Veteran’s Stroke Exposes Blame Game For VA Versus University Surgeons


University Surgeons

One veteran’s near death from malpractice at Minneapolis VA exposes how VA shirks its duty while paying university surgeons while letting students learn on sick veterans.

The players in this game are the Minneapolis VAMC and government contractors like the University of Minnesota Physicians’ Cardiothoracic Surgery Services. That department runs a fellowship program instructing new fellows and residents how to treat sick veterans while earning millions each year.

ARTICLE: Army Veteran Survives Active Duty, But “VA Almost Killed Me”

The upside for VA is that it denies responsibility for affected veteran’s death or injury. Many veterans never know the physician treating them is not a VA employee. When they try to sue under FTCA, VA denies liability.

Does that sound fair? VA pays big bucks to fill its ranks with university employees and their students while simultaneously exculpating its liability? Like being a guinea pig?

For veterans submitting for surgeries, the stakes are high. You may get a “cheap” procedure, but you may also get what you pay for.

The veteran on point here is Craig Brewster. Award winning reporter Jamie Reno covered his case and published the story yesterday.

Craig was 65 and went to VA for what should have been a routine triple bypass. VA missed acute decompensated heart failure and underestimated his risk of stroke prior to the procedure.


The procedure was performed by one Dr. Herbert Ward, a thoracic surgeon contractor from the University of Minnesota. He oversees the university’s fellowship department where participants practice the trade on veterans at VA.

Brewster went under the knife. The procedure went fine.

After the procedure, because VA underestimated Brewster’s risk of complications, the facility released him from ICU into regular care too early. He experienced respiratory complications, a heart attack, and then respiratory failure during the day he was released.

The attending, Dr. Ward, was nowhere. Brewster experienced respiratory collapse, stopped breathing, atrial fibrillation and required 4 cardioversions.

RELATED: VA Malpractice Attorney

VA did not call his wife. They did not call an attending. Only residents and fellows floated around the facility.


It was Easter Weekend, and all VA staff doctors and the attending Dr. Ward was nowhere in sight, the whole time.

After the experience, Brewster laid back in ICU but did not see a medical doctor for over 24 hours despite being at incredibly high risk of stroke following atrial fibrillation and cardioversion.

VA made no attempts to assess Brewster for risk of stroke. They made no attempt to provide adequate anticoagulants like Warfarin or IV Heparin.

VA left him to die. The standard of care is to protect against cardioembolic stroke in this instance. VA failed to even consider the option.

The next day, he experienced a heart attack and respiratory failure again. The then exhibited signs of a severe stroke.

All this went down over the course of 4 days. No staff doctor or attending physician saw him. He experienced hypoxia and likely other complications during his initial stroke.

Adding insult to injury, after VA learned Brewster intended to sue, discharge medical notes from his attending physician were deleted from the medical record. Luckily, we caught the decision and found them in a backup file that was not deleted.

Two years later, VA is still denying its responsibility. Not because Brewster wasn’t injured. He most certainly was injured.

VA asserts it is not responsible because Dr. Ward is a contractor from the University of Minnesota. They ignore that VA employees failed to call in Dr. Ward and failed to call in staff physicians to evaluate Brewster prior to the stroke.

Again, instead of doing the right thing on Easter Weekend, they let Brewster sit in ICU heavily sedated, misled his wife about what happened, and ignored standard protocol to protect Brewster’s life.

Next time you opt for cheap care at a VA facility, you may be paying for that care with your life.


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  1. 09/01/2016

    Dear Benjamin Krause,

    “We reviewed over 1 million email messages, approximately 190,000 files from 11 encrypted computers and/or devices, and over 80,000 converted messages from Veterans Health Information Systems and Technology Architecture emails.”

    The Government want to make sure they were looking under all the rocks—August 26, 2014; 14-02603-267 —
    Review of
    Alleged Patient Deaths,
    Patient Wait Times, and
    Scheduling Practices at the
    Phoenix VA Health Care System

    “In February 2014, a whistleblower alleged that 40 veterans died waiting for appointments. We pursued this allegation, but the whistleblower did not provide us with a list of 40 patient names.”

    “As of April 22, 2014, we identified about 1,400 veterans waiting to receive a scheduled primary care appointment who were appropriately included on the PVAHCS EWL. However, as our work progressed, we identified over 3,500 additional veterans, many of whom were on what we determined to be unofficial wait lists, waiting to be scheduled for appointments but not on PVAHCS’s official EWL.”

    The Media focuses on the number 40 and or less—when the Number the OIG used is 45; “The 45 cases discussed in this report reflect unacceptable and troubling lapses in follow-up, coordination, quality, and continuity of care.”

    Two years later we have more than enough evidence that the 1,700 [3,500] waiting vets were being denied in the years leading up to 2014. Now add two more years and two less Directors in a City/County/State that does not give a damn.
    How do I know–I wrote them all and asked.

    Only Rep. Schweikert and Sen. McCain, and Phoenix Police Chief wrote back.

    You stated, “Next time you opt for cheap care at a VA facility, you may be paying for that care with your life.” Is that not a given?

    Why was he rushed out of ICU?

    Too Save Money? Make room for another patient? Was there a lack of room in the hospital? Or the nurses and doctors did not know any better? Etc…

    Or they don’t give a Damn like so many in my community where they are afraid of losing their jobs if they go against “management.”


    Don Karg

  2. If given the choice of greeting “The Man Upstairs” and the VA performing “Prick The Vet”, I will choose “Meeting The Man Upstairs” each and every time unless a REAL Witch Dr. from Haiti is available instead. Seriously, are we Vets just rats in a cage to them to practice on? VA Dr.’s need to do more practicing with the game of “Operation”…red buzzer for nose and all. THEN….maybe hamsters and work up the food chain to Veterans after perfection with real Lab Rats. Not Veterans. Rat Bastards.

    This is not isolated to Univ. of MN. either. The VA utilizes local Univ. Dr.’s in training which in-turn is HUGE $$$$ for these Universities and the VA also recruits new Dr.’s from same dead pools of legions of Dr. Residents from non-English-speaking countries. English is definitely not a requirement because they do not even communicate properly with Vets so the language barrier is a perfect storm added to anxiety that you have just submitted yourself to people playing Dr.

    • The one experience I have of a university doctor at a VA, that I am aware of anyway, was in Madison, WI. I was there to have my knee evaluated and see if my severed ACL would be repaired. The VA actually did an MRI, but claimed nothing was wrong. I questioned them about it, but they said their Ortho doctor, who also worked for UW Madison, was not available due to an emergency.

      I said well that is real interesting. I told them I just had an ortho appointment at a private hospital nearby, they did an MRI, found my ACL was severed and the doctor asked about surgery to repair it.
      I said I wanted to go to the VA first since it was service connected.

      It was amazing how fast their Ortho doctor suddenly became available. He ordered an MRI, and the VA demanded the MRI films from the private doctor so “they had something to compare to”.
      It was also amazing how fast I got the MRI from the VA confirming the problem.

      This was sometime in March or April, and the VA said the earliest they could do surgery was August or September. I said I already had an appointment for surgery with that private doctor the next week, and the VA was going to pay for it using CHAMPVA.
      They argued, I said they couldn’t do the surgery in a timely manner, so tough shit.

      The VA did pay for the surgery.

      The VA likes to tout their affiliation with universities, until it comes time to actually provide proper care.

      I’m curious though. I wonder how that affiliation would be affected in Minnesota if the family filed a complaint against that university doctor. Would that doctor point the finger back at the VA saying they had failed in their duty to notify him of any complications?

      • thanks for your comment . if I ever need any type of surgery I will definitely use a private doctor and hospital

      • Rick, That happened in the late 1990s. I don’t know how the VA would respond now. They likely would refer you to Choice since they gutted CHAMPVA, and you would still wait months for Healthnet to act on scheduling the appointment.

