Wednesday, April 6, 2011

Rx for Danger--and It's Called "Ignorance"

Though not worthy of re-publication, I have decided to discuss an article on my blog because it appears that since I will not give out all my real, private information I am not able to become a "verified" user thus I am unable to post my thoughts (aka corrections) to this piece of... So, fine, I will just post the response to my own blog because something like this should not be allowed to persist without some worthy two cents:

"Painkillers put doctors under scrutiny" published by

Is it really that difficult to write an article that is actually accurate?

First error--Michael Jackson did not die from "painkillers". There were no "painkillers" in his house, prescription or otherwise, or in his body at the time of death. His cause of death had nothing to do with current or previous use of "painkillers". To infer the use or abuse of "painkillers" in Jackson's death is a serious fallacy that discredits everything written in this article, correct or not.

Second error--Conrad Murray is not to be compared with doctors who have written prescriptions for their patients who then go pick them up at a pharmacy and subsequently overdosed by their own hand and doing, accidental or not. Murray was in the house with Michael when he died--how often do you hear of such? Never. Michael Jackson did not even die from an "overdose"--he died because of Conrad Murray and his failure to prepare for what was to inevitably to happen to Michael due to Murray's own actions and non-actions. Murray personally administered the medications to Michael, none of which should have been used by Murray for insomnia or otherwise and these were medications Murray ordered from a pharmacy himself with his own debit card. Murray claims Michael was asking for this or that that morning of 06/25/2009 but as more evidence comes out it appears Michael was not even awake to know what was happening to him during the duration of the night. Michael had no medications in his stomach, no medication in his blood other than those provided directly by Murray. Murray chose not to prepare for any sort of problems that could occur from the regimen he chose to give to Michael. He did not even choose to do appropriate CPR, opting for one-handed CPR on a bed while making phone calls to security rather than 911. How dare anyone attempt to say Murray should not be facing criminal charges. He is a menace to society and a disgrace to medical professionals everywhere. If he can practice medicine then we might as well allow death row inmates interested in medicine to practice medicine, too .

The ignorance surrounded Jackson's death, which is no less then murder, is appalling. It should not be that difficult to understand the gist of the autopsy report which holds the key to Jackson's death which is no less than murder.

When are journalists going to get it through their thick heads that Michael's death had NOTHING to do with "painkillers"?

Monday, April 4, 2011

Discrepancies--Part II

This is the continuation of "Discrepancies--Part I":

g) Did Murray have a non-rebreather bag present?

The autopsy report states, "a tank of oxygen with some kind of non-rebreathing bag with a clear plastic mask (for positive pressure ventilation) was near where the patient was found by the paramedics. This tank was empty when examined on 07/13/2009. A non-rebreathing bag was not attached when the tank was examined." So--it is not clear whether this bag was left by paramedics or was part of Murray's equipment (notice investigators found it near where Michael was found by paramedics not that it was found by paramedics on their arrival as far as we know). Regardless of whether or not it was Murray's bag it was not used based on information we know thus this vital piece of equipment was useless. This lack of use of this bag is evidenced by the failure of it being connected to the empty oxygen tank--there is no valid reason to have detached it from the tank that I am aware of at this time.

Whether the tank was empty that morning on 06/25 is unknown but it seems Murray was administering oxygen throughout the night to Michael via a nasal cannula. For Murray not to have more than one oxygen tank present in the room is also a problem as oxygen tanks do not hold week's worth of oxygen--they hold hours' worth depending on how much is being administered to the patient and the size of the tank. The more oxygen given and/or the smaller the tank, the less oxygen available. There has been no mention of more than one oxygen tank found in the bedroom. Chef Douglas B. Smith claims the tanks he saw Murray with during his time of employment were about waist-high (so approximately 3 feet tall assuming Smith to be of average height). The tanks had to be small enough that Murray could move them himself.

