January 6th, 2011
RICHELLE COOPER, M.D--Dr. Cooper is an emergency medicine physician at UCLA. She did her training at UCLA and became an attending physician for UCLA in 1998. She supervises residents as faculty for UCLA as well as caring for patients who come to the ER.
DIRECT EXAMINATION: BY MR. WALGREN
Cooper confirms she was working in the ER at UCLA on June 25th, 2009. She recalls being contacted via the base station radio nurse regarding the events concerning this case. She states the medical intensive care nurse who answers the radio calls is located in a separate room in the ER next to the treatment rooms. The nurse radios back and forth with the paramedics in the field regarding appropriate protocols and care to be given to patients. She confirms she is consulted as needed when the nurse needs assistance for a call.
Cooper confirms she was consulted by the radio nurse regarding Michael Jackson.
Walgren: FROM THE TOTAL OF YOUR INVOLVEMENT WITH THE RADIO NURSE AND THE COMMUNICATIONS WITH THE PARAMEDICS, WHAT WAS YOUR UNDERSTANDING OF THE PHYSICAL CONDITION OF THE PATIENT PRIOR TO HIS ARRIVAL AT UCLA?
Cooper: THE SUMMARY OF THE REPORT I HAD WAS A RADIO CALL, I BELIEVE, AROUND 12:18 THAT THERE WAS A PATIENT WHO WAS UNRESPONSIVE, ASYSTOLIC, WITHOUT PULSES, NOT BREATHING. THAT THE PARAMEDICS HAD INSTITUTED PROTOCOL TO RESUSCITATE THE PATIENT, INTUBATED THE PATIENT, PLACED AN I.V. AND STARTED PROTOCOL DRUGS. THERE WAS NO RESPONSE AND NO SPONTANEOUS CIRCULATION.
Cooper states she was aware paramedics responded to a 911 call. She states she has briefly seen the run sheet from that particular 911 call but has not seen any dictated report or transcript of the call. Cooper clarifies that a run sheet is hospital form or document the radio nurse creates for each call. Cooper state she saw that sheet and signed it at the time she was called to give advice.
Cooper states she cannot say for sure the exact time of the 911 call.
Cooper: I CAN'T SAY FOR SURE THE EXACT TIME OF THE 911 CALL. I DID REVIEW MY RECORDS, AND MY UNDERSTANDING WAS THE ARREST WAS AROUND 12:18.
Walgren asks if the arrest occurring at 12:18 p.m. was her understanding and she agrees. Cooper states if she could look over her report she could indicate a time as she recalls transcribing one.
Cooper is able to examine the base hospital form (run sheet). It states cardiac arrest was at 12:18. She states that is the estimated time of cardiac arrest, not the time of the 911 call.
Cooper confirms this time of cardiac arrest could have come from Conrad Murray. However, she confirms she does not have any first-hand knowledge as to the source of cardiac arrest time.
Cooper confirms she continued doing other tasks and was consulted on an as-needed basis. Cooper confirms she was contacted for a pronouncement as resuscitations efforts appeared to have not been producing any response.
Walgren: WHAT DO YOU MEAN BY PRONOUNCEMENT?
Cooper: BASED ON L.A. COUNTY E.M.S. PROTOCOLS, A PATIENT FOUND WITHOUT PULSE, NOT BREATHING, PUPILS FIXED AND DILATED, ATTEMPTED RESUSCITATION, NO RESPONSE TO RESUSCITATION, AND RESUSCITATION EFFORTS MORE THAN 20 MINUTES, THEY MAKE PROTOCOL TO BE ANNOUNCED IN THE FIELD.
Cooper states she gave authorization for a pronouncement of death at 12:57 p.m. for the patient whom at the time she did not know was Michael Jackson.
Cooper confirms she was then made aware there was a personal physician at the scene who wanted other treatments given, including sodium bicarbonate. Cooper remarked if the physician had a valid California license, the paramedics could give sodium bicarbonate but the physician would need to accompany the patient to the nearest hospital. She also instructed that the personal physician would need to assume care of the patient. To the best of her knowledge, her instructions were followed by Murray, et. al.
Cooper confirms she was present in the ER at 1:13 p.m. when the ambulance arrived. She states everyone was prepared for arrival of the patient and everyone knew their roles.
Cooper: AS THE PATIENT ROLLED PAST, I WAS INTRODUCED TO DR. MURRAY. AND AS THE PATIENT WAS BEING PUT ON THE MONITOR AND EVERYONE WAS STARTING THEIR WORK, I ASKED, "WHAT HAPPENED?"
Cooper identifies Murray in court for the record. Walgren asks Cooper what Murray told Cooper, if anything.
Cooper: DR. MURRAY REPORTED THE PATIENT HAD BEEN IN HIS USUAL STATE OF HEALTH, NOT ILL, BUT HAD BEEN WORKING VERY HARD AND HE THOUGHT HE MAY BE DEHYDRATED. HE HAD BEEN HAVING TROUBLE SLEEPING, AND HE HAD GIVEN HIM TWO MILLIGRAMS OF LORAZEPAM THROUGH AN I.V.
Cooper confirms Murray stated the patient had not been ill, had been working long hours, had had trouble sleeping and was dehydrated.
Walgren: DID YOU ASK ABOUT ANY NARCOTICS DR. MURRAY HAD GIVEN THE PATIENT?
