diabetes Help! Va Sent For A Medical Opinion From Vamc 4times

[Lzjump]

I have a Claim for Cause of Veterans Death & TDIU. My husband was 90% SC at the time of his death in 2004. He had applied for TDIU & reopened claim for Hep C. but that claim was not decided until after his death and was denied. I refiled as the widow and was denied. I appealed the decision, had a BVA hearing in March 2008, in August 2008 was awarded the TDIU and claim for cause of veterans death was remanded. Remanded stated that they were to try to locate the STR from service and also get a medical opinion to opine if any of his SC conditions contributed to his death. I received a letter stating that they could not locate the Service Treatment Records from when he was hospitalized in Nam after trying 3 times. (Husband had Hep C and had a Liver Transplant in 2002). He was hospitalized for 6 weeks in Quin Hon and had blood transfusions. He was SC for PTSD, Diabetes Mellitus type II, PN, Gunshot wounds. He was boots on the ground vietnam vet with purple heart, air medal etc. His death certificate stated cause of death was Multi System Organ Failure and Sepsis. (he had chronic renal insufficiency secondary to DM in 11/03 he was on insulin & restricted diet) My claim was sent for a medical opinion in August 2009 and has been sent back 4X for medical opinions. the latest being Feb 24, 2010. Yesterday I went to the VAMC to get a copy of his medical records and the opinions and now I see where the problem is.

Medical Opinion Sept. 2009.

the relationship of the veteran's Hep C to his military service is speculative. Service connected disability listed. the only one that could be considered as contributing to the veteran's death is his diabetes mellitus.

Nov 2009

see exams 9-09 with explanation/rationale and cfile reviewed.

Feb 2010

the degree of contribution of his diabetes mellitus to his death is speculative.

Feb 2010

Claim Back again for heart condition.(he had a AMI with left branch bundle block before he passed away) so now I guess they want his opinion on that.

My question, Does the Doctor have to give a rationale for his opinion?

Should I get another medical opinion and submit to AMC with more rationale?

I have 3 medical opinions from his Physicians who treated him for over 8 years. stating that the Diabetes did contribute to his death and one stated that all though diabetes was not listed on the death certificate it is well document thru out his treatments. I have hospital ICU records showing his blood sugars some over 300 and all over 180. Also have a Veterans Affairs study stating that even mild hyperglycemia was associated with as much as a 15-fold increased risk of death in study of ICU patients and a correlation between hyperglycemia and renal failure and sepsis. This study was done at VA medical centers.

Thanks for any help.

[Berta]

"I have 3 medical opinions from his Physicians who treated him for over 8 years. stating that the Diabetes did contribute to his death and one stated that all though diabetes was not listed on the death certificate it is well document thru out his treatments."

I finally was award AO death because the VA considered my IMOs based on the same thing as what you stated.

DMII wasnt on the death certificate but the IMOs stated with full medical rationale that the undiagnosed DMI contributed to my husband's death.

The VA had one C & P aganst the claim whch was rebutted bu one of my IMOs and then they got another C & P opinion that used the word speculative whoch the BVA did not consider and awarded the claim.

"His death certificate stated cause of death was Multi System Organ Failure and Sepsis"

The VA probably didnt comprehend what the multi system failures were.

Was an autopsy done?

Did you contact the ME or Coroner to see if the certificate could be amended to define better what the multi system failure consisted of?

"Claim Back again for heart condition.(he had a AMI with left branch bundle block "

Has any doctor stated or suggested that the left branch bundle block has anything to do with ischemic heart disease?

Ischemic heart disease is going onto the AO presumptive list.

Did he have documented hyperlipedimia ( His Trygycides and cholestrol values would be on hs blood work charts.)or atherosclerosis?

"My question, Does the Doctor have to give a rationale for his opinion?"

Yes they do.

"Should I get another medical opinion and submit to AMC with more rationale?

I have 3 medical opinions from his Physicians who treated him for over 8 years. stating that the Diabetes did contribute to his death and one stated that all though diabetes was not listed on the death certificate it is well document thru out his treatments"

Did the VA list these opinions as evidence and then refer to them in the decision as to exactly why they discounted them?