If Murray did possess a non-rebreathing bag, it should have been attached to an oxygen tank (one that had oxygen in it) and being used during CPR to give oxygen/breaths while another person did compressions. Or, if Michael still had a pulse like Murray claims then all one would have done is give oxygen with this bag and the heart should have never stopped beating with subsequent death, certainly not from propofol administration since the medication wears off in minutes. In fact, since Murray was administering IV benzodiazepines and propofol to Michael it would have been very ideal for him to have used this bag or had one of these bags with him and actively using one during or directly after the administration of the medications, namely propofol with or without lorazepam. Michael was reportedly found with a nasal cannula present. Such an finding is like applying a band-aid to a gangrenous wound.

Simply stated, if Murray had in fact had this non-rebreathing bag and had oxygen in the room and found Michael with a pulse then Michael would be alive today had Murray taken appropriate action. One must not forget Murray's one-handed, in-the-bed, and failure-to-call-911 or in-house help technique of CPR which would not save anyone. There was no defibrillator on the scene though the goal would be not to allow Michael to get to a point where he needed a defibrillator--these are meant to be used to save someone's life when they suddenly collapse, not from physically drugging an individual and then failing to give them even sub-adequate care and monitoring. With that in mind it makes sense Murray would not bother to have a defibrillator, either, as he lacked just about every piece of life-saving equipment and supplies known to medical professionals across the globe. Why remains a question many would like to have answered.

h) Did Michael have a pulse-ox on monitoring his oxygen/carbon dioxide levels? What is the expert consensus on the items found at the residence?

The autopsy report states, "full patient monitoring is required any time propofol is given. The most essential monitor is a person trained in anesthesia and in resuscitation who is continuously present and not involved in the on-going surgical diagnostic procedure. Other monitors expected would be a continuous pulse oximeter, EKG and blood pressure cuff preferably one that automatically inflates. An end-tidal CO2 monitor would be used for fully anesthetized patients and is also highly desirable in sedated patients. Although the measurement or CO2 would not be accurate in sedated patients, who have a loose mask or nasal cannula for supplemental oxygen, the presence of CO2 documents that the patient is breathing and that the airway is open. If CO2 stops being present for whatever reason, the monitor will alarm (audible and visual signals) which calls attention to the possible apnea and/or airway obstruction, so action can be taken promptly. Of course. airway devices and drugs for resuscitation must always be present. Supplemental oxygen should always he delivered to patients receiving propofol and they should always have a recovery period with monitoring and observation by trained recovery nurses."

Murray apparently had no assistance by means of nurses or other personnel. He did not have an EKG machine present (though being a cardiologist he should have had easy access to one) nor did he have an automatic blood pressure cuff (one was found in the closet in the other room with the pulse oximeter but this one was likely not an automatic cuff nor would it be "automatic" without a machine to operate it). He supposedly had a nasal cannula on Michael but no other means to deliver oxygen (and possibly no oxygen in the tank). He did not even provide a CPAP machine (used on patients with sleep apnea) and though a CPAP machine would not be proper equipment to have for anesthesia it would have been better than the nasal cannula or nothing at all. Murray should have been able to access a CPAP machine, certainly with more ease than the propofol he purchased. Murray did not have any resuscitation medications with him such as atropine, epinephrine or sodium bicarbonate. He did not have any medications with him to raise blood pressure if Michael began to suffer from low blood pressure which is common with propofol administration. The only rescue drug Murray had was flumazenil which is only useful for a benzodiazepine reversal. Murray was not prepared in any form to render any sort of treatment to Michael, certainly not anesthetic care.

Dr. Friedberg states, "in none of the published photographs of Jackson's bedroom do any safety monitors appear. Murray reportedly told police he had been using a pulse oximeter. When the police searched for it, the pulse oximeter was discovered in a closet in an adjoining room. If this account proves correct, it casts serious doubts on Conrad Murray's credibility" He goes on to say, "in conclusion, giving multiple drugs with the well-known potential to stop breathing, failing to remain in observation, and failing to use a pulse oximeter are all clear predictors of a bad outcome. Although he may not have intended to kill Jackson, Murray clearly caused Jackson's death involuntarily. The only thing more reckless Murray could have done was taking Jackson up in an airplane and pushing him out without a parachute. What would have prevented Jackson's death? A knowledgeable, conscientious physician who both watched and monitored his oxygen--at very least--absolutely would have."

