Conrad Murray trial week 6. ANYTHING FOR MONEY
Week 6 will become the week of learning the truth about the way Michael Jackson died. The truth will be told by Dr. Shafer. If it hadn’t been for this thorough researcher and modest, honorable man we would have never learned the truth. Because Dr. White, the direct antipode of Dr. Shafer, would have easily fooled us. This part will start with the testimony of this liar.
Day 21. Monday, October 31
We are now listening to Dr. Paul White and I hope the jury is getting the difference between the true and selfless scientist like Dr. Shafer and Dr. White who is ready to do whatever they ask of him for money.
Dr. White has had a tremendous difficulty to say what total sum he is expecting from his involvement in this case. He says he usually charges $3500 per day. However for today only he has received $11,200 and considering that he has already spent 12 days sitting in the courtroom the total should come to quite a sum ($132,000 to be precise) plus reimbursement of all his expenses.
To be fair to Dr. White he said he wouldn’t expect to be paid $11,000 or even $3500 for every day.
All this talk about money made me once again recall that Conrad Murray is able to afford to pay this much money to one of his experts but could not afford to buy a pulse oxymeter for some $750- $1200, and monitored Michael with a device which costs $275. He economized on the necessary piece of monitoring equipment which could have saved Michael Jackson’s life.
Dr. White had a very had time trying to avoid an answer about the need for such equipment. At a third or fourth attempt from David Walgren he finally agreed that using a pulse oxymeter without an alarm when the doctor is out of the room is a pointless thing to do.
His answers about a call to 911 were incredible for a doctor – he went as far as saying that calling 911 in that setting was difficult as there was a gate with security outside and the telephone was not working! Another five or six attempts from Walgren and he finally agrees that making a 911 call from a cell phone is a quicker thing to do than sending a voice mail to Michael Jackson’s assistant Michael Amir Williams.
In his two-page thunderous review of the case he solemnly proclaimed, “It is my opinion that Michael Jackson self-administered propofol either intravenously or orally”. However now he says he based his opinion on no scientific research or data whatsoever and admits that that the only thing he did was looking up “oral propofol” in the Internet! He didn’t find any information there but nevertheless stated it as “his opinion”!
Now he calls his paper “his preliminary thoughts” and says he just wanted to list all “possibilities”. When Walgren asked him if he ever looked into the possibility of Michael Jackson not administering any drug himself, Dr. White started on his usual routine of running away from an answer. But Walgren reworded it again and again each time making it even worse for Dr. White:
- So you considered only two options – you blame Michael Jackson for the possibility of oral ingestion or you blame Michael Jackson for the possibility of intravenous self-injection?
- Did you have any theory other than Michael Jackson did it himself?
- Have you come up with any theories other than attributing Michael Jackson’s death to self-injecting himself?
Dr. White finally had to admit, “No, I don’t believe so”.
Well, at the moment (I keep my fingers crossed) the artillery fire from Walgren is deafening. I wonder how much of any remaining reputation Dr. White will be able to scrape off the ground after being so totally demolished.
However he LIED and LIED FOR MONEY and fully deserves this.
* * * * *
Dr. Paul White retired in September last year (2010) from his academic and clinical position at the University of Texas. Good for him that after all this shame he will not have to face students any more.
In the opening part of cross-examination Dr. White agreed that Murray had violated the standard of care and that administering propofol in a bedroom setting without proper equipment was dangerous.
However having said that he immediately started twisting his own answer, so that Walgren had to extract definitive replies from him piece by piece (in a courtroom it is preferable to give a definitive yes or no answer to make it totally clear to the jury).
Walgren: “Do you agree that Dr. Murray deviated from the standard of care on multiple instances?”
(White asked for “a more specific question” regarding the word multiple)
Walgren: Do you agree that there are instances when Dr.Murray deviated from the standard of care in his treatment of Michael Jackson on June 25, 2009?”
White: “Yes, I would”.
Walgren: “Would you agree that Dr. Murray deviated from the standard of care in the preceding two months as related in Dr. Murray’s statement to the police?”
White: “Yes, I would”.
Dr. White wanted to be a spokesman for Dr. Murray whose every word he says he believes (despite his several slips of the tongue about Michael Jackson’s death being the “crime scene”).
Trying to speak for Conrad Murray he referred to two extensive conversations with him. But since this would be equivalent to telling Murray’s story unchallenged by a cross-examination, the judge sustained Walgren’s objections to any references to those conversations.
(If Conrad Murray wants to tell us his lies, let him go on the witness stand and subject himself to questions from the prosecution).
However Dr. White kept referring to those conversations and at some point Dr. White’s disregard for the court reached such a note that the judge had to ask the jury to leave them for a moment (while he restrained Dr. White).
This was probably the only way to make Dr. White agree not to introduce any of Murray’s lies into the courtroom. David Walgren reminded him that only Murray’s statement to the police was regarded as evidence for this trial.
Dr. White’s cross-examination was long, so I will break it up into several parts.
ADMINISTERING PROPOFOL IN A HOME SETTING
On the basis of Murray’s own words Dr. White said that for about two months Murray had been giving to Michael Jackson a bolus of Propofol followed by a drip. His “understanding” was that it was nearly every night and that the initial bolus was 25-50ml mixed with 50ml of lidocaine. Each night the bolus was followed by an infusion (drip).
Based on Murray’s statement to the police Dr. White could not say how Murray would administer Propofol by infusion – he said he didn’t know the exact details. And since he didn’t know them, he agreed with Walgren that the two infusions lines demonstrated by Dr. Shafer the previous week were quite possible.
Walgren: “It could be as two separate IV lines as described by Dr. Shafer?”
White: “That’s possible, yes”.
Walgren: “Would you agree that in these prior two months administering bolus doses of Propofol followed by a drip of Propofol throughout the night in that type of bedroom setting would be extremely dangerous?”
White: “Without careful bedside monitoring it could be dangerous, yes”.
Walgren: “With complications that could result in death, correct?”
White: “…If the infusion was not carefully controlled, … you could achieve an effect that could result in a cardio-respiratory depression, yes”.
Dr. White said that he had administered propofol in different types of setting (but not at home) and claimed that different settings required different type of monitors. Some Dr. White said were “desirable” to have, while others outside hospital setting “might not be available”.
(Of course not everything is available in a field tent, only Murray was not working in a refugee camp!)
The Prosecutor asked him about monitoring equipment for the worst-case scenario. Dr. White pretended he didn’t know what it was, though even we know that this scenario means a stop in breathing and death that follows it:
Walgren: “It is a desirable thing to have if you are concerned about not having the patient die, correct? … As a doctor administering this type of agents you prepare for the worst-case scenario, don’t you?
White: “I don’t know what you mean by the worst-case scenario, but you certainly prepare to treat the complications that are likely. You cannot have every device in an office setting where propofol is administered” .
Since White was flagrantly disputing the very basic anesthesia rules regarding equipment Walgren had to go over the list of monitors required for such cases. Driven into the corner by specific questions Dr. White agreed that a Pulse Oxymeter was a must and for all kind of sedatives too (not only propofol). The EKG machine “is also pretty standard” and “available pretty much”, he said. Dr. White found Capnography (a device for analyzing exhaled air) useful too. The blood pressure cuff, not necessarily automatic, was also needed – in deep sedation the blood pressure is to be measured every 5 minutes, in minimal sedation it is measured every 15 minutes.
In his list David Walgren forgot to mention the Infusion Pump – a device which allows to administer a precise dose of propofol. For propofol it is a complete must. If a single additional drop of propofol is given the patient can easily drift from moderate sedation (when breathing is natural) to general anesthesia (when breathing stops).
And when it comes to propofol a stop in breathing is the only problem – though a totally expected one – that may arise.
Needless to say, Murray was lacking all of the above. The only thing he had was the cheapest type of pulse oxymeter which is not suitable for continuous monitoring. Since it doesn’t have an alarm which sets off when the level of oxygen drops, it requires the doctor to sit and watch it without taking his eyes off. This type of a pulse oxymeter is used only for occasional check-ups or by 911 for example.
The other equipment which was available to Murray was the device for measuring blood pressure – but it was not even open and was still wrapped in various boxes and bags.
This device wasn’t fit for the situation anyway as measuring blood pressure manually takes at least a minute – which in critical situations of a stop in breathing is too long. In a hospital setting the cuff is placed on an arm and measuring is done automatically.
After publicly doubting that not all of this totally indispensable equipment was necessary for infusing propofol Dr. White involved himself in an long and tiresome debate with Walgren whether the lack of the equipment and Murray’s failure to keep medical records were or weren’t an egregious and unconscionable violation of care.
This was the way Dr. Shafer called it, but Dr. White said he was “not familiar” with those terms and “could not quantify” the measure of violation – these could be moderate violations or even minor. In his opinion the records are necessary for only treating a patient by several doctors and for the purposes of billing.
As for the other use of medical records – which in Murray’s case were not made for 2 months of infusing Propofol and which is a totally unheard-of thing for anesthesiologists – he somewhat shrugged his shoulders.
Walgren: Do you think it is extreme violation of standard of care to fail to maintain any medical records for a period of treatment going at least two months?”
White agreed that it was a deviation but again didn’t know how to quantify the degree of severity in this case. His definition would be that it is between moderate and serious (as if quantifying it this way would change anything!).
Walgren: “Do you maintain medical records in your practice?”
White: “When I am in a hospital setting, absolutely” (implying that when he is not in the hospital setting he is not?!)
In short Dr. White gave all sorts of pretexts for Murray’s hugely substandard treatment to Michael Jackson and even implied that when administering drugs to patients at home doctors can be… you know… lax in their work (they can go without medical records and the necessary equipment, confining themselves to “what was available to them”, as if what Murray purchased didn’t depend on Murray himself!).
The totally impossible and inexplicable Dr. White’s leniency towards Murray was later in the day dealt by David Walgren by quoting Dr. White’s own papers and making his own words testify against him.
This blow to Dr. White came as a series of articles and chapters in textbooks where Dr. White was teaching others that under no circumstances the standard of care could be violated. The same care is to be provided independent on whether it is mild sedation or general anesthesia and no matter where the drug is being administered.
By “drug” Dr. White means not only Propofol but benzodiazepines too (like Lorazepman and Midazolam given to Michael that night) as even Midazolam could produce long sedation if given in sufficient doses and would require monitoring.
When Dr. White realized what Walgren was driving at he tried his usual tactic of avoiding direct replies. You can see his skill in evasion techniques by numerous questions Walgren had to ask to extract a definitive answer from him:
- Walgren: “Are you saying that if propofol is provided in the absence of a procedure then it needs less care?” (…..)
- Walgren: “You are not stating that lesser care is acceptable just because a procedure is not taking place?” (Dr. White asks for the quotation not to be taken out of context).
- Walgren: “Are you saying that lesser care is required if propofol is given absent the procedure?” (Dr. White refers to the context again).
Dr. White even checked on several occasions whether his own articles were quoted correctly. They were.
He hoped that the context from which the quotations were taken would change their damaging effect on the jury. No, the context didn’t change it – on the contrary, the more quotations were read the worse it was getting for Dr. White.
Walgren mentioned “off-label” usage of Propofol. “Off-label” is using propofol for maintaining sleep – it is possible in an experimental study, but is far from being accepted as a standard, so it is not the “on-label” usage. As usual Dr. White mostly avoided direct answers:
Walgren: “You are not saying that if Propol were used in an off-label manner that the level of care is lesser, are you?”
White: “I am not commenting on that at all”.
Walgren: “Would you agree that using Propofol whether off-label or for therapeutic reason would still require the same level of care?”
Walgren: “Are the standards for basic monitoring during MAC (monitored anesthesia care) the same as for general anesthesia?”
Walgren: “One of your articles said that MAC requirements would apply even if no anesthesia was applied at all?”
White: The article referred to an anesthesia care-giver monitoring the patient.
(This means that even before or after applying anesthesia the care-giver should still monitor the patient. By the way the care-giver cannot find it satisfactory that the patient is still sleeping after being administered anesthesia. This is something Dr. White will dispute later, though the matter is totally indisputable – each patient should by all means return to a conscious state after anesthesia).
Walgren focused on the need for constant monitoring and quoted Dr. White:
- “Vigilant monitoring is required because patients may rapidly progress from a “light” level of sedation to “deep” sedation (or unconsciousness) and thus may be at risk for airway obstruction, oxygen desaturation, and even aspiration”
(Aspiration is when the stomach content gets into the airway which may be fatal for the lungs).
White was smashed by his own words.
Walgren asked him about the rules of administering anesthesia in office organizations. White said he “was not familiar” with those guidelines because he didn’t practice in the office-based setting.
Walgren again quoted Dr. White’s article:
Walgren: “You wrote about them in your article, right?”
White: “It is possible, yes”.
Naturally those guidelines said that an appropriate personnel and equipment were needed, complete documentation was to be provided and even that “safety standards could not be jeopardized for patient convenience or cost saving”.
Dr. White tried to take the conversation elsewhere but Walgren made him stick to the point and asked him to read all ten guidelines from his own article one after another.
Listening to Dr. White reading out loud his own recommendations after he had just interpreted them so loosely was unforgettable experience.
Walgren: “Would you agree that these requirements would apply equally if Propofol was administered in a private bedroom?”
White: “….Ah… I would not administer it in a bedroom as I said earlier. When you administer propofol for a surgical or diagnostic procedure it may be a different scenario than administering propofol for an off-label use.”
Walgren: “Is it your testimony that if you are administering propofol for an off-label use you should use less safety precautions than when you are using it for appropriate use?”
White: “I didn’t say that”.
I’m embarrassed to listen to the way Dr. White is disputing things which are obvious even to non-specialists.
Walgren asked for “yes” or “no” answers but since Dr. White was still playing a hide and seek game, Walgren asked him to go over each of the points one by one again.
However this time they got stuck on the very first point concerning trained personnel. For some reason the need for a specially trained physician to administer anesthesia which is obvious to us laymen, is not obvious to Dr. White.
Walgren asked Dr. White if he thought that administering propofol in an office setting required a higher standard of care than when you are doing it in a bedroom in someone’s private residence.
White said he had a problem with the words “higher or lower” .
Walgren: “Are you disputing the need for a properly trained and credentialed anesthesia personnel if you are administering Propofol in a bedroom?”
White: “I am not disputing it. I am just saying that this section of my chapter refers to an office-based anesthesia”.
Walgren: “And I am referring to a bedroom in a private residence because this is what this case involves. So I am asking you if you think that the same standard of care should apply in a bedroom in a private residence? Or in a bedroom it is not necessary?”
White:” That’s not what I said”.
Walgren: “So how would you revise No.1 to apply to a bedroom standard of care?”
White: “Well, the analogy would be a home or hospice standard of care. Hopefully there physicians there who are trained in safe administration of the drug in conscious sedation.”
Walgren: “Would you at least agree that administering propofol in a home should entail minimum safety requirements involved in administering propofol in an office-based setting?”
White: “Yes, I would”.
Walgren: “Okay. Thank you”.
The noon break saved Dr. White from further embarrassment and us from his all too obvious desire to stretch the truth.
After the break Walgren cited three more articles. Dr. White debated with him as usual and said that now Propofol had a wider use and that many anesthesiologists, surgeons, etc. were using propofol in intensive care units for sleep.
Let me exclaim once again here – why do some people find Michael to blame for what is commonly provided to intensive care unit patients? Michael was a sleep invalid and also needed help! The only difference is that it shouldn’t have been done in a home setting or was to be done by a proper person and with all the requirements fully adhered to!
Since the core of the matter is not even propofol itself, but the same standard of care independent of the place where it is administered, Walgren returned to the matter again.
He showed Dr. White guidelines worked out by the American Society of Anesthesiologists for non-anesthesiologists and asked him if he thought it was “a good idea to observe all those regulations in a home setting”?
White: “If I were using an infusion of Propofol, absolutely. These are excellent recommendations for infusing Propofol in any environment. These are the highest possible standards. In practice … it won’t be a bad idea to have those in a home setting. You wouldn’t want to compromise the patient’s care.”
Walgren: “So it would be a good idea to have all the recommendations in place if you are administering even bolus doses in a home setting?”
White: “In an ideal situation, absolutely. Right”.
Let me ask another question here. What prevented Dr. Murray from creating an ideal setting for “off-label” administering propofol in Michael’s situation? Was he in a desert attending to a poor peasant or what? He was hired for an extremely high salary to help his patient to sleep with an understanding that he would provide the best possible care. And all he gave in return was the worst ever care possible.
One would think that with all those makeshift IV stands and total lack of equipment Conrad Murray was working in a refugee camp and not in the home of the best entertainer in the world and was not paid $150,000 a month for his invaluable work….
BASIC STANDARDS OF CARE and CALLING 911
David Walgren asked Dr. White how he understood a doctor-patient relationship.
Dr. White said it involved having a responsibility for a patient, having an understanding for him and his diseases, showing compassion for the patient and doing his best to take care of their health care needs. He agrees that the doctor gives a solemn obligation to do no harm to a patient.
As regards Murray-Michael Jackson’s relationship Dr. White said a very strange thing – he said that THERE WAS NO HARM. Yes, you got it right – Michael Jackson died in the hands of Dr. Murray and still there was no harm!
He said he was just “providing him a service” which Michael requested.
It seems that Dr. White doesn’t know that doctors don’t provide services. Doctors have a duty to provide medical care and have to adhere to a strict code of medical ethics in doing so!
White: “Dr. Murray provided a service to Michael Jackson which he has requested”.
Walgren: “Provided a service?”
White: “I said he provided… medical care… let’s choose a better word than a service. It is a more appropriate choice of word”
Walgren: “He was offered money to provide Propofol on a nightly basis, correct? Based on Conrad Murray’s own interview with the police”.
White: “It is my understanding that he wasn’t paid any money”
Walgren: I didn’t ask you that, did I?
By the way why did AEG Live indeed fail to pay Murray and delay making a contract with him for about two months? I remember Murray filing a suit against AEG for that. Isn’t it interesting that he didn’t even try to approach the Estate with the same claim? So Murray does know who he was working for?
Walgren asked Dr. White, “Who is the final decision-maker when it comes to making medical judgments – the patient or the doctor”? Dr. White said it was a shared responsibility. Walgren asked who the final decision maker was in case of a conflict – when the doctor is requested to do something which is harmful for a patient. White answered that the physician always has the option to walk away from the patient. He himself would never administer what he considers inappropriate medical care to the patient.
Walgren asked why there is a need for continuous observation of patients when they are sedated by propofol. White said the major reason is because it is very easy to go from one level of sedation to another one (to deeper sedation or lighter one which is no good either as the patient might wake up).
Walgren asked him, if 25ml of propofol were given, would it be okay to walk out of the room and leave the person alone without any monitoring equipment? Dr. White lied that it would, if after 20-30 minutes of observation the situation was stable.
Walgren asked Dr. White about the patient continuing to sleep after that, but didn’t stress the point that before going anywhere at all the physician was to first make sure that his patient woke up.
This point did not receive the attention it should have – however this rule is top important for anesthesiologists.
Propofol is effective only while it is still in the system and it wears off very quickly (after a 25ml dose a patient will be expected to wake up in some 4-7 minutes) so if the patient is not waking up it is a sign of a grave distress and a very big trouble. This factor was stressed by several doctors who gave their testimonies before Dr. White.
However for Murray’s case Dr. White is ready to break even the most basic rules. He says:
White: “This was an unusual case. The doctor was trying to achieve a sleep state. Once the patient was resting apparently comfortably and had been observed by a period of time it is not unreasonable to leave the patient”.
But this is basically wrong… If a patient does not wake up after an anesthetic no matter how the doctor feels about it it is his duty to make sure that the patient has “returned back” from it. For example, if you are given propofol while having your tooth pulled out, the dentist is obliged to make sure that you do not keep sleeping after that. If you do, he knows that something went wrong and you are in trouble.
Walgren did not argue with a doctor who is breaking the very basic law of anesthesia and focused on the necessary monitoring equipment instead. He wondered what would be the value of a pulse oxymeter if it had no alarm. It would mean absolutely nothing, would Dr. White agree?
But Dr. White was not inclined to agree even to the most obvious things. It took him several more questions from Walgren to finally admit that without an alarm that device was totally useless.
Walgren: “What value does it serve in your absence?”
White: ” In your absence it probably has little… if any value”
White: “Well… that’s true”.
Walgren reminded Dr. White of Murray lying to the police that “the patient liked pushing the propofol himself”. If a patient was really like that wasn’t it dangerous to leave him alone with propofol beside him?
Walgren: “Will that change your willingness to simply walk out of the room and leave the patient alone with no monitoring?”
White: “It would certainly … make me careful about …eh…allowing access to drugs”
Walgren: “Would you walk out of the room in that situation? Yes or No”.
White: “I would.. no.. I would not leave the room”.
Walgren: “Thank you”
Walgren asked Dr. White if he could justify Conrad Murray’s failure to call 911 and waiting for 20 minutes to call it.
Dr. White said, “No, I cannot”.
However even a simple answer like that did not go without a long debate. I’ve put it down almost in full so that no precious grain of it is lost:
Walgren: “That’s an extreme deviation of care from the standard, would you agree?
White: “Again this classification is not familiar with me. I would say that given the fact that Dr.Murray is a cardiologist who is certified in advanced cardio-pulmonary life support…”
Walgren: “Objection… not evidence” (It is clear that to Walgren these words are no evidence that Murray is a certified cardiologist, or doctor at all. Overruled)
Walgren: “Did he act like someone who was well-skilled in advanced cardiac life support? Did he act like that?
White: “I was not present to make that assessment, sir”.
Walgren: “You’ve taken all his statements as true in your assessments, correct?”
Walgren: “What would you have done?”
White: “I would have called for help. Though I understand it was an isolated area”
Walgren: “Isolated area?“
White: “Yes, I understand it was a special suite…”
Walgren: “It was a bedroom in a house. Upstairs. ….Okay, so what would you have done?”
White: “I would have called for help, assessed the patient and initiated cardio-pulmonary resuscitation, immediately”
Walgren: “…Would you call 911?”
White: “Yes, I would call 911, but my understanding that this was an unusual situation, because this was a house that had a secure perimeter and had no phone lines”
Walgren: “But Conrad Murray had a cell phone in his hand by his own statement and used it to call Michael Amir Williams. Are you saying he was not capable of pushing 9 -1 -1 ? And putting your phone down and continuing with your cardio-pulmonary resuscitation?”
Dr. White said something about not knowing the address and a gate blocking access to the house. Walgren nearly laughed:
Walgren: “Are you saying that because there was a gate around the house that excuses Conrad Murray not calling 911? Is that your testimony? Because you’ve mentioned this gate a couple of times now”.
White: “No, it doesn’t. It doesn’t at all”
Walgren: “Okay. So we can set aside the gate. It has no bearing on Conrad Murray’s need to call 911 as soon as possible, correct?”
White: “I think it is the reason to call the security individual, Michael Amir to inform him that he needed emergency medical assistance”.
(Michael Amir Williams was Michael Jackson’s personal assistant and when Murray left an voice mail for him he was downtown).
Walgren: “You realize that when he called Michael Amir Williams he didn’t tell Michael Amir to summon medical emergency assistance, you do realize that, don’t you?”
White: “If that’s what you say, yes”.
Walgren: “Would you agree that it is much quicker to call 911 than to call someone’s personal cell phone number, have it ring through the voice mail and then leave a message on that voice mail?”
White: ” Well, you can call people on speed dial and even faster than 911. Certainly 911 is easier to dial, you are absolutely right”
It is totally unbelievable that answering a simple question about calling 911 is taking so long!
Walgren: “….How long would it take you to decide in that setting that you needed to call 911?”
White: “Are you saying if I felt a pulse?”
Walgren: “Well, Conrad Murray said he felt a pulse”.
White: “He said he felt a thready pulse”.
Walgren: “He checked the pulse oxymeter and it read 122 and then he felt the femoral pulse and he felt a thready pulse. Correct. How long would it take you to decide that you should call 911?”
White: “…I would immediately start resuscitating the patient and call 911 shortly thereafter.”
Walgren: “What shortly thereafter?”
White: “You know… 3 to 5 minutes I would guess”.
While putting down that crazy half-an-hour conversation I realized one important point. Dr. White is having a difficulty with this elementary question for a reason. Later in his testimony he will present some highly distorted charts based on the false concept that Michael Jackson died instantly, due to a cardiac arrest (and not breathing arrest as Dr. Shafer proved to us). And if the death was immediate and registered by a doctor there was no need to call 911.
Dr. White needs Michael Jackson to have died immediately and from a heart attack, because only in this case he will be able to claim that the 25ml of propofol (supposedly left by Murray for Michael Jackson in a syringe nearby!) were allegedly pushed in too quickly by Michael Jackson himself.
Only in this case this small doze of propofol would probably reach a high level in blood just for a second which would be enough to bring about Michael’s death.
Dr. White’s scenario is that the bolus of 25ml of Propofol pushed quickly reaches a high level in blood – Michael Jackson dies of a heart attack – his heart stops beating immediately – propofol metabolism stops – so it remains in the blood at the level which it initially reached.
This is the only way they can explain why Michael had a huge dose of propofol in his blood and this is the only reason why Dr. White claims Michael had a heart attack. And even Murray’s own story that he felt a thready pulse when he returned to Michael Jackson and that the pulse oxymeter was registering 122 beats is not standing in the way of Dr. White’s fantasies. Dr. White will simply disregard all that.
And you were wondering why 911 was not an easy question for Dr. White…
* * * * *
Thursday, November 3, 2011
Despite the stream channel not working for me on the day when Prosecution and Defense made their closing statements some fragments did show David Walgren calling Dr. White science junk and garbage.
Frankly it is the first time I hear the truth being told in such a bold and straight manner . We are not used to it and the feeling of it is unforgettable. Scientists are polite people and the most they usually say is that “the opponent’s ideas are not substantiated enough” – but Walgren’s profession is different and I am happy to hear him call a spade a spade.
Dr. White’s whole testimony was nothing but junk science. Outwardly it looked more or less okay as all his junk was wrapped in a scientific vocabulary – but the essence of it was complete garbage.
A true scientist will never voice an opinion on any subject if he hasn’t done at least some research of it – while Dr. Paul White has absolutely no problem in saying things which he does not have the slightest idea of.
He did a perfunctory word-search for “oral propofol” in the Internet which brought him no result, but it didn’t stop him from sending to the defense a written report that Michael Jackson was responsible for his own death by taking propofol orally.
The media immediately picked up this novel idea from this self-proclaimed father of propofol and chewed it up until the defence team publicly withdrew it at the trial.
By the way, Dr. E. Glenn [the spelling requires correction], the real father of propofol, who developed it from the first molecule to its clinical use, later informed his colleague that even his studies made in the 80s showed that oral propofol was not effective. But it didn’t teach Dr. White any lesson and he went on popularizing the same junk ideas.
He has already publicly doubted the standards of care which are a complete must for all anesthesiologists the worldwide and taught us that it is not necessary to call 911 if you see a person in trouble.
Now he is presenting some charts which were made by another person, of whose studies (and standards) he knows nothing and whom he met only last week. Okay, this Gabriela Ornales may know something on pharmacokinetics as she is working now for a Master’s degree in this science, but Dr. White also relied on her to collect all the data for making her charts and never even checked whether she was using the correct figures and reliable sources.
In fact some of her figures were incorrect and the data she based her model on were taken from an outdated article, which even said that the data required further correction – but when she provided Dr. White with this article he didn’t even properly read it because in court he could not answer a single question about it and didn’t even know that the data was not final!
To all Walgren’s questions about the charts he said he could not be responsible for them as he wasn’t the one who had made them. But if you can’t prove what you are testifying about why come to the courtroom at all? The euphemisms he used to shift the responsibility for any inaccuracy to Gabriela Ornales will hopefully not be lost on the jury:
- “I prefer to give credit to the person who actually did the model”.
- “I believe in the expertise of those who prepared this chart”.
- “I didn’t make those graphs”. “I became aware of them the night before my testimony”, etc.
Some professors practice this method of research – their students, working for various degrees, do all the job for them and are only happy when their professor puts his name to the resulting paper giving more ‘weight’ to their findings, while the professor’s list of writings is growing by a dozen without any effort on his part. However when such a professor puts his name to their paper he at least gives himself the trouble to check up the results – to save himself from the embarrassment if the results turn out to be untrue.
But over here it was not needed so he didn’t even read or check it up.
When Flanagan of the Defense ordered a study of the effect of oral propofol on beagles with a veterinarian he knew, Dr. White didn’t even ask what, where and how the negative result was obtained.
If those beagles were given liters of propofol he could not care less. He just took the ready answer provided by Flanagan and presented it as his opinion in court. And this despite the fact that he had a full opportunity to oversee the experiment and learn all the details as he was staying in Flanagan’s house.
David Walgren said that this doctor displayed total lack of responsibility and integrity, “academic rigor and seeking for the truth”. Most probably Dr. White expected the prosecutor to let him get away with all his sloppiness or otherwise I cannot explain why he risked his reputation so much.
Why he thought his lies would go unnoticed is probably due to the habit of thinking – formed by many years of Michael’s media harassment – that when it comes to Michael Jackson one will get away with just anything. Dr. White simply didn’t notice that the wind had changed and it is no longer possible to bash and slander Michael Jackson without eventually having to answer for it.
And after Tom Sneddon’s example in the 2005 case Dr. White also never expected a prosecutor to seek truth for Michael Jackson.
However prosecutor David Walgren and his chief scientific consultant Dr. Shafer, who is the embodiment of integrity and professionalism in science, are the first signs of this big change. New people have come to stand by Michael Jackson and this is a big difference from what we had only several years ago.
There is no doubt that if Michael had died earlier and a similar trial had taken place in Tom Sneddon’s time Dr. White’s speculations would have never been disputed because the prosecutor would have been too ready to believe the junk science of Dr. White. Dr. White would have been applauded to and praised and would have received more regalia and fame for adding just one more big lie to his career.
The total demolition of Dr. White’s reputation now should serve as a good warning to all those who are choosing to ignore this wind of change.
Under the fire of David Walgren’s cross-examination Dr. White used a whole range of various excuses – all of which are totally inexcusable for a true scientist.
He did read the documents but long ago and now doesn’t remember obvious things. He didn’t conduct his own research, relied on others and now it is their responsibility and not his. He says it isn’t his expertise but nevertheless testifies about what he doesn’t have any idea of. He cannot explain why he is using other people’s models without knowing what data stands behind it. He lies that he got familiar with numerous studies while he actually didn’t. He says he believes Murray but disregards Murray’s own words in order to prove his false theory. He doesn’t know why the equipment he uses to demonstrate his ideas was meddled with. He offers all sorts of excuses for Murray’s behavior but says that he himself would absolutely never allow any of it ….
In short his cross-examination was a complete marvel and for those who missed it I am offering the continuation of my notes about Day 21.
Day 21. Monday, October 31
NOT MENTIONING PROPOFOL “IS A DETAIL”
Dr. White called Conrad Murray’s failure to mention propofol to paramedics and emergency room doctors a detail he just overlooked.
Walgren asked Dr. White if a doctor has a moral and ethical obligation to reveal all medicines to the paramedics who arrive at the scene. Dr .White said that in that kind of a situation it is often difficult to recall all details.
Walgren: Is it your testimony that the failure to mention Propofol to paramedics is inability to recall details, Dr. White?
White: Well, I’m just saying details can be overlooked. I don’t think it was done in a devious fashion.
Walgren: I want to make it clear. So you think it was just a detail that was overlooked when Conrad Murray failed to advise the paramedics of administering Propofol, is that your testimony? A detail that was overlooked?
White: I don’t think I used those words. …I think it was something he overlooked.
Walgren: Was it still another detail at the UCLA when the emergency room doctors specifically asked him what had taken place? Is that your testimony that it was again a detail that was overlooked?
White: It was obviously overlooked. He didn’t…
Walgren: Well, not obviously. It could also be a lie, correct? That’s another option?
White: Eh, if you say so, I guess. Yes, it’s an option.
Walgren: Thank you.
DR. WHITE KEEPS VIOLATING THE JUDGE’S ORDERS
From the very start of the cross-examination it was made clear to Dr. White that he could base his testimony only on the official statement Conrad Murray gave to the police. No other conversations and lies from Murray could be allowed:
Walgren: Who is responsible for bringing propofol into Michael Jackson’s home in your opinion?
White: Well, Conrad Murray certainly purchased propofol, but I understand Mr. Jackson had his own supply as well.
Walgren: Really? Where is that in the police interview by Conrad Murray?
White: Well, I’d heard… (objection)
Walgren: Where in Conrad Murray’s report is that reflected?
White: Well, I don’t have the report in front of me. I reviewed it in February and as I indicated I had two conversations… (Walgren: Objection, would the court admonish the witness?)
Judge M.Pastor: May I ask a favour, ladies and gentlemen, if you could just leave us for a moment?
I don’t know whether it happened at that moment or at some other time but Dr. White was even fined for not observing the court’s rulings:
Conrad Murray Trial; Defense Witness Dr. Paul White Held In Contempt
No. 1, 2011 A key witness in Dr. Conrad Murray’s involuntary manslaughter trial has been held in contempt of court and fined $1,000 (£625) for refusing to heed judge Michael Pastor’s warning not to talk about a conversation he had with the defendant.
As the prosecution and defence teams wrapped up their cases in court on Monday (31Oct11) before turning to jurors for a decision, there was final drama during expert witness Dr. Paul White’s latest day in court, when he repeatedly violated orders to refrain from testifying about private conversations with Murray.
White is the defence team’s final witness.
It’s the second time Pastor has held White in contempt – he used a profanity during a heated exchange with a member of the prosecution team on 21 October (11). The judge recalled White back to court for a hearing on 16 November (11).
On Monday, the courtroom was briefly cleared after Dr. White referred to a conversation he had had with Murray, who is accused of administering the fatal dose of anaesthetic propofol which cost pop star Michael Jackson his life. Judge Pastor told him he could not offer up private responses he’d had from Murray.
Less than two hours later, White upset Pastor further when he testified he had additional information to share with the jury but the judge told him he couldn’t. He was held in contempt and fined. (c) WENN
For those who believe Murray’s lies about Michael keeping a stack of propofol at home, let me bring to their attention that firstly, it was Murray who brought the drug into that home and had its reserve in the bags hidden in the closet and secondly, if La Toya who stayed in the house had found a big store of some unknown substance, she would have been the first to make a big fuss over it, in the same way she did it when finding some ancient rotten marijuana there.
It is surprising that even La Toya’s never-ending desire to do harm Michael’s image can sometimes be a way to debunk other people’s lies.
“I DO NOT KNOW WHY THIS IV TUBING WAS MODIFIED”
It turns out that our good Dr. White used in his Friday Oct. 31st demonstration a modified infusion tubing – a cap of a vent on it was cut off as if by a knife. This cap is important as with it propofol gets stuck in the bottle, while without it it flows freely.
Walgren asked Dr. White if he agreed that it had been modified. Dr. White said he didn’t know how the cap had been removed from the defense exhibit. Here is a small excerpt from their rather long conversation over it:
Walgren: Did you do it?
White: I’ve never seen it before.
Walgren: It wasn’t intended to mislead Dr. Shafer, was it?
White shook all over as if in an electric shock.
Walgren: Would you agree that it is easily concealable?
White: It could be, yes.
Walgren: Can it be slipped into your pocket? It fits into my hand, right?
HIS REPORT SENT TO THE PROSECUTION WAS “PRELIMINARY CONCLUSIONS” ONLY
Walgren asked Dr. White about the conclusions he made on March 8, 2011 concerning Michael Jackson taking propofol orally. Walgren reminded him that the three and a half pages report was the only document Dr. White had provided to the prosecution.
But now Dr. White calls it just a letter to Mr. Flanagan containing some “preliminary thoughts”.
Walgren: This is the only document you’ve ever provided – this is the letter containing preliminary thoughts?
Walgren: You initially speculated that Michael Jackson drank propofol himself, correct?
White: I speculated that oral administration may have played a role.
Walgren: And you now reject that theory, right? As a cause of death?
(let me omit numerous White’s distracting techniques)
White: As a cause of death, yes.
Walgren: But you did at the outset as early as March 2011 attribute a possible cause of death to Michael Jackson himself? … And in your preliminary thoughts you concluded either “self-administered” or “he drank propofol”, correct?
White: Yes, and I based that on some of the other expert testimony that I read in February.
Walgren: Which testimony are you referring to, because there is no report where any expert speculates about any oral consumption of propofol?
White: I thought it was the report by Dr. Ruffalo?
Walgren: Can you show me the reference where he is talking about oral propofol?
White: I didn’t say it was the report. I think it was in the preliminary hearing.
Walgren: When Mr. Flanagan asked him about oral propofol? Is that what you are referring to?
A small note: In court only the answers of witnesses are taken into account. Dr. White took Flanagan’s question for the other expert’s answer and says that he based his opinion on that expert’s “testimony”. The above is a glaring example of Dr. White’s standards of accuracy. Now he is pretending that his own report was nothing but a letter.
Walgren: How long did it take you to prepare that report?
White: Are you referring to the letter? The letter was asked to prepare on a very short notice – a couple of days. I was extremely busy at the time but I agreed to provide a letter and my preliminary thoughts based on the information I reviewed at the time.
Walgren: You’ve had seven months now and again the only letter I have is the one which you had to rush.
White: I have not been asked to prepare a report. Correct.
Walgren: What is the two days’ reference referring to?
White: That was the time from when Dr. Flanagan contacted me and told me they needed something in writing, preliminary thoughts.
(more deviations are omitted)
Walgren: Is there anything in this report where you say that “these are my preliminary thoughts or my preliminary opinion”? …. Is it stated anywhere in your March 8, 2011 letter?
White: Well, I haven’t looked at that letter some time. (He is given a chance to review it again).
Walgren: Does it anywhere say that these are your preliminary thoughts?
White: I didn’t use the word preliminary.
Walgren: “It is my opinion” – I am quoting – “it is my opinion that Michael Jackson self-administered these drugs intravenously and/or orally”. Correct?
White: That sounds correct, yes.
Walgren: There is nothing characterizing it as simply preliminary thoughts? It says it is your opinion..?
White: Correct, based on the information I had been able to review in the short time prior to writing a letter to Mr. Flanagan.
Walgren: You did a word search for oral propofol and that didn’t come up with the piglet study and then you wrote your report? Was there other research that you did regarding oral propofol before you put this in writing?
White: I don’t believe so. And I also looked up the autopsy report which showed propofol in the stomach, the gastric contents.
Walgren: Is there anything else? As far as your opinion… you said, “It is my opinion that Mr. Jackson self- administered these drugs intravenously and/or orally”?
Walgren: As far as the issue of propofol being oral bioavailable from a scientific point of view did you do any other research other than a word search for “oral propofol”?
White: Well, later…I received Dr. Shafer’s report which suggested it was unlikely…
Walgren: Actually it said it was not possible.
White: Not possible. Then I communicated electronically with Dr. Glenn who also confirmed that it was his understanding that the studies were made by the Imperial Chemical Industries in the 70s suggested that it wouldn’t be effective.
Walgren: Dr. E. Glenn’s study done in the 80s dealt with oral propofol, correct? You were aware of his paper that discussed oral propofol not being bioavailable based on his animal study, correct?
White: Incorrect. I think I said earlier that I was unaware of any studies, either on animals or on human beings.
Walgren: Prior to writing your opinion?
White: I could not find any scientific information.
Walgren: So you had NO scientific information and wrote this report stating it was your opinion that he either orally ingested or self-administered propofol, correct?
White: I was just trying to cover all the possibilities… I just thought it was appropriate to leave open the possibilities. … I wanted to list possibilities that seemed reasonable.
Walgren: And the two possibilities you came up put the blame in your mind squarely on the deceased victim, correct?
White: Well, if Dr. Murray had only given the 25ml that he claims to have given there must have been another factor that contributed to Michael Jackson’s demise.
Walgren: In your March 8, 2011 letter the only options you came up with were – you blamed it on Michael Jackson for possibly orally ingesting and you blamed on Michael Jackson for possibly self-administering, correct? Those are the two options you came up with, correct?
White: I believe that’s correct, yes.
Walgren: And since that time you’ve rejected oral propofol and you’ve come up with a new theory to say that Michael Jackson did it himself, correct? (Defense: objection)
Walgren: Did you mention that Michael Jackson swallowed eight 2ml Lorazepam pills in your March 8, 2011 letter?
White: No, because at that time I had no time to really analyse the Lorazepam levels until my colleague Dr. Shafer provided his report in mid-April.
Walgren: So that new theory that you came up with followed that March 8, 2011 letter, correct?
White: It isn’t a new theory, it just presents a more indepth look at all the information available. Theory still is that the death was a result of rapid IV injection of propofol.
Walgren: Have you ever put forward a theory other than – in your mind – blaming on Michael Jackson himself?
White: If you are asking if I believe what Dr. Murray stated I did take his word that he administered 25 ml of propofol because the prior night he’d been trying to wean Mr. Jackson from propofol.
Walgren: You took everything Conrad Murray said as the truth in your evaluation, right?
White: Well, I certainly…
Walgren: Yes or no?
Walgren: Have you come up with any theories other than attributing the drug intake to Michael Jackson himself? Have you put forth any other theory?
White: I don’t believe so.
THE WAY DR. WHITE CONDUCTS HIS RESEARCH
In order to prove his irresponsible statements about Michael Jackson dying from oral ingestion of propofol Dr. White commissioned a research on beagles made by some veterinarian in Indiana.
He did not overview it, had no idea how the research was made, how long it took or what dosages were involved.
Actually he didn’t know the first thing about the way the experiment was made and was only interested in the result. The result showed that propofol taken orally does not have any effect.
If the poor things were given litres of propofol to prove Dr. White’s theory that it worked orally Dr. White simply would not know.
However he raised his brow and said he was shocked that Dr. Shafer had conducted a study on human beings. Dr. Shafer indeed made a joint study with a Chilean professor of anesthesiology involving 3 volunteers who took 20ml and 3 more who took 40ml. The study was made in a hospital setting with their health fully monitored during the process. In the course of it Dr. Shafer swallowed propofol himself.
Dr. Shafer’s study also showed that oral propofol was ineffective. This evidence was needed by Dr. Shafer not only for Murray’s case, but its primary goal was to keep the Drug Enforcement Agency from making propofol a controlled drug. It was necessary for Dr. Shafer to prove that propofol is effective only if taken IV and cannot be abused outside a hospital setting.
During his testimony Dr. Shafer stressed that Propofol should be easily accessible to anesthesiologists – each patient is different and you never know how much propofol will be required for anestheisa, so its lack during the operation will result in numerous complications for patients in the first place.
Dr. White wanted to disprove Dr. Shafer’s results and ordered an experiment on beagles. Walgren asked Dr. White about the way he conducted his study.
Walgren: When did you request a study on animals?
White: Perhaps after being shown a copy of Dr. Shafer’s report. ….
Walgren: Had you made any research between your March 8, 2011 report and April 18, 2011 (the date of Dr. Shafer’s report) to confirm that your preliminary thoughts were accurate?
White: No, I hadn’t done any research.
Walgren: So when did you request that animal study?
White: We discussed it at the end of April or May.
Walgren: Did you do the study and did you have someone do it for you?
White: Mr. Flanagan said that he knew a veterinarian in Indiana who could conduct the study.
Walgren: So you had nothing to do with the study as a scientist?
White: I directly did not participate, no.
Walgren: Mr. Flanagan had someone do the study in Indiana.
White: That’s correct.
Walgren: Did you oversee it in any way?
White: I was not directly involved as I said.
Walgren: So Mr. Flanagan requested an animal study in Indiana sometime after you received Dr. Shafer’s report, is that correct?
Walgren: Did you ever review any data or were you provided any report regarding that study?
White: No formal report. Only an oral report that it had no effect.
Walgren: Who provided this oral report?
White: Mr. Flanagan.
Walgren: As a scientist you were not interested in providing the data or speaking to the people who did the research?
White: It was a negative study which confirmed what Dr. Glenn and Dr. Shafer had suggested, so I didn’t see the need to pursue it. To be honest I was quite shocked to hear that Dr. Shafer had taken his own medication and commissioned a study on human beings.
Dr. White’s junk science allows him to be critical of other people’s work while he doesn’t give a damn how his own research is being done.
DR.WHITE EXCUSES MURRAY FOR ALL VIOLATIONS
Dr. White says he strictly observes the standard of medical care himself but for some reason never minds Conrad Murray doing the opposite. In the incredible scenario he suggests for the morning of June 25, 2009 he easily excuses Murray for breaking every possible rule of medical ethics.
He allows Murray to leave Michael’s bedside and talk over the phone implying that Murray ‘just’ received a phone call and had to answer it. This way Dr. White pretends that this in and of itself is not an unheard-of-thing to do for doctors who are monitoring their patients under anesthesia.
His further scenario allows Murray to leave a drawn-up syringe with a ready-made mix of Propofol and Lidocaine beside his patient. This crazy idea is needed for Dr. White to avoid questions how Michael could have drawn up propofol and lidocaine from glass vials himself – Dr. Shafer showed us that it was a difficult process due to a vacuum created inside (you have to push it back and forth and do it bit by bit to fill the glass vials with air first).
In his desire to stretch the truth Dr. White turns the scenario into a total farce and suggests that Murray left the syringe in the infusion port of the IV stand for Michael just to press it.
All this is totally is amazing as he does not accompany any of these statements by a single word of reprimand for Murray. Listening to Dr. White one would even think that it is a normal thing for an anesthesiologist or surgeon to keep a syringe in a patient’s hand during an operation and leave the operating room for some 30-45 minutes to answer the phone or go and relieve himself in the bathroom!
And when Dr. White’s scenario comes to Michael walking about the room with an IV stand and a condom catheter and urine bag attached to him there is simply no word to describe it – no description can surpass the original in its absurdity.
But first David Walgren asks Dr. White about his own attitude towards administering propofol at home. White makes a solemn face and says that it is absolutely ruled out:
Walgren If Michael Jackson had come to you and indicated that he would like to hire you to administer propofol to him to put him asleep each night in this bedroom, would you do it?
White: Absolutely not. That would be a job I would never consider. ..No amount of money would convince me to accept it because of time and the responsibility for someone, because of the fact that it was a complete off-label use of the drug which had not been studied prior to 2011.
Then Walgren asks White about the time frame when Michael in his opinion could have self-injected 25ml of propofol.
Dr. White tells his story and in the process of fabricating it forgets that Murray claimed he gave only 25ml of propofol.
Now Dr. White says that Murray actually left in the room a fully drawn up 100ml (10cc) syringe filled with 50ml of Propofol and 50ml of Lidocaine.
It will totally contradict his own charts and models based on 25ml only – but is a slip of the tongue similar to his earlier tale-telling description of that bedroom as “a crime scene”:
Walgren: In the scenario that you put forward when Michael Jackson self-administered the 25 ml of propofol – that’s not at the time when Conrad Murray left the room for 2 minutes?
White: I cannot be sure of the time frame. From the phone records that I’ve reviewed, after observing Mr. Jackson for a period of twenty to thirty minutes Dr. Murray had got some phone calls and he began returning phone calls …
Walgren: The question is, when Michael Jackson self-administered the 25ml of propofol, is it taking place – in your mind – when Conrad Murray leaves the room for 2 minutes or is it at a different point in time that Conrad Murray left Michael Jackson alone?
White: It could well be at a different time. I don’t know whether the time is established.
Walgren: And in your scenario when you put forward that Michael Jackson may have consumed eight 2ml tablets of Lorazepam at 7 a.m. does it also assume that Conrad Murray left Michael Jackson alone?
White: Not necessarily, because I understand that Mr. Jackson walked around, he apparently had …(objection)
Walgren: Does your theory that you put forward assume that Conrad Murray was out of the room when Michael Jackson could have consumed eight 2mg Lorazepam tablets?
White: I assume that Dr. Murray was in some other part of the room – in the bathroom or adjacent bedroom. My understanding is that there were two bedrooms connected and since he apparently moved between the bedrooms I think it is likely that Dr. Murray was somewhere in the vicinity but certainly…
Walgren: Does your analysis assume that Dr. Murray was unaware that Michael Jackson swallowed eight 2mg tablets?
Walgren: So he was either in a different room or not watching? Is that fair to say?
White: Fair to say.
Walgren: And then you know from Conrad Murray’s statement that the only time he tells the police that he left the room was 2 minutes to use a rest room and when he came Michael Jackson was not breathing. So we have the time when he is either gone or not paying attention at 7 am, correct, based on your scenario?
(Dr. White starts coughing)
Walgren: Based on your analysis it is a different time when Michael Jackson self –administers the 25ml of propofol, correct?
White: I’m not sure, sir. All I said is that I’ve reviewed the phone records where Mr. Murray was on the cell phone presumably away from Mr. Jackson because Mr. Jackson was trying to sleep.
Walgren: And that is just a common sense assumption that if his whole job is to put Michael Jackson to sleep when he is on the phone for a lengthy period of time he is probably not standing there in Michael Jackson’s presence, correct?
White: That’s what I would assume, yes.
Walgren: …so you are assuming that Michael Jackson is in bed and at some point Conrad Murray leaves him, correct?
Walgren: And as you demonstrated on Friday that Michael Jackson takes a syringe and draws up 25 ml of lidocaine , correct?
White: My understanding is that Dr.Murray drew up 50ml of propofol and 50ml of lidocaine into a 10cc syringe.
Walgren: So your scenario is assuming that Conrad Murray drew up a syringe and left it there, is that what you are assuming in your scenario, yes or no?
White: Can I finish my ..?
Walgren: … Are you assuming that it was Conrad Murray who drew up the syringe or Michael Jackson – which one?
White: I am assuming that it is the 25ml that Dr. Murray had drawn up.
Walgren: So Conrad Murray drew up the syringe? In your analysis? Yes or no?
Walgren: And he left this syringe in the bedroom when he left the bedroom?
White: First of all I don’t know if he left the bedroom. I’m told that he was standing in the kind of a hall .. (objection)
Walgren: Conrad Murray leaves the room with the syringe accessible to the patient?
White: I didn’t say where the syringe was left.
Walgren: You would agree that in the statement he gave to the police Conrad Murray he only references to leaving Michael Jackson alone for those 2 brief minutes, correct?
White: I believe that’s correct.
Walgren: But it is your opinion that it took place when Conrad Murray was on the telephone for a lengthy period of time, is that correct?
White: That’s pretty correct, yes. More or less correct.
Walgren: So in your scenario how long would Conrad Murray have had to leave Michael Jackson unattended in order for Michael Jackson to self-administer the propofol?
White: Well, it’s hard to say without exactly knowing where the syringe was. What I do know is that the phone records suggest that after this observation period Dr. Murray was on the phone for a time of 35-40 minutes.
Walgren: And this is when this event transpired?
White: Followed by the 2 minutes when he went to the bathroom to relieve himself. It was some time during that 40 minute period where I believe Michael Jackson had the opportunity and likely self-administered the final fatal dose of propofol, yes.
Walgren: And in your scenario Michael Jackson does this through the port on the IV tubing, is that accurate?
White: That would be the likely site, yes.
Walgren: And in your analysis was the syringe left in that port for Michael to have access to it or was it left somewhere else or do you simply have no opinion in that regard?
White: …I think that was a syringe with a needle attached in that side port.
Walgren: Well, if the syringe for example, had been left, let’s say on the chair filled with propofol as you described and Conrad Murray came back into the room and found Michael Jackson not breathing and now the syringe is in the port do you think it would raise alarms to Conrad Murray? (sustained)
Walgren: So the syringe is left somewhere, under your analysis. Conrad Murray is gone out of the room for 35 or 40 minutes.
White: I don’t think I said he was out of the room.
Walgren: I mean he is not watching, correct?
White: He is not directly watching Mr. Jackson.
Walgren: You are not putting forward to the jury that Conrad Murray stood there and watch Michael Jackson self-administer propofol, are you?
White: No, I don’t.
Walgren: And during this period of absence it is your theory that Michael Jackson woke up and self-administered the 25ml and killed himself?
White: This is what I suggested in my testimony on Friday, correct.
Walgren: And are you assuming that after Michael Jackson did that that he fell back in the same location he had been on the bed prior to Conrad Murray leaving the room?
White: I’d be my assumption that once he secured the syringe from where it was left that he probably returned to bed and the IV was in his leg but clearly accessible in the common position…
Walgren: Did you say “he probably returned to bed?”
White: Before he injected the propofol? Yes, I would think so.
Walgren: So you are assuming he got out of bed to get the propofol?
White: He could have got out of bed. I understand that he moved around the room.
Walgren: Did you know that he had a condom catheter attached with an urine bag?
White:.. Yes, I did.
Walgren: Did you know that he was hopped up to the IV line attached to an IV stand?
White: An IV stand has wheels and is mobile.
Walgren: So just to be clear, under your scenario Michael Jackson is walking around the room wheeling the IV stand and holding his urine bag connected to a condom catheter? And Conrad Murray is somewhere else on the phone, is that is your assumption, correct?
White: That’s not the only scenario, that’s possible scenario, yes.
Walgren: And you would agree that a possible scenario is that Conrad Murray administered more propofol, correct?
White: It is possible if he wanted to potentially harm Mr. Jackson.
What is totally impossible is that Dr. White is speaking of all these crazy things – Murray talking on the phone for 40 minutes, leaving a full syringe unattended, putting it into the IV infusion port as if ready for a push – and does not give his assessment of it, as if all that would be a totally normal thing to do!
DR. WHITE’S DEATH MODEL BASED ON THE LORAZEPAM THEORY
Despite all the fun of Dr. White’s crazy excuses for Murray his main job was to fabricate the models of Michael Jackson’s death based on totally arbitrary assumptions. The modelling itself was done by Gabriela Ornales.
Dr. White expected to make a grand entree with these models but David Walgren’s and Dr. Shafer’s scrutiny of them showed that the models had no leg to stand on.
The simulations themselves were made following the same formula which Dr. Shafer used. Paul White stressed it on several occasions that the formula was worked out by another scientist – Dr. Schneider. One of the goals of that emphasis was to produce the impression that Dr. Shafer was not using his own unique method and all this modelling could be done by anyone.
However there is absolutely no equal mark between the modelling done by Dr. Shafer and the one done by Dr. Gabriela Ornales.
Any formula is correct only if the data fed into it is correct too. And the data fed into Gabriela Ornales’s formulas was heavily distorted. And though Dr. White says he had nothing to do with it I strongly suspect that it was on his order (or request) that Ornales made her models on false or totally arbitrary assumptions.
There is a lot to say about those charts, however to make the long story short I will focus only on the main points.
First comes a word about Dr. Gabriela Ornales and how Dr. White came to know her.
Dr. White met her at Flanagan’s house a few days before his testimony after “someone from the defense team” had contacted her. He doesn’t know of her expertise or integrity and has nothing to say about her except her official CV from which he was reading out in court. We learn that she is no medical doctor but is a Ph.D. student in pharmacokinetics who is working for her degree.
Dr. White’s choice of a person to do the models is surprising.
Blindly taking the calculations from someone totally unknown to you is a somewhat reckless thing to do – especially if you cannot check them yourself (and Dr. White repeatedly said that pharmacokinetics was beyond his expertise and was like “Greek” to him).
Dr. White could have approached Dr. Shafer as he was offering his services to him and actually had even worked out one model for Dr. White. Dr. Shafer’s reputation is impeccable and if Dr. White’s model had turned out a more accurate one Dr. Shafer would have accepted it as a true scientist does – his goal in this trial is not to defend Michael Jackson, his goal is to find out the truth of what happened there.
But surprise-surprise, Dr. White preferred to approach someone totally unknown. This way it is easier to manipulate the result and shift the blame for it to another person too:
Walgren: Had you heard of Dr. Ornales before someone in the defence team told you to contact her?
White: I had never met her.
Walgren: Had you ever heard of her in the pharmacokinetic field? In anaesthesiology? Yes or no.
White: The answer is no.
Walgren: Did you ask her to create some computer models for you?
White: I don’t recall asking her specifically to create models.
Walgren: Was this last week that you met her? And we have models here today in court and you don’t recall if you asked her to create those?
White: She created them overnight and emailed to me.
Walgren: You are aware that Dr. Shafer provided his spread sheet and software to the defense, correct?
White: Yes, I am.
Walgren: What you have provided to the people from Dr. Orneles is a piece of paper with computer code written on it, with no software, correct?
White: I was not asked to provide software, so all I provided was a print out, yes, sir.
Walgren: Can you make sense of this computer code?
White: I think I said earlier that pharmacokinetic modelling is not my expertise.
Walgren: So you knew it wouldn’t mean anything to me, right?
The idea of various Dr. White’s models of Michael’s death was to show that Michael died not because his breathing stopped (as Dr. Shafer had proven) but because all of a sudden he had a heart attack.
There was nothing to show that Michael had a poor heart but this didn’t stop Dr. White from developing his theory.
As I’ve said according to his model it is an absolute must for Michael to have had a poor heart and have died immediately.
That is why White is ready to disregard even Murray’s own words who said that the pulse oxymeter showed 122 beats and he could feel Michael’s pulse when he re-entered the room.
Dr. White’s explanation of that fact is laughable. Acording to him Murray did not feel Michael’s pulse – no, he felt his own pulse. And when confronted with information that a pulse oxymeter showed 122 beats Dr. White simply avoided answering.
Walgren: You reviewed the autopsy report?
White: Yes, I did some time ago.
Walgren: And you noted that Mr. Jackson had a strong heart and no heart problems, nothing in that nature, correct?
(White says something about arhythmia sometimes happening even to a structurally healthy heart)
Walgren: Is there any indication in the coroner’s report that there is any problem with Michael Jackson’s heart?
White: No, there is not.
Walgren: According to Murray’s own words Michael’s heart was beating when Murray re-entered the room and the pulse oxymeter read 122 beats.
Dr. White said something incoherent about it, so Walgren had to refresh his memory by showing some excerpts from Murray’s interview.
Walgren: “He looked at his pulse oxymeter right away and his heart rate was like 122 beats”. That would mean he has a heartbeat, correct?
White: Without feeling the pulse and knowing that there was a profusing pulse I am not sure I agree with that.
Walgren: “So I immediately felt for a pulse, and I was able to get a thread pulse in the femoral region”, correct?
White: That’s what Dr. Murray reported.
Walgren: So he not only checked the pulse oxymeter, saw the 122 beats but he then felt the femoral region and felt a thread pulse, correct?
White: He reported feeling a thread pulse, correct.
Walgren: That was suggest his heart was beating, right?
White: It might suggest that or alternatively it might suggest that Dr. Murray was simply feeling his own pulse since it was very weak and thready. In these kind of situations…
Walgren: So you don’t believe Conrad Murray when he says he felt a thread pulse in the femoral region?
White: I don’t believe it may have been profusing. He may have felt…
Walgren: Are you disputing that?
White: I am merely suggesting that clinicians may be deceived and can feel their own pulse when they are under stress..
Walgren: Because if he felt a pulse it doesn’t match up with your theory that Michael Jackson died instantly upon receiving 25 ml by self-administration, correct?
White: It happens clinically.
Walgren: Would you agree that the primary cause of Michael Jackson’s death is that he stopped breathing?
White: I don’t see any evidence of that.
Walgren: Do you see any evidence that contradicts that?
White: I don’t any evidence that contradicts either respiratory or cardiac event or a combined cardio-respiratory event following the rapid administration of propofol to a patient who also had extremely high levels of Lorazepam.
Walgren: In your March 8, 2011 letter you do reference respiratory issues as a potential to presume respiratory cause of death, correct?
White: I think I said cardio-respiratory and it was a preliminary letter I prepared for Mr. Flanagan.
Walgren reads out from White’s letter, which say “…it can produce significant ventilator depressing effect as well as upper airway obstruction”, correct?
White: That’s of course a possibility. Among other things, yes, sir.
Walgren: Among other things including the theory that Michael Jackson drank propofol? Which you now reject?
White: Now that I have more data and more evidence I can say that it was extremely unlikely.
All this twisting, pretending and denying the obvious are simply unbearable.
Walgren raises Lorazepam.
Over here it turns out that Gabriela Ornales used the wrong figure for Lorazepam in Michael’s stomach:
White: It is a very, very small amount of Lorazepam but as I testified even a small amount of free Lorazepam would suggest oral administration.
Dr. White had no idea where the 0,0013 number cited there came from – he would have to consult Dr. Ornelas.
Walgren: As you sit here today you have no idea where that 0,0013 ml came from, correct?
White: Not as I sit here today, sir.
White: Well, she did the simulation so that you could try to take into account the fact that he had been receiving Lorazepam prior to the day of his death and we don’t really have a good handle on that number.
Walgren: But it is very specific – assuming 10mg per day for 5 days.
White: Well, as I said it was an arbitrary assumption based on what he might have been taking prior to the day of his death.
Walgren: And the level of Lorazepam was 0,0169 – do you know where this 0, 0164 came from?
White: Maybe a typographical error.
Let me explain the point about these falsifiers assuming that there was some Residual Lorazepam in Michael’s body after taking 10mg of it per day for 5 days running.
Even Dr. White says that it was a totally arbitrary assumption (or just pure guesswork not based on any data at all).
Why 10mg, which is five 2mg pills of Lorazepam per day?
And why for 5 days running?
Because it is only if they make this assumption about this level of Lorazepam in Michael’s blood prior to that night will their model of Lorazepam death be workable at all.
And it is only if Michael takes those mythical eight pills from that level will the curve line in their model will reach the level of Lorazepam found in Michael’s blood on autopsy.
Only on this condition.
And if he didn’t take 5 pills of Lorazepam every day for the last 5 days (the total of 25 pills) the model will not be working.
Well, all of us can make any assumptions we like – only it won’t be science. I can also make assumptions on the basis of their assumptions. One of them, for example is that 8 pills would not make much difference to Michael and would not kill him if he was given 5 pills on a daily basis. People are known to get used even to poison if it is given regularly to them.
Another of my assumptions is that all this is just a plain lie because the bottle found on the night stand said that Lorazepam was prescribed by Murray on April 28, 2009 and originally contained 30 tablets. At the time of death it had 9 tablets which means that Michael took only 21 pills for the past 2 months – or one tablet in three days! And absolutely not five pills for 5 days running!
One more of my assumptions is that it could be Murray who could offer Michael any amount of Lorazepam pills in a glass of juice, for example, without Michael knowing it. By the way the Prosecutor David Walgren also made such an assumption during the trial. Evidently we are thinking along the same lines:
Wagren: Is there any way scientifically to exclude, for example, Michael Jackson swallowing Lorazepam on his own or Conrad Murray giving Michael Jackson oral Lorazepam to swallow?
Dr. Shafer: They would look the same.
However these are only our assumptions. And assumptions are no science and are no proof of anything at all.
* * * * *
We are coming to the crucial point in the argument between True Science and Dr. White.
The point over which they really clashed was Propofol as the cause of Michael Jackson’s death or the unnaturally high level of propofol in his blood found on autopsy.
In order to understand under which condition propofol can remain in the body in so big quantities it is necessary to learn how the drug is functioning.
Propofol easily breaks up (metabolizes) in a human body and disappears from it while the heart it still beating and is pushing blood along its veins. This is why almost immediately after the drip stops the patient wakes up – all propofol has broken up and evaporated from his system and he wakes up almost totally clean of it.
However if the heart stops beating and the blood stops circulating, propofol no longer metabolizes. If the drug happens to be dripping into the dead body it starts collecting there and its level in the blood rises.
And when it comes to propofol it is top important to figure out what happened to the patient and what was the cause of his death – a stop in breathing or a stop in the heart beating.
If breathing stops first the heart will go on beating for approximately 10 minutes due to some oxygen left in the lungs. During these 10 minutes the blood will go on circulating and even a huge dose of propofol will break up and leave the system.
But if the heart stops first even a relatively small dose of propofol will immediately “freeze” in the veins and its concentration will not drop.
This is why Dr. White’s goal was to prove that Michael died of a heart attack when he “self-administered 25ml of propofol”, as a result of which the drug reached the peak level just for one single moment at which Michael suddenly and instantaneously died.
Dr. Shafer worked out an opposite model based on Michael’s having a breathing arrest first. Under Dr. Shafer’s model the stop in breathing made the heart stop, and it is then that propofol started accumulating in the blody and gradually reached the peak level found in Michael’s blood upon autopsy.
After trying on his computer a great deal of simulations Dr. Shafer came to the conclusion that Michael received at least 100ml of Propofol part of which dripped into his body after his heart stopped.
The reason why Dr. Shafer focused on the breathing arrest is because this is the only complication which takes place with propofol at all.
Propofol works on the brain and not on the heart. As soon as propofol reaches the brain it stops sending signals to the lungs to breathe. And as the lungs no longer breathe, so the heart begins starving of oxygen and dies in some 10 minutes after the intake of oxygen stops.
Cardiologist Alon Steinberg who testified on week 2 specifically differentiated between a cardiac and respiratory arrests and said that Michael had a respiratory arrest. This fact is not disputed by any scientists except Dr. White who stubbornly argues that Michael’s heart stopped first and he died of a heart attack.
Though propofol does not affect the heart and cardiac attacks are possible only when someone has a heart problem – which Michael did not have – Dr. White’s theory did leave some room for doubt which could be critical for the jury’s decision.
Dr. White had to prove his crazy theory and in order to do it he looked into the amount of propofol which went into the urine. He asked Gabriela Ornelas to calculate whether the amount of propofol found upon autopsy in the urine was consistent with the amount of propofol in the blood.
It is clear to any of us that if Michael’s blood was saturated with propofol, his urine must have been saturated with it too.
If the level of it was consistent with Dr. White’s theory (of 25ml self-injected by MJ) then it is he who is right.
If the level of it was consistent with Dr. Shafer’s conclusion (that Michael received at least 100ml under infusion), then it is Dr. Shafer who is right.
THE FINAL ARGUMENT
The amount of propofol in Michaels’s bladder found on autopsy was 0,15 micrograms per ml which multiplied by the amount of urine recovered (approx. 500ml) made up 82,5mcg (micrograms)
In comparison with the 1000mg (or 100ml) of Propofol which Dr. Shafer thinks Michael received it is a very small amount.
Especially if you consider that one microgram (mcg) is equal to 1/1000 of milligram (mg).
So now we will have to find out whether the big 100ml (or 1000mg) bottle of propofol infused into blood could produce the tiny quantity of only 0,0825mg in the urine.
Dr. White approached Gabriela Ornelas to make a computer model and see whether 1000mg amount of propofol could result in only 0,0825mcg in the urine.
She made a model and it said that it couldn’t – this tiny amount of the drug in the urine could result only from a very small dose infused or injected into Michael’s blood. Like 25ml for example suggested by Dr. White.
So no matter how unlikely Dr. White’s theory sounded Ornelas’s calculations coincided with his theory and not Dr. Shafer’s?
However every model is true only when it is based on correct data. And in her calculations Dr. Ornelas used the findings published in 1988 (by Simons and other authors) which were approximate and outdated.
What that article basically says is that propofol evaporates from the system so quickly that the amount of propofol excreted into urine is extremely small – less than 0,3% of the drug originally infused into the blood.
The only problem is that these scientists did not know how much propofol that 0,3% number contained as an unchanged drug.
Their number included both the original propofol as a drug (in Michael’s case it was the drug calculated and recorded in the toxicology report) and propofol metabolites (which the autopsy report did not have).
Like all other substances in the body the drug of propofol breaks up into metabolites which are also excreted into urine – and how much of propofol was excreted as a drug and how much as its metabolite was impossible to measure in the year 1988 when Simons’ study was made. The radioactive technology they used did not allow to make more precise calculations.
But the percent of unchanged drug excreted into urine is crucial for comparing with Michael’s results on autopsy as the propofol found in Michael’s bladder was the drug (or unchanged propofol) and not its metabolite!
Simons wrote in 1988 that their 0,3% number had both and they could not differentiate one from the other. He also wrote that the 0,3% was an overestimate.
However Gabriela Ornelas did not provide all those details. Or probably she did, but the details were in the article. Only Dr. White did not read the article. He said he had read it, but Walgren’s questions showed that he didn’t. He was satisfied with her conclusions and that’s that.
After hearing Gabriela Ornelas’s conclusions Dr. Shafer checked up all the data once again.
He studied the scientific literature published since that 1988 article and each of the follow-up articles (by the same authors) indeed said that 0,3% was a huge overestimate. The percent of unchanged propofol in the urine was much smaller.
What that means we will see later, but first let us look at the article which provided the definitive and precise data on that problem.
The study which decided it all was made in 2002 in Poland (judging by the names of the authors). When these people were making their research there was no way to know that their findings would determine the exact amount of propofol Michael Jackson was given by Murray and was ultimately killed with.
These authors studied patients receiving propofol during several hour long operations and managed to calculate the molecules of propofol as a drug and the molecules of it as a metabolite left in their urine. They found that the drug excreted into urine in its unchanged form comes in the incredibly tiny amount of 0,004% of the dose initially infused into blood.
So in application to the results in Michael’s toxicology report it means that 82,5mcg found in his bladder make up only 0,004% of the dose which was infused into his veins.
Now please take a calculator and find what the full 100% of the dose is if the 82,5mcg remaining in the urine make up only 0,004% of it.
I came up with the dose of 2062500 mcg = 2062,5mg = 206ml of propofol.
This means that to be able to get 82,5mcg of unchanged propofol in one’s urine you need to be first given 2062,5mg (or 206ml) of propofol in one’s blood.
And this means that Michael received NOT ONE 100ml vial of propofol. No, he received TWO 100ml vials of propofol from Murray, amounting to 206ml all in all.
The same 2002 year article had a reference table where we can check our calculations with the average figures provided by Polish scientists.
They actually measured the unchanged propofol in the urine of patients who underwent long surgery under a drip of propofol.
- The average amount of propofol given to those patients was 2000mgs or 200ml.
- The average amount of urine each of them collected during that time was 530ml (which is comparable with Michael’s).
- The average propofol found in the urine was 70,71 mcg of unchanged propofol.
So the 70,71 mcg residual unchanged propofol is associated with the dose of 2000mcgs or 200ml of Propofol given.
And this again proves that if Michael had 82,5mcg in his urine he received more than 200ml of Propofol that night.
We have checked ourselves.
Murray infused into Michael MORE THAN TWO 100 ml vials of propofol.
So Dr. Shafer’s model is absolutely correct and his verdict is a clear one:
Murray put Michael under a drip of propofol.
He was infusing more than 200ml that night.
While Michael was under the infusion, Murray went about his business – making calls, sending emails, typing text messages.
He simply did not notice Michael die and propofol kept on flowing into his body after his breathing stopped.
10 minutes after that his heart stopped too, but Murray didn’t notice it either.
Propofol went on dripping into Michael’s body until it reached the levels found on autopsy.
Most probaby by then the bottle had simply run out of the liquid.
And it was only then that Murray finally looked at his patient.
And noticed that he had died.
Now it does not even matter whether Michael died of a heart or respiratory arrest.
What matters is that Murray told us huge lies.
And Dr. White’s junk science has been adjusting to Murray’s huge lies trying to whitewash a criminal.
And if it hadn’t been for Dr. Shafer we would have never learned the truth.
Here is the actual cross-examination which will illustrate the above conclusions.
DR. WHITE’S DEATH MODEL BASED ON THE PFOPOFOL THEORY
Walgren: You felt it was the most accurate account of unchanged propofol in the urine?
White: Actually I didn’t make the determination. Dr. Ornelas is the one who did the pharmacokinetic modelling. She is the one with expertise, not me.
To Dr. White it looked like a very accurate estimation.
Walgren: Did you read the article, Dr. White?
White: I did look over the article. I didn’t really analyse it.
Walgren: You came to testify in the court room regarding unchanged propofol levels in the urine. Told us that this was your opinion. Did you read this article in detail upon which to base your opinion?
White: I didn’t read it in detail, no.
Walgren: And you started working with Gabriela Ornelas the first time last week?
White: She was contacted by someone in the defence team, is an expert in pharmacokinetics…I met her last week, later in the week, Wednesday, Thursday.
Walgren: How many hours did you put into collaborating with Dr. Ornelas to conduct her computer modelling you’ve testified to this jury?
White: I don’t know how many hours Dr. Ornelas spent working on this. I asked her a simple question, how much propofol you’d expect in the urine if the patient got two 25ml boluses of propofol versus 1000ml, because the numbers that were provided at autopsy in terms of concentration of free propofol in the urine did not seem to be consistent with the one thousand ml infusion given for 3 hours before Mr. Jackson died.
Walgren: I’m sorry, Doctor. How many hours did you put in collaboration with Dr. Ornelas prior to your testifying so that you are confidently informed as to the data and the literature that you are relying upon?
White: I had a conversation with her, she came over to the house where I was staying – the Flanagans’ house …
Walgren: The Flanagans’ house?
White: The Flanagans’ house, yes. And we had a conversation about kinetics, I asked her if she could provide the details about the modelling used, and she was kind enough to provide the hard copy.
Walgren: When was that meeting?
White: I believe it was near the end of last week.
Dr. White assumed that Murray injected Michael Jackson with 25 ml of propofol at about 10.40 (they must have looked up for a break between the calls to fit it in there) and Michael Jackson supposedly self-administered another 25ml between 11.30 and 12 o’clock.
Then they discussed the urine model.
Walgren: Did you make your research to make sure that the very premise of the model – namely the 0,3% measurement was accurate and reflected in the literature?
White: Well, there is variability among papers, I am sure, but we can repeat the model with another paper if you want to suggest better reference source.
Walgren: Did you do any research of your own to make sure you are giving accurate information to this jury before you came in and testified to the 0,3% measurement?
White: Sir, I was given her hypotheticals shortly before I had to testify.
After several more attempts from Walgren White said that his “feeling” was that 0,3% was the lowest estimate:
White: I didn’t look the articles on elimination. I cannot say that I researched every paper. My feeling was that it was most probably the most conservative estimate.
Looking at the article on which he was basing his testimony Dr. White says:
White: It is the article which I believe Dr. Ornelas used in her modelling upon which I based my testimony that the amount of free propofol in the urine after a three hour infusion would have been substantially higher than that reported at autopsy.
Walgren: It says less than 0,3%. Do you know how much less then?
White: No, I do not. But I think that there is another article which suggests that it could be as high as 1%. I suspect that Dr. Ornelas looked at the various papers available and picked what was a conservative number.
Walgren: Dr. White said he had had read some of the papers, but he didn’t “recall right off”.
White: I’ll be happy to provide you with a list of references if I am given time to do the research.
Walgren: Do you know how the unchanged propofol was measured in this research article?
White: I think it was by gas liquid chromatography.
White: Yeh, I see that.
Walgren: So they were not analysed that way?
White: I don’t know how they were analysed.
Wagren said that it was the basics of the model Dr.White was presenting in his testimony.
White: I haven’t had a chance to critically review that paper. It was an analysis done for me. I am not comfortable to comment on the article which is outside my expertise and which I have not been able to carefully analyse.
Walgren read the article much more attentively than Dr. White and pointed to a statement saying that “it is possible that the estimated value (0,3%) is an overestimate”. However to Dr. White it doesn’t make any difference:
White: It could be an overestimate, it could be an underestimate. There is tremendous variability. The fact of the matter is that these small difference that you are point out would not explain the massive difference that was determined based on the 3 hour infusion of a thousand milligrams and two 25ml doses.
It was my impression that the fact that urine concentration was only minimally higher than the propofol concentration in the urine that was collected at 7 am, suggested to me that it was highly unlikely and improbable that … (objection, the answer is stricken)
Walgren: Were you aware that the authors of the article in the very article itself indicated themselves that the 0,3% could be an overestimate?
Walgren: Thank you.
Walgren asked him if he knew of article by the same author dated three years later. White said he didn’t think he had found it in the very fast search he had made.
He lied that he had looked into the articles involving humans only because there is a great variance between species (and because of other pretexts for not looking into anything at all).
White: I did not research this topic. I merely asked a question.
The answer from Dr. Gabriela O. was that in case 1000ml of propofol were administered the residual propofol number in urine should be significantly higher.
Walgren: The answer was based on one outdated, isolated article, is that right?
Dr. White is always ready to deny the obvious.
* * * * *
Day 22, November 1
First Walgren asked how would Lorazepam find itself in the stomach if it was administered intravenously.
Walgren: It will still enter the stomach, is that correct?
Shafer: Correct. Drugs taken intravenously go into all the tissues. They go to the brain, the organ , the muscles, the intestines and the stomach.
Walgren: And is it a correct statement that this has nothing to do with post-mortem redistribution?
Shafer: That is correct.
Walgren: Is there any way scientifically to exclude, for example, Michael Jackson swallowing Lorazepam on his own or Conrad Murray giving Michael Jackson oral Lorazepam to swallow?
Shafer: They would look the same.
Walgren: In your simulation where based on the evidence you discussed that the infusing line was running and Michael Jackson stopped breathing and the propofol continued to infuse into his body, do you recall that?
Shafer: Yes, I do.
Walgren: In that simulation were you designating a precise time that Michael Jackson stopped breathing?
Shafer: No. What the simulation shows is how the level (of propofol) initially rises initially fast and then slowly through a period of time. The simulation has shown that Michael Jackson could have died at any time with the propofol concentration continue to be high in his blood. And there is no suggestion that he had to die at any specific time. He died with a high level of propofol during the infusion.
Walgren: You wouldn’t say that it was precisely at noon?
Shafer: No, not at all.
Walgren: And when you demonstrated the two infusion lines that’s a fairly typical setup when you would be using two separate.
Shafer: Except than when you use an (infusion) pump, but other than that, yes.
Walgren: Dr. White commented on the gravitational differences in the bottle, for example, in the saline bag and the saline bag with saline solution. Can you comment on how you deal with any such difficulty?
Shafer: If you recall the infusion set up that I showed you I demonstrated how by controlling the roller clamps you can all being the saline coming out or all being the propofol coming out – simply by the adjustment of the roller clamps.
Walgren: This is common and typical how it is done?
Shafer: No, it is common to do without the infusion pump. And it is commonly done with non-critical things like antibiotics.
– – – –
Walgren: What is the risk if propofol is applied? What happens if complications arise?
Shafer: The serious risk of propofol is that you stop breathing either from the lack of effort (you don’t have the desire to breathe) or because the tongue falls into the back of your throat and the airway is obstructed. And that is the main cause of serious injury from infusions of propofol – the failure to breathe.
Walgren: Was this failure to breathe eventually led to failure of cardiac activity which caused Michael Jackson’s death in this case?
Shafer: Correct. When oxygen does not run into your lungs, the lungs run out of oxygen. The blood runs out of oxygen and the heart runs out of oxygen. And it is the lack of oxygen in the heart is that it kills the heart.
Walgren: Dr. Shafer, have you reviewed the models presented by the defence that reflect the levels of unchanged propofol in the urine?
Shafer: Yes, I have.
Walgren: You’ve had an opportunity to research the various literature as it exists today in regard to the amounts (of propofol) to be found in the urine?
Shafer: Yes, I have.
Walgren: Are you aware that the defence’s findings relied on Simons’ article from 1988?
Shafer: Yes, I am. The Simons article found that there was very little unchanged propofol – so little that it is actually difficult to measure it. What they did was mix oil with the urine knowing that propofol would go into the oil.
He explained that the researchers employed a radioactivity method but they didn’t know whether they were measuring unchanged propofol or its metabolite. They said that the upper limit of the overall radioactivity measured was 0,3% but they didn’t know how much of it was actually unchanged propofol – because they didn’t know what the source of the radioactivity was. It could be propofol or it could be propofol metabolite that also goes into oil.
So in that article they stated that out of those 0,3% the level of free propofol could be all the way down to zero because all the radioactivity could be the result of metabolites going into oil.
Dr. Shafer conducted research into more recent studies on unchanged propofol. There were multiple articles published since 1988.
One particular article Dr. Shafer found definitive on this issue. It is a 2002 Polish manuscript where the authors referred to the Simons paper which stated that “what we measured might be a metabolite”.
The authors said that Simons was right – what he showed was a metabolite and the actual unchanged propofol is much, much less.
The reason why this article was more precise is because for 14 years additional technology for measuring molecules was developed. A radioactivity method was much more crude.
Walgren: Based on that improvement in technology they were able to be much more precise in their measurements?
Shafer: That’s correct.
Their measurement was 0, 004% of unchanged propofol eliminated into urine of the totally applied dose.
The level of unchanged propofol found in the urine found upon autopsy was 0,15 micrograms per ml. And the urine in the bladder was 500 ml. Converting it into micrograms Dr. Shafer came up with the number of 82,5 mcg.
In the 2002 article they actually had a table where they listed out the amount of propofol excreted unchanged and the doses administered to give those amounts.
- The first column is how long the patients were undergoing surgery under propofol.
- The second showed the method of calculations.
- The third is the total amount of propofol delivered to each patient. The average amount of propofol given was 2000mgs or 200ml.
- The fourth is the amount of urine. The average was 530ml.
- The fifth shows the average amount of propofol excreted. The average per patient was 70,71 mcg of unchanged propofol.
This is quite close to what was measured in Michael Jackson’s case – his was 82,5mcg.
The 70,71 mcg residual propofol is associated with the dose of 2000mcgs or 200ml of Propofol given.
So if Michael Jackson had 82,5mcg it means that he had more than 200ml of Propofol.
It absolutely rules out the hypothesis offered by Dr. White (who said that Michael died of 25ml).
Actually it suggests that Michael Jackson received more than in Dr. Shafer’s simulations.
Walgren: Dr. Shafer, would you agree that the need for monitoring and safety precautions will be even greater in a home setting?
Shafer: Yes. Anesthesiologists spend a certain amount of time providing care in what we call remote locations. A remote location may be a radiology suite, or perhaps a difficult patient in an eye clinic, or a patient in some location where we normally don’t give anesthesia.
And what we are taught is that when we are in a remote location you have less tolerance for air. You have to be particularly careful. You have to adhere to the standards as careful as possible, and the reason is that you have no back-up.
So to your question if there were such a thing as bedroom based anesthesia the standard guidelines would be considered a minimum because you have no back up, no tolerance for air.
And if you have no air, you have the mortality.
Walgren: Thank you , Dr. Shafer.