And the murderer is…

Tuesday, February 9, 2010

Michael Jackson remains a star even in death. Last week it was on stage at the Grammy awards and this week it is in the courtroom. Propofol was named as the killer by the LA coroner but the accomplice was his personal physician who administered the medication and allegedly failed to properly monitor its use.

Propofol is a pretty wonderful drug and its use has changed the way patients have been treated in the ER and operating room. The drug is injected intravenously to quickly sedate a patient and then can be dripped in slowly to maintain that sedation. Once the intravenous drip is stopped, sedation wears off quickly. Its important side effects are expected: the patient gets so sedate that breathing slows or stops completely. Not really a big issue as long as there is somebody here to breathe for the patient. Interestingly, propofol doesn’t have any pain relief or analgesic effect, so pain medication may need to be added.

When patients require an operation or another procedure, anesthesia and sedation may be needed. They are not one and the same. Anesthesia decreases or stops pain sensation while sedation causes the patient to become more relaxed and hold still. Some procedures need the patient to be paralyzed to stop muscles from moving and going into spasm.

Depending upon the part of the body that needs care, the anesthesia may be local, regional or general. Most people have had local anesthesia to have dental care or have a laceration sutured. Lidocaine or similar drug can be injected into an area to make it numb for a few minutes’ work. These drugs can also be injected near a nerve to make a whole region numb. Again, dentists are skilled at making a patient feel as if half their face is about ready to fall off. And for larger areas, using a tourniquet to control where it goes, these medications can be injected into veins making whole arms or legs go numb.

For longer operations, general anesthesia may be required to make the whole brain numb. The difficulty is that many medications that do this also depress parts of the brain that are involved with basic life support functions like breathing and blood pressure control. The induction of the anesthesia requires a skilled person to monitor the patient’s ability to deliver oxygen to the body. Sensors can measure blood pressure, pulse rate and oxygen saturation and there is skill in balancing good sedation and pain control with basic bodily functions. Some cases require that the patient be paralyzed, so intubation with a tube placed in the trachea used with a ventilator is required. Since the thought of being awake and paralyzed is pretty awful, patients who require paralytic drugs are almost always sedated first.

Sometimes patients only need sedation, like a baby who needs to hold still for a CT or MRI. Sometimes patients need to be unconscious for only a few seconds like when their heart needs to be cardioverted (the scenario of “everybody clear?…shock”). Different medications can be used depending upon the situation to get the patient comfortable and in the right state of relaxation, sedation, pain control and paralysis.

What most patients don’t get is left alone once the medications are given. They are hooked up to heart and breathing monitors that do no good unless they are truly monitored. Patients are touched and examined to make certain that they remain asleep. They are not abandoned for any reason.

Michael Jackson was injected with propofol to help him sleep, not necessarily a recognized use of the drug, but the issue isn’t the drug but rather the circumstances. A few things were missing including a heart monitor, an oxygen saturation monitor and perhaps the most important monitor of all, the doctor at the bedside. The coroner’s autopsy report declared that Mr. Jackson dies of “acute propofol intoxication.” Perhaps the English translation of that statement should be that he died when his doctor forgot to breathe for him.

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