MJ~Leben u. Sterben~u das Geschehen danach!

I grew up listening to Michael Jackson’s music, just like the rest of the world. Thriller was the only album that I knew well, and “Beat it” is my favorite track from it. The message and the music both appealed to me.

I knew very little about his personal life, other than the occasional sensational headlines. I intentionally read nothing about his life before the trial, because I did not want to introduce bias into my testimony. I’ve read a lot since the trial.

Yes. During the trial I saw him as a patient, just like many patients I’ve cared for. During the trial I had no mental image of Michael Jackson as an icon or famous entertainer. He was a patient who died receiving medical care. It was important to keep focused on him as a patient.

Having said that, I was conscious that his interactions with Conrad Murray were, in part, a tragic side effect of his wealth. I spent 20 years on the faculty at Stanford University, and more recently at Columbia University. Patients who are very wealthy often choose a big-name medical center. Most wealthy patients are very kind and decent people. However, I occasionally encounter a wealthy patient who believes that because he or she is rich, he or she can simply tell me how to give anesthesia. That is what they are used to: giving orders and having people say “yes.” I believe that Michael Jackson fell into this trap: believing that he could tell doctors what to do and expect them say “yes.” This doesn’t excuse his doctors for saying “yes.” However, wealth and fame can be a curse.

My opinion of Michael Jackson is that he was an immensely gifted musician, entertainer, and genuinely compassionate individual. However, he was thrust into (well deserved) stardom as a youngster, and spent his entire life under the glare of public scrutiny. That does not seem like a blessing to me. To me it seems like a tragedy. He never lived a normal life.

“Addiction” is a lay term, not a medical term. The correct medical term is substance dependency. You will find an accurate explanation of this in Wikipedia. You can also find a good description at http://www.csam-asam.org/pdf/misc/DSM_criteria_for_diagnosis.doc (Archiv-Version vom 19.11.2011).

I think Michael Jackson likely had a dependency on sedatives at the time of his death, because he was receiving intravenous sedatives every night. That type of regular exposure is almost certain to cause dependency.

Propofol is commonly used for infusions in intensive care units. I am not aware of any primary effect of propofol on the lungs. However, because Michael Jackson’s trachea (windpipe) was not protected while he was receiving propofol, he could have regularly inhaled small amounts of saliva or regurgitated stomach contents while anesthetized from propofol. That can damage the lungs and produce chronic inflammation.

I’ve shared with some members of the MJJCommunity my personal story about my father’s passing. I’ll spare you the details, other than to say that for me, the trial brought me an unexpected gift: the chance to be with my father when he died. Had it not been for the trial, I would have been in New Jersey. As it was, I was at his bedside, offering love and morphine. (I can only hope that one of my kids decides to take up a career in anesthesia.)

During my testimony, I felt that my father was beside me. It gave me confidence, particularly during cross examination. I knew that since my Dad was with me, I’d be OK.

I knew that the defense would reject animal studies as not applying to humans, just as Paul White did when asked about animal studies of propofol in urine. There is no way that I could conduct a human study in the US in three months, so I thought the best evidence I could get was to simply drink propofol and report if it had any effects. I knew the pharmacology well enough to be absolutely certain it was inert.

About a week later my colleague Pablo Sepulveda in Chile told me he would be able to conduct a clinical trial in volunteers. That made my drinking propofol completely irrelevant.

However, please remember that propofol is unique in the complete “first pass” metabolism. One should not try this with other drugs. Indeed, many drugs on the anesthesia cart would be fatal if consumed like that. This should not be attempted as a party trick!

No, that’s his job. It didn’t bother me at all.

I thought about that question quite a bit afterwards. I was not expecting it, probably because I am not an experienced expert witness. This was only the second time I have testified in court.

Mr. Chernoff was playing to my scientific training. Scientists are reluctant to state that something is a certain fact. There is evidence, and conclusions, but science is always open to new evidence and new conclusions. His asking me “wasn’t your testimony entirely your opinion” was an invitation to say “yes”, based on my interpreting “your opinion” as referring to my scientific opinion. If I had answered “yes,” it would have opened the door for him to say in his closing statement “Dr. Shafer himself admitted that his views were just his opinions.” That would play to the common use of “opinion” as mere speculation unsupported by data.

There were two aspects to my testimony: standard of care, and propofol pharmacology. I need to discuss fact vs. opinion for these separately.

Many aspects of the “standard of care” have been codified by organizations. For example, the American Society of Anesthesiologists has practice guidelines that very clearly spell out the standard of care during administration of anesthesia. My testimony was based largely on those guidelines. One could argue that it was merely my “opinion” to represent the published guidelines of the American Society of Anesthesiologists as fact. However, it is a fact that they have published guidelines on the standard of care, and those published guidelines were the basis of my “opinion.”

