New investigation: VA hospital’s “chaotic care” failed to save Vietnam veteran

A Vietnam veteran who died late last year of severe liver disease complications was a victim of substandard care at the Grand Junction Veterans Affairs Medical Center, according to an investigation by a nationally prominent liver specialist.

In a report released Monday, Dr. Joanne C. Imperial, a fellow of the American Association for the Study of Liver Disease, cataloged the many missed opportunities at the VA hospital to provide adequate care for veteran Rodger Holmes over an eight-month period in 2014. She called his care “chaotic and reactive rather than proactive.”

Imperial was hired to look into Holmes’ illness and death by advocates who took up the 64-year-old’s case after his social worker at the veterans’ hospital became alarmed at the way the hospital was handling his care. The advocacy group, called Remembering Veteran Rodger Holmes, is hoping that highlighting his case will help more veterans in a health-care system that has come under increasing fire for poor performance nationally.

“This all confirmed my impressions since day one about the extent of the poor medicine practiced in this case,” said Chris Blumenstein, who resigned his social work position at the VA hospital last year in protest over Holmes’ care.

Hospital spokesman Paul Sweeney said he couldn’t comment on the report because the Office of Inspector General is currently doing an investigation of Holmes’ case. Sweeney pointed out that past internal and regional VA reviews of Holmes’ care found it was adequate.

Holmes died Dec. 20, 2014 after going through a high-risk treatment program for advanced hepatitis C. His disease dated back to the 1970s after he served in Vietnam and subsequently began abusing alcohol and became homeless. In the last four years of his life, Holmes had been sober and had been a steady volunteer – driving a van and playing drums – at the Salvation Army in Grand Junction.

Holmes agreed to aggressive treatment for his chronic condition after his primary care provider referred him to a hepatitis C clinic at the Grand Junction hospital in March, 2014. The clinic was staffed by a part-time internist, a psychiatric nurse practitioner and a pharmacist. There was no liver specialist on staff .

The internist recommended Holmes be treated with a trio of antiviral drugs, including interferon, a drug that can have severe side effects. Within weeks, Holmes complained of weakness, dizziness and nausea. But his physician noted in his chart that he was “tolerating the interferon fairly well.”

Holmes continued to get sicker. Several weeks later, he went to the emergency room complaining that he was “sick as a dog.” He was treated for dehydration and sent home.

Less than a week later, at his monthly hepatitis C-clinic appointment, the clinic pharmacist noted that Holmes was beginning to develop liver failure. His interferon treatment was discontinued. But Holmes continued to get sicker and developed an infection.

A liver specialist at a VA hospital in Denver was consulted and recommended that Holmes be referred to specialty liver care in a private Grand Junction hospital or at the University of Colorado hospital. He was not referred.

Instead, Holmes spent 10 weeks in the Grand Junction VA hospital. The hospital was one of the Veterans Administration hospitals cited in a national 2014 study, for providing deficient care to other patients.

When Holmes was discharged, he was provided with home nursing-care visits. On Dec. 2, Holmes called for an ambulance because he was experiencing severe abdominal pain.

He was taken to St. Mary’s Hospital where he was diagnosed with a severe infection and multiple-organ failure. He died 18 days later.

Imperial commented in her report that the health care providers at the VA “clearly lacked an in-depth understanding of liver disease.” She noted that providers missed many opportunities to change the course of treatment for Holmes.

“This substandard care is described by a succession of potentially harmful treatment decisions or omissions,” Imperial wrote.

She also noted that many medical-care providers at the hospital “worked diligently and industriously to provide the patient with the best care possible within their abilities.”

But their abilities did not include enough expertise in chronic liver disease.

The Office of Inspector General’s report into Holmes’ care is expected to be released in several months. It was initiated in January after U.S. Sen. Michael Bennet requested a study. U.S. Sen. Cory Gardner wrote a letter stressing the need for a thorough investigation. And the Colorado Legislature also weighed in with a request for action in the case.

Blumenstein said he is giving Imperial’s report to the Inspector General’s investigators, and he has hopes it will have an impact on the findings.

Blumenstein said that Holmes, in his last months, expressed hope that his case would help improve the care given to many other veterans.

“I’ve stuck with this campaign. I promised him on his deathbed that I would,” Blumenstein said. “I told him, ‘I will see this through, my friend’.”