Re: Murray Trial _ All daily trial Summaries - No discussion October 5th / Day 7 Full Testimony
Murray Trial Day 8 October 6 ,2011
Elissa Fleak Testimony continued
Walgren direct continued..
Walgren enters more photographs into evidence.
Walgren talks about "broken syringe". EF says she shouldn't have described it at broken syringe. She says she misdescribed the item, she should have written them seperately. She made an assumption that it was the pieces of the same syringe but she was wrong. EF says that she later realized that they have different tips (one square, one circle) and they don't fit together.
Fleak's thumb print was found on the syringe. She doesn't know when that happened. EF says it might have happenned when she was moving the tables to take photos or repackaging the items.
EF subpeonad CM through his counsel Chernoff. EF wanted any and all medical records of MJ on July 1. Chernoff provided records to her. Walgren asks if the records covered April, May, June 2009. EF says they were all dated before that date.
Walgren goes over the medical records they are from 2006 , 2007, 2008 and use the names of Michael Jackson, Omar Arnold and Paul Farance (also Mike Smythe but letter crossed out).
Chernoff asks if EF took more photos then it was shown to the jury. EF says yes.
Chernoff talks about EF's role in this case. Chernoff talks about being a coroner investigator and the importance of her job. EF's job is to collect as much as information about the cause of the death and the motive for death. Chernoff mentions the importance of being accurate and being through with the investigation.
Chernoff is asking who was there on June 25th. Detective Scott Smith from LAPD, her supervisor coroner Ed Winters and LAPD Crime Scene photographer. EF took notes, took photos and collected evidence.
June 29. She went to the residence based on the information she got from Detective Smith. Smith told her that there would be additional medical evidence to be collected from the room next to the bedroom. EF didn't ask any more questions and she said that she would meet him at Carolwood. In Carolwood Smith told her where the bags he was told to would be. EF , Smith , another detective (possibly Myers) and LAPD crime scene photographer was at the house collecting evidence.
They got the items out of the closet and placed it on a table. They took pictures. EF doesn't remember if she or LAPD took the pictures. She laid items out on the table. Defense shows a picture of items on the table. She and Smith was taking notes and observing.
IV bag with slit and Propofol bottle. Chernoff asks if there were more photos taken of it. EF doesn't remember.
3A form- evidence log form to record medical evidence in coroner's office. She did 3 3A forms on June 25, June 29 and July 8th.
EF goes over her June 29 record. In her handwritten notes she list the cut IV bag and the propofol bottle. Chernoff asks if any of her reports that she mentioned the propofol bottle was in the IV bag. She says no. Chernoff says that "propofol in IV bag" was added to her notes in March 2011. Chernoff tries to ask question about her revised notes. A lot of objection and sustained.
A week before she revised her notes , EF met with Chernoff at Coroner's office with other coroners and lawyers. Chernoff says he asked her about the IV bag and what was in it. EF says she doesn't remember. Chernoff asks when was the first time she told prosecution about the propofol bottle in the IV bag. Chernoff asks if she heard about Alberto Alvarez and his testimony. EF says that he didn't know him or didn't hear about his testimony saying that he saw a bottle in an IV bag.
Chernoff asks about her handwritten notes from June 25th. She says after she copies her notes to her reports, she destroys her handwritten notes intentionally in all her cases.
Chernoff asks if she would agree that she made substantial mistakes. She doesn't agree. Chernoff asks if not keeping her notes was a mistake, she says no. EF says she has her report and put everything from her notes to the written report.
Flumanezil bottle found on the floor but she moved to the table. Syringe Chernoff asks if she moved the syringe from the floor to the table. EF says no, she found it on the table.
Chernoff again mentions the "Broken syringe" - EF says she should have described it as two pieces and not broken. Chernoff asks about her scene report and how she wrote there was gloves on the floor and asks her to show it in the picture. She says it was closer to the urine bottle chair and cannot be seen in the current picture. Chernoff shows a picture of gloves on a chair and asks if she wrote about them in her notes. She says no. Chernoff asks if that's a mistake, EF says no.
Chernoff asks about the droplets in the IV bag and argues that they are clear and it's not a milky liquid. Chernoff asks if the IV bag was tested. Yes it was.
June 25 . She was primarily working on the bedroom. Chernoff asks if she went into other rooms. Chernoff asks if she went into the far left bedroom or not. EF says she did not go to that bedroom. That bedroom also has a bathroom attached to that bedroom. Coroner collected some items from that bathroom on June 26.
mid morning break
Several photos of urine on the chair from different angles marked by the defense. Pictures of EF shown. Chernoff asks when those pictures was taken. EF doesn't know the exact dates whether it was June 25th or 29th.
Chernoff asks how far was the table from the bed. EF says a couple feet.
Syringe on IV. Chernoff asks when that picture was taken. Chenoff shows 2 different pictures one taken on June 25th and another taken on June 29. One of the pictures showing the tubing around the IV pole and one does not. Chernoff says that someone was moving evidence.
Chernoff asks who's decision was to not the secure the house. EF says such decisions are up to LAPD. EF also doesn't know if the house was open for access of not.
Detective Smith informed her about the additional medical items CM mentioned there. EF went to the house on 29th. EF says she doesn't know if LAPD went to the house between June 27 and June29.
Chernoff mentioning some items such as the IV stand and IV bag being collected on June 29. EF also did not mention the IV stand, saline bag or the syringe in her June 25 record. EF mentioned those in the case notes in June 27 case notes. She wrote she had additional items to write that she did not mention in the first narrative.
After June 29, EF did not go to Carolwood. EF collected medical records from other doctors as well. EF collect those to get a better understanding of MJ's medical history. She requested medical notes from Murray, Klein, Metzger, Adams, Tadrissi, Slavit, Rosen, Lee, UCLA medical center, Kopplen, Hoefflin. Objection. Sidebar. She collected extensive records. There were other doctors that said there wasn't any records or did not treat MJ.
Chernoff asks about the juice bottle on the stand. EF says that she did not collect the juice bottle.
Walgren goes over the documents EF prepared. Investigator's narrative : Overall description of the scene. Evidence log : things are itemized and logged into evidence. Case notes : additional information for a case is listed here. 3A form medical evidence form that will detail the medical evidence versus the physical evidence or trace evidence.
Handwritten notes from June 25 was put into these documents.
Walgren asks she observed the IV stand on June 25 and have it photographed. Yes she did. On June 27 she mentioned IV stand in her notes. June 29 she picked up the IV stand and the bags from residence as evidence.
Walgren mentions her preliminary hearing testimony and how she mentioned Propofol bottle inside IV bag in January 2011. EF removed the propofol bottle from the IV bag to see what it was. She put propofol bottle on the IV bag to photograph it. Walgren asks if there was a reason if she photographed them together. She says she intentionally photographed them together because they were found together inside one another.
March 2011. Walgren, EF, Dr. Rogers examined some evidence. At that time Dr. Rogers mentioned that it was an IV catheter and EF found out that they don't go together.
Walgren asks if this was a perfect investigation, she says no. Walgren asks if she ever conducted a perfect investigation , EF says no. Walgren asks if she in other investigations she thought she could do a better job. EF says yes and she did her best.
Chernoff again goes over to say EF didn't take the picture of the Propofol bottle in the IV bag.
Chernoff shows a bunch of photos asking if EF took them.
Fingerprints information is stipulated
Murray's fingerprint was found on 100ml Propofol bottle found inside the IV bag.
Fleak's fingerprint was found on the syringe on the table.
IV bag with the slit had 4 fingerprints on it. 2 fingerprints was found on saline bag and 20ml Propofol . 1 fingerprint was found on 20 ml propofol bottle. but no identification was made about these fingerprints. The following people were eliminated by manual comparison: Michael Jackson, Conrad Murray, Alberto Alvarez, Michael Amir Williams, Faheem Muhammed, Scott Smith, Mark Goodwin, Martin Blount, Jimmy Nicholas, Blanca Nicholas, Elissa Fleak, Kai Chase.
No useable fingerprints on : 2 midozolam vials, 1 lorazepam vial, 2 lidocaine vials, 1 lidacaine vial, eyedrops, tube marked bq, a bottle labelled ephedrine/caffeine/asprine , 2 100ml propofol vials, 7 20 ml propofol vials, 2 lidocaine vials, 1 lidocaine vial, 2 lorazepam vials, 4 flumanezil vials, 3 midazolam vials, IV tubing, IV y connector tubing, syringe with needle.
In short MJ's fingerprints was not on any of the items. Murray's fingerprints was only found on a 100ml Propofol bottle.
Dan Anderson Testimony
Anderson is employed by LA Coroner as a toxiologists for 21 years. His current position is the supervisor. He's responsible for the people and the results. Anderson mentions his education, work history and certifications.
Anderson talks in detail about toxicology, the type of tests they do ,the terms used and how they do the tests and the equipment they use.
Walgren starts talking about this case. Anderson received 4 samples of blood taken at the hospital and hand delivered to him by Fleak.
June 26. Anderson attended to the beginning of autopsy to tell what he wanted as samples. June 26 afternoon they started testing. Tests take several hour and days. They started evaluating them by Monday. They generated a 8 page report about all the samples tested.
ng/ml - nanogram ug/ml - micrograms. micrograms are 1000 times bigger than nanograms.
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Re: Murray Trial _ All daily trial Summaries - No discussion October 5th / Day 7 Full Testimony
Murray Trial Day 8 October 6, 2011
Dan Anderson testimony continued
Walgren direct continued
Anderson goes over each of the findings in the report. Most majority of the test is done is using heart blood. It's the starting point.
-Femoral blood is taken from leg.
-Heart blood is taken from heart.
- Hospital blood is taken at hospital.
- Vitreous fluid is taken from behind the eyeballs.
- Liver they took a portion.
- Gastric contents are stomach contents.
- Urine samples : Urine from scene brought in a plastic urine bottle also they collected urine from the bladder during autopsy
Anderson lists all the findings. You can see some of them in the following pictures. For full details check the the autopsy report.
Important findings: MJ had no alcohol, no Demerol (Meperadine) , no metabolized Demerol (normeperidine) and no Cocaine, Marijuana and such. MJ had Valium, Lorezepam and Midazolam, Propofol in his system. They tested femerol blood, heart blood and hospital blood. They did 2 tests on liver for lidocaine and propofol - both was detected in liver. Stomach contents showed Lidocaine and Propofol. Urine from autopsy shows lidocaine, Midazolam, Ephedrine and Propofol. Jug of urine was tested and it showed Lidocaine, Midazolam, Ephedrine and Propofol. Vitreous (clear fluid behind the eye) showed Propofol.
Anderson made a summary about positive toxicology findings.
Walgren again clearly states that there was no Demerol in MJ's system. Anderson says correct.
Walgren mentions Propofol in MJ's stomach. Anderson compares amount of propofol in MJ's stomach is equivalent to 'specks of sugar granules'. So they are basically saying that it's too small.
Syringe on the nightstand was tested. They found 4 drops of liquid in it. They detected propofol and lidocaine in it.
Saline bag, tubing, Y connector and syringe on the IV was tested. They draw a diagram and determined how to test it. Walgren identifies each of the items.
Propofol, lidocaine and flumazenil was found on the IV on the syringe and the short side of the tubing. Saline bag and long section of IV tubing had no drugs detected.
mid afternoon break.
Flanagan is going over the summary report about positive toxicology findings.
Flanagan asks why Propofol was tested on 3 different blood samples. Anderson says they generally make tests on 2 samples : general blood and peripheral blood (such as from the leg femoral blood) due to postportem distribution. Anderson explains that the body tissue releases the drugs back into the circulation after death and moving the body will also distribute the drugs. On this instance they also got hospital admittance blood.
Flanagan asks if the reason for hospital blood result be higher is due to the drugs not having chance to be redistributed. Objection. Judge finds the question vague. Flanagan " Do you know why the hospital blood results are higher?" Answer : No. Flanagan "why is the femoral blood results are the lowest?" Answer : Postportem distribution. Flanagan confuses the witness to the point that he can't understand what is being asked. Flanagan "Why is femoral blood has the lowest results?" Answer : That's typical because tissues release drugs to the central cavity artifically raising the heart blood.
Lidocaine higher in femoral blood then the heart blood. Anderson says it's drug dependent. Some drugs might have different distribution pattern.
Flanagan asks why the eye fluid was analyzed. They analyzed it for Propofol because Propofol was the real issue. Anderson says that they didn't have enough fluid to make a full analysis. It tells him that Propofol doesn't distrubute very well to the eyeball fluid. They didn't give an exact number amount for Propofol in the eye fluid because they didn't have enough sample. Protocol tells that they can't give exact numbers in such instances as they can't gurantee the accuracy.
Urine from the scene. Flanagan asks why they couldn't get the exact number amount for Propofol amount. Again It was below their lowest caliber. It was almost negligible.
Ephedrine was present in the urine but wasn't in blood. It's because bladder can store things for a long time. Flanaggan asks how long ago it was used. Anderson says it can't be recent as it's not in the blood and it could be used anywhere between 24 to 72 hours ago.
Propofol was found in the urine from the scene. Flanagan asks if it could be from a few days ago as well. Anderson agrees and says that it could also be recent. Flanagan asks if the urine from the scene was accumulated before urine from autopsy. Anderson says he has no idea when it was collected or even it's from MJ.
Flanagan gives a scenario that the urine from the scene was in 7 AM and the time of death being around 12:00 and 2:26 and says that not much urine is collected after death. Anderson corrects him that they actually had over 500 ml of autopsy urine which he says to be alot.
Flanagan is trying to say that MJ got/given propofol after the urine in the scene was deposited in the plastic bottle because the propofol level was higher in the autopsy urine. Flanagan again confuses the witness and no one can understand what he's asking.
Lorazepam. Flanagan asks if it's high. Anderson says it's normal high therapeutic range. Flanagan asks how much lorazepam MJ was given in mg. Anderson says that calculation could be done but it would not be a perfect calculation as there has to be several assumptions made. Anderson says it shouldn't be done.
Anderson mentions assumptions that needed for such calculation :drug fully distributed, redistrubution didn't happen after death and the heart blood level is not falsely elevated.
Flanagan shows a book saying that Lorazepam is not subject to redistribution after death. Anderson doesn't agree with it and says there have been only 2 cases stating that but he wouldn't be comfortable with generalizating it to the whole population.
Flanagan still asks Anderson to give a mg number. Anderson goes over his records saying that based on several assumptions, it's approximately 11 mg. Anderson says that they can't determine how Lorazepam was given (orally or IV) from a blood level and he doesn't know when it was given.
Flanagan asks if the results indicate that lorazepam has been in the system for a while. Anderson says yes. Propofol levels was not equilibrium. Flanagan asks if a person was on a drip , would he expect the propofol levels to be in equilibrium. Anderson says he doesn't know how Propofol metabolizes.
Flanagan mentions that the summary Anderson did has no information about Lorazepam in the stomach contents. Anderson says that they only analyze stomach contents for overdose cases. Their blood test results showed Lorazepam to be in the acceptable range so they didn't test it in the stomach.
Defense has tested the stomach for Lorazepam , it was .634 micrograms/ml.
Flanagan says Lorazepam is 4 times concentrated in the stomach then the blood. Anderson disagrees saying that it's not significant in it's opinion. Flanagan asks if it's consistent with oral digestion. Anderson says no and explains that drugs will be in stomach in small levels due to "ion trapping" and doesn't necessarily mean that it's taken orally. Anderson converts it to mg : 0.046 mg , that means 1/40th of a normal 2 mg pill. Anderson says that it could come from the blood.
