Perfect Poison

by M. William Phelps

  “Yes,” Rix agreed, “we need to do something—soon.”

  “I’m going to Melodie,” Walsh said. “That’s it! If you and John don’t want to take it any further, I’ll understand.”

  “Don’t go alone, Renee,” Rix advised. “I’ll go with you. And call John. I’m sure he’ll go, too. You shouldn’t have to do this by yourself.”

  “I’ll call Melodie tonight.”

  When Ed Skwira arrived at the VAMC on February 15, he wasn’t feeling all that well. Inside the VA van during the ride over, he had been experiencing some mild chest pain. But chest pain—or “angina”—was something he had suffered from for decades. He’d even been taking nitroglycerin pills for quite a few years now to ease the pain.

  Admitted shortly after 2:00 P.M., Skwira was mentally confused and “appeared . . . hypotensive,” meaning his blood pressure was low. This was Skwira’s first time at the VAMC. Maybe the thought of what was ahead scared him?

  Upon a further check of his medical history, doctors learned that Skwira had developed some serious cardiovascular problems throughout the years. Maybe it wasn’t anxiety and stress causing his chest pain after all; perhaps it was a heart attack.

  Ed Skwira had suffered from hypertension for many years; coronary artery disease; peripheral vascular disease; and carotid artery disease with hypercholesterolemia. In the late 1980s, he’d undergone abdominal aortic aneurysm repair surgery. Common in patients with hypertension, the large blood vessel going through the diaphragm to the abdomen becomes engorged, like a backed-up garden hose, and has to be relieved. Although he went through the surgery without any complications, the continuing angina pain Skwira suffered from was an indication he still had some blockages, which limited blood flow.

  The admitting doctor, after examining him, noted there was a “slight change on his EKG.” With Skwira now acting confused and restless, this worried the doctor.

  Maybe he is having a heart attack?

  But heart attacks don’t, normally, come on as suddenly as they did to people on television or in the movies. Often, a heart attack was days in the making, and sometimes people didn’t even know they had one.

  Not taking any chances, the doctor ordered some fluids, got Skwira stabilized, and sent him up to the ICU in Ward C to be monitored more closely.

  It was about 2:30.

  When Gilbert came in at four, she was assigned to the ICU, where now, mildly sedated, Skwira rested comfortably.

  Placing him in the ICU was a precautionary measure. His EKG readings were normal, but the admitting doctor wanted to be sure there was nothing else wrong. By this point, Skwira had even stopped complaining about the chest pain he’d had, yet the doctor still wanted to rule out the possibility, he later said, of a heart attack.

  Shortly after four, Dr. Nabil Raheb, the attending physician, came in and ordered Gilbert to give Skwira a chest X-ray and full body CAT-scan. There was a slight chance, Raheb contended, that Skwira’s aorta had a tear in it.

  Radiology was on the same floor as Ward C, but with Skwira being as heavy as he was, there was no way Gilbert was going to lift him up on the gurney herself. So she called nursing assistant Lisa Baronas in for some help.

  When they got down to Radiology, Lisa helped Gilbert lift the overweight vet off the stretcher and onto the table.

  “Call me when you’re done, Kristen. I’ll come back and help you.”

  “Thanks.”

  It was now 4:15.

  Within the hour, Lisa Baronas was summoned back to the CAT-SCAN room, where she helped Gilbert return Skwira to his room in the ICU and, when they finished, left the room and continued preparing the supper trays she was getting ready to distribute.

  Dr. Raheb learned quickly what all the fuss had been about. Ed Skwira, Raheb diagnosed, had a “bulge in [his] aorta.” Medically speaking, it was called a “thoracic aortic aneurysm.”

  After studying Skwira’s X-rays and CAT-scans, Dr. Raheb thought there was a possibility he also had a tear in his aorta, which meant disaster. Blood can leak into the chest cavity and cause all kinds of problems, resulting in a drastic drop in blood pressure and, ultimately, death.

