Husel Trial -- NOT GUILTY

[Robotic Wis-Hipple]

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Honestly, the only scenario I’m not ok with is Husel getting criminal murder. I just don’t think you can prove his intent. The dosing alone doesn’t do it despite being way outside any of our comfort levels AND most of us believing those doses would hasten death in most not elephants. Iirc the patient that received the highest dose given survived for DAYS after 2500ug! I just think you have to allow for the possibility, however small it may be, that he was dealing with the most opioid tolerant pt in existence. Or it’s a charting error. Or the patients IV was SubQ and they were getting fentanyl depot’s etc.

If he gets off everything? I’m ok with that. His career practicing medicine is over.

If he gets convicted of any of the lesser yet still prison time charges…. I’m ok with that, and that’s because he quite simply practiced so far out of the boundaries that he was reckless and dangerous.

 

[Birdstrike]

The intent that must be shown for a murder charge is the intent to kill.

I think you all have demonstrated intent quite nicely on this thread. You would never give those doses, in those combinations, in un-ventilated patients who didn't have massive opiate and benzo tolerances, because you don't intend to kill your patients. If one knows the result of an action and they commit that act, it proves they intended to create the result.

Even a 3rd year medical student knows what would happen if he put twenty 100mcg fentanyl patches on a patient and had them take 10mg of a benzo, let alone IV pushes. But an experience ICU physician doesn't?

 

[neurodoc]

I asked for your specific opinion. At what dose does it become murder beyond a reasonable doubt during palliative end of life care?

Well, I gave you my honest answer to your sophistic question, so now let me try referring to a well-known joke. There are many versions of the joke, but the example here is attributed to Winston Churchill:

Churchill: Madam, would you sleep with me for five million pounds?
Socialite: My goodness, Mr. Churchill… Well, I suppose… we would have to discuss terms, of course…
Churchill: Would you sleep with me for five pounds?
Socialite: Mr. Churchill, what kind of woman do you think I am?!
Churchill: Madam, we’ve already established that. Now we are haggling about the price.

 

[thegenius]

I think you all have demonstrated intent quite nicely on this thread. You would never give those dose, in those combinations, in un-ventilated patients who didn't have massive opiate and benzo tolerances, because you don't want to kill your patients.

Even a barely passing medical student wouldn't have an opiate naive patient put on twenty 100mcg fentanyl patches and take 10mg of a benzo unless they intended them dead that day.

This is why I wish we could view years of ICU notes from Husel. If he always gave ~1000 mcg fentanly to every single patient in the ICU, for whatever reason, whether intubated or not, then I would easily come to the conclusion that he was NOT trying to hasten death or kill the patients who were brought to trial.

But I have a funny feeling in my pants that he doesn't regularly push huge doses.

 

[Birdstrike]

This is why I wish we could view years of ICU notes from Husel. If he always gave ~1000 mcg fentanly to every single patient in the ICU, for whatever reason, whether intubated or not, then I would easily come to the conclusion that he was NOT trying to hasten death or kill the patients who were brought to trial.

But I have a funny feeling in my pants that he doesn't regularly push huge doses.

That's a really good point, that no one has brought up yet on this thread and I hadn't thought to wonder about, either. And I don't recall it coming up on any of the trial summaries I've read. But it brings up a great question. What was his prescribing trend over time?

Did he always give these doses? What doses was he taught to give and was he giving in training, in fellowship? Did the doses gradually creep up over the years? Or was there a sudden shift, a sudden increase? If so, what triggered it?

That seems super, super important. If these are the same doses he was taught to give and was giving in training while under supervision, it would be incredibly helpful to his defense. If not, it would be incredibly helpful to the prosecution.

 

[neurodoc]

I don’t think drunk drivers get murder, typically the type of homicide or manslaughter charges likely on the table for Husel.

Actually some do. Here in California they can be charged with 2nd Degree Murder (so-called DUI "Watson Murder" ). Involves the concept of "implied" malice.

 

[dpmd]

I think you all have demonstrated intent quite nicely on this thread. You would never give those doses, in those combinations, in un-ventilated patients who didn't have massive opiate and benzo tolerances, because you don't intend to kill your patients.

