Southern California Navy Hospitals Are Navigating in Troubled Waters : Inquiry Blames Overwhelmed System for Malpractice Suits and Settlements

Southern California Navy hospitals show alarmingly high rates of medical malpractice, symptomatic not of a handful of incompetent doctors but of a system overwhelmed and outflanked, trying to treat too many people with too few doctors and health workers.

A 4-month Times inquiry into malpractice and the quality of patient care at the three Navy hospitals--San Diego, Camp Pendleton and Long Beach--has found 25 cases involving malpractice errors that have left 13 people dead and 12 injured--including five babies who suffered birth injuries from which they cannot recover. Almost all of these cases have occurred in the last five years.

Navy records released under the Freedom of Information Act show a total of 53 malpractice cases at San Diego, Camp Pendleton and Long Beach that the government has settled since 1982--with an additional 169 pending. But the inquiry found evidence that naval records--which only have been computerized in the last couple years--are incomplete and that the true number of settled and pending malpractice cases may be greater.

Who Studied the Cases

Analysis of these and other Southern California Navy malpractice cases included reviews by civilian medical consultants, scrutiny of court and medical records and interviews with Navy and civilian doctors who treated the victims.

Although civilian and Navy attorneys agree settlements in military malpractice cases often are significantly lower than in civilian litigation, the Navy, at just these three hospitals, has paid at least $10.8 million to malpractice victims in the last three years--nearly six times per bed as much as the often-maligned Los Angeles County public hospital system.

While Navy and Defense Department figures that have been released do not cover the identical period, totals suggest pay-outs for the Southern California hospitals account for a disproportionate share of the Navy’s total.

For 1982 and 1983, all Navy malpractice pay-outs totaled $14.5 million. From 1982 through 1984, malpractice payments for all three services increased from $29.0 million to $41.3 million a year.

Government and civilian experts cite two factors that hold down the number of lawsuits against military hospitals and physicians: the structured disciplinary system of the military that generally inhibits litigation, and a legal doctrine, now being challenged in Congress, that bars active-duty personnel from suing, no matter how badly they are injured by physicians and medical personnel.

‘Apples and Pomegranates’

Though the Navy and the Department of Defense contend that military medicine in general and Navy medicine in particular result in malpractice allegations significantly less often than civilian practice, observers ranging from Sen. Pete Wilson (R-Calif.) to lawyers who specialize in medical litigation agreed that while a comparison of the military and civilian health-care systems is tempting, the two are so different that intelligent comparisons virtually are impossible.

“It’s like apples and pomegranates,” said one malpractice insurance executive with experience in civilian hospitals. The comparison is difficult because military health-centers function as sort of a cross between public facilities like County-USC Medical Center and programs like Kaiser’s health- maintenance plan.

Figures that are available imply that the Navy’s malpractice experience is far worse than that of the Los Angeles County Department of Health Services--$12,138 paid out in verdicts and settlements for each bed in the three Navy hospitals versus $2,071 per bed in the three largest county centers during the last three years--and that the three Navy hospitals in question pay nearly twice as much as the average California civilian hospital in claims the Navy settles or loses in court. Statewide, reported paid claims against hospitals averaged $103,873 in civilian centers last year, with the Navy paying an average of $204,297.

Wilson--who has taken what his aides say is an unexpected leadership role in Congress’ mounting concern over the quality of military medicine--said in a Washington interview that he may ask congressional investigators to look systematically into military medical facilities all over the country. A separate General Accounting Office probe is under way, with a report expected in 1986.

Surgeon Investigated

Recent interest in Congress has been piqued by the case of Dr. Donal M. Billig, a Navy heart surgeon in Bethesda, Md., currently undergoing proceedings that could result in his being court-martialed for gross negligence in the deaths of five patients. It would represent the first court-martialing in memory for alleged negligence by a military doctor, the Defense Department said.

