An Almost Perfect Murder
Page 19
“And it could make your patient very aggravated if they were conscious to have that slow onset of paralysis,” Houston said.
“Well, yeah, I suppose you could argue that,” Mailander said. “As you get agitated, you get weaker.”
“Sure. How many times have you injected a conscious patient with succinylcholine?”
“Never.”
“And how many times have you injected a patient with succinylcholine in the adipose tissue, not the muscle?”
“Never.”
“Would a reason not to inject in the adipose tissue be that we wouldn’t know the time of onset or the dosage with any reliability?”
“I would say not a primary reason, but certainly a reason.”
“Okay. And adipose tissue is fat, right?”
“Correct.”
“Now, when we talk about the buttock area, there’s a big muscle back there,” Houston said. “That’s the gluteus maximus?”
“Yes. And the medius and the minimus.”
“And in some people, there may be a little bit more padding than others in reference to fat tissue, right?”
“Very much so.”
“That’s a delicate way to put it,” Houston said. “So that being said, if you’re injecting into the buttock area in order to get to the muscle, you’d have to have a needle long enough to do the job.”
“Yes.”
“Are you aware in this case that the autopsy had indicated what they thought might be this punctate-type area was only one point five or two centimeters deep?”
“I believe we discussed that in your office. Yes.”
Houston was attempting to show the length of 1.5 to two centimeters, when Mailander explained that it was just under an inch. Houston also pointed out that the autopsy had shown how much fat existed from the surface of the skin on Kathy’s buttocks to the point where it reached the muscle and characterized it as an important consideration in determining whether the injection dose had ever entered the muscle. Mailander expressed some concern over Houston’s depiction of the fat and whether the dose had entered the muscle because, he pointed out, fat can be displaced if it is pushed upon with added force. Mailander also confirmed that succinylcholine is not a fat soluble drug.
Houston also questioned the state’s expert witness whether he was aware of any scientific study or statistics that address dosage of succinylcholine in adipose tissue, and Mailander responded that he had found a study on the subcutaneous injection of the drug from the Korean Journal of Anesthesia that was done in 1995. It had been a controlled study, he said, in which they used identical doses of succinylcholine for IV versus intracutaneous or subcutaneous administration. The study, he said, had used patients who were asleep.
“If you inject succinylcholine in a subcutaneous way and the patient is awake, would it be fair to say it’s going to burn or sting?” Houston asked.
“I would say it would probably hurt, yeah,” Mailander responded. “I’m guessing. But . . . let’s say yes.”
“And then after that, we have the onset, which results in slowly depriving you of oxygen, true?” Houston asked.
“Well, you get weaker, yeah,” Mailander said.
Mailander affirmed that a patient in pain and being deprived of oxygen would fight or thrash about. He also confirmed that there was no dosage specified in the medical literature for a subcutaneous injection of succinylcholine; however, he said, the standard accepted dose for the drug injected intramuscularly is typically three to four milligrams per kilogram of body weight, and that such dosage results in a one-to-four-minute onset before the drug takes effect.
“In this particular case,” Houston said, “if Miss Augustine weighed one hundred eighty-nine pounds, that’s approximately eighty-six point three kilograms, correct?”
“Approximately, yes.”
“I’m not really that smart,” Houston said. “I wrote it down.”
“We knew that,” Barb interjected.
“You didn’t know that. You were amazed,” Houston countered. “Again, using the charting, if we use three milliliters per kilogram, that appears to be a nine-point-five-cc dose.”
“At twenty milligrams per cc. Yeah,” Mailander responded.
“And the common . . . hospital vial . . . is twenty milligrams per cc, correct?”
“That’s right.”
“Now, if we factor in a twenty-five- or twenty-seven-gauge needle—I’m using that because of the depth—what amount of time do you think it would take to empty almost a ten-cc syringe into someone through a needle with that small a port?”
“It can be done relatively quickly,” Mailander responded. “Within the course of about maybe ten seconds. I’m guessing.”
“Okay,” Houston said. “Your Honor, may I have an opportunity? I just happen to have a ten-cc syringe with a twenty-seven-gauge needle on it. I’d like to put some water in it, if I could.”
“As long as you don’t use it on me,” responded Judge Kosach.
“That’s a promise,” Houston said.
Houston and his co-counsel, Alan Baum, approached the witness with the syringe and needle, and Mailander confirmed that it was a 10 cc syringe and what appeared to him to be a 27-gauge needle. He asked the anesthesiologist to fill up the syringe with water and to demonstrate how long it would take to empty it through the needle by squeezing the plunger.
“Doctor,” Houston said during the demonstration, “if I were to put this in somebody . . . a live, conscious patient . . . injecting that succinylcholine into them in the left buttock, what do you think they’re going to be doing while I’m doing that?”
“I—I imagine the patient would be moving around or trying to get away from it.”
“Quite a bit probably, right?”
“Couldn’t begin to tell you,” Mailander responded.
“Doctor, would you anticipate if there were a needle mark—because I noted you said something on direct. You said, ‘When something is done to you that is painful, you twitch.’”
