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The Good Nurse
A True Story of Medicine, Madness, and Murder
By Charles Graeber Grand Central Publishing
Copyright © 2014 Charles Graeber
All rights reserved.
ISBN: 978-0-446-50529-1
CHAPTER 1
October 3, 2003
Charlie considered himself lucky. The career had found him, by accident or fate he couldn't say. After sixteen years on the job, Charles Cullen was an accomplished veteran, a registered nurse with a GED and bachelor of science in nursing. His Advanced Cardiac Life Support (ACLS), Intra-Aortic Balloon Pump, and Critical Care Unit certifications earned him a healthy $27.50 an hour in hospitals across New Jersey and Pennsylvania. There was always work. Even within the rotted cores of Allentown or Newark, medical centers were still expanding profit centers, each proliferating with new specialties and services, and each locked in desperate competition to attract experienced RNs.
By 4:40 p.m., Charles Cullen was in his car, shaved, gelled, and dressed in his whites—white top and bottom with a soft yellow cardigan and a stethoscope draped across his neck, such that anybody might guess the handsome young man was a hospital professional, possibly even a doctor, despite his baby-blue Ford Escort station wagon, ten years old and freckled with rust. After a decade living in a basement apartment in New Jersey, Charlie's commute now started from across the border, in Bethlehem, Pennsylvania. His new girlfriend, Catherine, had a cozy little cape there, which she'd dress up with little card-shop knickknacks—red paper hearts or singing jack-o'-lanterns or accordion turkeys, depending on the season—and though Charlie was growing bored with Catherine and her two teenage sons, he still liked being at her place okay, especially the little plot out back where he could putter on warm days, pinching deadheads or staking tomato plants. He also appreciated the five easy minutes it took to cross the Lehigh River to the familiar slipstream of I-78 East, the aortal artery pumping thousands of workers to shifts at labor-starved hospitals across the Garden State, only five or six of which were, unofficially, closed off to hiring him.
Over the course of his sixteen years, Charles Cullen had been the subject of dozens of complaints and disciplinary citations, and had endured four police investigations, two lie detector tests, perhaps twenty suicide attempts, and a lock-up, but none had blemished his professional record. He'd jumped from job to job at nine different hospitals and a nursing home, and been "let go," "terminated," or "asked to resign" at many of them. But both his Pennsylvania and New Jersey nursing licenses remained intact, and each time he filled out a new application, Nurse Cullen appeared to be an ideal hire. His attendance was perfect, his uniform pristine. He had experience in intensive care, critical care, cardiac care, ventilation, and burns. He medicated the living, was the first code responder when machines screamed over the dying, and exhibited origamilike artistry when plastic-wrapping the dead. He had no scheduling conflicts, didn't seem to attend movies or watch sports, and was willing, even eager, to work nights, weekends, and holidays. He no longer had the responsibilities of a wife nor custody of his two children, and his downtime was spent primarily on Cathy's couch flicking through channels; a last-second sick call or an unexpected patient transfer could have him dressed and on the highway before the commercial break. His fellow nurses considered him a gift from the scheduling gods, a hire almost too good to be true.
His new job at Somerset Medical Center took forty-five minutes each way, but Charlie didn't mind the drive. In fact, he required it. Charlie considered himself a talker, and he was quick to share cringingly intimate details of his showdowns with Cathy or his comically crumbling home life, but there were some privacies he could never talk about—secret scenes that looped through his head, replayed for him alone. Between shifts, only the commute allowed Charlie to ruminate.
His little Ford hiccupped as it crossed from the cheap Pennsylvania asphalt to the smooth New Jersey tar. Charlie stayed in the left lane until the signs for exit 18, a fierce little one-way toward US 22 Somerville and Rehill Avenue. This was the nice New Jersey, wealthiest state of the union, the Jersey nobody ever joked about—suburban streets, lined with grand trees, well-tended yards uncramped by abandoned bass boats or broken trampolines, pristine driveways featuring leased Saturns rather than old Escorts. He killed the engine in the parking garage, early as usual, and hurried toward the hospital's back entrance.
Beyond the double doors lay a thrumming twenty-four-hour city lit by humming overhead fluorescents, the only place Charlie ever truly knew he belonged. He felt a thrill of excitement as he stepped onto the shining linoleum, a wave of familiarity as he breathed in the scents of home: sweat and gauze and Betadine, the zing of astringent and antibacterial detergent and, behind it all, the florid note of human decay. He took the back stairs two at a time. There was work to do.
