Perfect Poison (10 page)

It wasn't the throbbing pulse of a fifteen-year-old boy, but after about four minutes of giving Francis Marier CPR, nurses and doctors were able to get his heart beating again on its own. A moment later, one of the nurses heard faint breathing sounds coming from his mouth.

“He's alive!”

After being stabilized, he was transferred to the ICU, where Kathy Rix, Renee Walsh and April Gougeon were waiting for him.

All three nurses agreed they had never in their lives seen a patient who had a BSL as low as Francis Marier's.

“I was stunned. Shocked. I had never seen a patient not respond to [one] push of D-50—and certainly if not one, the second one would do it,” Renee Walsh later said.

Gilbert said that after checking his BSL, and finding it at 44, as she gave Marier an ampoule of D-50, he coded. But Rix did another finger prick test in the ICU shortly after Marier's code, and his blood level was at a staggering 37. It had actually gone down.

Restless and agitated, Marier was thrashing around the bed, in danger of disconnecting several tubes and IVs that had been hooked up. They tried restraining him, but he just wouldn't calm down.

At 11:15, Kathy Rix gave Marier a shot of Valium . . . but it did nothing. Then she gave him another ampoule of D-50, and his BSL immediately shot back up. Contrary to what had happened an hour before with Gilbert, Marier didn't go into cardiac arrest when Rix pushed the D-50 into his system. Instead, as if it had been the first ampoule of D-50 he'd been given, his BSL rose to 76.

One brick of D-50 generally did the trick for comatose diabetics. But here was Francis Marier, who had maintained a BSL of 155 for the past twenty-four hours, just now responding to what was seemingly a second ampoule of D-50.

Checking his chart, Rix noticed that at five, Gilbert had administered a scheduled dose of long-acting NPH insulin. This type of insulin is designed to begin working about four or five hours after it is injected, then peak about eight hours later, and begin to decline after that.

Rix realized that between 10:00 and 11:00—the time Marier had gone into cardiac arrest and ultimately ended up in her ICU—the NPH would have reached its peak effect.

Many now questioned how much insulin Gilbert had given him.

Near midnight, Kathy Rix stepped out of the ICU and yelled down the hall, “I need some help down here.” She was still having problems restraining Marier.

With no response, Rix ran down to the nurse's station while April Gougeon stayed with Marier and the other two patients in ICU. Carl Broughear, a third-shift RN, and Gilbert were standing around chit-chatting. Rix noticed that Gilbert was all dolled up, wearing bright red lipstick, a skin-tight blouse and pants to match.

“I need some help,” Rix yelled, and ran back to the ICU.

By this point, Gilbert and Broughear must have realized it was serious, because they rushed right down after hearing Rix scream.

Marier was still restless, thrashing around, waving his arms and legs, while the nurses fought with him to keep his tubes in place.

While trying to calm him with the help of April Gougeon and Carl Broughear, Rix turned to Gilbert and said, “Why don't you write up the ICU note so we can all leave closer to on time?”

Nodding, Gilbert agreed.

Not only had Marier's BSL remained low, but his heart rate continued to climb throughout the night, reaching anywhere from the mid-150s to as high as 175.

There was no reason for Francis Marier to have an actively increasing heart rate and low blood sugar. It made little sense to his nurses and doctors.

Kathy Rix's last note of the night established that Marier's heart rate had decreased considerably to about 145 by 11:55, with his blood pressure at about 170.

Like Henry Hudon, Marier was tough. He was a fighter.

Oddly enough, though, his BSL remained at 76.

Carl Broughear took over for Rix in the ICU after she left. At one
A.M.
, he checked Marier's BSL, and it had gone back down.

While sweating profusely and sustaining a rapid heart rate, Marier continued to thrash around, kicking and waving his arms. This, Broughear thought, was strange, because patients—at least by his experience—with low blood sugar levels were far less active.

A few minutes after one, Broughear gave Marier another push of D-50. His BSL immediately rose to 78 . . . but only for a few minutes . . . then dropped back down to 48.

Marier's doctor came in and ordered two more ampoules of D-50. Broughear administered them and then checked Marier's BSL right away.

It shot right up—

—but only to 99.

Damn, it should be much higher,
Broughear thought as he looked at the results.

As if something inside Marier's body were consuming the D-50 as fast as Broughear could pump it in, a few moments later, his BSL dropped back down to 47.

