Q: What are the drugs that have been mentioned in connection with Jackson’s death and how do they work?
A: Propofol (Diprovan): A powerful intravenous sedative — not a DEA controlled substance — was found on the premises. It is used by anesthesiologists to put a patient to sleep before general anesthesia and surgery, or alone in a surgical suite for an elective procedure such as a colonoscopy or biopsy. Only small doses are necessary to be effective, and it can easily be misused by an untrained health professional leading to a respiratory arrest.

Narcotics: Demoral, Percocet, Vicodan — there are varied reports of prescriptions for these being found. All can lead a patient to stop breathing or sustain a cardiac arrhythmia and cardiac arrest if overdosed — especially if used in combination. These are controlled substances and prescriptions are subject to DEA review. Misuse can lead to loss of license or criminal prosecution.

Sedatives: A prescription for Xanax was reportedly found. This can also lead to supressed breathing.

Q: What are the questions about substandard care that surrounded Jackson’s death?
A: Excess prescriptions of narcotics and sedatives. When he stopped breathing, no opiate antagonist (narcan) was given to reverse the effects of narcotics. The doctor in residence did not coordinate the 911 call. CPR was done on the bed without a backboard, rather than on the floor where more force could be administered to the heart. No defibrillator was available, and no mouth-to-mouth breathing was reportedly given.

Q: Why is there a delay in getting the autopsy results?
A: The initial autopsy apparently showed no structural damage to the heart to explain his death. There is speculation that prescription drugs contributed to or caused Jackson’s sudden death, and initial toxicology reports may soon be ready. More extensive reports take longer because they look at blood and hair to quantify the exact amounts and combinations that could have led to his death. This will include a microscopic examination of the brain itself, which could show the effects of drugs and help determine the exact cause of death.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.” Read more at www.doctorsiegel.com

There has been a firestorm of medical coverage, my own included, on Michael Jackson’s untimely death last week. There is much we still don’t know, including the final toxicology report which may help us to determine the combination of chemicals that appear to have led to his demise.

Here is what we do know:

1 – The initial autopsy appears to have shown no structural heart disease, in other words, no heart attack or heart failure. This increases the likelihood that prescription drugs were involved as a cause, leading to either a respiratory arrest (most likely), or an irregular heart rhythm which led to the heart stopping.

2 – The behavior of the medical team, especially Jackson’s personal physician, is very questionable, at least by my standards. I am a practicing internist, and I worked in the Bellevue Hospital Emergency Room for 8 years, and here are some of the points I and others have raised. Why wasn’t narcan, which rapidly reverses the effects of narcotics, administered? Why wasn’t he brought to the hospital if he wasn’t feeling well? Why did his personal physician allow or facilitate this concoction of pills that Jackson was supposedly taking. It isn’t simply a matter of writing or not writing a prescription; as a primary care doc I feel responsible for knowing and overseeing ALL medications my patients are taking. Why was CPR done on the bed instead of the floor, when the amount of force necessary to provide 30% cardiac output (the goal in CPR) requires full force that can be wasted on a bouncy mattress. Was Mouth to Mouth resuscitation used? Why didn’t the doctor direct the 911 call – why did he leave it to a security guard?

3 – The latest news involves a drug known as propofol or Diprivan. There are reports that Jackson may have been demanding, and possibly receiving this intravenous drug, which could certainly have led him to stop breathing. This is a drug that anesthesiologists ONLY use to induce anesthesia either as a stand alone treatment in elective procedures such as colonoscopies, endoscopies, small plastic surgeries, etc., or as a pre-anesthetic to put patients to sleep followed by general anesthesia and intubation. As a stand alone for colonoscopy, it is generally accompanied by a mask, though it is given intravenously. The dose must be very carefully regulated by an anesthesiologist, and in the doses used, generally only lasts for a half hour or hour. It is never used outside of a hospital or surgical suite.

