The Death Shift

by Peter Elkind

  In the middle of it all, performing CPR (cardiopulmonary resuscitation) or injecting drugs, was the patient’s nurse, the one who called the code in the first place. The code might last for several minutes, or—when a child’s heart, like a sputtering motor, turned over but wouldn’t quite start—it might last an hour. But in the center of the crisis, there was no consciousness of time. “You tune people out,” said Genene Jones. “It’s an incredible experience. Oh, shit, it’s frightening. You’re aware of everything, but you only tune in to two or three different people…You really have to control your physical abilities, because you really get keyed up.”

  Most children who went through a code would die—either then or during another code later. The failed attempts to revive children, the codes that ended with a pronouncement of death, gave ICU nurses their most depressing moments. “You feel so helpless,” said one RN. “It’s like they just slip through your fingers. You try everything—and they just keep fading away.”

  When a child died in the pediatric ICU at Bexar County Hospital, his nurse had the responsibility of taking the body down to the hospital’s morgue, a locked chamber in the basement known as the “cold room.” Often, after a doctor pronounced the child dead, the parents wanted to hold him one last time, in which case the nurse first had to clean the body—wash off the blood and pluck out the catheters and tubes. When the parents were done, the nurse wrapped the body in a blanket or plastic shroud and summoned a security guard, who brought the key to the morgue. If the child was large, the nurse placed the body on a wheeled metal stretcher, known among staff as a “cold plate.” If the patient was an infant, the nurse sometimes carried the corpse in her arms. Before the nurse left the pediatric ICU, the security guard walked down the long fifth-floor hallway, clearing the corridor and closing patients’ doors so they would not witness the procession. The guard then walked with the nurse to a staff elevator that took them to the basement, and there he unlocked the morgue door. “Especially at night, it’s very eerie down there,” recalled one pediatric ICU nurse. “A lot of times, there would be patients who died during the day. Sometimes their bodies wouldn’t be covered. You’d walk into the cold room, and you’d see blood dripping out of every possible opening. It’s a creepy feeling.”

  The codes and trips to the cold room were the dark side of work in the pediatric ICU, the part that made a nurse, every few months, ponder whether she wanted to find a less difficult job. But Genene Jones seemed attracted to the dark side. By early 1981, she had begun asking for assignment to the sickest children. Many experienced nurses liked the challenge of a critical patient and sought it out from time to time. Genene did more. She demanded the sickest patients.

  The charge nurse on each shift, always an RN, had responsibility for making patient assignments. Yet Genene was unwilling simply to take what she would get. If she considered a case boring, she would refuse to care for the child; she would sit in the patient’s room and just rock in a chair. Often arriving early for her shift, Jones penciled in next to her name the room number of the child she wanted. Challenging Genene ran the risk of setting her off on an obscenity-spewing rampage; most preferred to let her have her way. “She pretty much made her own assignment,” said one RN. “She was so strong she ran the shift like a charge nurse. She was just an LVN. She had no authority or power to do it, but she did it anyway.”

  Responsibility for the sickest children gave Genene patients who often had codes. But even when other nurses’ patients had emergencies, Genene was involved. Anytime there was an arrest, Genene was there—in the middle and helpful. She seemed to thrive on the excitement. “If there was a crash in the unit,” said a nurse who worked with Genene, “she’d climb over everyone to get there.” CPR on a tiny child is vastly different from the pounding given adults during an arrest. A baby’s fragile chest must be kneaded delicately, with the middle and index fingers from each hand, or it will snap like a frame of twigs. Burned in the memory of many ICU nurses was the image of Genene Jones performing compressions: her heaving, sweaty bulk hovering over a helpless infant.

  When a child didn’t make it, Genene broke down and cried. Nurses commonly shed tears over a longtime ICU patient, but Jones seemed deeply wounded by every death. She would ask the doctor who pronounced the child dead to wait a few moments before summoning the parents. Then she would pick up the body and rock it. Said one pediatric resident: “We all thought it was bordering on being a little pathologic.”