Near 2:30, Marier's doctor ordered even more glucose. “And check his BSL with the machine from Ward D,” the doctor told Broughear. Perhaps there was a problem with Ward C's machine?

But Broughear got the same results.

Confused, not believing the BSL results in front of him, Marier's doctor ordered a sample of Marier's blood be sent to another hospital to be double-checked.

It was almost 5:30 in the morning,

Something is wrong here,
the doctor thought as he wrote up the order.
Maybe our machines aren't working?

RN John Wall, who had celebrated his forty-third birthday in September, had a movie star air about him. A trim, one hundred and fifty-five pounds, Wall was well respected among his VAMC superiors and colleagues. At six foot one, with a full head of kinky brown hair that he kept pushed back, and bushy eyebrows to match his thick, Tom Selleck-like mustache, Wall didn't quite match the stereotypical image of most nurses.

There wasn't a nurse who worked with Wall who could dredge up a bad word about him.

“He was an excellent nurse,” Renee Walsh later said. “Very dedicated.”

“He was very caring and diligent with patients,” April Gougeon later noted.

Working with Gilbert, Wall had gotten to know Glenn Gilbert throughout the years and they had become pretty good friends.

There was one time in the middle of October when Glenn had stopped by Wall's house to help him out with his boat, and the two got to talking.

“You guys have been really, really busy up at the hospital lately, huh, John?” Glenn asked.

Wall didn't know what to say. They hadn't been any busier than usual. So he just went along with Glenn. “Yeah, I guess there's some overtime available.”

“Kristen has been working till two and three in the morning.”

Wall knew then that Kristen had been lying so she could get out of the house and run off somewhere with Perrault.

 

 

Wall's proficiency reports mimicked the saintly consensus he had among staff. Each year, he was heralded as a nurse who was rising up through the ranks on his way toward a managerial position. While in his sixteenth year of nursing—thirteen of which spent at the VAMC—Wall's nursing manager, Melodie Turner, wrote of his performance throughout 1995 that he “routinely exceed[ed] expectations to an exceptional degree . . . is professional and accountable. He serves as a leader.... He is [thorough], accurate [and] timely in documenting and reporting administrative and clinical information.... Mr. Wall has made significant contributions,” Turner went on to write, “to the nursing profession. . . .”

There was no doubt about it: John Wall loved his job, valued the responsibility of being a nurse, and took every part of the job seriously. Codes, Wall later recalled, were especially trying on him because the patient who was being resuscitated was usually a patient he had gotten close to. But with the astonishing rate codes were occurring lately, Wall, like Kathy Rix and Renee Walsh, was beginning to worry that there was more to it than just coincidence.

 

 

Respiratory therapist Bonnie Bledsoe, a cute blonde from a well-to-do family in Western Massachusetts, took a job at the VAMC in early 1991, and began dating John Wall almost as soon as they met.

Bledsoe was tall, about five-nine, big-boned, like a volleyball player or swimmer, and seemed to carry a cheerful disposition wherever she went.

By October 1991, Wall had asked Bledsoe to move into his Northampton home, and she gladly accepted.

As their relationship blossomed, Bledsoe and Wall found out that they had a lot more in common than long walks on the beach and working in the same hospital.

They both had huge appetites for illegal drugs.

For Bledsoe, it was heroin. It started in the fall of 1994, when she fell into a trap Wall had been caught in already for some years.

Together they had been using between five and ten bags of heroin a day each. They would use in the morning, before work, and at night, after work. Although Wall never admitted to using at work, Bledsoe did.

How could, one might wonder, two VAMC employees use between $250 and $500 of heroin every day and not one of their colleagues—especially their nursing manager, Melodie Turner—pick up on it?

Bledsoe later explained.

“When you first start using heroin, you have to—when you take it, you get kind of a euphoric high. The more you use heroin, the less of an effect it has and the more you need, the more the body becomes physically dependant upon the drug, and eventually you're taking the drug just not to get the withdrawal symptoms, but you don't get high anymore.”

Bledsoe claimed her drug use never affected her job performance, and many who worked with her over the years, along with her performance evaluations, agreed with her contention.

In April 1995, quitting heroin came easy to Bledsoe . . . but not for long. Because by late August, she had fallen in love with crack cocaine—and never looked back. While Wall stuck to using heroin, Bledsoe began using crack three or four times per week, spending anywhere between $100 and $200 dollars per use. Although she said never used crack at work, whenever she did use, she usually took the following day off to recuperate.

