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Undereducated about the Unknowns

I know, I know. So far this hasn’t been a very positive post and for a condition that effects a large proportion of people, I don’t want to scare anyone. Like always, my goal is to educate and that is why I go into detail about these things—for some people they need to know the why before they understand the solution. As such, let’s go into the way we approach Obesity and weight loss and see how we solve it. Short answer: it's very difficult, not easy, and requires lots of encouragement and motivation for everyone involved but the payoff is huge. As a pharmacist working in addiction and psychiatry, part of my job is to recommend agents to assist someone’s treatment. Because of my background I feel that I have a unique perspective on medical issues because I am the drug expert and so I can balance the drug benefit with the side effects of other drugs OR complications of other conditions. That being said, no size fits all and everyone needs a different approach.
Currently I work with many individuals with weight loss challenges due to behavioral conditions (such as Binge Eating Disorder), their medication regimens, or genetics. One of the most important aspects of recommending a weight loss agent is understanding the mechanism of why that person’s calorie intake is more than their calorie expenditure. This section refers to a person who may not be aware of what goes into a proper calorie intake and how to balance intake and output. In a sense this is the field of Nutrition and is where Dieticians come in (please note that registered Dieticians are medical professionals with a degree in Nutrition which enables them to perform medical nutrition counseling and diagnose or treat nutritional illnesses. Depending on the state, a nutritionist does not have a license to practice Medical Nutrition).
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• The essentials of Nutrition come down to the idea of Energy Balance or how energy is taken into the body, generated, and then expended. A positive energy balance is when more energy is taken in and then stored resulting in weight gain while a negative energy balance is where less energy is taken in than used so fat stores must be used. Remember that the goal of eating food is to make energy which is represented by the molecule ATP (produced by the Mitochondria!). However, depending on the kind of activity done, we may not have enough stored ATP in the body to cover the activity and thus have to use other means of ATP production.
  • When we are at rest, the activities we do such as swiping your thumb on a screen and moving your eyeballs to read do rapidly deplete the amount of stored ATP—this is why you can sit all day without feeling winded. If we perform a more intense activity, such as walking, the stored ATP is used incredibly quickly (lasts <10sec) and we have to use Aerobic Metabolism to create ATP while doing the activity. Aerobic Metabolism utilizes oxygen to make ATP and is incredibly efficient which enables us to do low-impact activities for an extended period, like walking down a hallway. As the impact level of the activity increases or the length of time increases the body switches from Aerobic Metabolism to Anaerobic Metabolism which is ATP production when oxygen is not available. This isn’t to say that your muscles have 0 oxygen when you are running but more that oxygen demand (moving the muscle) is much higher than oxygen supply (oxygen capacity of red blood cells). As such, the body utilizes Anaerobic Metabolism which produces ATP for energy but also Lactic Acid which causes that muscle pain after exercising.

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• To make it simple, Aerobic Metabolism is used in low-impact activities while Anaerobic is used short bursts of high-impact (like a 2-min workout) OR prolonged high impact activity (like crossfit or HIIT exercises). Now that we understand that, we can see what kind of energy source is used in what kind of metabolism. As you can see, Fatty Acids are part of Aerobic Metabolism but only after about 1.5-2hrs of activity. What this means is that in order to burn fat you need to burn your Liver glucose stores (called Glycogen) first and then you can start burning fat. So the 20 minute treadmill run while great for raising your mood and improving blood vessel health may not touch the fat in your belly.
• This brings us to the other aspect of Nutrition—diet. Now this is where the lack of words to describe the science is cumbersome. Someone’s food intake, aka their diet, is different from dieting (cutting out certain foods) which is different from following a Diet (capital D), a more strict set of food guidelines. I don’t have the training to discuss what is a good Diet but I can talk about what are the necessary components of what makes up a good diet (lower case d). In general, it is all about ensuring you have the essential nutrients and reduce the intake of weight gaining foods. Essential nutrients like Vitamins, Minerals, Trace Elements, essential Amino Acids are required from our food in order to live and there are lots of sources online about which foods create balanced meals that fit your preferences. What is nonessential is carbohydrates, proteins, and fats (except omega-3 fatty acids). Yeah, kinda weird to think that the main components of our foods are nonessential but what that means is that we can change it up as needed to fit your current need.
  • Carbohydrates are a group of macromolecules that consist of carbon, hydrogen, and oxygen and are very energy rich. Carbs come in two flavors: nondigestible and digestible. Nondigestible carbs are the dietary fiber we need to ensure that our stools can form solidly and move along the intestines. There are lots of types of fibers but the one for weight specifically is Viscous Fiber which forms a gel in the intestines to reduce sugar and fat absorption. Unprocessed oats, flaxseeds, asparagus, beans, and Psyllium Husk are great sources of Viscous Fiber which help reduce the amount of fat and sugar we take in from our food. Digestible carbs on the other hand are the sugar we normally think, the sweet stuff like glucose, sucrose, fructose, and starches. All digestible carbs can result in weight gain but it all depends on the amount you eat. The essential of a diet is not what you eat but how much you eat; so yes you can have some cake one day but you should abstain for the next few days.
  • Unsurprisingly the fat we eat can be absorbed into the body and used to make fat that is stored. Animal products and processed foods are highest in fats that are likely to be stored while plant based fats and oils are less likely to be stored (more likely to be immediately used as energy).
  • Finally proteins which are not required for weight loss but are essential for muscle gain and the best way to promote further energy expenditure after exercise is to promote muscle synthesis. Essentially, when we exercise the muscle is damaged either by the flexing of the muscle or by the lactic acid produced and so needs to recover with protein in our diet. In order to use the protein the body needs to spend energy which can be done in the form of using more stored fat. Thus, eating protein while trying to lose weight can provide additional benefits.
  • So what does this all mean in terms of the exercise we were talking about before? Well remember that in order to burn fat someone needs to exercise about 1.5 hours to burn through stored glucose stores. Now this can be really cumbersome but the way around this is to starve the Liver of glucose to rebuild those glucose stores. By keeping a low-carb diet, your liver wouldn’t be able to use dietary glucose to rebuild the Glycogen stores and instead have to use more fat! As such, keeping the amount of glucose in your diet low aids in getting to the 1.5 hours sooner and can facilitate using fat as a main energy source when you are at rest.
• Now diet and exercise is all well and good but there is a big factor here that we have to consider: ability to diet and exercise. Yes physical ability is a major aspect but this is why this section is titled Undereducated—for individuals who are lower socioeconomic status (SES) they have a harder time achieving the necessary diet and exercise goals to find significant weight loss. Is this because they are uneducated? No, most Obese people of any SES know that eating better and exercising will make them lose weight, but performing those actions uses another major commodity: time. Unfortunately, those of lower SES face several challenges that make it extremely difficult to lose weight: often they are working lower wage jobs meaning that more time is spent working and less time available for exercise. Combine this with the higher cost of living, especially when caring for children, and lower SES correlates heavily with buying cheaper foods which are often not the most nutritious. If a parent has to feed 4 children with a few dollars, they will use sources of food that maximize the value of that dollar—this means processed foods filled with salt and fat to make them taste good. This is part of the benefit of food stamp programs which enable lower earning families to purchase more nutritious foods. But this is where the undereducated part comes in.
  • For many people they think that a weight loss meal is salad, and while its not wrong, its a lot of what is in the meal. Part of my work in college working in a food kitchen was helping families understand how to maximize the benefit of the canned or frozen vegetables and fruits they have access to rather than feeling that healthy food is only fresh produce. A person can accomplish the same nutritive goals on frozen or canned vegetables as they can on fresh or raw foods and often on a smaller budget. I highly encourage those who are on a limited budget to get in touch with their local food bank—often they can connect you with a dietician who can guide you through how to cook nutritious meals on a small budget and for a large family. Please know that diet and exercise is extremely possible even with added time constraints.

And a quick buck was made

Okay I think we have come to the part that people were really waiting for—the drugs! Please take this next section as educational only and to merely inform you of the thinking behind weight loss agents. You must talk to your doctor or pharmacist before starting, stopping, or changing any medications including herbals, supplements, or illicit substances. The first group of medications we will look at are those with an FDA approved indication for weight loss:
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• First up we have Orlistat, a medication that does not require a prescription in the United States to use. Orlistat is an inhibitor of stomach and pancreas Lipases, a type of enzyme responsible for breaking down dietary fats. This means that when someone takes Orlistat the fats they eat are unable to be broken down for absorption and instead stay in the stool for excretion. When used correctly, about ¼ to ⅓ of dietary fat isn’t absorbed and there is a sizeable reduction in LDL (bad cholesterol). While its nice its over the counter, Orlistat has some…major drawbacks. The biggest is it’s tolerability—because Orlistat prevent fat digestion, most of the fat stays in the intestines causing oily stools, urgent diarrhea, and smelly flatulence. In its official documentation the term “explosive diarrhea” is used. Now, to avoid these unfortunate side effects a person should meals that are high in fat (no more than 30% of their daily recommended fat amount). Now this begs the question: is Orlistat effective in losing weight because of how it works or because people avoid fat like its poison to prevent explosive diarrhea? Either way someone should expect to lose around 15 lbs at 6 months of regular use which is nothing to sneeze at.
  • Speaking of over the counter weight loss aids we should talk about a few. One of the biggest ingredients included in these supplements is Caffeine. Caffeine is thought to work by increasing someone’s metabolic rate or in other words to increase the amount of energy someone uses while at rest. Part of this is because the heart is working harder (Caffeine increases heart rate) but there is some more systemic effects that are not explained by simple increased fight or flight effects. I can’t find the source I heard this from, because I believe I learned it during a seminar, but somewhere near 65% of OTC weight loss supplements have some form of Caffeine in them. Caffeine can be listed by itself or be hidden in an herb like green tea, yerba mate, green coffee beans, kola, guarana, yaupon, and dozens more. I'm not anti-caffeine, I drink plenty of it everyday but these supplements often have people exceeding the safety limit of caffeine by combining these herbs together. Caffeine can worsen anxiety, put significant strain on the heart, and isn’t recommended for pregnant women. Just be careful!

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• One supplement that used to be on the market in the US and is now banned is Ephedra. Ephedra is preparation of the chinese herb Ma Huang which contains the alkaloid Ephedrine and Pseudoephedrine. Both chemicals are part of the stimulant class of medications and when used in large enough doses will cause appetite suppression. Essentially these chemicals stimulate the fight or flight region of the nervous system which suppress the urge to eat. This is actually the reason why stimulants like Amphetamine (Adderall) and Methylphenidate (Ritalin) are used off-label to treat Binge Eating Disorder and help weight loss. Suppressing the urge to eat helps the person eat correct portion of food or prevent binge episodes thus reducing calorie intake. One OTC product that was extremely popular in the late 1990s and early 2000s was Hydroxycut which heavily marketed itself on TV and on the unregulated internet. In 2003 the Missouri Attorney General sued the company over their claims that Hydroxycut was “clinically proven” to burn fat but the case was settled out of court. Later in 2003 the NYT uncovered hidden documents that showed Hydroxycut knew its product didn’t work and have tampered with documents in another lawsuit in Oklahoma to show otherwise. Regardless, the usage of Hydroxycut wasn’t significantly hampered but due to its widespread use and unscrupulous advertising, the FDA banned Ephedra in 2004 after 155 deaths were attributed to the herb. It was the first time a supplement was banned in the US. Hydroxycut then switched to using Hydroxycitric Acid which required a lower dose than the Ephedra based formulations. The company failed to advertise the change in dosing and dozens of cases of serious liver failure resulting in liver transplant were reported and at least one death (19yo male). Hydroxycut is now mostly Caffeine.

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• Similar to the stimulants is Bupropion which is combined with the opiate antagonist Naltrexone in the product Contrave. Bupropion is an antidepressant that causes a raise in Dopamine and Norepinephrine in the brain while Naltrexone works by preventing endorphins from binding to the opioid receptor in the brain. Together its thought that Contrave works in Hypothalamus to reduce pro-eating stimulation as well working in the Mesolimbic Dopamine Circuit to reduce the reward feedback someone feels when eating. In a sense, the drugs work by causing someone to be less hungry and then reduce the pleasurability of eating. Contrave can be incredibly useful in people who are mindless snackers (such as eating large quantities of food when not paying attention) or for binge eating disorder. The benefit of using this medication over the stimulants like Adderall or Ritalin because it helps treat the cause of the Obesity (overeating) rather than just preventing the symptom (weight gain). Generally people see around a 25lb weight loss around 6 months.
  • Similar to Contrave is another combination product: Phentermine and Topiramate in the branded product Qsymia. This combo pill utilizes the stimulant Phentermine which comes from the same class as Adderall and Methylphenidate to suppress appetite and Topiramate, originally an anti-epilepsy medication that is thought to suppress appetite, increase satiety, and reducing pleasure from eating. Qsymia produces similar results to Contrave.

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• Okay, this brings us to a very controversial medication in the pharmacy world: GLP-1 agonists. If you remember from earlier I described how White Fat releases the appetite-suppressing hormone Leptin due to the stomach and intestine releasing GLP-1. GLP-1 is released when the GI tract detects carbohydrate or fat rich foods and their release triggers a cascade resulting in long term appetite suppression. LIkewise it is believed that the very common side effect of nausea and vomiting reduces the desire to eat. So in a lot of ways, they are working the same as the stimulants are—reducing appetite but not really touching the reason for overeating. GLP-1 agonists like Semaglutide (Wegovy) and Liraglutide (Saxenda) are used primarily for their influence on Insulin in Type 2 Diabetics to help lower blood sugar levels and reduce A1c, a marker of overall health in Diabetes. In diabetes, the clinical benefits of GLP-1s cannot be understated on the heart, kidney, liver and many other organs. In non-Diabetes weight loss? Well…don’t get me wrong they do work—people usually see a 15 lb loss at about 6 months but they miss the mark in the same way that the stimulants do. They prevent symptoms but don’t really help the underlying cause for why someone might be Obese.
  • The other aspect that I am always weary of is when drugs become “popular” in the media and especially with celebrities. Many celebrities and social media influencers are touting the benefits of GLP-1 agonists, i.e. the weight loss, but the consequence of this fad is that Diabetics who rely on this drug are unable to get it anymore. There is a massive shortage in GLP-1 agonists for people who could use another agent with similar efficacy but are using GLP-1s due to the social media presence. Likewise the weight loss isn’t sustained—at about 1 year the weight loss plateaus and after stopping only around 50% maintained the weight loss. Compare this to the other agents we’ve talked about who had a sustained weight loss around 80% and the choice is clear. Another aspect I have against these drugs for weight loss is the use of a side effect as a selling point—the rate of nausea is about 44% which means that someone is making themselves sick in order to lose weight. This is not a life I would put my patients on.

Finally, I have to talk about the pills mills, or I guess injection stations since the GLP1s are injectable medications, that have popped up around Wegoxy and Saxenda. Weight loss is an extremely tough, emotional, and sometimes unbearable process. For some individuals it is the worst trigger to think about and I really do feel for the people who have tried good eating and exercising but are unable to do it. This is why I believe that weight loss agents should be used just prior to or at the same time diet and exercise routines are implemented. While the drugs are effective, the true power in sustained and increased weight loss is by learning to eat properly and exercise consistently. That being said, I am the kind of person who is results driven and to be encouraged to lose weight I would need to see the pounds come off first before I would feel comfortable starting a diet or exercise. For some its that initial loss due to the drug that pushes them to go for the walk around the block, take the stairs, or choose an apple over a bakery item. I believe in the drug’s ability as much as I believe in the initial push to get the process going. But, and this is the sticking point for me, the process should be an active collaboration between the patient and the healthcare provider. I don't think giving a weight loss agent with a) educating the person on how to diet and exercise, b) follow up on the challenges of implementing those lifestyle modifications, and c) allowing weight loss despite a sedentary lifestyle is okay. I want the best for my patients and sometimes that means giving a boost in the beginning, guiding through the process, and encouraging when things get tough.
One of the trends we are seeing right now is telehealth doctors prescribing GLP-1s. Telehealth is awesome because it connects people to healthcare providers when local doctors aren’t available—but in these cases it is just a formality for a drug to be prescribed. Weight loss needs to be a concerted effort on both people and unfortunately those only prescribing GLP1 agonists are doing it to make money at the expense of the patient. This was the same for doctors that prey on men searching for erectile dysfunction medications, the same for doctors preying on people who believe they have ADHD but haven’t gotten a formal neurologist or psychiatrist and are put on unnecessary stimulants, and now it is the same for weight loss. Drug companies are using social media influencers to push drugs on people—imagine if that was OxyContin. There are dozens of online health clinics and telehealth companies whose sole goal is to get people on high cost drugs to make money. I’d hate to see a wave of pancreatitis and gallstones because due diligence wasn’t being applied.
Okay, I’m off my soapbox. Regardless, weight loss is a difficult topic because there is no easy solution. There is no drug that cures Obesity and it takes time and effort to have the sustained benefit that people are looking for. Remember that weight loss is the first goal, the second is preventing the weight from coming back. Drugs do the first, diet and exercise do the second. Both work together.
Cheers!

1972- The Jackson 5 perform "Ain't Nothing Like The Real Thing" on the Flip Wilson Show
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1974- Michael performs "Whatever You Got I Want" , "What You Don’t Know" & "If I Don’t Love You This Way" on Soul Train
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1979- On their Destiny Tour, The Jacksons perform at Market Square Arena (closed-1999) in Indianapolis, Indiana
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1983- "Beat It" is chosen as 'Best Overall Clip' and cleans up at the 1st Billboard Magazine Video Music Awards, winning 5 honors
1983 - Arena magazine [Yugoslavia (Serbia and Montenegro)] featured Michael on their cover
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1984- On their Victory Tour, The Jacksons perform the first of two nights at the Municipal Stadium in Cleveland, Ohio
1985- Michael visits Princess Margaret’s Children Hospital in Perth.
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Later he is presented with the City’s Keys by Mayor Michael Agapitos.
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The crowd stirs and begins to invade the stage and Michael was quickly evacuated via the Entertainment Center, prompting Michael to meet and pose for photos with members of the Western Australia Police in charge of security.
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In the afternoon, Michael visits the home of Robert Holmes a Court and his wife, Janet. Michael provides for an auction, two fedoras and a pair of rhinestone socks he wore on stage during the Victory Tour, accompanied by a certificate of authenticity signed by himself. Janet serves as a guide to Michael during his stay and he asks her to go shopping.
In the afternoon, a toy store closes for him. A three year old girl, Bree Rosenthal will have the chance to pose with Michael inside the store. While shopping, Michael also takes time to leave his footprints for Betts & Betts (Australian shoe company) Walk Of Fame.
At night Michael appears live on Australian TV Telethon with Peter Waltham & Molly Meldrum. The telethon is a program that aims to raise funds for hospitals and charities focused on the health and protection of children.
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1988- On his Bad world tour, Michael performs the last of four nights at the Capitol Centre (closed-2002) in Landover, Maryland
1989- Michael gives a deposition in the copyright infringement lawsuit regarding The Girl Is Mine, Thriller and We Are The World
1993- On his Dangerous tour, Michael's show at Maracanã Stadium in Maracanã, Rio de Janeiro, Brazil is cancelled due to health problems
2001- "What More Can I Give" is completed & will premiere in two days
2009 - Two legal documents, signed by Michael, handing to USA for Africa the profits from the 1985 hit "We Are the World" that Jackson and Lionel Richie wrote, and which brought in "tens of millions", will go to auction, benefiting VH1's Save the Music Foundation.
"(Michael Jackson) was a bigger philanthropist than most people gave him credit for," USA for Africa Executive Director, Marcia Thomas, says. "He didn't do it for the credit. He did it because he felt it was the right thing to do."
Nancy Birdsall, president of the Washington-based Center for Global Development, adds that "We Are the World marked what at that time was a high point in rich-world concern about poor people in the developing world. That sort of awareness helps to open the way not only for more effective foreign assistance but for other changes in policy, such as trade and migration, that can have a big impact on poor people's lives."
The 2 legal documents, transferring his rights and profits to the group USA for Africa, are estimated to gross in 50,000 dollars at the Alexander Autographs auction at the Mohegan Sun Casino in Connecticut.
2009- Kenny Ortega, director of This Is It, appears on Oprah to discuss Michael & the documentary
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2011 - People v. Murray Trial Day 13. Week 3
Dr. Shafer Testimony continued/Walgren Direct continued
Walgren goes over again the credentials of Dr. Shafer by showing the journal he's editor in chief and multiple research articles he's written. Research articles examine the differences in regards to gender and age. Dr. Shafer also has done research on Lorazepam, Midazolam and Lidocaine. DA Walgren says that he will ask about these topics during testimony.
Walgren mentions difference between intensive care sedation and procedure related sedation (MAC). Dr. Shafer tells that intensive care sedation would be for longer time, MAC would be shorter.
Dr. shafer says that all the work he has done on this case was for free. He says he never charged money for testimony because he feels it's inappropriate and unethical to benefit from medical misadventures. Shafer says he doesn't want his integrity to be questionned as well Shafer also says he wanted to get involved in this case to restore general public's confidence in anesthesia and doctors. Dr. Shafer says that he's asked daily by his patients "Are you going to give me that drug that killed Michael Jackson?" He says that he hopes to alleviate this unneeded fear with his testimony.
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Mid morning break
Dr. Shafer has brought several medical items for demonstration. First he starts with explaining Saline bag and it's ports. Later Shafer tells what an IV is. Infusion (Drip) when the drug drips in slowly. Shafer explains that Propofol comes in a glass vial, there's an aluminium seal and a rubber stopper on top. To get the drug out you need to go through with a slow needle or a large spike to get the drug out.
Walgren asks Shafer to demonstrate to get Propofol out of the bottle.
Shafer demonstrates how to get out Propofol with a syringe / needle. Shafer tells to get Propofol out you need to replace Propofol with air so that Propofol will go into the needle.
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Walgren asks Dr. Shafer to examine 100 ml Propofol bottle from the scene. Shaffer says that it has a spike hole and not a needle hole.
Dr Shafer has made a video for his case, to demonstrate what is necessary for sedation, even for 25mg propofol. They play the video : "An over view of safe administration of sedation"
The doctor first prepares the room, checks the equipment. Video shows multiple equipment for airway management such as a tube for the throat, a tube for the nose, equipment for intubation, a throat mask for air. Organizes these items.
Then the doctor checks the oxygen equipment. Doctor checks if the oxygen supply work, checks nasal cannula, checks to see if nasal cannula is measuring carbon dioxide by capnometer. Doctor tests anesthesia breathing circuit. This is the equipment used if the patient stops breathing and the doctor needs to push oxygen into the lungs. Doctor then checks the back up oxygen. This is used if for some reason the breathing circuit fails.
Doctor then checks suction apparatus. This is important because if the contents of the stomach gets into the lungs or if the vomit (bile) gets into the lung, it would destroy the lungs. This is why patients are told to not to eat or drink prior to anesthesia. if the patient vomits or the contents of the stomach come to the mouth, the doctor has to be very quick to clean them with the suction equipment before it goes into the lungs and destroys the lungs.
Next step is to set up the infusion pump. It takes a few minutes to set it up. In the video they use a syringe pump. Doctor first draws Propofol into the syringe. As Dr. Shafer demonstrated this is not easy. You need to draw air into the syringe and do multiple draws to fill the syringe. Dr. Shafer tells a narrow tubing has to be used in the infusion pump as the wide tubing could be problematic. Then the doctor programs the pump, putting the patients weight, correct drug name, infusion rate. Doctor verifies the information for a second time.
Next step is to assess the patient. Anesthesiologist is repsonsible for knowing his patient. Makes a physical examination, first thing is airway, listens to the lungs, checks the heart. Always done for each procedure, for every patient. No exception.
Doctor also gets the informed consent of the patient. Doctor informs the patient of risks and explains what the procedure entails, asks the patient if he has any questions, then patient signs the informed consent form. Dr. Shafer says oral consent is not binding, and is not recognized.
Some steps are not shown on the video. These are: patient put on table, monitoring equipment such as blood pressure cuff, pulse oximeter, ECG are put on patient. Oxygen in place, intravenous catheter is put into the patient. After these,the doctor pauses to verify again. Doctor does one last check before injecting the propofol.
Propofol infusion pump is started. Anesthesiologist is close to the patient, monitors the patient. Doctor keeps records of the vitals. Chart is a necessity to track the patient and the patterns. It's a responsibility to the patient.
In this part of the video, we are shown examples of what can go wrong.