The Billig case, which first came to public attention more than a year ago, already has prompted all three services with medical corps--the Navy, Army and Air Force--to tighten disciplinary and quality-assurance programs. A crackdown has resulted in 66 military physicians--including 28 in the Navy--being stripped of their practice privileges and reported to civilian license officials in a 14-month period. A total of 101 military doctors have been slapped with less serious restrictions growing out of incompetency cases.

Yet the Times inquiry found no evidence that the equivalent of a Billig case exists at the three Navy hospitals in Southern California. In fact, only two physicians’ names appeared in more than one of the cases studied; those two doctors--who each was linked to two cases--were only minor figures in each.

Instead, the problems with Navy medicine--and armed forces medicine in general, apparently--are that it is a worldwide bureaucracy in which patients often are forced to endure care in which they seldom see the same physician more than once; find their records in constant disarray--with harried doctors and paramedical personnel often too busy to carefully review a new case, and crowd into overburdened specialty clinics. (Vice Adm. Lewis H. Seaton, the Navy’s surgeon general, said there are only enough surgeons and other specialists to deal with the equivalent of the number of active-duty personnel, who account for 25% of the patients at Navy hospitals.)

The Navy’s problems--at the three hospitals in question and in Navy medicine in general--are typified in the cases of Mathew Titus, 3 1/2, and Philip Cote, 68, two people at different ends of life’s spectrum, living in places far apart and who have not met. Mathew suffers from the aftereffects of botched heart surgery at San Diego and Cote has massive, terminal lung cancer that Navy doctors in San Diego and Camp Pendleton failed to diagnose for 10 months.

Southern California Navy medicine is atypical, even by military standards. Because of growing concentrations of Navy ships and personnel in San Diego and Long Beach, the large Marine detachment at Camp Pendleton and the clustering--by Navy estimates--of as many as 750,000 military retirees in this part of the state, the three Navy hospitals serve a patient load that is made up of 44% active-duty personnel, 32% dependents and the rest retired.

The system is huge, by any measure. Military medical operations have a budget of $9.6 billion, including $2.1 billion for the Navy, alone. With 170,000 health workers--13,000 of whom are doctors--military medical facilities have as many physicians as New Jersey, Massachusetts or Michigan. On any day, 23,500 people are patients in the 168 military hospitals--31 of which are Navy.

Navy medical care provides for the needs of 250,000 inpatients, 13 million outpatients, 34,000 newborns and 150,000 surgeries a year.

Overwhelmed by Caseload

In Southern California, the problems imposed by the sheer volume of care are particularly overwhelming and will get worse, top Navy officers agree. For example, in 1978, five ships were assigned to Long Beach; 35 are there now and the number is to reach 55 by the end of the decade.

The San Diego hospital staggers under an average load of 723,000 outpatient visits a year--64,200 a month these days, with 2,350 a month admitted. But to deal with this demand, San Diego has 287 staff doctors and 210 physicians still in training. To cope adequately, said Capt. Harold Koenig, the hospital commander, San Diego would require a staff as large as the entire Navy Medical Department and a physical plant with at least four or five times the 615 beds the hospital has.

“And you couldn’t run such a hospital,” Koenig said.

“There seems to be a constant repetition of the same kind of case,” said Sheldon Deutsch, a prominent San Diego medical malpractice attorney who defended dozens of Navy cases while he served as an assistant U.S. attorney in San Francisco and San Diego until resigning 12 years ago. Litigation against Navy hospitals now accounts for the largest single share of Deutsch’s practice. Navy medicine, Deutsch said, often becomes nothing more than a disjointed series of fruitless encounters between patients and either corpsmen or nurses who often are put in situations in which they must diagnose cases they cannot understand.

