If you are interested in or have questions about anesthesia, whether you are a patient, the loved one of a patient, or a medical professional, you will find Dr. Friedberg’s insights interesting and useful.

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Paid propofol expert, Paul White, prevaricates under oath… no such thing as ‘standard of practice’

When paid propofol expert, Paul White, testified in the Conrad Murray Michael Jackson manslaughter case, he tried to make a case for the ‘standard of practice’ being somehow different than the accepted ‘standard of care’ for sedation.

The only problem with his testimony is there is no such thing as the ‘standard of practice,’ and White knows it.

It is bad enough that White is facing 2 counts of contempt, but now, it appears he is trying to add perjury to his courtroom record.

Having given sedation for office-based surgery for nearly 2 decades, I can empathize with non-paid, propofol expert, Steven Shafer’s comment that ‘bedroom anesthesia’ has no tolerance for error because you have no backup.

In a surgeon’s office, it is not uncommon for only the surgeon, a non-RN scrub tech and myself to be giving elective cosmetic surgery care.

While, at least in accredited offices, there is oxygen, Ambu bag, suction, defibrillator & crash cart available, that ‘backup’ provides only a slight increment of patient safety.

More critical than the basic safety equipment is the ability to measure the organ medicated, the patient’s brain, in addition to the usual vital signs.

With direct brain measurement, one avoids over-medication, dramatically increasing patient safety by never taking the patient to deeper than intended sedation levels, thereby avoiding the need to rescue.

I can only speculate on what could have possibly motivated White to testify on Murray’s behalf but I am delighted with my decision to turn that offer down before White accepted it.


ADA Walgren missed the point on Paul White cross exam

LA ADA David Walgren did a great job with Dr. Paul (cited 2X for contempt) White but missed the essential point:

Jackson could not have died from 25 mg propofol push in the 2 minutes Murray claimed to have been out of the room – just one of the multitude of lies Murray has spun to cover his a**.

Now the defense has suddenly suggested Jackson was already dead when Murray returned to the room. Duh.

Blown pupils are a sign of brain death which follows a minimum of 3-5 minutes without heart pumping activity.

Doesn’t really matter if breathing stoppage or abnormal heart rhythm (White’s ‘suggestion’) was the cause of the heart failing to pump oxygen carrying blood to the brain.

The lethal activity was leaving Jackson alone – reckless negligence, depraved indifference – guilty of involuntary manslaughter unless we’ve imported the Casey Anthony jury.

Stay tuned…


Steven Shafer on Conrad Murray & propofol… today in court

While Dr. Steven Shafer attempted to explain to the jury what the terms ‘pharmaco-mechanics,’ & ‘pharmaco-kinetics’ meant, I could not help thinking what utter nonsense these areas are relative to what really matters to you, the patient, in general and Michael Jackson, the victim, in particular.

Direct brain measurement devices, like the bispectral (BIS) index, have been FDA approved for 15 years & validated in over 3500 published scientific studies.

Anesthesia is medicine given to your brain.

Unlike TEE (transesophageal echocardiography), BIS monitoring does not earn the anesthesiologist in the OR any extra money on a case by case basis.

The hospital views the use of the $20 disposable BIS sensor as a non-recoverable loss because there is no billing code for it.

There is no billing code for the sensor because universal brain monitoring would result in a 30% loss of drug sales to the companies who also supply the American Society of Anesthesiologists (ASA) with millions of dollars in various forms of support.

Expecting the ASA endorse universal brain monitoring would be asking them to threaten their financial viability.

Only you, the patient, are left to deal with the long term effects of your short term anesthesia care.

Those long term effects include delirium or postoperative cognitive dysfunction (POCD) that can last up to a year, dementia that never goes away and one patient anesthesia over-medication death DAILY.

The model for change is the same one that ultimately got fathers in the delivery rooms. Public awareness leading to public demand!

Having surgery under anesthesia without a brain monitor is like playing Russian roulette with your mind.

Download 3 free letters to save your mind & your life @ www.drbarryfriedberg.com

RE: Perhaps you are getting a better picture of just how hard it is to get my message out to the public.

Hi Barry,

Thank you for keeping me posted in your quest to inform the public of the dangers inherent in “going under.”

I watched with interest your interview; it made complete sense. The interviewer found it interesting and insightful as well. I believe you did more good than you will ever know. You have certainly opened my eyes.

As for the L.A. Times article about HLN that essentially belittles your effort to awaken the public to the dangers of anesthesia by referring to you as “a white robed man describing himself as an anesthesiologist dragging a rolling IV bag around campaigning for better sedation monitoring” I don’t think it understands the disservice it did.

I admire your courage and encourage you to keep up the good and necessary endeavor. Now, whenever I speak with anyone about to have surgery I tell them to Google your name and learn of the dangers in the anesthesia itself, as well as the surgery they are about to undergo.


Just in from ‘The Telegraph’ of London

The querulous parties are temporarily silenced by the arrival of a white-haired man in his hospital scrubs, a heart monitor under his arm. Dr Barry Friedberg, a renowned anaesthetist, hands out leaflets to the perplexed onlookers, and proceeds to explain the reason for his visit.

“It’s not the Propofol that killed Michael Jackson, it’s the unsafe Dr Murray,” he said. “There’s no lethal dose of Propofol, there’s a lethal failure to intervene when breathing is inadequate.” A self-professed “Propofol expert” who champions the use of a brain monitor with anaesthesia for optimum safety, Dr Friedberg insists Jackson’s alleged drug dependencies are irrelevant in the case against Dr Murray.