Flanagan asks questions about Midazolam. Anderson has not made calculations about it because the amounts are really small.
Flanagan by looking to urine level of Midazolam trying to establish blood levels for it. Anderson says it's not a comparison that could be done.
Flanagan talks about urine and whether it would be representative of the metabolization of the drugs such as if a person urinated at 1 AM and then at 7 AM , Flanagan asks if the 7 AM urine would be representative of the 1 AM - 7AM period. Anderson says there will be some contamination. Flanagan asks if the autopsy urine would be an average level of 12:30 - 7:30 AM time period. Anderson is having trouble with understanding the question. Judge and Walgren also doesn't understand the questions. Flanagan asks if urine would be in equilibrium with the blood, it's beyond Anderson's level of expertise. Anderson says just from the urine results he cannot tell when the person would have higher levels of Midazolam in his system. Anderson says he can't do it for Propofol as well.
Back to stomach contents and not analyzing it for Midazolam and Lorazepam. Switching to IV set testing. Saline bag and the tubing that goes down to the y port had no propofol or lidocaine. Propofol, lidocaine and flumazenil was found in the syringe and short tubing. Flanagan asks about the amounts of those drugs. Anderson says that they didn't quantify them because they didn't think it was relevant and they didn't have a standard procedure to quantify fluids from medical evidence. Flanagan asks if they can tell the proportions of lidocaine and propofol and flumazenil. Anderson says they can't. Anderson says they also had a very small amounts of liquids that complicated the testing as well.
end of day 8
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Re: Murray Trial _ All daily trial Summaries - No discussion October 6th / Day 8 Full Testimony
Murray Trial Day 9, October 7, 2011
Dan Anderson Testimony continued
Flanagan Cross continued
Flanagan starts off by asking about the IV bag on the stand in MJ's room where he died. Flanagan asks if the bag was analyzed for all chemicals and the only thing was saline solution, Anderson states they do not analyze for solution, but there were no drugs found in it. Flanagan asks about the tubing (hanging from the IV stand), and Anderson states that it was not found to have any drugs in it.
Flanagan asks repeatedly whether the tubing and the IV bag were attached, Anderson repeatedly states that they were not attached when received into medical evidence, according to notes. Flanagan asks if Anderson tested two syringe barrels, Anderson states yes and when asked, states that both barrels tested positive for propofol and lidocaine. Flanagan asks if Anderson tested any apparatus that had only propofol in it, Anderson states no. Anderson states that the only medical equipment that had propofol and lidocaine in them were the Y tubing (connector) and the syringe barrels. Anderson states that each of the syringes and the Y tubing each had Flumanezil. Flanagan asks if the proportion of propofol and lidocaine were the same in both the Y tubing and the 2 syringe barrels, Anderson states that proportionality testing was not performed.
Flanagan asks for Anderson to define equilibrium as it relates to bodily fluids, Anderson states he believes it is when the samples of the drug or their concentrations are equal. Flanagan asks how long it takes for the blood system to come to an equilibrium, Anderson states its beyond his scope of expertise. Flanagan asks Anderson to define therapeutic range (of a drug), Anderson states that a concentration of the drug that achieves the desired effect, generally it is a safety concern because they are not safe at all concentrations. Flanagan asks what determines therapeutic range, Anderson states clinical trials from the FDA, as well as the literature provided with each drug. Flanagan asks if there is a therapeutic range for propofol, Anderson states no. Flanagan asks about therapeutic range for Lorazepam, Anderson states that it averages 100-200 micrograms per mililiter. Anderson clarifies that the average can be 180, but that everybody tolerates medications differently, and he cannot give specific ranges.
Flanagan shows a Lorazepam bottle, prescription for MJ, asks Anderson to read the bottle, Anderson reads Lorazepam 2 mgs, 1 tablet by mouth. Flanagan asks about MJ's blood concentration of .16% and asks if that would equal about five Lorazepam tablets, Anderson states yes, regardless of the route, whether it was in tablet or IV form. Flanagan asks if MJ had the equivalent of 11 mg of Lorazepam, Anderson states yes, approximately. Flanagan asks how many pills would MJ have to take to get to that level (11 mg), Anderson states that it could be an accumulation over several days, and that he does not feel comfortable with assumptions of routing of medications or form of medications.
Flanagan asks about ion trapping with respect Lorazepam, Anderson states that he knows little about Lorazepam and postmortem redistribution. Anderson states that the only way to get propofol in the stomach is through oral ingestion or ion trapping, it's not postmortem redistribution.
Flanagan asks Anderson to define the term ion trapping. Anderson states that an acidic environment traps the ions of the drug in that environment, beyond that, is beyond his area of expertise. Anderson states that other than ingestion, the only way propofol can get into the stomach by diffusion of the surrounding specimens. When Flanagan asks about the surrounding specimens, Anderson answers that the liver is close, blood samples and blood itself are close to the stomach.
Flanagan states that Anderson is saying that Lorazepam can get into the stomach through redistribution, Anderson states that it can get into the stomach by ion trapping. Anderson states time and time again that this information is beyond the scope of his expertise. Anderson states that he has seen many different decendents who had stomach contents with drugs in them, and that the drugs were not given orally.
Anderson states he does not have personal experience with a decendent that had Lorazepam in their stomach.
Flanagan asks Anderson about ephedrine. Flanagan asks if Anderson came to understand that propofol was the most important drug in the case, Anderson states yes he did. Flanagan asks if Lorazepam was important, Anderson he thinks it has its importance, but that it does notraise a flag. Anderson states that propofol in any case is important, Lorazepam was in therapeutic range, and that he previously testified that propofol was within range only a proper setting. When Flanagan asks what does a setting have to do with therapeutic range, Anderson states that it's very important. Flanagan states that therapeutic range is desired effect, Anderson states yes. Flanagan states that the literature does not take into consideration the setting, Anderson states that every drug literature takes setting into consideration.
Flanagan asks if Anderson did the calculations with regard to Lorazepam last weekend, Anderson states it was two weekends ago, Anderson states that he did them because of the Lorazepam in the gastric sample, and the two urine samples done by the defense. Anderson states that the urine is a historical perspective, and could be an accumulation from several days. Anderson states that the Midazolam testing was done in the urine because the concentration is much higher, which helps to confirm the blood level of Midazolam. Anderson states that Lorazepam levels were much more elevated in the urine than the Midazolam. Anderson states Lorazepam 12,974 nanograms/ml (13 micrograms/ml) Midazolam 0.025 nanograms/ml. Anderson states that the Lorazepam concentration goes up in the autopsy urine, and with Midzolam much less than Lorazepam.
Anderson states that the half life of Lorazepam is 9-16 hours, and that he looked it up in a medical reference book to gain that information. Anderson states he doesn't know what the absorption time and/or the peak time of Lorazepam, that it is in the book, but he doesn't remember what it said.
Anderson clarifies that he never went to 100 North Carolwood. Anderson states that he received vials of blood, a broken syringe with plunger, an IV catheter from Investigator Fleak. Anderson states that the IV bag and IV tubing was brought to him at the lab, simply marked medical evidence #2.
Anderson states that the difference between blood sample and urine sample, is that the blood is what is usually happening in the body, and in the urine represents everything that the body is metabolizing out, and that the urine concentration expectation is that it would be much higher. Anderson states that the urine is historical in nature and what is being expelled from the body over a certain amount of time.
Anderson states that the PACTOX gastric contents analysis, shows 634 nanograms/ml of Lorazepam. Anderson states that the lab measured in concentration, he was provided 73.5 mls of gastric contents, in which he would multiply the two numbers to get the nanograms of stomach contents which would be 46,599 nanograms of Lorazepam left in the stomach. But the numbers Anderson should have used for calculation (micrograms not nanograms) he needed to divide by a thousand, so 46,599 divided by a thousand equals 46.599 divided by another 1000 to get a mg amount, equals 0.04599 of Lorazepam in the stomach. Anderson states that he went further and got a more exact amount and arrived at 0.046599. Anderson states that with a 2 mg Lorazepam pill, the gastric contents are equal to 1/43rd of a single 2 mg tablet, which is a very small amount
Flanagan asks if there is a high concentration of ephedrine in the urine, but a low concentration in the bladder, would it be fair to say it was recently taken, Anderson says it’s a fair assumption. Flanagan asks if it's the same with propofol, Anderson states that he is not familiar with the excretion patterns of propofol.
Flanagan asks if a person were to take 7 or 8 Lorazepam tablets, and he found 14 miligrams in the stomach, would Anderson state that the person had taken it recently, Anderson states yes. There are numerous questions asked after this by Flanagan, but prosecutor Walgren objects and judge Pastor sustains them.
Elissa Fleak recall testimony
Walgren goes over evidence collection and when Fleak recovered multiple evidence items. Walgren asks if there are a lot of photographs taken on multiple days. Fleak looked over the photos to identify which photograph was taken which day (June 25th or June 29th). Fleak says she went into the master bedroom briefly, looked around but did not search it.
Walgren talks about IV stand and the photographs about it. 2 photos of IV tubing taken on June 25th. Tubing is draped over the handle. June 29 photos of IV stand /tubing. June 29 it's still draped over as it was on June 25. Later photos taken same day, it's no longer draped over the handle. One June 29, the investigators freed the tube (undraped it) so that the syringe can be photographed.
mid morning break
Chernoff again questions about whether she went into MJ's master bedroom or not. And again brings the subject of master bathroom and photographs taken in it.
In MJ's master bedroom fire place is on , TV is on as well. Chernoff shows pictures inside the master bathroom and asks if Fleak remembers the pill bottles. Fleak says she wasn't there in June 26 and those bottles were collected on June 26. Fleak says she doesn't know who collected them and who took those pictures. Chernoff shows a picture where there's no pill bottles. Chernoff asks about the briefcase in the pictures.
Detective Scott Smith Testimony
LAPD Detective for 20 years. He was assigned to robbery-homicide division in June 25, 2009. He learned about the death of MJ 3:30PM from his supervisor. He arrived at UCLA at 4:25 PM. Smith went to the emergency area. He stayed there till 7:00PM. Smith did not see Murray at UCLA. Smith obtained security footage from UCLA showing Murray. They got footage of Murray leaving at 4:38PM.
Walgren plays the video and then shows an aerial photo of UCLA and asks Detective Smith to mark the way Murray let the hospital.
Smith talked with Faheem Muhammed, Alberto Alvarez at UCLA very briefly. FM just told he was employed by MJ and gave his contact information. AA said the same things and also mentioned he went into the room to help MJ and called 911. Detective Smith didn't do any more interviews at that day. He arrived to Carolwood around 7:30PM.
Smith didn't know the cause of death at that point of time. At that time this was a death investigation and not a homicide information. Death investigation could be natural causes and detectives may or may not be involved. If it is homicide investigation the police department takes full responsibility. It becomes a homicide investigation if there's an obvious cause of death such as gunshot etc. This was a death investigation and coroner was leading the investigation not the police department. Detectives was on the scene to assist and support coroner's office as needed.
Walgren asks if this had been an homicide investigation would LAPD be leading the investigation and collect evidence. Smith says yes. On June 25th evidence was collected by coroner's office. Det. Smith was assisting and overseeing the LAPD photographer. Smith says they left the residence around 9:30 PM. They released the house at the request of Jackson family to private security.
June 26, Detective Smith attended the entire autopsy of MJ. He didn't have cause of death by the end of autopsy. They had no information to assist with the investigation. It was deferred pending toxicology results. At this time it was still a death investigation and not a homicide investigation. On June 26th Smith went to Carolwood again. Coroner Ed Winters called him and said some items were given to him by family. Smith went to take those items. They initially thought it was tar heroin which turned out to be old rotten marijuana. It was found in a shaving kit. Those items had no relevance to MJ's death and determining the reason of his death.
In the shaving kit there was also temazepam bottle prescribed by Murray. Smith had also found some empty pill bottles on June 26 in MJ's master bathroom.
Walgren goes over the pictures of MJ's master bathroom taken over several days. June 25th pictures. Bathroom appears to be messy, drawer doors open, a few notes taped on the bathroom mirror. Pictures from June 26. There was no empty pill bottles or briefcase on June 25th pictures. On June 26th there's a briefcase, Smith doesn't know whose suitcase it is. June 26 pictures show empty pill bottles on a ledge. Smith says that he placed them on the ledge to photograph them.
On June 27 Murray's attorney Michael Pena spoke with Detective Martinez. They made arrangements to meet at Ritz Carlton at 4 PM. Murray's attorneys had chosen the place. Detective Martinez and Smith met with Murray and his lawyers in a room at the hotel. They conducted and recorded the interview.
Audio of Murray’s interview with the police is played
June 27th Ritz Carlton. Murray is at the interview with his lawyers Chernoff and Pena. Detective Smith and Martinez is doing the interview.
First part of the interview: Officer is going through and asks Murray basic information as his address, phone number, weight, when he was born, how tall he is etc.
Detective says the detectives at the hospital was from another division and was not handling the case. They took some notes but didn’t do a formal interview. Murray seems surprised to hear that other detectives took notes after he left.
Murray talks about how he met Michael. They met in 2006 and saw MJ on and off since 2006. The first time Murray saw MJ was because MJ and his kids had the flu, a bodyguard of MJ whose parents were patients of Murray referred him.
Murray says he had been caring for MJ for the last 2 months. Murray tells that he received a phone call from MAW. MAW said MJ was going to do a concert-tour in London and MJ wanted Murray with him. Murray said he needed more details before accepting. He then say MJ called and said he was happy Murray was going to join him – although he had not yet committed to join MJ’s team.
Detectives ask about who is Murray is working for AEG or MJ. Murray says he’s an employee of MJ but paid through AEG.
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Re: Murray Trial _ All daily trial Summaries - No discussion October 6th / Day 8 Full Testimony
Murray Trial Day 9 October 7 2011
Audio of Murray’s interview with the police is continued
Murray says he had no idea that AEG were going to pay him.
Detectives ask about MJ’s general health. Murray says generally speaking MJ did not eat well and was very thin. He did not find any major physical change in MJs condition except for something called subluxation of his right hip (MJ’s right hip would slip out and slide back to the joint). MJ had fungal disease on his toes which was treated. Nothing more that Murray noticed.
On June 24th – Murray got a called from MAW around 12:10 am that MJ was done with rehearsals. MJ had attended meetings and did a partial performance (not a full rehearsal). MJ wasn’t complaining about anything but wanted Murray to be at Carolwood by the time he came home.
Murray spent every night at Carolwood except nights he where off, which were Sundays. He spent the night there per MJs request.
Murray arrived to MJs home at 12:50am before MJ and waited at MJs room. MJ arrived shortly after, around 1am. Once MJ arrived, they greeted each other and talked about their days. MJ told Murray he was tired and fatigued and was treated like a machine. MJ took a quick shower and changed and came back to the room.
When MJ came back to the room, Murray put on some cream/lotion on his body and back for Vitiligo.
Detectives ask Murray about the bedroom. Murray tells that MJ had 2 bedrooms. No one not even cleaners would be allowed to go into the master bedroom and it would be in a bad state. Murray would see MJ in the second bedroom , the one that had IV stand and oxygen tanks.
After cream, MJ wants to sleep. Murray says MJ is not able to sleep naturally. Murray says he would put an IV for hydration on MJ’s right or left leg below the knee. They then talked a bit and he gave MJ Valium 1 pill 10 mg orally.
