This is Part 2 of 3 of Dr. Steve Shafer's answers to MJJCommunity questions. In this second installment Dr. Shafer will be answering questions about Dr. Paul White, Conrad Murray and Michael Jackson's death.
Questions about Dr. White
MJJC: While watching the trial it felt like there’s an animosity or fall out between you and Dr. White. Are we correct about this? If yes did this fall out stem from the events of the trial or is there a history to this?
Dr. Steve Shafer: Paul has been a friend for nearly three decades. The Paul White you saw on television was not the Paul White that I have known since medical school. He has made many contributions to our specialty. It is my hope that his contributions are his permanent legacy, not his defense of Conrad Murray.
Paul has been a cherished mentor since I was medical student. I was not his “student” as Chernoff stated, and I did not appreciate the implication that Paul taught me what I knew about propofol. However, Paul has given me counsel on everything from medical school to romance. I was expecting Chernoff to ask “Hasn’t Dr. White been a mentor to you?” I was ready to say “yes”.
MJJC: What did you think of Dr. White’s testimony and his behavior? Did anything he said change your opinion about your colleague? Were you surprised by the things he said and things he did (such as his comments to the media) or didn’t do (such as not doing his own charts, not overseeing the Beagle experiment)?
Dr. Steve Shafer: There were factual errors in Paul’s testimony. Paul is capable of outstanding scholarship. I don’t know the dynamics of his relationship to the defense team that led to him not doing the heavy lifting that he usually does when it comes to checking the literature. I wish he had contacted me in advance. I would have been happy to help him review the literature and explain the science.
The different approaches of science and law to discerning the truth failed Paul. If this had been an argument over a scientific manuscript, Paul and I would have spoken directly, without attorneys trying to discredit either one of us. We would have lined up papers, and arguments, and “duked it out” by e-mail, or perhaps over an extended lunch at one of our favorite Mexican restaurants. That would have worked and the science would be right (at least as “right” as we could get it). There would be no adverse consequences for either of us. As scientists collaborating to “get it right” we would have done well. The criminal justice system isn’t set up to allow scientists representing opposing sides to collaborate in an effort to find the truth.
MJJC: Are you still friends with Dr. White?
Dr. Steve Shafer: There may be some bruised feelings, but we will get past it. We have a lot of shared history.
MJJC: You worked with Dr. White and you are/were friend with him. So how it's possible to have 2 completely different opinions about what happened the night of 25 June 2009 from two close people?
Dr. Steve Shafer: Paul White admitted in court that he only considered self-injection scenarios. This severely limited the scenarios he considered.
MJJC: What do you think of your colleague Dr. White going out of his way to justify Conrad Murray's actions, from a medical point of view?
Dr. Steve Shafer: I don’t understand it at all.
Questions about Dr. Murray
MJJC: Did you purposely NOT refer to Conrad Murray as a doctor during your testimony? Have you heard the news reports about how furious it made him?
Dr. Steve Shafer: I was not aware of that. It would be very unlike me to refer to him as “Mr. Murray,” as my habit is to be respectful. I probably referred to him simply as “Conrad Murray”. If I never said “Dr. Conrad Murray”, then this is indeed a Freudian slip. I don’t see him as a doctor.
MJJC: Viewers at home could see Murray losing his temper when you started the IV demonstration, was that temper flare up noticeable to you from where you were positioned in the courtroom?
Dr. Steve Shafer: I read about it, but I didn’t personally observe it. I was focused on the jury.
MJJC: If so, were you fearful of what Murray may do (i.e. did you think there was a possibility that he would physically attack you)?
Dr. Steve Shafer: Not at all.
MJJC: What are your thoughts on Murray as a doctor?
Dr. Steve Shafer: I believe he violated the fundamental trust between doctors and patients, and that he did so not in an isolated incident under duress, but intentionally and repeatedly. That is not something a doctor would do.
MJJC: Did you hear about and/or watch the Conrad Murray documentary.
Dr. Steve Shafer: No, I just heard about it.
MJJC: If so what are your thoughts about it. Do you feel that his participation in this documentary further proves Murray's lack of professional ethics and an unsuitable candidate for the medical profession?
Dr. Steve Shafer: I can’t imagine why he would participate in a documentary that would be shown prior to sentencing. Evidently they filmed the attorneys swearing at each other, with Paul White and Conrad Murray on a couch in Flanagan’s home. It seems reckless for everyone involved.
Questions about the role of propofol in Michael Jackson’s death
MJJC: Based on everything you know, what do you think happened on June 25, 2009?
