Murray Trial Day 11, October 12 2011
Dr. Alon Steinberg Cardiologist Testimony
Steinberg is a board certified cardiologist for 13 years. He is not an expert in anesthesia, sleep medicine, pharmacology or addiction medicine.
Steinberg has reviewed CM's resume. CM was not board certified on June 25th 2009. Steinberg tells board certification is an extensive 2 day test and 90% of the cardiologists that take it pass it.
Steinberg is an expert reviewer for the California Medical Board, he reviews other doctors' actions to ensure the standard of care has been respected. 3 levels are possible: no deviation, simple deviation and extreme deviation. Extreme deviation is also defined as gross negligence.
Steinberg has conducted a review for this case. He had conducted 8 prior reviews. In 4 cases he found no deviation; in 4 cases he found simple deviation of care. This is the first time he's seen an extreme deviation from standard of care.
Cardiologists use sedation for many procedures and sometimes they use Propofol. Cardiologists are expert in mild or moderate sedation. In conscious sedation the patient is able to talk and respond to touching. Deep sedation is when patients are only responsive to pain or repeated stimuli. General anesthesia is when patients feel no pain. Cardiologists are not trained in deep sedation. When deep sedation is needed, they call anesthesiologist and that’s the only time they use Propofol.
When they are giving mild or moderate sedation they use benzodiazepines. For deep sedation they are required to give Propofol with an anesthesiologist.
Steinberg has reviewed this case. He has focused his review based on CM interview with police. Steinberg wanted to judge CM on his own words.
Steinberg found 6 separate extreme deviations from standard of care.
1: Propofol was not medically indicated. Steinberg mentions Propofol is an anesthesia. Steinberg tells there was no written informed consent. The patient must be informed of the risks and benefits of treatment. Steinberg never heard of Propofol used for insomnia. Steinbers says that using propofol for insomnia is gross negligence and extreme deviation.
2: Propofol was given in a home setting, without proper equipment and without proper staff.
Walgren asks what equipment needed. Steinberg says that first a pulse oximeter with an alarm is needed but Murray's oximeter didn't have an alarm. Steinberg says he had to stare to MJ nonstop every second. Steinberg says he should have automated blood pressure cuff, to check blood pressure at least every 5 minutes. Murray had a manual cuff and did not use it. Next thing is needed is an EKG monitor to track the heart rhythm. Another thing that is needed is oxygen with a nasal cannula or mask. You need suction in case the patient regurgitates and you need to get it before it goes into patient’s lungs. Another equipment needed is an Ambu bag. Murray had an Ambu bag but did not use it, he did mouth to mouth. You also need to have a way to call for help. Backboard is needed in case CPR is needed. You also need a back up battery for the equipment in case of a black out. Other equipment needed is equipment needed for airway such as endotracheal tube. Endotracheal tube requires trained staff to place it. Also you need a defibrillator.
A lot of special drugs are also needed. Those are fluamzenil, narcan, lidocaine, betablockers, atropine, dopamine, epinephrine, prednisone, dextrose.
Steinberg says when giving sedation you also need BLS (basic life support) and ACLS (advanced cardiac life support) trained assistant.
3: Inadequate preparation for an emergency. You need to have the drugs ready, equipment ready, have a person ready to help you. You need to be prepared to use those medicine and equipment in the case of emergency.
4: Improper care during the arrest. MJ’s breathing had stopped and CM didn't follow proper protocol.
Steinberg explains cardiac arrest which is when heart stops beating. There’s no blood pressure and the patient collapses. In that case you call 911, use a defibrillator, and do CPR on a hard surface.
In MJ's case, it was a respiratory arrest. MJ stopped breathing and the oxygen goes down. Then heart started to beat harder while trying to distribute little oxygen in the body. According CM’s statement this is where CM found MJ. If you do nothing, the heart weakens because of lack of oxygen, and stops contracting but there is still an electrical activity. That’s PEA (Pulseless Electrical Activity). After PEA, there's asystole.
