Dr. Steven Shafer's testimony continues - Day 14 -
Anesthesiologist Dr. Steven Shafer, an expert on propofol, continued his testimony today saying that it’s impossible for the drug to enter the bloodstream in any sizeable amount if it is swallowed.
Defense attorneys for Murray said last week they had abandoned the theory that Jackson swallowed propofol.
Still, the theory was included in a report by their propofol expert, Dr. Paul White, who also suggested that Murray probably gave Jackson more of the sedative lorazepam than he told police.
Defense lawyers have suggested throughout the four-week trial that Jackson swallowed eight lorazepam pills without Murray’s knowledge and that may have been enough to kill him.
Shafer, however, said the defense’s own testing showed Jackson hadn’t swallowed any lorazepam pills in the four hours before his death, and the amount of the medication found in his stomach was “trivial.” In addition, prosecutors have said coroner's officials recently conducted tests that showed the levels of lorazepam in Jackson's stomach were far lower than defense attorneys have led jurors to believe.
Regarding oral ingestion of propofol, Dr. Shafer on Thursday walked jurors through studies dating back 1985 on animals and more recently on humans showing propofol that is swallowed wouldn't produce sedation or reach the bloodstream in any sizeable amount.
Dr. Shafer said Murray’s case is unlike any he’s ever seen.
“We are in pharmacological never-never land here, something that was done to Michael Jackson and no one else in history to my knowledge,” Shafer told jurors.
The professor reminded jurors that Murray had bought more than four gallons of propofol to use on the singer over the course of his employment, talked on the phone in the morning of June 25, and delayed calling 911 when he found Jackson unresponsive.
“The worst disasters occur in sedation and they occur when people cut corners,” Shafer said. In Jackson’s case, “virtually none of the safeguards were in place,” he added.
"The very first time Michael Jackson said, 'I need propofol to sleep,' a doctor would say, 'You have a sleep disorder, and you need to be seen by doctors who specialize in sleep disorders and not having me show up with propofol,' " Shafer said.
Murray told police he left Jackson's side for two minutes to relieve himself in the toilet, but Shafer said a doctor should never leave a sedated patient unwatched "because it's very likely there's going to be a disaster."
"No matter how full your bladder is, you don't leave the steering wheel," Shafer said, comparing it to a driver going to the restroom while his motor home was barreling down a highway.
When a patient stops breathing, it should be "no big deal" for a competent doctor who is prepared, Shafer said.
"If Dr. Murray had been at the head of the bed and next to Michael Jackson and saw Michael Jackson stop breathing, he would simply have opened up the route for air, either chin lift, something simple, or perhaps ventilate Michael Jackson's lungs with that mask and that squeeze bag that I showed you and then nothing would have happened. There would have been no adverse outcome at all."
Murray appeared "quite clueless" about what to do when he returned from the toilet and realized Jackson was not breathing, Shafer said.
Even without proper emergency treatment from Murray, Jackson "would be alive but with neurological injury," if paramedics had been called immediately, he said.
Shafer's video showed doctors and nurses reviving a pretend patient using equipment, drugs and staffing Murray did not have at Jackson's home.
"It's a terrifying dramatization of a person experiencing cardiac arrest, complete with visual effects," defense attorney Ed Chernoff said, arguing against letting jurors see the video.
Chernoff said the video was designed to "inflame the jurors' minds," but Deputy District Attorney David Walgren said it was intended to inform them about the safe methods of administering propofol.
Los Angeles County Superior Court Judge Michael Pastor ordered Walgren to edit several segments from the video, but he allowed much of it to be shown in court, including a demonstration of what happens when a patient experiences cardiac arrest while under propofol.
Shafer, one of the world's foremost experts on anesthesiology, testified he is not being paid for his testimony because he did not want people to think money would influence his testimony.
"This is just a Steve Shafer thing," Shafer said.
He agreed to testify at no charge because he feared that the publicity surrounding Jackson's death had harmed "the reputation of physicians," Shafer said. "I felt a need to help restore confidence that physicians put patients first."
"As an anesthesiologist seeing sedation given in ways that do not reflect how anesthesiologists practice, I wished to present how an anesthesiologist approaches sedation so that patients are not afraid," he said.
Propofol, which he regularly uses, has been given a bad reputation, he said.
"I am asked every day, 'Are you going to give me the drug that killed Michael Jackson?' " Shafer said. "This is a fear patients do not need to have."
Prosecutors said they will conclude their direct presentation Thursday, but rebuttal witnesses could be called next week after the defense rests its case. The defense is set to start Friday.
"Michael Jackson died because Dr. Conrad Murray failed to notice that his patient had stopped breathing while he was hooked up to an IV drip of the surgical anesthetic propofol," Dr. Shafer testified today.
Dr. Steven Shafer said Murray should have realized Jackson had stopped breathing about 11:45 a.m. on June 25, 2009.
"When you're there, you see it, you know it," Shafer said.
Phone records and testimony showed that Murray was on the phone with one of his clinics, a patient, and then a girlfriend about the time that Shafer calculated the oxygen in Jackson's lungs became depleted, causing his heart to stop beating.
"Had Conrad Murray been with Michael Jackson during this period of time, he would have seen the slowed breathing and the compromise in the flow of air into Michael Jackson's lungs, and he could have easily turned off the propofol infusion," Shafer said.
Murray could have then easily cleared Jackson's airways and resichaelored his breathing by lifting his chin, he said.
According to his calculations, Murray would have had to inject Michael Jackson with 10 consecutive shots of 4 mg each to reach the the blood levels in the toxicology report.
Dr. Shafer said it's unlikely Jackson injected himself with a fatal dose of Propofol because it would have taken him way too long to do it without the doctor noticing and even if he did, he would have had to self-inject 6 shots of more than 100 ml to reach the levels found in his blood.
