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Murray Trial Day 22, November 1st

Praise the Lord! I was about to have a nervous breakdown. Now I can relax "a little bit" at least.

I figured Mr. Walgren wouldn't let us down, but it's so nerveracking nonetheless.
 
Oral or given lorazepam would look the same. No way to know. Walgren asks about the simulation of infusion by Shafer. Was he designating a precise time Michael stopped breathing? Shafer says no. The simulation was to show that Michael could have died at any time throughout the time concentration was high in his blood. He didn't need to die at any particular time, just while concentration was high. He didn't say it was precisely at noon.
 
Shafer talking about the infusion setup and how the roller clamp works, how you control what comes out simply via adjustment. In the simulation there's no difficulty controlling how fast saline or propofol is done, you do it with the roller clamp. The roller clamp setup isn't typical though because you virtually always use a proper infusion pump.

Walgren asks if the simulations took lidocaine levels into account. Were the levels inconsistent with his hypothesis? Shafer says no. Because according to Murray's interview Michael was concerned about the pain on injection. The mixture theory is totally consistent contrary to White's statements because the lidocaine COULD fit - you simply remove some propofol from the vial to accomodate it.
 
Okay, Imma say something really kooky but I think it's a good sign that both Walgren and Shafer are wearing red ties today. They are virtually twins. Today is a good day to rest. :)
 
Was it a failure to breathe that eventually led to cardiac arrest, in Shafer's opinion? Yes, he says. Explaining about how arrest of breathing kills.

Walgren asks if Shafer has looked at White/Ornellis' models in relation to urine concentration. Yes he has. Is he aware that the defense simulation relied on a Simons article from 1988? Yes he knows that article. The Simons article found very little unchanged propofol. So little they didn't measure it. They used oil and measured the amount of radioactivity in the oil. There was too little to determine if there was actually propofol or something else.
 
They didn't know how much was unchanged propofol and didn't know what the source of radioactivity (which they measured) was. Unchanged propofol could have been 0.3% or 0%. ALL of the radioactivity might have been from a metabolite. This blows the defense out of the water on unchanged propofol in the urine.
 
Dr White and Dr Shafer will no longer be friends .....
 
in the 2002 article did they address more prior research and the Simons Article? Yes. Almost the entire article is contrasting with the Simons paper. The Simons paper says what they measured could have been just metabolites. The 2002 article confirms that it was indeed just metabolites, backing up the Simons paper's suggestion. Technology is far better so they can actually measure the unchanged propofol levels vs metabolite, unlike in the days of the Simons article.
 
The obtained results may suggest that propofol in an unchanged form is not excreted by kidneys at all provided that all propofol determined in presented study originated from conjugates hydrolysis
Click to expand...

this is from an abstract of that article
 
Walgren asks if Shafer is aware of the 0.15 micrograms/ml in the autopsy, and the urine was 550ml. Shafer says yes. Converting that into micrograms, you come up with 82.5.

Walgren marks another exhibit, people's #248. It's Table 1 from the 2002 paper. Asking Shafer to explain the data.
 
It's a study done in 5 patients undergoing major surgery who had continuous propofol infusions during the surgery. The first column is the duration of propofol infusion, it usually ran longer than the surgery which is what you expect. The next part he looks at shows the total amount of propofol delivered. From a low of 1300mg to a high of 3300mg. The average amount winds up being 2000mg. The next is the volume of the urine. Shafer wants to focus on the amount of excreted unchanged propofol in relation to Michael's urine.

What you see is that the average is 70.71 micrograms. Quite close to Michael's. 70.71 vs 82.5 very similar. You can see that the 70.71 number came from a dosage of 2000mg.

This suggests Michael received MORE propofol than was suggested by Shafer's simulations.

In a standard of care, would Shafer agree that in any requisite of standard of care, that the delivery of propofol would require a much GREATER level of care in a home than in a hospital or medical setting? Shafer says yes. In a remote location there's less tolerance for error. You need to be very careful and adhere to standards. You have no backup. You're by yourself. In a remote location the teaching is that you take NO SHORTCUTS.

If there were such a thing as "bedroom-based anesthesia" the standard guidelines would be considered an absolute minimum. An error means a mortality.

Walgren ends direct.
 
Holy ish! They got the urine pegged that Michael received MORE propofol than both White or Shafer simulated. :blink:
 
According to the exhibit it seems Michael was given more than 2000mg of propofol
 
Flanagan begins cross.

In Dr. Shafer's report, didn't he indicate that lidocaine injected would correspond with lidocaine found in the femoral vein? Shafer wants to see the report.
 
Oh gosh, here we go with Flanagan! Did anyone else see him and Chernoff laughing to each other earlier on when Shafer was talking about it being possible to remove some of the contents of the propofol bottle and replacing it with lidocaine?
 
Flanagan re-asks question. Shafer says the report did not indicate that.

