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Hier der entsprechende Fakten-Thread zum heutigen Prozesstag.
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13. Prozeßtag - Mi. 19.10.2011
33. Zeuge: Steven Shafer - Anästhesist / Fortsetzung der Vernehmung durch Walgren
Walgren geht nochmals ueber Dr. Shafer's Referenzen und zeigt dazu ein Magazin, bei dem er Chef-Editor ist, und mehrere Forschungsartikel, die Dr. Shafer geschrieben hat. Die Artikel untersuchen die Unterschiede in Bezug auf Geschlecht und Alter. Dr. Shafer hat auch Lorazepam, Midazolam und Lidocain erforscht. Walgren sagt, dass er nach diesen Dingen fragen wird.
Walgren erwaehnt Unterschiede zwischen Intensiv-Sedierung und Sedierung in Zusammenhang mit einem Eingriff (MAC). Dr. Shafer sagt, Intensiv-Sedierung ist fuer laengere Zeit, MAC ist kuerzer.
Dr. Shafer sagt, all die Arbeit, die er fuer diesen Fall gemacht hat, macht er gratis. Er sagt, er hat nie Geld verlangt fuer Aussagen, weil er denkt, es ist unangebracht und unethisch von einem medizinischen Unglueck zu profitieren. Shafer sagt, er will auch nicht, dass seine Integritaet in Frage gestellt wird. Shafer sagt ausserdem, er will auch das generelle Vertrauen der Oeffentlichkeit in Narkose und Aerzte wiederherstellen. Dr. Shafer sagt, dass er taeglich von Patienten gefragt wird - "Werden Sie mir das Medikament geben, das Michael Jackson umgebracht hat?". Er sagt, er hofft, dass er mit seiner Aussage die unnoetige Angst mildern kann.
Vormittagspause
Dr. Shafer hat einige medizinische Gegenstaende zur Demonstration mitgebracht. Er beginnt damit, IV-Beutel mit Kochsalzloesung und dessen Anschluesse zu erklaeren. Dann erklaert er, was ein IV ist. Infusion (Drip) heisst, das Medikament wird langsam "eingetropft". Shafer erklaert, Propofol ist in einer Glasampulle mit einem Aluminium-Siegel und einem Gummi-Stopper. Um das Medikament herauszubekommen, muss man durch den Gummi-Stopper stechen, mit einer Nadel oder einem grossen Spike. Walgren bittet Shafer zu demonstrieren, wie man Propofol aus der Ampulle bekommt.
Shafer demonstriert, wie man Propofol mit einer Nadel/Spritze aus der Ampulle bekommt. Shafer sagt, um das Propofol herauszubekommen, muss man das Propofol in der Ampulle mit Luft ersetzen, damit das Propofol in die Nadel geht.
Walgren bittet Dr. Shafer, die 100-ml-Ampulle Propofol vom Tatort zu untersuchen. Shafer sagt, sie hat ein Loch von einem Spike, nicht von einer Nadel.
Dr. Shafer hat fuer den Fall ein Video gemacht, um zu demonstrieren, was notwendig ist fuer eine Sedierung, sogar fuer 25 mg Propofol. Das Video wird gespielt: "Ein Ueberblick ueber die sichere Gabe von Sedierung".
Der Arzt bereitet zuerst den Raum vor, ueberprueft das Equipment. Das Video zeigt mehrere Vorrichtungen fuer die Handhabung der Luftwege wie einen Schlauch fuer den Hals, einen Schlauch fuer die Nase, Equipment fuer Intubation, eine Atemmaske. Der Arzt organisiert diese Dinge.
Dann ueberprueft der Arzt das Equipment fuer Sauerstoff. Der Arzt ueberprueft, ob die Sauerstoff-Zufuhr funktioniert, ueberprueft die Nasenkanuele, ueberprueft am Kapnometer, ob die Nasenkanuele das Kohlendioxid misst. Der Arzt ueberprueft den Narkose-Atem-Kreis. Das ist das Equipment, das benuetzt wird, wenn der Patient aufhoert zu atmen und der Arzt Sauerstoff in die Lungen pumpen muss. Der Arzt ueberprueft dann den Reservesauerstoff. Das wird benuetzt, wenn der Atem-Kreis fehlschlaegt.