One has to ask, based on Friedberg's commentary, how could a doctor, not a lay person but a doctor of 20 years not monitor his patient? Monitoring Michael was not out of Murray's physical control, it was a conscious decision--he had the duty and the physical ability to monitor Michael as well as the ability to access monitoring equipment, too. Phone calls or not, he knew Michael's life lay in his hands, in his control. He either chose to not monitor Michael, phone calls were more important than Michael's life and his grossly-inflated quoted income or he did monitor him and ignored any obvious signs of distress and subsequent death. If pushing Michael out of an airplane is the only thing Murray could have done more reckless then how could there be such a big difference in the mentality of what Murray did that morning to Michael? Can all of his actions really be involuntary? Michael was only a few-minutes' drive from one of the best medical facilities in the United States. Murray had within his possession a oxygen monitoring device and either failed to use it or he failed to acknowledge the alerts provided by it either by consciously ignoring the audible tones or consciously removing himself from the fatal scenario he created. Whether Murray failed to use the critical pulse oximeter, failed to heed the alarm or failed to be in earshot of the alarm one still must ask "why?" to all three of those scenarios as none of them make logical, basic medical-sense. A doctor should and would know better, regardless of his specialty area, and would especially know better if he is willing to engage in medical Russian Roulette. Furthermore, if Murray had given propofol and benzos before like he claims, then he by all means knew what was at minimum necessary to keep Michael alive or Michael would have died weeks prior.

i) Did Murray give propofol via a drip, via bolus injections (using a syringe) or both?

My reply at this time is I simply do not know if he used a gravity-drip, bolus injections with a syringe or both methods to administer propopfol. It really does not matter--none of these scenarios would exonerate Murray from his actions. But, I want to address what we know (or likely know) and hopefully others who know more about the administration of IV drugs or come across new information will come forward and give their hypotheses as I think this should be discussed as those of us who care deeply about Michael want to understand exactly what happened as Murray is not giving any honest answers. I personally feel at this time evidence points to the definite use of bolus injections with or without the use of a gravity-drip. I will discuss information shortly that seems to indicate there was not a drip though I will not state this as a fact and am open to all opinions and information as there is still a lot unknown about that morning.

For this particular write-up a "bolus injection" is referring to the administration of a medication via a syringe into short tubing via an IV catheter and a "gravity-drip" refers to the a medication (propofol, in this case) given directly from the bottle to the bloodstream through the use of tubing and an IV catheter. "Gravity" implies the use of gravity to give the medication rather than using a IV pump which can precisely measure the amount drug given to the patient.

For starters, administration of propofol given by a gravity-drip is never appropriate or seen in normal medical practice. The drug is almost always given via some regulated means like a IV pump or a syringe pump--some means to give precise, accurate dosing down to so many micrograms per minute. This sort of micro-precision control cannot be achieved through gravity administration of any drug or substance. Gravity administration is usually regulated by clamps placed on the IV tubing. There may be other means available I am unaware of but they still could not achieve the accuracy or safety of that of an IV pump. If Murray did attempt to use some sort of gravity-drip (as no pump was in the house for him to use) then his intentions about this drip should be questioned because, anesthesiologist or not, he should have known not to give this medication as gravity-drip. It would be an act of certain death.

Murray has claimed to have given 25 mg of propofol with a subsequent "drip" afterward. Whether or not this drip was supposedly propofol or saline is unknown. Murray only ordered 9 saline bags April 6th and 12 more saline bags on June 15th so he was not apparently giving saline for either medication administration or hydration on a nightly basis prior to June 15th, or possibly after except on June 25th. Supposedly that 25 mg of propofol was given over 25 minutes. However, giving 2.5 mL of a medication undiluted is impossible without some means like a syringe pump. I do not think such a small amount of propofol given over such a long length of time would be capable of sedating anyone either, diluted or not. Regardless, we know there is no way only 25 mg was given based on the toxicology results so it is likely Murray's entire statement is a lie.