“Yes. Absolutely.”
“That’s even when you’re unconscious, right?”
“Yes. Absolutely.”
In the courtroom with poor acoustics, nearly everyone sat perfectly still during this portion of Houston’s cross-examination of the state’s expert witness, anticipating the moment when it would become clear just where he was going with his line of inquiry.
“So if you’re conscious,” Houston continued, “or not rendered unconscious, but if you’re conscious and somebody jabs you in the behind with a needle and starts pumping that drug into your skin, would you anticipate them to at least twitch?”
“Oh, yeah.”
“Are you aware that when the autopsy was done in this case, this proposed punctate-type area did not show any tearing or anything that would suggest the needle was moved, if it is a needle mark?”
“No. I have no idea what the autopsy results are.”
“But wouldn’t you anticipate that if it was a needle mark—and somebody was injecting succinylcholine—that they’re going to twitch or move?”
“I’d expect them to move, yeah.”
“Okay. Doctor, that was at the base-minimum dosage for an IM (intramuscular) at three milliliters per kilogram,” Houston said. “If we go to four milliliters per . . . kilogram, we’ve jumped up to seventeen point two-five cc’s. . . . Now I need either a syringe that’s twice that size or two syringes, right?”
“If you use that dose, yes,” Mailander said.
“Now, just out of curiosity, each bottle that we note at the hospitals is two hundred milligrams, right?”
“Yes, that’s correct.”
“So, if I’m going to inject three hundred forty-five milligrams, now I’ve got to have two bottles, true?”
“Yes.”
“If I were to inject five milliliters per kilogram, I’d require four hundred thirty-one milligrams, which is twenty-one point five-five cc’s, true?”
“Yes.”
“That’s correct.”
“And if I’m to do four hundred thirty-one point eight milligrams, now I’ve got to have three bottles because I’m out, if I’m just using two, right?”
“Yes. Sure.”
“Can you envision a situation where someone could inject that kind of quantity under the skin in somebody’s left buttock without it not leaving some sort of welt or pronounced area?”
“Yes.”
“And how much time do you think it would take for the introduced substance to . . . diffuse? Is that the word?”
“Diffuse, sure. Dissipate.”
“How much time do you think?”
“Don’t know because I’m not familiar with subcutaneous diffusion. We don’t do subcutaneous injections.”
“You think it might take more than thirty minutes?”
“I couldn’t tell you.”
“All right. Fair statement. And, of course, if we’re talking about an intramuscular dosage, and the numbers just keep going up, then we’re anticipating a much larger syringe, much more time to get it through the needle port, and you need more bottles to get the job done, correct?”
“If you do it that way, yes.”
Mailander confirmed that he has frequently used succinylcholine as an anesthesiologist. When Houston asked him about its use with regard to intubation, he erroneously stated that the drug is used to prevent the gag reflex during the intubation procedure. Mailander corrected the defense attorney by explaining that the succinylcholine weakens the facial and neck muscles so that medical personnel can open the patient’s mouth to insert the air tubing. The gag reflex goes away, along with the weakening of the facial and neck muscles.
“And when you have a patient in a surgical procedure, if you’re going to airway them, and you’ve already kind of put them down a little with VERSED or something, do you still use something like succinylcholine to intubate them?”
“Every time.”
“And so it doesn’t matter really whether they’re conscious or unconscious?”
“If they’re conscious, they fight harder,” Mailander responded.
“And if they’re unconscious, you’d use it because you want to be able to weaken the facial muscles enough to where you can get that tube down their throat.”
“Yes.”
In finishing up his cross-examination, Houston asked Mailander if critical care nurses typically assisted in the administration of succinylcholine. However, Mailander said that he did not know the answer, and Hicks was left again, at center stage, with a brief redirect examination of the witness.
Hicks went through the intramuscular (IM) dosages that Houston had questioned the witness about previously, and he and Mailander agreed that it was three to four milligrams of the drug per kilo of body weight for an IM.
“Is that your therapeutic dose?” Hicks asked.
“That is a dose to create what we call intubating conditions,” Mailander responded.
“And what . . . does that mean?”
“That means to make you weak enough, fast enough, that we can open your mouth, manipulate your neck, and gain access to your airway.”
“Is that a requisite level for succinylcholine to have an effect on a person?”
“No.”
“Would you like to expand on that?” Hicks invited.
According to Mailander’s testimony, one milligram of the drug per kilogram on any one individual would be a typical intravenous dose. However, he said, the dose would vary for each individual depending upon his or her size, weight, age, and health. Less than a milligram per kilogram, say .2 milligram—about one-fifth of that given intravenously—would weaken someone profoundly. He explained that such a small dose may not enable the medical practitioner to gain surgical control of the patient’s airway, but that it would be sufficient to weaken the patient. He said that patients who had been accidentally injected with a small dose of succinylcholine during the course of having surgery have shown profound weakness with a fairly small dose.
“Enough to not even be able to breathe on their own?” Hicks asked.
