Conrad Murray’s trial resumed today with more evidence from Dr Kamandar who explained his view of Murray’s appalling treatment of Michael. He told the court that it was a competent doctor’s right to refuse sleep drugs to a patient who asked for them and that they should try to make the patient use other methods of falling to sleep by using different therapies to correct underlying problems with insomnia.
Dr Kamandar said that he would not give drugs to a patient just because he asked for them.
Mr Flanagan, who was cross-examining for the Defence, explained that Michael had been given Propofol by Murray over a period of weeks and had suffered no prior problems but Dr Kamandar said Murray’s treatment was outside of every required standard of care.
Flanagan then said; “a doctor can sometimes give ‘bad medicine’ and things can end up okay, right?” The doctor answered that the end result is not important, the doctor has a duty to apply the correct standard of care and if he does not do so, he is negligent.
“What happened that day?” asked Flanagan. The doctor explained again that Michael was given a very potent cocktail of drugs, with inappropriate access to the necessary monitoring equipment and failed to call for help from 911 or anyone else for help. Flanagan then asked if all the medications given, then 25ml of Propofol by IV would that cause death. The Doctor replied; “Absolutely.”
Flanagan commented that Murray’s failure to keep charted records didn’t mean that he didn’t know what he had done. Dr Kamander made the point that a doctor HAS to document all treatments given and observations made to ensure better patient care, but that was not the only reason, as with a complicated case a doctor cannot rely on his memory. A nurse always takes notes of any action taken by a doctor and any form of response from a patient. Murray didn’t record anything, so there was no history for the Ambulance staff or the ER staff.
The failure to record was just one of many violations. Michael died from Acute Propofol Intoxication, according to the autopsy. The combination of Propofol and Lorazepam can be varied in different individuals and the additive effect makes the Propofol stronger which can be lethal.
A discussion followed on different types of insomnia. The doctor said it was impossible to judge Michael’s insomnia because no records had been kept, but there were obviously secondary issues suggested by Michael’s anxiety over his upcoming performances, and by his previous use of Demerol. There were other sleep medications in the house, given by other doctors, an obvious indication of long-term insomnia.
Flanagan asked if the doctor had reviewed Arnold Klein’s records for April, May and June of 2009, during which period Klein had given Michael 6,500 mls of Demerol, plus Medazolam. “Did Michael have a Demerol problem?” He asked the doctor. Dr Kamandar replied saying he knew it as a narcotic drug for pain relief and Michael had received a Botox Injection with a CC or two of Medazolam, which is a sedative for small procedures.
Flanagn resumed his questioning about insomnia and the required standard of care in its treatment. He asked if a patient is not forthright in giving a history, how would a doctor find out what he needed to know? Dr Kamander answered that before treatment, the doctor should get the information from other doctors and hospitals where treatment had been given. Failing that, he could ask family members and partners for the details of the patient’s sleep disorder. He would also ask the patient to keep a sleep log/diary for two to three weeks, and give a physical examination.
As Michael was being injected with Demerol up to three times a week in this period, Murray should have noticed a slurring of his speech, and if Michael hadn’t told him of the Demerol, he should have asked his staff, drivers and security who would have taken him to Klein’s clinic, Dr Kamandar explained. To fail to do so was a deviation from the standard of care. If he could find no information to confirm his suspicions, he should not have treated for insomnia.
Flanagan next tried to discuss the study which took place in China for the treatment of insomnia with Propofol. The doctor explained that it was a study at a preliminary level and needed much more experimentation and further studies before the results could be considered, as it has no real clinical applicability.
The use if Propofol for insomnia in a home setting is incomprehensible to Dr Kamandar, who would not use it, even in a hospital. Propofol is used for sedation, NOT for sleep, he said.
Flanagan asked if Murray’s 25 mls of Propofol injected over three to five minutes could be expected to cause complications. The doctor answered that if there were underlying issues and other sedatives were also given, he could not be sure that breathing would not be compromised. Dr Kamandar was also critical of Lorazepam being given by IV. This is not FDA approved, but could possibly be used if given orally. Given orally, it is acceptable for a couple of weeks. However, given by IV for inappropriate use, dependency on the drug would result after a few weeks. Again constant monitoring is essential, the doctor said and usage should be restricted to less than two weeks.
Flanagan asked about Michael’s treatment while employed on a world tour. The doctor recommended that he should have sought expert psychiatric evaluation for the best possible treatment.
After the court’s morning recess Flanagan continued his questioning of Doctor Kamandar asking about Michael’s treatment at the hands of Doctor Murray. Again he queried the dose of Propofol and Lorazepam given to Michael by Murray and was told again that with the dosage given Michael, meant he would sleep for six to ten minutes and then wake up automatically. If he did not wake up, Murray should have ensured that he was actually sleeping and not unconscious, by seeing his response to external stimuli. His primary responsibility should have been to ensure the patient was safe and then consider the cause of the prolonged sleep and he added it could do more harm to leave him asleep than to jeopardise his wellbeing.
Doctor Kamandar told Flanagan that he had read Murray’s statement to the police and admitted discussing it with Mr Walgren. Again he reiterated that in Pulmonary arrest time is of the essence. Michael had most likely stopped breathing, hence the cardiac arrest at 12 o’clock. Flanagan asked what Murray should have done and the answer was “Call for help!”
Again the question was asked: if he had self medicated, was Dr Murray at fault? Again the answer came “Absolutely.”
Mr Walgren then spoke on redirect and went through the standards of care in which Murray had failed…that ethical moral standards must apply. A doctor must know his limitations, know when to say “no,” to being asked for Propofol. Dr Kamandar also said the doctor had the final word when asked.
Mr Walgren then asked the doctor: “Did Conrad Murray’s gross negligence cause Michael Jackson’s death?” The answer was again “Absolutely!”
On re-cross examination Flanagan reminded the doctor that Murray was performing CPR and therefore how could he have called for help? The doctor replied that he should have called out for help. He had gone to the kitchen, instead of calling 911. Flanagan made the point that the chef did not call 911, but he had also told Alberto Alvarez that he needed help.
Doctor Kamandar’s evidence was then complete.
The next witness to be called by the Prosecution was Doctor Steven Shafer, a man with an incredible list of qualifications who had been responsible for calculating the dosages of Propofol to be used in every eventuality. His calculations were used worldwide, for use before and during surgery, and afterwards for pain management. He has attended and lectured at Columbia University, Stanford University and University of California at San Francisco. He teaches a graduate level class on the science of drugs, to help doctors to use correct doses safely to minimise toxicity. He is also the Editor in Chief of the Anaesthesia Journal and sees over two thousand manuscripts every year, working on them for fifty to sixty hours each week.
Doctor Shafer explained to the court in great length exactly his dealings with Propofol and his part in it’s development for general use.
Surprisingly, as the judge decided to break for lunch, it was decided to end the proceedings for the day and to return next Monday for the next session