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Murray Trial- Day 13- October 19th Discussion

I remember someone saying at the Staple center Michael ate chicken breast, green beans, broccoli and had a protein shake that night
 
He is SO eloquent...and passionate about his profession and responsibilities...
He is carving up murray and serving him in small bits...
 
He told intimate details about Michael like it was gossip. What a betrayal. I am so disgusted. I love Dr Shafer
 
Oh my god. Murray, give up. There really is no point, the defence don't have a chance in hell. I like this doctor (witness not Murray obviously)
 
Dr Shafer is my hero. What a wonderful man.
 
I think all three of the Prosecution Experts have been amazing and destroyed the defence case....they must be ashamed of having Murray in their Medical Profession, they all seemed peeved with what Murray did.
 
That testimony was really trying to listen to. Completely frustrating! I'm off to bed :cry:
 
Murray was comprehensively buried by that testimony. There is no way back for him. He's sunk.
 
Dr. Shafer did an amazing job. There's just no excuse for what happen on June 25th and the days leading up to the 25th by Murray!
 
I am so glad that Shafer made the point to say that when Murray brought that propofol and saline bags to MJ's house everynight he was only thinking about Dr Murray, not MJ..
 
Dr. Shafer's final words brought tears to my eyes. Good words to end the day upon, Murray needs to go under.
Big props and much respect to Dr. Shafer, that's how a doctor is supposed to be.
 
also Shafer pointed out that ANY dose of propofol is TO MUCH..when the right monitoring equipment is not present. Each patient is different and each responds to a different level of propofol. So it didn't matter if Murray gave Michael 25mg or 200mg...Murray is still to blame for not having the proper life saving equipment. Also the level is different because Michael also had beno's on board. Shafer did very well.
 
Dr Shafer

Walgren

lack of continuous monitoring : egregious violation. It directly caused Mjs death

lack of continuous documentions : egregius and unconscionable violation : documenting is part of giving care; if he had done this, he would have seen that the oxygen saturation lowered, the different heart rythm. Violated the right of MJ and his family, because they do not know what happened.

failure to timely call 911 : egregious violation . In that setting, MJ could not have been revived without assistance. It was the highest priority , given the lack of help and equipment. If there had been impediments to call 911 , propofol should not have been given.
Assuming CM realised there was a problem at 12, doesn't understand that CM left a voice message to MAW and how it took 20 mn to call 911. Unconceivable, completely and utterly inexcusable. Doesn't know what to say.
If Cm left only for 2mn, believes MJ would be alive, with a bad brain damage, because the necessary equipment was not there. After 2mn, with the possibility to ventilate, MJ would be alive and uninjured.

How effective is a one hended CPR on a bed : when you push on the chest , the patient sinks into the bed, it's ineffective. You need 2 hands, one hand is not enough. Even if cm had his hand behind Mjs back, it's ineffective, you need your body weight.

Cm should have called 911, moved Mj to the floor. Based on Cms interview, the issue here was not that the heart stopped, he stopped breathing. If there was a pulse, he needed to have oxygen into his lungs. There was no need for CPR if there was a pulse.

Mouth to mouth is for a lay person, when there is no other means. For a docor it's the demonstration you dont have the equipment you need to ressucitate. Mouth to mouth air has only 18% oxygen. The patient needs oxygen.

Cm described raising MJ's legs : minor violation : it's a waste of time. You would do this if you think there is not enough blood in the heart. Suggests that CM was clueless about what to do.

What is flumazenil : it's a drug that can reverse or antagonize valium type of drugs. Works with lorazepam and midazolam.
Was it appropriate to give flumazenil : there was nothing wrong with giving it, but Dr Shafer thought it was curious , because it doesn't fit with 2 X 2 mg given hours before. Dr Shafer thinks that CM knew that there was a lot more lorazepam.

Deception of paramedics an UCLA doctors, not mentionning propofol : egregious and unconscionable violation. A person's life was in the balance, it's inexcusable. He also lied about the witnessed arrest. A witnessed arrest is usually something like a heart attack. A respiratory arrest is assumed to not have occured in the presence of a physician, it would not have led to a cardiac arrest. So the therapy of the paramedics and ER doctorq was not appropriate. In an arrest you have only seconds to choose a treatment, peramedics and Er doctors were not given the corect information. Witholding information is a violation of patient's trust.