Dozen Cases Uncovered

Under these circumstances, even the most serious illnesses and most ominous danger signs often are missed because normal medical logic--in which the most serious possible diagnoses are ruled out first --is not followed. A dozen such cases were uncovered in the Times inquiry, typified by that of Mary Garcia, 28, the wife of a Navy enlisted man, who went four times to the emergency room at San Diego Naval Hospital and once to its internal medicine clinic early last year complaining of high fever, diarrhea, a bad cough and dizziness.

At each visit, she was told to get plenty of bed rest, drink fluids and take Tylenol. On March 2, vomitting, her diarrhea continuing, coughing incessantly and running a fever of 104 for the fourth day, she went back to the emergency room only to be sent home again by a corpsman who described her case in the medical record as “non-emergent.” She returned to the hospital for the final time three days later with her condition unchanged. Still, no one ordered even a chest X-ray. She was sent home yet again.

The next morning, Mary Garcia died of undiagnosed bronchial pneumonia--a cause of death virtually unheard of in young people treated in private practice in the United States today, according to a civilian doctor who reviewed the Garcia record for The Times. The family is pressing a malpractice suit. To San Francisco lawyer John Link, representing the Garcias, the case underscores a basic problem.

“If (all you say is), ‘Take two aspirins and go home’ often enough,” Link said, “you’ll have a lot (of) 28-year-olds die of bronchial pneumonia.

‘Lack of Communication’

“I think some of the things wrong in military medicine--especially Navy--are the lack of communication or systematic recording of complaints (in the record) so that subsequent treating doctors can find out what the essence of the case is, know the history of the patient and do something about it.

“What’s wrong is very basic. If there is no communication (between doctor and patient), there is a failure to make a prompt diagnosis. If there is a failure to make a correct diagnosis, you can’t undertake timely treatment. You lose the patient and the government is going to lose a lot of money. The government should not have to pay for this ongoing, recurrent negligence.”

In Washington, Wilson has already held three Senate subcommittee hearings on military medicine and said a fourth may be scheduled to accommodate unexpectedly intense public interest. A House subcommittee chaired by Rep. Dan Glickman (D-Kan.) conducted hearings on a series of horror stories about malpractice among active-duty service personnel so striking that the House passed--by a 317-90 vote that crossed party lines--a Glickman bill to repeal the legal restriction that makes it impossible for active soldiers, sailors and Marines to sue.

A similar measure is pending in the Senate where, though it is supported by Sens. Edward M. Kennedy (D-Mass) and John Glenn (D-Ohio), its prospects for passage this year are uncertain. The Department of Defense opposes it, contending the bill would damage military discipline. Sponsors believe President Reagan would veto it if passed.

Wilson, who said he would have vociferously opposed such legislation six months ago--before he conducted hearings of his own--said he is not sure now how he would vote on it, but that his uncertainty now springs from fears about adding to the already enormous amount of litigation in American courts and not because he doubts there is a major problem in military medicine.

“Each of the services has some real horror stories,” Wilson said. “It is pure speculation whether (the growing number of horror stories) accurately profiles service health care at large. But there is no question that they (the horror stories) have occurred and (there are) some awful ones. The extent to which they have occurred you can only infer from what data are available and that is, unhappily, pretty incomplete.

“With respect to uniformed, active-duty personnel, there is probably a greater number (of malpractice cases) than we know about and it could be (even) more widespread than among dependents (and retirees), where you do have some statistical basis.”

This year’s hearings have represented one of the first times military medicine has come under intense scrutiny of a type to which many other public facilities--like the Veterans Administration and local county and state hospitals--have long been accustomed. By many accounts, the continuing parade of lurid accounts by injured patients and their families has begun to take a toll on morale in military medicine.

“We have been devastated in Navy medicine by the bad press we have gotten--some of it, obviously, deserved, because some of the cases were problem cases and the Billig situation is a real disaster to us,” said Commodore James Sears, commander of the San Diego-based Naval Medical Command’s southwest region, which takes in all three hospitals examined in The Times’ inquiry. “I think one of the perspectives that’s often lost when people look at Navy medicine is the workload and the magnitude of the stuff we do and the places that we do it.

