T & T is pleased to offer guest commentary from KZ. KZ, a practicing nurse anesthetist, has offered knowledgeable commentary regarding the use of propofol and correct medical techniques. This is the first of two write-ups.
Anesthesiology Consult:
I agree with everything medically that Selma Calmes enumerated. I have some issues with how she portrayed "other" anesthesia providers in her commentary, but that is another long discussion! I think, if anything, she did not elaborate enough about a number of issues. Her comment: "It is not known whether trained medical personnel were continuously observing the decedent while propofol given" could actually help the defendant. He could claim to be a trained medical person continuously observing the decedent, but I think he'll lose that one with the phone records.
Medical Evidence Analysis Summary:
See my comments in the IV technique document I sent earlier (Caligirl9 note: This will be posted later today or tomorrow; there are visuals that go with that excellent write-up). That explains why propofol was not found in the remaining bag or tubing. (And may I comment that the senior criminalist was a bit light on the details of what size IV bags, what crystalloid they contained, and what size needles and syringes he documented in the autopsy report?! How about the brand name of the IV tubing, and mini or maxi drip, needle-less, etc. Nothing documented. But maybe there are other evidence docs with this that we don't have access to.)
Summary of Positive Toxicological Findings:
The propofol in the vitreous humor and the propofol and lidocaine in the gastric contents is a VERY small amount. I believe 70cc of dark fluid stomach contents were described. With the specimen scale noted as ug/ ml or ug/g at the top of the chart, it is difficult to interpret the gastric contents. Is it 0.13mg propofol PER ML of stomach contents, or 0.13mg total volume?
Gastric Propofol: Propofol comes 10mg/ml. 0.13mg, which is 0.013ml of propofol, and extremely tiny amount. Taking stomach contents into account, it is possible that result is some kind of diffusion from the arterial or vascular system. If that is so (and I'm no toxicologist!), all that says is that MJ's arterial and venous system was saturated with propofol to the extent that passive diffusion into avascular fluids (gut and eye) occurred! (The DRUG molecules only, not the lipid delivery system, the white stuff. The drug molecules are what is measured in the vitreous, also.) Still looking for a journal article comparing venous concentration with vitreous and gastric concentrations by diffusion. Don't know if I'll find one, though. If MJ had consumed a portion of propofol orally close to his time of death, it would have been visually noted in the gastric fluid recovered, or in the duodenal contents. The ME would have recorded "white liquid" or something like that, in the narration of stomach contents. Instead, the narration says "70g of DARK fluid." (My emphasis.) Remember that propofol is a lipid (fat) suspension, and the white liquid lipid portion would likely not break down until bile acids had acted upon it. So I think the oral ingestion hypothesis (ie, MJ woke up and drank some propofol) is not a very likely scenario, IMO.
Gastric Lidocaine: Lidocaine 1% is 10mg/ml, which is the most common preparation available for admixtures, and likely what Murray had. So 1.6mg of lidocaine is 0.16cc of 1% lidocaine. That is a TINY amount that could possibly be attributed to some kind of diffusion, like the propofol.
Monday, January 10, 2011
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15 comments:
Thanks for this information. Keep up the great work.
Anne
Thanks KZ (and Sprocket). Very much looking forward to the IV technique documentation.
I found your theory (from prelim blog Day 1) about administration following asystole in relation to blood levels more than interesting - it's something I've been trying to find out more about without success.
Would also be interested to hear what you have to say about the empty oxygen tank and the non-rebreathing bag and mask found (anesthesiology report in AR).
Anon,
I have to give credit where credit is due. I had no input into this entry. It was all another T&T writer, CaliGirl9 & blog reader, KZ.
Hopefully they can answer your questions.
Apologies for leaving out CaliGirl9. Sincere thanks to all involved with this site.
ug/ml - The 'u' is not actually a u but the Greek letter m (miu), which stands for micrograms. This shows the concentration of the substance, not the total amount.
PS, you are entirely correct about the microgram abbreviation. Unfortunately, not all fonts have all the symbol options, and it isn't an option for me in this window. Many health care professionals use "ug" as a shorthand; others use "mcg".
And so everyone is up to speed on metrics, there are 1000 micrograms in one gram. And a mililiter is the same thing as a "cc", which is cubic centimeter. There are 1000 cc or 1000 ml in a liter (or litre, if you're from the great nation of Canada!) Many health care professionals use ml and cc interchangeably to describe volume. Grams refers to weight, or more precisely, a quantity of molecules. So mg/ ml is the quantity of a substance per a given amount of volume (one ml). (Concentration, as PS said.)
Abbreviations may become more important in a future post about medications, so don't hesitate to ask questions or point out errors.
There may be typos, too! We're all human! Someone once said, it's important to proofread to see if you anything out.
Anonymous, yes, the empty O2 tank adds to the layers of concern/ doubt about Murray's competence and rational decision making on behalf of his patient. Remember that just because Murray is a doctor, he doesn't actually DO patient care in an acute care setting as a cardiologist. He is NOT a cardiac surgeon, either. Cardiologists simply are not trained to deliver sedation or anesthesia, period. Murray suffered from hubris, and he voluntarily killed his patient because of that, IMO.
