by Gary C. King
“And did you know what she meant when she said ‘succinylcholine’? What is succinylcholine to you?”
“Oh, absolutely,” Seher responded. “Succinylcholine is a paralytic drug. It’s a type of curare. There are several drugs in that category that we use in the hospital as a paralytic agent.”
Seher said that when he indicated to her that she needed to call the police, Ramey had been reluctant to do so at first. Seher recounted what Ramey had testified to about not wanting to go to the police because “she had just gone through a divorce, and I think she sort of had it with the legal system.” He said that he continued to urge her to contact the police.
“I said, ‘You know, this isn’t like a traffic violation.... This is a real crime. You have to report it. You have to call.’”
“Did you take any steps yourself once you heard what she had spoken with Mr. Higgs about and then after she had told you everything?” Hicks asked. “What did you do?”
“I called my partner, Dr. Richard Ganchan,” Seher said. “And there’s two large cardiology groups in town, and we take care of the sickest of the sick people. So, if somebody is ill, there’s a fifty-fifty chance we’re taking care of them. So I called my partner . . . and I said, ‘Are we taking care of Kathy Augustine?’”
“And did you find out if you were, in fact, taking care of her?”
“He confirmed the fact that we were indeed physicians consulting on her case.”
“Did you give any specific instructions to . . . Dr. Ganchan?”
“We had a very brief conversation,” Seher responded. “I said, ‘Get a succinylcholine level now.’ And he said—after a pause—‘Got it,’ and hung up the phone.”
Chapter 24
“The state calls Dr. Paul Mailander,” Washoe County Deputy District Attorney Christopher Hicks said.
After being sworn in, Dr. Mailander took the witness stand and attempted to get comfortable. In response to questions from Hicks, Mailander explained that he worked as an anesthesiologist for Sierra Anesthesia in Reno and nearby Sparks, where he performed surgical anesthesiology.
“If you could please explain for the jury what schooling you had that led you to where you are today,” Hicks asked.
Mailander explained that he earned a bachelor’s degree in medical engineering from the University of California at Berkeley, and a master’s degree in biomedical engineering from the same university. He went to medical school at Case Western Reserve University in Cleveland, Ohio, after which he did two years of general surgical residency at Cleveland’s Lutheran Medical Center, three years of general anesthesia residency at the Cleveland Clinic, and a year of postanesthesia fellowship in cardiothoracic anesthesia and pain management, also at Cleveland Clinic. He had been practicing in Reno since that time. He also had served as chair of the Department of Anesthesia at Washoe Medical Center from 1994 to 1996.
“Your Honor, I would offer Dr. Mailander as an expert in anesthesia,” Hicks proclaimed.
The defense team stipulated and made no objection.
In response to a question from Hicks about the role of the anesthesiologist, Mailander explained that it was his job to take patients who are about to undergo surgery and render them comfortable and safe so that they could tolerate the stress and duress of surgery. Of course, he said, this was accomplished through the use of a variety of medications that place the patients in a hypnotic, or unconscious, state in which they would not be aware of what was happening to them. He said that the patients were carefully monitored during the surgery for any changes in their vital signs, and to ensure that they remained unconscious. When the procedure had been completed, he said, his job involved bringing them back to a conscious state and monitoring them through their recovery as they woke up.
“We have a variety of tools,” Mailander explained, “but, basically, on any given general anesthetic, for example, where a patient is going to sleep, we use a rock-bottom minimum of about seven different medications. And that’s for someone who is having a simple procedure, who is essentially healthy and doesn’t have any outstanding medical conditions.”
He said that an anesthesiologist will typically sedate patients preoperatively to alleviate any anxiety that they might be experiencing. To keep patients safe, their blood pressure is checked frequently, as is their pulse rate, oxygen saturation levels, and carbon dioxide levels. The patients’ EKGs are monitored closely throughout their operations, and their motor responses are checked.
“Then we give them medications [that] will put the patient into a state of what we call hypnosis,” he said. “Most people . . . call it going to sleep. Most people are familiar with sodium pentothal . . . a sleeping medication that makes you basically fall into a state of unconsciousness.”
Once a patient is asleep, he explained, the anesthetic needs to be maintained so that the patient will not wake up on the operating table. Sodium pentothal, which has no pain-relieving properties, works clinically for only approximately two to three minutes.
“We have to give the patient other medications to keep them comfortable for the duration of the procedure,” he testified. “And, if needed, we give them medication to keep them immobile so they can’t move. Surprisingly, if you’re asleep, but not very deeply asleep, if someone does something painful to you, you’re going to twitch or move. So by giving you some medications [that] either make you more comfortable, or in some case simply prevent you from moving, it makes things safer and faster for the surgeon and for the patient.”
“Now, are one of those drugs that will prevent a patient from moving called succinylcholine?” Hicks asked.
“Yes,” Mailander replied.
“If you would, please explain to the jury what, in a nutshell, succinylcholine is and what it is used for.”
