The Conrad Murray trial has now entered day 21 and week 6 of proceedings. Dr Paul White, the defence’s star witness, is due for cross-examination today.
Dr Paul White
Dr White is the final witness for the trial (unless Conrad Murray does decide to testify) and his testimony is key. Last week he told the court how he believed that Michael Jackson gave himself the fatal dose of drugs. Dr White dismissed Dr Shafer’s scenarios and showed the court his own scenarios around injecting Propofol and swallowing Lorazepam pills on his own accord.
Standard of care
The prosecution started their cross-examination by discussing standards of care. These are guidelines of how a patient should be medically treated. Dr White did agree that Dr Murray deviated away from standards of care in the 2 months he was hired by Michael Jackson before his death. When discussing Murray’s care of Jackson Dr White based parts of his testimony on conversations he had with Dr Murray. This is not allowed at all in court. Judge Pastor had words with Dr White about this.
Dr White then spoke about the set up that Murray was using. Dr White told the court that he had never heard of Propofol being administered in a bedroom before. He stated that if an infusion was to take place and not properly controlled you would need equipment present to monitor and to save the patient’s life if anything were to go wrong. Propofol can cause respiratory depression so Dr White stated he would have at least a bag and a mask present (to help with breathing). He also stated suction apparatus was desirable and that a pulse oximeter was essential. Dr White then told the court that during an infusion the patient needs to be monitored every 5 minutes. If this was minimal sedation in a hospital setting then it would be every 15 minutes.
Dr White told the court that airway obstruction and cardiovascular depression are the two most common risks with using Propofol, although it is very rare for these to occur. Dr White stated that it is very rare for a patient to experience apnoea but if Propofol is combined with an opioid or analgesic the risk is heightened. (Such as in this case.)
The prosecution then asked if Dr White disagreed with Dr Shafer’s testimony that Dr Murray’s treatment was an egregious and unconscionable deviation of standard of care. Dr White was very reluctant to answer this question. Eventually he did agree that is was a deviation of standard of care but it was a minor deviation.
Paid Witness
As previously mentioned during the trial Dr White had confirmed he was a paid witness. This was something the prosecution were keen to pick up on. Dr White told them so far he had been paid around $11,000 by the defence. He usually charges $3,500 a day to appear in court. He has been in the court so far for 12 days but does not believe the defence will have enough money to pay for all of his time.
This highlights two points. One, how objective can a witness be if they are paid by the defence and have regular conversations with the defendant which they then try to submit into court? And secondly, he has pointed out that the defence has very little money. I have previously written about the fact that Conrad Murray is virtually bankrupt so does not have the money to hire a first class team (such as the brilliant lawyers that the Michael Jackson Estate have been able to afford to hire). I think throughout this trial it is apparent that this lack of funds has meant a poor defence team, and in particular Ed Chernoff. I feel Chernoff has been very damaging for Murray’s case and it shows that money has a far bigger influence on the outcome of a trial than almost anything else.
But in saying that it is also a fact that the evidence against Murray has been very condemning. But if Murray had the money to hire excellent lawyers he may have more of a fighting chance. (Take for example the O.J Simpson trial. The world believed in Simpson’s guilty yet he had an incredible lawyer who managed to get a not guilty verdict. A good lawyer can make the case go anyway they want – but you need money to enable this.)
Appropriate medical care
The prosecution then questioned Dr White about the way he would respond if a patient were to stop breathing. Dr White stated that he has been in this situation before and he assisted the patient using a bag and mask and performed a tracheal intubation.
Dr White then told the court that as a doctor he has a solemn obligation to do no harm to a patient and you need to do your best to meet their health care needs. The prosecution asked if Dr White believed Conrad Murray had adhered to this in his treatment of Michael Jackson. Dr White stated that Murray was “providing a service to Michael Jackson that he had requested and insisted on”. Dr White then told the court that medical care is more appropriate than being of service to a patient. A doctor always has the option to walk away if they are not happy or comfortable with what is being asked of them.
