Killer Nurse (5 page)

With all these health problems going on at the same time, Mr. Kelley developed gangrene in one leg. The doctors had no choice but to amputate it.

One longtime friend of Garlin Kelley's said, “Even after he lost his leg, there was never a time when he felt sorry for himself. There was never a time when he didn't attempt to lift people up around him. It just wasn't in Garlin's nature to focus on his problems.”

This was what set Mr. Kelley apart from many others. Not only DaVita employees, but his family, friends, and even casual acquaintances all said that if you weren't already aware of Mr. Kelley's health problems, there was no way of knowing from his actions or demeanor. LaFrancis said of her husband, “He never met a stranger. You never knew what he had gone through the way he carried himself.”

No one ever had an unkind thing to say about Mr. Kelley. The other DaVita patients also liked him. Carolyn Risinger, who'd spent hours with Mr. Kelley while they received treatments, told KTRE-TV, “I knew Mr. Kelley. He came in early with me. He was a sweet man.”

As it turned out, “He was a sweet man” was the worst thing anyone had to say about Mr. Kelley.

Early on the morning of April 16, 2008, Mr. Kelley woke early as he usually did. He took a boiled egg and a grilled cheese sandwich to eat as snacks at DaVita—he was known as much for his boiled egg as he was for his warm personality. LaFrancis dropped him off at DaVita's front door, where Mr. Kelley walked himself in using his walker. He'd spent many an hour with a therapist to get in shape and learn to use the walker because he didn't want to be a burden on anyone.

As the med nurse that day prepared the patient's medication, Mr. Kelley's PCT, Sharon Dearmon, hooked him up to the machine. Dearmon said that he was his normal joking self, and ate his boiled egg while he watched ESPN on TV. There weren't any problems with his vitals or anything else when they hooked him up at 5:36
A.M
. His flow chart showed that he was fine between 5:36 and 7:30 that morning. In fact, a notation in his flow sheet said he was resting comfortably at 7:30.

Half past seven was break time for the employees, and Dearmon said that a lot of employees were off the floor then, including shift supervisor Sharon Smith. Dearmon was monitoring her own patients as well as another PCT's while that person was on break. At 7:35, she had her back to Mr. Kelley as she was taking care of another patient when the alarm on Mr. Kelley's dialysis machine went off. She turned and found Kimberly Saenz, the med nurse, by Mr. Kelley's machine trying to reset the alarm. After running over, Dearmon also found Mr. Kelley unresponsive, and called for help. After clamping off his lines, she started CPR, and someone called for an ambulance.

One of the people who responded to that call for help was RN Sharon Smith, charge nurse for that bay, who'd just returned from break. Smith later noted that she saw something in the bloodline that she'd never seen before. It looked to be a very unusual blood clot. It was fibrous, almost like hair. She said, “I've never seen it before and I've never seen it since.”

Dearmon echoed Smith's description of the strange clot.

The DaVita employees did everything in their power to save LaFrancis's husband, but he was still unconscious when paramedics arrived to transport him to the hospital. Once at the hospital, Garlin Kelley remained in a coma for months until on August 15, almost four months to the day that he lost consciousness at DaVita, he died without ever waking.

After Mr. Kelley died, LaFrancis told a reporter, “He was the love of my life. But I know he's happy where he is. He's whole again.”

One question lingered in everyone's mind: How could he go from resting comfortably at 7:30 to massive cardiac arrest in five minutes with no symptoms?

DaVita investigators had found no problems with either the new or the reuse dialyzers. However, after the incident with Mr. Kelley (who was using a reuse dialyzer), DaVita Lufkin immediately suspended the use of reuse dialyzers on April 16. As they would soon learn, it wouldn't help.

