Michael Jackson Did Not Administer Propofol to Himself--A Medical Perspective

Michael Jackson Did Not Administer Propofol to Himself--A Medical Perspective

Introduction:
A few months ago I caught wind that Conrad Murray's defense strategy was going to put the blame on none other than the victim--Michael Jackson--in a way I never thought possible--by saying Jackson delivered the fatal dose of propofol to himself during Murray's supposed 120-second absence from the room. For Murray to imply this chain of events is a gross disrespect for the victim he claims was a "friend". I thought initially this defense was a bogus tabloid report, after all, Jackson's death was ruled by experts to be "homicide via injection from another". Thus, this defense strategy goes against the entire ruling of death by experts who I hope will testify and back up their (what I believe to be correct) conclusion--if there is a trial.

Before this hideous accusation of self-injection by Jackson, Murray had been trying to shift blame on Jackson all along through other methods, such as claiming he demanded propofol from him, essentially forcing him to do it. Murray did and still does possess free will. The exact wording of the Las Vegas search warrant states, "Jackson remained awake and at approximately 1040 hours Murray finally administered 25 mg of propofol diluted with lidocaine, via IV drip to keep Jackson sedated, after repeated demands/requests from Jackson." First, there was no IV drip delivering propofol as there was no manual/electronic pump to do so. The only drip used was a gravity-fed saline drip per the autopsy report. Second, you do not dilute propofol with lidocaine. Third, how is someone who is being kept sedated in fact wide awake and making repeated demands and/or requests? I pray the police and DA are carefully examining every word and every shred of evidence presented to them. I do not know if they are or not, but I believe if they were examining the evidence closer, the charges presented would be much higher than involuntary manslaughter.

Murray's false claim that Jackson self-injected, which will be examined in detail shortly, even if true still avoids providing plausible explanations for such issues as: the massive lapse in time (approximately 90 minutes) that Murray allowed to pass without rendering sufficient aid, lacking proper devices to render aid (the Ambu-bag was apparently part of the paramedics' paraphernalia as if Jackson was not breathing but had a pulse then Murray should have used the Ambu-bag with oxygen rather than performing mouth-to-mouth CPR; the autopsy report states the Ambu-bag was not even connected to the oxygen tank that was reported empty on 07/13/2009, rendering this life-saving object useless and likely unused), why Murray was seen toting oxygen tanks which without sufficient equipment were insufficient to treat apnea from propofol administration, why he performed CPR in a bed, why he did not get Jackson to the hospital when he was merely 4 minutes away, why he did not call 911 upon discovering Jackson yet had been using a cell phone that morning, why Jackson did not recover from the apnea when most people recover in less than 3 minutes, why there were "multiple opened bottles of propofol found, with small amounts of remaining drug", etc.? These are all questions desperately needing answers.

Murray also withheld information from paramedics, UCLA staff, and for two days, police. Admitting to only administering Ativan and saline prevented health care staff from determining what they were really treating. Treatment for propofol intoxication would likely have only been supportive/symptomatic but Murray should have been honest about what he had been administering Jackson, especially if some sort of accident (and should have administered appropriate supportive/symptomatic care to Jackson himself). Why lie, then, and how does a patient get denied such elementary care when a doctor is present and getting paid $150,000 a month to make sure the patient remains alive? How does one fail a patient like Murray failed Jackson when he has been a physician for 20 years? Murray deliberately, for whatever reasons, made no attempt to revive or save Jackson's life regardless of whom or what administered the medications based on information we know. In addition, by him refusing to declare Jackson deceased at the residence he delayed making the residence a crime scene which has without a doubt compromised this case and allowed room for corruption (see http://law.justia.com/california/codes/gov/27490-27512.html).

