Another Experimental Cocktail To Die For

Here we go again. State prisons all around the country have been having increasing difficulty achieving their public duties to execute convicted felons. Drug companies have made it a policy not to sell their pharmaceuticals for executions because, well, they were not approved by the FDA for that purpose. In the meantime, the court systems have halted executions when they believed the prisoners would suffer any kind of pain during the process. In desperation, prison systems have been experimenting with different cocktails of drugs to carry out their deathly functions.

We saw recently how Florida became the first state to use etomidate as part of their drug cocktail for executions. Propofol has been getting more difficult to attain as drug companies and pharmacies demand that their wares not be sold to the penal system. Now Nevada is trying another novel drug: cisatracurium. The state will be trying a new potion consisting of fentanyl, diazepam, and cisatracurium on Scott Raymond Dozier. Mr. Dozier was convicted of two separate murders. He is schedule to be executed November 14.

Naturally there are all sorts of objections to this, besides the general disagreement with capital punishment. The state's Chief Medical Officer, Dr. John DiMuro was an anesthesiologist. However he resigned a week ago and his replacement is a psychiatrist. Some fear that a psychiatrist would not know how to administer these drugs. The state assured that there would be trained medical personnel at the time of injection.

The ACLU also objects that cisatricurium would paralyze the prisoner but not actually kill him, causing him to die of slow painful asphyxiation. This actually makes some sense. None of the drugs being used would be considered fast acting. With this combination, the prisoner would die from oxygen deprivation, which is very slow. This is unlike the previous drug cocktail of pentathol, succinylcholine, and potassium. Those drugs are all rapid acting and lead to amnesia and cardiac arrest quickly. So if not enough benzos are given, and this can be tricky since many of these prisoners have histories of drug abuse that require larger than normal pharmaceuticals to work properly, the condemned may awaken before the cisatricurium has stopped his breathing long enough for the heart to fail. They would have to administer massive doses to be sure the drugs take effect quickly.

Naturally this debate will continue since they are trying to execute somebody using chemicals that were developed to help life, not end it. If they truly wanted to end Mr. Dozier's life quickly, history has cleverly invented all sorts of contraptions to do just that. However, we Americans are just too squeamish to consider using them as part of our "sophisticated" modern society.

Dubious Milestone In Anesthesia

Anesthesiology has given the world great advances in medicine and healing. In fact, it was voted one of the highest achievements in the history of medical literature. Unfortunately, lately the only time anesthesia is mentioned is when it causes harm, or even death, usually in a sensational fashion.

Now anesthesia has entered the public discussion once again with the news of a prisoner execution in Florida last week. For the first time ever, the drug etomidate was used as part of the IV cocktail to cause the death of a convicted inmate. This news seems to be more widely covered in British media. They appear to be more fascinated with capital punishment than the Americans probably because capital punishment is outlawed in most of Western Europe.

Mark Asay, a white Floridian, was convicted of the racially motivated murders of two minority men back in 1987. After decades of litigation, he was finally put to death with a combination of etomidate, rocuronium, and potassium. This has caused an uproar besides the usual moral handwringing over the death penalty in general. The defense attorneys argued that etomidate is an unproven method for achieving death. They hired doctors who testified that etomidate can cause pain prior achieving its effects.

Meantime, the pharmaceutical company that manufactured the etomidate is objecting to its obviously non-FDA approved use of the drug. This is the reason that more drugs are becoming off limits for use in the death penalty. Previous attempts using pentathol, propofol, and midazolam have been thwarted because the penal system was unable to acquire the drug due to manufacturers' refusal to sell the product or the courts have deemed them cruel and unusual punishment and thus illegal.

Because of these difficulties with IV injections for capital punishment, some states like Mississippi are considering bringing back the old reliables like a firing squad, electrocution, or the gas chamber. That is probably the proper approach. Stop bastardizing anesthetics that were invented for medical purposes to somehow humanize an inhuman act. Centuries of human executions have given us plenty of methods to kill somebody for state reasons. Don't drag anesthesia into this mess.

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.

If He's Done The Crime...

It is now official ABA policy. The American Board of Anesthesiology has decided that any board certified anesthesiologist must not assist in carrying out capital punishment. Based on the ancient dictum of do no harm, the ABA states that an anesthesiologist risks losing his board certification if found to be helping the execution of a death row inmate.

I wrote of my feelings about this situation last year. If a person (?) can rape and murder an innocent child with his bare hands, why should he get the expertise of an anesthesiologist in getting an IV started? Is it really cruel and unusual punishment to get poked with a needle multiple times trying to get an intravenous line when he has committed a heinous act? Let him get poked until he resembles an acupuncture model. Why should he expect a nice little subcutaneous lidocaine injection to ease the discomfort of an IV? Many of our normal patients don't need it so why should death row inmates expect it? I say if he's done the crime, he should serve his time, for all of eternity. Just don't expect to get there on a pillow cloud of empathy from the rest of civilized society.

Cruel and Unusual Punishment?

Ohio has now become the first state to use a single drug method for executing prisoners. Their previous three drug method was stopped by the Ohio Supreme Court for being cruel and unusual. This moratorium on capital punishment came about when the execution of Romell Broom was halted because a vein could not be found to start the IV. He was reportedly stuck 18 times before the procedure was called off. His lawyer argued in court that being poked with a needle 18 times was inhumane. They said that the three drug execution could cause severe pain and suffering if the initial dose of thiopental did not adequately sedate the prisoner. The prisoner would then suffer severe pain when paralyzed and potassium was injected to stop the heart. The state will now use only thiopental for executions, using a dose 2 1/2 times greater than normal to put the prisoner to sleep and slowly watch him go apneic and hopefully die in his sleep.

There are so many flaws with this. First of all, the only painful part seems to be getting stuck multiple times trying to get an IV. But this is no different from what many hospital patients suffer every day. These prisoners frequently are IV drug abusers so they have few accessible veins. Remember that prisoners are placed on death row because of the inhumane despicable acts they committed. Mr. Broom raped and murdered a frightened 14 year old girl. He now complains that getting stuck with needles is inhumane? His victim did not have the luxury of being sedated when she was tortured and killed.

The lawyers also argued that prisoners would feel pain if they were not adequately sedated. But how would anyone know? Nobody is arguing that the three drug cocktail is ineffective. This raises the old philosophical question about trees falling in the forest and nobody is around to hear it. If the prisoner dies from a lethal injection but isn't around to complain about the pain during the injection, did he really have pain?

Is a single overdose of thiopental adequate for an execution? It's only used routinely in veterinary euthanasia. All other state executions add a paralytic and potassium to stop the respiratory and cardiac functions. Many of these prisoners have histories of IV drug abuse. That's why their veins are difficult to find. It might take a larger dose of pentathol to cause death than they calculate. Since these prisoners have bad veins, there is also a high likelihood that their IVs may infiltrate upon injection, causing excruciating pain as the pentathol is forced into the musculature. Will that lead to another moratorium on executions?

It seems like our society coddle these murders. They commit atrocious acts and yet expect to be treated like some hospital patient. The lawyers and judges need to watch the History Channel to remember what real cruel and unusual punishment was: dismemberment, disembowelment, burnings, drownings, beheadings, etc. I believe this one drug method will ultimately fail as a prisoner will wake up from the seeming "lethal" dose of pentathol and complain that he suffered during the execution.