Rev. Florian Gall coded at approximately 9:32 a.m. the morning of June 28. He went unexpectedly into cardiac arrest, and heroic measures were undertaken. They were unsuccessful. His time of death was noted in his chart: 10:10 a.m. Gall’s bloodwork showed that his digoxin levels were off the charts.
The Somerset Medical Center administration had a problem. It was not a natural death. And Gall wasn’t the first. They called him “Patient 4.”
The plan was to deal with it internally15 and as quickly as possible. Pharmacy would examine the Pyxis around the dates of the digoxin deaths. Assistant Pharmacist Nancy Doherty was assigned to contact New Jersey Poison Control Center. The question was, how much dig would have been required for the numbers they saw in Gall’s blood work. The only part they needed help with was the math.
25
July 7, 2003
The hold music is lite jazz, upbeat and hopeful. The recorded voice said, “Thank you, a poison specialist will be with you shortly, please…”
Then: “New Jersey Poison Control Center, can I help you?”1
“Uh, yeah.” The caller identified herself as Nancy Doherty, calling from the pharmacy department of Somerset Medical Center. “It’s actually not something that’s happening now—we’re trying to investigate, um, a ‘didge’ toxicity that occurred in a patient and I don’t know if you have somebody that I could discuss it with…”
“Okay,” the operator said, figuring the date. “So this is a case that happened…”
“It happened… um… a couple… well, the person is actually…”
Dead. But Nancy stopped herself.
“Six twenty-eight, it happened,” she said.
New Jersey Poison Control pharmacist Dr. Bruce Ruck2 called back to Somerset Medical Center ten minutes later. He was put on hold and listened to Vivaldi behind a professional female voice: “At Somerset Medical Center, patient safety comes first…”
“Nancy Doherty.” Nancy’s rounded Jersey vowels were a shock after the clipped broadcaster English: Nyancy Dowyty.
“Nancy, hi, it’s Bruce Ruck.” Broose shared Doherty’s accent and much of her training. He knew that Nancy was only a messenger, tasked with handling a serious internal matter at Somerset.
“Yeah,” Nancy said. She exhaled into the phone. “It’s… getting real… complicated.”
Doherty was calling on the instruction of her bosses, to get help figuring the probable drug dosages in two patients. She told Bruce that the first patient coded in their Cardiac Care Center three weeks ago, on June 16. A blood test revealed the patient had excessive levels of the heart drug digoxin. In small doses, “didge” helps stabilize heart rhythm. But Nancy was not calling about small doses.
“Then on the twenty-eighth, on the same unit, we had another dig toxicity….”
“Wait,” Ruck said. That couldn’t be right. Two patients, same drug, different nights? “And this was in the same unit?”
“Yeah.”
Ruck asked about the first patient, Mrs. Han—had she come into the hospital with dig toxicity?
No, Nancy said. “We called the lab. She had normal dig levels when she came in.”3
“Oh my,” Bruce said. “Nancy, what hospital are you in again?”
“Somerset Medical Center,” Nancy said. “I feel like I’m a detective.”
“Well, it sounds scary to me!” Bruce said.
“Yeah,” Nancy said. She sounded relieved, hearing another pharmacist acknowledge that.
Nancy put Ruck on hold, so she could explain the rest from the privacy of her office. “Patient 4, the Reverend Gall—” Nancy read his dig numbers from the lab reports: 1.2. on the twentieth, 1.08 on the twenty-second, 1.59, 1.33,… and then, just after dawn on the twenty-eighth, it suddenly jumped to 9.61.
“So after the twenty-seventh, before he spiked—when did he get his next dig?”
“He never got another dig,” Nancy said. His digoxin levels spiked a full day after doctors took him off the drug.
“First thing I think of is lab error…”
“Well, they’re telling me they retested it.”
“Mmm,” Ruck said. “Then it couldn’t have gone up to nine-point something…”
Bruce wasn’t getting it. “He coded,” Nancy said. “He died, okay? All right?”
Ruck was struck silent. “Okay,” he said finally. “Let me slow myself down. I’m going to take a deep breath.”