The autopsy report refers to four components of an "IV system being tested"--this included a medication-free IV bag (containing normal saline), medication-free long IV tubing (containing normal saline), a syringe found with propofol, lidocaine and flumazenil and short tubing (13.5 cm) with propofol, lidocaine and flumazenil. There is no mention of any IV components that would insinuate the explicit use of a gravity-drip of propofol from these items tested. It would seem there would need to be some form of long tubing with propofol and lidocaine in it to accept this possibility--otherwise it seems medications were introduced into the short tubing via syringes only. The likelihood of some components of propofol gravity-drip being unaccounted for seems slim (but not impossible) given so much incriminating evidence was left behind at the house.

There were two syringes with propofol found at the residence. One was found with the medical and IV equipment in the closet and the other was found in the bedroom, syringe on the bedside table, needle on the floor. There is no evidence that Murray used the syringes to transfer the propofol to an IV bag. Murray did not need to bolus the propofol on top of a subsequent propofol gravity-drip to assist Michael in "sleeping". These syringes laced with propofol and lidocaine indicate boluses were used to administer propofol at some point.

Some theories for gravity-fed administration claim propofol was given directly from the propofol bottle with an empty, cut saline bag used to hold the bottle up at an appropriate height from the IV tree/pole. Supposedly the IV bag was cut up-to-down, not right-to-left. There is no mention of a cut at the bottom of the bag so that tubing could have been threaded up to the bottle encased in the bag. Depending on the length of the cut, a up-to-down cut would not sufficiently hold a bottle in place in a IV bag. In court testimony given in January, investigator Elisa Fleak agreed with Murray's defense attorney that the propofol bottle in the saline bag could be trash. However, Elisa Fleak is a criminal investigator not a medical expert. Of course the defense would want to try and avoid any possibility that a gravity-drip was used. The bottle found in the cut saline bag is being heavily questioned because of guard Alberto Alvarez's testimony. He seems to imply this contraption was used to create a gravity-fed propofol drip that he was asked to help dismantle, not knowing what it was at the time. Alvarez' statements are the strongest evidence at this time that Murray may have not only bolused Michel with propofol but also provided him with a propofol gravity-drip on top of at least 7-12 mg of IV lorazepam. There is no reasonable reason for any of those scenarios to have occurred at any given time. Individually they could be lethal--together they would be lethal.

Propofol comes in glass bottles to prevent the breakdown of the medication. A glass bottle must be vented (allow air to exchange for liquid) to flow. Was any vented supplies found? Can a bottle be effectively vented by any other means besides vented tubing or needles? There is no indication Murray ever transferred propofol directly to a saline bag; no saline bag has been reportedly found containing propofol. Reports theorize Murray spiked a bottle of propofol and merely used a saline bag to hold the bottle up. Never in my life have I see a saline bag used to hold a bottle for medication administration. If Murray did in fact do this I cannot even find the words to say how truly appalling this would be, not that other actions carried forth by Murray are any less deplorable.

The only IV tubing mentioned in the autopsy report containing medications was the 13.5 cm (6 inches) tubing. This tubing is not long enough to hang onto a IV tree/pole. No additional tubing has been reported as containing medications. The 13.5 cm tubing was apparently the last tubing used by Murray since it contained propofol, lidocaine and most importantly flumazenil-- the last drug supposedly given by Murray to Michael through the IV catheter before paramedics arrived. Unless the public autopsy report does not list all the evidence or evidence was somehow removed it seems unlikely a propofol gravity-drip could have been successfully created with the supplies found.

Dr. Calmes only discredited the notion of self-injection via boluses in the autopsy report. She did not discuss the set-up of a gravity-drip or the possibility of such, either, though she did say someone with medical knowledge or experience would need to set up the IV. There is NO evidence Michael knew how to set up an IV or would even desire to do such on himself or anyone else. Michael had an interest in medicine as he had an interest in many subjects like art and history but he did not have any medical training. People like Arnold Klein and Mark Lester say Michael was petrified of needles. Murray has not denied placing the IV in Michael's leg. He admits to using the IV catheter to administer medications that was apparently started by him. It would seem if someone else was assisting Murray he would have named them by now and shifted blame onto them as he has done to others.