There are aspects of the standard of care are not covered by published guidelines because they are self-evident. I believe doctors should not lie. I believe Conrad Murray’s misrepresentation of the drugs that he gave to Michael Jackson was an unconscionable violation of the standard of care. Is it my opinion? Yes. However, I think every person on the planet shares my opinion that a doctor should not lie. Similarly, it is my opinion that doctors must place the interest of their patients ahead of their personal interests. That is my “opinion.” However, again I think it is an opinion that is universally shared. Can that be dismissed as “mere opinion?”

Regarding the scientific part of the testimony, my “opinion” is that of an expert in the field. The simulations I presented were mathematically accurate representations of the pharmacokinetics. Baring a mathematical error on my part, the simulations show exactly the blood and effect site propofol concentrations predicted by specific pharmacokinetic models for specific doses. The “expert” aspect is to decide what doses should be simulated, and whether these are likely scenarios. I did a lot of simulations, and even shared with the defense my spreadsheets so that they could do simulations as well. I chose some over others based on data. That is an “expert opinion.” However, it is more scientifically precise to say “conclusion, based on the data” that to call it “opinion”, since the latter implies uninformed speculation.

Yes. I think everyone was amused.

I spoke with them briefly several times walking to or from the courtroom. They were very kind, and offered condolences on the death of my father. I shared that we both had suffered loss, and offered condolences in return. I appreciated their kindness.

I learned a huge amount from the trial, including:
• A lot about the pharmacology of propofol and lorazepam (I did a LOT of reading to educate
myself on the issues, and to respond to claims made by the defense).
• Something about how the criminal justice system works. I was impressed by what I saw.
In particular, the office of the District Attorney was absolutely honest and transparent. This was
not a “game.” It was an attempt to determine the truth.
• Different approaches to discerning truth. In science, “truth” is determined by
experiment, observation, peer review, and the ever-questioning nature of science. In science,
the burden of proof is on the person making the claim. In criminal law, “truth” is determined by
a jury that arrives knowing almost nothing, the exact opposite of peer reviewers. In criminal law,
the burden of proof is on the prosecution. The defense can assert anything without evidence.
I learned that both systems work.

I have received wonderful feedback from my professional colleagues. It won’t change me, but it has been rewarding.

I have had very kind letters from the Michael Jackson community. I did not expect these, but they have been appreciated.

It didn’t expect it! However, I do understand that not knowing what happened to Michael Jackson has been a cause of considerable pain to his millions of fans. If my testimony was helpful, and perhaps brought a closure to his passing so they can again focus on his music and message, then I’m honored to have had the opportunity.

I have tried to answer many of the e-mails I have received. I am appreciative of the kind comments I have received from his fans all over the world.

All of the above.

I did not watch the first two days of Paul White’s testimony, because I was back in the operating rooms at Columbia University giving anesthesia. I love clinical anesthesia. I love taking care of patients. We all need to define who we are. For me, it’s simple: I’m a doctor. I care for patients. If I ever stop caring for patients, I won’t know who I am. That’s what I do.

Having said that, my work as Editor-in-Chief of Anesthesia & Analgesia requires about 60 hours per week. Even during the trial I would go home and read a dozen new submissions every night, assign editors and reviewers, and process another dozen decision letters. I will be doing that every day until my term as Editor-in-Chief ends in 2016.

I continue to teach. You will get a laugh at the most recent lecture I have given at Columbia: the role of clinical pharmacology (e.g., pharmacokinetics) in the trial of Conrad Murray.

Anesthesia & Analgesia is the largest medical journal in the field of anesthesiology. I use Anesthesia & Analgesia as a platform to advocate for patient education, patient care, and patient safety
( http://www.anesthesia-analgesia.org (Archiv-Version vom 22.12.2011) ). Only rarely does that involve my own writing. The Journal advances patient care through editorial policies anchored in doing what is best for patients.

I continue to pursue my own research, primarily modeling the behavior of drugs used in anesthesia. Much of this is now in collaboration with my wife, Pamela Flood, who is the chief of Obstetrical Anesthesia at the University of California in San Francisco.

I am actively involved in developing new drugs to improve the safety of anesthesia and pain management. In 2003 I co-founded a biotech company to develop better drugs for anesthesia and pain management. You can find it at http://www.pharmacofore.com (Archiv-Version vom 02.02.2011). Our work is progressing well, and this also consumes some of my attention.

The response has been uniformly positive. There has been considerable appreciation that I spoke for the values that physicians hold, as well as for clearly explaining the medical and scientific issues involved. I didn’t testify to garner any attention or recognition, and it makes me a little uncomfortable. However, the validation of my testimony from my medical colleagues has been affirming that I did the right thing.

Yes, I was approached, but I don’t think the interviews were aired. I think the reason is that they didn’t like my answers. I was asked about what I thought Conrad Murray’s sentence should be. I answered honestly that I didn’t have the background to judge that. I said that our lawmakers determine the appropriate sentences for criminal behavior, and judges then impose sentences based on the dictates of the law. I said that this was really a question for Judge Pastor, who IS an expert. I don’t think they liked that answer. They probably hoped for something much more vengeful from me.

