Murray Trial day 21 October 31, 2011

Morning Session

Dr White Testimony

Walgren cross

Dr White is retired after 30 years of clinical care, teaching and research. White says he’s an expert in the use of Propofol, not expert in pharmacokinetics and dynamics modeling. He asks other people to do that such as Dr Shafer.

Walgren asks if there were instances Dr Murray deviated from standards of care on June 25th and the preceding 2 months. Dr White agrees.
Walgren asks what did Dr. White understood from CM’s police interview. White says he understood CM gave 25mg to 50 mg Propofol with 5 CC of lidocaine. Based on interview, could not say how CM administered the drip. White says there could be a number of possibilities about the drip and multiple IV tubes as described by Dr. Shafer is one of the possibilities.

White agrees and says that giving Propofol without proper monitoring could be dangerous and could result in cardio-respiratory depression. White says at the minimum he would want to have an ambu bag. 

Walgren asks White if he has given Propofol in a bedroom. White says he has never heard of it. White says that he knows Propofol being given in medical offices and clinics. 

Walgren asks about the suctioning equipment. White says it’s desirable to have it but vomiting is fairly rare. White says pulse oximeter is essential and blood pressure cuff is important. White says for an infusion you measure blood pressure every 5 minutes and for minimal sedation you measure it every 5 minutes. Capnography is not utilized everywhere, White finds it useful but not very precise.

Walgren asks if failing to maintain medical records is egregious deviation from standard of care. White says charts are needed but in this case it didn’t contribute to death. White also classifies it as minor to moderate deviation from standard of cares. 

Walgren asks about pre procedural assessment. It’s when the patients overall condition is evaluated to see if there are any factors that can increase cardio respiratory depression. Respiratory depression from Propofol is mentioned to be rare and generally happens when narcotics are present. 

Walgren asks how much Dr. White has been paid by the defense. White says that he was paid $11,000 so far. White says he also charges $3,500 a day for court appearances but he didn’t ask that because defense doesn’t have the resources.

Walgren asks if White ever had a patient that stopped breathing after Propofol. White says he did (after general anesthesia) and he assited them with an ambu bag and mask or other ventilation techniques such as endotracheal intubation or laryngeal mask.

Walgren mentions doctor’s oath of “do no harm” and asks if CM violated this by giving Propofol. White says CM did not harm. 

Walgren asks who makes the final decision – the doctor or the patient. White says both share the responsibility but the doctor have the option to walk away. White says he would never administer something he considers inappropriate, he would walk away. 

Walgren asks if it is easy to go from a level of sedation to the other. White agrees that the monitoring is required but 25 mg dose is a very minimal dose that would wear off after 15 minutes. He says monitoring a patient for that dose for around 15-30 minutes would be enough and then it’s okay to leave the patient. 

Walgren asks about pulse oximeter without an alarm. White says it has no value when you are out of the room. White also states that 25 mg propofol wouldn’t have effects after 25-30 minutes. Walgren asks if benzodiazepines would have an effect, White says if they have been given hours before they would have little effect. 

White tries to justify CM’s treatment saying that this was an unusual case with the goal being sleep and what CM leaving MJ was acceptable.

Walgren asks what if the patient liked to push Propofol. White says he would not left the room. 

White asks about failure to call 911. White says he cannot justify it but also adds the situation was different, CM didn’t know the address and the house was not easily accessible. Walgren pushes White. White says CM should have called 911 sooner but it wouldn’t have made a difference in this case. White says he would have started resuscitation and call 911 within 3 to 5 minutes. 

White say he doesn’t think everything CM said to the police is true. White says in emergency situations it’s hard to remember the details and CM could have overlooked to mention Propofol and didn’t do it in a devious way. Walgren suggests that the other alternative is that CM lied. White reluctantly agrees. 

Walgren does over the letter White gave to the defense. In the letter it’s written that sedatives, analgesic and benzos may increase the risk of Propofol. White says high concentration of lorazepam and 25mg propofol given too fast causes arrhythmia, and a rapid demise.

White mentions although CM bought Propofol MJ had his own stocks of Propofol. Walgren asks where he saw this information. White says CM told that to Dr. White. 

