Sunday, December 4, 2011

Discrepancies of the IV Stand

***Please note due to some personal issues my blog went on hiatus for some time--then I began a new job. Thus, I was not able to view all testimony from the trial or keep abreast with everything that has followed since the trial. I am waaaay behind. At some point I will go back and view expert testimony I missed as I will also view Conrad Murray's so-called documentary. In the meantime, I wanted to get this piece up that I began working in on October. There may be some information left out or "old"--but it can always be added in over a period of time and at least this portion will be a good start, I hope.***

One night it occurred to me that something is very wrong with the set-up of the IV found in the bedroom at Michael's home. For starters, it was moved at some point in time. Besides that, other things do not add up when one looks at this IV stand and what was connected to it at various times. This issue ties somewhat into the issue of was there a gravity-fed propofol drip or not (which will be covered later). I think the best way to describe the inconsistencies is to use verbatim witness testimony from January, not October, with accompanying photos from the trial. I know there may be some changes in what these witnesses said in the trial but I will cover any differences later when those transcripts are available. The main objective of this blog is just to visually see the changes that occurred with this IV and see there is inconsistency.


The following testimony is from Alberto Alvarez:

When Alvarez made it to the second story of the home he states of Murray:

Alvarez: I SAW DOCTOR MURRAY COMING FROM LIKE A HALLWAY, AND HE WAS WALKING IN TOWARDS THE ROOM, SIR.

He states Murray was in the "Landing Area" and walking towards the "Foyer Area". Alvarez states Murray was "walking"--not running--towards the room.

Click on the photos to enlarge them.



Alberto states the only equipment he saw was an IV stand and oxygen tank. He states it was located on the far side of the bed, by the nightstand and the chairs.

Walgren: OKAY. AND COULD YOU TELL AT THAT TIME WHETHER THE I.V. STAND HAD ANYTHING ATTACHED TO IT AND THEN ATTACHED TO MICHAEL JACKSON?

Alvarez: WELL, I DIDN'T LOOK. I JUST -- I NOTICED IT WAS THERE. I DIDN'T FOCUS ON IT UNTIL I WAS GIVEN, I WAS TOLD TO GRAB SOMETHING FROM THERE.

Alvarez states Murray removed vials from the nightstand and placed them in a clear bag that Alvarez grabbed, located in or by a chair. Alvarez states at this time Murray was kneeling, not standing. Alvarez was at the foot of the bed. Alvarez was then instructed to place the clear bag with vials into a brown bag that was to the left of a chair that was facing the bed, right at the bottom. Alvarez states there was a blue bag next to the brown bag.

Walgren: NOW IN REGARD TO THE I.V. BAG REMOVAL, CAN YOU DESCRIBE WHAT DOCTOR MURRAY SAID AND DID IN INSTRUCTING YOU TO REMOVE THE I.V. BAG FROM THE I.V. STAND?

Alvarez: YES, FROM HIS POSITION, HE POINTED WITH ONE HAND TO THE I.V. STAND AND HE SAID, "REMOVE THAT, REMOVE THAT BAG AND PUT IT IN THE BLUE BAG."

Walgren: AND DID YOU NOTICE ANYTHING ABOUT THAT I.V. BAG THAT CAUGHT YOUR ATTENTION WHEN YOU REMOVED IT?

Alvarez: YES, SIR. THE I.V. BAG WAS HANGING MORE OF EYE LEVEL AND SO AS I AM REACHING TO DISCONNECT IT FROM THE TOP OR UNHANG IT, I NOTICED AT THE -- AND INSIDE, THERE WAS LIKE A BOTTLE INSIDE THE BAG. AND I JUST -- I NOTICED THAT AND THEN I NOTICED THAT AT THE BOTTOM OF THE BAG, THERE WAS LIKE A MILK-LIKE SUBSTANCE, SIR.

Walgren: OKAY. SEPARATE FROM THE BOTTLE, YOU ARE TALKING ABOUT A LIQUID?

Alvarez: YES. IT WAS AT THE TIP OR AT THE BOTTOM OF THE BAG, SIR.
Walgren: AND WHEN YOU SAY "MILK-LIKE," DO YOU MEAN COLOR? CONSISTENCY?

Alvarez: IT LOOKED LIKE MILK.



Walgren: AND WHEN YOU REMOVED THAT I.V. BAG, IT APPEARED TO HAVE A BOTTLE INSIDE OF IT. WAS THERE STILL ANOTHER I.V. BAG HANGING FROM THE I.V. STAND?

Alvarez confirms there was another bag.

Walgren: OKAY. DID DOCTOR MURRAY EVER INSTRUCT YOU TO REMOVE THAT BAG?

Alvarez: NO, SIR.

Walgren: OKAY. ONCE THE 911 CALL WAS CONCLUDED AND THE 911 OPERATOR HAD ADVISED YOU TO GET MICHAEL JACKSON TO THE FLOOR, WHAT DID YOU DO?

Alvarez: I WENT AND, I BELIEVE, I SAID WE GET HIM TO THE FLOOR. AND THEN I GRABBED, I GRABBED MR. JACKSON'S LEGS. BUT AT THAT TIME, I DIDN'T KNOW HOW TO GRAB BECAUSE THERE WAS AN I.V. STUCK IN HIS LEG AND DOCTOR MURRAY PROCEEDED TO TAKE IT OFF WHEN HE SAW THAT I WAS HESITATING AND SO I GRABBED HIS LEGS, AND HE GRABBED THE UPPER PART OF HIS BODY. AND BY -- WHILE HE WAS REACHING FOR THAT, HE ALSO PUT THIS APPARATUS IN HIS FINGER. AND THEN WE PROCEEDED TO BRING HIM DOWN TO THE FLOOR.

This apparatus was a pulse-oximeter. Alvarez had not seen it placed on Michael before but had seen the device a few days prior as Murray asked for batteries for it.

Chernoff: IT (the IV) WAS STILL CONNECTED TO MICHAEL JACKSON WHEN YOU MOVED HIM?

Alvarez: PRIOR TO US MOVING HIM, MR. CONRAD MURRAY REMOVED THE I.V.

(You will later see this statement by Alvarez clashes with that of Richard Senneff.)

Chernoff: OKAY. SO, AND THIS WAS JUST RIGHT BEFORE YOU MOVED HIM DOWN TO THE FLOOR?

Alvarez: YES, SIR.

Chernoff: AND I ASSUME THAT YOU HAD TO MOVE THE I.V. STAND AS WELL SINCE IT WAS RIGHT THERE IN THE WAY OF WHERE YOU WERE PLACING MICHAEL JACKSON?