Der Arzt ueberprueft dann die Absaug-Vorrichtung. Das ist wichtig, denn wenn Mageninhalt oder Gallenfluessigkeit durch Uebergeben in die Lunge geraet, wuerde das die Lunge zerstoeren. Deshalb wird Patienten gesagt, nichts zu essen oder zu trinken vor einer Narkose. Wenn sich der Patient uebergibt oder Mageninhalt in den Mund geraet, muss der Arzt das sehr schnell mit dem Absaug-Geraet reinigen, bevor es in die Lunge kommt und diese zerstoert.
Der naechste Schritt ist es, die Infusionspumpe einzustellen. Es dauert einige Minuten, diese einzustellen. Im Video benuetzen sie eine Spritzenpumpe. Der Arzt zieht zuerst das Propofol in die Spritze. Wie Dr. Shafer demonstriert hat, ist das nicht einfach. Man muss Luft in die Spritze ziehen und mehrere Zuege machen, um die Spritze zu fuellen. Dr. Shafer sagt, dass ein enger Schlauch mit der Infusionspumpe benuetzt werden muss, weil ein weiterer Schlauch problematisch sein koennte. Dann programmiert der Arzt die Pumpe, gibt das Gewicht des Patienten ein, den Medikamentennamen, die Infusionsrate. Der Arzt ueberprueft die Eingaben nochmals.
Der naechste Schritt ist es, den Patienten zu evaluieren. Der Narkosefacharzt ist dafuer verantwortlich, den Patienten zu kennen. Er macht eine koerperliche Untersuchung, die Atemwege, hoert sich die Lunge an, ueberprueft das Herz. Das wird immer gemacht fuer jeden Patienten, fuer jeden Eingriff. Keine Ausnahmen.
Der Arzt bekommt auch die "informierte Zustimmung" des Patienten. Der Arzt informiert den Patienten ueber die Risiken und was bei dem Eingriff passiert, fragt den Patienten, ob er irgendwelche Fragen hat, dann unterschreibt der Patient das Formular ueber die "informierte Zustimmung". Dr. Shafer sagt, muendliche Zustimmung ist nicht bindend und deshalb nicht anerkannt.
Einige Schritte werden nicht im Video gezeigt, und zwar die folgenden: Patient wird auf den Tisch gelegt, Equipment wie eine Blutdruckmanschette, Pulsoximeter, EKG werden dem Patienten angelegt. Sauerstoff wird angelegt, intravenoeser Katheder wird angelegt. Danach pausiert der Arzt, um alles nochmals zu ueberpruefen. Der Arzt macht noch eine letzte Ueberpruefung, bevor er das Propofol injiziert.
Die Infusionspumpe mit Propofol wird gestartet. Der Narkosefacharzt ist nah beim Patienten, beobachtet den Patienten. Der Arzt macht Notizen zu den Vitalwerten. Der Chart ist notwendig, um den Patienten und die Muster nachzuvollziehen. Es ist die Verantwortung des Arztes gegenueber dem Patienten.
Im naechsten Teil des Videos werden Beispiele gezeigt, was schief gehen kann.
Das erste Beispiel ist, wenn der Blutdruck faellt. Dr. Shafer sagt, das ist sehr haeufig und man sieht das jeden Tag. Propofol senkt den Blutdruck, besonders, wenn der Patient dehydriert ist. Der Arzt gibt Ephedrin durch den IV. Generell hebt das den Blutdruck auf ein normales Level.
Das zweite Beispiel ist Kohlendioxid. Der Monitor zeigt, dass das Kohlendioxid gestoppt hat. Das heisst, der Patient atmet nicht aus und die Atemwege sind blockiert. Der Arzt hebt sofort das Kinn und macht einen "Kiefer-Handgriff". Dr. Shafer sagt, das ist auch Routine. Shafer sagt, der haeufigste Grund ist, dass die Zunge die Atemwege blockiert, und wenn man das Kinn hebt und den "Kiefer-Handgriff" vornimmt, bewegt das die Zunge.
Das dritte Beispiel ist Atemstillstand. Das passiert, wenn der Patient nicht einmal mehr versucht zu atmen. In diesem Fall muss man das fuer den Patienten uebernehmen und Luft in die Lunge pumpen. Der Arzt entfernt die Nasenkanuele, platziert die Maske ueber den Mund und die Nase des Patienten und drueckt den Beutel, um Sauerstoff in die Lunge zu pumpen.
