by Peter Elkind
It is a fact of life in the world of medicine that considerations of turf and politics and personality can jeopardize lives as readily as an errant scalpel or a botched diagnosis. Thus Jim Robotham’s terrible suspicions about Genene Jones could be dismissed for weeks, even months, as the histrionics of an obsessed, hotheaded doctor. Robotham—trained as a physician, not as a criminal investigator—was left alone with the burden of trying to catch a murderer. But one angry voice was to change that: It belonged to the hospital’s most prominent surgeon, who believed that a child he sent to the pediatric ICU should have recovered instead of died.
Conventional wisdom attributes a distinct bundle of personality traits to doctors who practice in each of medicine’s specialties. This lore places surgeons and pediatricians at opposite ends of the temperamental spectrum. Pediatricians are gentle, sensitive, and kind. Surgeons are brutish, bullheaded, and overbearing. Pediatricians treat with drugs and fluids, and believe in letting nature work its delicate magic. Surgeons want to cut. The economics of modern medicine also divided the two specialties. Because of regulations governing reimbursement for federal health insurance in the 1980s, doctors engaged in hands-on, primary care—pediatricians, internists, family practitioners—earned far less than specialists, such as surgeons and radiologists, who mostly performed procedures. In 1982, pediatricians were America’s lowest-paid group of doctors, with a median income of $62,000 a year. Surgeons were among the best rewarded, at $110,000.
The pediatric ICU was a setting where the conflicting personalities and medical philosophies of pediatrics and surgery clashed. The surgeons sent children to the unit to recover after operations, and as the admitting doctors, they retained control over the treatment plan of their patients there. Infection and fluid balance—the problems children usually experienced during recovery—were actually pediatricians’ area of expertise. But the surgeons thought they could handle postoperative patients better than anyone and held pediatricians as a breed in particular contempt. They regarded the baby doctors’ lack of assertiveness as cause to disregard their advice. Even surgical interns learned to sneer at them as “pedi-pods.” Although Robotham and his residents kept hourly watch over children in the ICU, when the surgeons rejected their counsel, the pediatricians could do nothing more than fume. The events of late 1981 had escalated the natural conflict. The surgeons were upset about several postoperative patients who had died unexpectedly in the pediatric ICU. Each death had set off feuding over who was to blame.
On January 14, the surgeons sent Patrick Zavala to the pediatric ICU to recover from open-heart surgery. Four months old, Patrick had gone under the knife for repair of a cardiac birth defect. The procedure had gone smoothly; not long after arriving in the unit, the baby was kicking his feet in his crib. By Sunday, January 17, Patrick was progressing so well that doctors were preparing to wean him from the respirator that aided his breathing. The last note from the nurse who cared for Patrick until 3 P.M. was “alert, all shift.” At 4 P.M., Genene Jones recorded that the baby was “somewhat lethargic.” Jones’s nursing notes over the next two hours reported steadily worsening problems, even though Patrick’s mother left his bedside at 6 P.M. with her child sleeping comfortably. About thirty minutes later, Genene summoned Dr. Edward Eades, the surgery intern on duty. He discovered the baby almost totally unresponsive to even painful stimulation.
Unable to tell why Patrick’s condition had deteriorated, the surgeons—at Genene Jones’s suggestion—decided to take him for a brain scan, despite protests from a pediatric resident who felt his condition was too unsteady. Accompanied by Genene and another nurse, the surgeons wheeled the child to the CAT-scan room in the hospital basement. As they waited for the machine to warm up, Patrick’s heart suddenly stopped. Uncomfortable handling the arrest—the surgeons were uncertain what doses of emergency drugs to administer to a baby—they put out a distress call for a pediatrician. When a pediatrics resident arrived from the fourth-floor nursery to take over, he discovered that Genene Jones had already started the child on dopamine, a drug that raises blood pressure, without a doctor’s order. The doctors revived Patrick, then wheeled him back to the ICU. “Very puzzling picture,” one resident wrote on the child’s medical chart. Not long after returning to the unit, Patrick went into seizures and arrested again. Doctors worked to save him but finally realized it was hopeless.
