“Yep.”
“And…?” Ruck led.
Silence.
“Um, did they come back in correlation?”
“Yes,” Lund said finally. “They did.”
“Well,” Cors began, “the endocrinologist on the case… he, um, felt that, um… at least in one of the cases… um…. I’m trying to remember which one, I don’t have the charts just right in front of me, but um… he would be hard-pressed to explain what happened to the patient, absent an….” Cors paused to think, then finally remembered the word he was looking for. “… an exogenous source of influence.”
“Well, hey!” Marcus said. Cors had said it. Their own physicians had concluded that someone must have injected these patients with overdose levels of the drug. “That—yeah, that is our worry about this whole thing!” Marcus boomed. “Because my gut feeling is that, they’re all victims of the same thing!”
“Well, we have gut feelings, too,” Cors admitted. “And what we’re wrestling with is, um, you know, throwing the whole institution into chaos, versus, you know, our responsibility to, you know, to keep patients from further harm. And, um, that’s what, that’s what we’re, that’s what we’re wrestling with, right now.”
The Poison Control end of the line was silent, waiting to know the outcome of Cors’s wrestling.
Finally, Cors continued. “We have been trying to investigate this. To get some more information before we made any kind of rush to, you know—judgment. Part of that investigation involves an expert opinion. Which we solicited from you. And now puts you in an unfortunate position.”
“Yeah!” Marcus snorted. “You see, the problem is that in every single report like this in the literature in years gone by, there was significant delay in the hospitals instituting any sort of a legal investigation. You know, physicians—I don’t care how good your background is, they are really infamously poor at doing forensic investigation. And, the problem, in the past, has always been that somebody then moves on—and, and, you have trouble tracking them.”
“Yeah,” Cors said. “Who does do good forensic investigation?”
“This is a police matter,” Ruck blurted. He’s said it a half dozen times over the past two days.
“Yes, it’s a police matter,” Marcus said.
“Um, oh-kay,” Cors said.
“Okay, I mean, quite honestly,” Marcus said, “if you don’t report it to the police, and somebody else dies, and then it comes up that you stonewalled it—you’re really going to look terrible!”
“Well, oh-kay.” Cors chuckled. “We’re looking at protecting patients.”
“No no, no,” Marcus said. “Obviously I’m concerned in protecting all of the patients in your hospital as well. But I’m also concerned that, that we’ll all be caught with our pants down, and we’ll all look like morons!”
Cors listened, then cleared his throat. “One of the reasons we called you was to determine if there’s really any further benefit, at this point, with you coming in and taking a look, um, through the, the actual records,” he said. “And, maybe we should defer… maybe what we should do is maybe kind of, end this call at this point, so that we can confer with our legal counsel and, uh, get some advice—just lay out all the facts and, um, make sure we do the… right thing.”
Marcus sighed wearily. “Well I…. sure. We’d be more than happy to come look at it. My gut reaction, having been doing this for, you know, a number of years, being involved with the police investigation of several, other… situations over the last twenty years, is that, yeah, you need to get your legal people on board—but I would not waste time.”
Marcus knew of several cases in which hospital staff members had poisoned patients, some in the literature, others that he had worked on personally. They called these killers Angels of Death. All of those cases shared a simple but disturbing pattern; 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. That was the pattern he saw repeating itself at Somerset.
“I would make sure you go to the authorities, and make sure that they know that there is this question. And then it’s in their hands, and if they decide not to do anything, then that’s their problem.”
“Oh, I understand,” Cors said. He sounded tired of being scolded, and ready to end the call.
“We do hear you,” Lund added.
“And also including the Department of Health!” Ruck reminded them.
“I mean, this is certainly a sentinel event,” Marcus said.2 He knew the effect of those words on a hospital administrator. A sentinel event is any event in which patient safety is threatened. Marcus had thrown the gauntlet; by law, Somerset had to report such an event to authorities. “They need to know about it,” Marcus added.
“All right,” Lund said… finally, using the sing-song tone that signals the end of a phone call.
“Well, we surely appreciate your input,” Cors said. “And, we will, um, indeed get back to you… so… you’ll hear from us one way or the other…”
“Hopefully it was nothing, inappropriate,” Ruck said, trying to lighten the murder thing, keep them moving. “Hopefully just an error or whatever.”
