Thursday, January 27, 2011

Dr. Conrad Murray's Death Drip: Explained - - Part 3

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This is a GUEST ENTRY by KZ. KZ, a CRNA, is giving T&T readers her analysis of the events that apparently caused Michael Jackson's death, based on the evidence presented at the preliminary hearing. Sprocket

Conrad Murray's Death Drip: Explained
Part 1 - IV Technique: Tutorial on the Basics
Part 2- The Evidence: What we think we know
Part 3 - The Lies: Conrad Murray's words and actions
Part 4 - Putting it all together: What I think really happened

This is the third part of a 4-part series examining Conrad Murray's (CM) administration of propofol to Michael Jackson (MJ) in MJ's private home.

My report of the evidence in this article, and my conclusions are the result of my own critical thinking and speculation. I did not sit in the courtroom listening to testimony, nor have I seen any actual evidence or photographs of evidence in this case, and I don't know a single person connected to this case. So, as a disclaimer, think of this article as a couple of us private citizens gathering at Sprocket's home for some great conversation, coffee, and dessert. (And I hear Sprocket is a generous and gracious host!)

Part 3 will discuss the myriad lies CM has told and promulgated as they pertain to his administration of propofol to MJ. To clarify, my personal opinion is that CM is an accomplished liar-- beginning with a string of mistresses and out-of-wedlock children that he had difficulty "remembering" to support financially. To be sure, $150,000 a month is a potent incentive, IMO, to do a lot of things that one might not do for other, less wealthy or less prominent people. Trouble is, once I started looking, I found so many lies that I really don't have time to discuss ALL of them. So I had to make a command decision to just focus on a few (ok, 10) of the really BIG whoppers that lead directly to the Propofol Death Drip that CM absolutely denies he ever had hanging the morning of June 25, 2009. So, that leads us to lie #1.

Part 3 - The Lies: Conrad Murray's words and actions

Lie #1:
Conrad Murray was providing LEGITIMATE medical care for MJ's intractable insomnia by dosing him with injectable propofol and injectable benzodiazepines EVERY NIGHT for at least 8 weeks. (The lie is that it was legitimate medical care. I absolutely believe MJ had insomnia.)

Testimony of Orlando Martinez, Law Enforcement Officer who conducted an official recorded interview with CM and his attorneys.

"In describing these evenings, last couple days, did he tell you he’d been giving MJ propofol every single night for over 2 months?

This is a cut and paste of my comment January 21, 2011 9:22 AM, from the thread discussion from Part 1- IV Technique: Tutorial on the Basics.
I'd like to address the issue of "standard of care." This really amused me when I read that line of questioning from the prelim, because to even begin a conversation about what IS or IS NOT standard of care, one has to agree that what Murray was providing met a definition of some kind of LEGITIMATE medical care.
To begin at the very beginning, propofol has absolutely no indication, on-label or OFF label, or in published or anecdotal literature, for use in the outpatient or home setting, for the reasons Murray said he was using it-- treatment of insomnia. So, to suggest or imply that there is some kind of standard of care for a cardiologist, anesthesiologist, CRNA, doctor, lawyer, nurse, or layperson to administer propofol to someone in a private home would be to give in to the urge to analyze Murray's actions AS IF they were legitimate medical care. NOTHING about what Murray did constituted legitimate medical care. The use of injectable propofol and injectable benzodiazepines in a HOME setting for relief of insomnia in a presumably healthy 50 year old man IS NOT MEDICAL CARE.
So NO, there is NO standard of care for what Murray was doing. That is the whole point. Just because Murray sports "M.D." after his name does NOT mean that anything he wants to do outside of a hospital is legitimate medical care. We do not treat ANY patients IN hospitals for insomnia with injectable propofol, so how can there possibly be a "standard of care" for Murray to do this in a private home? Even if Murray had carted in truckloads of monitors and equipment, and converted the "treatment bedroom" to a fully functional operating suite, he would STILL not have met any standard of care, or have been in compliance with any legitimate use of that drug! EVEN if he was an anesthesiologist!

And I will say this again, also: Conrad Murray would NEVER have received clinical privileges in ANY hospital to do what he was doing in that bedroom. The letters M.D. after his name are NOT sufficient to receive clinical privileges to administer sedation and/ or anesthesia in a hospital-- he would have had to document a bunch of training and education to receive those privileges, and document a legitimate need to have the privileges, as a cardiologist. Even then, the insurance carriers, hospital medical staff committee, and hospital attorneys would have a LOT of heartburn about giving him privileges to personally perform sedation and anesthesia in a hospital.

Let me say it again: there is NO legitimate medical indication for the use of propofol and boatloads of injectable benzodiazepines in a home care setting for the treatment of insomnia in a healthy 50 year old person! Therefore, there is NO standard of care to be met. That is precisely why Murray's actions were criminal, and not "mere" civil negligence.
And if the defense thinks they can find a Board Certified Cardiologist expert witness who will come in and say that what Murray was doing met the standard of care for a Board Certified Cardiologist who was treating a patient at home for insomnia by using IV propofol, well, GOOD LUCK with that search, defense team! How many Cardiologists are going to stick their neck out for Conrad Murray on this one? That would be professional suicide.

Lies #2 & #3:
Conrad Murray was trying to wean MJ off of propofol. (Stop laughing, I can hear you.) CM was giving propofol to MJ as a treatment for insomnia. (Lie #3)

To save some space, please refer back to Part 2- The Evidence: What We Know from the preliminary hearing testimony. 4 gallons of propofol ordered in about 8 weeks time for only one intended recipient (not patient; see Lie #1 above) is not a pattern of weaning anybody off of propofol.

Or if it IS, someone please explain this to me. Because I'm just a lowly CRNA. I can't possibly be expected to understand the complex logic and verbal gymnastics that spin this situation into legitimate medical care. Defense team-- go for it! We all have our listening ears on and are sitting quietly with our hands folded.

And I am personally outraged that he was so meticulous in his ordering of propofol and benzodiazepines, but this CARDIOLGIST did not order any CARDIAC LIFE SUPPORT medications from that pharmacy. Why? Because he simply never anticipated that he would need them. We'll talk about hubris in a minute.

Questions for Conrad Murray:
Who did you consult about your concerns about MJ's propofol use? Who advised you to continue to give him propofol? Did you consult any specialists with specialized knowledge about propofol addiction, or daily propofol abuse? Or did you make the decision to give MJ propofol on your own? What sources or references can you show us that support the use of IV propofol for the treatment of insomnia in the home setting? Who are other peers, doctors, or Cardiologists, who are using IV propofol in a home setting for the treatment of insomnia? Who have you talked to about using propofol in this manner? Have you published any anecdotal reports in peer reviewed journals about the emerging indications for IV propofol as a home care treatment for severe insomnia? Are you conducting investigational studies about using IV propofol as a home care treatment for insomnia? Please show us any notes or records you have about using IV propofol at home as a treatment for insomnia.

As to Lie #3, that propofol was somehow a legitimate treatment for insomnia, I will offer that Murray's goals for his treatment (benzodiazepines and propofol) was to induce a level of unconsciousness equivalent to a general anesthetic. Heavy use of benzodiazepines and propofol, and other poly-pharmacy, tend to upset the body's natural ability to sleep. Anesthesia is NOT the same thing as sleep.
General Anesthesia More Like Coma Than Sleep

According to a review of general anesthesia, sleep, and coma in the Dec. 30 online issue of the New England Journal of Medicine, coma and general anesthesia appear to share key similarities. The researchers found that when patients are under general anesthesia, their brain is not "asleep" but instead enters a state comparable to a reversible coma. In the review, the three doctors—each specializing in one area of the study—discuss how a fully anesthetized brain more closely resembles the deeply unconscious brain that is seen in coma patients and is less like that of a sleeping brain. They go on to conclude that being under general anesthesia is tantamount to being in a drug-induced coma, in which states of consciousness and unconsciousness operate on different time scales. The researchers hope the findings will help to create new approaches to general anesthesia and improve the diagnosis and treatment of sleep abnormalities and emergence from coma.

From "General Anesthesia More Like Coma Than Sleep"

Medical News Today (12/30/10) Paddock, Catharine

Lie #4:
Conrad Murray was guilted, manipulated, finagled, finessed, maneuvered, persuaded, railroaded, arm twisted, tricked, fooled, or otherwise "FORCED" into giving propofol to MJ. Lots and lots of IV propofol. Over and over. Every night for AT LEAST 8 weeks straight, by his own report. And four enormous pharmacy orders, just for MJ. (And I'm havin' a really hard time mustering up sympathy for CM here.)
CM's 4-Part plan of care related to propofol should have been:
1. Say "no."
2. You are a big, strong, tall DOCTOR. Walk away, DOCTOR, walk away.
3. Just say NO!
4. Get this man, MJ, your PATIENT the care that he so DESPERATELY needed.

