Husel Trial -- NOT GUILTY

[AlmostAnMD]

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All patients were extubated

Today most of the time was spent on the VPMA of Mount Carmel West. Direct was spent blaming husel for everything

Cross had some fun points

-VPMA had given a statement that he hugged husel and told him everything would be okay
-VPMA was fired from mount carmel. His settlement agreement terms included not testifying for the defense. This is not the first time that has occurred
-lots of issues with the "messaging" given to the public.

Some of that was confusing. Like this highlight (attached):

It implies that family members were investigated? Haven't heard anything from families yet. Would be curious if any of them were, um, more aware than they let on.

(Also, scenario 1 was "talking points for detectives", a hospital gave talking points to police).

I think the BIGGEST item on cross was a video that had to edited.

In brief, Mount Carmel went on an apology tour after this was publicly released that a doc was euthanizing patients (my words, but c'mon, that's what it is). What was interesting is was the scripting.

In one version of the video they say that lethal doses of fentanyl killed patients and a doctor was responsible. Then, Mount Carmel completed their RCA of the three main cases. After the RCA concluded no definite cause could be found (how do you charge for murder then????) Mount Carmel did not update detectives of RCA results. Instead they changed their video to words like "doses that could be high enough to kill" and changed "all" to "some" patients. Pretty big change.

Reading between the lines, Mount Carmel was more concerned with covering their ass than anything else, a part of why they had a vice president of strategy meet with prosecutors. Looks even shadier when this is a MURDER trial but Mount Carmel interviewed all "murder witnesses" first, a month before police. My take: That's where they threatened all the witnesses to make sure no one backs husel when cops come.

Oh, another fun thing on cross. The doses submitted for prosecutors were from edited reports. One report was on Tracy Young, a patient that received a single bolus of 2,5000 mcg of fentanyl and died 9 days later. She is NOT a murder charge. It's the same patient the one doc almost cried over yesterday, so I assume it was not even Husel that gave it. They also clearly stated the report only ran deaths by husel and no other doc. It's possible other docs there are euthanizing patients. On redirect none of this was challenged, unless I zoned out and someone can correct me.

 

[njac]

Have we heard yet if these were 1000mcg boluses or just cumulative doses over relatively short periods of time?

 

[Robotic Wis-Hipple]

Have we heard yet if these were 1000mcg boluses or just cumulative doses over relatively short periods of time?

There’s no way 2500mcg was given as a bolus and then the pt died 9 days later. That has to be cumulative dose.

 

[AlmostAnMD]

There’s no way 2500mcg was given as a bolus and then the pt died 9 days later. That has to be cumulative dose.

Prosecutors cut him off before further info could be given.

There is at least one extubated patient that got 1,000 mcg fentanyl and 6 or 8 of versed. Then 10 minutes later the dose was repeated. It's probably the 2500 was given at once, and possibly not even by him. The progress note that contains that info wasn't allowed to be shown by prosecutors so I assume it's something good for defense case.

 

[Robotic Wis-Hipple]

Prosecutors cut him off before further info could be given.

There is at least one extubated patient that got 1,000 mcg fentanyl and 6 or 8 of versed. Then 10 minutes later the dose was repeated. It's probably the 2500 was given at once, and possibly not even by him. The progress note that contains that info wasn't allowed to be shown by prosecutors so I assume it's something good for defense case.

If dose of 1,000mcg was REPEATED after 10min they didn’t go apneic. What kind of doses fentanyl/hr were these folks on prior to terminal extubation? 1,000mcg should cause apnea in all but the most tolerant possible, especially if repeated 10min later.

I also don’t understand how progress notes pertaining to a patient in question can be not allowed? Seems like they’re “buffing the chart” in the prosecutions favor. Shameful imo.

 

[Arch Guillotti]

Prosecutors cut him off before further info could be given.

There is at least one extubated patient that got 1,000 mcg fentanyl and 6 or 8 of versed. Then 10 minutes later the dose was repeated. It's probably the 2500 was given at once, and possibly not even by him. The progress note that contains that info wasn't allowed to be shown by prosecutors so I assume it's something good for defense case.

I have to believe that there is zero chance a nurse would give such a big dose of fentanyl at once. Then again, didn’t a nurse give vecuronium instead of versed in the MRI scanner or somesuch?

