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  Featured Article
  September 2009

              Malpractice, Manslaughter or Murder-RIP MJ

                              Arthur H. Weintraub, MD, PhD                        

         The biggest medical-legal case of the year, maybe the decade, is Michael Jackson's demise,
         presumably at the hands of his personal physician, cardiologist Dr. Conrad Murray. With a supporting
         role played by numerous other physicians, pharmacists and friends and family that accepted
         prescriptions for Michael in their own names. And, oh yes, Jackson himself, who was addicted to
         numerous benzodiazepine (Valium, Ativan) tranquilizers, opioid painkillers and possibly propofol
         (Diprivan), the drug the Los Angeles coroner says did him in. Addiction to propofol is rare and largely
         confined to medical professionals, usually anesthesiologists who have easy access to the drug. It
         is not a  even a scheduled drug (controlled substance) by the DEA as are opiates and the
         benzodiazepines. All these drugs, however, depress respiration and administration together or at
         short intervals must be particularly closely monitored. No leaving the room to make telephone calls
         or even for a bathroom break allowed.

         By now everyone with a TV set knows that the good doctor shouldn't have given propofol as a
         sleep-inducing agent nor should it be given outside a hospital or outpatient surgical setting. It's
         usually used to induce unconsciousness before surgery or other procedures such as colonoscopy
         by a trained anesthesiologist familiar with the drug. It induces coma quickly after intravenous
         injection but is metabolized rapidly so that a continuous infusion of the drug must be given to
         keep the patient asleep and feeling no pain. Strict patient monitoring of heart rhythm, blood
         pressure, blood oxygen saturation and perhaps most important, respirations is required. An Ambu
         bag (face mask with compression bag to deliver artificial respiration) and an endotracheal tube 
         (breathing tube) must be ready for immediate use in case of apnea (no respirations) or other
         breathing complications.

         According to the coroner, Jackson's manner of death was homicide (death at the hands of another)
         and the cause was acute propofol intoxication. According to Dr. Murray's statement to the Los
         Angeles police he gave 25 mg of propofol to his patient around 10:45 AM. He previously had given
         Jackson several benzodiazepine drugs earlier in a vain attempt to get him to sleep. These were
         diazepam (Valium), midazolam (Versed) and lorazepam (Ativan). When he was still awake in
         mid-morning and demanding propofol (which previously had good results putting him to sleep)
         Murray gave him 25 mg. This appears to be a correct induction dose or even slightly lower than 
         recommended in the package instructions for the drug, assuming Jackson weighed about
         135 pounds. Nothing is mentioned about a maintenance infusion. Since Jackson was an
         habitual user of tranquilizers and pain killers and did not fall asleep despite more than adequate
         doses of the benzodiazepines, we assume he had some tolerance to these drugs.

         Since all of the drugs Jackson received are respiratory depressants it is assumed that the total
         "cocktail" of the drugs he received were to blame for his death. While Murray claims that he only
         left Jackson's bedside for two minutes to use the bathroom. the police reports have indicated
         that he made several cell phone calls shortly after 10:45 AM. When the doctor returned he found
         Jackson was not breathing and began CPR. Inexplicably a call to 911 was not made until around
         noon, leading to speculation that Jackson was already dead by the time the emergency call was
         made. Adding to the mystery is Murray's lack of appearance around 9 AM in the downstairs kitchen
         of the rented mansion, his daily habit, to pick up Jackson's breakfast.
           
         It's likely that one or more of the drugs that Jackson was taking enhanced the effects of the  
         propofol. The fact that he was given multiple injections of several benzodiazepines in the wee
         small hours of the morning but this failed to put him to sleep attests to a high degree of tolerance,
         consistent with a history of addiction to these drugs. Interestingly the coroner's toxicology report
         did not specifically mention Oxycodone or other opiate painkillers commonly used by prescription drug
         addicts. The autopsy result itself indicated that most of Jackson's internal organs were in good
         shape except the lungs which showed some evidence of inflammation and scarring. This may also
         have contributed to increased sensitivity to respiratory depressant drugs.

         Here is a section of the drug interactions of propofol from the package instructions for its use. "The
         induction dose requirements of DIPRIVAN Injectable Emulsion may be reduced in patients with
         intramuscular or intravenous premedication, particularly with narcotics (e.g., morphine, meperidine,
         and fentanyl, etc.) and combinations of opioids and sedatives (benzodiazepines, barbiturates,
         chloral hydrate, droperidol, etc.). These agents may increase the sedative or anesthesia effects of
         DIPRIVAN Injectable Emulsion and may also result in more pronounced decreases in systolic, diastolic,
         and mean arterial pressures and cardiac output."

         So, malpractice for certain: extreme negligence in giving propofol in a home environment without
         proper monitoring equipment and after multiple other drugs that depress respiration; leaving the
         patient while he was unconscious, although the period of time is disputed; failure to call 911
         promptly. Dr. Murray will surely lose his license to practice in California and probably the other
         states where he has offices. Murder: doubtful for there is no intent to kill the patient. After all,
         Murray was killing the golden goose that was paying him $150,000 a month for personalized medical
         care. Manslaughter appears to be the most likely criminal charge. It will not be a slam dunk case for
         the prosecution, however, since they must prove reckless negligence in the doctor's treatment.

         How about the other doctors that prescribed for Jackson, often excessive doses and under a variety
         of patient pseudonyms? The situation is reminiscent of the Anna Nicole Smith case in which both
         lawyer-boyfriend and personal psychiatrist have been accused of illegally providing her with
         tranquilizers and narcotic painkillers. Here it may be more difficult to initiate a criminal case since
         it's hard to prove that the doctors knew of other physicians prescribing the same or similar drugs. 
         Although it is illegal in California to prescribe a drug for a false-named patient, this is a common
         practice in the entertainment community who wish to keep their ailments and drug use confidential.
         The defense may even be able to argue that this is the standard of care for high profile patients.