Sleepless Supernova: Propofol Lullabies In Neverland

That an anesthesiologist could be on tour with Michael administering propofol is both baffling and repugnant. The King of Pop was effectively anaesthetized every night, while our profession was asleep at the wheel.
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Michael Jackson's death is already a fading memory despite an acute expression of global despair as we witnessed the untimely extinction of a supernova. For physicians, struggling against a climate of national examination in this era of healthcare reform, there is a distinctly darker anguish which must finally be examined, an anguish which has been little discussed in the public arena. What has become of a profession which repeatedly fails its most important client: the patient, all the while profiting from the hapless same? At a time when an entire industry stands accused of cavalier profiteering, this is an important question to consider.

Michael Jackson was a patient failed by those who attended him. Even though some (including Jack Kevorkian in a recent article here on HuffPost) may argue that 'he got what he wanted", the discovery of propofol in his home brought our profession to new levels of mercenary depravity. Physician colleagues expressed shock and disbelief. Patients in consultation talked about their fears of becoming dependent on sleep aids, sometimes even referring to Michael's cautionary tale.
The cumulative pain from these decades of assaults on Michael's privacy, identity, and self, all contributed to the erosion of his identity. Was it any wonder the man would be in severe psychological pain from his first memories until perhaps his last hours? The accounts of a desperate insomniac entertainer craving propofol-induced 'sleep' were, to me, the most staggering salvo in the final, painful ballad of a dying star. Propofol lullabies in an unmonitored, non-sterile bedroom could be no more certain a prescription for death than a smoking gun.

A drug I have prescribed with due respect in the critical care arena when I was a practicing intensivist, propofol was a wonderful tool to induce sedation and facilitate difficult procedures which my patients needed. But using this agent required a team of monitoring professionals and devices in an advanced, high-tech environment to maintain both the safety of my patients and the peace of mind of their doctor. That an anesthesiologist could be on tour with Michael administering this drug for sleep onset is both baffling and repugnant. The King of Pop was effectively anaesthetized every night, while our profession was asleep at the wheel.
Everyone recognizes the disability of the poor but few recognize how handicapping extreme wealth can be, holding its victims hostage to boundless access. In the world of the uberwealthy, doctors become enablers, dispensers, predators, little more than licensed pushers.

Michael Jackson had spent a lifetime entertaining us at late, adult schedule hours from the time when he was barely out of infancy himself. This was a man who never had the benefit of unscheduled time, never learned the first experience of parental discipline so fundamental to a child's development: a fixed sleep-wake routine. Instead, at five he was already performing during the evening. By the time he appeared at the Apollo in 1969, he was a veteran of late night entertainment. Peter Pan's insomnia was yet another feature of not being allowed a full and healthy childhood.

Entertainers often experience delayed sleep phase syndrome.....a delayed physiologic timing in the arrival of sleep which the patient experiences as sleep onset insomnia. Bill Maher has described suggestive features reporting in one interview in his own words that he 'keeps VERY late hours'. Unsurprising, if one thinks about this. A natural tendency to sleep later and stay up later, easily described as being a night owl, may be a draw to the professional nightlife.
While some entertainers may gravitate to the industry because of their night owl tendencies, most are likely permanently rendered 'delayed sleep phase types' because of their exposure to late night bright light, stimulation, social interaction and stimulating substances including caffeine, nicotine or in some instances recreational drugs which all drive to delay the bedtime further.

Television itself can inhibit sleep onset because of the impact of ambient light from the screen on the body's intrinsic hormone of darkness, melatonin, Television watching, in a recent American survey published this spring in the Journal Sleep "Dubious bargain: trading sleep for Leno and Letterman' has been identified to be responsible for delaying sleep by up to 52 minutes in 68% of Americans. A dubious bargain indeed, when the nation is so frequently sleep deprived.

Out of desperation, insomniacs may problem-solve independently, most commonly resorting to alcohol as a self medication, not understanding that there is in this country, more so than anywhere else, a certified subspecialist sleep medicine community which exists to solve exactly these problems. Michael would have been exposed to this environment and these behaviors at an extremely early age, setting the scene for a lifetime of sleep disorders and drug dependencies.

