Conrad Murray trial week 3. A MURDER?
This is a place to collect all information about week 3 of Murray’s trial.
First comes the link to Thomas Mesereau’s radio interview conducted by PositivelyMichael – he answers questions about Murray’s trial and talks about some aspects of the 2005 case:
Day 10. October 11, 2009
Detective Scott Smith is continuing his testimony. From the tape of his interview with Murray on June 27, 2009 (see here please) one gets the impression that he and Detective Orlando Martinez were having more of a gossipy chat with Murray than an official police interview. There were times when they laughed and Murray apparently felt very relaxed throughout the process.
The policemen disclosed to Murray some of their findings and when Murray heard of Michael using eye drops he said “Surprise, surprise” and sounded like rolling his eyes– he didn’t know that the drops were prescribed by Arnold Klein and his reaction implied that you could expect any unaccounted for behaviour from Jackson, to which the policemen tacitly agreed.
Those seasoned detectives allowed Murray to lead them in the discussion and left his monologue unchallenged – in fact they looked like two gullible housewives who listen to someone’s story with their mouths open. The detectives were too ready to believe anything bad about Jackson and this is the reason why they didn’t take the case seriously – at least until August 27 when the Coroner’s office suddenly pronounced the cause of death as HOMICIDE.
They were so sure there was nothing to look into that they didn’t do the basic things they were expected to do. They didn’t really talk to Alberto Alvarez and Faheem Mohammed as all they got from them was their contact information. Now, at the trial, this gives a chance to the Defense to claim that these witnesses initially “withheld” something from the police as they shared it only in August. But what if they were asked only in August?
They actually went into every direction Murray sent them to, losing valuable time and overlooking the real criminal under their very nose. They didn’t issue the search warrants of Conrad Murray’s home and went to Arnold Klein instead.
Their first “serious” (Walgren’s word) search warrants were executed on June 29 only when they searched Michael Jackson’s house. They also looked into Murray’s car though and found his contract with AEG there.
They didn’t demand then and there Murray’s medical records about his patient – in fact they are not doing it even in the June 27 interview as the tape shows it – and they let him go on his own after that. None of them could locate Murray the day before as his telephone was not answering and all their messages went to voice mail but even this did not raise a red flag for them.
They didn’t search the closet until Murray told them he had left his bags there. Now the defense presents it as Murray’s virtue claiming that he admitted it of his own free will, while his “honesty” has a totally different root – he was sure that the police had found the bags and was startled to find out that they had not. Detective Smith described Murray’s eyes widening and him leaning forward in amazement at hearing this news.
The police didn’t seal Michael Jackson’s home and if Murray had known it he could have very well entered it again and destroyed the valuable evidence. Detective Smith asked if it would be sealed but was told that under the circumstances it wasn’t needed.
They searched Murray’s clinic on July 22 and only on July 28 went to his home, office and storage room – which was actually a month after Michael Jackson’s death. Needless to say that there was no propofol found there.
And it was only after the search was made at the Applied Pharmacy Services conducted on August 11th that they found all those numerous invoices of shipments to Murray which finally sent them on the right track.
All that slackness on the part of the police gave Chernoff a chance to find numerous faults with them and their witnesses.
He asked questions like “You did talk to Alvarez in the hospital and he didn’t tell you of the vials or bag until August, did he?” “And Faheem Mohammed didn’t tell you that Dr.Murray wanted to go back to the residence?” Of course they didn’t as the police never asked and took only their contact information!
Chernoff made a mammoth story out of Smith not seeing the coroner investigator Ms. Fleak taking a propofol bottle out of the IV bag (as if her statement is not enough for it). Well, Detective Smith was simply not looking at that moment.
Chernoff further pressed the point and said that Smith wrote in his notes that an empty Lorazepam bottle from the master bathroom was found in a bag and presumed it was that very IV bag, but Walgren with the help of Smith clarified that it was a debris bag. To me the whole thing sounded like Smith didn’t really care what bag it was when he was writing it.
Chernoff turned some policeman’s phrase “Stop looking into other doctors!” into another big mountain, but Smith said that it was a “head-on” between the departments as others were looking into those doctors and they were interfering with each other.
Even with all those points duly clarified Walgren sounded a little embarrassed and tried to excuse the detectives’ lack of attention and too much confidence in Murray’s story by suggesting questions like:
– “Your knowledge of the case was limited at that time?” “Yes, very limited”
– “There is very little questioning done by Orlando Martinez and you during that interview. Was it your tactic to allow Conrad Murray to tell his story?” “It wasn’t an interrogation. It was an interview”
– “Did you have the phone records at the time?” ”No, we didn’t”.
– “Were you prepared for it? Do you have any medical education?” “No”.
Well, whatever the detective says now it is clear that their unwillingness to regard what happened in Michael Jackson’s house as a scene of crime could spring only from their preconceived notions about the man and the habitual wrong way of thinking that whatever happens to Michael Jackson he is always to blame for it.
This is why these seasoned detectives simply didn’t believe that Michael could become a victim of a crime – they were of so bad an opinion of him that it seemed natural he would die of some drug. And this is what Murray was very much hoping for when reciting his fairy tale to the detectives.
Under the heavy influence of this “he-is-always-to-blame” stereotype the detectives allowed themselves to never doubt Murray’s story and go in the directions he willfully sent them into.
In short people let Michael down even in his death – even those who were specially trained not to.
* * * * *
Dr. Rogers is Deputy Medical Examiner for Los Angeles and Chief of Forensic Medicine, which is part of the pathology medicine that deals with violent and unexplained deaths. His entire career was devoted to pathology. He personally handled several thousand autopsies and conducted an autopsy of Michael Jackson on June 26, 2009.
An autopsy is an examination of the outside and each of internal organs in pursue of the cause of death. The outside of Michael’s body did not have any abnormalities which would be suggestive of the way he died.
This reminded me of the Discovery channel’s plans to show an online autopsy of Michael’s body which besides being totally unethical was also absolutely useless – what was there to show if there was nothing on the outside?
On the day of the autopsy Dr. Rogers was unable to determine the cause of death. Specimen for toxicology tests were sent out for further examination. Prosecutor David Walgren asked the doctor about the overall health of Michael Jackson and he said that Michael was healthier than the average person of his age is.
Yes, all those Michael Jackson’s detractors who still call him derogatory names, please remember that he was healthier than any of you who entered or will enter the age of 50. And this, my dear ones, can only be the result of a healthy way of life and healthy way of thinking…
Unfortunately David Walgren showed a picture of Michael Jackson dead. I didn’t really look because I didn’t want to. However here is the picture of Michael’s arm which shows where all those numerous punctures found on his body came from.
Dr. Rogers said that Michael’s coronary system did not show any atherosclerosis (the build-up of fat and cholesterol in the blood vessels of his heart).
The extremely reserved Dr. Rogers looked visibly surprised when he said it and when Walgren asked why, he explained that at the age of 50 almost everyone has atherosclerosis – however Michael Jackson didn’t have any.
Among Michael’s specific features he noted his vitiligo skin disorder, a chronic inflammation and scarring of lungs, enlargement of prostate which made it difficult to urinate (this malady of ageing men did not unfortunately bypass him, poor thing), arthritis, an irregular depigmentation area on the top of his scalp (where he had a burn during the filming of a commercial) and some other minor points like root canal therapy and others.
Michael Jackson’s height was 5 feet 9 inches / 175 centimeters and he weighed 63 Kgs / 136 lbs. Walgren suggested that Mr. Jackson was thin but Dr. Rogers said that his body mass index was within the normal range.
The doctor analyzed all parts of Michael’s digestive and respiratory systems for signs of propofol – beginning from mouth to the stomach and from the upper airway to the lungs – but didn’t find any signs of it. The stomach contained 70ml of dark liquid which he specifically examined for presence of any pills or tablets as the cause of death, but the liquid did not contain any.
