The Death Shift

by Peter Elkind

  Dr. Holland admitted Anthony Winn to the hospital and sent him to the ICU. The nurses there ran a blood-sugar test to check Jones’s claim that the child was hypoglycemic; the test came back normal, just as it had more than a year earlier during an identical situation at Medical Center Hospital in San Antonio. The Sid Peterson nurses had caught Jones in another lie. Dr. Holland performed a spinal tap on Anthony to check for meningitis, but the test revealed no evidence of the disease. Anthony Winn left Sid Peterson after four days. There was no evidence that anything serious had ever been wrong with him.

  After making sure Anthony was stable, Kathy Holland had asked her nurse why she hadn’t sent the Winns directly to the emergency room when they called. Genene told her that the Winns had phoned from a telephone booth opposite the clinic, that she thought Anthony’s problem would be routine, and that she didn’t want to bother Holland on a rare night alone with Charleigh. Holland scolded Jones for treating the baby herself.

  “I’m not going to let some kid die because you’re so far away,” Genene snapped.

  Monday, September 20

  The emergencies of the previous week had made a mess of Kathy Holland’s clinic. In the morning, Genene approached Dr. Holland and told her they needed to restock the crash room with several drugs that they had used during the codes. The nurse rattled off a list of medications—calcium gluconate, atropine, epinephrine, sodium bicarbonate, potassium chloride, Dilantin, heparin—and Holland authorized their purchase. An order was placed with the pharmacy at Sid Peterson Hospital later that day.

  Dr. Holland’s clinic was closed during the afternoon for the funeral of Chelsea McClellan. Genene had marked the event in the office appointment book:

  no appt’s today

  Funeral’s @ 2 p.m.—

  Must go

  Petti and Reid had arranged to bury Chelsea at the Garden of Memories Cemetery in Kerrville. Their little girl was dressed for the occasion all in pink—dress, booties, and bow—like a fine porcelain doll. A knit blanket covered her body. Petti and Reid had Chelsea’s favorite plaything—a foot-high yellow rubber Tweety bird—placed in her casket and ordered a small headstone with the words “Our Little Angel” for her grave.

  The McClellans could not understand why their daughter had seemed so well and suddenly become so sick. Petti was still unable even to accept that Chelsea was gone. She walked around their trailer home carrying her daughter’s toys and talking to them. When Petti saw the small sealed box containing her daughter’s body at the funeral, she screamed, “You’re killing my baby!” and collapsed.

  Kathy Holland, Genene Jones, and Gwen Grantner all attended the ceremony, and the McClellans were grateful for their support. A few days after the burial, the McClellans took out a two-column advertisement in the Kerrville Daily Times. It was addressed “To All of Our Friends in Kerrville:”

  Often we live our lives without a tendency to acknowledge those friends around us. Then something will happen which causes us to become aware of others. Such was the case in the loss of our little Angel, Chelsea Ann McClellan. The response from the people of Kerrville, many of who we only knew in passing was both heartwarming and most helpful in our grief. The many beautiful flowers, cards, and letters we received made us realize the city of Kerrville has a heart.

  A special thanks to Dr. Kathryn Holland and Jeane Jones for extending Chelsea’s stay longer by their caring in such a sensitive way. A care which extended beyond our loss and helped us more than anyone could ever know.

  Sincerely

  Reid & Petti McClellan

  In her nursing notes in the office medical records, Genene Jones wrote her own tribute. She summarized the arrest, the unsuccessful attempts to revive Chelsea, and the death, then added, “I would have given my life for hers—Goodbye Chelsea.”

  Sixteen

  The rash of emergencies at the new pediatrician’s office had not gone unnoticed within Kerrville’s small medical community. The nurses and doctors at Sid Peterson were used to seeing adults in the hospital, not infants. But since Dr. Holland’s arrival, there had been as many as three children in the ICU at a time. The number of kids getting sick prompted doctors to joke that Dr. Holland needed to change the air-conditioning in her office. Privately, they wondered what was going on.

