by John Foxjohn
One thing that gave them some pause was the heparin that the DaVita clinic was using. Heparin is a common drug used in dialysis to prevent blood clots in veins, arteries, and lungs. Given that the patients’ blood was being removed and put back in their bodies after traveling through a filter, the chances of clots were high. There had been a manufacturer recall of one brand of heparin, however, and even though it wasn’t for the brand DaVita was using, the investigators gathered up all their heparin, and brought in another batch from a different facility. In the end, this didn’t help either.
The stumped investigators and administrators didn’t have a clue as to what was causing the problem. In a last-ditch effort to find anything that explained it, they even looked at the possibility of simple chance, but like everything else, they eventually ruled this out, too. The odds of the two deaths simply didn’t allow for it to be a chance occurrence.
During this time, two of the nurses made the same comment: “The only thing they didn’t check was the employees.” Indeed, they hadn’t. They didn’t think they needed to; they believed that medical professionals wouldn’t intentionally harm their patients.
After Clinton’s arrival, the problems at DaVita ceased for a short time. But that moment of calm turned out to be merely the eye of the storm—a temporary respite before a horror that no one had seen before, or even imagined, fell upon DaVita.
* * *
Wednesday, April 16, 2008, was a gorgeous East Texas day. Temperatures were in the sixties, skies were clear, and there was just enough of a breeze to cool off those who were working outside, as Mr. Garlin Kelley Jr. was that morning. Neighbors walking or driving by his home routinely saw him outside doing yard work, and honked at him or waved and yelled hello. Most of them knew that he wasn’t in great health—one of his legs had been amputated and he was learning to use a walker to get around.
Just the sight of a man with one leg doing yard work drew some attention. But this wasn’t just any man. A ring of respect jingled in everyone’s voices when they said Mr. Kelley’s name.
Mr. Garlin Kelley Jr. was born and grew up in segregated Lufkin, and he’d lived in segregated neighborhoods and attended segregated schools all the way up through college in the late 1960s and early 1970s. It had taken East Texas a long while to get on board with integration. In fact, Dunbar High, Mr. Kelley’s alma mater, did not integrate until 1970, and only then because the school district was forced to do so by a federal court order. These experiences could have had a negative effect on anyone—caused feelings of prejudice or harbored anger—but not with Mr. Kelley. Even early on, his friends said that he recognized that it wasn’t up to him to judge others, and that as he had no control over how other people felt, it did him no good to worry about it. He would let the Lord judge him on who he was, and others on who they were.
As a boy, young Garlin and his friends would go to watch the Dunbar Tigers play every Friday night in football season. Dunbar High School had hired a coach by the name of Elmer Redd, who became a legend not only in Lufkin, but in the entire state of Texas. Dunbar had an abundance of talented athletes, but it was Coach Redd who molded that talent into state championship winners. Growing up in this environment, Garlin Kelley dreamed of playing football for the coach. He watched Tiger players like future NFL hall of famer Ken Houston receive college scholarships, and dreamed that he could, too, someday.
As Garlin entered junior high, he was smaller than many of the other boys, but that only meant that he had to work harder. From his parents and coaches, he learned the value of hard work, honesty, education, and the Good Lord. With encouragement and teaching from the coaches, and his own willingness to work and push himself, he progressed, and by the time he reached high school, Garlin Kelley was a force to be reckoned with on the football field.
Owing to hard work, desire, and plain old heart, Garlin Kelley first became an all-district player, and then was voted as an all-state player. He was instrumental in helping Dunbar High bring home three more state championships in his four years of high school. He was offered a college scholarship to Prairie View A&M University to play football. He would be following in the footsteps of not only one of his heroes, Dunbar star Kenny Houston, but also his mentor. Coach Redd had also attended the school.
Garlin Kelley never gained the stardom that Houston did in college or in the National Football League, and he wasn’t a first ballot Hall of Famer like Houston. But in 1966, Garlin Kelley won a whole lot more than football games—he also won the heart of a young lady named LaFrancis. Infatuation turned to puppy love, and continued to grow into a deep friendship and a lifelong love affair. After graduating from college, Mr. Kelley soon accomplished his greatest feat—he married LaFrancis.
