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 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?
(No.)
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.)
XXXX
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."
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?
Yes.
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?
Yes.
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?
Yes.
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?
Yes.
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!
~KZ
Posts
32 comments:
Absolutely fascinating! Thank you, KZ and Sprocket!
SeniorMoments
KZ, the degree of substandard care given here and your detailed analysis of its implications is quite disturbing. Now I'm beginning to understand the terminology and the connections between the testimonies, which you've integrated so well into your own analysis.
I wonder, though, with all the left over 'detritus' in the room, if it's possible that the IV bags and bottles containing propofol weren't from another evening? (i.e could the defense say something like that, even finding a way to explain the condom catheter issue?)
I'm also curious to know what happened to all those other nights of left over stuff. There must be a cleaning woman in this case somewhere!
If CM was using the amount of Propofol that the frequent pharmacy orders indicate, does that mean that a person can develop a tolerance for it? Needing more to sleep? Or that he was using all of it to give MJ a nights' 'sleep' i.e. 6 hours or more? Or something else?
Thanks so much for this analysis, KZ, and to Sprocket for letting you share it with the readers.
“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).”
Maybe, and maybe not.
It is possible that Michal Jackson, for many reasons that may have zero to do with any act or omission to act on Dr. Murray’s part was incontinent and habitually word a condom catheter in bed.
Therefore, it is difficult to draw inferences from these two facts to support of any kind of “plan” to render MJ unconscious for an extended time period—especially according to the applicable beyond a reasonable doubt standard.
Don’t you agree?
What reasons?
Thanks again, ... I also have some pending questions but I rather wait until part 4, I have a feeling the answers will be there.
Lupa
UK
Thank you so much KZ for your analysis! And Sprocket thanks for delivering to us. Now onto my opinion what I've read so far... I'm in shock! That's an unbelievable amount of propofol to be delivering to Michael in that short amount of time, isn't it?? This will no doubt come up during the trial. Weaning him off his propofol addiction my ***. I'm surprised Michael didn't die of an overdose earlier.
I'm curious though.... how come the man who worked at Applied Pharmacy Services didn't get suspicious? How could he turn a blind eye like that? He had to know this was an odd request, wouldn't he? What cardiologist personally orders that volume of an anesthesia??? I'm really scratching my head over that. Or maybe he was suspicious, but the business was too good to turn down. That's a real shame. Is it normal for a cardiologist to be placing orders like that?
Thank KZ for the effort you put into breaking this down for us.
One question I have for you is that is it possible that CM reused the propofol left over in a bottle instead of discarding it? I had read a few months ago that reusing propofol left out over a certain number of hours could cause sepsis which may not necessarily show up in an autopsy report. Just curious as to your take on this.
Thanks
~Athena
Thanks KZ, much appreciated.
Anne
Not KZ here, but I'm trying my hand at answering a question.
Athena:
I don't see why Dr. Murray would "reuse" propofol. He had a ton of it at his disposal. Still had 12 unused bottles when FLEAK went back to the house. Even if all 12 were the smaller 20ml bottles, that's still a lot of propofol.
I believe the respiratory failure happened first, then cardiac arrest. From my understanding, that is supported by the autopsy. Hopefully KZ can answer if sepsis would create respiratory failure.
Dark Sky:
Any investigation in Applied Pharmacy Services would be (I believe) on the Las Vegas end, and not necessarily as part of this investigation.
From the preliminary hearing, the Pharmacist did the due diligence he was required to do: verify the individual was allowed to purchase drugs. Remember, the first shipment ordered was delivered locally to Dr. M's Las Vegas clinic. When the delivery person got there, Dr. M asked that part of the order, the propofol, be forwarded to his "clinic" in Santa Monica.
I don't know the laws (KZ might) regarding state to state drug purchases/shipments. Time will tell if the owner is or was under investigation for shipping drugs out of state.
I hope we get some more questions from our readers. KZ has put quite a bit of her personal time and knowledge into bringing everyone this synopsis, even taking some photographs herself.
Dear Ronni:
Various medical reasons cause persons of varying ages to wet the bed. MJ was such a physical and psychological mess, so who knows.
The man was weird enough to have worn it just so he would not have had to trek to the bathroom.
Maybe he got tired of diapers.
