Husel Trial -- NOT GUILTY

[Fox800]

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I can go to the ER at 3:00 AM with no symptoms because my BP was 172/88 after checking it ten times in a row and my cardiologist told me that's "stroke level blood pressure".

 

[RustedFox]

I can go to the ER at 3:00 AM with no symptoms because my BP was 172/88 after checking it ten times in a row and my cardiologist told me that's "stroke level blood pressure".

I absolutely don't understand these old folks.
They come in with urinary retention and a BP 218/103.
Place foley.
129/88.

"But muh pressure."

 

[Birdstrike]

“Gripping testimony now from the physician assistant stepdaughter of 1 of the deceased patients. She said Husel ignored her medical question and quickly ordered a huge Fentanyl dose & withdrew the breathing tube, without telling her and her mother what he was doing or why.” - Harris Meyer, journalist

 

[Birdstrike]

“…after being called back for more testimony, just said she wished she had called the police after her stepfather was extubated and died without her mother being asked to sign permission. Powerful testimony.” - Harris Meyer, journalist

 

[dpmd]

“Gripping testimony now from the physician assistant stepdaughter of 1 of the deceased patients. She said Husel ignored her medical question and quickly ordered a huge Fentanyl dose & withdrew the breathing tube, without telling her and her mother what he was doing or why.” - Harris Meyer, journalist

Are you under the impression that family members have perfect recollection of events from years prior especially once they start getting told things by the hospital and lawyers?

 

[VA Hopeful Dr]

Are you under the impression that family members have perfect recollection of events from years prior especially once they start getting told things by the hospital and lawyers?

Also, that's the journalist we banned for continually promoting himself.

 

[Robotic Wis-Hipple]

“…after being called back for more testimony, just said she wished she had called the police after her stepfather was extubated and died without her mother being asked to sign permission. Powerful testimony.” - Harris Meyer, journalist

Question for those that actually terminally extubate;

Is there a formal consent process? With paperwork? In the periop/surgical arena this certainly is required unless a true emergency. If an obtunded pt was taken to surgery without formal consent from the family/POA it’s a huge deal, considered assault or worse.

I imagine the end of life consent process is orders of magnitude more difficult and I can see discussions being had and documented in notes with little more than a tearful head nod as confirmation of acceptance of the plan. Literally signing a paper is likely very different in the average family members eyes.

But if there is a formal process, I cannot believe any Doc would do something that callous and aggressive more than once without serious repercussions.

 

[ACSurgeon]

Question for those that actually terminally extubate;

Is there a formal consent process? With paperwork? In the periop/surgical arena this certainly is required unless a true emergency. If an obtunded pt was taken to surgery without formal consent from the family/POA it’s a huge deal, considered assault or worse.

I imagine the end of life consent process is orders of magnitude more difficult and I can see discussions being had and documented in notes with little more than a tearful head nod as confirmation of acceptance of the plan. Literally signing a paper is likely very different in the average family members eyes.

But if there is a formal process, I cannot believe any Doc would do something that callous and aggressive more than once without serious repercussions.

No paper consent. Discussions are documented. We always have a nurse as a witness to the discussion when changing to DNR/DNI or comfort. It’s usually not ambiguous for the family

 

[Birdstrike]

"Powerful testimony now from a deceased patient's brother, who said Husel never spoke to him until after his brother was extubated and died, even though he was the power of attorney for his brother. That's despite the fact that the brother was there at bedside." - Harris Meyer, journalist

 

[Apollyon]

Also, that's the journalist we banned for continually promoting himself.

Wait, when did you get made Admin? When did you become "The Man"? You know, the establishment?

 

[dpmd]

Question for those that actually terminally extubate;

Is there a formal consent process? With paperwork? In the periop/surgical arena this certainly is required unless a true emergency. If an obtunded pt was taken to surgery without formal consent from the family/POA it’s a huge deal, considered assault or worse.

I imagine the end of life consent process is orders of magnitude more difficult and I can see discussions being had and documented in notes with little more than a tearful head nod as confirmation of acceptance of the plan. Literally signing a paper is likely very different in the average family members eyes.

But if there is a formal process, I cannot believe any Doc would do something that callous and aggressive more than once without serious repercussions.

There is a formal pocess of discussing with the decision maker and a requirement that specific details have to be documented for me to place the order and then another party has to confirm with the family that this was what was decided on (the nurse verifying the order) which is similar to surgical consent but no signature is required because removing an endotracheal tube never requires a signature from anyone besides the doctor. Same goes for not doing cpr. I am trying to think of any situation where not doing something to a patient or not continuing something on a patient requires a signature from anyone besides the doctor making that decision (I am excluding the times we don't do something but feel strongly it should be done in which case we make the patient sign a refusal) and the doctor then needing to document the reason for that decision. I am fairly certain the family never expressed anything in real time about not having wanted the tube to be removed and not having wanted the patient to get comfort medications because that would be a huge deal the very first time (I went to med school where years prior an unidentified patient was eventually made dnr and died despite no family ever having been found-despite a thorough search within the limits of the technology of the time-and then later family was found and made a stink over it so they wouldn't make anyone dnr without the patient being identified and next of kin notified even if the situation was clearly hopeless). But maybe we should consider making them sign a paper to protect against this sort of selective or defective recall.

