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I don't know who believes in what anymore, because as of this post, there are #700 prior, generally obfuscating ones on this topic.
Husel Trial -- NOT GUILTY
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I don't know who believes in what anymore, because as of this post, there are #700 prior, generally obfuscating ones on this topic.
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Why wasn't Husel called as a witness by the prosecution?
Would he plead the 5th or something?
Would he plead the 5th or something?
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If I were an ICU director I don't think I would hire him. What am I going to do? Vet all of his major decisions? Put a cap on the dosages he orders? I think he's done practicing ICU medicine, and probably medicine overall.
Imagine he worked in an Urgent Care. What would you do if he, over a year, prescribed 6x the number of pain Rxs or pills on average more than the other providers?
Its just surprising to me. I worked very hard to become a doctor. Why on earth would I ever give 1000 fentanyl. Why not just give 200 fentanly, 4 of versed, and go home and eat a nice meal? Just go home and relax and watch a movie. pleasure yourself to online porn. Drink a beer. But why put your professional career in serious jeopardy?
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The fifth amendment prohibits the prosecution from compelling any testimony from the defendant. The right to remain silent is not limited to refusing to answer specific questions. Unless the right is waived by the defendant they don't have to answer anything at all.
The prosecution can't call or force a defendant to testify except in specific situations that would "open the door" to compelling the defendant to take the stand. One of these would be where a defense expert (like the one who testified for the defense) said something about which the prosecution would be entitled to question the defendant. In this case, there was potentially such a situation, in that Dr. Zivot apparently spoke with Dr. Husel before he formed his expert opinion. The prosecution objected to this (since it apparently violates some Ohio rules for expert witnesses) but after discussion in chambers the judge apparently allowed it. HAD Zivot discussed his discussions with Husel in testimony (he didn't and for some reason the prosecution did not or was not allowed to ask about it on cross), the prosecution could not compel Husel to take the stand.
As to why the defense closed after calling just one witness, who knows? They might feel that they've already made their case and don't need to bore the jury with more information. Or they might not have been able to get more experts.
That Dr. Zivot didn't mention his discussions with Husel is interesting...and very likely was intended to NOT open the door to allow the prosecution to force Husel to the stand, where he could be asked all sorts of potentially damaging questions, including his opinions about euthanasia. Who knows what evidence the prosecution gathered about his email and on-line communications on social media about things like that, and perhaps other things that the proscecution might not have been allowed to bring into evidence before the jury (like his bomb-making conviction, etc.).
For these reasons I'm less inclined to believe the defense decision not to call more witnesses and not let Husel take the stand is due to their confidence that they've convincingly made their case so much as concern that if Husel takes the stand he'll wind up convicting himself.
We will see how this goes. There are a whole lot of people here who think Husel deserves to and will get off scot free. I doubt that very much, but with a jury trial anything is possible.
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If Husel is found not guilty on all accounts, does that essentially legalize euthanasia in Ohio, by precendent?
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Seeing as the jury would have to specifically decide that his actions did not amount to euthanasia in order to acquit him... No.
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If Husel is found not guilty, what message does it send to doctors?
What message dose it send, if he's found guilty?
What message dose it send, if he's found guilty?
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The message it would send to me is that it is illegal to intentionally hasten patients' deaths in the state of Ohio.
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I obviously can't speak for everyone, but my personal takeaway would be:
Not guilty: In actively dying patients, it is ok to use whatever medications / doses you feel are reasonable to ensure that the patient dies as comfortable a death (both for patient and for family observing) as possible. Use your discretion, but give whatever you want.
Guilty: In actively dying patients, giving doses of pain or sedating medications which are higher than would otherwise be used in general is not routinely permitted. You can obviously still use opioids/benzos at routine doses, and slowly uptitrating doses to effect is probably an option, but if you start approaching doses which reach some nebulous upper limit of what is acceptable, you will likely need to stop dialing things up lest you risk winding up in court. I personally probably wouldn't give anyone more than 100mcg of fent q30min without a well documented and witnessed conversation with family about the dual effect nature of opioids vis-a-vis increasing comfort + increasing risk of respiratory depression.