 

[WilcoWorld]

Have we heard yet if these were 1000mcg boluses or just cumulative doses over relatively short periods of time?

I saw an order for "1000 mcg fentanyl IV over 3-5 minutes" presented by the prosecution.

 

[AlmostAnMD]

I have to believe that there is zero chance a nurse would give such a big dose of fentanyl at once. Then again, didn’t a nurse give vecuronium instead of versed in the MRI scanner or somesuch?

I, uh, think you've got a lot of catching up to do. 38 staff were fired, I assume almost all if not all knew what was going on.

They were euthanizing patients for years. These were the kind of people you would do it to if you could. They just...did.

 

[Robotic Wis-Hipple]

If any of the above is true (1,000mcg BOLUS, repeated after 10min, or 2500mcg given then pt died 9 days later);

1.) those pts were on huge doses of fentanyl/versed per hr

2.) they had been on high dose fentanyl for awhile and it required massive doses to increase the blood level (fentanyl’s context sensitive half time comes into play)

 

[Arch Guillotti]

I, uh, think you've got a lot of catching up to do. 38 staff were fired, I assume almost all if not all knew what was going on.

They were euthanizing patients for years. These were the kind of people you would do it to if you could. They just...did.

lol I have obviously not been following it closely. This has all the makings of a “conspiracy”. Somebody’s head has to roll.

 

[bravotwozero]

Sounds like this is a good case for jury nullification.

On what grounds?

 

[deleted87051]

Depending on the circumstances, I think I’d prefer acid, MDMA, or psilocybin on my death bed.

 

[njac]

I have to believe that there is zero chance a nurse would give such a big dose of fentanyl at once. Then again, didn’t a nurse give vecuronium instead of versed in the MRI scanner or somesuch?

At the very hospital the prosecutions expert witness works at…

 

[thegenius]

I don’t disagree with any of that.

And no I wouldn’t give anyone 8mg of dilaudid up front. But what if that same person from your example had acute chest s/p ECMO and the decision was made to turn ECMO off and go comfort care? Would you then?

I push a lot of fentanyl. And I’ve seen a wide range. I’ve had to narcan in order to wake up/emerge and extubate a pt after 100mcgs of fentanyl that was given during surgery. I fairly regularly push 250mcg of fentanyl intraop and let me tell you, you don’t always go to a backup rate with that dose if you’re on a support mode at the time.

So let me counter your question with a question;

Consider two scenarios (numbers made up but believable imo):

Dr. A gives 250mcg fentanyl for comfort care with terminal extubation and d/c of pressor support. 25% of patients continue to have discomfort, 73% exhibit decreased clinical indicators of pain, and 2% go apneic and arrest in minutes.

Dr. B gives 1000mcgs of fentanyl for same indication. 0% of patients show clinical signs of pain and 99.9% go apneic and arrest in minutes.

Who served the patient more? No dose of fentanyl above let’s say 100-150mcg of fentanyl is guaranteed not to produce apnea in 100% of patients. So regardless of the dose you’re giving I think it’s fair to say a couple percent of the time you are hastening death by the letter of the law.

So, aside from legal and standard of care arguments (which I understand and would follow myself for self preservation purposes) I don’t see a difference, and in fact I think under-dosing is the greater travesty to the pt.

It's simply not standard of care to give gargantuan doses of opiates to opiate naive patients. It's very simple to determine if patients can detect severe pain: You do painful things to them. You pinch their skin, do a jawthrust, sternal rub etc. Most of these patients whom I referring to don't have responses to noxious stimuli. So unless they are overbreathing the vent or bucking the tube or showing some sort of distress, there isn't a need to do all that much.

The issue is not "who served the patient more". That's not the legal question. It's not even the moral question either. Most of these patients will die within 1 hr of having life support withdrawn. They will not tremendously suffer. Do what most docs will do, give 10 mg morphine, or 1 dilaudid, or something in that area and let the patient be.

 

[Southpaw]

I have to believe that there is zero chance a nurse would give such a big dose of fentanyl at once. Then again, didn’t a nurse give vecuronium instead of versed in the MRI scanner or somesuch?

Yeah that was at Vandy. She overrode the Pyxis looking for ‘versed’, saw vec, got it and gave it. Awful.

