Chapter One

Southern Illinois, the triangle of land north of the junction of the Mississippi and Ohio Rivers, 350 miles from Chicago, feels more like the Deep South than like the industrial Midwest. Summers are hot and steamy, and in June 1979, most of the students and faculty members at Southern Illinois University in Carbondale who could get away after graduation had fled, leaving the campus feeling sleepy and underpopulated. An exception was the medical school, whose year-round schedule enabled students to complete the standard four-year medical school curriculum in three years. They began during the summer, spent the first year at SIU's main campus in Carbondale, then moved to SIU's campus in Springfield, the state capital, to complete their degree.

Late one June night, James Rosenthal, a newly admitted member of the SIU medical school class of '82, was sitting in a college dorm room, sweating from a combination of the heat and his anxiety over an enormous stack of introductory medical texts: anatomy, physiology, biochemistry....The topics seemed endless, the books huge. He should have been asleep. He turned out the lights and noticed that another window in the adjacent dorm was still brightly lit.

It was Rosenthal's classmate Michael Swango, wearing military fatigue pants and doing jumping jacks. Swango was lean and muscled at a time when fitness was far from most students' minds. He'd been in the Marines, and his name was stenciled on the military garb he usually wore to class. It was weird, Rosenthal thought. Many of his classmates had been antiwar protesters. Swango was the only member of the class he knew who had been in the military.

Swango's military garb and fanatical devotion to fitness were noticed by just about everyone in his class at SIU. Besides the military fatigues, he wore combat boots to class. When Rosenthal and other classmates struggled out of bed in the morning after a late night of studying, they would often see Swango outdoors doing early-morning calisthenics, chanting Marine cadences. Sometimes, at breakfast in the cafeteria, they teased him about his uniforms and military bearing. Swango bridled at their ribbing and increasingly kept to himself.

Everyone in the class was soon nearly overwhelmed by the workload and the battery of tests administered to first-year med students. As a relatively new medical school, SIU had been able to build a curriculum from the ground up, unfettered by traditional approaches. It was the first medical school in the country to create a written set of criteria for the medical degree, criteria derived from an extensive survey of medical educators. The goal was to graduate students prepared for careers in primary care -- family practice, internal medicine, pediatrics, and obstetrics/gynecology -- as opposed to research or the subspecialties, such as ophthalmology and cardiology. Every first-year medical student was required to take and pass 476 written tests during the first year. Each test covered a curricular "module," such as heart murmurs, within one of the core topics, such as the heart. Ten to fifteen closed-book tests were given every Saturday morning on the modules that had been covered in classes that week. Notes and textbooks weren't allowed in the exam room.

That didn't deter Swango, however, from using his notes during the exam. He would choose one of the tests, take it, then choose his next test topic and sprint from the room back into the hallway. There he would frantically page through his notes and books, cramming for the second test. Then he would return, take that test, and repeat the process. His fellow students were dumbfounded, and some were disgruntled. Dashing into the hallway between tests seemed perilously close to cheating, though it wasn't expressly forbidden. As the weeks went by and Swango continued the pattern, several students mentioned to him that they thought it wasn't fair, but Swango was defiant, and continued his cramming. Inevitably, other students began to do likewise, which led to considerable faculty concern. Finally Chandra Banerjee, the first-year professor of pulmonary medicine, admonished his students: "Goddammit, no Swangoing." A new word was coined. "Swangoing," the noun, or "to Swango," the verb, described the practice of racing into the hall and cramming between tests.

Swango was notorious not only for his test-taking regimen. During their first year, medical students dissect a cadaver. A ritual familiar to every medical student, the process bonds students and they usually remember it for the rest of their careers. At SIU, the first-year students were divided into groups and each student was assigned one part of the cadaver to dissect and present to the rest of the group. Swango's assignment was the hip and buttock region, including the gluteus muscles.

