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发表于 2011-10-13 16:04:17
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Flanagan talks about Kai Chase : CM went downstairs and asked for help. Objection from Walgren : CM didn't ask Kai Chase to call 911. Sustained.
Are you aware of the Medical quality assurance board ? No.
Did you talk to CM to review this case ? No.
Did you ask to : No.
What should he have done in these 2mn : call 911, protect the airway, make him breathe (intubation, ambu bag), give flumazenil.
Did he make a mistake in asking someone to call 911 ? he didn't ask anyone to call. The time it takes to call for security was the time it would have taken to call 911. He had a cell phone, could have put 911 on loudspeaker.
Are you aware that the EMTs said MJ was cool to the touch ? Yes, but CM said he was warm. The firemen got there 26 mns later. You get cold in 26 mn when you have no bood pressure.
You have no doubt that if 911 had been called immediately MJ would still be alive ? No, I have no doubt about that, they could have saved him. CM said that he lost the pulse after calling MAW at 1212. So if the paramedics had been there at 1205 or 1210, they could have saved him. There is clear evidence that there was a delay in calling 911 : CM went dowstairs and called MAW.
Based upon these facts do you think he's responsible of MJ's death ? Yes.
He should have anticipated a power shortage (back up battery) : yes.
He should have dropped MJ on the floor, in spite of the IV line ? He should stop the propofol drip first. And yes, he should be careful with the line.
You indicated there should be suction ? Wouldn't clearing his mouth with a finger be enough ? No, you need suction.
Have you ever seen propofol given without a defebrilator ? No
If you only have 1 patient do you need to document everything you do ? Obvioulsy he didn't recall what he had given when he talked to UCLA or with the paramedics. But that didn't cause MJ's death.
Lunch break .
re direct by Walgren :
Murray did not act like he was ACLS certified.
Propofol given in NY : it was in hospital settings
Gastro dentist ER doctors who use propofol : they receive appropriate training , trained staff and equipment are necessary
Article about the study in Taiwan : published in 2010, was an experimental study. The patients were given propofol in a hospital , with the appropriate equipment, the experiment was approved by their ethical comittee. They obtained written consents from the patients. 8 hours of fasting prior to being given propofol, propofol was given by an anaethesiologist. No other benzos were used. So what CM was doing was essentially an experiment.
Assume that dr Murray gave only 25mg, that there was no drip. Would you draw the same conclusions ? Yes
Was it a foreseeable risk that the patient could go into respiratory deperession and cardiac arrest ? Yes
Do you think CM caused MJ's death ? Yes
re cross by Flanagan
Did that study showed propofol helped insomnia : yes
in this case you need to analyse if the deviations from standard of care directly impacted MJ's death : yes.
Did the lack of back up battery lead to MJ's death ? No, but the other 5 deviations did;
CM gave propofol for 45 days without problems, so you're assuming things. Answer : no I didn't asume that he gave propofol, that he didn't have the equipment, the delay in calling 911, improper care during the arrest.
Dr Kaimangar : Pulmonary critical care and sleep medecine physician, UCLA medical center
direct examination Walgren
board certified : internal medicine, pulmonary medecine, critical care, sleep medecine.
Medical reviewer for the Cali Medical Board , assessed CM's care to MJ for the medical board.
Is propofol used in critical care unit : yes, daily.
Are you trained in using propofol : Yes. Propool is used for placement of endotracheal tubes, and for people on breathing machines. Propofol is the most commonly used drug for this.
What is your training for using of propofol ? You need to be well prepared for an emergency, It's necessary to be aware of the potential problems that could happen . Propofol is not used on unstable patients.
Is the staff trained : yes, there is a special training for using propofol. If there is no none especially trained for propofol, they call an anesthesiologist.
the continuum of sedation : there is a fine line between moderate sedation to deep sedation and to general anesthesia (not responsive to painful stimulation). It's difficult to predict how the patient will react.
When propofol is used , who is present ? For induction : an intensivist or an anesthesiolgist and a nurse, and respiratory therapist (except in extreme emergency the respiratory therapist might not have to time to come)
what is the monitoring equipment you need for propool: EKG machine, blood pressure (every 2 to 3 minutes), pulse oxymeter with an alarm, capnometer (for patients under ventilation, measures carbon dyoxide )
About CM's care of MJ : found multiple deviations of standard of care :
1 propofol given in an unacceptable setting : using this deep sedation agent in a home setting is unconceivable.
2 ACLS certified : the persons who gives propofol must be trained in ACLS and airways management. There is a risk of hypoventilation, and obstruction of the airway.
3 Need of assistance : CM needed a a second person to monitor, especially if you're going to leave the room. That goes withot saying
4 Pre procedure setup : imperative to be prepared for possible consequences. Things can change very quickly. A patient may look good, and the next minute there's a problem. You need a suction catheter, because patients can regurgitate into their airway, and block the airway, this can cause death. A crash cart (medication on hand : adrenaline, epehdrine, medication to correct the heart beat, etc...) , defibrilator, automated infusion pump (precise dosing for propofol) even with people who are intubated;
Theses are extreme deviation of standard of care = gross negligence.
