Lorali Spearman of Suisan City, Calif., says her son Bob was affected by her cancer. 'He's very angry ... It's like the cancer took his mom away and replaced her with this person who is physically disabled.' SAM DEANER / FOR DAYTON DAILY NEWS

Lorali Spearman thought the man in the white coat was a doctor. So when he dismissed the lump on her breast as harmless, she thought she was getting sound medical advice.

Three years later, the lump had grown to the size of a softball, and surgeons were forced to remove her breast and some of her chest muscles.

The man in the white coat was no doctor. He was a physician assistant with a degree in sociology and two years of additional schooling. Yet, at the Air Force base clinic in California where he worked, he and three other physician assistants were seeing most of the patients.

A Dayton Daily News examination found that the military sometimes cuts costs and fills doctor shortages by allowing medical personnel without medical degrees or licenses to provide the same care that civilians frequently get from licensed doctors.

Some states allow expanded roles for nonphysicians, too, and some civilian medical facilities, especially in rural areas, rely on them. But in the military, they're used throughout the services in hospitals of all sizes and often with less supervision than states require for civilian practitioners.

Spearman is not the only one who paid a price.

Medlyn Lyons had to rely on a nurse anesthetist to administer anesthesia when she went into labor at a South Carolina military hospital. The mother's pulse rate dropped dangerously low, and Lyons' baby was born brain-damaged.

Jose Tirador was left brain-damaged after a nurse anesthetist trainee was allowed to administer his anesthesia before surgery at an Army hospital in Hawaii. The trainee, who had a 10-to-20 percent error rate administrating epidurals during the previous year, allegedly injected about four times the required dose of anesthetic into Tirador.

Kris Knowles was left severely brain-damaged after the Air Force assigned `medical service specialists' with approximately eight weeks of training to monitor the infant's temperature at an Air Force Base in South Dakota. The specialists, looking for a rising temperature, failed to report that his was dropping.

"In the military, sometimes, people are asked to do a lot more with a lot less," said Dr. Scott Hadaway, an Air Force Reserve doctor who works as an anesthesiologist at Miami Valley Hospital in Dayton.

Because a wounded soldier on a battlefield can't wait for a doctor, the military often gives nurses, medics, physician assistants and other medical personnel more authority than their civilian counterparts. But the military doesn't limit their authority to the battlefield.

The physician assistant who treated Spearman said in a deposition that four physician assistants were seeing most of the patients at the California military clinic where he conducted the breast examination.

`They use them because they can't hire doctors for what they pay,' said Stephen Merrill, a former Navy lawyer and former special assistant United States attorney in Norfolk, Va.

They also use many of them with the full blessing of Congress. In 1982, Congress eliminated the requirement of physician referral and supervision for some nurses and social workers. In 1986, Congress sought to eliminate physician involvement with all other mental health professionals, questioning "whether such services can be delivered in a more cost-effective manner without the intervention of a physician."

Sen. Daniel K. Inouye, D-Hawaii, who helped sponsor the 1982 bill, has fought to make maximum use of Army nurses because he feels they are highly skilled, and using them is `highly cost-effective,' said Patrick H. DeLeon, the senator's chief of staff.

Department of Defense officials, in a written statement, said: "All practitioners in our military hospitals may practice within the scope of privileges granted each hospital in which they serve. As in civilian hospitals, privileges are based on an individual's training and experience as well as the needs of the hospital."

Nonphysician workers given more authority

The military tried to put restrictions on some nonphysician medical personnel in 1983, issuing a directive that put nonphysicians under the supervision of a doctor "in all patient care activities that determine, start or alter a regime of medical treatment.'

But the restrictions have been slowly removed in recent years.

In 1988, the military canceled the directive, replacing it with one that offered no clear rules regarding supervision of some health care workers.

In the 1988-89 National Defense Authorization Act, the House Committee on Armed Services stated that it was "extremely skeptical" of a proposal to require anesthesiologists, doctors specializing in administering anesthesia, to supervise nurse anesthetists. The committee noted that some small hospitals with no anesthesiologists to supervise nurses wouldn't be able to administer anesthesia at all if the directive were enforced.

The committee was also concerned that restrictions would `adversely impact the morale of nurse anesthetists and possibly hurt recruiting and retention.'

Nurse anesthetists are registered nurses trained to administer anesthesia. They are required to have about seven years of college education and specialized medical training.

Anesthesiologists are doctors with about 12 years of college and medical training.

Unlike many civilian hospitals, the military doesn't require nurse anesthetists to be directly supervised by anesthesiologists. Civilian nurse anesthetists often work unsupervised in clinics and small hospitals, but the military policy extends even to many of its largest hospitals and medical centers.

On Aug. 1, 1995, the Army implemented a new regulation, expanding the roles of nonphysicians by allowing them to practice under less supervision. The new regulation allows nurse anesthetists to practice independently as long as an anesthesiologist can be reached by phone.

If there's no anesthesiologist in the operating room, the doctor in charge can supervise the nurse - even if the doctor has little experience in dealing with reactions to anesthesia.

