I have been writing articles lately about the reasons for the H1N1 vaccine shortage and what to do about it. You can find these pieces in Forbes.com, Slate, and most recently as an oped in Wednesday’s NY Daily News. I believe that fear has played a major role in governing our public health response to H1N1 swine flu and the pressing need for a plentiful pandemic vaccine. I realize that it is easy to bludgeon our officials with the retrospectoscope, on the other hand, many of these nervous responses are chronic, and require significant adjustment going forward:

• Vaccine fear mongers do significant harm. Fear of thimerosal (a mercury-containing preservative that is used to bundle doses and has been shown not to cause autism) led to too much time spent trying to produce single vaccine doses without it.
• The CDC’s fear of overreacting to a possible pandemic, as they did in 1976 when 40 million people were vaccinated unnecessarily for a pandemic that never came, led to too much caution here, where instead a shift in vaccine production to the H1N1 vaccine could have led to many more million doses available now.
• Fear of seasonal flu, which doesn’t peak until much later, if at all (maybe crowded out by the H1N1 pandemic strain), led to 115 million doses of seasonal flu vaccine produced, when there is no seasonal flu around.
• Fear of new vaccines in the U.S. has led the FDA to fail to approve several new vaccines which use more up to date technologies such as mammalian cell culture instead of hen eggs, or additives known as adjuvants which make vaccines more potent so a smaller supply can be used for more inoculations. One American company, Baxter, makes a mammalian cell vaccine that will be used extensively in Europe, especially for those with egg allergies, but is not approved for use here.
• Fear of vaccines has led to poor compliance, especially for children, the group that currently seems to be most at risk for complications of the disease.
• Fear of admitting error has led our public health officials to delay in acknowledging the shortage or in correcting it, delay in accepting that it is H1N1 that is the predominant flu this year, not the seasonal strains.
• Fear of the spreading flu may be useful to combat fear of the vaccine, but a better approach would be a rational discourse based on statistics and real risk.

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’s new Ebook: Swine Flu; the New Pandemic, will be published in early October. Dr. Siegel is also 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 am sitting here in my white lab coat with dirty sleeves (from use), thinking that there is no reason for a practicing physician to support the current health reforms before Congress.  Patients are going to have a rude awakening when their new insurance cards don’t give them the kind of access to doctors they are expecting. Doctors are too frustrated and marginalized to play ball with the president. Here are the reasons that every doctor I know is vehemently against Obamacare:

*  No comprehensive tort reform. Most surgeons I know are struggling with a constant fear of malpractice claims. Most have had at least two or three frivolous lawsuits in their careers to contend with. Most have spent hundreds of hours with lawyers going over the fine print of their records only to have the case settled. Most surgeons are now opting out of accepting insurances in order to afford their malpractice premiums which are often close to $100,000 yearly. Caps on pain and suffering are only one part of the problem.  32 states have some kind of tort reform already, but there needs to be a consistant federal mandate or doctors will hop from state to state.  In California, when caps of $250,000 were instituted, doctors’ premiums did not decrease until a second law compelled insurers to transfer savings to physicians. Nuisance suits can be blocked by creating boards of doctors and lawyers to review cases before they are brought (these boards already exist in Tennessee and Michigan). “Loser pays” statutes can be added (doctors win the vast majority of suits) so that liability insurance companies won’t force doctors to prematurely settle claims to avoid large legal fees.
*  The bills before Congress all include large Medicare cuts. The Baucus bill would cut Medicare by $500 billion over a decade. This will lead to cuts to hospitals who will then be compelled to cut patient services and doctor salaries. The moratorium for not cutting doctor reimbursements across the board by 21% as Congress is supposed to do is not likely to last. Medicare cuts to doctors will cause more to quit or game the system. A changeover from fee-for-service to bundled payments, as the Baucus bill envisions, will leave many doctors out in the cold when they are denied payment for a service that is considered unnecessary or redundant.
*  The growing doctor shortage – the Association of American Medical Colleges calculates we will be 125,000 doctors short by 2025 – does not leave us with the manpower to take care of an additional 30 to 40 million patients. Doctors will be more rushed than ever.          
*  The extension of Medicaid to 10 million more people as the Baucus bill proposes will be a disaster for doctors. Consider that Medicaid often pays doctors less than $10 per office visit. 50% of doctors don’t take Medicaid, and states have already been cutting Medicaid payments to hospitals because most states are having trouble funding Medicaid. Medicaid networks of services and service providers within hospitals are being cut, making it impossible for doctors like me to take care of these patients (we have nowhere to send them for services or procedures).

We doctors are being squeezed, marginalized, ignored, and criticized. Of course we aren’t happy. Of course we feel that it will impact our patients’ care.      

