Q&A with Dr. John Dombrowski, Part 2: Anesthetizing Michael Jackson "indefensible"

This is the second part of my conversation with Dr. John Dombrowski, a Washington D.C. anesthesiologist and pain management specialist who sits on the American Society of Anesthesiology's administrative affairs committee. Dombrowski has written and talked a lot about the need for better pain management practices in the wake of Michael Jackson's death.

I reached him at his home in the Washington D.C. area. Here is a recap of our conversation. It has been edited for space and clarity.

Q: Let's talk about some of propofol's side effects. How do they usually play out? Does a patient go home and end up with a heartbeat that is too fast, too slow or too irregular and then end up in cardiac arrest?

A: Not exactly. With propofol and most anesthetics used in same-day surgeries, people are pretty much street ready a few hours after the surgery. We have to make sure they are physiologically and hemodynamically stable before they go home, so, if there are side effects, we will know about it.

Q: How do you do that?

A: We measure their ability to breathe, their color, their arousability, their heart rate and blood pressure. You don't leave until all your parameters are exactly where they started. Propofol is such a short-acting medication. I give it to you, you're asleep and, literally, minutes later you're awake, clear-headed and eating and drinking. That's how clean it can be to use. This drug replaced a drug called pentathol. You might remember people in the movies saying, "Give him some truth serum." This was truth serum. It would make you so relaxed that you would just say anything. It also would go everywhere in your body and took hours to get out of your system. That's why, when propofol came on the field 20 years ago, it was a huge revolution.

Q: Can you visually tell if someone is suffering side effects, or do you need equipment from the hospital or office setting?

A: The main side effect is sleepiness. That's the most obvious side effect. That's why it's not a good idea to use it as a sleep aid. Now you're trying to achieve the side effect. Going beyond that, the most obvious side effect would be the patient is not breathing quickly. The respiratory rate is eight breaths a minute instead of 16 breaths a minute. Obviously the best equipment that you have is the anesthesiologist who is looking at the patient and touching the patient, checking his breathing, asking questions. All the other monitors that you have are then backing up your visual analysis.

Q: In most cases, how long would a patient be asleep after a typical dose of propofol?

A: Three to five minutes is typically how long you would be asleep. That's for most simple procedures. If you doing a more involved surgery, you would hang the medication and drip it in to keep the patient at a constant level of sedation. That's called total intravenous anesthesia. You would do that for bypass surgery, and you would be done within two or three hours.

Q: The risk of sudden low blood pressure as a result of propofol can be as great as 26%, meaning, in some circumstances, that as many as a quarter of the patients administered the drug can end up with low blood pressure immediately after. Does that seem acceptable?

A: It sounds terrible if you don't treat it. People aren't given the medication in a vacuum. If someone develops low blood pressure, you give them extra fluids and maybe a medication to counteract the blood pressure. You give them Sudafed, basically, Afrin.

Q: You're a board-certified anesthesiologist. Why is it important for a doctor to be credentialed when administering this drug?

A: The credentialing shows that you have the education and training to handle these medications. And, more importantly, it shows that you can handle the complications. Any doctor can give any patient most drugs. Bad things are always going to happen. It's how you manage the problems once they arise.

Q: As a patient, what can one do to make sure they are given anesthesia medicine by a certified anesthesiologist?

A: People should say, "I don't want to insult you, doctor, but this is an anesthetic you are going to give me. Do you think you need an anesthesiologist here?" If the doctor says, "no," you can say, "I would rather have someone with the appropriate training give me that medication." Any doctor should understand that. I would never give someone chemotherapy. Do I have the right do it, as a physician? Yeah. Is it appropriate, given my background and training? No.

Q: In the American Society of Anesthesiology's recent statement on propofol, the group says that "use of the drug should be directly supervised by a physician trained in anesthesia and qualified to provide physiologic rescue should too much drug be given." What would that sort of rescue look like if the drug wasn't administered in an operating room but instead in someone's house?

A: You would have to have the appropriate resuscitation equipment. That means oxygen. That means a defibrillator and IV fluids and adrenaline to pop someone's heart rate up. That means the appropriate monitoring equipment, like a pulse oximeter.

Q: What might Dr. Conrad Murray's response be if he is accused of inappropriately administering propofol?

A: I'm thinking it's indefensible. He might say, "I'm a doctor. I can do anything I want." The way I have seen some of the articles about this case is that he did have oxygen in the room, etc. If so, he could say, "I tried my best to provide my patient with the care he needed. I tried everything I could to help him sleep. I wanted to make sure he had a restful sleep. I didn't want to give him any more narcotics to help him sleep. I was trying to give him something short-acting that seemed safer."

Q: Is there a legitimate scenario where he could have been using the drug to help Jackson sleep?

A: No. It's only used in a controlled setting. A doctor's office and a hospital for a procedure. That's like me recommending chemo for someone because they are tired of shaving their head.

Q: Jackson may have been taking other drugs, painkillers, Xanax, etc. How might that have interacted with the propofol?

A: In a very bad way. It's because he's already got this cocktail of respiratory depressants in his system. We are in college and doing shots of Jack Daniels, and then we go out and have just a couple of beers. Those beers on top of those shots just tip me over. And that's exactly how this happens with propofol on top of painkillers.

Q: Dr. Murray might not have known what Jackson was taking, right?

A: Amen, brother. That's the point. That's why you have everyone trained in their subspecialty. He knows how to do an angioplasty, and I respect that. I don't. But I wouldn't try to do an angioplasty.

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