Are you able to scan and attach the actual denial here ?(cover the personal stuff)

I would like to see how the IMOs

'stating that the Diabetes did contribute to his death' contained their medical rationale for that.

Did it mention causing his heart disease too?

We have another widow here who s trying to prove Hep C contributed to her husband's death.That can be very difficult.

What did the VA attribute the sepsis too?

[Berta]

Did your IMO docs say that his renal insufficiency (which probably caused one of the multi organ failures )-Kidney failure-was directly due to his DMII?

I mentioned my claim because it seemed that everything had to be carefully spelled out to the VA over and over again-aside from C & Ps the raters arent docs and dont really hace a clue on causation.

The IMO format here I developed as a guideklne for IMOs and I based on my IMO docs IMOs.

AN IMO doc must have a strong medical rationale that they can support with medical facts and documentation from the SMRS or any other medical records.It seems to me if the death certificate had specified heart failure and renal failure the claim could have been awarded as to the DMII causing the renal problems that contributed to his death.

But I am assuming that.

Diabetes has a distinct relationship to the kidneys.(Renal system)

[Lzjump]

Did your IMO docs say that his renal insufficiency (which probably caused one of the multi organ failures )-Kidney failure-was directly due to his DMII?

I mentioned my claim because it seemed that everything had to be carefully spelled out to the VA over and over again-aside from C & Ps the raters arent docs and dont really hace a clue on causation.

The IMO format here I developed as a guideklne for IMOs and I based on my IMO docs IMOs.

AN IMO doc must have a strong medical rationale that they can support with medical facts and documentation from the SMRS or any other medical records.It seems to me if the death certificate had specified heart failure and renal failure the claim could have been awarded as to the DMII causing the renal problems that contributed to his death.

But I am assuming that.

Diabetes has a distinct relationship to the kidneys.(Renal system)

[Lzjump]

Berta,

Thank you for your reply. I have not received a decison from the AMC yet! My claim keeps going back to the vamc for medical opinions. The vamc Dr will not give a straight answer just speculates with no rationale. That is why I asked if the Dr. must give a rationale for his opinion.

No Autopsy done.

Medical records do show End stage renal disease secondary to DM

I have submitted all medical records and doctors opinions with lab results, ICU records etc.

everything is well documented.

My IMO's were from his personal doctors who treated him. He was not seen at the vamc for anything other than C&P exams etc. I did get all the records vamc had yesterday which is no more than 10 pages.

When I received the VAMC medical opinions I was kind of shocked, thought there would be more to it than what it was. all opinions are one liners with no rationale, what you see in my first post is all they state and this has been going back and forth since August 2008.

I really do not see how they can take his medical opinion and grant or deny my claim as they have nothing to go by except that he speculates and gives no rationale for his decisions.

As far as the Hep C is concerned I have buddy statement who was medic with my husband in Nam and he states that they often shared razors & toothbrushes, that he treated him for Hepatits while in country. Also he was in combat blood to blood contact, was in a fox hole for 3 hours with other dead and wounded until they could be safely evacuted. All of this is well documented also. They denied it first time stating that medical records from 1969-1971 do show treatment for gunshot wound but did not show a need for transfusion. (but they could not locate the medical records so where did they come up with that) and since they cannot locate the medical records from the hospital and have tried 3x to do so I would think benefit of the doubt would have to come into play somewhere. BVA Judge ordered them to search again for the medical records and opine on the HEP C.

What would be your next course of action if you were me? Any advice is welcomed.

[Berta]

"His death certificate stated cause of death was Multi System Organ Failure and Sepsis."

The VA holds to the exact wording of a death certificate.This is why I stress here that vets in their lifetimes tell the spouse to have autopsy done at their death.

My husband's death certificate contained only one line stating the cause of his death. His autopsy,however, was 6 pages long and far more detailed and without it I could not have succeeded in my DIC claim.The only reason it was done was because he was an organ donor-but then I realized -as VA fought me over my claim-that it was critical to the DIC claim too.

Has any of the IMO doctors specifically stated in an opinion exactly how his service connected diabetes mellitus directly contributed to the multi system organ failure? A strong rationale will overcome speculations on VA's part.

The Va appears to be considering the sepsis as the cause of death and that the MOSF was due to the sepsis.