Students had keys to the anatomy lab and could come and go on their own time. Many worked late into the night, though the lab was busiest in the afternoons, when faculty members were on hand to offer advice and suggestions. But Swango never came in during the day or evening, preferring to work on his dissection after midnight, when the lab was usually deserted. Indeed, some members of his group, who never saw him in the anatomy lab at all, wondered how he was going to make his presentation.

What Swango gained in privacy from his unorthodox hours he lost in guidance from faculty and other students. For when his presentation finally came, and he unveiled his dissection, his fellow students gasped. He had transformed the hip region of his cadaver into an unrecognizable mess of tangled flesh and bone. As some classmates described it, it was as though he had done his dissection using a chain saw rather than a scalpel. Even Swango finally recognized that he couldn't adequately describe the region's anatomical characteristics using his own handiwork. He abandoned the cadaver and completed his presentation by showing his group pictures from an anatomy text.

Swango had few, if any, friends at SIU; his fellow students later realized they knew almost nothing about his past, his family, his education, or his military service. Yet the combination of his weird garb, chiseled physique, odd nocturnal habits, "Swangoing," and now the cadaver mishap, made him one of the best-known of the seventy-two members of the class, much talked about and derided at the many class parties and gatherings, from which he was usually absent. The cadavers remained on display in the anatomy lab, and members of Swango's group made a point of showing their friends Swango's mangled handiwork, generally with a comment like, "Can you believe this?" One classmate, Kevin Sweeney, paraded nearly half the class through the anatomy lab to see it.

The experience must have been humiliating for Swango, who had received almost nothing but praise and perfect grades before enrolling in med school. Michael was the second of Muriel and John Virgil Swango's three sons. (Richard Kerkering, Muriel's son from a previous marriage, lived with his father.) Michael had excelled at the private Catholic boys' high school he attended in Quincy, Illinois, beginning in 1968. Bob and John were educated at public schools, but -- largely at the insistence of his mother, who recognized that he was academically gifted -- Michael was enrolled in Christian Brothers High School. The family wasn't Catholic (his father once described his religion as "the brotherhood of man"), but Christian Brothers was perceived as academically superior to the public schools. John Virgil Swango also liked the strict ethical and moral foundation of the Catholic curriculum. He didn't want Michael to become an antiwar activist like his older brother, Bob.

Virgil needn't have worried; Michael seemed oblivious to the social and political upheavals sweeping the country. While Bob listened to Bob Dylan and the Rolling Stones, Michael's favorite popular music group was the brother-sister duo the Carpenters. He was a model student, named to the honor roll every year. He took the usual precollege course load, but the only topic in which he seemed to show unusual interest was the Holocaust, which was covered in world history. He ranked in the ninety-seventh percentile on his college aptitude tests. Though he ran on the track team during his freshman and sophomore years, he wasn't very athletic. He participated in a whirlwind of extracurricular activities: he was a class officer, and served on the student council, yearbook, and newspaper staffs.

His main interest mirrored his mother's love of music. He was a talented pianist and spent many evenings playing classical music for his mother. He was the band's first-chair clarinet, as well as its president, and he sang in the glee club. As a senior, he performed the demanding Mozart clarinet concerto in the band's spring concert, the only student featured as a soloist. Mrs. Swango had bought him a Buffet clarinet, an expensive brand manufactured in Paris and used by many leading players. He was so precocious that his clarinet teacher, who played in the Quincy Symphony and taught at Quincy College, recruited Michael for the Quincy College Wind Ensemble, which toured Illinois during Swango's senior year in high school.

When Michael graduated from Christian Brothers in 1972, he was showered with honors: the "Outstanding Musician" and John Philip Sousa band awards (followed by a party for band members and their parents hosted by his mother); a citation as a National Merit Scholarship finalist; and the place of class valedictorian. A flurry of articles in The Quincy Herald-Whig, the local newspaper, memorialized his achievements. His mother clipped the articles and circulated them among relatives. A 1972 yearbook picture shows Michael in his band uniform, smiling, with tousled blond hair. Curiously, in the same yearbook he described his "ambition" as "to be an Illinois State Trooper."

