by Peter Elkind
Three days after Joshua Sawyer’s death, Dr. Robotham ordered nurses to immediately notify him or Dr. Victor German, the ICU’s newly appointed deputy medical director, of every code on every child. But he was particularly interested in emergencies involving Genene Jones. Robotham had taken trusted nurses aside and asked them to keep an eye on the LVN. The medical director’s favorite nurse had become his prime target.
Genene was well aware of Robotham’s shift in attitude. J.R. had twice refused her requests for a letter of recommendation. She regarded his suspicions as an act of personal betrayal. The medical director wasn’t trying to uncover what was going on; he had simply turned against her. After Robotham ordered drug tests on another of her patients, Jones phoned his medical school office with her own interpretation of the result: “Your son-of-a-bitch toxicology screen was negative.”
One friendly RN counseled Genene to let tensions cool by treating less sick patients for a while. But that wasn’t her style. It would be like admitting she was guilty, Genene explained. She preferred instead to take her accusers on, to remain in the center of the storm. One day she pulled Robotham aside and confronted him. “What the hell’s going on?” she demanded. “Do you think I’m doing something to kids?” Robotham looked her straight in the eye. “I don’t know,” he told her honestly.
Another day, she issued a warning. “This unit is my life,” she told Robotham and Belko. “If you try to take me away from this unit, I have my little black book with the name of every kid who’s died in the unit—and the doctor who caused the death.” She was blackmailing them! Jones had mentioned a “black book” in conversation with other nurses. Now Belko and Mousseau called Genene in to question her: Did she really have such a book? Genene backed down; she said she did not. Furious at the threat, Robotham told the nursing administrators he wanted Genene fired—or at least out of the ICU. But they saw no reason for such action; Genene was just upset. They refused to do more than briefly take her off the most critical patients.
In mid-December, the beleaguered medical director, resting at home, received another late-night call from the ICU. There was a problem with a patient; they needed him to come in. Robotham explained that his wife was visiting her family in France, and it was too late to call a baby-sitter. Could someone getting off work come to watch his infant daughter? There was a pause for a few moments, then a familiar voice came on the line: “I’ll be right over.” It was Genene.
Robotham had always told his residents to treat every patient they cared for as if the child were their own. Now his medical philosophy, so sincere in the abstract, was being put to the test. The nurse he suspected of harming patients would arrive in minutes to be alone with his little girl. Dare he trust her? Robotham figured he had no choice. After several hours at the hospital, the doctor returned to his house at 3:30 A.M. Genene was dozing on the downstairs couch. Robotham woke her up, offered thanks, and quickly ushered her out the door. Then, terror in his heart, he crept up the stairs and peered through the darkness into his baby’s bedroom. The little girl was sound asleep.
The three months since Suzanna Maldonado’s visit to Pat Belko had left Robotham at wit’s end, brimming with fatigue and angry frustration. The unit was full, the patients critically sick, and the staff overworked and divided. Robotham had been fighting more than natural illness and injury. He was locked in a personal guerrilla war with a nurse, an adversary he was unable to entrap and powerless to remove.
By late December, Bob Franks had decided his young colleague was obsessed with Genene Jones. Since completing his chart review, Robotham had reported back to the acting chairman almost daily. Still he had no proof of criminal conduct. Belko had complained that the residents were screening for improper drugs only on Genene’s patients. Franks knew the ICU wasn’t operating well, but he considered Robotham’s focus on Jones unjustified—and an open invitation to a lawsuit. Besides, Genene Jones was a nursing problem. There was nothing they could do.
Franks recognized that Robotham was operating under enormous pressure. For twenty-one months, as primary consultant to the ICU, he had been making rounds six or seven days a week, answering questions at all hours from home, and often returning to the hospital in the middle of the night. It was time for him to take a break—whether he liked the idea or not. The acting chairman informed Robotham that he was being temporarily relieved. He needed the time off, and besides, a fresh perspective might help dispose of this problem. Victor German would take over the unit chores during January. Franks instructed Robotham not to set foot in the pediatric ICU for a month. The medical director was relieved to have a respite but a bit sour about being exiled. “Why?” he asked Franks. “Are you concerned I’m doing something?”