Dr. Steve Shafer: Michael Jackson died from respiratory arrest (his breathing stopped) while receiving propofol, exactly as the coroner reported. There was a contribution of the lorazepam, also as reported by the coroner. The coroner got it right.
MJJC: How convinced are you that MJ was on a drip that night?
Dr. Steve Shafer: I’m completely convinced. Murray admitted to using a drip every night. He said he was trying to wean Michael Jackson. I don’t believe him. The urine propofol levels suggest massive doses, more than 2000 mg, as I explained in my rebuttal testimony. The blood levels show anesthetic concentrations of propofol. It all fits with an infusion (drip).
MJJC: If we disregard Murray's police interview, in your professional opinion, how long was MJ gone before Murray finally found him? Some experts are under the impression that the delay in calling 911 can only be explained by him knowing MJ was already dead.
Dr. Steve Shafer: I think he was already dead, but that is really speculative. I don’t believe anything Conrad Murray says, and there are no records. My guess that he was dead is based on the limited window between stopping breathing and death (10-20 minutes). Murray would have to observe him in that window to have a chance to revive him.
MJJC: There are some rumors that Michael actually ate a meal the night he died in Murray's so-called "care". Do you think Michael was fasting for the required time? Or was this yet one more deviation from the standard of care by Murray? What are your thoughts on this?
Dr. Steve Shafer: I’m not aware of any data suggesting Michael Jackson ever fasted. It doesn’t come up anywhere in the record. My guess is that he ate, because he would likely be hungry after a vigorous rehearsal.
MJJC: What do you think about June 19th (Kenny Ortega's email describing Michael- chills, seeming lost), and June 21st (hot and cold symptoms described by Cherylin Lee). What could those symptoms come from?
Dr. Steve Shafer: It is hard to know. The defense proposed that those might be withdrawal from Demerol, and that is correct. It might also be withdrawal from lorazepam. Propofol withdrawal hasn’t been described, because nobody other than Michael Jackson has ever received propofol night after night for insomnia. However, at least in theory it could be propofol withdrawal.
However, it could also be the usual sort of illness: the “stomach flu” or a bad cold. There is no way of knowing.
MJJC: Do you have an opinion about June 23rd and 24th, when Michael seemed to be feeling great? What could this improvement come from?
Dr. Steve Shafer: I don’t know. After the trial I watched “This is It.” There was obvious excitement and exuberance as rehearsals were nearing the end, and the tour was approaching. It could simply be excitement and exuberance in expectation of the tour.
MJJC: Does it surprise you MJ didn't die sooner than June 25th after finding out Murray was given MJ Propofol without proper equipment for 2 months (according to Murray) prior to MJs death?
Dr. Steve Shafer: Yes. I think that is quite surprising. We don’t know if there were prior close calls, because there are no records.
MJJC: May 2009 audio recording of Michael in which he was slurring his words attracted a lot of attention. In an interview Dr. Murray said Michael was under the influence of Propofol during that recording. However some people say Propofol does not cause slurred speech. What do you think about that recording? Any idea what drugs can cause that speech?
Dr. Steve Shafer: Sedatives cause slurred speech. This could have been caused by midazolam, lorazepam, or propofol.
MJJC: Do you think there was a chance for Michael to be in good health and to continue normal usual life after such long respiratory arrest even if paramedics could reanimate him?
Dr. Steve Shafer: Definitely, if they arrived in time.
MJJC: This is a hard question but we have to ask. When there is overdose of Propofol and it causes death, like it happened to Michael, does the person suffer? Do they feel pain? Or is it like dying in your sleep that you feel nothing?
Dr. Steve Shafer: It is an easy question to answer: there is no suffering with a propofol overdose. The person falls asleep quickly and comfortably. The brain is deeply depressed, and the brain never returns to consciousness.
MJJC: If Michael had been your patient and asked you for Propofol to help him sleep, how would you have responded? What would you suggest to him? Would you have recommended he see a sleep specialist?
Dr. Steve Shafer: Absolutely the right question to ask! I would have referred him to a sleep specialist. He had a very serious sleep disorder that was threatening his tour, his ability to perform, his ability to create music, and potentially his life. It needed urgent care from someone who knows what he or she is doing.
MJJC: Do you know what the long-term effects of using Propofol would be? Murray has indicated that MJ was using Propofol for 6 weeks, apparently for sleeping 8 hours or so a night. Have you ever read about case studies of patients doing this or, as it was put forward in the trial, was MJ an experiment?
