Husel Trial -- NOT GUILTY

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AlmostAnMD said:
A friend of mine is a lawyer and said as much. It's probably the right thing to do but technically illegal. He thinks he'll be guilty, which will trigger some kind out outrage, then a law change in Ohio and subsequently freed.
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So an apt defense would be if I stop Levo and Vaso am I hastening a patients life?
 
rofl

today prosecution called their first opinion witness

some d-bag from vanderbilt that said all patients were opioid naïve and could have survived

got wrecked in cross on individual cases then also for about 30 minutes as cross quoted numerous Christian writings, including an article where multiple people described a patient of his as living a "hellish" life as he sat and read Psalms to her from the bible

Sad.
 
AlmostAnMD said:
rofl

today prosecution called their first opinion witness

some d-bag from vanderbilt that said all patients were opioid naïve and could have survived

got wrecked in cross on individual cases then also for about 30 minutes as cross quoted numerous Christian writings, including an article where multiple people described a patient of his as living a "hellish" life as he sat and read Psalms to her from the bible

Sad.
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The prosecutors "expert" is a tool with some impressive credentials which is all the more shocking with his profoundly non factual statements. Get a real expert on the stand. Someone who does end of life care and palliative medicine
 
coffeebythelake said:
The prosecutors "expert" is a tool with some impressive credentials which is all the more shocking with his profoundly non factual statements. Get a real expert on the stand. Someone who does end of life care and palliative medicine
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Well, he does. He's so and so professor, wrote books on palliative care, 30 years of critical care, etc...he's just super into jesus and it colors his testimony. Defense will likely call their own, I'm sure.
 
from all of these posts it sounds like this guy was trying to be compassionate and alleviate suffering in a moribund patient. What I don't get is that doesn't every hospital have comfort care or actively dying ordersets that if you follow to the max - you can give a very high escalating doses of opioids, thus avoiding any image of imprioriety?
 
AlmostAnMD said:
Well, he does. He's so and so professor, wrote books on palliative care, 30 years of critical care, etc...he's just super into jesus and it colors his testimony. Defense will likely call their own, I'm sure.
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He has the credentials behind his name but i do wonder how he practices. Are midlevels and residents doing everything and he shows up for an hour to round, as is common with old guards in ivory tower CCM? The stuff he said on the stand are laughable when you see usual clinical practice compared to what he is preaching. He wants to give patients 25 mcg of fentanyl at a time?! As an expert witness, you also don't make unverifiable and almost certainly false statements like 1000 mcg fentanyl will kill an adult elephant.
 
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Yeah I hope the defense calls a vet to comment on that

I wish a vet here would comment on that

I'm 99% sure I already know the answer though
 
I listened to some of the expert witness testimony and there is no doubt the intent was to kill the patients... whether or not it was murder or Kevorkian, that's beside the point.
69 yo F with copd, extubated that night and then after gives 1000mcg fentanyl bolus. Dead 8 minutes later.
39 M with some type of overdose presents with cerebral edema, received narcan in the ER and still comatose. No gag, fixed pupils. He was intubated already. Then goes to the ICU and gets 10mg of dilaudid, 10mg of versed and 1000mcg of fentanyl, then gets a repeat dose of all 3 meds at the same doses. Then is pronounced 30 min later.
 
n2b8me said:
I listened to some of the expert witness testimony and there is no doubt the intent was to kill the patients... whether or not it was murder or Kevorkian, that's beside the point.
69 yo F with copd, extubated that night and then after gives 1000mcg fentanyl bolus. Dead 8 minutes later.
39 M with some type of overdose presents with cerebral edema, received narcan in the ER and still comatose. No gag, fixed pupils. He was intubated already. Then goes to the ICU and gets 10mg of dilaudid, 10mg of versed and 1000mcg of fentanyl, then gets a repeat dose of all 3 meds at the same doses. Then is pronounced 30 min later.
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Can u provide some more details here regarding these patients? Dont care so much about age. But prognosis matters. Mental status.. pH... pressors use... etc. Also someone with no gag and fixed pupils make me think irreversible catastrophic brain injury involving the brain and brainstem, possibly with brain herniation.
 
