LAS VEGAS (KLAS) — They served our country, and veterans should expect to get the care they deserve. But in one case the 8 News Now I-Team is uncovering, a veteran may not have received lifesaving measures he should have.
Video was leaked to the I-Team because of concerns about how an 88-year-old Marine Corps veteran was treated after a medical episode. The incident occurred at a VA medical clinic on the east side of Las Vegas on June 7, 2021.
We want to warn you — some of the video is disturbing.
We showed the video to neurosurgeon Dr. Scott Glickman, who runs his own medical office, and attorney Larissa Drohobyczer, who says she has experience in medical malpractice, so they could both weigh in about medical care and the response time of staff at the clinic.
The veteran is seen struggling and then collapsing. A bystander immediately tries to comfort him.
More than 30 seconds later, an officer arrives and appears to call for help.
“Where is the nursing staff? Or doctor staff, or some tech person?” Dr. Glickman asked as he reviewed the video.
There is a puddle of blood underneath the veteran’s head that gets worse by the minute.
“Okay, tik tok, it’s been like a long time already,” Drohobyczer said.
Two minutes later, a woman identified as a nurse by I-Team sources arrives.
“Here comes somebody with a monitor. She’s not moving very quickly,” Glickman observed.
She appears to check for a pulse. At three minutes, she removes his mask.
“I would have expected maybe somebody to start CPR, some kind of resuscitation,” Drohobyczer said.
After four minutes …
“She’s saying get over here, she’s got the AED, the defibrillator,” Glickman said. “There should have been much more fuss, much sooner, I would expect.
At four and half minutes …
“So one person, the lady in blue, finally comes running,” Glickman observed.
She begins CPR, but Dr. Glickman points out no one is delivering air to the patient sooner.
“There (are) multiple people around that could be helping,” he said. “They seem to be doing a lot of standing around rather than, ya know, getting things done.”
Vanessa Murphy: How critical is this situation?
Dr. Glickman: He’s dying.
After 11 minutes, the Clark County Fire Department shows up. They assess the patient and do CPR as a team and appear to deliver breaths.
“It’s commendable,” Glickman said.
The veteran is taken to a hospital and pronounced dead.
Drohobyczer said, “It’s sad. It’s emotional that somebody … you’re in a facility where you think that you’re going to get medical attention and you think people are going to run to your rescue. That’s just not happening here.”
She continued: “You could assume that there would be an older population that would be visiting this clinic and that they would have proper policies and procedures to deal with a medical emergency.”
The I-Team sat down with William Caron, the head of the VA Healthcare System in Southern Nevada.
Vanessa Murphy: Do you think care was delayed? Hands-on care to this patient?
William Caron: So without getting into the details of that patient, I would have to say no.))
What we didn’t tell Caron at the time of this interview is that we have the video.
“I’d say we responded accordingly that you would see in any other healthcare clinic of that nature,” Caron said at the time.
He said all clinical staff are trained in basic life support and CPR. But he also told us that his staff did a refresh on emergency management procedures after this happened.
Vanessa Murphy: I mean I would think in a medical setting like that you should be able to get more lifesaving care.
William Caron: Yeah, unlike a hospital setting, there’s no crash cart. There’s no code blue response.
But as Dr. Glickman points out, air still could have been delivered to the patient. “The biggest fail on this is that they did not put oxygen on the patient immediately and they did not deliver breaths for 10 minutes,” he said.
Monday morning, after the VA learned we had the video, a spokesman sent a lengthy email stating mistakes were made that led to a delay in initiating basic life support, suggesting the delay was caused in part by a transition of staff and management due to the pandemic.
The statement appears below:
VA Southern Nevada Healthcare System Statement on June 7, 2021 incident at Northeast Las Vegas VA ClinicCHARLES W. RAMEY,
On June 7, 2021, a Veteran patient appeared to have a cardiac event while in the waiting room of the Northeast Las Vegas VA Clinic and fell to the floor. Clinical staff responded and initiated basic life support within approximately five minutes of the beginning of the incident, and emergency 911 was activated for higher resuscitation capability and transport to an emergency capable facility. Paramedics arrived within 11 minutes of the start of the incident and the Veteran was transported to the Sunrise Medical Center Emergency Department where advanced cardiac life support was continued until a decision was made to discontinue resuscitation efforts. The patient was pronounced deceased shortly thereafter.
Immediately following this incident, VA Southern Nevada Healthcare System Emergency Management reviewed its medical emergency response processes and procedures to identify improvement opportunities for managing in-clinic emergencies at our geographically separated units.
The event at the Northeast Las Vegas VA Clinic happened during a transitional period of staffing and management changes due to the pandemic. As a result, many staff were still in a telework status as we worked toward providing expanded on-site services and face-to-face appointments during COVID-19 contingency operations. Due to the pandemic response and the split operations, regular emergency management response training and exercises were limited. VASNHS’ review determined that these factors contributed to staff at the Northeast Las Vegas VA Clinic being insufficiently prepared to handle an unplanned medical emergency at the time of the incident, resulting in a delay to begin initiating basic life support. Specifically, the review found that:
a) There was no clearly established command and control during the incident, and no one quickly took control of the scene as required by the Emergency Operation Plan; and
b) Staff did not quickly deploy supplies and equipment required to manage the emergency.
Emergency Management, VA Police and Nursing Professional Services conducted refresher Incident Management and Life Safety training for all staff at the Northeast Las Vegas VA Clinic within two weeks of the event, and all staff at VASNHS’ other outpatient VA Clinic in the weeks that followed. The training re-educated staff on:
a) Use of the Emergency Operations Plan and how to establish incident command and properly respond to medical emergencies (to include specific assigned roles and responsibilities for site managers, VA Police, nursing, primary care, mental health and social work leaders); and
b) Reorientation on the location and proper use of life safety equipment and PPE to provide first aid and basic life support; as well as specific procedures to address cardiac arrest.
Additionally in the weeks, following the incident, VASNHS conducted comprehensive training on emergency medical response and notification procedures at each outpatient clinic, validating training with functional exercises. VASNHS also realigned VA clinic site managers directly under executive leadership to establish clearer roles and responsibilities, lines of authority, and command and control for day-to-day operations and emergency situations.
In closing, VA Southern Nevada Healthcare System is saddened by this event and our condolences go out to the Veteran, his family, and all affected. VASNHS takes its obligation to provide southern Nevada’s Veterans with the best care and services possible seriously. This includes being proficient in training and competencies and ready to respond quickly at an appropriate level during emergency events and we will do everything in our power to mitigate any delays in the future.
Chief, Communication & Customer Experience
VA Southern Nevada Healthcare System (VASNHS)
The veteran’s daughter said the family was not aware of any video or possibly delayed care, she asked us not to identify her father, and the family was told he died of a heart attack.
No autopsy was done to help determine an exact cause of death, so we don’t know if the delay in care contributed to his death.
And what about the woman seen walking with the cart, the first employee to respond? Our sources say she was promoted shortly after.