"I talked to one guy who can't touch his wife anymore. He's been married 25 years," said Brown. "He was one of the unlucky ones (who has an infectious disease)."
According to the York VA Medical Center's Web site, on Dec. 1, 2008, staff at the G.I. Clinic noticed a discrepancy in tubing while conducting a routine colonoscopy. After a complete review, the Tennessee Valley Healthcare System and the VA's National Center for Patient Safety could not rule out the possibility that an incorrect valve was used that day.
Ultimately, even though the Tennessee Valley Healthcare system believed the occurrence was isolated, all patients who received colonoscopies at York campus between April 23, 2003, and Dec. 1, 2008, were notified to come in for precautionary testing.
According to June 1 numbers on the York VA Web site, 6,805 patients were potentially affected, and all were notified. Of that number, 6,503 responded to the VA's outreach and agreed to be tested for possible infection. A total of 512 patients declined testing or appointment, while 302 patients are subject to continuing VA outreach efforts.
A total of 5,140 patients have been notified of test results, with six having the Hepatitis B virus, 19 Hepatitis C cases and one case of HIV exposure.
Brown continues to go to the Murfreesboro hospital regularly for medical care.
"It's pretty good," he said, "but they ought to get their equipment right."
Problems run deep
In a tell-all book, Rudolph Cumberbatch, 77, a retired chief of surgery at the York VA, hurls numerous criticisms at the VA health system, and at procedures between the Murfreesboro and Nashville campuses in particular.
"Two of the major problems were the mixing up the instruments from both campuses during the repackaging after sterilization, and the damage of the smaller and delicate instruments, particularly eye instruments, during the transportation back by truck to Murfreesboro," he wrote.
But Cumberbatch maintains that there were no incidents of botched tests reported while he was there.
"From 2001 until I left (in 2005), there was no incident" of an improper valve being used, he said.
Cumberbatch joined the Veterans Administration after 18 years of private practice in Washington state, beginning as chief of surgery in Cheyenne, Wy. He later served in similar capacities at VA hospitals in Salisbury, N.C., and Topeka, Kan., before moving to Murfreesboro in July 1992.
He spent 13 years in the Tennessee Valley Healthcare System, which oversees both York and Nashville VA campuses, with most of his time as chief of surgery at the Murfreesboro site.
The last four years of his employment, he was assistant chief of surgery over quality assurance. His specific assignment during that time was to review all the clinical data, internal and external reports. He had to evaluate the data and make recommendations for improvements on the quality of surgical care being delivered at the York and Nashville VA campuses.
In his recent book, "Failure Masquerading as Success," he writes:
"There are two critical reasons why the Veterans Healthcare System continues to be a dismal failure in multiple locations, including the Middle Tennessee region: An air of arrogance, a complete lack of knowledge and curiosity of the past history of the institutions by those folks chosen to manage these institutions ..." (and) "the level of mediocrity, lack of understanding of the basics of the health care delivery they are managing, and in many instances, the lack of integrity which exists among the many directors, associate directors, chiefs of staffs and other managers currently in the VHS."
He goes on to cite problems resulting from the process of sterilizing all surgical instruments from the York VA and the Nashville campus.
In speaking with The Murfreesboro Daily News Journal, Cumberbatch said that if any incidents of an improper valve being used were reported in Murfreesboro from 2001 to 2005 he would have known about it; he thinks the valve mix-up happened later.
"I think it is a valve mix-up in Nashville," Cumberbatch said. "All the valves were cleaned in Nashville, and none were cleaned (in Murfreesboro)."