“In many cases,” Mailander said.
“So, assuming the hypothetical . . . one-hundred-eighty-nine-pound person, eighty-six point three kilos, you would not have to give that (previously described massive) dosage to get the effect that could cause them to stop breathing . . . ,” Hicks said.
“That is correct.”
“. . . cause their heart to stop and suffer brain damage?”
“Does not cause the heart to stop.”
“Their breathing—excuse me. Let me rephrase. Cause them to stop being able to breathe, and ultimately causing the damage to organs that you spoke of earlier.”
“It’s a graduated process,” Mailander explained. “A little bit of paralytic medication weakens one to a degree. More weakens you more. So you reach a point where someone cannot exchange and ventilate, breathe, very successfully. But they don’t have to be completely paralyzed.”
“When you say it weakens the person, they might not be completely paralyzed. Would they be able to stand up and walk around?” Hicks asked.
“If they’re not able to breathe, I sincerely doubt it.”
“So they might just be able to . . . shrug a shoulder or blink an eye, or something like that?”
“They can try.”
“You had indicated that the gluteus maximus and the tissue around it varies from person to person, obviously . . . and that fat can be displaced. Now, what did you mean by that exactly?”
Mailander explained that the reason the gluteus maximus muscle is used by medical personnel for most injections is because “it’s a good recipient muscle for an injection.” Because everybody has a fairly significant fat pad in the area of their buttocks, it isn’t very difficult—with some pressure—to push a needle through the skin, through the subcutaneous fat and into the muscular tissue, he said. Because the fat is not a constant thickness, it compresses when pushed upon.
“So, if you take someone with an average fat pad and push really hard, you can compress the fat and get a needle through it,” Mailander testified. “We do this all the time in putting in epidurals for pain control for labor and delivery. We have an enormous number of fairly hefty expectant moms, and we have to push on our needles substantially to get them into the target tissues.”
“You had also indicated that for the most part the critical part of succinylcholine is getting it to work . . . its process in getting into the blood flow, is that correct?” Hicks asked.
“That’s correct.”
“Now, if you were to see a picture of a puncture wound on a buttock, and there was blood raised up to the level of the skin from the puncture, would that satisfy you that the succinylcholine had reached the blood system?”
“Not necessarily. Only because you can break a blood vessel going through the skin or into the fat. You can lacerate a capillary and have the needle point well beyond the level of laceration.”
“You had indicated that you have never given a conscious patient succinylcholine,” Hicks said.
“No.”
“And why is that?”
“Well, for three reasons,” Mailander explained. “Every anesthesia textbook advises against it except under emergency circumstances. Every anesthesia instructor I’ve ever had threatened to kill me if I did. And thirdly, it—to paralyze someone with no sedation is a terrifying experience.”
Mailander explained that accounts of patients who were aroused or even awakened under anesthesia while undergoing surgery have been uniformly one of terror.
“Imagine how it would be for someone who has no anesthetics and no sedation,” Mailander said, “being unable to breathe, being unable to open your eyes if they’re closed, or close them if they’re open, and being unable to do anything about that. It�
�s reputedly one of the most horrifying experiences out there. At least, that’s what they describe in the literature.”
“Mr. Houston had also asked you about a conscious person being stuck with a needle, the amount of struggle that one might expect,” Hicks said. “It sounds to me from what you’re saying is that a conscious person administered succinylcholine unwillingly, if they fight, they’re just making it worse. Is that right?”
“Well, if it’s increasing their circulation, yes, it will help mobilize the medication faster.”
“And the dosage in which he demonstrated for you and the jury is not what is required to affect somebody who has been administered succinylcholine, is that right?”
“Personally, I would think not,” Mailander responded. “That would be, again, those doses—recommended doses are textbook numbers for intubating conditions . . . in a surgical setting.”
With no further questions, Hicks handed the witness off to the defense for recross-examination.
“Doctor, this notion of struggle and fighting, we can’t put a time frame on that in reference to not knowing the time of onset of the amount [of drug] that may or may not have been introduced, correct?” Houston asked.
“If I may, discussing what we call a ‘dose response reaction, ’” Mailander clarified, “we don’t know how much medication was injected, and we have no idea what the response was.”
“And if you inject it IV, certainly you get a faster response regardless of the dosage, right?”
“That would be correct, yes.”
“When you talk about displacing fat with the needle, then hitting a muscle, if we have an autopsy that demonstrates the track ceases, doesn’t go as though somebody pushed it through, that kind of struggles against the notion that somebody pushed it all the way through the muscle, since there’s no physical evidence of it, doesn’t it? Or the fat,” Hicks corrected himself. “I’m sorry.”
“Again, I would have to study the mechanics of fat motion. That’s a bachelor’s degree in biological mechanics.”
“That would be a guess, then?”
“I really don’t have a good answer for that.”
“Okay. In this particular case, if you want to use a needle to push through a large fat pad to get to a muscle, would you agree chances are therapeutically you’re going to use a larger needle than a twenty-five- or twenty-seven-gauge needle?”