Mr. Kelley first worked as an insurance agent and later for the Lufkin Independent School District. However, his love for football never ended. Through most of his adult life until his health failed him, he refereed high school football games.
Over the years, the Kelleys had three daughters: Ulrica, Angela, and LaTonya, and Mr. Kelley couldn’t have been any prouder of them. He instilled in them the same values he’d learned from his parents and coaches, and all three girls graduated from college.
Then at the age of fifty-three, Mr. Kelley was diagnosed with renal failure. It took a while, but he finally had a successful kidney transplant. For a while, things looked good, but three years later, the kidney gave out and Mr. Kelley had to start dialysis. He began treatment at the DaVita Lufkin Dialysis Center. The doctors later said that he was in excellent health considering the problems he had; in addition to his kidney problems, Mr. Kelley had type 2 diabetes, COPD, and hypertension.
With all these health problems going on at the same time, Mr. Kelley developed gangrene in one leg. The doctors had no choice but to amputate it.
One longtime friend of Garlin Kelley’s said, “Even after he lost his leg, there was never a time when he felt sorry for himself. There was never a time when he didn’t attempt to lift people up around him. It just wasn’t in Garlin’s nature to focus on his problems.”
This was what set Mr. Kelley apart from many others. Not only DaVita employees, but his family, friends, and even casual acquaintances all said that if you weren’t already aware of Mr. Kelley’s health problems, there was no way of knowing from his actions or demeanor. LaFrancis said of her husband, “He never met a stranger. You never knew what he had gone through the way he carried himself.”
No one ever had an unkind thing to say about Mr. Kelley. The other DaVita patients also liked him. Carolyn Risinger, who’d spent hours with Mr. Kelley while they received treatments, told KTRE-TV, “I knew Mr. Kelley. He came in early with me. He was a sweet man.”
As it turned out, “He was a sweet man” was the worst thing anyone had to say about Mr. Kelley.
Early on the morning of April 16, 2008, Mr. Kelley woke early as he usually did. He took a boiled egg and a grilled cheese sandwich to eat as snacks at DaVita—he was known as much for his boiled egg as he was for his warm personality. LaFrancis dropped him off at DaVita’s front door, where Mr. Kelley walked himself in using his walker. He’d spent many an hour with a therapist to get in shape and learn to use the walker because he didn’t want to be a burden on anyone.
As the med nurse that day prepared the patient’s medication, Mr. Kelley’s PCT, Sharon Dearmon, hooked him up to the machine. Dearmon said that he was his normal joking self, and ate his boiled egg while he watched ESPN on TV. There weren’t any problems with his vitals or anything else when they hooked him up at 5:36 A.M. His flow chart showed that he was fine between 5:36 and 7:30 that morning. In fact, a notation in his flow sheet said he was resting comfortably at 7:30.
Half past seven was break time for the employees, and Dearmon said that a lot of employees were off the floor then, including shift supervisor Sharon Smith. Dearmon was monitoring her own patients as well as another PCT’s while that person was on br
eak. At 7:35, she had her back to Mr. Kelley as she was taking care of another patient when the alarm on Mr. Kelley’s dialysis machine went off. She turned and found Kimberly Saenz, the med nurse, by Mr. Kelley’s machine trying to reset the alarm. After running over, Dearmon also found Mr. Kelley unresponsive, and called for help. After clamping off his lines, she started CPR, and someone called for an ambulance.
One of the people who responded to that call for help was RN Sharon Smith, charge nurse for that bay, who’d just returned from break. Smith later noted that she saw something in the bloodline that she’d never seen before. It looked to be a very unusual blood clot. It was fibrous, almost like hair. She said, “I’ve never seen it before and I’ve never seen it since.”
Dearmon echoed Smith’s description of the strange clot.
The DaVita employees did everything in their power to save LaFrancis’s husband, but he was still unconscious when paramedics arrived to transport him to the hospital. Once at the hospital, Garlin Kelley remained in a coma for months until on August 15, almost four months to the day that he lost consciousness at DaVita, he died without ever waking.