Dr White then stated that he would never administer inappropriate medical care to any patient. If they insisted he would walk away. He later went on to say that is Michael Jackson had approached him with the same request he would have never accepted the job. No amount of money could persuade him to take it.
Monitoring
The questioning then moved onto monitoring patients. The prosecution asked why it is important to monitor patients. Dr White told them that it is very easy for a patient to move from one level of sedation to another. Dr White then stated that a standard of care would include monitoring the patient but this was an unusual case “as Dr Murray was trying to achieve a sleep state”.
Dr White was then asked if he would leave a patient unmonitored. He told the court that if he had administered a small dose for minimal sedation that last 15 – 30 minutes he would have no problem leaving the patient. The prosecution then highlighted that this would be in a hospital environment. Dr White stated that is the only place he had ever administered Propofol. Dr White also stated that if a patient also had benzodiazepines in their system he would monitor them for 30 minutes.
Dr White stated that having a pulse oximeter on the patient is using monitoring equipment. The prosecution then pushed the point that a pulse oximeter without an alarm is pointless. Dr White was very reluctant to answer this but eventually did agree this was correct.
Vitally Dr White stated he would not leave a patient unmonitored if he knew that the patient liked to push the syringe themselves. This is something that Jackson had requested from Murray and had performed with at least one other doctor before.
Responding to the situation
The questioning then moved onto Murray reaction to Jackson not breathing. Dr White stated he could not defend the fact that Murray did not call 911 right away. He then told the court that he believed that Murray probably did this because it was a “very stressful” situation. He also stated that it occurred in an “isolated part of the house” and that there were no working phones in the house. Walgren then pointed out that Dr Murray had a mobile phone in his hand on which he called Michael Amir Williams before phoning 911. Dr White agreed this was true and it would have been quicker to phone 911 instead.
Dr White then told the court that he does not believe that if Dr Murray had phoned 911 any sooner that it would have made any difference. Once the overdose had occurred there was no way to bring Jackson back to life. It is important to remember that when Murray first found Jackson there was a thready pulse. Therefore in my personal opinion if 911 had been called immediately there may have been an opportunity to try and save Jackson’s life. It is also important to remember that every other medical expert that has been asked about this stated that Jackson would be alive today if Murray had called 911 immediately.
The prosecution then asked Dr White about Murray decision to withhold information from medical personnel about the drugs he had administered to Jackson. Dr White stated he believed Murray “overlooked” giving details about the Propofol he had administered but this was not done in a devious way.
Demonstration
A brief discussion about last week’s demonstration then took place. There was an issue about the apparatus used and if it had been modified. Dr White agreed that this was the case.
Walgren also asked if the IV equipment was small enough to have been removed from the scene without being obvious. Dr White stated that it did appear to be.
Dr White’s Report
Dr White was asked by the defence to write a report (he wrote a letter) that stated he theory on what happened. Initially Dr White stated that he believed Michael Jackson drank Propofol. Dr White stated he has now rejected this theory. He told the court that this report was prepared at short notice.
Dr White stated how he believed that Jackson had self-administered Propofol, whether it be oral or intravenously. Dr White had tried to research oral Propofol ingestion but found no such reports. He wanted to research the area as he “was just trying to cover all the possibilities”. In his original report Dr White did not mention Jackson taking Lorazepam pills.
Dr White states he never had any other theory than Michael Jackson killing himself. He took everything that Conrad Murray had told him to be the truth.
Dr Ornelis
Dr White then mentioned a model that he used to come up with his theory. As he does not have the maths or computer skills to create such a model he hired an expert, Dr Ornelis. Dr White met Dr Ornelis for the first time last week. Dr Shafer had provided a report in court for calculations using his own software. Dr White then used this report to test whether Dr Shafer’s account was possible.
