DR. RICHARD RUFFALO
DIRECT EXAMINATION
BY MR. WALGREN:
Q GOOD MORNING, SIR.
A GOOD MORNING.
Q SIR, WHAT DO YOU DO FOR A LIVING?
A I’M A PHYSICIAN.
Q WHAT TYPE OF PHYSICIAN ARE YOU?
A WELL, I’M AN ANESTHESIOLOGIST AND ALSO A CLINICAL PHARMACOLOGIST.
Q WHAT IS AN ANESTHESIOLOGIST?
A WELL, AN INDIVIDUAL THAT DOES WHAT WE CALL PERI-PROACTIVE MEDICINE, BOTH DURING AND AFTER SURGERIES, ACUTE PAIN, SOMETIMES CHRONIC PAIN MANAGEMENT, OUT-PATIENT, AND PARTS OF CRITICAL CARE ISSUES THAT WE DEAL WITH AS WELL.
Q WHAT IS A CLINICAL PHARMACOLOGIST?
A A CLINICAL PHARMACOLOGIST IS AN INDIVIDUAL WHO STUDIES DRUGS AND PRIMARILY IN A CLINICAL SENSE, HOW THEY ARE USED BOTH IN ANIMALS, BUT MOSTLY WHAT I DO IS WITH HUMANS.
Q CAN YOU GIVE ME — TELL US A LITTLE BIT ABOUT YOUR EDUCATIONAL BACKGROUND THAT QUALIFIED YOU OR ENABLED YOU TO BECOME BOTH AN ANESTHESIOLOGIST AND PHARMACOLOGIST.
A OKAY. AFTER I GOT MY BACHELOR’S AND MASTER’S AT UCLA, I THEN WENT TO THE UNIVERSITY OF SOUTHERN CALIFORNIA SCHOOL OF PHARMACY WHERE I RECEIVED MY DOCTORATE IN PHARMACY. I THEN DID A RESIDENCY IN CLINICAL PHARMACOLOGY AT USC, THEN TAUGHT FOR A FEW YEARS THERE AND AT LOMA LINDA SCHOOL OF MEDICINE IN CLINICAL PHARMACY AND CLINICAL PHARMACOLOGY. I THEN WENT BACK TO MEDICAL SCHOOL AT G.W. IN WASHINGTON, D.C., COMPLETED MY MEDICAL SCHOOL TRAINING, STARTED AN INTERNAL MEDICINE PROGRAM AND THEN SWITCHED TO ANESTHESIOLOGY, WHERE I DID THAT AT UCLA. AND FROM THAT POINT ON, I STAYED ON AS, WELL, SHORT-TERM FULL-TIME FACULTY THERE, THEN LONG-TERM AS AN ASSOCIATE CLINICAL PROFESSOR AT UCLA. AND PRIMARILY, MY WORK IS IN CLINICAL PRACTICE AT HOAG IN NEWPORT BEACH.
Q I’M SORRY. GO AHEAD.
A I ALSO DO CONSULTING WITH VARIOUS PHARMACEUTICAL COMPANIES FROM TIME TO TIME AND HAVE DONE RESEARCH IN PHARMACOLOGY.
Q OKAY. AND YOUR WORK AT HOAG, THAT IS H-O-A-G?
A YES, CORRECT.
Q WHAT DOES THAT INVOLVE?
A WELL, IT IS THE LARGEST, I GUESS, LARGEST HOSPITAL IN ORANGE COUNTY WHERE I PRIMARILY PRACTICE MOST OF MY TIME AS A CLINICAL ANESTHESIOLOGIST. SO THAT IS THE MAJORITY. PART OF THE PRACTICE IS ALSO IN CLINICAL PHARMACOLOGY WHERE I DO CONSULTS IN THE AREA OF DRUG TREATMENT, MEANING LOOKING AT POTENTIAL PROBLEMS OR ANALYSIS OF ISSUES, AND SO ON, SO FORTH.
Q THEN YOU INDICATED YOU ALSO ARE A PART-TIME PROFESSOR?
A THAT IS CORRECT.
Q AND WHAT DO YOU TEACH, OR WHAT ARE YOUR DISCIPLINES?
A IT IS ANESTHESIOLOGY, BUT I TIE THAT IN AGAIN WITH CLINICAL PHARMACOLOGY AT UCLA.
Q HOW LONG HAVE YOU BEEN DOING THAT IN EITHER FULL-TIME OR PART TIME CAPACITY?
A ABOUT 20 YEARS.
Q AS A MEDICAL DOCTOR, IN YOUR CAREER HAVE YOU ALSO MADE YOURSELF AVAILABLE TO THE CALIFORNIA MEDICAL BOARD TO ASSIST IN MEDICAL BOARD INVESTIGATIONS?
A I HAVE.
Q AND IS THAT ESSENTIALLY A VOLUNTEER TYPE PROGRAM WHERE DOCTORS CAN PARTICIPATE IN AND ASSIST OR NOT?
A THAT IS CORRECT.
Q AND HOW LONG HAVE YOU MADE YOURSELF AVAILABLE TO DO THAT?
A A COUPLE YEARS TO ACTUALLY DO IT FOR THE MEDICAL BOARD, BUT FOR MANY YEARS I’VE ACTUALLY REPRESENTED DEFENDANTS THAT ARE BEING INVESTIGATED BY THE MEDICAL BOARDS. SO MOSTLY DEFENSE WORK FOR MANY YEARS.
Q WHEN YOU SAY MOSTLY DEFENSE WORK, IN YOUR EXPERIENCE AS IT RELATES TO MEDICAL BOARD INVESTIGATIONS, YOU PRIMARILY HAVE WORKED FOR A DOCTOR THAT IS BEING ACCUSED OF PROVIDING INSUFFICIENT OR IMPROPER CARE; IS THAT CORRECT?
A THAT IS CORRECT.
Q NOW, WERE YOU ASKED TO OFFER CONSULTATION OR YOUR EXPERTISE IN REGARD TO THIS CASE REGARDING THE DEATH OF MICHAEL JACKSON?
A I WAS.
Q IN FACT, DID YOU RECEIVE A LETTER FROM ME BACK IN 2009 ASKING YOU TO REVIEW A BODY OF MATERIALS AND OFFER YOUR OPINION WHETHER THERE WAS ANY DEVIATION FROM THE STANDARD OF CARE AND, IF SO, THE EXTENT OF THAT DEVIATION?
A I DID.
Q WERE YOU PROVIDED A 281-PAGE NOTEBOOK WITH A TABLE OF CONTENTS AND A COVER LETTER FROM ME TO CONDUCT YOUR REVIEW AND YOUR ANALYSIS?
A I WAS. THAT IS CORRECT.
Q DID THAT 281-PAGE NOTEBOOK INCLUDE A NUMBER OF REPORTS AS WELL AS MEDICAL RECORDS, THE AUTOPSY REPORT, AND THINGS OF THAT NATURE?
A IT DID. THAT’S CORRECT.
Q THEN IN RESPONSE TO THE REQUEST FROM THE DISTRICT ATTORNEY’S OFFICE, DID YOU WRITE A REPORT SUMMARIZING YOUR FINDING?
A I DID.
Q DID YOU NOTE IN YOUR REPORT THE MATERIALS THAT YOU HAD REVIEWED?
A I DID. THAT’S CORRECT.
Q YOUR REPORT, BY THE WAY, THAT IS, I BELIEVE, A 47-PAGE DOCUMENT; IS THAT ACCURATE?
A THAT’S PROBABLY RIGHT. THAT IS A LOT OF PAGES. YOU ARE RIGHT. THAT’S CORRECT.
Q ON THE FIRST PAGE OF YOUR REPORT, YOU INDICATE THAT YOU HAVE REVIEWED A COVER LETTER FROM DEPUTY DISTRICT ATTORNEY DAVID WALGREN DATED SEPTEMBER 18, 2009?
A I THINK THAT IS THE DATE, YES.
Q AND THEN YOU GO THROUGH ALL THE MATERIALS THAT YOU REVIEWED, INCLUDING A TIME LINE OF EVENTS, INTERVIEW STATEMENTS, AUDIO RECORDINGS OF THE AMBULANCE TRANSMISSIONS TO UCLA, DR. COOPER’S STATEMENT, DR. NGUYEN’S STATEMENT, DR. MOORE’S STATEMENT, DR. MORGAN’S STATEMENT, UCLA RECORD, VARIOUS CIVILIAN WITNESS STATEMENTS, AS WELL AS THE INTERVIEW OF DR. MURRAY, SOME SUMMARY PHONE RECORDS, SOME PHOTOGRAPHS, AS WELL AS AUTOPSY PROTOCOL AND A DIAGRAM OF THE BEDROOM AREA OF 100 CAROLWOOD. IS THAT A FAIR SUMMARY OF THE ITEMS YOU REVIEWED SPECIFICALLY LISTED ON YOUR REPORT?
A THAT WOULD BE CORRECT.
Q AND REGARDING THE AUTOPSY REPORT, DID YOU SPECIFICALLY INDICATE THAT IN THE D.A.’S OFFICE PROVIDING THAT AUTOPSY REPORT TO YOU, THE ANESTHESIOLOGIST’S OPINION IN CONSULTATIVE REPORT WAS REMOVED FOR YOU NOT TO CONSIDER?
A THAT IS CORRECT.
Q SO YOU HAVE NOT REVIEWED, SEEN, OR IN ANY WAY LOOKED AT THE ANESTHESIOLOGIST CONSULTATION REPORT?
A THAT’S CORRECT.
Q AND THE OPINIONS YOU DREW IN SUMMARIZING YOUR REPORT ARE INDEPENDENT OF ANY SEPARATE ANESTHESIOLOGIST’S REPORT FROM THE CORONER’S OFFICE?
A CORRECT.
Q IS THAT IMPORTANT THAT DOCUMENT WAS REMOVED FROM THE AUTOPSY REPORT FROM YOUR ANALYSIS?
A ABSOLUTELY. IT COULD HAVE BIASED MY OPINIONS.
Q NOW, IN YOUR REPORT THEN, IN THIS 47-PAGE REPORT, YOU GO THROUGH A NUMBER OF TOPIC AREAS; IS THAT RIGHT?
A I DO.
Q I WANT TO GO THROUGH SOME OF THESE WITH YOU. FIRST, I WANT TO SPEAK TO THE TOXICOLOGY ISSUES. DID YOU COVER THAT IN YOUR REPORT?
A I DID.
Q SPECIFICALLY, I BELIEVE YOU MADE REFERENCE TO THE TOXICOLOGY FINDINGS FROM THE CORONER’S OFFICE; IS THAT RIGHT?
A THAT IS CORRECT.
MR. WALGREN: MAY I HAVE ONE MOMENT, YOUR HONOR?
THE COURT: PLEASE.
Q BY MR. WALGREN: DOCTOR, I WANT TO SHOW YOU WHAT WAS EARLIER MARKED PEOPLE’S 68 FOR IDENTIFICATION. I’LL LEAVE THAT ON THE SCREEN. MAY I APPROACH THE WITNESS?
THE COURT: PLEASE.
Q BY MR. WALGREN: SIR, LOOKING AT PEOPLE’S 68, THE SUMMARY OF POSITIVE TOXICOLOGY FINDINGS, WAS THAT ONE OF THE DOCUMENTS YOU REVIEWED IN CONDUCTING YOUR ANALYSIS?
A IT WAS.
Q IN REVIEWING THOSE FINDINGS, DID YOU, BASED ON YOUR ANESTHESIOLOGY BACKGROUND AS WELL AS CLINICAL PHARMACOLOGY BACKGROUND, WERE YOU ABLE TO DRAW ANY CONCLUSIONS OR MAKE OBSERVATIONS REGARDING THE VARIOUS LEVELS OF THESE DRUGS IN THE VARIOUS SPECIMEN SAMPLES?
A YES, I WAS.
Q COULD YOU EXPLAIN THAT TO US, PLEASE.
A WELL, LOOKING AT THE VARIOUS BLOOD SAMPLES EITHER FROM UCLA WHEN MICHAEL JACKSON FIRST ARRIVED, OR THE ONES THAT WERE DRAWN AT THE TIME OF THE AUTOPSY BY THE CORONER OR THE CORONER’S FORENSIC PATHOLOGIST, BASED ON MY KNOWLEDGE AND EXPERIENCE OF DOING THIS FOR MANY YEARS IN BOTH AREAS OF MY EXPERTISE, I WAS ABLE TO DRAW CONCLUSIONS AS TO WHAT THOSE LEVELS MEANT FOR THE VARIOUS DRUGS.
Q IN DISCUSSING PROPOFOL, WHAT CONCLUSIONS, IF ANY, WERE YOU ABLE TO DRAW AS FAR AS THE MEANING OF THE NUMBERS?
A WELL, UNFORTUNATELY, THE NUMBERS, THE ONE THAT IS MOST REPRESENTATIVE WOULD BE THE HOSPITAL NUMBER BECAUSE THAT IS SORT OF — IT IS NOT A TRUE POSTMORTEM BECAUSE THE POSTMORTEM CHANGES THAT OCCUR IN THE BODY OVER TIME AFTER DEATH ARE SOMEWHAT DIFFERENT THAN WHAT HAPPENS IN LIFE. SINCE HE WAS STILL HAVING SOME DEGREE OF CIRCULATION, STILL MANY OF HIS ORGANS WERE STILL GETTING PERFUSED.
Q THAT WOULD BE THROUGH MANUAL COMPRESSIONS, THINGS OF THAT NATURE?
A THAT WOULD BE CORRECT. SO THAT IS MORE CLOSELY RELATED TO WHAT WE CALL A TRUE IN LIFE, IN VIVO, OR ANTEMORTEM BLOOD LEVEL. HOWEVER, ONE OF THE ISSUES IS THAT IT WAS DRAWN AFTER THE PATIENT HAD RECEIVED A SIGNIFICANT AMOUNT OF I.V. FLUID, SO IT WOULD BE A DILUTED VALUE. WE CALL IT HYPODILUTION, MEANING THE BLOOD IS BEING DILUTED WITH EXOGENOUS FLUID. THE LEVEL WOULD BE ESSENTIALLY LOWER THAN WHAT IT WOULD HAVE BEEN BEFORE THE FLUID RESUSCITATION STARTED BY BOTH PARAMEDICS AND AT UCLA. SO THAT LEVEL AGAIN, EVEN BEING LOWER, AND ONE OF THE OTHER UNFORTUNATE ISSUES IS WHEN BLOOD IS DRAWN AND PUT IN A PLASTIC TEST TUBE, LIKE PROPOFOL, IT DEGRADES OVER TIME. THAT MAKES IT AGAIN EVEN LOWER. SO ESSENTIALLY, EVEN THAT LEVEL IS WELL KNOWN TO BE A — WOULD CREATE A STATE OF DEEP GENERAL ANESTHESIA. IN FACT, WHEN WE DO CASES AND IN OUR LITERATURE THAT IS REPORTED, LEVELS HALF THAT WOULD BE ALSO CONSIDERED TO BE EQUIVALENT TO DEEP GENERAL ANESTHESIA IN MANY PATIENTS.
Q YOU ARE TALKING ABOUT HALF OF THE 3.2 HEART BLOOD?
A NO. THE 4.1.
Q THE 4.1 HOSPITAL BLOOD?
A THAT WOULD BE A CLINICALLY THERAPEUTIC LEVEL FOR DEEP GENERAL ANESTHESIA WHERE A PATIENT CANNOT CONTROL THEIR OWN REFLEXES, THEIR BREATHING, VARIOUS THINGS LIKE THAT. SO AGAIN, THAT BEING DILUTED, IT WOULD BE EVEN A HIGHER LEVEL AT THIS TIME ROUGHLY THAN WHEN HE STARTED, OR NEAR DEATH THE LEVEL WOULD HAVE BEEN EVEN HIGHER THAN THAT.
Q BUT OF THE SPECIMENS CONTAINED IN THIS DOCUMENT, PEOPLE’S 68, THE MOST ACCURATE SPECIMEN FOR PURPOSES OF DRAWING ANY CONCLUSIONS WOULD BE THE HOSPITAL BLOOD?
A BY FAR, YES, THAT IS CORRECT.
Q NOW, I THINK YOUR WORDS WERE THAT WOULD BE MOST COMPATIBLE WITH ANTEMORTEM LEVELS?
A THAT IS CORRECT.
Q IN OTHER WORDS, THAT LEVEL WOULD BE, OF THE OPTIONS AVAILABLE, WOULD BE THE MOST CONSISTENT WITH THE LEVELS IN MICHAEL JACKSON’S BLOOD AT THE TIME OF HIS DEATH OR WHILE STILL ALIVE IMMEDIATELY BEFORE THE TIME OF HIS DEATH?
A MORE CONSISTENT, BUT ACTUALLY EVEN LOWER FOR THE REASONS I’VE GONE OVER. THAT IS CORRECT.
Q CAN YOU EXPLAIN WHAT OCCURS AND WHAT IS MEANT BY POSTMORTEM REDISTRIBUTION?
A SURE. IT IS KIND OF A MISNOMER, BUT IT MEANS THAT VARIOUS DRUGS, DEPENDING UPON WHAT KIND THEY ARE, COULD CHANGE THE CONCENTRATION THAT IS FOUND IN THE BLOOD, EITHER HIGHER OR LOWER, DEPENDING UPON WHAT KIND OF DRUG IT IS. IT ALSO DEPENDS UPON WHERE THE SAMPLE IS DRAWN FROM. FOR EXAMPLE, IN THIS CASE, HEART VERSUS FEMORAL. FEMORAL MEANING THE VEIN OR ARTERY AT THE GROIN AREA. IT ALSO DEPENDS UPON HOW THE BLOOD IS STORED ONCE IT IS DRAWN AND REFRIGERATED UP UNTIL THE TIME OF ANALYSIS BY THE TOXICOLOGY LAB. AND ALSO THE BODY TEMPERATURE AND ISSUES OF DECOMPOSITION THAT OCCUR BOTH AT ROOM TEMPERATURE OR BODY TEMPERATURE, OR EVEN WHEN REFRIGERATED IN THE MORGUE. ALL THOSE THINGS HAVE VARIOUS EFFECTS. THEN A LOT OF OTHER WHAT WE CALL PHARMACOLOGIC EFFECTS THAT ALSO ACCOUNT FOR HOW DRUGS WILL CHANGE THEIR BLOOD LEVELS AGAIN IN DEATH AND DEPENDING UPON WHAT TYPE OF DRUG THEY ARE.
Q IS THERE, BASED ON THE DRUG THAT YOU ARE LOOKING AT, BASED ON YOUR TRAINING AND EXPERIENCE, DO YOU HAVE WAYS TO PREDICT OR INTERPRET THE REDISTRIBUTION OF THESE DRUGS IN THE BODY POSTMORTEM?
A TO SOME EXTENT. THE MORE KNOWLEDGE YOU HAVE, HOW FAST THE BODY WAS CHILLED DOWN, OR WHERE THE SITE WAS FROM, HOW LONG FROM DEATH UNTIL THAT BLOOD SAMPLE WAS DRAWN, HOW THE SAMPLE WAS MAINTAINED, WAS IT PRESERVED WITH USUALLY SODIUM FLUORIDE, OR WAS IT UNPRESERVED TO INHIBIT ANY FURTHER DEGRADATION OF THE DRUG BY OTHER MEANS, EITHER BACTERIA OR INTRACELLULAR METABOLISM, THE MORE YOU KNOW, THE BETTER IDEA YOU CAN HAVE. IT IS SORT OF SOMEWHAT IMPERFECT.
Q THERE ARE A LOT OF VARIABLES THAT COME INTO PLAY IN TRYING TO DO THAT ANALYSIS?
A THERE ARE A LOT OF VARIABLES, BUT FORTUNATELY THERE IS A LOT OF LITERATURE IN FORENSIC TOXICOLOGY LITERATURE WHERE WE HAVE COMPARED, YOU KNOW, DEATH IN PATIENTS WHO HAVE TAKEN CERTAIN DRUGS. AND SOME OF THEM DO ANALYSIS BODY TEMPERATURE STORAGE, LOOKING AT VARIABLES, AND THEN LOOKING AT A BROAD SPECTRUM OF DEATH PATIENTS THAT HAVE INGESTED DRUGS. WE CAN ALSO LOOK AT ANIMAL MODELS WHERE WE HAVE INTENTIONALLY DONE SOMETHING ALONG THAT LINE AND CAN MAKE SOMEWHAT OF A CORRELATION AS WELL.
