You might notice the sting of the injection. Within seconds you'd realize you're having trouble moving your eyes and fingers, followed by your arms and legs. If you were standing, you'd collapse. In a heap on the floor, you'd realize nearly every muscle in your body was paralyzed. Being fully conscious, your sense of panic would be rising as rapidly as the paralysis was spreading. Swallowing and breathing has become more and more difficult. Slipping into unconsciousness, your last conscious thought may well be "I am going to die."


Statistically speaking, you're not going to die. Not because what was injected isn't lethal – it most certainly is. No, you're probably not going to die because if you've been injected with succinylcholine (also known as suxamethonium chloride or simple ‘sux') you're most likely in a hospital, undergoing intubation with accompanying respiratory support. The administration of sux is part of the rapid sequence intubation (RSI) protocol, which means a medical team is actually trying to keep you alive – they've just got to paralyze you do to it. If you're being intubated, your airway is blocked and the RSI protocol is employed to get a breathing tube down your throat. To get this tube in quickly, they'll paralyze and sedate you.

Sedation means you won't be conscious when the paralysis sets in. Respiratory support means something will be breathing for you when the muscles involved in respiration stop working. In 5 – 10 minutes, a clinical dose of sux wears off as it's rapidly metabolized by your body. The sedation will likely last longer. The goal is that by the time you're awake, your breathing has been stabilized and perhaps other medical issues have been (or are being) addressed. This is the intended use of sux. But, like many chemicals, people can use it for nefarious reasons.


If you're hit with clinical dose of sux and have no respiratory support, you will likely die. Though the effects of sux wear off in 5-10 minutes, your body's need for oxygen renders those minutes far too long. If you're hit with sux without sedation, you'll spend those minutes before death in a state of waking terror, realizing there is nothing you can do. It is a horrible way to die. For a time, it was a clever way to kill someone.

Since the early 1950s, sux has been used in a clinical setting mainly by anesthesiologists. It's a mystery when it was first used in a homicide, but the first high-profile killings came in the 1966 and 1967. This salacious tale of murder involves anesthesiologist Dr. Carl Coppolino, his mistress, his mistress' husband dying suddenly in '66, Coppolino's wife dying suddenly in '67, a quick remarriage by Dr. Coppolino (not to that mistress), two trials in different states leading to different verdicts.

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Coppolino's first trial in New Jersey involved a shaky witness (that jilted mistress) and a tricky toxicology problem. In their 2006 J Am Soc Mass Spectrom paper, Ballard et al. expound on sux's tricky tox.

…few forensic laboratories will even attempt to analyze these compounds. This is partially because there is little need to measure them clinically and, thus, no routine assays are available, and partially because they are analytically challenging compounds. Nevertheless, the potential for their use as murder weapons must be considered, particularly in cases involving sudden, unexpected, and unexplained death with a medical professional as a potential suspect, both within and outside of a hospital setting. Succinylcholine in particular has a long reputation as an undetectable, "perfect" poison. The analysis of quaternary ammonium neuromuscular blocking agents in a forensic setting is challenging for two reasons. The first reason is that the chemical behavior of these compounds, involving both hydrophilic and lipophilic characteristics, makes them difficult to isolate from biological specimens. The second reason is the extraordinary variability of the types of specimens encountered; this variability is such that each specimen must be considered unique.


Back in the mid-to-late sixties, sux was likely considered a "perfect poison" as no tried-and-true method for detecting it in tissues was developed until the 1980s. Previous analysis had holes – including the analysis presented in both of Coppolino's trials. It wasn't sux that was detected, but the metabolites succinic acid and choline. Here's a big hole: what else could give rise to those detected metabolites?

While Coppolino's soon-to-be very famous defense attorney F. Lee Bailey focused on the tricky tox of sux in both trials, Coppolino was only aquitted of the death of his ex-mistress' husband. That second set of jurors in the Florida trial for Mrs. Coppolino's murder returned a guilty verdict.


The Coppolino trials shined a light on the challenges of detecting sux. In the decades that followed, advances were made but even these new techniques had their limits. Police in Osaka, Japan had a string of missing persons in 1993-1994, which they linked to single suspect who subsequently confessed to killing five people. Oddly, the suspect was a dog breeder. Typically, suspicious deaths involving sux have one thing in common – access to sux. This usually means medical professionals are involved. Just how did a dog breeder get his hands on drug typically associated with anesthesiologists? The suspect explained both his access to sux and his mode of administrating sux to police.