If CM had done any of the above four things, MJ might still be alive.

Conrad Murray has seven children
. Wouldn't you think at one point, during a parenting moment, he would have had to say "NO"? So, he should be very practiced at saying "NO", right? What am I missing here.....hmmmmm.....oh yes. A little incentive in the amount of $150,000 A MONTH. That might be just a wee bit persuasive, if one is inclined to be unethical.

Lie #5:
(Paraphrased) I'm just giving him a little bit of propofol....really...... I gave him 25mg at 10:40 or 10:50. That shouldn't have killed him.

Testimony of Orlando Martinez; L.A. Robbery/ Homicide
Being questioned about the interview 6-27-09 with Mr. Pena, Ed Chernoff, CM, and Detective Smith.

(KZ note: it is a bit uncertain to me which person Martinez is describing as answering questions here, but it appears CM is present during the interview at the hotel.)

How did he say he was assisting?
He would assist Mr. Jackson with 50 milligrams of propofol. An injection to get him to sleep and with an IV drip to keep him under.

"Initial infusion followed by a drip? Objection. Sustained.

You mentioned 50 milligrams, did he say that was 50 milligrams every night?
That was the maximum.

Did he say that was the total or the amount of one dose? ???
I don’t think he specifically noted.

He told me it was a dosage, to put him under and then a specific drip."

(Testimony snipped.)

"In describing these evenings, last couple days, did he tell you he’d been giving MJ propofol every single night for over 2 months?

(Testimony snipped.)

"10 am June 25th 2009, according to Dr. Murray, what is happening?
MJ was still awake, and was asking for “milk” which was his name for propofol.

Around 10:40 or 10:50, did he give propofol (according to Dr. Murray)?

Did he look at his watch?
Yes. According to Dr. Murray he had to look at his watch, to calculate
(miss last)

He said he halved his normal dose, gave him only 25 milligrams over 25 minutes.
It was simply an injection to put Mr. Jackson asleep, and then a slow drip to keep him asleep."

Okay, time for another math lesson.

Please refer back to Part 2: The Evidence for the initial math explaining the amount of drug found in MJ's blood at autopsy.

We know that an induction bolus dose of approximately 150mg for a 62 kg person (which is 2.5 mg/ kg) will produce blood levels of (averaged) approximately 4.0 micrograms per ml of blood volume.

Range is 1.3 to 6.8 ug/ ml......1.3 + 6.8 =8.1......8.1 divided by 2 = 4.05

So, rounding off, 4 ug/ml as the average of what we know should be produced by an induction bolus of 2.5mg/ kg of propofol.

Therefore, we can construct an equation using that ratio to determine what the micrograms per ml should be using a different, smaller dose. Let's use a 25mg dose, since that is what CM claims to have given at 10:40 or so.

We can construct a proportional ratio equation using algebra and cross multiplying:

150mg..=..4.0 ug/ml
25mg..............x..........150x = 100.....100 divided by 150 = 0.67 ug/ ml

Now, let's assume CM is actually telling the truth. (No snickering-- I can hear you.) So let's take him at his word that he did not give MJ any propofol the morning of June 25, 2009, UNTIL the dose at 10:40 or 10:50. He reports he gave MJ 25mg.

MJ's results at post mortem, from the autopsy report. Summary of Toxicological Findings

Heart: 3.2 ug/ ml
Hospital: 4.1 ug/ ml (possibly from a venous draw during or right after attempted resuscitation)
Femoral: 2.6 ug/ ml

To recap, 0.67 is a whole heckuva lot less than 3.2, 4.1, 0r 2.6.

Without question, MJ received a whole lot more propofol than CM's 25mg dose, that he embellished with pushing over "2 to 5 minutes". (Yeah, right-- using a 10cc syringe??) Even with that detail embellished, that he gave the 25mg over 2 to 5 minutes, well, the person would still have been talking to him at that rate. Pushing 25mg over 2 to 5 minutes would NOT put even an average person who has not been exposed to daily propofol to sleep.

Hmmmm........I'm beginning to get VERY suspicious about the "IV bag with bottle" that CM directed Antonio Alvarez to take down and placed (hid) in the blue costco bag that was found by Elissa Fleak. How about you?

And lest we all get too wrapped up in the math about whether or not the amount of propofol in MJ's body at autopsy was too much, too little, or just right, let me emphasize AGAIN that there was NO legitimate medical reason for ANY propofol to be administered to him in his home. Even by a doctor.

Lies #6, #7, and #8:
Dr. Murray, a Cardiologist, believed successful resuscitation from asystole was possible at UCLA Medical Center. He was frantic to reach the hospital quickly so that advanced measures could be utilized to successfully resuscitate MJ. (Lie #6.)

Well, he was certainly frantic, but not because he didn't have an intra-aortic balloon pump (IAPB) available in the "treatment" bedroom of the rented mansion.

He was frantic to start cleaning up all of the evidence of the propofol, as we have heard from Antonio Alvarez. So frantic, that calling 911 must have slipped his mind for 20 minutes or so. So frantic that he forgot that 20 minutes of pulseless arrest means the victim has virtually no chance of being successfully resuscitated, and if his heart is miraculously restarted, his brain is very likely mush. So frantic that he, a Cardiologist, panicked and forgot how to do proper CPR. So frantic he forgot that there was an ambu bag present in the room.

Cardiologists are extensively educated in all manner of the anatomy and physiology, health and disease processes, of the human heart. It's their primary business.

When paramedics hooked up the cardiac monitor to MJ in the bedroom of the mansion, and he saw aysytole with occasional agonal spasms of PEA (pulseless electrical activity), he knew his patient was dead. Unless Conrad Murray was asleep in every single class he ever took related to Advanced Cardiac Life Support, and also slept through his entire internship, fellowship, and board certification process, HE of all people at the scene KNEW the likelihood of resuscitation for MJ was essentially zero. He knew, when he saw asystole, and a few errants bits of electrical activity, that the game was over. And he KNEW at that moment that he had been out of the room yakking on his cell phone for FAR too long.

Make no mistake-- Conrad Murray KNOWS that asystole with bits of agonal PEA in a 50 year old man with a healthy heart is a very LATE stage of cardiac arrest. There was NO doubt in Murray's mind about what he was seeing. There was NO doubt that the asystole was from any other cause than a long respiratory arrest that deteriorated into a long cardiac arrest. Murray KNEW the window for successful resuscitation was past. But he didn't want to be the one to both CAUSE the cardiac arrest AND call the code and pronounce the victim dead.

Asystole at Wikipedia

So he LIED (Lie #7) again to the paramedics and didn't tell them all the meds MJ had received, most especially, propofol. So they loaded up the ambulance and headed to UCLA Medical Center.

Where CM LIED (Lie #8) again, to multiple members of the ER resuscitation staff, who asked him for a history of the arrest, and what meds the victim had received. Again, that propofol seems to have slipped his mind. Ask yourself, WHY would a DOCTOR who is certain he provided appropriate care, LIE about the meds he gave the victim?

Lies #9 & #10:
Dr. Conrad Murray could not possibly have foreseen that any of his actions surrounding the administration of propofol to MJ could have caused the death of MJ. (Lie #9)

(To be accurate, Lie #9 has been told and promulgated by CM's defense attorney on CM's behalf, but I'm including it here anyway.)

If that is true, then Conrad Murray is the dumbest doctor on planet earth, IMO. A layperson or elementary school student could have foreseen that death was a possibility in that bedroom, using an IV surgical anesthetic to help a man in his home, battle "insomnia". How is it remotely possible that CM did not anticipate death could be a possible outcome?

Hubris. And $150,000 a month.

Hubris whispered to CM that he was a big, strong, smart, important, infallible DOCTOR. Hubris told CM he could do whatever he wanted to do in the name of medical care in that private home. And the laws allowed CM to do just that. Until we change the laws about what doctors are allowed to do in private homes and offices, these situations will continue to happen, and people who trust these "doctors" will be hurt, or die as a result of their incompetence. We have extensive safeguards in place that regulate the practice and credentialing of doctors in hospitals and clinics; we minimally regulate procedures provided by doctors in private homes, or in their offices.

