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

“Charlie considered it one of the neater equations in life: the world pushed, and the pressure suit pushed back.”

Charlie’s overall cold nature and tendency toward calculation is evident early in his nursing career. Rather than empathizing with the patients in the burn unit, one of the more traumatic units to which a patient can be admitted, Charlie instead focuses on technology and logic. This obsession with technology later manifests in his abusing it to enable his crimes.

“It never ends well for saints, no matter how good they are. Castration, defenestration, hot pincers, prison—the saint is a scapegoat, a martyr, a patsy. Barnabas was stoned to death, but his story lived beyond him. Every Catholic knew his name. It was the paradox of the saints, one thing Charlie held on to form his childhood: remembered well, remembered forever, but only after being hated to death.”

A central conceit of martyrdom is the idea that a divine afterlife will alleviate earthly suffering. Charlie interprets this as a concept to support human suffering rather than healing, which morphs into abuse and murder.

“They were still trying when, all of a sudden, Charles Cullen simply went away. The problems with the insulin spikes disappeared with him.”

People are slow to notice Charlie’s crimes and equally slow to investigate them, giving him the opportunity to leave once attention becomes too great. In this passage, Graeber shares an example of the circumstantial evidence that surrounds Charlie’s case by stating two true facts, implying a connection between them.

“But for all his suicide gestures, the fact was that Charlie wouldn’t kill himself, not really; the nuns in Catholic school had taught him that suicide was a sin, and Charlie didn’t want to end up in purgatory. But he could make himself sick, and in many ways, sick was better. Nobody loves you the way they do when you’re dying.”

The author outlines Charlie’s attempts to die by suicide as a path to connection or reconciliation. He tries to hurt himself because he wants someone to acknowledge and sympathize with his pain, but he lacks the language or emotional intelligence to ask for love in a healthy way. He has learned through his job and past relationships that love is a symptom rather than something freely created, so he seeks it through self-destructive habits.

“This was him, an earnest health-care professional, lovesick and concerned, the sort of foolish heart who had told the policeman that he’d drive right over and did just that, on time. He figured that later, when the pills kicked in, he’d be Romeo, overwhelmed with love and poison, right on stage.”

In the events following his stalking a fellow nurse (and short-term girlfriend) and breaking into her home, Charlie reveals how he thinks about himself in the context of the broader world. He attempts to die by suicide to romanticize himself, to gain the love and affection of people who’d otherwise ignore or disdain him. This illustrates the chasm between who Charlie is and who he perceives himself to be, contributing to his overall casual approach to perpetrating crimes.

“Stress-relieving impulses like this had driven most of his actions during the previous year. His intervention on behalf of his patients was a compulsion that had little to do with the patients themselves; often, in fact, he failed to notice the patients at all, only their outcomes. Each spasm of control offered a period of relief and afterglow.”

This moment is the closest the book comes to revealing Charlie’s murderous motivations. He considers his killing tendencies a way to relieve stress, to feel some control over his own life by exerting control over other people’s lives.

“Not all the nurses noticed at first. People die, that’s what happens in a hospital, especially the CCU, and sometimes deaths seem to come in clusters, but something seemed to have changed. The veteran nurses felt it, a new night wind blowing their patients away. It seemed to some that the codes were almost constant now. And they weren’t ending now.”

Graeber highlights the transformative nature of Charlie’s presence, illustrating how his actions affected the capabilities of the people around him. By providing this moment from the perspectives of other nurses, Graeber invites contemplation of their point of view and of the confusion and conflict associated with such an increase in patient mortality. This re-centers the narrative on the patients after a section focusing on Charlie’s point of view.

“He was so much more being anonymous. There was power in that role. Anonymous could deny; anonymous could disappear. Anonymous was an unapologetic mystery, godlike in control.”

