What do you think - is VA hospital at fault in Marine veteran's death?

2015-09-19T12:25:42-04:00

What do you think - is VA hospital at fault in Marine veteran's death?

RP Community we have lost another Brother!

http://www.usatoday.com/story/news/politics/2015/08/20/wisconsin-va-hospital-death/32062485/

An investigation into the death of a former Marine at a Tomah, Wis., VA Medical Center found that staff improperly prescribed medications and blundered its response when the veteran was found unresponsive in his bed.

Jason Simcakoski, 35, of Stevens Point, Wis., died Aug. 30 in the hospital’s short-stay mental-health unit from “mixed drug toxicity.”

He took 13 prescribed medicines, including several that cause respiratory depression, in a 24-hour period. Staff psychiatrists had added new medications to Simcakoski's lengthy list of prescriptions in the days preceding his death, according to a Veterans Affairs Department Inspector General report released Aug. 6.

Response by LTC Stephen F. made Sep 19 at 2015 12:27 PM

2015-09-19T12:27:14-04:00

I don't think so COL Mikel J. Burroughs. Perhaps the treatment Jason Simcakoski received or didn't is the fault of part of the team that was responsible for treating him.
In any event it is sad that Jason Simcakoski died while under VA treatment.
Each human being is unique. While most of us benefit or respond similarly to the same medicine there are group that don't. I have learned that some medicines make me psychotic, one mimicked the symptoms of a heart attack, and other medicines I must take in multiples of the doses that the general populations requires to be effective.

Response by SGT Scott Bell made Sep 19 at 2015 12:32 PM

2015-09-19T12:32:40-04:00

Yesi do

Response by Sgt Kelli Mays made Sep 19 at 2015 12:34 PM

2015-09-19T12:34:33-04:00

First of all with all of those other medication in his system and lord knows how long he'd been self mediating, we don't know how much damage was already done to his system/organs.....however, this being said....It seems like the staff there is not well trained and I certainly wouldn't want them working on me or anyone I know.

Sounds like this VA or at least it's Psychiatric facility needs a huge over all, training and protocols updated.

Response by CPT Private RallyPoint Member made Sep 19 at 2015 12:38 PM

2015-09-19T12:38:02-04:00

COL Mikel J. Burroughs It sounds like they have poor patient management. Different doctors prescribing meds. It happens sometimes that one doctor is unaware of what another doctor is prescribing. The doctors took the stance of blaming the patient for his own death which bothers me because it appears they did so without having any facts or evidence to support their claim. Everyone who touched this patient seems to have failed him. The description says they stopped giving CPR because firefighters arrived and they thought they would take over but investigators stated "However, firefighters at the facility are not designated as first-line staff to provide hands on emergency care."
I'm confused, on that one. I can't believe staff would stand around not taking care of a dying patient. It is the RESPONSIBILITY of hospital staff and rescue personnel to attempt to save lives not to be complacent about it while they die.

Response by MSG Brad Sand made Sep 19 at 2015 12:49 PM

2015-09-19T12:49:52-04:00

This is a tragic story and I think it is too early to place all the fault on the VA Medical Center...while there appears to be a LOT of smoke, I think they need to prove there is actual fire. IF Jason is buying additional medications, on top of all he is already taking, makes me wonder if there is an even more tragic element to this story.
When something is broke, everything else that breaks around it is going to refocus attention on them. No matter who is fully at fault, this Medical Center needs a couple of people slapped or throat punched...someone on this many meds is allowed to leave for a 'few hours'?

Response by SPC Margaret Higgins made Sep 19 at 2015 12:53 PM

2015-09-19T12:53:21-04:00

I believe that Absolutely the VA Hospital was at fault; and responsible, for Marine Jason Simcakoski's tragic, tragic death.
The way that the VA Hospital handled this case was deplorable.
And COL Mikel J. Burroughs, I was very much pro the VA Hospitals in our country; until now.

Response by LTC Christopher Sands made Sep 19 at 2015 8:59 PM

2015-09-19T20:59:48-04:00

Very sad. RIP.

Response by PO3 Miguel Mojado made Sep 19 at 2015 11:38 PM

2015-09-19T23:38:38-04:00

Yes, this is not a unique situation. Many physicians tend to prescribed medications based on their specialties. Often times, they would fail to review the patient's current medication regimen and would add on to the list of their medications. How many times have I notified physicians about probably drug interactions due to polypharmacy. As a nurse, I've called out to doctors some adverse reactions from multiple drugs due to their synergistic effects which could have been fatal to the patients. In the hospitals and nursing homes, the nurse and the pharmacist are your best friends. Drugs can kill if not used appropriately.

Response by CPT Private RallyPoint Member made Sep 20 at 2015 12:30 AM

2015-09-20T00:30:42-04:00

This was a failure on so many levels. I can't say for certain without looking at the medication list that there was necessarily any drug-drug interaction. Some medications on their own will cause respiratory depression/failure at certain doses. If there was a synergistic issue with multiple medications, then the MDs and pharmacists should have deconflicted this prior to administration. As nurses, we are the next line of defense against these errors. We should know what any medication we are administering is for and at least know the potentially dangerous, most common side effects. There have been several occasions where I have given a medication in the emergency department and a patient experienced respiratory depression. No big deal. Know why? Because I had them on a simple oxygen saturation monitor and noticed it dropping before it became an issue. At this point, all I had to do is either wake them up and have them take some deep breaths, or bag them for a few minutes until they came around. Had things progressed to the point they did in the above story, I would have known how to handle it because I know how to administer counteracting agents such as Narcan, and I have been trained in ACLS protocols. This story was just a big, sad confluence of mistakes that could have been avoided at any level. The VA needs to provide more education to staff and have the medications/equipment available to treat for issues such as these so that something like this never happens in the future.

Response by LCDR Rabbah Rona Matlow made Sep 20 at 2015 10:33 AM

2015-09-20T10:33:02-04:00

Suboxone is used to treat narcotic addictions. This marine must have been using narcotics in an unsanctioned way. He was also given Tramadol. Both of these are narcotic and shouldn't be used together.

It seems that the hospital people really screwed up on managing his medicines, and didn't monitor him properly.

I hope that the family is able to sue the VA for this, and that the providers who contributed are at least sanctioned, if not prosecuted.

It will take an autopsy to know whether he took unapproved meds on his own during this fiasco, or whether all the meds were provided by the hospital. If it turns out that all the meds were administered by the hospital, then it's clear that there is malfeasance and malpractice...