If there is a hardworking doctor out there who thinks the current health reforms are good for doctors or America, I don’t know her.

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’s new Ebook: Swine Flu; the New Pandemic, will be published in early October. Dr. Siegel is also 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

Here is the latest about the novel A(H1N1) swine flu pandemic virus, and what we are doing about it. Also check out my new Ebook: “Swine Flu; the New Pandemic.”

The best way to decrease the amount of circulating AH1N1 flu virus is to vaccinate as many people as possible. This is known as herd immunity.

The current H1N1 though mild, has infected millions and hospitalized more than 10,000 here in the U.S., killing close to 1000, so mass vaccination is warranted.

Unfortunately, once the vaccination program starts, it will be TOO easy to blame ANY deaths on the vaccine. This happened in Great Britain with the HPV Vaccine, where Cervarix is expected to cut deaths from cervical cancer by 650 and 1.4 million women have already been vaccinated, the vast majority with no problems. Yet a single death which was later found to be unrelated to the vaccine caused hysteria.

Though the 1976 swine flu vaccine was linked to several hundred cases of Guillain Barre Syndrome (paralysis) for a pandemic that never happened, this time there is a real pandemic, and the vaccine has been well studied in clinical trials and found to be very safe and has not been linked to GBS.

This vaccine is made the same as the yearly flu vaccine, with hen eggs, and will be just as safe, with the major complication in the vast majority of cases being local irritation around the injection site.

In discussions with senior officials at the CDC I have determined that it is acceptable to give both the seasonal flu shot and the H1N1 swine flu shot at the same time.

The CDC also recommends H1N1 vaccines even for those who believe they have had the disease. Serological tests to confirm immunity are considered unreliable and are not readily available.

The flu mist inhaled vaccine is being released this week. Since it is using an attenuated (weakened) live virus, it should not be given to pregnant women, those with chronic conditions, or those who are immunocompromised. It has also not been tested in the elderly.

The injectable inactived H1N1swine flu vaccine will start becoming available in two to three weeks. It uses an inactivated (dead) virus, and can NOT give you the flu. It is safe in all except for those with severe egg allergies. It should be given first to health care workers, pregnant women, children, and those with chronic conditions. 250 million doses should be available by sometime in November, and I will be recommending it for all.

Swine flu parties are a bad idea. They are an example of deliberate infection to provoke immunization. Since flu is so easily transmissable, it can easily get beyond the party and spread to someone who is more likely to have a severe outcome, such as a pregnant woman, a young child, or someone with a chronic condition.

The risk of the flu is far greater at this point than the risk of the vaccine. It is still a very mild virus, but must be taken seriously, as flu is tricky, and can kill. Coming out of the southern hemisphere, whose winter just ended, the prevailing strain of H1N1 swine flu is a good match for the vaccine.

For daily updates on the H1N1 swine flu strain, twitter me at marcsiegelmd.  I will post my latest articles, updates, and answer questions.

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’s new Ebook: Swine Flu; the New Pandemic, will be published in early October. Dr. Siegel is also 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 are several reasons why I believe that most doctors are unhappy with the direction that health insurance reform is taking. I address several of these reasons in my oped in today’s NY Post (September 23rd, 2009). I will also outline them here. Suffice it to say that adding more patients to the health care turnstiles and promising them access to quality physicians when there is a growing doctor (and nurses) shortage and a growing doctor (and nurse) discontentment is problematic at best. The blanket of health insurance that Congress and the president envision is not long enough to cover the body of health care. If we pull it down to cover the toes, the head will be exposed. If we stretch it to cover the uninsured without dealing with cost or the doctor shortage, we will end up taking care away from those who currently have it and need it (the elderly and the disabled to name two groups who are endangered). Remember, physicians who aren’t functioning well have a negative impact on health care.

Reasons for doctor discontentment:

• No meaningful tort reform is included in any of the current bills under consideration in Congress. No shared liability with insurances or the government, no caps on pain and suffering, no review boards to limit nuisance suits, no “loser pays” allowance, despite the fact that physicians win the vast majority of suits.
• No significant subsidies to primary care education, despite the fact that there has been a decline in those choosing primary care of over 50% over the past decade.
• Big cuts to Medicare and Medicaid payments to doctors and hospitals of hundreds of billions of dollars in the bills, despite the fact that doctors are already cut to the bone in terms of increasing expenses and decreasing reimbursements.
• Cuts in payments for procedures and mechanical devices will put more pressure on doctors as patients express their (deserved) discontent, and there is nothing a doctor can do.