Q MOVING THEN TO THE VARIOUS BENZODIAZEPINES LISTED ON PEOPLE’S 68, SPECIFICALLY DID YOU REVIEW — WELL, LET ME JUST ASK YOU. CAN YOU TELL US GENERALLY ON PEOPLE’S 68 WHAT OBSERVATIONS, CONCLUSIONS, YOU MADE BASED ON THE VALUES LISTED THERE AS IT RELATES TO THE VARIOUS BENZODIAZEPINES?
A WELL, THE MOST IMPORTANT ONE IS LORAZEPAM, ALSO KNOWN AS ATAVAN IS ITS MAJOR TRADE NAME. UNFORTUNATELY, WE DON’T HAVE A HOSPITAL VALUE THAT WOULD HAVE BEEN MORE HELPFUL, BUT WE DO HAVE THE HEART AND FEMORAL LEVELS. AND CLEARLY, THOSE LEVELS ARE SUBJECT TO A VERY SMALL DEGREE OF REDISTRIBUTION BECAUSE IT IS A MORE WATER-LUGGING DRUG. IT DOESN’T HAVE AS MUCH REDISTRIBUTION PHENOMENA AS SOMETHING LIKE PROPOFOL OR EVEN ITS FIRST COUSIN, WHICH IS DIAZEPAM OR VALIUM. SO IT IS A LITTLE LESS SUSCEPTIBLE TO THAT. IF YOU WERE TO COMPARE ANTEMORTEM BLOOD LEVELS AND ASSUME THEY ARE EQUIVALENT, FOR EXAMPLE, THOSE WOULD BE EXCEEDINGLY HIGH BLOOD LEVELS, THE EQUIVALENT OF TAKING ANYWHERE FROM SEVEN TO 12 MILLIGRAMS OF LORAZEPAM EITHER ORALLY OR I.V. OR I.M. SO IT TELLS US THAT THERE IS A SIGNIFICANT AMOUNT OF LORAZEPAM IN THE BLOOD. IT IS WHAT WE CALL A VERY, VERY HIGH LEVEL. NOT LETHAL, BUT VERY, VERY HIGH. BUT WOULD INDUCE, DEPENDING UPON THE PATIENT’S TOLERANCE TO THE DRUG, YOU KNOW, SIGNIFICANT DEGREE OF SEDATION.
Q AND ARE THESE LEVELS OF LORAZEPAM AS NOTED IN THE HEART BLOOD, ARE THEY AFFECTED BY THE SAME DILUTION AS A RESULT OF RESUSCITATIVE FLUIDS BEING GIVEN TO THE PATIENT AS YOU DESCRIBED FOR PROPOFOL?
A THEY ARE. SO AGAIN, IT WOULD BE NICE TO HAVE A HEART BLOOD OR THE BLOOD THAT WAS DRAWN AT UCLA, BUT AGAIN THEY WILL BE LOWER ARTIFICIALLY JUST BECAUSE OF THE DILUTIONAL EFFECT. THEY ARE NOT SUBJECT TO THE METABOLISM OR BREAKDOWN THAT PROPOFOL IS, BUT THEY STILL WOULD REPRESENT A SOMEWHAT LOWER LEVEL THAN YOU WOULD PROBABLY FIND. BUT AGAIN, THAT IS A LITTLE DIFFICULT BECAUSE I DON’T HAVE THE EXACT — SOME OF THE OTHER DATA. AGAIN, IT WOULDN’T BE THAT MUCH LOWER OR HIGHER THAN WHAT WE ARE SEEING HERE. STILL AGAIN, REPRESENTING A SIGNIFICANTLY HIGH THERAPEUTIC LEVEL.
Q BUT AGAIN, JUST AS YOU SAID WITH PROPOFOL, IF ANYTHING, THE ANTEMORTEM LEVELS OF LORAZEPAM YOU WOULD EXPECT TO BE HIGHER THAN IS SHOWN ON PEOPLE’S 68?
A WELL, NOT NECESSARILY. THE LORAZEPAM, AGAIN BECAUSE IT DOESN’T UNDERGO — IN OTHER WORDS, IF IT WAS DRAWN FROM THE UCLA BLOOD, THEN DEFINITELY IT WOULD BE THE CASE BECAUSE OF THE DILUTION. THE PROBLEM IS WE DO HAVE SOME DEGREE OF POSTMORTEM REDISTRIBUTION, BUT NOT QUITE THE SAME AND SO THE LEVELS ARE STILL A LITTLE INCONSISTENT. BUT CLEARLY, THEY MIGHT BE 25 OR 30 PERCENT LOWER THAN MIGHT HAVE BEEN IN LIFE ANTEMORTEM BUT NOT MUCH MORE THAN THAT. THEY COULD EVEN BE SLIGHTLY HIGHER BY THAT AMOUNT, TOO, DEPENDING UPON A NUMBER OF OTHER FACTORS BUT IT IS SORT OF IN THAT RANGE. BASICALLY, THERAPEUTIC LEVELS OF, SAY, A TWO-MILLIGRAM DOSE THAT WAS GIVEN SHOULD REPRESENT A LEVEL ABOUT ONE-SIXTH TO ONE-EIGHTH OF THAT. THAT WOULD BE A SINGLE TWO-MILLIGRAM I.V. DOSE, KIND OF WHAT WE CALL PEAK, RELATIVELY.
Q YOU REVIEWED THE DEFENDANT’S INTERVIEW TRANSCRIPT?
A I DID.
Q WHERE HE INDICATED HE GAVE TWO SEPARATE DOSAGES OF TWO MILLIGRAMS EACH LORAZEPAM?
A I DID.
Q FOR A TOTAL OF FOUR MILLIGRAMS?
A THAT’S CORRECT.
Q NOW, YOU HAVE TESTIFIED THAT THE LORAZEPAM READINGS YOU ARE SEEING ON PEOPLE’S 68 IS MORE CONSISTENT WITHIN THE RANGE OF SEVEN TO 12 MILLIGRAMS?
MR. FLANAGAN: THAT IS A MISSTATEMENT. HE IS TALKING ORAL VERSUS I.V.
THE COURT: REPHRASE IT.
Q BY MR. WALGREN: ARE THE READINGS ON PEOPLE’S 68, AS IT RELATES TO LORAZEPAM, CONSISTENT WITH FOUR MILLIGRAMS GIVEN VIA I.V.?
A IT IS EXTREMELY HIGH FOR FOUR MILLIGRAMS GIVEN I.V. NOW, YOU KNOW, AGAIN, LIKE I SAID, SOMEWHERE PROBABLY SIX TIMES. IN OTHER WORDS, I WOULD EXPECT ABOUT ONE-SIXTH, YOU KNOW, AT THE MOST. SO IT IS A BIT ODD. THERE MIGHT BE EXPLANATIONS FOR THAT, WHAT WE CALL DRUG ACCUMULATION. IF THE PATIENT HAD BEEN GETTING LORAZEPAM FOR MANY DAYS, IT WILL ADD UP.
Q OKAY. NOW, I WANT TO TALK ABOUT SOME OF THE MONITORING PARAMETERS THAT YOU MENTIONED IN YOUR REPORT, AND SPECIFICALLY AS IT RELATES TO THE ADMINISTRATION OF PROPOFOL IN YOUR ANALYSIS AND YOUR CONCLUSIONS REGARDING THE MONITORING PARAMETERS. CAN YOU FIRST EXPLAIN, AS YOU DESCRIBED IN YOUR REPORT, THE LEVELS OF CONSCIOUSNESS?
A THE LEVELS OF CONSCIOUSNESS WE CALL A CONTINUUM. WHEN WE GIVE ANY KIND OF SEDATIVE, HYPNOTIC DRUG — MEANING THE FAMILY OF THE BENZODIAZEPINES LIKE VALIUM, LIBRIUM, ATAVAN, XANAX, MIDAZOLAM WHICH IS CALLED VERSED, RESTORIL WHICH IS DIAZEPAM, WHICH HE WAS ON MANY OF THOSE DRUGS — THEY CAN CAUSE DIFFERENT LEVELS DEPENDING UPON THEIR BLOOD LEVELS AND DEGREE OF TOLERANCE THE PATIENT MAY HAVE HAD. SO YOU CAN HAVE WHAT WE CALL STATE OF JUST VERY, VERY MILD SEDATION OR ANXIOLYSIS. YOU GET RID OF ANXIETY.
THE COURT: YOU HAVE TO SPELL THAT, PLEASE.
THE WITNESS: A-N-X-I-O-L-Y-S-I-S. JUST MEANS GETTING RID OF ANXIETY. THEN MODERATE SEDATION WOULD BE HAVING THE PATIENT SEDATED. THEY COULD STILL RESPOND TO COMMANDS READILY. THEY KIND OF CLOSE THEIR EYES. DEEP SEDATION IS WHERE IT WOULD TAKE – YOU MIGHT HAVE TO KIND OF SHAKE THEM A BIT OR YELL AT THEM, AND THEN THEY WOULD RESPOND. AND THEN A STATE OF GENERAL ANESTHESIA WHERE THEY WON’T RESPOND TO EVEN NOXIOUS STIMULI, HARD STERNAL RUB, OR PINCHING A FINGER HARD. YOU MIGHT BE ABLE TO STICK THEM WITH A PIN. THEN AGAIN ON THE CONTINUUM OF GENERAL ANESTHESIA, YOU HAVE SOMEBODY EXCEEDINGLY DEEP, LIKE WHEN WE DO MAJOR SURGERY. A LITTLE LESS DEEP FOR MORE MINOR SURGERY. BUT AT THAT POINT BETWEEN DEEP SEDATION AND GENERAL ANESTHESIA, ANY PLANE ON THAT CONTINUUM, THEY CAN OBSTRUCT THE AIRWAY. ALTHOUGH IT LOOKS LIKE THEY ARE BREATHING, YOU CAN SEE THE CHEST MOVING, THEY ARE NOT EXPELLING CARBON DIOXIDE.
Q BY MR. WALGREN: CAN YOU EXPLAIN IN THIS CASE IF MICHAEL JACKSON IS ON THE BED AND HIS AIRWAY HAS BEEN OBSTRUCTED, HOW IS IT THAT HIS CHEST WILL CONTINUE TO RISE AND FALL, IF YOU WILL?
A BASICALLY, BREATH IS STIMULATED BY LEVELS OF CARBON DIOXIDE. IF YOU ARE BREATHING SHALLOWER AND LESS OFTEN, YOU WILL START BUILDING UP CARBON DIOXIDE. THESE DRUGS, BENZODIAZEPINES, EVEN MORE IMPORTANTLY PROPOFOL, UNFORTUNATELY SHIFT THE BRAIN’S RESPONSE. SO IT SLOWS DOWN RESPIRATORY DRIVE DEPENDING UPON THE DOSE AND EFFECT, AND SO IT REQUIRES HIGHER LEVELS OF CARBON DIOXIDE TO STIMULATE YOU TO BREATHE. AND SO THE OTHER THING THESE DRUGS DO IS THEY RELAX THE MUSCLES WITHIN THE BACK OF THE THROAT. THAT CAN CAUSE, NUMBER ONE, YOUR TONGUE TO FALL INTO THE BACK, OBSTRUCT YOUR BREATHING. THE MUSCLES CONTRACT OR RELAX, AND EVERYTHING FALLS TOGETHER. WHEN YOU ARE LYING FLAT ON YOUR BACK, THAT IS WHY PEOPLE SNORE, FOR EXAMPLE. THAT IS NOT EVEN DEEP SEDATION. AND THEY COULD EITHER SNORE, HAVE APNEIC SPELLS MEANING THEY ARE NOT BREATHING, AND BUILD UP CARBON DIOXIDE WHICH IS ACTUALLY A TOXIN, IF YOU WILL. THEN AS THEY GET DEEPER AND DEEPER, YOU GET TO A POINT WHERE YOU ARE COMPLETELY OBSTRUCTING. AGAIN, YOUR CHEST MUSCLES, YOUR ACCESSORY MUSCLES, MEANING DIAPHRAM, THE INTERCOSTAL MUSCLES, MUSCLES IN HERE, ARE ALL HELPING YOU BREATHE. IT LOOKS LIKE YOU ARE BREATHING. BUT IF YOU PUT YOUR HAND OVER THEIR NOSE AND THROAT OR, EXCUSE ME, NOSE AND MOUTH, YOU WON’T FEEL ANY EXHALATIONS.
Q LET ME ASK YOU ABOUT A PULSE OXIMETER. WHAT IS A PULSE OXIMETER?
A WELL, IT IS A PROBE WE USUALLY PUT ON A FINGER OR THUMB, TOES, EARS, OR BRIDGE OF THE NOSE MOST OFTEN, AND IT MEASURES THE SATURATION OF OXYGEN BY THE RED BLOOD CELLS. AND IT ALSO MEASURES WHAT WE CALL THE PULSATILE FLOW. WHAT THAT MEANS IS EVERY TIME YOUR HEART BEATS, IT SHOOTS BLOOD EVERYWHERE. IF YOU HAVE IT ON YOUR THUMB, EVERY TIME THE HEART BEATS, IT PUSHES BLOOD FORWARD. YOU GET A PULSATION. SO IT IS MEASURING THAT WHICH GIVES YOU A HEART RATE AND A WAVE FORM. IT IS MEASURING BY SPECTROMETRY, MEANING A LIGHT EMITTANCE AND REFLECTION OF THE DEGREE OF HOW MUCH OXYGEN IS IN THE AVERAGE AMOUNT OF BLOOD RED BLOOD CELLS. SO THAT IS A FUNCTION OF HOW WEL OXYGENATED YOUR BLOOD IS. THAT IS AN IMPORTANT THING. SO THE THINGS THAT ARE IMPORTANT, IT WILL GIVE YOU HEART RATE. IT WILL GIVE YOU HOW MUCH OXYGEN SATURATION. AND BY THE WAVE FORMATION, IT WOULD ALSO GIVE YOU AN IDEA OF HOW WELL YOU ARE PROFUSING. IF YOU ARE PROFUSING WELL, YOUR WAVE FORM WILL LOOK ONE WAY. IF YOU ARE NOT PROFUSING AS WELL, IT WILL LOOK DIFFERENT. IF YOU ARE PROFUSING, IF YOU HAVE VERY, VERY LOW BLOOD PRESSURE, IT MAY BE GIVING YOU EITHER A DIFFERENT WAVE OR HAVE TROUBLE SENSING, FOR EXAMPLE. SO IT CAN’T GET A GOOD HEART RATE OR GOOD VALUE OF EITHER THE WAVE FORM OR HOW MUCH OXYGEN IS ACTUALLY IN THE BLOOD. SO IT HELPS YOU FIGURE OUT A NUMBER OF DIFFERENT THINGS.
Q DOES A PULSE OXIMETER IN ANY WAY HELP DETERMINE WHETHER SOMEONE’S AIRWAY IS OBSTRUCTED?
A NO. UNFORTUNATELY, THAT IS THE PROBLEM. I MEAN, ESPECIALLY IF YOU ARE BREATHING SUPPLEMENTAL OXYGEN. YOU CAN STOP BREATHING, BUT IT MAY TAKE A MINUTE OR TWO, OR EVEN FIVE OR SIX DEPENDING UPON HOW MUCH OXYGEN YOU ARE BREATHING, BEFORE THE OXIMETER NOTES YOUR OXYGEN SATURATION IS FINALLY STARTING TO DECLINE. SO IT IS A VERY POOR WAY OF TELLING YOU HOW OBSTRUCTED ONE IS. THERE ARE OTHER MUCH BETTER WAYS.
Q WOULD A PULSE OXIMETER THEN IN YOUR OPINION WITH SOMEONE WHO HAD BEEN ADMINISTERED BENZODIAZEPINES AS DESCRIBED IN THE TRANSCRIPT AS WELL AS PROPOFOL, WOULD A PULSE OXIMETER BE SUFFICIENT TO PROVIDE AT LEAST THE REAL MONITORING REQUIRED?
A WELL, IT WOULD BE PART OF WHAT YOU NEED, BUT IT IS INCOMPLETE.
Q IT WOULD BE INSUFFICIENT?
A THAT’S CORRECT.
Q WHAT WOULD YOU IN YOUR OPINION NEED TO HAVE IN THAT SITUATION AS FAR AS MONITORING?
A WELL, ONE OF THE THINGS IS YOU NEED TO HAVE BLOOD PRESSURE AND A BASE LINE MEASUREMENT BEFORE YOU START ON WHAT YOU ARE DOING SO THAT YOU CAN TRACK THAT OVER TIME. YOU NEED TO HAVE A BASE LINE FROM YOUR PULSE OXIMETER TRACKING THAT OVER TIME.
Q WHEN YOU SAY BASE LINE, DOES THAT REQUIRE SOME TYPE OF DOCUMENTATION AS TO THE VITAL READINGS?
A ABSOLUTELY.
Q THAT WOULD REQUIRE A DOCTOR DURING, FOR EXAMPLE IN THIS CASE, DURING THE COURSE OF THE NIGHT TO DOCUMENT READINGS FROM TIME TO TIME SO THERE IS THIS BASE LINE TO REFERENCE?
A RIGHT, BECAUSE WITHOUT HAVING THAT BASE LINE, THEN FOLLOWING IT IN TIME SEQUENCE, YOU CAN’T FIGURE OUT OR NECESSARILY REMEMBER WHAT YOU STARTED WITH AND WHERE YOU END UP. AND BECAUSE SUBTLE CHANGES OCCUR IN HEART RATE, BLOOD PRESSURE, PULSE OXIMETRY READINGS, WAVE FORMS THAT YOU SEE, THOSE ARE ALL AFFECTED BY THESE DRUGS. SO YOU NEED TO HAVE NOT ONLY THE BASE LINE BEFORE YOU START, BUT THEN CONTINUOUS LOG OF WHAT IS GOING ON OVER TIME. TRYING TO GET BACK TO YOUR QUESTION —
Q PLEASE.
A — THE OTHER MONITORS, LIKE I SAY, EKG BECAUSE THAT CAN SHOW DIFFERENT THINGS.
Q WHAT IS AN EKG?
A WELL, IT IS LIKE IN THE MOVIES, YOU SEE A SCREEN. YOU SEE THE BLIPS UP AND DOWN JUST AS A MEASURE OF THE ELECTRICAL ACTIVITY OF THE HEART. DOESN’T MEAN THE HEART IS EVEN PUMPING BLOOD NECESSARILY. THE HEART CANNOT BE PUMPING BUT STILL HAVE ELECTRICAL ACTIVITY, BUT IT CAN GIVE YOU ANY KIND OF ARRHYTHMIA, HEART RATE CHANGES, THAT OCCUR DUE TO TOXIN BUILDUP IN THE BLOOD, LIKE CARBON DIOXIDE, FOR EXAMPLE. AND SO IT GIVES YOU A NUMBER OF OTHER THINGS. EVEN THOUGH THE PULSE OXIMETER GIVES YOU A HEART RATE, IT DOESN’T TELL YOU ELECTRICAL ACTIVITY OF THE HEART. THE BLOOD PRESSURE, BECAUSE THESE DRUGS ALL AFFECT BLOOD PRESSURE. AND THEN ANOTHER THING WHICH WE HAVEN’T REALLY TOUCHED ON, ALTHOUGH TALKING ABOUT AIRWAY OBSTRUCTION, IS WHAT WE CALL VENTILATION. THERE IS A NUMBER OF WAYS YOU CAN MONITOR VENTILATION. YOU CAN HAVE YOUR HAND OVER THE PATIENT’S NOSE AND MOUTH LIKE THAT. SO YOU ARE SITTING THERE FULL-TIME WITH YOUR HAND OVER THE NOSE AND MOUTH. AND IN THE OLD DAYS, THAT OFTEN HAPPENED IF THE PATIENT DIDN’T HAVE AN ARTIFICIAL AIRWAY.
Q OBVIOUSLY, IF YOU LEFT THE ROOM, YOU WOULDN’T BE ABLE TO DO THAT?
