MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers

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Before I post Dr. Steve Shafer's answers to our questions, I think I must tell you what happened behind the scenes so that you can understand the generosity of Dr. Shafer better and realize what a wonderful human being he is.

When we approach people for Q&A's , we generally have a discussion about a reasonable number of questions that they are willing to answer. In the end the questions we send range between 15 to 25.

When I asked Dr. Shafer if he would do a Q&A with us and he replied as "Yes", we were all ecstatic. It was such a wonderful opportunity to ask questions about Michael's death that still bothered us. Surprisingly rather than giving me a maximum question number, Dr. Shafer asked me to send him the questions as they come. Soon enough I realized that he was planning on answering them all. To be honest I couldn't even believe that it was happening. It was beyond our expectations.

I omitted some questions that was either i)similar to questions asked before ii) too general iii)clearly out of Dr. Shafer's area of expertise and iv)too confusing. I sent him 86 questions and he answered them all.

In his conversations with Gaz, Dr. Alon Steinberg would describe Dr. Shafer as "bright and unselfish". Indeed, Dr. Shafer might be the most generous person I have ever seen. I thought that you all should know that not only Dr.Shafer agreed to our Q&A but answered all the questions we sent his way. Dr. Steve Shafer deserves all the credit.

Furthermore Dr. Shafer also told me that he would be happy to answer any follow up questions if needed. Well if that happens let's agree to send him a more reasonable number of questions this time.

Now as we have 86 questions, I will be posting Dr. Shafer's answers in 3 parts - so that we can discuss them better.

Part 1 will be posted today (December 19). It will have 28 questions covering Michael Jackson, Dr. Steve Shafer and Murray Trial in general.

Part 2 will be posted on December 21. It will have 33 questions covering Dr. White, Conrad Murray and Michael's death.

Part 3 will be posted on December 22. It will have 25 questions covering Propofol, Demerol, Lorazepam, Flumanezil, Insomnia etc..

So once again I want to thank Dr. Steve Shafer for his generosity for answering our high number of questions. And let's start discussing.

 

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MJJC Exclusive Q&A with Dr. Steve Shafer Part 1

This is Part 1 of 3 of Dr. Steve Shafer's answers to MJJCommunity questions. In this first installment Dr. Shafer will be answering questions about Michael Jackson, himself (Dr. Shafer) and Conrad Murray trial in general.

Questions about Michael Jackson in general

MJJC: Have you ever listened to Michael Jackson’s music and if yes, what song is your favorite?

Dr. Steve Shafer: I grew up listening to Michael Jackson’s music, just like the rest of the world. Thriller was the only album that I knew well, and “Beat it” is my favorite track from it. The message and the music both appealed to me.


MJJC: What was your opinion about Michael Jackson before this trial?

Dr. Steve Shafer: I knew very little about his personal life, other than the occasional sensational headlines. I intentionally read nothing about his life before the trial, because I did not want to introduce bias into my testimony. I’ve read a lot since the trial.


MJJC:Did your opinion about Michael Jackson change during and after this trial? Positively or negatively, and what is your current opinion about Michael Jackson?

Dr. Steve Shafer: Yes. During the trial I saw him as a patient, just like many patients I’ve cared for. During the trial I had no mental image of Michael Jackson as an icon or famous entertainer. He was a patient who died receiving medical care. It was important to keep focused on him as a patient.

Having said that, I was conscious that his interactions with Conrad Murray were, in part, a tragic side effect of his wealth. I spent 20 years on the faculty at Stanford University, and more recently at Columbia University. Patients who are very wealthy often choose a big-name medical center. Most wealthy patients are very kind and decent people. However, I occasionally encounter a wealthy patient who believes that because he or she is rich, he or she can simply tell me how to give anesthesia. That is what they are used to: giving orders and having people say “yes.” I believe that Michael Jackson fell into this trap: believing that he could tell doctors what to do and expect them say “yes.” This doesn’t excuse his doctors for saying “yes.” However, wealth and fame can be a curse.

My opinion of Michael Jackson is that he was an immensely gifted musician, entertainer, and genuinely compassionate individual. However, he was thrust into (well deserved) stardom as a youngster, and spent his entire life under the glare of public scrutiny. That does not seem like a blessing to me. To me it seems like a tragedy. He never lived a normal life.


MJJC: During the trial, the defense and various media outlets repeatedly called Michael Jackson a "drug addict". Based on your knowledge and research in this case, would you say that Michael Jackson was a "drug addict" or not?

Dr. Steve Shafer: “Addiction” is a lay term, not a medical term. The correct medical term is substance dependency. You will find an accurate explanation of this in Wikipedia. You can also find a good description at www.csam-asam.org/pdf/misc/DSM_criteria_for_diagnosis.doc.

I think Michael Jackson likely had a dependency on sedatives at the time of his death, because he was receiving intravenous sedatives every night. That type of regular exposure is almost certain to cause dependency.



MJJC: Can Dr. Shafer render an opinion on the chronic condition of Michael’s lungs (respiratory bronchiolitis, multifocal chronic interstitial pneumonitis, chronic inflammation)? Some TV doctor (Dr. Drew) alleged that it could be due to continuous/long term Propofol use. However MJ is known to have Pleurisy at 1977 and reported to say “he had a blister on his lungs” in later years. Could it be caused by the Propofol or could it be related to his Lupus?

Dr. Steve Shafer: Propofol is commonly used for infusions in intensive care units. I am not aware of any primary effect of propofol on the lungs. However, because Michael Jackson’s trachea (windpipe) was not protected while he was receiving propofol, he could have regularly inhaled small amounts of saliva or regurgitated stomach contents while anesthetized from propofol. That can damage the lungs and produce chronic inflammation.
 

Questions about Dr. Shafer in general

MJJC: Since your father passed away during the trial, was it hard to do the testimony? (and please accept our most sincere condolences for your loss)

Dr. Steve Shafer: I’ve shared with some members of the MJJCommunity my personal story about my father’s passing. I’ll spare you the details, other than to say that for me, the trial brought me an unexpected gift: the chance to be with my father when he died. Had it not been for the trial, I would have been in New Jersey. As it was, I was at his bedside, offering love and morphine. (I can only hope that one of my kids decides to take up a career in anesthesia.)

During my testimony, I felt that my father was beside me. It gave me confidence, particularly during cross examination. I knew that since my Dad was with me, I’d be OK.


MJJC: During testimony we learned that you drank Propofol. Did you drink it before you conducted the scientific research? What prompted you to drink it yourself?

Dr. Steve Shafer: I knew that the defense would reject animal studies as not applying to humans, just as Paul White did when asked about animal studies of propofol in urine. There is no way that I could conduct a human study in the US in three months, so I thought the best evidence I could get was to simply drink propofol and report if it had any effects. I knew the pharmacology well enough to be absolutely certain it was inert.

About a week later my colleague Pablo Sepulveda in Chile told me he would be able to conduct a clinical trial in volunteers. That made my drinking propofol completely irrelevant.

However, please remember that propofol is unique in the complete “first pass” metabolism. One should not try this with other drugs. Indeed, many drugs on the anesthesia cart would be fatal if consumed like that. This should not be attempted as a party trick!


MJJC: Any comments on Mr. Chernoff referring to you as a "cop"?

Dr. Steve Shafer: No, that’s his job. It didn’t bother me at all.


MJJC: During your cross examination Defense asked "Are you aware that everything you said here was your merely your opinion?" In your answer you concluded that this was an interesting question- where does 'personal opinion' end and where does "Dr. Shafer" begin? So did you, Dr. Shafer, come to any conclusion in this conundrum? Do you consider it wise or even desirable to split your mind in the Dr. figure- and Steven Shafer? Is it even possible to do so? What would the result most likely be? Could there be considerable "strength" in a personal, honest opinion?

Dr. Steve Shafer: I thought about that question quite a bit afterwards. I was not expecting it, probably because I am not an experienced expert witness. This was only the second time I have testified in court.

