To see Michael Jackson doctor's alleged slipup, look at the label

Published on
July 26, 2009

UPDATE: The Associated Press reported Monday afternoon that Dr. Conrad Murray gave Jackson propofol to help him sleep, and the dose proved to be lethal. Today, police and federal drug enforcement officials are reportedly searching Murray's Las Vegas home.

It is the most anticipated autopsy in modern history.

Michael Jackson died of cardiac arrest on June 25, but the results of the coroner's investigation into his death are expected to be released this week. Celebrity stalkers everywhere and genuine fans of the King of Pop will now know what killed him on the eve of his comeback tour.

The Associated Press reported that Jackson's personal physician, Dr. Conrad Murray, had an impromptu visit from the Drug Enforcement Agency and the Los Angeles Police Department last week, on the hunt for computer records, files and other information at his Houston office that might explain how Jackson might have ended up with what appears to be a lethal dose of the anesthetic propofol. Murray could be charged with manslaughter, according to the search warrant used in the raid.

"A manslaughter charge would require proof there was a reckless action that created a risk of death or great bodily injury. If a doctor is aware of the risk, there might also be an issue of whether the patient was made aware of that risk and decided to take it," the AP report. Investigators appear to be focusing on a powerful anesthetic, propofol. The drug was found in the Beverly Hills mansion Jackson was renting, according to a person with knowledge of the investigation who is not authorized to speak publicly."

Propofol, sold under the name Diprivan by AstraZeneca, is indeed powerful, and rarely used outside the operating room. The FDA approved propofol in 1989 solely for use by anesthesiologists because it slows breathing, heart rate and blood pressure down to a very low level, and patients need to be helped into and out of the sedation.

Murray, for those of you living a life light on celebrity news, was at Jackson's rented mansion in Los Angeles on June 25 when he found the superstar unconscious in a bedroom, his lawyer has said. He then attempted to revive him and then called for someone on Jackson's staff to call 911. This was just 10 days after he had announced he was leaving his practice in Houston in a letter to his patients.

Murray, through his lawyer, has denied any wrongdoing.

He is not an anesthesiologist. As I noted in an earlier post, he's not even a board-certified cardiologist, which has not stopped him from practicing heart medicine in Houston or Las Vegas. If investigators can make the case that Murray was administering propofol in Los Angeles, it will be very difficult for him to explain why. The drug's warning label makes it clear:

For general anesthesia or monitored anesthesia care (MAC) sedation, DIPRIVAN Injectable Emulsion should be administered only by persons trainedin the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure. Patients should be continuouslymonitored, and facilities for maintenance of a patent airway, artificial ventilation, and oxygen enrichment and circulatory resuscitation must be immediatelyavailable.

The drug set off alarm bells when it first became popular because it put patients into such a deep sleep. The American Society of Anesthesiologists and the American Association of Nurse Anesthetists issued joint guidelines on the drug in 2004 to try to make sure that doctors used it correctly.

Whenever propofol is used for sedation/anesthesia, it should be administered only by persons trained in the administration of general anesthesia, who are not simultaneously involved in these surgical or diagnostic procedures. This restriction is concordant with specific language in the propofol package insert, and failure to follow these recommendations could put patients at increased risk of significant injury or death.

Propofol also has some serious potential side effects in one of every 100 patients that Murray should have known about. Here's just a sample: bradycardia (slow heart beat), arrythmia (irregular heart beat) and tachycardia (fast heart beat).

All of these could have lead to the heart attack that killed Jackson. Perhaps most importantly, the risk of hypotension, or low blood pressure, can be as great as 26 percent, 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. Extremely low blood pressure starves the brain and other organs of oxygen and can throw the body into a state of shock.

Part of Murray's defense thus far has been that he was not in the room when Jackson collapsed. If he hooked him up to a propofol drip and then left the room, he would not have heard a thing if Jackson's blood pressure plummeted and his heart gave out.

Murray will have three big defenses, though:

1. Rolling Stone's Claire Hoffman uncovered in a recent cover story how Jackson used aliases to buy prescription drugs. If he was taking things Murray didn't know about, they could have combined in a lethal way.

2.The AP also reports that, "Los Angeles County coroner's officials were piecing together Jackson's medical history from subpoenaed records related to nutritionist Cherilyn Lee's treatment of Jackson, according to Lee's spokeswoman, Belinda Foster." (In Beverly Hills, the nutritionists have spokeswomen.) "The registered nurse is cooperating with investigators but required a subpoena because the records were protected by law, Foster said." Who knows what Lee was advising or even prescribing. She has said in interviews that Jackson begged her to find him an anesthesiologist who would give him Diprivan to help him overcome his insomnia.

3. Prior to Jackson's death, Propofol had been the subject of FDA recalls and warnings in the past because it was causing severe fevers in some patients. After Jackson's death, the CDC issued a warning about generic versions of propofol, and the drugmaker voluntarily recalled two tainted lots of the drug. If tests on any remaining propofol in Jackson's home show that it was tainted in any way, Murray could try to deflect the blame to the drugmaker.

Everyone seems to want a piece of poor Michael Jackson while he makes his way to his maker. Let's hope the autopsy at least clarifies the cause of death and puts the blame where it belongs.