I was asked how I felt about my role in convicting Conrad Murray. I honestly replied that I don’t think I had much of a role. Conrad Murray gave Michael Jackson propofol in a bedroom, with no training, no monitoring, no backup, no accountability, abandoned him to talk on the phone, and then lied about his action. His guilt was obvious when the facts emerged in 2009, and it just as obvious after my testimony.

I spent dozens, and perhaps hundreds, of hours in preparation. I read well over 100 papers. I analyzed the data numerous ways, and even made my spreadsheets available to the defense. I did the “heavy lifting” that is expected of an expert. This isn’t unique to this case – it’s how I approach everything I do.

Yes, the consistency Conrad Murray’s behavior. In the sentencing hearing Judge Pastor outlined in detail Conrad Murray’s pattern of repeated lying, self-serving actions, and reckless disregard for the wellbeing of his patient. That was what I saw also.

Many physicians choose a medical career very early in life. I knew from the time I was 9 years old that I wanted to be a physician. The inspiration was my pediatrician. He seemed to know absolutely everything, and I was amazed at the breath of his knowledge. Additionally, every year he spent several months on the “Ship Hope” practicing medicine in third world countries. I profoundly admired his sense of service to others. That was my role model

I am the first physician in my family. My father was a management consultant, and my mother was a housewife. Both of them took pride in having a son who went to medical school. I became the family resource for all medical questions.

Yes. He liked it a lot. He told me it made him proud. He was also aware that I was visiting him every day because I was in Los Angeles for the trial.

He watched my testimony on Thursday morning, and died that evening.

He is brilliant, dedicated, and absolutely honest. He worked incredibly hard. I think he got about 4 hours of sleep every night of the trial.

Part of my job was educating Mr. Walgren in the science. By the time of the trial, he was occasionally correcting my calculations! He was so effective when dealing with expert opinion in part because he truly understood the scientific principles.

As a taxpayer, it is amazing that attorneys like Mr. Walgren work for the State of California at a public servant’s salary. We are really getting our money’s worth!

Yes, I watched it live. I smiled when Judge Pastor used specific words and ideas that I introduced in my testimony. Also, having read all of the documents numerous times, it was clear to me that Conrad Murray repeatedly lied. However, that was irrelevant to my testimony, and so I appropriately kept that opinion to myself. I appreciated hearing the judge, who is better able to judge Murray’s veracity than I am, lay out the pattern of self-serving lies by Conrad Murray.

The fatal mistake was saying “Yes” to Michael Jackson’s request for a physician to administer propofol. That was followed by innumerable other fatal mistakes, but it all traces back to the initial lack of judgment.

I’m not qualified to judge this, and am very glad I was not asked for an opinion on this during my testimony. I am glad he was found guilty. That was important: doctors are accountable for their actions. We are not above the law.

I only gave one television interview after the trial, because I had to teach a course (www.nonmemcourse.com) immediately after the trial. I was asked what I thought about the fact that the worse possible sentence was 4 years in jail. I answered that I wasn’t qualified to render an opinion. I think they wanted a much more bloodthirsty response, because they never ran the interview.

Emphasizing that this is just my uninformed personal opinion, I believe that he must lose his license, never practice medicine again, and be accountable to the Jackson family. Please let me emphasize again that criminal punishment isn’t something I know about.

Mr. Chernoff’s statement is false. The lack of record keeping did contribute to Michael Jackson’s death. Without records Conrad Murray could not look for trends, such as seeing if larger doses were needed each day. Without records Conrad Murray could not look at past doses to determine what was a safe dose, and what was a dangerous dose.

Record keeping re-enforces vigilance. When you write down the vital signs every 5 minutes, it forces you to keep an eye on the patient. Record keeping would have forced Conrad Murray to stay close to Michael Jackson and continuously write down vital signs (at a minimum he had the pulse oximeter on the finger and could physically count the rate of breathing and heart rate). Record keeping would have forced Conrad Murray to monitor the intravenous infusion rate. Record keeping might have kept Michael Jackson alive. Thus, Mr. Chernoff’s statement is false.

I initially believed that the IV tubing that Conrad Murray purchased in large quantities from Sea Coast Medical was non-vented, because I did not see the vent in the picture taken by the medical examiner, no vent is described in the product description from Sea Coast Medical, and I was unsuccessful in my initial effort to purchase the tubing from Sea Coast Medical. It turns out that it was vented, which I only realized after I physically examined the tubing in court.

However, the fact that the smaller infusion set was vented only increases the ease with which Conrad Murray set up the infusion, and the ease of concealing the tubing set on the day Michael Jackson died.

However, it still comes back to the big picture: Conrad Murray was giving Michael Jackson an anesthetic drug in his bedroom with inadequate training, inadequate monitoring, and no backup. That is why Michael Jackson died. None of these issues changes the big picture.

All In Your Name [Official Music Video] - Michael Jackson Feat. Barry Gibb [2002]

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The full official All In Your Name music video released 19.12.2011 by Barry Gibb. We thank you so much!