  Dr. Duan Packard, the dean of the Kerrville medical community, had been particularly suspicious ever since the incident involving his patient, Misty Reichenau. A family practitioner who earned his medical degree in 1939, Packard lacked Kathy Holland’s knowledge of modern medical technique. But he possessed a wealth of wisdom leavened by decades of experience. Packard had kept a close eye on Holland ever since Misty’s visit, and he was distressed by the number of arrests taking place in the pediatrician’s office. “I’ve been in practice forty-three years and never had one,” he said. “To the best of my knowledge, we’ve never had one in Kerrville. Something had to be wrong.”

  Packard speculated that the inexperienced pediatrician was being too aggressive—overreacting by cramming breathing tubes down the throats of babies who were just holding their breath because they were angry about getting shots. Packard knew most sick children get well with little help from a doctor. But Holland seemed unwilling to let nature take its course. The children rushed from her office always arrived intubated and with an IV. In the hospital, Holland always performed a battery of invasive procedures, such as spinal and bladder taps. She put her patients on powerful antibiotics and sedatives before being certain of what caused their problems.

  The nursing staff had also been complaining. The children brought in by Dr. Holland often didn’t seem sick enough to be in the ICU. They all had experienced emergencies in her office, but in the hospital there was no sign of what had caused their crises. The newcomers, Holland and her nurse, had annoyed the emergency room and ICU nurses with their condescending attitude. Jones seemed to make a point of displaying how much more she knew about pediatrics than the nurses at the hospital. Yet when Holland and Genene arrived to handle an emergency, there was inevitably chaos. They would ask for equipment, then would toss it down angrily if handed the wrong instruments. Jones made rounds at the hospital and wrote in patients’ medical records—something no office nurse in Kerrville had ever done. When nurses phoned Holland for instructions, Genene Jones sometimes answered and gave them orders, often not even saying they were on the doctor’s behalf.

  The incidents fueled gossip about the new doctor’s personal life. Many had taken note of Holland’s unusual living arrangement; they didn’t understand why all those women were living together in the same house. And where was Dr. Holland’s husband? Kerrville was a small, chatty town where outdated conventions were respected, but Kathy Holland made the mistake of taking few pains with appearances. She usually wore pants, used little or no makeup, and wore her hair short. For the residents of Kerrville, it was all more than enough to prompt unfounded talk that the house on Nixon Lane was a den of lesbians.

  On Wednesday, September 22, Tony Hall, Sid Peterson’s administrator, convened a small group in his office to discuss the problems Dr. Holland and her nurse had caused in the hospital. The group included Dr. Packard, then chief of the hospital’s medical staff, two other doctors, and the head ICU nurse. They went down the list of complaints. Things would have to change, they agreed. Hall called Dr. Holland and arranged to meet with her shortly after noon the next day.

  Thursday, September 23

  As Tony Hall prepared for his meeting with Dr. Holland at Sid Peterson Hospital, Clarabelle Ruff brought her five-month-old daughter, Rolinda, into Holland’s clinic for the first time. Mrs. Ruff was a secretary for a Kerrville urologist. She had called earlier to make an appointment, explaining that Rolinda had been suffering from intermittent diarrhea for the past thirteen days.

  Mrs. Ruff and Rolinda arrived about 10:15 A.M., the same time as Mary Ann Parker and her son. Chris Parker’s earlier visit to the clinic for raspy breathing had resulted in a three-day stay at Santa Rosa
Hospital. Now suffering from diarrhea and an ear infection, he seemed sicker than Rolinda; Mrs. Ruff suggested the doctor see him first. But when Genene Jones came out to the waiting room, it was Rolinda she wanted.

  The nurse told Mrs. Ruff she was taking her daughter to the treatment room to check her temperature. Dr. Holland appeared a few minutes later and invited Mrs. Ruff into the hallway. After examining Rolinda, Holland told Mrs. Ruff that her daughter was a little dehydrated; she wanted to start an IV line to get some fluids into her system, then admit her to Sid Peterson for tests and observation. But there was no need to worry, said Holland; this wasn’t an emergency.

  The doctor walked back into the treatment room, where her nurse had prepared the IV equipment. Spotting a good vein, Holland threaded the needle into Rolinda’s left hand. Then she flushed the line clear of blood, injecting clear fluid from a syringe that Genene handed her. Mrs. Ruff soon heard sounds from within the treatment room—sounds of Rolinda choking and someone pleading aloud: “Come on, come on!” Holland came out of the treatment room for a moment, and Mrs. Ruff got a glimpse of her daughter. Rolinda had an oxygen mask over her face. Nobody in the office had even taken her child’s medical history, Mrs. Ruff said later.