Polypharmacy : it's administering many drugs at once; it was the case. Serious violation; Doesn't make any sense. Midazolam and lorazepam are very similar drugs. They do the same thing to the brain. The only difference is how long they stay in the system. Doesn't understand why CM switched from midazolam to lorazepam and back. Suggests that CM did not understand the drugs he was giving.

Was 25mg a safe dose ? In this setting, there was no safe dose. Midazolam an lorazepam were given. MJ had received benzos for 80 nights, he could have been dependant, or in withdrawal from the benzos. MJ could have been dependant or in withdrawal from propofol (Dr Shafer has never heard of propofol given for 80 nights, doesn't know what it would do). There is no safe dose in these cicumstances.

Taiwan study : dr shafer has evaluated this study, as a result of his work in this case. There are over 13 000 papers about propofol, 2500 about propofol and sedation. Propofol and insomnia : 1 article, its the Taiwan study, published in 2010.
Treating insomnia with propofol was an egregious violation.
Would not have published the Taiwan study : the dose of propofol that was given is not mentionned i the study. Inadequate evidence : 64 people is not enough, the editors were not familiar with propofol or with insomnia. The study was done in a hospital, by anesthesiolgists, patients fasted, were monitored, an infusion pump was used, propofol was used for 2 hours , for 5 days, during two weeks. No other medication was given. The patients were treated within the standard of care. The article highlights CMs deviations from standard of care.

Described 17 egregious deviations , among those 17, 4 are both egregious and unconscionable. Each one individualy were likely to result in Mjs death. They were foreseeable.
Walgren lists the 17 deviations, to fast for me.

Even if MJ had taken lorazeapm and self adminsiterd propofol, would these 17 deviations still stand, would you consider CM responsible for Mjs death ? yes.

Doctor patient relationship : dates back centuries ago. Doctors are permitted to know the most private and personal details. Doctors are entitled to give powerful drugs thant can kill and do harm, cut open a patient's body, you are entrusted to do that because you put the patient first. When Cm agreed to give propofol to MJ, he put CM first. When CM was showing up every night with propofol and saline bags, he was putting CM first. When Cm withheld info from paramedics and ER doctors, he put CM first.

Recess, until tomorrow 8 45
 
jaydom7 said:
I am so glad that Shafer made the point to say that when Murray brought that propofol and saline bags to MJ's house everynight he was only thinking about Dr Murray, not MJ..
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$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ murray.
 
I feel so gutted just knowing that all Murray had to do was stay by his side,,,and lift his chin to save his life. I think that will stay with me forever..:(
 
xthunderx2 said:
also Shafer pointed out that ANY dose of propofol is TO MUCH..when the right monitoring equipment is not present. Each patient is different and each responds to a different level of propofol. So it didn't matter if Murray gave Michael 25mg or 200mg...Murray is still to blame for not having the proper life saving equipment. Also the level is different because Michael also had beno's on board. Shafer did very well.
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I am glad he said this too. It never mattered to me the amount because it should have never been given in the first place especially in a home. He had nothing to help Michael and he didn't do anything right. Michael was at risk every single time.
 
So is shaffer still on direct or has he finished his testimony?
 
bouee;3515072 said:
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

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OMG OMG OMG. This is soooooooo heart breaking. why o why did it have to happen this way? Michael had the worst luck when it came to people.
 
marebear said:
I don't know how Murray can sit there thinking he did nothing wrong.
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I know! wtf! Does he have no conscience whatsoever. I can't believe he did this and then gave that police interview 2 days later, completely without remorse, trying to blame Michael, outing his secrets and generally acting like the biggest asshole on the planet. Oh man, to think this guy might spend a few months in jail for this!!!!! My god, thi is unbearable
 
mijaons said:
OMG OMG OMG. This is soooooooo heart breaking. why o why did it have to happen this way? Michael had the worst luck when it came to people.
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yes, exactly mt thoughts. Dr Safer almost made me cry.

It sounds unbelievable.

It's almost 2 am here, so I'll go to bed, and see you all tomorrow
 
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