  Dr. Raheb saw the bubble in Skwira’s chest, put that together with his low blood pressure and confusion, and thought, Dissection! This patient has a dissecting aortic aneurysm.

  The VAMC wasn’t equipped for emergency open-heart surgery. So a decision had to be made right away.

  At the same time, however, a tear in the aorta was extremely painful. And Skwira hadn’t complained of any chest pain in a number of hours. In fact, since his admission, he’d been seen by several doctors and nurses and his condition hadn’t changed one bit.

  A decision was soon made to have Skwira transferred to Baystate Medical Center, a full-facility hospital more equipped to deal with a patient in his condition. If nothing else, doctors at Baystate could make a more calculated diagnosis and take things from there.

  Alone now, while Lisa Baronas handed out dinner trays, Gilbert monitored Skwira’s status in the ICU.

  It was pushing five o’clock.

  The charge nurse, David Rejniak, was down at the nurse’s station doing some paperwork when Gilbert called him from the ICU.

  “Call Dr. Raheb,” Gilbert said. “Ed is having chest pain.”

  She sounded excited and anxious. So Rejniak called Dr. Raheb right away.

  Moments later, at 5:07, Gilbert called a code, and efforts began to resuscitate Skwira immediately afterward.

  Soon, the room filled with all sorts of medical personnel and, of course, the one guy who seemed to be on duty whenever a code was called: Gilbert’s lover, security guard James Perrault.

  In her notes, Gilbert wrote that Skwira had gone into “sudden cardiac arrest” for no apparent reason. Nowhere in the note had she written that he had been experiencing chest pain right before he coded, as she had told David Rejniak. Nor had Dr. Raheb reported it. This was odd, because with all the confusion surrounding his condition for the past several hours, knowing that he was going to be transferred to Baystate, Skwira’s nurses would want to document anything—and everything—that happened so his doctors at Baystate could have a clear picture of what had been going on.

  But Gilbert didn’t see fit to add any information above and beyond the fact that he had coded.

  Down at the other end of the ward, Kathy Rix had been going about her normal nightly duties when the team pager she was wearing went off.

  Looking down at the blinking light, Rix shook her head.

  Here we go again.

  Shortly after she arrived for work at four, Rix had, without telling anyone, gone directly into the ICU medicine cabinet and, once again, counted the ampoules of epinephrine.

  There were three—same as there had been for the past week.

  As Rix entered Skwira’s room shortly after his code, she was told the situation was under control. But before leaving the room, Rix took a look in the medicine cabinet to see if the three ampoules of epinephrine she had counted an hour or so ago were still there.

  As she approached, she hoped her suspicions were off base. But here she was now, faced with the prospect of Gilbert calling yet another code.

  She had to find out.

  Please be in there, please, please, Rix kept thinking as she went for the drawer.

  But it was empty.

  Her knees buckled, and she felt sick to her stomach.

  “I was useless,” Rix later recalled. “I was sure I couldn’t function anymore. To me, that made it positive that there was something going on.”

  CHAPTER 30

  When Renee Walsh got home on February 15, she picked up the phone, dialed John Wall and explained the conversation she’d had with Kathy Rix earlier that day.

  “Okay,” Wall said. “I’m with you guys.”

  After that, Walsh phoned Melodie Turner.

  “Melodie . . .” Walsh said apprehensively, pausing for a moment. “Okay, here it is. John and Kathy and I . .
. we need to talk to you professionally about something very serious, and it’s very important that we do it as soon as possible.”

  “What’s wrong, Renee? What is it?” Turner, wild with curiosity, asked.

  “I’d rather wait until we’re all together, Melodie. We need to have absolute confidentiality with this. No one can know that we’re meeting with you, or even talking right now. We have to meet in a secure place—not on the ward, though. We can’t been seen coming and going.”

  “Just tell me, Renee. What’s so important that the three of you need to speak to me? I need to know now.”

  Walsh knew Turner hated being left in the dark about things. But as much as she would have liked to, she couldn’t tell her.