By showing your support, please buy and download the music video and/or the song from his official website.

The song was recorded and filmed at Middle Ear Studios in December 2002

All credits goes to Barry Gibb and Michael Jackson.

SUBSCRIBE for more MJ material in the near future!

FaceBook; http://on.fb.me/WWEUniverseHD

Michael Jackson - Human Nature.

The Live Video Mix.

Peformances From 1987 - 1992 - 1996 - 2009.

Video Production By; Jacob Angle

Michael Jackson And Barry Gibb - All In Your Name (Music Video) (Full Song) (HD)

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Hochgeladen von Deluxnz am 26.06.2011
Michael Jackson And Barry Gibb - All In Your Name
(Full Song)

In December 2002 Michael and Barry Gibbs worked on a song called All In Your Name. Barry Gibb released the full song in June 2011 in Michael Jackson's Aniversary

In Tribute to Michael Jackson
1958-2009

Hochgeladen von ThePhonchrist am 31.08.2011

If you enter this world knowing you are loved and you leave this world knowing the same, then everything that happens in between can be dealt with

In your mind you can go anywhere. And where your mind consistently goes, the rest of your life will follow.

Ich bin mit Michael Jackson's Musik aufgewachsen, genau wie der Rest der Welt. Thriller ist das einzige Album, das ich gut kannte, und "Beat It" ist mein Lieblingslied von dem Album. Die Message und die Musik haben mich beide angesprochen.

Ich wusste sehr wenig ueber sein persoenliches Leben, abgesehen von gelegentlichen sensationellen Schlagzeilen. Ich habe absichtlich vor dem Prozess nichts ueber sein Leben gelesen, weil ich keine Befangenheit in meine Aussage einbringen wollte. Ich habe seit dem Prozess viel gelesen.

Ja. Waehrend des Prozesses habe ich ihn als Patienten gesehen, genau wie die vielen Patienten, um die ich mich gekuemmert habe. Waehrend des Prozesses hatte ich kein geistiges Bild von Michael Jackson als eine Ikone oder einem beruehmten Entertainer. Er war ein Patient, der durch medizinische Behandlung gestorben ist. Es war wichtig, auf ihn als Patenten konzentriert zu bleiben.

Allerdings war mit bewusst, dass seine Wechselbeziehung mit Conrad Murray zum Teil eine tragische Nebenwirkung seines Reichtums war. Ich habe 20 Jahre an der Fakultaet der Stanford Universitaet verbracht, und in letzter Zeit an der Columbia Universitaet. Patienten, die sehr wohlhabend sind, waehlen oft ein Spital mit grossem Namen. Die meisten wohlhabenden Patienten sind sehr freundliche und anstaendige Menschen. Ich begegne jedoch gelegentlich einem wohlhabenden Patienten, der glaubt, weil er oder sie reich ist, kann er oder sie mir einfach sagen, wie ich Anaesthesie zu verabreichen habe. Das ist es, was sie gewoehnt sind: Befehle geben und von den Leuten "ja" gesagt zu bekommen. Ich glaube, dass Michael Jackson in diese Falle getappt ist: Zu glauben, dass er Aerzten sagen kann, was sie tun sollen und von ihnen zu erwarten, dass sie "ja" sagen. Das entschuldigt nicht seine Aerzte, die "ja" gesagt haben. Jedoch koennen Reichtum und Ruhm ein Fluch sein.

Meine Meinung zu Michael Jackson ist, dass er ein ungemein begabter Musiker, Entertainer und eine aufrichtig mitfuehlende Person war. Er wurde jedoch als Junge in (wohlverdiente) Beruehmheit gedraengt und hat sein ganzes Leben unter dem pruefenden Blick der Oeffentlichkeit verbracht. Das scheint mir kein Segen zu sein. Mir erscheint es wie eine Tragoedie. Er hat nie ein normales Leben gefuehrt.

"Sucht" ist ein Laienbegriff, kein medizinischer Begriff. Der korrekte medizinische Begriff ist Substanzabhaengigkeit. Man findet eine genaue Erklaerung dazu in Wikipedia. Ihr koennt eine gute Beschreibung auch hier finden:
http://www.csam-asam.org/pdf/misc/DS..._diagnosis.doc

Ich glaube, Michael Jackson hatte zur Zeit seines Todes wahrscheinlich eine Abhaengigkeit von Sedativa, weil er jede Nacht intravenoese Sedativa erhalten hat. Diese Art von regelmaessiger Aufnahme verursacht fast mit Sicherheit eine Abhaengigkeit.

Propofol wird üblicherweise für Infusionen in Intensivstationen verwendet. Mir ist kein primaerer Effekt von Propofol auf die Lungen bekannt. Weil jedoch Michael Jackson's Luftroehre nicht geschuetzt war, waehrend er Propofol bekommen hat, koennte er regelmaessig kleine Mengen Speichel oder erbrochenen Mageninhalt inhaliert haben, waehrend er mit Propofol betaeubt war. Das kann die Lunge schaedigen und chronische Entzuendung hervorrufen.