4 – We have an epidemic of pill popping in our society. Narcotics are vastly overused, in combination with sedatives. These are dangerous combinations, especially when you consider that people become tolerant, requiring more and more to achieve the effect they want, and can easily slip into a toxic, life-threatening range.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.” Read more at www.doctorsiegel.com

President Obama has mentioned many times that the health reforms he is proposing will not alter the health care of those who already have health insurance and want to keep what they have. But this is NOT the view of most practicing physicians — myself included. I may be one of the most vocal, but I am not alone.

1.  First of all, there is a critical and growing shortage of primary care physicians. Only about 2 percent of the current medical school graduating class is going into primary care. Those of us who already practice primary care are overwhelmed and many are quitting. The public insurances have the most trouble. Surveys show that 50 percent of doctors don’t take Medicaid, and in 2008, the Medicare Payment Advisory Commission found that 28 percent of Medicare patients looking for a primary care physician couldn’t find one. This problem will only get worse under any Obama plan. You may have new government-provided insurance, but you may not be able to find the doctors who take it. And if you do, they may be buried under a pile of paperwork, or be too busy changing over to the new Electronic Medical Records system to spend time with you.

2.  More than 150 million Americans have employer-provided health insurance. But if there is a public option, your employer may stop providing you with insurance. You may be compelled to take the public option, which will probably provide you with less real health care choices.

3.  If the public option grows bigger, because private insurers find they can’t compete, expect care to be rationed, as the government makes choices to try to contain costs. Reimbursements to doctors will be cut, as they have been under Medicare and Medicaid, but also, you may not be able to get dialysis if you are over a certain age, or you may have to wait on long lines for procedures, as they do in Canada.

4.  Bottom line — extending a system that already has too few primary care doctors who are overworked to the entire population does not bode well for prevention or quality of medical care. The costs will continue to spiral upward, and access will decrease rather than increase. A better approach would be to work on re-organizing the health care system towards prevention rather than intervention BEFORE expanding it. One way would be to pay for the education of primary care doctors and create a task force to treat the uninsured.

For more on my take on public health insurance and how doctors view it, check out my oped in Monday’s NY Post.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.”  Read more at www.doctorsiegel.com

The Food and Drug Administration, which has received criticism in the past for allowing risky devices like electronic muscle stimulators to go into the stores uncontested, has just given its approval for Palomar Medical Technologies to go over-the-counter with its light-based LED laser. This new toy uses a light-emitting diode to supposedly stimulate normal skin growth and reduce wrinkles.

I spoke to three top dermatologists at NYU Langone Medical Center — which has one of the top dermatology programs in the world — and all three said the same thing. They said the laser was most likely quite safe, and it’s very unlikely it will damage the eye — but it is not likely to be effective, is expensive, and may only remove the tiniest wrinkles with prolonged use 20 to 30 minutes, twice a day. So in evaluating the FDA’s performance here, score one for safety, but zero for effectiveness and cost. And don’t expect National Health Insurance to cover the cost of this one.

If you really want to help your skin and decrease your chance of wrinkles, then use sunscreen, eat and sleep properly, exercise and don’t smoke.

Dermatologists are now using new kinds of lasers to remove wrinkles, known as fractionated CO2. These are VERY effective, but can only be done by highly-trained doctors.

If you are serious about your wrinkles, (or have to appear on High Definition TV) see your dermatologist. Do-it-yourself lasers that are now being marketed for home use may be used for attacking the tiniest wrinkles, but should not be a primary treatment. The FDA needs to crack down on the devices they approve. This one is okay, except that it is expensive (several hundred dollars) and largely placebo.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.”  Read more at www.doctorsiegel.com

The problem with trying to treat cancer has always been that the body does not accept cancer as something foreign. It is hard to target a tumor for destruction if you don’t recognize cancer as an invader. So traditional chemotherapies have been based on the idea that cancer is rapidly growing. Powerful drugs that destroy rapidly growing cells do well against cancer, unfortunately they also damage rapidly growing normal cells, especially the hair, stomach lining, and bone marrow – hence the usual side effects from Chemo, hair falling out, nausea, and anemia.