A RIGHT. YOU CAN’T TELL. ANOTHER THING IS A STETHOSCOPE ATTACHED TO THE CHEST TO LISTEN TO BREATHING AND HOW WELL THEY ARE BREATHING. ANOTHER ONE IS YOU COULD PUT A STETHOSCOPE RIGHT HERE JUST ABOVE OR BELOW YOUR ADAM’S APPLE AND LISTEN FOR THE BREATH SOUNDS IN AND OUT. YOU HAVE A LONG TUBE THAT IS CONNECTED TO EITHER — YOU COULD EITHER HAVE AN AMPLIFICATION SYSTEM TO HEAR IT OR PUT IT IN YOUR EAR. IT IS CALLED A PRECORDIAL STETHOSCOPE. YOU CAN MONITOR THAT WAY.
Q THAT IS ACTUALLY HOOKED UP TO MACHINE, RIGHT?
A MACHINE OR TO YOUR EAR. BUT AGAIN, IF IT IS HOOKED UP TO YOUR EAR, OR IF YOU WALK AWAY, YOU WILL NOT HEAR IT. SO THAT IS A DEFINITE PROBLEM. ANOTHER METHOD IS IN SPITE OF LOOKING AT SOMEBODY’S BREATHING, BECAUSE THEY COULD BE COMPLETELY OBSTRUCTED, YOU WON’T KNOW IT, IS WHAT WE CALL A CAPNOGRAPH. IT MEANS THAT YOU ARE MEASURING EXHALED CARBON DIOXIDE WITH EVERY BREATH. AND LIKE A PULSE OXIMETER, THAT GIVES YOU A NUMBER OF DIFFERENT PARAMETERS. EVERY TIME YOU BREATHE OUT, IF YOU HAVE A BIG BREATH, YOU WILL GET A BIG TYPE OF PEAK. WHEN YOU ARE NOT BREATHING, IT IS A FLAT LINE. THE NEXT BREATH, ANOTHER BIG PEAK. IF YOU ARE BREATHING LESS BIG, YOU WILL GET A SMALLER, NOT AS TALL AND NOT AS WIDE, PEAK. AND EVERY TIME YOU SEE A PEAK, THAT IS AN EXHALATION. SO IT IS REAL TIME MEASURING OF BREATHING. NOW, AGAIN YOU NEED A BASE LINE SO YOU CAN SEE WHAT WAS THE PATIENT’S DEPTH OF BREATHING BEFORE THEY ARE ASLEEP, THEN THE CHANGES. NOW, THOSE WAVE FORMS GIVE YOU AGAIN A DEPTH IDEA, AND THEY WILL ALSO GIVE YOU — THERE IS A NUMBER THAT IS PRINTED THAT WILL GIVE YOU SOME IDEA OF THE KIND OF CONCENTRATION OF CARBON DIOXIDE, ALTHOUGH, BECAUSE IT IS NOT A CLOSED SYSTEM, IT WON’T GIVE YOU THE ACTUAL REAL NUMBER. BUT THE FACT IS WITH EXPERIENCE, YOU CAN FIGURE THAT OUT. SO YOU COULD SEE AS PEOPLE’S BREATHING SLOWS DOWN, THE WAVE-TO-WAVE DISTANCE GETS FARTHER AND FARTHER APART. AND AS THEY ARE BREATHING LESS DEEP IN AND OUT, THE WAVES GET SMALLER AND SMALLER.
YOU CAN ALSO SEE PERIODS OF APNEA WHEN THEY STOP BREATHING ANYWHERE FROM FIVE TO 60 SECONDS. YOU WILL SEE THE APNEA PHASES, THEN CHANGES ALSO ON THOSE WAVE FORM PATTERNS. SO YOU CAN PREDICT EXACTLY WHAT IS HAPPENING NOW, WHAT YOU NEED TO DO ABOUT IT, HOW YOU INTERVENE. AND SO THOSE ARE THE ISSUES. AND AGAIN, THAT IS THE MONITOR THAT IS USED BY CLINICIANS WHO ARE DOING PROPOFOL OR PROPOFOL MIXED WITH OTHER DRUGS FOR VARIOUS REASONS.
Q IN REGARD, AGAIN ON THIS TOPIC OF MONITORING, YOU HAVE TALKED ABOUT WHAT WOULD BE REQUIRED FOR VENTILATION AS FAR AS THE HEART, EKG, CAPNOGRAPHY, TYING IN THIS MONITORING REQUIREMENT WITH THE CONTINUUM OF SEDATION THAT YOU MENTIONED EARLIER. LET’S JUST GO FIRST WITH THE ASSUMPTION THAT ALL THE PATIENT HAS BEEN ADMINISTERED IS PROPOFOL. ASSUME ALL THESE MONITORING REQUIREMENTS APPLY.
A THAT’S CORRECT.
Q NOW, IF YOU COMBINE ADMINISTRATION OF PROPOFOL WITH A SERIES OF BENZODIAZEPINES, DOES THAT REQUIRE YOU TO EVEN BE MORE VIGILANT OR HAVE HEIGHTENED MONITORING?
A WELL, GENERALLY SPEAKING, IT DOES. IF YOU ARE MIXING IT WITH — I MEAN, NUMBER ONE, IT IS NOT SO MUCH IT IS GOING TO INCREASE MONITORING. YOU HAVE TO KNOW EVEN MORE NOW WHAT THE DRUG INTERACTION ISSUES ARE.
Q MAYBE MY QUESTION WAS POORLY WORDED. THE MONITORING REQUIREMENTS WOULD BE THE SAME, BUT IS IT FAIR TO SAY THE RISKS OF SOME TYPE OF BAD REACTION WOULD BE INCREASED?
A RIGHT. SO YOU NEED TO KNOW EITHER A PRIORI HOW TO ADJUST FOR THAT AND CLEARLY PAY EVEN MORE ATTENTION. NOW, ONE OF THE THINGS BECAUSE I DON’T WANT TO CONFUSE YOU, ANYWAY IF YOU ARE GIVING A SINGLE DOSE OF PROPOFOL AND YOU ARE NOT GOING TO CONTINUE IT FOR ANY REASON BY ITSELF, YOU DON’T NECESSARILY — IN OTHER WORDS, FOR VERY SHORT ACTION AND YOU KNOW HOW TO MANAGE THE PATIENT, YOU MAY NOT NEED TO HAVE WHAT THEY CALL EXPIRED CARBON DIOXIDE LEVEL MONITORING. YOU KNOW WHAT YOU ARE DOING. YOU ARE GOING TO CREATE A VERY SHORT-TERM, A MINUTE TO TWO MINUTES, MAYBE EVEN THREE, OF SORT OF A DEEP STATE. BUT YOU KNOW HOW TO MONITOR EVERYTHING ELSE. SO YOU MAY NOT NEED THAT CAPNOGRAPHY. BUT IF YOU ARE USING IT WITH OTHER DRUGS THAT HAVE LONG DURATIONS OF ACTIONS, FOR EXAMPLE, THAT MAY BE APPROPRIATE. AGAIN, IT DEPENDS UPON THE OTHER THINGS YOU ARE DOING. SO IF YOU KNOW IT IS A SHORT-TERM, YOU KNOW THE PATIENT WILL WAKE UP AGAIN AS OPPOSED TO KEEPING HIM ASLEEP, YOU MAY NOT NEED TO DO THAT. YOU CAN DO A NUMBER OF OTHER THINGS. PUT YOUR HAND OVER THE MOUTH, OR LISTEN WITH THE PRECORDIAL STETHOSCOPE. BUT WHEN YOU ARE USING LONG-ACTING DRUGS LIKE BENZODIAZEPINES AND MIXING IT WITH PROPOFOL, AND YOU ARE INDUCING A STATE OF SLEEP, THE CONTINUUM OF SEDATION CAN CHANGE AT ANY POINT IN TIME TO A LOT OF VARIOUS PARAMETERS, THEN YOU HAVE GOT TO USE IT. YOU HAVE TO USE REAL TIME CAPNOGRAPHY, IF YOU WILL.
Q AND EVEN IN THE FIRST PART OF YOUR ANSWER, WHERE REAL TIME CAPNOGRAPHY MAY NOT BE NECESSARY, THE PREREQUISITE IS YOU NEED TO KNOW WHAT YOU ARE DOING?
A YOU NEED TO KNOW WHAT YOU ARE DOING WITH THE EXPECTATION THAT YOUR PATIENT WILL WAKE UP QUICKLY, OKAY, BECAUSE THAT IS THE INTENT. AND IF YOU ARE MIXING IT WITH ANOTHER DRUG OR MAYBE TWO, YOU EITHER HAVE IMMEDIATE REVERSAL. YOU DO WHATEVER YOU NEED TO DO FROM A RESUSCITATION POINT OF VIEW, WHICH ALMOST NEVER IS NEEDED, BUT YOU HAVE TO KNOW HOW TO DO THAT.
Q YOU NEED TO BE PREPARED, AND WE WILL GET INTO THAT, BUT YOU NEED TO BE PREPARED TO DO EFFECTUAL RESUSCITATIVE EFFORTS?
A RIGHT.
Q WITH THE NECESSARY EQUIPMENT FOR THOSE EFFORTS AND YOUR OWN KNOWLEDGE AND ABILITY TO PERFORM THOSE RESUSCITATIVE EFFORTS?
A THAT IS CORRECT.
Q STAYING STILL WITH THE MONITORING GUIDELINES THAT YOU HAVE MENTIONED, WE TOUCHED ON IT BUT I WANT TO GET A LITTLE MORE SPECIFIC AS TO THE GUIDELINES IN THE FIELD AS IT RELATES TO RECORDING AND MEMORIALIZING VITAL SIGNS, OXYGENATION, VENTILATION, THINGS OF THAT NATURE. CAN YOU DESCRIBE THAT?
A WELL, AGAIN, ONCE YOU ARE EMBARKED UPON A PATHWAY, EVEN IF YOU WERE GOING TO USE PROPOFOL FOR A VERY SHORT PROCEDURE, YOU NEED TO HAVE YOUR BASE LINES BECAUSE IT CAN DROP. YOUR BLOOD PRESSURE INHIBITS THE HEART’S ABILITY TO SQUEEZE BLOOD OUT. IT CAN CREATE ARRHYTHMIAS. IT CAN DO A LOT OF UNFORTUNATE THINGS. THEN THE MORE DRUGS YOU MIX WITH IT, THE GREATER LIKELIHOOD OF ISSUES. SO YOU HAVE TO START OUT WITH BASE LINE BEFORE YOU GIVE THE DRUGS, WHAT YOUR OXYGENATION IS, PULSE OXIMETER, BLOOD PRESSURE, EKG. YOU KNOW, THOSE ARE THE KINDS OF THINGS YOU NEED TO DO. AGAIN, IF YOU ARE INTENDING TO GO MORE LONG TERM, YOU NEED TO HAVE END TIDAL CO2 AS WELL.
Q I’M SORRY?
A THEN I WAS GOING TO TRY TO ANSWER THE REST OF YOUR QUESTION. ONCE YOU HAVE THE BASE LINE, YOU CAN FOLLOW CHANGES OVER TIME. SO NOT ONLY DO YOU GET THE VITALS, IF YOU WILL, BUT YOU WILL GET THE CONTINUUM. NOW, ANOTHER BACKUP THAT IS OFTEN USED IS A BRAIN WAVE MONITOR. WE CALL THAT A B.I.S. MONITOR. SO IF YOU ARE TRYING TO KEEP A PATIENT IN A STEADY STATE, IT IS ONE WAY AGAIN TO LOOK AT ALL YOUR PERIPHERAL MONITORS THAT ARE MEASURING NON-BRAIN TYPES OF FUNCTION — CARDIOVASCULAR, RESPIRATORY WHICH IS WHAT WE ARE REALLY KIND OF TALKING ABOUT HERE, AS WELL AS BRAIN WAVE ACTIVITY. SO THIS IS A KIND OF A CRUDE EEG. NOT AN EKG, LOOKING AT THE HEART; BUT EEG, LOOKING AT BRAIN ACTIVITY. THAT IS ANOTHER MONITOR THAT IS OFTEN USED AS WELL. YOU CAN TELL THE DEPTH OF SEDATION IN THE BRAIN ITSELF. SO THOSE TYPES OF THINGS, ALTHOUGH THAT IS NOT NECESSARILY STANDARD CARE, IS VERY OFTEN USED AS WELL DEPENDING UPON WHAT YOU ARE TRYING TO ACHIEVE. BUT ALL THOSE THINGS WILL GIVE DATA POINTS OUT, AND YOU FOLLOW THOSE DATA POINTS OVER TIME. BLOOD CHANGES, EKG CHANGES, RESPIRATORY RATE CHANGES, DEGREE OF SEDATION, IF YOU WILL, WHICH YOU CAN TEST BY TOUCHING A PATIENT’S EYELASHES. THAT WILL TELL YOU HOW DEEPLY SEDATED THEY ARE. YOU MAY THEN, IF YOU GET NO EYELID REFLEX, YOU MAY DECIDE, WELL, IF I PINCH THEM REAL HARD, DO A BIG STERNAL RUB, WILL THAT AROUSE THEM. THAT IS MORE THAN TOUCHING EYELASHES. YOU CAN LOOK AT THEIR PUPILS. YOU CAN DO A NUMBER OF DIFFERENT THINGS. YOU CAN LOOK JUST WITH THE HUMAN EYE, JUST KIND OF LOOK AND SEE IF THEY ARE OBSTRUCTED. IF SOMEBODY DOESN’T HAVE AN ARTIFICIAL AIRWAY, YOU CAN HEAR WHEN THEY STOP BREATHING. APNEIC SPELLS. YOU CAN HEAR SNORING. ALL THOSE ARE CLINICAL SIGNS YOU NOTE AND MONITOR FOR.
Q AND AGAIN, THE REASON YOU NOTE THESE AND RECORD THESE VITAL SIGN MEASUREMENTS IS SO AGAIN YOU HAVE A BASE LINE FROM WHICH TO COMPARE IT LATER ON IN THE TREATMENT OR CARE?
A AND ON A CONTINUUM. IT TELLS YOU WHAT THINGS ARE CHANGING OVER TIME. Q AND IN REGARD TO LEVEL OF CONSCIOUSNESS, HOW FREQUENTLY SHOULD THAT RECORDATION AND MEMORIALIZING OF THOSE LEVELS BE NOTED?
A WELL, EVERYTHING IN TOTO SHOULD BE, AND THE MOST COMMON ARE ALL THE TYPICAL VITAL SIGNS AND CAPNOGRAPHY EVERY FIVE MINUTES.
Q NOW, ARE THERE SPECIFIC PUBLISHED GUIDELINES RELATED TO NON-ANESTHESIOLOGISTS ADMINISTERING PROPOFOL OF THIS NATURE?
A THERE ARE. THEY HAVE BEEN AROUND FOR, I DON’T KNOW, PROBABLY 12 TO 15 YEARS, SOMEWHERE AROUND THAT TIME.
Q CAN YOU DESCRIBE THOSE PUBLISHED GUIDELINES AS IT RELATES TO NON-ANESTHESIOLOGISTS AND PROPOFOL?
A WELL, THE GUIDELINES HAVE BEEN PROMULGATED FOR PEOPLE WHO AGAIN ARE USING PROPOFOL, PROPOFOL IN COMBINATION WITH OTHER DRUGS, AND AGAIN HOW TO MONITOR. THOSE MONITORING DEVICES ARE THE SAME AS WE HAVE SPOKEN TO HERE, EXCLUDING THE B.I.S. MARKER. THAT IS NOT NECESSARILY IN ANY OF THAT. AND THOSE ARE FOR CREATING ACTUALLY A STATE OF CONSCIOUS SEDATION WHICH IS REALLY A MISNOMER. IT IS REALLY MODERATE TO VERY DEEP SEDATION BORDERING ON GENERAL ANESTHESIA MANY TIMES BECAUSE OF THAT RAPID CHANGE IN CONTINUUM. THAT IS THE KEY THING. SO THAT IS ONE THING TO MONITOR. THE OTHER IS THERE ARE QUALIFICATIONS, FOR EXAMPLE, IN HOW TO INTERVENE BASED ON THE DATA THEY SEE AND PERCEIVE, MEANING AIRWAY INTERVENTION BY A NUMBER OF DIFFERENT TECHNIQUES, SUPPORTING BLOOD PRESSURE OR HEART RATE. AND IF THERE’S A PROBLEM, SEVERE PROBLEM, THEY MAY HAVE TO GO IN A HOSPITAL SETTING. THE CRITERIA ALSO STATE AN ANESTHESIOLOGIST MUST BE IMMEDIATELY AVAILABLE, THAT IS THE TERMINOLOGY THEY USE, TO GET YOU OUT OF TROUBLE. IN ADDITION, YOU MUST BE TRAINED IN ADVANCE CARDIAC LIFE SUPPORT WITH FULL KNOWLEDGE AND THE SKILL IN HOW TO DO ALL OF IT.
Q WHAT IS ADVANCED CARDIAC LIFE SUPPORT?
A WELL, IT IS AS OPPOSED TO BASIC, WHICH WE TEACH LAY PEOPLE, AND PHYSICIANS, NURSES, AND HEALTH CARE PERSONNEL. IT IS THE NEXT MAJOR STEP WHERE YOU USE DRUGS. YOU KNOW HOW TO INTERPRET VITAL SIGNS, EKG, OXIMETRY DATA, PATIENT CLINICAL RESPONSES. HOW DEEPLY DO THEY APPEAR TO BE OUT OF IT. IS THEIR AIRWAY OBSTRUCTED. THEN HOW TO RESUSCITATE DEPENDING UPON WHAT IS GOING ON. SO IT MAY BE, YOU KNOW, A TRUE ARREST SITUATION. YOU HAVE TO KNOW HOW TO INTERVENE IN A FULL ARREST, EITHER PRIMARILY RESPIRATORY, OR RESPIRATORY AND CARDIAC, OR CARDIAC. SO IT IS LEARNING HOW TO USE ALL THE DRUGS, ALL THE INTERVENTIONAL TOOLS, AIRWAY RESUSCITATION EQUIPMENT AND TOOLS.
Q WOULD THAT INCLUDE TRACHEAL INTUBATION?
A EVERYTHING. YES, THAT’S CORRECT.
Q AS FAR AS WOULD IT INCLUDE AS FAR AS ADVANCED CARDIAC LIFE SUPPORT, WOULD THAT INCLUDE A DEFIBRILLATOR?
A THAT IS CORRECT.
Q AND I ASSUME THE KNOWLEDGE AND POSSESSION OF THE NECESSARY ADVANCED CARDIAC LIFE SUPPORT MEDICATIONS?
A THAT’S CORRECT.
Q NOW, LET’S TALK ABOUT MORE SPECIFICALLY THE EQUIPMENT. FOCUSING ON THE EQUIPMENT, IN YOUR EXPERT OPINION, WOULD THE TREATMENT THAT YOU LEARNED THROUGH YOUR REVIEW OF THE MATERIALS PROVIDED, WHAT TYPE OF BASIC AIRWAY EQUIPMENT WOULD YOU FEEL WAS NECESSARY FOR THE SAFE AND PROPER TREATMENT OF THE PATIENT?
A WELL, ESSENTIALLY YOU HAVE TO START OUT WITH AIRWAY EQUIPMENT THAT IF A PATIENT IS OBSTRUCTED, YOU NEED TO KNOW HOW TO DEAL WITH THAT OBSTRUCTION. IN OTHER WORDS, THE FIRST THING YOU WILL DO IS TO DO MANEUVERS. SO YOU CAN DO A JAW LIFT. YOU CAN PULL THE TONGUE OUT. SEE IF THAT HELPS RELIEVE IT. THE NEXT THING, IF THAT DOESN’T DO ANYTHING, YOU CAN PUT IN WHAT WE CALL A NASAL TRUMPET, SORT OF A RUBBER-LIKE, PUT IN ONE OR BOTH NOSTRILS. IT GOES BEHIND THE TONGUE, CREATES LIKE A GIANT STRAW OR TWO GIANT STRAWS AND AIR PASSAGE FOR BREATHING, KIND OF AN EXTENSION OF THE NOSTRILS, IF YOU WILL.
