Perfect Poison (2 page)

There are sections of landscape bordering the quaint New England town of Northampton, Massachusetts, as flat as a tabletop—acres of farmland that, from a bird's-eye view, might make one think this small section of the Northeast is no different from Indiana or Kansas.

And in many ways, there is no difference.

In May 1995, for example, the unimaginable happened. A tornado whipped through Great Barrington, Massachusetts, killing three people and injuring twenty-four. With a top wind speed of two hundred and four miles per hour, farming tractors were tossed into the air and willow trees pulled from the ground and snapped in half as if they were plastic toys in a child's train-set collection.

Farmers and townspeople, in a matter of moments, were left devastated. Twisters, locals protested, were supposed to be confined to the Midwest and Deep South. Northampton, like Great Barrington, is located on the edge of the Berkshires, in mountainous terrain, fenced in by steep, rocky cliffs. It is a quiet place, full of agricultural history and laid-back living. Nothing ever happens there of any national interest—and residents like it that way.

From Interstate-91, the only hint that Northampton exists somewhere within the throng of massive pines, clapboarded homes and small businesses is the steeple of the old clock tower, which pokes through the tops of the trees like the point of a witch's hat.

On any given night, one can walk through downtown and see a wide variety of cultures mixing company. Passed on from generation to generation, Northampton, where Calvin Coolidge once sat in the mayor's chair, is rumored to be the lesbian capital of the nation. That distinction, however, is perhaps derived from the presence of Smith College, a prestigious liberal arts school for women.

Surrounding downtown, and split into three neighborhoods, or “villages,” as the locals like to say—Leeds, Florence and Bay State—Northampton fits every bit of the Smalltown, U.S.A., image portrayed in many of nearby Stockbridge resident Norman Rockwell's paintings. There are old-fashioned ice cream parlors for the kids, cafes for the intellectuals and diners for the blue-collar workers. Coffee houses, art museums, book stores and pubs line Main Street. Street musicians are everywhere, shaking tambourines, strumming guitars, banging on bongos and tooting horns for tip money.

Made up of roughly thirty-thousand residents, Northampton encompasses some thirty-six square miles, with approximately one hundred and seventy miles of roadway intertwined through its thousands of raised ranches, colonials and rustic farms. One could easily agree it is every bit of what writer Tracy Kidder calls, in his book
Home Town,
a “quintessential landscape.” Classic New England all the way: from its rolling hills to its maple syrup to its antique shops . . .

“Shake it,” Kidder wrote, “and it snows.”

 

 

Visible from just about anywhere in town, the Veterans Affairs Medical Center (VAMC) in Leeds has served the health needs of Massachusetts veterans since 1924. The main building of the hospital sits high atop Old Bear Hill, a rather steep stretch of land with a man-made duck pond at its base, perfect for sledding during winter months. Just off Route 9, the VAMC grounds rise out of the center of town like a monument and, to some extent, the main building looks a bit like a Victorian mansion. There are twenty-six smaller red-brick buildings, or “cottages,” that doctors rent, spread over one hundred and five acres of some of the most sprawling landscape the Northeast has to offer. Perhaps deliberately, the entire compound resembles a military base rather than a full-facility hospital, where six miles of roadway snake around a piece of property that visitors who often come here say is but a small slice of “God's country.”

On any given day, scores of vets stand and sit outside the main entrance, smoking cigarettes, drinking from brown paper bags, waiting for the VA bus to take them home. They wear tattered and torn camouflage Army jackets, berets and medals, and speak of their days in the war to anyone who will listen.

The VAMC provides “tertiary psychiatric and substance abuse services, as well as primary and secondary levels of medical care” to a veteran population of men and women in western Massachusetts of more than eighty-five thousand. With nearly six hundred thousand veterans statewide—twelve percent of Massachusetts's population—the one-hundred-and-ninety-seven-bed medical center at Leeds specializes in post-traumatic stress disorder and chronic mental illness, two ailments that often plague these men and women who sometimes return from overseas combat duty damaged for life by what they have seen.

“Our staff,” an open letter to veterans reads, “is dedicated towards one purpose—fulfilling [a veteran's] needs as a patient. Veterans are the most important people in our Medical Center.”

By the time U.S. Army veteran Stanley Jagodowski turned sixty-six, on August 12, 1995, his reputation for being an uncompromising pain in the ass had already preceded his frequent stays at the VAMC.

During the past eight months, the Korean War vet had become a permanent fixture at the hospital, admitted three times since January because the sores on his feet and legs had become unbearable.

