in a Texas hospital babies are dying another come on the way in I kept thinking that he's going to get better and what appears to be a mysterious epidemic May in fact be murder and this child was going to die if I didn't do something only Medical Science can identify the colorless odorless killer and neutralize the lethal dosage [Music] [Music] San Antonio Texas 1981 at the county hospital the Pediatric Intensive Care Unit Pik was considered state-of-the-art a small intimate Ward the piku was reserved for the hospital's youngest sickest patients [Music] the County's most vulnerable children what's going on he's not breathing lagging Christopher hoga was one such patient the 15-month-old had been in and out of hospitals for much of his young life fighting off infections pneumonia and hepatitis got it his condition had been considered unstable though doctors marveled at the Bo's ability to bounce back's in no response get the crash C now I'll take he was a blue baby when he was born he had several things wrong with him he had a enlarged heart he has Bronco tubes were too large he had a hole in his heart but he was still surviving he wanted to live so badly all right everybody clear stand clear all clear what do we have charging in May the boy suffered a cardiac arrest nothing nothing all right everybody clear Christopher's parents were called to the hospital late that evening really they lived in a small workingclass town 250 Mi away we got the call that uh he was not doing good so my husband had made an arrangement to find a car and we were driving very fast all we knew was that we wanted to be there with him the hogas had transferred their son to the county hospital several months earlier hoping his chances would improve at the high-tech Medical [Music] Center the young couple was exhausted they had made the long drive countless times before I kept thinking that he's going to get better and I just prayed every day every single [Music] day but the little boy did not recover as his parents had hoped I'm going to call it time of death is [Music] 12:45 Christopher hoga d died on May 21st 1981 and when we walked in we we were course our palms were all sweaty thinking maybe he's pulled out this time again I got a phone call from Janine saying something was wrong with Christopher uh yes let me get the doctor for you I'll be right back okay his parents' concern grew as they walked to their son's room in the Pediatric Ward this time we saw that there was no lights in the room and it was very quiet we knew that okay this is it he really is gone for staffers like Dr Lawrence huis then a pediatric intern the death was frustrating but not unexpected we don't have he was a very very sick child complex cardiac problems and all that and so I understood that but it it was still hard it's difficult to watch a baby die I mean everybody expects babies to live you know so uh you then you have to regroup and you say well now I have to go tell the parents you look them in the eye and typically they can tell they're reacting already they they know they looking for Hope but typically they can tell tell what's going on it was L Chun believe it you know I thought my son had a chance to live I wanted a miracle to consider something nurse Janine Jones stood by as doctors mentioned they could perform an autopsy to determine the exact cause of death if the family desired one the hogas felt their son had suffered enough I said no we don't need him him to be cut up again what for I mean let him be at rest let him be peaceful he he's gone we got him a little suit a little blue suit and we put on some shoes he could walk in God's world Christopher Hog's death weighed heavily on the ICU staff I'll be back it's difficult I don't think you ever get over that it just it might become a little easier you might your shell might be get a little thicker but uh it's the most difficult thing to do in San Antonio spring turned to Summer and Christopher heda's death faded into memory by August new patients like Lisa Rivera consumed the attention of the Pediatric staff little Lisa was only 3 weeks old suffering from chronic diarrhea and vomiting when her parents brought her to the hospital what kind of pressure do we have what's going on she's in DET At first she appeared stable her illness was minor and doctors expected her to recover even though you knew enough medicine to sort of predict things uh and disease processes particularly usually take a certain course all of a sudden out of blue something would happen that you just couldn't explain status she began to ooze blood from her IV [Music] give me the back I want up [Music] down her blood pressure dropped and then her heart stopped beating [Applause] completely pushing [Music] up give your crash when drugs like epinephrine failed to jump start her heart nurse Janine Jones and doctors resorted to a defibrillator we got full AR rest Mark note full arrest the paddles shocked the baby's heart no blood pressure reset clear clear and firing status nothing okay one more time full charge rator is charg and firing anything [Music] nothing time of death Lisa Rivera was the eighth child to die in just 3 [Music] months the fatality rate which had been on the rise since the death of Christopher hogeda at first seemed like a run of bad luck patients are sick in the ICU they're very sick sometimes so and sometimes deaths occur in clusters you you don't you don't average