Q OKAY.
A AND IF THAT DOESN’T WORK, YOU CAN TRY AN ORAL AIRWAY, WHICH IS ONE THAT GOES IN THE MOUTH. IT HAS ACTUALLY A LARGER HOLLOW PIECE THAT CAN HELP WITH ALL THREE THINGS, OR YOU CAN USE ANY COMBINATION. IF THAT DOESN’T WORK, WHICH MANY TIMES IT DOESN’T, YOU CAN USE INSTEAD AN ENDOTRACHEAL TUBE THAT GOES BEHIND THE TONGUE, BEHIND THE VOCAL CORDS, DOWN THE WINDPIPE. WE HAVE A LARYNGEAL MASK AIRWAY, LIKE A TUBE THAT GOES IN THE BACK OF THE THROAT AND FITS IN SUCH A WAY THAT YOU DON’T ACTUALLY HAVE TO GO BETWEEN THE VOCAL CORDS, BUT GETS ALL OBSTRUCTED AIRWAY PROBLEMS OUT OF THE WAY AND ALLOWS FOR A GREAT BREATHING PASSAGE. YOU CAN HOOK IT UP TO AN EXTERNAL OXYGEN SOURCE, VENTILATE THE PATIENT THROUGH THAT LIKE YOU WOULD ON A VENTILATOR, OR HAND VENTILATE BY SQUEEZING A BAG, OR THE PATIENT JUST WHEN THEY FINALLY GET A LITTLE MORE LIGHT, CAN BREATHE THROUGH IT ON THEIR OWN. WE ALSO USE IT FOR PEOPLE UNDER GENERAL ANESTHESIA. SAME THING. SO IT IS ONE OF THE TECHNIQUES. THEN THERE ARE MORE ADVANCED AIRWAY TECHNIQUES.
Q BEFORE WE MOVE TO ADVANCED, WHAT IS THE JAW LIFT? WHAT IS THE PURPOSE OF THAT, AND WHAT IS THE RESULT YOU ARE LOOKING FOR?
A AGAIN, PART OF AIRWAY OBSTRUCTION IS MORE OFTEN A COMBINATION OF THE TONGUE FALLING IN THE BACK OF THE THROAT OBSTRUCTING YOUR AIRWAY BREATHING. AND SO THE JAW LIFT WILL HELP LIFT. YOU LIFT KIND OF BEHIND THE ANGLE OF THE JAW. YOU REALLY LIFT FORWARD. NOW, INTERESTING THING IS THAT NOT ONLY ARE YOU LIFTING THAT THERE. YOU ARE ACTUALLY LIFTING HERE. YOU KIND OF — I HAVE TO SHOW IT ON SOMEONE, SOMEBODY ELSE. YOU ARE GETTING ONE HAND OR TWO HANDS HERE AND LIFTING LIKE THAT (INDICATING). SO YOU ARE LIFTING THE JAW UP AND FORWARD. THAT USUALLY LIFTS YOUR TONGUE OFF THE BACK. NOW, YOU CAN DO THAT WITH ONE HAND, WHICH IS OFTEN GOOD, BUT SOMETIMES YOU NEED TWO. IF YOU ARE USING BOTH HANDS TO DO THAT, THEN YOU CAN ONLY HOPE, IF YOU ARE THE ONLY PERSON THERE, THE PATIENT MAY BREATHE SPONTANEOUSLY UNLESS THEY ARE TOO DEEP AND WON’T BREATHE.
Q WITH TWO PEOPLE, I ASSUME ANOTHER PERSON WOULD BE DOING COMPRESSIONS AT THAT TIME?
A NO, NO. YOU STILL HAVE A HEART RATE, BLOOD PRESSURE. JUST AIRWAY, PURE AIRWAY. BUT THEY ARE STILL VERY, VERY DEEP. OKAY. SO THE OTHER BEAUTY OF THIS IS THAT WHEN YOU REALLY PUSH BACK HERE — IF YOU WERE TO DO IT TO YOURSELF, IT IS PRETTY PAINFUL. IT WILL ACTUALLY AROUSE YOU TO SOME DEGREE FROM A DEEPER STATE TO A LIGHTER STATE AND MAY ACTUALLY STIMULATE BREATHING. IF THIS IS AN ARREST SITUATION, THAT IS IRRELEVANT. BUT IF YOU ARE UNDER VERY DEEP SEDATION TO LIGHT GENERAL ANESTHESIA, IT MAY AWAKEN THE PATIENT ENOUGH AND STIMULATE THEM TO BREATHE DUE TO THE, QUOTE, PAINFUL STIMULATION.
THE COURT: “HERE” IS BEHIND THE EARS?
THE WITNESS: WELL, IT IS THE ANGLE OF THE JAW JUST KIND OF BELOW THE JAW. AND YOU ARE PUSHING REAL HARD AT THAT BACK ANGLE, IF YOU WILL, WITH USUALLY YOUR THUMB. THEN YOU LIFT THIS PART HIGHER. IF YOU ARE DOING IT WITH ONE HAND, THE OTHER HAND IS HOLDING A MASK THERE SO THAT YOU ARE HOPING THE PATIENT WILL START BREATHING. NOW, YOU CAN’T SQUEEZE THE BAG BECAUSE YOU DON’T HAVE ENOUGH HANDS TO DO THAT, UNLESS YOU KNOW THE TECHNIQUE OF HOLDING THE JAW LIKE THIS AND LIKE THIS. YOU ARE HOLDING THE MASK, WHICH WE ARE ALL TRAINED TO DO, AND YOU ARE SUPPOSED TO BE TRAINED TO DO THAT AS WELL. THAT WAY, YOU CAN SQUEEZE THE BAG AS WELL. THAT IS PURE AIRWAY, OKAY.
Q BY MR. WALGREN: AGAIN, PURE AIRWAY. YOU MENTIONED IT WAS A TONGUE LIFT. IS THAT WHAT YOU CALLED IT?
A YOU COULD DO THAT AS WELL. SOMETIMES THAT IS ALL YOU NEED TO DO, BUT MOST PEOPLE DON’T DO THAT. WHY TAKE A CHANCE TO GET BIT. OFTENTIMES, PEOPLE, IF THEY ARE GOING TO DO IT, OPEN IT AND TAKE SORT OF LIKE A PLIERS LIKE THING, AND THEY WILL GRAB THE TONGUE AND PULL IT FORWARD. BUT USUALLY, IF THERE IS TWO PEOPLE, ONE PERSON WILL DO THAT AND YOU CAN DO OTHER THINGS. OKAY, IF YOU DON’T HAVE ALL THE EQUIPMENT, SO IF YOU ARE OUT SOMEWHERE, THAT IS ONE OF THE THINGS YOU CAN THINK OF DOING. DEPENDING UPON THAT, YOU COULD ALSO HAVE A CHANCE OF GETTING BIT WHEN THE PATIENT WAKES UP.
Q WOULD YOU ALSO NEED TO HAVE ADVANCED AIRWAY EQUIPMENT ON BOARD IN THIS TYPE OF SETTING?
A RIGHT.
Q WHAT WOULD THAT INCLUDE?
A AGAIN, LARYNGEAL MASK AIRWAY IS ALWAYS A GOOD FALL-BACK PROVIDING YOU KNOW HOW TO USE IT. THEN INTUBATION WHERE YOU PUT A BREATHING TUBE. YOU HAVE TO KNOW HOW TO DO THAT. AGAIN, IT IS NOT EASY FOR SOMEBODY WHO HAS NEVER DONE IT BEFORE. YOU HAVE TO HAVE A SIGNIFICANT AMOUNT OF TRAINING TO DO IT SO THAT YOU CAN MOVE THE TONGUE TO THE SIDE, LOOK DOWN THE DEEP PART OF THE BACK OF THE THROAT WHERE YOU SEE THE VOICE BOX, IF YOU WILL, AND THE VOCAL CORDS. YOU PASS THE TUBE BETWEEN IT, AND THAT GETS IT INTO THE WINDPIPE. NOW YOU CAN VENTILATE. NOW, MOST OF THE TIME IF YOU ARE UNSKILLED, YOU WILL NOT GET THERE. YOU WILL GO DOWN THE SWALLOWING TUBE, THE ESOPHAGUS. YOU CAN’T VENTILATE SOMEBODY LIKE THAT. THAT IS A PROBLEM. ANOTHER ONE IS, AS I SAID, THE LARYNGEAL MASK AIRWAY. THE OTHER THINGS THAT USED TO BE USED IN THE FIELD IS CALLED A COMBI TUBE, WHERE IT IS A TUBE THAT IF YOU ARE LUCKY ENOUGH TO GET IT BETWEEN THE VOCAL CORD AND WINDPIPE, YOU CAN VENTILATE LIKE THAT. IF IT GOES DOWN THE ESOPHAGUS, YOU CAN MANEUVER A DIFFERENT PART OF IT AND INFLATE A BALLOON. SO NOW YOU CAN VENTILATE, SOMETHING LIKE A LARYNGEAL MASK AIRWAY, AND NOT HAVE TO WORRY ABOUT VENTILATING THE STOMACH INSTEAD OF THE LUNGS. BUT THAT IS NOT USED VERY MUCH ANYMORE.
Q ANYTHING ELSE AS FAR AS ADVANCED AIRWAY EQUIPMENT?
A WELL, AGAIN YOU NEED, IF YOU CAN’T INTUBATE A PATIENT, IF YOU CAN’T GET WHAT THEY CALL THE LARYNGEAL MASK AIRWAY TO WORK, IF THERE IS OTHER PROBLEMS YOU MUST BE READY TO DO WHAT WE CALL EMERGENCY CRICOTHYREOTOMY. SO RIGHT BELOW YOUR ADAM’S APPLE IS A LARGE SPACE YOU CAN FEEL. IT IS NOT QUITE A QUARTER OF AN INCH WIDE. YOU PUT A VERY, VERY LARGE BORE NEEDLE THROUGH THAT. THAT THEN GETS YOU RIGHT INTO THE WINDPIPE BELOW THE VOICE BOX BUT PAST THE VOCAL CORDS. YOU THEN PUT A WIRE THROUGH. OKAY. YOU PUNCTURE THE SKIN, GO RIGHT THERE, PUT THE CATHETER IN. THEN YOU PUT A WIRE THROUGH THAT. YOU CAN PULL THE CATHETER BACK OUT, TAKE A SCALPEL, MAKE A LARGER INCISION, THEN TAKE THIS VERY HARD PLASTIC PIECE THAT GETS THROUGH THERE, DILATES IT UP, AND THEN YOU CAN PUT AN AIRWAY THROUGH THAT. THAT IS THE MOST FINAL THING.
Q NOW, YOU ALSO MENTIONED IN YOUR REPORT THE NEED IN THIS TYPE OF SETTING TO HAVE VARIOUS PHARMACOLOGICAL ANTAGONISTS. WHAT DID YOU MEAN BY THAT?
A FOR EXAMPLE, WHEN WE GIVE AN OPIATE — HEROIN, MORPHINE, METHADONE, DILAUDID, DEMEROL, WHATEVER, OXYCONTIN, OXYCODONE, CODEINE — THOSE ARE ALL OPIATES. THERE IS A SPECIFIC ANTAGONIST THAT YOU CAN GIVE I.V. THAT WORKS VERY QUICKLY CALLED, TRADE NAME IS NARCAN. ALSO GOES BY THE GENERIC NAME OF NALOXONE. IT IS ONE OF THE THINGS IF YOU DON’T KNOW WHAT IS GOING ON WITH THE PATIENT, YOU WILL OFTEN GIVE. THEY USE THIS IF THEY SUSPECT DRUG OVERDOSE, ESPECIALLY MULTI-DRUG OVERDOSE. ON THE OTHER HAND, THERE IS A DIRECT ANTAGONIST TO THE FAMILY OF BENZODIAZEPINES — LORAZEPAM, MIDAZOLAM OR VERSED, DIAZEPAM OR VALIUM, RESTORIL – ALL THOSE OTHERS WORK THE SAME LIKE ALL OPIATES WORK THE SAME. THAT ANTAGONIST IS FLUMAZENIL. IT GOES BY THE TRADE NAME ROMAZICON. THOSE ARE THE ONLY TWO SPECIFIC ANTAGONISTS WE HAVE FOR TWO DIFFERENT CLASSES OF THE MOST COMMON DRUG FAMILIES THAT CREATE OVERDOSE AND RESPIRATORY ARREST AND/OR CARDIAC ARREST ISSUES.
Q NOW, THE NARCAN DOES NOT WORK AS A REVERSAL AGENT ON PROPOFOL, DOES IT?
A NO, IT DOES NOT.
THE COURT: THAT IS CORRECT?
THE WITNESS: THAT IS CORRECT. IT DOES NOT WORK ON PROPOFOL, NOR DOES IT WORK ON THE FAMILY OF BENZODIAZEPINES. SPECIFIC FOR OPIATE.
Q BY MR. WALGREN: AND IF IT WAS ADMINISTERED, IF IT WAS AVAILABLE AT SCENE AND ADMINISTERED IN THE HOPES IT WOULD HELP BECAUSE THE DRUGS IN THE BODY WERE UNKNOWN, WOULD IT CAUSE ANY HARM TO GIVE NARCAN?
A GENERALLY SPEAKING, NOT.
THE COURT: MR. WALGREN, LET ME KNOW FOR PURPOSES OF THE NOON BREAK.
Q BY MR. WALGREN: OKAY, IF I COULD FINISH THIS SECTION HERE, YOUR HONOR. I WANT TO TALK ABOUT THE ADVANCED CARDIAC LIFE SUPPORT EMERGENCY MEDICATIONS THAT NEED TO BE PRESENT IN THIS TYPE OF SETTING WHERE ONE IS BEING TREATED WITH BENZODIAZEPINES AND PROPOFOL.
A OKAY.
Q ARE THERE AGAIN PUBLISHED GUIDELINES AS TO WHICH ACLS, ADVANCED CARDIAC LIFE SUPPORT, EMERGENCY MEDICATIONS SHOULD BE AVAILABLE AND READY FOR USE?
A TALKING ABOUT REVERSAL AGENTS LIKE THE NARCAN, OR NALOXONE, OR REVERSAL AGENT FOR BENZODIAZEPINES OR ALL OF THEM?
Q THE WHOLE RANGE OF MEDICATIONS BEGINNING WITH EPINEPHRINE.
A AGAIN, NARCAN IS ON THAT LIST. FLUMAZENIL, NARCAN, EPINEPHRINE, WHICH IS A VASOCONSTRICTOR AND STIMULATES THE HEART TO RETRACT. NOREPINEPHRINE, WHICH IS MORE OF A VASOCONSTRICTOR TO INCREASE BLOOD PRESSURE. PHENYLEPHRINE, ALSO KNOWN AS NEOSYNEPHRINE, LIKE THE NOSE DROPS, HAS A PURE NASO-CONSTRICTOR EFFECT ON THE HEART. ATROPINE, WHICH IS SOMEWHAT OF AN ANTAGONIST FOR ONE PART OF THE NERVOUS SYSTEM TO HELP INCREASE THE RATE OR SPEED, HOW FAST THE HEART CONTRACTS. DOPAMINE, WHICH IS ANOTHER KIND OF STIMULANT FOR THE HEART TO BEAT AND CONTRACT MORE STRONGLY AND TO SOMEWHAT RAISE YOUR BLOOD PRESSURE. SODIUM BICARBONATE TO NEUTRALIZE ACIDOSIS. CALCIUM IN CASE THERE IS CERTAIN TIMES YOU MIGHT WANT TO USE THAT, ALTHOUGH NOT VERY COMMONLY. AMIODARONE, WHICH IS ANTI-ARRHYTHMIA, PART OF THE ACLS PATHWAY. PROCAINAMIDE, WHICH IS ANOTHER ANTI-ARRHYTHMIC DRUG. LIDOCAINE, WHICH IS ANOTHER TYPE OF ANTI-ARRHYTHMIC DRUG THAT YOU MAY CONSIDER USING. DEXTROSE, USUALLY CALLED D-50. IT IS 50 PERCENT DEXTROSE IN CASE SOMEONE IS VERY HYPO, LOW, LOW BLOOD SUGAR. THOSE ARE COMMON I.V. FLUIDS, THEN THERE IS EQUIPMENT THAT GOES ALONG WITH THAT.
Q STAYING ON THE MEDICATION, WHAT ABOUT VASOPRESSIN?
A THAT IS ANOTHER ONE. THANK YOU FOR REMINDING ME. THAT IS AN AGENT THAT WHEN CERTAIN PEOPLE FOR A NUMBER OF DIFFERENT REASONS WILL NOT RESPOND TO EPINEPHRINE OR NOREPINEPHRINE, VASOPRESSIN HAS AN EFFECT ON A WHOLE DIFFERENT PATHWAY, IF YOU WILL, THAT CAN OVERCOME THAT EFFECT AND IS NOW WELL RECOGNIZED FOR BOTH IN-THE-FIELD AND IN-THE-HOSPITAL ARRESTS, WHERE THOSE OTHER DRUGS ARE SEEMINGLY NOT WORKING, AND ACTUALLY IN SOME CASES ACTUALLY IS THE DRUG OF CHOICE.
Q NITROGLYCERIN?
A THAT IS AGAIN IF YOU HAVE A PATIENT YOU SUSPECT OF HAVING A HEART ATTACK AND ISCHEMIA. THAT IS THOUGHT TO BE A VASODILATOR OF THE HEART.
Q PART OF THIS ACLS EMERGENCY MEDICATION THAT SHOULD BE ON BOARD?
A CORRECT, OR PART OF YOUR ARMAMENTARIUM, WE CALL IT.
Q GLUCOSE?
A THAT IS DEXTROSE. YES, SAME THING.
Q AND DID YOU MENTION DIPHENHYDRAMINE?
A THAT IS ONE OF THEM FOR PART OF THE PEOPLE THAT DEVELOP ANAPHYLAXIS. THAT IS ONE OF THREE DIFFERENT DRUGS. DIPHENHYDRAMINE, ONE OF THE STEROIDS. USUALLY SOLUCORTEF IS GIVEN FOR ANAPHYLACTIC REACTIONS. AND ANOTHER DRUG IN THE FAMILY OF WHAT WE CALL H2 BLOCKERS, PEOPLE KNOW AS ZANTAC. YOU CAN BUY THAT OVER THE COUNTER, IS A WAY TO HELP REVERSE ANAPHYLACTIC PROBLEMS.
Q OKAY. THEN LASTLY, IN THIS AREA THEN BEFORE WE BREAK FOR THE NOON HOUR, IN ADDITION THEN TO THE EQUIPMENT YOU HAVE MENTIONED, BASIC AIRWAY EQUIPMENT, ADVANCED AIRWAY EQUIPMENT, THE PHARMACOLOGICAL ANTAGONIST, ACLS EMERGENCY MEDICATIONS, WHAT ABOUT A DEFIBRILLATOR?
A A DEFIBRILLATOR IS DEFINITE BECAUSE YOU NEED TO, NUMBER ONE, IF YOU HAVE A SHOCKABLE RHYTHM, YOU NEED A DEFIBRILLATOR. NUMBER TWO, A DEFIBRILLATOR AUTOMATICALLY GIVES YOU AN EKG PRINTOUT. SO IT DOES TWO THINGS. IT TELLS YOU WHAT THE RHYTHM IS. AND ALMOST ALL THE DEFIBRILLATORS IN THE LAST FIVE YEARS WILL ONLY SHOCK ON A SHOCKABLE RHYTHM. THEY ARE SMART ENOUGH, SMARTER THAN WE ARE, TO MAKE THAT DETERMINATION BECAUSE IF YOU SHOCK THE WRONG RHYTHM, YOU CAN ACTUALLY CREATE A COMPLETE ARREST. SO THEY ARE PROGRAMMED TO TRY TO RECOGNIZE THE RHYTHMS AS BEST THEY CAN, ARRHYTHMIA AS BEST THEY CAN. IF YOU THINK IT IS SHOCKABLE AND YOU HIT THE BUTTON, IT MAY NOT SHOCK BECAUSE IT IS SAYING, NO, YOU HAVE THE WRONG DIAGNOSIS. SO IT IS VERY HELPFUL. IT GIVES YOU ABILITY TO SHOCK. IT HELPS YOU UNDERSTAND WHAT THE SHOCKABLE RHYTHM IS AND ALSO DISPLAYS THE EKG.