The report suggests initially a mixing of 10ml of lidocaine with 100ml of propofol and performs a simulation. The simulation does not give a high level and suggests the 10:1 ratio was probably wrong. Probably Murray didn't use standard dilutions, but probably diluted lidocaine with propofol 1:1.
 
Court starts
Chernoff says the defense is resting now,


Walgren calls Shafer as a rebuttal witness


Walgren asking Shafer about lorazepam, asks if lorazepam if given by iv still enter the stomach or not, shafer says yes they go to all the tissues, brain, stomach, musclles etc
shafer says it has nothing to do with post mortem redistribution,
walgren asks if there is a scientific way of excluding mj swalloing lorazepam or murray giving him it via iv, shafer says both are the same scientificly
walgren asks about his theory of an iv line running, asks if he ever designated a precise time of mjs tod, shafer says no, he wasn't showing any specific time
but just the way, he says his models doesnt mention precise times but just that mj had a lot of propofol when he died.
walgren asks about him using two infusion lines like he used in his demonstration, shafer says that's the common way to use it.
walgren wants to know about the gravity when it comes to the iv lines, and saline, shafer goes on about the roller clamps and how one could control the amount, and speed
walgren asks if one ususally controls it via those clamps shafer says no usually u use an infusion pumb but in this case that was the only way.
walgren wants to know about the lidocaine levels and if he'd incorporated them in his models, shafer says yes but they dont change his models, says it's consistent.
walgren now asks about the risks about propofol shafer says the serious risk is lack of breathing, stoping of breathing, either by the lack of ability or the tongue falling into the airvy
walgren asks if he thinks that's what happened to michael, shafer says yes he thinks thats what happened, says lack of oxygen kills the heart etc
Walgreen wants to know if he'd viewed whtie's simulations and the various literature on the amount of propofol n the urine,
walgren wants to know if he is aware of the simon's article the one the defense relied upon, shafer says he is, shafer says the ones that meassured the levels didn't know what they were meassuring says they didn't meassure unchanged propofol but something called
hexa.. says they didn't know if they were meassuring propofol or propofol free metabolite.
Walgren wants to know if he is aware that White relied on that Simon's article and conducted additional research relying upon it, Shafer says yes he is, Walgren brings up a more recent article White says that's the article from 2002 and says that in that article it addressed the priior research
and the 1988 study, says the 2002 articles mentions the simons meassurements wasn't that precise says the 2002 article states that the actual amount of propofol would be a lot lesser than 0/3 percent meassured in the simons 1988 article.
Shafer says they were able to be more precise due to technological improvement.


walgren asks about the actual amount of unchanged propofol in the 2002 article shafer says they meassured 0.004, says that's more specific.
walgren asks him the amounts of propofol in the autopsy and scene urine, shafer converts it to micrograms per mili liter.

walgren showing the table 1 of the 2002 article, wants shafer to explain the amounts specifically
shfer says that's a study done in 5 patients undergoing major surgery, says the table shows how long the surgery lasted )(in mins) says the infusion ran longer than the surgery in the table
says the total amount of propofol in each dose is shown in the table, says the average amount of prop is 2000 miligrams
shafer wants to focus on the amount of excredeted unchanged propofol says that's the real issue here. says the average of unchanged propofol was 70.71 micrograms of propofol says that's very similar to what was found in michael 80 point something
walgren asks if the amount is an average amount (70.71) shafer says yes.
Walgren goes on about standard of care, how the safety settings in a home setting should even be greater than in an office setting or hospital setting. shafer says yes, cuz cuz in remote locations u dont have any backup and the standards should be even higher, says the normal standard guidelines should be considered minimal in remote locations or even
home settings as there would be air which means mortality.


walgren's done flanny crossing now.
flanny asking about the 5 mililitres of lidocaine injected between the hours of 10 and 12 would equal the amount found in the autopsy, shafer says no the report doesn't state this,




Couldn't follow all of it my stream froze for like 1 min or 2.


flanny asks if he rejected the simon's article shafer says no he hasn't rejected the article but flangans interpretation, says the principle investigator agrees with him now.
faln wants shafer to assume mike weighed 61kg says the 25mg means 4, 7mg/kg shafer says in a patient that has no other meds on board it would be pre anasthetic/sub anathetic,
 
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Shafer says that Flanagan misread his report. Flanagan asks him to read the entire last sentence of the report. Suggesting that Shafer's report coincides with defense notions of lidocaine.
 
Flanagan says Shafer rejected the Simons article. Shafer says the Simons article is fine, but that you have to interpret it properly. He discussed it with the author of the article and the author agreed with Shafer.

Flanagan brings exhibit #247 by HPLC.
 
Lol at Flamazepam, he was standing there like "ok, now I am screwed, what to say now?"
 
Flanagan points out the article distinguishing between anesthesia levels and sub-anesthesia levels. Shafer says sure, but he's not sure why Flanagan brings it up since it seems pointless to do so.
 
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