At the end of the day, this doesn't change much of anything for me as an ED doc as I'm not doing any sort of terminal extubation / aggressive palliative care in the ED.
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Closing statements were supposed to be Monday
Then they were supposed to be today
Now they're Wednesday. Unknown reasons are delaying them.
Open legal issues I'm aware of:
1) (possibly) one charge getting thrown out. Not sure which one. Briefly alluded to outside of Jury presence
2) what the actual charges will be. Judge last mentioned he was still considering if lesser charges are allowed.
If only murder allowed I think he walks on all counts
If lesser charges not sure since I don't even know what qualifies what lesser charge
Not giving any opioids ever to dying patients and/or severely crippling doses and let them suffer forever since I'd rather them be in pain than go to Jail
You're a pain doctor. To my knowledge, pain does not (directly) kill. But painkillers can! State prosecutors are welcome to bring their sick relatives to my ED to receive up to 25 mcg fentanyl once per hour since their own state witness said that was a good ceiling. And forget combining them with any other drugs, because "synergy."
That seems to be the case. I don't think it legalizes euthanasia at all, since a crux of the defense's argument is no euthanasia occurred.
Then they were supposed to be today
Now they're Wednesday. Unknown reasons are delaying them.
Open legal issues I'm aware of:
1) (possibly) one charge getting thrown out. Not sure which one. Briefly alluded to outside of Jury presence
2) what the actual charges will be. Judge last mentioned he was still considering if lesser charges are allowed.
If only murder allowed I think he walks on all counts
If lesser charges not sure since I don't even know what qualifies what lesser charge
Not giving any opioids ever to dying patients and/or severely crippling doses and let them suffer forever since I'd rather them be in pain than go to Jail
You're a pain doctor. To my knowledge, pain does not (directly) kill. But painkillers can! State prosecutors are welcome to bring their sick relatives to my ED to receive up to 25 mcg fentanyl once per hour since their own state witness said that was a good ceiling. And forget combining them with any other drugs, because "synergy."
That seems to be the case. I don't think it legalizes euthanasia at all, since a crux of the defense's argument is no euthanasia occurred.
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The witness said that?!? Can you please provide the actual quote? It is such a bonkers number (particularly given that 25mcg/hour is the second lowest fentanyl patch dose that's even available) that it strains credulity.
I mean, if a patient takes oxycodone 5mg every 4 hours, that's an almost equianalgesic dose of opioids.
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There's a lot of testimony I'd have to dig through but yes that's a quote
Shocking that would be endorsed by the state
He said sometimes, in rare circumstances, he could give up to 50 mcg *dramatic chord*
That was from Dr. Ely, the one happy to brag about baptizing patients in the ICU
and the last man I would ever let touch a dying family member
EDIT: while I'm ****piling on him he's also the one that said 1,000 mcg was enough to tranquilize an elephant. I'm sad defense never called a vet about that.
EDIT 2: Sorry, he didn't say tranquilize. That's my false memory. He said it would "take out" an elephant. A whole elephant. The state paid this man 10k to tell these lies under oath.
Shocking that would be endorsed by the state
He said sometimes, in rare circumstances, he could give up to 50 mcg *dramatic chord*
That was from Dr. Ely, the one happy to brag about baptizing patients in the ICU
and the last man I would ever let touch a dying family member
EDIT: while I'm ****piling on him he's also the one that said 1,000 mcg was enough to tranquilize an elephant. I'm sad defense never called a vet about that.
EDIT 2: Sorry, he didn't say tranquilize. That's my false memory. He said it would "take out" an elephant. A whole elephant. The state paid this man 10k to tell these lies under oath.
