In his opening address Mr Waalkens said it was likely the patients knew Lim was "overtly gay" and that this created a situation "ripe for misunderstanding".
"We anticipate that it's likely each of these four young men recognised that when they came into the consultation they knew that he was demonstrably, overtly as I say, a gay person."
Mr Waalkens said one of the side effects of Midazolam was hallucination where patients feel, hear and see things that don't occur.
However when the prosecution called its first witness, emergency medicine expert Dr Craig Ellis, the court heard Dr Ellis had administered the drug hundreds of times and never knowingly had a patient have hallucinations of a sexual nature.
Dr Ellis, who oversaw Lim for more than three years as a senior special emergency physician at the Hawke's Bay Hospital, said Midazolam was "used extensively" in the emergency department for moderately painful procedures to relax patients.
He said the emergency department followed protocol that specified at least two people had to be present at all times during procedures for the safety of both the patient and the doctor.
"We have an absolute rule of a minimum of two people being present. We would usually have three people be present if that's logistically possible."
The Crown allege Lim repeatedly tried to rid the treatment rooms of medical staff and family members so he was alone with the patients while they were in a sedative state.
When put to him by Mr Waalkens, Dr Ellis said it was "bizarre" that The Doctors followed a protocol of having two doctors on-site and not necessarily in attendance of a procedure. The court heard Lim was one of the contributors to this particular document.
Mr Manning said three of the four victims, all of whom were Maori or Pasifika, were not native English speakers which made them "vulnerable to the very attentions that Dr Lim had for them."
He said the Crown's case would put to the jury the "inherent unlikelihood" that four men completely unknown to each other would each come forward to testify to similar experiences in the same practice with the same doctor.
The Crown's case will resume this morning and the trial is set down to continue into next week.