In October 1974, a 3-year-old boy and a 21-year-old man were treated for what appeared to be minor injuries in Marion Memorial Hospital. Both were routinely injected with a common anesthetic. Both died. The anesthetic had been poisoned with the injection of a muscle relaxant that can affect breathing.
Officials at the hospital did not conduct an immediate, thorough investigation. Most hospital employes were not questioned. Hospital officials neglected to tell law enforcement officials about the deaths for four and a half months, putting investigators on a cold, year-old trail. And, if the deaths had been caused by a "bad batch" of drugs, as hospital officials at first suspected, people in eight states could have been killed because no one reported the deaths to the drug manufacturers until three months later.
These conclusions are based on the results of a three-week investigation conducted by a team of Southern Illinois reporters.
Even after hospital officials learned Jan. 24 that the drugs had been contaminated, it took them another three weeks to notify law enforcement officials of the deaths. Williamson County State's Atty Robert Howerton said six other persons who later recovered also are suspected of having similar, but not fatal, reactions to the drugs at various times between August 1974 and January.
It took hospital officials more than three months to submit samples of the drugs for testing. Tests showed they were contaminated with another, deadly drug. Hospital officials finally notified law enforcement officials of the deaths Feb. 18, more than four months after the first victim died.
On Sept. 21, 1974, Jimmie Dean Watson, 21, of Marion, cut his foot in an auto accident. At the hospital emergency room he was administered Proteaine, a local anesthetic. Within minutes he went into convulsions and had several heart attacks. He was transferred to St. Lukes Hospital in St. Louis, where he died Oct. 5.
On Oct. 2, 1974, 3-year-old Brian Schutzenhofer of White Ash was ad-ministered Blockain, another local anesthetic, after he hit his head in a fall. He stopped breathing and died several minutes later. The next day a similar reaction occurred in Michael Simmons, 15, of jural Marion, after he was given Procaine for a cut over his eye. But he survived to tel1 about it. Simmons said after, he was given the shot, "It started getting bad. I couldn't hear. I couldn't see. I was about half gone. I couldn't move a muscle."
A similar reaction was noted in Lonnie Barnes, 26, of Marion, after he was administered an anesthetic Aug. 27, 1974. Barnes also recovered. At first his was thought to be another case involving adulterated drugs. But Michael Wiseman, director of the Williamson County Detective Unit, said Barnes' case now has been ruled out. Barnes said he does not know whether he was administered Procaine, Blockain or a third anesthetic.
Pathologists' reports on both the Schutzenhofer boy and Watson "could not objectively pinpoint the cause of death," Howerton said. Dr. H.T. Merrell, now with the health service at Southern Illinois University-Carbondale, treated both the Schutzenhofer boy and Simmons while practicing in Marion. Dr. Merrell said he suspected something was wrong with the drugs after Simmons had the reaction. "I don't know what I had in mind," he said. '"I just knew something was wrong because two nights in a row these people stopped breathing."
Dr. Merrell said be ordered that all open bottle of drugs in the emergency room be turned over to Nolan England, the hospital administrator. "To my knowledge, all the vials that were open were gathered up and taken to Mr. England." From early October until January — nearly three months — the vials of local anesthetics apparently remained in England's possession. No tests were made on-the drugs'until Jan. 10, when samples of one of the drugs were delivered to Abbott Laboratories in North Chicago for testing.
Kenneth Powless, chairman of the hospital board, said be does not know what England did with the anesthetics during that time. England refused to comment, referring all questions to Powless. When the test, results were returned at the end of January it was discovered that both vials of local anesthetics contained lethal quantities of succinylcholine chloride, a muscle relaxant most often used in operating rooms. The Blockain contained less of the relaxant than the Procaine, but both had high concentrations. Howerton said since the three drugs all are manufactured: by different companies, the possibility the drugs became mixed at the factory is highly remote.
The succinylcholine chloride comes in powder form that must first be mixed, or in a liquid form that must be refrigerated. Howerton said the mixing of the relaxant with the anesthetics, which are clear liquids, had to be deliberate. He said a syringe would have to be inserted through a self-sealing rubber top on the, anesthetics in order- to add the relaxant.