Dr. Ruffalo, the prosecution's expert witness, stated during the January hearing he suspected 100-200 mg, minimum, of propofol was given just prior to death. This would be more indicative of bolus dosing rather than drip administration. However, Dr. Calmes states in the autopsy report, "The levels of propofol found on toxicology exam are similar to those found during general anesthesia for major surgery (intra-abdominal) with propofol infusions, after a bolus induction." This seems to somewhat contradict what Ruffalo stated. There were at least three empty bottles of propofol--one 100 mL bottle (1000 mg) and two 20 mL bottles (200 mg). It would seem he was given 1400 mg (140 mL) based on the empty bottles that should have been thrown away after use. It is confusing trying to understand how much propofol Michael was actually given that morning because of the rapid metabolism of propofol. Though it is difficult to precisely interpret propofol levels in the blood, organs and urine it seems Michael was not given propofol during the early AM hours but only shortly before death and was given at least 100-200 mg or possibly more, enough that he was considered "fully anesthetized" when he died based on his blood levels. However, the trace amounts of propofol in Michael's urine would indicate his body did not have much time to metabolize the propofol and excrete it before his death, meaning not much was given before his death. Michael's propofol urine levels were 0.15 ug/g and less than 0.10 ug/g. One young man who passed after administering approximately eleven 20mL vials (2200 mg) of propofol to himself over 6 hours had a propofol urine level of 5.4 ug/g. This young man's level in his liver was 27 ug/g compared to Michael's 6.2 ug/g. Interestingly, this young man had a fatty liver, possibly from propofol abuse or some other sort of drug abuse (he was 26 years old) though a friend said he did not think he had been using propofol for at least six months. Michael's liver was normal. This young man also had kidney damage from previous drug abuse and scarring on his skin indicative of IV drug abuse, neither of which were noted in Michael's autopsy report.

If a propofol gravity-drip was administering propofol to Michael there is no way he should have been able to have suddenly awoke and then injected himself with a much smaller-yet-fatal dose as he would almost have certainly died from the gravity-drip almost immediately. A gravity-drip, especially one containing 1000 mg (100 mL), would likely be lethal within minutes without respiratory support because of the failure to recover from apnea. If a gravity-fed drip was created and used to administer propofol to Michael then Murray's defense strategies, including self-injection and drinking propofol, are null and void on top of the already numerous facts that discredit these claims.

Murray's defense team has claimed that Michael injected about 175 mg of propofol to himself and caused his death, based on the solo empty 200 mg bottle of propofol found under the nightstand, minus 25 mg given by Murray before leaving the room for less than two minutes. This amount is rarely lethal even without respiratory support. However, only one 10 mL needleless syringe was found on the nightstand. If only one 10 mL syringe was available than Michael could not have injected more than approximately 100 mg at one time, nearly half of what Murray is trying to claim Michael self-injected. The sedative properties of the medication should have occurred before any immediate re-dosing could have occurred. This dose should not have been lethal unless Michael was actively sedated on the lorazepam which Murray denies for obvious reasons--he bases his reason for giving propofol on Michael's "demands". Dr. Ruffalo estimated that Murray gave Michael a minimum of 7-12 mg of lorazepam before his death. He also said he believe he would have been sedated on that dose. Murray only admits to giving 4 mg or lorazepam, 2 mg per dose with the last dose being at 5:30 am. The dosing and time are both lies. If only 100-200 mg of propofol killed Michael then it was almost certainly from an additive effect from the lorazepam (which is laid out as the cause of death in the autopsy report). That being said, the lorazepam should have been sedating him to have been suppressing his ability to breathe and thus destroys the claims that Michael was demanding propofol from Murray.

Throughout this seemingly impossible scenario the questions that beg to be answered are--where was Conrad Murray when Michael needed him and how could he do what he did to him? How could a doctor consenting to the use of anesthetics for sleep aids neglect his patient when he knows respiratory and blood pressure will be effected by all the medications he was administering? Any medical doctor knows this would occur with propofol and benzodiazepines. If Murray created some gravity-drip then why did he not go back to check on him to replenish the drip (assuming he left the room)? Murray was on the phone for approximately 45 minutes. If he was not in the room during those phone calls then what is his excuse for not going back to give more propofol? Is it because he knew what the outcome would be? Propofol's effects only lasts a few minutes, not hours. Conrad Murray has so much explaining to do. It is just a shame that it appears he may get away with never having to tell the truth about what really happened to Michael Jackson.