Alvarez: I DON'T RECALL, SIR, BECAUSE IT WAS A LONG, PRETTY LONG TUBE, CLEAR TUBE THAT WAS CONNECTED TO THAT I.V. SO THE I.V. WASN'T IN THE WAY. WE JUST BROUGHT HIM DOWN RIGHT BESIDE THE BED, SIR.

Chernoff: NOW THIS I.V. BAG THAT YOU TOOK OFF THE STAND, THE I.V. STAND, IT WASN'T SUCH -- WAS IT A SITUATION WHERE YOU COULD JUST QUICKLY REMOVE THE I.V. BAG? OR WAS IT SITUATED WHERE YOU HAVE TO, KIND OF HAVE TO TURN IT AROUND TO CURLY Q. IT ON?

Alvarez: THAT IS CORRECT. I HAD TO CURL IT AROUND BECAUSE IT WAS A LITTLE HOOK LIKE THAT. SO.

Chernoff: SO YOU CERTAINLY HAD A PERIOD OF TIME WHERE YOU WERE HOLDING THAT I.V. BAG, CORRECT?

Alvarez agrees.

Chernoff asks if it had any fluid in it.

Alvarez: VERY LITTLE FLUID AT THE BOTTOM. AND THE ONLY REASON I NOTICED IT WAS BECAUSE IT WAS UP TO MY EYE LEVEL. I NOTICED AT THE BOTTOM OF IT, THERE WAS THAT MILKY WHITE SUBSTANCE, SIR.

Chernoff: WE ARE GOING TO GET TO THAT, BUT WAS THE ONLY FLUID THAT SMALL AMOUNT OF FLUID THAT WAS GOING INTO THE CONNECTOR?

Alvarez agrees.

Chernoff: WHERE WAS THAT BOTTLE THAT YOU SAW INSIDE THE I.V. BAG?

Alvarez: IT WAS TOWARDS THE BOTTOM OF THE BAG, SIR.

Chernoff: AND YOU ARE SURE TODAY IT WAS INSIDE THAT I.V. BAG, RIGHT?

Alvarez: TO MY BEST OF MY RECOLLECTION, YES.

Chernoff: THE I.V. BAG THAT YOU SAY WAS LEFT ON IT, ON THE STAND WAS THE ONE THAT WAS CONNECTED TO MICHAEL JACKSON? YOU REMEMBER THAT?

Alvarez: YES, SIR.

Chernoff: OKAY. THE ONE THAT YOU TOOK OFF FROM THE I.V. STAND WAS NOT CONNECTED TO ANYBODY OR ANYTHING?

Alvarez: NO, SIR.

Chernoff asks if it was just hanging there and Alvarez states this is correct.

Alvarez did note that he recalled seeing an ambu-bag (he referred to it as a breathing apparatus and said it was on the floor). Though there are no photos of the vial in the bag as it was seen by Alvarez or Fleak, Fleak did retrieve this vial from the cut bag. Alvarez stated the propofol was secured in the IV bag and slightly diagonal. This could have contributed to some of the propofol in the corner of the bag though some appears to be on the outside of the bag as well.



See here for some additional photos regarding Alvarez.


Now, we move onto paramedic Richard Senneff and his testimony about the IV set-up:

Walgren: DID YOU SEE AN I.V. STAND OR I.V. KIT?

Senneff confirms he did.

Walgren asks where the IV was located.

Senneff: THAT WAS ON THE SAME SIDE OF THE BED BETWEEN THE DOCTOR AND ME, YEAH.

Notice that Senneff states the IV pole was located on the same side of the bed as the nightstands, or the left/far side of the bed.

Walgren: NOW, LET'S TALK ABOUT THE I.V. STAND. YOU SAW THE I.V. AT LEAST WHEN YOU ARRIVED, THE I.V. WAS HOOKED UP TO THE PATIENT?

Senneff agrees.

Walgren: DO YOU RECALL WHERE IT WAS HOOKED UP TO?

Senneff: I BELIEVE IT WAS HIS LEFT LEG ON THE CALF, ON THE INSIDE OF HIS LEFT CALF.

Walgren: DID THAT APPEAR TO BE HOOKED UP TO A STANDARD SALINE BAG OR I.V. BAG?

Senneff: YES, IT DID. I DIDN'T EXAMINE THE BAG, BUT AT A DISTANCE IT APPEARED TO BE A STANDARD SALINE BAG.

Now, Alvarez stated that Murray removed the IV when they moved Michael to the floor. Given the IV catheter was still in place, it seems Murray disconnected the IV tubing from the bag to the catheter only, not the catheter itself (at least, not at that point in time). At some point then, it seems Murray reconnected the IV tubing though there is an overlapping of when Michael was being moved to the floor by Murray and Alvarez and when paramedics arrived in the bedroom. Murray would have had to have reconnected the IV fairly quickly.

Walgren: WHEN YOU GAVE THE FIRST ROUND OF EPINEPHRINE AND ATROPINE, WAS THAT ADMINISTERED VIA THAT I.V. THAT HAD ALREADY BEEN IN PLACE OR A NEW I.V.?

Senneff agrees it was already in place.

Walgren: WAS THERE SOME TYPE OF, I GUESS, RESTRUCTURING OF THE I.V. PORT THAT NEEDED TO BE DONE TO MAKE YOUR EQUIPMENT COMPATIBLE WITH THAT I.V.?

Senneff agrees and Walgren asks for a explanation.

Senneff: THERE IS TWO SYSTEMS FOR ADMINISTERING MEDICATIONS THROUGH I.V.'S. IT IS WITH A NEEDLE AND WITHOUT A NEEDLE, COMMONLY REFERRED TO AS NEEDLE-LESS. IN THE PRE-HOSPITAL CARE SETTING, WE CHANGED OVER TO A NEEDLE-LESS SYSTEM YEARS AGO BECAUSE IT IS JUST TOO EASY TO STICK YOURSELF WITH A CONTAMINATED NEEDLE WHEN YOU ARE DRIVING DOWN THE STREET IN THE BACK OF AN AMBULANCE. THE DIFFERENCE IS YOU HAVE THE I.V. CATHETER, THE TUBE THAT IS ACTUALLY IN THE VEIN. IT HAS A LITTLE HUB ON IT, THEN THE PORT THAT GOES INTO IT. THAT IS THE DIFFERENCE IS THE TYPE OF PORT. A NEEDLE PORT HAS LIKE A LITTLE RUBBER STOPPER ON THAT YOU PUT THE NEEDLE IN THE CENTER. A NEEDLE-LESS HAS A VALVE INSIDE. YOU SCREW THE NEEDLE-LESS SYRINGE ONTO IT, AND THEN THAT RELEASES A VALVE AND YOU PUSH THE SOLUTION IN THEN YOU UNSCREW IT TO REMOVE IT. WITH A NEEDLE, YOU SLIDE THE NEEDLE IN, INJECT SOLUTION, AND SLIDE THE NEEDLE BACK OUT.