‘Oversimplification’

“In perspective, the number of problems--which you’re always going to have in a medical system--is really quite reasonable. A lot of the press we’ve gotten, we have felt, has been a great deal of oversimplification of cases and some sensationalism.” Sears complained, in particular, that some cases that have made their way into national media accounts of what has been identified repeatedly as the “mess in military medicine” are more than a decade old and don’t represent current practices.

“I have no fear of being compared to civilian hospitals,” Navy Surgeon General Seaton said at his Pentagon office. “I have confidence we will show up well.”

But there are indications that within the Navy, in particular, a debate is raging behind the scenes over whether military hospitals can be as good as civilian ones--and whether they should try to be. In a blunt August memorandum to Seaton, Capt. E. S. Amis Jr., commanding officer of the Bethesda, Md., Naval Hospital, concluded that “the absolute best the Navy can hope to attain in comparisons with the civilian community . . . is a medical system not unlike the community hospital, though we may delude ourselves by talk of the ‘best health care delivery system in the world.’

“No one familiar with the best the civilian community has to offer in any way believes this platitude. We must realize that significant differences exist between civilian and military . . . institutions. We simply cannot continue to support the fleet (with preparations for wartime medical care) and keep our programs going in the current atmosphere which requires (us) to meet civilian standards.”

Some Navy officers have even begun to question whether the publicity over quality assurance problems in the military may eventually lower morale to the point that greater problems develop. “The (public) perception is that we’re the one part of the health-care system that is in deep trouble and the civilian world is not,” San Diego’s Koenig said. “. . . I fear that if this role continues, eventually we will become that way, because (our) people believe we are that way and they will give up.”

Capt. Mary Hall, commander of the Long Beach hospital, disagreed, however, saying in a group interview with three other top Navy health officers that “the integrity and pride in the system will not permit that. We will take our hits.”

‘Volume Medicine’

Like many observers, Glickman--who as a congressman receives his own medical care at military facilities and said he has experienced the impatience of waiting for two hours for an eye examination at Bethesda--said he believes military medicine is staffed by a large number of caring physicians and health workers who simply are overwhelmed by the volume of patients.

“This is volume medicine,” the Kansas Democrat said in Washington. “This is what you would have for everyone if we had national health insurance. Just by its very nature, (it) does not permit the kind of individualized attention that civilian medicine does.”

Long Delays, Red Tape

Navy lawyers who handle malpractice claims said suits sometimes may be brought on simply because patients grow so angry with long delays and other bureaucratic difficulties. The extent of the problem seldom has been systematically explored in any service, but in a recent survey of the Fort Bragg, N.C., Army hospital, the National Military Family Assn.--an organization of dependents that has been critical of military health care--said it found that in July, only 1,868 requests for outpatient appointments were granted of a total of 10,902 requests and that the Fort Bragg hospital makes patients wait for four to six months for a breast cancer X-ray examination, three or four months for an appointment with an ear, nose and throat specialist and as long as months for an examination by an orthopedic surgeon.

“I think that in the real serious cases, the military (health facilities) are generally as good as civilian ones. I’d say the problem is in that mass between a common cold and a heart attack,” Glickman said.

“I think (if I were not a congressman) myself, if I had something wrong with me, unless I were an emergency and had no choice, I would not go to a military hospital.”

There was no such choice for then-Marine Corps Pfc. Donald Titus and his wife, Beth, who learned, weeks after son Mathew was born at the San Diego Naval Hospital in 1982 that the boy had a small birth defect in his heart that required immediate surgery in which an opening in the heart would be tied shut. But the surgical team blundered and tied off the artery supplying blood to his left lung, instead--then failed to realize the mistake for more than two weeks.

