On April 29, 2014 CNN reported the story of the botched intravenous lethal injection execution of convicted murderer Clayton Lockett in Oklahoma. The recipe for the execution included three drugs: midazolam, vecuronium, and potassium chloride.
Prior to the execution, medical officials tried for nearly an hour to find a vein in Clayton Lockett’s arms, legs and neck before finally inserting an IV into his groin, prisons director Robert Patton wrote in a letter to the governor May 1st detailing Lockett’s last day.
In the middle of the injection process, the convict was observed to cry out, “Man,” “I’m not,” and “something’s wrong,” before the blinds were closed to witnesses. Lockett died of a heart attack 43 minutes after the first drug was injected.
Dean Sanderford, Lockett’s attorney, stated his client’s body “started to twitch,” and then “the convulsing got worse. It looked like his whole upper body was trying to lift off the gurney. For a minute, there was chaos.”
After administering the first drug, “We began pushing the second and third drugs in the protocol,” said Oklahoma Department of Corrections Director Robert Patton. “There was some concern at that time that the drugs were not having the effect. So the doctor observed the line and determined that the line had blown.” He said that Lockett’s vein had “exploded.”
CNN further states that, “Oklahoma had announced the drugs it planned to use: midazolam; vecuronium bromide to stop respiration; and potassium chloride to stop the heart. Two intravenous lines are inserted, one in each arm. The drugs are injected by hand-held syringes simultaneously into the two intravenous lines. The sequence is in the order that the drugs are listed above. Three executioners are utilized, with each one injecting one of the drugs.”
The article further states that, “The doctor checked the IV and reported the blood vein had collapsed,and the drugs had either absorbed into tissue, leaked out or both,” according to the timeline. The director of the corrections department then asked whether Lockett had been given enough of the drug combination to kill him, and the doctor said “no.” “Is another vein available? And if so, are there enough drugs remaining?” the doctor was asked, according to the timeline.
The doctor’s answer to both questions: “No.”
Lockett’s attempted execution was carried out at the Oklahoma State Penitentiary in McAlester, where he had been housed following his conviction and death sentence for shooting Stephanie Nieman and then watching as two others buried her alive in 1999.
What happened in this apparent “botched” execution? I have no additional information other than what has been published in the lay press, but as an anesthesiologist I can make some inferences:
In the three drug combination of midazolam, vecuronium, and potassium chloride, each drug has a specific purpose. The sedative midazolam is intended to make the convicted murderer fall asleep. Midazolam (Versed) is a benzodiazepine, a drug commonly given immediately prior to surgery to relieve a patient’s anxiety. A typical adult dose is 2 mg. Midazolam is also commonly used for conscious sedation for colonoscopy procedures, when repeated 1 – 2 mg doses are titrated for relaxation. Let’s assume an executioner administered massive overdoses in the range of 50 mg of midazolam. This dose should reliably guarantee unconsciousness, unless the intravenous catheter is not properly placed inside the vein. If the IV infiltrates, only a portion of the midazolam circulates in the bloodstream, and the expected unconsciousness may not be obtained.
The second drug, vecuronium, is a paralyzing drug. Anesthesiologists commonly inject vecuronium prior to or during surgical anesthetics. Anesthesiologists first administer a hypnotic drug such as propofol to insure unconsciousness, and then administer a muscle relaxant drug such as vecuronium to paralyze the patient so a metal laryngoscope can be inserted into the patient’s mouth to facilitate the placement of a breathing tube into the trachea. The anesthesiologist will then support ventilation of the patient’s lungs by connecting the breathing tube to a ventilator. The paralyzed patient is unable to breathe on their own, and without the controlled ventilation the patient would die within minutes. This is the rationale of using vecuronium in a lethal injection cocktail. The other rationale in using a paralyzing drug such as vecuronium is that a paralyzed individual will not writhe or seize during the death process.
A concentrated dose of potassium chloride causes sudden cardiac arrest by ventricular fibrillation of the heart.
Why did the Oklahoma execution not go smoothly? As reported in the press, the intravenous line infiltrated. Why does this happen? The intravenous line was either improperly inserted, improperly secured, or it dislodged. The success of a lethal injection depends specifically on the lethal drugs being reliably delivered into the convict’s vein via a properly running IV line.
Some individuals have difficult IV access, which apparently was the case in the convict Lockett. Medical personnel typically place IV’s in arm veins, followed by legs, neck or groin as alternate locations. The placement of an IV in the groin, as was reported in Lockett’s case, is typically done by a physician, utilizing a longer IV catheter called a central venous catheter or CVP catheter. In modern hospitals, this CVP placement is often done using ultrasound imaging for increased accuracy and success. In a hospital setting, CVP placement would be done by an M.D., not by a nurse or a technician.
