Propofol is a great drug – in context.


That’s right, in context. Let me explain.

Propofol is a great anesthetic drug, one that has allowed for a faster recovery from anesthesia and allowed for a greater safety in sedating patients, while still allowing physicians to turn it off with little residual. It’s used in the OR, in various procedure suites – GI, cardiac, etc – to sedate patients. It’s used as sedation in the intensive care unit when a person is on a ventilator. The nice thing about it is that an intensivist can turn it off, and ten minutes later be able to assess the neurological function of a patient.

That said, Propofol is like gasoline.

If you’re given an open bowl filled with gasoline while standing in two feet of water, soaking wet, you’re not really going to be too concerned. If it’s sitting in a proper container, stored safely, you aren’t concerned. And when the proper people use it, you aren’t too concerned either.

Now, a bowl of gasoline would be much more unsafe if you were near something rather hot, or near a fire, or on fire yourself. In fact, most people would regard you as borderline stupid if you did these things.

same thing with Propofol

It should never be administered in a home
It should never be given and the patient left alone
(I’m feeling very Dr Seuss-ish now)
It shouldn’t be given by personnel not trained in its use, and how to rescue someone who’s been sedated too deeply with it
It should never be given without the proper monitoring

Anesthesia p1 – Conscious Sedation, MAC, and Michael Jackson

Conscious sedation. It has a lot of names that people may know it as.
Monitored Anesthetic Care, or MAC, as anesthesiologists refer to it
Twilight (not the book, though that might cause it)

Basically, it’s when medication is administered to a patient to make a procedure tolerable, usually in conjunction with local anesthetics at the site of the procedure. Patients will likely have little remembrance of the procedure and may even lightly snooze during it. A patient can typically be aroused easily, answering questions or performing certain tasks.

Of course, there are levels to it. Light sedation is akin to having a drink, where it’s important for the patient to participate in the procedure. For example, the implantation of certain kinds of neurostimulators rely on the patient explaining what they’re feeling. Heavy sedation is used when the patient doesn’t really need to be with it for what’s going on. Sometimes patients in the Intensive Care Unit who are on a ventilator will receive heavy sedation; in the old days it was referred to as being ‘put into a coma’, which really doesn’t happen much anymore except in very isolated cases.

This is in contrast to general anesthesia, where the patient is at a much lower level of consciousness. Patients under general anesthesia receive either IV or inhaled anesthetics which render them completely unaware of what’s going on and unresponsive to stimulation. More on all that in another post. Just know that when you’re getting your gallbladder or appendix out, you’re under general anesthesia.

For a long time, it was believed that MAC anesthetics are safer than general anesthetics. However, studies have shown that bad things can still happen under sedation. While rare, it’s always possible for a patient to stop breathing if the sedation gets too deep. Yeah, that sounds pretty bad. However, when inducing a general anesthetic, patients stop breathing nearly 100% of the time. It’s part of our everyday job, and a patient not breathing under sedation is easily corrected without adverse complications to the patient. It does require, however, that the person pushing the medications pay attention.

And that’s what brings me to Michael Jackson, and his cardiologist.
There are certain standards involved in the administration of anesthesia. And make no mistake, MJ was receiving an anesthetic. But first, a few words on Propofol.

Propofol is an anesthetic, and when initially approved by the FDA it changed anesthesia. A lot. I use propofol every day, most days in every single case I’m involved in. Give a little, you get a reliable MAC drug that disappears within minutes of being turned off. It goes away quickly, independent of liver or kidney function. There’s no hangover effect afterwards, unlike with the drug it mostly replaced – sodium thiopental, also called Pentathal, long known as a ‘truth serum’.
More on that in a minute.

Anyway, there are standards that we follow in anesthesia. We use certain monitors on every case we do, and there are national guidelines for this. These guidelines are followed by all physicians as the golden rule for caring for patients under sedation. It includes, at a minimum, an EKG on the patient, a pulse oximeter measuring blood oxygenation, a blood pressure cuff going off every 5 minutes or less, an end tidal CO2 monitor, and – when shifts in temperature are expected – a method of measuring body temp.