Das vierte Beispiel ist Aspiration (nicht im Video gezeigt) - wenn der Patient sich uebergibt und/oder Mageninhalt in den Mund gelangt. Der Patient wird auf die Seite gelegt und vor dem naechsten Atemzug muss alles abgesaugt werden.
Das fuenfte Beispiel ist Herzstillstand. Das Herz hoert auf zu schlagen und der Patient hoert auf zu atmen. Der Arzt ueberprueft binnen 2 - 3 Sekunden, ob der Monitor das richtig anzeigt. Dann ruft der Arzt um Hilfe. Das erste, was man macht, ist, immer nach Hilfe zu rufen. Eine Person beginnt mit CPR, eine Person beatmet den Patienten und eine Person gibt Medikamente zur Wiederbelebung. All das wird gemacht, um den Patienten lang genug am Leben zu erhalten, damit man das Problem, das den Herzstillstand verursacht hat, reparieren kann. Diese Anstrengungen werden weitergefueht, bis der Patient wiederbelebt ist oder bis er fuer tot erklaert wird.
Mittagspause
Vielen Dank Cosima
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Zeuge der Anklage Tag 13:
Dr. Steven Shafer, Prof. für Anästhesie - Columbia University
Hier die Videos zu Tag 13 .......
part 1:
part 2:
Kommentar
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20. Oktober 2011, 10:30 Uhr
Prozess um Conrad Murray Anästhesist belastet Michael Jacksons Leibarzt
Conrad Murray wurde im laufenden Verfahren um den Tod von Michael Jackson erneut belastet. Narkose-Experte Steven Shafer machte dem Arzt schwere Vorwürfe, er habe beim Umgang mit dem Arzneimittel Propofol medizinische Standards nicht beachtet.
Der Anästhesie-Experte Steven Shafer trat am Mittwoch im Verfahren gegen den Hausarzt des verstorbenen Michael Jackson in den Zeugenstand. Die Gerichtsmediziner bestätigten bereits, dass der Popstar an einer akuten Propofol-Vergiftung starb. Zudem erklärten sie, dass in seinem Körper auch das Medikament Lorazepram gefunden wurde.
Shafer hat die grundsätzliche Verwendung Propofols nun verteidigt, das Medikament sei von Conrad Murray jedoch falsch angewendet worden. "Propofol ist ein außergewöhnliches Medikament. Ich möchte, dass die Menschen verstehen, dass es ein gutes Medikament ist, wenn es von jemandem verabreicht wird, der etwas davon versteht." Was in Michael Jacksons Fall passiert sei, habe nichts mit einer normalen Propofol-Behandlung zu tun. "Jeden Tag sage ich den Patienten im Operationssaal, was ich machen werde, und jeden Tag werde ich gefragt: 'Geben sie mir das Medikament, das Michael Jackson umgebracht hat?'"
Er sei der Meinung, dass Murray immer wieder gegen die gängigen Standards bei der Verwendung des Mittels verstoßen habe. Auch sei der ehemalige Leibarzt des Sängers eher ein Angestellter als ein Arzt des Musikers gewesen und hätte ihm deshalb aus medizinischer Sicht das Mittel gar nicht verabreichen dürfen.
Murray drohen vier Jahre Haft
Anschließend bekamen die Geschworenen ein Video vorgeführt, in dem gezeigt wurde, wie Propofol im Tagesgeschäft eines Krankenhauses eingesetzt wird. Durch die Aufnahmen wurde deutlich, wie wichtig es ist, bei Auffälligkeiten sofort Hilfe zu rufen. Murray wird jedoch vorgeworfen, dass er 20 Minuten lang telefoniert habe, nachdem er festgestellt hatte, dass sein Patient nicht mehr atmete.
Sollte der Leibarzt für schuldig befunden und wegen fahrlässiger Tötung verurteilt werden, könnte Murray für vier Jahre lang ins Gefängnis wandern.Kommentar
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Leibarzt war äußerst nachlässig
Im Prozess gegen Michael Jacksons früheren Leibarzt Conrad Murray hat ein Mediziner den Arzt als äußerst nachlässig kritisiert. Der Popstar habe vor seinem Tod jede Nacht nach dem Narkosemittel Propofol verlangt und Murray habe es ihm, ohne zu zögern, verabreicht.
Das sagte der Anästhesist Steven Shafer am Mittwoch (Ortszeit) vor einem Gericht in Los Angeles. "Ein Arzt hätte gesagt: 'Ich gebe dir nichts, du hast eine Schlafstörung.'"