 

[southerndoc]

I have to believe that there is zero chance a nurse would give such a big dose of fentanyl at once. Then again, didn’t a nurse give vecuronium instead of versed in the MRI scanner or somesuch?

That was by mistake that vec was given instead of Versed. She typed "ve" and pulled the first drug that popped up.

We also have to wonder if there was some diversion going on. I remember a hospital near where I live had patients on extremely high doses of Dilaudid PCAs. Come to find out, there was a nurse that was drawing all the Dilaudid out of the PCA and refilling it with saline. So patients weren't getting any pain meds. (This info came from a friend who worked at the hospital.)

 

[Birdstrike]

What was something bad? The vent dependent patient that you just terminally extubated died?

If the families of patients think it's "something bad," correct or not, that's got to be acknowledged. If multiple families are walking away thinking you illegally euthanized their family member, then you've got a problem. Catastrophic communication failure, is a problem.

In any relationship, doctor/patient/family included, its important to ask what the other's viewpoint is. You don't have to agree with it. Acknowledging that it's different than yours doesn't mean it's correct. But being aware that its different can be incredibly helpful. And protective.

It looks like somebody left the impression with families that their loved ones didn't die from their medical ailments, but that they died at the hand of a doctor. Catastrophic failure of communication is a bad place to be.

 

[Southpaw]

It's simply not standard of care to give gargantuan doses of opiates to opiate naive patients. It's very simple to determine if patients can detect severe pain: You do painful things to them. You pinch their skin, do a jawthrust, sternal rub etc. Most of these patients whom I referring to don't have responses to noxious stimuli. So unless they are overbreathing the vent or bucking the tube or showing some sort of distress, there isn't a need to do all that much.

The issue is not "who served the patient more". That's not the legal question. It's not even the moral question either. Most of these patients will die within 1 hr of having life support withdrawn. They will not tremendously suffer. Do what most docs will do, give 10 mg morphine, or 1 dilaudid, or something in that area and let the patient be.

I don't disagree with a lot of what you say. Just a couple quick points - some number of those patients had been in the ICU for weeks, intubated, on fentanyl or other opiate gtts. I wouldn't classify them as opiate naive. Yes, the bolus doses were still high and not what most would do.

He's charged with 14 counts of murder. It is on the prosecution to show he had a pre-meditated plan to kill people, and his actions killed people. Like you said, those people were dead within 1 hr of terminal extubation regardless of what happened. Perhaps sooner for many of them. It is on the prosecution to prove beyond a reasonable doubt that it was the fentanyl that killed them and not their disease. I don't believe they can do that. Some of those patients lived 20-30 minutes after the initial bolus of fentanyl. Can you definitively, beyond all doubt, tell me it was the fentanyl that killed those patients and not their disease state considering how sick they all were? In my opinion absolutely not. Keep in mind one of the patients (that the prosecution tossed out because they knew it would look awful for their case) lived 9 days after high initial fentanyl boluses!

Does that mean it was perfectly fine to go around willy nilly bolusing grams of fentanyl to everyone? No. It just means in my opinion he isn't guilty of murder.

 

[WilcoWorld]

Like you said, those people were dead within 1 hr of terminal extubation regardless of what happened. Perhaps sooner for many of them.

I just want to clear up a common misconception. I staff a palliative care unit and death isn't nearly as predictable as most doctors think it is. I routinely see people live for a week with an O2 sat below 80 and a systolic below that. You swear that person on 3 pressors is going to die as soon as life support is stopped on Wednesday, then you're rounding on them on Monday wondering how the hell they're still alive.

 

[Robotic Wis-Hipple]

I just want to clear up a common misconception. I staff a palliative care unit and death isn't nearly as predictable as most doctors think it is. I routinely see people live for a week with an O2 sat below 80 and a systolic below that. You swear that person on 3 pressors is going to die as soon as life support is stopped on Wednesday, then you're rounding on them on Monday wondering how the hell they're still alive.

Hypoxemia in the 80’s is well tolerated in most people. Same with a systolic in the 80’s or means of high 40-50’s. By that I mean surviving days to weeks with either or both statuses does not surprise me.

Sometimes the noxious stimuli/pain is the only thing keeping their BP in the 80’s.