one death a week and in a place that where patients are sick sometimes you have several people die and then you don't have anybody die for [Music] months but staff members had begun to notice something odd thank you children who seemed on the path to recovery one day were inexplicably deteriorating the next but after a while you just um get more suspicious I took it personal and and I just really had a SI sense like you know there's something there's something going wrong here everything about the victims appeared random except for one thing it had to do with the afternoon change and shift every day at 3:00 a new set of doctors and nurses took over patients and case files from the morning crew hi hey many children appeared fine early in the day but those who took a sudden turn for the worse only did so after 3:00 in fact since Christopher Hog's death almost every code blue in the piku had occurred late in the day on the 3: to 11:00 p.m. [Music] shift Dr Kenneth Copeland was an attending physic on the ward I don't think I fully grasped the Gras cavity of of it the director of the Pediatric ICU at County Hospital spoke to me and said um keep your eyes open let's be aware of whether or not this is mere coincidental or something more serious it was horrible because uh each time you you inherited those patience for the evening um you didn't know what to expect it was it was sort of like you were you were waiting for an ambush the time for waiting was through doctors would have to determine what was making the children so sick and fast or more babies would continue to [Music] die in the summer of 1981 children at the county hospital in San Antonio Texas were dying in mysterious ways they suffered from strange seizures and bleeding episodes that seemed to come out of nowhere the hospital staff used to resuscitating three or four young patients a month had handled nine CPR events in August 13 in September by Fall the death rate was up 75% the frequency of morbid events are events that you know injure people in the ICU seem to be somewhat more frequent than you'd expect even though you're in an ICU setting and patients are sick it seemed like there were incidences where it didn't appear to be a reasonable explanation doctors at the hospital were determined to solve the mystery there are not too many causes of unexplained bleeding in a baby especially one that has been doing fine and then suddenly uh bleeds with no uh apparent reason there seemed to be only one possible medical explanation the sudden bleeding could be caused by a rare blood clotting disorder known as disseminated intravascular coagulation or DIC we don't know exactly what causes DIC but it is a associated with uh a a both clotting where there should not be clotting and paradoxical bleeding where there should not be [Music] bleeding patients with DIC can bleed from injection sites or experience blood clots which block the flow of fluids and other medication be right no back up here the condition is serious treatment however is routine tried everything else and nothing work okay Physicians often prescribed Hein a drug used to flush out blood clots in IV lines heprin is a common agent that you would find in virtually any Intensive Care Unit it's a a wonderful drug when used properly because it prevents clotting when you don't want clotting to occur nothing there clots and IV lines were commonplace so all hospitals Awards had abundant supplies of Hein on hand okay yeah yeah flow is back great to identify the culprit a series of blood tests was ordered to establish whether patients were suffering from DIC we drew the appropriate diagnostic tests for DIC and at this point they came back inconclusive without a definite diagnosis doctor's hands were tied it would have been imprudent to prescribe Hein to patients who might not need it and at very tiny doses used to flush these catheters uh it's very very very safe and usually does not cause any systemic problem to the baby's body or or course on the other hand at very high doses heprin can be uh life-threatening or fatal on October 15th Roberto Sanchez was brought to county [Music] hospital he was just 3 months old okay basically what we're going to do is just give him some more FS make sure Roberto was recuperating from a bout of diarrhea dehydration and a chemical imbalance thank you can you come in here a minute in the 3 days since the boy's admission doctors had been called to his bedside twice each time after 3 p.m. the line and it's clotted he's bleeding everywhere I can see that and the line is clotted each time the boy was found bleeding from puncture sites where needles or IVs had been placed one IV line also appeared clogged have you tried giving him a saline flush yes how about a head flush I'm getting ready to do that right now following standard procedure nurse Janine Jones began filling a syringe with Hein Janine was a highly opinionated Brash abrasive but incredibly talented nurse I was impressed with her skills espe especially her technical skills she was very good at starting IVs on little baby babies what we're getting ready to do here but Dr Larry ho just stopped her before she flushed out the line i l how much of that are you given three c c I approached her and I said um are you sure you're using to write do Hein because we we've had we've had a couple patients bleed in the unit and she abruptly said to me that well I'm using a lot less uh