Tuesday, September 27, 2011

Guest Entry by KZ: The Conrad Murray Case

Pool Photo

Guest Blogger KZ, a CRNA, offers her opinion on why we should care about the Conrad Murray case. The following entry is copyrighted by T&T. Please contact T&T for permission to reproduce on any web site or forum. Sprocket.

The Conrad Murray Case-- Why should we care?

Just as we are all collectively recovering from the international frenzy and widespread outrage at the verdict in the Casey Anthony trial, the next "trial of the century" is poised to begin. Conrad Murray is the private physician of Michael Jackson, who is charged with involuntary manslaughter in the death of the King of Pop. The trial is certain to receive widespread and nonstop coverage by the media, and will be televised according to a ruling earlier this year by Judge Michael Pastor. It is expected that many of Michael Jackson's ardent fans and supporters will have a presence in the area during the trial.

For background into what Conrad Murray is accused of doing, please refer to the 4 part series I wrote earlier this year for Trials and Tribulations. You can start reading it, HERE.

So, why should we care about Conrad Murray? For the enthusiastic fans of Michael Jackson, (MJ) the answer is obvious. He is accused of causing (but not on purpose) the death of the King of Pop. But why should this case be of interest to casual fans of MJ, or those without an emotional connection to the man or his music?

I believe that we all should care about the conduct and outcome of this trial, but not simply because of the superstar victim.

We should care because of the deaths of the following individuals:

Osvaldo Hernandez
Denise Hendry
Ralph Gonzalez
Alicia Santizo Blanco
Leslie Ann Ray
Stephanie Kuleba
Maria Shortall
Walter Riley
Julie Rubenezer
Krista Stryland
Claudia Anderotimi
Kay Cregan
Aura Javellana

And literally DOZENS, if not hundreds more people. You have likely never heard of a single one of the people in the above list. They were average citizens, and in some cases, such as Osvaldo Hernandez, they were illegal immigrants. But their deaths fall into the same category as Michael Jackson-- namely, they were killed by the breathtaking, reckless incompetence of a licensed physician, or someone posing as a licensed physician, either in a private home, or a "private office" clinic. That's why we should care about the Conrad Murray case.

But wait! What does the deaths of illegal immigrants or average citizens have to do with Michael Jackson, the incredibly wealthy superstar musician, and his private cardiologist?

It's quite simple. In every case, the physician involved was practicing as a "lone wolf", not affiliated with hospitals, legitimate clinics, or involved in any way with mainstream medicine. None of these physicians accepted insurance payments, or medicare or medicaid for their services. They all hung out a shingle asking for "cash on the barrel head." Cash only business. None were credentialed in any legitimate facilities to perform the surgeries or services that they used to kill their patients. And yes, I use the word "kill" intentionally.

For the individuals POSING as legitimate, licensed physicians, they were able to do this because of the laws which allow REAL physicians to do this. It becomes confusing for patients (customers) to determine who is a real doctor, allowed to do liposuction in a hotel room, from someone posing as a physician, doing liposuction in a hotel room.

Once a person (rich or poor) decides to seek out a "lone wolf" physician, every single safety net provided by legitimate, mainstream medical care is gone. The transaction becomes a fee for service, based only on whatever the two parties agree to. People who are determined to have care from these individuals generally aren't overly concerned with doing a lot of investigation of the provider's credentials, licensing and inspection of the facilities, periodic maintenance and calibration of equipment, etc. They accept the M.D. as the ultimate safety credential, and don't question much further.

Now KZ, a cash only business isn't illegal.

No, it isn't. And small business entrepreneurs are what our country's economy was founded on, so this is an American economic value. But, in my strong opinion, it is a very bad thing for safe medical care. Lone wolf physicians target vulnerable populations in order to sell their trade. And vulnerable populations who seek care from these individuals are typically either VERY poor......or VERY rich....or vulnerable due to a devastating diagnosis not amenable to mainstream medical therapies.

The very poor, like Osvaldo Hernandez, who was undocumented, seek needed care in the shadows of the legitimate medical system. They do not want to become known to immigration authorities. You can read about Osvaldo Hernandez' horrifying death, and about his lone wolf neighborhood surgeon, Roberto Bonilla, here.

LA Times article 4/25/2010

LA Times Blog article 2/2011

LA Times Blog article 7/2011

Other ordinary people seek out lone wolf doctors to perform cosmetic surgeries at "bargain" prices, in offices or converted homes. There are numerous stories of the deaths of patients who underwent shoddy surgeries under substandard conditions, in hotel rooms, rented storefronts, and private offices. Notably, California and Florida, and a few other states have become alarmed at the reports of healthy people dying under these circumstances, and have moved to enact laws aimed at deterring these surgeries in these environments. But deterring doesn't mean prohibiting.

