Recap ; sorry, i can't be as fast as Elusive …
Alan Steinberg Cardiologist
as a cardiologist is not an expert in anesthesia, sleep meecine, addiction drugs
board certified = took a course and 2 days test that covers the basics of cardiology. 90% of the people who take it pass it
Has reviewed CM's resume. Cm was not board certified on june 25th 2009.
he's an expert reviewer for the California Medical Board : reviews other doctors' actions to ensure the standard of care has been respected; Extreme deviation from staard of care = gross negligence;
has conduted a review for the cali medical board in this case.
Has conduted 8 different reviews : in 4 found no deviation, in 4 other found simple deviation of care. First time he's seen an extreme deviation from standard of care.
Cardiologists use sedation for many procedure, so he's used to sedation. As a cadiologist he's an expert in mild or moderate sedation; Conscious sedation : you're still able to talk. Cardiologists are trained in moderate sedation or conscious sedation.
Deep sedation = only responsive to pain or repeated stimula. As a cariologist, not trained in deep sedation.
When Deep sedation is needed, calls anesthesiologist, because as a cardiologist he's not trained to do that.
Mild or moderate sedation : uses benzos. Deep sedation : uses propofol with an anesthesiologist.
Has reviewed this case : has focused his review based on CM interview with police : wanted to judge CM on his own words.
Found 6 seperate extreme deviation from standard of care
1 propofol was not medically indicated. Never heard of propofol used for insomnia. Using propofol for insomnia is an extreme deviation
No written informed consent : the patient must be informe of the risks and benefits
2 propofol given in a home setting, without proper equimpent and proper staff :
equipment needed : pulse oximeter with an alarm, Murray's didn't have an alarm. Automated blood pressure cuff, to check blood pressure at least every 5 mn. Murray had a manual cuff and did not use it. EKG machine. Oxygen + nasual cannula or mask, Suction in case you regurgitate into your lungs, an Ambu bag. Murray had an ambu bag but did not use it (did mouth to mouth). Have a way to call for help . Backboard : in case you need to give CPR. A back up battery in case of a black out for the equipment. Device that keeps the airway open, equipment to rescue the airway (endotracheal tube). The endotracheal tube requires trained staff.
A patient can become oversedated, where a patient goes from moderate to deep sedation.
You need a defibrilator.
Need special drugs : fluamzenil, narcan, lidocaine, betablockers, atropine, dopamine, epinephrine, prednisone, dextrose (missed one, sorry)
deep sedation : you need a trained Bls & ACLS assistant
bls = basic life support. ACLS : adanced cardiac life support.
3 inadequate preparation for an emergency : have the drugs ready, equipment ready, have a person ready to help you
4 improper care during the arrest : didn't follow proper protocol; arrest = cardiac arrest = heart stops beating. No blood pressure, the patient collapses. Call 911, use a defibrilator, and do CPR on a hard surface.
In MJ's case , it was a repiratory arrest : the oxygen goes down, the heart beats harder : this is where CM found MJ, based on CM's words. If you do nothing, the heart weakens because of lack of oxygen, and stops contracting but there is still an electrical activity. Thats PEA. After PEA, there's asystoly.
Should have called 911 immediately, tried to awake MJ (heart wound ??), give flumazenil, should have used the ambu bag. Should NOT have done CPR, because there was a pulse.
Cpr was poor quality, because MJ was on a bed. Says it would have been very easy to put MJ on the floor.
5 failing to call for help. Should have called 911 immediately. Instead called MAW, caused a further delay.
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.
Thought it was bizarre and strange to call an assistant instead of calling 911.
6 failure to maintain proper medical records. Important because of insurane companies, litigation, better health care. Dr Murray did not document anything at all. Cm was confused (or dihonest) and was not able to explain MJ's history or what he gave him to the ER doctoe or EMTs.
These extreme deviations lead to MJ's death. Without these deviation, Mj would still be alive.
Even with only 25mg propofol pthe risk of respiratory depression is still here.
Even if MJ took pills or self administered, the extreme deviations still stand and still lead to MJ's death. If MJ self administered, means that Murray was away, and that should not have happened. Compares leaving a patient under propofol to leaving a baby sleeping on he kitchen counter.
Medication should not have been within MJ's reach
End of direct exam. Recess.
Excellent witness, he did a fantastic job. I'm in love.
