Coroner rules Jackson’s death a homicide..

[Oh_My_Goth]

LOS ANGELES - The Los Angeles County coroner has ruled Michael Jackson’s death a homicide, a law enforcement official told The Associated Press, a finding that makes it more likely criminal charges will be filed against the doctor who was with the pop star when he died on June 25.

A designation of homicide means that Jackson died at the hands of another, but does not necessarily mean a crime was committed.

Forensic tests found the powerful anesthetic propofol acted together with at least two sedatives to cause Jackson’s death June 25 in his rented Los Angeles mansion, according to the official, who spoke on condition of anonymity because the findings have not been publicly released.

Dr. Conrad Murray, a Las Vegas cardiologist who became Jackson’s personal physician weeks before his death, is the target of a manslaughter investigation by the Los Angeles Police Department. Dateline NBC's Josh Mankiewicz confirmed that Murray is the target of a manslaughter probe.

A search warrant affidavit unsealed Monday in Houston includes a detailed account of what Murray told investigators.

According to the document, Murray said he’d been treating Jackson for insomnia for about six weeks with 50 milligrams of propofol every night via an intravenous drip. But he said he feared Jackson was forming an addiction to the anesthetic, which is normally used in hospitals only, and was attempting to wean his patient by lowering the dose to 25 milligrams and adding the sedatives lorazepam and midazolam.

Singer called propofol his ‘milk’

That combination succeeded in helping Jackson sleep two days prior to his death, so the next day, Murray told detectives he cut off the propofol — and Jackson fell asleep with just the two sedatives.

Then around 1:30 a.m. on June 25, starting with a 10-milligram tab of Valium, Murray said he tried a series of drugs instead of propofol to make Jackson sleep. The injections included two milligrams of lorazepam around 2 a.m., two milligrams of midazolam around 3 a.m., and repeats of each at 5 a.m. and 7:30 a.m. respectively.

But they didn’t work.

Murray told detectives that around 10:40 a.m. he gave in to Jackson’s “repeated demands/requests” for propofol, which the singer referred to as his “milk.” He administered 25 milligrams of the white-colored liquid, — a relatively small dose — and finally, Jackson fell asleep.

Murray remained with the sedated Jackson for about 10 minutes, then left for the bathroom. No more than two minutes later, he returned — and found Jackson had stopped breathing.

“There’s no surprise there” that death could result from such a combination, said Dr. David Zvara, anesthesia chairman at the University of North Carolina at Chapel Hill.

“All those drugs act in synergy with each other,” Zvara said. Adding propofol on top of all the other sedatives “tipped the balance.”

Singer had bed sores

Besides the propofol and two sedatives, the coroner’s toxicology report found other substances in Jackson’s system but they were not believed to have been a factor in the singer’s death, the official told the AP.

When he died, Jackson was skinny but not overly emaciated, and his body had bed sores, the official said. The singer is believed to have developed bed sores in the months following his 2005 acquittal of child molestation charges, when he went into seclusion and spent long stretches in bed.

Murray has spoken to police and last week released a video saying he “told the truth and I have faith the truth will prevail.” Murray did not say anything about the drugs he gave to Jackson. Murray’s attorney, Edward Chernoff, had no immediate comment but has previously said Murray never administered anything that “should have” killed Jackson.

A call to the coroner’s office was not returned Monday.

Jackson’s family released a statement Monday, saying it has “full confidence” in the legal process and the efforts of investigators. It concludes: “The family looks forward to the day that justice can be served.”

The 25 milligrams of propofol Murray told police he gave Jackson the day he died “is not a whopping amount,” said Lee Cantrell, director of the San Diego division of the California Poison Control System. But by combining propofol with a cocktail of the other sedatives, known as benzodiazepines, it “may have been the trigger that pushed him over the edge,” Cantrell said.

Cantrell said it’s perplexing that someone would give various benzodiazepines if one was found not to be effective.

“This is horrible polypharmacy,” he said, referring to the interaction between the various drugs. “No one will treat an insomniac like this.”