      • This just shows duplication of service’s. All veterans could be seen in the private sector and the VA would not be needed ( Period ) !
        The VA does nothing different or special that outside medical staff do

        Veterans are pawns and are being lied to. We are not men. Were mice and are being treated like mice.

        The. VA Is called a teaching hospital. What are they teaching anyway. Teaching them veterans are mice and If they screw up. Oh well. Their not real people they are the Expendables

        They joined to fight for this country. So the veterans would die for this country. So they don’t mind saving lives. By loosing theirs.

        Shut it down. !


      • In many respects, I wouldn’t mind the VA being shut down and me going to a university teaching school for medical care. At least one could try for better competence in a university doctor wanting to teach students the right way, as opposed to turning a student loose in a VA without oversight and letting them do whatever they want. With no oversight or accountability.
        I would not want to be treated by a university researcher, and students observing a procedure would be fine depending on what procedure in order for them to learn.
        Government could pay for it using Medicare rates plus 15% for an incentive to provide proper care. They could also do dollar for dollar reduction of student loans for licensed doctors. Veterans would have access to this century’s medical care and there would be state oversight.

      • Here’s the way the FTCA goes. You file a FTCA claim, the VA denies it, you file in federal court under the FTCA and they have a shitload of exemptions most attorneys don’t know or care about. Like the doctor was an independent contractor, student, resident or intern, or borrowed servant. 5th Circuit uses that a lot. To overcome that, instead, you go thru the notification process of filing a FTCA but when its denied, you have to file suits in both state and federal court claiming federal law in federal court and state law in state court, also make it clear in your complaint that you are suing them in both their official and individual capacity. And then the real fight begins. If the guilty party is a federal employee, the US Attorney will remove your state case to federal court, certify that they were acting under the scope of federal employment as a federal actor, substitute himself and motion to dismiss the guilty parties. Now your suing the United States and the guilty parties go free but are usually called as witnesses or give sworn statements for a summary judgment to verify their exemptions, which they are immune from prosecution. Its certainly not fair, because now the guilty parties can freely admit their guilt, why not, they are immune, so you can’t do shit. Yeah, I did that on purpose, so what? And, it was my own decision. Now, your case is dismissed completely under one or both or any of the many FTCA exemptions. If the U.S. Attorney does not remove your state case to federal court and certify the guilty parties as employees, then you have the guilty party right where you want them, in State Court. Even if the U.S. Attorney removes them to federal court and certifies them as employees, you must challenge the certification because if you don’t then here comes all the exemptions, like they were acting under discretion or it was an intentional tort. Federal actors get sovereign immunity that you must overcome. State actors get qualified immunity that you must overcome. Its one or the other and unfortunately the VA isn’t going to just volunteer all this information and even when they do, challenge it because they are slick about hiding true employment status. See, its not enough just to be a VA employee, you must be acting under your employment status, thus a VA janitor cannot give patient care and a VA doctor can’t do the job of a VA dentist, you get the idea. You have to do your research before you do anything. Try to find out the real employment status of the guilty party, the VA won’t volunteer this info. Find out if the equipment used was federal or state property. It makes a difference for state sovereign immunity which Universities of the State claim. Find out facts that support whether the guilty party was acting according to the VA status accorded him or certified by the VA. Its so complicated, attorney don’t like to take these cases and the ones that do, don’t usually win if they are not on the cutting edge of knowing their legal shit and know how to do research before they file anything. These attorneys are rare to find, so if you find a good one, pass it on to other veterans. Good luck and Peace Out.

      • Good comment Sandy.

        That explains why some VA providers are considered contractors or affiliates.

        When its convenient.

      • Uhhhhh. Veterans are screwed. Only one way to fix it so veterans can getting s fair shake

        Close the VA down. Everything is fixed against the veterans and everything for the employees. !

        Save money. Shut it down

  3. Ever wonder why VHA’s are built so close to medical universities?
    The answer is in today’s blog!
    We are guinea pigs. We’re what these students practice on daily.