Q AND THAT WOULD BE CONSTANT DISPLAY AGAIN AS YOU MIGHT SEE ON TV WITH THE LINE AND BLIPS SHOWING THE RHYTHM OF THE HEART?
A THAT IS CORRECT.
MR. WALGREN: THIS IS AN APPROPRIATE TIME, YOUR HONOR.
THE COURT: THANK YOU. WE WILL TAKE AN HOUR AND A QUARTER BREAK UNTIL 1:20 P.M. THIS AFTERNOON. SO WE WILL BE IN RECESS UNTIL 1:20 P.M. THE DEFENDANT AND ALL COUNSEL ORDERED BACK. DR. RUFFALO, PLEASE COME BACK AT 1:20 P.M.
RESUMPTION OF DIRECT, MR. WALGREN. MR. WALGREN: YES, BUT MAY WE APPROACH BRIEFLYBEFOREHAND?
THE COURT: YES, PLEASE.
(THE FOLLOWING PROCEEDINGS WERE HELD AT SIDEBAR:)
MR. WALGREN: YOUR HONOR, DURING THE LUNCH HOUR, I REVIEWED THE AUDIOTAPE. AS REFLECTED ON PAGE 37, I BELIEVE IT IS THREE TO FIVE MINUTES RATHER THAN 25 MINUTES, AND THAT IS IN REFERENCE TO THE INFUSION RATE, NOT THE AMOUNT GIVEN. BUT THAT IT WAS GIVEN – THE TRANSCRIPT READS CURRENTLY, PARAPHRASING, BUT IT IS PAGE 37, “IT WAS GIVEN SLOWLY OVER 25 MINUTES.” MY REVIEW OF THE AUDIO IS THAT IT IS THREE TO FIVE MINUTES AND THAT THE TRANSCRIPT HAS A TYPOGRAPHICAL ERROR. SO WE ARE WILLING TO STIPULATE TO THAT OR DEAL WITH IT IN ANY WAY APPROPRIATE.
THE COURT: THAT IS UP TO COUNSEL. HOWEVER YOU WISH TO HANDLE IT. DO YOU WISH TO STIPULATE TO IT?
MR. FLANAGAN: WE WILL STIPULATE TO IT.
MR. CHERNOFF: AND MOVE ON.
MR. WALGREN: OKAY.
MR. CHERNOFF: THAT SHOULDN’T SLOW ANYTHING DOWN.
THE COURT: THIS HAD TO DO WITH THE TESTIMONY OF — IT HAD TO DO WITH THE QUESTION POSED TO THE DOCTOR.
MR. WALGREN: THAT HE EVENTUALLY ASKED THAT QUESTION.
MR. FLANAGAN: I WAS EVENTUALLY ABLE TO ASK THE QUESTION SUBJECT TO MAKING AN OFFER OF PROOF BECAUSE THERE WAS NO FACTS IN EVIDENCE AT THAT POINT IN TIME. EVERYBODY THOUGHT IT WAS 25. MR. MARTINEZ TESTIFIED TO THAT IS WHAT HE PUT IN THE TIME LINE THAT WAS GIVEN.
MR. CHERNOFF: THAT IS JUST ARGUMENT. WE WILL DO THAT ARGUMENT LATER.
THE COURT: IF YOU DO WANT TO ENTER INTO A STIPULATION, WE WILL DO THE STIPULATION AFTER THE TESTIMONY OF THE WITNESS. SOMEBODY CAN OFFER THE STIPULATION.
MR. WALGREN: ALL RIGHT.
MR. CHERNOFF: CAN WE DO IT ORALLY?
MR. WALGREN: YES.
THE COURT: YES.
MR. FLANAGAN: IT SHOULD BE DONE BEFORE THE WITNESS TESTIFIES FURTHER.
MR. WALGREN: I WOULD ASK.
THE COURT: DO YOU WANT TO DO IT RIGHT NOW?
MR. WALGREN: YES.
THE COURT: WHO WANTS TO OFFER THE STIPULATION?
MR. WALGREN: I’LL DO THE STIPULATION.
THE COURT: DON’T FIGHT OVER IT. YOU WILL BOTH BE STIPULATING.
MR. WALGREN: BUT THE ISSUE OF DR. ROGERS GAVE HIS OPINION EVEN ASSUMING THAT FACT, SO NO ONE IS PROPOSING DR. ROGERS NEEDS TO BE RECALLED. IF YOU ARE, I MEAN HIS OPINION ON HOMICIDE WAS NOT DEPENDENT ON THAT. HE EVEN SAID IF IT WAS SELF-ADMINISTRATED, IT WAS STILL HOMICIDE. DOES THE DEFENSE EXPECT TO RECALL DR. ROGERS?
MR. CHERNOFF: PROBABLY NOT, BUT WE DO WANT TO BE ABLE TO CROSS THIS WITNESS BASED ON THAT INFORMATION.
MR. WALGREN: ABSOLUTELY.
THE COURT: WE WILL HAVE THE STIPULATION RIGHT NOW.
(THE FOLLOWING PROCEEDINGS WERE HELD IN OPEN COURT:)
THE COURT: WE HAVE BEEN CONFERRING ABOUT A STIPULATION. MR. WALGREN, WOULD YOU LIKE TO OFFER THE STIPULATION?
MR. WALGREN: PLEASE, YOUR HONOR. THAT WOULD BE, WE WOULD OFFER A STIPULATION, YOUR HONOR, REGARDING THE TRANSCRIPT OF DEFENDANT CONRAD MURRAY’S INTERVIEW AS REFLECTED ON PAGE 37 OF THAT INTERVIEW, LINE 18, THERE IS A TYPOGRAPHICAL ERROR WHERE IT STATES, THE SENTENCE IN FULL CURRENTLY READS, “SLOWLY INFUSED OVER, I WOULD SAY, 25 MINUTES.” IT SHOULD READ, “SLOWLY INFUSED OVER, I WOULD SAY, THREE TO FIVE MINUTES.” PEOPLE WOULD STIPULATE TO THAT FACT FOR PURPOSES OF THE PRELIMINARY HEARING.
THE COURT: DOES THE DEFENSE?
MR. CHERNOFF: WE DO.
MR. FLANAGAN: WE ACCEPT THAT STIPULATION.
THE COURT: THANK YOU. THE COURT ACCEPTS IT AS WELL. BOTH PARTIES WANT TO OFFER THE STIPULATION. IT IS JUST THAT WE ARE AT THE POINT WHEN MR. WALGREN IS DOING THE EXAMINATION, SO IT IS A JOINT STIPULATION AND IT IS ACCEPTED.
MR. WALGREN: THANK YOU, YOUR HONOR.
THE COURT: RESUMPTION OF DIRECT, MR. WALGREN.
MR. WALGREN: THANK YOU.
DIRECT EXAMINATION (RESUMED) BY MR. WALGREN:
Q DOCTOR, WHEN WE BROKE AT THE NOON HOUR, I BELIEVE WE LEFT OFF SPEAKING ABOUT THE REQUISITE EQUIPMENT NECESSARY FOR THESE TYPES OF BENZODIAZEPINE AND PROPOFOL TREATMENT, RIGHT?
A THAT’S CORRECT.
Q CORRECT ME IF I’M WRONG. JUST TO BE CLEAR, HAD YOU MENTIONED AN END TIDAL C02 MONITOR?
A CORRECT, GOES BY END TIDAL, MEANING THE END OF EXHALATION OF A TIDAL BREATH, WHICH IS NORMAL RESTING BREATH, THEN C02. THAT IS A NICKNAME FOR THE TECHNICAL TERM WHICH IS CAPNOGRAPHY.
Q THAT RELATES TO THE CAPNOGRAPHY READINGS THAT YOU MENTIONED BEFORE THE NOON HOUR?
A EXACTLY.
Q IS AN END TIDAL C02 MONITOR SOMETHING THEN THAT WOULD BE IN YOUR OPINION REQUIRED FOR THE TYPE OF TREATMENT YOU HAVE LEARNED ABOUT THROUGH YOUR REVIEW OF THE MATERIALS?
A THAT IS EXACTLY CORRECT.
Q IS AN END TIDAL C02 MONITOR SOMETHING THAT WOULD BE ABLE TO DETECT SOMETHING, FOR EXAMPLE, LIKE AN AIRWAY OBSTRUCTION?
A CORRECT.
Q NOW, I WANT TO DIRECT YOUR ATTENTION BACK TO EXHIBIT 68 ON THE SCREEN. CAN YOU SEE THAT, DOCTOR?
A I CAN.
Q I WANT TO ASK YOU SPECIFICALLY ABOUT SOME OF THESE FINDINGS AS THEY MAY OR MAY NOT RELATE TO ONE ANOTHER. GOING FIRST TO THE GASTRIC CONTENTS, DO YOU SEE WHERE IT INDICATES PROPOFOL AT 0.13 MILLIGRAMS?
A THAT IS CORRECT.
Q AND LIDOCAINE AT 1.6 MILLIGRAMS?
A I SEE THAT, CORRECT.
Q AND WERE YOU ABLE TO DETERMINE ALSO THROUGH YOUR REVIEW OF THE MEDICAL EVIDENCE THE CONTENTS, PHYSICAL CONTENTS, OF THE STOMACH?
A YES. THE CORONER REPORTS THAT THERE WERE 70 GRAMS OF DUODENAL FLUID WHICH, BECAUSE IT IS A LIQUID, WOULD BETTER BE STATED AS A VOLUME WHICH WOULD BE MILLILITER. SO WHAT YOU WOULD DO IS THAT IS THE TOTAL CONTENT OF THE STOMACH. FOR EXAMPLE, THE PROPOFOL OF 0.13 MILLIGRAMS INSIDE 70 MILLILITERS OF DUODENAL FLUID. THE SAME THING FOR THE LIDOCAINE. THEREFORE, TO FIND THE CONCENTRATION, YOU DIVIDE BY 70, WHICH I DID. AND I HAVE MY NOTEBOOK HERE IF YOU WOULD LIKE ME TO TELL YOU WHAT THE ANSWER IS.
Q I WOULD, AND LET ME ASK YOU BEFORE WE GET THERE, THEN THE NUMBERS REFLECTED IN PEOPLE’S 68, 0.13 MILLIGRAMS PROPOFOL, 1.6 FOR THE LIDOCAINE, DO THOSE NUMBERS REFLECT THE CONCENTRATION?
A NO. THOSE NUMBERS JUST REFLECT THE AMOUNT, NOT A CONCENTRATION, BUT A TOTAL AMOUNT THAT WAS FOUND WITHIN THE 70 MILLILITERS OF DUODENAL FLUID.
Q THEN THROUGH YOUR EXPERTISE AND THEN THROUGH YOUR MATH REGARDING THE 70 GRAMS, WERE YOU ABLE TO CONVERT WHAT IS THE PHYSICAL AMOUNT INTO A CONCENTRATION?
A I WAS.
Q FOR PROPOFOL, WHAT NUMBER DID YOU COME UP WITH?
A I’D HAVE TO, IF I CAN JUST LOOK IN MY BINDER.
Q PLEASE.
A (EXAMINING DOCUMENT) FOR PROPOFOL, THE CONCENTRATION IS 0.00186 MILLIGRAMS PER MILLILITER.
Q OKAY. AND WHAT DOES THAT MEAN TO YOU AS FAR AS THE LEVEL OF CONCENTRATION ON A RANGE, IF YOU COULD DESCRIBE IT?
A OKAY. WHAT IT MEANS, IT IS A VERY, VERY DILUTE CONCENTRATION, ESPECIALLY WHEN YOU COMPARE IT TO THE BLOOD, THE LIVER, SO ON, SO FORTH. BUT IT WOULD BE WHAT I WOULD EXPECT. SOMEWHAT SIMILAR TO THE LIDOCAINE IF YOU WERE TO CONVERT THAT TO CONCENTRATION. IT IS A PHENOMENA WE CALL POSTMORTEM REDISTRIBUTION, MEANING DRUGS GO FROM AREAS OF HIGH CONCENTRATION TO LOW CONCENTRATION. SO THE EXAMPLE HERE, THE LIVER, WHICH IS A VERY HIGH CONCENTRATION, FOR EXAMPLE, FOR PROPOFOL, IT IS 6.2 MILLIGRAMS PER MILLILITER. IT IS A VERY HIGH CONCENTRATION COMPARED TO 0.00186 FOUND IN THE STOMACH. THAT IS BECAUSE THE LIVER SITS, YOU KNOW, KIND OF RIGHT NEXT TO THE STOMACH. SO EVEN THOUGH THE LIVER IS A HIGH CONCENTRATION IN DEATH, THE CELLS START DYING. THERE IS NO BLOOD FLOW TO INHIBIT THAT CONCENTRATION FROM MOVING BACK AND FORTH AND BEING KIND OF PUT WHERE IT BELONGS. SO IN DEATH, WHAT HAPPENS IS A PASSIVE DIFFUSION. SO DRUGS GO FROM THEIR HIGH CONCENTRATION TO LOW CONCENTRATION, BUT THEY ARE INHIBITED TO A DEGREE BY THE VARIOUS TISSUES AND MEMBRANES AND THE DISTANCE AS WELL.
Q OKAY.
A SO IT IS EXACTLY WHAT WE WOULD EXPECT IN A POSTMORTEM FINDING FROM A HIGHER CONCENTRATION. YOU COULD ALSO EVEN USE THE SAME WITH THE HEART. THE HEART LITERALLY SITS ABOUT NOT QUITE AN INCH FROM THE STOMACH ITSELF. SO AGAIN, IT IS GOING FROM A HIGH CONCENTRATION TO A LOW CONCENTRATION, AND BASICALLY THAT IS WHAT WE FIND.
Q THEN DID YOU DO THE SAME CONVERSION FOR THE LIDOCAINE FOUND IN THE GASTRIC CONTENTS?
A I DID.
Q WHEN YOU CONVERT IT TO GET ACTUAL CONCENTRATION OF LIDOCAINE, WHAT DO YOU COME UP WITH?
A THE NUMBER IS 0.0228 MILLIGRAMS PER MILLILITER.
Q HOW WOULD YOU CHARACTERIZE THAT CONCENTRATION?
A IT IS THE SAME ISSUE AS THE PROPOFOL. THE DIFFERENCE IS A DIFFERENCE IN CONCENTRATIONS, DIFFERENCE IN THE HIGH TO LOW, AND THEN DIFFERENCE IN DIFFERENT DRUGS ARE EITHER MORE OR LESS READILY DIFFUSED BASED ON THEIR SIZE, WHAT THEY CALL ELECTRICAL CHARGES, THE TYPES OF MEMBRANES THAT ARE TISSUES AND MEMBRANES THAT SEPARATE THEM. BUT AGAIN, IT IS EXACTLY WHAT YOU WOULD EXPECT.
Q THEN ONCE YOU HAVE THE CONCENTRATION VALUES THAT YOU HAVE COMPUTED, AND YOU HAVE INDICATED VERY LOW CONCENTRATIONS?
A CORRECT.
Q ARE THOSE CONCENTRATION LEVELS CONSISTENT WITH SOMEONE ORALLY INGESTING PROPOFOL OR LIDOCAINE?
A NOT AT ALL.
Q WHY IS THAT?
A WELL, FIRST OF ALL, IF YOU INGEST LIDOCAINE, YOU WOULD HAVE A MUCH HIGHER CONCENTRATION BY AT LEAST PROBABLY ONE AND A HALF TO TWO ORDERS OF MAGNITUDE. ORDER OF MAGNITUDE WOULD BE TIMES TEN. TWO ORDERS OF MAGNITUDE WOULD BE A HUNDRED. IT WOULD HAVE TO BE MUCH HIGHER CONCENTRATION.
Q HOW ABOUT PROPOFOL?
A SAME THING.
Q DR. RUFFALO, IN YOUR REVIEW AND ANALYSIS OFTHIS CASE AND IN THE REPORT, THE 47-PAGE REPORT THAT YOU CREATED, DID YOU THEN IDENTIFY PARTICULAR ISSUES YOU FOUND DEVIATED FROM THE STANDARD OF CARE IN THIS CASE?
A I DID.
Q DID YOU ALSO GO THROUGH THOSE DEVIATIONS IN THE STANDARD OF CARE TO OFFER IN YOUR OPINION THE LEVEL OF DEPARTURE FROM THE STANDARD OF CARE THAT ONE WOULD EXPECT IN THIS MEDICAL SETTING?
A I DID.
Q NOW, I WANT TO FIRST ASK YOU ABOUT A SERIES OF ISSUES YOU HAVE IDENTIFIED AS SIMPLE DEPARTURES. YOU INDICATE FAILURE TO RECOGNIZE THE SIGNIFICANCE OF THE THREADING PULSE AND HEART RATE OF 122. CAN YOU DESCRIBE WHAT YOU MEANT BY THAT?
A OKAY. WHAT I MEAN BY THAT IS SOMEONE WHO SHOULD BE EXPERIENCED IN RECOGNIZING WHAT THOSE MEAN. THREADING PULSE MEANS THERE IS A PALPABLE PULSE, MEANING YOU DON’T START CHEST COMPRESSIONS WITH THAT. THERE IS SIGNIFICANT WHAT WE CALL CENTRAL SHUNTING OF BLOOD TO THE VITAL ORGANS. THREADING PULSE AND READING ON A PULSE OXIMETER, THAT MEANS YOU HAVE GOT GOOD ENOUGH. IT MEANS THERE IS AT LEAST A 70 MILLIMETER SYSTOLIC BLOOD PRESSURE, POSSIBLY MORE. HOW WELL, HOW GOOD YOUR FINGERS ARE, IF YOU FEEL THE EXTREMITY HERE VERSUS A CAROTID PULSE OR FEMORAL PULSE, YOU WILL BE MERELY THREADING, OR LESS, OR NOT AT ALL. SO THAT WOULD CLEARLY TELL YOU DON’T START CPR, MEANING THE CHEST COMPRESSION PART. DO THE FIRST PART OF CPR, MEANING AIRWAY. THEN BASIC AND ADVANCED CARDIAC LIFE SUPPORT. A, B, C. AIRWAY, BREATHING, CIRCULATION. AIRWAY IS FIRST, BREATHING IS SECOND. CIRCULATION IS THIRD. YOU ANALYZE IT BY UTILIZING THAT. SO A THREADING PULSE, FOR EXAMPLE, YOU KNOW WHAT YOU SHOULD OR SHOULDN’T DO. SO THIS WOULD BE A SIMPLE DEPARTURE FOR SOMEBODY WHO IS NOT, YOU KNOW, SHOULD KNOW THE DIFFERENCE. AND DEPENDING UPON WHAT YOU DO WITH THAT PIECE OF INFORMATION COULD BE AN EXTREME DEPARTURE. SO IT DEPENDS UPON HOW YOU DO THINGS.
Q HOW ABOUT THE FAILURE TO APPRECIATE THE DRUG-ON-DRUG INTERACTIONS?
A THE SAME THING GOES. AGAIN, THE DEPARTURE FROM STANDARD OF CARE IS NOT RECOGNIZING AT LEAST SOME OF THE ISSUES AND THEN HOW YOU REACT TO IT. SO THE ISSUE OF NOT RECOGNIZING YOU CAN FORGIVE IF YOU DO THE RIGHT THINGTO FOLLOW UP.SO AS AN INDIVIDUAL ISSUE, IT MAY BE A SIMPLE DEPARTURE. BUT IF YOU DON’T FOLLOW UP APPROPRIATELY, THEN IT BECOMES OR OBVIOUSLY COULD BECOME AN EXTREME DEPARTURE.
Q YOU ALSO IDENTIFIED DR. MURRAY’S FAILURE TOIDENTIFY THE ADDICTIVE NATURE OF PROPOFOL. CAN YOU DESCRIBE THAT?
