The Death Shift

by Peter Elkind

  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 a barrage 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 doctor in sight; the nurses were meeting in the unit’s back room. Robotham stepped 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, Robotham 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.

  When he arrived at Bexar County Hospital, Jim Robotham felt certain he had known many nurses like Genene Jones. You could find a few at every busy charity hospital. They populated late-night shifts, handling thankless chores during dark hours. They were unattractive and rough. Ridden with guilt about the mess they had made of their own lives, they buried themselves in their work, volunteering for extra shifts and hanging around the hospital during free hours. They had an exaggerated sense of their importance and talked big to their peers. Often they were LVNs and thus consigned forever to the lowest rung of the nursing hierarchy. But hospitals depended on them: They had savvy and experience, and they made the place run. Robotham came to think of such nurses, bruised and battle tested, as the charity hospital’s staff sergeants.

  Robotham had faith in their gut judgment, for it was instinct that had led him into medicine. Robotham was one of those doctors who grew up worshiping Albert Schweitzer and Tom Dooley—who knew, from early youth, that they could enter no other field. Growing up in Scituate, a tiny town on the Massachusetts coast, Robotham pored over anatomy texts, memorizing the names of bones and muscles. At seventeen, he entered a combined undergraduate-medical school program at Boston University. Robotham’s middle-class parents were Presbyterian and Irish Catholic, but six years in a BU dorm, surrounded by Jewish kids from Long Island, tagged him forever with a New York accent. He graduated at twenty-three, ranked second in his medical school class.

  Robotham had harbored idealistic childhood dreams of following Dr. Schweitzer’s footsteps to Africa. But during his internship year in pediatrics at Boston City Hospital, which picked up the pieces from Boston’s harshest slums, Robotham learned he didn’t need to leave America to encounter Third-World conditions. He finished his residency at Johns Hopkins, returned to Boston City for a year as chief resident, then moved to Toronto to train at the renowned Hospital for Sick Children. There, Robotham worked under Dr. Alan Conn, one of the fathers of pediatric intensive care. In 1976, he returned to Baltimore, where he joined the Johns Hopkins Medical School faculty and later married. In the world of academic medicine, Robotham was a hot property because he was a double threat: an expert clinician and a productive researcher. He attracted his own funding and published in prestigious medical journals. After deciding to leave Johns Hopkins, Robotham entertained several offers. The freedom to pursue his considerable ambitions lured him to San Antonio’s young medical school.

  Robotham arrived in Texas with a personal five-year plan. He intended to split his time evenly during the first years between the pediatric ICU and the lab. Funded by two federal research grants, Robotham was conducting experiments with baboons aimed at avoiding the lung problems that plagued premature babies placed on respirators. He planned to wean himself later from the draining ICU chores and hand over the day-to-day responsibilities to younger disciples.

  Reality rewrote the plan. On inspecting the pediatric ICU, Robotham was appalled at its antiquated facilities. Even before taking over, he sent the pediatrics chairman a ten-page memo detailing $120,000 in new equipment he considered essential to raise the ICU to “an acceptable level allowing proper care of patients.” Robotham ended his letter with a postscript: “I know I’ve forgotten something.” The unit’s staffing needs were just as great. Doctors had been forced to postpone several elective procedures on children because the pediatric ICU lacked the nursing staff to care for them after surgery. At times, the shortage forced Robotham to cut the ICU census from eight to four beds; when there were more than four critical patients, the hospital had to send them elsewhere.

  Trying to solve problems at the county hospital was an energy-sapping nightmare. There was never enough money for anything; every purchase of basic equipment required hours of negotiation. Replacing the ICU’s broken refrigerator took a special appeal to the hospital administrator. When Robotham wanted a microwave oven to reheat patient meals—which invariably arrived on the pediatric floor cold—he had to recruit a local merchant to donate the appliance. There were dozens of petty annoyances. The hospital’s public areas were always dirty, and the lobby contained rudely worded messages ordering parents to mind their children. The pediatric floor had no waiting area for parents of critically ill children; when they dozed off late at night on a windowsill, hospital security guards rousted them as though they were vagrants.

  Everywhere Robotham looked, administrators were holding meetings and writing memos. In addition to an executive director, Bexar County Hospital employed a senior associate executive director, three associate executive directors, an executive assistant to the executive director, an administrator, and three assistant administrators. Memoranda from the top man arrived on baby-blue paper; others used white or pink. One critical message carried the signatures of the assistant administrator for resource management, the assistant administrator for support services, the director of supply and equipment management, and the director of housekeeping; it laid out the official hospital procedure for moving things. (“Significant movements of equipment or furniture are to be accomplished…with the assistance of Hospital Supply.”)

  While some aspects of the bureaucracy were merely maddening, others threatened lives. When Robotham arrived in San Antonio, there were no beepers to contact the pediatricians on call in an emergency. Getting lab results or x-rays, particularly on weekends, often took hours. Blood samples sent for testing were frequently lost or confused. Critical pieces of equipment took weeks to replace or repair.

