by Peter Elkind
At night at Bexar County Hospital, a team of two pediatric interns, a second-year resident, and a third-year resident took overnight call in the pediatric ICU, a shift that kept them on duty—and sometimes awake—for up to thirty hours at a stretch. During the one-month rotation, each team took call every third night and covered the sixty-bed pediatric ward as well as the ICU. While Genene Jones worked there, the doctors made rounds in the morning and drifted in and out during the day; none remained in the unit full time.
This meant that in the pediatric ICU, even more than in most hospital wards, nurses were a critical presence. A pediatric ICU nurse spent all her time on one or two patients who demanded almost constant attention—feeding, changing, drugs, and observation. These children were capable of doing nothing for themselves. Not all of them were on the brink of disaster, but many were; one out of seventeen patients who entered the pediatric ICU never left. It was a situation where the work of a single nurse could tip the scales between life and death.
The nurses who choose ICU work thrive on that kind of high-pressure challenge. They are bored with the low-key atmosphere out on the floor; they scoff at it as baby-sitting. ICU nurses pride themselves on their ability to spot problems early and intervene—to step between a medical calamity and a child like a superhero jumping in front of a speeding bullet. They pride themselves on being aggressive.
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 once again to the 3–11 P.M. shift. 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. She knew more anatomy and physiology than most LVNs: And when she didn’t understand something, she would run for the medical textbooks to try to figure it out.
But Genene’s most distinctive nursing skill was her extraordinary talent for putting intravenous lines into veins. Most 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, the woman of nimble fingers, it was a breeze. There was no IV she could not start—no patient too restless, no vein too small. Her reputation spread quickly, and nurses on the pediatric floor began calling her out of the unit to start IVs for them. “She could stick an IV in a freaking fly,” remarked one doctor.
Genene’s natural talent dazzled her supervisors—most notably Pat Belko, the matronly head nurse of the pediatric ICU. A native of New Hampshire, Belko had earned her RN degree in 1955. Her career bridged the years when hospital nurses timidly did doctors’ bidding; modern medicine advanced the notion that physicians and nurses were a team. At Bexar County Hospital, the partnership concept was practiced to a fault. While doctors called the shots on patient care, even the chief of a medical service lacked the power to fire—or even discipline—an incompetent or a dangerous nurse. A separate hierarchy of nursing bureaucrats presided over the nursing staff; they brooked no intrusion from doctors on their turf.
In a profession where annual turnover in big-city hospitals averaged about 25 percent, Pat Belko had risen to mid-level management by remaining in one place. Bexar County Hospital had particular trouble holding on to its staff. Talented young nurses went there to gain experience, then usually left after a few years for private hospitals or clinics, where the pay was better and the work softer. Married to a retired air force sergeant who became a mail carrier, Belko began at Bexar County Hospital in 1971, after taking several years off to devote to her six children. She was assigned to the pediatric ICU, where she started at the bottom: the 11 P.M. to 7 A.M. night shift. Supervisors praised Belko’s solidity: They called her “reliable” and “congenial” and noted that her attendance record was virtually perfect. She rose to charge nurse on the night shift after three years, took over the day shift after four, and was appointed head nurse of the entire pediatric ICU in February 1978.
At forty-four, Belko was a cordial, moon-faced woman, pleasant enough but bland, with a fireplug build. Disinclined to offend, she quickly displayed an inclination to follow the path of least resistance, to smooth over problems rather than resolve them. Government institutions all over America were filled with people like Pat Belko; they rose to positions of authority not through brilliance or initiative but by earnestly putting in their time.
Belko’s biggest headache since her promotion had been finding enough nurses to staff the ICU around the clock. Several open positions had gone unfilled for months. Genene Jones endeared herself to the boss by volunteering often for extra shifts. And unlike many of the young nurses, who openly ridiculed Pat for being stuffy and indecisive, Genene was solicitous and respectful. Uncomfortable holding the reins of leadership, insecure about how subordinates regarded her, Belko was grateful for Genene’s fealty. “Ms. Jones has adapted to working with Pediatric patients well,” wrote Belko, in evaluating the new LVN after three months. “She shows a great deal of enthusiasm and loyalty to the PICU. She gives priority to consideration of the patients as human beings.” Genene could become an even better nurse, Belko added, if she could maintain “better control of emotionalism.”
Despite the praise, Genene had already committed the first of an increasingly serious collection of nursing errors; eight were formally noted during her first year alone. She failed to obey a doctor’s orders to give a child an anticonvulsant drug. She didn’t notice a malfunctioning intravenous line. She set an IV solution at an improperly high rate, allowing fluids to pour into a child’s body over thirty minutes instead of six hours. She miscopied drug orders, in one case transcribing 50 milligrams as 500 milligrams; before the mistake was discovered, Genene’s patient received three dosages of ten times the proper amount.
