People v. Murray

2011 manslaughter trial in California
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People v. Murray
CourtLos Angeles County Superior Court
Full case namePeople of the State of California v. Conrad Robert Murray
DecidedNovember 7, 2011
VerdictMurray found guilty of involuntary manslaughter
Case history
Subsequent action(s)Murray was sentenced to four years in prison; he was released on October 28, 2013 after serving 1 year and 11 months.
Court membership
Judge(s) sittingMichael E. Pastor

People v. Murray (The People of the State of California v. Conrad Robert Murray) was the American criminal trial of Michael Jackson's personal physician, Conrad Murray, who was charged with involuntary manslaughter for the pop singer's death on June 25, 2009, from a dose of the general anesthetic propofol.[1] The trial, which started on September 27, 2011, was held in the Los Angeles County Superior Court in Los Angeles, California, before Judge Michael Pastor as a televised proceeding, reaching a guilty verdict on November 7, 2011.

The prosecutors in the case, David Walgren and Deborah Brazil,[2] both Los Angeles deputy district attorneys, in their opening statement told jurors, "misplaced trust in the hands of Murray cost Jackson his life." Murray's defense counsel (Edward Chernoff, Matthew Alford, J. Michael Flanagan and Nareg Gourjian) claimed Jackson, who was tired and under pressure from rehearsing, took eight tablets of lorazepam (Ativan), a sedative. "When Dr. Murray left the room, Jackson self-administered a dose of propofol that, with the lorazepam, created a perfect storm in his body that ultimately killed him. The whole thing is tragic, but the evidence is not that Dr. Murray did it", Chernoff said.[3] Testimony during the trial showed Murray stayed with Jackson at least six nights a week and was regularly asked—and sometimes begged—by the singer to give him drugs powerful enough to put him to sleep.

Murray told authorities Jackson was especially eager to be administered propofol, a surgical anesthetic that put him to sleep when other powerful sedatives could not. Testimony indicated that propofol, in conjunction with other drugs in Jackson's system, had played the key role in his death. In 2011, the jury found Murray guilty after about eight hours of deliberation,[4][5][6][7][8] and he was sentenced to four years in prison, but was released after one year and eleven months on October 28, 2013, owing to prison overcrowding and good behavior.

Timeline of prosecution case

September 27, 2011: Day 1

Both sides made opening statements. The jury viewed a photograph of Jackson lying on a gurney, taken minutes after he was declared dead. The jury also heard a tape of Jackson's slurred speech near the end of his life. Murray's attorney told the court that Murray is not to blame for Jackson's death, that Jackson gave himself a dose of drugs that killed him so quickly Jackson "didn't even have time to close his eyes." "What happened during that time frame is that the acts and omissions of Michael Jackson's personal doctor Conrad Murray directly led to his premature death at age 50," prosecutor Walgren said. "That misplaced trust in Conrad Murray's hand is the cause of Michael Jackson's death." The first witness, Kenny Ortega, was called to testify.[9]

September 28, 2011: Day 2

Michael Amir Williams, known as Jackson's personal assistant, testified.[10]

September 29, 2011: Day 3

Two former members of Jackson's staff, bodyguard Alberto Alvarez and Chef Kai Chase, took the stand. Alvarez was the first person into Jackson's bedroom after Murray raised the alarm. He indicated that Murray asked him to place vials from Jackson's bedside cabinet in a bag and remove an IV drip (containing saline solution) from its stand and what appeared to be a propofol bottle, according to Alvarez), before Murray asked him to phone 911.[11]

September 30, 2011: Day 4

Bob Johnson, owner of a company that manufactures pulse oximeters, testified first. The next witness was a former patient of Murray's, Robert Russel from Las Vegas. The third witness was the first paramedic to enter Jackson's house and bedroom, Richard Senneff. The fourth witness was paramedic Martin Blount. Dr. Richelle Cooper, an emergency room physician at UCLA Medical Center, testified fifth. Although not pronounced dead until sometime after reaching the hospital (2:26 pm),[12] the paramedics never saw any signs of life from the time they first entered Jackson's bedroom (12:26 pm).[13]