Mr. Chernoff was playing to my scientific training. Scientists are reluctant to state that something is a certain fact. There is evidence, and conclusions, but science is always open to new evidence and new conclusions. His asking me “wasn’t your testimony entirely your opinion” was an invitation to say “yes”, based on my interpreting “your opinion” as referring to my scientific opinion. If I had answered “yes,” it would have opened the door for him to say in his closing statement “Dr. Shafer himself admitted that his views were just his opinions.” That would play to the common use of “opinion” as mere speculation unsupported by data.

There were two aspects to my testimony: standard of care, and propofol pharmacology. I need to discuss fact vs. opinion for these separately.

Many aspects of the “standard of care” have been codified by organizations. For example, the American Society of Anesthesiologists has practice guidelines that very clearly spell out the standard of care during administration of anesthesia. My testimony was based largely on those guidelines. One could argue that it was merely my “opinion” to represent the published guidelines of the American Society of Anesthesiologists as fact. However, it is a fact that they have published guidelines on the standard of care, and those published guidelines were the basis of my “opinion.”

There are aspects of the standard of care are not covered by published guidelines because they are self-evident. I believe doctors should not lie. I believe Conrad Murray’s misrepresentation of the drugs that he gave to Michael Jackson was an unconscionable violation of the standard of care. Is it my opinion? Yes. However, I think every person on the planet shares my opinion that a doctor should not lie. Similarly, it is my opinion that doctors must place the interest of their patients ahead of their personal interests. That is my “opinion.” However, again I think it is an opinion that is universally shared. Can that be dismissed as “mere opinion?”

Regarding the scientific part of the testimony, my “opinion” is that of an expert in the field. The simulations I presented were mathematically accurate representations of the pharmacokinetics. Baring a mathematical error on my part, the simulations show exactly the blood and effect site propofol concentrations predicted by specific pharmacokinetic models for specific doses. The “expert” aspect is to decide what doses should be simulated, and whether these are likely scenarios. I did a lot of simulations, and even shared with the defense my spreadsheets so that they could do simulations as well. I chose some over others based on data. That is an “expert opinion.” However, it is more scientifically precise to say “conclusion, based on the data” that to call it “opinion”, since the latter implies uninformed speculation.


MJJC: Did it amuse you like it did many when Dr. White was called "Dr. Shafer" several times in court by Prosecution, Defense and even the Judge?

Dr. Steve Shafer: Yes. I think everyone was amused.


MJJC: Have you met any of the Jackson Family before, in between or after the trial? If so did they ever asked you any medical questions?

Dr. Steve Shafer: I spoke with them briefly several times walking to or from the courtroom. They were very kind, and offered condolences on the death of my father. I shared that we both had suffered loss, and offered condolences in return. I appreciated their kindness.


MJJC: Did your life change after this trial? If yes, positively or negatively?

Dr. Steve Shafer: I learned a huge amount from the trial, including:
• A lot about the pharmacology of propofol and lorazepam (I did a LOT of reading to educate myself on the issues, and to respond to claims made by the defense).
• Something about how the criminal justice system works. I was impressed by what I saw. In particular, the office of the District Attorney was absolutely honest and transparent. This was not a “game.” It was an attempt to determine the truth.
• Different approaches to discerning truth. In science, “truth” is determined by experiment, observation, peer review, and the ever-questioning nature of science. In science, the burden of proof is on the person making the claim. In criminal law, “truth” is determined by a jury that arrives knowing almost nothing, the exact opposite of peer reviewers. In criminal law, the burden of proof is on the prosecution. The defense can assert anything without evidence. I learned that both systems work.

I have received wonderful feedback from my professional colleagues. It won’t change me, but it has been rewarding.

I have had very kind letters from the Michael Jackson community. I did not expect these, but they have been appreciated.


MJJC: What do you think about Michael Jackson fans love and appreciation towards you? Do you know that many fans publicly express their love and gratitude to you, and use your pictures and quotes to express themselves? What do you think about that?

Dr. Steve Shafer: It didn’t expect it! However, I do understand that not knowing what happened to Michael Jackson has been a cause of considerable pain to his millions of fans. If my testimony was helpful, and perhaps brought a closure to his passing so they can again focus on his music and message, then I’m honored to have had the opportunity.

I have tried to answer many of the e-mails I have received. I am appreciative of the kind comments I have received from his fans all over the world.


MJJC: Now that the trial is over what’s next for Dr. Steve Shafer? Returning to practice? Teaching? Patient education and advocacy?

Dr. Steve Shafer: All of the above.

I did not watch the first two days of Paul White’s testimony, because I was back in the operating rooms at Columbia University giving anesthesia. I love clinical anesthesia. I love taking care of patients. We all need to define who we are. For me, it’s simple: I’m a doctor. I care for patients. If I ever stop caring for patients, I won’t know who I am. That’s what I do.

Having said that, my work as Editor-in-Chief of Anesthesia & Analgesia requires about 60 hours per week. Even during the trial I would go home and read a dozen new submissions every night, assign editors and reviewers, and process another dozen decision letters. I will be doing that every day until my term as Editor-in-Chief ends in 2016.

I continue to teach. You will get a laugh at the most recent lecture I have given at Columbia: the role of clinical pharmacology (e.g., pharmacokinetics) in the trial of Conrad Murray.

Anesthesia & Analgesia is the largest medical journal in the field of anesthesiology. I use Anesthesia & Analgesia as a platform to advocate for patient education, patient care, and patient safety (http://www.anesthesia-analgesia.org). Only rarely does that involve my own writing. The Journal advances patient care through editorial policies anchored in doing what is best for patients.

I continue to pursue my own research, primarily modeling the behavior of drugs used in anesthesia. Much of this is now in collaboration with my wife, Pamela Flood, who is the chief of Obstetrical Anesthesia at the University of California in San Francisco.

I am actively involved in developing new drugs to improve the safety of anesthesia and pain management. In 2003 I co-founded a biotech company to develop better drugs for anesthesia and pain management. You can find it at http://www.pharmacofore.com. Our work is progressing well, and this also consumes some of my attention.


MJJC: How the medical community has responded/reacted towards you since your testimony?

Dr. Steve Shafer: The response has been uniformly positive. There has been considerable appreciation that I spoke for the values that physicians hold, as well as for clearly explaining the medical and scientific issues involved. I didn’t testify to garner any attention or recognition, and it makes me a little uncomfortable. However, the validation of my testimony from my medical colleagues has been affirming that I did the right thing.


MJJC: Did media approach you for interviews? If yes, why didn’t we see you on TV?

Dr. Steve Shafer: Yes, I was approached, but I don’t think the interviews were aired. I think the reason is that they didn’t like my answers. I was asked about what I thought Conrad Murray’s sentence should be. I answered honestly that I didn’t have the background to judge that. I said that our lawmakers determine the appropriate sentences for criminal behavior, and judges then impose sentences based on the dictates of the law. I said that this was really a question for Judge Pastor, who IS an expert. I don’t think they liked that answer. They probably hoped for something much more vengeful from me.

I was asked how I felt about my role in convicting Conrad Murray. I honestly replied that I don’t think I had much of a role. Conrad Murray gave Michael Jackson propofol in a bedroom, with no training, no monitoring, no backup, no accountability, abandoned him to talk on the phone, and then lied about his action. His guilt was obvious when the facts emerged in 2009, and it just as obvious after my testimony.


MJJC: One of the most shocking parts of Dr. White’s testimony was when he admitted that he had not fully reviewed the current scientific literature on Propofol. Under cross-examination he also admitted that had not completely read the journal articles that were used to create the Propofol simulations that he presented as the basis of his court testimony. As a scientist I found this to be extremely irresponsible professional behavior. Can you please discuss how you prepared for your testimony in this trial?

Dr. Steve Shafer: I spent dozens, and perhaps hundreds, of hours in preparation. I read well over 100 papers. I analyzed the data numerous ways, and even made my spreadsheets available to the defense. I did the “heavy lifting” that is expected of an expert. This isn’t unique to this case – it’s how I approach everything I do.


MJJC: Judge Pastor picked out Murray's recording of MJ as the piece of evidence that affected him the most during the trial. Was there any one thing that affected Dr Shafer in all the evidence that he looked at?

Dr. Steve Shafer: Yes, the consistency Conrad Murray’s behavior. In the sentencing hearing Judge Pastor outlined in detail Conrad Murray’s pattern of repeated lying, self-serving actions, and reckless disregard for the wellbeing of his patient. That was what I saw also.


