Saturday, January 18, 2014

Capital Punishment By Asphyxiation

There is a great deal of controversy over the lengthy execution of convicted murderer and rapist Dennis McGuire in Ohio. Since the state did not have access to the usual drugs for completing their capital punishment sentences, such as propofol or pentathol, they decided to use a new untested two-drug cocktail of midazolam and hydromorphone. The results were not what they had hoped.

After injecting the medications, what doses were given is not available, Mr. McGuire at first became still. But shortly afterwards he started gasping for breath. His family saw him clench his fists as his abdominal muscles heaved desperately to maintain respiration and oxygenation. Finally, after about 25 minutes, his body went still for the final time. Naturally his family is shocked at the prolonged and agonizing way the death was carried out. They have vowed to sue the state to halt any more executions.

Forget for the moment that Mr. McGuire's death was far more humane than what he did to his pregnant victim back in 1989. As Ohio's assistant attorney general, Thomas Madden, says the constitution does not guarantee a "pain free execution." But Mr. McGuire essentially died of asphyxiation caused by a large drug overdose of Versed and Dilaudid administered by the state. This is how drug abusers and patients who are overly sedated in the hospital die.

Mr. McGuire's body was doing what it needed to do when confronted by an obstructed airway. He was using his accessory respiratory muscles in the chest and abdomen to try to force his airway open in a desperate attempt to replenish oxygen to his brain. These are motions we anesthesiologists see on an almost daily basis when we induce our patients with anesthetic. The airway obstructs and the abdominal muscles will tense as the patient attempts to inspire more oxygen. Of course the difference is that we either insert an LMA at that point to start ventilating the patient or we paralyze the muscles so we can intubate the airway and provide oxygen.

That is the problem with Ohio's two-drug cocktail. They only have two thirds of a complete recipe to complete a quick execution. In this situation, without adding a third drug to speed up the process, the inmate would have been better off with somebody holding a pillow over his face. That might have been faster. Since propofol is now difficult to obtain for death penalty cases, Ohio was on the right track in using a large dose of Versed. This will produce a profound amnesia so that the prisoner won't remember what is happening. The Dilaudid will help with analgesia and respiratory depression. But for a truly quick death, they need to also inject something more definitive, like a potassium bolus to rapidly induce cardiac arrest. That is the reason potassium used to be routinely injected for capital punishment. Another drug that will almost certainly work is rocuronium. Roc is cheap and extremely fast acting. Its paralyzing affect may take longer to cause cardiac arrest from hypoxia but at least it doesn't burn in the veins like potassium. And the body remains motionless, which will be a relief for the witnesses present at the death chamber.

Frankly, to me, all these concerns about comfortable, pain free executions for our society's worst criminals feels ludicrous. Just remember, dead men tell no tales.

1 comment:

  1. Rocuronium does burn. Maybe a better option would be:
    1) Very high dose benzo, like midazolam 1mg/kg
    2) Very high dose opioid, like morphine 20mg/kg
    3) Followed 30sec later by pancuronium at 4 x ED95
    4) Plus cardiac arrest dose of potassium

    This should hopefully guarantee amnesia and analgesia prior to arrest. If they are on benzos or opioids already (e.g. tolerance), then maybe 4 times their current dose for the induction.