Hein than than you're using are you sure I'm absolutely [Music] possible I proved it to her I showed her on a on a sheet I remember drawing out the calculations once you see just as I thought and I said well you could very easily heize this baby by giving a very small amount stuff that you're using in that thing could heize somebody that weighs 3 Kg draw that back down to one [Music] cc put it in there I was kind of shocked that was like with all the experience she's had with Hein she should have [Music] known [Music] that the head nurse was informed of the incident the nurse in question was Janine Jones an LVN or licensed vocational nurse typically ICU Wards were run by registered nurses but at San Antonio both RN's and lvns ran the wards registered nurses RNs had far more experience in training than most lvns come on the head nurse explained that the error was a simple miscalculation why don't you we need to have a conversation about what's been going on overall I've been looking at all the records and all the but it pointed to an issue that was much more troubling and complex but I want everything from medication to the patient double checked doctors had observed the nursing staff on the 3 to 11 shift making an increasing number of mistakes you know how many times can you be surprised until you start saying well what's the pattern here what's going on is it lack of training is it you go through a process there was a total review I mean we discussed a bunch of medications that uh may cause some of the things that were happening in the unit there was very strict rules implemented for for most [Music] medications according to new procedures amounts of Hein were reduced and nurses were required to administer the drug in pairs to prevent any errors [Music] Dr you depend on those nurses they're they're watching the patient while you're not there okay good boy they're taking care of the orders that you written for that patient so uh you depend pretty heavily on the nurses so they're involved as much or if not more with the families and and the care of these patients got was it possible the drug had been tampered with during the manufacturing process lab technicians measured concentrations found in any unopened bottles you get enough samples tonight some more right now the drugs were [Music] safe definitely pure IV tubes syringes and other equipment were also gathered and tested for bacterial contamination but they too were found to be clean it got to the point with me that it it started becoming personal that it was like a it was something I need to figure out I mean cuz you're respons those patients and it's uh it's sort of inbred into you as a training a physician I mean it's your responsibility I took I took it very personally for Dr hois and his colleagues there were two likely scenarios either an exotic disease was plaguing the Pediatric Ward or human error was to blame they were desperate to find the answer before the ward went empty and there were no more patients left to [Music] save in a San Antonio County hospital patients were dying in unexpectedly large numbers from May to October 1981 the Pediatric ICU or piku had lost 18 patients all but one had died during the same 3 to 11 p.m. shift I was extremely uh suspicious and I got to the point where whenever I had my shift I I didn't go to the call Rooms To Sleep I actually slept in the ICU I said well the only way I'm going to watch everything close enough is I'm asleep here Pedro Madera was rushed to the hospital on December 27th please me me [Music] his family came from a poor farming Community 1 hour south of San Antonio a local Health Clinic there had diagnosed the infant with a cold and sent the parents home instead they drove to the city Pedro was having trouble breathing and his parents were concerned the boy was just 1 month old the admitting diagnosis was pneumonia and he was on antibiotics and required respiratory support with uh a ventilator and this was fairly typical most children would respond to treatment recover and go home within through four five days but Pedro was not so lucky after a few good days in which the infant showed Improvement he suddenly suffered a seizure after being stabilized Pedro underwent a brain scan on December [Music] 29th the Radiology report found nothing abnormal in the boy's brain nothing to explain the seizure for the next several days um he seemed to improve and get better until January the 6th and at that point uh suddenly for no explainable reason uh he deteriorated This Time by bleeding excessively as with the other babies Pedro's blood was tested for the rare blood clotting disorder known as diic lab tests came back with the same result as before inconclusive for DIC the other causes of unexplained bleeding in a baby that has otherwise has been normal are really very few and at the top of the list was heprin Hein was stored in large amounts throughout the [Music] ward it's possible that this child was receiving accidental heprin by flushing his arterial [Music] line my solution was to remove the arterial line because by so doing we also eliminate the possibility that he could be receiving Hein as an accidental process bloing on January 9th while under the care of Janine Jones Pedro's condition worsened once again I found this baby in dire circumstances near death bleeding like the previous time but to a much much more massive in extent this time the baby