For the safety of the public, I strongly support more regulation of doctors in the activities they perform in private homes and offices. Doctors should not be able to do procedures and give drugs in their offices or private homes that they would not be able to receive hospital privileges to perform. Whether we like it or not, there was nothing illegal about CM ordering 4 gallons of propofol from a compounding pharmacy. The pharmacy did not have to notify ANY agency that this activity was occurring. No agency had oversight responsibility to make sure there was a legitimate need for that much propofol in the "clinic" of a Cardiologist. Apparently, there is nothing illegal about shipping that propofol through the mail or using a cargo carrier like FedEx to ship that dangerous drug to a private apartment. And yes, he lied (Lie #10) to the pharmacist Tim Lopez about THAT, too, and said the address was a "clinic" in L.A. Why did he lie if it was legal? Hmm. "Wherever I am at the moment, or wherever I'm going, is a clinic." Hubris.

We should all be enraged that what he did was LEGAL. Right up until he killed the person he was giving it to. The district attorney has called that involuntary manslaughter. A lot of us think it should have been charged as second degree murder. I really wish someone could explain to me why it is that a person who is driving under the influence and kills another person, is charged and punished more harshly than a DOCTOR who invents a new "off-label experimental" use for a dangerous anesthetic in a private home, and KILLS his victim?? Yeah...maybe that will be the defense strategy-- Conrad Murray was investigating a new off label use for propofol. I'm looking forward to reading that in a peer reviewed Cardiology journal. CM should have a couple of years to write it up while he rests in prison, hopefully.

The biggest gift Conrad Murray has ever received in his life was the charge of Involuntary Manslaughter, in my opinion. That gift says he was simply too stupid and oblivious to realize that the totality of what he was doing could have caused another person's death. So in that respect, I guess the charges are correct.

As a post script, I would like to take a moment and say that despite my ire, it is not doctors I am upset with. It is this particular doctor's conduct that invokes my indignation. Incompetence and recklessness from any health care provider invokes my outrage and indignation, on behalf of the vulnerable patients who are harmed. Competence or incompetence has little to do with the letters after the name of a health care professional. A doctor is not automatically competent simply because he has M.D. after his name.

There are competent and incompetent practitioners in every profession. My profession, Nurse Anesthesia, is forever proving that our outcomes are excellent, and that we provide competent care, and yet there are still "attacks" on my profession from those who opine that we could not possibly be knowledgeable and competent, because our basic education did not occur in a medical school. Fortunately, the tide is turning, and laws are slowly changing to recognize that the overlap between some professions is simply a turf war over money that has nothing to do with safety, outcomes, or competence.

And yes, this Nurse Anesthetist dares to say that Conrad Murray, M.D. IS an incompetent, arrogant fool, who recklessly killed his victim. (Victim, not patient.) The victim just happened to be a famous musician named Michael Jackson, or none of us would ever have heard of Conrad Murray. Hubris.

Thanks for reading! Part 4: Putting it all Together: What I think Really Happened, will be out soon!

Casey Anthony's Defense Asks For Delay

January 26 was the deadline for Jose Baez and his fellow defense team members to file all the expert reports ordered under sanction by Judge Belvin Perry.

Foolish me, I expected that Mr. Baez would have gotten the message Judge Perry sent and get the long over-due reports in. It didn't happen. Instead, Baez filed a Motion For Extension Of Time To Comply With Order For Expert Witness Reports! Later the same day, he filed a Notice of Unavailability for February 21-25.

Notable is the fact that notice states that

2. The undersigned request that no appointments, mediations, depositions, conferences, hearings or other legal proceedings be scheduled during that time.

I find it interesting that the "undersigned" is initialed as "WCS", and the names of Jose Baez, Michelle Medina, and William C. Slabaugh follow the signature.

Given that Monday, February 21 is a Federal Holiday, that leaves 4 work days during the month the State is supposed to be doing depositions. Their current deadline is February 28. The defense obviously feels that Judge Perry will willingly grant their 45 day extension and everybody else will have to stop working the case while he and his staff are "otherwise occupied". Casey Anthony has three other outstanding attorneys who could pitch in for 4 days! Why can't Cheney Mason, Ann Finnell, or Dorothy Sims take care of depositions? I would think Ms. Sims would want to be there anyway, since they are expert witness depositions.

As I've been contemplating the motion for the extension of the deadline, I've been listening to the January 3 hearing in which Judge Perry ruled with the State for sanctions. Baez & Co. managed to delay further by filing a Motion for Reconsideration. That motion dragged the issue out until January 20, when Perry made his ruling denying it.

With this background, it is astounding that the defense has not fully complied with the judge's order.

In the motion, Baez indicates that the defense has "...made a good faith effort to comply" with the January 6 order. Another phrase used to describe compliance is that they have "substantially complied in part...".

At this point in time, the defense has supplied the reports of Dr. Jan (sic) Bock, Dr. Kenneth Furton, Richard Eiklenboom (sic), Dr. Timothy Huntington, and Dr. Scott Fairgrieve.

Among the missing are reports from:

Dr. Henry Lee -- he will not be called as a witness

Dr. Michael Freemen -- withdrawn from the defense witness list

Dr. Leeson -- will only consult with the defense

Dr. Werner Spitz -- is not available (while the defense put this under seal, it is widely known Dr. Spitz has had surgery and is recuperating) He also has been on the case from the discovery of the remains and did his "autopsy" two years ago. He should have already written a report!

Dr. Barry Logan -- the defense "anticipates" compliance, but they haven't been able to get him on the phone lately

Dr. Bill Rodriguez -- has not yet had the opportunity to review all the information as he was recently retained

Dr. Kathy Reichs -- is traveling and needs more time (although she has been on the case from the beginning).

Baez again cites financial reasons for all these experts not having the opportunity to meet together to "properly consult with and furnish all information needed, in order for them to reach well-informed opinions." Hello, what ever happened to Skype and all sorts of teleconferencing media?

Also, Baez actually puts the blame on the Court for ordering that precludes "testimony that is not either in reports or disclosed in deposition".

The kicker here is that Baez tells the court that he will have a "unique opportunity" to meet with, "Reichs and Rodriguez prior to them rendering their opinions as they may have additional opinions after review of additional material."

Could it be that Mr. Baez has asked for 45 days so that he can travel to Chicago where these two experts will be attending the Forensic Sciences Annual Meeting?

Now, I would love to know how the State is going to reply to this astonishingly audacious document. Will they file an objection? Will they file another motion for sanctions? Will they file a motion for both?

Regardless of what they do, the defense is fighting tooth and nail to avoid completing discovery in accordance with the court rulings and in spite of having already been sanctioned.

Jeff Ashton must be very hot under the collar about this and I'm sure he's conferring with his superiors up the chain of command on how to handle this situation. A beautifully crafted reply takes time and effort to create. I'm just anxious to see it!

I don't even want to think of what Judge Perry is thinking. He will start this trial on time in spite of the devious defense tactics. Will there be sanctions? Will the defense be held in contempt?

Stay tuned for the next chapter of this saga.

Just in! News 13 has just put up a short article about tomorrow's document dump. It seems there will be a lot of information about the investigation of Laura Buchanan. I hope they are right on this. The whole nasty TES situation has been one of my major complaints in this case.

I'm glad we are having a snowy weekend. I can spend my "snow days" reading!

Tuesday, January 25, 2011

Dr. Conrad Murray Arraignment on Involuntary Manslaughter Charges

Dr. Conrad Murray, (right) and his attorney, Ed Chernoff at today's arraignment.

Updated 11:30 am
I now understand why the case is going to trial so quickly. According to the LA Times, Dr. Murray invoked his right for a speedy trial. Judge Pastor commented that it was unusual. I agree. Thanks to Judy for the tip.
First off, I did not attend the arraignment. I knew it would be very short and I did not know beforehand if I would get a seat inside the courtroom. With those odds, I was not willing to dedicate several hours of my day to go downtown for an arraignment that lasts only a few minutes.

Mainstream media (MSM) reports that jury selection will start March 28th of this year. I'm very surprised that a trial date has been set so soon. I would have expected there to be a long delay before a jury selection starts. Hey, I'm not infallible. Understand however, that this date may change once prosecutors present motions to introduce evidence at trial and the defense tries to block that evidence and, vice versa.

Dr. Murray pled not guilty at today's quick arraignment. Or rather, according to E Online, he first said, "I am an innocent man." When Judge Pastor asked again for his plea, that's when he stated his plea of not guilty. Ed Chernoff, one of Dr. Murray's three attorneys gave a brief statement outside the courthouse on the Temple Street Plaza. When questioned by E Online reporter Ken Baker, Chernoff stated he did not know that Dr. Murray would make the "innocent" statement.

