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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December 22, 1981: Doraelia Rios, 25 months old, died at 8:12 p.m. She had been hospitalized several times previously for gastrointestinal surgery, and she entered the hospital again on December 21, suffering from diarrhea, dehydration, and possible inflammation of an internal membrane. She was given fluids to deal with the dehydration and antibiotics to fight the infection, but she suffered a fatal cardiac arrest. Genene Jones was there during the arrest and finished her nursing notes with a brief remark: “A legend in her own time. Merry X-mas Dora. I love you. Jones LVN.”
“I WANT HIM OUT NOW!”
By early January 1982 Robotham had completed his review of the ICU’s medical records. It revealed no evidence of wrongdoing. Franks notified Corum, and they relaxed a bit. Maybe there wasn’t a problem. Judy Harris, a nursing administrator, had begun her own review of the records, but there still was no solid evidence of anything—not until Rolando Santos.
Rolando Santos entered Medical Center Hospital (the name was changed from Bexar County Hospital that month) on December 27, 1981, at the age of four weeks. He had pneumonia and breathing problems, so after admitting him to the pediatric ICU, doctors placed him on a respirator. On December 30 he suddenly went into seizures, but a brain scan revealed nothing that would explain the problem. Then he had a cardiac arrest but was revived. On January 1 his blood pressure fell; he was bleeding from old needle-puncture sites. On January 6 he began bleeding again. Dr. Ken Copeland, a boyish-looking pediatric endocrinologist with a mop of curly hair, was the attending physician in the pediatric ICU. He ordered tests for the presence of heparin. They came back positive.
When Rolando Santos began bleeding again, on January 10, Copeland was ready. He called the hospital pharmacy and ordered a does of protamine—a drug used to reverse the effects of heparin. The child was given the drug, and he quickly stopped bleeding. On January 12, when he came in for rounds, Copeland ordered nurses to transfer Rolando Santos out of the pediatric floor, even though he was really too sick to leave the ICU. Early in the afternoon of that day, Copeland returned to the ICU and found that Rolando was still there. He was furious. “I want him out now!” he told the nurses, and they wheeled him out of the ICU, onto the main pediatric ward. Four days later Rolando Santos was well enough to go home.
Now, for the first time, there was real evidence of a heparin overdose in the pediatric ICU; in response, Robotham ordered heparin removed from patients’ bedside tables and kept in the drug cabinet with the narcotics. Franks, who had been receiving daily reports from Robotham on developments in the ICU, on January 19 dictated a memo to the dean of the UT medical school, Dr. Marvin Dunn. “From the outset there had been innuendo that purposeful nursing misadventure was involved,” Franks wrote. Robotham’s review of the charts “could not substantiate that suspicion.” But now, Franks told Dunn, there had been a documented case of heparin overdose; there was laboratory proof of it. Though the problem had not been linked positively to any one employee, Franks wrote that he had returned “to a position of not knowing whether or not there is a problem.”
“I have several obvious concerns,” he went on. “One is that there will be inappropriate comments resulting in unjustified publicity.” To avoid that, Franks would personally conduct a second review of the deaths in the pediatric ICU. “We are continuing to evaluate ‘unexpected events’ in the unit in a formal way,” he concluded.
Two days earlier, on January 17, a baby named Patrick Zavala had died in the pediatric ICU. Patrick, four months old, had been brought to the ICU after an operation on his pulmonary artery. During the evening shift he suddenly experienced irregularities in his heartbeat, and he died at 9:45 p.m. Nurses in the ICU were so puzzled by his death that three of them sat in on the child’s autopsy the next morning. But if they were puzzled, the hospital’s surgeons were furious. For months the surgeons had been upset about what was happening to their postoperative patients in the pediatric ICU. This was the last straw.
Dr. Kent Trinkle, a moody but highly regarded chest surgeon, talked to Dr. Howard Radwin, another surgeon who was serving as head of the medical-dental staff. On January 21 the two men met with B.H. Corum, the director of the county hospital district. Something had to be done, Trinkle told Corum; he would send his pediatric patients elsewhere if things didn’t change. Corum said they would.