Who knows.
I have been an ER RN for 29 years. I am just asthonished by what MJ was doing in his home. The amount of Propofol being ordered by CM is just "Jaw dropping" KZ you are doing an excellant job. I look forward to reading more. I'm hoping as you're moving along that you mention the value of a good RN. In my practice I have never ever seen a cardiologist start an IV, maintain an IV, or even do CPR. I'm just amazed that MJ and CM would "play" with Propofol in the home setting.
When a person dies they deficate not only urine, but they ooze from their rectum. It is impossible for a chux to have remained clean. That shows that CM was doing things and staging things.
Another question I thought of... I'm not very good at figuring medication dosages and usage, but if Michael was being put "down" every night for 8 hours or so for 8 weeks; would that explain the large quantity of propofol ordered?
Also, is propofol a type of drug that a person can build a tolerance to... which would require more as time goes on to get the same effect?
Thanks again!
I have a question about autopsy reports. I was struck by the MJ autopsy report that stated he was generally a healthy, 50 year old male. Yet he weighed only 136 lbs for his height, had a BMI of 20, used drugs, drank alot, and was known to periodically have issues with anorexia. His extreme thinness, evident in the This Is It movie, was alarming.
Given all this, KZ and Sprocket, do autopsy reports only give baseline measures? So a thin man with MJ's numbers could be at the lower end of the range for his height? Or rather, what are they responsible for reporting?
Thanks
Not KZ but I will try to answer some questions.
Anon @ 1:05 am:
Not "everyone" defecates when they die. If there is little to nothing in the large intestine (colon) then there would be nothing to pass.
Dark Sky:
In a nutshell, yes. That would explain the huge amounts of propofol.
As to the second part of your question, I'm not positive. If I'm remembering correctly from testimony, either the coroner or Dr. Ruffalo talked about the body's ability to learn to "clear" a drug faster from the system via the liver. There is a special name for this; I can't remember what it is, but it's well known in the medical field.
Propofol is a drug that clears from the body pretty quickly anyway, which is why you need a continuous infusion of it, to keep someone sedated. There are calculations that must be done, using the individual's body weight, to determine "how much" of the drug is needed to keep a person sedated. I believe that's correct.
When KZ has time, she will have the correct answers to all questions.
tiya:
I believe the coroner stated that although MJ appeared thin, he was "within the range" of accepted height/weight ratios. I would have to go back and check testimony to be sure.
The coroner testified that he was in generally good health when he died. He did not have any underlying, unknown medical condition that would have caused his death.
I don't believe the autopsy mentioned anything about drinking alot, using drugs, or anorexia. I'm sorry, but I have not read the autopsy report. I did not even know if I would be covering the prelim until the afternoon of Monday, Jan 3rd. There is quite a bit about the case reported in the media before the prelim that I don't know.
Jackson did not die of alcohol poisoning.
Although he did die of a drug overdose, (propofol and benzodiazapines: drugs that supress respiration) but it was not narcotic, addicting type drugs.
Jackson was not anorexia-thin to the point where it would kill him. Although you do hear about anorexia cases where the individual dies, those are cases where the person weighs less that 80-90 pounds and doesn't eat.
Thank you KZ. Your in-depth information and the time it must have taken you to put it all together is much appreciated. Thank you also sprocket & T&T.
Do I understand the following things correctly?
If all the orders were being used, 50mg "maximum" is incorrect. That would refer to the initial injection only?
"He had to look at his watch to calculate..."
Would/could this be 2.5cc over 25 minutes via IM injection?
Would seem to be a lot of waste of the 20cc vials if these were used for the initial injections. Is it possible the remainder of each of the 20cc vials was added to the IV bag?
The first order was perhaps a "test" order?
While this is all shocking and sickening, I feel the empty O2 tank is of significant importance.
GB
@ KZ: Do you think it's possible that Murray was stockpiling the propofol instead of actually using such large quantities?
Martinez said "50mg maximum."
GB
GB:
I have to check testimony. Did Dr. Murray tell detectives 50 "cc" or 50 "mg" ??? Big difference.
If he was stockpiling it, where were all he empty bottles? (255 ordered) from a massive infusion at one time on the morning of June 25th?