Walgren shows the IV tubing found in the scene and asks if it is easily concealable and fits in the hand or in the pocket. Dr White admits to that.

Walgren mentions how White speculated that MJ drank propofol and now White rejects that's the cause of death. White says Dr Shafer explained why there could be propofol in the stomach and why it would not cause death.

White says he did his 3 page letter in a very short time as Flanagan needed something from him. White says he did not write any other report. In the letter White wrote MJ self administered either by injecting or orally. Flanagan had mentioned oral Propofol before he wrote the letter and White say he did a search but did not find anything about it. 

Walgren asks if according to White the only option was to blame the victim. White says if CM only given what he said he did, there was to be something else. Walgren asks if White now blames MJ for Lorazepam as well. White says yes. Walgren asks if White took everything CM said to be the truth. White says yes. White says what CM said in regards to drug administration is consistent with the autopsy report. 

Walgren goes over the report and point outs that White now says MJ died of a rapid bolus but he never wrote that in his report / letter. Walgren asks if he came up with any other theory that does not attribute the drug taking to MJ. White says no. 

Walgren asks who Dr. Gabriella Ornelas is. White says she’s a PhD in biomedical engineering. White met her for the first time last week and asked is she could calculate the amount of free propofol you would expect to see in the urine after a 3 hour 100mk infusion. 

Mid morning break

Walgren mentions that Dr. Shafer provided software for the models to the defense and White only provided computer codes on paper. 

Walgren goes over the 10 AM Lorazepam theory. As the peak effect will be in 2 hours it first nicely with 12 AM. Last week when Dr. Shafer testified that Lorazepam had to be taken at least 4 hour prior to death that’s when White met with Ornelas. She created several scenarios. White says he was not aware of the 10 AM Lorazepam theory. 

Walgren asks if MJ came and asked him to work for him to give Propofol , if he would accepted the job. White says absolutely not. He says no amount of money could convince him to do it because of time required, the responsibility and off label use of propofol. 

Walgren asks if White’s 11:40AM self administration theory is based on a lot of assumptions for the lack of medical records. White agrees.

Walgren asks if for his theory he used CM leaving the room for 2 minutes. White says no. 

Walgren asks about the beagle Propofol study. White says that Flanagan knew a veterinarian that could do the study and he had no part in it. White says he only got a report from Flanagan that oral propofol had no effect on beagles. 

Walgren asks when White assumes that MJ took Lorazepam was CM out of the room as well. White says MJ was walking around. Walgren objects as White is telling what CM told him. White says he understood that CM was in the another part of the room (adjacent bedroom etc) or not watching. White says CM wasn’t aware that MJ took Lorazepam. 

Walgren asks White if he’s aware that CM left the room only once. White says yes. He also says that he believes CM was away around 7 AM. Dr. White says when CM was on the phone he was presumably away from MJ because he was sleeping.

White’s theory is that CM drew 50 mg Propofol and lidocaine and gave half of it to MJ and left the half full syringe. White then says CM was in the corridor, Walgren objects as he is once again telling what CM told White. White thinks after CM gave MJ the half the syringe and observed him left him to talk on the phone and went to the bathroom. White thinks MJ could have injected in that 40 minutes.

Walgren asks if MJ injected through the IV port and the syringe was originally on the chair. Walgren asks if wouldn’t it raise an alarm when CM found the syringe in the injection port. Walgren also asks if according to his theory MJ fell back to bed in the same position.

Walgren asks if it’s White’s understanding that MJ moved around the house wheeling an IV stand with a condom catheter on him and a urine bag attached to his leg. 

Walgren asks if isn’t it a possibility that CM injected the additional Propofol. White answers yes if he wanted to harm MJ. 

Walgren asks if putting MJ to sleep was mild/ minimal sedation which means response to verbal stimuli. Walgren asks if it makes sense to him. White says providing sleep doesn’t need a higher level of sedation.

White says he believes that MJ didn’t receive Propofol on the 23rd and 24th based on the urine levels. 

