© 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.
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."
"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."
"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?
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?
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?
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?
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?
The one that you took off the IV bag wasn’t connected to anything?
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.
No sir I didn’t see any. I remember seeing one of those things that you put over your mouth and pump with air.
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?
And did you notice anything about that blue bag?
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?
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?
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!