Even a 3rd year medical student knows what would happen if he put twenty 100mcg fentanyl patches on a patient and had them take 10mg of a benzo, let alone IV pushes. But an experience ICU physician doesn't?

If one knows the result of an action and they commit that act, it proves they intended to create the result.

These patients all had reasons for suspecting/knowing the bolded was true. I have no hard upper limit on doses of opioids I am giving patients who are unventilated. For those for whom I am focusing on prolongation of life I accept a higher risk of discomfort by starting smaller doses but my starting point is likely higher than most would feel comfortable with in an opioid naive patient. But the higher doses are not given to opioid naive patients so what do I care if someone else thinks the dose is higher than standard. The standard is not law and I am allowed to proceed using my medical judgement. For patients in whom my focus is no longer prolonging life and simply wish to provide comfort I give doses that I believe will be most likely to provide that comfort even if I know it is a dose likely to cause death in an opioid naive patient because they aren't opioid naive and even if the dose is so high that I might cause death in an opioid tolerant patient the risk of death is acceptable in the pursuit of comfort. That is legally acceptable just like not giving tube feeds to a dying patient is legally acceptable while not giving nutrition to a patient you are trying to prolong life on would not be appropriate. Unless the dose is one that kills every patient in every circumstance then intent to kill can't be inferred from the selection of the dose.

 

[neurodoc]

These patients all had reasons for suspecting/knowing the bolded was true. I have no hard upper limit on doses of opioids I am giving patients who are unventilated. For those for whom I am focusing on prolongation of life I accept a higher risk of discomfort by starting smaller doses but my starting point is likely higher than most would feel comfortable with in an opioid naive patient. But the higher doses are not given to opioid naive patients so what do I care if someone else thinks the dose is higher than standard. The standard is not law and I am allowed to proceed using my medical judgement. For patients in whom my focus is no longer prolonging life and simply wish to provide comfort I give doses that I believe will be most likely to provide that comfort even if I know it is a dose likely to cause death in an opioid naive patient because they aren't opioid naive and even if the dose is so high that I might cause death in an opioid tolerant patient the risk of death is acceptable in the pursuit of comfort. That is legally acceptable just like not giving tube feeds to a dying patient is legally acceptable while not giving nutrition to a patient you are trying to prolong life on would not be appropriate. Unless the dose is one that kills every patient in every circumstance then intent to kill can't be inferred from the selection of the dose.

Your argument in defense of Husel's practice would be much more believable if he hadn't given such high bolus doses right at the time of extubation, but would have started with something more "standard" and titrated, rapidly if need be, to achieve adequate pain relief. I'm not sure at this time exactly how you would determine the presence or absence of pain in a patient he already determined (or at least told the family) was "brain dead." But that's another issue...

 

[NITRAS]

These patients all had reasons for suspecting/knowing the bolded was true. I have no hard upper limit on doses of opioids I am giving patients who are unventilated. For those for whom I am focusing on prolongation of life I accept a higher risk of discomfort by starting smaller doses but my starting point is likely higher than most would feel comfortable with in an opioid naive patient. But the higher doses are not given to opioid naive patients so what do I care if someone else thinks the dose is higher than standard. The standard is not law and I am allowed to proceed using my medical judgement. For patients in whom my focus is no longer prolonging life and simply wish to provide comfort I give doses that I believe will be most likely to provide that comfort even if I know it is a dose likely to cause death in an opioid naive patient because they aren't opioid naive and even if the dose is so high that I might cause death in an opioid tolerant patient the risk of death is acceptable in the pursuit of comfort. That is legally acceptable just like not giving tube feeds to a dying patient is legally acceptable while not giving nutrition to a patient you are trying to prolong life on would not be appropriate. Unless the dose is one that kills every patient in every circumstance then intent to kill can't be inferred from the selection of the dose.

I have been amazed at the level of tolerance of some patients. . . And how quickly it develops. I saw one guy, 30’s 7 foot guy with bad feet who didn’t have neuropathy who could Be a bit dramatic post operatively got snowed with 2 mg hydromorphone IV when I first saw him. A month later, still in the hospital I go on service and he is on 5mg IV by PCA q 20 min and 90 mg of methadone daily. And he got every single one of those PRN doses. He wasn’t even what i called sedated. I called the palliative care doc who was managing the pain medicine and was like wtf? A touch Of Narcan infusion helped with the itching. . . .

