27 July 2009

MJ's weird doctors

Michael Jackson's doctors have behaved very oddly indeed. CyberShrink comments.

The mystery thickens around the death of pop icon Michael Jackson. Not around his death, maybe, but around the investigation into it.

First let us look at some of the peculiarities of what has been reported so far about his doctors. Though the facts are not yet established, and while it may be very much in the interest of some people to prevent some of the facts from coming out, the wide reporting and failure to refute certain stories opens the door to speculation.

Of course he's a suspect
For instance, we keep getting told that Dr Conrad Murray, the doctor who was actually present at the death, "is not a suspect". Of course he is a suspect. Anyone who is present at or shortly before an unexplained death must be considered a suspect.

He may be totally innocent of any wrongdoing, and that may eventually be proved, but that cannot be assumed, and the police have to consider as suspects everyone who had any opportunity to contribute, deliberately, accidentally, or negligently, to someone's death. Recent reports state that police spent over two hours in his medical offices in Houston, seeking documents, leaving with papers and a copy of a computer hard-drive.

Peculiar responses to the emergency
Much needs to be clarified about exactly what happened when MJ collapsed, but the story so far does not make good medical sense. Whether he collapsed with a heart attack or stopped breathing, for whatever reason, there seems to have been an inexplicable delay in getting an ambulance to the house and in getting Michael to the hospital.

If someone such as the doctor was actually present when he collapsed, at least the timing could be known. If someone walked into his room and found him already collapsed, it may be harder to know how long he had been in respiratory or cardiac arrest. The 911 caller said Dr Murray was alone with him when Jackson collapsed, and there are several reports that the collapse occurred just after the doctor had given him an injection, reportedly a strong narcotic pain-killer.

Murray's lawyer has been quoted as saying to CNN: "There's nothing in his history, nothing that Dr Murray knew, that would lead him to believe he would go into sudden cardiac arrest or respiratory failure ... There was no red flag available to Dr Murray, which led him to believe he would have died the way he did. It's still a mystery how he died."

Now, rumours that MJ was taking large doses of prescription medicines and analgesics were widespread, and it's surprising the doctor wasn't aware of them. Did MJ not properly inform his doctor, or did he deny the use of the drugs he was using? Did the doctor not ask very specifically about all forms of drug use?

We need to know why Dr Murray was in attendance at the time. Unless it was an entirely social call, he was presumably there because of some medical complaint, and in order to deal with it. Who called him, and why? What therapeutic benefit was there in having a doctor actually living in the house, without proper equipment including resuscitation equipment, and whatever medication might have helped revive the patient in an emergency? One does not generally have a live-in doctor simply to write prescriptions.

Where was the guide-dog? We have heard various odd excuses for delays in even calling the ambulance: claims that the doctor in attendance somehow did not have access to a phone, which is flatly unbelievable. It was said that the landline phones had been disconnected for "security reasons", and if so, this was security that endangered those in the house. The reports suggest that he only discovered this disconnection when he tried to call 911. In fact, if you are the only person present able to perform proper CPR, wouldn't you scream for help, and ask someone else to call 911?

Some reports suggest that when he yelled, nobody came, which would be very strange. This report suggests that after 30 minutes of CPR, he left MJ in bed and went to seek someone who could call 911, eventually finding a chef elsewhere in the house, who found a bodyguard, who made the call. If MJ was left without ongoing resuscitation for long enough for all this to occur, it is probable that irrecoverable brain damage would have occurred in the meantime.

Then it was said by his lawyer that there was a further considerable delay, as the doctor could not call the ambulance from his cell-phone, and had to get one of the guards to do so, because he didn't know the exact address of the house.

Bizarre resuscitation
Then there are reports, including mention in the 911 emergency call, that the doctor was performing CPR while MJ was on the bed. This is entirely bizarre. On a bed the body would merely bounce. Every competent doctor, and a great many lay people, would know that the patient should have been placed on the floor, so that CPR could be performed against a solid surface. Murray's lawyer is quoted as saying, "The doctor compressed his chest with one hand, braced his back with the other hand. He checked to make sure there was blood flow. There was. He was getting blood." This fits another description, that the doctor had one arm behind the chest, and the other in front of it. This is profoundly peculiar, and tends to confirm that the bed was too soft for CPR. Any junior first aider would know better.

Other oddities
His lawyer said he made “frantic attempts” to revive MJ, including the prolonged method of CPR for around 30 minutes. But if there was any question of the patient self-medicating with drugs such as opiates, or of these being administered to him, there should have been a cardiac monitor and defibrillator at hand. Also drugs such as Narcan, an antidote which can reverse the effects of opiates. To have given intravenous opiates to someone without such precautions (and even with them) would generally be considered negligence.

