The medication tampering and investigation at Saint Luke’s Hospital exposed a hidden pattern of dangerous drug handling around the CCU and placed Charles Cullen under suspicion. Nurses found large quantities of missing medication discarded in a sharps container, including empty vecuronium vials and the Pronestyl that had been disappearing for months. The hospital’s response identified Cullen as a serious concern, but its arrangements for his departure and its limited warnings to other institutions left crucial information outside public and law-enforcement channels.

An unexplained shortage

For six months, Pronestyl was replenished in the medication room each afternoon and gone by night. Nurses joked about the disappearance, but no one initially investigated. In April 2002, day charge nurse Thelma Moyer noticed that the drug seemed to run out in spurts. She raised the matter with her supervisor, Ellen Amedeo, and hospital pharmacist Tom Nugen. Nugen could not account for the missing medication in his records; Amedeo took note but did not pursue the matter further.

The losses were part of a wider pattern of deliberate waste. Cullen had been throwing Pronestyl away on the days he worked, along with other drugs, and disposing of items such as talc. He also repeatedly moved chairs and used lotion despite supervisors’ objections. These acts were his indirect way of expressing hostility toward the hospital and testing whether anyone would understand the message. He regarded the destruction of medication as something he could do, even though it cost the hospital money. The drug shortage was therefore not simply a stock-control puzzle: it was a repeated act within reach of the ward’s routine, and one that initially drew jokes rather than an inquiry.

The scale of the problem became more alarming when Kim Wolfe, a CCU nurse, tried to discard a used needle and found the sharps container would not accept it. Looking inside, she saw white cardboard boxes among the sharps. Gerry Kimble, a veteran nurse, called for Environmental Services to unlock the container. Kimble and Candy Wahlmark emptied it into a bedpan and sorted the recovered material in a spare room, recording what they found on a legal pad.

The contents of the sharps container

The recovered drugs included six bottles of vecuronium bromide, magnesium sulfate, phenylephrine, Levophed, dobutamine, nitroglycerine, labetalol, and forty boxes of Pronestyl. The mixture did not resemble the familiar pattern of medication theft for recreational use or resale: many of the drugs had no obvious appeal as intoxicants. The empty vecuronium bottles were especially troubling. Vecuronium came sealed as a powder in a vial; using it required injecting saline through the stopper, shaking the vial, and withdrawing the reconstituted drug into a syringe. Empty bottles indicated that someone had prepared it for use, and in substantial quantities.

The danger was not abstract. Vecuronium is a powerful paralytic: it can prevent a person from moving or calling for help without removing the capacity to feel pain, and excessive dosing can cause the muscles involved in breathing and heart function to fail. Yet no patient on the CCU had been prescribed it during the four-shift weekend. Nurses had found no clinical explanation for the drug’s presence or apparent preparation.

While Kim and Candy watched the medication-room door, they saw people enter to restock it. Cullen arrived early for his night shift, as he often did, and went through his familiar routine of moving chairs. He then entered the medication room, punching in the code; the door shut behind him. Five minutes later, Kim and Candy saw him leave. Kim went in to check, and the sharps container was full again. She and Candy alerted Amedeo, telling her they believed they knew who had been using the vials. Cullen remained on shift after the day staff left. The account then connects the discarded drugs to a patient: by the Monday morning shift change, investigators found ten spent vials of vecuronium, which had already been used on Edward O’Toole seven hours earlier.

Confrontation and departure

The discoveries prompted a formal response. Saint Luke’s risk manager Janice Rader established a protocol for the day shift to check the sharps container regularly. When Cullen was not working, it remained empty. Rader brought the matter to Ken Vail, the hospital’s risk-management director. With dangerous cardiac drugs missing and large quantities of a paralytic prepared and gone, they considered what would be best for the hospital. Cullen was due back on shift within hours, so they consulted in-house counsel Sy Traub, who brought in the law firm Stevens and Johnson. Paul Laughlin, a former Philadelphia assistant district attorney, was assigned to the matter.

When another cache of drugs was found after Cullen returned to work, Laughlin interviewed him in an empty room near the ICU. Cullen described arriving early and stocking the drug totes. As Laughlin laid out the shifts on which medication had been found, and explained the preparation required for vecuronium, the dates and evidence converged on Cullen. Cullen saw the questioning as an accusation whose conclusion had already been decided. He resigned under an arrangement that provided neutral references and kept the incident off his employment record. Hospital security escorted him through the unit and out to the parking garage.

Three days later, Cullen began work at Sacred Heart Hospital, listing his Saint Luke’s employment as continuing through that June. The neutral reference helped make the transition possible. Saint Luke’s administrators later said that Laughlin’s investigation, chart reviews by Rader and nursing supervisor Terry Koehler, and inquiries by Traub had not identified suspicious deaths connected to the empty vials or other actions by Cullen at the hospital. At the same time, the hospital did not want him working in its health-care system. The resignation resolved his immediate employment there without resolving what had happened to patients.

Warnings, investigation, and evidentiary limits

Saint Luke’s did make calls to colleagues in the Bethlehem area. In August 2002, senior vice president Charles D. Saunders asked local colleagues whether they had experienced unusual incidents involving Cullen and said he was not to be considered for rehire. Saint Luke’s executive vice president Vince Joseph and Laughlin also contacted colleagues. These warnings were not passed on to the public, police, or the State Nursing Board, and Somerset Medical Center was not among the hospitals contacted.

The failure to alert outside authorities did not end the questions raised inside Saint Luke’s. Nurse Pat Medellin, dissatisfied with the hospital’s assurance that Cullen had harmed no patients, told an acquaintance in the Easton police department what she had seen. Her account moved through local police and the coroner to the Lehigh County district attorney, after which state troopers interviewed Saint Luke’s staff. Nurses described patients who had seemed to be recovering and then died unexpectedly, sometimes soon after Cullen changed their IVs. Lynn Tester calculated that Cullen had worked 26 percent of the hours but was present for 58 percent of the deaths. Robin Saulsberry recalled seeing him leave a patient’s room shortly before the patient coded, and believed Pronestyl might have been involved. Another nurse recalled frequent Code Blues while Cullen worked and a six-month stretch without one after he left.

Those accounts were serious investigative leads, not by themselves proof of a particular killing. Coroners reviewed medical charts, and an outside pathologist examined records for seventeen patients selected by Saint Luke’s. The review found nothing prosecutable in the paperwork. The distinction between a disturbing pattern and proof in an individual case remained central: unusual deaths, timing, drug access, and staff recollections could focus an investigation, but the records did not establish exactly what had happened to each patient.

The medication records also had limits. In the later Somerset investigation, Pyxis retained drug-access data for only thirty days; when investigators sought information relating to Reverend Gall, who had died months earlier, they were told the relevant records were gone. That problem underscored how a hospital’s routine systems could leave investigators with a gap between suspected access and demonstrable evidence. At Saint Luke’s, the discarded vials and the repeated shortages had made the danger visible, but the resignation agreement and restricted warnings allowed Cullen to move on before the questions were settled. The episode thus joined an identifiable act of drug tampering to a broader failure of institutional follow-through: suspicion prompted internal action, yet the information needed to protect patients elsewhere was not fully carried forward.