Dm Ii And Vascular Disease

[harleyman]

Does anyone have referenes or experience in getting vascular disease of the lower limbs service connected as secondary to DM II?

Veteran is s/c for DMII and PN with loss of use of one of the lower extremity ( 2 K awards one for loss and the other for ED),and also s/c for IHD. But recent claim for DVT (blood clot and infection in lower leg secondary to DMII ,VA has denied stating the leg condition is not related to the DMII.

Might the veteran get the DVT (clot and or infection)s/c as secondary to IHD?

Thanks!

Edited July 27, 2013 by harleyman

[harleyman]

Berta, this post is really long but I think it needs your expertise and I believe you need to know about 90% of the events in order to provide your opinion. I am sorry to long so I understand if you need to shelve this one for a while. I can wait for your response. Here goes....

Veteran had complaints of leg pain on Thanksgiving day. He states his leg was red and hot to the touch and painful. Being a holiday weekend he went to the urgent care down the street from his home. They sent him to the emergency at the local hospital. The hospital gave him antibiotics as they suspected infection.

He stayed on antibiotic for a week or so, but the symptoms stayed the same, so he went to the VA clinic. His regular VA doctor said she didn’t know what was wrong and suspected compartment syndrome. She did order an ultrasound, it was not positive he had DVT but they thought he might have. They called the Vet and told him to go to the emergency at the VA. The VA decided the veteran had a DVT, as ultra sound report stated there appeared to be a “partial blockage” in vessel in the leg, The Vet was in the hospital for two or three days and they sent him home on blood thinners and preloaded syringes for warfarin shots in his stomach to be administered by his wife for what they said was DVT.

The veteran’s leg kept getting worse and worse to the point where he was not able to walk. He purchased a power chair on his own because he was supposed to go to the VA lab 3 times a week to have his blood monitored and he could not even walk. By this time his leg was so bad he could not ambulate or operate a car and the pain was unbearable.

He went back to his doctor at the VA, in his power chair with his wife, the VA doctor did not want to fill the pain prescriptions anymore, she told the Vet his condition did not call for extended use of pain meds. (that should have been a clue to her right there that something else was going on). The Vet told me she literally asked the him, “what would you like me to do for you”?) ……Like maybe she could actually be a doctor, just saying!

The problem is once you are diagnosed with something, all the other learned medical professionals think the diagnosis is legitimate. So when the Veteran went to a private hospital the first time they thought he had DVT because the Vet thought he had DVT and that’s what VA told him he had, SO they kept him for 3 days at the private hospital and continued to treat him for DVT with blood thinners and stuff and sent him home to follow up with VA.

What I found interesting is this Private hospital did an MRI of his big toe suspecting an infection but never looked at what was causing the leg to be swollen, because they all trusted the VA diagnosis of DVT. However the VA and the private hospital both gave him prophylactic antibiotics. Which just kept masking the infection. He went a second time to the private hospital because VA called him and told him to go wherever he wanted but his blood count was too low and he needed a transfusion. So he went back to this same private hospital and his blood pressure was measured at 76/48 and they said he was only dehydrated, gave him an IV and sent him home. They also told him he might have to live with this condition for up to two years or longer as some people never recover from a DVT. (all the while he had a roaring massive infection that went undiagnosed., because they trusted the VA diagnosis.)

Finally the Veteran found a private doctor who would take charge and be a primary care physician, as he refused to go back to the VA doctor. He met with the new PCP doctor on a Friday and the doctors started to change his meds and try to figure out what was happening, when the Veteran’s leg tore open and started to drain fluid . The new primary private care doctor sent him to a DIEFFERENT HOSPITAL than VA and the first PRIVATE Hospital he went to before. When he arrived at the second private hospital emergency, with his draining leg unable to walk, or sit, the Veteran layed on the floor on the ER waiting to be seen, When they finally examined him they did an ultrasound and an MRI. It was then they discovered he had a massive infection and there was no sign of DVT, according to the radiologist.

The problem the Veteran faced at this point was his blood cell counts were so messed up from the VA and the first private hospital and the massive amount of blood thinners, the surgeons were afraid to do surgery as he was so anemic.

He did have the first surgery on the Sunday night following his admission earlier that afternoon, and the second surgery was 3 or 4 days later. Before the second surgery, he was administered 2 bags of whole blood and 9 bags of plasma in order to be prepped for the second surgery. He was in the hospital for 11 days and in an acute care nursing facility for 2 weeks more, then home with home care nursing 3 times per week.

