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 âcodeâ 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 Jagodowskiâs room at a frantic pace. Securityâwhich was required by hospital policy to send a representative to each codeâarrived 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 âclear!â and then shocked Jagodowski with paddles, he was brought back to life, put on a ventilator, and transferred to the ICUâwhere his real troubles were about to begin.
CHAPTER 2
Stanley Jagodowskiâs daughter, Susan Lessard, received a phone call from the VAMC around 9:30 that same night.
âYour fatherâs heart stopped,â the nurse said. âCome to the hospital right away.â
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 Claireâs 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, heâd complain, because the pain had become so severe.
But ever since the amputation in July, Lessard noticed, her father had been feeling much better.
âIt was written on his face,â she later recalled. âHe looked one hundred percent better. He was more relaxed.â
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 weekâs vacation with her family. She felt comfortable about leaving, she said later, because her father seemed to be in great spirits.
âI would not have gone on vacation unless he was improving.â
On Friday, August 19, Lessard, her husband and two kids returned home to find that things hadnât really changed much. She checked with her mother and was told that her fatherâs condition, if anything, had improved since sheâd 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 âpull him out of the state he was inâ 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, âDaddy, please squeeze my hand.â
Jagodowski would, clamping down