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Wisconsin VA Dentist May Have Infected Veterans With HIV, Hepatitis

Wisconsin VA Dentist May Have Infected Veterans With HIV, Hepatitis

Almost 600 veterans are at risk.

The VA in Tomah, Wisconsin, has become entangled in a scandal after a dentist may have infected veterans with hepatitis or HIV:

Nearly 600 veterans who received care at the Tomah VA may have been infected with several types of disease due to violations in infection control procedures.

VA administrators made the announcement Tuesday afternoon at a press conference.

The Tomah VA says it’s in the process of notifying 592 veterans that they may be infected with Hepatitis B, Hepatitis C, or HIV after they received care from one particular dental provider.

Acting Medical Center Director Victoria Brahm said the dentist was using his own equipment, then cleaning it and reusing it, which violates the VA’s regulations.

The dentist’s new assistant noticed the dentist cleaning and reusing his equipment and reported the violation. The VA has said it only “uses sterile and disposable equipment.” From News 8000:

Brahm said the dentist had one assistant for most of the time, but it was a different assistant who reported the issue.

“He had a replacement dental assistant, and she noted this particular piece of instrument being used,” Brahm said. “She reported it the next day, Oct. 20, to the dental chief who reported it to senior leadership. We took action Oct. 21.”

The VA requires dental burs to be disposable.

“He brought in his own burs and cleaned them with Virex solution, salt and a wipe which is nothing we endorse,” Brahm said.

The hospital has offered free screenings for the veterans at risk. Experts believe “the risk of infection is very low.” At least two dozen veterans have taken up the offer and received blood tests. WEAU News reported:

That dentist has been removed from patient care and is now working in an administrative role.

The VA also referred the case to the inspector general for assessment of any criminal charges.

“It was purposeful that he was violating VA regulations,” Brahm said. “During all of the orientation, he used all of our equipment. He used it appropriately, so it was very purposeful from what we found in our investigation that he knew exactly what he was doing, and preferred to use his own equipment against procedure.”

This scandal comes at a time when the Tomah VA has tried to improve its image:

“There was culture issue here, one of non-psychological safety, one of opioid abuse,” the center’s acting director, Victoria Brahm, said. “Those things are changing.”

Part of that change, Brahm said, is weeding out employees that put veterans at risk, like the dentist who she said knowingly went against the VA’s standards from October 2015 to October of this year.

Brahm said the dentist had one assistant for most of the time, but it was a different assistant who reported the issue.

In August, the family of Marine Jason Simcakoski filed a wrongful death lawsuit against the Tomah VA after he died “from a mixture of drugs that included opioids” in August 2014. He sought treatment for his mental health.

The VA fired chief of staff Dr. David Houlihan and reassigned its medical center’s director.

Some veterans at the VA called Houlihan the “candy man” because “of his supposedly easy and widespread distribution of painkillers to his patients.” A report from the Senate Homeland Security and Governmental Affairs Committee stated that Houlihan and Deborah Frasher, his nurse practitioner, “may have been ‘impaired’ themselves during a 2012 interview.


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The risk of infections isn’t all that low. There was a huge case back in the early 90s in Florida where a dentist infected numerous patients using improperly sterilized equipment. That is the reason for the specific regulation requiring disposable dental burrs, among other things.

    Gremlin1974 in reply to Granny. | December 1, 2016 at 2:03 pm

    Yea, but they are incredibly easy to prevent, simple universal precautions that are supposed to be practiced in all medical settings does a remarkable job.

And the guy is still alive. Amazing.

    Gremlin1974 in reply to Old0311. | December 1, 2016 at 2:42 pm

    While I never advocate violence, I also don’t believe there would be any great loss in this case.

    Valerie in reply to Old0311. | December 1, 2016 at 8:11 pm

    If one of those were my father, would be tempted.

    JackRussellTerrierist in reply to Old0311. | December 2, 2016 at 11:35 am

    ….and he’s been placed on administrative duty, not canned. At least not yet. WHY IN HELL ARE WE STILL PAYING THIS DERELICT? Why doesn’t the VA release his name? Why are they protecting him?

    Take him out and inject him with some filth and send him packing? Beat him senseless.

    Was this another one of the federal government’s AA hires?

It’s even worse than I thought at first, it’s not even the dentist who is infected as in the case in the early 90’s that Granny mentioned. This person (I refuse to give him the respect of any title) basically transmitted these diseases patient to patient, by using instruments on a patient he knew was infected and then basically wiping them off and using them on the next patient.

“That dentist has been removed from patient care and is now working in an administrative role.”

WTF? This is what is wrong with the entire federal system. The person has admitted to not following procedure which has put 592 patients at risk for life threatening diseases and all they do is shove him behind a desk. I don’t care that they referred the case to the IG, who I hope charges him with attempted murder for every person he put at risk. This disgrace to the medical profession should be barred from ever entering another VA facility for the rest of his natural life. I pray to God that someone has the thought to make a complaint against his licenses.

    C. Lashown in reply to Gremlin1974. | December 1, 2016 at 3:41 pm

    re: “This is what is wrong with the entire federal system”

    Federal employee unions and union contracts are the problem. That’s why criminally incompetent workers cannot be removed. The government has embraced a ‘feather bed’ philosophy of manpower, except when it comes to a ‘hands on’ interactive treatment with the veterans themselves.

    This is just my opinion, as a person who uses the VA for the past 12 years. The VA workers are aggressively pro-VA and whistle blowers are punished, both staff and patient whistle blowers; dissenting voices are squelched.