Just as the physician running the code officially pronounced the baby dead, Genene Jones grabbed a syringe and, like a priest sprinkling holy water, made the sign of the cross with the needle while squirting fluid on Patrick’s forehead. Then Genene repeated the gesture on herself. Sobbing, she picked up the dead baby’s body and clutched it to her chest.
The death of Patrick Zavala stunned other nurses who had cared for him. When she arrived for work at 11 P.M., Eva Diaz, a surgical ICU nurse who worked overtime in the pediatric unit, grilled Genene about what had happened. Jones later complained that Diaz had accused her of murdering the baby. Although Diaz denied doing so, Pat Belko barred her from working any more shifts in the pediatric ICU.
The doctors and nurses who had treated the baby were so puzzled by his death that several sat in on his autopsy the next morning. But the postmortem offered not a clue; the baby’s heart was in even better shape than the surgeons had expected. On Patrick’s death certificate, doctors attributed his fatal cardiac arrest to “presumed sepsis”—a medical term for infection.
J. Kent Trinkle was not satisfied with that explanation. A beefy forty-seven-year-old midwesterner with a choirboy face, Trinkle was the hospital’s star chest surgeon—San Antonio’s counterpart to Houston’s legendary Michael DeBakey. Chief of the cardiothoracic surgery division, he was known throughout the hospital as a man of swagger as well as skill. Trinkle listened to country music in the operating room while he sliced through lungs and stitched veins. His worshipful surgery residents lived in fear of his temper. And despite having extracted a lung from dozens of cancer patients, Trinkle smoked a pack of cigarettes a day, as though he were immune from a disease afflicting mere mortals. At Medical Center Hospital, Kent Trinkle was a powerful figure. He performed glamorous, daring operations that brought the institution money and public attention. Everyone figured Trinkle was the man who would carry out San Antonio’s first heart transplant. He was the sort of doctor whom hospital administrators worked to keep happy.
Trinkle had observed the operation on Patrick Zavala’s heart, and he was furious about the child’s death. There had been too many such surprises in the pediatric ICU. The surgeons had done the hard part. Why should they let another medical service botch up their cases during recovery? On January 20, Trinkle went to Howard Radwin, another surgeon, who held the post of chairman of the hospital’s medical-dental staff. Something had to be done, Trinkle declared. He threatened to start sending his postoperative pediatric patients to the neonatal ICU.
Bob Franks later that day discovered that alarm about the pediatric ICU was spreading. In a memo for his files, the acting pediatrics chairman wrote of learning that Trinkle “had asked Radwin ‘what the f--- is going on in the Ped ICU?’” Franks tried to calm the angry surgeon. “I discussed with him the origin of his concern re: Ped ICU,” noted Franks. “He said that for 6–9 months things had ‘not seemed right’—lots of friction, hostility, etc., between his people and nursing. He remarked on the difference in morale, esprit de corps, i.e. general atmosphere in that Unit vs Neonatal ICU. He commented on ‘being pushed aside’ by ‘Jeanine Jones’ following the death of a baby as she picked up and cuddled the corpse, as he was attempting to talk with the parents.” By the time the conversation ended, Trinkle had agreed—for the time being—to keep using the pediatric ICU.
But the surgeons were persuaded that the pediatricians were incapable of handling the problem. Radwin was astounded to learn from Franks that pediatrics had for months been harboring suspicions that a nurse was harming children. The morning after hearing from Trinkle, Radwin dispatched a memo instru
cting Robotham and nursing administrator Judy Harris to investigate the surgeon’s “concern over the quality of care” in the pediatric ICU and report back to a special committee on February 1. To avoid any possibility that the problem would get ignored, Radwin spread news of the ICU’s crisis by circulating blind copies of his memo around the medical school. Radwin notified B. H. Corum and Marvin Dunn that he was organizing his own investigation.
Both men, of course, already knew about the ICU’s problems; Corum had been informed back in early November. But Kent Trinkle’s complaint spurred them to take their first independent action. Three months after the first accusation that a nurse was killing children, the top officials of the hospital and the medical school arranged to discuss the problem together for the first time.
