Dr Kaimangar
direct , Walgren
Assuming CM finds MJ at noon, calls MAW at 12 12 : what is the significance of these 12 mn ? : lack of blood flow to vital organs, especially to the brain. Some individuals are more susceptible than other to lack of oxygen. Generally it take 3 to 4 mn before brain cells start to die. Time is really important. 911 was called at 12 20. At that point, 20 mn after, it reaches a point where it becomes irreversible.
Deception of paramedics & ER staff : did not provide the acurate info to paramedics and ER staff, deviation of standard of care.
Insomnia :
CM din't properly evaluate insomnia. Insomnia can have may causes, so it's important to have a detailed history. You need to exlude secondary probems (psychological problems, substance abuse, underlying conditions, chronic ansiety, depression , etc...)
Insomnia = no restful sleep for 4 weeks or more. Once you've ruled all the secondary problems, you can talk about primary insomnia.
You need a detailed sleep history : when do they go to bed, when do they fall asleep, when do you wake up, etc.. check sleep apnea. In some cases you need a sleep study.
You need a detailed pharmaceutical history : both prescribed or over the counter (example migraine pills contain caffein, that can cause insomnia), illicit drugs.
You need a detailed physical examination : some underlying conditions can cause insomnia : for example asthma, congestive heart failure, diabetes, bladder problems, enlargement of prostate, thyroid conditions, etc..
You need blood testing to rule out certain conditions : examples diabetes, kidney problem, restless legs , etc..
would a good blood work reveal the use of narcotics ? If you ask for it yes.
If you feel the patient is not giving the information, you can simply refuse to treat that patient ? Yes, absolutely. You can also do a tox screen without his knowledge, but Dr Kaimangar doesn't want to do that.
Then you treat the underlying condition that causes the insomnia.
In this case , CM didn't have a detailed history. Didn't check what the root problem for MJ's insomnia was before treating him.
CM did say that he saw that other doctors were treating MJ, he said he saw IV sites. If he could not get that info from MJ, CM should have refused care, refused to give further medication. CM didn't do that, that was unethical.
Bypassing the evaluation of insomnia, bypassing the detailed history was a deviation of care.
It was obvious there was probably secondary causes in MJ's insomnia (substance abuse or anxiety or depression ) these underlying causes should have been treated.
He talks about sleep hygiene techniques that can help in case of insomnia (using a bedroom to sleep only, amog other things)
He talks about sleep restriction : tell the patien to go to bed later , and limit their time in bed.
You can use relaxation techniques.
All these can usually work better to treat insomnia than pharmacological approach. But pharmacological approach can also be used.
Were those techniques used on MJ ? No. CM went directly to the pharmacological approach.
Phmacetical approach : 3 medications are not benzos and should be used first, because they are not addictive . A newer drug is melatonin something (sorry) , less addictive.
Benzodiazepines : cites 4 different benzos that deal with insmnia. Others are used also, but their main goal is to treat underlyng conditions (anxiey). They are used in tablet form
Midazolam : not appropriate for long term use for primary insomnia
Valium : not appropriate for long term use for primary insomnia
Lorazepam : can be used on short term basis, tablet form. Really addictive after 3 to 4 weeks. Used to treat underlying conditions, not primary innsomnia.
The use of midazolam and lorazepam to treat insomnia was an extreme deviation of care. Especially in IV form.
Propofol : inconceivable to use this drug for the management of insomnia, regardless of the setting. It is «*beyond comrehension, iconceivable, disturbing*». It's beyond a departure of standard of care.
Especially when underlying causes for insomnia were not treated.
Did CM cause MJ's death, even if MJ took lorazepam and propofol himself ? Yes, especially if the patient has had problems of substance abuse. The lorazepam and propofol should not have been within his reach.
Using «*only*» 25 mg propofol there is a risk of respiratory complications ? : yes, absolutely especially if the patient is dehydrated. Any competent doctor would have been aware of the risk.