  In this environment, Robotham toiled to impart his treatment philosophy to those who worked in the pediatric ICU. As an intensivist, he was schooled to consider the unlikeliest medical possibilities. Reviewing an ICU patient with a group of residents, he often required them to list fifteen complications the child’s illness might produce—even if their statistical probability of occurring were a tenth of one percent. Day after day, he drilled his young doctors. “Look for the zebras!” he told them. After the Robothams had a child, his wife half-seriously remarked to friends: “Jim is the best person to have around with a sick kid—and the last person you want to have around with a healthy kid—because he thinks of everything that could go wrong.”

  It was only natural that J.R. and Genene Jones would develop a rapport. The byword of Robotham’s style was “aggressive.” He taught the residents and nurses to look for the tiny changes that marked impending disaster—the twitch or the shift in respiration rate—then to move fast to head off trouble. In Genene Jones, he saw a nurse who personified that approach. “What he said was look for the subtle signs,” said Genene. “Damn aggressive. He was extremely aggressive. And it was great!” If residents thought she overreacted, cried wolf, and woke them up too much, Robotham thought she was often right. When Pat Belko assigned another
nurse to help him insert a special catheter in a child, Robotham said he wanted Genene instead. He told Belko he considered Jones the best nurse in the ICU.

  All her life, and especially since she had become a nurse, Genene Jones had felt sure she knew the right way to do things. Now she had two superiors—Belko and Robotham—who felt that way about her too. After winning the medical director’s confidence, Genene did not hesitate to take full advantage of his respect. When she got into a conflict with a resident, she would call J.R., knowing he would listen. “They used to call me Robotham’s pet,” said Genene. “To have him there was a kind of protection for me.”

  Six

  In November 1980, Genene Jones moved out of her mother’s house and into an apartment of her own near Bexar County Hospital. Genene characterized the move as a personal declaration of independence. She was feeling increasingly secure about her place in the pediatric ICU; with Dr. Robotham’s encouragement, she had even begun to talk about returning to school to earn her RN degree. But Genene also had a personal imperative for setting up house on her own. Gladys’s relationship with Genene’s son was rapidly becoming volatile.

  Since beginning her career as a nurse, Genene had relied almost exclusively on her aging mother to care for Edward and Crystal. It was Gladys who was there when they came home from school, Gladys who prepared their dinner, Gladys who tucked them into bed. Genene was absent far more than the usual forty-hour week. She pulled countless extra shifts, went to work early, and often returned late. She seemed almost chronically incapable of separating herself from the hospital, as though she were the only one who could care properly for her ICU patients. She lavished less attention on her own kids.

  While three-year-old Crystal was little trouble, Gladys was hard-pressed to keep up with Edward, who was nearly nine. Typical of kids raised by a grandmother, he was undisciplined. Frequently bored, he spent his free time roaming the neighborhood, where he had the habit of appearing in people’s homes uninvited. When something turned up missing, neighbors would naturally think of Edward. Gladys did what she could to rein him in, but at sixty-nine, she lacked the strength to handle a rambunctious preadolescent. When Gladys yelled at him in frustration, Edward accused her of favoring Crystal. Like Genene during her own childhood, Edward was jealous of his sister.

  The move to an apartment did not lighten Genene’s load of personal woes. She continued to leave her kids with Gladys much of the time, and her own relations with Edward were equally poor. Genene accused him of lying to her, often about school, where he was getting into fights and stealing. Genene took Edward to a local guidance center for testing and psychological counseling. She complained that Edward never obeyed her instructions, causing her to feel inadequate and powerless, frustrated and angry. One day, Genene showed up at the ICU in tears, saying she’d just beaten up her son. At Dr. Robotham’s request, Pat Belko temporarily shifted the LVN to the day shift to give her more time with her family.

  Friends found Genene burdened by her work as well. She was dating Steve Seubert, a high school friend who had been an usher at her wedding. After her shift, they would meet at a bar called the Recovery Room, near the hospital. There, Seubert recalled, Genene emptied her heart. “She kept saying, ‘The babies cry; they cry a lot.’ She talked about the doctors making mistakes. A doctor made an assessment of one kid, and she said it wasn’t right, and she talked to another doctor. She was saying she made the correct diagnosis, that she saved the babies.”

  Drawn compulsively to the hospital, Genene developed excuses to become a patient herself. During her first twenty-seven months of employment, Genene made thirty visits to the county’s outpatient clinics or emergency rooms, where she presented an extraordinary assortment of complaints. She had diarrhea and cramps, vomiting, acute gastroenteritis, indigestion, belching, and “burning up” constipation. She felt shooting chest pains and dizziness. Her thumb was cut; her hands itched. She suffered from excessive menstrual bleeding and lack of menstrual bleeding. She had a sore throat; she experienced an allergic reaction to medication. Most of all, she experienced pain: neck pain, knee pain, abdominal pain, lower back pain.

