Murray Trial Day 12 October 13, 2011

Morning Session

Dr Kamangar (NK) Testimony continued

Flanagan cross

CM treated MJ with Propofol with no problems for 2 months.3 days before MJ’s death CM tried to change the treatment. NK says he read it in CM’s statement police. 

Flanagan asks if he experience any patient that was resistant to his recommendations. NK says he would send them to another specialist if it’s not in his area of expertise such as psychological issues. NK says he would realize his limitations. 

NK says patients have right to refuse therapy as long as they make an informed decision.

Flanagan asks what if a patient is totally resistant and wants to do it in a certain way, what he would do. NK says he would refuse the treatment and try to understand the problem and why the patient does want it and may refer the patient to another specialist.

Flanagan asks if CM had these conversations with MJ. NK doesn’t know as there were no medical records. 

NK says if a patient asks for inappropriate therapy you need to get to the root of it. You should try to understand why they are refusing an appropriate therapy and try to get the appropriate care for that patient. He would make sure that they get the right care and says that he would not give the patient a care that he thinks is inappropriate.

Flanagan says CM gave propofol for 2 months and MJ had no problems. NK says he can’t answer because he doesn’t know MJ’s state of mind and his situation. 

NK says in the evaluation of the degree of deviation from standard of care, the end result doesn't matter. He didn’t consider MJ’s death. Flanagan says a doctor can practice bad medicine but the result might not be bad. NK says it doesn’t make it okay. Even if a treatment doesn’t cause death, it might still be gross negligence. 

Flanagan asks if NK can tell what happened on june 25th. NK says MJ was receiving very inappropriate therapy in home setting, with inappropriate cocktail drugs, with inappropriate equipment, in a dehydrated patient, delay in calling 911. NK says it was a disaster that resulted in MJ's death.

Flanagan asks what was an inappropriate cocktail: valium + mizadolam +lorazepam+ 25 mg propofol. Flanagan asks if this cocktail can cause MJ’s death. 

NK says “absolutely”, especially combination of Propofol and lorazepam, in a dehydrated patient, whose vitals were unknown ( blood pressure, heart rate etc ). NK calls this the “perfect storm” that killed MJ.

Flanagan says NK doesn’t know if Murray had that info or not. NK says CM didn’t record anything, had no records; there was no way to determine the trends and changes. Flanagan says not having documents doesn’t mean CM didn’t know those vitals. NK says not having documentation means that CM didn’t have the information. NK says you can’t take care of a patient only from a memory. NK says it’s a recipe for disaster. 

NK gives an example of being with a single patient for long hours. NK says they keep notes. NK says needs to refer to the charts frequently to get a better picture. It's imperative to have charts. NK says without them you can’t see the trends and see differences. 

Flanagan asks if NK thinks there's no way CM remembered what he was doing. NK says keeping records is standard care especially when you give such a powerful drug as propofol. 

Flanagan says not keeping the charts, for example not writing down 2 mg Lorazepam, did not kill MJ. NK says he’s talking about vital signs, it’s not only about writing the medicines. NK says it's a combination of many factors that killed MJ and says the failure of chart is a contributing factor. NK says it’s bad medicine to not keep charts. 

NK says MJ death was directly caused by Propofol + Lorazepam. NK says Lorazepam increased the side effects of Propofol. NK says it can be a lethal combination in a patient that is not monitored. 

Flanagan asks questions about levels of the medicines, NK says he wants to defer it to a pharmacologist.

Flanagan asks if NK reviewed the records of Arnold Klein and saw that he gave MJ 6500 mg Demerol (pain killer) with Midazolam (sedative) over 3 months. Flanagan asks if MJ had a Demerol problem. NK says he cannot answer that question. 

Flanagan asks if 200mg Demerol is a large dose. NK says it’s a significant dose and says he avoids using Demerol because it makes someone more hyper, excitable and creates more stimulation. Flanagan asks if Demerol can cause insomnia. NK says it’s correct. 

Flanagan asks if MJ had insomnia problems. NK says he clearly had insomnia. Flanagan asks if NK made a determination of what type of insomnia. NK says doctors made no effort to determine that. NK says there were suggestions about the reasons for MJ’s insomnia such as performance anxiety and issues with certain medication (Demerol). 

Flanagan asks if MJ had refractory insomnia. NK says he cannot say that. 

Flanagan asks if he read CM’s records from 2006 -2009 on MJ. NK says CM gave MJ sleep medications as well as knew he was prescribed sleep medicines by other doctors. Flanagan says multiple doctors prescribed sleep medicines. 

