August 4, 2016
Congresswoman Ann McLane Kuster
2nd District New Hampshire
18 North Main Street, 4th Floor
Concord, NH 03301
Dear Representative Kuster,
This letter follows our conversation on Friday, June 3. As we discussed there are
numerous issues interfering with the proper care of Veterans who are patients of the VA
Center in Manchester New Hampshire. Each of these issues is serious on its own, but the real
issue is the Administrations’ unwillingness or inability to correct systemic problems. The
Center is “governed” by a Quadrad.
The leadership style adopted by the Quadrad is both insular and not focused on
patient care. There are no treating clinicians represented on the Quadrad, and the four
members ignore the views of the physicians, even those who have worked at the Center for
many years. The VA Center is run solely by an Administration whose main goal is to put on a
good face for the various entities who review their facility. The members of this foursome
have a vested interest in covering up issues that would shine a negative light on the actual
serious lapses in patient care resulting from the above behavior.
The Quadrad measures problems in the VA Center with a yardstick of how they can
provide cover for themselves. The results of this behavior have been actions or better yet,
inactions, that have endangered patients and have ruined many lives. What follows is a litany
of the many issues that have caused substandard treatment of our Veterans. The recent
example in the medical malpractice action brought in US District Court in Concord, New
Hampshire, where a judge rendered a verdict in excess of $21 million in 2015, illustrates just
how poorly this facility operates. The doctors named in that lawsuit were unfairly blamed by
the judge for actions that were not of their making. I can certainly flesh out the specifics of
what was wrong with the conclusion of the presiding Justice if need be.
The most troublesome example of the disconnect between the bureaucrats and the
clinicians is the situation involving Myelopathy, a condition that became preventable twenty
(20) years ago. However, despite this, there is a list of approximately seventy (70)
Manchester Veterans who were patients at the Center who have suffered quadriplegia or
quadra paresis, through clinical neglect as well as the lack of effective neurosurgical
intervention. These conditions as indicated above, were all but eradicated twenty (20) years
ago, when patients were given the proper neuro-surgical intervention. This shocking number

 will in fact grow at the current time because of the Administrative decisions that have
recently been enacted by the Quadrad at the Manchester VA.
The facility in Manchester, New Hampshire does not have a neurosurgeon on staff
and so patients must be referred to the Boston VA for stenosis of the cervical spine. The
Boston VA was not treating these patients appropriately and so the former Chief of Staff of
the Manchester VA, Dr. Andrew Breuder agreed to fund private “fee care” in the community
for these Veterans. Dr. W. E. Kois, a pain specialist, who became employed at the Manchester
VA in 2012, is the physician who discovered these seventy (70) cases of paralysis. For more
than three years under Dr. Kois and Dr. Breuder, these Veterans were sent to New England
Baptist Hospital in Boston to be treated by a reknowned neurosurgeon. This neurosurgeon
was shocked at the condition that he found Veterans to be in. His letter, attached herein,
illustrates his opinion on the substandard care provided to spinal stenosis Veterans at these
facilities.
When these Veterans were seen at the Boston and West Haven VA’s they were
referred to physical therapy instead of to a neurosurgeon. In some instances these Veterans
were seen by a Chiropractic Resident instead of a Neurosurgeon, which is beyond the pale.
One such patient drove his own vehicle to the Boston VA and walked into the hospital for his
surgery. At the conclusion of his surgery this patient was rendered a quadriplegic and was
forced to use a motorized wheelchair. He now has limited use of his right hand to work the
controls on said wheelchair. As stated above, this result would never occur in the private
treatment setting. Why is it acceptable for our Veterans to be subjected to such low quality
treatment?
One of the doctors who met with you is the Chief of Medicine, Dr. Stewart Levenson,
and is directly involved in securing treatment of these Veterans, but, under the current
Manchester Administration and the new Chief of Staff, Dr. Shlosser, he has been thwarted.
He has been told that there is no money in the budget to fund “fee care” in the community
and that Veterans must be referred to Veterans Choice. As you know, this is a new program
which has numerous problems, not the least of which is the refusal of many community
based doctors to accept this plan. In addition, the HealthNet telephones are answered by
unqualified persons with no medical training. This has resulted in many Veterans being
referred to inappropriate specialists. In addition, the use of Veterans Choice cuts off the
Veteran from his actual treating physicians at the Manchester VA and they are, therefore,
unable to follow up on their patients to assure that they are receiving the appropriate care.
Tragically, there are no participating neurosurgeons in this program that will see
Veterans on a timely basis. Unfortunately many providers have had difficulty getting their
fees paid under this program and refuse to see Veterans until this situation is resolved.
Although some providers have agreed to come back into the system, their stay is tenuous and
wholly dependent on the payment status. This has left many patients at the Manchester VA
languishing in pain and without care. The previously cited neurosurgeon in Boston, who is
part of the neurosurgeon practice at New England Baptist, as well as a professor at Harvard
Medical School, has agreed to see these patients on a priority basis, but the Manchester
Quadrad refuses to authorize this.

