Rose was a petite woman whose slender figure belied the fact that she had borne six children. She took care of her home and flower garden and homeschooled her children, too, while managing to look as spic and span as her home. Rose was a devout Catholic and a very compassionate woman, but she wasn’t afraid to speak up when something bothered her. There came what she called “a defining moment” when she had to say something.
It was Sunday, August 8, when Rose came to see Debbie again. She was horrified to see her friend propped up in a recliner chair in the corner of the living room. Anthony was lying on the living room couch with the TV remote in his hand.
“I looked at Debbie, and my heart just sunk. It was like looking at my mother-in-law, whom I had just lost,” Rose said with a shudder. “It was the look of death—that’s the only thing I can say to you. She was swollen, puffy.”
As Rose moved closer to Debbie she saw that she was chalky pale, with huge purple circles beneath her dark eyes.
Debbie made no move to get up and offer her a cup of coffee or an iced tea—something she always had done. Rose realized that Debbie probably couldn’t get up, but she insisted on giving Rose a check for her Tupperware order.
“She couldn’t even hold a pen,” Rose remembered. “It was just awful. She spoke to me, but her words were slurring, and I had trouble understanding her.
“I was so worried about her; she was so sick,” Rose said. “I asked Anthony if she shouldn’t be in the hospital, and he told me that she was better off at home, because hospitals weren’t very well staffed over weekends. He said, ‘I’m a doctor. Don’t you think I would know what’s best for her? She’s much better off under my supervision.’”
Rose tried to argue with Anthony a little, but he dismissed her concern.
“When I went home, I cried,” Rose recalled. “I told my husband that Debbie looked so bad that I was scared. I said, ‘She looks like Ma did—just before…And I was scared. Debbie looked so bad, so bloated and funny, and she wasn’t at all like herself.”
Anthony’s lack of concern was remarkably similar to his response to Connie Vinetti, the woman who developed a dangerous infection after he performed a tummy tuck on her, and not that different from his slow response when Sarah Smith stopped breathing. But this was his own wife. And still he lay on the couch watching television as Debbie sat so still in the recliner. To everyone else who saw her, she appeared to be dying, but he brushed their fears away. He was not concerned, and he refused to be rushed into taking her back to the hospital.
Debbie could barely walk. Her legs, feet, and hands were alternately numb and painful. Her stomach screamed with pain, and she was beyond nauseated.
Finally, finally, Anthony agreed to take her to see a doctor the next day. Caroline stayed with the children, anxious to hear from Debbie what the doctors had said. But Anthony came home alone. He told Caroline that Debbie was having tests at the hospital and he’d pick her up later. He did—but as Debbie tried to walk to her front door, she fell heavily. Caroline was frightened to see how she had failed over the space of a few days.
“I called her brother to tell him something was wrong,” Caroline said. “Debbie was crawling because she couldn’t walk. She was wobbling when she tried to stand up.”
Caroline Rago was frantic, and so was Debbie’s brother, Carmine. Anthony thought they were all overreacting. He greeted Carmine with his usual joking: “Hi, big guy!”
Anthony explained that Debbie probably had only the flu or something like it, and the tests would prove that. He didn’t seem at all alarmed and thought everyone else was being somewhat hysterical.
Dr. Jahangir Koleini was Debbie’s attending physician for the tests she had done that Monday in August 1999, with Dr. M. Reeza Samie consulting. Dr. Samie was called in because Debbie was having new symptoms: numbness and clumsiness in her right hand. After Dr. Samie examined her, she encouraged Debbie to return to the hospital.
But Anthony didn’t want her to be admitted. He assured the examining physicians in the ER that all she needed was more pain medication. He would take her home and see that Debbie took her pills. He was sure she would be fine.
But she wasn’t. Even Anthony’s aversion to having Debbie hospitalized was overcome that night, and she was back in Buffalo Mercy the next morning.