At this point I recalled all those tabloids screaming of dozens of terrible pills in Michael’s stomach and printing huge pictures of Xanax and Demerol on their front pages. Here is the one I made a screen shot of – let it stay here as a monument to their disgrace.
Dr. Rogers sought medical records from Conrad Murray regarding his treatment of Michael Jackson but was not able to obtain any.
He had consultations with other doctors including anesthesiologists before determining the cause of Michael’s death and after collecting all the results concluded that it was HOMICIDE. This determination was based on several issues:
- Murray’s own statement to the police in which he admitted administering benzodiazepines and the propofol
- the risk of administering propofol under those circumstances outweighed the benefits of it
- the setting was outside the clinic
- there was no precision device that could measure how much propofol was being given
- there was no monitoring and resuscitation equipment present, no equipment to improve MJ’s circulatory function
- the overall circumstances did not support self-administration of propofol.
In forming his conclusion over the “self-administration” point he chose between two scenarios. The first was that MJ supposedly woke up and still being under the effect of sedation drew propofol from a vial, reached for the IV port and self- injected it there. Since the injection was supposedly given in the leg (under the knee) it also takes longer time to reach the brain, so within 2 minutes while Murray was away it was not a realistic scenario to happen.
The alternate scenario was that the doctor gave Michael a bigger doze than required.
Dr. Roger explained this point in detail. The initial 25mg (2.5ml) doze of propofol reportedly given by Murray was not big. After that he had to give additional dozes to keep MJ sleeping – this would be 2-3 table spoonfuls of propofol per hour. It was imperative that the dosage should be precise for fear of excessive administration – however they didn’t find any precision dosing device on the scene and without it the doctor was unable to estimate how much propofol he was giving. Since the device was missing it was more likely that Murray overdosed his patient (in the best case scenario).
The cause of death was acute propofol intoxication with a contributing effect of benzodiazepines (Midazolam and Lorazepam). These two drugs would bring about a quicker depression of breathing and would exacerbate the effect of propofol.
Considering that the paramedics worked on Michael’s body for some 20 minutes or so and then the emergency room doctors did the same for an hour and 15 minutes the punctures made were numerous. I hope that tabloids will finally shut up after hearing that.
And before going on an afternoon break Dr. Rogers and David Walgren dropped a sort of a bomb. They examined the photos of the stopper on the 100ml propofol vial (the one in the IV bag) and found that it had a totally different puncture mark that the one usually left by a syringe needle.
That stopper had a slit. It was a line stretching from side to side all through the middle of the stopper.
Dr. Roger said that he had seen such marks before. They come from a device which is seldom used now (the last time he used it was in medical school). It is called a spike. It cuts through the rubber and the propofol will freely flow down the end of it.
A spike allows the propofol to uncontrollably drip from the vial or even produce a steady stream from it.
You put the vial upside down, attach some tubing to it and here it is dripping slower or quicker depending on how big the slit is…
At that point it occurred to me that the case was beginning to rapidly turn into a murder one.
It probably occurred to many of us as after the break John Michael Flanagan of the Defense suggested all sorts of fantasy theories to explain the strange mark on the rubber stopper. Unfortunately Dr. Rogers simply confirmed that some theories were possible without giving his evaluation of such actions – thus possibly creating the impression that it was okay to do all those things.
What Flanagan suggested, for example, was that the vial of propofol (with a slit in the rubber) was put inside the IV saline bag in order to dilute it with saline and administer propofol this way. The theory is totally outrageous – a dirty vial is dropped into a sterile liquid and creates some sort of a mix which is then dripped into a body? Even in war-time conditions doctors would not do a thing like that! And the propofol concentration will be so little that it won’t take any effect either!
After listening for half an hour to this crazy talk we finally hear Flanagan admitting that no signs of propofol were found in the IV bag (so all that show was for the sake of show only).
The Defense does indeed grasps at straws.
One of Flanagan’s attempts attracted my attention though. He started to develop a theory that after the first 5 minutes of sleep, which would be induced by the initial 25ml of propofol, the patient could go on sleeping naturally just “because he was tired”.
This by the way may be pointing to what really happened in that bedroom – Murray could have administered propofol, and when his patient did not wake up, he could go on with his business happy that the patient was quiet at last and was no longer a nuisance. Dr. Rogers merely said “yes” to this theory without giving his assessment of it.
Though propofol is a clear reason for Michael’s death (in whichever way it was given), the Defense now is diverting our attention from this drug and is switching over to Lorazepam. On the next day of the trial they announce that they are no longer pursuing the theory of self-administering Propofol:
Attorneys for Dr. Conrad Murray told the judge in his manslaughter trial that they were dropping their claim that Jackson swallowed propofol when Murray was out of the room. The defense still is arguing that the singer could have injected himself with an extra, fatal dose on June 25, 2009.
“We are not going to assert at any point in time in this trial that Michael Jackson orally ingested propofol,” Murray’s attorney J. Michael Flanagan told the judge.
With the jury out of the courtroom on Wednesday, Murray’s attorneys and prosecutors presented medical studies to the judge that have shown propofol has no major effects on a person when swallowed.
Now they claim that in his desperation for sleep Michael Jackson swallowed Lorazepam pills which were in a bottle on the night stand.
This medication was prescribed by Murray on April 28, 2009 (to be taken 1 pill at bedtime). The bottle contained 30 pills and two months later had 9 and a half pills left. This means that for approximately 60 days Michael took 20 pills and a half. It also means that Michael was so cautious with it that there were cases when he took pills by half.
However Flanagan forced Dr. Rogers to make some calculations and admit that the concentration of Lorazepam in the stomach was four times as big as in the femoral blood. (Femoral blood is periphery blood and is different from central blood near the heart as it is less susceptible to postmortem changes).
Femoral blood had a concentration of 0, 169 milligrams of Lorazepam, while the gastric contents had 0,634 milligrams of it.
However whatever concentration it was we still remember that the amount of Lorazepam found in the stomach was equal to only 1/43d part of one 2mg pill of Lorazepam which is a ridiculously small dose unable to cause death.
Proof of it was presented by David Walgren on week 2 of the trial during the testimony of toxicologist Dan Andersen.
During re-crossing Dr. Rogers David Walgren specifically noted that most of the Defense’s questions centered on pharmacology and were beyond Dr. Rogers’s area of expertise.
Finally Walgren asked him a very important question.
Even if Murray’s scenario was correct and the half-sedated patient was left with Lorazepam or Propofol beside his bed and took it while the doctor was away WAS IT STILL A HOMICIDE?
Dr. Rogers said “YES”.
* * * * *
Days 11-12. October 12-13, 2009
Before reading about the testimony of Dr. Alon Steinberg who testified on that day we first need to look at Murray’s initial version of the events of June 25, 2009 the way they are related in his interview with Detectives Smith and Martinez.
The reason for that is because the full meaning of Dr. Steinberg’s testimony will become clear only after we get familiar with the real timeline of the events and what Murray said about his actions during that period. Though this information was placed at the end of week 2 I place the transcript of the interview here again for easier reference, together with the chart of Murray’s telephone conversations that morning:
DETECTIVE SMITH: OKAY. SO YOU GAVE HIM THIS PROPOFOL.
DR. MURRAY: YES.
DETECTIVE SMITH: DO YOU REMEMBER ABOUT WHAT TIME IT WAS NOW? THE LAST TIME I GOT WAS ABOUT 10:00 O’CLOCK, WHEN THERE WAS STILL NO EFFECT AND HE’S COMPLAINING THAT HE IS GOING TO HAVE TO CANCEL.
DR. MURRAY: IT WAS — I KNEW I LOOKED AT THE TIME. I LOOKED AT THE SUN. AND IT WAS — IT WAS – I SAW 10:30. SO I WOULD SAY ROUGHLY 10:40.