Cooper: I ASKED EVERYTHING. WHAT MEDICATIONS THE PATIENT WAS ON AND WHAT HAD BEEN ADMINISTERED.
Cooper states Murray reported to her he had given 2 mg of lorazepam at some point in the morning and later on given another 2 mg of lorazepam and then witnessed the patient arrest. Cooper confirms Murray never mentioned any other medications, narcotics or drugs he had administered to the patient at that time. She confirms the only medication mentioned was the total dose of 4 mg of lorazepam and he did claim to have witnessed the actual arrest.
Walgren: WHAT DOES THAT (arrest) MEAN?
Cooper: I TOOK IT TO MEAN HE GAVE THE MEDICINE, THEN THE PATIENT'S HEART STOPPED OR HE HAD STOPPED BREATHING, AND THEN HE INSTITUTED CPR.
Walgren: AS A DOCTOR, WHAT IF SOMEONE SAYS, "I WITNESSED THE ARREST." WHAT DOES THAT MEAN, "I WITNESSED THE ARREST"?
Cooper: IT MEANS YOU ARE IN THE ROOM AND YOU HAVE SEEN THE EVENT WHERE THE PATIENT HAS DIED IN FRONT OF YOU.
Cooper is asked if she specifically asked Murray about any other drug use or history of drug use. She states at that point she was managing the patient's care but did have several conversations with Murray where more questions were asked as she was trying to determine what exactly had happened. She did ask about purported past drug use or any drug that he may have been taking in addition to the purported Vailum and Flomax.
Cooper: IT WAS REPORTED NO OTHER DRUG USE, NO PAST MEDICAL HISTORY, NO SEIZURE ACTIVITY BEFORE THE ARREST, AND PATIENT NOT COMPLAINING OF CHEST PAIN OR ANYTHING BEFORE THE ARREST.
Cooper confirms the lorazepam was mentioned in the initial conversation with him. Subsequent questioning was directed to Murray in which she was able to retrieve additional information from him.
Cooper confirms Murray told her there was no seizure activity by the patient preceding the arrest and no reported trauma. She confirms she asked Murray if the patient took any additional information to which Murray mentioned the patient was taking Flomax and Valium. Cooper states Valium (diazepam) is a benzodiazepine, a sedative, as is lorazepm. She states Flomax is usually used for urinary problems, in someone who has an enlarged prostate. She states Flomax assists those who "go to the bathroom a lot" as it relaxes the urinary muscle.
Cooper again confirms Murray stated there had been no reports of chest pain or anything of that nature.
Cooper confirms the patient was deceased as he had no signs of life upon arrival. She confirms she and her team did everything possible to attempt to revive the patient. She states they started with a full assessment: endotracheal tube was correctly placed and ventilation was positive.
Cooper: WE THEN PUT AN ULTRASOUND ON THE PATIENT'S HEART TO SEE IF THERE WAS ANY (cardiac) MOTION AND THERE WAS SOME MOVEMENT OF THE HEART AND MOVEMENT OF THE VALVE BUT NOT WHAT I WOULD SAY IS GOOD HEART FUNCTION IN TERMS OF A HEART THAT WAS PUMPING. THERE WAS NO PALPABLE PULSE. THERE WERE NO OTHER SIGNS OF TRAUMA.
(On a side note, this heart movement could have been being caused by the medications being administered. A dying heart muscle may move, too.)
Cooper states they proceeded to resume CPR and administered more medications including initial IV fluids (based on the reported dehydration) and did obtain further IV access to administer the medications.
Cooper confirms the patient was continuing to be ventilated and chest compressions were being done. She also confirms there is continuous cardiac monitoring taking place. Walgren asks if CPR chest compressions can artificially create a detectable pulse from time to time. Cooper states that "is the goal". She confirms Walgren's statement that is important to stop compressions from time to time to check and see if the body is spontaneously creating the pulse. Cooper confirms she did not note, observe or feel a pulse independent from CPR and compressions.
Walgren asks Cooper if at 1:21 in the afternoon a weak femoral pulse was noted by someone. She confirms yes and continues to elaborate.
Walgren: DO YOU KNOW WHO INDICATED THAT?
Cooper: I DON'T. THE NURSE SCRIBE SHEET IS AN AMALGAMATION OF WHAT IS BEING CALLED OUT BY THE DOCTORS, THE NURSES, THE TECHS. SOMEONE REPORTED FEELING A PULSE, BUT I DO NOT RECALL WHAT IT WAS.
Cooper confirms Murray was in the room during that time.
Walgren asks about what medications were given in the ER.
Cooper: THE PATIENT RECEIVED, I BELIEVE, ANOTHER EPINEPHRINE, RECEIVED SODIUM BICARBONATE, RECEIVED VASOPRESSIN. A DOPAMINE DRIP WAS STARTED, AND LATER EPINEPHRINE AND BICARB DRIP WAS STARTED.
Cooper states this medications mentioned above did not lead to a return in spontaneous circulation.
She states care continued until the pronouncement of death at 2:46 p.m.
Walgren confirms care was administered in the ER for approximately 1 hour and 13 minutes. Cooper confirms she was the one who made the pronouncement of death. Cooper then confirms from the time of her initial pronouncement at 12:57 p.m. through the paramedics until the pronouncement time at the ER at 2:46 p.m. there was no notable changes in the patient's condition, as in no return of spontaneous circulation.