  At Sid Peterson Hospital, word quickly spread that there was a code blue on the way to the emergency room—a code blue from Dr. Holland’s office. A crowd of doctors rushed to the ER. There was Dr. Packard, whose office was just a few steps away; Dr. Frank Bradley, an anesthesiologist, who had heard the code blue call after finishing up morning surgery; Dr. Larry Adams, Dr. Earl Merritt, and Dr. M. B. Johnston. They stood around and watched as Holland and her nurse rushed in with Rolinda Ruff.

  The patient’s color seemed to be returning. Her breathing was labored but growing easier. Holland wanted to insert a breathing tube. Dr. Merritt told her the child was breathing fairly well, that intubation didn’t seem necessary. But Holland intubated the baby anyway. The child began fighting the tube. She was struggling to raise her right arm…but she couldn’t quite do it. Finally, she pulled her arm up. Dr. Bradley, the anesthesiologist, was watching closely, and suddenly it clicked: The child was coming out from under Anectine! “It just reminded me of what I’d seen in the operating room,” said Bradley later. “The child appeared to be trying to reach up, but [she] just didn’t seem to be able to get [her] hand up. It was jerky, uncontrolled movements with a purpose, but an inability to accomplish that purpose.” Bradley confided his revelation to Dr. Adams, who called Dr. Packard over. Packard went up to see Tony Hall. The two quickly agreed to hold an emergency meeting of the medical staff’s executive committee later that afternoon.

  Meanwhile, down in the ER, there was yet another emergency. As she ran out of the clinic during Rolinda’s arrest, Genene Jones had told Mary Ann Parker to bring her son down to the hospital. Less than an hour later, Genene came out to the Sid Peterson waiting room for Chris Parker. She took the baby back into the emergency room and placed him on a bed being prepared for a cardiac patient coming in by ambulance. An ER nurse had to ask Genene to move Chris; after all, he was just having a routine exam. Miffed, Genene snorted, “Well, I hope to hell this baby doesn’t go into cardiac arrest.” After carrying Chris into another cubicle, Genene ordered some x-rays and began drawing blood for tests. A few minutes later, she called a code, shouting that Chris Parker had arrested.

  Genene told the staff to call Dr. Holland, but the ER physician, Dr. Mason, and two hospital nurses were first on the scene. Chris’s throat was clogged with mucus; the nurses suctioned it out. Racing down from the ICU, where she was tending to Rolinda, Kathy Holland ordered two different drugs to ease the baby’s distress, and the nurses injected them. Chris seemed okay. Just then, everyone noticed a half-filled syringe on the child’s bed. Holland picked it up. It wasn’t one of the needles the nurses had just used. “What’s this?” Holland asked. The hospital nurses and Genene all looked at one another; no one knew. “Well, let’s get rid of it then,” Holland said. She squirted out the mysterious clear liquid and tossed the syringe in a disposal box. Dr. Holland called the ICU to ask the head nurse whether she had another bed available. The nurse told Holland that the intensive care unit was full. Rolinda Ruff had just been admitted; Holland decided to bump her to a ward bed to make room for Chris Parker.

  At about noon, weary from two more emergencies, Dr. Holland showed up for her appointment with Tony Hall. The Sid Peterson administrator was harboring a terrifying suspicion: that, somehow, children in Dr. Holland’s office were receiving succinylcholine, the powerful muscle relaxant sold as Anectine. For the moment, however, Hall was anxious not to tip the pediatrician off. He told Holland that her office nurse, Genene Jones, had irritated the hospital staff by giving orders and making notations on charts. Holland apologized. Genene might be a bit too aggressive, she conceded; she would speak to her.