October 3, 2011: Day 5

Cooper continued testifying. According to Cooper, drugs including intravenous sodium bicarbonate, vasopressin, epinephrine, atropine, and dopamine were used during the attempted cardiopulmonary resuscitation of Jackson in the trauma bay of UCLA Medical Center. From the time Jackson was under the care of Cooper until Jackson's death was pronounced, continuous chest compressions and "bagging" were conducted via an endotracheal tube.[citation needed]

Cooper testified that Jackson was clinically dead upon arriving at the hospital, and that Murray had told her he had given Jackson 2 mg of lorazepam (a benzodiazepine) sometime earlier that day, then another 2 mg, which caused the cardiac arrest. During cross-examination, Cooper was asked about the effect of propofol as a sedative. She said about a "milligram per kilogram" would be the starting dose on a patient and would be administered into the patient's arm through an injection port. The administration would take place over a period of "a minute to a minute and a half," and personnel would constantly monitor the patient. She further testified that sedation would be expected to last 10 minutes. When asked what effect "25 mg over 3–5 minutes" would have on a patient, she responded that she would not expect that to have any effect. When asked about administering propofol through an IV drip, she said that only occurs if the patient is intubated and the desired effect is deep sedation.[citation needed]

Next to the stand were employees from phone companies AT&T and Sprint Nextel, who were asked to guide the jury through the meaning of various data on Murray's phone records from June 25, 2009.[citation needed]

Dr. Thao Nguyen, a cardiologist from UCLA Medical Center, testified that she was paged on that day to help with the care of "a V.I.P. patient, named Michael Jackson." She was under the impression the patient was "coding," meaning resuscitation was partially successful. She further testified that when Murray arrived at the hospital, he was "desperate and devastated," and he told the staff: "Do not give up easily, try to save his life."[14]

Nguyen's testimony then turned to the effects of Ativan (brand name of lorazepam), the drug that Murray claimed started Jackson's cardiac arrest. According to Nguyen, Ativan acts on the brain to "make you sleep" and can cause respiratory apnea ("not breathing"). She testified that "you do not typically use narcotics (such as Ativan) to treat insomnia, they are used for sedation," but, when cross-examined, she admitted that it is one of its uses.[15]

Testimony then turned to the use of flumazenil (a benzodiazepine antagonist) as an antidote to Ativan. Ativan would cause the patient to have slurred speech but propofol would not; it is "quick onset [and] quick offset." Propofol is only to be used in a hospital, "not just any hospital room, but only in an intensive care unit or procedure room, by specialist personnel" (an anesthesiologist present throughout its use). Constant monitoring is required because [we] "wouldn't be sure of the patient's tolerance threshold" to the drug and there should be a crash cart at hand. Nguyen also testified that Murray never mentioned propofol.[16]

October 4, 2011: Day 6

Stacey Ruggles, Michelle Bella, and Sade Anding, each of whom was in contact with Murray on June 25, 2009, testified about their relationships with him.[17][18] Anding, who is thought[by whom?] to be the person Murray was speaking to when he noticed Jackson was not breathing,[17] said she heard coughing and mumbling after Murray stopped speaking on the call, which lasted "three or four minutes."

Murray's girlfriend, Nicole Alvarez, was living with Murray in Santa Monica. She is the mother of Murray's son born in March 2009. They met in Las Vegas in 2005, where she was working in a strip club.[19] She testified about visits to Jackson's home and her plans to travel to London with Murray for the concerts. She also told how she was accepting FedEx packages at her home in Murray's name. Prosecution provided FedEx receipts to the court and Alvarez testified that they were accurate and that her signature was on some of them. Alvarez was the person Murray called while he was in the ambulance with Jackson's body. He showed up at her apartment later that evening.[20]

Tim Lopez, employed by Applied pharmacy services, liaised with Murray over purchases of propofol and Benoquin. He testified about orders Murray placed for propofol and for Benoquin cream, to use in the treatment of the disease vitiligo, from April to June 2009 (225 vials in total).[21] Murray's propofol orders were being routed through his Las Vegas office and then shipped to Alvarez's apartment in Los Angeles. He was also ordering increasing quantities of propofol as time went on.[22]