Cooper agrees that blood was drawn at the hospital for necessary testing.
Walgren asks if a particular labeling system was used for Michael. Cooper states that for any critically ill patient there are registration packs created that have all the information they will need, including labels. Those particular labels were used to label blood initially. Cooper clarifies that the name "Gershwin" is similar to that of a "John Doe" situation. However, "John Doe" cannot be used every time so there is a generated list of names to be used, including Gershwin, which is used for the registration packet. This method is used to prevent a delay of care from the inability to label items. There is a particular medical record number that is unique to the patient, regardless of the name.
Cooper, Walgren and Flanagan begin to review the handwritten report written by Cooper. They are referencing the unique medical record number which is "Trauma WM0241, Gershwin". Cooper confirms this was the one affixed for the records of Michael Jackson. She confirms the medical record number as well.
Cooper begins to discuss the use of condom catheters. She states it is a urinary catheter used to collect urine that is used externally rather than internally via the urethra. She states it is typically used for someone with issues with incontinence or sedated in an operating room.
(Side note, I have never heard of use of a condom catheter in the OR--I have only heard of internal or Foley catheters used in the OR with condom catheters being used for incontinence only.)
Cooper confirms a condom catheter was visible upon the patient's arrival to the trauma room.
Cooper confirms that from the first encounter with Murray until the last he never mentioned administering propofol to Michael. She confirms Murray only mentioned the use of lorazepam and Valium concerning the use of benzodiazepines.
Cooper confirms in her experience as a medical doctor she has never been involved in, witnessed or been present for a situation where an MD administered propofol in a home setting.
Cooper confirms she uses propofol in the ER. She uses it for procedural sedation.
Walgren: WHAT DO YOU MEAN BY PROCEDURAL SEDATION?
Cooper: WE USE IT IF WE ARE PERFORMING A PAINFUL PROCEDURE AND THE PATIENT NEEDS TO BE SEDATED DEEPLY, WE WILL OFTEN ADMINISTER THE MEDICATION TO, SAY, REDUCE A BROKEN BONE, A DISLOCATED JOINT, SOME SORT OF PROCEDURE THAT YOU WANT THE PATIENT TO BE COMFORTABLE FOR AND WE ALSO USE IT SOMETIMES WHEN WE HAVE PATIENTS WHO ARE INTUBATED. GENERALLY, HEAD TRAUMA PATIENTS WE WANT TO BE ABLE TO WAKE UP AND REEVALUATE THE NEUROLOGIC STATUS.
Walgren: IN YOUR EXPERIENCE THEN, OTHER THAN IN A PROCEDURAL SEDATION WHERE YOU WANT TO PUT THE PATIENT UNDER, OR IN, FOR EXAMPLE, A HEAD TRAUMA PATIENT, HAVE YOU EVER SEEN PROPOFOL USED IN YOUR EXPERIENCE IN ANY OTHER SETTING?
Cooper: OUT-PATIENT SURGERY SETTINGS, O.R. SETTINGS, BUT I'VE NEVER SEEN IT USED OR HEARD OF IT USED IN A HOME SETTING, IF THAT IS THE QUESTION.
Cooper again states she has never seen or heard of propofol used in a home setting.
Walgren completes his direct examination.
CROSS-EXAMINATION: MR. FLANAGAN
Flanagan: DO YOU YOURSELF USE PROPOFOL?
Cooper: PERSONALLY, I DON'T. I HAVE ADMINISTERED IT TO PATIENTS, IF THAT IS THE QUESTION YOU HAVE.
Cooper is asked if she is an anesthesiologist. She states she is not, she is a board-certified emergency medical physician with privileges for procedural sedation at UCLA.
Cooper is asked if one must be an anesthesiologist to give a medication. Cooper states any doctor can use any medication.
(Side note, this is partially true, though if a doctor does not practice within their scope there can be legal ramifications for doing so and a doctor should not attempt to practice out of their scope, either.)
Flanagan asks if it was 30 minutes from time of the initial pronouncement of death until the arrival at the hospital. Cooper clarifies it was less than 30 minutes considering an initial pronouncement time of 12:57 p.m. and an arrival time of 1:13 p.m. She agrees it was approximately 10-20 minutes.
Flanagan: BUT NEVERTHELESS, YOU UNDERTOOK TO TRY TO RESUSCITATE?
Cooper: THERE WAS A REPORT BY DR. MURRAY THAT HE HAD FELT A FAINT PULSE SEPARATE, WHICH CONFLICTED WITH THE REPORT OF THE PARAMEDICS THAT THERE WASN'T A PULSE. WHEN THE PATIENT ARRIVED, I MADE DECISION WE WILL ATTEMPT TO RESUSCITATE TO CONFIRM.
Flanagan asks if having a faint pulse justifies the resumption of resuscitation. Cooper states if there is a pulse, resuscitation could be resumed. Flanagan asks if a pulse was felt later on that morning. Cooper states there was one person who said they felt a pulse but she could not confirm such nor did she feel the pulse. She could not recall who called out they felt a pulse as it was not recorded. Cooper is asked if she has a copy of the medical record with her. She does not. A copy is made available to her. She confirms after receiving the records she did not write the name of the person who stated they felt a pulse.
Cooper looks over a nurse scribe note.