Flanagan asks if NK ever had a patient that was not forthright in their medical history. NK says he tries to get information from patient and from other doctors and hospitals. Flanagan says patients have to sign a release; they can’t get the medical records. NK says it’s true. NK says if they can’t get information from the patient, they would ask people that live with the patient for information and use sleep diary logs. NK says without getting these information we wouldn’t give Ambien to a patient. NK says if a doctor gives Ambien without a work up it would not be a serious deviation. NK says the doctor still needs to determine the cause and gather information.

Flanagan mentions physical examination and asks if an enlarged prostate can cause insomnia. NK says urination problems can keep a patient up. Flanagan asks if they would check the arms for needle marks. NK would be a part of a physical exam. Flanagan asks if he can determine if a person is taking intra muscular Demerol. NK says you can able to see it in some individuals and not by some. 

NK says CM could have understand if MJ got Demerol from MJ’s behavior, slurred speech and from people who witnessed the change of behavior such as the bodyguards. NK says CM could have talked to his security, assistant and CM could have confronted the patient. 

Flanagan asks if there are studies about Propofol as a treatment for insomnia. NK says they are just experimental and it’s in no way in a standard of care. They go over the Taiwan study. It dates back to November 2010. Patients had been extensively evaluated, informed consent was obtained, and they fasted for 8 hours. The study was done in a highly monitored setting, receiving propofol via an IV pump. 64 patients received propofol. Patient fell asleep better and have less sleep interruptions. Patients had no complications because they were highly monitored. It's very preliminary experiment with good results. It has no clinical applicability and the doctor that conducted the study stated that there was need for further study. 

Flanagan asks why it is incomprehensible to use propofol for insomnia. NK says it was a study, in a highly monitored setting. NK says it is incomprehensible and inacceptable to give Propofol, especially with no monitoring and home setting. 

Flanagan asks if 25 mg propofol is a very low dose. NK says yes. Flanagan states you wouldn't expect problems with such a small dose. NK says it depends on the patient. Such as if the patient is dehydrated (low blood pressure), had other medication (such as lorazepam) etc, there can be a problem that can lead to respiratory depression. 

Flanagan asks questions about Lorazepam. NK says it’s not FDA approved for primary insomnia, especially the IV form. Lorazepam in oral form can be used if cause of insomnia is anxiety, for a very short period of time of 3 to 4 weeks. NK says oral form is appropriate for a short period of time as it created dependency and IV is inappropriate because monitoring is necessary. Even with monitoring, it’s not FDA approved for insomnia.

Flanagan asks if Lorazepam was appropriate with anxiety due to This is it. NK says there should have been a psychological or psychiatric help and says he would not have used it in this case and try to cure the underlying issue. 

mid morning break

NK states that Ativan/Lorazepam in short periods of time, can be used for secondary insomnia associated with anxiety, even though it is not FDA approved. NK stresses that either drug should be only used for secondary insomnia, not primary insomnia.

NK states that Murray indicated he had a bag of saline infused, but because there was no charting of medical records, there is no way to know how much saline was being infused into MJ.

NK states that MJ was producing urine, based on Murray's interview with LAPD. 

NK states that 25 mg of propofol would sedate someone for 6-10 minutes with no other meds, with no residual effects. NK states he would expect the person to have an increasing consciousness, and that the person would wake up by the 6-10 minutes. NK states he would not expect a patient to sleep after that time period, even if they were extremely tired. NK states that it would be the doctor's obligation to determine whether the patient was sleeping (if possible) and wake them up, and determine if they are responsive to stimuli. 

NK states that even if a doctor has the lack of judgment to use propofol like Murray did on MJ, it is incumbent on the doctor to continually monitor the patient.

NK states that by visually monitoring, there is no way to determine if the patient is naturally asleep or still sedated. NK states that propofol can be used for conscious sedation in a highly monitored setting.

NK states that in his initial report, he stated that MJ had massive doses of propofol. NK states that he believes that MJ was given an unregulated drip IV of propofol, after the initial injection push of propofol. 

NK states that he believes that the sequence most likely is that MJ had a respiratory arrest, causing cardiac arrest. 

NK states that Murray should have called 911 first, especially given the lack of tools Murray had available. NK states that he should have determined whether he was breathing, determined his pulse, manipulate the airway, and tilt the jaw back to determine if there was blockage. 
NK states that he is aware that there were no working landline phones at Carolwood. NK states that he is aware that the 911 call took 2:43, and that paramedics got there in less than 6 minutes.