As Valium’s effect was delayed so around 2 AM Murray gave MJ 2 mg of Lorazepam which it was IV pushed slowly. Murray says he observed MJ but he continued to be awake for 1 hour, he says he watched him because he wanted to be cautious. So Murray decided to give him Midazolam (2 mg injected slowly) around 3 AM. Murray waited again but MJ was wide awake. MJ said he couldn’t sleep. Murray suggested to lower the music MJ likes to sleep with and dim the lights and told MJ to meditate while he rubbed his feet. MJ did that reluctantly and MJs eyes closed. Murray estimates that MJ closed his eyes around 3:15-3:20; he doesn’t know it for certain because he wasn’t looking at his watch at that time. 10-15 minutes later MJ was again awake.
MJ was surprised that he managed to sleep after he had meditated. And they tried mediating again but by 4:30 AM MJ was sill wide awake. MJ starts to complain saying that says he has rehearsals he needs to perform and tomorrow he will need to cancel his rehearsals because he can’t function if he can’t sleep. Murray says then he gave MJ another 2mg of Lorazepam at 4:30 – 5:00 AM because a safe time had passed. That didn’t put MJ to sleep as well.
MJ complained that if he can’t perform he would have to cancel the rehearsals and it would put the show behind and cannot satisfy fans if he’s not rested well. Murray says that it put a lot of pressure on him. Murray tells MJ he isn’t normal and the medications that he gave would make a normal person sleep for 1-2 days. (due to wanting the medications/can’t sleep)…
By 7:30 MJ was still awake.At that time he gave another 2 mg Midazolam. There was still no effect. Murray says he cautiously checked the IV site to make sure the fluid and medicines was going to MJ because he wondered why MJ wasn’t responding to medications.
At this time Murray says Michael also urinated.
10 AM in the morning. Nothing has worked. Murray was watching and trying to get MJ to sleep. MJ is complaining he can’t sleep, he has to cancel the dates and everything has to be pushed back.
MJ at that time asks “Please give me some milk so that I can sleep, because I know this is all that really works for me”. Detectives think that they are talking about actual milk and asks if MJ wanted hot or warm milk. Murray tells them it’s a medicine Propofol which is “a sedative that could also be used for anesthesia”. Murray gave MJ propofol through IV around 10:40. Murray had asked him how long he would sleep if he gave him Propofol because MJ needed to get up at a certain time. MJ told him it doesn’t matter when he wakes up, told him to just make him sleep.
Murray say he gave him small amounts to get him to sleep, he administered 25 mg of Propofol together with Lidocine, he pushed it slowly. This time it must have been 10:50, effect is quick and Michael was sleeping now.
Detectives ask if Murray had any monitoring equipment. Murray says he took all the precautions that were available to him such as oxygen and pulse oximeter.
Detectives questions Murray about the dosage. Murray says 50 mg propofol was the highest amount propofol he had given MJ ever. That night he gave less due to the other medications he had given to MJ. Murray says he roughly gave MJ Propofol every day, there were rarely exceptions. Murray also says that three days leading up to MJs death, he tried to wean MJ off propofol
He was not aware that MJ was taking this on a daily basis before he was hired. Murray was surprised by MJs pharmacological knowledge and his mention of “milk” and “antiburn”. MJ said he had taken propofol before.
MJ said he used it in Germany but never disclosed other doctors’ names. MJ never told him he administered it himself but other doctors let him infuse it by himself.Murray told him NO he wouldn’t let him to that.
Murray says MJ knew that propofol was the only thing that worked for him. Murray says he often warned him about it.
MJ told him he was seeing a Dr Lee that she was giving him a cocktail for energy. Murray says there were a lot of IV sites on MJ’s body and his veins were sclerotic. Murray asks MJ what is in the cocktail and wants to review it. MJ says he doesn’t know. Later they got of Lee because MJ felt she was unprofessional and cancelled an appointment. MJ felt she wasn’t telling him the truth.
Once in Las Vegas Murray got a call from MAW. MJ was in Vegas with his children for a show and he was staying at Wynn Hotel. MJ says he having difficulties to sleep. Murray tells MJ to use sleep medications (lorazepam or restoril) that he gava to him. MJ tells Murray nothing that he or Klein or Metzger gave to him works. Murray says he doesn’t have any other alternatives. MJ then asks about Diprivan / Propofol and says that he knows that it works. Murray says he doesn’t have it. MJ mentions Dr. Adams and that he gave him Propofol. Murray doesn’t know Adams. MJ gives Murray Adams phone number. Murray calls Adams. The plastic surgeon’s office Adams used doesn’t allow them in the office so Murray lets them into his office on a Sunday. Adams puts MJ on a Propofol drip for 6 hours. Murray says he had monitoring equipment. Murray comes back to his office after 6 hours and MJ says he’s feeling wonderful because he has slept.
MJ tells Murray that this is divine guidance and other doctors helped MJ sleep for 15 10 18 hours. MJ mentioned of having another doctor – Adams- on tour with them. Adams was willing on to go on tour with them and wanted $1.2 - $1.3 million a year. Murray told it to MJ but there was no follow up and Adams didn’t end up joining the team.
Murray mentions that MJ wanted him to be around forever, after the tour. Murray mentions MJ’s plans for a children’s hospital and wanted Murray to be medical director.
Detectives go back to the night of June 25. Murray gave MJ 25 mg Propofol. MJ falls to sleep but he’s not snoring. Generally when he’s in deep sleep he snores so he’s not in deep sleep. Murray monitors him. Everything looked stable and he was comfortable. Murray needed to go to the bathroom to pee and empty MJ’s urine jar.
When he came back after 2 minutes he sensed MJ wasn’t breathing because he usually looked at his chest to see if he was breathing. He immediately checked MJs pulse and got a thread pulse from the femoral area and MJs body was WARM and he assumed everything happened quickly and immediately started CPR and mouth-to-mouth. He wanted to apply medicine as well but not first because he wanted to ventilate and compression first. He saw MJs chest rise. Murray says he couldn’t move him from the bed to the floor by himself. He then got his left hand under MJs body and then gave him CPR and also ventilating him and made sure his chest was rising completely. He looked for the phones but phones do not work in the house. He doesn’t know the address zip-code; only know its North Carolwood. The house is closed during nights and only MJ, he and the children would be there. Murray tells that security doesn’t come to the house. Murray thinks it’s inhumane that the security are not allowed into the house to pee.
He says to talk to 911 would be to abandon him and he didn’t wanted abandon him. He reached his cell phone and called MAW. Murray tells MAW to send up security. Murray says he didn’t ask MAW to call for 911 because then MAW would have asked why and Murray was trying to assist MJ. Murray realizes that MJ doesn’t have a pulse now so he lifts MJs legs for a brief moment for auto transfusion and continue to do CPR etc. No one came to the door, no one knocked on the door. So he gave Michael 0.2 mg Flumazenil because he wanted to reverse the affects of the other drugs but MJ would not still breathing and no help was coming. He then opened the door and ran down to the kitchen and saw the chef (Kai Chase) to have the security immediately and security (Alvarez) comes upstairs. Murray tells Alvarez to call 911 and want help to move MJs body to the floor and still helps with chest compression.
Alberto talked to 911 but Murray told him to just tell the paramedics to hurry up because he wanted help to move MJ to the floor. Paramedics came and called UCLA, MJ was not breathing. They were doing chest compressions. Murray says Michael was PEA –pulseless electrical activity – which means you don’t shock a patient. MJ was given starter drugs. Murray says that he felt the communication and the orders coming from UCLA was kind of slow.
After 20 minutes of effort – which Murray thinks was limited – he knew MJ hadn’t been gone too long and he had felt a femoral pulse. So Murray asked UCLA instead to calling MJ dead to transfer the patient to him. Murray took over the care and they took MJ to UCLA. Emergency personnel met them. They worked on MJ for an hour. Murray says probably they would have stopped sooner if Murray wasn’t insisting. They don’t know why MJ died but thinking pulmonary embolism could be a reason (a clot in the lungs that would shut the circulation in the lungs). MJ is pronounced dead. Murray doesn’t want to sign the death certificate as he doesn’t know the cause of death.
Chernoff jumps in and changes the topic to Murray trying to wean off MJ 3 days before leading up to MJs death. Murray says he didn’t know MJ used propofol before and that it was kind of a habit. Murray says he wanted to MJ to sleep naturally and tried to wean him off. Murray asks what MJ would do once the tour was over; MJ tells him he thinks he can be able to sleep then. Murray switches to lesser drugs (such as Lorazepam) to wean MJ off. Murray says MJ knew it but he was reluctant. Murray says he never told MJ that he believed he had drug dependency. He was trying a strategy and was trying Michael to transfer his confidence in Propofol to something lesser. First night Murray reduces Propofol and starts Lorazepam and Versed. Second night he removed Propofol and only gave Lorazepam and Versed. Michael told him he felt a little hangover in the day. The night MJ died Murray started with Lorazepam and Versed but nothing was working. Murray doesn’t know if it was withdrawal from Propofol or if it was psychological. Murray says after trying all night with those 2 drugs he finally gave MJ Propofol so that he can sleep and so that he can produce the next day. Murray says he didn’t want MJ to fail and he cared about him.
Judge stops the tape.. Rest will be continued on Tuesday.
Court ends early due to Yom Kippur (Jewish Holiday)
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Re: Murray Trial _ All daily trial Summaries - No discussion October 7th / Day 9 Full Testimony
There won't be any testimony on Monday October 10, 2011. It's Columbus Day and it's a federal holiday in USA.
Testimony will continue on Tuesday October 11, 2011. At that time they will continue to play the audio of Murray's interview with the LAPD Detectives. You can find the summary of the remaining portion of the interview below.
Murray mentions Michael probably having withdrawal symptoms to Propofol on June 25. He says that it can be either physical or psychological or mental.
In the hospital Murray talked to the detectives briefly and gave them his phone number.
Murray says he and emergency room doctor went into the room Katherine Jackson was waiting and told her that MJ had died. Murray says he stayed with her to console her and asked UCLA to bring in a psychologist to help Katherine. Murray then learns that children are in another room and decided to notify the children. Murray , Dileo and Michael Amir Williams and a social worker went into the room the children were and told them MJ was dead. Murray says the children were weeping and the stayed there to console them. Murray says Paris mentioned her unhappiness and said she didn't want to be an orphan. Dileo and Murray say that they will take care of her. Murray tells Paris that he tried her best to save Michael. They bring MJ's kids and Katherine together. Murray says he doesn't know how close they are.
The children want to see Michael, psychology team says it's a good idea and it would bring them closure. UCLA was prepping MJ's body for viewing. During this time Jermaine, Latoya and some cousins of MJ came to the hospital. They were briefed about what happened. Murray went into the room where the family was, family asked Murray if he knew why MJ died. Murray said no and recommended them to get an autopsy. MJ's body was ready for viewing and the children went to see MJ. Murray asked Katherine if she wanted to see MJ as well, she said no.
Murray talked with the bodyguards and asked them where would the children go. Bodyguards told him they can't go back to the house because it was on lock down. Murray talked with Randy Phillips, Frank Dileo and the bodyguards and asked if he can do anything. Murray says Jermaine as asked to make a announcement and they wanted Murray to review the press release. Murray says he added the cause and Jermaine edited the part that asked fans to respect their privacy to ask media to respect their privacy. Murray says he talked with Jermaine a little bit. Murray says then he was tired and let the hospital to go home.
Murray again mentions he talked to Detective Porche and gave him his phone number. Detectives mention that they called Murray several times but the calls went to voice mail. Murray's lawyer Pena says it was his advice to Murray to leave his phone off and wait for his lawyers to talk to detectives later.
Detectives ask if Murray knew MJ had any preexisting conditions. Murray says he treated MJ for pneumonia in 2008, fractured toe in 2008, upper respiratory issues multiple times over the years, lethargy and for callouses on his feet. Murray also treated fungal infection on MJ's feet. Murray says he gave MJ Lamisil and did a full blood work before to make sure that his liver was okay.
Chernoff asks detectives if there's any preliminary toxicology results and the detectives say they are not aware of it. Chernoff then asks Murray if he knew of other medications Michael might be taking. Murray says he heard that MJ was seeing Klein. Murray says around 3 weeks ago he hear MJ calling Jason Pheiffer and asking him if he can squeeze him to see Klein. Murray says he also saw pill bottles with Dr. Metzger's name on them. Murray says MJ doesn't disclose all the physicians that he's seeing.
Detectives list a number of medicines and ask Murray if he prescribed them and what are they used for. Murray explains Flomax and says that MJ has hard time urinating. Murray is surprised to find out that MJ had some sort of eye drops. Murray says that MJ had a very bad eyesight and he thought that MJ could be legally blind. Murray arranged for an appointment but MJ didn't go to see the eye doctor so Murray is surprised to hear about eye drops.
Murray says MJ's production team has told him that MJ's worst days was after he came from seeing Klein and MJ would be wasted and require 24 hours to recover. Detectives mention finding marijuana and Murray says that MJ denied it and surprised to find out MJ would be using stuff like that. Detective tells Murray it was old and rotten. Detectives ask about empty cigarette packs they found , Murray says he doesn't know if MJ smoke. Detectives ask if MJ packed his suitcases and Murray says he did. Murray mentions MJ using excessive cologne and could not understand why he would use that much and says it might be to dismiss any odor.
Detectives ask how many syringes Murray used and Murray replies 2. He says he would recap them and he would use medication and mix them with saline. Detectives asked Murray what he did with those syringes Murray say he would put them in his bag and put them into the cupboard. When detectives ask where those syringes are Murray tells them he left them at the house at the closet. Detectives ask which closet and Murray describes it to them. Murray says MJ showed him the cabinet and told him to put his stuff there.
Detectives ask for the keys to Murray's car so that they don't have to break into his car and damage it.
At the end of the recording Detectives ask if Murray ever gave MJ Demerol. Murray responds no. Detective Smith says they didn't find any and Detective Martines says he doesn't know how that came up.
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Re: Murray Trial _ All daily trial Summaries - No discussion October 7th / Day 9 Full Testimony
Murray Trial Day 10 October 11, 2011
Detective Smith LAPD Testimony continued
Walgren Resumption Direct
They finish playing the Murray interview tape.
Smith states that the first time propofol was mentioned was in his interview with LAPD two days after MJ died, and that prior to that Murray had only mentioned he administered a sedative.
Smith states that he responded to UCLA and also attended the autopsy but that his knowledge was limited.
Smith states that very little of the questioning of Murray was limited, but that they allowed Murray to speak freely. Smith states that Murray did not mention the phone calls he placed or received on June 25, and was unaware of Sade Anding at that time.
Smith states that Murray was surprised by the fact that LAPD had not recovered Murray's medical bags at the time of the interview, dated June 27, 2009.
Smith states that on June 26, 2009, there were some business cards belonging to Conrad Murray and David J. Adams found in the Carolwood home. Smith states that the business cards were recovered from MJ's master bathroom by a LAPD detective. Smith states that also recovered were Latanoprost, a skin cream, and three vials of eye medication from the master bedroom, prescribed by Arnold Klein. Smith states that a large plastic bag with Applied Pharmacy on it, inside with benoquine to Dr. Murray was recovered the bathroom area of MJ's bedroom.
Smith states that there were a series of search warrants issued, the first being on June 29, 2009, to 100 North Carolwood Drive and the tow yard where Murray's BMW was. Smith states that a contract recovered from the pocket of the door, and a few business cards. Smith states no propofol bottles were recovered from the car.
Smith states the next search warrant issued on July 22, 2009 to Murray's cardiology practice and a storage unit in Houston, but that no propofol bottles were found.
Smith states that next search warrant issues on July 28, to Murray's Las Vegas office, home or storage unit were done, no propofol bottles found.