Flanagan: DOES THE NURSE REPORT WHO REPORTED THE PULSE?
Cooper: NO. IT SAYS, "13:21, WEAK FEMORAL PULSE PALPATED WITHOUT CPR," THEN THE PERSON WHO WROTE THE NOTE INITIALS IT.
Flanagan: AND THEN 13:22?
Cooper: WHEN SOMEONE REPORTED THEY FELT A PULSE, AND I LOOKED AT THE MONITOR AND SAW THE SLOW WIDE RHYTHM, I WENT AND PUT THE ULTRASOUND ON THE HEART, SAW THE SAME CARDIAC ACTIVITY AND ATTEMPTED TO FEEL A PULSE AND DIDN'T. I ORDERED CPR TO BE CONTINUED AT 13:22.
Cooper confirms again Murray was in the room at that time.
Flanagan: YOU ARE NOT MAKING A CLAIM THAT HE IS THE ONE THAT WAS FEELING FOR THE PULSE?
Cooper: I DO NOT KNOW WHO REPORTED THE PULSE. DR. MURRAY WAS IN THE ROOM AND INITIALLY DID HAVE GLOVES ON, MAKING ATTEMPTS TO FEEL A PULSE. WHEN WE STARTED TO PERFORM LINES, I ASKED HIM. I SAID HE IS NOT ALLOWED TO PROVIDE MEDICAL CARE, ALTHOUGH HE WAS IN DISCUSSION WITH ME.
Cooper confirms Murray initially was hands-on with Michael in the trauma room. However, Cooper cannot recall if he was still hands-on at 1: 21 p.m.
Flanagan: DO YOU THINK THAT THE PULSE THAT WAS REPORTED IN THIS RECORD IS NOT FACTUAL?
Cooper: I THINK IT IS FREQUENT IN A RESUSCITATION WHEN YOU ATTEMPT TO FEEL A PULSE, PEOPLE MAY SAY THEY FEEL A PULSE. IT MAY BE THEIR OWN PULSE THEY ARE FEELING. IT CAN BE VERY DIFFICULT. AT TIMES, PULSES ARE RECORDED THAT AREN'T THERE. I WAS NEVER ABLE TO INDEPENDENTLY CONFIRM A PULSE WITHOUT CPR.
Cooper asks if she was working hands-on at that time by Flanagan.
Cooper: AT THAT TIME SOMEONE REPORTED A PULSE, THEN I WENT AND I ATTEMPTED TO FEEL A PULSE, DID NOT FEEL A PULSE, AND ORDERED CPR BE RESTARTED.
Flanagan asks when Cooper had a conversation with Murray regarding his medical history. Cooper states she took a brief history initially. As drugs were being administered and circulating she asked Murray more questions.
Cooper states she began questioning Murray as soon as he came in the door because he was the one who initially gave report of what had happened to the patient. Cooper agrees it was reported to her by Murray he was there to witness when the patient stopped breathing. Cooper states she did not ask for a specific time, however.
Cooper: HE BASICALLY TOLD YOU THAT HE WAS THERE TO SEE WHEN THE PATIENT STOPPED BREATHING?
Flanagan: WHEN YOU USE THE TERM WITNESSED, A WITNESSED ARREST, WHAT IS IT THAT YOU SEE THAT CAUSES YOU TO THINK YOU ARE WITNESSING AN ARREST?
Cooper: I INTERPRETED THAT TO MEAN HE WITNESSED THE PATIENT STOP BREATHING AND THEN STOPPED TO HAVE A PULSE, AND RESUMED CPR AND RESUSCITATION.
Flanagan asks a couple questions which are objected to by Walgren. The Court sustains the objections. Flanagan asks if the term "witnessed arrest" is a term of art/medical term.
Cooper: IF I WAS IN A ROOM WITH A PATIENT AND THE PATIENT'S EYES ROLLED BACK, HE STOPPED BREATHING, AND DIDN'T FEEL A PULSE, I WOULD REPORT THAT WHILE I WAS IN THE ROOM I WITNESSED AN ARREST. I'M NOT SURE IF YOU WOULD CALL THAT ART OF MEDICINE. THAT IS WHAT I WOULD TAKE AS WITNESSING THE ARRESTING IN THE ROOM AT THE TIME.
Flanagan and Cooper continue the discussion of what would constitute "witnessing arrest". Cooper agrees that part of witnessing an arrest is witnessing someone go from conscious to unconscious-- so long as one visibly observes such.
(Not every loss of consciousness is an arrest of some sort.)
Flanagan asks Cooper if Murray said he witnessed the arrest. Cooper states her recollection of what was told to her by Murray did include him saying he witnessed the arrest. She states she did not ask for further details.
There is some discussion between Flanagan and Cooper as to whether or not all physicians agree as to what the term "witness arrest" means.
Cooper: I CAN'T SPEAK FOR ALL MEDICAL PEOPLE. THE PARAMEDICS, AND EMERGENCY PHYSICIANS, AND CARDIOLOGISTS DO RESUSCITATIVE WORK. THERE IS STANDARD TERMINOLOGY USED WHEN WE TALK ABOUT CARDIAC ARREST, WITNESSED PHYSICAL BYSTANDER CPR. THESE ARE GENERAL PHRASES THAT WE USE THAT I WOULD ASSUME FOR ALL PHYSICIANS WHO DO THIS TYPE OF WORK WOULD SAY WITNESSED ARREST IS YOU OBSERVED THE DEATH OCCUR.