What Anthony didn’t know was that another doctor had been monitoring Debbie’s condition for weeks. Dr. Michael Snyderman, a hematologist whose specialty was the blood and the blood-forming organs, had done a bone marrow test on her during one of her earlier hospitalizations. Snyderman found the results so bizarre that he wondered if Debbie might be suffering from some kind of poisoning. He spoke to Anthony on August 9 and asked that he bring Debbie in for more blood tests. But he didn’t even hint at poisoning. He said only that he wanted to test for a condition known as porphyria.
When Dr. Snyderman told Anthony that he felt Debbie should really be in the hospital at once, Anthony said that he would have to consult with Drs. Samie and Koleini and see what they thought. That struck Snyderman as a patent lie; he had already consulted with them, and they had agreed with him that she needed to be in the hospital as soon as possible.
Finally, Anthony agreed to bring Debbie in to be admitted. Debbie’s in-patient records began somewhat routinely, written, as all medical records are, without emotion.
“The patient is a 42-year-old white married female with history of recurrent episodes of major depression and pancreatitis two weeks ago. She was admitted to the hospital because of increasing ataxia on standing, distal sensory loss, and sluggishness of the ankle and knee reflexes. Two weeks ago, the patient had an episode of pancreatitis and about four days prior to admission the patient started to have the gradual onset of tingling, numbness and clumsiness of her hands and lower extremities. The patient was seen by Dr. Samie as an outpatient prior to admission and had an MRI of the brain done which was normal.”
For the layperson, this meant that Debbie’s history of crippling stomach pain now had new symptoms that didn’t seem to tie into inflammation of the pancreas. The new symptoms had come on quite suddenly. She couldn’t feel her hands and feet, and the tingling sensations had progressed to numbness and inability to pick up anything with her hands without dropping it or tipping it over. She did have the history of many surgeries to her neck, which could have caused numbness in her arms and hands, but her other symptoms couldn’t be explained by cervical disk problems.
Once admitted to Buffalo Mercy, she could be given a whole array of tests to try to find out what was wrong with her.
What was wrong with Debbie Pignataro? Was it possible that Dr. Snyderman was right? Was it possible Debbie was being poisoned?
16
It was the hottest time of the year in Buffalo, and the towering snow drifts of winter seemed years away. Rose Gardner’s flowers wilted and began to dry up as the neighbors watched the Pignataro house, saw Anthony come and go, and wondered aloud about how Debbie was doing. They had heard that she could not have visitors. Rose lit candles and said prayers for Debbie, even though she believed it would take a miracle for Debbie to survive. She was convinced that she would probably never see her again. There had been such a pallor of death about her the last time Rose saw her.
In the vineyards, the grapes hung heavy on their vines, and the apple and pear trees began to ripen. Wild berry pickers moved deep into the brush. Soon, the familiar roadside stands would be stocked with enough produce to make it worthwhile to leave downtown Buffalo and drive to outlying areas. Chuck Craven played golf, and the tourists flocked to both the American and the Canadian sides of Niagara Falls.
The best part of summer meant nothing to Debbie Pignataro as she lay on snowy white sheets in a darkened room. Her world was limited now to four hospital walls. Doctors struggled to diagnose her condition, ignoring Anthony, who assured them that there was really nothing wrong with his wife beyond a somewhat complicated case of gallstones.
They considered all pos
sibilities. She had no history of diabetes; she had no history of alcohol abuse. Her temperature was 98.3, but her pulse raced at 120 beats a minute. Her blood pressure was 110/60 (ideal for an athlete in good condition).
As they listened to her heart and took her pulse, they asked questions, and she seemed alert. They didn’t know that she would soon have no memory of what they had asked her. When she spoke, her words were clearly understandable. She had no head wounds; her ears, nose, and throat were fine. Her jugular vein didn’t stick out, and the carotid arteries on either side of her neck had no ominous sounds when they placed their stethoscopes there. Her heart rhythm was normal; her lungs sounded normal.
They kept searching. The membranes in her eyes were a little pale. She was anemic. She suffered from leukopenia—a very low white cell count, usually caused because new cells weren’t being formed. Although her muscle tone was normal, she did have that lack of strength and the strange tingling and numbness in her hands and feet, more on the right side than the left. There were no deep tendon reflexes in her knees or ankles. The reflexes in her feet were normal enough to assure them that she hadn’t suffered brain damage.