October 5, 2011: Day 7

Sally Hirschberg, a customer service and sales employee of Seacoast Medical, a pharmaceutical distributor in Omaha, Nebraska, was first called to the stand.[23] Testimony included details of Murray's dealing with the firm: he opened an account December 2006; ordered various medical items during April 2009, including "safe site" IV set; and cancelled an order for condom catheters on June 26, 2009. On cross-examination, Hirschberg testified that the items Murray was ordering were not unusual for a medical practice specializing in cardiovascular treatment.[citation needed]

Stephen Marx, a computer forensics examiner working for the DEA in Virginia during June 2009, testified next.[24] He performed an analysis of Murray's iPhone and extracted screenshots, emails, and recordings from it. The emails pertained to medical handwritten notes for patients named Omar Arnold and Paul Farance, in which both names were aliases that Jackson utilized under Murray's care. One email asked Murray: "Is that him too?"

Emails pertaining to Jackson's insurance while in London were also shown. The insurance company confirmed that Murray was Jackson's only doctor since 2006, and that they wanted very thorough medical reports and records and a review of Jackson during rehearsals before agreeing to cover him, but that Jackson had refused authorization to release his medical records.[25]

During the testimony, a recording was played of a conversation between Murray and Jackson from May 10, 2009. The recording featured Jackson's talking about healing the world and helping children because he did not have a childhood, in slurred, almost incomprehensible speech. The recording ended with Murray's asking: "Are you OK?" and with Jackson's replying "I am asleep."[26]

Next to testify was Elissa Fleak, a Los Angeles County coroner for the past eight years.[27] Her duties include investigating deaths (natural/suicide/homicide) and working with medical examiners to determine causes of death. Fleak went to UCLA Medical Center at 5:20 pm on June 25, 2009, to examine Jackson's body and get information surrounding his death. She examined the body in a private room, as well as notes and photographs, and looked for external wounds/injuries; any sign to signal the cause of death. None were found. She took four vials of Jackson's blood for toxicology testing and went to Jackson's house to perform an onsite investigation. While in Jackson's bedroom, she found an empty 20 ml propofol bottle and an empty 5 ml flumazenil bottle on the floor next to the bedside table. She also recovered other prescription drugs, such as diazepam, lorazepam, and tamsulosin (Flomax), one bottle prescribed to Mick Jackson, and some medicines prescribed by Alan Metzger. Other drugs found were Benoquin, hydroquinone, lidocaine, and an oxygen tank beside the bed. Medical equipment recovered included alcohol prep pads, a 10cc syringe with the needle removed, an IV catheter on the floor under an Ambu bag, an aspirin bottle, a syringe box, catheters, a jug of urine, and an IV pole with a saline bag and tubing draped over it.[citation needed]

Three bags were recovered: a black bag containing a Starline blood pressure cuff box and 3 bottles of lidocaine; a blue Costco bag (found in the closet) containing "medical debris" including a pulse oximeter, a lanyard, vials, an empty 20 ml propofol bottle, two bottles of midazolam, an opened IV administration set, a urinary leg bag, a wideband bag, two empty dressing bags, two empty catheter bags, opened alcohol prep pads, dressing backings, an empty syringe packet, four vial tops and a needle cap. Also the saline bag with a cut in it containing the "more or less empty" 100 ml propofol bottle that Alvarez recalls removing from the IV stand; and a light blue "baby essentials" bag, containing an array of bottles that included 100 ml propofol and 20 ml propofol bottles (filled to various levels, some opened, some closed), lorazepam, flumazenil, lidocaine, and Benoquin. Murray's business cards from his Houston practice were also found.[citation needed]

October 6, 2011: Day 8

Fleak confirmed the presence of an IV stand, a saline infusion set, and a depressed syringe in a y-port connected to the tubing beside Jackson's bed. The court heard that she issued a subpoena to Murray for Jackson's medical records, and only the records pre-2009 were submitted to her. During cross-examination, Chernoff asked Fleak about a number of "mistakes" during her examination, such as picking up a bottle from the floor before photographing it, ignoring the presence of the IV stand, not taking a picture of the propofol bottle inside the cut saline bag (she said she took it out to see what it was then photographed it), and destroying her handwritten notes from June 25, 2009. It was heard that Fleak did not mention the propofol bottle was inside the saline bag in writing until March 2011. The defense suggested that she changed her story to fall into line with other witness' stories regarding the bottle in the bag.[28]