At five-foot-seven, two hundred and twenty-eight pounds, the gray-haired, brown-eyed former truck driver with the Jimmy Durante nose was severely overweight for a man his size and age. Because he smoked, drank, and maintained eating habits that were a nutritionist's worst nightmare, Jagodowski's doctors begged him to exercise, but he rarely did.

When he was transferred from the Providence, Rhode Island, VAMC and admitted to the Leeds facility on July 21, Jagodowski's doctors speculated that he wouldn't be returning home again. Not only had he suffered from non-insulin-dependent diabetes and high blood pressure, but he had enlarged heart ventricles and an irregular heart rhythm. Claire, his wife of nearly forty years, had recently told doctors she couldn't care for him anymore. They lived in a small, four-room ranch-style house in Holyoke, and Claire, who herself had just had a heart attack, took care of their two small grandchildren during the day. She just wasn't up to feeding, bathing, and helping a grown man go to the bathroom anymore. About a month before his VAMC admission, Jagodowski had fallen, and Claire had to call the police to help her pick him up off the floor.

A stubborn man, Jagodowski didn't believe his eating habits would ever catch up with him. Under a doctor's strict orders to sustain a healthier diet, he would hide snacks—candy bars, crackers, chips—under his bed so he could eat what he wanted, when he wanted. Nurses would ask him what he wanted for dinner off his restricted menu and, with his trademark sarcastic scowl, he'd snap, “Give me two eggs, bacon, sausage, hash browns and coffee.”

Stanley Jagodowski just didn't get it.

Months before his latest admission, on April 27, 1995, the bad habits Jagodowski had developed throughout the years had finally gotten the best of him.

After an ongoing infection in his right foot failed to heal, doctors in Providence were forced to remove it. Three months later, on July 17, the infection spread throughout his entire right leg, and doctors had to amputate it just above the knee.

Jagodowski had been transferred to Leeds to recover from the amputation. Paranoid, confused and bitter, he often moaned because the sound of it, he claimed, made him feel better. To stir up trouble, he'd lay on the nurse's call bell until a nurse came into the room. As soon as she left, he'd do it again.

But Jagodowski's cynicism for life wasn't without merit or irony. He'd survived the Korean War, was discharged from the Army in 1954, and lived a quiet life as a truck driver for decades. Yet here he was now, confined to a hospital bed and wheelchair, dependent upon other people to help him move his bowels, watching diabetes eat away at his body as though it were rust on a car.

Despite his prior health problems, however, by August 21, 1995, things began to look up for the aging veteran. Only a month after his transfer from Providence, Jagodowski not only was feeling better, but he was looking healthier than he had in years.

The amputation had apparently done the trick. So much so, that for the past week, he had been free from any injectable medicines—which was a significant sign of improvement in itself. When pain did come on and his stump began to throb—as Jagodowski would put it, “like five toothaches”—doctors prescribed oral treatments of Demerol, a painkiller.

A week earlier, on August 14, doctors had agreed Jagodowski was doing so well that he could leave Ward C—the VAMC's chronic ward—and transfer to the long-term nursing care unit of the hospital.

The only thing standing in his way was the availability of a bed.

 

 

The Leeds VAMC has many different wards scattered throughout its complex of buildings, with Ward C located in the main building, Building One. The entire ward was shaped like the letter T. Down at the end of the hall—the top of the T—was a four-bed intensive care unit (ICU). There was a short hallway between the ICU and the L-shaped nurse's station, where the charge nurse sat. With about thirty beds, the ward was split into teams and the workload divided up among the nurses on duty.

 

 

At about 7:00 P.M., on August 21, 1995, respiratory therapist Michael Krason gave Stanley Jagodowski a treatment of “three puffs of Albuterol,” a drug that helped patients breathe easier. Prior to August 21, Jagodowski had been receiving four puffs of Albuterol, however. With over twenty-three years' experience, Krason agreed with everyone else that Jagodowski's condition was improving. He wrote in his medical chart that he was “alert, his breath sounds were clear, he [was] in no distress, and his color [was] good.” To top it off, Krason also noted that Jagodowski showed no adverse reactions to the respiratory treatment.

Near 8:00
P.M.
, Jagodowski's primary care nurse, Jeff Begley, asked fellow nurse Beverly Scott to assist him in getting Jagodowski ready for bed. Begley said he didn't want to deal with the difficulties the heavyset Army vet was likely to create.

Scott agreed to help.

“Hi, Mr. Jagodowski,” Scott said, entering his room. “How are you tonight?”

“I'm fine, Beverly.”

After straightening his bed linen and changing his gown, Scott and Begley switched Jagodowski's position in bed.