Walgren: JUST TO BE REAL SIMPLE HERE, WHEN YOU GET THERE, THERE IS AN I.V. BAG HANGING FROM THE I.V. STAND?

Senneff agrees.

Walgren: A TUBE IS COMING FROM THAT BAG, AND IT IS ATTACHED TO MICHAEL JACKSON'S LEG AREA?

Senneff agrees.

Senneff states the bag was connected to Michael but as will be pointed out after all testimony is covered, the bag found at the scene may not have had tubing attached to it.

Walgren: THEN OFF OF THAT TUBE AT SOME LOCATION IS A PORT ALLOWING FOR THE ADMINISTRATION OF DRUGS INTO THAT I.V. TUBING?

Senneff agrees. Senneff states it was a needle system kit when he arrived.

Walgren: SO WHAT WAS CHANGED TO ALLOW YOUR SYRINGES TO SCREW IN, TO BE ACCESSED VIA THE PORT THAT ALREADY EXISTED?

Senneff: WE REMOVED THE SALINE LOCK ITSELF OF THE PORT SYSTEM. JUST CHANGE IT OUT. LEFT THE HUB IN AND PUT A NEW ONE IN.

Walgren: WHILE LEAVING THE EXISTING TUBE, I.V. BAG?

Senneff agrees.

Walgren: JUST CHANGED OUT THE PORT?

Senneff: YES. THE PORT IS WHERE WE ARE GOING TO BE INJECTING OUR MEDICATIONS.

Senneff is asked how many rounds of epinephrine and atropine he gave in the IV catheter in the leg. He states two rounds of each medication.

Walgren: AT SOME POINT THEN AFTER THESE TWO ROUNDS, DID THE LEG I.V. -- WAS IT COMPROMISED IN SOME WAY?

Senneff agrees.

Walgren: DID YOU SEE HOW THAT HAPPENED?

Senneff states he did. Walgren asks what happened.

Senneff: WE HAD OUR MEDICAL KIT OPEN. WE REFER TO IT AS A STARTER KIT. IT HAD THE MEDICATIONS THERE, THE COMMON CARDIAC MEDICINE THAT EVERYBODY IS FAMILIAR WITH IN THE BUSINESS. DR. MURRAY TOOK SOME OF OUR -- TOOK SOME OF THE MEDICINE, AND HE USED THE I.V. PORT AND INJECTED INTO THAT. BUT HE IS USED TO A --

Walgren tells him not to speculate what Murray is used to and asks him what he saw. It seems Senneff was going to speculate Murray was accustomed to a needle-based system only rather than a needleless one.

Senneff: IN USING IT, HE PULLED IT OUT. HE PULLED THE I.V. OUT.

After Michael was transported downstairs, Senneff went back upstairs to retrieve equipment.

Walgren: WHEN YOU WENT BACK UP THE STAIRS TO CHECK ON YOUR EQUIPMENT, DID YOU SEE DR. MURRAY UP IN THE ROOM?

Senneff states he did. Senneff is asked what, if anything, was he doing.

Senneff: HE WAS STANDING AGAIN ON THE OTHER SIDE OF THE BED HERE BY THE NIGHTSTAND AND HE HAD A BAG. I WANT TO SAY WHITE, LIKE A PLASTIC TRASH BAG TYPE THING. HE WAS STRAIGHTENING UP, PICKING THINGS UP.

Senneff did not say what Murray was picking up as he was not focusing on him that intensely.

Low (former attorney): AS YOU ARE LOOKING AT THAT SCENE, WERE YOU ABLE TO SEE IF THERE IS ANY MEDICAL LOOKING EQUIPMENT ANYWHERE AROUND?

Senneff states he saw the IV pole with the saline bag.

Low: WHERE, IN RELATION TO THE PERSON IN THE ROOM, IS WHERE THAT I.V. BAG IS?

Senneff: IT IS ADJACENT TO THE BED, APPROXIMATELY WHERE THE PATIENT'S KNEES ARE.

Low: ARE YOU ABLE TO APPROXIMATE DISTANCE INSIDE THE BEDROOM OR FROM THE PATIENT?

Senneff states it was within a foot.

Again, Senneff locates the IV was by the bed.


Paramedic Blount also gave his account of what he saw regarding the IV set-up"

Blount: HE SAID THAT THE REASON WHY THE PATIENT HAD THE I.V. BAG ATTACHED TO HIS LEG WAS BECAUSE HE REHEARSALED THE NIGHT BEFORE. HE WAS EXHAUSTED.

Blount also confirms an IV was attached to Michael as well.

Blount: IT WAS, I THINK IT WAS A HYPODERMIC NEEDLE HE CAME OUT WITH, AND IT WAS LIKE A BLUE COLOR. AND HE SAID, "YOU SHOULD BE ABLE TO USE THIS HERE." AND I THINK WE ALL SAID, NO, THAT IS OKAY.

This remark by Blount is a bit odd to me given it seems Murray had items, such as needles, directly on him, such as his pockets.


Michael was taken to the hospital. Coroner investigator Elissa Fleak went to the house that evening and spent about 80 minutes collecting evidence, mostly looking for "pills" as she stated. She did see the IV stand but did not pay any special attention to it at that time. It was not until June 29th, 4 days later, that the IV pole and what it contained was on it was inventoried.

Fleak: THE STAND IS THE METAL POLE WITH THE HOOK AT THE TOP. SALINE BAG IS HERE. THERE IS TUBING DOWN TO THIS AREA WHERE THERE IS A FORK OR A CLAMP IN THE TUBING WHICH HAS A SYRINGE IN IT THEN TUBING CONTINUES DOWN AND IS CLOSED.

Fleak states she entered the IV bag and IV kit into evidence on June 29th, 2009.

She states there was liquid in the IV bag.

Flanagan: AND THIS I.V. BAG HAD SOME TUBING COMING DOWN FROM IT?

Fleak agrees. However, photographs seen below would question her agreement to this statement:



Flanagan: IN THAT TUBING, THERE WAS A SYRINGE?

Fleak: HALFWAY DOWN THE TUBING, THERE WAS A CLAMP, A V-SHAPED CLAMP AND IN ONE OF THE HEADS OF THE CLAMP THERE WAS A SYRINGE. IT WAS NOT DIRECTLY IN THE TUBING.

