Cocaine or Novocaine

Novocaine??

For an ANSWER, a
life, its cost«.
Somera Case {1928}
Cocaine or Novocaine
Novocaine??

For an ANSWER, a
life, its cost«.
Somera Case {1928}
Bt goes without saying that every aspect of the
practice of a profession is interwoven directly or
indirectly with legal rules and sanctions
sanctions.
. The
examination and registration of applicants for the
practice of a profession, the professional conduct
of registered practitioners, the maintenance of
ethical and technical standards of the provision,
the illegal practice of unregistered persons and
even the exercise of the powers and duties of the
board created to examine applicants and administer
the law regulating such profession, are all
governed by specific provisions of law, for the
purpose of attaining a normal and orderly procedure
in the practice of the profession
profession. . Knowledge of law
is essential not only in settling lawsuits but also
in preventing or minimizing them
them..
ike any other citizen, a nurse may incur criminal
liability or subject herself to criminal
prosecution either by committing a felony or by
performing an act which would be an offense against
persons or property
property.. Bgnorance of the law is not an
excuse for failure to comply therewith
therewith.
. Violators
of the criminal law cannot escape punishment on the
ground of ignorance of the law law;
; neither can
violators of private right escape liability for
actual loss thereby inflicted on the ground that
they are ignorant of the law
law.
.
ike any other professions, a professional nurse
has many legal responsibilities to assume in the
practice of her profession
profession.. These legal
responsibilities are entwined in every service she
renders to a patient and they may be felt by her
especially when questions arise involving
negligence in the performance of her duties, or in
the care or supervision of patients, or in the
fulfillment of contractual obligations
obligations.
. Bt is of
importance to a nurse that she knows the legal the
responsibilities attached to the various phases of
her professional practice so that she may be
properly guided in the discharge of her functions
functions.
.
Cocaine or Novocaine
Novocaine??

For an ANSWER, a
life, its cost«.
Somera Case {1928}
Bt is one of the earliest and most famous cases of
negligence by a nurse, the Somera case, reported in
the Bnternational Review, July 1, 1930
1930,
, pp
pp..325
325--334
334..
A Case in point is that of one orenza Somera
Somera, , a
Registered Nurse and as the head nurse, who was
found guilty of the crime of Homicide through
reckless imprudence for the death of a young girl
in the operating room
room.
. The facts of this case are
narrated in the book, Þ




 

    





 

 


was directed by the operating surgeon to prepare
10%
10 % cocaine with adrenalin for administration to a
patient for tonsillectomy
tonsillectomy.
. Below are the case facts
in condensed from which was published in 1930 from
the Bnternational Nursing Review and it is read as
follows:
follows :
Sometime in May, 1928 1928,
, one Pedro Clemente took his
daughter, Anastacia Clemente, who was below fourteen
years of age, to one Dr Dr.. Gregorio Favis of Manila for
treatment.
treatment . After examining her, the doctor decided that
she should undergo a tonsillectomy, to which the father
agreed.
agreed . So she instructed the father and his daughter to
go to the St . Pauls Hsospital on May 26th, where he would
St.
perform the operation at 7:00 O¶Clock in the morning
morning.. Dr
Dr.
.
Favis then called up Sister Mercedes of the St St.
. Paul¶s
hospital and requested her to have intended operation
fixed on said date and hour
hour.. He also informed her that he
would follow the same orders given in previous cases of
tonsillectomy performed in the hospital
hospital.
. The Head Nurse
in the operating room in the morning of May 26th was one
orenza Somera
Somera.. Valentina Andaya and Consolacion
Montinola were student Nurses working in the operating
room under Somera
Somera.. Montinola was the sterilizing nurse
and Dr
Dr.. Armando Bartolome was the assistant surgeon
surgeon..
 A 2,000 year
year--old surgical procedure in which
the tonsils are removed from either side of the
throat.
throat . Bs performed in response to cases of
repeated occurrence of acute tonsillitis or
adenoiditis, obstructive sleep apnea, nasal airway
obstruction, snoring, or peritonsillar abscess
abscess.
.

