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Nightmare Conditions in Dallas VA Medical Center’s Psych Ward

The voices in Jack Edenburn’s head began soon after he returned from Vietnam. They told him to end it all.

He ignored them for almost 40 years, until the day he stood at the railroad tracks near his Lancaster home, fantasizing about stepping in front of a train. That’s the day he went to Dallas VA Medical Center. And some days, he says, he regrets that decision.

“Imagine hell,” he said of his five days in the psychiatric unit, “then think worse.”

Patients soiled with feces and soaked in urine wandered aimlessly, screaming, rolling delirious on the floor. One woman, he said, removed ceiling tiles and crawled into the space above the day room.


“I was more traumatized after five days in the VA than I was when I was admitted,” said Mr. Edenburn, who works in the mail room of an insurance office. “And remember, I was suicidal when I went there.”

Officials for the VA North Texas Health Care System say more than $250,000 has been spent in the last six months to improve safety on the ward, part of the VA hospital on South Lancaster Road.

But after four patient suicides in four months – including those of two men who hanged themselves during treatment in the 51-bed psychiatric unit – hospital officials effectively closed the ward two weekends ago.

Investigators from the Department of Veterans Affairs ordered patient records and other material after the latest suicide on April 4. They are expected to tour the hospital and begin assessing its safety next week.

Chris Demopoulos, a 58-year-old Marine Corps and Vietnam veteran, was released from the Dallas VA on Jan. 22. The next day he hanged himself from the second story of a La Quinta Inn in Plano.

His body was discovered by Pat Ahrens, a friend he had met in the veterans hospital. Two nights later, Mr. Ahrens, a 50-year-old landscaper and Air Force veteran, backed his silver Lincoln Navigator into an oversized storage unit on 14th Street in McKinney.

Family members said he swallowed handfuls of pills and washed them down with Bacardi and Coke. He died later that day.

Larry Johnson, a 55-year-old Air Force veteran, hanged himself using a modified wheelchair while he was a patient in the psychiatric ward on Feb. 5.

Two months later, another patient committed suicide at the hospital by attaching a sheet to a door frame and tossing a noose over the other side of the door.

A local psychiatrist who finished his residency at the Dallas VA said it’s difficult to predict what mentally ill patients like Mr. Demopoulos and Mr. Ahrens will do once discharged from a hospital.

“But when you have suicides on the unit, where people should be checked every 15 minutes, that’s well within the control of the VA,” said the physician, who requested anonymity out of fear of professional retribution. “When that happens once, that’s really a problem. And then it happens again, that’s really unconscionable.”

He said the psychiatric unit does not meet the safety standards of other hospitals because of its age.

As recently as a few months ago, he said, most patients were cared for by resident physicians, the least experienced psychiatrists on the unit. The attending physicians, he said, only meet with patients at admission – never during their treatment, and they do not personally make the decisions about when patients are ready for discharge.

Dr. Catherine Orsak, head of mental health for the VA’s North Texas health system, said attending physicians see patients at least three times during their stay, including at discharge.

She said the age of the 68-year-old facility presents risks to suicidal patients. Door knobs, shower curtains and power cords can be used in hanging deaths. Windows can be broken, and even pencils can be instruments of self-destruction.

“It’s a challenge in an older facility and in older units to maintain the highest level of care,” Dr. Orsak said. “And yet we’ve put a lot of money and energy into it.”

She pointed to the more than $250,000 spent in the last six months.

“We thought we had completed everything we had identified,” she said. “The point is to identify risks and then determine how significant that risk is. It seems there is always something else to do.”

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