Roberto Bonilla was fully aware of the California requirements for general anesthesia, and flagrantly decided to "appear" to comply with those requirements by attempting the complex surgery under "local" anesthesia. Apparently he did this a number of times without severe complications. But that trick was guaranteed to come back to create a disaster. It was only a matter of time, but Bonilla's arrogance would not allow him to consider the possibility of local anesthetic overdose. Success so emboldened Bonilla, that he just kept pushing the envelope, until he killed Hernandez with a local anesthetic overdose. True, I must agree with Bonilla that by the time Hernandez was in full cardiac arrest, there was an overwhelming possibility he would die regardless of whether advanced measures were implemented. But Bonilla, in his arrogance, either didn't know what simpler measures to try (such as high dose intralipid rescue), and clearly never thought that the hospital a few blocks away would be able to help him problem solve what was going on. Or maybe he just wanted to keep the whole situation quiet. But I digress. Let's get back to Conrad Murray and Michael Jackson.

But wait, KZ. How can the VERY rich be "vulnerable"? After all, they can afford the very best of the best medical care, right?

Sure they can. But the very rich (and famous) have privacy concerns that you and I don't have. And the very rich have definite ideas about a lot of things in their lives. Extreme wealth provides options and opportunities that less wealthy people don't have access to. For some very wealthy people, they want, what they want, when they want it. And there are definitely people and doctors willing to provide what they want, for a price. And the M.D. credential insulates the activity from scrutiny. After all, anything a licensed doctor does in the care of his patients is assumed to be without malice, right? No malice, no murder charge, as long as the death occurred during care provided in the context of the doctor-patient relationship. As long as a doctor doesn't MEAN to kill a patient, there was never any malice.

But wait! Second degree murder can also be charged if an action was sufficiently reckless that the accused should KNOW that death can be an outcome. Well, there can be no doubt that Conrad Murray knew he was administering propofol to Jackson, in a bedroom, in a private home, with substandard monitoring. So that's reckless, right?

Well, it would be if you or I did that. But it IS NOT sufficiently reckless because Murray DID NOT THINK IT WAS POSSIBLE TO KILL JACKSON BECAUSE HE IS A DOCTOR AND CAN HANDLE THE SITUATION. He didn't mean to kill Jackson.That is the argument for involuntary manslaughter, with its pitiful 4 year sentence. Prosecutors have tried in various locations to "win" with second degree charges against doctors, with very unpredictable track records. Involuntary manslaughter is easier to "win" than second degree charges.

But wait! Gifted with the prospect of only 4 years if convicted, Murray pushes back even harder, and tries to make the dead musician responsible for his own death!! That is such unimaginable, jaw dropping hubris that I almost can't finish this article. Basically, what Murray wants us all to agree is that it was perfectly OKAY for him to provide the propofol and other drugs, to start the IV, to hang the drip (and yes, it WAS a drip, imo), and then absolve himself of any responsibility when things went horribly MORE wrong. Really?? Is anyone buying this, other than Murray and his attorney?

Well.....it WAS perfectly legal for Murray to buy 4 gallons of propofol, ship it to his girlfriends apartment in another state, and cart it into the mansion. Was it okay? Was it medically legitimate care, with outcome based evidence, and well documented in the literature? No. Was it even slightly documented in the literature as a valid technique or therapy for insomnia? No. Was it reckless? Yes. YES. Holy crap, yes it was reckless. SO reckless, that in my opinion, it was criminal. Involuntary?? Hell no. I believe the case is sorely undercharged, but I also believe that prosecutors would not be able to get a conviction on second degree. That is the conundrum.

Conrad Murray, in my opinion, was lured into Michael Jackson's exclusive circle of people as one who Jackson perceived as willing to provide him with what he wanted. Namely, propofol and other prescription substances, under the thinly disguised veil of "legitimate" medical care. Legitimate, because it was a licensed doctor (not a nurse, a technician, or a layperson) providing the substances, even though there is NO medical indication or research precedence for what Murray was doing. Had it been ANYONE other than a licensed physician providing those drugs to Jackson, under those circumstances, the criminal charges would have been AT LEAST 2nd degree murder, due to the recklessness. I do not think Conrad Murray wanted to kill Michael Jackson, or intended to kill him. But I also do not buy the argument that he was too dumb to know propofol could kill Jackson, yet so smart that he believed he could rescue Jackson from any mishap. Or wait, maybe I do. I guess that is the very definition of hubris. So maybe involuntary manslaughter IS the right charge, after all.