Powless said England told him of the deaths shortly after they occurred and he told England to have the drugs tested at an independent laboratory. He said he did not know the exact date he found out about the deaths. He said he assumed the drugs were being tested until he asked England about them in December.
Powless said he was running an unsuccessful campaign for circuit judge in Williamson Couniy at the time of the deaths, and said he only verbally approved England's reports to him before December. He did not specifically ask about the attempts to test the drugs until then, he said.
He said he was trying to protect the families of the victims by having the drugs tested at an independent laboratory. He said if the drugs were from a "bad batchy" the families could file lawsuits against the companies.
Powless said England told him he tried to have the drugs tested and was turned down by several laboratories. In a statement to hospital employes, Powless said, "The reason for their declining was stated to be some regulation or directive, but it was interpreted as just not wanting to get involved." Powless said he does not know what laboratories England contacted, and England again refused to answer questions.
Most drugs are manufactured high large quantities, called lots, and the lot number is printed on each of 10,000 to 15,000 bottles that are distributed from each lot. A spokesman at Abbott Laboratories in Chicago said one lot can be distributed to hospitals in as many as eight states, and a "bad batch" could have affected patients in all those hospitals. "If it was a bad batch people could have been killed all over the world" because of the hospital officials' failure to notify the drug companies immediately of the deaths, Howerton said.
Dr. Merrell said he was busy closing out his Marion practice and preparing to go to SIU-C after the deaths, and did not ask about the drugs again. I assumed something was probably being done; maybe they were secretly analyzing them,'' he said.
Glen Reed, pharmacist at the hospital, said he heard about the deaths and occasionally questioned England about whether the anesthetics had been tested. England told him he had written and was awaiting a response, Reed said. While England kept the apparently contaminated vials of local anesthetics he also was keeping two vials of a muscle relaxant called Anectine that were found at the hospital about Oct. 1, 1974.
Anectine is a brand name, for succinylcholine chloride, the drug that later was found to be contaminating the local anesthetics. The vials of Anectine were found by William G. Flack, who helped organize the hospital's respiratory therapy department. Flack said he found the vials in an open common locker in the respiratory therapy department at the hospital. He said he turned the. vials over to William Houlihan, a nurse-anesthetist to whom Flack reported.
Houlihan, however, said the vials were found on the parking lot at the hospital, and, said he did not know anything about any vials found in the locker. Howerton later said he had confirmed the drugs, were found in the locker. Houlihan said, he turned the bottle's over to Administrator England. The bottles, which were unopened and sepled, apparently remained in England's possession, along with the contaminated drugs; until i the law enforcement investigation began in February. England refused to say what he did with them.
The fact that the bottles of Anectine were found in the respiratory therapy department is unusual. Respiratory therapists do not use the drug in their work, nor are they supposed to have access to it, according to several of the therapists.
Reed said at the time of the deaths Aneotine was kept both in the pharmacy and the operating room, which was next to the emergency room until a recent remodeling. Reed said Anectine was used by nurse-anesthetists, who often would check out as many as 10 vials from the pharmacy for use ih the operating room. He said that during an inventory after Flack found the two bottles, "We knew what we had in stock but not what was in the operating room."
Powless said after their death and after the Arectine was found, hospital officials reviewed and revised medical, and emergency room supply procedures. After that revision, Powless said, some drugs were locked up to prevent unauthorized persons from handling them. Despite the fact that Anectine should not have been at their work, nor are they supposed to have access to it, according to several of the therapists.
Reed said at the time of the deaths Aneotine was kept both in the pharmacy and the operating room, which was next to the emerge'ncy room until a recent remodeling. Reed said Anectine was used by nurse-anesthetists, who often would check out as many as 10 vials from the pharmacy for use in the operating room.
He said that during an inventory after Flack found the two bottles, "We knew what we had in stock but not what was in the operating room." Powless said after the death and after the Arectine was found, hospital officials reviewed and revised medical,and emergency room supply procedures.
