In June 2016, newly-deployed surgical staff who had recently arrived at the clinic at Al Udeid Air Base in Qatar started to clean a colonoscope there ― and made a disturbing discovery.

That colonoscope, as well as the clinic’s other endoscopes used for upper and lower gastrointestinal procedures, had not been cleaned and sterilized properly, potentially exposing patients to blood-borne diseases such as HIV and Hepatitis B and C.

What’s worse, it was a problem stretching back to April 2008 ― and as many as 135 patients had procedures using those medical tools during that eight-year span.

But the first of those 135 patients would only find out about their mishandled medical care and potential exposure nearly a year later.

According to emails obtained by Air Force Times via the Freedom of Information Act and written responses to questions from the Office of the Air Force Surgeon General, the effort to figure out a plan to notify the patients, answer their questions, and offer testing and care to make sure they had not been infected dragged on for months.

“The delay in notifying patients is frankly unacceptable,” one unidentified colonel from U.S. Air Forces Central Command at Shaw Air Force Base, South Carolina, said in a March 29 email, at least five months after officials began discussing the need to send registered letters notifying affected patients. But, the colonel said, the delay “occurred for various reasons all of which are being addressed.”

That email was sent to two other colonels, whose names were also redacted, and AFCENT commander Lt. Gen. Jeffrey Harrigian, who oversees the war against the Islamic State.

In a statement, Harrigian said he’s committed to the safety of all personnel assigned to AFCENT locations. As soon as Harrigian learned about the problem, he said, he immediately told his medical team to figure out what happened, coordinate with the necessary agencies, and keep him posted on how they would proceed, which he said they did.

“Although the notification process took a considerable amount of time due to a number of complexities associated with the deployed setting and the rotational construct of AFCENT personnel, I am confident the appropriate steps were taken to notify affected personnel,” Harrigian said.

“I‘ve directed my team to leverage the findings of the quality assurance investigation on this matter and move forward with the development of a comprehensive clinical quality and patient safety oversight process to ensure and enhance patient safety for all deployed AFCENT airmen and coalition personnel who receive treatment at our medical facilities. I am committed to ensuring these deployed warriors receive the best medical care possible so they can remain focused on the warfighting mission.”

There is currently no indication anyone contracted a disease from the improperly-cleaned equipment at the clinic, which is run by the 379th Expeditionary Medical Group. The surgeon general’s office said 41 patients have so far contacted their primary care provider or a healthcare resolution specialist provided by the Air Force. Of those, 27 have completed all the testing, and the tests came back negative.

Larine Barr, a spokeswoman for the surgeon general, said in June that the risk of infection was very small because all service members are required to have a negative HIV test before they deploy, and that the Air Force also tests for Hepatitis B.

‘Just starting the process’

In the written responses, the surgeon general’s office said that Al Udeid leadership investigated the problem and, in late fall 2016, decided that affected patients needed to be notified. All patients who had an endoscopy during that eight-year period were considered potentially affected, the office said.

But progress was slow.

There were several reasons for that delay, the surgeon general’s office said. Finding and notifying the patients was complicated ― too complicated for Al Udeid to take on. Most of the clinic staff and patients who may have been involved or affected had long since returned to their home stations, so the Air Force Medical Operations Agency at Joint Base San Antonio-Lackland in Texas took on the responsibility of notifying them.

Viable addresses needed to be tracked down to make sure the letters ended up in the right hands. And patients who were no longer eligible for care at a military treatment facility needed a “secretarial designation” allowing them to get onto a designated base for care.

But before people could be notified, the Air Force needed a comprehensive plan spelling out how the patients should go about getting counseling and medical follow-up treatment.

On March 29, Maj. Gen. Dorothy Hogg ― the Air Force’s deputy surgeon general and head of its Nurse Corps, who on Oct. 17 was nominated to be the service’s next surgeon general ― said in an email to officials that “Al Udeid should not move forward with contacting any patients until we have clearly evaluated the potential risk and made a plan on what kind of follow up and/or recommended treatment should be done.”

Ultimately, the surgeon general’s office said, the first round of notifications went out to 32 patients on May 31, and a second group of 60 patients were sent notifications June 15. The Air Force mailed notifications to two foreign nationals July 20.

Also, 44 patients ― presumably those who weren’t eligible to get on base anymore ― were sent “secretarial designee” letters Sept. 15. The last seven patients could not be located, even though the Air Force searched five different databases.

Patient safety

The surgeon general’s office said the problem came about because the clinic’s medical technicians didn’t have the right skills and expertise to properly keep the equipment clean ― especially in a deployed environment.

“A contingency hospital is not staffed with expertise in upper or lower GI [gastrointestinal] endoscopy infection control because GI endoscopy is not a clinical procedure related to contingency support,” the surgeon general’s office said.

The Al Udeid clinic hoped that offering endoscopy services on-site would mean fewer service members would have to be flown to other locations for that procedure, the surgeon general’s office said. The clinicians deployed knew how to operate the equipment properly, the office said, but the medical technicians didn’t know how to clean the equipment in accordance with the manufacturer’s guidelines and monitor infection control.

“GI endoscopy equipment requires a robust ‘hand-off’ between technicians, and that could not easily be sustained in a deployed setting given the frequent rotations,” the surgeon general’s office said. “This enabled the long period before the noncompliance was detected.”

The Air Force said in June that the Al Udeid clinic no longer provides endoscopies or colonoscopies.

“GI endoscopy is no longer performed at [most] deployed medical units,” the surgeon general’s office confirmed.

Endoscopies still are conducted at the Craig Joint Theater Hospital at Bagram, Afghanistan, the office said, and the proper training of technicians there has been verified.

AFCENT and the Air Force Medical Service are working on a “comprehensive clinical quality and patient safety oversight process,” the surgeon general‘s office said.

“While a formal process is being completed, newly-revised quality assessment tools are being used by patient safety and clinical leaders at all AFCENT military treatment facilities,” the surgeon general’s office said. “There are frequent and recurrent patient safety cross talk opportunities with all [Air Force] facilities to transparently discuss patient safety and clinical quality issues and concerns.”

Stephen Losey is the air warfare reporter for Defense News. He previously covered leadership and personnel issues at Air Force Times, and the Pentagon, special operations and air warfare at Military.com. He has traveled to the Middle East to cover U.S. Air Force operations.

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