 

[VA Hopeful Dr]

Wait, when did you get made Admin? When did you become "The Man"? You know, the establishment?

 

[dpmd]

"Powerful testimony now from a deceased patient's brother, who said Husel never spoke to him until after his brother was extubated and died, even though he was the power of attorney for his brother. That's despite the fact that the brother was there at bedside." - Harris Meyer, journalist

So we are to believe that the brother sat there and watched the tube be removed and died without saying anything but he didn't want that to happen?

 

[NITRAS]

Question for those that actually terminally extubate;

Is there a formal consent process? With paperwork? In the periop/surgical arena this certainly is required unless a true emergency. If an obtunded pt was taken to surgery without formal consent from the family/POA it’s a huge deal, considered assault or worse.

I imagine the end of life consent process is orders of magnitude more difficult and I can see discussions being had and documented in notes with little more than a tearful head nod as confirmation of acceptance of the plan. Literally signing a paper is likely very different in the average family members eyes.

But if there is a formal process, I cannot believe any Doc would do something that callous and aggressive more than once without serious repercussions.

In Texas, the state requires a formal consent for DNR, which can only be signed by A pt with capacity, a legal guardian, or MPOA. A surrogate family decision maker can make a patient DNR if a physician deems them terminally ill (but doesn’t have the right to revoke). This is a fairly recent change in the law. Before that, I documented who the decision maker and acted appropriately. Our forms have actually changed quite a bit. The healthcare system i work with currently actually tried really hard to keep patients who are DNR out of the ICU.

These things can very quite a bit by state and by hospital system. I have no idea what Ohio requires. I don’t need an MPOA’s permission if the patient has given clear permission.

 

[BoardingDoc]

"Powerful testimony now from a deceased patient's brother, who said Husel never spoke to him until after his brother was extubated and died, even though he was the power of attorney for his brother. That's despite the fact that the brother was there at bedside." - Harris Meyer, journalist

As @dpmd said... what? The brother was at the bedside, and Husel came in and just extubated the patient without talking to him? Barring an extremely unlikely reality, this quote seems to be either a gross misrepresentation of the facts (wouldn't be surprised given the sensationalist style of the "journalist" reporting this) or at least absurdly misleading.

 

[BoardingDoc]

Also, that's the journalist we banned for continually promoting himself.

Yeah, he was. I've edited some above posts to remove the link to his twitter feed.

 

[dpmd]

As @dpmd said... what? The brother was at the bedside, and Husel came in and just extubated the patient without talking to him? Barring an extremely unlikely reality, this quote seems to be either a gross misrepresentation of the facts (wouldn't be surprised given the sensationalist style of the "journalist" reporting this) or at least absurdly misleading.

From context clues I think this is referencing the patient James Timmons whose brother Lynn testified today and no article I found in my search for quotes indicates anything like not having had goals of care discussion. In fact I found one that describes how the patient declined abruptly and he was spoken to several times about DNR before he came in to the bedside. This is also the patient who was a long time drug addict who they describe as having had compartment syndrome induced muscle necrosis which I have seen typically in the context of neglected infection and necrotizing fascists where the patient starts out looking ok ish and then goes into multi system organ failure after you filet them so any terminal extubation in a opioid tolerant patient with a large wound is going to need some hefty doses to ensure they don't suffer. I have given some pretty crazy doses to the ones lucky enough to only get a little organ dysfunction that recovers both while intubated and after they wean from the vent.

 

[Apollyon]

Yeah, he was. I've edited some above posts to remove the link to his twitter feed.

C'mon, man, that is his style. "We report, you decide". Even though the reporter was banned, hey, his stuff still has to go up. No commentary, of course - only what the other person has written. And, the twitter link is giving attribution, man!

 

[Birdstrike]

Also, that's the journalist we banned for continually promoting himself.

Yeah, he was. I've edited some above posts to remove the link to his twitter feed.

@BoardingDoc @VA Hopeful Dr I didn’t realize it was the same person from earlier in the thread. I’ll quote other sources. He’s not banned, though.

 

[Birdstrike]

"The third witness was Geraldine Brown, who is the partner of eight years with Brandy McDonald’s mother. McDonald is one of Husel’s alleged victims. Brown described her relationship with Brandy McDonald 'like she was my own.'

Fourteen minutes after receiving what family members said was 'a lethal dose of fentanyl' ordered by Dr. Husel on Jan. 14, 2018, McDonald, 37, died, according to a wrongful death lawsuit filed by McDonald’s family.

Brown, who was asked about McDonald’s hospital care, testified that no one from McDonald’s family gave a request that Brandy McDonald receive pain medication." - NBC4i

 

[Birdstrike]

"Timmons, a 39-year-old who arrived at Mount Carmel West suffering from compartment syndrome... 'I told them to save him; I wouldn’t give them a DNR order,' Marshall [his brother] said...Marshall testified that although he eventually agreed to move his brother’s code status to do not resuscitate, he did not authorize the administration of 1,000 micrograms of fentanyl to his brother." - NBC4i

 

[Robotic Wis-Hipple]

At times these statements and reporting just sound far too crazy to believe. And that’s the problem. Do we really think Husel was coming on service at 7pm and aggressively diuresing the ICU census 1000ug of fentanyl and an FU to family members at a time? On patients he literally just met that night?