As his class valedictorian and a National Merit finalist with high test scores, Swango would have been highly sought after by top colleges and universities all over the country. But minimal college counseling was available in Quincy, his parents were relatively unsophisticated about higher education outside the military, and almost all his classmates stayed close to home; consequently, Swango's horizons seem to have been limited. He decided to attend Millikin University, a small, private liberal arts school in Decatur, Illinois, about a three-hour drive from Quincy, where he received a full-tuition scholarship in music. Millikin's music department was highly regarded in Illinois, and was considered the school's strongest department.

As he had in high school, Swango excelled academically at Millikin, earning nearly perfect grades during his first two years. But during his first year, a girlfriend broke off their relationship. Though he had typically worn a sports jacket to class, which was unusual in the early seventies, after the breakup he began to dress in military garb. He painted his old Ford Fairlane in camouflage olive green. When a friend asked him about this, he said he planned to join the military and was fascinated by guns. About this time, too, he first mentioned an interest in pre-med courses. And he showed an intense interest in photos in the local paper of car crashes, which his classmates found peculiar. By the end of his sophomore year, he was spending more time alone, and his friends and roommate had less and less contact with him. That summer, he enlisted in the Marines, and didn't return for his junior year. No one ever heard him play the clarinet or the piano again.

Michael completed basic training at the Marines' boot camp at San Diego, where he was trained as a rifleman, earning the designation of sharpshooter. His personnel record states that he entered the service at St. Louis, attended administrative procedures courses at Camp Lejeune, North Carolina, and Washington, D.C., and was working at Camp Lejeune in 1976, when he received an honorable discharge. He received a National Defense Service Medal and a "Meritorious Mast," a minor commendation.

When he returned to Quincy after his discharge, Swango was lean and fit and carried himself with military bearing. He announced to his family that he wanted to become a physician, something that especially pleased his mother, who had once worked as a medical secretary. He enrolled in pre-med courses at the local community college and had no difficulty gaining admission to Quincy College for the following fall. A small, private college founded by the Franciscan Brothers in 1860, and still affiliated with the Catholic church, the school had long drawn applicants from students at private Catholic high schools, mostly in Illinois. But the population of such students had been dwindling. With his near-perfect grades at the more competitive Millikin and his outstanding high school record, Swango must have been one of the college's top applicants. Still, after he was admitted he decided to embroider his record. On a form he submitted to the college's public information office, he falsely claimed that he had received both a Bronze Star for heroism in combat, and a Purple Heart for combat wounds during his relatively brief tenure as a Marine.

Swango was an outstanding student at Quincy College. Having abandoned music, he plunged into the sciences, earning a 3.89 grade-point average with a double major in chemistry and biology. He studied prodigiously, working late into the night at the college library or in the science labs. In contrast to high school, he pursued few outside activities. He didn't participate in any sports; and in the yearbook he listed the biology club and the college radio station as his only extracurricular activities. In a further reflection of his newfound interest in medicine, he worked part-time as an orderly at Blessing Hospital in Quincy and became a certified emergency medical technician.

During his senior year, Swango wrote a paper, evidently his senior thesis in chemistry, on the poisoning murder of a prize-winning Bulgarian writer living in exile in London. It isn't hard to fathom why the death of Georgi Markov might have drawn Swango's attention. As the Bulgarian crossed the busy Waterloo Bridge in central London in September 1978, he felt a faint pricking on his thigh. A heavyset man mumbled, "Sorry," to Markov as the man stooped to pick up an umbrella he had dropped. That night, Markov developed a high fever and then violent nausea. He died four days later.

An autopsy discovered a tiny capsule, about the size of a head of a pin, embedded in Markov's thigh. The capsule, which could have been carried on the tip of an umbrella, contained a poison called ricin, a castor-bean derivative that causes fever, vomiting, and finally massive blood clots throughout the body. In sufficient doses it is invariably fatal; "there is no specific treatment...other than making the person comfortable," according to the U.S. Navy's Bureau of Medicine and Surgery. There was also no pathological test for the presence of ricin, which left no identifiable trace in the bloodstream or body. Though the Bulgarian secret police were suspected in Markov's death, the murder remains unsolved.