My initial impression is that the tank was empty because it was either used up, or more likely, "someone" forgot to turn it off after an episode of using it, and didn't bother to figure out how or where to get another one. More importantly, why was there only ONE tank? One tank says to me there was no anticipation that it would be used regularly. Meaning, it was for emergency use only. Anyone who uses O2 regularly has a back up plan; ie, another full tank at the ready. I was a military long-haul flight nurse years ago, and when the plane buttoned up for a medevac, we had to have all the O2 on board we anticipated we'd need, PLUS extra for unforseen emergencies, until we reached our destination. Sometimes our missions were 20+ hours long, in the Pacific theater, and we couldn't exactly drop down to a little island for a new tank! So I think Murray was either too lazy to have it replaced, or didn't know where to go to get a full tank, or just had a complete failure of imagination that he would ever need more. BTW, if nasal cannula O2 supplementation on a nightly basis was a goal, it would have been far better to have obtained a portable home O2 system, or a concentrator, etc, and kept the tank for emergencies. And we don't know what size the tank was, either! I doubt it was a huge H tank, but D or E tanks won't last long.
As to the ambu bag, I'm not at all sure it WAS a resuscitation/ positive pressure bag, without seeing pictures. I have variously read that there was nasal cannula tubing, ambu bag, and "nonrebreathing" bag/ mask present. These are all vastly different delivery devices. Even Dr. Calmes was unsure exactly what kind of bag/ mask was in the bedroom. A poster opined that the paramedics left an ambu behind, but I highly doubt that, as MJ was intubated and being bagged as they departed for the hospital. Paramedics wouldn't leave an ambu behind during a full code.
One more comment about the ambu bag. If there was an ambu bag present, there was absolutely nothing stopping Murray from USING it to attempt to resuscitate MJ. Just because an O2 tank happens to be empty does not mean that the ambu bag was nonfunctional. A resuscitation Ambu bag is SELF INFLATING. It simply means that the person using it would have to be aware that they were only delivering 21% O2, or ROOM AIR, with their positive pressure ventilations. That Murray apparently never even considered this, is more indication of his inexperience and incompetence in caring for patients in an acute care situation.
We have a saying in the anesthesia community that "bad breath is better than no breath at all", and that translates to "SOME room air would have been better than NO air at all!"
Let me add to KZ's excellent commentary: Pretty much any RN would have known to (at minimum) insert an oral airway, which helps move the tongue down and away from the back of the throat slightly, and use an Ambu bag (preferably hooked up to an O2 tank, but they work just fine on room air) on a non-breathing patient.
We do not yet know the truth, nor might we ever know the truth, if Jackson was simply apnic (without spontaneous breathing) or pulseless/in asystole with no electrical activity in his heart, and by all intents and purposes, already deceased, when Murray interrupted his flirty phone call to Texas.
@KZ
What do you think of the last witness testimony and the calculation mistake and the witness saying it can mean oral digestion?
can you explain the mistake to us and what this means medically and for the future of the case.
Regarding the oral propofol ingestion, I do NOT personally think it is at all possible. I think it is remotely possible that MJ woke up with Murray out of the room yakking on his cell phone, and bolused himself from the IV propofol drip. (Yes, I am 100% convinced there WAS a drip infusing-- more on this soon.)
I also think it is equally likely Murray set up the drip and went to another room to make phone calls, while his patient respiratory arrested and died. But oral propofol? 100% NO WAY. That's just my humble, but experienced, opinion!
Stay tuned for much more on this topic here at T & T in the next day or so. We are not done discussing this!
Thanks KZ & CaliGirl9 for your comments on the O2 tank and non-rebreathing bag. There have been reports of empty O2 tanks stored at the property and an interview with a chef (not Kai Chase) saying Murray would be seen regularly carrying an O2 tank outside in the mornings.
I was considering the possibility that it may have been the usual procedure to have the O2 (tank) with non-rebreathing bag and mask used in combination with the benzos/propofol but that after administering benzos and propofol and having the non-rebreathing bag working, the O2 tank may have emptied when Murray was either not present or not monitoring.
Would appreciate any comments either of you have regarding this.
It's obvious that what Dr.M said happened in that room that night is a total BS LIE! I don't know why he is lying? 2 mins in the bathroom? Didn't want to call 911 because they could interrupt his patient care? Didn't give MJ anything that should of killed him? I am beginning to wonder if Dr.M was even in the HOUSE that night let alone the practicing hired doctor! We will never know the truth about what happened to MJ in his final hours but then again the way MJ lived his life he probably wouldn't want us to know anyway..
Great summary KZ and so easy to understand. It is much appreciated.
Just a comment on his stomach contents. Even if it were possible that MJ drank propofol; why would they have also found lidocaine in his stomach contents? I do believe it was port mortem diffifusion of the drugs and not that MJ drank it.
Would be very interested to read the KZ document (with visuals) explaining the IV technique. Is this still to be posted?
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