http://www.washingtonpost.com/wp-dyn/content/discussion/2009/08/24/DI2009082402471.html
Michael Jackson Dies From Lethal Dose of Propofol
Powerful Anesthetic Administered by Dr. Conrad Murray
Lawrence Kobilinsky
Forensic Scientist and Chairman, Dept. of Sciences, John Jay College of Criminal Justice
Tuesday, August 25, 2009; 1:00 PM
Michael Jackson died in his rented mansion June 25 from a deadly dose of the
powerful anesthetic drug propofol, according to an affidavit unsealed Monday. The Los Angeles coroner made that assessment after reviewing preliminary toxicology results from Jackson's autopsy, according to the search warrant affidavit given by police Detective Orlando Martinez.
Lawrence Kobilinsky, a forensic scientist and chairman of the Dept. of Sciences at the John Jay College of Criminal Justice in New York, was online
Tuesday, Aug. 25, at 1 p.m. ET to discuss the report and explain what the findings may further indicate.
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Washington, D.C.: According to Dr. Murray, he administered 25 mg of propofol to Michael Jackson. The coroner has determined that Jackson died from a lethal dose of propofol. Is 25 mg a lethal dose if administered in the proper conditions.
Lawrence Kobilinsky: The dosage administered by Dr. Murray (if accurate) is far below a lethal dose. It is the combination of Propofil and the other benzodiazepines that resulted in death due to respiratory failure and cardiac arythmia resulting in cardiac arrest.
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Washington, D.C.: Every anesthesiologist I've ever spoken to has told me that you just don't screw around with Propofol without oxygen and assisted breathing. Even then, most will not go anywhere near it except in the context of an operating room. The fact that a cardiologist without proper training even ventured into this territory tells me that someone is going to prison.
Lawrence Kobilinsky: Propofol is a very commonly used anesthetic and if administered by a trained physician anestesiologist does a fantastic job. It has its effect manifested quickly and upon cessation of administration, the patient wakens with virtually no side effects. This is not a drug to be administered in a home setting. When it is used, the patient must be constantly monitored and there must be equipment available to resuscitate the patient if he/she begins to go downhill.
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Germantown, Md.: I wonder how realistic it is to press criminal charges in a case where a patient demanded the drugs. Certainly there are medical ethics questions, and I can easily envision a wrongful death suit, but homicide?
Lawrence Kobilinsky: A person has died. The question is: Did the patient die as a result of "bad judgement" on the part of the physician. There is a line between malpractice and criminal behaviour. The question is whether or not the charge will be manslaughter and if so, then to what degree. Ethics is certainly part of the issue. The oath that every physician takes is "to do no harm." Mr. Jackson's death was certainly a harm that cannot be reversed. Did the doctor intend to kill Michael Jackson? Of course not. But...he should have realized that administering so many CNS depressing drugs was dangerous to say the least. Bad judgement can kill.
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Washington, D.C.: If Michael Jackson had been taking all of the drugs found in his system for years how can the doctor be charged with homicide?
Lawrence Kobilinsky: Because, whatever Michael Jackson took in the past is almost irrelevant to the present case. The Doctor will certainly argue that Mr. Jackson was addicted to a host of drugs including propofol and that he was trying to wean him off of these drugs while at the same time helping him deal with his horrible insomnia. Jackson was obtaining all types of prescription drugs (Schedule IV) from a number of physicians. In a sense they all share in the problem of caving in to the request of a very wealthy but needy celebrity
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Chattanooga, Tenn.: I've heard the coroner ruled MJ's death a homicide. What exactly does that mean?
Lawrence Kobilinsky: The medical examiner is charged with finding the cause and manner of death. Cause of death is a medical explanation for what resulted in the death (stroke, severing of an artery by knife, etc). Manner of death has 5 categories:
Homicide, Suicide, Accidental, Natural Causes, Cause unknown (for the time being). Calling the death a homicide does NOT mean that Dr. Murray will be charged with homicide. It does mean that the death was criminal and somebody must be charged as a result.
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Washington, D.C.: In such a case, where a patient needs such heavy medication to sleep, shouldn't the doctor be trying to find out the cause rather than medicate so heavily? And...what could have been the cause of this severe insomnia?
Lawrence Kobilinsky: Insomnia is a terrible condition and affects millions of people in this country. Typically, physicians will prescribe a drug in a class called benzodiazepines. Each of these has a number of effects on the patient: 1. sedatiion; 2. Muscle relaxant; 3. relieves anxiety 4. Anticonvulsant; 5. Amnesic. Each by itself in the right dosage will not harm a normal individual. Patients with respiratory issues can be seriously effected by any of these drugs and they should be avoided. Assuming that Jackson had no such problems but suffered only from insomnia, administering one of these drugs makes sense. But not all of these drugs in combination. Michael Jackson was certainly addicted to this class of drugs and because of the fact that his body was accomodated, he required higher dosages to fall asleep. After becoming addicted to these medications, one will have a rebound effect if they are abruptly stopped. Insomnia is what I mean by a rebound effect.