Dr. Murray made an attempt to clean up the scene by instructing Alberto Alvarez what to do. However, all the items Alvarez testified he collected under Murray's instructions were located in the adjoining closet/room by the coroner's investigator days later.
Dr. Murray told detectives in the taped interview that he was giving MJ propofol every night for eight weeks. Although he STATED that he was giving him only 50 (cc's? mg's?) a night, we know that can't be true because of the amount found in Jackson's body at autopsy.
It it was true that he was ONLY giving Jackson 50(cc's? mg's?) a night, why order the 100ml bottles? Once opened propofol bottles pass the six hour shelf life, it has to be discarded.
Hope that answers your questions.
Hm...Alvarez says " underwear". The report says: "The body was no clothed and no clothing is available for review". Somebody lies!!!!
Hello everyone, and thank you to all for your questions and kind words! I must apologize for being away--my real life has been very busy the last 48hours! I have a bit of time now, and will return later this evening to try to elaborate on Sprocket's answers-- and may I say most of her answers were very close to what I would have answered! (Sprocket rocks!)
One question I have a minute to address is the issue of whether or not propofol is "addicting". The DEA and FDA have weighed in on this. Due to an alarming number of deaths of health care providers, and large numbers of reports of propofol abuse among health care providers, these agencies were persuaded to formally address the issue. The Anesthesia and Analgesia article imbedded in the Part 2 article (in the part about blood levels) is excellent. If you haven't had a chance to read the whole A & A article-- I HIGHLY recommend it.
DEA compiled reports from the health care industry, commissioned studies, sought comment, etc.It is a very complicated process to schedule a drug under the Controlled Substances Act that is not a narcotic. October 10th, 2010, Propofol was moved onto the list of controlled substances in the U.S. as a "schedule IV" substance. (The same as benzodiazepines.) The initial petition to schedule propofol was filed just 68 days prior to MJ's death, so it took 1 1/2 years to go thru the process. Some of my colleagues tell me that is LIGHTNING fast for DEA and FDA to act!
However, IMO, it would not have made a single bit of difference in 2009 if propofol had already been a controlled substance, because CM had the proper credentials to obtain controlled substances legally. I'll talk about this more in part 4, and answer the reader's questions above about CM's orders from the compounding pharmacy not attracting attention.
Unquestionably, benzodiazepines are addictive substances-- there was a comment above that I think hinted that perhaps benzo's aren't addictive. They are some of the hardest drugs to get off of, once physical dependence occurs.
I will write a lot more about the issues of psychological dependence, physical dependence, and tachyphylaxis, which is the physiology of tolerance to meds. One of the dominant systems involved is the cytochrome P-450 enzyme system in the liver (google it), which, essentially kicks into high gear and becomes more efficient at removing drugs from the body.
So, it takes an increasing amount of drug to achieve some effects, like pleasure or euphoria, but other effects, like respiratory depression, remain a high risk that is compounded by poly-pharmacy. Drugs interact, and some are synergistic, such as benzodiazepines and propofol.
Hope that answers some questions! I'll be back later.
~KZ
Anon @ 2:04pm
Jackson's body was taken to the emergency room at UCLA hospital before taken to the morgue.
It's a good bet that while in the ER any clothing he was wearing was "cut off" of him there. That's pretty standard for people coming into the ER in his condition. It's not always like what you see on TV shows.
Once the clothing is removed from the body, it does not go to the coroner's office. It would go to the LAPD crime lab.
The coroner's office only collects and examines items that are with/ on/ attached to the body when they collect it (such as, like at a crime scene).
Anonymous at 2:04 pm.
No one is lying.
Alvarez saw MJ in the BEDROOM of the mansion, before paramedics arrived. The language in the autopsy report was generated a day or 2 later in the office of the Coroner, after resuscitation attempts at the hospital failed to revive MJ. The body was nude, which is not surprising from the hospital resuscitation, and preparation of the decedent's body for transport to the morgue.
Resuscitation attempts in the ER included the extraordinary measure of an intra-aortic balloon pump, which was inserted in the groin vessels. You don't wear underwear during placement of an IABP. He also had multiple femoral blood sticks and IV attempts. No undies during those, either.
~KZ
In addition, paramedic firefighter Richard Senneff who testified at the preliminary hearing, also described the pajamas that Michael Jackson was wearing when he first entered the "treatment" room and saw him.