Steinberg says CM should have called 911 immediately then try to arouse MJ, should have used the Ambu bag and give him Flumanezil. Steinberg says it’s inexcusable that CM did chest compressions. This was a respiratory arrest not a cardiac arrest and there was blood pressure and pulse. CM should NOT have done CPR.
CM’s CPR was poor quality because MJ was on a bed. It has to be done on a hard surface such as on the floor and should have done CPR with 2 hands. Steinberg says it would have been very easy to put MJ on the floor.
5: Failing to call for help. CM should have called 911 immediately. CM should have known that he didn’t have any of the medications and the equipment and he had to call for help. But CM instead called MAW which caused a significant delay. EMS was only 4 minutes away. If CM had called them he could have gotten help sooner.
For every minute delay in calling EMS, there are less and less chances the patient will survive and there is a risk of permanent brain damage. Walgren: “Every minute counts”.
Steinberg also thought it was bizarre to call an assistant instead of calling 911. CM as a medical doctor should have realized he needed help and call 911.
6: Failure to maintain proper medical records. Medical records are important because of several reasons. Insurance companies want them. Second reason is litigation. The most important reason is for better health care for the patient. CM did not document a single thing. He didn’t ask when the last time MJ ate was, he had no vital sign records, he had no physical exam. There was no informed consent. He didn’t write what medication he gave and what was the reaction. CM was confused and was not able to explain MJ's history or what he gave him to the ER doctor or EMTs. Walgren asks if he could be dishonest rather than confused.
Steinberg concluded that these extreme deviations directly contributed to MJ's death. Without these deviations, MJ would still be alive.
Walgren asks based on CM’s statement if he gave benzodiazepines and only 25mg Propofol if the risk of respiratory depression is foreseeable. Steinberg answers yes.
Walgren assumes everything happened as CM described and as CM left MJ alone, MJ was able to take Lorazepam pills or Propofol. Steinberg says all the things he said still apply. Steinberg says you never leave the patient and always monitor patient. If MJ self administered, means that Murray was away, and that should not have happened. Steinberg compares leaving a patient under the effect of Propofol to leaving a baby sleeping alone on the kitchen counter. Steinberg says the baby might have woke up and fall down.
Steinberg also mentions that medication should not have been within MJ's reach. Steimberg explains how in hospitals every medication will be under lock and says that having medications out in the open is a foreseeable risk that the patient can self administer and take the wrong medication.
Mid morning break.
Steinberg is not currently trained in using Propofol. When Steinberg was NY he had privileges to use Propofol. In his current work he does not have the privileges and he hasn’t used it in 7 years. When he was in NY he felt confident in using Propofol because he was trained in protecting airways.
Flanagan asks if there is a difference in the equipment needed for moderate and deep sedation. Steinberg answers no, they will be the same.
Flanagan asks if Steinberg thought CM's declaration to the cops was thorough and complete. Steinberg says he assumed it was complete.
Flanagan asks how Steinberg knows CM didn’t have informed consent. Steinberg says because there was none. Flanagan asks if the informed consent can be oral. Steinberg says it has to be written. “If it's not written it's not done.” Steinberg says he has never heard an oral consent. Flanagan asks if any written document had anything to do with MJ’s death. Steinberg says if MJ had been informed about risk and benefits, he might not have agreed to this.
Steinberg says he cannot know if MJ had been informed, but assumes he was not informed that a powerful dangerous drug would be used on him without proper monitoring. Steinberg assumes MJ would not have agreed to it.
Flanagan asks if Steinberg know anything about MJ's propensity towards drugs and mentions Demerol and Klein. Flanagan asks what if MJ was an addict; would he have agreed to it? Steinberg says if he was an addict, he wouldn't give it to him in the first place.
Other doctors that use Propofol could be dentists, gastroenterologist, pulmonary doctors, ER doctors. But their societies have advice on how to use it and they are trained. Their societies outline the same monitoring equipment that Steinberg mentioned. Steinberg says there’s no difference in equipment needed for conscious sedation.
Flanagan asks what killed MJ? Steinberg says a respiratory arrest because he still had a pulse that means there was a heart rate and blood pressure. CM said there was blood pressure and pulse, it was later PEA.