was bleeding from all of the old puncture wounds from heel sticks where blood had been obtained actually from all mucus membranes the eyes the nose the ears the genitalia uh anywhere you would touch on tender tissue would be bleeding if the hemorrhaging was not stopped Pedro would bleed to death with within minutes the blood pressure was falling and this baby despite receiving IV fluids and blood and blood products we were getting behind and losing this baby blood pressure is dropping even further doctor there was only one option only one drug that could save little Pedro protamine is a very specific antagonist to heprin wherever heprin is protamine comes along and completely neutralizes its ability to prevent clotting but doctors faced a serious dilemma there was no way to know for certain if pein was the cause of the bleeding and protamine could do more harm than good small doses of protamine are fairly innocuous but large doses uh are very dangerous pressure 30 over 25 an overdose could further injure or even kill the child it was very clear in my mind that if I was wrong it could be disastrous but I really had no choice the doctor drained an entire bottle of protamine 100 mg and injected it into the baby nothing happened at that point of course I was scared to death I was certain that I had made a foolish [Music] decision at that point I ordered the second VI knowing that that babies after open heart surgery require far less than one [Music] V just came on all at once okay keep an eye on reading he pushed the drugs slowly into the boy's system 10 mg 15 mg then 20 and bingo the bleeding stopped we've got a better blood pressure doctor 90 over 60 I've often thought about why I did it and if I would do it again and I truly don't know okay better I just knew that this child was going to die if I didn't do something looks a lot stronger he's breathing he also knew that the child was still in danger as long as he stayed on the [Music] ward Copeland ordered that the boy be transferred to a pediatric Ward on another floor I was very suspicious not certain but quite sus suspicious that there was something happening to my baby of a malicious [Music] intent Copeland ordered a hematology report as suspected there was something strange present in Pedro's blood the amount of heprin that had been infused was uh in the order of magnitude of 100 100 fold more than one would give to a baby for open heart surgery this was no mysterious illness no elusive germ or accidental overdose it was attempted murder plain and simple never happened my Hospital the hospital staff found it hard to believe that someone anyone on the 3 to 11 shift was deliberately killing babies you go through Medical School typically nobody's mentioning okay number five you've got to watch the staff they're trying to kill somebody that's not something you think of your your gut says that nobody would do this see please administrators conducted an internal investigation please tell me exactly what you have found about what's going on here pein they realized was the perfect weapon it was virtually undetectable in the body [Music] there are heprin vials in virtually every room in an intensive care unit it was so common and spread throughout the unit that there was no uh specific accounting or little specific accounting for where each vial was here we have the investigation became heated um I've asked doctors blame nurses and put together schedule RN's accused lvns turned into the most uh horrific situation I've ever been associated with I mean how how much uh how much worse can it can it get than that I hate to tell this but it's after a month with evidence of only one Hein overdose and no proof as to how the other children died the investigation was closed that's right it's not doing anything administrators felt they could do little but reorganize the staff they brought in more RNs and transferred all licensed vocational nurses out of the P stock it with our ends right I suspected that my babies and the other babies would be safer now in the unit and in fact as time played out that was the case many were less than satisfied with the committee's decision Dr Susan Wilder took the opportunity to move on and build a practice of her own and others like nurse Janine Jones quit the hospital in protest ask Jones was an LVN who felt angered and betrayed by the administration's handling of the case she soon found work however with Dr Wilder in her new practice outside the city in March 1982 months later the mysterious events in San Antonio ceased and the children of County hospitals seemed secure the frequency of code Blues deteriorated dramatically and the number of deaths deteriorated rapidly following that uh reorganization the question was how how long would that last in less than a year babies in Texas would once again fall prey to mysterious seizures and Physicians would face rumors of undetectable poisons and murder 5 months after the strange events at a San Antonio Hospital seemed to end Dr Susan Wilder moved to a small town outside the city she opened what was considered to be a state-of-the-art Pediatrics practice word of Wilder's arrival had spread quickly among the young mothers in town be the problem today C's had a little cough you know a little thing Petty mlen had been eager to meet the newly trained young doctor do you think that you could be a big boy and open your mouth really wide Cameron Cameron my