Conrad Murray trial week 4. LORAZEPAM theory. The brilliant DR. STEVEN SHAFER
This is a place to collect all information about week 4 of Murray’s trial.
Monday, October 17, 2009
Learning the news that the trial was put on hold due to the death of Dr. Shafer’s father made me recall that I didn’t say a word about Dr. Shafer testimony which began on Thursday, October 13 and was to be continued today. Poor thing, how is he going to testify after such an event which is so hard on any human being?
Dr. Steven Shafer is an anesthesiologist, Professor and Associate Professor of three universities and a leading expert on propofol. Twenty years ago he was hired by the company producing propofol for figuring out the correct dosages for administering this drug.
The doctor specializes in the area of pharmaco-kinetics which has to do with mathematical models to determine the appropriate doses of drugs and providing doctors with correct numbers which they later use in their work.
Dr. Shafer is editor-in-chief of the largest medical journal on anesthesiology and together with the editorial board of 17 leading anesthesiologists reviews thousands of articles annually. The articles arrive from all over the world which gives them an opportunity to have a broad exposure to the latest studies and trends.
He is not a pupil of anesthesiologist Dr. White, who is going to be one of the experts from the Defense side, as the defense claims but has known Dr. White since early 90s when they co-authored an article.
Dr. Shafer took part in establishing the current dosages for propofol. Since the time he worked out the mathematical model for using it the dosages have never been revised or disputed. Actually the text of the current insert accompanying a propofol vial contains the recommendations worked out by Dr. Shafer.
Dr. Shafer has published 19 articles on Propofol and it was his first article which was written in cooperation with Dr. White. The contribution he made to that article was the mathematics of it and working out the program for determining the correct doses.
This was about all I could make out of the highly technical and very specific information Dr. Shafer provided on the first day of his testimony.
TMZ learned of Dr. Shafer opinion of this case which has not yet been voiced at the trial:
A prosecution witness will testify … Dr. Conrad Murray committed “multiple egregious and unconscionable violations” in his treatment of Michael Jackson the day he died … this according to documents obtained by TMZ.
Prosecutors filed the document because they want to shoot down the defense theory that MJ may have orally ingested the fatal dose of Propofol.
According to Dr. Steven Shafer, “There is a zero possibility that the propofol was orally ingested.”
Dr. Shafer believes, “There is almost nothing in Murray’s care of Michael Jackson that reflected the actions of a trained physician.”
However the ever-changing Defense of Conrad Murray recently declared that they will no longer claim that Michael Jackson took the propofol orally. Now they are focusing on Lorazepam allegedly taken by MJ in addition to the IV injections Murray gave him twice during that night.
Positivelymichael.com says that the Prosecution has asked for a new test to be made to determine the amount of Lorazepam and its metabolite in Michael’s stomach:
Trial will not be in session again tomorrow because of a new issue having to do with a new test done on Michael Jackson stomach content.
Judge Michael Pastor has ordered jurors to call the court tomorrow afternoon at 3 to find out if the trial will resume on Wednesday or not.
Attorneys are ordered to appear tomorrow at 1:30 pm to further discuss the new test prosecution ordered on Michael Jackson’s stomach contents
After Dan Anderson testified last week, prosecutor Walgren ordered a new test to quantify how much Lorazepam was found in MJ’s stomach.
Defense had ordered the test through a private lab and concluded there were the equivalent of 8 Lorazepam pills on MJ’s stomach.
But prosecution reordered the test through Dan Anderson with results showing the amount of the drug and its metabolite.
There’s discrepancy between the results for both sides. Besides that, defense claims Anderson testified he couldn’t test the drug’s metabolite .
On the other issue, Prosecutor David Walgren said he spoke with Dr. Steven Shafer and he said he would be available to come back tomorrow.
However, Judge Michael Pastor said he did not want to put extra pressure on Dr. Shafer and his family and make him feel anxious to come back
With the new issue to be ironed out, the extra day off will probably work better for Dr. Shafer’s family issue.
Defense attorneys spent most of the hearing this morning asking for more time to be able to address this new study with their experts.
Prosecutor Walgren said he’s going to address the results of the new test during Dr. Shafer’s direct examination.
Walgren says the result of his test is significantly different from the defense test. “An inflated number was presented to the jury”.
Walgren said the real amount of the drug Lorazepam found in Michael Jackson’s stomach is “inconsistent with oral consumption”.
Let me remind you that the quantity of Lorazepam in Michael’s stomach was so small that it wasn’t determined in the original Coroner’s report. The additional Coroner’s lab test showed the amount which was equal to 1/43d of one 2mg Lorazepam pill.
As far as I understand it the Defense does not dispute this quantity but claims that some pills were digested orally on the basis of the blood tests which showed the level of 0, 169 ug. How they came to the number of 8 pills out of that is beyond my understanding but the Coroner Dr. Rogers made some brief calculations during his testimony and did say that achieving that blood level required 8 pills. Only all of them seemed to forget that Murray gave 4 mg of Lorazepam IV and this quantity should also be there in the blood.
In short in matters like these all we can rely on is a good and sound expertly opinion, so let us wait and see.
This article says that when the trial resumes Dr. Shafer is expected to testify for a whole day:
The judge in the Murray trial has announced testimony will resume Wednesday.
Shafer, who briefly testified before Thursday’s session was concluded, was slated to testify Monday that Murray’s use of propofol was negligent in his care of the late King of Pop, using scientific explanations to support his idea.
When Shafer returns from his father’s funeral, Deputy District Attorney David Walgren said, his testimony will last a day.
After Shafer testifies, defense lawyer Nareg Gourjian said, the defense will begin their presentation.
The article below provides more detail and mentions that the defense claims Michael Jackson took Lorazepam while Murray was away.
Even if Murray was out of the room for 5 minutes this theory is totally crazy as it implies that Michael was to have woken up, taken 8 pills from a bottle which was on the far end of the night stand (behind all other medication), then carefully placed it back and immediately went into a coma – though the pills still need time to be digested in the stomach.
Considering that there were no pills found in the stomach at all and the amount of Lorazepam in the gastric contents was 1/43d of one pill the scenario described below is totally crazy:
Trial of Michael Jackson’s doctor postponed
By Martin Kasindorf, Special for USA TODAY
The manslaughter trial of Michael Jackson’s personal doctor, which was shut down Monday because of a death in the family of a prosecution witness, was further postponed until Wednesday.
Superior Court Judge Michael Pastor said he was putting off trial testimony for two reasons: giving Steven Shafer of New York, the witness, more time to handle family matters, and allowing defendant Conrad Murray’s lawyers to obtain experts’ response to a new toxicology test the coroner’s office performed for the prosecution.
At a sometimes ill-tempered hearing with Murray and the jury absent Monday, defense lawyers Ed Chernoff and J. Michael Flanagan objected to prosecution plans to present the new test on Jackson’s stomach contents when they resume questioning Shafer, an anesthesiologist.
Pastor gave the defense more time to find its own expert opinions to support cross-examination of Shafer. The judge scheduled another hearing for Tuesday afternoon to discuss the status of the defense’s preparation.
Murray, 58, is accused of negligently causing Jackson’s death in 2009 through an overdose of the surgical anesthetic propofol, which, according to the coroner’s autopsy report, combined with the sedative lorazepam to stop Jackson’s breathing.
Murray, a cardiologist, has pleaded not guilty to a charge of involuntary manslaughter. His lawyers say Jackson ingested lethal doses of drugs himself when the doctor was out of the room.
Prosecutor David Walgren said Monday that his office had requested that Jackson’s stomach contents be retested for lorazepam. This, he said, was in response to a defense-commissioned toxicology report on lorazepam that Flanagan presented to the jury last week during cross-examination of the coroner’s toxicologist, Dan Anderson.
The defense’s lab report enabled Flanagan to say there was enough lorazepam in the singer’s stomach to prove that he had swallowed eight 2-milligram tablets of lorazepam, “enough to put six people to sleep.”
By contrast, the new report that Walgren ordered says there was much less lorazepam than the defense claims. In addition to questioning Shafer on the coroner’s latest test, Walgren will recall Anderson to testify to his office’s new report, he said.
The hearing grew tense after defense lawyers accused the prosecution of violating a September 2010 court order forbidding new tests on medical evidence without specific permission from the judge. Walgren said the order related only to syringes and other medical supplies, not to “biological evidence” such as stomach contents.
The defense ultimately agreed and apologized. “We’re sorry, David,” Chernoff said in a tone of sarcasm. “You did not violate a court order.”
The judge interrupted. “His name is not David,” Pastor said, implying that Chernoff should have addressed his opponent more formally.
Pastor ended the spat by saying, “There was an allegation the facts do not support, and there’s an apology by the defense.”
Chernoff said that having until Wednesday to study Anderson’s new report “may rectify the problem.” He had suggested not allowing Walgren to offer the report until the prosecution’s rebuttal case, which will follow the presentation of the defense’s expected 15 witnesses.
Pastor said he would prefer that the lorazepam evidence be introduced this week during the prosecution’s main case. http://www.usatoday.com/news/nation/story/2011-10-17/michael-jackson-doctor-trial/50805114/1
New lab test forces new delay in Conrad Murray trial
By Alan Duke, CNN
updated 2:22 PM EST, Mon October 17, 2011
Los Angeles (CNN) — Dr. Conrad Murray’s involuntary manslaughter trial has been put on hold at least until Wednesday to give the defense time to study new lab test results the prosecution contends show Michael Jackson did not ingest a fatal overdose of sedatives.
Testimony was suspended last Thursday afternoon to allow the prosecution’s anesthesiology expert to attend a medical convention, and again Monday because that witness’s father died. The trial, in its fourth week, is still expected to conclude with the start of jury deliberations next week.
The Los Angeles County coroner tested Jackson’s stomach contents for the level of the sedative lorazepam last Wednesday at the request of the prosecution, Deputy District Attorney David Walgren revealed at a hearing Monday.
The testing was ordered after Murray’s defense contended that Jackson swallowed eight tablets of lorazepam, a sedative, in a desperate search for sleep the day he died. The results show “a much smaller amount of lorazepam in the stomach that is totally inconsistent with oral consumption of lorazepam tablets,” Walgren said.
The coroner ruled that Jackson’s June 25, 2009, death was from “acute propofol intoxication” in combination with several sedatives, including lorazepam.
The defense complained that the coroner should have done the test two years ago, not during the trial.
“It’s about the time,” defense lawyer Ed Chernoff said. “It’s about the fairness issue.”
Dr. Steven Shafer, an anesthesiology expert, is crucial to the state’s effort to prove Jackson’s death was caused by Murray’s gross negligence in using the surgical anesthetic propofol to help the pop icon sleep.
Shafer began testifying Thursday morning before the judge recessed for the weekend so he could travel to a medical convention. He never made it there because of the death in his family, Walgren said Friday.
Shafer, who is expected to give a detailed scientific explanation of how propofol is metabolized in the human body, will be on the witness stand for at least a day, according to Walgren.
Shafer’s testimony is expected to echo the opinions of a sleep expert and a cardiologist who testified that Murray’s treatment of Jackson was so grossly negligent that it was criminal.
The defense presentation would follow, lasting until Friday or the following Monday, according to defense lawyer Nareg Gourjian.
Along with two or three medical experts and a police officer not called by the prosecution, the defense has lined up several patients of Murray to testify about how he’s helped them, Gourjian said.
There is no indication Murray will take the stand to testify in his defense, which would subject him to intense cross-examination by Walgren. The jury already heard the recording of his interview with detectives two days after Jackson’s death.
Murray’s lawyers contend that Jackson used a syringe to inject the fatal overdose through a catheter on his left leg while Murray was away from his bedside. They dropped the theory pushed earlier that Jackson may have orally ingested the propofol that the coroner says killed him.
The self-administered propofol, along with the eight lorazepam tablets, killed Jackson, not the drugs Murray gave him earlier in the morning, the defense contends.
Murray should be found guilty even if jurors accept the theory that Jackson self-administered the fatal dose because the doctor was reckless in leaving propofol and lorazepam near his patient when he was not around, Dr. Alon Steinberg, a cardiologist testifying for the prosecution, said last week.
“It’s like leaving a baby that’s sleeping on your kitchen countertop,” Steinberg said. “There’s a very small chance the baby could fall over, or wake up and grab a knife or something.”
On Thursday, UCLA sleep expert Dr. Nader Kamangar testified that the combination of drugs Murray gave Jackson “was the perfect storm” that killed him.
“Mr. Jackson was receiving very inappropriate therapy, in the home setting, receiving very potent sedatives, including propofol, lorazepam and midazolam, without monitoring by Murray, and ultimately this cocktail was a recipe for disaster,” Kamangar said.
But Kamangar, testifying for the prosecution, said Jackson “clearly” suffered from insomnia that could have been caused by Demerol, a narcotic he was getting frequently from a doctor other than Murray.