DETECTIVE SMITH: HOW MUCH DID YOU ADMINISTER INITIALLY?
DR. MURRAY: 2 5 MILLIGRAMS.
DETECTIVE SMITH: OKAY. AND AGAIN, THIS WAS APPROXIMATELY 10:40 NOW, GIVE OR TAKE?
DR. MURRAY: WELL, BY 10:40, WE — WE HAVE DISCUSSED THAT NOTHING IS HAPPENING. SO BY THE TIME I WITHDRAW IT FROM THE BOTTLE, GET IT DILUTED — I HAD TO DILUTE IT, AND USUALLY I DILUTE IT WITH LIDOCAINE, L-I-D-O-C-A-I-N-E, BECAUSE IT COULD BE VERY — IT BURNS THE VESSELS. IN THE SENSE OF THE SIDE EFFECT, IT CAUSES IT TO BURN
DETECTIVE SMITH: AND I’M SORRY. YOU GAVE HIM HOW MUCH NOW?
DR. MURRAY: 2 5 MILLIGRAMS.
DETECTIVE SMITH: OKAY. AND ALWAYS THE SAME WAY.
DR. MURRAY: YES.
DETECTIVE SMITH: REGARDLESS OF WHAT YOU WERE GIVING HIM, WAS INTO THE —
DR. MURRAY: YES, I PUSHED IT.
DETECTIVE SMITH: OKAY.
DR. MURRAY: UH-HUH.
DETECTIVE SMITH: OKAY. I AM SORRY I INTERRUPTED YOU. BUT WE WERE GETTING TOWARDS THE TIME AT 10:40, YOU REALIZED THAT NOTHING WAS HAPPENING, AND SO BY THE TIME YOU GOT YOUR THINGS TOGETHER AND YOU PUSHED IT, IT WAS —
DR. MURRAY: IT WOULDN’T TAKE A LONG TIME FOR ME TO JUST WITHDRAW FROM A VIAL AND DILUTE IT WITH THE LIDOCAINE, WHICH IS A LOCAL ANESTHETIC AGENT THAT, YOU KNOW, ALSO IS A SODIUM BLOCKER TO MAKE HIM NOT FEEL THE BURNING SENSATION OF THE SLOW INJECTION. SO I HAD A TOTAL OF MEDICATION MIXED WITH THE LIDOCAINE, AND I ADMINISTERED IT.
DETECTIVE MARTINEZ: OKAY. DOES THAT TAKE YOU ABOUT AN EXTRA 5 MINUTES OR 10 MINUTES?
DR. MURRAY: SLOWLY INFUSED. SLOWLY INFUSED OVER, I WOULD SAY, 3 TO 5 MINUTES.
DETECTIVE MARTINEZ: 3 TO 5?
DR. MURRAY: YEAH, BECAUSE THE EFFECT IS GONE VERY QUICKLY.
DETECTIVE MARTINEZ: SO WE’RE LOOKING LIKE AT 10:50ISH.
DR. MURRAY: YES. YEAH, THE EFFECT IS GONE VERY QUICKLY. SO THE EFFECT WAS ONLY LAST — ONLY LASTS ABOUT 15 MINUTES.
DETECTIVE SMITH: OKAY. SO NOW WE’RE AT ROUGHLY 10:50, 11:00 O’CLOCK.
DR. MURRAY: UH-HUH.
DETECTIVE SMITH: WHAT TAKES PLACE NEXT?
DR. MURRAY: WELL, YOU KNOW, HE’S NOW ASLEEP, YOU KNOW.
DETECTIVE SMITH: HE DOES GO TO SLEEP.
DETECTIVE MARTINEZ: OKAY. WE’RE GOING TO GET BACK ON TRACK. WE’RE AT ABOUT 10:50 HOURS.
DETECTIVE MARTINEZ: WHERE YOU GIVE HIM THE PROPOFOL. WE’VE GONE INTO THE HISTORY OF HOW HE ALREADY KNEW ABOUT IT. HE’S THE ONE WHO REQUESTED YOU —
DR. MURRAY: YES.
DETECTIVE MARTINEZ: –FOR IT, GIVING YOU SOME PRESSURE.
MR. CHERNOFF: WE GOT THE MILLIGRAMS, 25.
DETECTIVE MARTINEZ: 25 MILLIGRAMS, HALF OF WHAT YOU NORMALLY GIVE. NOW, WHAT HAPPENS NEXT?
DR. MURRAY: I AM — I’M MONITORING HIM AT THE HOUSE. AND HE FELL ASLEEP.
DETECTIVE SMITH: 11:00 O’CLOCK NOW? LATER?
DR. MURRAY: HE FELL ASLEEP FAIRLY QUICKLY, I WOULD SAY. BUT HE WAS NOT SNORING. NORMALLY, IF HE’S IN DEEP SLEEP, HE WOULD BE SNORING. I WAS A LITTLE BIT HESITANT THAT HE WOULD PROBABLY JUMP OUT OF SLEEP, BECAUSE THAT IS – HE DOES. HE JUST (SNAPS) GETS UP LIKE THAT, AND HIS EYES GOES, AND HE’S WIDE AWAKE. AND WHENEVER HE’S UP, HE REACHES FOR HIS I.V. SITE.
… I MONITORED HIM. I SAT THERE AND WATCH HIM FOR LONG ENOUGH PERIOD THAT I FELT COMFORTABLE. THEN I NEEDED TO GO TO THE BATHROOM. SO I GOT UP, WENT TO THE BATHROOM TO RELEASE MYSELF OF URINE AND ALSO CONSIDER GETTING RID OF SOME OF HIS URINATION THAT HE HAD PUT IN THE JUGS OVERNIGHT.
THEN I CAME BACK TO HIS BEDSIDE AND WAS STUNNED IN THE SENSE THAT HE WASN’T BREATHING.
DETECTIVE MARTINEZ: ALL RIGHT. SO YOU HAD THE IMPRESSION HE WASN’T BREATHING, AND YOU SAID HIS PULSE WAS HIGH?
DR. MURRAY: WHEN I CAME BACK, YEAH.
DETECTIVE MARTINEZ: GO ON.
DR. MURRAY: BEDSIDE AND MY CLINICAL OBSERVATION. SO IMMEDIATELY I FELT FOR A PULSE, AND I WAS ABLE TO GET A THREADY PULSE IN THE FEMORAL REGION.
HIS BODY WAS WARM. THERE WAS NO CHANGE IN COLOR. SO I — I ASSUMED THAT EVERYTHING HAPPENED VERY QUICKLY, JUST ABOUT THE TIME I WAS GONE, WITHIN THAT TIME AND COMING BACK. SO I STARTED IMMEDIATELY TO PERFORM C.P.R. AND MOUTH-TO-MOUTH RESUSCITATION.
Let us go over it again.
He says that he “looks at the sun” and checks up the time – it is 10.30.
Then he dilutes the propofol with lidocaine and about 10 minutes later – at 10:40 – starts administering it slowly. It takes him 3 to 5 minutes to make the injection. This brings us to 10.43 – 10.45.
He says that the effect of the injection will last only for 15 minutes – which takes us to 11.00, after which he supposedly finds that Michael is not breathing.
So beginning with 11.00 o’clock he is supposed to begin frantically working on his heart, etc.
Let me remind you that this was Murray’s story told to the detectives on June 27, 2009 or two days after the event. Later on he changed it and we will have to look specifically into the reasons why he did and what the meaning of it is.
In the meantime though let us just compare his story with what was really happening at the described crucial period of time.
The description of all calls to and from Murray’s cell phones that morning is found in the testimony of Detective Myers at the preliminary hearings. Murray’s calls will enable us to draw a timeline of the events, determine the real background for what was happening in that room on June 25, 2009 and compare it with Murray’s story told to Detective Martinez and Smith on June 27, 2009.