MJJC: How did you decide to choose your profession? What did it start with?

Dr. Steve Shafer: Many physicians choose a medical career very early in life. I knew from the time I was 9 years old that I wanted to be a physician. The inspiration was my pediatrician. He seemed to know absolutely everything, and I was amazed at the breath of his knowledge. Additionally, every year he spent several months on the “Ship Hope” practicing medicine in third world countries. I profoundly admired his sense of service to others. That was my role model


MJJC: Did any of your parents relate to medical sphere?

Dr. Steve Shafer: I am the first physician in my family. My father was a management consultant, and my mother was a housewife. Both of them took pride in having a son who went to medical school. I became the family resource for all medical questions.


MJJC: Did your father know about your intention to take a stand in Conrad Murray's trial? If yes, what were his thoughts about it, if any?

Dr. Steve Shafer: Yes. He liked it a lot. He told me it made him proud. He was also aware that I was visiting him every day because I was in Los Angeles for the trial.

He watched my testimony on Thursday morning, and died that evening.

 
Questions about trial in general

MJJC: What do you think about DA Walgren?

Dr. Steve Shafer: He is brilliant, dedicated, and absolutely honest. He worked incredibly hard. I think he got about 4 hours of sleep every night of the trial.

Part of my job was educating Mr. Walgren in the science. By the time of the trial, he was occasionally correcting my calculations! He was so effective when dealing with expert opinion in part because he truly understood the scientific principles.

As a taxpayer, it is amazing that attorneys like Mr. Walgren work for the State of California at a public servant’s salary. We are really getting our money’s worth!


MJJC: Did you see Judge Pastor give his sentencing statement? Any comments on that?

Dr. Steve Shafer: Yes, I watched it live. I smiled when Judge Pastor used specific words and ideas that I introduced in my testimony. Also, having read all of the documents numerous times, it was clear to me that Conrad Murray repeatedly lied. However, that was irrelevant to my testimony, and so I appropriately kept that opinion to myself. I appreciated hearing the judge, who is better able to judge Murray’s veracity than I am, lay out the pattern of self-serving lies by Conrad Murray.


MJJC: Do you think Murray just made a 'fatal mistake' or do you think it’s something more?

Dr. Steve Shafer: The fatal mistake was saying “Yes” to Michael Jackson’s request for a physician to administer propofol. That was followed by innumerable other fatal mistakes, but it all traces back to the initial lack of judgment.

MJJC: Do you believe Murray got the appropriate charge of Manslaughter or do you believe what he did was much more serious that it should have been something like Murder 2?

Dr. Steve Shafer: I’m not qualified to judge this, and am very glad I was not asked for an opinion on this during my testimony. I am glad he was found guilty. That was important: doctors are accountable for their actions. We are not above the law.

I only gave one television interview after the trial, because I had to teach a course (www.nonmemcourse.com) immediately after the trial. I was asked what I thought about the fact that the worse possible sentence was 4 years in jail. I answered that I wasn’t qualified to render an opinion. I think they wanted a much more bloodthirsty response, because they never ran the interview.


MJJC: What kind of punishment would be appropriate in your personal opinion?

Dr. Steve Shafer: Emphasizing that this is just my uninformed personal opinion, I believe that he must lose his license, never practice medicine again, and be accountable to the Jackson family. Please let me emphasize again that criminal punishment isn’t something I know about.


MJJC: In his closing argument Ed Chernoff stated once more that "lack of record keeping did not kill Michael Jackson". Would you find this a particularly irresponsible assumption- especially in light of your lengthy and detailed explanation of Pharmacokinetics and Pharmacodynamics? Would Ed Chernoff's closing argument be especially irresponsible and outrageous- considering that the assumed physician did not keep any records?

Dr. Steve Shafer: Mr. Chernoff’s statement is false. The lack of record keeping did contribute to Michael Jackson’s death. Without records Conrad Murray could not look for trends, such as seeing if larger doses were needed each day. Without records Conrad Murray could not look at past doses to determine what was a safe dose, and what was a dangerous dose.

Record keeping re-enforces vigilance. When you write down the vital signs every 5 minutes, it forces you to keep an eye on the patient. Record keeping would have forced Conrad Murray to stay close to Michael Jackson and continuously write down vital signs (at a minimum he had the pulse oximeter on the finger and could physically count the rate of breathing and heart rate). Record keeping would have forced Conrad Murray to monitor the intravenous infusion rate. Record keeping might have kept Michael Jackson alive. Thus, Mr. Chernoff’s statement is false.


MJJC: Lots of hyperbole has been made of the IV tubing/matching/non matching. Could you explain in detail once more (with no defense attorney interrupting) why this has no bearing on the statements made by you?

Dr. Steve Shafer: I initially believed that the IV tubing that Conrad Murray purchased in large quantities from Sea Coast Medical was non-vented, because I did not see the vent in the picture taken by the medical examiner, no vent is described in the product description from Sea Coast Medical, and I was unsuccessful in my initial effort to purchase the tubing from Sea Coast Medical. It turns out that it was vented, which I only realized after I physically examined the tubing in court.

However, the fact that the smaller infusion set was vented only increases the ease with which Conrad Murray set up the infusion, and the ease of concealing the tubing set on the day Michael Jackson died.

However, it still comes back to the big picture: Conrad Murray was giving Michael Jackson an anesthetic drug in his bedroom with inadequate training, inadequate monitoring, and no backup. That is why Michael Jackson died. None of these issues changes the big picture.


Note: Part 2 of 3 will be posted December 21st.

 

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MJJC Exclusive Q&A with Dr. Steve Shafer Part 2

This is Part 2 of 3 of Dr. Steve Shafer's answers to MJJCommunity questions. In this second installment Dr. Shafer will be answering questions about Dr. Paul White, Conrad Murray and Michael Jackson's death.

Questions about Dr. White

MJJC: While watching the trial it felt like there’s an animosity or fall out between you and Dr. White. Are we correct about this? If yes did this fall out stem from the events of the trial or is there a history to this?

Dr. Steve Shafer: Paul has been a friend for nearly three decades. The Paul White you saw on television was not the Paul White that I have known since medical school. He has made many contributions to our specialty. It is my hope that his contributions are his permanent legacy, not his defense of Conrad Murray.

Paul has been a cherished mentor since I was medical student. I was not his “student” as Chernoff stated, and I did not appreciate the implication that Paul taught me what I knew about propofol. However, Paul has given me counsel on everything from medical school to romance. I was expecting Chernoff to ask “Hasn’t Dr. White been a mentor to you?” I was ready to say “yes”.


MJJC: What did you think of Dr. White’s testimony and his behavior? Did anything he said change your opinion about your colleague? Were you surprised by the things he said and things he did (such as his comments to the media) or didn’t do (such as not doing his own charts, not overseeing the Beagle experiment)?

Dr. Steve Shafer: There were factual errors in Paul’s testimony. Paul is capable of outstanding scholarship. I don’t know the dynamics of his relationship to the defense team that led to him not doing the heavy lifting that he usually does when it comes to checking the literature. I wish he had contacted me in advance. I would have been happy to help him review the literature and explain the science.

The different approaches of science and law to discerning the truth failed Paul. If this had been an argument over a scientific manuscript, Paul and I would have spoken directly, without attorneys trying to discredit either one of us. We would have lined up papers, and arguments, and “duked it out” by e-mail, or perhaps over an extended lunch at one of our favorite Mexican restaurants. That would have worked and the science would be right (at least as “right” as we could get it). There would be no adverse consequences for either of us. As scientists collaborating to “get it right” we would have done well. The criminal justice system isn’t set up to allow scientists representing opposing sides to collaborate in an effort to find the truth.


MJJC: Are you still friends with Dr. White?

Dr. Steve Shafer: There may be some bruised feelings, but we will get past it. We have a lot of shared history.


MJJC: You worked with Dr. White and you are/were friend with him. So how it's possible to have 2 completely different opinions about what happened the night of 25 June 2009 from two close people?

Dr. Steve Shafer: Paul White admitted in court that he only considered self-injection scenarios. This severely limited the scenarios he considered.


MJJC: What do you think of your colleague Dr. White going out of his way to justify Conrad Murray's actions, from a medical point of view?