Sometimes the adenoids are removed at the

same time (adenoidectomy)
(adenoidectomy).
. Although performed less
frequently than in the 1950
1950s,
s, it remains one of the
most common surgical procedures in children in the
United States
States..
Effectiveness of the tonsillectomy

Bt has been questioned in a 2009 systematic

review of 7765 papers, published in the journal
Otolaryngology²
Otolaryngology ²Head and Neck Surgery
Surgery..
The reviews found that

Bt was most likely not effective all the

time, but rather was modestly effective, and that
"not a single paper reported that tonsillectomy is
invariably effective in eliminating sore throats".
There was only a short
short-
-term benefit - "A
child who meets these strict criteria will probably
suffer from 6 throat infections in the next two
years.
years . A child who has surgery now will probably
suffer from 3 throat infections
infections.. And in two years
there will probably be no difference
difference.."
 The generally accepted procedure for
tonsillectomy involves separating and removing the
tonsils from the   
 ± a fascia of
tissue that surrounds the tonsils
tonsils.. Removal is
typically achieved using a scalpel or with
electrocautery,
electrocautery , although harmonic scalpels or
lasers have also been used
used.. Bleeding is stopped
with electrocautery
electrocautery,, ligation of sutures
sutures,
, and the
topical use of thrombin
thrombin,
, a protein that induces
blood clotting
clotting..
 The procedure is carried out with the patient
lying flat on their backs, with the shoulders elevated
on a small pillow so that the neck is hyperextended ±
the so
so--called 'Rose' position
position.. A mouth gag is used to
prop the mouth open ; if an adenoidectomy is also being
open;
performed, the adenoids are first removed with a
curette;
curette ; the nasopharynx is then packed with sterile
gauze.
gauze . A tonsil is removed by holding it by the upper
part, pulling it slightly medially , and making a cut
medially,
over the anterior faucial pillar
pillar.. After the tonsil is
removed from its position, a snare can be used to make
a small cut on the lower portion prior to removal of
the tonsil
tonsil.. The use of electrocautery minimizes the
blood loss
loss.
.
 On the Day set for the operation, Dr Dr.
. Favis
arrived at the St St.
. Paul¶s Hospital a little before
7:00 o¶clock in the morning
morning.. After scrubbing his
hands and examining the patient, he asked for a ten
percent Cocaine solution with Adrenaline and with
it he swabbed the patient¶s throat, and Miss Somera
repeated and verified the order order.. The sterilized
table was prepared, with solutions and other needed
articles.
articles . Dr
Dr.. Favis asked his assistant, Dr Dr.
.
Bartolome,
Bartolome , for the Novocaine
Novocaine/Procaine
/Procaine solution
solution.
.
Thereupon, Montinola handed to Dr Dr.
. Bartolome a
syringe filled with solution and in turn, Dr Dr.
.
Bartolome handed it to Dr Dr.
. Favis
Favis,, who then injected
it to the patient
patient.. A few minutes later, Dr Dr.
. Favis
asked for more solution, which he injected again to
the patient
patient..
 After the second injection, Dr Dr.
. Bartolome
noticed that the patient became pale and acted as if
she was dizzy, to which condition he called Dr Dr..
Favis¶
Favis ¶ attention
attention.. Dr
Dr.. Favis said that the same was
not unusual and he then asked for a third syringe of
the solution, which he again injected to the patient
patient..
A few moments later, the patient showed symptoms of
convulsion to which Dr Dr.
. Bartolome again called Dr Dr..
Favis¶
Favis ¶ attention
attention.. Thereupon, Dr Dr.
. Favis ordered
adrenalin and then injected it to the patient patient.
. A
second injection was administered and the patient
again showed signs of convulsions
convulsions.
. After a few
moments, the patient dieddied.
. Dr
Dr.
. Favis then asked if
the Novocaine was fresh
fresh. . Somera replied that it was
not Novocaine but a 10 percent solution of cocaine
cocaine..
„ Bs a crystalline tropane alkaloid that is obtained
from the leaves of the coca plant
plant..
„ The name comes from "coca" in addition to the alkaloid
suffix 
,, forming 


