Alon Steinberg

**Alon Steinberg** was a witness for the prosecution in the involuntary manslaughter trial of Conrad Murray. Steinberg was an expert witness, and had been a cardiologist for 13 years and board-certified in cardiovascular diseases, Cardiac CT and Nuclear Cardiology at the time of the trial.

## Education

Steinberg attended the University of Texas Medical Branch for medical school.

## Testimony

Steinberg testified that, of the three degrees of breaching the standard of care (no deviation, mild deviation, extreme deviation), this case was the first time Steinberg has seen extreme deviations from the standard of care. Steinberg testified that propofol is only used in cases of needing deep sedation when the patient will go through a significantly painful procedure and there are risks that the patient could stop breathing; that is why it is used with constant monitoring and emergency equipment on hand. He testified that he only uses propofol with performing cardioversions and that he is required to have an anaesthetist present. For instances of mild and moderate sedation, Steinberg stated that he would use benzodiazepines and would never prescribe propofol for insomnia. He received Murray's case and was asked to review his acts and omissions against the standard of care. The review was based on Murray's own words from his police interview previously heard by the court. His findings: "Six separate and distinct extreme deviations from the standard of care".

Propofol is not medically indicated for sleep. "I have never even heard of it being used for insomnia, it is a very powerful surgical sedation agent." There was also no informed consent signed by the patient. Risks, benefits, indications and alternatives should all be explained, understood and agreed before any treatment.

Propofol was being administered in the home, with no equipment, no medical personnel, no back-up and no physical observation by the attending physician. "Each of these individually would be an extreme deviation on their own". Equipment needed for propofol: alarm on the pulse oximeter, automated blood pressure cuff, EKG to monitor heart rhythm, ambu bag for ventilation assistance, a backboard for chest compressions, a back-up generator in case the power goes out, a way to summon help and a device for keeping the airway open such as an endotracheal tube. Murray had none of this equipment. Personnel required: Intubation specialist to rescue the airway, nurses for the procedures, emergency personnel close by, and an anaesthesiologist. Personnel trained in basic life support and advanced life support should be in attendance to deal with the airway maintenance, IV maintenance and any arrests that may occur. Drugs required during sedation in the event of an emergency: flumazenil, naloxone, lidocaine, atropine, beta blockers, dopamine, epinephrine, methylprednisolone. All of these should be available in a crash cart very close by.

Inadequate preparation for emergency situation. Attending physician must have the drugs and personnel prepared.

Improper care during arrest. Jackson had a respiratory arrest, and Murray did not follow the protocol for such an event. During respiratory arrest, the patient stops breathing, causing the oxygen levels in the blood to drop lower and lower, which causes the heart rate to increase. Lack of oxygen weakens the heart, and the heart will have electricity present but will not contract (pulseless electrical activity). Finally, the heart's electricity dies (asystole). Murray should have tried to arouse Jackson, placed an ambu bag over his mouth, cleared the airway, called 911 and administered flumazenil. Instead, Murray started chest compressions, which do not help respiratory arrest. "The heart was already working, he didn't need chest compressions". Even then, the CPR was of poor quality, since it should have involved having both hands on a hard surface rather than having one hand on a bed.

Failure to summon emergency help. Murray should have called 911 on his cell phone immediately. Instead he waited until 12:21 pm, which was approximately 20 minutes after Jackson stopped breathing. Help was four minutes away. "I would have allowed two minutes to check the situation before calling 911. He had a cell phone."

Failure to maintain proper medical records. No informed consent. No records of Jackson's vital signs, doses given, responses to the medication. Murray was confused or dishonest about the records when they got to the emergency room.

Question: "Dr. Murray's deviations in the standard of care contributed to Jackson's untimely death?" Steinberg: "Yes." Question: "If Jackson administered the drugs to himself, was it still gross negligence?" Steinberg: "Yes." All medicines are kept in locked and passworded cabinets. There would have been no opportunity for self-administration in a proper setting.

During cross-examination, Steinberg testified that if the patient had a blood pressure (caused by there being a pulse) and a pulse of 122, he was savable. If a patient is not breathing but has a pulse, the course of action is to clear the airways and give breaths.