TULSA - Inhumane.
That's how veteran Monty Collins described his treatment from Veterans Affairs.
When we first met Monty tubes were pumping life into his veins. Too weak to walk, he was confined to a hospital bed.
It was the agonizing aftermath of a journey through the VA system.
As oxygen pumped into his nose, Monty's niece, Sabrina Aston, reminisced about her uncle's days as a soldier in the Korean War.
She pulled out an old newspaper clipping of Monty and his brother, Sabrina's father, in their Coast Guard uniforms. It was something Sabrina says made Monty proud.
"He would always say you need to be proud of your father for being in the military and being on the front lines, but he (Monty) would always minimize his role," said Sabrina.
Monty served two years in the Coast Guard.
Following his service, Monty enrolled in college, studied psychology and went to work for the Michael E. DeBakey VA Medical Center in Houston, Texas. At the end of his career, he retired and moved to Tulsa. Little did he know, he would return to the Houston VA years later.
Fast-forward to late April. Monty had a mild heart attack and was taken to a local heart hospital.
"They prepped me for the surgery and just before they got to it, the VA called and said we're not going to pay for that expensive surgery," said Monty.
But it wasn't a quick decision. Monty said two days had passed between his surgery prep and the VA's decision.
"When I say prepped, that's no food or water," he said.
Finally, the VA decided to fly Monty to its Houston hospital. Once they arrived, "We waited and waited," said Monty.
At the end of the day, the doctor came in and said they would perform heart surgery. They prepped Monty once again.
"Again, we waited and waited and waited," said Monty.
Three days had now past since Monty's heart attack in Tulsa.
Monty said the doctor came in and, "said he couldn't do it, there's too many blockages."
Once again, the surgery was off. And yet another day had past while Monty went without food or water.
The doctor returned the next day, now day four.
"He started to run another test and I said, 'Let's just stop.' I said, 'I've had enough,'" said Monty.
After suffering a heart attack, going four and a half days without food or water and never getting a decision on surgery, Monty just wanted to go home.
The VA put Monty on a gurney in the back of ambulance and drove him back to Tulsa, an eight-and-a-half-hour ride that left Monty with sores and bruises.
"Bumping and bouncing. It just tore me up," he said.
He returned home, but Monty said the VA left him without oxygen, something Monty needed to survive. So he ended back up in the hospital where he'd started, with tubes again in his nose.
"I can't help but think if I had gotten timely care when I first hit this place on the 27th of April, that things might have been a whole lot different," said Monty.
Prior to his heart attack, Monty called the VA about chest pains but says no one returned his call.
Monty isn't alone. The Inspector General is investigating cases of poor care in VAs across the country. The department says an audit of 731 VA hospitals and large outpatient clinics found that the agency's complicated appointment process created confusion among scheduling clerks and supervisors.
The audit revealed 200 patients waited 90 days or more to see a doctor at Jack C. Montgomery VA Medical Center in Muskogee. Plus, 500 patients waited a month.
"You know what, no. It isn't acceptable,"said Richard Crockett of the Muskogee VA when we asked him about Monty's care.
When we asked why the VA moved Monty to Houston after he was prepped for surgery in Tulsa, Crockett said, "Since we have those doctors anyway, it's cheaper for us, it's more efficient."
Cheaper yes, but the VA says it's not about the money.
"In these particular instances, cost never comes up. It just doesn't. You've just got to trust me on that. It's always about the patient," said Crockett.
We took those responses and Monty's story to Congressman Jim Bridenstine, R-Tulsa.
"This is a nightmare. This is exactly what's wrong with the VA. People need to be held accountable. This is not how we treat our veterans," said U.S. Representative Jim Bridenstine.
Now, Bridenstine is backing legislation so no other veteran has to experience what Monty did.
Should either the Muskogee VA or the Houston VA be held accountable for the treatment Monty received?
"What we have heard now from the Justice Department, is where appropriate there will be criminal investigations," said Bridenstine.
"I may not make it through this, but maybe the next one (veteran) that has a heart attack will get timely care," said Monty.
Sadly, Monty did not make it.
"He just kept saying, 'I don't know if I can go anymore days.' He was short of breath," said Sabrina.
Monty took his own life, six weeks after he went to the Houston VA and two days before he was supposed to meet Bridenstine
to talk about the need for change.
"You're going to make me emotional, right. I will tell you, there's nothing I want to do more than to help the people that fought for this county," Bridenstine said about Monty's death.
Monty's final mission for a system he fought for, he worked for and he felt ultimately let him down.
He voiced his concerns even before his journey through the VA began.
In a letter dated April 26, 2014, the day before his heart attack, Monty wrote to the administration at the Tulsa VA clinic. In it, he talks about the difficulty he had getting in touch with his doctor and wrote, "This does not strike me as professional medical treatment for veterans."
Sen. Jim Inhofe's office is also looking into Monty's case. It's investigating whether the VA violated any procedures. Inhofe wants to see an overhaul of the Department of Veterans Affairs.
If you're a veteran or know of a veteran that's concerned about the healthcare at the Muskogee VA hospital send the 2NEWS Investigators an email at firstname.lastname@example.org .