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#VAFail: Veteran’s arm has to be amputated after receiving poor care at Baltimore VA

Empty Hospital Hall with VA Fail Text

By Concerned Veterans for America

When veterans visit a Veterans Affairs emergency room, they expect to be treated with the care and attention they deserve. But for a Baltimore-area veteran, that wasn’t the case. 

A recent VA Office of Inspector General report details the tragic story. 

The veteran went to the Baltimore VA emergency room with pain in his hand and a ring stuck around his finger after a fall, among other issues. The VA cut the ring off the veteran’s finger, diagnosed him with a sprained hand, and sent him home. 

The next day, the veteran returned to the VA because his hand was still in pain, and he had an open wound on his finger. A physician assistant examined him, prescribed medication for possible cellulitis (a skin infection) or gout and told him to come back if he continued to have issues. 

While this may all sound routine so far, the report details some crucial mistakes the physician assistant made that led the story down a terrible road. 

Poor care for veteran at VA led to disaster

When the veteran went to the VA the second time, the physician assistant neglected to order blood work and didn’t consider the patient’s diabetes in making his diagnosis and treatment plan. Without lab work, the physician assistant couldn’t make a complete diagnosis or see all the full evidence of an infection. He told the OIG investigators that lab studies “probably should have been done” but the wound “didn’t look that bad”. 

The veteran’s electronic records were also not up to date, and his diabetes did not appear on his list of problematic medical conditions.  

Two days after what the Baltimore VA Chief of Staff later deemed “substandard care”, the veteran went to a non-VA emergency room for his worsening condition. He was admitted for cellulitis, suspected sepsis, and loss of consciousness. That ER did do blood work and found evidence of infection along with poorly controlled diabetes. 

The veteran was transferred to another non-VA hospital where he went into septic shock and had to have his left forearm amputated. 

The OIG stated the failures on the VA’s part may have contributed to the veteran’s amputation. While we can’t know with certainty, we do know that the OIG found the veteran received poor care and is now adjusting to life without a left forearm.  

Veterans need choice over medical care

While this veteran was able to visit a non-VA emergency room and get the treatment he needed, it was too late to save his arm. And now many Baltimore-area veterans are probably wondering if they would get the same poor treatment from their local VA in a potentially life-threatening situation. 

Stories such as this one are exactly why choice for veterans in their medical care is so important. 

Veterans should not be relegated to substandard care at the VA. They should have the option to get care wherever they choose is best for them while using their VA health benefits to receive that care. 

Read more #VAFails and learn about our ideas for reform.