Dr. Steve Shafer: I don’t understand it at all.


 
Questions about Dr. Murray

MJJC: Did you purposely NOT refer to Conrad Murray as a doctor during your testimony? Have you heard the news reports about how furious it made him?

Dr. Steve Shafer: I was not aware of that. It would be very unlike me to refer to him as “Mr. Murray,” as my habit is to be respectful. I probably referred to him simply as “Conrad Murray”. If I never said “Dr. Conrad Murray”, then this is indeed a Freudian slip. I don’t see him as a doctor.


MJJC: Viewers at home could see Murray losing his temper when you started the IV demonstration, was that temper flare up noticeable to you from where you were positioned in the courtroom?

Dr. Steve Shafer: I read about it, but I didn’t personally observe it. I was focused on the jury.


MJJC: If so, were you fearful of what Murray may do (i.e. did you think there was a possibility that he would physically attack you)?

Dr. Steve Shafer: Not at all.


MJJC: What are your thoughts on Murray as a doctor?

Dr. Steve Shafer: I believe he violated the fundamental trust between doctors and patients, and that he did so not in an isolated incident under duress, but intentionally and repeatedly. That is not something a doctor would do.


MJJC: Did you hear about and/or watch the Conrad Murray documentary.

Dr. Steve Shafer: No, I just heard about it.


MJJC: If so what are your thoughts about it. Do you feel that his participation in this documentary further proves Murray's lack of professional ethics and an unsuitable candidate for the medical profession?

Dr. Steve Shafer: I can’t imagine why he would participate in a documentary that would be shown prior to sentencing. Evidently they filmed the attorneys swearing at each other, with Paul White and Conrad Murray on a couch in Flanagan’s home. It seems reckless for everyone involved.


 
Questions about the role of propofol in Michael Jackson’s death

MJJC: Based on everything you know, what do you think happened on June 25, 2009?

Dr. Steve Shafer: Michael Jackson died from respiratory arrest (his breathing stopped) while receiving propofol, exactly as the coroner reported. There was a contribution of the lorazepam, also as reported by the coroner. The coroner got it right.


MJJC: How convinced are you that MJ was on a drip that night?

Dr. Steve Shafer: I’m completely convinced. Murray admitted to using a drip every night. He said he was trying to wean Michael Jackson. I don’t believe him. The urine propofol levels suggest massive doses, more than 2000 mg, as I explained in my rebuttal testimony. The blood levels show anesthetic concentrations of propofol. It all fits with an infusion (drip).


MJJC: If we disregard Murray's police interview, in your professional opinion, how long was MJ gone before Murray finally found him? Some experts are under the impression that the delay in calling 911 can only be explained by him knowing MJ was already dead.

Dr. Steve Shafer: I think he was already dead, but that is really speculative. I don’t believe anything Conrad Murray says, and there are no records. My guess that he was dead is based on the limited window between stopping breathing and death (10-20 minutes). Murray would have to observe him in that window to have a chance to revive him.


MJJC: There are some rumors that Michael actually ate a meal the night he died in Murray's so-called "care". Do you think Michael was fasting for the required time? Or was this yet one more deviation from the standard of care by Murray? What are your thoughts on this?

Dr. Steve Shafer: I’m not aware of any data suggesting Michael Jackson ever fasted. It doesn’t come up anywhere in the record. My guess is that he ate, because he would likely be hungry after a vigorous rehearsal.


MJJC: What do you think about June 19th (Kenny Ortega's email describing Michael- chills, seeming lost), and June 21st (hot and cold symptoms described by Cherylin Lee). What could those symptoms come from?

Dr. Steve Shafer: It is hard to know. The defense proposed that those might be withdrawal from Demerol, and that is correct. It might also be withdrawal from lorazepam. Propofol withdrawal hasn’t been described, because nobody other than Michael Jackson has ever received propofol night after night for insomnia. However, at least in theory it could be propofol withdrawal.

However, it could also be the usual sort of illness: the “stomach flu” or a bad cold. There is no way of knowing.


MJJC: Do you have an opinion about June 23rd and 24th, when Michael seemed to be feeling great? What could this improvement come from?

Dr. Steve Shafer: I don’t know. After the trial I watched “This is It.” There was obvious excitement and exuberance as rehearsals were nearing the end, and the tour was approaching. It could simply be excitement and exuberance in expectation of the tour.


MJJC: Does it surprise you MJ didn't die sooner than June 25th after finding out Murray was given MJ Propofol without proper equipment for 2 months (according to Murray) prior to MJs death?

Dr. Steve Shafer: Yes. I think that is quite surprising. We don’t know if there were prior close calls, because there are no records.



MJJC: May 2009 audio recording of Michael in which he was slurring his words attracted a lot of attention. In an interview Dr. Murray said Michael was under the influence of Propofol during that recording. However some people say Propofol does not cause slurred speech. What do you think about that recording? Any idea what drugs can cause that speech?

Dr. Steve Shafer: Sedatives cause slurred speech. This could have been caused by midazolam, lorazepam, or propofol.


MJJC: Do you think there was a chance for Michael to be in good health and to continue normal usual life after such long respiratory arrest even if paramedics could reanimate him?

Dr. Steve Shafer: Definitely, if they arrived in time.


MJJC: This is a hard question but we have to ask. When there is overdose of Propofol and it causes death, like it happened to Michael, does the person suffer? Do they feel pain? Or is it like dying in your sleep that you feel nothing?

Dr. Steve Shafer: It is an easy question to answer: there is no suffering with a propofol overdose. The person falls asleep quickly and comfortably. The brain is deeply depressed, and the brain never returns to consciousness.


MJJC: If Michael had been your patient and asked you for Propofol to help him sleep, how would you have responded? What would you suggest to him? Would you have recommended he see a sleep specialist?

Dr. Steve Shafer: Absolutely the right question to ask! I would have referred him to a sleep specialist. He had a very serious sleep disorder that was threatening his tour, his ability to perform, his ability to create music, and potentially his life. It needed urgent care from someone who knows what he or she is doing.



MJJC: Do you know what the long-term effects of using Propofol would be? Murray has indicated that MJ was using Propofol for 6 weeks, apparently for sleeping 8 hours or so a night. Have you ever read about case studies of patients doing this or, as it was put forward in the trial, was MJ an experiment?

Dr. Steve Shafer: This was an experiment. I don’t think any other patient in the world has ever received this. There may be long term effects – that is a question that can’t be answered without clinical research. I don’t know what effects to expect, but it seems likely that tolerance and dependence would develop.


MJJC: How about even longer terms such as months or even years taking of deep sedation of Propofol, could it affect human health and any organs? Is it possible to take Propofol for a long time and don’t have any associated negative side effect?

Dr. Steve Shafer: We don’t know – the studies have not been done.


MJJC: There might not be enough information to have a clear picture of what was going on, but we would like to know your opinion about what Murray was prescribing to Michael (from late 2006), the amounts of midazolam, lorazepam and flumazenil Murray was buying, and the possible consequences of such a treatment.

Dr. Steve Shafer: I am not sure what amounts you are referring to. I am aware of the drugs that Murray purchased in 2009, but I did not review his previous treatment of Michael Jackson, because it didn’t relate directly to the questions I was trying to answer at the trial.


MJJC: According to his police interview, it seems that Murray knew he shouldn't mix Lorazepam and Propofol, so we are confused about their use together. Why would Dr. Murray or anyone mix those together?

Dr. Steve Shafer: There is nothing wrong with giving lorazepam and propofol at more or less the same time. Anesthesiologists routinely give midazolam at the start of an anesthetic, and propofol a few minutes later. Midazolam and lorazepam are closely related. You just have to know that the effects are “synergistic”, meaning that you need to reduce the dose of propofol when you give a lot of midazolam or lorazepam.


MJJC: Do you have any idea about how much lorazepam had he been given and when?

Dr. Steve Shafer: Yes, he gave a lot. The lorazepam levels in the blood were high enough to contribute to the cause of death, as stated in the coroner’s report, and as emphasized by the defense. As accurately stated by the defense, the lorazepam concentration in his blood was enough to put most of us to sleep. There were 8.4 milligrams of lorazepam in his autopsy urine, and another 5.8 milligrams of lorazepam in the urine that was recovered at the scene, which presumably was from the same night. So Michael Jackson received a lot of lorazepam. However, because there are no records, and I don’t trust what Conrad Murray says, it is hard to be more precise.