..
„ Bt is a stimulant of the central nervous system and an
appetite suppressant
suppressant..
„ Specifically, it is a serotonin
serotonin-
-norepinephrine
norepinephrine-
-
dopamine reuptake inhibitor, which mediates
functionality of such as an exogenous catecholamine
transporter ligand
ligand..
„ Because of the way it affects the mesolimbic reward
pathway, cocaine is addictive
addictive..
 The pharmacodynamics of cocaine involve the
complex relationships of neurotransmitters
(inhibiting monoamine uptake in rats with ratios
of about
about:: serotonin
serotonin::dopamine = 2:3,
serotonin:
serotonin :norepinephrine = 2:5)
 The most extensively studied effect of
cocaine on the central nervous system is the
blockade of the dopamine transporter proteinprotein.
.
Dopamine transmitter released during neural
signaling is normally recycled via the
transporter;
transporter ; i.e., the transporter binds the
transmitter and pumps it out of the synaptic cleft
back into the presynaptic neuron, where it is
taken up into storage vesicles
vesicles..
 Cocaine binds tightly at the dopamine
transporter forming a complex that blocks the
transporter's function
function.
. The dopamine transporter
can no longer perform its reuptake function, and
thus dopamine accumulates in the synaptic cleft
cleft.
.
This results in an enhanced and prolonged
postsynaptic effect of dopaminergic signaling at
dopamine receptors on the receiving neuron
neuron..
 Prolonged exposure to cocaine, as occurs
with habitual use, leads to homeostatic
dysregulation of normal (i (i.
.e. without cocaine)
dopaminergic signaling via down down-
-regulation of
dopamine receptors and enhanced signal
transduction.
transduction .
 Cocaine is a potent central nervous system
stimulant.
stimulant . Bts effects can last from 20 minutes
to several hours, depending upon the dosage of
cocaine taken, purity, and method of
administration.
administration .
The initial signs of stimulation are

„ hyperactivity
„ restlessness
„ increased blood pressure
„ increased heart rate
„ euphoria
 Although cocaine overdose is not common, it
can occur and can be fatalfatal.
. Because cocaine
affects the heart and respiratory system, an
overdose can cause death, especially when the drug
is injected
injected..
An overdose of cocaine can lead to
to::
„ Brregular heart beat or heart failure
„ High blood pressure resulting in a brain
hemorrhage
„ Repeated convulsions
„ Respiratory failure
„ Bt is a local anesthetic drug of the amino ester
group
„ it is used primarily to reduce the pain of
intramuscular injection of penicillin, and it is
also used in dentistry
„ owing to the ubiquity of the trade name
Novocain, procaine is sometimes referred to
generically as novocaine
 Procaine is used less frequently today since more
effective (and hypoallergenic) alternatives such as
lidocaine (Xylocaine
Xylocaine)
) exist
exist.. Prior to the discovery of
procaine, cocaine was the most commonly used local
anesthetic.
anesthetic . ike other local anesthetics (with the
exception of cocaine), procaine is a vasodilator, and is
often co
co-
-administered with epinephrine for the purpose
of vasoconstriction
vasoconstriction.
. Vasoconstriction helps to reduce
bleeding and prevents the drug from reaching systemic
circulation in large amounts
amounts.
. Also unlike cocaine,
procaine does not have the euphoric and addictive
qualities that put it at risk for abuse
abuse.
.
 Allergic reactions to procaine are usually
not in response to procaine itself, but to PABA
PABA.
.
About 1 in 3000 people have an atypical form of
pseudocholinesterase,
pseudocholinesterase , which does not hydrolyze
ester anesthetics such as procaine, resulting in a
prolonged period of high levels of the anesthetic
in the blood and increased toxicity
toxicity..
 At the trial before the court of first instance of
manila, Consolacion Montinola
Montinola,
, when questioned by the
prosecution on direct examination, affirmed that she did
not know who prepared the drug
drug;
; that she heard Dr
Dr.
. Favis
ordered cocaine with adrenalin for injection
injection;
; and that
likewise, she heard Somera verified the order order.
. When
questioned by the defense, Montinola Again testified that
she heard Somera verified the order was given and
verified.
verified . Even on the part of the prosecution, the
evidence had brought out the fact that Dr Dr.
. Favis ordered
10 percent Cocaine Solution for injection and that Somera
verified said order
order.
. The autopsy report and testimony of
the Medico
Medico--legal Officer showed that the patient was
suffering from status lymphaticus and that such patients
were known to die even with so slight an injury as a
needle-
needle-prick
prick.
.
 The decision on the case was rendered by the
trial Court on May 7, 1929
1929.
. in its decision, the
court absolved Dr
Dr.
. Favis and Dr Dr.
. Bartolome of the
crime of which they were accused, but declared
Somera guilty of the crime charged in the complaint
and condemned her {a} to suffer imprisonment for
one year and one day, {b} to indemnify the heirs of
the deceased Anastacia Clemente in the sum of one
thousand {1000
1000}} pesos, with subsidiary imprisonment
in case of insolvency, {c} to suffer further the
accessories provided in Article 61 of the Penal
Code, and {d} top pay one one--third of the costs,
somera then appealed to the supreme court
court.
. She was
accused of homicide through reckless imprudence
imprudence.
.
„(atin 
 ,
, 