Have you ever seen someone giving propofol at home in such settings : no, and would not have expected to see that.
5 Charts / medical documentation : or medical history, reactions to a medication. For example a blood pressure can look normal, but not be normal for a particular patient. And that change in blood pressure could be the indication of a problem.
6 : MJ was left alone : that is really not acceptable. Espacially since CM didn't have the right equipment.
7 Use of benzos : using lorazepam and midazolam on top of propofol can have higher effects : more significant respiratory depression, decrease cardiac output (often a consequence of resiratory depression), decreased blood pressure.
Cardiac arrest can occur directly, or because of low levels of oxygens.
8 dehydration : blood circulation is not good when you are dehydrated , causes low blood pressure. Benzos and propofol would also lower blood prossure . You should not use benzos or propofol if the patient is dehydrated.
9 failure to call 911 : 911 should have been called immediatey
10 improper CPR : if there was a pulse , the problem was breathing. CM should have dealt with airway management .
CPR was ineffective : was not on a hard surface, doing it with one hand was ineffective. If you do CPR correctly, you just allow about 20% of the normal blood circulation, so if you do it incorrrectly ...
break
Dr Kaimangar
direct , Walgren
Assuming CM finds MJ at noon, calls MAW at 12 12 : what is the significance of these 12 mn ? : lack of blood flow to vital organs, especially to the brain. Some individuals are more susceptible than other to lack of oxygen. Generally it take 3 to 4 mn before brain cells start to die. Time is really important. 911 was called at 12 20. At that point, 20 mn after, it reaches a point where it becomes irreversible.
Deception of paramedics & ER staff : did not provide the acurate info to paramedics and ER staff, deviation of standard of care.
Insomnia :
CM din't properly evaluate insomnia. Insomnia can have many causes, so it's important to have a detailed history. You need to exclude secondary probems (psychological problems, substance abuse, underlying conditions, chronic ansiety, depression , etc...)
Insomnia = no restful sleep for 4 weeks or more. Once you've ruled all the secondary problems, you can talk about primary insomnia.
You need a detailed sleep history : when do they go to bed, when do they fall asleep, when do you wake up, etc.. check sleep apnea. In some cases you need a sleep study.
You need a detailed pharmaceutical history : both prescribed or over the counter (example migraine pills contain caffein, that can cause insomnia), illicit drugs.
You need a detailed physical examination : some underlying conditions can cause insomnia : for example asthma, congestive heart failure, diabetes, bladder problems, enlargement of prostate, thyroid conditions, etc..
You need blood testing to rule out certain conditions : examples diabetes, kidney problem, restless legs , etc..
would a good blood work reveal the use of narcotics ? If you ask for it yes.
If you feel the patient is not giving the information, you can simply refuse to treat that patient ? Yes, absolutely. You can also do a tox screen without his knowledge, but Dr Kaimangar doesn't want to do that.
Then you treat the underlying condition that causes the insomnia.
In this case , CM didn't have a detailed history. Didn't check what the root problem for MJ's insomnia was before treating him.
CM did say that he saw that other doctors were treating MJ, he said he saw IV sites. If he could not get that info from MJ, CM should have refused care, refused to give further medication. CM didn't do that, that was unethical.
Bypassing the evaluation of insomnia, bypassing the detailed history was a deviation of care.
It was obvious there was probably secondary causes in MJ's insomnia (substance abuse or anxiety or depression ) these underlying causes should have been treated.
He talks about sleep hygiene techniques that can help in case of insomnia (using a bedroom to sleep only, amog other things)
He talks about sleep restriction : tell the patien to go to bed later , and limit their time in bed.
You can use relaxation techniques.
All these can usually work better to treat insomnia than pharmacological approach. But pharmacological approach can also be used.
Were those techniques used on MJ ? No. CM went directly to the pharmacological approach.
Phmacetical approach : 3 medications are not benzos and should be used first, because they are not addictive . A newer drug is melatonin something (sorry) , less addictive.
Benzodiazepines : cites 4 different benzos that deal with insmnia. Others are used also, but their main goal is to treat underlyng conditions (anxiey). They are used in tablet form
Midazolam : not appropriate for long term use for primary insomnia
Valium : not appropriate for long term use for primary insomnia
Lorazepam : can be used on short term basis, tablet form. Really addictive after 3 to 4 weeks. Used to treat underlying conditions, not primary innsomnia.
The use of midazolam and lorazepam to treat insomnia was an extreme deviation of care. Especially in IV form.
Propofol : inconceivable to use this drug for the management of insomnia, regardless of the setting. It is «*beyond comrehension, iconceivable, disturbing*». It's beyond a departure of standard of care.
Especially when underlying causes for insomnia were not treated.
Did CM cause MJ's death, even if MJ took lorazepam and propofol himself ? Yes, especially if the patient has had problems of substance abuse. The lorazepam and propofol should not have been within his reach.
Using «*only*» 25 mg propofol there is a risk of respiratory complications ? : yes, absolutely especially if the patient is dehydrated. Any competent doctor would have been aware of the risk. |
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发表于 2011-10-13 12:25:02
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