The little girl could barely breathe. She lay on the hospital bed, her chest rising with each forced inhalation. Irma Nicanor held her only child's hand. The six-year-old's eyes were closed, but Irma felt her tiny fingers squeezing.
"Stay strong, Claudialee," she told her in Spanish.
Irma was dazed by how everything had gone so bad so quickly. It was early on a January evening in 2010. They'd checked into New York Hospital in Flushing that afternoon. Claudialee was nauseated and had a tummy ache. Irma figured she'd caught a stomach virus from a boy in their apartment building. She now knew that it was more than that.
Two days before, Cladialee was running around the house, climbing over couches and crawling under tables. She seemed as healthy as she'd ever been. Yes, she was overweight, and her blood sugar was slightly high, but Irma was seeing to it that her daughter would get fit.
A bubbly girl with a loud laugh, full cheeks, and a thick mop of dark brown hair, Claudialee had plenty of energy for that mission. The girl took ballet and karate lessons. She ran around the park with her dad and rode bikes with her cousin. During snack time at P.S. 32, she pulled out sandwich bags filled with celery and carrots and sliced fruit. Her first-grade teacher would eat with Claudialee so that she wouldn't feel bad about not having sweets like the other kids.
Irma was always conscious about her daughter's health. Over the past three months alone, she'd taken Claudialee to six medical appointments: three times to her pediatrician, Dr. Thelma Cabatic, for flu shots and checkups; and three times to her endocrinologist, Dr. Arlene Mercado, to deal with her blood sugar. At each visit, Mercado would tell Irma that her girl was fine, in need of nothing more than diet and exercise.
Yet two weeks after her last checkup, here was Claudialee struggling for air, half-conscious in an emergency room. "Patient has slight movement of all four extremities spontaneously but not on command," the hospital notes read. "Mumbles occasionally."
The scene was overwhelming for a mother. Nurses scurrying around. Chemicals with smells much stronger than the cleaning supplies Irma used in her job as a housekeeper. Intravenous tubes attached to Claudialee's arms, alternately streaming potassium salts, water, and glucose. The girl's blood sugar had risen to 525 milligrams per deciliter—more than five times the normal level.
How could this happen? Irma kept asking herself.
Claudialee's lungs struggled as the night wore on. Nurses strapped an oxygen mask to her face. It wasn't enough. They decided to push a tube down the child's throat so a ventilator could help her breathe. But Claudialee wasn't having it. Even half-conscious, she was still a flare of vigor. Her arms flailed and her legs kicked. The nurses didn't expect such strength. They retreated and injected her with a sedative. Then they inserted the tube. Claudialee was now unconscious and dependent on a machine to supply her with oxygen.
Irma sat in the waiting room, praying. She called her sister Marta. It was about 4 a.m., but Marta rushed to the hospital. She got lost in the hallways, missed the waiting room, and ended up at Claudialee's bedside. The two were alone, the only sounds coming from the robotic hums and beeps of intensive care.
"It hurts," Marta thought she heard the girl whisper.
"Where does it hurt?"
There came no reply.
St. James Avenue was quiet and still on October 31, 2009. Irma and Claudialee passed the modest wood-frame homes with yards fronted by low chain-link or wrought-iron fences. American flags fluttered beside satellite dishes. Not a single person was in sight. Just the kind of tranquility a family hopes for when they move to Elmhurst.
Mother and daughter stopped in front of a cream-colored three-story house, then walked up the driveway to a concrete backyard. Irma might as well have been taking Claudialee to a classmate's birthday party.
Court documents, medical records, and interviews would detail what followed.
The pair descended a stairwell to a minimalist setup: a desk and several chairs. Curtains forming two makeshift rooms. Dr. Arlene Mercado's office was in the basement of her sister Myra Mercado Capistrano's house.
Mercado opened the clinic in 2007. Thirteen different insurance companies listed her practice in their network. She had a second practice at the SUNY Downstate Medical Center in Brooklyn. And she accepted Medicaid, the government health program for low-income people. She was a pediatric endocrinologist, specializing in children and the hormones and chemicals that could stunt growth or bring on early puberty. The most common issue she dealt with was diabetes.
