January 6th, 2011
THAO NGUYEN, M.D.--Cardiology Fellow at UCLA in Los Angeles. A Cardiology Fellow is a physician-in-training; Nguyen states she is to finish her "residency in internal medicine, then take a fellowship in cardiology". She states she is "4th year cardiology" and doing post-doctoral research as she is an M.D/PH.D, also known as a physician scientist. On 6/25/2009 she was the cardiology fellow responsible for cardiac intensive care at UCLA. At the time of her testimony (January 2011) she had been a cardiology fellow three and a half years--in June of this year she would have completed her cardiology fellowship and post-graduate doctoral research fellowships. She states she will stay on with UCLA as a clinical instructor.
DIRECT EXAMINATION: MR. WALGREN
Nguyen recalls on June 25th, 2009 she was a fellow and responsible for the cardiac care unit. She recalls being summoned to the ER by Dr. Richelle Cooper. Nguyen states Cooper is the attending physician for the ER. Nguyen recalls being introduced to Conrad Murray by Cooper in the ER.
Nguyen recalls approaching Murray for the purpose of asking about the situation and the patient. Murray told Nguyen he was the physician for Michael Jackson. He told her Michael was preparing for a concert tour in England, had been tired and had some difficulty in sleeping and required some medications for sleep. Nguyen states she had follow-up questions for Murray which included asking what Murray gave to Michael. Murray told Nguyen he gave 4 mg of Ativan (lorazepam), IV.
Nguyen is asked if she knew the condition of the patient. She confirms she knew. Based on the condition of the patient, Nguyen asked more questions. She asked Murray if he'd given any other medications besides Ativan, any other sedatives or narcotics. Nguyen states Murray's reply was, "no".
Nguyen asked Murray if he tried to reverse the effects of the Ativan. Murray's reply was "no".
(On a side note, Murray did apparently use flumazenil at some point which is the reversal agent for Ativan. Flumazenil was found in a syringe and in the terminal-end short tubing found at the residence. Whether any reached Michael's bloodstream or whether it was given when Michael was still alive is unknown.)
Nguyen then asked Murray what happened after he gave Michael the medication (Ativan). Nguyen states Murray told her he "later found the patient not breathing". Nguyen asked Murray when he found the patient not breathing and his reply was "he did not know the time". Nguyen asked Murray for an estimate of time as to when he found Michael in relation to when he had called 911 (correction, Murray did not call 911, Alberto Alvarez made the call to 911). Murray stated he "had no concept of time". Nguyen confirms those were in fact Murray's words in relation to the questions he was asked and not her opinions of Murray.
Walgren: SO HE WAS NOT ABLE TO GIVE YOU A TIME ESTIMATE?
Nguyen: ...AND HE DID NOT HAVE A WATCH AND DID NOT HAVE ANY CONCEPT OF TIME.
Nguyen confirms the statement above to Walgren.
(On a side note, Murray appears to have been wearing a watch when he arrived at UCLA that afternoon:
Nguyen again confirms Murray was unable to give her any estimate of time between when the drug was injected intravenously, to the time when he was found not breathing, or to the time in which 911 was called.
Nguyen recalls Murray asking her not to give up easily and to try her best to save the patient.
Nguyen states that is what was done on her behalf. Nguyen again confirms that Murray never mentioned any other medications other than Ativan (lorazepam). Nguyen states he did not mention anything about propofol or any other benzodiazpines (ex. midazolam or diazepam which Murray later admitted to administering during the night).
Nguyen states her team placed an intra-aortic balloon pump. She states a balloon pump is used for certain indications, such as in this particular case, for drug-induced cardiovascular failure, in order to decrease the work required of the heart and to increase the oxygen supplied directly to the heart. Nguyen adds it is a "last ditch effort". Nguyen states she did not have an optimistic view of the balloon pump working based on the observations and readings she had available to her. However, Nguyen states the balloon pump was utilized at the request of Murray to not give up easily. Nguyen states, BUT BEFORE INSERTING THE BALLOON PUMP, THERE WAS AN UNDERSTANDING THAT WAS MADE WITH DR. MURRAY THAT IF THIS METHOD OR MEASURE SHOULD FAIL TO REVIVE THE PATIENT, RESUSCITATE THE PATIENT SUCCESSFULLY, WE WILL CALL IT QUITS."
Nguyen states the balloon pump was inserted successfully but failed to revive the patient. Death was pronounced as a result of the failure to revive the patient.
Nguyen recalled glancing at her pager when she was questioning Murray about what had happened and what the time frame was concerning key events--the time was 1:35 p.m.
Walgren completes his direct examination. Recess was taken.