If one of your ICU colleagues came in at night and terminally extubated a pt you thought would live literally hours into his shift would you not go directly to your director if not the medical board? I mean holy crap.

And finally even if he did, the patient’s family doesn’t authorize medications. I don’t know why that’s being reported that multiple family members didn’t authorize fentanyl. If they’d agreed to comfort care/terminal extubation, then the drugs/doses given can be debated medically but the docs orders don’t need to be screened or preapproved by family.

 

[dpmd]

"Timmons, a 39-year-old who arrived at Mount Carmel West suffering from compartment syndrome... 'I told them to save him; I wouldn’t give them a DNR order,' Marshall [his brother] said...Marshall testified that although he eventually agreed to move his brother’s code status to do not resuscitate, he did not authorize the administration of 1,000 micrograms of fentanyl to his brother." - NBC4i

Deemer also testified about Timmons' death on Oct. 24, 2018. He said minutes after administering the 1,000-microgram dose as instructed by Husel, Timmons' brother called for Husel and Deemer to "do something" because Timmons was "in pain."

https://www.google.com/url?sa=t&source=web&rct=j&url=https://amp.dispatch.com/amp/9408986002&ved=2ahUKEwjx3b-doMn2AhXHk2oFHW3FBtgQFnoECAgQAQ&usg=AOvVaw20f9NuRp-JUv9d4B5i5nBF

 

[dpmd]

"The third witness was Geraldine Brown, who is the partner of eight years with Brandy McDonald’s mother. McDonald is one of Husel’s alleged victims. Brown described her relationship with Brandy McDonald 'like she was my own.'

Fourteen minutes after receiving what family members said was 'a lethal dose of fentanyl' ordered by Dr. Husel on Jan. 14, 2018, McDonald, 37, died, according to a wrongful death lawsuit filed by McDonald’s family.

Brown, who was asked about McDonald’s hospital care, testified that no one from McDonald’s family gave a request that Brandy McDonald receive pain medication." - NBC4i

Bourke said McDonald – who had ovarian cancer – came to the hospital after having trouble breathing. After being intubated and with her condition deteriorating while on a ventilator, Bourke testified how Dr. Husel remarked about how many vials of fentanyl Bourke had to pull from a medication dispensing machine in order to fill his order for 1,000 micrograms of fentanyl.

“He said ‘ oh you have to do all those little vials?’ Bourke said, adding that Husel said in the operating room the vials are larger than 100 micrograms. Husel told her the vials in the operating room were 400 microgram vials – noting that this was “the dose we give for open-heart surgery.”

Bourke said she thought if this was enough for open-heart surgery, it would be enough to address any potential pain for a palliative patient who had her ventilator removed and was going to suffocate.

Redirect Notice

From another article we learn McDonald was 280 lbs so are we really thinking that an obese woman with metastatic ovarian cancer is opioid naive and has no reason to have pain to preemptively treat?

 

[AlmostAnMD]

The "question that was ignored" according to the stepdaughter was her asking about the results of a head ct. He had just rolled into icu directly from the scanner, even by her own admission about 5-10 minutes ago.

How could husel have an answer for that question? And based off the rest of the train wreck of his body, I'm not even sure the answer is relevant after 3 or 4 codes and 20+ minutes of downtime, the head ct could have a sandwich in it for all that matters

 

[dpmd]

“Gripping testimony now from the physician assistant stepdaughter of 1 of the deceased patients. She said Husel ignored her medical question and quickly ordered a huge Fentanyl dose & withdrew the breathing tube, without telling her and her mother what he was doing or why.” - Harris Meyer, journalist

The "question that was ignored" according to the stepdaughter was her asking about the results of a head ct. He had just rolled into icu directly from the scanner, even by her own admission about 5-10 minutes ago.

How could husel have an answer for that question?

Also, using context clues the stepdaughter of the deceased who testified is Mariah havens and is a medical assistant not PA. Also from another article Havens testified she remembered Husel in Allison's room, advising them that Allison was in total organ failure and that he could made comfortable during the removal of the breathing tube.

 

[Robotic Wis-Hipple]

The "question that was ignored" according to the stepdaughter was her asking about the results of a head ct. He had just rolled into icu directly from the scanner, even by her own admission about 5-10 minutes ago.

How could husel have an answer for that question? And based off the rest of the train wreck of his body, I'm not even sure the answer is relevant after 3 or 4 codes and 20+ minutes of downtime, the head ct could have a sandwich in it for all that matters

Yes and no. Clinically, the results may not have mattered. But socially they do. Why order the test or allow it to happen if you aren’t going to share it with the patient’s family? They’re looking for any reason to have hope. So sure, it all could be fruitless, but not giving those results before terminally extubating is terrible optics to the family. They think you hid something, or gave up.

There’s definitely a skill involved in traversing these waters. Tact is necessary let alone just ethically the right thing to do. It’s already a terrible day for family, don’t seem callous or like you’re above or more omnipotent than the results of the test.

 

[dpmd]

Yes and no. Clinically, the results may not have mattered. But socially they do. Why order the test or allow it to happen if you aren’t going to share it with the patient’s family? They’re looking for any reason to have hope. So sure, it all could be fruitless, but not giving those results before terminally extubating is terrible optics to the family. They think you hid something, or gave up.