She was well versed in practice, if not theory. Mercado was not board-certified in her specialty, American Board of Pediatrics records show. She failed the certification exam more than five times. Without passing that, she couldn't attempt the next step, the pediatric endocrinology test. But these setbacks didn't stop her. Board certification isn't mandatory. In fact, though she couldn't pass the test herself, Mercado taught a certification-exam review course in Children's Hospital at SUNY Downstate.
Her business was a family affair. Mercado had two paid employees: Myra, the clinic manager, and Myra's husband, Edward Capistrano, the billing supervisor. The Capistranos' children handled the patients.
Paul, a 23-year-old political science grad student with a degree in math, and Bernard, a 21-year-old graphic design major, measured heights, weights, and blood pressure. Twelve-year-old William sat at the front desk, answering phones and filling out appointment cards.
Irma handed William a referral card from Claudialee's pediatrician, Dr. Cabatic.
She'd taken Claudialee to see Cabatic five days earlier for the first in a series of flu vaccinations. Claudialee had the sniffles, so Cabatic ran her through a full examination. Four days later, the doctor called to say that Claudialee's urine and red blood cells showed abnormal glucose levels. Her blood sugar was above normal, suggesting the girl might become diabetic. In her notes, Cabatic wrote, "probable diabetes mellitus."
The disease stems directly from high blood sugar. In type 1 diabetes, the immune system kills off cells that produce insulin, the hormone that brings the body's glucose supply to muscle and fat. If the body doesn't get more insulin, the person will die.
In type 2, a person has a lot of insulin, but the stuff just doesn't work. Insulin resistance, doctors call it. Obesity is the usual cause. The damage is slower and can be treated through diet, exercise, and medication.
Cabatic knew Claudialee was at high risk for diabetes. The girl's maternal grandmother, paternal grandfather, and three of her uncles had it. She recommended that the girl see a specialist and gave Irma the name of a pediatric endocrinologist who spoke Spanish and would accept her Metroplus Medicaid card. (Metroplus, a nonprofit healthcare organization that provides Medicaid in New York, did not respond to interview requests for this story.)
Irma called Mercado's office to set up an appointment for the next morning.
After asking about the family history, Mercado took a blood sample from Claudialee. The doctor was a short, round woman who peered over thin spectacles and disarmed with a cheerful smile. She told Irma she would send the blood to a lab and they'd discuss the results in two weeks.
The test would duplicate Cabatic's results: Claudialee's blood sugar level was higher than normal, but not high enough to be considered diabetes. She was "prediabetic." During the next visit, Mercado explained to Irma that the results were nothing to be too concerned about. The girl just needed to lose weight. Diet and exercise. She handed Irma a sheet of paper with a food pyramid on it.
In her notes, Mercado wrote that if the patient didn't lose weight by her next checkup in mid-December, she would prescribe Metformin, a drug used to treat type 2 diabetes.
Though type 2 used to be called "adult-onset" diabetes, Mercado knew recent studies had shown that a growing number of kids were getting it. At 3-foot-9 and 67 pounds, Claudialee was clinically obese. Mercado noticed a dark spot on her neck, often a sign of insulin resistance.
By her next appointment on December 12, things were looking up. Claudialee was thinner. Mercado didn't conduct any tests or ask many questions. It was a brief but reassuring meeting, full of grins and calming words. Claudialee is fine, the doctor told Irma. She just needs to drop another pound or two. Diet and exercise.
In her notes, Mercado wrote that she'd administer another blood glucose test on the next visit. As Irma left, William handed her an appointment card telling them to come back on February 23.
Cabatic echoed Mercado's optimism when the mother and daughter returned on January 9 for the girl's final flu shot. It happened that Claudialee had come home early from school the day before. During snack time, she complained that her heart was beating faster than normal. The nurse sent Irma a note saying a doctor had to sign off before Claudialee could return to class. Cabatic assessed her vital signs. Normal heart rate and blood pressure. No cough. No chest pain. No difficulty breathing. All was stable.