Still, Melodie Turner's work evaluations of Bledsoe and Wall thrived with praise.

“Exceptional and fully successful,” one report noted of Bledsoe's performance between April 1995 and March 1996. “I have received compliments,” Melodie Turner wrote of Wall in 1996, “from peers and clinicians on his professionalism and nursing knowledge.... I expect Mr. Wall to become the Acute Medical Laboratory problem resolution expert.”

For her entire life, Bledsoe had been asthmatic—and one of the only things that really worked for the severe asthmatic fits she sometimes had was a shot in the arm of epinephrine. What's more, no one knew it just yet, but there were enough ampoules of epinephrine missing from Ward C lately to start a small pharmacy.

Was it Bonnie Bledsoe who was stealing them?

Early in the morning on December 21, a nurse at the VAMC called John Wall and explained to him what had happened to Francis Marier the previous night. As far as Wall was concerned, Marier had shaved, showered, eaten his dinner and fallen asleep. The only worry Francis Marier had was falling out of bed in his sleep.

Concerned, Wall went to work early and reviewed Marier's chart. He was “stunned and shocked” to find out how much D-50 had been pumped into Marier's system throughout the night without any response—a total of eight ampoules—and that he'd had a cardiac arrest just moments after Wall left his side.

Wall soon learned that Marier had also been put on a D-5 and later a D-20 drip, which were the same as the D-50, except they came in a drip form and were hooked to a patient's IV. For the entire night, Marier's BSL wouldn't climb. And by six the next morning, it still wasn't anywhere near where it should have been, taking into account he'd had enough glucose pumped into his system during the night to crystallize his blood.

But the most striking aspect of the night's events occurred around nine
A.M.
After several hours of the D-20 and D-5 drips, Marier's BSL suddenly shot back up to a normal level, as if whatever had been in his system eating up the glucose somehow dissolved.

Wall then went to Kathy Rix with a scenario.

“I think she might have sabotaged my patient because she was angry at me for not letting her go home early last night,” Wall said, referring to Gilbert.

Rix confided in Wall that she, too, was developing suspicions. In fact, she had been watching Gilbert for some time. Since November, Rix explained, she had been keeping track of the medical emergencies on Ward C, and the one nurse who kept popping up on her list was . . . well, she didn't even have to finish her sentence . . .
Gilbert.

When Renee Walsh arrived, she was overwhelmed by the news that Carl Broughear had spent eight to ten hours trying to get Marier's BSL to rise. When she thought about it, the only thing that made sense was that somebody had given Marier a mass dose of insulin.

By December 22, Francis Marier had made an impressive recovery and was transferred out of the ICU and back into the regular population on Ward C. Later that afternoon, he was given a clean bill of health, scheduled for an outpatient follow-up on February 29, and discharged.

 

 

For the past twenty years, sixty-one-year-old Korean War vet Thomas Callahan had consumed upward of a quart of whiskey per day. There were times when he couldn't even remember his own name. A two-pack-a-day smoker, Callahan had developed a severe case of COPD and was a frequent patient at the VAMC because of it.

Yet it was a battle with schizophrenia that consumed most of Callahan's medical care.

When he was admitted to the VAMC on January 18, 1996, Callahan had a simple request for the admitting nurse.

“Where's my whiskey?”

After he failed to get the answer he'd perhaps hoped for, he cursed the nurse and said, “I was trying to call home . . . they kept saying, ‘Go back to Oz. Go back to Oz.' ”

Before this, “Tomcat” Callahan had spent two days in the ICU at Baystate Medical Center. He'd been admitted with “right lower lobe pneumonia,” along with a “severe exacerbation of his COPD,” which he had been battling for the past eight years.

For the nurses who treated him, Callahan was extremely high maintenance. “Eccentric” and “gregarious,” one nurse remembered. “Difficult” and “loud,” another recalled. Since 1986, he'd been hospitalized at the VAMC at least twenty times. Calling him “Father Callahan” behind his back was a running joke because he liked to take confession from anyone who entered his room.