I'd like to see Murray convicted and do his full 4 years. But it almost doesn't matter to me whether he is convicted or not. Because what we REALLY need to do, to prevent these kind of situations like Osvaldo Hernandez and Michael Jackson, is to change the laws and privileges that physicians have when working outside of valid clinics and hospitals. That, in my opinion, is what will save lives. If you can't be credentialed to perform a certain procedure in a hospital, then that physician should not legally be able to provide that service in a private home or private office/ clinic. Conrad Murray would NEVER have been allowed to provide propofol in that manner for that indication in a legitimate medical setting. That doesn't make him a visionary, or a researcher. It makes him a reckless, incompetent, arrogant man, who happened to go to medical school. Physicians, including lone wolf physicians, need to be held to the same standards as physicians who practice in legitimate settings. And the penalties should be enough to be a deterrent.


KZ said...

Ok, so I'm catching up on the morning's opening statements. I simply have to comment on Defense Attorney Ed Chernoff's ridiculous comment in his opening statement that a bolus of propofol would kill "so rapidly, so instantly, Michael Jackson had no chance to close his eyes." Baloney. We give large boluses of propofol EVERY DAY in operating rooms all over the country, and the world. I can categorically state that a large bolus of propofol will not "kill" instantly. A large bolus of propofol will render the recipient UNCONSCIOUS within seconds. A large bolus of propofol can induce severe low blood pressure. It DOES NOT stop the heart "instantaneously". The combination of respiratory arrest, which deteriorates into asystolic cardiac arrest would occur over the expected 3-7 minutes, or even a little longer, if no one intervened with respiratory and cardiovascular support! That is NOT instantaneously, and is ample opportunity for a practitioner WHO IS CLOSELY MONITORING THE PATIENT to take action to save their life. I really hope that prosecutors correct that misinformation with later expert testimony. Sheesh.

Anonymous said...

So do I hope they correct that nonsense. The other nonsense that he drank it. Only vials were found at the scene no IV bag of Propofol. What Murray did was put a vial inside a cut open empty bag of IV fluid? That is what Alberto Alverez helped him take down before he started his version of CPR. So how did Michael Jackson get enough of anything into a syringe to squirt in his mouth to kill himself and push it in his IV at the same time while Murray was out of the room for 2 minutes. Not possible.

CaliGirl9 said...

I did not listen to all of opening arguments, but the defense promised to call a physician who is akin to the "father of propofol" (paraphrasing). How can a reputable doctor every honestly say what was done in that bedroom on Carrolwood Drive was medically safe or medically indicated? How much was he paid to drop his standards?

I did laugh at the "died so fast he couldn't close his eyes" thing. Gunshot to the head, yeah; "drinking" propofol or whatever else they say he drank/injected. Oh please. Unless a bolt of lightning came through the room and zapped him dead.

Tape recording: Sad. Why did Conrad Murray take that recording? Why did he keep that recording? Blackmail? Job security?

I did not realize the dates of the concert were so spread out. I do not think 50 shows over 9 months (with the long fall break because the venue was booked) would have been any problem, IF he was well taken care of and had let AEG hire a local guy who was not a: (1) yes man; and (2) not a witch doctor. What in the hell was a "cardiologist" doing treating Jackson's kids? I believe we have used the word hubris to describe Conrad Murray. Hubris. Omnipotent. Arrogant. Incompetent.

And even if the jury is lead to believe MJ did self-administer anything, who brought it into the bedroom? Whose prescribed it, who bought and paid for it?

I really don't want to watch this trial. The circus that TMZ showed on the way out—pathetic. I am also sure fans will have their panties in a wad over the Power Point slide that had a photo of MJ dead on the gurney (I think that may have been a photo taken through Photoshop and turned into a drawing). It served to remind us there is a dead someone at the end of all of this.

CaliGirl9 said...

Demerol is back into play? Must have found normeperidine in the hair samples. Yes, I'll admit that normeperidine toxicity sucks (I've been there after surgery) and Demerol is a terrible, terrible drug. But there wasn't any detected in MJ's tissues at autopsy? KZ, do you have a PDR that can answer this? The answer is in the hair samples. Don't want to miss that testimony.

KZ said...

CaliGirl9, I don't know all the particulars, but I did hear that MJ received demerol injections from Arne Klein somewhere in the neighborhood of 50 times in 90 days. I don't know when that was, related to when he died. We know head hair grows about a half inch a month, and IIRC, they pulled a sample from MJ posthumously that was about 2" long. So his hair has about a 4 month history of whatever would show up on a hair tox test. I didn't get a chance to watch live, so I'm catching up.I'll go look for the hair tox test results.

Anonymous said...

If there are any highly-paid "expert witnesses" I hope the DA rips them to pieces. Next thing you know somebody will haul out Dr Michael Baden for the defense, good gawd..............!!
=Wes J.

Anonymous said...

I tried to post a link on HLN's website for all the people who are blaming MJ for his own death but it wouldn't work.

Thanks for a great column. Please consider posting part of this on HLN'S FACEBOOK PAGE TO EDUCATE PEOPLE.