Gathered at 10 A.M. on January 25 in the executive director’s office at Medical Center Hospital was a solemn group of six: B. H. Corum, his deputy, John Guest, nursing administrator Virginia Mousseau, medical school dean Marvin Dunn, Bob Franks, and Jim Robotham. Each was destined to play a critical role in the unfolding tragedy.
Speaking from two pages of scribbled notes, Robotham briefed the group about the history of suspicion: the sudden increase in cases of bleeding and irregular heartbeat, his desperate search for an explanation, and the inevitable focus on a single nurse. Robotham detailed Genene Jones’s pattern of emotional instability and burnout—her mothering of dead children, her frequent hospitalizations and family troubles, and her threat to sue them all with details from her “little black book.” While nurses had pointed the finger first, senior doctors and residents had independently complained about her. The group heard about the case of Rolando Santos: about the repeated bleeding incidents that almost claimed his life, about the laboratory evidence that the baby had twice received too much heparin.
Trained as a pathologist, Dunn mused about the history of medical serial murder. Most perpetrators used a single modus operandi, he noted; children in the ICU had suffered an assortment of different problems. If this nurse was indeed using an array of drugs to cause each of the unexpected problems in the ICU—bleeding, irregular heartbeat, seizures, and limpness—she would go down in the books as one of the most sophisticated medical killers in history.
The discussion finally turned to the looming question of what to do. There was brief talk of trying to arrange surveillance: perhaps a private detective under cover as a hospital employee. Maybe even hidden television cameras. Such conversation made those sitting around Corum’s office nervous. This was treacherous ground indeed—the sort of mess that led to lawsuits. It was obvious they needed help. After an hour and forty minutes, the group decided to summon the hospital’s malpractice lawyer, a well-connected San Antonio attorney named Paul Green. They invited Howard Radwin to join them too.
After a break, the group reassembled at 1:30 P.M., with eight now in attendance. Robotham repeated his summary for the newcomers. Franks revealed a worrisome new nugget of information. He had recently learned that a pediatric ICU nurse had told her psychiatrist that an LVN was killing babies by putting heparin in their intravenous bottles. The unnamed nurse—in fact, it was Pat Alberti—had been voicing the suspicion since November; more recently, she had complained that no one was lifting a finger to stop the slaughter. To Franks, who had been describing the situation for months in euphemisms—“nursing misadventure” and “unexpected events”—such blunt talk was jarring. The group put the problem 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 alert the medical examiner? Tip off the district attorney?
After listening intently, Green asked: Was there proof—not just that something bad was going on, but that this nurse was responsible? The doctors and administrators told him there was none. Green offered his advice. Without hard evidence, he informed them, firing Genene Jones or calling the district attorney could put them on shaky ground. The nurse could sue them, and she might well win. Green hinted that he might try to slip word to a friend in the DA’s office informally—but any official action, he advised, would be most unwise.
Paul Green, in effect, was telling the hospital officials they couldn’t do the right thing because some other lawyer might sue them. But that was merely a recommendation. The ultimate responsibility belonged to B. H. Corum; as the administrator liked to remind subordinates, he wrote the nurse’s paycheck. On this occasion, however, the man who fancied himself the master of the bureaucracy lacked the will to rid his hospital of a lowly LVN. Corum made the fatal decision that the hospital could not fire her. Instead, he and the others decided to keep the whole matter quiet while launching yet another investigation.
When Dr. Alan Conn arrived in San Antonio in late January 1982, Marvin Dunn summoned him to his plush second-floor office at the medical school. Jim Robotham was already there. Conn was a fifty-seven-year-old anesthesiologist on the staff of Toronto’s Hospital for Sick Children, perhaps the world’s foremost pediatric institution. He was one of the pioneers of pediatric intensive care; Robotham was among the many intensivists he had trained. Now Conn had a six-month sabbatical, and he had arranged to spend it as a visiting professor in San Antonio, doing research on drowning victims in a medical school lab. At the January 25 meeting, Robotham had suggested that his old mentor would be the perfect man to investigate the pediatric ICU.