The affidavit says Murray told investigators he didn’t order or buy any propofol and had found about eight bottles of it in Jackson’s home along with numerous other medications. But investigators served a search warrant Aug. 11 at a Las Vegas pharmacy and uncovered evidence showing Murray legally purchased from the store the propofol he gave Jackson the day he died.

Murray didn’t tell paramedics or doctors at UCLA hospital where Jackson was rushed June 25 about any drugs he administered other than lorazepam and flumazenil, according to the affidavit. The document says it was only during a subsequent interview with Los Angeles Police detectives that Murray gave a more full accounting of the events leading up to the 911 call.

The coroner’s office has not publicly released its autopsy findings, citing a request from police detectives to withhold results until their investigation is complete.

[Fidget(+)]

Is it sad im tired of the whole michael jackson mess?

[candyman]

It sucks that he died but I still don't see a reason for why he ended up on those drugs. If it were a good reason then wouldn't more people be on this stuff? Is it maybe time for celebs to start taking responsibility for their actions and for them not to get a free pass whenever they do something wrong?

If the drugs didn't get Jackson then his body would have tried to take him out.

[jynxxxedangel]

I won't even say "I told y'all so..."

* see all of my previous posts in the Michael Jackson thread.

...damn the Shining, and these vibes.

Edited August 25, 2009 by jynxxxedangel

[TitsMcGee]

I was really hoping it wasn't going to be homicide...because now we will be hearing about this mess for at least the next year if not longer.

[pomba gira]

I was really hoping it wasn't going to be homicide...because now we will be hearing about this mess for at least the next year if not longer.

That was my first thought, too.

OK, I don't have the extensive pharmaceutical knowledge I used to... but the cocktail of benzos and the anesthetic sounds like a really bad idea, and rather pointless to boot. And I'm pretty sure the ramping-up the benzos strategy isn't standard practice, either. Won't even go into the very important difference between "sleeping" and "being rendered unconscious" over the long term. I am very glad this guy is going to lose his license (at the very least). Not because I'm eager to see him punished... but anyone whose judgment is that poor doesn't need to be practicing medicine. Sounds like MJ was done in by "Yes-Man Syndrome" in the end.

[StormKnight (1)]

The times and drugs given is per cnn's report. Note, *all* of these drugs are available in IM/IV form, and I have used them all. Most likely, he had an IV, as propofol is NOT given IM (it burns like a SOB,) so all of these drugs were probably given IV (quick acting route,) or IM. My commentary is based on MDConsult manuscripts, Epocrates Formulary, product inserts, pharmacology classes. Doses assume Jackson was 70kg (not unreasonable,) and drug-naive (probably unlikely.)

0130: Valium (diazepam): 10mg. Sedative dose/pre-op dose. Given once. Onset time is upwards of 30 minutes. Long acting (half-life is anywhere from 30-60 hours, with its active breakdown products having half-lives upwards of 100 hours.) 10mg is a fairly hefty dose; 5-10mg is usually given as a sedative before a minor procedure, and 20mg given prior to endoscopy.

0200: Ativan (lorazepam): 2mg. Sedative dose as well. Pretty quick acting. 2-4mg orally is used to treat some insomnia, but on a short term basis. 2mg IV/IM is enough to knock most of us on the DGN down. It is used in inpatient psychiatry for violent patients because an IM dose kicks in in a couple of minutes. Half-life is 12 hours in adults. IMO, this should have been given first, as it is fairly quick acting. Also, I think they were wrong in giving it 30 minutes after the Valium, as the Valium might have started to work by then.

0300: Versed (midazolam): 2mg. This is a quickest acting of the lot. 2mg IV is standard sedative dose for pre-op patients (and the one most commonly used.) Had this stuff myself for a tooth extraction. 30 seconds after I saw the plunger depressed in the syringe, I forgot the next 30 minutes of my life; the next thing I know is that I am being hauled to the car taking me back to the barracks. I tell my patients this stuff is like slamming a 6-pack in 5 seconds without the upchuck factor. There is a black box warning that if you are given this stuff, you MUST be hooked up to a heart monitor. (I was when I was given it.)

0500: Ativan 2mg again: this can be given once every 3-4 hours, with every 6 being the standard.

0730: Versed 2mg again, with the addition of a pulse oximeter (part of the monitors that should have been on him with the first dose, along with an EKG.)

1040: Diprivan (propofol): 25mg: Available as IV ONLY. Stuff is quick on, (20-40 seconds,) and quick off (5-10 minutes after the drip stops.) It is quick off because it first gets out of the blood and into the fat tissues, then it is broken down and eliminated (70% is out of your body in 24 hours.) In other words, as long as it is injected at a constant rate, you will stay asleep. It is white because the drug itself is not water soluble, and it is suspended in an emulsion of lipids and egg phospholipid to keep it emulsified (hence one of the reasons anesthesia types ask if you are allergic to eggs.) I have used this stuff, both in the OR and the ICU for anesthesia/sedation. The reason this stuff is so popular, in addition to the rapid onset and offset, is:

1. It is not a barbiturate NOR a narcotic, which takes forever to wake up from, and is a pain in the ass to track, especially long cases (ketamine counts as a narcotic for tracking.)
   
2. It is the only agent we have that we use for anesthesia that DOESN'T cause nausea and vomiting (unlike the above and the inhaled gasses.) In fact, it prevents it.
   
3. There are a bunch of anti-inflammatory effects that are benificial to healing from surgery.
   
4. It can be used as a sedation or a general anesthetic agent.
   

It is one of the few agents used commonly (narcotic induction is rarely used anymore,) that doesn't induce malignant hyperthermia. You want to see an anesthesiologist freak out, an MH crisis would do it.

I think CNN made an error. The report says propofol *drip*, which for this drug is MICROGRAM per kilogram per minute (mcg/kg/min.) 25mg as a one shot of this stuff is barely enough to induce drowsiness, let alone sleep. To get him to sleep, assuming he was 70kg, a one shot would have been 100-200mg of propofol. However, a drip set up at 25mcg/kg/min is the middle of the road for sedation in the ICU (5-50mcg/kg/min.) This would have gotten him to sleep. I have never in my time using this stuff have given the medication without EKC, pulse oximetry, blood pressure monitoring, and airway support available. This stuff is NEVER should be given outside of a monitored bed. This stuff induces apnea, especially if given as an induction dose (100-200mg) (patients are going on a ventilator after the apnea hits.)

Stupidity on behalf of the doctor in charge:

1. He is *not* a sleep specialist (usually pulmonologists.) He is an internal medicine doctor, sub-specialist cardiology (i.e. he is a cardiologist.) Unless he was planning to do a cardiac catheterization of Jackson in his bedroom or if Jackson's bedroom was an ICU, he had no right to be dispensing Versed or Propofol at all. Had the man had any sense at all, he would have referred Jackson to a sleep specialist, who would want to find out WHY he was an insomniac (this was a long term problem with him,) NOT JUST TREAT THE SYMPTOM.
   
2. Ativan and Valium are not first line treatments. Lunesta and Ambien are, if drugs are given. Sleep hygiene is usually the first thing enforced.
   
3. He gave three different forms of the same class of drug. Valium, Ativan, and Versed are all benzodiazapines, with differences in their onset and length of time in the body. This can constitute an overdose. Also, he didn't give enough time for the Valium to work (usually should wait an hour,) before either dosing him again with Valium (remember, 20mg for endoscopies,) or tried something else.
   
4. No monitoring with the first dose of Versed. Anesthesia-types give this stuff en route to the OR, but we have the patient right in front of us, and the monitors are on the patient within a minute or two, not 4.5 hours later.
   
5. No qualified relief. According to reports, he went to relieve himself after starting the propofol drip, leaving Jackson alone and unmonitored, at which point he died. This is abandonment, in my opinion. Anesthesiologists and anesthetists DO NOT leave a patient under any of these drugs without being relieved by another anesthesia provider under ANY circumstances; it's part of our training. Even when nursing is away from patient bedside in the ICU, those monitors you see are being watched in a telemetry room that will sound the alarms if something hits the fan.
   

Propofol and Versed should never be used outside of the hospital/surgery center.

Overall:

This guy screwed the pooch big time. He let his ego and greed get away from himself, and used drugs outside of where they were supposed to be used. His ego in not referring Jackson out to a sleep specialist to be properly treated for his insomnia is incredible. I think crucifixion is in order. They need to revoke his licenses to practice (he is licensed in Nevada, California, and Texas.) He misused drugs that I use daily when I am in a clinical environment (with no adverse events like death and such; this is the first time I have heard of fatalities from these drugs in experience,) and I will end up having to allay fears of patients who see this high profile case as the norm, not the exception and stupidity of the doctor giving the drugs, for years to come.

(And people wonder why I beat my ego so much? Because I don't want to let it run away and become a blind idiot like this guy, killing people. Ego kills.)

[dragonluv]

I will admit this was very hard to read. There were parts that I skip. It not because I do not care. It just makes me sad.

I love Michael so much, which is why I look at this thread. This might seem silly, but for me, I am keeping the good memories of Michael in my heart.

I know Michael was a huge star.

I understand that questions need to be answer about his death.

Regardless, I just wish Michael could rest in peace. He had so much tragedy he had to deal with in life. To me, he just need proper care and more real love, to deal with all the shit he had to deal with it.

Michael, I love you and miss you so much . Sending hugs to you Michael.

[pomba gira]

1. He is *not* a sleep specialist (usually pulmonologists.) He is an internal medicine doctor, sub-specialist cardiology (i.e. he is a cardiologist.) Unless he was planning to do a cardiac catheterization of Jackson in his bedroom or if Jackson's bedroom was an ICU, he had no right to be dispensing Versed or Propofol at all. Had the man had any sense at all, he would have referred Jackson to a sleep specialist, who would want to find out WHY he was an insomniac (this was a long term problem with him,) NOT JUST TREAT THE SYMPTOM.

I wondered about that... whether a cardiologist would even be qualified for this kind of thing. Didn't seem likely to me.

1. No qualified relief. According to reports, he went to relieve himself after starting the propofol drip, leaving Jackson alone and unmonitored, at which point he died. This is abandonment, in my opinion. Anesthesiologists and anesthetists DO NOT leave a patient under any of these drugs without being relieved by another anesthesia provider under ANY circumstances; it's part of our training. Even when nursing is away from patient bedside in the ICU, those monitors you see are being watched in a telemetry room that will sound the alarms if something hits the fan.

Yeah, I thought that was incredibly stupid. Don't know if it's accurate, but I heard one report that he actually went & made phone calls, not just to the loo.

Overall:

This guy screwed the pooch big time. He let his ego and greed get away from himself, and used drugs outside of where they were supposed to be used. His ego in not referring Jackson out to a sleep specialist to be properly treated for his insomnia is incredible. I think crucifixion is in order. They need to revoke his licenses to practice (he is licensed in Nevada, California, and Texas.) He misused drugs that I use daily when I am in a clinical environment (with no adverse events like death and such; this is the first time I have heard of fatalities from these drugs in experience,) and I will end up having to allay fears of patients who see this high profile case as the norm, not the exception and stupidity of the doctor giving the drugs, for years to come.

Oh, I'm pretty sure dude's doctorin' days are over. As they should be.

Like I said... "Yes-Man Syndrome". I think when people spend a lot of time with a celebrity who is surrounded by yes-men and has no one to say, "wait a minute dude, maybe you need to re-think this", they start falling into the celeb's hubris-driven worldview. Which of course does not excuse this guy for failing to keep his judgment & ethical sense about him.

I would bet anything MJ refused to see a sleep specialist... in his mental state, his pet doc was probably like a security blanket. Of course what Dr. Halfwit should've done at that point was walk... that's what ethics, and self-preservation for that matter, would demand.

[Homicidalheathen]

He may have ASKED to die at the hands of another...I think this maybe a case for Jeffrey as he defended DR death.

Seems waCkO wanted to die like elvis...and he did.

[n0Mad]

Damn good post StormKnight. I think that's the most informative and interesting thing I've read on MJ to date.