From Serial Productions: The Retrievals

The patients had generally two kinds of questions about what went on at the clinic. The first kind of questions were about the system.

But most of the patients never got to ask those questions. Staffers were told not to talk with patients about what happened with the fentanyl. And for some of the patients, it was hard to bring up to.

The staffers I spoke to did care, and yet this happened. How? From Serial Productions and “The New York Times,” I’m Susan Burton, and this is “The Retrievals.” This is episode four, The Clinic.

[THEME MUSIC]

It was hard to find staffers who were willing to speak about what happened at the clinic. Some of the reticence had to do with the fact that there’s an ongoing lawsuit. Six months after Donna was sentenced, several patients filed a complaint against Yale.

Over the next few months after that, more and more patients joined.

Now, there are almost 70 patients in the lawsuit in all. But the lawsuit says about how long Donna was doing this is a lot longer than what she says about how long she was doing it. Donna told investigators that she started stealing fentanyl and replacing it with saline in June 2020 when the clinic was located in a suburb of New Haven.

But patients and their lawyers believe that she began doing it before then when the clinic was located in New Haven proper. About half the patients in the lawsuit say they experienced severe pain before June 2020. Some as far back as 2017. Here’s Lynn, a special ed teacher who had, maybe you remember this number from the first episode, eight painful retrievals at the clinic.

Again, Donna did not respond to my request to speak for this story. 200 patients may have been affected during the five-month period Donna admits to stealing fentanyl. If she started earlier, she could have affected 100 more.

One of the lawyers who represents Lynn and other patients is named Josh Koskoff. He’s well known for his suit against the gun manufacturer in the Sandy Hook school shooting and the related case against Alex Jones. Early on, when Josh started getting calls from a lot of patients who said this had happened to them before June 2020, he felt like he should share that information. He contacted the US Attorney’s office and —

When I presented this to Yale they responded that the Department of Justice had conducted a thorough investigation and concluded that this took place specifically from June through October 2020. Yale declined to make anyone in a position of oversight available for an interview with me. But I did talk to staffers, people who worked at the clinic alongside Donna.

You won’t be hearing from them on tape. None of them wanted to be identified for fear of being retaliated against or losing a job. I don’t think it’s going to come as a surprise that I didn’t talk to any doctors who were like, yeah, for months, patient after patient was screaming and cursing me out. And looking back, I guess I should have done something about that.

If there is such a callous doctor, they did not respond to me. The people I talked to were talking to me because they were troubled by what had gone on at the clinic. Some of them had left. But this wasn’t about a vendetta, as one staffer put it to me. This was about telling what happened to prevent it from happening again.

I wish I could write about the staffers, like I’ve written about the women as a cohort with a shared experience and also as individuals whose identity shaped the way they made sense of it. But I can’t offer details about anyone I spoke to. This makes the way I approach the story of the clinic a little more forensic, a little more procedural, a little more like a case study in drug diversion, which is what stealing drugs in a medical setting is called. And this clinic could be a case study in how that happens and how it is missed.

I’m going to start the story in an office the clinic occupied for years, an office in an older building in a medical complex off I-95. The Long Wharf exit. And I’m going to start in the retrieval room with the drugs they use there, fentanyl and midazolam.

These drugs are one of the first things most staffers I talked wanted to make sure I understood. There’s a lot of variation in the way patients responded to these drugs. Some were out of it. Some were alert, even giddy, singing along to the pop songs, playing at a low volume on the radio.

And for some patients, the drugs were not effective enough. Even the maximum dose of fentanyl was not enough to manage their pain. Even when that fentanyl was actually fentanyl, the highest dose might not be enough for a bunch of reasons, like existing tolerance to narcotics, challenging anatomy. Sometimes a patient would be in so much pain that she would be kicking and screaming.

How often would something like that happen? One or two times a year was when answer I got. Another person said even less. So that kind of extreme response was unusual, but not unknown. But these drugs didn’t treat pain 100 percent for all patients. With the medication approach that was used at Long Wharf, one staffer told me, this procedure can hurt.

[MUSIC PLAYING]

Maybe 25 years ago, moderate sedation, like this fentanyl and midazolam combo, used to be standard retrievals. But it’s not anymore. Today, what’s more common is deeper sedation with propofol administered by an anesthesiologist or nurse anesthetist. At Long Wharf, a fertility nurse gave the drugs. And there was a limit to how much they were allowed to administer.