son he was four at the time was sick and I knew he was running fever bad cough and we took him in Petty also brought along her younger child 15-month-old Chelsea actually can you get Chelsea right there on that cabinet Janine doing so I was wondering um actually Janine here Dr Wilder told her nurse Janine Jones to take Chelsea to another room to get caught up on her booster shots go ahead her records are right in there just go ahead and get her up to date okay great thanks and you you ready to finish Jones had also come from the county hospital in San Antonio Dr wild I need you to nurse Jones had only been alone with the child for a few minutes when she called for Dr Wilder so I went down the hallway and they were doing a full cat on her she wasn't breathing she was lip she was discolored come it was not the first time that paramedics had been called to the young doctor's office it was just like something in me saying there's just something not right I had worked Ems for a long long [Music] time in one month six children had suffered seizures while under Wilder's care [Applause] I work many many many calls but you don't have the same consistent calls in a short period of time and I I thought that was pretty pretty darn odd the five other children had recovered but would Chelsea she was rushed to S Peterson Hospital a few minutes [Music] away it was terrifying you know it was like how could this possibly happen it was really overwhelming you couldn't it was hard to digest what was happening and how it could have happened and happened so fast once Chelsea's condition had stabilized Dr Wilder ordered her transferred to the county hospital in San Antonio transport this baby to San Antonio they know coming she felt it would be better equipped to handle the unusual case out she looked real tired but she was fine I mean she knew who we were and she was babbling and she just looked tired Chelsea's parents followed Dr Wilder and the ambulance as it raced against time but along the way ambulance driver Steve Brown had a strange sensation I felt that that something just wasn't right everything fine and we wasn't probably 15 mies out and all of a sudden I heard things kind of uh scattering in the back moving and and so I looked up in the rear viw mirror and I I knew something was wrong at that point [Applause] over I got out and I ran to the back and again the the baby hit was in in a complete uh respiratory arrest I don't feel a pulse what are he doing what's going [Music] on Jones couldn't detect a heartbeat Chelsea had flatlined and wasn't responding to chest compressions anything without immediate help nothing could save her there was no way she'd make it to San Antonio not [Music] alive she needed to get to an ER any ER and fast I was pretty much lost it at that point because it wasn't routine anymore you know I mean it wasn't there was something very deadly and very seriously wrong within minutes paramedics reached at tiny Community Hospital in the small town of Comfort Texas where doctors were awaiting their [Music] arrival Janine Jones took command of the situation barking out orders and fighting to save the girl's life get her hooked up come on she was in charge she was uh in control let's get this tney out of here come on there was nothing for petty and Reed mclen to do but wait I knew she was [Music] gone I mean they worked on her for a long time well she's gone Chelsea and mlen died on September 17th 1982 and they said I could see her and you go what it you know you go through no I'm just going to take her home she's fine she's just [Music] sleeping she would news of Chelsea mullen's death reverberated throughout the small medical community Dr Joseph vinus a surgeon at Sid Peterson Hospital was asked to look into the strange events six respiratory arrests in one month just didn't make sense there was never an arrest in a doctor's office of that time so I offered to help and that's how I got acquainted with it vinus called a friend at San Antonio's County Hospital hoping to gain information about the Town's new pediatrician Dr Susan Wilder he said she may be a little easy to rattle but she's young she's competent here we got to C I asked him if he knew of her nurse because the word had it that she had come also from County when I mentioned the name Janine Jones there was silence and when I uh repeated the name Janine Jones He said the short answer is it looks like you have a baby killer on your hands just for his exact words vinus learned of the many unusual deaths at County Hospital and the internal investigation the head nurse had compiled a chart listing every case in which a child had died in the piku that that year uh it's basically the lvns that we're looking at a shocking pattern had emerged the more you study this the more you see that those who died were most often under the care of one nurse section her name was Janine Jones when Pedro Madera was given a near fatal Hein overdose Janine Jones was there when Roberto Sanchez mysteriously deteriorated Janine Jones was there when Christopher hoga and Lisa Rivera and more than a dozen other babies died in 1981 Janine Jones was there overseeing each and every case for whatever reason Janine Jones was the eye of the storm vinus and officials at the small rural Hospital believed that if Janine Jones was a serial killer she had to be stopped first they had to uncover a weapon it was not happent Wilder's patients