Dr Husel trial begins

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amyl

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coffeebythelake said:
Very gray area for palliation with end of life patients. Giving such high doses of fentanyl does raise eyebrows. Withdrawal of care leading to death is not illegal. But active euthanasia is.
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I use high doses (though not that high) at end of life comfort care because the only way I can fail my patient at that point is to wimp out on the dosing and make their last moments misery. The icu lawsuits seem to stem from patient families (allegedly) not understanding they were agreeing to end of life care.
 
amyl said:
10mg diluadid. 2000mcg fentanyl. Has anyone ever pushed these doses?

At my hospital this would have raised red flags instantly - and people would likely be thinking diversion. I don’t know a nurse that would push even 250 of fentanyl
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How can anybody push this dose of medicine and not expect some blowback.

Also, I would immediately think diversion if someone in the hosptial did this.
 
coffeebythelake said:
Very gray area for palliation with end of life patients. Giving such high doses of fentanyl does raise eyebrows. Withdrawal of care leading to death is not illegal. But active euthanasia is.
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Euthanasia is legal in a couple of states but the patients must have a very short life expectancy and initiate it, the patient must be counseled about alternatives eg palliative care, and give consent. Finally the patients need to be able to self administer the medications.
 
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amyl said:
10mg diluadid. 2000mcg fentanyl. Has anyone ever pushed these doses?

At my hospital this would have raised red flags instantly - and people would likely be thinking diversion. I don’t know a nurse that would push even 250 of fentanyl
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In the 1990s, a typical heart would get midazolam 20mg and fentanyl 2000-3000mcg (40-60ml) for their anesthetic but definitely not on the floor. And that was the whole anesthetic. No vapor, no propofol although some perfusionists would crack a little forane on pump.
 
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nimbus said:
In the 1990s, a typical heart would get midazolam 20mg and fentanyl 2000-3000mcg (40-60ml) for their anesthetic but definitely not on the floor. And that was the whole anesthetic. No vapor, no propofol although some perfusionists would crack a little forane on pump.
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Heh, more like late 2000s. Some anesthesiologist still does the same stuff they learned in residency 30 years ago, without any desire to change... If it works, I guess.
 
nimbus said:
In the 1990s, a typical heart would get midazolam 20mg and fentanyl 2000-3000mcg (40-60ml) for their anesthetic but definitely not on the floor. And that was the whole anesthetic. No vapor, no propofol although some perfusionists would crack a little forane on pump.
Click to expand...

I've done this anesthetic. I like the stability but definitely think 2 of midaz is better than 20
 
These families are in it for the money.

""It is shocking that this is happening. I am completely shocked and disappointed in the whole judicial system," said Sean Thomas, son of Jan Thomas.
"Every time this is covered, she dies again," Sean Thomas said. "Every time her name flashes in the story -- it's back in the news. There is movement in the case. She dies all over again. And now to hear that 11 of these cases were dismissed, she is dying all over again.""

What a crock of horse****. This doc made sure their loved one had a peaceful death after they were already dead (if not actually brain dead). Of course he went overboard with his dosing, but it just shows the hypocrisy of the "double effect principle" (Goods, causes and intentions: problems with applying the doctrine of double effect to palliative sedation - BMC Medical Ethics).

He's an idiot for being so liberal with his dosing, but if he gets convicted of murder then nobody better ever make anybody comfort in the hospital anymore.
 
Ronin786 said:
These families are in it for the money.

""It is shocking that this is happening. I am completely shocked and disappointed in the whole judicial system," said Sean Thomas, son of Jan Thomas.
"Every time this is covered, she dies again," Sean Thomas said. "Every time her name flashes in the story -- it's back in the news. There is movement in the case. She dies all over again. And now to hear that 11 of these cases were dismissed, she is dying all over again.""

What a crock of horse****. This doc made sure their loved one had a peaceful death after they were already dead (if not actually brain dead). Of course he went overboard with his dosing, but it just shows the hypocrisy of the "double effect principle" (Goods, causes and intentions: problems with applying the doctrine of double effect to palliative sedation - BMC Medical Ethics).

