In the early 1980s, an unusual number of patients of Southern Illinois University medical student Michael Swango coded; at least five died. As chronicled in James B. Stewart's Blind Eye (Simon & Schuster, 1999), Swango nevertheless obtained an internship at Ohio State University Medical Center in 1983, despite a negative report from SIU. At OSU, patients in his care had a habit of dying mysteriously. One nurse reported this, but her concerns were dismissed. Swango was not offered a residency once his internship ended.
Swango poisoned coworkers (non-fatally) while working as an EMT in Illinois, was convicted in 1985 of battery, and served four years. Once released, he changed his name and got work as a physician in Sioux Falls, S.D., using forged documents. But when he sought to join the American Medical Association, his conviction was revealed, and he was subsequently fired.
Swango went on to a residency at the State University of New York–Stony Brook medical school, where once again, patients in his care started dying. He was fired, and the dean, who was forced to resign, warned every medical school and teaching hospital in the country about the good doctor.
Swango moved on to Zimbabwe, where several of his patients died, and was on his way to Saudi Arabia when he was arrested in 1997. He was first charged with fraud, but in 2000 he was convicted of murder and is serving three life terms. He killed 35 to 60 people, and perhaps many more.
Nurse Orville Lynn Majors likely murdered more than 100 elderly patients at the Vermillion County (Ind.) Hospital between 1993 and 1995. Although other nurses were suspicious, some did not report their concerns because they were afraid of lawsuits or of losing their jobs. Others said that they notified hospital authorities. Majors was arrested in 1997 and convicted of six killings. He is serving 360 years.
The Beast Goes On
Nurse Robert Diaz murdered at least 12 patients in 1981. Pediatric nurse Genene Jones was convicted in 1985 of killing as many as 46 infants and children. Terry Rachals, also a nurse, was found guilty in 1986 of killing six patients. Nurse Kimberly Saenz killed several dialysis patients in 2008 by injecting them with bleach.
Nurse Charles Cullen has confessed to murdering 29 patients, but may have dispatched as many as 400. He is serving multiple life terms. Cullen says that he began killing in 1988 and kept at it until 2003, when the hospital where he was working notified state authorities about him. Charles Graeber chronicles the case in The Good Nurse (Hachette Book Group, 2013).
Cullen manipulated computerized hospital drug order tracking systems so that his inappropriate orders were not detected. He managed to find work, and kill patients, in nine different hospitals. He was stopped because another nurse became suspicious about his drug ordering patterns and notified law enforcement authorities.
Anthony Garcia, M.D., despite receiving negative reports during his medical education, obtained a residency at Creighton University Medical School in Omaha, Neb., in 2000. He was dismissed a year later, an action approved by, among others, Roger Brumback, M.D., and William Hunter, M.D.
Garcia then held several short-lived jobs in various places. He lost a residency in Louisiana in 2008 when it was found that he had concealed the termination at Creighton. He returned to Omaha in 2008 and allegedly killed Hunter's son and housekeeper. Last year, Brumback and his wife were murdered in their Omaha home. Garcia was arrested in July and is awaiting trial in Nebraska for the killings.
David Kwiatkowski was an itinerant radiology technician who was addicted to Fentanyl. Beginning in 2002, he stole syringes of painkillers and replaced them with syringes that he had used on himself and refilled with saline.
David Kwiatkowski has hepatitis C.
Over the next eight years, he worked in 19 different hospitals, leaving behind a trail of infected patients and a mountain of evidence. He was fired twice for stealing drugs. He was arrested for DUI. He was found in a hospital bathroom in a stupor with a Fentanyl syringe floating in the toilet next to him. Yet he was always able to obtain employment, often through temporary staffing agencies, which supposedly checked his credentials.
He was finally stopped in 2012 at Exeter (N.H.) Hospital, when several patients in the cardiac cath lab where he worked were found to have a specific strain of hep C. He was the only employee who had the same strain. He pled guilty to a variety of counts and was sentenced to 39 years in December. At least 8,000 patients whom he may have exposed have been advised to get tested for hep C. So far, one patient he apparently infected has died.
What Can and Should Be Done?
