Blind Eye: The Terrifying Story of a Doctor Who Got Away With Murder (11 page)

Knowing this history, Dickson considered the possibility that the doctors’ first instinct might be to rally around Swango, a fellow doctor. She had seen how protective of one another doctors were, both at Ohio State and in other hospitals where she had worked. Yet these circumstances were extraordinary, with the lives of patients possibly at stake. She took the lead, presenting the evidence she had been able to collect during the course of the day. She reviewed the
Cooper incident, described Utz’s observations, mentioned the syringe found by Risley, and briefly reviewed the McGee, DeLong, Walter, and Barrick cases. Then she listened with mounting dismay as the doctors undercut the gravity of her disclosures. She thought the doctors seemed more concerned about Swango’s rights than they did the patients’ lives.

Hunt immediately cast doubt on anything Utz might have said, noting that she was awaiting treatment for a brain tumor. The group discussed what might have caused Cooper’s respiratory arrest, and while conceding that a toxic drug might be one explanation, the doctors noted that there might also be many others.

Dickson and Boyanowski thought the evidence was sufficiently serious and compelling that the police should be notified. Cincione, the lawyer, disagreed and said there was no evidence any crime had been committed, nor was there enough evidence to know how to proceed. Cincione recommended that the hospital’s medical staff—the doctors—conduct a discreet internal investigation.

Dickson, Boyanowski, and Cramp all thought it was a mistake for the hospital to try to investigate itself, but they deferred to Cincione’s legal judgment. Dickson was expressly ordered not to question any nurses further—this because of the fear, first expressed by Dr. Goodman, that to do so would only fuel the nurses’ “tensions and concerns,” which might in turn alarm patients. Instead, Goodman himself, who from the outset had been highly skeptical of the nurses’ claims, took charge of the investigation. He agreed to report his findings to the group at a meeting the following Saturday morning.

The meeting ended at about eight
P.M
. Swango had been sitting on a bench in the lobby. Dr. Carey suggested he “go home for a few days” because of the incident report. Swango took the news calmly.

Dickson was upset by the meeting, but felt if she could only get her message across to Tzagournis, whom she knew and respected, he would surely recognize how serious the situation was. She couldn’t reach the dean, so she called Holder, the assistant attorney general, who had been briefed on the meeting by Cincione, to try the same tack. She asked him to meet with her in her office, which he did the next day. Holder insisted on deferring to Cincione’s judgment that there wasn’t any credible evidence of a crime
and they should await the results of Goodman’s investigation, but he did agree to pass on Dickson’s request to meet with Tzagournis. The next day, Dickson narrated the alarming events to the dean; she thought he at least listened carefully. Tzagournis seemed to recognize the gravity of the matter, and though he made no commitments, she felt she was making headway.

On February 9, the day after the meeting, Goodman began what would prove to be a pivotal investigation of Swango’s activities. His investigation had three components. At 3:30
P.M
., he interviewed Cooper; next, he reviewed the files of seven patients who had died since Swango began his neurosurgery rotation; last, he considered the results of a blood test on Cooper. He did not interview either of the residents, Freeman and Brakel, who responded to the code on Cooper. Had he interviewed Brakel, he would have learned more about Swango’s involvement in Ruth Barrick’s death the same day, since Brakel had responded to Barrick’s code as well.

Nor did Goodman interview any of the nurses who witnessed the events, or the orderly who discovered the syringe, or Utz, Cooper’s roommate. He did not ask to see the syringe, still in Nurse Moore’s custody. He didn’t speak to any witnesses to any of the patient deaths, such as Nurse Ritchie. No autopsies or physical tests were ordered for any of the possible victims, nor were any experts in toxicology or anesthesia consulted for possible explanations of the deaths and of Cooper’s apparent paralysis. While Goodman did not purport to be a trained investigator, the extremely limited scope of his inquiry is hard to comprehend unless he had already largely concluded that Swango was innocent and that the nurses’ “grapevine,” as he had put it, was largely to blame for the rumors sweeping the hospital. These were sentiments he had expressed from the outset.

The following statements appear in a memorandum Goodman wrote the next day, summarizing the interview with Cooper: “Someone was standing by the bed and injected something into the I.V.”; “Blonde, short, unable to see face”; “Yellow pharmacy jacket.”