A SURE. DR. MURRAY IN HIS STATEMENT HE GAVE TO THE POLICE OFFICERS TALKS ABOUT HIS FEELING THAT HE WAS LIKELY TO BE ADDICTED. HE WASN’T SURE. HE DIDN’T KNOW IF THE LITERATURE TALKED ABOUT THAT. HOWEVER, HAD HE SEARCHED, FOR A NUMBER OF YEARS THAT HAS BEEN REPORTED IN LITERATURE. IT IS AN ABUSED SUBSTANCE BY, FORTUNATELY, A SMALL GROUP OF PEOPLE, AND IT IS ADDICTING. SO THE FACT IS THAT IS ONE OF THE ISSUES.THAT WOULD BE A SIMPLE DEPARTURE, ESSENTIALLY.
Q THAT HE FAILED TO HAVE BEEN PROPERLY INFORMED OF THAT?
A RIGHT.
Q AND AGAIN, WITH THE BENZODIAZEPINES, DID YOU ALSO NOTE THAT DR. MURRAY FAILED TO RECOGNIZE THE ADDICTIVE NATURE OF THE BENZODIAZEPINES?
A RIGHT. THAT IS A WELL-KNOWN FACT IN THE LITERATURE. THEY ARE ADDICTIVE. PEOPLE EASILY BECOME RELIANT ON THAT EITHER AS AN ANTI-ANXIETY DRUG OR SEDATIVE, HYPNOTIC DRUG FOR SLEEP TO TREAT INSOMNIA, ORBOTH. ALSO, IN MILD STATES OF DEPRESSION, IT IS USED. SO IT IS A WELL-KNOWN FACT, SO THAT IS AT LEAST A DEPARTURE.
Q AND IS PROPOFOL PROPERLY INDICATED FOR THE TREATMENT OF SLEEP AID OR INSOMNIA?
A ABSOLUTELY NOT.
Q DID YOU IDENTIFY DR. MURRAY’S FAILURE TO RECOGNIZE THAT PRINCIPLE AS A SIMPLE DEPARTURE?
A THAT IS CORRECT.
Q IN REGARD TO DR. MURRAY’S STATEMENTSREGARDING WHAT HE DID WITH THE FLUMAZENIL AFTER FINDING MICHAEL JACKSON NOT BREATHING, DID YOU IDENTIFY THAT AS A SIMPLE DEPARTURE?
A I DID.
Q WHAT WAS IT THAT DR. MURRAY DID WRONG IN THAT AREA?
A WHEN YOU HAVE A PATIENT IN A SITUATION WHERE YOU SUSPECT RESPIRATORY DEPRESSION DUE TO A BENZODIAZEPINE TYPE DRUG — VERSED, DIAZEPAM AND LORAZEPAM — THE REVERSAL ENGINE IS FLUMAZENIL. THE DOSE HE GAVE WAS A VERY, VERY SMALL DOSE IN RESUSCITATION TYPE PHENOMENA THAT IS OCCURRING. SO THE APPROPRIATE DOSE WOULD BE FIVE TO TEN TIMES, UP TO ONE AND TWO MILLIGRAMS, I.V. PUSH. THE WORST THAT COULD HAPPEN IS WAKE UP FASTER. HE MIGHT GET REALLY ANXIOUS, BUT YOU SAVE A LIFE.
Q NOW, BEGINNING WITH THE SIMPLE DEPARTURES, I BELIEVE YOU HAVE IDENTIFIED SIX SEPARATE SIMPLE DEPARTURES. TAKING ALL THOSE TOGETHER, WOULD YOUCHARACTERIZE THAT AS AN EXTREME DEPARTURE FROM THE STANDARD OF CARE?
A RIGHT, BECAUSE THERE IS SO MANY DIFFERENT SYSTEMS. ONCE THAT BECOMES ADDICTIVE, IF NOT SYNERGISTIC, MEANING THE WHOLE IS GREATER THAN THE SUM OF THE PARTS, THEN IT BECOMES AN EXTREME DEPARTURE.
Q FOCUSING JUST ON THOSE YOU HAVE MENTIONED, WOULD THOSE IN TOTAL REPRESENT AN EXTREME DEPARTURE FROM THE EXPECTED STANDARD OF CARE?
A THAT IS CORRECT.
Q WHEN YOU USE THE WORD EXTREME DEPARTURE, WHAT DO YOU MEAN?
A WELL, IT IS SO EGREGIOUS THAT TAKEN IN WHOLE, ANYBODY, ANY PHYSICIAN WHO HAS SOME SENSE OF TRAINING, SHOULD BE ABLE TO UNDERSTAND THE COMPLEXITY AND KNOW WHAT TO DO. SO EACH INDIVIDUAL ONE, WHEN YOU PUT THEM TOGETHER, IS SO EGREGIOUS. I DON’T KNOW. IT IS EXTREME, I GUESS IS THE BEST WAY TO PUT IT.
Q SO EGREGIOUS THAT ANY PHYSICIAN WITH EVEN SOME SENSE OF TRAINING SHOULD KNOW?
A RIGHT. THEY SHOULD KNOW THAT YOU ARE PRESENTED WITH A PROBLEM AND YOU BETTER HANDLE IT. AND THE PHYSICIANS ARE SUPPOSED TO BE TRAINED IN AT LEAST BASIC LIFE SUPPORT, AIRWAY BREATHING, RESUSCITATION, AND CIRCULATION.
Q AND NOW I WANT TO GO TO INDIVIDUAL FINDINGS THAT JUST STANDING ALONE YOU FOUND TO BE EXTREME DEPARTURES. FIRST, YOU IDENTIFIED THE FAILURE TO USE APPROPRIATE MONITORING EQUIPMENT. CAN YOU DESCRIBE THAT WITH SPECIFICITY AS IT RELATES TO THIS CASE?
A OKAY. THAT WOULD BE A BLOOD PRESSURE CUFF, TAKING BLOOD PRESSURE. EITHER DO IT MANUALLY OR USE WHAT WE CALL A NON-INVASIVE BLOOD PRESSURE CUFF WHICH IS ELECTRONIC. A LOT OF PEOPLE HAVE THEM IN THEIR HOME TO TAKE THEIR BLOOD PRESSURE. YOU CAN SET THE TIME INTERVAL FOR EVERY, YOU KNOW, THREE MINUTES, FIVE MINUTES, TWO MINUTES, TEN MINUTES, WHATEVER, ALTHOUGH FIVE MINUTES WOULD BE THE STANDARD FOR MONITORING AT A MINIMUM. THEN YOU RECORD IT. THE NEXT WOULD BE EKG. ALL RIGHT. SO EITHER YOU HAVE AN OSCILLOSCOPE WITH EKG TRACING. YOU COULD HAVE A DEFIBRILLATOR THERE. YOU GET TWO FOR THE PRICE OF ONE THAT WILL DO THE SAME THING. YOU THEN HAVE A PULSE OXIMETER WHICH SHOULD HAVE A TONAL SOUND, PITCH, FOR CHANGE IN OXYGEN SATURATION AND ALARM SO THAT WHEN IT HITS EITHER PREPROGRAMMED, WHICH ALL MANUFACTURERS PRE-PROGRAM FOR 90 PERCENT, IT WILL ALARM UNLESS YOU TURN IT OFF OR MAKE IT HIGHER OR LOWER INTENTIONALLY. THAT WILL ALERT YOU THAT SOMETHING IS GOING ON. AND THEN END TIDAL CO2 CAPNOGRAPH TO MEASURE EXHALED CARBON DIOXIDE SO YOU GET A REAL TIME QUALITATIVE TRACING OF THE DEPTH OF BREATHING, THE RATE OF BREATHING AND YOU COULD EVEN FACTOR IN HOW THAT WOULD CHANGE YOUR CARBON DIOXIDE LEVELS WHICH YOU MAY ALSO SEE DEPENDING UPON APNEIC PHASES, OR FULL ARREST OF BREATHING, AND COMPLETE AIRWAY OBSTRUCTION.
Q THE ABSENCE OF THE EQUIPMENT YOU JUST LISTED OFF WOULD BE EXTREME DEPARTURE?
A ABSOLUTELY.
Q LET ME ASK YOU ABOUT THE FAILURE TO INFORM THE PARAMEDICS OF THE DRUGS THAT HAD BEEN GIVEN AND THE FAILURE TO INFORM UCLA EMERGENCY PERSONNEL OF THE DRUGS THAT HAD BEEN GIVEN. WOULD THAT BE EXTREME DEPARTURE?
A YES, IT IS EXTREME DEPARTURE BECAUSE YOU SHOULD LET RESCUE PERSONNEL KNOW OF ANYTHING AND ALL DRUGS OR SITUATIONS THAT HAVE BEEN ENCOUNTERED THAT YOU HAVE SEEN. IN THIS CASE, ALL THE DRUGS THAT HAVE BEEN GIVEN — LORAZEPAM, DIAZEPAM, VERSED WHICH IS MIDAZOLAM, AND PROPOFOL.
Q YOU HAVE ALSO IDENTIFIED THE FAILURE TO PERSONALLY MONITOR AND RECORD VITALS?
A CORRECT.
Q WAS THAT FAILURE AN EXTREME DEPARTURE?
A RIGHT, BECAUSE IT IS THE ONLY WAY YOU CAN KEEP TRACK OF THINGS, ESPECIALLY OVER A LONG PERIOD OF TIME. YOU ARE NOT GOING TO NECESSARILY REMEMBER WHAT HAPPENED AN HOUR AGO IN CERTAIN SITUATIONS. YOU CAN GO BACK AND CORRELATE THAT OVER TIME AND SEE, YOU KNOW, AM I GETTING A TREND OF A SLOWER RESPIRATORY RATE, SMALLER DEPTH OF BREATHING, A SLOWER HEART RATE, HIGHER HEART RATE, LOWER OXYGEN SATURATION, HIGHER, IF MY CAPNOGRAPHY WAVE FORM IS CHANGING OVER TIME. ALL THOSE THINGS YOU THROW IN, AS WELL AS THE CLINICAL SIGNS. WHICH IF YOU DON’T HAVE AN EEG OR A B.I.S. MARKER, YOU COULD CERTAINLY CHECK EYELID REFLEXES, STERNAL RUB FOR DEPTH OF SEDATION, TO MONITOR TO GENERAL ANESTHESIA. CHECKING ALL THOSE THINGS CAN BE FACTORED IN AND YOU RECORD THAT SO YOU CAN KEEP TRACK OF EXACTLY WHAT IS GOING ON.
Q YOU ALSO IDENTIFIED THE FAILURE TO BE IMMEDIATELY PRESENT AND VIGILANT, AND YOU IDENTIFIED THAT AS EXTREME DEPARTURE.
A THAT IS CORRECT.
Q WHAT DID YOU MEAN BY THAT?
A WELL, A COUPLE OF THINGS. NUMBER ONE, IF YOU HAVE A PATIENT WHO IS GETTING A COMBINATION OF DRUGS LIKE THIS, OR JUST PROPOFOL ALONE, AND YOUR INTENTION IS TO CREATE A STATE OF MODERATE TO DEEP SEDATION WHERE A PATIENT CAN EASILY GO INTO A LIGHT OR DEEP GENERAL ANESTHESIA AND END UP WITH SEVERE PROBLEMS, YOU HAVE TO BE VIGILANT. YOU HAVE TO BE THERE AT ALL TIMES, OR YOU GET SOMEBODY ELSE TO COME IN AND RELIEVE YOU. DOESN’T MATTER EITHER WAY. SOMEBODY WHO IS QUALIFIED TO KNOW HOW TO HANDLE THE ISSUES, KNOW THE MONITORING. THEY HAVE TO BE THERE AT ALL TIMES. NOW, THE OTHER THING IS IF YOU WALK OUT AND LEAVE THE PATIENT, BAD THINGS CAN HAPPEN. IF YOU COME BACK AND YOU DON’T KNOW WHAT THE PATIENT DID AND, FOR EXAMPLE, THE PATIENT JUST STOPS BREATHING. YOU DIDN’T NOTICE IT. YOU DIDN’T RECORD IT. YOU DON’T HAVE ALL THE RIGHT EQUIPMENT. YOU ARE GOING TO MISS IT. SO NO MATTER WHAT, YOU ARE RESPONSIBLE A HUNDRED PERCENT FOR THE SAFETY OF THAT PATIENT.
Q NOW, YOU ALSO IDENTIFIED THE FAILURE TO PROVIDE APPROPRIATE ADVANCED CARDIAC LIFE SUPPORT CARE. YOU IDENTIFIED THAT AS AN EXTREME DEPARTURE, CORRECT?
A THAT IS CORRECT.
Q WITHIN THAT VERY LARGE CATEGORY OF ACLS CARE, YOU IDENTIFIED MULTIPLE INDIVIDUAL FAILURES TO PROVIDE APPROPRIATE CARE, CORRECT?
A I DID.
Q YOU IDENTIFIED THE FAILURE TO CALL 911?
A THAT IS THE FIRST THING YOU DO IF YOU ARE A SINGLE INDIVIDUAL WITH A PATIENT BECAUSE IF YOU JUST TRY TO DO IT BY YOURSELF AND THINGS GO BAD AND YOU CAN’T RESUSCITATE HIM, NOBODY IS GOING TO COME TO HELP YOU. THE FIRST THING, YOU EITHER HOLLER, “CALL 911,” WHATEVER, THEN YOU IMMEDIATELY — AT WHICH POINT IT TAKES 15, 20 SECONDS, AND THEN YOU GO AHEAD AND PROVIDE YOUR CARE.
Q YOU IDENTIFIED FAILURE TO USE THE AMBU BAG WITH OXYGEN?
A THAT IS CORRECT.
Q DESCRIBE THAT, PLEASE?
A WELL, AGAIN, IT IS THE BAG — EXCUSE ME – IT IS A MASK SYSTEM THAT GOES OVER THE NOSE AND MOUTH THAT YOU CAN SEAL WITH YOUR HAND. YOU CAN DO A JAW LIFT LIKE WE TALKED ABOUT EARLIER, THEN SQUEEZE THE BAG. IT IS HOOKED UP TO OXYGEN, SO YOU CAN VENTILATE WITH ALMOST A HUNDRED PERCENT OXYGEN. YOU CAN ALSO CHECK VENTILATION BY LOOKING EVERY TIME BREATH COMES OUT, YOU WILL SEE FOGGING BECAUSE ALL THE MASKS ARE CLEAR PLASTIC. YOU CAN SEE IT FOG UP. IF YOU ARE NOT GETTING GOOD VENTILATION, YOU WON’T SEE ANY FOG OR SEE JUST A LITTLE. YOU LOOK AT CHEST RISING, THE STOMACH. SO YOU HOPEFULLY AREN’T SQUEEZING AIR IN THE STOMACH. YOU ARE GETTING THE APPROPRIATE JAW LIFT. SO IT IS THE WAY TO FIRST, IF YOU HAVE SOMEBODY WITH A PULSE AND HEART RATE, I DON’T KNOW WHAT THE SATURATION WAS, BUT THE AIRWAY AND BREATHING ARE THE TWO FIRST STEPS. IF YOU HAVE A THREADED PULSE, YOU DON’T NEED TO START CHEST COMPRESSIONS.
Q YOU DID IN A SEPARATE SECTION OR SEPARATE ANALYSIS IDENTIFY THE FAILURE TO UTILIZE A, B C, OF BASIC LIFE SUPPORT?
A BASIC CARDIAC LIFE SUPPORT. THAT’S CORRECT.
Q AGAIN, THE AIRWAY, THE BREATHING, AND CIRCULATION?
A CORRECT.
Q AND IN REGARD TO THAT, DID YOU ALSO OFFER AN OPINION REGARDING THE ONE-HANDED CPR ON THE BED THAT DR. MURRAY INDICATED HE GAVE THE PATIENT?
A TOTALLY USELESS.
Q TOTALLY USELESS?
A TOTALLY USELESS.
Q YOU READ IN DR. MURRAY’S STATEMENT THAT HE PLACED ONE HAND BEHIND THE BACK AND THEN DID COMPRESSIONS. IS THAT STILL TOTALLY USELESS?
A IT IS ALMOST TOTALLY USELESS. THE FACT IS YOU CAN’T GET ENOUGH LEVERAGE TO PUSH DOWN ON THE STERNUM. WE DO THAT FOR NEONATES AND VERY SMALL INFANTS WHERE THAT ACTUALLY IS GOOD, OR YOU CAN GO LIKE THAT WITH YOUR THUMBS.
Q WITH AN INFANT?
A WELL, AN INFANT, NEONATE. VERY SMALL INFANT AND NEONATES. WITH AN ADULT, THE FIRST THING YOU DO IF THEY ARE IN A BED, IF YOU CAN’T LIFT THEM EASILY, YOU TAKE YOUR HAND UNDER THEIR SHOULDERS WITH THEIR HEAD KIND OF IN YOUR FOREARM, AND JUST SLIDE THEM OFF THE BED. LET THEM DROP, BUT CRADLE THE HEAD AND SHOULDERS SO THEY DON’T HURT THEIR HEAD. THEY ARE ON A HARD SURFACE. IF YOU NEED TO START CHEST COMPRESSIONS, THAT IS WHAT YOU DO.
Q EVEN IF YOU CLAIMED THAT YOU COULDN’T MOVE THE PERSON FROM THE BED, A 136-POUND PERSON, THE PROPER TRAINING WOULD BE TO AGAIN PROTECT THE HEAD AND JUST SLIDE THE INDIVIDUAL OFF THE BED WITH THEIR FEET LAYING ON THE FLOOR BUT WITH NO INJURY TO THE HEAD. AT THAT POINT YOU COULD DO THE TRUE TWO-HANDED COMPRESSIONS ON A HARD SURFACE?
A RIGHT. FEET, BUTTOCKS, LOW BACK, THAT DOESN’T MATTER. YOU ARE SAVING THEIR LIFE. THEY MIGHT GET SOME BRUISES. SO WHAT? THE MAIN THING IS SAVE THEIR HEAD, NECK, AIRWAY. YOU ARE CREATING A SOFT LANDING, SO TO SPEAK. EVEN IF THEY ARE MORBIDLY OBESE, YOU COULD GENERALLY DO THAT.
Q YOU HAVE ALSO IDENTIFIED HIS FAILURE TO USE NASAL TRUMPETS OR ORAL AIRWAY FOR AIRWAY MANAGEMENT?
A RIGHT. IF A PATIENT HAS AN OBSTRUCTED AIRWAY, THAT IS THE FIRST THING YOU DO. IF THE AMBU BAG DOESN’T GIVE YOU GOOD, YOU KNOW, CONDENSATION WITH EXHALED BREATHING, YOU OPEN THE AIRWAY. SO IF THE JAW LIFT DOESN’T WORK WELL AND YOU ARE NOT THAT EXPERIENCED, WHATEVER, JUST SLIDE IN A NASAL TRUMPET OR AIRWAY, TWO TRUMPETS, WHATEVER IT TAKES TO GET THAT AIRWAY OPEN. IF THAT DOES THE TRICK, THEN PROCEED WITH THE AIRWAY BREATHING PART.
Q THE ORAL AIRWAY IS INCLUDED IN THIS CATEGORY OF FAILURE TO PROVIDE APPROPRIATE ACLS. YOU ALSO IDENTIFIED FAILURE TO HAVE THE APPROPRIATE ACLS MEDICATIONS ON HAND.
A CORRECT.
Q THOSE ARE MEDICATIONS YOU TESTIFIED TO EARLIER DURING THE NOON HOUR?
A THAT IS CORRECT.
Q BEFORE THE NOON HOUR RATHER?
A YES, THAT’S TRUE.
Q YOU ALSO IN THIS SECTION COMMENTED ON THE FAILURE TO USE ADEQUATE FLUMAZENIL DOSE. IS THAT A DEPARTURE IN THIS SECTION OF YOUR REPORT REGARDING FAILURE TO PROVIDE ACLS CARE?
A ABSOLUTELY.
Q AND YOU ALSO MADE AN INDEPENDENT FINDING THAT DR. MURRAY FAILED TO ACCURATELY ASSESS THE SITUATION AND NOT DELAY IN DOING ANY OF THE ABOVE COMPONENTS OF APPROPRIATE ACLS CARE; IS THAT CORRECT?
A THAT IS CORRECT.
Q AND ALL OF THESE INDIVIDUAL FACTORS THEN COMBINE AND LEAD YOU TO CONCLUDE HIS FAILURE TO PROVIDE ACLS CARE WAS AN EXTREME DEPARTURE?