After that revision, Powless said, some drugs were locked up to prevent unauthorized persons from handling them. Despite the fact that the Anectine should not have been in the respiratory therapy department, and despite the two deaths, no formal questioning of hospital employes ever was made by the hospital, according to Powless.
All the time time the cases were under study, Powless said, the families of the-victims were not notified. He said he wanted to be sure of the facts before telling the families.
While hospital officials were waiting to have the anesthetics tested, another person had a severe drug reaction. Allen Lindsey, 21, of Scottsboro was in the hospital Jan. 5. after he had been accidentally shot in the leg while hunting. The buckshot had been removed and he was hooked up to an intravenous bottle (IV) to replace lost fluid in his body.
Lindsey said he noticed someone came in the room and "put a little bottle" on the IV. He said within .a few minutes he felt so bad he told his wife to call a nurse. He was removed from the IV, but soon went limp again. Lindsey said he does not remember what happened, but he was told he was given mouth-to-mouth resuscitation, then put on a ventilator bag and an inhalator machine to help him breathe.
After that incident Lindsey was on a heart monitor in the intensive care unit for five days. Lindsey said he does n o t know who put the smaller bottle on his IV. He said someone told him that a doctor "put some stuff in the bottle" and the doctor now is working in St. Louis. Lindsey said he does not remember who told him about the doctor and cannot recall the description of the person putting the smaller 'bottle on his. IV. No doctor has left the hospital to go to St. Louis since Lindsey was treated.
Law enforcement officials, including Howerton and Wiseman, could not confirm that Lindsey was one of the six possible other cases involving contaminated drugs. Both said Lindsey's medical records are being studied, but Lindsey said he has not talked to any investigators. Howerton said Lindsey's IV bottle, like others for other patients, apparently was thrown out and was not available to investigators.
Shortly after Lindsey was admitted a sales representative from Abbott Laboratories took a sample of the Procaine from England, who had been keeping the drugs since Oct. 3. The representative took the sample Jan. 10 and delivered it to Abbott's North Chicago laboratory. Abbott manufactures Procaine. A spokesman for Abbott said the tests on the Procaine. were completed Jan. 24, and the hospital was notified the same day that the sample was contaminated.
Samples of the Blockain were deliveredv to Abbott, Jan. 29, and the test results were ready Jan. 30, when England and Powless flew to Chicago to get more complete results. Powless said they went to Chicago because they wanted to determine whether the adulteration could have been accidental, and to make sure they understood the test results.and their implications.
The tests showed the Procaine had succinycholirie chloride in concentrations of 80 to 120 milligrams per milliliter, and the Blockain had 10 to 20 milligrams per milliliter. A spokesman for Abbottt said the Pracaine was not tested as soon as it was received because, "It was a low priority. It had already been so long (since the deaths) we didn't see any need to rush."
From Jan. 30, when England and Powless received the test results, until Feb. 18, the hospital apparently did little more than ask the Federal Bureau of Narcotics to confirm that the contamination of the drugs could not, have been accidental. In the meantime, some key persons left the hospital and the area.
Flack, the man who said he found the sealed bottles of Anectine had been dismissed from this job at Marion by England shortly after the test results on the anesthetics were received, and was continuing in his job as head of the respiratory therapy department at Doctors Hospital in Carbondale. He since has transferred to a Kirkwood, Mo., hospital.
Powless said "some stories we heard" about Flack convinced him Flack should be dismissed, so .he told England to dismiss him. He would not. elaborate on what the "stories" were. England again refused comment.
Another respiratory therapist, David Dobbs, had completed his courses at Southern Illinois University-Carbondale and had taken a job in a hospital in Colorado Springs, Colo. It was not until Feb. 18, more than four months after the two deaths and one near death, that Powless went to Howerton with the story.
Asked why he waited so long to inform law enforcement officials, Powless said the hospital officials were not sure anything was amiss in the two deaths until the test results were received. Howerton then picked up on the investigation, followmg a trail that already was months old.
UNDER CONSTRUCTION