Steinberg says that according to CM he found MJ around noon and EMS arrived at 12:26. There was a delay in calling 911 for at least 12 minutes. Flanagan mentions CM made a lot of time estimations and it might be all precise.
Flanagan asks what 2mg of Lorazepam would do to a patient. Steinberg says he’s not an expert, he gave it as a sedative orally before but he never used IV. Steinberg says he gives it an hour before the procedure orally. Flanagan asks further questions about Lorazepam, Midazolam. Objections. Sustained. It’s beyond his area of expertise.
Flanagan turns the subject to Propofol and say that MJ and CM had been discussing Propofol for the past 3 night and CM told MJ it was not good for him and he was trying to wean MJ off.
Steinberg states that CM said that he gave 25mg initially and started MJ on IV. Flanagan denies that there was an IV. Steinberg understood that after that initial 25mg dose, there was a drip based on his police interview. Steinberg cites a lot of examples in CM interview referencing IV and says it makes sense because 25mg would not keep MJ asleep.
Flanagan insists there was no drip on the 25th, Steinberg insists there was a drip, they both give examples in CM's LAPD interview. They agree it's not clear, but Steinberg says it makes no sense. It's logical CM gave a drip. MJ logically would have woken up, and there was no reason that CM changed his methods.
Flanagan says that 25mg is not a heavy dose and it would make MJ sleep 4 to 7 minutes. Steinberg agrees. So Flanagan asks if MJ was still asleep he was sleeping for other reasons such as being tired. Steinberg says that he would have worried that MJ was still asleep if MJ was not on a drip. Protocol says that after Propofol you should watch the patient. Steinberg says just looking at MJ doesn't tell if he's in mild sedation or in deep sedation. Steinberg says they need to be continuously checked for their reaction to stimuli. Steinberg says CM should have woken MJ up. Steinberg says the fact that MJ was still asleep after 10 minutes, if there was no drip, is very alarming. Steinberg it might mean that something was going wrong.
Flanagan mentions a study that Propofol was successfully used on refractory chronic primary insomnia in Taiwan. Steinberg says that the article dates back to 2010, in 2009 when CM gave propofol there was no medical knowledge that Propofol could be given for sleep. CM was unethical in giving Propofol with no medical knowledge. Article mentions Propofol given for 2 hrs per night 5 nights, not 8 hours per night for 2 straight months. The article says that this test was successful, but it's still not used as a sleep medication because it's still experimental, there is not enough data about this. It needs to be extensively researched and tested. CM is the first doctor he's heard who used propofol for insomnia.
Flanagan asks how Steinberg knows CM didn't use Ambu bag, Steinberg says because CM said he did mouth to mouth. Flanagan asks how Steinberg knows CM didn’t use the blood pressure cuff, Steinberg says because it was not on MJ. Steinberg says pulse oximeter was not on MJ.
Steinberg says he doesn’t know what happened between 11 and 12 or how long CM watched MJ or when CM went to bathroom. Flanagan asks if he has an idea about the actual time of death. Steinberg says MJ was pronounced dead at 2:26PM but he was probably clinically dead for some time.
Steinberg says MJ savable when CM found him based on his interview. Steinberg says CM said he left MJ for 2 minutes. By using Ambu bag, by arousal and changing the effects of the medicines and if 911 was called MJ was savable.
Flanagan tries Steinberg to assume that CM was gone longer than 2 minutes. Steinberg is not comfortable making those assumptions as he based his report on CM’s statements. Flanagan mentions the phone calls; Steinberg does not want to comment on them. Steinberg says saying CM was on the phone tells him that CM shouldn’t have been on the phone and if MJ would only given 25mg it would wake him up. Steinberg says that it tells MJ was on a drip.
Flanagan wants him to assume if CM was gone longer than 2 minutes if MJ was savable. Steinberg says he was savable because according to CM’s statement MJ had a pulse, blood pressure and heart was still beating and with proper equipment he could have been saved. He could have given MJ oxygen. Steinberg says MJ wasn’t PEA when CM came back because he had a pulse. Flanagan asks how he knows know MJ had a pulse, Steinberg says because CM said so. Flanagan asks if it could PEA. Steinberg says in PEA there’s no pulse.