Discussion Regarding TMZ Live's Video Aired on 04/05/2010 Which Discusses the "Suicide Theory":
Please view the following video: http://www.tmz.com/videos?autoplay=true&mediaKey=54706d3d-e4e4-4f6a-b092-a55d8875de4a

Experts' Analysis Against Self-Administration:
From the autopsy report on page 11, in regard to the support of homicide, statement number four states, "(t)he circumstances do not support self administration of propofol."--Dr. Christopher Rogers and Dr. Lakshmanan Sathyavagiswaran

From Dr. Selma Calmes' report contained within the autopsy report:

"Could the decedent have given propofol to himself? It is unknown where the propofol physically came from. It would have been difficult for the patient to administer the drugs (others besides propofol were administered) to himself, given the configuration of the IV set-up. The IV catheter was in the left leg. The injection port of the IV tubing was 13.5 cm from the tip in the catheter. He would have had to bend his knee sharply or sit up to reach the injection port and push the syringe barrel, an awkward situation, especially if sleep was the goal. If only bolus injections via a syringe were used, sleep would not have been maintained, due to the short action of propofol. Someone with medical knowledge or experience would have started the IV. Anyone could have drawn up and administered the medications after the IV was started."

Please keep in mind that anyone could administer the drug but the IV configuration limited if not completely barred Jackson from being capable of giving it to himself nor was he skilled at IV injections. Also, the autopsy report says, "(l)ividity was consistent with a supine position" meaning when he expired and as fluids settled it was consistent with him lying down on his back. Dr. Calmes said he would either have to have bent his knee sharply or sat up in order to inject himself--his knee was not bent nor does lividity in the supine position support him expiring while sitting up and being left in this position. Murray could have placed his body in the supine position before lividity set in, but if this were the case, would that not mean Murray likely was in Jackson's presence during a time in which he should have saved his life and failed to do so? It could also mean Jackson remained in the supine position throughout Murray's medical "care" that night, further supporting that Murray was the only one to administered drugs to Jackson.

Syringe Size Debacle:
Perhaps one of the most pivotal errors in this defense is the claim that Jackson injected himself with the remaining contents of a 20 mL bottle of propofol. Only 10 mL syringes were available and used. This means Jackson could only inject 100 mg (10 mL) in one inoculation because of the very rapid onset of action of propofol. This dose should have in fact rendered him unconscious, unable to subsequently inject the remaining 75 mg (7.5 mL) until the preceding dose of propofol had worn off. He would have then had to have awaken to have injected the remaining 75 mg, representing another bout of unconsciousness only as long as 75 mg would keep him unconscious. It is impossible that Jackson gave himself 175 mg of propofol at one time based on medical supplies available. If Jackson was given more than 100 mg at one time then someone else had to do it to him as an unconscious man cannot manually administered drugs to himself.

What is a "Massive Overdose" and how Likely is Suicide/Accidental Overdose with Propofol?
Harvey Levin states that the bottle (a 20 mL bottle) was a "massive overdose". This is far from being true. Death from excessive propofol abuse by Iwersen-Bergmann, et al. states, " (t)he risk of death due to a self-administered propofol intoxication is very low, primarily due to the low concentration found in commercial ampoules (20 mL containing 200 mg). This is equivalent to a standard dose of 2-2.5 mg/kg body weight for the induction of general anesthesia within 1-2 min after injection and arousal after 5-10 minutes. The fast-acting narcotic effect of propofol prevents the self-injection of more than one ampoule at one time." Thus, 200 mg would almost certainly not result in death due to an overdose, especially not in a healthy adult patient like Jackson even if he was thin. The only way this may have presented a problem is if the benzodiazepines in Jackson's system were in fact sedating him and causing some respiratory depression. This would also mean Jackson was in fact unconscious. As mentioned in the previous paragraph, Jackson could not have administered the entire ampoule himself due to the small size of the syringes and subsequent loss of consciousness after receiving 100 mg (10 mL), the maximum amount one syringe could hold assuming no lidocaine was added. Sedation can be achieved from doses of 100 mg and less. In fact, 25 mg and 50 mg are typical bolus doses for induction of sedation according to Lexicomp and can cause sedation, albeit for a matter of minutes, if subsequent sedation is not continued with propofol or another substance.