Fleak is the first person to mention a syringe connected to the IV tubing, in any form. Recall Senneff stated that some portion of the tubing also had the valve changed from one that required a needle to one that did not. The syringe was connected to the tubing via the Y port built into the tubing using a needle. We know this syringe contained flumazenil, propofol and lidocaine as did the distal, short end of the tubing.





Fleak states she cannot recall if the tubing below the Y port had liquid in it but did recall clear liquid in the tubing above the Y port. She also states the bag was clear--no white substance. She states the IV bag appeared to be 3/4 full, 1/2 to 3/4 full when hanging.

Walgren: DID YOU ALSO RECOVER -- EXCUSE ME -- WAS THERE ALSO AN I.V. STAND WITH AN I.V. KIT ATTACHED TO IT AT THE SCENE?

Fleak: YES, THAT WAS IN THE ROOM. IF YOU ARE FACING THE BED, AT THE FOOT OF THE BED IT WAS TO THE RIGHT, TO YOUR RIGHT.

Walgren: IF YOU ARE AT THE FOOT OF THE BED LOOKING TOWARD THE HEAD OF THE BED, IT WOULD BE TO YOUR RIGHT?

Fleak: TO YOUR RIGHT.

Now we see at some point the IV stand was relocated. See the photo below to get a general idea of where the IV was at one point versus where it was later moved.









The golden curtains with the photo of a child in the chair is situated directly across from the bed. If you were lying in the bed, and lifted up, that is what you would see. If you looked to the left, that is where the IV pole had been moved, close to a set of drawers with photos. The chairs were between the bed and the closet/bathroom.

Criminalist Jaime Lintemoot examined the IV equipment and provided a diagram show below:



Walgren: BUT THIS IS A BASIC DIAGRAM OF THE I.V. KIT, INCLUDING THE I.V. BAG, AS WELL AS THE ACCOMPANYING I.V. PLUG, TUBING, THUMB CLAMP, WHITE CLAMP, A Y-FORK, AS WELL AS THE SYRINGE, AND THE SHORT TUBING?

Lintemoot agrees.

Walgren: LET'S JUST BEGIN THEN WITH ITEM "A" SHOWN IN THE TOP LEFT PORTION OF YOUR DIAGRAM. WHAT IS THAT?

She states item A is a diagram of the IV bag. She states it was not attached to the rest of the system at the time she received it for analysis. The particular bag used by Murray came from a company called Hospira. I called Hospira to ask if once a bag was spiked, would it leak once the spike was removed. Hospira confirmed that it would leak all contents once the spike was removed from the bag. Thus, it seems this bag seen by the paramedics, Fleak and Lintemoot was never spiked with IV tubing. Rather, the bag with the propofol bottle enclosed had been spiked and used for saline administration sometime prior to Michael's death, as well as prior to being slit and having a bottle placed in it. Recall that no propofol was found in the long tubing--only the short tubing which also had a syringe hanging out of it when found by Fleak. There was no mention of a syringe by Alvarez, Senneff or Blount.







Walgren: ON YOUR DIAGRAM THEN IN THE LOWER LEFT CORNER, THERE IS A LEGEND INDICATING WHICH ITEMS OR WHICH LABELS APPLY TO WHICH ITEMS?

Lintemoot agrees.

Lintemoot agrees to Walgren's reading of the the key or legend to her diagram. "B" is the syringe--consisting of barrel, plunger and needle. "C" is the "Y" connector. Lintemoot states she does not know if it was plastic or not.

Walgren asks for Lintemoot to describe the syringe and "Y" connector.

Lintemoot: IT WAS A "Y" CONNECTION PIECE. THE SYRINGE WAS GOING INTO ONE END, A PIECE OF SHORT TUBING COMING OUT THE OTHER END, AND A PIECE OF LONG TUBING GOING INTO THE THIRD END.

Lintemoot agrees that "D" is the short tubing that lies below the "Y" connection.

Walgren: AND THE SHORT TUBING THEN PROCEEDS TO "E," WHICH YOU LABEL AS CLEAR TIP. WHAT IS THAT?

Lintemoot: IT WAS A CLEAR TIP THAT HAD A LITTLE BIT OF RED FLUID OR RED STAINING ON THE END OF IT.



Lintemoot confirms "F" is the long tubing.

Walgren: WITH THE "Y" PORT OR THE "Y" CONNECTOR, YOU HAVE A SHORT TUBE COMING OUT OF THE BOTTOM, THE SYRINGE GOING IN THROUGH THE TOP, THEN YOU ALSO HAVE THE LONG TUBING COMING OUT THE THIRD AND FINAL PORT; IS THAT RIGHT?

Lintemoot agrees.

Lintemoot states "G" is a white clamp attached to the tubing and "H" is a white thumb clamp.

Lintemoot states "I" is an "IV bag plug" and describes it:

Lintemoot: IT WAS A CYLINDRICAL PIECE THAT THE LONG TUBING WAS ATTACHED TO WITH A SPIKE ON THE END. TYPICALLY, IT GOES INTO THE I.V. BAG.

It seems Lintemoot is actually referring to the spike and drip chamber as an IV bag plug which is something else which will be covered here shortly.

Lintemoote then covered the following:

Propofol and lidocaine were contained in 0.19 g (approx. 0.2 mL) of fluid from the syringe on the nightstand.

Propofol, lidocaine and flumazenil were contained in 0.17 g (approx. 0.2 mL) of fluid from the syringe connected via needle to the "Y" connection.

Propofol, lidocaine and flumazenil were contained in 0.47 g (approx. 0.5 mL) of fluid from the short IV tubing.

No medications were detected in 17 g (or about 20 mL) from the long IV tubing or 0.38 g (about 0.4 mL) of fluid from the saline bag.


Given the descriptions above along with the photos provided--the IV found in the bedroom at Carolwood was altered at some time by someone. Was it altered by Murray as Michael was being taken downstairs by paramedics? Was it altered by someone other than Murray? I am not sure. I can say that with the syringe being placed in the tubing as it were--it almost seems as if that was planted there as a distraction. Now, this would go against Murray wanting anyone to know he had ordered propofol, but propofol in the IV does not mean that Murray ordered, either. It could, however, have been a useful way to try and say Michael self-injected something. After all, Murray initially tried to claim Michael had his own supply of propofol which is a lie. I already covered in a previous blog the evidence excludes the possibility of Michael self-injecting anything on June 25th.

