The Good Nurse: A True Story of Medicine, Madness, and Murder (19 page)

The second crucial difference came twenty minutes into the call, when Marcus informed the Somerset Medical Hospital administration that all their conversations had been recorded.

A
few hours later,
⁹
Mary Lund contacted the Department of Health and reported their four patient incidents, Gall and Han by digoxin and the others by insulin.
¹⁰
The report, by fax and e-mail, explained the steps thus far taken to account for these incidents. They’d checked for manufacturer’s recalls and adverse drug interactions. They’d ensured that IVs and bedside
monitors were serviceable and accurate. It couldn’t have been a lab error—they’d already rerun all the lab tests. They were running out of alternate theories, and as a caution, Somerset tightened pharmacy controls on digoxin, as they had on insulin, making their nurses now accountable for these commonly used medicines; if the drugs were being used to harm their patients, the least they could do was make them more difficult to get.

The most likely scenario to account for the incidents was human error of some sort—medication errors were always possible in a hospital, and mistakes were possible anywhere. Proof of an innocent mistake would probably show up in the paper trail. The Somerset Medical administration assured the DOH they were already reviewing all their documentation systems. The hospital employed two major computerized systems; the Pyxis MedStation 2000, for the drugs, and Cerner, which stored computerized patient charts. So far, they hadn’t found any innocent mistakes.

But what else was possible? Something unusual, and far more sinister than a mistake. “Human resource factors are being evaluated,” Lund’s July 10 letter assured the DOH. “Independent investigators are conducting interviews of involved staff.”
¹¹

O
n July 14, attorney Raymond J. Fleming, of the law firm of Sachs, Maitlin, Fleming, Greene, Marotte and Mullen of West Orange, drove out to Somerset Medical Center. Fleming was briefed on the situation by Mary Lund, then set up in a room to meet with Charles Cullen.
¹²

Charlie found Fleming seated at a conference table wearing the telltale dark-suit-bright-tie combination that distinguished corporate lawyers from undertakers. Charlie knew this had to be about the recent deaths on his ward; he’d been through this sort of thing plenty of times before. He was ready for the questions.

Ray Fleming seemed to already know a bit about him. He knew that Charlie had worked at Somerset for less than a year, and that he had left jobs at many other hospitals in the past. To Charlie, that suggested that the man had looked at his application. Charlie hadn’t listed the proper dates there. Maybe this lawyer knew that, too. Maybe that mattered, maybe not. Charlie didn’t think it did. It never had before.

Fleming also knew about the Reverend Gall. That seemed to be the point of the meeting. He knew, for example, that Cullen was not Gall’s
nurse the night the reverend died, but that Cullen had worked with him before, and that he was familiar with Gall’s medical history. Fleming knew that history, the medical issues Gall came in with, the time line of his illness and apparent recovery, and the spiking of his digoxin levels just prior to his code. He also knew that Charlie had been assigned to Reverend Gall for three nights, June 15 to 17.

Charlie had ordered digoxin for Gall on his first night, the fifteenth. He’d then canceled the order. It was on his Pyxis. Charlie was also working on the night Gall died. On that night Charlie had again ordered, then canceled, digoxin. It was one of his two cancellations that night.

Neither of these cancellations made much sense as mistakes—if Charlie had typed in the wrong code, or pressed the wrong button, then you’d expect the mistake would be immediately followed up with another, presumably correct, drug order. The Pyxis orders were time coded. There had been no immediate follow-up orders. Apparently, Charlie had typed in his name, the patient, and the drug on the keypad, only to suddenly realize, as the drawer popped open, that he needed nothing from the machine, at which point he’d simply cancel the order and walk away. It was a bizarre scenario.

Fleming had another interesting fact at his disposal. He’d checked with the pharmacy and discovered that a number of vials of dig had been unaccounted for that month. Fleming didn’t put any of this in a particular order as far as Charlie could tell, and he didn’t accuse Charlie or threaten him or offer to let him resign, as other interviewers had done before. It was a curious interview, Charlie had to admit, and it got stranger when Fleming asked him a question:

Was Charlie aware that if he ordered a drug, and then canceled the order, that the cancellation still showed up on his computerized Pyxis record?

“Yes,” Charlie told the lawyer. If he didn’t know it before, he certainly did now.

27

C
harlie was pretty certain they were just looking at his digoxin, as if dig was somehow the problem. But the night before Fleming’s interview, Charlie had killed a man with dobutamine,
¹
a chemical relative of adrenaline. It worked fine.

H
is shift hadn’t started yet, but Charlie was already in his whites when he walked into James Strickland’s room to watch him breathe. Then Charlie felt a presence, someone at the door behind him. He tucked the sheet, as if finishing up nurse work, then ducked toward the door.

“Charles?” It was Mr. Strickland’s daughter Janece, a middle-aged blonde woman with an oversized purse denting her shoulder. The daughter noticed things, used his name, asked questions. It was uncomfortable for Charlie, like walking too close to a strange dog on the street.