  After a death, Genene volunteered for the ghoulish task of taking the body to the cold room—even when it wasn’t her patient. Other nurses wheeled all but infants down on a cold plate. But Genene would carry the corpse of a five-year-old boy in her arms. As she walked down the hospital hallway, resembling a grieving mother bearing her child, the stiffened body protruded like a board beneath its shroud.

  Genene Jones had become the dominant force on the ICU’s 3–11 shift by exploiting a power vacuum. The continuing shortage of nurses had grown dire by early 1981. To staff the ICU, Pat Belko had been forced to fill the evening shift—which required about six nurses a night—with newly graduated RNs and nurses from temporary agencies. The rookie nurses lacked experience, and the skills of the agency nurses were unknown; Belko chose not to move one of her veteran RNs from the day shift. As a result, the 3–11 shift often lacked an experienced RN to serve as charge nurse.

  While the new RNs took turns formally occupying that role, Genene Jones took charge, telling others what to do and claiming the sickest patients for herself. Genene reasoned that she had no choice—that because she was the most experienced nurse on the shift, it was her duty to run the show. Genene saw herself as “charge nurse incognito,” and it was clear that she reveled in her de facto authority. To experienced colleagues, she spoke giddily of “me and my little RNs.” On encountering an older nurse in a hospital hallway, Genene sighed dramatically: “You know, it’s hard being in charge all the time.”

  At first, the new RNs didn’t mind Genene’s usurpation. The pediatric ICU was an intimidating place, and they had been thrown into the fray with little orientation. Jones seemed solicitous and helpful, anxious to answer their questions and teach them procedures. With their hands full treating patients, they readily deferred to the cocksure LVN.

  Many of them even joined Genene on social occasions, where they came to understand her reputation for saying and doing the outrageous. For one nurse’s bachelorette party, they visited a San Antonio male-stripper bar called La Bare. Genene announced to the group that she had purchased each of them a man for the evening. (The offer was declined.) On another night, they went kicker-dancing at a country-and-western hall north of town. Driving a load of nurses home, Genene took a scenic detour around a lake, where she relived her drag-racing days, burning rubber around the winding roads, barely dodging deer while her passengers held on for their lives. Spotting a man she admired, Genene would make a show of opening an extra button on her blouse. She publicly boasted of offering her sexual services to a doctor whose wife was pregnant. Despite all her heterosexual bravado, doubts about Genene’s preferences lingered. During one night out with the girls, she scrawled a note on a paper napkin and slipped it privately to a friend, a female RN. It read: “My greatest fantasy is to have an affair with a woman.” The nurse dodged what she interpreted as a sexual overture by telling Genene she couldn’t read the message.

  As they came to know Genene Jones better, the new RNs learned to depend on her less. As registered nurses, they had far more training than an LVN. When they gained the experience they needed, they stopped asking Genene questions. They were ready to claim their rightful place in charge of the evening shift.

  But Genene wouldn’t back off. “She was angry with us because we were not going to her for help,” recalled Judy Cacciola, who started in January 1981. “If a patient came in, she wanted to assume the responsibility of making the assignment, doing what had to be done. I told her: ‘We can handle this now.’ She’d get angry and
stalk off.” Genene believed the newcomers were stabbing her in the back. Who were they to give her orders, merely because they were RNs? Hadn’t she trained them? Influence and attention were slipping from her grasp. The nurses were like her son. They weren’t listening to her anymore; they were making her feel ordinary and ineffectual. After all the hours that she had put in, all that she had sacrificed for the unit, she was on the verge of becoming just another LVN. She could not allow that to happen.

  Seven

  For Diana and Crecencio Hogeda, Jr., the sad news came by phone. It was not entirely unexpected. Their baby, Christopher James, barely a year old, had spent almost half his life in the hospital. Born with a severe heart defect, he had been admitted to the pediatric ICU with pneumonia and diarrhea in December 1980. In May, he developed hepatitis, and infection ravaged his body. The call had come from Christopher’s nurse, Genene Jones, who had cared for him from the beginning, who seemed so sympathetic to their ordeal. “He’s gone to play with the angels,” Genene had informed them.