“It is a clear, colorless liquid that we inject almost exclusively intravenously into our patients,” the doctor responded. “Virtually all of the anesthetic agents we use work on your nerves and your brain primarily. The muscle relaxants, including succinylcholine, work at the level of the muscle. It’s the one medication, or one of very few, that actually works at the level of the muscle itself.
“Whenever you move a muscle purposefully,” he continued, “making a fist, moving your hand . . . your brain sends a nerve impulse to your muscles, and there’s a chemical released at the nerves on to the muscle [that] triggers the muscle to twitch. So I tell my hand to make a fist, the nerves stimulate the muscle fibers with chemical reaction, and I make a fist.... The muscle fibers all pull together.
“Succinylcholine is a medication [that] looks very much like the chemical that is the neurotransmitter, from the nerve to the muscle. And it is very avidly bound on to the receptors of the muscle. And by binding to the receptors of the muscle it blocks the neurotransmitter from working. As a result, the muscle fibers do not work. And that medication will stay in effect clinically on the muscle, making the muscle unable to respond to nerve stimulus until it is metabolized. And then it goes away and . . . regains normal function.”
Mailander explained that succinylcholine is used in numerous types of surgery situations, and is commonly used in the intubation of a patient. He explained that succinylcholine wasn’t the only medication used for that purpose, but that it was one of the earliest discovered. Because it has certain side effects that are not beneficial for the patient, its clinical use is avoided whenever possible.
“But in a circumstance where we need to place a breathing tube into a patient relatively quickly,” Mailander explained, “succinylcholine is still the fastest-acting muscle relaxant that we use clinically. By giving it to the patient, they can be rendered motionless within about a minute of its injection, and then we can open their mouths and place a breathing tube basically into the top of their windpipe at that point.”
“I just want to make sure I understand correctly,” Hicks said. “If a person is administered succinylcholine, they are paralyzed, correct?”
“That is correct.”
“Can they move anything?”
“Any muscle you can voluntarily control, your breathing, your eyelids, shrugging your shoulders, anything you voluntarily control, will be paralyzed and unable to move. Your heart will work. Your intestines will work. Other muscles that you don’t normally control voluntarily will continue to work. But the skeletal muscles are what we call them, all will stop functioning, and the patient will be unable to move.”
“So I assume your brain is not a voluntary muscle,” Hicks said, generating mild laughter from the gallery. “It’s always working. Is that right?”
“Well, your brain is not a muscle. In most cases.”
“In some of us, it is,” Hicks said, taking another stab at creating levity. “So it doesn’t affect your brain?”
“No, it does not.”
“And you said it doesn’t affect your heart.”
“No, it does not, either.”
“So, if someone was administered solely succinylcholine, would they be totally awake during that state of paralysis?” Hicks asked.
“Yes, they would.”
“Again, sir, assuming someone is administered succinylcholine. . . if there was no airway intervention, something to help them breathe, what would happen?”
“They basically would lose the capacity to breathe voluntarily, and it would be incumbent upon us to maintain an airway and either lift the patient’s chin, make sure there’s no obstruction, and then using a bag and a mask, which we use in surgery paramount to forcefully ventilate the patient for him or herself. So we would be driving oxygen and other anesthetic acid into the patient’s lungs for their benefit and on their behalf until they can regain their own muscle tone.”
“And if that didn’t happen?”
“The patient would not breathe,” Mailander responded. “And then it’s a matter of how much oxygen they have in their system and how long a wait before they amass enough carbon dioxide. Their blood is still circulating, so there is CO2, carbon dioxide, accumulation in the lungs as well during a period of paralysis. So it’s a matter of how long you want to wait before the patient starts suffering the ill effects of too much carbon dioxide and too little oxygen.”
“And if that happens?”
“You start basically having a condition that we call ischemia, which is a lack of oxygen, and you start suffering organ damage.”
“To what organs?”
“Primarily to the most sensitive ones,” Mailander responded. “And the nerves and the brain are the most sensitive organs to oxygen deprivation. They will be the first ones to suffer irreversible damage.”
“After the nerves in the brain, are there any other organs that would suffer damage?”
“Well, all organs will eventually, but the actively metabolic organs. The liver, the kidneys are very sensitive as well. Not as sensitive as the nerves, but the kidneys and liver will start to show signs of ill effect. And eventually the muscles will, too.”
He explained that the heart is a highly metabolic organ, a muscle that is constantly working, but that in the absence of oxygen and nutrition from the blood, it will start to suffer ill effects as well and will begin to fail.
“You had indicated that this particular drug is primarily administered intravenously,” Hicks reminded the witness.
“Yes.”
“Are you aware if it can be administered intramuscularly?”
“It can,” Mailander affirmed. “And most of the anesthesia books [and] most . . . anesthesia instructors will tell you that in a pinch, if you have to get someone paralyzed and there is no intravenous access, you can give them a shot in a muscle. It will take a little longer to act, but it will act, and the patient will be paralyzed, and you have to move accordingly.”