Cooper is asked if she explored this further with Murray and states no, she did not as she was trying to resuscitate the patient. She agrees she had other things to do.
Flanagan: AND YOU ASKED HIM IF MICHAEL JACKSON WAS AN ABUSER OF RECREATIONAL DRUGS?
Cooper: I DON'T BELIEVE I SAID WAS HE AN ABUSER OF RECREATIONAL DRUGS. I ASKED WAS THERE ANY DRUG USE IN THE PAST OR CURRENTLY.
Cooper states Murray's reply to her was "no".
Flanagan: YOU ALSO ASKED IF HE WAS TAKING ANY DRUGS ON A REGULAR BASIS; IS THAT CORRECT?
Flanagan: WHY DID YOU ASK THAT?
Cooper: I HAD A 50-YEAR-OLD MALE WHO WAS DEAD. I DIDN'T KNOW WHY. I WAS TRYING TO THINK OF REASONS FOR SOMETHING I MAY BE MISSING OR SOMETHING RELATED TO THE EVENT THAT WOULD EXPLAIN, AND IT IS A COMMON QUESTION WHEN YOU ARE TAKING HISTORY IS WHAT IS THE PAST MEDICAL HISTORY AND WHAT OTHER DRUGS MAY BE USED.
Cooper agrees this information was to be used in the treatment of Michael and her medical decision making.
Cooper confirms Murray stated he gave 2 mg of lorazepam earlier in the day. She states she cannot recall asking for a specific time. Cooper then confirms Murray told her she gave Michael another 2 mg of lorazepam. Cooper is asked if she asked when the last dose was given. She states no, she did not.
Flanagan: WOULDN'T THE TIME BE OF SIGNIFICANCE TO YOU?
Cooper: I ASSUMED I WAS RECEIVING A CLEAR TESTIMONY. "I WAS AT THE PATIENT'S BED. I GAVE TWO MILLIGRAMS OF LORAZEPAM. I WITNESSED ARREST. I INSTITUTED CPR. 911 WAS CALLED." MY ASSUMPTION IS THIS WAS ALL PROXIMATE TO THE PARAMEDICS ARRIVING AND THE PATIENT ARRIVING TO ME.
Flanagan asks if she assumed the patient arrested on the induction of the 2 mg of lorazepam.
Cooper: I WAS TOLD BY DR. MURRAY THAT THE PATIENT WAS GIVEN TWO MILLIGRAMS OF LORAZEPAM AND SUBSEQUENTLY ARRESTED.
Cooper again confirms she was not given a time sequence and she did not ask for one.
Flanagan asks if lorazepam contributes to an arrest, is there something she would do from a treatment standpoint. Cooper replies the circumstances of the arrest were not clear as 2 mg of lorazepam would not typically cause an arrest in an adult male. She states it would typically cause respiratory depression and would expect the doctor to say the patient is not breathing well. Flanagan asks what she would expect Murray to do and she replies she would expect him to first stimulate/wake the person as generally people will breathe better on their own with a little bit of sedation.
(There onset of action and peak drug concentrations differ for the oral vs. intramuscular vs. intravenous administration of lorazepam. Two milligrams taken as a tablet is different than two milligrams given intravenously.)
Cooper is against asked if Murray had told her about Michael being given Valium. Walgren objects and the question is restated. Cooper agrees to a Valium being included in the medical history.
Flanagan asks if she asks when and she states no.
Flanagan: YOU DIDN'T CARE?
The Court: WAIT. IS THAT A QUESTION?
Flanagan: WELL, YEAH, THAT IS A QUESTION. DID YOU CARE WHEN?
Cooper: I ASKED WHAT MEDICATIONS HAD BEEN GIVEN AND WHAT WAS GIVEN PRECEDING WHAT HAPPENED WITH THE ARREST. I DID NOT ASK SPECIFICALLY WHAT THE LAST DOSE OF HIS REGULAR MEDICATIONS WERE.
Flanagan asks if the timing is of the dose is not important. Cooper states it could be important if she were to be administering more sedatives.
Cooper reaffirms she is familiar with propofol.
Flanagan: DO YOU USE IT FOR ANESTHETIC PURPOSES OR JUST SEDATION PURPOSES?
Cooper: THE VAST MAJORITY OF THE TIME, WE USE IT FOR PROCEDURAL SEDATION. I DO NOT WORK IN THE OPERATING ROOM. AT TIMES, WE DO USE IT ON PATIENTS WHO ARE INTUBATED AND BEING VENTILATED. THAT IS MOST COMMONLY IN THE SHORT-TERM AND THE PATIENT HAS A HEAD INJURY, A TRAUMA PATIENT.
Flanagan asks Cooper if she has been trained to give a certain amount of propofol for procedural sedation and she confirms he has been trained on such. She states she typically starts with a dose of 1 mg/kg and that dose is usually sufficient. She agrees for someone weighing 136 lbs (about 60 kg) 60 mg would be the amount for 1 mg/kg. She states that dose would be sufficient for most patients and it is a conservative amount for procedural sedation.
Flanagan: WHEN YOU SEDATE A PATIENT WITH ONE MILLIGRAM PER KILOGRAM, ARE WE TALKING ABOUT UNCONSCIOUS OR JUST IN KIND OF A--
Cooper: OUR GOAL IS TO NOT SEDATE SOMEONE TO BE COMPLETELY UNCONSCIOUS.