1. Blood pressure drops . Dr. Shafer says this is very common and he sees it everyday. Propofol lowers blood pressure especially if the patient is dehydrated. Doctor gives ephedrine through the IV line. Generally blood pressure comes to normal levels.
2. Carbon dioxide. The monitor shows that carbon dioxide stopped. It means the patient is not exhaling and the airway is obstructed. Doctor immediately does chin lift and jaw thrust. Dr. Shafer says this is also done very routinely. Shafer says the most common reason is because the tongue is blocking the airway and by doing a chin lift and jaw thrust you can move the tongue.
3. Apnea. This is when the patient doesn't even try to breath. In this instance you need to take over for the patient and force air into the lungs. Doctor removes the nasal cannula, places the mask on the patient's mouth and nose and squeezes the bag to push oxygen into the lungs.
4. Aspiration (not shown on video). This is when the patient vomits and/or stomach contents come to the mouth. Patient is turned sideways and before the next breath you need to suction everything.
5. Cardiac arrest. Heart stops beathing and the patient stops breathing. Doctor does a 2-3 second assesment to make sure that the monitor has not failed. Then the doctor calls for help. First thing is always to call for help. One person begins CPR, one person is ventilating the patient and other person gives resuscitation drugs. All of this is done to keep the patient alive for enough time to fix the problem that caused the arrest. These efforts are continued until the patient is revived or is pronouced dead.

Lunch break
Afternoon session
Dr. Shafer Testimony continued/Walgren Direct continued
Dr. Shafer says that the safeguards and requirements apply to all doctors who perform sedation, for any type of IV sedatives. Some nurses are also trained about sedation. These guidelines apply to them as well.
Walgren asks if Murray's intent were to give 25mg would these standards still apply. Shafer says yes and continues to say the patient (MJ) had other IV sedatives, profound inability to sleep, he was exhausted, dehydrated and he had been given sedatives for some time and he could have same elements of dependency or withdrawal.
Walgren asks if it's possible to go in saying "I'll only give a small amount so I don't need these guidelines". Dr. Shafer says it's a trap. Even for a little sedation , it's a slippery slope, you may have to give more. You never know how the patient will react. Shafer says there's no such thing as a little sedation and the worst disasters happen when people cut corners.
Facts in this case suggest that virtually none of the safeguards for sedation were in place when propofol was administered to Michael
Walgren asks Shafer to explain how patients react differently to the same dose of sedatives. Shafer says that some patients will need half the usual dose and some patients will need double the dose. Shafer says 25 mg is the limit when a patient might stop breathing. Shafer says you can't assume that this will be an average patient. Shafer says you always assume your patient is at the edge of sensitivity and prepare for the worst case scenario.
Shafer did a report about this case dated 4/15/11. In his report he used some terms.

• Minor violation : not consistent with standard of care, but would not expect to cause harm for the patient unless there are several other violations
• Serious violation : expected to cause harm to the patient, in combination of other violations
• Egregious violation : These should never happen in the hands of competent doctors. An egregious violation can alone be catastrophic for the patient. Competent doctors know that a bad outcome is a high possibility
• Unconscionable violation : It goes beyond the standard of care. It's an ethical and moral violation as well as a medical violation.

Walgren goes over Dr. Shafer's report and 17 egregious violations he identified.

• Lack of basic airway equipment. Michael died because he stopped breathing which is expected when you give IV sedatives. It must be there without question.

Walgren asks Dr. Shafer to assume that Murray had left only for 2 minutes and if he had the equipment could Michael have been saved? Dr. Shafer says yes and Michael probably had an obstructed airway and even a simple chin lift might have been required to save him. Shafer says that Murray says he didn't use the ambu bag. Shafer says mouth to mouth is less effective and gives used air.

• Lack of advanced airway equipment. Those are equipment such as laryngeal masks, or laryngoscope and endotracheal tube. Shafer had described it as a serious deviation originally but changed his mind to an egregious because of the setting. Murray had no help.

Shafer says that it's his view that Murray had anticipated to give 100 ml vials. He had purchased at least 130 100 ml vials, Shafer believes that's at least one per night. Shafer says it's an extraordinary amount for one patient; between April – to June 25th, that's 80 nights, 1937 mg/night. Walgren asks how he came to this determination. Shafer says Propofol is an environment for bacteria development. Once a bottle is opened with a needle, it has to be used within 6 hours. Shafer says this suggests Murray planned to use 100ml, if he didn't he would purchase smaller vials.
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• Lack of suction apparatus. Shafer reminds the jury that any stomach content and/or vomit has to be suctioned so that it won't go into the lungs. Shafer says there's no evidence that Michael was asked to fast for 8 hours prior being given Propofol. Due to this he was at greatly higher risk. Therefore suction equipment was needed.
• Lack of infusion pump. There was no infusion pump. Without it the rate cannot be precisely controlled and the risk of overdose is very high. Shafer says in his opinion this likely contributed to Michael's death.

Walgren asks without an infusion pump how can one person control the drip. Shafer answers by roller clamp. It's a plastic wheel that pinches the tubing to decrease the amount . Shafer says it's extremely imprecise and that was the only thing available to CM when he gave propofol.

• Lack of pulse oximetry. The pulse oximeter that Murray used was completely inappropriate. It's not intended to be used for continuous care as it had no alarm. Shafer says that on monitors in hospital they can see it on the screen and there is a tone. Doctors will hear the tone changes which alerts them that there's a problem. In Michael's case the only way to monitor was to take his hand and continuously look at it. If there was proper equipment, there would be a monitor showing the vital signs from a distance and there would be an alarm that could have saved Michael's life.

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• Lack of blood pressure cuff. Propofol lowers everyone's blood pressure. Doctors would treat it with additional saline solution or with less propofol. Michael was dehydrated, the risks are higher for exaggerated response. If blood pressure falls the body shuts down the flow to the arms and legs and concentrates on providing blood to heart and the brain. The drug becomes more potent. Dr. Shafer says the manual blood pressure cuff that Murray had in his bag in the cabinet is useless.
• Lack of ECG. ECG allows you to see the heart rate & rhythm. This is routine monitoring. In this case Murray couldn't know what kind of therapy to use when Michael went into arrest.
• Lack of capnography. Dr. Shafer initially thought that it was not a violation as other specialists don't use it. However in Michael's environment, it was a disaster. If Murray had it he would have known immediately that Michael had stopped breathing.
• Lack of emergency drugs. Dr. Shafer doesn't think lack of emergency drugs contributed to Michael's death. Shafer says if Michael had low blood pressure as he wasn't going through surgery, he could have been woken up and hydrated; stopping propofol would have been enough.
• Lack of charts (egregious violation as well as unethical). Shafer says a doctor needs charts to assess what's going on and the changes. Shafer says the patient or if the patient doesn't survive the family has a right to know what happened and what the doctor did.

Dr. Shafer gives an example and Dr. Shafer looks clearly upset. Dr. Shafer says he knows how he would feel if his father , brother or son went to a medical facility for 80 days and died and the doctors told him they don't know what happened because they have no reports. Dr.Shafer says it's unbelieveable that after 80 days of treatment there's not a single record of treatment. Dr.Shafer says that not keeping records is also illegal in California. Dr. Shafer says that doctors have to keep records even if the patient doesn't want them and confidentiality cannot be an excuse.
Shafer says that in Murrays interview he mentioned Michael could have been dependent on Propofol and that would require a referral but he can't do that referral as he had no records.

• Obligation to get information about the patient. Shafer says it's doctors responsibility to know everything about their patient to provide care. Shafer says Murray mentions IV sites but didn't follow through and ask what was happening. Walgren asks what if the patient says it's none of your business, Shafer says that then he would say "Then I can not be your doctor".

Dr. Shafer the only physical evidence of Michael was done months ago. Shafer says Murray mentioned Michael being dehydrated but yet he didn't do a simple blood pressure check. Shafer says there's no history, not even a simple recording of the vital signs. Shafer calls this a serious violation and that no doctor does that.

• Failure to maintain a doctor patient relationship. In this relationship the doctor would put the patient first. It doesn't mean to do what the patient asks, it's to do what's best for the patient. If patient asks for something foolish or dangerous, doctor should have said no. Dr. Shafer describes the relation between Murray and Michael as employeemployee relationship. Patient stated what he wanted, Murray says yes. Shafer compares Murray to a housekeeper that does what they're told. That's what an employee does. Shafer says Murray was not exercising his medical judgement and he was not acting in Michael's best interest. Murraycompletely abandoned medical judgement.Shafer says the very first time Michael asked for propofol, Murray should have sent him to a sleep specialist.
• Lack of Inormed consent (egregious and unconscinable). An informed consent would have involved that propofol is not a treatment for insomnia, It woud have explained risk of death and alternative treatments. Dr. Shafer says there's no proof that Michael knew that he was putting his life at risk. Shafer again mentions that the consent has to be written. Michael was denied his right to make an informed decision.
• Need to continuously observe the mental status (egregious and unconscinable). Dr. Shafer says that doctors need to stay with the patient and Murray abandoned his patient. Shafer compares giving sedation to driving a motor home. Shafer says you cannot leave the steering wheel on a highway to relieve yourself. If you do it would be an disaster. Dr. Shafer says in 25 years he has been a physician he have never walked out of the room.
• Continious monitoring / observation. Murray left Michael alone and he was on the phone. Shafer says you can't multi-task especially if you have no monitoring equipment. Dr. Shafer: "A patient who is about to die, doesn't look that different from a patient that is okay". Dr. Shafer says from a distance you can't tell if a person is breathing. Shafer says he believes Murray may have been in the room and not realized Michael had stopped breathing.

Shafer says resuscitation would have been easy as all that is needed is to stop propofol and make Michael beathe. Shafer once again reminds that it's common that patients would stop breathing during anesthesia and it's expected. Shafer says as Murray was monitoring all he needed to do was to lift the chin and ventilate.
Mid afternoon break

• Lack of continuous documentation (egregius and unconscionable violation). Dr. Shafer says documentation is part of giving care. Shafer says if Murray had the reports he would have seen that the oxygen saturation lowered or the heart rhythm changed.
• Failure to call 911 timely. Shafer says in that setting Michael could not have been revived without assistance. Shafer says calling 911 was the highest priority given the lack of help and equipment. Shafer says if calling 911 was not possible, Propofol should not been given at all.

Shafer says assuming Murray realized there was a problem at 12:00, he doesn't understand that Murray left a voice message to Michael Amir Williams and how it took 20 minutes to call 911. Shafer calls it inconceivable and completely and utterly inexcusable.
Shafer says if Murray left only for 2 minutes and called paramedics immediately Michael would be alive with some brain damage. If Murray realized Michael was in trouble within 2 minutes and had the airway equipment, he would be alive and uninjured.
Walgren asks how effective is one handed CPR on a bed. Shafer says the patient sinks into the bed and it's ineffective. Even if Murray had his hand behind Michael's back it's ineffective because you need your body weight to do effective CPR. Shafer says you need 2 hands, one hand is not enough. Shafer says Murray should have called 911 first and then moved Michael to the floor. Shafer also says based on Murray's interview the issue here was not that the heart stopped; Michael stopped breathing. Murray said there was a pulse. If there was a pulse what he needed to do was to have oxygen into his lungs. There was no need for CPR if there was a pulse. Shafer says a lay person would use mouth to mouth as they have no other means. For a doctor it shows that the doctor doesn't have the equipment needed.
Shafer says that he doesn't understand why Murray raised Michael's legs. Shafer calls it a waste of time. Shafer says raising the legs is done when you think there's not enough blood in the heart but that wasn't Michael's problem. His breathing had stopped. Shafer says that it shows Murray was clueless about what to do.
Walgren asks what is flumazenil. Shafer explains it's a drug that reverses the effects of lorazepam and midazolam. Dr. Shafer says he's curious why Murray gave it. Shafer says it doesn't fit with only giving 2 doses of 2 mg several hours before. Dr. Shafer says he believes that Murray knew that there was a lot more lorazepam.

• Deception of paramedics and UCLA doctors and not mentioning propofol (egregious and unconscionable violation). Dr. Shafer says a person's life was in the balance, it's inexcusable. Shafer says he also mischaracterized this event as a witnessed arrest. Shafer says a witnessed arrest is not an arrest for lack of breathing, it is usually something like a heart attack. So the therapy of the paramedics and ER doctors was not appropriate. In an arrest you have only seconds to choose a treatment, paramedics and ER doctors were not given the corect information. Shafer says witholding information is a violation of patient's trust.

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Walgren asks what is polypharmacy. Shafer explains it's administering many drugs at once and it's a serious violation. Shafer says what Murray gave to Michael didn't make any sense. Shafer says Midazolam and lorazepam are very similar drugs and the only difference is how long they stay in the system. Shafer says he doesn't understand why Murray switched from midazolam to lorazepam and back. Shafer says that he thinks that Murray did not understand the drugs he was giving.
Walgren asks if 25mg of Propofol is a safe dose. Shafer says in this setting there was no safe dose. Midazolam and lorazepam were given. Michael had received benzos for 80 nights, he could have been dependent or in withdrawal from the benzos or propofol. Dr. Shafer says he never heard of a person being given propofol for 80 nights and doesn't know what would happen.
Walgren asks about the Taiwan study. Shafer says there are over 13,000 medical articles about propofol, 2,500 articles about propofol and sedation and there's only one article on Propofol and insomnia. It's this study done in 2010. Dr. Shafer says that he wouldn't publish the Taiwan study because the dose of Propofol that was given is not mentioned. Dr. Shafer also says that the conditions of the study don't apply here. That study was done in a hospital, by anesthesiologists, patients had fasted for 8 hours, they were monitored, an infusion pump was used, propofol was used for 2 hours for 5 days during two weeks. There was no other medication. The patients were treated within the standard of care. Shafer says the article actually highlights Murray's deviations from standard of care.
Walgren asks even if Michael had taken Lorazepam and/or Propofol would these 17 deviations would still be relevant and if Shafer would consider Murray responsible for Michael's death. Dr. Shafer answers "Yes".
Walgren asks about the doctopatient relationship. Dr. Shafer says it's dated back centuries ago. Dr. Shafer says that doctors have power to give drugs and cut open a patient,etc and this is because they are entrusted to do that because they are supposed to put the patient first. Dr. Shafer reads hippocratic oath. Shafer says when Murray agreed to give propofol to Michael, he put himself first. When Murray was showing up every night with propofol and saline bags, he was putting himself first. When Murray withheld info from paramedics and ER doctors, he put himself first
Video
2012- Bad25 premiered on the big screen in both Los Angeles and New York theaters for an exclusive one-week engagement

1972 - "Ben" is the #1 song in the US
1979- On their Destiny tour, The Jacksons perform at Spectrum Arena (closed-2009) in Philadelphia, Pennsylvania
1979- "Don't Stop 'Til You Get Enough" hit #1 on Billboard's Hot 100, giving Michael his first #1 hit since "Ben" in 1972
The song also gave Michael his first solo #1 for five weeks on the R&B singles chart.
1984 - On their Victory Tour, The Jacksons perform at Comiskey Park(closed-1990) in Chicago, Illinois
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1985- Diana Ross' single "Eaten Alive" hit the charts in the US. The song was co-written, co-produced and co-vocalized with Michael Jackson and Barry Gibb
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1987- Michael plays the last of three nights at Osaka Stadium (closed-1998) in Naniwa-ku, Osaka, Japan
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1987- Michael is on the cover of People magazine with the headline "MESSAGE FROM MICHAEL", featuring a handwritten letter from Michael
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He sat down at the desk in his room at the Capitol Tokyo Hotel in Tokyo and, on the back of a piece of hotel stationery, wrote what he said would be his only discussion of his private life.
"As an old Indian proverb says... 'Don't judge a man until you've walked two moons in his loafers.' Most people don't know me, that's why they write things that most of them aren't true. I cry a lot because it hurts and I care about the kids, all my kids all over the world, I live for them If a man can't say anything he can't prove, against a character, the story can't be written. Animals don't attack out of malice, but because they want to live, it's the same with those who criticize me, they want our blood, not our pain. But I still have to reach my goals, I have to seek the truth in all things. I have to bear for the power that I was sent, into the world for the children. But have mercy, because I'm bleeding already long time now." - MJ
​
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1993- On his Dangerous tour, Michael performs the 3rd & final night at the Estadio Monumental in Buenos Aires, Argentina
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1995- "You Are Not Alone" was certified Gold and Platinum.
1997- Michael plays the second of two nights at Johannesburg Stadium in Johannesburg, South Africa to an audience of 58,000. His parents, Lisa Marie & her children attend
1999- History: Past, Present & Future Book 1 was certified 7X Platinum
2001 –Tele Poche magazine (France) featured Michael on the cover with the headline: "Michael Jackson – Verites ou mensonges?" ["Michael Jackson – Truth or lies?"]
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2002- As a personal acknowledgement of the gallantry and sacrificial services made by the military in his community, Michael invites over 200 US Air Force members from "Team Vandenberg" (recently returned from overseas deployments) and their families to spend the day at Neverland.
2004- Michael calls the Steve Harvey Morning Radio Show to ask TV networks not to air Eminem's video for the song "Just Lose It", the new video which makes fun of him.

"I would like to thank you, Steve, Radio One, the African-American community, my fans from around the world, and some of the members of the media, for the support that you have given to me. I would also like to thank Mr. Robert Johnson, Chairman and Founder of BET for pulling the Eminem video from BET's airplay. I appreciate very much the love and support that you all have shown me. I am very angry at Eminem's depiction of me in his video. I feel that it is outrageous and disrespectful. It is one thing to spoof, but it is another to be demeaning and insensitive. I've admired Eminem as a artist, and was shocked by this. The video was inappropriate and disrespectful to me, my children, my family, and the community at large. It is my hope that the other networks will take BET's lead and pull it"

BET accepts but not MTV which creates a new controversy
2004 – CBS Early Show airs an interview of Genevieve, Randy Jr, Dante, Jaffar, & Jermajesty Jackson at Hayvenhurst defending their uncle Michael.
2005- Michael takes Prince, Paris & Blanket to Harrods where they are greeted by owner Mohamed Al Fayed.
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Michael raced around the posh London store and reserved two watches worth £55,000 and £30,000
​
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​
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His children Prince Michael, eight, Paris, seven and Prince Michael II, three, then descended upon the toy department.
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An insider said:

"He was only in the store for about 30 minutes. His kids had a fantastic time in the toy department. They fell in love with this gigantic toy Hummer".
"After spending thousands of pounds on gifts for them, including life-size teddy bears, Michael signed autographs for fans."

Michael’s spokesman said:

"Last time he came to London he went to Hamleys - but he loves the cuddly toys at Harrods."