There’s definitely a skill involved in traversing these waters. Tact is necessary let alone just ethically the right thing to do. It’s already a terrible day for family, don’t seem callous or like you’re above or more omnipotent than the results of the test.

If the stepdaughter was asking a question he didn't have the answer for yet and the mother was saying to make him comfortable you would say no to the mom to wait for the CT head results to give to the stepdaughter?

 

[WheezyBaby]

If the stepdaughter was asking a question he didn't have the answer for yet and the mother was saying to make him comfortable you would say no to the mom to wait for the CT head results to give to the stepdaughter?

I'm not sure what it's like in the true community as I've only ever worked academic / semiacademic, but if I've gone through the trouble of transporting someone to CT, it takes me all of 15 minutes tops to call radiology and have them take a look at it, and I would 100% do that prior to palliatively extubating someone (this is not to say I would necessarily have gotten the CT in the first place without knowing the case). I can ensure someone's comfort on the vent for the 15 minutes and have trouble imagining a family really pushing back on that

 

[Robotic Wis-Hipple]

If the stepdaughter was asking a question he didn't have the answer for yet and the mother was saying to make him comfortable you would say no to the mom to wait for the CT head results to give to the stepdaughter?

I think you could at least make an effort to appear to be doing both. Now if mother is the decision maker and she’s saying make him comfortable and terminally extubate him then you do that. But why was the test done at all then?

Even if his goals and intent were pure he still found himself in this situation because of his methods and lack of tact…. So do with that as you wish for your own practice.

 

[dpmd]

I'm not sure what it's like in the true community as I've only ever worked academic / semiacademic, but if I've gone through the trouble of transporting someone to CT, it takes me all of 15 minutes tops to call radiology and have them take a look at it, and I would 100% do that prior to palliatively extubating someone (this is not to say I would necessarily have gotten the CT in the first place without knowing the case). I can ensure someone's comfort on the vent for the 15 minutes and have trouble imagining a family really pushing back on that

I don't think he ordered it or was involved with him getting it. That plus it being the stepdaughter not the wife asking is what makes me not worry that he didn't address it. But I get your point about it probably being something that one could call about or just take a quick peek at the images on. Though if it was a study I wouldn't have even ordered I don't know that I would do more than just explain why the results don't matter and see how they respond.

 

[WheezyBaby]

I don't think he ordered it or was involved with him getting it. That plus it being the stepdaughter not the wife asking is what makes me not worry that he didn't address it. But I get your point about it probably being something that one could call about or just take a quick peek at the images on. Though if it was a study I wouldn't have even ordered I don't know that I would do more than just explain why the results don't matter and see how they respond.

Even in that scenario I'd just get the read. Much easier than navigating the potential discussion of "well whyd the last doctor order a study that doesn't matter" even if it doesn't. But regardless I don't think that's likely going to be a key part of the case

 

[ACSurgeon]

Even in that scenario I'd just get the read. Much easier than navigating the potential discussion of "well whyd the last doctor order a study that doesn't matter" even if it doesn't. But regardless I don't think that's likely going to be a key part of the case

If a study was ordered while we are full steam ahead and the decision maker decides to halt and transition to comfort only, you better believe I wouldn’t bother discuss the results or wait for the results unless the decision maker needed said results to make the decision.

Once the decision is made to transition to comfort, The goal becomes to support the family in any way they need, and mostly stay out of their way so they can have their last moments with their loved one.

It would be weird for a family member to ask about the result and the doctor to ignore it. I would certainly get the result of the CT but if the decision maker had other reasons to decide we’re done; we’re done.

 

[WheezyBaby]

If a study was ordered while we are full steam ahead and the decision maker decides to halt and transition to comfort only, you better believe I wouldn’t bother discuss the results or wait for the results unless the decision maker needed said results to make the decision.

Once the decision is made to transition to comfort, The goal becomes to support the family in any way they need, and mostly stay out of their way so they can have their last moments with their loved one.

It would be weird for a family member to ask about the result and the doctor to ignore it. I would certainly get the result of the CT but if the decision maker had other reasons to decide we’re done; we’re done.

Sure, generally speaking. But if you're obtaining a CT head in these patients its generally for neuroprognostication (or to "prove the injury" to a family member for whatever closure they may need), and the process of transporting an intubated ICU patient to CT and back takes 3 times as long as it does to get a prelim. I said 15 minutes above but it's more realistically less than 5 minutes, I could have it before the patient's re-settled in their room. It's an inconsequential amount of time. Beyond that, there's this data you've now obtained but not factored into the decision making, say it's for a patient with ingestion and presumed anoxic brain injury and an exam consistent with brain death, you withdraw, and they have a normal head CT. Maybe it was a brain death mimic like baclofen and they just needed more time to clear. Specifically with regard to a simple head CT, I just can't picture myself withdrawing prior to at least a prelim after it had been obtained 🤷

 

[dpmd]

Sure, generally speaking. But if you're obtaining a CT head in these patients its generally for neuroprognostication (or to "prove the injury" to a family member for whatever closure they may need), and the process of transporting an intubated ICU patient to CT and back takes 3 times as long as it does to get a prelim. I said 15 minutes above but it's more realistically less than 5 minutes, I could have it before the patient's re-settled in their room. It's an inconsequential amount of time. Beyond that, there's this data you've now obtained but not factored into the decision making, say it's for a patient with ingestion and presumed anoxic brain injury and an exam consistent with brain death, you withdraw, and they have a normal head CT. Maybe it was a brain death mimic like baclofen and they just needed more time to clear. Specifically with regard to a simple head CT, I just can't picture myself withdrawing prior to at least a prelim after it had been obtained 🤷

Yeah but this was a patient with multi system organ failure who had already coded several times so it wasn't like the status of the brain was vital. Like cool yeah the brain looks perfect, too bad your heart, lungs, kidneys, and liver suck.

