WICHITA, Kansas August 20, 2008 - "Our veterans deserve better than this," Wichitan Terry Gray said. "What I saw there was egregious. Criminal."

Terry Gray is talking about Wichita's Robert J. Dole V.A. Hospital, where he worked for twenty years as a bio-medical engineer. Gray says his last four years at the hospital were cause for concern.

"I saw things I couldn't believe," Gray said. "The nurses weren't paying attention to the alarms."

Gray is referring to cardiac alarm monitors used to monitor patients in the hospital's intensive care unit. Gray says the nurses not only weren't paying attention to the critical alarms, but they were disabling the alarm speakers.  An act that made the monitor's warning tones unable to be heard.

Through the Freedom of Information Act, KSN News obtained internal memos from the hospital.

A 2001 memo shows red, critical cardiac alarms sounding for as long as seven and six hours before being attended to. The memo explains the severity of the issue by reminding staff that, "what is significant is that no other red alarm will be displayed until the original alarm is silenced." Meaning if the first alarm was false and not reset, nurses could not be warned of further cardiac emergencies.

"There were so many false alarms, that they just treated it like every alarm was a false alarm, and you didn't have to pay attention," Gray said.

However, top officials at the Dole V.A. Center were paying attention. In emails obtained by KSN News, those officials considered the situation, "extremely serious." The hospital's own investigation continued to find, "cardiac alarms with no sound, and speaker cords disconnected."

The hospital went as far as to have V.A. Police officers perform random checks to make sure the alarm speakers were properly connected.

While the V.A. says that fixed the issue, subsequent memos reveal a twist on the problem. Someone has now been, "programming the alarms so they cannot be heard." Nurses are using, "towels to further muffle the alarm tones."

The issue reached a point where nurses are reminded they could be violating the Kansas Nurse Practice Act. The hospital even considers using fingerprinting and camera surveillance to find out who exactly is unplugging the cardiac alarm speakers.

"I think this is an issue that has gotten blown out of proportion due to misinterpretation and misunderstanding," Tom Sanders said.

Sanders is the Director of the Dole V.A. Medical Center.  He points out that while there was an issue with the cardiac alarm speakers, at no time were any patients in danger.

Sanders says Terry Gray's complaints were thoroughly investigated, not only by the hospital but the Inspector General, the Joint Commission, and even the Veterans Affairs Committee at the request of Congressman Todd Tiahrt. All found nothing wrong.

Even so, the issue persists evident by this internal email from March of this year. It says a staff member is, "turning off alarms because they are annoying." The person writing the e-mail says they are, "concerned for patient safety and their own liability."

"It's difficult to understand the issues that are going on in a clinical setting, if you don't have that clinical background," Nurse Executive Jan Yeager said.

That is why Yeager took us on a tour of the hospital. Yeager showed us that even without the alarm speakers, there are several monitors throughout the I.C.U. where nurses can be alerted to problems. Yeager also pointed out that the Dole V.A. Medical Center has dedicated monitor techs who are constantly watching patients. Something they didn't have when this issue first surfaced.

"We never had a bad system or a faulty system, but we are continually improving it to make it better and better," Sanders said.

However, whether it be internally or publicly, some continue to sound the alarm. 

"I hope things change out there, so the veteran is number one," Gray said.

"Our patients can be 100 percent assured that if they are in any of our hospital beds or I.C.U., they are being monitored," Sanders said.