White says during the 6 weeks prior CM gave MJ 1 or 2 boluses of Propofol (25 to 50 mg) and followed it with an infusion with the Propofol bottle. Walgren again objects as White is once again telling what CM told him. White speculates that it was minimal to moderate sedation. 

Walgren cites several articles written by Dr White. One article says that MAC (moderate sedation) requires the same level of standard of care as general anesthesia. 

Guidelines for Office based anesthesia (written by Dr White) :
1-appropriately trained personnel
2-anesthesia equipment
3-complete documentation of care provided 
4-monitoring equipment
5-recovery area with appropriate staff
6-availability of emergency equipment
7-plan for emergency transport of patients to a site that provides more comprehensive care, should a complication occur
8-documention on a quality assurance program
9-continuous training of physician
10- safety standards that can't be jeopardized for patients' comfort or cost 

Walgren asks if these standards should apply if Propofol is administered in a bedroom ? White says that he wouldn’t give it in a bedroom and White eventually agrees that giving Propofol in a home requires the minimum requirements of office based anesthesia 

Lunch break


Murray Trial Day 21 October 31, 2011

Afternoon Session

Dr White Testimony

Walgren cross

Walgren continues with quotes from Dr. White's books/articles: "because of the profound risk of cardio respiratory depression, propofol should always be administered by anesthesiologists, not by gastroenterologists, etc (other doctors)". White states that the book was published in 1996, things have evolved since then. White states that he would agree that propofol has profound a risk of cardio respiratory depression, but it can be administered by trained doctors other than anesthesiologists, in a proper setting.

White states that the guidelines for sedation, for non anesthesiologists are: "even if moderate sedation is intended, the same standard of care should be applied as for deep sedation" and that "because it's not always possible to predict how a patient will react, the caregiver needs to prepared to rescue a patient from deep sedation."

Dr White agrees that for moderate sedation (when an infusion is used), the patient should receive the same care as for deep sedation. 

For mild sedation, Dr. White states that the doctor should be prepared in the event that the patient goes into moderate sedation, not deep sedation.

Dr. White states that he wouldn't administer propofol in a home, but thinks that these guidelines should be followed with an infusion. White states that he doesn't know if a second person is necessary, assuming the doctor is monitoring the patient, while the propofol is being administered.

Walgren asks what about administering benzodiazepines and a propofol bolus? Dr. White states that in an ideal situation, it would be great to follow the guidelines.

Walgren shows Ornelas model with 25mg propofol infused over 3 to 5 minutes versus a 25mg fast injection and the differences in blood concentration and free propofol in urine levels. Her model is based on a 1998 article.

Dr White has not read the article in detail. Dr White had a conversation with Ornelas at the Flanagan’s house for a few hours at the end of last week. The models Dr White testified to, were not done by him, he is not an expert in models.

Walgren again shows the model with Murray infusing 25mg at 10:40 am versus MJ self injecting at 11:40 am. Before the self injection, blood level was near 0.

Walgren shows a zoom of the same graph, zooming on the self injection. Dr White believes that self injection occurred later than 11:40.

Dr White thinks this scenario is the most likely as it’s consistent with Murray's interview with LAPD, not recovering the tubing, matches the concentration of free propofol in the urine, matches blood concentration.

Walgren shows another zoom of the same graph, over 10 minutes, showing only blood concentration. The circulation stops almost immediately. Dr White says it could have been arrhythmia, the cause is unclear.

Walgren brings up the autopsy report: MJ had no heart problems. Dr White says that doesn't preclude an arrhythmia.

Murray told LAPD that when he returned to the room, MJ's heart rate was 122. Dr White said it's unclear what 122 was and it could have been the saturation. Walgren reads the police interview; Murray also reported that he felt a thready pulse. Dr White says that Murray might have felt his own pulse, he was under stress. He might not have felt a perfusing pulse. Walgren: "This fits with you new theory that MJ died instantly"

Dr White states he doesn't see any evidence of respiratory arrest, or cardiac arrest, or both combined.

Walgren goes back to March 8th letter White sent to the defense. First cause of death Dr. White thought of is respiratory depression. Dr White corrects "cardio pulmonary depression" among other things. Walgren mentions the oral consumption is one of the other things.