Once again, Charlie confuses relationships and power. His peers reject him when he reveals himself as a “secret admirer,” so he concludes that making himself vulnerable to the attentions of others is a negative thing. He instead correlates anonymity with power, which his administering of anonymous, random overdoses to his patients reinforces.

“Charlie was quickly singled out by one of the nurses he was often with, a tall, pretty blonde named Amy Loughren. She was a self-proclaimed ‘pain in the ass,’ which meant she was outspoken and honest, the kind of person who cast a shadow Charlie could shade himself by.”

Graeber describes Amy and Charlie’s relationship and, in doing so, sets them up as foils. Amy is attractive, loud, and firm in her care of her patients—all things that Charlie isn’t. By establishing their connection, the author quickly makes it apparent why they interact the way that they do, illustrating the reasons behind Amy’s ultimate confusion about Charlie’s criminal status.

“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 […].”

Charlie’s ability to manipulate others extends to his personal appearance, which is unthreatening and almost endearing. This draws attention away from him because he’s seemingly harmless. Amy is drawn to Charlie for this reason, showing both her maternal spark and her desire to defend, which build the foundation for their relationship.

“It was chemistry, not magic. No elevated C-peptide meant that the insulin wasn’t human. It came from a laboratory. There was no other way to look at it: if it was in the patients’ bodies, and they hadn’t made it themselves, it meant that somebody put it there. And that someone was killing patients.”

Nancy Doherty speaks to Bruce Ruck about the presence of foreign chemicals in patients’ bodies that signifies an overdose. This is the first conversation in the book in which two people begin explicitly exploring the likelihood that someone is killing patients through overdosing. The facts clearly point to a crime. This begins the push for a formal investigation and the end of Charlie’s career, although much progress must be made to explicitly expose his crimes and bring him to justice. Additionally, this moment underscores the selfishness of for-profit healthcare institutions because, after this conversation, hospital administration is still slow to contact authorities. This information is frustrating given that the narrative has revealed Charlie’s culpability.

“But of course, the ultimate effect was death. The only trick was figuring out the right dosage.”

Charlie’s actions are the antithesis of nursing. Instead of taking care of his patients and finding the correct dosage to cure their ailments or alleviate their pain, he seeks the correct dosage to cause dramatic reactions within their bodies and end their lives. Graeber precedes this section with a graphic depiction of what happens during an insulin overdose, providing a visual representation to accompany the scientific coldness of Charlie’s musings and contemplations.

“He watched the nurses at the station, stirring their coffees, his coffee, helped by what he did, dependent really but not even knowing it.”

Charlie once again perceives power in anonymity. Graeber repeatedly refers to Charlie’s desire to be helpful, and Charlie does things like refill the coffee at the nurses’ station to be helpful. He finds power in performing these acts before others can, creating a secret dependency that only he recognizes.

“Every body is a death, but not every death is a crime scene.”

As the story transitions into the investigation that ends Charlie’s crimes, the author highlights an aloofness and desensitization other than what’s typical for nurses. While healthcare workers, Charlie especially, necessarily become somewhat desensitized to the immediate intimacies of death, homicide detectives become distanced from the later practicalities of death.

“‘Yeah.’ Tim said. He thought on that. ‘You know what?’ he said finally. ‘I bet those assholes know exactly who did it.’”

Early on, Tim predicts the culpability of the healthcare administrators who ask him and Danny to conduct an investigation into their “not natural” hospital deaths. By making this prediction, he validates the narrative’s frustrating effect and builds a point of tension, establishing animosity between the police and the hospital.

“‘It’s bullshit, what it is,’ Danny said. Everything ends up on paper in an investigation. Detectives knew that, lawyers—especially former prosecutors—knew that, too. There were printouts, records, memos, date books. You make lists, you make notes in interviews—at the very least, you’ve got names and phone numbers on a piece of paper, so you know who to talk to. A five-month investigation, six suspicious deaths, and a unit’s worth of nurses, and the guy came out without so much as a doodle on a legal pad?”