He's an idiot for being so liberal with his dosing, but if he gets convicted of murder then nobody better ever make anybody comfort in the hospital anymore.
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asdfdsaf.jpg


From the em thread
Looks like they died multiple times already
 
From an outsider’s perspective I think it’s interesting that in the EM thread nobody mentioned diversion but in the Anesthesiologist thread multiple people mention it within the first few posts.

I know there are plenty of good reasons for it, just thought it was interesting.
 
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Ronin786 said:
These families are in it for the money.

""It is shocking that this is happening. I am completely shocked and disappointed in the whole judicial system," said Sean Thomas, son of Jan Thomas.
"Every time this is covered, she dies again," Sean Thomas said. "Every time her name flashes in the story -- it's back in the news. There is movement in the case. She dies all over again. And now to hear that 11 of these cases were dismissed, she is dying all over again.""

What a crock of horse****. This doc made sure their loved one had a peaceful death after they were already dead (if not actually brain dead). Of course he went overboard with his dosing, but it just shows the hypocrisy of the "double effect principle" (Goods, causes and intentions: problems with applying the doctrine of double effect to palliative sedation - BMC Medical Ethics).

He's an idiot for being so liberal with his dosing, but if he gets convicted of murder then nobody better ever make anybody comfort in the hospital anymore.
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In my ICU rotations anytime we did comfort measures I had to document something along the lines of “spoke with patient/family about comfort measures and that while our goal is palliation the administration of these medications could in theory hasten the patient’s death.”

I always hated it because I felt like having that conversation with families was almost selling them against the idea of comfort care but thankfully nobody ever refused it.
 
HemeOncHopeful19 said:
From an outsider’s perspective I think it’s interesting that in the EM thread nobody mentioned diversion but in the Anesthesiologist thread multiple people mention it within the first few posts.

I know there are plenty of good reasons for it, just thought it was interesting.
Click to expand...

That's because it is very tough for them to divert. They order the meds and it is drawn up by the nurse and administered by the nurse. We basically do everything ourselves. Even the methods used to look for diversion are easily gamed and completely useless.
 
HemeOncHopeful19 said:
From an outsider’s perspective I think it’s interesting that in the EM thread nobody mentioned diversion but in the Anesthesiologist thread multiple people mention it within the first few posts.

I know there are plenty of good reasons for it, just thought it was interesting.
Click to expand...
Also, within anesthesia itself, drug diversion is something that we’re taught about in our CMEs because it is a little more common than among anesthesiologists than the rest physician population.
 
I feel like we are veiewing these patients as intact hemispheres. These patients only had intact mesenesephalons these are not intact hemispheric patients. First thing I thought when I saw the 500mcg escalation to 1000mcg is was the IV intact? I do not believe Dr Husel intentionally ended these terminal individuals lives more so gave palliative care to his capability. I rarely use beyond 250mcg of fentanyl for a case. OR physiology aint ICU end of life physiology. I feel the hospital created a witchhunt. If the CEO was concerned about the dosages first time this happened it should have sent of flags and practice modified. In addition where was the pharmacist? Nurses at bedside?
I trained with Dr Husel. And I hope for his families sake he pulls through. Both myself and my wife who is a Board Certified EM doc believe he is innocent of the charges.
Btw we can talk about these 14 patients but how many patients did Dr Husel discharge in the ICU to the floor or step down? Whats at fault here is a process issue not a murder case.
 
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Across the board we do not provide enough pain and anxiety medications at end of life. So many people suffer needlessly. Thats what these meds should be used for. Ive never given someone 2000mcg of fentanyl but 250-500 over the course of an hour? Until diaphoresis and tachypnea improves? Yes. I am treating end of life symptoms. Please do the same for me if I am in the ICU.

I dont know enough about this case. I hope that he was indicted due to something actually nefarious rather than a doctor trying to ease end of life suffering.
 
Yea with a ph of 6.94 and probably non-existent cardiac output the standard dosing of any drug falls out the window. Hopefully the expert wit esses they conjure up actually are experts and npt the usual crock of hacks collecting a paycheck to drive the standard of care in to the toilet.
 
