Synopsis of presentation from Hill Co. Veterans Council to
 JOINT COMMISSION ON ACCREDITATION OF HEALTH CARE ORGANIZATIONS 
 Audie Murphy VA Medical Center on July 13, 1999

by: Lieutenant General Murphy Chesney, USAF Retired MC

We are here today as the Hill Country Veterans Council representing 18,000 veterans in the Hill Country. This takes in the area from San Antonio to El Paso east to west; Del Rio to Big Spring north and south. The Kerrville VA Hospital is the only VA medical facility of any type in that large area to support these 18000 veterans plus veterans all over the state who come to Kerrville to receive care. Our goal is to sustain the care for the future that the veterans have been receiving at Kerrville hospital for many years.

I am also here in support of the Kerrville VA physicians. Many of the physicians at the Kerrville VA Hospital have come to me unhappy with their present status and unhappy with the way they have been treated by Audie Murphy especially concerning the transfer of patients and other things. They somewhat feel that I personally have left them in an untenable situation since I hired most of them. These Kerrville physicians have not requested that I come to JACHO but they have asked me to support them. The Kerrville VA Hospital is more than 75 years old having been built in the mid 20s to support veterans across the state. Over the years it has been one of the best VA hospitals in the country with as many as 500 beds and now is down to 25 beds. When I was at the Kerrville Hospital five to ten years ago we had 283 operating beds including surgical specialties of all kinds, orthopedics, general, plastic, ophthalmology, and urology. It was supported by pathology, we also had psychiatry, alcohol drug and detox, a very good medical service including a pulmonary disease section, and a 160 bed extended care nursing home.

Four years ago the management of the Kerrville VA Hospital was turned over to Audie Murphy and in the interim between then and now, Audie Murphy has gradually closed down most of the Kerrville VA Hospitals facility. Beds have been closed; we've lost more than 100 staff people within the last year. It was announced last September that the hospital would be closed early in 1999 and the date was set for the 15th of March. In January of 1999, very suddenly, all surgical procedures requiring anesthesia were closed; we lost general surgery, ophthalmology, urology, pathology and psychiatry at the same time. Many patients who had been scheduled for surgery were taken off the roles and the surgery still has not been done for most of these patients. Sixty on the waiting list for opthmalogy have not been re-scheduled and most have not even been contacted.

When the closure was announced there was somewhat of a local revolt among veterans and Kerrville VA patients. Many meetings were held in the VFW Hall and American Legion Hall: a meeting was held on the grounds of the Kerrville VA Hospital with more than 300 people in attendance, including a band and speakers. Congressman Lamar Smith brought management from the Audie Murphy VA Hospital in San Antonio, and from the regional office in Dallas, for a general meeting at the Kerrville Municipal Auditorium . More than 1500 attended and more than three hours worth of discussion ensued. The Hill Country Veterans Council was then formed and has been very active in supporting the Kerrville facility. Our major problem with the Kerrville Hospital has been the closure of beds, the loss of other services, and the inability to have these patients taken care of at any other place. The transfer of patients as in-patients to Audie Murphy is very difficult. It takes somewhere between 3 to 14 days to accomplish a normal transfer. I, personally, have waited as long as two weeks to transfer a patient; and then ended up having to send the patient to Wilford Hall Medical Center for brain tumor surgery. Its a complex system where you have to call down and talk to the Secretary and find the Resident, or you have to talk to the staff man. Then "they" will make a decision whether they want the patient or not. Many times they will tell the Kerrville doctors to try "so and so" and, of course, that usually doesn't work. Waiting times for surgery averages about 4 months, and in some modalities such as neuro-surgery, the waiting time can be as long as 6 months to a year. I will give an example of something that happened in the previous week: a patient was admitted at night at Kerrville Hospital with severe right upper quadrant abdominal pain that was thought to be an acute and complicated cholecystitis. The patient was worked up, and it was the opinion of a board certified family practice physician, the ER doctor, and board certified surgeons, that the patient needed emergency surgery. Since this could not be done in Kerrville the patient was transported to Audie Murphy. When he arrived, the Ambulance Driver was told to keep the motor running and the ambulance there, as they would probably send the patient back. They examined the patient and sent him back to Kerrville without opportunity for the needed medical care, in the middle of the night.

Transfer of patients from the out-patient clinic in Kerrville to Audie Murphy is also very difficult. When a Kerrville doctor sees a patient that needs to be seen by a specialty clinic at Audie Murphy, he fills out a consult and transports the paperwork with the next busload down to Audie Murphy. There the secretary handles the request and gives it to a resident who will review it and then talk to the staff man. Audie Murphy may make a decision that the patient does not need to be seen at that time. I will give you an example of what has happened at Kerrville within the last 30 days:
 A Kerrville doctor had a patient who was having symptoms that made the doctor think the patient had coronary artery disease. A treadmill was done immediately and after walking a few steps on the treadmill the patient had an ST depression of 2 1/2 millimeters which is indicative of severe coronary obstruction, usually with 90 to 95% blockage of all three major coronary arteries. The patient needed a catheritization and surgery to relieve this condition. A consult was sent to Audie Murphy and
about 30 days later the resident called back to the Kerrville doctor and said that Audie Murphy had decided to not see the patient since he had no myocardial-infarction and was not having true angina at that time.