After Mr. Kelley died, LaFrancis told a reporter, “He was the love of my life. But I know he’s happy where he is. He’s whole again.”
One question lingered in everyone’s mind: How could he go from resting comfortably at 7:30 to massive cardiac arrest in five minutes with no symptoms?
DaVita investigators had found no problems with either the new or the reuse dialyzers. However, after the incident with Mr. Kelley (who was using a reuse dialyzer), DaVita Lufkin immediately suspended the use of reuse dialyzers on April 16. As they would soon learn, it wouldn’t help.
As far back as September 2007—one month after Kimberly Saenz was hired—DaVita had instituted a new policy. They were to collect all the bloodlines and other instruments used on patients who experienced cardiac problems while undergoing treatment, put these items in biohazard bags, put the patient’s name on the bag, and put the bags in a freezer to preserve them. But they’d never followed this policy until Ms. Strange and Ms. Metcalf died on April 1, 2008. On April 16, they followed protocol and preserved Mr. Kelley’s bloodline, and that included a syringe still attached to that bloodline. This would not be the last anyone heard about that bloodline and syringe.
CHAPTER 5
WHAT IF
The same morning that Mr. Garlin Kelley arrived at the clinic, on April 16, 2008, so did Ms. Graciela Castaneda. She was an elderly Hispanic woman who didn’t speak English. She’d been married for forty years and had three daughters. Prior to April 2008, she’d been a dialysis patient for ten years, and felt fine that morning—no different than any other day.
Yet at 8:00 that morning, after Mr. Kelley’s incident, Ms. Castaneda went into cardiac arrest. Just before she passed out, Ms. Castaneda remembers, she was talking to a woman doing something to her lines, but didn’t remember anything else. The DaVita staff, maybe because of all the recent practice, reacted immediately with the crash cart and gave her a shot of epinephrine at 8:08.
Ms. Castaneda was a lucky woman—at the hospital she recovered and survived that day.
Several months later, she saw a picture of a woman in the newspaper, and pointed it out to her daughter. Ms. Castaneda identified the woman in the photo as the nurse who had been talking to her right before she lost consciousness. The picture was of Kimberly Clark Saenz.
Two days before her heart attack, Ms. Castaneda’s LDH level had been measured at 219, well within normal range. LDH, which stands for lactic acid dehydrogenase, is an enzyme that helps produce energy. It is also present in almost all of the tissues in the body and becomes elevated in response to cell damage. Twenty minutes after Ms. Castaneda’s cardiac arrest, her LDH level was 2150.
Besides being an indicator of hemolysis, or cell damage, an elevated LDH level is also a marker for bleach poisoning.
* * *
Unfortunately for DaVita and especially the patients, instead of calming down, the storm plaguing DaVita was gathering strength, and it focused on Ms. Marie Bradley next.
Ms. Bradley was a Lufkin native who’d graduated from Lufkin High School in 1948. She later went to work for Jim Walter Homes in Lufkin where she remained for twenty-five years, advancing to upper management. In 2000, she began having heart and kidney problems, and started dialysis at Woodland Heights Hospital.
On May 7, 2007, Ms. Bradley began her treatments at the DaVita Lufkin Dialysis Center. From the time the news first broke about Saenz, and all through her trial, many people referred to Saenz as “an angel of mercy.” It was just so difficult to accept the idea that a medical professional could have been intentionally harming or killing her patients in the first place; if she really were doing so, it was far easier for people to believe that perhaps Saenz had had noble motivations, such as ending unnecessary suffering. However, Ms. Bradley was one of the patients who knocked down the “angel of mercy” theory. Although ill and in need of dialysis, Marie Bradley was notably robust and energetic. Her doctor said of her, “She was one of the exceptional patients as far as health went.” Unlike many dialysis patients, Ms. Bradley drove herself to and from her treatments.
April 23, 2008, was her regularly scheduled appointment. After all the preliminaries, she was hooked up to the machine at 11:00 A.M. As she neared completion at about 3:30 that afternoon, her blood pressure took a surprising drop, from 145/66 to 97/50, and her oxygen levels also fell drastically.