But the latest treatments are clever – they are based on genetic differences that lead to the production of certain abnormal proteins that promote cancer growth. They take into account that certain cancers, such as melanoma, are antigenic, meaning they have surface proteins that can be used to trigger our body’s immune system in ways that can shrink the cancer.

These treatments which are less toxic and more focused are generally better tolerated and cause less side effects. Once you convince the body that cancer is foreign, you can then provoke the immune system to fight it.

Three targeted therapies for cancer made very exciting news at the annual meeting of the American Society of Clinical Oncology this past week. First, with stomach cancer, a breakthrough treatment with the use of Herceptin, a very successful drug already in regular use for breast cancer. Herceptin targets an abnormal protein found in 1/4 of women with breast cancer and decreases recurrence in 50 percent.

This protein, (HER2) was now found in high amounts in 22 percent of patients with stomach cancer. There are 21,000 new cases a year of stomach cancer in the U.S. one million new cases worldwide. In a study out of Belgium, Herceptin used in stomach cancer patients with high amounts of this abnormal protein lived three months longer than those who weren’t treated. The risk of death decreased by 26 percent.

Second, in women with extensive breast cancer, another new option was found to be useful. PARP inhibitors are chemicals which keep cancer from repairing its damaged genes. Breast cancer patients who received this lived twice as long, an average of 9.2 months, even with extensive cancer. This treatment is exciting because it stops only the cancer from repairing itself, NOT normal tissue. It may be especially useful in patients where breast cancer is linked to specific genetic abnormalities such as BRCA gene.

Third, a cancer vaccine has been developed against lymphoma, using the body’s own immune cells to fight the cancer, was shown with a small group of patients to keep them in remission for 44 months compared to 31 months for those who didn’t receive it.

These are all preliminary studies, but they together show progress in using technology, genetics, and specific therapies to help patients based on their characteristics and not just bombing cancer with a one-size-fits-all, kill-the-cancer-before-you-kill-the-body approach.

In contrast, by using tailored treatments that take into account the specifics of a patient’s cancer, you may get a better result than the shotgun poisons of chemotherapy. The research here is early but promising.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.”  Read more at www.doctorsiegel.com

While the Obama administration pushes for national health insurance, expensive overuse of technology based on the defensive practice of medicine by doctors is not being considered at all. Doctors over order tests and treatments for fear of missing a remote diagnosis. Doctors are afraid of being sued by aggressive trial lawyers who lobby Congress against real reform.

Though 98,000 people die in U.S. hospitals every year from medical mistakes, at the same time according to a recent Harvard study, 40 percent of malpractice lawsuits are not legitimate, though they lead to 15 percent of the money paid out. Often times the doctors who are sued did nothing wrong, while those who make mistakes too often escape retribution.

Most malpractice cases are won by doctors, but they suffer a long-extended process first where they must meet with lawyers. I know many doctors who have quit medicine or become even more defensive and ordered more unnecessary tests as a result. I remember when the best urologist and one of the top cardiologists at my hospital quit practice abruptly because of extended lawsuits where they weren’t at fault.

On the defense side, lawyers milk doctors for billable time, and on the plaintiff side, ambulance chasers thrive, creating and exploiting frivolous cases for profit.

Many patients get unnecessary operations because of defensive medicine. C-section is on the rise and is vastly overdone because of doctors fearing lawsuits. There is a culture of fear that motivates doctors to practice defensively, which causes costs to skyrocket.

With rationing of care that is inevitable under the Obama health care reform, especially with a public option, malpractice will skyrocket because tests and procedures will be denied and doctors will be blamed. Yet we doctors are too busy and too scared of being singled out to band together to resist.

What is the solution? One solution is to create state review boards like Michigan has to limit frivolous lawsuits. Doctors and lawyers can serve on these boards together and provide a barrier to nuisance suits. More peer review in the hospitals is also a good idea, regular mortality and morbidity conferences where doctors behavior is examined without the fear of lawsuits.