I know the experts during the trial (Drs. Shafer and White) battled it out over whether or not there was a drip utilized. However, this syringe found would seem to indicate that boluses, either with a drip or without one, were used. Why this was not highlighted clearly, I am not sure. Perhaps it is because boluses would place a person there witnessing any arrest whereas a drip would not (hence, the "involuntary" charge). At some point soon I hope to cover everything the experts said as I think both men should be given credit for their years of study though that does not mean everything stated by them is necessarily fact. With Murray being the only one who knows the truth--all anyone can do is try to guess at what he did to the victim, the victim being Michael in this case. I hope Murray thinks about releasing some details after his stint in jail--even if it is pointing the finger at others (besides Michael), maybe a portion of it will be true given he will be angry after some time that he is the only one who had to be "punished".

Sunday, October 16, 2011

Seacoast Medical Orders by Conrad Murray

This will be another blog in progress, which means it will be updated over time as more information become available as we only have bits and pieces as it stands right now.

I thought it would be a good idea to post up photos of some of the items we know Murray ordered (or attempted to order as some items were on back-order and cancelled) and how they may or may not have pertained to Michael's death--or to just give everyone a general idea of what they may be in this case. This information here will play a part in my next blog where I will be discussing the IV found in the bedroom.

For this blog, I will be covering the items Murray ordered from Seacoast Medical.

Below are copies of *some* of the orders from Seacoast from the trial. Some may be duplicated and some may be missing as well; information regarding dates that is currently known or thought to be known will be provided at the end of this blog:



























For some of the items that are not easily understood, I will briefly explain what they are and provide a photo if available. I was able to trace back to the manufacturer what was exactly what through Seacoast's online product inventory--if you have any questions of how I was able to do this for verification purposes as I do not mind my work being checked, please ask:

#101143 Sodium Chloride Bacteriostatic 0.9%, 30 mL, 25 vials
--this is normal saline (0.9% NaCL or salt), "bacteriostatic" means it contains preservatives and can be used multiple times vs. using a vial only once, this could be used to dilute medications, like IV lorazepam

#002366 Welch Allyn Cuff, etc. and #002672 Aneroid Access
--these are both components to a basic blood pressure cuff, with accessories

#105777 Medex Injection Adapater, etc.
--photo provided below; this adapter is an IV tubing extension--it would connect via Luer Lock and provide for administration via a syringe and needle into IV tubing



#106091 Medex T Connector, etc.
--photos provided below; this is an IV extension kit that has a syringe w/ needle valve (the top port) and a Luer Lock connection as well (bottom port, this would connect to an IV catheter, for example); Murray had one of these, unused, in one of the bags he placed in the closet





#309578 BD 20 G X 1" 3CC Syringe/Needle
--these are 3 mL syringes that come with a 1 inch, 20 gauge needle

#011281 Medex Jelco IV Catheters Radiopaque 24G X 3/4"
--these are IV catheters that are inserted into a vein to administers medications and IV fluids; the larger the gauge of a needle, the smaller the needle actually is (inversely related)

#???483 Syringe 10CC Luer Lock Needle 22G X 1"
--these are 10 mL syringes, with Luer Lock (twist on rather than push or snap on) needles attached, 22 gauge, 1 inch long

#???068 3G Latex Free Glove, Large

#007774 Exel IV Administration Sets, 15 drops/mL, 50 per case
--this is the IV tubing featured below and what was found in the bedroom









#013452 QMS Exam Table Paper
--this sounds like office supplies to me--odd to be ordering it when a doctor is rarely present and his office is ran by non-medical staff

#106176 Avalon Exam Cape Disposable
--appears to be more office supplies

#105884 QMS Exam Gloves Vinyl, Medium

#105883 QMS Exam Gloves Vinyl, Small

#105841 Dukal Alcohol Prep Pads
--these are like the alcohol pads used before you insert a needle into the body

#009737 Starline Gauze Sponge 4" X 4"

#011611 2-Ply Fanfold Drape Sheet
--again, appears to be more office supplies

#798302 Sodium Chloride (IV) 0.9%, 250 mL bag, 48 bags ordered
--these are 250 mL normal saline bags

#798309 Sodium Chloride (IV) 0.9% 1000 mL bag, 24 bags ordered
--these are 1 liter saline bags; apparently Murray ordered some bags from Seacoast and some from Applied Pharmacy Services as well

#007827 Exel Luer Lock Syringes, 10 CC, 100 per box
--these are 10 mL syringes, using Luer Lock, but did not come with accompanying needles

#103483 Syringe 10 CC Luer Lock Needle, 22G X 1", 100 per box
--these apparently go to the syringes mentioned directly above, 22 gauge, 1 inch long

#007853 Exel Hypodermic Needles, 18G X 1 1/2", 100 per box
--these are additional needles, not sure if they are Luer Lock or not, 18 gauge, 1 1/2 inches long

#????85 QMS Exam Gloves Vinyl, Large

#102902 Blood Pressure Device, Child
--this is a child's blood pressure cuff; adult cuffs were ordered as well

#103293 3M Transpore, 12 per box, 1" X 10 yards
--this is basic medical tape

#103653 Tourniquets, Latex Free, 10 per bag

#011287 Medex Jelco IV Catheters, Radiopaque 22G X 1", 50 per box
--these are IV catheters that are inserted into a vein to administers medications and IV fluids, these are slightly larger than the 24 G (22 G are blue, 24 G are yellow)





#103747 Starline Prem. Blood Pressure Unit, Black, Latex-Free Adult
--this may be the one that was located in the bedroom, apparently unopened and unused

#??5914 Kendall Tendersorb Underpads
--these are the "chux" pads or padding that was on the bed, for incontinence

#??6613 External Catheter--Medium (Condom Catheter) and #004241 Tegaderm Transparent Dressing, 2 3/8 inch X 2 3/4 inch
--photo provided below (these would not be used together, to save time I included them together in the photo; the Tegaderm dressing could be used to help keep IV catheters in place



#??6653 External Catheter, Small, 30 per box

#??4839 Leg Bags for Catheters, Medium, 12" extension tubing, 17 oz.

#???466 Ambu-Bag w/ Adult Mask, 1 ordered
--photo provided below; apparently Murray had this very important piece of equipment but did not care to use it as he used mouth-to-mouth resuscitation instead--an ambu-bag, oxygen or not, is a better method



#????66 Berman Airway 6, Single-Use Kit
--photo provided below; these are disposable airway kits, only 2 were ordered and apparently no such set was at the house on June 25th; commonsense should tell anyone that if you are thinking you need something like this for a regimen for sleep, then something is wrong



#309650 BD Syringes, 30CC, 40 syringes
--these are 30 mL syringes, no needles provided

#005667 Chester Ultrasound Gel, 5 Liters w/ 8 ounce bottle
--given Murray is a cardiologist, this gel would be used to do echocardiograms in the office; an echo tech may do the echo (this requires training) but a doctor needs to review the echo to determine if there is a problem or not

#103568 Cardiosens Electrodes Disposable Ultra II Tabs, 500 per box
--photo provided below; these are the pads that connect to wiring which connects to an EKG machine--something Murray obviously had at his disposal but failed to use to keep Michael alive (though again, if you are needing something like this to treat insomnia, something is wrong)



#009729 Starline Brand Gauze, 2" X 2"

Oddly enough, Murray claims in the LAPD interview that he kept those 3 bags found by Fleak regularly at the house, and in the closet per Michael's request. Though he had plenty of medications, used and unused--he apparently did not have spare condom catheters, spare IV tubing, more normal saline bags for rehydration, etc. I also wonder--where was some of the trash? Where are the syringes that were used to administer midazolam and lorazepam? Where is the old IV tubing, where are the old IV catheters, where were used needles? Why were only vials of medications kept by Murray? Did the LAPD examine any trash in the home, did Murray or others take any items as they left the house? What about the fireplace in the master bedroom--did Murray have access to this room and is there any evidence anything was burned in the fireplace?