human being + 
 to cut,
kill)
„ Refers to the act of killing another human being.
being.
„ A common form would be murder(i
murder(i.
.e. slaughter,
abortion, death penalty, etc
etc..)
„Bt can also describe a person who has committed such
an act, though this use is rare in modern
English.
English.
„Homicide is not always an illegal act, so although
"homicide" is often used as a synonym for "murder
murder,"
,"
this is not formally correct
correct..
 Homicides do not always involve a crime
crime. .
Sometimes the law allows homicide by allowing
certain defenses to criminal charges
charges.
. One of the
most recognized is self defense, which provides
that a person is entitled to commit homicide to
protect his or her own life from a deadly attack
attack..
Some defenses include:

1. Right of self-defense and defence of others

2. Bnsanity defense²There are several tests to
check insanity
d M'Naghten Rules
d Bnsane delusion
d Brresistible impulse test
d Substantial capacity test
d Durham rule
d Diminished capacity test
3. Duress
4. Defence of property
5. Prevention of a crime
6. Privilege of public authority²
authority²A person who has
public authority to commit an act is not criminally
liable.
7. Entrapment²
Entrapment²The defense of Entrapment exists when
a law enforcement officer (or an agent of an
officer) solicits, induces, or encourages another
to commit a crime which they otherwise would not
have committed.
8. Mistake of fact
fact²
²The defense of Mistake of Fact asserts
that a mistake of fact will disprove a criminal charge if
it is honestly entertained, based upon reasonable grounds
and is of such a nature that the conduct would have been
lawful had the facts been as they were supposed to be
be..
9. Mistake of law
law²
² Not a valid defense to crime except in
rare instances where it negates an essential element of
the crime
crime.. Therefore the old saying "ignorance of law is
no excuse" is appropriate as a general rule
rule.
.
10.Unconsciousness
10. Unconsciousness²
² The defense of Unconsciousness holds
that one who is unconscious, for instance, someone
walking in their sleep, does not have the capacity to
commit a crime
crime.
.
 Criminal Negligence may be classified into
reckless imprudence or simple imprudence
imprudence.
. Bt is
reckless imprudence when a person does an act or
fails to do it voluntarily but without malice
malice.. From
which a material damage results immediately
immediately.. Simple
imprudence means that the person or nurse did not
use precaution and the damage was not immediate or
the impending danger was not evident or manifested
manifested..
 Reckless Bmprudence if he does an act or
fails to do an act, voluntarily but without
malice, from which act or omission a material
damage result because of his inexcusable lack of
precaution, taking into consideration his
employment or occupation, degree of intelligence,
physical condition, and other circumstances
regarding persons, time and place
place.
.
 Any person who by reckless imprudence shall
commit an act which had it been intentional, would
constitute a grave felony, can be liable to a
penalty of imprisonment ranging from 4 months and
one day to 2 years and four monthsmonths;
; if the
negligent act constitutes a less grave felony, the
offender can be punished by imprisonment of one
month to four months
months..
Rules for Graduating penalties
For the purpose of Graduating the penalties
which, according to provisions of Article fifty to
fifty seven, inclusive, of this code, are to be
imposed upon persons guilty as principals of any
frustrated or attempted felony, or as accomplices
or accessories, the following rules shall be
observed:
observed :
1. When the penalty prescribed for the felony is
single and indivisible, the penalty next lower in
degree shall be that immediately following that
indivisible penalty in the respective graduated
scale prescribed in the respective graduated scale
scale..
2. When the penalty prescribed for the crime is
composed of two indivisible penalties or of one or
more divisible penalties to be imposed to their
full extent, the next lower in degree shall be that
immediately following the lesser of the penalties
prescribed in the respective graduated scale
scale..
3. When the penalty prescribed for the crime is
composed of one or two indivisible penalties and
the maximum period of another divisible penalty,
the penalty next lower in degree shall be composed
of the medium and minimum periods of the proper
divisible penalty and the maximum period of that
immediately following in the said respective
graduate scale
scale..
4. When the penalty prescribed for the crime is
composed of several periods, corresponding to
different divisible penalties, the penalty next
lower in degree shall be composed of the period
immediately following the minimum prescribed and of
the two next following, which shall be taken from
the penalty prescribed if possible
possible;; otherwise from
the penalty immediately following in the above
mentioned respective graduate scale
scale..
5. When the law prescribes a penalty for a crime in
some manner not specially provided for in the four
preceding rules, the courts, preceding by the
analogy, shall impose the corresponding penalties
upon those guilty as principals of the frustrated
felony, or an attempt to commit the same , and upon
accomplices and accessories
accessories..
 Bn court, MsMs.
. Montinola testified she heard
Dr.
Dr . Favis order cocaine with adrenalin for
injection and heard Ms Ms.. Somera to have verified
the order
order. . Facts not brought in the trial were 1)
that Ms
Ms.. Somera
Somera.. Had finished her training only on
May 20
20,, 1929
1929;
; 2) that she had not received her
registration certificate and was not an
experienced graduate as states in the prosecution
prosecution;
;
3) that DrDr.
. Favis had performed tonsillectomy but
once previously in St St.
. Paul¶s and that no order
from Dr
Dr.. Favis was given before his arrival
arrival..
 The two accused doctors were absolved of the
crime but orenza Somera was condemned to suffer one
year and one day imprisonment and to indemnify the
heirs of Anastacia Clemente the sum of P1, 000000.
.00
with subsidiary imprisonment in case of insolvency
and to pay one
one--third of costs
costs..