I used to cringe while in the cvicu during training whenever the “palliative care” trained physicians came around. For withdrawal of care for ecmo patients they’d order 2mg versed and 8mg morphine. Even the young ones…

That being said, there has to be some middle ground. I don’t think the guy is guilty of murder by any means but those doses are pretty crazy.
 
gcc322 said:
I used to cringe while in the cvicu during training whenever the “palliative care” trained physicians came around. For withdrawal of care for ecmo patients they’d order 2mg versed and 8mg morphine. Even the young ones…

That being said, there has to be some middle ground. I don’t think the guy is guilty of murder by any means but those doses are pretty crazy.
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What is wrong with 2 midaz and 8 of morphine.
 
Narcus, I initially thought the same thing… no way Will would do this purposely - but then I read about his criminal history prior to ccf and came to the conclusion that I really didn’t know him.
 
amyl said:
Narcus, I initially thought the same thing… no way Will would do this purposely - but then I read about his criminal history prior to ccf and came to the conclusion that I really didn’t know him.
Click to expand...
Amyl
His criminal history has minimal bearing on his practice as a physician. He committed a crime in college got a 2nd chance and from that point forward acted in good practice through medical school and residency. Albeit my faith in the criminal justice system is minimal. If it was me who had his history I would have never made it as a physician. I do know he saved many lives in his practice many of which were folks with serious criminal backgrounds. I met with him toured his ICU with my wife. The place was scary full of biker gangs, gang members, and a huge population of poor foreigners. His goal was to prevent pain and suffering for people many physicians would not treat let alone step foot into the hospital. Life has taught me I really don’t know anyones past but what they tell me. The only person in this world I am sure of is the beautiful woman I sleep next to. I pray for him and his family and that the truth is made evident.
 
My hospital is rough too. Skin popping heroin abusers, crazy homeless, gsw almost daily…. And lots of foreigners - more than Ohio for sure. I take care of pall med patients daily…. But I’ve never pushed 10mg of diluadid. I don’t believe the intent was criminal but his judgement is highly questionable. I hope he gets off… I don’t think he deserves to go to jail but I don’t think he should be a doctor anymore. I certainly don’t want him as a representative of my profession and I wouldn’t let him put me to sleep…I thought that then too.
 
amyl said:
My hospital is rough too. Skin popping heroin abusers, crazy homeless, gsw almost daily…. And lots of foreigners - more than Ohio for sure. I take care of pall med patients daily…. But I’ve never pushed 10mg of diluadid. I don’t believe the intent was criminal but his judgement is highly questionable. I hope he gets off… I don’t think he deserves to go to jail but I don’t think he should be a doctor anymore. I certainly don’t want him as a representative of my profession and I wouldn’t let him put me to sleep…I thought that then too.
Click to expand...
What if your ph was 6.9 in terminal shock after a recent cardiac arrest with the usual broken ribs and a pneumothorax with a large bore chest tube that was put in with no lidocaine peri-arrest with intact brainstem reflexes and the decision had been made to extubate you and cease support. Would you be worried about the dose being too high then?
 
chessknt said:
What if your ph was 6.9 in terminal shock after a recent cardiac arrest with the usual broken ribs and a pneumothorax with a large bore chest tube that was put in with no lidocaine peri-arrest with intact brainstem reflexes and the decision had been made to extubate you and cease support. Would you be worried about the dose being too high then?
Click to expand...
I’m fine if you want to give doses got and titration to effect and go up, or start an infusion and go up, but giving a large dose at once like the ones he did will be considered intentionally giving a drug that will cause death, no way around it.
 
dipriMAN said:
I’m fine if you want to give doses got and titration to effect and go up, or start an infusion and go up, but giving a large dose at once like the ones he did will be considered intentionally giving a drug that will cause death, no way around it.
Click to expand...
When death is going to occur on the order of minutes you only get to have one dose, there is no titration...
 
dipriMAN said:
I’m fine if you want to give doses got and titration to effect and go up, or start an infusion and go up, but giving a large dose at once like the ones he did will be considered intentionally giving a drug that will cause death, no way around it.
Click to expand...
The problem there is that those infusion adjustments are not instantaneous. As we all know, ICU nurses are stretched thin. They may increase the fentanyl drip from 150 -> 200 then leave the room. Now the patient has another 15-20 minutes of poorly controlled pain. Now add in the act of donning/doffing COVID gear. My personal preference is to order more than I need and have at the bedside. In the presence of a nurse I administer the medications in repeat dosing until the patient is objectively comfortable. Then we can start the infusion. I dont abandon my patient based on a lawyers definition of what is an appropriate dose of pain medicine