Another problem we are having at Kerrville has to do with our Nursing Home. The facility at Kerrville has been a long term nursing home facility and has kept patients up to 15 years.

We have a fairly large Alzheimer's Unit which takes intermediate state patients and is graded as one of the best Alzheimer*s Units in the world. We've had visitors down from Boston and other places just to see how our Alzheimer's Unit works. The decision was made by Audie Murphy that Kerrville would revert to a transitional care nursing home. That would mean patients will not be kept longer than 90 days. At this time patients that have been there for an extended time of one year or longer are being forced out of the Kerrville hospital Nursing Home. Most of these patients do not go out under VA care but are under the financial auspices of their spouses. Many of these patients have no one who can look after them. Many of our patients have lost confidence in Audie Murphy and do not wish to go back. About 1/3 of Kerrville's patients have asked never to be sent there and this fact is recorded in their charts.
The other major problem that Kerrville has to deal with is the morale of the people on staff. As I said before, we have lost more than 100 people. Everyone that works at Kerrville right now is worried about their job and don't know, day in or day out, when they are going to be called in and fired. So many of them have quit and now there is now a shortage of nurses at Kerrville. It is very difficult to hire nurses into a hospital where the length of operation is totally unknown. Kerrville VA Hospital employees are working on a day to day basis and many are looking for a good job opportunity.

Let me digress a minute and mention that nothing I have said here today should reflect on the medical care in the Kerrville Hospital or upon the leadership of Dr. Dan Bacon. We, the members of the Hill Country Veterans Council, think that Dr. Bacon has done an outstanding job trying to work for his San Antonio bosses to comply with their wishes as well as to continue to give outstanding care to the veterans of the Hill Country. He has been put in a very difficult position but is doing an outstanding job.

The Hill County Veterans Council feels that the Kerrville Hospital is one of the best veterans hospitals in the nation. In patient care surveys Kerrville has ranked first for many years. Although Kerrville is small, it gives personalized primary care to its patients, with the same doctor seeing to the individual patient each time. Whereas, when the patients come to Audie Murphy, they are seen by residents who are off-and-on service. Because of this, continuity of care is sometimes lost. We strongly support the Kerrville hospital. Now, as you know, we have sent a package to the Joint Commission highlighting some of the problems we have with medical care in the Hill Country. We have more than 100 letters from patients that were primarily written at the request of the local U. S. Congressman who wanted to know what was going on. Many of those who have had care at Kerrville and San Antonio wanted to come down here today to talk to the Joint Commission; however, we had to limit the number. We brought six people down. I will describe their problems and you can talk to them if you so desire.

The first is patient W. S. who was scheduled for ophthalmologic surgery last January, needing laser surgery on his eyes. His surgery was canceled when the whole surgical department was terminated. He has not been contacted or spoken to as of this time. We also hear of one patient who has allegedly lost his sight because of the delay of his medical care.

A second patient with the initials of BW was a Jewish prisoner of war of the Germans. Because of his religion he received especially harsh treatment and was put before a firing squad twice. He has multiple problems; primarily orthopedic. He's been to Audie Murphy many times and he has said he will not go back again. At times he has had to go to Audie Murphy as many as four times to see the right doctor. He's had some orthopedic problems with his feet and was told that nothing could be done. He's gone to a civilian doctor who was able to fix his problem.
The third patient, initials BB, has had extensive care at Audie Murphy VA Hospital. He detailed many medication errors and reported having to return to the hospital 3 times before he got his treadmill done. Finally, when it was finally completed, he had some kind of coronary event and has said he will not return to Audie Murphy.

The fourth patient, initials BH, has been treated at Audie Murphy and has had problems with post operative and nursing care associated with it. Immediately post surgical, he was put into a room without nursing care, messed on himself and on the bed and could get no one to help him. Finally one of the other patients got up and aquired some clean clothes and cleaned him off. He is also said he will not return to Audie Murphy.

Fifth patient is Mrs. G. L. whose husband has been in the nursing home in Kerrville for more than one year. At one time he was placed out, but did so poorly in a non-Kerrville VA care unit, that he's had to be brought back in. He has multiple medical problems, including post cerebral hemorrhage and other things. He has now been notified that he will be forced out of the Kerrville hospital sometime during the next 4 to 6 weeks. Mrs. G. L. found a nursing home for him but she's afraid he will die outside of the facility that has given him the best care.

Patient number 6 initials TN had cancer of the throat in 1993 with radiation and other treatment. This has totally blocked his ability to swallow (even liquids). He has a hole in his stomach and is force fed through a gastric tube with bags and pump. He's always obtained these pumps and bags from Audie Murphy and Kerrville Hospital, and one a day is required. The packaging for these materials indicates that it should not be used longer than 24 hours as it can become contaminated and is a threat to the patient if it is not changed regularly. However last year AM pharmacy committee decided they were spending too much money on these and started giving him one bag and pump for every 6 days. Mr. TN had problems with this. He developed multiple symptoms, including recurrent diarrhea and pneumonia, (probably from aspiration), three times during this period. He has finally gone back repeatedly to the committee and has won his case. They are now giving him his one tube and pump per day but there are probably 200 people who may or may not be receiving that change in care.

I would like to thank the Joint Commission for allowing us to appear here today and we will try to answer any questions. Thank You!

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