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  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.

&
nbsp; 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.

  CHAPTER 2

  Stanley Jagodowski’s daughter, Susan Lessard, received a phone call from the VAMC around 9:30 that same night.

  “Your father’s heart stopped,” the nurse said. “Come to the hospital right away.”

  Lessard lived with her husband and two kids in nearby Chicopee, Massachusetts, about a twenty-minute drive from the VAMC.

  Stunned by the news, Lessard and her husband stopped by her mother Claire’s house to pick her up, and arrived at the VAMC at 10:30.

  During the spring of 1995, Jagodowski had complained to Lessard about the pain in his legs just about every day. He had even lost his appetite, he’d complain, because the pain had become so severe.

  But ever since the amputation in July, Lessard noticed, her father had been feeling much better.

  “It was written on his face,” she later recalled. “He looked one hundred percent better. He was more relaxed.”

  Lessard visited her father about five times a week while he was at the VAMC. In the middle of August, because he was doing so well, she decided to take a week’s vacation with her family. She felt comfortable about leaving, she said later, because her father seemed to be in great spirits.

  “I would not have gone on vacation unless he was improving.”

  On Friday, August 19, Lessard, her husband and two kids returned home to find that things hadn’t really changed much. She checked with her mother and was told that her father’s condition, if anything, had improved since she’d left.

  Lessard was relieved.

  But when she showed up at the VAMC three days later and first laid eyes on her unconscious father, she fell apart.

  He looks so helpless, Lessard thought as she pulled up a chair next to his bed. With faint wheezing sounds coming from his mouth, she wanted to “pull him out of the state he was in” but realized it was impossible.

  RN John Wall, a clean-cut, well-liked nurse who was often in charge of the ward, had admitted Jagodowski to the ICU at 9:00. Wall intubated him, placing a tube down his throat and into his lungs so he could breathe.

  For the next few moments, Lessard sat with her father and held his hand while the machines around them buzzed and beeped. A ventilator to her right methodically kept her father alive as though it were a metronome counting down what little time he had left.

  Every once in a while, Lessard would burrow up next to his ear and whisper, “Daddy, please squeeze my hand.”

  Jagodowski would, clamping down gently.

  “See,” Lessard would say to the doctor in the room, “he’s not unconscious. He knows I’m here.”

  As the night progressed, RN Wall recommended that Lessard receive a sedative because she was so distraught over what had happened.

  She refused.

  For about forty-five minutes, she sat by her father’s side hoping he would, through some miracle, come around.

  But nothing happened.

  Shortly before Lessard and her family had arrived to the ICU, RN Kristen Gilbert had come in and relieved Wall for a few moments. While Gilbert was there, she made a mandatory “progress report” of Jagodowski’s code and his current condition.

  Signed at 9:30, after briefly describing the code, Gilbert wrote:

  . . . [Jagodowski was] . . . awaiting placement to a long- term care ward and developed some . . . edema. . . . Today, patient was noted to be confused and lethargic. Edema and mottling of upper extremities noted.

  Though no one caught it at the time, not one other nurse or doctor who had treated Stanley Jagodowski had made similar observations.

  For some reason, RN Gilbert falsified the report.

  Feeling a bit drained after the visit, Lessard prepared to leave the hospital. She stopped in Admissions downstairs and told the nurse she was feeling “light-headed” and “very warm”—and while explaining her condition, she fell back and passed out.

  When she awoke several minutes later, Lessard found herself in an Admissions bed . . . being treated with a sedative. Her father, she was told, had coded again while she had been out.

  “It didn’t look so good, Ms. Lessard,” one of the nurses said.

  Shortly after midnight, for the second time since Lessard had been admitted, Claire Jagodowski walked down to Admissions to give Lessard a status report.

  After coding for a third time at 11:38, Stanley Jagodowski died. There was a priest up there now, Claire explained through tears.

  It was all over.

  CHAPTER 3

  In 1978, Renee Walsh graduated from East Tennessee State, married a local serviceman, and moved to Germany, where she began working at the Frankfort Army Regional Medical Center as a staff nurse. When Walsh came back to the States two years later, she got a job at the Cape Fear Valley Medical Center’s ER and trauma center, in Fayetteville, North Carolina. Eight years after that, she took a job at the local VA hospital.

  In November 1990, Walsh’s husband at the time was offered a job in Northampton, and she subsequently took a job at the Leeds VAMC.

  By 1995, Walsh was a permanent daytime staff nurse on Ward C.

  When the short nurse with black hair and an unmistakable Southern accent showed up for work on August 22, 1995 and heard that Stanley Jagodowski had died, she was curious about what had happened. Jagodowski had been sick—there was no denying that. But Walsh never expected him to just drop dead one night.

  When Gilbert came into work later on that day, Walsh asked her about Jagodowski’s code.

  Gilbert and Walsh had become good friends through the years. Even though they no longer worked the same shift, they still socialized outside of work. Gilbert and her husband of six years, Glenn, owned a boat. They would often take Walsh and her young son out on the Connecticut River and go tubing.

  “The Jagodowski code was really a sight, Renee,” Gilbert said, rolling her eyes. “You should have been there.”

  “What do you mean?”

  Gilbert smiled.

  “Well, Claire Jagodowski began to have chest pains herself right in the ICU. So someone took her downstairs to get checked out. While she was down there, I got a call to go do
wn because there really wasn’t a real nurse around.”

  “She’s okay, though, right?”

  “We did an EKG . . . she’s fine.”

  Gilbert began to laugh a bit louder.

  “I wish you would tell me what’s so darn funny, Kristen.”

  “Well, that’s just it. While I was down there, Susan Lessard—you know, Jagodowski’s daughter—she fainted! It was fucking hysterical. Here you have Claire Jagodowski nursing chest pains and the daughter is lying on the floor, completely out cold. . . .”

  “What?”

  “Claire was just standing over Susan saying, ‘Get up! Get up! You have to go see your father upstairs! You’ll never forgive yourself if you don’t see him again.’ ”

  Walsh was taken aback. She could clearly see that Gilbert was getting a charge out of telling the story.

  Later, when Walsh got home and thought about it, she questioned how a nurse—of all people—could find humor in the death of one of her patients and the family’s reaction to it.

  On November 15, 1967, the Red Cross sent U.S. Coast Guard serviceman Richard Strickland, who was stationed on an island one thousand miles off the coast of Hawaii, a telegram. It’s a girl. Mother and baby are doing fine, the terse note read. Strickland’s first child, Kristen, the note went on to say, had been born two days before.

  A few weeks later, a photograph arrived. There she was, little Kristen Heather Strickland, with her perfect oval face perched underneath a modest shock of dark brown hair, in the arms of her charming mother, the former Claudia Morgan. Six months after Kristen was born, Richard got word that he was going home to Fall River, a tiny mill town on the southern coast of Massachusetts where he and Claudia had grown up. In May 1968, Claudia and baby Kristen, along with Richard’s mother and father, welcomed him at Boston’s Logan International Airport.