Cabatic had more good news: In the 10 weeks since the October 26 checkup, Claudialee had lost five pounds and grown two inches.
As far as the doctors could tell, Claudialee was getting healthier by the week.
On January 21, Marta Nicanor, Irma's sister, picked up her six-year-old son, Gustavo, and Claudialee from school. Irma worked as a housekeeper for a family in Port Washington, Long Island. Most days she left her apartment at 8:30 a.m. and didn't get home until nearly 8 p.m, so Claudialee spent most of her evenings at her aunt's place. She'd play with Gustavo, her best friend.
Claudialee told Marta she was tired and that her stomach had been bothering her. She wanted to lie down. Marta called Irma, who called Dr. Cabatic to schedule an appointment for first thing the following morning. She left work early and arrived at her sister's apartment about 4:30 p.m.
When Claudialee heard her mother come in, she hopped out of bed, ran over to her, and threw up. Irma took her to their apartment, one floor up in the same building.
Born less than 15 months apart, Irma and Marta were closer to one another than to any of their other six siblings. The family grew up poor in the state of Puebla, southeast of Mexico City, and they both dreamed of raising their children in the United States. When they were in their early 20s, they made their way north. Over the years, they would earn the solid, working-class life they'd aspired to.
For a while Irma lived in East Harlem with Claudialee's father, Napolean Gomez. They separated when Claudialee was a year old. Irma moved in with Marta and her husband in Flushing. She stayed for a year, waiting for an apartment to open up in the same building. She wanted to live near her sister, who stayed home to look after her three children. There was nobody Irma trusted more with the care of her daughter.
Irma took Claudialee's temperature. No fever. She offered food but the girl wasn't hungry. She was very thirsty, though. Irma placed Gatorade and ginger ale on the nightstand by her bed, but Claudialee only wanted water. She napped for a couple of hours, then gulped more water. She fell back to sleep at about 10 p.m., with her mother lying beside her.
Claudialee woke up drowsy. She always dressed herself, but on this day Irma had to do it for her.
They made the 10-minute walk and got to Dr. Cabatic's clinic at 9:30 a.m. It didn't open until 10, but Irma routinely arrived at doctors' appointments early. Then 9:30 became 10:30 and 10:30 became 11. The door remained locked. Irma called Cabatic's cell phone and office line seven times. No answer.
Claudialee kept saying her stomach ached, that she felt tired and really thirsty. She'd vomited three more times that morning.
She normally didn't complain about things—she was the type of girl who fell off a scooter, scraped her knee, and got right back on without hesitation. Irma called a cab and asked the driver to take them to New York Hospital.
Claudialee began to sway and stumble as they walked toward the emergency room. Before reaching the entrance, she nearly collapsed. Irma picked her up and carried her the rest of the way.
As hospital workers ran tests, a nurse asked Irma if Claudialee had been urinating more and drinking more than usual recently. Irma said she had noticed her daughter doing both since Christmas.
This suggested that Claudialee's blood sugar had been rising.
The test results—five times the normal level—supported that hypothesis.
"When the doctors came in and told me about blood-sugar levels—that was a surprise," Irma tells the Voice. "That was the last thing I expected to hear. That's when I knew something was really wrong."
There had been other signs. Months after Claudialee checked into New York Hospital's ER, pediatric endocrinologist Craig Alter reviewed her medical records. He was shocked, unable to understand why Dr. Mercado had so quickly ruled out type 1 diabetes.
"If you tell me there is a five-year-old with diabetes, the chance that they have type 1 is probably 99.99 percent," he would later testify. "If you tell me they are obese, I would say, okay, the chance is 99.7. It's almost definitely type 1."
Alter, a physician at the Children's Hospital of Philadelphia, is one of the world's top experts on diabetes in kids. He teaches a pediatric endocrinology class at the University of Pennsylvania's medical school. He is chairman of the Educational Committee for the Endocrine Society and gives lectures across the globe. In 2001, he founded Camp Freedom, a summer program in Pennsylvania that brings together diabetic youth for a week of swimming, hiking, and sharing insulin-injection stories around the bonfire. Last year, 140 kids registered; 139 of them had type 1.