Smith states that the next search warrant was issued on August 11 to Applied Pharmacy at Las Vegas, owner Tim Lopez. Smith states that this is when LAPD discovered that propofol was being sent to an apartment in Santa Monica, CA belonging to Nicole Alvarez. Smith states that then a search warrant was issued for Alvarez Santa Monica home, on August 13, 2009. Smith states that there were no propofol bottles recovered from Alvarez' home.
Chernoff Cross Examination
Smith states that attempts had been made to contact Murray by the LAPD by phone, but that he did not personally make those calls, and that the detective who had made those calls, states that the calls went to voicemail.
Smith states he was aware that the press release for MJ's death was done by Jermaine Jackson, but not aware whether the press conference was actually done.
Smith states that he and Detective Orlando Martinez were initially assigned to MJ's death case, but that Detective Porsche was the original detective who tried to contact Conrad Murray.
Smith states that on June 27, 2009, the initial meeting between Murray and LAPD was set up for 2 pm, but it was rescheduled for 4 pm by LAPD.
Smith states the he spoke with Michael Amir, Faheem Muhammad, Alberto Alvarez, Larry Tolbert, Nanny Roslyn Muhammad, Kai Chase, MJ's family members, some housekeepers, Larry Muhammad had all spoken to LAPD on June 25, 2009. Smith states that Chernoff/Murray never made any limitations as to what he did not want to talk about or time limits, during the initial meeting with LAPD.
Smith states that he did meet with Michael Amir Williams on August 31, 2009 and that he vaguely remembers that Williams had to leave the room briefly at one point to speak to his attorney. Smith states that Murray did not leave the room, nor did he put time limitations on the interview with LAPD on 6/27/09.
Smith states that he had been with robbery/homicide for 1 and half years, before that he worked in another division for 10 years, 24 years as a police department, 14 in homicide. Smith states that he is an avid note taker, and that he took notes for various individuals and evidence collected regarding MJ' death, because he understands the importance of those notes. Smith states that he was in and out of the room while Elyssa Fleak was investigating on June 29, 2009. Smith states that while Fleak was removing items, he did not make notes about what she was removing them, but after that when all items had been laid out for display purposes for photographs.
Smith states that on June 29, 2009, he never mentioned that he never mentioned that a propofol bottle was found in an IV bag. Smith states that he was very specific with miligrams, lot numbers, etc., empty IV bags, empty pill bottles. Smith states that on June 29, in the search, he found Murray's medical bags exactly where Murray said they were.
Smith states that there were Lorazepam bottles found in the master bathroom of MJ's bedroom, but that he was not the person who found them. Smith states that the business cards were found in the vanity of the master bathroom, and that Detective Sanchez told him where they were found.
Smith states that he interviewed Dr. David Adams in Las Vegas.
Smith states that while he was at UCLA, he spoke to Alberto Alvarez. Smith states that Alvarez said he was called into the bedroom, and that Alvarez was told that MJ was having a bad reaction. Smith states that Alvarez never mentioned CPR, or that the propofol bottle was inside the IV bag was on August 31, 2009. Smith states that Faheem Muhammad made a statement on June 25, but that he said nothing about Murray wanting to go back to the Carolwood home on that date, nor did Michael Amir Williams until 8/31/09.
Smith states that there was another interview with Alberto Alvarez after August 31, 2009, and but he can't remember when. Smith states that he requested fingerprints from Alvarez, and he did turn them in, and they were analyzed.
Smith states that SID came in and downloaded surveillance video, that there were video cameras were not pointed toward the front door of the home door, but there was one on the front gate, on the keypad at the front gate, and one in the back of the house. Smith states that the video that was selected to download was made collectively, but Detective Martinez did the actual downloading. Smith states that they never requested any more video surveillance after June 25, 2009. Smith states that although the Carolwood home was locked and guards were there, that there were people allowed in the home for the 26th, 27th, 28th of June, 2009. Smith states that he does not know if a log had been kept regarding visitors at Carolwood after MJ died through June 29, 2009.
Smith states that he never talked to the new security at Carolwood to get a list of the people who had been in the house on the 27th, 28th, 29th. Smith states that marijuana was found by family members in MJ's closet in a suitcase.
Smith states that he asked upon leaving Carolwood if he the home would be sealed, he stated that he was told no.
Smith states that Conrad Murray told Detective Porsche that he would not sign a death certificate because an autopsy needed to be performed.
Smith states that he interviewed other doctors besides Dr. Adams and Dr. Murray.
Smith states that Murray gave him the keys to his car in order to search it.
Smith states that he did not go personally to search Murray's property in Houston. Smith states that in Las Vegas, Smith recovered Murray's cell phone from his home, computer hard drives from his office, paperwork involving his practice from his offices in Las Vegas.
Smith states that he can't recall if he interviewed a Patrick Muhammad was interviewed, Isaac Muhammad was interviewed, and a Derek Cleveland was interviewed by Smith, all of whom were security at Carolwood.
Smith states that MJ's death was deemed a homicide case on August 27, 2009. Smith states that there was some discussion and that the lieutenant from LAPD told Ed Winter from the coroner's office to stop looking into other doctors besides Murray.
Smith states that a lieutenant from LAPD contacted Ed Winter, who had already contacted Arnold Klein, which caused some friction between the two. Smith states that the DEA was assigned to look into specific doctors ultimately and that LAPD was to focus on the homicide investigation.
Smith states that when Conrad Murray stated he gave MJ milk, Smith asked whether the milk was hot or cold. Smith stated he had no idea that milk meant propofol.
Smith states that only one IV bag was recovered on June 25, 2009. Smith states he was not present when the propofol bottle inside the IV bag was discovered, but was present when it was all laid out on a table.
Smith states regarding video cameras, first pointed at gate area on the outside of gates, second on an entrance underneath the residence but inoperative, third and fourth were on either side of the back side of the entrance facing pool and backyard, fifth pointed at right portion on exterior of house, one pointed facing at the inside of the gate. Smith states no camera showed any door entrances, primarily for exterior perimeter video surveillance.
Smith states that when he found an empty Lorazepam bottle inside an empty IV bag, he starred it and underlined it, marking the lot number. Smith states that he did not note that the propofol bottle was inside an IV bag in his notes, as he did with the Lorazepam bottle.
Smith again states he did not see the propofol bottle inside the IV bag, and that is why he did not document it.
Smith states that the DEA was going to investigate Mickey Fine Pharmacy, and that Arnold Klein was linked to the pharmacy.
Dr. Christopher Rogers LA County Coroner's Office Testimony
Rogers states that he is a deputy medical examiner for LA county, and that he does autopsies to find cause of death, and that he has done this since 1988. Rogers' current position the Chief of Forensic Medicine.
Rogers states he has been present for several thousand autopsies over his career. Rogers states that he did the autopsy report for Michael Jackson on June 26, 2009. On that specific day, Rogers states he was not able to specify a cause of death, there was nothing anatomically obvious to state cause of death.
Rogers states that MJ was healthier than the average person of his age. Rogers states that there were incidental findings, that MJ had an enlargement of the prostate gland which meant that it was difficult to urinate so he was retaining urine, he had vitiligo, and he also had a polyp in the colon. Rogers states that the nervous system showed mild diffuse swelling, lung exam showed chronic inflammation and scarring, radiology showed an extra rib and also some arthritis. The dental examination showed root canals and implants were done. Rogers states that an anesthesiology consultation was also done.
Rogers states that a previous scalp injury caused an area of pigmentation at the top of the scalp which was scarred, Rogers was aware of the scalp injury. Rogers states that MJ was 5'9" and that he weighed 136 pounds, BMI index was within the normal range, however a thin individual.
MJ's autopsy photo is shown in court. Rogers states that is, indeed Michael Jackson. Rogers states that also the autopsy photo shows 8-25-09, the date is incorrect.
Rogers states that MJ did not have heart disease and no abnormalities were detected in the heart. Rogers states that coronary arteries were clear, and that almost everybody has some athrosclerosis in their coronary arteries, but that MJ had none, meaning no fat or cholesterol in MJ's arteries.
Rogers states that initially he felt there was no natural disease that caused his death. Rogers states that MJ's esophagus was intact, and that there was no white, milky substance in the esophagus.
Rogers states that the stomach content was examined, and that Rogers found 70 grams of drug fluid but did not show pills or capsules. Rogers states that he looked for that specifically to determine cause of death.
Rogers states that he checked the mouth and upper airway (meaning the entrance to the breathing passages, mouth down the throat into the windpipe or trachea) and found no foreign material.
Rogers states that he requested toxicology reports to assist him to report cause of death. Rogers states that he sought out other doctors in specialties to help him with cause of death. Rogers states he read Conrad Murray's interview with LAPD to help him and asked for medical records from Murray, but was never able to obtain any records from Murray.
Rogers states that he was at some point, able to determine cause of death, and the manner was homicide. Rogers states that he based his homicide report on 1) Murray's statement to the police he administered the propofol and benzodiazepines 2) it's not appropriate to give propofol for insomnia, that the risk outweighs the benefit, and in addition, the setting in the home did not provide for the use of an EKG monitor, a precision dosing monitor, equipment available to revive MJ adequately, not an endotracheal tube, no meds to improve circulatory function and 3) and that the circumstances do not support self-administration of propofol, because Murray stated that he only gave MJ 25 mgs, went to the bathroom, returned from the bathroom to find MJ not breathing. Rogers states that you would have to assume that even though MJ was under the influence under the influence of propofol and other sedatives, injects himself with propofol, seems less reasonable than Murray giving MJ propofol from time to time.
Rogers states that since they did not find a precision dosing device, and that he feels that it would be easy for the doctor to give too much propofol, rather than MJ self injecting propofol himself.
Rogers states that the cause of death was acute propofol intoxication, and the contributing condition was the benzodiazepine effect. Rogers states that Lorazepam and Midazolam, both sedatives were a smaller contribution to MJ's death, and could exacerbate respiratory depression, causing someone to stop breathing. Rogers states that it could have also stopped the heart from beating.
Rogers states that a diagram was made of MJ's body during the autopsy, noting various IV puncture marks during revival efforts. Rogers states that on MJ's right arm, left arm, neck, just below the left knee (where Murray had administered the IV, not revival puncture mark). Rogers states that he observed the empty propofol bottle that was found in MJ's bedroom, noting that it was unusual as the stopper had a center which had a linear opening, showing that it did not show any needle punctures. Rogers states that the linear opening is an opening from side to side in the center of the rubber stopper of the empty bottle of propofol, indicating it was not made by a syringe needle. Rogers states that the linear opening could have been made by a spike.
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Re: Murray Trial _ All daily trial Summaries - No discussion October 7th / Day 9 Full Testimony
Murray Trial Day 10 October 11, 2011
Dr. Rogers Testimony Continued
Walgren Direct continued
Walgren asks if Roger checked the autospy picture during the lunch break and if the picture was corrrectly dated as June 25th. Rogers says yes.
Walgren reminds that when they went to break they were talking of a spike. Walgren shows a spike and asks Rogers to identify it.
On March 2011 Rogers reviewed some evidence. Rogers identified what Fleak called a needle as IV catheter with a needle still present. It appeared unused. Rogers also examined the syringe from the nightstand. According to Rogers it did not appear to fit.
Defense asks if Rogers reviewed his preliminary testimony, the coroner's report,his notes, expert reports to refresh his memory before today's hearing. Rogers says he reviewed those items as well as another autopsy report and reviewed toxicology results. Flanagan asks if he reviewed a report from Dr. Shafer who is an anesthesiologist in Columbia University. Rogers reviewd that as well. Flanagan asks if he has reviewed toxicology results from outside labs about stomach and urine. Rogers did not see those.
Flanagan asks if Midazolam, Diazapem and Lidocaine toxicology results are consisted with what Murray told the cops. Rogers answers yes.
Flanagan asks if it's correct that what Murray said about Lorazepam in his interview doesn't match with the toxicology results and also mentions that Propofol is hard to determine as it metabolizes fast. Rogers says it's true and they also don't know how much and how fast Murray gave MJ Propofol.
Flanagan asks if they can't be sure who gave it. Rogers says yes.
Flanagan asks why would IV bottle be spiked. Rogers says it's done for giving it continuosly to maintain sedation. Flanagan asks if spiking would also help to emptyPropofol bottle quickly than getting it out with syringe. Flanagan asks if you wanted to mix Propofol with saline spiking it would make it faster to pour it into the saline bag.
Flanagan mentions a way of doing Propofol drip by mixing with saline solution. Flanagan again mentions that emptying the Propofol bottle with a spike would be more efficient than using a syringe to get it out.
Flanagan asks if propofol - saline mix was done, you would expect to see an IV bag with Propofol in it. Rogers says there was no Propofol found in the bag. Flanagan asks if any evidence of propofol was in the y connector, syringe and the tubing below the y connector. Rogers answers yes. The portion above the y connecter was negative for Propofol.
Flanagan mentions Propofol's shelf life of 6 hours. If it's not used it has to be thrown out. Flanagan says that it doesn't make sense if one will only use 5ml of Propofol to get it from a 100 ml propofol bottle as they will need to throw away the 95 ml.
Flanagan asks about lidocaine and Rogers explains why it's used.
Flanagan asks about if Propofol needs to be slowly infused and not rapidly. Flanagan asks what the blood levels will show if a person is given 25mg of propofol. Rogers doesn't know. Flanagan asks how much sleep would such dose of Propofol would bring. Rogers says 5 minutes and Propofol would have no effect after 5 -10 minutes.
Flanagan asks what happens if 25 mg is injected rapidly. Rogers say that you'll have a locally high concentration and it would mean a higher risk of cardiao respitory arrest. Flanagan goes over the information that propofol needs to be slowly administered. Flanagan asks if someone is slowly administering Propofol if they would see any negative effects such as breathing stopping. Rogers answers yes.
Flanagan asks if a slow injection is given and the patient is watched for 15-20 minutes and if after that time period if something goes bad if it wouldn't be due to Propofol. Walgren objects because it's not considering other benzos. Flanagan changes his hypothetical to ask if a person is sleeping more than 5 minutes that wouldn't be due to Propofol and if he could be sleeping due to being tired / fatigue. Rogers agree.
Therapeutic level of Propofol. Rogers says it's dependent on intended use. MJ had 2.6 mg Propofol in his femoral blood. Flanagan asks if due to post mortem redistribution if that numbers could be problematic. Flanagan goes over articles to say that Lorazepam does not redistribute and ask Rogers about the Lorazepam amounts. Rogers say that they are very close and it might or might not show that there was no redistribution.
Pills in stomach. They wouldn't distribute to the body until they are disolved. Flanagan switches to stomach contents. It was a dark liquid. Flanagan asks if there could be fruit juice in the stomach and asks if they ever identified the content of the stomach. Rogers say they didn't. Flanagan asks if they saw any tablets or capsules. Rogers says they didn't. Flanagan says they could get dissolved and they can't tell if a person has taken tablets by looking to stomach contents. Toxicology would be needed to determine it. Flanagan asks if toxicology results show that Lorazepam , would it mean consumption of Lorazepam. Flanagan shows the Lorazepam in stomach toxicology results. Flanagan mentions Lorazepam concentration being 4 times higher than the femoral blood levels. Flanagan mentions the amount equals to 1/43 of a tablet but it doesn't show how many tablets are actually taken as the pills dissolve over time.
Lorazepam levels in the blood didn't cause any red flags because it wasn't too much. Flanagan shows 2 Lorazepam pill bottles found in MJ's house. Both had 30 pills (60 total), one bottle is empty the other one has 9.5 pills left in it.