Corum set up a meeting on January 25 with Paul Green, the hospital’s malpractice attorney, and invited Bill Thornton (the hospital district’s board chairman), Marvin Dunn (the medical school dean), and a handful of others. The group met in Corum’s office, and the problem was put to the lawyer: there was trouble in the pediatric ICU and a single nurse was in the middle of it. Could they fire her? Should they call in the district attorney? Green listened and asked questions: Was there proof that the nurse was doing something? The doctors and administrators told Green there was none. The problem was described as a matter of poor leadership in the pediatrics department and a “catfight” among nurses, according to Thornton. “I asked, ‘what are the numbers, what is the mortality rate?’” recalls Thorton. “They said, ‘No, that’s not a problem.’” Green offered his advice. Without facts, he told them, firing Genene Jones or calling the district attorney would put them on shaky legal ground. She could sue them, and she might well win. The administrators and doctors decided to continue the internal investigation but otherwise to keep the whole thing quiet.
THE INVESTIGATION
When Dr. Alan Conn arrived in San Antonio in January 1982, Marvin Dunn called him into his plush second-floor office at the medical school. Conn, a 57-year-old anesthesiologist as the Hospital for Sick Children in Toronto, had run the pediatric ICU there for twenty years; now he had a six-month sabbatical, and he had arranged to spend it as a visiting professor in San Antonio, doing research in a medical school lab on drowning victims. Dunn knew that Conn’s hospital had conducted an investigation of its own into reports that a nurse (who was indicted, tried, and not found guilty) was harming children with drugs. In his office he explained to Conn the problems the Medical Center Hospital had been having and asked him to begin yet another investigation of the pediatric ICU.
As Conn rounded up his team to evaluate the ICU, the level of tension there rose steadily. The nurses had become reluctant to prepare any kind of drug without a witness. “Everybody was having people check and double-check them.” Dr. Debbie Rasch says. “You double-checked with another nurse. Then you double-checked with a doctor. Then you had the nurse and the doctor standing there when you gave the medication… A lot of us felt like we couldn’t go to sleep, because we had to keep watching to make sure nothing happened. It was a real stressful time.”
Everyone knew that Genene Jones was the prime target of suspicion. “They’re out to hang me,” Genene told Glory Ann Johnson, another nurse, one day. “They might as well let me go.” Robotham, once her protector, had turned against her. One day she confronted him. “I asked him if we could talk; I asked him what the hell was going on,” she remembers. “I said ‘Do you think I’m doing something to the kids?’ He said, ‘Yeah.” I said, ‘Why?’ He said he didn’t know.
Another day she used a less subtle approach. “This unit is my life,” she told Robotham. “If you try to take me away from this unit, I have my black book with the name of every kid who’s died in the unit and the doctor who caused the death.” Genene had made references to a black book when talking to other nurses and administrators. She wouldn’t leave, she announced, “without a bang.” Belko and a nursing administrator called Genene in and questioned her: Did she have such a book? Genene backed down; she said she did not. Robotham told Belko he wanted Genene fired, or at least out of the ICU. But Belko only took her off the most critical patients for a week.
To conduct his investigation of the pediatric ICU, Alan Conn assembled a high-powered team of six specialists: the medical directors and head nurses of pediatric intensive care units at three prominent hospitals. They began work on February 15, meeting in a conference room at the medical school and bringing in witnesses one at a time: nurses, residents, administrators, senior pediatricians, and surgeons. They got an earful. Almost everyone was angry at someone, and most were willing to speak their mind—especially about Genene Jones. The hospital’s employees had been told that Conn’s group was doing a routine review of the ICU, the sort of study that takes place in all hospital departments from time to time. But no one believed it.
When it came time to analyze the ICU’s problems, the committee members decided to view the complaints about Genene Jones merely as a symptom of a broader malady. Their report makes no mention of her name; after all, there was never anything but circumstantial evidence to link her to the incidents in the ICU. “You don’t pay much attention to rumors of increased mortality,” says Conn. “When you have a limited number of trained and experienced people, they tend to get the sickest kids. If the kids die, it’s only a minor step to saying they must be doing something wrong.” But the Conn report is extremely critical of the operations of the ICU, to the point of raising the possibility of closing it temporarily. The committee made many stern recommendations, among them that James Robotham and Pat Belko be relieved of their duties.
Looking for a graceful way to accomplish this, the committee suggested a new job for Robotham: director of critical care research. But Robotham didn’t buy it. He told friends he thought he’d been screwed, resigned his position at the medical school, and in June 1983 returned to Johns Hopkins. Belko was luckier; a last minute plea by Virginia Mousseau, her boss, won her a reprieve. She was placed under close watch for a six-month unofficial probationary period, and when it was over, she kept her job.
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