A few days earlier, her LDH levels had been 169. After she was rushed to the hospital on April 23, they were 1372. At the time, however, Ms. Bradley had no idea what had actually happened to her. She woke up in the hospital two and a half days later. She didn’t know about the DaVita employees who’d frantically worked to save her life or the mad dash to Memorial Hospital in the ambulance. Nor was she aware of the Memorial emergency doctors and nurses who’d revived her and then closely monitored her condition in the intensive care unit.
As Ms. Bradley herself later said, it was clear that during her treatment on the twenty-third, “Something went horribly wrong.”
* * *
What would a patient in the dialysis center feel like as she watched EMTs rush two other patients before her to the hospital? What could she have been thinking when her turn for treatment arrived, and the nurse who had helped her pass the long dreary hours by telling her jokes hooked her up to the machine?
Imagine the patient’s horror as her arm, at the point where she was attached to the machine, began to bleed and wouldn’t stop. As the blood flowed out of her, she started throwing up, and pain shot through her entire body. Then, agonizing pain made her believe her chest would explode. Imagine her terror as DaVita employees loaded her into another ambulance and whisked her off to the same hospital where others before her had gone—others who hadn’t survived the trip.
This terrible experience was what happened to Ms. Debra Oates, another patient at the DaVita Lufkin Dialysis Center, on April 26—one of the worst days of the storm. Ms. Oates, like Ms. Bradley, was a Lufkin resident. Also like Ms. Bradley, she was healthy enough to drive herself back and forth to dialysis for treatments.
On April 26, she had been watching TV and her treatments were going well—no problems at all. Then LVN Kimberly Saenz came over to give her medication, and that’s when she started to feel bad. At 9:13 A.M. Debra Oates’s blood pressure was 147/73, but at 10:39 it dropped to 83/56. During this interval Ms. Oates experienced nausea and vomiting and trouble breathing. She said she “hurt all over.” Her heart was beating faster and she was sweating, and the access in her arm where they hooked the dialysis lines up started bleeding and wouldn’t stop.
She also had a funny taste in her mouth. She’d been a dialysis patient since February 2005 and was familiar with the process, and knew that each medication given through the blood while on dialysis had a different taste. This taste was unfamiliar.
Sharon Smith, the nurse supervisor, overheard this question from Debra Oates and she said that she’d never heard her ask that before. However, Ms. Oates didn’t get an answer to her question. Kim Saenz just walked off.
And then Ms. Oates’s condition worsened.
PCT Werlan Guillory was again on duty that day, and said that Ms. Oates had been doing well until 9:43 A.M. and then she became sick to her stomach and started throwing up. They immediately got her into an ambulance, where the technicians gave Ms. Oates some nitro and more of it at the hospital. Like Ms. Bradley, Ms. Oates was one of the exceptional patients, and she somehow survived the storm.
However, neither of the patients Ms. Oates and Werlan Guillory had watched them carry out earlier that day was as lucky as Ms. Oates was. The first was ninety-one-year-old Ms. Opal Few, and the other was Ms. Cora Bryant.
Ms. Bryant was born on May 10, 1943, in San Augustine, a small town east of Lufkin. She settled down in Lufkin and raised four daughters and one son. People said that Ms. Bryant loved her kids and family and could always make people laugh.
The family talked about the values their mother taught them, and how their mother inspired them. Angela Scott told the newspaper, “Our mama passed on a will to never give up. She refused to give up. And she has given me the strength to carry on.”
The day before Ms. Bryant went for her appointment at DaVita for the last time, she took a walk with her granddaughter, Jamina Agnew. Ms. Agnew related how Ms. Bryant was feeling that day, telling her granddaughter, “I feel good. Come on, keep up.”
On the morning of April 26, Candace Lackey, an LVN at DaVita Lufkin, hooked up Ms. Bryant to the machine. She said that Ms. Bryant was in a good mood that day. She’d had some clotting problems early in the treatment, but they’d changed out her lines and that took care of it.