When I told one fertility doctor from another clinic what Yale had used at Long Wharf she said, I’m shocked they do that with fentanyl and midazolam. In my opinion, that is not enough for this procedure. She wondered if it was a money saving thing.

But another doctor, who’d done hundreds of retrievals with fentanyl and midazolam back in the day and sometimes still does, said in her experience, this combination was absolutely fine. That as long as it was working properly. There wasn’t anything wrong with using it.

And staffers at Long Wharf said that retrievals were generally fine. But they wanted deeper sedation. The bottom line is that you want patients to be comfortable for their own sake, and because comfort is necessary for safety. There’s a long needle inside the pelvic cavity. Sudden movement presents a risk.

I wondered why Long Wharf didn’t have deeper sedation. Staffers had different and often vague understandings of the reason. Something about the oxygen access, one staffer said. But whatever the practical reason for not getting better anesthesia was, there was also a cultural one.

There’s a ton of just inertia in trying to get things done at Yale, the staffer said. And I think if someone in a position of administrative leadership decides that something is not that important, then it just doesn’t happen.

So this is the baseline. This is the context. For years and years, Yale is giving these drugs that offer a relatively light level of sedation for this procedure. Patient response to these drugs varies. Some pain has been normalized.

One of the things I wanted to know from staffers was if there was a point when they’d started seeing more pain than usual. Nobody could identify an exact date. But some people did remember something changing before June 2020, the date Donna confessed to.

As one staffer put it, I remember a shift in feeling like we were doing things reasonably well and pretty much achieving our goals of minimizing pain. And then gradually, it didn’t seem like we were. A nurse recalled, I remember distinctly times a patient would say, oh, my God, I feel everything.

I looked at the physician and said, I gave the max. What can I give? Whether it was water, I don’t know. In hindsight, it makes you think it had been water. Not everyone was seeing this.

Retrievals were divided up among a lot of different doctors and nurses at the clinic. Often, doctors weren’t even doing retrievals on their own patients. But staffers who did register that something seemed off started coming up with theories to explain it, stories, the way everyone here did.

One theory was just the basic, we need better anesthesia. Another, there was a new manager, and there was a lot of frustration with her. Nurses were leaving the clinic, and those who remained were spread thin.

Could that have something to do with it? But also, and this was the theory I heard most consistently, maybe it was because of this one doctor, someone who didn’t have great hands, as one staffer put it to me, or a great bedside manner. One staffer told me that all of the nurses were talking about how, in retrievals, this doctor would be like, if you don’t stop yelling, I’m just going to leave.

Another recalled of this doctor that, quote, their response was more often kind of an impatient. I can’t do this unless you stop moving, kind of almost scolding the patients for the discomfort that they were having. During this time, a doctor from Yale’s family planning service was invited to the clinic to speak to staffers about how to be more gentle during procedures.

Some staffers were offended by the idea that they needed a refresher course. One said, we had this very sort of condescending talk about how to treat our patients and how to be empathic and responsive. I mean, the whole thing was just like, what is happening here? Are we all being subject to this insulting training because of one person?

One theory that none of the staffers I talked to had was that a colleague was stealing drugs. That’s usually how it works with diversion. People don’t suspect their coworkers. But increased complaints of pain are a known sign of drug diversion.

And leadership is responsible for seeing the big picture. And if a manager was aware enough of pain to invite someone to speak on it, they should have investigated all possible reasons for the pain, including the drug supply.

Probably, the most basic step in preventing diversion is how you handle and store the drugs in the first place.

At Long Wharf, these systems were not great. For one, the Long Wharf clinic didn’t have a Pyxis, a kind of secure vending machine for drugs that records each transaction. A machine is not a solution for poor oversight, and not every outpatient setting has one of these machines.

But two patients who worked as nurses were shocked that the clinic didn’t have a Pyxis. I can’t even take something as simple as a Tylenol out of the Pyxis without somebody wanting to know which patient it went to, when it was given, how much was given, one of them told me.

A staffer at the Yale clinic told me that when they wandered to a manager why they didn’t have a Pyxis, they were told Yale didn’t want to buy one because it was too expensive.

The way drugs are procured is supposed to be tightly regulated too. Because obviously, that’s a point where they could be pocketed. At Long Wharf, at least some of the clinic’s drugs came from Walgreens, including fentanyl, like it was somebody’s job to run out to Walgreens and pick up fentanyl. It sounds weird, and it was, even to people who worked at the clinic.