  After gathering the clothes in which they planned to bury their son—Diana had crocheted a special blanket—the Hogedas climbed in their car and raced toward San Antonio. The Hogedas lived in the West Texas town of San Angelo, more than two hundred miles away; they had taken Chris to the big city, to Bexar County Hospital, to make sure that he received the best medical care available. Three hours later, their eyes wet with grief and fatigue, the Hogedas walked into the ICU to view their baby’s remains. They were stunned at what they saw: Christopher was still alive! He was lying quietly on his ICU bed, hooked up to the machines; everything was just as it had been for months. The Hogedas asked for Genene. The other ICU nurses told them that she had completed her shift and gone home.

  Chris Hogeda was one of the children in whom Genene Jones took a special interest. She insisted on caring for him herself, day after day, for weeks. It was during this time that Genene, never one to lavish time on her own children, stopped showing up for counseling appointments with Edward. It was as though she had transferred her maternal affections from her own children—one of whom gave her trouble—to surrogate offspring who were totally under her control. “He was my boy,” she said later of Chris Hogeda.

  On May 14, 1981, Genene left Chris’s room a little after 11 P.M. to report his condition to the next shift. The baby’s health was so poor that no one expected him to live long; he had been experiencing unusual episodes of irregular heartbeat. But the nurses had grown weary of Genene’s regular predictions of his demise. “Tonight’s the night,” she would announce.

  As the nurses were giving report in the ICU’s break room, they heard a crash. Genene rushed out and shrieked; the child with the delicate heart condition was dangling from his bed, suspended by respirator tubing and arm restraints. Genene had left Chris’s bed rails down, and he had rolled out. She returned the child—apparently unhurt—to bed. Genene later recounted what had happened to nurses who were off that day with a laugh. The LVN received another written scolding for the incident, but she continued to treat the child. When Chris Hogeda died of cardiac arrest a week later, he was under Genene’s care.

  Summoned for good cause this time, Chris’s parents asked Genene to remain with their son until they arrived. She pulled the plastic tubes out of the body and washed it, crying and talking out loud all the while. “I would bathe the children, and I would sing to them while I bathed them,” Genene later explained. “If that sounds insane, tough shit. If you can’t die with dignity, why live with dignity?” She paused. “We talked to them even after death. We’re not God. We don’t know when the spirit leaves the body.” After cleaning Chris Hogeda, Genene wrapped his body in a blanket. Then she settled into a chair and held the corpse to her chest for more than an hour while she waited for his parents to arrive.

  Diana and Crecencio Hogeda were unaware of some of Genene’s offenses in the treatment of their son, and forgiving of the rest. On the day Chris Hogeda was buried, Genene Jones was a welcome guest at his funeral.

  The death of Christopher Hogeda marked the beginning. Over the next four months, the pediatric ICU began to experience a rash of strange events and unexpected emergencies. Kids who seemed stable suddenly stopped breathing. They had seizures. Their hearts halted—or started beating irregularly. Babies pricked with intravenous needles began oozing blood, their clotting mechanisms inexplicably gone haywire. Some of the children, like Chris Hogeda, were terribly sick and expected to die; but what befell them defied explanation.

  Terry Lynn Garcia was among the victims. Admitted to the hospital at three weeks of age for diarrhea and vomiting, she entered the pediatric ICU a month later after developing fever and appearing lethargic. On the night of her transfer, Terry Lynn had three episodes of abnormally slow heartbeat, called bradycardia, before her heart stopped entirely. Doctors revived her, but she arrested again the next evening and was barely rescued with drugs, two jolts of electric shock, and ninety minutes of CPR. The next day she started bleeding, and her blood pressure plummeted. She developed breathing problems that required a respirator. After two more arrests, she died at 6:15 P.M. on August 11.