Dr. Steve Shafer: This was an experiment. I don’t think any other patient in the world has ever received this. There may be long term effects – that is a question that can’t be answered without clinical research. I don’t know what effects to expect, but it seems likely that tolerance and dependence would develop.
MJJC: How about even longer terms such as months or even years taking of deep sedation of Propofol, could it affect human health and any organs? Is it possible to take Propofol for a long time and don’t have any associated negative side effect?
Dr. Steve Shafer: We don’t know – the studies have not been done.
MJJC: There might not be enough information to have a clear picture of what was going on, but we would like to know your opinion about what Murray was prescribing to Michael (from late 2006), the amounts of midazolam, lorazepam and flumazenil Murray was buying, and the possible consequences of such a treatment.
Dr. Steve Shafer: I am not sure what amounts you are referring to. I am aware of the drugs that Murray purchased in 2009, but I did not review his previous treatment of Michael Jackson, because it didn’t relate directly to the questions I was trying to answer at the trial.
MJJC: According to his police interview, it seems that Murray knew he shouldn't mix Lorazepam and Propofol, so we are confused about their use together. Why would Dr. Murray or anyone mix those together?
Dr. Steve Shafer: There is nothing wrong with giving lorazepam and propofol at more or less the same time. Anesthesiologists routinely give midazolam at the start of an anesthetic, and propofol a few minutes later. Midazolam and lorazepam are closely related. You just have to know that the effects are “synergistic”, meaning that you need to reduce the dose of propofol when you give a lot of midazolam or lorazepam.
MJJC: Do you have any idea about how much lorazepam had he been given and when?
Dr. Steve Shafer: Yes, he gave a lot. The lorazepam levels in the blood were high enough to contribute to the cause of death, as stated in the coroner’s report, and as emphasized by the defense. As accurately stated by the defense, the lorazepam concentration in his blood was enough to put most of us to sleep. There were 8.4 milligrams of lorazepam in his autopsy urine, and another 5.8 milligrams of lorazepam in the urine that was recovered at the scene, which presumably was from the same night. So Michael Jackson received a lot of lorazepam. However, because there are no records, and I don’t trust what Conrad Murray says, it is hard to be more precise.
MJJC: Dr Kamangar said that dependency would be faster if benzos were given IV. Now was this a "treatment" that would have made him highly dependent on benzodiazepines? If Michael had survived, would he have been able to recover from this?
Dr. Steve Shafer: Yes to both questions. Intravenous drug use typically results in faster dependence. Regardless of the degree of dependency, one can recover from it with appropriate treatment. The big problem for Michael Jackson would have been whether he would be willing to stay away from intravenous sedatives for the rest of his life. Without a change in life priorities it is often very hard to wean individuals who are dependent on drugs.
MJJC: After spending what must have been hours of going through Murray's police statement, then the evidence itself, did you feel shocked with the results you were coming up with - the amount of propofol that had to have been given by Murray to obtain the blood results found at autopsy, the botched attempt by Murray to create his own Tate Gallery of Modern Art drip, etc.?
Dr. Steve Shafer: Since Conrad Murray ordered staggering quantities of propofol to give to Michael Jackson, and Michael Jackson had an anesthetic concentration of propofol in his blood, I expected the simulations to confirm that he received anesthetic quantities of propofol. They did.
MJJC: During your testimony you have stated that MJ first had a respiratory arrest and then a cardiac arrest. Dr.Steinberg also testified similarly based on Murray’s own words (that there was heart beat/ blood pressure when he found Michael). We have seen the defense argue that it might have been a cardiac arrest rather than respiratory arrest first. Even in the Murray documentary they showed a scene between defense lawyers that they planned to ask you if direct cardiac arrest was possible but later decided to not ask that question as they were afraid of your possible answer. Can you elaborate on this a little?
Dr. Steve Shafer: I cannot find any evidence that the scenario outlined by the defense, instant cardiac arrest in 90 seconds, has ever occurred. I have spent hours looking for such evidence, including searching the medical literature and communicating with company officials who tracked propofol adverse events. To the best of my knowledge this has never been reported. Not even once.
I also do not believe any anesthesiologist has ever seen this. There is no mechanism by which lorazepam and propofol would act together to cause instant death. If the Judge had permitted it, I believe the trial could have been extended for several years while every anesthesiologist in the United States took the witness stand to testify that this scenario was complete bunk.