Staffers told me that when Donna had this job, she had often been insistent in trying to get doctors to sign the prescriptions she needed for the drugstore. One staffer remembered, she’d be very, very, very aggressive. Another said that Donna was constantly harassing fellows to write scripts for patients that were going to be done the following week.

At the time, both of these staffers attributed this to a kind of mania for organization, but both also clocked it as odd. It was, OK, she’s like super efficient, one of them said. She’s trying to get her job done so she can go home to her kids, take her kids to their activities.

In early 2020, the clinic moved out of the Long Wharf office to a newly renovated building in Orange. Almost immediately, the pandemic started. One patient remembers shaking her doctor’s hand on like March 8, and the handshake already feeling a little strange. The clinic shut down for a while. And by the time things started up again, it was June 2020, the month that Donna says she started stealing fentanyl.

[MUSIC PLAYING]

At the new building, there were new drugs. Now, patients were offered deeper sedation. Anesthesiologists came to the clinic for most retrievals, adding powerful sedatives like propofol into the mix with fentanyl and midazolam. Some staffers noticed a difference right away. The patients were more deeply asleep, one of them said to me.

It was more like a full on surgery. By comparison, they looked tremendously comfortable. But propofol, isn’t a pain drug. It just kind of knocks you out. And to the fertility doctors, that deeper sedation likely masked the fact that some patients weren’t getting fentanyl.

So in the procedure room, some patients appeared comfortable. But in the recovery room, some of them came to in severe pain. At home, some continued to feel severe pain. And that part didn’t make sense to several doctors I spoke to, people not from Yale.

Fentanyl is short acting. Maybe it would cover pain for up to a half hour after the procedure ends. But that’s probably it. So how to explain the severe pain patients felt hours later or the next day? People I talked to didn’t doubt the patients were in severe pain. They just didn’t know where it was coming from.

But any patient in severe pain after an egg retrieval should not have been discharged, doctors said. It’s just not supposed to hurt that much. And severe pain is a sign that something might be really wrong.

[MUSIC PLAYING]

When Donna got to Orange, she basically took over the drugs. In March 2020, two months before she says she started stealing fentanyl, she completed an application with the DEA that allowed her to sign controlled substance orders. She was in charge of ordering drugs for the clinic.

The room where the drugs were stored was sometimes unlocked, and Donna was able to enter without swiping her access card. Obviously, things went wrong with this setup. And even more things went wrong with this setup than were reflected in Donna’s criminal case.

Days after the loose cap was first discovered, the DEA investigated the clinic. Their audit found that a lot of drugs went missing under Donna’s watch. 6 percent of the ketamine, 24 percent percent of the midazolam, 35 percent of the fentanyl. This is in addition to vials she tampered with.

These are hundreds of other missing vials that just who knows what happened to them. It’s possible that this was just very bad record keeping. The records from this time are messy, handwritten logs. But was Donna also stealing the midazolam and the ketamine? It is speculation to ask, but it is also weird not to ask, given that she was stealing the fentanyl.

No matter what happened with those drugs, these are serious discrepancies. Yale agreed to pay the DEA $308,000 fine to settle these and other violations of the Controlled Substances Act. So that’s accountability on a regulatory level.

On a personnel level, just who was or was not looking at those logs? Who was managing Donna? A staffer I spoke to emphasized the lack of oversight during this time. The nurse manager was new, and it was summer 2020, the pandemic.

The clinic was operating with a skeleton crew, is how this staffer described it. A lot was happening on Telemedicine. In retrospect, it was ripe for abuse, the staffer said.

[MUSIC PLAYING]

The pandemic made it easier for Donna to hide what she was doing. But there is one thing that would have been very hard for her to disguise, how did nobody notice that she’d tampered with the vials, especially the caps? People I talked to who work with fentanyl vials were just kind of blown away by that.

The caps on these vials pop off, and it would be impossible to reseal them the way they came. Of course, ultimately, an anesthesiologist did notice a loose cap. And now, the problem wasn’t that the fentanyl diversion was hidden. The problem was with how it would be addressed.

The loose cap was discovered on a Friday. And the following week, the news was shared, fentanyl was missing. It was almost immediately clear that Donna was under suspicion. Poor Donna, one staffer remembers a manager saying.

The staffer thought, poor Donna. Poor patients. Lawyers advised staffers not to talk about this even among themselves. It was all basically about protecting Yale, one staffer remembered. Nobody cared about anything that we went through as providers.

