David Schaper, NPR
Katrina Shank, standing next to a picture of her late husband, Bob, and what has become a living room memorial to the Air Force veteran.
David Schaper, NPR
Early in the morning on Aug. 9, Katrina Shank and her husband, Bob, made the two-hour drive from their apartment in Murray, Ky., to the VA hospital in Marion, Ill.
"The drive up, you know, we were cutting up and carrying on, we were really light hearted, you know, really comfortable," Katrina says. She was what Bob called a constant "worry wart," but on this summer morning, she says he succeeded in calming her down.
Katrina says her husband was eager to finally get some relief from painful gall stones. He was scheduled for a 9 a.m. laparoscopic gall bladder surgery, a fairly routine and minimally invasive procedure. It was so routine, Mrs. Shank says, that since she had just started a new job the week before, she almost didn't take the day off to be with her husband during the surgery. But she went along anyway.
"Before he went in, you know, before they wheeled him off, he told me that he loved me and told me to pay real close attention to the doctor, that I'd understand what he was saying," Katrina Shank said. "That was the last time I saw him alive — or awake, anyway."
Sitting at her kitchen table with snapshots of her husband in front of her, Katrina remembers that around noon, the surgeon, Dr. Jose Veizaga-Mendez, told her they couldn't wake Bob up. As her mind swirled, the doctor suggested the 50-year-old Air Force veteran may have had a heart attack or a stroke. He asked if Bob had liver damage. Bob was moved up to the ICU, where nurses continued giving him blood transfusions, but Bob's blood pressure kept dropping.
Finally, Veizaga-Mendez cut Shank open to try to find where the blood was going, but by then, Katrina says her husband had received so many transfusions that his blood would no longer clot.
"They closed him back up, brought him back into ICU, kept giving him blood through the night," she says. Then, "at 9:47 the next morning, he was gone ... just that quick."
Katrina Shank says the autopsy revealed her husband didn't have a heart attack or a stroke or liver damage, as Veizaga-Mendez had suggested. "You know, I don't know if he didn't know, or if he was trying to cover his tracks or what, but he pretty much let my husband bleed to death."
Three Cases in as Many Weeks
A week later, while back at the Marion VA hospital to sign some papers, Katrina says a hospital staffer pulled her aside, checking to make sure that no one could see or hear them. Then he told her in a hushed voice "that this doctor had up and resigned after my husband passed away," she says, " and that it would probably be a good idea to hire an attorney, because it was the third case recently, which I found out later, 'recently' was in a three-week span."
In fact, the Veterans Administration is investigating the deaths of at least 10 patients who were operated on by Veizaga-Mendez over the 20 months he worked there. Repeated attempts to reach Veizaga-Mendez and his attorneys in Illinois and Massachusetts for this story were unsuccessful.
Veizaga-Mendez, 69, was born and educated in Bolivia. He did medical residencies in the U.S. in the early 1970s. He was licensed in Illinois, New York and Massachusetts, and it appears he practiced for several years, 20 or more, in Massachusetts, without incident. Problems on his record began to surface about 10 years ago. But he didn't need any state license to practice medicine for the VA. As a federal institution, the VA is exempt from state regulations.
Before he was hired by the Marion VA in January 2006, the state medical board in Massachusetts was investigating Veizaga-Mendez for at least eight complaints against him alleging dangerously substandard care, including two deaths.
But VA officials say they couldn't have known about that, because Massachusetts is one of several states that doesn't report such investigations until they are complete.
A Troubled History in Medicine
Sen. Richard Durbin (D-IL) says there were other warning signs, though. "The fact is, this doctor had two malpractice claims filed against him in Massachusetts and one disciplinary action taken by a hospital," Durbin said. "Regardless, he was still hired by the Veterans Administration."
In July 2006, Veizaga-Mendez voluntarily surrendered his medical license in Massachusetts before it could be revoked, essentially ending disciplinary proceedings there. Durbin says the VA was informed of that action and asked the doctor about it, but was satisfied when Veizaga-Mendez said he just didn't want to pay dues in a state where he no longer practiced.
Illinois' department of professional regulations says Veizaga-Mendez's decision to relinquish his Massachusetts license triggered an investigation into his credentials in June 2007, which culminated with regulators indefinitely suspending the doctor's license last month. But that came too late for Bob Shank, and possibly other patients.
Now, Durbin says his office is hearing from whistle-blowers from within the Marion VA hospital; they claim they had warned administrators for some time that Veizaga-Mendez was dangerous to patients. "The allegations include not just incompetent administration, but the destruction of medical records and the changing of patient records," Durbin said. "That, I believe, is criminal."
Durbin wants the U.S. attorney's office for the Southern District of Illinois to investigate.
Hospital Under Scrutiny
A spokeswoman for the Marion VA Medical Center said she could not comment on those allegations. Community Affairs Officer Becca Shinneman confirms there are several investigations underway, including one by the VA's inspector general. "They're investigating deaths. They're investigating processes within our facility," she said. "They're looking at maybe personnel, training. They're looking into the building, everything."
Shinneman says the hospital has experienced a significant increase in the rate of "negative outcomes" from surgeries, including the post-operative patient mortality rate. As a result, since Aug. 31, all in-patient surgeries at the hospital have been suspended. She adds that "the hospital's director, the chief of staff, the chief of surgery, and another top official have been placed on administrative leave" while the investigation proceeds.
The Senate Committee on Veterans Affairs will hold a hearing in Washington on Tuesday on the Marion VA hospital's recent problems and on broader concerns about the medical hiring and quality-control practices within the entire VA.
A second doctor at Marion has been suspended after it was discovered that he, too, had faced disciplinary action in another state. Some fear there could be other doctors with troubled pasts working in VA hospitals across the country.