As far back as September 2007—one month after Kimberly Saenz was hired—DaVita had instituted a new policy. They were to collect all the bloodlines and other instruments used on patients who experienced cardiac problems while undergoing treatment, put these items in biohazard bags, put the patient's name on the bag, and put the bags in a freezer to preserve them. But they'd never followed this policy until Ms. Strange and Ms. Metcalf died on April 1, 2008. On April 16, they followed protocol and preserved Mr. Kelley's bloodline, and that included a syringe still attached to that bloodline. This would not be the last anyone heard about that bloodline and syringe.

CHAPTER
5

WHAT IF

The same morning that Mr. Garlin Kelley arrived at the clinic, on April 16, 2008, so did Ms. Graciela Castaneda. She was an elderly Hispanic woman who didn't speak English. She'd been married for forty years and had three daughters. Prior to April 2008, she'd been a dialysis patient for ten years, and felt fine that morning—no different than any other day.

Yet at 8:00 that morning, after Mr. Kelley's incident, Ms. Castaneda went into cardiac arrest. Just before she passed out, Ms. Castaneda remembers, she was talking to a woman doing something to her lines, but didn't remember anything else. The DaVita staff, maybe because of all the recent practice, reacted immediately with the crash cart and gave her a shot of epinephrine at 8:08.

Ms. Castaneda was a lucky woman—at the hospital she recovered and survived that day.

Several months later, she saw a picture of a woman in the newspaper, and pointed it out to her daughter. Ms. Castaneda identified the woman in the photo as the nurse who had been talking to her right before she lost consciousness. The picture was of Kimberly Clark Saenz.

Two days before her heart attack, Ms. Castaneda's LDH level had been measured at 219, well within normal range. LDH, which stands for lactic acid dehydrogenase, is an enzyme that helps produce energy. It is also present in almost all of the tissues in the body and becomes elevated in response to cell damage. Twenty minutes after Ms. Castaneda's cardiac arrest, her LDH level was 2150.

Besides being an indicator of hemolysis, or cell damage, an elevated LDH level is also a marker for bleach poisoning.

* * *

Unfortunately for DaVita and especially the patients, instead of calming down, the storm plaguing DaVita was gathering strength, and it focused on Ms. Marie Bradley next.

Ms. Bradley was a Lufkin native who'd graduated from Lufkin High School in 1948. She later went to work for Jim Walter Homes in Lufkin where she remained for twenty-five years, advancing to upper management. In 2000, she began having heart and kidney problems, and started dialysis at Woodland Heights Hospital.

On May 7, 2007, Ms. Bradley began her treatments at the DaVita Lufkin Dialysis Center. From the time the news first broke about Saenz, and all through her trial, many people referred to Saenz as “an angel of mercy.” It was just so difficult to accept the idea that a medical professional could have been intentionally harming or killing her patients in the first place; if she really were doing so, it was far easier for people to believe that perhaps Saenz had had noble motivations, such as ending unnecessary suffering. However, Ms. Bradley was one of the patients who knocked down the “angel of mercy” theory. Although ill and in need of dialysis, Marie Bradley was notably robust and energetic. Her doctor said of her, “She was one of the exceptional patients as far as health went.” Unlike many dialysis patients, Ms. Bradley drove herself to and from her treatments.

April 23, 2008, was her regularly scheduled appointment. After all the preliminaries, she was hooked up to the machine at 11:00
A.M
. As she neared completion at about 3:30 that afternoon, her blood pressure took a surprising drop, from 145/66 to 97/50, and her oxygen levels also fell drastically.

A few days earlier, her LDH levels had been 169. After she was rushed to the hospital on April 23, they were 1372. At the time, however, Ms. Bradley had no idea what had actually happened to her. She woke up in the hospital two and a half days later. She didn't know about the DaVita employees who'd frantically worked to save her life or the mad dash to Memorial Hospital in the ambulance. Nor was she aware of the Memorial emergency doctors and nurses who'd revived her and then closely monitored her condition in the intensive care unit.

As Ms. Bradley herself later said, it was clear that during her treatment on the twenty-third, “Something went horribly wrong.”

* * *

What would a patient in the dialysis center feel like as she watched EMTs rush two other patients before her to the hospital? What could she have been thinking when her turn for treatment arrived, and the nurse who had helped her pass the long dreary hours by telling her jokes hooked her up to the machine?