MJJC: Dr Kamangar said that dependency would be faster if benzos were given IV. Now was this a "treatment" that would have made him highly dependent on benzodiazepines? If Michael had survived, would he have been able to recover from this?

Dr. Steve Shafer: Yes to both questions. Intravenous drug use typically results in faster dependence. Regardless of the degree of dependency, one can recover from it with appropriate treatment. The big problem for Michael Jackson would have been whether he would be willing to stay away from intravenous sedatives for the rest of his life. Without a change in life priorities it is often very hard to wean individuals who are dependent on drugs.


MJJC: After spending what must have been hours of going through Murray's police statement, then the evidence itself, did you feel shocked with the results you were coming up with - the amount of propofol that had to have been given by Murray to obtain the blood results found at autopsy, the botched attempt by Murray to create his own Tate Gallery of Modern Art drip, etc.?

Dr. Steve Shafer: Since Conrad Murray ordered staggering quantities of propofol to give to Michael Jackson, and Michael Jackson had an anesthetic concentration of propofol in his blood, I expected the simulations to confirm that he received anesthetic quantities of propofol. They did.


MJJC: During your testimony you have stated that MJ first had a respiratory arrest and then a cardiac arrest. Dr.Steinberg also testified similarly based on Murray’s own words (that there was heart beat/ blood pressure when he found Michael). We have seen the defense argue that it might have been a cardiac arrest rather than respiratory arrest first. Even in the Murray documentary they showed a scene between defense lawyers that they planned to ask you if direct cardiac arrest was possible but later decided to not ask that question as they were afraid of your possible answer. Can you elaborate on this a little?

Dr. Steve Shafer: I cannot find any evidence that the scenario outlined by the defense, instant cardiac arrest in 90 seconds, has ever occurred. I have spent hours looking for such evidence, including searching the medical literature and communicating with company officials who tracked propofol adverse events. To the best of my knowledge this has never been reported. Not even once.

I also do not believe any anesthesiologist has ever seen this. There is no mechanism by which lorazepam and propofol would act together to cause instant death. If the Judge had permitted it, I believe the trial could have been extended for several years while every anesthesiologist in the United States took the witness stand to testify that this scenario was complete bunk.

Consider the absurdity of claiming that 25 milligrams injected over 4 minutes was so safe that almost no monitoring was required, while the same dose injected over 1 minute was so toxic as to cause magical instant death! It makes no sense.

Of all the misrepresentations by the defense, the assertion of magical instant death from a small dose of propofol is the most harmful to patients. It is false. Asserting instant cardiac death from a very small dose of propofol can only be expected to increase the anxiety of patients requiring sedation and anesthesia.



MJJC: As far as we can understand from Defense line of questioning and Dr. White testimony defense theory of what happened on June 25, 2009 is as follows: Murray gave MJ Valium and then 2 doses of Lorazepam and 2 doses of Midazolam. As MJ was unable to sleep Murray gave him a bolus of 25mg Propofol. During the night/day (unclear when) MJ swallowed 8 pills of Lorazepam unknown to Dr. Murray. MJ was moving around the room even though he had an IV and a condom catheter on and with all these medications on board, he self injected an already filed and left on the night stand syringe that had 25mg of Propofol. What can you say about the Defense’s version of the events?

Dr. Steve Shafer: The primary point is that it doesn’t matter. Michael Jackson would be alive if Conrad Murray had not committed multiple egregious and unconscionable violations of the standard of care. He was administering a general anesthetic to Michael Jackson in his bedroom, with no training, monitoring, or backup. He abandoned his patient. When he returned, his patient was either dead or nearly so. It speaks for itself.

We know that Michael Jackson received a lot of lorazepam. Maybe he took pills. Maybe Conrad Murray gave him more intravenously than he admitted to. We do know is that there was not enough unmetabolized lorazepam in Michael Jackson’s stomach to suggest recent ingestion. We do know that there was evidence in the room of large doses of intravenous propofol administration. We do know that the amount of unchanged propofol in the urine suggests administration of well over 1000 mg (100 mls) of propofol. Thus, the defense scenario is not consistent with the physical or autopsy data for either lorazepam or propofol.


MJJC: Dr. Shafer, you said at the trial that probably at the time of death the drip was still on and that would explain why the propofol concentration on the femoral blood was so high. But Dr. White said that he would doubt the propofol could still be infused once the blood circulation has stopped. Could you expand on this, please?

Dr. Steve Shafer: I claimed that Michael Jackson died during the infusion, which is why the blood concentration was as high as it was. He didn’t have to die at the end of the infusion, and there is no reason to think that he did. He simply died during the infusion. The 100 ml propofol bottle was empty, I expect that he died before the bottle was empty, but that by the time Conrad Murray found him the bottle had run out as well.

I was surprised that the defense claimed that my simulations required that Michal Jackson die at the end of the infusion. There was no such requirement. I was disappointed that Paul White went along with this.


MJJC: In case there was cardiac arrest initially and not subsequently after respiratory arrest as Murray told the police, that cardiac arrest could have been caused by a sudden high/fast dose from the drip since there was no infusion pump to regulate the rate of the drip?

Dr. Steve Shafer: No. The heart is quite a reliable organ. It can stop suddenly, but not from anything propofol does. What makes the heart stop abruptly is: 1) an arrhythmia, typically from an acute heart attack, 2) something that completely blocks circulation, such as injection of a large dose of air, or a blood clot from the legs that suddenly blocks flow into the lungs, 3) administration of a large dose of intravenous potassium, which interferes with the electrical activity of the heart. Propofol will stop breathing, and it will drop the blood pressure. Neither of those will cause the heart to abruptly stop. As far as I can tell, nobody has ever seen a patient’s heart suddenly stop from any dose of propofol.


MJJC: According to Walgren's words during closing arguments "we don't know whether Michael awoke, yelled for help and choke while Conrad Murray wasn't in his bedroom, and we'll never know" and to Alberto Alvarez testimony that Michael's eyes and mouth were wide open, I want to ask you: could Michael suffered before death and could he really yelled for help and choke while dying? And if no, why his eyes /mouth were open if he died sleeping?

Dr. Steve Shafer: Michael Jackson did not suffer. He died because he stopped breathing. He was unconscious at the time. If he had been conscious, he would have been breathing.

It doesn’t mean anything if a patient’s eyes or mouth are open or closed after death. I witnessed my own father’s death during the time I was testifying. I was at his bedside. He was in and out of consciousness for about two hours before his death. My last communication from him, an “OK” sign with his hand, was about an hour before his death. After he died, I noted that his eyes and mouth were both open. I closed them.

Note: Part 3 of 3 will be posted on December 22, 2011.

 

[ivy]

MJJC Exclusive Q&A with Dr. Steve Shafer Part 3

This is Part 3 of 3 of Dr. Steve Shafer's answers to MJJCommunity questions. In this third and final installment Dr. Shafer will be answering questions about Propofol, Lorazepam, Flumanezil, Insomnia and related matters.

Questions about propofol in general

MJJC: Do you feel that your testimony helped alleviate patient concerns about Propofol or are things more or less the same?

Dr. Steve Shafer: It may have helped, but only a little. On the Friday that Paul White testified I was working at the “Allen Pavilion,” a regional hospital run by Columbia University that serves a low-income area of Manhattan and the Bronx. I was caring for an elderly man who asked what drug he would get. I told him “propofol.” As usually happens, he asked if that was the drug that killed Michael Jackson. I told him that propofol didn’t kill Michael Jackson, Conrad Murray killed Michael Jackson. I also said that propofol was very safe drug. He said “I heard that doctor say that at on television, but I don’t believe him.”

I told him I was the doctor he saw on television. He thought that was hilarious: the doctor in blue scrubs, wearing a surgical hat, with a stethoscope around his neck working in this clinic for poor patients might be the “famous” doctor he saw on television. “Yea, right” was his answer. He didn’t believe me for a second. However, he was reassured by my “joke” about being the doctor he saw on television, and everything went well.