    The price of their freedoms is slowly evaporating. Sooner or later they will have a “judgment day”, in front of whatever GOD they pray to.
    I pray it’s sooner, rather than later!

  4. Yesterday, Baghdad Bobby spoke in Cincinnati at the American Legion, along side “Hildabeast Clinton”!
    It was covered by “”, titled;

    “VA Secretary Warns More Vets May Get Stuck Appealing Claims”

    by, Hope Hodge Deck

    After y’all read it. Here’s a suggestion – “How about our country stop starting new wars!”
    Finish the ones we’re in now. By allowing the military to do its job! Tell this “Pussy in charge” to quit hiring “Yes Men” and start hitting the enemy HARD!
    I think the world leaders would be surprised IF we actually started letting our military men and women stop playing a “defensive game of war!”

  5. In all fairness in a critical thinking way I can attest to having spent many weeks on different occasions, all in private hospitals on Medicare and on the weekends the nurses pretty much run the show and many of the emergency room Dr.’s are now on-call, so they are not necessarily available to those stuck in a hospital bed, and always had to wait for the attending/My Dr. to make his/her rounds that day and that could even mean right at lunch time, not even first thing in morning.
    I am not defending the VA but am just reflecting that it all comes down these days to Billable Hours, we patients just happen to be the ticket number to those $$’s.
    Sure, if a DIRE situation arose on weekend at a private hospital not affiliated with the VA, they would be more apt to page/text the Dr. immediately and more readily due to technology now BUT really it also comes down to that Malpractice Insurance. People are incredibly litigious these days. The VA has no such worries because of no accountability and number one reason the VA continues to recruit lackluster players with people’s lives with no repercussions and all inherent protections of the U.S. Gov.

    Also, I would propose you would be very hard-pressed to find a private hospital or medical system NOT affiliated with the VA/VHA these days. We Vets are low-hanging fruit.

    Rant Out.

  6. everyone knows that the VA medical is bad, my dad died from lack of care at the VA and I also go to the VA and the medical treatment I get there is day I am gonna wear a body cam and expose them for all they are!

  7. Minnesota, (for the Black Hills VA Medical Center) reads MRIs benignly compared to the same MRI being read by the University of Colorado School. Do we have a lobbyist at work there like the one connected to Phoenix and Cheyenne?

  8. Thanks to you Ben and Jamie for covering this farce. Jamie is very thorough in his reporting and I enjoy reading his articles.

    I can’t fathom how some damn bureaucrat at the VA thinks they can absolve themselves of liability. That they are proves they know what happened is wrong.
    As a veteran, I go to the mechanic to get my car fixed, the grocery store for food and the gas station to fill up. As a veteran, I should be able to go to the VA and expect medical care and believe it is provided within the VA system. To have them claim they have no liability in this disaster ignores many things. It ignores the contract between the VA and the University. Both are gaining by this relationship, so in my opinion, both are liable. Both failed to properly oversee the program and relationship. It ignores any semblance of safe care and an appropriate response by numerous VA employees who are supposed to be licensed professionals who failed to call any doctor for help. The VA might as well suggest their nursing staff go to the University to find a doctor if they want to claim the university is at fault and the VA is not to blame. The VA may want to contract with CPAs, mortgage companies and the sham wow guy since they appear to let anyone do business in their facility while accepting no liability.
    Most of all, the VA is ignoring their obligation to care for the veteran.
    Why not just invite in the local witch doctor and veterinarian to perform surgeries if the VA claims they have no liability for anyone operating in their facilities? Does the VA also blame the University for deleting patient records? Why take that step if they claim they have no liability?

    This is serious medical care. Imagine the relationship between the VA and any human researcher?

    Should veterans be required to check the credentials of every nurse, PA, doctor and surgeon before getting any kind of care at a VA to determine who has liability? If we do and decide, based on this case, that we don’t want interns and students and university doctors providing that care, what kind of retaliation and delays in medical care will we see since we are jeapordizing that contract between VA and a university?