Following each of her mistakes, Genene received what was known under hospital procedure as “informal guidance”: She had to discuss the incident with her superiors, who placed a report of it in her personnel file. In several cases, Genene insisted she had done nothing wrong; she submitted notes for the record containing elaborate excuses for her transgressions. Genene’s fourth medication error in twelve months obligated her to repeat a special class on the administration of drugs. When Genene twice failed to show up, she received another written scolding. But even during the first year, those were not her most serious offenses.
At 7 A.M. on August 11, 1979, Genene completed two consecutive shifts caring for a ten-month-old girl in the throes of terminal heart failure. Her supervisor, Cherlyn Pendergraft—the nurse who had given Genene her orientation—ordered her to go home at the end of the second shift. Genene refused. For an hour, she ignored direct orders to leave the pediatric ICU. She departed only after a higher-level nursing administrator was summoned. In a written explanation, Genene said she felt her presence was essential because she had developed a rapport with the child’s parents—and because the little girl needed her. “I felt that seeing her through this crisis, her biggest, was very important, not only to me, but for her,” Genene wrote. Under Bexar County Hospital’s complicated system of personnel sanctions, Genene’s action could have been classified as an act of “industrial insubordination,” resulting in an automatic three-day suspension and probable firing. But Pat Belko, citing Genene’s professed concern for her patient, decided to give her a warning instead. She placed her on notice that a similar failure to obey orders would result in suspension—and probable dismissal.
Just such an incident came less than two months later. On September 29, after completing the previous night’s 3–11 shift, Genene appeared unexpectedly in the ICU at 5 A.M. Accompa
nied by a friend, she went to the bedside of the patient she had been treating, fetched a syringe, and started tinkering with the child’s medical equipment. Smelling alcohol on Genene’s breath, doctors and nurses ordered her to leave. Genene insisted she wasn’t drunk, before weaving out of the room and departing the ICU.
Genene had used “very poor judgment” in returning to the ICU “apparently under the influence of alcohol,” Pat Belko wrote in her report on the incident. Under hospital rules forbidding conduct that endangers the health of patients, the head nurse noted, Genene could have been suspended and fired for that incident alone. But she was not to miss a minute of work—previous offenses notwithstanding. Wrote Belko: “Because of Ms. Jones positive contributions to the unit, her concern for the patients and the voluntary overtime she has worked, she is notified that this is a final written warning.”
The last entry in Jones’s personnel file for 1979 took note not of her five medication errors during fourteen months of employment, nor of her failure to attend required classes on the use of drugs, nor of the two episodes of serious misbehavior, any one of which could easily have justified her dismissal. Instead, on December 28, 1979, Pat Belko submitted for Genene’s file a written commendation for “meritorious contributions.” Written by the charge nurse on Genene’s shift, the letter was cosigned by Belko. “Over the last 4 months when the PICU was going through a severe staffing shortage, Ms. Jones worked in excess of 12 extra shifts to help cover the unit; these extra shifts often involved sacrificing days off…Ms. Jones is to be commended for her support and dedication to the PICU.”
Other nurses were amazed at Jones’s ability to elude punishment. Those who had reported her for discipline became frustrated; Belko refused to deal harshly even with misconduct that endangered patients. Bitter at the head nurse’s failure to back her up, Cherlyn Pendergraft—the nurse who had oriented Genene—transferred out of the ICU. Genene appeared emboldened by her apparent invulnerability. It seemed as though no one could rein her in.
Five
In the span of twelve months, Genene Jones’s presence had divided the pediatric ICU. Those who crossed her path came quickly to see her in a white or a black hat. Her most important supporter was Pat Belko—evidence of Genene’s ability to appeal to people, particularly superiors, at will. But several of Genene’s peers were drawn to her flame too. Foremost among them was Debbie Sultenfuss, a thirty-two-year-old woman whose devotion to Genene Jones would prove blind.
Sultenfuss met Genene after going to work on the pediatric floor in August 1979, fresh out of LVN school. Genene’s fast mouth and mind quickly made a deep impression on her. In January 1980, Debbie transferred from the floor to the pediatric ICU to work the 3–11 shift with Genene. They became inseparable: Genene the clever teacher, Debbie the eager, if slow, pupil. Debbie began trying to act like Genene, even to dress like Genene. But she was a poor imitation. Debbie, a six-foot, two-hundred-pound giantess, lumbered. Her spelling, grammar, and handwriting were nearly unintelligible. On several occasions she was late to work, and supervisors regularly noted her inability to master the terminology of medicine. Debbie’s infatuation with Genene prompted gossip in the ICU—never substantiated—that they were lesbians. Genene sneered at the suggestion; Debbie would later explain that they shared “a sisterly love.”