  “You’ll have to wait!”

  A few minutes after they hung up, Turner called back. She was even more anxious and impatient. Walsh had never heard her act like this before.

  “What is it that could be so serious? Just tell me, Renee.”

  “No!” Renee said. “Wait until we can all get together.”

  The following day, February 16, wasn’t going to work. It would have to be the day after. It was the only day Wall, Rix and Walsh could meet together.

  On the morning of the sixteenth, Turner called Walsh again.

  “Can’t we push this meeting up . . . maybe have it today?”

  “No,” Walsh said. “We’re busy, Melodie. It’ll have to wait.”

  “What about tonight?”

  “No.”

  For the next twenty-four hours, Turner called half a dozen more times, demanding to know what the problem was. But Walsh repeatedly told her no.

  “Well, I guess if you’re going to talk to me about something so serious,” Turner finally said in defeat, “I can’t think of three finer people to come and talk to me besides you and Kathy and John. I’m sure you have something very important and worthwhile to say, but can’t we do it any sooner?”

  “Absolutely not.”

  Any anxiety and fear Walsh had been dealing with now seemed to be doubled. She kept thinking about Gilbert, Glenn, and their kids. She had known Gilbert as a friend, colleague. It wasn’t every day someone accused a coworker of murder.

  But ultimately, it came down to the patients: as a nurse, Walsh had a responsibility, both professionally and ethically, to do something. As a person, she had a moral obligation. How, she wondered, could she look at herself in the mirror every day if she didn’t do something?

  On the other hand, if Gilbert was indeed a cold-blooded murderer, what would she do to Walsh and her family if she ever found out what Walsh was planning? Walsh knew it was possible that Gilbert had tried to “do something” to Glenn. If she was capable of trying to kill her husband, Walsh thought, what wasn’t she capable of?

  The entire situation scared the hell out of all three nurses. But underneath the apprehension and fear was a layer of suppressed anger that had compressed over time. They were upset that they were the ones who had to come forward. Where was upper management in all of this? Why didn’t Melodie Turner see it? Why didn’t Turner’s boss, Priscilla McDonald, notice the increasing number of codes, deaths and medical emergencies? What about Quincy Garfield, the Chief of Nurses? The Medical Emergency Committee? The Chief of Medicine? The Chief of Staff?

  Where in God’s name was Quality Management?

  CHAPTER 31

  After unsuccessfully intubating Ed Skwira for a fifth time, Dr. Raheb decided they couldn’t wait any longer for his transfer to Baystate Medical Center. He had to go now. Something was dreadfully wrong. He wasn’t responding to treatment.

  By this point, Skwira’s family had been notified about his code and were en route to Baystate. While awaiting his transfer, Skwira coded again and underwent CPR. Within moments, the team at the VAMC got his heart to beat at a normal rhythm. He was then sedated, where his blood pressure remained at 141 over 91, his heart rate at 100.

  Shortly after six o’clock, Phillip Skwira, Skwira’s youngest son, showed up at the VAMC and followed his father’s ambulance to Baystate.

  Meanwhile, Dr. Raheb had made the diagnoses that Skwira had suffered a “dissecting descending aortic aneurysm”—a fatal condition.

  But the doctor was wrong.

  As it would later be proved, Ed Skwira had been showing all the classic signs of epinephrine poisoning—and now his killer, undoubtedly worried sick that he was still alive, was riding with him in the ambulance to Baystate.

  After Skwira was gone, Kathy Rix went back into his room.

  While putting the medical equipment away, Rix grabbed the needle-disposal bucket near his bed and looked inside to see what she could find out about his code. Being a nurse for almost two decades, Rix knew that during codes doctors ordered 1:10,000 bristo-jet plunges of epinephrine, not the 1:1,000 ampoules she had been counting.

  Rix couldn’t believe it, but when she opened the bucket, there were three broken ampoules of 1:1000 epinephrine in the bottom of it.

  Her legs went numb.