Cooper is asked if she would expect unconsciousness in Michael if he was given 60 mg of propofol. She states it could produce deep sedation, unconsciousness as some patients respond differently.
Flanagan: AND 25 MILLIGRAMS DEFINITELY WOULD HAVE PRODUCED UNCONSCIOUSNESS, WOULDN'T IT?
Cooper states she would not expect unconsciousness.
Cooper is asked if propofol lasts for a short period of time and agrees.
Cooper states hypothetically she would expect for 60 mg in Michael to lasts about 10-20 minutes. Flanagan then asks if 25 mg would last about 5-10 minutes.
Cooper: IN A DOSE THAT IS LOW, I DON'T KNOW HOW MUCH SEDATION YOU WOULD HAVE. THE MEDICATION, HOW LONG THE MEDICATION IS AROUND TO METABOLIZE MAY NOT CHANGE. I WOULDN'T EXPECT DEEP SEDATION.
Flanagan: YOU WOULDN'T EXPECT SEDATION TO LAST MORE THAN FIVE OR TEN MINUTES ON 25 MILLIGRAMS. YOU WOULDN'T EXPECT MORE THAN FIVE, TEN MINUTES OF SEDATION, WOULD YOU?
Cooper: I DON'T KNOW HOW LONG IT WOULD LAST. THE TYPICAL DOSE THAT I GIVE WHEN I GIVE A DOSE OF SEDATION, AND THE HALF-LIFE AND THE METABOLISM OF THE DRUG IS DIFFERENT IN EVERY PATIENT. A DOSE USUALLY TAKES TEN TO 20 MINUTES TO COMPLETELY WEAR OFF. SOMETIMES LESS IN SOME PATIENTS.
Cooper agrees she does not always know how patients are going to respond. She agrees there are certain guidelines that she begins with when dosing propofol.
Cooper agrees she would likely start with 60 mg of propofol for procedural sedation for a painful procedure in Michael given a weight of 60 kg. Again, she would expect it to wear off in 10-20 minutes.
Flanagan: SO NOW IF DR. MURRAY WERE TO GIVE THE PATIENT 25 MILLIGRAMS OF PROPOFOL BETWEEN 10:40 AND 10:50 IN THE MORNING, YOU WOULDN'T EXPECT THAT TO PRODUCE BREATHING PROBLEMS AT 12:00 O'CLOCK, WOULD YOU?
Cooper: I WOULDN'T KNOW WHY ONE WOULD BE USING A MEDICINE THAT IS USED TO PRODUCE DEEP SEDATION AND NOT GIVE A DOSE THAT IS SEDATING. TWENTY-FIVE MILLIGRAMS, I WOULDN'T EXPECT TO HAVE THAT EFFECT. I WOULD NOT EXPECT 40 MINUTES LATER, IF THERE WAS NO ADVERSE EVENT, THAT THE MEDICINE WOULD STILL BE HAVING AN EFFECT.
Flanagan: SO HYPOTHETICALLY, IF YOU HAD AN INJECTION OR INFUSION, A SLOW INFUSION OF PROPOFOL BETWEEN 10:40 TO 10:50 AND YOU SEE A PERSON STOP BREATHING AT ABOUT 12:00 NOON, YOU WOULDN'T THINK IT WAS THE PROPOFOL, WOULD YOU?
Cooper states when she administers propofol it is given as a bolus, a single bolus dose. She states the only time the medication is given as a continuous drip is when the patient is intubated and being artificially ventilated.
Cooper: SO YOU ARE TALKING ABOUT A SLOW INFUSION OVER SOME PERIOD OF TIME. IF YOU COULD CLARIFY WHAT YOU ARE STATING.
Flanagan states he is talking about the infusion of 25 mg over 3-5 minutes at around 10:40 a.m. or 10:50 a.m.
Flanagan: YOU WOULDN'T EXPECT THAT TO HAVE ANY EFFECT ON THE PATIENT AT 12:00 O'CLOCK, WOULD YOU?
Cooper: IF NO OTHER -- IF THE PATIENT HAD NOT STOPPED BREATHING OR HAD ANY OTHER EVENT AND WAS OKAY AFTER THAT, I WILL NOT EXPECT THAT WOULD BE A PROBLEM LATER.
Flanagan: SO WHAT I'M SAYING IS THAT IF, ALL OF A SUDDEN, IF THIS IS WHAT YOU HAVE DONE BETWEEN 10:40 AND 10:50 AND ALL OF A SUDDEN YOU SEE A PATIENT THAT IS NOT BREATHING AT 12:00 O'CLOCK, YOU ARE NOT GOING TO THINK IT IS THE PROPOFOL, ARE YOU?
Cooper: IF I ADMINISTERED MEDICATION THAT PRODUCED SEDATION AND A PATIENT STOPPED BREATHING, I WOULD BE CONCERNED THE MEDICATIONS I GAVE OR MEDICATIONS THAT THE PATIENT HAD INGESTED IN ADDITION TO WHAT I GAVE, OR THAT HAD PRODUCED SEDATION, HAD PRODUCED RESPIRATORY ARREST, IF THAT IS WHAT OCCURRED.