“I know…,” Nancy said.
“I apologize. Okay.”
“All right.”
“First of all,” Bruce began, “as far as I’m concerned, on the twenty-seventh to the twenty-eighth? It’s impossible for the level to go up like it did… unless he got more digoxin. Right?”
“Okay…”
“Let’s take that, okay?”
“Okay,” Nancy said. It was that simple. And it was bad.
“I want to run this by somebody else,” Ruck said. “This—this is a huge issue.”
“Yeah,” Nancy said. “And Bruce?” she whispered.
“Yeah?”
“Off the record?”
“Yeah?”
“There were two more people. Before this.”
Nancy Doherty paced the pharmacy until the phone rang again. As promised, it was Bruce. “Um, can you hold? I want to take this in my office,” she whispered. The line clicked over to a recording: “Our new million-dollar computer system is guaranteed to further reduce the possibility of medication errors…”
Nancy closed the office door and pressed the blinking Hold button. “Thank you,” she breathed. “Okay. Hi.”
“Nancy,” Bruce said. “You know, you’ve got a real—”
“Yeah,” Nancy said.
“I’m picking my words carefully here.”
“Yeah.”
“—dilemma.”
“Yeah,” Nancy said. “Dilemma. Right.”
“And several things, I used several different calculations, okay?”
“Yeah?”
“And to get that kind of level increase, at minimum you’re going to need two to four milligrams of digoxin.”
“Two to four milligrams,” Nancy said, jotting it down. “Okay, of dig?”
“Yeah,” Bruce said. But it wasn’t the math that was scaring him. “You see, the main issue, as far as I’m concerned, is the body does not make digoxin.”
“Right,” Nancy said.
“So, I don’t know any way possible of that level going from 1.33 to 9.61 without the patient getting the drug.”
“Uh-huh,” Nancy said. Nancy knew this, and she wasn’t alone. She had been talked to by Mary Lund and Dr. William K. Cors, the medical director. They needed some calculations done, to connect the dig spike to the nursing schedule. If Gall’s heart stopped at 6 a.m., what time did he get that drug, and how much?
“What they, they were—and I don’t know if it’s possible, but they want to visualize, like a curve almost,” Nancy said. “A curve, you know what I mean?”
“But Nancy,” Bruce said. “You know, what also got me a little nervous is your two hypoglycemics you told me about.”
“Yeah,” Nancy sighed. “Which you’re probably not supposed to know, because they’re like, they’re like, you know…” She and Marty Kelly, the nurse practitioner who first alerted Risk Manager Lund to the issue, had panicked4 when they saw those numbers. They had insulin ODs and dig ODs. Calling the hotline for help with the dig math was supposed to be a neutral resource, like a police tip hotline or a crisis center. She’d tried to put the hypoglycemics behind her. Now Bruce is making it complicated.
“I don’t want this…,” Nancy sputtered. “You know, they’re not—”
“Nancy, Nancy, you know something?”
“We’re not looking at them now,” Nancy finally blurted.
“But we are, Nancy,” Bruce said. “We have to. We have to look at them.”
“Yeah,” Nancy said.
Bruce spoke slowly, to make certain Nancy couldn’t miss it. “Not o
nly do you have to look at them,” he said, “but you have a police matter.”
Ruck waited.
“And I’m going to put it right in your hands,” Ruck said finally. “You now have a police matter.”
“Okay, I, I…,” she said.
“In my opinion, you have a police matter.”
“Okay, you know what I see, it—”
Ruck wouldn’t stop until she heard it. “Look, Nancy,” he said. “I hate to say it—it’s a police matter.”
Nancy was silent. “Okay,” she said finally.
“Whether this is a pure accident where somebody screwed up, or—”
“Right,” Nancy said. She could do this. “Okay.”
“That’s the best-case scenario.”
“Okay.”
“But Nancy? On those two hypoglycemics? If they had high insulin levels, and they showed no C-pep, then somebody gave them insulin.”
“Okay.”
“You know what I’m saying?”