Goodman’s principal reaction to the interview seems to have been distress that Cooper was spreading stories that were agitating other patients. He called Cramp, the hospital chief, at 4:30
P.M
. to complain that rumors about Swango were “rampant” on the floor
and to say he was moving Cooper to a private room to stop them. Although Cramp objected, Goodman did so. He also ordered that only Amy Moore, the head nurse, would be allowed contact with Cooper; this move, too, was intended to contain her inflammatory allegations.

That Saturday morning, the initial group involved in the matter met to hear Goodman’s report and conclusions. Three important people joined this meeting: Holder, Tzagournis, and Michael Whitcomb, the hospital medical director, a close friend and protégé of Tzagournis. Although Dickson and others had urged that the university president, Edward Jennings, and Richard Jackson, the vice president, attend, Tzagournis had decided that there was no need.

To Dickson’s amazement, Goodman was even more dismissive of the allegations against Swango than he had been at the first meeting. His interview with Cooper, he assured the group, had gone a long way toward eliminating the possibility that Swango had been involved in foul play of any kind. Goodman reported that Cooper had identified the alleged assailant as a “female” and “neither a nurse nor physician on the hospital staff.” Since his notes also indicated the person was wearing a “yellow pharmacy jacket,” he concluded the suspect was probably a woman pharmacy technician, and he had already determined that there was no one who fit that description.

Virtually everything about Goodman’s conclusions and interview with Cooper is puzzling. Cooper insisted she never described her assailant as a “female.” Indeed, in her numerous other accounts of the incident, Cooper said consistently that she couldn’t see the person’s face, and whenever she identified her attacker’s sex she said he was male. In her first handwritten note she referred to the assailant as “he.” Nor, she maintained, did she ever mention anything about a yellow pharmacy jacket; her roommate
did
refer to a yellow tourniquet. Goodman said that Nurse Moore was a witness to the interview and, by implication, would support his account. However, Cooper herself said she remembered that only Goodman was present.
⁵
In any event, at the time participants in the meeting had only Goodman’s version.

Goodman also reported on his review of the files of patients who died. While he conceded that seven deaths in a little more than two weeks was abnormally high (he said the norm was two or three), he said that all the patients had been “extremely ill” and that the deaths were “clearly explainable medically.” As another doctor put it, sometimes the “grim reaper of death” just sweeps through a hospital. While Goodman also conceded that Swango had been present when at least half the patients died, this was only to be expected given that he was an intern assigned to the floor, working long hours. The only death that caused Goodman any concern at all, he said, was that of Cynthia Ann McGee, the young gymnast. Goodman noted that she had been improving and that the sudden death had come as a surprise. But an autopsy had been performed, and Goodman said he’d been told the cause of death was a pulmonary embolism. Such embolisms aren’t uncommon in cases where patients have been transported, as McGee had been from Illinois, he explained. Goodman’s colleague and mentor Dr. Hunt said he, too, had reviewed the patient files and seconded Goodman’s conclusions.

McGee’s autopsy results in fact cite “cardiopulmonary arrest due to incipient pneumonia” as the cause of death. There is no mention of a pulmonary embolism.

Finally, the group discussed the results of the blood test on Cooper. But no such blood test results were ever found in Cooper’s medical file. It is at least possible that the blood test ordered by Freeman was never administered, or that the results were lost. The notes of the meeting don’t make clear whether Goodman reviewed the results himself, or relied on a hearsay report that they were normal. In either case, the results may have come from a blood test given Cooper when she entered the hospital; they were in her file and, not surprisingly, showed nothing suspicious.

That was the end of the investigation as far as Goodman was concerned.

The group did consider some troublesome evidence that seemed to call Goodman’s conclusions into question. Dickson, for example, circulated the written eyewitness accounts of the Cooper incident she’d collected from the nurses, including Karolyn Beery, who had been only several feet from Swango when she saw him inject something into Cooper’s IV line. She also showed the meeting
participants Cooper’s handwritten notes. Dr. Carey reported on his conversation with Swango, in which he denied injecting anything into Cooper’s IV, a statement also in conflict with Beery’s observations. But the doctors, especially Goodman and Whitcomb, dismissed their significance, noting disdainfully that Beery was a student nurse. “What does a student nurse know?” one of the doctors asked, to knowing snickers around the table. The comment left Dickson quietly seething.