5: 54 am An email comes from London from Bob Taylor who writes that the insurers require full information MJ’s various medical conditions including the period of the 2005 trial or otherwise the insurance could be called into question. The email is long and demanding. It demands a 5-year medical record of the artist and lots of other information concerning press reports on Michael’s back injury, lupus, reasons why he appears in wheelchair, whether he has skin cancer, etc.
…. 7:01 am Murray calls Andrew Butler. Butler says that Murray is his doctor and friend. He doesn’t remember if he received a call from Murray that morning but acknowledges Murray’s number (evidently in the printout of calls).
8:49 am a call is placed to Murray by Antoinette Gill, his patient and friend. She says she spoke to Murray. The reason why she called is because she “received a letter in the mail indicating that he was not going to be in the office. Someone else would be seeing her, and that she called the doctor to ask, to inquire”.
9:23 am a call comes in from a girlfriend of Channel, Murray’s daughter.
10:14 am a call comes from Acres Home And Cardiac Care, the clinic where Murray practiced in Texas.
10:22 – 10:24 am a call comes from Dr. Prashad. It is a consultation about one of Murray’s patients. The prosecutor tells it all in one sentence: “So Dr. Prashad conveyed to you that in her short telephone call of approximately less than two minutes, 111 seconds, Dr. Murray was able to recollect the patient that she was referring to, provide her with necessary information concerning that patient’s current prescription and medication needs, as well as a previous procedure some two months earlier that Dr. Murray had conducted on that patient?” “Correct”.
10:34 am a call comes from Murray’s personal assistant Stacey Ruggles . They “discussed a document that was to be drafted to the London medical boards indicating his pending arrival and what facilities may be available to him, if needed”. She says that Dr. Murray doesn’t sound distracted or tired, as Detective Myers testifies:
Q. Dr. Murray was directing her, requesting of her to draft a letter concerning his activities at the upcoming tour in London?
A. That’s correct
Q. Did you ask Ms. Howe-Ruggles whether or not Conrad Murray seemed distracted or preoccupied at any time during the phone conversation that she had with him on June 25, 2009?
A Yes, I did.
Q. What was her response?
A. She did not indicate that he appeared to be distracted or tired.
11:07 – 11:08 am Murray places a call to Stacey Ruggles and speaks to her for one minute.
11:17 am Murray sends out an email to Bob Taylor of the insurance company in London.
11:18 – 11:49 am comes a call from Murray’s Las Vegas practice. It lasts for 32 minutes.
Q Moving to 11:18 a.m., a call from (702) 862-0973 placed to (702) 866-6802. That call duration reflects 32 minutes. Detective, did you contact the (702) number that ends 6802 during your investigation to make determination as to who that number belongs to?
A Yes, and I was actually at the location as well.
Q What is that location associated with that telephone number?
A It was Dr. Murray’s practice in Houston — in Las Vegas. It is known as global cardiovascular & associates.
11:26 am a call comes from Bridgette Morgan over another cell phone. Murray does not answer it. He is talking to his Las Vegas practice.
11:49 am a voicemail is sent by Murray to his patient Robert Russell which lasts 3 minutes. In his testimony Russell explained that on June 25 he called Murray’s office and expressed his frustration at continuous cancellation of his appointments with the doctor. Both his June 15 and June 22 appointments had been cancelled and he wanted to know where he stood. Only a few weeks prior to that he had been near death and now he had no information whatsoever and was not referred to any other cardiologist.
When calling Murray’s office he said that he expected a return call or he would proceed to legal action. He said he felt abandoned and needed answers. In reply to his complaints a voice mail from Murray came at 11:49 am. In his message Murray was saying that the patient’s “heart was repaired”. Russell was pleased that Dr. Murray responded so quickly but was disappointed that there was still no information about another doctor to whom he could be referred.
11:51 – 12:01 am Murray calls Sade Alding. She says that 5-6 minutes into the calls she realizes that Murray is not responding. She hears a cough and mumbling of voices. She listens to that noise for some 3-4 minutes and then hangs up. She tries to call him again but cannot reach him.
12:12pm Murray types a message from the same telephone to Michael Amir Williams, assistant to Michael Jackson. He is writing: “Please call me right away”. Williams calls him back at 12:13. “Where are you?” asks Murray. Williams says, “I am in downtown”. Murray: “Get here right away. He had a bad reaction!”
1:08 pm Murray calls his girlfriend Nicole Alvarez by whom he has a son and with whom he is living in Los Angeles. In her testimony she said he told her that he was on the way to the hospital in the ambulance with Mr. Jackson and that she should not be alarmed … “because he knew she would learn this through the news.” The paramedics who overheard the conversation recalled Murray saying: “It’s about Michael, and it doesn’t look good.”
If you ask for my interpretation of the above I will say that ever since Conrad Murray received a long and demanding email from the insurers in London at about 6 o’clock in the morning he was was extremely busy with various business matters. In addition to the insurance his patient threatened to sue him and a doctor called him for a consultation about another of his patients.
Conrad Murray simply had no time for Michael Jackson.
Beginning with the 10:14 call he is on the phone practically non-stop talking, typing emails, sending voicemails.
First Dr. Prashad calls him at 10:22 to consult him about one of his patients.
Then his employee Ruggles talks to him about the insurance at 10:34 am. He asks her to draft a letter to Bob Taylor of the insurance company, then calls her back, receives the draft email, checks it up and sends it out to London at 11:17. After settling that problem he attends to Robert Russell.
His assistant Ruggles has evidently told him about the imminent legal complaint from Robert Russell unless he answers his calls. So Murray first talks to his Las Vegas staff for 32 minutes to find out what he wants and what he can answer him in respect of his health condition. When that conversation is over at 11:49, he immediately starts dictating a voicemail to Russell. The voicemail is registered as going out at 11:49.
He simply cannot stop talking and at 11:51 he calls his girlfriend Sade Alding. And 5-6 minutes after the conversation started he finally notices that his patient is not breathing.
By the condition of Michael’s body temperature and other signs he realizes that Michael has been dead for about an hour already. After the initial panic and some frantic movements like cutting the saline bag and putting the empty 100ml of propofol inside it to imitate the dripping he runs back and forth to the chef, calls Michael Amir Williams and starts the CPR.
Only he is late in doing it by more than an hour.
In fact Michael could have died earlier than that (and Murray wouldn’t have noticed it either), but since he is still a doctor he managed to calculate the approximate time of his death by the condition of his skin, body temperature, etc.
This is why during his interview with Detectives Martinez and Scott on June 27 he blurts out the approximate real time of Michael’s death – either because he is afraid the police will be able to determine it by themselves (and he doesn’t want to be caught in this lie) or because in his panic he isn’t able to think of anything better.
In any case the description of his real actions on that day shows that the story he related to the detectives in his June 27 interview IS A COMPLETE LIE.
Among many other things the real timeline shows that Michael was most probably asleep while Murray was attending to his business.
The sadness that Michael Jackson’s life was in the hands of this man is indescribable.
* * * * *
Dt. Steinberg spoke in a clear and understandable way and used his testimony not only for assessing Murray’s standard of care but for educating people on various medical issues, including the correct way to perform the CPR in case you see someone down.
In short he is a real doctor, and a doctor is always a doctor – even if he is in the witness stand at a trial.
Dr. Steinberg is one the leading cardiologists of the Californian medical board which is a government agency licencing, regulating and disciplining physicians. He himself is board certified in two areas of cardiology.
To be board certified means completing a cardiology fellowship and passing an extensive two day exam that goes over the basic knowledge and skills in cardiology.
As of 2009 Dr. Murray was not board certified despite the fact that 90% of the cardiologists who take the exam pass it – not because it is easy (it is not), but due to their good training.