Although many Michael Jackson fans have petitioned the District Attorney's office to increase the charges, that has not happened and I correctly predicted that would not happen.

District Attorney Spokesperson, Sandi Gibbons stated that Judge Pastor is considering allowing cameras inside the courtroom. There is a pretrial hearing to hear arguments on the issue scheduled for February 7th, 2011. Dr. Murray does not have to attend that hearing. If a defendant files the appropriate paperwork with the court, he is not required to attend all pretrial hearings in the case. Apparently, Dr. Murray's attorneys have made that filing.

If cameras are allowed inside the courtroom, then I would most likely not cover this case. I "may" try to attend the February 7th hearing, but that's not set in stone. Often it depends on what my personal commitments are at the time.

Added 4:35 PM
Short video from hearing.
(Video was from E! online, and is no longer available. Sprocket.)

Monday, January 24, 2011

Casey Anthony's Defense Gets Funding

Today's hearing was not televised due to the fact that the hearing room where it was conducted is not wired for live broadcast. WESH capably filled the gap with it's LiveWire updates by Gabe Travers. We have been promised video of the hearing, but as of this time it is not available. I will post the link here when it becomes available.

Jose Baez and Ann Finnell both submitted requests for funding. Finell's motion asked for the $5000 cap originally discussed. Check out the financial paperwork she provided to show her expenses. Perhaps Jeremy Lyons could learn a thing or two about bookkeeping by checking them out.

Baez' motion was followed by Lyons' accounting. It is minimal at best. In his motion, Baez complained about all the pages of discovery and additional witnesses provided by the State.

Judge Belvin Perry agreed to grant Finell's motion and he will have an order ready on Friday.

As for Baez' motion, after the usual arguments about all the discovery being dumped on him by the State, Linda Drane Burdick, who was present for the telephonic hearing pointed out that the majority of the material released to the defense has consisted of letters to Casey Anthony, Dominic Casey's e-mails, and transcripts from Laura Buchanan. Ms. Drane Burdick didn't believe there was a whole lot to investigate there.

Nevertheless, the judge granted Baez' motion. Considering that Baez was in the red by about 124 hours, he's not gained all 300 for future use. I'm sure we'll see him back for more.

I'm sorry I haven't been around too much lately. About three weeks ago my husband came down with the nasty stomach virus that's been going around. One week later, I fell victim to it myself. Unfortunately for me, the 24 hour bug lasted a lot longer than that and I've not had much energy.

I've been printing out all the motions and orders that have come down and only have a few things to say. Most of the orders signed by Judge Perry were announced at the January 3rd hearing. Funny, I didn't see an order on the Jib-Jab video!

As for Mr. Kronk, I can finally retire the yellowed stack of papers that comprise that motion and file them away for good. It's amazing that the motion, filed in November, 2009 was never argued in open court. Perhaps the reason is that once the state deposed the witnesses under oath, they didn't have as much to say as they did in the "designer videos" circulated by the defense in 2009. If Mr. Kronk gets grilled on the stand by the defense, it will be more about his August calls and how he figured out where to locate the body.

Our next hearing is Friday, February 4th, less than two weeks away. I wonder how that hearing will go!

Dr. Murray's Death Drip Explained - - Part 2

© Trials & Tribulations 2007-2011. All rights reserved, do not reproduce in whole or in part without the express written consent of Trials & Tribulations.

This is a GUEST ENTRY by KZ. KZ, a CRNA, is giving T&T readers her analysis of the events that apparently caused Michael Jackson's death, based on the evidence presented at the preliminary hearing. Sprocket

Conrad Murray's Death Drip: Explained

Part 1 - IV Technique: Tutorial on the Basics

Part 2- The Evidence: What We Think We Know
Part 3 - The Lies: Conrad Murray's Words and Actions
Part 4 - Putting it all Together: What I Think Really Happened

This is the second of a 4 part article detailing Conrad Murray's (CM) medication administration technique in the care of Michael Jackson (MJ).

Today we will look at the evidence presented from 3 sources: the official autopsy report of the victim, (Autopsy Report at The Smoking Gun) the testimony from eye witnesses describing what they saw, and the testimony from Law Enforcement officers and investigators about evidence and official interviews admitted into evidence. The source that I have used for the passages quoted from preliminary hearing testimony is the transcription prepared and posted here by Sprocket. The transcription is not the official court transcription. To my knowledge, the official transcript has not been released to the public. You can read Sprocket's transcription by using the Dr. Murray Quick Links.

My report of the evidence in this article, and my conclusions are the result of my own critical thinking and speculation. I did not sit in the courtroom listening to testimony, nor have I seen any actual evidence or photographs of evidence in this case, and I don't know a single person connected to this case. So, as a disclaimer, think of this article as a couple of us private citizens gathering at Sprocket's home for some great conversation, coffee, and dessert. (And I hear Sprocket is a generous and gracious host!)

There are 3 individuals who provided testimony during the preliminary hearing that is quite valuable to understanding Conrad Murray's Death Drip technique. Those 3 individuals are: Alberto Alvarez, a member of MJ's personal security staff; Elissa Fleak, a member of the investigative staff of the L.A. County Coroner's office, and Tim Lopez (Pharmacist, owner of Applied Pharmacy Services, Las Vegas), who personally interacted with CM, and filled his orders from the compounding pharmacy where CM ordered medications he used to treat MJ.

We will also look at testimony from Orlando Martinez, L.A. County Robbery/ Homicide Division, the law enforcement officer who officially interviewed Conrad Murray (CM) on 6-27-09, 2 days after the death of Michael Jackson (MJ). The interview took place at a hotel, and was recorded. CM did not take the stand at the preliminary hearing, so this officer's testimony serves as CM's own statements.

Pour a favorite beverage and settle in. This is a long discussion about "what we think we know" from the evidence!

Part 2- The Evidence: What We Think We Know (from preliminary hearing testimony)

To begin, let's look at the autopsy report first. This link (Autopsy Report on The Smoking Gun) is the source I will refer to, and my page numbers correspond to the PDF numbers "1 of 23", etc. on that site.

Page 3 of 23 Autopsy (Elissa Fleak)

"Reportedly, this is the bedroom where the decedent had been resting and entered cardiac arrest. His usual bedroom was down the hall."

This passage, and the paragraphs to follow, tells us that CM was providing care to MJ in a bedroom that was presumably set up as a "treatment" room on the second floor of the mansion. House staff report that the second floor was designated as "restricted" access, and one security staff member reported placing items from fans for MJ on the steps for him to receive, as he was restricted from the second floor.

"There was a blue plastic pad lined with cotton on the left side of the fitted sheet near the center of the bed."

This was likely what we refer to as a "chux" disposable pad.

Example of a chux pad in use.

We use them for all sorts of messy things in hospitals. The position of this pad is described as "near the center of the bed", and that there was no blood reported on it says to me it was likely not placed to protect the sheets during IV placement, or used during resuscitation attempts. During all of the resuscitation commotion and moving the victim, it didn't get dragged on the floor.

Security Guard Alvarez reported the description of a condom catheter in place on MJ.

"At some point, on your return to the room after escorting children out, did you notice tubing or some type of tubing in Michael Jackson's groin areas?

His penis was out of his underwear and he had an apparatus on his penis and there was tubing attached to his (cover?).

Do you know what a condom catheter is?

Was that something that attracted your attention?
I saw that.

Autopsy report page 6 of 23 confirms a condom catheter in place on the decedent.

Condom catheters are notoriously "leaky", so the position of this chux pad and the presence of the condom catheter tell me two things: There was a prolonged period of time prior to his cardiac arrest where MJ was not expected to be able to use the bathroom in the normal and usual manner, nor was he expected to be able to use a urinal (plastic urine bottle).

The above image is a condom catheter diagram. These can be configured with extension tubing to drain into other style bags and bottles. This shows a smaller capacity bag, for a person who may be able to walk around, and fits under ordinary clothing.

The more important thing that this says to me (relating to the Death Drip: Explained), is that during the time immediately preceding MJ's cardiac arrest, he was not expected to have voluntary control of his own urination. Even if the safety of the patient were in question, such as, he may be dizzy as a result of medications, and we don't want him to fall if he gets up to use the bathroom, the presence of the condom catheter says to me that even voluntarily (while conscious or drowsy) using a urinal in bed (or receiving assistance to use a urinal) was NOT the plan. As a nurse for more than 25 years, one thing I know is that most healthy adult, mentally intact men (and women) do not like the idea of being incontinent of urine, EVER.