Doctors who tried to piece the case together later were baffled by how the Navy failed to detect the error--much less than by how it could have been made--since the surgery Mathew was supposed to have (to close a defect called a patent ductus arteriosis) normally produces a dramatic, overnight improvement in a child’s condition. Mathew got worse, instead, but, said his mother, Navy doctors kept telling the parents everything was normal and not to worry.

Dr. Iraj Kashani, the UC San Diego pediatric heart specialist who eventually treated Mathew, said the most likely explanation for the initial blunder was that the Navy doctors who did the surgery were inexperienced, untrained or both in operating on the heart of an infant. A civilian expert who reviewed the case for the Navy confirmed Kashani’s suspicions. “I would guess that if it had been picked up the first day after surgery, there may have been hope to save the lung,” Kashani said. “It (the mistaken obstruction of the artery) was there and it should have been picked up.”

By the time Navy doctors answered the pleas of Donald and Beth Titus and referred Mathew to Kashani’s nearby hospital, the left lung seemed virtually unsalvageable. Eventually, the Navy paid the boy’s parents $300,000 to settle the case--a sum lawyers and doctors familiar with the case said would have been far greater if the child could be reasonably expected to survive to adulthood.

In the three years since the error was made and left unrecognized, the boy has had other heart problems and now requires more surgery--this time an attempt using experimental techniques to re-establish some left-lung function. If that doesn’t work, doctors have told his parents, who now live in Iowa, not to expect Mathew to live to his 10th birthday. Donald Titus accepted his discharge from the Marine Corps last year.

Halt to Surgery

Though the step comes too late to help Mathew, Koenig, who took over as commanding officer of the San Diego Navy hospital three months ago, said he recently imposed a prohibition on pediatric cardiac surgery in the hospital because such cases are unrelated to the primary military mission of Navy medicine and because they represent unacceptable risks. “I can’t support that (heart surgery on children). I have to pick and choose and I try to make the kind of surgical experiences (Navy surgeons) have be the ones that will help them in a combat environment.” Sears supported Koenig’s action, saying, “This is an example of a service the Navy should not be involved in.”

All the Titus family can do now is hope. Last Monday, Mathew came home from his latest surgery at the University of Iowa Medical Center. In a complicated operation, surgeons tried to bypass the portion of his left pulmonary artery that remains closed. The surgeons noticed, Beth Titus said late in the week, that the arterial passages are quite small and said the doctors said they could promise nothing.

Speaking by phone from her home in Muscatine, Beth Titus said of the surgery: “They (Mathew’s doctors) said they won’t know until the future if it worked or not.”

Outlook Dim

If Mathew’s prospects for survival are uncertain, Philip Cote’s are worse.

A retired Navy chief petty officer who served aboard ships in the South Pacific in World War II, Cote sought help in October, 1984, at the Camp Pendleton hospital after he was bothered by a bloody cough. He’d recently had heart surgery and took the cough to be a bothersome post-operative complication. Doctors took X-rays and told Cote (pronounced “COAT-ee”) not to worry; it probably wasn’t serious. He should return to his home in an Oceanside mobile-home park and wait, they said.

The results never came, and after 10 months of waiting and--by a count of records kept by Cote’s wife, Marjorie--27 more visits to the Camp Pendleton and San Diego hospitals, Cote found out why. His initial lung X-ray had been lost--at least for a time--and none of the doctors who had seen him in the ensuing months recognized the error or realized something was catastrophically wrong. One doctor told him he needed an emergency X-ray scan, but when the Cotes went to another department in the San Diego hospital to get it, they were notified in June that the scan could not be done for four months.

Had the original X-ray been analyzed and the results acted upon, it would have shown doctors that Cote had lung cancer in October, 1984--a fact of which Cote was not informed until July. One mystified Navy doctor confirmed in Cote’s medical records that the tumor clearly had been recognizable in the first X-ray, only no one formally diagnosed the case or told Cote what was wrong with him.