Flanagan: BUT NOW IF DR. MURRAY HAD TOLD YOU THAT EARLIER IN THE MORNING, LIKE AT 10:40, THERE HAD BEEN ADMINISTRATION OF 25 MILLIGRAMS OF PROPOFOL, WOULD THIS HAVE ALTERED YOUR TREATMENT?
Cooper states at the time she was going to standard resuscitation for a patient in cardiac arrest thus no, it would not have changed what she was doing at the time.
Cooper states when she has given propofol, on a 1 mg/kg basis, she usually sees an onset of action usually within 1 minute.
Flanagan: AND THE ELIMINATION, IF YOU ARE NOT GIVING A DRIP, IS ALSO VERY QUICK?
Cooper: IF YOU ARE NOT GIVING REPEAT DOSE, THE ELIMINATION IS GENERALLY TEN TO 20 MINUTES THE PATIENT IS RECOVERED.
Cooper affirms when giving a 1 mg/kg bolus typically the onset of action within a minute and she does expect them fully awake within 20 minutes. She states the patient is able to awake early in relation to the duration of action of the medication, as in it wears off fast.
Flanagan: NOW, FROM A MEDICAL STANDPOINT, AS A DOCTOR, IN THE EVENT THAT THERE IS A 25 MILLIGRAM DOSE OF PROPOFOL BETWEEN 10:40 AND 10:50 THAT WAS ADMINISTERED TO A 60-KILOGRAM WEIGHING PATIENT, WHEN THAT PATIENT SUFFERS A CARDIAC ARREST AT 12:00 O'CLOCK, WOULD YOU LINK THOSE TWO?
Cooper: I WOULD -- I WOULD BE CONCERNED PARTICULARLY IF THERE WERE OTHER MEDICATIONS THAT WERE GIVEN, THAT IT WOULD PRODUCE AN ARREST WHICH WOULD LEAD TO CARDIAC ARREST.
Flanagan asks if Cooper would think propofol was the cause of cardiac arrest at noon.
Cooper: IF THE PATIENT WAS AWAKE AND COMPLETELY NORMAL AND NOT SEDATED AFTER THE MEDICATION, AND THEN HAD A SUBSEQUENT PROBLEM WITH NO OTHER MEDICATIONS GIVEN, I WOULD NOT THINK IT WAS RELATED.
Cooper states she does not know anything about propofol blood levels. She would not know how to calculate a particular level in a particular organ or the blood.
Cooper is asked if lorazepam is different than propofol. She states yes, it is. She agrees lorazepam lasts longer than propofol.
Flanagan: YOU CAN GIVE LORAZEPAM, SAY, THREE HOURS AND IT WOULD STILL BE HAVING AN EFFECT IF IT IS A TOTAL OF FOUR MILLIGRAMS?
Cooper states yes, it would.
Flanagan: BUT PROPOFOL WOULDN'T HAVE AN EFFECT THAT LONG, WOULD IT?
Cooper states no, but propofol in combination with another sedative could have an additive effect.
Flanagan: BUT THE ADDITIVE EFFECT WOULD ONLY HAVE AN EFFECT AS LONG AS THE PROPOFOL WAS ADMINISTERED?
Flanagan: YOU WOULDN'T EXPECT ANY EFFECT AFTER AN HOUR, WOULD YOU?
Cooper: IF A SINGLE DOSE OF PROPOFOL WAS GIVEN IN A ONE-TIME DOSE, I WOULD NOT EXPECT THE PATIENT WITH NORMAL HUMAN FUNCTION AND NORMAL HEALTH, THAT WOULD STILL HAVE ANY EFFECT ON SEDATION IN AN HOUR, NO.
Flanagan states he has nothing further.
REDIRECT EXAMINATION: MR. WALGREN
Walgren: MR. FLANAGAN'S HYPOTHETICAL CENTERED AROUND A PARTICULAR FACT PATTERN, BEING THAT HE WANTED YOU TO ASSUME DR. MURRAY GAVE ABOUT 25 MILLIGRAMS OF PROPOFOL AROUND 10:40 AND 10:50. DO YOU RECALL THAT?
Cooper state she recalls him giving her times and doses.
Walgren asks Cooper if Flanagan was asking her to assume Murray have 25 mg of propofol sometime between 10:40 a.m. and 10:50 p.m. She agrees. Walgren asks if when answering the question about what kind of effect that would have had at noon, she assumed the former statement of Murray's to be true. Cooper agrees.
Walgren: OBVIOUSLY, IF THAT WAS NOT A TRUTHFUL STATEMENT, YOUR ANSWER MIGHT VARY CONSIDERABLY?
Cooper states that is correct.
Walgren asks what is meant by the additive effects of narcotics.
Cooper: IF YOU GIVE PROPOFOL AND YOU GIVE AN ADDITIONAL MEDICINE THAT PRODUCES SEDATION, A BENZODIAZEPINE, OR IF YOU ARE GIVING NARCOTIC MEDICATIONAS SOMETIMES WE DO WHEN WE ARE DOING PROCEDURAL SEDATION, WE COMMONLY DO THAT. YOU CAN HAVE DEEPER LEVELS OF SEDATION THAN YOU ANTICIPATE.