So, my conclusions here are that whatever was going on in that bedroom, the expected outcome of that situation was that MJ would not have voluntary control of his urination. That there were no urine soaked sheets or pads in evidence from ordinary incontinence says to me that the "problem" of actual or probable incontinence had been successfully "solved", because at least one bottle of urine was found in the room.

Fleak Testimony, Day 4 Part II

DDA Q: In addition to observations of what you described, did you locate a jug that appears to be a jug of urine?

Fleak: There was a chair behind and to the left of you that had a bottle of urine and several urine pads.

My questions for CM: What kind of bottle was this? Were they empty bottles re-purposed for urine collection, or a plastic urinal bottle? Why did you keep the urine in a bottle by the chair? Why didn't you dump it out? Why did you need several urine pads close by? Was MJ able to void on his own at night? Did you assist him to the bathroom? Did you assist him to void in bed using a urinal? Why did you protect the bedding in the treatment bedroom? Where did you obtain the condom catheters and chux? Why did you use them in your care of MJ? Did you use them each night in your treatment of MJ?

The above image is a male urinal bottle. Note the angled neck for use by patients who may not be fully upright.

By the way, if CM was able to find time to empty his OWN bladder, as he said, why did he not ALSO empty that smelly, and potentially spill-able bottle of urine in the toilet? Was he lazy? Perhaps it was just too icky, and he hoped someone else would eventually take care of it. Doctors, especially important ones who make $150,000 a month, don't do mundane tasks like emptying urine bottles. Or then again, perhaps he simply had his hands full managing all of the medications, IV's, and closely monitoring the patient's every breath....nah, that probably didn't happen either, since he had ample time to text and talk on his cell phone with his girlfriends.

So, to recap, THE PLAN was to render MJ to a level of unconsciousness that precluded the patient from having voluntary control of his bladder for a PROLONGED period of time.

I can tell you with absolute certainty that almost none of our healthy patients in the operating room with procedures less than 2 hours in length require ANY type of incontinence protection or drainage devices. And that includes conscious sedation, all the way up to general anesthetics. We simply have them drain their bladders in the holding room before we begin, and we monitor the total amount of fluids we infuse. (This excludes patients undergoing procedures involving the urinary system.) And we monitor the patient's ability to void in the post anesthesia care unit, using devices such as ultrasound if we suspect the bladder is overly full and the patient has no urge to void. Then we intervene as necessary.

And yes, I know MJ had prostatic hypertrophy and was supposed to be taking Flomax-- that is actually not pertinent to the discussion above.

The goal of CM's "treatment" was to render his patient unable to control his urination. In other words, CM planned to render MJ unconscious (deeply unconscious!) for a number of hours, and took measures to protect the bedding. (Too bad CM didn't bother taking simple measures to protect his patient's life, but I digress.)

I speculate that it is highly unlikely that MJ was incontinent of urine when he was awake and going about his daily routine. Video of his final rehearsal indicates a vigorous, athletic dancer, wearing fairly snug-fitting pants. It is unlikely MJ wore a condom catheter during his waking hours.

We will discuss the "IV hydration lie" told by CM in Part 3 of this series.

Moving on to page 14 of 23 of the Autopsy Report.

We know there are 26+ evidence photographs of the scene and medical evidence, taken on 6-25-09, and 6-29-09. Five of them were enlarged for Dr. Selma Calmes to review for her consultant report. (She is the anesthesiologist whose consultation is part of the autopsy report.) As I understand it, California does not have "sunshine laws" about releasing evidence to the public, so unfortunately, none of us are likely to see those photographs. (KZ is disappointed about that.)

Page 21 of 23; "Medical Evidence Analysis Summary Report"

"Propofol and Lidocaine were detected in approximately 0.19 g of while fluid from a 10cc syringe barrel with plunger."

Referring back to Part 1 of this series, syringes come in various sizes. Different sizes are more useful or less useful for different purposes. If one needed to draw up a large amount of something, and only had small syringes, one would have to repeat the actions of drawing up over and over to get to the desired amount. Conversely, if one needed to draw up a very small amount of something, and only had big syringes, it would be extremely difficult (or impossible) to measure precisely enough. So, the right size for the right purpose. So now we know that CM had access to 10cc syringes, and that he was using 10cc syringes for drawing up Propofol and Lidocaine. CM has admitted to giving MJ propofol as an IV bolus (which is a separate individual injection technique, in contrast to a continuous drip), and he has reported 2 separate types of dosages. He also appears to have admitted in the following interview that he gave a bolus dose, then began a "slow drip."

Testimony of Orlando Martinez; L.A. Robbery/ Homicide

Being questioned about the interview 6-27-09 with Mr. Pena, Ed Chernoff, CM, and Detective Smith.

(KZ note: it is a bit uncertain to me which person Martinez is describing as answering questions here, but it appears CM is present during the interview at the hotel.)


How did he say he was assisting . He would assist Mr. Jackson with 50 milligrams of propofol. An injection to get him to sleep and with an IV drip to keep him under.

"Initial infusion followed by a drip? Objection. Sustained.

You mentioned 50 milligrams, did he say that was 50 milligrams every night?
That was the maximum.

Did he say that was the total or the amount of one dose? ???
I don’t think he specifically noted.

He told me it was a dosage, to put him under and then a specific drip."

(Testimony snipped.)

"In describing these evenings, last couple days, did he tell you he’d been giving MJ propofol every single night for over 2 months? Yes."

(Testimony snipped.)

"10 am June 25th 2009, according to Dr. Murray, what is happening?
MJ was still awake, and was asking for “milk” which was his name for propofol.

Around 10:40 or 10:50, did he give propofol (according to Dr. Murray)?

Did he look at his watch?
Yes. According to Dr. Murray he had to look at his watch, to calculate
(miss last)

He said he halved his normal dose, gave him only 25 milligrams over 25 minutes.
It was simply an injection to put Mr. Jackson asleep, and then a slow drip to keep him asleep."

A few words about propofol.

Propofol only comes in one "strength" or dilution, and that is 10milligrams per one milliliter, abbreviated as 10mg/ ml in medical shorthand. The abbreviation for milliliter is "ml"; and the abbreviation for cubic centimeter is "cc". One ml and one cc are equivalent and are used interchangeably by health care professionals. So, to recap, a 50mg dose is 5cc. A 25mg dose is 2.5cc.

Propofol is packaged in 20cc vials and ampules, 50cc vials, and 100cc vials. (This information is important to remember as we next look at CM's ordering information from the compounding pharmacy.)

This picture below shows a 100cc bottle/ vial on the left, and a 20cc vial on the right. The mug is to give you some perspective on the sizes.

Propofol is sold under the name brand "Diprivan", and it is also sold as a generic equivalent, "Propofol". The dominant difference between the two formulations is that the generic drug is packaged with a preservative that some people are allergic to. Propofol drug molecules are suspended in a white lipid (oil) carrier emulsion. This carrier solution is very vulnerable to rapid bacterial growth. Unlike other medications that can be opened and used for days to weeks, unused portions of remaining propofol in vials MUST be discarded after the vial has been opened for 6 hours. IV bottles and tubing for sedation patients should be discarded after 6 hours. ICU patients for whom the lines are not entered or manipulated as much can have tubing hanging for 12 hours.

Prescribing Information for brand name Diprivan

Generic Propofol FDA information

We do not know if CM was using brand name Diprivan, or generic propofol.

Moving on to CM's pharmacy orders.

Testimony of Tim Lopez (Pharmacist, owner of Applied Pharmacy Services, Las Vegas) Day 5, Part 1

For this section, rather than cutting and pasting in the quotes from Tim Lopez, I'll refer the reader directly to Sprocket's transcription of Lopez' testimony (Day 5, Part 1). Tim Lopez confirms that CM ordered propofol (and other meds) four times. Because I'm focusing this series on building my conclusions toward the Propofol Death Drip technique CM employed, I'm not going to devote much discussion to the boatload of injectable benzodiazepines CM also ordered. The propofol alone is interesting enough! Because I think it is somewhat confusing to talk about the different size vials CM ordered, I will convert the vial sizes to total cc (or ml) for propofol. This is MUCH more understandable (and relevant) than the "255 vials" of propofol that some media outlets have reported.