 

[Birdstrike]

These patients all had reasons for suspecting/knowing the bolded was true.

Provide a link where you saw that Husel's patients had "massive opiate and benzo tolerances."

 

[thegenius]

That's a really good point, that no one has brought up yet on this thread and I hadn't thought to wonder about, either. And I don't recall it coming up on any of the trial summaries I've read. But it brings up a great question. What was his prescribing trend over time?

Did he always give these doses? What doses was he taught to give and was he giving in training, in fellowship? Did the doses gradually creep up over the years? Or was there a sudden shift, a sudden increase? If so, what triggered it?

That seems super, super important. If these are the same doses he was taught to give and was giving in training while under supervision, it would be incredibly helpful to his defense. If not, it would be incredibly helpful to the prosecution.

I did write something like this on message #228 LMAO

Husel Trial -- NOT GUILTY

Sure, I'll venture a guess. How about something that reduces the symptoms without unwanted side effects? And what magic drug would that be that you use since it seems you disagree with what most everyone else uses?

forums.studentdoctor.net

I think it just got lost in the 750 posts.

(At the time of post #228, I thought he was an ER doc. So that's why I was bringing up patients who I think he would see in the ER.)

 

[dpmd]

Your argument in defense of Husel's practice would be much more believable if he hadn't given such high bolus doses right at the time of extubation, but would have started with something more "standard" and titrated, rapidly if need be, to achieve adequate pain relief. I'm not sure at this time exactly how you would determine the presence or absence of pain in a patient he already determined (or at least told the family) was "brain dead." But that's another issue...

I don't believe the family was ever told that patient was brain dead. He gave numerous types of dosing to numerous palliative extubation patients including many that were initially scrutinized at being outrageously high doses but further reviewed showed the doses were not outrageous for a variety of reasons such as having been given over time not as a bolus or being given a bolus dose considered too high yet the patient lived (and had signs of pain requiring repeat dosing) for days after. The patients he gave the highest doses to were on high doses prior to extubation as well. To me that shows he was trying to pick a dose that would work for that patient's comfort. Otherwise he would give the same dose to everyone. Whether it is malpractice to do what he did is a different question than is that reckless enough to be criminal. And both of those are very different than questioning if it is murder.

 

[Tigers540]

Well, I gave you my honest answer to your sophistic question, so now let me try referring to a well-known joke. There are many versions of the joke, but the example here is attributed to Winston Churchill:

Churchill: Madam, would you sleep with me for five million pounds?
Socialite: My goodness, Mr. Churchill… Well, I suppose… we would have to discuss terms, of course…
Churchill: Would you sleep with me for five pounds?
Socialite: Mr. Churchill, what kind of woman do you think I am?!
Churchill: Madam, we’ve already established that. Now we are haggling about the price.

Funny lol. But we still don’t know where murder begins since this case entirely depends on the dose to some people. I’m not sure where “standard of care” ends

 

[dpmd]

Provide a link where you saw that Husel's patients had "massive opiate and benzo tolerances."

I have posted previously regarding the patient with the diabetic foot and recent amputation before the critical illness admit and the metastatic cancer patient as well as morbidly obese patients (who due to volume of distribution may need higher doses to get initiak effect even though it can then overshoot later). Here is another article that talks about how sometimes he would give a lower dose to appease a nurse and it would not be sufficient so the nurse would have to give more. Former Mount Carmel Nurses Fight Back: 'Our Goal Was To Stop The Pain'

 

[Tigers540]

I have posted previously regarding the patient with the diabetic foot and recent amputation before the critical illness admit and the metastatic cancer patient as well as morbidly obese patients (who due to volume of distribution may need higher doses to get initiak effect even though it can then overshoot later). Here is another article that talks about how sometimes he would give a lower dose to appease a nurse and it would not be sufficient so the nurse would have to give more. Former Mount Carmel Nurses Fight Back: 'Our Goal Was To Stop The Pain'

One of the family members said her mother was taking 30mg morphine daily for years.
Another patient tested positive for carfentanil…..so there’s that.