 

[Birdstrike]

I just want to clear up a common misconception. I staff a palliative care unit and death isn't nearly as predictable as most doctors think it is.

I'm not a palliative care specialist. But in my Pain fellowship we did a month of palliative care. On my first day, we had a 99-year-old terminal patient who was extubated, taken off all O2, not receiving any tube feeds, and only receiving 10cc/hr of saline sub-Q. If I asked 100 doctors how long that person would live, 99 would say she'd die in 3 days. 100 would likely say she couldn't live longer than a week. She had been alive before I came on service and she was still alive when I went off service a month later. She actually smiled when you'd come see her. Nothing is 100% in Medicine.

 

[Birdstrike]

He's charged with 14 counts of murder. It is on the prosecution to show he had a pre-meditated plan to kill people, and his actions killed people.

That's right. And all they've got to do is get one of them to stick.

 

[Robotic Wis-Hipple]

It's simply not standard of care to give gargantuan doses of opiates to opiate naive patients. It's very simple to determine if patients can detect severe pain: You do painful things to them. You pinch their skin, do a jawthrust, sternal rub etc. Most of these patients whom I referring to don't have responses to noxious stimuli. So unless they are overbreathing the vent or bucking the tube or showing some sort of distress, there isn't a need to do all that much.

The issue is not "who served the patient more". That's not the legal question. It's not even the moral question either. Most of these patients will die within 1 hr of having life support withdrawn. They will not tremendously suffer. Do what most docs will do, give 10 mg morphine, or 1 dilaudid, or something in that area and let the patient be.

This is 100% a legal question. The entire issue here is that he decided to give 2-5x the dose everyone else does. So from a purely standard of care standpoint he’s in trouble.

The communication issue that @Birdstrike described above is why he’s in trouble.

But there were probably 30-50 people in that hospital that knew those things were happening. So at one point he either had all 30-50 people afraid of him and just doing it which I would be surprised about, or they had mostly bought in. RNs weren’t grabbing 1,000mcg or 2000mcg of Fentanyl and 10mg of dilaudid and IV pushing those doses. I just don’t see it.

So the issue is they (the Prosecution) have to prove they were doing just that. And it looks like they’re trying by striking contextual progress notes.

I completely and totally agree with you that what he is charged with doing is entirely outside of the standard of care, it was foolish, and I wouldn’t do it (in particular the 1-2000 fentanyl AND 10mg of dilaudid). But I also don’t actually believe these were single boluses.

But these folks were all very sick, they were not opioid naive. And if he gave 1000mcgs of fentanyl and they survived more than 10min I don’t see how you can say the fentanyl was a lethal dose. Which I think proves one of two things; these patients could take far more narcotic than the typical Intensivist is willing to order or those doses were given in divided/titrated doses. In both cases I don’t think it’s murder.

 

[Southpaw]

I'm not a palliative care specialist. But in my Pain fellowship we did a month of palliative care. On my first day, we had a 99-year-old terminal patient who was extubated, taken off all O2, not receiving any tube feeds, and only receiving 10cc/hr of saline sub-Q. If I asked 100 doctors how long that person would live, 99 would say she'd die in 3 days. 100 would likely say she couldn't live longer than a week. She had been alive before I came on service and she was still alive when I went off service a month later. She actually smiled when you'd come see her. Nothing is 100% in Medicine.

Had she received 3 rounds of CPR, intubated on levo/epi/vaso, pH less than 7? I agree with you, nothing is 100%, but the odds are that those patients were actively dying and would be dead quickly once support stopped.

 

[coffeebythelake]

Had she received 3 rounds of CPR, intubated on levo/epi/vaso, pH less than 7? I agree with you, nothing is 100%, but the odds are that those patients were actively dying and would be dead quickly once support stopped.

Exactly, we need to zoom in on this particular subset of patients that are circling the drain. They have already died a few times and were brought back by ACLS, and only remain barely alive because aggressive measures, machines and drips keep them alive.

 

[dpmd]

If the families of patients think it's "something bad," correct or not, that's got to be acknowledged. If multiple families are walking away thinking you illegally euthanized their family member, then you've got a problem. Catastrophic communication failure, is a problem.

In any relationship, doctor/patient/family included, its important to ask what the other's viewpoint is. You don't have to agree with it. Acknowledging that it's different than yours doesn't mean it's correct. But being aware that its different can be incredibly helpful. And protective.