n2b8me said:
I listened to some of the expert witness testimony and there is no doubt the intent was to kill the patients... whether or not it was murder or Kevorkian, that's beside the point.
69 yo F with copd, extubated that night and then after gives 1000mcg fentanyl bolus. Dead 8 minutes later.
39 M with some type of overdose presents with cerebral edema, received narcan in the ER and still comatose. No gag, fixed pupils. He was intubated already. Then goes to the ICU and gets 10mg of dilaudid, 10mg of versed and 1000mcg of fentanyl, then gets a repeat dose of all 3 meds at the same doses. Then is pronounced 30 min later.
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Shoot, maybe he just likes the number 10.
 
coffeebythelake said:
He has the credentials behind his name but i do wonder how he practices. Are midlevels and residents doing everything and he shows up for an hour to round, as is common with old guards in ivory tower CCM? The stuff he said on the stand are laughable when you see usual clinical practice compared to what he is preaching. He wants to give patients 25 mcg of fentanyl at a time?! As an expert witness, you also don't make unverifiable and almost certainly false statements like 1000 mcg fentanyl will kill an adult elephant.
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I did find this: https://www.jstor.org/stable/20094842
 
Other cases:
70 yo man from the SNF, full arrest, multiorgan system failure, gangrenous toe. Intubated. After ROSC gets the cocktail with 1000mcg fentanyl
Another case 37 F with metastatic ovarian CA, liver/kidney failure, intubated. Gets palliative extubation, followed by 500mcg fentanyl with 4 versed.
The expert just presents the take home points. It sounds like the patients were all extremely sick.
 
coffeebythelake said:
Can u provide some more details here regarding these patients? Dont care so much about age. But prognosis matters. Mental status.. pH... pressors use... etc. Also someone with no gag and fixed pupils make me think irreversible catastrophic brain injury involving the brain and brainstem, possibly with brain herniation.
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The cases start with about 1 hour 15 minutes left in the video
 
VA Hopeful Dr said:
I did find this: https://www.jstor.org/stable/20094842
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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?
 
coffeebythelake said:
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.

I think I got thr math right. Someone can double check it?
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That's about the same I got as well, though I didn't do the carfentanil to fentanyl math since I wasn't sure about that conversion.
 
n2b8me said:
39 M with some type of overdose presents with cerebral edema, received narcan in the ER and still comatose. No gag, fixed pupils. He was intubated already. Then goes to the ICU and gets 10mg of dilaudid, 10mg of versed and 1000mcg of fentanyl, then gets a repeat dose of all 3 meds at the same doses. Then is pronounced 30 min later.
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If you have a comatose brain dead person, why would they need massive doses of sedatives and narcotics?
 
n2b8me said:
Other cases:
70 yo man from the SNF, full arrest, multiorgan system failure, gangrenous toe. Intubated. After ROSC gets the cocktail with 1000mcg fentanyl
Another case 37 F with metastatic ovarian CA, liver/kidney failure, intubated. Gets palliative extubation, followed by 500mcg fentanyl with 4 versed.
The expert just presents the take home points. It sounds like the patients were all extremely sick.
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So...is there evidence that family members are in agreement to stop resuscitation, withdraw care, and make the patient "comfortable?" If that were the case...I have no problem giving 1000 mcg fentanyl. But family has to be in agreement.

It's a super large dose and I tend to believe, without extenuating circumstances, that 200 is enough.

I would be comfortable with 1000 mg fentanyl. I guarantee you I would have no pain at all.
 
n2b8me said:


The cases start with about 1 hour 15 minutes left in the video
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How much do you think he's being paid?

I'm listening to him right now. Whether we think he is right or wrong (and I tend to think that guy at 1:15 mins is giving more-or-less true testimony), its going to sound good to the jury.

If someone is brain dead with no evidence of brain activity at all except respirations, this is basically, for all intents and purposes, DEAD. The chance of being independent of ADLs in the future is about as close to 0 as you can get. 1/20,000? Maybe lower?

That being said...the doctor gave some young 39 yo M who is basically brain dead with anoxic brain injury, 1000 fentanyl, 10 dilaudid, and 10 versed. This is to a person who had no response to noxious stimuli. Why do that?

I think this doc will be found guilty.
 
thegenius said:
How much do you think he's being paid?

I'm listening to him right now. Whether we think he is right or wrong (and I tend to think that guy at 1:15 mins is giving more-or-less true testimony), its going to sound good to the jury.

If someone is brain dead with no evidence of brain activity at all except respirations, this is basically, for all intents and purposes, DEAD. The chance of being independent of ADLs in the future is about as close to 0 as you can get. 1/20,000? Maybe lower?