Ich habe mit einigen Mitglieder von MJJCommunity meine persoenliche Geschichte ueber den Tod meines Vaters geteilt. Ich erspare Euch die Details, ich sage nur, fuer mich brachte der Prozess ein unerwartetes Geschenk: Die Moeglichkeit, bei meinem Vater zu sein, als er starb. Waere da nicht der Prozess gewesen, waere ich in New Jersey gewesen. Unter den gegebenen Umstaenden war ich an seinem Krankenbett und gab ihm Liebe und Morphium. (Ich kann nur hoffen, dass sich eines meiner Kinder fuer eine Karriere in der Anaesthesie entscheidet.)

Waehrend meiner Aussage fuehlte ich, dass mein Vater bei mir war. Es gabe mir Selbstvertrauen, besonders waehrend des Kreuzverhoers. Ich wusste, da mein Dad bei mir war, wuerde ich OK sein.

Ich wusste, die Verteidigung wuerde Tierstudien als nicht auf den Menschen zutreffened ablehnen, so wie Paul White das getan hat als er nach Tierstudien zu Propofol im Urin gefragt wurde. Es war unmoeglich, dass ich in den USA eine Studie am Menschen in drei Monaten durchfuehren konnte, also dachte ich, der beste Beweis, den ich bekommen konnte, war, einfach Propofol zu trinken und ueber die Effekte zu berichten. Ich kannte die Pharmakologie gut genug, um absolut sicher zu sein, dass es inaktiv war.

Etwa eine Woche spaeter sagte mir mein Kollege Pablo Sepulveda in Chile, dass er in der Lage waere, eine klinische Studie mit Freiwilligen durchzufuehren. Das machte mein Trinken von Propofol voellig irrelevant.

Bitte bedenkt, dass Propofol einzigartig ist in seinem vollstaendigen "erster Durchgang"-Metabolismus. Man sollte das nicht mit anderen Medikamenten versuchen. Tatsaechlich waeren viele Medikamente auf dem Anaesthesie-Rollwagen toedlich, wenn man sie so einnimmt. Das sollte nicht als Partytrick versucht werden!

Nein, das ist sein Job. Es hat mich ueberhaupt nicht gestoert.

Ich habe spaeter ziemlich viel ueber die Frage nachgedacht. Ich habe sie nicht erwartet, wahrscheinlich weil ich kein erfahrener Gerichtssachverstaendiger bin. Es war erst das zweite Mal, dass ich vor Gericht ausgesagt habe.

Mr. Chernoff hat mit meiner wissenschaftlichen Ausbildung gespielt. Wissenschaftler sind zurueckhaltend damit, etwas als sicheren Fakt darzustellen. Es gibt Hinweise und Schlussfolgerungen, aber Wissenschaft ist immer fuer neue Hinweise und neue Schlussfolgerungen offen. Seine Frage "war Ihre Aussage nicht gaenzlich Ihre Meinung" war eine Einladung "ja" zu sagen, basierend darauf, wie ich "Ihre Meinung" in Bezug auf meine wissenschaftliche Meinung interpretiere. Haette ich "ja" geantwortet, haette das fuer ihn eine Tuer geoeffnet, um in seinem Schlussplaedoyer zu sagen "Dr. Shafer selbst hat zugegeben, dass seine Ansichten nur seine Meinungen waren." Das haette auf die allgemeine Verwendung von "Meinung" als eine blosse Spekulation nicht unterstuetzt von Daten angespielt.

Es gab zwei Aspekte in meiner Aussage: den Pflegestandard und Propofol-Pharmakologie. Ich muss Fakt gegenueber Meinung fuer diese getrennt eroertern.

Viele Aspekte des "Pflegestandards" sind von Organisationen kodifiziert. Z. b. hat die Amerikanische Gesellschaft für Anaesthesiologie Anwendungsrichtlinien, die sehr klar den Pflegestandard waehrend der Gabe von Narkose darlegen. Meine Aussage basierte weitgehend auf diesen Richtlinien. Jemand koennte dagegenhalten, dass es lediglich meine "Meinung" war, die veroeffentlichten Richtlinien der Amerikanischen Gesellschaft für Anaesthesiologie als Fakt zu repraesentieren. Es ist jedoch ein Fakt, dass sie Richtlinien zum Pflegestandard veroeffentlicht haben, und diese veroeffentlichten Richtlinien waren die Basis meiner "Meinung".

Es gibt Aspekte beim Pflegestandard, die nicht in veroeffentlichten Richtlinien enthalten sind, weil sie selbstverstaendlich sind. Ich glaube, Aerzte sollten nicht luegen. Ich glaube, Conrad Murray's falsche Darstellung ueber die Medikamente, die er Michael Jackson gegeben hatte, war eine sittenwidrige Verletzung des Pflegestandards. Ist das meine Meinung? Ja. Ich denke jedoch, dass jede Person auf diesem Planeten meine Meinung teilt, dass ein Arzt nicht luegen sollte. Gleichfalls ist es meine Meinung, dass Aerzte das Interesse ihrer Patienten ihrem persoenlichen Interesse voranstellen muessen. Das ist meine "Meinung". Ich denke jedoch hier wieder, es ist eine Meinung, die universell geteilt wird. Kann das als "blosse Meinung" abgetan werden?

