The Good Nurse: A True Story of Medicine, Madness, and Murder

by Charles Graeber

  Amy Loughren had emerged from an abusive childhood with a bold defiance toward the fundamental bullshit of life and a mystical conviction that the universe owed her one. Thirty-six hard, impulsive years had brought Amy ten boyfriends, two daughters, an RN degree, and a leased white Jaguar, but behind the blonde highlights lay a void she struggled to name. Her off days were punctuated by panic attacks that sometimes kept her from even leaving the house, and her nights were spent either working or drinking wine. She split her time between her house in upstate New York and her job in New Jersey, her personality between home and hospital, and worked hard to maintain the shelter of that division. She didn’t share herself fully with her daughters or boyfriends or most of her coworkers; only her new friend, Charlie Cullen, made her feel totally safe. Charlie seemed to need her protection, too.

  When Charlie had first started working at Somerset that September, Amy knew, almost right away, that she liked the new guy—not ‘liked-liked’; she was single, but not that single, not in a million years, and she sensed the new guy understood that. He seemed to know his limitations. Amy was blonde, nearly six feet tall and conspicuously curvaceous, even in scrubs, and she was accustomed to unwelcome attentions. But Charlie seemed safe to Amy. He paid attention without an obvious agenda, and he never hit on her. And if he didn’t always keep eye contact, at least it wasn’t because he was trying to steal glances down her scrub tops. He was quiet, too, at least at first, and Amy was instinctively drawn to quiet people. This guy, she thought, has secrets, too, just like me.

  The new male nurse also seemed as serious about the job as Amy was, maybe more so—efficient and attentive to the point of obsession. He was a little eccentric, but he wasn’t flakey. Charlie tended his patients alone, with the door closed and the blinds drawn. He stripped them naked and bathed them before lathering them comically pearlescent with moisturizer. Amy called them his “Butterball turkeys,” too greasy to turn. His other eccentricity was an obsessive use of the Cerner machine. Charting was the necessary paperwork of nursing but Charlie took it to an extreme, spending hours tapping away on the mobile unit far from the scrutiny of the nurses’ station. Amy teased him that he was writing a novel. Uncharacteristically, he welcomed her teasing, recognizing it as guileless affirmation.

  Like many nurses, Amy saw herself as a hero defending humanity’s most fragile, an advocate and facilitator for the voiceless and immobile. With his question mark posture, soft gray hair, and ratty old-man cardigans, the new nurse struck Amy as another sensitive soul in need of defending—a sad Mr. Rogers type, both drippy and depressed. His nurse whites had the dingy air of bachelor washing, and behind his greasy drugstore glasses his eyes held a darkness and desperation that Amy recognized as masked anger. It took only a couple overnights together before Amy realized that Charlie Cullen was also one of the funniest people she had ever met. At 4 a.m. Charlie could make her laugh with a story or complaint that put her own crazy life in perspective. Humor and gossip provided a buffer against the suffering and grief that came with the job, and Charlie always delivered. Several stories centered on the absurdity of his Navy years, his assignment to guard nuclear missiles with a billy club, or the indignities suffered when he refused to pee into a cup in front of another man, but most involved Charlie’s girlfriend, Cathy, and her sporadic attempts to get Charlie to move out of the house. Amy called it “The Charlie and Cathy Show,” and she tuned in nightly. Eventually, she reciprocated with confessions of her own.

  Each night, Charlie would zip through his responsibilities with patients and then cruise the block of rooms until he found her. Amy was a procrastinator, always running late, and she appreciated his technical proficiency, born of fourteen years’ experience10 at nine other hospitals. Soon, she came to rely on it. Her position at Somerset was the best Amy had held in her nearly fifteen years of nursing. The $20,000 bonus on salary for a seven-month contract plus $1,700 a month for local lodging was “crazy money.” She wanted to keep it, even if it was killing her.

  Midshift that October, Charlie found her listing against the hard white wall of the nurses’ station. He helped her to an empty room and shut the door. Amy sat on the bed, gasping for air until she could explain. It was a funny story, at least to the gallows sensibilities of a veteran nurse; she was working in one of the nation’s top cardiac care units, and secretly, slowly, dying of heart failure.