The both saw the pajamas.
When a body is delivered to the coroner with clothing/ items attached, it's my understanding those individuals who removed the articles (clothing, etc.) at the coroner's office would write the report to describe the clothing.
I don't believe the coroner does that.
Thank you so much KZ and Sprocket, your work is brilliant and very much appreciated.
I've read that a doctor-friend of MJ's in England (Dr. Susan Etok) said he asked her to get propofol for him, but she said no. I was wondering if maybe CM could have been ordering extra drugs and stockpiling them to take to England with them. Is that a possible scenario?
Sandy L
Stockpiling for England?
Interesting. Now I see where the "stockpiling" is going.
IF SO, where are the drugs? Did Dr. Murray keep them at his girlfriend's pad? If he kept them at MJ rented mansion, I would think they would have been found in that large "closet" off the "treatment" room.
There were 12 unopened bottles found there with the other items.
I would think that, if LE did find a stockpile of propofol, it would have been found by either a search warrant, or the family found it when clearing out the rented mansion, and hopefully, turned it over to LE. We may never know until trial.
However, with that being said, from what KZ has explained about propofol, and it's very short "shelf life" once a bottle has been opened, I can see how Dr. Murray would need lots of propofol to keep Jackson unconscious for 8 hours at a time.
Just wanted to thank the writer for
all your work in putting together
this terrific series. So happy I
found it. Informative, accurate,
complete...excellent.
I agree SandyL/ anonymous posed an interesting question about stockpiling in advance of the England tour. I don't know when he was supposed to leave, or how long he was going to be touring. However, the same issue of vial sizes plagues that question-- once opened, they have to be used or discarded in 6 hours. There would have been no incentive to try to "save over" an opened bottle, because CM could simply order more trays of 20cc vials instead of big ones.
The choice to order large 100cc vials was deliberate-- he had at least 2 size choices. A 20cc vial of generic propofol costs our hospital $1.33, and a 100cc bottle costs $9.43. These are wholesale prices, NOT RETAIL. Lopez' pharmacy would have marked it up, but even if he tripled or quadrupled the price, that was "peanuts" in the big scheme of how much money was available. We don't know if CM himself paid out of his contract fee, but I'm betting he did (or thru his NV clinic billing), because if AEG company had set up the billing at the pharmacy, we would have heard about it.
So, I don't think he ordered ENOUGH if he was stockpiling for a long tour.
And I agree with Sprocket that IF there was a stockpile at the girlfriend's home, or in the mansion, it would have been found by search warrant or family. AND Murray himself would have been shouting it to the rafters that he DIDN'T give very much to MJ-- "see the big pile of unopened vials?? Here they are!"
KZ answer... in two parts.
PART I
To Athena/ Anonymous, 7:36 pm January 24th
Thanks for your comment and question. You are correct that sepsis is a distinct worry with propofol, because the lipid (oil) carrier emulsion supports rapid bacterial colonization. Strict aseptic technique is required when administering propofol. (Please keep this firmly in mind when Part 4: The Death Drip: Explained" is posted. As a preview, IMO the technique could not possibly be described as even clean, let alone sterile.) Prescribing information (the "PI") for propofol addresses handling and storage procedures to minimize the possibility of contamination that could inoculate a patient's bloodstream inadvertently.
You are also somewhat correct that sepsis can lead to respiratory distress, but please understand that while the progress can be rapid, it is not instantaneous. Nor is it without evidence that would be quite apparent at autopsy. The type of respiratory distress that patients with sepsis suffer is ARDS, or Acute Respiratory Distress Syndrome. This is characterized by widespread inflammation of the airways, with resultant "seeping and weeping" of fluid from small airways, which essentially drowns the patient's small air sacs, called alveoli, and no gas exchange is possible. Respiratory arrest is a very late consequence of ARDS from sepsis.
Accute Respiratory Distress Syndrome at Wikipedia
End Part I answer, see next comment for Part II answer.
FROM KZ:
Part II answer
The following is a cut and paste of my comment from Jan. 8, 2011 from CaliGirl9's article, "Michael Jackson's Drugs: A Cast of Characters":
"This is contrasted with respiratory arrest due to a person receiving medications which depress the respiratory drive.