Capping pain and suffering awards would seem like a simple enough solution, but some patients truly deserve a high reward if they’ve been badly mistreated by a physician (as when the wrong organ is removed or a diagnosis is blatantly missed). A better approach is to target nuisance suits for destruction.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.”  Read more at www.doctorsiegel.com

 I don’t want to be picky, but I have to admit that as a fear expert I was more affected by President Obama’s statement a few weeks ago in response to the emerging swine flu threat that we should all wash our hands, then I was to Vice President Biden’s blatant misstatement about not flying on planes. Let me explain: clearly, we carry many bacteria and viruses on our hands, and in fact most of our stomach viruses as well as cold viruses are passed back and forth this way. It is hard to fault anyone for recommending hand washing, but consider that Obama’s statement carried the subliminal message that we might be carrying this virus, despite the fact that the statistical chances of that then and now remain extremely low.

The president followed that up by asking Congress for $1.5 billion to prepare us for this flu, an amount that seems totally reasonable until you consider what other health care needs it might be taken away from. Stockpiles of the anti-flu drug Tamiflu will have to be discarded if they aren’t used in 5 years, and we still have no idea what the extent of spread or severity of this swine flu virus will be. Preparing a vaccine seems wise, taking needed resources away from current pandemics like TB, HIV, or even the yearly flu does not.   It is paramount that at a time when our government is considering expanding the system for health coverage, that issues of allocation and proper use of resources be at the top of the list.

The Centers for Disease Control and Prevention has been front and center during the initial stages of the swine flu outbreak, and they have been very effective at identifying and tracking the virus, somewhat less effective at explaining it in context during press conferences (this may have something to do with the nature of the beast – press conferences themselves immediately become amplified).

I have more of a bone to pick with the World Health Organization in terms of their poor conveyance of contextual information. The WHO all too often seems like “fright night” though they too have been tremendous when it comes to “boots on the ground.”

Check out my article in today’s Slate magazine about how the WHO has dealt with swine flu.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.”  Read more at www.doctorsiegel.com

As we watch swine flu through the rear view mirror, and our concerns begin to fade, it is easier to see it in a more proper context. I tried to do just that in my oped in USA Today.

Even as we turn our attention to the southern hemisphere, and watch via the World Health Organization FluNet tracking system for the extent of the virus over the winter, I can’t help but comment on the WHO handling of the Pandemic Alert System as it applies to the swine flu outbreak.

The problem is that the current alert system was put in place in 2005 in reaction to the Avian Flu scare. Of course a tracking system in response to a scare has a built in tendency for overreaction. I don’t have a problem with the notion that level 5 involves sustained transmission of a new flu strain from person to person in 2 countries in the same region. Nor do I have a problem with the idea that a full pandemic (a scare term which is too vague to be descriptive) involves a sustained outbreak in different regions of the world. What I do have a problem with is the lack of statistics —number of cases and number of deaths don’t factor in. So it is possible to have a pandemic with only a few thousand cases. Where would the Bubonic Plague or the Spanish Flu, diseases which killed many millions of people, fit on a pandemic alert scale where a relatively small outbreak of Swine Flu is already listed near the worst possible ranking?

Not only that, but these pandemic alerts are used by the U.S. and other countries as a justification to divert needed health resources from other essential medical problems to the fear of pandemics. Sometimes that is justified, but often it isn’t. Keep in mind that Tamiflu and vaccines (which are stockpiled and then mobilized in anticipation of a pandemic), are perishable. We have already discarded hundreds of thousands of doses of unused smallpox and anthrax vaccines. How much excess expensive Tamiflu will we also discard when it expires?

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.”  Read more at www.doctorsiegel.com

The following statements are where I think we are currently on the new swine flu H1N1 influenza A strain. I’ve also communicated with Drs. Ann Schuchat and Nancy Cox at the CDC, who responded that they agree with these comments.

