Murray Trial Day 20 October 28, 2011

Morning Session

Dr White Testimony

Flanagan Direct

They still discuss the variability between people. Propofol’s effect site is the brain and the amounts in the brain are not measurable in living humans so they use alternative measures such as EEG. 

Flanagan shows several papers and graphs that show that levels and effects in patients vary a lot. White explain why models are not representing each and every patient and models are just an average.

Flanagan switches to Dr. Shafer’s graph for Lorazepam (2 doses of 2 mg). White says this is accurate for an average patient but not for MJ. White says if MJ was taking oral Lorazepam, you would expect to see residual levels of Lorazepam from previous days. Walgren objects to the use of word “oral”. 

White says as CM said he treated MJ with Midazolam and Lorazepam, he would expect to find residual levels but White doesn’t know how much MJ was given to make this determination. 

Flanagan shows Shafer’s graph for Midazolam (2 doses of 2 mg given at 3AM and 7:30AM). Actual blood concentration for midazolam in autopsy report was close to Shafer’s model. 

Flanagan shows graphs done by Shafer that combines Midazolam and Lorazepam, another graph that shows 25mg Propofol given over 3 to 5 minutes and another graph combining all (25mg Propofol, 2 doses of 2 mg Lorazepam and 2 doses of 2 mg Midazolam).This combination doesn’t show a dangerous situation. 

Flanagan and White goes over a study and based on that White says that 25mg of Propofol would provide minimal sedation and help with anxiety relief and bring a little sleepiness. White says that CM gave minimal sedation.

Flanagan asks what is moderate / mac/ conscious/ procedural sedation. White says there’s verbal response, airway is unaffected and cardiovascular functions will be okay. 

White says hospitals require doctors that use conscious sedation be trained so that if they mistakenly sedate the patient in a deep sedation they can rescue the patient. 

Flanagan shows that CM has a certification from Sunrise Hospital in Las Vegas for moderate sedation. That allows CM to evaluate the patient, administer sedation, manage a compromised airway, provide adequate ventilation in case of apnea, rescue a patient from deeper sedation, and monitor the patient to evaluate sedation.

Flanagan shows Shafer’s graph for 40mg Lorazepam. Initially the doses started around 12:00AM but later Shafer corrected the time. White says the average patient would be dead at the very least comatose for several hours, receiving 40mg over 5 hours. Shafer did that simulation because of the 10ml vial found at the house. For Shafer’s modified simulation ( 9 doses of 4 mg each starting at 1:30AM), White says it doesn’t fit with the vial found in the house. Also last doses would have been given when he was still asleep. 

Flanagan shows the graph with 40 mg Lorazepam with 2 doses of midazolam and Lorazepam. White says that it doesn’t make sense when MJ was highly sedated with Lorazepam, Midazolam would be given to him. 

Flanagan shows a computer simulation: 2 doses of 2 mg Lorazepam (2AM and 5AM) and an oral dose of 20 mg (10 pills taken at the same time) at 7AM. This graph assumes there was no residual Lorazepam from previous days.

Flanagan shows another graph. It’s the same but assumes a residual level for 10mg for last 5 days. It would achieve the same result with 16 mg oral Lorazepam (8 pills) taken at 7AM. 

Flanagan says the amount of Lorazepam in MJ’s stomach was very low. White says the pill will dissolve in 15 minutes and the absorption halftime is 22 minutes. White says that it’s normal that there was a little Lorazepam found in his stomach.

White says that his Lorazepam simulations are more reasonable and that 40 mg simulation of Shafer is irrational. White says the simulation with residual level is more realistic. 

White says that maybe MJ didn’t take 8 pills at once. Maybe he took a few at one time and then later took some more such as at 6 AM and 8 AM. White says it’s a speculation but it’s more reasonable than 4mg boluses every 30 minutes. 

White explains the small amount of Lorazepam in the stomach by absorption half-life.

Flanagan mentions another article and asks finding equivalent of 1/300th of a pill in stomach is consistent with White’s simulation. White says you would not expect to find free Lorazepam in the stomach if it was given via IV. 

Mid morning break.

White says that as there was free Lorazepam in the stomach it has to be oral consumption.

White goes over Dr. Shafer’s simulations. White says Shafer’s simulations have Propofol injections in 30 seconds to 60 seconds and say that it’s inconsistent with CM’s interview. White says Shafer’s simulation of 100mg bolus is inconsistent with lidocaine. White says such injection would burn tremendously in small veins. 

White says multiple injections of 50mg is inconsistent with lidocaine levels found at autopsy. White says it would be difficult for MJ to draw Propofol himself 6 times and the defense never claimed that. 

White says 25mg scenario is less absurd as its minimal sedation. Flanagan asks if a person could be awake to do a 25mg injection over 30 seconds and White answers yes. White adds that the blood concentration depends on how fast the injection is done. Slow injection would have less effect on the heart and respiratory system. 

Flanagan shows a graph with Lorazepam and Midazolam and a rapif 25mg bolus Propofol. White says if a fast bolus was put on the Lorazepam levels , the combination could be lethal. 

White says Shafer’s 100ml infusion (IV) was inconsistent with CM’s interview. White says that an IV system was needed and the handle of Propofol was not used. White says bottle in the bag would be too low and it would be dangerous. Also White says if the patient moves or someone touches the tube the bottle could fall. White says he can’t think of a reason to not use the handle and go to the hassle of cutting the bag with a knife. 

White says before the infusion pumps the practice was to empty the propofol bottle into the saline bag. If you do that when the bag is empty you would see the Propofol residue on the bag and the chamber. There was no propofol in the bag or in the long tube. 

White says there’s no evidence that there was an IV and says that he think there was no infusion.

White again mentions Shafer’s simulation of 100ml IV. He says it’s an incredible coincidence that the patient dies when the bottle runs out. 
White also says that Propofol in the urine doesn’t support the 100ml IV over 3 hours. White says according to urine levels the most consistent scenario is a self injection of 25mg Propofol between 11:30AM and 12:00PM. 

White says that Shafer’s scenarios don’t reconcile with CM's statement, evidence at the scene, urine concentration. White says his scenario with self injection fits fit everything. 

Court ends early. Media reports that Prosecutor Walgren asked for time to get ready for cross.