So, what went wrong with MJ?

Well, to start with, the above listed monitors were sitting in the corner of the room, not on the patient. That’s pivotal. An end tidal CO2 monitor measures the amount of carbon dioxide in a patients exhalation. In a patient being sedated with propofol, it would’ve provided an early warning that Michael had stopped breathing. It would’ve alarmed if it hadn’t detected a breath for 30 seconds. The other important monitor is the pulse ox. When he went apneic, as his blood levels of oxygen declined, it would’ve been picked up by the pulse ox, which also would’ve alarmed. And finally, when his EKG started to change due to lack of oxygen and ischemia of the heart, the EKG monitor would’ve alarmed.

They don’t work if they aren’t on the patient. They also don’t work if they’re on the patient and you can’t hear them. We don’t leave our patients. One of the central tenets of our profession is vigilance.

Also, the physician should’ve explained to MJ about anesthesia better. We’ve really shot ourselves in the foot by calling anesthesia ‘sleep’ over the years. I understand why the practice was started, as it conveys a sense of something natural that we do every night and is perceived as safe. Before the monitors described above were required, anesthesia wasn’t that safe. Patients would stop breathing or not breath enough, and the only clue was when they turned blue. The widespread acceptance of pulse oximetry greatly changed the safety factor in anesthesia. These days, it’s safer to be anesthetized than to drive on the highway.

Still, anesthesia isn’t sleep, it’s unconsciousness. While that may sound like splitting hairs, the fact of the matter is that unconsciousness doesn’t provide the restful REM sleep that we all need to stay sane. By sedating MJ, his physician made his tired feeling worse. I’ve had plenty of patients emerge from anesthesia and tell me how tired they are. I’ve yet to have one wake up in ten years and feel refreshed. It’s more akin to running a 5k than taking a nap.

More next week!

Medicine and fiction writing

So, every time I’ve tried to write a blog post lately, I’ve had nothing in my head to write about. Except, that is, one idea. So, I’m finally giving in, just to get it out of my cranium if nothing else.

I’m going to write about something near and dear to my heart.
My job.

While I’m slowly writing my way through a variety of novels and short stories, I keep the lights on and the roof over my head as a practicing anesthesiologist.
I think there are a lot of misconceptions about anesthesia out there, and I’ve critiqued a number of short stories in the past regarding their use of it.

So, I’m going to write a series of posts covering the following:
Conscious sedation
The death of Michael Jackson
General anesthesia, and the drugs related to it
Lethal injection
How to use anesthesia for nefarious purposes in your fiction

So keep checking back in. First post goes up this week!

Recent Readings

So, I’ve been writing a new story lately, but I’ve also been doing a fair amount more reading as well. I’d been trying to reread GRR Martin’s Song of Fire and Ice – or the Game of Thrones books, for those only familiar with the HBO series – but was having a hard time getting back into the story. I’d forgotten how many screwball tangents he throws into his books, how choppy the narrative was. I really wanted to read the fifth book, but knew I’d be lost without being grounded in the story. Anyway, I then learned there are two more coming, which’ll take a decade at least, so I stopped reading.

It’s the same thing that I felt with the Wheel of Time series from Robert Jordan. I read quite a few, but the plot became so complex, following 4, 5, 6 different threads at a time, that I got lost when a new book came out and it had been a year since reading the others. I resolved to wait until the entire series is out before reading any more. The last couple are coming out soon, though the series has actually outlived its author.

It’s a catch-22 I guess. I love the complex stories while I’m in them, but caring over between books is too much.

ANYWAY, I’ve been reading different authors lately. I’m continuing to read Lilith Saintcrow’s Jill Kismet series. I reviewed the first one about a month ago. The same issues I had with that one I’ve had with the others, which are few. She spins an enjoyable tale, dark and gritty urban fantasy, with a minimum of plot carryover between books. I did see where she’s ending the series after seven I believe. Definitely a recommended read.