 

[AlmostAnMD]

Sure, generally speaking. But if you're obtaining a CT head in these patients its generally for neuroprognostication (or to "prove the injury" to a family member for whatever closure they may need), and the process of transporting an intubated ICU patient to CT and back takes 3 times as long as it does to get a prelim. I said 15 minutes above but it's more realistically less than 5 minutes, I could have it before the patient's re-settled in their room. It's an inconsequential amount of time. Beyond that, there's this data you've now obtained but not factored into the decision making, say it's for a patient with ingestion and presumed anoxic brain injury and an exam consistent with brain death, you withdraw, and they have a normal head CT. Maybe it was a brain death mimic like baclofen and they just needed more time to clear. Specifically with regard to a simple head CT, I just can't picture myself withdrawing prior to at least a prelim after it had been obtained 🤷

I see what you're saying. I'll only add that usually the ct of anoxic injury immediately after a prolonged arrest is going to be normal. Profound edema/herniation/etc is a delayed effect. Fyi the ct was normal.

But with such prolonged downtime and a lactate of 25 it would make no difference to me what was in it. As was said he didn't even order it. I mean I guess you can wait on the result as you said but it doesn't seem like a result that changes anything

 

[Birdstrike]

ATTENTION: Residents, medical students and Pre-med students

It's very important for you to know (in my opinion) that there is some extremely fringe advise being implied on this thread.

It is not legal in any state to perform euthanasia. It is not going to be perceived as legal, in any state in the United States to give 10-20 times the standard dose of a potentially fatal medicine, to people that are clinging to life. Even in states like California with the End of Life Option Act, and Oregon with the Death With Dignity Act, euthanasia is not legal. (Those involve patient ingested medications, which is not the same as physician or nurse-administered medications).

Just because a health care worker is numb to the circumstances around death and dying. Just because a patient is deemed to be "almost dead." Just because a family is in severe distress and "just wants it to end." Just because "it's going to happen anyways." Just because someone might not think it "seems as bad" as some other acts deemed more "cold blooded" in their opinion. Does not make euthanasia legal. Neither does any of that make creating the perception of possibly having performed euthanasia, or something close to it, as anything other than problematic.

Furthermore, there is no special law against euthanasia with a lighter sentence, or "slap on the wrist" because in someone's opinion, it doesn't "seem as bad" as other killings, to them. The laws the act breaks, are the same laws against all other illegal killings: Murder, manslaughter, homicide.

Ignore the catastrophically bad advice some are implying, on this thread. Regardless of the outcome of the trial of Dr. Husel (who is presumed innocent of any crime unless proven otherwise), realize that giving five, ten or twenty times the standard dose your peers are giving, of a potentially lethal drug, repeatedly over time, is always going to get you in severe trouble. It's always going to be viewed as abnormal by your peers, family members and law enforcement. It's always going to show devastatingly bad judgement. And it's always going to be stupid. Catastrophically stupid.

Even if Husel is found not guilty, all of the above will remain true.

 

[ACSurgeon]

ATTENTION: Residents, medical students and Pre-med students

It's very important for you to know (in my opinion) that there is some extremely fringe advise being implied on this thread.

It is not legal in any state to perform euthanasia. It is not going to be perceived as legal, in any state in the United States to give 10-20 times the standard dose of a potentially fatal medicine, to people that are clinging to life. Even in states like California with the End of Life Option Act, and Oregon with the Death With Dignity Act, euthanasia is not legal. (Those involve patient ingested medications, which is not the same as physician or nurse-administered medications).

Just because a health care worker is numb to the circumstances around death and dying. Just because a patient is deemed to be "almost dead." Just because a family is in severe distress and "just wants it to end." Just because "it's going to happen anyways." Just because someone might not think it "seems as bad" as some other acts deemed more "cold blooded" in their opinion. Does not make euthanasia legal. Neither does any of that make creating the perception of possibly having performed euthanasia, or something close to it, as anything other than problematic.

Furthermore, there is no special law against euthanasia with a lighter sentence, or "slap on the wrist" because in someone's opinion, it doesn't "seem as bad" as other killings, to them. The laws the act breaks, are the same laws against all other illegal killings: Murder, manslaughter, homicide.

Ignore the catastrophically bad advice some are implying, on this thread. Regardless of the outcome of the trial of Dr. Husel (who is presumed innocent of any crime unless proven otherwise), realize that giving five, ten or twenty times the standard dose your peers are giving, of a potentially lethal drug, repeatedly over time, is always going to get you in severe trouble. It's always going to be viewed as abnormal by your peers, family members and law enforcement. It's always going to show devastatingly bad judgement. And it's always going to be stupid. Catastrophically stupid.

