Published July 13, 2010
ST. LOUIS – A former medical supply technician at the St. Louis VA Medical Center told a congressional hearing Tuesday that she warned more than a year ago that dental equipment sterilization was inadequate, but her pleas were ignored.
Earlene Johnson spoke at a special hearing in St. Louis called by the House Committee on Veterans' Affairs. The committee convened the hearing after the VA sent letters two week ago, warning 1,812 veterans treated at the St. Louis dental clinic that lapses in sterilization of dental equipment potentially exposed them to viruses including hepatitis B, hepatitis C and HIV.
A VA official said Tuesday that some veterans have since tested positive for the viruses but it was too soon to tell if the dental equipment was the cause.
Johnson had worked at other VA hospitals and went to work in St. Louis in December 2008 in the sterilization division. She did not work directly in the dental division but said she saw flaws in dental sterilization.
She said that starting in March 2009, she tried to alert VA officials at the St. Louis center and in Washington about the inadequacies, but no one listened. It was a full year later that VA notified veterans of the sterilization problem and urged them to get blood tests. Meanwhile, Johnson was fired — she believed because of the concerns she raised. She is appealing to get her job back.
"What happened in the dental clinic shouldn't have ever happened," Johnson said during emotional testimony. "If people were taking their jobs seriously, not passing the buck and pointing the finger, none of this would have happened."
The VA determined in March 2010 that lapses in dental sterilization had occurred from Feb. 1, 2009, through March, 11, 2010. As part of the investigation, dental services chief Danny L. Turner was put on administrative leave. An internal investigation is planned in addition to the congressional inquiry.
Dr. Robert Petzel, VA undersecretary for health, said the problem arose because workers prewashing dental equipment failed to use a detergent before the equipment was sterilized.
"Even though the risk of infection to our veteran patients is in this instance statistically low, the psychological consequence of the error is a high price to pay for those men and women who have already paid so much on behalf of this nation," Petzel said in written testimony to the committee.
Procedures have been corrected, Petzel said, so those who have undergone procedures since March 11 are not considered at risk.
Dr. George Arana of the Veterans Health Administration said 950 veterans have come in for free blood screenings so far, and some have tested positive for hepatitis B, hepatitis C and HIV. He would not say specifically how many have tested positive nor what viruses they had but stressed that more testing is necessary to determine the cause.
St. Louis VA medical facilities provide services for veterans in Missouri and Illinois. Five members of the Missouri delegation and two from Illinois participated in the St. Louis hearing in a packed courtroom of the Eagleton U.S. Courthouse.
Veteran Terri Odom told the committee she went to the dental clinic for partial dentures and noticed "dirty and rusty" molding pieces and a filthy room. Odom told the committee she suffers from severe post-traumatic stress disorder from military sexual trauma while serving in the Navy.
"So with my panic attacks and anxiety level already on overdrive, this terrible mistake by the VA has made me even more anxious," she told the committee.
Veterans Affairs Committee chairman Bob Filner, D-California, said his concerns extend beyond the inadequate sterilization. He wondered why problems were substantiated in March, but no one was told until the June 28 letter and news release.
"I think that's intolerable that it took those four months before everybody was notified," he said. "It just seems to me we have to do a far better job, not only with the transparency of the mistake, but in the counseling and handling of people."
Petzel agreed the response was too slow.
"We did not respond quickly enough," he said under questioning from Filner. "We took too long to investigate this and we took too long to notify you."
VA officials have said the delay was because officials were evaluating the risk posed to veterans.
Other VA centers around the country have had problems in recent years.
In 2007, Walter Reed Army Medical Center in Washington came under scrutiny over concerns about conditions at the hospital and treatment of veterans. That same year, a surgeon at the VA hospital in Marion, Ill., resigned after a patient bled to death following gall bladder surgery. The VA found at least nine deaths between October 2006 and March 2007 resulted from substandard care at the Marion hospital.
In 2008, inadequate sterilization of endoscopy equipment at VA centers in Florida, Georgia and Tennessee potentially exposed 10,000 veterans to viruses including HIV and hepatitis.
"The problem I have is every time we have a hearing on one of these incidents, VA says we've put in new procedures and controls and it's not going to happen again," said committee member Jeff Miller, R-Florida. "But it happens over and over again."