This link gave me more understanding of why the death certificate was worded the way it was worded.

http://emedicine.medscape.com/article/169640-overview

Sepsis derives from an infection.The VA treated me for a sepsis infection 2 years ago but although they said it was serious -I overcame it fast with antibiotics. But I am in very good overall health. I would think that diabetes and the other conditions your husband had certainly could have affected his immune system and could have caused the sepsis to become fatal.

This is the link I feel the VA needs to see from your IMO doctors.Have they made that point clear to the VA?

They(VA) will hold to the wording of a death certificate but it contains nothing specifically associated with his SC conditions.

I hope your IMO doctors opinions did associate the sepsis to his diabetes and any other SC condition with a full and strong medical rationale.

As this link shows sepsis can be very serious in anyone with a weakened immune system:

http://www.nlm.nih.gov/medlineplus/ency/article/000666.htm

Diabetes also has been known to cause resistance to infections of many types:

http://www.nlm.nih.gov/medlineplus/ency/article/000666.htm

It was symptoms and diagnosis of an unusual infection my husband had that VA ignored at first and then treated-that was one of the prime pieces of evidence I used for my DMII claim.The infectious

disease was associated to diabetes by VA itself in their DMII training letter along with other types of infections that can be associated to DMII.

What did his doctors say was the actual cause of the sepsis?

The IMO docs have to medically associate the sepsis to his DMII or any other SC condition in order to use the wording of the death certificate to explain how a SC disability contributed to his death.

I assumed renal failure as a direct consequence of the DMII- but that was just an assumption as, after I read this all over again and again-

I feel the VA is holding to sepsis as cause of death due to the system failures and they see no SC involvement with the sepsis.

Have you contacted the Coroner or the Medical Examiner to see if the death certificate can be amended to include a SC condition as contributing?

Your county also might have a way this could be done.Here in NY it is a rigamorale.But I helped a widow years ago here get her husband's death certificate amended to include a SC condition contributing to death.She was awarded DIC when she got that done.

The sepsis could have been contributed to by the end stage renal disease that you said is noted in his medical records.

Any cause of death for DIC purposes does not have to directly cause death as long as it is medically proven that it had contributed to death.

Edited March 6, 2010 by Berta

[Lzjump]

"His death certificate stated cause of death was Multi System Organ Failure and Sepsis."

The VA holds to the exact wording of a death certificate.This is why I stress here that vets in their lifetimes tell the spouse to have autopsy done at their death.

My husband's death certificate contained only one line stating the cause of his death. His autopsy,however, was 6 pages long and far more detailed and without it I could not have succeeded in my DIC claim.The only reason it was done was because he was an organ donor-but then I realized -as VA fought me over my claim-that it was critical to the DIC claim too.

Has any of the IMO doctors specifically stated in an opinion exactly how his service connected diabetes mellitus directly contributed to the multi system organ failure? A strong rationale will overcome speculations on VA's part.

*Yes, doctor stated his medical history included type 2 diabetes mellitus, peripheral neuropathy and hemoly anemia. He died of multi system organ failure and sepsis, these medical conditions clearly made him more at risk of this condition. He was weakened by these conditions and due to their chronicity, they were factors in all of his illnesses. I submitted all lab reports, ICU reports etc.

The Va appears to be considering the sepsis as the cause of death and that the MOSF was due to the sepsis.

*I believe that is true also. I do have hospital notes 6 weeks prior to his death that he had Chronic Renal Insufficiency secondary to Diabetes Mellitus.

This link gave me more understanding of why the death certificate was worded the way it was worded.

http://emedicine.medscape.com/article/169640-overview

Sepsis derives from an infection.The VA treated me for a sepsis infection 2 years ago but although they said it was serious -I overcame it fast with antibiotics. But I am in very good overall health. I would think that diabetes and the other conditions your husband had certainly could have affected his immune system and could have caused the sepsis to become fatal.