It looks like somebody left the impression with families that their loved ones didn't die from their medical ailments, but that they died at the hand of a doctor. Catastrophic failure of communication is a bad place to be.

My understanding is none of the families had anything bad to say until they were falsely told well after the fact that their loved ones didn't die from their medical ailments. That is on the hospital for how the investigation proceeded once one staff member made allegations.

 

[Birdstrike]

the odds are that those patients were actively dying and would be dead quickly once support stopped.

Even if their chance of long term, meaningful survival is zero, it still doesn't make euthanasia or murder legal in Ohio. Whether or not this guy broke the law, and whether or not laws related to death and dying should be changed, are two entirely different issues, are they not?

 

[Birdstrike]

...their loved ones didn't die from their medical ailments.

I have 2 questions for you:

1) Who is this "one staff member" that decided their loved ones "didn't die from their medical ailments"?

2) Was it truly only "one staff member" that thought so, is disagreement with everyone else involved?

 

[Southpaw]

Even if their chance of long term, meaningful survival is zero, it still doesn't make euthanasia or murder legal in Ohio. Whether or not this guy broke the law, and whether or not laws related to death and dying should be changed, are two entirely different issues, are they not?

Yes they are.

And to prove he’s guilty of murder they need to prove beyond all reasonable doubt it was because of the fentanyl. If all 14 patients were completely healthy, walking and talking, and he boluses them and they die within 5-10 minutes, it’s straightforward.

We currently have 14 of the sickest patients that would be found in any hospital, barely alive with massive support, and the question now is can you prove beyond a reasonable that they died because of boluses of fentanyl that aren’t standard and most don’t agree with, or did they die of the disease that required massive amounts of medical support to maintain their barely alive state? There’s not an easy straightforward answer.

 

[coffeebythelake]

Even if their chance of long term, meaningful survival is zero, it still doesn't make euthanasia or murder legal in Ohio. Whether or not this guy broke the law, and whether or not laws related to death and dying should be changed, are two entirely different issues, are they not?

Define long term. Based on available data I would expect these patients to die within minutes to hours of coming off life support. So how do you prove the fentanyl killed these patients when they die within a time frame that they would die off life support?

 

[Birdstrike]

Define long term. Based on available data I would expect these patients to die within minutes to hours of coming off life support.

If they're going to die so quickly on their own, why 10 times the normal fentanyl dose?

 

[coffeebythelake]

If so, why 10 times the normal fentanyl dose?

Would it have made a difference to you if the fentanyl was given an hour, 2 hour, 6 hours before terminal extubation vs. After extubation? Why?

 

[Birdstrike]

We currently have 14 of the sickest patients that would be found in any hospital, barely alive with massive support,... There’s not an easy straightforward answer.

"Barely alive with massive support." Just hanging on. About to flatline on their own within seconds or minutes, without intervention. Then why perform an intervention?

 

[Birdstrike]

Would it have made a difference to you if the fentanyl was given an hour, 2 hour, 6 hours before terminal extubation vs. After extubation? Why?

Yes it would matter. What was specifically done in this case?

 

[coffeebythelake]

"Barely alive with massive support." Just hanging on. About to flatline on their own within seconds or minutes, without intervention. Then why perform an intervention?

Probably because gurgling, choking, coughing, and grimacing is distressing for families even if the patient themselves is unaware of what's going on.

 

[Birdstrike]

Probably because gurgling, choking, coughing, and grimacing is distressing for families even if the patient themselves is unaware of what's going on.

What's the treatment for "gurgling, coughing and grimacing"?

 

[dpmd]

I have 2 questions for you:

1) Who is this "one staff member" that decided their loved ones "didn't die from their medical ailments"?

2) Was it truly only "one staff member" that thought so, is disagreement with everyone else involved?