He had a third surgery about 4 weeks after he was home as the leg remained swollen and the doctors suspected infection had been trapped in the leg. He wore a wound vac on his leg following surgery for about 8 to 10 weeks. He had an IV pic line for IV antibiotic for about 11 weeks and self-administered IV antibiotics three times a day. He still takes a pill antibiotic to date. The leg is still swollen and hard to the touch and he has trouble using the leg. The other leg is 40% for loss of use, so the Veteran is very unstable while trying to ambulate.

This is one of those things you hear about, but this time, I knew the Veteran and it was a very hellish ordeal, with both VA and private facilities, because I believe VA made the initial first diagnosis incorrectly and the treatment weaken the Veteran causing the infection to worsen and worsen. I suspect this was an infection from the start as the initial ultrasound was not conclusive and DVT was VA’s best guess

Berta.... I am SORRY this is so long but it was a long ordeal and there was a lot going on. I think it is an 1151 claim but it may also be a malpractice suit against the first private hospital who did the MRI of the big toe but never addressed the leg which was swollen and red from the ankle to the hip. I still don’t get that. I have reviewed these records and still do not understand why someone didn’t question the VA diagnosis until the Veteran’s leg ruptured. The doctors at the hospital who did the surgery said they had never seen anything like this before.

Question: If the Veteran files an 1151 claim and it is denied by VA, is the Veteran allowed to file a civil suit against the VA after the 1151 is denied? Also, the Veteran is 90% TDIU, so an 1151 claim would not really help the vet as the VA would be entitled to recoup any funds paid out for an 1151 grant. So is there any point in pursuing this claim? Yes, I work for VA, but this case is so confusing and honestly, Berta, you have more experience in this area than most of the people I work with, including myself!!

Edited July 28, 2013 by harleyman

[Berta]

. “I think it is an 1151 claim but it may also be a malpractice suit against the first private hospital who did the MRI of the big toe but never addressed the leg which was swollen and red from the ankle to the hip.”

Yes, that is sure possible.

“ I still don’t get that. I have reviewed these records and still do not understand why someone didn’t question the VA diagnosis until the Veteran’s leg ruptured. The doctors at the hospital who did the surgery said they had never seen anything like this before. “

Yeah..I dont get that either.

“If the Veteran files an 1151 claim and it is denied by VA, is the Veteran allowed to file a civil suit against the VA after the 1151 is denied? “

Only if he/she is still within the 2 year Statute of Limits for FTCA.

FTCA is the beginning of a suit against the US of A (that's who I settled with, and the settlement was signed by the VA General Counsel.

{Private hospitals or doctors dont fall under FTCA and certainly malpractice can occur in the best non VA hosps in the country...as well as VA.

If the 1151 is denied then he could get a vet's lawyer to continue the 1151 claim.

In many cases it pays to file under both FTCA and 1151.VA denied my 1151 claim twice until I used my settlement papers from the General Counsel VA, and then they awarded.

There is an offset factor however,if one succeeds in both FTCA and 1151. It is explained here in our FTCA forum.

“Also, the Veteran is 90% TDIU, so an 1151 claim would not really help the vet as the VA would be entitled to recoup any funds paid out for an 1151 grant. So is there any point in pursuing this claim? “

YES!!!!!

If the 1151 can be traced back to his SC conditions, then no recoupment under FTCA.if you mean the FTCA Offset.

What I mean is I had a high 5 figure offset to my 1151 DIC, awarded due to VA causing death due to misdiagnosis and lack of treatment for my husbands IHD and stroke.They didnt even know he had DMII then and neither did I,until my daughter, a veteran, insisted I go over the whole 9 yards again in his med recs.

Then I immediately claimed and I proved death due to AO DMII and AO IHD.

VA had to refund my 5 figure offset because SC death trumps FTCA death.

If he succeeds in 1151 and it does not involve a SC condition there is possible combined rating to his SC rating but not a total offset..

Maybe this helps explain it better…. I was awarded accrued for my husband's 100% P & T PTSD in 1998.

In last January part of my AO IHD award involved a SMC CUE claim .that VA awarded that,paying me accrued benefits for my husband's malpracticed 100% disabling 1151 Stroke, along with the AO IHD retro.They did not combine it with his PTSD rating nor did they say,well he got 100% anyhow so no soup for you.

The regs I used are in M21-1MR Part IV, Subpart B,Chapter 3,Section D but they involve DIC claims.

