Valid Complaint?

[pwrslm]

Hi Im new here. Thanks for having me.

I was set up with the VAMC Apr 14. First time since I left the Army in 84 that I had any real heal care. Back problem from service still is an issue, first time out, brought to the attention of my PCP. She gave me a tube of "stuff" to rub on my back, and that's all. Fast forward, 6 months, notified her on that next visit that the back problem is still there. She didn't say anything, no physical contact, no exam nada. Next thing I know, appointment for Phys Therapy comes in the mail so off I go.

PT gives me the going over, tells me that hyperextension of my back will help me. OK, Im game. First trip back, a week later, I have tingling down my left leg. I tell PT, who instructs me to go farther back, extend all the way back like a push up, but keep my pelvis on the ground. I trusted the PT knew what was going on, so I did. Next trip another week after, twitching in my leg and foot started, reported to PT. PT said keep hyperextension exercises up, and put a rolled up towel behind my low back when I sleep, and a pillow under my knees.

Next visit, I found out my PCP left town. The PT fed me a line, asked me if its good as its gonna get, I said aye, it is. Discharged me, with my tingling leg and twitching foot. Told me keep doing this exercise for the rest of your life. I said ok, but really felt like I was dumped.

Fast forward, the symptoms in my left leg got worse over the next month, foot drop, weakness, new pain central back, so I stopped the hyperextension, see if it would heal. But it got worse, 60 days later, Im a walk in at the clinic. They sent me to xray, and got me an MRI. I also got a prosthesis for foot drop. Turns out Ive had advanced arthritis in my facet joints for a while. The hyperextension jammed them, now I have 3 discs herniated and stenosis. Not sure how far the disc problem was all along, but nothing in the world outside of a crystal ball could tell anyone. Needless to say, it was probably an existing condition.

The question; Does this classify as a valid aggravation of the existing condition, and exactly how should VA personnel handle this issue once they become aware that I may have been harmed by treatment.

The 3 Surgeons Ive talked to all say I need surgery, L3 to S1 decompression and fusion.

Edited July 10, 2015 by pwrslm

[pwrslm]

My SC was granted 2 Sep 2015.  Left Service w/ back problem in 84.  Had IME/O from a highly qualified spine surgeon and won my SC, my L5/S1 disc was gone, literally, from the years that I went without any treatment.  They gave me SC based on his IMO.  You generate enough pressure on the spine doing sit ups to cause a disc to herniate.  These type of herniation's typically push out to the front, or anterior, part of the spine, leading to minimal symptons and pain initially, until over the years, the degenerative effect of the herniation progresses into a much more substantial problem, as it did in my case.  I dealt with it for 30 + years thinking this was the effect of scoliosis (which was also diagnosed during active duty) that the Army Dr. said I had 19 months after I hurt my back.  He said it was genetic, and I was born with it, and I believed him.  Never got xrays or mri, they barely touched my back and came up with the conclusions that my condition was back strain due to Scoliosis.  After learning how scoliosis could be a secondary condition to a herniated disc, I sought out help.  This is when I found a specialist who deals with scoliosis, and he told me that he has seen this before, it is not that uncommon.  This is how I developed my case.

When I first started this, I was pretty naïve of what the long term effects of this was.  I am a bit smarter now.  The exercise they gave me literally caused me to get fusion of my spine, because of the compression that hyperextension exercises did to my nerves, which will affect me for the rest of my life.  I'm pretty sure that I can prevail, and have 1 year still to get this filed.  I have an appeal/reconsideration and a 100% temp total disability (for convalescence) in the works now, sitting at prep for notification.  This should be (I hope) done soon.

Edited January 1, 2016 by pwrslm

[pwrslm]

just to point out, there is no time limit for 1151 claims but the Statute of Limits is 2 years for FTCA.

Sometimes a claim for "aggravation "of a SC disability is as good as a 1151 claim.And easier to succeed in, with a strong IMO,.

However a strong IMO could also cover both of those theories.

FTCA and 1151 need the same  evidence:

Documented medical proof of negligence/malpractice in the VA med recs and

Documented medical proof that those errors caused additional disability.

 

at this point, I have a VA PCP stating that she had given me a clinical examination of my back (contained in the referral she filled out to send me to physical therapy) when she did no such thing, and there is no records to indicate that she did in my VA Treatment records....also in my VA Treatment records...the Physical Therapist (PT) indicated tingling in my legs, and twitching, and failed to halt the exercises, both of these are indications of nerve compression...following the reports of symptoms of nerve compression in my records, they dumped me...ceased all treatment, no follow up care whatsoever...

Prior to these events, there is not a single mention of any leg problems or radiculopathy in any medical records in my medical history.

All of this is in my records, and I have copied the whole thing and retrieved copies from ROI officer....IMO malpractice exists when the PCP failed to provide a clinical examination of my back, yes she said she did, and then....referred me to therapy...this is furthered by...a trained PT (4 yr degree or better)...failed to recognize symptoms of nerve compression as they developed over a 2 week period...

 

The IMO that I need is that the exercises were contraindicated in my condition...prior to PT...and the reason they did not identify this fact, is because of the lack of ordinary care that my PCP gave me...proof of that is in the records where there is no notes indicating that a clinical exam was ever done on my back...If I had received ordinary care...the PCP would have noted the pain in my back was centralized in the facet joint regions of my spine....and the ordinary standard of care...would have called for XRays, which would have exposed my condition to the PCP...and ensuing any referral to PT, the therapist would have adequate knowledge of my condition and would never have subscribed to the hyperextension exercises that I was given, because it would have been clear that that exercise was contraindicated due to arthritis in my facet joints...

 

My current surgeon has already indicated that he considered this as the cause of the severity of the stenosis...if I had received the proper care in these examinations...I probably would not have had the radiculopathy issues...leading to the fusion surgery...for many many years...if ever at all...

Edited January 1, 2016 by pwrslm

[broncovet]

So, you had scoliosis diagnosed in service.  Did you apply for or receive benefits for scoliosis?  Remember, Veterans are not required to be medical experts to apply for benefits.  You may not know the difference between scoliosis, and scionosis (a condition where people buy Scion's instead of real cars), but that should not matter.  You can simply point to your back and say, "it hurts there".  You dont have to self diagnosise a c3-c4 herniated disc, and then be denied becausee its a C4-c6 herniated disc from scoliosis.  

[pwrslm]

My outside spine specialist gave me a diagnosis that my scoliosis was secondary to lumbar strain ( which was actually a herniated disc at S1/L5)...evidence he concluded was the advanced degeneration of the disc (which was literally non existent) which was proof of a previous injury...which he said was more likely than not...caused by the incidents recorded in my SMR's, which he reviewed...

they approved me for IVDS  and added (also claimed as) and listed everything that was in my claim...the only diagnosis for IVDS in the record comes from a PA who conducted a C&P Examination....(go figure)...I had 5 separate diagnosis (multilevel spinal stenosis, thoracolumbar scoliosis, advanced DDD, lumbar strain, and advanced degenerative arthritis) provided by a specialist which I listed in my claim...but they only gave me the IVDS...diagnostic code from the CFR...im trying to get them all included

the VA likes it when we are not educated...I noted that from the start...reading this forum...and many other sites...I began educating my self on the internet and from the library...about my spine condition...

Edited January 2, 2016 by pwrslm