Even though rates of type 2 are rising among minors, the condition remains rare in children under 10 years old. The National Institutes of Health report that one out of every 5,000 kids in that age group has type 1 diabetes, while one out of every 250,000 gets type 2. The reason is simple: Type 1 is a condition people are born with or acquire very early in life; type 2 develops over time—enough time for the body to build a resistance to insulin.
Not only is type 1 far more common in six-year-olds, it is also far more urgent.
"Type 2, you have a little more luxury of time. Type 1, you do not have the luxury of time," Alter testified. "Type 1, if we don't give them insulin, they will die."
Blood sugar is like temperature—it rises gradually. In the months since Claudialee's last tests, the girl's blood sugar level continued to rise, right under her doctors' noses.
Even as the puzzle pieces began to emerge, each showing a symptom of the disease, neither Mercado nor Cabatic saw the whole picture. Weight loss can indicate that the body is starving as a result of its failure to absorb glucose. Sudden heart palpitations can indicate that the body is dehydrated from losing the sugar-laden fluids via urination.
"In a child where there is a possibility of diabetes, any symptoms that develop that might be linked to diabetes have to be assumed diabetes until proven otherwise," Alter said. "You look for anything to tip you over the edge. The appropriate treatment would have been more-frequent monitoring to determine if diabetes was present then, or to catch it early within a few days, had it progressed."
Because Mercado had locked in on type 2, she did not monitor her patient's blood. She did not tell Irma to purchase a $20 blood sugar meter from the drugstore. She did not ask Irma about the frequency with which her daughter drank and urinated. And neither she nor Cabatic described to Irma the danger signs to look out for.
"Being that she has a family history of diabetes, I would be thinking that she would know the symptoms of diabetes," Cabatic later testified in court.
Even after it was clear that Claudialee suffered from type 1, Mercado stood by her diagnosis. When later questioned in court, she disagreed with the notion that type 2 diabetes is uncommon in young kids.
"How many type 2 infant diabetics have you treated?" a lawyer asked her.
"A lot," she replied. "Maybe it's geographical, because I work at Brooklyn as an assistant professor and also in wellness program where there are a lot of obese children, so we diagnose a lot of children with type 2 diabetes."
It's tempting to assume that Claudialee received substandard care because of her family's income status. Doctors don't make as much money treating Medicaid beneficiaries, explains Jim Sheehan, former New York State Medicaid inspector general. A specialist earns as little as $30 a visit. By contrast, a pediatric endocrinologist treating someone with private insurance gets nearly $100 an hour. So Medicaid providers often have trouble filling their networks with enough doctors who specialize in common issues like diabetes. Patients are sometimes left to the lesser skilled or lesser known—doctors who can't afford to turn away the business.
"Some specialties, they have a very tough time recruiting people to be Medicaid-based," says Sheehan. "And so you're not gonna say, 'We want board-certified.'"
Though she'd failed to earn certification, Arlene Mercado had established a respectable career. She graduated from the University of Santo Tomas's medical school in the Philippines in 1984 and spent much of the next decade treating poor people in rural villages. She came to the U.S. in the mid-1990s, interning at Harlem Hospital before beginning her residency at Pitt County Memorial Hospital in Greenville, North Carolina. Her transition reflected competence: Foreign doctors must complete a rigorous testing process to become licensed here.
After two years of endocrinology training at the National Institutes of Health, Mercado took a position as a senior fellow at Mt. Sinai Hospital in Manhattan. In 2006, SUNY Downstate hired her as an attending physician. Two years later, she was named associate medical director of the hospital's wellness program for obese and diabetic patients. (SUNY did not respond to interview requests for this story.)
By the time Mercado treated Claudialee, a good number of experienced doctors had vouched for her. She'd co-authored at least seven academic papers in peer-reviewed journals. Multiple private insurance companies added her to their networks. Over the course of her career in New York, she sustained a spotless record. Not once had the Office of Professional Medical Conduct, an investigatory division of the New York State Department of Health, taken disciplinary action against her.