That being said...the doctor gave some young 39 yo M who is basically brain dead with anoxic brain injury, 1000 fentanyl, 10 dilaudid, and 10 versed. This is to a person who had no response to noxious stimuli. Why do that?

I think this doc will be found guilty.
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I think the intention of those doses is clear - to ensure a swift death.

It's too bad, I don't think Dr. Husel was trying to hurt anyone, but I do think he was acting outside the law.
 
Euthanasia is illegal in Ohio. Murder is illegal in Ohio. People that are already "dead" don't need someone to give them any medicine at all, let alone lethal doses and combinations. I think it's likely he's going to jail, for a long, long time.
 
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More Ohio framejob today

There was an hour delay when defense tried to introduce a progress note from a different patient than one in the murder. It was a progress note written by the prosecution witness, another crit care doc than Husel. He asked a few questions leading up to it that implied the patient was dying but that it was a "bad death," what happened next was stopped by objection. She started to get emotional so I assume she either euthanized the patient herself or wrote something strongly supporting it. Ohio buried whatever it was so jury did not get to see. At the end they read a text she sent to him shortly after the news broke where she basically said wtf is all this about and conveyed how sorry she was that he was getting canned.

The pharmacy director said on cross he thought mount carmel treated him unfairly. They also got him to say that he could only RETIRE if he AGREED not to be a defense witness. What a scam!!! How is any of this legal!!!!

And yes, I know euthanasia is illegal in Ohio. I do think prosecution needs to be very careful here because a giant push towards overturning that is happening with this case...

EDIT: Also, I was sad to see the jesus-enthusiast pro-life award recipient doctor not return for cross today. If they said why he was not going to finish cross I did not hear. If they didn't I suspect it wasn't going very well, but that's exactly why I wish they would have finished his cross.
 
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dpmd said:
My understanding is that carfentanil is 100x more potent so 2000 of fentanly would be the dose for a 10kg elephant according to this.
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The carfentanil dose of 2 mcg/kg for elephants appears to be correct and found in multiple veterinary sources. Need to figure out IM to IV conversion.

Carfentanil | elephantcare

elephantcare.org elephantcare.org
 
coffeebythelake said:
Can u provide some more details here regarding these patients? Dont care so much about age. But prognosis matters. Mental status.. pH... pressors use... etc. Also someone with no gag and fixed pupils make me think irreversible catastrophic brain injury involving the brain and brainstem, possibly with brain herniation.
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Unfortunately, Ohio law doesn't allow euthanasia. This patient could have respiratory effort that would've lasted for hours or it could've been permanent. Ohio would rather you struggle along with what remains of life as a vegetable being fed through a tube than to go out peacefully.

Birdstrike said:
Euthanasia is illegal in Ohio. Murder is illegal in Ohio. People that are already "dead" don't need someone to give them any medicine at all, let alone lethal doses and combinations. I think it's likely he's going to jail, for a long, long time.
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Correct. Going to be a tough case for the defendant to win. He's swimming upstream a very rapid river.
 
coffeebythelake said:
Can u provide some more details here regarding these patients? Dont care so much about age. But prognosis matters. Mental status.. pH... pressors use... etc. Also someone with no gag and fixed pupils make me think irreversible catastrophic brain injury involving the brain and brainstem, possibly with brain herniation.
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The intubated case sounds like a slam dunk to me for the prosecution.

If they haven’t been declared brain dead then they’re alive if they have a heart beat (even if they function at the level of a zucchini). Giving fentanyl and bdzs is fine if they’re on the vent, almost no matter the dose, because you have a protected airway and you just change the setting on the vent.

That an intubated pt had a respiratory arrest —> cardiac arrest after a massive dose of narcotics is difficult to defend as anything but euthanasia, barring some other clear explanation (they had a back up rate that was high enough and they just coincidentally died, which would be hard to show).

From the sounds of the cases they are presenting, these are excellent arguments for euthanasia to be legal. But it isn’t.
 
southerndoc said:
Unfortunately, Ohio law doesn't allow euthanasia. This patient could have respiratory effort that would've lasted for hours or it could've been permanent. Ohio would rather you struggle along with what remains of life as a vegetable being fed through a tube than to go out peacefully.



Correct. Going to be a tough case for the defendant to win. He's swimming upstream a very rapid river.
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I think this take is unfortunately the way this is seen and how the sentencing goes.

