StormKnight

Happy Birthday!

Hanging.

How much longer until the word comes down...hmmm

Blocking for at least another hour, then adding the primary antibodies.

The times and drugs given is per cnn's report. Note, *all* of these drugs are available in IM/IV form, and I have used them all. Most likely, he had an IV, as propofol is NOT given IM (it burns like a SOB,) so all of these drugs were probably given IV (quick acting route,) or IM. My commentary is based on MDConsult manuscripts, Epocrates Formulary, product inserts, pharmacology classes. Doses assume Jackson was 70kg (not unreasonable,) and drug-naive (probably unlikely.) 0130: Valium (diazepam): 10mg. Sedative dose/pre-op dose. Given once. Onset time is upwards of 30 minutes. Long acting (half-life is anywhere from 30-60 hours, with its active breakdown products having half-lives upwards of 100 hours.) 10mg is a fairly hefty dose; 5-10mg is usually given as a sedative before a minor procedure, and 20mg given prior to endoscopy. 0200: Ativan (lorazepam): 2mg. Sedative dose as well. Pretty quick acting. 2-4mg orally is used to treat some insomnia, but on a short term basis. 2mg IV/IM is enough to knock most of us on the DGN down. It is used in inpatient psychiatry for violent patients because an IM dose kicks in in a couple of minutes. Half-life is 12 hours in adults. IMO, this should have been given first, as it is fairly quick acting. Also, I think they were wrong in giving it 30 minutes after the Valium, as the Valium might have started to work by then. 0300: Versed (midazolam): 2mg. This is a quickest acting of the lot. 2mg IV is standard sedative dose for pre-op patients (and the one most commonly used.) Had this stuff myself for a tooth extraction. 30 seconds after I saw the plunger depressed in the syringe, I forgot the next 30 minutes of my life; the next thing I know is that I am being hauled to the car taking me back to the barracks. I tell my patients this stuff is like slamming a 6-pack in 5 seconds without the upchuck factor. There is a black box warning that if you are given this stuff, you MUST be hooked up to a heart monitor. (I was when I was given it.) 0500: Ativan 2mg again: this can be given once every 3-4 hours, with every 6 being the standard. 0730: Versed 2mg again, with the addition of a pulse oximeter (part of the monitors that should have been on him with the first dose, along with an EKG.) 1040: Diprivan (propofol): 25mg: Available as IV ONLY. Stuff is quick on, (20-40 seconds,) and quick off (5-10 minutes after the drip stops.) It is quick off because it first gets out of the blood and into the fat tissues, then it is broken down and eliminated (70% is out of your body in 24 hours.) In other words, as long as it is injected at a constant rate, you will stay asleep. It is white because the drug itself is not water soluble, and it is suspended in an emulsion of lipids and egg phospholipid to keep it emulsified (hence one of the reasons anesthesia types ask if you are allergic to eggs.) I have used this stuff, both in the OR and the ICU for anesthesia/sedation. The reason this stuff is so popular, in addition to the rapid onset and offset, is: It is not a barbiturate NOR a narcotic, which takes forever to wake up from, and is a pain in the ass to track, especially long cases (ketamine counts as a narcotic for tracking.) It is the only agent we have that we use for anesthesia that DOESN'T cause nausea and vomiting (unlike the above and the inhaled gasses.) In fact, it prevents it. There are a bunch of anti-inflammatory effects that are benificial to healing from surgery. It can be used as a sedation or a general anesthetic agent. It is one of the few agents used commonly (narcotic induction is rarely used anymore,) that doesn't induce malignant hyperthermia. You want to see an anesthesiologist freak out, an MH crisis would do it. I think CNN made an error. The report says propofol *drip*, which for this drug is MICROGRAM per kilogram per minute (mcg/kg/min.) 25mg as a one shot of this stuff is barely enough to induce drowsiness, let alone sleep. To get him to sleep, assuming he was 70kg, a one shot would have been 100-200mg of propofol. However, a drip set up at 25mcg/kg/min is the middle of the road for sedation in the ICU (5-50mcg/kg/min.) This would have gotten him to sleep. I have never in my time using this stuff have given the medication without EKC, pulse oximetry, blood pressure monitoring, and airway support available. This stuff is NEVER should be given outside of a monitored bed. This stuff induces apnea, especially if given as an induction dose (100-200mg) (patients are going on a ventilator after the apnea hits.) Stupidity on behalf of the doctor in charge: He is *not* a sleep specialist (usually pulmonologists.) He is an internal medicine doctor, sub-specialist cardiology (i.e. he is a cardiologist.) Unless he was planning to do a cardiac catheterization of Jackson in his bedroom or if Jackson's bedroom was an ICU, he had no right to be dispensing Versed or Propofol at all. Had the man had any sense at all, he would have referred Jackson to a sleep specialist, who would want to find out WHY he was an insomniac (this was a long term problem with him,) NOT JUST TREAT THE SYMPTOM. Ativan and Valium are not first line treatments. Lunesta and Ambien are, if drugs are given. Sleep hygiene is usually the first thing enforced. He gave three different forms of the same class of drug. Valium, Ativan, and Versed are all benzodiazapines, with differences in their onset and length of time in the body. This can constitute an overdose. Also, he didn't give enough time for the Valium to work (usually should wait an hour,) before either dosing him again with Valium (remember, 20mg for endoscopies,) or tried something else. No monitoring with the first dose of Versed. Anesthesia-types give this stuff en route to the OR, but we have the patient right in front of us, and the monitors are on the patient within a minute or two, not 4.5 hours later. No qualified relief. According to reports, he went to relieve himself after starting the propofol drip, leaving Jackson alone and unmonitored, at which point he died. This is abandonment, in my opinion. Anesthesiologists and anesthetists DO NOT leave a patient under any of these drugs without being relieved by another anesthesia provider under ANY circumstances; it's part of our training. Even when nursing is away from patient bedside in the ICU, those monitors you see are being watched in a telemetry room that will sound the alarms if something hits the fan. Propofol and Versed should never be used outside of the hospital/surgery center. Overall: This guy screwed the pooch big time. He let his ego and greed get away from himself, and used drugs outside of where they were supposed to be used. His ego in not referring Jackson out to a sleep specialist to be properly treated for his insomnia is incredible. I think crucifixion is in order. They need to revoke his licenses to practice (he is licensed in Nevada, California, and Texas.) He misused drugs that I use daily when I am in a clinical environment (with no adverse events like death and such; this is the first time I have heard of fatalities from these drugs in experience,) and I will end up having to allay fears of patients who see this high profile case as the norm, not the exception and stupidity of the doctor giving the drugs, for years to come. (And people wonder why I beat my ego so much? Because I don't want to let it run away and become a blind idiot like this guy, killing people. Ego kills.)