The absence of response from the professional sleep medicine community to the abuse of propofol as a sleep aid in the setting of profound insomnia is puzzling to me but possibly intentional. Michael's insomnia, like that of Heath Ledger's was a lost teachable moment and in their lifetimes, a lost opportunity for intervention. Unrecognized insomnia has become a familiar motif in our most vulnerable icons, one which steals them away in the night. Too frequently insomnia is ascribed to 'drugs' without looking at why these individuals may have resorted to drug dependency in the first place.

Trouble sleeping is a serious multi-factorial disorder, one which needs careful evaluation. Insomnia is a disorder characterized by symptom focused definitions: trouble falling asleep, trouble staying asleep, waking up before socially desirable or sleep which is simply not rejuvenating, Insomnia patients can have several of these symptoms together. Insomnia however is no longer considered merely a symptom but seen as a viable disorder itself, requiring detailed evaluation, multidisciplinary approaches and sometimes long term therapies. Board certified sleep specialists can guide a patient to treatment, which often involves more than solving an isolated psychiatric disorder or drug addiction but actually involves the teaching of new behaviors, restructuring disordered beliefs relating to insomnia, examining medical conditions, searching for primary sleep disorders and exploring all the factors which are contributing to disrupted sleep. Many patients who are resistant to seeking psychiatric help which may be very much needed, can be coaxed to such aid through a sleep specialist. An ethical sleep specialist in the setting of Michael Jackson's insomnia could have been a life line into the chaos surrounding him, though agreed, Michael was recalcitrant to sensible intervention, as Dr. Deepak Chopra sadly relayed in his CNN interviews shortly after Michael's death.

Unrecognized sleep disorders are often a harbinger of coexistent anxiety and depression. We know that Michael could well have experienced major depression at being stripped of a childhood and compelled 'to be an adult' very early, in the words of Brooke Shields as she eulogized him. Finally, the last decade of his life punctuated by a punishing trial would be very likely to have triggered severe depression as a reaction whether or not it touched on the truth of his inner life.

Most of all this event speaks to the national culture of Sleep Machismo a phrase which captures American workaholism as a disordered belief system, almost uniquely American. Imagine a performer so desperate for sleep he resorts to anesthetic sedation and yet so pressured to perform he was committed to dozens of concerts in a compressed time frame. His doomed concert was even aptly named as 'THIS IS IT". For Michael at that point in his career it was 'Do or Die'. Unfortunately, this time it would be 'Die'.

In this country, we value, emulate and even laud sleep loss in the pursuit of achievement, accolade and advancement. Michael's lifestyle and his learned behaviors of self-medicating sleep disorders were an exaggerated form of Sleep Machismo which appears in my office every day in a number of guises. His loss leaves many questions and an agitated hunger to pin blame on a single miscreant. Indeed major responsibilities are borne by the clinicians prescribing and administering him drugs at the patient's whim, which ultimately would be likely to act as cumulative respiratory depressants. Yet to me his loss was, in sum, a collective responsibility of an unfettered culture which has become almost singularly oral and consumptive, a culture with an insatiable appetite for interminably 'more' at the expense of our icons, our sanity and often our sleep.

As physicians we would do well to remember the Hippocratic Oath of first doing no harm. Clearly in the misery of his sleeplessness, his physicians betrayed the most basic of ethical boundaries. They put self interest ahead of patient interest. Sadly, the icon had become the golden goose for failing careers. These physicians too suffered from the drive to consume and appease an insatiable appetite for cash, celebrity and personal gain. My profession failed a national treasure, no matter how disordered, and failed him in pursuit of personal greed. We failed in his diagnosis, in his treatment, in disengaging from the dance with a manipulative addict and ultimately failed in the recognition of a critically important sleep disorder. Let us not fail in his wake to examine the lessons to found in the debris of destruction and share them with Americans everywhere.

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