Murray hingegen habe sich wie ein "folgsamer Angestellter" verhalten, statt das Wohl seines Patienten vorn anzustellen. "Seine medizinische Urteilskraft hat er nicht angewandt", sagte Shafer über Murray.
Die Staatsanwaltschaft wirft Murray vor, Jackson eine Überdosis Propofol gegeben und ihn dann vernachlässigt zu haben, was zum Tod des King of Pop geführt habe.
Im Falle eines Schuldspruchs wegen fahrlässiger Tötung drohen ihm bis zu vier Jahre Haft. Bereits vor einigen Tagen hatte ein Herzspezialist dem Mediziner Versagen vorgeworfen und vor Gericht erklärt, der Sänger hätte bei richtigem Verhalten seines Leibarztes gerettet werden können.
Shafer bezeichnete Murrays Verhalten vor Gericht als "ungeheuerlich und skrupellos". Einer der größten Fehler des Arztes sei es gewesen, Jackson bedingungslos jeden Wunsch zu erfüllen. Zudem habe er sich mit der genauen Wirkung des Narkosemittels nicht gut genug ausgekannt.
Propofol sei bei richtiger Anwendung ein "hervorragendes Medikament", sagte der Anästhesist. Murray hingegen habe für Jackson in den 80 Tagen vor seinem Tod rund 15,5 Liter des Mittels besorgt. Das sei eine "außergewöhnlich" hohe Medikamentenmenge für einen einzelnen Patienten.
http://www.rp-online.de/panorama/aus...d_1028123.htmlKommentar
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With L.O.V.E. and respectMurray Trial Day 13 , October 19, 2011
Dr. Shafer Testimony continued
Walgren Direct continued
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Walgren goes over again the credentials of Dr. Shafer by showing the journal he's editor in chief and multiple research articles written by Dr. Shafer. Research articles examine the differences in regards to gender, age. Dr. Shafer also had research done on Lorazepam, Midazolam and Lidocaine. DA Walgren says that he will ask about these topics during testimony.
Walgren mentions difference between intensive care sedation and procedure related sedation (MAC). Dr. Shafer tells that intensive care sedation would be for longer time, MAC would be shorter.
Dr. shafer says that all the work he has done on this case was for free. He says he never charged money for testimony because he feels it's inappropriate and unethical to benefit from medical misadventures. Shafer says he doesn't want his integrity to be questionned as well Shafer also says he wanted to get involved in this case to restore general public's confidence in anesthesia and doctors. Dr. Shafer says that he's asked daily by his patients " Are you going to give me that drug that killed Michael Jackson?". He says that he hopes to alleviate this unneeded fear with his testimony.
mid morning break
Dr. Shafer has brought several medical items for demonstration. First he starts with explaining Saline bag and it's ports. Later Shafer tells what and IV is. Infusion(Drip) when drug drips in slowly. Shafer explains that Propofol comes in a glass vial, there's an aliminium seal and a rubber stopper on top. To get the drug out you need to go through with a slow needle or a large spike to get the drug out.
Walgren asks Shafer to demonstrate to get Propofol out of the bottle.
Shafer demonstrates to get out Propofol with a syringe / needle. Shafer tells to get Propofol out you need to replace Propofol with air so that Propofol will go into the needle.
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Walgren asks Dr. Shafer to examine 100 ml Propofol bottle from the scene. Shaffer says that it has a spike hole and not a needle hole.
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Dr Shafer has made a video for his case, to demonstrate what is necessary for sedation, even for 25mg propofol. Playing the video : «*an over view of safe administration of sedation*»
The doctor first prepares the room, checks the equipment. Video shows multiple equipment for airway management such a tube for the throat, a tube for the nose, an equipment for intibation, a throat mask for air. Organizes these items.
Then the doctor checks the oxygen equipment. Doctor checks if the oxygen supply work, checks nasal cannula, checks to see if nasal cannula is measuring carbon dioxide by capnometer. Doctor tests anesthesia breathing circuit. This is the equipment used if the patient stops breathing and the doctor needs to push oxygen into the lungs. Doctor then checks the back up oxygen. This is used if for some reason the breathing circuit fails.
Doctor then checks suction apparatus. This is important because if the contents of the stomach gets into the lungs or if the vomit (bile) gets into the lung, it would destroy the lungs. This is why patients are told to not to eat or drink prior to anesthesia. if the patient vomits or the contents of the stomach come to the mouth, the doctor has to be very quick to clean them with the suction equipment before it goes into the lungs and destroys the lungs.