 

[Robotic Wis-Hipple]

One of the family members said her mother was taking 30mg morphine daily for years.
Another patient tested positive for carfentanil…..so there’s that.

You sure that wasn’t the elephant that was evidence?

 

[neurodoc]

Funny lol. But we still don’t know where murder begins since this case entirely depends on the dose to some people. I’m not sure where “standard of care” ends

I offered this joke because your original question was framed as a sort of reverse "slippery slope" argument to equate massive and likely lethal doses to progressively lesser and less likely lethal doses to somehow "prove" Husel's dosing was just fine. This kind of argumentation is favored by the old-timey Sophists and modern-day lawyers. It's referred to as a logical fallacy and doesn't prove the point you were trying to make. My original answer was clear enough, but since you didn't accept it I felt you might at least like a joke that shows, in a humorous way what I just explained above. Glad you liked it.

 

[Birdstrike]

One of the family members said her mother was taking 30mg morphine daily for years.
Another patient tested positive for carfentanil…..so there’s that.

-30mg of po morphine per day would not produce significant tolerance in comparison to 2,000 mcg of fentanyl which converts to over 5,760 mg of daily po morphine.

-As far as carfentanil, I seriously doubt all of Husel's patients were daily abusers of a synthetic analog of fentanyl which is 100 times more potent than fentanyl and used an an elephant tranquilizer. In fact, it strains credulity that someone that took carfentanil, which is 10,000 more potent than morphine, would ever survive to see Husel. In fact, why would any lab even be testing for carfentanil? Was that picked as a metabolite of IV fentanyl post mortem?

You all are just getting ridiculous at this point.

 

[Tigers540]

I offered this joke because your original question was framed as a sort of reverse "slippery slope" argument to equate massive and likely lethal doses to progressively lesser and less likely lethal doses to somehow "prove" Husel's dosing was just fine. This kind of argumentation is favored by the old-timey Sophists and modern-day lawyers. It's referred to as a logical fallacy and doesn't prove the point you were trying to make. My original answer was clear enough, but since you didn't accept it I felt you might at least like a joke that shows, in a humorous way what I just explained above. Glad you liked it.

No, I was legitimately asking what the standard of care definition is and what is outside that standard enough to equate to murder.

The doctrine of double effect exists because these situations are rarely “standard”. Patients are hanging on by a thread and have wildly different tolerances. Like the defense expert said, you only get one chance at a “good death”, so it is totally within standard to preemptively treat pain or err on the upper limit due to the doctrine of double effect.

 

[Tigers540]

-30mg of po morphine per day would not produce significant tolerance in comparison to 2,000 mcg of fentanyl which converts to over 5,760 mg of daily po morphine.

-As far as carfentanil, I seriously doubt all of Husel's patients were daily abusers of a synthetic analog of fentanyl which is 100 times more potent than fentanyl and used an an elephant tranquilizer. In fact, it strains credulity that someone that took carfentanil, which is 10,000 more potent than morphine, would ever survive to see Husel. In fact, why would any lab even be testing for carfentanil? Was that picked as a metabolite of IV fentanyl post mortem?

You all are just getting ridiculous at this point.

I was simply providing evidence these weren’t all opioid naive people. And one person certainly did test positive for carfentanil. Perhaps there were trace amounts mixed into some of the other drugs, I’m not sure.

 

[Tigers540]

"The Ohio Supreme Court confirmed Thursday that it has received an affidavit of disqualification to have Judge Michael Holbrook removed from presiding over the case."

Here's the reason why the case has stalled. The judge has been a joke

 

[AlmostAnMD]

Funny lol. But we still don’t know where murder begins since this case entirely depends on the dose to some people. I’m not sure where “standard of care” ends

State put a number on it at 50 mcg fentanyl. Anyone here that has ever given more than 50 is liable for murder per state.

That witness was ridiculous for sure. But if the people in charge of putting you in prison for the rest of your life believe it to be true, don't ever give more than 50 mcg fentanyl in ohio.

Even for escalation that doc preferred more 50 mcg doses, seemed to squirm on cross when defense suggested you can titrate higher.

