Today, an eminent cardiologist, Dr Elon Steinberg, took the stand to give evidence of Murray’s standard of care in this case and was questioned by Mr Walgren.
Dr Steinberg is certified by the California Medical Board and works in a nine-man private practice in Ventura, in the entire gambit of cardiology.
As chief of Cardiology in Ventura, he is responsible for examining credentials of doctors who apply to the Board for membership. All the members of his practice are Board certified. 90% of doctors applying for certification pass the examination. He confirmed that Conrad Murray was not a certified cardiologist with the California Medical Board in 2009.
In examining doctors’ credentials he is responsible for the veracity of their credentials. He examines their performance in five or six procedures, supervises to ensure their ability, the quality of their work, their competency and educational qualifications and their regard for patient safety.
One of his duties is to review California Medical Board Cases. He told the jury about the protocol for review and the standards of care expected from a cardiologist. He would allow no deviation from the expected standards of care.
An extremely long and protracted discussion took place during which he was asked by Mr Walgren if he had reviewed the Michael’s case. He replied that he had. He was asked if he’d previously reviewed other cases. He answered that he had reviewed approximately eight prior reviews. Half of those cases had showed no deviation from the standard of care and the rest only simple deviations. He said that Conrad Murray’s care was the first to show gross negligence.
As a cardiologist he was then asked if he was used to sedatives being used in procedures. He replied that they are used to ensure comfort and co-operation from the patient. When asked if Propofol is ever used, he replied that most cardiologists use it for mild and moderate sedation and it is usually given by an anaestheiologist who has been trained and is often supervised.
He had previously reviewed scans of Michael’s heart and in reviewing this case he had based his report on Murray’s own statement to the LAPD, finding six areas of gross negligence.
He told the court that Propofol was not medically indicated for rest or psychological reasons and that the patient would need to be informed of the risks, benefits and other options, and would need to sign a consent form.
Dr Steinberg indicated that he had never heard of a doctor treating insomnia with Propofol and agreed that this method of use was gross negligence. In addition to this, using Propofol in a home setting without equipment, staff and physical observation, also showed gross negligence.
For monitoring purposed a Pulse Oximeter with an alarm was essential, he explained. Conrad Murray’s machine had no alarm. This would necessitate staring at that machine every second that Propofol was in use.
Murray had an IV, but had no IV blood pressure cuff attached. He had a cuff, but it was not in use and the patients blood pressure should be checked every five minutes.
Dr Steinberg also pointed out that Murray didn’t have a EKG machine or nasal canula to prevent regurgitation. He did have a Ambibag, but did not use it, using mouth to mouth resuscitation instead.
He also said that the most important thing was to have a way to summon help, in the form of a nurse or an alarm.
Michael needed a good room, well lit, a backboard for CPR and a backup battery in case of power failure, Dr Steinberg said. He also needed a device to keep the airway open and equipment to incubate the patient. He said you should never leave the patient’s side when monitoring and never give the patient the opportunity to self administer anything.
Doctor Steinberg spoke next about a 2010 report on Refactory Primary Insomnia in which trials had been conducted giving Propofol to induce sleep for two hours a night for five nights. The trial was successful in curing the insomnia but Dr Steinberg stated that the trial was totally different from Murray’s treatment of Michael. He said that it was absolutely not a viable source of treatment, it was absolutely experimental and the study would have to be followed up with much further experimentation. In Dr Steinberg’s opinion, the report didn’t matter as Murray knew nothing about it in 2009. He also said that Conrad Murray was the only doctor he knew who had used Propofol for sleep.
Dr Steinberg went through Murray’s statement to the police and pointed out each error he had made.
Murray’s delay in calling 911 was reprehensible, he said. He should have used his cell phone immediately, putting it on speaker while he tried to resuscitate Michael. He said, chest compressions were not necessary as his heart was still beating adding, the most important thing would have been to get his oxygen level up to keep the heart beating, so that the brain would not begin to deteriorate. Dr Steinberg said that Murray had done everything wrong and there were no records of care undertaken causing confusion in the ER and Murray couldn’t tell the staff that he had administered Propofol, but that lapse could have been intentionally deceptive.
The doctor concluded that all of these breaches of standards of care had directly contributed to Michael’s death.
When it came to cross-examination, Mr Flanagan asked if Murray’s statement was complete and Dr Steinberg said that he assumed it was complete.
Flanagan asked if informed consent, must it always be written. Dr Steinberg answered that if it wasn’t written, it wasn’t done! The correct standard of care is a written statement with the patient’s signature.
Flanagan asked if he knew that Michael was taking other drugs, would he administer Propofol, and Dr Steinberg answered; “I wouldn’t offer it in the first place.”
Flanagan asked several more questions about the use of Propofol in hospitals, seemingly pointless to Dr Steinberg. After a resume of Murray’s actions and a timeline recap, Mr Flanagan argued with Dr Steinberg saying if Murray had only given 25mls of Popofol, but the doctor argued that the statement definitely stated that he also used a drip. The argument became protracted with neither man willing to give way.
Flanagan asked if Michael had self administered the medication, would those standards of care still have been negligent and the reply was a resounding “YES!”
The doctor had been taken through every step of Murray’s treatment of Michael that night and morning and did not vary from his opinion that Murray was grossly negligent, and that Michael would have been saved if Murray had called 911 as soon as he found that he was not breathing. “In those circumstances every minute counts,” he said.
Flanagan then made a very important point. He asked the doctor if he thought Murray had been out of the room for more than two minutes and asked, if he had heard the evidence about all his phone calls! He said he had made his decisions based on Murray’s own words!
Dr Steinberg also stated that Murray should not have done chest compressions as the heart was already beating and that he should have concentrated on getting oxygen to the brain.
The doctor went on to explain exactly the steps that should have taken to help Michael, insisting that the first thing to do was to call 911.
At the end of his cross examination Flanagan asked if Murray was responsible for Michael’s death, to which he answered “Yes, he’s responsible!”
The next witness for the Prosecution was Dr Nader Kamandar, who is a Critical Care and Sleep Medicine Physician. He stated his long list of impressive qualifications and spoke of his work at UCLA Medical Centre. He discussed sleep medicine in general terms at length. He was asked by the Prosecution to if he had found any extreme deviations from standards of care in Michael’s case. He answered “Yes.” He said that everything Murray had done was incorrect, the setting in a home, no expert to control the drug, no medical assistance to prevent risks and hazards of using a deep sedation for sleep, no life support available, etc; etc; He also went through each deviation in Michael’s care in great detail.
At one point he spoke at length saying Michael’s insomnia could have been treated by other methods than deep sedation.
Dr Kamandar testimony regarding standards of care matched that given by Dr Steinberg. He listed the incidents of gross misconduct, including failure to call for help immediately and ineffective CPR. He said that by the time the 911 call was placed at 12.20p.m., the lack of circulation and oxygen to Michael’s brain made the results irreversible and that it would have been impossible to help him.
Dr Kamandar went on to discuss various types of insomnia. He said that doctors should chart the patient’s full insomnia history to search for patterns and underlying problems. Then any problems could be treated and solutions sought, before medication was prescribed.
In the doctors opinion Murray was unethical, bypassing causes, going straight to an infusion of Propofol which was a violation of the standard of care. Other therapies should have been attempted.
Lastly, Dr Kamandar stated that through acts of omission and gross negligence Conrad Murray had caused Michael’s death, even if Michael had self-administered drugs. He said that all risks were foreseeable.