3 The Road to Hell #vahealthcare #VAmalpractice

Added: 2026-05-18

[00:00:07]I want to clarify something that people may not know. Some chemo can affect the bone marrow where blood cells are made.

[00:00:13]That's how it fights the cancer, but this weakens the immune system and also causes anemia. It also wipes out the platelets that help your blood to clot.

[00:00:24]When they're low or zero, like Todd's were, there's a risk of spontaneous bleeding and patients are dependent on transfusions until the bone marrow recovers.

[00:00:35]According to this guy, a patient with no platelets who hits their head would be at very high and very well-known risk for serious brain bleed. The team at the Seattle VA knew this, too. For example, just 1 week before the fall, Todd reported a level five out of 10 headache. The nurse on duty knew exactly what that could mean, and she called the doctor right away. Todd was sent for an emergency CT scan, but 1 week later, on the night of the fall, Todd reported a level eight headache, a worse symptom in a more vulnerable patient.

[00:01:10]After a head injury on a tile floor, the same nurse just gave him Tylenol and left the room.

[00:01:17]She waited almost 3 hours to report it.

[00:01:21]They had no idea how long he had been unconscious, and they never once performed a proper neurological exam.

[00:01:30]There was never any neurological monitoring, even after the doctor was notified. They all knew he had hit his head and had amnesia, but there was no assessment of the severity of the TBI in real time.

[00:01:45]The Glasgow Coma Scale is an essential part of how TBI severity is determined, but it has to be done at the time of the injury, and it has to be monitored for changes afterwards. That's the whole point.

[00:01:58]That 3-hour delay and the failure to assess him using the Glasgow Coma Scale was a missed critical window of opportunity to document his baseline so they could recognize and track his neurological condition declining.

[00:02:16]As soon as the doctor was told about the fall, she ordered two platelet transfusions and sent him for a CT scan.

[00:02:23]He had two CTs that day and both were negative. But, then she dropped the ball.

[00:02:30]A CT scan doesn't rule out TBI, first of all.

[00:02:34]But, the bigger problem is that in people with anemia and low platelets, bleeding in the brain can be delayed, so it doesn't always show up on the first images.

[00:02:45]And there were no follow-up images for another 10 days, even though his mental status was worsening daily.

[00:02:53]Todd never had another pain-free day and he never got out of bed again.

[00:02:59]He spent the next week becoming increasingly confused and lethargic with headaches, neck, and back pain that was barely controlled with morphine. And he had a new sudden hearing loss after he hit his head.

[00:03:12]But, here is what I really need you to understand. That nurse is one part of a much bigger picture. Staff are required to assess fall risk every single shift for every patient. Before Todd fell, the nursing staff performed 43 of those assessments. Only four were correct.

[00:03:35]That's documented in the medical records. And after the fall, the staff failed to properly document that it happened. 76 out of 119 times.

[00:03:47]This wasn't one person having a bad night. This was a systemic failure across multiple nurses on multiple units over multiple months.

[00:03:58]Nobody caught it. Nobody fixed it. By the VA's own diagnostic criteria, what Todd experienced on July 12th was a traumatic brain injury and it was never diagnosed. Not that day, not that week, not once.

[00:04:15]What followed was a decline that nobody could explain. And the reason nobody could explain it is because the one diagnosis that made sense of everything had never been written down. By the time he died, the fall itself had been mentioned in the medical records 57 times and not one provider acknowledged his TBI while it rapidly progressed.

[00:04:41]In part four, I'll tell you about how an unbelievable series of VA failures brought Todd from having a hopeful outlook to a terminal diagnosis in 10 weeks.