`The most beautiful baby I'd ever seen'

There wasn't an anesthesiologist in the hospital when Medlyn Lyons went to Moncrief Army Hospital at Fort Jackson, S.C., to give birth to Desiree Delilah Lyons by Caesarean section. There was only a nurse anesthetist, and she had to be called from home.

Many hospitals in America not only require an anesthesiologist to be in the building, they require the doctor to either administer the anesthesia or personally supervise no more than three, usually two, certified nurse anesthetists at a time.

`It's the way our medical malpractice (insurance) provider likes us to operate,' said Dr. Peter J. Wilson, anesthesia director at Miami Valley Hospital.

On the day Lyons had her baby, by virtue of the 1995 regulation, Dr. Irving Russell Smith supervised the nurse anesthetist, Maj. Lois J. Schretenthaler.

Smith didn't see Lyons until 17 hours after she was admitted, having been tied up with patients at the civilian hospital where he also worked.

Smith also had no experience supervising nurse anesthetists. He acknowledged in a deposition that he was not competent to administer the anesthesia himself and was unaware of the policies regarding supervision of nurse anesthetists.

"The nurse anesthetist at every other (civilian) medical center that I have trained at was supervised ... There was an anesthesiologist at the head of the patient," Smith said in a deposition.

The same is true for Miami Valley Hospital.

"There's somebody (an anesthesiologist) here 24 hours a day, 7 days a week," Hadaway said. "That's a big difference."

Lyons wasn't admitted to Moncrief until 1:20 a.m. By that time, Schretenthaler was home.

Schretenthaler's training in obstetrical anesthesia came from the military. Her primary instructors were not anesthesiologists but other nurse anesthetists.

She first administered an anesthetic to Lyons' spine. But when the surgeon touched Lyons with a clamp, she complained of pain and Schretenthaler gave Lyons general anesthesia for the surgery.

Then the problems started.

An alarm sounded, indicating an abnormal drop in the mother's pulse rate, and Smith noticed the mother was not getting enough oxygen, which also affects the unborn child.

Dr. Smith said in a deposition that Schretenthaler was having trouble opening Lyons' mouth to help her breathe.

"I can't get the mouth open," Smith quoted the major as saying.

The nurse then put a breathing mask on Lyons. In the meantime, Smith said, he decided to do "sort of an unusual forceps delivery."

She was born brain-damaged.

"This child was perfect - just a beautiful child," said Charles L. Henshaw, Jr., a Columbia, S.C., attorney who represented Lyons. "This child went from being the most beautiful baby I'd ever seen to being deformed."

The Army negotiated a settlement with the family that could pay $8 million to $10 million over the life of the child.

Nurse giving anesthesia without full training

Jose Tirador didn't get a nurse anesthetist for his elective surgery at Tripler Army Medical Center in Hawaii in May 1992. He got a student who hadn't finished her nurse anesthetist training.

The student, Elizabeth Ohland Kelly, first had trouble getting the needle into the epidural space in his spine.

Soon after, a doctor became concerned about Tirador's condition. A surgical resident wrote on a chart that Tirador had received four times the normal dose of Lidocaine.

"In quick succession, he rolled his eyes up, apparently in loss of consciousness, and had some involuntary movement of his extremities and an immediate indication of drop of blood pressure and lowering of the pulse, slowing of the heart rate," Dr. Arthur F. Thompson said in a deposition.

Thompson, a civilian anesthesiologist working under contract, was put in charge of watching Kelly, who had a 10-to-20 percent failure rate for epidurals during the previous year. Thompson had been at Tripler less than 10 days. He had never met Kelly, and in 15 years of practice in Montana, had never worked with a student nurse anesthetist before.

He had worked at a small hospital in Montana and planned to retire in 1992, but he spotted an advertisement for "short-term relief physicians" needed by the Army in Hawaii and decided to go.

Following his seizure, Tirador's surgery was canceled. The next day, Tirador was wheeled into an operating room again, with the hospital using the same consent form from the previous surgery. He was again given spinal anesthesia by Kelly, the same student nurse accused of botching the procedure the previous day.

After the second surgery, Tirador suffered brain damage, lost control of his bowels and bladder and suffered severe depression. He had a stroke in 1994, and he died about a year later.

The family sued the government, claiming the second surgery was done before he had recovered from the first. The government settled out of court, giving the family a six-figure amount.

'Perfectly healthy child ... brain damaged'

Had even a nurse known about Kris Knowles' temperature, he might be a normal child today.

The infant was taken to Ellsworth Air Force Base hospital in South Dakota in 1989 for a fever. Put in charge of monitoring his temperature were `medical service specialists' with approximately eight weeks of training each, according to a lawsuit the family filed.

The Knowles family (from left) are Jane; Bene, 9, William; Kris, 7; Randi, 13; and Kody, 7. Kody is the twin of Kris, who the family says suffered brain damage as an infant when Air Force medical 'specialists' with about 8 weeks of training failed to notice his temperature was abnormally low. DAVID PURDY / FOR THE DAYTON DAILY NEWS

Even some of the training military technicians receive has raised questions.