No one cared what patients went through. It was all just sort of minimizing this as much as quickly as possible. The staffers I talked to emphasized that what they went through was nothing compared to what the patients went through. But they had also been betrayed by Donna.

And now, they had to wrestle with the repercussions of that, what cues they might have missed, what it meant to have caused pain to their patients, or to not have recognized the pain they were in, or the reason for it. Obviously, they were going to talk about it with one another. I mean, there was constant talking, one staffer said. That just wasn’t realistic. I’m sorry. It’s crazy. We can’t keep working and not vent and provide support to each other.

Six weeks after the loose camp was discovered, Yale sent out that letter that infuriated patients, staffers too. I found that letter so offensive, said one of them. The letter was an official story, Yale told about these events. And the staffer and some of the patients had the same reaction to this story. As it was told in the letter and would be told later, the story evaded. It blame shifted. It focused attention onto a person and away from the institution.

It is a source of deep frustration for many of us that the party line up and down has been about one bad egg, a staffer told me. I would have liked to see my institution acknowledge mistakes, apologize to patients for a systemic failure on Yale’s part, take ownership, and clearly outline steps to prevent this from ever happening again.

[MUSIC PLAYING]

Two former staffers gave me the same reason for leaving the clinic, that they felt they could not provide good patient care. To be, quote, “not proud of the carrier providing and constantly apologizing. It’s just exhausting,” one staffer said to me. In the end, the staffer felt that good patient care was not the driving force at Yale. It wore me down. I got really tired of feeling like I was expressing the same patient care concerns and either being told that someone was working on it, or that it wasn’t an issue.

[MUSIC PLAYING]

While Yale declined to answer almost all of my questions, they did offer me a statement. Yale deeply regrets the distress suffered by some of its patients when a former nurse at the Yale fertility center diverted pain medication intended for patient procedures. After Yale discovered the nurse’s misconduct, it removed her from the center, alerted law enforcement agencies, and notified patients who might have been affected. The center also reviewed its procedures and made changes to further oversight of pain control and controlled substances.

That phrase, pain control. It wasn’t part of the earliest statements Yale gave about these events, at least not the ones I’ve seen. As if it took them a while to understand the issue here, not just the institution’s failure to control drugs, the institution’s failure to control pain. How to think about that pain as a patient and as a practitioner? That’s coming up after the break when episode four of the Retrievals continues.

[MUSIC PLAYING]

Early on in my reporting, a staffer suggested to me that not all of the patients in the lawsuit had actually been victims of Donna’s crime. Could their pain just be the reality of the retrieval? And the moment, I did not know what to make of the suggestion. What would it mean for me to consider the question that maybe not all of the patients had been victims?

In situations that involve disbelief, questioning can be construed as doubt. And to be clear, the staffer was sensitive to these nuances too, emphasizing that no matter what, these patients had been betrayed by the clinic. Leah told me on that original Department of Justice call, this was, quote, “the million dollar question.” How do I know if this happened to me? And the answer was, you don’t.

My answer to this question is that the underlying issues are still the same. Patients reported severe, unexpected pain, and that pain was not properly addressed, and maybe hadn’t been for years before these events. For example, after hearing this podcast, a patient who had undergone a painful retrieval at the clinic some years ago contacted me.

Soon after her retrieval, she’d complained in writing, asking why Yale didn’t offer, quote, “additional pain control options during egg retrievals similar to those offered at other fertility centers here in Connecticut, such as propofol.” After a follow up meeting to address this and other issues, a doctor in a leadership position emailed the patient a list of action items. We’ll work on making anesthesia available to our patients, he wrote. That was in 2014.

When this patient heard this podcast, it was like she was hearing the story of her own retrieval. I was crying out in pain, she told me. Before the retrieval, a nurse had assured this patient that she would hold her hand to help her through it. I don’t want your hand, the patient remembers thinking. I want the drugs I had for my dental surgery.

Even a decade later, her retrieval is a trauma she does not speak about. Patients say that Yale dismissed the pain they reported. Offering inadequate pain control is another way of dismissing pain, another way of saying, this doesn’t matter. It’s upsetting either way. Whether patients were in pain because their drugs were stolen or because the drugs the clinic used were just not enough for too many patients.

