Dangerous21
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Ok here's my problem with the current situation. I know everyone is sort of making a big deal of the propofol use but i feel it is still being downplayed considering how horrendous this mistake was.
1: I feel that the fact that "Propofol" was used by this doctor OUTSIDE a hospital setting is being taken lightly and not seriously enough. I would have thought just proof of use of this drug would render his medical license invalid for the rest of his life. I am a doctor but i would never ever take chances with such a potentially dangerous drug with a very narrow index of safety(without proper monitoring)
There is something called a "sedation score" which the nurses usually keep in patients given sedatives which is essentially to make sure the patient doesn't get overdosed and stops breathing etc. It requires VERY meticulous and time specific monitoring of the patient. I can't believe that he gave MJ propofol and then had the time to even go to the loo.
2: A patient normally has no clue what "Propofol" is. It is a general anaesthetic and not a used for hypnosis primarily. Someone told MJ about it. I highly doubt he was able to google it. I suspect that someone was a doctor or a nurse. It is imperative that the person who suggested this drug as a sleep adjunct be found out and prosecuted separately for negligence.
3: There were additional sedatives in his system as well. Being a doctor myself, i am usually shit scared if i have to give a second sedative to someone and i instruct that the patient be monitored very closely. Any conscientious doctor would think long and hard before loading up a patient with multiple sedatives ESPECIALLY knowing that there wasn't adequate monitoring equipment on hand. He screwed up badly here.
4: Monitoring equipment. Unbelievable how he didn't have any. Sorry, but a simple pulse oximeter isn't going to give you all the information you need. The patient has to be on a Cardiac Monitor as well so his heart rhythm, rate and BP can be monitored. Propofol can cause changes in all these variables along with depressing breathing. How could he even think about administering the drug without all that equipment?
5: Intervention equipment. Equipment for intubation and resuscitation HAVE to be on hand. Laryngoscope, Endotracheal tube, Ambu bag, Ventilator, Oxygen source, Defibrillator etc are just some of the most important things that should have been present. I've seen propofol being used in surgeries and intensive care units and in all instances patients were connected to intensive monitoring equipment and were intubated(which means a machine was breathing for them).
6: Propofol is generally used as an inducer medication unless the surgery is really short. It is a very fast acting drug which wears out really quickly. Hence it can cause respiratory depression very very quickly because of it's quick onset of action. In intensive care units, they generally use it to instantaneously sedate the patient and only continue it when the patient requires sedation for a relatively small period when it's given as an infusion. When they want prolonged sedation they sometimes use other sedatives which act for a longer period of time and wear off slowly.
Now, if CM wanted to induce sleep he was taking a HUGE gamble because he was subjectively assessing MJ's sedation level after administering propofol. He was LOOKING at MJ to see how his breathing was. He couldn't tell what his heart rhythm etc was objectively. It was SO easy for him to miscalculate and overdose MJ especially since there are so many medications that sedatives can interact with. Why he would give propofol in the presence of other sedatives is beyond me but if he actually wanted to use propofol continuously(which i suspect he did) then his actions are beyond stupid. You HAVE to have certain propofol levels in the blood stream to keep the patient sedated. Not everyone responds the same to the same dose of propofol either. Calculations have to be made to cater for the weight of the patient. I think CM screwed up BADLY when calculating his dosages. He either didn't cater for MJ's weight or other medication that he had already given. Or, maybe, he just turned up the rate of propofol when he felt MJ wasn't responding to the propofol and then went away to make his calls. Either way, bad bad decisions.
7: Propofol is absolutely contraindicated in the presence of other Central nervous system depressant medication unless being administered in a hospital monitored setting because that INCREASES the efficacy and as an extension, the side effects of propofol.
8: His claim that he only gave 25mg of propofol sounds ridiculous because the levels of propofol in MJ's body indicate that the propofol had been given as an infusion at a higher dose and for a fair period of time. Definitely not as a single injection.
9: The claim that MJ self administered is a bit far fetched. Deaths by self administration have happened before but usually at therapeutic levels of the drug because as soon as the levels get high enough for sedation you fall asleep and can't fiddle with your dose anymore. The levels found in MJ's body were higher than those levels and the only way those could have been achieved were if he were to wake up somehow and turn the rate of the drip really high before getting sedated. It is highly unlikely though that that could have happened considering the drug's properties and in any case CM should have been there at the bedsise to make sure nothing of that sort happens which he is taking CARE of the patient and earning big bucks while doing it.
10: There is no antidote to Propofol unlike other opioids. The only management is, yep, supporting the heart and the breathing with the equipment i mentioned above till the patient loses all the propofol from the body. That makes it all the more apparent how unprepared the doctor was for any eventualities.
11: Presence of Lignocaine in the system. Now what was Lignocaine doing there? Who administered it? It's a local anaesthetic when used topically but an anti-arrhythmic when given IV. It also has the potential to cause abnormal heart rhythms on it's own. If it was given at UCLA then that's fine because it can be used for resuscitation if required but if it was administered prior to that by CM then i would like to hear his reasons for giving it.
Sorry for the long post guys. Just had to let some of my concerns out. Of course there's other stuff like time wasting, improper CPR and withholding information. All those things should be more than enough to get him at least a few years behind bars without question.
When we sedate patients for diagnostic purpouses (usually doesn't last longer than an hour), we only use a pulse oximeter as well. It is enough when you just sedate the patient. However, we always have an anesthesiologist and a nurse present. And we ALWAYS have intubation gear, emergency drugs, suction, and anything else you might need in an emergency, close by. If the patent is sedated for some small "surgery" or something where a doctor is needed, then the one sedating the patient is NEVER the one to do the procedure...so in that case you have the doctor for the procedure, the anesthesiologist, and usually at least one or two nurses there. The patient always gets extra oxygen with an oxygen mask throughout the sedation . But again, the patient is only monitored with a pulse oximeter.
Lignocaine...I take it you mean Lidocaine? That is used with Propofol so that the Propofol doesn't burn. If you give Propofol into a CVC (central line), you won't need Lidocaine, but if you give it into an i.v. you usually always use Lidocaine to prevent the burning sensation.
Agree almost completely with DangerouslyBad. In all my training, I've only seen propofol being used in the ICU, OR, or ER, and always with cardiac monitoring. I'm shocked this dude still has his license.
I'm sure different hospitals have their own protocols for propofol use, but at mine, we always have a patient on a cardiac monitor as well as pulse ox. We do use propofol for prolonged sedation in the ICU for intubated patients, etc.
I don't see how there is even the slightest reason to use propofol as CM did.