 

[AlmostAnMD]

"The Ohio Supreme Court confirmed Thursday that it has received an affidavit of disqualification to have Judge Michael Holbrook removed from presiding over the case."

Here's the reason why the case has stalled. The judge has been a joke

Nice. Guy clearly has a bias against defense. He also stares at baez like he wants to hit him in the face.

What happens then if that's true? Mistrial? Finish trial with new judge?

If there was a mistrial I wonder if the state would do this all over again. As I said when this first started, prosecution is definite more comfortable with pew pew pew murder, not palliative care.

 

[WilcoWorld]

State put a number on it at 50 mcg fentanyl. Anyone here that has ever given more than 50 is liable for murder per state.

Citation please.

The video I watched of the prosecution's expert witness showed him acknowledging that doses higher than 50mcg can be appropriate. That said, I haven't watched anywhere close to the whole trial.

 

[AlmostAnMD]

He did concede more than 50 could be but my point is he held 50 as standard of care max dose as a start

 

[WilcoWorld]

He did concede more than 50 could be but my point is he held 50 as standard of care max dose as a start

Is that where you get "Anyone here that has ever given more than 50 is liable for murder per state" from? Because that's not the conclusion I would take away from that testimony.

 

[neurodoc]

"The Ohio Supreme Court confirmed Thursday that it has received an affidavit of disqualification to have Judge Michael Holbrook removed from presiding over the case."

Here's the reason why the case has stalled. The judge has been a joke

I'm going to guess that the affidavit was filed by the showboating (IMHO) defense attorney Baez, possibly because the Judge refused to exclude the lesser included charges, which of course the defense most likely doesn't want to be allowed. If so, I'd call it a cheap sleazy shot. Of course I don't know for sure, but since so many folks lack of any certainty doesn't seem here seem to disqualify posts on this thread I figured I'd express my opinion on this interesting aspect of the trial.

 

[Tigers540]

I'm going to guess that the affidavit was filed by the showboating (IMHO) defense attorney Baez, possibly because the Judge refused to exclude the lesser included charges, which of course the defense most likely doesn't want to be allowed. If so, I'd call it a cheap sleazy shot. Of course I don't know for sure, but since so many folks lack of any certainty doesn't seem here seem to disqualify posts on this thread I figured I'd express my opinion on this interesting aspect of the trial.

Maybe.
But at one point the judge himself was alerted by a neutral party that he was “making faces” during defense cross exam and had to instruct the jury to disregard it.

This could be nothing. But it doesn’t surprise me either.

 

[To Infinity and Beyond]

I have watched pretty much the entire trial. From the looks of it, the judge gave the appearance of favoritism to the prosecution. Whenever the defense tried to object, the judge overruled. When the prosecutor objected, more often than not, the judge sustained. To the casual observer, it appeared biased.

 

[Birdstrike]

Delayed AGAIN. Closing was supposed to be today, Thursday after several delays. Now scheduled for Monday

Rumor has it the defense filed a motion with the State Supreme Court to have the judge taken off the case based on a comment by the judge saying the defense resting so quickly was a "tactical decision" that caught him off-guard. Same source is saying it was already rejected by the Supreme Court. (Columbus Dispatch)

 

[dadaddadaBATMAN]

Rumor has it the defense filed a motion with the State Supreme Court to have the judge taken off the case based on a comment by the judge saying the defense resting so quickly was a "tactical decision" that caught him off-guard. Same source is saying it was already rejected by the Supreme Court. (Columbus Dispatch)

Seems like a risky move to piss off the person in charge of the trial, and potentially alienate a future judge if/when there is an appeal case since this will be a known action to them as well.

But who knows, not my field. Maybe it lays the groundwork for an appeal?

 

[To Infinity and Beyond]

I was pretty surprised that the defense rested so quickly. Scuttlebutt amongst other casual observers suggest this was "brilliant". Others are questioning the wisdom of it. I do find it hard to believe the jurors will be able to completely stay away from any news about this case since it will be over two weeks when they finally reconvene.