Next called to testify was Dan Anderson, chief toxicologist at the coroner's office. He has 21 years' experience in this field. He tested blood and urine taken from Jackson in UCLA and at autopsy on June 26, 2009. Blood taken from a femoral vein showed propofol (2.6 μg/ml), lidocaine (0.84 μg/ml) and lorazepam (0.169 μg/ml). Blood taken from Jackson's heart showed propofol (3.2 μg/ml), lidocaine (0.68 μg/ml), diazepam (<0.1 μg/ml), lorazepam (0.162 μg/ml), midazolam (4.6 μg/ml) and a hemoglobin percentage of 5.1%. Vials of blood taken from Jackson at UCLA were found to contain propofol (4.1 μg/ml). Other results included liver (lidocaine (0.45 μg/ml), propofol (6.2 μg/ml)), stomach (lidocaine (1.6 μg/ml), propofol (0.13 μg/ml)), urine (jug found in bedroom and more than 500 ml collected at autopsy) (lorazepam, lidocaine, midazolam, propofol and ephedrine), vitreous humour (propofol (0.4 μg/ml)). Propofol was found in all eight specimen samples. Also tested were the 10cc syringe and plunger, the syringe barrel, the fluid in the syringe and the IV tubing (propofol and lidocaine found). No alcohol, barbiturates, cocaine, sedative hypnotics, marijuana, methamphetamine, opiates, codeine, morphine, hydrocodone, or Demerol were found in the samples.

During cross-examination it was heard that post-mortem redistribution occurs in the blood stream, and hence different concentrations of drugs were found in different parts of the body from which they initially entered. It was also heard that: the jug of urine from the bedroom could be from days before and might not even be Jackson's urine, that the low amount of propofol in the vitreous humour was negligible, and that there was no propofol found on the IV pole. The only place it was found was in the lower portion of the tubing and the syringe; the drug proportions couldn't be ascertained.[citation needed]

October 7, 2011: Day 9

Dan Anderson continued to answer questions about the levels of drugs in Jackson's system and the substances found in the IV bag (no drugs), tubing, and syringes (in which propofol and lidocaine found) found in Jackson's bedroom. It was heard that the level of lorazepam in Jackson's system (0.162 μg/ml) was within the therapeutic range (0.1–0.2 μg/ml), the level at which it has its desired effect. It was shown that the total amount of lorazepam in Jackson's stomach was 0.046599 mg; about 1/43 of a 2 mg tablet. It was noted that if there were a lot of a certain substance in the blood but not much in the urine then it was recently taken; the same can be said for substances in the stomach.[citation needed]

Fleak was recalled to clarify some issues with photographs and the placement of items in the photographs that she testified to on October 6.[citation needed]

Next called to testify was Detective Scott Smith of the LAPD. With 24 years experience in the LAPD (20 years as a detective), he was working for the Robbery Homicide division during June 2009. On June 25, 2009, he entered the UCLA emergency room at 4:25 pm and stayed until 7 pm. In that time he did not see Murray, but collected CCTV footage of Murray's leaving the ER at 4:38 pm and appearing in the west lobby at 5:02 pm. Before Smith left, he had brief interviews with Mohammed and Alvarez. Smith then went to the Carolwood residence to assist and support the coroner's investigators. It was heard that everyone left the house at 9:30 pm, and Jackson's security was left in charge of the house. On June 26, Smith attended the autopsy, which was deferred pending toxicology, and then went back to the house to further investigate because the Jackson family had handed some items to the police (some rotten cannabis in a shaving kit, some lotion, paper, an envelope, and other "debris"). Inside the shaving kit was a bottle of temazepam prescribed by Murray to Omar Arnold dated September 26, 2008. While at the house, Smith found some empty pill bottles in the master bathroom.[citation needed]

While Smith was on the stand, a two-hour police interview with Murray, taken 48 hours after Jackson's death, was played to the court. It was held in the Ritz Carlton hotel, and Orlando Martinez asked the questions; Chernoff was present. It was heard that Murray first met Jackson in 2006, a security guard (a patient's son) asked Murray to meet him, and Murray first treated Jackson's children for the flu. Amir (Michael Amir Williams) told Murray that Michael Jackson would like Murray to be there for the concerts. Murray understood that he would be an employee of Jackson's, but then discovered his salary would be paid by AEG Live. Murray said Jackson was not a person who ate well, and he was probably seeing doctors for issues he did not disclose to Murray. It was heard that Murray spent six nights a week at Jackson's house, only having Sundays off, and it was usually just Murray, Jackson, and Jacksons' children in the house.[citation needed]