Also, we need to think about what the perfect pain strategy at end of life would look like. Ideally, regardless of the underlying pathology, we would want JUST enough pain and anxiety medicine that a patient is awake, happy, able to talk to family and have a quality of life in those last minutes/hous/days/weeks etc. However, when someone has horrible anoxic brain damage or massive brain bleed or horrible metastatic lung cancer with bone pain, chronic dyspnea etc, are we able to get them there to that perfect level of coherence and lack of pain? Probably not. Again, i dont know what exactly was going on with this guy, but if he was the bedside physician and he was truly trying to relieve suffering at end of life with a higher than typical dose of opioid in patients who were clearly dying, then I truly hope he gets off. What comes from all this? More nursing checks? More limits on bolus administration of opioid. All this will accomplish is more pain, more headache for providers and worse patient care.
 
RemyMcswain said:
The problem there is that those infusion adjustments are not instantaneous. As we all know, ICU nurses are stretched thin. They may increase the fentanyl drip from 150 -> 200 then leave the room. Now the patient has another 15-20 minutes of poorly controlled pain. Now add in the act of donning/doffing COVID gear. My personal preference is to order more than I need and have at the bedside. In the presence of a nurse I administer the medications in repeat dosing until the patient is objectively comfortable. Then we can start the infusion. I dont abandon my patient based on a lawyers definition of what is an appropriate dose of pain medicine

Also, we need to think about what the perfect pain strategy at end of life would look like. Ideally, regardless of the underlying pathology, we would want JUST enough pain and anxiety medicine that a patient is awake, happy, able to talk to family and have a quality of life in those last minutes/hous/days/weeks etc. However, when someone has horrible anoxic brain damage or massive brain bleed or horrible metastatic lung cancer with bone pain, chronic dyspnea etc, are we able to get them there to that perfect level of coherence and lack of pain?
Click to expand...


This is anesthesia style of care that basically nobody else does. Standing at the bedside rapidly bolusing and titrating medications until we achieve the desired effect.

I did do some palliative care as part of my chronic pain rotations in residency. We had a very dedicated director of pain at the time and we would go to a freestanding hospice, stand at the bedside, and titrate low dose ketamine and lidocaine infusions on end stage patients to get them symptom relief. This was in the mid 1990s.
 
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RemyMcswain said:
The problem there is that those infusion adjustments are not instantaneous. As we all know, ICU nurses are stretched thin. They may increase the fentanyl drip from 150 -> 200 then leave the room. Now the patient has another 15-20 minutes of poorly controlled pain. Now add in the act of donning/doffing COVID gear. My personal preference is to order more than I need and have at the bedside. In the presence of a nurse I administer the medications in repeat dosing until the patient is objectively comfortable. Then we can start the infusion. I dont abandon my patient based on a lawyers definition of what is an appropriate dose of pain medicine

Also, we need to think about what the perfect pain strategy at end of life would look like. Ideally, regardless of the underlying pathology, we would want JUST enough pain and anxiety medicine that a patient is awake, happy, able to talk to family and have a quality of life in those last minutes/hous/days/weeks etc. However, when someone has horrible anoxic brain damage or massive brain bleed or horrible metastatic lung cancer with bone pain, chronic dyspnea etc, are we able to get them there to that perfect level of coherence and lack of pain? Probably not. Again, i dont know what exactly was going on with this guy, but if he was the bedside physician and he was truly trying to relieve suffering at end of life with a higher than typical dose of opioid in patients who were clearly dying, then I truly hope he gets off. What comes from all this? More nursing checks? More limits on bolus administration of opioid. All this will accomplish is more pain, more headache for providers and worse patient care.
Click to expand...
This sounds quite appropriate, but even you admit that you titrate to effect as quickly as possible, certainly you don’t push milligram doses of fentanyl at a time. Even though it achieves the same effect, pushing a huge bonus all at once is just not justifiable medical legally.
 