    Every day I think the VA cannot shock me any more. Every day I am wrong. How many nurses, nurses aides, and any other kind of medical provider present during his stay has been absolved of any liability by the VA taking this position?
    It reminds me of being in the VA hospital after knee surgery and thinking I needed to call 911 because the nurses refused pain medication. Or refused a knee brace to get home. Or left the IV port in my arm. Luckily I wasn’t in for more serious surgery.

    Yet the AFGE watered down any accountability legislation that Congress wants to pass, with the support of that jackass Isakson.

    Why even continue the farce of pretending a Patient has rights in a VA. Take down all those Patient Bill of Rights posters in the VA. The VA needs that material to wipe their ass after shitting on so many veterans.

  9. On accountability, there are a couple news articles here and there reporting on McDonald’s speeches to the DAV and Legion convention.
    McDonald and Isakson are quoted as wanting their VA “Reform” legislation passed. Accountability being watered down is mentioned, but not by those two.

    I believe the real meat of that legislation is the VA wanting more flexibility in spending.


  10. The va actually pays daily for private contracted ambulances and emt staff to sit outside of operating rooms to rush failed surgery cases to private facilities, This makes me wonder if somebody has made a risk assessment and determined that va care is substandard?

    • Wow. That would be something to get on video. An ambulance waiting, then a veteran asking an EMT why they are waiting.

      • It’s almost like it’s an admission of guilt to some degree. I’m sure the talking points are prepared to counter this claim if it were brought up.

  11. VA DEATHCARE IS A FEDERAL RICO CRIME RACKET RUN BY @ FOR AFGE UNION CONTRACTS !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! VA KILLS VETS FOR THE BONONOUS $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

  12. Jez, Ben. You know they almost killed me the same way with Univ. of Washington “surgeons”. They let me lie there after a failed operation on my guts for 10 days swelling into Octomom and total sepsis. They finally called Deb when I ripped out my PICC lines and tried to leave.Said I was being “combative”. I sure don’t remember that. 3 more operations and a year in the Seattle VAMC. The attending Doogie Howser shit for brains said “Well, there’s always a little swelling after abdominal surgeries.” Sure is if your abdomen is filling up with shit leaking out of you intestines.

  13. Here are two articles put out through “” by other sources. #2 is a great opinion I believe many could learn from!

    #1.) “Former Senator Pledges to Support Vets in Fukushima Lawsuit”

    31 Aug. 2016
    Stars & Stripes | by Mathew M Burke

    The Senator in question is John Edwards.

    “Military Life”
    “Don’t Pity Wounded Vets or Use Them for Your Message”

    Posted by a “Guest Blogger” on 31 Aug. 2016.
    When you read this “opinion”, the author is “Sidra Montgomery”!
    He/She has a very impressive BIO!

  14. I was stationed in a pow hospital in Nam, ’69. I witnessed many pow’s recovering from surgery there. I thought then, these Dr’s are good. There was always a doctor around, and the Dr.’s were dedicated to serve these pow’s. I don’t get why the VA treats veterans worse, much worse, than our Dr’s treat veterans. The VA scares the he’ll out of me.

    • Me too! I read where McD actually opened his mouth today to praise how well their doing. I feel like I’m getting J-ked off. My Medi-cal got cut off today because I have life insurance . Thanks Obomass. Now my wife is without any medical care. I’m about to —– some sonzabitches. Iv’e fucking had it!

      • I would be really mad also. I have a friend who had a heart transplant and was on ssi or something and he had child support

        He had 3 payments left and he had the extra $150 dollars and paid it off

        Ssi. Came back and said that extra $50 a month. Put him over the threshold and cut him off. Now he gets $0

        Still has his chest partially open and wears a brace

        He’s not a veteran. But hell of a nice guy

  15. Thanks for the reply man. It made me feel better today knowing I’m really not alone about being screwed around by our gov’t constantly shoving their hands into our empty pockets searching for something. (Army 71-77) I guess I’ve said enough.

    • Roger that… bitter sweet though. We are all in it together but it also sucks knowing that you are also being ground through the meat grinder the VA calls a hospital. Nothing can fix this quagmire.