Medical expert: Husel's painkiller doses enough 'to take out an elephant'
Dr. Wesley Ely, of Vanderbilt University, testified as an expert for the prosecution on Monday in the trial of William Husel.
www.dispatch.com
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I think it was this day's testimony:
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Thanks, if I can find time I'll watch the testimony, if anyone else could help out with a time stamp of the ceiling of 25mcg/hour quote I'd appreciate it.
Phrasing matters, but if that's his verbatim testimony I'm tempted to take action against him.
Phrasing matters, but if that's his verbatim testimony I'm tempted to take action against him.
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Dude, it's things like this that look sketch. You asked the question, got very reasonable replies, then post a very similar question again. It looks like you have an angle.
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I realized the first question was a badly phrased legal question (and I’m not a lawyer). Rather than deleting it, I rephrased it into two, more reasonable (I think) questions. If you think that looks “sketch” then, you think that “looks sketch.” Whatever.
But I agree, their answers were very reasonable. I wasn't fishing for a different answer, or anything.
As far as do I “have an angle”? Yes, of course, because everyone has an angle, i.e. opinion.
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OK I was wrong, that's Ely's 2nd testimony. I've found his first day which is where I remember his more... unique practices came up. I'll watch the video and see if I can find the right spot.
The video I linked above does a call back to his first day of testimony but that's not the same as hearing it straight from him.
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That the practice of medicine is practiced by…… medical doctors. Not lawyers, bureaucrats, hospital admins, or family/layman.
That he grossly exceeded the accepted upper limit of normal for a drug and was found to have hastened death. Narcotic availability, dosing, order systems, and “providers” that will be administering these drugs in the future will change drastically.
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In what way, specifically, do you think those things will change drastically?
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Verbal orders disappear entirely. Many nurses refuse to push drugs (this case plus the recent nursing case), Pyxis/hospital systems will not allow narcotics to be dispensed without verified orders (no override) as there’s no “emergency” analgesic requirement (I don’t agree/believe that but legally or from a risk mitigation standpoint hospitals may adopt this thinking), hard limits on narcotic dosing without multi-provider/pharmacy approval.
Just off the top of my head
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Hard caps on dosing
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Maybe I'm being pollyanna-ish, but I don't see a Husel conviction being as detrimental to medicine as many others do. Did Neurosurgeons stop being able to do spine surgery after Christopher Duntsch?
On the one hand, administrative responses to bad outcomes are often ineffective overreactions. On the other hand, if I'm told I can't bolus 1000mcg of fentanyl in non-ventilated patients it will not effect my practice because I don't do that anyway.
On the one hand, administrative responses to bad outcomes are often ineffective overreactions. On the other hand, if I'm told I can't bolus 1000mcg of fentanyl in non-ventilated patients it will not effect my practice because I don't do that anyway.
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What if they place a hard limit on total dose over a time period?
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Yeah, I’m likely overreacting but I 100% can see some RNs becoming uncomfortable with drugs that can get them charged, and I can see Pyxis/hospital medication order and dispense systems becoming heavily restricted.
They won’t just limit it at 1,000ug. They’ll go 2 SD lower and enact the limits so the next case isn’t one of their docs that pushed 500ug. 250ug hard limit without multi-doc, outside non biased observer, and pharmacy acceptance is in play I’d say.
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None. Juries are random number genrators, and I don’t take much of a message from them.
As for how I would react to either verdict. I wouldn’t do what he did, so it probably won’t change my practice significantly. I am concerned he euthanized the patients. If the doses reported by the prosecution were admibistered as single bonus doses he did euthanize them. The length of time they would have survived is irrelevant.
I am uncertain how I feel about euthanasia in general. I know I don’t want my dog to suffer: if they get an incurable illness, and are suffering, I am putting them down. It causes a lot more emotional upheaval to think about doing the same thing to my mother, but i have trouble finding an argument why allowing her to suffer to the bitter end is actually better.
However, without consent it’s just murder, which is more black and white.