Next step is to set up the infusion pump. It takes a few minutes to set it up. In the video they use a syringe pump. Doctor first draws Propofol into the syringe. As Dr. Shafer demonstrated this is not easy. You need to draw air into the syringe and do multiple draws to fill the syringe. Dr. Shafer tells a narrow tubing has to be used in the infusion pump as the wide tubing could be problematic. Then the doctor programs the pump, putting the patients weight, correct drug name, infusion rate. Doctor verifies the information for a second time.
Next step is to assess the patient. Anesthesiologist is repsonsible for knowing his patient. Makes a physical examination, first thing is airway, listens to the lungs, checks the heart. Always done for each procedure, for every patient. No exception.
Doctor also gets the informed consent of the patient. Doctor informs the patient of risks and explains what the procedure entails, asks the patient if he has any questions, then patient signs the informed consent form. Dr. Shafer says oral consent is not binding, and is not recognized.
Some steps are not shown on the video. These are: patient put on table, monitoring equipment such as blood pressure cuff, pulse oximeter, ECG are put on patient. Oxygen in place, intravenous catheter is put into the patient. Afther these doctor pauses to verify again. Doctor does one last check before injecting the propofol.
Propofol infusion pump is started. Anesthesiologist is close to the patient, monitors the patient. Doctor keeps records of the vitals. Chart is a necessity to track the patient and the patterns. It's a responsibility to the patient.
In this part of the video, we are shown examples of what can go wrong.
First example is when blood pressure drops. Dr. Shafer says this is very common and they see it everyday. Propofol lowers blood pressure especially if the patient is dehydrates. Doctor gives ephedrine through the IV line. Generally blood pressure comes to normal levels.
Second example is carbon dioxide. The monitor shows that carbon dioxide stopped. It means the patient is not exhaling and the airway is obstructed. Doctor immediately does chin lift and jaw thrust. Dr. Shafer this is also done very routinely. Shafer says the most common reason is because the tongue is blocking the airway and by doing a chin lift and jaw thrust you can move the tongue.
Third example is apnea. This is when the patient doesn't even try to breath. In this instance you need to take over for the patient and force air into the lungs. Doctor removes the nasal cannula, places the mask on the patient's mouth and nose and squeeze the bag to push oxygen into the lungs.
Fourth example is aspiration (not shown on video). This is when the patient vomits and/or stomach contents come to the mouth. Patient is turned sideways and before the next breath you need to suction everything.
Fifth example is cardiac arrest. Heart stops beathing and the patient stops breathing. Doctor does a 2-3 second assesment to make sure that the monitor has not failed. Then the doctor calls for help. First thing is always to call for help. One person begins CPR, one person is ventilating the patient and other person gives resuscitation drugs. Alls of this is done to keep the patient alive for enough time to fix the problem that caused the arrest. These efforts are continued until the patient is revived, or is pronouced dead.
Lunch break
Murray Trial Day 13 , October 19, 2011
Afternoon session
Dr. Shafer Testimony continued
Walgren Direct continued
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Dr. Shafer says that the safeguards and requirements apply to all doctors who perform sedation, for any type of IV sedatives. Some nurses are also trained about sedation. These guidelines apply to them as well.
Walgren asks if CM's intent were to give 25mg would these standards still apply. Shafer says yes and continues to say the patient (MJ) had other IV sedatives, profound inability to sleep, he was exhausted, dehydrated; and he had been given sedatives for some time and he could have saome elements of dependency or withdrawal.
Walgren asks if it possible to go in saying I'll only give a small amount so I don't need these guidelines. Dr. Shafer says it's a trap. Even for a little sedation , it's a slippery slope, you may have to give more. You never know how the patient will react. Shafer says there's no such thing as a little sedation and the worst disasters happen when people cut corners.
Facts in this case suggest that virtually none of the safeguards for sedation were in place when propofol was administered to MJ.
Walgren asks Shafer explain how patients reacts different to the same dose of sedatives. Shafer says that some patients will need half the usual dose and some patients will need double the dose. Shafer says 25 mg is the limit when a patient migh stop breathing. Shafer says you can't assume that this will be an average patient. Shafer says you always assume your patient is at the edge of sensitivity and prepare for the worst case scenario.