That is also true. I also submitted documentation showing his blood sugars were all above 350 some over 450 while in ICU. While researching I found a document from the American Diabetes Associations 66th Scientific Session. This was written by Dr. Falciglia, Veterans Affairs Inpatient Evaluation Center at the Cincinnati VA Medical Center. Study noted that mortality risk began at very mild level of hyperlycemia among all patients, starting with the hyperglycemia range of 111mg/dl to 145 mg/dl, there was already a 40% increase in mortality rates. Conditions in which researchers noted a correlation between hyperglycemia and mortality included respiratory failure, sepsis and renal failure. The link between hyperglycemia and mortality was greatest in those admitted with Acute MI, and strokes. Hyperglycemia increased acute MI patients risk of death up to 5 times. Hospital discharge report on date of death indicated Stroke, AMI, Renal Failure, Sepsis.

This is the link I feel the VA needs to see from your IMO doctors.Have they made that point clear to the VA?

*I have gone bact to both doctors and requested a more in depth link with more rationale.

They(VA) will hold to the wording of a death certificate but it contains nothing specifically associated with his SC conditions.

I hope your IMO doctors opinions did associate the sepsis to his diabetes and any other SC condition with a full and strong medical rationale.

*Not sure how strong the medical rationale is other than their statements supported by labs, ICU reports etc. I have since gone back to the doctors and asked for more rationale with their opinions. The VA doctors opinion had no rationale. I spoke to my VSO friday she has talked to the AMC and they indicated that the VA medical opinion is not acceptable and this is why it keeps going back to VAMC.

As this link shows sepsis can be very serious in anyone with a weakened immune system:

http://www.nlm.nih.gov/medlineplus/ency/article/000666.htm

Diabetes also has been known to cause resistance to infections of many types:

*Doctor reports state "His hospital stay continued to be complicated due to multiple infections.

I have clear medical reports showing DM thru out his treatments, Peripheral Neuropathy with cellulitis

http://www.nlm.nih.gov/medlineplus/ency/article/000666.htm

It was symptoms and diagnosis of an unusual infection my husband had that VA ignored at first and then treated-that was one of the prime pieces of evidence I used for my DMII claim.The infectious disease was associated to diabetes by VA itself in their DMII training letter along with other types of infections that can be associated to DMII.

*Can you point me to that training letter?

What did his doctors say was the actual cause of the sepsis?

*Ecoli bactermia

The IMO docs have to medically associate the sepsis to his DMII or any other SC condition in order to use the wording of the death certificate to explain how a SC disability contributed to his death.

I assumed renal failure as a direct consequence of the DMII- but that was just an assumption as, after I read this all over again and again-

*Renal failure was indicated on the hospital discharge summary in November 03, Chronic Renal Insufficiency (stage 4) secondary to DM

also stated physical restrictions "slow & steady" and restricted ADA Diet.

I feel the VA is holding to sepsis as cause of death due to the system failures and they see no SC involvement with the sepsis.

*Well hopefully with the paper that I submitted "Hyperglycemia linked to death risk in some ICU patients. (study conducted at the VA medical centers) should have some weight along with medical opinions etc.

Have you contacted the Coroner or the Medical Examiner to see if the death certificate can be amended to include a SC condition as contributing?

* Yes I have. Dr submitted statement that all though DM was not listed on his death certificate it is well documented thru out his medical history. I have read that DM is not always listed on Death Certificate but that it is a underlying cause of death.

Your county also might have a way this could be done.Here in NY it is a rigamorale.But I helped a widow years ago here get her husband's death certificate amended to include a SC condition contributing to death.She was awarded DIC when she got that done.

The sepsis could have been contributed to by the end stage renal disease that you said is noted in his medical records.

Any cause of death for DIC purposes does not have to directly cause death as long as it is medically proven that it had contributed to death.

*BVA remand stated "forward claim to a medical specialist for review and:

opine wheter any service-connected disablility or disablility related to the veteran's service was the immediate or underlying cause of the veteran's death, or etiologically related thereto:

if not, opine wheter any service connected disablity or disablity related to the vetern's service contributed substantially or materially to such death, combined to cause it, or aided and lent assistance to the production thereof;

in so opining consider the collective effect of the vetern's service connected disablilities and all other disablilities related to the vetern's service and whether, as alleged, they might have debilitated the veteran to such an extent, he was unable to resist or fight the symptoms of his nonservice-connected disablilities: and

provide detailed rationale with specific references to the record, for all opinions provided.

I feel that those instructions are very clear, to the point and hopefully will assist me in this claim. What do you think about the remand?

Thanks for any assistance.