MJJC: Can a person become dependent or addicted to propofol? If yes what kind of dependency is it physical or psychological?

Dr. Steve Shafer: There is not much data about this, because propofol must be given intravenously, and it really burns, which discourages abuse. However, there have been a number of deaths of anesthesiologists and other health care personal from propofol abuse. Based on this, I am reasonably confident that it is addictive.


MJJC: Why would someone even have the idea to use Propofol as a sleep aid? If it is only to be used for surgery then why would anyone suggest giving it someone to get some sleep?

Dr. Steve Shafer: The mechanism of action of propofol is the same as drugs like Ambien that are commonly used to induce sleep. This is a reasonable research question. However, it should never be put into practiced until it has been studied in a proper research setting. After that work has been done, it should only be used with appropriate documentation and precautions.



MJJC: Are the drug companies who make Propofol looking into testing Propofol for sleep? Do you think there will be more research studies about Propofol being used for sleep?

Dr. Steve Shafer: Yes to both questions.


MJJC: What are the known effects on the nervous system & the brain of long term Propofol use?

Dr. Steve Shafer: Not a lot, because it is rarely used for long term use. I have been able to find one report of a patient who received propofol in the intensive care unit for 51 days. This is from the conclusion of the article: “To our knowledge, this report represents the first documentation of propofol use for long-term sedation in a mechanically ventilated pregnant patient and the longest duration of continuous infusion propofol published in the medical literature. Propofol was used for 51 days with no documented maternal adverse events.” (Tajchman SK, Bruno JJ. Prolonged propofol use in a critically ill pregnant patient. Ann Pharmacother. 2010;44:2018-22)

This patient was weaned from propofol over several days without adverse consequences. So administration for 2 months appears to not have long term consequences, at least based on this example, and the fact that Michael Jackson continued to function at rehearsal. However, those are just two data points. More research needs to be done if one contemplates development of propofol for long term use.


MJJC: Does one get a "restful sleep" from Propofol? We have heard experts contradict each other on this.

Dr. Steve Shafer: The contradiction reflects the state of the science. I received propofol for anesthesia about a year ago, and I have given propofol to thousands of patients. There is often a feeling of having slept well after awakening from propofol.

However, studies suggest that propofol sleep it is quite different from normal sleep, and is not “restorative” the way that normal sleep is restorative. For example, dreams are important in brain function. Patients don’t dream on propofol, except at the time of awakening. My interpretation of the data is that propofol might be OK for getting a patient off to sleep, but that maintaining a patient on propofol for sleep (as we sometimes do in intensive care units) probably is denying patients restorative sleep.


MJJC: Do you agree that Propofol should be re-classified as a controlled substance?

Dr. Steve Shafer: No. I think this will hurt patients. In emergencies we need propofol immediately, and in large quantities. I am opposed to placing obstacles in the way of doctors caring for patients, unless there is clear benefit. Conrad Murray could have still obtained propofol for Michael Jackson, because doctors can order controlled substances. Since most propofol abuse is by doctors, making it controlled won’t limit the ability of doctors to abuse it. It will just impair their ability to care for emergency patients.

This has been the subject of an issue of Anesthesia & Analgesia. Here is the cover of that issue: http://www.aaeditor.org/HWP/Covers/0710.cover.jpg.


MJJC: Do you think now the anesthesiology community will be more careful in how they promote and teach one to use Propofol?

Dr. Steve Shafer: We already take this very seriously. We are very involved in teaching the safe use of sedatives to our medical colleagues. This will continue. Perhaps they will be more receptive to the importance of safe sedation. However, nothing we can do will reach a doctor who does not put patients first.


MJJC: Do you think the medical community has learned from Michael’s death in regards over prescribing to a powerful wealthy person and wrong doing by a doctor?

Dr. Steve Shafer: Absolutely. I mentioned this above. I am aware of this because I occasionally see this in my practice. Doctors serve patients by acting as doctors. That is a message for doctors and patients alike.


MJJC: Can you explain “Propofol lollipop” a little more?

Dr. Steve Shafer: Propofol absorbed from the stomach never reaches the brain, because it is all removed by the liver. However, the blood supply to the mouth and esophagus (above the diaphragm) does not return directly to the liver. Instead, it just goes to the heart, and from there goes everywhere including the brain. So a propofol lollipop would provide propofol to the venous blood, and from there to the brain. Paul White and I discussed this at one of the breaks prior to his testimony. It is a reasonable idea, provided the dose was adequately controlled.

Should this ever become available, then I would reconsider my position on classifying propofol as a controlled substance. My current view is highly influenced by the fact that it only works when given intravenously, and that really burns!


MJJC: What does Propofol taste like?

Dr. Steve Shafer: It has the consistency of skim milk, and tastes like a very medicinal salad dressing.


MJJC: Beagle Propofol experiment done by the Defense has made PETA and MJ fans angry. We don’t expect that you have any direct information about the Beagle experiment but as the humans weren’t affected by drinking Propofol, is it safe to assume that the Beagles were unharmed as well?

Dr. Steve Shafer: I think it is very unlikely that any harm came to the beagles. There should be no effect from drinking propofol. However, I am uncomfortable that neither the experimental protocol nor the results of the experiment were presented in court. I believe that when animals or humans participate in trials, there is an ethical obligation to write up and publish the research to add to the body of knowledge. It is the increased knowledge that morally justifies the research. I wrote our human study up for publication, asked Paul White to review it, and gave it to the defense. I believe they should have done the same with their beagle study.


MJJC: We heard the theory of some of the Benzos or/and Propofol that were given to MJ by Murray can be used for people with drug addiction to help them off their addiction to other drugs such as Demerol, Is this true? Can you comment on this?

Dr. Steve Shafer: There is a technique of rapid detoxification that involves placing patients under general anesthesia for a long period of time (hours to days) and pharmacologically reversing opioids with “opioid antagonists”, drugs that chemically block the effects of Demerol and similar drugs. This is controversial, but it probably works in some patients.


Questions about Demerol

MJJC: Was the amount of Demerol Dr. Klein give to Michael normal or was it too large a dose?

Dr. Steve Shafer: I can’t answer without knowing why Demerol was given. Dr. Klein did not testify at the trial. I’m uncomfortable offering any opinion without more information.


MJJC: Does your answer change if you consider MJ’s history (burn victim) with the drug? Do you think it was excessive?

Dr. Steve Shafer: Again, I apologize, but I don’t want to render an opinion without knowing why Dr. Klein was administering Demerol. This probably reflects my caution as an Editor-in-Chief of a medical journal. Medical editors are reluctant to render a public opinion unless they are confident they understand the facts.


MJJC: In your opinion, does Demerol aggravate insomnia as a side effect? Did it play any part in Michael's physical and mental health? What was the best treatment for Michael's insomnia?

Dr. Steve Shafer: There are three questions here. I’ll answer them in order:

Demerol’s chemical name in the United States is “meperidine.” In many countries it is known as “pethidine.” Meperidine has a metabolite, “normeperidine”, that is a nervous system stimulant. As a nervous stimulant, I would expect it to exacerbate insomnia.

The coroner examined both blood and urine for meperidine (Demerol) and normeperidine. Neither could be detected. Thus, meperidine did not play a direct role in Michael Jackson’s death on June 25th. However, you asked a more general question about “play any part in Michael’s physical and mental health.” It is a good question, and I will again need to apologize for not answering it. I have not read Dr. Klein’s medical records or heard a detailed explanation of Michael Jackson’s care. I am uncomfortable speculating without that information.

Sleep disorders are complex, and treating them is a specialized branch of medicine. It is my understanding that any drug that affects the level of consciousness can exacerbate sleep disorders. There is a nice description of sleep disorders, and the treatment of common sleep disorders, at http://www.sleepfoundation.org/article/sleep-related-problems/sleep-aids-and-insomnia.


Questions about lorazepam, flumazenil, and ephedrine

MJJC: Could the free lorazepam detected in the gastric liquid be explained by the stomach hemorrhage caused by CPR or even by accidental mixing of adjacent blood at the time of autopsy (as it was suggested by the Coroner, Dr. Rogers in the preliminary, though not mentioned again during the trial)?