dipriMAN said:
This sounds quite appropriate, but even you admit that you titrate to effect as quickly as possible, certainly you don’t push milligram doses of fentanyl at a time. Even though it achieves the same effect, pushing a huge bonus all at once is just not justifiable medical legally.
Click to expand...
But it is justifiable based on context... Some of the people he withdrew care on must have died within minutes of stopping support given the labs posted. How long do you think it takes for the fentanyl to work and see an effect? If the goal is comfort and you give 200 mcg bolus to someone who has been on a gtt at 150/hr for 2-3 days do you think it is going to work? Why is 1000 a crime but 500 is ok if the person is going to die in a few minutes anyways?

I guess the lesson we should take home here is that the dead can't complain so we might as well protect ourselves and underdose them to avoid being called out even if it means whatever perception they have in their final minutes of life are pure agony.
 
Do we even know that those doses were given as a single push? When I do procedural sedation in the unit, I stand at the bedside and personally administered the medications to effect. Then afterwards I enter the total dose into EPIC as a single order so it would look like a single dose in the MAR. Have I missed additional information released?

In the ED thread people were emphasizing that it isn't clear that these meds were given in the setting of extubation. Do people have links to more information?
 
For those who don’t remember, this was a similar case complicated by the fact that the child was a DCD donor. Fentanyl 500mcg was given to a 21kg child who was gasping for breath. I think charges were eventually dropped.


www.foxnews.com

Doctor accused of using painkiller to quicken death of 8-year-old boy, police say

Police are investigating a claim by a Los Angeles County coroner's investigator that an anesthesiologist used a painkiller to hasten the death of a gravely injured boy to increase the likelihood his organs could be harvested without deterioration, a newspaper reported Monday.
www.foxnews.com www.foxnews.com
 
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HemeOncHopeful19 said:
From an outsider’s perspective I think it’s interesting that in the EM thread nobody mentioned diversion but in the Anesthesiologist thread multiple people mention it within the first few posts.

I know there are plenty of good reasons for it, just thought it was interesting.
Click to expand...

In most ED's, physicians don't even have access to medication storage. Nurses grab the drug, prepare it, and then waste the left-over even if a physician ends up pushing the actual drug. Diversion by ordering large doses wouldn't really work in our world. Controlled substance education in our world focuses more on patient's diverting and prescribing patterns that minimize addiction potential.
 
nimbus said:
For those who don’t remember, this was a similar case complicated by the fact that the child was a DCD donor. Fentanyl 500mcg was given to a 21kg child who was gasping for breath. I think charges were eventually dropped.


www.foxnews.com

Doctor accused of using painkiller to quicken death of 8-year-old boy, police say

Police are investigating a claim by a Los Angeles County coroner's investigator that an anesthesiologist used a painkiller to hasten the death of a gravely injured boy to increase the likelihood his organs could be harvested without deterioration, a newspaper reported Monday.
www.foxnews.com www.foxnews.com
Click to expand...
This story was even worse since it was a vindictive RN that had a bone to pick with the doctor and kept making it an issue despite the family's insistence that they felt their kid had been wonderfully taken care of.

Then that same RN sued the state and won millions.
www.dailynews.com

Former LA County coroner’s investigator gets $8.4 million in lawsuit

A Los Angeles Superior Court jury deliberated for less than a day before finding in favor of Denise Bertone, who also is a registered nurse.
www.dailynews.com www.dailynews.com
 
Ronin786 said:
This story was even worse since it was a vindictive RN that had a bone to pick with the doctor and kept making it an issue despite the family's insistence that they felt their kid had been wonderfully taken care of.

Then that same RN sued the state and won millions.
www.dailynews.com

Former LA County coroner’s investigator gets $8.4 million in lawsuit

A Los Angeles Superior Court jury deliberated for less than a day before finding in favor of Denise Bertone, who also is a registered nurse.
www.dailynews.com www.dailynews.com
Click to expand...

Yes there are a lot of crazy nurse crusades out there, because they delude themselves into thinking they are the "only ones who care"
 
nimbus said:
This is anesthesia style of care that basically nobody else does. Standing at the bedside rapidly bolusing and titrating medications until we achieve the desired effect.