Among Murray's claims in his taped statement to police:

October 11, 2011: Day 10

The proceedings began with the conclusion of the recording of Murray's interview with the police from 48 hours after Jackson's death. Afterwards, Smith continued his testimony. Smith never mentioned in any notes referencing a propofol bottle being inside a saline bag during searches of Jackson's home in June 2009. He saw the propofol bottle beside a cut saline bag after Fleak had removed them from the Costco bag and it was the only saline bag found. Search warrants were executed of Murray's house in Las Vegas, offices in Las Vegas and Houston, his girlfriend's apartment, his warehouse and his car, and no propofol was found. During brief statements taken from Mohammed and Amir at the hospital on June 25, 2009, neither of them mentioned Murray asking to be brought back to the residence. Alvarez did not mention propofol in an IV bag or Murray asking him to put things in bags until after the cause of death was released on August 27, 2009.

Dr. Christopher Rogers, chief of forensic pathology at the coroner's office, testified he had conducted the autopsy of Jackson on June 26, 2009. There was nothing obvious indicating the cause of death, and he was healthier than the average person of his age because there was no atherosclerosis on the walls of his coronary arteries. Jackson did not have heart disease, and there were no irregularities in his heart. There was no evidence of natural disease or trauma, his esophagus was intact with no milky fluid there or in the stomach. The stomach contained no pills or capsules. His mouth, upper airway and trachea were all intact with no foreign material present. Rogers took samples from each organ and sent them to the relevant experts for consults because he was not able to determine the cause of death and wanted a toxicological analysis. Rogers also requested Jackson's medical records from Murray but never received them.

After toxicological analysis, Rogers determined the cause of death to be acute propofol intoxication with contributing effects from benzodiazepines exacerbating respiratory and cardiovascular depression. When asked about the manner of death, he testified it was a homicide. Propofol was not necessary‍—  it was outside of a hospital or clinic, and the proper equipment to be used with propofol was not there. Murray administered too much propofol. The "circumstances do not support self-administration" because Jackson would have had to have woken up, self-administer the drugs, circulate to the brain, and then be found not breathing – all in the space of 2 minutes. Rogers said that was a "less likely scenario." The "more likely scenario" was that "Murray was estimating the doses" to give Jackson and that "Murray accidentally gave too much." There was a cut in the rubber stopper in the propofol inconsistent with a needle but a medical device called a spike, which is used to get the liquid to flow out, to "set up constant flow" of the drug.

During cross-examination, Rogers testified that the only evidence of propofol in the medical equipment was in the syringe, in the Y-connector and the tubing thereafter. None was found in the upper tubing or the IV saline bag. Defense council Flanagan asked "Would 25 mg propofol pushed over 3-5 minutes make the patient sleep?" Rogers replied yes. Flanagan: "How long would they sleep for?" Rogers: "Approximately 5 minutes." Flanagan: "So a 25 mg dose of propofol at 10:50 am would have no effect after 11.05?" Rogers: "Correct." Flanagan: "After this you would assume the patient sleeping was caused by something else and not propofol, wouldn't you?" Rogers: "Yes." The therapeutic blood concentration range of propofol required for major surgery was 4 μg/ml, and for lesser operations it was 2 μg/ml. Jackson had 2.6 μg/ml in his femoral blood, which is used for post-mortem examination because as it is not located near any large organs and is less prone to redistribution after death. Rogers stated that a lethal level of propofol has been documented anywhere between 1 and 17 μg/ml. Jackson's stomach level of lorazepam was 0.64 μg/ml, and his femoral blood level was 0.169 μg/ml. It was hypothesized that Jackson must have ingested lorazepam fairly close to the time of death for it not to have been absorbed and distributed yet. Flanagan: "A 2 mg pill of lorazepam gets you to 0.018 μg/ml blood level?" Rogers: "Yes, in Shafer's literature." Flanagan: "If you pushed (all at once) a dose of lorazepam to get you to 0.169 μg/ml blood level, it would stop your heart, wouldn't it?" Rogers: "Yes."