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Lawrence Kobilinsky: My name is Lawrence Kobilinsky Ph.D. and I am a Professor of Forensic Science and the Chairman of the Department of Sciences at John Jay College of Criminal Justice in New York City. I have been asked to discuss a number of cases wherein a celebrity has died as a result of drug toxicity. I have found that the cause of these deaths is not any one drug but a combination of drugs that act in a similar fashion to depress the central nervous system, to slow respiration and to affect heart rhythm. It is a tragedy that we now have another celebrity fatality due to a combination drug situation.
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Washington, D.C.: Do you think it is plausible that Jackson could have slipped out of consciousness such that he couldn't be resuscitated in the supposed 2 minutes that the doctor was out of the room? Even if the doctor hadn't left the room, do you think that he could have saved Jackson once all of the drugs had been administered?
Lawrence Kobilinsky: This is a very tough question to answer. There is a point during which CPR and counteracting meds will fail to save a life. Dr. Murray administered CPR and gave Jackson an antagonist (anexate) to counteract the effects of the benzodiazepines. Nothing helped. He made two mistakes:
1. the anesthesiologist should never leave a patient's side when the patient is administered i.v. propofol and 2. he should have called paramedics immediately upon learning that Jackson had respiratory failure. These issues will haunt him when the trial commences.
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Reston, Va.: What could have caused such severe insomnia?
Lawrence Kobilinsky: Jackson was under great pressure and I suspect his mind was racing "a mile a minute." All he could think about is "why can't I fall asleep." His body was accomodated to these drugs and therefore required a higher than normal dosage to have any effect. The propofol was the straw that broke the camel's back. Some people can fall asleep listening to music or by doing breathing exercises, or by drinking milk or by counting sheep. Others request and demand drugs. The physician's responsibility is to treat the patient without making the problem worse. Not an easy task.
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Newport, R.I.: My God. Dr. Murray should clearly bear the consequences of forsaking the boundaries prescribed by his medical license and the poor professional judgment he has shown and never, ever be permitted to practice again. If he or any other physician can be so easily compromised by the clout of a celebrity and the smell of a stack of greenbacks, he should not be put in such a position of trust again. That said, it is insidious that the Jackson family is crying foul play in a situation where Michael has a well documented history of prescription drug abuse and where Michael apparently insisted on the medications or as he called it, his "milk." It is patently clear that had he not gotten it from Murray, he would have just gone to someone else -- and he apparently has. The sad truth is that this family sees profit in keeping the Michael Jackson tragedy alive.
Lawrence Kobilinsky: Your comments are reasonable and logical. I think that Dr. Murray felt (and perhaps still feels) that he did nothing wrong. He was trying to cure the insomnia while at the same time weaning Jackson off of propofol. At some point, he had to make a choice. Should I give him more valium? ativan? versed? or must I provide the propofol. He decided that he had to provide all of these drugs to get the desired effect. Bad decision. Bad result! Michael Jackson got his sleep....... permanently!
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Anonymous: How important is the timeline in this tragedy? In your opinion could this have been averted if emergency help was called sooner?
Lawrence Kobilinsky: It is hard to say if paramedics could have saved him. Once the heart stops beating, oxygen depletion of the brain follows quickly and the results are irreversible in a matter of minutes. Waiting more than an hour to call 911 was another poor choice of action.
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Boston, Mass.: Do you think 2nd degree murder charges are possible?
The negligence of this case is crazy; no doctor can get away with this and the other involved should get some kind of punishment also.
Lawrence Kobilinsky: I highly doubt that the charge against Dr. Murray will be murder. The laws are fairly clear as to which charges might apply. Often the D.A. will start with "higher" charges and then as the trial approaches the charges are "lowered." The jury may be given a menu of charges to decide from. We will have to wait to see what the D.A. decides to do. I think the big piece of the puzzle that is missing is the Toxicology Report. What will that say? This is the most important part of the case which we still have not as yet seen.
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Washington, D.C.: So, do you think Dr. Murray will be criminally charged? Even if he isn't convicted, could a separate process bar him from practicing medicine based on his negligence?
Lawrence Kobilinsky: I do thin that Dr. Murray will face criminal charges as well as malpractice charges. There is a good possibility that he will be sanctioned by the medical board and that his license will be suspended. We have to be careful however. He has not been tried. There is no indictment. He is entitled to a defense once he is charged. There may be facts that we still do not know. A person is innocent until convicted by a jury of his peers. The case will continue to be of interest to me and to the rest of the world.
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Washington, D.C. (not a state yet): Why would a physician not just say no? The crime to me is that Michael Jackson had so many people around him who could be bought off.
Lawrence Kobilinsky: You hit the nail on its head, my friend. A physician should learn how to say no. Of course, that would mean that he could be fired and lose his incredible salary ($150K/month plus expenses). No doubt, othere physicans would be called in and pressured in the same way to provide sleep aiding drugs. The bottom line is that it makes perfect sense to say: I am your physician. What you are asking for could kill you. I will not give you these drugs because I have taken an oath as a physician to do no harm. Sorry!