Den wissenschaftlichen Teil meiner Aussage betreffend ist meine "Meinung" die eines Experten in dem Bereich. Die Simulationen, die ich praesentiert habe, waren mathematisch exakte Darstellungen der Pharmakokinetik. Abgesehen von einem mathematischen Fehler meinerseits zeigen die Simulationen praezise die Propofolkonzentrationen im Blut und am Effektort, prognostiziert durch spezifische Pharmakokinetik-Modelle fuer spezifische Dosen. Der "Expertenaspekt" ist es, zu entscheiden, welche Dosen simuliert werden sollten und ob diese wahrscheinliche Szenarien sind. Ich habe viele Simulationen gemacht und habe sogar mit der Verteidigung meine Tabellen geteilt, damit sie auch Simulationen machen konnten. Ich habe einige anderen vorgezogen basierend auf den Daten. Das ist eine "Expertenmeinung". Es ist jedoch wissenschaftlich praeziser zu sagen "Schlussfolgerung basierend auf Daten" als es als "Meinung" zu bezeichnen, weil letzteres uninformierte Spekulation impliziert.

Ja. Ich glaube, alle waren amuesiert.

Ich habe mehrere Male kurz mit ihnen gesprochen, als ich zum oder aus dem Gerichtssaal kam. Sie waren sehr freundlich und haben mir ihre Kondolenz ausgesprochen zum Tod meines Vaters. Ich habe mit ihnen gemeinsam, dass wir beide einen Verlust zu beklagen hatten und habe ihnen im Gegebenzug meine Kondolenz ausgesprochen. Ich habe Ihre Freundlichkeit geschaetzt.

Ich habe eine grosse Menge von dem Prozess gelernt, wie:

- Eine Menge ueber die Pharmakologie von Propofol und Lorazepam (ich habe VIEL gelesen, um mich ueber diese Themen zu unterrichten und um auf Behauptungen der Verteidigung antworten zu koennen).

- Etwas darueber, wie das Strafjustizsystem funktioniert. Ich war beeindruckt von dem, was ich gesehen habe. Im Besonderen war das Buero des Bezirksstaatsanwaltes absolut ehrlich und transparent. Dies war kein "Spiel". Es war ein Versuch, die Wahrheit zu ermitteln.

- Verschiedene Herangehensweisen, um die Wahrheit zu festzustellen. In der Wissenschaft wird die "Wahrheit" durch das Experiment eruiert, durch Beobachtung, durch Peer-Review (Anm.: "Kollegenkontrolle") und die immer-fragende Natur der Wissenschaft. In der Wissenschaft liegt die Buerde des Beweises bei der Person, die die Behauptung aufstellt. Im Strafrecht wird die "Wahrheit" von Geschworenen entschieden, die damit ankommen, fast nichts zu wissen, das genaue Gegenteil von Peer Reviewern. Im Strafrecht liegt die Buerde des Beweises bei der Anklage. Die Verteidigung kann alles Moegliche ohne Beweise behaupten. Ich habe gelernt, dass beide Systeme funktionieren.

Ich habe wunderbares Feedback von meinen professionellen Kollegen erhalten. Es wird mich nicht veraendern, aber es war bereichernd.

Ich habe sehr freundliche Briefe von der Michael Jackson-Gemeinschaft erhalten. Ich habe diese nicht erwartet, aber ich habe sie geschaetzt.

It may have helped, but only a little. On the Friday that Paul White testified I was working at the “Allen Pavilion,” a regional hospital run by Columbia University that serves a low-income area of Manhattan and the Bronx. I was caring for an elderly man who asked what drug he would get. I told him “propofol.” As usually happens, he asked if that was the drug that killed Michael Jackson. I told him that propofol didn’t kill Michael Jackson, Conrad Murray killed Michael Jackson. I also said that propofol was very safe drug. He said “I heard that doctor say that at on television, but I don’t believe him.”

I told him I was the doctor he saw on television. He thought that was hilarious: the doctor in blue scrubs, wearing a surgical hat, with a stethoscope around his neck working in this clinic for poor patients might be the “famous” doctor he saw on television. “Yea, right” was his answer. He didn’t believe me for a second. However, he was reassured by my “joke” about being the doctor he saw on television, and everything went well.

There is not much data about this, because propofol must be given intravenously, and it really burns, which discourages abuse. However, there have been a number of deaths of anesthesiologists and other health care personal from propofol abuse. Based on this, I am reasonably confident that it is addictive.