 

[Tigers540]

I was pretty surprised that the defense rested so quickly. Scuttlebutt amongst other casual observers suggest this was "brilliant". Others are questioning the wisdom of it. I do find it hard to believe the jurors will be able to completely stay away from any news about this case since it will be over two weeks when they finally reconvene.

While I think their expert was pretty good, I do agree with the poster earlier who said the defense should have, at minimum, asked a veterinarian expert to testify to the lethal dose of fentanyl for an elephant. Dr. Ely was probably the most effective witness for the prosecution because his statements were so ridiculously extreme. 1,000mcg isnt even recognized as the lethal dose in humans, so I'm not sure how they let him get away with that statement.

For reference, the LD50 of fentanyl in dogs is 14mg/kg. 1,000mcg is not even in the ballpark of being lethal to an elephant.

citation: https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/016619s034lbl.pdf

 

[To Infinity and Beyond]

While I think their expert was pretty good, I do agree with the poster earlier who said the defense should have, at minimum, asked a veterinarian expert to testify to the lethal dose of fentanyl for an elephant. Dr. Ely was probably the most effective witness for the prosecution because his statements were so ridiculously extreme. 1,000mcg isnt even recognized as the lethal dose in humans, so I'm not sure how they let him get away with that statement.

For reference, the LD50 of fentanyl in dogs is 14mg/kg. 1,000mcg is not even in the ballpark of being lethal to an elephant.

I agree that witness may have been effective with such crazy testimony. I do think that it's possible the jury may have information overload. Some of the testimony was so dry you could light it on fire. I'm not saying that theatrics are better, but I will say the defense's one witness seemed to explain his point of view in a more interesting way.

 

[WilcoWorld]

While I think their expert was pretty good, I do agree with the poster earlier who said the defense should have, at minimum, asked a veterinarian expert to testify to the lethal dose of fentanyl for an elephant. Dr. Ely was probably the most effective witness for the prosecution because his statements were so ridiculously extreme. 1,000mcg isnt even recognized as the lethal dose in humans, so I'm not sure how they let him get away with that statement.

For reference, the LD50 of fentanyl in dogs is 14mg/kg. 1,000mcg is not even in the ballpark of being lethal to an elephant.

citation: https://www.accessdata.fda.gov/drugsa

While I think their expert was pretty good, I do agree with the poster earlier who said the defense should have, at minimum, asked a veterinarian expert to testify to the lethal dose of fentanyl for an elephant. Dr. Ely was probably the most effective witness for the prosecution because his statements were so ridiculously extreme. 1,000mcg isnt even recognized as the lethal dose in humans, so I'm not sure how they let him get away with that statement.

For reference, the LD50 of fentanyl in dogs is 14mg/kg. 1,000mcg is not even in the ballpark of being lethal to an elephant.

citation: https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/016619s034lbl.pdf

tfda_docs/label/2013/016619s034lbl.pdf

Thanks for the citation.

Providing the full sentence, as it seems relevant: "The intravenous LD50 of fentanyl is 3 mg/kg in rats, 1 mg/kg in cats, 14 mg/kg in dogs and 0.03 mg/kg in monkeys."

 

[Robotic Wis-Hipple]

Thanks for the citation.

Providing the full sentence, as it seems relevant: "The intravenous LD50 of fentanyl is 3 mg/kg in rats, 1 mg/kg in cats, 14 mg/kg in dogs and 0.03 mg/kg in monkeys."

The LD50 is all over the place to the point of not being useful. Which I think jives with what we all know about opioids and their varied pharmacokinetics in humans.

I guess if you inferred the LD50 of 30mcg/kg in primates was similar in humans that’s 2,000-3000mcg in a 70-100kg pt. Which sounds incredibly high to me for a naive patient.

 

[dpmd]

The LD50 is all over the place to the point of not being useful. Which I think jives with what we all know about opioids and their varied pharmacokinetics in humans.

I guess if you inferred the LD50 of 30mcg/kg in primates was similar in humans that’s 2,000-3000mcg in a 70-100kg pt. Which sounds incredibly high to me for a naive patient.

Just goes to show you can't really claim intent to murder based on his dose selection.

 

[Tigers540]

Thanks for the citation.