Murray’s defense team contends Dr. Arnold Klein injected Jackson with 6,500 milligrams of Demerol during visits to his Beverly Hills, California, dermatology clinic in the last three months of his life, and that Murray did not know about it.
Jackson desperately sought sleep the day he died, worried that without rest he could not rehearse that night, which could force the cancellation of his “This Is It” comeback concerts, according to Murray’s interview with police.
If convicted of involuntary manslaughter, the maximum sentence Murray could face is four years in prison and the loss of his medical license. Source: http://us.cnn.com/2011/10/17/justice/california-conrad-murray-trial/?hpt=ju_t2
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Dialdancer has sent us the following video (thanks a lot!).
Ryan Smith, Matt Semino, Christi Paul and Mike Brooks on IN SESSION (10-17-11) discuss Murray’s gross negligence:
It is all about standard of care – GROSS NEGLIGENCE! This is a doctor who was present at the time his patient died. He was supposed to be there – not talking on the phone, not going to the bathroom – he was supposed to be there. Plain and simple!
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Tuesday, October 18.
There are no trial proceedings yet. This gives us some time for a little discussion. Let me tell you something which I initially didn’t want to share not to give any suggestions to anyone. However I’ve checked on what Flanagan said to Dr. Nguyen on week 2 and see in which direction the events are going – so let me say it now to that we are more or less prepared for what the defense will say.
On week 2 Flanagan asked Dr. Nguyen what would happen if a dose of 20mg of Ativan (Lorazepam) was taken. She said that 20 mg would be a very large dose. Ativan does not cause directly respiratory depression – what it does is working on the brain and making the brain sleepy. And that brain would be so sleepy that it would not tell the diaphragm to breathe and therefore the patient’s respiration will stop, producing a respiratory arrest (not a cardiac arrest).
This is important as everything Dr. Steinberg said about Murray’s incompetent actions during a respiratory arrest will fully apply to the Lorazepam theory too.
Flanagan also asked a question “When you do Ativan by IV the effect is very quick and when you do it orally it the effect takes longer?” which was an obvious shot against Jackson and his first test of a hypothesis that he could have taken it orally and long before he died.
The Lorazepam pills defense theory is potentially dangerous and though it is false it will be difficult to refute it. Much will depend on the experts and the way they calculate the time of Lorazepam taking effect and being absorbed into blood.
The way I understand it the basic points of further discussion will be the following ones:
- Generally speaking 8 tablets of Lorazepam are so powerful a dose that they will probably send a person into a coma within the period of an hour – two hours (?) depending on the level of individual built-up tolerance to the drug. So if Michael stopped breathing at 11 o’clock – according to Murray’s own interview with the detectives- under the Lorazepam theory those 8 pills were to have been taken at something like 9 o’clock in the morning.
- However for two hours or so the pills could not have disappeared from the stomach yet. They would have left there a huge amount which could be detected at autopsy. And the autopsy did not show any significant amount of Lorazepam in the stomach. The recently made new test seems not to show it either.
- Since Lorazepam was not found in the stomach, but was found in the blood (in minor quantities), the defense will shift the supposed self-administration to a much earlier time – let’s say the very beginning of the night, when Michael was only going to bed. This theory will say that from around 2.00 to 11.00 some nine hours passed, within which period Lorazepam should have fully dissolved and already went into the blood. (As far as I remember the defense claimed that the Lorazepam level was too high in the blood, and not the stomach).
- But this means that firstly, Michael should have taken those 8 pills well in advance, when he did not yet know that he would not be able to fall asleep (which is absurd) and secondly, it means that for some reason those 8 tablets had an effect on him only 9 hours later.
- So most probably the defense will shift the time of the supposed self-administration to the middle of the night, allowing only 5-6 hours for Lorazepam to go from the stomach into the blood. It could have as it is rather quick-acting, but at this point pharmacologists should have their say and determine whether it is possible for Lorazepam to totally disappear from the stomach during 5-6 hours.
- In my humble opinion it is not possible, and its amount in the stomach will still be too big for the toxicologists not to notice it during the autopsy.
In short the discussion will be centering on two factors – the time and possible amount of Lorazepam taken. By comparing the amount with the time of its processing by the body criminalists are usually able to say 1) when the drug was taken and 2) in which way the drug initially came into the body – from the stomach into blood (in case of pills) or from the blood into the stomach (in case of an IV injection).
I hope that medical people and pharmacologists will prove that the defense’s theory is false. But even in the case they are not able to prove it, it it won’t change anything in respect of Murray’s non-stop cynical lies and a totally criminal way he was neglecting his patient during the crucial hours of June 25, 2009.
Murray was to have monitored Michael and it is clear that he wasn’t. He was attending to his own business.
So whatever is the case with Lorazepam he is still guilty like hell.
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Here is some additional information on Lorazepam:
WIKI says http://en.wikipedia.org/wiki/Lorazepam :
Lorazepam is used for the short-term treatment of anxiety, insomnia, acute seizures including sedation of hospitalised patients, as well as sedation of aggressive patients. Among benzodiazepines, lorazepam has a relatively high addictive potential (Thank you Dr. Murray for introducing Michael to it).
Due to tolerance and dependence, lorazepam is recommended for short-term use, 2–4 weeks only. (And how long did Murray administer it to Michael?)
It has a fairly short duration of action (Venable and Aschenbrenner 2009). Withdrawal symptoms, including rebound insomnia and rebound anxiety, may occur after only seven days’ administration of lorazepam. (So administering Lorazepam for SEVEN days only can rebound in insomnia??? And anxiety??? What was this ignorant Murray thinking of?)
Lorazepam injectable solution is administered either by deep intramuscular injection or by intravenous injection. The injectable solution comes in 1 mL ampules containing 2 mg or 4 mg lorazepam. The solvents used are polyethylene glycol 400 and propylene glycol. Toxicity from propylene glycol has been reported in the case of a patient receiving a continuous lorazepam infusion ( I wonder if empty vials of solvent were found on the scene. After all we have only Murray’s word that he gave him Lorazepam intravenously. He could have given him pills!)
Intravenous injections should be given slowly and patients closely monitored for side effects, such as respiratory depression, hypotension, or loss of airway control. (So respiratory depression and loss of airway control may be the result of Lorazepam too if it is given IV!)
Peak effects roughly coincide with peak serum levels,which occur 10 minutes after intravenous injection, up to 60 minutes after intramuscular injection, and 90 to 120 minutes after oral administration, but initial effects will be noted before this. (So if taken orally the effect would be seen in approximately a hour and a half. This means that the pills were to have been taken at 9.30 in the morning, and at 11 o’clock the pills should have still been in the stomach!).
A clinically relevant lorazepam dose will normally be effective for 6 to 12 hours, making it unsuitable for regular once-daily administration, so it is usually prescribed as two to four daily doses when taken regularly (so this medication is relatively quick-acting as it has to be resumed every 6 hours).
Sedation is the side effect that most patients complain of. In a group of around 3500 patients treated for anxiety, the most common side effects complained of from lorazepam were sedation (15.9%), dizziness (6.9%), weakness (4.2%), and unsteadiness (3.4%). Side effects such as sedation and unsteadiness increased with age. Cognitive impairment, behavioural disinhibition and respiratory depression as well as hypertension may also occur. (A very nice drug to be given to Michael! Dr. Kamangar did say that it was totally inappropriate in his case.)
Potent benzodiazepines such as lorazepam have the highest risk of causing a dependence. Tolerance to benzodiazepine effects develops with regular use. Patients at first experience drastic relief from anxiety and sleeplessness, but symptoms gradually return, relatively soon in the case of insomnia but more slowly in the case of anxiety symptoms. (So after the initial relief Michael’s insomnia returned plus Murray could have formed a dependency on it!)
Withdrawal symptoms can occur after taking therapeutic doses of Ativan for as little as one week. Withdrawal symptoms include headaches, anxiety, tension, depression, insomnia, restlessness, confusion, irritability, sweating, dysphoria, dizziness, derealization, depersonalization, numbness/tingling of extremities, hypersensitivity to light, sound, and smell, perceptual distortions, nausea, vomiting, diarrhea, appetite loss, hallucinations, delirium, seizures, tremor, stomach cramps, myalgia, agitation, palpitations, tachycardia, panic attacks, short-term memory loss, and hyperthermia. (What a list!)
It takes approximately 18–36 hours for the benzodiazepine to remove itself from the body.
Lorazepam is not usually fatal in overdose, but may cause fatal respiratory depression if taken in overdose with alcohol. In cases of a suspected lorazepam overdose, it is important to establish whether the patient is a regular user of lorazepam or other benzodiazepines, since regular use causes tolerance to develop. Also, one must ascertain whether other drugs were also ingested.
Management is by observation, including of vital signs, support and, if necessary, considering the hazards of doing so, giving intravenous flumazenil. (So firstly, Murray was to monitor his patient closely – because of both Propofol and lorazepam he was administering, and secondly, he was to immediately give him flumazenil, which he heavily delayed).
Lorazepam may be quantitated in blood or plasma to confirm a diagnosis of poisoning in hospitalized patients, provide evidence in an impaired driving arrest or to assist in a medicolegal death investigation. Blood or plasma lorazepam concentrations are usually in a range of 10-300 ug/L (micrograms) in persons either receiving the drug therapeutically or in those arrested for impaired driving, and 300-1000 ug/L (micrograms) in victims of acute overdosage.
The above information is crucial in my opinion.
“Therapeutically” means a “normal dose which is enough to take effect”, while “an overdose” is everything which is above that level.
Michael had 0,169 milligrams (equal to 169 ug or micrograms) of lorazepam in his blood and this is well within a therapeutic dosage.
Or was it even 0,169 micrograms as the headline of the table says?
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Beth Karas’s TV report makes it absolutely clear that the Lorazepam theory is NOT valid.
- According to the new test result Michael Jackson DID NOT swallow 8 pills.
Prosecutor David Walgren said that it was a deceiving number that M. Flanagan of the defense had been using to cross-examine the state witnesses.
Based on the new testing done – for the drug itself and its breakdown called metabolite – the number M.Flanagan was using does not represent the amount of Lorazepam Michael Jackson had in his body – it was much less. It was more consistent with the injections Dr. Murray says he gave Michael Jackson:
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Day 13. Wednesday, October 19
Prosecutor David Walgren and Dr. Steven Shafer were not leaving a single stone unturned and were not missing a single point in displaying Murray’s crimes against Michael Jackson. It was both breathtaking and extremely sad to see Murray’s behavior finally shown in its full monstrosity.
Hopefully no one will dare say a word of support for Murray now – he is not only a non-doctor but is also someone who is totally devoid of all human ethics.
First Dr. Steven Shafer made an outstanding demonstration of how propofol should be given to a patient.
He started with showing how to draw propofol by a syringe from a propofol vial. The foil covering the rubber stopper is removed, the needle is inserted into the bottle and then … then you understand that a lay person will not be able to draw more than just a little bit of propofol into the syringe!
The bottle is made of glass and wouldn’t shrink as a plastic bag would when the liquid goes out of it. The vacuum inside it will not allow the propofol to flow – so in order to fill the syringe you first have to push some air into the bottle (as a replacement for the liquid volume drawn out of it) and only then draw propofol into the syringe. You have to do it bit by bit, pushing air inside and drawing the liquid out of it, by multiples attempts which take quite a time.
When you see how complicated the process is you understand that Michael could not even possibly draw a 100ml vial of propofol into the syringe by himself (as a first step before supposedly self-administering it).
Then Dr. Shafer compared the mark left by a needle with the mark found on the 100ml empty propofol vial used by Murray. The needle mark was so small that it could not be even seen, and the hole on the vial he was using for demonstration purposes even self-healed.
In contrast to the usual needle mark Murray’s vial had a big slit in the rubber stopper which could be left by a spike only – a much larger device to which an infusion line is attached. Dr. Shafer compared the two marks and said that “a needle would never do that” and “that’s the mark expected from a spike”.
The tubing attached should be very narrow – the entire tube should have no more than 1cc of propofol (not to impede the correct dosing process).
Dr. Shafer and David Walgren will surely return to that spike and its tubing, but first Dr. Shafer commented on the video made by another anaesthesiologist, Dr. Hun. The video showed all the equipment necessary for giving propofol and inspired in many of us awe for how responsible the work of anaesthesiologists is.
It also showed that Murray was either monstrously ignorant of what he was to do or was monstrously negligent as he allowed himself to administer propofol without a single of those totally indispensable devices .
This is critical and anaesthesiologists have multiple systems for providing unimpeded flow of air to the patient – there is a tube to be inserted between the vocal cords and another “failsafe” system which pushes air inside the lungs through a mask without going into the wind pipe.