Shafer said the only theory that fits is this: Murray started Jackson on a 1000 mg Propofol drip at around 9 AM, which caused the singer to stop breathing around noon.
He said Michael Jackson was still on the drip when he died.
In a dramatic and extremely painful moment, Shafer demonstrated to the jury how, he believed, Murray set up a Propofol drip. He said Murray failed to use an automated pump, which caused the anesthetic to drip at a dangerous rate.
After explaining and rejecting scenarios involving self-ingestion by Jackson or single injections of 25, 50 or 100 milligrams of the anesthetic by Murray, Shafer said the "workable scenario" was a steady IV drip of propofol diluted by saline solution. He demonstrated to the jury of seven men and five women how he believed bags holding the fluids were hung from an IV pole and fed into a vein in Jackson's leg.
"Only that three-hour drip of a total of 100 milliliters of propofol, an entire bottle, from 9 a.m. until Jackson's death at about noon, would account for the high level of 2.6 milligrams of propofol per milliliter of Jackson's blood found in the coroner's autopsy", Shafer said.
"It was likely that Murray, lacking proper monitoring equipment, didn't notice Jackson's breathing slowing down and left the bedroom thinking he was "just fine," Shafer said. "Had Conrad Murray been with Michael Jackson during this period of time, he would have seen the slowed breathing and the compromise in the flow of air into Michael Jackson's lungs, and he could have easily turned off the propofol infusion," Shafer said.
Murray could have then easily cleared Jackson's airways and restored his breathing by lifting his chin, and there would have been no injury to Michael Jackson," Shafer said. Shafer also said the continuous-infusion scenario was the only one that was consistent with the way Murray told police he had given Jackson propofol nightly for 80 nights, and with Murray's ordering from a pharmacy of 130 100-milliliter propofol bottles.
"This fits all of the data in this case, and I am not aware of a single piece of data that is inconsistent with this explanation," Shafer said.
With Shafer's repetition of his opinion that Murray was "directly" responsible for Jackson's death — even if Jackson himself had taken the drugs that Murray provided — prosecutor David Walgren ended his questioning.
After the defense cross-examination of Shafer on Friday afternoon, Murray's lawyers will start calling witnesses, including their own anesthesiology expert.
Shafer demonstrated for the jury how he believed Murray set up the propofol infusion by hanging a 100-milliliter vial from a stand with tubing attached that would have led to a catheter port in Jackson's left leg.
"This is the only scenario that I could generate" that would produce the high level of propofol found Jackson's blood during his autopsy, Shafer said.
"This fits all of the data in this case, and I am not aware of any data that is consistent," he said.
Shafer examined and ruled out other scenarios, including Jackson injecting himself with propofol or Murray administering a fatal dose with a syringe. Computer model projections could not identify a scenario that would duplicate the high blood levels found, he said.
Although Murray told police he used an IV drip to give Jackson propofol on previous nights, the defense contends that he did not use it the day Jackson died. Instead, they say, Murray put Jackson to sleep about 10:40 a.m. with a single injection.
Sometime after that, Jackson woke and used a syringe to inject himself, the defense contends.
Shafer said the theory makes no sense.
"People just don't wake up hell bent to grab the next dose in a syringe, draw it up and shove it in their IV again," Shafer said. "It's just a crazy scenario."
The defense contends that Jackson swallowed eight lorazepam tablets, a claim based on testing of lorazepam levels in Jackson's stomach contents. Shafer discredited the defense lab tests, saying a new test showed the equivalent of only "1/43rd of a tablet" of the sedative in the stomach.
The level of lorazepam in Jackson's blood was far higher than what would be expected based on the dosages Murray told detectives he gave Jackson in the hours before his death, Shafer said.
Murray said he gave Jackson a total of 4 milligrams of lorazepam in two separate doses starting 10 hours before his death. Toxicology results indicated that Jackson was given 40 milligrams -- not four -- in a series of 10 doses, he said.
Although the defense recently abandoned the theory that Jackson may have swallowed propofol, the prosecution still worked to use its old theory to discredit Dr. Paul White, the anesthesiologist who will testify soon for the defense.
A report prepared by White in March concluded that oral ingestion of propofol could have killed Jackson, but Shafer testified that it ignores the "first pass effect" that is taught to first-year medical students.
The liver is a "powerful mechanism" for filtering propofol from the digestive tract so that only a very small percentage can reach the blood, Shafer said.
Shafer cited several studies on rats, mice, piglets, dogs, monkeys and humans that he said proves swallowing propofol would have no effect.
"There was no sedation at anytime following oral consumption of propofol," Shafer said, describing the results of research he commissioned on university students in Chile over the summer.
The human study was done not only to prepare for the Jackson trial, Shafer said, but also to counter an effort by the Drug Enforcement Agency to consider tighter restrictions on propofol.
The drug is not currently a controlled substance, but publicity over the theory that Jackson's death might have been caused by oral ingestion prompted federal regulators to considered a new requirement that "it to be handled almost like morphine," he said.
"Patients will be hurt if it is restricted," he said. "Anesthesiologists have to have ready access."
The new study assures that if the drug is abused, it would be done only with the intravenous route, which only health care providers have, he said.
Shafer testified Wednesday that Jackson would be alive now but for 17 "egregious deviations" by Murray from the standard of care required of physicians.
Murray's use of propofol almost every night for two months to help Jackson sleep was so unusual, there is no documentation on the dangers, Shafer said.
"We are in pharmacological never-neverland here," Shafer said, "something that's only been done to Michael Jackson."
The trial, in its fourth week, is expected to conclude with the start of jury deliberations near the end of next week.
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