I’ve also read two of the three Twenty Palaces novels by Harry Connolly. This’s another urban fantasy, first person POV. They’ve really been keep-reading-long-after-I-should-be-sleeping novels. The protagonist is a clever guy, though sometimes I wish he had more than just one spell to use. It gets a little repetitive, and it’s always the way out of a jam, it seems. Still, I’d highly recommend these books. There’s only three out, so make ’em last.

Lastly, I’m reading the second Lee Child book about ret. Major Reacher. Great thrillers, wonderful protagonist. Not urban fantasy, but still a book to pick up as a cleanser between fantasy series. Fortunately, there are a lot more of the Reacher novels to read.

If you’ve never been in a hurricane….

I’ve seen a lot of comments and tweets from people in the New York area about Hurricane Irene and their plans – or lack thereof. I’d like to offer some advice. First, I’ll mention my experiences with hurricanes. If you just want the advice, scroll down.

My Experiences
From 2002-2009 I lived in New Orleans, training and then working at a hospital in town. Yes, that means I was there for Katrina.
I’ll get to that in a second.
In the three hurricane seasons I was there for before the Big K, there wasn’t a season that went by that we weren’t targeted by a hurricane. Some of them veered off into Mississippi or Alabama. Some of them powered down into tropical storms. The first year I stayed at the hospital for the night (a tropical storm). The next one that came through, I drove to the hospital for my shift in the midst of a Cat1 hurricane landing.
The summer of ’05 kinda sucked for us (the Mrs. and I). We’d evacuated for storms twice, once with me staying behind to man the hospital while my wife flew off. Both times the government officials and weathermen prophesied disaster. Both times, nada happened. A few branches down, the occasional power line, but mostly nothing.
I think that’s why Katrina was so bad. Yes, it was more powerful, but it was the exact same doom and gloom forecasts as the previous two times. So, a lot of people blew it off. I’d worked the night shift that Friday night. By noon Saturday, my wife woke me up to say the track hadn’t changed. I was off on Monday, so we packed up three days worth of clothing, our photos, computer, guns, etc. We debated on taking the cat, since the last time he was a royal pain in the butt driving to Houston. Ultimately, we shoved him in the Jeep too and took off.
Imagine our shock when Katrina devastated New Orleans. Ultimately, our apartment had rainwater in it, and abundant mold. The house we were buying was outside the city and unharmed. Still, it was a month before things got back to normal.
We also went through Gustav several years later. My wife was evacuated for two weeks with that one. I slept in my office at the hospital for a week before I could meet up with her. Our house was without power for two weeks but unharmed.

The Tips

  • If you can leave the area, just do it.  You’re not going to be better off in the path of a hurricane.   You are more important than your stuff.  And don’t stay to protect your things – you aren’t going to keep the couch from getting sucked out a window if things get that bad.  Looters?  Do you really want to be there when some guy tries to cart off your TV, the phone circuits to  911 are jammed, and your cell phone is dead?
  • Duct tape on a window is pretty useless.  It doesn’t add strength, and is a pain in the butt to get off when things are done.
  • Everything depends on power.  The greater the length of time a community is without power, the longer the recovery process.
  • Fill your fridge and freezer.  More stuff in there that’s cold means it stay the right temperature longer with the power out.  Longer than 36 hours, though, and it’s time to start grillin’ all the meat you’ve got in the freezer.  You can fill the fridge with water.
  • Don’t forget to dump out your ice tray if things are starting to melt
  • Minimize how often you open the fridge.
  • Fill your bathtub with water.  Not for drinking, but for using to flush the toilet.  And the occasional sponge bath.
  • If you’ve evacuated and you’re coming back, buy groceries wherever you are.  Most likely, the grocery store owners / workers evacuated as well.  Plus, the supply chains have been disrupted.  The shelves will be bare at the store until everything gets back in swing.  Bring enough for a week.
  • Better to clean out the perishables in the fridge and freezer early.  Wait more than 3 days and you’ll regret it.
  • If the place you go to is in a different area code, buy a disposable cell phone.  Circuits in New Orleans were busy for a few days around most hurricanes, and impossible in New Orleans for two weeks after Katrina.  Calling out is easy.  No one will be able to get through to you, though.
  • If you stay in town for the hurricane, keep in mind that 911 will be flooded with calls.  If you need help, it might take a significant amount of time to call for it, much less for it to arrive.
  • You should have an alternative way to charge your cell phone.  Your best friend for information will be a battery powered radio, until power’s back on.
  • Beware of rushing water.  Contrary to what the movies show, it only takes a few inches of swiftly moving water to knock you off your feet.  Those images of people stuck in trees following a storm?  Yeah, they started off in shallow water.  Same thing for cars.  Yes, your car’s engine will run as long as the air intake and exhaust are above the water.  But here’s the thing – cars are relatively buoyant.  It doesn’t take much water before you’re manly SUV is floating.  And if it’s floating, it might float into water that’s too deep and dangerous to swim through when it decides to sink.
  • Generators can be a wonderful thing.  But you’ve got to maintain them, keep an eye on them, and watch out for that gasoline.  Buddy of mine in high school had his neighborhood flood.  His house was above the water.  It burned to the ground from a generator fire.