A THAT IS CORRECT.
Q NOW, IS ANY OF YOUR TESTIMONY OR SUBSTANCE OF YOUR REPORT — WELL, LET ME STRIKE THAT. DURING THE NOON HOUR, DID I INDICATE TO YOU THAT THERE IS A TYPOGRAPHICAL ERROR REGARDING THE INFUSION TIME NOT BEING 25 MINUTES, BUT THREE TO FIVE MINUTES?
A CORRECT. YOU DID.
Q AND IN ALL THE OPINIONS YOU HAVE GIVEN TODAY BOTH DURING THE LUNCH HOUR AND AFTER THE LUNCH HOUR, DO THOSE OPINIONS ALL STAND IN REGARD TO YOUR FINDINGS AND THE LEVEL OF DEPARTURE, EVEN IF DR. MURRAY INFUSED OVER THREE TO FIVE MINUTES?
A RIGHT. IT DOESN’T MAKE ANY DIFFERENCE.
Q LET ME ASK YOU THIS. FOR THE SAKE OF ARGUMENT, ASSUME THAT DR. MURRAY GAVE THE BENZODIAZEPINES AS HE ADMITTED IN THE INTERVIEW AND THAT HE GAVE 25 MILLIGRAMS OF PROPOFOL AND NO MORE. JUST ASSUME THAT IS TRUE. AND THAT HE THEN, EITHER THROUGH BEING ON THE TELEPHONE WITH A GIRL FRIEND OR BEING IN THE RESTROOM OR WHEREVER HE MAY HAVE BEEN, HE ALLOWED A SITUATION WHERE THE PATIENT SELF-ADMINISTERED. WOULD YOU STILL HAVE THE SAME OPINION AS TO THE LEVEL OF DEPARTURE YOU HAVE TESTIFIED TO?
A WELL, THE SAME, AND AGAIN IT WOULD BE ANOTHER TYPE OF EXTREME DEPARTURE.
Q THIS WOULD BE A NEW EXTREME DEPARTURE?
A A NEW EXTREME DEPARTURE WITH A KNOWN ADDICT. FROM WHAT I READ, DR. MURRAY WAS AWARE THAT MICHAEL JACKSON LIKED TO PUSH IT HIMSELF. OTHER DOCTORS LET HIM. SO WE KNOW WE HAVE AN AT-RISK PATIENT WHO LOVES TO HAVE THE MILK, AND HAS THE POTENTIAL, IF HE FELT LIKE HE IS NOT GETTING WHAT HE WANTS, HE MAY IN FACT, IF YOU LEAVE THE ROOM, REACH FOR IT AND GIVE IT TO HIMSELF. IF YOU ALLOW THAT, IT WOULD BE THE SAME AS TAKING A HEROIN ADDICT AND LEAVING THE SYRINGE FULL OF HEROIN RIGHT NEXT TO HIM AND WALK AWAY. IT IS THE SAME THING. IT IS AN EXTREME DEPARTURE OF STANDARD OF CARE. PLUS, IF YOU HAVE A PATIENT YOU DON’T SUSPECT OF DOING THAT, THAT IS AN EXTREME DEPARTURE. IN EITHER CASE, IT IS AN EXTREME DEPARTURE.
Q OKAY. AND THAT WOULD TIE BACK IN TO THE NEED FOR MONITORING OF THE PATIENT?
A WELL, AND MAKING SURE THE PATIENT CANNOT HAVE ACCESS TO A DRUG WHERE THEY MAY SELF-ADMINISTER.
Q PHYSICAL ACCESS?
A PHYSICAL ACCESS, CORRECT.
Q AND ALLOWING SUCH PHYSICAL ACCESS, ESSENTIALLY ABANDONING THE PATIENT IN THE ROOM, WOULD BE AN EXTREME DEPARTURE?
A YES.
MR. WALGREN: THANK YOU. NOTHING FURTHER, YOUR HONOR.
THE COURT: MR. WALGREN, THANK YOU.
CROSS-EXAMINATION, PLEASE, MR. FLANAGAN.
MR. FLANAGAN: THANK YOU.
CROSS-EXAMINATION BY MR. FLANAGAN:
Q DOCTOR, YOU WORKED OUT YOUR MATH ON THE GASTRIC SYSTEM OVER THE LUNCH HOUR?
A I DID.
Q IT CERTAINLY WASN’T ADDRESSED IN YOUR REPORT, WAS IT?
A NO, IT WAS NOT.
Q SO YOU GUYS DID THESE CALCULATIONS AT THE NOON TIME?
MR. WALGREN: OBJECTION. MISSTATES THE TESTIMONY. HE SAID HE DID THE CALCULATIONS.
THE COURT: CHARACTERIZATION OF “YOU GUYS” MAY MISSTATE. SUSTAINED. REASK, PLEASE.
Q BY MR. FLANAGAN: WHO DID THE CALCULATIONS?
A I DID.
THE COURT: THE WITNESS IS RAISING HIS RIGHT HAND.
THE WITNESS: I’M SORRY.
Q BY MR. FLANAGAN: I’M TRYING TO BACKTRACK HOW YOU CAME UP WITH THE NUMBER OF 0.00186 FOR THE GASTRIC CONTENTS OF PROPOFOL.
A I DID.
Q YOU CAME UP WITH NUMBER 0.0228 GASTRIC CONTENTS OF LIDOCAINE; IS THAT CORRECT?
A NOT CONTENTS. CONCENTRATION. YOU ARE MISSTATING TWO DIFFERENT THINGS. CONTENTS WOULD BE THE NUMBERS THAT ARE THERE THAT THE CORONER REPORTS. THE CONCENTRATION IS WHAT THE CONCENTRATION PER UNIT OF VOLUME IS.
Q DON’T ALWAYS ANSWER WHAT I ASK. ANSWER WHAT I MEAN.
A OKAY.
Q CONCENTRATION. NOW, WOULD YOU COME UP WITH THOSE NUMBERS — I’M NOT VERY GOOD AT MATH, BUT WOULD YOU JUST DIVIDE THOSE NUMBERS BY 70?
A THAT’S CORRECT.
Q SO IN DIVIDING BY 70, I WILL PUT A LITTLE PIECE OF PAPER DOWN HERE. 70 INTO 0.13, AND YOU DID THAT AND YOU CAME UP WITH 0.00186?
A CORRECT.
Q SO THAT IS CONVERTING IT TO CONCENTRATION?
A CORRECT.
Q OKAY. ON THE LIDOCAINE, YOU DIVIDED 70 INTO 1.6, AND YOU CAME UP WITH 0.0228?
A I CARRIED IT OUT TWO EXTRA DECIMAL PLACES.
Q 0.0228. AND YOU SAID THOSE QUANTITIES ARE SO MUCH REDUCED, THE LARGE AMOUNT WILL HAVE A TENDENCY TO FLOW TO THE SMALL AMOUNT?
A CORRECT.
Q THAT IS WHAT YOU THINK HAPPENED HERE?
A I KNOW THAT IS WHAT HAPPENED HERE.
Q YOU KNOW THAT IS WHAT HAPPENED HERE?
A YES, I’VE SEEN THIS HAPPEN BEFORE.
Q IF YOU HAVE A LARGER AMOUNT OF LIDOCAINE IN THE BODY IN THE HEART BLOOD, THE FEMORAL BLOOD, AND THE HOSPITAL BLOOD, YOU WOULD EXPECT IT TO REDISTRIBUTE INTO THE LIQUID THAT IS IN THE STOMACH?
A CORRECT.
Q AM I ALSO CORRECT THIS LIQUID DOESN’T HAVE ANY CIRCULATORY SYSTEM?
A CORRECT.
Q IT IS KIND OF SITTING THERE WITHOUT ANY BLOOD FLOWING THROUGH?
A THAT’S CORRECT.
Q BUT YOU STILL THINK THERE IS GOING TO BE THAT DISTRIBUTION INTO OPEN SPACE?
A IT IS NOT OPEN SPACE. THE LIQUID IS ACTUALLY TOUCHING THE SURROUNDING MEMBRANE OF THE ORGAN. IN THIS CASE, THE STOMACH. SO AS THE DRUG PASSES THROUGH FROM HIGH CONCENTRATION IN THE LIVER OR HEART — THE LIVER IS BEST BECAUSE IT IS CLOSEST — IT THEN PASSES THROUGH TISSUES WHICH ACTUALLY SLOW DOWN THAT AND DECREASE THE AMOUNT THAT GETS THERE, WHICH IS WHY WE SEE THE CONCENTRATION SIGNIFICANTLY LOWER WHICH IS WHAT YOU WOULD EXPECT.
Q NOW, IF YOU ARE GOING TO COMPARE CONCENTRATION NUMBERS THAT YOU HAVE COME UP WITH WITH THE CONCENTRATION NUMBERS THAT YOU HAVE IN THE BLOOD, WOULD IT BE BEST TO USE THE SAME UNITS?
A THAT IS WE ARE DOING.
Q THE BLOOD, DOCTOR, IF YOU WOULD LOOK AT YOUR LETTER, THIS EXHIBIT HERE, DID YOU REALIZE THAT IS MICROGRAMS?
A PER MILLILITER.
Q PER MILLILITER?
A CORRECT.
Q THE CALCULATION YOU JUST MADE, WOULDN’T THE CALCULATIONS YOU JUST MADE BE MILLIGRAMS?
A THOSE IN THE MICROGRAM STATE, OKAY, AGAIN THEY WOULD BE ZERO, OR EXCUSE ME.
Q WE HAVE TO MULTIPLY BY A THOUSAND, DON’T WE?
A YES. SO YOU MOVE THAT OVER TO 22.8 MILLIGRAMS PER MILLILITER. BUT I THINK YOU ARE – THAT WOULD BE MICROGRAMS.
Q NOW, IT IS CONVERTING TO MICROGRAMS, HAVEN’T WE?
A YES. LET ME SEE WHAT THE CORONER REPORTED IT AS. MICROGRAMS PER MILLILITER, RIGHT.
Q WE HAVE AN AMOUNT OF LIDOCAINE IN THE STOMACH THAT IS 40 TIMES WHAT IT IS IN THE HOSPITAL BLOOD. FORTY-FIVE TIMES WHAT IT IS IN THE HOSPITAL BLOOD, DON’T WE?
A RIGHT.
Q THIS IS INCONSISTENT WITH YOUR THEORY?
A THAT WOULD BE. I MADE A MISTAKE. YOU ARE ABSOLUTELY RIGHT.
Q THE STOMACH, IF IT WAS GOING TO BE REDISTRIBUTED —
A THERE ALSO MAY BE ISSUES IN ACIDITY ISSUES AS WELL. SO YOU MIGHT BE RIGHT. I ACTUALLY MADE A MISTAKE ON THAT ONE.
Q NOW, DOCTOR, IF WE HAVE CONCENTRATION OF 45 TIMES IN THE STOMACH WHAT IT IS IN THE BLOOD, ORAL INGESTION IS AN ALTERNATIVE, ISN’T IT?
A EXCUSE ME, SIR, FOR ONE SECOND. NOW, YOU KNOW THE ONE THING WE MAY HAVE TO DO IS WE HAVE TO CHECK WITH THE CORONER AND ASK THEM WHAT THOSE NUMBERS MEAN. I MADE ASSUMPTION ON THIS. IT MAY BE THE CONCENTRATION PER MILLILITER RATHER THAN THE 70. AGAIN, I CAN’T TELL YOU EITHER. NOW, IT DOESN’T MAKE SENSE UNLESS HE INGESTED IT ORALLY, A HUGE AMOUNT.
Q SO HE HAD TO INGEST IT ORALLY?
MR. WALGREN: OBJECTION. MISSTATES THE TESTIMONY.
THE COURT: I’M UNCLEAR. WHEN YOU ARE SPEAKING OF INGESTED WHAT ORALLY?
THE WITNESS: THE PROPOFOL AND LIDOCAINE.
THE COURT: OVERRULED.
Q BY MR. FLANAGAN: IT IS THE ONLY WAY IT MAKES SENSE, ISN’T IT?
A IT WOULD SEEM TO MAKE SENSE THEN AT THAT POINT. SO I MAY HAVE MADE AN ASSUMPTION BASED ON HOW THE CORONER REPORTED THIS. SO WE NEED TO CLEAR IT UP WITH THE CORONER OR THE CORONER’S FORENSIC PATHOLOGIST.
Q THE TOXICOLOGIST IS THE ONE WHO REPORTED THIS.
A YES.
Q THE CORONER’S TOXICOLOGIST IS THE ONE WHO REPORTED THAT STUFF?
A YES.
Q YOU HAD ACCESS TO THE CORONER’S REPORT?
A I HAVE ACCESS TO IT. THAT IS ALL I HAVE IS HERE.
Q THE CORONER’S BLOOD SAMPLES WERE REPORTED IN MICROGRAMS PER MILLILITER?
A CORRECT.
Q AND THE GASTRIC CONTENTS WERE MILLIGRAMS. A GRAM IS THE SAME AS A MILLILITER, ISN’T IT?
A CAN YOU HOLD ON?
THE COURT: THERE ARE MULTIPLE QUESTIONS.
THE WITNESS: HOLD ON.
THE COURT: THE WITNESS IS CHECKING SOME OF THE RECORDS.
THE WITNESS: (EXAMINING DOCUMENT) ALL RIGHT. SO THE CORONER IS REPORTING DEFINITELY EVERYTHING LOOKS LIKE I THOUGHT WAS IN MICROGRAMS PER MILLILITER, RIGHT.
Q BY MR. FLANAGAN: SO AS IT STANDS, YOU MADE A MISTAKE THERE?
A I HAVE TO AGREE. I MADE INTERPRETATION, MISTAKE. I WAS THINKING IT WAS, WITHOUT LOOKING CAREFULLY, I WAS THINKING IT WAS MICROGRAMS. IT ACTUALLY SAYS MILLIGRAMS.
Q SO THAT THEORY IS OUT THE DOOR, AND WE ARE BACK TO ORAL INGESTION BEING THE MOST LIKELY.
A WELL, WE HAVE TO TALK TO THE CORONER TO SEE. WE HAVE TO SEE WHAT THOSE NUMBERS MEAN. WHEN I LOOKED AT IT, AND I HAVE TO AGREE I MADE A MISTAKE, I THOUGHT IT SAID MICROGRAMS, WHICH IS MCG, OR THE LITTLE GREEK LETTER “MU.” THAT IS WHAT I THOUGHT, WHICH OBVIOUSLY I DIDN’T HAVE MY GLASSES ON WELL.
Q IT IS A BIG DIFFERENCE?
A IT IS A BIG DIFFERENCE. I TOTALLY AGREE.
Q IT TAKES LIDOCAINE BEING IN THE STOMACH FROM SMALLER TO BIGGER?
A YES.
Q IN YOUR REPORT YOU WENT THROUGH, YOU READ ALL THE STATEMENTS, THE TOXICOLOGY, THE TIME LINES. YOU EVEN HAD TIME LINES FOR PHONE CALLS AND EVERYTHING, DIDN’T YOU?
A I DID. THAT’S CORRECT.
Q AND DR. MURRAY STATED IN DR. MURRAY’S STATEMENT, HE SAID HE GAVE 25 MILLIGRAMS OF PROPOFOL BETWEEN 10:40 AND 10:50, DIDN’T HE?
A I BELIEVE THAT IS APPROXIMATELY RIGHT.
Q AND THE STATEMENT THAT YOU READ SAID THAT WAS OVER 25 MINUTES?
A THAT’S WHAT I ORIGINALLY ASSUMED BECAUSE THAT WAS WHAT I GOT IN THE DICTATED REPORT.
Q YOU BELIEVED IF HE GAVE IT OVER 25 MINUTES, IT WOULD BE TOTALLY INEFFECTIVE?
A MINIMALLY EFFECTIVE, RIGHT.
Q IF HE GAVE IT OVER THREE TO FIVE MINUTES, IT MAY BE EFFECTIVE?
A STILL, IT IS A VERY SMALL DOSE. NOW, IT WILL HAVE A GREATER DEGREE OF EFFECTIVENESS, THAT IS TRUE.
Q IT IS A VERY SMALL DOSE. BUT WHEN YOU PUT IT ON TOP OF 0.162 OR 0.169 LORAZEPAM, AS THE CORONER FOUND IN THE HEART BLOOD AND THE FEMORAL BLOOD —
A YES.
Q — IT WOULD BE MORE EFFECTIVE?
A SLIGHTLY MORE EFFECTIVE, YES.
Q SYNERGISTIC?
A NO. ADDITIVE. THEY ARE BOTH GABA SUBSCRIPT “A” RECEPTOR ANTAGONIST IS WHAT THEY ARE CALLED.
THE COURT: HELP ME OUT. WHAT DOES THAT ALL MEAN?
THE WITNESS: GABA IS A RECEPTOR THAT THESE DRUGS AFFECT PRIMARILY IN THE CENTRAL NERVOUS SYSTEM TO MAKE YOU — THEY ARE AN INHIBITOR SIGNAL TO THE CENTRAL NERVOUS SYSTEM. IT MAKES YOU MORE SLEEPY, SLOWS THINGS DOWN, AND THAT IS THE WAY THESE DRUGS WORK. THERE IS A SIMILARITY BETWEEN THE TWO. THAT IS WHY THEY ARE NOT SYNERGISTIC. THAT IS WHY THEY ARE ADDITIVE.
Q BY MR. FLANAGAN: OKAY. NOW, ASSUMING THE 25 MILLIGRAMS BETWEEN 10:40 AND 10:50, THAT COULD PUT YOU TO SLEEP FOR A SHORT PERIOD OF TIME, COULDN’T IT?
A MAYBE MAKE YOU SLEEPY FOR MAYBE FOUR TO SIX MINUTES. FIVE AVERAGE. THAT WOULD BE IT.
Q AND AFTER, IF YOU STAYED THERE AFTER INJECTING HIM FOR FIVE TO SIX MINUTES, YOU WOULD THEN FEEL THAT PROPOFOL WAS NO LONGER KEEPING HIM ASLEEP?
A CORRECT.
Q SO AS OF ELEVEN O’CLOCK, THE PROPOFOL IS NO LONGER WHAT IS KEEPING HIM ASLEEP, IS IT?
A CORRECT, IF HE IS ASLEEP.
Q IF HE IS ASLEEP, HE MIGHT JUST BE TIRED OR MAYBE THE LORAZEPAM IS WORKING ON HIM A LITTLE BIT IN ADDITION WITH HIS FATIGUE?
A SURE, THAT IS ALWAYS POSSIBLE.
Q NOW, YOU HAVE ALSO COME TO THE CONCLUSION, I BELIEVE IT WAS ON PAGE 7 OF YOUR REPORT, THAT DR. MURRAY
WAS PROBABLY NOT IN THE ROOM FOR 40 MINUTES?
A FOR 40 MINUTES. WHEN I FIRST READ THAT, I HAD TO MAKE ASSUMPTION BASED ON THE TELEPHONE RECORDS.
Q YOUR ASSUMPTION WAS THE TELEPHONE RECORDS THAT STARTED AT 11:18 AND GO THROUGH 12:00 O’CLOCK, DUE TO THE FACT HE HAD A PATIENT THAT WAS HAVING A DIFFICULT TIME SLEEPING, HE PROBABLY STEPPED OUT OF THE ROOM TO TALK ON THE PHONE. IS THAT WHAT YOUR ASSUMPTION WAS?
A THAT WAS MY ASSUMPTION.
Q LET’S ASSUME THAT IS RIGHT. AND YOU ALSO MADE ASSUMPTION THAT HE DISCOVERED THAT MICHAEL JACKSON WASN’T BREATHING SOMETIME BETWEEN 11:56 AND 12:02.
A THAT’S WHAT IT SEEMS TO BE.
Q AND YOU MADE THAT ASSUMPTION BECAUSE THAT IS WHEN SADE ANDING SAID SHE WAS TALKING TO HIM. SHE NO LONGER FELT THAT HE WAS PAYING ATTENTION. SHE HEARD THE RUSTLING OF THE PHONE?
A COMMOTION, I THINK, SOMETHING LIKE THAT.
Q SO IF HE DISCOVERS HE IS NOT BREATHING AT 12:00 O’CLOCK, THAT WOULD PUT HIM INTO A LITTLE BIT OF A PANIC PHASE, WOULDN’T IT?