Providing the full sentence, as it seems relevant: "The intravenous LD50 of fentanyl is 3 mg/kg in rats, 1 mg/kg in cats, 14 mg/kg in dogs and 0.03 mg/kg in monkeys."

True, I used the highest one for dramatic effect. But even .03mg/kg for an average elephant is 100,000+ mcg fentanyl.

Whether thats true or not for elephants, my point is that Dr. Ely was way out of his element claiming that "1,000mcg would take down an elephant"

 

[Robotic Wis-Hipple]

Just goes to show you can't really claim intent to murder based on his dose selection.

Well, I think that’s how it could be used but I’m not sure it actually says that. How many of us have ever looked up the LD50 for fentanyl? I literally use it daily and I never had.

In addition I think intent is more personal. As a thought experiment speaking for myself; if I went off the rails and intended to euthanize a patient with fentanyl I’d think 1,000mcg’s would be enough to cause apnea in 95% of people so you’d have to say my intent was there regardless of if I used the LD50 or LD95 dose or if I merely caused anoxic brain injury.

(I STILL don’t think we can infer intent from Husel despite what I just said about my own thinking)

 

[WilcoWorld]

I'm just trying to keep the discussion honest and appropriately contextualized. If we're going to cite an LD50 in this conversation, we should probably at least mention the LD50 that's most relevant to humans (in this case, primates). Personally, the elephant testimony seems unhelpful and unnecessary to me. Husel isn't on trial for his care of elephants!

 

[VA Hopeful Dr]

True, I used the highest one for dramatic effect. But even .03mg/kg for an average elephant is 100,000+ mcg fentanyl.

Whether thats true or not for elephants, my point is that Dr. Ely was way out of his element claiming that "1,000mcg would take down an elephant"

We did the math way earlier on in this thread:

Lets do some basic calculations. Carfentanil is 30 to 100x more potent than fentanyl. Even if we extreme low ball the weight of an adult elephant to 1000 kg (they typically range from 3000 kg to 6000 kg) the dose used in this vetwrinary study to immobilize is around 2 mcg/kg which would be 2000 mcg of carfentanil. Equivalent to 60,000 mcg to 200,000 mcg fentanyl at the most conservative range. To immobilize. Not to render apneic and kill. Seems like the "expert" is orders of magnitude off.. which is kind of sloppy since he offered this false information as fact without prompting.

I think I got thr math right. Someone can double check it?

 

[Tigers540]

We did the math way earlier on in this thread:

apologies for rehashing.

 

[VA Hopeful Dr]

apologies for rehashing.

I didn't mean it like that, I was just trying to answer your question regarding the elephant dosing. Wasn't trying to call you out or anything.

 

[dadaddadaBATMAN]

I'm just trying to keep the discussion honest and appropriately contextualized. If we're going to cite an LD50 in this conversation, we should probably at least mention the LD50 that's most relevant to humans (in this case, primates). Personally, the elephant testimony seems unhelpful and unnecessary to me. Husel isn't on trial for his care of elephants!

The ld50 of fentanyl as a single agent in a healthy opiate naïve animal is fairly irrelevant here.

These patients were not healthy, did not have normal brain function, and had many other factors (infection, multi-organ dysfunction, metabolites of other sedatives, etc) which would affect the ld50.

They also likely had far higher tolerances from prolonged sedation, which complicates the question further.

And husel gave many of them multiple agents, which by itself would make ld50 of a single agent irrelevant.

Any reasonable doubt for me came from what the previous doses each patient was on prior to bolus dosing, and whether all medications were given as a single bolus or as multiple smaller boluses (and charted as single doses for convenience) which would suggest titration, though with whopping doses to start with clearly. Those were the questions that never seemed to get a clear answer to me, though with the spirals of threads of 800+ somewhat heated messages I may have missed it.

 

[To Infinity and Beyond]

I only recall the defense witness even remotely discussing titration but I could be wrong. I got bored during much of the prosecution witness rambling.

 

[Birdstrike]

The ld50 of fentanyl as a single agent in a healthy opiate naïve animal is fairly irrelevant here.

These patients were not healthy, did not have normal brain function, and had many other factors (infection, multi-organ dysfunction, metabolites of other sedatives, etc) which would affect the ld50.