By the time the cancer was diagnosed, Cote had given up on Navy medicine and sought treatment from civilian physicians--one of whom, Dr. Vincent Bradley, is a Navy veteran who holds a reserve commission as a captain. Bradley, who served at the San Diego and Camp Pendleton hospitals, left Navy medicine earlier this year after more than nine years on active duty.

He said that what happened to Cote at the two health centers does not surprise him. He left the Navy, he said, because “I didn’t want to be responsible for people who are not competent or qualified.”

Cote’s cancer is an extremely serious type--oat cell carcinoma--that few survive. But Cote is still alive, a little more than a year after the diagnosis should have been made--and despite the 10-month delay in beginning his treatment. Those factors, Bradley said, have led Cote’s doctors to suspect he might have had a reasonably good chance of surviving for at least a few years if therapy had begun promptly.

A blunt-talking general internist, Bradley has an analysis of what happened in the two Navy hospitals that is characteristic of reviews by other doctors and attorneys of Navy medical performance in case after case:

“That cancer should have been spotted earlier. It was there (clearly) on the X-rays 10 months before. I think somebody screwed up.”

Late last week, Cote said by phone that his condition continues to deteriorate. He has developed noticeable weakness in his legs, he said, though he hopes to find a physical therapy program that can help him.

It is difficult for Cote to sit through an interview now. His rapidly progressing cancer is constantly painful. In a conversation in the living room of his mobile home a few weeks ago, Cote’s voice occasionally trailed off into sobs.

“I love the Navy,” Cote said in a weak, child-like voice as he cried. “But what in the hell am I going to do? What is she (Marjorie) going to do when I die?”

Teri German was 28 and three to seven months’ pregnant--Navy medical records conflict over how far along she really was--when, one day in October, 1983, she sought treatment at the Camp Pendleton Naval Hospital because she had pain in her right side and symptoms suggesting a urinary tract infection.

A nurse performed a routine examination, noting there was either no sound of the heart tones of German’s unborn baby or that the sound was weak. The nurse, German and medical records agree, suggested that a doctor try again to listen for the fetal heartbeat.

Given a Prescription

The doctor on duty, a lieutenant who has since been transferred, declined, saying, German recalls, “I’m the doctor and I know what’s wrong with you.” With that, he dispatched her with a prescription for a pain reliever and told her she would feel better the following morning. The doctor had made what even the Navy would later concede was a serious error: Not only had he not thoroughly examined German, but he prescribed Motrin, a drug clearly labeled in standard reference books as dangerous for pregnant women.

Things weren’t any better two days later and German returned to the hospital only to be sent away again--this time with a prescription for Tylenol and ampicillin.

German’s symptoms did not improve and, on Oct. 29, 1983, she returned to the emergency room where she confronted the same physician--who again declined to listen for fetal heart tones. It was at that point that German lost her temper, angrily refusing to accept treatment from the man who took the extraordinary step of signing a notation in her chart conceding that “patient refuses to be seen by me because of supposed misdiagnosis.” The doctor also noted that he told German if she wouldn’t accept care for him, she would have to wait at least 2 1/2 hours for another physician.

What no one had discovered was that German’s unborn son was in dire trouble. Finally, on Nov. 1, 1983, other doctors took her to surgery and delivered her baby dead.

German and her husband, Tom, a Marine Corps sergeant, filed a formal complaint. Months later, the Navy agreed to pay the couple $10,000 for the wrongful death of their unborn son and government attorneys even included an unusual acknowledgement that German’s baby was killed by “negligent treatment” and the use of inappropriate medicines. The amount of the settlement was low, said John Tranberg, the Germans’ attorney, because under California law--and military malpractice claims, though adjudicated in federal court, are tried under the tenets of prevailing malpractice law of the state in which they are filed--unborn fetuses have little financial value in litigation because no long-term financial hardship has been imposed on the parents.