Order 1- date unknown from testimony transcription

* 1 box of 100cc vials = 10 vials =1000cc propofol
* 1 box of 20cc vials = 25 vials = 500cc propofol

Order 2- April 28, 2009

* 4 boxes of 100cc vials = 40 vials =4000cc propofol
* 1 box of 20cc vials = 25 vials = 500cc propofol

Order 3- May 12, 2009

* 4 boxes of 100cc vials = 40 vials = 4000cc propofol
* 1 box 20cc vials = 25 vials = 500cc propofol
* Flumazenil ordered for the first time-- a BUNCH of it. (This medication reverses benzodiazepines, but NOT propofol.)

Order 4 - June 10, 2009

* 4 boxes of 100cc vials = 40 vials = 4000cc propofol
* 2 boxes of 20cc vials = 50 cials = 1000cc propofol

You will first note that CM appears to be ordering propofol about every 4 weeks toward the end, and that he ESCALATED his orders after the first ordering cycle. Order 2 and order 3 are only two weeks apart, and order 4 doubles the box of small vials again.

Let's do a bit of math: that is 15,500cc of propofol in about 8 weeks or so. That is more than 15 liters of propofol. Nearly 4 GALLONS of propofol. A mere 12 unopened vials (unknown sizes) were found in the mansion, and there were 2 weeks left in CM's ordering cycle of 4 weeks. So, is that a lot of propofol? Enough to drop an elephant, several times over.

Let's look at a comparison, to understand just HOW much propofol CM was ordering for ONE patient. Our small hospital does about 35 cases a week in the O.R. using varying amounts of propofol per patient. We use less than a liter (1000cc) a week for ALL 35 patients combined.

Let me also say that it is highly unlikely that CM was ordering all of these vials just to line them up on the shelves of the walk-in closet. He ORDERED that much because he was USING that much, plain and simple. The particular sizes of vials he chose to order is HIGHLY significant, also, and relevant to the Death Drip technique. Knowing that propofol must be discarded after 6 hours to prevent blood infections in patients, once a vial is opened, it has to be used or discarded. So if he planned to give small amounts, CM would have ordered all small vials (the 20cc size), to minimize wastage.

Also notice the amount of 100cc vials ordered: 40 per order beginning April 28th. Simple math says that CM's administration to MJ was averaging about 1 to 2 100cc vials/ bottles every night. (Plus a boatload of other meds.) This is NOT the usage pattern of a patient who is weaning off of anything. CM's final order June 10th doubled the small vials from 25 to 50 ordered.

Let's run back to the autopsy for a moment. Page 22 of 23 is the Summary of Toxicological Findings.

The expected range of propofol that should be measured in the blood after a bolus dose of 2.5mg per kg (kilogram) of body weight is 1.3 to 6.8 ug/ ml (where the u is the abbreviation for micrograms). ** Please note that a bolus does of 2.5mg/ kg is NOT the same as a 2.5mg DOSE for sedation. MJ blood analysis at post mortem is indicative of a dose roughly 8 times bigger than what CM claims to have given.

This article explains in great detail that a 138 lb woman who was found to have been murdered with propofol had blood levels astonishingly similar to MJ's, who weighed 136 pounds at autopsy.

So, let's take a hypothetical 2.5mg/kg dose and give it to a 136 lb patient. 136lb = 62kg. 2.5mg x 62kg = 155mg (using algebra, and cross multiplying)

2.5mg... = ...xmg
1kg............. 62kg..... 1x = 155.... For a 62 kg patient, a 2.5 mg/ kg dose = 155mg (15.5 ml)

To know how much volume of drug to push out of a syringe, you must divide again to get cc of drug. Propofol comes 10mg/ 1cc. 155 divided by 10 = 15.5cc, or a 15 to 16cc bolus dose should produce blood levels in the range of 1.3 to 6.8 ug/ ml.

MJ's results at post mortem:

Heart: 3.2 ug/ ml
Hospital: 4.1 ug/ ml (possibly from a venous draw during or right after attempted resuscitation)
Femoral: 2.6 ug/ ml

I will close this article with the testimony of Alvarez and Fleak, as to the IV "bottle in bag" each of them observed. (Note: Sprocket has verified with a reporter who was in the courtroom during Fleak's testimony that the propofol bottle was 100ml/ cc.)

Aberto Alvarez testimony (Day 2, Part 1b)

"Before you placed him on the floor, exhibit brought out.... can you please show us where this IV stand was?

In around that direction.

Was it still connected to Michael Jackson?

Prior to us moving (Jackson), Dr M removed the IV.

Just before (he was) moved to the floor?

Yes sir.

(Testimony snipped)

And Dr Murray told you he had a bad reaction and that’s when you say that Dr. Murry told you to put some things in the bags.


And that Dr, Murray told you take something of an IV bag and put it in bag. You put the IV bag off the stand and put it in a blue bag?

And you looked for a plastic bag, and put it in front of Dr. Murray? All of this happened, and you still have not called 911?

(Testimony snipped)

Can you tell us what these vials were?

I just can remember they were the type of bottles that you get syringes in them and you get medicine out of them. (Another question here?) The whole things were clear.

And was there a color to the top of the vial?

I remember they were surrounded by a silver... don't remember.

Any other color than silver? How many were there?

I don't know sir. I remember there were a few.

So you're saying it could be three or four?


Could it be two?

I know there were more than two.

So you're standing while that happens?

I didn’t look into the bag, but I saw him drop them in the bag.

Was there anything else in that bag?

No sir.

(Testimony snipped)

This bag that you touched, took (the IV?) off this stand,

That’s correct. I had to curl it around.

There was a period of time you were holding that that IV bag?

That’s correct sir.

(You stated?) that there was something in the bottom, that white milky fluid, and you’re sure that was absolutely in that was milky white?

Yes sir.

And there was a bottle “inside the bag” and that’s something that you told the police as well?


In fact that you drew a drawing for the police.

It was towards the bottom of the bag.

And you are sure that it was IN that IV bag? There’s no doubt about it?


I don’t know how that could be. Very confusing. (Q? A? My comment?)

It, the IV bag that was left on the stand, was the one that was connected to Michael Jackson? Do you remember that?

Yes sir.

The one that you took off the IV bag wasn’t connected to anything?

Yes sir.

When he asked you to take that off, that was a very quick operation, it all happened all at the same time? One instruction after another?

Was anything, was that IV bag (stand?) moved?

I mean I don’t know sir, I don’t know if it rolled away.

Did you move it yourself?

I could have. I don’t recall.

(Testimony snipped.)

No sir I didn’t see any. I remember seeing one of those things that you put over your mouth and pump with air.

(Testimony snipped.)

He then instructed me to remove the IV bag.

At this point 911 had not been called yet?

That's true sir.

At this point he had not instructed you to call 911?

That's a true statement. (Q? A?)

(DDA Question?) From his position, he pointed in one hand at the IV stand, (said) remove that bag and put it in the blue bag?

Did you remove it per his instructions and did you put it in a blue bag?

That's correct.

And did you notice anything about that blue bag?

Yes sir.

The IV bag was handing at eye level. (Q? A?)

I noticed that inside there was an bottle inside the bag. I noticed that, at the bottom of the bag there was a milk like substance. (Separated?)

It was a milk like color?

It was whitish, yes sir.

And when you removed that IV bag that appeared to have a bottle inside, was there another bag hanging from IV?


Did Dr. Murray instruct you to remove that bag?

No sir.

Elissa Fleak testimony (Day 4, Part 2)

"Large dark blue Costco bag.

DDA Q: Did you find saline bag that had been apparently cut open?

Fleak: Yes I did.

DDA Q: Find anything in that saline bag?

Fleak: A bottle of Propofol inside that cut-open bag.

DDA shows Fleak a photo.

Flea: Yes (that’s what she found).

DDA Q: Can you describe what I’m showing; can you describe?

Fleak: It’s a slit in the bag.

DDA Q: Did you take this photograph? That was the Propofol bottle that was inside the IV bag?

Fleak: Yes.

DDA Q: In addition the IV bag with the slit in and the 100 mg. Propofol you mentioned, what else did you find?

Fleak: 20 ml bottle of Propofol bottle. Back to 100 ml bottle; it was open and had liquid in it. Twenty ml. open with liquid in it. Ten ml. lorazepam (Ativan) bottle open with liquid in it. Two bottles of midazalom (Versed) 10 ml both open, both had liquid in them."

Part 3: The Lies: Conrad Murray's Words and Actions will be out soon! Thanks for reading!

Friday, January 21, 2011

Justice For Caylee Marie Anthony: Little Steps Make For A Good Day

There are times when following the Casey Anthony murder trial that Caylee Marie gets left out of the equation. Her mother is the focus of the trial and we tend to keep our attention on what is going to happen next in the now two year and seven month saga, if you count from the last day she was seen by anyone but her mother.