At the request of the Californian medical board Dr. Steinberg reviewed Murray’s case to check whether the doctor’s actions were within the “standard of care”, which he described in a simple way – it is “what all ordinary doctors should do in the same situation”.
There are three possible resolutions to be passed on the standard of care by a doctor:
- No deviation
- A minor or simple deviation
- A severe or extreme deviation.
Dr. Steinberg said that it was the first time he encountered a case of an extreme deviation (as far as I know after his review Murray’s licence was suspended).
To make his judgment in the case Dr. Steinberg had several reports available to him but chose to use Murray’s own interview with the detectives. He said he wanted to judge him on his own words.
This was an absolutely brilliant decision as Murray’s story presented two days after June 25th was his highly polished version of the events. In short it was the best story Murray could come up with and Dr. Steinberg decided to judge Murray on what he considered his best.
Following Murray’s own account of the events Dr. Steinberg found 6 extreme deviations each of which amounted to gross negligence:
1) The propofol was not medically indicated. It means that doctors don’t use it for rest, sleep or psychological problems
2) It is gross negligence to get a patient under propofol without proper monitoring him, without proper equipment and personnel,and without proper physical observation of the patient
Dr. Steinberg gave a list of the equipment which was required for giving propofol:
- a proper pulse oxymeter with an alarm. This device measures oxygen in the heart and rings an alarm if the oxygen gets low. Murray’s oxymeter did not have an alarm and this means that he was supposed “to sit and stare at the device every second while his patient was under propofol”, as Dr. Steinberg put it. ( Did you also recall at this point that Murray did not only fail to stare at the device and monitor Michael but was talking on the phone for hours on end?)
- an automated blood pressure cuff was to check the patient under propofol at least every 5 minutes and this was not done either. Murray had a manual cuff but it was not in use
(remember the picture of it being packed in several bags and a box?)
- there was no EKG machine to monitor the heart rhythm to avoid arrhythmia (any rhythm different from normal is arrhythmia)
- another requirement was a mask with an ambu bag for pushing oxygen into lungs in case the patient stops breathing. It is interesting that Murray had this device but he didn’t use it – it was lying on the floor. When Walgren asked him how he knew it wasn’t in use Dr.
Steinberg explained that he took it from Murray’s own statement to the police where he said he did mouth to mouth but didn’t use the ambu bag.
- A hard board was to be placed under the patient in case CPR was needed. If CPR is done on a soft bed and the patient’s heart is pushed down by the required 2 inches, it is useless as the body is just being displaced down – so a hard surface is a must
Many other things are required like a back-up battery in case lights go out, a tube for intubating a patient directly into lungs if the mask is no help and some small device which keeps the tongue from obstructing the airway during sedation – in short at least a dozen important things are needed for proper monitoring a patient under propofol.
3) Another extreme deviation was inadequate preparation for the emergency situation.
When you do propofol you need to be prepared for any foreseeable consequence and Murray was not. Propofol can very easily pass from mild sedation to moderate, and from moderate to deep sedation (a stage when there is no breathing). It has a “narrow threshold” as Dr.Steinberg described it so a patient can pass from one edge to another in no time and get over-sedated.
Let me make a comment here.
Now we know that instead of using a proper dosing device to measure every tiny drop of propofol Murray used vials with slits in them so that propofol dripped down freely. With so much excessive propofol poured into his system nightly Michael could possibly experience breathing stops very often – probably even every night. This could be the reason why his health was deteriorating very quickly under Murray’s “care”.
And what happens when breathing stops Dr. Steinberg explained in the next point of extreme deviation from standard care.
4) The fourth extreme deviation was Murray’s improper care during the respiratory arrest or stop of breathing.
Since this is one of the crucial points in the testimony I’ll follow Dr. Steinberg’s words in even more detail. It made me realize that Michael was dying slowly which is a terrible thing to imagine, but on the other hand it means that if Murray had called for help at once Michael could have been saved.
- Michael’s case was not a cardiac arrest –which is when the heart stops beating and contracting. In cases of a cardiac arrest doctors do chest compressions (CPR) to make the blood flow through the body while they wait for a defibrillator to arrive. Defibrillator is used for making an electric shock and restarting the heart.
- Michael’s case was a respiratory arrest. It means that he stopped breathing – but since there was still some oxygen in the lungs, his heart went on beating. However when the oxygen slows down, the heart starts to get excited and the heart rhythm goes higher. Eventually, due to the absence of oxygen the heart slowly weakens and finally stops. The electricity is still in the heart and can be registered (it is called pulseless electrical activity), but there is no heartbeat and no pulse. At the final stage electricity also dies and you see a flat line on the monitor.
What is important is that at the moment of respiratory depression, when the heart is beating like mad, CPR is not done at all – it is oxygen which the heart needs, not CPR!
And here Dr. Steinberg referred to Murray’s own words in that interview.
Murray said he left Michael’s side when the oxygen was “in the 90s” which is normal. He said he was away for two minutes.
When he came back his patient was not breathing and his heart rate was a hundred and twenty two (122) which is a lot. Murray says he checked the pulse using a pulse oxymeter – and this device won’t detect a pulse unless there is a blood pressure, so according to Murray’s own words when he returned from the bathroom Michael’s heart was still beating.
Dr. Steinberg says that at this moment Murray should have called 911. After calling for help he should have tried to arouse Michael, put an oxygen mask on his face and start pushing oxygen into the lungs via an ambu bag. Simultaneously he was to inject Flumazenal as soon as possible in order to reverse the effect of the benzodiazepines given earlier.
And what did he do? Instead of those three steps – dialling 911, oxygen and Flumazenal – Murray, according to his own words, started doing chest compressions which was inexcusable as Dr. Steinberg put it.
The other factor was that his CPR was of poor quality. He shouldn’t have done it on the soft surface and with one hand too. He should have slipped Michael to the floor and with his size Murray it was no problem to slide down a man who weighed 136lbs.
In fact each of those actions was an extreme deviation for standard of care but Dr. Steinberg regarded it just as one point.
5) The fifth extreme deviation was Murray’s failure to summon immediate help.
Dr. Steinberg said, “It’s basic knowledge, you don’t have to be a health-care professional — when you see someone down, you have to call 911.”
When Murray saw Michael not breathing he knew that he had no equipment, no personnel and no necessary medications – so he needed help quick and should have called 911.
And the delay in calling 911 was significant. According to Murray’s own words first he did CPR and mouth-to-mouth, then he called Mr. Amir Williams and even then he didn’t ask even Williams to call 911.
The paramedics were only four minutes away, so instead of that huge 20 minute delay he could have got help within 4 minutes only.
Dr. Steinberg says there is statistics that for every minute of a delay there is a much less chance that the patient will survive. In such situations every minute counts as even if the heart survives a long delay may result in a permanent damage to the brain (if it stays too long without oxygen).
Dr. Steinberg described Murray’s behaviour as bizarre – he had a chance to call 911 but called Michael’s assistant instead?
6) The sixth extreme deviation was Murray’s failure to maintain proper medical records.
The records are kept not only for insurance or possible litigation but for providing better care of the patient, registering the history of each procedure, reaction to medications, lab results, etc. However Murray did not document a single thing.
If he had kept them those records could have been handled to the emergency room doctors when they arrived at the UCLA hospital and could have told them what he was unable to say when he was asked to.
In conclusion Dr. Steinberg said that all those breaches directly contributed to Michael Jackson’s untimely death. If it had not been for them he would be alive now.
Same as with Dr. Rogers, Walgren asked Dr. Steinberg a question whether it would matter IF THE PATIENT SELF-ADMINISTERED some medication. Dr. Steiberg confirmed that all those extreme deviations WOULD STILL APPLY.
