Eb Davis visits his wife at her grave. She died in 1994 after a military nurse anesthetist gave her the wrong medicine (Sam Deaner / for the 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. 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. 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 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."

next: Nonphysicial workers given more authority

day 4 index:
part 1: Double Standards of Care
part 2: Nonphysicial workers given more authority
part 3: Nurse gives anesthesia without full training
part 4: 'Where was the doctor?'