  Patricia Sambrano, three months old, entered the ICU two days after Terry Lynn’s death. Hospitalized after going into seizures following a routine inoculation, she arrived at 7 P.M. in the unit, where she was placed on a respirator and under Genene Jones’s care. Patricia arrested that evening, but doctors revived her. Nurses on the next two shifts noted no seizures and described the girl’s condition as stable. Back on duty, Genene reported seizures that were worsening at 5:30 P.M. The child soon arrested, and doctors saved her again. After a third arrest, she died at 9:36 P.M. on August 14.

  Four-month-old Paul Villarreal died in late September. Taken to surgery for an elective procedure on his skull, he returned to the pediatric ICU to recover and instead went downhill fast. A day after the operation, following a seizure, doctors hooked the baby to a respirator. Blood began pouring out of a tube placed down his throat. He arrested but was revived. The next night Paul began oozing again; he arrested and died at 8:30 P.M. Lab tests showed his bleeding was caused by problems with his clotting mechanism.

  Twice, doctors discovered patients’ respirators improperly set. At 11 P.M. one night, two-year-old Rosemary Vega, recovering from a routine heart operation, suffered a seizure and became sluggish after being placed on a respirator. At 2:15 A.M., a surgery resident noticed that Rosemary’s breathing machine was feeding her too little oxygen. “…Ventilator setting had been altered by unknown source…” one physician noted. Rosemary died at 7:52 P.M. that day. Four-month-old Placida Ybarra had entered the ICU for treatment of heart failure. At 7:20 P.M. on the day of her admission, it was discovered that her respirator was pouring out 100 percent oxygen—a dangerously rich concentration, which can throw the blood chemistry out of balance. On her fifth day in the hospital, Placida unexpectedly went limp, and her heartbeat began to race; she died at 10:25 P.M.

  Too many babies were dying in the ICU—dying of problems that shouldn’t have been fatal, problems that patients had been able to lick in the past. Other kids would recover—but only after experiencing unexpected problems. Doctors covering the pediatric ICU were accustomed to handling three or four resuscitations a month. There were nine CPRs in August 1981, thirteen in September. The residents wondered what was happening.

  The frantic search for answers began with explanations that were benign. Was there some mysterious germ in the air? A San Antonio strain of Legionnaires’ disease? Perhaps a new type of meningitis? Doctors wondered if the ICU’s medical equipment had become contaminated. Or was it just a run of bad luck? As the emergencies became more frequent, a less innocent pattern emerged. The children were dying during a single nursing shift—the 3–11 evening shift. And they were dying under the care of a single nurse. They were dying on Genene.

  One child arrested on three consecutive days—in each case on the 3–11 shift, in each case on Genene. “I’d leave a
patient I thought was stable,” said Toni Grosshaupt, an RN. “She’d come on, and I’d find out the patient had a bad spell—had seizures or codes. That happened consistently. It just got to the point where I hated to come back the next day.”

  As codes and death became more common, a job that was naturally difficult became almost unbearable. The unit was already short-staffed; everyone was working extra. Concerned about the growing pressure, Dr. Robotham had arranged for a psychiatrist to visit regularly with the staff in the ICU. Genene’s predictions of medical catastrophe were becoming eerily accurate. When the LVN announced during report that a baby would die, other nurses set up emergency medications at the patient’s bedside in anticipation of the arrest.

  The burden was greatest on those who worked with Genene on the 3–11 shift, where all the emergencies were taking place. On one particularly dark night, they had two codes going at once; the doctors and nurses stabilized the first baby, moved to the second child, who died, then had to return to the first patient, who was suffering a second arrest, which would prove fatal. “It was getting too stressful,” said Judy Cacciola. “I was depressed a lot of the time. It was just very frustrating to go in, work our tails off, and have all those kids dying around us. After a while, the codes almost became a joke. I had to get out of there.” Cacciola quit in September, after nine months in the ICU.

  Genene herself seemed devastated by the rash of deaths and near deaths. “They’re going to start thinking I’m the Death Nurse because I’m always taking these babies downstairs,” she told one resident. In September, another of her patients died, and Genene fell into a chair in a corner of the unit and broke into tears. A young female doctor walked over to comfort her, and Genene looked up, her eyes red and puffy. “Why do babies always die when I’m around?” she asked.