The only way 200 mg theoretically kills a typical adult is to give it too rapidly (and to subsequently not have anyone there to render aid)--this itself is a rare event as death from propofol is infrequent even from people who abuse many times a day for months or in some rare cases years. Death from propofol almost always initially suspects third-party involvement, too, until proven otherwise. Death from Propofol: Accident, Murder or Suicide? by Kirby, et al. states, "Whether suicide is possible with propofol has been debated. Some investigators historically said no, because the maximum that was thought to be injectable, before the individual lost consciousness and was incapable of injecting more, was one vial (200 mg). This amount is equivalent to a standard anesthetic induction dose of 2.5 mg/kg to a healthy 80 kg individual." Jackson's weight was determined to be 136 lbs or 62 kgs. That means a standard dose for approximately 10 minutes of unconsciousness would have been 125-155 mg, slightly less than the supposed 175 mg self-administered (200 mg minus the 25 mg Murray admits to giving). Such a dose should not have been an overdose in Jackson. As discussed previously it is also impossible for Jackson to have over-rapidly injected propofol himself, too, based on IV configuration. The syringe size also limited Jackson to what amount he could have self-injected if able to defy the IV configuration. That leaves only Murray either lying about the amount he gave Jackson or possibly over-rapidly injecting him with a large amount of the drug and then failing to render appropriate aid while present.

Healthy patients who receive propofol for short-term procedures (ex. cardioversion, dental procedures, etc.) do not have to be intubated though propofol is almost always used with a patient intubated and having their breathing supported. Jackson, a healthy patient, had received propofol legitimately in the recent past by Dr. David Adams for dental work (http://www.lvrj.com/news/55332672.html) and no had problems. Cardiopulmonary equipment, such as an Ambu-bag and an oxygen with oxygen or a ventilator is on standby as a precaution any time propofol is given. Death after excess propofol abuse further states, "Hypotension and apnea are relevant side effects...and are probably dependent on dose and speed of propofol administration. Apnea during anesthesia induction occurs more frequently with propofol than with other anesthetics. The apena duration is usually short but it can persist for up to 3 minutes." Three minutes of cessation of breathing does not typically result in death, nor is this length of apnea common even from 200 mg. Furthermore, if Jackson had had his breathing assisted during the period of apnea with something like an Ambu-bag and oxygen, then there is no reason he should not have recovered fully. Jackson would still be alive today.

What about the Arm?
TMZ's video states Jackson had a "huge amount" in his arm. This has never been stated before nor have I found it stated anywhere else for that matter. This could all be a misunderstanding by the staff at TMZ given they do not have sufficient medical knowledge. Could Murray have administered this into his arm because the IV catheter tubing was no longer viable or desirable or the amount was too small to give via tubing? Jackson was essentially immobile with the IV catheter in his leg--was the propofol, syringes and needles within arm's reach to self-inject in the arm? Which arm had more propofol as Jackson being right-handed he would not inject into his right arm? Was Jackson even capable of injecting himself in the first place as he was not a trained medical professional? Was there any evidence of injection of propofol into his arm such as skin-popping? If in fact he had a higher concentration of propofol in his arm, could this indicate Jackson had limited-to no-circulation in his body (he was deceased or almost deceased) and the last dose essentially stalled within the circulatory system where administered, meaning Jackson was unconscious and it was given by Murray with Jackson in a grave state? I simply do not know what to make of this comment. I think it is better left for experts to examine or disregard.

Preparing the Syringe:
Another aspect of this case that bars Jackson from self-administering is the time frame he had in which to do it. It would indeed take many minutes, not seconds, to draw up and administer this medication, especially drawing the entire contents out of the glass bottle which wages a war with the syringe--it is difficult to get the medication into the syringe as it tries to continuously return to the bottle, even when air is misplaced for the liquid. Unless trained in giving IV drugs or preparing them it is a time-consuming task to draw up any large amount of contents from a glass bottle. Lack of training and experience often results in some loss of the drug when the syringe is removed from the bottle, too. In other words, using a syringe to pull medication from a glass bottle has a tendency to "spray" the contents out either from the bottle and/or syringe. Unless someone is highly trained or they have a vented needle these issues are almost inevitable. It does not appear that Murray had any vented supplies. Lidocaine was also found in the syringe, too, and would have needed to have been withdrawn from its glass bottling as well. I do not believe Jackson, within two minutes or less, could draw out propofol and /or lidocaine from glass bottling after just arousing from being sedated, self-injecting, then being in such a severe state that when Murray came back that he was not able to be revived. To further hint that Jackson was able to prepare not one but two syringes containing propofol and lidocaine, self-inject against all likelihood, and then be in such a shape he was not revivable--all in less than two minutes--is impossible.