Even if Husel is found not guilty, all of the above will remain true.

The only time I saw high doses of fentanyl was when the medical icu at my residency was using fentanyl as a sedative and analgesic. Those patients were on drips in the several hundred per hour… still, in my icu practice I’m usually giving 25-50 of fentanyl. If someone is opioid tolerant, I’m using dilaudid since the ER at some places routinely gives 1mg at a time, that seems like an ok dose to give and even double if needed.

As many have said, most dying icu patients don’t need much pain medicine at the end of life. Stopping their pressors will often lead to a quick death.

 

[dadaddadaBATMAN]

ATTENTION: Residents, medical students and Pre-med students

It's very important for you to know (in my opinion) that there is some extremely fringe advise being implied on this thread.

It is not legal in any state to perform euthanasia. It is not going to be perceived as legal, in any state in the United States to give 10-20 times the standard dose of a potentially fatal medicine, to people that are clinging to life. Even in states like California with the End of Life Option Act, and Oregon with the Death With Dignity Act, euthanasia is not legal. (Those involve patient ingested medications, which is not the same as physician or nurse-administered medications).

Just because a health care worker is numb to the circumstances around death and dying. Just because a patient is deemed to be "almost dead." Just because a family is in severe distress and "just wants it to end." Just because "it's going to happen anyways." Just because someone might not think it "seems as bad" as some other acts deemed more "cold blooded" in their opinion. Does not make euthanasia legal. Neither does any of that make creating the perception of possibly having performed euthanasia, or something close to it, as anything other than problematic.

Furthermore, there is no special law against euthanasia with a lighter sentence, or "slap on the wrist" because in someone's opinion, it doesn't "seem as bad" as other killings, to them. The laws the act breaks, are the same laws against all other illegal killings: Murder, manslaughter, homicide.

Ignore the catastrophically bad advice some are implying, on this thread. Regardless of the outcome of the trial of Dr. Husel (who is presumed innocent of any crime unless proven otherwise), realize that giving five, ten or twenty times the standard dose your peers are giving, of a potentially lethal drug, repeatedly over time, is always going to get you in severe trouble. It's always going to be viewed as abnormal by your peers, family members and law enforcement. It's always going to show devastatingly bad judgement. And it's always going to be stupid. Catastrophically stupid.

Even if Husel is found not guilty, all of the above will remain true.

I don’t think anyone is pushing back that this is extremely poor practice.

No matter the outcome of the trial Husel made serious errors both interpersonally and otherwise.

The question is whether he can be proven beyond a reasonable doubt to have been practicing euthanasia. It’s possible that the prosecution can prove this, but the evidence thus far leaves room for doubt. However, a lay person may not see the subtle questions that produce the room for this doubt. We see the trial from the outside, and don’t get full access to the mar.

I have no doubt that either in a civil trial or a board investigation that he will be roasted slowly over an open fire. As said earlier by myself and others who are uncertain of the outcome of the criminal trial, I would never do what he did.

 

[Robotic Wis-Hipple]

ATTENTION: Residents, medical students and Pre-med students

It's very important for you to know (in my opinion) that there is some extremely fringe advise being implied on this thread.

It is not legal in any state to perform euthanasia. It is not going to be perceived as legal, in any state in the United States to give 10-20 times the standard dose of a potentially fatal medicine, to people that are clinging to life. Even in states like California with the End of Life Option Act, and Oregon with the Death With Dignity Act, euthanasia is not legal. (Those involve patient ingested medications, which is not the same as physician or nurse-administered medications).

Just because a health care worker is numb to the circumstances around death and dying. Just because a patient is deemed to be "almost dead." Just because a family is in severe distress and "just wants it to end." Just because "it's going to happen anyways." Just because someone might not think it "seems as bad" as some other acts deemed more "cold blooded" in their opinion. Does not make euthanasia legal. Neither does any of that make creating the perception of possibly having performed euthanasia, or something close to it, as anything other than problematic.

Furthermore, there is no special law against euthanasia with a lighter sentence, or "slap on the wrist" because in someone's opinion, it doesn't "seem as bad" as other killings, to them. The laws the act breaks, are the same laws against all other illegal killings: Murder, manslaughter, homicide.

Ignore the catastrophically bad advice some are implying, on this thread. Regardless of the outcome of the trial of Dr. Husel (who is presumed innocent of any crime unless proven otherwise), realize that giving five, ten or twenty times the standard dose your peers are giving, of a potentially lethal drug, repeatedly over time, is always going to get you in severe trouble. It's always going to be viewed as abnormal by your peers, family members and law enforcement. It's always going to show devastatingly bad judgement. And it's always going to be stupid. Catastrophically stupid.

Even if Husel is found not guilty, all of the above will remain true.

I think this is a very fair and likely necessary disclaimer for anyone that may be reading and not truly understanding the nuance and/or admittedly pedantic discussion here.

I agree, Husel may or may not have had euthanasia as his intent, but he seems very much oblivious or maybe callous to the very fact that he appears to be doing just that to the vast majority.

 

[dpmd]

The only time I saw high doses of fentanyl was when the medical icu at my residency was using fentanyl as a sedative and analgesic. Those patients were on drips in the several hundred per hour… still, in my icu practice I’m usually giving 25-50 of fentanyl. If someone is opioid tolerant, I’m using dilaudid since the ER at some places routinely gives 1mg at a time, that seems like an ok dose to give and even double if needed.

