Exactly. I don't know how any doctor can say what Murray did was okay.
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Exactly. I don't know how any doctor can say what Murray did was okay.
Bonnie Blue
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Shafer is as brutal as Steinberg. And the defence have ...Karen faye.
82Thriller84
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Courts Back 
bouee
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Dr Shafer
Walgren
the safeguards and requirements apply to all doctors who perform sedation, for any type of IV sedative. many docs adminster sedation, they all follow these standards. These are required for IV sedatives of any sort.
Some nurses are trained to certain aspects of sedation. Nurses, emergency techniciens, all follow these guidelines.
IF CM's intent were to give 25mg would this apply : yes, there were other IV sedative, profound inability to sleep, patient was exhausted; exhaustion will block the response.
Patient had been given drugs , maybe was in withdrawal, maybe dependant, possibly dyhadrated from exercise.
Can you find a way tu use smaller amounts of sedative safely ? No, it's a common set up. «*a little bit of sedation*», it starts a slippery slope : you may have to add a little bit of this, and a little more of that. You don't know how the patient will react.
Facts in this suggest that virtually none of the safeguards were in place when propofol was given to MJ
asked to describe how patients react differently to the same dose : typically it's 50% : some patients will need half the usual dose, others will need the double of the usual dose.
The doctor has to prepare for the worst case scenario. 25Mg propoofol is the limit when a patient might stop breathing. You always assume your patient is at the edge of sensitivity.
Report about this case dated april 15th :
documentd the various devietion of standard of care.
Minor violation : not consistent with standard of care, but no problem for the patient, unless there are several violations
serious violation : harm to patient, in combination of serveral vioaltion
egregious violation : should never happen in the hand of comptent doc. An egeregious violation can be catastrophic for the patient. Bad outcome is at least a high possibility
unconscionable vioation : includes egregious violation. Unconscionable gets to ethics, violation of the rights of patient. It's a medical and moral violation.
Specific deviations in this case
1 basic airway equipment : egregious violation. MJ died because he stopped breathing, which is expected when you give IV sedatives. All it takes is a mask or intubation. If CM had left only 2 mn, and the equimpent was present, coud MJ have been saved ? Yes, absolutely. MJ probably had an obstructed airway, a chin lift would have probably worked.
CM didn't use the ambu bag, did mouth to mouth, ithat was less effective , it gives used air.
What was needed was a laryngeal mask, or laryngoscope and endotracheal tube. Described it a a serious deviation originally, changed his mind to en egregious because of the setting : CM had no help.
It is your view that CM had anticipated to giv 100 ml vials : purchased at least 130 100 ml vials, that's at least one per night. Has gone thruough applied pharrmacy's records. Now showing applied pharmacy recods. Says it's an extraordinary amount for one patient; between april – to 25th june, that 80 nights, 1937 mg/night;
propofol is a culture media for bacteria. Once a bottle is opened it has to be used within 6 hours; it suggests usage of 100ml, if not you would purchase smaller reports.
Lack of suction apparatus lack of : egregious violation. MJ was not asked to fast. He was at greatly higher risk ; Could have caused death
infusion pump : egregious violation . there was no infusion pump. Without it, the rate can not be precisely controled; the risk of overdose is very high. Likely contributed to Mjs death in his view.
Roller clamp : plastic wheel squeezes the tubing , it's extremely imprecise, was the only thing available to CM when he gave propofol. Lack of infusion pump was direct cause of Ms death.
Pulse oximetry : egregious violation . The pulse oxieter that was used is completely inappropriate. Not intended to be used for continuous care. No alarm. On monitors in hospital, here is a tone, the tone changes if there is a problem, so everybody in the room is aware that there is a problem.
What would a proper monitor would have shown : it would have had 100 oxygen satuaration at the beginning; there would be a 30 or 60 secs delay, because of xygen reserves in the lungs, then the rate would have started to fall, to 97, 92, 90, you would hear at tone, then at a certain level, the alarm would have gone off. This WOULD have saved MJ's life.
Blood pressure cuff: egregious violation. Propofol lowers BP. Usually no consequence, it's expected. We would treat it with hydratation, less propofol, medication; MJ was dehydrated, the risk are higher. If BP falls, the drug becomes more potent, because when there is less blood flow, it concentrate on heart an brain. Not monitoring, not knowing if he had a low bp, MJ might have had an exagerate response to propofol. A manual BP cuff in a cabinet is not usefuel there.
ECG : egregious violation . ECG allows you te see he heart rate, the heart rythm. This is routine monitoring. In his case, CM can't tell us what the heart was doing, CM couldn't know what kind of therapy to use when MJ went into arrest.
