bouee
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Hi everyone,
sorry guys, my computer (and a lot of other stuff) are giving me a hard time today, couldn't post the recap earlier.
*******
Dr Kaimangar
cross by Flanagan
If a patient is not in his area of expertise, he would send him to another specialist.
If a patient patient has had a bad therapy but was insisting on reciving it, what would you do ? : Nk would refuse the care, try to understand the problem, make sure the patient understands, patient may need another specialist
Did CM have theses conversations with mj : i don't know, there were no records
what if a patient asks for unapprioate therapy ? you should try to understand why they are refusing an appropriate therapy, and what does the patient really needs, and send him to the appropriate doctor, make sure that they get the right care , would not give the patient a care that he thinks is inappropriate
CM gave propofol during 2 months, and MJ had no problem : I don't know, there are no records, how don't know if MJ had no problems
In the evaluation of the degree of deviation from standard of care , the end result doesn't matter.
Do you know what happened on june 25th ? : MJ was receiving inappropriate therapy, with inappropriate equipment, in a dehydrated patient, delay in calling 911, that resulted in MJ's death
valium + mizadolam +lorazepam+ 25 mg propofol was an inappropriate cocktail,
Can this coctail be the cause of MJ's death : absolutely, especially Propofol and lorazepa, in a dehydrated patient, whose vitals we don't know ( blood pressure, heart rate, medication, etc )because there are no records
Flanagan : you don't know, if Murray had that info : in medecine, we can not take care of patient if we don't document things. It allows us to follow the patient.
You prepare a record for every patient so that you can remeber, and other ppl can know what happened : that is not the only reason.
The fact that CM did not keep records means that you can not interpret what happened : no it means that he didn't have the info, you can't take care of a patient only from memory. It's a recipe for disaster
have you been with one patient for 9 hours : yes, sometimes longer . Keeps notes. Nurses keep notes. Needs to refer to the charts frequently to get a better picture. It's imperative to have charts.
You think there's no way CM remebered what he was doing : keeping records is imperative, it's standard of care, especially when you give such a powerful drug as propofol.
Not keeping the charts did not kill MJ : it's a combination of many factors that killed MJ. The ailure of chart is a contributing factor in this particular context
You consider lack of charting bad medecine : yes it is clerly bad medicine.
Propofol + lorazepam was the direct cause of M's death, yes and they were given in bad circumstances
Lorazepam + propofol : lorazepam increased the side effects of propofol: I can't anser that, only can say that can be a lethal combination in a patient that is not monitored. Doesn't want to comment on the effect of lorazepam and propofol : he's not phamacologist. Has an understanding, but is not an expert in pharmacology.
Would the level of propofol be lethal without the lorazepam : defers to a pharmacologist
You don't know how much of propofol was given based on a 2.6 level : seen in people who self injection who had levels between 1 and 6, but would like to refer to a pharmacology expert.
Have you reviwed the records of A Klein : yes
did you review treatments given by Klein for april may june : yes
did he give 6500 mg demerol : he treated MJ with demerol
did you see that when MJ was getting demerol he was also getting midazolam : yes
MJ had a demerol problem : can't answer the question
What is demerol : pain killer, narcotic
what is midazolam : sedative , so the patient is not aware of the procedure
Is 200 mg demerol a large dose : it's a signifant dose. Avoids using demerol, makes someone more hyper, excitable, creates more stimulation.
Basic injection is hypnotic : can create euphoria, can cause neuro exitory effects, can cause insomnia in certain people. Secondary cause of insomnia.
Did MJ had insomnia problems : yes, he clerly had
What type of insomnia ? : there was no type of effort done to determine that. Can not say, can only make suggestions, but perhaps anxiety, dependency to certain medication (demerol) . There was some indication that there were suggestions of secondary causes.
Did MJ have refractery insomnia : NK can not say that;
What is primary insomnia : when there is no secondry causes, when no other treatment works.
Did you read CM 2206 2007 medical records for MJ: yes they were scatterd records
There were other sleep mediactions in mj's house prescriped by other doctors : yes
He had several doctors precribing for insomnia : yes, Metzger, Klein, doesn't recall dr Adams
So several drs tried : yes
Have you ever had a patient that was not forthright in their history , how do you handle it : Yes, he tries to get information from patient and from other doctors.