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Fairfax, Va.: Jackson had said (supposedly to his then-wife Lisa Marie Presley) that he was afraid he would die the way Elvis did. And it wound up he did. Do you think this internal fear and sort of self-professing philosophy actually contributed to his death?
Lawrence Kobilinsky: It is interesting to make this point in retrospect. However, I think that Michael had everything to live for and was not suicidal. He had only one thought in mind. I need to sleep and I will do anything to cure my insomnia. I have experienced the effects of many drugs in the past and I never was harmed. I pay a small fortune to my personal physician and he has to help me. I know what is best for me. (This is me trying to get into the mind of Michael Jackson). The Doctor should have said NO to his demands for propofol.
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Washington, D.C.: In such a case as severe insomnia, is it better to treat or just look for a cause...it seems that nothing was working except the drug that killed Michael Jackson.
Lawrence Kobilinsky: Many people are under great stress in their everyday lives. Sometimes the source of the stress cannot be eliminated or eased. It is important that the body gets sufficient sleep to recover from the daily "assaults" that we all encounter as we live our lives. Sometimes, sleep medication is called for. BUT, it must be administered in the correct amount and not abused. All of these drugs are addicting and physicians need to be alert when prescribing these medications to avoid potential abuse of these drugs.
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Washington, D.C.: If the drug propofol is so dangerous, then how is it possible that any doctor without any anethesia experience able to puchase it so easily.
Lawrence Kobilinsky: The answer to your question is that physicians cannot obtain this type of medication from the local pharmacy or from the manufacturer. I suspect that the propofol was obtained 1. from outside of the United States where there are less strict controls on such drugs or 2. from a hospital. I suspect that the DEA and LAPD Narcotics detectives are trying to determine where the propofol came from.
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Anonymous: What defense is the doctor likely to mount in this case ?
Lawrence Kobilinsky: The doctor will argue that he was attempting to solve a medical problem by administering (normal) doses of benzodiazepines and that he was trying to wean his patient off of propofol which he had been getting by i.v. nightly for the past 6 weeks prior to his death. He was trying to respond to the complaint of insomnia through accepted means without propofol. It was only many hours later in the late morning that he realized that Jackson could not sleep when he made the fateful decision to give him a "low" dose of propofol. He administered CPR. He administered anexate to counteract the benzo drugs. He then called for help. He will have a tough uphill defense battle on his hands.
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Westport, Conn.: Was Jackson's personal MD a trained anaesthesiologist and did he always have the proper equipment, like an intubation kit and AMBU bag so someone else could breathe for Michael if he did become unconscious from this sedation? Can he lose his license for misprescribing this drug as a sleep aid?
Lawrence Kobilinsky: His personal physician is a cardiologist and not an anestesiologist. My understanding is that he did have equipment on hand to resuscitate a patient including oxygen if it was needed. I do not know if he had the kind of equipment that you mention in your question. I suspect that there is a significant chance that he will lose his license as a result of the death of Mr. Jackson. Again, I want to repeat that he has not as yet been charged. There is no indictment. There are no malpractice charges and he is innocent until convicted in a court of law. We will have to wait and see how this all plays out.
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Anonymous: How much will Jackson's mental health be an issue here? Is the case to be made that this was a very sick man who was trying to medicate away very serious mental illness?
Lawrence Kobilinsky: Whether or not Michael Jackson was in control of his destiny and was in his right mind is not the issue. The doctor was directly responsible for Jackson's well being. If he refused to administer the drugs, perhaps Mr. Jackson would be on his European tour right now.
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Richmond, Va.: Bravo to the comments from Newport, R.I. Michael Jackson was a drug addict, whose death was no more tragic than than thousands of addicts who die each year from drug overdoses, legal and illegal. As Newport points out, if it hadn't been Dr. Murray it would have been someone else.
It's time we stop lionizing a pedophile and a drug addict.
Lawrence Kobilinsky: The issue for me is that a person who was under the care of a physician has died. Did the doctor have any responsibility for the death. Whether Michael Jackson was a good person or an evil person is not an issue about which I have sufficient knowledge to address.
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Washington, D.C.: You wrote that Jackson had been receiving propofol by I.V. nightly for the past six weeks prior to his death. Why would the propofol kill him then on this particular day? Or was it the drug interaction that killed him, the combination that Murray gave him?
Lawrence Kobilinsky: The propofol did not kill him. It was the propofol plus the valium plus the ativan plus the versed that killed him. Multiple drugs all effecting the Central Nervous System is a toxic cocktail. The toxicology report will clarify exactly what happened.
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Lawrence Kobilinsky: I would like to thank you all for your excellent and thoughtful questions. There is much that we still do not know. On July 4th, my sister was in a hospital and was administered ativan despite the fact that she had respiratory problems. She died as a result of the administration of this drug. They refer to this as iatrogenic meaning that death was not due to natural causes but rather, the doctor, made a bad decision. We have to stop doctors from making bad choices. Doctors are trained to help patients and not hurt them. On that note, I must depart. Thanks again for your wonderful questions. Lawrence Kobilinsky