NK states that even if MJ self medicated with excessive Lorazepam and bolus pushed propofol, Murray is still responsible for MJ's death. 

Walgren Redirect

NK states that he would call 911 immediately, it's a moral/professional obligation, but it's basic common sense as well.

NK states that Walgren provided him with Dr. Klein's medical records. NK states that Murray stated in his interview with police multiple times that he was aware that MJ was seeing Dr. Klein.

NK states that the study done in China on propofol was done in a hospital, highly monitored, using a very precise drip, was used as an experiment and would need another study done to positively state that propofol could be used for insomnia.

NK states that one of the fundamental tenets of the doctor/patient relationship is putting the patient first. NK states that this means knowing when to say no to a patient, and that if, assuming MJ asked for the propofol, the doctor has the professional, ethical and moral obligation to say no. 

NK states that he makes the final decision as to the appropriate care of the patient, not the patient. 

NK states that Murray's interview indicates his inability to give precise information about oxygen saturation, although Murray indicated the oxygen saturation was in the high 90's and then stated 02 saturation was 90. 

NK states that a doctor could be grossly negligent and survive, however in MJ's case, Murray was grossly negligent in multiple cases and this is what caused MJ's death.

Recross Flanagan

NK states that Murray said he immediately performed CPR, but that NK should have called 911. NK states that he is aware Murray said he went partially down the stairs, but that nobody could do the same job as the paramedics, so that should have been done first.

NK states that although Murray states he asked the chef to call security and she did not do so, NK is not sure whether he is aware of that fact.

Re-redirect Walgren

NK states again that Murray should have immediately called 911. 

Re-recross Flanagan

NK states that if there was someone in a hallway, and he was in a room with a person who was medically down, he might shout to the hallway, but ultimately it is his responsibility as a doctor to call 911. 

Dr. Steven Shafer Anesthesiology Expert Testimony

Walgren Direct

SS states that he is a professor of anesthesiology at Columbia University, adjunct professor and Stanford and UCSF. SS states that he has worked at Columbia since 2007, at Stanford since 1987, tenured at 2000. SS states that he teaches a class in pharmacokinetics at UCSF. 

Pharmacokinetics deals with math models that deals with drug concentrations in the body to determine what the drug actually does to the body, which helps determine dosages of meds and what is effective and what is not. 

SS states that pharmacokinetics is a discipline that is growing, and that it determines labels for every med, core of pharmaceutical companies, core of FDA, and services doctors on how to use the med safely and reduce toxicity.

SS states that the three schools he hold professorships at are ranked among the top medical schools in the US.

SS states that he is editor-in-chief for the journal Anesthesiology and Analgesia, which publishes manuscripts (studies) of issues related to anesthesiology. Among the 70 board members that sit under Shafer, SS states is defense witness Dr. Paul White. SS states that the journals' acceptance rate for manuscripts is roughly 21%, so about 4 out of 5 submitted are rejected. SS states that due to the editor in chief position for the journal, he is exposed to unusual cases that he never thought he might read about.

SS states that in 1987 the FDA had problems determining proper dosage levels of Midazolam, therefore the FDA was very particular about dosing instructions for infusing propofol. SS states that he did the infusion rate analyses and the start rate of propofol for the label AstraZeneca. 

SS states that in particular, he analyzed the reduction of dosing in elderly patients, and that almost all label dosing was done by SS in 1991. 

SS states that drugs that are marketed, one drug is marketed as a chemical name, in this case propofol. SS states that the retail name is Diprivan, and that it differs slightly from propofol because there is a fat solution (emulsion) added to the propofol.

SS states that max sedated means monitored anesthesia care, the care a patient expects, with a controlled dose, and monitoring. SS states that titration means increasing or decreasing the dose according to each patient. 

SS states that pharma means drugs, kinetics means motions, so pharmacokinetics means drugs in motions. SS explains that when meds are given, drugs go thru several processes or motions, first when meds goes into the patient it becomes more diluted. Second the bloodstream takes the drug everywhere in the body, delivers to the brain, and will move the drug to the liver and metabolized there. SS states that the liver chews the drug up, that the pieces can go to the blood, or to the bile, then to the intestine. SS states that they can go to the kidneys and the kidneys then remove the blood from the body. 

SS states that he is an expert in pharmacokinetics, specific to propofol. SS states that he developed the module of the software that eventually determined propofol dosing on labels for all propofol bottles. 

court ends early due to a scheduling issue. There's no court on Friday October 14 as well. Testimony will resume on Monday October 17.