Dr. Steve Shafer: Maybe. However, free lorazepam would be expected simply because molecules like lorazepam would be expected to cross from the blood into the stomach, just like they cross into all tissues. That is how the lidocaine and propofol got into the stomach. Lorazepam should behave just the same way.

Additionally, the enzyme beta glucuronidase is secreted by the wall of the stomach into the stomach fluid. Beta glucuronidase is the enzyme that would turn lorazepam glucuronide back into lorazepam. So blood could account for it, but most of it is likely the simple diffusion of lorazepam from the blood into the stomach.


MJJC: Is there any other reason for Flumazenil to be administered apart from reversing the effects of benzodiazepines (in this case Lorazepam)?

Dr. Steve Shafer: No.


MJJC: Does it even make sense to give a person Flumazenil who according to Dr. Murray only received 4 mg of Lorazepam to begin with?

Dr. Steve Shafer: The most critical part of any resuscitation is to move air in and out of the patient’s lungs. The problem with giving flumazenil is that it distracted Conrad Murray from the critical task of moving air in and out of Michael Jackson’s lungs. If there were several people were involved in the resuscitation, then giving flumazenil would have made sense. However, since Conrad Murray was alone, any interruption longer than a few seconds was too long.


MJJC: Can you explain your consideration of the Lorazepam levels, in more detail?

Dr. Steve Shafer: I’ll answer as well as I can, but I’m not sure exactly what you want to know. The lorazepam levels were high enough that you or I would have been very sleepy from them. However, patents become tolerant to lorazepam and related drugs (the “benzodiazepines&#8221. Since Michael Jackson had a fairly high concentration, and according to Conrad Murray that was not enough drug to induce sleep, he must have been tolerant.

The defense wanted to attribute Michael Jackson’s death, in part, to oral lorazepam. The problem with this theory is that there was only a minute amount of lorazepam in Michael Jackson’s stomach. To explain this minute amount, the defense alleged that Michael Jackson swallowed lorazepam about 5 hours before the time of death. If that were true, then the lorazepam concentration would have peaked about the time Conrad Murray claims Michael Jackson was pleading for more drug to fall asleep. So that argument doesn’t make sense.


MJJC: According to autopsy report there was ephedrine found in Michael's body. It's a drug that aggravates insomnia. How ephedrine goes with benzos and propofol, could it subdue effect of these drugs?

Dr. Steve Shafer: There was a bottle of capsules composed of ephedrine, caffeine, and aspirin in the room. Ephedrine is sometimes used in resuscitation. Since there was ephedrine in Michael Jackson’s autopsy urine, as well as the urine that was found at the scene, I would assume that the ephedrine was from oral ingestion, and not from administration as part of the resuscitation.

Ephedrine can reduce the effects of propofol and benzodiazepines on blood pressure and heart rate. Chronic ephedrine might aggravate insomnia.

 
Question about medical research in general

MJJC: Judge Pastor referred to Murray as making Michael Jackson part of a “scientific experiment”. This could unfortunately dissuade patients from feeling comfortable participating in clinical trials and other types of beneficial scientific and medical research. Can you discuss the important intersection between the research of scientists and the clinical practice of physicians?

Dr. Steve Shafer: I’ve performed dozens of clinical trials. I don’t think this will adversely affect recruiting patients into clinical trials, because this “experiment” bears no resemblance to a scientific study. I think “experiment” is an accurate term, because it correctly implies that Conrad Murray had no idea what he would find day after day of propofol administration. So this was an experiment that he was conducting every day to see how Michael Jackson would respond. However, I don’t think anybody would confuse this experiment with a proper scientific experiment.

The larger question you ask is about the intersection between research and practice. This is an important question, and (fortunately) one that has been given very careful consideration. The answer goes back to the Nuremberg Code, which followed the trial of Nazi doctors guilty of atrocities at the end of World War II. You can find an excellent account on Wikipedia. This was updated by the Belmont Report, published in 1978. Again, there is an excellent account in Wikipedia. As explained in the Belmont Report, “research” differs from clinical practice in that research is a systemic investigation intended to create generalizable knowledge. “Systematic” means that the investigator intentionally gathers data to answer a question. Generalizable knowledge means that the investigator believes the information gathered is useful to others, and intends to “generalize” the knowledge, usually by publishing it. If you Google “Anesthesia & Analgesia policy in institutional review board approval and informed consent for research” you will find an editorial I wrote in March on the subject.


 
Questions about insomnia

MJJC: Decades of lies, slander, deceit, inhuman treatment from the media and public misconceptions had caused Michael immense hurt, pain and anguish resulting in insomnia. We know Propofol was not the answer, but what do you think he should have done (medically) to treat it?

Dr. Steve Shafer: He should have been in the care of a sleep medicine doctor. He had a terrible affliction, one that requires expert care.


MJJC: Do you think meditation that Murray was talking about in his police interview could really help Michael to sleep?

Dr. Steve Shafer: Maybe. Conrad Murray mentioned both propofol and lorazepam. These are both sedatives that act on the same receptor in the body, the “GABA” receptor. Most sleeping medications also act on GABA, the exceptions being antihistamines (e.g., benedryl) and melatonin. So I would expect these drugs to induce sleep. However, they should not be used to maintain sleep, because the drugs interfere with some of the brain function that is required for sleep to be “restorative”, meaning that it refreshes the brain.

 
Final comments

MJJC: Anything you want to say to the members of MJJCommunity and Michael Jackson fans in general.

Dr. Steve Shafer: Once your questions about Michael Jackson’s tragic death have been answered, I encourage you to set it aside. Conrad Murray has been convicted. We have a reasonable understanding of what happened. It’s time to return to the bonds that brought the MJJCommunity together in the first place: your celebration of Michael Jackson’s life, his message, and his music.

I appreciate the opportunity to address your questions, and hope that the answers are helpful to the MJJCommunity.

Sincerely,

Steve Shafer

 

[ivy]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1 posted

Place holder to post our communications with Dr. Shafer

 

[ivy]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1 posted

Place holder 1

 

[PaceMioDolceCuore]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

Oh, holy cow, thank you Dr. Shafer- and thank you Ivy for posting. Lovely to read his well thought out take on things. His answers are NOT run-of-the-mill copy and paste answers.

The appearance of physicians like Dr. Shafer help to restore a sense of "order" in my messed up universe since that fateful day and perhaps it is only well befitting that Michael's fans extend the love to a man who seems bottomlessly generous in answering the multitude of questions.

"Gratitude" isn't strong enough a word and neither is Dankeschoen!

 

[Diplomate]

Thanks Ivy ! And thanks to the Dr Shafer! I like when he says " Mr. Chernoff’s statement is false. The lack of record keeping did contribute to Michael Jackson’s death. " One more time we can see how stupid is Chernoff.

 

[Mirabella76]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

JEEEZZZ!!!! It's a real huge interview! I can't believe we did it! God bless Steve Shafer, MJJC and Ivy! I really can't believe! I suspected he'd just answer briefly and that's it. Can't believe he's so kind.
It's a late night in my country and i'll read all tommorow. But i can see he answered two of my questions!
Love you Steve Shafer! :wub::wub::wub:

 

[mjmirror]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

Dr Shafer has a heart of gold! So many questions and he answered them all..simply, wow.

 

[ivy]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

and if you prefer I can post all the sections once rather than waiting a few days between them.

 

[PaceMioDolceCuore]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

^^^All of it, yes. Me greedy cookie monster! Thank you!

 

[The Brown Gangsta]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

So he works around 60 hours a week for the medical journal, teaches, still works in the operating room and he still took the time to put in countless hours of research for the Conrad Murray trial...and pro bono too?? That's incredible! By my not so scientific calculations, I approximate that Dr. Shaffer probably sleeps a total of 10 minutes every 3 weeks....he deserves a vacation

 

[elusive moonwalker]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

thanks ivy and thanks steve. hes one in a million. what can you say.taking time to answer everything and going into detail.

 

[ivy]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

So he works around 60 hours a week for the medical journal, teaches, still works in the operating room and he still took the time to put in countless hours of research for the Conrad Murray trial...and pro bono too?? That's incredible! By my not so scientific calculations, I approximate that Dr. Shaffer probably sleeps a total of 10 minutes every 3 weeks....he deserves a vacation

and he also answered our 86 questions.

