The tools of an anesthesiologist rarely make headlines. We are one of the invisible specialties, performing our best work while our patients are unconscious. But these days a lot of people ask me if I'm planning to use that "Michael Jackson Drug" to put them to sleep. I usually answer "yes," and then start explaining.
I make my living helping people safely sleep through painful events. Michael Jackson's probable mode of death, propofol, is a drug I use everyday in the operating room. In a full dose propofol induces general anesthesia in less than two minutes, and when drizzled slowly through the veins it causes a lovely sedation famous for spinning pleasant dreams with very few nasty after affects -- a big improvement over biting bullets, whiskey, and every other drug that came before it. The most prized characteristic of this milky white chemical is its quick action; in moderate doses propofol is in and out of the system in about ten minutes. This roller coaster ride through the body and brain means patients can stay soundly anesthetized for short surgeries, but be awake and on their way home an hour after they leave the operating room.
It's that same quick onset and disappearance, however, that makes propofol so dangerous. The line between a light, pleasant nap and asphyxiation is perilously narrow, and it takes training and experience to use it judiciously. Remarkably, the drug isn't closely monitored by the Drug Enforcement Agency, though it is now under discussion. Anyone with access to a procedural suite or operating room can walk out with handfuls of the stuff and no one would be counting the lost vials. That wouldn't be possible with tightly controlled drugs more famous for abuse, such as narcotics like morphine, fentanyl or Demerol, whose long history of addiction dates back to opium dens.
When I treat a patient with narcotics I am required to sign out each dose and account for its use or disposal. It isn't a perfect system, even the best governmental oversight won't stop a determined, troubled individual, particularly when they have sufficient influence over a doctor with easy access. But in Michael Jackson's case better regulation would have imposed one more layer of safety between his desires and his doctor's irresponsible acquiescence. Unfortunately the only point of control lay with the cardiologist on Jackson's personal payroll, who apparently forgot his Oath when he cashed his check.
Jackson is only the most recent victim of medical judgment apparently blinded by the bright lights of stardom. But a doctor's ethical imperative is to be paid for advice and skill, not drugs or an ill-advised, patient-designed plan of care. Demerol, Adderall, oxycontin and propofol aren't stocked on Rite Aid's shelves because the margin between a therapeutic dose and a toxic overdose for these potent medications is not financially negotiable. The cardiologist who treated Michael Jackson succumbed to a blatant conflict of interest: dangerous practice in exchange for dollars. Such conflicts bleed through many layers of healthcare today, from pharmaceuticals to scientific studies to durable medical goods and, yes, even the protected realm of the doctor-patient pact. It is a shadowy cost of healthcare -- in both lives and money -- that few lobbyists are likely to decry, but a cost Congress needs to examine before finalizing our next healthcare financing scheme.
I will continue to reassure my patients that propofol is an excellent drug, safe when used in the controlled environment of an operating room or ICU. Like the vast majority of doctors, I will promise to listen to my patients' requests and concerns, and then make the most educated and objective decisions for their care -- regardless of their ability to pay me.
I wasn't a huge Michael Jackson fan, but I still mourned for this talented man who seemed so tortured by early fame and money. Maybe for that reason I found it even more tragic to surmise that Jackson's death resulted from his own desperate search for an artificial pathway to that most natural state of healing: sleep. Like millions, I wish I could know what music we lost when his doctor helped him slip too deeply into that dream.
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