If the patient doesn't sign the relaese , you dont get his medical records : yes, you can't get them
Then what do you do : ask the people who live with the patient, asks for a sleep log
Using Ambien without a proper evluation of insomnia is not right, but not a serious deviation
Enlarged prostate can cause insomnia : yes.
Would you check arms for needle marks : yes, it's part of physical exam;
Would you detect IM (intra muscular) demerol : : it's variable, you may see it in some individuals
you know MJ had demeraol : yes, doesnt remeber the fequency. CM should have known, from the people around MJ, MJ's behavior, slurred speech, from people who witnessed the change of behavior. Example : his drivers.
So CM, should have interviewed security : yes . If he had heard that MJ was acting differently, CM should have found out.
There are studies about propofol as a treatment for insmonia : These are just experimental , it is in no way is a standard of care.
Taiwan study : dates back to november 2010. Patients had been extensively evaluated, informed constent was obtained, they fasted for 8 hours, the study was done in a highly monitored setting, reciving propofol via an IV pump. 64 patients received propofol. The patient fell asleep better, have less sleep interruptions. No complications because they were highly monitored. It's very prelimanry experient, good results. It has no clinical applicability, the Dr that conducted the study stated that there was aneed for further study.
Why is it incomprehensible to use propofol for insomnia : it was astudy, in a highly monitered settings. It is incomprehensible and inacceptable , especially with no monitoring and home setting.
25 mg propofol is a very low dose ? : yes.
You wouldn't expect problems with such a small dose : it depends on the patient : if the patient is dehydrated, had other medication (ie lorazepam), low blood pressure , there can be a problem that can lead to respiratory depression.
Lorazepam ; is not fda approved for primary insomnia, especially IV. Lorazepam in oral form can be used if cause of insomnia is anxiety, for a very short period of time: 3 to 4 weeks.
What is the diffrence in IV in oral : Lorazepam creates a great dependancy. Oral form is appropriate for short period of time. Iv is anappropriate, because monitoring is necessary, you get a larger dose when given IV. Even with monitoring, it is not FDA approved for insomnia.
Was lorazepam appropriate with anxiety due to an upcoming event (this is it) : what should have been done is to have psychological or psychiatric help. NK would not have used it in this case
EDIT : NK said he wouldn't have cancelled the event, but would have tried to find a solution to the anxiety
break
sorry guys, my computer (and a lot of other stuff) are giving me a hard time today, couldn't post the recap earlier.
*******
Dr Kaimangar
cross by Flanagan
If a patient is not in his area of expertise, he would send him to another specialist.
If a patient patient has had a bad therapy but was insisting on reciving it, what would you do ? : Nk would refuse the care, try to understand the problem, make sure the patient understands, patient may need another specialist
Did CM have theses conversations with mj : i don't know, there were no records
what if a patient asks for unapprioate therapy ? you should try to understand why they are refusing an appropriate therapy, and what does the patient really needs, and send him to the appropriate doctor, make sure that they get the right care , would not give the patient a care that he thinks is inappropriate
CM gave propofol during 2 months, and MJ had no problem : I don't know, there are no records, how don't know if MJ had no problems
In the evaluation of the degree of deviation from standard of care , the end result doesn't matter.
Do you know what happened on june 25th ? : MJ was receiving inappropriate therapy, with inappropriate equipment, in a dehydrated patient, delay in calling 911, that resulted in MJ's death
valium + mizadolam +lorazepam+ 25 mg propofol was an inappropriate cocktail,
Can this coctail be the cause of MJ's death : absolutely, especially Propofol and lorazepa, in a dehydrated patient, whose vitals we don't know ( blood pressure, heart rate, medication, etc )because there are no records
Flanagan : you don't know, if Murray had that info : in medecine, we can not take care of patient if we don't document things. It allows us to follow the patient.
You prepare a record for every patient so that you can remeber, and other ppl can know what happened : that is not the only reason.
The fact that CM did not keep records means that you can not interpret what happened : no it means that he didn't have the info, you can't take care of a patient only from memory. It's a recipe for disaster
have you been with one patient for 9 hours : yes, sometimes longer . Keeps notes. Nurses keep notes. Needs to refer to the charts frequently to get a better picture. It's imperative to have charts.
You think there's no way CM remebered what he was doing : keeping records is imperative, it's standard of care, especially when you give such a powerful drug as propofol.
Not keeping the charts did not kill MJ : it's a combination of many factors that killed MJ. The ailure of chart is a contributing factor in this particular context
You consider lack of charting bad medecine : yes it is clerly bad medicine.