Flanagan asks what CM should have done. Steinberg says he should have called 911 and it would have taken 2 seconds. Steinberg says protocol says doctors are allowed 2 minutes to determine the situation. Flanagan asks if CM went down to ask for help in 12:05 – 5 minutes after – if it would be a violation of standard of care. Steinberg says he didn’t have the right equipment so he should have called 911 immediately.
Flanagan tries to talk about Kai Chase. Steinberg says CM didn’t ask Kai to call 911. Flanagan asks what if CM called for help in 5 minutes but not in 2 minutes. Steinberg says it’s still a deviation from standard of care.
Flanagan asks if he talked to CM to review the case. Steinberg says no and he didn’t ask. Steinberg used CM’s 2 hour interview.
Flanagan asks what CM should he have done in 2 minutes. Steinberg says call 911, tilt the head to open airway, make him breathe with Ambu bag and give Flumazenil. Steinberg says he would have called 911 first. Steinberg says CM had to increase MJ’s breathing.
Flanagan asks if CM make a mistake in asking someone to call 911 Steinberg says he had no one around and he had to call 911. Steinberg says for the time it takes to call for security CM could have called 911. He had a cell phone. Steinberg says it would have taken him 2 seconds to say “I’m a doctor, there’s an arrest, come to 100 Carolwood now” and then CM could have put 911 on loudspeaker and continue to do what he was doing.
Flanagan asks if he’s aware that EMS said MJ was cool to the touch. Yes but CM said he was warm. Steinberg says you get cold in 26 minutes when you have no blood pressure.
Flanagan asks if Steinberg have no doubt that if 911 had been called immediately MJ would still be alive. Steinberg says he have no doubt about that, they could have saved him. CM said that he lost the pulse after calling MAW at 1212. So if the paramedics had been there at 1205 or 1210, they could have saved him.
Flanagan says that CM was in emergency situation and he could be mistaken in his estimations. Steinberg says there is clear evidence that there was a delay in calling 911 as CM went downstairs and called MAW rather than calling 911.
Flanagan asks based upon these facts if Steinberg thinks CM is responsible of MJ's death. Steinberg says yes.
Flanagan asks if CM should have dropped MJ on the floor, in spite of the IV line. Steinberg says he should stop the Propofol drip first and then he should be careful with the line when he’s putting MJ down the floor.
Flanagan asks rather than suction would it be okay to turn patient his side and clean the mouth with a finger will be okay. Steinberg says suction is needed.
Flanagan asks if a doctor has only 1 patient, he would still need to document everything he does. Steinberg says he does because obviously CM didn't recall what he had given when he talked to UCLA or with the paramedics.
Flanagan says that not having records did not kill MJ. Steinberg says it wouldn’t cause his death but it’s still deviation.
Lunch break .
Murray Trial Day 11 , October 12 2011
Steinberg states that Murray did not act like he was ACLS certified.
Steinberg states that he used propfol in New York, but it was in hospital settings.
Steinberg states that gastroenterologists, dentists and ER doctors who use propofol receive appropriate training, with a trained staff and appropriate monitoring equipment are necessary.
Steinberg states that an article about the propofol study in Taiwan : published in 2010, was an experimental study. The patients were given propofol in a hospital , with the appropriate equipment, the experiment was approved by their ethics committee. Steinberg states that written, informed consents were obtained from the patients. Steinberg states that 8 hours of fasting occurred prior to being given propofol, and that the propofol was given by an anesthesiologist. Steinberg states that the patients were constantly monitored and pulse oximeters were attached to the patients. Steinberg states that the propofol was administered by an infusion pump, a drip was not used. Steinberg states that no other benzos were used. Steinberg states that the authors of the article specifically state that the study was experiment, and that is does not dictate a standard of care. Steinberg states that what Murray was doing was essentially an experiment.
Steinberg states that if he had to assume that Murray gave only 25mg, that there was no drip, would he draw the same conclusions? Steinberg states yes, that standard of care was deviated from in an unmonitored setting, without appropriate equipment, response was inappropriate, medical records were inappropriate and that it was be a foreseeable prediction that there would be respiratory depression (stop breathing).