Walgren shows models of lorazeapm (multiple 4 mg injection, 2 X 2 mg IV +16mg oral). 

The graph shows 0.0013 mg in the stomach, Dr White doesn't know where this number comes from, but it is smaller than the 0.006mg. 

White states that the fact that there is free lorazepam in the stomach suggests oral ingestion.

White states that residual lorazepam is an assumption of 10mg for the past 5 nights.
Walgren shows the graph where Murray would have injected 25mg of propofol, and where MJ would have self injected. When MJ self injected, the lorazepam was a little lower.

Walgren again goes back to Ornelas model with 25mg propofol over 3 to 5 minutes, 25mg fast injection blood concentration and free propofol in urine levels. Walgren asks why it doesn’t show the effect site (brain). White says it’s because she was only asked about the free propofol in the urine. 

Graph by Dr Shafer added effect site concentration to Onnelis' graph: the levels at effect site are the same in both Murray's injection, or the supposed MJ's self injection. Dr White says these numbers are meaningless, because of variability. Dr White would be more interested in the heart concentration.

Afternoon break

Walgren asks White if he did any research to make sure that the 0.3% used by Ornelas (0.3% of the propofol is excreted unchanged) was accurate. White says it’s his feeling that it was the most conservative number. 

Walgren shows an article used by Dr Ornelas as a basis for her analysis. It was published in 1988. It indicated that less than 0.3% of propofol is excreted unchanged, but the model uses 0.3%. Dr White recalls a paper that said 1% . 

Walgren asks based on this paper (less than 0.3%), could it be 0? Dr White doesn't agree.
Walgren says that the article says that 0.3 could be an overestimate. Dr White says that the difference with a 3 hour infusion would still be huge.

Walgren shows a 1991 article about animals (dogs, rat). There was no unchanged propofol at all whether it was bolus or infusion. Dr White says he doesn't rely on articles about animals, he would prefer to rely on articles about humans.

Walgren shows a 1999 article: they found no free propofol in the urine. Dr White indicates he did not search the subject 

Walgren shows a 2002 article in which the levels found were much smaller. Objection, sustained. The judge asks Walgren to change the subject.

Flanagan redirect 

Flanagan talks about 911 not being called for 20 minutes. Flanagan says mentions that it was a large house, fenced, gate closed that can only be opened by security, guards were just outside the kitchen, incident happens upstairs , there are no landlines. Flanagan asks would it be unreasonable to ask a person in the kitchen for help. 

White says he would resuscitate the patient and ask the person in the kitchen, it sounds more reasonable than going to security.White says that CPR should be given within 1 to 2 minutes, and sustained for at least 3 minutes, before leaving the patient. 

Flanagan asks what kind of CPR should be given. White says mouth to mouth and adds that an ambu bag would be better but mouth to mouth is a possibility.

Flanagan asks Dr. White what would be his assessment if the patient was not breathing and his eyes and mouth were open. White says he would assess the patient to see if they are alive as they are often a sign of death. 

Flanagan asks if the patient was dead at 12:00PM, could anything be done. White says if the patient was dead, not keeping a chart would not have changed anything. 

Flanagan asks White if he would suspect Propofol to have anything with the death. White says if the propofol was given at 10:40 and the patient was dead at 12:00 he wouldn’t suspect propofol. 

Flanagan asks after the EMT’s received the authorization to declare the patient dead if the further attempts was realistic and had a chance of saving the patient. White says no.

White says even if the ER doctors had known about propofol, it would not change the outcome. 

Flanagan and White talk about 25 mg Propofol bolus over 3 to 5 minutes. White says if it had any negative effects it would be apparent by the end of the bolus and there would have been no reason to suspect anything at a later time. 

Flanagan asks about concelling the IV tube and White says it’s easier to conceal an IV tube than an IV bag but if the IV tube was in a pocket there would be liquid in the pocket. 

Flanagan mentions that at preliminary hearing 2 witnesses indicated the possibility of oral consumption of propofol.

Flanagan asks if Walgren has contacted Dr. White. White says Walgren called him and they talked. White said that he was contacted by the defense. Walgren asked him if he was paid and White said he was. White says this is his only source of income.