We rarely see her name in the defense motions. She is usually referred to as the "victim". Her picture is omitted from many articles because we have been focused on the judge, the attorneys, the grandparents, and the Defendant as Casey is often called.

When I find myself "forgetting" about Caylee, I Google her images and feast my eyes on the many photographs of her, mostly taken by her mother. She was a child on the go, lively and full of childhood spirit. With her death, we need to see that she receives the full justice she deserves.

If, indeed, Casey Anthony murdered Caylee to gain her own time to be on the go and live the "Bella Vita", then, as Cindy Anthony has said, "Justice for Caylee is justice for Casey".

The little bits of news yesterday put me in a positive mood about justice for Caylee. There were no major breakthroughs; certainly no smoking guns. Just a few little things that give me hope.

First was an article from WESH. In it, we learn that three of the TES searchers affirmed that they were fish the defense had caught. Unfortunately, they weren't keepers.

First, Kevin and Lisa Galloway, a couple who had searched Suburban Drive with TES on ATV's reported that they "were probably the closest to her of anyone on the search". They also reported that "the area where the remains were later found was under waist-deep water in September 2008. From what they saw, they said they believe Caylee Anthony's remains were present and submerged".

Another witness that testified on Thursday, Melinda White, told WESH 2 news she never searched the exact area where the remains were found.

There were another seven to ten searchers who reported for depositions yesterday as well. I have a strong feeling that what they had to say wasn't much different. They either said they didn't search the spot where Caylee was found or that the area was under water.

None of these individuals were added to the defense witness list prior to the depositions, a fact I find very unusual. It leads me to believe that the PI (probably Jeremy Lyons) was the one who interviewed them and considered them to be prime rebuttal witnesses to all the other witnesses from TES which are on the State's witness list.

Did anyone from the defense team ever sit down and talk to these people? Did Baez and Mason just take Mr. Lyons' reports as totally factual? One would think that the defense team would have learned a lesson from their experience with Laura Buchanan and Joseph Jordan.

For the defense teams massive "fishing expedition" to work, they would have to find far more than one credible witness to buttress their argument that Caylee's remains were placed on Suburban Drive after Casey was incarcerated. I don't think it's going to happen during the next four months. I don't believe it will ever happen.

We also received a copy of Judge Perry's Order denying the defense Motion For Reconsideration. In it, he pointed out that "The assessment of $583.73 against counsel was a sanction authorized by Florida Rule of Criminal Procedure 3.220(n)(2) for willful violation of a discovery order...".

Perry added that, "The Court then issued an Order clarifying the specific information each side was required to produce, and concluded that counsel willfully violated the very specific direction in that Order.".

In a footnote to the above quote, the judge indicated that he wasn't buying into the "traffic" issue included in the defense motion since, "Counsel did not previously offer the information set forth in page six of the instant Motion for Reconsideration.". As I recall from that hearing, Cheney Mason had no idea why the documents were late and Jose Baez muttered something about not having all the information and preferred to file a complete compliance late. In fact, he had assumed that the judge wouldn't mind if it were a day late!

Judge Perry concluded that the 300 pages the defense "dropped", when all was said and done, were still not in compliance with his order!

This latest development is also good news for Caylee's justice. The defense will have to comply with reciprocal discovery for face even more dire consequences such as being cited for contempt and possibly paying a much more hefty fine. The playing field has now been leveled in terms of discovery.

Lastly, Baez has filed yet another motion asking for 300 more investigative hours. It should be interesting to see how many more hours Judge Perry provides the defense. I would hope by then, the results of all the TES searcher depositions will be known to the judge. I would expect to see an amended defense witness list if any of these people support the defense theory. Otherwise, the defense expended huge amounts of taxpayer money and came up empty.

As a contrast to Baez' request for investigative hours, Ann Finnell does stand a much better chance of receiving what she has asked for in her motion. Her investigators also submitted expense summaries. They are detailed and meticulous, marking time spent on task to .1 hours!

Compare the two lists provided in the two motions to see the difference.

Just a reminder that the next status hearing is scheduled for February 4 at 1:30 PM.

Casey Defense Witnesses: Area Was Submerged

Perry Won't Reconsider Defense Sanctions

Thursday, January 20, 2011

Dr. Conrad Murray's Death Drip: Explained - - Part 1

© Trials & Tribulations 2007-2011. All rights reserved, do not reproduce in whole or in part without the express written consent of Trials & Tribulations.

This is a GUEST ENTRY by KZ. KZ, a CRNA, is giving T&T readers her analysis of the events that apparently caused Michael Jackson's death, based on the evidence presented at the preliminary hearing. Sprocket

Conrad Murray's Death Drip: Explained

Part 1 - IV Technique: Tutorial on the Basics
Part 2- The Evidence: What we think we know from preliminary hearing testimony
Part 3 - The Lies: Conrad Murray's words and actions
Part 4 - Putting it all together: What I think really happened

This is the first of a 4 part series. At the end of part 4, I hope that you, the reader, will be as convinced as I am that Conrad Murray recklessly, quite irresponsibly, and thoroughly incompetently killed his patient, who happened to be a famous celebrity musician named Michael Jackson (MJ). That MJ may have indirectly sought out the services of CM expressly for the purpose of administering IV propofol and other meds is irrelevant; the licensed doctor had the MUCH higher responsibility to safeguard the life of his patient. And, IMO, he egregiously failed to do so. I also am very disappointed that CM is only facing 4 years in prison for what he has done.

I will do my best to explain the chain of events, the technical aspects of the equipment in evidence, and the lies told by Dr. Murray subsequent to the death of his patient. Along the way, I will pose questions to Dr. Murray, which I'm sure he will want to answer if asked by a lowly CRNA, or prosecutors, to clear his good name of these terrible charges and accusations. I know I would be chomping at the bit to explain myself if I felt I were unfairly accused of a crime, or incompetence. So we will ALL be closely watching the pre-trial and trial events unfold to see how, or if, Dr. Murray explains exactly what he was doing in that bedroom.

I will also offer that I have never posted my opinions on any other site about the circumstances of the death of MJ except here at T & T. I will further offer that I am but a lowly CRNA. (Certified Registered Nurse Anesthetist. If you have ever met a CRNA, we have a reputation for our confidence, our competence, our compassion, as well as our intense passion for our patients' safety, and the reputation of our profession.) Many other experts with prominent letters after their names would be quite satisfied to squash my opinions into oblivion, simply because I am not a physician. I'm fine with that, by the way. Bring 'em on! There is plenty of room on Sprocket's sofa for all of us!

In the past, I have contracted my services as a consultant and expert witness for civil medical malpractice/ negligence cases, but I am certainly not infallible. I have not personally seen the evidence in this case, or sat in the courtroom. My conclusions are drawn from Sprocket's transcription of the hearings, the autopsy report, and what I have gleaned from news reports. These are MY conclusions and opinions. But I'm pretty convinced I have Conrad Murray's actions and techniques figured out. (And, in my opinion he's a big liar, as well as incompetent.) As the discussion unfolds, I'll periodically pose questions to Conrad Murray/CM, who, I'm sure, desperately wants to answer them, to clear his good name and reputation. (That's a snarky remark, for any who missed my sarcasm.)

The conduct of Dr. Murray has been quite disturbing to me. Patients still express concern from time to time that we do not use "the drug that killed MJ" on them. The first thing I tell those patients is that we should not blame the drug-- propofol is a miraculous, and safe, anesthetic drug-- in the right circumstances and setting, for the right patients, and the right indications, when given by a knowledgeable and vigilant practitioner. These are not the circumstances under which MJ was receiving this drug, and there is only one person who holds that blame, Conrad Murray.

As I have told Sprocket and CaliGirl9, I am just an educated "nobody" as far as this case is concerned, and expensive experts well above my pay grade have reviewed the evidence and testified. However, as an anesthetist, I wanted to figure out exactly what was going on in that bedroom-- that is what drives my interest in this case, not because of who the victim was. I will do my best to explain the technical equipment and medications in ordinary language, with the understanding that simplifying some explanations is not completely thorough and accurate. I will frame my explanations in language that I would discuss with any patient or family member. I'm also a part time faculty member for two university graduate programs, and a clinical instructor in the operating room (OR), so I'm used to being put on the spot by smart students! I'm not afraid of hard questions, and I have no issue admitting when I have something wrong. Having thrown down those disclaimers, if you are still interested in what I have to say, read on. I have my flak jacket on! (And I have MANY years of military experience, too!)

