Thursday, January 20, 2011

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

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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 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!


Anonymous said...

Excellent, thank you for this series. I'll be reading avidly.


Anonymous said...

So helpful for us untrained in medical terminology and equipment!
Thank you!


katfish said...

KZ I have enjoyed your informative comments here at T&T, so it's a real pleasure to "meet you". Just piggy-back me to Anne, I'll be reading over her shoulder. ;)

Anonymous said...

@ KZ

Excellent. Have been waiting and hoping and checking back for this.

Regarding your thoughts on maxi-size tubing - it depends on what you're delivering, or what you're not delivering through it.

In this whole situation, you have to suspend what you know of usual practices and procedures, and think outside the box. However, basic principles of patient care and safety should never be suspended or compromised, no matter what. Right KZ?

Anonymous said...

Thank you so much for this well explained Tutorial! It helps those of us that don't have the medical expertise in this field, such as yourself, to better understand. Very much looking forward to your upcoming chapters!

KZ said...

Thank you, Anne, SeniorMoments, Katfish, and to Sprocket and CaliGirl9-- it is very therapeutic for me to write about this to express the anger and frustration many of us feel about the circumtances that allow a provider like Conrad Murray to do what he did. I'm glad to have the opportunity to be a guest here at T & T!

And Anonymous above,you're exactly correct that "...maxi-size tubing - it depends on what you're delivering, or what you're not delivering through it." As the truth of what Murray was doing dawned on me, I had to practice a lot of "suspending disbelief" to accept what he did. His actions departed VERY far from any accepted medical or nursing practice. It is pure folly that Murray wasn't aware that what he was doing could kill someone-- is he really THAT stupid? I guess so. We will see if others agree.

Anonymous said...

I am only a nurse and this case has me very upset. This is also not about being Michael Jackson, it is about the standard ( or lack of Standard)of care that the patient was given. I cann't wait to real more, this will be a good artical explaining to lay people about this case.

tiya said...

KZ, thanks so much for this information, which those of us not in the medical community would never have access to understanding on our own. I wondered about alot of stuff you explained as I read T&T''s transcripts.

Maybe at some point you could address these questions.

1. Is there a different standard of care based on practice or specialty? This is from the defense wrap-up

Only we did not hear from a like minded similar cardiac doctor say on the stand in a similar situation to present on the standard of care. We heard from a professor and a clinicitian, says HE would require for standard of care. But that’s from an anethesiologist what he would use as a standard of care. We didn’t hear from a cardiologist in a similar situation and training.

2. The defense also mentioned something - and I cant' find the quote so I'm hesitant to write but...- about the difference between 'conscious sedation' and delivering 'anesthesia', the implication that this is CM was doing the former - can propofol be used for that reason in small dosages? Again, I'm not certain I've got this correct since I can't find the quote.

Thanks for everyone's great work in reporting all of this for us. Now if you all can't attend the trial we'll be really out in the field depending on msm!

Sprocket said...

KZ answers:

Hi tiya,

Thanks for your questions. First of all, yes, propofol is used for conscious sedation, as well as moderate and deep sedation, and general anesthesia. There is considerable debate among anesthesia professionals about exactly where the "line" is between deep sedation and a breathing general anesthetic. Many of my colleagues will define GA as the point at which they have to put in some kind of airway device, or whether or not they have turned on a little anesthetic agent (gas), but I really disagree with that for a number of reasons I don't have time to go into right now! That could be a 2 or 3 hour discussion! The obliteration of respiratory effort and protective airway reflexes is clearly a sign one has crossed over into general anesthesia, however, patients under general anesthesia can and do breathe when we feel it is appropriate for the diagnostic or surgical procedure that is occurring. We have the ability to control the presence or absence of intrinsic respiratory effort with lots of different medications. Suffice it to say, that sedation and general anesthesia is a continuum.

(Warning- rant ahead.) 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. (Rant complete.)

tiya said...

Great information, KZ, thanks so much for this. I tend to read with a fine tooth comb so have come across alot I don't understand. Everyone at T&T plus guests has been very patient :) with my questions, and extremely knowledgeable with the answers.

I don't blame you for ranting on the standard of care issue. I think even the most hardened nurse or physician was shocked by this whole sham setup. In a different and 'humorous' vein (oops), even Celebrity Rehab's own Dr. Drew, was shocked, had never heard of such a thing, and in a home, no less - 'outrageous' is what he called it.

Seriously, it's all pretty ugly. I just wonder what the defense is going to come up with that could convince a jury to do other than to convict - but I expect the defense will get pretty ugly, too.

DarklySky said...

KZ - Question for you. When can we expect to see Part II about The Evidence?? Very much looking forward to it. Thanks!

Sprocket said...


I know KZ is working on Part 2 (in-between spending time with family). As soon as the article is completed and sent to me, it will be posted.

Lupa said...

Informative, revealing & entertaining read, thanks KZ & Sprocket. KZ should be in court asking all those questions to CM. :-)

Look forward to part 2 .
Regards from the UK

Anonymous said...

Thank you for this blog. Good job. I'll continue to read you!