Comas Don't Count as Sleep
Lessons from the Murray-Jackson trial.
Posted October 13, 2011
Does Sleep = Unconsciousness?
June 25, 2009. I was rapidly scanning BBC News when I shouted "No" at the monitor and gasped before recognizing why. Michael Jackson was so young. How could he die?
We're now finding out. And hopefully the public will learn that anesthesia is not sleep, and cannot substitute for the necessary regeneration it provides.
I was not surprised when I heard propofol had been used by Jackson as a sleep aid—I was shocked. I've never administered propofol, but I've had it given to me (for colonoscopies). After these procedures I recalled precisely nothing. Amnesia is part of what anesthetics do. The major purpose of propofol is induced unconsciousness—a version of coma.
Propofol is an exclusively intravenous anesthetic. Most doctors like myself associate it only with surgical suites and anesthetist observed anesthesia. That you would use it to "help" someone sleep is bizarre.
At least to a doctor. But many of the people I talk to equate anesthesia with unconsciousness and sleep.
Putting You To Sleep
Anesthesiologists tell patients that they're "putting you to sleep."
They're not. Anesthesia is not sleep, but something much closer to coma. You are effectively short circuiting parts of the brain that talk to each other, creating what we call consciousness.
The brain works through information flow. Anesthetics produce amnesia, among many other things, because the brain cannot process the information received from the rest of the body—and communication within those parts of the brain that are partially active is multiply blocked.
Information processing is what the body does. Information comes in, is processed, remembered, or forgotten.
Much of that process of remembering and forgetting occurs during sleep. In sleep the brain and body remake themselves through an intricate series of processes which require great and carefully calibrated intrabrain communication.
During sleep you grow skin. You reboot the immune system. You completely change brain circuits and synaptic density.
The recent work by Tononi and Cirelli's group at the University of Wisconsin shows that even short periods of sleep deprivation potentially harm major brain functions in animals. So what do clinical studies show happens to chronically sleep deprived humans?
Lots. Memory and learning deteriorate. Judgement goes out the window.
Immunity becomes far worse. The risk for heart attack and stroke goes up. Mood lowers.
It appears that Michael Jackson, like many, identified unconsciousness with sleep. And he probably was not getting much real rest.
There were lots of other drugs in Jackson's body, including multiple benzodiazepines—lorazepam, midazolam, and diazepam. Benzodiazepines can decrease anxiety, impair cognition, and increase relaxation. And they are commonly used as sleeping pills.
Not midazolam, though. Generally it's used intravenously. Intravenous midazolam "knocks you out," obliterating memory—not a bad result if you're trying to avoid the pain of the knife. But midazolam for insomnia? No doctor I know would use it that way. And the potentially lethal respiratory depression provoked by benzodiazepines are far more likely when given intravenously, as well as with other respiratory depressants like propofol.
Also found in his body was lidocaine and ephedrine. Lidocaine is often used a topical anesthetic—sometimes cutting the pain that comes with propofol injections. Ephedrine, however, was a real outlier, a pharmacologic congener of epinephrine, our potent flight or fight hormone.
Anesthetics, multiple "downers" and ephedrine. Had Jackson been part of the Up-Down Syndrome? Many entertainers get hooked on medications like benzodiazepines to rest or sleep, and then take uppers like ephedrine to "get in the zone." Legal versions of the Up Down trap are common—many teenagers get "up" with energy beverages ("anti-relaxation drinks") and come "down" with so called "relaxation drinks," whose cocktails of "natural substances" include neurohormones like melatonin.
It was reported in the New York Times that Jackson had walked into the Bellevue Emergency Room in 1994 and requested propofol for "sleep." The incredulous docs talked instead of sending him to the police.
Dr. Murray has declared on the stand that Jackson asked him for "milk"—the white colored propofol is sometimes called "milk of amnesia." Apparently Murray had 4 gallons of propofol sent to his girlfriend's apartment.
Sleep Is Not Turning Off a Switch
Sleep is many things, but coma is not one of them. The American version of sleep, often described as "lie down and die," equates unconsciousness with sleep. You lie down. Then you wake up. Sort of like turning the electricity on and off on your computer.
Except we're not machines.
We're alive. We survive through regeneration. The internal processes of human life work so fast that we use up most of the materials in our body quickly. Subtract skeletal elements like bones and teeth plus bits of DNA and you're pretty much new in about a month—and different from what you were before.
If you get enough rest, that is. Rest is critical to that regeneration, like food.
A jury will decide if Dr. Murray was culpable in Jackson's death. But you don't get life renewing rest through an IV pole spewing coma inducing anesthetics.
You get something far, far worse.