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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Genene Jones quickly came to think of herself as an ICU nurse. After spending her first three months at Bexar County Hospital working nights—11 p.m. to 7 a.m.—Genene moved to the 3 p.m. to 11 p.m. shift. But Bexar County, like many hospitals, had a nursing shortage, and Genene frequently volunteered to work over-time. Registered nurses, who have at least two years of training, often look down on LVNs, but Genene’s enthusiasm, knowledge, and technical skill impressed everyone. “For an LVN, she was absolutely excellent,” says Pat Belko, an RN who is the head nurse of the pediatric ICU. “She understood a lot of anatomy and physiology that was [on] a higher level than a lot of LVNs.” Pam Sturm, a RN who later supervised Genene for more than a year and became a close friend, admired her curiosity. “She was always inquisitive,” Sturm says. “If she didn’t understand something, she would pull out all my books and try to figure it out.”
But Genene’s most distinctive nursing skill was her extraordinary talent for putting intravenous lines into veins. Many hospital patients are given IVs to provide direct access to a vein-vital for injecting drugs, drawing blood, and giving fluids. Without IVs, nurses would have to turn patients into pincushions, sticking them a dozen times a day in a dozen different places. For a hospital nurse, starting an IV is a daily chore, but it’s one that many never master. Veins move under the skin, and it is easy to miss a few times before finding the mark. The job is even trickier with an infant, whose veins offer a target only the size of a thread. But for Genene it was a breeze. There was no IV she could not start, no vein too small, no patient too restless. Her reputation quickly spread, and nurses on the pediatric floor began calling her out of the ICU to start IVs for them. “She could stick an IV in a freaking fly,” says one doctor. Even those who disliked Genene conceded her technical skills. “She knew nursing,” says Pat Alberti, an LVN who worked in the unit. “She was probably the most competent nurse there.”
As Genene finished her first year in the ICU, however, her personality began to earn her many enemies as admirers. She was loud and coarse. She thought nothing of bellowing out four-letter words or telling dirty jokes in a crowd of nurses and doctors. She spoke freely of the joys of sex, boasting of past conquests and pointing out those she had in mind for the future. The ICU was no convent, but Genene was saltier than most. She had strong opinions—about doctors, other nurses, patient care, the hospital—and she voiced all of them without hesitation.
In that group of medically aggressive nurses, she stood out as the most aggressive. She would spot problems in her patients before anyone else could see them—problems that the weary residents she dragged out of call-room beds often said didn’t exist. Exhausted doctors began to think of her as the most serious possible obstacle to a few hours’ rest: the nurse who cried wolf. “She’d always call you for crap,” says a former resident now in private practice in San Antonio. “After a while, you’d be tired of going over there. Any little thing, she’d be calling you—two, three, four times as much as anyone else. She wanted a lot of attention. After a while, you’d think she was a pain in the ass.”
If one doctor rejected her advice, Genene called another. “There was always a resident and an intern on to cover the evenings,” says Dr. Barbara Belcher, who completed her residency in 1981. “If the intern didn’t jump, she’d talk to the resident. If the resident didn’t jump, she’d go higher up.” Genene questioned medications, treatment, dosages, and diagnoses. When her recommendations for a patient were ignored, she predicted disaster. “This kid’s going to die if you don’t do this,” she told one doctor.
She issued her warnings to fellow nurses as well. Every eight hours, when shifts changed, the nurses would meet for “report,” during which those who had been on duty would describe the condition of their patients. “She would predict gloom and doom,” says Toni Grosshaupt, an RN who began working in the ICU in January 1981. “She would just say, ‘This patient is really bad; this patient isn’t going to make it through the night.’ It was like she knew what was going to happen. I was a new nurse. I’d come out of report shaking like a leaf.”
With parents of the critically ill children in the pediatric ICU, Genene Jones displayed a completely different personality. To them she was a comforting figure, a woman of patience and understanding. She had long talks with them. She listened to their complaints and fears. While faceless doctors rushed by, week after week. Genene was there, caring for their kid. She called them by their first names. She became a friend.
J.R.
IN MARCH 1980 GENENE JONES GAINED AN important ally: Dr. James Robotham, who that month became the medical director of the pediatric ICU and an associate professor at the UT medical school. Robotham, a 33-year-old pediatrician, came to San Antonio from the John Hopkins medical school in Baltimore, where he had spent three years. Before that, he had trained in pediatric intensive care at Toronto’s Hospital for Sick Children. Robotham is a brilliant, volatile, compulsive, and demanding man, and he quickly made his mark on the pediatric ICU.