CROSS-EXAMINATION: MR. FLANAGAN
Nguyen is asked if she uses lorazepam in her practice (recall, she is a cardiology fellow and Murray is a cardiologist). She responds she does. Flanagan asks how long 4 mg of Ativan would keep at 136 lb. patient asleep and if it would cause him/her to sleep at all.
Nguyen states Ativan is a short or intermediate acting medication. She states it would take about 15 minutes or so (to sedate or taken an effect in the patient). The Court states he does not know what Flanagan means in terms of what type of effect the drug creates. Flanagan proceeds to ask more questions about Ativan (lorazepam).
Nguyen states it is a benzodiazepine. It is an anxiolytic or anti-anxiety drug. Nguyen confirms it is also used to induce sleep and can be used for insomnia.
Flanagan again asks how long this medication would work in a 136 lb. patient (Michael's estimated weight at the time of his death). Nguyen states the half-life of the drug is 14 hours but it is hard for her to give a duration of action as every patient is different--not just factoring in weight. Nguyen states someone who is used to receiving Ativan would likely respond differently than someone who is naive to the drug (someone who rarely takes or does not take the drug).
Nguyen clarifies that the half-life of a drug is the time it takes for the drug to drop to half of its initial concentration.
(On a side note, the half-life does not correlate to the duration of action for a drug).
Flanagan against attempts to get information from Nguyen about the effects Ativan would have on a patient of certain criteria (weight, sex, age, etc.). Nguyen asks Flanagan questions in an attempt to establish what kind of patient Flanagan is inquiring about during his cross-examination. Nguyen states she would want to know whether or not a person has been exposed to a benzodiazepine as it would not be her first drug of choice. She states there are other options besides benzodiazepines, especially for naive patients. She states benzodiazepines are known to have a high addictive (tolerance) potential so she would not want to create a larger issue (of tolerance) if the patient is not naive.
Flanagan asks Nguyen to assume she is to give Ativan to a patient for insomnia who weighs 136 lbs. but has no medical history (nothing else is known about the patient). Nguyen states she would start very low, with 1 or 2 mg orally. She states she would not use IV administration of the drug. She would wait to see if the patient received any benefits from the medication and if not she would advance to"a little bit more". She states she would not start off with 4 mg of Ativan IV.
Flanagan lets it be known that Murray states he gave 2 mg at one point and another 2 mg of Ativan at another point in time--not a total of 4 mg at one time.
Walgren objects--the Court states Flanagan may ask what was and was not told to her. Nguyen states she has not reviewed Dr. Cooper's report for this particular case.
Nguyen again states she would start out with 1 or 2 mg of Ativan in a 136 lb. patient (recall she would use oral administration and not IV). She is asked how long she would expect that amount of Ativan to induce sleep. She states again, it depends on the patient and the history, but would expect it to last a couple hours. She is asked what would occur if she used 4 mg. She states again she would expect it to work a couple hours, depending on the background history of the patient. She states if the patient is not naive to the medication and the same medication is used, one would need to reach a higher concentration to achieve the same effect.
Flanagan asks about blood concentrations of lorazepam. She states depending on the liver and the excretion, certain levels would be attained. She states she is not aware of the blood level in this patient.
Flanagan attempts to ask if Michael's blood level of 169 ng/mL would produce sleep. Walgren objects and the objection is sustained. Nguyen states they (physicians) do not typically order blood levels for Ativan. She reiterates this notion again with Flanagan's subsequent questions. She states in practice it is common to monitor for a clinical effect (what you physically see occurring to the patient) rather than using lab values to determine dosing. She further states that the same scenario exists for propofol use--a clinical effect is monitored rather than a lab value to determine how much of the medication should be given for the desired effect.
Flanagan asks about the term "no concept of time". Nguyen states this was not her wording but rather her recollection of Murray's words. She states again it was not her conclusion he had no concept of time but rather her recollection of Murray stating he had no concept of time.
Flanagan asks how Murray appeared at UCLA, as in terms of his emotional state. Nguyen said he appeared "devastated" based on his facial expressions. She states his voice was normal--she further states his voice appeared "calm" and she was able to have a "calm" conversation with Murray.
Nguyen states he appeared devastated simply based on his facial expressions. She is asked to compare how Murray looked at the hospital to how he looks in court. She states he is not talking in court, thus she cannot tell. She states there was no emotion on his face, she could not tell--she saw the emotion only when he was talking. She states it was his body language and verbal expression that led her to believe he was devastated.
Flanagan begins asking some of the same questions Walgren asked during the direct examination regarding what drugs were administered, what time they were given (to which Murray did not know what time he gave Ativan and could not estimate a time, either), the interval between when he gave Ativan and observed Michael not breathing (to which he could not give an estimate for, either). Flanagan asks Nguyen if she asked Murray if he could estimate within a scope of a couple hours to when anything occurred to which Nguyen replied "his answer was negative, he could not".