I keep telling you, remote detonation. The EMP will hide the signal after detonation, or the wire will be vaporized in the inital blast. As for me, still on the books, depending on how things fall out.

I know, but still...a remake of Red Dawn.

must head home soon.

*facepalms*

Things to go right.

Active.

Waiting for gels to set to load them.

The student isn't here. WTH?!

The Touch by Stan Bush

Welcome.

Get better.

welcome to our corner of the net.

Frazzled.

I need a cup of something to help organize a paper, please.

I need a brief break from this paper. I need to think of running sometime soon.

Welcome to our corner of the net.

Great. A headache. Got to try and get my head around this paper.

DGN @ City Club, Saturday, August 29th. 400 Bagley Street Downtown Detroit You enter by going through an unmarked door on the First Street side of the Ramada Hotel building, located at 400 Bagley Street in downtown Detroit. The club is at the top of the stairwell. (see picture in the link above in the DGN calendar entry) Come. Join us. Meet us. Hang out. We're not that scary in person, really. Leland City Club All are welcome. Come meet some of us weirdos. Saturday nights from 10:00 p.m. to 4:30 a.m. Alcoholic drinks until 2:00 a.m., pop and juices served all night. Admission is $4 18 and up, 21 to drink with proper ID (no exceptions). No drugs, weapons, chains or spikes. We've had reports that the CC parking lot will not break bills larger than $10, so try to bring smaller bills with you. Zoom able map to Leland City Club MDOT lane closure (The map isn't quite exact. The Leland is located within the Bagley, 1st, Cass, Plaza Dr. block.) In case you don't know the "DGN Corner" is to the right of the bar. Currently theres a table, pillar and long narrow wooden table, impossible to miss. Come say hello. If no one is there, stay there, they will show up. Note: If you're NOT going this isn't the place to post about it.