• The H1N1 influenza A is a new strain — a swine flu strain — with some genetic components that are characteristic of human and bird flu viruses. It bears watching and tracking, as any new influenza does.
• It is spreading human to human, and may have the attack rate of a typical yearly influenza A, but this is particularly difficult to determine because of both the overreporting (everyone thinks they have it), and under reporting (we are not really tracking the full spectrum of disease as we are not testing those with mild symptoms). It is also too early to really determine transmissability, because there are too few cases.
• Virulence appears to be low and if this continues, it will be a mild pandemic at worst. It currently appears to be very transmissible, but the outbreak could wane further if transmissability decreases. A severe pandemic will likely result only if it mutates into a more virulent strain. But assessment of the strain’s virulence is also based on a limited number of cases.
• It is worthwhile to begin preparing a vaccine, but we don’t yet have the upgraded technology (mammalian cell culture, reverse genetics) in regular use for flu, so we may have to rely on the older technologies (using hen eggs to provide a medium for growing the dead virus). This has yet to be determined.
• It is likely to wane soon due to summer weather, but bears watching carefully over our summer in the southern hemisphere, and mapping carefully for resurgence in the fall.
• Since the WHO designations for pandemic alert don’t include severity of illness or even true extent of illness, raising the pandemic alert levels have led to the public misperception that massive deaths are about to occur, which is part of the reason why the fear level is so high. It is best to provide calm accurate contexted information to avoid this, as I point out in “False Alarm; the Truth About the Epidemic of Fear.”

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for the LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.”  Read more at www.doctorsiegel.com

1. What is swine flu?
It’s a new strain of Influenza A, coming from a pig. The pig has contracted one human strain, two pig strains, and one bird strain of the flu. These all combined to make a new strain. Pigs are a Grand Central Station for flu and other viruses.

2. What are the symptoms?
They’re similar to regular flu viruses, but the gastrointestinal symptoms are more severe. They include:

• Severe fatigue
• Headache
• Sore throat
• Nasal congestion
• Vomiting
• Diarrhea
• Nausea
  *Keep in mind regular flu season is over, so if you are experiencing flu-like symptoms, call your doctor. Do NOT go to the ER.

3. How do you get it?
Mostly by infected people coughing/sneezing around you, also passing it by touch is likely.

4. How is it passed?
You can pass it on to other people by coughing/sneezing on or near them, and possibly even touching surfaces that they later touch (and then touch their face, eyes, nose, etc.).

5. How is it treated?
There’s no ‘cure’ for it, but you need:

• Isolation/Rest
• Fluids
• Keep fever down
• Consider anti-viral drugs such as Tamiflu and Relenza, but keep in mind this strain is resistant to many older anti-viral drugs.

6. How do you protect yourself?

• Frequent hand-washing
• Avoid sick people
• Don’t cough or sneeze on others
• Stay home if you’re sick!

7. Can you catch it from eating pork products?
While people in Mexico likely contracted this from handling infected pigs, eating pork products should be safe. Keep in mind to cook pork to a temperature of 160° Fahrenheit to kill any viruses.

8. Is traveling safe?
Travel to Mexico is still statistically quite safe; the problem is still mainly one of perception, as the actual risk remains low. I would also consider the psychological effects this could have on children; consider what precautions they might take at airports, with customs officers wearing masks, etc.

9. How long does it last?
The virus can incubate a day or two before symptoms occur. It takes about a week to recover from the full-blown virus.

10. Is this real or hype? Do I need to be worried?
The danger is getting a lot of hype, but it is real. You probably don’t need to be worried, though.

Dr. Marc Siegel is an internist and associate professor of medicine at the NYU School of Medicine. He is a FOX News medical contributor and writes a health column for LA Times, where he examines TV and movies for medical accuracy. Dr. Siegel is the author of “False Alarm: The Truth About the Epidemic of Fear“ and “Bird Flu: Everything You Need to Know About the Next Pandemic.”  Read more at www.doctorsiegel.com