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’s new Ebook: Swine Flu; the New Pandemic, will be published in early October. Dr. Siegel is also 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

If you are a child:

• Children have not shown any immunity to this new strain of flu.
• Kids are super spreaders of flu, with schools being petri dishes for spread.
• Children should wash hands frequently for at least 30 seconds with soap and water, use hand sanitizers, and sneeze or cough into their sleeve.
• Children who have fatigue, fever, sore throat, nausea, or muscle aches, should STAY HOME and the family pediatrician should be consulted.
• Rapid flu tests are about 60% sensitive for H1N1 swine flu, and a presumptive diagnosis can be made by a child’s doctor, based on symptoms.
• Kids with the flu should stay home for at least two days after symptoms resolve.
• The H1N1 swine flu vaccine will be available beginning in late October. ALL children should take it, especially those with chronic illnesses. It will likely be offered in schools. It is not clear yet whether children will require one or two shots.
• The use of Tamiflu (anti-viral) in children is somewhat controversial; recent studies from the UK appear to show that it isn’t well tolerated or effective, though previous studies have shown that it is safe, shortens the course of illness, and can also prevent spread (80-95%) if given to close contacts. This was the experience of several summer camps in Maine this summer, where Tamiflu was also well tolerated.
• Secondary bacterial infections are common, and should be treated promptly with antibiotics.

If you are an adult:

• Especially at risk are adults with chronic illnesses such as COPD, Crohns Disease, Rheumatoid Arthritis, HIV, cancer, etc. These patients should be especially careful, take Tamiflu early for flu symptoms, be on the lookout for secondary infections including bronchitis, pneumonia, sinus and ear infections.
• The H1N1 vaccine should be given to these groups as soon as available, as well as pregnant women (currently in clinical trials), health care workers, and close contacts of those with chronic conditions.
• New studies just published in the New England Journal of Medicine show that the new vaccine works in 7-10 days, is well tolerated, and provides immunity with a single dose.
• Elderly patients appear to have partial immunity to this H1N1 swine flu strain, if born before 1957, probably because of exposure to a related virus when they were younger, but should still be considered for this vaccine, especially if they have chronic medical conditions.
• Those who had H1N1 swine flu in the Spring or Summer are likely immune. There may be a blood test available to test this.

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’s new Ebook: Swine Flu; the New Pandemic, will be published in early October. Dr. Siegel is also 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

In the current push for national health insurance, expensive overuse of technology based on the defensive practice of medicine by doctors is being overlooked. Yet doctors often over-order tests and treatments for fear of missing a remote diagnosis. Doctors are afraid of being sued by the same aggressive trial lawyers who lobby Congress against real reform. Keep in mind that it isn’t just a dreaded error like removing the wrong kidney that motivates doctors to practice defensively, it is the fear of lawyers and having to meet with them as part and parcel of responding to arbitrary lawsuits. Doctors who have done nothing wrong can be targeted with frivolous suits that drag them into the lawyer’s office. The process of having your records scrutinized in an effort to determine how well you’ve documented things and if you’ve made errors can be instructive, but it can also be humiliating. This process can alter the way a doctor practices as he or she struggles to avoid the nightmare of legal exposure in future.

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 not before they endure the protracted painful process of meeting with lawyers. Many doctors quit medicine or become even more defensive and order more and 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 may 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 the possible rationing of care that may occur in the name of cost control under an expanded system, malpractice could skyrocket as more and more tests and procedures are denied yet doctors continue to be blamed when something goes wrong. It is especially problematic that neither insurers nor the government have direct legal responsibility while at the same time turning down tests. Most doctors are too busy and too scared of being singled out to band together to protest this uneven system.

What is the solution? One solution is to create state review boards like Michigan or Tennessee 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 direct 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 initial approach is to target nuisance suits for destruction.

It is estimated that tort reform can lead to an initial savings of 2% on health care costs, without even considering the billions of dollars that will be saved by decreasing the defensive practice of medicine (based on overuse). But even with tort reform, the current plans for health insurance reform combined with decreased reimbursements to hospitals and doctors will lead to more and more patients being seen in shorter periods of time. This will lead to more and more medical mistakes, and more and more malpractice.

There hasn’t been much of a push yet to combine tort reform with the current health insurance reform initiative being considered by Congress. This could change. The Democrats could decide to add some tort reform (probably Caps to pain and suffering) as a sweetener to a bitter pill (or bill). This might cause more physicians to support the current health reform, but would do nothing to correct the larger problem of physician dissatisfaction, overwork, attrition, and scarcity, all of which lead to medical mistakes.

Plus, simply capping pain and suffering is not a guarantee that doctors will see their liability insurance premiums lowered. In California in the 1980s, when a cap on pain of suffering to $250,000 was first initiated, there was no overall savings to physicians. Instead, the insurance companies made more profits. It took an additional law to ensure that the savings was transferred to physicians in terms of lower premiums.  