Capnography : egregious violation; initially thought that it was not a violation; in anesthesia its a standard, but tother specialiste don't use it. Thats why he didn't think initally that it was a violation. But in Mjs environement, it was a disatster : CM would have known immediately that MJ had stopped breathing. Caused Mjs death
Emergency drugs : serious violation. drugs to raise the BP, drugs used to stabilise the heart rythm, accelarate the heart. Phenolephrine (?), Ephedrine would raise the BP. If a breathing tube needs to be placed, you give a muscle relaxant so you can open the mouth fully. Succinocoline (sp ?) : paralyses the muscles so the tube can be placed. Doesn't think it contributed to Mjs dath : if low bp happened : hydratation and stopping propofol would have been enough. Mjs case is different, he could have been woken up, was not undergoing an operation where the patient can not be woken up.
Lack of charts : egregious violation. And unconscionable Needs chart to asses what's going on : is the BP too high ? What was it 10 mn ago ? . If MJ had had a bad experience, he had a right to know what happened to him. If he shouldn't survive, the family has the right to know what happened. Gives an example (Dr Shafer is clearly upset) : If my father , brother or son went to a medical facility for 80 days and died, I know how I would feel if i can't be told what had happened. It's illegal in California. Doctor has to keep records even if the patient doesn't want to. Dr has to put the patient first. Records are also used for other medical care providers. The state has a right check the records.
Doctors have responsability to know everything about their patient, to provide care. Mentions CM interview : said he saw IV sites on MJ , CM's obligation would have been to put his patient first. If the patient doen't want to tell, CM should have said : i can not be your doctor.
IV sedatives : no physical exam for months. Ex dehydration : why ot measure the blood pressure. No history, not even a simple recording of the vital signs; serious violation. No doctor does that.
Failure to maintain a doctor patient relationship : egregious violation. The dr would put the patient first. Doesn't meean to do what the patient asks, it's to do what's best for patient. If patient asks for something foolish or dangerous, doctor should have said no. Described the relation between Cm and MJ as employer employee relationship. Patient stated what he wanted, CM says yes. That's what an employee does. He's not exercising his medical judgement, not acting in Mjs best interest. Cm completely abandonned medical judgement. This did result in Mjs death. The very first time MJ asked for propofol, cm should have sent MJ to a sleep specialist.
Inormed consent : egregious and unconscinable. Informed consent would have involved that propofol is not a treatment for insomnia. It woud have involved risk of death. No proof that MJ knew that he put his life at risk. The consent has to be written.
What is a right of autonomy : your body is your body, you have a right to make decision, through the process of informed consent. CM should have informed mj that he may die as a result of propofol In this case MJ was in huge risk, no evidence that it was discussed. The right of autonomy desn't mean that CM had to do what he did, he should have said no. There should have been an informed consent every night. Mj was denied his right o make an informed decision.
Need to continuously observe the mental satus : egrgious and unconscionable deviation: assessing how awake the patient is. You need to saty with the patient. CM abadonned his patient. Giving sedation is like driving a motorhome. If you need to relieve yourself, you don't leave the steering wheel when you'e on a highway. CM left the steering wheel. «*In 25 years, I have never walked out of the room when the petient was receiving drugs*. If needed to leave, another colleague would come, but it has never happened*».
Being on the phone : egregious unconscionable : you can't multi task , especially if you have no monitoring. A patient who is about too die, doesn't look that different. From a distance you can't tell if a person is breathing. That's the only thing CM was supposed to watch, since he had no monitoring equipment. Believes Murray may have been in the room, and not have realised that MJ stopped breathing.
Continuous motitoring / observation : egregious violation : you need to constantly monitor . CM left, and was on the phone.
Ressuciation would have been easy : stop propofol, and make him beathe. In general anesthesia, patient stops breathing everyday, every patient stops breathing. It's no big deal, because it's expecetd. If CM had been been there, he would just have had to lift the chin or ventilate
break
Walgren
the safeguards and requirements apply to all doctors who perform sedation, for any type of IV sedative. many docs adminster sedation, they all follow these standards. These are required for IV sedatives of any sort.
Some nurses are trained to certain aspects of sedation. Nurses, emergency techniciens, all follow these guidelines.
IF CM's intent were to give 25mg would this apply : yes, there were other IV sedative, profound inability to sleep, patient was exhausted; exhaustion will block the response.
Patient had been given drugs , maybe was in withdrawal, maybe dependant, possibly dyhadrated from exercise.
Can you find a way tu use smaller amounts of sedative safely ? No, it's a common set up. «*a little bit of sedation*», it starts a slippery slope : you may have to add a little bit of this, and a little more of that. You don't know how the patient will react.
Facts in this suggest that virtually none of the safeguards were in place when propofol was given to MJ
asked to describe how patients react differently to the same dose : typically it's 50% : some patients will need half the usual dose, others will need the double of the usual dose.