What was the mechanism of Lockett’s heart attack and death? I don’t know for sure, but possibilities are: 1) enough potassium chloride accumulated in his blood stream to cause his heart to arrest; 2) enough vecuronium accumulated in his blood stream to weaken his breathing so that he could not ventilate his own lungs with oxygen; or 3) a combination of 1) and 2).
Dr. Jack Kevorkian invented a euthanasia machine for assisted suicide. His machine injected three drugs that parallel the drugs used in Oklahoma: the sleep drug sodium thiopental, the paralyzing drug pancuronium, and potassium chloride. In 1999 Kevorkian was arrested for his role in executing patients in the fashion. Kevorkian was convicted of second-degree murder.
The manufacturer of the sleep drug sodium thiopental has banned the use of the product for lethal injection of prisoners. Because of this ban, there have been recent occurrences of midazolam replacing thiopental in the lethal injection recipe in the United States in 2014.
A second midazolam execution occurred in January 2014, during the lethal injection of convicted murderer Dennis McGuire at the Southern Ohio Correctional Facility in Lucasville, Ohio. This was the first time any state used the combination of midazolam and hydromorphone for an execution. It was reported that McGuire took 15 minutes to die. A reporter who witnessed the execution described McGuire as struggling, gasping loudly, snorting and making choking noises for nearly 10 minutes before falling silent and being declared dead a few minutes later. Dennis McGuire’s execution was discussed in an earlier blog entry (https://theanesthesiaconsultant.com/2014/01/16/january-2014-lethal-injection-with-midazolam-and-hydromorphone/).
Is midazolam an inferior drug to sodium thiopental for lethal injection? Probably not. In sufficiently high doses, midazolam will make any individual unconscious. An apparent flaw in McGuire’s case was the absence of a paralyzing drug and potassium chloride in the recipe. The apparent flaw in Lockett’s case was the absence of a reliable functioning IV.
Will an anesthesiologist ever insert the IV and supervise a lethal injection on death row? No. No anesthesiologist will ever use his or her skills to end a human’s life. State governments will have to find someone else to supervise lethal injections. An anesthesia doctor’s job is to keep patients alive.
Introducing …, THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a legal mystery. Publication date September 9, 2014 by Pegasus Books.
The first four chapters are available for free at Amazon. Read them and you’ll be hooked! To reach the Amazon webpage, click on the book image below:
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.
Bang-Up Debut Novel, November 16, 2014
By Norm Goldman “Publisher & Editor of Bookpleasures”
This part legal and medical thriller is structured with a mixed bag of situations involving relationships, jealousy, evil, lies, courtroom drama, operating room mishaps as well as moments that engender conflicting and unexpected outcomes. Noteworthy is that as the suspense builds readers will become eager to uncover the truth involving a mishap concerning Nico and a surgical procedure that has unanticipated ramifications.
This is a bang-up debut from a writer who understands timing and is able to deliver hairpin turns, particularly involving the courtroom drama,that you would expect from a book of this genre.
TwinCities.com PIONEER PRESS Entertainment
by Mary Ann Grossman, Entertainment Editor, St. Paul Pioneer Press firstname.lastname@example.org, January 4, 2015
“The Doctor & Mr. Dylan” by Rick Novak (Pegasus Books, $17.50)
Dr. Nico Antone doesn’t hide the fact he hates his wife, but he says he didn’t kill her during an operation. The authorities think otherwise and his trial is the riveting suspense in this novel that is part medical thriller, part legal thriller, part exploration of family relationships.
Nico is an anesthesiologist (as is the author) who leaves his wife, their plush life in California and his job at Stanford to move to his hometown of Hibbing so their son, Johnny, has a better chance of getting into a prestigious college. Johnny hates the idea of moving to a small, cold town, but he’s popular from the first day in school. Nico doesn’t do so well. He’s envied by Bobby, an anesthetist who’s jealous of the better-educated Nico. But it’s hard to take Bobby seriously, since he thinks he’s the young Bob Dylan and lives in the house where Bobby Zimmerman grew up. To complicate matters, Nico is attracted to the mother of the young woman his son is dating. When the two teens get in trouble, Nico’s furious, rich wife comes to Minnesota and needs an emergency operation that puts her on Nico’s operating table.
Novak grew up in Hibbing, where he worked in the iron ore mines and played on the U.S. Junior Men’s Curling championship teams of 1974 and ’75. After graduating from Carleton College, he earned a medical degree at the University of Chicago and spent 30-plus years at Stanford Hospital, where he was an associate professor of anesthesia and Deputy Chief of the Anesthesia Department. His courtroom scenes are based on his experiences as an expert witness.
The Physician’s Late-Night Reading List
Two Pritzker alums pen captivating tales
By Brooke E. O’Neill, University of Chicago Pritzker School of Medicine, editir, Medicine on the Midway Magazine
For most physicians, writing — patient notes, case histories, perhaps journal articles — is part of the job. But for anesthesiologist-novelist Rick Novak, MD’80, and neurosurgeon-memoirist Moris Senegor, MD’82, it’s a second career that consumes early morning hours long before they step into the OR.