Dr White asked Dr Ornelis to calculate how much Propofol appears in urine after a three hour infusion.
Walgren asked Dr White who thought of the theory that Michael consumed Lorazepam tablets at 10AM. Dr White states that no specific theory was put forward. He stated that Dr Ornelis had been following the trial and chose the timeframe herself.
Animal testing
Dr White then was asked about an animal study he had conducted. He stated after seeing Dr Shafer’s report in April he contacted a vet to conduct research on Propofol ingestion. The test was conducted on beagles. No report was written up from this test. There was only an oral report from Michael Flanagan stating that the study produced negative results.
Dr White stated he was unaware of any tests that had been conducted on humans in regard to oral doses of Propofol. He did mention that Dr Ian Glenn, who is referred to as the “father of Propofol” had told him that oral consumption did not have an effect.
Self-administration
As mentioned Dr White believes that Michael Jackson self-administered the doses of drugs which killed him. Dr White told the court he could not be sure of the timeframe when the Lorazepam pills were taken. He stated that when Dr Murray was not paying attention Jackson took Lorazepam tablets. He was not sure of where Murray was at the time this occurred but he believed Murray was “somewhere in the vicinity”. Dr White based his simulation on this. He believes it occurred around 7AM.
Dr White was then asked about the two minute toilet break that Murray had just before he found Michael not breathing. Dr White believes that Dr Murray had drawn up a syringe of Propofol and left this in the room somewhere. After observing Jackson for 25 minutes Murray felt it was safe to leave the room to make phone calls. Sometime during the 46 minutes that Murray was out of the room Jackson self-administered the fatal dose of Propofol.
Dr White believes that Jackson used a port on the IV tube to take the dose, although he states that Murray did not leave the syringe in the port. Dr White stated that Jackson had the ability to walk around the room and find the syringe. When the prosecution cast doubt on this claim, as Jackson was hooked up to an IV stand and was using a condom catheter, Dr White stated this is not the only theory but it is a possible theory. Dr White also stated he believed Jackson didn’t “realised the potential danger” of administering Propofol to himself.
The prosecution also brought up the point that it has been constantly referenced that the 25 mg dose of Propofol Murray administered would give light sedation. MJ had told Ms Lee that he wanted to be knocked out completely. Would Jackson have hired a doctor just to be slightly sedated? Dr White agreed that he would have wanted a deeper, restful sleep.
MAC Care
MAC care stands for Monitored Anaesthetic Care. Dr White had written an article about the use of Propofol in ambulatory care settings. The prosecution were keen to speak about this article as it is easy to trap an expert witness by their own works.
The prosecutions showed multiple quotes from Dr White’s article. The article discusses how standards for MAC are the same as for general anaesthetics and that the same level of care must be applied to patients no matter what venue they are in. It is stated that “during procedures patients are monitored to ensure safety and comfort”. It is important to note that MAC care does not involve off-label use of drugs.
In this section Dr White was very uncomfortable as his article shows that Dr Murray was not acting inappropriately. Dr White seemed very unhappy to have to answer questions that showed this.
A key part of the article for this trial was that it states “vigilant monitoring is required'. Dr White eventually had to agree with his own work and state this was true. Dr White stated monitoring is important because patients can rapidly progress through different levels of sedation.
Dr White went on to say that he has never practised in an office based setting so is not familiar with the requirements, although he did write about them in his article. All major US anaesthesia bodies give out information on the requirements of office based anaesthetic administrations. Mr White then had to read the guidelines out in court. It was clear Dr Murray did not follow these guidelines.
The prosecution then asked if similar guidelines would need to be followed in a bedroom setting. Dr White was very reluctant to answer. Dr White stated that “many of the requirements would be appropriate” but complex re-wording would be needed. But at the very least when administering Propofol in a home setting the minimum safety requirements must be followed.
The article also stated that every patient should receive care as if they were going to be receiving deep sedation, even if they are getting minimal sedation.