Part 1 - IV Technique: A Tutorial on the Basics

What is an IV? First off, "IV" is the common term for "intravenous." Let's confine the discussion to peripheral (small veins in arms and legs), not central lines. Basically it's a plastic straw sleeved over a needle. The needle pierces the skin and vein, and the "straw" is slid off into the vein, then taped into place, and the needle removed. IV's come in different widths (represented by standardized color coding) and lengths. There are different indications for different sizes.

First question for CM: What size IV did you place in MJ's left leg?

IV's are usually placed in hand and arm veins that are easy to see and feel. Leg or foot veins are reserved for occasions of special need, when arm and hand veins are inaccessible. Inaccessible could mean that the veins are not suitable for IV cannulation due to repeated punctures and scarring; inaccessible can also mean that limbs are not suitable due to infection, surgical procedure, positioning of the patient for care, etc. Speculation can also include that punctures and bruising are easier to conceal on a patient's legs than arms, once the patient is dressed and going about his daily routine. The point is, without a report from Murray, we don't know exactly why Murray placed an IV in the patient's leg (likely the left saphenous vein, according to testimony and anatomy, which is a nice big vein in most people). However, we do know that this is fairly unusual in a healthy patient who is ambulatory, and presumably may need to be up walking or to the bathroom while undergoing this "therapy."

In terms of the diameter of intravenous cannulae, bigger size equals more flow. If you remember back to basic physics, doubling the diameter of a tube does not double the flow; it actually increases the potential volume of flow by 16 times. This is useful to know when it is necessary to infuse large amounts of volume rapidly, such as when a patient is bleeding excessively, or when aggressive IV hydration is planned. Larger IV's (20g and larger-- the smaller the number the bigger the IV) can be kept several days by capping and flushing several times a day, and protecting the equipment beneath a bandage. Generally, large IV's are placed for hydration (which do not last long; they clot off or infiltrate, slipping out of the vein). Smaller IV's, such as 22g, are placed for intermittent injection, such as a patient who needs IV antibiotics for several days or weeks, or frequent pain meds. (A smaller IV usually lasts more days in adults)

CM: Why exactly did you place an IV in MJ's leg on the last day of his life? How long was that IV in place? You spoke with a LEO and stated you had given this patient IV propofol and other intravenous medications nightly for the past 8 weeks. Did you start a new IV each night? Did you ever attempt to "keep" any IV beyond one therapeutic episode? If so, how did you do that? If not, why not? After several weeks of nightly use, did it occur to you that a nightly IV would be needed for the meds you planned to give MJ?

IV Tubing
For purposes of this discussion, we will confine the descriptions to very simple sets of IV tubing. There has not been any reports that any electronic infusion devices were found at the scene, or reported to have been used by CM. CM has admitted to placing an IV for "hydration". So we will assume he was using simple IV tubing. Like this:

Simple IV tubing

We also know from paramedic testimony at the scene that CM's tubing was simple and "old fashioned", as it was not a needle-less system, and the paramedic's equipment was not compatible with CM's rubber capped medication ports (Y-sites). Paramedics had to change out CM's tubing for their own, in order to be able to administer drugs during resuscitation attempts. This older style of IV tubing requires a needle to pierce the rubber Y-sites to inject meds into a running IV, or to "piggyback" in another IV line. There are many brands of tubing, but nearly all of them have a Y-site about 5 inches from where the end of the tubing connects to the IV cannula in the patient, and at least one Y-site halfway down the tubing, for injecting meds.

Y-site Example
Piggyback lines are typically hooked into the Y-site closest to the patient. With this old style tubing, one would slip a needle attached to the second IV line directly into the rubber stopper, and tape it in place. These systems have fallen out of favor in the past 10-15 years as nearly all hospitals and home health agencies have had to change to needleless systems to meet patient safety requirements. I've been a nurse since the mid 1980's so I have had lots of experience using these "old" systems in the past.

Piggyback Example

This type of tubing flows by simple gravity into an IV, and many things can speed up or slow down the flow, such as the size of the IV, or the position of the limb. There are 2 general types of tubing: maxi drip, and mini drip. Maxi drip is 10 to 15 drops per cc, and is typically used on adults. Mini drip tubing is 60 drops per cc, and is typically used on infants and children, as well as adult drips that require more precise regulation. Rate of infusion is achieved by adjusting the roller clamp (in blue, above) counting how many drops per minute are seen in the drip chambers, and multiplying by 60 to determine hourly rate. In the old days, a strip of tape was placed on the bag and "time taped" so all caregivers would know how much should have infused at a certain point in time.

This is a maxi drip drip chamber.

This is a mini drip drip chamber.
Note the needle-like dropper inside. (Sorry- not a great pic.)

Another question for our doctor:

CM: What kind of tubing were you using? Where did you get it? How many sets of tubing did you purchase at one time?

It is a virtual certainty that CM was using maxi drip tubing.

Needles and syringes:
They come in many sizes. Most people order them by the box or case, so I would be highly surprised if CM had a wide variety of different sizes available. Educated speculation leads me to believe CM probably had 3cc syringes, and possibly 5cc or 10cc syringes. I think it's doubtful he had 20cc syringes, or 1cc syringes.

Propofol 20cc with Syringes

CM: What size needles and syringes did you have in use when providing care to MJ at his home? Where did you get them?

IV Bags:
1000cc plastic bags of Normal Saline (NS) were in evidence in the room, and on the pharmacy order by CM.

What is curious to me is on an initial pharmacy order reported, CM ordered only 9 1 liter bags. This is curious because a full case of liter bags is 12 bags. Why would a doctor order only a partial case from a pharmacy, and why would a pharmacy fill a partial case order without requiring the customer to purchase a full case? NS is cheap, so cost likely wasn't a factor. More on meds ordered will be addressed in Part 2.

1000cc Bag of Normal Saline

Glass and plastic medication vials:
These are stoppered with a rubber cap and a plastic flip off lid, for sterility. To access the medication, you must push some air into the sealed vial, in order to create positive pressure to withdraw a medication into a syringe. (Using sterile technique.) CM did not have needle-less systems in use, so he would have had to do this with an ordinary needle. Inject an equal quantity of air into the vial, flip it upside down, and withdraw medication into a syringe. If you don't do this, you can usually withdraw smaller amounts of medication, but beyond about 5cc, there is a vacuum built up in the vial that makes sucking out the med with a needle and syringe difficult.

The plunger of the syringe will have a tendency to be sucked back toward the vial. This is also true if someone attempts to drip medication from a sealed glass vial without properly "venting" the bottle to allow air inside. (This will be an important detail to remember as the 4 part series unfolds.) The "-pam" injectable drugs CM ordered (lorazepam and midazolam) come in 2cc single use vials-- ordering records indicate CM was not using multi-dose vials. It also does not appear CM was using pre-filled syringes from the pharmacy ordering information. Lidocaine comes in 10cc vials most commonly, but it is also available in larger vials. Propofol comes in 20cc vials, and 100cc vials. (It also comes in 50cc vials, but CM was not ordering this size.) I have not discussed glass "crack open" ampules because there is no evidence reported that these were in use.

To close this article, I'd like to take a minute to discuss rate control devices for IV's. Many people know about electronic IV and syringe "pumps" and have seen them on TV or in a hospital. There have been no reports of any of this type of equipment found at the scene, and no reports from CM that he used any kind of pump in the care of MJ. However, there are several "old fashioned" volume control devices that I'd like to discuss. These are very cheap and easy to use, if a provider knows about them and has access to purchasing them. The first is a simple pediatric buretrol.

This fits in between the IV bag and the regular tubing, and a provider allows a small amount of fluid or meds to fill the chamber. The bigger bag is then clamped off. This only permits what is in the buretrol to infuse, not the whole bag or bottle of meds. A buretrol costs about $20. A cheap IV pump about $300.

Buretol & Bag

Another low tech option for rate control of IV medications is a "grenade" pump. This is a hard plastic shell with an interior balloon that is filled by syringe. It infuses at a preset rate, such as 2cc/ hr, or 10cc/ hr, until the balloon is empty. These are commonly used in joint surgeries for post op pain control, and I used a similar "grenade" pump for labor epidurals many years ago. They are cheap and low tech, but a layer of added safety for the patient. They can be easily pressed into use for IV medications, and when I was flying military air evac years ago, I used them occasionally in flight.
"Grenade" Pain Pump

So why did I bring up low tech infusion control devices? Precisely because CM did not have any in use that we know of during the care of MJ. This information will be important in part 4 of this article.

That's enough for today! Part 2: The Evidence: What we think we know, will be out soon!