  On March 10, 1981, Genene was admitted to Bexar County Hospital with a puzzling set of symptoms, all duly noted by a doctor:

  The patient was in the usual state of health until September or October of 1980 when she noted difficulty walking up the hill from the parking lot to work. This progressed until she had to stop altogether and began parking in the handicapped parking lot. She could not manage the hill any longer and had cramping pains in the calves and thighs…After several weeks of progressive difficulty…piano playing was prevented by cramping and weakness of all forearm muscles. The patient had difficulty blow-drying her hair. The patient also feels like she wants to sleep all the time. Has constant lack of energy. The patient denies emotional lability, early morning awakening, difficulty in falling asleep…Denies chills or fever and denies weight loss or gain. [In fact, Genene had ballooned from 160 to more than 200 pounds.] Admits to sweating all the time, day and night…

  Assigned to the neurology service, Genene underwent a battery of tests to rule out nine different diseases. During a test called an EMG—a muscle study that involved insertion of an electrically charged needle in her leg—Genene became hysterical and refused to allow completion of the procedure; she returned to her room in tears. Later, she told nurses she had felt something pop in the back of her neck. On another occasion, she complained of breathing trouble. Unable to find a cause for the muscle pain and weakness that had brought her to the hospital, the neurologists sent Genene for a psychiatric consultation.

  In relating her family history, Genene told the doctor that she had planned to marry the man who had fathered her daughter, but that he had died in an automobile accident. “The patient was obviously moved by this tragedy,” the physician noted. “She is however able to talk about the grieving period for this loss and seems to have accepted it.” The “tragedy” that “obviously moved” her—the death of Keith Martin—had, of course, never happened. The doctor concluded that Genene’s personality exhibited “some hysterical features,” but in general she was “more aware of her areas of psychologic conflict than most.”

  Unable to find any physical problem more serious than bronchitis—induced by a dozen years of smoking thirty cigarettes a day—doctors dismissed Genene after eight days of tests. She was back in the emergency room at 10 P.M. the next day, complaining of coughing spells, chills, blurred vision, and first sharp, then pounding, pains about the temples. An emergency room doctor took note of Jones’s “tearful affect,” diagnosed her problem as a migraine headache, and sent her home with medication.

  For further study of her muscle problems, Genene was seen in the private clinic of Dr. Robert Schwartzman, chief of the hospital neurology service. After a thorough examination, Schwartzman reported his findings to Jim Robotham, who had been worried about the health problems of his ace LVN. “Careful muscle testing revealed no objective weakness,” wrote Schwartzman. “…I am really not quite sure what the cause of her difficulty with her muscles is. I am beginning to think that it is not an objective one.” Subsequent tests persuaded the neurologist that Genene Jones had fooled him. “…On my first two examinations, I was thoroughly convinced that she had real proximal weakness of both upper and lower extremities,” Schwartzman later wrote Robotham. “…However after negative muscle enzymes…negative sed rate as well as a negative EMG and muscle biopsy, I felt that she had psychosomatic problems.”

  Thus was the stage set for a nightmare. A woman with a strange attraction to medicine, unable to distinguish between true illness and imagined calamity, is drawn to employment as a nurse. So powerful is her attraction that she needlessly subjects herself to invasive medical procedures. She is set loose in a hospital to care for the most helpless of human beings, where all the warning signs are ignored: her firing from Methodist Hospital, her history of telling lies, her on-the-job errors, her inability to
admit mistakes, her unwillingness to follow orders, her exaggerated sense of her abilities, her need to be in control, her desperate craving for attention. For a while, Genene Jones would be satisfied to point out medical problems that didn’t exist. It was only a matter of time before that would no longer be enough.

  In a hospital, a medical emergency is called a code. In the pediatric ICU where Genene worked, it happened several times a month, and it was a frightening thing to watch: Someone was dying before your eyes.

  A code usually began when a nurse noticed that a child’s breathing or heart had stopped. The nurse would shout over to the nursing station in the center of the ICU. Whoever was closest pressed a small white emergency button, and an alarm went out across the pediatric floor, bringing doctors running. When a nurse believed there was a severe emergency, she called a code blue. An operator switched on the public-address system and announced, “Code blue to pedi ICU,” throughout the hospital, summoning help from everywhere. ICU nurses rushed to the patient’s bedside with the unit’s “crash cart,” loaded with emergency drugs and equipment. People began pouring through the ICU’s double doors: doctors on the floor, nurses from the pediatric ward, respiratory therapists to handle resuscitation, pharmacists to draw up drugs, medical students. The patient’s room filled with people. The doctors shouted orders; one of them would take command. Everything was happening fast.