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On as personal level, I find it deeply troubling that someone might go to prison for actions that amount to facilitating the imminent passage of patients in peace and comfort. I agree that the systemic repercussions of his conviction may not have much of an impact on our daily lives or practice. However, just as I don't foresee myself ever being suffocated to death at the hands of police, I still am infuriated when it happens to someone else (even if they happen to be under the influence of multiple illicit substances and acting belligerently). The abuse of state power is a serious matter, even absent a slippery slope.
However, I think that there's a more troubling undertone to both this and the vanderbilt case, in which hospital administration seems to be actively encouraging and facilitating criminal prosecution of clinicians for professional (mis)actions. If this is truly a trend, I worry about the ramifications of working in a system where our interests are even more misaligned with those of our employers.
I don't think that anyone's going to prison for failing to adhere to SEP-1. But I could envision referrals to prosecution for more egregious errors such as wrong-site surgery, anaphylaxis after cross reactions, anesthesia awareness, etc.
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Are you saying that Husel was "facilitating the imminent passage of patients" or that these were "errors"?
Those two seem significantly different to me.
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Hmm…if I order ceftriaxone on a patient with a known penicillin allergy and they develop anaphylaxis, is that an error? Or am I criminally liable b/c it was intentional #007.
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He makes a very valid point. In both this and the Vanderbilt case there are serious system flaws and each system threw both providers under the bus and made them the exclusive cause of the problem, despite mountains of evidence that is not the case.
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For one of our longterm and extremely sedation tolerant patients who transitioned to comfort focused care including palliative extubation, this is the path that was taken (discussion between treating attending + med director + pharmacy about postextubation medication dosing; can't remember what the nursing involvement if any was). This was well before the Husel case. It seemed, I don't want to say excessive, but somewhat cautious at the time, but I would certainly do the same in the future and document well with this case in mind. Not necessarily thinking criminal charges would be likely in absence of any strong pattern, more so to protect from future civil suit
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Context is everything. Extensive documentation of extreme tolerance to sedatives, multiple consultations, multiple other colleagues expressly on board and in writing (not just simply unaware, looking the other way, or actively wondering 'wtf'). And like you said, and outlier, not a pattern. No trail of bodies leading to one individual.
Can you say beyond a reasonable doubt that he even gave "lethal doses of medication"? Even in a vacuum regardless of patient tolerance (some of these patients took opioids daily at home), to my knowledge there is no established lethal dose in humans, but tested in animals its astronomically high. Some estimate the lethal human dose to be 2mg, but the defense has a record of a "bad death" where Husel was unable to control a patient's pain with 2500mcg and she suffered for days after 1000mcg boluses.
And if you do believe these are lethal doses of fentanyl because it "hastened their death" (this is the phrasing used by prosecution), where is the line drawn now? 100mcg fent would undoubtedly "hasten death" in select patients, but in others it may leave them in agony.
In my humble opinion, the hospital needs a policy for palliative care if it doesn't trust the judgement of their doctors. This entire case screams of a witch hunt. He obviously gave liberal / high doses based on his prior experiences, but not a single person batted an eye at it until it became a problem for the hospital financially. If he's found guilty it's because this has been a kangaroo court with a rather unprofessional judge and "expert witnesses" saying 1000mcg fent would kill an elephant.
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I think that's a bit much. "Any"....you are allowed to give some. If this homeboy ICU doc gave 100 fentanyl and 2 versed...this thread wouldn't exist.
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Closing arguments delayed AGAIN. no public explanation. Now scheduled for Thursday. Third delay.
Any legal minded people care to even speculate? Is this, um, normal to have this kind of delay? Plea deal? Charges changing? Random usual two-sided bickering?
Any legal minded people care to even speculate? Is this, um, normal to have this kind of delay? Plea deal? Charges changing? Random usual two-sided bickering?
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If your intention is to treat pyelonephritis, and your decision is based on the very low rate of cross reactivity between PCN and ceftriaxone, then this is not criminal.
If your intention is to induce fatal anaphylaxis, then it is criminal.