Swango’s file was reviewed, and the group discussed the evidence suggesting that he had “attitudinal problems.” Carey mentioned the residents’ reports that Swango had “weird ideas about death,” that he was fascinated by the Nazis, and that his work was “sub-standard.” But Cincione’s sketchy notes of the meeting conclude only that “this discussion shed no light on the situation at hand.” Nor could any support for the proposition that a pharmaceutical technician was the culprit be produced. Boyanowski, the administrator, had investigated that possibility, and there were no “blonde, female” technicians. Cooper hadn’t been scheduled to receive any medication during the relevant time period.

The group also discussed at some length what might have caused Cooper’s respiratory failure, a fact which could hardly be ascribed to nurses’ paranoia. Potassium was mentioned as a chemical that, when injected, can easily cause cardiac arrest, but the doctors pointed out that Cooper didn’t suffer a heart attack; she experienced a respiratory failure. Her IV line had been discarded, so no tests on it were possible. Curiously, the mention of possible tests on the IV line triggered no mention of the syringe by Goodman, although he had been told of its existence by Nurse Moore. The group concluded that the cause of Cooper’s seizure was probably unknowable.

Then the lawyers weighed in. Without knowing the cause of Cooper’s code, Cincione told the group, they had no legal basis for accusing Swango of a criminal act or, for that matter, even removing him from the intern program. But while the lawyers seemed to have been focusing on Swango’s rights and the potential liability of Ohio State, they seem to have given no consideration to an Ohio statute that requires any “physician” to report “any serious physical harm to persons that he knows or has reasonable cause to believe resulted
from an offense of violence.” In any event, these requirements were never mentioned at any of the group’s meetings, despite the presence of two lawyers, Holder and Cincione.
⁶

The meeting lasted about three hours. At its conclusion, Tzagournis ordered that Swango be returned to the hospital, but watched closely. He asked Dr. Whitcomb to conduct a “quiet inquiry” into the matter, and report his findings at another meeting in three days. At least some participants understood that the report was to be in writing. Both Dickson and Boyanowski objected, again arguing that the hospital couldn’t effectively investigate itself, and that there was enough evidence to justify notification of the campus police. But Tzagournis disagreed, no doubt in part because he was steeped in the medical profession’s tradition of “peer review,” in which only other doctors are deemed competent to evaluate a fellow physician. Dickson, increasingly troubled by the direction of the inquiry, asked if she could assist Whitcomb by at least being present at interviews with the nurses. Tzagournis said no.

As Ohio State’s medical director, Whitcomb held the number two medical position in the hospital, just under Tzagournis. Like his boss, Whitcomb was an Ohio native and graduate of Ohio State, though he attended medical school at the University of Cincinnati. He worked at Walter Reed Army Hospital before returning to Ohio State in 1974. He was largely given responsibility for the investigation by virtue of his position as medical director, and because he was a pulmonologist, or lung specialist, it made some sense to assign him to investigate what appeared to be a respiratory failure.

But Whitcomb looked terrible, as if he hadn’t had much sleep. It hadn’t surprised anyone that he couldn’t be located in time for the first meeting. It was much discussed in the hospital that he had been having an affair with his secretary, and was involved in a messy divorce. At the meeting Whitcomb’s hands were visibly trembling, so much so that Dickson later asked if he was suffering from some neurological condition. (He later publicly acknowledged a drinking problem.)

Some who felt Swango should be vigorously investigated were
dismayed that Whitcomb was put in charge, and their concerns were soon borne out, for Whitcomb’s investigation was even more cursory than Goodman’s. He spoke to Goodman and reviewed his notes; interviewed Beery, the student nurse; and, significantly, interviewed Swango. He did little else. Incredibly, he may not even have interviewed Rena Cooper, relying instead on Goodman’s notes. (Cooper later insisted that Whitcomb never interviewed her.) Whitcomb kept no notes of his investigation and prepared no written conclusions. He delivered his report orally on February 14, 1984, to the same audience, which included Tzagournis and Holder.