Steinberg states that Murray played a direct, causal role in MJ's death.
Steinberg states that the sleep study showed that propofol helped insomnia.
Steinberg states that in his analysis for the CA medical Board, that Murray deviated from the standard of care for MJ.
Steinberg states that the lack of a backup battery did not lead to the cause of MJ's death, however, 5 out of 6 deviations did lead to MJ's death.
Steinberg states that he did read Murray's interview with LAPD that he gave MJ propofol for 40-50 days without incident. Flanagan asks if Steinberg has made certain assumption, Steinberg states no. Steinberg states that he didn't assume that Murray gave propofol, that Murray didn't have the proper equipment, the delay in calling 911, improper care during the arrest, that all of these things are facts.
Steinberg states that even if the defense theory that MJ self-injected propofol and therefore accidentally killed himself, according to Conrad Murray's own words, Murray would still be the causal factor in MJ's death.
Dr. Nader Kamangar/ Sleep Medicine Expert Testimony
NK states he is a pulmonary care/sleep medicine/critical care physician at UCLA. NK states he is board certified in four areas: internal medicine, pulmonary medicine, critical care, and sleep medicine.
NK states he is a medical reviewer for the CA Medical Board , and that he assessed Murray's care to MJ for the medical board. NK states that is propofol used in critical care unit on a daily basis. NK states he is trained in using propofol. NK states propofol is used for placement of endotracheal tubes, and for people on breathing machines. NK states that propofol is the most commonly used drug for this.
NK states that he found multiple deviations of standard of care with regard to Conrad Murray's care of MJ :
1. Propofol was given in an unacceptable setting : using this deep sedation agent in a home setting is inconceivable and an egregious violation of standard of care.
2. ACLS certified : the person who gives propofol must be trained in ACLS and airways management. There was a risk of hypoventilation (diminishment in rate of breathing), apnea and obstruction of the airway.
3. Need of assistance : Murray needed a second person (a nurse) to monitor, to pay complete and utter attention to MJ, especially if Murray was going to leave the room; this goes without saying. This violations Hippocratic oath, to abandon his patient.
4. Pre-procedure setup : imperative to be prepared for unforeseen circumstances. Things can change very quickly. A patient may look good, and the next minute there's a problem. Murray needed a suction catheter, because patients can regurgitate into their airway, and block the airway, this can cause death. A crash cart (medication on hand : adrenaline, ephedrine, medication to correct the heart beat, etc...) , pulse oximeter, defibrillator, automated infusion pump (precise dosing for propofol) even with people who are intubated;
NK states that all of these factors are extreme deviation of standard of care and are the equivalent of gross negligence.
NK states that he has never seen someone giving propofol at home in such settings, and would not have expected to see that.
5. Charts / medical documentation : or medical history, reactions to a medication. For example a blood pressure can look normal, but not be normal for a particular patient, and that change in blood pressure could be the indication of a problem.
6 . MJ was left alone, which is not acceptable, especially since Murray didn't have the right equipment.
7. Use of benzodiazapines: using lorazepam and midazolam on top of propofol can have higher effects : more significant respiratory depression, decrease cardiac output (often a consequence of respiratory depression), decreased blood pressure and cardiac arrest can occur directly, or because of low levels of oxygen.
8. Dehydration : blood circulation is not good when you are dehydrated , causes low blood pressure. Benzos and propofol would also lower blood pressure . Murray should not have used benzos or propofol if the patient is dehydrated.
9. Failure to call 911 : 911 should have been called immediately.
10. Improper CPR : Murray stated there was a pulse, therefore the heart was beating, so the problem was respiratory not cardiac. Murray should have dealt with airway management by placing an ambu-bag over MJ's mouth. Murray's administration of CPR was ineffective; it was not on a hard surface, and it was done with one hand . Correct CPR correctly allows about 20% of the normal blood circulation, so if you do it incorrectly
NK states that assuming Murray found MJ at noon, and calls MAW at 12:12 pm, the significance of the 12 minutes is that the what is the lack of blood flow to vital organs, especially to the brain. NK states that some individuals are more susceptible than others to a lack of oxygen. NK states that generally it takes 3 to 4 minutes before brain cells start to die. NK states that time is really important. NK states that because 911 was called at 12:20 pm, with the passage of 20 minutes, it reaches a point where it becomes irreversible.