First, from a clinical standpoint, there are 2 ways that respiratory arrest can occur in heavily medicated situations such as was occurring in MJ's bedroom. The "obvious" is a respiratory arrest induced by "too much" medication, which produces central nervous system depression (ie, the body doesn't even try to breathe).
About 3-5 minutes later, the heart will begin to experience abnormal rhythms due to oxygen deprivation and carbon dioxide accumulation, which deteriorate usually to profound bradycardia (very slow heart rate), and then, with no intervention, the rhythm will become agonal, and deteriorate further into asystole (flat line).
The treatment is appropriate positive pressure (ambu bag and high flow oxygen) support, +/- advanced airway measures such an a breathing tube & mechanical ventilator, reversal of any reversible drugs, and support of BP and heart rhythms until such time that the meds wear off.
The second type of respiratory arrest occurs from airway obstruction in a heavily medicated unconscious patient, which can be due to a "mostly appropriate" amount of depressant drugs, before an accumulation of drugs sufficient to shut down the respiratory center in the brain.
This is as simple as observing "snoring" type respirations, as the upper airway relaxes and the tongue occludes the airway. A simple repositioning of the head or a finger beneath the jaw can relieve this type of early respiratory depression and abnormal respiratory pattern IF it is observed by a clinician who knows what to do. (In addition to airway support with supplemental oxygen and a high flow mask or an ambu bag.)
A very common error inexperienced clinicians make when giving sedation for procedures is that they think snoring equals an effective level of sedation, when in fact, snoring indicates an obstructed airway, and impending respiratory arrest. With an obstructed airway arrest, the chest moves in a paradoxical way, with obvious chest and abdominal muscle use, as the body tries to breathe against the obstruction. If not corrected, the heart begins to beat faster (tachycardia from hypoxia and catecholamines released), followed by rapid rate abnormal rhythms, which deteriorate into bradycardic (slow rate) rhythms, agonal rhythms, then asystole (flat line).
The treatment here is to intervene early with airway and positioning support, back off on the drugs, support BP and heart rate as needed, and possibly reverse any reversible meds to restore adequate ventilatory efforts. Advanced measures, such as intubation and positive pressure ventilation as needed.
Almost no one recovers once aystole occurs, no matter why it occurred. It is indicative of a very advanced state of cardiac arrest. (In fact, it is a sign of irreversible death.)
Hope this explanation is helpful!
~KZ
Thanks Sprocket and KZ. I see, stockpiling those quantities doesn't make sense because of the shelf life. The stockpiling occurred to me because of media reports stating that boxes were removed from a storage facility held by Murray in Houston on that day.
Also, I was getting confused by mc v ml. Milligrams was the word mentioned in a Search Warrant, which included an affidvait from Martinez:
"...Murray finally administered 25mg of Propofol (Diprivan) diluted with Lidocaine (Xylocaine) via IV drip to keep Jackson sedated.."
Milligram was also the word he used to describe "the maximum" in the testimony at the prelim:
"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."
The DDA in his question to Fleak is also confusing mg with ml. He mentions the 100mg propofol bottle found in the closet. (Fleak later appears to correct this to say 100ml.)
"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."
Because of the vial quantities used, could you conclude that Murray was using the smaller vial for an initial injection following by the 100cc bottle for the drip?
Martinez (on Murray's actions the last day):
"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."
Anon @ 11:16pm:
We don't know what was removed from the storage facility. That wasn't entered into evidence at the preliminary hearing.
You are not alone Anon. I'm confused by the mg/ml discrepancies too.
The search warrants issued, (link to them in the QUICK LINKS page) which has detailed information from the taped interview with Dr. Murray states MG was administered.
My notes say ML. My notes could easily be wrong, since I'm learning the medical terms and drug names after the fact.
cc and ml are the same thing
mg is SMALLER than ml/cc.
For example, in direct questioning, DDA Brazil referred to a 20ml empty propofol bottle as 200mg, (correct; same thing 200mg = 20ml) totally mixing me up and making me at first THINK there was a 200ml bottle on the premises, when there wasn't.
Hope that helps.
Thanks again Sprocket. Perhaps even Conrad Murray might have confused mg and ml. (Sarcasm.)
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