During his senior year, Swango took the Medical College Admission Test (MCAT) and applied to a number of medical schools. He graduated summa cum laude in 1979 and won the American Chemical Society's award for academic excellence.

Competition for admission to any accredited American medical school in the spring of 1979 was intense, as it had been ever since the baby boom generation began graduating from college in the late sixties and applying in droves to professional schools. This was the case not just at the country's most prestigious institutions, but also at newer, less well-known medical schools such as Southern Illinois University. Demand for doctors was so strong that lucrative careers awaited med school graduates. Huge numbers of applicants with good records were rejected from every medical school to which they applied, and many migrated to medical schools in foreign countries, Mexico being a common destination. Swango's classmate Rosenthal, despite good grades in his science classes at highly regarded Knox College and decent scores on the MCAT, had been rejected outright by sixteen schools before securing a place on SIU's waiting list. Another of Swango's classmates had applied for seven years in a row before she was accepted.

Applications to U.S. medical schools were funneled through a centralized office in Washington, D.C., which sent preliminary applications to the medical schools named by the applicant. If a medical school thought it might be interested, then, and only then, would it send a candidate its own application. Besides needing outstanding grades in a pre-med curriculum and high MCAT scores, applicants had to sit for a personal interview in which their maturity, commitment, and aptitude for medicine were evaluated.

Because it was founded in part to improve medical services in southern Illinois, SIU accepted only Illinois residents and looked for a commitment to family practice in small-town or rural Illinois. After a committee evaluated all the information candidates submitted, SIU (like other medical schools) placed them into one of three categories: "Reject," "Accept," or "Accept When Place Available."

Muriel proudly reported to family members that Michael had been accepted at several medical schools. Given his excellent academic record and test-taking ability, Swango would have been a strong candidate. His work in a hospital as an orderly would also have worked in his favor. And SIU would have been especially interested in someone like Swango, who was from Quincy, part of the area the medical school was meant to serve.

Yet his classmates speculated that Swango had been admitted from the waiting list, because he moved into the dorms late, along with students who, like Rosenthal, had been admitted at the last minute. They surmised that Michael hadn't performed well in the admissions interview and wondered what he had answered when asked why had wanted to become a doctor. Among his classmates, the decision to become a doctor formed a large part of their getting-acquainted conversations. Swango never participated in these conversations; he seemed blank when the topic surfaced. Swango never expressed any interest in patients.

Still, apart from the cadaver incident, nearly everyone conceded that Swango seemed hardworking and disciplined. Some classmates were astounded to learn that he was working as a paramedic for America Ambulance in Springfield while a first-year student. Not only was outside employment during the first year frowned upon (Rosenthal had to get permission from the dean to teach a Sunday school class in Carbondale), but Swango was commuting to a city one hundred miles away. And his violation of the antimoonlighting policy was particularly brazen, for the Springfield hospitals the ambulances served were affiliated with SIU and staffed with many SIU residents and professors. These staffers soon realized what Swango was doing, but no one on the faculty complained. He passed all 476 tests, however unorthodox his methods, and all of his courses, including anatomy. One member of the class had to repeat the first year, and one person flunked out, but when the rest of the class moved on to the second year in Springfield, Swango was among them.

The central Illinois city of Springfield, with a population just over 100,000, seems a metropolis compared with Carbondale. It boasts the state capitol building and is steeped in the lore of its most famous resident, Abraham Lincoln, whose restored home is a major tourist attraction. The city is attractive to SIU because its two hospitals, St. John's and Memorial, are much larger than any in Carbondale, and it is there that SIU medical students gain their first clinical experience. Beginning with the second year, the medical school's curriculum turns away from basic science and anatomy to disease-oriented courses, including pharmacology, radiology, and pathology. Pathology, which includes toxicology, the study of poisons, seemed particularly to fascinate Swango. It was taught by a popular professor, Dr. John Murphy, who was favorably impressed by him.