 

[Erikmjfan]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

wow, he answeared all 86 questions! he is the kind of guy that just make u feel a bit more hopeful about the world and mankind.

 

[myosotis]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

Thank you so much to Dr Shafer for answering so many questions with such thoroughness and care; you write with wonderful clarity and rare compassion, humility, honesty and insight. This must have been a tremendously emotionally painful time for you, but your scientific focus never wavered and your testimony cut through a very murky defence like a laser light. The University, your patients, and your research community are so lucky to have you (but I am sure they know that already!)

 

[Ashtanga]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

I sent him 86 questions and he answered them all.

Wow! Happy that he devoted his time to answer questions.

 

[xthunderx2]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

Thank you Ivy..I didn't know that it was ok to discuss in this thread,,but now I do. Thank you so much Dr.Shafer for taking the time to answer ALL those questions...you are just amazing,

 

[ivy]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

yes please discuss his answers on this thread

 

[qbee]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

I am so overwhelmed Dr. Shafer took the time out of his important busy schedule to answer each and everyone of our questions. I just cant explain how much respect, gratitude and yes even love I have for the MAN. Not only did he answer graciously but he took time and thoughtful care on each one. I imagine that is how he also cares for patients and everything he does with thoughtful care. Do you realise how much respect Dr. Shafer just gave us in doing that.
I feel so special I just cant put in words how much I love him for doing this for us. Both he and Mr Walgren are Honest hard working men with integrity and both a genius in their field.


Thank you Ivy and Gaz for arranging this for us

 

[ivy]

okay let's go over some stuff

Dr. Steve Shafer: I grew up listening to Michael Jackson’s music, just like the rest of the world. Thriller was the only album that I knew well, and “Beat it” is my favorite track from it. The message and the music both appealed to me.

I was like yes ! I also found out recently that Dr. Steinberg also likes Michael's music

My opinion of Michael Jackson is that he was an immensely gifted musician, entertainer, and genuinely compassionate individual.

so true.

However, he was thrust into (well deserved) stardom as a youngster, and spent his entire life under the glare of public scrutiny. That does not seem like a blessing to me. To me it seems like a tragedy. He never lived a normal life.

sad but true I guess. his fame has always been his curse as well.

Dr. Steve Shafer: I knew that the defense would reject animal studies as not applying to humans, just as Paul White did when asked about animal studies of propofol in urine. There is no way that I could conduct a human study in the US in three months, so I thought the best evidence I could get was to simply drink propofol and report if it had any effects. I knew the pharmacology well enough to be absolutely certain it was inert.

wow. Dr. Shafer is an unbelievable individual. How many other people would have done this? Drink Propofol when push come to shove?

MJJC: Did it amuse you like it did many when Dr. White was called "Dr. Shafer" several times in court by Prosecution, Defense and even the Judge?

Dr. Steve Shafer: Yes. I think everyone was amused.

So were we

MJJC: What do you think about Michael Jackson fans love and appreciation towards you? Do you know that many fans publicly express their love and gratitude to you, and use your pictures and quotes to express themselves? What do you think about that?

Dr. Steve Shafer: It didn’t expect it! However, I do understand that not knowing what happened to Michael Jackson has been a cause of considerable pain to his millions of fans. If my testimony was helpful, and perhaps brought a closure to his passing so they can again focus on his music and message, then I’m honored to have had the opportunity.

I have tried to answer many of the e-mails I have received. I am appreciative of the kind comments I have received from his fans all over the world.

so let's insert this here. I actually emailed this to Dr. Shafer as well.

For me, it’s simple: I’m a doctor. I care for patients. If I ever stop caring for patients, I won’t know who I am. That’s what I do.

he's a wonderful doctor.

Dr. Steve Shafer: I spent dozens, and perhaps hundreds, of hours in preparation. I read well over 100 papers. I analyzed the data numerous ways, and even made my spreadsheets available to the defense. I did the “heavy lifting” that is expected of an expert. This isn’t unique to this case – it’s how I approach everything I do.

can we get an applause for Dr. Shafer?

MJJC: Did your father know about your intention to take a stand in Conrad Murray's trial? If yes, what were his thoughts about it, if any?

Dr. Steve Shafer: Yes. He liked it a lot. He told me it made him proud. He was also aware that I was visiting him every day because I was in Los Angeles for the trial.

He watched my testimony on Thursday morning, and died that evening.

This is really sad. I once again wanted to say how sorry I am for his loss.
 

Questions about trial in general

MJJC: What do you think about DA Walgren?

Dr. Steve Shafer: He is brilliant, dedicated, and absolutely honest. He worked incredibly hard. I think he got about 4 hours of sleep every night of the trial.

Part of my job was educating Mr. Walgren in the science. By the time of the trial, he was occasionally correcting my calculations! He was so effective when dealing with expert opinion in part because he truly understood the scientific principles.

As a taxpayer, it is amazing that attorneys like Mr. Walgren work for the State of California at a public servant’s salary. We are really getting our money’s worth!

Do you remember? During the trial we were asking if Dr. Shafer was educating Walgren and it turned out he was. This made me all giddy inside.

Dr. Steve Shafer: Mr. Chernoff’s statement is false. The lack of record keeping did contribute to Michael Jackson’s death. Without records Conrad Murray could not look for trends, such as seeing if larger doses were needed each day. Without records Conrad Murray could not look at past doses to determine what was a safe dose, and what was a dangerous dose.

Record keeping re-enforces vigilance. When you write down the vital signs every 5 minutes, it forces you to keep an eye on the patient. Record keeping would have forced Conrad Murray to stay close to Michael Jackson and continuously write down vital signs (at a minimum he had the pulse oximeter on the finger and could physically count the rate of breathing and heart rate). Record keeping would have forced Conrad Murray to monitor the intravenous infusion rate. Record keeping might have kept Michael Jackson alive. Thus, Mr. Chernoff’s statement is false.

and there you go Chernoff. Dr. Shafer told you.

 

[PaceMioDolceCuore]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

^^^ That 'lack of record keeping did not kill him" bugged the $%^& out of me, I just wanted to hit a wall, or something. I understand that Chernoff is doing his job- but this entire 'pretending I did not understand" and willfully saying things you know to be wrong is just getting under my skin. AAAAAAAAAAAH. I wished he had a chance to get these things out on TV where the world would have to take note.

And oops, when that macro macroed itself- I had no idea Dr. Shafer's wife was the head of the Obstetrics anesthesia department- all giddy on the inside made me laugh today. I couldn't have made that up. :hysterical::hysterical:

 

[Rhilo]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

Wow, I'm so impressed by Dr. Shafer and his answers. They are long, descriptive and informative. How kind of him to take time off his busy schedule to answer all the questions. I am just so impressed by his humbleness and generosity. Thank you Dr. Shafer!

 

[mlg2804]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

Wow, I loved reading that. Thank you so much Dr Shafer. Just brilliant and what an interesting read.

 

[allieb]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

Beautiful!!!! Thank you soooo much MJJC and Dr. Shafer. He is an angel!

 

[Bridgett_361]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

Thank you doctor shafer, you are one of the few true gentleman around, lot of blessing to you and you family

 

[The Brown Gangsta]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1 posted

okay let's go over some stuff

I was like yes ! I also found out recently that Dr. Steinberg also likes Michael's music

lol with Dr. Steinberg, I could already tell that he listened to Michael's music (he kind of gave that "one of us" vibe

okay actually emailed this to Dr. Shafer as well.

lol lol lol!!! I really hope he found the humor (bonus points if he got the BOTDF reference) in that picture!

 

[Dialdancer]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1

As someone else said on another site: "Dr Shafer sounds like a very kind gentleman. Not a word we hear much any more."

MJJC is doing an incredible job on behalf of Michael.


Thank you.

 

[ivy]

Re: MJJC Exclusive Q&A with Dr. Steve Shafer - Read his answers - Part 1 posted

lol lol lol!!! I really hope he found the humor (bonus points if he got the BOTDF reference) in that picture!

probably he didn't get the reference (as he said he's only knowledgeable about Thriller album) and thought that we are a bunch of crazies