Before his arrival, the role of the ICU medical director at Bexar County was a minor one. The job was part time, and the doctors who held it were content to let the individual physicians who admitted patients to the unit manage their care. But Robotham believed that critically ill children required care from someone specially trained to treat them; that, after all, was why he was there. He began spending much of his day in the ICU. He had little formal authority to hire, fire, or set policy, but through his presence and knowledge he shifted more and more of the burden for the patients’ medical treatment onto his own shoulders. He told residents and nurses to call him with any problem, at any hour. When the calls came in the middle of the night, he didn’t just tell his doctors what to do; he showed up at the hospital.
Fully conscious of his own abilities, Robotham wanted the nurses and residents to learn what he knew. At seven-thirty each morning he led them on teaching rounds, reviewing each patient’s condition and treatment plan. That routine goes on in every teaching hospital, but Robotham’s rounds were special. Residents accustomed to offering shallow presentations of a patient’s status suddenly faced an endless succession of pointed questions: What were the lab results? What do they mean? Why do you say that? Are you sure? When residents were caught short, forgot a dosage or a patient history, Robotham pressed them: Don’t you think it’s important to know? It was painful—Robotham often wasn’t satisfied until he had humiliated a young doctor—but the residents learned. He kept after the nurses as well. One day he walked into the ICU and there wasn’t a nurse or a doctor in sight; the nurses were meeting in the unit’s back room. Robotham went into a patient’s room and set off the alarm on one of the monitors. Nurses know those alarms are supposed to indicate a dire medical emergency, but no one came out. Furious, he walked into the nurses’ meeting and announced what had happened. The nurse whose patient he had picked broke into tears. The ICU staff quickly found a suitable nickname for the new medical director: they called him J.R.
It was only natural that he and Genene Jones would develop a rapport. The byword of Robotham’s style was “aggressive”; in Genene Jones he saw a nurse who personified that approach. If residents thought she overreacted, cried wolf, and woke them up too much, Robotham thought she was often right. “Robotham at the beginning was an absolute idol,” says Genene. “He is an absolute genius—unbelievably so. He’s astounding. He knows medicine with his eyes closed.” Most of all, Genene says, she admired Robotham’s approach. “What he said was look for subtle signs. Damn aggressive. He was extremely aggressive. And it was great.” When Pat Belko assigned another nurse to help him insert a special catheter in a child, Robotham said he wanted Genene instead. All her life, and especially since she had become a nurse, Genene had been sure she knew the right way to do things; now she had a superior who felt that way about her too. Robotham and Belko both encouraged her to take charge of the sickest patients. “They used to call me Robotham’s pet,” Genene says.
CODES AND THE COLD ROOM
IN A HOSPITAL, A MEDICAL EMERGENCY IS called a code. In the pediatric ICU where Genene worked, a code begins when a nurse notices that, for instance, a child has quit breathing or that his heart has stopped; she shouts over to the nursing station. Whoever is closest presses a small white emergency button, and an alarm goes out across the pediatric floor, bringing doctors running. When a nurse believes there is a severe emergency, she calls a code blue. An operator switches on the public address system and announces “code blue to pedi ICU” throughout the hospital, summoning help from everywhere. ICU nurses rush to the patient’s bedside with the unit’s “crash cart,” loaded with emergency drugs and equipment. People begin pouring through the ICU’s double doors: doctors on the floor, medical students from the pediatric ward, a team of respiratory therapists to handle resuscitation, a team of pharmacists to draw up drugs, residents, supervisors. The room fills with people. In the middle of it all, performing CPR or handling drugs, is the patient’s nurse, the one who called the code in the first place. The code may last for minutes or—when a child’s heart, like a sputtering motor, turns over but won’t quite start—it may last an hour. But in the center of the crisis there is no consciousness of time. “You tune people out,” says 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.”
When a child dies in the pediatric ICU at Bexar County Hospital, his nurse has 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 pronounces the child dead, the parents want to hold him one last time, in which case the nurse first has to clean the body—wash off the blood and pluck out the catheters and tubes that remain in it. When the parents are done, the nurse wraps the body in a blanket or a plastic shroud and calls a security guard to get the key to the morgue. If the child is large, the nurse places the body on a metal stretcher. If it is an infant, she carries the body in her arms.
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