Flanagan mentions that Rogers thought benzodiazepines had an effect on the death. Midazolam and Diazepam found in the blood was low and insignificant. Flanagan asks what level one Lorazepam pill would cause. Rogers says it should be at therapeutic level. Flanagan brings out the Baselt book that says for 1 pill .018 in 2 hours. Flanagan tries to ask if 1.69 blood level would mean it would require 9-10 pills. Objection.
By judge's order Flanagan goes into hypothetical scenarios. Rogers can't understand questions. A lot of objections and judge sustains them one after another very quickly.
Mid afternoon break
Flanagan mentions half life of Lorazepam (9 to 16 hours) and bioavailability. It's beyond expertise of Rogers.
Flanagan asks if what level of Propofol would be lethal. Rogers says 1 to 17 mg per ml. Flanagan asks if a person with 2.6 level of Propofol would feel pain. Rogers says yes.
Flanagan again asks Lorazepam levels of 1.69 and how many pills it would mean. Overruled due to improper hypothetical. After several hypotheticals Flanagan gets Rogers to say it would equal to 9 pills.
Flanagan mentions that stomach and urine wasn't tested for Lorazepam. Flanagan talks about urine samples. If urine sample in autopsy has higher levels of Lorazepam then the scene urine, would the blood would have higher level of Lorazepam then the blood at 7:30 AM as well. Rogers says he can't answer because there are too many variables. Flanagan gives the scenario of 2 mg Lorazepam at 2AM and 5 AM and then 8 pills being taken around 10 AM , if the urine level of Lorazepam would be higher at autopsy urine then the scene urine. Rogers answers yes.
Flanagan goes over the homicide conclusion. Rogers mention 4 factors contributed to that conclusion.
1st factor propofol and benzodiazepines is administered by another. Flanagan again asks questions about Lorazepam which is beyond expertise of Rogers.
2nd factor non hospital setting. Flanagan asks if chronic insomnia cannot be treated by Propofol. Rogers says that it's not general way to treat it. Flanagan mentions insomnia has different levels and if Propofol might be used. It's beyond Rogers expertise.
3rd factor standard of care. Rogers made that determination with the help of the anesthologist.
4th factor Circumstances do not support self administeration. Rogers says that he thought what was reasonable. To Rogers it's reasonable to believe that Murray miscalculated and gave too much Propofol. He finds it less reasonable for Michael to wake up and while still under influence of sedatives and manage give himself Propofol and it killed him and all these happened within 2 minutes.
Flanagan talks about the positioning of the IV line. IV was beyond left knee and it was 6 inches long till the y connector. Flanagan asks if a person can touch an area around their knee. Rogers agree. Flanagan asks about if anyone can do a bolus injection and if it can stop the heart.
Flanagan asks if someone else was giving the injection other than MJ would they see if there's a problem. Rogers say you hope that they do.
Walgren brings up what was mentioned earlier and asks is it true if a person found with eyes open it would mean they died quickly. Rogers says it's not true. People can die slowly and still have eyes open.
Oxygen tank was analyzed at july 13, 2009. It was empty.
Walgren says that most of the defense questions pharmacology - what happens to drugs when they enter into the body. It's not Rogers area of expertise. Rogers is an expert in determining cause of death. He's not an expert in propofol or lorazepam.
Walgren mentions the lethal levels of 1 to 17 mg Propofol and asks if smaller numbers than we have seen in MJ can cause death. Rogers answer yes.
Walgren goes over Lorazepam bottles. They are both prescribed by Murray. One is filled April 28, 2009. It was for 30 pills - 9.5 remaining. Second one is filled April,2.2009. It was for 30 pills and it's now empty.
Walgren mentions the hypotheticals Flanagan asked. Tells Rogers to assume Murray was telling the truth in his interview and gave MJ Valium and then 2 injections of midozolam and lorazepam and then propofol. In that scenario if he left the patient alone to swallow lorazepam pills, and there's no monitoring equipment, no airway management equipment and no resusitive equipment. Rogers says it's still homicide. Walgren gives the same sets of events but the scenario self administration of Propofol instead of Lorazepam. Rogers would still classify it as homicide.
Flanagan asks about the oxygen and asks if the valve was open or closed. Rogers doesn't know. Flanagan asks how long would it take it to become empty. Rogers say it depends on how open the valve is. Flanagan asks if it's in therapeutic levelswould it empty in 2 weeks. Rogers say probably.
Flanagan mentions Rogers answers about how he's not knowledgeable about Lorazepam and asks doesn't he need to be knowlegeable about that to make determination in this case in regards to the cause of death. Rogers says he doesn't know how these levels are achieved but they are the cause of death.
Flanagan talks about Lorazepam levels being close to the levels required to be unresponsive to painful stimuli and Propofol levels are half the required to be unresponsive to painful stimuli.
Flanagan asks Rogers to assume that Murray was telling the truth in his interview. Flanagan mentions the midazolam and diazapam numbers match but Propofol and Lorazepam levels are a lot higher.
Walgren asks why he do an consult with an anesthologist. Rogers says because it was a comples problem. The doctor he consulted told him that the levels was consisted with general anesthesia.
Flanagan mentions rapid injection again and asks if rapid injection would have negative effects of respitory and cardiovasculary depression
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Re: Murray Trial _ All daily trial Summaries - No discussion October 7th / Day 9 Full Testimony
Day 10 testimony has now fully posted
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Re: Murray Trial _ All daily trial Summaries - No discussion October 11th / Day 10 Full Testimony
Murray Trial Day 11, October 12 2011
Dr. Alon Steinberg Cardiologist Testimony
Steinberg is a board certified cardiologist for 13 years. He is not an expert in anesthesia, sleep medicine, pharmacology or addiction medicine.
Steinberg has reviewed CM's resume. CM was not board certified on June 25th 2009. Steinberg tells board certification is an extensive 2 day test and 90% of the cardiologists that take it pass it.
Steinberg is an expert reviewer for the California Medical Board, he reviews other doctors' actions to ensure the standard of care has been respected. 3 levels are possible: no deviation, simple deviation and extreme deviation. Extreme deviation is also defined as gross negligence.
Steinberg has conducted a review for this case. He had conducted 8 prior reviews. In 4 cases he found no deviation; in 4 cases he found simple deviation of care. This is the first time he's seen an extreme deviation from standard of care.
Cardiologists use sedation for many procedures and sometimes they use Propofol. Cardiologists are expert in mild or moderate sedation. In conscious sedation the patient is able to talk and respond to touching. Deep sedation is when patients are only responsive to pain or repeated stimuli. General anesthesia is when patients feel no pain. Cardiologists are not trained in deep sedation. When deep sedation is needed, they call anesthesiologist and that’s the only time they use Propofol.
When they are giving mild or moderate sedation they use benzodiazepines. For deep sedation they are required to give Propofol with an anesthesiologist.
Steinberg has reviewed this case. He has focused his review based on CM interview with police. Steinberg wanted to judge CM on his own words.
Steinberg found 6 separate extreme deviations from standard of care.
1: Propofol was not medically indicated. Steinberg mentions Propofol is an anesthesia. Steinberg tells there was no written informed consent. The patient must be informed of the risks and benefits of treatment. Steinberg never heard of Propofol used for insomnia. Steinbers says that using propofol for insomnia is gross negligence and extreme deviation.
2: Propofol was given in a home setting, without proper equipment and without proper staff.
Walgren asks what equipment needed. Steinberg says that first a pulse oximeter with an alarm is needed but Murray's oximeter didn't have an alarm. Steinberg says he had to stare to MJ nonstop every second. Steinberg says he should have automated blood pressure cuff, to check blood pressure at least every 5 minutes. Murray had a manual cuff and did not use it. Next thing is needed is an EKG monitor to track the heart rhythm. Another thing that is needed is oxygen with a nasal cannula or mask. You need suction in case the patient regurgitates and you need to get it before it goes into patient’s lungs. Another equipment needed is an Ambu bag. Murray had an Ambu bag but did not use it, he did mouth to mouth. You also need to have a way to call for help. Backboard is needed in case CPR is needed. You also need a back up battery for the equipment in case of a black out. Other equipment needed is equipment needed for airway such as endotracheal tube. Endotracheal tube requires trained staff to place it. Also you need a defibrillator.
A lot of special drugs are also needed. Those are fluamzenil, narcan, lidocaine, betablockers, atropine, dopamine, epinephrine, prednisone, dextrose.
Steinberg says when giving sedation you also need BLS (basic life support) and ACLS (advanced cardiac life support) trained assistant.
3: Inadequate preparation for an emergency. You need to have the drugs ready, equipment ready, have a person ready to help you. You need to be prepared to use those medicine and equipment in the case of emergency.
4: Improper care during the arrest. MJ’s breathing had stopped and CM didn't follow proper protocol.
Steinberg explains cardiac arrest which is when heart stops beating. There’s no blood pressure and the patient collapses. In that case you call 911, use a defibrillator, and do CPR on a hard surface.
In MJ's case, it was a respiratory arrest. MJ stopped breathing and the oxygen goes down. Then heart started to beat harder while trying to distribute little oxygen in the body. According CM’s statement this is where CM found MJ. If you do nothing, the heart weakens because of lack of oxygen, and stops contracting but there is still an electrical activity. That’s PEA (Pulseless Electrical Activity). After PEA, there's asystole.
Steinberg says CM should have called 911 immediately then try to arouse MJ, should have used the Ambu bag and give him Flumanezil. Steinberg says it’s inexcusable that CM did chest compressions. This was a respiratory arrest not a cardiac arrest and there was blood pressure and pulse. CM should NOT have done CPR.
CM’s CPR was poor quality because MJ was on a bed. It has to be done on a hard surface such as on the floor and should have done CPR with 2 hands. Steinberg says it would have been very easy to put MJ on the floor.
5: Failing to call for help. CM should have called 911 immediately. CM should have known that he didn’t have any of the medications and the equipment and he had to call for help. But CM instead called MAW which caused a significant delay. EMS was only 4 minutes away. If CM had called them he could have gotten help sooner.
For every minute delay in calling EMS, there are less and less chances the patient will survive and there is a risk of permanent brain damage. Walgren: “Every minute counts”.
Steinberg also thought it was bizarre to call an assistant instead of calling 911. CM as a medical doctor should have realized he needed help and call 911.
6: Failure to maintain proper medical records. Medical records are important because of several reasons. Insurance companies want them. Second reason is litigation. The most important reason is for better health care for the patient. CM did not document a single thing. He didn’t ask when the last time MJ ate was, he had no vital sign records, he had no physical exam. There was no informed consent. He didn’t write what medication he gave and what was the reaction. CM was confused and was not able to explain MJ's history or what he gave him to the ER doctor or EMTs. Walgren asks if he could be dishonest rather than confused.
Steinberg concluded that these extreme deviations directly contributed to MJ's death. Without these deviations, MJ would still be alive.
Walgren asks based on CM’s statement if he gave benzodiazepines and only 25mg Propofol if the risk of respiratory depression is foreseeable. Steinberg answers yes.
Walgren assumes everything happened as CM described and as CM left MJ alone, MJ was able to take Lorazepam pills or Propofol. Steinberg says all the things he said still apply. Steinberg says you never leave the patient and always monitor patient. If MJ self administered, means that Murray was away, and that should not have happened. Steinberg compares leaving a patient under the effect of Propofol to leaving a baby sleeping alone on the kitchen counter. Steinberg says the baby might have woke up and fall down.
Steinberg also mentions that medication should not have been within MJ's reach. Steimberg explains how in hospitals every medication will be under lock and says that having medications out in the open is a foreseeable risk that the patient can self administer and take the wrong medication.
Mid morning break.
Steinberg is not currently trained in using Propofol. When Steinberg was NY he had privileges to use Propofol. In his current work he does not have the privileges and he hasn’t used it in 7 years. When he was in NY he felt confident in using Propofol because he was trained in protecting airways.
Flanagan asks if there is a difference in the equipment needed for moderate and deep sedation. Steinberg answers no, they will be the same.
Flanagan asks if Steinberg thought CM's declaration to the cops was thorough and complete. Steinberg says he assumed it was complete.
Flanagan asks how Steinberg knows CM didn’t have informed consent. Steinberg says because there was none. Flanagan asks if the informed consent can be oral. Steinberg says it has to be written. “If it's not written it's not done.” Steinberg says he has never heard an oral consent. Flanagan asks if any written document had anything to do with MJ’s death. Steinberg says if MJ had been informed about risk and benefits, he might not have agreed to this.
Steinberg says he cannot know if MJ had been informed, but assumes he was not informed that a powerful dangerous drug would be used on him without proper monitoring. Steinberg assumes MJ would not have agreed to it.
Flanagan asks if Steinberg know anything about MJ's propensity towards drugs and mentions Demerol and Klein. Flanagan asks what if MJ was an addict; would he have agreed to it? Steinberg says if he was an addict, he wouldn't give it to him in the first place.
Other doctors that use Propofol could be dentists, gastroenterologist, pulmonary doctors, ER doctors. But their societies have advice on how to use it and they are trained. Their societies outline the same monitoring equipment that Steinberg mentioned. Steinberg says there’s no difference in equipment needed for conscious sedation.
Flanagan asks what killed MJ? Steinberg says a respiratory arrest because he still had a pulse that means there was a heart rate and blood pressure. CM said there was blood pressure and pulse, it was later PEA.
Steinberg says that according to CM he found MJ around noon and EMS arrived at 12:26. There was a delay in calling 911 for at least 12 minutes. Flanagan mentions CM made a lot of time estimations and it might be all precise.
Flanagan asks what 2mg of Lorazepam would do to a patient. Steinberg says he’s not an expert, he gave it as a sedative orally before but he never used IV. Steinberg says he gives it an hour before the procedure orally. Flanagan asks further questions about Lorazepam, Midazolam. Objections. Sustained. It’s beyond his area of expertise.
Flanagan turns the subject to Propofol and say that MJ and CM had been discussing Propofol for the past 3 night and CM told MJ it was not good for him and he was trying to wean MJ off.
Steinberg states that CM said that he gave 25mg initially and started MJ on IV. Flanagan denies that there was an IV. Steinberg understood that after that initial 25mg dose, there was a drip based on his police interview. Steinberg cites a lot of examples in CM interview referencing IV and says it makes sense because 25mg would not keep MJ asleep.
Flanagan insists there was no drip on the 25th, Steinberg insists there was a drip, they both give examples in CM's LAPD interview. They agree it's not clear, but Steinberg says it makes no sense. It's logical CM gave a drip. MJ logically would have woken up, and there was no reason that CM changed his methods.
Flanagan says that 25mg is not a heavy dose and it would make MJ sleep 4 to 7 minutes. Steinberg agrees. So Flanagan asks if MJ was still asleep he was sleeping for other reasons such as being tired. Steinberg says that he would have worried that MJ was still asleep if MJ was not on a drip. Protocol says that after Propofol you should watch the patient. Steinberg says just looking at MJ doesn't tell if he's in mild sedation or in deep sedation. Steinberg says they need to be continuously checked for their reaction to stimuli. Steinberg says CM should have woken MJ up. Steinberg says the fact that MJ was still asleep after 10 minutes, if there was no drip, is very alarming. Steinberg it might mean that something was going wrong.
Flanagan mentions a study that Propofol was successfully used on refractory chronic primary insomnia in Taiwan. Steinberg says that the article dates back to 2010, in 2009 when CM gave propofol there was no medical knowledge that Propofol could be given for sleep. CM was unethical in giving Propofol with no medical knowledge. Article mentions Propofol given for 2 hrs per night 5 nights, not 8 hours per night for 2 straight months. The article says that this test was successful, but it's still not used as a sleep medication because it's still experimental, there is not enough data about this. It needs to be extensively researched and tested. CM is the first doctor he's heard who used propofol for insomnia.