Other Fallacies:
The mentioning of 10:00 p.m. in the TMZ video is false. Jackson was at rehearsals well past midnight that night per many witnesses. Furthermore, it makes no sense that Jackson was able to sleep on Ativan and Versed the night before (June 23rd) then suddenly on June 24th-25th Ativan, Versed and Valium could not induce sleep or apparently even drowsiness (though again Murray said he was "keeping him sedated"). An examination of Table 3A is not consistent with abuse or addiction to benzodiazepines, either. There is also an issue with Murray administering parenteral (through the skin) benzodiazepines when he had readily-available oral Valium and Ativan he could have given Jackson to try to induce sleep. A man who is sedated cannot swallow tablets, however. If Jackson really wanted to sleep, why not simply grab or ask for these tablets and take them in excess and wash them down with the water or orange juice on the bedside table? Why did Murray not continue giving Jackson benzodiazepines until he was sedated? If Jackson was overdosed on benzodiazepines, Murray could have remedied this with the flumazenil he had available.

This video mentions a drip of propofol again. There was no propofol drip. There was no manual/electronic pump. If the tubing used to administer propofol was 13.5 cm that is not long enough to hold up a glass bottle for a gravity drip, either. Furthermore, you would need vented tubing (which has never been said to have been found) for fluid to actually flow from the bottle. There was likely no vented tubing available based on evidence found at the scene. Given the finding of syringes with propofol and lidocaine, this seems to be the method Murray used to administer propofol to Jackson--via bolus injections which would place Murray there witnessing Jackson's response to the medications.

No reports have ever said that Murray was giving propofol for 60 days (eight weeks). Some say six weeks, some say two weeks. Thus far only one receipt has been discussed in the California search warrant. A receipt from 05/12/2009 shows what was purchased by Murray himself through Applied Pharmacy Services in Las Vegas. Multiple bottles of propofol, two vials of midazolam, one vial of flumazenil and one container of lidocaine cream were purchased. This receipt does not completely correlate with what was said to have been found at the residence so where did the remaining supplies come from and when? How many bottles of propofol did Murray buy during his duration of "care" of Jackson? One must understand a 20 mL vial only gives approximately 10-15 minutes of sedation if given via bolus (syringe). A 1000 mg bottles would give approximately an 60-90 minutes of sedation if given via boluses. If Murray was using propofol regularly on Jackson, whether one week or six weeks, then he would have needed numerous bottles of propofol, not just 5 or so bottles, regardless of size. Further examining the California search warrant also seriously questions the doses Murray claims to have given Jackson the day he died. Many vials, including vials of propofol, midazolam, lidocaine and lorazepam were empty. Empty vials do not correlate with Murray's small amounts stated as being administered on 06/25/2009. Either Murray was a vial hoarder, he wasted the medications to stage repetitive use of the drugs or he is lying about how much he administered of various medications to Jackson. Hair samples from Jackson could clarify this discrepancy in better detail.

"Dr. Murray's Defense--Jackson Killed Himself"
Please read the following link: http://www.tmz.com/2010/04/05/Jackson-jackson-dr-conrad-murray-propofol-death-cause-iv-addict-overdose-heart-legal-defense/59/#c3365156

Synergism Denied:
First off, the likelihood of the administration of three benzodiazepines failing to sedate Jackson is slim if not impossible. However, if they were not sedating him as Murray claims then a synergistic effect would be null as propofol would not suddenly cause the benzodiazepines to sedate Jackson--they either would or would not sedate him and propofol would take an effect independently. Propofol decreases the clearance of midazolam by inhibiting CYP3A4: An in vivo and in vitro study by Hamaoka, et al. states that midazolam (Versed) may be cleared at a slower rate when given with propofol but propofol's clearance is not affected. Propofol inhibits midazolam from being metabolized from possible competition of CYP3A4. This mean that if the midazolam had in fact been sedating Jackson the effects would have been prolonged but propofol's duration of action would not be effected. But, Murray claims Jackson was not sedated. Thus, once the propofol wore off within minutes as it normally would then Jackson would have awoke again as the benzodiazepines are said to have had no initial effect. If Murray is lying and Jackson was sedated, whether fully or partially on midazolam, then the midazolam had a longer duration of action than one would expect (the half-life of midazolam is prolonged by approximately 61%).