Imagine the patient's horror as her arm, at the point where she was attached to the machine, began to bleed and wouldn't stop. As the blood flowed out of her, she started throwing up, and pain shot through her entire body. Then, agonizing pain made her believe her chest would explode. Imagine her terror as DaVita employees loaded her into another ambulance and whisked her off to the same hospital where others before her had gone—others who hadn't survived the trip.

This terrible experience was what happened to Ms. Debra Oates, another patient at the DaVita Lufkin Dialysis Center, on April 26—one of the worst days of the storm. Ms. Oates, like Ms. Bradley, was a Lufkin resident. Also like Ms. Bradley, she was healthy enough to drive herself back and forth to dialysis for treatments.

On April 26, she had been watching TV and her treatments were going well—no problems at all. Then LVN Kimberly Saenz came over to give her medication, and that's when she started to feel bad. At 9:13
A.M.
Debra Oates's blood pressure was 147/73, but at 10:39 it dropped to 83/56. During this interval Ms. Oates experienced nausea and vomiting and trouble breathing. She said she “hurt all over.” Her heart was beating faster and she was sweating, and the access in her arm where they hooked the dialysis lines up started bleeding and wouldn't stop.

She also had a funny taste in her mouth. She'd been a dialysis patient since February 2005 and was familiar with the process, and knew that each medication given through the blood while on dialysis had a different taste. This taste was unfamiliar.

Ms. Oates asked Saenz, “What did you give me?”

Sharon Smith, the nurse supervisor, overheard this question from Debra Oates and she said that she'd never heard her ask that before. However, Ms. Oates didn't get an answer to her question. Kim Saenz just walked off.

And then Ms. Oates's condition worsened.

PCT Werlan Guillory was again on duty that day, and said that Ms. Oates had been doing well until 9:43
A.M.
and then she became sick to her stomach and started throwing up. They immediately got her into an ambulance, where the technicians gave Ms. Oates some nitro and more of it at the hospital. Like Ms. Bradley, Ms. Oates was one of the exceptional patients, and she somehow survived the storm.

However, neither of the patients Ms. Oates and Werlan Guillory had watched them carry out earlier that day was as lucky as Ms. Oates was. The first was ninety-one-year-old Ms. Opal Few, and the other was Ms. Cora Bryant.

Ms. Bryant was born on May 10, 1943, in San Augustine, a small town east of Lufkin. She settled down in Lufkin and raised four daughters and one son. People said that Ms. Bryant loved her kids and family and could always make people laugh.

The family talked about the values their mother taught them, and how their mother inspired them. Angela Scott told the newspaper, “Our mama passed on a will to never give up. She refused to give up. And she has given me the strength to carry on.”

The day before Ms. Bryant went for her appointment at DaVita for the last time, she took a walk with her granddaughter, Jamina Agnew. Ms. Agnew related how Ms. Bryant was feeling that day, telling her granddaughter, “I feel good. Come on, keep up.”

On the morning of April 26, Candace Lackey, an LVN at DaVita Lufkin, hooked up Ms. Bryant to the machine. She said that Ms. Bryant was in a good mood that day. She'd had some clotting problems early in the treatment, but they'd changed out her lines and that took care of it.

When Lackey went on break, everything was fine with Ms. Bryant—she tested well. But when she came back from break, Lackey found Kim Saenz trying to reset the alarm on Ms. Bryant's dialysis machine, even though she was assigned to a different bay. Ms. Bryant, however, seemed okay and was watching TV. Lackey hadn't expected Ms. Bryant to start clotting again, but because of the earlier incident, this was the first thing she checked. There was no appearance of clotting in the bloodlines.

Lackey explained that “a number of things can make the alarm go off, including clotting, or pushing medication into a port too fast. When the alarm goes off, the machine shuts down the blood from entering or leaving the patient. The machine has to be reset before the patient can continue to receive treatment.”

