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.
An overdose of the drug causes the heart to beat faster and faster until it cannot sustain the rate, thus collapsing it into v-fib, where it quivers without beating.
Epinephrine is extremely hard to detect in the human body. Not because the body produces it naturally, but that it is the first drug given when a person goes into cardiac arrest.
If one were in the business of killing people, it could be said that EPI is the perfect poison.
A thought occurred to Rix as she looked at the broken vials in disbelief. In over twelve years on the job, she had never known anyone to use the drug in that form.
Quickly, Rix opened up the medicine cabinet to see if there were any other drugs stocked that, in appearance, even remotely resembled the three broken vials of epinephrine she had just seen. Maybe there was another answer?
There were none.
After the initial shock set in, Rix grabbed a piece of paper and jotted down how many unused ampoules of EPI were in the medicine cabinet.
Eighteen, she wrote as her hand trembled.
From that point on, Rix decided she was going to keep track of the EPI inventory herself. With a drug like EPI, which was rarely e
ver used, it wouldn’t be hard to figure out if Gilbert was, as Rix and Wall now highly suspected, using it to poison patients.
“I can’t believe it,” Rix said to Wall in a whisper after she realized what could be happening. “I just can’t believe it . . .”
CHAPTER 20
John Wall and Kathy Rix didn’t need much more convincing. Patients at the VAMC were dying at alarming rates, and medical emergencies were being called just about every other day on what seemed to be only during the second shift—and Kristen Gilbert’s signature was all over them. The questions plaguing Rix and Wall, however, were a bit more difficult: What should they do about the spent epinephrine ampoules they had found in Callahan’s room? Whom should they go to? Was it even proof of anything?
Rix was scheduled to leave for vacation on January 26. So whatever she and John Wall were going to do would have to wait until she got back a week or so later. Wall, of course, wasn’t going to act on anything alone. If this thing went as far as he and Rix thought it would, once it became known, Wall himself would have some explaining to do. He was addicted to heroin, he had been using the drug for years, and he had been lying about it to everyone around him. The last thing he wanted was to draw attention to himself.
The day before Rix left, she removed all the disposal needle buckets and replaced them with new ones.
“If I find any spent ampoules of EPI when I return,” she told herself, “I’ll know they aren’t from the Callahan incident.”
It seemed like a good plan.
Then she took out her pad and counted the ampoules in the medicine cabinet.
Bonnie Bledsoe, on January 28, 1996, was working in Ward D, which, being in another building altogether, was a considerable distance to walk from Ward C. Gilbert was alone in the ICU with one patient, Michael Cascone, a seventy-five-year-old World War II vet who, like Callahan, had been admitted to the VAMC with a severe case of pneumonia. Cascone, a big man, had spent twenty-eight years in the Army, reaching the rank of master sergeant, and was well respected by anyone who wore camouflage green.
Because she was the only respiratory therapist on duty that night, Bledsoe would be responsible to show up for any codes called on Ward C.
At 7:00, Gilbert called a code on Cascone, and Bledsoe rushed over from Building Two. No sooner had she made it back to her post in Building Two after she helped Gilbert get Cascone out of trouble, than Gilbert called a second code.
When Bledsoe made it back to her post in Building Two after the second resuscitation effort on Cascone had been successful, her pager went off again—sure enough, for a third time, Michael Cascone was fighting for his life.
After things calmed down and Cascone was out of trouble for the third time, Bledsoe walked toward the door in the ICU to leave, but stopped for a moment.
She had something to say.
“If I have to run over here one more time, Krissy, I’m going to start wheezing.”
Bledsoe was an asthmatic. She and Gilbert had been out with their significant others on a number of occasions, and because she knew Gilbert was so knowledgeable in medicines, Bledsoe brought up her asthma all the time.
Standing about ten feet away from Gilbert in the ICU, Bledsoe explained how all the running back and forth was making her asthma act up. When she finished talking, Gilbert reached into the front pocket of her smock and pulled out a small vial of some type of medication.
Gilbert flashed the vial. “Do you need some EPI, Bonnie?” she asked. Then, quickly, put it back into her pocket.
“No, thank you,” Bledsoe snapped and walked away.
As for Michael Cascone, his heart wasn’t as strong as Francis Marier’s. After a fourth code was called later that same night, he died.
CHAPTER 21
A proud father, former Navy crewman Walter Cutting watched his son, Kenny, play football for the Lunenburg High School Blue Knights during the early seventies, perhaps dreaming of him one day becoming the next all-star running back for the New England Patriots.
A clean-cut kid with bushy, Groucho Marx-type eyebrows set above his sad brown eyes, Kenny was motivated to succeed at anything he did. Marrying his high school sweetheart on January 26, 1976, Kenny joined the U.S. Army a year later. In a matter of weeks, he was off to Fort Leonard Wood, Missouri, for recruit training. It was a far cry from the Yankee confines of Lunenburg, Massachusetts, but it was what Kenny wanted. On April 11, only months after he left, Jeffrey Cutting, Kenny’s son, was born.