And yet, she staggered almost drunkenly when she tried to walk.
At this point, there were any number of diseases and conditions that had to be considered. In New York State, she could have been bitten by a deer tick and have developed Lyme disease, but she said she hadn’t been out in the woods for months. She hadn’t traveled to any other area where she might have contracted some disease. They had to rule out Guillain-Barré syndrome, a disease that can come on suddenly and completely paralyze a formerly healthy person—a malady that usually reverses itself in time.
The lab tests took longer than the questions and answers and the observation of skilled doctors. When the results came back, more possibilities were eliminated. A spinal tap produced crystal clear fluid. No meningitis.
There remained that one diagnosis that Dr. Snyderman didn’t want to be right about: the diagnosis that most doctors don’t turn to until all other options have been considered. They approached it gradually, asking Debbie if she was a gardener. When she said “Yes,” they wondered if she had used toxic chemicals to kill weeds. She had, but she was stunned when they asked her if she had swallowed any. Of course not. And she hadn’t ingested any rat poison, insect killers, or preservatives, either.
Had she ever worked where someone used heavy metal poisons, or had she ever been exposed to them, to her knowledge? No.
But the blood tests and the urinalysis came back with a shocking result. Debbie Pignataro’s 24-hour collection of urine showed that it contained arsenic at an almost unheard-of level: 29,580 micrograms per liter.
To put that in context, it’s necessary to know that we all have some percentage of arsenic in our systems, normally deposited through the environment. Soil has small amounts, and most seafoods—especially clams and oysters—have minute concentrations of the poison. Fuel oils and coal emit arsenic into the air when burned, and of course many weed killers and insecticides have arsenic as a component. Most humans have between 5 and 20 micrograms per liter of arsenic in their entire blood supply. It’s nothing to worry about.
In 1998, according to the American Association of Poison Control Centers’ (AAPCC) Toxic Exposure Surveillance System, there were 956 non–pesticide-related arsenic exposures with four fatalities, and 399 arsenic-containing pesticide exposures with no fatalities reported. Mystery writers often use arsenic as a way to kill characters; in real life, it is rare.
Blood arsenic concentrations should not exceed 50 micrograms per liter. In patients with arsenic poisoning, the blood arsenic concentrations usually range from several hundred to several thousand. But Debbie had 29,580 micrograms per liter of arsenic in her body, considerably more than even “several thousand.” Indeed, that was far more than any of her doctors had ever seen—or heard of. She was alive, and she didn’t seem to be in severe pain as long as she lay very, very quietly in her bed.
Every one of her symptoms made sense now. The numbness of her hands and feet was classic for chronic exposure to arsenic: it was glove or stocking paresthesia, in which the deadening of sensation perfectly fits the area where a person wears gloves or stockings. Her vomiting, diarrhea, and pain were signs of acute exposure. She apparently had swallowed both large and small doses of arsenic.
The rule of thumb for causes of arsenic exposure is almost always homicidal, occupational, or suicidal. Debbie had been horrified when her doctors asked her if she had taken poison deliberately. How could they even think she would do something like that? She would never, never leave her children. No, she was not suicidal. There was absolutely no occupational or avocational link between her and arsenic.
That left only the possibility that someone was trying to kill her. Nobody pointed that out to her. She was too sick and too upset for them to even think of bringing such a subject up.
Whatever the source of Debbie’s massive poisoning, treatment had to begin at once. The preferred method of getting arsenic out of her system is chelation therapy. Debbie would be given capsules of Succimer (DMSA), an agent that would bind with the heavy metal of the arsenic in her bloodstream and render it weaker and weaker as it left her body, but she had so much arsenic in her body that they wondered if it wasn’t too late. It would take nineteen days of chelation therapy to go through the whole course of Succimer treatment.
Somehow, Debbie had been poisoned with one of the most infamous poisons known to man—and yet, for the moment, she was alive. It would take a while to see how much permanent damage had been done to her liver, kidney, and heart functions.