I did do some palliative care as part of my chronic pain rotations in residency. We had a very dedicated director of pain at the time and we would go to a freestanding hospice, stand at the bedside, and titrate low dose ketamine and lidocaine infusions on end stage patients to get them symptom relief. This was in the mid 1990s.
Click to expand...

dipriMAN said:
This sounds quite appropriate, but even you admit that you titrate to effect as quickly as possible, certainly you don’t push milligram doses of fentanyl at a time. Even though it achieves the same effect, pushing a huge bonus all at once is just not justifiable medical legally.
Click to expand...
I watched part of the opening arguments in the trial a moment ago. It sounds like for at least one of the patients, he titrated fentanyl in 100-200mcg doses over the course of minutes as the patient was still tachypnic post palliative extubation.
 
Ronin786 said:
This story was even worse since it was a vindictive RN that had a bone to pick with the doctor and kept making it an issue despite the family's insistence that they felt their kid had been wonderfully taken care of.

Then that same RN sued the state and won millions.
www.dailynews.com

Former LA County coroner’s investigator gets $8.4 million in lawsuit

A Los Angeles Superior Court jury deliberated for less than a day before finding in favor of Denise Bertone, who also is a registered nurse.
www.dailynews.com www.dailynews.com
Click to expand...
8.4 million dollars. Imagine what we could have done with that. Brand new pediatric hospice building? International outreach program with quality hospice care provided to a country in central America perhaps? Probably best spent on this individuals vacation house in Key west
 
Ronin786 said:
This story was even worse since it was a vindictive RN that had a bone to pick with the doctor and kept making it an issue despite the family's insistence that they felt their kid had been wonderfully taken care of.

Then that same RN sued the state and won millions.
www.dailynews.com

Former LA County coroner’s investigator gets $8.4 million in lawsuit

A Los Angeles Superior Court jury deliberated for less than a day before finding in favor of Denise Bertone, who also is a registered nurse.
www.dailynews.com www.dailynews.com
Click to expand...
The Husel likely came to the attention of the hospital and law enforcement because of a nurse or other staff member who didn't agree with the doses being ordered (or maybe just didn't like him I suppose).
 
RemyMcswain said:
I watched part of the opening arguments in the trial a moment ago. It sounds like for at least one of the patients, he titrated fentanyl in 100-200mcg doses over the course of minutes as the patient was still tachypnic post palliative extubation.
Click to expand...

This makes sense to me. He is anesthesia trained so he would be very comfortable in titrating medications in this way.
 
So some of you are ok with extubating someone *with the purpose of hastening their death* but are going to split hairs about the doses used to keep them comfortable while this death is happening? In case it speeds up their death?? Which is exactly what taking them off the vent does???

I just don't get the hand-wringing over the dose. The ethical dilemma here is academic and manufactured. Give me the big dose if it ever comes to that. And if you're worried that the dose might not be big enough, give me a bigger one. The only real failure here is if the dose is too small.
 
itwasalladream said:
So some of you are ok with extubating someone *with the purpose of hastening their death* but are going to split hairs about the doses used to keep them comfortable while this death is happening? In case it speeds up their death?? Which is exactly what taking them off the vent does???

I just don't get the hand-wringing over the dose. The ethical dilemma here is academic and manufactured. Give me the big dose if it ever comes to that. And if you're worried that the dose might not be big enough, give me a bigger one. The only real failure here is if the dose is too small.
Click to expand...


Agree.


Compassionate extubation followed by compassionate symptom management.
 
So some palliative extubations the patients are ordered fentanyl patches. How many mcgs of Fentanyl are on a Duragesic patch? What if the injection was IM due to a faulty IV. Get another IV. But how is the IM dosing any different? What if you didnt have Duragesic patches?
 
narcusprince said:
So some palliative extubations the patients are ordered fentanyl patches. How many mcgs of Fentanyl are on a Duragesic patch? What if the injection was IM due to a faulty IV. Get another IV. But how is the IM dosing any different? What if you didnt have Duragesic patches?
Click to expand...
That would be malpractice unless the person is going to take months to die since that patch will take 3 days to work
 
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