There are reports that the ambulance staff, after further long attempts to resuscitate him, wanted to declare him dead at the house, but that Dr Murray refused to allow this. I would assume that the ambulance had available drugs such as Narcan and if these were not administered, they cannot have been told there was any chance of such drug overdose.

Other reports claim he did not tell the hospital staff what medications MJ was receiving or what he had administered to his patient. If this is so, it was negligent. He apparently did not sign the death certificate, which would have been normal for the treating doctor to do.

Whether he promptly disclosed all relevant facts to the police and the coroner, is not clear. He apparently left the hospital, his whereabouts unknown for some 48 hours, before reappearing, with an experienced criminal defence lawyer. Not exactly typical behaviour for a doctor in such situations.

Then there have been odd reports, with pictures of the bare-chested Dr Murray surrounded by pretty Caribbean girls, that recently he went to Trinidad to promote an unwholesome "health" and energy drink called "Pit Bull"; and that he has a record of financial problems and judgements against him, including, purportedly, failures to pay child support and student loans.

Curious qualifications
Dr Conrad Murray's qualifications are not entirely clear. Born in Grenada, he grew up in Trinidad, West Indies, and trained in Tennessee. There were earlier reports that he was a cardiologist, though no evidence has emerged that he was qualified or certified as a cardiologist. Yet MSNBC reports he did Fellowships in cardiology at a couple of major medical centres. Having no known heart disease, why would MJ need a resident cardiologist?

Another early report said he had been a certified internist (a specialist in general medicine) but that his speciality registration had oddly lapsed in December 2008. It is said that though he was employed by the concert promoters, this was done at MJ's insistence, and one wonders why anyone should have been so insistent on having this particular doctor at his side.

Possibly not licensed to prescribe drugs
There have been more recent reports that he is registered with the DEA to prescribe such drugs as have been named, in Nevada and Florida, but not in California. He was medically licensed in California, but not to prescribe or use such drugs. He would not have been entitled to prescribe even relatively mild sleeping pills or strong cough medicines.

He could not have legally prescribed Demerol or Oxycontin, for instance, which are reported to have been used, let alone Diprivan/Propofol. It would have been illegal for him to have brought such drugs from anywhere else, to have fetched them from a pharmacy, or to have administered them had some other doctor prescribed them.

Yet he was reportedly being paid $150,000 a month for his services, whatever they were.

Paternity or sterility
Murray isn't the only curious doctor to be involved with Jackson. There's his interesting dermatologist of 20 years, Dr Arnold Klein, whose "assistant", Debbie Rowe, became MJ's second wife, and the mother of his oldest two children. He is said to have sent the estate bills for around $100,000 for prescription drugs and unspecified services.

This is odd: not the billing nor the amounts, necessarily, but billing large amounts for unspecified services. Doctors generally wouldn't expect to be paid $65,000 for unspecified activities. And he apparently charged $12,500 for a home visit. That's around R100,000. And you think SA doctors are expensive?

There were also rumours that Dr Klein may have supplied the sperm to MJ for the artificial insemination of his wife and the unknown mother of the third child. There seems no clear evidence on this, beyond rumour. If it is true, it goes many miles beyond the services of any dermatologist I have come across. There are reports someone has claimed MJ told him he was sterile, having been kicked so often in the testicles by his father; though one of his brothers, in contrast, says MJ was a nimble dancer well able to evade their father's attempts to hit him with a belt. We have heard denials that homicide is being investigated, which is understandable, though members of the family have suggested sinister causes for the death. More likely would be charges of manslaughter, linked to what might have been negligence and reckless neglect of expected standards of care and protection.

Manslaughter and possible defences
To prove manslaughter, there would need to be evidence of actions by the doctor which created a significant and predictable risk of death or serious physical injury. If, for instance, Propofol was administered in a private home, or for reasons other than the usual medical indications, this would be negligent and potentially manslaughter. Many of the allegations of drug use and abuse could lead to such charges. The doctor should be aware of such risks - especially as they are very well known with the drugs that have been described.

Some lawyers might argue (and California celebrity lawyers specialise in such creative arguments) that if the patient was warned of such risks and agreed to accept the risks, such complicity could mitigate the doctor's culpability. I think this could be seriously challenged.

This could well apply to relatively small and rare risks associated with drugs genuinely used to treat disorders themselves dangerous. But where the drugs are used in ways or for reasons no responsible doctor could possibly recommend, proper informed consent could not be obtained. With the patient dead, a doctor could claim to have informed him even if this was not in fact done. But where the drugs have no defensible legitimate use, no such exculpatory information could have been given.

(Professor M.A. Simpson, aka CyberShrink, July 2009)


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