I just think it also exemplifies where law fails. There’s clearly a dose of fentanyl when looking at the broad strokes in a cohort of comfort care ICU patients and then generalizing that is seen as acceptable. Do I think it’s in the 12.5-25 or 50mcg range like that quack Vandy expert witness opined? Absolutely not. Is it 1,000mcg? Also obviously not. But is it 200, 250, or 500mcg? And can you honestly argue that any respiratory depression in the setting of severe acid/base disturbance and prior cardiac arrest(s) absolutely won’t contribute to the final arrest or won’t make this occur 10min or 1min sooner? I mean the pts we’re talking about here were dying promptly once extubated regardless of the fentanyl given.

So the issue is that this case will inevitably dictate to anyone giving comfort care, or more likely hospital order sets to have a hard set limit. It’ll probably be 250mcg as max bolus, which, I’ve got to say I can definitely see cases where that’s not enough.

Once again, I’m glad I don’t have that job either.
 
nimbus said:
Same. I’ve given some opioid tolerant patients 500mcg in less than 5min and they still talked to me like I haven’t given them anything.
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One time as an academic attending I gave 3x that just to prove a point.
 
Every patient is kind of different. I once had a metastatic cancer hospice patient on 30 mg dilaudid per hour at home come in wide awake complaining of severe pain but having continuous jerks (neurotoxicity from high dose dilaudid). Very distressing for family, nurses and me to watch. Family was requesting something alternate for severe pain. I doubt there was any dose of morphine or dilaudid that would have made this patient comfortable.
I called palliative they changed from dilaudid to fentanyl 250 mcg by patch. Pt then became comfortable and the jerking stopped. She passed peacefully a day later.
 
Arch Guillotti said:
One time as an academic attending I gave 3x that just to prove a point.
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I gave an alcoholic 550 mg of propofol and 100 mg of ketamine IV the other day just to sedate him for a shoulder reduction. Despite this massive dose (that was given pretty quickly), he was still groaning as I pulled on his shoulder. He awakened about 2 mins later wide awake.

On paper, it looks like I could've killed him with that dose. In reality, he wasn't even really that sedated and I manhandled his shoulder back into place.
 
Robotic Wis-Hipple said:
I mean the pts we’re talking about here were dying promptly once extubated regardless of the fentanyl given.
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I think this is the rub, and I hope defense can key in on this. I didn't listen to any of the cross on Dr. Ely (not sure he's been cross-examined yet) but per the prosecution once theese people were terminally extubated they received a hefty dose of fentanyl (1000mcg for many of the patients) and died in like a range of 8-30 minutes. If they're dying anyway, and they certainly were, I really don't know how you can blame it on the fentanyl. Yeah, it's a lot of fentanyl, but I don't know how you can definitely prove that people as sick as they were would live more than 30 minutes without pressors and an ETT.
 
Robotic Wis-Hipple said:
I think this take is unfortunately the way this is seen and how the sentencing goes.

I just think it also exemplifies where law fails. There’s clearly a dose of fentanyl when looking at the broad strokes in a cohort of comfort care ICU patients and then generalizing that is seen as acceptable. Do I think it’s in the 12.5-25 or 50mcg range like that quack Vandy expert witness opined? Absolutely not. Is it 1,000mcg? Also obviously not. But is it 200, 250, or 500mcg? And can you honestly argue that any respiratory depression in the setting of severe acid/base disturbance and prior cardiac arrest(s) absolutely won’t contribute to the final arrest or won’t make this occur 10min or 1min sooner? I mean the pts we’re talking about here were dying promptly once extubated regardless of the fentanyl given.

So the issue is that this case will inevitably dictate to anyone giving comfort care, or more likely hospital order sets to have a hard set limit. It’ll probably be 250mcg as max bolus, which, I’ve got to say I can definitely see cases where that’s not enough.

Once again, I’m glad I don’t have that job either.
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It's hard to justify, in any situation, giving someone 1000 mcg up front. It's just not standard of care nor the norm.
Lemme ask this.

Say a sickler comes in that you've never taken care of. They say they need dilaudid 8 mg IV to control their pain. You have no reason to think they are lying about their sickle cell disease. But you've never seen them before. Would you give dilaudid 8 mg IV up front? Would it matter if they look like their in distress?

I would never give that much to anyone, ever. Even if I knew the patient. It's just too much. I would start at 2 mg IV q15 and titrate up. There is no substantive harm to someone's life (besides suffering) if they experience pain for an hour longer than normal. This sickler isn't at increased risk of dying.