- “When you monitor a patient, you never leave his side, especially after giving propofol,” Steinberg said. “It’s like leaving a baby sleeping on your kitchen countertop. You would never do it because there’s a small — a very, very small — chance that the baby could fall or grab a knife or something.”
You’ll find the above Dr. Steinberg’s testimony in this video:
The cross-examination by Flanagan was a rare circus which is difficult to explain.
I’ll start with Murray’s interview of June 27 where he implied that Michael stopped breathing at 11 o’clock.
The detectives were so much taken in by his story that neither of them asked a question why he found the patient not breathing at 11.00 but didn’t call for help until 12.20. Since they didn’t talk to Alvarez they assumed it was the doctor who called 911, but the huge gap of an hour and a half in Murray’s story did not raise a red flag for them. They simply did not notice it.
However Murray later realized that he had pronounced a damning verdict on himself by revealing to the police how long he had not been calling 911. So he changed his story by shifting all the events by an hour forward – probably explaining it by his “poor estimation of time” at that moment.
By shifting the events forward Murray turned his totally criminal negligence into something more plausible as now the time of his lingering over the patient was reduced from an hour and 20 min. to just 20 minutes.
Dr. Steinberg based his review of Murray’s actions on the above Murray’s (false) account of the events. However since the defense’s primary goal was to neutralize Dr. Steinberg’s brilliant review at least in some way, they chose to show that it was inconsistent with the real timeline and was therefore not as perfect as it was.
It does not matter that the real events and real timeline are ten times as bad as Murray’s own version – what does matter to the defense at the moment is to confuse Dr. Steinberg and the jury with strange questions and pretend that the truth is being told by the defense and not the prosecution witness.
Dr. Steinberg firmly stuck to Murray’s own words and proved that even Murray’s favorable account of the events showed that his actions were totally incompetent and a delay in calling 911 was criminal. Even if the delay was no longer than 20 minutes it was still inexcusably long – Murray was to call 911 immediately.
The paramedics arrived in 4 minutes and if the patient was in a state Murraydescribed it to the police they were still able to save Michael Jackson. His heart was still beating and all they needed was to give him enough oxygen.
Flanagan asked him how he knew the heart was beating. Steinberg said that according to Murray’s words he felt a pulse of 122 beats.
Flanagan noted that the pulse was thready. Steinberg explained that it was because the blood pressure was low (but it was still there, so the heart was still pumping blood).
Flanagan said it could be the state of “pulseless electrical activity”. Steinberg said that it couldn’t, because “pulseless electrical activity” is by definition NO pulse – while Murray said he could feel it. The heart was asking for oxygen and he should have used an ambu bag.
Flanagan asked how he knew it was not used. Steinberg said that Murray did not mention it in his statement and he was basing his conclusions on Murray’s own words.
Flanagan started playing with the idea that Dr. Steinberg was basing his report not only on Murray’s words, but on “other sources”. Steinberg said that he was aware of some other information but he didn’t use it in his review.
Flanagan ventured to say that Murray was away from the patient’s bed for a period longer than 2 minutes. Steinberg agreed. His estimation was that it takes the heart to reach the condition described by Murray as “a thready pulse which is122 beats” longer than two minutes – it takes time for the oxygen to go down and the heart rate to go up, so Murray was probably away for several minutes longer than a mere two minutes.
Flanagan suddenly asked a question which was least expected of him – and what if it wasn’t two minutes? what if the patient had not been breathing for 10 minutes? 15 minutes? 20 minutes? Steinberg said that from Murray’s own words Mr. Jackson still had a pulse and therefore he was still savable.
Flanagan asked what Murray should have started first – dial 911 or do chest compressions? Steinberg replied that he shouldn’t have done chest compressions at all and should have dialed 911 immediately.
Flanagan wondered “So shouldn’t have Murray tried to save his patient?” Steinberg replied that a health provider is allowed to do a short resuscitation effort for only two minutes before calling 911. Seeking professional help was the only logical thing to do – he had no life-saving equipment and no personnel, so needed someone who had all the necesary tools. But instead he called Williams.
Flanagan said that Murray went downstairs to the chef to call for help, and Steinberg said he shouldn’t have – it was a severe deviation from standard of care. In such a situation every minute counts. And the time he was calling security and chef he should have spent on calling 911 instead.
Flanagan asked if Murray called for help in 5 minutes, would it still be a deviation? Steinberg said “Yes”. “And if it was 3 minutes?” “Yes”. “So that one minute is a severe violation? “Yes, sir”, said Steinberg.
Flanagan asked him if he knew that the landline telephone was not working. Steinberg said that Murray had a cell phone.
Flanagan said that Murray could not waste time on explaining the situation to 911. Steinberg said that the only thing that was required of him was to say: “I am Dr. Murray. I am at Carolwood Drive, 100. Come now”.
At here Flanagan began to do the impossible – I could harldly believe my ears when he suddenly started telling the truth: “But the paramedics said that he was cold to touch and dead for 20-30 minutes”. Steinberg agreed that when Murray came back from calling the chef he had lost the pulse, but even at that stage Michael was still savable. But altogether Murray wasted at least 26 minutes if the time was to be calculated from around noon time.
At this point Flanagan disclosed the secret why he had been chewing up his impossible questions for so long. Now his theory is that Murray could not properly estimate time (so the death could have occurred earlier) and since Murray was mistaken it could affect the results of Dr. Steinberg’s report: “If he is mistaken in his assessment you would be mistaken too?”
It is my personal opinion that the defense should not be allowed to so willfully misguide the jury and the public. What he is essentially saying is that it was a mistake to analyze Murray’s lies. Murray lied, Dr. Steinberg analyzed his lies and proved that his actions were criminal negligence even in the case of a favorable (and false) picture Murray had painted, and now the defense says the Murray made a “mistake”, so the report is no longer valid? But the truth is a hundred times worse than Murray’s fictional story!
He first lied one thing – that he noticed Michael stop breathing at 11.00 and then wasted a full hour and a half doing God knows what. He then lied another thing – that he noticed the patient not breathing at around 12.00 and presumably immediately started working (wrong way) on his body. And the truth is a third thing – he was so busy with his phone calls that he simply did not notice that his patient had died! And he noticed it only at noontime when the situation was already beyond repair.
If Dr. Steinberg found extreme deviations of care based on Murray’s favorable story – which said that he was away from Michael Jackson’s room for 2 minutes only and had 20 minutes for calling 911 – how much more damning his review would have been if Murray had said to the police that he didn’t monitor Michael for an hour and a half?
The questions Flanagan asked of Steinberg were so impossible and his whole line of defense for Murray so absurd that I decided to transcribe part of it:
– Do you know what happened between 11 and 12?
– Do you know how long he continued to watch Mr. Jackson?
– When Mr. Jackson was found – your indication being around 12 o’clock – do you know what Dr. Murray did?
– At unknown time he gave him propofol and since then, he says “I sat there and watched him long enough period that I felt comfortable”, so we don’t know how long he monitored him for afterwards. And then he needed to go to the bathroom.”
– Do you know anything else he did between 11 and 12?
– Did he state the time he went to the bathroom? What time it was?
– No, he didn’t.
– When he came and found Mr. Jackson not breathing would you be of the opinion that based on your records it would round 12 o’clock?
– If that was what was established, yes.
– Do you have any idea about Mr. Jackson’s time of death?
– He was pronounced a couple of hours later, but he was clinically dead when he arrived at the emergency room.
– Did you read the paramedics’ report where they stated that at 12.26 he’d been dead for a period of time longer that 20 or 30 minutes?
– I’ve read it but I didn’t incorporate it in this report. I just used Dr. Murray’s (testimony). His own words.
– At 12 o’clock was Michael Jackson savable?
– If you are asking me if Michael Jackson was savable when Dr. Murray found him, YES.