Shafer did a report about this case dated April 15th, 2011. In his report he used some terms.
Minor violation : not consistent with standard of care, but would not expect to cause harm for the patient unless there are several other violations
Serious violation : expected to cause harm to the patient, in combination of other violations
Egregious violation : These should never happen in the hand of comptent doctors. An egeregious violation can alone be catastrophic for the patient. Competent doctors know that bad outcome is a high possibility
Unconscionable vioation : It goes beyond the standard of care. It's an ethical and moral violation as well as a medical violation.
Walgren goes over Dr. Shafer's report and 17 egregious violations he identified.
Lack of basic airway equipment, egregious violation. MJ died because he stopped breathing which is expected when you give IV sedatives. It must be there without question.
Walgren asks Dr. Shafer assume that CM had left only for 2 minutes and CM had the equipment if MJ could have been saved? Dr. Shafer says yes and probably MJ had an obstructed airway and even a simple chin lift might have been required to save MJ. Shafer says that CM says he didn't use the ambu bag. Shafer says mouth to mouth is less effective and gives used air.
Lack of advanced airway equipment. Those are eqipment such as laryngeal mask, or laryngoscope and endotracheal tube. Shafer had described it a a serious deviation originally but changed his mind to en egregious because of the setting. CM had no help.
Shafer says that it's his view that CM had anticipated to give 100 ml vials. CM had purchased at least 130 100 ml vials, Shafer believes that's at least one per night. Shafer says it's an extraordinary amount for one patient; between april – to 25th june, that 80 nights, 1937 mg/night. Walgren asks how he came to this determination. Shafer says Propofol is an environment for bacteria dveelopment. Once a bottle is opened with a needle, it has to be used within 6 hours. Shafer says this suggests CM planned to use 100ml, if he didn't he would purchase smaller vials.
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Lack of suction apparatus, egregious violation. Shafer reminds the jury that any stomach content and/or vomit has to be suctioned so that it won't go into the lungs. Shafer says there's no evidence that MJ was asked to fast for 8 hours prior being given Propofol. Due to this MJ was at greatly higher risk. Therefore a suction equipment was needed.
Lack of infusion pump, egregious violation . There was no infusion pump. Without it the rate can not be precisely controled and the risk of overdose is very high. Shafer says in his opinion this is likely contributed to MJ's death.
Walgren asks without an infusion pump how can one person control the drip. Shafer answers by roller clamp. It's a plastic wheel that pinches the tubing to decrease the amount . Shafer says it's extremely imprecise and that was the only thing available to CM when he gave propofol.
Lack of pulse oximetry, egregious violation . The pulse oxieter that CM used was completely inappropriate. It's not intended to be used for continuous care as it had no alarm. Shafer says that on monitors in hospital they can see it on the screen and there is a tone. Doctors will hear the tone changes which alerts them that there's a problem. In MJ's case only way to monitor was to take his hand and continoiusly look to it. If there was a proper equipment, there would be a monitor showing the vital signs from distance and there would be an alarm that could have saved MJ's life.
Lack of blood pressure cuff,egregious violation. Propofol lowers everyone's blood pressure. Doctors would treat it with additional saline solution or with less propofol. MJ was dehydrated, the risk are higher for exagerated response. If blood pressure falls the body shuts down the flow to the arms and legs and concentrates on providing blood to heart and the brain. The drug becomes more potent. Dr. Shafer says the manual blood pressure cuff that CM had in his bag in the cabinet is useless.
Lack of ECG, egregious violation . ECG allows you te see he heart rate, the heart rythm. This is routine monitoring. In this case CM couldn't know what kind of therapy to use when MJ went into arrest.
Lack of capnography, an egregious violation. Dr. Shafer initially thought that it was not a violation as other specialist doesn't use it. However in MJ's environment it was a disaster. If CM had it he would have known immediately that MJ had stopped breathing.
Lack of emergency drugs, serious violation. Dr. Shafer doesn't think lack of emergency drugs contributed to MJ's death. Shafer says if MJ had a low blood pressure as he wasn't going through surgery, MJ could have been woken up and hydration and stopping propofol would have been enough.
Lack of charts, egregious violation as well as unethical. Shafer says a doctor needs charts to asses what's going on and the changes. Shafer says the patient or if the patient doesn't survive the family has a right to know what happened and what the doctor did.