Flanagan asks how Steinberg knows CM didn't use Ambu bag, Steinberg says because CM said he did mouth to mouth. Flanagan asks how Steinberg knows CM didn’t use the blood pressure cuff, Steinberg says because it was not on MJ. Steinberg says pulse oximeter was not on MJ.
Steinberg says he doesn’t know what happened between 11 and 12 or how long CM watched MJ or when CM went to bathroom. Flanagan asks if he has an idea about the actual time of death. Steinberg says MJ was pronounced dead at 2:26PM but he was probably clinically dead for some time.
Steinberg says MJ savable when CM found him based on his interview. Steinberg says CM said he left MJ for 2 minutes. By using Ambu bag, by arousal and changing the effects of the medicines and if 911 was called MJ was savable.
Flanagan tries Steinberg to assume that CM was gone longer than 2 minutes. Steinberg is not comfortable making those assumptions as he based his report on CM’s statements. Flanagan mentions the phone calls; Steinberg does not want to comment on them. Steinberg says saying CM was on the phone tells him that CM shouldn’t have been on the phone and if MJ would only given 25mg it would wake him up. Steinberg says that it tells MJ was on a drip.
Flanagan wants him to assume if CM was gone longer than 2 minutes if MJ was savable. Steinberg says he was savable because according to CM’s statement MJ had a pulse, blood pressure and heart was still beating and with proper equipment he could have been saved. He could have given MJ oxygen. Steinberg says MJ wasn’t PEA when CM came back because he had a pulse. Flanagan asks how he knows know MJ had a pulse, Steinberg says because CM said so. Flanagan asks if it could PEA. Steinberg says in PEA there’s no pulse.
Flanagan asks what CM should have done. Steinberg says he should have called 911 and it would have taken 2 seconds. Steinberg says protocol says doctors are allowed 2 minutes to determine the situation. Flanagan asks if CM went down to ask for help in 12:05 – 5 minutes after – if it would be a violation of standard of care. Steinberg says he didn’t have the right equipment so he should have called 911 immediately.
Flanagan tries to talk about Kai Chase. Steinberg says CM didn’t ask Kai to call 911. Flanagan asks what if CM called for help in 5 minutes but not in 2 minutes. Steinberg says it’s still a deviation from standard of care.
Flanagan asks if he talked to CM to review the case. Steinberg says no and he didn’t ask. Steinberg used CM’s 2 hour interview.
Flanagan asks what CM should he have done in 2 minutes. Steinberg says call 911, tilt the head to open airway, make him breathe with Ambu bag and give Flumazenil. Steinberg says he would have called 911 first. Steinberg says CM had to increase MJ’s breathing.
Flanagan asks if CM make a mistake in asking someone to call 911 Steinberg says he had no one around and he had to call 911. Steinberg says for the time it takes to call for security CM could have called 911. He had a cell phone. Steinberg says it would have taken him 2 seconds to say “I’m a doctor, there’s an arrest, come to 100 Carolwood now” and then CM could have put 911 on loudspeaker and continue to do what he was doing.
Flanagan asks if he’s aware that EMS said MJ was cool to the touch. Yes but CM said he was warm. Steinberg says you get cold in 26 minutes when you have no blood pressure.
Flanagan asks if Steinberg have no doubt that if 911 had been called immediately MJ would still be alive. Steinberg says he have no doubt about that, they could have saved him. CM said that he lost the pulse after calling MAW at 1212. So if the paramedics had been there at 1205 or 1210, they could have saved him.
Flanagan says that CM was in emergency situation and he could be mistaken in his estimations. Steinberg says there is clear evidence that there was a delay in calling 911 as CM went downstairs and called MAW rather than calling 911.
Flanagan asks based upon these facts if Steinberg thinks CM is responsible of MJ's death. Steinberg says yes.
Flanagan asks if CM should have dropped MJ on the floor, in spite of the IV line. Steinberg says he should stop the Propofol drip first and then he should be careful with the line when he’s putting MJ down the floor.
Flanagan asks rather than suction would it be okay to turn patient his side and clean the mouth with a finger will be okay. Steinberg says suction is needed.
Flanagan asks if a doctor has only 1 patient, he would still need to document everything he does. Steinberg says he does because obviously CM didn't recall what he had given when he talked to UCLA or with the paramedics.
Flanagan says that not having records did not kill MJ. Steinberg says it wouldn’t cause his death but it’s still deviation.
Lunch break .
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Re: Murray Trial _ All daily trial Summaries - No discussion October 11th / Day 10 Full Testimony
Murray Trial Day 11 , October 12 2011
Steinberg states that Murray did not act like he was ACLS certified.
Steinberg states that he used propfol in New York, but it was in hospital settings.
Steinberg states that gastroenterologists, dentists and ER doctors who use propofol receive appropriate training, with a trained staff and appropriate monitoring equipment are necessary.
Steinberg states that an article about the propofol study in Taiwan : published in 2010, was an experimental study. The patients were given propofol in a hospital , with the appropriate equipment, the experiment was approved by their ethics committee. Steinberg states that written, informed consents were obtained from the patients. Steinberg states that 8 hours of fasting occurred prior to being given propofol, and that the propofol was given by an anesthesiologist. Steinberg states that the patients were constantly monitored and pulse oximeters were attached to the patients. Steinberg states that the propofol was administered by an infusion pump, a drip was not used. Steinberg states that no other benzos were used. Steinberg states that the authors of the article specifically state that the study was experiment, and that is does not dictate a standard of care. Steinberg states that what Murray was doing was essentially an experiment.
Steinberg states that if he had to assume that Murray gave only 25mg, that there was no drip, would he draw the same conclusions? Steinberg states yes, that standard of care was deviated from in an unmonitored setting, without appropriate equipment, response was inappropriate, medical records were inappropriate and that it was be a foreseeable prediction that there would be respiratory depression (stop breathing).
Steinberg states that Murray played a direct, causal role in MJ's death.
Steinberg states that the sleep study showed that propofol helped insomnia.
Steinberg states that in his analysis for the CA medical Board, that Murray deviated from the standard of care for MJ.
Steinberg states that the lack of a backup battery did not lead to the cause of MJ's death, however, 5 out of 6 deviations did lead to MJ's death.
Steinberg states that he did read Murray's interview with LAPD that he gave MJ propofol for 40-50 days without incident. Flanagan asks if Steinberg has made certain assumption, Steinberg states no. Steinberg states that he didn't assume that Murray gave propofol, that Murray didn't have the proper equipment, the delay in calling 911, improper care during the arrest, that all of these things are facts.
Steinberg states that even if the defense theory that MJ self-injected propofol and therefore accidentally killed himself, according to Conrad Murray's own words, Murray would still be the causal factor in MJ's death.
Dr. Nader Kamangar/ Sleep Medicine Expert Testimony
NK states he is a pulmonary care/sleep medicine/critical care physician at UCLA. NK states he is board certified in four areas: internal medicine, pulmonary medicine, critical care, and sleep medicine.
NK states he is a medical reviewer for the CA Medical Board , and that he assessed Murray's care to MJ for the medical board. NK states that is propofol used in critical care unit on a daily basis. NK states he is trained in using propofol. NK states propofol is used for placement of endotracheal tubes, and for people on breathing machines. NK states that propofol is the most commonly used drug for this.
NK states that he found multiple deviations of standard of care with regard to Conrad Murray's care of MJ :
1. Propofol was given in an unacceptable setting : using this deep sedation agent in a home setting is inconceivable and an egregious violation of standard of care.
2. ACLS certified : the person who gives propofol must be trained in ACLS and airways management. There was a risk of hypoventilation (diminishment in rate of breathing), apnea and obstruction of the airway.
3. Need of assistance : Murray needed a second person (a nurse) to monitor, to pay complete and utter attention to MJ, especially if Murray was going to leave the room; this goes without saying. This violations Hippocratic oath, to abandon his patient.
4. Pre-procedure setup : imperative to be prepared for unforeseen circumstances. Things can change very quickly. A patient may look good, and the next minute there's a problem. Murray needed a suction catheter, because patients can regurgitate into their airway, and block the airway, this can cause death. A crash cart (medication on hand : adrenaline, ephedrine, medication to correct the heart beat, etc...) , pulse oximeter, defibrillator, automated infusion pump (precise dosing for propofol) even with people who are intubated;
NK states that all of these factors are extreme deviation of standard of care and are the equivalent of gross negligence.
NK states that he has never seen someone giving propofol at home in such settings, and would not have expected to see that.
5. Charts / medical documentation : or medical history, reactions to a medication. For example a blood pressure can look normal, but not be normal for a particular patient, and that change in blood pressure could be the indication of a problem.
6 . MJ was left alone, which is not acceptable, especially since Murray didn't have the right equipment.
7. Use of benzodiazapines: using lorazepam and midazolam on top of propofol can have higher effects : more significant respiratory depression, decrease cardiac output (often a consequence of respiratory depression), decreased blood pressure and cardiac arrest can occur directly, or because of low levels of oxygen.
8. Dehydration : blood circulation is not good when you are dehydrated , causes low blood pressure. Benzos and propofol would also lower blood pressure . Murray should not have used benzos or propofol if the patient is dehydrated.
9. Failure to call 911 : 911 should have been called immediately.
10. Improper CPR : Murray stated there was a pulse, therefore the heart was beating, so the problem was respiratory not cardiac. Murray should have dealt with airway management by placing an ambu-bag over MJ's mouth. Murray's administration of CPR was ineffective; it was not on a hard surface, and it was done with one hand . Correct CPR correctly allows about 20% of the normal blood circulation, so if you do it incorrectly
NK states that assuming Murray found MJ at noon, and calls MAW at 12:12 pm, the significance of the 12 minutes is that the what is the lack of blood flow to vital organs, especially to the brain. NK states that some individuals are more susceptible than others to a lack of oxygen. NK states that generally it takes 3 to 4 minutes before brain cells start to die. NK states that time is really important. NK states that because 911 was called at 12:20 pm, with the passage of 20 minutes, it reaches a point where it becomes irreversible.
NK states that Murray Deceived paramedics and ER staff because did not provide the accurate information, which is a deviation of standard of care.
NK states that Murray did not properly evaluate insomnia. NK states that insomnia can have many causes, so it's important to have a detailed history. NK states that Murray needed to exclude secondary problems (psychological problems, substance abuse, underlying conditions, chronic anxiety, depression , etc...)
NK states that insomnia is defined by no restful sleep for 4 weeks or more. NK states that once all the secondary problems are ruled out, primary insomnia is considered.
NK states that in order to diagnose/treat insomnia. a detailed sleep history is needed. : when do they go to bed, when do they fall asleep, when do you wake up, etc.. check sleep apnea. In some cases you need a sleep study.
NK states that a detailed pharmaceutical history was needed; both prescribed or over the counter (example migraine pills contain caffeine, that can cause insomnia), illicit drugs.
NK states that a detailed physical examination was needed; some underlying conditions can cause insomnia, for example asthma, congestive heart failure, diabetes, bladder problems, enlargement of prostate, thyroid conditions, etc..
NK stated blood testing was needed to rule out certain conditions : examples diabetes, kidney problem, restless legs , etc..
NK states that a good blood workup would reveal the use of narcotics, if the doctor asks the patient for one. NK states that if the patient is not giving the information, a doctor can simply refuse to treat the patient.
NK states that when all the above mentioned are done, then the doctor can treat the underlying condition that causes the insomnia.
NK states that in this case , Murray didn't have a detailed history. In addition, Murray didn't check what the root problem for MJ's insomnia was before treating him.
NK states that Murray did say that he saw that other doctors were treating MJ, he said he saw IV sites. NK states that if Murray could not get that info from MJ, Murray should have refused care, refused to give further medication. Murray didn't do that, and that was unethical.
NK states that Murray bypassed the evaluation of insomnia, bypassed the detailed history which was a deviation of care.
NK states it was obvious there was probably secondary causes in MJ's insomnia (substance abuse or anxiety or depression ) and that these underlying causes should have been treated.
NK explains about sleep hygiene techniques that can help in case of insomnia (using a bedroom to sleep only, among other things)
NK explains about sleep restriction, that the doctor should tell the patient to go to bed later , and limit their time in bed.
NK states that relaxation techniques can be used to treat insomnia.
NK states that all these can usually work better to treat insomnia than pharmacological approach, but that the pharmacological approach can also be used.
NK states that Murray did not use any of the above approaches on MJ, that Murray went direct to the pharmacological approach.
NK states that the pharmaceutical approach : 3 medications that are not benzos should be used first, because they are not addictive . NK states that a newer drug is melatonin something less addictive.
NK cites 4 different benzodiazepines that deal with insomnia. NK states that others are used also, but their main goal is to treat underlying conditions (anxiety). They are used in tablet form.
Midazolam : not appropriate for long term use for primary insomnia
Valium : not appropriate for long term use for primary insomnia
Lorazepam : can be used on short term basis, tablet form. Really addictive after 3 to 4 weeks. Used to treat underlying conditions, not primary innsomnia.
NK states that the use of midazolam and lorazepam to treat insomnia was an extreme deviation of care, especially in IV form.
NK states that it is inconceivable to use propofol for the management of insomnia, regardless of the setting. NK states that it is "beyond comprehension, inconceivable and disturbing." NK states that it is beyond a departure of standard of care, especially when underlying causes for insomnia were not treated.
NK states that even if MJ took lorazepam and propofol himself, Murray was the causal factor in MJ's death, especially if MJ had substance abuse problems. NK states that the lorazepam and the propofol should not have been readily available to MJ.
NK states that there is a risk of respiratory complications, especially if MJ was dehydrated, and that any competent doctor would have been aware of the risk.
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Re: Murray Trial _ All daily trial Summaries - No discussion October 12th / Day 11 Full Testimony
Murray Trial Day 12 October 13, 2011
Dr Kamangar (NK) Testimony continued
CM treated MJ with Propofol with no problems for 2 months.3 days before MJ’s death CM tried to change the treatment. NK says he read it in CM’s statement police.
Flanagan asks if he experience any patient that was resistant to his recommendations. NK says he would send them to another specialist if it’s not in his area of expertise such as psychological issues. NK says he would realize his limitations.
NK says patients have right to refuse therapy as long as they make an informed decision.
Flanagan asks what if a patient is totally resistant and wants to do it in a certain way, what he would do. NK says he would refuse the treatment and try to understand the problem and why the patient does want it and may refer the patient to another specialist.
Flanagan asks if CM had these conversations with MJ. NK doesn’t know as there were no medical records.
NK says if a patient asks for inappropriate therapy you need to get to the root of it. You should try to understand why they are refusing an appropriate therapy and try to get the appropriate care for that patient. He would make sure that they get the right care and says that he would not give the patient a care that he thinks is inappropriate.
Flanagan says CM gave propofol for 2 months and MJ had no problems. NK says he can’t answer because he doesn’t know MJ’s state of mind and his situation.
NK says in the evaluation of the degree of deviation from standard of care, the end result doesn't matter. He didn’t consider MJ’s death. Flanagan says a doctor can practice bad medicine but the result might not be bad. NK says it doesn’t make it okay. Even if a treatment doesn’t cause death, it might still be gross negligence.
Flanagan asks if NK can tell what happened on june 25th. NK says MJ was receiving very inappropriate therapy in home setting, with inappropriate cocktail drugs, with inappropriate equipment, in a dehydrated patient, delay in calling 911. NK says it was a disaster that resulted in MJ's death.