Pain: an ounce of prevention is worth a ton of cure

re: Tara Parker-Pope ‘Giving Chronic Pain Medical Platform of its Own’


As a 34 year practicing, board certified anesthesiologist, I found the ‘ounce of prevention’ for postoperative pain in the fall of 1992.

Since I work exclusively in the world of elective cosmetic surgery, my anesthesia colleagues have been quick to dismiss my ‘nifty fifty’ paradigm shift as only being applicable to this type of surgery.

The ‘nifty fifty’ is 50 milligrams of ketamine 3 minutes prior to surgical stimulation.

In 1997, I added the BIS monitor to my propofol ketamine regimen, thereby creating a numerically reproducible level of propofol to effect to reliably prevent ketamine hallucinations.

Since that time, none of my several thousand patients have taken opioids for postoperative pain.

Disclaimer: Neither I nor my non-profit Goldilocks Anesthesia Foundation receive financial support from the makers of the BIS or other brain monitors.

Despite years of encouragement, I have not found a single academic university department of anesthesia willing to formally study this extremely simple paradigm. Shame on them.

Not until I personally received the benefit of the ‘nifty fifty’ preemptive analgesia for my total hip replacement have I been able to refute my fellow anesthesiologists’ assumption that it is only useful for cosmetic surgery.

see comment #20 to Tara Parker-Pope ‘When Pain Goes Beyond Words’


Goldilocks anesthesia is BIS monitored propofol ketamine. Since your brain dictates the anesthesia dosage, you cannot get too much or too little, but only just the right amount.

Over the $20 sensor, don’t let anyone play Russian roulette with your brain when having surgery.

75% of US hospitals have the BIS monitor, yet it is only used 25% of the time.

Avoid routine anesthesia over medication by insisting on a brain monitor.

Download 3 free letters from www.drbarryfriedberg.com to help you get Goldilocks Anesthesia for any surgery.

The anesthesia dementia link

Denverpost.com 07/13/2011

Q: My 77-year-old mother recently had knee-replacement surgery and now is suffering from some form of dementia. She asks the same questions over and over. She had small memory problems before, but nothing like this. Did her surgery cause something to happen to her brain? — Denise, via e-mail

Re: Patient with aggravated dementia after anesthesia

Anesthesia is given without using a brain monitor guarantees the dose of anesthesia must be greater than that thought necessary for fear of under medication.

A brain monitor like BIS directly measures the anesthetic effect on the brain. 75% of US hospitals have this equipment yet it is only being used 25% of the time.

Goldilocks anesthesia is never too much or too little but always just the right amount because it is your direct brain response dictating to the anesthesiologist exactly how much anesthesia you need not to hear, feel or remember your surgery.

No one, especially those over 50, should ever have anesthesia for surgery without a brain monitor.

Download 3 free letters @ www.drbarryfriedberg.com to make sure you get Goldilocks anesthesia & that your anesthesiologist does not play Russian roulette with your brain while you are having surgery.

Thirty-four years ago today…

July 5, 1977, at Mt. Diablo Hospital in Concord, California, I stood ready to give my first anesthetic in private practice.

Several years earlier, on the very first day of his residency, on his first case, one of the Stanford residents had a child die from malignant hyperthermia (MH). (The antidote, Dantrolene, was not introduced until many years later.)

This unlucky resident’s liability insurance carrier even tried (but failed) to rate his private practice policy based on this hugely unfortunate experience.

My good fortune was to have started and finished my Stanford residency without ever seeing an MH case. However, I was hoping to get through my first private practice case without any such bad luck, too.

There I stood awaiting the arrival of plastic surgeon, Hale Tolleth, M.D. He was an hour late…

He introduced himself to me then explained the facial surgery case would take the whole day, but he did not want me to intubate the patient, ‘just’ sedate her.

There I was, prepared to anesthetize any cardiac case including a transplant but was being asked to provide a service about which I knew nothing.

During my residency, I had given intravenous sedation for cases as long as 45 minutes, typically with diazepam and meperidine.

I had never heard, read about, or had presented a ‘game plan’ of sedation for an 8 hour case.

Welcome to private practice, Dr. Friedberg, I thought.

After giving the problem some consideration, I guessed at what might provide the conditions for which my surgeon asked.

I took a 500cc bottle of saline, injected 500 mg thiopental and 100 mg meperidine, spiked the bottle with a 60 drop per cc set, gave some nasal oxygen & proceeded to titrate the patient.

She was in a semi-sitting position. The surgeon must have been very good with local anesthesia because I have no recollection of the patient moving or him re-injecting.

Another unique moment happened about half way through the case. Tolleth looked over to me and asked what I would like for lunch. I thought surely he must be teasing me. Having lunch was never a consideration during my 2-year residency.

I thought I would return the tease saying ‘lox and bagel would be just fine.’ To my astonishment, the surgeon told the nurse to fill my request and bring him his ‘usual.’

About 30 minutes later, in came the nurse with both lunch orders. My surgeon removed his gloves and we sat down and ate our lunch.

Never in the ensuing 34 years have I had such an experience.

Never lost the airway through the entire facelift, etc. case.

Needless to say, though, the patient was so hung over at the case’s end, she spent the night in the hospital. In 1977, no one thought it was an odd outcome after an 8-hour surgery.

However, I thought it would be really wonderful to have a drug that would go away after a case like that. Propofol was not introduced until 1989. We had no pulse oximeter until 1984.

As I think back over the triumphs and disasters through which I have persevered, I would have surely been incredulous if anyone would have told me I would author not one, but two books, receive a US Congressional award as recognition for contributing to the anesthesia safety of wounded troops in the forward units and create a non-profit foundation to promote patient awareness of the critical need for brain monitoring during anesthesia.

As the song goes, “What a long strange trip it’s been.”

Thank you for sharing this moment in history with me.