A I WOULD SAY SO, YEAH.
Q DID YOU KNOW THAT AT 12:05, HE WENT DOWN THE STAIRS TO GET ASSISTANCE?
MR. WALGREN: OBJECTION. MISSTATES THE TESTIMONY.
THE COURT: SUSTAINED.
Q BY MR. FLANAGAN: HE WENT PARTWAY DOWN THE STAIRS AND YELLED FOR SECURITY AND FOR PRINCE. DID YOU KNOW THAT?
A I REMEMBER SOMETHING TO THAT EFFECT. THAT’S CORRECT.
Q HE YELLED FOR SECURITY AT 12:05. SO THE DELAY BETWEEN DISCOVERY — WELL, WHAT SHOULD HE DO WHEN HE FIRST DISCOVERS MICHAEL JACKSON IS NOT BREATHING?
A ANALYZE THE SITUATION. APPARENTLY, HE SAID HE HAD A HEART RATE OF 122. IF THE PULSE OXIMETER IS PICKING THAT UP, BECAUSE HE DIDN’T HAVE AN EKG, THAT IS THE ONLY WAY HE KNOWS. THAT MEANS HE HAS GOOD PERIPHERAL CIRCULATION BECAUSE THE OXIMETER IS PICKING IT UP WITH THE HEART RATE ELEVATED DUE TO PROBABLY HYPOXIA AND POSSIBLY HYPERCARBIA, ELEVATED CARBON DIOXIDE LEVELS. FIRST STEP IS AIRWAY AND BREATHING. YOU HAVE GOOD CIRCULATION. YOU ACT. SO CIRCULATION IS THE LEAST YOU NEED TO ATTEND TO. IT IS AIRWAY AND BREATHING. AIRWAY AND BREATHING.
Q NOW, HOW LONG SHOULD HE SPEND DIAGNOSING THE SITUATION AND DOING AIRWAY AND BREATHING BEFORE HE RUNS FOR HELP?
A IF HE WOULD HAVE DONE THE APPROPRIATE AIRWAY BREATHING MANAGEMENT, HE WOULDN’T NEED TO EVEN RUN FOR HELP. HE WOULD PROBABLY BE ABLE TO JUST WATCH THE OXIMETER. IF IT WAS LOW, THEN IT WAS 60, 40, 80, WHATEVER IT HAPPENED TO BE, HE COULD SEE THE CHANGE BRINGING UP THAT. AS LONG AS YOU SEE AN OXIMETER READING, IT MEANS YOU HAVE GOOD BLOOD PRESSURE. SO JUST GET THE PATIENT THROUGH THAT STATE. SO ALL YOU NEED IS AIRWAY AND BREATHING RESUSCITATION. YOU DON’T NEED TO GO TO THE NEXT STEP.
Q YOU JUST NEED TO CLEAR THE AIRWAY AND FIX THE BREATHING?
A THAT’S EXACTLY CORRECT.
Q NOW, LET’S ASSUME THAT MICHAEL JACKSON GOT A PROPOFOL LEVEL AS IT STATES UP THERE OF 4.1 IN THE HOSPITAL BLOOD, WHICH MEANS IT WOULD HAVE BEEN WAY HIGHER AT THIS POINT IN TIME. IS THERE ANY WAY THAT AIRWAY AND BREATHING IS GOING TO COME BACK?
A EVENTUALLY, IT WILL. BUT IF YOU FEEL AFTER YOU SPEND TEN OR 15 MINUTES WITH AIRWAY BREATHING RESUSCITATION YOU STILL HAVE GOOD OXIMETER READINGS, YOU CAN SEE THE OXIMETER COME UP. AS LONG AS HE HASN’T DEVELOPED ANY KIND OF OBSTRUCTION OR PULMONARY EDEMA THAT WILL COME UP, SO THEN YOU CAN EVEN STOP. AND YOU BASICALLY COULD STOP FOR TWO MINUTES, DIAL THE PHONE, DO WHATEVER YOU NEED TO DO TO CALL SOMEBODY. YOU KNOW, AND THEN GO BACK TO AIRWAY BREATHING RESUSCITATION UNTIL HELP ARRIVES.
Q SO THEN IT WAS FAIR FOR HIM WHEN HE COMES UPON THIS SITUATION AT 12:00 O’CLOCK, IT IS FAIR FOR HIM TO SPEND FIVE MINUTES THERE TRYING TO CORRECT THE SITUATION BEFORE HE GOES FOR HELP?
A AT LEAST FIVE MINUTES TO KEEP HIM WELL SATURATED WHICH, OF COURSE, HE DIDN’T DO, AND KEEP HIS SATURATION UP. AND THEN ONCE YOU ARE GIVING A HUNDRED PERCENT OXYGEN, AS LONG AS YOUR OXYGEN TANK ISN’T EMPTY, YOU COULD LEAVE BECAUSE THEN YOU HAVE WHAT WE CALL PASSIVE OXYGENATION EVEN THOUGH HE MAY NOT BE BREATHING. IF YOU FILL THE LUNGS UP WITH AIR NEAR A HUNDRED PERCENT OXYGEN, YOU CAN STOP BREATHING FOR HIM. IT WOULD PROBABLY TAKE THREE OR FOUR MINUTES BEFORE HE BEGAN EVEN TO START TO DE-SATURATE. IT GIVES YOU PLENTY OF TIME TO DO WHATEVER ELSE YOU NEED TO DO.
Q NOW, THIS IS REALLY GOOD WHEN YOU LOOK AT IT IN RETROSPECT. YOU SEE THIS IS THE PROBLEM UP HERE. DO YOU THINK DR. MURRAY KNEW THAT WAS THE PROBLEM?
A STANDARD OF CARE REQUIRES THAT YOU KNOW THE PROBLEM.
Q HOW DO YOU KNOW HE HAS 4.1 IN HOSPITAL BLOOD OF PROPOFOL?
A YOU DON’T KNOW. YOU HAVE TO SUSPECT THERE IS PROPOFOL. IT’S THE COMBINATION OF BENZODIAZEPINES. MAYBE HE TOOK SOMETHING ELSE. BUT YOUR JOB NOW IS TO BE THERE AND RESUSCITATE THE PATIENT. THAT IS STANDARD OF CARE.
Q WHY WOULD YOU SUSPECT THAT PROPOFOL IS IN HIS BLOOD AT THAT KIND OF CONCENTRATION?
A MAYBE HE SELF-INGESTED. HE KNOWS THE PATIENT LIKES TO GIVE IT TO HIMSELF. HE TOTALLY ADMITS HE KNEW THAT.
Q WELL —
A THAT IS THE STANDARD OF CARE. YOU DON’T LEAVE YOUR PATIENT SO THAT THE PATIENT CAN EITHER DRINK IT, INJECT IT, WHATEVER. THAT IS EXTREME DEPARTURE FROM THE STANDARD OF CARE.
Q YOU SHOULD ANTICIPATE THAT YOUR PATIENT IS GOING TO GET A SYRINGE, WITHDRAW PROPOFOL, AND SOMEHOW DRINK IT?
A HE KNOWS HE LIKES TO PUSH IT. SO WHY WOULD HE DRINK IT UNLESS HE IS TRYING SOMETHING NEW. BUT ASSUMING HE DID, THE FACT IS YOU HAVE A KNOWN ADDICTED PATIENT WHO MAY DO ANYTHING. IT IS JUST LIKE YOU HAVE A HEROIN PATIENT. YOU ARE GOING TO WALK AWAY WITH A SYRINGE OF HEROIN NEXT TO HIM? I DON’T THINK SO. SAME WITH PROPOFOL, ANY DRUG. YOU DO NOT LEAVE ANYTHING TO RISK. PRIMUM NON NOCERE. FIRST, DO NO HARM.
Q YOU KNOW, EVEN IF YOUR PATIENT THE LAST TIME YOU SAW WAS ASLEEP, SLEEPING LIGHTLY, WASN’T SNORING, HE WAS SLEEPING LIGHTLY, YOU ARE SUPPOSED TO ANTICIPATE THAT HE IS GOING TO WAKE UP AND DRINK PROPOFOL?
A WELL, YOU KNOW, I WOULDN’T ANTICIPATE HIM DRINKING IT, BUT I WOULD CERTAINLY ANTICIPATE HIM INJECTING IT. IF HE DRANK IT, OKAY, WHAT IS THE DIFFERENCE? YOU ARE STILL GOING TO GET IT IN THERE.
Q YES, IT IS GETTING IN THERE?
A RIGHT.
Q AND FAILURE TO ANTICIPATE THAT HE IS GOING TO DRINK THIS PROPOFOL, THAT IS AN EXTREME DEPARTURE?
A FAILURE TO ANTIPICATE HE WILL INJECT, OR DRINK, OR WHATEVER HE IS GOING TO DO. OF COURSE, IT IS. YOU KNOW THIS PATIENT. HE ADMITS HE KNEW THIS PATIENT. HE ADMITS THAT THIS PATIENT LIKES HIS MILK, AND HE GETS UPSET IF HE DOESN’T GET HIS MILK. WHAT DO YOU THINK THE PATIENT MIGHT DO IF YOU LEAVE HIM UNATTENDED?
Q HAVE YOU EVER HEARD OF ANYBODY DRINKING PROPOFOL BEFORE?
A I CAN’T SAY AS I HAVE, BUT IT IS POSSIBLE.
Q YOU WOULD ANTICIPATE THAT POSSIBILITY?
A I WOULD PROBABLY NOT ANTICIPATE THAT. IF I HAD SYRINGES LAYING AROUND, I WOULD MORE ANTICIPATE, ESPECIALLY IF I KNEW THAT AND IF HE WERE USED TO THAT, LIKE THIS CASE, THEY WOULD PROBABLY INJECT IT THROUGH THE I.V. LINE. THAT WOULD BE MUCH MORE SENSICAL.
Q BASED UPON THE TOXICOLOGY FINDINGS, IT LOOKS AS THOUGH HE DRANK IT, DOESN’T IT?
A NOT NECESSARILY. YOU WOULD HAVE TO CLEAR IT UP WITH THE CORONER’S INVESTIGATORS.
Q HE MAY HAVE?
A I GRANT YOU THAT EITHER WAY, IT DOESN’T MATTER. DOESN’T CHANGE THE OPINION. HE ABANDONED HIS PATIENT AND DIDN’T RESUSCITATE APPROPRIATELY. THAT I THE KEY.
Q NOW, WHEN HE CALLS KAI CHASE AT 12:05 AND THEN GOES BACK TO HIS PATIENT, YOU SAW WHERE HE CALLED FOR MICHAEL AMIR WILLIAMS?
A WELL, I DON’T KNOW WHAT TIME. HE CALLED FOR SOMEBODY ELSE. I DON’T REMEMBER THE NAMES EXACTLY.
Q HE WAS CALLING FOR A PERSON WHO HE THOUGHT WAS THERE AND STILL SEEKING ASSISTANCE?
A WHO WAS SEEKING?
Q DR. MURRAY.
A SURE, AS OPPOSED TO TAKING CARE OF HIS PATIENT.
Q IT IS HARD TO DO ALL THIS AT ONCE, ISN’T IT?
A NO, IT IS NOT. IF YOU HAVE A CELL PHONE, YOU DIAL 911. HE KNEW THE ADDRESS. DOESN’T MATTER WHAT THE ZIP CODE IS.
Q IS IT BEYOND THE STANDARD OF CARE TO ASSIGN THAT TASK TO SOMEONE ELSE?
A ABSOLUTELY, UNLESS YOU COMMUNICATE WITH THEM DIRECTLY EITHER VERBALLY OR ON THE PHONE.
Q NOW, LET’S GO ON TO ANOTHER SUBJECT. THESE DOSES UP HERE — HEART BLOOD, HOSPITAL BLOOD, FEMORAL BLOOD — JUST LOOKING AT THOSE NUMBERS, WHAT IS YOUR BEST ESTIMATE OF BOLUS SIZE THAT WOULD HAVE TO GO IN TO CREATE THAT?
A WELL, I’M FAMILIAR WITH THE STUDIES INTRAVENOUSLY, BUT NOT WITH THE STOMACH. SO I CAN’T TELL YOU WITH THE STOMACH IF HE INGESTED IT THAT WAY. BUT I CAN TELL YOU INTRAVENOUSLY, FOR A PATIENT OF HIS SIZE, I WOULD ASSUME IF THOSE ARE PEAK LEVELS, HE PROBABLY INJECTED AT LEAST A HUNDRED MILLIGRAMS TO SOMEWHERE BETWEEN A HUNDRED AND TWO HUNDRED MILLIGRAMS.
Q SOMEWHERE BETWEEN A HUNDRED AND TWO HUNDRED MILLIGRAMS?
A I WOULD ASSUME SOMEWHERE IN THAT AREA.
Q AND WOULD YOU ALSO AGREE THAT INGESTION OF PROPOFOL WOULD BE SOMEWHAT LESS EFFICIENT THAN I.V.?
A RIGHT. I MEAN, IT WILL TAKE TIME TO BE ABSORBED, BUT IT WILL STILL BE ABSORBED BECAUSE IT IS A HIGHLY FAT SOLUBLE DRUG.
Q YOU WOULDN’T GET QUITE AS HIGH. LET’S ASSUME IF YOU WENT FROM A HUNDRED TO TWO HUNDRED. LET’S SAY FOR PURPOSES OF CONVERSATION, LET’S CALL IT 150.
A FINE. THAT IS FINE.
Q YOU INJECT IN AN I.V. 150 MILLIGRAMS. THOSE NUMBERS ARE IN THE BALLPARK.
A THE FEMORAL, HEART BLOOD, AND HOSPITAL BLOOD?
Q YES.
A YES, THEY ARE IN THE BALLPARK.
Q NOW, DIGESTION, ORAL INTAKE, PROBABLY WOULD ONLY BE THREE-QUARTERS AS EFFICIENT, WOULDN’T IT?
A YOU KNOW WHAT, I HAVEN’T SEEN STUDIES. BUT BECAUSE IT IS SUCH A FAT SOLUBLE DRUG, I WOULD IMAGINE IT WOULD BE VERY, VERY EFFICIENT. I CAN’T TELL YOU THE SPEED OF ABSORPTION. THE HIGHER THE FATTY QUOTIENT OF THE DRUG, THE GREATER THE ABSORPTION THROUGH BIOLOGIC MEMBRANE, MEANING STOMACH, INTESTINE, WHATEVER IT HAPPENS TO BE.
Q HAVE YOU HEARD THE TERM CONSCIOUS SEDATION?
A VERY MUCH SO. IT IS A MISNOMER, BUT THAT IS WHAT PEOPLE CALL IT.
Q THEY WRITE ABOUT THAT IN THE BOOKS AND LITERATURE, DON’T THEY?
A CORRECT.
Q THAT IS DIFFERENT THAN AN ANESTHETIC, ISN’T IT?
A WELL, WE HOPE IT IS, BUT USING DRUGS TO CREATE ANY LEVEL OF CONSCIOUS SEDATION, DEPENDING UPON VARIOUS DIFFERENT THINGS, BASED ON A PATIENT’S PHYSIOLOGY, CONCURRENT DISEASE STATE, OTHER DRUGS THAT MAY BE GIVEN, OR THE DOSE OF WHATEVER PARTICULAR SINGLE DRUG YOU ARE GIVEN, CAN CREATE A CONTINUUM OF THAT SEDATION LEVEL FROM, YOU KNOW, ANXIOLYSIS, LIGHT SEDATION, MODERATE SEDATION, DEEP SEDATION, AND ANY LEVEL OF GENERAL ANESTHESIA. THAT IS WELL WRITTEN. THAT IS ALL PART OF THAT MISNOMER, BUT IT HAS GOTTEN THE NICKNAME OF CONSCIOUS SEDATION.
Q AND THE SAME RULES AREN’T APPLICABLE TO CONSCIOUS SEDATION AS THEY ARE TO ANESTHETIC SEDATION, IS IT?
A WELL, DEPENDING UPON THE DRUGS YOU ARE GIVING. IF YOU ARE USING AN I.V. GENERAL ANESTHETIC LIKE PROPOFOL, THE RULES DEFINITELY APPLY.
Q BUT 25 MILLIGRAMS, THAT WOULDN’T PRODUCE ANYTHING MORE THAN A CONSCIOUS SEDATION, WOULD IT, OVER THREE TO FIVE MINUTES?
A DEPENDS UPON — IN THIS PARTICULAR CASE, IS THAT WHAT YOU ARE ASKING?
Q YES.
A WELL, IN THIS PARTICULAR CASE, WE DON’T KNOW WHAT THE EXACT EFFECT OF THE LORAZEPAM, DIAZEPAM, AND MIDAZOLAM ARE, HOW DEEPLY HE WAS SLEEPING, YOU KNOW, HOW SLEEPY HE WAS. THEN YOU ADD PROPOFOL, AND THEN THERE IS ALWAYS A POSSIBILITY THAT COULD CREATE A STATE OF SEVERE DEEP SEDATION OR LIGHT GENERAL ANESTHESIA.
Q SO WE DON’T REALLY KNOW IF THIS IS JUST CONSCIOUS SEDATION OR DEEP SLEEP?
A THAT IS WHY YOU MUST BE ABLE TO EVALUATE AND RAPIDLY RESUSCITATE YOUR PATIENT.
MR. FLANAGAN: I HAVE NO FURTHER QUESTIONS, YOUR HONOR.
THE COURT: MR. FLANAGAN, THANK YOU.
REDIRECT, MR. WALGREN.
MR. WALGREN: THANK YOU, YOUR HONOR.
REDIRECT EXAMINATION BY MR. WALGREN:
Q DOCTOR, AGAIN ASSUMING SELF-ADMINISTRATION, AS MR. FLANAGAN INCLUDED IN HIS QUESTIONS, WOULD ANY OF YOUR OPINIONS CHANGE AS TO THE LEVEL OF CARE PROVIDED BY DR. MURRAY TO MICHAEL JACKSON?
A NO. I MEAN, THE WHOLE THING IS YOU DON’T WALK AWAY FROM A PATIENT, AS WE HAVE KIND OF GONE OVER BEFORE, WHO MIGHT BE TEMPTED TO SELF-ADMINISTRATE, WHO HAS CLEARLY STATED TO THE TREATING PHYSICIAN THAT HE LIKES TO SELF-ADMINISTRATE AND ACTUALLY SUPPOSEDLY ASKED. HE WANTED TO DO IT BECAUSE OTHER DOCTORS LET HIM DO IT. SO I MEAN, THAT IS THE FIRST TIP-OFF. IT IS LIKE AGAIN THE EQUIVALENT OF A HEROIN ADDICT WHO LIKES TO INJECT. YOU WILL WALK AWAY WITH HEROIN SITTING NEXT TO HIM? I DON’T THINK SO. THAT IS EXTREME DEPARTURE FROM THE STANDARD OF CARE.
Q YOUR OTHER CONCLUSIONS REGARDING EXTREME DEPARTURE ARE NOT DEPENDENT ON WHETHER A SUBSEQUENT DOSAGE OF PROPOFOL WAS SELF-ADMINISTERED OR GIVEN BY DR. MURRAY?
A THAT IS CORRECT. IT DOESN’T MATTER IF HE SELF-ADMINISTERED ORALLY, OR INTRAVENOUSLY, OR INTRAMUSCULARLY. IT IS ALL THE SAME.
Q AND AGAIN, THE RESUSCITATIVE EFFORTS AND EXTREME DEPARTURE IN THAT REGARD, NONE OF THAT CHANGES IN YOUR OPINION?
A NO, BECAUSE IT WAS ALL THE SAME. IF HE SELF-ADMINISTERS AND YOU WALK AWAY AND DIDN’T SEE IT, YOU BETTER MAKE SURE YOU KNOW WHAT YOU ARE DOING. AGAIN, THAT IS YOUR JOB.
MR. WALGREN: THANK YOU. NOTHING FURTHER, YOUR HONOR.
THE COURT: MR. WALGREN, THANK YOU.
RECROSS-EXAMINATION, MR. FLANAGAN?
MR. FLANAGAN: I HAVE NO FURTHER QUESTIONS OF THIS