Consider the absurdity of claiming that 25 milligrams injected over 4 minutes was so safe that almost no monitoring was required, while the same dose injected over 1 minute was so toxic as to cause magical instant death! It makes no sense.
Of all the misrepresentations by the defense, the assertion of magical instant death from a small dose of propofol is the most harmful to patients. It is false. Asserting instant cardiac death from a very small dose of propofol can only be expected to increase the anxiety of patients requiring sedation and anesthesia.
MJJC: As far as we can understand from Defense line of questioning and Dr. White testimony defense theory of what happened on June 25, 2009 is as follows: Murray gave MJ Valium and then 2 doses of Lorazepam and 2 doses of Midazolam. As MJ was unable to sleep Murray gave him a bolus of 25mg Propofol. During the night/day (unclear when) MJ swallowed 8 pills of Lorazepam unknown to Dr. Murray. MJ was moving around the room even though he had an IV and a condom catheter on and with all these medications on board, he self injected an already filed and left on the night stand syringe that had 25mg of Propofol. What can you say about the Defense’s version of the events?
Dr. Steve Shafer: The primary point is that it doesn’t matter. Michael Jackson would be alive if Conrad Murray had not committed multiple egregious and unconscionable violations of the standard of care. He was administering a general anesthetic to Michael Jackson in his bedroom, with no training, monitoring, or backup. He abandoned his patient. When he returned, his patient was either dead or nearly so. It speaks for itself.
We know that Michael Jackson received a lot of lorazepam. Maybe he took pills. Maybe Conrad Murray gave him more intravenously than he admitted to. We do know is that there was not enough unmetabolized lorazepam in Michael Jackson’s stomach to suggest recent ingestion. We do know that there was evidence in the room of large doses of intravenous propofol administration. We do know that the amount of unchanged propofol in the urine suggests administration of well over 1000 mg (100 mls) of propofol. Thus, the defense scenario is not consistent with the physical or autopsy data for either lorazepam or propofol.
MJJC: Dr. Shafer, you said at the trial that probably at the time of death the drip was still on and that would explain why the propofol concentration on the femoral blood was so high. But Dr. White said that he would doubt the propofol could still be infused once the blood circulation has stopped. Could you expand on this, please?
Dr. Steve Shafer: I claimed that Michael Jackson died during the infusion, which is why the blood concentration was as high as it was. He didn’t have to die at the end of the infusion, and there is no reason to think that he did. He simply died during the infusion. The 100 ml propofol bottle was empty, I expect that he died before the bottle was empty, but that by the time Conrad Murray found him the bottle had run out as well.
I was surprised that the defense claimed that my simulations required that Michal Jackson die at the end of the infusion. There was no such requirement. I was disappointed that Paul White went along with this.
MJJC: In case there was cardiac arrest initially and not subsequently after respiratory arrest as Murray told the police, that cardiac arrest could have been caused by a sudden high/fast dose from the drip since there was no infusion pump to regulate the rate of the drip?
Dr. Steve Shafer: No. The heart is quite a reliable organ. It can stop suddenly, but not from anything propofol does. What makes the heart stop abruptly is: 1) an arrhythmia, typically from an acute heart attack, 2) something that completely blocks circulation, such as injection of a large dose of air, or a blood clot from the legs that suddenly blocks flow into the lungs, 3) administration of a large dose of intravenous potassium, which interferes with the electrical activity of the heart. Propofol will stop breathing, and it will drop the blood pressure. Neither of those will cause the heart to abruptly stop. As far as I can tell, nobody has ever seen a patient’s heart suddenly stop from any dose of propofol.
MJJC: According to Walgren's words during closing arguments "we don't know whether Michael awoke, yelled for help and choke while Conrad Murray wasn't in his bedroom, and we'll never know" and to Alberto Alvarez testimony that Michael's eyes and mouth were wide open, I want to ask you: could Michael suffered before death and could he really yelled for help and choke while dying? And if no, why his eyes /mouth were open if he died sleeping?
Dr. Steve Shafer: Michael Jackson did not suffer. He died because he stopped breathing. He was unconscious at the time. If he had been conscious, he would have been breathing.
It doesn’t mean anything if a patient’s eyes or mouth are open or closed after death. I witnessed my own father’s death during the time I was testifying. I was at his bedside. He was in and out of consciousness for about two hours before his death. My last communication from him, an “OK” sign with his hand, was about an hour before his death. After he died, I noted that his eyes and mouth were both open. I closed them.
Note: Part 3 of 3 will be posted 24 hours later - on December 22, 2011.