On December 2020,
, 1929
1929,
, the supreme court
affirmed the aforesaid decision, stating as follows
follows::
³Wherefore finding the decision of then lower court
to be in accordance with the facts and the law, it
is confirmed in all respect, with costs against the
appealant.
appealant .
 Bn view of the recommendation of two of the
justices of the supreme Court who reviewed the case

 the appeal of the counsel of the defense, the
unanimous recommendation of the Board of Pardons,
and the petition of the Philippine Nurses
Association for executive clemency, the Governor
Governor-
-
General remitted the part of the sentence which
called for prison confinement provided that
olrenza Somera would not, in the future, Violate
any of the penal laws of the Philippines
Philippines.
.
 Executive Clemency is the power of a
President in federal criminal cases, and the
Governor in state convictions, to pardon a person
convicted of a crime, commute the sentence
(shorten it, often to time already served), or
reduce it from death to another lesser sentence
sentence.
.
There are many reasons for exercising this power,
including real doubts about the guilt of the
party, apparent excessive sentence, humanitarian
concerns such as illness of an aged inmate, to
clear the record of someone who has demonstrated
rehabilitation or public service, or because the
party is a political or personal friend of the
Governor.
Governor .
Additional Bnfo:
Bnfo:

1. Bn 1929
1929,
, in Manila, orenza Somera (a nurse),
was found guilty of manslaughter, sentenced to a
year in prison, and fined one thousand pesos for
following a physician's orders
orders..
.. She was found
guilty because when the doctor said cocaine
instead of procaine, she did not question his
orders.
orders .
 Manslaughter is a legal term for the killing of
a human being, in a manner c onsidered by law as
less culpable than murder
murder..
The law generally differentiates between levels of
criminal culpability based on the 
 , or state of

,
mind.
mind. This is particularly true within the law of
homicide, where murder requires either the intent to
kill, a state of mind called  , or 
,
, which may involve an unintentional killing



,
but with a   

 for life
life..
Manslaughter is usually broken down into two
distinct categories
categories:
: 
 
 
and

 
 
.