Nguyen recalled this conversation occurring at 1:35 p.m. via her pager. She recalls she was in the room with Michael, attempting to revive him. Flanagan asks how many doctors were in the room--she states she recognized Cooper but there could have been other unknown doctors in the room. Flanagan asks if there was a lot of confusion in the room to which Nguyen states there was no confusion in the room. Nguyen states there was "orderly activity" going on for the purpose of running the code (Code Blue). Nguyen recalls there maybe being 5 or 6 people in the room, at least, all having a role in the code.
Nguyen confirms her questioning of Murray took place in the same room in which Michael was in and being attended to by hospital staff. She states Murray was in close proximity to what was occurring in the room to Michael.
Flanagan asks if Nguyen thinks Murray had full concentration at the time he was being questioned by her. Her reply is, "YES. HE WAS NOT WATCHING THE PATIENT WHILE HE TALKED TO ME. HE ESTABLISHED EYE CONTACT WITH ME...THROUGHOUT THE CONVERSATION." She states the conversation took place over a "couple of minutes". She states the room was small and Murray was standing by the left leg of the bed right by Michael. Murray's back was to Michael. Nguyen was facing Michael.
Nguyen states her team member Dr. Cruz came to assist with the balloon pump. She states it was Cruz's idea to insert the balloon pump with her approval. Nguyen confirms there is no indication for a balloon pump to be used if the patient is without a pulse. She confirms they used the balloon pump though there was no pulse. She states they used the balloon pump "per request of Murray not to give up easily and the code was already ran and there was nothing else that could be tried except for that (the balloon pump)".
Flanagan: WOULD IT BE ACCURATE TO STATE THAT DR. MURRAY WAS ADAMANT. HE DID NOT WANT TO GIVE UP ON MICHAEL JACKSON?
Nguyen: HE DID NOT WANT US TO GIVE UP.
Nguyen states no drugs were used to reverse the Ativan by UCLA. Nguyen states, "BEFORE DECIDING NOT TO USE IT, I TURNED TO DR. COOPER AND ASKED HER, "HAS LORAZEPAM BEEN REVERSED?" SHE SAID, "NO." AT THAT TIME, BASED ON OUR ESTIMATE, THE WINDOW OF TIME THAT THE REVERSAL OF LORAZEPAM BY INJECTION OF FLUMAZENIL WAS ALREADY LOST."
Flanagan asks what that window of time is.
Nguyen: AS SOON AS THE PATIENT WAS FOUND DOWN, AT EARLIEST SIGN THAT THE PATIENT WAS IN DISTRESS. NOT WHEN THE PATIENT WAS ALREADY DEAD.
Flanagan asks if it was Nguyen's opinion that Murray did not give any flumazenil to Michael. She states it was her opinion, it was his answer to her (as well).
Nguyen states she has not read the autopsy report in this case. She also confirms Murray did not give the order for the balloon pump and he was not in charge at UCLA. Nguyen states it was not Murray's advice to put in a balloon pump--it was her (and Cruz's) decision. She confirms the indication could have been drug-induced cardiovascular failure, as in there was an indication in this case.
Flanagan tries to ask why Nguyen did not give flumazenil--Walgren objects. The Court states the evidence is being misstated and Nguyen has already indicated the patient was deceased and that is the answer as to why it was not given.
Flanagan attempts to state the balloon pump was to reverse the drug-induced cardiovascular failure. Nguyen states he is incorrect--she did not say that but rather she stated it could help in situations of drug-induced heart failure. She states it does not reverse the drugs-it only helps the heart.
Nguyen again states the reason reversal medications were not given is because the window of time had already elapsed. Nguyen states there was a window of time for the balloon pump, when there is still a pulse. However, she confirms there was no pulse.
(On a side note, it is accurate that balloon pumps are not used when there is no pulse. They do not make the heart beat but rather allow a beating heart to work less which gives it some sort of "break" with the heart continuing to beat the entire time. It appears the only reason a balloon pump was used in this instance was to pacify Murray's request for the team at UCLA "not to give up easily". Otherwise, there was really no indication for the balloon pump since Michael was without a pulse and in fact deceased on arrival.)
REDIRECT EXAMINATION: MR. WALGREN
Walgren asks for clarification on one of the answers Nguyen gave while being questioned about her hypothetical dosing of Ativan for a 136 lb. patient. He clarifies with her that "P.O." means to be taken orally. She confirms she would give the medication orally because it would be safer than giving it intravenously. Nguyen states there is no confusion as to what Murray told her in relation to what was discussed in court. She confirms she has a recollection of what Murray told her on June 25th, 2009. She confirms she was able to hear him clearly.
Walgren completes the redirect examination. Flanagan declines to re-cross examine Nguyen. She is excused.