Dr. Shafer gives an example and Dr. Shafer looks clearly upset. Dr. Shafer says he knows how he would feel if his father , brother or son went to a medical facility for 80 days and died and the doctors told him they don't know what happened because they have no reports. Dr.Shafer says it's unbelieveable that after 80 days of treatment there's not a single record of treatment. Dr.Shafer says that not keeping records is also illegal in California. Dr. Shafer says that doctors has to keep records even if the patient doesn't want them and confidentiality cannot be an excuse.
Shafer says that in CM's interview he mentioned MJ could have been dependent on Propofol and that would require a referral but he can't do that referral as he had no records.
Obligation to get information about the patient. Shafer says it's doctors responsability to know everything about their patient to provide care. Shafer says CM mentions IV sites but didn't follow it through and asked what's happening. Walgren asks what if the patient says it's none of your business, Shafer says that then he would say "Then I can not be your doctor".
Dr. Shafer the only physical evidence of Michael was done months ago. Shafer says CM mentioning MJ being dehydrated but yet he do a simple blood pressure check. Shafer says there's no history, not even a simple recording of the vital signs. Shafer calls this serious violation and that no doctor does that.
Failure to maintain a doctor patient relationship , egregious violation. In this relationship doctor would put the patient first. It doesn't meean to do what the patient asks, it's to do what's best for patient. If patient asks for something foolish or dangerous, doctor should have said no. Dr. Shafer describes the relation between Cm and MJ as employer employee relationship. Patient stated what he wanted, CM says yes. Shafer compares CM to a housekeeper that does what she's told. That's what an employee does. Shafer says CM was not exercising his medical judgement and he was not acting in MJ's best interest. CM completely abandonned medical judgement.Shafer says the very first time MJ asked for propofol, CM should have sent MJ to a sleep specialist.
Lack of Inormed consent , egregious and unconscinable. An informed consent would have involved that propofol is not a treatment for insomnia, It woud have explained risk of death and alternative treatments. Dr. Shafer says there's no proof that MJ knew that he was putting his life at risk. Shafer again mentions that the consent has to be written. MJ was denied his right o make an informed decision.
Need to continuously observe the mental satus, egregious and unconscinable. Dr. Shafer says that doctors need to stay with the patient and CM abadonned his patient. Shafer compares giving sedation to driving a motor home. Shafer says you cannot leave the steering wheel on a highway to relieve yourself. If you do it would be an disaster. Dr. Shafer says in 25 years he has been a physician he have never walked out of the room.
Continious monitoring / observation, egregious violation . CM left MJ alone and he was on the phone. Shafer says youcan't multi task especially if you have no monitoring equipment. Dr. Shafer a patient who is about to die, doesn't look that different from a patient that is okay. Dr. Shafer says from a distance you can't tell if a person is breathing. Shafer says he believes Murray may have been in the room and have not realised MJ stopped breathing.
Shafer says resuciation would have been easy as all needed is to stop propofol and make MJ beathe. Shafer once ahain reminds that it's common that patients would stop breathing during anesthesia and it's expected. Shafer says all CM was monitoring all he needed to do was to lift the chin and ventilate.
mid afternoon break
Lack of continuous documentions, egregius and unconscionable violation. Dr. Shafer says documentation is part of giving care. Shafer says if CM had the reports he would have seen that the oxygen saturation lowered or the heart rythm changed.
Failure to call 911 timely, egregious violation. Shafer says in that setting MJ could not have been revived without assistance. Shafer says calling 911 was the highest priority given the lack of help and equipment. Shafer says if calling 911 was not possible, Propofol should not been given at all.
Shafer says assuming CM realised there was a problem at 12:00 he doesn't understand that CM left a voice message to MAW and how it took 20 mn to call 911. Shafer calls it unconceivable and completely and utterly inexcusable.
Shafer says if CM left only for 2 minutes and called paramedics immediately MJ would be alive with some brain damage. If CM realized MJ was in trouble in 2 minutes and had the airway equipment MJ would be alive and uninjured.
Walgren asks how effective is a one handed CPR on a bed. Shafer says the patient sinks into the bed and it's ineffective. Even if CM had his hand behind Mj's back it's ineffective because you need your body weight to do effective CPR. Shafer says you need 2 hands, one hand is not enough. Shafer says CM hould have called 911 first and then moved Mj to the floor. Shafer also says based on CM's interview the issue here was not that the heart stopped; MJe stopped breathing. CM said there was pulse. If there was a pulse what he needed to do was to have oxygen into his lungs. There was no need for CPR if there was a pulse. Shafer says a lay person would use mouth to mouth as they have no other means. For a doctor it shows that the doctor doesn't have equipment needed.