Still Are Bitter

The settlement decree, signed in September of this year, acknowledged that a formal investigation had been conducted in the case before the government decided to admit fault. German and her husband are still bitter about it.

The German case is one of the smallest settlements listed in the official Navy roster of malpractice actions released to The Times. But Tranberg and Kathryn Cooney, another Vista lawyer who has handled numerous Navy childbirth injury cases, agree the German case is typical of a pattern clearly evident at the Camp Pendleton hospital--and in San Diego, too.

The problems have not gone unrecognized at high levels of the Navy command. Camp Pendleton and San Diego have inaugurated drastic programs to reduce the number of deliveries they attempt--referring the rest of the cases to civilian hospitals. The delivery pressure is explained at least in part by an unforeseen development throughout the military, where women have come into uniform in unprecedented numbers in the last decade.

Today at San Diego, said Koenig, the most common admitting diagnosis among active-duty sailors and Marines has nothing to do with trauma, infectious disease or broken bones. It is pregnancy--accounting for more cases than the next two most common diagnoses, combined, Koenig said. Camp Pendleton, which was averaging what Navy commanders said was a dangerously high total of 200 deliveries a month--with a staff of five obstetricians--has been ordered to try to drop the number to 125. But, said Capt. Donald Hagen, the hospital commanding officer, continuing demand by female Marines and dependents has made it impossible to reduce the number to fewer than about 155 a month--a figure Hagen said still is unacceptably high for the number of trained obstetricians assigned to the base. Cases not delivered in the hospitals are referred to civilian doctors and paid for under the Civilian Health and Medical Program of the Uniformed Services, a type of health insurance.

When Hagen reported to his post 15 months ago, he said, a review of the poor quality of obstetrical care at Camp Pendleton prompted him immediately to strip one of his five obstetricians of his practice privileges. “We recognize that obstetrics has been a particular problem,” Hagen said.

Fewer Babies Delivered

At San Diego, Koenig said concern over the quality of obstetrical medicine prompted a reduction from 400 to 300 deliveries a month--a figure that still makes the Navy hospital the second- or third-busiest delivery room in the county.

German said she knows of perhaps a dozen other Camp Pendleton wives who have vowed not to deliver in the base hospital because they judge giving birth there to be too risky. Though a spokesman for nearby Tri-City Hospital said it has noticed no major infusion of Camp Pendleton obstetrics cases, Cooney and Tranberg said they had heard similar reports from on the base.

Both lawyers are former Marine Corps officers and still hold reserve commissions. They have also handled Camp Pendleton birth-injury cases previously, they said, and Cooney recently settled a case in which a pregnant woman was detained at Camp Pendleton for four hours while inexperienced physicians tried ineffectively to monitor her baby’s heartbeat. When that failed, instead of recognizing the woman was in the advanced stages of toxemia of pregnancy, Camp Pendleton doctors sent her by ground ambulance to San Diego--ignoring the availability of helicopter services. The baby died en route and the mother barely survived. The Navy eventually paid a cash settlement.

Cooney, who grew up as the daughter of an Army officer and has been intimately familiar with service hospitals for her entire life, said that, as a Marine officer, she was once embarrassed by a senior Navy doctor because she was the only woman among a group of officers scheduled for physical examinations by a local hospital commander.

When it got to be Cooney’s turn, though, a secretary emerged from a side door and told her she would have to see someone else because “the captain says he doesn’t do women’s physicals and things.”

“I took ‘and things’ to mean Pap smears and pelvics,” Cooney said.

“Maybe they (Navy doctors) resent looking at long lines, because there are always long lines of sick women at any military hospital,” Cooney said. “There is definitely an attitude: ‘I’m doing you a favor, so enjoy it and get off my back.’

“It’s like Baskin and Robbins in that you get the next doctor who’s free. They aren’t going to read all of your records. They don’t have time. They are the prisoners of being overworked.”