  16. @Nexdeceptus, Your not alone on here.
    Vets and nonvets have to stand together.
    All our ‘Stories’ are important. Sharing those stories is also important.

    Army (Vietnam Vet, 65-69)
    Navy vet 76-82 (Beirut 20 Jun 1976)

  17. Out of control. Madness. Third world medical care. These young university doctors are being trained by trainees and then go one to practice the voodoo witch craft. Pure Evil… greed, corruption, malpractice and neglect…. this institution should be shut down yesterday and all parties contractors, VAOIG, all investigated and prosecuted with extreme prejudice.

  18. these the same doctors? that write incorrect med data in vets’ med records insuring it is vague enough to veterans lose out on rightful service connected disability?

    >Next time you opt for cheap care at a VA facility, you may be paying for that care with your life.

    i hope my ssi/medicare pays for upcoming surg. way to apprehensive to allow VA to do it. VA says they don’t really see anything, and that they have seen worse…REALLY!!!

    >Adding insult to injury, after VA learned Brewster intended to sue, discharge medical notes from his attending physician were deleted from the medical record.

    deliberately omitting med data, which happens so often over the decades, and this attending physician deletes data from med records, happens more than would think. reason: ensures vets can’t get their rightful service connected disability and lessons any accountabilithy/liability from VA workers or “contract” workers.

    yes, i agree with @niminbor, nd hav thought so for yeard, we vetsare indeed rats for research. and investigative journalists know it as do many in the veteran community.

    we know too from experience that the VA doc will order/contract tests like MRIs, those contracted with will return very bland written interpretations for VA docs to skirt the issues and say something like, “i don’t see anything on your MRI”. that’s only if you’re lucky they even go over your MRI with you, as @91Veteran mentions

    i’ve mentioned it a hundred times, but if one gets a good/great MRI place where the interpretations are written well and include liner notes for references, the patient/veteran is armed with quality data regarding health and decision if to have surgery or whatever treatment. versus the opaque smoke-screen crap the VA docs “typically” verbalize.

    again, i urge all of us veterans who have had these experiences, gotta be in the millions, the shame any former doctor that worked at VA because most of them followed the same bs rules to undermine rightful disability for veterans. prove me, i’m wrong. i doubt any vet on thise blog can, or any of the other vet watchdog websites.

    • Your comment reminds me…does anyone else who may get an xray or MRI have those films reviewed with you during your appointment with the doctor who ordered them?

      Before 2012, any time I had an xray or MRI, the doctor who ordered it would review the radiologist notes, and review the findings with me in the appointment, including pointing out on the films what was found.

      After 2012 when I had knee replacement surgery and an MRI of my back, not once has any doctor reviewed the radiologist notes with me, and I have never seen film other than if I request them through Release of Information. Typically I am told of the results in a 1 or 2 sentence voice mail, which happens more often than getting the same response in person. And just as typically, that short voice mail minimizes any finding.

      I have had at least two sets of xrays since having that knee replaced because of ongoing problems,,and both times I got the results in a voice mail simply telling me the hardware has not shifted.

      But hey, Bob and some suck ass VSOs say the VA is improving and gives better care than the private sector.

    • Cantigny – 91Veteran

      In June 2016 I had MRI done on both shoulders. The Letter the DR sent me read: MRI L Shoulder – apart from some arthritis, these results look ok.

      Nothing said about the R Shoulder.

      The actually impression written by the imaging center is inferior to other scans I’ve had done & DR minimized the results even further in the letter she sent to me.

      The pain IS REAL doc, not in my head. Keep your mind altering drug Gabapentin. The neurons in my brain are firing correctly.

  19. My mother in law served during the Korean Conflict & would travel either to Calif or Virginia for treatments & stay w/family because Ohio’s VA’s were not acceptable.

    In 2012 @ 79 she used the Dayton Oh Cardiology for what was thought a simple heart surgery; she drove herself, planned on driving herself back home afterward but instead died on the table.

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