“Yeah,” Nancy said. It was chemistry, not magic. No elevated C-peptide meant that the insulin wasn’t human. It came from a laboratory. There was no other way to look at it: if it was in the patients’ bodies, and they hadn’t made it themselves, that meant somebody put it there. And that someone was killing patients.
“Yeah,” Nancy said. “I hear you.”
“You’ve got a big issue here, Nancy. And I’ll tell you something, you—and I’m, again, I’m not telling you what to do, I’m not being—”
“Oh, no,” Nancy said.
“I mean, maybe there’s a good reason for all of this.”
“Right,” Nancy said.
“But you know what?” Ruck warned. “If this turns out to be a police issue, and you guys are waiting, Nancy? They’re going to smear you like crazy.”
Nancy sighed. “They don’t know that I told you about the hypoglycemic…”
“Nancy, you’re doing the right thing.”
“Okay…,” Nancy said.
“You’re doing the right thing,” Bruce reassured her.
“Yeah,” Nancy said. She needed to get off the phone and deal with this. Ruck was talking about driving down from Newark and looking through the files. It was her phone call, her information, that had precipitated that. That wasn’t the plan. Now she’d need to tell her bosses.
Nancy asked Bruce not to come down. She’d brief Cors and Lund herself.
Bruce Ruck gave Nancy his direct line. Nancy promised they’d call back, as soon as possible.
Ruck hung up and hurried down the hall. He found his boss’s door open. Poison Control director Dr. Steven Marcus was leaning over his crowded desk. Ruck only got a few sentences into it before Marcus cut him off. Data are not ambiguous. His gut told him that somebody at Somerset Medical Center was “knocking off patients.”5 And the longer the Somerset Medical Center administration waited to acknowledge the facts, the more patients might suffer.
But a day later, Ruck and Marcus were still waiting for the callback from Somerset. Finally Bruce Ruck dialed the Somerset Medical Center Pharmacy operator again, identifying himself, and waited until the hold music clicked over to the extension. The voice that answered was male, and not friendly. Stuart Vigdor was the head of pharmacy, and Nancy’s boss. Bruce decided to drop the emergency tone for something friendly and casual.
“So,” Bruce said. “I was just trying to follow up with the outcome. What’d you guys decide to do?”
“Actually, Administration has kind of taken over the investigation,” Vigdor said stiffly.
“Uh…”
“They’ve called in our attorneys. And they’ve asked me really not to talk to any outside agencies at this point in time, until our internal investigators—”
“Okay,” Bruce said. “Just, just so they know, Stu, I’ll speak to my medical director, it should be his choice—but you guys put him in a real bad spot.”
Vigdor didn’t say anything to that. Ruck tried again. “So, you don’t know if they’ve gone to the authorities yet?”
“I don’t know that now,” Vigdor said. It seemed to Ruck that Stuart Vigdor was shutting this conversation down before it began. And Vigdor knew it would be his ass on the line, not Nancy’s.6 “I’m asked to direct all calls up to Risk Management, up to Mary Lund.”
“Okay.”
“I think you spoke to her?”
“Yeah,” Ruck said. It was a lie, small but quick enough to keep Vigdor from closing the door. “Do you know her number? Let me call her then.”
“All right,” Vigdor said. He sounded relieved.
“You know, I totally understand,” Bruce said, still friendly. “And, they’re doing the right thing, in terms of that.”
“Yeah,” Vigdor continued, “because, we don’t know for a fact if these patients have been…” He paused. “It’s an ongoing investigation at this point,” he said finally.
“Right.”
“Right,” Vigdor said. “We don’t know that we have devious activity or—”
“Oh, absolutely,” Ruck said. “But again—whose responsibility is it to investigate—”
“We are investigating,” Vigdor started, then backed off the defense. “We can—you know, they can… I’m sure I can give you assurance of that.”
“Sure, sure,” Ruck said. “Okay, so, what’s the number?”
Bruce heard a rustling of papers, then silence. A few moments later Vigdor returned. He didn’t have the phone number, but he’d been thinking, and he needed Ruck to know, this whole overdose thing, it wasn’t a pharmacy mistake. It sounded to Ruck like Vigdor didn’t want to be caught in the middle, the way maybe Nancy was now. This was a job for the administrators.