  Amy had diagnosed it herself as advanced atrial fibrillation brought on by prolonged chronic sick sinus syndrome. The condition was at least partially responsible for her crippling panic attacks and the reason those attacks were so unsettling. The synaptic wiring in her heart muscle was misfiring. The result was an erratic heart rhythm insufficient to cycle oxygenated blood between her lungs and her body. Amy was drowning in her own stagnant bloodstream. The most logical medical explanation was that her heart muscle had been ravaged by a virus from one of her patients, but Amy wondered if perhaps it was something more mystical: an emotional virus of some kind, psychological shrapnel from the monsters of her childhood, the damage of memory. Amy’s failing heart wasn’t the only secret in her life. Those were killing her, too.

  Charlie listened, nodding like a doctor. Then he left the room, returning a minute later with a mint-green oval in his palm—diltiazem, 0.5 mg. Amy popped the pill and pulled herself upright with an empty IV tree. It was just 2 a.m., and she still had work to do.

  “No, listen,” Charlie told her. “You rest. Doctor’s orders.” He gave her the hint of a smile. “I’ll handle your patients tonight.”

  “Charlie…,” Amy started.

  “Don’t worry,” Charlie said, turning to leave. “I can keep a secret.”

  Charlie never knew how many he did at Somerset, only that it started around when Amy got sick, and once it started it did not stop.

  Amy’s cardiomyopathy went unchecked until February, when she collapsed at work and was rushed to the ER. She would require a pacemaker and a leave of absence. Charlie was alone on the overnight. He replaced her attentions with his own compulsions.

  The specific ones, the very old, the very sick, the memorable, seemed to begin mid-January11 with digoxin and a sixty-year-old housewife named Elanor Stoecker. Two weeks later, Charlie worked the night of his forty-third birthday, and used Pavulon, a strong paralytic similar to vec. It was an effective drug by itself, but Charlie had incorporated it with others, and at the end of the night he wasn’t exactly sure who had died as a result of his actions, nor what, precisely, had killed Joyce Mangini and Giacomino Toto. He was, however, quite certain that it was norepinephrine which blew out John Shanagher’s heart on March 11. As he worked the code, Charlie’s knowledge of which drugs might reverse the old man’s sudden failure seemed, to the other nurses, almost magically prescient. Even the young residents on call stepped back to let Charlie take charge. His reputation as a code genius grew, and by the time Dorthea Hoagland’s hammering heart stopped beating and Code Blue bleated through the speakers that May, Charlie once again seemed to have the answers. Each patient had complex and interlacing issues with their organs or chemistry, and each responded uniquely. It was a busy spring, and Charlie was less interested in names than in causes and effects.

  Michael Strenko was young for the unit, their only patient with hair gel, and his illness was particularly upsetting to the nurses. The twenty-one-year-old Seton Hall computer sciences student had a genetic autoimmune disease that cascaded into complicated symptoms and system failures. Amy, back on the unit from a pacemaker surgery and bed rest, was deeply worried that young Michael wouldn’t survive. Charlie was sure of it.

  In the end, it had been digoxin, or epinephrine, or some combination which had put Strenko over the edge—the sick were so precariously balanced, it only took a little push, a sigh that floats a feather, a nudge so subtle and dispersed that nobody noticed the cause, only marveled at the effect. The codes that night were multiple, and not pretty. After the second, Charlie shuffled out to the waiting room to find Michael’s
terrified mother, giving her a graphic and technically accurate word picture of what was happening, at that very moment, inside her son’s dying body. He explained how the EKG indicated the failing pulses in his heart, and how you could affect those pulses with drugs, norepinephrine or digoxin, up or down, depending. He told Mrs. Strenko that Michael was sick, and that sick people, like it or not, eventually died.

  Michael’s parents were horrified by this rendering, and they asked Charlie to leave. But Charlie was right. And at approximately 2 a.m. on May 15, when Mrs. Strenko finally waved off the last shock paddle from her son’s exhausted body, the flatline proved it.