This might help better..........because DIC is a different aspect of 1151....

:

:”Combine the disability rating(s) assigned to disabilities for which compensation is payable under 38 U.S.C. 1151 with the disability ratings assigned to SC disabilities, as if the former were service-connected.

If two or more disabilities (at least one being a qualifying disability under 38 U.S.C. 1151) are rated 0 percent disabling but interfere with the Veteran’s employability, the assignment of a 10 percent disability rating under 38 CFR 3.324 IS acceptable.

Note: 38 U.S.C. 1151 disabilities may serve as the basis of an individual unemployability (IU) award.”

source:

M21-1MR, Part IV, Subpart ii, Chapter 1, Section A (under G)

http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=4&ved=0CE4QFjAD&url=http%3A%2F%2Fwww.benefits.va.gov%2FWARMS%2Fdocs%2Fadmin21%2Fm21_1%2Fmr%2Fpart4%2Fsubptii%2Fch02%2FM21-1MRIV_ii_2_secG.doc&ei=mHH1UZeGC4XA8AT-uoDgCw&usg=AFQjCNH3PWlFVrhaPUPZG2fnFyWj193wEQ&bvm=bv.49784469,d.eWU

However how can the VA combine 100% SC with 100% 1151....They cant so this is why they had to pay me for the 100% 1151 separately from the 100% SC PTSD with no offset nor any funny VA combo math.

Or the VA could award SMC under 1151 in addition to the TDIU he gets now or SMC at higher level then what he gets now.They did that in my above case.....award of 100% for the 1151 Stroke and then SMC for the fact that my husband was Housebound,due to the 1151 stroke.

I will look all you posted over tomorrow Harleyman and get back to you...this is a very alarming scenario but then again I am not a doctor and the VA would need a strong IMO on all factors involving the VA here...

I dont know the process for suing a non VA hospital

.

Those blood thinners, given for the wrong condition, could have killed him.

It sounds like both his private medical care and the care from the VA came from

the Keystone Cops.!!!!!!

Edited July 28, 2013 by Berta

[Berta]

Does he have copy of his med profile......

I wonder if something else he takes such as the pain medication :

“the VA doctor did not want to fill the pain prescriptions anymore “ is or was contraindicating the antibiotics and/or the warfarin.

Probably one of the first things an IMO doctor would read is his Medication profile.

Was VA aware of (and vice versa) of any meds prescribed by the private hosp?

"However the VA and the private hospital both gave him prophylactic antibiotics." But he didn't take them all at the same time did he????

He needs copies of any private treatment medical records too.

I am a civilian. VA treated me years ago under CHAMPVA for an infection so bad that I had to spend the night sleeping with about 150 veterans.

(It was at a VAMC Ha Ha )

My med rec listed multiple potential names for and causes for the infection but they never narropwed it down and the antibiotics helped right away.

I wonder ,in this vet's case, if VA or the private ER was able to identify exactly what the type of infection was......MRSA I think was still going around when I was hospitalized by VA but I dont know if they even check for MRSA anymore.

I assume he had not taking any very long plane trips before this happened...the association of DVT to sitting in a cramped plane for many hours is a weak association but then again possible.... yet I bet it started, just as you said, with the blister that became infected.

I cant understand why the antibiotics didnt nip this all in the bud right away.If it was an infection and not DVT.

Edited July 29, 2013 by Berta

[harleyman]

Berta, I am working on reply, just finding time to give it the proper attention. - Harleyman

[GuaymasJim]

Berta, you made me spit coffee all over my keyboard with:

I am a civilian. VA treated me years ago under CHAMPVA for an infection so bad that I had to spend the night sleeping with about 150 veterans.

(It was at a VAMC Ha Ha ) Do the math: You'd have been a millionaire in Da Nang! Thank you for the best laugh I've had in weeks!

On the serious side, my best wishes for the veteran!

[harleyman]

Does he have copy of his med profile......

Yes, we have copies of all the records from VA as well as the copies from all the private providers except one- still working on that.

I wonder if something else he takes such as the pain medication : this veteran only took medication for Diabetes PN I think he took Gabapentin (sp) he never took any type of narcortic pain meds until the leg became so painful that OTC pills would not come close to touching this. When he was in the hospital they had him of IV pain meds as well as Narcotic pain pills- this was a very painful and life threatening ordeal.

“the VA doctor did not want to fill the pain prescriptions anymore “ is or was contraindicating the antibiotics and/or the warfarin.

