They push and he pushes back.

“They push and he pushes back” begins as Charles Cullen’s compact account of pressure answering pressure: first a treatment that might help burned children grow, later his own increasingly lethal way of responding to a hospital that he felt would not hear him. The expression’s force comes from that reversal. What starts as an image of care becomes a private rule for retaliation, while the people caught in its later application are patients who have no part in the grievance.

The phrase as a medical equation

At Saint Barnabas Medical Center, Cullen cared for children with severe burns. Their pain was difficult to control: nurses were not permitted to give children medication stronger than Tylenol 3, though some wanted to give more and some did. The children faced repeated operations to release scar tissue that could otherwise restrict their growth and movement. Their treatment also involved pressure suits, wetsuitlike garments that pressed against scars to thin and soften them over time.

The image of pressure pushing back belongs, in this setting, to an extended process of care. A suit’s steady compression might make scarred tissue more pliant; after pain and time, a child might move and grow. Cullen regarded this as one of life’s neat equations: the world pushed, and the pressure suit pushed back. The force is not denied or magically undone. Instead, pressure is met with a controlled counterpressure meant to preserve the possibility of change.

The passage also connects this equation to Cullen’s own remembered pain. He had experienced pain and punishment in the military, and he saw the children’s suffering as something he recognized but could not fully understand or remedy. That recognition sits beside his sense that nursing could make a practical difference: at Saint Barnabas he liked caring for dependent patients and felt helpful and needed. In its first context, then, the expression joins bodily suffering to the limited, concrete work of tending to someone vulnerable.

From care to grievance

At Saint Luke’s Hospital, the same logic takes on a different object and a different moral weight. Cullen disliked the hospital’s attitude and believed a Catholic institution should behave better, even while he considered it a world-class place to receive care. His objections surfaced in small acts of defiance. He put chairs away only to see them brought back. He used lotion heavily despite supervisors’ objections, then threw away talc bottles he found in patients’ rooms.

The missing Pronestyl became the most sustained version of this indirect resistance. Every afternoon the medication was restocked in the medication room; every night it disappeared. For six months, staff joked about the unexplained loss, but no one investigated. Cullen had been throwing the drug away each day he worked. He understood the waste as something he could do, and estimated that it cost the hospital hundreds or perhaps thousands of dollars. The recurring disappearance was meant to send a message without stating one openly.

Cullen’s account of himself as someone pushing back was entangled with personal and religious losses. He had left the religion of his upbringing for marriage and children, then lost his marriage and the children. At a Catholic hospital, he described himself as an Irish Catholic Jew working for Saint Luke, the Christian physician whose name the institution bore. The mismatch sharpened his sense of grievance, but it did not make the message clear to its intended audience. He imagined that staff would notice and understand; the narrative presents this expectation as a test of faith as much as a deliberate act of provocation.

The signal becomes harm

The hospital did receive a warning, but not in the form Cullen intended. In April 2002, day charge nurse Thelma Moyer told supervisor Ellen Amedeo and pharmacist Tom Nugen that Pronestyl seemed to be disappearing “in spurts.” Nugen could not explain the loss from his records. Amedeo heard the concern but did not take further action. The pattern had become visible without revealing its cause.

On June 1, 2002, Cullen found the medication room stocked full again. The detail recalls the chairs repeatedly returned to their places: the institution’s routine seemed to him to undo his small acts of resistance. He interpreted that return as renewed pressure and resolved to keep making himself heard. Yet his next indirect action was not another act of waste. While alone in the room, he prepared syringes, tampered with IV bags, and placed the resulting medication mixtures in named patient trays. The sequence of seeming helpfulness—stocking medication, later assisting colleagues with IVs, and then helping during a medical emergency—concealed the connection between his actions.

The repeated expression therefore marks a severe transformation. In the burn ward, pressure was part of treatment and the hoped-for outcome was a child’s greater freedom of movement. At Saint Luke’s, Cullen made institutional frustration the supposed pressure and patient harm his answer. His claim that he would be heard is set against the actual result: colleagues had not connected the earlier acts, and the people who bore the consequences were patients. By the next morning, the medication closet held less medicine and fewer patients were breathing in the CCU.

The expression’s reversal

The phrase is not simply repeated; its moral direction changes. In its first appearance, pushing back describes a measured intervention within care, where pain and pressure serve a possible future of growth. In its later echo, the same verbal balance lends Cullen’s retaliation the appearance of an equation: the institution pushes, so he pushes back. But the symmetry is false. His private acts do not strike only at the institution he resents; they endanger patients who are separate from the conflict.

That gap between the neatness of the formula and the disorder of its consequences is central to the expression’s significance. Cullen treats sabotage as communication and hopes that repeated signals will force recognition. The narrative instead shows how an indirect message can go unrecognized, recur, and escalate. What had once named pressure applied in the service of healing becomes the language through which Cullen makes grievance into harm.