The mechanism of action of propofol is the same as drugs like Ambien that are commonly used to induce sleep. This is a reasonable research question. However, it should never be put into practiced until it has been studied in a proper research setting. After that work has been done, it should only be used with appropriate documentation and precautions.

Benny007 schrieb:Yes to both questions.

Not a lot, because it is rarely used for long term use. I have been able to find one report of a patient who received propofol in the intensive care unit for 51 days. This is from the conclusion of the article: “To our knowledge, this report represents the first documentation of propofol use for long-term sedation in a mechanically ventilated pregnant patient and the longest duration of continuous infusion propofol published in the medical literature. Propofol was used for 51 days with no documented maternal adverse events.” (Tajchman SK, Bruno JJ. Prolonged propofol use in a critically ill pregnant patient. Ann Pharmacother. 2010;44:2018-22)

This patient was weaned from propofol over several days without adverse consequences. So administration for 2 months appears to not have long term consequences, at least based on this example, and the fact that Michael Jackson continued to function at rehearsal. However, those are just two data points. More research needs to be done if one contemplates development of propofol for long term use.

The contradiction reflects the state of the science. I received propofol for anesthesia about a year ago, and I have given propofol to thousands of patients. There is often a feeling of having slept well after awakening from propofol.

However, studies suggest that propofol sleep it is quite different from normal sleep, and is not “restorative” the way that normal sleep is restorative. For example, dreams are important in brain function. Patients don’t dream on propofol, except at the time of awakening. My interpretation of the data is that propofol might be OK for getting a patient off to sleep, but that maintaining a patient on propofol for sleep (as we sometimes do in intensive care units) probably is denying patients restorative sleep.

No. I think this will hurt patients. In emergencies we need propofol immediately, and in large quantities. I am opposed to placing obstacles in the way of doctors caring for patients, unless there is clear benefit. Conrad Murray could have still obtained propofol for Michael Jackson, because doctors can order controlled substances. Since most propofol abuse is by doctors, making it controlled won’t limit the ability of doctors to abuse it. It will just impair their ability to care for emergency patients.

This has been the subject of an issue of Anesthesia & Analgesia. Here is the cover of that issue: http://www.aaeditor.org/HWP/Covers/0710.cover.jpg.

We already take this very seriously. We are very involved in teaching the safe use of sedatives to our medical colleagues. This will continue. Perhaps they will be more receptive to the importance of safe sedation. However, nothing we can do will reach a doctor who does not put patients first.

Absolutely. I mentioned this above. I am aware of this because I occasionally see this in my practice. Doctors serve patients by acting as doctors. That is a message for doctors and patients alike.

Propofol absorbed from the stomach never reaches the brain, because it is all removed by the liver. However, the blood supply to the mouth and esophagus (above the diaphragm) does not return directly to the liver. Instead, it just goes to the heart, and from there goes everywhere including the brain. So a propofol lollipop would provide propofol to the venous blood, and from there to the brain. Paul White and I discussed this at one of the breaks prior to his testimony. It is a reasonable idea, provided the dose was adequately controlled.

Should this ever become available, then I would reconsider my position on classifying propofol as a controlled substance. My current view is highly influenced by the fact that it only works when given intravenously, and that really burns!

It has the consistency of skim milk, and tastes like a very medicinal salad dressing.

I think it is very unlikely that any harm came to the beagles. There should be no effect from drinking propofol. However, I am uncomfortable that neither the experimental protocol nor the results of the experiment were presented in court. I believe that when animals or humans participate in trials, there is an ethical obligation to write up and publish the research to add to the body of knowledge. It is the increased knowledge that morally justifies the research. I wrote our human study up for publication, asked Paul White to review it, and gave it to the defense. I believe they should have done the same with their beagle study.

There is a technique of rapid detoxification that involves placing patients under general anesthesia for a long period of time (hours to days) and pharmacologically reversing opioids with “opioid antagonists”, drugs that chemically block the effects of Demerol and similar drugs. This is controversial, but it probably works in some patients.

I can’t answer without knowing why Demerol was given. Dr. Klein did not testify at the trial. I’m uncomfortable offering any opinion without more information.

Again, I apologize, but I don’t want to render an opinion without knowing why Dr. Klein was administering Demerol. This probably reflects my caution as an Editor-in-Chief of a medical journal. Medical editors are reluctant to render a public opinion unless they are confident they understand the facts.

There are three questions here. I’ll answer them in order:

Demerol’s chemical name in the United States is “meperidine.” In many countries it is known as “pethidine.” Meperidine has a metabolite, “normeperidine”, that is a nervous system stimulant. As a nervous stimulant, I would expect it to exacerbate insomnia.

The coroner examined both blood and urine for meperidine (Demerol) and normeperidine. Neither could be detected. Thus, meperidine did not play a direct role in Michael Jackson’s death on June 25th. However, you asked a more general question about “play any part in Michael’s physical and mental health.” It is a good question, and I will again need to apologize for not answering it. I have not read Dr. Klein’s medical records or heard a detailed explanation of Michael Jackson’s care. I am uncomfortable speculating without that information.