Insinuating Jackson was out an hour on 25 mg of propofol in conjunction with non-sedating doses of Ativan and Versed (which also wears off fast) is impossible. Plus, this does not match with the story Murray told detectives that is contained in the search warrant. Murray said he gave 25 mg, observed Jackson for 10 minutes then left no more than two minutes to use the restroom. I do not believe 25 mg of propofol is capable of keeping someone out for 10 minutes. If not previously sedated, which Murray claims he was not, then he would have woke up while Murray was monitoring him, before he went to the restroom.

(Lack of) Addiction vs. (Unintentional) Abuse:
Addiction to propofol is something I hope to speak about heavily in the near future. For a short synopsis, please read this blog, "Was Jackson an addict?". Please understand, one statement that remains consistent across the board is Jackson wanted to use propofol "to sleep". He did not wish to use it for a "high" or euphoria as if this was the reason for use then it would have been used in short bursts and Jackson would not have desired to use it under a doctor's care for the duration of the night with the anticipation of simply waking up in the morning to start the day after getting a much desired snooze. I cannot deny that using propofol for sleep is a form of abuse. That makes Jackson's case unique in that he was not abusing it for reasons of arrogance. Insomnia and fatigue can be catastrophic and even fatal and there is no doubt Jackson did in fact suffer from insomnia for years. Abuse and addiction are not the same thing. Jackson's reported request for propofol is a form of abuse that a lay person could naturally assume as reasonable as Jackson, I promise you is not the first, not the last or the only person to ever ask for propofol for sleep because they were fatigued or unable to sleep. Jackson, as a lay person, did not understand this drug did not render him true sleep, that it put him at grave risk for infection and apnea nor did he understand how it was administered or used given when it was administered he was unconscious. It was the duty of medical professionals to deny him of his what he likely assumed to be a harmless request in which he could not seriously consider the possibility of fatal consequences.

Enjoying Liquid Fire?
For TMZ to insinuate that Jackson "liked the sensation of propofol being administer by IV, adding, "Jackson liked to push it."--they should be sued for libel. Though not everyone experiences a burn with propofol it seems likely Jackson did given IV lidocaine was used. Many describe the administration of propofol as the most painful experience of their life. Propofol is only given by IV (peripheral, PICC or central line, etc.) and saying he liked to push it, well, that is a difficult task considering those receiving propofol become unconscious many times within seconds of administration. If Jackson wanted to abuse the propofol himself or thought that what he was doing was in fact abuse he would not have had Conrad Murray there to administer it and monitor him. Jackson did not think he was abusing propofol, he thought a physician was treating his insomnia.

The Fallen Bottle:
Below are photos of the crime scene/bedroom for discussion about the bottle found under the night stand:
http://www.intmensorg.info/images/mjdb.jpg

http://www.thesun.co.uk/sol/homepage/news/2573786/Pictures-of-Jacksons-death-mansion.html

This particular bottle of propofol was the only bottle found during the initial exam of the residence on 06/25/2009. It was found on the floor under a night stand in the bedroom (see Table 3A of the autopsy report also for this information). This is reported to be the bottle Jackson used to self-inject according to Murray.

Medical supplies were on the gold table/trolley/night stand seen in the photographs. He was lying on the left side of the bed if you are visualizing this from the foot of the bed. He was in the supine position. If Jackson was self-injecting he would have the bottle in his left hand and the syringe in his right hand as he was right-handed. He then likely would have used two hands on the syringe to draw out the medication from the bottle, likely suspending the bottle in the air with the syringe. This is most easily done with two hands even for a man with large hands. After withdrawal, he likely would have left the bottle in the bed, to his left, as the syringe should have stayed in his right hand. He would subsequently have pushed the syringe with his right or both hands. Under no circumstances does it make sense he would he have injected and then dropped the bottle to his right on the floor. He had to have been using his right hand to push in the contents of the syringe. The bottle could only drop under the table if it was in his right hand but this hand had to have been utilized to push the contents of the syringe. This essentially rips Murray’s notion that the empty bottle under the table was dropped by a self-injecting Jackson. Plus, was the bottle on the rug or hard floor? If it had been tossed and hit the hard floor would it not have shattered?