“I know!” Cors said. “I just wish somebody would come forward and say, ‘Hey, I screwed up.’ I’d sleep a lot better.”
“Well, you’ve got two patients with dig and two patients with insulin,” Marcus said. “That doesn’t sound to me like it’s going to be a simple screwup.”
Bruce Ruck knew he was pushing his luck, especially after the bomb Dr. Marcus let off at with the last call, but he needed to check on Nancy. He dialed the number for the Somerset Medical Center pharmacy again, figuring if he got Vigdor, he’d make something up. A female voice answered on the second ring. This time, he didn’t identify himself.
“Hey,” Ruck said. “I’m trying to get in touch with Nancy—”
“Yeah hold on, she’s right here.” The phone at the other end was muffled. “That’s for you.”
“Nancy Doherty, can I help you?”
“Nancy, it’s Bruce.”
“Um, hi,” Nancy said quickly.
“Look,” Bruce said.“I know you can’t talk about the case, and that’s fine…”
“Um-hmm,” Nancy said.
“Nancy,” Bruce said, “the only thing I want to tell you is, if they’re going to try and get you in trouble in any shape or form…”
“Um-huh.”
“The medical director, he and I have talked about it. We will back you five hundred percent, ’cause you did nothing wrong.”
“Okay,” Nancy said.
“Are they giving you a hard time?”
“Ah, there’s some…” Nancy picked her words. “There’s a lot of… issues. Floating around…”
“Okay.”
“A lot of issues,” she said. “Floating around.”
“Okay,” Bruce said. “But Nancy, Nancy.”
“Yeah?”
“You did nothing wrong.”
“Yeah.”
“And that’s why him and I sat down and discussed it.”
Nancy sounded like she was trying hard to keep it together. “Okay…”
“Because if, God forbid, Nancy, if they try to do anything to you, professionally?”
“Yeah?”
“We will one hundred and fifty percent back you up.”
“Okay.”
“I put it together,” Bruce said. “You? You just called for information.”
“Yeah.”
“On how to increase dig levels, or whatever.”
“Okay,” Nancy said. She sounded grateful at Ruck helping her, getting the story straight.
“You should not take the brunt.”
“I really appreciate that,” Nancy said. “I do.”
“You know,” Bruce said.
“Yeah,�
�� Nancy sighed. She sounded on the edge of tears. “You don’t know how much that means to hear you say that right now.”3
There would be only one more conference call between Dr. Marcus at Poison Control and the Somerset Medical Center administration. Again, Marcus told the Somerset administrators in no uncertain terms that they were obligated to report these incidents to the state within twenty-four hours of their occurrence, and they were already out of compliance with their obligations. And again, Marcus was told by Somerset that until they’d mounted a thorough investigation, they were not planning on reporting them to anyone: not the New Jersey Department of Health and Senior Services (commonly known as the DOH), and not the police.4
But this second conversation differed from the first in two crucial aspects. The first was raw volume, most of it from Dr. Marcus. He was, in his own words, “extremely concerned” and “frustrated”; “rude, confrontational, and adversarial in his dealings with Somerset Medical Center employees,” was how Dr. Cors would later characterize Marcus’s phone manner. The poison control director was furious and unmuzzled. He loudly protested that this was a police matter, a matter of patient safety. He gave them twenty-four hours; if Somerset refused to act, Marcus had an obligation to report their problem to the DOH, personally, and he added that it would “look a lot worse if I do it.”
In fact, Marcus had already reported the issues at Somerset.5 Earlier that afternoon he’d called Eddy Bresnitz, MD, the state epidemiologist and assistant commissioner of the DOH, pulling him out of a meeting. Marcus would recall6 telling Dr. Bresnitz of “a cluster of illnesses in the hospital in the state which may be based on a criminal act.” He then dashed off an e-mail to Amie Thornton, the assistant commissioner of health, summarizing both “what appears to be a cluster of four untoward clinical events” at the hospital,7 and Somerset’s unwillingness to report them until after they mounted a thorough investigation themselves.8
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
On 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
Charlie 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.
His 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
The Good Nurse: A True Story of Medicine, Madness, and Murder Page 12