Dr. Mailander said that he had not seen firsthand succinylcholine administered intramuscularly because, he explained, if a patient needed to be put to sleep emergently without an IV line, there were other anesthetic and sleeping medications, such as the hypnotics that he had discussed earlier, that could render the patient unconscious without paralyzing him or her. Paralyzing a patient without knowing that you can establish an airway is a major risk factor, he said. One of the circumstances in which a physician would not be able to administer succinylcholine intravenously would be when dealing with an uncooperative patient in an emergency situation.
“Now, if you were to administer succinylcholine intravenously, how quickly would it take effect?” Hicks asked.
“In a normal, healthy individual, normal circulation, in under a minute,” Mailander responded.
“And intramuscularly?”
“About three minutes.”
“Again, back to my hypothetical of a patient who is not being cooperative, and you have to administer it intramuscularly,” Hicks said. “Would that three-to-five-minute window speed up if the person was still fighting?”
“Well, the faster someone moves, the faster their blood circulates, the faster the medication is picked up in the muscle and circulated through their system, yes,” Mailander responded. “So, if someone is struggling, then medication takes effect faster.”
“Are you familiar with a drug called etomidate?” Hicks asked.
“Yes.”
“Is there any reason why a person would have etomidate at their home?”
“I can’t think of a good therapeutic reason, no. I can’t think of a reason.”
“What is etomidate?” Hicks asked.
“It’s a hypnotic medication,” Mailander said. “Back to inducing an anesthetic, putting someone from essentially awake to asleep, etomidate is another medication we have, to inject in someone, which will put them into a state of sleep. It creates amnesia, which is a good thing. And anesthesia, which means you’re unable to respond to stimulus. It does not . . . relieve any pain.”
Mailander explained that etomidate, a controlled drug, is not commonly used because it has a side effect that affects the adrenal glands in that it interferes with normal adrenal gland hormone production, a complication that is potentially hazardous to patients. However, it has the benefit of maintaining normal cardiovascular stability when injected into patients to put them to sleep.
“(For) patients who have unstable cardiovascular systems,” Mailander added, “whether they are anemic or have lost a lot of blood or simply have weak hearts, etomidate is a better choice than others because it maintains a normal blood pressure, normal pulse rate.”
Hicks led the expert witness through a series of questions in which he confirmed through Mailander’s answers that, among other things, etomidate is a drug that cannot be obtained through pharmacies because they don’t stock it, and that etomidate, as well as succinylcholine, is under controls, with limited access in a hospital setting.
“Dr. Mailander, I want to digress for a second to intramuscular injections,” Hicks said. “Again we’ll go back to the uncooperative patient in which you need to get paralyzed, for lack of a better term, and you need to administer intramuscularly. Would the buttocks be an appropriate spot to do that?”
“Yes.”
“And in your training and experience as an anesthesiologist, is there any pause you have as to say whether or not succinylcholine would work if administered in that manner?”
“It should work very well.”
“And why would that be?”
“It’s a large muscle. One of the reasons the buttocks is a general muscle of choice for shots is that it’s a very large muscle mass, so the odds of hitting the muscle are very, very good without going too deep in the bone or going too superficially. And has a very, very good, strong blood supply for rapid uptake.”
“And why is a strong blood supply important in a case of succinylcholine?” Hicks asked.
“Again, I don’t inject succinylcholine intramuscularly if I can help it.... I have not done it myself. But the faster the medication gets to its target organs, which would be all of the muscles in the body, then the faster the patient is put into a condition
where we can work with them more successfully.”
“Dr. Mailander . . . again I am speaking to you hypothetically. . . if you were to . . . administer succinylcholine to a person in hopes that it would not be discovered by treating physicians or treating emergency personnel soon thereafter, where would you pick . . . ? Would the buttocks be an acceptable spot?”
“I think the buttocks are as good a choice as any,” Mailander said. “I can’t begin to imagine where a spot would be undetectable. But the buttocks, I presume, like the crease in the buttocks, might be a good choice because there’s a natural body fold there. People might not look so carefully. I haven’t got a great answer for that. Sorry.”
“I understand,” Hicks said. “Thank you very much. That’s all I have, Your Honor.”
Chapter 25
With Dr. Paul Mailander still on the witness stand, defense attorney David Houston fashioned much of his cross-examination in such a way that it was easy for everyone present to see that he was attempting to diminish at least some of what the state’s expert witness had testified to in the presence of the jury during direct examination. It wouldn’t be easy to change the image that had been presented to the jury, but it was his job to try. He had clearly done his homework, and he began after the usual greetings and introductions.
“Doctor, succinylcholine is primarily—and please excuse my vocabulary being not medical—designed to be administered IV, true?” Houston asked.
“Yes.”
“And it’s designed to be administered IV because you have better controls as far as time of onset and dosage, right?”
“That, and the fact that you don’t want paralysis to onset slowly . . . if you can help it because it makes your patients a little unstable.”