A third device with two tubes – called nasal cannula – is fixed to the nose so than one tube brings in oxygen, while the second one is used for measuring carbon dioxide exhaled by the patient, the absence of which is actually the first sign that breathing has stopped. There are some others too all of which make up part of a multiple system which has several stand-by variants in reserve.
The doctor is to verify all the equipment well before the procedure and make sure that everything is working. All the devices should be close at hand and be made available immediately – within seconds.
The anaesthesiologist should be ready for any complication. One of the gravest complications is acid aspiration – this is when the contents of the stomach accidentally goes into the lungs. Since the stomach contains acid it may be fatal for the lungs functioning so doctors take every precaution for this never to happen.
The time they have for taking action to remove the contents of the stomach from the airway is just a couple of seconds before the next breath – during which they will use a suction device which will remove everything alien before even a drop of it goes into the lungs. This is why patients are not allowed to eat or drink before sedation.
The above means that the doctor cannot leave the patient even for a second (before his next breath), not to mention several minutes of being in the bathroom let alone hours spent on the phone!
Propofol lowers the blood pressure so one of the possible complications is a drop in the blood pressure. To help to restore it to a normal level an injection of ephedrine is given IV.
If the level of carbon dioxide drops this is a warning of another complication – the airway has been obstructed. The doctor lifts the chin of the patient and makes a jaw thrust which moves the tongue from the back of the throat and the patient starts breathing on his own again.
Dr. Shafer says that physicians are taught this simple maneuver during the first days of training, so it is does not even require any time for thinking.
In case of apnea (a prolonged period of not breathing which is often found during snoring) and the patient just lying there not breathing, the doctor should force air into his lungs using their “failsafe” device – the one which pressurizes oxygen through a mask.
If cardiac arrest takes place the doctor calls for immediate help and then a team of doctors attends to the patient within seconds – one is doing CPR, another forces oxygen into the lungs, and a third one is administering resuscitation drugs. These measures keep the patient alive long enough to fix the problem with the heart.
Dr. Shafer repeats that the main theme of anesthesiologists is to ensure an uninterrupted flow of air into the lungs.
The actual process of administering propofol is as follows. After the propofol is drawn into a syringe through multiple injections of air into the bottle the syringe is placed into an infusion pump which is a device measuring its precise dosing.
Before the infusion starts certain parameters are fed into the computer which measures how much propofol will be administered depending on the weight of the patient, the level of the required sedation and other factors.
All throughout the process the doctor is beside the patient’s side monitoring him and filling in the chart, recording his blood pressure, heart rhythm, the pulse, etc. Dr. Shafer stresses that it is part of the therapy process and is an integral part of it.
It is the doctor’s fundamental responsibility to record every parameter at least every 5 minutes in order to keep track of the drug and how it affects the patient’s blood pressure, oxygen saturation and everything else which is vital for patient’s health.
It shows the history of what was given when and how the patient reacted which helps the doctor to take decisions while monitoring the patient further.
Before starting the procedure the doctor is to obtain an informed consent of the patient. This is not just a piece of paper, but a process of describing the foreseeable risks and providing alternatives to the proposed procedure. If the patient doesn’t have questions and agrees he signs the document.
Dr. Shafer stresses that a verbal consent is not binding, doesn’t exist and is not recognized. A written verbal consent is so important that if at the last minute it turns out that the patient has not made it the procedure is put off (unless it is a life-threatening situation).
All these requirements apply not only to anesthesiologists but to all physicians (and nurses) who administer sedation. All of them are to follow these basic standards – which apply not only to propofol but also to sedatives of any sort.
Prosecutor Walgren asked if these standards would apply if just 25 ml of propofol were administered.
Dr. Shafer said, “Absolutely”. Considering that Michael Jackson had been given other sedatives, was dehydrated and exhausted from long exercise, had profound inability to sleep even 25ml of propofol mattered a lot.
The doctor explains that there is no such thing as “little anesthesia”. Every patient is different – one requires half the usual starting dose, and another requires twice the dose. Due to this variability even after 25 ml of propofol some patients may stop breathing – though they were given propofol before and no such complication previously arose. It is a doctor’s obligation to be always prepared for a worst-case scenario – he always has to assume that the patient will be at a new and unexpected edge of sensitivity.
None of the above was done in Murray’s case and Dr. Shafer’s outstanding testimony proved that the “care” Murray provided to Michael Jackson for $150,000 a month was as far from the basic standard of care as the Moon is from the Earth.
* * * * *
Before we go on with Dr. Shafer’s testimony let me note that the doctor is not charging any fees for reviewing Murray’s case. Prosecutor David Walgren asked him why and Dr. Shafer explained that he was doing it for several reasons.
- The primary one is not to compromise his integrity.
This is his general principle – he has no criticism for those who charge fees, but his choice is doing it pro bono (which means professional work undertaken voluntarily as a public service). In Conrad Murray’s case he had three more specific reasons for doing it this way.
- The case has become so public that the reputation of physicians is questioned (so he is doing it for the sake of all medical community).
- As an anesthesiologist Dr. Shafer also wished to present the proper way how an anesthesiologist approaches a patient.
- And lastly, since he is first and foremost a practicing anesthesiologist he now hears patients say to him almost every day, “Are you going to give me the drug which killed Michael Jackson?” So Dr. Shafer wants to dispel the fear many patients have acquired after Murray’s case .
Dr Shafer has been an active practicing anesthesiologist for 25 years and regards his work in the operating room as the most important part of his professional life. In addition to that he is the editor in chief of Anesthesiology journal and is on the editorial board of several other journals. He himself published 160 papers and several books. Only this year he has spoken at various medical conferences some 10- 15 times all over the world (the locations were so many that I lost track while he was enumerating them all).
Many of his papers were devoted to finding an answer to a question – What is the influence of gender, weight and age of the patient on the effect of the drug? Numerous studies were made to get to a mathematical model of determining the precise dose depending on many variables and get the prediction of the drug effect for each specific case as accurately as possible.
Another part of the research was to work out models of administering propofol to patients in intensive care units who may stay sedated for very long hours (in contrast to those who are put into sleep for a short period of time during minor operations).
Dr. Shafer also conducted similar research in respect of Midazolam and Lidocaine. All those papers were published in Anesthesia & Analgesia journal for which he was an editor too.
* * * * *
Upon reviewing Conrad Murray’s case Dr. Shafer made a report registering numerous deviations from the standard of care. He found so many that they had to be broken down into three categories – minor, serious and egregious.
- A minor deviation is something which is not consistent with the standard of care but would not lead to problems.
- A serious one is expected to cause harm to a patient.
- And an egregious deviation is something that should never happen in the hands of a competent doctor as there is a very high probability that it will bring about a catastrophic outcome. The dictionary defines the word is as “Conspicuously bad or offensive and outstandingly bad, flagrant”, so this is something really unheard of for a doctor to do.
In addition to that Dr. Shafer found several deviations not only egregious but unconscionable. This word is defined as “Not restrained by conscience; unscrupulous” and now that I’ve learned it I realize that this is the exact word we were looking for in order to describe Conrad Murray’s actions. These are UNCONSCIONABLE actions, where human conscience simply does not take part or where it never existed in the first place.
Dr. Shafer called Murray’s deviations from the standard of care unconscionable when they were the fundamental ethical and moral violations of Michael Jackson’s rights as a human being (which were the last drop in a huge violation of human rights Michael had to endure the whole of his life).
Here is the list of what Dr. Shafer found:
Lack of basic emergency airway equipment is an egregious violation.
Michael Jackson died because he stopped breathing. This complication is expected during anesthesia, and all it takes is to pressure oxygen into the lungs by means of an Anesthesia Breathing Circuit which they call their “failsafe”.
“No competent doctor will ever administer sedatives without this equipment – it should be there without question”, says Dr. Shafer.
“It was nice that the ambu bag was present”, he says. But from Murray’s own account (the interview with the detectives) it is clear that he did not use it. Instead he used a mouth-to-mouth method which is not as effective as it delivers expired air which has less oxygen – usually no more than 18-20%.
Murray says that he was away for 2 minutes.
What most probably happened during that period, says Dr. Shafer, is that the tongue fell backwards and obstructed the airway. If that was the case all that was required was to lift Michael’s chin and normal breathing would have resumed.
Lack of the tools which are capable of getting the tongue back in place was another egregious violation in that setting. One of the tools is
a laryndoscope which is something which should be prepared well before the procedure and should be accessible within seconds when the problem is detected.
Dr. Shefer has also made calculations of how much propofol was purchased and how much of it was delivered to Michael Jackson on a nightly basis.
The total amount of propofol shipped was 130 pcs of 100ml vials and 125 pcs of 20 ml vials.
This makes 15,5 liters which is an extraordinary amount for a single patient.
If calculated in terms of the amount administered within the period of April 6 – June 25 from the date of its first shipment to the date of Michael’s death the daily consumption was to have been 1, 937mg, or around two 100ml vials each night (if the whole amount bought was used up).
Dr. Shafer drew our attention to a extremely important point.
Vials of propofol are an easy environment for bacteria growth once they are opened – so all leftovers should be thrown away 6 hours after opening the vial.
In these circumstances no one would buy 100ml vials unless he wants to use them in full – otherwise he will have to throw away too much unused medication.
In short you buy 100ml vials only if you want to use 100ml vials.
Therefore the fact that Murray ordered 13 liters in the form of 100ml vials (130pcs) suggests that he was administering huge doses of propofol per night. Otherwise he would have predominantly purchased smaller ones.
Let me remind you that in his first shipment of April 6 Murray received 10 pcs of big and 25 pcs of small vials, but for his second shipment he ordered already 40 pcs of big (and 25 pcs of small) vials. And 40 pcs of big 100ml vials make up 4 liters of propofol delivered to Murray already on April 28.
Lack of the suction apparatus is a totally egregious violation.
There is no evidence that Michael Jackson was instructed not to eat or drink before going to bed and this put him at a greater risk than other patients. In fact I remember that there was some juice on Michael’s night stand, so he might have been drinking it!
And if my memory is correct the chef also cooked something for Michael to eat after the rehearsals and left it in the fridge, only that night that he didn’t take anything…
Lack of the infusion pump is another of egregious violations.
Without the infusion pump the rate of propofol delivery cannot be precisely controlled. In the absence of this equipment the danger of an overdose increases many times over. Dr. Shafer says that this factor widely contributed to Michael Jackson’s death.
David Walgren asked if it was possible to control propofol by means of a plastic wheel on the tubing. Dr. Shefer answered that the little roll which squeezes the tubing and stops the flow was extremely imprecise for propofol. The failure to have the infusion pump was a direct cause of Michael Jackson’s death.
Another egregious violation was the pulse oxymeter which Conrad Murray used.
This basic model was completely inappropriate for continuous monitoring of the patient. It is designed for a quick measurement of the pulse only. The models used in the hospital setting are supplemented by a sound device which accompanies each beat and even if the doctors don’t see it they can hear the beats slowing down – so they know what is happening just from listening.
In case of a respiratory arrest the oxygen starts dropping from the norm of 100%. By the time it reaches 92% the alarm starts off. This moment is simply impossible to miss and it requires an immediate intervention on the part of doctors to return oxygen into the blood.
Dr. Shafer says that a proper pulse oxymeter would have saved Michael Jackson’s life.
Let me add that the model used by Murray costs $275 while the models that could have saved his life cost $750-1500.
Murray and those who were to supply the equipment (AEG Live) were economizing on Michael Jackson.
Lack of a blood pressure cuff is another egregious violation.
Propofol lowers the blood pressure – everyone’s blood pressure. This is an expected event which is handled by anesthesiologists either by giving another drug (ephedrine for example) or by administering less propofol.
Considering that Michael Jackson was dehydrated from strenuous exercise (lacking enough liquid in his system) his blood pressure had a tendency to be low. Dr. Shafer explained the phenomenon which takes place when the blood pressure drops – the body closes legs and hands (that is why they feel cold) and preferentially sends the blood to vital organs only – like the heart, for example.
But since propofol is circulating mostly to the vital organs it also becomes more potent and this is what physicians call “an exaggerated response”. It is an increase in the power of the drug simply due to a drop in the blood pressure – which in case of propofol may be crucial (any change in its concentration can involve a breathing arrest). This is why it is so important to have a blood pressure cuff fixed to the arm of the patient and monitoring his blood automatically and on a regular basis.
Murray’s blood measuring device was manual but even this was not in use – it was packed into a cardboard box and looked like it was seldom used.
Lack of an ECG machine was a separate egregious violation.
This machine allows you to monitor the heart rate and see whether it s low, high, normal or abnormal. Dr. Shafer says that Murray cannot even tell us what Michael’s heart was doing at the time of the arrest.
Capnography is the monitoring of the concentration of carbon dioxide (CO2). Failure to measure this concentration is an egregious violation.