When a patient is in pain during a retrieval, what do the people in the room with her feel? Let’s walk it through. Let’s walk through the essential unit of this story about the Yale clinic, the retrieval. Here’s how it worked at Long Wharf.

The doctor would walk into the room. Lights are dim. Patient already there. Once the patient was sedated, the doctor would begin. If the patient flinched, the doctor would stop, ask the nurse to give more meds, wait for them to kick in.

If the meds still didn’t work, the same thing again. And then if there were no more times to stop, no more fentanyl to give, the doctor might say something have, you have this many follicles left. Would you like me to stop or keep going? And most of the patients would say, keep going.

There’s competing interests, right? One Yale staffer said to me. They’re uncomfortable, but they want to have a baby.

This is an impossible position for the patient, of course. The patient is saying, yes, I want this. But what else could they say?

By this point in their treatment, there’s already so much they’ve submitted to and so much control they’ve relinquished. And there’s a time sensitivity. A doctor doesn’t have all day. There’s only a window of a couple hours to get this done.

After that, the patient will ovulate and lose all of her eggs. There’s an awareness of what’s come before this. Money, time, maybe previous losses. The last shot before the insurance runs out. It’s not a life saving procedure, one Yale staffer said to me. But also, I don’t think elective is the right word to use for something that’s allowing someone to build a family when they otherwise aren’t able to.

Doctors know what the patient has put into this and what she wants out of it. Each time I’m doing a retrieval and getting follicles, a doctor from another clinic said to me, I remind myself that this egg could be the baby.

But getting through a painful retrieval does not feel good.

It’s awful, one staffer from Yale told me. That’s not why I went into medicine, to cause people pain.

So what are the people in the room with a patient feeling? A lot. It’s not that they aren’t aware of pain. It’s that they’re attuned to multiple varieties of it, including the pain of longing.

The patient puts up with the pain because she longs to have a child. The doctor knows the depth of that longing. Getting the eggs causes one kind of pain but relieves another.

[MUSIC PLAYING]

The literature on pain and fertility procedures is, for the most part, very concrete. What should we use for pain rather than how should we think about it? But I did come across one study with a more holistic approach. A paper on, quote, “trust pain and exit points.” This paper explored why patients chose to endure the pain of fertility treatment and what experiences of pain made them quit.

It was an idiosyncratic paper, kind of a mix of the sociological and the personal. And the research had been done 20 years ago in Israel, in a setting where egg retrievals were done via an incision through the abdomen. But what still felt applicable, actually what felt timeless, was the author’s conclusion that you endure the pain of fertility treatment because you, in a way, are already a mother.

You are in the future in which you are already a mother, and you are suffering on behalf of your children. Put aside the notion that suffering on behalf of your children is intrinsic to motherhood or that all fertility patients want to be mothers. Of course, there are patients who would not use this word or find that identity relevant.

What’s meaningful here is that you put up with the pain and the present because of how badly you want what you want in the future, whether that is a particular identity or anything else.

So that’s why patients stayed in fertility treatment. Why did patients leave? A higher level of hurt is required than that of pain or humiliation alone, the doctors wrote. Only when the women felt that the treatment endangered their physical or mental existence that the women quit their IVF treatments.

[MUSIC PLAYING]

Some of the ill patients did stop fertility treatment. Most kept going, and most who did had babies. That’s what matters, right? The baby is just one outcome. What do the other ones look like for the patients and for Donna? That’s next on the final episode of The Retrievals.

[MUSIC PLAYING]

The Retrievals is produced by me and Laura Starecheski. Laura edited the series with editing and producing help from Julie Snyder. Additional editing by Katie Mingle and Ira Glass. Research and fact checking by Ben Phelan and Caitlin Love. Music supervision, sound design, and mixing by Phoebe Wang.

Original music by Carla Polone, and music mixing by Thoma Polley. Indie Chubut is the supervising producer for Serial Productions. At “The New York Times,” our standards editor is Susan Wesling. Legal review by Dana Green. Art direction from Pablo Delcan.

Producing help from Jeffrey Miranda, Kelly Doe, Renan Borelli, Desiree Ibekwe, and Anisha Muni. Sam Dolnick is the assistant managing editor. Special thanks to Marcel Cedars, Lindsay Goucher, Cara Murray, Megan Olson, Shannon Page, Rebecca Phelan, Lisa Szuchman, Maggie Smith, and Adam Starecheski. The Retrievals is a production of Serial Productions and “The New York Times.”

[MUSIC PLAYING]