.
B. Voluntary manslaughter
Ð
 
 
occurs when the
defendant kills with malice aforethought
(intention to kill or cause serious harm), but
there are mitigating circumstances which reduce
culpability.
culpability . Voluntary manslaughter is a lesser
included offence of murdermurder.. The traditional
mitigating factor was provocation, however others
have been added in various jurisdictions
jurisdictions..
The following are some examples of defences which
may be raised to mitigate murder to voluntary
manslaughter:
manslaughter :

1. Provocation
A killing occurred after 



 by an
event which would cause a reasonable person to lose
control.
control .
2. Bmperfect self
self--defense
Allowed only in a limited number of
jurisdictions in the United States
States.
. Self
Self--defence
is generally a complete defence to murder murder.
.
However, a person who acted in an honest but


 belief that deadly force was
necessary for self
self--defence could still be
convicted of voluntary manslaughter or deliberate
homicide committed without criminal malice
malice.. 
is found if a person killed intentionally and
without legal excuse or mitigation
mitigation..
3. Diminished capacity or a mental breakdown
can be a defence to negate the mental state of
"malice".
"malice" . Bf a jurisdiction recognizes that a
person can kill with justification, but also
without any evil intent, that jurisdiction is free
to define the crime as something less than murder
murder.
.
Not all US states do this
this;
; in many, a mental
defect, or even mental illness, won't reduce the
seriousness of the offence whatsoever
whatsoever.. However, if
a US state legislature chooses, a diminished
mental state may justify the finding of a lesser
crime.
crime . This is distinguished from the complete
defence of Bnsanity
Bnsanity..
 . Bnvoluntary manslaughter
BB.
BB
B
 
 
is the unlawful
killing of a human being without 
. Bt is distinguished from voluntary



.
manslaughter by the absence of intention
intention.
. Bt is
normally divided into two categories
categories;; constructive
manslaughter and criminally negligent
manslaughter.
manslaughter .
The egal Metaphor
1. Bn 1929
1929,, in Manila, orenza Somera (a nurse),
was found guilty of manslaughter, sentenced to
a year in prison, and fined one thousand pesos
for following a physician's orders
orders..

a. She was found guilty because when

the doctor said cocaine instead of
procaine, she did not question his
orders.
orders .
The egal Metaphor
2. Nurses cannot just depend on what the doctors
say;
say ; they have to know if what the doctor orders
is correct
correct..

3. Nurses have adopted the ethic of advocacy for

patients

a. Unfortunately hospitals don¶t like having

problems called to the public's attention,
and give the nurses a very bad time about
it.
it .
Conclusion:
Conclusion:
Discussion of this case among Nurses and nursing
students led to remarks that the incident should not
have happened had Miss Somera asked, ³Doctor, did you ask
for Cociane or Novocaine
Novocaine?´
?´ and if the doctor insisted on
cocaine, she should have directed the nursing student tp
dip a cotton pledget in cocaine was administered
topically.
topically.

A nurse must see to it that she understands the

action of a drug, its minimum and maximum dosages, route
of administration, the untoward effects so that she may
skillfully, safely, and effectively carry them out
out.
. She
should be able to report and record the effects on the
patient so that the doctor can judge its therapeutic
value and know when to discontinue their use
use..
 Tests and treatments should be explained to
the patient in accordance with the general plan of
his care so that the patient casn give full
consent and cooperate in its implementation
implementation.. Any
unfavorable psychologic or physical reaction
should be likewise reported so that the proper
action may be taken
taken.
. Sometimes, however, refusal
may be due to inaccurate presentation of facts facts.
.
Patients must receive special sympathetic
attention from the nurse
nurse.
. Every effort should be
made to correct inaccurate views and modify
superficially-
superficially -held beliefs
beliefs.
.
Cocaine or Novocaine
Novocaine??

For an ANSWER, a
life, its cost«.
Somera Case {1928}
Cocaine or Novocaine
Novocaine??

For an ANSWER, a
life, its cost«.
Somera Case {1928}
Cocaine or Novocaine
Novocaine??

For an ANSWER, a
life, its cost«.
Somera Case {1928}
Cocaine or Novocaine
Novocaine??

For an ANSWER, a
life, its cost«.
Somera Case {1928}