In the report Dr. Shafer listed it among serious violations first but later elevated it to the egregious one. He explained – in the hospital setting it wouldn’t be that crucial as there is a lot of other monitoring equipment which will set off the alarm in case of a problem. But in a home setting with no equipment available, capnography is one of the first things to have as its absence is a set-up for disaster.
A capnogram can show when the patient stopped exhaling carbon dioxide and it may serve as the very first warning of a respiratory arrest. And a respiratory arrest is all we are talking about here.
Another egregious violation is not having the emergency drugs at hand.
These include drugs to raise the blood pressure, stabilize the heart rhythm and accelerate the heart if it gets too slow. If we come to think of it Murray did not have any medication at all to help Michael’s heart and cardiovascular system though he is supposed to be a cardiologist.
The medication needed included ephedrine to raise the blood pressure (which acts as adrenalin) and a muscle relaxant in order to paralyze the very strong muscles in the mouth which won’t allow the tubing to be inserted into the airway for bringing in oxygen there.
This didn’t contribute to the death of Michael Jackson, but Dr. Shafer said but it shouldn’t have even got to the point when such medication was required.
Failure to make records is an egregious and unconscionable violation.
Dr. Shafer stressed it again and again that keeping the records was not optional. It is part of the care of the patient. The doctor should always be able to reference himself to what happened 10 minutes ago and find an answer to a question – What did you do why the patient is having this reaction now?
These questions should be asked and answered even after the procedure. And this is why Dr. Shafer listed this violation not only as egregious but as an unconscionable one too.
If the next day after the procedure Michael Jackson felt unwell he had the full right to ask his doctor what he had done to him. With no medical records kept he was denied the right to know it.
And since he didn’t survive, his family is denied to know what happened either. Dr. Shafer gave an example of his father – what was he supposed to think and how he would feel if his father had gone to a medical facility, stayed there for 80 days and died, and doctors would not have been able to provide a single record to explain what happened? And shrugged their shoulders saying that they didn’t know?
No matter how absurd it looks this is exactly the situation with Conrad Murray who didn’t keep a single record!
David Walgren asked Dr. Shafer, “What if the patient asked not to keep records?” Dr. Shafer said it didn’t matter. He was still to do it – there is no basis for claiming any confidentiality here. Any such claims would be completely false here.
At this point I recalled that Dr. Klein did record giving Demerol to Michael during those cosmetic procedures though it was probably an area where Klein would like to avoid questions.
I also recalled that Kenny Ortega shared his concerns about Michael’s health with this “doctor” and Murray replied to him to stop being an amateur doctor or psychologist and told him to leave Michael’s health to him. Let me remind you of the email Kenny Ortega sent to Randy Phillips of AEG on the night of June 20 2009 where he described how Michael felt on June 19:
Randy Sat, June 20, 2009 at 2.04 am
I will do whatever I can to help with this situation. If you need me to come to the house just give me a call in the morning. My concern is, now that we’ve brought the Doctor into the fold and have played the tough love, now or never card is that the Artist may be unable to rise to the occasion due to real, emotional stuff. He appeared quite weak and fatigued this evening. He had a visible case of the chills, was trembling, rambling and obsessing. Everything in me says that he should be psychologically evaluated. If we have any chance at all to get him back in the light, it’s going to take a strong Therapist to help him through this as well as immediate physical nurturing. I was told by our Choreographer that during the Artist’s costume fitting with his Designer tonight they noticed he’s lost more weight. As far as I can tell there is no one taking responsibility (caring for) him on a daily basis. Where was his assistant tonight? Tonight I was feeding him, wrapping him in blankets to warm his chills, massaging his feet to calm him and calling his doctor. There were four security guards outside his door, but no one offering him a cup of hot tea. Finally, it is important for everyone to know, I believe he really wants this. It would shatter him, break his heart if we pulled the plug. He’s terribly frightened it’s all going to go away. He asked me repeatedly tonight if I was going to leave him. He was practically begging for my confidence. It broke my heart. He was like a lost boy. There still may be a chance he can rise to the occasion if we get him the help he needs.
Needless it to say that not only Murray fully neglected the first warnings of a tragedy but he didn’t record any of Michael’s complaints into his medical records for a simple reason that there were no medical records whatsoever.
Dr. Shafer said that the records were indispensable as in case another doctor were to treat the patient he should have the full medical history (his lab results, his reaction to this or that medication, duration of certain drugs administered, the effect they had, etc.). Medical records are indispensable for making a referral to another doctor. After all, the state which licences doctors is responsible for the care the doctor provides to patients and has the right to demand their records too.
Murray’s irresponsibility towards his patient had one more side to it. Dr. Shafer reviewed Murray’s statement to the detectives and noted that Murray complained about “not knowing what therapy was given to Michael by other doctors” (for example Dr. Klein).
Dr. Shafer says it was Murray’s obligation to follow upon it and find out, because providing a certain therapy and not knowing what others are doing is inconceivable. Walgren asked him – and what if the patient says it is none of your business? In that case Murray should have said that he could no longer be his doctor, replied Dr. Shafer.
From that interview with the police Dr. Shafer learned that the only reference to a physical examination of Michael Jackson had been done months prior to those nightly propofol infusions. However according to the standard of medical care a physician is to make assessment of his patient each time he intends to do a sedation procedure.
And if he saw that Michael was dehydrated as he was sweating a lot during exercise – why didn’t he measure his blood pressure and pulse? And he didn’t do as little as a simple recording of the vital signs! Any physician does that, while Murray did not. Lack of a regular physical assessment is another serious departure from the standard of care and coupled with the failure to keep records is so profound a violation that Dr. Shafer could hardly find a word to describe it.
He said it had no excuse.
Failure to have a proper doctor-patient relationship is an egregious violation
This relationship is built on the foundation that the doctor will always put the patient’s interests first. It doesn’t mean doing what he asks of – it means doing what is right for the patient and acting in his best interests. If the patient requests something foolish or dangerous, it is a doctor’s obligation to use medical judgment and say ”no”.
Dr. Shafer called it an employee-employer relationship where one stated what he wanted and the other said “yes”.
With due respect for Dr. Shafer I will correct him a bit here and say that it was not so much an employee-employer relationship between Murray and Michael Jackson – it was an employee-employer relationship between Murray and AEG Live.
On the instructions of AEG (who thought that Michael was “simulating” a problem) Murray totally disregarded Michael’s deteriorating state of health and cut short even feeble Ortega’s attempts to seek professional medical help.
Murray took orders from Randy Phillips of AEG who demanded that Michael should stop seeing Klein and should attend every rehearsal no matter in which condition he was – or they would “pull the plug”.
In the above email Kenny Ortega says it himself that they “have brought the doctor into the fold and have played the tough love”. They have brought, and not Michael Jackson and they have “played the tough love” towards him together with Murray.
So when Dr. Shafer speaks of Murray acting as an employee of Michael Jackson he assumes that there were only two parties in this relationship, when one asked for propofol and the other agreed. Even in his worst dream Dr. Shafer is unable to imagine that there could be a third party to this process which would dictate its will to Murray and ask him to fully disregard Michael Jackson’s complaints.
But as to the essence of the problem Dr. Shafer is right – Murray did fully abandon medical judgment and was not acting in his patient’s interests at all.
Dr. Shafer says that if Murray had acted as a doctor he would have referred Michael Jackson to sleep disorder specialists for evaluation and therapy.
In fact even Kenny Ortega saw the need for Michael to be evaluated by psychology experts and a qualified therapist – only no one paid attention to his words, including Conrad Murray. However it noteworthy that Kenny Ortega did not approach Murray with this request – no, he approached Randy Phillips with it!
This alone shows who the real master of the situation was. However a true doctor will never bend to anyone’s orders and will be guided by nothing else but medical judgment and the oath of Hippocrates he takes to observe a code of medical ethics.
Dr. Shafer says that Murray’s unwillingness to say “no” and his failure to refer Michael to a proper specialist directly resulted in Michael Jackson’s death.
And I would add to that package Murray’s full willingness to say “yes” to those in whose real employment he was.
Failure to obtain an informed consent is an egregious and unconscionable violation.
Dr. Shafer says an informed consent would have involved making clear to the patient that the risk of death from propofol (administered in that environment) was very real and there is no evidence whatsoever that Michael Jackson knew that his life was at risk. The informed consent requires discussion of an alternative therapy and there is nothing to show that this conversation ever occurred.
It was to be a written consent and was to have been signed every night .
“What is meant by a patient’s right to autonomy as it relates to informed consent?” asked Walgren. Dr. Shafer explained that a person has the right to dictate what happens to his body and his life. It is a fundamental human right and principle of ethics, and health-care providers recognize and respect the right of the patient to take these decisions – through the process of informed consent.
Dr. Shafer said that by not obtaining an informed consent Jackson was denied this autonomy.
Failure to continuously observe the mental status of the patient is another egregious violation.
When administering sedation the doctor converses with his patient assessing his mental status and how awake he is. Since it is no deep anesthesia (where the body is cut and there should be no pain) for sedation the doctor gives just enough drug and takes care not to give more. The doctors stays by a patient’s bedside and never abandons him. Dr. Shafer says that in his 25 years of practice he has never walked out of the operating room.
An anesthesiologist giving sedation is like a driver at the steering wheel who cannot walk away for 2 minutes to relieve himself because it is very likely that during that time a disaster will take place. And Dr. Murray did leave the steering wheel. If he needed to leave the room there should have been some back-up personnel to replace him.
“And will being on the phone even in the general vicinity of the patient be an independent egregious violation?” asked Wlagren.
Dr. Shafer said that it was a setup of disaster.
“The patient is receiving IV drugs and the doctor is not focused on the patient – instead he is talking on the cell phone, sending text messages, answering emails. You cannot multitask like this, even if you are a couple of feet away, particularly with no monitors in place and no alarms. A patient who is about to die does not look that different from a patient who is okay”.
“You don’t know that the oxygen saturation is dropping, you don’t know that breathing has stopped, because you are distracted” and all “this is when the patient is essentially dying”, Dr. Shafer said. You cannot be distracted by all those activities and the period of 45 minutes – while Murray was busy on the phone – speaks for itself.
From a distance it is not that easy to say whether the patient is breathing. All that happens is that the stomach rises and falls a little bit. There were no monitors, no blood pressure equipment and from a distance Conrad Murray could not see the readings on the pulse oxymetry device he had on the patient’s finger. Michael Jackson could have been not breathing for a considerable period of time and it would not have been obvious to a person standing at a distance if there were no monitors in place.
Michael Jackson could look okay to Conrad Murray while actually he was not – and this Dr. Shafer says is what he believes what happened.
The need to monitor the patient has to be done continuously. Even if the equipment had been present it had to be continuously checked, followed every few minutes for blood pressure, carbon dioxide and oxygen saturation in the blood – and it is every few seconds which matter.
So there is a need not only to set these monitors in place but to constantly observe them. It is violation not to have the equipment in the first place and it is a separate violation not to use it and not make continuous observation. The latter fact is evidenced by Murray leaving the room and by a long period of phone calls and distracting activities.
Michael Jackson’s death was an expected consequence of Murray’s failure to continuously monitor the patient.
If Murray had left the room for two minutes only it would have been relatively easy to resuscitate Michael Jackson. All it would require is to ventilate his lungs and turn off the infusion line so that no more propofol was administered.
A stop in breathing is no big deal for anesthesiologists. They give so big doses for anesthesia that every patient stops breathing. It is routine and normal, it happens every day and is completely expected when administering propofol. The anesthesiologist knows that it is going to happen and makes the necessary intervention so that there is a continuous flow of air to the patient.
If Conrad Murray had been at the head of the bed and seen Michael Jackson stop breathing he should have lifted his chin to open up the route for air or filled the lungs with oxygen through the mask – and nothing would have happened. There would have been no adverse outcome at all, said Dr. Shafer.
In short if Conrad Murray had paid a little attention to Michael Jackson it was no problem to save his life.
The lack of continuous documentation is another fundamentally egregious and unconscionable violation.
As you make the observation you write it down – the blood pressure, the heart rate and how fast the person is breathing, said Dr. Shafer. If he had been doing it he would have seen in a few minutes that Michael Jackson was dying.
The family has the right to know what happened during the administration of propofol. That right has been denied to them by lack of continuous charting the process. It violates the rights of Michael Jackson and the Jackson family.
The failure to call 911 was another of those outrageous, egregious violations.
In that setting it was almost impossible for Michael Jackson to have been revived without an assistance. You have to get advanced support there instantly, immediately and there is nothing that has a higher priority than calling 911.
Conrad Murray was expected to immediately assess the situation and then call 911. The assessment would include checking the pulse and looking for signs of responsiveness (you literally shake the patient) – so it takes a matter of seconds to make an assessment. And the fact that the propofol was given (which shouldn’t have) is no impediment for calling 911 immediately.