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 The decisions about patient care at the Manchester VA are made by Administrators
without input from the treating physicians or the Chief of Medicine or other Specialists. This
is not a situation that exists in the private sector. The corporate structure of the Manchester
VA is an inverted pyramid. The Chief of Medicine in Manchester has attempted on
numerous occasions to educate Dr. Mayo Smith on these serious issues and has asked for his
assistance, all to no avail.
In addition to the Administrations’ refusal to consider the doctor’s input on treatment,
the equipment at the Manchester VA is substandard and is known to be so by the Quadrad.
Although the cost of a new nuclear medicine scanner had been expensed well over a year
ago, the build out for the new scanner has been delayed to an unknown time in the future.
The old scanner is so out of date that it is off line as much as 50% of the time and it is so old
that parts are no longer being manufactured for it. Again, this impacts directly on the care
available to our Veterans.
This past winter there was an instance where dirty surgical instruments were reused
without sterilization. The instruments were placed in bags to be autoclaved but instead were
placed on the supply table. OR techs then picked up the bags and brought them for reuse to
another OR. Each bag has not one, but two indicators, to demonstrate sterility, yet no one
picked up on this error. When Administration was informed of this serious lapse, their only
concern was damage control and did nothing to investigate how and why this had occurred or
take any steps to assure it didn’t happen again. In addition, many instruments are used
beyond their useful life. The Surgery Chief discovered that the bladder curettes were so dull
that they would not cut out tumors in the bladder. When he asked for replacements he was
told by Administration that this would have to wait to be purchased until next year when a
new budget cycle started! The building is so old that flies come into the OR through the
bricks and the surgeons have had to cancel surgeries frequently because of this unsanitary
issue. The director hired the lowest bidder to eradicate the flies but the company has been
totally ineffective in solving this situation.
Another example of the low regard in which physicians are held at the Manchester
VA facility has to do with the safety and security of its doctors. There is no screening
apparatus, security guard or locked doors at the entranceway or in the hallways, which would
prevent patients from walking into a doctor’s office without notice. This became an issue
subsequent to 2012 when Dr. Kois became the only Specialist in Pain Management at the
Center. Prior to his employment at the Manchester VA, Dr. Kois was in private practice for
25 years. He was shocked to discover the rampant use of opioids in the treatment of our
Veterans in the Manchester facility. Sadly, it had been the prior Administrations policy to
start pain patients on opioids because they were cheap to buy at the VA Medical Center when
compared to definitive surgical treatment. At one point, Dr. Kois tried to prescribe topical
non-steroid gels or oral Cymbalta, but was denied and told to use opioids first, because they
were cheaper. Fortunately he refused to do this and has been successfully weaning Veterans
off said opioids. However this has come with a personal cost to Dr. Kois.

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 In the past six months several unhappy Veterans, not the majority of pain Veterans,
but a small group, who are at high risk for overuse or diversion of the drugs, threatened the
life of Dr. Kois when he cut them off. They did this in writing as well as verbally and
specifically mentioned using guns and aluminum baseball bats to kill him. This was reported
to the Security personnel at the VA and a meeting was held by the Quadrad to address this
issue and a decision was made to install a secure door for his office. The security door has
not been installed. This event occurred more than four months ago and when asked about the
status of the security door the Administration stated that it is “in the works”. Meanwhile,
when a threat was made against some Administrators, a security door was installed within a
week.
The treating physicians and clinicians at the Manchester VA are woefully
understaffed. They lack Physician’s Assistants, nurses and secretarial help. Oftentimes nurses
must assist four or more physicians. The doctors must type their own reports and they must
wait for more than a week for their dictated chart notes to be transcribed. Unfortunately this
lag time has resulted in numerous instances where the lack of continuity of care has
negatively impacted the patient. Again, complaints about these issues fall on deaf ears.
While hiring a needed clinician is woefully difficult, if not impossible, adding new
layers of ineffectual bureaucrats happen routinely. In the past new hires have been made for
data safety officers, patient safety officers, compliance officers, research compliance officers,
privacy officers and most recently, an attorney was hired for Risk Management.
At the Manchester VA , the Quadrad has a complete distrust of the clinician to the
point of total exclusion from decision-making processes that directly involve patient care. A
prime example of this is in the decision made two years ago by Administration to purchase a
$1.4 million dollar cardiology camera without consultation with the Cardiologists. When said
camera arrived at the Manchester VA facility the Administration discovered that it did not fit
into the space that the old camera was occupying. To this date this $1.4 million dollar camera
remains in a warehouse waiting for a larger room to be built in Cardiology to house it.
Meanwhile the Manchester VA is left with an old camera that only functions half the time
and as a result, once again, the Veterans suffer.
An easy illustration of these priorities are demonstrated by a look at the employee
parking lot. Out of the 800 vehicles parked in that lot, only 80 belong to clinicians who
provide direct patient care. As I stated to you during our meeting with the five doctors
currently employed at the Manchester VA, these doctors are greatly concerned about the
substandard care that the VA in Manchester provides to our Veterans, and they have failed in
all attempts to have their voices heard or to find a person above them who will take
corrective action. Each of them became VA physicians because of their deep commitment to
the care of our Veterans and each are totally frustrated with their ability to provide care. The
Administration in Manchester has failed and continues to fail to provide these physicians
with the necessary resources to do their jobs.
These doctors have asked me to assist them in being heard by Mr. Shulkin and you
have graciously agreed to present their concerns to him. If needed, the Chief of Medicine as

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 well as the Pain Management Specialist and a cardiologist are happy to come to Washington,
DC for a personal meeting with Mr. Shulkin.
Thank you for your attention to this matter and the doctors truly appreciate your time
and input and concern about these important issues. I will be happy to provide any other
documentation which you feel is needed to move this forward.

Sincerely,

Andrea Amodeo-Vickery
aamodeovickery@aol.com
(603) 625-6441
AAV/mrw
cc: Dr. William Kois
/mnt/cloud_crowd/document_import/unit_19597395/d20170712-32160-174fshq/VA-2.docx

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