After Lackey checked the machine and reset it, she returned Ms. Bryant's blood to her. Like Ms. Oates, Ms. Bryant was familiar with the tastes and sensations of her medications, and detecting something unusual, she asked, “What are you giving me?” She then turned her head and her heart stopped.

As Ms. Bryant coded, employees rushed to save her, all but one. Martha Mann, a PCT on duty that day, said, “Kim was just standing there watching. She never attempted to help give CPR to save the patient.”

Four years later, Candace Lackey was asked if she knew then what she did now, would she have returned Ms. Bryant's blood to her. A tearful Lackey responded that she would not have returned the blood.

After Ms. Bryant coded at DaVita, she was also rushed to the hospital in a coma—one that she never awoke from.

Angela Scott, one of Ms. Bryant's daughters, told
The Lufkin News
in 2009, “We knew my mother was going to die eventually of kidney failure, but not this way. Not by the hands of someone else.”

* * *

People confronted with disappointment or tragedy often become fixated on the “What if?” questions. What if I had stopped sooner? What if I hadn't gone there? What if I'd never agreed to do this, or not do that? We can never know, of course, but everyone's said it at some time in their lives. Would certain things be different if I had or hadn't acted a certain way?

April 26, 2008, was a day rife with “What if?” questions, and it wasn't over yet. While horror unfolded within the DaVita clinic, outside it was another perfect spring day in Lufkin. The temperature was in the mid-sixties with little wind and no rain. Many of the East Texas residents would be heading to the lakes for fishing or other activities.

Ms. Opal Few's usual dialysis appointment was scheduled at the DaVita Lufkin Dialysis Center in the afternoon, but that morning she had received a call from DaVita asking her if she would like to come in early. A couple of patients had canceled their appointments.

Ms. Few was a little silver-haired woman—short and small, but with a feisty and large personality. When she came into a room, people knew she was there. DaVita employees who knew her referred to her as a dream patient—always cheerful and full of life. One employee said she was the kind of patient who made employees happy to take care of her.

When hearing friends, family, and acquaintances speak of ninety-one-year-old Ms. Few, regret spirals through the listeners. She sounded like the type of person whom anyone would have really liked to have known.

Opal Mae Jordan Few was born in Pollok on October 13, 1916, and graduated from high school at Central ISD, a small school in Pollok. She married, and for many years ran a boardinghouse in Lufkin. The family lived downstairs and the boarders lived upstairs.

Linda James, one of Ms. Few's daughters, stated, “My mother was a family person who loved her family above all else except God. She devoted her entire life to her children, grandchildren, and great-grandchildren.” Above all else, Ms. Few's children, Linda Few James, Selena Lynch, and Donald Young, remember that their mother believed in doing what was right. Ms. Few instilled these virtues in her children, and lived the moral values she taught them.

One story about Ms. Few epitomized the way she led her life. Ms. Few's income was based on the number of boarders she had and the money they paid her. One time in particular, her children remember that the house was totally empty of boarders. Their mother had gone to church on Sunday morning with just enough money to either pay the light bill or give a tithe to the church. They said that their mother prayed and asked what the right thing to do was.

Ms. Few left the church with no money. That very afternoon there was a knock on the door, a man looking for a room. By Monday afternoon, the boardinghouse was completely filled.

Linda James, a drug and alcohol abuse counselor, told this story about how her mother instilled values in her: When she was about five or six years old, she went with her mother to the Big Chief convenience store. She wanted a piece of bubble gum, but because she had bad teeth, her mother wouldn't get her any. So Linda swiped a piece.

On their way home, Linda turned her head so her mother couldn't see her plop the gum in her mouth, but she didn't fool her mother, who said, “Linda, look at me.” Her mother figured out she'd stolen the gum, turned around, and made her go back in the store, spit it out into a Kleenex in front of the manager, apologize, pay for the gum, and when they got home, she made Linda iron sheets as punishment. Linda said she still got punished after all that, and she didn't even get to chew the gum.