ANESTHESIA FACTS FOR NON-MEDICAL PEOPLE: LETHAL INJECTION AND THE ANESTHESIOLOGIST

In the 2011 movie The Lincoln Lawyer, Matthew McConaughey’s character, a criminal defense lawyer working in Los Angeles, taunts his client who is on trial for murder to tell the truth in order to “avoid the needle.”  The needle he is talking about is the specter of execution by lethal injection.

Since 2006, there have been no death penalty executions by lethal injection in the state of California.  In February 2006, U.S. District Court Judge Jeremy D. Fogel blocked the execution of convicted murderer Michael Morales because of concerns that if the three-drug lethal injection combination was administered incorrectly, it could lead to suffering for the condemned, and potential cruel and unusual punishment.  The ruling arose from an injunction made by the U.S. 9th Circuit Court of Appeals, which stated that an execution could only be carried out by a medical technician legally authorized to administer intravenous medications.  This led to a moratorium of capital punishment in California, as the state was unable to obtain the services of a licensed medical professional to carry out an execution.

The three intravenous drugs involved in lethal injection are (1) sodium thiopental, a barbiturate drug that induces sleep, (2) pancuronium, a drug that paralyzes all muscles, making movement and breathing impossible, and (3) potassium chloride, a drug that induces ventricular fibrillation of the heart, causing cardiac arrest.  The potential of cruel and unusual punishment can occur if the sodium thiopental does not reliably induce sleep, so that the individual to be executed is awake and aware when the paralyzing drug freezes all muscular activity.

How could sodium thiopental fail to induce sleep?  The lethal injection administered dose of sodium thiopental is always a massive dose, up to 3000 mg.  To compare, the usual dose of sodium thiopental administered by an anesthesiologist to begin a general anesthetic is 200 mg.  The 15-fold increase in the dose should insure lack of awareness, right?

Not necessarily.  What if the intravenous catheter or needle is incorrectly positioned, so that the drug does not enter the vein in a reliable fashion?  Is this a possibility?  It is.  If the catheter is not inserted by a trained medical professional, it’s possible that the catheter will be outside of the vein, and the intended medications will spill into the soft tissues of the arm.  The intended site of action of sodium thiopental is the brain.  To reach the brain, the drug must be correctly delivered into a vein.

Cases in which failure to establish or maintain intravenous access have led to executions lasting up to 90 minutes before the execution was complete.Thus, the role of a medical professional to insert the intravenous catheter and administer the lethal injection is critical.  The dilemma is that medical professionals are trained to save lives, not to execute people.  The Hippocratic Oath clearly states that physicians must “do no harm” to their patients.

The American Medical Association states, “A physician, as a member of a profession dedicated to preserving life when there is hope of doing so, should not be a participant in a legally authorized execution.”

The American Society of Anesthesiologists states, “Although lethal injection mimics certain technical aspects of the practice of anesthesia, capital punishment in any form is not the practice of medicine … The American Society of Anesthesiologists continues to agree with the position of the American Medical Association on physician involvement in capital punishment. The American Society of Anesthesiologists strongly discourages participation by anesthesiologists in executions.”

The American Nurses Association states, “The American Nurses Association is strongly opposed to nurse participation in capital punishment. Participation in executions is viewed as contrary to the fundamental goals and ethical traditions of the profession.”

Without a trained medical professional to administer the intravenous catheter and inject the drugs in a reliable fashion, the practice of lethal injection has stalled in the State of California.  The last prisoner executed by lethal injection in California was Clarence Ray Allen on January 17, 2006.

In 2010, a Riverside County judge scheduled the execution of Albert Greenwood Brown, after a California court lifted an injunction against capital punishment with the certification of new procedures.  The new procedures included the option of increasing the sodium thiopental dose to 5000 mg, and administering the drug alone without the pancuronium and potassium chloride.  (In this scenario, death would occur because the large dose of sodium thiopental would by itself induce both general anesthesia and the cessation of breathing, leading to death by lack of sufficient oxygen levels to the brain and heart.)  However, prior to the execution, the same Judge Jeremy D. Fogel halted the execution to permit time to determine whether the new injection procedures addressed defense arguments of cruel and unusual punishment.