David Walgren assumed that Murray became aware of Michael Jackson’s condition at around noon and the delay in calling 911 was something like 20 minutes. How would Dr. Shafer assess that Dr. Murray called Michael Amir Williams at 12.12, left a voicemail message to him and then had the bodyguard Alvarez make a 911 call at 12.20?
Dr. Shafer said: “That is so egregious that I actually find it difficult to comprehend. You have a patient who had a respiratory arrest and you call and leave a voice message? It is just inconceivable. A physician would not do that…. I almost don’t know what to say. It is completely and utterly inexcusable”.
Walgren assumed that Michael Jackson stopped breathing when Dr.Murray was away for 2 minutes – would he be alive if Murray promptly called 911?
Dr. Shafer said that he would but most probably have sustained a neurological brain injury due to the lack of proper resuscitation effort and lack of equipment. If there had been the resuscitation equipment [or it had been used, like the ambu bag, for example], he would have survived and would be uninjured.
Walgren asked, “And how effective is a one-handed compression on the bed?”
Dr. Shafer said, “Not at all”. When you do chest compressions on the bed the patient just sinks into the cushions. You have to push the force against the spine and squeeze the heart. It should go directly down and with one hand it is difficult to do it in the right direction. So it is always two hands, pushing straight down and a patient being on a hard surface.
Even if Murray says he had one hand under Michael’s body and compressed with the other hand, you cannot muster your force like that because you need your body behind this effort – in that kind of positioning there is no power. You need to throw your body into it because this is what it takes to move the breast bone and effectively pump blood for the patient.
However based on Murray’s own words that when he returned Michael had a thread pulse, the issue here was not that Michael’s heart had stopped – the issue was that he stopped breathing and because of that oxygen was running out of his lungs. His heart only stopped because it was starved of oxygen. In the presence of a pulse the heart doesn’t need to be compressed – what you need to do is get oxygen into the lungs.
A mouth-to-mouth resuscitation done by Murray to resuscitate his patient was a serious violation in these circumstances.
Dr. Shafer says that if nothing else is available a mouth-to-mouth resuscitation is the only alternative. But for a health-care provider the need to resort to it means the admission of a failure to have the necessary resuscitation equipment available. The mask would have been much more efficient – because when you breathe into a patient it is your expired air. The usual level is no more than 20%. And if he had ventilated Michael’s lungs with oxygen he would be alive now.
In his interview with the police Murray described raising Michael’s legs. This was a minor violation as Dr. Shafer said it was just a waste of time. You raise a person’s legs if you believe you need more blood going into the heart, but since Michael’s heart was beating anyway Dr. Shafer said he didn’t know why Murray had done it – he needed oxygen and not raising his legs!
It shows that Dr. Murray was clueless as to what to do.
Walgren asked – and what is flumazenil used for? Dr. Shafer said that this is a drug which is used to reverse the effects of any of the Valium type of drugs which include Lorazepam and Midazolam. Intravenous Flumazenil is an antidote as it can quickly reverse an overdose of those drugs.
There was nothing wrong with giving Flumazenil but the small 4 mg dose of Lorazepam given hours before would not require a reversal, so Dr. Shafer found it curious that Conrad Murray would choose at this critical moment of Michael’s life to give a drug which would reverse Lorazepam. It does not fit.
Dr. Shafer’s interpretation of it is that Murray knew that he had given a lot more of Lorazepam than the 4mg he mentioned in his statement – which is why he quickly reached for an antidote for it!
The fact that Murray did not admit to the paramedics and the UCLA emergency room doctors that he had given propofol is another egregious deviation from the standard of care.
When a person’s life hangs in the balance as it did to withhold information is inexcusable. In addition to that he mischaracterized it as a witnessed arrest which is very different from what it was. A witnessed arrest is usually not the arrest for lack of breathing – it is something like a heart attack. You see the person and suddenly he is down and you realize that something catastrophic has happened.
You assume it is some sort of a cardiac disaster because in the presence of a physician a patient should not be allowed not to breathe, therefore a cessation in breathing is assumed not to have occurred. So the therapy that was directed at Michael Jackson was a therapy towards a cardiac event. The fact that it was a respiratory arrest caused by sedatives, specifically Propofol, was withheld – so neither the paramedics, nor the physicians knew what they were treating.
When a patient goes into an arrest you have only seconds to go one way or the other. They were not given the information to choose a treatment path that was appropriate for what had happened.
In a scenario when the patient is transferred from one physician to another one it is a professional, ethical and moral obligation to tell the truth. The doctor is obliged to tell the truth, the whole truth and nothing but the truth. Anything less than the truth is inexcusable. And this is another egregious and unconscionable violation of the standard of care.
Dr. Shafer stressed again that the doctor-patient relationship is built on trust and the patient’s interest always going ahead of the doctor’s interests. By withholding such information you violate this trust. “When it is withheld from the people who are trying to save the life of your patient you violated that trust in ways that are so foreign to me that I truly have trouble of conceiving it”. The patient has a right to expect the doctor to be honest.
Walgren asked – what is polypharmacy? Dr. Shafer said that it is administering many drugs at once.
Walgren enumerated the drugs Conrad Murray administered that night – Lorazepam, Diazepam (Valium), Midazolam as well as Propofol. “Is it polypharmacy?” “Absolutely”, said Dr. Shafer. “How would you characterize it?”
Dr. Shafer shook his head and said that it didn’t make any sense. Lorazepam and Midazolam are very similar drugs and from the perspective of the brain they are nearly identical. The molecules do exactly the same thing in the brain. The only difference is how long they hang around for.
Dr. Shafer does not see any rationale for switching between Lorazepam and Midazolam in a patient who is having trouble falling asleep. So the therapy that was used does not suggest any understanding of these drugs.
Additionally they’ve been given along with Propofol. That is common. “We commonly combine Medazolam with Propofol during anesthesia, but we do it with an understanding”, said Dr. Shafer. We don’t go willy-nilly – let’s give him more Lorazepam, let’s give him more Midazolam. The care of the polypharmacy in this case suggests that it was done without any real understanding of the drugs being used, how they worked and how they interacted. And this of itself was a serious violation of the standard of care.
Dr. Shafer looked very sad when he was saying all that because it clearly means to him that Conrad Murray is ignorant, incompetent and totally unprofessional.
Walgren asked, “And would you consider the 25ml dose of Propofol safe in this setting?” “Not at all”, said Dr. Shafer.
“In this setting there are so many variables than make it impossible to predict the response to a dose of Propofol. It is no safe dose.
“Midazolam has been given. Lorazepam has been given. It would take me a couple of days to try and figure out with the models that I have what the effect of that would be. Then you have a patient who may be withdrawing from benzodiazepines (Valium-like drugs). After all this patient has been given them for 80 days every night and he may have withdrawal from them. Or he may have tolerance to them. We don’t know”.
“Could the patient have tolerance to Propofol? It is not well-documented because nobody does this. But we do know that all the other drugs act at the same location (the same receptors). All the other drugs that act there are associated with dependence and symptoms of withdrawal. So maybe the patient is dependent on it? Or may be withdrawing?
Any dose of Propofol is potentially dangerous in these circumstances.
“We are in the pharmacological Never-Neverland here – something that only has been done to Michael Jackson and no one else in history, to the best of my knowledge”, said Dr. Shafer.
The study of treating insomnia with propofol was an experimental study, was made a year after Michael Jackson’s death and there were no deviations from the standard of care during the experiment.
Dr. Shafer evaluated the article published in China after Michael Jackson’s death in November 2010. The article claims that treatment of refractory chronic primary insomnia by means of propofol showed successful results. (This paper is important as Dr. Shafer’s opponent, Dr. Paul White is expected to cite this article).
Dr. Shafer said that at the time propofol was given to Michael Jackson there was no literature about propofol being used for treatment of insomnia.
“There are over 13,000 publications in the medical literature about propofol. Out of that number over 2,500 papers are about propofol sedation. If you ask for literature on propofol and insomnia you get one article in the entire world and it is this one”, Dr. Shafer said.
As an editor of one of the leading Anesthesiology journals Dr. Shafer would not accept it for publication as there is a number of red flags – it does not tell how much propofol was used, it claims that after 5 days of 2 hour propofol infusions six months later the patients were still much improved in their sleep pattern, etc. The evidence is not adequate for such an extraordinary claim and Dr. Shafer did not find the conclusions of the paper convincing.
The paper says that propofol therapy is “an efficacious and safe choice for restoring normal sleep in patients with refractory chronic primary insomnia”.
“Efficacious and safe based on 64 patients is too bold a statement for such poor evidence”, said Dr. Shafer. This suggested that the paper was poor edited. To be fair to the authors they say that more studies should be made before conclusions can be drawn.
What is also important that before the study was conducted its protocol had been approved by the hospital’s ethics committee, and each of the participants had given his or her written consent. The experiment took place in a hospital setting in a sleep disorder center. Prior to the treatment each participant had fasted for 8 hours. Their blood pressure and oxygen saturation were constantly monitored during treatment. Propofol was infused intravenously for 2 hours using a micro-injection pump (an infusion pump). And there was no polypharmacy, but just propofol.
Though Dr. Shafer was concerned about the validity of the results in that paper he had no concerns over the standard of care in treatment of those patients. What is described, he said, is entirely appropriate. And it only highlighted the violations in the standard of care made by Murray in treating Michael Jackson’s insomnia.
(S0 that study was a decided difference from the criminal experiment Murray was conducting on Michael Jackson. However to me it shows that propofol as a means to treat insomnia may has some prospects. And also – what was okay to do in a proper setting, with a proper consent and proper monitoring for 64 Chinese people would also have been okay for Michael Jackson had it been done in the same way. If he had had at least 3 or 4 hours of sleep every night he would have been able to function and give his shows).
All in all Dr. Shafer described 17 egregious violations of the standard of care out of which 4 were also unethical and unconscionable.
The egregious ones were likely to end in a catastrophic outcome and death of Michael Jackson. David Walgren and Dr. Shafer stressed that each of those violations individually was likely or should have been expected to result in death. And all those risks were completely foreseeable too.
Walgren asked, “ssuming that Murray gave a polypharmacy of drugs to a dehydrated, exhausted patient who may or may not have fasted and that Dr. Murray gave 25ml of propofol and walked out of the room and assuming purely for hypothetical reasons that Michael Jackson ingested either Lorazepam or Propofol – would it be Dr. Shafer’s opinion that Conrad Murray would be DIRECTLY responsible for Michael Jackson’s death? The answer was ABSOLUTELY.
Answering Walgren’s question the doctor stressed once again the fundamental principles of a doctor-patient relationship. He said that this relationship goes back down to the dawn of civilization. Doctors are permitted to know the most private details of a person’s body and of a person’s life. Doctors are permitted to give very powerful drugs that might harm or kill a patient, and are permitted to cut into a patient’s body to remove a cancer or repair an organ or replace a knee.
Doctors are allowed to do these things because they give a Hippocratic oath which dates back to 500 BC. It says: “In every house in which I come I will enter only for the good of my patients”, because at the core of a doctor-patient relationship is that the principle that you put the patient first. This is the cornerstone of this relationship. It is because you put the patient first that you are entrusted with surgery, drugs and intimate knowledge of the patient, said Dr. Shafer. The Geneva Declaration says: “The health and life of my patient will be my first consideration”. Columbia University says: “We put patients first”.
And when Dr. Murray agreed to treat Michael Jackson with propofol and disregarded his patient’s interests in so many ways Dr. Shafer said that Dr. Murray put himself first – not Michael Jackson.
* * * * *
Day 14. Thursday, October 20
This day is so important that I will try to transcribe it the best I can.
1. David Walgen talked about Propofol first.
He reminded Dr. Shafer that in March 2011 he had enquired whether Dr. Shafer would be able to give his expert opinion on this case and when Dr. Shafer agreed he provided him with all the materials concerning the case – medical records, statements and the like.
Dr. Shafer also received a review made by his colleague and friend Dr. Paul White made on March 8, 2011 where Dr. White suggested that Michael Jackson may have orally consumed the propofol.
Dr. Shafer said “I was disappointed because it is not possible” and explained, “On the first-passed principle alone oral propofol has no biological activity”.
The first-passed principle required explaination. It means that Propofol is so rapidly metabolized by the liver that very little propofol gets past it. Everything that enters the stomach and the intestines goes first to the liver.
And “the liver has such powerful mechanisms for metabolizing propofol that only a very small percent can get past it. This is the principle that is taught to first-year medical students”
“It is called the first-passed effect.” Any stuff you take first passes the liver, the liver seizes it from the stomach and in the case of propofol you would expect nearly all the drug be removed by this first passed effect.”