The Va doctor’s rational was that the diagnosis of DVT which she still believed he had even though it continued to get worse and worse to the point where he could not ambulate due to swelling and pain- she should have realized that if the pain was this bad and the leg continued to worsen that there was something wrong. Her note did not even reflect the level of pain and edema there was I the leg. I can’t figure out where her head was in all of this based on the records. Hopefully , that is where Dr. Bash will come in. (I contacted him but I tld him this was not urgent so I think he will contact me in a few days or so).

Probably one of the first things an IMO doctor would read is his Medication profile.Which she had him on about 30 different medications, they are slowly being withdrawn

Was VA aware of (and vice versa) of any meds prescribed by the private hosp?- Yes, the Veteran signed the release and had all the records sent to VA, and also signed the VA forms to have the private facility send all the records to VA. I don’t know if she reviewed them but, she did tell the veteran at one point she didn’t know all this was going on with him. But the Veteran he would call and she would put him off. So I am trying to match up the dates and times and see if I can actually follow the “treatment trail tie-line”. Very time consuming. Ther was one instance that the Veteran told the VA doctor the hospital has him on antibiotic pills and he ran out would she re-fill the antibiotics and she told him to go to back to that doctor at the hospital and have him refill the prescription. I think that is BAD, I didn’t know the VA could refuse the care of a veteran like that,

???? "However the VA and the private hospital both gave him prophylactic antibiotics." But he didn't take them all at the same time did he No each time he got the antibiotics he took them until they were gone. His leg would feel better, but hen a week later it would be raging pain and swelling again.

He needs copies of any private treatment medical records too.- they are expensive, The first private hospital charged him $279.00 for “real” full copy of his records for his 5 day stay

I am a civilian. VA treated me years ago under CHAMPVA for an infection so bad that I had to spend the night sleeping with about 150 veterans.

(It was at a VAMC Ha Ha )

My med rec listed multiple potential names for and causes for the infection but they never narrowed it down and the antibiotics helped right away.

I wonder ,in this vet's case, if VA or the private ER was able to identify exactly what the type of infection was......MRSA I think was still going around when I was hospitalized by VA but I don’t know if they even check for MRSA anymore.

YES- the final hospital at the time of the emergency surgery had test come back as a streptococcus –NOT MRSA - the kind from strep throat- that’s why the vet thinks this started from his big toe. He thinks he may have walked somewhere when this blister on his toe wasn’t healed and it come into his body through the toe due to his numbness from diabetes. What I found interesting is after the VA diagnosed him with DVT and he got worse and ended up at the first hospital, and they did the MRI of the foot, they diagnosed him with an infection and cellulitis and the DVT was a secondary diagnosis. That;s when he was released and told to follow-up with the VA and he tried and she told him to go back to the hospital for the antibiotics. VA really screwed up on this in my opinion. But so did the private hospital as they never told the Veteran he had a massive infection and actually downplayed the infection telling him he might have to live with the pain and DVT for 2 years or maybe forever as DVT sometimes does not get resloved and people have to live with it.

That’s why he doesn’t think it ever was a blood clot he still believed it was an infection from the beginning. I am reading the records and it looks like the ultra sound done by VA was supposed to have some confirmation testing and it was not done, or at least I have not found any confirmation in the records yet, still looking.

I assume he had not taking any very long plane trips before this happened...the association of DVT to sitting in a cramped plane for many hours is a weak association but then again possible.... yet I bet it started, just as you said, with the blister that became infected.

No, quite the opposite he had been working at the wet/tile saw and bending and lifting walking standing laying tile. No way it was a DVT due to non-ambulation.

I can’t understand why the antibiotics didn’t nip this all in the bud right away. If it was an infection and not DVT.

They did not give them to him continually. He got a prescriptions like 5 day or 7 day supply. I think the problem was it was enough to suppress but not enough to cure the condition and little by little it got worse and worse as each time he would stop the antibiotic when the prescription ran out.

The other thing that got my attention is he did not run a fever. He had Chills but no fever/ If you look up infection and cellulitis which is what he ended up being diagnosed with they say this condition does not always have a fever and cellulitis often needs IV antibiotics from the beginning.

I am hoping Dr. Bash will take a look at this, but I need to have it all time lined out to make it easy reference and the Veteran needs to get me all the rest of the records

The more I read he more I think your statement “It sounds like both his private medical care and the care from the VA came from the Keystone Cops.!!!!!! IS TRUE!