Health care serial killers are rarities. There are 3.5 million nurses in the United States, and 878,194 physicians have active licenses. The vast majority would never knowingly harm a patient. But that does not change the fact that there are monsters in our midst.
So why can't we stop them?
There are many reasons. Health care professionals find the thought of serial murderers in their ranks hard to swallow. Most clinicians do not receive training in how to spot a murderous colleague, and the signs can be subtle. Coworkers are afraid to report their suspicions for fear of litigation, reprisal or loss of employment. Human resource professionals are often intimidated into providing nothing other than the barest bones. And many people think that it isn't their job to intervene.
Most of the responsibility falls on hospitals, because that is where these predators usually prowl. And hospitals have not always done all they could, although there has been great improvement. Among actions that provider organizations could take or have taken:
Lose the denial. Even if we don't want to believe that a colleague is injuring or killing patients, that doesn't make it untrue.
Don't let fear of litigation paralyze you. This is the most often-cited excuse for not taking action. If we terminate this guy, he'll sue us. If we reveal that we have a rogue practitioner in our ranks, her patients will sue us. Or they'll get us on defamation.
Although employers should be wary of misinformation, they cannot ignore skyrocketing mortality rates associated with one nurse or sudden deaths of healthy infants cared for by a certain physician. And while you are investigating, keep the suspect from harming patients through temporary suspension of privileges, reassignment or close monitoring by colleagues.
Empower intimidated staff members. Every organization should have a policy whereby suspicions about possible harm to patients can be reported without the witness fearing loss of employment. The policy should include a means of bypassing the chain of command if the superiors of the complaining employee are involved.
Check out all claims. Every claim by someone seeking employment or privileges has to be checked, whether the applicant is applying directly to the organization, the application comes through a staffing agency or verification is being done by a third party.
Do not tolerate concealment of information. Applicants who conceal information about bad behavior should be automatically rejected. Employees who have done so should be fired.
Provide adequate answers to appropriate inquiries. Ethicist Paul Hofmann often speaks about his frustration with the nearly universal hospital practice of providing nothing more than "name, rank and serial number" to prospective employers of former staff members. Often, only dates of employment are offered. That's how the Swangos, Cullens and Kwiatkowskis of this world are able to waltz from hospital to hospital.
Support more robust action by state entities. Every state and territory has a medical and a nursing board, which can issue a variety of sanctions, up to and including loss of license. The problem is, they're all over the map in terms of how aggressive they are. In a report last year, Public Citizen concluded that "most states … are not living up to their obligations to protect patients from doctors who are practicing substandard medicine."
Furthermore, a 2007 piece in the Journal of Health Politics, Policy, and Law by Grant D. Alfred found that "there are a very large number of repeat offenders among physicians who have received board sanctions." Rehabilitation and promises not to do it again don't always work.
Consider a national database. One way to get around lackadaisical state regulation would be a national database that included all relevant information on employment, complaints, firings, imprisonment, state board sanctions and the like. But this literally would require an act of Congress.
A national database would limit the ability of killers to migrate from state to state undetected. But if control passes from the states to the feds, and the feds choose not to pursue the effort vigorously, then the states would be helpless and there would be no protections. Perhaps a middle ground would be a means whereby states could at least exchange information with each other when a problem arises.
Be aware that these crimes touch — and demean — us all. In a "60 Minutes" interview, Cullen spoke about how easy it was for him to keep killing. At St. Barnabas Medical Center in Livingston, N.J., it was known that he spiked IV bags with insulin. Yet he was able to move on and work in other hospitals. He eventually got a job at St. Luke's University Hospital in Bethlehem, Pa., after being forced out of five other facilities. He observed, "I was caught at St. Barnabas, and at St. Luke's. There's no reason that I should've been a practicing nurse after that. ... They said, 'If you resign, we'll give you neutral references.'"
Let's do whatever is necessary to stop this. Our patients deserve it. Our caring colleagues deserve it. And our field deserves it. As long as even one of these killers operates with impunity among us, we are all demeaned. And we all share their guilt.
Emily Friedman is an independent writer, speaker and health policy and ethics analyst based in Chicago. She is also a regular contributor to H&HN Daily and a member of Speakers Express.