Acting Veterans Affairs Secretary Sloan Gibson on Thursday had no criticism of a local policy that barred a VA emergency code team of health providers from responding to a 71-year-old Vietnam veteran who collapsed in the Albuquerque VA cafeteria last month and later died.
JEMS: Veteran Dies Waiting for Ambulance in New Mexico Hospital Cafeteria
But Gibson told a press conference that he has ordered a "rigorous" review of what occurred from the moment Jim Napoleon Garcia collapsed on June 30 "until quite frankly up to this moment right now."
"The fundamental question I ask myself is, did we do everything we reasonably could do in difficult circumstances to save this veteran's life?" Gibson said Thursday at the VA's education building.
Gibson praised the bystanders who gave CPR to Garcia until Albuquerque Fire Department paramedics arrived about 11 minutes after being summoned via a 911 call made from the cafeteria.
The bystanders included members of the U.S. Air Force's 377th medical group who were eating lunch at the time.
After about 20 minutes of trying to revive the unresponsive Garcia, Albuquerque paramedics assisted in his transport to the VA emergency room, where he was pronounced dead. He died of an apparent heart attack.
"I know it's counterintuitive - it was to me - that we call an ambulance when someone's stricken on a medical campus," Gibson said. But, he said, there are "very good reasons" why that is the proper action under certain circumstances.
A 4-year-old local VA policy establishes certain areas of the 100-acre VA campus in Southeast Albuquerque in which a VA "Code Blue Team" is to respond to emergencies.
The cafeteria lies about 500 yards from the medical center, where there is an emergency room, but the cafeteria isn't included in the response area.
Locations outside the designated code blue areas are to be served by Albuquerque paramedics.
Dr. Tom Lynch, assistant deputy undersecretary for health for clinical operations, accompanied Gibson to New Mexico.
"I think everything was done to help this veteran," Lynch said. "I think, though, that if we are going to be a great health care system we need to examine what we did, we need to learn from it and we need to improve what we do so we can deliver better care to veterans in the future."
Ideas under review are to train more VA medical center personnel in advanced lifesaving techniques and setting up "crash carts" of equipment and resuscitative medications in more locations on the VA Medical Center campus.
"There are a number of (VA) medical centers that use the same policy," Lynch said. "We're going to look at this as a systemwide issue. We're going to not just ask the question about New Mexico. We're going to ask the question across our health care system."
Gibson did chide local VA officials for their public response to Garcia's death.
"One of the areas that we did not distinguish ourselves was in the openness and the transparency that we displayed in the earliest days and hours after this happened," he said. "I think we have sort of a reflex action that when something bad happens we sort of close up."
Transparency has been a goal of Gibson's since he assumed the leadership of the VA after the resignation of former Secretary Eric Shinseki in May.
The shake-up came amid a nationwide scandal over falsification ofpatient appointment records, and reports in the VA Medical Center in Phoenix that up to 40 veterans died while on a secret waiting list.
The VA Medical Center in Albuquerque is among the 80 or so nationwide that have been the focus of a VA criminal investigation into why schedulers altered medical records to hide long wait times for care.
Gibson said Thursday that he didn't believe records at VA medical centers were falsified to help top managers qualify for hefty performance awards, as has been suggested.
"I don't think it was about bonuses," Gibson said. "I think it was cultural. What happened is we let metrics get in between us and veteran. And the metrics became an end in and of itself."