Shafer says that he doesn't understand why CM raised MJ's legs. Shafer calls it a waste of time. Shafer says raising the legs is done when you thing there's not enough blood in the heart but that wasn't MJ's problem. His breathing had stopped. Shafer says that it shows CM was clueless about what to do.
Walgren asks what is flumazenil. Shafer explains it's a frug that reverses the effects of lorazepam and midazolam. Dr. Shafer says he's curious why CM gave it. Shafer says it doesn't fit with only giving 2 doses of 2 mg several hours before. Dr. Shafer says he believes that CM knew that there was a lot more lorazepam.
Dr. Shafer talks about deception of paramedics and UCLA doctors and not mentionning propofol, egregious and unconscionable violation. Dr. Shafer says a person's life was in the balance, it's inexcusable. Shafer says he also mischaracterized this event as a witnessed arrest. Shafer says a witnessed arrest is not an arrest for lack of breathing, it is usually something like a heart attack. So the therapy of the paramedics and ER doctors was not appropriate. In an arrest you have only seconds to choose a treatment, paramedics and ER doctors were not given the corect information. Shafer says witholding information is a violation of patient's trust.
Walgren asks what is polypharmacy. Shafer explains it's administering many drugs at once and it's a serious violation. Shafer says what CM gave to MJ didn't make any sense. Shafer says Midazolam and lorazepam are very similar drugs and the only difference is how long they stay in the system. Shafer says he doesn't understand why CM switched from midazolam to lorazepam and back. Shafer says that he thinks that CM did not understand the drugs he was giving.
Walgren asks if 25mg Propofol is a safe dose. Shafer says in this setting there was no safe dose. Midazolam an lorazepam were given. MJ had received benzos for 80 nights, he could have been dependant or in withdrawal from the benzos or propofol. Dr. Shafer says he never heard a person given propofol for 80 nights and doesn't know what would happen.
Walgren asks about the Taiwan study. Shafer says there are over 13000 medical articles about propofol, 2500 articles about propofol and sedation and there's only one article on Propofol and insomnia. It's this study done in 2010. Dr. Shafer says that he wouldn't published the Taiwan study because the dose of Propofol that was given is not mentioned. Dr. Shafer also says that the conditions of the study doesn't apply here. That study was done in a hospital, by anesthesiolgists, patients had fasted for 8 hours, they were monitored, an infusion pump was used, propofol was used for 2 hours for 5 days during two weeks. There was no other medication. The patients were treated within the standard of care. Shafer says the article actually highlights CMs deviations from standard of care.
Walgren asks even if MJ had taken Lorazepam and/or Propofol would these 17 deviations would still be relevant and if Shafer would consider CM responsible for MJ's death. Dr. Shafer answers yes.
Walgren asks about doctor patient relationship. Dr. Shafer says it's dated back centuries ago. Dr. Shafer says that doctors have power to give drugs and cut open a patient etc and this is because they are entrusted to do that because they are supposed put the patient first. Dr. Shafer reads hippocratic oath. Shafer says when Cm agreed to give propofol to MJ, he put CM first. When CM was showing up every night with propofol and saline bags, he was putting CM first. When Cm withheld info from paramedics and ER doctors, he put CM first.
Lg rip.michaelKommentar
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"I dont know what to say. That is utterly and completely inexcusable"
- Dr. Steve Shafer -
Zuletzt geändert von geli2709; 21.10.2011, 05:55.Kommentar
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"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."
-Dr. Steven Shafer, one of the world's foremost experts on anesthesiology-
"That is so egregious that I actually find it difficult to comprehend – you have a patient who has been arrested and you call and leave a voice message for someone. ... That is so completely and utterly inexcusable. Dr. Murray was quite clueless as to what to do."
-Dr. Steven Shafer-Kommentar
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Conrad Murray-Trial - Day 13-October 19, 2011:
"Day 13, Session 01 (TMZ-stream)"
+ YouTube Video
"Day 13, Session 02 (TMZ-stream)"
+ YouTube Video
"Day 13, Session 03 (KABC-stream)"
+ YouTube Video
"Day 13, Session 04 (KABC-stream)"
+ YouTube Video Kommentar
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