The nursing profession had welcomed Charlie as few other aspects of life ever had, starting with childhood. Charlie described it as "miserable." He'd been a late-life mistake that his working-class Irish-Catholic parents could hardly afford, arriving soon before his father died and long after most of his eight siblings had grown up and moved out. Their wooden row house in West Orange was a dark, unhappy, place haunted by drug-addicted brothers, adult sisters who drifted in and out on tides of pregnancy or need, and strange, rough men who came at all hours to visit them both. Only Charlie's mother shielded him from the chaos of those upstairs rooms. He fed desperately on her affections, but there were never enough to go around. When she was killed in a car crash during his senior year in high school, Charlie was truly alone. He was furious with the hospital that had taken her body, and beyond consolation. He tried suicide, then the Navy, failing at both. Finally, he returned to the very same hospital at which his mother had died, and discovered his life's true calling.
In March 1984, Charles Cullen was the only male student at the Mountainside Hospital School of Nursing in Montclair, New Jersey. He was bright and did well. The coursework suited him, as did the uniform, and the sisterly dynamic was familiar and comfortable. When the honorary class president dropped out two weeks into the first semester, one of Charlie's classmates insisted he run in her place. He was a natural choice for leadership, she told him: Charlie was bright, handsome, and, most important, male. Charlie was flattered, but running for president didn't sound much like him. The more he demurred, the more adamant she became. He wouldn't have to risk anything, she told him—she'd do it all. Charlie found himself surprisingly happy in the passive role of grudging candidate, and even happier when he won. It was only a symbolic position, but it seemed to signal the arrival of a new Charlie. Six years after losing his mother to the Mountainside hospital morgue, Charlie was Mountainside's chosen son, crowned and confirmed by a white-uniformed navy of professional nurturers. For the first time in his life, he was special. It was as close to love as Charlie could imagine.
Charlie paid for his schooling with anonymous franchise shift work, racking up hours pushing powdered donuts or shoveling piles of shaved meat. He restocked boxes or filled condiment bars and mopped floors in between—there was always mopping to be done. He found it ironic that, just as the recruiter had promised, his military experience so neatly translated into civilian skills. And just like the Navy, each of his civilian jobs required a uniform. For Dunkin' Donuts, it was the orange-and-brown shirt and a visor. For Caldor, the uniform was also orange and brown but the stripes were different. Charlie had to be careful to grab the right one from the pile from the floor. Roy Rogers required a rust-colored shirt seemingly designed to hide barbeque sauce the way casino carpets hide gum. It was a hideous garment, except when Charlie's manager, Adrianne, wore it. He especially liked the way her name tag hung.
Adrianne Baum was a different class of girl from the ones Charlie had known in West Orange, an ambitious, newly minted college grad with a business degree and student loans to pay. Charlie watched her, mooning over his mop handle as he worked cleanup in her West Orange Roy's location. But Adrianne had a boyfriend and was scheduled to be transferred. Charlie quit, and doubled his hours at the Caldor next door, but he still took his lunch breaks at Roy's, just in case. When Adrianne was transferred back a month later without the boyfriend, Charlie was there, waiting.
The relationship moved as quickly as Charlie could accelerate it. He needed her attentions and pushed for it every way he could, showering her with gifts and playing the model boyfriend for her family. Adrianne was surprised to discover that hidden inside the shy, wide-eyed boy she'd watched wiping the sauce station was a surprisingly confident man. Charlie obsessed on gaining her affection, and he kindled its flame with constant gifts, flowers, or candy, little things from the mall. Any little thing Adrianne mentioned liking, Charlie needed to get her, until Adrianne finally had to tell him to stop. She pretended to be annoyed—but really, how could she be? She was aware how many girls would have killed to take her place. The boy was a catch. That Charlie seemed to be constantly quitting or getting fired could be chalked up to his high standards and busy schedule. Adrianne told her girlfriends, wow, here was a guy working three jobs, president of his nursing school class, as serious about his career as she was about hers. Yes, so, he was a goy—he wasn't perfect. But he was close enough.
Soon, whatever spare time the young couple could winnow between their respective shifts and Charlie's schooling was spent together. They were a unit, complete but closed. They called it love, and six months after their first date they were engaged. They married the week after Charlie graduated nursing school. The rented hall in Livingston, the tuxedos, the honeymoon trip to Niagara Falls—it was like a fairy tale to Adrianne. They returned a day early so her prince could start on his new job in the Burn Unit at Saint Barnabas Medical Center in Livingston, New Jersey. The hospital was willing to allow him extra time, but Charlie was adamant. It had to be that day; he didn't want to be late. Adrianne waved good-bye, and she felt the future rolling out before her like a strange red carpet.
CHAPTER 2
June 1987
Saint Barnabas Medical Center had the only certified burn unit in the State of New Jersey, so it took everyone—the horrible husks of humans, people burned in car accidents, house fires, industrial spills; men and women and most often children, burned to stubs, without hair or eyelids, their body surfaces cooked beyond repair. Charlie's job was to clean these burn victims on a metal gurney—to scrape and wash away the charred, necrotic skin with antibacterial soap. Even within the field of critical care medicine, this is an almost unimaginably gruesome procedure; as a first job straight out of nursing school, it's something close to hell.