One of the major failures of Somerset Medical Center and institutions that employed Charlie before was a lack of notetaking and evidence definition, which culminated in Charlie’s being protected from capture. The implication is that this is an intentional failure—that the layers and private detectives involved in the initial, internal investigation intentionally didn’t take notes so as to protect their own interests. Danny and Tim reinforce the culpability of the medical center by highlighting this lack of a paper trail.

“Certainty could only come from science.”

While pursuing Charlie, nurses and detectives alike try to calculate how his presence impacts death and overdoses. Their ability to prosecute Charlie depends on certainties, not speculation, making such numbers vital for their case despite the many things still unclear to them.

“He had been a nurse for fifteen years. He had seen the Pyxis arrive and he’d seen it change. Now digoxin would be treated with the same security protocols previously reserved for narcotics like OxyContin or morphine. They’d already taken those precautions with insulin. His actions were subtle, his effects public. That affirmed him. That pleased him.”

Charlie reflects on the many changes that his industry has gone through and interprets them as a strange validation of the consequences of his actions. He wants to know that he has the power to make changes in the world but is uninterested in enacting positive change. Instead, he takes pleasure in fear and the power of anonymity.

“‘You’re late!’ [Bruce] said. ‘I was expecting you five months ago!’”

The two primary drivers of the investigation—the detectives and the poison control researchers—finally interact, reinforcing the slow pace of the investigation. This half-joking remark reflects the narrative’s tension and underscores the seriousness of the situation.

“‘They’re covering their asses,’ Tim said. ‘We’re trying to catch a killer.’ Amy reached over for a cigarette and threw herself back into the groaning wicker. How weird was that? It was too much to process, but at least Lund’s call had made one thing clear: the hospital was concerned for themselves. Amy would have to look after herself. Right now, having two big homicide cops in her living room made her feel like the safest girl in the world.”

This turning point in the book reinforces the differences in priorities of the many people involved in Charlie’s case. A clear separation is evident between those trying to be helpful and support the greater good, and those acting in their own self-interest. Amy, despite her initial confusion and feelings of guilt about turning on Charlie, firmly joins the people trying to stop the deaths. This shows her own moral code and strength.

“Charlie liked this version of events; it was a reminder of his lasting effect on the world, his picture and its consequences. He was a victim, but a famous one. They’d mailed him out, his face, smiling, handsome, Charles.”

The intense irony of Charlie’s photo having been taken as part of a nursing recruitment effort is evident when one considers his significant crimes against his patients and his negative impact on the broader field. He once again alters the narrative about himself, falsifying the true nature of events to Amy while not knowing that she’s in the loop. He claims a “victim” status to hide the truth and make himself more sympathetic, to make himself seem more social and acceptable.

“They were asking Cullen to tell them things that Cullen believed he could not tell them. The detectives’ job was to help resolve this paradox for him. He needed to challenge his belief system so deeply that the architecture of his universe failed. They then needed to rebuild the world into one in which confessing to murder seem [sic] like a good option. And the only way to do that was to create a situation where not talking was actually worse.”

Graeber describes a fundamental part of getting a criminal to confess. In Charlie’s case, a confession is particularly necessary because the evidence surrounding his case is mostly circumstantial. Without a confession, enough doubt surrounds his situation that a conviction isn’t certain.

“In crisis, whenever he felt cornered or impotent, Charlie’s instinct had always been to subvert those feelings with the threat of death. But in truth, he wasn’t always particularly interested in being dead, not personally. His nursing career resolved the paradox. Access to the vulnerable allowed him to manifest death without dying. He’d learned to kill himself by proxy.”

Charlie sees death as an escape from his problems, leaning into it to avoid the real source of his concerns. In this moment, exploring his thoughts about death by suicide, he not only shows his desire for power and sympathy but also shows that he often considered his victims an extension of himself. This psychological extension of self shows the extent to which Charlie doesn’t understand—or doesn’t wish to understand—the world around him.