“I don't want to turn over. You're hurting me,” Jagodowski kept repeating. “Stop it . . .”

“Oh, come now. Just help us out here, Mr. Jagodowski,” Scott said. “We go through this
every
night.”

Shortly after they were finished, Begley and Scott watched RN Carole Osman as she checked Jagodowski's IV to make sure it was in good working order. Osman said it looked fine. Like Scott and Begley, she also agreed that Jagodowski had no edema (body swelling) or mottling (graying of the skin because of lack of oxygen)—frequent ailments that plague diabetics.

After Osman finished, Scott and Begley, who had assessed Jagodowski as “stable,” walked out of his room, stood outside the doorway and chit-chatted.

It was 8:20.

A short time later, as they continued to talk, twenty-seven-year-old Kristen Gilbert, a well-respected RN who had been working at the VAMC since 1989, came walking down the corridor toward them.

She was holding a syringe in one hand and an alcohol swab in the other.

 

 

Many of the nurses and doctors who had worked with RN Gilbert over the years agreed the good-looking bleached blonde was one of the most intelligent nurses on the ward. As far as codes or cardiac emergencies were concerned, Gilbert was probably the best the VAMC had to offer. Since she'd started working at the VAMC, Gilbert had built a stellar reputation for being the “go to” nurse during cardiac arrests, and many said she excelled during medical emergencies and had no trouble keeping her mind focused during all the chaos.

This was exceptional. In reality, codes weren't the picture-perfect, sterile scenes depicted on television shows like
ER
and
Chicago Hope,
where nurses and doctors acted in unison, always complementing each other's work. To the contrary, codes were disorganized and feverish. Nurses tripped over one another. Orders were barked out in desperation. Nurses and doctors made mistakes.

But Gilbert had become known as the “take charge” nurse. She'd give accurate orders at the appropriate times, and usually lead the emergency team the entire way.

Her expertise, however, went much farther. Her knowledge of medications was by far her strongest asset—which was one of the main reasons why she was assigned to the med cart and administered medications on most nights.

Nurses would often go to Gilbert with medical questions and she would always come through, giving a detailed description of each drug and its side effects as if she were, as one doctor later put it, a “virtual medical textbook.”

 

 

Insofar as Begley and Scott were concerned, Stanley Jagodowski wasn't scheduled to receive any meds. But doctors would order medication all the time without letting the entire nursing staff know about it. So they assumed Gilbert was on her way to give him a shot that had been ordered by one of his doctors.

But less than a minute later, at 8:40, Begley and Scott's discussion was interrupted by a piercing scream.

“Ouch! Stop! Stop! You're killing me,” Jagodowski yelled.

Just then, as if in slow motion, Gilbert walked out of the room and made her way up the hallway in an uneventful manner.

Startled by the outburst, Begley and Scott rushed into his room.

“Are you all right, Mr. Jagodowski?” Scott asked.

“Yes,” Jagodowski said, holding onto his arm.

Yet Scott could tell by his facial expressions that he was in a great deal of pain.

“Everything okay?” she asked again.

“My arm hurts,” Jagodowski complained.

There was no doubt that Stanley Jagodowski was a chronic complainer and generally had something nasty to say about everything the nurses did. But Scott had never heard his voice sound so troubled and panicky. What was more, why would Gilbert, an experienced nurse, after administering a shot, just walk out of the room while one of her patients was yelling out in pain?

It seemed odd.

Begley and Scott stayed with him for about five minutes to make sure he was okay and then continued on with their rounds. Jagodowski had no reason to be connected to a heart monitor, so the two nurses had no way to tell that his heart was, at that moment, beginning to flutter out of control.

Minutes later, at 8:43, Jagodowski went into sudden cardiac arrest.

Then his heart stopped.

With one RN in the bathroom, another in the lab, and Gilbert now in the ICU relieving RN John Wall, the emergency medical team responsible for responding to codes was, for two and half minutes, without the presence of a RN.

But even worse was that Gilbert, who had worn the “code” pager while making her rounds out on the floor, forgot to pass it off to Wall as he left the ICU.

Following a bit of confusion and delay, nurses soon piled into Jagodowski's room at a frantic pace. Security—which was required by hospital policy to send a representative to each code—arrived next. Within moments, a team of nurses, doctors and security personnel surrounded Stanley Jagodowski and began resuscitation efforts.

After several defibrillations, where the nurse in charge yelled “clear!” and then shocked Jagodowski with paddles, he was brought back to life, put on a ventilator, and transferred to the ICU—where his real troubles were about to begin.