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Murray Trial - 12 October - Day 11 - Discussion

witness says its not acceptable to leave the patient, extreme violation of standard of care..

talks about you can tell if the patiens have a hard time breathing and if u leave u will obviously not notice if the patiens are not able to breath properly
 
witness says more pronounced decreased blood-pressure if you mix propofol and the benzos..... same regarding your oxygen level. if u mix the drugs u will get lower oxygen level

heart stops because lack of breathing....

low pressure and lack of breathing (lowering of oxygen level) can lead to cardiac arrest

deviation of standard of care if you do this to a patient knowing he/she is being treated for dehydration as well.

important to be know about the patiens underlying physical and medical history so u can prevent tragic events
 
Dr Murray had noted Michael was dehydrated....this means the blood circulating is limited of lack of replenishment and can cause lowering of blood pressure and adding two separate sedatives can culminate in the resulting storm that occurred in Michael.

This lack of dehydration another deviation of standard of care as he needed to be aware of underlying physiology and not to do things that will exacerbate things.

not calling 911 also deviation along with his improper care.

Thready pulse and not breathing...most impt if there was a pulse was to deal with breathing issue, fact CPR performed on any surface other than hard surface provides for inefficient chest compressions, should use two hands, standing over the patient where can use some force, doing with one hand is difficult to imagine how you can effectively provide for that on a surface other than a hard surface.
 
witness says CALL 911, you call for help... thats the first thing u should do.
 
What's the significance of dehydration CM mentioned?
To be dehydrated...the blood circulation is limited, lowering the blood pressure, that added to two separate sedatives, that could be another element that culminates in the perfect storm that killed Mr. Jackson.

It's really critical to asses your patients, and every patients have risks. If a patient has low blood pressure, he administers fluids in addition to having him put on a ventilator when administering Propfol, to avoid disastrous consequences and one should always be prepared for the worst when administering substances.

Two more words before break.

The rule of thumb is to call 911, it's critical.
 
When Mr Jackson was first found he had 122 bpm and he was not responsive, the most important point was to deal with the breathing activity. For a non medical, if one finds another unresponsive is to do CPR but this is not the case here.

CPR is done on a hard surface. Any other CPR is ineffective.
 
important to deal with brething issues/ventilating issues when u find a patient in same condition as MJ (assuming he had a pulse like Murray said)

non responsive to do CPR... cpr was not performed on a hard surface...u shld use 2 hands and standing over the patient so u can use force and allowing the blood to circulate... if u do it like murray did, u can not get the circulation properly
 
Dr. Kamanager says that if you do not have the tools to help the patient, the basic life support thing to do would to call 911 as soon as possible.

Doing CPR on anything but a hard surface and only using one hand robs from the effectiveness of the CPR.

Mid-Afternoon break is now. :)
 
One hand in the front, one hand in the back is particularly difficult to imagine.
Even if CPR is performed, doing everything right, you're just circulating blood at 20% of it's normal capacity. If CPR is not done properly, the effect is even less.
 
Awesone updates guys. im still at work. thank u all so much. first witness sounds incredible
 
These witnesses are exceptional and they keep hammering home the fact that Murray did not have proper equipment, did not call 911 in proper tim, should have never left his patient's side after giving propofol and gave ineffective/improper CPR. The prosecution needs to keep hammering those points til the jury hear them in their sleep.
 
Stienberg
re direct by Walgren :

Murray did not act like he was ACLS certified.

Propofol given in NY : it was in hospital settings

Gastro dentist ER doctors who use propofol : they receive appropriate training , trained staff and equipment are necessary

Article about the study in Taiwain : 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 ethical comittee. They obtained written consents from the patients. 8 hours of fasting prior to being given propofol, propofol was given by an anaethesiologist. No other benzos were used. So what CM was doing was essentially an experiment.

Assume that dr Murray gave only 25mg, that there was no drip. Would you draw the same conclusions ? Yes

Was it a foreseeable risk that the patient could go into respiratory deperession and cardiac arrest ? Yes

Do you think CM caused MJ's death ? Yes

re cross by Flanagan

Did that study showed propofol helped insomnia : yes

in this case you need to analyse if the deviations from standard of care directly impacted MJ's death : yes.

Did the lack of back up battery lead to MJ's death ? No, but the other 5 deviations did;

CM gave propofol for 45 days without problems, so you're assuming things. Answer : no I didn't asume that he gave propofol, that he didn't have the equipment, the delay in calling 911, improper care during the arrest.



Dr Kaimangar : Pulmonary critical care and sleep medecine physician, UCLA medical center
direct examination Walgren

board certified : internal medicine, pulmonary medecine, critical care, sleep medecine.