Sleep disorders are complex, and treating them is a specialized branch of medicine. It is my understanding that any drug that affects the level of consciousness can exacerbate sleep disorders. There is a nice description of sleep disorders, and the treatment of common sleep disorders, at http://www.sleepfoundation.org/article/sleep-related-problems/sleep-aids-and-insomnia

Maybe. However, free lorazepam would be expected simply because molecules like lorazepam would be expected to cross from the blood into the stomach, just like they cross into all tissues. That is how the lidocaine and propofol got into the stomach. Lorazepam should behave just the same way.

Additionally, the enzyme beta glucuronidase is secreted by the wall of the stomach into the stomach fluid. Beta glucuronidase is the enzyme that would turn lorazepam glucuronide back into lorazepam. So blood could account for it, but most of it is likely the simple diffusion of lorazepam from the blood into the stomach.

Benny007 schrieb am 12.12.2011:No.

The most critical part of any resuscitation is to move air in and out of the patient’s lungs. The problem with giving flumazenil is that it distracted Conrad Murray from the critical task of moving air in and out of Michael Jackson’s lungs. If there were several people were involved in the resuscitation, then giving flumazenil would have made sense. However, since Conrad Murray was alone, any interruption longer than a few seconds was too long.

I’ll answer as well as I can, but I’m not sure exactly what you want to know. The lorazepam levels were high enough that you or I would have been very sleepy from them. However, patents become tolerant to lorazepam and related drugs (the “benzodiazepines”). Since Michael Jackson had a fairly high concentration, and according to Conrad Murray that was not enough drug to induce sleep, he must have been tolerant.

The defense wanted to attribute Michael Jackson’s death, in part, to oral lorazepam. The problem with this theory is that there was only a minute amount of lorazepam in Michael Jackson’s stomach. To explain this minute amount, the defense alleged that Michael Jackson swallowed lorazepam about 5 hours before the time of death. If that were true, then the lorazepam concentration would have peaked about the time Conrad Murray claims Michael Jackson was pleading for more drug to fall asleep. So that argument doesn’t make sense.

There was a bottle of capsules composed of ephedrine, caffeine, and aspirin in the room. Ephedrine is sometimes used in resuscitation. Since there was ephedrine in Michael Jackson’s autopsy urine, as well as the urine that was found at the scene, I would assume that the ephedrine was from oral ingestion, and not from administration as part of the resuscitation.

Ephedrine can reduce the effects of propofol and benzodiazepines on blood pressure and heart rate. Chronic ephedrine might aggravate insomnia.

I’ve performed dozens of clinical trials. I don’t think this will adversely affect recruiting patients into clinical trials, because this “experiment” bears no resemblance to a scientific study. I think “experiment” is an accurate term, because it correctly implies that Conrad Murray had no idea what he would find day after day of propofol administration. So this was an experiment that he was conducting every day to see how Michael Jackson would respond. However, I don’t think anybody would confuse this experiment with a proper scientific experiment.

The larger question you ask is about the intersection between research and practice. This is an important question, and (fortunately) one that has been given very careful consideration. The answer goes back to the Nuremberg Code, which followed the trial of Nazi doctors guilty of atrocities at the end of World War II. You can find an excellent account on Wikipedia. This was updated by the Belmont Report, published in 1978. Again, there is an excellent account in Wikipedia. As explained in the Belmont Report, “research” differs from clinical practice in that research is a systemic investigation intended to create generalizable knowledge. “Systematic” means that the investigator intentionally gathers data to answer a question. Generalizable knowledge means that the investigator believes the information gathered is useful to others, and intends to “generalize” the knowledge, usually by publishing it. If you Google “Anesthesia & Analgesia policy in institutional review board approval and informed consent for research” you will find an editorial I wrote in March on the subject.

He should have been in the care of a sleep medicine doctor. He had a terrible affliction, one that requires expert care.

Maybe. Conrad Murray mentioned both propofol and lorazepam. These are both sedatives that act on the same receptor in the body, the “GABA” receptor. Most sleeping medications also act on GABA, the exceptions being antihistamines (e.g., benedryl) and melatonin. So I would expect these drugs to induce sleep. However, they should not be used to maintain sleep, because the drugs interfere with some of the brain function that is required for sleep to be “restorative”, meaning that it refreshes the brain.

Once your questions about Michael Jackson’s tragic death have been answered, I encourage you to set it aside. Conrad Murray has been convicted. We have a reasonable understanding of what happened. It’s time to return to the bonds that brought the MJJCommunity together in the first place: your celebration of Michael Jackson’s life, his message, and his music.

I appreciate the opportunity to address your questions, and hope that the answers are helpful to the MJJCommunity.

Sincerely,

Steve Shafer

abgesehen davon tut es mir unwahrscheinlich leid, dass poor Hannibal-Conrad-Lecter-Murray's traum von "weihnachten im kreise seiner lieben familie" wohl doch nicht in erfüllung gehen wird ;) .....