  She didn’t set out to make a stink, but Amy questioned everything. Amy figured, if that made her a pain in the ass, if sometimes she went too far and wasn’t nice about it, then fine, at least she wasn’t cattle. That was her, she always said so, a hotheaded, reactionary bigmouthed girl with a temper, but not cattle. She wouldn’t just go along. They heard about her all the way down in Oncology: Amy, the ICU nurse who refused the exasperating new safety protocol, the one who wouldn’t put her name on their new insulin sign-out sheet. That told her what a big deal she was making—you practically needed a shuttle bus to get from the ICU to Oncology.

  They were calling the new drug protocol an “insulin adjustment form.” Her manager, Val, had explained it, trying to convince Amy to sign. Previously, the insulin had always just been there in the little fridge. But now for some reason they were changing the protocol, making the nurses more accountable by forcing them to put their electronic signature on their guess as to how much was left in the vial. Amy thought it was inaccurate and stupid. How could she eyeball exactly how much was left? They were asking her to bet her nursing license on a jellybean counting contest. Clearly, something had happened, on her unit, possibly to her patients. Amy demanded to know what was going on, but her supervisor wasn’t about to tell her. Why treat insulin like a narcotic? Amy demanded. What was so dangerous about insulin?

  When her manager wouldn’t answer, Amy refused to cooperate. Val said “Sign,” and Amy said no. “Just do it,” Val said. Amy wouldn’t.

  Now Val was angry, too. Amy didn’t understand the reaction. Why the hell get so worked up over a simple piece of protocol—what, did somebody die?

  Val was practically screaming as she finally told Amy, “Look, just sign it—this whole thing isn’t about you, anyway!”

  What did that mean? Who was this about?

  At the time, Amy did not connect the new protocol requirements with the sudden frequency of codes. All she knew was she was wrapping so many bodies now, probably more in the past half year than during her entire career. She had no idea there was a problem, much less did she imagine that Charlie, or anyone, was the cause. Charlie was a good nurse, extraordinary even. She was always glad to find his name on the whiteboard schedule. Her doctors had told Amy to take it easy, but with multiple patients under her care, easy wasn’t always an option. Often she had to choose between being careful of her own heart or tending to theirs. With Charlie on shift, she had a third option. He was never too busy to help.

  On June 14, 2003, Charlie was early by a full half hour—he couldn’t wait. He checked the computerized Cerner charts of various patients and decided on the Oriental lady.12 Mrs. Jin Kyung Han wasn’t his patient now, but she had problems. Han had come into the hospital June 12 with Hodgkin’s lymphoma and heart disease. Her cardiologist, Dr. Zarar Shaleen, had Han on digoxin already, small doses, usually 0.125 mg, keeping her at the therapeutic level of around 0.63. Her doctor had ordered another dose of digoxin for Han on June 13. Then, when he studied her EKG, he discovered that dig wasn’t helping her new cardiac arrhythmias. In fact, it might kill her. He ordered that the drug be discontinued.

  At 7 p.m., the nursing shifts went through their handoff report. Charlie was free again by 7:30, going straight to the Pyxis drug computer and calling up dig. He placed an order of the drug for his own patient, then quickly canceled it. The drug drawer popped open anyway. It was that easy. The new security protocols were stupid. Charlie pulled out two units and closed the drawer.

  Charlie entered Han’s room; the woman was asleep. He took the direct route, injecting the digoxin dose as a piggyback into the IV line snaking between the hanging bag and her vein. Han was no longer supposed to receive dig; the IV bolus Charlie injected represented a dose eight times what Han had ever received.13 Then he ditched the needle in the sharps bin and left the room. It was nearly dawn; the dose would take full effect only after his shift was over. The anticipation echoed across his day off, blurring thought. Charlie reported back for work on the evening of the sixteenth, early, to check. But Han was still there.

  Charlie took the Cerner and went back through her chart. Han’s heart rate had plummeted, she’d been throwing up on the morning shift, and a blood screen found the dig in her system, which had spiked from her normal level of 0.63 up to 9.94. Han’s cardiologist immediately ordered an antidote, and Han settled down. Afterward she teetered through the day shift and into the night, not well, but surviving.