Medical reviewer for the Cali Medical Board , assessed CM's care to MJ for the medical board.

Is propofol used in critical care unit : yes, daily.

Are you trained in using propofol : Yes. Propool is used for placement of endotracheal tubes, and for people on breathing machines. Propofol is the most commonly used drug for this.

What is your training for using of propofol ? You need to be well prepared for an emergency, It's necessary to be aware of the potential problems that could happen . Propofol is not used on unstable patients.

Is the staff trained : yes, there is a special training for using propofol. If there is no none especially trained for propofol, they call an anesthesiologist.

the continuum of sedation : there is a fine line between moderate sedation to deep sedation and to general anesthesia (not responsive to painful stimulation). It's difficult to predict how the patient will react.

When propofol is used , who is present ? For induction : an intensivist or an anesthesiolgist and a nurse, and respiratory therapist (except in extreme emergency the respiratory therapist might not have to time to come)

what is the monitoring equipment you need for propool: EKG machine, blood pressure (every 2 to 3 minutes), pulse oxymeter with an alarm, capnometer (for patients under ventilation, measures carbon dyoxide )

About CM's care of MJ : found multiple deviations of standard of care :

1 propofol given in an unacceptable setting : using this deep sedation agent in a home setting is unconceivable.

2 ACLS certified : the persons who gives propofol must be trained in ACLS and airways management. There is a risk of hypoventilation, and obstruction of the airway.

3 Need of assistance : CM needed a a second person to monitor, especially if you're going to leave the room. That goes withot saying

4 Pre procedure setup : imperative to be prepared for possible consequences. Things can change very quickly. A patient may look good, and the next minute there's a problem. You need 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, epehdrine, medication to correct the heart beat, etc...) , defibrilator, automated infusion pump (precise dosing for propofol) even with people who are intubated;
Theses are extreme deviation of standard of care = gross negligence.

Have you ever seen someone giving propofol at home in such settings : no, 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 : that is really not acceptable. Espacially since CM didn't have the right equipment.

7 Use of benzos : using lorazepam and midazolam on top of propofol can have higher effects : more significant respiratory depression, decrease cardiac output (often a consequence of resiratory depression), decreased blood pressure.
Cardiac arrest can occur directly, or because of low levels of oxygens.

8 dehydration : blood circulation is not good when you are dehydrated , causes low blood pressure. Benzos and propofol would also lower blood prossure . You should not use benzos or propofol if the patient is dehydrated.

9 failure to call 911 : 911 should have been called immediatey

10 improper CPR : if there was a pulse , the problem was breathing. CM should have dealt with airway management .
CPR was ineffective : was not on a hard surface, doing it with one hand was ineffective. If you do CPR correctly, you just allow about 20% of the normal blood circulation, so if you do it incorrrectly ...


break
 
I have been at work all day and missed everything and catching up now. So the first witness really kicked the defense butt? I hope so. I hope the jury really listened. I always knew that if Michael had gotten immediate help he would still be here.
 
Murray found MJ around noon and called Michae Amir at 12:12pm... the first 4-5 min are the golden minutes, longer than this the brain-cells starts to die.. the golden minutes important to maintain bloodflow to the brain...

911 was called 12:20pm.... took 20 minutes for Murray to call 911... critical says witness
 
The higher part of the brain is what makes us who we are, so people who are in a comatose state, even if the body survives, they usually slide in a vegetative state. Longer there is lack of perfusion to the brain, higher the risk.

Beyond 5 minutes, the brain cells start to die if there is no circulation, in the best case scenario - if the person does not die.

CM calls MA at 12.12 and there are 20 minutes from the time CM found MJ to the time the paramedics came.
 
I can't wait to hear Flannagan after this one:

" If....if....if......the dog had eaten the equipment, you wouldn't be thinking that now. Would CHA'?''
 
Deception (CM not telling about the propofol) as incoscionable and extreme lack of care. Particularly to exclude the strongest agent, which could have allowed the professionals to focus on the problem.
 
His report says Murray deceived paramedics and hospital staff by not telling them about the propofol....this was unconscionable...if he gave this critcal information and would have allowed the hospital staff to focus on the main cause..

First person to bring up that murray wasn't honest with the hospital and paramedics.
 
Walgren says, assumes that Murray finds Michael at Noon at then rings Michael Amir at 12:12.

What is the significance in those 12 minutes.

The longer the brain is without adequate oxygen the worse the outcome. 4-5 minutes without can be quite devastating.

911 is called at, 12:20, Nader Kamanger says that, that underlines it and that it then becomes impossible .

It is essential to provide every part of a patients medical history. By not providing all the history, goes against the basic principals and that's care of your patient.
 
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