But Robotham was in no position to quarrel. The one man who was intent on determining Genene Jones’s connection to the mysterious deaths in the ICU—the only hospital official who believed there was a connection—would begin the New Year working with baboons in his research lab.
After the staff nurses learned that Dr. Robotham would be absent from the pediatric ICU in January, Genene Jones encouraged her peers to believe the worst. She circulated a rumor that the excitable medical director had suffered a nervous breakdown.
Even as Robotham was banished, a critical piece of the puzzle lay buried and ignored within the bureaucracy. Since early 1981, a hospital clerk named Patricia Lopez had been complaining to her superiors about the disappearance of supplies from the pediatric ICU. The young woman’s duties included equipping the unit’s crash cart. She checked the cart daily and showed up at codes to replace everything that was used. On about ten occasions during 1981, Lopez had found the crash cart open when no code had taken place. Each time, the cart had been opened during the 3–11 P.M. shift. Each time, Lopez discovered the same items missing: a tourniquet, a handful of gauze pads, several syringes—and a 10,000-unit bottle of heparin. Lopez reported each of the incidents, in at least one case in writing. But her supervisors worked in a different hospital department from those who knew about the problems in the ICU. They figured nurses were using the blood-thinner from the crash cart during their normal duties because it was close at hand. They told Lopez just to keep replacing the missing heparin.
December 1981 had been a special time at San Antonio’s charity hospital. The first day of the month marked Bexar County’s official reincarnation as Medical Center Hospital, part of B. H. Corum’s “New Horizons” campaign to boost the institution’s image. The hospital district’s executive director was also busy preparing organizational charts for a major administrative reshuffling; it would retitle Virginia Mousseau from assistant administrator for nursing service to associate administrator for patient care services. On December 16, the district auxiliary threw the annual employees’ Christmas party in the hospital cafeteria.
But in the pediatric ICU, December 1981 had been another horrible month. After a brief calm in November, there had been ten CPRs in December, an unusually high number even for the beginning of the busy winter season. Seven children had died—six of them on the 3–11 shift, including four assigned to Genene. Two-year-old Doraelia Rios was among them.
Hospitalized several times previously for surgery on her digestive tract, Dora entered the pediatric ICU on December 21, suffering from diarrhea, dehydration, and possible inflammation of an internal membrane. At the time of her admission, Dora was listed in guarded condition. She was given fluids to deal with the dehydration and antibiotics to fight the infection, but she suffered a cardiac arrest and died at 8:12 P.M. the next day. After being present for the final code, Genene Jones finished her nursing notes with a brief message to the dead child: “A legend in her own time. Merry X-mas Dora. I love you. Jones LVN.”
Ten
Rolando Santos was dying. Not from ravaging disease or tragic injury or even an act of God—reasons any doctor could accept—but because someone, someone sworn to help make him well, was trying to kill him. Why else would a baby with simple pneumonia go
into seizures and cardiac arrest and begin pouring out blood? Why else would such troubles develop not once or twice or even three times, but on four separate occasions—always during the same hours? Dr. Kenneth Copeland could reach no other conclusion: They were dealing with a murderer.
As the pediatric faculty’s epidemiologist, Copeland was an expert in the outbreak of disease. Thirty-three years old, he was thin and boyishly handsome, with a mop of curly blond hair. Copeland was spending January as an attending physician in the ICU, in charge of a team of pediatric residents. He was working with Dr. Victor German, who would fill Robotham’s role as consultant on any sticky problems that developed. At the beginning of the month, Robotham had bluntly told the two doctors that he suspected Genene Jones was harming children. Like a baseball manager given the thumb, J.R. would be available to offer advice from the clubhouse. But it would be up to them to try to catch her.