This is the crux of the case: intent.
Since I can't get into Husel's head I can not know the answer for sure. I can only make inferences based on the facts presented and my own personal experience providing end of life care.
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I need a little more information, @turkeyjerky
Did you do it once, realize your error and work to keep the patient alive?
Or did you do it 20 times in a row, with 10 times the typical dose of ceftriaxone and let those 20 patients die?
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Since extubation isn't an emergency, and I think maintaining a squeaky clean reputation is important for Palliative Care (lest we loose the confidence of families and physicians), I do take the time to laboriously discuss and document my rationale for abnormally high opioid doses.
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Letting those patients die was the goal though….
You really can’t equate doses given to healthy or non-terminal patients to end of life scenarios. Just like you likely provide much higher daily totals of opioids to late stage non-surgical or post radiation cancer patients than you would the run of the mill back pain patient.
If I am comfortable pushing 250mcg of fentanyl to a severe post op pain patient and 10% of them require ventilatory support (NIPPV etc) that’s potentially an acceptable risk and/or acceptable rate of “overdose”. In end of life terminal extubation cases do you not accept that at any dose that is actually reasonably expected to provide comfort in most patients there are some that may be “overdosed” and technically have death hastened? So yes, his doses were crazy. If he had the intent to euthanize it’s criminal. If he didn’t I think there’s at least reasonable doubt that he was just used to and comfortable with providing much higher doses than anyone here with the goal of reaching comfort immediately rather than 25-50, or even 100mcg’s at a time. Is that intention criminal? Is being outside of the standard of care IMMEDIATELY a criminal offense?
I'm not a legal expert, but I wonder if there are a couple of things happening. 1) The judge is still wrestling with the inclusion of lesser charges and 2) the prosecution was caught off-guard with the short defense case and wasn't ready to close. Both incidences could be related to the unexpectedly short defense.
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And yet that would have hastened death in a vent dependent patient being extubated, which is all the prosecutor seems to care about. If the jury agrees with them do you really expect that doctors in Ohio at least are not going to be extremely careful in how they approach terminal extubations?
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Unfortunately it may cause suffering at the end of life for some. Perhaps that suffering, witnessed over time, would have the state of Ohio or other states to re-evaluate end of life care. In a perfect world it would be the people who placed the hard limit to be told at the end of life "I will do my best to control your pain but as you may well know there are limits." jk but maybe not
All that said I don't think any of this would be a problem had he titrated and documented "patient still showing signs of pain increasing dosage to alleviate pain." I am unsure as to why he did not do that. To everyone paying much more and better attention than myself--was that question asked?
I am pretty ignorant so read if you want my opinion:
1. Dr. H: lets extubate, give them a whopper combo, next patient. Guilty
2. Dr. H: math = 1g is an appropriate dose. Innocent
3. Dr. H: last 10 patients in severe pain so upping starting dose to huge amount. Grey area
4. Dr. H: patient is suffering on this dose give more. Innocent
I think #1 is the more likely reason. I'd also guess that the defense would like to exclude "lesser included charges," since getting the jury to all agree on murder would be more difficult. That's a big gamble for obvious reasons, but with the right jury it does give Husel a better shot at getting off scot free. With the wrong jury it increases his chances of leaving the courtroom a convicted murderer. I'd say from what I've read about this case that Husel seems like a risk taker who might encourage his lawyers to go for broke. We'll soon see how this plays out.
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I don’t even think it’s a risk taker/go for broke attitude in that scenario. His career is over. Done. His income generation potential is 20% what it was, unless he wins some lawsuit against the hospital.
If he gets murder it’s likely 20 years. If he gets a lesser homicide it’s 10-15yrs (I’m making up sentence length as I don’t know the legal requirement). But allowing only for murder or nothing it’s a much much higher likelihood he does no jail time. If lesser charges are allowed he’s going to the pokey for a decade. Why wouldn’t you go for the coin flip?