2009- A never-before released song from Michael, "This Is It", was unveiled on his website
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2011 - People v. Murray Trial Day 11
Dr. Alon Steinberg (Cardiologist) Testimony
Walgren Direct
Steinberg is a board certified cardiologist for 13 years. He is not an expert in anesthesia, sleep medicine, pharmacology or addiction medicine.
Steinberg has reviewed Conrad Murray's resume. Murray was not board certified on 6/25/09. Steinberg tells board certification is an extensive 2 day test and 90% of the cardiologists that take it pass it.
Steinberg is an expert reviewer for the California Medical Board, he reviews other doctors' actions to ensure the standard of care has been respected. 3 levels are possible:

• no deviation
• simple deviation
• extreme deviation

Extreme deviation is also defined as gross negligence.
Steinberg has conducted a review for this case. He had conducted 8 prior reviews. In 4 cases he found no deviation; in 4 cases he found simple deviation of care. This is the first time he's seen an extreme deviation from standard of care.
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Cardiologists use sedation for many procedures and sometimes they use Propofol. Cardiologists are experts in mild or moderate sedation. In conscious sedation the patient is able to talk and respond to touching. Deep sedation is when patients are only responsive to pain or repeated stimuli. General anesthesia is when patients feel no pain. Cardiologists are not trained in deep sedation. When deep sedation is needed, they call an anesthesiologist and that’s the only time they use Propofol.
When they are giving mild or moderate sedation they use benzodiazepines. For deep sedation they are required to give Propofol with an anesthesiologist.
Steinberg has reviewed this case. He has focused his review based on Murray's interview with police. Steinberg wanted to judge Murray on his own words.
Steinberg found 6 separate extreme deviations from standard of care.

• Propofol was not medically indicated. Steinberg mentions Propofol is an anesthetic. Steinberg tells there was no written informed consent. The patient must be informed of the risks and benefits of treatment. Steinberg never heard of Propofol being used for insomnia. Steinberg says that using propofol for insomnia is gross negligence and extreme deviation.
• Propofol was given in a home setting, without proper equipment and without proper staff.

Walgren asks what equipment is needed. Steinberg says that first a pulse oximeter with an alarm is needed but Murray's oximeter didn't have an alarm. Steinberg says he'd have to stare at Michael nonstop every second. Steinberg says he should have an automated blood pressure cuff, to check blood pressure at least every 5 minutes. Murray had a manual cuff and did not use it. Next thing is needed is an EKG monitor to track the heart rhythm. Another thing that is needed is oxygen with a nasal cannula or mask. You need suction in case the patient regurgitates and you need to get it before it goes into patient’s lungs. Another equipment needed is an Ambu bag. Murray had an Ambu bag but did not use it, he did mouth to mouth. You also need to have a way to call for help. Backboard is needed in case CPR is needed. You also need a back up battery for the equipment in case of a black out. Other equipment needed is equipment needed for airway such as endotracheal tube. Endotracheal tube requires trained staff to place it. Also you need a defibrillator.
A lot of special drugs are also needed. Those are fluamzenil, narcan, lidocaine, betablockers, atropine, dopamine, epinephrine, prednisone, dextrose.
Steinberg says when giving sedation you also need BLS (basic life support) and ACLS (advanced cardiac life support) trained assistant.

• Inadequate preparation for an emergency. You need to have the drugs ready, equipment ready, have a person ready to help you. You need to be prepared to use those medicines and equipment in the case of emergency.
• Improper care during the arrest. Michael’s breathing had stopped and Murray didn't follow proper protocol.

Steinberg explains cardiac arrest which is when the heart stops beating. There’s no blood pressure and the patient collapses. In that case you call 911, use a defibrillator, and do CPR on a hard surface.
In Michael's case, it was a respiratory arrest. Michael stopped breathing and the oxygen went down. Then the heart started to beat harder while trying to distribute little oxygen in the body. According to Murray's statement this is when Murray found Michael. If you do nothing, the heart weakens because of lack of oxygen, and stops contracting but there is still an electrical activity. That’s PEA (Pulseless Electrical Activity). After PEA, there's asystole.
Steinberg says Murray should have called 911 immediately then try to arouse Michael, should have used the Ambu bag and give him Flumanezil. Steinberg says it’s inexcusable that Murray did chest compressions. This was a respiratory arrest not a cardiac arrest and there was blood pressure and pulse. Murray should NOT have done CPR.
Conrad Murray’s CPR was poor quality because Michael was on a bed. It has to be done on a hard surface such as on the floor and should have done CPR with 2 hands. Steinberg says it would have been very easy to put Michael on the floor.

• Failing to call for help. Murray should have called 911 immediately. He should have known that he didn’t have any of the medications and the equipment and he had to call for help. But Murray instead called Michael Amir Williams which caused a significant delay. EMS was only 4 minutes away. If Murray had called them he could have gotten help sooner.

For every minute delay in calling EMS, there are less and less chances the patient will survive and there is a risk of permanent brain damage. Walgren: “Every minute counts”.
Steinberg also thought it was bizarre to call an assistant instead of calling 911. Murray as a medical doctor should have realized he needed help and called 911.

• Failure to maintain proper medical records. Medical records are important for several reasons. Insurance companies want them. Second reason is litigation. The most important reason is for better health care for the patient. Murray did not document a single thing. He didn’t ask when the last time Michael ate was, he had no vital sign records, he had no physical exam. There was no informed consent. He didn’t write what medication he gave and what was the reaction. Murray was confused and was not able to explain Michael's history or what he gave him to the ER doctor or EMTs. Walgren asks if he could be dishonest rather than confused.

Steinberg concluded that these extreme deviations directly contributed to Michael's death. Without these deviations, he would still be alive.
Walgren asks based on Murray’s statement if he gave benzodiazepines and only 25mg Propofol if the risk of respiratory depression is foreseeable. Steinberg answers yes.
Walgren assumes everything happened as Murray described and as Murray left Michael alone, Michael was able to take Lorazepam pills or Propofol. Steinberg says all the things he said still apply. Steinberg says you never leave the patient and always monitor patient. If Michael self administered, it means that Murray was away, and that should not have happened. Steinberg compares leaving a patient under the effect of Propofol to leaving a baby sleeping alone on the kitchen counter. Steinberg says the baby might have woken up and fallen down.
Steinberg also mentions that medication should not have been within Michael's reach. Steimberg explains how in hospitals every medication will be under lock and says that having medications out in the open is a foreseeable risk that the patient can self administer and take the wrong medication.
Mid morning break
Flanagan Cross
Steinberg is not currently trained in using Propofol. When Steinberg was NY he had privileges to use Propofol. In his current work he does not have the privileges and he hasn’t used it in 7 years. When he was in NY he felt confident in using Propofol because he was trained in protecting airways.
Flanagan asks if there is a difference in the equipment needed for moderate and deep sedation. Steinberg answers no, they will be the same.
Flanagan asks if Steinberg thought Murray's declaration to the cops was thorough and complete. Steinberg says he assumed it was complete.
Flanagan asks how Steinberg knows Murray didn’t have informed consent. Steinberg says because there was none. Flanagan asks if the informed consent can be oral. Steinberg says it has to be written. “If it's not written it's not done.” Steinberg says he has never heard an oral consent. Flanagan asks if any written document had anything to do with Michael's death. Steinberg says if Michael had been informed about risk and benefits, he might not have agreed to this.
Steinberg says he cannot know if Michael had been informed, but assumes he was not informed that a powerful dangerous drug would be used on him without proper monitoring. Steinberg assumes he would not have agreed to it.
Flanagan asks if Steinberg knows anything about Michael's propensity towards drugs and mentions Demerol and Klein. Flanagan asks what if Michael was an addict; would he have agreed to it? Steinberg says if he was an addict, he wouldn't give it to him in the first place.
Other doctors that use Propofol could be dentists, gastroenterologist, pulmonary doctors, ER doctors. But their societies have advice on how to use it and they are trained. Their societies outline the same monitoring equipment that Steinberg mentioned. Steinberg says there’s no difference in equipment needed for conscious sedation.
Flanagan asks what killed Michael? Steinberg says a respiratory arrest because he still had a pulse that means there was a heart rate and blood pressure. Murray said there was blood pressure and a pulse, it was later PEA.
Steinberg says that according to Murray he found Michael around noon and EMS arrived at 12:26. There was a delay in calling 911 for at least 12 minutes. Flanagan mentions Murray made a lot of time estimations and it might be all precise.
Flanagan asks what 2mg of Lorazepam would do to a patient. Steinberg says he’s not an expert, he gave it as a sedative orally before but he never used IV. Steinberg says he gives it an hour before the procedure orally. Flanagan asks further questions about Lorazepam, Midazolam. Objections. Sustained. It’s beyond his area of expertise.
Flanagan turns the subject to Propofol and say that Michael and Murray had been discussing Propofol for the past 3 nights and Murray told him it was not good for him and he was trying to wean him off.
Steinberg states that Murray said that he gave 25mg initially and started Michael on IV. Flanagan denies that there was an IV. Steinberg understood that after that initial 25mg dose, there was a drip based on his police interview. Steinberg cites a lot of examples in Murray interview referencing IV and says it makes sense because 25mg would not keep Michael asleep.
Flanagan insists there was no drip on the 25th, Steinberg insists there was a drip, they both give examples in Murray's LAPD interview. They agree it's not clear, but Steinberg says it makes no sense. It's logical Murray gave a drip. Michael logically would have woken up, and there was no reason that Murray changed his methods.
Flanagan says that 25mg is not a heavy dose and it would make Michael sleep 4 to 7 minutes. Steinberg agrees. So Flanagan asks if Michael was still asleep he was sleeping for other reasons such as being tired. Steinberg says that he would have worried that Michael was still asleep if he was not on a drip. Protocol says that after Propofol you should watch the patient. Steinberg says just looking at Michael doesn't tell if he's in mild sedation or in deep sedation. Steinberg says they need to be continuously checked for their reaction to stimuli. Steinberg says Murray should have woken him up. Steinberg says the fact that he was still asleep after 10 minutes, if there was no drip, is very alarming. Steinberg it might mean that something was going wrong.
Flanagan mentions a study that Propofol was successfully used on refractory chronic primary insomnia in Taiwan. Steinberg says that the article dates back to 2010, in 2009 when Murray gave propofol there was no medical knowledge that Propofol could be given for sleep. Murray was unethical in giving Propofol with no medical knowledge. Article mentions Propofol given for 2 hrs per night 5 nights, not 8 hours per night for 2 straight months. The article says that this test was successful, but it's still not used as a sleep medication because it's still experimental, there is not enough data about this. It needs to be extensively researched and tested. Murray is the first doctor he's heard who used propofol for insomnia.
Flanagan asks how Steinberg knows Murray didn't use Ambu bag, Steinberg says because Murray said he did mouth to mouth. Flanagan asks how Steinberg knows Murray didn’t use the blood pressure cuff, Steinberg says because it was not on Michael. Steinberg says pulse oximeter was not on Michael
Steinberg says he doesn’t know what happened between 11 and 12 or how long Murray watched Michael or when Murray went to bathroom. Flanagan asks if he has an idea about the actual time of death. Steinberg says Michael was pronounced dead at 2:26PM but he was probably clinically dead for some time.
Steinberg says Michael was savable when Murray found him based on his interview. Steinberg says Murray said he left Michael for 2 minutes. By using Ambu bag, by arousal and changing the effects of the medicines and if 911 was called Michael was savable.
Flanagan tries to get Steinberg to assume that Murray was gone longer than 2 minutes. Steinberg is not comfortable making those assumptions as he based his report on Murray’s statements. Flanagan mentions the phone calls; Steinberg does not want to comment on them. Steinberg says saying Murray was on the phone tells him that he shouldn’t have been on the phone and if Michael was only given 25mg it would wake him up. Steinberg says that it tells Michael was on a drip.
Flanagan wants him to assume that if Murray was gone longer than 2 minutes if Michael was savable. Steinberg says he was savable because according to Murray’s statement Michael had a pulse, blood pressure and heart was still beating and with proper equipment he could have been saved. He could have given Michael oxygen. Steinberg says Michael wasn’t PEA when Murray came back because he had a pulse. Flanagan asks how he knows know Michael had a pulse, Steinberg says because Murray said so. Flanagan asks if it could PEA. Steinberg says in PEA there’s no pulse.
Flanagan asks what Murray should have done. Steinberg says he should have called 911 and it would have taken 2 seconds. Steinberg says protocol says doctors are allowed 2 minutes to determine the situation. Flanagan asks if Murray went down to ask for help in 12:05 – 5 minutes after – if it would be a violation of standard of care. Steinberg says he didn’t have the right equipment so he should have called 911 immediately.
Flanagan tries to talk about Kai Chase. Steinberg says Murray didn’t ask Kai to call 911. Flanagan asks what if Murray called for help in 5 minutes but not in 2 minutes. Steinberg says it’s still a deviation from standard of care.
Flanagan asks if he talked to Murray to review the case. Steinberg says no and he didn’t ask. Steinberg used Murray’s 2 hour interview.
Flanagan asks what Murray should have done in 2 minutes. Steinberg says call 911, tilt the head to open airway, make him breathe with Ambu bag and give Flumazenil. Steinberg says he would have called 911 first. Steinberg says Murray had to increase Michael’s breathing.
Flanagan asks if Murray made a mistake in asking someone to call 911 Steinberg says he had no one around and he had to call 911. Steinberg says for the time it takes to call for security Murray could have called 911. He had a cell phone. Steinberg says it would have taken him 2 seconds to say “I’m a doctor, there’s an arrest, come to 100 Carolwood now” and then Murray could have put 911 on loudspeaker and continue to do what he was doing.
Flanagan asks if he’s aware that EMS said Michael was cool to the touch. Yes but Murray said he was warm. Steinberg says you get cold in 26 minutes when you have no blood pressure.
Flanagan asks if Steinberg has no doubts that if 911 had been called immediately Michael would still be alive. Steinberg says he has no doubt about that, they could have saved him. Murray said that he lost the pulse after calling Williams at 12:12. So if the paramedics had been there at 12:05 or 12:10, they could have saved him.
Flanagan says that Murray was in an emergency situation and he could be mistaken in his estimations. Steinberg says there is clear evidence that there was a delay in calling 911 as Murray went downstairs and called Williams rather than calling 911.
Flanagan asks based upon these facts if Steinberg thinks Murray is responsible for Michael's death. Steinberg says yes.
Flanagan asks if Murray should have dropped Michael on the floor, in spite of the IV line. Steinberg says he should stop the Propofol drip first and then he should be careful with the line when he’s putting Michael down the floor.
Flanagan asks rather than suction would it be okay to turn the patient on his side and clean the mouth with a finger will be okay. Steinberg says suction is needed.
Flanagan asks if a doctor has only 1 patient, he would still need to document everything he does. Steinberg says he does because obviously Murray didn't recall what he had given when he talked to UCLA or with the paramedics.
Flanagan says that not having records did not kill Michael. Steinberg says it wouldn’t cause his death but it’s still a deviation.
Lunch break
Afternoon Session
Dr.Steinberg Testimony/Walgren Redirect
Steinberg states that Murray did not act like he was ACLS certified.
Steinberg states that he used propfol in New York, but it was in hospital settings.
Steinberg states that gastroenterologists, dentists and ER doctors who use propofol receive appropriate training, with a trained staff and appropriate monitoring equipment are necessary.
Steinberg states that an article about the propofol study in Taiwan, published in 2010, was an experimental study. The patients were given propofol in a hospital , with the appropriate equipment, the experiment was approved by their ethics committee. Steinberg states that written, informed consents were obtained from the patients. Steinberg states that 8 hours of fasting occurred prior to being given propofol, and that the propofol was given by an anesthesiologist. Steinberg states that the patients were constantly monitored and pulse oximeters were attached to the patients. Steinberg states that the propofol was administered by an infusion pump, a drip was not used. Steinberg states that no other benzos were used. Steinberg states that the authors of the article specifically state that the study was an experiment, and that is does not dictate a standard of care. Steinberg states that what Murray was doing was essentially an experiment.
​
Steinberg states that if he had to assume that Murray gave only 25mg, that there was no drip, would he draw the same conclusions? Steinberg states yes, that standard of care was deviated from in an unmonitored setting, without appropriate equipment, response was inappropriate, medical records were inappropriate and that it was be a foreseeable prediction that there would be respiratory depression (stop breathing).
Steinberg states that Murray played a direct, causal role in Michael's death.
Recross Flanagan
Steinberg states that the sleep study showed that propofol helped insomnia.
Steinberg states that in his analysis for the CA medical Board, that Murray deviated from the standard of care for Michael
Steinberg states that the lack of a backup battery did not lead to the cause of Michael's death, however, 5 out of 6 deviations did lead to his death.
Steinberg states that he did read Murray's interview with LAPD that he gave Michael propofol for 40-50 days without incident. Flanagan asks if Steinberg has made certain assumption, Steinberg states no. Steinberg states that he didn't assume that Murray gave propofol, that Murray didn't have the proper equipment, the delay in calling 911, improper care during the arrest, that all of these things are facts.
Walgren Re-redirect
Steinberg states that even if the defense theory that Michael self-injected propofol and therefore accidentally killed himself, according to Conrad Murray's own words, Murray would still be the causal factor in his death.
Dr. Nader Kamangar (Sleep Medicine Expert) Testimony
Walgren Direct
Kamangar states he is a pulmonary care/sleep medicine/critical care physician at UCLA. He states he is board certified in four areas: internal medicine, pulmonary medicine, critical care, and sleep medicine.
Kamangar states he is a medical reviewer for the CA Medical Board , and that he assessed Murray's care to Michael for the medical board. Kamangar states that propofol is used in critical care unit on a daily basis. He states he is trained in using propofol. Kamangar states propofol is used for placement of endotracheal tubes, and for people on breathing machines. Kamangar states that propofol is the most commonly used drug for this.
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Kamangar states that he found multiple deviations of standard of care with regard to Conrad Murray's care of Michael :

• Propofol was given in an unacceptable setting : using this deep sedation agent in a home setting is inconceivable and an egregious violation of standard of care.
• ACLS certified : the person who gives propofol must be trained in ACLS and airways management. There was a risk of hypoventilation (diminishment in rate of breathing), apnea and obstruction of the airway.
• Need of assistance : Murray needed a second person (a nurse) to monitor, to pay complete and utter attention to Michael, especially if Murray was going to leave the room; this goes without saying. This violations Hippocratic oath, to abandon his patient.
• Pre-procedure setup : imperative to be prepared for unforeseen circumstances. Things can change very quickly. A patient may look good, and the next minute there's a problem. Murray needed a suction catheter, because patients can regurgitate into their airway, and block the airway, this can cause death. A crash cart (medication on hand : adrenaline, ephedrine, medication to correct the heart beat, etc...) , pulse oximeter, defibrillator, automated infusion pump (precise dosing for propofol) even with people who are intubated;

Kamangar states that all of these factors are extreme deviations of standard of care and are the equivalent of gross negligence.
Kamangar states that he has never seen someone giving propofol at home in such settings, and would not have expected to see that.

• Charts / medical documentation : or medical history, reactions to a medication. For example a blood pressure can look normal, but not be normal for a particular patient, and that change in blood pressure could be the indication of a problem.
• Michael was left alone, which is not acceptable, especially since Murray didn't have the right equipment.
• Use of benzodiazapines: using lorazepam and midazolam on top of propofol can have higher effects : more significant respiratory depression, decrease cardiac output (often a consequence of respiratory depression), decreased blood pressure and cardiac arrest can occur directly, or because of low levels of oxygen.
• Dehydration : blood circulation is not good when you are dehydrated , causes low blood pressure. Benzos and propofol would also lower blood pressure . Murray should not have used benzos or propofol if the patient is dehydrated.
• Failure to call 911 : 911 should have been called immediately.
• Improper CPR : Murray stated there was a pulse, therefore the heart was beating, so the problem was respiratory not cardiac. Murray should have dealt with airway management by placing an ambu-bag over Michael's mouth. Murray's administration of CPR was ineffective; it was not on a hard surface, and it was done with one hand . Correct CPR correctly allows about 20% of the normal blood circulation, so if you do it incorrectly

Kamangar states that assuming Murray found Michael at noon, and calls Williams at 12:12 pm, the significance of the 12 minutes is the lack of blood flow to vital organs, especially to the brain. He states that some individuals are more susceptible than others to a lack of oxygen. Kamangar states that generally it takes 3 to 4 minutes before brain cells start to die. He states that time is really important. Kamangar states that because 911 was called at 12:20 pm, with the passage of 20 minutes, it reaches a point where it becomes irreversible.
Kamangar states that Murray Deceived paramedics and ER staff because he did not provide the accurate information, which is a deviation of standard of care.
Kamangar states that Murray did not properly evaluate insomnia. He states that insomnia can have many causes, so it's important to have a detailed history. Kamangar states that Murray needed to exclude secondary problems (psychological problems, substance abuse, underlying conditions, chronic anxiety, depression , etc...) He states that insomnia is defined by no restful sleep for 4 weeks or more. Kamangar states that once all the secondary problems are ruled out, primary insomnia is considered.
Kamangar states that in order to diagnose/treat insomnia. a detailed sleep history is needed : when do they go to bed, when do they fall asleep, when do you wake up, etc.. check sleep apnea. In some cases you need a sleep study.
Kamangar states that a detailed pharmaceutical history was needed; both prescribed or over the counter (example migraine pills contain caffeine, that can cause insomnia), illicit drugs.
Kamangar states that a detailed physical examination was needed; some underlying conditions can cause insomnia, for example asthma, congestive heart failure, diabetes, bladder problems, enlargement of prostate, thyroid conditions, etc..
Kamangar stated blood testing was needed to rule out certain conditions; examples: diabetes, kidney problems, restless legs , etc..
Kamangar states that a good blood workup would reveal the use of narcotics, if the doctor asks the patient for one. He states that if the patient is not giving the information, a doctor can simply refuse to treat the patient.
Kamangar states that when all the above mentioned are done, then the doctor can treat the underlying condition that causes the insomnia.
Kamangar states that in this case , Murray didn't have a detailed history. In addition, Murray didn't check what the root problem for Michael's insomnia was before treating him.
Kamangar states that Murray did say that he saw that other doctors were treating Michael, he said he saw IV sites. Kamangar states that if Murray could not get that info from Michael, Murray should have refused care and refused to give further medication. Murray didn't do that, and that was unethical.
Kamangar states that Murray bypassed the evaluation of insomnia, bypassed the detailed history which was a deviation of care.
Kamangar states it was obvious there was probably secondary causes in Michael's insomnia (substance abuse or anxiety or depression ) and that these underlying causes should have been treated.
Kamangar explains about sleep hygiene techniques that can help in case of insomnia (using a bedroom to sleep only, among other things)
Kamangar explains about sleep restriction, that the doctor should tell the patient to go to bed later , and limit their time in bed.
He states that relaxation techniques can be used to treat insomnia.
Kamangar states that all these can usually work better to treat insomnia than pharmacological approach, but that the pharmacological approach can also be used.
He states that Murray did not use any of the above approaches on Michael, that Murray went direct to the pharmacological approach.
Kamangar states that the pharmaceutical approach : 3 medications that are not benzos should be used first, because they are not addictive . He states that a newer drug is melatonin something less addictive.
Kamangar cites 4 different benzodiazepines that deal with insomnia. He states that others are used also, but their main goal is to treat underlying conditions (anxiety). They are used in tablet form.

1. Midazolam : not appropriate for long term use for primary insomnia
2. Valium : not appropriate for long term use for primary insomnia
3. Lorazepam : can be used on short term basis, tablet form. Really addictive after 3 to 4 weeks. Used to treat underlying conditions, not primary innsomnia.

Kamangar states that the use of midazolam and lorazepam to treat insomnia was an extreme deviation of care, especially in IV form.
He states that it is inconceivable to use propofol for the management of insomnia, regardless of the setting. Kamangar states that it is "beyond comprehension, inconceivable and disturbing." He states that it is beyond a departure of standard of care, especially when underlying causes for insomnia were not treated.
Kamangar states that even if Michael took lorazepam and propofol himself, Murray was the causal factor in his death, especially if Michael had substance abuse problems. He states that the lorazepam and the propofol should not have been readily available
Kamangar states that there is a risk of respiratory complications, especially if Michael was dehydrated, and that any competent doctor would have been aware of the risk.
Video

TRIGGER WARNING : The 2011 SEGMENT CONTAINS TESTIMONY ABOUT THE DAY MICHAEL DIED. SOME PEOPLE MAY BE SENSITIVE TO THIS
1969- “I want You Back”, the Jackson 5’s debut single is released by Motown and soon reaches #1 on Billboard's Hot 100. It would be the 1st of 4 #1 singles in a row for the J5
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1969- Michael moves in to Diana Ross’s home where he'll live for a year until his family moves permanently from Gary, Indiana to Encino, California in 1971.
1971- Motown releases Michael’s first ever solo single “Got To Be There" in advance of his debut solo album of the same name. The single made #4 on both the Hot 100 and R&B chart, and sold an impressive 1.6 million copies in U.S. It also hit #3 in neighboring Canada and #5 in the UK.
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1972- The Jackson 5 perform "That’s How Love Goes", "I Want You Back", "Daddy’s Home", "Lookin’ Through the Windows" and "Corner of the Sky" on Soul Train
1979- On their Destiny tour, The Jacksons perform at Freedom Hall in Louisville, Kentucky
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1984- On their Victory Tour, The Jacksons perform their 3rd & final show at Exhibition Stadium (closed-1996) in Toronto, Ontario, Canada
1993- Michel arrives in Buenos Aires with Frank & Eddie Casio.
1995- Michael appeared on the popular German Game show Wetten Dass? (Wanna Bet?) where he performed "Earth Song" in public for the first time.
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The appearance broke German viewing records when aired on November 4th, with 25 million tuning in to watch Michael's guest spot, by far the highest German TV audience of the year
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1996- Michael performed a historic concert at El Menzah Stadium before 60,000 people in Tunis, capital of Tunisia.The performance marked the first time Jackson performed in the continent of Africa. Four days prior to the concert, speaking via Kingdom International, Michael said:
"This concert will be of special significance for me because it will be my first in Africa and the Arab world. The people and nations of both regions have always held a special place in my heart and I always wanted to perform for them"
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This concert was aired on 9/18/10 by the Nessma TV channel in Tunisia. Before then, only parts of this concert were shown on television as well as a very poor quality amateur-filmed far from the stage. The broadcast ended at “Heal The World”, cutting off the final number, “HIStory”. The quality of the broadcast was rather average as the entire concert was on a VHS, and a red ball (Nessma TV’s logo) occasionally rolled across the screen as a means of copyright protection. The concert broadcasted twice, with the red ball appearing in different places in both broadcasts.
1997- Michael, Omer, Katherine & Joseph visit Nelson Mandela’s home.
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Later Michael is best man at his friend Gerry Inzerillo ‘s wedding to Prudence Solomon
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2005- Michael is at The Power House Studios, working on a charity song, "From The Bottom Of My Heart" , to help the victims of hurricane Katrina.
Michael said:

"It pains me to watch the human suffering taking place in the Gulf Region of my country. My heart and prayers go out to every individual who has had to endure the pain and suffering caused by this tragedy. I will be reaching out to others within the music industry, to join me in helping to bring relief and hope to these resilient people who have lost everything"

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Within 24 hrs of the devastation, Michael penned the song and reached out to artists who would like to work with him on this project, some of the enlisted celebrity friends, including R. Kelly, Ciara, Snoop Dogg, Jay-Z, James Brown, Mariah Carey and Mary J. Blige, which he humbly hopes will make a tremendous difference to all individuals who have been affected by this tragedy.
2011 - People v. Murray Trial Day 9
Morning Session
Dan Anderson Testimony continued/Flanagan Cross
Flanagan starts off by asking about the IV bag on the stand in Michael's room where he died. Flanagan asks if the bag was analyzed for all chemicals and the only thing was saline solution, Anderson states they do not analyze for solution, but there were no drugs found in it. Flanagan asks about the tubing (hanging from the IV stand), and Anderson states that it was not found to have any drugs in it.
Flanagan asks repeatedly whether the tubing and the IV bag were attached, Anderson repeatedly states that they were not attached when received into medical evidence, according to notes. Flanagan asks if Anderson tested two syringe barrels, Anderson states yes and when asked, states that both barrels tested positive for propofol and lidocaine. Flanagan asks if Anderson tested any apparatus that had only propofol in it, Anderson states no. Anderson states that the only medical equipment that had propofol and lidocaine in them were the Y tubing (connector) and the syringe barrels. Anderson states that each of the syringes and the Y tubing each had Flumanezil. Flanagan asks if the proportion of propofol and lidocaine were the same in both the Y tubing and the 2 syringe barrels, Anderson states that proportionality testing was not performed.
Flanagan asks for Anderson to define equilibrium as it relates to bodily fluids, Anderson states he believes it is when the samples of the drug or their concentrations are equal. Flanagan asks how long it takes for the blood system to come to an equilibrium, Anderson states its beyond his scope of expertise. Flanagan asks Anderson to define therapeutic range (of a drug), Anderson states that a concentration of the drug that achieves the desired effect, generally it is a safety concern because they are not safe at all concentrations. Flanagan asks what determines therapeutic range, Anderson states clinical trials from the FDA, as well as the literature provided with each drug. Flanagan asks if there is a therapeutic range for propofol, Anderson states no. Flanagan asks about therapeutic range for Lorazepam, Anderson states that it averages 100-200 micrograms per mililiter. Anderson clarifies that the average can be 180, but that everybody tolerates medications differently, and he cannot give specific ranges.
Flanagan shows a Lorazepam bottle, prescription for Michael, asks Anderson to read the bottle, Anderson reads "Lorazepam 2 mgs, 1 tablet by mouth". Flanagan asks about Michael's blood concentration of .16% and asks if that would equal about five Lorazepam tablets, Anderson states yes, regardless of the route, whether it was in tablet or IV form. Flanagan asks if Michael had the equivalent of 11 mg of Lorazepam, Anderson states yes, approximately. Flanagan asks how many pills would he have to take to get to that level (11 mg), Anderson states that it could be an accumulation over several days, and that he does not feel comfortable with assumptions of routing of medications or form of medications.
Flanagan asks about ion trapping with respect to Lorazepam, Anderson states that he knows little about Lorazepam and postmortem redistribution. Anderson states that the only way to get propofol in the stomach is through oral ingestion or ion trapping, it's not postmortem redistribution.
Flanagan asks Anderson to define the term ion trapping. Anderson states that an acidic environment traps the ions of the drug in that environment, beyond that, is beyond his area of expertise. Anderson states that other than ingestion, the only way propofol can get into the stomach by diffusion of the surrounding specimens. When Flanagan asks about the surrounding specimens, Anderson answers that the liver is close, blood samples and blood itself are close to the stomach.
Flanagan states that Anderson is saying that Lorazepam can get into the stomach through redistribution, Anderson states that it can get into the stomach by ion trapping. Anderson states time and time again that this information is beyond the scope of his expertise. Anderson states that he has seen many different decedents who had stomach contents with drugs in them, and that the drugs were not given orally. Anderson states he does not have personal experience with a decendent that had Lorazepam in their stomach.
Flanagan asks Anderson about ephedrine. Flanagan asks if Anderson came to understand that propofol was the most important drug in the case, Anderson states yes he did. Flanagan asks if Lorazepam was important, Anderson he thinks it has its importance, but that it does notraise a flag. Anderson states that propofol in any case is important, Lorazepam was in therapeutic range, and that he previously testified that propofol was within range only a proper setting. When Flanagan asks what does a setting have to do with therapeutic range, Anderson states that it's very important. Flanagan states that therapeutic range is desired effect, Anderson states yes. Flanagan states that the literature does not take into consideration the setting, Anderson states that every drug literature takes setting into consideration.
Flanagan asks if Anderson did the calculations with regard to Lorazepam last weekend, Anderson states it was two weekends ago, Anderson states that he did them because of the Lorazepam in the gastric sample, and the two urine samples done by the defense. Anderson states that the urine is a historical perspective, and could be an accumulation from several days. Anderson states that the Midazolam testing was done in the urine because the concentration is much higher, which helps to confirm the blood level of Midazolam. Anderson states that Lorazepam levels were much more elevated in the urine than the Midazolam. Anderson states Lorazepam 12,974 nanograms/ml (13 micrograms/ml) Midazolam 0.025 nanograms/ml. Anderson states that the Lorazepam concentration goes up in the autopsy urine, and with Midzolam much less than Lorazepam.
Anderson states that the half life of Lorazepam is 9-16 hours, and that he looked it up in a medical reference book to gain that information. Anderson states he doesn't know what the absorption time and/or the peak time of Lorazepam, that it is in the book, but he doesn't remember what it said.
Walgren Redirect
Anderson clarifies that he never went to 100 North Carolwood. Anderson states that he received vials of blood, a broken syringe with plunger, an IV catheter from Investigator Fleak. Anderson states that the IV bag and IV tubing was brought to him at the lab, simply marked medical evidence #2.
Anderson states that the difference between blood sample and urine sample, is that the blood is what is usually happening in the body, and in the urine represents everything that the body is metabolizing out, and that the urine concentration expectation is that it would be much higher. Anderson states that the urine is historical in nature and what is being expelled from the body over a certain amount of time.
Anderson states that the PACTOX gastric contents analysis, shows 634 nanograms/ml of Lorazepam. Anderson states that the lab measured in concentration, he was provided 73.5 mls of gastric contents, in which he would multiply the two numbers to get the nanograms of stomach contents which would be 46,599 nanograms of Lorazepam left in the stomach. But the numbers Anderson should have used for calculation (micrograms not nanograms) he needed to divide by a thousand, so 46,599 divided by a thousand equals 46.599 divided by another 1000 to get a mg amount, equals 0.04599 of Lorazepam in the stomach. Anderson states that he went further and got a more exact amount and arrived at 0.046599. Anderson states that with a 2 mg Lorazepam pill, the gastric contents are equal to 1/43rd of a single 2 mg tablet, which is a very small amount
Flanagan Recross
Flanagan asks if there is a high concentration of ephedrine in the urine, but a low concentration in the bladder, would it be fair to say it was recently taken, Anderson says it’s a fair assumption. Flanagan asks if it's the same with propofol, Anderson states that he is not familiar with the excretion patterns of propofol.
Flanagan asks if a person were to take 7 or 8 Lorazepam tablets, and he found 14 miligrams in the stomach, would Anderson state that the person had taken it recently, Anderson states yes. There are numerous questions asked after this by Flanagan, but prosecutor Walgren objects and judge Pastor sustains them.
Elissa Fleak recall testimony/Walgren Direct
Walgren goes over evidence collection and when Fleak recovered multiple evidence items. Walgren asks if there are a lot of photographs taken on multiple days. Fleak looked over the photos to identify which photograph was taken which day (June 25th or June 29th). Fleak says she went into the master bedroom briefly, looked around but did not search it.
Walgren talks about IV stand and the photographs about it. 2 photos of IV tubing taken on June 25th. Tubing is draped over the handle. June 29 photos of IV stand /tubing. June 29 it's still draped over as it was on June 25. Later photos taken same day, it's no longer draped over the handle. One June 29, the investigators freed the tube (undraped it) so that the syringe can be photographed.
Chernoff Cross
Chernoff again questions whether she went into Michael's master bedroom or not. And again brings the subject of master bathroom and photographs taken in it.
In Michael's master bedroom the fireplace is on , TV is on as well. Chernoff shows pictures inside the master bathroom and asks if Fleak remembers the pill bottles. Fleak says she wasn't there on June 26 and those bottles were collected on June 26. Fleak says she doesn't know who collected them and who took those pictures. Chernoff shows a picture where there's no pill bottles. Chernoff asks about the briefcase in the pictures.
Detective Scott Smith Testimony
Walgren Direct
LAPD Detective for 20 years. He was assigned to robbery-homicide division on 6/25/09. He learned about the death of Michael at 3:30PM from his supervisor. He arrived at UCLA at 4:25 PM. Smith went to the emergency area. He stayed there till 7:00PM. Smith did not see Murray at UCLA. Smith obtained security footage from UCLA showing Murray. They footage shows Murray leaving at 4:38PM.
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Walgren plays the video and then shows an aerial photo of UCLA and asks Detective Smith to mark the way Murray let the hospital.
Smith talked with Faheem Muhammed, Alberto Alvarez at UCLA very briefly. Faheem just told he was employed by Michael and gave his contact information. Alvarez said the same thing and also mentioned he went into the room to help Michael and called 911. Detective Smith didn't do any more interviews that day. He arrived to Carolwood around 7:30PM.
Smith didn't know the cause of death at that point of time. At that time this was a death investigation, not a homicide information. Death investigation could be natural causes and detectives may or may not be involved. If it is a homicide investigation the police department takes full responsibility. It becomes a homicide investigation if there's an obvious cause of death such as gunshot etc. This was a death investigation and coroner was leading the investigation not the police department. Detectives were on the scene to assist and support the coroner's office as needed.
Walgren asks if this had been an homicide investigation would LAPD be leading the investigation and collect evidence. Smith says yes. On June 25th evidence was collected by coroner's office. Det. Smith was assisting and overseeing the LAPD photographer. Smith says they left the residence around 9:30 PM. They released the house at the request of Jackson family to private security.
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June 26th - Detective Smith attended the entire autopsy of Michael. He didn't have cause of death by the end of autopsy. They had no information to assist with the investigation. It was deferred pending toxicology results. At this time it was still a death investigation and not a homicide investigation. On June 26th Smith went to Carolwood again. Coroner Ed Winters called him and said some items were given to him by family. Smith went to take those items. They initially thought it was tar heroin which turned out to be old rotten marijuana. It was found in a shaving kit. Those items had no relevance to Michael's death and determining the reason for his death.
In the shaving kit there was also temazepam bottle prescribed by Murray. Smith had also found some empty pill bottles on June 26th in Michael's master bathroom.
Walgren goes over the pictures of the master bathroom taken over several days.
June 25th pictures - Bathroom appears to be messy, drawer doors open, a few notes taped on the bathroom mirror.
Pictures from June 26th - There was no empty pill bottles or briefcase on June 25th pictures. On June 26th there's a briefcase, Smith doesn't know whose suitcase it is. June 26 pictures show empty pill bottles on a ledge. Smith says that he placed them on the ledge to photograph them.
On June 27th Murray's attorney Michael Pena spoke with Detective Martinez. They made arrangements to meet at Ritz Carlton at 4 PM. Murray's attorneys had chosen the place. Detective Martinez and Smith met with Murray and his lawyers in a room at the hotel. They conducted and recorded the interview.
Audio of Murray’s interview with the police is played
June 27th Ritz Carlton. Murray is at the interview with his lawyers Chernoff and Pena. Detective Smith and Martinez are doing the interview.
First part of the interview: Officer is going through and asks Murray basic information as his address, phone number, weight, when he was born, how tall he is etc.
Detective says the detectives at the hospital was from another division and was not handling the case. They took some notes but didn’t do a formal interview. Murray seems surprised to hear that other detectives took notes after he left.
Murray talks about how he met Michael. They met in 2006 and saw him on and off since then. The first time Murray saw Michael was because he and his kids had the flu, a bodyguard of Michael's whose parents were patients of Murray referred him.
Murray says he had been caring for Michael for the last 2 months. Murray tells that he received a phone call saying Michael was going to do a concert-tour in London and he wanted Murray with him. Murray said he needed more details before accepting. He then says Michael called and said he was happy Murray was going to join him – although he had not yet committed to join the team.
Detectives ask about who Murray is working for AEG or Michael. Murray says he’s an employee of Michael's but paid through AEG.
Lunch break
Afternoon Session
Audio of Murray's interview with the police is continued
Murray says he had no idea that AEG were going to pay him.
Detectives ask about Michael's general health. Murray says generally speaking Michael did not eat well and was very thin. He did not find any major physical change in his condition except for something called subluxation of his right hip (Michael's right hip would slip out and slide back to the joint). Michael had fungal disease on his toes which was treated. Nothing more that Murray noticed.
On June 24th, Murray got a call around 12:10 am that Michael was done with rehearsals. He had attended meetings and did a partial performance (not a full rehearsal). MJ wasn't complaining about anything but wanted Murray to be at Carolwood by the time he came home.
Murray spent every night at Carolwood except nights he was off, which were Sundays. He spent the night there per Michael's request.
Murray arrived to the home at 12:50am before Michael and waited at his bedroom. Michael arrived shortly after, around 1am. Once he arrived, they greeted each other and talked about their days. Michael told Murray he was tired and fatigued and was treated like a machine. Michael took a quick shower and changed and came back to the room.
When Michael came back to the room, Murray put some cream/lotion on his body and back for Vitiligo.
Detectives ask Murray about the bedroom. Murray tells that Michael had 2 bedrooms. No one, not even cleaners, would be allowed to go into the master bedroom and it would be in a bad state. Murray would see Michael in the second bedroom , the one that had the IV stand and oxygen tanks. After cream, Michael wants to sleep. Murray says Michael is not able to sleep naturally. Murray says he would put an IV for hydration on Michael's right or left leg below the knee. They then talked a bit and he gave him Valium - 1 pill 10 mg orally.
As the Valiums effect was delayed, so around 2 AM Murray gave Michael 2 mg of Lorazepam which it was IV pushed slowly. Murray says he observed Michael but he continued to be awake for 1 hour, he says he watched him because he wanted to be cautious. So Murray decided to give him Midazolam (2 mg injected slowly) around 3 AM. Murray waited again but Michael was wide awake. He said he couldn't sleep. Murray suggested to lower the music that Michael likes to sleep with and to dim the lights. He told Michael to meditate while he rubbed his feet. Michael did that reluctantly and his eyes closed. Murray estimates that Michael closed his eyes around 3:15-3:20; he doesn't know it for certain because he wasn't looking at his watch at that time. 10-15 minutes later Michael was again awake.
Michael was surprised that he managed to sleep after he had meditated and they tried mediating again but by 4:30 AM Michael was still wide awake. He starts to complain saying that he has rehearsals he needs to perform and tomorrow he will need to cancel his rehearsals because he can't function if he can't sleep. Murray says then he gave Michael another 2mg of Lorazepam at 4:30/5:00 AM because a safe time had passed. That didn't put Michael to sleep as well.
Michael complained that if he can't perform he would have to cancel the rehearsals and it would put the show behind and cannot satisfy fans if he's not rested well. Murray says that it put a lot of pressure on him. Murray tells Michael he isn't normal and the medications that he gave would make a normal person sleep for 1-2 days. (due to wanting the medications/can't sleep)
By 7:30, Michael was still awake. At that time he gave another 2 mg of Midazolam. There was still no effect. Murray says he cautiously checked the IV site to make sure the fluid and medicines were going to Michael because he wondered why he wasn't responding to medications. At this time Murray says Michael also urinated.
10 AM in the morning - nothing has worked. Murray was watching and trying to get Michael to sleep. He is complaining he can't sleep, he has to cancel the dates and everything has to be pushed back.
Michael at that time asks, "Please give me some milk so that I can sleep, because I know this is all that really works for me". Detectives think that they are talking about actual milk and asks if Michael wanted hot or warm milk. Murray tells them it's a medicine, Propofol, which is "a sedative that could also be used for anesthesia". Murray gave Michael propofol through IV around 10:40. Murray had asked him how long he would sleep if he gave him Propofol because he needed to get up at a certain time. Michael told him it doesn't matter when he wakes up, told him to just make him sleep.
Murray say he gave him small amounts to get him to sleep, he administered 25 mg of Propofol together with Lidocine, he pushed it slowly. This time it must have been 10:50, effect is quick and Michael was sleeping now.
Detectives ask if Murray had any monitoring equipment. Murray says he took all the precautions that were available to him such as oxygen and pulse oximeter.
Detectives questions Murray about the dosage. Murray says 50 mg propofol was the highest amount propofol he had given Michael ever. That night he gave less due to the other medications he had given to him. Murray says he roughly gave MJ Propofol every day, there were rarely exceptions. Murray also says that three days leading up to Michael's death, he tried to wean him off propofol
He was not aware that Michael was taking this on a daily basis before he was hired. Murray was surprised by Michael's pharmacological knowledge and his mention of "milk" and & "antiburn"; Michael said he had taken propofol before.
Michael said he used it in Germany but never disclosed other doctors' names. Michael never told him he administered it himself but other doctors let him infuse it by himself.Murray told him NO he wouldn't let him do that
Murray says Michael knew that propofol was the only thing that worked for him. Murray says he often warned him about it.
Michael told him he was seeing a Dr Lee & she was giving him a cocktail for energy. Murray says there were a lot of IV sites on Michael's body and his veins were sclerotic. Murray asked Michael what is in the cocktail and wants to review it. Michael says he doesn't know. Later they got rid of Lee because Michael felt she was unprofessional and cancelled an appointment. Michael felt she wasn't telling him the truth.
Once in Las Vegas Murray got a call that Michael was in Vegas with his children for a show and he was staying at Wynn Hotel. Michael says he was having difficulties sleeping. Murray tells Michael to use sleep medications (lorazepam or restoril) that he gave to him. Michael tells Murray nothing that he, Klein or Metzger gave to him works. Murray says he doesn't have any other alternatives. Michael then asks about Diprivan / Propofol and says that he knows that it works. Murray says he doesn't have it. Michael mentions Dr. Adams and that he gave him Propofol. Murray doesn't know Adams. Michael gives Murray Adams phone number. Murray calls Adams. The plastic surgeon's office Adams used doesn't allow them in the office so Murray lets them into his office on a Sunday. Adams puts Michael on a Propofol drip for 6 hours. Murray says he had monitoring equipment. Murray comes back to his office after 6 hours and Michael says he's feeling wonderful because he has slept.
Michael tells Murray that this is divine guidance and other doctors helped him sleep for 15/10/18 hours. Michael mentioned having another doctor, Adams, on tour with them. Adams was willing to go on tour with him and wanted $1.2 - $1.3 million a year.
Murray mentions that Michael wanted him to be around forever, after the tour. Murray mentions Michael's plans for a children's hospital and wanted Murray to be the medical director.
Detectives go back to the night of June 25th. Murray gave Michael 25 mg Propofol. Michael falls asleep but hes not snoring. Generally when he's in deep sleep he snores so he's not in deep sleep. Murray monitors him. Everything looked stable and he was comfortable. Murray needed to go to the bathroom to pee and empty Michael's urine jar.
When he came back after 2 minutes he sensed Michael wasn't breathing because he usually looked at his chest to see if he was breathing. He immediately checked his pulse and got a thread pulse from the femoral area and Michael's body was warm and he assumed everything happened quickly and immediately started CPR and mouth-to-mouth. He wanted to apply medicine as well but not first because he wanted to ventilate and compression first. He saw Michael's chest rise. Murray says he couldn't move him from the bed to the floor by himself. He then got his left hand under his body and then gave him CPR and also ventilating him and made sure his chest was rising completely. He looked for the phones but phones do not work in the house. He doesn't know the address or zip-code; only know its North Carolwood. The house is closed during nights and only Michael, he and the children would be there. Murray tells that security doesn't come to the house. Murray thinks it's inhumane that the security are not allowed into the house to pee.
He says to talk to 911 would be to abandon him and he didn't want to abandon him. He reached his cell phone and called Michael Amir Williams. Murray tells Williams to send up security. Murray says he didn't ask Williams to call for 911 because then he would have asked why and Murray was trying to assist Michael. Murray realizes that Michael doesn't have a pulse now so he lifts Michael's legs for a brief moment for auto transfusion and continues to do CPR, etc. No one came to the door, no one knocked on the door. So he gave Michael 0.2 mg Flumazenil because he wanted to reverse the affects of the other drugs but Michael was not still breathing and no help was coming. He then opened the door and ran down to the kitchen and told the chef (Kai Chase) to have the security immediately and security (Alvarez) comes upstairs. Murray tells Alvarez to call 911 and wants help to move Michael's body to the floor and still helps with chest compressions.
Alvarez talked to 911 but Murray told him to just tell the paramedics to hurry up because he wanted help to move Michael to the floor. Paramedics came and called UCLA, Michael was not breathing. They were doing chest compressions. Murray says Michael was PEA (pulseless electrical activity), which means you don't shock a patient. Michael was given starter drugs. Murray says that he felt the communication and the orders coming from UCLA was kind of slow.
After 20 minutes of effort which Murray thinks was limited, he knew Michael hadn't been gone too long and he had felt a femoral pulse. So Murray asked UCLA instead of calling Michael dead to transfer the patient to him. Murray took over the care and they took Michael to UCLA. Emergency personnel met them. They worked on Michael for an hour. Murray says probably they would have stopped sooner if Murray wasn't insisting. They don't know why Michael died but thinking pulmonary embolism could be a reason (a clot in the lungs that would shut the circulation in the lungs). Michael is pronounced dead. Murray doesn't want to sign the death certificate as he doesn't know the cause of death.
Chernoff jumps in and changes the topic to Murray trying to wean Michael off 3 days before his death. Murray says he didn't know Michael used propofol before and that it was kind of a habit. Murray says he wanted to help Michael to sleep naturally and tried to wean him off. Murray asks what Michael would do once the tour was over; Michael tells him he thinks he can be able to sleep then. Murray switches to lesser drugs (such as Lorazepam) to wean him off. Murray says Michael knew it but he was reluctant. Murray says he never told Michael that he believed he had drug dependency. He was trying a strategy and was trying to get Michael to transfer his confidence in Propofol to something lesser. First night Murray reduces Propofol and starts Lorazepam and Versed. Second night he removed Propofol and only gave Lorazepam and Versed. Michael told him he felt a little hangover in the day. The night Michael died Murray started with Lorazepam and Versed but nothing was working. Murray doesn't know if it was withdrawal from Propofol or if it was psychological. Murray says after trying all night with those 2 drugs he finally gave Michael Propofol so that he can sleep and so that he can produce the next day. Murray says he didn't want Michael to fail and he cared about him.
Judge stops the tape. The rest will be played next week
Court ends early due to Yom Kippur
There won't be any testimony on 10/10/11, it's Columbus Day
Summary of the remaining portion of the interview below:
Murray mentions Michael probably having withdrawal symptoms to Propofol on June 25th. He says that it can be either physical or psychological or mental.
In the hospital Murray talked to the detectives briefly and gave them his phone number.
Murray says he and emergency room doctor went into the room Katherine Jackson was waiting and told her that Michael had died. Murray says he stayed with her to console her and asked UCLA to bring in a psychologist to help Katherine. Murray then learns that children are in another room and decided to notify the children. Murray , Dileo, Michael Amir Williams and a social worker went into the room the children were and told them Michael was dead. Murray says the children were weeping and the stayed there to console them. Murray says Paris mentioned her unhappiness and said she didn't want to be an orphan. Dileo and Murray say that they will take care of her. Murray tells Paris that he tried his best to save Michael. They bring Michael's kids and Katherine together. Murray says he doesn't know how close they are.
The children want to see Michael, psychology team says it's a good idea and it would bring them closure. UCLA was prepping Michael's body for viewing. During this time Jermaine, Latoya and some cousins of Michael's came to the hospital. They were briefed about what happened. Murray went into the room where the family was, family asked Murray if he knew why Michael died. Murray said no and recommended them to get an autopsy. Michael's body was ready for viewing and the children went to see him. Murray asked Katherine if she wanted to see Michael as well, she said no.
Murray talked with the bodyguards and asked them where would the children go. Bodyguards told him they can't go back to the house because it was on lock down. Murray talked with Randy Phillips, Frank Dileo and the bodyguards and asked if he can do anything. Murray says Jermaine asked to make an announcement and they wanted Murray to review the press release. Murray says he added the cause and Jermaine edited the part that asked fans to respect their privacy to ask media to respect their privacy. Murray says he talked with Jermaine a little bit. Murray says then he was tired and left the hospital to go home.
Murray again mentions he talked to Detective Porche and gave him his phone number. Detectives mention that they called Murray several times but the calls went to voice mail. Murray's lawyer, Pena, says it was his advice to Murray to leave his phone off and wait for his lawyers to talk to detectives later.
Detectives ask if Murray knew Michael had any preexisting conditions. Murray says he treated him for pneumonia in 2008, fractured toe in 2008, upper respiratory issues multiple times over the years, lethargy and for callouses on his feet. Murray also treated fungal infection on Michael's feet. Murray says he gave him Lamisil and did a full blood work before to make sure that his liver was okay.
Chernoff asks detectives if there's any preliminary toxicology results and the detectives say they are not aware of it. Chernoff then asks Murray if he knew of other medications Michael might be taking. Murray says he heard that Michael was seeing Klein. Murray says around 3 weeks ago he heard Michael calling Jason Pheiffer and asking him if he can squeeze him in to see Klein. Murray says he also saw pill bottles with Dr. Metzger's name on them. Murray says Michael doesn't disclose all the physicians that he's seeing.
Detectives list a number of medicines and ask Murray if he prescribed them and what are they used for. Murray explains Flomax and says that Michael has a hard time urinating. Murray is surprised to find out that Michael had some sort of eye drops. Murray says that Michael had very bad eyesight and he thought that he could be legally blind. Murray arranged for an appointment but Michael didn't go to see the eye doctor so Murray is surprised to hear about eye drops.
Murray says Michael's production team has told him that his worst days were after he came from seeing Klein and he would be wasted and require 24 hours to recover. Detectives mention finding marijuana and Murray says that Michael denied it and surprised to find out he would be using stuff like that. Detective tells Murray it was old and rotten. Detectives ask about empty cigarette packs they found , Murray says he doesn't know if Michael smoked. Detectives ask if Michael packed his suitcases and Murray says he did. Murray mentions Michael using excessive cologne and could not understand why he would use that much and says it might be to dismiss any odor.
Detectives ask how many syringes Murray used and Murray replies 2. He says he would recap them and he would use medication and mix them with saline. Detectives asked Murray what he did with those syringes Murray say he would put them in his bag and put them into the cupboard. When detectives ask where those syringes are Murray tells them he left them at the house at the closet. Detectives ask which closet and Murray describes it to them. Murray says Michael showed him the cabinet and told him to put his stuff there.
Detectives ask for the keys to Murray's car so that they don't have to break into his car and damage it.
At the end of the recording Detectives ask if Murray ever gave Michael Demerol. Murray responds no. Detective Smith says they didn't find any and Detective Martinez says he doesn't know how that came up.
Video

1973 - The Jackson 5, are in the studio recording "Call On Me", for Motown Records in Detroit, Michigan
1983 - CIAO 2001 magazine[Italy] featured Michael on their cover
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1988 - On the 2nd leg of the BAD World Tour, Michael performs at Parkstadion (closed-2008) in Gelsenkirchen, Germany to an audience of 52,000 fans
1988 - Joepie magazine featured Michael on the cover
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1992- On the Dangerous World Tour, Michael performs at the Friedrich-Ludwig-Jahn-Stadion in Berlin Germany to an audience of 35,000 fans
1993- On the Dangerous tour, Michael performs the first of two nights at the Taipei Municipal Stadium in Taipei, Taiwan to an audience of 40,000 fans
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1994- Michael and Lisa Marie leave the Côte d'Azur and head back to Paris.
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Their final destination is Euro Disneyland Amusement Park. They stay in the Royal Suite, located on the 3rd floor of the Disneyland Hotel
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1994 – Woman’s Day magazine features Michael on the cover with the caption: "Jacko Finally Tackles Those Evil Charges"
1997- Michael cancelled a performance at the Olympic Stadium in Barcelona, Spain, because the local promoter had failed to meet financial and technical requirements for the Tour.
1999 - Michael attended the 4th Kora All-Africa Music Awards in Sun City, South Africa where he was given a Lifetime Achievement award.
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Michael presents Nelson Mandela and his 'Nelson Mandela Children's Fund' with a check for 1 million (a portion of the proceeds from the Michael Jackson and Friends concerts in Seoul, South Korea and Munich, Germany)
The former President declaring the following on the donation:

“The trustees of the Children’s Foundation and myself would like to express our deepest appreciation to our friend, Michael Jackson. He is a supporter of worthy causes and I’m happy that the foundation is tonight one of his benefitions (sic). […] And the contribution of Michael Jackson, I hope, will inspire people not only in our country, but throughout the world, to follow his example and to bring a measure of happiness to our children. […]”

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2008 - The Jacksons were named BMI Icons at the 8th Annual Urban Awards ceremony, held at the Wilshire Theater in Beverly Hills. The invitation-only event also honored the world's premier R&B, Rap and Hip-Hop songwriters, producers and publishers of the past year's top urban music.
Four of the Motown Legends - Tito, Jackie, Marlon, Randy - except Michael & Jermaine, reunited onstage to accept the Lifetime Achievement prize from sister Janet at the ceremony.
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The Jacksons did not perform at the event, and it was also attended by their father Joseph, mother Katherine and sisters LaToya and Rebbie Jackson.
Following the acceptance of the icon award, the Jackson brothers posed on stage for photos with father Joseph, mother Katherine and sisters Janet, LaToya and Rebbie
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2013 - Jackson VS AEG Trial Day 79
No Jackson family members are in court today.
Dr. Paul Earley Testimony
Jackson cross
Dr. Earley's cross continued. Boyle started out by asking Earley about his experience writing articles for medical publications and any conflicts of interest. Earley said he had written two or three peer-reviewed articles. He said some were published in European journals. Boyle then showed Earley the conflict of interest policy for the journal where the AEG-funded article ran. The policy states potential conflicts of interest should be disclosed on the cover sheet when the article is submitted. Earley said he did disclose that AEG Live paid for the research funding as spelled out in the policy. AEG's payments were listed on the article's 7th page. Earley said he had no control over where the disclosure was listed, that was the journal's decision. The first item was the Propofol Study that he published at the beginning of 2013. Dr. Earley said the published report had a different format so it was not on the front page of the report. Under tough questioning, he insisted that he did not have a conflict of interest as an AEG consultant with having AEG pay for the study. He testified he was not trying to hide the AEG connection saying that was ridiculous. He was asked if the 22 medical pros in the propofol study funded by AEG are still alive? Dr. Earley did not know. Wasn't part of study. The journal article focused on case studies of 22 medical professionals who had a propofol addiction. Boyle asked if they were all alive. Dr. Earley said didn't know and he couldn't contact the people in the study due to medical privacy laws.
Jackson lawyer Kevin Boyle also grilled Earley over his nondisclosure that he was working as a paid consultant in AEG Live's defense when he submitted the study for publication in a medical journal. He said the concert promoter did not try to influence his findings, which were published in March in the Journal of Addiction Medicine
Boyle also showed Earley the ethical guidelines of the American Society of Addiction Medicine, which state members should only provide general information about addiction and not offer diagnosis on celebrities or other public figures. Boyle questioned whether Earley's blog posts on Michael violated those guidelines. Earley said he didn't think they did. As yesterday, he was questioned about the blog he wrote a few weeks after Michael died. He restated he did not characterize Michael as an addict. Boyle, this morning, also showed Earley a second blog post he wrote on 12/5/11 that had the headline: "Murray Convicted -- Addiction Wins". Earley said he wrote the post to draw attention to an article written by friend and journalist William C. Moyers. Despite the title, he says he's not saying Michael was an addict. At the time on the blog, Earley was an AEG consultant. He said the title had Addiction winning not Michael and Addict. Asked about a line in the blog "another superstar going to oblivion", Earley said the purpose of blog is to talk about addiction.
Q: When he posted blog did he ask AEG permission?
A: No
Q: Consult AEG?
A: No
After more AEG questions Earley, exasperated, said he was tired of this!
Boyle pressed Earley on his use of the term addiction, again asking whether he'd made up his mind about Jackson's case by then. Earley said he hadn't made up his mind about Jackson and was merely trying to draw attention to the problem of addiction.
Boyle: "You were referring to Michael Jackson"
Earley: "I was referring to the addiction problem, so the answer is no"
By this point, Earley was already doing research for AEG Live, although the company hadn't agreed to fund his study by then. Boyle asked about Earley's payments on the case. The doctor estimated he'd been paid $80-90k on the case, not including his testimony
Earley had overcome a drug addiction about 30 years ago. He was asked details. He used several drugs including oxycodone and heroin. He was almost homeless and had his medical license suspended. He was in treatment for 9 months and got clean. Earley spoke extensively today about his own addiction to opioids and how he was able to be rehabilitated and keep his medical license. Boyle asked if Earley was relying on his own experiences as the basis for his opinions in the case. The doctor said only to a small extent. Earley was very candid about his addiction, saying he was at one point nearly homeless and had to relinquish his medical license. He was criminally charged with writing prescriptions to himself under false names and went into treatment. His work in the addiction medical field grew out of his recovery and rehabilitation. His issues were in the early 1980s, he said. Earley said his drugs of abuse were oxycodone, heroin, codeine and hydrocodone. Boyle repeatedly commended him on his recovery. The attorney asked Early whether in the depths of his addiction, his prognosis was grave. "Yes it was", Earley responded. Earley said in response to one question about his recovery that while he survived, many of his colleagues with addiction have not. The doctor said it was a miracle, by the "grace of God" that he survived. Many of his patients have been addicted physicians
Boyle asked the doctor whether during his addiction, he had a concert promoter involved in his life & medical care. Earley said he didn't. Boyle asked about the role of a family's love in the recovery of an addict. Earley said it was important in his early stages of recovery. "Michael had a lot to live for", Earley said of Jackson and his love for his children, which could have aided in a recovery. Boyle asked whether Jackson having full time access to a doctor like Conrad Murray would be a trigger for his addiction. Earley said Jackson had access to the doctor, but it was the doctor's responsibility to be a gatekeeper to drugs and medications
Asked about the Physician Desk Reference, Earley checked and propofol was not in the book. Can't get the drug with a prescription. PDRs are for General Practitioners not some specialized fields like Anesthesiologists or some cancer drugs. One last thing from the morning session, according to Jackson's attorney a common name for Propofol is 'Milk of Amnesia', it's even in wikipedia
In general, there were a lot of delays in testimony today. Lots of sidebars and objections and some charts that had to be quickly redone. One such delay happened when Boyle asked Earley to find the entry for propofol in the 2009 edition of the Physicians Desk Reference. The Physicians Desk Reference, AKA PDR, has detailed entries on many drugs. It's the book Cherilyn Lee used to discuss propofol with Michael. Earley couldn't find the entry in the PDR so Boyle asked partner Brian Panish to locate it. He couldn't find it either. It turns out another lawyer, Michael Koskoff, had ripped out the pages on propofol while questioning another witness, Dr. Levounis. There's Laughter in the courtroom
They continued about the drugs that were found at Michael's house. The list of drugs found at the house but not in Michael's body according to the Coroner report was Lidocaine and Ephedrine. From there they moved on to Demerol. Dr. Earley said he was only aware of 3 cases that a person died of an overdose given by a doctor. Attorney Boyle tried to make the case that dying of Demerol administered by a doctor was more rare than being trampled by an elephant or hit by tsunami. With a graph showing Michael's Demerol Injections from Dr. Klein, in the last couple months of his life. He went only 4 days until May 5th
Attorney Boyle made the point that on May 6th AEG Exec Paul Gongaware sent Dr. Murray the email 'Done, $150,000'
Boyle's examination after lunch focused on the times that Jackson requested propofol over sleep _ they said in court it was four times. That wouldn't include anesthesiologist Dr. David Adams, who Jackson approached in 2009 but didn't discuss propofol by name. Boyle showed a chart listing those requests by Jackson, adding the 5/6/09 date that AEG exec Paul Gongaware said Murray's deal was done. Boyle's point was that Jackson didn't request propofol from anyone else after Murray was working with Michael on the This Is It tour
Then Earley was questioned if Propofol can mask the symptoms of Demerol withdrawal. He said it can mask some of those symptoms
On to Michael's general health.
Q: No evidence of heart, kidney, diabetes?
A: No
Q: Blood Pressure?
A: Coroner report says no pressure!
AEG redirect
On redirect Earley says he didn't see the Gongaware email until court. They put back up the Propofol slide with info added. Added:
Jan 2006 - Michael starts to see Dr. Murray
2/4/09 - Michael says Dr. Salvit Murray is his personal physician
4/6/09 - Dr. Murray makes the first order for propofol
4/28 - Murray orders more
5/12 - More
6/6/09 - More
AEG's lawyers point to Murray ordering propofol before that date. Boyle later noted Gongaware's testimony about talking to Murray about working on the tour and his request for $5 million. That happened 3 to 5 weeks before the May email indicating Murray's deal was done. Cahan showed Earley and the jury a chart that listed Murray's first treatments of Michael in 2006, and propofol shipments from April-June 2009
Earley said in response to a question by Cahan that before Jackson's death, propofol addiction was virtually unknown by the public. Cahan asked the doctor about his blog posts. He said he didn't think they were an issue because he wasn't making any diagnoses
Dr. Earley wrote his first Blog in 2009, 6 weeks after Michael died. He said he learned of the propofol overdose in news reports. He said he had begun seeing propofol cases in medical pros in 2008. He started cataloging cases to look at them at a later date and possibly do a study at a later date. Study funded by AEG.
A second blog was brought up that Earley posted when Dr. Murray was convicted. The first line written by another addiction doctor. It was attributed to him in the second line of the blog. That was read to the jury.
Earley was asked whether Michael should have avoided doctors. He said "no, he needed treatment but he needed to disclose all his conditions"
Jackson recross
On recross Dr. Earley was questioned about the Study. He is asked about a conflict of interest with AEG funding he says it didn't affect the result. Findings were very uncommon addiction for medical pros. 1.6% are addicted. Half use other drugs. More women are addicted and there is a rapid decline. Addicts commonly are depressed and have had child trauma
Earley told the details of his addiction. Used for about 5 years. Wrote prescriptions with other names for self and was arrested. He went to drug court and was sentenced to the program where he is now. His license was suspended but he got it back. Program is why he is alive.
On recross, Dr. Fivner was brought up. After a 5 minute sidebar in chamber Earley testified that Fivner had a suspended license at the time. Boyle took back over and asked some questions about Earley's co-author on his AEG-funded propofol study. It turns out Earley's co-author had his medical license suspended due to some addiction-related legal problems. He wasn't working in medicine at the time the study was written. Earley said his co-author has since had his license reinstated and is working in New York
Boyle also asked Earley about whether he had any control over how AEG used his study in the case. The doctor said no. Earley said he also didn't have control over how the plaintiff's used his research, or any other research that's been published. Boyle likened AEG's payments to Earley's research as similar to private money turning into a nuclear weapon. "This is a small study. I'm not building the atomic bomb", Earley responded
At the end of his questioning Boyle asked Earley about his opinion that you can't blame an addict for their addiction. "In medicine, we don't talk about blame", Earley said. This opinion was played earlier in the case for the jury
AEG redirect
On direct testimony he said the co-author of a study on propofol addiction funded by AEG Live and used in their defense in the Michael Jackson wrongful death trial lost his medical license for writing illegal drug prescriptions, according to testimony. Dr. Torin Finver was hired to help with the AEG Live study after he lost his job at a pizza parlor and took a job driving a Goodwill truck, said Dr. Paul Earley, who testified as an expert witness for the concert promoter. Finver was "destitute, dead broke, and I wanted to help him," Earley, himself a recovering heroin addict, testified. Earley testified that he never disclosed to AEG Live lawyers that his co-author had lost his medical license.
In his blog he characterized Michael's prognosis as grave. Earley says he treats many grave patients. That is why he is good. He never gives up
Jackson recross
Boyle ended by asking Earley if he was aware that Murray ordered more than four gallons of propofol for Jackson. The doctor said he was
Court transcript

1975- Jackson 5 perform at the Chicago Stadium (now closed - 1994) in Chicago, Illinois
1988 - Michael plays the first of two nightsat Eriksberg in Gothenburg, Sweden, to an audience of 53,000.
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1999 - Michael meets with Sony executives in New York.
2002 - Michael Jackson has dinner with Uri Geller and his family. Geller introduces him to British journalist Martin Bashir, who wants to do a TV documentary on Michael.
2003 - Michael returns for the first time in 20 years to his hometown, Gary, Indiana, where, during a news conference Mayor Scott L. King, presents him the key to the city. He then walked to his limo and emerged to sign some autographs for fans who packed the street in front of City Hall. Gary school district officials are now planning to name a school in his honor.
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Michael returned to his childhood home at 2300 Jackson St. for a brief visit inside. It was his first trip back to his hometown since his youth.
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After about 10 minutes inside, Jackson then went over to nearby Roosevelt High School, where the Jackson 5 perfomed in the 60's.. The school presented Michael with a letter jacket at an assembly in the school's auditorium. Although Jackson is not a Roosevelt graduate, one of his brothers went there. He tells students that "with a will of iron, with perseverance and determination" they "can do anything they want"
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He is given presents and made an honorary Roosevelt graduate and later in the evening he participates at the "Salute To The Troops", an event open to the public with free admission, where the troops were recognized.
2009 - Michael invites several fans on the set of Thriller 3-D in Culver Studios including Marika, from the french team of followers
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When they see how thin is Michael, the fans decide to write e-mails to Michael’s friends and family including Karen Faye. Karen replies that she is “aware of Michael’s condition” and is “doing everything humanly possible”.
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2009 -Ephedrine pills are delivered to Murray. It causes rapid weigh loss
Karen Faye:

"The week before he died, he lost probably about 15 pounds"

2012 - Thriller, Michael's Bengal tiger dies of lung cancer at actress-activist Tippi Hedren's Shambala wildlife preserve in California. Thriller was born on November 20, 1998, she was 13 years old.
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2013 - Jackson v AEG Trial Day 27
Katherine Jackson was present court for the morning session.
Randy Phillips Testimony
Jackson direct
Phillips said on Jun 25, the day Michael died, he was going to head to Staples Center
Much of the questioning centered on Jackson's manager relationships and This is It production costs. Panish focused on a letter that Phillips sent to Jackson's former manager Tohme Tohme on June 28, 2009, three days after Michael died. The letter, signed by Tohme, was to confirm the Michael Jackson Co. was responsible for all the production costs for This Is It
After Michael died, Phillips said Jackson's costs had exceeded $7.5 million. Michael was responsible for production costs, according to the contract. Phillips said he was not sure if Michael was the sole signatory to approve the costs or if Dr. Tohme had power of attorney as well. On the contract, it said the undersigned Dr. Tohme Tohme represents and warrants that he is an officer of the Artist. Phillips said he didn't have any information that anyone else could sign and approve the expenses on behalf of Michael
Panish also showed Phillips a letter signed by Michael Jackson on May 5, 2009, terminating Tohme's authorization to act on his behalf. Randy Phillips said on June 28, 2009, he wasn't sure whether Tohme had authority to act on Jackson's behalf or not. Tohme signed and returned the authorization to AEG Live, but Phillips said he didn't know how quickly that happened
Phillips said he received a note where Michael said Dr. Tohme was no longer his representative.

Panish: "Did you get anything confirming that Dr. Tohme was back in as an agent?"
Phillips: "No"

Phillips said he didn't read a budget of production costs that was attached to the June 28 letter. Budget had $450k allocated for Conrad Murray
Phillips said he was concerned with Michael's weight during rehearsals. He asked his friend Loughner to assist getting Michael to eat. Email on 7/16/09 from Phillips:

We all were worried about Michael's weight which was 130 Ibs during rehearsal and encouraged him to eat properly since he was so obsessed w/the creative on the show he would either skip meals or forget to eat. Kenny Ortega used to personally feed him and I hired a person to be his "food" person

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Panish: "It says you hired a person just to be his food person"
Phillips: "Didn't hire him, just did it as a favor"

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Phillips said his friend never got paid to be Michael's "food person"
Panish asked Phillips about lucrative merchandising opportunities for AEG Live after Jackson's death. He showed executive an email he wrote.
Email on 8/4/09 from Phillips:

Michael's death is a terrible tragedy, but life must go on. AEG will make a fortune from merch sales, ticket retention, the touring exhibition and the film/dvd. I still wish he was here!

AEG Live CEO Randy Phillips told jury he did wish that Jackson was still alive
In a later email, Phillips stated that profits from the sales would go to Jackson's mother, children and charities. About pressuring Jackson to perform, Phillips noted that Jackson died before he had performed a single show
As to Dr. Tohme: Phillips testified in the Labor Commission hearing in a dispute between Dr. Tohme and Michael''s estate. At the hearing, Phillips testified that Tohme wasn't a traditional music manager, and he didn't have a staff.
Phillips:

'I don't even know where his office was other than the bar at the Bel Air Hotel"

Some of the jury laughed when this was shown
Phillips was then asked about Tohme's contract, which called for him assist promoter in the production of tour events.Tohme's $100k a month contract was signed by Phillips and Michael Jackson. Phillips said fee would be paid as an advance to Jackson. Panish asked whether Tohme's contract was a conflict of interest, since he was representing both AEG and Jackson.

Panish: "Does it seem to be a conflict of interest for artist manager to take direction from the producer?"
Phillips: "Actually, no. Michael Jackson signed this document so he must have agreed to it"

Phillips said he wanted Michael to have somebody to manage him, because they needed somebody to deal with on his behalf
Panish asked if Michael became more anxious as the tour approached. "In my opinion, I never witnessed Michael being anxious," Phillips testified.
Phillips said Michael never told him he had sleeping problems. Panish asked several questions about whether Jackson ever told him he had a sleeping disorder. Phillips said no each time.
After the lunch on May 4, Phillips said he had one phone call with Dr. Tohme, but they never discussed this case
Phillips was also asked whether he ever saw a signed agreement for Frank Dileo to work as Jackson's manager. Panish showed a May 2, 2009 letter signed by Jackson indicating that Dileo was one of his representatives. The letter included the curious phrasing that Dileo could conduct business on Jackson's behalf 'only when instructed'. AEG exec Paul Gongaware wrote Phillips:

"This is a bit strange. Only when instructed? How are we to know?"

Phillips replied that they'd need a signed contract or letter with Jackson authorizing that Dileo could be paid a $50k advance.
As to Frank DiLeo: Phillips said Frank DiLeo asked AEG to advance him $50,000, and he believes Michael approved it. Phillips wrote in an email:

"I think we need to, but I am not sure how without a contract in place or Michael directing us to via signed letter"

Gongaware replied:

"We just sign off and pray"

Phillips wrote back:

"But what we apply it against. I think we need Michael to acknowledge for our record and direct us. You know he has amnesia when it comes to paying people"

Phillips reiterated how difficult it could be to figure out who was authorized to act on Jackson's behalf. Phillips:

"You needed a scorecard to keep track of who was in and who was out"

Panish asked Phillips about statements he made regarding Jackson lacking representation in June 2009.
Phillips said he believe Michael must've had a lawyer on June 2, 2009. He said Michael used different lawyers for different things. On 6/2/09, Phillips wrote to Jeff Wald (maker coffee table books):

"Jeff, remember getting Michael to focus is not the easiest thing in the world we still have no lawyer, business manager, or, even, real manager in place. It is a nightmare!"

Panish noted that Phillips in the email meant that Tohme Tohme wasn't a real manager for Jackson.
In an email at the time Jackson was preparing for his This Is It comeback concerts, an AEG lawyer, Kathy Jorrie, said she had questions about whether Tohme was "the real McCoy" and suggested the company hire a private investigator to do a background check on Tohme "and/or at a minimum, that someone at AEG Live meet with Michael Jackson to make sure he understands that we are entering into a tour agreement with him that will require him to perform a worldwide tour"
Phillips expressed some of the oddities of dealing with Tohme when he testified before the state labor board in the sometime manager's claim against Jackson's estate. Phillips said he thought Tohme did a "phenomenal job" for Jackson. "He is a good guy who has done miracles for Michael, just not a manager," he wrote in an email
Phillips said he didn't mean to say that Frank DiLeo wasn't a real manager. Phillips said he didn't act as MJichael's manager. Panish asked if crisis management is responsibility of personal manager, he said lawyers do it
Part of the agreement with Michael was that AEG would buy a house in Las Vegas for the artist.
Before concluding his questioning Panish asked Phillips about emails he exchanged with music executive Irving Azoff. In one of the emails, Phillips asked Azoff the 'odds of' Jackson making it through 50 concerts at London's O2 arena. Azoff replied that having insurance was key.
Panish asked Phillips whether he was trying to act as Michael Jackson's manager before his death. Phillips said "No". Panish cited Phillips trying to manage several lawsuits Jackson was facing and other business transactions. Randy Phillips denied that his actions were manager functions.
Panish's final question:

"You felt it was exhausting taking care of all of Michael Jackson's affairs?"

Phillips:

"I did not deal with Michael's affairs, but dealing with Michael was exhausting"

AEG Cross
Putnam showed an email that Phillips sent to Jackson's assistant, Michael Amir Williams, arranging a meeting to discuss various deals. Topics included the purchase of Neverland, settling a lawsuit over Jackson memorabilia and a perfume deal. Phillips said the meeting was arranged at the request of Frank Dileo. Frank DiLeo was the person Phillips dealt with on behalf of Michael

Putnam: "You've indicated that dealing with Michael Jackson was (pause) challenging"
Phillips: "Michael was mercurial. It was one of the things that made him great. It was also one of the things that made him impossible to do business with. He would change his mind. He would change representatives -- like we change our socks"

Putnam asked Phillips why he didn't stop Jackson from changing reps.

Phillips: "How would I do that?"
Putnam: "Could you dictate who Michael hired?"
Phillips: "No"

Putnam asked Phillips about several people involved in Jackson's business affairs. He asked about estate executor John Branca. Phillips recounted their history, that Branca had represented Jackson for part of his career, but the pair had a falling out. "Michael brought him back in", Phillips said of Branca. Katherine Jackson shook her head
Putnam then asked Phillips about Tohme Tohme. "Dr. Tohme was introduced to me as Michael's manager," Phillips said. Phillips said Michael and Dr. Tohme seemed to have a very close relationship and Dr. Tohme seemed to care very much about Michael. Dr. Tohme was introduced to Michael by Jermaine Jackson, Phillips said. There was a familiarity between all of them, he said. Phillips said MJ wanted to get 'back on the saddle', so Jermaine introduced him to Dr. Tohme. "He said Michael was determined to restart his career," Phillips said Dr. Tohme told him.
"It was time for a comeback," he recalled hearing. "The only way I dealt with Michael was through Dr. Tohme," Phillips said he received Michael's letter terminating Dr. Tohme. "Dr. Tohme obviously could not fulfill his obligations then."
Phillips said there are three ways AEG Live checks out people it does business with. Phillips said no reference/background check is needed if the person has done business with AEG Live before. The company checks references of people who it hasn't done business with, Phillips said. If someone is referred directly by the artist, Phillips said no check would be done. That was the case with Tohme.
Putnam then showed Phillips Tohme's agreement for $100k a month. Phillips noted that Jackson signed the agreement. Phillips noted that Tohme's contract was predicated on him getting cancellation insurance, which didn'tt happen in time. Phillips said to the best of his understanding, Tohme was never paid by AEG Live
He said that about 10 days before Jackson died, Michael asked to see Tohme. Phillips said it was his understanding that Jackson wanted Tohme to handle some of his business affairs, including buying a home in Vegas. He said that the plan was for Tohme and Dileo to work together as Jackson's managers.
Phillips recounted a meeting at estate executor John Branca's office after Jackson died. Phillips said the Estate wanted a detailed expenditure of the production. On the tour production expenses that Tohme approved was only part of the expenses. He said Dileo signed a similar document. The production expenses were eventually submitted and approved by Jackson's estate, Phillips said
Putnam then asked Phillips about a meeting the pair had with Tohme and his lawyer a few weeks ago at the Polo Lounge in Beverly Hills. Phillips said Tohme's lawyer wanted to meet with them. By that point, Tohme said he'd already met with Katherine Jackson's lawyers. Phillips said he didn't directly discuss the case with Tohme, but wasn't surprised that the lawyers wanted to discuss it, given the stakes. As to meeting at the Polo lounge, Phillips said he picked the Polo lounge because it was a convenient and public location. Phillips said lunch meeting lasted about 90 minutes, but he left the table for about half of the meeting to talk to other people. Putnam asked Phillips if there was some secret reason for meeting with Tohme.

Phillips: "If it was going to be secret, it wouldn't have been at the Polo Lounge, it would have been in someone's office"

After the lunch break, defense attorney Marvin Putnam asked Phillips a few questions that Panish likes to ask after every break.

Putnam: "Did you meet with your attorneys over lunch?" (the jury laughed.)
Phillips: "Yes"
Putnam: "Did they show you any documents?"
Phillips: "Just the menu"

There was more laughter.
Phillips said Estate of Michael Jackson asked him to be a witness for them in the Labor Commission dispute between Dr. Tohme and the estate.
Phillips testified about a conversation with Brenda Richie, Lionel Richie's ex-wife. Phillips used to be Lionel Richie's manager, and he says Brenda Richie called him a few weeks after Jackson died. This first came up in questioning by Panish, who asked why Phillips didn't disclose the conversation to police
"Yes, I served as his manager for 10 years," Phillips said about his relationship with Lionel Richie.
Phillips had written an email to an AEG spokesman on Aug. 18 after Murray released a videotaped statement. Phillips email:

"I wonder why now. I think I know what Michael died of and this would exonerate Conrad"

Panish asked if he had info to exonerate Murray, why he didn't call police. Phillips said info came from Brenda Richie, but didn't elaborate. He would only say the information was somewhat weird.
Putnam inquired about email Phillips sent to AEG's publicity rep on 8/18/09:

"I think I know what Michael died of and this would exonerate Conrad"

"Brenda had called me to tell me that she was in communication with Michael either through a medium or directly," Phillips testified. Panish objected: triple hearsay! Courtroom bursted into laughter. Phillips said Michael told Brenda that it wasn't Dr. Murray's fault and he had accidentally killed himself. "I told you it was weird," Phillips expressed. Putnam asked why he didn't tell LAPD what Brenda said. "I didn't want to be in that straight jacket Dan was talking about," Phillips said. Phillips clarified he didn't think it was relevant information.
Phillips said his deposition happened three and a half years after Michael died. He believed there were over 9,000 emails turned over. In preparation for his testimony, Phillips said he watched his testimony given in Dr. Conrad Murray's criminal case. Phillips said he prepared himself prior to his deposition, but not like he did for testifying in court. Phillips said he didn't believe he knew what emails were going to be used, thus he didn't want to read everything they produced. Phillips explained he has had time to look over all the emails in detail since his depo, therefore he was able to remember the events better.
"We are not a very litigious company," Phillips clarified. "I did not realize there's that 'gotcha' politics, 'gotcha' legal process." "Even though you know the answer to a question, you want the person to use it wrong so you can use it against them," Phillips opined. Phillips said he was not designated as PMK (person with most knowledge) or PMQ (person most qualified) for AEG. Phillips said he made only one substantive correction to his deposition transcript.
Phillips said he's the president and CEO of AEG Live. Phillips said AEG Live has at least 10 divisions, deal, with talent, produce shows, international tours, festivals. In college, Phillips became the director of special events for students association. He graduated from Stanford in Political Science. He went to law school at University of Santa Clara. Phillips promoted the Harlem Globetrotters. One of the stars asked to manage him. Phillips said he thought it was a good move to start his career, moved to LA, transferred to Loyola Law School. He started management career with Management West International, then worked at Stiefel & Phillips through 1996. He managed Rod Stewart and Matthew Brodrick. Then they repped Guns N Roses, Toni Braxton, Prince, Simple Minds, Morrisey.
Phillips worked with Michael at this point. He represented the artist in an endorsement deal and a line of sneakers. "He was hot as a pistol," Phillips described Michael. "This was in early 90s, right before History. It was one of the biggest endorsements made at the time," Phillips said. "The deal was a success." Phillips said the line of sneakers was not successful, though. The company he made the deal was LA Gear. "When Michael didn't like something, he was less than demure," Phillips testified. "Some of the shoes was really quite hideous," Phillips said. "Let's stop this st, it's ugly, they don't know what they're doing, this stuff is st, they're going to ruin me" Phillips said Michael reacted. Phillips described Michael as 'incredibly sharp' doing business. After the LA Gear deal, Michael and John Branca asked Phillips to manage him and he said no. His next dealing with Michael was not until 2007
Phillips left Stiefel and Phillips to work at Red Ant Entertainment from 96 to 99, continued to co-manage Toni Braxton. Managed group called Dream on Puffy Combs Label. Then approached by John Meglan and Paul Gongaware to start Concerts West, now AEG Live. "They wanted me to help them secure a tour with an artist named Britney Spears," Phillips explained. Phillips said he had a very good relationship with her manager at the time. It was the first big break tour of Britney Spears. Phillips was consultant on the tour and had a piece of the profits. After the tour, Leiweke asked Phillips to consider in-house position. Phillips wrote the business plan over the weekend and became the president and CEO of AEG Live in 2001. Phillips said AEG Live created Coachella festival. They used the infrastructure, equipment for another genre of music, Stagecoach festival. Phillips talked about the residency shows AEG Live promotes in Las Vegas: Celine Dion, Elton John, Cher, Shania Twain, Rod Stewart. Phillips said AEG Live promoted and produced Prince's most successfully tour, "Musicality" in 2004. Phillips testified they produced and promoted Prince's 21 sold out Nights at the O2 arena and residency show in Vegas at Rio Hotel in 2006
Artist management team: attorney, business manager, agent, broker, personal manager, generally four people, Phillips explained. Phillips said there are two ways a tour begin: once artist releases new album, Phillips goes to the artist team and pitches the company. Other way is management of an artist pitches the tour to AEG. "My job is to go and actually sell the concepts and ideas," Phillips said. He described himself as "schmoozer in chief". A few jurors smiled
Phillips said superstars who fill up big arenas, like Staples, work on a 90-10 split, where 90% of profits goes to artist, 10% to promoter. Once he wins the bid, Phillips passes the deal on to someone else within AEG Live better prepared to handle it. "I don't think I sit on this throne," Phillips explained. "We have a very open decision-making process at AEG Live. "I'm like manager's promoter, I think like a manager, I think in term of the brand itself," Phillips explained.
Phillips has a deal w/ AEG Live where he's allowed to manage 2 acts, Dream and Lionel Richie. Dream dissolved, AEG allowed him to manage Usher. Phillips said Live Nation is about three times bigger than AEG Live. They are competitors when it comes to touring. "I think we're a better company," Phillips opined. He said Live Nation is in the amphitheater business and AEG is strictly an arena touring. In interview w/ Telegraph, Phillips said AEG Live was under assault by 800lb gorilla called Live Nation, planning to merge w/ Ticketmaster. "Number 1 doesn't necessary make you the most profitable," Phillips said. "Why take all this risk in deploy capital in this way if you're not to make a profit?" Phillips explained. "I don't particularly love music, that's not why I got into it. I love the deal," Phillips testified. It's difficult as it can be to deal with the artists, but Phillips said he loves the challenge. Phillips said he is told all the time to just follow their business plan and not even look at Live Nation. It is a competitive business. Phillips said he has to deliver good news and bad news to artists. He said some musicians want big productions, but also big profits. He noted that Live Nation is a publicly-traded company and has to answer to shareholders, investors. AEG Live does not
Putnam then asked Phillips about the upcoming BET Experience music festival. Beyoncé is scheduled to perform. So are the Jacksons on June 30. The BET Experience is being promoted by AEG Live.
AEG Live is working on a BET Music Festival on June 28.
Friday: Beyonce, more mainstream artist
Saturday: Snoop Miguel and Kendrick Lamar, younger crowd
Sunday: Adult contemporary: R Kelly, Boyz to Men, The Jacksons.
"We book them," Phillips said. Deal was done by someone else at AEG Live, who will be promoting and producing this festival.
Phillips talked about the difference between promoting and producing. Michael didn't have touring team or money to produce This Is It tour. Phillips said it's very expensive to keep everyone on staff if you're not touring regularly. Jackson hadn't toured for many years.
AEG Live is promoting Justin Bieber world tour. It will be 130 shows over 14-15 months. "It's a very substantial amount," Phillips said. AEG promoted The Rolling Stones, 21 shows. Putnam asked why the difference in the amount of shows. "He's 19, Mick Jagger is 70," Phillips responded. Rolling Stones sales is gigantic, so they don't have to do as many concerts.
After a break, Phillips testified about how different tours work. He noted that the AEG-promoted Rolling Stones tour is only a few shows. The ticket prices are so high, Phillips said, that the Stones can make a lot of money off of a few shows. They also employ their own crew.
Phillips said concert promotion is risky. "Until you put tickets on sale, you just never know", he said. He said AEG Live cannot force artists to perform

Putnam: "Can AEG Live force an artist to perform on a show?"
Phillips: "No, the artist has the ultimate veto power. We live in a free society, they are not my slaves. If the artist doesn't want to perform, there's nothing we can do"

Phillips then recounted the series of meetings leading up to announcing This Is It. The first two meetings were in Las Vegas in 2007. Phillips said Jackson was animated and appeared healthy. He said in the first meeting, Jackson was "elated" to see him and Paul Gongaware because they were "familiar faces to him". There was a later meeting at the Colony Capital offices in LA. He said by that point, they were talking about Jackson performing. Phillips said Jackson was most concerned about getting a house for him and his children. In a proposal for the concerts, Phillips wrote that he believed Jackson could "net, at least, $1 (million) per night" after fees.
Phillips said Peter Lopez, an attorney for Michael, asked for a meeting with AEG Live in 2007. It took place in Las Vegas. "I was told by John that Michael wanted to get back to work and that's why we were there," Phillips testified. "Michael, for all the complexities of dealing with Michael, was one of the biggest stars in the world," Phillips testified. Phillips said Michael talked about putting out new music, doing something different, constantly putting music out, every 6 weeks, and touring around it. They also discussed the idea to do a miniseries on King Tut and do mini movies. Meeting lasted about 90 minutes, Phillips said. "He looked great, very animated, he talked a lot about what he wanted to do," Phillips described. "He seemed fine to me." Phillips said he didn't think Michaeel was abusing prescription drugs at the time and he was not concerned with his health. There was another meeting where Phillips said MJ showed a mini-film he called Ghost. They also discussed mini-series on King Tut. "Michael was great, animated, clear, like the star he was" Phillips described. He detailed scene of meeting where Michael threw a pencil at him, joking. "We picked London because his popularity was less diminished because of the troubles he had had," Phillips explained. Michael ended up not moving forward with the tour then. "That was Michael", Phillips explained.
Phillips said Colony Capital, a real estate investment company, got involved with Michael's finance. They purchased the note of Neverland from a bank for $23 million and Michael wanted to start his career again and make money. Colony asked for a meeting with Phillips. That's where he learned about Dr. Tohme, who Phillips says was Michael's manager at the time. Meeting happened in 2008 at the bar of the Bel Air Hotel at the request of Dr. Tohme. "The most pressing thing for him, Michael, at that time, he was fixating on getting a house for him and his children, Phillips said. "He didn't want to live in other people's house anymore," Phillips expressed.
Putnam showed the email from Jun 13, 2008 with plans for MJichael (the 'not fast, need to be controlled as much as possible' email).
"Perfection is expensive, and incidentally impossible to achieve," Phillips opined, saying they tried to control MJ's spending, nothing else.

Putnam: "How did you do controlling him financially?"
Phillips: "Not very well, but I blame Paul" (Gongaware)

Court Transcript

Disclaimer: Some of these events have unknown May dates. They are identified with a '*'
1971 - Maybe Tomorrow, the 5th album by The Jackson 5 enters both the Billboard US Black and Pop Albums charts in the USA. It will reach #1 on the Black Albums chart & #11 on the Pop Chart
https://imgur.com/a/oc3isPE
1973 - The Jackson 5 play at the Festival Hall in Osaka, Japan
https://youtu.be/m_kyZ1MlDEk
1974 * - Michael and his brothers record background vocals for Stevie Wonder’s song “You Haven’t Done Nothin’” at the Record Plant studios in Hollywood. The politically aware song would reach # 1 on both the pop & soul charts
https://youtu.be/0SEGHvLElxc
1981* - Michael goes to East Sussex to stay with Paul & Linda McCartney. He records two songs for Paul’s upcoming solo album : “Say Say Say” & “The Man*

Michael rang up, and said he wanted to work together. I said, ‘What do you mean?’ He said, ‘I wanna make some hits, you know?’ I said, ‘Sounds good.’ So he came over.
We sat around upstairs in my office in London, I grabbed a guitar and ‘Say, Say, Say’ came out of that. He helped with a lot of the words. It’s not a very wordy song, but it was fun working with him because he’s enthusiastic. But again it’s nothing like working with John. At that stage with Michael, you weren’t even talking about a writer, more just a vocalist and a dancer. But he said, ‘Let’s make a couple of hits’, and that’s exactly what we did.
- Paul McCartney, from *Conversations with McCartney

https://imgur.com/a/wylMvxJ
https://youtu.be/aIwTJ1Dl8jU
1984 - Michael is on the cover of Ebony magazine's '100 Most Influential Black Americans' issue
https://imgur.com/a/37IAvMQ
1986 - Michael, Elizabeth Taylor, Lionel Richie & Mikhail Baryshnikov attend the LA Bullet Opening Night party in Los Angeles
https://imgur.com/a/20JKEqH
1987* - Quincy Jones sets up a meeting between Michael & Prince
Prince turned down the collaboration, following a secret meeting at Jackson's mansion.

“We invited [Prince] out to Michael’s house to sing on Bad, and he was very intelligent about it,” says Jones, 83.
“Prince was always competing with Michael. So I told Michael, ‘you sit there and Prince sits there, so it won’t look like we’re ganging up on him to do the record’.
“It was a beautiful meeting, a funny meeting, and [Prince] said ‘you don’t need me on this, it’s going to be a number one anyway’ – which it was.”
Prince did not leave without handing “a lot of funny presents” for Jackson, cryptically addressed to “Camille”, added Jones.

1989- Michael is seized by armed police after being mistaken for a robber while shopping in disguise with Jimmy Safechuck at Zales jewellers in Simi Valley. Police were called after employees reported a suspicious person
The encounter happened about 5 p.m. in the Sycamore Plaza Mall. Wearing a wig, mustache and fake teeth, Jackson was looking at rings.
Employee Julie Andrews (not the singer), said she became suspicious because he kept adjusting his mustache and looking in a mirror. Another Zales store had recently been robbed by men wearing disguises.
Employees summoned security guard H. N. Edwards, who asked the suspicious character to step outside. Why was he wearing a false mustache? Edwards demanded.
“I have to,” he answered. “I’m in disguise. I’m Michael Jackson.”
“My first thought was this guy had gotten off the elevator between floors,” Edwards said
Jackson said the disguise was necessary to avoid being mobbed.
Edwards asked him to remove the mustache. He did and, sure enough, fans began gathering and asking for autographs(he obliged)
“The officers were convinced he was who he said he was & he went on his way,” Officer Diane Sliester said
"Jackson and a boy he was with visited a gift store and bought several toy figurines and a pair of heart-shaped sunglasses",Sliester said, "Then they drove away in a brown Mercedes-Benz"
https://youtu.be/l3DyN8Jvnz4
1992-The single “Someone Put Your Hand Out” is released in Europe as an exclusive Pepsi promotional single, to promote the upcoming Dangerous World Tour.
https://imgur.com/a/23ZtFPc
1992-Michael is in Washington to accept his 2nd Point Of Light Award from President Bush.
In 1990, the Point of Light Foundation created by President Bush SR, was to encourage American citizens to lend their services to the community in "a call to action."
President Bush presented Michael with an award acknowledging him as a Point of Light Ambassador. The award was in recognition to Jackson's efforts in inviting disadvantage and under privliged kids to his ranch, as well as giving his time to visiting hospitals, orphanages, assisted living homes and hospices.
Jackson spoke briefly at an East Room ceremony in which the president honored 21 winners of the 1992 President's Annual Points of Light Awards, a culmination of National Volunteer Week. In his speech, Michael stated, "I believe each person can make a difference in the life of someone in need. That is what a point of light is"
"I know each person can make a difference in the life of someone in need," Jackson said. "I love you all."
https://imgur.com/a/0rqP48Z
https://youtu.be/Qn0df421ffg
While in Washington , Michael visits a little girl, Raynal Pope, who was mauled very badly by four dogs on March 21 in District Heights, Maryland.
When Jackson first heard about the brutal attack four weeks ago, he immediately placed a call to Children's Hospital to speak with Raynal, who was in intensive care, but her mother, Jackie Pope, didn't believe it was really him. When he called back the next day, Pope believed and put the phone next to Raynal's ear. Jackson blew Raynal a kiss and promised to visit her.
After the Points of Light ceremony, he decided to fulfill his promise to Raynal. Twenty minutes later he was on her doorstep.
Raynal, her 5-year-old sister Myja, and her cousins Tianna, 6, and Vincent, 10, played hide-and-seek with Jackson ("He hid in the closet!" squealed Raynal) and wrestled around and danced during the 45-minute visit.
Jackson posed for pictures. And he signed a red leather "Beat It" jacket that Raynal's father, Michael, bought during the "Thriller" hysteria a decade ago. "We're going to frame it," Jackie Pope said.
Before he left, Jackson gave Raynal a kiss on the cheek. And she got to give him one back. "His face was soooooooft!" she exclaimed.
https://imgur.com/a/eR2gCD7
1993 - Everedde McCrimnon, 33 year old man of Los Angeles, was arrested for repeatedly attempting to scale the front gate of the Hayvenhurst estate. He was twice escorted from the compound by security guards.
He was arrested after a motorist told officers he had seen a man scaling the gate.
McCrimmon, who is free on $250 bail, had to be subdued during his arrest because he refused to obey commands from the officers and shouted obscenities
“Several other people have been prosecuted for attempting to gain entrance to the Jackson property, but this is the first case in the past few years”, said Deputy City Atty. Laura Van Eyk
1994* - Michael starts working on a remake of a musical named The Seven Faces Of Doctor Lao with special effect specialist Stan Winston.
Jackson's spokesman says he is 'in active development' on a musical remake of The Seven Faces of Dr. Lao, a fantasy for Turner Pictures Worldwide with Jackson in the title role. The original 1964 film starred Tony Randall as seven characters. Jackson's updated version is about a traveling minstrel 'who brings miracles -- and a little mayhem -- to a distressed urban community,' according to his publicist. 'Michael Jackson has been interested in 'Dr. Lao' for some time, and he is actively involved in all the creative aspects of the development process,' Jackson's manager Sandy Gallin said. 'He's very excited that it is being done.' Jackson has been keeping a low profile since aborting his world tour last November.
“One [project] was to remake 7 Faces of Dr. Lao, which was a Tony Randall film… and the other was to remake Angels with Dirty Faces”, says Rusty Lemorande(Captain Eo producer). “Michael was a huge James Cagney fan. Michael loved both projects. And everything was going great. And then the first scandal hit. Suddenly, nobody wanted to touch him. It was quite sad that it never happened, because it was very important for Michael to be in movies. He used to talk about Elvis Presley’s career and say, ‘If Elvis hadn’t made all those films, he wouldn’t be as remembered as he was.’”
1996* - Debbie Rowe visits Michael on the set of the “Ghosts” short film and announces that she’s pregnant with their baby.
She rode her Harley Davidson motorcycle to meet Michael on the Van Nuys Airport set of his short film “Ghosts” and break the baby news.
The photo of Rowe riding her Harley Davidson with Michael on the back (still in makeup while shooting his “Ghost” video), was taken that day. According to Rowe,she told him that she needed to talk to him alone, without the ubiquitous film crew that followed him
​
https://i.redd.it/i557jpz1f7xa1.gif
Michael was getting ready to do a shoot but she convinced him to hop on back of her Harley so they could find a private spot to talk.
“I said, ‘You’re going to be a dad!’ I'm pregnant,” Rowe recalled. “He was so excited, he ran around the tarmac screaming.”
1999 -Michael Jackson receives a charity award at the Bollywood Awards held at the Nassau Veterans Memorial Coliseum in New York. He is dressed in a black Indian suit designed by Manish Malhotra. He accepts a special “Humanitarian Award” from London-based industrialist S.P. Hinduja for his role in promoting the cause of global peace.
https://imgur.com/a/8nxgjAW
https://youtu.be/VPQWbg1TbLI
2001* - Michael, Frank, Grace & the kids check in the Sheraton Bel Harbour in Miami Beach where Michael completes the recording & mixing of Invincible with Bruce Swedien, Rodney Jerkins & Teddy Riley.
Michael meets Dr Alex Farshchian who becomes his personal physician.
Farshchian treated Michael in 2001- 2003. He said that Michael was having an issue with his ankle prior to the Madison Square Garden shows and that he had to rehearse. The doctor said that; “And he had an ankle issue that was more like a sprained ankle that was not healing and he had to continue to dance on it. He made an appointment like everybody else,” Dr Farshchian said
Jackson and Farshchian met when Michael was being treated for a broken foot after slipping on stairs at his Neverland ranch. Farshchian, according to the Mirror, traveled with Jackson in 2002 and 2003 and was in the room during the infamous baby-dangling incident. The friendship and doctor-patient relationship is said to have fizzled after the Martin Bashir interview and subsequent trial.
2001* - Michael meets comedian Chris Tucker through Gavin Arvizo. Michael & Chris become friends& record a new version of “Don’t Stop Til You Get Enough” for the soundtrack of Rush Hour 2
They actually first briefly met in the early 1990s, when Tucker was starting out as a stand-up comedian
Fast forward to 2001:

"I was in New York for two days waiting to meet MJ," Tucker recalled to GQ. "I took a private jet there. I said, well, I ain't heard from him, I got to go. Took a private jet back to LA and as soon as I landed, I had a message: 'Michael Jackson wants to meet you tomorrow morning.' I was still on the plane. I went up to the captain and said, 'I'll pay you whatever you want to take me back to New York.'"
Tucker told GQ that he and Jackson later became close friends, and Jackson encouraged him to take on more work in Hollywood.

2002* - It was reported that Michael Jackson wanted to direct his first movie. Michael loved the book so much that he wanted to make an adaptation of Jennings Michael Burch's book, They Cage the Animals at Night. Bryan Michael Stoller & Michael Jackson were scheduled to co-direct the motion picture. Mel Gibson hired Stoller to write the screenplay adaptation of Burch's book, with Stoller and Jackson signed to co-direct. Stoller was also mentoring Michael Jackson and his three children on film making
2002 - Celebrate the Magic Foundation's 1st Magic Life Award
Michael is honored for making the world a better place, standing up for children and humanity in NYC.
"It was up to the citizens of the world, especially our children, to confirm who is deserving of this honor. This makes the Magical Life Award truly unique, in that it is an award from the hearts of children, and those adults who still have the heart of a child."
When given the opportunity to vote for the person that inspired them the most, to stay in touch with the Magic of their inner child, thousands of children from around the world, voted for Michael Jackson
2002* - Katherine, Jackie, LaToya, Tito, Janet, Rebbie & Randy stage an intervention at Neverland to help Michael on his prescription-drug dependency.
But after her other children told her they believed he was addicted to prescription drugs despite Michael's denial, she participated in an intervention at his Neverland ranch in 2002.
“I knew he was taking them (pain pills) but I didn’t know he was abusing them,” Katherine told the jury. She said Michael was upset when the family staged the intervention "because when we got there, there was nothing wrong with him.” The intervention, she added, didn't really take place because Michael Jackson was upset and yelled at his family, and Katherine Jackson became embarrassed to be there, she testified
2009* - Conrad Murray ordered Ephedrine for Michael in early May but he told the pharmacy owner that it was for Himself. Did Michael know he was being given Ephedrine? Witnesses state that Michael’s weight dramatically decreased in the last weeks prior to his death. Ephedrine causes rapid weight loss

Prosecutor: During the same conversation in early May, did Dr. Murray inquire about what you might call energy formulations?
Tim Lopez (owner of Applied Pharmacy): Yes, we had a brief conversation about some sort of formulation that would give increased wakefulness or more energy
Prosecutor: Did Dr. Murray indicate to you during the inquiry about the energy formulation that it was HE HIMSELF who was in need of an energy formulation?
Tim Lopez : Yes*

2013 - Jackson v AEG trial day 3
Today's court session was only one hour as one of the alternate jurors had a funeral to attend.
Nobody from the Jackson family was present at court
Det. Martinez's testimony resumed with him discussing documents on Murray's finances he obtained during his investigation
The detective had to explain how he got the documents; authenticate them - so they can be entered into evidence. Some documents were obtained with subpoena, others public record
Attorneys argued about the docs they want to admit as evidence. Defense objected to a bunch of docs, saying they weren't authenticated. AEG attorney objected to admission of several of the documents, saying it wasn't clear whether they were public records. Judge sustained many of the objections. Judge also had testy exchanges with Jacksons attorney Panish with Judge telling him to move along. After several minutes of discussions, Judge said to put the exhibits/evidence issues aside; she wanted better use of jurors' time
Martinez testified about eviction notices for Conrad Murray's medical offices (2007 & 2009) and other liens issued against the doc. The detective also walked jury through Murray's credit reports, which were obtained through a subpoena
Income and Expense Declaration filed with San Diego Court shows Dr. Murray's net month disposable income was negative $2,706.33 in July 2009
Panish asked Martinez about 5 day notice to pay rent or quit -- Dr. Murray owed $7,058.38 in business rent, had an eviction note and tax liens
One 2007 judgment against Murray in Missouri ordered him to pay $135,000. There were also eviction notices for his medical business and liens for being behind on child-support payments
Panish: What's the relevance of Dr. Murray having delinquent taxes?
Martinez: shows more evidence of him being in financial dire straits
Panish listed several other docs showing Dr. Murray's liens & unpaid bills in an effort to show the jury the doctor was in financial distress
Panish: did you check Dr. Murray's credit?
Martinez: yes, by serving grand jury subpoena on experian, equifax and transunion
"If anyone would have run the credit report, they would have got the same information?" Panish asked. "Yes", Martinez said
The credit report shows Dr. Murray was current on some of his accounts. Panish noted Murray was paying some debts but defaulted on his home
Panish is trying to show the jury that a simple background check on Dr. Murray would show AEG that the doc was in deep financial troubles
Jackson attorney, Panish showed the jury documents showing Murray's debts, including those for student loans, homeowner association fees, and bills from medical firms and cellphone companies. His Las Vegas home, on which he owed $1.6 million, was in foreclosure
"Student loans, credit cards, credit medical companies, cell phone companies, funding companies, there were all kinds of debts", Panish said
Orlando obtained docs from state licensing medical boards regarding Dr. Murray to check his status and if he had any disciplinary actions
Martinez told reporters he got Murray's phone records and focused on a 12 hour period between June 24 and June 25, 2009
Martinez: "For criminal liability, that 12 hours of care, from when he arrived at the house until he called 911, was pertinent"
Martinez was asked about the calls Murray made to Nicole Alvarez ( his girlfriend), including one he made in the back of the ambulance on June 25, 2009. The detective said he didn't know what Murray and Alvarez discussed
11:26 am-- received phone call, possibly Michael Amir Williams
1:08 pm -- made call to Nicole Alvarez while in the ambulance
Call was a bit over 2 minutes (133 seconds). Martinez did not know for sure what they were talking about, questioned Alvarez about it
Detective Martinez also testified about a search warrant he served on Alvarez's apartment in August 2009. Martinez said he didn't find any of Murray's belongings. The detective said he only found one slip of paper with Murray's name on it in Alvarez's apartment. He says he found that odd
"He was living there and none of his stuff was there", Martinez said
Panish: "Do you have an opinion as to the substance of that call?"
Martinez: "Yes",explaining that he had interviewed Alvarez and served a search warrant at her house.
Panish: "What was determined?"
Martinez: "I found one piece of paper with Dr. Murray's name & that had fallen behind the door of a cabinet in the entire apartment (where) he'd been staying at (for) at least two months", Martinez replied.
Panish asked whether he found that suspicious.
"Yes", Martinez replied, "He was living there, and none of his stuff was there"
Martinez indicated that Dr. Conrad Murray may have requested help from mistress in covering his tracks
Hearing:
AEG agreed to stipulate Michael Jackson is dead, but need to think about stipulating that Dr. Murray is the cause of his death
Panish: "I'm asking for a stipulation that Michael Jackson died and the cause of death. Are you willing to stipulate that Michael Jackson died?"
Putnam: "Absolutely."
Panish: "Are you willing to stipulate that the cause of his death was Dr. Murray?"
Putnam: "That you've never asked before. Let me look at what that means"
AEG's attorney asked judge to take some witnesses out of order, since they have to travel for work. Jacksons added more witnesses too.
Jackson's lawyers said they believed they could locate Michael's longtime nanny and confidante, Grace Rwaramba, and plan to call her as a witness as the trial proceeds.
"We couldn't find her, no one could find her", lawyer Kevin Boyle said of the last-minute addition, "But we think we're going to be able to find her, hopefully"
Court transcript

Hello and welcome back to SAR! Today we talk about a very tricky topic—the Methamphetamine Epidemic. Methamphetamine is a highly addictive stimulant that has recently seen a rise in the United States (as well as other Western countries) that is slowly starting to take over Opiates as the illicit substance of choice for substance abuse. Meth isn’t a new recreational drug, we saw the first wave in the 1990s, but in the current Opiate Epidemic viewpoint we hold we now have different approaches to an addictive and destructive drug. There have been some approaches that have worked and many that haven’t and in order move forward we should acknowledge both. As always I try to stay incredibly neutral on these current topics because unlike Pellagra from 1910, we are seeing the effects of Meth right here, right now. See this post as a springboard to learn more and educate yourself on what is currently going on and if you are inspired considering getting involved yourself. So let’s chat about Amphetamines, Stimulants, and Meth!

Meth by any other name is still just as… sweet? Addictive?

​
https://preview.redd.it/itbpni6jxcva1.png?width=516&format=png&auto=webp&s=8b2b14c4c88da60c230d0be41039a2b3b355fd35
Methamphetamine is one drug part of a larger drug class called Amphetamines which are considered Stimulants. Stimulants, which include other non-Amphetamines like Cocaine, Caffeine, Khat, and Nicotine all cause feelings of increased energy, euphoria, and confidence which are the main reasons they are used or misused. Methamphetamine comes in several forms and each one has different properties and reasons why its used. Powdered Meth, commonly called Crank, is fine enough that it can be snorted or applied to the inner lower lip for a quick ‘bump.’ Crystal Meth is a smokeable form or injectable form of Meth that causes a more potent reaction due to the higher dose. Less popular is Base which is an oily form that is melted down and injected or sometimes swallowed.

• The onset and duration of Methamphetamine's rush (the intense euphoria feeling) is entirely dependent on what form is used and how it enters the body. Snorting has an onset within 5 minutes and usually lasts about 30 minutes; IV injection happens within one minute and lasts 10-20 minutes; smoking has an instant effect and lasts for about 5-10 minutes. It should be noted that the rush that someone feels is seconds long the quicker the onset is meaning that someone needs to take multiple hits to continue the euphoric rush. The high, which is the mind/body altering feelings after the rush can last anywhere from 4 to 24 hours with most people landing around 12 hours.

“I’ll be your master, you’ll be my slave. Don’t fear being lonely, I'll walk with you to your grave.”

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Before we can start about the epidemic we have to understand the drug. Inside the brain we have several neurotransmitters that coordinate the generation, transfer, and termination of information. Now, the complexities of this neurotransmission is a little bit too broad for this post but we do have three neurotransmitters that we need to think about: Dopamine (DA), Serotonin (5-HT), and NorEpinephrine (NE). As you can see in the diagram on the right, all three of these neurotransmitters come from a common precursor molecule so we dub this triad the Monoamines since they contain a single amine group on the tail of a hydrophilic aromatic ring. Chemistry aside we can see broadly 4 mechanisms of Amphetamine drugs:

1. Increasing the Release of Monoamines from their neuronal storage so that their signal is boosted
2. Inhibits Monoamine Ruptake Inhibitors so that any released neurotransmitter is kept in the synapse causing the signal to be boosted.
3. Reverses transporter exchange so any neurotransmitter that is removed from the signal is released again thus boosting the signal
4. Weakly inhibits Monoamine Oxidase which prevents the breakdown of the neurotransmitters to have a longer lifespan and thus boost the signal.

If you can’t tell, the overall effect is BOOST THE DOPAMINE, NOREPINEPHRINE, AND SEROTONIN SIGNAL. But this effect of boosting NorEpi, Serotonin, and Dopamine is not unique; lots of drugs increase the concentrations of these neurotransmitters in the body and have a wide range of effects. Many antidepressants increase Serotonin or NorEpi concentrations and Bupropion (Wellbutrin) is a unique antidepressant in that it increases NorEpi and Dopamine. To explain Methamphetamine I want to take a novel approach—I want to pull Methamphetamine out of the nebulous environment of “street drug” and compare its effects to prescription drugs. Now keen readers know that there is a prescribed form of Methamphetamine called Desoxyn for ADHD but that would be a cheap comparison; its the same drug! So let’s dive in.
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• Central Nervous System - Euphoria, Increased Energy, and Feelings of Power. Some of the main reasons why people misuse stimulants is their ability to increase energy, prevent sleepiness, conquer tasks, and of course the euphoria of a high. One of the most common forms of Amphetamine misuse in young adults ages 18-26 is buying prescription drugs like Adderall and Ritalin to help with studying in college. As I went over in my post about ADHD (link), this condition is not cause by a person having too much energy and so we take a drug to dampen that but rather that the person physically does not have the energy to focus. An analogy would be that it is incredibly hard to focus when you are tired, ADHD is similar except the person is not tired but doesn’t have the energy to focus. In a fatigued state the decision making region of the brain, the Prefrontal Cortex, lacks pro-focus neurotransmitters Dopamine and NorEpi. By administering stimulants we are boosting these neurotransmitters in the brain enabling the person to have enough energy to focus. Now its important to note that this effect of focusing is seen at clinical doses (i.e. prescription dose) but when someone is abusing stimulants for a high, they are taking 5 to 50 times the dose of someone taking their prescribed medication. This means we would see the effect of the medication at the lower dose but also the toxicities of taking the stimulant at these enormously high doses.

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Ropinirole overlaid with Dopamine

• One of the biggest effects of abusing Amphetamines is that Dopamine levels will sky rocket. In pop culture we see Dopamine as the happy chemical in the brain but the more accurate way to describe it as the Motivational Salience chemical or in other words it enhances the desirability of doing a task while simultaneously dampening aversion to that same task. We can see this in the Cognitive-Behavioral sense where doing a task becomes pleasurable which encourages us to do it again—taking Methamphetamine would make tasks a more pleasurable experience (the Dopamine concentration rise alone ensures that) and so it drives the brain to seek out those activities more.
  • A parallel to this are the Dopamine Agonists like Ropinirole (Requip), Pramipexole (Mirapex), and Rotigotine (Neupro) which are used primarily in the treatment of Parkinson’s Disease (oh look we have a post on it!). Parkinson’s is caused by the neurodegeneration of Dopamine neurons meaning that there are physically fewer neurons producing Dopamine in the brain. Other than its role in motivation, one of the other main functions of Dopamine receptors is in the initiation and progression of movements. As the illness progresses the number of Dopamine receptors being activated by Dopamine starts to decrease leading to the characteristic movement dysfunction we see in Parkinson’s. This is where the Dopamine Agonists come in—they directly bind to the Dopamine receptor and activate the receptor to replace the Dopamine production that is slowly disappearing.
  • At lower doses, drugs like Ropinirole works primarily with the Dopamine-2 receptor to improve movement but in people who are extra sensitive to the drug we start to see some unwanted side effects. When the drug works on the Dopamine-1 and Dopamine-5 receptors we start to see the feelings of euphoria and behavioral changes in the patient. It is well documented that people who take a Dopamine Agonist are at risk of developing addictions like shopping, gambling, and even sex after they start one of these drugs. Why? Well for similar reasons to an Amphetamine—the drug is activating the Dopamine receptor causing pro-motivation towards those rewarding behaviors thus reinforcing them. In fact there was a big lawsuit in 2012 in France when a patient sued the manufacturers of Ropinirole for his risky hypersexual behaviors and excessive gambling while he was taking the medication from 2003-2010. The behaviors immediately ceased upon discontinuation of the drug and this is why doctors and pharmacists must warn patients to watch out for these extreme behavioral changes.

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• Central Nervous System - Feelings of Paranoia. As we have discussed, low doses of Amphetamines allows for an increase in Dopamine and NorEpi in the Prefrontal Cortex allowing them to focus but at abuse levels we see enormous concentrations. The effect of this excess Dopamine in this region of the brain, as well as elevation in the Hippocampus and Amygdala (emotional and fear regions of the brain) is the development of Anxiety and especially Paranoia. Part of this plays into the Reward Circuit of the brain and the addictiveness of the drug but the other is Methamphetamine-Induced Psychosis. Because reward and paranoia are so closely linked, the more someone chases the Euphoria of misuse the more paranoid they are likely to become. Someone can develop visual or auditory hallucinations that can be incredibly scary. All of these are incredibly distressing thoughts but because Methamphetamine can cause a significant withdrawal the person has almost no choice but to continue using the drug else they become incredibly sick.
  • A parallel to the Methamphetamine Psychosis is Schizophrenia—a severe mental illness marked by delusional thoughts, bizarre behaviors, and/or blunted emotions (and yes we do have a post on Schizophrenia found here). It is believed that Schizophrenia is caused by an excess of Dopamine in many different regions of the brain resulting in the wide range of symptoms we see. The hallmark symptom of Schizophrenia is Psychosis or thoughts that do not align with reality—this is where the stereotype that the government is watching the individual come from. The mainstay treatment of Schizophrenia are Antipsychotics (a.k.a Neuroleptics) which act as Dopamine-2 Inhibitors. These drugs block over stimulation of the Dopamine receptor thus preventing overactivation of the Dopamine systems in select regions in the brain to hopefully decrease Psychosis. In a way, Methamphetamine abuse can be seen as a drug-induced Schizophrenia that is very dose dependent.

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• As discussed in the Schizophrenia post there are two generations of Antipsychotics: the first generation almost exclusively works on the D2 receptors while the later second generation focuses on D2 and a Serotonin receptor 5HT2a and Alpha-2 receptor (A2). Generally we find better efficacy with these later agents because of their broader effects which suggests that Schizophrenia may have some pathology in Serotonin and NorEpi circuits as well. Remember that Amphetamines also increase Serotonin and NorEpi concentrations so its no wonder why we see this drug-induced psychosis that mimics many symptoms of Schizophrenia.
• Now, does this mean we should treat Methamphetamine use with D2 antagonists? When someone is currently using Amphetamines it would be a terrible idea because we would immediately precipitate withdrawal which is why doctors have to be careful when diagnosing true Schizophrenia vs Methamphetamine Psychosis. It is not hard to imagine a scenario in which a person is brought to the ER in an acute psychotic episode and pumped full of Haloperidol (Haldol) immediately causing a Methamphetamine withdrawal which thankfully is not fatal (unlike Alcohol withdrawal). That being said Antipsychotics do have a role in maintaining sobriety from using Methamphetamine and they are increasingly becoming a go-to treatment for helping people stay away from Meth.

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• Cardiovascular - Arrhythmias, Hypertensive Crisis, and Heart Attacks. So far we have focused on Dopamine but now we are going to switch focus to the other main neurotransmitter NorEpi. NorEpi is a widely distributed neurotransmitter in the brain and in the rest of the body. We see the effects of NorEpi when the Sympathetic Nervous System (SNS) is activated such as during Fight or Flight; let me set the scene: you just get to class and discover that, shock, you forgot to wear trousers today! You are ass naked in the middle of the lecture hall and desperately need to get back to your dorm to put on the clothes that you somehow forgot. In addition to the stress hormones Cortisol and Epinephrine, the main effect we are going to see is NorEpi to take your wind-chilled butt all the way back home. All of the actions of the SNS are to ensure that you can MOVE QUICKLY to avoid whatever danger you are in (cue bear attack analogy that is normally talked about).
  • In the eyes we see the pupils dilate so that more light can enter to let you see more of your surroundings. Likewise blood is shunted away from the digestive tract (because this is no time for energy to be wasted on something so slow) to the muscles so they can get the extra oxygen delivered. This means that the stomach will secrete less acid, the intestines stop moving waste, and the mouth stops secreting saliva (which is why people get dry mouth when scared). In the lungs the airways dilate to allow more air to be inhaled to oxygenate the blood and the heart is stimulated to beat faster and harder to move that blood to where it's needed, the muscles. We also see smaller blood vessels near the surface of the skin constrict to shunt blood to more important places, like the muscles.

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• Running home to get some pants is all well and good but, ahem, what about Methamphetamine? Well remember that Amphetamines cause an increased release and decrease reuptake (removal) of NorEpi in the central nervous system. This means that we are increasing NorEpi concentrations which would simulate Fight or Flight when we don’t need it.

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• Even though Methamphetamine will cause a wide range of effects I want to focus specifically on the heart because the relationship between Methamphetamine abuse and Cardiotoxicity is huge. Let me not mince my words: abusing Methamphetamine is incredibly toxic to the heart. (A) Firstly remember that NorEpi causes constriction of blood vessels and we see that Methamphetamine also causes constriction. If the blood vessels that nourish the heart are constricted we see the development of a Myocardial Infarction or Heart Attack which is potentially fatal. This risk of a Heart Attack is cumulative and the risk of having a Heart Attack increases exponentially for every year that someone uses.
  • (C) Next we see the effect of NorEpi on regulating heart rate. The ability for the heart to contract and move blood across the body is an incredibly essential mechanism for us to stay alive. During Fight or Flight more NorEpi is released causing the heart to beat faster and harder so that more blood is moved per minute. Like any muscle the heart can get tired and become dysfunctional if it constantly pushed to its limits—luckily people don’t live in a constant Fight or Flight mode else they would see Cardiomyopathy or weakening heart muscle. With constant Methamphetamine use we see two effects: first the constant stimulation disrupts the very carefully coordinated electrical stimulation on the heart to cause a heart beat. The result is pretty significant arrhythmias or a bad heart beat sequence. Secondly constant stimulation on the heart causes thickening of the heart wall making it more stiff and harder to contract. A stiffer heart means it is less able to move blood in the body and may develop a clot that could potentially cause a stroke. This remodeling is irreversible most of the time and is a real long term consequence of abusing Methamphetamine.

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• (D) We also see Methamphetamine being directly toxic to heart cells leading to induced cell death and necrosis. This means patches of the heart are dead and won’t be repaired even if the person stops using Meth. This process takes place by Methamphetamines binding to the Sigma-1 Receptor on the Mitochondrion (makes energy for the cell, but you already knew that) and the Endoplasmic Reticulum (remember this one from biology? It makes and stores proteins) which are essential for the continued survival of the cell. No Mitochondria or ER? Dead cell.

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• Teeth and Skin — Meth Mouth and Crank Bugs. Now that we have talked about the effects of Dopamine and Norepinephrine we can talk about the most recognizable signs of Methamphetamine use. I want to talk about it not to shame a user but because it's important to understand the complications related to the teeth and skin to avoid serious infections and further health complications. Despite how shocking they appear, its important to know that these conditions don’t happen overnight and through repeated misuse they get worse. Let’s dive in.
  • “Meth Mouth” as it is known is the characteristic breaking, decay, and loss of teeth and gums in those who use Methamphetamine. The mouth (which is featured in this post about sugar) is both tough and sensitive to the different conditions we put it under—in a lot of ways it is incredibly dynamic to the very different kinds of things we put in it. For instance we can put exceptionally acidic foods like lemonade which wears away teeth, too hot food that burns the palate, and not brush for weeks at a time without dying. Seriously, humans have been neglecting their dental health for all of time except for 60 years ago and we made it! Well barely, there is a lot of evidence that says good oral health is good general health (seriously go brush AND FLOSS). Looking at the cause of mouth damage due to Methamphetamine is multifactorial with the outcome being more of AND than one or the other.

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• 1) Meth is acidic — Okay this is a bit of a misnomer because any chemist will tell you that an amine is very basic BUT bear with me. Acidic foods wreak havoc on the teeth because they erode the protective enamel on the teeth allowing for them to become very sensitive and potentially damaged. Meth itself is not acidic but Crystal Meth is manufactured via the Red, White, and Blue Method which uses primarily Red Phosphorus (usually sourced from matches or flares), Pseudoephedrine tablets (white in color), Iodine (blue in color) in addition to a whole list of unsafe and toxic solvents. This manufacturing process utilizes the strong acid Hydroiodic Acid which may be left in the final product thus eroding the teeth.“Meth mouth” typically begins with the yellowing of the user’s teeth and rapidly deteriorating enamel “flaking” off from the underlying tooth structure. Repeated use of the drug eventually leaves the user’s teeth looking grayish-brown or black stained, decayed to the gum line, and often non-restorable. The rapid destruction of tooth enamel is thought to be a result of the heated vapors released by toxic chemicals produced while smoking methamphetamine.
• 2) Meth dries out the mouth — remember how I said that Methamphetamine turns on the Sympathetic Nervous System which turns off digestion? Well one of the effects is that the salivary glands stop producing saliva which dries out the mouth. Saliva is protective because it dilutes any acid in the mouth AND washes away bacteria on the teeth that could be doing damage.
• 3) Meth users clench and grind their teeth — similar to another Amphetamine, Ecstasy, people who use Methamphetamine are activating Dopamine receptors that cause the muscles in the jaw the clench. Sometimes the person is clenching so hard that they can crack and break their teeth and if the teeth are already weakened from erosion then the likelihood of breaking is greater.
• 4) Addicts are concerned with their next high not about dental health — probably most sadly is that the engrossing nature of Meth addiction is that it removes any motivation for anything other than the drug. Someone who is in the middle of their addiction is less likely to take care of their teeth because it's just not a priority for them.
• Moving onto the skin we encounter “Crank Bugs.” Remember that Methamphetamine causes a hyper-Dopaminergic state that is similar to the pathology of Schizophrenia which can result in intense hallucinations. This can result in pretty significant disordered thinking, especially Delusional Parasitosis or the idea that the body is infested with parasites and bugs leading to severe agitation. A person using Methamphetamine may start to scratch their skin to remove the bugs from their skin which can lead to lesions that can become infected very quickly. If someone does not have the delusions they may still pick at their skin like a tic (which is also a hyper-Dopaminergic state) causing skin lesions. Like the teeth, someone using Meth is not likely to care about the lesions when they are looking for their next high. Likewise someone who chooses to inject Methamphetamine may have degradation of the tissue around the injection site. Also remember that Methamphetamine causes vasoconstriction of the blood vessels of the skin shunting blood away from it which means its not being nourished with oxygen and nutrients that it needs preventing adequate repair.

The next epidemic? Or just an old one becoming worse?

Whew, what a lot of information. What was this post about again? Oh yeah the Meth Epidemic as a whole not just what is Meth. Fly over the middle states in the US and you will see countless communities decimated by this drug and now that you know the effects of the drug you can imagine how devastating it is. Methamphetamine was originally discovered in 1893 from the precursor Ephedrine in 1893 but found popular use in WWII by Axis soldiers as a way to stay awake and fight despite fatigue during the war. It’s utility in the war wasn’t lost on militaries and the US used Amphetamines in both the Korean War and Vietnam War as an unofficial way of making sure soliders stayed alert. In fact during the Vietnam War, the US military adminsitered upwards of 225 million dextroamphetamine tablets to soldiers and up to 50% of personnel were taking the drug. By 1973 when America started to leave Vietnam, that number jumped to 70%.

• The domestic use of Amphetamines in the US starts a bit differently than the military however. As I detailed in the ADHD post, the original use of Amphetamines was in the diagnosis of a type of encephalitis vs flu in children. By the 1950s Amphetamines were marketed towards housewives for weight loss, athletes and students for performance enhancers, and truck drivers to stay awake on long hauls. In 1959 the FDA banned Amphetamine inhalers to curb the rise in abuse and in 1962 we saw the first use of “Speed Freak” to describe users of Amphetamines. To combat the continued rise of Ampethamine misuse among biker gangs, the Controlled Substances Act of 1970 established Amphetamine-derivatives as Schedule II classified substances which designated them as highly addictive prescription drugs. In 1980 the federal government tightly regulated the movement and sale of Phenyl-2-Propanone (P2P), the original precursor, meaning that home Meth cooks had to turn to other sources to make Meth.

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• In the early 1980s, Mexican Cartels, bike gangs, and home cooks turned to the drugs Ephedrine and Pseudoephedrine (Sudafed) as a better precursor thus birthing the Red, White and Blue Method we talked about earlier. This enabled the DEA to regulate Ephedrine and Pseudoephedrine but big pharma companies pushed back against any regulation so the DEA compromised by regulating powdered Ephedrine and Pseudoephedrine but not finished tablets in the pharmacy in 1986. The switch to using Ephedrine tablets instead of powders was not difficult for home Meth labs and by 1993 the majority of home labs were using over the counter Sudafed tablets to make meth OR purchasing it in bulk from Mexico.
• In 1993 legislation was passed to require pill sellers, like pharmacies, to register with the DEA to hopefully catch and stop any major diversion. Meth cooks switched to using Psuedoephedrine tablets which required flammable solvents to extract the ingredients from the tablet—the Meth task force said that 60% of explosions and fires in labs was due to this switch. In 1996 the DEA required all Pseudoephedrine to be sold in blister packs believing it would be too much hassle for people to acquire enough precursor. It did not and up to 73% of raided labs showed evidence of blister packs being used int he cook. FINALLY in 2004 Oklahoma was the first state to require the purchaser to show ID and sign at the register when buying Pseudoephedrine. By 2005, 35 other states passed similar laws and the federal government passed the Combat Methamphetamine Epidemic Act of 2005 to move Pseudoephedrine behind the counter and require ID.

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• When we look at the trends of Methamphetamine we see an alarming increase. In the last 10 years, especially since the beginning of the pandemic, we have seen a sharp increase in the use of Methamphetamine. Methamphetamine use remains incredibly high and the drug of choice in the Western half of the United States (West of the Mississippi River) while the East is mostly Fentanyl. When compared to other drugs, Methamphetamine remains one of the highest rated harmful drugs, and is one drug that is most likely to cause harm to the user. \

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• In just 20 years we have seen overdose and death due to Methamphetamine skyrocket as seen in this graph from Utah. Methamphetamine was associated with a 16,200% increase in mortality in urban Black users when compared against urban White users. Perhaps scariest is that the rate of Methamphetamine deaths independent of other drugs has sharply risen meaning that the Meth Epidemic is becoming a distinct issue outside of the Opiate Epidemic. This has led some public health officials to state that we are seeing the rise of a Second Wave, the first being in the 1990s to 2000s. Right now there is heavy lobbying in the US to combat Meth production inside and outside of the states but progress is extremely slow. Some states that instituted the electronic system to track Pseudoephedrine purchases by showing ID have seen no decrease in Meth use since the program started. So where does this leave us? Well we are stuck at the beginning of a second wave that we may not be prepared for because we have yet to recognize the danger that is looming. Should there be more done to combat the Meth Epidemic? Yes, no doubt but it's plotting the right course that is extremely tricky. And those solutions will have to wait for another post. Cheers!