During their third year of SIU's medical school, students undergo a series of rotations, including pediatrics, obstetrics and gynecology, internal medicine, and surgery. In the surgery rotation, students were assigned in pairs to give oral presentations. Rosenthal and Swango were partners, and at Rosenthal's suggestion, they chose to discuss the repair of certain defects through open-heart surgery. A relative of Rosenthal's was a heart surgeon and volunteered some original papers the students could use. But Rosenthal ended up having very little contact with his partner. This may have been because Swango was still working for the ambulance corps and frequently was either unavailable or fidgeting because he was going to be late for ambulance duty. But it was also because Rosenthal didn't like being around Swango. He was jumpy, nervous, and seemed unable to relax. He wore a beeper and would rush off whenever the ambulance service called. The pair ended up giving their presentation in two discrete sections, which might as well have been separate reports. Swango had assembled several slides and gave a creditable, if unmemorable, performance.

But given that the topic was heart surgery, his subsequent performance in class was baffling. Swango's class assembled at the start of each day for what's called morning conference; one day Dr. Roland Folce, the chairman of surgery, led a discussion of X rays. He put a chest X ray on a screen and pointed to a shadowy area in the middle of the image. He looked around at the class, then focused on Swango. "Mike, tell us what's in this picture," he said. Swango was silent. Finally he said, "I don't know." There were some titters from other students. "That's the heart, Mike," Folce said, sarcastically emphasizing the word "heart." It was almost as big a debacle as the cadaver incident, for any medical student this close to getting his degree should have been able to recognize the heart on an X ray. It was so obvious that his classmates concluded that Swango must simply have panicked and frozen.

Yet the episode was one of many that led some of his classmates to conclude that Swango was taking a surprisingly cavalier approach not only to medical school, but to the well-being of his patients. One of the first clinical assignments medical students receive is to take histories and perform physicals -- "H & P's" -- on hospital patients. Students interview patients, record their medical histories, undertake routine physical examinations, and post the results on the patients' charts. Depending on the patient, the procedure can take anywhere from a half-hour to ninety minutes. His classmates observed that Swango was completing his entire rounds in less than an hour, sometimes spending what seemed like as little as five minutes with a patient. Yet he filed complete H & P's. In at least one instance, another student charged that Swango had plagiarized or fabricated his entire write-up. The claim triggered renewed talk and concern about Swango among his classmates; Rosenthal and several others even wondered whether Swango should be reported to the Student Progress Committee, a group of twelve faculty and two students that heard complaints of student misconduct. But no one did so.

Within their third-year rotations, students can choose areas of specialization. There was a standing joke at SIU that the dumb and the lazy chose anesthesia; the smart and the lazy went into radiology; the dumb hard workers chose pediatrics; and the smart hard workers went into neurosurgery. Thus, it came as a surprise to many when Swango concentrated his courses in neurosurgery, especially considering the cadaver incident. Neurosurgery, involving delicate operations on the brain and other parts of the nervous system, is one of medicine's most demanding (and highly paid) specialties. It is emotionally taxing, because patients needing neurosurgery are often in dire straits, and because deaths and catastrophic incidents on the operating table are probably more common than in any other area of practice. Still, competition for internships and residencies is intense. But Swango was no more forthcoming to his classmates about his choice of a specialty than he had been about why he had chosen medicine as a career.

Swango's decision came as a particular shock to his classmate Sweeney, who had been so dismayed by the cadaver incident and thought Swango was ill-equipped to practice medicine at all, much less neurosurgery. Furthermore, neurosurgery happened to be Sweeney's area of concentration as well, so he and Swango would share patients and work closely together.

The two were jointly assigned to a resident, Mark Zawodniak, who would oversee their work and act as a mentor. Though that meant Sweeney and Swango had to see each other virtually every day, they avoided each other as much as possible. Though most students sharing a neurosurgery specialty would observe each other's surgeries, Sweeney stayed away from Swango's -- he was horrified by the prospect of what he might see -- and Swango never showed up at Sweeney's, either.