Flanagan asks what was an inappropriate cocktail: valium + mizadolam +lorazepam+ 25 mg propofol. Flanagan asks if this cocktail can cause MJ’s death.
NK says “absolutely”, especially combination of Propofol and lorazepam, in a dehydrated patient, whose vitals were unknown ( blood pressure, heart rate etc ). NK calls this the “perfect storm” that killed MJ.
Flanagan says NK doesn’t know if Murray had that info or not. NK says CM didn’t record anything, had no records; there was no way to determine the trends and changes. Flanagan says not having documents doesn’t mean CM didn’t know those vitals. NK says not having documentation means that CM didn’t have the information. NK says you can’t take care of a patient only from a memory. NK says it’s a recipe for disaster.
NK gives an example of being with a single patient for long hours. NK says they keep notes. NK says needs to refer to the charts frequently to get a better picture. It's imperative to have charts. NK says without them you can’t see the trends and see differences.
Flanagan asks if NK thinks there's no way CM remembered what he was doing. NK says keeping records is standard care especially when you give such a powerful drug as propofol.
Flanagan says not keeping the charts, for example not writing down 2 mg Lorazepam, did not kill MJ. NK says he’s talking about vital signs, it’s not only about writing the medicines. NK says it's a combination of many factors that killed MJ and says the failure of chart is a contributing factor. NK says it’s bad medicine to not keep charts.
NK says MJ death was directly caused by Propofol + Lorazepam. NK says Lorazepam increased the side effects of Propofol. NK says it can be a lethal combination in a patient that is not monitored.
Flanagan asks questions about levels of the medicines, NK says he wants to defer it to a pharmacologist.
Flanagan asks if NK reviewed the records of Arnold Klein and saw that he gave MJ 6500 mg Demerol (pain killer) with Midazolam (sedative) over 3 months. Flanagan asks if MJ had a Demerol problem. NK says he cannot answer that question.
Flanagan asks if 200mg Demerol is a large dose. NK says it’s a significant dose and says he avoids using Demerol because it makes someone more hyper, excitable and creates more stimulation. Flanagan asks if Demerol can cause insomnia. NK says it’s correct.
Flanagan asks if MJ had insomnia problems. NK says he clearly had insomnia. Flanagan asks if NK made a determination of what type of insomnia. NK says doctors made no effort to determine that. NK says there were suggestions about the reasons for MJ’s insomnia such as performance anxiety and issues with certain medication (Demerol).
Flanagan asks if MJ had refractory insomnia. NK says he cannot say that.
Flanagan asks if he read CM’s records from 2006 -2009 on MJ. NK says CM gave MJ sleep medications as well as knew he was prescribed sleep medicines by other doctors. Flanagan says multiple doctors prescribed sleep medicines.
Flanagan asks if NK ever had a patient that was not forthright in their medical history. NK says he tries to get information from patient and from other doctors and hospitals. Flanagan says patients have to sign a release; they can’t get the medical records. NK says it’s true. NK says if they can’t get information from the patient, they would ask people that live with the patient for information and use sleep diary logs. NK says without getting these information we wouldn’t give Ambien to a patient. NK says if a doctor gives Ambien without a work up it would not be a serious deviation. NK says the doctor still needs to determine the cause and gather information.
Flanagan mentions physical examination and asks if an enlarged prostate can cause insomnia. NK says urination problems can keep a patient up. Flanagan asks if they would check the arms for needle marks. NK would be a part of a physical exam. Flanagan asks if he can determine if a person is taking intra muscular Demerol. NK says you can able to see it in some individuals and not by some.
NK says CM could have understand if MJ got Demerol from MJ’s behavior, slurred speech and from people who witnessed the change of behavior such as the bodyguards. NK says CM could have talked to his security, assistant and CM could have confronted the patient.
Flanagan asks if there are studies about Propofol as a treatment for insomnia. NK says they are just experimental and it’s in no way in a standard of care. They go over the Taiwan study. It dates back to November 2010. Patients had been extensively evaluated, informed consent was obtained, and they fasted for 8 hours. The study was done in a highly monitored setting, receiving propofol via an IV pump. 64 patients received propofol. Patient fell asleep better and have less sleep interruptions. Patients had no complications because they were highly monitored. It's very preliminary experiment with good results. It has no clinical applicability and the doctor that conducted the study stated that there was need for further study.
Flanagan asks why it is incomprehensible to use propofol for insomnia. NK says it was a study, in a highly monitored setting. NK says it is incomprehensible and inacceptable to give Propofol, especially with no monitoring and home setting.
Flanagan asks if 25 mg propofol is a very low dose. NK says yes. Flanagan states you wouldn't expect problems with such a small dose. NK says it depends on the patient. Such as if the patient is dehydrated (low blood pressure), had other medication (such as lorazepam) etc, there can be a problem that can lead to respiratory depression.
Flanagan asks questions about Lorazepam. NK says it’s not FDA approved for primary insomnia, especially the IV form. Lorazepam in oral form can be used if cause of insomnia is anxiety, for a very short period of time of 3 to 4 weeks. NK says oral form is appropriate for a short period of time as it created dependency and IV is inappropriate because monitoring is necessary. Even with monitoring, it’s not FDA approved for insomnia.
Flanagan asks if Lorazepam was appropriate with anxiety due to This is it. NK says there should have been a psychological or psychiatric help and says he would not have used it in this case and try to cure the underlying issue.
mid morning break
NK states that Ativan/Lorazepam in short periods of time, can be used for secondary insomnia associated with anxiety, even though it is not FDA approved. NK stresses that either drug should be only used for secondary insomnia, not primary insomnia.
NK states that Murray indicated he had a bag of saline infused, but because there was no charting of medical records, there is no way to know how much saline was being infused into MJ.
NK states that MJ was producing urine, based on Murray's interview with LAPD.
NK states that 25 mg of propofol would sedate someone for 6-10 minutes with no other meds, with no residual effects. NK states he would expect the person to have an increasing consciousness, and that the person would wake up by the 6-10 minutes. NK states he would not expect a patient to sleep after that time period, even if they were extremely tired. NK states that it would be the doctor's obligation to determine whether the patient was sleeping (if possible) and wake them up, and determine if they are responsive to stimuli.
NK states that even if a doctor has the lack of judgment to use propofol like Murray did on MJ, it is incumbent on the doctor to continually monitor the patient.
NK states that by visually monitoring, there is no way to determine if the patient is naturally asleep or still sedated. NK states that propofol can be used for conscious sedation in a highly monitored setting.
NK states that in his initial report, he stated that MJ had massive doses of propofol. NK states that he believes that MJ was given an unregulated drip IV of propofol, after the initial injection push of propofol.
NK states that he believes that the sequence most likely is that MJ had a respiratory arrest, causing cardiac arrest.
NK states that Murray should have called 911 first, especially given the lack of tools Murray had available. NK states that he should have determined whether he was breathing, determined his pulse, manipulate the airway, and tilt the jaw back to determine if there was blockage.
NK states that he is aware that there were no working landline phones at Carolwood. NK states that he is aware that the 911 call took 2:43, and that paramedics got there in less than 6 minutes.
NK states that even if MJ self medicated with excessive Lorazepam and bolus pushed propofol, Murray is still responsible for MJ's death.
NK states that he would call 911 immediately, it's a moral/professional obligation, but it's basic common sense as well.
NK states that Walgren provided him with Dr. Klein's medical records. NK states that Murray stated in his interview with police multiple times that he was aware that MJ was seeing Dr. Klein.
NK states that the study done in China on propofol was done in a hospital, highly monitored, using a very precise drip, was used as an experiment and would need another study done to positively state that propofol could be used for insomnia.
NK states that one of the fundamental tenets of the doctor/patient relationship is putting the patient first. NK states that this means knowing when to say no to a patient, and that if, assuming MJ asked for the propofol, the doctor has the professional, ethical and moral obligation to say no.
NK states that he makes the final decision as to the appropriate care of the patient, not the patient.
NK states that Murray's interview indicates his inability to give precise information about oxygen saturation, although Murray indicated the oxygen saturation was in the high 90's and then stated 02 saturation was 90.
NK states that a doctor could be grossly negligent and survive, however in MJ's case, Murray was grossly negligent in multiple cases and this is what caused MJ's death.
NK states that Murray said he immediately performed CPR, but that NK should have called 911. NK states that he is aware Murray said he went partially down the stairs, but that nobody could do the same job as the paramedics, so that should have been done first.
NK states that although Murray states he asked the chef to call security and she did not do so, NK is not sure whether he is aware of that fact.
NK states again that Murray should have immediately called 911.
NK states that if there was someone in a hallway, and he was in a room with a person who was medically down, he might shout to the hallway, but ultimately it is his responsibility as a doctor to call 911.
Dr. Steven Shafer Anesthesiology Expert Testimony
SS states that he is a professor of anesthesiology at Columbia University, adjunct professor and Stanford and UCSF. SS states that he has worked at Columbia since 2007, at Stanford since 1987, tenured at 2000. SS states that he teaches a class in pharmacokinetics at UCSF.
Pharmacokinetics deals with math models that deals with drug concentrations in the body to determine what the drug actually does to the body, which helps determine dosages of meds and what is effective and what is not.
SS states that pharmacokinetics is a discipline that is growing, and that it determines labels for every med, core of pharmaceutical companies, core of FDA, and services doctors on how to use the med safely and reduce toxicity.
SS states that the three schools he hold professorships at are ranked among the top medical schools in the US.
SS states that he is editor-in-chief for the journal Anesthesiology and Analgesia, which publishes manuscripts (studies) of issues related to anesthesiology. Among the 70 board members that sit under Shafer, SS states is defense witness Dr. Paul White. SS states that the journals' acceptance rate for manuscripts is roughly 21%, so about 4 out of 5 submitted are rejected. SS states that due to the editor in chief position for the journal, he is exposed to unusual cases that he never thought he might read about.
SS states that in 1987 the FDA had problems determining proper dosage levels of Midazolam, therefore the FDA was very particular about dosing instructions for infusing propofol. SS states that he did the infusion rate analyses and the start rate of propofol for the label AstraZeneca.
SS states that in particular, he analyzed the reduction of dosing in elderly patients, and that almost all label dosing was done by SS in 1991.
SS states that drugs that are marketed, one drug is marketed as a chemical name, in this case propofol. SS states that the retail name is Diprivan, and that it differs slightly from propofol because there is a fat solution (emulsion) added to the propofol.
SS states that max sedated means monitored anesthesia care, the care a patient expects, with a controlled dose, and monitoring. SS states that titration means increasing or decreasing the dose according to each patient.
SS states that pharma means drugs, kinetics means motions, so pharmacokinetics means drugs in motions. SS explains that when meds are given, drugs go thru several processes or motions, first when meds goes into the patient it becomes more diluted. Second the bloodstream takes the drug everywhere in the body, delivers to the brain, and will move the drug to the liver and metabolized there. SS states that the liver chews the drug up, that the pieces can go to the blood, or to the bile, then to the intestine. SS states that they can go to the kidneys and the kidneys then remove the blood from the body.
SS states that he is an expert in pharmacokinetics, specific to propofol. SS states that he developed the module of the software that eventually determined propofol dosing on labels for all propofol bottles.
court ends early due to a scheduling issue. There's no court on Friday October 14 as well. Testimony will resume on Monday October 17.
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Re: Murray Trial _ All daily trial Summaries - No discussion October 13th / Day 12 Full Testimony
Monday October 17, 2011 session has been postponed due to death in Dr. Shafer's family. It's currently unclear when the testimony will resume. Court officials say that resumption of the trial will be announced when further information is available
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Re: Murray Trial _ All daily trial Summaries - No discussion October 13th / Day 12 Full Testimony
Murray Trial will not be in session on Tuesday October 18 because of a new test done on Michael Jackson stomach content. DA Walgren told Judge Pastor that coroner's office re-tested for lorazepam levels and found that they were lower than the defense analysis suggested. DA Walgren said the real amount of the drug Lorazepam found in Michael Jackson's stomach is "inconsistent with oral consumption".
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Re: Murray Trial _ All daily trial Summaries - No discussion October 13th / Day 12 Full Testimony
Murray Trial Day 13 , October 19, 2011
Dr. Shafer Testimony continued
Walgren Direct continued
Walgren goes over again the credentials of Dr. Shafer by showing the journal he's editor in chief and multiple research articles written by Dr. Shafer. Research articles examine the differences in regards to gender, age. Dr. Shafer also had research done on Lorazepam, Midazolam and Lidocaine. DA Walgren says that he will ask about these topics during testimony.
Walgren mentions difference between intensive care sedation and procedure related sedation (MAC). Dr. Shafer tells that intensive care sedation would be for longer time, MAC would be shorter.
Dr. shafer says that all the work he has done on this case was for free. He says he never charged money for testimony because he feels it's inappropriate and unethical to benefit from medical misadventures. Shafer says he doesn't want his integrity to be questionned as well Shafer also says he wanted to get involved in this case to restore general public's confidence in anesthesia and doctors. Dr. Shafer says that he's asked daily by his patients " Are you going to give me that drug that killed Michael Jackson?". He says that he hopes to alleviate this unneeded fear with his testimony.
mid morning break
Dr. Shafer has brought several medical items for demonstration. First he starts with explaining Saline bag and it's ports. Later Shafer tells what and IV is. Infusion(Drip) when drug drips in slowly. Shafer explains that Propofol comes in a glass vial, there's an aliminium seal and a rubber stopper on top. To get the drug out you need to go through with a slow needle or a large spike to get the drug out.
Walgren asks Shafer to demonstrate to get Propofol out of the bottle.
Shafer demonstrates to get out Propofol with a syringe / needle. Shafer tells to get Propofol out you need to replace Propofol with air so that Propofol will go into the needle.
Walgren asks Dr. Shafer to examine 100 ml Propofol bottle from the scene. Shaffer says that it has a spike hole and not a needle hole.
Dr Shafer has made a video for his case, to demonstrate what is necessary for sedation, even for 25mg propofol. Playing the video : «*an over view of safe administration of sedation*»
The doctor first prepares the room, checks the equipment. Video shows multiple equipment for airway management such a tube for the throat, a tube for the nose, an equipment for intibation, a throat mask for air. Organizes these items.
Then the doctor checks the oxygen equipment. Doctor checks if the oxygen supply work, checks nasal cannula, checks to see if nasal cannula is measuring carbon dioxide by capnometer. Doctor tests anesthesia breathing circuit. This is the equipment used if the patient stops breathing and the doctor needs to push oxygen into the lungs. Doctor then checks the back up oxygen. This is used if for some reason the breathing circuit fails.
Doctor then checks suction apparatus. This is important because if the contents of the stomach gets into the lungs or if the vomit (bile) gets into the lung, it would destroy the lungs. This is why patients are told to not to eat or drink prior to anesthesia. if the patient vomits or the contents of the stomach come to the mouth, the doctor has to be very quick to clean them with the suction equipment before it goes into the lungs and destroys the lungs.
Next step is to set up the infusion pump. It takes a few minutes to set it up. In the video they use a syringe pump. Doctor first draws Propofol into the syringe. As Dr. Shafer demonstrated this is not easy. You need to draw air into the syringe and do multiple draws to fill the syringe. Dr. Shafer tells a narrow tubing has to be used in the infusion pump as the wide tubing could be problematic. Then the doctor programs the pump, putting the patients weight, correct drug name, infusion rate. Doctor verifies the information for a second time.