After boot camp graduation, Kenny was transferred to the 39th Engineers Station at Fort Devens, which worked out perfectly, because Fort Devens was located in Ayers, a mere stone’s throw from the new ranch-style house he and Nancy bought in Leominster.
He was living the life he had only dreamed about. But shortly after Cutting arrived at Fort Devens, tragedy struck.
For the past few years, he had been experiencing stiffness in his legs and his eyesight had been poor. But it never amounted to anything. While in training, only about fifteen months into his military career, Kenny called his father at home with some rather grim news.
“My doctor just informed me that I’ll be dead in a few years . . .” Kenny said, not a speck of worry, discontent or concern in his voice.
“What?”
Kenny wasn’t overly emotional or tattered in the slightest by what appeared to be the worst news a married man of twenty could ever imagine hearing from his doctor.
“They say I have multiple sclerosis,” Kenny continued.
At the time Kenny was diagnosed, little was known about the affliction his father would later tag a “horrendous disease.” Many doctors, in the late seventies, had equated MS with a death sentence.
Nonetheless, each day after the initial diagnosis offered a new set of problems for Kenny. His body deteriorated quickly as the disease grew at an extraordinary rate—and within only a couple years after being discharged, Kenny was having trouble walking and seeing.
Like almost everyone who had ever entered Kenny’s life, his in-laws adored him. Kenny always had something nice to say and never once complained about having been dealt a deck of cards that might end his life years before he’d planned. He vowed to fight the disease with everything he had.
By 1980, it was obvious to Nancy that caring for Kenny at home was going to be almost impossible. One day, shortly after he first started using a wheelchair, Nancy wheeled him out on the front porch so he could enjoy a promising summer afternoon. Kenny loved just sitting, soaking up the sunshine. After a while, Nancy went out to check on him and found the skin on his feet stuck to the cement, as if they had melted to it like a piece of gum. The roughest part for Nancy was that Kenny was oblivious to what had happened; he couldn’t feel his feet.
After that, the Cuttings placed Kenny in a long-term care program at a Jamaica Plain VA hospital. Within days, he began saying how uncomfortable it was. The Cutting family thought that for a man like Kenny Cutting, who was as gentle as a falling leaf, a man who never once complained about anything, to begin fretting, the conditions in Jamaica Plain must have been deplorable.
The VAMC in Leeds was a long drive from Leominster, but it had a reputation for being one of the best VA hospitals in the state. Perfect for Kenny’s situation, the VAMC had both short-and long-term care units, an acute medical ward, and a staff of doctors that could help make Kenny’s life as comfortable as possible.
Before moving him into the VAMC, Nancy had once again tried taking care of him at home, but by this time he was bedridden, his eyesight nearly gone. And one of his main problems brought on by the MS was bowel obstruction, which was usually accompanied by fever and infections.
His muscles just didn’t want to work anymore.
Throughout all of it, though, Kenny’s spirit never wavered. He stayed focused on the good in his life.
“He never fussed,” Walter later said. “He was always cheerful. He was [a] very happy . . . happy man.”
As he began to get comfortable at the Leeds VAM
C, Nancy and Walter soon realized that they had finally found a place where they could feel comfortable about leaving Kenny.
“He could not have had any better care,” Walter later said.
Nurses at the VAMC fell in love with Kenny and his angelic attitude, and he soon became a favorite patient of many nurses.
“Everyone loved Kenny,” Rachel Webber recalled. “He had these big, brown eyes, and he would look at you and [say], ‘You look beautiful tonight . . . you look so beautiful.’ ”
A favorite saying of Kenny’s to all the female nurses was, “Can I tell you something? You’re looking very beautiful today.”
By the fall of 1995, he was being spoon-fed and had lost total use of his hands and legs. But, as if he had accepted his fate and made peace with the outcome, he never looked back.
In late October, Cutting had been sent back to the Jamaica Plain VA hospital for small bowel obstruction surgery, where he underwent an “exploratory laparotomy.” But after opening him up, doctors found “no mechanical obstruction . . .”
Being cleared for surgery and subsequently undergoing it without any cardiovascular problems was significant for someone in Kenny Cutting’s condition because coronary artery disease and myocardial infarction—heart disease—are equally the number-one cause of death during general surgery. This was why doctors did extensive research beforehand, profiling patient risks for cardiovascular disease. A quick check of Kenny’s medical history showed that he didn’t have the disease, and there was no history of it in his family. Many people confuse MS with some of the more common diseases. MS patients, at the end stages of the disease, deteriorate in increments, each organ—liver, pancreas, kidneys, etc.—failing, in succession, like dominoes. After that, respiratory failure slowly develops, and, finally, death.
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