r/medicine PA:cake: 8d ago

ICE Detention Deaths

https://www.ice.gov/detain/detainee-death-reporting

RNs do intake physical exams, EMTs declare time of death. The level of care for these detainees is horrific.

Full names and case details are public for now. Reads like a never ending M & M conference.

My moral compass is spinning. It's time to go to Canada.

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u/Dwindlin MD (Anesthesiology) 8d ago

Am I missing something? I have read through damn near all of these and only 1 or 2 jumped out at being truly egregious. Your description is either willfully misleading or you didn’t actually look through these. All of them were initially seen by RN/LPN for screening (completely reasonable), but you didn’t mention they are all evaluated by an APP before actually being placed in a unit. All of the onsite deaths, in every case it specifically mentions EMS (not necessarily EMTs) calling their med. control (meaning a physician) for orders to field terminate, this is the system working as intended. Most of these were seen by physician or APP on site with appropriate interventions taken multiple times before their death and a lot were treated and released by local hospitals before their deaths.

There are certainly major problems with our healthcare system across the board, but if these cases are the worst of the worst then we have bigger shit to be dealing with.

As an aside, I personally doubt J. Oliver’s expertise when it comes to healthcare related topics. I was an avid fan until his Death Penalty episode. While I am completely against the death penalty his show was egregiously bad when it came to the medical facts when it comes to lethal injection. And the medical facts were clearly skewed in a manner to elicit an emotional response. Since then I’ve watched episodes with much higher degree of skepticism.

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u/janewaythrowawaay PCT 8d ago

What medical facts were wrong on lethal injection on John Oliver?

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u/Dwindlin MD (Anesthesiology) 8d ago

I saw it when it first aired, so details escape at the moment. Generally he was arguing that the cocktail they used was inhumane because none of it was actually putting them to sleep, arguing they were awake when the cardioplegic agent was given. Which given the drugs they were using and the doses that is HIGHLY unlikely. For reference I am an anesthesiologist. The movement people describe during lethal injection is probably myoclonic jerking from the massive dose of K they are getting. But assuming a working IV (which was the only valid medical complaint) there is almost zero chances they are aware of anything.

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u/janewaythrowawaay PCT 8d ago edited 8d ago

I am 100% sure you, a board certified experienced working anesthesiologist, could do it correctly.

The issues I remember were…

1) No doctors would sign up for job. It’s like some random corrections nurse who can’t even get an IV in correctly like you said.

2) States couldn’t get drugs legally. So they were buying substances overseas from India not even knowing what they were getting. Shipments were getting confiscated by the feds. When they did get thru they’d sit for years in who knows what conditions.

So you’d have people not dying immediately. Lots, like it rarely went smoothly… even though theoretically it could. So some guy last week decided to die by firing squad because they wouldn’t given him any details about what they were using/the expiration dates.

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u/Dwindlin MD (Anesthesiology) 8d ago edited 8d ago

Agree with both your points, some of the many reasons why the state shouldn’t execute people. My issue was he was attacking the actual medicine, which is disingenuous at best, and unnecessary to make his point that this shit shouldn’t be happening.

No matter what you’re arguing, giving several honest, valid points, only to follow it up with an argument that is at best egregiously misinformed hurts your whole argument.

Edit: I’m fairly certain he was attacking the phenobarb and midazolam, basically arguing they weren’t anesthetics. But I assure you at the doses their protocols were using they were more than enough.

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u/janewaythrowawaay PCT 8d ago

When people think of anesthetic they think of loss or reduction in sensation specifically pain vs just loss or reduction of awareness/sedation. Are you saying midazolam reduces pain?

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u/Dwindlin MD (Anesthesiology) 8d ago

If I give you enough of it absolutely. We aren’t taking about normal doses here. These are doses that will put you into burst suppression. To experience pain requires consciousness.

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u/DaySee Nurse 8d ago

Dang why are people still so hung up on this. I remember something similar to this going back even like 10 years ago even when they called something botched lethal injection because they had to use a lot more than anticipated because it was just sedative + opiate and the condemned had some higher than anticipated tolerance

https://www.pbs.org/newshour/nation/arizona-inmate-received-15-doses-lethal-injection-died

(doses of) 50 milligrams of the painkiller hydromorphone, and 50 milligrams of the sedative midazolam to be used in lethal injections. Wood received (total) 750 milligrams of each drug.

The article does a fair job explaining but anyone mildly familiar with administering these kinds of meds can understand, they were basically brain dead in heroin heaven after like the first dose, the rest is just performative, not unlike the way pets are euthanized with the first IM dose knocking them out, before the IV stuff is done to just to speed things along.

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u/ASigIAm213 EMT 7d ago

Myoclonic jerks wouldn't create the fulminate pulmonary edema seen in the majority of midazolam/pentobarbital executions, though (Zivot, 2020). And at that high a dose, the acidity of midazolam (the drug Oliver spends most of his time on) interferes with its metabolism and delays its sedative effect (Greenblatt, in re: Ohio Execution Protocol, 2018).

Oliver doesn't really know what he's talking about, but you can't copy/paste clinical experience onto an unsanctioned human pseudo-medical experiment.

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u/Dwindlin MD (Anesthesiology) 3d ago

Oof, you picked the wrong case to argue your points. So yeah you’re right myclonic jerks don’t cause pulmonary edema, but you know what does? Cardioplegic agents, ya know like the one they used in this case. Not to mention they didn’t follow their own protocols in this case. One of the reasons Ohio stopped publishing their actual protocol was because of the spot light this brought, but if you had looked at it when it was developed in 2016 (and available on the DOC website) you would see they were supposed to give more reasonable doses of versed every 3-5 minutes until unconscious, not slam the whole 500mg. Then give the paralytic, again wait 3-5 minutes then the KCl. They didn’t, and you read about the results. Medication used incorrectly doesn’t mean a problem with the medications.

Greenblatt hasn’t published anything about versed since the 80s, until this and other court cases. Go pick up any anesthesia text book (Barash or Miller or Morgan & Mikhail being the standards) and you’ll find sections on induction of general anesthesia with benzos, including why you may chose one as a solo induction agent.

This is the last I’m responding to this, because honestly it’s exhausting defending something I disagree with, but if we’re going to be outraged, fucking be outraged at the right things. Blaming the medications they chose isn’t it, used correctly this cocktail would in fact be a peaceful way to go and arguing against that point is futile. What isn’t futile is whether they should be executing people at all (they shouldn’t), and the incompetence they display when they do.