NK states that Murray Deceived paramedics and ER staff because did not provide the accurate information, which is a deviation of standard of care.
NK states that Murray did not properly evaluate insomnia. NK states that insomnia can have many causes, so it's important to have a detailed history. NK states that Murray needed to exclude secondary problems (psychological problems, substance abuse, underlying conditions, chronic anxiety, depression , etc...)
NK states that insomnia is defined by no restful sleep for 4 weeks or more. NK states that once all the secondary problems are ruled out, primary insomnia is considered.
NK states that in order to diagnose/treat insomnia. a detailed sleep history is needed. : when do they go to bed, when do they fall asleep, when do you wake up, etc.. check sleep apnea. In some cases you need a sleep study.
NK states that a detailed pharmaceutical history was needed; both prescribed or over the counter (example migraine pills contain caffeine, that can cause insomnia), illicit drugs.
NK states that a detailed physical examination was needed; some underlying conditions can cause insomnia, for example asthma, congestive heart failure, diabetes, bladder problems, enlargement of prostate, thyroid conditions, etc..
NK stated blood testing was needed to rule out certain conditions : examples diabetes, kidney problem, restless legs , etc..
NK states that a good blood workup would reveal the use of narcotics, if the doctor asks the patient for one. NK states that if the patient is not giving the information, a doctor can simply refuse to treat the patient.
NK states that when all the above mentioned are done, then the doctor can treat the underlying condition that causes the insomnia.
NK states that in this case , Murray didn't have a detailed history. In addition, Murray didn't check what the root problem for MJ's insomnia was before treating him.
NK states that Murray did say that he saw that other doctors were treating MJ, he said he saw IV sites. NK states that if Murray could not get that info from MJ, Murray should have refused care, refused to give further medication. Murray didn't do that, and that was unethical.
NK states that Murray bypassed the evaluation of insomnia, bypassed the detailed history which was a deviation of care.
NK states it was obvious there was probably secondary causes in MJ's insomnia (substance abuse or anxiety or depression ) and that these underlying causes should have been treated.
NK explains about sleep hygiene techniques that can help in case of insomnia (using a bedroom to sleep only, among other things)
NK explains about sleep restriction, that the doctor should tell the patient to go to bed later , and limit their time in bed.
NK states that relaxation techniques can be used to treat insomnia.
NK states that all these can usually work better to treat insomnia than pharmacological approach, but that the pharmacological approach can also be used.
NK states that Murray did not use any of the above approaches on MJ, that Murray went direct to the pharmacological approach.
NK states that the pharmaceutical approach : 3 medications that are not benzos should be used first, because they are not addictive . NK states that a newer drug is melatonin something less addictive.
NK cites 4 different benzodiazepines that deal with insomnia. NK states that others are used also, but their main goal is to treat underlying conditions (anxiety). They are used in tablet form.
Midazolam : not appropriate for long term use for primary insomnia
Valium : not appropriate for long term use for primary insomnia
Lorazepam : can be used on short term basis, tablet form. Really addictive after 3 to 4 weeks. Used to treat underlying conditions, not primary innsomnia.
NK states that the use of midazolam and lorazepam to treat insomnia was an extreme deviation of care, especially in IV form.
NK states that it is inconceivable to use propofol for the management of insomnia, regardless of the setting. NK states that it is "beyond comprehension, inconceivable and disturbing." NK states that it is beyond a departure of standard of care, especially when underlying causes for insomnia were not treated.
NK states that even if MJ took lorazepam and propofol himself, Murray was the causal factor in MJ's death, especially if MJ had substance abuse problems. NK states that the lorazepam and the propofol should not have been readily available to MJ.
NK states that there is a risk of respiratory complications, especially if MJ was dehydrated, and that any competent doctor would have been aware of the risk.