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Anesthesiology:
doi: 10.1097/ALN.0b013e3182a7cb00
Reviews of Educational Material

The Good Nurse: A True Story of Medicine, Madness, and Murder. By Charles Graeber. New York, Twelve–Hachette Book Group, 2013. Pages: 320. Price: $26.99.

Litman, Ronald S. D.O.

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The Good Nurse is the true story of Charles Cullen, a nurse who likely took the lives of hundreds of patients in nine hospitals along the New Jersey–Pennsylvania border, over a 16-yr period from 1987 to 2003. If these estimates are correct, Cullen would be one of the most prolific serial killers in U.S. history. Cullen, who had a substantial background of mental illness and multiple suicide attempts, accomplished his murders by injecting lethal doses of medications, such as insulin and digoxin, while working as an intensive care nurse. Earlier this year, he was interviewed for a 60 Minutes segment; it was the first time this television news show had ever interviewed a serial killer.
Medical serial killers are well known throughout history and are often given the label “Angel of Death.” Although the term invokes altruistic motivations, very few of these nurses or physicians killed to relieve suffering. Most are like Cullen—they possess a complicated dysfunctional and insecure emotional life that leads them to a position of power where they become euphoric while witnessing the consequences of their actions, or as they rise to hero status during the subsequent rescue.
The Good Nurse is written by Charles Graeber, a freelance journalist and former medical student and scientific researcher. He conducted a series of interviews with Cullen (from prison) as well as with the detectives who cracked the case and a host of supporting characters.
The story of Charles Cullen is described in two roughly equal parts. The first is Cullen’s personal story, that of a complicated and insecure psychopath who was also a very competent and reliable nurse. As a sensitive and enduring listener, he befriended female coworkers easily, and was generally well liked by those who did not know his inner secrets. Graeber describes how Cullen sidestepped the hospital’s electronic drug dispensers and medical record systems, so his removal of certain drugs became undetected and largely untraceable. Much of this first section describes the details of how Cullen poisoned his victims, with information presumably learned from Cullen himself. After coworkers and hospital officials became suspicious because of a pattern of inappropriate deaths on Cullen’s shifts, they conducted their own internal, superficial, and ineffective investigations, each of which led to Cullen being asked to resign, with the proviso that he would be issued a neutral letter of reference, and sometimes resulted in disciplinary action for the whistle blower. Although some hospitals strongly suspected Cullen of poisoning patients, they chose not to alert authorities because of the negative publicity that would be generated.
The case gained strength when a pharmacist at Somerset Hospital in New Jersey called the State’s Department of Poison Control to inquire about the dose of digoxin required to achieve the astronomically high levels found in the bodies of two victims after their deaths. Neither patient was ordered to receive digoxin nor was there any record of its administration. Massive digoxin toxicity in one patient is a mystery, but in two it is murder.
If we lived in an ideal world, at the moment of this chilling revelation, everything would have come to a halt: law authorities would have been alerted, toxicologists summoned, and the scenes of the purported crimes sealed off with yellow tape. Every needle dispenser would have been quarantined and searched and video camera footage inspected. At the very least, Cullen would have been placed on 24-h surveillance and not allowed anywhere near a patient. But none of this occurred. Dr. Steven Marcus, head of New Jersey’s Poison Control, urged hospital officials to contact law enforcement when he began to connect the dots, but did not appear to realize that his recommendations went unheeded as Cullen continued to kill. He rued this decision during a tearful moment while being interviewed for the 60 Minutes segment.
The second half of the book details the investigative efforts of the two detectives who doggedly pursued evidence of Cullen’s guilt, with the help of one of Cullen’s former coworkers, who needed considerable persuading that Cullen would be capable of such heinous activities. It reads more like a police procedural, as law authorities from New Jersey and Pennsylvania eventually realize the extent of Cullen’s murderous activities.
Reading this book, I became enraged at the system surrounding the inappropriateness of neutral professional references. Hospitals that strongly suspected Cullen of wrongdoing were unwilling to offer those suspicions to subsequent employers because of the fear of litigation for unlawful termination. Graeber takes hospitals to task for their willingness to turn a blind eye to potential problematic employees as long as the wards are adequately staffed. For example, while working at Warren General Hospital, in Warren, Pennsylvania, Cullen attempted suicide after stalking a coworker and breaking into her house in the middle of the night. As his coworkers looked on, Cullen was treated in the hospital’s emergency room and subsequently sentenced to treatment in a high-security psychiatric institution. During his stay there, the nursing office of Warren Hospital left him a message asking how soon his psychiatrist could clear him so that he could return to his previous position.
The Good Nurse is a solemn, but enjoyable read. I learned a lot about the paucity of hospital security systems, and I was surprised by the brazen haughtiness of hospitals in the name of preserving their bottom line. In the future, I will be more circumspect of unusual circumstances that occur in the hospital. I was surprised when my background research on this topic revealed many more medical serial killers than I had heard about. No one can predict where and when the next Angel of Death will strike, but we can state with 100% certainty that one will again appear somewhere. Unexplained medical deaths should be thoroughly examined, without deference to fear of litigation or political incentives, and neutral references should be investigated further.
Ronald S. Litman, D.O.
, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania. litmanr@email.chop.edu

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