On redirect, Walgren asked whether it would still be a homicide if Jackson had self-administered the propofol or lorazepam because of the negligence by Murray, and Rogers said, "Correct." Walgren asked whether the propofol found was the same as in major surgery, and Rogers replied, "Yes." Walgren: "Would 25 mg over 3–5 minutes get you to 2.6 μg/ml blood level?" Rogers: "No."

October 12, 2011: Day 11

Dr. Alon Steinberg, a cardiologist for 13 years and board-certified in cardiovascular diseases, Cardiac CT and Nuclear Cardiology, testified that he was not an expert in anaesthesia or pharmacology and that Murray was not board-certified in June 2009. Of the three degrees of breaching the standard of care (no deviation, mild deviation, extreme deviation), this case was the first time Steinberg has seen extreme deviations from the standard of care. Steinberg testified that propofol is only used in cases of needing deep sedation when the patient will go through a significantly painful procedure and there are risks that the patient could stop breathing; that is why it is used with constant monitoring and emergency equipment on hand. He testified that he only uses propofol when performing cardioversions and that he is required to have an anaesthetist present. For instances of mild and moderate sedation, Steinberg stated that he would use benzodiazepines and would never prescribe propofol for insomnia. He received Murray's case and was asked to review his acts and omissions against the standard of care. The review was based on Murray's own words from his police interview previously heard by the court. His findings: "Six separate and distinct extreme deviations from the standard of care."

  1. Propofol is not medically indicated for sleep. "I have never even heard of it being used for insomnia, it is a very powerful surgical sedation agent." There was also no informed consent signed by the patient. Risks, benefits, indications and alternatives should all be explained, understood and agreed before any treatment.
  2. Propofol was being administered in the home, with no equipment, no medical personnel, no back-up and no physical observation by the attending physician. "Each of these individually would be an extreme deviation on [its] own." Equipment needed for propofol: alarm on the pulse oximeter, automated blood pressure cuff, EKG to monitor heart rhythm, ambu bag for ventilation assistance, a backboard for chest compressions, a back-up generator in case the power goes out, a way to summon help and a device for keeping the airway open such as an endotracheal tube. Murray had none of this equipment.
  3. Inadequate preparation for emergency situation. Attending physician must have the drugs and personnel prepared. Personnel required: Intubation specialist to rescue the airway, nurses for the procedures, emergency personnel close by, and an anaesthesiologist. Personnel trained in basic life support and advanced life support should be in attendance to deal with the airway maintenance, IV maintenance and any arrests that may occur. Drugs required during sedation in the event of an emergency: flumazenil, naloxone, lidocaine, atropine, beta blockers, dopamine, epinephrine, methylprednisolone. All of these should be available in a crash cart very close by.
  4. Improper care during arrest. Jackson had a respiratory arrest, and Murray did not follow the protocol for such an event. During respiratory arrest, the patient stops breathing, causing the oxygen levels in the blood to drop lower and lower, which causes the heart rate to increase. Lack of oxygen weakens the heart, and the heart will have electricity present but will not contract (pulseless electrical activity). Finally, the heart's electricity dies (asystole). Murray should have tried to arouse Jackson, placed an ambu bag over his mouth, cleared the airway, called 911 and administered flumazenil. Instead, Murray started chest compressions, which do not help respiratory arrest. "The heart was already working, he didn't need chest compressions." Even then, the CPR was of poor quality, since it should have involved having both hands on a hard surface rather than having one hand on a bed.
  5. Failure to summon emergency help. Murray should have called 911 on his cell phone immediately. Instead he waited until 12:21 pm, which was approximately 20 minutes after Jackson stopped breathing. Help was four minutes away. "I would have allowed two minutes to check the situation before calling 911. He had a cell phone."
  6. Failure to maintain proper medical records. No informed consent. No records of Jackson's vital signs, doses given, [or] responses to the medication. Murray was confused or dishonest about the records when they got to the emergency room.

Question: "Dr. Murray's deviations in the standard of care contributed to Jackson's untimely death?" Steinberg: "Yes." Question: "If Jackson administered the drugs to himself, was it still gross negligence?" Steinberg: "Yes." All medicines are kept in locked and passworded cabinets. There would have been no opportunity for self-administration in a proper setting.