– What were the chances of him being able to save him?
– Walgren: Assuming that he was gone for only two minutes.
– Based upon Dr. Murray finding him not breathing and his eyes open dilated at 12 o’clock?
– He did not find him with dilated pupils. At 12 o’clock – Dr. Murray left him for two minutes – he was alive, supposedly at 11.58. So he left him for only two minutes and you what happens – he would have stopped breathing and there is still an oxygen level and it takes a few minutes for the oxygen to go down and for the heart rate to go up. So the fact that he left him for only two minutes he was savable.
We do conscious sedation and sometimes it happens that patients stop breathing, so we use the bag mask, get them oxygen, trying to arouse them, trying to reverse whatever medications that we give. And he was definitely savable at that point. Also he had a delay in calling for help and if they had gotten there 6 minutes later Mr. Jackson would have been alive.
– You use the term 2 minutes?
– That’s what Dr. Murray said.
– Do you think that he was gone from Michael Jackson’s side for only two minutes?
– Estimating from this report he was gone [for two minutes]according to what I know what can happen in two minutes. Probably I would guess a few more minutes than two. But I am trusting Dr. Murray’s own words and his testimony.
– And Dr. Murray said that he’d gone maybe at 11 o’clock.
– It’d be nice to have medical records and documentation. It is standard of care to have the documentation to state what exactly happened. And there was none. So I had to use what Dr. Murray is telling me and he said two minutes.
– But you don’t think it was two minutes, do you?
– My report is based upon those two minutes. So I am assuming it is two minutes.
– So if it is not two minutes you have a different answer?
– Walgren: Objection.
– Judge: There are a way too many variables. The objection is sustained.
– Let’s assume that Dr. Murray was gone a longer time than two minutes.
– All my testimony is based on what’s written – that he was on a drip and that he was gone for two minutes, you want me to pretend that he only gave him 25 ml and that he was gone for more than two minutes, is that right?
– You know for a fact that Dr. Murray was gone for longer than two minutes.
– No, I don’t.
– Have you heard of the phone calls that he made?
– I heard about the phone calls. And I don’t comment on the phone calls because I only took his words. If you are telling me he was on the phone and are giving me this information, he shouldn’t have been on the phone and it just tells me that maybe he was on a propofol infusion because you can’t talk on the phone when someone got just 25 ml of propofol.
Why would I talk on the phone and wake Mr. Jackson up? That just tells me that he was on a propofol infusion and again, you don’t ever leave anyone who got propofol, you don’t leave him unmonitored, and you shouldn’t have given him propofol in the first place for sleep.
The above point about the propofol infusion is extremely important.
Murray claims that he gave Michael only 25 mg (2.5ml) of propofol, but Dr. Steinberg is sure that after giving the initial 25 mg Murray put Michael on a drip. When talking about it to the detectives Murray even corrected one of them, who mentioned only a dose, by saying: “Dose and drip”.
No matter how Flanagan tried to shatter Dr. Steinberg’s position he was unmovable on that point – Michael Jackson was put on a drip that night too.
He is most probably right. That empty 100ml vial (found in the IV bag) is still unaccounted for, same as a full hour which passed from 11.00 until noontime (which could be spent on dripping).
And if it was a drip, we know that Murray didn’t use any dosing device – he simply made a slit in the vial stopper which let the propofol freely flow into the body. And while Michael was on this makeshift uncontrollable drip Murray went about his business of telephoning and emailing, leaving Michael unattended for a full hour or more!
Not only didn’t he do the proper dosing and was overfilling his patient with propofol, but he was also not monitoring the process either!
And some say he is not guilty of murder? It is the same as non-stop filling your car with gas and not really looking for an hour and a half at what’s going on there and saying later you are not responsible for the explosion when the whole street was burnt out due to your negligence!
Falaganan made his last attempt to save Murray by suggesting that when Michael didn’t wake up after the initial 25ml of propofol Murray thought he was sleeping in a natural way as “he was tired” and Murray didn’t want to awaken him. Steinberg replied to it that propofol is not intended for sending the patient to sleep at all – it is used for anesthesia which should wear off at an estimated time and if this time comes and the patient is not waking up it is a sign for a grave alarm:
– He has given it to him for sleep and after 4 to 7 minutes he continues to sleep and Dr. Murray continues to watch him. Is it you testimony that he should have tried to wake up?
– Absolutely. When you give propofol you should always assess the sedation level and you do not leave the patient unmonitored until they are back to the pre-sedation level. You do not give propofol for sleep, and that’s an extreme deviation of standard of care.
So if you tell me that there was no infusion and he gave him 25mg of propofol and the guy was still sleeping after 7 or 8 minutes I’d be concerned that something is going on and you absolutely stay there and monitor them until they wake. You don’t leave their side.
If you give propofol and afterwards they are still sleeping, there is something wrong. You need to arouse the patient and you need to figure out the level of sedation, because something could be going wrong.
– Dr. Murray spent 9 hours trying to get him to sleep and now you tell me he should have awakened him?
The same question was asked of Dr. Nader Kamangar, who is a critical care/sleep medicine physician and an advisor to the CA Medical board.
The doctor answered that in the event the patient was still sleeping after the initial 25ml dose of propofol, it is his obligation to make sure that the sleep is not the effect of the drug. “You cannot make exceptions here”, he said.
“So will you wake him up?” asked Flanagan. Dr. Kamangar said that it would be his obligation to do it as the well-being of the patient is a priority and if there is a potential danger the doctor is obliged to make sure that the patient isn’t having a significant problem. He said, “We have to prioritize”.
Flanagan tortured Dr. Kamangar for some 3 hours or more with the same chewed up questions. The testimony started on Day 11 and continued in Day 12 when Flanagan asked the doctor what he would do first if he (Flanagan) fell on the floor in the court room – call 911 or render him help?
Prosecutor David Walgren reacted to Flanagan’s question by asking Dr. Kamangar: “If Mr. Flanagan fell on the floor, would you wait 12 minutes and then call his legal secretary and ask her to call 911?” The question was sustained but produced the desired thunderous effect.
Same as Dr. Steinberg Dr. Kamangar stressed that even in (the unlikely) case the patient self-medicated himself with an excessive amount of propofol Dr. Murray was still responsible for his death.
I didn’t understand Dr. Kamangar very well and will rely mostly on the articles to tell his testimony:
Doctor: Drug ‘cocktail’ killed Michael Jackson
By LINDA DEUTSCH
updated 10/13/2011 10:16:41 PM ET
LOS ANGELES — Dr. Conrad Murray’s use of a cocktail of drugs on Michael Jackson as he struggled to fall asleep on the day he died was a “recipe for disaster” and ultimately caused his death, a UCLA sleep therapy expert testified Thursday.
Dr. Nader Kamangar described Murray’s treatment as “unethical, disturbing and beyond comprehension.”
“To summarize, Mr. Jackson was receiving very inappropriate therapy in a home setting, receiving very potent therapies without monitoring,” Kamangar said.
He said diazepam (Valium), lorazepam (Ativan) and midazolam (Versed) were given to the sleepless star during a 10-hour period throughout the night and morning.
“This cocktail was a recipe for disaster,” Kamangar said.
Noting the addition of propofol (Dipravan), a powerful anesthetic used in surgeries, Flanagan asked: “Could this have caused death?’
“Absolutely,” Kamangar said. “Absolutely.”
The witness, one of the experts who evaluated Murray’s actions for the California Medical Board, expressed dismay about the drugs Murray gave the pop star, his failure to immediately call for help, and his lack of monitoring and record-keeping.
Murray was unable to produce any written records on his treatment of Jackson, Kamangar noted.
“It is an egregious violation of the standard of care when you are using sedatives like propofol and you are not writing it down,” Kamangar answered.