The doctor has to prepare for the worst case scenario. 25Mg propoofol is the limit when a patient might stop breathing. You always assume your patient is at the edge of sensitivity.
Report about this case dated april 15th :
documentd the various devietion of standard of care.
Minor violation : not consistent with standard of care, but no problem for the patient, unless there are several violations
serious violation : harm to patient, in combination of serveral vioaltion
egregious violation : should never happen in the hand of comptent doc. An egeregious violation can be catastrophic for the patient. Bad outcome is at least a high possibility
unconscionable vioation : includes egregious violation. Unconscionable gets to ethics, violation of the rights of patient. It's a medical and moral violation.
Specific deviations in this case
1 basic airway equipment : egregious violation. MJ died because he stopped breathing, which is expected when you give IV sedatives. All it takes is a mask or intubation. If CM had left only 2 mn, and the equimpent was present, coud MJ have been saved ? Yes, absolutely. MJ probably had an obstructed airway, a chin lift would have probably worked.
CM didn't use the ambu bag, did mouth to mouth, ithat was less effective , it gives used air.
What was needed was a laryngeal mask, or laryngoscope and endotracheal tube. Described it a a serious deviation originally, changed his mind to en egregious because of the setting : CM had no help.
It is your view that CM had anticipated to giv 100 ml vials : purchased at least 130 100 ml vials, that's at least one per night. Has gone thruough applied pharrmacy's records. Now showing applied pharmacy recods. Says it's an extraordinary amount for one patient; between april – to 25th june, that 80 nights, 1937 mg/night;
propofol is a culture media for bacteria. Once a bottle is opened it has to be used within 6 hours; it suggests usage of 100ml, if not you would purchase smaller reports.
Lack of suction apparatus lack of : egregious violation. MJ was not asked to fast. He was at greatly higher risk ; Could have caused death
infusion pump : egregious violation . there was no infusion pump. Without it, the rate can not be precisely controled; the risk of overdose is very high. Likely contributed to Mjs death in his view.
Roller clamp : plastic wheel squeezes the tubing , it's extremely imprecise, was the only thing available to CM when he gave propofol. Lack of infusion pump was direct cause of Ms death.
Pulse oximetry : egregious violation . The pulse oxieter that was used is completely inappropriate. Not intended to be used for continuous care. No alarm. On monitors in hospital, here is a tone, the tone changes if there is a problem, so everybody in the room is aware that there is a problem.
What would a proper monitor would have shown : it would have had 100 oxygen satuaration at the beginning; there would be a 30 or 60 secs delay, because of xygen reserves in the lungs, then the rate would have started to fall, to 97, 92, 90, you would hear at tone, then at a certain level, the alarm would have gone off. This WOULD have saved MJ's life.
Blood pressure cuff: egregious violation. Propofol lowers BP. Usually no consequence, it's expected. We would treat it with hydratation, less propofol, medication; MJ was dehydrated, the risk are higher. If BP falls, the drug becomes more potent, because when there is less blood flow, it concentrate on heart an brain. Not monitoring, not knowing if he had a low bp, MJ might have had an exagerate response to propofol. A manual BP cuff in a cabinet is not usefuel there.
ECG : egregious violation . ECG allows you te see he heart rate, the heart rythm. This is routine monitoring. In his case, CM can't tell us what the heart was doing, CM couldn't know what kind of therapy to use when MJ went into arrest.
Capnography : egregious violation; initially thought that it was not a violation; in anesthesia its a standard, but tother specialiste don't use it. Thats why he didn't think initally that it was a violation. But in Mjs environement, it was a disatster : CM would have known immediately that MJ had stopped breathing. Caused Mjs death
Emergency drugs : serious violation. drugs to raise the BP, drugs used to stabilise the heart rythm, accelarate the heart. Phenolephrine (?), Ephedrine would raise the BP. If a breathing tube needs to be placed, you give a muscle relaxant so you can open the mouth fully. Succinocoline (sp ?) : paralyses the muscles so the tube can be placed. Doesn't think it contributed to Mjs dath : if low bp happened : hydratation and stopping propofol would have been enough. Mjs case is different, he could have been woken up, was not undergoing an operation where the patient can not be woken up.
Lack of charts : egregious violation. And unconscionable Needs chart to asses what's going on : is the BP too high ? What was it 10 mn ago ? . If MJ had had a bad experience, he had a right to know what happened to him. If he shouldn't survive, the family has the right to know what happened. Gives an example (Dr Shafer is clearly upset) : If my father , brother or son went to a medical facility for 80 days and died, I know how I would feel if i can't be told what had happened. It's illegal in California. Doctor has to keep records even if the patient doesn't want to. Dr has to put the patient first. Records are also used for other medical care providers. The state has a right check the records.