As many have said, most dying icu patients don’t need much pain medicine at the end of life. Stopping their pressors will often lead to a quick death.

Interesting, most every patient I have had in the icu who is getting fentanyl drip has been on 100 to 300 mcg per hour. I am no longer the one that writes the orders but I do take a peek at their drips when I round.

 

[Robotic Wis-Hipple]

The only time I saw high doses of fentanyl was when the medical icu at my residency was using fentanyl as a sedative and analgesic. Those patients were on drips in the several hundred per hour… still, in my icu practice I’m usually giving 25-50 of fentanyl. If someone is opioid tolerant, I’m using dilaudid since the ER at some places routinely gives 1mg at a time, that seems like an ok dose to give and even double if needed.

As many have said, most dying icu patients don’t need much pain medicine at the end of life. Stopping their pressors will often lead to a quick death.

I am not being critical here so don’t misinterpret me. But for discussion sake let me ask something.

Opioid tolerant is opioid tolerant, it’s by and large not drug specific (excluding route of metabolism/excretion differences). Does 1-2mg of dilaudid appear equianalgesic to 25-50mcg of fentanyl in your experience? Because it probably shouldn’t given that Fentanyl is “50-100x” more potent than Morphine and Dilaudid is “10-15x”. I would say if I was comfortable pushing 2mg dilaudid I’d be comfortable pushing 150-200mcg of fentanyl.

It sounds like you’re comfortable with dilaudid, and use the context of 1mg to 2mg IVP in the ED to support your comfort and practice. Which is 100% fine. But again, for arguments sake, isn’t this what Husel was doing? In patients we assume were on decent doses of fentanyl for sedation/pain preceding the terminal extubation? He, like most anesthesiologists use fentanyl preferentially as it’s faster on faster off which we like in the OR.

I’m NOT saying 1000mcg was absolutely fine. I’m NOT saying I’d have done this. There’s a separate outside of standard of care concern as well (saying nothing of intent).

I’m just saying we all practice based on our experience/comfort and utilize the drugs we are comfortable with in addition to the local cultural factors such as your dilaudid in the ED example.

 

[AlmostAnMD]

I think this is a very fair and likely necessary disclaimer for anyone that may be reading and not truly understanding the nuance and/or admittedly pedantic discussion here.

I agree, Husel may or may not have had euthanasia as his intent, but he seems very much oblivious or maybe callous to the very fact that he appears to be doing just that to the vast majority.

Oh, I 100% think this was in his mind, prosecutors just have to prove it.

Cases like this, I think, will become important for the future. Indeed, euthanasia is illegal. As I've said earlier I think it's something that this country will have to revisit. Ohioans have such a terrible attitude towards death. Everyone over 90 with few exception is full code. Technology and medicine has advanced so much we can now spend millions a year watering vegetables. Meanwhile, everyone bitches about the cost of healthcare while a precious few use 70% of all resources (exact numbers escape me but I'm sure you can google, it's well known majority of care dollars is spent on minority of patients). At some point, I think, the pendulum needs to swing the other way towards physician discretion if families are going to be in denial. How that would look or work would of course not be like Husel's actions but I'm very dissatisfied with my current option of just doing whatever the family wants to the max. I follow a lot of my cases on the floor and I'm seeing medical ethics getting consulted more and more because families are insisting on full and aggressive care of their potato.

If anything in this broken system is going to change (slim hope, but hope keeps me going) it starts with a not guilty verdict. Or a conviction on all 14 counts and he's sentenced to like 200 years in prison for all counts, something so wild and ludicrous it triggers an outcry for legislation.

 

[dpmd]

Oh, I 100% think this was in his mind, prosecutors just have to prove it.

Cases like this, I think, will become important for the future. Indeed, euthanasia is illegal. As I've said earlier I think it's something that this country will have to revisit. Ohioans have such a terrible attitude towards death. Everyone over 90 with few exception is full code. Technology and medicine has advanced so much we can now spend millions a year watering vegetables. Meanwhile, everyone bitches about the cost of healthcare while a precious few use 70% of all resources (exact numbers escape me but I'm sure you can google, it's well known majority of care dollars is spent on minority of patients). At some point, I think, the pendulum needs to swing the other way towards physician discretion if families are going to be in denial. How that would look or work would of course not be like Husel's actions but I'm very dissatisfied with my current option of just doing whatever the family wants to the max. I follow a lot of my cases on the floor and I'm seeing medical ethics getting consulted more and more because families are insisting on full and aggressive care of their potato.

If anything in this broken system is going to change (slim hope, but hope keeps me going) it starts with a not guilty verdict. Or a conviction on all 14 counts and he's sentenced to like 200 years in prison for all counts, something so wild and ludicrous it triggers an outcry for legislation.

Just to clarify, none of that is really applicable to this trial because none of the cases involve overruling a family wishing to continue maximal aggressive life prolonging therapy.

 

[neurodoc]

The question is whether he can be proven beyond a reasonable doubt to have been practicing euthanasia. It’s possible that the prosecution can prove this, but the evidence thus far leaves room for doubt. ...