The Times learned from Navy sources that there have been at least two major internal investigations of the general performance of the obstetrics and gynecology department at Camp Pendleton in the last year. The Navy declined to disclose a list of investigations at the two hospitals and Long Beach, as well--saying such reports are for internal use only.

Navy Surgeon General Seaton confirmed that obstetrics and gynecology--as well as women’s health care, in general, has sparked significant concern. Seaton said the Navy is gradually closing down the inpatient obstetrical service at Long Beach so doctors and nurses can be redistributed between Camp Pendleton and San Diego in an attempt to reduce the incidence of poorly handled cases.

Long Beach obstetrical patients will be seen by civilian physicians in the Los Angeles area if the plan comes to complete fruition, Seaton said. Commodore Sears said the selective shutdown of obstetrics departments at eight Navy hospitals may become a pattern for further consolidation of specialty services at Navy facilities all over the world. A meeting of specialists from throughout the service has been set for later in November to study plans for such a program.

The acute problems with women’s health care have been spotlighted, too, as a major finding of congressional investigators and Defense Department experts. Rep. Glickman said he believes the pervasive problems with women’s health care grow directly out of the conflict between the wartime mission of military health care--to repair trauma from battle wounds and prevent and treat disease that can keep troops out of combat--and the practice of routine obstetrics and gynecology.

“Women’s disease have not historically been a focus of military medicine,” Glickman said. “Parasitic tropical disease? They (military health officials) have been interested in it for years. But up until maybe 10 years ago, I don’t think they treated tremendous numbers of women at the major military medical centers (like Bethesda Naval Hospital and Walter Reed Army Hospital near Washington).

“I don’t think it (women’s health) got a lot of attention from the top down. That has begun to change.”

A close review of malpractice cases at the Long Beach, Camp Pendleton and San Diego Navy hospitals shows that Philip Cote’s missed lung cancer is far from an isolated incident in which a single patient got lost in the Navy’s medical bureaucracy. And lawyers and House and Senate investigators agree that, were it not for the blanket ban on lawsuits by active-service personnel and other factors, the armed services would probably be sued for malpractice far more than they are.

The absolute prohibition on suits by active-duty personnel has a more pronounced effect on Southern California Navy hospitals than the nationwide total since 44% of hospital users here are on active duty versus just 25% of the Navy-wide total. San Diego attorney Deutsch said he turns down about 10 clearly valid malpractice cases a year just because the victims--as active sailors or Marines--have no standing to sue.

Even when cases are filed, they often are more difficult to litigate than civilian ones, said Deutsch, Tranberg and Cooney. Because military doctors and patients are transferred so often, it is difficult to reassemble or locate parties to a suit when litigation has been filed. Cooney tells a story about settling a wrongful-death case involve a mishandled Camp Pendleton delivery that she settled for $25,000 at her client’s instructions because the father--a Navy enlisted man--and his wife were being transferred to Guam and all doctors who had cared for the mother had been transferred, too.

Cooney estimated that trying the case might cost $50,000--to fly witnesses in from all over the world. The family opted to take the government settlement offer. But, to this day, Cooney said she is confident a civilian suit would have produced a much larger settlement.

Moreover, while Navy attorneys--who discussed the situation on the condition they would not be identified--cautioned that hospital-by-hospital comparisons should be interpreted with care, Navy figures indicate there may be pronounced disparities in the malpractice performance of the local hospitals.

From July 1, 1982, to Sept. 9, 1985, for instance, the number of pending administrative complaints alleging malpractice--a mandatory first step that must be taken before a court suit can be filed against the Navy--rose from 35 to 83 at San Diego and from 11 to 34 at Camp Pendleton, but declined at Long Beach, from 19 to 17, defying a national malpractice trend in government and private health centers. The number of such preliminary claims settled with money payments was the same--four each--for Camp Pendleton, with 155 beds, and Long Beach, with 122. San Diego, with 615 beds, settled 13 cases.