During cross-examination, Steinberg testified that if the patient had a blood pressure (caused by there being a pulse) and a pulse of 122, he was savable. If a patient is not breathing but has a pulse, the course of action is to clear the airways and give breaths.

Next to the stand was Dr. Nader Kamanger, board-certified in internal medicine, pulmonary medicine, critical care, and sleep medicine. He employs propofol daily for sedation when placing an endotracheal tube. It is the classic induction agent for deep sedation during painful procedures. It is the most common drug for maintaining sedation on patients on mechanical breathing apparatus. Doctors have to call an anaesthesiologist to administer it, someone who can maintain the airway, and someone who can reverse the effects of the drugs. Kamanger also pointed out Murray's extreme deviation of the standard of care, consistent with Steinberg's testimony.

October 13, 2011: Day 12

Next to the stand was Steven Shafer, a professor of anesthesiology at Columbia University since 2007 and adjunct professor of anesthesiology at Stanford University since 2000. He is an expert on pharmacokinetics (rate of onset of drug action, duration of action, and elimination of drug action, in sum) and pharmacometrics with 20 years of experience working with the Food and Drug Administration (FDA). His field of interest involves mathematically modeling how a dose of drug translates to concentrations in the body and its effects on a patient. He has published 19 papers about the pharmacokinetics of propofol. Pharmacokinetics involves the study of the dilution of drug in a patient's blood stream. Shafer is the current editor in chief for the Journal of Anesthesia and Analgesia and on the editing board of many other journals.

He testified about the history of the dosing guidelines of propofol.

October 19–20, 2011: Days 13 and 14

Shafer showed a video of the use of propofol during a procedure. He testified about his review of the Murray case. He found seventeen "separate and distinct egregious violations" of the standard of care, of which four were unconscionable, based on Murray's police interview:

  1. The lack of the basic emergency airway equipment.
  2. The lack of the advanced emergency airway equipment.
  3. The lack of suction apparatus.
  4. The lack of an IV infusion pump.
  5. The lack of alarmed pulse oximetry.
  6. The failure to use a blood pressure cuff.
  7. The lack of an electrocardiogram.
  8. The lack of capnography.
  9. The failure to maintain a doctor-patient relationship.
  10. The failure to continuously monitor the mental status of the patient.
  11. The failure to continuously monitor the breathing of the patient.
  12. The failure to continuously monitor blood pressure and pulse oximetry, and to have heart monitors.
  13. The failure to call 911 immediately.
  14. The failure to chart at the outset of the procedure (egregious and unconscionable).
  15. The failure to maintain written informed consent (egregious and unconscionable).
  16. The failure to document throughout the course of sedation (egregious and unconscionable).
  17. The failure to disclose to both the paramedics and UCLA the use of propofol and what Murray witnessed at the arrest.

Question: "Each one of these seventeen egregious violations is individually likely or expected to result in injury or death to Michael Jackson?" Response: "Yes."

Shafer showed simulations of propofol and lorazepam on his computer models. (i) If the drugs were bolus pushed: He stated that the drugs administered (as described in Murray's interview statement) could not have produced the femoral blood levels at autopsy. He also testified that Jackson repeatedly self-administrating the drugs would not have caused the femoral blood levels found at autopsy. (ii) If the drugs were IV administered: Administration by continued IV infusion would produce the femoral blood levels found at autopsy very shortly after initiation of the drip. After the patient stops breathing, the heart would still be beating so the IV would continue. This scenario would result in the blood levels at autopsy. According to Shafer: "That's what I think happened, based on all the evidence."

Shafer demonstrated the set-up of an IV infusion of propofol. The IV line for propofol would need an air vent to allow air into the bottle and an infusion pump to control the dose. Without a pump, it is very hard to control the dose. He testified that he had never seen anything like the cut bag set-up and had never seen anyone do it.

Walgren asked Shafer a number of questions regarding his testimony over the last few days:

October 21, 2011: Day 15

Chernoff cross-examined Shafer on his CV and about his relationship with the defense's expert Dr. Paul White.

October 24, 2011: Day 16

The cross-examination of Shafer concluded, and the prosecution rested.

Timeline of defense case