Now, I missed this critical testimony myself but thanks to my "research family" I was able to get some information about these orders though it needs to be thoroughly reviewed when transcripts are made available to the public. Most videos on YouTube have cut a majority of critical testimony that was shown on TV. If you can add any information to the information below, please do.

Murray had apparently opened an account with Seacoast in 2006. He ordered some lidocaine through the company and he had possibly ordered pumps AND/OR IV pump tubing usually used with pumps in July 2007, October 5th 2007, June 24th 2008 and then attempted to request Safsite IV tubing March 25th but it was not in stock. He attempted to order it via the manufacturer but his credit card was denied.

This is the image of what I believe he attempted to order on March 25th (#105778 SAFESITE HORIZON PUMP IV SET 24/CASE, Manufacturer #SS3140 via B Braun Medical) , though there is a mismatching of the names of this product--I matched the manufacturer numbers to come up with this:



Possible Order Dates:
April 14th (3 pages)
May 12th--Exel IV sets purchased (notice this is after the May 10th recording though who knows what Murray really had collected overtime)
May 19th
June 1st (this order included the ambu-bag and 2 airway kits)
June 15th--talks with Connie Ng about urine catheter supplies, she attempted to order but not available (Connie Ng inquired with Seacoast for all purchases)
June 17th--follow-up conversation, but out of stock
June 22nd--invoice for catheters, small, shipped that day, leg bags not shipped (however a wrapper with medium sized catheters was found at the house and apparently some bag was used)
June 26th--at 9:26 a.m. PST Connie Ng cancelled back orders and asked for a refund

Seacoast would not allow items to be shipped to a house in California--items had to be shipped to the office in Las Vegas (this was attempted on April 13th only)

I realize there is some confusion regarding the condom catheters so if someone can add more information, please do.

QUESTIONS:

Had Murray ever actually ordered an IV pump or was it just IV tubing typically used in a pump? WHY? To the best of my knowledge a cardiologist does not need tubing or especially an IV pump in their office. Did he order any lidocaine while treating Michael? I never saw any on the invoices. He did order some medium-sized condom caths--when? I saw the order for small condom caths and medium bags as well--so out of this, what all did Murray get and not get and when?

Again, this blog will morph over time and/or be added to as time progresses as more information is obtained or understood so stay tuned.

Wednesday, October 12, 2011

Is Propofol Safe for Sleep?

Is propofol safe for sleep? Simply put, the answer is no. However, there is a study that was published online in November 2010 entitled "Propofol-Induced Sleep: Efficacy and Safety in Patients with Refractory Chronic Primary Insomnia".

Here is a link to the study so you can read it yourself and I urge everyone to read it carefully as it does contain some great insight into insomnia and how it is conventionally treated (and how many conventional treatments fail):

http://www.springerlink.com/content/q1383124j665v845/fulltext.pdf

The study was done in China on patients who were considered to have "refractory chronic primary insomnia". This means these patients do not have any underlying causes for their insomnia (ex. sleep apnea or bad habits), they have it continuously and conventional treatments have failed them. A friend of mine who is a nurse told me there is no listing for "refractory chronic primary insomnia" in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders) so I am not sure if people can be diagnosed as having such or if this type of insomnia was coined specifically for this study. Regardless, the study states 30-40% of adults suffer from insomnia and that is a considerable sum of people who suffer from this ailment.

For the clinical trial there were 103 participants--64 received propofol and 39 received saline. I am not sure how much (milligrams) each patient received but the study states the 64 who received propofol received propofol at a concentration of 3 g/L. This seems to indicate propofol was diluted as it is typically in a concentration of 10 mg/mL which is also equal to 10 g/L. The study states, concerning administration, "the protocol for propofol administration was based on our earlier study according to some clinical parameters such as age, weight, liver function, renal function, etc." I have not been able to locate this study yet (the name is included in the study as a source) and have attempted to email the professor who did this study to see just exactly how much propofol was received by these patients as I am very curious to know. Anyhow, those who received propofol received a 2 hour infusion at rate based on the guidelines from a previous study, starting at 10:00 pm each night, for 5 nights.

The patients had their brainwaves monitored and also filled out questionnaires that were used to determine if the propofol had made any improvements in sleep on the first morning after the last treatment and 6 months later as well.

According to the questionnaire that patients took part in, those who received propofol were more likely to report improvements in how long it took them to fall asleep, their quality of sleep, their ability to wake up after sleeping and what waking up in a better mood. These improvements were still evident 6 months later as well. Individuals who received propofol also reported longer sleep times, faster times at falling asleep and fewer awakenings during the night.

There are four stages of non-REM (NREM) sleep and then there is REM sleep, which is the deepest state of sleep and the most restorative. According to this study, Stage I NREM was shortened with propofol, Stage II NREM was unchanged, and there was an increase in NREM Stage III, IV sleep as well as REM sleep. Stage I NREM is the lightest level of sleep while Stage IV is heavier.

For those who received propofol, there were few reported adverse events. Four said they experienced somnolence during the morning after treatment, two reported being dizzy and two had mild nausea. There were no reported issues 6 months later.

The researchers who conducted this study state they believe that propofol may be able to restore sleep homeostatis after sleep deprivation. This would seem likely given positive results even 6 months later.

The study closes with the following paragraph:

Future studies on the efficacy and safety of propofol induced
insomnia should be aimed at confirming these findings in a multi-center cohort study. Since our study participants did not suffer from an ongoing psychiatric or medical condition, it would be useful to know whether propofol-induced sleep would be therapeutically beneficial in such patients who also suffer from insomnia. Lastly, the results of this study also calls for further investigation on the mechanism of propofol action on the attenuation of the sleep debt in patients with refractory chronic primary insomnia.