Zawodniak, though he was genial and friendly, also developed an aversion to Swango. When Swango was out of earshot after one particularly frustrating encounter, Zawodniak turned to Sweeney and lamented, "What did I fucking do to deserve him?"

But finally, in the person of a faculty neurosurgeon, Dr. Lyle Wacaser, Swango seemed to find a kindred spirit. Wacaser raved about Swango. He would brook no criticism of Swango's alleged haste, sloppy habits, or indifference to patient care. The two seemed all but inseparable, Swango eagerly accompanying the neurosurgeon on his rounds and into his surgeries. Indeed, Swango had persuaded the nursing staff to beep him on his ambulance pager whenever they learned that one of Wacaser's patients was about to be admitted. That way Swango was usually on the scene even before Wacaser, and sometimes before the patients themselves. This naturally froze Sweeney out of numerous opportunities for clinical experience, and it hardly endeared Swango to fellow students. (The first-come, first-served system for assigning medical students to patients was subsequently changed.) But naturally, Swango's eagerness made a favorable impression on Wacaser, who found him remarkably pleasant and industrious. He thought Swango's patient write-ups were close to perfect.

Wacaser was one of several Springfield doctors in private practice who also served as clinical instructors. He was popular among students and highly respected in his field, and the fact that he championed Swango went a long way to ease student concerns about Swango's competence. He was also eccentric. Wacaser drove around town in a truck that had emblazoned on it in bold letters, "Lyle Wacaser, M.D., Neurosurgery and Light Hauling." Recently divorced and in his early fifties, Wacaser would often invite students for postsurgery beers at his spacious office in a house across the street from the hospital, where he displayed the brain of a former patient in a jar of formaldehyde on the fireplace mantel. He also threw numerous parties. His office phone could be connected to the hospital's public address system; Wacaser would get on the system and announce, "Fluid and electrolyte rounds in progress." The signal sent medical students flocking to the parties, which were often rowdy affairs where they could blow off steam. But Swango didn't drink alcohol and, despite his close relationship to Wacaser, never attended the parties. Indeed, after Swango's surgery rotation ended, Wacaser hardly ever saw him, and later realized that he knew nothing about Swango's background or personal life, even who his parents were or whether they were alive.

During their third year at SIU medical school, students have significantly more contact with patients and are responsible for hundreds of H & P's in the course of the year. Swango's classmate Rosenthal noticed that Swango seemed unusually interested in, even preoccupied with, the sickest patients. The hospital maintained a large blackboard on which were written patient names and treatment remarks. When a patient Swango had seen died, he scrawled "DIED" in large capital letters across the person's name. Rosenthal and other students found this distasteful, almost as though Swango were celebrating the demise and wanted to call attention to it. When Effie Walls, a kindly patient whom Rosenthal had met, and whom Swango had been treating for an injury, died suddenly after a visit from Swango, he scrawled "DIED" over her name as well. Rosenthal went up to Swango and asked him why he did such a thing. "Don't you feel bad that she died?"

Swango gave Rosenthal a blank look. "No," he replied. "That's just what happens."

It happened often with Swango. A standing joke among the students was that if they wanted to get rid of a patient, they should assign Swango to do an H & P.

One day Zawodniak mused to Sweeney that unusually often, it seemed, when he assigned Swango to do an H & P, the patient would suddenly "code," meaning suffer a life-threatening emergency. "Do you think it was just coincidence?" But even as Zawodniak spoke, he dismissed the thought, and the two laughed it off. Swango was correct, after all, that death is a regular occurrence in a hospital.

Zawodniak, Sweeney, and many of their classmates were developing a black sense of humor under the twin pressures of medical school and hospital life. After about five deaths in patients who seemed to be recovering satisfactorily, all of them soon after an

H & P by Swango, Zawodniak coined a nickname for his seemingly disaster-prone protégé: Double-O Swango.

Other medical students thought the nickname was hilarious, and soon it was in widespread use. "Double-O Swango" meant License to Kill.

Copyright © 1999 James B. Stewart