While fighting pneumonia in the ICU on January 22, 1996, Callahan's body began to detox violently from its addiction to alcohol. During the daytime hours, nurses in the ICU fought continuously with him to keep a biPAP mask attached to his face. His emphysema was chronic. He had pneumonia. The biPAP mask helped him breathe. While he continually grabbed at his IV, at one point, it took three nursing assistants to restrain him. Yet not once while this was happening did Callahan's heart rate rise. He did have a history of heart disease, but he had never been admitted to a hospital for it. Further, the only medication he was taking was for his pneumonia, mental illness and COPD.

His heart condition was not even an issue.

As usual, Gilbert came into work on January 22 at 4:00. John Wall was again the charge nurse, and he ordered Gilbert to work in the ICU. Kathy Rix was in charge of distributing meds to Teams One and Two.

On January 18, RN Liz Corey, who had been Callahan's nurse during the day shift, made a note that Callahan had been in ICU coughing for a good portion of the day, but his heart rate, throughout the entire day, had not changed.

The next day, respiratory therapist Michael Krawiec gave Callahan a treatment and noted that he had “a productive cough and that he tolerated his treatment with no adverse reaction.” Later that same day, RN Frank Bertrand noticed that he was “highly agitated,” but his heart rate was “sinus rhythm to sinus tach . . . [he had] no irregular heartbeats” and was running at a rate of “90 to 110.”

A stickler for detail, RN Rix saw Callahan later that night and assessed his condition a little more differently. Like many of her colleagues, Rix was dedicated to providing the next shift with as much information about a patient as possible. All the nurses were required to give extensive written and/or tape-recorded reports of each patient they cared for so the patient's doctor and the nurse on the following shift would know exactly what was going on.

The only nurse who hadn't been routinely doing this was Gilbert.

Nursing manager Melodie Turner had even sent the nursing staff e-mail messages reminding them of the “importance of charting” patients and including rhythm strips in medical files.

But again, neither Turner, nor anybody else in the VAMC administration, went any further than that. Awareness, apparently, was enough; following up and checking the actual medical files to see who was adhering to protocol and who wasn't would have been the obvious next step, but no one did it.

Back on December 8, it would have taken only one look to notice how poor Gilbert's record-keeping was. She had found Henry Hudon in cardiac arrest four times. Even an inexperienced nurse would have known to include no fewer than eight heart strips from Hudon's telemetry monitor on his chart, so his doctor—if no one else—could see what had transpired during Hudon's codes. But Gilbert placed only two strips in his file: one at the beginning of her shift—before the first code—and another when Hudon was dead, a flatline.

Then there were the vital sign records. Turner had clearly spelled out in countless memos how the system was supposed to work: Patients' vital signs in the regular population, during an eight-hour shift, were to be taken and recorded no less than two times; in the ICU, it was mandatory that they were checked and recorded every hour.

A quick glance at many of Gilbert's patients throughout the past few months would have shown that she rarely recorded
any
vital signs.

But again, those who should have did nothing about it.

 

 

Thomas Callahan remained stable throughout the day on January 22. During that afternoon, RN Ann French sat with Callahan in the ICU and watched him eat. She noticed that he was shoveling the food in his mouth as fast as he could, and she feared he might choke.

Sure enough, Callahan began gagging, but quickly spit out his food before any more problems arose.

Gilbert had come on duty at four and, by seven, had spent the better part of three hours with Callahan. Other than the earlier choking incident, French explained, his condition went unchanged.

By 7:15, Gilbert had made her first assessment: he was “alert and orientated to person [and] place, but not time. Less agitated this evening, but [he] remains very manic.”

At 7:17, Callahan began singing “Ave Maria” at the top of his lungs and had eaten “one hundred percent of his meal,” Gilbert noted.

A readout coming off his telemetry monitor reflected that, at 7:25, Callahan's heart rate was sinus tach, 100 to 115, which was normal under the circumstances. Dr. Michael DiBella, Callahan's attending physician, had even come in and ordered a transfer for him out of the ICU back into the general population as soon as the next day.

But at 7:45, while Gilbert stood by his side, Callahan began “coughing forcefully,” she later wrote, and then yelled, “I think I'm going to die.”

His scream was so loud that it rang throughout the entire corridor. Many were startled but quickly wrote it off as another one of his manic episodes.

Gilbert claimed that as Callahan began coughing, his heart rate more than doubled: from 100 beats per minute to a deadly 240. When this happened, Gilbert yelled for help, as Callahan continued to scream.