Medical school administrators often recruited outside experts to deal with their thorniest personnel problems. Often such consultants weren’t expected to uncover anything new; they merely insulated timid administrators from a tough decision. The report of a consultant could give a predetermined firing an aura of objectivity, shielding the boss (it was reasoned) from bitter feelings and a lawsuit. When those attending the January 25 summit meeting agreed to seek Dr. Conn’s help, Jim Robotham was pleased. He figured it would give his superiors the courage to do what he had been prodding them toward for weeks: fire Genene Jones. Robotham did not dream that he had set in motion his own undoing.
Now, in the dean’s office, Dunn and Robotham detailed for the Canadian doctor all their suspicions about what was happening in the pediatric ICU. Conn agreed to investigate. The next morning, he told Dunn and Corum that he needed a team of outside doctors and nurses to conduct a proper inquiry. Corum fretted about the cost of bringing in such a committee; there was no money for it in his budget. When Dunn arranged for the medical school to foot part of the bill, Corum agreed to the plan.
The decision to retain an outside expert helped satisfy others in a position to intercede. On January 26, B. H. Corum had briefed the hospital district’s board chairman, an ambitious and politically active San Antonio dentist named William Thornton. In a quick session before a board meeting, Thornton learned that there had been a documented heparin overdose but it was possible that drug bottles had been confused. As Thornton later recalled it, Corum attributed the problem to poor leadership in pediatrics and a “catfight” among nurses. Thornton asked about the ICU’s mortality rate. He was told that was not a problem. The hospital board chairman saw no reason to get involved.
On February 1, Robotham and Judy Harris addressed the ad hoc committee that Howard Radwin had appointed following Kent Trinkle’s tirade. Voicing faith in his old mentor, Robotham explained that Dr. Conn was assembling a team of experts to review the intensive care unit. The chairman of the surgery department asked whether a consistent pattern was evident in all the ICU deaths. No, said Robotham—taking the question literally—not in all cases. According to Radwin’s minutes of the meeting, “the group concurred that there is no threatening situation in the PICU which would require immediate intervention.”
Inside the ICU, tensions peaked, even as Dr. Conn was rounding up his team of experts. Everyone was paranoid. Rather than sleep when they had a chance, pediatric residents stood guard on their patients throughout the night. Rolando Santos’s brush with death had prompted Robotham to order heparin removed from each patient’s bedside and kept in t
he unit’s drug cabinet. But many nurses had become reluctant to prepare any kind of drug without a witness. One RN made a practice of throwing out all medications and syringes that he hadn’t drawn up himself. “It got stressful enough,” the nurse remarked, “that I didn’t trust anybody.”
On January 23, a two-month-old baby had gone into respiratory arrest and experienced slow heartbeat shortly after Genene left his room to eat. Another nurse discovered that the alarm on the child’s heart monitor had not sounded because it had been turned off. Pat Belko had defended Jones, suggesting to Dr. German that the alarm might have been switched off for days. Monitor alarms in the ICU were taped in the On position; nurses were ordered to chart at the beginning and end of every shift that all alarms were on and functioning.
Everyone knew that Genene was the prime target of suspicion. “They’re out to hang me,” she told a friendly RN one day. “They might as well let me go.” Friends outside the hospital found her looking haggard and harassed. Genene told them that teenagers in her neighborhood kept trying to break into her apartment; she said she was going to get a shotgun to stop them.
On February 2, the hospital district announced in a press release that Dr. Alan Conn would lead an “evaluation” of the pediatric ICU. Issued to maintain the pretense that nothing was amiss, the statement characterized the inquiry as “part of the on-going review of patient care programs” illustrating “our commitment to New Horizons for the Bexar County Hospital District.” But no one in the pediatric ICU believed it. They knew this Canadian doctor was conducting an investigation—and so did Genene Jones. In a two-page note dated February 2, the LVN informed Belko that she had had enough.
