Inside the case of Jacko's doc

Preliminary hearings have begun in Los Angeles, into the conduct of the curious Dr Conrad Murray in his treatment of Michael Jackson and the death of his patient.

In most countries, on the basis of the facts and allegations revealed so far it would be considered utterly obvious that a serious criminal trial was essential, to decide on the legal issue of guilt or innocence on several potential charges. Also required is a major professional inquiry into what might be considered unusually gross professional misconduct.

But this is happening in California, where the law can be loopy in its substance and application, especially when celebrities and rich folks are involved. So there is now a preliminary inquiry to decide whether he should stand trial. So it's a sort of trial to decide whether to have a trial, like a party at which one will decide whether to have a party.

To a dispassionate professional expert observer it seems obvious that some extremely peculiar things happened, which would be exceedingly difficult to describe as professional, competent, safe or justifiable. Indeed, one waits eagerly to hear what the defence arguments will be. The charge apparently being considered is "Involuntary Manslaughter" which sounds like an elaborate way of saying that whatever Murray did, he did not intend to end up with Jackson dead. Of course it's rare for anyone to wish to kill their cash cow.

When one looks at what has been alleged by the authorities and witnesses thus far, it's hard to see how this doctor's actions could be found to be innocent and entirely legal and professional. The state may concentrate on a pattern of behaviour that appears to have been attempts to cover up the truth. So does this behaviour signify the guilt of the doctor? And was he aware of his guilt in this matter?

Propofol and an unconvincing potential defence
There have been hints that the defence may try to suggest that Jackson injected the lethal Propofol himself. This would be rather hard to prove, and even if proved beyond doubt, would not absolve Murray of convincing allegations of dangerously mishandling the situation. If, as reported online, the defence will be that Jackson gave himself more Propofol after Murray had already injected some, that would be really hard to believe.

If, as alleged, Dr Murray failed to call for emergency back-up immediately he discovered his patient's calamitous collapse, but instead delayed between 9 and 21 minutes while scooping up bottles of Propofol and other such materials, it would appear that his primary concern at that critical moment was to protect himself rather than to try and save his patient.

I am aware of some reports of suicides by means of Propofol, usually by medical personnel, but these involved placing a large amount of the Propofol into a bag of infusion fluid, which was then allowed to run in rapidly. I am less sure that it would be possible, as Propofol acts so quickly, for someone to self-administer a very large dose by direct injection into an IV tube.

If a doctor had any idea that the patient might abuse or self-administer such a dangerous drug, he would of course not allow any of the drug nor syringes to be left within reach of the patient. Benzos can interfere with memory, it is believed that some people may accidentally overdose because they wake up and have forgotten that they have already taken their meds, and then take more, but this is not a known effect of Propofol. Propofol addiction, which may be suggested, is not really recognised, though its abuse is indeed known.

What would a good doctor do?
When you are hired as a full-time direct personal care physician, you would, if professionally competent and responsible, review the situation and do everything possible to promote the individual's health and minimise all obvious risks to his life. You would not tolerate the presence of a dangerous drug such as Propofol in a private home (let alone write prescriptions for it or administer it) and would not enable or tolerate a setup in which the person could possibly inject himself with such medication.

People do not die of lack of sleep; and generally it is their agitation over their insistence on sleeping when it suits them, that helps to keep them awake. But they do, almost inevitably, die of the use of dangerous drugs in the pursuit of sleep, whether administered by a physician or by themselves with the assistance of the doctor.

Important issues in this case
There seems to be a real risk that many highly relevant issues might be overlooked by the court. For instance, Propofol can never ever be used to manage insomnia, however severe it is claimed to be; it can never be properly used outside of a hospital setting, without full resuscitation facilities and staff, and needs to be administered by experienced anaesthetic specialist staff.

A doctor could not accept any responsibility for a situation in which such a drug was being inappropriately used at home for such a trivial reason, whoever was prescribing or administering it. Although Propofol is the most dramatically, grossly, inappropriate "treatment" which was used, the rest of it seems to have been incompetent, too. You do not give intravenous drugs of any variety for insomnia. And a combination of various sedatives has more complex and unpredictable effects.

A cardiologist with no experience in CPR? 
Murray is described by a witness as having been performing CPR with one hand, while Jackson's body lay on a bouncy bed. Boy Scouts know better than to do anything so silly, let alone medical specialists. Another witness said, incredibly, that Murray had asked if anyone else in the house could perform CPR, and had later said it was the first time he had ever performed mouth-to-mouth resuscitation. Could he really have qualified as a doctor, let alone as a cardiologist, without knowing much about resuscitation ? 

Full medical disclosure was essential
If, as reported, Murray failed to tell the paramedics and doctors exactly what drugs Jackson has been using, that would be astoundingly incompetent. A witness has said that on the contrary he told the paramedics that Jackson had not received any drug and did not have any significant medical problems. Why someone would have a doctor in attendance and an IV set up, if there was nothing wrong, would surely have puzzled the paramedics. If Murray failed to tell everyone that Propofol may have been involved, this, like the reported and priority concern with collecting the bottles and other traces of its use, suggests a very clear understanding that its use was unjustifiable.

Were stimulants involved? 
If Jackson's insomnia was really so troubling, why was he not referred to the recognised expertise of a major sleep clinic for proper and competent investigation and treatment?  No recognised sleep expert on earth would have recommended the treatments Jackson received.

One issue that hasn't been raised, is whether there was any use of stimulants, formally or informally, which might help to explain the insomnia. Though Propofol acts dangerously rapidly, and also wears off rapidly (which is why, even if it were utterly safe, it would be useless to manage a chronic problem) the benzodiazepines and similar sedatives used have lasting and cumulative impacts, and could lead to the person being drowsy and sedated when they needed to be alert for performances or rehearsals. It would be tempting then to use various stimulants, which would add to the later insomnia. It would certainly not be the first time a major performer became hooked on cocktails of sedatives and stimulants to switch them on and off as needed.

The dangers of being awfully rich
One of the risks the really rich run, is that their staff, and sadly, this may at times include a doctor, give them what they want and demand, rather than what they need. Yes, of course, if you refuse to provide what is demanded, you may be dismissed and that is the option you must choose rather than compromise your professional expertise and obligations just to make the rich guy content, whatever the dangers.

(Professor M.A. Simpson, Health24 January 2011)

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