Rolando Santos was like most of the kids who came to the pediatric ICU. His parents were Hispanic and poor. His father, Eusebio, picked crops on a farm forty-two miles southwest of San Antonio. His mother, Jesusa, made dolls and tended the couple’s children. Rolando was their eleventh, born in November. On December 27, when the baby was a month old, his mother had taken him to the Brady-Green clinic in downtown San Antonio, site of the old Robert B. Green Hospital. Mrs. Santos believed Rolando had a cold. But a pediatrician there discovered pneumonia and sent the baby to the pediatric ICU at Medical Center Hospital. Placed on a respirator, Rolando improved during his first two days. His type of pneumonia was predictable; with antibiotics, most such children went home within a week. Then, during the 3–11 shift on December 29, Rolando began seizing. A brain scan revealed nothing to explain the seizure, but the baby’s heart stopped two hours later. After reviving him, doctors ran more tests on his brain and heart to try to figure out what was going on. All of them came back normal.
Rolando again started to improve. By January 1, he was doing so well that doctors were ready to take him off the respirator. That afternoon, Rolando suddenly excreted a massive amount of urine, dehydrating his body. The baby’s blood pressure began to drop; he showed symptoms of a seizure, then turned sluggish. Doctors poured fluids into Rolando to replace the urine and stabilized him. Copeland began to wonder if someone was giving the baby drugs. A diuretic would explain the urine output; a narcotic could made him lethargic. Searching for an answer, Copeland gave Rolando a medication that counters the effect of narcotics. But it didn’t have any effect.
Rolando bounced back quickly from his crisis on New Year’s Day. On the evening of January 3, nurses noticed that he was oozing a bit of blood. Doctors presumed the problem was DIC, the rare clotting abnormality caused by infection. They gave Rolando plasma, and by early the next morning, the bleeding had disappeared. On January 6, Genene Jones returned to work after three days off. As she had every day while on duty recently, the LVN assumed responsibility for Rolando Santos’s care. At 7 P.M. that night, the baby began bleeding heavily. Everywhere doctors had stuck a needle in him, blood was oozing out. The hemorrhaging sapped Rolando’s blood pressure, and he fell into cardiac arrest. It took electric shock and three rounds of emergency drugs to restart his heart.
Copeland sent blood samples to the lab for tests. They were inconsistent with DIC. But they were positive for excessive heparin. The next day, Copeland instructed nurses to remove the baby’s arterial line. Without a line to keep clear, there would be no need for Rolando to receive any heparin. This would eliminate the remote possibility that a nurse could give him an overdose by mistake. But Copeland didn’t think the previous episode was an accident. Every time Rolando got better, something terrible seemed to happen. It was as though someone was playing with him, cruelly toying with the child’s health, like a cat with a crippled bird.
Jesusa and Eusebio Santos didn’t understand why their baby was taking so long to get well. Lacking the money to stay in San Antonio and remain at Rolando’s bedside, they phoned the hospital several times a day to check on his condition. The day nurses always told them Rolando was doing fine. But at night, they would hear that he was having problems. Genene Jones had her own explanation for why Rolando had been on a roller coaster since his arrival in the ICU. Standing near the nursing station one night, she remarked, “The doctors are fucking up.”
On the afternoon of January 9, Rolando started bleeding again. Genene was the first to spot the problem, which worsened into the evening. Summoned by a resident, Copeland arrived in the ICU about 7 P.M. to find a crisis. Blood was leaking out of the baby as if he were a water balloon filled with needle holes. It trickled from old puncture sites all over his arms and his legs, his neck and his scalp. Blood oozed from the mucous membranes in his nose and mouth and eyes. Rolando’s urine was red, and nurses suctioning his throat found even more blood. Working in a crimson puddle, residents were pushing plasma into the child as fast as they could. But it wasn’t fast enough. His blood pressure was dropping. Then he fell into a coma; they were about to lose him.
Desperate, Copeland decided to try protamine sulfate—the drug used to reverse the effects of heparin. The doctor was gambling. Protamine could harm a child who hadn’t received heparin. But there was no time to wait for lab results, no time to do anything else. At 7:30 P.M., Copeland threaded a small IV line into a vein in Rolando’s scalp, drained a 100-milligram bottle of protamine into a syringe, and injected it slowly into the baby. Nothing happened. Even if his gamble was right, Copeland had no idea how much protamine he would need. He sucked another bottle into a syringe and pushed it into the IV. The bleeding continued. Copeland began to sweat; he had been pushing protamine for twenty minutes. The doctor drew up a third bottle. At 7:55, after he had injected another 30 milligrams, Rolando’s bleeding suddenly stopped.