All burns start with a story. A mother in a nightgown reaching for the teakettle, a paraplegic with a dropped cigarette, a drunk feeding a flagging campfire, the punctured gas tank of the crumpled car. Fire is the punch line. The body reacts predictably to the trauma. Third-degree burns are more deadly—complex layers of the skin, nerves, veins, arteries, and muscle cooked and dead—but second-degree burns are more painful because the nerves are still alive. Even in the 1980s, burn wards were scream wards. The drug of consolation was morphine.
Some patients will recover; others are kept on the ward only to suffer and die. The nurses know which is which. Fate in the burn unit is a statistic written on skin. Sooner or later, all nurses can read it. It's always the same drawing on the burn sheet: a human figure, bald and naked, ageless, sexless, hairless. Its toes point toward an unseen ground. Its arms stretch palms up in the universal expression of supplication and surrender. The figure's eyes are open and lidless, its lips full but without expression. You can tally the figure precisely, marking the drawing for pieces of thigh, a half a leg, a piece of the head. One point for the genitals, 1.25 for each palm. But there is an easier way.
It's called the rule of 9s. Each big piece—a leg, the back, the head—counts as 9. Add up the total, then add that to the patient's age; the sum is the mortality rate. By this rule, a fifty-year-old patient burned over half his body is 100 percent dead. If not now, soon. The rule helps soften the blow of the inevitable, indicate where on the burn ward the meager rations of hope are best invested. Every burn nurse knows there's no point talking about it; you use the formula, then try to forget it. The impending death is like a black car you see in the rearview mirror, always there if you look. So why look?
Meanwhile the pain on the burn ward is unbearable, and the nurses have no options for treatment except to hit their patients with more and more morphine. When these patients die, it isn't always clear whether they've overdosed or simply died of unsustainable wounds. All anyone knows is they aren't in pain anymore.
They may arrive in surprising ways, on stretchers or walking, alone or in packs. Sometimes they are lucid, talking, worried about their watch or a missed hair appointment. That's shock. Reality follows soon enough.
Burn victims are connected to machines, lines snaked into wrists and femoral arteries, plastic tubes shoehorned into holes top and bottom. Saline, electrolytes, pain meds, anxiety meds, liquefied food; the body swells with the fluids, sometimes doubling in size. The scrotum inflates like a beach ball, the eyes puff to slits, lips balloon and break like overcooked sausages. The body swells against the skin until the patient is as hard as carved marble. The blood vessels are squeezed shut. The core begins to die. And so they cut. It is simple surgeon's work. A blade runs the length of the arms and legs, front and back. Even the hands, puffed fat as udders, get cut. The knife runs tendon deep, five whisker-flicks beneath the knuckles like vents on a leather glove. The cuts allow space for the insides to expand, like pleats on pants, sighing open along a sudden fault line, canyon walls of yellow fat, a valley welling blood. The smell can be terrible, but the bleeding is a good thing. If it bleeds it is alive. But bleeding makes more work.
The pleated skin is loose, a greased shirtsleeve of leather. It takes time for nurses to acclimate to the point where they can effortlessly handle this tactile detail of damage. When these details become too much, they leave. Some nurses leave the burn Intensive Care Unit right away, switch to something—anything—less brutal.
Nearly a third of the patients on the unit are children. Sometimes their burns were delivered as punishments, for peeing on a mattress or forgetting a chore. Nurses recognize the signs of abuse. There are burns from radiators and cigarettes, lighters and stove tops, red-hot water scalds and blackened electrical scorches. Each has its unique signature of pain. Charlie saw them all.
Some pain blossomed across skin in crenulated carnations of tissue, some blistered or knifed in thin white stalks. The nurses did their best to hide the pain beneath gauze and tape, behind the mask of drugs. But Charlie knew that pain could be held in secret, a banked ember, burning from the inside, endured without expression. Especially by children. Unlike adults, children didn't scream when he cleaned them, they didn't whimper in their beds. Children tolerated the pain and held their secrets to avoid being punished again. Charlie's mother had never used a stove top or a hot pan to punish him, but he'd been punished, pushed around, hit by his sister's boyfriends, big guys with rings and Camaros and bulging jeans. He'd felt their adult power, and he had never forgotten what it was to be a child abnegated in its shadow. One of his sisters had a live-in boyfriend, who had beaten her ruthlessly through her pregnancy. She had run away, but the boyfriend would not leave, and Charlie had known that man's relentless attentions, too.
(Continues...)
Excerpted from The Good Nurse by Charles Graeber. Copyright © 2014 Charles Graeber. Excerpted by permission of Grand Central Publishing.
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