March 4th, 1998.
A WWII Veteran and his wife of nearly 50 years wait at the Veterans Hospital in Salem, Virginia for an appointment to see his cancer specialist. As it would turn out they would be there all day going back and forth between labs, waiting to see doctors, and then waiting for more prescriptions, all necessary before beginning a new treatment the following day.
Little did anyone know that in less than 24 hours this “solider” would rapidly progress from someone optimistic about his future, and looking forward to the birth of his first great-grandchild in a few weeks, to descending a flight of stairs carrying his shotgun with the intent of ending his life. His wife and daughter would witness the immediate aftermath of the horrific scene that followed. A vision and memory that neither can, nor will, ever be able to erase.
I often think about his last day, that day at the VA Hospital. How he must have felt at learning his life, as he knew it, was coming to a conclusion. After many months of investigation I am overwhelmed with the knowledge of how these prescribed drugs had affected his mind during that time. The absolute living hell he was going through. He may have felt he was doing the only right thing, the last unselfish act on his part in trying to protect and save his family, and himself, from the emotional and physical hardships associated with such a crippling disease as that of Alzheimer’s, a disease the doctor said he now had. The medical experts say the side effects of the numerous and specific drugs he was taking was the deciding factor. He was simply unable to control the impulses that compelled him to take the course he did.
I ask myself everyday, how do you load a gun knowing that in a few minutes you’re going to place that gun to your temple and pull the trigger? What does it take to pull the trigger ? Please take a few moments and think about that. This man was an expert hunter and served during WWII. He was a marksman. He had many disturbing memories of war, and he knew what the realities of such an act would be.
I believe, and I believe the evidence brought out in court proved beyond any reasonable doubt that the incompetent, reckless, inhumane medical directives, information, and complete negligence he had received hours earlier, in addition to the numerous and unnecessary mind-altering medications he had been given, compelled him to pull that trigger. The crippling disease he thought he had, in reality he did not. I do not believe that today anymore than I believed it when I first heard it. For a moment put yourself in his shoes. Can you imagine going through what he did those last few hours, and in the same millisecond it took to pull that trigger finding out the truth? How devastating for his family!
I know there are many capable and brilliant medical doctors and other healthcare providers, as well as institutions in this country that have standards of quality in place to deliver the very best medical care imaginable. Some within the VA system. They are also sensitive to the emotional as well as physical needs of their patients and family members, and excel in all areas of healthcare. I personally know many such professionals. This is not intended, nor should be construed, as a witch-hunt on my part.
However, having said that I believe as a society it appears what happened to this family, this solider, is viewed by our country as an ”acceptable loss,” just another “statistic.” You read the reports from the various committees, you see the numbers—-maybe, and it’s just that. It’s a piece of paper, it has no face, no feelings, and no meaning—until it happens to you. Until perhaps you’re the one left to wipe away brain tissue from the walls before chancing your mother would see it, as his daughter did that night.
I am not sharing this information for the purpose of gaining sympathy or condolences for the family. No one can take that day back, give his daughter the opportunity to intervene in the events and change the outcome. All the lawsuits filed, won or lost, sympathy expressed, or condolences given could eliminate the pain, the tears, or the pictures she has of her father lying on the floor in a pool of blood. Nor can it erase the heartbreak she feels of sitting with him for three days and telling him everything would be OK, and then when it was apparent it would not, letting him know it was OK to let go. She assured him she would watch after her mother and take care of things. She held his hand, told him she loved him, and then watched in silence as he took his last breath at 4:37 p.m., March 8, 1998.
On the evening of March 4, 1998 when her mother told her what the VA doctors had said to them that day, she told her not to worry. “I will take care of it first thing tomorrow morning,” she said. Her daddy didn’t have Alzheimer’s and it was clear there had been an error. He was overmedicated and his symptoms were directly related to that, nothing more. Obviously, she never had the opportunity to make that call. However, as her father lay dying of a self-inflicted gunshot wound to his head she again promised she would take care of things, only this time she would do better.
You can help her keep that promise in several ways. One, by reevaluating your own perceptions as it relates to quality of healthcare in this country, most especially the plight of our Veterans. Carefully consider the “losses” and “statistics” as you read them next time and in a positive and proactive way proceed in such a manner as to move these systems, operating in such a reckless fashion, to change.