Anyway, I hope those help.  Above all, be safe and smart.  Keep your wits about you, and a healthy dose of caution.

I’ve got an idea

So, I’ve been barreling along with my current books and stories with a particular character. I’m fairly nervous about the landscape of the publishing world, so I’m adopting a wait-and-see attitude before I jump in either direction (self pub vs getting an agent).

(Of course, I’ve writing short stories, and now that I have a small stack, I’ve got to decide whether to get them published in some short story forum – i.e. magazine / website – or put them up in a variety of collections for sale, to build a bit of name recognition out there. That’s a topic for another post, thought.)

Anyway, I’ve got several novels plotted out for this character, some cool stuff that happens to him and great adventures to whack him in the face. Peril, a damsel or two, and subplots galore.

Then it happens. I have an idea, and it’s for a different character. Different circumstances, different kind of guy, different things he’d deal with from my other character. I’m thinking it’d be the same world, even the same city. Having short stories where the two’d interact would have some potential, plus introduce people to both of them. One of the series would be first person POV, the other third.

I’m even adopting a different process of writing for this one. The first series has detailed plots and subplots, spanning several novels and is third person POV. I write it out longhand first, then revise as I type it up. The new series has no outline. I’ve got an idea of where I want the novel to go, how the next few scenes will play out. I’m typing it, not writing it. First person POV. It’ll be interesting to see how such a switch works for changing voice and crafting an interesting story.

There is some research out there that demonstrates typing out a story versus writing it longhand engages separate parts of the brain, beyond those needed to type versus write. So, this should be an intriguing experiment. It’ll also be my first foray into including a bit of romance – my first series has a main character who’s a widower, hasn’t dealt with that and so can’t handle a relationship.

I’ll update occasionally on how the experiment’s going, or if I write myself into a dark corner with a serial killer nearby.


When I was a boy, my father ran a collectibles shop in New Orleans.  Not like you think of these days; this’s back in the 40’s.  Back then that meant stamps, pocket watches, high end men’s accessories – cufflinks, diamond tie pins, mother of pearl clad shaving sets – and coins.  Mostly coins.  I remember the sound of the currency clinking together as he sorted it into stacks.

The shop wasn’t big, tucked into a crevasse between a burlesque club and a by-reservation-only restaurant in the French Quarter.  Tall display shelves stood along the walls, sentinels glaring down at the lone horizontal counter.  I’d do my homework in the back room, kept company by a radio and the sound of Father counting coins at the front desk behind the counter.  I remember how I used to stare at the massive safe in that cramped room, where Father kept gold coins, silver bars, and loose diamonds.  The cash box went in there every night, next to the Colt .45 Peacemaker that’d been my grandfather’s.  It was probably the only thing in the shop that was plain – unadorned steel, unvarnished rosewood handles, and unmistakable intent.  

