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
Introduction
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?
Yes."
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 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.
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.
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 SleepLie #4:
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
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?
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)?
Yes.
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.
www.anesthesia-analgesia.org
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!
~KZ
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