How often have we heard since September 11th “America is at War against Terrorism” ? How often have we heard of our military being called upon to make the ultimate sacrifice. Today we have many more just like this Veteran that lay their lives on the line for the sake of others. Those fortunate enough to actually return home, our Veterans of tomorrow, are your sons and daughters, your brothers and sisters, your husbands and wives. Many have, and many will, continue to return with both physical and emotional illnesses. These are the very ones you are reading about each day in your local newspapers. Is the best we have to offer for their sacrifice the current standard of care at VA Medical Centers ? How tragic for this country ! How tragic for these Veterans !
I have seen no accountability for the sub-standard of care Veterans receive at some of these hospitals. It is appalling ! We should not allow ourselves to sit on the sidelines of this issue one-minute longer while thousands are suffering and dying needlessly every year, caught up in bureaucratic red tape designed specifically to encourage, no—worse yet, to hide this beast called VA Medical Center. Don’t take my word, don’t take the word of those Veterans fortunate enough to select healthcare outside of the Veterans Administration. Go instead and talk to the Veterans “in these hospitals,” the ones that have to go there day after day.
A positive change will only be realized once we, individually as well as collectively, take an active part and insist on nothing less than excellence from these providers. We should not only expect but also demand an accounting from those in charge of organizing and overseeing the necessary changes in the government’s healthcare systems. We should not expect anything less than qualitative, measurable results! Is the health, and in many instances lives, of ones you love worth any less?
How can anyone possibly ask another to lay their life down, risk their children growing up without a mother or father, or put themselves in a position to be exposed to harmful environmental elements and then turn their backs on this issue?
It appears more and more we have gone so far from the “human” factor in our daily lives that we have become desensitized to and have actually accepted the fact we must tolerate these losses and statistics because that’s just the way things are, it’s the government—–shame on us all!
A few years ago I spoke to a Senator in Washington about what happened. He told me he had already heard the story from other Senators and his next comment to me was that the Salem VA had simply “screwed up.” Those were his exact words to me—-they had “screwed up.” I was devastated. Yes, I know all to well they “screwed up,” now what? What is being done about it? What is being done to prevent this from happening to others? This is not how things could or should be. A thousand superior healthcare facilities, with outstanding programs and providers will never excuse one found to be equally inferior, especially one designed to provide care to Veterans.
The Honorable Lawrence M. Baskir, Chief Judge said:
“The United States Court of Federal Claims has endeavored to serve our Nation and to embody the spirit of Abraham Lincoln’s message to the Congress in 1861: It is as much the duty of government to render prompt justice against itself, in favor of citizens, as it is to administer the same between private individuals.”
That did not happen in this case, and there are hundreds just like it. The government denies private citizens the very rights and privileges that our American soldiers are this very day fighting and dying for, and we allow it to continue. How sad.
It’s pretty staggering if you will give it a few minutes thought, and you really should. What happened to this solider can happen to you or someone you love at any time. Don’t think for a moment it can’t.
On March 5th, 1998 at approximately 7 a.m. when many of you were just starting your day my father was making his way quietly downstairs carrying his shotgun, still in its case. He walked over to my bed and took the gun out of its case. He most likely loaded it there and proceeded to a little entrance area at the back door approximately 10 ft. away. Police investigators determined that he lowered himself to his knees and braced the gun against the door jam, placing the barrel to his left temple. He then pulled the trigger, all approximately 13 hours after leaving the VA Medical Center. A 100% completely avoidable and tragic end to a life that had many more years left to enjoy.
I encourage you to remember my father the next time you have the opportunity to make a difference and don’t. Remember him the next time you sit silently and observe injustices and deficiencies in medical care occur, whether you are directly affected or not, and fail to act. And remember, next time a medical “screw up” takes place it definitely won’t affect my father, but it very well could yours.
I urge you to pass this information along to others. One voice, my voice, heard alone will never make a difference. United however, we may be able to save other families, other Veteran’s, from experiencing the horrors of medical malpractice at VA Medical Centers.
For the sake of those fighting, and dying, on the soil of foreign countries for freedom from terrorism, for our freedom, I really hope we can. You should too.