Throughout the night, the baby improved; he was awake and alert by morning. That evening, he was taken off the respirator and began breathing on his own. But Copeland believed that Rolando’s life was still in danger. On January 11, when he came in for morning rounds, he ordered nurses to transfer the baby out to the pediatric floor. Rolando was really too sick to leave the ICU; he had been near death thirty-six hours earlier. But to Copeland, he was also too sick to stay. The doctor was determined to remove him from the place where uncomplicated pneumonia had almost claimed his life. Early that afternoon, Copeland returned to the ICU and discovered Rolando was still there. He was furious; the 3–11 shift would soon begin. “I want him out now!” he told the nurses, and they wheeled him out of the unit. Copeland secretly arranged with the head nurse on the pediatric ward to have Rolando guarded around the clock. He ordered a list kept of everyone—especially from the ICU—who went into the baby’s room.
Five days later, Rolando Santos was well enough to go home.
At last, thought Jim Robotham, they had real evidence of a heparin overdose in the pediatric ICU. The medical school’s blood expert put it in writing: Rolando had received too much heparin during the 3–11 shifts on January 6 and January 9. The effectiveness of the protamine sulfate—a specific antidote to heparin—had presented independent proof. Someone even offered an explanation of how the baby might have gotten the blood-thinner. A few days after Rolando’s last bleeding episode, Robotham discovered on his desk a copy of a nursing-journal article. Titled “You Can Inject Heparin Subcutaneously,” it detailed how the drug could be given directly under the skin without leaving a visible bruise; a series of accompanying photographs showed “seven steps to trouble-free injections.” Robotham’s secretary could not tell him who had placed the article on his desk. Although no one had seen Genene Jones inject the blood-thinner, Robotham and Copeland both felt certain she was somehow responsible. The two men informed Bob Franks of their belief. Finally, thought Robotham, something would be done.
But the nursing administrators had an alternative to the doctors’ ugly suggestion that one of their own would try to harm a child. Determined to fight this smear on their profession and on their staff, th
ey suggested it was all just a simple mistake. Pat Belko had complained bitterly about Copeland’s decision to move Rolando Santos out of the ICU. Now she and her superiors drew their explanation for the baby’s bleeding from the woman suspected of causing it. Genene had blamed an agency RN working the day shift, suggesting the nurse had confused bottles of heparin and ampicillin, an antibiotic that Rolando was receiving through an IV. Such a mix-up was improbable. The two drugs came in bottles of different sizes that bore labels of different colors. Rolando had bled on 3–11, not the day shift. And at the time of his final episode, the child had no arterial line; there was no reason for a vial of heparin even to be in his room. But Belko, Harris, and Mousseau—without bothering to investigate—embraced the alibi anyway, muddying waters that had briefly cleared.
Buffeted by the conflicting claims, anguished about what to do, Franks did very little. He informed B. H. Corum about the case of Rolando Santos. He also sought the aid of his own boss: Dr. Marvin Dunn, dean of the UT medical school. In a January 19 memo to the dean, Franks detailed the history of suspicions in the ICU, noting: “From the outset there had been innuendo that purposeful nursing misadventure was involved.” Robotham’s review of the patient charts “could not substantiate that suspicion,” Franks informed Dunn. But now they had proof that someone had given a child too much heparin. As a result, wrote Franks, he had “returned to a position of not knowing whether or not there is a problem.” The acting pediatrics chairman told the dean that the nursing department—which, of course, felt nothing was wrong—would investigate the matter further. “I have several obvious concerns,” he wrote. “One is that there will be inappropriate comments, resulting in unjustified publicity.” Franks said he would continue to evaluate “unexpected events” in the pediatric ICU and welcomed Dunn’s advice. The dean did not immediately offer any.