An additional barrier to lethal injection arose in January 2011, as Hospira Corporation, the sole manufacturer of sodium thiopental, announced that they would stop making the anesthetic sodium thiopental, the key component in the drug cocktails used by 35 states for chemical executions.

Hospira had planned to shift production of thiopental from the U.S. to Italy, but Italian officials wanted assurances that the drug would not be used for lethal injections.  Hospira’s response was that while they “never condoned” the use of thiopental in executions, the company determined that it could not prevent corrections departments in the United States from obtaining the drug. “Based on this understanding, we cannot take the risk that we will be held liable by the Italian authorities if the product is diverted for use in capital punishment,” Hospira said in a statement.

The American Society of Anesthesiologists released a statement on January 21, 2011 condemning Hospira’s decision to cease manufacturing sodium thiopental. The American Society of Anesthesiologists “certainly does not condone the use of sodium thiopental for capital punishment, but we also do not condone using the issue as the basis to place undue burdens on the distribution of this critical drug to the United States. It is an unfortunate irony that many more lives will be lost or put in jeopardy as a result of not having the drug available for its legitimate medical use.”  According to the American Society of Anesthesiologists, thiopental is an important alternative for geriatric, neurologic, cardiovascular and obstetric patients “for whom the side effects of other medications could lead to serious complications.”

In current anesthetic practice in the U.S. and around the world, sodium thiopental is occasionally but rarely utilized in anesthetic or intensive care unit practice.  Propofol replaced sodium thiopental, as propofol is a shorter-acting drug with fewer side effects of post-operative sleepiness and nausea.

Propofol or other sedative drugs such as midazolam, Valium, etomidate, or methohexital could be used to replace sodium thiopental to carry out lethal injection, but the key issue of obtaining a trained medical professional to administer the drug still looms as a roadblock.

I recommend The Lincoln Lawyer as riveting entertainment, but when Matthew McConaughey urges the defendant to “avoid the needle” of lethal injection, you have to understand … it’s unlikely any anesthesiologist is ever going to assist in that execution.

 

 

 

Introducing …, THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel. Publication date August 31, 2014 by Pegasus Books. Available on all major online book vendors. THE DOCTOR AND MR. DYLAN can be ordered in print or ebook from Amazon.com. To reach the Amazon webpage, click on the book cover image below:

http://www.amazon.com/Doctor-Mr-Dylan-Rick-Novak-ebook/dp/B00N869JSM/ref=sr_1_1?ie=UTF8&qid=1409773354&sr=8-1&keywords=rick+novak

Brief description: Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.

Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ Fargo, The Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.

Amazon Review: 5.0 out of 5 stars I thoroughly enjoyed reading this September 5, 2014
By dlb
This book gives you some insight as to the life of a physician.
Many of us wind up in hospitals to undergo some procedure or another and our life is in their hands. It was so interesting to read about their side of the story and the effects it all has on them. The influence of friends and family plays a part in all our lives and so often we forget how much help that can be, too. Dr. Novak follows the path that Carol Cassella blazed in the genre of Anesthesiologist authors.
I thoroughly enjoyed reading this book.

By Mark in Manhattan on September 24, 2014
Format: Kindle Edition
Great beginning. Terrific ending. I’m a junkie for courtroom drama, and this book reminds me of John Grisham’s best. Hard to believe it was written by a doctor. The Dylan character is a hoot. A top-notch novel.

A real page turner!
By Maddiepup on October 1, 2014

Format: Kindle Edition
This book get your attention from the first page — a real page turner. A great mystery with humor intertwined. A great read!!

Learn more about Rick Novak’s fiction writing at

https://ricknovak.com

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