Shortly after sunset on January 23, 2010, Irma and Napolean sat in the waiting room at New York Presbyterian Cornell Medical Center. Claudialee had been transferred there a few hours before. Family and friends surrounded the parents.
A doctor approached and explained what was happening to their daughter. Claudialee's blood sugar had been rising for months. Because she didn't have enough insulin, her body burned fatty acids as an alternative fuel source. As those acids accumulated, they poisoned her body, and its systems began to shut down. The resulting nerve damage allowed fluids to seep into her brain, causing it to swell and pushing her further from consciousness. Twice that evening, doctors had had to resuscitate Claudialee. Now only machines kept her alive.
There was almost no chance she would recover.
That reality was dawning on Irma. She'd tried to stay optimistic, to stay strong for her only child. She'd dedicated herself to building a life for her daughter. She thought she'd done everything right. Coming to America. Working the long hours that might pull them up the economic ladder. Signing the girl up for dance classes and after-school tutoring sessions. And all those doctor visits. She wondered what she should have done better.
She felt guilty and betrayed. She'd put her faith in the healthcare process and it failed her.
Irma asked about organ donation. The doctor told her that wouldn't be possible. Her daughter's organs were damaged beyond repair.
The family members entered Claudialee's room and said their goodbyes.
On a summer afternoon, the waiting room of Downstate Pediatrics Associates is filled with nearly two dozen people. There are babies in strollers, parents reading magazines, and grade-schoolers playing tag. There are giggles and stomps and adults saying things like "give that man his sunglasses back" and "take that sticker off your face."
A reporter approaches the front desk and asks to speak with Dr. Arlene Mercado. The receptionist goes to get her.
It has been a rough few weeks for Mercado. In July, a jury found her 100 percent liable for the death of Claudialee Gomez-Nicanor. (Cabatic, also a defendant, was cleared.) In her testimony, Mercado admitted to having thrown away her original notes from Claudialee's treatments after learning she had been subpoenaed. Before discarding them, she typed up copies for the court. The new version indicated that she had intended to administer a blood test at Claudialee's next appointment in January 2010, days before the girl's death.
But Irma had been meticulous with her daughter's medical documents. She'd kept the appointment card for their next visit, which wasn't until February 23.
Jurors awarded Irma $100,000 for economic loss, $400,000 for her daughter's pain and suffering, plus $7.5 million in punitive damages for Mercado's malpractice. "It's not covered by insurance," Judge Darrell Gavrin pointed out at trial. Gavrin has yet to make a final judgment on the total sum Mercado must pay.
It's unlikely that Mercado has to worry about a state sanction. Historically, the Department of Health has doled out punishment only once it recognizes a pattern of misbehavior or incompetence. (The department did not respond to interview requests.)
"There are many physicians who have been sued and lost a malpractice case and are still practicing," says a New York government official who works closely with the medical industry and was not authorized to publicly discuss the subject. "The Office of Professional Medical Conduct will take a look at trends, as opposed to an isolated incident."
Staten Island cosmetic surgeon Robert Cattani, for instance, tallied 40 malpractice suits before the state revoked his medical license in September 2012. Another plastic surgeon in Brooklyn didn't lose his license until regulators found negligence on seven occasions.
Between 2001 and 2011, according to a USA Today investigation, of about 400 doctors who had their clinical privileges reduced or revoked by a medical institution in New York, more than half had never been assessed a single state penalty.
Mercado still runs a private practice. She still serves on the SUNY faculty. So it's understandable that she's reluctant to discuss the case. She stands at the door that separates the waiting area from the treatment rooms, holding it halfway closed like a reluctant homeowner talking to a salesman.
"I did my best for this patient," Mercado says. "I know in my heart that I did everything for this patient."
She declines to go into specifics or answer any questions.
"I'll just stay silent on this, because God knows best," she says, pointing to the ceiling with both index fingers.
Then she closes the door. Her afternoon schedule is full. There's a roomful of patients awaiting treatment.