The article also mentions that they believe they are the first to demonstrate propofol-induced sleep is a safe and effective alternative treatment for patients with this kind of insomnia.

Now--with all that being said, I think it is important to distinguish how this study does NOT relate to anything Conrad Murray did to Michael Jackson.

1. This study was the first of its kind--this means there were NO studies for Conrad Murray to base his "treatment" on for Michael. This study was published almost 18 months after Michael was killed. Murray is not an anesthesiologist, neurologist or a sleep specialist. He is nothing as far as I am concerned.

2. Though we do not know exactly what Murray did to Michael as far as what all he administered, how he administered it and when he administered it, in this particular study propofol was only used for 5 days from 10:00 p.m. until midnight. That is a total of 10 hours of propofol use for the entire treatment. Whatever Murray was doing lasted far more than 10 hours and Michael was obviously having adverse effects that were lingering into his rehearsals.

3. This clinical study took place in a clinic--not a home setting.

4. Propofol was administered continuously with a micro-infusion pump--not a gravity-drip device with a roller clamp, as Murray had ordered supposedly for rehydration.

5. Blood pressure was continuously monitored.

6. An EKG, or the heart rhythm, was constantly monitored.

7. Oxygen saturation was constantly monitored.

We can gather from this study that someday, with more research, propofol may be useful to those who are healthy and have insomnia that is not successfully treated with conventional methods. Does this mean that Murray was right in what he did? No. Does it mean propofol can now safely be used for insomnia? No. Does it mean it will ever be safe to use for insomnia? No. There is too much that needs to be learned before such a leap is made. There are still no excuses for what Murray did and absolutely no justification in his actions, be it administering propofol or simply refusing to administer appropriate aid to his patient. Murray's actions continue to baffle even the most seasoned of medical professionals. No one can put a direct finger on what exactly he did to Michael--but as Dr. Alon Steinburg said today in court--Michael Jackson was savable. He should have been saved but for whatever reasons, he was allowed to die. Many of you reading this hurt from Michael's death and though we may see Murray found guilty there is still a huge knife in our hearts because we do not know why he had to die or how he died. Yes, we have a cause of death but we do not know how it came about and that for me is painful, especially knowing that the man who sits in court everyday looking like a clown yet not shedding a tear (except for the first day when the discussion was focusing on him) knows what happened and why but is not talking and will never talk if he has it his way. Well, he will talk but it will not be the truth.

The following articles remind us of why propofol is not currently used for sleep and why it would never be used for sleep in a home-setting:

http://sciencelife.uchospitals.edu/2009/07/31/propofol-a-dangerous-kind-of-rest/

Though the following study does not promote or detest the use of anesthetics for sleep it is a fascinating read that discusses how general anesthesia is basically synthetic brain-stem death rather than sleep:

http://isafars.org/uploads/anjoman/General%20Anesthesia%20NEJM%202010.pdf

We can gather in the propofol for insomnia study that propofol was not used like it is for general anesthesia--a key indication of this is the lack of intubation in those patients who received propofol. However, it is important to remember that there is a fine line between the different stages of sedation (from consciously sedated to general anesthesia), especially when using propofol. Because of that, precautions will always need to be put in place, just in case. As the Boy Scout motto says--"be prepared".

Monday, October 10, 2011

Lorazepam

I want to rehash some basic information that toxicologist Dan Anderson provided during his testimony last week about lorazepam. Though he stated he could not determine whether or not the elevated blood level of lorazepam was from oral or IV administration, he was clear in stating there were no tablets in the stomach and the level of lorazepam was high, but not toxic. The defense's argument that Michael took eight 2 mg tablets of lorazepam then quickly gave himself propofol and then died... instantly... actually died instantly with Anderson's testimony. That is the point I want to bring home in this blog.

First, here is some numbers for lorazepam (Ativan) for oral vs. intramuscular (IM) vs. intravenous (IV) administration:

Oral: onset of action--~30 minutes; time to peak (drug concentration)--~ 2 hours
Intramuscular: onset of action--~20-30 minutes; time to peak (drug concentration)--~1-3 hours
Intravenous: onset of action--~5-20 minutes; time to peak (drug concentration)--~10-20 minutes


Peak time for amnesic effects for oral is 60 to 90 minutes.
Peak time for amnesic effects for intravenous is 15 to 20 minutes.

The maximum recommended dose for insomnia is 4 mg--ORAL only unless a patient is NPO (nothing by mouth) in the hospital--then IV may be used.

All methods above have effects that last approximately 6-8 hours. Oral lorazepam is slightly less potent than intramuscular and intravenous (90% bioavailablity). Bioavailability of 90% means that an oral dose is roughly 90% as effective as an IM or IV dose. Or, think of it as taking a 1 mg tablet and 0.9 mg of that tablet being "active" lorazepam.

An IV 4-mg dose provides an initial concentration of approximately 70 ng/mL.
An oral 2 mg dose provides an initial concentration of approximately 20 ng/mL.

Michael's blood level was around 160-170 ng/mL. Therapeutic levels are listed as 50-240 ng/mL (most sources state therapeutic can be as low as 10 ng/mL and anything over 300 ng/mL is toxic). As you can see from this data, it is impossible that Michael was given only 2 mg of IV lorazepam twice by Murray, especially not with the last 2 mg dose being at about 5:30 a.m. This blood level does not tell us how the drug was administered but given it takes some time for an oral dose to get distributed into the body (see the times above) it is impossible this blood level was the result of oral administration within minutes of death. There were two 10 mL vials of lorazepam used (these vials were either 20 mg or 40 mg each, depending on the concentration which I do not know at this time but will hopefully know soon). Murray admits to giving IV lorazepam and was there at the house--why would Michael need to take anything oral or even IV with Murray there? There was no reason, to make it simple.

Doses of 8 mg to 10 mg of intravenous lorazepam (2 to 2-1/2 times the maximum recommended dosage) will produce loss of lid reflexes within 15 minutes. I simply found this interesting though it may not relate to this case. However, it tells us how sedated one can become on doses similar to that in Michael's body. Tolerance or not, 10 mg should have had some effect on him, especially if Murray is being honest and said he slept fine the night before on benzodiazepines only. There is no such thing as physical withdrawal of propofol so Murray's claim that the benzodiazepines did not work the next day because of "propofol withdrawal" is fallacious based on the lack of physical withdrawal of propofol and the inability to build a tolerance to benzodiazepines within a day, too. Once again, Murray is lying.

So how did the lorazepam end up in the stomach?