He’d seen her several times during her visits to her father. They’d interacted and, gradually, fallen into roles Charlie was more comfortable with. He liked to explain the technical aspects of her father’s medical condition, and she seemed to listen. She also sometimes brought her younger son along, an autistic boy, a child Charlie thought of as vulnerable, though tonight, she was alone.

“Charles?” the woman said again. “Charles, are you my father’s nurse tonight?”

Charlie didn’t want to talk. He kept moving, pretending he hadn’t heard as he turned down the hall into another room and waited until the daughter left. Then Charlie pulled the Cerner cart to the end of the hallway and called up Mr. Stickland’s charts. No, he wasn’t Mr. Strickland’s nurse,
not technically. He shouldn’t even have been in Strickland’s room. But Mr. Stickland was still within Charlie’s sphere, and he had decided.
Insulin.

Unlike digoxin, insulin was a hormone, a drug the human body produced naturally. In the hospital, it dripped into the patient from an IV. In the body, it dripped from the pink waterlogged pinkie of the pancreas, radiating from special cells the textbooks called the islets of Langerhans. The name made it sound like it came from pirates. When Charlie was in nursing school, the foreign insulin, the drug diabetics used, all came from animals, pigs or cows, usually, as if it were a by-product of hot dogs. They’d all laughed about that in class, letting out a collective
eew
after they’d been so tough about so much else.

Insulin was like a volume control for sugar. Not enough and you were diabetic. Too much and you were hypoglycemic. It wasn’t a poison—you can’t eat insulin and get sick; the stomach juices would gobble the bonds like hamburger. But injected overdoses happened, sometimes on purpose.

First the lips and fingers go tingly and numb, then it’s the brain. The flood of insulin gives orders to the cells, makes them hungry. The cells take up the glucose; the blood is left barren and the extremities starve. The human brain, surviving on oxygen and sugar alone, begins to shut down, resulting in a confused stupor that occasionally lands hypoglycemics in the drunk tank by mistake. It’s a space-out, a fuzziness. The body goes insubstantial, the personality light, and individuals become either cranky or giddy, depending on their nature. Then the stomach sinks. Sweat beads form on the scalp. The head pounds, the heart skips, concentration evaporates. Vision slurs and pixilates. Moments pass, unfiled in memory.

All this happens quickly. With a patient who is unwell, or already zonked on a tranquilizer or paralytic agent, these intellectual and perceptual effects may go unnoticed by the outside observer. The next stages will not.

Insulin overdose is like a chemically induced drowning. The brain is literally strangled; the pupils dilate, then clench shut and refuse the light entirely. The movement of glucose triggers a sympathetic cascade of ions across the cell membranes. And then the convulsions start.
²

Some of the most extensive research on insulin overdose was undertaken by Nazi scientists. At some concentration camps, children were injected with graduated doses of insulin to measure their endurance to extreme hypoglycemia.
³
The bell curve on these so-called terminal
experiments tapered at death. It’s the ultimate outcome for every insulin overdose of sufficient volume.

But the use of intentional insulin overdose had its origins as therapy. The intentional induction of a coma, or shock, was considered the ultimate sobering slap for certain maladies of mind, a treatment started in Switzerland soon after the discovery of the hormone in the 1920s. Like electroshock, insulin shock therapy was used throughout the 1950s in the treatment of paranoid schizophrenia, before being discontinued due to the violence and occasional brain damage that were the occasional side effects of the brain-starving procedure.

Surviving an insulin coma is like surviving a near drowning, and the extent and permanence of the injuries are related to the length of time that the brain was starved of nutrient. Continued starvation damages the cerebral cortex. The microscopic chemical architecture of the brain collapses, the surface area smoothes, and crenulations simplify, much like the brains of patients with neurodegenerative disorders. The effects range from Parkinson’s-like symptoms of rigidity and the choreiform, or jerky, movements of a damaged motor cortex, all the way to permanent intellectual retardation.

But of course, the ultimate effect was death. The only trick was figuring the right dosage.

28

C
harlie always preferred the hospital at night, without extras: the candy stripers, administrators, and visitors. The gift shop was closed, the public bathrooms locked. Even the janitors were gone, their whirring machines lassoed with yellow extension cord.

Overhead, the mercury vapor lights hummed like neon. The vending machines murmured down the empty hall. The break room tables showcased teeth-marked Styrofoam cups, lipsticked bendy straws, still lifes with Snack Mix and mini-donuts. Some of the other nurses ate this crap all night, but not Charlie. Charlie never ate on shift. He waited.

He watched the silhouettes through the Levolors, waiting for the small hours. Then he waited on Mr. Strickland. He checked his chart on the Cerner, made coffee, checked again. He was still there. Charlie always made the coffee. Some people were so inconsiderate about that; they used the coffee but they never refilled it, which was okay, but he was always taking care of it, helpful in that way, secretly helpful. He watched the nurses at the station, stirring their coffees, his coffee, helped by what he did, dependent really but not even knowing it.