Next step is to assess the patient. Anesthesiologist is repsonsible for knowing his patient. Makes a physical examination, first thing is airway, listens to the lungs, checks the heart. Always done for each procedure, for every patient. No exception.
Doctor also gets the informed consent of the patient. Doctor informs the patient of risks and explains what the procedure entails, asks the patient if he has any questions, then patient signs the informed consent form. Dr. Shafer says oral consent is not binding, and is not recognized.
Some steps are not shown on the video. These are: patient put on table, monitoring equipment such as blood pressure cuff, pulse oximeter, ECG are put on patient. Oxygen in place, intravenous catheter is put into the patient. Afther these doctor pauses to verify again. Doctor does one last check before injecting the propofol.
Propofol infusion pump is started. Anesthesiologist is close to the patient, monitors the patient. Doctor keeps records of the vitals. Chart is a necessity to track the patient and the patterns. It's a responsibility to the patient.
In this part of the video, we are shown examples of what can go wrong.
First example is when blood pressure drops. Dr. Shafer says this is very common and they see it everyday. Propofol lowers blood pressure especially if the patient is dehydrates. Doctor gives ephedrine through the IV line. Generally blood pressure comes to normal levels.
Second example is carbon dioxide. The monitor shows that carbon dioxide stopped. It means the patient is not exhaling and the airway is obstructed. Doctor immediately does chin lift and jaw thrust. Dr. Shafer this is also done very routinely. Shafer says the most common reason is because the tongue is blocking the airway and by doing a chin lift and jaw thrust you can move the tongue.
Third example is apnea. This is when the patient doesn't even try to breath. In this instance you need to take over for the patient and force air into the lungs. Doctor removes the nasal cannula, places the mask on the patient's mouth and nose and squeeze the bag to push oxygen into the lungs.
Fourth example is aspiration (not shown on video). This is when the patient vomits and/or stomach contents come to the mouth. Patient is turned sideways and before the next breath you need to suction everything.
Fifth example is cardiac arrest. Heart stops beathing and the patient stops breathing. Doctor does a 2-3 second assesment to make sure that the monitor has not failed. Then the doctor calls for help. First thing is always to call for help. One person begins CPR, one person is ventilating the patient and other person gives resuscitation drugs. Alls of this is done to keep the patient alive for enough time to fix the problem that caused the arrest. These efforts are continued until the patient is revived, or is pronouced dead.
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Re: Murray Trial _ All daily trial Summaries - No discussion October 13th / Day 12 Full Testimony
Murray Trial Day 13 , October 19, 2011
Dr. Shafer Testimony continued
Walgren Direct continued
Dr. Shafer says that the safeguards and requirements apply to all doctors who perform sedation, for any type of IV sedatives. Some nurses are also trained about sedation. These guidelines apply to them as well.
Walgren asks if CM's intent were to give 25mg would these standards still apply. Shafer says yes and continues to say the patient (MJ) had other IV sedatives, profound inability to sleep, he was exhausted, dehydrated; and he had been given sedatives for some time and he could have saome elements of dependency or withdrawal.
Walgren asks if it possible to go in saying I'll only give a small amount so I don't need these guidelines. Dr. Shafer says it's a trap. Even for a little sedation , it's a slippery slope, you may have to give more. You never know how the patient will react. Shafer says there's no such thing as a little sedation and the worst disasters happen when people cut corners.
Facts in this case suggest that virtually none of the safeguards for sedation were in place when propofol was administered to MJ.
Walgren asks Shafer explain how patients reacts different to the same dose of sedatives. Shafer says that some patients will need half the usual dose and some patients will need double the dose. Shafer says 25 mg is the limit when a patient migh stop breathing. Shafer says you can't assume that this will be an average patient. Shafer says you always assume your patient is at the edge of sensitivity and prepare for the worst case scenario.
Shafer did a report about this case dated April 15th, 2011. In his report he used some terms.
Minor violation : not consistent with standard of care, but would not expect to cause harm for the patient unless there are several other violations
Serious violation : expected to cause harm to the patient, in combination of other violations
Egregious violation : These should never happen in the hand of comptent doctors. An egeregious violation can alone be catastrophic for the patient. Competent doctors know that bad outcome is a high possibility
Unconscionable vioation : It goes beyond the standard of care. It's an ethical and moral violation as well as a medical violation.
Walgren goes over Dr. Shafer's report and 17 egregious violations he identified.
Lack of basic airway equipment, egregious violation. MJ died because he stopped breathing which is expected when you give IV sedatives. It must be there without question.
Walgren asks Dr. Shafer assume that CM had left only for 2 minutes and CM had the equipment if MJ could have been saved? Dr. Shafer says yes and probably MJ had an obstructed airway and even a simple chin lift might have been required to save MJ. Shafer says that CM says he didn't use the ambu bag. Shafer says mouth to mouth is less effective and gives used air.
Lack of advanced airway equipment. Those are eqipment such as laryngeal mask, or laryngoscope and endotracheal tube. Shafer had described it a a serious deviation originally but changed his mind to en egregious because of the setting. CM had no help.
Shafer says that it's his view that CM had anticipated to give 100 ml vials. CM had purchased at least 130 100 ml vials, Shafer believes that's at least one per night. Shafer says it's an extraordinary amount for one patient; between april – to 25th june, that 80 nights, 1937 mg/night. Walgren asks how he came to this determination. Shafer says Propofol is an environment for bacteria dveelopment. Once a bottle is opened with a needle, it has to be used within 6 hours. Shafer says this suggests CM planned to use 100ml, if he didn't he would purchase smaller vials.
Lack of suction apparatus, egregious violation. Shafer reminds the jury that any stomach content and/or vomit has to be suctioned so that it won't go into the lungs. Shafer says there's no evidence that MJ was asked to fast for 8 hours prior being given Propofol. Due to this MJ was at greatly higher risk. Therefore a suction equipment was needed.
Lack of infusion pump, egregious violation . There was no infusion pump. Without it the rate can not be precisely controled and the risk of overdose is very high. Shafer says in his opinion this is likely contributed to MJ's death.
Walgren asks without an infusion pump how can one person control the drip. Shafer answers by roller clamp. It's a plastic wheel that pinches the tubing to decrease the amount . Shafer says it's extremely imprecise and that was the only thing available to CM when he gave propofol.
Lack of pulse oximetry, egregious violation . The pulse oxieter that CM used was completely inappropriate. It's not intended to be used for continuous care as it had no alarm. Shafer says that on monitors in hospital they can see it on the screen and there is a tone. Doctors will hear the tone changes which alerts them that there's a problem. In MJ's case only way to monitor was to take his hand and continoiusly look to it. If there was a proper equipment, there would be a monitor showing the vital signs from distance and there would be an alarm that could have saved MJ's life.
Lack of blood pressure cuff,egregious violation. Propofol lowers everyone's blood pressure. Doctors would treat it with additional saline solution or with less propofol. MJ was dehydrated, the risk are higher for exagerated response. If blood pressure falls the body shuts down the flow to the arms and legs and concentrates on providing blood to heart and the brain. The drug becomes more potent. Dr. Shafer says the manual blood pressure cuff that CM had in his bag in the cabinet is useless.
Lack of ECG, egregious violation . ECG allows you te see he heart rate, the heart rythm. This is routine monitoring. In this case CM couldn't know what kind of therapy to use when MJ went into arrest.
Lack of capnography, an egregious violation. Dr. Shafer initially thought that it was not a violation as other specialist doesn't use it. However in MJ's environment it was a disaster. If CM had it he would have known immediately that MJ had stopped breathing.
Lack of emergency drugs, serious violation. Dr. Shafer doesn't think lack of emergency drugs contributed to MJ's death. Shafer says if MJ had a low blood pressure as he wasn't going through surgery, MJ could have been woken up and hydration and stopping propofol would have been enough.
Lack of charts, egregious violation as well as unethical. Shafer says a doctor needs charts to asses what's going on and the changes. Shafer says the patient or if the patient doesn't survive the family has a right to know what happened and what the doctor did.
Dr. Shafer gives an example and Dr. Shafer looks clearly upset. Dr. Shafer says he knows how he would feel if his father , brother or son went to a medical facility for 80 days and died and the doctors told him they don't know what happened because they have no reports. Dr.Shafer says it's unbelieveable that after 80 days of treatment there's not a single record of treatment. Dr.Shafer says that not keeping records is also illegal in California. Dr. Shafer says that doctors has to keep records even if the patient doesn't want them and confidentiality cannot be an excuse.
Shafer says that in CM's interview he mentioned MJ could have been dependent on Propofol and that would require a referral but he can't do that referral as he had no records.
Obligation to get information about the patient. Shafer says it's doctors responsability to know everything about their patient to provide care. Shafer says CM mentions IV sites but didn't follow it through and asked what's happening. Walgren asks what if the patient says it's none of your business, Shafer says that then he would say "Then I can not be your doctor".
Dr. Shafer the only physical evidence of Michael was done months ago. Shafer says CM mentioning MJ being dehydrated but yet he do a simple blood pressure check. Shafer says there's no history, not even a simple recording of the vital signs. Shafer calls this serious violation and that no doctor does that.
Failure to maintain a doctor patient relationship , egregious violation. In this relationship doctor would put the patient first. It doesn't meean to do what the patient asks, it's to do what's best for patient. If patient asks for something foolish or dangerous, doctor should have said no. Dr. Shafer describes the relation between Cm and MJ as employer employee relationship. Patient stated what he wanted, CM says yes. Shafer compares CM to a housekeeper that does what she's told. That's what an employee does. Shafer says CM was not exercising his medical judgement and he was not acting in MJ's best interest. CM completely abandonned medical judgement.Shafer says the very first time MJ asked for propofol, CM should have sent MJ to a sleep specialist.
Lack of Inormed consent , egregious and unconscinable. An informed consent would have involved that propofol is not a treatment for insomnia, It woud have explained risk of death and alternative treatments. Dr. Shafer says there's no proof that MJ knew that he was putting his life at risk. Shafer again mentions that the consent has to be written. MJ was denied his right o make an informed decision.
Need to continuously observe the mental satus, egregious and unconscinable. Dr. Shafer says that doctors need to stay with the patient and CM abadonned his patient. Shafer compares giving sedation to driving a motor home. Shafer says you cannot leave the steering wheel on a highway to relieve yourself. If you do it would be an disaster. Dr. Shafer says in 25 years he has been a physician he have never walked out of the room.
Continious monitoring / observation, egregious violation . CM left MJ alone and he was on the phone. Shafer says youcan't multi task especially if you have no monitoring equipment. Dr. Shafer a patient who is about to die, doesn't look that different from a patient that is okay. Dr. Shafer says from a distance you can't tell if a person is breathing. Shafer says he believes Murray may have been in the room and have not realised MJ stopped breathing.
Shafer says resuciation would have been easy as all needed is to stop propofol and make MJ beathe. Shafer once ahain reminds that it's common that patients would stop breathing during anesthesia and it's expected. Shafer says all CM was monitoring all he needed to do was to lift the chin and ventilate.
mid afternoon break
Lack of continuous documentions, egregius and unconscionable violation. Dr. Shafer says documentation is part of giving care. Shafer says if CM had the reports he would have seen that the oxygen saturation lowered or the heart rythm changed.
Failure to call 911 timely, egregious violation. Shafer says in that setting MJ could not have been revived without assistance. Shafer says calling 911 was the highest priority given the lack of help and equipment. Shafer says if calling 911 was not possible, Propofol should not been given at all.
Shafer says assuming CM realised there was a problem at 12:00 he doesn't understand that CM left a voice message to MAW and how it took 20 mn to call 911. Shafer calls it unconceivable and completely and utterly inexcusable.
Shafer says if CM left only for 2 minutes and called paramedics immediately MJ would be alive with some brain damage. If CM realized MJ was in trouble in 2 minutes and had the airway equipment MJ would be alive and uninjured.
Walgren asks how effective is a one handed CPR on a bed. Shafer says the patient sinks into the bed and it's ineffective. Even if CM had his hand behind Mj's back it's ineffective because you need your body weight to do effective CPR. Shafer says you need 2 hands, one hand is not enough. Shafer says CM hould have called 911 first and then moved Mj to the floor. Shafer also says based on CM's interview the issue here was not that the heart stopped; MJe stopped breathing. CM said there was pulse. If there was a pulse what he needed to do was to have oxygen into his lungs. There was no need for CPR if there was a pulse. Shafer says a lay person would use mouth to mouth as they have no other means. For a doctor it shows that the doctor doesn't have equipment needed.
Shafer says that he doesn't understand why CM raised MJ's legs. Shafer calls it a waste of time. Shafer says raising the legs is done when you thing there's not enough blood in the heart but that wasn't MJ's problem. His breathing had stopped. Shafer says that it shows CM was clueless about what to do.
Walgren asks what is flumazenil. Shafer explains it's a frug that reverses the effects of lorazepam and midazolam. Dr. Shafer says he's curious why CM gave it. Shafer says it doesn't fit with only giving 2 doses of 2 mg several hours before. Dr. Shafer says he believes that CM knew that there was a lot more lorazepam.
Dr. Shafer talks about deception of paramedics and UCLA doctors and not mentionning propofol, egregious and unconscionable violation. Dr. Shafer says a person's life was in the balance, it's inexcusable. Shafer says he also mischaracterized this event as a witnessed arrest. Shafer says a witnessed arrest is not an arrest for lack of breathing, it is usually something like a heart attack. So the therapy of the paramedics and ER doctors was not appropriate. In an arrest you have only seconds to choose a treatment, paramedics and ER doctors were not given the corect information. Shafer says witholding information is a violation of patient's trust.
Walgren asks what is polypharmacy. Shafer explains it's administering many drugs at once and it's a serious violation. Shafer says what CM gave to MJ didn't make any sense. Shafer says Midazolam and lorazepam are very similar drugs and the only difference is how long they stay in the system. Shafer says he doesn't understand why CM switched from midazolam to lorazepam and back. Shafer says that he thinks that CM did not understand the drugs he was giving.
Walgren asks if 25mg Propofol is a safe dose. Shafer says in this setting there was no safe dose. Midazolam an lorazepam were given. MJ had received benzos for 80 nights, he could have been dependant or in withdrawal from the benzos or propofol. Dr. Shafer says he never heard a person given propofol for 80 nights and doesn't know what would happen.
Walgren asks about the Taiwan study. Shafer says there are over 13000 medical articles about propofol, 2500 articles about propofol and sedation and there's only one article on Propofol and insomnia. It's this study done in 2010. Dr. Shafer says that he wouldn't published the Taiwan study because the dose of Propofol that was given is not mentioned. Dr. Shafer also says that the conditions of the study doesn't apply here. That study was done in a hospital, by anesthesiolgists, patients had fasted for 8 hours, they were monitored, an infusion pump was used, propofol was used for 2 hours for 5 days during two weeks. There was no other medication. The patients were treated within the standard of care. Shafer says the article actually highlights CMs deviations from standard of care.
Walgren asks even if MJ had taken Lorazepam and/or Propofol would these 17 deviations would still be relevant and if Shafer would consider CM responsible for MJ's death. Dr. Shafer answers yes.
Walgren asks about doctor patient relationship. Dr. Shafer says it's dated back centuries ago. Dr. Shafer says that doctors have power to give drugs and cut open a patient etc and this is because they are entrusted to do that because they are supposed put the patient first. Dr. Shafer reads hippocratic oath. Shafer says when Cm agreed to give propofol to MJ, he put CM first. When CM was showing up every night with propofol and saline bags, he was putting CM first. When Cm withheld info from paramedics and ER doctors, he put CM first.
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