The Widdershins

Archive for May 1st, 2014

Good Thursday, Widdershins.  Another week, another botched execution.

Oklahoma’s fiasco is just the latest in a lengthening line of fumbled final exits, but what’s a poor executioner to do?   We no longer manufacture drugs here in the good ol’ ewe ess of ayy, the Europeans have cut off supplies, and the best that state governments can do is to rely on compounding pharmacies for their drugs.  Several states have reformulated their lethal cocktail, with varying degrees of success.

Back in The Day, things were relatively simple.   Just start an IV, push some sodium thiopentol or pentobarbitol, followed by some pancurium bromide, and finish up with a blast of potassium chloride.  The first drug group produces loss of consciousness, the second paralyzes muscles and thus stops respiration, and the last will stop the heart.  Voila!  There could still be problems, however.  IV drug abusers have terrible veins.  They are hard to cannulate and harder yet to keep from rupturing or collapsing.  As medical and nursing boards in general frown upon their members participating in such activities (“First, do no harm.”), the skill level of the person starting the IV is not always world-class.   In and of itself, starting an IV is not a difficult procedure.  I’m reasonably confident that I could teach almost anyone how to do this in about fifteen minutes.  Basically, you apply a tourniquet and locate a vein.  Cleanse the skin with alcohol, and let it dry a bit, then remove the cap from the angiocath and end insert it through the skin and into the vein.  A little flush of blood will appear in the clear plastic hub.  Pull the needle portion back and feed the plastic cannula into the vein.  Attach the fluids and regulate the flow rate.  Tape firmly into place.  That part is easy.  The hard part is doing it well, and  doing it well requires practice.  A lot of practice.

Not only can you go completely through a vein, but it can literally collapse, or  tear a portion of the wall and infuse the surrounding tissue with  IV fluid and the drugs.  While they will eventually absorb, this is not a quick process.  You can also not flush well enough between the drugs, which can they co-mingle, react,  and form a crystalline precipitate.  That can make it almost impossible to get the next drug in.  All of these drugs are used medically on a regular basis.  In fact, if you have ever had surgery, drugs of this nature (excluding the potassium which will kill you if enough is given by bolus) are used to induct anaesthesia – the difference being that we then intubate you and control respiration throughout the procedure.  Oh, and we also wake you up.

Now there is a whole new degree of difficulty.  Those pantywaist Europeans have cut off supplies, and death penalty states are scrounging around for “suitable” replacements.  Seems that those are few and far between.  So, the states are trying out new cocktails and turning to compounding pharmacies to replicate those marvelous drugs of yesteryear.  Admittedly, it’s tough to know in advance how well things will go, as there are few volunteers for field trials in the case of new combinations for lethal injection cocktails.  Also, compounding pharmacies have notoriously lax oversight, and that just can’t be good, either.

The great state of Ohio turned to a new combo in January in order to execute,Dennis McGuire.  They selected midazolem (versed) and hydromorphone (dilaudid).  This combination of  drugs is pure genius from the perspective of availability, as any prison hospital would have them in stock.  Versed is used to stop seizures, and to induct anesthesia.  It’s also given as sedation during procedures.  Another useful side effect is that it produces a mild amnesia of the surrounding period – certainly more functional in the case of a colonoscopy than lethal injection.  Dilaudid is a major painkiller.  Hmmm – nothing to paralyze the muscles, nothing to stop the heart.  It took Dennis McGuire 25 minutes to die, and I’m stunned that it wasn’t even longer.  Not everyone reacts the same to drugs.  Some people have a massive tolerance, others not so much.   Midazolem has been known to have a paradoxical effect and may produce a near-manic state rather than sedation.  You just never know until it’s given.   Who came up with this idea?

The latest mess in Oklahoma has Governor Fallon demanding a full investigation.  (Yawn.)  Yep, the same Governor who was dead certain that their cocktail of  God-knows-what would be just dandy, and fought to keep the details secret will now check into things and get back to us.  Amazingly, this badly botched procedure is said to have been carried out by a doctor, and is now being attributed to a blown vein.  Not that a blown vein is necessarily the docs fault, they happen to the best of us.  I’m just amazed that he didn’t pick up on it sooner and stop the proceedings.  They are easy enough to spot – the patient complains bitterly of pain, the arm swells up and is cooler to the touch than the rest of the body.  Having all those meds end up in subcutaneous tissue would be both painful and agonizingly slow to take effect, to say the least.

Maybe – just maybe – this sorry episode will open up debate.  We can hope.

This is an open thread.

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