Walgren: SO IF SOMEONE HAD BEEN GIVEN AN I.V. OF LORAZEPAM, FOLLOWED LATER BY AN I.V. OF MIDAZOLAM, FOLLOWED LATER BY ANOTHER I.V. OF LORAZEPAM, FOLLOWED LATER BY ANOTHER I.V. OF MIDAZOLAM, THOSE WOULD HAVE ALL A CONTRIBUTORY EFFECT IF, SUBSEQUENT TO THAT, THE PERSON WAS THEN GIVEN PROPOFOL?
Cooper states yes it could. Walgren asks if that could certainly have an additive effect that could result in respiratory and cardiac arrest. Cooper states yes, it could. Cooper agrees as an ER doctor she would want to know that whole medical history and have all that information available to her. She agrees she was not given any such history by Murray on June 25th, 2009.
Cooper agrees with Walgren that people can respond differently to propofol.
Walgren: AND BECAUSE PEOPLE RESPOND DIFFERENTLY TO PROPOFOL, THAT IS WHY IN YOUR EXPERIENCE IT IS ONLY GIVEN IN A HOSPITAL SETTING; IS THAT TRUE?
Cooper: FOR CLARIFICATION, IT IS A MEDICINE THAT CAN PRODUCE DEEP SEDATION. AND WHEN IT IS BEING ADMINISTERED, APPROPRIATE MONITORING EQUIPMENT NEEDS TO BE AVAILABLE BECAUSE YOU CAN'T ANTICIPATE HOW SEDATED SOMEONE WILL BE. SO OUR PROTOCOLS IN THE HOSPITAL FOR USE REQUIRE SPECIFIC MONITORING AND PERSONNEL AVAILABLE.
Cooper states the type of personnel and monitoring equipment required include oxygen and typically carbon monoxide monitoring devices, equipment available to manage the airway (as in the equipment needed to intubate someone) as well as someone capable of ventilating the patient and someone whose sole responsibility is to monitor the sedation. She states a heart monitor is also used. She agrees this protocol is to prevent any respiratory and/or cardiac arrest, by having all the equipment needed and the people responsible for their sole tasks. She affirms this is to make sure the patient does not die.
Walgren completes his redirect examination of Cooper.
RECROSS-EXAMINATION: MR. FLANAGAN
Cooper agrees when she is taking a history of a patient it is for the purposes of treatment. She is looking for a relevant history.
Flanagan: THE FACT THAT MICHAEL JACKSON HAD BEEN TAKING, SAY, A HUNDRED MILLIGRAMS OF DEMEROL IN THE PAST, YOU WOULDN'T NEED TO KNOW THAT FOR THIS PURPOSE, WOULD YOU?
Cooper: WHEN I ASKED THE QUESTION ABOUT PRIOR DRUG USE, ONE OF THE CONSIDERATIONS WAS IS THIS SOMEONE WHO HAD OTHER MEDICATIONS IN ADDITION TO THE LORAZEPAM THAT WAS PROVIDED THAT WOULD PROVIDE AN EXPLANATION FOR WHY THE PATIENT WAS NOT ALIVE.
Cooper agrees she is asking for relevant drug use.
Flanagan: AND IF THE DRUG IS GIVEN AT A POINT IN TIME WHERE IT COULD NOT BE PERTINENT TO THE PATIENT'S CURRENT CONDITION, THAT INFORMATION WOULDN'T BE OF ANY USE TO YOU, WOULD IT?
Walgren objects but the objection is overruled.
Cooper: FREQUENTLY, WHEN WE TAKE A HISTORY, I WILL ASK ABOUT ALL HOSPITALIZATIONS, ALL SURGERIES, ALL MEDICATIONS. I WON'T NECESSARILY ASK EVERY MEDICATION THE PATIENT HAS TAKEN IN THEIR LIFE. I NEED TO KNOW RELEVANT INFORMATION CONCERNING THE EVENT.
Flanagan: BY MR. FLANAGAN: YOU WEREN'T TAKING AHISTORY THIS NIGHT TO DETERMINE ALL PAST SURGERIES, PAST CONDITIONS AND STUFF, WERE YOU?
Cooper states she was trying to do so. Cooper agrees she wanted information that would be relevant at that point in time for the purposes of treating Michael that particular day. Cooper agrees if Murray had told her he had been administering propofol in the past to Michael that would not have changed the resuscitative efforts made on that particular day.
Flanagan completes his re-cross examination.
FURTHER REDIRECT EXAMINATION: MR. WALGREN
Cooper agrees she wanted to obtain as much information as possible related to the medical and narcotic history of the patient.
Walgren: AND AS YOU MENTIONED PREVIOUSLY, THE HISTORY OF BENZODIAZEPINE THAT HE LISTED OFF, IF THAT INFORMATION WAS GIVEN TO YOU, THAT WOULD HAVE BEEN HELPFUL AS IT RELATED TO THE ADDITIVE EFFECT YOU MENTIONED?
Cooper states yes, it would have been.
Cooper is asked if she wanted to know about any other benzodiazepine that had been given to the patient. She states she would want to know about any medication that was given to the patient, including benzodiazepines and the propofol.
Cooper agrees had she known about the benzodiazepines and propofol, and knowing the additive effect she was aware of, that would have given her a fairly clear explanation of what had occurred.
Cooper agrees she assumed, as a doctor speaking to another doctor, that she was being told the truth by Murray.
Walgren completes his examination.
Flanagan declines the chance to further re-cross examine Cooper. Cooper is excused.