If a bottle of propofol was on the floor to begin with, which is possible, then Jackson could not have retrieved it with an IV catheter in his leg. Anyone could have placed the bottle under the night stand--including Murray. Whose fingerprints are on the bottle? Fingerprints would not necessarily implicate anyone but could rule out individuals--especially Jackson if his fingerprints are lacking and if he accomplished self-administration against all odds. I am sure he did not take the time to apply gloves if he could even reach them. If Jackson's fingerprints are lacking and Murray's present then that should answer the question of who used the bottle. Have fingerprints been lifted from the evidence? Would such occur for a involuntary manslaughter case?

The Broken Syringe:
One of the two syringes collected was a broken syringe discovered on 06/25/2009. This broken syringe contained propofol and lidocaine only. This syringe was apparently not hidden in a closet like the remaining supplies (including multiple empty bottles of propofol) listed on Table 3A as collected on 06/29/2009. Was this syringe found in the bed, on the floor, on the night stand, etc.? If it was used to self-inject it should have either been in the bed or attached to the tubing that was subsequently hidden. Did this syringe even contain a needle or was a needle found used to withdrawal propofol? Were fingerprints lifted off the syringe? When did this syringe break? Was it broken by means of the plunger (the part you push and pull) separate from the barrel (what holds the contents)? If this is true, then this syringe would not have been useable. Jackson could not have used a broken syringe to have either drawn up or injected propofol. He certainly could not have broken it after losing consciousness either.

What does the tubing say about dosing?
I previously questioned the doses Murray claims to have administered to Jackson due to numerous empty vials found. Murray claims to have given only 25 mg (2.5 mL) of propofol to Jackson. The tubing used to administer propofol was said to be 13.5 cm long (approximately 5 inches long). Could 2.5 mL travel through the tubing to reach Jackson? That seems unlikely unless Murray flushed the line. Supplies to flush the line were apparently lacking and he did not flush the tube before disconnecting it. The tubing contained 0.47 g of liquid containing propofol, lidocaine and flumazenil. If Jackson was given only 2.5 mL of propofol then it seems this would have to have been given directly through a vein, not the tubing as it would not have reached the blood stream. If the tubing was used it seems that Murray had to have given more than 2.5 mL. Regardless of which scenario this points to Murray again lying about how much propofol he gave Jackson that morning.

Clean Up Before They Come:
Murray’s lawyer maintains that Murray did not do a "clean up" before paramedics arrived. Really?
http://www.tmz.com/2010/03/22/conrad-murray-Jackson-jackson-propofol-cpr-drug-vials

http://www.tmz.com/2010/03/22/witness-dr-conrad-murry-hid-propofol-Jackson-jackson-death-police-closet

http://www.silive.com/news/index.ssf/2010/03/unsealed_search_warrants_revea.html

In the autopsy report, an empty glass vial of propofol, an empty glass vial of flumazenil, and the broken syringe with only propofol and flumazenil are mentioned being found on 06/25/2009. These items were not hidden.
Multiple bottles of propofol (some of which were used), another syringe containing flumazenil, propofol, and lidocaine as well as IV tubing also containing these three medications were found on 06/29/2009 in a closet (http://www.radaronline.com/photos/image/15324). Also found in a closet on 06/29/2009 were a blood pressure cuff and pulse-ox--two items that should have been at the bedside the entire time and caused no suspicion, whether giving propofol or not. These two items, if used, would have helped keep Jackson alive. These items were likely not used, for if they had been used Jackson not only would likely be alive but they would have alerted Murray of possible trouble and then later confirmed that Jackson was deceased. All the mentioned items above were indeed hidden, indicating a "clean up".

It has been stated that Alberto Alvarez was asked by Murray to remove the IV tubing that contained "a white liquid", that being propofol. Did paramedics take notice of the propofol bottle and/or flumazenil bottle later found by detectives on 06/25/2009? Were these left accidentally on purpose in an attempt to stage a scene? Possible alteration of the crime scene to make it look like a suicide is highly possible given Murray's defense. This, in turn, could indicate pre-mediated murder if enough forethought was given to stage the scene in such a manner. Murray's claim that he needed to go back to retrieve petty skin creams (and having Jackson taken to the hospital instead of being declared dead at the residence) also indicate he wanted to go back to either alter the scene further or remove some items from the scene. Why did Murray take the time to hide evidence while insisting Jackson was alive and implied he could be saved? Why would anyone who is responsible for keeping someone alive take the time to hide evidence rather than render or seek aid continuously? Why are Murray and his defense team lying about a "clean up" when one is clearly evident?