For about fifteen minutes, Gilbert and several nurses monitored him closely. His blood pressure hovered at around 191 over 116, and his heart rate at about 215 to 200, but he never coded.

By 8:10, Callahan's heart finally calmed down to 115, and it appeared that everything was going to be fine.

As Kathy Rix stood by the nurse's station, Mike Krawiec came walking by, shaking his head.

“What is it?” Rix asked.

“She's at it again. . . .” Krawiec muttered under his breath.

Rix bolted for the ICU. When she got there, Callahan's episode, just winding down, seemed to be under control. Although Rix was a bit disheveled and confused, she logged the situation in her growing mental bank of emergencies and went back to her assignment.

In her progress note, Gilbert implied that Callahan's cardiac event had been brought on by the coughing fit he'd had. But cardiologist Dr. Thomas Rocco later summarized that it was impossible for a cough to cause a heart attack. And since Callahan had been singing “Ave Maria” right before his heart rate doubled, Rocco further acknowledged, “[he] was improved to the point where he could sing.”

Gilbert also wrote that she obtained a full twelve-lead EKG, which meant she would have stuck twelve round leads all about Callahan's chest and feet and thus taken a full readout of his heart rate. She also said she called the on-duty physician to examine him.

But there was no evidence that she had done any of it.

When a nurse in the ICU takes an EKG, she makes three copies of the results: One goes into the record at the patient's bedside, and two get placed in the hospital mail to be sent to the EKG department, where a doctor officially reviews the results, initials them, and then places them in the patient's permanent record.

Soon after Callahan's cardiac event ended, Gilbert went on a scheduled break and RN Wall relieved her. When Rix found out that Gilbert had gone on break and Wall had taken over, she ran down to the ICU to see what she could find out.

“Let's take a look at the heart strips,” Rix suggested.

Wall agreed.

After reviewing the strips, Wall and Rix decided to search the room. Other than the obvious, they were looking for any possible reason why Callahan's heart rate could have doubled.

“John,” Rix asked, “what kind of medication could have possibly been given to him that might have caused his heart to go into such a fast rhythm?”

Half-joking, Wall said, “Wouldn't it be funny if we looked in the needle-collection container and saw EPI . . .” referring to the drug epinephrine.

Besides potassium, Rix and Wall made the determination that epinephrine was the only other drug that could have made Callahan's heart rate, along with that of a growing list of other patients, ascend out of control. They had checked what medication he had been on since being admitted and knew from experience that none of it could have caused his heart rate to climb like it had.

“What about potassium?” Rix asked.

Potassium was another drug, like epinephrine, that was extremely taxing on a healthy heart.

Inside the ICU, there was a red and tan needle-disposal bucket attached to the wall similar to those on the counter in any doctor's office. There was also one inside Callahan's room, one on the IV cart, one on the crash or “code” cart, and one in the medicine cabinet where medications were stocked under the cupboard.

Rix looked inside the one in the ICU first, but because of its small oval cover, she had a hard time seeing past the top. After carefully pushing the lid down, she didn't see anything.

Then she walked over to the bucket underneath the medicine cabinet.

As soon as she looked inside, there they were: three broken glass ampoules, each one about the size of a Magic Marker cap, lying on the bottom. The glass was the same texture and color of a beer bottle—only thinner and more brittle. Easy to see, stretched across the front of the white label, were three hot-pink-colored stripes, as if to warn the person thinking of using it that it was a powerful, life-threatening drug. Staring at Rix across the top of the vials was the word
EPINEPHRINE
in capital letters. On the bottom were the numbers 1:1000, which meant it was one of the highest concentrated forms of epinephrine available. Shaped like an hourglass, or a miniature Coke bottle, with a thin and breakable neck, an ampoule of 1:1000 epinephrine could be snapped in an instant if a patient had had an allergic reaction to food, a bee sting, or was suffering from a severe asthmatic fit.

 

 

Epinephrine—or “EPI,” as those in the medical field call it—is produced naturally in the body's system, more commonly called adrenaline. It causes the blood pressure to rise, the heart to race. It is stocked in two forms at the VAMC: a large bristo-jet pre-filled syringe, 1:10,000 strength, used mainly during cardiac emergencies for patients found in cardiac arrest; and, a 1:1000 form packaged in a smaller glass ampoule, used for treating people with food and bee sting allergies or asthma.