“And you want them to report it, too?”
“Well… yeah…”
“You know Stu, you don’t have to say it,” Ruck said. He’d been picturing Vigdor all wrong. Vigdor was probably just a kid. Not bad, just ambitious and scared of stepping out of rank.
“I really feel, that they feel you guys are forcing their hand, um, inappropriately. For what that’s worth,” Vigdor said. “And, you know, you guys…”
“Sure,” Ruck said, “sure…”
“You’re supposed to be there as a viable, um, you know…”
“Sure.”
“Resource…”
“Sure. Sure.”
“So that, you know, we shouldn’t be afraid to call you guys.”
“No, absolutely, I agree,” Ruck said. “But Stu, when it comes to toxicological surveillance, we do have an obligation to report to the State.”
“Right…,” Vigdor said.
“So, that’s one of the—that’s one of the sticking points, there.”
“Yeah, uh, well—,” Vigdor started.
Ruck cut him off. “What’s her number?”
Vidgor read it out, sounding relieved.
“That’s the risk—the quality assurance manager,” Vigdor said, correcting himself. “Mary Lund.”
“Sure,” Ruck said.
“You spoke with her yesterday…” Vigdor said, half asking.
“Sure.”
“And I believe that was with, with Bill Cors—”
“Sure,” Ruck said.
“And I know that, you know, um—upper management has come to me, and told me that it’s an internal investigation at this point. They brought legal counsel in on it. They are bringing in investigators.”
Ruck smiled at that one—he was a pharmacy investigator, here on the phone, ready to investigate. But apparently they didn’t want him in there. “Okay,” he said.
“Okay?”
“Yeah, “Ruck said. “No problemo.”
“You know,” Vigdor said, “I probably said more than I should have right now.”
“Stu. What you tell me is—listen to me, Stu—”
“Yeah?”
“It’s between, you know—it’s just us,” Ruck said. “It’s confidential.”
But what Bruce Ruck failed to m
ention was that all their conversations were also on tape.
26
July 8, 2003
The conference call with the Somerset Medical administrators was set for nine o’clock, pushed by increasingly heated calls from the New Jersey Poison Control director.1 This was Somerset risk manager Mary Lund’s second call with Dr. Steven Marcus; the first conversation hadn’t gone so well. This time, it was her bosses’ turn to catch a direct blast.
“You see, my problem here is that you’ve put us in a… a ticklish bind,” Marcus boomed over the conference room speaker. “And that’s why my comment to you last night was that—look. If there is somebody out there, that is purposely doing this to individuals at your hospital, we have a legal obligation to report it!”
“Um, okay…,” Cors said.
“And not just as an adverse drug reaction!” Marcus continued, working himself up. “I mean, this is a forensic thing. And I sure as heck don’t want to get involved in—get caught with my pants down, like they did on Long Island a few years ago. Or Michigan, you know, five or ten years ago, when they had somebody that was going around, doing in patients!”
Marcus’s blunt language seemed to have stunned the room. Several awkward seconds passed before Lund filled the gap.
“We’re listening to you,” she said finally. “We do understand your concerns. And as I said yesterday, we’re struggling with these same questions and what our responses need to be.”
Now Ruck jumped in. “And there’s supposedly two other patients with very strange glucoses, as well?”
“Um, yes. I think Nancy discussed these with you?”
Ruck had promised Nancy Doherty that he would protect her, and so instead of giving up his source, Ruck answered Lund’s question with a question, one he already knew the answer to. “Did you guys ever run C-peps and insulin levels and all that on these patients?”
Again, there was a protracted silence. Ruck had asked the critical question. The C-pep tests would have indicated whether the insulin in their patients had come from their own bodies, or from some other, outside source. If it was an outside source, they obviously had a real problem.
Finally, Cors and Lund both answered, barely audible:
“Yeah.”
The Good Nurse: A True Story of Medicine, Madness, and Murder Page 11