Parents of the critically ill children Genene treated also regarded her as a godsend. Genene worked them like customers in her beauty chair, and they came to see her as a comforting figure, a woman of patience and understanding. She had long private talks with them, where she confided tidbits about the hospital and listened to their complaints and fears. While faceless doctors rushed by, week after week, Genene was there, caring for their child. She called them by their first names; she became a friend. Genene took pains to cultivate even parents who were suspected of abusing their children—usually the lowest form of life in any pediatric nurse’s book. While other nurses shunned such families, Genene rushed to greet them. The evidence in such cases was typically both ugly and overwhelming, but Genene would say that she believed the parents were innocent.
While Genene turned on the charm for parents, she displayed a completely different personality among colleagues. 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—unit nurses were legendarily boisterous—but Genene talked like a sailor. She had strong opinions—about doctors, other nurses, patient care, the hospital—and voiced them without hesitation.
Happiest while the center of attention, Genene told colorful stories about her life: that she had spent time in a coma after a terrible car accident; that she had shot her brother-in-law in the groin after he’d beaten her sister. Genene’s peers did not know with certainty that such tales were the product of her imagination. But they sensed what friends since high school had known: that she often did not tell the truth.
In this group of medically aggressive nurses, Genene 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. Her impulse to exaggerate medical problems, harmless while Genene was a beautician, was now being exercised in an environment where it was dangerous. Exhausted doctors began to think of her as the most serious obstacle to a few hours’ rest: the nurse who cried wolf. “She’d always call you for crap,” said one resident who worked with Genene. “Any little thing, she’d be calling you—two, three, four times as much as anybody 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 would call another. When the intern didn’t jump, she’d talk to the resident; when the resident didn’t jump, she’d call the attending physician. Genene questioned medications, dosages, treatment, 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.
Interns became special targets for Genene’s tactics. Unsure of their knowledge, they were easy prey for a nurse certain of her own. Genene made it clear she believed she knew more than the interns, that she was really protecting the patients from the doctors. She was always testing, searching for an opening, seeing how much she could get away with. When an intern hesitated, she pushed: “Don’t you think the baby needs this?” Strong personalities reined her in; weak ones were steamrollered.
Several residents discovered Genene drawing up drugs without bothering to wait for their orders. Dr. Debbie Rasch arrived at the scene of one child’s cardiac arrest to find Jones ready to inject. “I asked her what she was pushing, and it was calcium,” said Rasch. “If she had gone ahead and given the medication, it would not have been appropriate. When I got there, she had syringe in hand.”
The problem wasn’t that a nurse was telling a doctor what to do. The best ICU nurses could handle many calamities almost by instinct—much faster than the average resident. But the doctor must make the call. A good nurse could save him from a serious mistake; a bad nurse could get him—and his patient—in grave trouble. Genene Jones disturbed the young residents who worked in the pediatric ICU because she left many of them uncertain: In which category did she belong?
But to Genene, nothing was uncertain. It was simply a matter of fighting for her patients, of pointing out problems the residents were too green or too stupid or too lazy to spot—problems she invariably saw in life-and-death terms. “I could sit and look at a baby, and they’ll smile,” Genene would say. “You’ll blink your eyes, and they’re dead.”
Jones’s dramatic perspective rattled her peers. Every eight hours, when shifts changed, the nurses would meet for “report,” during which those who had been on duty would detail the condition of their patients. There, Genene issued chi
lling pronouncements. This baby is really bad; this baby isn’t going to make it through the night! “It wasn’t like she was predicting it,” recalled one young RN who began her career in the pediatric ICU. “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.”
The spring of 1980 brought to San Antonio a man who would serve first as Genene Jones’s ally—and later as her nemesis. In March, Dr. James Lawrence Robotham became an associate professor at UT and medical director of the pediatric ICU. Robotham, thirty-three, wiry and bearded, was a pediatric intensivist—an expert in critical care. He belonged to big-time medicine’s new breed of sophisticated subspecialists, doctors who trained specifically to transplant bone marrow or deal with fertility problems or handle trauma cases in emergency rooms—or run ICUs. He arrived from the prestigious Johns Hopkins Medical School in Baltimore, after having learned his trade at two other top programs. Robotham was 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’s medical director had been 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 schooled to treat them; that, after all, was why he was there. He began spending much of his day in the ICU. Robotham 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 patients’ 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.
Robotham had skills—and clout—that other doctors in the ICU lacked, and his presence made a difference. An LVN on the night shift saw that early one morning, when a five-month-old boy started fading fast and Robotham came in from home. “Blood was oozing from everywhere, and the kid was dying,” she said, wincing at the memory. “Blood was bubbling out of his mouth, blood was bubbling out of his rectum. As fast as we could push blood in, it came squirting out. Robotham got on the phone: He got the chief gastro man; he got the chief cardiologist. They pulled that baby out, and he lived. He didn’t have to come in at two o’clock in the morning when we said, ‘This kid is bleeding.’ He came in because he cared. I saw him save the kid.”
