The mix of drugs given to Michael Jackson by his personal physician was a "recipe for disaster" that, combined with other missteps by the doctor, ultimately led to the singer's death, a prosecution expert testified today in the doctor's involuntary manslaughter trial.
Testifying in the trial of Dr. Conrad Murray, Olive View-UCLA Medical Center pulmonary/critical care specialist Dr. Nader Kamangar said Jackson was receiving "very inappropriate therapy in (a) home setting."
Kamangar said Murray administered the powerful anesthetic propofol, along with the sedatives midazolam and lorazepam that he had given earlier on June 25, 2009, "without appropriate monitoring" or record-keeping that would have allowed Murray to follow patterns once the medications were given.
"... Ultimately this cocktail was a recipe for disaster,'' Kamangar testified.
Combined with the facts that Murray did not keep records of what drugs he administered that day and never conducted a full battery of tests to determine what was causing Jackson's insomnia, "I think this was the perfect storm I described that ultimately culminated in his demise."
Kamangar told jurors that he believed Murray should have called 911 upon making his initial assessment of Jackson after returning to the singer's bedroom and finding that he was not breathing, citing the doctor's lack of appropriate emergency equipment to treat his famous patient.
Jackson, 50, died from acute propofol intoxication, with "benzodiazepene effect" as a contributing condition, according to the coroner's office. Toxicological testing showed propofol, midazolam and lorazepam in Jackson's system at the time of his death.
Prosecutors contend the 58-year-old Murray, a cardiologist who served his residency at Loma Linda University, gave Jackson propofol, then left him unattended to make phone calls and send emails. Previous witnesses have testified about being on the phone with Murray that
morning, or about emails the doctor sent from his iPhone in that time period, despite the doctor's assertion that he only left Jackson's side for two minutes
to use the bathroom.
Defense attorneys have insisted that Murray was trying to wean Jackson off propofol, a medication the singer called his "milk" and had been using to combat insomnia.
Kamangar testified that he couldn't determine whether Jackson had a "problem" with another drug, Demerol, based on records provided by Jackson's dermatologist, Dr. Arnold Klein, but said it could cause insomnia. He said Murray indicated in a June 27, 2009, interview with police that he was aware Jackson was seeing Klein.
The prosecution witness noted that the most important thing in a doctor-patient relationship is putting the patient first, knowing one's own limitations and "knowing when to say no'' to a patient.
Murray told police that he agreed to give Jackson a 25-milligram dose of propofol following pleas from Jackson to "give me some milk" after giving him three other medications. He said he had begun three days earlier to try to wean
Jackson off the anesthetic, which he had been giving him for about two months.
Defense attorney Edward Chernoff told jurors in his opening statement that the defense would prove that Jackson "self-administered" the fatal dose of propofol after Murray left Jackson's bedroom. But the defense team announced Wednesday that they no longer planned to argue that Jackson drank the fatal dose of propofol without Murray's knowledge.
Defense attorney J. Michael Flanagan asked Kamangar if he believed Murray's failure to keep medical charts on June 25, 2009, caused Jackson's death.
"It's one of many factors," he said. "If you take that as an isolated event, just a physician that was just doing everything else right but was not charting, that would be very difficult to imagine, but it's really in the context of everything else that was done wrong."
Kamangar said it was "absolutely incomprehensible" to give a patient propofol in a home setting without any proper monitoring.
In a police interview two days after Jackson's death, Murray told investigators the singer had been using propofol to help sleep, and he begged for it that day after he had been unable to sleep for several hours.
Kamangar said the combination of propofol and lorazepam "can really have a profound effect.''
"... That combination can be a lethal combination when you mix those drugs in a patient that is completely unmonitored and not being watched attentively,'' he said.
Jurors also began hearing testimony from what may be the prosecution's last witness, Dr. Steven Shafer, before being excused for the weekend because of scheduling conflicts.
The anesthesiologist -- who is the editor-in-chief of the Anesthesia and Analgesia medical journal -- has opined that ``there is almost nothing in Murray's care of Michael Jackson that reflected the actions of a trained physician,'' according to court papers filed by the prosecution last month.
Murray was treating Jackson at his rented Holmby Hills estate, where the singer was staying while rehearsing for his planned series of 50 sold-out concerts in London dubbed "This Is It."
On Wednesday, Ventura County cardiologist Dr. Alon Steinberg testified that Murray violated multiple standards of patient care in his care of Jackson -
- primarily by using propofol in an unmonitored setting.
Steinberg outlined six "extreme deviations" in standards of care he believes Murray committed.
The heart specialist said Murray used propofol without any medical need, administered the drug in an unmonitored and unprofessional setting, failed to adequately prepare for an emergency, failed to follow emergency procedures, failed to summon help immediately and failed to maintain proper medical records.
Steinberg testified that there appeared to be a "significant delay" of about 20 minutes before Murray called for an ambulance. For every minute Jackson was left unattended by emergency personnel, there was a "less and less chance" of the singer's survival, he said.
Murray's "strange" behavior at the scene "directly impacted (Jackson's) death. If all these deviations hadn't happened, Mr. Jackson would've been alive" today, Steinberg said.
Steinberg said it was particularly egregious for Murray to have left Jackson's side after giving him propofol.
"When you monitor a patient, you never leave their side," Steinberg told the seven-man, five-woman jury. "It's like leaving a baby that's sleeping
on your kitchen countertop."
Terri Vermeulen Keith, City News Service