Dr White told the court that he could not say that a second person would need to be present when performing this treatment in a home. If the physician is qualified and paying attention Dr White would say only that physician needs to be present.
Simulation
Dr White then spoke about the simulation he has based his testimony on, created by Dr Ornelis. Dr Ornelis created a graph based on two scenarios, the scenario the defence are pushing and the scenario the prosecution are pushing. The test was to see how much unchanged Propofol is in urine sample after being filtered by the kidneys. Dr White asked Dr Ornelis to give an estimation of the result from two 25 mg doses of Propofol versus a 1000 mg infusion of Propofol.
The two urine samples from Jackson were compared. One was taken from the scene so would have been expelled prior to the Propofol overdose. The second sample was taken from the autopsy urine. Dr White stated that the Propofol levels in the scene urine were very low.
Dr White states that from the results of this modelling it looks more consistent with two 25 mg doses of Propofol rather than an infusion. This was also consistent with Murray’s police interview and the fact that there was no Propofol residue in the top part of the IV tubing.
Dr White was also asked about the heartbeat Dr Murray claims he saw. Dr White states this could mean that Jackson had a pulse or that Dr Murray was feeling his own pulse. Dr White told that court that in stressful situations doctors can be deceived into feeling their own pulse.
Dr White stated he was happy to testify using Dr Ornelis model as he trusts her integrity.
Re-direct by Flanagan
The prosecution then finished their cross-examination and a re-direct by Flanagan took place.
Flanagan started by asking Dr White how one should react when confronted with a patient not breathing. Dr White stated that you should start CPR straight away, in case the arrest had only just suddenly happened. He suggests CPR with an Ambubag be performed. Then 911 should be dial.
Flanagan then put forward the argument that nothing Dr Murray would have done could have saved MJ’s life. He also tried to establish that the Propofol’s effect would have elapsed so even if Murray had told the paramedics or hospital doctors about the Propofol it would have been irrelevant. Dr White agreed with this.
It was then stated that there is no specific antidote to Propofol and the only real treatment is to allow the drug to be redistributed and eliminated by the body.
Summary
Today was always going to be an explosive day as the prosecution were going to be able to grill the defence’s star witness. This certainly was the most confrontational day of the trial. Walgren machine gunned Dr White and left so many holes in his testimony it was unreal. Walgren showed how exceptionally skilled he is in cross-examination. Maybe Chernoff could learn a thing or two!
Walgren would often change topic suddenly to try to throw Dr White. And I thought it was very clever to use Dr White’s own words and works against him. It did very much seem that Dr White went in with an agenda and planned what he was going to say. But once Walgren used Dr White’s previous articles he had no choice but to backtrack on many of the statements he made in his testimony. It came across that Dr White was trying very hard to not incriminate Dr Murray but it was not possible to avoid answering Walgren’s questions. It was a wise choice for the prosecution to question in this manner as Dr White either has to show Conrad Murray made inappropriate choices or show that as a witness he is evasive.
I still find it odd that Dr White was a paid witness and that he was staying with Michael Flanagan during the trial. To me it seems he is too in the defence’s pocket to be objective. He was also scolded by Judge Pastor for constantly trying to use conversations he had had with Conrad Murray as evidence and as part of his testimony. This certainly is in no way acceptable. I read a quote from a lawyer who is covering the case and I think it surmises the relationship between Dr White and the defence team: “experts destroy their credibility when they stop being independent but start acting as advocates for the people who pay them.”
Yesterday it seemed the Dr White’s testimony shook the case up a bit. Today as Dr White had to change many of his statements and admit that Conrad Murray had multiple deviations of standard of care it seems that Dr White’s testimony was not strong enough to totally turn the case around.
Today Conrad Murray told the judge that he has not made a final decision as to whether he will testify or not. Judge Pastor told Murray he would ask him one final time for his decision tomorrow.
The trial continues on Tuesday.
Sophie Dewing
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