Anthony doubted the diagnosis, and he didn’t tell anyone about it. Instead, he demanded that Debbie have surgery to take out her gallbladder. That, he insisted, was her real problem. Until that happened, he was convinced that she wouldn’t get well.
And her doctors looked at him, amazed. For her to undergo any kind of surgery in her condition would be akin to signing her death warrant. She probably wouldn’t live long enough to waken from surgery. They stonewalled his demands.
With the diagnosis of arsenic poisoning by some unknown cause, it was mandatory for the Erie County District Attorney’s office to be notified. Frank Sedita, Chuck Craven, and Pat Finnerty were not really surprised that they were hearing about Anthony Pignataro and a patient in critical condition only eight months after his release from prison. All kinds of possibilities came to mind. The wild card was that the patient was Pignataro’s own wife—the same wife who had stood beside him with unflinching loyalty when he was investigated for Sarah Smith’s death.
One of Sedita’s strongest memories was a phone call from the Poison Control Center. “They asked me when the patient’s funeral was,” he recalled. “And I said, ‘There is no funeral—she’s alive.’ They couldn’t believe it. It was unheard of that anyone could have more than 29,000 micrograms per liter of arsenic in them and be alive. But Debbie Pignataro was.”
Debbie had both disliked and feared Frank Sedita when he cross-examined her in the grand jury after Sarah Smith’s death, but now he was on her side—although she didn’t know that yet.
And so were Chuck Craven and Pat Finnerty. The two D.A.’s investigators had great expertise in any number of areas, but they had never worked on an arsenic poisoning case before.
“Both of us are interested in finding out new ways to investigate,” Craven recalled, “and we learn wherever we can. We’re always watching shows like Justice Files and the Discovery channel documentaries on television. And we found a lot of information on the Internet. We played catch-up fast on arsenic.”
There was a great deal of information on the Internet about poisons. Sedita, Craven, and Finnerty read everything they could find about arsenic poisoning. They learned that it is tasteless and odorless and that its crystals look like sugar. Absorption occurs primarily through the digestive tract, although some arsenic can be taken up through the skin. Once arsenic is in
the body, it binds to hemoglobin, plasma proteins, and white blood cells and is then carried to the liver, kidneys, lungs, spleen, and intestines. After a few weeks, arsenic deposits can be found in the skin, hair, nails, bone, muscles, and even the nervous tissues. Ingestion of arsenic often leaves white marks on the fingernails, called “Mees’ lines.”
“We learned how to check for arsenic deposits by watching one of the Justice Files shows,” Craven said. “You can find it by taking hair cuttings, fingernail cuttings, and urine samples. You can almost date the times the victim was given arsenic—particularly when they’ve been given large amounts.”
Although they couldn’t really question Debbie at the moment—she was fighting for her life—they would have heard answers that rang true for arsenic poisoning. Those with acute exposure suffer from nausea, vomiting, and diarrhea. They have low blood pressure and a rapid heart rate, and they may complain of a metallic taste in their mouths. Some have a garlic odor on the breath.
An armed guard was placed outside Debbie’s room in Buffalo Mercy Hospital, and her visitors were carefully monitored. Anthony was her most faithful visitor, hovering next to his wife’s bed.
Rose Gardner was surprised to find Anthony at her door the Thursday after Debbie was admitted to the hospital. He asked her if she had a Bible. Of course she had a Bible.
“Anthony said he needed to look up a certain passage of scripture. It was the part about ‘An eye for an eye, a tooth for a tooth…’ I knew it was in the Old Testament—probably in Exodus. I loaned him a Bible.”
Anthony talked somewhat obscurely about people who might want to wreak revenge upon him because they blamed him for something he had done. Rose, of course, had read about Sarah Smith’s death in Anthony’s surgery. Anyone who read the papers or watched television in Buffalo knew about that. Later, when Rose thought about it, she sensed that Anthony was hinting that Sarah’s husband or family might be plotting against him. But, for the moment, he didn’t seem all that worried about Debbie’s being in the hospital. He seemed more focused on his own fears.