The person who started all this hasn't been identified publicly as far as I know, but until the process got rolling there were a lot of staff members that agreed with what Husel was doing. The first case where doses were alleged to be higher than reasonable was in February of 2015 (dose was 400 mcg). The first report was in October of 2018 and the families were notified in December of 2018. The lawsuits and statements by patient families that they were misled didn't come until after. In Feb 2019 the hospital announced they believed some of the patients would have lived if treatment was continued and that they feel the doses were excessive regardless. It was March 2019 before they reported the involved staff to their boards and terminated people. All of this based on three formal reports (I only knew about the one before I made this post so I guess it could have been three people, but they were all very close in time so could have been one person which I suspect to be the case). Either way you have close to 40 people on board with how things were done for at least three years with onle one to three disagreeing until administration got involved.

 

[Birdstrike]

I know nothing about this Husel case other than what I've read in this thread. As far as I'm concerned, he's innocent, until proven guilty.

 

[dpmd]

What's the treatment for "gurgling, coughing and grimacing"?

During comfort care? More drugs.

 

[coffeebythelake]

What's the treatment for "gurgling, coughing and grimacing"?

You want to make a guess?
It's not to make no intervention

 

[Birdstrike]

During comfort care? More drugs.

Which ones, and how much?

 

[Birdstrike]

You want to make a guess?

Sure, I'll venture a guess. How about something that reduces the symptoms without unwanted side effects?

 

[TJRock]

Yes they are.

And to prove he’s guilty of murder they need to prove beyond all reasonable doubt it was because of the fentanyl. If all 14 patients were completely healthy, walking and talking, and he boluses them and they die within 5-10 minutes, it’s straightforward.

Not only that, they have to prove beyond all reasonable doubt that he intended to kill them rather than make them comfortable.

 

[Birdstrike]

... It was March 2019 before they reported the involved staff to their boards ...

Have any of those people been sanctioned by their medical boards?

 

[Robotic Wis-Hipple]

Yes it would matter. What was specifically done in this case?

I’m not sure we will ever know. If the prosecution can throw out patients that don’t fit their narrative and throw out progress notes that describe “dose x given and 15min later pt remains objectively uncomfortable so dose y is ordered” they aren’t looking for the truth. They’re looking for a scapegoat.

I don’t think anyone is truly making an argument that if Husel bolused 1000-2000mcg of fentanyl sometimes with 10mg dilaudid as well that it isn’t illegal. We all understand that you can’t do that to an extubated patient and expect nobody to come for you.

Many of us are making arguments that IF we are to believe that an order for 1000mcg of fentanyl was placed AND it was given as a bolus after extubation BUT said patient didn’t die within minutes then it really can’t be euthanasia/murder.

 

[TJRock]

Not only that, they have to prove beyond all reasonable doubt that he intended to kill them rather than make them comfortable.

It feels weird quoting myself, but I looked up the definition of murder under the Ohio statutes and I'm a bit surprised that he wasn't charged with reckless homicide. All the prosecutor has to do for that is to show that he had acted recklessly, not intentionally. I think standard of care could come into play with that charge. However, as charged, they have to prove that he purposely intended to cause death. I'm not sure that standard of care comes into play in a criminal setting versus a malpractice setting.

 

[coffeebythelake]

Sure, I'll venture a guess. How about something that reduces the symptoms without unwanted side effects?

I hope you realize, you have actually written nothing in this response. You "venture a guess" and described an ideal drug which does not exist. Were you going to say scopolamine? Aggressive suctioning for secretions? Face it, opioids have a place in this situation you just don't agree with the dosing.

 

[Southpaw]

Which ones, and how much?

Most would say the standard is fast acting opioid and benzo because air hunger is real and distressing. Fentanyl and versed. How much? Well for years Dr Husel, nursing, pharmacy, and admin at the hospital appeared fine with his decisions. So did the families. At some point someone decided it was all wrong.

 

[coffeebythelake]

I am most curious to see what some of our colleagues in hospice and palliative medicine think about this case.

It feels weird quoting myself, but I looked up the definition of murder under the Ohio statutes and I'm a bit surprised that he wasn't charged with reckless homicide. All the prosecutor has to do for that is to show that he had acted recklessly, not intentionally.

And Husel would argue that he wasn't acting recklessly.

I'm not sure that standard of care comes into play in a criminal setting versus a malpractice setting.

The more one deviates from the standard of care the more likely one finds themselves open to people questioning why they did something the way they did. I am not explicitly referring ti malpractice or a crime.

 

[Birdstrike]

Face it, opioids have a place in this situation you just don't agree with the dosing.

I don't agree or disagree. I'm watching.