Guys, with so much medical information studied here we can also regard ourselves as first-year medical students. After this first-passed principle was explained I see that when we take a pill it does not go into our blood immediately – first it may be (at least partially) broken into pieces in the liver and the body will receive very little. This is why if pharmacologists want the drug to be really effective they must work on the way it passes the liver barrier first.
And it is clear that propofol does not pass that barrier because it was designed to be taken straight into blood.
Walgren produced a paper called “Propofol is not bio available” (exhibit 216) made by Dr. Shafer specially for this testimony.
“Bio-available” was also explained. Dr. Shafer said, “It refers to whether the drug is available to the body after it is taken orally. If you inject something intravenously by definition it is all in the blood stream. But if you eat something it may or may not get into the blood stream. And the amount which gets into the blood stream is the amount called “bio-available”.
What it essentially means is that you can take some drugs in kilos but they will still be cleaned out of the body before they enter the blood stream and start working there for the simple reason that they are not bio-available. And propofol is this kind of a non-bio-available drug.
Dr. Shafer presented a series of slides which show a human digenstive system. Any drug is first processed in the stomach, then goes to the small intenstines, then to the large intenstines (if anything of the drug is still left after that) and eventually out through the rectum. Liver is a huge organ near the stomach into which all blood from the digestive tract organs flow.
When propofol enters the stomach absorption of propofol into blood starts almost immediately. The nature of the propofol molecule is that it can pass immediately through the tissue of the stomach into the blood stream.
All the organs in the digestive tract have blood vessels inside them (and will absorb propofol), but the matter is that all blood from these vessels will first go through the liver. And only when that blood passes through the liver, what remains of the drug is taken to the heart and the brain.
This picture shows that all veins coming from various parts of the digestive tract first come together into a large vein which then takes all blood (with propofol in it) through the liver.
In the liver propofol is metabolized (or undergoes a reaction which break it down into other biochemical elements). This means that practically none of it is left in its original form and goes to the heart and brain to work there.
And this is exactly the first-passed effect named earlier.
“How would you characterize the degree that propofol is activated?”, asked Walgren. Dr. Shafer says that as a result of the first-passed effect 99% of the drug is removed and there is no reason to expect the propofol taken orally to have any biological activity in the body.
Dr. Shafer added that due to the most recent information the lining of the guts is very active against propofol, is resistant to it (and therefore is not absorved and does not go into the blood in these organs).
All of the above confirmed Dr. Shafer’s conclusion made in April 2011 that “there was ZERO possibility that Michael Jackson could have died of an oral consumption of propofol”.
Walgren stressed that this conclusion was based on the fundamental principles taught to first-year medical students? Yes, Dr. Shafer sadly agreed.
Neither of them is saying it but what is known to every first-year student should be known to Professor White too and this is why Dr. Shafer said he was disappointed by the statement Dr. White of March 8, 2011. He knows that Dr. White also knows that it is untrue, is sad about it and can only wonder why he claimed a non-scientific thing like that.
The theoretial part was confirmed by the studies where animals were given propofol orally but it did not take any effect on them (so all of them should be alive!).
Propofol was studied by various scientists (Dr. Gwen studied it for 15 years) before bringing it to the market. In 1985 propofol was given to mice via different routes. It was found that even a small dose of 5-15mg per kg given intravenously was effective, while even a massive dose of 300mg per kg given orally did not cause the animals to go into general anesthesia – and all this due to the first-passed effect taking place in the liver.
In 1991 the same result was confirmed on piglets – there less than 1% of propofol was bioavailable and the rest was cleaned out of the system. In rats there was some study to study difference as one study said 10% of propofol was bioavailable (1996) but the other study made 15 years later said that only 1% was.
Dogs and monkeys also received propofol orally but the most they showed in blood was around 0, 25%.
Naturally all of them survived the process – and later we will learn that Dr. Shafer also drank propofol to test it on himself and he is still here to testify!
These findings absolutely rule out the possibility which Dr. White suggested in his report – that Michael Jackson could have taken propofol orally and this could have led to his death.
Walgren pointed it out and Dr. Shafer agreed that by the time Dr. White had made his statement in March 2011 all those studies had been published and available to the scientific community.
Translated from the highly polite and politically correct scientific language it means that Dr. White couldn’t have known about those studies (if he is a true scientist) and was therefore willfully misrepresenting the scientific data (or was lying if we put it in simpler terms).
While this unpleasant fact was touched upon in the court room Dr. White seemed to be very much engrossed by something in his computer.
With the help of Dr. Pablo Sepulveda, Professor of anesthediology in Chile, one of the leading scientists in the field and the host of an international conference in May, Dr. Shafer also made research on human volunteers who took the propofol orally.
There were 6 subjects in the study – the first three took 20ml (or 200mg) of propofol and the next 3 took twice as much dose – 40ml(or 400mg).
Naturally the pulse oxymetry was present and their blood pressure was constantly monitored – but neither the oxygen level nor the blood pressure ever dropped. Blood samples were taken from their arms and was measured for propofol. The level of their sedation/alertness was measured by a common validation scale used by anesthesiologists.
However none of them showed any sedation levels at any time – propofol did not take any effect when taken orally.
The paper on those findings was presented to the annual International Society of Anesthetic Pharmacology by Dr. Shafer’s colleagues last Friday in Chicago which is a forum which brings together doctors and pharmacologists.
Dr. Shafer himself could not attend it due to his father’s death.
By the way Dr. Shafer was the recepient of a life-time award for his work in pharmacology at that conference.
Murray’s trial and Dr. White’s review were not the only reason why Dr. Shafer conducted that human study. The other reason is that there is an effort on the part of the Drug Enforcement Agency (DEA) to make propofol a restricted drug and handle it almost like morphine. It was Dr. Shafer’s view the publicity of Michael Jackson possibly drinking propofol might be one of the reasons that it is being pursued by the DEA.
If the drug becomes controlled Dr. Shafer’s personal belief is that patients will be hurt. Anesthesiologists need to have easy access to propofol during the process of administering this drug. If you run out of it the patient will wake up – therefore it shoudl be always freely available to them. Any additional paperwork requirements as is usual for controlled drugs will place patients at risk.
Now Dr. Shafer’s study has shown that the drug cannot be abused orally – if the drug is to be abused it will be done only by IV which limits the range of abusers to health-care providers (the public does not generally have access to IV).
Dr. Shafer concluded that the human study only confirmed his initial opinion that there was ZERO possibility that Michael Jackson’s death was caused by a possibility of him orally consuming propofol.
Let me make a note here.
I was somewhat surprised when the defense approached the judge that they would no longer pursue the propofol-taken-orally-line of defense. It seemed to me that it was an unnecessary move – if they don’t claim it any more why not keep quiet over it and just not raise it during the trial?
But now I see that by approaching he judge they didn’t want the Prosecution not to touch upon this subject either and the only reason why they didn’t want it was saving the reputation of their main expert Dr. White.
They didn’t want the jury to know that Dr. White disregarded the fundamental principle of “first-passed effect” which is known to every first-year medical student and that he was clearly not telling the truth when he spoke about Michael taking propofol orally.
Well, now we know that Dr. White is capable of claiming something which will totally contradict the medical science. At least my trust for this expert has diminished greatly.
2. The theory of Lorazepam taken orally and Lorazepam in general came next.
When I was watching it for the first time it seemed that it was difficult even for the power of science to make an absolutely precise determination on what happened with Lorazepam that night (though it doesn’t change anything in respect of Murray’s guilt). Let us see what the second viewing will bring us.
The Lorazepam study and its pharmacokinetics was an even bigger set of slides, prepared by Dr. Shafer (exhibit 217).
Dr. Shafer is totally amazing – so much work done at the expense of his free time, with no fees charged, at a difficult time like his father’s death and all in pursuit of the truth and restoring the good name for his profession! Only true scientists are capable of that…
In one of his earlier papers Dr. Shafer was the principal investigator of Lorazepam and Midazolam administered IV to patients in intensive care units and for today’s study he relied on the findings related in that paper.
Dr. Shafer explained that the paper was looking into the difference between Lorazepam and Midazolam which were given in the intensive care unit (ICU) by a computer. The computer was used to target exactly the right amount of drug in the blood.
Also the computer recorded precisely how much drug it gave to the patients in the IC unit where patients stay for a long time. Depending on how deep a sedation was needed the computer increased or reduced the dose.
It was a “double-blind” study where the scientists didn’t know which drug the computer was giving – the computer knew which drug went to which patient but the person using the computer did not. The idea was to see the difference between those two drugs.
The scientists regularly took blood samples from the arterty to get a precise link between the dose of each drug and its concentration in the blood.
The data for the article was so huge and its conclusions so reliable that Dr. Shafer’s article is widely cited by other researchers. The study was done at Stanford University – Dr. Geller, the Head of the Intensive Care Unit, was responsible for conducting the study and Dr. Shafer was responsible for the data analysis.
Walgren asked Dr. Shafer why he relied on this study in discussing the present case. Dr. Shafer said it was because of the huge amount of data gathered then – the number of patients was huge, each patient was studied very intensively and for a long period of time too. Therefore this study provides the best pharmacokinetic model to use in order to predict the level of Lorazepam concentration in the blood after a dose.
Aha, so the basis for that article was Dr. Shafer’s huge collection of data on the correlation between what dose of Lorazepam produced what concentration in the blood?And since we know what concentration of Lorazepam was in the blood in this case he will probably be able to tell us what dose was given?
Only will it be possible to find out whether it was given intravenously or taken orally? There is no doubt that it was given intravenously and by Murray – the only problem is how to prove it as not everything is in the power of science. Okay, let’s go on and see.
Dr. Shafer reviewed both Dr. Murray’s statement that he had given Michael Jackson 4mg of Lorazepam in two doses 2mg each and the toxicology report which stated a reading of 0,169 micrograms/ml of Lorazepam in the femoral (peripheral) blood.
Walgren asked him if he was able to find out whether the statement about the given dose matched up to the level found in the blood. Dr. Shafer said “yes” and provided a computer model called “2 doses of 2 mg each” which shows what happens to such a dose of Lorazepam over time.
The red horizontal line of the diagram starts at midnight and goes all the way to 12 o’clock noon time. The vertical line shows the level of Lorazepam concentration in the blood (in micrograms per ml). The green horizonal line is the concentration of Lorazepam in the femoral blood measured on autopsy.
The diagram allows us to see what happens to the concentration of drug with time.
According to Murray’s statement the first IV injection was made at 2 in the morning. The model shows that initially the drug is all in the vein, but then due to its going to other tissues (called distribution process) and due to the process of metabolism the concentration of the drug in the blood falls rather quickly. If at the moment of the IV injection it was O,05 an hour later is it is already one third of it.
The second dose given at 5 am goes higher than the first (as the first dose is still working) – but again there is a very rapid washout of the drug and by 12 o’clock as the supposed time of Michael Jackson’s death we see that the predicted concentration of Lorazepam in the blood is much lower than what was found on autopsy.
It is only 10% of what was measured at the time of Michael’s death. And after death all processes in the body stop as the circulation of blood stops (and no further changes take place).
So speaking of the above scenario Dr. Shafer said “This did not happen”, because otherwise the coroner would have found Lorazepam at the low level shown in the picture. (And this means that Michael Jackson received much more than 4mg).
In order to explain what dose of Lorazepam could produce the level of 0,169 mcg/ml in the blood Dr. Shafer presented a different computer simulation called “10 doses of 4mg each”.
Under this model the dose of 4mg was to be given 10 times with an half an hour break between them. If the doses are stacked that way and after the amount given reaches 40mg it will then start to drop and by noontime will generate the level measured on autopsy.
Let me say one thing about this model.
According to this model the drug administration is supposed to start at midnight and finish by approx. 4.30 am after which the level of Lorazepman in the blood begins falling. At cross-examination of Dr. Shafer the next day Chernoff will ask him questions as to why his diagram starts at midnight when Michael was even away from home.
I don’t remember what Dr. Shafer replied but to me it does not change much – Dr. Shafer could have used a dose of not 4mg but 8 mg given 5 times and then the period of administering the drug would be reduced by half. It seems that this simulation was made in a hurry as the defense only recently declared their Lorazepam theory. With his father’s funeral Dr. Shafer had no time to take care of this point. If he had had more time he would have corrected midnight to 1 or 2 o’clock in the morning and would have doubled the dose which would roughly produce the same result.
Actually Dr. Shafer himself said that he didn’t know the dose. Usually the dose should be on the medical record but in Murray’s case there was no medical record – so the only number Dr. Shafer could work with is the final concentration of Lorazepam in Michael’s body while all the rest is open to assumption. And it is impossible to simulate the situation precisely in the absence of medical records.
