More than 1400 people receive training at the system every year in multiple areas, including dentistry, dental hygiene, pharmacy, social work, psychology, and physical therapy. Overall, the system has 112 affiliations with colleges and universities.

    2. Also from the full report they felt the need for the following regarding this nurse.

      “Prior to this event, system managers had taken administrative actions against the registered nurse (RN) involved in this incident in regards to his involvement in clinical events that occurred in 2012 and 2015. Therefore, we reviewed the care provided to patients involved in these two events. We also reviewed all 115 patient deaths at the system from December 27, 2015 to December 27, 2016. In addition, we reviewed the VA and Department of Defense personnel records of the RN involved in this incident.”

      1. Any indication in the reports why they would dig into this nurse so much? Yes, the vet died, but it seems unusual the IG would look into his background this thoroughly.

      2. 91Veteran,

        While there is no indication of why the investigation of the Nurse has been so intense and why investigators have not completed their investigation into the Nurse responsible. Noting that the investigation into the Nurse is still ongoing.

      3. 91Veteran,

        It is worth noting some of the Ann Arbor VAMC’s rich history of Veterans being murdered at the Facility. Also, the failure to prosecute medical staff involved in murdering Veterans at that VAMC. In one case, between July and August of 1975 more than 50 Veterans were murdered at the hospital by two Nurses that were there training and part of an educational program for foreign students.

        Source: Cox, K. (1984, Jul 14). U.S. case mirrors metro police probe of hospital deaths. The Globe and Mail Retrieved from “”

      4. From the article:

        “The similarities with the Michigan case, where more than 50 patients at a veteran’s hospital were believed to have been poisoned with the muscle relaxant pancuronium bromide, in July and August of 1975”

        “In the Ann Arbor case, two nurses from the Philippines, Pia Narciso and Leonora Perez, were charged with five counts of murder and 10 of poisoning patients.

        All the deaths at the Michigan hospital occurred on the intensive care unit when the nursing team on which the two women worked was on duty – between 3 p.m. and 11 p.m. The patients apparently suffocated after being given overdoses of the muscle relaxant through their intravenous lines.”

      5. “Also from the article:
        “The Michigan murder charges were thrown out by the trial judge because all the evidence was circumstantial. The nurses were ultimately convicted of three charges each of poisoning and one count each of conspiracy.

        They were, however, never jailed because of a “free the nurses” campaign, that even included one of the jurors who had convicted them. The charges were dropped before an appeal could be heard.”

      6. “In a report submitted to then Metro police chief Jack Ackroyd in February, 1983, homicide officers Jack Press and Anthony Warr said the U.S. investigators probed the Ann Arbor hospital deaths for nearly a year before charging the two nurses.”

        “In the Ann Arbor case, the report said, the co-workers of the accused women “all loved these two women and, as a result, they were hostile to police. Their basic attitude at the outset was that they really couldn’t believe it was a nurse. The stance they took was, ‘You may be right, but we won’t help you.’ ” The problems with what police perceived as a lack of co-operation from the medical staff and the refusal of nurses to testify against Miss Nelles or anyone else are expected to be major issues before the royal commission now probing the police investigation and the prosecution of the nurse.

        The report says of the Ann Arbor case that “apparently the two accused seduced everyone with their charm and it is obvious nurse number one (who was present for all the sudden seizures of patients) had a very strong effect on the investigation.” In the Ann Arbor case, the report said, there was a nurse other than the two who were charged that everyone wanted to blame for the deaths.

        Tragically that nurse, who had cancer and suffered a nervous break- down, committed suicide, leaving a note saying, “I can’t believe the two nurses did it; I’m taking my own life.” The FBI had a long list of suspects, which included a male nurse at the hospital who had undergone a sex change, and then the hospital refused him permission to revert back to his original sex.

        The police report says the U.S. investigators had one major advantage over their Canadian counterparts, because the Michigan victims were between the ages of 26 and 87 and several lived to testify against the two nurses.

        One of the patients underwent hypnosis and, while in a trance, he identified the second nurse as giving him the drug.”

    3. Also from the Full report the patient’s surgery was on his leg to bypass a blocked artery. a relatively simple procedure none life threating.

      “At the time of the event at issue, the patient initially sought treatment at a non-VA medical facility for new onset right leg numbness and right leg pain with walking. Providers determined that the patient had a blocked artery that was likely the cause of the right leg pain. Surgery to bypass the blockage was recommended. The patient requested transfer and was admitted to the system in late 2016, where he underwent a surgical bypass of the blockage in his artery. His post-operative course was notable for challenges maintaining adequate anticoagulation and, several hours before his death, an episode of chest pain that lasted about 15 minutes. Documentation indicates that the patient’s resuscitation status was full-code.”

      Talk about learning a lesson the hard way. Transferring your care to a VA Health Care Facility is truly suicidal.

      1. What does his status being “full code” mean?

        One would think any competent facility providing medical care would have strapped on a monitor after chest pain regardless of a DNR order.

        It reminds me of the signs that used to be posted in various VA clinics about reporting chest pains. I haven’t seen them for some time, but aftet reporting chest pains once and how I was treated, I would rather die on the sidewalk.

      2. VA has repurposed “Code” to be several shades of Deprived Oxygen-Deprived Blue in a rating system corresponding with buzzers in the new VA command center.

      3. 91Veteran,

        From the IG’s full report it defines Full Code as follows:

        “A patient is considered “full-code” if he/she has not designated a DNAR preference. For “full-code” patients, clinicians provide emergency measures such as CPR, defibrillation, and medications in an attempt to resuscitate the patient.”

      4. So if the documentation indicated full code, how is it any medical provider in contact with him could not determine that? I guess we now know why the IG looked into his past, but still, why do that if they were not going to refer him for prosecution?

        It should really give vets a warm fuzzy about how competent the VA is. At any level.

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