  Amy called Charlie in, he was especially good at after-death care, helpful and quick. He had a serious routine, and he didn’t like to talk as he did it. He would wash the body, pull the IV needles from the veins, wrap the lines, unhook the catheters and feeding and vent tubes. Then he gathered the death kit and the shroud. Shroud: to Amy the word conveyed a holy thing, it was solemn and homespun and grave, but at Somerset the shrouds were thin sheets of cheap, clear plastic that ripped easily and were never large enough. They reminded her of generic Saran Wrap. Working alone, her dignified attempts always devolved into macabre slapstick. Wrapping a body required working multiple pieces of this plastic material under the dead weight of the corpse without ripping or wrinkle. It was like making a bed with someone lying in it. Amy’s pulling, lifting, and tugging generally made a mess of the job. She’d tried fitting the four-foot squares so they overlapped, but there was always a gap in the middle that exposed the belly. Adjusting them this way and that she’d end up with the feet hanging out, then the head uncovered. Eventually she’d simply just wind rolls of tape around the crinkled gob, the way a child wraps a birthday present. Or, better yet, she’d call Charlie.

  Charlie had it down. He squared the sheets neatly and with just the right overlap, angling and creasing and fixing the deceased into a professional polymer cocoon, head and feet and all. Charlie was good. She told him so. He told her it was easy. He’d had plenty of practice.

  The Rev. Florian Gall had arrived by ambulance before being delivered to the Somerset Medical CCU, nearly nine months to the day after Charlie’s own arrival on the unit. His fever was three-digit and his lymph nodes swollen to stones, both symptoms of an overwhelming bacterial infection, probably pneumonia. His lungs, sodden as wet facecloths, labored to deliver minimal oxygen to his heart or brain. A machine would have to breathe for him. Gall’s chin was raised, his mouth opened, and a plastic tube was shoehorned into his windpipe, fitted into an accordianed length of plastic ductwork, and attached to a ventilator. Meanwhile, Gall’s overwhelmed kidneys began to fail. They would recover if he did; until then, a machine would filter his blood as well.14

  The reverend’s sister visited his bedside daily. Lucille Gall was a senior nurse at a nearby hospital, which allowed her to stay at his bedside late, a professional courtesy. The sister had opinions about her brother’s care. Charlie wasn’t always assigned to the reverend, but he always checked up on him, and he didn’t appreciate her proprietary attitude. She had argued with him, more than once, about which drugs he was giving her brother and why, acting as if she was in charge. She didn’t, for instance, think Tylenol was a good idea, considering the reverend’s failing liver. Her attitude bothered him, to the point that when he thought about Gall, the image in his mind was not him, but her. It was only when she left that Charlie could get down to business.

  Gall’s real problem was his heart—atrial fibrillation, probably, mean
ing that one of his heart chambers was contracting too rapidly to effectively fill or pump. The cardiologist on call prescribed digoxin. It would slow the atrium, and oxygenated blood would once again circulate through the reverend’s body. At least, that was the idea.

  At that point, and for that whole first week, it was impossible to know whether the Reverend would live or die. His family consented to a Do Not Resuscitate order; if Gall’s body did quit on him, at least he would pass unto the Lord without the earthy indignity of dramatic and “extraordinary measures.” But then, gradually, the reverend started to improve. The DNR order was rescinded and his digoxin was discontinued. By the second week, Gall began to sit up and take his meals. As his pneumonia subsided and his heart rhythm stabilized, he would chat with his sister, who remained vigilant by his bedside. Grousing about the nurses who cared for him, unhappy to be hooked to tubes and drips and bleeping machines, the reverend was his old self again, cantankerous but familiar. He could eat and talk. Eventually, if he continued to improve, he would leave.

  Charlie would study the man at night, his bald head glowing in the light of the machines, his clerical vestments exchanged for a disposable frock. He looked nothing like the priests of Charlie’s youth, nothing like God’s man on earth—he looked sick, and very human. That was his prognosis. Charlie knew the charts, he’d pulled the little computer cart to the corner of the Cardiac Care Unit to pore through the drama of numbers.