Walgren showed Dr. Shafer a vial of Lorazepam and Dr. Shafer said that it was a 10ml vial, where each millilitre has 4 milligrams each. So 10ml x 4mg makes 40mg. Dr. Shafer said that the simulation he prepared was consistent with the level measured on autopsy and the dose in each vial (though in my opinon nothing could have stopped Murray from using two vials for one syringe, or making the infusions not every half hour but every quarter of an hour)
Then Prosecutor Walgren and Dr. Shafer determined the way some Lorazepam found its way into Michael Jackson’s stomach. What is important here is that if it was taken my mouth then it would be in the stomach in its original form, and if it was injected into the blood system it would get into the stomach as a metabolite.
Lorazepam may be found in the body in two forms – as lorazepam proper and as its metabolite, the chemical thing which is produced by the liver when the drug goes through it. It is called lorazepam-glucoronide. This “gluco” stands for a molecule of sugar which liver attaches to the drug so that it could be taken out by kidneys. Without attaching that molecule the body cannot clean it out of the system.
The lorazepam-glucoronide loses it biological activity, becomes inactive and will not put a person to sleep. Why it is necessary for the body is because it allows the drug to be taken away from the system by the urine.
What puts a person to sleep is the original molecule of Lorazepam and it was this original Lorazepam which was measured by the coroner in Michael’s blood as 0,169 micrograms/ml. Why it was in the blood is because it was injected by IV.
The same type of original Lorazepam was measured by Dr. Shafer in his study at Stanford University.
Let me note once again that the coroner measured Lorazepam in the blood and the defense’s lab test measured it in the stomach . So the amount of Lorazepam in the blood has to be compared with the amount of it in the stomach in order to see where it came first and via which route it found itself in the stomach.
Walgren produced the lab report from the private company (exhibit 218) which analyzed the amount of Lorazepam in Michael’s stomach at the request of the defense.
The amount found by the private lab in the stomach was 634 micrograms/ml which is 0,634 mg (or approximately four times as much as the 0,169 mg amount found in the blood by the coroner, if my calculations of all these mg are correct).
Trying to find out by what procedure the private lab (Pacific Toxicology) calculated the Lorazepam in the stomach Dr. Shafer approached this company and asked for their procedure manual, however they didn’t provide any. It was only after David Walgren got their standard operations procedure document that Dr. Shafer was able to see how the lab had come to that number.
What he found out was that they summarized both the drug itself and its metabolite produced by the liver (which as far as I understand is not done as it inflates the result). Due to their method the lab came to a substantially inflated number, said Dr. Shafer. Now it is difficult to say by how much it was inflated, but it clear that it was.
Walgren wondered, “Even though the number was substantially inflated, some Lorazepam was nevertheless found in the stomach, so how could Lorazepam administered intravenously find itself in the stomach?”
In answer to that Dr. Shafer showed a very complicated route Lorazepam goes and how it gets into the stomach even if injected into the blood by IV.
The blood takes the drug to the liver and from the liver it goes to the bile duct and the gall bladder, and from the gall bladder it sloshes back into the stomach. “Sloshes” means it is being spilled or splashed.
Unfortunately it does happen as many of us have a burning sensation in the stomach because of this bile juice thrown back there.
And if there is Lorazepam there it will go there together with it – however whatever amount of Lorazepam is found there it can be found only in the form of a metabolite (as it went through the liver and was processed there).
This splosh happens to approximately 25% of the drug processed by the liver, while the rest 75% is successfully washed out of the system and goes to the colon. Dr. Shafer says that 25% is that Lorazepam metabolite in the stomach is quite an expected result after its IV administration.
Then Dr. Shafer took the defense’s accumulative result of Lorazepame in the stomach (of Lorazepam proper and its metabolite wrongly calculated together) and multiplied it by how much fluid there was, and this is the way he came to a trivial or very small amount of Lorazepam of 0, 047 mg.
So even in case we talk of the inflated number of 634 micrograms of Lorazepam from the Pacific Toxicology lab, it was still no more than 1/43d of the usual 2mg Lorazepam tablet in the stomach of Michael Jackson.
Dr. Shafer’s conclusion also included a very important fact that nearly all of that amount was a metabolite and not a drug in its original form (and this shows that it came from the blood via the liver and not from the mouth).
Dr. Shafer said that this way the defense’s own test results prove that Michael Jackson did not take Lorazepam orally anywhere near the time of his death.
The period of “near the time of death” means at least four hours before it – if the death took place sometime around noon. Dr. Shafer said it firmly that if it occurred at noon time the results obtained by the defense totally disproved that Michael Jackson could have taken Lorazepam orally during the four hours prior to his death (if he died at around 11.00 am I gather that the time span would be 7.00-11.00 am).
But since the conclusion covers only the period of four hours before death just as I was afraid the defense would be now arguing about the earlier time of taking Lorazepam. Frankly, to me it does not change a thing. Murray is so terribly guilty over everything else that even if science is unable to precisely determine what happened at a period of time prior to 8 or 7 o’clock it will be nothing but a small vague spot on the otherwise absolultely clear picture.
Especially since we cannot rule out that it was Murray himself who dissolved some pills in the juice and offered it to Michael Jackson for drinking. By the way can anyone who tried Lorazepam say whether it is bitter or neutral to the taste?
Why I am asking is because Chernoff verified with the coroner investigator Ms. Fleak whether the juice on the night stand had been tested for its contents. She answered “No”.
The question itself is a curious one. It is suggestive of the idea nurchured by the defense – that Michael could have dissolved something in there. However when a patient takes tablets he doesn’t dissolve them in liquid (unless they are huge) but swallows them and then drinks something afterwards. If the defense thinks that Michael could dissolve those pills in the juice, we can think the same about Murray. Indeed, who can guarantee that he didn’t give any liquid cocktails of Lorazepam to Michael for those three days when he was supposedly “weaning him off propofol”?
Murray offering Michael a cocktail of Lorazepam is just a speculation – but you will agree that it is a no less speculation than Michael swallowing Lorazepam himself.
Walgren asked Dr. Shafer about the possibility of taking Lorazepam orally earlier than 8 o’clock. Dr. Shafer said that he would need time to make more calculations but said that at midnight the night before it was entirely possible (only Michael would not take that crazy number of pills at the beginning of the night when he didn’t yet know that he would not be able to fall asleep).
Whatever is the case Dr. Shafer said that the amount of Lorazepam in Michael’s stomach was trivial (“trivial” means a drop in the bucket). Let me add to it that Michael Jackson died of acute propofol intoxication with the effect of bensodiazepines being only an additional one (and Murray himself said that he had given Michael a good deal of them that night).
3. So Walgren turned to Propofol again and moved into the area of simulating the response of the body to this drug.
Walgren wondered, “If a researcher were to seek out an expert to conduct this type of modeling would you be one of probably two people in the world they would seek out?”
Dr. Shafer modestly said, “Yes, it is a small community” (so he is probably a unique or even best expert in the world!)
In pharmacokinetics they look at drugs in motion in the body and specifically at how a certain dose of drug gives you a certain concentration and at how it rises and falls over time. This science gives you a chance to learn how much propofol will be found in the blood after a particular dose.
Pharmacodynamics is about the power of the drug and how powerful the drug in your body. It does not talk about the concentration of drug but about the effect of it in your body (the concentration may be low but the effect may be high).
For these sciences to be useful they need to be mathematical – equations show which concentration of a drug has which effect and bring scientists to a number they can work with.
His comment on the picture:
You give a dose of a drug and pharmacokinetics shows which is the concentration of it in the blood. By a dose he means all doses. Maybe a little bit here, a little bit there, a little bit later – so whatever was given and at whatever time it was given is the dose.
The concentration you predict is not just one number – it is a curve over time, the concentration of drug over time following the dose (falling or rising).
The pharmacodynamics then says for will be the drug effect for each given concentration at any given point in time. Since the concentration changes over time, the drug effect will change over time too.
Dr. Shafer refers to his two papers which provided the corresponding data and computer models for infusing propofol in every operating room all over the world. His model is unique as it includes the patient’s weight, age and even gender – and this is why it could be precisely matched to Michael Jackson.
Besides the ability to measure the concentration of propofol in blood Dr. Shafer also developed a technique for measuring the concentration of propofol in the brain. One paper on that was written with Dr. White (who is now the defense’s expert). They were studying apnea (a stop in breathing) and Dr. Shafer took Dr. White’s numbers at which concentration of propofol apnea will occur.
Dr. White’s paper says that at the number of 2,3 mg/ml of propofol half of all patients will be expected to be apnic (not breathing). But as every patient is different Dr. White provided a range which is plus-minus 0,5mg which is called a standard deviation.
The lowest figure in the range will account for the most sensitive patients, while the higher one will refer to the most resistant ones. At the lower end of that dose 5% of patients will be at risk of apnea, while at the higher end 95% will be at such risk. And at the level of 3,3mg/ml everyone will be apnic.
After breathing stops the heart will go on beating. While it is beating, propofol will still be circulating in the blood. And while it is circulating, it will be metabolised and will be going away out of the system. The experiment on some unfortunate piglets showed that the heart stops beating 9 minutes after breathing stops (I gathered that the piglets were revived by CPR though).
For a human being the period until the heart stops was calculated as 10 minutes.
Having all that data Dr. Shafer was able to make simulations of several scenarios of administering Propofol to Michael Jackson and see whether any of them could be realistic.
The 1st simulation was based on Dr. Murray’s statement that he had given only 25 mg (2.5ml) of Propofol.
The vertical line shows the concentration of propofol in the blood.
The central green horizontal line shows the amount of propofol found in Michael Jackson’s femoral (peripheral) blood after his death (2,6 mcg measured on autopsy).
Below it is another horizontal line called “apnea threshold”. It shows Dr. White’s number of 2,3 mcg as the concentration of propofol in the brain where half of patients will be apnic (not breathing).
The level of propofol in Michael Jackson’s femoral blood is very close to the level where apnea is expected (actually it is higher than that).
The assumption is made that 25mg of propofol are injected as a bolus (pushed at once).
At the moment of the injection the concentration of propofol in the blood is very high. This concentration descends incredibly fast. There are two reasons for that – first, as this large amount of drug hits the liver it is metabolized there, and second, it is quickly removed by the fat tissues in the body.
However it takes time for propofol to get into the brain. There is so much propofol outside the brain that it really pushes itself in, says Dr. Shafer. So the level there gradually rises and in two minutes reaches a peak. After the peak the brain level of propofol falls slowly, as it still needs to be removed from the brain in order to be metabolized.
However in this scenario the brain concentration does not even remotely reach the apnea threshold at which breathing stops in half of the patients (according to Dr. White’s figures).
Then Dr. Shafer adds two standard deviations in two directions (from Dr. White’s work). Below the edge of this range no one will be apnic. Above the upper edge of that range everyone will be apnic (nobody will be breathing).
And this new addition shows that even with this small dose a very small fraction of patients will be at risk . The risk arises when propofol reaches a peak concentration in the brain (the period of 0,5- 2,5 minutes). After 3 minutes there will be no more risk again and everyone will be expected to breathe.
Dr. Shafer said that the level of propofol found in Michael Jackson’s femoral blood and used for this model was the most conservative one (2,6). The level measured at the hospital was 4,1. One more was 3,2 from the heart and 2,6 was measured at the coroner’s office.
So even with this small amount of propofol a stop in breathing could occur in Michael’s case (and that is why Murray should have been careful even with this small dose).
And its effect was aggravated by the benzodiazepines he also gave to Michael – Lorazepam, Midazolam and Diazepam. All these drugs have a potential to decrease breathing, so giving Propofol on top of it was gravely increasing the risk of apnea and the standard of care for administering propofol was required even with this small dose too.
Dr. Shafer says, “This is why I say that there is no such thing as a small dose of anesthesia. Even with this small dose there is some risk”.
But then Dr. Shafer says that the scenario of only 25 mg given is not what really happened to Michael Jackson. Even if he stopped breathing at the peak brain level, his heart would go on beating due to oxygen in the lungs for some 10 minutes more. During this period the concentration of propofol would go on falling and at the time of death its level would be vanishingly small – many times as low as the level actually found in his femoral blood.
Dr. Shafer said:
- “So this did not happen. Michael Jackson received more than 25 mg”.
The second simulation model was made on the assumption that Michael Jackson received 50 mg of propofol by IV.
The way Conrad Murray described giving propofol he took a syringe and filled it with propofol and lidocaine. The description in his police statement said that he was using equal mixtures (the words 1:1 showed up in the interview). Therefore a 10cc syringe would have 5cc of propofol (or 5 ml).
5ml of propofol are equal to 50mg of it and Dr. Shafer suggested a simulation for 50 mg of propofol administered by a syringe on the assumption, firstly, that it was done as a bolus (pushed all at once) and only propofol was used (lidocaine was disregarded).
In the model provided the propofol in the blood initially rises so high that its top doesn’t even show in the diagram, but then it goes down quickly.