  About 2 P.M., after his afternoon rounds, Duan Packard sat in the doctors’ seventh-floor lounge, sipping coffee and puzzling over the problem. Dr. Joe Vinas, a ruggedly handsome young surgeon, sat down beside him and asked what was wrong. Packard explained. Vinas was not surprised at the doctor’s suspicions. “Packard’s the old man of Kerrville medicine,” Vinas said later. “He smells a rat real fast.” Like the other doctors in town, Vinas believed that the number of children who had had emergencies in Holland’s office meant that something was very wrong. “Seizure? Respiratory arrest? Cardiac arrest? Bullshit. That doesn’t happen in Kerrville. It never has.” Now, in the coffee room, Packard told Vinas he could help. Vinas had done his residency at Medical Center Hospital and would know people who had worked with Kathy Holland. “We need to find some things out,” Packard told him. “You have the job of tracing her background.”

  The medical staff’s executive committee gathered at 5:15 P.M. in a wood-paneled conference room on the hospital’s second floor. The group included the chief of each of the hospital’s medical specialties, but it was no bastion of power. Seats on the committee rotated annually, and the panel’s usual business was mundane: granting hospital privileges and setting rules for doctors. Sid Peterson had never experienced a problem like this. Tony Hall and Dr. Packard briefed the doctors on what they knew. They related the complaints from the nursing staff and Dr. Bradley’s observations concerning Rolinda Ruff. Joe Vinas was checking into Holland’s background, Packard told them. They decided to see what Vinas learned, then have a talk with Dr. Holland.

  Late that afternoon, after yet another frenetic day, Kathy Holland walked out of the Sid Peterson intensive care unit with her nurse. The two women stopped to contemplate a commemorative portrait hung outside the door of the ICU. “Maybe someday,” said Genene Jones, “this will be the Chelsea Ann McClellan Memorial Pediatric Intensive Care Unit.”

  Joe Vinas, charged with investigating the two women whose arrival in Kerrville had produced so much tumult, also left for home late Thursday afternoon. About 6 P.M. he made his first call, to a surgery resident still at Medical Center Hospital. Vinas briefed his colleague on what was going on in Kerrville. The resident told him there had been problems in the pediatric ICU in San Antonio, a number of deaths no one could explain. He said there was one particular nurse who seemed to be the common denominator. But the resident couldn’t remember her name. Was it Genene Jones? Vinas asked. The resident said he would check and call back. The phone rang five minutes later. “You’ve got a baby-killer on your hands,” the resident said.

  Friday, September 24

  The executive committee met again at 1 P.M., and Vinas revealed what he had learned. A baby-killer. The doctors were stunned. Then Dr. Holland was brought in. She sat at the oblong table, surrounded by eleven men—one of them a psychiatrist, asked to scrutinize her behavior. The room grew quiet. A lot of children seemed to be getting sick in her office, Dr. Packard began gently. Why did she think that was happening?

  Holland said she shared everyone’s concern and would welcome advice, but she knew of no problem. Each of the children, sh
e explained, was a separate medical situation. Each had displayed clear symptoms that explained what had happened. Holland began to elaborate; to the other doctors she seemed tense but self-assured and professional. She had brought index cards with her, one for each of her emergency patients, and she began flipping through them, explaining each child’s symptoms and the treatment she had given. The doctors asked about the drugs she had used. Had she ever used succinylcholine, the muscle relaxant sold under the brand name Anectine? Yes, during her residency. Did she have it in her office? Yes, but she had never used it. Did she trust her nurse? Yes. Genene had taught her things about resuscitating children, Holland told them. Did she know the result of the investigation in San Antonio? The LVNs had been moved out to upgrade the ICU, Holland said, and all had been offered jobs elsewhere in the hospital. As the conversation continued, Packard told the pediatrician he wanted her to have another physician consult on all her hospital patients’ treatment. Holland’s beeper went off, and she left the room briefly, then returned. Jimmy Pearson, back at Sid Peterson, seemed about to arrest, she said. “Would one of you care to accompany me?” Holland left the room.

  The doctors sat back and talked about what they had heard. The psychiatrist said Holland was bright but excessively voluble, and noted the absence of emotion in her voice; he told the group she seemed depressed. Holland had clearly offered plausible medical explanations for each individual case. But when the incidents were taken together—and Vinas’s information from San Antonio was considered—there was far too much smoke. The doctors were in agreement. They would lift Dr. Holland’s privileges to admit and treat patients at the hospital. The only remaining question as they left the conference room was when.