Kamangar was the third prosecution expert to criticize the conduct ofMurray. He said his first mistake was using propofol to treat insomnia, calling it an unacceptable application of the drug.
He said Jackson’s demand for the drug — the subject of previous testimony — was not a sufficient reason to give it. He also suggested Murray should have done a physical examination, taken a history from his patient about his insomnia, and called in other medical experts if necessary to evaluate the problem.
“The most important thing he should have done is call for help,” Kamangar said.
He said Murray’s interview with police made it clear that he waited too long to call for an ambulance when he found Jackson not breathing.
On Wednesday,Murray’s defense team announced they were dropping a claim that was the centerpiece of their case — that Jacksons wallowed additional propofol when Murray was out of the room. Flanagan did not bring up self-dosing on Thursday. http://today.msnbc.msn.com/id/44886109#.Tps7h5svDGY
Sleep Expert — Dr. Nader Kamangar Testifies, Day 2
Updated 10/13/11 at 8:45 AM
Dr. Kamangar took the stand again today to continue his testimony, insisting he would never cave to a patient’s drug demands.
* Kamangar also said Murray should have ruled out other possible problems that could have caused MJ’s insomnia before loading him up with a boatful of drugs.
* He told the court, the first thing Murray should have done was to have MJ write a “sleep diary” to figure out what the underlying problem was.
* Flanagan asked Kamangar about a study showing Propofol is safe to use for insomnia. Kamangar said the study was done in a monitored area after secondary problems have been ruled out … he insisted it’s incomprehensible to use Propofol at home.
* Kamangar said using Lorazepam to treat insomnia is inappropriate.
* Kamangar told Flanagan that — based on the transcripts from the police interview — he believed Murray gave MJ 25 mg of Propofol PLUS an additional unspecified amount through an IV drip on June 25.
* Kamangar said Murray subjected MJ to an experiment by giving him Propofol to treat his insomnia.
So Dr. Kamanger also thinks that Murray put Michael Jackson on a drip that night! And he also said that Lorazepam given by Murray was inappropriate for treating insomnia! The only way Lorazepam could be used was orally (and not as IV), for a short term and as an auxilliary to an anti-depressant to address Michael’s anxiety over the tour (and AEG’s nastiness in making ultimatums to him – you remember that they threatened to pull the plug if he missed a single rehearsal).
A couple of other things stood out for me in Dr. Kamangar’s testimony:
- a gross negligence still remains a gross negligence even if the patient survives it. It doesn’t matter that the result was positive – the standard of care was still not adhered to. (It was a life-threatening situation which didn’t bring about a tragedy simply by a miracle).
- it is imperative for a physician to observe his patient the whole time while he is under propofol. In Murray’s case there was a period of time when the patient was left alone – which is another extreme deviation. Continuous observation is all the more important if there is no equipment to monitor the patient.
- Propofol is a powerful drug with a fine line between mild sedation and moderate sedation and between moderate and deep sedation (when there is no breathing), so it is very easy to pass from one stage to another. At the time when there was no proper dosing equipment nurses used to count each drop of propofol in order to determine how many milliliters were given per minute (Needless to say, Murray did not only count drops but probably let propofol stream down from a hole he made in the vial rubber).
- Murray’s ability to remember facts does not compensate for his failure to keep records. Records are needed also for registering tendencies and charting various data. If the blood pressure changes from 180/100 to 100/60 within some 5 minutes it is a sign of a catastrophic scenario, so recording a tendency is a must. (Murray did not make any records and did not measure the blood pressure either – the device was not even opened)
- When Murray said to the detectives that the level of oxygen in Michael’s blood was “in the high 90’s, 90 percent” it was an ignorant way of saying it as these are profoundly different figures and there is no way to know what level he is referring to.
- Not giving oxygen and not calling help for the full 20 minutes does irreversible damage to the brain. The first 4-5 minutes are critical for restoring respiration, after that the brain cells start dying. (This means that Murray’s insistence on “saving Michael’s life” at the hospital some two hours after his clinical death was meant for show only – the most it could do was turning Michael into a vegetable.)
- unfortunately the Demerol under which Klein was making his cosmetic procedures on Michael’s face is capable of producing insomnia, as it activates the nerves and creates more stimulation. This could be at least one of the secondary reasons for Michael’s insomnia.
- Murray should have made a diagnostic evaluation of Michael’s insomnia (before boldly handling the problem he had no idea of).
Let me repeat here what I’ve earlier said in a comment. Murray never looked into the reasons for Michael’s insomnia. He simply jumped at the opportunity to make big money and never thought of rendering real help to Michael. He probably never knew how to handle this malady, but took it upon himself to treat it despite his total incompetence in this area. And this is his first major crime against his patient.
We know that the first shipment of propofol was made as early as April 6. Considering that fulfilling the order required some time it means that the discussion took place sometime in the second half of March. At that time they still had 3 months at their disposal for proper treatment of Michael’s insomnia. Instead Murray immediately agreed and pumped Michael with so much of it by June that everyone started noticing that Michael’s health began quickly deteriorating.
And we don’t even know how Murray was administering Propofol. Most probably it was the same substandard way he did it on June 25 – with no proper dosing device and not closely monitoring him – which is why Michael was probably experiencing temporary breathing problems every night.
And if his breathing stopped every night and each time the heart was beating like mad asking for oxygen and each time the situation was alleviated by finally ventilating oxygen into Michael’s lungs, it means that Michael was dying every night for those 2 months.
And all this because Murray simply did not know how to properly administer propofol – he is no anesthesiologist and doesn’t know that every additional drop there may be critical for the patient. And the fact that he agreed to administer propofol not knowing how to do it is his second major crime .
And this in addition to all the craziness that took place on June 25 – neglecting his patient, not calling 911, doing improper CPR, etc., all of which is a separate crime requiring capital punishment.
As he didn’t know what an extremely dangerous thing he was doing he simply made slits in the vials and propofol freely flowed down. And it was a miracle that Michael was able to wake up after gallons of propofol poured into him in such an uncontrolled way. It is one thing to wake up after you’ve received a minimal dose given by a proper anesthesiologist and it is another thing to wake up after Murray oversedated you with surplus propofol night after night.
And again, if at the very start of it Murray had referred Michael to sleep specialists and if during those 3 months of preparations before the show the problem had not been resolved without administering propofol, it was for the council of physicians to decide what to do further.
Let me also say what will surely go counter to the opinion of the medical community. It is easy for them to talk – they were not suffering like Michael was. He had to do the shows and they had to find a way to help him. And if it came to the worst I do not rule out that an unconventional method like propofol could have probably be used – of course in a hospital setting or at home, but with all the equipment present and a qualified team attending to the process.
What I mean is that a doctor has two duties to his patient – he cannot do harm to him but he cannot abandon him in his problem either. And we know of cases when desperate patients agree to experimental ways of treating their health problems. In my opinion experimental treatment was possible – only it should have been done under full and even double medical control.
And this is something which the incompetent, careless and insolent “doctor” Murray simply had no idea of.
* * * * *
A short note about the experimental studies of using propofol for treating insomnia. John M. Flanagan of the defense referred to a study made in 2010 which provided the first data that propofol was indeed successful in treating insomnia. In that experiment 64 patients were given theurapeutic doses which sent them into deep sedation for 2 hours for 5 days running. 6 months later doctors made additional tests and found that the condition of all patients improved.
Dr. Steinberg and Dr. Kamangar said that those were experimental studies only which were made under full control of doctors. Its results were very limited and before (and if ever) propofol becomes recommended treatment it should first undergo extensive research the results of which should get the approval of the Medical Board.
In any case – when Murray was giving propofol to Michael Jackson he could not know of those studies as it was published a year later. And the progress the medical science is making does not release Murray of his negligence which was so gross that it looked more like a murder than medical treatment provided by a doctor.