That day, that horrendous day, I’d huddled under the back room desk to reenact D-Day with my tin soldiers.  The bell on the front door jingled, an event that’d been less common in the weeks before.  Thing that perked my attention was my Father’s voice as he addressed the entrant.  Father had a strong voice, deep and mighty.  Yet that day his voice quavered when he spoke.

“Mr. Malucci, I’m honored by your-”

“Stow it,” the other man growled.  “I’m here for my money.”

There was a pause.  “I don’t have it.”

“What?” Menace lurked behind the question.

“Business – it’s been slow the last few months.”

I could hear the sound of Malucci’s shoes as they came around the counter.  “Now, how am I supposed to protect you if you don’ pay?  This’s three months inna row.”

“P-p-please, I’ll get it for you somehow.  Or I could pay in merchandise?”

“You’re makin’ me look bad,” Malucci said.  “Maybe my other clients’ll get the same idea, thinkin’ they don’ need to pay neither.  Bad for business, that.”

I’d moved far back under the desk, pressing my back against the wall that divided the store.  When the shots came, I squeezed my eyes closed but didn’t make a peep.  I heard the dull thump as Father hit the desk.  The coins he’d been stacking hit the floor, mixing with the noise of spent cartridges doing the same.  

I forget how many times that 1911 barked.   Malucci’d brought it back with him after his tour of duty.  It’d killed untold numbers of the Germans, only to be turned against Americans stateside.

Tears streaked down my cheeks.  I imagined Father on the other side of the wall.  I imagined what I’d have to tell Mother.  I imagined the Peacemaker not five feet away.  

My hands slipped around the handle of my grandfather’s iron.  It took both hands to hold it.  As I came around the door frame, a singular sob escaped.  Malucci looked down at me, at the Colt in my grasp.  He didn’t try to take it; he didn’t lift his weapon.  Instead, the mob enforcer pulled out a Lucky Strike pack, popped a cigarette between his lips, and fired it with the silver lighter Father kept on the counter.  

Smoked ringed his head.  “Well?  You gonna shoot, or just stand there?”

I reached up with a thumb for the hammer.  I envisioned using the Peacemaker to send Malucci into the afterlife with Father, though headed in the other direction from him.  But my seven year old hands betrayed me.  I couldn’t cock the hammer.  I’d failed my father – they’d find my body next to his, I was sure.

Malucci harrumphed, a note of derision.  “Listen, kid.  You tell anyone I was here, I’ll have to rub ya out.  But I can appreciate if ya want to try your hand at revenge later in life.  Someday, when you’re big enough, you come find me and we’ll settle things.”  And with that, he left.

Forty years passed before I saw him again.  He’d risen in power, becoming head of the New Orleans mob before the Feds busted him.  He spent fifteen years in prison.

When I caught up to him, he was a wasted man.  Old, withered, hunkered down in a battered recliner with his oxygen tank.  I’d brought the Peacemaker, a heavy weight in its holster at the small of my back.  I’d also brought my father’s favorite pearl handled straight razor.  But in the end, I decided to go my own route.

“Who’re you?” Malucci rasped.

“Does it matter?” 

“No,” he admitted, sucking on a cigarette.  “I always thought the old ways would catch me.”

I tell him about my father, remind him of the little boy with the revolver, and his parting words to me decades before.

He shakes a bald head.  “Doesn’t ring a bell.  But whatever.  You’re here to collect a debt.  Stop yammerin’ and get done with it.”

Opening the case at my feet, I pull out my favorite. The smooth wood of the Tommy gun’s stock and foregrip caress my hands.  I thumb the safety, pull the trigger, and don’t stop until the drum magazine’s empty.  The cartridges eject to ring against the tiles, the coin of vengeance spilling across the den’s floor.

When it’s done, I hear a snuffling behind me.  I whirl, the Peacemaker jumping into my hand with practiced ease.  A girl huddles in the corner, no more than ten or eleven.  Letting the hammer down on the revolver, I can see the fire in her eyes.  

I nod at her. “Someday, when you’re big enough, you come find me and we’ll settle things,” I say, repeating the words I’d heard in my head for four decades.  Vanishing into the cool New Orleans night, I go to wait for my own coin to come due.