It is the current insurance-oriented climate for practicing medicine that must be changed before doctors (and their patients) will reach any kind of comfort level or be able to cut costs in a reasonable way. Insurance of both kinds (private and public) is the problem, not the solution. Costs spiral upward because of doctors’ fear of malpractice and rush to see more and more patients in a short period of time amid shrinking reimbursements. The easiest way to do this if you’re a primary care doctor is to quickly refer a patient to a specialist of for an expensive test, jacking up costs. At the same time, patients are inclined to overuse their health insurance because they don’t pay for each procedure or as many have put it, because patients don’t have any “skin in the game.”

Tort reform is essential and must include not only caps on pain and suffering and reflected decreases in liability premiums, but also a way to ferret out nuisance suites. I am in favor of more peer review in the hospitals as well as a lawyer and doctor staffed board in every state to review claims before they are brought. I strongly believe that private insurance companies as well as the government (Medicare and Medicaid), should incur liability themselves for tests they decline.

But I do not think that any of this should be done as a way to manipulate physicians to support a kind of health reform that is not in our best interest, or in the best interest of our patients.

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 have long been concerned about potential overuse of the anti-flu drug Tamiflu, in fact there are sections on this topic in both my book on fear and my book on flu. But in my opinion, the current situation with H1N1 swine flu calls for the careful use of Tamiflu at large camp outbreaks. Use of the drug is warranted to help decrease shedding time in patients with mild cases and to prevent additional cases in their close contacts.

The CDC does not agree with me.

Here are the plusses:

1 – Since Tamiflu is highly successful at slowing spread, its use to squash outbreaks can help keep camps open which has the added benefit of keeping sick kids from bringing flu home to many different zip codes and thereby expanding the outbreak. People who are more at risk (including pregnant women, infants, and those with chronic conditions) may catch it that way. Even though this is a mild virus so far, with millions of cases around the world and only 700 plus deaths, there is always the chance that it will get worse; in fact a recent study shows that it lingers in the lungs of Ferrets (who react to flu like humans), causing lung infections.

2 – More circulating virus may increase the chance of a lethal mutation. The famous second mutation that may have occurred in 1918, when the virus became much more severe in time for the fall flu season, is extremely unlikely, but possible.

3 – Children seem more at risk for severe cases, perhaps because of a lack of immunity to an older H1N1 virus that was circulating before 1957. Older patients who have that immunity may have milder cases.

4 – Isolation of sick people and their contacts is the first priority, but use of Tamiflu (especially when there is no vaccine available), is a useful adjunct which may help to keep the camp open.
Here are the minuses:

1 – Use of Tamiflu may increase the chance of resistance occurring. There are some excellent articles on recent Tamiflu resistance, which also demonstrate that resistance sometimes occurs spontaneously, without exposure to flu:

H1N1 swine flu – the non-sustained Danish and Japanese resistance cases were in patients taking Tamiflu prophylactically. (see New Scientist article)

The interesting case in early July of a girl from San Francisco who picked up Tamiflu resistance in Hong Kong but NEVER took Tamiflu. (see NY Times article)

And the spontaneously generated resistance to seasonal H1N1 (NOT SWINE FLU) in last year’s flu season which led to massive resistance to that strain. (See NY Times article)

2 – Tamiflu shortages could emerge (although the CDC has stockpiled 50 million dose courses, and it is difficult to envision a scenario where there is a shortage of this magnitude, especially with a vaccine in the offing.

3 – Potential side effects of Tamiflu, including nausea, or an allergic reaction. But side effects are rare, Tamiflu is a very well tolerated drug overall.

4 – By having the flu now, when it is mild, a person should be immune later on, during flu season, when the flu could return in a more severe form.

I must admit, some of what drove me to put my own 12 year old son on Tamiflu prophylaxis at Camp Modin where there were more than 80 cases was because I have a 4 year old son at home with asthma and chronic ear infections. I was worried about my older son bringing the flu home. But my own scenario was far from unique, which is why I recommended that all of Camp Modin take Tamiflu.

My article on the Modin Protocol I created was published in Slate on July 10th. (see Slate article)

This was followed by a front page article by Tamar Lewin this past Thursday July 23d in the NY Times which described the problem – and solution – at the camp. (see NY Times article)

The following day, Dr. Anne Schuchat, director of the National Center on Immunization and Respiratory Diseases at the CDC, reacted to the Times article by disagreeing with camps using Tamiflu to control outbreaks. She said she “strongly recommended” giving the drug only to people already seriously ill, or to their family members who are pregnant, have asthma or have other conditions that could be life-threatening if they caught the flu.

Finally, on Saturday, July 25th, Donald McNeil wrote an excellent balanced article in the Times describing Camp Modin’s use of Tamiflu, the rationale for my advice compared to the reasons for the CDC’s disagreement. (See NY Times article)

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

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