    My question is: Why Tomah? Why the recurring leadership failures in that one particular VA, or is it hidden and systemic in the entire system (which I don’t believe)? I have been to good VA’s hospitals, with a knowledgeable and attentive staff… AND, then there are other’s that I shouldn’t mention by name.

      Gremlin1974 in reply to C. Lashown. | December 1, 2016 at 5:46 pm

      Also I would be the lowly dental assistant that didn’t turn him in for the past few months will end up fired and blamed for the whole thing while the Dentist is promoted to Admin.

      Old0311 in reply to C. Lashown. | December 2, 2016 at 11:12 am

      Like in any federal bureaucracy the unions stand in the way of getting rid of the duds. The only way out for veterans that I can see is the Choice Program if they qualify. This gives veterans access to treatment outside the VA.

      While I’m on my soapbox, in my generation (Vietnam) veterans were easy to recognize because everyone wore their field jackets and kind of banded together. While we were not particularly welcome at the service organizations, we most of us got help from individual WW2 veterans that got us though the dangerous early years of readjustment. They gave us a street version of suicide prevention.

      The veterans of this generation aren’t as easy to pick out from the general population and I wonder if this is one of the factors influencing their suicide rate. I’m not sure of a solution, but we need to find one and quickly. Rant over.

        JackRussellTerrierist in reply to Old0311. | December 2, 2016 at 11:41 am

        The Choice Program was just another obastard scam. The VA doesn’t pay the bills submitted by these outside doctors. Eventually, the provider gets tired of not being paid and then refuses to take VA patients.

          I actually worked for a GI doc and the VA approached our clinic about helping them catch up on colonoscopies for Vets, since the Doc and I are both vets we of course said yes before we even knew the particulars. OMG, we never ever realized it would be hundreds. It took us and 7 other GI doc’s 6 months to help get the VA back into compliance but we did it and believe it or not the VA was prompt with payment, probably mostly because it was done on contract that our lawyers made sure was iron clad.

          Want to take a guess at how long it took for the VA to have to come back to us again before they were hundreds behind once again? I will save you some time it was 6 months.

          What was the problem? The VA schedules 2 hours actual procedure time for the colonoscopy. A good reliable colonoscopy should take a max of 20 to 30 minutes if it is normal, many are actually more like 15 minutes procedure time. My doc was doing 3 times as many procedures a day than the VA docs in the same amount of time. So what were the VA docs doing with the extra hour and a half they got with each procedure? Well I can tell you what they were doing…documentation because it was 6 months behind as well!

          Vets who had colon cancer were finding out 3 months later if their procedure was done at the VA and then waiting more months to even start getting treatment. When we found cancer in a patient I knew with in about 48 hours, by the time 72 hours was up, the Doc had spoken personally via phone with the person to discuss the results and I already had a plan of action and appt’s with us and oncology set up and ready to go within the next week.

          I know taking Vet’s healthcare to the private sector would be more expensive than the VA, but damn isn’t it worth the difference in level of care? The VA has the same problem the rest of the government has they don’t have to produce anything or maintain a bottom line, so there is no real incentive to do better.

buckeyeminuteman | December 1, 2016 at 2:18 pm

To think there are still people out there who want the government to run all facets of healthcare…

Richard Aubrey | December 1, 2016 at 4:30 pm

Six hundred patients is, what, two and a half months? Operating that long without management visits or supervision?
Time for him to get a performance bonus.

It’s impossible to tell what’s going on from this account.

Problems in administration of opiods is mixed in with concerns over sterilization procedures. Poor practice re one of these hardly implies poor practice re the other.

The sterilization dispute seems to be about organization SOP, not about the concept or technique of sterilization itself. It wasn’t all that long ago that just about all medical equipment was painstaking whittled out of chunks of stainless steel by EDM (or “spark machining”), then sterilized between uses for many years thereafter. Nowadays there are often much cheaper ways to ensure that only sterilized tools are used. And the facility, quite properly, generally specifies what equipment is to be used and how it is to be handled. But that by itself doesn’t imply that any other equipment or procedures are medically inadequate.

Nevertheless, if there’s any doubt, tests are a good idea … I suppose … particularly as they’re billable. In the medical industry, billable procedures are the organization’s life blood, just as billable hours are to law firms.

Patients were not dying fast enough, he had to speed their demise.

How about a name for the offending dentist?

You are right. They have always been a no/slow pay for outside providers. It worked well for me once. Not so much for some of my friends. They definitely need a good spring cleaning.

    Gremlin1974 in reply to Old0311. | December 2, 2016 at 4:47 pm

    At this point I think the only real help for the VA is to shut it down and try something else. I mean I have a buddy who uses VA and he had me drop him off at 9 AM for a GI appt. just a follow up, something that would take less than an hour in the real world. His wife finally picked him up at 6:30 PM, oh and he had never actually gotten to see the GI doc he had to go back the next day and wait 5 hours before finally getting to see the GI doc for a grand total of 7 minutes.

    What is the VA’s response if you have finally had enough and leave because of their completely unjustified wait times substandard service and pitiful excuse for care? Well you have to wait or your benefits could be in danger. And God forbid you actually need any real care. Need a hip replacement…well that’s gonna take about 10 months so here have 5 bottles of Oxycontin and just wait it out.

    I am a vet and and a Nurse, my living will says if the choice is the VA or death, I chose death.