They also likely had far higher tolerances from prolonged sedation, which complicates the question further.

And husel gave many of them multiple agents, which by itself would make ld50 of a single agent irrelevant.

Any reasonable doubt for me came from what the previous doses each patient was on prior to bolus dosing, and whether all medications were given as a single bolus or as multiple smaller boluses (and charted as single doses for convenience) which would suggest titration, though with whopping doses to start with clearly. Those were the questions that never seemed to get a clear answer to me, though with the spirals of threads of 800+ somewhat heated messages I may have missed it.

You bring up an important concept. Typically, a person's ability to withstand a medication harmful in overdose is proportional to their overall health. Everyone will agree that, all other things being equal, the healthier you are, the more likely you are to survive an insult, either chemical, infectious, toxicologic or otherwise. The converse is also true. The worse your general state of health, the less likely one is able to withstand an insult that might not be fatal to another.

The patients we're talking about by and large were extremely unhealthy. They were so sick, their health so tenuous, it's assumed they didn't have long to live (although we know we don’t predict well). Therefore, they were much, MUCH more likely to be harmed, killed or otherwise affected by a potentially harmful medication. They were on the ledge and didn't need much force to push them off. We all agree on that.

But all of a sudden, out of nowhere, it's claimed, "They could withstand THOUSANDS OF MICROGRAMS of fentanyl!" "Add 10 mg of versed! Even that won't kill these people! They're unkillable!"

Five minutes ago they were so sick, they were going to die without help. Now suddenly, even massive doses of drugs that stop breathing, "Couldn't possibly have killed them!"

I'm starting to think half of this thread is internet sock-puppets paid for by the defense.

 

[Tigers540]

You bring up an important concept. Typically, a person's ability to withstand a medication harmful in overdose is proportional to their overall health. Everyone will agree that, all other things being equal, the healthier you are, the more likely you are to survive an insult, either chemical, infectious, toxicologic or otherwise. The converse is also true. The worse your general state of health, the less likely one is able to withstand an insult that might not be fatal to another.

The patients we're talking about by and large were extremely unhealthy. They were so sick, their health so tenuous, it's assumed they didn't have long to live. Therefore, they were much, MUCH more likely to be harmed, killed or otherwise affected by a potentially harmful medication. They were on the ledge and didn't need much force to push them off. We all agree on that.

But all of a sudden, out of nowhere, it's claimed, "They could withstand THOUSANDS OF MICROGRAMS of fentanyl!" "Add 10 mg of versed! Even that won't kill these people! They're unkillable!"

Five minutes ago they were so sick, they were going to die without help. Now suddenly, even massive doses of drugs that stop breathing, "Couldn't possibly have killed them!"

I'm starting to think half of this thread is internet sock-puppets paid for by the defense.

I think you’re oversimplifying it quite a bit.

Placing / removing ANYTHING in the airway is one of the most stimulating things you can do to a patient. I’m always in shock that a patient will tolerate massive surgical incisions under general anesthesia, but the second I try to even place an oral airway they buck and go crazy.
I think a large portion of his dosing was to prevent reactions like that so the family wouldn’t have to see bucking/flopping/gasping. Again, there’s only one chance at a “good death. Did he overshoot just to make sure he hit that mark? Possibly. Does that make it murder? To me, no.

I see your point of view though.

 

[To Infinity and Beyond]

Again, there’s only one chance at a “good death.

Interestingly enough, the prosecution did not want this term to be brought up at all during testimony and cross. I'm not entirely sure why.

 

[dpmd]

Interestingly enough, the prosecution did not want this term to be brought up at all during testimony and cross. I'm not entirely sure why.

Because pretty everybody would want a "good death" if death is inevitable. The only reason so many people have bad ones instead is because it is hard for people to accept the inevitability. So if the jury hears that this doctor was working hard to ensure a good death it might make them less willing to convict.

 

[To Infinity and Beyond]

Because pretty everybody would want a "good death" if death is inevitable. The only reason so many people have bad ones instead is because it is hard for people to accept the inevitability. So if the jury hears that this doctor was working hard to ensure a good death it might make them less willing to convict.

I agree and figured as much. It is essentially what this is all about.