Jeff Sweeney and Galen Warman were not surprised by the findings. Any of them.
Not by the first report issued by the Office of the Medical Inspector, or the second, or the third, released last week in an investigation into the Manchester VA Medical Center’s competency and procedures.
“They’re notorious for covering things up,” said Sweeney, 40. “I am fed up for having to fight for everything and I’m fed up being in pain all the time, but I’m not surprised.”
Their skepticism is easy to understand, since the Office of the Medical Inspector is the VA’s own investigative arm. That’s why they think the OMI essentially shouted, “Nothing to see here,” in its recent findings, when it ruled on a variety of issues, including suspected mistreatment, misdiagnosis and slow response times connected to Myelopathy, a compression of the spinal cord.
Sweeney and Warman both live in Concord, were both injured while serving their country and both sought medical help for their severe back and neck pain. They’ve moved on, started new lives, learned to live with their pain, and the ongoing process of an organization investigating itself has dulled their senses.
“It falls in line with what they’ve been trying to do,” Warman told me. “I expected this all along, so no one is plowing new ground.”
Indeed, this is old ground. Warman suffered back and neck injuries in a construction accident 30 years ago and a car wreck in 2007. Sweeney’s truck was hit by an improvised explosive device in Iraq in 2011.
They both have since gotten some relief through surgery, but years had passed before they received the proper care, and they still have plenty of aches and pains.
That’s why the whistleblowers we’ve been hearing about since the summer of 2017, the ones with those medical and nursing degrees – the ones who documented incompetency and delays in treatment and immoral record keeping and a poor monitoring system on degenerative spinal conditions – won’t let this go.
In fact, they remain fighting mad, complaining about the conflict of interest they’ve seen as part of the VA’s investigation and the lack of accountability since the story exploded in the Boston Globe.
“It’s what they do, like a damage control system,” said whistleblower Dr. Ed Kois, head of the spinal cord clinic at the Manchester VA. “They say they’re going to investigate, bring in the OMI knowing they’ll do a lengthy investigation and then wash their hands.”
The Office of Special Counsel, an independent entity that oversees the OMI, isn’t buying it. In a prepared statement emailed to me, the OSC’s special counsel, Henry Kerner, wrote that “clear discrepancies undermine the assertion that VA leadership was open to concerns and worked to ensure Veterans receive timely care.”
Those words were golden to Kois and Stewart Levenson, the Manchester VA’s former Medicine Department chairman, who were the loudest whistleblowers among the 12 staff members who came forward.
They want you to know they are not doctors with axes to grind, nor are they trying to further their careers, working as self-promoters, promised by an outside government entity to expose trouble at the VA.
Kois says he hasn’t been promised a better parking spot, and Levenson insists he did not come aboard to boost his chances of winning a seat in the U.S. House of Representatives.
Kois’s parking spot remains unchanged, and he’s still courting the press, trying to make as much noise as possible. And Levenson did not win in the primary election, yet he’s writing op-eds and calling columnists back so these problems don’t fade from view.
“All these investigative bodies descended on Manchester and you would think more would have been done,” Levenson said by phone. “But how can you investigate yourself? It was garbage. You can’t explain it away.”
Added Dr. Ted Daly, another reputable whistleblower: “I’m flabbergasted by their conclusions.”
Levenson, Kois and the others cited dirty surgical instruments, flies in the operating room and mismanagement up top, but it was the mistakes made on patients with compressed spinal cord problems that were the most alarming and damaging.
Kois called it a “perfect storm” of factors. The Manchester VA had no neurosurgeons, forcing patients to the Boston VA in West Roxbury, which was overworked and not able to give the proper care.
Record keeping between Boston and Manchester failed to clearly show who needed surgery, and a doctor named Muhammad Huq, the former head of the spinal cord clinic at the Manchester VA, was found to be cutting and pasting notes in medical charts, meaning information remained unchanged for years.
Some whistleblowers and staff felt that upper management was more concerned with ratings and budgets than actual care, which led to the ouster of top officials once the story broke.
Caught in this perfect storm were nearly 100 patients with spinal cord problems, many of whom were never properly treated. Some ended up in wheelchairs, others were forced to use canes, and still others simply had to endure pain needlessly for years, for a condition that one doctor said often goes untreated in third-world countries like Nigeria.
But certainly not here in the U.S.
Try telling that to Warman, 67, an Army Veteran who later served in the Air National Guard. His back pain went undiagnosed for years at the Manchester VA, leading to an endless supply of painkillers and a drastic change in lifestyle.
“They were not forthcoming on how to treat it,” Warman told me. “It was like, ‘Take two of these in the morning and have a nice day.’ I was addicted to painkillers.
“I tried to have some kind of life and I kept asking for help and getting none,” Warman continued. “They said they were not responsible.”
Kois, new to the facility, first examined Warman in 2015. His response after viewing an MRI was “Holy s---.”
“It showed he had severe narrowing of the spinal canal,” Kois said. “I sent him for further evaluation and he had surgery and I saw him again and he was doing great.”
Pain remains, but Warman is strong enough to work at Cumberland Farms and deliver newspapers.
And then there’s Sweeney. After midnight, riding in the lead truck in a convoy of at least 30 vehicles, he heard a bang, saw a flash and, after running for cover and the adrenaline rush had worn off, awoke with his back “killing me.”
The Manchester VA sent him for physical therapy, which did nothing. Neither did steroids. Surgery was performed in Boston, but Sweeney awoke in even more pain.
He was told during subsequent checkups that the pain was a normal part of the recovery process, but the pain grew worse and he later was let go from his job with the Department of Transportation for missing eight months.
Sweeney said the VA eventually stopped taking his calls. He contemplated suicide. He drank a lot of beer. Then he went to see Kois, who took a CAT scan and told Sweeney, “I want you in my office, now.”
Sweeney pulled out his phone and showed me what Kois had shown him: a picture of his spine, with a screw inserted into bone, which was fine, and another screw penetrating a nerve, which was not.
“Permanent nerve damage caused by the VA,” Sweeney said. “I didn’t put that screw in there myself.”
But following 14-hour surgery to remove the misplaced screw at New England Baptist Hospital, Sweeney’s life changed.
“I was shocked that I was walking,” Sweeney said. “I went for a walk with the nurse and I felt good walking around. I’ll have contact with Dr. Kois for the rest of my life, if I can. Dr. Kois saved my life.”
There’s still pain, though. Sweeney has been taking steroid injections since January. He installs natural gas lines and hopes surgery in the future will return him to some sense of normalcy.
And, soon, his story and that of five others from across the country will be told in a documentary called, The Care They’ve Earned, an unflinching look at flaws and holes in the VA system.
Advanced screenings have been shown in selective theaters this summer. Sweeney didn’t know the film’s release date around here, and its producer, Justin Springer, was unavailable for comment.
Sweeney showed me a trailer on his phone, which included that CAT scan, the one that clearly showed those two screws in his back.
“I hope people see it,” Sweeney told me. “I lived it and it was still an eye-opener for me.”