The Death Shift
When nurse Genene Jones was on duty in a San Antonio hospital, babies had mysterious emergencies and sometimes died. Then she moved to a Kerrville clinic, and the awful pattern began again.
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The McClellans could not understand why their daughter had seemed so well and suddenly became so sick. It took Petti weeks even to accept that Chelsea was gone. She walked around the trailer home carrying her daughter’s toys and talking to them. At Chelsea’s funeral, when Petti saw the casket, she screamed, “You’re killing my baby.”
Kathy Holland, Genene Jones, and Gwen Grantner attended the ceremony, and the McClellans were grateful for their support. A few days after the funeral, the McClellans took out a two-column advertisement in a local paper. 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 whom 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 notes about the day’s events in the office 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 her. Goodbye, Chelsea.”
Three hours after Chelsea McClellan’s death, Lydia Evans arrived at Dr. Hollands’ office with her five-month-old son, Jacob. Her appointment had been for mid-morning, but Dr. Holland’s receptionist had called to say the doctor was transferring a patient to San Antonio. A little while later, Gwen called Mrs. Evans again. The doctor and her nurse would be returning because the patient they were transferring had died. Mrs. Evans was bringing Jacob to the doctor because of his crying spells. They’d been going on for a month and probably were just normal, but she was a first-time mother and would feel better to have a doctor say everything was fine.
Mrs. Evans says that when she arrived, Genene Jones took Jacob into the treatment room and told her she needed to take some blood for tests; Dr. Holland hadn’t returned to the office yet. Genene also wanted to start an IV. “I asked her why,” says Mrs. Evans. “She said it was in case he went into a seizure while they were running tests, so they could give him medication right away. I said, ‘Jacob’s never had any seizures.’ ”
Genene then asked her to leave the room. “She said, ‘Now, I’m a mother, I know what it’s like to see your baby crying while someone takes blood from him. Why don’t you leave the room?’ ” Mrs. Evans recalls. A few minutes passed. “We heard Jacob start screaming all of a sudden. He screamed six or seven times, then in mid-scream there was dead silence”—she snapped her fingers—“just like that.” Gwen came out of the treatment room and dialed the hospital. “Page Dr. Holland—stat!” she told the operator. The ambulance arrived, and Jacob was carried into the back.
At the hospital, after Jacob’s condition had stabilized, Genene came out to speak to Lydia Evans. “She was shaking all over,” said Mrs. Evans, “and she was sweating very badly. The expression in her eyes [was] like she was almost in a utopia, like she was really enjoying it….Her eyes looked very excited—a happy excited. She looked like she was enjoying every minute of it. She looked like she was in her element.” Mrs. Evans’ husband, Shane, arrived at the hospital about 9 p.m. She introduced him to Genene: “This is the woman that saved our son’s life,” she said. Jacob remained in the hospital for six days, three in the ICU and three on the floor. The tests showed nothing to explain the episode in the office.
On the same day that Chelsea McClellan died, Medical Center Hospital in San Antonio began its last and most detailed investigation into the strange deaths in the pediatric intensive care unit. A three-member committee led by Dr. John Mangos, the new chairman of the pediatric department, began reviewing medical records for 94 children who had been patients in the ICU during 1981 and early 1982. The group worked in secret until February 1983, when the Bexar County district attorney’s office seized copies of what has become known as the Mangos report, which was still in draft form.
The document focuses on the cases of thirteen pediatric ICU patients who experienced sudden and unexplained problems—arrests, seizures, or bleeding episodes. Ten of the thirteen died. “It is possible that such events may occur in sick infants and children in PICU settings at any time,” says the report. “It is of interest, however, that Nurse G. Jones was present during the final events occurring during the p.m. (3-11 p.m.) shift of nursing in all these cases.” There are three possible explanations for Genene Jones’ presence “during events leading to the death of children and infants in the PICU,” the report says. “This presence could be: 1) coincidental; 2) Because Nurse G. Jones volunteered the care of very sick infants and children; 3) Due to negligence or wrongful doings by Nurse G. Jones resulting in the sudden deterioration and death of patients.”
“Something Had to be Wrong”
Wednesday, September 22
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 emergency room at a time. The number of children getting sick prompted doctors to joke that Dr. Holland needed to have the air conditioning in her office changed. 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. Packard had kept a close eye on subsequent events and was distressed by the number of arrests taking place in Holland’s office. “I’ve been in practice forty-three years and never had one,” he says. “To the best of my knowledge, we’ve never had one in Kerrville. Something had to be wrong.”
The nursing staff had also been complaining. The children that Dr. Holland brought in often didn’t seem to be sick enough to be in the ICU. They had all experienced emergencies in her office, but in the hospital there was no sign of what had caused them. The newcomers, Holland and her nurse, had annoyed the emergency room and ICU nurses with their condescending attitude. Genene Jones seemed to make a point of displaying how much more she knew about pediatrics than they did. Yet when Holland and Genene arrived to handle an emergency, there was invariably chaos. They would ask for equipment, and if they didn’t get what they wanted, they would toss it down angrily. Genene made rounds and wrote in patients’ medical records—something no office nurse in Kerrville had ever done. She also gave orders to other nurses, often not even saying they were on Dr. Holland’s behalf.
Now Tony Hall, Sid Peterson’s administrator, convened a small group in his office to discuss the problem of Dr. Holland and her nurse. The group included Dr. Packard, then chief of staff; Dr. George Schuster, a general surgeon; Dr. Larry Adams, a radiologist; and Martha Carlson, head nurse in the ICU. They went down the list of problems. Things would have to change, they agreed. Hall called Holland and arranged to meet with her shortly after noon the next day.
Rolinda Ruff
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 office. Mrs. Ruff, a secretary for a Kerrville urologist, had called earlier to make an appointment and to explain that Rolinda had had diarrhea for the past two weeks. When she arrived, Genene Jones came out and said that she needed to take Rolinda into the treatment room to check her temperature. A few minutes later, Holland came out into the waiting room. Holland told Mrs. Ruff that Rolinda was a little dehydrated; she wanted to start an IV line to get some fluids into her system and then admit her to Sid Peterson for tests and observation. Holland walked back into the treatment room, and the IV was started. As Holland went in and out of the treatment room, Mrs. Ruff got a glimpse of her daughter. Rolinda had an oxygen mask over her face. Mrs. Ruff heard sounds from the treatment room—sounds of Rolinda choking and Genene pleading aloud: “Come on, come on!” Nobody in the office had even taken Rolinda’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. Soon after Holland and Jones arrived in the emergency room with Rolinda Ruff, a crowd gathered. 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 morning rounds), Dr. Larry Adams, Dr. Earl Merritt, and Dr. M. B. Johnston. They stood around and watched as Dr. Holland and her nurse rushed in.
The patient wasn’t blue; her color seemed to be returning. Her breathing was labored but growing easier. Holland said she 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 Rolinda 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 Anecitne! “It just reminded me of what I’d seen in the operating room,” says Bradley. “The child appeared to be trying to reach up, but [she] just didn’t seem to be able to get [her] hands up. It was jerky, uncontrolled movements with a purpose, but an inability to accomplish that purpose.”
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