The suspect (the dog breeder) confessed that he had injected around 40 mg (one ampule dose) of succinylcholine (suxamethonium chloride) intramuscularly into one arm of the victims after sedating them by oral administration, via some soft drink, of a small amount of bromovalerylurea (bromisovalum) and/or nitrazepam. The drugs had been illegally provided by a veterinary surgeon of his acquaintance under the pretense of killing unwanted animals. The suspect had prior experience of killing dogs with succinylcholine. [excerpt from here]


During his confession, this dog breeding killer directed police to the burial sites of all five victims. At the site of one victim, a plastic syringe was found. A needle mark was noted for one victim during autopsy, but not for the other four. In 1994, body decomposition and the rapid metabolism of sux proved too big a hurdle for a sux tox screen to overcome – no sux was found in any of the victims. Sux was found in that recovered syringe, however. Though no sux was found in the victims, the suspect was convicted based on his confession and other evidence.

By the time of Kathy Augustine's death in 2006, analysis of sux in tissues and biological fluids had advanced greatly. Like Mrs. Coppolino, Augustine's death was first thought to have been the result of a heart attack. Found unconscious at home by her husband Chaz Higgs, Augustine was rushed to the hospital where she died a few days later. Augustine, the first female state controller in Nevada history and a political mover-and-shaker, was a high profile death in Nevada from day one.


Like Coppolino and the dog breeder before him, Higgs had access to sux. Higgs was a critical care nurse who had experience administrating sux. But it wasn't Higgs' access to, and familiarity with, sux that raised a red flag. It was the troubled Higgs – Augustine marriage, along with something Higgs supposedly told fellow nurse Kim Ramey.

Ramey told police that she and Higgs had talked at work just a day before Augustine was rushed to the hospital. At the preliminary hearing, Ramey said Higgs had mentioned a well known local murder case involving a man who had stabbed his wife to death. "He said, ‘That guy did it wrong.' He said, ‘If you want to get rid of somebody,' and he made a gesture like this (holding a needle), ‘You just hit her with a little Sux, because they can't trace it post mortem,'" Ramey told the court. "I looked him at the face and I said, ‘Chaz, that's too much anger to carry around.' And the hair on my arm arose." [excerpt from here]


After hearing from Ramey, police sent urine collected during Augustine's hospital stay directly prior to her death. Analysis of Augustine's urine showed sux metabolites and sux. At no time during her hospital stay was Augustine administered sux.

The detection of sux, not just sux metabolites, in Augustine's urine was dismissed by Higg's defense attorney David Houston.

…he argues the amount of succinylcholine detected by the urine test is inconsequential. "What they're talking about from the prosecution's stand point is finding what they euphemistically refer to as traces. Well, I'm not really sure what a trace is, but it's certainly not enough to convict somebody beyond a reasonable doubt of a murder," Houston says. [excerpt from here]


Traces of sux was enough for Tom Barb, the prosecutor handling the Higgs case.

"Succinylcholine is not a recreational drug. If that's present, somebody put it in her, and the only one that had the opportunity to put it in her was her husband," argues Tom Barb. "I guess it's just pretty straightforward. It's murder by injection, as opposed to a gunshot." [excerpt from here]


Interestingly, the way sux was put into Augustine was a focus of Higgs' defense. Higgs' attorney David Houston raised what can be called the "my client knows better" defense.

He also tried to raise doubts about the medical evidence, including the site of the injection, which was in the muscle of the buttocks. The drug works fastest if delivered intravenously, and Higgs would have known that, Houston argued. [excerpt from here]


Nearly a year after Augustine's death, a jury convicted Higgs of first degree murder.

The cases discussed here weren't cracked by some routine tox screen. The tip-off to sux came from a jilted mistress, a confessed killer and a coworker. Such witness tips have helped resolve other high profile sux cases. Tips aren't usually enough in today's criminal prosecutions, neither is a suspect's access to sux. This is where modern analytical techniques come in. Tests can bolster, or weaken, witness tips and other circumstantial evidence against accused killers that sux.


Image from Hospira

Republished from the Journal of Are You Fucking Kidding under kind permission from DrRubidium.