Well, if they convince the jury it was euthanasia, they could find him guilty of murder. If not, he could be found guilty of manslaughter. Both are serious felonies with serious prison time.

 

[Birdstrike]

I have no doubt that either in ... a board investigation that he will be roasted slowly over an open fire.

He already was 'roasted slowly over an open fire' during his board investigation and lost his license very quickly.

As far as the jury, I could see their thinking (this is purely speculation, opinion, not intended as fact) going like this: "I don't know for sure if his large fentanyl doses resulted in the death of each and every one of these patients. But I believe it had to in at least one or a few of them, since he was giving multiple times the standard dose. Therefore, I'll take the one (or two) cases where the dose was highest (2.000 mcg, for example) and vote guilty on any that got that dose. Not guilty (or lesser charge) on the others."

That's all it will take. One.

Whether they convict of murder, or some lesser charge like reckless homocide or manslaughter, is almost irrelevant. Either one will result of permanent loss of career, financial ruin and multiple years in a maximum security prison.

Does anyone really think he's going to walk, on each and every count, and not even a single lesser count, will stick?

 

[ACSurgeon]

Interesting, most every patient I have had in the icu who is getting fentanyl drip has been on 100 to 300 mcg per hour. I am no longer the one that writes the orders but I do take a peek at their drips when I round.

Sorry bad wording. Yes sick patients on drips will frequently need 50-150 mcg/hour or more.

Patients who are extubated and not on drips are usually getting smaller doses as blouses.

My last comment about dilaudid was just my preference for patients who need bigger doses to give them dilaudid rather than bigger doses of fentanyl pushes. It’s painful to bolus 150 of fentanyl as you’d end up needing multiple vials vs dilaudid syringes come loaded with 1 mg each. It’s especially nice when you’re trying to start small and go up, a single syringe is often enough to start somewhere and go up.

 

[dpmd]

He already was 'roasted slowly over an open fire' during his board investigation and lost his license very quickly.

As far as the jury, I could see their thinking (this is purely speculation, opinion, not intended as fact) going like this: "I don't know for sure if his large fentanyl doses resulted in the death of each and every one of these patients. But I believe it had to in at least one or a few of them, since he was giving multiple times the standard dose. Therefore, I'll take the one (or two) cases where the dose was highest (2.000 mcg, for example) and vote guilty on any that got that dose. Not guilty (or lesser charge) on the others."

That's all it will take. One.

Whether they convict of murder, or some lesser charge like reckless homocide or manslaughter, is almost irrelevant. Either one will result of permanent loss of career, financial ruin and multiple years in a maximum security prison.

Does anyone really think he's going to walk, on each and every count, and not even a single lesser count, will stick?

At least one of those high dose cases the patient lived for says after the dose though. I think that is sufficient to show that the dose is not universally fatal and therefore it is unable to prove beyond a reasonable doubt that he was not prescribing according to the doctrine of double effect based on the doses he was used to the patients he took care of requiring (due to opioid tolerance, obesity, associated painful wounds or whatever else he factored in when selecting his doses-and we have already heard that some of the patients got multiple doses over hours rather than a single huge dose further suggesting his primary desire was comfort not hastening death). Whether that is what the jury will decide is debatable but to me it would be the appropriate outcome.

 

[dpmd]

Sorry bad wording. Yes sick patients on drips will frequently need 50-150 mcg/hour or more.

Patients who are extubated and not on drips are usually getting smaller doses as blouses.

My last comment about dilaudid was just my preference for patients who need bigger doses to give them dilaudid rather than bigger doses of fentanyl pushes. It’s painful to bolus 150 of fentanyl as you’d end up needing multiple vials vs dilaudid syringes come loaded with 1 mg each. It’s especially nice when you’re trying to start small and go up, a single syringe is often enough to start somewhere and go up.

Plus if they are going to remain in pain for a while better to use a longer acting medication.

 

[ACSurgeon]

I am not being critical here so don’t misinterpret me. But for discussion sake let me ask something.

Opioid tolerant is opioid tolerant, it’s by and large not drug specific (excluding route of metabolism/excretion differences). Does 1-2mg of dilaudid appear equianalgesic to 25-50mcg of fentanyl in your experience? Because it probably shouldn’t given that Fentanyl is “50-100x” more potent than Morphine and Dilaudid is “10-15x”. I would say if I was comfortable pushing 2mg dilaudid I’d be comfortable pushing 150-200mcg of fentanyl.

It sounds like you’re comfortable with dilaudid, and use the context of 1mg to 2mg IVP in the ED to support your comfort and practice. Which is 100% fine. But again, for arguments sake, isn’t this what Husel was doing? In patients we assume were on decent doses of fentanyl for sedation/pain preceding the terminal extubation? He, like most anesthesiologists use fentanyl preferentially as it’s faster on faster off which we like in the OR.

I’m NOT saying 1000mcg was absolutely fine. I’m NOT saying I’d have done this. There’s a separate outside of standard of care concern as well (saying nothing of intent).

I’m just saying we all practice based on our experience/comfort and utilize the drugs we are comfortable with in addition to the local cultural factors such as your dilaudid in the ED example.

My post was unclear. 25-50 mcg of fentanyl are examples of small doses of narcotics. People who need big doses I usually go to dilaudid instead. 1 mg of dilaudid is much more than 50 of fentanyl.