Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.

On January 16, 2014, the New York Times reported that Dennis McGuire was executed by a lethal  injection of midazolam and hydromorphone. McGuire was previously convicted of the 1994 rape and murder of a 22-year-old pregnant woman.


The lethal injection occurred at the Southern Ohio Correctional Facility in Lucasville, Ohio. It 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.

What happens to a human when you inject midazolam and hydromorphone? Anesthesiologists use these drugs every day to provide safe anesthesia care in operating rooms.

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.

Hydromorphone (Dilaudid) is a narcotic similar to morphine. Physicians inject Dilaudid to relieve pain. A typical adult intravenous dose is 0.2 mg. Doses may be repeated and titrated to effect if the patient continues to hurt.

Both midazolam and hydromorphone are respiratory depressants. When administered together in high doses, these two drugs will (1) cause unconsciousness, and (2) depress breathing, and perhaps cause breathing to cease if the doses are high enough.

When anesthesiologists inject doses of midazolam and hydromorphone we routinely administer supplemental oxygen, and monitor the patient with a pulse oximeter, an ECG machine, an end-tidal carbon dioxide monitor and a blood pressure cuffs. Anesthesiologists give moderate doses of midazolam and hydromorphone safely every day.

Can you kill someone with mega-doses of these two drugs? Absolutely. I have no idea what doses were used in the Ohio execution, but let’s assume an executioner administered massive overdoses in the range of 50 mg of midazolam and 5 mg of hydromorphone. The mechanism of death would be hypoventilation and hypoxia. In layman’s terms this means the patient’s ventilation will decrease markedly, and because of this decreased breathing the patient’s oxygen level will decrease. If the oxygen level decreases to a lethal level–a level low enough that the heart and brain will have inadequate oxygen–the patient will have a cardiac arrest. Can 10 -15 minutes pass by before the inadequate oxygen levels cause cardiac arrest? Yes, they could.

Would a patient dying in this fashion suffer? No, it’s unlikely they will suffer. If the doses of midazolam and hydromorphone are large enough, the patient will be unconscious before and during their cardiac death.

Will an anesthesiologist ever supervise such a lethal injection on death row? No. Per my earlier blog entry, ANESTHESIA FACTS FOR NONMEDICAL PEOPLE: LETHAL INJECTION AND THE ANESTHESIOLOGIST, listed in the column at your right, 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.


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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.


In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:


Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below: