Conrad Murray, THE MAN WHO KILLED MICHAEL JACKSON. Part 3 on how NOT to do it
The majority of us are no specialists in medicine and need a standard to look up to in order to get at least some idea of the scope of Murray’s incredible negligence, ignorance and stupidity coupled with his no less incredible arrogance and conceit.
The testimony of Dr. Adams about the way he gave anesthesia to Michael Jackson for some dental procedures in 2008 can serve as a sort of a gold standard on how to do it, so in order to assess Conrad Murray all we need to do is set Murray’s own story against the standards of Dr. Adams and see the difference.
HOW TO DO IT
Below is the rest of Dr. Adams’s answers on the way he did it.
The tape of his deposition was played at the AEG civil trial on August 21, 2013.
Questioned by Mr.Putnam, the lawyer for AEG, about Propofol given to Michael in a dental office in 2008 Dr. Adams gave a few details which though being quite intimate are still necessary for our education.
Putnam: Can you remember anything else about this first procedure that was outside of the ordinary in any way?
Dr. Adams: Not out of the ordinary, but when we administered the Propofol, his tongue relaxed. And when I say it relaxed, I mean it obstructed his airway. So we had to position his head — he’s sitting in a dental chair so we tilted the chair back and we extended his neck and we held his chin, because Dr. Tadrissi is in his mouth so he gave him a jaw thrust which basically lifted the tongue off the back of the pharynx to open the airway, and we had to maintain that position the whole time. If not, he would obstruct. Every time we administered medication he would obstruct.
Q. And I know we are going to go over the three other times where you gave Propofol. That happened in each of the instances?
A. Every time.
Q. Each time that there was this reaction by Mr. Jackson, did you do something to physically intercede to correct it?
A. I would tell the surgeon or the dentist to pull his chin forward.
Q. Had you ever seen this reaction before in any other patient?
Q. And you did indicate that Mr. Jackson’s tongue was quite large. Did this make it even more of an issue?
A. It did.
Q. And if you hadn’t seen it with your own eyes, would you have eventually realized the same because of the oxygen levels that were being monitored?
A. Yes. But, you know, with the obstructed airway he would start to have labored breathing, you may hear a snoring. But with Dr. Tadrissi or the dentist being in the mouth, you know, we would — we noticed it right away.
Q. You indicated earlier an issue earlier whether one has sleep apnea. Did you ask Mr. Jackson whether he had sleep apnea?
A. I did. He said he didn’t know.
Q. During the course of the procedure, did you have any other concerns about the administration of Propofol to Mr. Jackson, other than the fact that there was this moment where his airway was obstructed by his tongue?
A. After the initial induction of the hundred milligrams of Propofol and we pulled the tongue off of the pharynx and we opened the airway, there were no other issues.
Q. Did he seem to come up okay?
A. Fine, perfect.
Q. Is there any procedure that you have with the patient afterwards to make sure they’re okay once they come up, any questions or any procedures that you use?
A. Outside of just monitoring their vital signs and making sure they can walk out of the clinic, then that’s about it.
So each time Dr. Adams gave Michael as little as 10ml (100mg) of propofol for the initial induction his tongue would relax and fall back obstructing the airway. This happened on all four occasions, and each time it manifested itself by labored breathing or snoring.
The doctors immediately corrected the situation by giving his jaw a thrust. It took the tongue off the back of his throat and they had to maintain that position the whole time. “If not, he would obstruct”, Dr. Adams says. Every time he administered Propofol Michael would obstruct, and this means that the same would happen to him in Murray’s hands too.
The second dental procedure (something to do with dental implants) was a month later, in August 2008:
Mr. Putnam: What date was that?
Dr. Adams: 6/3/08.
Q. All right. And here there are a number of boxes filled, et cetera, like previously. Can you look through and see if anything has a different meaning other than what you’ve already told us here today about your prior record?
A. No. Pretty much the same procedure, everything else pretty much the same.
Q. I was going to say, this one is again two hours?
Q. Again 200 milligrams of Propofol?
Q. Initially a hundred then 50 and 50?
Q. Again your signature throughout?
Q. And you indicated, I just want to ask it again if I may, again there was an incident during this procedure where once you gave Mr. Jackson the Propofol his tongue went back and started to block his airway?
A. That is correct.
Q. And were you expecting it this time?
A. I was. Always aware that can happen when Propofol or any other induction agent is given.
Q. How often has it happened to you?
A. I’ve probably done, including colonoscopies and EGGs, I’ve probably done 5,000 of these cases — that might be high — 4,000. I would say you get an obstruction like that maybe 500 times. So it’s not uncommon.
So obstruction of the airway is very common under Propofol and takes place once in every ten cases, and Michael was one of them. Obstruction occurs even in light sedation given to patients for some diagnostic procedures.
The biggest challenge for a doctor in these cases is to stay vigilant throughout the whole procedure, correct the situation as soon as obstruction happens and maintain the proper position of the patient until the end of anesthesia.
Is there anyone here thinking that Murray stayed the whole night holding Michael’s head? Certainly not? Then we can proceed:
Mr. Putnam: Do you remember the doctor performing a — Dr. Odabashian performing a root canal on Mr. Jackson?
Dr. Adams: I do.
Q. Was that on 6/18/08?
A. It was.
Q. Was that the third time you administered anesthetic to Mr. Jackson?
A. It is.
Q. Can you tell from this record what anesthetic you provided?
Q. And is that because it’s written here on the page?
A. That’s correct.
Q. And there, unlike the last time, here it says 100, 20, 20, 20?
Q. Could you tell me what that means?
A. That means I gave him a hundred for induction to put him to sleep or put him under, since sleep is a very controversial term in this case, and 20, 20 and 20 was basically to keep him under.
Q. And in this instance, and here it’s over the course of an hour; is that correct?
A. It’s about an hour and a half.
Q. What’s the difference between general anesthesia and sedation, one local anesthesia?
A. General anesthesia is going to be a deeper sedation, where normally a patient is going to be on a ventilator, and it’s — he’s not in a twilight sleep, he’s getting more medication for pain. He’s in a deeper state of sleep.
Q. For each of these, we were not in that deeper state of sleep, were we?
A. No, because we didn’t have a ventilator — we didn’t have him on a ventilator.
Usually Dr. Adams gave no more than 200mg (20 ml) of Propofol for a 2 hour procedure, however the root canal was expected to take less time, so Dr. Adams went with it bit by bit – first it was 10ml of Propofol, then 2ml, then 2ml again and then the final 2ml – all in all 16 ml (if only Murray could be that careful and precise!)
In all the four cases of dental anesthesia it was “twilight sleep” only. In this condition the patient is “out” but is under a much milder sedation than general anesthesia. The only outward visible difference would be that under general anesthesia the patient does not breathe on his own and his lungs have to be ventilated.
In case the level of propofol rises in the blood light sedation may turn into general anesthesia and this moment will be almost invisible to the eye.
Q. … The third time you performed a procedure on Mr. Jackson, did you provide Mr. Jackson with Propofol on that procedure as well?
A. I did.
Q. And that was with Dr. Letilier’s office, correct?
A. Letilier, that’s correct.
Q. Now, it was the fourth time?
A. It was.
Q. And it was still in 2008?
A. It was.
Q. And can you remember what the procedure was?
A. It was for the actual screwing the implants into his jaw.
Q. How many implants were there, if you recall?
A. I believe there were two.
Q. And did it all seem to be adequate for you?
A. It did.
Q. Was there anything out of the ordinary about this procedure?
A. In the previous three procedures, Michael asked me not to give him any narcotics. I asked him why. He just said he had had a problem with them in the past and he didn’t want to have a problem with them again. So if you look at my records, you won’t see any narcotics. I didn’t give him any, as requested. During this procedure, after it was over, he asked for something for the pain, and I remember saying are you sure? And we had mentioned Toradol, which is a non narcotic pain reliever, and he requested something stronger.
Q. What did he request?
A. He didn’t request anything, but he did say, you know, that Toradol is not going to work.
Q. Okay. So he asked for something stronger?
A. And we ended up giving him Versed, which is a benzodiazepine, and also morphine for the pain.
Q. Now, was that something — did you give him this for the pain in the office or was that something you prescribed him so he could take it home?
A. No, it was right there. It was through the IV.
Q. IV? And so was this after he came up out of the Propofol?
A. This was after the procedure, um-hum.
Q. And did you ask him if he wanted anything or did he request something?
A. He requested it.
Q. And how soon after he came to did he request this?
Q. And were you surprised by this?
A. I was surprised. But I also saw the procedure. And they screwed the implant into his jaw, and you know, it wasn’t unusual.
Q. Is there anything unusual about this visit that you can recall?
Q. Do you recall how long this procedure lasted?
A. Hour and a half, two hours.
Q. And I should ask this for this procedure, I know the answer, but since I don’t have the records, did you administer Propofol during this procedure?
A. I did.
Q. Do you remember how much?
A. Approximately the same that I’ve administered. It was 200 too. 200 milligrams.
Here again comes 20 ml [200mg] of Propofol for another 2 hours of having dental implants screwed in the jaw.
So what if Michael asked for a painkiller after that? When I briefly worked as administrator of a dental office our doctors always sent patients home with some painkillers and this is how I know that the post-operative period after the dental implants is indeed painful.
For the first three procedures Michael asked Dr. Adams not to give him any narcotics. He openly said he had a problem with them before and did not want to relapse. But after the implants were screwed in he did ask for something for the pain.
The Toradol offered by Dr. Adams Michael was familiar with – it was given to him in 1993 by Evan Chandler (Jordan’s father) when Michael stayed in his house for two days and suffered from a terrible migraine from his scalp surgery. At that time it worked and after interrogating Michael under this sedative (with no result) Evan Chandler carried the half-conscious Michael to bed putting him in no other place but Jordan’s room (evidently hoping to obtain some “evidence” this way).
Now Michael was afraid that Toradol would not work, so Dr. Adams chose to give him an opioid by IV. It is notable that Michael did not ask for it and the drug was of Dr. Adams’s choice.
You cannot imagine what the media made of this perfectly understandable situation. “See what a drug-addict he was, first asking for one thing and then for another” and so on and so forth all in the same style. I wish they could put all that pretence and hypocrisy aside and admitted that the situation did require a painkiller – propofol had already stopped working but the pain was still there.
Dr. Adams saw nothing unusual about the request for a painkiller after the gums were cut and the implants screwed in:
A. Well, basically you’re taking a tooth, an artificial tooth that has a screw in the bottom of it and you’re screwing it into somebody’s jaw. You’re cutting his gums and screwing it into the jaw.
Q. Based on your experience, is that a painful procedure?
A. I’ve never had one, but it looked painful to me.
Q. You’ve had other patients who have woken up from anesthesia in that circumstance and been under significant pain?
A. That’s correct.
Q. Anything unusual about giving somebody painkiller for that kind of surgery?
A. Not at all.
Q. Do you have any idea whether he got any additional, other than the one dose there at the time? I think you said it was morphine and Versed?
A. Morphine and Versed. I believe he got the Versed. I want to say before the procedure he got the Versed. I would have to look at the record or maybe during the procedure, but Versed is not a medication. So he either — he came in anxious. You know, he came in with a different demeanor than he normally came in for the first three times. He came in a little more anxious, so we gave him the Versed I want to say before the procedure started, and gave him the morphine after and the Propofol in between. Just a little more nervous.
Q. A little more nervous about the —
A. About getting ready to get the implant screwed into his jaw.
Q. As far as you know, was he given any kind of narcotics other than in Dr. Letilier’s office —
Q. — for that procedure?
A. As far as I know, no. Is there anything in your examinations that you determined was inconsistent with what he stated his medical history was?
A. Nothing at all.
Q. Did you ever see any needle marks on his arms, for example?
A. Nothing at all. Very difficult veins to stick to. Very muscular arms, very small veins.
Q. What does that have to — why do you mention that?
A. I just mentioned it because I can remember sticking him twice, three times, every time trying to get an IV.
Q. So is what you’re saying is that you believe you would have seen needle marks in his arms if there were?
A. That is correct.
Q. You never saw any?
A. Never saw any.
No wonder Michael was needle phobic – each IV injection into his veins required sticking a needle three times! And his veins were not those of an “addict” as Conrad Murray will readily tell you – they were simply very small veins and in very muscular arms too. And aside from the marks from Dr. Adams’s injections there were no needle marks in Michael’s arms whatsoever.
The same was said by Dr. Klein who insisted that in the period before Murray came into Michael’s life his arms were absolutely clean.
The autopsy report of course recorded a lot of those marks and all over Michael’s body too.
I wonder if those who will comment on that autopsy film will explain that the marks appeared as a result of Murray’s continuous experiments on Jackson and due to the efforts of paramedics and doctors to resuscitate him.
Does anyone here doubt that they will not explain it and will continue rubbing in their lies about “what an addict he was?” Nobody doubts it? Then we can proceed again.
As the final note about Dr. Adams let us remember that each time the doctor let Michael home he first checked his vital signs and made sure he was fully awake and had no problem walking out of the clinic.
Now after a little bit of education from Dr. Adams we can have a look at the way Conrad Murray did it.
HOW NOT TO DO IT
The craziness starts from the very beginning of it the way it was described in the 2011 film. Over there the British journalist Lee Hewlett asked Murray good and pertinent questions.
Here is the same film again, only now we are looking at the very beginning of it:
04:40 Hewlett: At this point I turned to the fateful day. Murray told the police that he had administered 25mg of propofol or milk as Jackson called it after a sleepless night at around 10:40 or 10:50 in the morning. He then said he left the room for 2 minutes before returning to find his patient in serious distress. What he didn’t tell the police was that he actually spent 50 minutes on the phone to relatives and girlfriends [and not only them]
05:05 Murray: In my interview I said it was at least 10:40. 10:30 – we are already beyond that. And at that time he pleaded for milk. In consideration of giving him that I had to get the appropriate medication, get the syringes, prepare it, so he really got propofol around 10:50. So here is Mr. Jackson, he gets an injection of propofol which is 25 milligrams, that’s it.
05:50 Hewlett: …You then said you left the room for 2 minutes to visit the lavatory and when you came back Michael was in some form of cardiac distress. That time frame doesn’t make sense because you talked on the phone to various people for 45 or 50 minutes.
06:05 Murray: I would say… this is what I’ll say I’ve done. So he got medicine at about 10:50, he drifted into sleep around 5 minutes. I sat there and waited as long as I felt that it was… that I was comfortable that the effect of the medicine – of propofol – was gone.
Hewlett: And then you left the room?
Murray: How long was that? Normally propofol would last about .. the effect of it would end.. the sleep state would be gone in ten minutes. I sat there for at least 30 minutes. If you look at the calls as they were coming through I made the very first call that came through from my daughter, I did not even pick it up. I’m still at the bedside.
Hewlett: Taking the calls at bedside?
Murray: Let me make it clear for you. After giving him his propofol I sat there long enough with Mr. Jackson looking at him, checking his vital signs, checking his oximeter, making sure his pulse was fine, making sure he was asleep, and he was asleep but not as deep as he would normally sleep because he was not snoring. And then by 11:20-11:25 I decided, well, look, if the calls start coming and he is now comfortable the effect of propofol is more than 20 minutes gone….
Hewlett: But the point is this – you never mentioned the phone calls to the police.
Murray: They never asked me!
Hewlett: You could tell them what happened.
Murray: Listen to me. I sat there. We never interrupted the policemen, we never told them what they could ask, they did not ask me the question. I didn’t think it was important!
Hewlett: Let me ask you this question. What do you think happened? It has been speculated that Mr. Jackson swallowed lots of propofol, but that was discounted. It is suggested by some people that you hooked him up to a drip and as a result of a longer-term infusion of propofol he ended up with a poisonous concentration in his blood. There was another suggestion that got widely reported that he may have medicated himself. What do you think happened?
Murray: I cannot answer your questions. Because you asked so many things that require a story of its own. I think let’s first of all go back to 11:20 when I left his side. When I left his side the effect of propofol was gone. I went to the adjacent [room]… Mr. Jackson was in the master room, that was separated into five compartments or chambers. I was in the chamber right adjacent to where he was, feeling that if he got up or he called for me, I would hear him. I then conducted phone calls right in the bedroom next door because I didn’t want to disturb his sleep. At the end of my conversations or thereabout when the last inconsequential phone-call I was making rather than going to him right away I go ahead to the farthest, distant chamber to urinate. That I did. And that’s why I talked about 2 minutes. I went to the very, very last chamber to urinate, then came back, but all of the time that I was in the adjacent room I felt that I was close to Mr. Jackson. Does that help you?
Hewlett: It does.
Well, it probably helped Lee Hewlett, but it does not help us.
First of all the police did ask Murray questions “what did you do next?” and Murray preferred to keep silence about the phone calls, so all his surprise now is just another of his big fakes.
Secondly, Murray says he used a barely visible dose of 2,5ml of propofol for 5 minutes of sleep only and after that he failed to wake Michael up. His assumption that it was the usual “state of sleep” was a huge and tragic mistake we already spoke about.
Third, all the 30 minutes Murray allegedly waited he didn’t hear any sonorous breathing which previously he had always heard.
This worried him but not as it would worry us after all the education we’ve got here – no, he was worried that it was too light a sleep and that Michael would wake up any minute and this is allegedly why he left his bedside (“in order not to disturb”).
However in the language of anesthesiologists the condition when the patient does not wake up is called coma.
This is what they say about it:
There are several possible causes for delayed “emergence” – the technical term for waking up – but no specific, single disorder that would cause a patient not to wake up at all after anesthesia.
The failure to wake up would be called coma, and in fact general anesthesia is nothing other than a highly controlled form of chemically-induced coma.
Any severe disruption of the supply of oxygen-carrying blood to the brain can damage it permanently. The oxygen-deprived brain cannot survive intact for more than 5 or 6 minutes. There are a variety of anesthetic and surgical “disasters” that can produce this result, for example major bleeding. Fortunately this outcome is rare.
Delayed emergence can of course be a result of delay in getting rid of anesthetic or sedative drugs. This can happen when large doses are given, in the elderly, and in those with liver or kidney function that is not normal and the drugs cannot be metabolized or excreted. A low body temperature, whether deliberately induced, or occurring accidentally, can slow emergence a lot.
I hope this gives you an idea of the possible causes of a fortunately very rare occurrence. http://netwellness.org/question.cfm/42251.htm
So even if it was the case of “delayed emergence” due to all the medication working in concert with each other this was still no reason for leaving the patient alone and going to make phone calls instead. It was exactly the reason to stay and make sure that nothing disastrous was going to take place.
But the problem here is that not only did Murray happily leave his patient’s side to go about his business but he also gravely misinterpreted the picture of no snoring which he was observing.
Let us make it clear once and for all what snoring or no snoring under Propofol means, especially in the case of MJ whose tongue blocked the airway even in case of a minimal dose of anesthesia.
THE “SNORING” FACTOR
Aesthesiologists say that snoring (apnea) under Propofol occurs even with those who do not generally snore. This happens because under anesthesia all muscles relax and the tongue is no longer controlled by the body. When Michael was under Dr. Adams’s care it happened each time during the four procedures, so there is no reason to believe that with Murray it would have been anything different.
However Dr. Murray thought that this “snoring” was a sign of only deep sedation. From the matter-of-fact manner Murray spoke about it, it’s clear he didn’t think it a big deal and never took any action to stop it. Murray is not the kind of man to stay by Michael’s side for hours on end maintaining his head in a certain position to avoid the air obstruction.
So when he didn’t hear any “snoring” he assumed that Michael went into a light sedation. However Dr. Adams already showed to us that in Michael’s case obstruction would happen even in case of a minimal dose of Propofol, and if no sonorous breathing was heard it means that it was the opposite of it – it was a coma.
Professional nurse anesthetists discussing Murray at the Trial and Tribulations website noticed it as soon as Murray’s interview with the police was published. Here is a quote from their discussion:
I see no one answered the question regarding whether or not Murray could have heard anything as Jackson lay dying. The answer is yes; MJ’s automatic responses would have been deep, sonorous breaths due to airway constriction, or his brain receiving a signal that the amount of oxygen in his bloodstream was low.
Most RNs who have done time in post-anesthesia recovery have heard those respiratory efforts plenty of times, and they will initiate treatment, by opening the airway by a head tilt, or insertion of an oral airway, or intubating the patient (some nurses can intubate, but the usual procedure is to call a physician in to do it).
Another nurse explains that taking snoring for an effective level of sedation is a common mistake of inexperienced clinicians. She describes the picture of dying that was previously explained to us by Dr. Shafer – first breathing will stop, then the heart will start fluttering, then it will slow down and in some 10 minutes or so it will stop too:
A very common error inexperienced clinicians make when giving sedation for procedures is that they think snoring equals an effective level of sedation, when in fact, snoring indicates an obstructed airway, and impending respiratory arrest.
With an obstructed airway arrest, the chest moves in a paradoxical way, with obvious chest and abdominal muscle use, as the body tries to breathe against the obstruction.
If not corrected, the heart begins to beat faster (tachycardia from hypoxia and catecholamines released), followed by rapid rate abnormal rhythms, which deteriorate into bradycardic (slow rate) rhythms, agonal rhythms, then asystole (flat line).
The treatment here is to intervene early with airway and positioning support, back off on the drugs, support BP and heart rate as needed, and possibly reverse any reversible meds to restore adequate ventilatory efforts. Advanced measures, such as intubation and positive pressure ventilation as needed.
Almost no one recovers once asystole occurs, no matter why it occurred. It is indicative of a very advanced state of cardiac arrest.
She adds that the lack of snoring under propofol is an even worse sign because it means that breathing has stopped and the obstruction is now complete:
Snoring type respirations are indicative of partial, or evolving obstruction, but if the obstruction is complete, you would not hear anything unless you were plugged into your patient with a precordial stethoscope.
Then you can hear squeaks that signal attempts at respiratory effort, but those in the room couldn’t hear that. You can also see and feel the obstructed respiratory efforts, if you are looking for it (which CM clearly wasn’t).
I will add that a centrally mediated respiratory arrest would not be audible. Deadly silent, in essence. It happens one of 2 ways: either progressively shorter, shallower respirations that end with apnea (no respiratory effort), or it can happen very suddenly, in 2-4 breaths time from a big dose of meds.
When I induce for general anesthesia with fentanyl, versed, and propofol, followed by a neuromuscular blocker, my GOAL is apnea as soon as possible. From the time I push that dose to complete apnea is usually less than 30 seconds. It happens quickly and silently.
We do a heckuva lot of other stuff before, during, and after that planned, induced respiratory arrest, which I won’t go into, because that is another discussion entirely! But rest assured, we know what we’re doing, and we keep you safe. Every breath, every heartbeat, we are watching and THERE to help you stay alive. Not in another room on our cell phones.
Let us sum up. When Michael did snore it was a bad enough sign, because it meant that his tongue fell back, but when he didn’t snore it was a much more dangerous sign as it meant that his breathing stopped.
If at that moment Murray had guessed to put a stethoscope to his chest he would have heard Michael’s lungs making those “squeaking” attempts at breathing. Needless to say that our cardiologist did not even have a stethoscope as none of it was found on the scene of the crime.
So Murray’s interpretation of the events that morning was exactly the opposite of what really happened.
When seeing that Michael didn’t snore Murray thought that his sleep was too light and he could wake up any minute. However Michael was dead silent because most probably the opposite happened – the sedation was so deep that the airway went into complete obstruction and his breathing stopped altogether.
A layperson who doesn’t know that all this “snoring” under propofol is a very specific thing will think exactly like Murray does – if a person snores it means that he is alive, while to an anesthesiologist it is the first sign that the person is dying.
Murray’s ignorance breeds more ignorance, and now we see the media repeating Murray’s story exactly as he is telling it. And the policemen also initially understood it the way he presented it to him in his interview.
For Murray’s ignorance to completely triumpth over science the only thing that remains to be done is for the appellate court to also believe Murray’s version. Hopefully at least there they will listen to experts who will explain to them what’s what…
Here is the respective piece from the police interview on that apnea phenomenon where Murray is lying like crazy that he was using the pulse oximeter and was checking Michael’s vital signs (he was doing none of it as he was probably not even present when the drip of Propofol stopped Michael’s breathing):
Detective Martinez: We’re at about 10:50 hours.
Mr. Chernoff: We got the milligrams, 25.
Detective Martinez: 25 milligrams, half of what you normally give. Now, what happens next?
Dr. Murray: I am- I’m monitoring him at the house. And he fell asleep.
Detective Smith: 11:00 o’clock now? Later?
Dr. Murray: He fell asleep fairly quickly, I would say, but he was not snoring. Normally, if he’s in deep sleep, he would be snoring. I was a little bit hesitant that he would probably jump out of sleep, because that is – he does. He just (snaps) gets up like that, and his eyes goes, and he’s wide awake. And whenever he’s up, he reaches for his IV site.
Detective Martinez: Real quick aside, because I’m not familiar. Is this something that has to be continually introduced into him as a drip, or is this something you just do a small injection and then –
Dr. Murray: You do a small injection to help him to sleep, and then you try to drip slowly.
Detective Martinez: okay.
Dr. Murray: So that he continues to sleep.
Detective Martinez: okay.
Mr. Chernoff: It’s like anesthetic. it’s like a general anesthetic. In fact, it’s used for that, primarily before it – before the gas goes down, a lot of times they’ll have that drip. That’s what he’s been sleeping on for years. [wrong, he hasn’t!]
Dr. Murray: But there’s also — used in patients who, you know, are very ill and they need to keep them completely sedated.. You know, it’s being used.
Detective Martinez: Okay, Sorry. Didn’t mean to interrupt. So he fell asleep quickly, but he wasn’t snoring. So he’s not in a deep sleep.
Dr. Murray: I was worried about that. Because when he is not deep, then he could just quickly wake up. But I was – I’m monitoring him. I stayed there and watched. I monitored, saw his oxygen saturation, it was in the high 90’s, 90 percent. Heart rate was roughly in the 70’s. Everything looked stable.
I monitored him. I sat there and watched him for long enough period that I felt comfortable. Then I needed to go to the bathroom. So I got up, went to the bathroom to release myself of urine and also consider getting rid of some of his urination that he had put in the jugs overnight.
Then I came back to his bedside and was stunned in the sense that he wasn’t breathing.
Besides Murray’s lies on how well he monitored Michael that morning, the above piece introduced us to three more noteworthy factors. First of all Murray admitted that after the initial infusion he usually followed it with a drip (“You do a small injection to help him to sleep, and then you try to drip slowly”).
Then he revealed his knowledge that critically ill patients can be kept under propofol for a long time and this makes me think that he himself encouraged Michael for Propofol and told him that it was absolutely safe (it is indeed safe, only not in Murray’s hands).
And third, he says that part of the urine had been disposed of and this means that not all of it was taken into account during the autopsy examination.
THE URINE FACTOR
The latter point is extremely important for understanding how much Propofol was given to Michael that night.
The concentration of propofol in the urine was calculated by the coroner per ml so the more urine was collected the more dosage of propofol was given to Michael that night.
The concentration of propofol in the bladder was 0,15 mcg (micrograms), the concentration of propofol in the jug was around 0,10mcg and what concentration of propofol was in the urine Murray disposed of we don’t know.
Based on the volume of the urine found by the coroners in the bladder (550ml) we already calculated no less than 206ml of Propofol given to Michael that night following the formula provided by Dr. Shafer.
To this quantity we need to add the Propofol found in the urine in the jug the concentration of which was a little lower (<0,10 mcg) and not included in the above calculation.
And how much more will the overall amount of Propofol come to if we also add to the above the jug Murray emptied sometime around 11 o’clock?
It is totally mind-boggling to think of the gigantic quantity of Propofol Murray fed Michael! Was it 250ml, 280ml or more?
But Propofol in the urine is not only the evidence of the overall quantity given to Michael that night – it is also the evidence of the way it was administered. The urine came in several portions, each of them containing propofol and this means that propofol was flowing into Michael throughout the night.
If the urine collected after 7:30 in the morning had propofol in it, and the one collected before that moment also contained it, it means that Michael was on a drip which lasted for many hours during the night, and all Murray’s talk about the tiny quantity he gave at 10:40 is a big lie.
The information Murray provided to the police is proving this fact:
Dr. Murray: He urinated then. I made him stand and had him urinate, and he filled a – he had a bag on him. And that was filled, and I emptied that. Then I filled another portable jug, which he placed another 6-700 cc’s in of urine. So he urinated, yeah. Oh yeah, he doesn’t – because he’s getting the IV fluid, you know, which is also hydrating him.
Detective Smith: Now we’re beyond 7:30. You’ve administered two more milligrams of the Versed.
Dr. Murray: Yeah….
THE DRIP FACTOR
Putting Michael on a drip was Murray’s usual practice. He explained that he would start with a syringe injection of Propofol diluted with lidocaine and when propofol was no longer burning the veins he would proceed with a drip. His initial dose was usually 50mgs (5 ml) but that night he allegedly gave 25mgs (2,5ml).
What he says about cutting the initial portion does not matter because it was a drip anyway. It sounds incredible but in his police interview Murray did give away that Michael was on a drip the night he died:
Detective Smith: The same dose?
Dr. Murray: The dose and the drip. Not the same dose in this case, because I had given him earlier Versed. I had given him the Ativan (Lorazepam) at different times during the night. And I know that their half-life is not as short as Lorazepam. So I took a precaution, knowing that there was possible all of the medication still on board. So the 25 milligrams ordinarily would not be a dose I would give him if he did not have those other agents on board. I would give him a higher dose.
Detective Martinez: Oh, okay. So it’s a lower dose than normal.
Dr. Murray: Yeah.
Detective Smith: What have you – what’s the highest amount of milk you’ve given him in the past?
Dr. Murray: Well, based —
Detective Smith: If these other agents weren’t in him?
Dr. Murray: Based upon his weight, it would be weight based.
Detective Martinez: Uh-huh.
Dr. Murray: And the highest amount I’d given him initially, direct on the IV before starting the drip on him, would be twice that amount, which is about 50 milligrams.
Detective Smith: So it was approximately half of what you’d given him before.
Dr. Murray: Yeah.
Later Murray changed his story and in the 2011 film the drip was vehemently denied. The film shows Flanagan trying to dispute this point at the trial but the prosecution expert witness Dr. Alon Steinberg absolutely disagrees with him.
Murray is outraged by Flanagan and says he should have asked him, but what’s the use of asking if Murray himself said to the police that it was a drip? Here is an excerpt from the film:
34:45 Voiceover: By week 3 of the trial the testimony of the prosecution expert witnesses is devastating.
Dr. Nader Kamangar: Propofol isn’t management for insomnia. It’s inconceivable.
Voiceover: In 2009 Murray gave a statement to the police in which he set out how he used propofol with Jackson. The prosecution’s interpretation of this statement is hotly contested by the defense, but Michael Flanagan is struggling to make any headway.
35:15 Flanagan: He never said he gave a drip.
Dr. Alon Steinberg: I disagree with you. He gave a drip. It says here. Dr. Murray goes: “The dose and the drip”. Line 22. He says it. This is about that night. Same dose AND DRIP.
Flanagan: Didn’t you understand it to be referring to what he’d handled before?
Dr. Alon Steinberg: No, I don’t see it that way.
35:55 Murray (sounding outraged): Flanagan needs a wake-up…. This is why I said I’m available! Ask me questions, I am the source. Talk to me, spend time with me, get to understand it. I’m available…
I will never tire to repeat that Dr. Shafer proved in still one more way that Michael was on a drip that night. He made a computer simulation and explained that since Propofol breaks up extremely quickly, when the drip is over in some 15 minutes or so would be completely gone from the system.
But in Michael’s system it did stay and it saturated his tissues so much that propofol was found even in his eyes. This drowning in Propofol could happen only if the drug flew into the veins of an already dead man and dripped there for a long time….
THE TUBING IN MURRAY’S POCKET
Some are still disputing the drip factor as the long tubing found on the scene did not have Propofol inside it and was attached to a saline bag. Since the long tubing with traces of Propofol was missing it is natural to assume that the drug was injected into a side port by means of a syringe. Propofol was found in the short tube only, at the very bottom part of the IV drip set-up.
To explain the drip arrangement I’ve made a sort of a diagram which has already been posted in the comments on another post. Here it is once again.
This picture shows that Propofol could be administered via several routes – 1) from the 100ml bottle in the bag, 2) from a syringe on the side port and 3) from both syringe and the bottle.
Hypothesis No.1: Propofol was given by a syringe and there was no second tubing at all.
Possible? Possible, but to be able to reach the level of Propofol in MJ’s blood and urine one had to make at least 20 undiluted 10cc syringe injections or 40 injections of Propofol diluted with Lidocaine. This hypothesis is ruled out as absurd.
Hypothesis No.2: Propofol went from the bottle in the bag and the tubing was missing on the scene of crime because Murray hid it.
Possible? Absolutely. This hypothesis explains the high level of Propofol in the blood and urine, and Murray was seen by Alvarez disattaching the tubing from MJ’s knee. This is when he could easily put part of the tubing into his pocket. The bottle in the bag he could not hide in a pocket, so he put it in a bag which he hoped to retrieve later. This is why he wanted to return to Michael’s house after the hospital.
The hypothesis is absolutely valid and was used as the main one at the trial.
Hypothesis No.3: Murray put MJ under a drip and went away. Someone in his absence came up, clapped the tubing to stop the flow from the bottle, pushed a syringe or two into a side port instantaneously raising the level of propofol in the blood to a lethal level, then unclapped the tubing again and it continued to drip.
Another variant of the same is that this someone unclapped the tubing to let Propofol flow freely from the bottle (raising it to a lethal level this way) and then brought it back to the old dripping mode so that Murray did not notice it. Or did not bring it back to the old mode as Murray would not notice it anyway.
This hypothesis will work only in case of a murder scenario, committed by someone else (or Murray?). To prove it we need other evidence testifying to the same.
At the moment this evidence is scarce though there are some clues – for example, the fact that Murray’s girlfriend Alde Salding heard some mumbling and couphing in the room when she was on the phone with him at around 12 o’clock.
Another unaccounted for fact is that the bag holding an empty Propofol bottle had four other fingerprints which could not be matched to any of the people who had been to that room. Similarly the other two saline bags and two more 20ml Propofol bottles carried some unidentified fingerprints on them too.
Hypothesis No.4: MJ himself put the bottle in the bag and unclapped the tubing.
A possible hypothesis? Absolutely not.
Firstly, Michael received not one, but more than two 100 ml bottles that night (judging by the quantity of propofol in his urine).
Secondly, after he woke up from the first bottle he was supposed to relieve himself into a jug and walk with all that tubing and IV stand attached to him into the side-room to get the second bottle and all this time Murray did not see or hear a thing? If someone with a vivid fantasy says that it is possible, here comes the third factor.
And the third factor is that there were no MJ’s fingerprints anywhere on those bottles, syringes, etc. It is crazy to assume that he would put latex gloves in order to make a slit in the bag, put a bottle there, then unclap the tubing and adjust the drip (difficult job), then lie on the bed and still have time to take the gloves off – and all this though Propofol works almost instantaneously!
The USA Today article says that testing did not show Michael’s fingeprints on any of the evidence:
Fingerprint mystery surfaces in Jackson doctor’s trial
By Martin Kasindorf, Special for USA TODAY
Posted 10/6/2011 1:22 PM ET
LOS ANGELES — Mystery over potentially critical fingerprint evidence descended Thursday on the manslaughter trial of Michael Jackson’s personal doctor.
The mystery surfaced when prosecutor David Walgren announced that his office and defendant Conrad Murray’s lawyers had accepted Los Angeles Police Department fingerprint test results on 23 items of medicine and medical supplies collected at Jackson’s home after he died on June 25, 2009.
Murray is accused of negligently giving Jackson, his only patient at the time, a fatal overdose of the powerful surgical anesthetic propofol while treating the singer for insomnia. Murray’s defense lawyers say Jackson self-administered the drug while the doctor was briefly away from Jackson’s bedside.
A three-page document Walgren read aloud in court said that a print matching Murray’s left index finger was found on a 100-milliliter bottle of propofol. Los Angeles County coroner’s investigator Elissa Fleak testified Wednesday that she had found that bottle four days after Jackson’s death within a saline IV bag. Both items were in a blue Costco Wholesale bag on the shelf of an armoire in the large walk-in closet adjoining the bedroom where Jackson was stricken, Fleak said.
But fingerprint testing of the saline bag did not reveal a Murray fingerprint, the document introduced Thursday said.
On the bag, police criminalists found four identifiable prints but could not match them to any person, the document said.
Testing specifically ruled out Murray, Jackson and 10 others known to have been in Jackson’s mansion at or shortly after his death. Those eliminated included two security guards, Jackson’s personal assistant, his personal chef, Fleak, an emergency paramedic and other investigators.
What use the prosecution or defense makes of this fingerprint evidence remains to be disclosed at the trial, which was in its eighth day Thursday. The evidence does raise questions about who was in Jackson’s bedroom the day he died.
Fleak’s thumb print was found on a syringe she had seized as evidence, the document said. Fingerprints that could not be matched to anyone also were found on two other saline IV bags and on two smaller, 20-milliliter bottles of propofol.
No prints were obtained from 17 other items, including IV tubing, a syringe with needle and vials of propofol, lorazepam, lidocaine, midazolam and Flumazenil.
The fact that Murray’s fingerprints were not found either (except for one fingerprint on the 100ml bottle) should not surprise anyone – Murray was supposed to work in latex gloves as Propofol requires strict aseptic technique.
So out of these four scenarios hypotheses No.1 and No. 4 are even theoretically impossible, hypothesis No.3 is intriguing and technically possible but needs proof, and it is only hypothesis No.2 which is a totally realistic and a rock solid one.
And this hypothesis says that Murray put Michael on a drip.
THE WEANING OFF THEORY IS FALSE
The fact that on his last night Michael was on a drip refutes Murray’s story about “weaning him off” propofol in the last three days of his life.
Murray says that he wanted to replace Propofol with Lorazepam (Ativan) and Midazolam (Versed) and even claims that on the two successful rehearsals were due to the exclusive use of those benzos.
The 2011 film retells Murray’s story and says that Ortega was finally “happy”:
36:00 Rehearsal footage of Michael Jackson is submitted as evidence of his well-being. It was recorded after the crisis meeting at Michael’s house and according to the doctor after he had started weaning the pop-star off his reliance on propofol. Two nights before Michael’s death, Murray claims, he finally got Jackson to sleep without administering any propofol. Jackson’s performances in those final days were a transformation.
Ortega: He entered into rehearsal full of energy, full of desire to work, full of enthusiasm, and it was a different Michael. We had two very successful days of rehearsals. Michael was feeling great. He looked at me and asked me if I was happy, and I said I was happy, and I asked him if he was happy and he answered that he was very happy.
The weaning off theory is false and not only because Propofol was delivered at least on one of those three last nights but also because Murray, as we already know it, was planning to use those benzodiazepines from the very start of it.
The invoices of shipments from the Allied Pharmacies where Conrad Murray was ordering medications show that he ordered Lorazepam and Midazolam in one of the first shipments – on April 30, 2009 when Propofol wasn’t even an issue and there was nothing to wean Michael off.
All in all there were three shipments of Lorazepam and Midazolam:
- On April 30, 2009 Murray received one tray of Lorazepam 10 vials x 10 ml (altogether 10 vials) and two trays of Midazolam 10 vials x 2 ml each (altogether 20 vials of it).
- 20 more vials of Midazolam were shipped on May 12, 2009
- And on June 10, 2009 10 vials of Lorazepam and 20 more vials of Midazolam were shipped again.
Altogether the Applied Pharmacies supplied 20 vials of injectable Lorazepam (80ml) and 60 vials of Midazolam (Versed) amounting to 120ml.
Murray said to the police that he had been giving Michael those substances for a long time, only in lesser quantities than in the last three days.
Both were found in Michael’s body on the night of his death.
And though Murray claimed that he gave only 4ml of Lorazepam that night, many hours after the injection the amount of it in Michael’s blood was still very high – 169mcg.
Murray’s defence argued that Michael could have taken a handful of Lorazepam pills from the bottle on his bedside table, but the self-administration theory was ruled out as the prosecution provided proof that MJ’s stomach contents contained only 1/43rd of one Lorazepam pill.
The levels of Versed and Valium were not clinically important but the question here is whether there was any necessity in them at all. Valium was prescribed to MJ by Murray on June 20th – immediately after the crisis meeting (?)
From what I’ve read about benzodiazepines the damage from them could be much heavier than that from Propofol and a respiratory arrest is only one of their many complications.
But the worst part of it is that those highly potent and dangerous benzos were given to Michael absolutely despite his will.
Murray admitted to the police that Michael agreed to the two benzos replacing Propofol reluctantly and actually fought him over the use of those medications.
Here is an excerpt from the police interview:
Detective Martinez: And you’re trying to bring down the Propofol and –
Dr. Murray: And get him off.
Detective Martinez: Right. And so you gave him —
Detective Smith: — Lorazepam and —
Dr. Murray: Lorazepam and the Midazolam, which is the Versed and the Ativan. Okay?
Detective Martinez: And he knows — he agreed for you to do this.
Dr. Murray: Reluctantly.
Detective Martinez: Okay.
Dr. Murray: Reluctantly. He fought me on it, and he said, “You know, I mean would it work the same way, because I” – but that was showing me some dependency here. “Would I be able to sleep?” I said, “Well, you know, clearly it is not as strong an agent. But if we can help you to sleep more naturally and then eventually you can be on your own, milk and cookes and all the different things that is nice and comforting before you go to bed, that would be better for you, Michael.” And he said, “Well, I really want to – but I really want to sleep. Sleep, but I’d like you to try.”
Mr. Chernoff: .. I think, the Detective is asking before those three nights, had he ever used the Versed?
Dr. Murray: Yes. But not where that would be the sole agents.
Detective Martinez: Okay.
Dr. Murray: Trying to —
Detective Martinez: So he’d use them in combination –
Dr. Murray: Yeah.
Detective Martinez: – And lesser amounts.
Dr. Murray: Lesser amounts. I never identified to him that I believed at that time he may — he was showing dependency or that he may have been drug seeking, because I was trying to form a different policy with him so he can transfer confidence from that agent to something lesser. So I gave him the Versed the third night. I gave him Versed, and I gave him Ativan, and I gave him a lower dose of the injection of the — of the Propofol milk I – at a slower dip rate.
So again Murray says that on the third night he let Propofol dip, but at a slower rate.
And it’s only now that I notice Murray saying that Michael allowed him to try those benzos on those last nights. Does it mean that he didn’t even know that Murray had already been giving him those drugs earlier, only in lesser amounts?
So he didn’t want those benzos and agreed to them reluctantly…. No autopsy report will ever tell you that Conrad Murray was forcing Michael to take those medications. Michael was fighting Murray over them and at some point of my little study I even found why.
What I learned about Versed, for example, was a complete shock to me.
THE SHOCK OF VERSED
The first thing I found about Versed [Midazolam] is that it cannot be used for any “weaning off” anesthesia as Versed is actually part of anesthesia too.
Versed is a pre-operative drug given at the induction stage of anesthesia. Dr. Adams also used it just once in order to reduce Michael’s anxiety connected with the dental surgery.
The indications for Versed pre-operative use are anxiety and inducing an amnesia so that the patient does not remember the unpleasant procedure. But besides the ability to wipe a patient’s memory which was absolutely unnecessary and even harmful in Michael’s case, it also has one other specific feature and is is the ability to keep the patient sedated but awake.
Versed was specifically created for the so-called “conscious sedation” when the patient stays awake and conscious in order to cooperate with the doctor during the procedure (for example, during colonoscopy).
Here is the description of Versed given by the anesthesiology website:
The majority of colonoscopies in the United States are performed under conscious sedation. Conscious sedation is administered by a registered nurse, under specific orders from the gastroenterologist. The typical drugs are Versed (midazolam) and fentanyl. Versed is a benzodiazepine, or Valium-like medication, that is superb in reducing anxiety, sleepiness, and producing amnesia. Fentanyl is a narcotic pain reliever, similar to a short-acting morphine. The combination of these two types of medications renders a patient sleepy but awake. Most patients can have minimal or no recollection of the colonoscopy procedure when under the influence of these two drugs.
Actually the above recommendation of Versed from a professional anesthesiologist is absolutely superb in its clarity – it reduces sleepiness and (in combination with a painkiller) renders a patient sleepy but awake.
Just apply it to Michael Jackson and you will see how inappropriate the use of Versed was for his case.
Also please remember that usually Versed is administered just once, prior to surgery and at the rate of 4-8ml only, while Michael most probably received Versed each time Murray was giving him Propofol and by June 25th he could easily use up the whole lot of 120ml he had.
And on those three final nights Murray claims to have given Michael an even bigger quantity of Versed together with Lorazepam as he wanted him to sleep with that combination.
And if we are to believe our good old ignorant Murray Versed was the medication he wanted to replace Propofol with.
In other words he wanted Michael to SLEEP with a drug that is actually intended to keep patients AWAKE.
Is it possible to think of anything more ridiculous and damaging than that?
However this is not all I’ve learned about Versed. There is even a special blog on this drug where the Versed victims are sharing their experience with others and the anesthesiologists who occasionally visit it are extremely surprised to learn of its adverse effect.
From what the Versed victims are saying I even have the impression that most of the symptoms Michael was increasingly displaying were due to his progressive poisoning with Versed and not Propofol.
In short the information from that blog is unique and will require a separate post.
* * *
The other posts in this series:
- Conrad Murray’s crazy lies or HOW HE KILLED MICHAEL JACKSON
- Conrad Murray, THE MAN WHO KILLED MICHAEL JACKSON. Part 1 about some British films
- Conrad Murray, THE MAN WHO KILLED MICHAEL JACKSON. Part 2 on Dr. Adams as another option