In August 1996, the Air Force Audit Agency found that 31 of 74 Air Force Reserve medical technicians studied were granted skill upgrades before they completed all their required training. In addition, 12 other technicians either had trainers or training certifiers who were not qualified.

Nine of 18 medical units reviewed by the Audit Agency did not maintain needed documentation of the training.

William Knowles, an Air Force jet mechanic who served 20 years in the service, recognized the rank of the people taking his son's temperature as among the lowest in the service. Not a sergeant among them.

`When you're dealing with 22-year-old boys, you don't expect them to know much,' he said.

The specialists were supposed to notify a supervisor of abnormal temperatures, but William Knowles believes they thought that only meant high temperature. Kris' temperature was falling, not rising.

`He froze to death, literally, and died on us a couple of times," said Knowles, now retired.

The Air Force paid the Knowleses $1 million, the limit under South Dakota law. But the state's Supreme Court overturned the law after reviewing Kris' needs, and the family is now free to seek more damages for Kris, who will need constant care the rest of his life.

"I said, `I don't see how I can give you a perfectly healthy child and you give me back a child who is 30 percent brain-damaged,''' Knowles said.

`Where was the doctor?'

Like other nonphysicians in the military, physician assistants are sometimes given greater responsibilities. They provide examinations, diagnoses, recommendations for medications and even do minor surgery. Some states allow physician assistants expanded roles, too. But in the military, they're not required to be licensed, though they must be certified with the national association of physician assistants.

`As a regulator, that's not something we're comfortable with, people roaming around without supervision,' said Lauren Lubow, who oversees the processing of disciplinary actions for the State Medical Board of Ohio.

Ann Davis of the American Academy of Physician Assistants said every state except Mississippi requires physician assistants to be licensed, and a few states grant licenses only if a doctor licensed in the state agrees to directly supervise the practitioner.

A 1996 survey by the academy shows that 4 percent of all physician assistants are full-time military members. Less that 2 percent of all the nation's doctors practice in the military.

Civilian doctors can be disciplined just for hiring unlicensed physician assistants. Last year, Virginia reprimanded a doctor for not ensuring a physician assistant was licensed.

But in the military, even medical personnel who work in the White House aren't required to be licensed. James C. Brennan's California medical license expired in April 1994. He was one of two Navy physician assistants listed as being assigned to the White House.

Though the Navy didn't require a license to work in the White House, Brennan said, the state of West Virginia required him to get a license this year to do clinical training for a graduate program.

The man who treated Lorali Spearman had a license to be a physician assistant, but he said in a deposition that he did "things that family practice docs do."

Spearman remembers the day in October 1989 when she found the golf-ball-sized lump on her breast. It was the same day the World Series was at Candlestick Park, the same day the San Francisco earthquake hit. She was 32 years old.

Worried, she got an appointment as soon as possible at Castle Air Force Base, where her husband worked. At the base, she saw a man with a white coat.

"I assumed he was the doctor ... He didn't touch me. He didn't examine me in any way, shape or form,' she said. "He wanted me out as quickly as possible.'

"I asked him: 'Could this be cancer?' He said, 'No, not unless you have a black or bloody discharge coming out of the nipple...' He said: 'Go home and don't worry about it.' I have those words burning in my memory. So that's what I did. I went home, and I didn't worry about it.'

Her medical record shows that she was told she should get yearly mammograms after she turned 50.

In three years, the lump grew to the size of a softball. It was cancer. Doctors did a modified radical mastectomy, removing her breast and much of the chest muscle around it. Five other surgeries followed.

The man who examined her, Antonio Luza, trained as a medic during the Vietnam war, had a bachelor's degree in sociology and two years of school to become a physician assistant, but he prescribed medication, did exams, made diagnoses and did minor surgery.

Luza acknowledged during an interview that it's possible he told Spearman the lump was not dangerous, but he said a mammogram test came back negative. He said his own sister had breast cancer at the time, so he knows he would have been concerned.

"I should have made sure somehow she followed up," he said. "We're basically caring people."

Doctors told Spearman she likely would never have lost her breast had the lump been removed years earlier.

"All my hair fell out. I was sick to my stomach. I couldn't eat ... I am clinically depressed. I had a nervous breakdown,' Spearman said. "My whole family has changed. My son thought he had caused me to have the breast cancer. He's very angry ... It's like the cancer took his mom away and replaced her with this person who is physically disabled.'

People at her church asked her, "Where was the doctor?' she said.

Spearman sued, and the Air Force paid her $350,000.

`They're taking care of too many people,' she concluded. "Not enough doctors, and too many people.'

Sidebar to Part 6

THE PATIENTS
MISTAKE ENDS VETERAN'S BOND WITH MILITARY
* Eb Davis' wife died in 1994 after a nurse anesthetist gave her the wrong medication.

Part 7:

Laws And Rulings Shield Doctors
Military personnel and their families often can do nothing when victimized by the military's health care system.