The brain level of propofol (the one which actually gives a signal to stop breathing) also rises quickly and when it reaches its peak level most patients will be expected not to breathe. Within 5-6 minutes after that it goes low enough for you to expect patients to be breathing again.
It is quite likely that Michael Jackson would have stopped breathing with this dose because there were so many other drugs he had already received from Dr. Murray. This would have happened in the period of 1-4 minutes after receiving the dose.
If he had not breathed for 3-4 minutes and had regained his breathing (due to resuscitation effort) Dr. Shafer expects Michael would not have sustained any brain injury.
After breathing stops, as an absolute minimum the heart would continue beating for another ten minutes. Provided the heart is beating there is still circulation and propofol is being metabolized. So the level one would expect on autopsy would be around 0,4 mcg which is only a fraction of what the coroner measured in Michael Jackson’s femoral blood.
- Therefore this model rules out that Michael Jackson was given a single dose of 50mg of propofol.
The next scenario is that Michael Jackson is given the entire 10ml (100mg) syringe of Propofol (without any lidocaine).
Under this scenario the brain level of Propofol will reach its peak almost immediately and all patients will stop breathing. This happens to all patients under general anesthesia and Dr. Shafer says he sees it every day.
If no ventilation had been provided the heart though would have stopped minimum 10 minutes later and by then the level of propofol in the blood would have dropped to 0,6mcg which is well below the level of femoral blood found on autopsy.
- So even if 100mg of propofol had been given it would still not be the right scenario either.
The next scenario looked into a purely hypothetical situation which supposed that the patient self-injected himself with 6 boluses of Propofol 50mg each.
Walgren wondered how one would inject himself with Propofol. It would be a time and labor consuming process as it is rather difficult to draw the drug into the suringe. Then some lidocaine should be drawn into the same syringe (to avoid the burning sensation) and then there are two possibilities.
Either the syringe is injected straight into the vein (but Michael Jackson had very poor veins – so poor that according to Murray’s statement he had to make an IV port under his left knee), or the syringe is attached to an injection port on the IV stand and the mixture is pushed into the tubing which then takes it to the body. This process requires time and a little bit of coordination to do. If the vein is missed the propofol will sting and will be extremely painful.
For this scenario to be realistic Michael Jackson would have had to wake up 6 times and reinject himself. However even with 6 injections of 50mg the level of Propofol in his blood – after the heart stops in ten minutes – would drop and would not be any close to the level of Propofol in the femoral blood found on autopsy.
The next scenario was the same self-injection crazy idea, only with 100mg (10ml syringe) of propofol used. Rejected again.
The next scenario is that of Conrad Murray repeatedly injecting Michael with 50mg of Propofol. I Am not going to talk about it as Murray is simply too lazy for it, though this is the first scenario where Propofol in the blood could finally reach the number of 2,6 mcg/ml which was found in the blood on autopsy.
Finally Dr. Shafer said that he was able to come up with a scenario which was consistent with all the data available. Under this scenario the Propofol was administered by a drip.
THE FINAL SCENARIO
Assuming that the time of death was around 12 o’clock (as Murray said) 100ml of Propofol started to be administered at 9.00 in the morning. It ran until 12 o’clock at which point all 100ml would have been infused into Michael Jackson.
Dr. Shafer says that for someone who does not understand the pharmacokinetics of Propofol after an hour of the infusion things will look pretty steady.
However the situation is not stable because the levels in the blood and brain continue to rise. Propofol is filling up all compartments in the body and the apnea threshold (when breathing stops) is approached slowly.
What happens when the apnea threshold is approached slowly is that the rate of breathing becomes slower too.
When we breath quickly we exhale less carbon oxide, when we breath slowly we exhale more of it. So if there had been capnography there it would have shown the rise of CO2 there.
CO2 is a very good stimulant for making us breathe – actually its lack is what makes us breath at all. Dr. Shafer conducted a research of this issue (2004) and made a mathematic model how Propofol and CO2 interact with each other (Propofol decreases and CO2 increases your desire to breathe).
So CO2 would make Michael go on breathing through the apnea threshold. Examination which would not involve capnography would probably suggest at this point that Michael Jackson is comfortably asleep.
However the propofol level is still going up and the CO2 cannot stimulate breathing any more and drawing closer to 12.00 pm it is no longer able to compensate for the level of Propofol which is accumulating in Michael’s blood. With that he starts to slow down his breathing to the point of apnea.
This slow-down in breathing could be detected – initially through measuring the CO2 with capnography, and as the breathing was getting so slow that no oxygen was getting in, it would have been picked up by pulse oxymetry.
Murray could have even observed it physically, especially if the tongue was compromising the airway. Dr. Shafer said, “If he had been with the patient during that period of time he would have seen the slowing breathing. He could have easily just turned off the propofol infusion, raised his chin or in the worst case could have used the mask and ventilation and there would have been no injury to Michael Jackson”.
According to Murray’s timeline at around 11.45 the flow of oxygen into Michael Jackson’s lungs stopped. Within 10-15 minutes the lungs no longer had oxygen for the heart and the heart stopped too.
But if the heart stops and the infusion still goes on there is no opportunity for propofol metabolism to occur and for its level to drop. Propofol begins to accumulate in the blood without breaking up into metabolites.
This is the only scenario which can explain the concentration of Propofol in femoral blood found in the toxicology report.
If the heart hadn’t stopped beating when the vial ran out of Propofol, it would have been quickly metabolized and within 5 minutes its level would have significantly dropped.
In fact if the 100 ml bottle had run out but the heart had been still beating the level of Propofol would have dropped to the same low level as before within only 5 minutes.
But it did not drop and this means that Michael Jackson died while the Propofol was still running into his veins – even after his heart stopped.
Dr. Shafer says that it fits with Conrad Murray’s description of the usual way he administered Propofol to Michael Jackson – which was a drip.
It is also consistent with the 100ml vials he had ordered and shipped. He ordered 130pcs of 100ml vials for a period of 80 days which suggests he could use at least one vial per night.
At some point while giving Michael a drip Murray left his bedside. Having observed him for a period of perhaps an hour and thinking that everything was okay he walked out of the room. At this very time the level of Propofol in Michael Jackson’s body was rising and reaching the critical level. Murray did not see that Michael’s breathing had slowed down and the level of CO2 was rising (he had no capnography).
Dr. Shafer said:” I don’t know a single piece of data which is inconsistent with this explanation”
Walgren asked: “When did the Propofol infusion end in this scenario?”
Dr. Shafer: “At noon.”
Walgren: “Is it because you assume that circulation stopped at noon?”
Dr. Shafer: “No. The stopping of circulation and the bottle running out of Propofol are independent events. I simply timed them in the simulation so that they both occur at noon”
It means that the same scenario may be applied to any time – 11 o’clock, 10 o’clock, whatever. If you ask me this could have happened at 11 o”clock as Murray initially said, and the results would have been the same.
* * * * *
Now here is a very short summary for those who missed the crucial meaning of the above.
– the key evidence upon which all scenarios are based is that the level of Propofol in Michael’s blood was exceptionally high
– even if you give huge doses of Propofol it won’t show in post-mortem blood as during the infusion the heart is beating and is taking it away from the system
– even a huge dose of Propofol will disappear from the body within 5 minutes
– however if breathing stops the heart goes on beating for 10 minutes and during this time almost all Propofol evaporates from the system
– so the only way it can accumulate in the blood is when it pours into a dead body – the body of a man whose heart stopped
– because it is only after the heart stops that Propofol no longer breaks up and starts accumulating
– and this means that Murray left Michael unattended, didn’t notice when Michael died and allowed Propofol to pour into him after his death.
* * * * *
Then Dr. Shafer made a demonstration of how it happened. The fist video below starts with the theoretical part and begins the demonstration towards the end of it:
The second video continues with the demonstration:
* * * * *
Dr. Shafer takes standard tubing (he wasn’t able to get the one shipped by Sea Coast) and shows an infusion port in the lower part of it where the syringe goes.
The upper part of the tubing goes to the saline bag and a Propofol vial hanging on the top. The very end of the tubing goes into the body through the IV catheter which was below Michael’s knee.
According to Murray this set-up was used by him for regular administration of Propofol by drip.
Then Walgren shows two invoices for 150 pcs of infusion sets (people’s exhibit 220) from SeaCoast medicals records providing the picture of it. Walgren compares Dr. Shafer’s infusion set with the one used by Murray, which was cut for the purposes of toxicology. All its key parts are the same.
Walgren says that the IV stand in Michael’s room had a saline bag with tubing attached to it. The upper tubing was clear of propofol, while the lower part tested positive for it. This could be the result of a syringe with 2,5ml of propofol being administered by Murray through a Y-connection.
There was one more saline bag on the scene of crime – an empty one with a slit on it which Murray hid into a bag. The tubing to it was never found (Walgren assumed that Murray had taken it away in his pocket). It should have been the same type as the tubing left hanging on the IV stand as it was shipped by the same company.
Dr. Shafer begins his demonstration by attaching a catheter to the tubing and showing that the fluid from the saline bag on top of the IV stand is drifting freely from it. The saline bag is plastic and shrinks as the liquid flows from it.
However with propofol it does not work. Propofol comes in glass bottles and therefore needs a vented infusion line which allows air to come into the bottle in replacement of the propofol coming out of it.
Without the air going into the glass bottle propofol will not drip out as there will be a vacuum inside.
Therefore the infusion set purchased by Conrad Murray for administering Propofol was different from the usual set – it had a small vent cap in it. When it is open the propofol flows freely down, when it is closed the propofol stops.
This special tubing is meant to be used with an infusion pump and usually has a special device for attaching it.
The Y-shape infusion port is in the middle of the tubing, approximately three feet from the catheter which was attached to Michael’s body. The bottom part is the shortest part of the tubing and is separated from the top longer part of it by a clap (the clap is used for shutting off the infusion).
Murray claimed that he clapped the tubing and slowly infused 25mg by a syringe into the middle port of it, so Dr. Shafer repeats his actions.
He takes a 20cc=20ml syringe (Murray’s was 10cc) , pierces the stopper of the 25mg vial, draws up the air into it and fills the syringe with one/tenth of it – 2.5ml of propofol (25mg).
Then Dr. Shafer injects this propofol into the port (wire connector) in the middle of the tubing and it flows down, and here we see that 25mg is so little a quantity that propofol does not even reach the end of the tubing and therefore does not reach the patient.
So the way Conrad Murray described the process the propofol should not have flown at all. It was to sit in the tubing until it was unclapped and the saline was allowed to push propofol to the patient.
Then Dr. Shafer hung the 100ml bottle (previously spiked) on the IV stand.
We see that when the vent is opened propofol races down. When it reaches the end Dr. Shafer attaches a needle to it. The needle is inserted into the wire connector in the middle of the tubing.
Parallel to it is a saline bag which is also attached to the wire connector to allow propofol to flow freely.
The arrangement has a form of a Y letter – the propofol and saline lines join each other at the wire connector and then turn into one common line.
This arrangement is extremely unsafe as two fluids are competing with each other. The speed of the propofol drip depends on the relative height of the saline bag – if the saline bag is raised there will be more force on it and the speed of propofol will slow down.
Since there is no pump control the drip is fully dependent on gravity and may drip quicker or slower depending on the height and weight of the saline bag on the other side of the IV stand. This is why the infusion pump was a must.
The only way to control the rate of propofol under this system is by using the roller claps on the propofol line and on the saline line. The rate appropriate for sedation would be 12 seconds between each drop and Dr. Shafer tries to set this rhythm by means of a roller clap, but it is really difficult (and this is why the infusion pump was needed).
If the roller clap is wide open propofol runs incredibly fast – like a stream.
Walgren notes that in the arrangement shown by Dr. Shafer the top (long) part of the saline line remains clean, while the bottom part of it, beginning with the port where it is joined by propofol, has propofol in it.
Then they talk about the recovered saline bag with a slit in it and a propofol bottle inside it. Dr. Shafer never saw that kind of an arrangement.
But he puts the bottle inside the bag and we see that it stays in the same vertical position as it was before when it was hanging on its own.
When all propofol flows down from the bottle and is finally empty, Dr. Shafer takes a spike out of it and disassembles the propofol line.
Walgren notes that the tubing with propofol inside it fits into the palm of a hand and would easily fit into the pocket. It is indeed very small.
Now the tubing on the IV stand has the form of letter Y that has lost one of its lines on the top but retained its bottom line.
The top part of the tubing is clean while the bottom part has propofol in it – and this is just the way it was found on the scene of the crime.
Dr. Shafer explained it perfectly well.
* * *
I’ve used a standard picture of the IV set up to show how Propofol could be missing on top but found at the bottom. This could happen if the second long tubing from the Propofol bottle was removed to cover up the traces: