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发表于 2011-1-12 10:52:03
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本帖最后由 stroller 于 2011-1-12 11:10 编辑
#22 麻醉师及药学专家Dr. Richard Ruffalo证词
Richard Lewis Ruffalo
What do you do? I’m physician and a clinical ???. What type? Anethesiologist.
And clinical ??? Individual that does peri medicine, before during after surgery, pain management.
And what’s a clinical pharmacologist? That’s someone who studies drugs and how they are used.
Can you give us educational background.
Bs, Ms, then degree in Pharmacology. Went back to medical school and completed his medical degree.
primarly my work is chinical practice and consult with companies from time to time.
Work at HOAGE. Largest hospital in orange county. Most of my time is a clinical anethesiologist.
Also a part time professor. Teaches at UCLA
Also assists medical board in medical investigations. Part time... made himself available to do that? For mant years, represented defendants investigated...
As it relates to medical board investigations, he usually works for the dr accused of providing insufficinet care. Thats corr.
He was asked to offer his consultation in the death of MJ? I was.
Received a letter from him, to review a body of materials and give an opinion. Yes.
281 page notebook. Did it include a number of reports, medical records, things of that nature? Yes.
In repsonse, did you write a report summarizing your findings Y
Did you note in your report materials that you had reviewed? Yes.
His report a 47 page document? It’s a lot of pages.
1st page, states reviewed coverletter from walgren.
go through all the materials reviewed, interview statemetns audio recordings of transmissions from UCLA
Lists all the UCLA doctors statements, UCLA records, phone records, photographs. He reviewed everything.
And regarding autopsy, rpt, did you speficially indicate, taht in The DA’s off providing autopsy to you, that the coroner’s anetheisolgist consultaton report. was removed.
So his review was completely independent.
COrrect.
And is that important that document was removed. Absolutely. it could have biased my opinions.
In your report, go through a nmber of topic areas. C orrect.
Did you cover toe toxicology in your rpeot? I did.
Made reference to the coroner’s tox report in your report? Yes.
People’s 68 for identifcation. Summary of positive tox findings.
One of the things he reviewed.
In reviewing those findings, based on your anethe background and the pharmicology background were you able to come to a conclusing. Yes I was.
Looking at the various blood samples, at the ones that were drawn. UCLA and at autopsy, based on my expertiese I was able to draw a conclusion as to what those levels meant.
As to propofol... unfortunately the numbers that’s most representative is the hospital number, that’s the true post mortem. because numbers change after time after death.
That is the most “colsely related” to antemortem. However it was drawn after the patient had recieved a significant amount of IV fluid. So that level would be lower than what would have been when the paramedics started resusitation.
When blood is drawn and put in a vial, propofol degrades over time. When we do cases in our literature, ...
We’re talking about half the 4.5?
Basically saying the time at death, would be even higher than that.
So for the basis of conclusion, the blood drawn at the hospital, would be the closest to antimortem...
Explain postmortem redistribution. It’s a misnomer, it means drugs can change their distribution. It also depends on where they were drawn, and how the blood was stored, and also the body temp, and issues of decomposition.
So all those things have various effects.
Some pharmologica drugs, ...change their effect. (ans.
Is there based on the drug looking at, do you have ways to predict or interpret redistrobution of these drugs in the body.? To some extent. (longer explanation about sample storage, etc.)
The more you know the better idea you can have.
Lot of variables that come into play that come into that analysis? A lot of variables, but luckily there is a lot of literature... (more ans)
Various benzodiazpines. Specifically, did you review the,
can you tell us generally, what observations conclusions you made as it relaes?
The most important was the lll know as adavan. clearly those levels are subject to a very small degree of difusion, it doesn’t have as much redistrobution. So it’s a little less susceptable to that. (more explanation)
So, it tiells us there was a significat amount of ?lorazapam in the blood. Significant degree of sedation.
So these levels of moraz, in the heart blood, are they ? ?
They were not being broken down like the propofol.....
He has such a low tone voice, it’s hard to follow him.
They are still 5 to 30 percent lower than what they would have been antimortem.
The readings on people’s 69 consistent with 4 milligrams given via IV. ? They are really high.... there is a lot. It’s about reflective of much higher (doses given).
So, he thinks the numbers of the benzodiazapams from the heart blood, he thinks reflect an injection/ingestion of a HIGHER dose than what Dr. Murray states he gave.
Explains the different states of sedation. Slight sedation, deep sedation, and under of anethesia general vs minor surgery.
Under general, they can obstruct theri airway even though they look like they’re breathing.
Asks to explain. So his airway is constricted, but his chest still rises and falls.
The breath is shallow, and not as often. (I’m thinking that the diaphram muscles keep working, but not necessarily air is moving.)
Talks about deeper and deeper sedation and how the air way can be constricted.
Asks about a pulseoxysemiter. It measures the saturaton of oxygen of blood cells.
Tells if blood is pushed through the thumb, then oxygen is being pushed forward. Tells you aobut how much oxygen is in the red blood cells. It’s an important thing.
Gives you heart rate, how much oxygen saturation, and profusing. (ans)
So it helps you to figure out a number of things.
Can it tell you if someone’s airway constricted? No, that’s the problem, You may stop breathing, but it may take a minute or two, before the oxysimeter tells that your oxygen has declined. There are much better ways.
Would a pulseoxsemiter be sufficient? It would be insufficient.
What would you need in the way of monitoring. One of the things would be you need blood pressure so you can track the base line over time.
When you say base line, that means some type of documentation over time? Yes.
All of thse things are affected by those drugs, (heart rate pulse rate, oxygen) so you need a monitor that measures all of that. (ans)
Even thoe the pusoxmeter gives you a heart rate, it does’t give you the spike (like on a screen). There’s no way to monitor ventelation. (with that equipment)
Another thing, a stethescope is attached to the chest to check the breathing... so you can listen to the breath sounds, in and out. You can monitor it that way...
But that’s hooked up to machinery. (yes explans)
Goes (above) over the many means you can moniter breath when no intubation.... (hand over nose mouth) real time, monitoring the breathing....
They give you depth, idea.... (ans)
Talks about the things that give you information so you can monitor, and predict, so if something goes wrong, you know what it is and what you can do.
If you combine administ. of propofol with benzodiazipones, does that require a hightened level of monitoring? It just means you have to know more of the blood interaction? The difficulty of drug interaction would be increased? (Yes?)
If you are giving a single dose of propofol, and you’re not going to continue, you may not need an expidoroxide monitoring.....because you might not need that monitoring, but when you’re giving it with other drugs...you need the extensive monitoring when you’re using long acting drugs.
More questions I’m having hard time getting.
You need to be prepared to do resussitative efforts, when giving the long acting drugs.
Guidelines regarding memoralizing, recording the patient sedation levels, etc.
Need to start to at basline, before you get to the drugs, (metions all the things equipment etc) an you need the anti? as well. Not only you get the vitals, but you get the continuation (of the state of the patient).
Brain wave monitor. If you’re trying to keep a patient in a steady state, you can look at all your non brain monitors, so this is a kind of crude EKG. It’s also another monitor that’s used as well. Those types of things, although not necessarily standard, all those things will give data points out and you follow those data oints over time.
Blood pressure, oxygen, heart activiities., etc. Things that tell you the level of sedation.
You can do a nmber of things. You can look at their pupils. These are all clinical things you can mark and that you can look for.
It tells you what things are changing over time.
Regards of level of consciousness, how often should those be noted... Counting everything, every five minutes.
Are they published guidelines, for non anethesiologists administering anethesia drugs? Yes, they’ve been around for al ong time.
For people who are using propofol in combo with other drugs. Those same monitor are incuded in to what we mentioned here.
and because of rapid cange, in continuim... on a monitor, how to monitor, the qualifications on ow to interven based on the data they see and receive.
11:48 am KFI’ Eric Leonard rushes off.
And must be trained in advanced cardiac life support.
what is ca life supp. In addition on basic, in addition how to determine data, you need to know how to intervene in a full arrest, and cardiac mycardia. Need to know how to do all the tools,
Would that include trachea intubation? Yes.
Would it include a defibulator? Yes.
And all the advannced cardiac medicaitons? Yes.
Focusing on the equipment.
In your review of the treamtent provided, what do you feel is necessar,
Airway equipment, if the patient is obstructed, you need ot know how to deal with that obstruction. you can do a jaw lift, you can pull the tongue out.... You can blow in one or both nostrils... if htatdoesn work you can try an oral airway, it’s one that goes in the mouth, if that doesn’t work, you can use insteand of a trackh tube, we have something called a low ridge mask airway. Describes.
But it creates, gets all the obstruction items out of the way.
Explains more techniques....
What is the jaw lift, and what is the porpose of that. Air way obst is more a combination of the tongue flling back into the throwat. solifting the jaw, that will cause the tongue to mve forward.
he’s showing how one lifts the jaw on both sides near the ear (medial attachment of the mandible?).
With two people, ...oh with soley an airway obstructon?
when you push back here, if ou do it youslefk it’s very painful and it can arouse you . But if they are in deep sedation, or under general anethesia.... that pressure and angle, it can be painful and cause them to wak up.
Shows the particular handling of the jaw and states that one should be trained in how to do that. (who monitors airway).
Would you also need to have advanced airway equipment on board in this setting?
.(??)... is also good to have and also an intubation tube, and you have to have training on how to do it.
Most of the time, if you’re unskilled, you’re going to get swallowing.
another thing that used to be used, is a combi tube. (com- bee?) Talks about where this tube goes, and how it’s used to inflate a balloon. Not used very much anymore.
Anything else for advanced airway equipment. Must be able to do an emergency tarco traciotomy. That gets you right into the windpipe .... and put a catheter in there.... and then put a very hard plastic piece that gets in there and pumps it back up.
Also mentioned in your report, to have various pharmological antagonists. What did ou mean by that, when you give (mentions opiates) ...you must have antagonists on hand.
If you don’t know what’s going on with the patient, you have those on hand. He mentions the drugs that reversse the benzodiazapines, and those other drugs that work to reverse common overdoses.
would it have caused any harm to give narcam (?)
Emergency ACL life support that should be present.? Are you now talking about the reversal agents...
I’m talking about the entire equipment (drugs, etc) that should be on hand to treat for ACL....
Mentions several drugs and what they do.
休息
Stipulation regarding the Dr. Murray transcript. Reflected on page 37 line 18 typo error, slowly infused over 25 minutes. Should read slowly infused over 3-5 minutes.
Requisite equipment for these type of benzo and prop treatment.
Had you mentioned an entitle CO2 monitor. Means entitle, the end of a resting breath. Tech term, capnograph.
Is an entitle cO2 monitor something thatwould be required? Exactly.
Is it something that would be able to detect an airway obstruction? that woud be correct.
Now, I want to direct attention back to exhibit 68, want to aks specif. about some of these foundings as they may or may not relate to one another.
Gastric contents. 1.3 lido 1.6 and were you able ot determine through review medical evidence.
Coronor reported there were aditional contents of fluid, what you would do total content, 1.3 of propofol inside the 70. Same with the lidocaine.
The numbers reflect in 68, do those reflect the concentraiton.
Those reflect the amout not concentration, taht was found within the 70 mil. And with your expertiese and math, convert to a concentration.
propofol = consults notes. 0.00186 mg per milliliter.
What does that mean as far as level of concetration. It’s a very (low?) concentration compared to the liver.
Now, the lidocaine, that’ waht I would expect.
The liver for example. the propofol, the concentration is higher than what is in the stomach. Even though the liver is a very high, there is no blood flow to give that concentration back and forth. Drugs go from a high concentration to low, but they are inhibited to a degree by the organs...
You could also say the same of the heart.
going fro a high to a low concentration.
Did same for lidocaine. When converted get concentration.
.0228 milligrams per milliliter. It’s same issue as the propofol difference is difference in concentrations difference in high to low and different drugs are more or less readily diffused. Depends on their type of charge, the molecules.....
Once you ahve the concentrations taht you’ve computed, they’re very low... yes.
Are they consistent with concentrations taken orally?
No.
With lidocaine it would have to be much higher.
And how about propofol. Same.
In the report you created, did you identify particular issues that deviated from the standard of care in this case. I did.
Did you go through those items to document the level of departure? I did.
Series of issues as simple of departure.
Failure to recognize the ? pulse. thready pulse.
Lengthy description. and that there is at least a solic blood pressure. I mis it all.
That woul d tell you, don’t start CPR. chest compression. Start air way.
Air way is first
Breathing is second
Compression is third.
So, thready pulse is the first departure.
How about the failure to appreciate the drug on drug on acton. Same thing. The issue of not recognizing you can forgive, but still you need to know what to do to correct it.
Propofol.
In statement, that he was likely but not sure that MJ was addicted but he was not sure. the fact is, that he was propperly informed of that. (That there are some cases of addiction that he did not research up.)
Insomnia.
And propofol indicated for the treatment as a sleep aid or insomnia. Absolutely not.
Dr. Murray to recognize that as a departure. correct.
As far s MJ not breathing, as a departure. I did.
When you have a patient with respitory depression involving benzodiazp... so the treatment to reverse.... (sheesh. I mis it.
Focusing on just those that ou mentioned, who now become an extreme departure of care. Yes.
So each individual, when you put them together, it becomes so agregous, that it becomes extreme. That any phoysician should know, should be trained in the basics of life support.
Standing alone, extreme.
Failure to use appropriate monitoring equip.
blood pressure equip, that is electronic. People have them in their home and they set the time.
Next EKG. Even have an o
A defribrilator.
Then have pulsoximitery. which should have a sound alarm for a change in oxygen. preprogrammed for an automatic alarm that you can set high or low.
CO2/ chap alarm, so that you get a qualatative depth of breathing. (more explaination)
And the absence of equip would be an extreme departure.
Yes.
Failure to inform the paramedics and doctor’s the nature of the drugs given. Yes. You should let those (trying to ressitate to know all drugs given.)
Failure to monitor and document all drugs given. Yes. Explains the details of what you monitor and what can change (the breathing, the blood pressure, depth of sedation) all those things can be factored in and recorded.
Failure to remain and be present. What did you mean by that.
1. if you have a patient that is being given drugs like this, with a patient in like anethesisa. you have ot be vigilant you have ot bet there all the time. Someone hwo is qualified ot handle the issue and monitor the equipment.
If you walk out and leave the patient, things can happen. If you do’t know what the patient did, if you didnt nitice it or record it or note it, no matter what, you are responsible 100 percent for the patient.
Failure to provide ACLS care. And you described that as an extreme departure.
Overall, identified several points of extreme deviation of care.
Failure to immediately call 911. If you are a single person by yourslef, the first thing you do is to call to get (other’s to help).
Failure to use ambu bag, with oxygen. Dr. Explains the use and how it’s used. Long explanation as to how the ambu bag can give you information back, (to see the chest move(
Airway and breathing, are the first steps.
Failure to apply the ABC’s of ACLS.
And addressed the one handed CPR on the bed. “Totally useless.”
One handed behind the back? It’s totally useless. You can’t get enough pressure to push down on the chest. We use that in neonatal. Describes what you should do with an adult in the bed. Describes how you get them out of the bed easily. Even if you claim you can’t move the person from the bed, the proper training would be to protect the head, slide the individual off the bed, and then bea ble to start chest compression.
Even if they are morbidly obese, you can generally do that. (ans)
Failure to use the nasal trumpets. (Yes. long explaination)
Long explanation about airway trumpets.
Included in this category you also identify the failure to have the appropriate ACLS medications o nhand.
Yes.
Fairlure to use the correct clomazinal dose. absolutely.
Fail to rappidly assess the situation and failure to give the appropriate ACLS care, and that all is an extreme departure. That’s correct.
during the noo hour, that there was an ifusion time error,
do those opinions all stand, even if he infused over 5 minutes.
Doesn’t make any difference. (ans)
Just asume that’s true, and either through being on the phone or where ever he was, and the patient self administered, even the, still stand,
That would be then another extreme departure, because the patient is a known addict, and the docotr then allowed that much like a known heroin addict, and leaving a syringe of drugs available. It’s an extreme departure.
And making sure the patient can’t have self access to drugs. That’s an extreme departure.
Cross.
Flanagan.
Did you work our your map on the gastric over the noon hour? yes.
Certainly wasn’t in your report was it? No.
who did caliculations? I did.
Trying to back track for what he came up with the contents .0xx for prop. in stomach. No. Content would be numbers there. Concentration is per unit of volume.
Would you come up with those numbers, would you just ivide those numbers by 70? Yes.
In dividing by 70, piece of paper here... now wants to put that on the ELMO...
Flanagan, does this on the ELMO... converting it to concentation. the math. too funny.
Questions, about the fluid in the stomach. I stop typing. I don’t see how they are important.
Now askng about micrograms vs milligrams of the stomach content...
45x what it is in the hospital blood.
That doesn’t go with your theory.
Yes, I made a mistake.
Now if we have 45x whats in the stomach than what’s in the blood. then we have evidence of oral ingestion.
We may have to check with the coroner, to check with what the numbers mean. Now, it doesn’t make sense unless he ingested it orally.
SO he had to have ingested it orally?
obj misstates evidence.
So, I may have made an assumption, depending on how the coroner reported this.
(So, his calculation over lunch may not be correct.) (me)
So as it stands, you made a mistake. I made an interpretation mistake. I thought it was micrograms and it’s really milligrams.
So, we’re back to it being orally? Well, we’ll have to talk to the coroner.
It’s a big difference isnt’ it? I totally agree.
Now, in your report, you went thorugh all the statements, (blah blah blah), and Dr. Murray statement, he said he gave 25 mil prop between 10 40 and 10 50. didn’t he.?
and the statement you said was over 25 minutes.
that’s what I reviewed in the report.
Oh, if he gave it over 3-5 minutes...?
Still, it’s a very small dose.
Now asking about the other drugs in the heart the coroner found....
JP asks about something.
This is getting down into the minucia.
Now, assuming the 25 ml between 10 40 10 50. That could keep him asleep short period of time. Well, six five minutes.
We are coming back tomorrow. PIO confirmed.
As of 11 oclock, propofol is no longer keeping him asleep. That’s always possible.
From Dr. M statement and phone records, Dr. Murray probably was out of the room for 40 minutes.
Let’s assume that’s right. ad made the assumption that he discovered that Dr. M discovered MJ not breathing around 11:50 something.
That would put him in a little bit of a panic state? I would assume (think?) so.
Did you know that at that time, he yells for security at 12:05.
So the delay from discovery, So what should he do...
He should have monitored the situation, the pulseoxsimeter.... (more explain) so, it’s airway and breathing.
Now how long should he spend diagnosing airway and breathing before he ran for health.
If he had done the airway and breathing, he probalby wouldn’t hae needed to run for help.
Just get the patient through that step.
So you just need to fix the airway and breathing.? Tha’ts correct.
The propofol in the blood from the hospital was 4.5 how could he have brought him back? (question not completely right)
doctor responds that sure. He could bring breathing back.
The doctor give a good explanation as to why if the intervention was immediate, and the right intervention, he could have brought the breathing back.
How would he know, that propofol was in the blood at that concentration? You don’t. But you know you have a known addict patient, who may do anything.
But you should anticipate that your patient... ?
Same situation as a heroin addict.
First, do no harm.
You would know the patient would drink it? Well, maybe not know drink it but certainly inject it. You know the patient. He’s a known addict. (Should have anticipated.)
But based on the toxicology, it looks as if he drank it? Not necesarily. He abandoned his patient.
If he had a cell phone, he could dial 911..
Is it beyond the care not to do that himself? Absolutely.
Now goes back to the numbers... with the stomach, and ingestion. Witness doesn’t know concerning ingestion.
Would you also agree that ingestion of propofol would be less efficient than IV. Yes, it’s going to take time (to absorb).
Propofol: another sort of hypothetical. of injecting 150 vs ingesting...? He doesn’t know about ingestion. No studies. It is a high fat solulable drug. The higher the fat solulability, the greater the absorption through biological tissues. (That may not be exactly what he said.)
have you heard the term conscious sedation. Yes. very much so. Write about it in the books. Yes. Different from general anethesia? yes, but long explanation about continuing that long sedation level. And that’s all part of that “misnomer” conscious sedation.
Conscious sedation diff from general anethesia? Depends on the drugs involved.
We don’t know in this case, how the mixture of drugs (worked on the body).
REDIRECT
Assuming self admistration as Mr. F included, would any of your opinions change in your standard of care? No. You don’t walk away from a patient. (explains in detail. Addicts, that is the first tip off, you dont walk away, just like a heroin addict.)
Your opinion doesn’t change whether or not there was a self administer.... No. the standard of care doesn’t change. You don’t walk away from a patient.
No recross.
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