Has anyone asked Murray what he did with the syringe when he gave the supposed 25 mg? If Murray's syringe had been moved from where he had left it prior to his restroom break, it would have been apparent immediately to Murray because the propofol bottle, syringe, etc. would all have been moved and placed in such a matter supporting self-injection. Why not leave the area as-is if it were an accident done by the victim himself? Murray should have left everything in place as time was of the essence and Jackson's life, according to Murray, was hanging in the balance though reports do not support him being deceased. Why essentially tear down an scene that really is an accident?

All the aforementioned statements above raise the question of why did Murray tamper with the scene. If he genuinely did not know what happened in that room while he was out he should have left everything in exactly the same place as he found it and focused on saving Jackson which did not require the removal of items into closets and medical bags. There is no excuse for the delay in calling 911 or not having proper resuscitative equipment either as that is precisely why propofol is given in a hospital setting only. Murray should have informed paramedics of his suspicions, and been honest, instead of saying he had only given Ativan to Jackson. Murray has been anything but honest.

Conclusion:
There has also been some mention that a 100 mL (1000 mg) bottle was found in a closet with a large rip in it, indicating it was used for some sort of make-shift drip. I have debated whether or not this is true and lean towards it being false. If Murray did not have some form of vented tubing there would have been limited to no flow of liquid from the bottle as glass bottling must be vented to flow. If Murray by some chance had some vented supplies on hand and given it by gravity it would have killed Jackson. He apparently would have also had to have held the bottle attached to the 13.5 cm tubing which means he would have witnessed what was occurring to Jackson. If he did in fact use the 100 mL bottle that would also indicate he staged the scene with the 20 mL bottle left behind in the room.
Death after excessive propofol abuse states, "After a bolus injection, consciousness is lost in patients at propofol blood concentrations of 1.3-6.8 mcg/mL Consciousness was regained after 8-10 minutes at concentrations of 1-2.5 mcg/mL." The article further states that in their patient case (a male nurse who died from rapidly injecting multiple 200 mg doses over a period of at least 6 hours based on urine samples) likely died immediately after the final, rapid propofol injection due to his blood level being 5.3 mcg/mL--compared to 4.1and 2.6 mcg/mL in Jackson, respectively. Both these levels are consistent with Jackson not only being unconscious but would seem to indicate he, too, may have died shortly after injection. We also, however, still have to grapple with the information from the autopsy report that states multiple bottles of propofol were found empty. Keep in mind even though many bottles were empty, an enormous amount of propofol is needed to keep someone sedated for any length of time--200 mg (one 20 mL bottle) roughly gives 10 minutes of sedation. How many bottles did Murray buy while Jackson was under his care? How did Murray intend to keep this routine up or was he inducing sedation with propofol then using benzodiazepines to keep him sedated/asleep? How was Murray to receive propofol in London? Did he intend on giving propofol to Jackson in London? Was Jackson expected to live to see London?

Jackson's urinary propofol levels do not support him receiving propofol for any serious duration of the night on 06/25/2009 (less than 0.10 mcg/ml and 0.15 mcg/ml versus 5.4 mcg/mL in the male nurse who had been using the previous 6 hours before his death). How much did Murray really give Jackson that morning when Jackson should have been up and ready to begin his day? Murray being a medical professional and by admitting he had given propofol to Jackson before knew the possible consequences of giving this drug too rapidly and knew how much to give as well. He may have given bolus injections before on patients for cardioversions. He also knew it was not a legitimate regimen for insomnia, either, as it does not even induce true REM sleep and can be fatal if given without respiratory assistance. He knew how to do CPR, he knew Jackson was deceased at the house and he knows what really happened. So why are people like me and others having to try and piece this together when Murray knows the truth?

If Jackson could not have injected the contents and killed himself nor could he have completed this while Murray was out of the room then Murray's defense is null and void . Evidence certainly seems support this and likely if more evidence was known then this could likely be established without reasonable doubt. If that is then true that a much deeper analysis should be completed regarding Jackson's death as pre-mediated murder seems to be more likely than anything accidental.

Special thanks to "QuirkyDiana" for her contributions.