Doctors have responsability to know everything about their patient, to provide care. Mentions CM interview : said he saw IV sites on MJ , CM's obligation would have been to put his patient first. If the patient doen't want to tell, CM should have said : i can not be your doctor.
IV sedatives : no physical exam for months. Ex dehydration : why ot measure the blood pressure. No history, not even a simple recording of the vital signs; serious violation. No doctor does that.
Failure to maintain a doctor patient relationship : egregious violation. The dr would put the patient first. Doesn't meean to do what the patient asks, it's to do what's best for patient. If patient asks for something foolish or dangerous, doctor should have said no. Described the relation between Cm and MJ as employer employee relationship. Patient stated what he wanted, CM says yes. That's what an employee does. He's not exercising his medical judgement, not acting in Mjs best interest. Cm completely abandonned medical judgement. This did result in Mjs death. The very first time MJ asked for propofol, cm should have sent MJ to a sleep specialist.
Inormed consent : egregious and unconscinable. Informed consent would have involved that propofol is not a treatment for insomnia. It woud have involved risk of death. No proof that MJ knew that he put his life at risk. The consent has to be written.
What is a right of autonomy : your body is your body, you have a right to make decision, through the process of informed consent. CM should have informed mj that he may die as a result of propofol In this case MJ was in huge risk, no evidence that it was discussed. The right of autonomy desn't mean that CM had to do what he did, he should have said no. There should have been an informed consent every night. Mj was denied his right o make an informed decision.
Need to continuously observe the mental satus : egrgious and unconscionable deviation: assessing how awake the patient is. You need to saty with the patient. CM abadonned his patient. Giving sedation is like driving a motorhome. If you need to relieve yourself, you don't leave the steering wheel when you'e on a highway. CM left the steering wheel. «*In 25 years, I have never walked out of the room when the petient was receiving drugs*. If needed to leave, another colleague would come, but it has never happened*».
Being on the phone : egregious unconscionable : you can't multi task , especially if you have no monitoring. A patient who is about too die, doesn't look that different. From a distance you can't tell if a person is breathing. That's the only thing CM was supposed to watch, since he had no monitoring equipment. Believes Murray may have been in the room, and not have realised that MJ stopped breathing.
Continuous motitoring / observation : egregious violation : you need to constantly monitor . CM left, and was on the phone.
Ressuciation would have been easy : stop propofol, and make him beathe. In general anesthesia, patient stops breathing everyday, every patient stops breathing. It's no big deal, because it's expecetd. If CM had been been there, he would just have had to lift the chin or ventilate
break
suzynyc
Proud Member
Honey, I'm home from work.
There's that word again...inconceivable. This entire two years has been inconceivable.
There's that word again...inconceivable. This entire two years has been inconceivable.
thrillerchild
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I dread to think of Michael Jackson with a neurological injury :'(
Karen Faye is testifying? Good lord. I have to say that it must be hard for the family especially Katherine to know that simple steps could have been done to save Michael. I am not related to Michael yet it is crushing to hear these experts. Michael should still be here.
suzynyc
Proud Member
I love how Walgren pauses after a significant witness statement. He's making like he's writing but I think he's also letting that statement sink into the juror's minds. Brilliant.
Justthefacts
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The only thing that has me worried is they have not gotten into the amount in Michael
smoothlugar
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"mouth to mouth for a health care provider is an admission you don't have proper rescue equipment"
suzynyc
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The raising leg's thing Murray did always seemed strange to this lay person (me).
smoothlugar
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raising his legs seems to Dr. Shafer Murray was clueless of what to do
smoothlugar
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curious that he chose at this critical moment a reversal for lorazepam (if he had given only 4mg hours before) doesn't fit (flumazenil)
his conclusion is that he gave more lorazepam
his conclusion is that he gave more lorazepam
Bonnie Blue
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Great point by shafer - Murray gave the flumezil to MJ to counteract the lorezepam - suggests he knew he had given more than 4mg.
xthunderx2
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exactly you would only give and antidote for a drug if YOU are AWARE that drug was taken. I am so glad that they made a point to say that. It again squashes the defenses...he ate it while Murray was out of the room.
cinzia
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Murray is from another planet...that's the only reason I have come up with...his actions are so alien to every medical standard...even looking at him he seems so...uninterested somehow.
xthunderx2
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I dont think they have anything to object to...they KNOW that what Shafer is saying is the truth and they cannot refute it,,,so therefore...they have no grounds for objection. They have no defense for it.
suzynyc
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Pharmacological never, neverland.
suzynyc
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Wow SEVENTEEN egregious violations of the standard of care.
smoothlugar
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17 egregious violations, 4 of them also unconceivable and unethical
suzynyc
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So, there is no indication that Michael fasted prior to receiving propofol?