Control over life and death

Control over life and death names the short-lived release Charles Cullen found in manipulating patients’ medical crises. The book presents this not as care or a stable sense of mastery, but as a compulsion: in the middle of conflict and helplessness, Cullen could alter a patient’s course, take charge when the crisis came, and feel relief afterward. The patients themselves could recede from view; what held his attention was the outcome. Repeated across hospitals and shifts, this pattern turns the language and tools of nursing into instruments of private control.

A method inside ordinary care

The conditions that made this control possible were ordinary features of hospital work. Pyxis MedStations tracked drug withdrawals by patient and nurse, supported billing, and helped the pharmacy identify what needed restocking. Cullen liked the computerized system and was comfortable with its technical demands. Yet the account stresses that the cabinet was only a tool in an intimate practice conducted by people, all of them fallible. At Somerset Medical Center, that human setting mattered: injecting a clear drug into an IV piggyback port could look like the routine act of flushing a line. The same gesture could belong to legitimate care or conceal a lethal intervention.

That ambiguity gave Cullen a way to act within the procedures that authorized nurses to handle medication. After injecting an elderly patient, he placed the vial and used needle in the sharps box, returned to the nurses’ station, and busied himself until the code began. When the crisis arrived, he took the role of code leader and appeared to fight for the patient’s survival. The sequence joined hidden intervention to visible command: he could help bring about the emergency and then occupy the position of authority within it. His apparent competence during the response did not undo the earlier act; it completed the performance of control.

Helplessness reversed at Lehigh Valley

At Lehigh Valley Hospital, Cullen felt treated as an inexperienced outsider despite regarding himself as a veteran burn nurse. He judged the senior staff cold toward both him and their patients, while they considered him strange. During overnight shifts, the conflict revived an older pattern of helplessness. In the Navy, he had been a quiet, friendless young sailor who struggled with hazing; he was mocked by both older sailors and fellow newcomers. At Lehigh Valley, by contrast, he was a nurse with access to patients and medications. The reversal did not resolve his earlier powerlessness so much as give him a new setting in which he could exert power.

Matthew Mattern made that reversal stark. The twenty-two-year-old had suffered burns over 70 percent of his body in a car accident; the account describes him as 92 percent likely to die under the Rule of Nines. Staff watched surgeons amputate his badly burned extremities, and many privately hoped for the end of what they saw as a grim, prolonged decline. On August 31, 1999, Cullen loaded Mattern’s IV with a bolus dose of digoxin. The slow code ended before sunrise, and some nurses understood the death as relief from suffering. Cullen simply returned to the parking garage. The contrast is central to the concept: the same death could be interpreted by staff as an inevitable mercy and by the narrative as the result of Cullen’s deliberate intervention.

Relief that repeats, then runs out

The book describes the acts as stress-relieving impulses that gave Cullen a period of relief and afterglow. That relief was temporary, and its recurrence mattered more than any single episode. At Lehigh Valley, he could not remember how many patients he had intervened with during sixteen months of overnight work, nor always the circumstances that had brought them to the unit. The patients blurred; their outcomes remained. During his final months there, he tried to transfer to the Cardiac Unit and was refused. He continued for three more months, killing patients to ameliorate the hurt while gradually canceling shifts and looking for nearby work.

The pattern continued at Somerset Medical Center. Cullen never knew how many patients he harmed there, but the book places its beginning around the time Amy Loughren became ill and absent from work. The more specific cases began in mid-January with Elanor Stoecker, a sixty-year-old housewife, and digoxin. On the night of his forty-third birthday, he used Pavulon, a paralytic, in a combination of drugs; afterward, he was unsure who had died because of his actions or exactly what had killed Joyce Mangini and Giacomino Toto. In other cases he felt more certain about the cause. His familiarity with drugs and codes helped build a reputation as a code expert, and even residents stepped back to let him take charge. The irony is not simply that he could appear skilled: his authority in the emergency could draw on the same knowledge he had used to create it.

Michael Strenko’s death shows how uncertain the boundary between intervention and outcome could appear to those around Cullen. Strenko, a twenty-one-year-old computer science student with a genetic autoimmune disease, was thought by his parents to be improving. Cullen believed he would not survive. The book says digoxin, epinephrine, or some combination pushed the precariously ill young man over the edge. After repeated codes, Cullen gave Strenko’s mother a detailed account of the drugs and efforts being used to save her son, then told her that people did not always survive. She ordered him to leave. At about two in the morning on May 15, Strenko died. Cullen’s account of the crisis was technically detailed, but the larger pattern makes that expertise unsettling: the person who could describe the medical response also understood how subtle a fatal push might be.

Detection and the limits of control

Control in this pattern was never secure. It depended on access, on the routines of nursing, and on the ability to pass within them without attracting notice. Amy Loughren’s questions about a new insulin adjustment form exposed a gap between institutional procedure and what staff were told: the form required nurses to sign for their estimate of the amount left in a vial, but her manager would not explain why insulin was being treated with new caution. Amy refused to sign. Later, after a detective showed her a Pyxis printout from the night Reverend Gall died, she recognized Cullen’s record and began to imagine that her friend could have done something terrible. The printout did not immediately reconcile the evidence with her trust in him, but it changed what she could believe.

Amy’s growing involvement in the investigation also threatened her own sense of safety. She worried that the detectives might be wrong or deceiving her, and that cooperating could cost her job or betray a friend. She nevertheless shared records with them, including her knowledge of Cerner patient files, while fearing dismissal and isolation at work. Her actions mark a counterforce to Cullen’s private control: the institutional records and a nurse’s refusal to accept unexplained procedure could make hidden patterns visible, even when recognition came at a personal cost.

Eventually the release Cullen drew from these acts ran out. After the recurrent stress of the holidays, he drove through cold rain to a Gas-N-Go, bought a disposable hibachi small enough for the clawfoot tub in his basement apartment, and lit it there. He returned to the bathroom with a drink. A few minutes later, Officer Duddy arrived after the landlord called 911; the officer found towels stuffed between the doors and Cullen opened the door after identifying himself. This final reversal does not make self-destruction equivalent to his assaults on patients. It does show the limit of the pattern: the acts that had offered temporary command over other people’s crises did not give him lasting command over his own life.