Husel giving that 38 yo m with anoxic brain injury pushes of 1000 fentanyl, 10 dilaudid, and 10 versed is totally NOT standard of care. And I believe that quack-a-doodle expert witness that someone with that severe anoxic brain injury probably isn't in that much pain.
 
southerndoc said:
I gave an alcoholic 550 mg of propofol and 100 mg of ketamine IV the other day just to sedate him for a shoulder reduction. Despite this massive dose (that was given pretty quickly), he was still groaning as I pulled on his shoulder. He awakened about 2 mins later wide awake.

On paper, it looks like I could've killed him with that dose. In reality, he wasn't even really that sedated and I manhandled his shoulder back into place.
Click to expand...

Had you had experience with this guy before? Did you push 550 propofol all at once? How did you titrate that up? Did he weigh 300kg?
 
southerndoc said:
I gave an alcoholic 550 mg of propofol and 100 mg of ketamine IV the other day just to sedate him for a shoulder reduction. Despite this massive dose (that was given pretty quickly), he was still groaning as I pulled on his shoulder. He awakened about 2 mins later wide awake.

On paper, it looks like I could've killed him with that dose. In reality, he wasn't even really that sedated and I manhandled his shoulder back into place.
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was he also a heavy MJ smoker? Those pt's just don't respond to propofol - I have seen 4 mg/kg IV with minimal response.
 
thegenius said:
It's hard to justify, in any situation, giving someone 1000 mcg up front. It's just not standard of care nor the norm.
Lemme ask this.

Say a sickler comes in that you've never taken care of. They say they need dilaudid 8 mg IV to control their pain. You have no reason to think they are lying about their sickle cell disease. But you've never seen them before. Would you give dilaudid 8 mg IV up front? Would it matter if they look like their in distress?

I would never give that much to anyone, ever. Even if I knew the patient. It's just too much. I would start at 2 mg IV q15 and titrate up. There is no substantive harm to someone's life (besides suffering) if they experience pain for an hour longer than normal. This sickler isn't at increased risk of dying.

Husel giving that 38 yo m with anoxic brain injury pushes of 1000 fentanyl, 10 dilaudid, and 10 versed is totally NOT standard of care. And I believe that quack-a-doodle expert witness that someone with that severe anoxic brain injury probably isn't in that much pain.
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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.
 
Giving someone with a very high opiate tolerance very high opiate doses, while still being able to breath and without dying, is not what's alleged here. The exact opposite is what is alleged.

"I gave the same dose as everyone else gives and something bad but unexpected happened once or twice," might be a persuasive defense, if true.

"I gave 10 times the normal dose everyone else gives and something bad and predictable happened, many times," is not a persuasive defense. It's a confession.
 
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thegenius said:
Had you had experience with this guy before? Did you push 550 propofol all at once? How did you titrate that up? Did he weigh 300kg?
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Yeah I’d have a heart attack if I was pushing 550 of prop all at once.
 
southerndoc said:
I gave an alcoholic 550 mg of propofol and 100 mg of ketamine IV the other day just to sedate him for a shoulder reduction. Despite this massive dose (that was given pretty quickly), he was still groaning as I pulled on his shoulder. He awakened about 2 mins later wide awake.

On paper, it looks like I could've killed him with that dose. In reality, he wasn't even really that sedated and I manhandled his shoulder back into place.
Click to expand...
I had to do something similar recently on a large, young alcohol enthusiast. I was a bit freaked out going through more than an entire bottle of propofol plus all that ketamine.
 
southerndoc said:
I gave an alcoholic 550 mg of propofol and 100 mg of ketamine IV the other day just to sedate him for a shoulder reduction. Despite this massive dose (that was given pretty quickly), he was still groaning as I pulled on his shoulder. He awakened about 2 mins later wide awake.

On paper, it looks like I could've killed him with that dose. In reality, he wasn't even really that sedated and I manhandled his shoulder back into place.
Click to expand...

Should have done an interscalene block 😉
 
Birdstrike said:
Giving someone with a very high opiate tolerance very high opiate doses, while still being able to breath and without dying, is not what's alleged here. The exact opposite is what is alleged.

"I gave the same dose as everyone else gives and something bad but unexpected happened once or twice," might be a persuasive defense, if true.

"I gave 10 times the normal dose everyone else gives and something bad and predictable happened, many times," is not a persuasive defense. It's a confession.
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What was something bad? The vent dependent patient that you just terminally extubated died?
 
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