The Widdershins

Remain Calm, Etc: No Way to Die

Posted on: May 1, 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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21 Responses to "Remain Calm, Etc: No Way to Die"

I’m just amazed that he didn’t pick up on it sooner and stop the proceedings.

Chat if what I’ve read is correct they probably could not see the blown vein.

The execution of Lockett seemed at first to be proceeding normally. When witnesses first saw him through windows, he was strapped onto a gurney with a sheet covering his body. A technician had placed an intravenous line, emerging from a wall, in each arm, with the locations covered by the sheet.

At 6:23 p.m., the warden, Anita Trammell, asked Lockett if he had any last words — he did not — and called out, “Let the execution begin.” That was a signal to begin pumping a sedative, midazolam, which the state had not used before, into both of Lockett’s arms.

http://www.bostonglobe.com/news/nation/2014/04/30/oklahoma-tries-stanch-execution-fallout/Zkx2AlsEbesZsscblgW9CI/story.html

Heh. It could be that Oklahoma was too damned cheap.

Tuesday was the first time Oklahoma used the sedative midazolam as the first element in its execution drug combination. Other states have used it before; Florida administers 500 milligrams of midazolam as part of its three-drug combination. Oklahoma used 100 milligrams of that drug.

http://www.bostonglobe.com/news/nation/2014/04/30/man-dies-heart-attack-after-botched-execution/hE9FuG9U3xan3JKhiZl1RM/story.html

It’s amazing. That they are literally experimenting on humans with this stuff! The level of callousness by the state governments is really astonishing. I’ve also never understood executioners. Such a strange vocation.

The usual dosage of midazolam is 10 mg.

DYB@3: The OK guv was determined that guy was gonna die, come hell, high water or screwed up protocols.

Fallin had been an ardent supporter of Lockett’s execution, promising to carry it out despite a stay from the state’s Supreme Court.

Fallin detailed their crimes during Wednesday’s briefing, and reiterated her belief that justice had been served.

She said Lockett “was convicted at trial by a jury of his peers” and “had his day in court.”

“Charles Warner also had his day in court — he also committed a horrific crime,” she said, “His fellow Oklahomans have sentenced him to death and we expect that sentence to be carried out.”

Life is so simple when you try not to think too much.

Usual Adult Dose for Light Anesthesia

Initial dose: 2 mg IV once at a rate not to exceed 1 mg/min immediately before the procedure. Additional doses of 0.5 to 2 mg may be administered after 2 minutes to achieve desired level of sedation. Most patients achieve adequate sedation with a total dose less than 5 mg.
Maintenance dose: Generally does not exceed 25% of the dose initially required to achieve sedation.

http://www.drugs.com/dosage/midazolam.html#Usual_Adult_Dose_for_Light_Sedation

Think they were shooting for more than light sedation?

We were in the Er, too. Ergo, 10 mg. 100 should have felled a horse unless he’s one of those folks who do not respond, responds paradoxically, or it was all in the soft tissues of his groin.

I am against the death penalty the state that is in the business of murdering its citizens will end up not really caring if they murder the innocent as well as the guilty.

What part of thou shall not murder did that “Christian Woman” not get?

For induction of anesthesia to lethal effects, 100mg sounds low.
0.6mg/kg for ~250 lb/113kg man = 67 mg then add 25% of that = 84 mg approx.

Midazolam
Induction of Anesthesia:
For induction of general anesthesia, before administration of other anesthetic agents.
Unpremedicated Patients: In the absence of premedication, an average adult under the age of 55 years will usually require an initial dose of 0.3 to 0.35 mg/kg for induction, administered over 20 to 30 seconds and allowing 2 minutes for effect. If needed to complete induction, increments of approximately 25% of the patient’s initial dose may be used; induction may instead be completed with inhalational anesthetics. In resistant cases, up to 0.6 mg/kg total dose may be used for induction, but such larger doses may prolong recovery.

http://www.drugs.com/pro/midazolam-injection.html

NW Luna:

It was mentioned in one article I read that the states are trying to use this “one size fits all” thing instead of individualizing the dosage.

Also, an article I read stated that Lockett did not have any problems with his veins, i.e. iv drug user or anything of that nature. Then on Maddow’s show tonight she had a timeline from Oklahoma which stated that Lockett did indeed have problems with his veins so that they started the iv in his groin. At this point do I trust anything that comes out of that state regarding this mess? No. I mean, this is the governor who tells her Supreme Court to shove it.

Enter Governor Mary Fallin. On April 22, Fallin overruled the court, issuing an executive order asserting that it had overstepped its constitutional authority and that the executions would move forward the following week.

http://www.thedailybeast.com/articles/2014/05/01/mary-fallin-s-killer-fiasco.html

The Governor has blood on her hands Oklahoma should be returned to Territorial status they obviously do not have the ability to handle their own affairs.,

Gads. The only vein they could find was in his groin. The neck veins are usually prominent and easy to hit, but apparently not this time. It took the “doctor” 21 minutes to figure out there was a problem, but that might be becuase he was unsure about the efficacy of the protocol.

@9: It depends on what other drugs come behind it, and what the inmate’s drug tolerance might be. That’s the problem.

I mean, they were so determined to kill him that they would have beaten him to death if he didn’t have a heart attack.

@15: Sadly, you got that right. The fact that he was moving and had facial expressions should have been a huge hint that their 3-drug wonder was not doing the trick.

Conservatives get ants in their pants when something like this happens because it reveals what a state “execution” really is–murder.
Cold blooded murder, to be precise.

Amen, Sweet Sue. It is indeed state sanctioned murder.

This must stop the Supreme Court Must grow some balls and say No more Death Penalty period.

Do not hold your breath, Fuzzy.

[…] you haven’t read Chat’s insightful post from last week, please make the time since it is an enlightening look at the clinical process of […]

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