were not found bleeding instead these children were brought in limp learic and suffering respiratory arrest let get as a surgeon vinus realized the symptoms were similar to those of patients in the O patients under the influence of an an anesthetic called sual choline sual choline is a paralytic agent that is used to allow the uh anesthesiologist to control the airway more easily by relaxing the muscles if correct this would be the perfect murder weapon virtually undetectable and a killer the patient is awake and unable to move or to breathe so the patient appears to have had a respiratory arrest which indeed they do they just sto breathing across town Dr Susan Wilder had suspicions of her own and called the Texas Rangers now the only other person besides myself who has access to these drugs is my head nurse Janine Jones one of the BS had puncture holes in it this is seal and this one has she said I don't know why the puncture holes are in there because we've never used it I took custody of the of the bottle and took it to our lab in Austin using a gas chromatograph the liquid in the vial was tested to determine its chemical contents and the results turned out that it was a bottle full of saline solution Davis suspected the sual Coline had been completely used and then replaced with saline this became a very frustrating uh investigation because we felt like we knew what happened proving it was going to be something else the pressure was on on September 27th yet another victim was rushed from Dr Wilder's office to the local emergency room the patient was semiconscious and having trouble breathing she had been in the hospital before but pulling a gurnie not riding on one the patient was not a child it was nurse Janine Jones on September 27th 1982 Janine Jones was rushed to a Texas emergency room give me b no stranger to hospitals Jones was a pediatric nurse linked to the mysterious deaths of dozens of babies in and around San [Music] Antonio for more than a year the crimes had gone unsolved but Petty mlen knew her daughter's death was anything but natural right now let's get her hooked up the come on and then we left the hospital and as soon as we got in the car I was just like I looked at Reed and I told him I said they did something to her he's like what do you mean I said they gave her a shot she was fine they gave her a shot and this happened Texas Rangers were on the case searching for any evidence that might link Jones to murder so I went to the S Peterson hospital and found out that she had overdosed and was uh fixing to be released they had pumped her stomach and uh everything a releaser Jones yeah Jones had taken an overdose of anti-anxiety medication after falling under police suspicion and losing her job do you have occasion to order drugs but in the presence of law enforcement she became confident even cocky once more does she order drugs also sure you can tell right off she had a big ego she was on really give you a lot of information she's denying any part of this we almost finished after interviewing her I could tell that we would going have to make a case on her because she wouldn't give you the time of day proving a case against the once trusted nurse would be difficult she was clever but perhaps too clever few people knew of or had access to the unusual anesthetic sual choline I spoke with the anesthesiologist at the hospital and uh he told me about the drug and said it in a matter of seconds it disperses within the body and there was no way to detect it I do believe you need to look at this although the drug did not show up on standard blood tests the Texas Rangers refused to give up we found out uh that the there was a possibility that a man by the name of Dr Homestead in Sweden had found a way to detect this drug the little girl that had died had been uh dead for approximately 6 months we told him that and we and he said well the only way to try it is to exume the body Chelsea mullen's body was exed on May 7th 1983 [Music] we didn't know what condition the baby would be in being buried for 6 months you would have thought it was a little doll laying there it just seemed to be in perfect [Music] condition the local coroner removed tissue samples which were packaged and sent to Sweden for [Music] testing investigators were playing a long shot the Swedish test was controversial and most American doctors were skeptical that it could really work the Skeptics conceded when tissue samples came back positive for sual [Music] choline there was the proof Chelsea mlen was [Music] murdered no longer able to hide behind medical emergencies and disappearing injections Janine Jones was arrested on May 25th 1983 come [Music] on some have suggested Jones had Munch housin by proxy adults with this rare and little understood disorder harm children in their care in search of sympathy and attention from doctor and others in positions of authority she wanted to become the hero she wanted to save uh lives and show these doctors that had criticized her down in San Antonio that she was uh uh doing this job here in kville and saving these babies and she went too far her motives will never be entirely clear in 1984 Janine Jones was found guilty of murder and injury to a child and sentenced to 159 years in prison no one will ever know just how many babies fell prey to the ruthless schemes of someone they trusted a caregiver with a Leal dosage [Music] [Applause] [Music]