There is a process some drugs undergo called "ion trapping":

http://en.wikipedia.org/wiki/Ion_trapping

Simply put, some drugs that are basic or alkaline (pH greater than 7) tend to go to acidic places in the body. The pH of the stomach is typically around 1-2 which means it is very acidic. Thus, it is natural for some lorazepam to essentially leech from the blood and into the stomach. I like to think of this as "opposites attract"--if something is basic it will look for an acidic environment--if it is acidic it will look for an alkaline or basic environment (ex. the bladder can be an alkaline environment if the urine is basic). Anderson explained this in very simple terms and also explained that given the amount found in the stomach, though four times the amount found in the blood, it amounted to 1/40th of a tablet of lorazepam. This is not equal to oral ingestion of lorazepam tablets.

Below is a snapshot of Anderson's math in which he derived his amount of propofol in the stomach:



There we have it--Michael did not die from the ingestion of lorazepam tablets, be it 1 or 8 tablets. One question that lingers is--where are the syringes used to give lorazepam and midazolam? I have always assumed Murray may have reused the syringes he had and the leftover amount of benzodiazepines were eradicated with reuse of the syringe for propofol administration or too low to detect after reuse. I would also think it is possible he tossed them in the garbage or possibly tossed them in the fireplace that was on in the master bedroom--a fireplace on in late June, mind you. Investigators did not search the house very well or close it off so that leaves the pursuit of justice with a lot of gaping holes.

To tie all this together, propofol begins to work in less than a minute and depending on the dose, wears off in usually less than 15 minutes even for large doses. Regardless of the method of administration, lorazepam takes at least 5 or so minutes, minimum, to begin working. That means the administration of these drugs, if given around the same time, should never be at peaks "together" unless lorazepam is already at a high level (which would likely indicate sedation) when propofol is administered. That would indicate someone other than the person sedated would have to administer propofol for both of these drugs to be at such high levels in the body, with the lorazepam being administered first since it takes longer to become active. For there to be additive effects, which were mentioned in the autopsy report, the lorazepam should have been having an effect on the patient (sedation, possibly breathing problems, etc.). People do not typically die from benzodiazepine overdoses but giving lorazepam with propofol in a setting with no airway or respiratory assistance--you are basically asking for someone to stop breathing and die.

In closing, here is a warning that is quiet visible to anyone who reads about lorazepam:

AIRWAY OBSTRUCTION MAY OCCUR IN HEAVILY SEDATED PATIENTS. INTRAVENOUS LORAZEPAM AT ANY DOSE, WHEN GIVEN EITHER ALONE OR IN COMBINATION WITH OTHER DRUGS ADMINISTERED DURING ANESTHESIA, MAY PRODUCE HEAVY SEDATION; THEREFORE, EQUIPMENT NECESSARY TO MAINTAIN A PATENT AIRWAY AND TO SUPPORT RESPIRATION/VENTILATION SHOULD BE AVAILABLE.

On June 25th, 2009 Conrad Murray had nothing with him to treat airway obstruction in Michael while he anesthetized him as a way to treat insomnia and though Murray had an ambu-bag he refused to use it, opting for mouth-to-mouth, one-handed, in the bed CPR. He did not even have a pulse oximeter on Michael. How could someone entrusted to take care of someone be so damn careless for another person's life?

Friday, October 7, 2011

The IV Bag--Photos

This blog will be a work in progress...

The following photos were taken by Elissa Fleak on June 25th, 2009:





The following is a photo from June 29th, 2009. Fleak also took this photo and stated that LAPD moved the syringe--it was not moved between the time she saw it on June 25th to June 29th.

Thursday, October 6, 2011

Conrad Murray's Medical Records for Michael Jackson





11/19/08:
Insomnia/Anxiety
Prescriptions:
Xanax 0.5 mg--Take one tablet by mouth every 6 hours (cut off)
Restoril 30 mg--Take one tablet at bedtime as needed

9/26/08:
Insomnia
Restoril 30 mg (cut off)--no refills

2/1/08:
Cough, nasal congestion, (cut off, but possibly says "chills")
generalize(d) fatigue, all (cut off)
Assessment/Plan: upper respiratory infection/(cut off, possibly "viral")
increase fluids (drink more fluids)




4/12/07:
Onychomycosis (spelling) -- Lami (cut off, but states Lamisil)
for 3 months, check liver function tests after 1st (month)
may take 6 months - 12 months
(Liver function tests are done when taking Lamisil because it has caused fatal
cases of liver failure.)

3/07 (not day given):
"M" -- cough, chills, (cut off)
with intermittent specs of blood (cut off)
Phlegm greenish brown
Pleuritic chest pain with cough (cut off)
lower rib cage
chest x-ray positive for right lower lobe pneumonia













"Omar Arnold", 49 years old
(Notice a date is present on one document and not any of the others though these appear to be the same document, appears to the one date is 1/24/06 but is likely 1/24/08, as he was 49 years old then, however it looks more like a "9" rather than "8" for the year)
Complain of weakness, body aches, persistent cough
with mild yellowish phlegm, ??? fever chills ???
have been fever, ???
children have same symptoms, ???
well. All ???
consuming liquids. No ??? loss of appetite
negative for chest pains

(The middle and lower portion of this document is sadly too blurry for me to make out at this time.)

Assessment:
Dehydration from decreased fluid intake
???
???
??? vitiligo (spelling?)
Plans:
Fluid hydration (cut off)
???
2
Benoquin 20% cream (cut off)
apply twice to ???
Youth Essense
Allergies -





Arnold, Omar (MJJ)
"M"
cough, chills, productive cough with intermittent
specs of blood with deep coughing ???
???, general weakness, pleurtic chest ...
cough worst on right lower rib cage
chest x-ray--positive for right lower lobe pneumonia/???
small ??? of pleural fluid with ???
Plan:
1. Omnicef 600 mg one a day
2. Z-pack
3. Lortab (for pleural pain and cough)





Omar Arnold
1/11/06 (date appears to be incorrect)
Cough, chills, fatigue, (cut off)
??? otherwise (cut off)

(This sheet also states Michael was negative for orthopnea and edema--possible signs of heart failure. This sheet appears to be one that Murray used for his cardiac patients.)




Michael
1. Robitussin AC--1 to 2 teaspoons every 4-6 hours as needed for cough
2. Omnicef 300 mg--Take one by mouth twice a day for 7 days
3. Nasonex--one puff (in each nostril) daily for 5 days, then as needed if sneezing and congested.





Prescription written on 2/10/07:
Youth Essence Moisturizing Cream--SPF 30









11/13/07

Page 1:
...tion of the posterior horn of the medial men...
subluxation of patella, with knee in neutral...
effusion, small Baker cyst with slight leakage...

Page 2:
Fluid without focal erosions or degenerative
...angular fibrocartilage tear or per
...fluid, ??? greater