Guest Entry by KZ: The Conrad Murray Case

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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.