  Before she finished cleaning up, Rix went around and picked up the various portions of heart rhythm strips that, like a fax machine, had spit out of Skwira’s telemetry monitor during and after his code. It was a detailed account of what had happened to his heart as it spiraled out of control.

  Rix collected them, rolled them into a scroll, and left them near his chart. This way, she thought, when Gilbert returned from Baystate, she could go through and cut out certain sections that best depicted the codes.

  It never occurred to Rix that Gilbert might want to dispose of what would ultimately be incriminating evidence against her: the rhythm strips. Rix was confused, scared. After seeing a second round of spent epinephrine ampoules, she had a hard time concentrating on anything else. Plus, she had no idea if Gilbert was falsifying medical records and failing to follow policy on top of everything else.

  Between the time Gilbert returned to the VAMC after escorting Skwira to Baystate and the next morning, those heart telemetry strips Rix had collected had disappeared—and Gilbert had not even cut and pasted one section to Skwira’s chart.

  At 6:30, on February 15, 1996, Ed Skwira was admitted to Baystate Medical Center and, oddly enough, doctors quickly ruled out the possibility that he’d had a heart attack. Moreover, after only a few tests they concluded that he, in fact, had a normal functioning heart.

  Yet on learning of his sudden cardiac event back at the VAMC, doctors believed that he had developed a “possible tear in his aorta,” a condition that, added to his thoracic aortic aneurysm, was a recipe for death. Then, upon further evaluation, they suspected that he also had a “perforated viscus.”

  Bad news all around.

  A perforated viscus is a tear in the wall of the stomach, which results in germ- and bacteria-laden air bleeding into the abdominal cavity. It was likely due to Skwira’s first code and the arduous time the VAMC staff had intubating him.

  For a person who had just suffered sudden cardiac arrest and now had a possible tear in his stomach, an operation to repair it carried a one hundred percent mortality rate—and Ed Skwira’s doctors were totally against doing it.

  But now they had to break the bad news to Skwira and his family, who were waiting patiently in his room for a status report.

  As Stacia and Phillip stood by, Skwira’s doctor came into the room and gave it to them straight.

  “Mr. Skwira, I’m sorry, but you’re going to die. There’s not much we can do for you.”

  Skwira began to cry. Stacia took his hand and kissed him on top of his head. Phillip, having trouble digesting it all, just stood there, stone-faced, waiting for someone to tell him it was all a joke.

  Under the misbelief that he had a swollen thoracic aortic aneurysm, doctors convinced Skwira and his family that the cardiac medication he was on should be stopped right away. It wasn’t doing him any good.

  This was a crucial decision, because the meds Skwira had been on were basically keeping his heart stable.

&n
bsp; Next, doctors suggested that he begin morphine treatment right away to make him more comfortable as he passed on.

  Skwira and his family agreed it was probably a good idea.

  Unfortunately, this type of painkiller actually suppresses respiration and “makes the heart muscle more irritable.” The morphine would, undoubtedly, put Skwira in another world and allow him to be comfortable as he died, but coupled with everything else that had happened, it would also help in killing him.

  The next day, Phillip went to see his father early in the morning. Skwira appeared to be well-rested when Phillip arrived, but was still showing signs of discomfort and, strangely, had developed a new set of symptoms.

  Every once in a while, Skwira would begin to have hallucinations and become fidgety, sitting up and lying down in his bed.

  His doctors had already decided to have him transferred back to the VAMC, where he would be more comfortable during his final days.

  Later that night, Skwira’s entire family visited. Time was short. It seemed like just weeks ago he was out in his garden tending to his vegetables and flowers, walking around the house watering his plants and cracking jokes.

  Now he was waiting to die.

  Some years ago, Skwira had asked someone in the family to take a picture of him standing at the base of a favorite maple tree he’d planted in the front yard. An avid bird-watcher, he had placed a bird feeder next to the tree that he wanted in the picture too.

  “Why?” his family asked when he said he wanted the picture taken.

  “Because . . . I just want a nice picture for all of you to remember me by.”