June 4, 2013 8:39:25 AM
Charles Cullen may have been the most prolific serial killer in history. The only reason we do not know for sure is that he has forgotten many of his hundreds of victims. Even though they were all hospitalized patients with full records, Cullen's crimes extended for sixteen years and records are now missing, or in many cases the hospitals are simply reluctant to dig into them again. Little could be gained now by doing so, but that sort of reluctance is what allowed Cullen to keep killing. It's the dismal lesson in The Good Nurse: A True Story of Medicine, Madness, and Murder (Twelve) by journalist Charles Graeber, a true crime story distinctive because of its medical setting and bureaucratic denial. Graeber has had the cooperation of Cullen in writing this book; he first covered the case when the imprisoned Cullen was approached in 2005 about donating a kidney, causing a public uproar. Graeber became the one journalist with whom Cullen would remain in correspondence.
The book is fascinating because of its picture of bureaucratic denial and the intrepid investigators who overcame it. The portrait of Cullen himself is vague; he remains an enigma, and the brief, partial history of his early life certainly does not explain what came after. His father died shortly after Cullen was born, and he grew up as the youngest of many siblings, in a gloomy place where the older siblings drifted in and out with drug addiction or serial pregnancies. Perhaps the death of his mother when he was in high school, a death within a hospital where he was eventually to work, explains something. He did a stint in the Navy, showing some bizarre behavior and suicide attempts, but also being the victim of hazing. He found himself when he went to nursing school, and was popular as the one male student in his class. He did well in his initial jobs, and anyone could see that he was punctual, neat, and well-spoken. He liked booking extra hours or volunteering for holiday shifts no one else wanted. He could tell funny or self-deprecating stories about his past, and had a capacity of eliciting sympathy from his female colleagues.
All the while he would be killing patients. Initially, he tampered with the IV bags, injecting insulin into the solution, which still looked normal when it was hooked up to be sent into the veins of a patient. He became adept at the use of digoxin, a classic medicine to treat congestive heart failure which in overdose slows the heart down as well as causing a spectrum of other nonspecific effects. Patients would get their doses and would have their consequent symptoms hours later, often when Cullen was off shift. He learned how to jimmy the Pyxis machine, an automated dispensing system which would allow him to order digoxin, remove it from the dispenser, and then cancel the order. The first part of the book deals with Cullen's pulling off one murder and then another, and the astonishing slowness of the system to do anything about it. One hospital after another (there were about ten) took him on, found there was some connection between his shifts and with patients dying, and let him go, often with referrals for his next job that did not indicate that there had been any difficulty. It was a pattern familiar to the investigators who eventually broke the case. Each time, "... the doctors treated the rash of crashing patients like a disease to be studied, while the administration and the lawyers treated them as a potential lawsuit. The institution dragged its feet before calling in the cops. And while they dragged, people died."
Soon after Cullen started working at Somerset Medical Center, an upscale hospital in Somerville, NJ, patients started dying, and the hospital noticed it. They had meetings on the issue. They had someone from the pharmacy department call poison control to figure out digoxin dosing and timings. The hospital was still reluctant to report that crimes were happening, but the official at poison control said repeatedly, "This is a police matter." He also explained that poison control taped its incoming phone calls, and he told Somerset officials that if they didn't call the cops, he was going to.
Two smart investigators were put on the case. They looked at the patterns and timings of the deaths, with hospital administrators sometimes acting to make the connections murky. For instance, the investigators could not literally come up with a smoking gun, but trying to find a specific digoxin syringe used at the scene of a crime would have been very helpful. The Pyxis machine kept such a record. The Risk Manager at Somerset, a former nurse, was assigned to be the investigators' liaison at the hospital. They told her that they needed to see the Pyxis records from a death four months before. The Risk Manager said sorry, the Pyxis stored such data for thirty days, and then forgot it; there were no records that could be examined. It was a dead end. On a whim, one of the investigators looked up Pyxis, called the manufacturer, and said he was a detective sergeant in homicide who needed help. Was there any way to recover data from a Pyxis machine older than thirty days? The Pyxis guy didn't understand the question: "Just pull it up. Is there something wrong with your machine?" The hospital had been lying to keep the investigators from getting the data.
That was one big step toward solving the crimes. The other was that the investigators got as an ally a nurse that worked with Cullen and liked him, but who wanted the investigation to succeed. It was she who looked at the Pyxis printouts and saw that Cullen was using the machine and withdrawing digoxin in a way no other nurse would. She agreed to wear a recording device in a conversation with Cullen, and got his confession on the record. She risked her career to make justice happen. She is one of the few hospital employees who looks good in these pages.
Charles Cullen represents a frightening bogeyman, a stealthy killer with no conscience. His story would be almost unbelievable, but Graeber has provided voluminous notes, and his account is even and matter-of-fact. Cullen isn't the scariest part of this book, though. Cullen endured complaints, disciplinary action, and even official suspicion that he was murdering patients, and yet he was able to go from one hospital to another for years and for hundreds of murders before anyone took serious action against him. If the trustees of the health of inpatients were doing so little about a murderer in their midst, how else is the system failing?