Propofol + lorazepam was the direct cause of M's death, yes and they were given in bad circumstances
Lorazepam + propofol : lorazepam increased the side effects of propofol: I can't anser that, only can say that can be a lethal combination in a patient that is not monitored. Doesn't want to comment on the effect of lorazepam and propofol : he's not phamacologist. Has an understanding, but is not an expert in pharmacology.
Would the level of propofol be lethal without the lorazepam : defers to a pharmacologist
You don't know how much of propofol was given based on a 2.6 level : seen in people who self injection who had levels between 1 and 6, but would like to refer to a pharmacology expert.
Have you reviwed the records of A Klein : yes
did you review treatments given by Klein for april may june : yes
did he give 6500 mg demerol : he treated MJ with demerol
did you see that when MJ was getting demerol he was also getting midazolam : yes
MJ had a demerol problem : can't answer the question
What is demerol : pain killer, narcotic
what is midazolam : sedative , so the patient is not aware of the procedure
Is 200 mg demerol a large dose : it's a signifant dose. Avoids using demerol, makes someone more hyper, excitable, creates more stimulation.
Basic injection is hypnotic : can create euphoria, can cause neuro exitory effects, can cause insomnia in certain people. Secondary cause of insomnia.
Did MJ had insomnia problems : yes, he clerly had
What type of insomnia ? : there was no type of effort done to determine that. Can not say, can only make suggestions, but perhaps anxiety, dependency to certain medication (demerol) . There was some indication that there were suggestions of secondary causes.
Did MJ have refractery insomnia : NK can not say that;
What is primary insomnia : when there is no secondry causes, when no other treatment works.
Did you read CM 2206 2007 medical records for MJ: yes they were scatterd records
There were other sleep mediactions in mj's house prescriped by other doctors : yes
He had several doctors precribing for insomnia : yes, Metzger, Klein, doesn't recall dr Adams
So several drs tried : yes
Have you ever had a patient that was not forthright in their history , how do you handle it : Yes, he tries to get information from patient and from other doctors.
If the patient doesn't sign the relaese , you dont get his medical records : yes, you can't get them
Then what do you do : ask the people who live with the patient, asks for a sleep log
Using Ambien without a proper evluation of insomnia is not right, but not a serious deviation
Enlarged prostate can cause insomnia : yes.
Would you check arms for needle marks : yes, it's part of physical exam;
Would you detect IM (intra muscular) demerol : : it's variable, you may see it in some individuals
you know MJ had demeraol : yes, doesnt remeber the fequency. CM should have known, from the people around MJ, MJ's behavior, slurred speech, from people who witnessed the change of behavior. Example : his drivers.
So CM, should have interviewed security : yes . If he had heard that MJ was acting differently, CM should have found out.
There are studies about propofol as a treatment for insmonia : These are just experimental , it is in no way is a standard of care.
Taiwan study : dates back to november 2010. Patients had been extensively evaluated, informed constent was obtained, they fasted for 8 hours, the study was done in a highly monitored setting, reciving propofol via an IV pump. 64 patients received propofol. The patient fell asleep better, have less sleep interruptions. No complications because they were highly monitored. It's very prelimanry experient, good results. It has no clinical applicability, the Dr that conducted the study stated that there was aneed for further study.
Why is it incomprehensible to use propofol for insomnia : it was astudy, in a highly monitered settings. It is incomprehensible and inacceptable , especially with no monitoring and home setting.
25 mg propofol is a very low dose ? : yes.
You wouldn't expect problems with such a small dose : it depends on the patient : if the patient is dehydrated, had other medication (ie lorazepam), low blood pressure , there can be a problem that can lead to respiratory depression.
Lorazepam ; is not fda approved for primary insomnia, especially IV. Lorazepam in oral form can be used if cause of insomnia is anxiety, for a very short period of time: 3 to 4 weeks.
What is the diffrence in IV in oral : Lorazepam creates a great dependancy. Oral form is appropriate for short period of time. Iv is anappropriate, because monitoring is necessary, you get a larger dose when given IV. Even with monitoring, it is not FDA approved for insomnia.
Was lorazepam appropriate with anxiety due to an upcoming event (this is it) : what should have been done is to have psychological or psychiatric help. NK would not have used it in this case
EDIT : NK said he wouldn't have cancelled the event, but would have tried to find a solution to the anxiety
break
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