Why are you equating this to an error? He didn't make an error or mistake. He deliberately chose those dosages based on his anecdotal experiences. We can say they are high or "outside the standard of care", but the only thing that matters here is intent. The difference between palliative pain management and euthanasia is 100% intent. I don't know how you can prove his intent here, at least beyond a reasonable doubt. If he wanted to euthanize them or put them out of their misery he'd sneak in their room and give them 100mg of rocuronium after extubation.
And as far as "work to keep the patient alive", he coded / intubated many of these patients prior to withdrawing life support. He worked to keep all of them alive. I'm just not following your narrative.
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Guaranteed win. His lawyers are private. Trinity malpractice refused to provide him an attorney because they said he committed a crime. But if he's found not guilty he'll turn right around and bend trinity over.
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So far, every single one of you Husel defenders will say, "He's innocent. But, but, ...I ...would never give the doses he did!"
Why not?!
Not a single damn ONE of you gives 2,000mcg fentanyl boluses with Versed 10mg to any of your patients who you're not prepared to breathe for. Ever.
Why?
15 pages of thread and over 700 responses and none of you will say it, so I'm going to say it for you. You don't give any of your patients that combination of medicine because you don't want to kill them. Period. End of story. Oh, sure, you know it might not kill every patient you give it to. Some might be able to withstand it. But you know sure as hell some won't. You know sure as hell some of them would die from it.
All the rationalizations, reasonable-doubt lawyer-talky stuff isn't going to explain away the fact that you know damn well that if it was your normal practice to give your unintubaned patients 2,000mcg of fentanyl with 10mg versed chasers regularly over months and years, eventually you're going to kill someone, with 100% certainty and ZERO reasonable doubt. There would ZERO doubt of your intent.
Period. End of story. Stop it with all these mental gymnastics. Because you all know damn well if you were doing that, you'd be dangerous. People would be wispering behind your back and people would be very VERY nervous, working anywhere near you.
15 pages and y'all are still playing games.
Let's cut out the crap.
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I wouldn’t because I wouldn’t want to get funny looks from the nurses or pharmacy, or end up getting written up.
We can debate the details until the end of days but nobody can deny that these patients with multiple arrests and >20 lactates were destined for death the moment the decision was made to withdraw their breathing tubes. You could give them 1mg, 1g or 1kg of fentanyl and the difference was probably on the order of minutes, not hours.
Did he place those orders to hasten death? I don’t know, you don’t know and none of us ever will IMO. I definitely think there is an argument to be made for “who cares if the dose is too high as long as it guarantees they won’t suffer.” Was that the argument he made? Again, we will never know. The only people he might have ever made that argument to have all made immunity deals.
I wouldnt do a lot of things other people do. Luckily that's not the standard for criminal cases. I've seen other providers place a LMA for a patient with a recent history of SBO. Ive seen providers use a LMA for an 8 hour procedure. Ive seen providers give so much dilaudid that they require a jaw thrust in PACU. None of that is my style. I don't think anyone is disagreeing that 1,000mcg of fentanyl is an extreme dose or something that we wouldn't all do.
I also havent disagreed that 1,000mcg of fentanyl potentially hastened some of their deaths. But like I stated earlier, 100mcg would hasten some people's deaths. Is that murder? The key here is intent. This is a criminal trial with someone's life at stake. If you can't prove his intent beyond a reasonable doubt then it simply isnt murder.
And you also can't prove beyond a reasonable doubt that it was the fentanyl and not:
1. the removal of breathing tube on vent-dependent patients
2. the removal of maxed-out vasopressors that couldn't even maintain perfusion as it is
3. muliti-organ failure
4. pH between 6.5-6.8
5. all of the above
The defense expert said opioids have been tried during lethal injections and the equivalent of 7,000mcg fent (I believe) was used, and they stopped using it because it wasn't good enough at killing people.
I'm all for Husel being investigated by the hospital, medical board, etc and potentially taking action against his ability to practice.......but criminally speaking this case is laughable.
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