Fans of John Grisham will find a kindred spirit in Novak, whose fast-paced medical thriller, The Doctor & Mr. Dylan (Pegasus Books, 2014), transports readers to rural Northern Minnesota, where an accomplished physician and a deranged anesthetist who thinks he’s rock legend Bob Dylan see their worlds collide in the most unexpected ways.
Delivering real-life twists and turns — and a love letter to the Bay Area — is Senegor’s Dogmeat: A Memoir of Love and Neurosurgery in San Francisco (Xlibris, 2014), a coming-of-age tale chronicling the author’s away rotation with renowned neurosurgeon Charles Wilson, MD, at the University of California, San Francisco. Brutally honest, it spares no details of a time Senegor, who also served as a resident under the University of Chicago’s famed neurosurgery chair Sean Mullan, MD, describes as “one of the biggest failures of my life.”
One a vividly imagined nail-biter, the other an intimate peek into the surgical suite, both books deliver an ample dose of intensity and drama.
The Doctor and Mr. Dylan (Pegasus Books, 2014) by Rick Novak, MD’80
“I thought it was a novel way of killing someone,” said Rick Novak, deputy chief of anesthesiology at Stanford University, describing the imagined hospital death that was the genesis of his dark thriller The Doctor & Mr. Dylan. A huge Bob Dylan fan — the rock icon was born in Novak’s hometown of Hibbing, Minnesota, where the story takes place — he then dreamed up a possible culprit: a psychotic anesthetist who thinks he’s Dylan.
From there, the words flowed. “I would write whenever I was with my laptop and had a free moment: in mornings, in evenings, in gaps between cases,” said Novak, who also blogs about anesthesia topics. “I don’t sleep much.”
After finishing the manuscript — one year to write, another to edit — came the challenge of finding a publisher. “In anesthesia, I’m an expert,” Novak said. “In the literary world, I’m an unknown.” After 207 responses of “no, thanks” or no answer at all, he landed an agent. Two months later, she informed him that Pegasus Books had bought his debut novel.
“I started crying,” Novak admits. “I have a third grader and at the time the big word the class was learning was ‘perseverance.’ That was it exactly.”
Dr. Joseph Andresen, Editor, Santa Clara County Medical Association Medical Bulletin, from the January/February 2015 issue:
BOOK REVIEW “THE DOCTOR AND MR. DYLAN”
This past month, Dr. Rick Novak handed me a hardbound copy of his debut novel The Doctor and Mr. Dylan. Rick and I go way back. It was my first week of residency at Stanford when we first met. A newcomer to the operating room, all the smells and sounds were foreign to me despite my previous three years in the hospital as an internal medicine resident. Rick, a soft spoken Minnesotan at heart, in his second year of residency, took me under his wing and guided me through those first few bewildering months, sharing his experience and wisdom freely.
Fast-forward 30 years later. Dr. Rick Novak, a novel and mystery author? This was new to me as I sat down and opened the first page of The Doctor and Mr. Dylan. I have to admit that I didn’t know what to expect. Few books highlight a physician/anesthesiologist as a protagonist, and few books feature a SCCMA member as a physician/author. However, a medical-mystery theme novel wasn’t at the top of my must read list. With my 50-hour workweek, living and breathing medicine, imagining more emotional stress and drama was the furthest thing from my mind. However, three days later, as I turned the last page, and read the last few words. “life is a series of choices. I stuck my forefinger into the crook of the steering wheel, spun it hard to the left and …” This completed my 72-hour journey of and free moments I had, completely immersed in this story of life’s disappointments, human imperfections, and simple joys.
Rick, I can’t wait for your next book. Bravo!
Hibbingite writes twisted medical tale
HIBBING — Readers who are looking for a whodunit that will keep them up all night are in for a treat.
Hibbing native Rick Novak recently released his first book “The Doctor and Mr. Dylan,” a fiction set in Hibbing that merges anesthesia complications, a tumultuous marriage and the legend of Bob Dylan.
“The dialogue is sometimes funny, and there are lots of plot twists,” he said.
Novak said the book will not only entertain readers, but teach them about anesthesiology, Dylanology, the stressful race for elite college admission, and life on the Iron Range.
“The book is very conversational and streamlined,” he said. “I try to write as one would tell a story out loud.”
Novak said “The Doctor and Mr. Dylan” took him three years to perfect. He is currently working on his second book.
This review is from: The Doctor and Mr. Dylan (Kindle Edition)
Just finished Dr. Novak’s delightful novel. I sincerely enjoyed his honest take about the pressures and values that exist within California’s Silicon Valley. He also brought the North Country of Minnesota to life with memorable characters and a twisting, addictive plot. Buried beneath the fun and funny story is a deeper message about how to best care for your kids, your relationships and yourself. Very well written and highly recommended.
Learn more about Rick Novak’s fiction writing at rick novak.com by clicking on the picture below: