Bader Cassin, MD
4 MS. ISAACSON: DEFENSE CALLS DR. BADER CASSIN.
5 THE COURT: DOCTOR, WOULD YOU STEP UP HERE PLEASE?
6 WOULD YOU RAISE YOUR RIGHT HAND PLEASE AND FACE CLERK AND
7 SHE'LL PLACE YOU UNDER OATH.
8 IF YOU'LL HAVE A SEAT UP HERE, DOCTOR. IF YOU'LL GIVE
9 US YOUR FULL NAME AND SPELL THE LAST NAME PLEASE.
10 THE WITNESS: THANK YOU. MY NAME IS BADER CASSIN,
11 C-A-S-S-I-N.
12 BY MS. ISAACSON:
13 Q. DR. CASSIN, WHAT IS YOUR OCCUPATION?
14 A. I'M A PHYSICIAN.
15 Q. AND DO YOU PERFORM AUTOPSIES?
16 A. I DO.
17 Q. AND WHAT FURTHER QUALIFICATIONS OTHER THAN BEING A
18 PHYSICIAN DO YOU HAVE TO PERFORM AUTOPSIES?
19 A. WELL, I'M -- I HAVE SUB -- EXCUSE ME. I HAVE SPECIALTY
20 TRAINING IN PATHOLOGY. I HAVE WORKED AS A HOSPITAL
21 PATHOLOGIST FOR OVER TEN YEARS. AND THEN I DID A FELLOWSHIP
22 IN FORENSIC PATHOLOGY AND HAVE BEEN DOING THAT FOR THE LAST
23 20 YEARS. SO I HAVE BEEN TRAINED, FIRST OF ALL, IN PATHOLOGY
24 AND THEN SUBSEQUENTLY TRAINED IN A SUBSPECIALTY OF FORENSIC
25 PATHOLOGY, WHICH ESSENTIALLY HAS ME DOING AUTOPSIES SOLELY
1 FOR THE LAST 15 OF THOSE 25 YEARS.
2 Q. AND ARE YOU A MEDICAL EXAMINER?
3 A. YES.
4 Q. AND DO YOU HAVE TO HAVE A LICENSE TO BE A MEDICAL
5 EXAMINER?
6 A. YOU HAVE TO HAVE A MEDICAL LICENSE TO BE A MEDICAL
7 EXAMINER, BUT THERE IS NO SUCH THING AS A MEDICAL EXAMINER
8 LICENSE.
9 Q. WHERE DO YOU PERFORM AUTOPSIES AND WHO DO YOU WORK FOR
10 CURRENTLY?
11 A. I WORK IN THE STATE OF MICHIGAN. I HEADQUARTER IN ANN
12 ARBOR WHERE I ALSO TEACH AT THE UNIVERSITY OF MICHIGAN. I'M
13 A MEDICAL EXAMINER FOR TWO OF THE COUNTIES IN THE STATE OF
14 MICHIGAN AND I DO THE FORENSIC AUTOPSIES FOR THE MEDICAL
15 EXAMINER IN AN ADJACENT COUNTY IN ADDITION TO THAT AS WELL AS
16 GETTING CASES REFERRED TO ME FROM AROUND THE STATE BY VARIOUS
17 PROSECUTORS OR MEDICAL EXAMINERS BECAUSE WE ARE A HEALTH
18 CENTER JUST AS THE SALT LAKE CITY AREA IS A HEALTH CENTER.
19 Q. AND SO HOW DOES AN AUTOPSY COME TO YOU TYICALLY?
20 A. AS A MEDICAL EXAMINER, IT COMES TO ME BECAUSE OF A
21 REPORT OF DEATH, A DEATH THAT WOULD APPEAR TO MEET THE
22 REQUIREMENTS OF LAW. AND YOU HAVE THE SAME LAW IN THIS
23 STATE. AND IS IS ESSENTIALLY THAT A PERSON HAS DIED UNDER
24 THE CIRCUMSTANCES OF EITHER AN UNNATURAL DEATH, WHICH MEANS
25 THAT THEY HAVE DIED BECAUSE OF SOMETHING THAT IS NOT DUE TO
1 DISEASE, AN INJURY IN OTHER WORDS, OR SOMETHING THAT MIGHT BE
2 DUE TO SOMETHING OTHER THAN DISEASE.
3 Q. AND HOW MANY AUTOPSIES HAVE YOU PERFORMED OVER THE
4 COURSE OF YOUR CAREER?
5 A. SOMEWHERE BETWEEN TEN AND TWELVE THOUSAND I'VE DONE
6 MYSELF. I'VE SUPERVISED THAT MANY MORE, BUT THAT I'M SURE IS
7 THE NUMBER I'VE DONE MYSELF.
8 Q. DO YOU ALSO PERFORM AUTOPSIES IN HOSPITALS? OR RELATED
9 TO HOSPITAL DEATHS?
10 A. RELATED TO HOSPITAL DEATHS, I HAVE PERFORMED MANY, AND
11 STILL DO. FOR INSTANCE, I AM ONE OF THE STAFF PATHOLOGISTS
12 FOR THE PATHOLOGY SERVICE AT THE UNIVERSITY OF MICHIGAN AS
13 WELL AS FOR THE ADJACENT TERTIARY CARE CENTER, WHICH IS
14 ST. JOB MERCY HOSPITAL IN ANN ARBOR. IN THAT ROLE I
15 SUPERVISE PATHOLOGISTS IN TRAINING IN DOING THEIR AUTOPSIES,
16 TRAIN THEM IN TECHNIQUES OF AUTOPSY AS WELL AS AN
17 INTERPRETATION OF THEIR FINDINGS, REVIEW OF THEIR FINDINGS,
18 THAT SORT OF THING. BEFORE THAT OF COURSE I DID HOSPITAL
19 AUTOPSIES MYSELF AS A HOSPITAL PATHOLOGIST.
20 Q. AND HOW ARE THESE HOSPITAL AUTOPSIES DIFFERENT FROM
21 OTHER TYPE OF AUTOPSIES?
22 A. HOSPITAL AUTOPSIES ARE DONE AS A WAY OF SUBSTANTIATING
23 OFTEN DIAGNOSES THAT ARE MADE CLINICALLY. THEY -- THERE IS A
24 GREAT ATTENTION TO DETAILS THAT MIGHT NOT OTHERWISE BE
25 ATTENDED TO FOR THE PURPOSES OF EDUCATION AT LEAST IN PLACES
1 WHERE I WORK. SO THAT MEDICAL STUDENTS THAT WE TEACH AS WELL
2 AS MEDICAL AND OTHER SURGICAL RESIDENTS AND PATHOLOGY
3 RESIDENTS CAN BE FURTHER TRAINED IN THE MINUTIAE OF WHAT IS
4 FOUND IN THE BODY, AND CORRELATE WITH RADIOGRAPHS AND OTHER
5 LABORATORY TESTS AND OTHER SUCH CLINICAL TESTS. WHEREAS
6 FORENSIC AUTOPSIES THAT ARE DONE UNDER THE AEGIS OF A MEDICAL
7 EXAMINER SYSTEM ARE DONE PRIMARILY TO IDENTIFY AN INJURY OR
8 TO EXCLUDE AN INJURY IF INDEED THERE IS A QUESTION ABOUT
9 WHETHER OR NOT ONE EXISTS. BUT THEY DONE THOROUGHLY TO FOCUS
10 IN UPON THAT ISSUE.
11 Q. SO IF YOU'RE DOING A HOSPITAL AUTOPSY, LET ME MAKE SURE
12 I UNDERSTAND, IS THIS A SITUATION WHERE YOU'RE TRYING TO
13 CONFIRM WHAT THE TREATING PHYSICIAN THOUGHT THE CAUSE OF
14 DEATH WAS? IS THAT -- DO I HAVE IT RIGHT?
15 A. THE EFFORT IS NOT TO CONFIRM. THE EFFORT IS TO BE
16 INDEPENDENT. THE CLINICIAN WOULD LIKE US TO CONFIRM THE
17 CLINICAL DIAGNOSIS. WE MIGHT, HOWEVER, FIND SOMETHING THAT
18 IS DIFFERENT, EITHER DIFFERENT IN DEGREE OR DIFFERENT FROM
19 EVEN KNOWN DIAGNOSIS. BUT THE EFFORT CLINICALLY IS TO -- IS
20 TO CONFIRM OR CORRELATE THE FINDINGS AT AUTOPSY WITH THOSE
21 FINDINGS MADE DURING LIFE.
22 Q. AND SO WOULD IT OFTEN BE THAT AN ATTENDING PHYSICIAN OR A
23 CLINICIAN WHO WAS TREATING THE PATIENT RIGHT BEFORE THEY DIED
24 WOULDN'T ALWAYS GET IT EXACTLY RIGHT ON THE CAUSE OF DEATH?
25 A. OH, THAT'S VERY TRUE. I WOULD SAY THE GREAT MAJORITY OF
1 CLINICIANS GET IT RIGHT, BUT AS YOU SAY, NOT EXACTLY RIGHT.
2 THERE MAY BE SOME ADDITIONAL THINGS EITHER BY DEGREE OR BY
3 PERHAPS SMALL DIFFERENCE FROM THEIR CLINICAL DIAGNOSES THAT
4 THEY LEARN THROUGH THE AUTOPSIES ON THEIR PATIENTS, WHICH IS
5 REALLY THE PRINCIPAL REASON FOR THE HOSPITAL AUTOPSIES --
6 Q. OKAY.
7 A. -- IN PLACES WHERE I DO THOSE.
8 Q. HOW DID YOU GET INVOLVED IN THIS PARTICULAR CASE?
9 A. I GOT -- I'M NOT EVEN SURE I REMEMBER, BUT I RECEIVED A
10 COMMUNIICATION FROM YOUR LAW FIRM ASKING ME TO REVIEW SOME
11 DEATHS AND TO INDICATE WHETHER I WOULD BE INTERESTED IN
12 MAKING A FORMAL DETERMINATION OF CAUSE AND MANNER OF DEATH IF
13 I WERE GIVEN THE OPPORTUNITY TO REVIEW THE RECORDS AVAILABLE
14 IN THAT CASE. I HAVE TO TELL YOU RIGHT AWAY, EVEN THOUGH
15 YOU'RE NOT ASKING ME THIS QUESTION --
16 MR. MAJOR: YOUR HONOR, WE'RE GONNA OBJECT. IT'S NOT
17 RESPONSIVE --
18 THE COURT: SUSTAINED.
19 MR. MAJOR: -- TO THE QUESTION.
20 Q. (BY MS. ISAACSON) WHAT IS IT THAT -- ONCE YOU RECEIVED
21 THAT COMMUNICATION FROM MY OFFICE, WHAT WAS YOUR NEXT STEP?
22 A. MY NEXT STEP WAS TO REVIEW THE MATERIALS THAT HAD BEEN
23 SENT FOR PREVIEW, WHICH I DID. AND THEN RESPONDED BY SAYING
24 THAT I WOULD PURSUE THIS.
25 Q. AND SO YOU REVIEWED THE MEDICAL EXAMINER FILES THAT OUR
1 OFFICE PROVIDED TO YOU?
2 A. I DID.
3 Q. AND THE MEDICAL RECORDS OF ALL THE PATIENTS DURING THEIR
4 STAY AT THE GEROPSYCHIATRIC UNIT?
5 A. I DID.
6 Q. IN REVIEWING EACH OF THESE FIVE PATIENTS -- WELL, LET ME
7 BACK UP A LITTLE BIT. WITH REGARD TO THE ISSUE OF MORPHINE,
8 IN YOUR EXPERIENCE AND IN YOUR PRACTICE, DO YOU SEE MORPHINE
9 OR OTHER OPIATES IN TOXICOLOGY REPORT -- IN TOXICOLOGY
10 RESULTS?
11 A. MANY TIMES.
12 Q. AND HOW DO YOU RESPOND OR HOW DO YOU INTERPRET THE
13 PRESENCE OF MORPHINE OR OTHER OPIATES IN TOXICOLOGY RESULTS
14 IN AN AUTOPSY?
15 A. WELL, IT'S ENTIRELY WITH REGARD TO THE CONTEXT. ONE
16 NEEDS TO PLACE THE FINDING OF MORPHINE POST MORTEM AND THE
17 TESTING DONE POST MORTEM INTO THE KNOWN INCIDENTS THAT ARE
18 PRESENT DURING LIFE SO AS TO INTERPRET THEM PROPERLY.
19 Q. WHAT KIND OF PATIENTS HAVE YOU SEEN THESE KIND OF
20 RESULTS IN?
21 MR. MAJOR: OBJECTION, YOUR HONOR. I'M NOT SURE WHAT
22 THE RELEVANCY OF THIS QUESTION IS.
23 THE COURT: OVERRULED. GO AHEAD.
24 THE WITNESS: THE KINDS OF PATIENTS WOULD BE PATIENTS
25 WHO ARE TREATED FOR SEVERE INJURIES DURING WHICH THEY ARE
1 CONSCIOUS AND EXPERIENCING PAIN. AND MORPHINE IS GIVEN AS A
2 WAY OF REDUCING PAIN. THEY ARE IN PATIENTS WHO ARE
3 SEMICOMATOSE AND DYING. AND THESE ARE PATIENTS WHO ARE
4 RECEIVING MORPHINE FOR CONTROL OF PAIN AS WELL AS FOR COMFORT
5 CARE IN THEIR LAST HOURS OR DAYS OF LIFE. THAT SORT OF
6 THING. I ALSO SEE MORPHINE IN PATIENTS -- NOT PATIENTS, IN
7 BODIES WHO HAVE NO CLINICAL HISTORY. WHO HAVE NO ABNORMALITY
8 IN THEIR BODY. WHOSE BODIES ARE FOUND IN PLACES THAT THEY
9 WEREN'T EXPECTED TO DIE. AS A MEDICAL EXAMINER, I SEE THOSE
10 AS WELL.
11 Q. (BY MS. ISAACSON) ALL RIGHT. LET'S TALK ABOUT THE
12 SPECIFIC PATIENTS. NOW, THE MEDICAL EXAMINER'S OFFICE HERE
13 IN UTAH PREPARED AN AUTOPSY REPORT IN EACH CASE THAT YOU'VE
14 REVIEWED, IS THAT RIGHT?
15 A. YES.
16 Q. I'D LIKE TO GO TO THE AUTOPSY REPORT OF ELLEN ANDERSON.
17 AND THIS IS, COUNSEL AND YOUR HONOR, STATE'S 2-D, PAGE 1 OF
18 ELLEN ANDERSON'S AUTOPSY REPORT. WE DON'T HAVE A -- WELL,
19 FIRST OF ALL, CAN YOU TELL ME WHAT -- WHAT IS INCLUDED ON
20 THIS FIRST PAGE OF ELLEN ANDERSON'S REPORT?
21 A. THIS IS A SUMMARY PAGE WHICH IS FREQUENTLY FOUND ON THE
22 FRONT OF AUTOPSY REPORTS AND IT IS THE FORMAT APPARENTLY FOR
23 THE STATE MEDICAL EXAMINER'S OFFICE IN UTAH WHEREBY IT GIVES
24 AN IDENTIFIER AT THE TOP. HAS THREE PARTS REALLY, IT HAS --
25 ON THIS PAGE ANYWAY, ALTHOUGH THERE ARE FOUR IN THE SUMMARY,
1 FOUR PARTS IN THE SUMMARY. THE FIRST PART OF THE SUMMARY IS
2 IDENTIFICATION DATA. WHO AND WHEN AND WHERE THE PERSON WAS
3 AND WHETHER THE AUTOPSY WAS DONE AND SO ON AND BY WHOM.
4 UNDER THAT, IT GIVES THE CAUSE AND MANNER OF DEATH, WHICH IS
5 WHAT A MEDICAL EXAMINER IS REQUIRED BY LAW TO DO. NAME A
6 CAUSE AND MANNER OF DEATH. THAT'S THE ONLY REASON TO DO A AN
7 AUTOPSY, OR SHOULD BE ACCORDING TO LAW. AND THE THIRD PART
8 OF THE SUMMARY IS TO GIVE DIAGNOSES, TO -- AN ENNUMERATION OF
9 DIAGNOSES, AND IN THIS CASE, CLUSTERED IN SOME WAY THAT SHOWS
10 RELATIONSHIP OF ONE FINDING TO THE OTHER.
11 Q. SO DO I UNDERSTAND WITH REGARD TO ELLEN ANDERSON, THIS
12 IS A LIST OF THINGS THAT THE MEDICAL EXAMINER FOUND WHEN HE
13 PERFORMED THE AUTOPSY?
14 A. THAT'S THE WAY I UNDERSTAND IT. AND I UNDERSTAND IT
15 THAT WAY BECAUSE FOLLOWING THIS, THERE IS A NARRATIVE THAT
16 DESCRIBES BY DIFFERENT ORGAN SYSTEMS AND REGIONALLY IN THE
17 BODY THOSE SPECIFIC FINDINGS AS THEY ARE DISCOVERED DURING
18 THE PROCEDURE. AND WHEN I CORRELATE THOSE PROCEDURES WITH
19 THIS LIST, I SAY, YES, THAT'S CLEARLY WHAT THIS EFFORT IS.
20 AND THAT'S CUSTOMARY, AS I SAID.
21 Q. IN ADDITION TO THE MEDICAL RECORDS YOU REVIEWED, DID YOU
22 ALSO OBTAIN PHOTOGRAPHS FROM THE MEDICAL EXAMINER'S OFFICE?
23 A. I DID.
24 Q. AND WERE PHOTOGRAPHS TAKEN OF -- WHAT WERE THE -- WHAT
25 DID THE PHOTOGRAPHS SHOW YOU WITH REGARD TO EACH PATIENT?
1 A. THE PHOTOGRAPHS DEPICTED THE REMOVAL OF BODIES FROM
2 THEIR BURIAL PLACES, THE TRANSPORT TO THE MEDICAL EXAMINER
3 OFFICE, THE APPEARANCE OF THE BODY CLOTHED AND UNCLOTHED.
4 AND IN SOME CASES, INTERNAL PHOTOGRAPHS OF THE BODY DURING OR
5 FOLLOWING AUTOPSY.
6 Q. AND WERE YOU ALSO ABLE TO REVIEW ALL OF MICROSCOPIC
7 SLIDES THAT THE MEDICAL EXAMINER'S OFFICE HAD WITH REGARD TO
8 EACH PATIENT?
9 A. YES, I DID REVIEW THOSE. THEIR DESCRIPTION WAS LIKEWISE
10 INCLUDED IN THE REPORT, BUT I ASKED TO BE ABLE TO REVIEW
11 THOSE SLIDES BECAUSE IT IS A WAY OF COURSE OF REVIEWING
12 SOMEBODY ELSE'S WORK, WHICH IS WHAT I DO COMMONLY IN
13 REVIEWING OTHER AUTOPSIES AS WELL AS MY OWN.
14 Q. WITH REGARD TO ELLEN ANDERSON AND THE DIAGNOSES THAT
15 WERE IDENTIFIED BY THE MEDICAL EXAMINER, COULD YOU EXPLAIN TO
16 US WHICH -- WHICH OF THESE DO YOU THINK ARE SIGNIFICANT AND
17 AND -- AND RELATE SPECIFICALLY TO CAUSE OF DEATH?
18 A. WELL, THE CAUSE OF DEATH IS STATED AS UNDETERMINED, AND
19 THEREFORE, EVERYTHING RELATES OR NOTHING RELATES TO
20 UNDETERMINED SIMPLY BECAUSE THE MEDICAL EXAMINER IN THIS CASE
21 HAS CHOSEN NOT TO FIND A CAUSE OF DEATH. THAT USUALLY IS A
22 PRIVILEGE GIVEN BY THE STATE TO MEDICAL EXAMINERS ALONE SO AS
23 TO ALLOW THEM TO SAY, I DON'T KNOW. THAT IS ESSENTIALLY WHAT
24 THAT MEANS. I DON'T KNOW. IT COULD ALSO MEAN THAT I DON'T
25 WANT TO KNOW OR I DON'T WANT TO TELL YOU. AFTER ALL, THAT'S
1 WHAT UNDETERMINED MIGHT LIKEWISE MEAN. FRANKLY, I DON'T KNOW
2 HOW THE MEDICAL EXAMINER MEANT IT HERE, BUT IN ANY CASE,
3 THERE WAS NO SPECIFIC FINDING OF A CAUSE OF DEATH.
4 Q. WHAT WERE THE SIGNIFICANT FINDINGS TO YOU IN THIS LONG
5 LIST OF FINDINGS BY DR. GREY? AND WE CAN -- WE CAN GO OVER
6 THIS OR WE CAN TALK ABOUT SOME OF YOUR FINDINGS, HOWEVER
7 YOU'D LIKE TO DO THAT.
8 A. WELL, YOU ASKED ME WHAT I THINK IS SIGNIFICANT, SO LET
9 ME QUICKLY GO OVER THIS WITH YOU AND THEN SHOW YOU SOMETHING
10 THAT I WOULD HAVE CONSTRUCTED HAD I CONSTRUCTED THE FINAL
11 AUTOPSY REPORT. HAVING READ THE REPORT THOROUGHLY, LOOKED AT
12 THE PHOTOGRAPHS, AND LOOKED AT THE MICROSCOPIC SECTIONS.
13 BECAUSE I DON'T BELIEVE THAT THIS LIST NECESSARILY REFLECTS
14 THE FINDINGS AS THEY SHOULD HAVE BEEN DEPICTED ON THE FINAL
15 AUTOPSY LIST. AND I THINK THE REASON MIGHT BE, IF I MIGHT
16 SAY THIS, THE REASON MIGHT BE THAT THE AUTOPSIES WERE CON --
17 MR. MAJOR: YOUR HONOR, WE'RE GONNA OBJECT TO THAT. IT
18 SOUNDS HE'S MAKING ASSUMPTION HERE.
19 THE COURT: SUSTAINED. YOU'RE NOT TO RESPOND TO THAT
20 QUESTION AT LEAST AT THIS POINT, DOCTOR. .
21 THE WITNESS: OKAY. OKAY.
22 THE COURT: GO AHEAD.
23 Q. (BY MS. ISAACSON) DR. CASSIN, OBVIOUSLY, THIS LIST WAS
24 COMPILED BY THE MEDICAL EXAMINER'S OFFICE HERE, AND WE'LL
25 TALK A LITTLE BIT LATER ABOUT THE LIST THAT YOU HAVE
1 COMPILED. WERE THERE FACTORS THAT YOU SAW IN THE PHOTOGRAPHS
2 OR IN THE REPORTS THAT WOULD SUGGEST TO YOU A REASON WHY HIS
3 FINDINGS WOULD BE DIFFERENT FROM YOUR --
4 MR. MAJOR: I OBJEC -- OBJECTION, YOUR HONOR. STILL
5 CALLS FOR SPECULATION.
6 THE COURT: OVERRULED.
7 THE WITNESS: I WOULD PROPOSE, ALTHOUGH I DON'T KNOW
8 PATHOLOGISTS WHO DID THESE FIVE AUTOPSIES, BUT I WOULD
9 PROPOSE THAT THEY MAY NOT HAVE HAD EITHER SUFFICIENT
10 EXPERIENCE IN DOING BODIES -- DOING AUTOPSIES ON BODIES LONG
11 DEAD AND BURIED. THIS BODY FOR INSTANCE WAS BURIED FOR FOUR
12 AND A HALF YEARS. OTHERS WERE BURIED FOR THREE AND A HALF
13 YEARS, BUT NONE LESS TIME THAN THAT. UNDERSTANDING WHAT
14 DECOMPOSITION DOES TO BODIES AND -- AND PERHAPS IN THAT
15 REGARD THERE WAS A GENERAL -- BECAUSE I DID FIND THIS, THERE
16 WAS A GENERAL UNDERINTERPRETATION OF FINDINGS PRIMARILY BECAUSE
17 THERE WAS NOT AN ADEQUATE UNDERSTANDING OF WHAT HAPPENS IN
18 THE DECOMPOSITION PROCESS. LET ME EXPLAIN THAT BY SIMPLY
19 SAYING --
20 MR. MAJOR: YOUR HONOR, THAT'S NOT RESPONSIVE TO THE
21 QUESTION.
22 THE COURT: OVERRULED. GO AHEAD.
23 THE WITNESS: LET ME SAY THAT BY EXPLAINING THAT THE
24 DECOMPOSITION PROCESS -- AND I DON'T MEAN TO GIVE AN LECTURE
25 ON THIS -- INVOLVES A DETERIORATION, A PROGRESSIVE
1 DETERIORATION ALL TISSUES OF THE BODY. WE'RE ALL SUPPOSED TO
2 GO BACK TO DUST, AND IN FACT, THAT'S WHAT EVENTUALLY HAPPENS.
3 BUT IT HAPPENS AT A RATE THAT IS DEPENDENT UPON ENVIRNMENTAL
4 FORCES, OF TEMPERATURE, HUMIDITY, TIME, AND OF COURSE
5 EMBALMING. HOWEVER, THERE IS A DETERIORATION OF ALL TISSUES
6 PROGRESSIVELY. IS IT NOT REASONABLE, FOR INSTANCE, TO
7 BELIEVE -- BECAUSE I FIND THIS TO BE TRUE UNIFORMLY -- THAT
8 IF NORMAL TISSUES DETERIORATE, SO ALSO SHOULD ABNORMAL
9 TISSUES DETERIORATE. WOULD SEEM TO MAKE SENSE. WELL, I THINK
10 IT DOES AND IT CERTAINLY CORRELATES WITH MY EXPERIENCE, AND I
11 BELIEVE IT YOU ASK THESE PATHOLOGISTS, THEY'D PROBABLY AGREE
12 WITH THAT IN THEORY AS WELL.
13 Q. (BY MS. ISAACSON) AND I HEARD YOU USE THE TERM ABNORMAL
14 PROCESSES. THAT'S WHAT WE'RE LOOKING FOR HERE IS WHEN YOU --
15 WHEN YOU PERFORM AN AUTOPSY, THAT'S WHAT YOU'RE TRYING TO
16 FIND, DO I HAVE THAT RIGHT?
17 A. THE EFFORT HERE IS TO DETERMINE WHAT'S WRONG WITH THE
18 BODY OR WHAT'S WRONG WITH THE HISTORY, IF YOU WILL, WHAT IS
19 IN THE MEDICAL HISTORY THAT IS OF SIGNIFICANCE WITH REGARD TO
20 ONE'S LONGEVITY. WHAT COULD AFFECT THEIR SURVIVAL.
21 Q. WELL, WHAT ARE THE HIGHLIGHTS HERE FOR YOU OR YOUR
22 COMMENTS HERE ON THE FINDINGS BY OUR MEDICAL EXAMINER'S
23 OFFICE?
24 A. WELL, I WOULD SAY, FIRST OF ALL, THAT THE -- THERE'S
25 POINTED OUT AND IT'S NUMBER ONE, THAT THERE IS A HISTORY OF
1 ANTEMORTEM ADMINISTRATION OF MORPHINE. I'D SAY, OKAY, FINE.
2 THAT'S ONE OF THE MANY FACTS THAT'S PRESENT IN THE HOSPITAL
3 RECORDS. AND IN SPITE OF THE FACT THAT NONE IS FOUND, BUT
4 PERHAPS THEY DIDN'T LOOK -- IN FACT, THEY DIDN'T LOOK IN THE
5 RIGHT SPECIMENS FOR IT, BUT MAYBE THEY DON'T KNOW THAT. BUT
6 IN ANY CASE, THEY DIDN'T FIND MORPHINE IN SPITE OF THE
7 PREVIOUS ADMINISTRATION. THE OTHER POSSIBILITY IS THAT
8 MORPHINE WASN'T PRESENT DURING -- AT THE TIME OF DEATH THAT
9 HAD BEEN ADMINISTERED PRIOR TO THAT. THE ARTERIOSCLEROTIC
10 CARDIOVASCULAR DISEASE IS A PRIMARY DIAGNOSIS. I THINK IT'S
11 VERY IMPORTANT HERE --
12 Q. CAN YOU TRANSLATE THAT INTO LAY --
13 A. THIS IS ATHEROSCLEROSIS. THIS IS THE PROCESS OF
14 HARDENING OF THE ARTERIES. IT HAPPENS BY TWO PROCESSES. ONE
15 IS THAT THE ARTERIAL WALLS THICKEN. THEY BECOME SLUDGED LIKE
16 OLD PIPES AND IN FACT, SOME OF THAT SLUDGE OCASSIONALLY
17 HARDENS AND CALCIFIES, BECOMES RIGID, STRICTLY SPEAKING LIKE
18 PIPES, AS OPPOSED TO HOSES THAT ARE NICE AND FLEXIBLE. THIS
19 LIMITS THE ABILITY OF BLOOD TO TRANSMIT OXYGEN ACROSS ITS
20 MEMBRANES. IN FACT, IT ELIMINATES IT, AS WELL AS TO TAKE
21 CARBON DIOXIDE BACK INTO THE VESSELS AND TO THE RED CELLS AND
22 TRANSPORT THEM TO THE LUNGS FOR -- FOR RESUSCITATION, SO TO
23 SPEAK, WITH OXYGEN. SO IN THIS CASE THE -- UNDER THE
24 CATEGORY OF ATERIOSCLEROSIS, WHICH IS LABELED NUMBER 2,
25 MAJOR SECTION NUMBER 2, THERE ARE FEATURES OF
1 ARTERIOSCLEROSIS THAT ARE -- THAT ARE NAMES. ONE IS
2 CORONARY ARTERY ATHEROSCLEROSIS. THOSE ARE THE VESSELS THAT
3 NOURISH THE HEART MUSCLE ITSELF. THERE IS THE AORTA, WHICH IS
4 THE LARGEST ORGAN -- EXCUSE ME, VESSEL OF THE BODY WHICH
5 BRINGS ARTERIAL BLOOD TO ALL THE ORGANS OF THE BODY. AND
6 THEN FINALLY, EVIDENCE OF THERE BEING SOME ADVANCED KIDNEY
7 ARTERIOSCLEROSIS BECAUSE EVEN MILD TO MODERATE RENAL
8 ARTERIOSCLEROSIS IS PRESENT ONLY WHEN YOU HAVE LONGSTANDING
9 SIGNIFICANT ARTERIOSCLEROSIS. MILD DOESN'T MEAN
10 INSIGNIFICANT IN THIS CASE.
11 Q. WHAT WHAT OTHER AREAS ARE SIGNIFICANT TO THE CAUSE OF
12 DEATH?
13 A. BRONCHOPNEUMONIA IS LISTED AS NUMBER 3.
14 BRONCHOPNEUMONIA OR AS IT'S DESCRIBED HERE AS ACUTE
15 INFLAMMATION IN THE LEFT LUNG. I'M NOT SURE WHY THE
16 PATHOLOGIST SAID THE LEFT LUNG BECAUSE BRONCHOPNEUMONIA IS
17 PRESENT IN BOTH LUNG SLIDES THAT HE MADE AND -- AND IS THERE
18 IN DIFFUSE PATTERN. AND IT'S ALSO VERY ACUTE.
19 Q. WHAT IS --
20 A. SO BRONCHOPNEUMONIA IS IMPORTANT HERE BECAUSE IT'S AN
21 ACUTE INFLAMMATION THAT QUITE FRANKLY CAUSES DEATH VERY
22 COMMONLY IN PEOPLE WHO ARE ELDERLY OR OTHERWISE IMPAIRED.
23 Q. YOU MENTIONED THE TERM DIFFUSE PATTERN. IS THAT THE
24 TERM YOU USED? WHAT IS THE SIGNIFICANCE OF THAT?
25 A. DIFFUSE MEANS THAT IT IS WIDESPREAD. IT'S AN
1 INFLAMMATION THAT IS NOT FOCUSSED IN ONE OR TWO LITTLE
2 POCKETS, MICORSCOPIC POCKETS OF THE -- OF THE LUNG, BUT
3 RATHER IT'S VERY PROMINENT.
4 Q. AND THIS WAS SOMETHING THAT YOU COULD ACTUALLY OBSERVE
5 IN THE MICORSCOPIC SLIDE THAT WAS SENT TO YOU? OR THE
6 MULTIPLE SLIDES.
7 A. ABSOLUTELY. IT WAS THE SAME SLIDE THIS PATHOLOGIST HAD
8 BEEN LOOKING AT.
9 Q. ANY OTHER DIAGNOSES THAT RELATE TO CAUSE OF DEATH?
10 A. INTERSTITIAL AND PERIBRONCHIAL FIBROSIS INDICATES THAT
11 THIS PERSON HAS SOME EMPHYSEMA. AND EMPHYSEMA IS A CHRONIC
12 DEBILITATING DISEASE OF THE LUNG. REMOTE PULMONARY
13 INFARCTION DUE TO THOMBO-EMBOLUS IS THE DESCRIPTION OF AN OLD
14 PHENOMENON, AND INDEED IN MRS. ANDERSON'S MEDICAL RECORDS,
15 SHE DID COMPLAIN OF CHEST PAIN ON A PREVIOUS OCCASION THAT
16 WAS VERY SPECIFIC AND THAT VERY LIKELY IS THE CAUSE OF THAT.
17 SHE HAD A BLOOD CLOST THAT TRAVELED TO HER LUNG, AND WHAT
18 HAPPENED THERE WAS THAT IT RESOLVED, IT HEALED, BUT IT -- IN
19 HEALING, IT DESTROYS ALL THE LUNG TISSUE AROUND IT, WHICH
20 MEANS THAT THAT PART OF THE LUNG IS NONFUNCTIONAL. SO IT
21 REDUCED THE LUNG MASS IN GENERAL FROM NORMAL FUNCTION JUST AS
22 EMPHYSEMA REDUCES THE ENTIRE LUNG MASS FROM NORMAL FUNCTION.
23 PULMONARY EMPHYSEMA IS THE SAME THING. IT'S JUST GIVEN A
24 DIFFERENT LISTING. I DON'T KNOW WHY. DEGENERATIVE BONE
25 DISEASE IS IMPORTANT IN THIS PERSON BECAUSE OBVIOUSLY SHE HAD
1 ADVANCED SOFTENING OF THE BONE, DECALCIFICATION, RESULTING IN
2 PRIOR FRACTURES AND OBVIOUSLY SURGICAL REPAIR OF THOSE
3 FRACTURES IN A NUMBER OF PLACES. I THINK IT WAS IN WRIST AND
4 ANKLE AS WELL AS IN BOTH HIPS. HISTORY OF DEMENTIA IS
5 IMPORTANT BECAUSE DEMENTED PEOPLE -- AND YOU PROBABLY WILL
6 HEAR OR HAVE HEARD ALREADY A LOT ABOUT THAT, SO I NEEDN'T
7 TALK MUCH ABOUT DEMENTIA EXCEPT TO SAY THAT I RECOGNIZE, AS
8 ALL PHYSICIANS DO, THAT DEMENTIA OR THE LOSS OF ONE'S MENTAL
9 REASONING OR MENTAL -- NORMAL MENTAL FUNCTION CAUSES YOU TO
10 HAVE ABNORMAL BEHAVIOR, SOME OF WHICH IS RELATED TO THINGS
11 LIKE DOING WHAT'S GOOD FOR YOU. BEING ABLE TO EAT OR
12 AGREEING TO EAT. TAKING MEDICATION. THAT SORT OF THING. SO
13 DEMENTIA IS WHAT -- IS A WAY OF THE BRAIN DETERIORATING OVER
14 TIME -- IT CAN BE A LONG PERIOD OF TIME OR A SHORT PERIOD OF
15 TIME -- AFTER WHICH OR DURING WHICH PEOPLE EVEN FORGET HOW TO
16 EAT, AND THAT'S WHY IN SOME CASES THEY REFUSE TO EAT BECAUSE
17 THEY DO NOT KNOW WHAT EATING HAS ANY GOOD TO DO. AND THAT'S
18 WHY MANY PEOPLE WHO ARE DEMENTED IN FACT, EVERYBODY WHO IS
19 DEMENTED BECOMES WASTED EVENTUALLY IN SPITE OF THE FACT THAT
20 PEOPLE TRY TO FEED THEM. THEY BECOME WASTED SIMPLY BECAUSE
21 THEY DON'T EAT AND THEY DON'T SWALLOW.
22 Q. AND THEN I GUESS THE LAST TWO RELATE TO SOME PREVIOUS
23 SURGERIES THAT SHE HAD HAD?
24 A. YES. REMOVAL OF HER GALL BLADDER, APPENDIX, AND HER
25 UTERUS.
1 Q. NOW, DESPITE THIS LONG LIST OF DIAGNOSES BY DR. GREY,
2 ULTIMATELY WHEN IT COMES TO MANNER OF DEATH AND IMMEDIATE
3 CAUSE OF DEATH, AS WE'VE TALKED ABOUT BEFORE, HE INDICATES
4 UNDETERMINED.
5 A. YES.
6 Q. DO YOU AGREE WITH THAT OPINION?
7 A. NO. I THINK THAT FOR WHATEVER REASON HE MADE IT
8 UNDETERMINED, AND I SUGGESTED THAT HE SIMPLY MIGHT NOT HAVE
9 WANTED TO DO SO. AND I DON'T KNOW WHAT HIS REASON WAS. I
10 DON'T BELIEVE THAT THE REASON IS FOR LACK OF EVIDENCE. HE
11 HAS PLENTY OF EVIDENCE TO NAME A CAUSE OF DEATH HERE.
12 Q. WELL, IF YOU WERE MAKING A FINDING AND ASSESSING MANNER
13 AND CAUSE OF DEATH IN THIS CASE, NUMBER ONE, WOULD YOU CHANGE
14 ANY OF THOSE DIAGNOSES AND THEN NUMBER TWO, WOULD YOU CHANGE
15 THE MANNER AND CAUSE OF DEATH?
16 A. YES TO BOTH. I WOULD CHANGE SLIGHTLY SOME OF THE
17 FINDINGS --
18 Q. WELL, WHY DONT WE --
19 A. -- AS IN THE LIST OF PATHOLOGIC DIAGNOSES ONLY BECAUSE I
20 SEE EITHER IN HIS DESCRIPTION OR IN HIS SLIDES, BOTH OF WHICH
21 ARE FROM HIM, SOME WAY TO ALTER AND IN MOST CASES TO ENHANCE
22 THE SEVERITY OF THE PARTICULAR PROCESS. AND ON THE OTHER
23 HAND, I WOULD CHANGE THE CAUSE AND MANNER OF DEATH SIMPLY
24 BECAUSE I BELIEVE THERE'S PLENTY OF EVIDENCE TO SAY WHAT IT
25 WAS.
1 Q. WELL, LET'S GO -- YOU'VE PREPARED, JUST SO THE COURT
2 CAN -- OR EXCUSE ME, THE JURY CAN SEE HOW YOU WOULD HAVE
3 ALTERED THESE DIAGNOSES AND THESE CONCLUSIONS, A DOCUMENT
4 THAT KIND OF SUMMARIZES YOUR -- WHAT YOUR FINDINGS WOULD BE.
5 SHALL WE GO TO YOUR EXHIBIT? IT'S DEFENDANT'S EXHIBITS 104.
6 IS THIS THE DOCUMENT THAT YOU PREPARED AND SUBMITTED TO ME?
7 A. YES.
8 Q. AND THIS IS -- WHY DON'T YOU EXPLAIN TO THE JURY HOW
9 THIS DIFFERS, HOW YOUR CONCLUSIONS DIFFER FROM THE
10 CONCLUSIONS OF THE PATHOLOGIST.
11 A. I -- FIRST OF ALL, LET ME EXPLAIN TO THE JURY THAT I
12 STRUCTURE THIS LITTLE BIT DIFFERENTLY. I'M INCLUDING BOTH
13 THE CAUSE OF DEATH AND MANNER OF DEATH IN MY LISTING OF
14 ABNORMAL FINDINGS. I ALSO INCLUDE IN MY LISTING OF ABNORMAL
15 FINDINGS PRINCIPAL CLINICAL FINDINGS; THAT IS, THINGS THAT
16 ARE NOTICED DURING LIFE, AS WELL AS FINDINGS THAT ARE PRESENT
17 AFTER DEATH, EITHER BY THE MEDICAL EXAMINER IN SALT LAKE CITY
18 OR BY ME IN REVIEW OF THE MEDICAL EXAMINER'S INFORMATION AND
19 MATERIALS.
20 Q. AND SO WHAT DOES -- WHAT DOES C.O.D. MEAN?
21 A. C.O.D. HERE MEANS CAUSE OF DEATH, IF YOU'LL LIVE WITH
22 THAT ONE. AND YOU'LL HAVE TO PUT UP WITH A LOT OF
23 ABBREVIATIONS HERE. I'M SORRY FOR THAT.
24 Q. AND WHAT DOES THIS MEAN HERE?
25 A. SO NUMBER 1 UNDER CAUSE OF DEATH -- AND BY THE WAY, I
1 GIVE -- I SET IT UP THE WAY IT IS SET UP ON A DEATH
2 CERTIFICATE. NUMBER 31 IN THE UTAH STATE DEATH CERTIFICATE
3 IS THE SECTION --
4 MR. MAJOR: OBJECTION, YOUR HONOR. I THINK THIS
5 IRRELEVANT --
6 THE WITNESS: -- WHICH THE PHYSICIAN IS --
7 THE COURT: WAIT A MINUTE. DO YOU HAVE AN OBJECTION?
8 MS. BARLOW: YES, YOUR HONOR. I DON'T THINK HE'S AN
9 EXPERT TO BE ABLE TO TALKING ABOUT UTAH LAW AND I THINK IT'S
10 IRRELEVANT AT THIS POINT DOING THAT.
11 THE COURT: OVERRULED. HE'S NOT TALKING ABOUT UTAH LAW,
12 BUT MERELY THE FORMS USED.
13 MS. BARLOW: I -- HE HAD REFERRED TO A UTAH STATUTE.
14 THAT'S WHY I WAS --
15 THE COURT: I THOUGHT HE REFERRED TO THE DEATH
16 CERTIFICATE.
17 MR. MAJOR: AND THE STATUTE THAT WAS GOVERNING THE DEATH
18 CERTIFICATE.
19 THE COURT: WELL, THE DEATH CERTIFICATE HE CAN REFER TO.
20 OVERRULED.
21 Q. (BY MS. ISAACSON) DR. CASSIN, YOU SAW THE ORIGINAL DEATH
22 CERTIFICATES IN THESE CASES.
23 A. YES.
24 Q. AND YOU KNOW WHAT THE FORM THAT WAS USED -- YOU KNOW THE
25 FORM THAT WAS USED IN THESE CASES?
1 A. YES.
2 Q. AND SO IF I UNDERSTAND YOUR TESTIMONY, YOU'VE TRIED TO
3 SET THIS UP IN SOME WAY CONSISTENT WITH THAT FORMAT.
4 A. YES.
5 Q. OKAY.
6 A. AND IT'S STANDARD FORMAT. IT'S USED THROUGHOUT THE
7 COUNTRY.
8 Q. OKAY. SO CAUSE OF DEATH AND NUMBER 1?
9 A. SO CAUSE OF DEATH IS ON THE UTAH STATE DEATH CERTIFICATE
10 AS WELL AS ALL OTHERS, DIVIDED INTO TWO SECTIONS. FIRST OF
11 ALL -- AND WE CALL THOSE PART 1, FIRST OF ALL, IS THE
12 IMMEDIATE CAUSE OF DEATH AS WELL AS THE UNDERLYING RATIONALE FOR
13 CHOOSING THAT AS THE CAUSE OF DEATH. AND THEN PART 2 ARE
14 THOSE CONDITIONS THAT MAY NOT BE IMMEDIATELY KILLING THE
15 PATIENT, BUT THEY ARE INFLUENTIAL, THEY ARE CONTRIBUTORY TO
16 THE CAUSE OF DEATH. IN OTHER WORDS, THEY MAKE DYING MORE
17 READILY POSSIBLE AT THE TIME THAT IT ACTUAL HAPPENED.
18 Q. AND SO WHAT'S YOUR -- WHAT DOES THAT A.C. -- A.S.C.V.D.?
19 A. A.S.C.V.D. ARE -- ARE INITIALS FOR THE TERM
20 ARTERIOSCLEROTIC CARDIOVASCULAR DISEASE. AND WHAT I'M
21 TALKING ABOUT THERE IS THE GENERAL PROCESS OF
22 ARTERIOSCLEROSIS, AND I INDICATE THAT THAT PROCESS HAS BEEN
23 PRESENT FOR YEARS. AND I SAY THAT ONLY BECAUSE THERE ARE
24 ADVANCED DEGENERATIVE CHANGES, NOT SURPRISING IN A
25 91-YEAR-OLD PERSON.
1 Q. AND THEN WHAT DO THESE -- WHAT DOES C.A.D. AND C.H.F.
2 MEAN?
3 A. C.A.D. MEANS THAT THERE HAD BEEN RECOGNIZED OVER A
4 PERIOD OF A LONG TIME CORONARY ARTERY DISEASE. THAT'S THE
5 C.A.D. FOR WHICH THIS LALDY HAD ACTUALLY BEEN TREATED WITH
6 NITROGLYCERIN WHEN SHE HAD BECOME UNCOMFORTABLE. SHE HAD HAD
7 CHEST PAIN AND SHE WAS GIVEN NITROGLYCERIN PERIODICALLY OR
8 GIVEN IT TO TAKE WHEN SHE WAS ABLE TO CONCENTRATE ON THAT SO
9 THAT SHE COULD RELIEVE HER OWN CHEST PAIN. AND IT WAS
10 ATTRIBUTED TO IT A NARROWING, A PROGRESSIVE NARROWING OF THE
11 CORONARY ARTERIES, AND THEREBY, A LESSER NOURISHMENT OF
12 THE -- OF THE HEART MUSCLE. THAT'S WHAT TYPICALLY HAPPENS.
13 Q. WHAT DO THESE NOTES OVER HERE MEAN?
14 A. THE NOTES TO THE RIGHT OF THAT, AND SPECIFICALLY THE
15 NOTE TO THE RIGHT OF THE ONE WE'RE TALKING ABOUT, CORONARY
16 ARTERY DISEASE, IS THAT, IS THE FINDING BASED ON MICROSCOPY.
17 LOOKING AT THE SLIDES WHICH WERE PREPARED AT THIS LADY'S
18 AUTOPSY, THERE ARE A COUPLE OF SECTIONS OF CORONARY ARTERIES
19 WHICH SHOWED DIFFUSE CALCIFIC CORONARY ARTERIOSCLEROSIS. AND
20 I CALL IT MODERATE ONLY BECAUSE THE GUNKY PART, THE SOFT
21 TISSUE PART OF THE ATHEROSCLEROSIS HAS ESSENTIALLY MELTED
22 AWAY. WHAT'S LEFT IS THIS RIGID PIPE. AND A LITTLE BIT OF
23 THE GUNK THAT'S INSIDE OF THAT. PERHAPS FOR THAT REASON, THE
24 PATHOLOGIST INTERPRETED THIS AS BEING OF LESSER SIGNIFICANCE,
25 BUT IN FACT, AFTER FOUR AND A HALF YEARS IN THE GROUND, THIS
1 IS INDICATIVE OF NOT ONLY DIFFUSE, BUT AT LEAST MODERATE,
2 WHICH MEANS VERY CLINICALLY SIGNIFICANT ARTERIOSCLEROSIS.
3 Q. EXPLAIN TO ME SO THAT -- IT WAS ACTUALLY A SLICE? WHAT
4 IS IT THAT YOU'RE LOOKING AT ON THE SLIDE?
5 A. I'M LOOKING AT THE CORONARY ARTERY THAT IS CROSSCUT. SO
6 THINK OF IT AS A PIPE. IN THIS CASE, IT'S -- THAT'S THE BEST
7 COMPARISON. A PIPE THAT HAS BEEN CUT ACROSS ON A 90-DEGREE
8 ANGLE, AND SET UP IN A PARAFFIN BLOCK, A SECTION MADE OF IT
9 AND SECTIONED, AND I'M LOOKING AT IT. I'M ALSO LOOKING IN
10 SECTIONS OF HEARTS THAT SMALL VESSELS AS THEY COURSE THROUGH
11 THESE SCALE -- THE HEART MUSCLE, WHICH IS IN THE NEXT
12 SECTION.
13 Q. AND SO YOUR ASSESSMENT BASED UPON YOUR REVIEW OF THE
14 SLIDES WAS THAT THE PREVIOUS PATHOLOGIST HAD UNDERREPRESENTED
15 THE SEVERITY OF HIS OBSERVATIONS?
16 A. YES.
17 Q. AND THEN HERE THE NEXT SECTION, C.O.P.D., WHAT DOES THAT
18 MEAN?
19 A. WELL, THE NEXT SECTION REALLY IS C.H.F. OR DO YOU WANT
20 ME TO SKIP TO --
21 Q. OH, THAT WAS ALL IN THAT FIRST SECTION, HUH?
22 A. C.H.F. MEANS THAT DURING LIFE -- THIS IS NOT A DIAGNOSIS
23 YOU CAN MAKE AFTER DEATH. DURING LIFE, THIS PERSON HAD
24 CONGESTIVE HEART FAILURE, AND FOR THAT REASON WAS TREATED
25 WITH A DIURETIC, WHICH IS A TYPICAL WAY TO DO SO. THAT'S
1 FUROSEMIDE. IN THAT REGARD AND MICROSCOPICALLY WHAT IS FOUND
2 IS THAT THERE IS FIBROSIS OR SCARRING ALL AROUND -- IN THE
3 HEART MUSCLE ALL AROUND THE SMALL VESSELS THAT ARE NOURISHING
4 THE HEART MUSCLE. THERE ARE EVEN SMALL SCARS. SO IN
5 ADDITION TO THE FIBROSIS IN THE IMMEDIATE VICINITY OF THE
6 SMALL VESSELS, THERE ARE SCARS THAT HAVE OCCURRED. THESE ARE
7 SMALL HEART ATTACKS THAT HAVE OCCURRED THAT HAVE WEAKENED
8 PROGRESSIVELY THE HEART MUSCLE OVER A PERIOD OF YEARS. AND
9 THIS IS IN THE -- IN THE LEFT VENTRICLE, THAT'S THE L.V.
10 THERE'S A RESOLVING MICRO-INFARCT IN THE SEPTUM. IN OTHER
11 WORDS, IN THE -- IN THE WALL BETWEEN THE RIGHT AND LEFT MAIN
12 PUMPING CHAMBERS, I FIND A MYOCARDIAL INFARCTION, A HEART
13 ATTACK. NECROSIS, DEATH OF THE THE -- AND THIS IS
14 MICROSCOICALLY. DEATH OF THE HEART MUSCLE THAT HAS BEEN
15 RESOLVED. AND IT'S TRYING TO HEAL ITSELF. SO THIS IS
16 SEVERAL WEEKS OLD, MAYBE A COUPLE OF WEEKS OLD AT THIS TIME.
17 AND I ALSO FIND AND THE PATHOLOGIST ALSO AS WELL FOUND THAT
18 THERE IS NEPHROSCLEROSIS. SO THE PROCESS OF ARTERIOSCLEROSIS
19 HAS PROGRESSED ALSO TO THE KIDNEYS, WHICH IN FACT CONTRIBUTES
20 AS WELL NOT ONLY TO KIDNEY FAILURE, BUT TO CONGESTIVE HEART
21 FAILURE.
22 Q. SO THE FIRST SECTION IF I UNDERSTAND IS THE
23 ARTERIOSCLEROSIS PART WHICH IS SEPARATE FROM THIS HEART ISSUE
24 AND -- BUT THESE WERE BOTH OBSERVED MICROSCOPICALLY, SLIDES
25 THAT YOU HAVE -- THAT YOU SAW THAT THE OTHER PATHOLOGIST ALSO
1 SAW.
2 A. SURE.
3 Q. OKAY. AND SO THEN THE NEXT SECTION C.O.P.D.
4 A. C.O.P.D. IS JUST A CHRONIC OBSTRUCTIVE PULMONARY DISEASE
5 WHICH IS THE JARGON TERM THAT PHYSICIANS USE FOR PULMONARY
6 EMPHYSEMA. AND I PUT IT HERE BECAUSE IT IS LIKEWISE IN THE
7 SECTION OF PRIMARY CAUSE OF DEATH. IT CONTRIBUTED DIRECTLY.
8 THE LUNGS ARE NOT ABLE TO OXYGENATE BLOOD THAT COMES TO THEM
9 WHEN IT'S PUMPED BY A WEAK HEART. SO YOU NOT ONLY HAVE A
10 WEAK PUMP, YOU ALSO HAVE LUNGS THAT DON'T WORK WELL, THEY
11 DON'T WORK PROPERLY, BECAUSE THEY ARE DIFFUSELY INVOLVED BY
12 THIS SCARRING AND REDUCTION IN AVAILABLE SPACE FOR GAS
13 EXCHANGE IN THE LUNGS.
14 Q. SO THE PRIMARY CAUSE -- IS THE TERM PRIMARY CAUSE OF
15 DEATH THE RIGHT TERM FOR THIS SECTION?
16 A. YES, YES.
17 Q. AND THERE ARE BASICALLY THREE SUBPARTS TO THE
18 CARDIOVASCULAR DISEASE PART, IS THAT --
19 A. YES.
20 Q. -- DO I HAVE THAT RIGHT?
21 A. WELL, THERE ARE TWO SUBPARTS. WHAT I'M OFFERING IS THAT
22 THERE ARE REALLY TWO THAT ARE WORKING TOGETHER. ONE IS THAT
23 THERE IS A WEAK HEART WITH BAD CORONARY ARTERY DISEASE AND A
24 HEART WEAKENED BY MULTIPLE INFARCTS IN THE PAST, AS WELL AS
25 CHRONIC CONGESTIVE HEART FAILURE. THERE IS ALSO ON THE OTHER
1 SIDE OF THAT, ONE OF THE REASONS THAT THE HEART PUMPS IS TO
2 CIRCULATE BLOOD ALSO THROUGH THE LUNG. AND THE FACT IS THAT
3 THROUGH THE LUNGS WHERE THE RED CELLS PICK UP ADEQUATE
4 OXYGEN, THERE IS LIKEWISE DISEASE WHICH REDUCES THE VOLUME
5 AVAILABLE FOR EXCHANGE. NOW, IN THAT REGARD OF PULMONARY
6 EMPHYSEMA, IT IS NOT UNCOMMON, AND IN THIS CASE WAS PRESENT,
7 AN ACUTE BRONCHOPHEUMONIA. THIS WAS PRESENT AS I INDICATE IN
8 BOTH LUNG SLIDES, SO IT WAS PRESENT IN BOTH LUNGS, AND THERE
9 WERE FIVE SECTIONS MADE OF THE LUNGS. AND THAT IS TO SAY,
10 FIVE SLICES. AND IT WAS PRESENT IN THREE OF THE FIVE SLICES
11 AND ON BOTH SLIDES. AND SO IT'S HARD FOR ME TO BELIEVE,
12 THOUGH IT MAY THEORETICALLY BE TRUE BECAUSE I DON'T KNOW THE
13 EXACT PLACE HE GOT THOSE SECTIONS, THAT SHE HAD ACUTE
14 BRONCHOPNEUMONIA IN ONLY ONE LUNG, BUT EVEN IF SHE DID, EVEN
15 THOUGH I THINK IT WAS PROBABLY BOTH LUNGS, EVEN THOUGH SHE
16 DID, IT WAS BAD DISEASE. AND IT WAS ACUTE. THAT IN ITSELF
17 CAN BE A CAUSE OF DEATH. THIS BRONCHOPNEUMONIA WAS
18 PRESENT -- AS I UNDERSTAND, MRS. ANDERSON WAS IN THE HOSPITAL
19 FOR ONE DAY. SHE COULD HAVE COME INTO THE HOSPITAL WITH THIS
20 BRONCHOPNEUMONIA. IT WAS ACUTE, BUT IT WASN'T PRESENT FOR AN
21 HOUR OR TWO. IT WAS PRESENT FOR A DAY, ANYWAY. SO I
22 INDICATE THAT IT HAS ORIGINATED EITHER BEFORE OR AT LEAST AT
23 THE TIME OF ADMISSION, ONE DAY. AND IT IS APPROXIMATELY ONE
24 DAY IN APPEARANCE.
25 Q. AND TALKING ABOUT THE SECONDARY CAUSES OF DEATH, YOU'VE
1 IDENTIFIED – I THINK WE'RE ALL AWARE THAT SHE HAD DEMENTIA AND
2 OSTEOPOROSIS AND COMPRESSION FRACTURES. THE JURY HAS HEARD
3 QUITE A BIT ABOUT THAT.
4 A. OKAY.
5 Q. HOW DO THOSE FACTOR INTO THE -- THE CAUSE OF DEATH?
6 A. DEMENTIA, AS YOU KNOW A LOT ABOUT I'M SURE, HAS CAUSED
7 HER BY VARIOUS PROCESSES TO BECOME WASTED. AND THAT'S THE
8 TERM I USED THERE, INANITION. I'M SORRY FOR THE JARGON, BUT
9 IN GENERAL, IT CAN BE INTERPRETED AS SHE'S BECOMING WASTED.
10 HER BODY HAS LOST ITS RESERVES. HER MUSCLE MASS HAS REDUCED.
11 SHE'S LOST MOST OF THE FAT IN HER BODY. SHE'S DOWN TO PRETTY
12 LOW WEIGHT. SHE'S 72 AND A HALF POUNDS. AND FIVE FEET TWO
13 INCHES. THIS IS A FRAIL LADY. VERY FRAIL. WHICH IS WHY
14 REVERSALS IN FORTUNE CAN HAPPEN VERY QUICKLY IN PEOPLE WHO
15 ARE THIS FRAIL. SHE HAS -- SHE HAS SO -- AN ACCELERATED
16 WEIGHT LOSS PROBABLY BECAUSE SHE'S NOT ABLE TO TAKE OR WILL NOT
17 TAKE ANY NUTRITION. AT LEAST IS NOT EFFECTIVE. AND SHE HAS
18 OF COURSE SURGICAL REPAIR, WHICH IS INEFFECTIVE REPAIR IN AT
19 LEAST ONE PLACE WHERE THE PIN HAS NOT EVEN BEEN ABLE TO SCAR
20 IN EFFICIENTLY OR BE CEMENTED IN EFFICIENTLY TO HOLD THE BONE,
21 AND SO THAT IS A CONTINUING PROBLEM FOR HER, I'M SURE AS
22 WELL.
23 Q. DR. CASSIN, BEFORE I ASK YOU ABOUT YOUR OPINION ON
24 MANNER OF DEATH, ARE THERE ANY OTHER OF THE FINDINGS BELOW
25 THERE THAT WE NEED TO GO INTO? THAT YOU THINK ARE
1 SIGNIFICANT OF FACTOR INTO THE MANNER OF DEATH THAT WE
2 HAVEN'T ALREADY COVERED?
3 A. IN THE MICROSECTION I MADE A NOTE THERE THAT THE THYROID
4 IS GOITROUS, WHICH MEANS THAT THERE'S A LOT OF FIBROSIS.
5 THERE'S NODULARITY. IT MEANS IT DOESN'T FUNCTION PROPERLY.
6 AND PEOPLE WHO HAVE POOR THYROID FUNCTION ALSO HAVE POOR
7 METABOLIC CONTROL. THESE PEOPLE DO NOT HAVE THE ENDOCRINE
8 HORMONAL STIMULUS TO PROPER NUTRITION AND PROPER STABLIZATION
9 OF CELL LIFE IN THE BODY. I POINT THAT OUT ONLY BECAUSE IT
10 IS IN FACT A SIGNIFICANT FINDING. ALSO THE ADVANCED ATROPHY
11 IN THE BRAIN IS CERTAINLY CONSISTENT WITH HER CLINICAL
12 DIAGNOSIS OF DEMENTIA. AND I FIND IN THE LIVER CELLS, GOOD
13 EVIDENCE, GOOD OBJECTIVE EVIDENCE OF ABSOLUTELY POOR
14 NUTRITION. IT SHOWS -- BASICALLY, IT'S THE LIVER OF A PERSON
15 WHO IS IN STARVATION.
16 Q. DR. CASSIN, DO YOU HAVE AN OPINION TO A DEGREE OF
17 REASONABLE MEDICAL CERTAINTY THAT WHAT YOU'VE IDENTIFIED HERE
18 AS PRIMARY CAUSE OF DEATH WAS IN FACT THE CAUSE OF DEATH FOR
19 ELLEN ANDERSON?
20 A. YES.
21 Q. AND WHAT IS THAT OPINION?
22 A. MY OPINION IS THAT ELLEN ANDERSON DIED AS A -- FROM A
23 COMBINATION OF ARTERIOSCLEROSIS, WITH ITS MAIN EFFECT ON THE
24 HEART, POOR HEART FUNCTION, AND IT WAS SUPPORTED BY, IF YOU
25 WILL, ENHANCED BY HER EMPHYSEMA, WHICH TERMINALLY IN THE LAST
1 DAY WAS POISONED REALLY BY BRONCHOPNEUMONIA SO THAT SHE BECAME
2 SEPTIC. SHE BECAME DIFFUSELY INFECTED. AND AS I SAID
3 BEFORE, WOULD HAVE DIED ALONE BY THAT.
4 Q. AND DO YOU HAVE AN OPINION TO A DEGREE OF REASONABLE
5 MEDICAL CERTAINTY AS TO THE MANNENR OF DEATH FOR ELLEN
6 ANDDERSON?
7 A. YES, I DO. THE MANNER OF DEATH IS NATURAL, AND I SAY
8 THAT BECAUSE SHE IS A VICTIM OF HER DISEASE, HER CHRONIC
9 DISEASES WITH THE OVERLAY OF THIS ACUTE BRONCOPNEUMONIA.
10 Q. LET'S GO TO DR. WEITZEL'S ORIGINAL DEATH CERTIFICATE.
11 THIS IS STATE'S EXHIBIT 3-D. NOW, WE TALKED A LITTLE BIT
12 ABOUT THE CERTIFICATE OF DEATH AND DR. WEITZEL ACTUALLY
13 IDENTIFIED THREE DIFFERENT -- OR IDENTIFIED THREE DIFFERENT
14 THINGS HERE. HOW DID HE DO IN ASSESSING WHAT THE CAUSE OF
15 DEATH WAS FOR ALLEN ANDERSON?
16 A. WHEN I FIRST LOOKED AT THIS DEATH CERTIFICATE, I
17 BASICALLY TRIED TO UNDERSTAND WHAT WAS IN DR. WEITZEL'S MIND
18 OR ANY CLINICIAN WHO WRITES A DEATH CERTIFICATE HAS TO
19 REFLECT BASICALLY ON WHAT THEIR DATA BASE IS. THEY DON'T
20 HAVE AN AUTOPSY, THEY DON'T HAVE MAYBE OTHER INFORMATION, BUT
21 THEY DO HAVE CLINICAL INFORMATION, THEY HAVE OBSERVATION, AND
22 THEY SEE THE COURSE OF A PATIENT THROUGH A PERIOD OF TIME,
23 HOWEVER LONG OR SHORT THAT MIGHT BE, UNDER THEIR CARE. AND
24 IN THIS CASE, HE INDICATED BY CARDIAC ARREST THAT HER HEART
25 STOPPED. AND BY MYOCARDIAL INFARCTION THAT SHE PROBABLY
1 HAD -- PROBABLY HAD, AND THIS IS THE ONLY -- THE STANDARD IS,
2 WHAT IS MORE LIKELY THAN NOT. SHE PROBABLY HAD A MYOCARDIAL
3 INFARCTION. WHY WOULD HE SAY THAT? PROBABLY BECAUSE HE
4 NOTED CLINICALLY THAT SHE HAD A SUDDEN LAPSE, A SEVERE
5 DETERIORATION OF HER HEART FUNCTION. I GO ALONG WITH THAT
6 BASED ON WHAT I FOUND. THERE'S EVERY REASON TO BELIEVE THAT
7 SHE WOULD HAVE HAD SEVERE DETERIORATION, AND I AGREE WITH
8 THAT. EVEN THOUGH THERE MIGHT NOT HAVE BEEN A MYOCARDIAL
9 INFARCTION AT THAT TIME MTHOUGH, WHO OF US KNOWS. A SAMPLE,
10 A RANDOM SAMPLE OF THE HEART SHOWS ME, IN FACT, A RECENT ONE.
11 ANOTHER RANDOM SAMPLE MAY HAVE FOUND AN ACUTE ONE. IT'S UP
12 TO CHANCE IN AN AUTOPSY. AND THEN A SINUS ARRHYTHMIA IS
13 CERTAINLY TRUE BECAUSE I SUSPECT THAT FOR WHATEVER REASON,
14 INFECTION, ARTERIOSCLEROSIS, OR CONGESTIVE HEART FAILURE
15 WITH PULMONARY EMPHYSEMA, EVERYBODY DIES OF A SINUS
16 ARRHYTHMIA. YOUR HEART GOES INTO AN -- AN UNWORKABLE RHYTHM
17 JUST AS A TERMINAL EVENT. NOW, SHE COULD HAVE HAD A SINUS
18 ARRHYTHMIA BEFORE THAT. AND I BELIEVE SHE DID CLINICALLY,
19 AND THE REASON FOR THAT MAY HAVE BEEN THAT SHE WAS ACUTELY
20 INFECTED. OR THAT SHE WAS ATTEMPTING TO RECOVER FROM A HEART
21 ATTACK, WHICH IS AT LEAST WHAT I CAN SAY BECAUSE OF WAY I
22 FOUND IN HER HEART.
23 Q. AND ATTENDING PHYSICIANS, UNLESS THEY ACTUALLY PERFORM
24 AN AUTOPSY, WHICH I ASSUME DOESN'T HAPPEN, CAN'T KNOW
25 PRECISELY WHAT THE CAUSE OF DEATH IS WHEN THEY'RE FILLING OUT
1 A DEATH CERTIFICATE.
2 A. WHO OF US KNOWS ABSOLUTELY EVERYTHING. WHO OF US
3 KNOWS -- WELL, HOW CAN I SAY THAT ANY BETTER? WHAT WE ARE
4 ASKED, AND THE STANDARD ON THE DEATH CERTIFICATION PROCESS IS
5 TO GIVE THE MOST LIKELY EXPLANATION FOR DEATH. I THINK BASED
6 ON A CLINICAL EXAMINATION OF THIS WOMAN AND OBSERVATION, THIS
7 IS ON TRACK.
8 Q. LET'S TALK ABOUT JUDITY LARSEN. LET'S GO TO HER AUTOPSY
9 REPORT. THIS IS STATE'S EX -- OR STATE'S EXHIBITS 3-C. AND
10 AGAIN, WE'RE GOING TO THE DIAGNOSES ON THE FRONT PAGE OF THE
11 PATHOLOGIST'S REPORT. ON THIS SECTION OF DIAGNOSES, CAN YOU
12 WALK US THROUGH -- SWITCH TO THE BLOWUP OF THAT SO WE CAN SEE
13 A LITTLE BIT BETTER. FIRST OF ALL, THERE'S THE TERM DRUG
14 INTOXICATION. WHAT IS MEANT BY THAT?
15 A. DRUG INTOXICATION LITERALLY MEANS THAT SHE HAS -- HAS
16 EXPERIENCED A TOXIC EFFECT OF A -- OF A DRUG. A DRUG MAY BE
17 A MEDICATION OR AN ILLICIT DRUG, BUT IT'S FROM SOME
18 PHARMACEUTICAL PRODUCT.
19 Q. SO THE PATHOLOGIST IDENTIFIES THIS AS NUMBER ONE AND
20 INDICATES IN LEVELS THAT WE'VE HEARD SOMETHING ABOUT, AND
21 THEN GOES ON TO TALK ABOUT OTHER CONDITIONS THAT HE OBSERVED
22 DURING HIS AUTOPSY. WHICH OF THESE -- WOULD IT BE HELPFUL,
23 WOULD YOU LIKE TO GO TO YOUR ANALYSIS OR WOULD YOU LIKE TO
24 EXPLAIN SOME OF THESE?
25 A. WELL, WE NEED TO BE EFFICIENT TODAY, AND I THINK THAT IT
1 MAY NOT BE NECESSARY TO BE AS THOROUGH AS WE HAVE BEEN
2 BEFORE. MY OWN -- LET ME JUST SIMPLY SAY MY OWN PRESENTATION
3 OF FINAL PATHOLOGIST DIAGNOSES DOES NOT NEGATE ANY OF THIS
4 PATHOLOGIST'S FINDINGS. I USE THEM, IN FACT. IT'S THE
5 AUTOPSY THAT HE’D DONE -- DID AND THE FINDINGS THAT HE
6 REPORTS, AS I SAID IN GENERAL. THE ONLY DIFFERENCE I HAVE
7 WITH THOSE IS MY UNDERSTANDING AND INTERPRETATION OF THESE
8 FINDINGS AS IN A NUMBER OF CASES BEING MORE SEVERE THAN THEY
9 WERE INTERPRETED AS, FOR WHATEVER REASON.
10 Q. WHY DON'T WE GO TO YOUR -- EXCUSE ME, YOUR FINDINGS.
11 AND THIS IS MARKED DEFENDANT'S EXHIBIT 105. AND AGAIN, THIS
12 IS A -- THE DOCUMENT THAT YOU PREPARED, AND AGAIN, YOU HAVE
13 MADE BASED UPON YOUR REVIEW OF THE SLIDES, THE PHOTOGRAPHS,
14 HIS REPORTS, HIS FILES, THE MEDICAL RECORDS, WHAT YOU BELIEVE
15 THE CAUSE OF DEATH IS FOR JUDITH LARSEN. AND I GUESS WE'RE
16 BACK TO THE SAME -- SAME ACRONYM BEFORE. TALK ABOUT WHAT YOU
17 SAW WITH REGARD TO JUDITH LARSEN ON THIS TYPE OF DISEASE.
18 A. WHAT I SEE IN JUDITH LARSEN IS ADVANCED
19 ARTERIORSCLEROSIS. AND IN FACT, I'VE INDICATED THAT IT IS
20 HER CAUSE OF DEATH. NOW, WHY IS IT HER CAUSE OF DEATH? IT
21 IS HER CAUSE OF DEATH BECAUSE, FIRST OF ALL, SHE'S HAD IT FOR
22 MANY YEARS AND IT IS ADVANCED. THIS IS NOT EARLY
23 ATHEROSCLEROSIS. THIS IS LATE ATHERSCLEROSIS. NOT ONLY
24 BECAUSE SHE'S 93 YEARS OLD, BUT IN FACT IT IS OBJECTIVELY.
25 IF THIS WERE IN A 63-YEAR-OLD, IT WOULD BE ADVANCED
1 ARTERIORSCLEROSIS. SHE HAS HAD A STROKE --
2 Q. I THINK --
3 A. -- BY HISTORY.
4 Q. -- SHE ACTUALLY PASSED AWAY ON -- IN JANUARY OF '96.
5 A. OH, I'M SORRY.
6 Q. DO YOU THINK THAT -- WHAT YEAR DO YOU THINK THAT WOULD
7 HAVE BEEN?
8 A. PROBABLY THE PREVIOUS YEAR.
9 Q. OKAY. SO THAT'S YOUR -- YOUR TYPO?
10 A. SORRY ABOUT THAT. THAT'S MY MISTAKE.
11 Q. SO SHE HAS A HISTORY OF STROKE. AUGUST OF 1995.
12 A. SO SHE HAS A RECENT STROKE. SHE HAS MULTI INFARCT
13 DEMENTIA. THIS IS DEMENTIA OR LOSS OF ONE'S MENTAL FACULTIES
14 BASED ON A CERTAIN PROCESS. IT'S A WAY OF SAYING WHAT THE
15 CAUSE IS, AS OPPOSED TO THE MORE MYSTERIOUS PATTERNS, BOTH
16 CLINICAL AND PATHOLOGICAL, OF DEMENTIA THAT YOU MAY HAVE
17 HEARD ABOUT, LIKE ALZHEIMER'S AND PICK'S AND ALL THOSE - LEWY
18 BODY DISEASE. THIS IS A FORM OF DEMENTIA THAT IS BASED ON
19 ARTERIOSCLEROSIS. ARTERIOSCLEROSIS HAS PRODUCED INFARCTS
20 WHICH ARE SMALL DEATH - AREAS OF DEATH OF BRAIN TISSUE. AND
21 FOR THE REASON THAT THERE IS ARTERIAL INSUFFICIENCY. THE
22 ARTERIES THEMSELVES HAVE FAILED TO ADEQUATELY NOURISH THE
23 BRAIN TISSUE. AND FOR THAT REASON, EVEN THOUGH THEY ARE NOT
24 VISIBLE GROSSLY, YOU CAN'T JUST LOOK AT THE BRAIN AND SAY
25 ANYTHING BUT THIS IS AN ATROPHIC BRAIN BECAUSE THEY ARE SO
1 SMALL. IN FACT, MULTI INFARCT DEMENTIA IS SEVERE
2 ARTERIOSCLEROSIS WITH THE CLINICAL PICTURE OF A WORSENING
3 DEMENTIA.
4 Q. AND SO ARE --
5 A. IN THAT REGARD -- EXCUSE ME. IN THAT REGARD, C.T.
6 SCANS, WHICH IS A WAY OF MAKING THAT DIAGNOSIS, CONFIRMED
7 THAT. AND SO I USE THIS TERM BECAUSE NOT ONLY WAS IT SAID
8 CLINICALLY, BUT THE BASIS, THE CLINICAL BASIS FOR THAT
9 DIAGNOSIS IS ESTABLISHED RADIOGRAPHICALLY BY A COMPUTERIZED
10 TOMOGRAPHY.
11 Q. AND SO WHAT CAN YOU SEE WITH A C.T. SCAN? YOU CAN SEE
12 AREAS WHERE THESE --
13 MR. MAJOR: YOUR HONOR, MIGHT WE INQUIRE JUST AS A VOIR
14 DIRE WHETHER HE ACTUALLY REVIEWED THE M.R.I. OR WHETHER HE'S
15 JUST REVIEWING --
16 THE COURT: YOU CAN ASK QUESTIONS IF YOU WANT.
17 BY MR. MAJOR:
18 Q. OKAY, DOCTOR, JUST QUICK QUESTION. WHEN YOU'RE TALKING
19 ABOUT THIS C.T. SCAN, AS PART OF YOUR PREPARATION FOR THIS
20 CASE, DID YOU ACTUALLY REVIEW THE M.R.I.?
21 A. NO, SIR, I DIDN'T.
22 Q. YOU JUST SIMPLY REVIEWED THE STATEMENTS OF THE --
23 WRITTEN FROM THE DOCTOR THAT WERE IN THE RECORDS.
24 A. THAT'S CORRECT.
25 MR. MAJOR: THANK YOU.
1 BY MS. ISAACSON:
2 Q. DR. CASSIN, WOULD IT BE TYPICAL FOR A MEDICAL EXAMINER
3 TO ACTUALLY REVIEW SUCH A C.T. SCAN ITSELF?
4 A. WELL, IT MAY BE, BUT I -- I DOUBT THAT MOST PATHOLOGISTS
5 WOULD EITHER BOTHER TO DO THAT OR DO IT ONLY FOR LACK OF
6 TRAINING SPECIFICALLY IN THAT. DEPENDS ON THEIR OWN
7 READINESS TO DO SO. IT'S A SPECIALTY IN ITSELF. THE C.T.
8 SCANS ARE ALL REPORTED, THOUGH, BY SPECIALISTS IN THAT AREA.
9 AND YOU REVIEWED THE REPORT OF THE C.T. SCAN IN THIS CASE.
10 A. YES.
11 Q. INCLUDED IN THE MEDICAL RECORDS. WITH REGARD -- KEEP
12 GOING ON THE -- SO THESE ARE SUBPARTS OF THE PRIMARY CAUSE OF
13 DEATH, AND YOUR EXPLANATION OF THE DETAILS OF THAT, WHAT IS
14 ISCHEMIC -- ISCHEMIC HEART DISEASE?
15 A. ISCHEMIC HEART DISEASE IS A TERM GIVEN TO CLINICALLY --
16 A CLINICAL TERM GIVEN TO A HEART, A HEART FUNCTION THAT
17 APPEARS TO BE LESSENING OVER TIME IN EFFICIENCY. IT MAY
18 INVOLVE HEART FAILURE, IT MAY INVOLVE ARRHYTHYMIA, THAT IS
19 NOT LETHAL ARRHYTHMIA, BUT NEVERTHELESS ARRHYTHMIA, ABNORMAL
20 HEART RHYTHM THAT IS BASED ALSO ON A CLINICAL FINDING OF
21 ARTERIOSCLEROSIS. ISCHEMIC HEART DISEASE MEANS THAT THERE IS
22 GRADUAL DYING OF HEART MUSCLE. OR IN -- BASED ON INEFFECTIVE
23 PERFUSION THROUGH THOSE SMALL BLOOD VESSELS BECAUSE OF
24 ARTERIOSCLEROSIS. ONE OF THE FINDINGS LIKEWISE THAT
25 SUBSTANTIATES THIS IS ANGINA, OR CHEST PAIN. THAT THIS WAS
1 REPORTED IN THIS LADY AND FOR WHICH SHE WAS TREATED WITH A
2 NITROGLYCERINE LIKE COMPOUND, ISORDIL, WHICH HAS A LONGER
3 LASTING EFFECT THAN NITROGLYCERINE. ALSO, SHE HAS ON
4 MICROSCOPY A VERY DENSE CALCIFIC CORONARY ARTERIOSCLEROSIS.
5 THESE ARE COLLARS OF CALCIFICATION. THERE IS NO HOLE THROUGH
6 WHICH GASSES CAN GO. THIS IS SEVERE CORONARY
7 ARTERIOSCLEROSIS. AND I INTERPRETED THIS FROM THE SLIDES
8 THAT THE PATHOLOGIST PROVIDED MADE -- MADE AT AUTOPSY. ALSO
9 THERE IS, AS YOU CAN SEE HERE, CLINICAL -- CLINICAL EVIDENCE
10 OF A SEIZURE IN DECEMBER FOR WHICH THIS LADY WAS GIVEN
11 DILANTIN I BELIEVE INTRAVENOUSLY.
12 Q. SO DO I UNDERSTAND THAT THE BIG PICTURE HERE IS THAT HER
13 ARTERIES ARE DISEASED?
14 A. YES.
15 Q. AND IT AFFECTS BOTH THE BRAIN AND THE HEART --
16 A. YES.
17 Q. -- IN THIS PATIENT?
18 A. YES, IT DOES. SIGNIFICANTLY SO.
19 Q. AND THERE'S --
20 A. WITH DYSFUNCTION. DYSFUNCTION OF THE BRAIN UP TO AND
21 INCLUDING SEIZURE. I MEAN THIS IS MASSIVE DYSFUNCTION.
22 Q. AND HOW DOES THIS CAUSE DEATH?
23 A. THIS CAUSES DEATH BY CAUSING FATAL ARRHYTHMIA. A SUDDEN
24 ABNORMAL RHYTHM THAT SIMPLY IS SO INEFFICIENT THAT IT DENIES
25 THE BRAIN SUDDENLY ANY KIND OF BASELINE KIND OF CIRCULATION.
1 Q. AND IS THERE ANY WAY TO TELL IN AN AUTOPSY, IS THERE A
2 WAY TO SEE THAT AN ARRHYTHMIA OCCURRED?
3 A. NO. IT'S A DYNAMIC PROCESS. IT'S A PHYSIOLOGIC
4 PROCESS. AND AT AUTOPSY, IN SPITE OF WHAT YOU MAY THINK FROM
5 LOOKING AT T.V., AUTOPSIES ONLY LOOK AT NONMOVING TISSUE, AND
6 SO IT'S A STRUCTURAL THING THAT AN AUTOPSY IDENTIFIES.
7 ARRHYTHMIA AS WELL AS A NUMBER OF OTHER CLINICAL PHENOMENA
8 SIMPLY CAN'T BE APPRECIATED AT AUTOPSY. THAT'S WHY I LOOK AT
9 THE MEDICAL RECORDS FIRST.
10 Q. AND THEN WE GO TO THIS SECONDARY OR CONTRIBUTING CAUSES.
11 YOU ALSO NOTE DEHYDRATION AND ANEMIA.
12 A. A CONTRIBUTING CONDITION I BELIEVE IN THIS CASE WAS
13 DEHYDRATION AND I BELIEVE THIS SINCERELY BECAUSE DEHYDRATION
14 AND ANEMIA WERE TWO THINGS THAT WERE DOCUMENTED WELL. THERE
15 WAS PERSISTENT NAUSEA AND VOMITING WHICH FIRST OF ALL
16 DESTROYS THE ELECTRICAL BALANCE IN THE BODY, AS WELL
17 ELIMINATING -- ELIMINATING NECESSARY FLUIDS BECAUSE THE ONLY
18 WAY SHE WAS ABLE TO TAKE FLUIDS WAS ORALLY. AND THIS WAS
19 PERSISTENT. ALSO, SHE HAD BLOODY EMESIS WHICH MEANS SHE
20 BEGAN TO THROW UP SOME BLOOD AND SHE HAD SOME BLOOD IN HER
21 STOOL, HEMATOCHEZIA, AND THE REASON FOR THAT WAS INADEQUATE
22 SUPPORT OF THE DELICATE LINING OF THE STOMACH. AND AS WELL
23 AS THE ENTIRE GASTROINTESTINAL TRACT. THERE WAS A NOTE --
24 AND I'LL REFER BACK TO WHAT WAS SAID ON THE -- ON THE AUTOPSY
25 REPORT BY THE PATHOLOGIST HERE, THAT SAID, WELL, THERE WAS NO
1 BLOOD FOUND IN THE GASTROINTESTINAL TRACT. WELL, THAT'S
2 FINE. THAT'S FINE. IT'S A GOOD OBSERVATION, BUT IT DOESN'T
3 MEAN THAT IT DIDN'T HAPPEN BEFORE. AND IN FACT, CLINICALLY,
4 IT DID HAPPEN ON DECEMBER 30TH AND 31ST TO THE POINT WHERE
5 HER HEMATOCRIT WENT DOWN BY ONE-QUARTER. SO THAT'S A SEVERE
6 DEPRESSION OF HEMATOCRIT. SHE BECAME ACUTELY ANEMIC. AND
7 THAT IN ITSELF COULD HAVE BEEN A CAUSE DEATH AND VERY LIKELY
8 PRECIPITATED THE PROCESS OF ARRHYTHMIA BECAUSE IT REDUCED THE
9 NUMBER OF RED CELLS TO CARRY GAS FROM THE LUNGS TO THE BRAIN
10 AND THE OTHER ORGANS. SO NOT ONLY WERE THE ORGANS
11 DYSFUNCTIONAL IN -- OF THE ORGANS OF THE PUMP SYSTEM, IN THE
12 HEART PART ONE, BUT ALSO THE NUMBER OF RED CELLS AVAILABLE TO
13 THIS BODY WERE REDUCED BY 25 PERCENT OVER THE COURSE OF --
14 OVERNIGHT, I THINK IT WAS. ONE DAY. AND SHE BECAME
15 HYPOTENSIVE WHICH MEANS THAT HER BLOOD PRESSURE DROPPED
16 PRECIPITOUSLY AS WELL. I INCLUDE HERE -- IF YOU WANT ME TO
17 GO ON.
18 Q. SURE.
19 A. I INCLUDE HERE HYPOTHYROIDISM. THIS LADY HAD HER
20 THYROID REMOVED. SHE HAD BEEN REPLACED WITH SYNTHROID, WHICH
21 IS L-THYROXINE. IT'S THE THYROID HORMONE, THE PRIMARY
22 THYROID HORMONE, THAT THAT GLAND PRODUCES FOR US TO MAINTAIN
23 THE METABOLISM OF THE BODY, TO REGULATE OUR BODY SYSTEM.
24 THIS LADY ULTIMATELY HAD BEEN REMOVED FROM ALL OF HER
25 MEDICATIONS, INCLUDING THYROID HORMONE. HYPOTHYROIDISM
1 THEREFORE BECOME A DIRECT -- A DIRECT INFLUENCE ON
2 MALFUNCTION, ORGAN MALFUNCTION, DIFFUSELY. AND I NOTE THERE
3 THAT PART OF THAT PROCESS WAS VERY READILY EVIDENT IN THE
4 RECORDS FROM NEW YEAR'S EVE UNTIL JANUARY 3RD WHERE THE DYING
5 PATTERN THAT WE SEE IN SO MANY PEOPLE WHO ARE DYING SLOWLY OF
6 ALTERED RESPIRATORY PATTERNS, THAT'S THE INCONSISTENCY,
7 FLUCTUATING BLOOD PRESSURE, RESTLESSNESS AND AGITATION FROM
8 INADEQUATE PERFUSION OF THE BRAIN, ALL -- ALL ARE PRESENT
9 DURING THAT PERIOD OF TIME. AND PROBABLY MADE WORSE BY THE
10 FACT THAT HER TERMINAL CARE WAS FOR SOME REASON, PROBABLY A
11 MISUNDERSTANDING, NOT PROPERLY TREATED MEDICALLY. BECAUSE AS
12 I RECALL, SHE WAS DENIED SOME OF HER REGULAR DOSING OF
13 MORPHINE, IF NOT OTHER THINGS, WHICH OF COURSE WOULD HAVE
14 STABILIZED HER DYING COURSE AND KEPT HER MORE COMFORTABLE.
15 Q. NOW, THIS -- IN ALL THE TOXICOLOGY RESULTS, THERE'S ONLY
16 ONE POSITIVE FINDING FOR MORPHINE, AND THAT'S WITH REGARD TO
17 JUDITH LARSEN. HOW DID THAT TOXICOLOGY RESULT FACTOR INTO
18 YOUR ANALYSIS WITH REGARD TO CAUSE OF DEATH?
19 A. WELL, I EXPECTED TO FIND MORPHINE IN THIS CASE AND
20 FRANKLY, I WOULD HAVE EXPECTED TO FIND IT HAD IT BEEN
21 PROPERLY TESTED FOR IN EVERY CASE HERE. BECAUSE THERE IS
22 EVIDENCE IN EVERY ONE OF THESE CASES THAT THESE PEOPLE, WITH
23 THE EXCEPTION OF ONE, HAD RECEIVED -- THAT'S MRS. ANDERSON --
24 HAD RECEIVED MORPHINE RELATIVELY CLOSE TO THE TIME OF DEATH.
25 AT LEAST THAT -- THE LAST DOSE. SO IT WOULD HAVE BEEN A
1 FINDING I THINK THAT WOULD HAVE BEEN EXPECTED OR SHOULD HAVE
2 BEEN EXPECTED. TO FIND IT HERE DOESN'T SURPRISE ME AT ALL.
3 Q. AND HOW IS IT THAT YOU DIFFER -- WHY IS IT THAT YOU
4 DIFFER FROM THE OTHER PATHOLOGIST ON THE CAUSE OF DEATH AND
5 THE MANNER OF DEATH?
6 A. LET ME CIRCLE BACK AND -- AND SAY SOMETHING MAYBE IN A
7 LITTLE DIFFERENT WAY. I THINK THERE'S A MISUNDERSTANDING
8 HERE, PERHAPS ABOUT THE DYING PROCESS. PERHAPS THERE WASN'T
9 AN EXAMINATION OF THE MEDICAL RECORDS IN SUCH A WAY THAT THE
10 DYING PROCESS WAS SEEN --
11 MR. MAJOR: YOUR HONOR, I'M GONNA OBJECT AT THIS TIME.
12 I'M NOT SURE THIS IS -- THIS IS BEYOND THE SCOPE OF HIS
13 EXPERTISE AS A PATHOLOGIST. I THINK WE'RE NOW GETTING INTO
14 AREAS THAT HE CANNOT TESTIFY TO ON HIS EXPERTISE.
15 THE COURT: OVERRULE THE OBJECTION. GO AHEAD.
16 THE WITNESS: BUT FOR SOME REASON, THERE WAS A FOCUSSING
17 UPON MORPHINE PRESENCE TO THE EXTENT THAT HE ACTUALLY SAID
18 DEATH HAD HAPPENED BECAUSE THERE WAS A TOXIC EFFECT OF
19 MORPHINE. I THINK THIS EXHIBITS, FRANKLY, A MISUNDERSTANDING
20 OF THE ENTIRE PROCESS. DEATH WITH MORPHINE IN THE BODY
21 DOESN'T MEAN DEATH BY MORPHINE IN THE BODY, JUST LIKE DEATH
22 WITH -- WITH ELAVIL IN THE BODY, AS IN MRS. ANDERSON, DIDN'T
23 MEAN DEATH BY ELEVIL. DEATH WITH ASPIRIN IN THE BODY DOESN'T
24 MEAN DEATH BY ASPIRIN, OKAY? TOXICOLOGY REVEALS A LOT OF
25 THINGS IF YOU LOOK FOR THEM. OKAY? AND IF THEY'RE THERE.
1 THE IMPORTANT THING IS THE INTERPRETATION OF THESE. IN THIS
2 CASE THE MORPHINE GIVEN AS A PART OF THE ASSISTANCE OF THIS
3 LADY DURING HER DYING PROCESS, WHICH IS VERY NICELY DEPICTED
4 FRANKLY, IN THE MEDICAL RECORD.
5 Q. (BY MS. ISAACSON) AND HAVE YOU SEEN SIMILAR FINDINGS IN
6 OTHER PATIENTS WHO'VE RECEIVED MORPHINE AT THE END OF LIFE
7 FOR COMFORT CARE?
8 MR. MAJOR: OBJECTION, YOUR HONOR. THINK IT'S
9 IRRELEVANT.
10 THE COURT: SUSTAINED.
11 THE WITNESS: FRANKLY, I SEE THIS A LOT. I WORK --
12 THE COURT: WAIT, WAIT --
13 THE WITNESS: OH, I'M SORRY.
14 THE COURT: SUSTAINED.
15 THE WITNESS: SUSTAINED --
16 THE COURT: THAT MEANS YOU DON'T ANSWER IT. GO AHEAD.
17 THE WITNESS: EXCUSE ME.
18 Q. (BY MS. ISAACSON) DO YOU HAVE AN OPINION TO A REASONABLE
19 DEGREE OF MEDICAL CERTAINTY AS TO THE CAUSE OF DEATH OF
20 JUDITH LARSEN?
21 A. YES.
22 Q. AND WHAT IS THAT OPINION?
23 A. MY OPINION, AS I'VE INDICATED HERE, IS THAT SHE DIED OF
24 ADVANCED ARTERIORSCLEROSIS. AND THAT THIS WAS PRECIPITATED
25 PRIMARILY BY THE CONDITION THAT MADE THIS COME TO FULL
1 FLOWER, SO TO SPEAK, WAS THE UNDERLYING ANEMIA, THE REDUCTION
2 OF AVAILABLE BLOOD SUPPLY, RED CELLS, AND DEHYDRATION, THE
3 LOSS OF FLUID FROM HER BODY. THIS I BELIEVE WAS ASSOCIATED
4 LIKEWISE WITH HYPOTHYROIDISM BECAUSE SHE WAS NO LONGER
5 GETTING HER THYROID REPLACEMENT MEDICATION. AND SHE HAD NO
6 THYROID GLAND TO PROVIDE IT TO HERSELF.
7 Q. AND DO YOU HAVE AN OPINION TO A DEGREE OF REASONABLE
8 MEDICAL CERTAINTY AS TO THE MANNER OF DEATH --
9 A. YES.
10 Q. -- FOR JUDITH LARSEN?
11 A. YES.
12 Q. AND WHAT IS THAT OPINION?
13 A. SHE DIED FROM DISEASE. SHE DIED FROM HER DISEASES. SHE
14 DIED IN A WAY THAT LOOKS PREDICTABLE TO ME CLINICALLY. I
15 FIND NOTHING TO CONTROVERT THAT, SO I CALL IT A NATURAL
16 DEATH.
17 MS. ISAACSON: IF I COULD JUST HAVE ONE MOMENT, YOUR
18 HONOR?
19 THE COURT: YOU MAY.
20 Q. (BY MS. ISAACSON) IN THE INTEREST TIME, WE'VE HEARD WHAT
21 YOUR FINDINGS AND YOUR CONCLUSIONS ARE ABOUT JUDITH AND SO
22 LET'S JUST MOVE ON TO THE -- TO THE NEXT PATIENT, MARY CRANE.
23 AND THIS IS STATE'S EXHIBITS 4-C. LET'S GO OVER -- WELL,
24 LET'S JUST BRIEFLY IDENTIFY FOR THE JURY WHAT -- WHAT'S
25 INCLUDED ON THE ORIGINAL REPORT AND THEN WE'LL GO TO YOUR
1 FINDINGS. I THINK THAT'S -- THAT MIGHT BE HELPFUL. WITH
2 REGARD TO MARY CRANE, FIRST OF ALL, LET'S TALK ABOUT THE
3 MANNER OF DEATH AND IMMEDIATE CAUSE OF DEATH. WE SEE NOW A
4 NEW TERM, UNDETERMINED INJURY. WHAT DOES THAT TERM MEAN?
5 A. WELL, I'M NOT SURE I'VE EVER HEARD THAT BEFORE. BUT AS
6 I UNDERSTAND IT, IT'S AN EXPLANATION FOR WHY THIS PATHOLOGIST
7 REFUSES TO DETERMINE IT. IT'S -- THE RESERVATION IS THAT THE
8 PATHOLOGIST IS NOT SURE IF THERE'S BEEN AN INJURY OF SOME
9 SORT. THERE MIGHT BE A NUMBER OF REASONS, AS I INDICATED,
10 FOR NOT WANTING TO DETERMINE THE CAUSE OF DEATH. BUT IT
11 SEEMS TO ME THAT THAT'S WHAT THAT WOULD MEAN.
12 Q. ULTIMATELY, SHE INDICATED SHE COULD NOT DETERMINE THE
13 CAUSE OF DEATH IN THAT CASE.
14 A. BECAUSE SHE'S UNABLE TO DETERMINE WHETHER THERE'S AN
15 INJURY.
16 Q. OKAY.
17 A. THAT'S THE WAY I UNDERSTAND THAT.
18 Q. AND THE FINDINGS BY THE PATHOLOGIST IN THIS CASE, DO YOU
19 DISAGREE GENERALLY WITH THE FINDINGS HERE?
20 A. NO. NO. IN FACT, I RELY UPON THEM. SHE DID THE
21 AUTOPSY. SHE MADE THE OBSERVATIONS. THERE'S NO WAY FOR US
22 TO REDO THE AUTOPSY IN EXACTLY THE SAME WAY, ESPECIALLY NOW.
23 SO I RELY UPON THEM. I TAKE THEM AT FACE VALUE.
24 Q. LET'S GO TO YOUR OUTLINE OF FINDINGS, AND THIS IS
25 DEFENDANT'S EXHIBIT 106. SAME THING WE'VE SEEN BEFORE. WITH
1 REGARD TO HER CAUSE OF DEATH, WHAT DID YOU -- WHAT DID YOU
2 FIND WAS HER PRIMARY CAUSE OF DEATH?
3 A. THIS LADY HAS TWO MAJOR PROBLEMS. BOTH OF THEM HAVE TO
4 DO WITH THE CARDIOVASCULAR SYSTEM, THE PUMPING SYSTEM AND THE
5 BLOOD SUPPLY SYSTEM. ONE IS HYPERTENSION OR HIGH BLOOD
6 PRESSURE, WHICH PRODUCES A PROGRESSIVE DELETERIOUS EFFECT
7 UPON THE PUMP AS WELL AS UPON THE KIDNEYS AND THE TISSUES THAT
8 ARE SUPPLIED. CARDIOMEGALY, AS I'VE INDICATED THERE IN
9 THE -- EXCUSE ME, LET ME FINISH THE QUESTION BEFORE. THE
10 OTHER DISEASE THAT IS VERY IMPORTANT IN THIS CASE IS
11 ARTERIOSCLEROSIS AS WELL. IT'S A DISEASE THAT IS ADVANCED
12 FOR THIS PARTICULAR LADY, EVEN THOUGH SHE'S CERTAINLY OLD
13 ENOUGH TO HAVE IT. SHE HAPPENS NOT TO BE AS OLD AS THE
14 OTHERS, BUT SHE HAS EVERY BIT AS SEVERE CORONARY ARTERY
15 DISEASE AS THE OTHERS DO. SO I BELIEVE THAT THOSE TWO
16 CATEGORIES ARE THE CAUSE FOR HER DYING.
17 Q. AND WHEN I SEE THIS MYOCARDIAL SCARRING, IS THAT IN THE
18 HEART?
19 A. RIGHT. THERE'S EVIDENCE IN HER HEART THAT SHE HAS,
20 FIRST OF ALL, OBSTRUCTED CORONARY ARTERIES. THEY ARE
21 SEVERELY OBSTRUCTED, AS THIS PATHOLOGIST HAS INDICATED. THE
22 LEFT ANTERIOR DESCENDING CORONARY ARTERY IS OBSTRUCTED 80
23 PERCENT. AND THAT'S AT THE TIME OF AUTOPSY, WHICH IS THREE
24 AND A HALF YEARS AFTER SHE'S -- SHE'S BEEN BURIED. IT WAS
25 PROBABLY CLOSED MORE THAN THAT AT THE TIME SHE ACTUALLY DIED.
1 BUT THREE AND A HALF YEARS LATER, SHE'S STILL AT 80 PERCENT
2 OBSTRUCTION OF THE AVAILABLE NORMAL SPACE OF THE CORONARY
3 ARTERY, AS WELL AS IN THE RIGHT CORONARY ARTERY BEING ABOUT
4 HALF OBSTRUCTED. THAT'S VERY ADVANCED DISEASE. THAT'S PART
5 OF THE REASON THAT SHE ALSO HAS MYOCARDIAL SCARRING. THE
6 HEART ITSELF HAS HAD HEART ATTACKS AND THE SCARS ARE EVIDENCE
7 OF THOSE HEART ATTACKS THAT HAVE RESULTED FROM POOR CORONARY
8 CIRCULATION OVER A LONG PERIOD OF TIME.
9 Q. SO TO KIND OF TRANSLATE INTO PLAIN LANGUAGE THIS
10 SECTION, ULTIMATELY, DO THE ARTERIES NOT GIVE BLOOD TO THE
11 HEART? HOW DOES SOMEONE ACTUALLY -- HOW DOES THIS CAUSE THE
12 DEATH?
13 A. THAT SECTION TALKS ABOUT POOR CIRCULATION BASICALLY.
14 POOR CIRCULATION BECAUSE OF ARTERIOSCLEROSIS IN THREE MAJOR
15 IMPORTANT ORGANS, THE HEART, THE LUNGS, AND THE KIDNEYS.
16 THAT'S WHAT THE NEPHROSCLEROSIS IS. THAT'S THE KIDNEYS. AND
17 THE PULMONARY ATHEROSCLEROSIS IS THE -- IN THE SECTIONS, THE
18 MICROSCOPIC SECTIONS OF THE LUNG, ONE CAN SEE THROUGHOUT THEM
19 ADVANCED ARTERIOSCLEROSIS.
20 Q. AND I GUESS I DON'T QUITE UNDERSTAND HOW THE
21 HYPERTENSION WORKS. CAN YOU EXPLAIN THAT IN AS PLAIN
22 LANGUAGE AS YOU CAN?
23 A. HYPRETENSION WORKS BY -- BASICALLY, IT STRESSES THE
24 HEART, WHICH IS THE PUMP, TO PUSH BLOOD AT THE BODY'S
25 NECESSARY RATE, WHATEVER THE DEMAND OF THE BODY IS AT ANY
1 GIVEN MOMENT, TO PUSH ADEQUATE BLOOD TO END ORGANS WHICH
2 REQUIRE THAT OXYGENATION AND NUTRITION, AGAINST PERIPHERAL
3 BLOOD VESSELS, SMALL BLOOD VESSELS IN THE PERIPHERY AND IN
4 THE END ORGANS THAT ARE STENOSED, THAT ARE CRIMPED DOWN. AND
5 NOBODY SEEMS TO KNOW EXACTLY WHY THIS HAPPENS, BUT IT'S A
6 PROCESS THAT CAN OBVIOUSLY BE CAUSED BY ARTERIORSCLEROSIS AS
7 WE INDICATED, BUT IT IS ALSO A SEPARATE PROCESS BECAUSE EVEN
8 WITHOUT ARTERIOSCLEROSIS, THOSE SMALL VESSELS CONTRACT, THEY
9 SQUEEZE DOWN, IF THEY ARE NOT ABSOLUTELY RIGID IN THE SMALL
10 VESSELS. AND THEY CAUSE THE BLOOD PRESSURE TO RISE. IT'S
11 LIKE OBSTRUCTING A HOSE WHEN YOU TRY TO PUSH -- PUSH WATER
12 THROUGH IT, YOU RAISE THE PRESSURE OF THE WATER IN THE LINE.
13 AND YOU HAVE TO PUSH HARDER TO GET IT BY AN OBSTRUCTION.
14 THAT'S WHAT HYPERTENSION DOES. NOW, THE BAD EFFECT OF ALL OF
15 THAT IS THAT THE PUMP WILL WEAR OUT. AND THAT'S WHY THE
16 HEART ENLARGES. THIS WAS OVER 400 GRAMS. NORMAL FOR THIS
17 LADY WOULD HAVE BEEN 250 TO 300 GRAMS. THIS IS OVER 400
18 GRAMS IN WEIGHT, AND SHE HAS A 1.8 TO 2 CENTIMETER THICKNESS
19 IN HER LEFT VENTRICULAR WALL. THIS INDICATES THAT HER LEFT
20 VENTRICULAR WALL, LIKE A -- LIKE A WEIGHTLIFTER'S MUSCLE,
21 BICEPS, HAS BECOME THICK BECAUSE OF ITS CONTINUING HARD WORK.
22 NOW, UNLIKE THE WEIGHTLIFTER WHO TAKES PRIDE IN THE BIG
23 BICEPS, A THICKENED HEART MUSCLE REQUIRES MORE NUTRITION.
24 AND IF ONE HAS ARTERIOSCLEROSIS AS THIS LADY DOES, NUTRITION
25 SIMPLY ISN'T GONNA BE ADEQUATE. AND THERE'S A BREAKING
1 POINT. AND THAT'S FRANKLY CALLED FATAL ARRHYTHMIA AND DEATH.
2 Q. WITH REGARD TO THE SECONDARY CAUSES, I SEE A LONG LIST
3 OF THINGS THAT YOU'VE INDICATED. HOW DO THESE PLAY INTO THE
4 CAUSE OF DEATH?
5 A. I CALL THESE CONTRIBUTING CONDITIONS BECAUSE THEY'RE
6 LABAELLED AS NUMBER 2, AND VERY QUICKLY, LET ME JUST SAY,
7 PEOPLE WITH DIABETES, LONGSTANDING DIABETES HAVE ACCELERATED
8 ARTERIOSCLEROSIS. IT'S JUST ONE OF THE PROBLEMS ASSOCIATED
9 WITH THAT DISEASE. THE OTHER PROBLEM IS THAT WITH UNSTABLE
10 BLOOD SUGARS, WHICH THIS LADY EXPERIENCED IN THE FIRST DAYS
11 OF JANUARY, THE UNSTABLE BLOOD SUGARS PROVIDE UNSTABLE
12 NUTRITIONAL BALANCE AND AVAILABILITY TO ALL THE TISSUES IN
13 THE BODY. SO THEY DON'T SUPPORT THE AMOUNT OF GLUCOSE, WHICH
14 IS AN ESSENTIAL NUTRIENT, IS NOT AVAILABLE ON A REGULAR
15 BASIS. LUNG ASPIRATION MEANS THAT SHE HAS ASPIRATED SOME OF
16 HER GASTRIC CONTENT. THIS IS SOMETHING THAT IS NOT UNCOMMON,
17 IN HEALTHY PEOPLE CAN BE SURVIVED, BUT IN UNHEALTHY PEOPLE,
18 IT CAN ACTUALLY DESTROY LUNG TISSUE. FIRST OF ALL, IT CAN
19 BE -- IT CAN BECOME INFECTED AS THE THIRD ITEM IS ACUTE
20 PURULENT BRONCHITIS. AND I TOOK THAT RIGHT OFF OF THE
21 AUTOPSY REPORT. THAT WAS IDENTIFIED BY THE PATHOLOGIST. AND
22 I FIND EVIDENCE FOR THAT IN THE CLINICAL RECORDS WHICH SAY
23 THAT SHE ASPIRATED ON TWO DIFFERENT OCCASIONS, THE 3RD AND
24 THE 7TH OF JANUARY. SHE HAD FEVER. SHE EVEN HAD A SEIZURE
25 BECAUSE OF THAT. PROBABLY A FEVER -- A FEVER-ASSOCIATED
1 SEIZURE. SHE HAD HYPOALBUMINEMIA, MEANING THAT BASICALLY SHE
2 HAD NO NUTRITION, EXTERNAL NUTRITION. SHE HAD A WASTING
3 DISEASE. SHE HAD DEHYDRATION, WHICH IS AN EXCELLENT BED FOR
4 THE DEVELOPMENT OF GENERALIZED INFECTION, AND IT'S POSSIBLE
5 THAT SHE COULD HAVE HAD GENERALIZED INFECTION. YOU FRANKLY
6 CAN'T DIAGNOSE THAT AT AUTOPSY. BUT I THINK IT'S A VERY
7 LEGITIMATE CLINICAL OR POSSIBLE CLINICAL DIAGNOSIS HERE. SHE
8 WAS TREATED FOR A RECTO/VAGINAL FISTULA WHICH MAY HAVE BEEN A
9 CAUSE OF THAT, IF NOT THE ACUTE PURULENT BRONCHITIS. SHE HAD
10 RENAL INSUFFICIENCY, KIDNEY INSUFFICIENCY, WHICH I INDICATED
11 ABOVE WAS DUE TO THE ARTERIOSCLEROSIS. SHE HAD SEVERE
12 DEMENTIA AND WASTING BECAUSE OF THAT. AND PSYCHOTIC
13 DEPRESSION WHICH CAUSED HER TO -- IF YOU RECALL, SHE WAS A
14 LADY WHO WAS SO CONFUSED THAT SHE -- SHE USED TO DRINK
15 PHENOMENAL AMOUNTS OF WATER. THIS ACTUALLY CAN BE
16 DELETERIOUS. POLYDIPSIA IS AN ABNORMAL -- THAT'S WHY IT'S
17 CALLED PSYCHOGENIC. IT'S AN ABNORMAL CONSUMPTION OF WATER
18 THAT PUTS YOUR ELECTROLYTES AND YOUR FLUID BALANCE OUT OF
19 WHACK. WELL, THE BEST WAY TO TREAT THAT IS RESTRICTION.
20 THIS LADY WOULD DRINK WATER OUT OF TOILETS WHEN RESTRICTED IF
21 NOT PROPERLY SUPERVISED OR CONTINUALLY SUPERVISED SIMPLY
22 BECAUSE SHE WAS DRIVEN TO CONSTANTLY DRINK WATER EVEN THOUGH
23 THE BODY DIDN'T REQUIRE ALL OF THAT. AND AFTER SHE HAD BEEN
24 RESTRICTED AND -- FROM IT ABSOLUTELY, THEN SHE BECAME
25 DEHYDRATED. SHE WENT TO THE OTHER WAY. SO SHE HAD A SEVERE
1 FLUID AND ELECTTROLYTE PROBLEM GOING THROUGH THE LAST DAYS OF
2 LIFE. AND THEN SHE HAD CHRONIC LOW BACK PAIN WHICH WAS
3 PRESENT EVEN AFTER SHE HAD DISK SURGERY FOR WHICH SHE WAS
4 TREATED, AS YOU PROBABLY HAVE DISCUSSED ELSEWHERE, WITH
5 OPIATE MEDICATIONS OVER A LONG PERIOD OF TIME.
6 Q. ULTIMATELY, DR. CASSIN, WITH REGARD TO MARY CRANE, DO
7 YOU HAVE AN OPINION TO A DEGREE OF REASONABLE MEDICAL
8 CERTAINTY AS TO THE CAUSE OF DEATH OF MARY CRANE?
9 A. YES.
10 Q. AND WHAT IS THAT OPINION?
11 A. I THINK THAT MARY CRANE DIED BY THE TWO PROCESSES I PUT
12 AT THE TOP OF THIS LIST. SHE DIED BECAUSE SHE HYPERTENSION,
13 WHICH LEFT ITS ANATOMICAL LANDMARK CLEARLY AND BOLDLY IN THE
14 AUTOPSY. ALL WE HAD TO DO WAS READ THE PATHOLOGIST'S REPORT.
15 AND ARTERIOSCLEROSIS, WHICH WAS THE OTHER SIDE OF THAT COIN,
16 MAKING HER BLOOD VESSELS CRIMPED DOWN AND OBSTRUCTED SO THAT
17 EVEN WITH HIGH BLOOD PRESSURE, SHE WAS GETTING VERY POOR
18 NUTRITION TO HER HEART, HER BRAIN, HER LUNG, AND HER KIDNEY.
19 Q. AND DO YOU HAVE AN OPINION TO A DEGREE OF REASONABLE
20 MEDICAL CERTAINTY AS TO THE MANNER OF DEATH OF MARY CRANE?
21 A. YES. THE MANNER OF DEATH, BECAUSE SHE DIED OF HER
22 DISEASES, AGAIN, IS A NATURAL DEATH.
23 MS. ISAACSON: YOUR HONOR, I HAVE TWO MORE AUTOPSIES TO
24 GO THROUGH. SHOULD WE TAKE A BREAK NOW?
25 THE COURT: I THINK WE NEED TO TAKE OUR LUNCH BREAK AT
1 THIS TIME. DOCTOR, YOU MAY STEP DOWN.
2 THE WITNESS: THANK YOU.
3 THE COURT: LADIES AND GENTLEMEN, WE'LL BE BACK AT 1:15.
4 AGAIN REMIND YOU OF MY PRIOR CAUTION. WE'LL SEE YOU BACK
5 THEN. 1:15. BE IN RECESS UNTIL THEN.
6 (MORNING SESSION ENDED.)
THE COURT: PARTIES AND COUNSEL ARE PRESENT. JURY
IS IN THE JURY BOX. DOCTOR, WILL YOU COME BACK UP TO THE
STAND, PLEASE. THE COURT REMINDS YOU, DOCTOR, THAT YOU'RE
STILL UNDER OATH.
THE WITNESS: THANK YOU.
THE COURT: YOU MAY CONTINUE WITH YOUR EXAMINATION,
MS. ISAACSON.
MS. ISAACSON: THANK YOU, YOUR HONOR.
DIRECT EXAMINATION (CONT'D)
BY MS. ISAACSON:
Q. DR. CASSIN, LET'S TALK ABOUT LYDIA SMITH. LET'S GO TO
STATE'S 5-C, PAGE 1 OF LYDIA SMITH'S AUTOPSY REPORT. AGAIN,
A LIST BY THE PATHOLOGIST OF HIS FINAL PATHOLOGIC DIAGNOSES.
FIRST, CAN YOU EXPLAIN WHY THAT LIST IS SHORTER THAN THE
PREVIOUS LIST?
A. WELL, ACTUALLY, I'M NOT SURE I CAN. BUT THE DIFFERENCE
IN THIS PARTICULAR CASE, AT LEAST THE MOST REMARKABLE
DIFFERENCE I THINK FROM THE STANDPOINT OF POSTMORTEM
EXAMINATION, IS THAT THIS BODY WAS LEAST WELL-PRESERVED, AND
IN FACT, WAS POORLY PRESERVED. THIS BODY HAD BEEN IN THE
GROUND FOR FOUR AND A HALF YEARS PRIOR TO AUTOPSY, AND I
SUSPECT THAT'S WHY WE HAVE KIND OF A TRUNCATED LIST. BUT I
CAN'T SAY FOR SURE BECAUSE THERE'S AN ABSENCE OF FINDINGS
STILL IN THIS FINAL LISTING OF ABNORMAL FINDINGS.
Q. WELL, LET'S GO TO THE LIST THAT YOU COMPILED THAT'S BEEN
MARKED DEFENDANT'S EXHIBIT 107. WITH LYDIA SMITH, WHAT HAVE
YOU IDENTIFIED AS HER PRIMARY CAUSE OF DEATH?
A. WELL, REMEMBERING THAT C.O.D. MEANS CAUSE OF DEATH AND
I'M INCLUDING UNDER THAT AN OUTLINE THAT IS
CHARACTERISTICALLY USED ON THE DEATH CERTIFICATION FORMAT.
WHAT YOU SEE HERE IS THAT I HAVE AGAIN IDENTIFIED -- AND
THIS IS THROUGH THE EXAMINATION OF THE PATHOLOGIST OF THE
BODY FOUR AND A HALF YEARS, NONETHELESS -- OR NOTWITHSTANDING
SOME ADVANCED DECOMPOSITIONAL CHANGES. BUT THERE WAS STILL
ATHEROSCLEROSIS AND IT WAS SIGNIFICANT, IT WAS SEVERE. AND I
INDICATE THAT THIS IS THE PRIMARY CAUSE OF DEATH HERE BECAUSE
OF THOSE FINDINGS, THAT IN SPITE OF THE FACT THAT MUCH OF
THIS BODY HAD MELTED AWAY SO TO SPEAK, THERE STILL WAS
IDENTIFICATION OF CALCIFIC RIGHT CORONARY RIGHT
ATHEROSCLEROSIS. THERE WAS STILL IDENTIFICATION OF A RIGID
AORTA BECAUSE OF THE CALCIFICATION AND THERE WAS STILL AN
IDENTIFICATION OF CYSTIC KIDNEYS, WHICH RESULT, OF COURSE,
AGAIN, ATHEROSCLEROSIS.
ALONG WITH THAT IS HISTORY OF UNSTABLE ANGINA. MEANING
THAT THIS PERSON FROM TIME TO TIME EXPERIENCED CHEST PAIN AND
WAS TREATED FOR THAT. THERE WAS ATRIAL FIBRILLATION WHICH IS
NOT UN COMMON IN PATIENTS WITH THAT DISEASE IN THEIR HEART
FROM ATHEROSCLEROSIS.
Q. WHAT DOES THAT TERM MEAN, THAT ATRIAL FIBRILLATION?
A. ATRIAL FIBRILLATION IS ARRHYTHMIA WHICH IS NOT FATAL. IT
MEANS THAT A PORTION OF THE HEART IS BEATING WITHOUT CONTROL
BUT IT ISN'T THE MAIN PUMPING CHAMBER. IT IS THE LESSER TWO
PUMPING CHAMBERS.
Q. AND SO THIS SECTION HERE, THIS IS THE HISTORY THAT YOU
SAW IN THE MEDICAL RECORDS?
A. THESE ARE HISTORICAL POINTS THAT COME UP IN REVIEW OF
MEDICAL RECORDS.
Q. RIGHT.
A. INCLUDING THE IDENTIFICATION -- OR THE CITATION OF A
PREVIOUS MYOCARDIAL INFARCT OR HEART ATTACK. IN SUPPORT OF
THAT AS WELL IS THE EFFECT ON THE BRAIN, AND THAT IS THAT
THERE WERE -- THERE WAS A HISTORY OF STROKES AND THE MOST
DRAMATIC BEING, OR AT LEAST ACCORDING TO THE RECORDS I
REVIEWED THE MOST DRAMATIC BEING, A RECENT ONE. BUT PRIOR TO
ADMISSION, THAT'S WHAT P.T.A. MEANS, THERE WAS A RIGHT
PARIETAL STROKE, MEANING THAT THE RIGHT SIDE OF THE BRAIN,
THE DOMINANT HEMISPHERE OR PART OF THE HEMISPHERE HAD BEEN
REDUCED SIGNIFICANTLY BY DESTRUCTION BY A STROKE. SO
VASCULAR OBSTRUCTION DUE TO ATHEROSCLEROSIS.
Q. AND DO I UNDERSTAND -- WE'VE BEEN TALKING A LOT ABOUT
THIS ATHEROSCLEROSIS AND ALL THESE PATIENTS IT'S INDICATED IN
THE RECORDS THEY HAVE DEMENTIA, IS THIS ACTUALLY PART OF THE
CAUSE OF THE DEMENTIA?
A. WELL, THIS PERSON AS YOU CAN SEE DOWN IN NUMBER TWO HAD
PSYCHOTIC DEPRESSION AND I SAY IT'S AFTER C.V.A., IT'S AFTER
THE STROKE. THE MAJOR PSYCHIATRIC PROBLEM THAT IS IDENTIFIED
IN THE TERMINAL RECORDS IS PSYCHOTIC DEPRESSION WITH
AGITATION, AND THIS IS DATED APPARENTLY BACK TO THE TIME
SEVERAL WEEKS BEFORE OF STROKE. AND SO IT'S ACCEPTABLE FROM
THE STANDPOINT OF ONCE ONE LOSES A LOT OF ONE'S BRAIN MASS,
ONE ALSO LOSES THE BENEFITS OF HAVING BRAIN CONTROL OF
FUNCTION AND OF OTHER THINGS LIKE ATTITUDE, BEHAVIOR PATTERNS
AND THAT SORT OF THING. SO, YES, IT IS A PART OF
ATHEROSCLEROSIS.
Q. OKAY. THEN YOU'VE INDICATED IN THE SECOND SECTION
VALVULAR HEART DISEASE. HOW IS THAT A CONTRIBUTING FACTOR?
A. THE BEST PRESERVED ITEM IN THE CASKET HERE OTHER THAN THE
CASKET ITSELF WAS THE HEART VALVE THAT HAD BEEN REPLACED IN
THIS LADY. AND WHAT THIS VALVE DID APPARENTLY -- IT WAS
DESCRIBED AS BEING FUNCTIONAL, MEANING THAT IT APPEARED TO
WORK OKAY. IT DIDN'T APPEAR TO BE DAMAGED, FOR INSTANCE, OR
ANYTHING LIKE THAT. NEVERTHELESS, THIS LADY HAD HAD A SEVERE
ENOUGH VALVULAR DAMAGE WHICH WAS STILL PRESENT BY WAY OF
CALCIFICATION, SO THE EFFECTS OF ATHEROSCLEROSIS AROUND THE
ANNULUS OR RING AROUND ITS BASE, EVEN THOUGH THOSE THINGS
WERE STILL PRESENT, THE HEART VALVE HAD BEEN REPLACED.
AND SO PEOPLE WITH VALVULAR HEART DISEASE, EVEN THOUGH
THEY MAY HAVE A REPLACEMENT OF THE VALVE, ARE STILL LIVING SO
TO SPEAK ON BORROWED TIME. THE VALVE MAY APPEAR TO BE
FUNCTIONING WELL BUT IT ISN'T THE SAME AS A REAL HEART VALVE.
IT'S SIMPLY A MECHANICAL VALVE THAT MAY OCCASIONALLY MISFIRE,
MISFUNCTION AND NOT REVEAL BY EXAMINATION EXCEPT UNDER
FLUOROSCOPY, AN IN-LIFE OR DURING-LIFE STUDY, THAT IT
ACTUALLY IS NOT FUNCTIONING ADEQUATELY.
IN ANY CASE, AFTER DEATH, IT WAS APPARENTLY STILL
FUNCTIONING. ON THE OTHER HAND, THE DISEASE THAT CAUSED THE
VALVE TO BE ABNORMAL WAS STILL PRESENT, AND THAT'S THE
CALCIFIC ANNULUS OR SURROUNDING TISSUE IN THE VALVE.
Q. WE'VE TALKED A LITTLE BIT ABOUT THE PSYCHOTIC DEPRESSION.
YOU'VE ALSO INDICATED HERE IN CONJUNCTION WITH THAT A REFUSAL
OF FLUIDS AND FOOD. HOW DOES THAT TIE INTO PSYCHOTIC
DEPRESSION AND INTO THE CAUSE OF DEATH?
A. THE PSYCHOTIC DEPRESSION IS TIED IN HISTORICALLY TO THE
STROKE. THE PSYCHOTIC DEPRESSION WAS ONE OF THE MAIN
MANIFESTATIONS OF THIS SEVERE RAPID ONSET OF DEMENTIA IN THIS
PERSON. SO IT IS A PART OF THE MANIFESTATION OF DEMENTIA
WHICH INCLUDES THE REFUSAL OF WHAT WOULD ORDINARILY BEEN
CONSIDERED NORMAL OR BENEFICIAL, SELF-PRESERVING BEHAVIOR
WHICH IS FOUND IN DEMENTIA ROUTINELY. IT'S A REFUSAL NOT
ONLY OF FLUID AND NOURISHMENT SUSTENANCE, BUT FRANKLY IN THIS
CASE, IT WAS ALSO A REFUSAL OF ORAL MEDICATION.
Q. NOW, WITH REGARD TO THE WEIGHT LOSS, OF COURSE, WE'VE
TALKED ABOUT THE REFUSAL OF FLUIDS AND FOOD. NOW, THIS ALL
TOOK PLACE DO I HAVE IT RIGHT IN THE RECORDS PRIOR TO HER
ADMISSION?
A. YES. THE 30-POUND WEIGHT LOSS YOU'RE REFERRING TO? YES,
SHE WAS STILL ANOREXIC MEANING THAT SHE DID NOT EXHIBIT ANY
APPETITE FOR FOOD. BUT SHE HAD OVER A RELATIVELY RECENT
PERIOD OF TIME LOST 30 POUNDS WHICH IS A DRAMATIC SHIFT IN
WELL-BEING DOWNWARD AND HAPPENS IN ELDERLY PEOPLE
CHARACTERISTICALLY ASSOCIATED WITH DEMENTIA.
Q. THEN HOW DOES A URINARY TRACT INFECTION PLAY INTO THE
CAUSE OF DEATH?
A. URINARY TRACT INFECTIONS FOR ALL THEIR APPARENT MINOR
CLASSIFICATION CERTAINLY BY A PATHOLOGIST BECAUSE THEY'RE
ASSOCIATED WITH A RELATIVELY SMALL PART OF THE BODY, BUT EVEN
BY SOME CLINICIANS WHO IN TREATING OTHERWISE NORMAL PATIENTS
CAN TREAT IT EFFECTIVELY. URINARY TRACT INFECTIONS HAVE A
WAY OF DEPLETING EVEN NORMAL PEOPLE OF NORMAL ENERGY. I
GUESS THE PROOF WOULD BE IN HAVING ONE YOURSELF AND
EXPERIENCING IT, BUT MANY PHYSICIANS CAN TELL YOU URINARY
TRACT INFECTIONS CAN DEPLETE PEOPLE OF ENERGY JUST LIKE
CONSTIPATION CAN DEPLETE YOU OF ENERGY FOR A PERIOD OF A TIME
OR HAVING A SEVERE UPPER RESPIRATORY TRACT INFECTION. IN ANY
CASE, IT'S ONE OF THOSE NEGATIVE INFLUENCES ON NORMAL
METABOLISM.
Q. AND WHAT IS THIS TERM IN THIS NEXT SECTION?
A. SPONDYLARTHRITIS MEANS THAT THERE IS SPINAL DISEASE. IT
MEANS THAT THERE IS ARTHRITIS OF THE SPINE. AND THE TERM
THAT I TAKE FROM THE AUTOPSY REPORT IS MILD SCOLIOSIS,
MEANING THAT THERE IS AN S-SHAPED CURVE IN THE SPINE. NOW BY
MILD WE'RE TALKING ABOUT SOMETHING LESS THAN SEVERE, OKAY.
SO THERE ISN'T SUCH A BEND IN THE SPINE A THE PERSON IS
ABSOLUTELY BENT OVER SIDEWAYS. BUT THERE IS AN S-SHAPED
CURVE, WHICH MEANS THAT THE NORMAL STRAIGHT CONFIGURATION OF
THE SPINE IS COMPROMISED BY A TILTING IN TWO DIFFERENT WAYS
OF THE SPINE WHICH CAUSES COMPRESSION IRREGULARITY AND
FRACTURES IN ELDERLY PEOPLE WITH OSTEOPOROSIS AND ALL ELDERLY
PEOPLE HAVE OSTEOPOROSIS.
Q. HOW DOES THAT FINDING FACTOR INTO CAUSE OF DEATH?
A. IT'S -- IT'S AN AGGRAVATION MINIMALLY. IT'S A SIGN OF
GENERALIZED WEAKNESS ALSO AND SO I PUT IT LOWER ON THE LIST.
BUT I CONSIDER IT AS ANOTHER MANIFESTATION LIKE DEPRESSION
AND SO ON AS A MANIFESTATION OF FRAILNESS AND LESS VIGOROUS,
PERHAPS EVEN PAINFUL EXISTENCE.
Q. AND THEN FINALLY RENAL FAILURE, WHAT DOES THAT MEAN?
A. THIS PERSON'S URINE OUTPUT DROPPED TO ZERO JUST BEFORE
DEATH INDICATING THAT THERE WAS LACK OF HYDRATION, LACK OF
ADEQUATE HYDRATION SIMPLY BECAUSE THERE WAS WITHDRAW OF
TREATMENT AND THE PERSON'S KIDNEY'S HAD FAILED. THIS IS A
PART OF THE DYING PROCESS. KIDNEYS WILL FAIL ACUTELY IN
VIRTUALLY ALL DEATH.
Q. WE'VE TALKED ABOUT THE ISSUE OF DEHYDRATION AND LACK OF
NUTRITION IN A COUPLE OF THE CASES. YOU'VE ALSO TALKED ABOUT
PATIENTS REFUSING NUTRITION. WAS THERE ANYTHING IN THE
MEDICAL RECORDS THAT SUGGESTED TO YOU A REASON WHY THIS
WASN'T PROVIDED ARTIFICIALLY?
A. WELL, IT WASN'T PROVIDED ARTIFICIALLY SUCH AS BY
INTUBATION, INTRAVENOUS HYDRATION, MEDICATION, THAT SORT OF
THING, IT WASN'T PROVIDED BECAUSE IT WAS PROHIBITED IN MOST
CASES.
MR. MAJOR: OBJECTION, YOUR HONOR. BEYOND THE SCOPE
OF HIS EXPERTISE.
THE COURT: OVERRULED.
MS. ISAACSON: YOU CAN ANSWER THAT.
THE WITNESS: THE RECORDS INDICATE THAT THERE WAS
FAMILY CONFERENCING AND THERE WERE IN SOME CASES WRITTEN
DOCUMENTS THAT SAID THAT AS A PART OF TERMINAL CARE THERE
SHOULD BE NO SUPPORT OF LIFE BEYOND MINIMAL MAINTENANCE OR
CARING FOR DISCOMFORTS. AND SO I UNDERSTOOD THIS THAT IT WAS
VERY LOGICAL, THAT EVEN THOUGH A PERSON WOULD GO INTO RENAL
FAILURE, WITHOUT ADEQUATE HYDRATION, THE ADEQUATE HYDRATION
WASN'T SUPPLIED SIMPLY BECAUSE IT WAS NOT PERMITTED BY THE
PERSON'S OWN WISHES, SUPPORTED BY THEIR THE FAMILIES AND
CAREGIVERS.
Q. (BY MS. ISAACSON) DO YOU HAVE AN OPINION TO A DEGREE OF
MEDICAL CERTAINTY AS TO THE CAUSE OF DEATH OF LYDIA SMITH?
A. YES.
Q. WHAT IS THAT OPINION?
A. LYDIA SMITH DIED WITH EVIDENCE OF CHRONIC ADVANCED
DISEASE. AGAIN, IN THIS CASE IT WAS ATHEROSCLEROSIS. IT WAS
MANIFESTED IN THE HEART BY HISTORY BECAUSE THE HEART WAS MUSH
IN THE CASKET. IT WAS PRESENT IN THE BRAIN WHICH LIKEWISE
WAS MUSH IN THE CASKET BUT HISTORICALLY WAS WELL-DOCUMENTED
THAT SHE HAD A SEVERE STROKE AND WAS COMPROMISED BY THAT AS
PSYCHIATRICALLY AS WELL AS PHYSICALLY. AND I INCLUDE
VALVULAR HEART DISEASE AND DEMENTIA AND ALL THE
MANIFESTATIONS OF DEMENTIA AS CONTRIBUTING TO THAT SEVERE
CHRONIC DISEASE.
Q. DO YOU HAVE AN OPINION TO A DEGREE OF REASONABLE MEDICAL
CERTAINTY AS TO THE MANNER OF DEATH OF LYDIA SMITH?
A. YES.
Q. AND WHAT IS THAT OPINION?
A. MY OPINION THAT THIS, AGAIN, IS A NATURAL DEATH. THERE
IS PLENTY TO SUPPORT HERE THAT THIS DEATH HAPPENED AS A
CONSEQUENCE OF DISEASE AND THAT ALONE.
Q. LET'S TALK ABOUT ENNIS ALLDREDGE. WE'LL GO TO STATE'S
6-C PAGE 1. I THINK THIS MAY ACTUALLY THE BE THE WRONG PAGE.
THIS MAY NOT BE THE FINAL PAGE.
MS. ISAACSON: WHY DON'T WE -- CAN YOU TELL,
COUNSEL, IS THAT THERE'S SOME HAND WRITING ON THAT.
THERE'S NOT THAT ON THE FINAL, IS THERE?
Q. (BY MS. ISAACSON) LET'S GO ON TO -- I DON'T ACTUALLY
HAVE HIS FINAL FINDINGS THERE SO WHY DON'T WE TALK ABOUT
YOURS THAT I ASSUME WE'VE TALKED ABOUT BEFORE.
YOU REVIEWED THE PATHOLOGICAL DIAGNOSES IN EVERY CASE
FROM THE OTHER PATHOLOGIST?
A. I DID AND I USED THEM HERE. I INCLUDE THEM IN HERE.
Q. SO WE'LL GO TO THIS PAGE THEN AND THIS IS GOING TO BE
DEFENDANT'S EXHIBIT 108, ENNIS ALLDREDGE. LET'S START WITH
AGAIN CAUSE OF DEATH, THE PRIMARY CAUSE -- AM I USING THE
RIGHT TERM PRIMARY CAUSE?
A. SURE, THAT'S FINE. SURE. CAUSE OF DEATH, AGAIN ALL IN
NUMBER ONE. AND YOU CAN SEE THAT THERE ARE THREE PRIMARILY
LISTED. ONE IS ATHEROSCLEROSIS WHICH HAD BEEN PRESENT FOR
YEARS AND WAS SEVERE, QUITE FRANKLY, ADVANCED ATHEROSCLEROSIS
AND WE'LL TALK ABOUT THAT IN A MINUTE. BUT ALONG WITH THAT,
AND WE SAW THIS BEFORE, WAS HIGH BLOOD PRESSURE. HIGH BLOOD
PRESSURE ADDING ITS OWN INSULTS TO THE BODY BY WAY OF
INCREASING HEART SIZE AND REDUCING KIDNEY FUNCTION. AND
THEN, OF COURSE, AGAIN, THERE WAS ACUTE BRONCHOPNEUMONIA. I
ADD THAT SIMPLY BECAUSE AS A TERMINAL FINDING, IT IS NOT
UNCOMMON IN THE DEATHS OF PEOPLE WHO ARE CHRONICALLY ILL TO
FALL VICTIM TO PNEUMONIA.
SO WE CAN GO BACK TO THE FIRST ONE, IF YOU WISH, AND LOOK
AT THE ITEMS THAT ARE DEMONSTRATIVE OF ATHEROSCLEROSIS BEING
THE PRIMARY CAUSE OF DEATH. AND THEY ARE FIRST OF ALL THE
HISTORY THAT HE HAD BYPASS GRAFTING. HE HAD THREE VESSEL
BYPASS GREATER THAN 10 YEARS BEFORE. MOST CARDIOLOGISTS WILL
TELL YOU 10 YEARS AND YOU'RE OUT. IN OTHER WORDS, 10 YEARS
FOR CORONARY ARTERY BYPASS IS A PRETTY GOOD LIFE EXPECTANCY.
HE HAD HAD THAT GREATER THAN 10 YEARS BEFORE.
NOW WHAT DID WE FIND THERE OR WHAT DID THE PATHOLOGIST
WHO DID THIS AUTOPSY FIND THERE THREE AND A HALF YEARS AFTER
THIS BODY WAS IN THE GROUND? SEVERE CORONARY ARTERY DISEASE.
EVEN AT THAT POINT THERE WAS 90 PERCENT OCCLUSION OF THE
RIGHT CORONARY ARTERY AND THE LEFT ANTERIOR DESCENDING ARTERY
AND 30 PERCENT OCCLUSION OF THE CIRCUMFLEX. THOSE ARE THE
THREE MAJOR BRANCHES OF THE CORONARY CIRCUIT. AND YOU SEE
THAT THERE IS MAJOR OBSTRUCTION, WHICH PERHAPS AT THE TIME OF
DEATH WAS EVEN VERY LIKELY GREATER THAN 90 PERCENT, BUT THREE
AND A HALF YEARS AFTER BEING IN THE GROUND THREE AND A HALF
YEARS, WE'RE STILL LEFT WITH 90 PERCENT OCCLUSION.
Q. I THINK WE COVERED THIS A LITTLE BIT BUT I GUESS THE IDEA
THAT YOU'RE EXPRESSING IS THAT WHAT YOU WOULD SEE THREE AND A
HALF YEARS LATER WOULD LIKELY BE DIMINISHED BY THE
DECOMPOSITION, DO I HAVE THAT RIGHT?
A. YES.
Q. SO YOU WOULD EXPECT THAT AT THE TIME OF DEATH THIS
CONDITION ACTUALLY WOULD HAVE BEEN -- YOU COULD SEE A MORE
SERIOUS CONDITION?
A. IT WOULD HAVE BEEN MORE SEVERE, YES.
Q. WHAT IS THIS SECTION TALKING ABOUT?
A. THE POSTERIOR AND ANTEROSEPTAL LEFT VENTRICULAR SCARS, WE
ARE TALKING HERE ABOUT SCARS, BIG AREAS OF FIBROSIS,
DESTROYED HEART TISSUE THAT HAVE RESULTED DURING LIFE FROM
HEART ATTACKS ON AT LEAST TWO DIFFERENT OCCASIONS. SO THIS
MAN HAD AT LEAST TWO SEVERE HEART ATTACKS, MOST LIKELY
RESULTING, OF COURSE, FROM THE SEVERE CORONARY ARTERY
DISEASE.
AND AS WE INDICATE BEFORE, HE HAS ALSO AS A RESULT OF
ATHEROSCLEROSIS, HE HAS DIMINISHED KIDNEY FUNCTION AND THE
ANATOMIC EVIDENCE FOR THAT IS IS THAT HE HAS ATHEROSCLEROSIS
IN THE KIDNEY, WHICH IS AN ADVANCED CHANGE.
ANOTHER BIT OF EVIDENCE THERE IS HE HAD -- IT IS
THOUGHT -- A PROBABLE STROKE IN THE HOSPITAL. THIS WAS
SHORTLY BEFORE HE DIED AND SHORTLY BEFORE THE DICTATES OF HIS
LIVING WILL WERE PUT INTO FULL EFFECT. AND AT THAT TIME IT
WAS CONSIDERED AN OCCIPITAL STROKE. I SUSPECT IT WAS
PROBABLY GREATER THAN AN -- IN OTHER WORDS, IT WASN'T SIMPLY
CONFINED --
MR. MAJOR: OBJECTION, YOUR HONOR, HE'S SPECULATING.
THE COURT: SUSTAINED.
THE WITNESS: OKAY.
Q. (BY MS. ISAACSON) WELL --
A. THERE WAS -- THE REASON I SAY THIS IS, THOUGH, IS THAT
THERE ARE RESPIRATORY ABNORMALITIES THAT CAME ON AT THAT TIME
THAT ARE NOT ASSOCIATED WITH OCCIPITAL STROKES. IT PROBABLY
WAS A LARGER THAN OCCIPITAL STROKE AT THE BACK AND BOTTOM OF
THE BRAIN TO CAUSE AN INFLUENCE ON THE BRAIN STEM.
Q. HOW ABOUT THE HYPERTENSION, HOW DOES THAT FACTOR IN?
A. HIGH BLOOD PRESSURE WE HAVE SPOKEN OF BEFORE. LET ME
QUICKLY REVIEW THAT TO SAY AGAIN THAT HIGH BLOOD PRESSURE
CAUSES AN ABNORMALITY OF THE PUMP. IT CAUSES IT TO EXPAND
AND GET BIGGER WHICH ONLY INCREASES ITS OWN LIABILITY FOR
SUPPORT BY THE VASCULAR SYSTEM, ESPECIALLY WHERE THE VASCULAR
SYSTEM IS SO POORLY ABLE TO GET NUTRITION. IT'S GOT A 1.9
CENTIMETER THICKNESS IN THE LEFT VENTRICLE, THE MAIN PUMPING
CHAMBERS, AND THIS IS WHAT THE PATHOLOGIST TELL US WHO DID
THE AUTOPSY, WHICH IS TWICE THE THICKNESS IT SHOULD BE. AND
OF COURSE, THERE IS ARTERIOLAR NEPHROSCLEROSIS, EVEN THE
SMALL VESSELS OF THE KIDNEYS WHICH ARE CHARACTERISTICALLY NOT
AFFECTED BY HIGH BLOOD PRESSURE ARE AFFECTED AS WELL. SO
THERE'S KIDNEY DISEASE ASSOCIATED WITH BOTH ATHEROSCLEROSIS
AND WITH HYPERTENSION.
Q. SO THIS THAT YOU JUST REFERRED TO THIS 1.9 IS ACTUALLY
SOMETHING YOU GOT FROM THE PATHOLOGIST?
A. OH, YES. IN FACT, EVERYTHING HERE I GOT FROM THE
PATHOLOGIST THAT I'VE TALKED ABOUT.
Q. OKAY. AND YOU'VE MENTIONED --
A. EXCUSE ME. ANOTHER THING I DIDN'T TELL YOU -- I SAID
CARDIOMEGALY. THIS IS A 570 GRAM HEART. THE NORMAL HEART
WEIGHT FOR THIS MAN WOULD HAVE BEEN ABOUT 350 GRAMS. THIS IS
A MASSIVELY ENLARGED PUMP. AND ENLARGEMENT ONLY MEANS
WEAKNESS, IT DOESN'T MEAN A GREAT BICEP.
Q. AND THEN THE BRONCHOPNEUMONIA, HOW DOES THAT FACTOR IN?
A. ACUTE BRONCHOPNEUMONIA IS A TERMINAL CHANGE. IT'S A
CHANGE THAT IS INFECTION, IT COMES AT THE END OF LIFE. IT
WAS PRESENT IN HALF THE SECTIONS THAT WERE PRESENT THERE AND
IT'S PRESENT ALSO IN BOTH LUNGS SLIDES. SO THERE'S -- WE
CAN'T DISMISS IT AS INSIGNIFICANT, IT'S IN BOTH LUNGS.
Q. YOU'VE MENTIONED THESE SLIDES. DO I UNDERSTAND CORRECTLY
THAT FOUR SLIDES WERE TAKEN OF SECTIONS OF THIS BODY'S LUNGS?
A. FOUR SECTIONS WERE MADE AND THEY WERE SET UP IN TWO
SLIDES. AND THE USUAL STANDARD IS TO PREPARE THE SECTIONS
FROM ONE LUNG IN ONE SLIDE AND THE OTHER LUNG IN THE OTHER
SLIDE.
Q. NOW, WHAT ABOUT THE SECONDARY ITEMS THAT YOU'VE
IDENTIFIED HERE, HOW DOES THE DIABETES FACTOR IN?
A. THIS MAN OF ALL OUR FIVE PATIENTS HAD THE MOST SEVERE
DIABETES. HE HAD THE LONGEST STANDING DIABETES, IT GOES FOR
20 YEARS, IT'S INSULIN DEPENDENT. IT'S THE WORST KIND SO TO
SPEAK, AND IN FACT, IT IS AS I SAID BEFORE ALWAYS GOING TO
CAUSE AN INCREASE IN ATHEROSCLEROSIS THERE IN ALL PATIENTS.
IT IS JUST PART OF THE UNFORTUNATE RESULT OF THAT DISEASE IN
PEOPLE WHO HAVE IT FOR A LONG PERIOD OF TIME.
IT WAS ALSO POORLY CONTROLLED. AS YOU CAN SEE THERE, THE
HEMOGLOBIN A1C WHICH IS A WAY OF TESTING ITS CHRONIC CONTROL,
A TEST THAT'S AVAILABLE FOR THE LAST 15 YEARS OR SO WAS
INCREASED INDICATING THAT THIS CONTROL OF DIABETES OR BLOOD
SUGAR WAS NOT VERY GOOD. THIS IS NOT TO POINT THE FINGER AT
ANYBODY. THE POINT IS THAT IT WAS PROBABLY NOT ABLE TO BE
CONTROLLED VERY WELL WHEN HE WAS NOT UNDER AN ACUTE CARE
REGIMEN.
Q. SO WHEN YOU'RE REFERRING TO THE POOR RECENT CONTROL, WAS
THAT PRIOR TO HIS ADMISSION?
A. OH, YEAH. YEAH. EXACTLY. YES.
Q. YOU ALSO DETECTED EMPHYSEMA?
A. YES. HE DID HAVE EMPHYSEMA. IT WAS A DISEASE THAT HE AS
WELL AS A NUMBER OF OTHERS HAD. IT'S NOT UNCOMMON IN OLDER
AGE -- AND I PUT IT IN THERE NOT AS A PRIMARY CAUSE BUT
SIMPLY AS A REASON WHY HIS BLOOD MAY NOT HAVE BEEN OXYGENATED
AS EFFICIENTLY HAD HE NOT HAD IT. SO IT MAKES
ATHEROSCLEROSIS, AS BAD AS IT IS, EVEN WORSE.
Q. WE'VE TALKED ABOUT DEMENTIA REALLY WITH ALL OF THE
PATIENTS AND I -- IS THERE ANYTHING DIFFERENT ABOUT HOW IT
WOULD HAVE AFFECTED MR. ALLDREDGE WITH REGARD TO CAUSE OF
DEATH?
A. WELL, HE -- HE HAD AS I INDICATE HERE AND I GET THIS OUT
OF THE MEDICAL RECORDS THAT HE HAD A VERY RAPID ONSET. IT
WAS MULTI-INFARCT, SO IT WAS DUE TO ATHEROSCLEROSIS BY THE
STUDIES AND CLINICAL OBSERVATIONS MADE. IT DID NOT HAVE A
MYSTERIOUS ORIGIN. IT WAS REALLY A PART OF HIS CHRONIC
DISEASE WHICH OBVIOUSLY WAS ALREADY SEVERE. IT CAME ON,
HOWEVER, FAIRLY RAPIDLY SO VERY LIKELY BECAUSE OF STROKES,
REPEATED SMALL STROKES THAT WERE PRESENT. AND IT WAS -- AND
IT WAS PREVALENT IN THE YEAR PREVIOUS TO HIS LIFE SO THAT IT
AFFECTED HIS ENTIRE WELL-BEING THE WAY DEMENTIA, AS WE'VE
SAID ALREADY, AFFECTS PEOPLE BY ALTERING THEIR ATTITUDE,
THEIR COOPERATIVENESS, THEIR SENSE OF SELF-PRESERVATION,
THEIR INTEREST IN THEIR OWN CARE AND THEIR OWN WELL-BEING AS
WELL. AND I INDICATE HERE THAT IT PRECIPITATED THIS ERRATIC
BEHAVIOR, RAPID ONSET AND DIMINISHING OF HIS WELL-BEING
PRECIPITATED THE FOLLOWING OF HIS LIVING WILL, WHICH I FOUND
TO BE AN ELOQUENT DOCUMENT AND VERY SPECIFIC --
MR. MAJOR: OBJECTION, YOUR HONOR.
THE COURT: SUSTAINED. STRICKEN. THAT'S A
DIFFERENT AREA, DOCTOR.
THE WITNESS: SORRY.
Q. (BY MS. ISAACSON) DR. CASSIN, LET'S TALK ABOUT THE
MYCOSIS FUNGOIDES, AM I SAYING THAT RIGHT? WHAT IS THAT?
A. MYCOSIS FUNGOIDES IS A SKIN CONDITION THIS IS SIMILAR TO
A LYMPHOMA OR A CANCER OF THE LYMPHOID SYSTEM, THE LYMPH
NODES. IT IS A SKIN DISEASE, HOWEVER, AND IT IS CHRONIC.
AND IN THIS CASE HAS BEEN TREATED AS IT OFTEN IS WITH TOTAL
BODY IRRADIATION. I DON'T KNOW WHAT IT'S CONTINUING EFFECT
ON HIM WAS BECAUSE THERE WAS NO SPECIFIC MENTION OF IT. I
CAN ONLY SAY FROM MY EXPERIENCE THAT PEOPLE WHO HAVE RECEIVED
IRRADIATION AND ESPECIALLY OVER THAT EXTENSIVE AREA OF THEIR
BODY ALSO RECEIVE A DIMINISHING OF THEIR IMMUNE SYSTEM MAKING
THEM MORE SUSCEPTIBLE TO COMMON DISEASES, PARTICULARLY
INFECTION.
Q. AND WE'VE TALKED I BELIEVE IN ANOTHER CASE ABOUT
HYPOTHYROIDISM, WOULD THAT FACTOR ANY DIFFERENTLY IN THIS
CASE?
A. IT WOULDN'T BE ANY DIFFERENT. I PUT IT HERE BECAUSE I
LEARNED FROM THE PATHOLOGIST REPORT THAT HE HAD A REMARKABLY
SHRUNKEN AS HE SAID, A REMARKABLY SHRUNKEN THYROID. SO HE
NOTED THAT THE THYROID WAS ALMOST GONE AND THAT WAS PROBABLY
BY -- RATHER THAN BY SURGERY IN THE PREVIOUS CASE, ONE OF THE
PREVIOUS CASES, IT WAS DIMINISHED TO THE POINT OF BEING
RELATIVELY NONFUNCTIONAL. AND IT MUST HAVE BEEN THAT WAY
BECAUSE HE WAS TREATED WITH THYROID HORMONE AS A SUPPLEMENT
DURING LIFE. THAT, OF COURSE, AS WE SAID WAS A CONDITION
THAT WOULD DIMINISH HIS METABOLIC CONTROL.
Q. AND THEN THE FINAL ISSUE, THE NEUROGENIC BLADDER, WHAT
DOES THAT MEAN?
A. HE HAD A POORLY FUNCTIONING BLADDER. IT PROBABLY WAS
RELATED AS WELL TO HIS REPEATED STROKES, HIS NEURO CONTROL BY
HIS NERVOUS SYSTEM WHICH ULTIMATELY IS ASSOCIATED WITH HIS
ADVANCED ATHEROSCLEROSIS, THIS ASSOCIATED WITH A URINARY
TRACT INFECTION WHICH WAS DOCUMENTED ON THE 12TH OF JANUARY.
Q. DO YOU HAVE AN OPINION, DOCTOR, TO A DEGREE OF REASONABLE
MEDICAL CERTAINTY AS TO THE CAUSE OF DEATH OF ENNIS
ALLDREDGE?
A. YES.
Q. AND WHAT IS THAT OPINION?
A. IN THIS CASE, I BELIEVE THAT ENNIS ALLDREDGE DIED OF HIS
DISEASE, PARTICULARLY HIS SEVERE ATHEROSCLEROSIS. IT WAS
ASSOCIATED WITH AS AN EQUALLY DELETERIOUS CONDITION. HIS
HIGH BLOOD PRESSURE AND THE RESULTS OF THAT ARE THE FINDINGS
IN THE HEART AS WE SAW AS WELL AS THE KIDNEY. AND THAT
TERMINALLY HE HAD A SERIOUS DISEASE, AN ACUTE INFECTION,
BRONCHOPNEUMONIA.
Q. DO YOU HAVE A OPINION TO A DEGREE OF REASONABLE MEDICAL
CERTAINTY AS TO THE MANNER OF DEATH OF THIS PATIENT?
A. YES. I BELIEVE THAT BECAUSE HE DIED OF HIS DISEASE HIS
DEATH SHOULD BE CHARACTERIZED AS NATURAL.
Q. WITH REGARD TO -- GOING BACK TO ELLEN ANDERSON, YOU'VE
TESTIFIED AS TO HER CAUSE OF DEATH BEING ATHEROSCLEROTIC
CARDIOVASCULAR DISEASE. DID THE ADMINISTRATION OF MORPHINE
TO ELLEN ANDERSON CAUSE THAT CONDITION OR CAUSE THAT DISEASE?
A. CAUSE WHICH DISEASE AGAIN DID YOU SAY?
Q. THE ATHEROSCLEROTIC CARDIOVASCULAR DISEASE.
A. NO. ABSOLUTELY NOT.
Q. DID THE ADMINISTRATION OF MORPHINE MAKE THAT CONDITION
WORSE?
A. NO.
Q. DID MORPHINE CAUSE CONGESTIVE HEART FAILURE?
A. NO. IT NEVER HAS THAT EFFECT.
Q. DID MORPHINE MAKE IT WORSE?
A. I DON'T SEE HOW IT COULD HAVE.
Q. WITH REGARD TO JUDITH LARSEN, AGAIN I THINK YOU'VE
MENTIONED ON BOTH JUDITH LARSEN, LYDIA SMITH AND ENNIS
ALLDREDGE THAT YOU DETECTED EVIDENCE OF ADVANCED
STAGES OF ATHEROSCLEROTIC CARDIOVASCULAR DISEASE, AGAIN DOES
MORPHINE CAUSE THAT DISEASE?
A. NO.
Q. DOES MORPHINE MAKE THAT DISEASE WORSE?
A. NO.
Q. ALL OF THE PATIENTS EXCEPT ELLEN ANDERSON WERE GIVEN
PSYCHOTROPIC MEDICATIONS, WEREN'T THEY?
A. YES.
Q. DO YOU BELIEVE TO A REASONABLE DEGREE OF MEDICAL
CERTAINTY THAT IN THESE CASES WHERE PSYCHOTROPIC MEDICATIONS
WERE ADMINISTERED THAT THESE MEDICATIONS MADE OR CAUSED ANY
OF THESE CHRONIC DISEASE PROCESSES THAT YOU'VE IDENTIFIED?
A. NO. THEY DON'T CAUSE ANY OF THOSE DISEASE PROCESSES. I
AM CERTAIN OF THAT.
Q. YOU INDICATED WHEN WE TALKED ABOUT JUDITH LARSEN THAT YOU
WERE NOT AT ALL SURPRISED TO LEARN THAT SHE HAD MORPHINE IN
HER SYSTEM. WHY DO YOU SAY THAT?
A. BECAUSE SHE WAS GIVEN MORPHINE, ACCORDING TO THE MEDICAL
RECORDS, WITHIN HOURS OF HER DEATH.
Q. AND DOES THE PRESENCE OF MORPHINE IN THE SYSTEM OF A BODY
THAT YOU EXAMINE MEAN THAT MORPHINE CAUSED THAT DEATH?
A. NO. ABSOLUTELY NOT. AS I SAID BEFORE, THE PRESENCE OF
MORPHINE IN A BODY OR ANYTHING, ANY MEDICATION FOR THAT
MATTER, DOESN'T MEAN THAT THE PERSON HAS DIED FROM IT. IT
HAS TO BE PLACED INTO CONTEXT, CLINICAL CONTEXT.
Q. AS A MEDICAL EXAMINER, ARE YOU FAMILIAR WITH SITUATIONS
WHERE SOMEONE MIGHT DIE IN AN UN -- STRIKE THAT.
AS A MEDICAL EXAMINER, ARE YOU AWARE OF SITUATIONS WHERE
INDIVIDUALS DIE SUDDENLY FROM CHRONIC DISEASES?
A. IT HAPPENS ROUTINELY. SOMEBODY MAY CALL IN THE MORNING
AND SAY MOTHER OR DAD DIDN'T WAKE UP, THEY'RE DEAD IN BED.
THEY ARE SURPRISED PERHAPS EVEN BECAUSE THE NIGHT BEFORE THEY
WATCHED TELEVISION WITH THEM OR HAD DINNER WITH THEM OR
ENJOYED A JOKE OR A MOVIE OR WHATEVER IT WAS OR RODE AROUND
IN A CAR WITH THEM. YES, THEY DO DIE SUDDENLY BECAUSE IT'S A
FREQUENT MANIFESTATION IN ELDERLY PEOPLE OF THE SEVERITY OF
THEIR DISEASE. FORTUNATELY THEY DON'T DIE BY A LONG
PROTRACTED COURSE IN CASES BUT THEY ALSO DIE FREQUENTLY
SUDDENLY.
MS. ISAACSON: THAT'S ALL I HAVE.
THE COURT: CROSS-EXAMINE, MR. MAJOR.
MR. MAJOR: THANK YOU, YOUR HONOR.
CROSS-EXAMINATION
BY MR. MAJOR:
Q. GOOD AFTERNOON, DOCTOR.
A. AFTERNOON.
Q. I'M STEVE MAJOR. I'M WITH THE PROSECUTION. I HAVE A FEW
QUESTIONS TO ASK YOU.
NOW, AS I UNDERSTAND, YOU HAVE BEEN HIRED BY THE DEFENSE
TO APPEAR TODAY AND TESTIFY; IS THAT CORRECT?
A. YES. THAT'S A WAY OF SAYING IT.
Q. WHEN WERE YOU FIRST CONTACTED BY THE DEFENSE?
A. I CAN'T REMEMBER EXACTLY BUT IT WAS APPROXIMATELY IN THE
SUMMER, EARLY SUMMER TO MID SUMMER.
Q. AND YOU WERE ASKED TO PREPARE YOUR FINDINGS THAT YOU
BROUGHT IN TODAY?
A. EVENTUALLY SO, YES.
Q. AND YOU CHARGED THE DEFENSE A FEE AS AN EXPERT FEE; IS
THAT CORRECT?
A. I DO. I HAVE A REGULAR FEE THAT I CHARGE FOR --
Q. AND HOW MUCH IS THAT?
A. I CHARGE $350 AN HOUR.
Q. DOES THAT INCLUDE TESTIFYING AND EVERYTHING LIKE THAT?
A. IT INCLUDES EVERYTHING.
Q. IN ADDITION, THERE'S I ASSUME YOU GET YOUR EXPENSES FOR
TRAVEL AND THAT TYPE OF THING?
A. YES.
Q. IS THAT TRUE?
A. WHATEVER I PAY FOR THAT I DO, SURE.
Q. NOW, IN MAKING THESE EXAMINATIONS THAT YOU MADE,
OBVIOUSLY YOU DID NOT ACTUALLY HANDLE THE BODY; IS THAT
CORRECT?
A. THAT'S TRUE.
Q. AND YOU WERE JUST PREPARING YOUR OPINION, RELIED ON THE
SLIDES AND PHOTOS THAT WERE PROVIDED YOU BY THE DEFENDANT --
OR THE DEFENSE I SHOULD SAY?
A. AN AUTOPSY REPORTS, YES.
Q. AND DURING THIS PERIOD OF TIME THAT YOU WERE PREPARING
THIS, DID YOU HAVE CONVERSATIONS NOT WITH THE DEFENSE ITSELF
BUT WITH THE DEFENDANT HIMSELF? DID YOU HAVE A CONVERSATIONS
WITH DR. WEITZEL?
A. NO, SIR.
Q. AND YOU ALSO INDICATED THAT AS PART OF YOUR FORMULATION
OF YOUR OPINION THAT YOU RELIED ON MEDICAL RECORDS THAT WERE
PROVIDED YOU; IS THAT RIGHT?
A. YES, SIR.
Q. LET ME SHOW YOU WHAT'S BEEN MARKED FOR IDENTIFICATION,
FOR EXAMPLE, I'LL GRAB ELLEN ANDERSON, THIS IS EXHIBIT 2-C.
HAVE YOU LOOK AT THAT. IS THAT BASICALLY THE TYPE DOCUMENT
THAT YOU HAD EXAMINED OR SIMILAR TO THE DOCUMENT YOU
EXAMINED?
A. YES, SIR. THAT LOOKS LIKE IT.
Q. OKAY. WERE YOU GIVEN ANY OTHER DOCUMENT? NOW, THOSE ARE
THE DOCUMENTS FROM -- THE MEDICAL DOCUMENTS FROM THE
HOSPITAL. DID YOU EXAMINE ANY OTHER DOCUMENTS?
A. NO. I GOT HOSPITAL RECORDS. THAT'S WHAT I MEANT BY
DOCUMENTS, HOSPITAL RECORDS.
Q. YOU DIDN'T GET ANYTHING FROM THE NURSING HOMES?
A. I DON'T RECALL THAT I DID. I THINK ALL I HAVE IS THIS
MATERIAL.
Q. JUST WHAT WAS PROVIDED TO YOU --
A. NOW, THERE'S REFERENCE IN THESE RECORDS TO NURSING HOME
DIAGNOSES AND CARE.
Q. YEAH.
A. SO THAT'S HOW I BELIEVE I LEARNED ABOUT THOSE THINGS.
Q. OKAY. AND BUT YOU DON'T RECALL RECEIVING ANY OTHER
DOCUMENTS OTHER THAN FROM ANY OF THE NURSING HOMES?
A. NO, SIR, I DON'T RIGHT NOW. I DON'T THINK SO. I THINK
ALL I HAVE ARE THE HOSPITAL RECORDS.
Q. OKAY. WELL, DOCTOR, NOW I WANT TO ASK YOU SOMETHING, YOU
HAVE FAMILIARITY YOU'VE SAID WITH MORPHINE; IS THAT CORRECT?
A. I DO.
Q. AND MORPHINE IS WHAT YOU WOULD CONSIDER TO BE A POWERFUL
DRUG?
A. YES.
Q. A POWER PAINKILLER?
A. YES.
Q. AND MORPHINE CAN HAVE SOME SIGNIFICANT SIDE EFFECTS;
ISN'T THAT CORRECT?
A. YES.
Q. ONE OF THOSE SIDE EFFECTS THAT MORPHINE HAS IS THAT IT
CAN LOWER RESPIRATIONS?
A. IT CAN.
Q. IT CAN LOWER BLOOD PRESSURE?
A. YES.
Q. AND WHEN A PERSON ACTUALLY DIES FROM AN OVERDOSE OF
MORPHINE -- I'M ASSUMING YOU'VE HAD PEOPLE DIE OF OVERDOSES
OF MORPHINE?
A. OH, YES.
Q. AND I'M ASSUMING THAT THE WAY PEOPLE DIE OR WHAT ACTUALLY
CAUSES THE DEATH ON AN OVERDOSE IS THAT THE BODY SHUTS DOWN;
IS THAT CORRECT?
A. IT DOES.
Q. IT DOESN'T GET ENOUGH OXYGEN, IT DOESN'T GET ENOUGH BLOOD
GOING INTO ITS ORGANS AND IT BASICALLY SHUTS DOWN?
A. YES.
Q. PRETTY MUCH?
A. YES.
Q. AND SO YOU WOULD AGREE THAT MORPHINE IN AND OF ITSELF
DOES CAUSE SOME PROBLEMS WITH OXYGENATION OF THE BODY; IS
THAT CORRECT?
A. IT CAN, YES.
Q. IT CAN. AND ESPECIALLY HIGH DOSES OF MORPHINE; IS THAT
CORRECT?
A. YES.
Q. NOW, LACK OF OXYGEN THAT GOES INTO THE BODY CAN CAUSE
PROBLEMS, SPECIFICALLY WITH THE BRAIN, THE KIDNEYS, THE
LUNGS, THOSE TYPE OF THINGS; IS THAT CORRECT?
A. OH, YES.
Q. AND THEY CAN ALSO CAUSE THE BODY TO START TO SHUT DOWN;
IS THAT CORRECT?
A. IT COULD, YES.
Q. AND ONE OF THE THINGS THAT IT CAN DO IS IT CAN PROHIBIT
THE ORGANS FROM DOING THEIR NORMAL FUNCTIONS AS EXCRETING
WATER FROM THE BODY OR THOSE TYPE OF THINGS?
A. WELL, I THINK THAT'S WHAT I MEAN -- WHAT YOU MEAN BY
SHUTTING DOWN.
Q. SHUTTING DOWN, YEAH. THE THING IT CAN ALSO DO IS IT CAN
AFFECT THE PERSON'S ABILITY TO COUGH OR CLEAR THEIR THROAT,
CORRECT?
A. THAT MIGHT HAPPEN.
Q. SO A PERSON WHO HAS SOME SEDATION WITH MORPHINE, THERE IS
A RISK THAT CAN THEY COULD ASPIRATE WATER OR WHATEVER INTO
THEIR LUNGS; IS THAT CORRECT?
A. IT'S POSSIBLE.
Q. AND IF THE ORGANS ARE SHUTTING DOWN AND THEY'RE HAVING
PROBLEMS WITH REMOVING THE WATER FROM THE BODY, THEIR LUNGS
COULD FILL UP WITH LIQUID?
A. IT'S POSSIBLE, YES.
Q. AND THAT COULD HAVE A SAME SIDE EFFECT AS HAVING
BASICALLY PNEUMONIA; IS THAT CORRECT?
A. SAY --
Q. HAVING A PNEUMONIA, THAT CAN CAUSE A PNEUMONIA?
A. IT'S SIMILAR.
Q. YOU DO -- ALSO IN THIS CASE THERE WAS EVIDENCE THAT THESE
PATIENTS HAD RECEIVED SOME PSYCHOTROPIC DRUGS. ARE YOU
FAMILIAR WITH THOSE DRUGS?
A. WELL, I'M GENERALLY FAMILIAR WITH THEM, SOME MORE THAN
OTHERS.
Q. ARE YOU FAMILIAR WITH RISPERDAL AND THOSE TYPE OF --
ATIVAN?
A. I AM IN ONLY A GENERAL WAY. I DON'T OBVIOUSLY USE THEM
IN ANY PATIENTS THAT I CARE FOR, BUT I'M AWARE OF THEIR USE.
Q. AWARE OF THEIR USE. WERE YOU ALSO AWARE THAT THOSE TYPE
OF DRUGS ARE I GUESS A BREATHING SUPPRESSANT WHERE THEY
SUPPRESS THE BREATHING?
A. I'M NOT AWARE OF THAT, NO.
Q. IF WE HAD TESTIMONY TO THE FACT THAT THEY WERE A
BREATHING SUPPRESSANT, THAT WOULD NOT BE CONTRARY TO ANYTHING
THAT YOU UNDERSTAND OR LEARNED?
A. I JUST DON'T KNOW THAT.
Q. OKAY. NOW, I WANT TO TURN JUST BRIEFLY TO ELLEN ANDERSON
AND ASK YOU A COUPLE OF QUESTIONS CONCERNING HER. I'M NOT
GOING TO GO THROUGH IN ANY DETAIL SPECIFICALLY WHAT HER --
EACH ONE OF THE CATEGORIES YOU LISTED AS CAUSE OF DEATH.
BUT BASICALLY ON THE LISTING THAT YOU HAD LISTED THAT YOU
BELIEVE OR THAT YOU FOUND THAT CAUSED ELLEN ANDERSON'S DEATH
IS SOMETHING THAT AFFECTS HER ABILITY TO ABSORB OXYGEN IN THE
BODY; IS THAT CORRECT?
A. IN ONE WAY OR ANOTHER THAT IS OFTEN THE CASE, YES.
Q. AND ALL OF THESE SYMPTOMS THAT YOU RECORDED HERE EXISTED
PRIOR TO HER COMING TO THE HOSPITAL?
A. YES.
Q. AND THEY'D EXISTED FOR A NUMBER OF YEARS PRIOR TO HER
COMING TO THE HOSPITAL?
A. WELL, I DID MENTION IN ELLEN ANDERSON AS I RECALL ACUTE
PNEUMONIA. SHE HAD AN PNEUMONIA THAT WAS VERY FRESH. THAT
MAY WELL HAVE HAPPENED PRIOR TO HER COMING TO THE HOSPITAL.
SHE WAS ONLY THERE A SHORT TIME, A DAY OR SO.
Q. YEAH.
A. THAT MAY HAVE BEEN PRESENT AT THE TIME OF ADMISSION, SO I
WOULDN'T SAY YEARS.
Q. IT COULD HAVE BEEN THERE BEFORE. NOW, WERE YOU AWARE
THAT THE TIME OF HER ADMISSIONS THAT THE NURSES AND NURSES
STAFF DID NOT FIND ANY SIGNS OF PNEUMONIA?
A. IT WAS NOT LISTED AS A FINDING, THAT'S CORRECT.
Q. CAN WE ASSUME THEN IF IT WAS NOT FOUND AT THE TIME OF HER
ADMISSION IT MAY HAVE DEVELOPED LATER?
A. NO. PNEUMONIA LIKE A LOT DISEASES STARTS INSIDIOUSLY AND
DOESN'T NECESSARILY MANIFEST ITSELF.
Q. NOW, DOCTOR, ONE OF THE QUESTIONS I WAS GOING TO ASK TO
YOU IS THESE -- AS I SAID, THESE SYMPTOMS EXISTED WITH ELLEN
ANDERSON FOR A PERIOD OF TIME PRIOR TO HER COMING TO THE
HOSPITAL, INCLUDING HIP SURGERY; IS THAT CORRECT?
A. YES.
Q. AND SHE HAD BASICALLY SURVIVED THAT PERIOD OF TIME, FROM
THE TIME SHE HAD THESE THINGS, UNTIL SHE HIT HOSPITAL; IS
THAT CORRECT?
A. CERTAINLY.
Q. AND THE FACT OF THE MATTER IS YOUR -- MR. CASSIN, THE
ONLY DIFFERENCE BETWEEN THE TREATMENT SHE RECEIVED PRIOR TO
COMING TO THE HOSPITAL AND THE TREATMENT SHE RECEIVED AT THE
HOSPITAL WAS THAT SHE WAS ADMINISTERED MORPHINE; ISN'T THAT
CORRECT?
A. I CAN'T SAY FOR SURE WITHOUT REVIEW OF THE RECORDS AGAIN.
SHE -- SHE WAS TREATED WHEN SHE CAME TO THE HOSPITAL, YES,
BUT --
Q. AND IF THE RECORDS INDICATED THAT THE ONLY MEDICATION
SHE'D RECEIVED AT THE HOSPITAL WAS MORPHINE, WOULD YOU AGREE
WITH THAT?
A. WELL, SURE.
Q. AND THAT WAS THE ONLY INTERVENING FACTOR THAT HAPPENED
BETWEEN TIME THAT SHE HAD ALL OF THESE DISEASES AND THE TIME
SHE HIT THE HOSPITAL; IS THAT CORRECT?
A. IF THAT'S WHAT THE RECORDS SHOWS, THEN I WOULD AGREE WITH
YOU.
Q. AND MORPHINE IN AND OF ITSELF, AS WE'VE TALKED ABOUT, CAN
SUPPRESS THE OXYGEN ABSORPTION INTO A PATIENT; IS THAT
CORRECT?
A. IT CAN.
Q. AND A PATIENT WHO IS ALREADY SIGNIFICANTLY SUFFERING FROM
CONDITIONS THAT PREVENT OXYGEN ABSORPTION, MORPHINE IS GOING
TO ENHANCE THAT, ISN'T IT?
A. IT MAY.
Q. AND, IN FACT, GIVING AS YOU RECALL SHE RECEIVED 12
MILLIGRAMS OF MORPHINE DURING THIS SHORT PERIOD OF TIME OF
HER STAY, THAT VERY WELL COULD SIGNIFICANTLY ENHANCED HER
ABILITY OR LACK OF ABILITY TO ABSORB OXYGEN; ISN'T THAT
CORRECT?
A. I CAN'T SAY THAT FOR SURE. I'M NOT REALLY SURE WHAT HER
OWN REACTION TO THAT WAS --
Q. SURE. BUT IT'S A POSSIBILITY --
A. -- NECESSARILY --
THE COURT: WAIT A MINUTE, MR. MAJOR. LET HIM
FINISH.
MR. MAJOR: I'M SORRY, YOUR HONOR.
Q. (BY MR. MAJOR) THAT IS A POSSIBLY, IS IT NOT?
A. THERE ARE A LOT OF POSSIBILITIES.
Q. RIGHT. AND IT'S SOMETHING THAT YOU CAN'T ELIMINATE TO
ANY TYPE OF SCIENTIFIC CERTAINTY?
A. CORRECT.
Q. AND THEREFORE IF MORPHINE COULD HAVE IN FACT CAUSED THIS
DEATH, THAT'S ANOTHER FACTOR IN DETERMINING WHAT THE CAUSE OF
DEATH WAS, WASN'T IT?
A. I DON'T THINK MORPHINE CAUSED THIS DEATH. I THINK THIS
MORPHINE TO MAKE THIS --
Q. WELL --
THE COURT: LET HIM FINISH, MR. MAJOR.
MR. MAJOR: IT'S NOT RESPONSIVE TO MY QUESTION.
THE COURT: LET HIM FINISH MR. MAJOR.
THE PLAINTIFF: I WILL.
THE WITNESS: I THINK MORPHINE WAS GIVEN TO ASSIST
THIS PERSON DURING A DYING PROCESS AND TO MAKE HER MORE
COMFORTABLE. WHAT ALL OF ITS EFFECTS WERE THERE, BUT I DON'T
BELIEVE NECESSARILY THAT IT SUPPRESSED HER RESPIRATION.
Q. (BY MR. MAJOR) YOU DON'T BELIEVE IT DID, BUT IT COULD
HAVE?
A. I SAID IT'S POSSIBLE, YES.
Q. AND DOESN'T THAT MAKE THE CAUSE OF DEATH UNDETERMINED,
BECAUSE YOU DON'T KNOW WHETHER IT DID OR DIDN'T?
A. WELL, INDEED. I THINK THEORETICALLY ANY DEATH CAN BE
CALLED UNDETERMINABLE IF ONE WANTS TO FALL BACK ONTO THE
DICTATES OR STANDARDS OF ABSOLUTE CERTAINTY, BUT WE'RE NOT
ASKED TO BE ABSOLUTELY CERTAIN IN AUTHORING DEATH
CERTIFICATES.
Q. SO IN YOUR POSITION THEN, THE UNDETERMINEDNESS OF WHAT THE
MEDICAL EXAMINER FOUND IN ELLEN ANDERSON ISN'T NECESSARILY
WRONG?
A. NO. IT IS -- IT IS HIS OPINION.
Q. OKAY.
A. AS I INDICATED, I DON'T KNOW WHY HE SAID IT WAS
UNDETERMINED.
Q. NOW, I WOULD LIKE TO TURN JUST BRIEFLY TO MS. LARSEN.
AGAIN, WITH MS. LARSEN ALL OF THE CONDITIONS THAT YOU LISTED
THAT YOU FEEL THAT SHE DIED FROM ARE CONDITIONS THAT AFFECT
HER BREATHING?
A. ULTIMATELY OR ONE WAY OR ANOTHER, YES.
Q. AND THESE CONDITIONS BASICALLY AFFECT HER ABILITY TO
ABSORB OXYGEN; IS THAT CORRECT?
A. WELL, PARTICULARLY THE ATHEROSCLEROSIS, YES.
Q. THAT WOULD. OKAY. AND THE QUESTION I HAD: YOU ALSO
INDICATED WITH MS. LARSEN THAT THERE WAS SOME PERSISTENT
NAUSEA AND VOMITING THAT OCCURRED; IS THAT CORRECT?
A. YES.
Q. AND THIS ALSO CAUSED HER PROBLEMS CONTRIBUTED TO HER
DEATH?
A. IT DID. I BELIEVE IT PROBABLY MADE HER ELECTROLYTES
ABNORMAL AND HER WATER BALANCE INSUFFICIENT SO I SUSPECT SHE
WAS SOMEWHAT DEHYDRATED BECAUSE OF THAT. IT ALSO COULD HAVE
PRECIPITATED HER GASTROINTESTINAL BLEEDING.
Q. BLEEDING. AND SHE HAD THIS CONDITION OF BLEEDING FOR
APPROXIMATELY 14 HOURS; IS THAT CORRECT?
A. I DON'T REMEMBER EXACTLY BUT IT WAS THERE FOR A WHILE.
Q. AND DURING THAT PERIOD OF TIME, THE DEFENDANT DID
ABSOLUTELY NOTHING TO ATTEMPT TO ALLEVIATE THAT VOMITING?
A. I DON'T KNOW THAT. I WOULD HAVE TO REFER --
Q. YOU DO NOT SEE ANYTHING IN THE RECORD THAT INDICATED THAT
HE DID?
A. I DON'T REMEMBER THAT DETAIL.
Q. AS A MATTER OF FACT, IN THESE CONDITIONS THAT WE HAD WITH
ELLEN ANDERSON, DID YOU SEE ANYTHING IN THE RECORDS WHICH
WOULD INDICATE THAT THE DEFENDANT DIAGNOSED THOSE CONDITIONS?
A. AGAIN, I WOULD HAVE TO REFER TO THE RECORD TO BE SURE.
Q. SO YOU DON'T RECALL IF HE DID OR DIDN'T?
A. I DON'T.
Q. OKAY. THAT WAS SOMETHING THAT YOU WOULD ASSUME THAT A
PHYSICIAN WOULD BE ABLE TO DIAGNOSIS AND DETERMINE WHAT THESE
CONDITIONS THEY HAD?
A. MIGHT, YES. AT LEAST UNDERSTAND BY WHAT'S HAPPENING TO A
PERSON WHO HAS THOSE CONDITIONS.
Q. NOW, DOCTOR, I WANT TO SHOW YOU WHAT'S BEEN MARKED FOR
IDENTIFICATION AS PLAINTIFF'S EXHIBIT 23. DOCTOR, I'M GOING
TO REPRESENT THIS TO YOU THAT THIS HAS BEEN ACCEPTED AS AN
EXHIBIT I BELIEVE AND THIS REFLECTS TALKED TO --
THE COURT: TURN THE LIGHTS OFF, MR. MAJOR.
MR. MAJOR: THANK YOU, JUDGE.
Q. (BY MR. MAJOR) AND THIS REFLECTS IN THE LAST TWO OR
THREE DAYS OF MRS. LARSEN'S LIFE THE AMOUNTS OF MORPHINE THAT
WERE ADMINISTERED TO HER. AND WOULD YOU AGREE BASED ON YOUR
REVIEW OF RECORDS ON THE 1ST OF JULY (SIC) SHE RECEIVED ONE,
TWO, THREE, FOUR, FIVE APPROXIMATELY SIX SHOTS OF MORPHINE?
THE COURT: IS THAT JULY 1ST?
MR. MAJOR: THIS WOULD BE JANUARY 1ST, 1996.
THE WITNESS: SORRY.
Q. (BY MR. MAJOR) THAT WAS BASED ON YOUR RECOLLECTION
THAT'S PRETTY MUCH --
A. I WOULD ACCEPT THAT, YEAH.
Q. AND CONTINUING OVER ON THE NEXT PAGE ALSO ON THE 1ST OF
JULY SHE HAD RECEIVED AN ADDITIONAL --
THE COURT: JANUARY?
MR. MAJOR: SORRY, YOUR HONOR. I APOLOGIZE.
Q. (BY MR. MAJOR) ON JANUARY OF -- JANUARY 1ST, SHE
RECEIVED AN ADDITIONAL FOUR SHOTS; IS THAT CORRECT?
A. I'LL ACCEPT THAT IF IT'S IN EVIDENCE.
Q. SO DURING THIS PERIOD OF TIME SHE RECEIVED APPROXIMATELY
10 SHOTS AND RECEIVED APPROXIMATELY 50 MILLIGRAMS OF
MORPHINE, YOU WOULD ACCEPT THAT?
A. MAKES SENSE.
Q. NOW, TURNING TO JANUARY 2ND, 1996, YOU CAN ALSO INDICATE
HERE THAT SHE RECEIVED A SERIES OF SHOTS AND I'D REPRESENT TO
YOU THAT THESE SHOTS WERE ORDERED APPROXIMATELY EVERY THREE
HOURS. DOES THAT SEEM TO BE CORRECT?
A. OKAY.
Q. AGAIN SHE RECEIVES ONE, TWO, THREE, FOUR, FIVE, SIX,
SEVEN, EIGHT, NINE SHOTS OF MORPHINE APPROXIMATELY 45
MILLIGRAMS OF MORPHINE DURING THAT PERIOD OF TIME, CORRECT?
A. YES.
Q. YOU ALSO RECALL DURING THIS PERIOD OF TIME READING IN THE
MEDICAL RECORDS ABOUT A NURSE WHO WITH HELD A CERTAIN AMOUNT
OF MORPHINE?
A. I DID READ SOMETHING ABOUT THAT.
Q. ON THE 3RD OF JULY BONNIE HARDY TESTIFIED AND I THINK
IT'S REFLECTED IN THE MEDICAL RECORDS THAT DURING THE EVENING
HOURS SHE OBSERVED MS. LARSEN AND SHE HAD VERY LOW
RESPIRATIONS, MOTTLING OF THE SKIN, FINGERTIPS WERE BLUE, AT
THAT TIME, DO YOU RECALL THAT?
A. I DO VAGUELY, YES.
Q. AND YOU RECALL THAT, IN FACT -- WELL, BASED ON THAT,
WOULD IT INDICATE TO YOU THAT THIS PATIENT WAS PRETTY CLOSE
TO DEATH?
A. YES.
Q. AND WOULD --
A. THIS WAS PART OF THE DYING PROCESS.
Q. DYING PROCESS.
A. YES.
Q. IT ALSO INDICATES AT THAT TIME THAT MS. HARDEY WITHHELD
APPROXIMATELY THREE SHOTS DURING THE EVENING, IS THAT
CORRECT, DO YOU RECALL THAT?
A. I DON'T REMEMBER THE EXACT NUMBER BUT YES THERE WAS
WITHHOLDING OF MORPHINE.
Q. AND THEN HER NOTE IS THAT AFTER WITHHOLDING THE SHOT THE
PATIENT REMARKABLY IMPROVED?
A. I DON'T RECALL THAT. I THINK THERE MIGHT HAVE BEEN A
LITTLE CHANGE IN STATUS, BUT I'M NOT SURE IT WAS AN
IMPROVEMENT.
Q. BUT IF THAT'S WHAT SHE HAD INDICATED, THEN YOU WOULD
AGREE WITH WHATEVER IS IN THE MEDICAL RECORDS?
A. WELL, I WOULD ACCEPT IT AS MEDICAL RECORDS.
Q. SO IF A PATIENT IS RECEIVING A PARTICULAR DRUG, IN THIS
CASE MORPHINE, STARTS TO HAVE -- BECOME CLOSE TO DEATH AND
THAT IS WITHDRAWN AND SHE IMPROVES, WOULDN'T THAT INDICATE
THAT THE MORPHINE IS HAVING AN EFFECT ON THAT PATIENT?
A. THE MORPHINE WAS HAVING AN EFFECT ON THE PATIENT, YES,
BUT I THINK WITHDRAWAL OF MORPHINE ENHANCED HER DYING SYMPTOMS.
Q. OKAY. SO MORPHINE WOULD HAVE HAD AN EFFECT ON HER DYING
AT THAT POINT IN TIME, EITHER WITHHOLDING OR GIVING IT?
A. IT HAS AN EFFECT ON HER, YES, ON THE PRESENTATION OF HER
PHYSIOLOGIC FUNCTIONS AND ON HER SYMPTOMS.
Q. THEN GOING ON --
A. THAT'S WHY IT'S GIVEN.
Q. I APOLOGIZE.
AFTER THIS PARTICULAR AMOUNT OF MORPHINE IS WITHHELD WE
START AGAIN. AS YOU INDICATE, 7:30 AND THEN 9:30 SHE IS
SHE'S GIVEN A TWO FIVE MILLIGRAM SHOT OR 10 MILLIGRAMS,
CORRECT?
A. YES.
Q. THEN A HALF HOUR LATER SHE IS A GIVEN 25-MILLIGRAM SHOT
OF MORPHINE?
A. YES.
Q. AND THEN AGAIN WITHIN AN HOUR AND A HALF OF THAT SHE WAS
GIVEN 30 MILLIGRAMS?
A. YES.
Q. AND THEN AN HOUR LATER IT'S 5 MILLIGRAMS AND
APPROXIMATELY I GUESS TWO HOURS AFTER THAT IT WAS 30
MILLIGRAMS. AND THEN WE HAVE A 5-MILLIGRAM SHOT AND 18:30 WE
HAVE A 25-MILLIGRAM SHOT. BASED ON THE RECORDS, THAT'S
PRETTY MUCH WHAT YOU GLEANED FROM THE RECORDS AS FAR AS THE
SHOTS BEING GIVEN?
A. YES. THAT LOOKS SIMILAR TO WHAT I REVIEWED.
Q. SO DOCTOR I GUESS IT'S WITH --
THE COURT: ARE YOU THROUGH WITH THAT, MR. MAJOR?
MR. MAJOR: NOT QUITE, YOUR HONOR.
THE COURT: TURN ON THE LIGHTS WHEN YOU USE IT NEXT
TIME SO THEY CAN SEE IT A LITTLE BETTER.
MR. MAJOR: OH, THE LIGHTS. I'M SORRY, YOUR HONOR.
I TURNED THEM OFF HOPING WE COULD SEE IT WITHOUT BOTHERING
THE JURORS. WE'LL DO THAT.
THE COURT: THEY NEED TO SEE IT CORRECTLY.
MR. MAJOR: OKAY.
Q. (BY MR. MAJOR) BUT DOCTOR SO YOUR TESTIMONY WOULD BE
TODAY THAT DURING THAT LAST DAY OF HER LIFE JUDITH LARSEN
RECEIVED NINE SHOTS FOR A TOTAL 130 MILLIGRAMS OF MORPHINE IN
APPROXIMATELY 1-2 HOUR PERIOD AND THAT DID NOT AFFECT HER
DYING IN ANY WAY?
A. OH, I THINK IT DID. I THINK IT MADE HER CONDITION MUCH
MORE STABLE THAN IT MIGHT OTHERWISE HAVE BEEN.
Q. BUT IT DIDN'T HASTEN HER DEATH IN ANY WAY?
A. I'M NOT SURE IT DID.
Q. AGAIN, MOVING ON TO MARY CRANE, IN DEALING WITH MARY
CRANE, AGAIN, YOU LISTED A NUMBER OF SYMPTOMS THAT YOU FOUND
HAD CAUSED HER DEATH; IS THAT CORRECT?
A. YES.
Q. ALL OF THESE SYMPTOMS AGAIN ARE JUST PRIOR TO HER COMING
TO THIS HOSPITAL?
A. MANY DID, YES.
Q. AND UPON ARRIVAL AT THE HOSPITAL UNIT, SHE RECEIVED AN
AMOUNT OF NOT ONLY MORPHINE BUT ALSO AN AMOUNT FROM A
DURAGESIC PATCH; IS THAT CORRECT?
A. OF FENTANYL THE DURAGESIC PATCH, YES.
Q. AND LET ME SHOW YOU AGAIN FROM THIS EXHIBIT I WILL
INDICATE ON THE 28TH SHE RECEIVED HER 50 MILLIGRAMS FROM A
DURAGESIC PATCH CORRECT?
A. YES.
Q. AND THAT CONTINUES FOR A PERIOD OF TIME. ON THE 3RD OF
JANUARY, AGAIN, SHE RECEIVED 3 MILLIGRAMS OF MORPHINE. SHE
RECEIVED ON THE 3RD OF JANUARY -- OR 3RD OF JANUARY AT 14:45
WHICH IS 2:45 ANOTHER 5 MILLIGRAMS OF MORPHINE. THE NEXT DAY
SHE RECEIVES 5 MILLIGRAMS AND THEY UP THE DURAGESIC PATCH TO
75 MICROGRAMS. SHE THEN RECEIVES ANOTHER ADDITIONAL 5
MILLIGRAMS OF MORPHINE AT 9:20 AND AT 10:30.
AND, AGAIN, IT'S YOUR TESTIMONY THAT EVEN THOUGH SHE HAS
THIS AMOUNT OF DURAGESIC PATCH, THE FENTANYL ON HER SYSTEM,
AND THAT AMOUNT OF MORPHINE IN HER SYSTEM, THE MORPHINE HAD
NO AFFECT ON HER DEATH?
A. NO. I THINK IT PROBABLY MADE HER DEATH MORE PEACEFUL
THAN IT MIGHT OTHERWISE HAVE BEEN.
Q. BUT IT DIDN'T HASTEN HER DEATH IN ANY WAY?
A. I'M NOT SURE IT DID.
Q. EVEN THOUGH THIS WAS A LADY WHO WAS SUFFERING FROM ACUTE
PROBLEMS IN BREATHING AND ABSORBING OXYGEN?
A. ABSOLUTELY. I'M NOT SURE THAT IT MADE IT ANY WORSE.
Q. SO YOU WOULDN'T INDICATE THAT THE MORPHINE WOULD HAVE
REDUCED THE AMOUNT OF OXYGEN INTAKE AND CAUSE ANY ADDITIONAL
PROBLEMS?
A. NOT NECESSARILY.
Q. OKAY. NOW GOING TO -- JUST QUICKLY GOING ON TO LYDIA
SMITH. AGAIN, THESE CONDITIONS EXISTED PRIOR TO HER COMING
ON TO THE UNIT; IS THAT CORRECT?
A. YES, SIR.
Q. AND, AGAIN, ONE OF THE THINGS THAT YOU FOUND WITH HER WAS
THAT SHE HAD RENAL FAILURE; IS THAT CORRECT?
A. YES.
Q. AND RENAL FAILURE ALSO AFFECTS THE BODY'S ABILITY TO GET
MORPHINE OUT OF THE SYSTEM, DOESN'T IT?
A. YES. IT IS ONE OF THE WAYS THAT IT DOES THAT.
Q. SO, IN FACT, WHAT IT COULD CAUSE HER TO DO IS TO RETAIN
THE LEVEL OF MORPHINE AND RAISE THE LEVEL OF MORPHINE WITHIN
HER SYSTEM?
A. YES.
Q. AND SHE ALSO RECEIVED A NUMBER OF PSYCHOTROPIC DRUGS?
A. SHE DID.
Q. AND YOU WOULD NOT -- YOU DON'T FEEL THAT THESE
PSYCHOTROPIC DRUGS, EVEN THOUGH THEY MAY SUPPRESS THE
RESPIRATION AND BLOOD PRESSURE WOULD HAVE ANY AFFECT ON HER
DEATH?
A. I'M NOT SO SURE THAT THEY DID, NO.
Q. ALL THESE CONDITIONS THAT SHE HAD PRIOR TO HER COMING TO
THE UNIT THAT WOULD HAVE CAUSED HER DEATH?
A. YES, SIR, I BELIEVE THAT.
Q. AND, AGAIN, JUST TURNING REAL QUICKLY ON ENNIS ALLDREDGE
BASICALLY THE SAME SITUATION. HE HAD A NUMBER OF CONDITIONS
THAT YOU FELT WERE LIFE-THREATENING THAT EXISTED PRIOR TO
COMING TO THE UNIT?
A. YES, SIR.
Q. ONE THING I WANTED TO ADDRESS REAL QUICKLY THOUGH WITH
YOU, YOU ALSO INDICATED THAT HE HAD A STROKE WHILE AT THE
HOSPITAL; IS THAT CORRECT?
A. I DID.
Q. DID YOU FIND ANYTHING IN THE ACTUAL AUTOPSY SLIDES OR
ANYTHING THAT WOULD INDICATE THERE WAS A STROKE?
A. WELL, NO, I COULDN'T BECAUSE THE BRAIN HAD SO
DETERIORATED THAT THE PATHOLOGIST WHO DID THE AUTOPSY COULD
NOT IDENTIFY ANYTHING LIKE THAT AND MADE NO SECTIONS OF THE
BRAIN SO AS TO BE ABLE EVEN MICROSCOPICALLY TO BE ABLE TO
LOOK AT IT.
Q. SO YOU WERE JUST BASING YOUR INFORMATION ON THE STROKE ON
WHAT YOU HAD BEEN TOLD AND WHAT YOU HAD READ IN THE RECORDS?
A. WHAT WAS IN THE RECORDS, THAT'S WHERE I GOT THAT
INFORMATION.
Q. AND THAT WAS FROM THE RADIOLOGIST REPORT?
A. YES. ACTUALLY, THAT'S WHERE IT ORIGINATED.
Q. THE RADIOLOGIST REPORT THAT INDICATES THE REPORT WAS
SOMEWHAT -- THERE WAS A PROBLEM WITH THAT REPORT, THAT THEY
COULDN'T GET A GOOD, CLEAR PICTURE OF IT?
A. I DO REMEMBER SOMETHING LIKE THAT, YES.
Q. DO YOU RECALL IN REVIEWING THE RECORDS, WAS THERE
ANYTHING IN THOSE RECORDS INDICATING THAT THE DEFENDANT IN
THIS MATTER DID ANYTHING TO DIAGNOSIS THAT STROKE?
A. I THINK IT WAS A CLINICAL IMPRESSION THAT WAS RECORDED
THERE, BUT I DON'T RECALL ANYTHING OTHER THAN THE RADIOLOGY.
Q. AND WHAT DO YOU NORMALLY EXPECT A DOCTOR WHO'S RECEIVED A
RADIOLOGY REPORT ABOUT A STROKE TO DO SOME TYPE OF DIAGNOSIS
TO CONFIRM THAT?
A. WELL, I SUSPECT HE DID --
Q. WELL --
A. -- DO A DIAGNOSIS BY TRYING TO GET A RADIOLOGICAL STUDY
TO CONFIRM IT.
Q. BUT AFTER THE STUDY COMES BACK AND IT'S A COMPROMISED
STUDY, WOULDN'T YOU EXPECT THAT A DOCTOR WOULD THEN DO SOME
FURTHER TESTING, PHYSICAL TESTING, THOSE TYPE OF THINGS TO
VERIFY THAT THE STROKE WAS PRESENT?
A. IT'S POSSIBLE, BUT I THINK IT'S PART OF THE CONTEXT. IN
THIS CASE IT WAS DIFFICULT TO DO THE RADIOLOGIC EXAM BECAUSE
OF THE AGITATION OF THE PATIENT.
Q. EXACTLY.
A. AND THE INABILITY TO KEEP HIM ADEQUATELY CONTROLLED AND
SO IT WAS DIFFICULT TO DO THAT. BUT I SAW -- I'D OFFER THIS,
THOUGH I DON'T KNOW FOR SURE, THAT IT MAY BE THAT IT WAS
THOUGHT THAT NOTHING BETTER COULD HAVE BEEN DONE TO
SUBSTANTIATE THE EXTENT OF BRAIN DAMAGE.
Q. BUT YOU COULD DO -- I'M NOT GOING TO BELABOR THE POINT,
BUT YOU COULD DO A PHYSICAL EXAM, STRENGTH EXAM, THOSE TYPE
OF THINGS?
A. THOSE THINGS ARE POSSIBLE TO DO, YES/I DON'T KNOW WHAT
THE EFFECT OF THAT WOULD HAVE BEEN.
Q. THE BOTTOM LINE I GUESS IN GOING BACK OVER EACH AND EVERY
ONE OF THESE PATIENTS YOU INDICATE WERE SEVERELY
HANDICAPPED -- PHYSICALLY HANDICAPPED OR I GUESS MEDICALLY
HANDICAPPED WHEN THEY CAME ON THE UNIT; IS THAT CORRECT?
A. I BELIEVE SO, YES.
Q. THEY WERE BASICALLY CLOSE TO BEING TERMINAL WOULD YOU
SAY?
A. I SAW THEM ALL AS BEING CLOSE TO OR IN TERMINAL PHASE
WHEN THEY CAME, YES.
Q. AS A MATTER OF FACT, THE DEFENDANT DID NOTHING TO
DIAGNOSE THESE CONDITIONS WHEN THEY CAME ONTO THE UNIT, DID
HE?
A. I THINK DIAGNOSES IN MANY CASES CAME WITH THE PATIENTS.
I GOT MUCH OF MY INFORMATION, AS YOU RECALL, FROM THE RECORDS
FROM WHICH I SPOKE AND THOSE THINGS WERE SUBSTANTIATED BY
AUTOPSY.
Q. BUT THESE ARE PEOPLE WHO ARE GOING ON TO A GEROPSYCH UNIT
WHERE THEY'RE GOING TO RECEIVE TREATMENT, WHERE THEY'RE GOING
TO RECEIVE DIFFERENT TYPES OF GROUP THERAPY, AND YOU -- DON'T
YOU BELIEVE IN YOUR MIND EVEN GIVEN THE SIGNIFICANT CONDITION
THAT THEY WERE IN THAT THEY SHOULD HAVE BEEN ON THAT UNIT?
A. WHERE THEY ARE ADMITTED IN A PARTICULAR HOSPITAL DEPENDS
ON THE HOSPITAL CUSTOMS AND THE WAY PATIENTS ARE MANAGED IN A
PARTICULAR AREA. I DON'T KNOW ABOUT THAT IN THIS CASE --
Q. OKAY.
A. -- SO I CAN'T COMMENT ON WHETHER OR NOT THAT WAS THE
RIGHT PLACE FOR THEM TO BE MANAGED.
Q. OKAY. ONE FINAL QUESTION: THE BOTTOM LINE IN THIS
MATTER IS YOU'VE GOT FIVE PATIENTS THAT COME ONTO THIS UNIT,
ALL OF THEM AS YOU HAD INDICATED WITH SOME SEVERE PROBLEMS,
THEY WERE ON THE UNIT FOR APPROXIMATELY 16 DAYS AND THEY ALL
DIE. AND THERE'S ONE COMMON FACTOR BETWEEN ALL FIVE OF THESE
PATIENTS AND THAT IS THE FACT THAT THEY RECEIVED MORPHINE; IS
THAT CORRECT --
A. WELL, THERE'S MORE COMMON FACTORS THAN THAT. THEY ALL
THE HAVE ADVANCED DISEASE AS WELL.
Q. AND THEY RECEIVED PSYCHOTROPIC DRUGS AND THEY RECEIVED
LARGE AMOUNTS OF MORPHINE?
A. SURE. THERE ARE A NUMBER OF OVERLAPPING FEATURES.
MR. MAJOR: THANK YOU. WE HAVE NO FURTHER
QUESTIONS, YOUR HONOR.
THE COURT: DO YOU WANT TO TURN THE PROJECTOR OFF,
MR. MAJOR.
MR. MAJOR: I WILL DO THAT, YOUR HONOR. I WILL EVEN
TURN ON THE LIGHTS.
RECROSS-EXAMINATION
BY MS. ISAACSON:
Q. DR. CASSIN, IN REVIEWING THE RECORDS YOU SAW THAT ALL OF
THESE PATIENTS HAD ADVANCED DIRECTIVES AS TO THEIR TREATMENT
AND CARE AT THE END OF THEIR LIVES; IS THAT RIGHT?
A. I KNOW THAT THEY WERE REFERRED TO OR IN -- I REMEMBER
EVEN READING ONE AT LEAST ONE IN THE RECORD.
Q. AND WITH REGARD TO JUDITH LARSEN, YOU SAW THE MORPHINE
THAT WAS ADMINISTERED TO HER, IT'S TRUE THAT AT A CERTAIN
POINT DURING HER HOSPITALIZATION A DECISION HAD SIMPLY BEEN
MADE BASED UPON HER ADVANCED DIRECTIVES AND THE WISHES OF HER
FAMILY TO KEEP HER COMFORTABLE?
A. YES.
Q. AND THAT'S ALSO TRUE WITH MARY CRANE, LYDIA SMITH, ENNIS
ALLDREDGE THAT A DECISION HAD BEEN MADE TO KEEP THESE
PATIENTS COMFORTABLE THROUGH THE DYING PROCESS?
A. THAT'S PART OF THE ADVANCED DIRECTIVES AND THAT'S TRUE IN
THESE CASES, YES.
Q. AND ONE OF THE THINGS THAT MORPHINE CAN DO AND CAN
PROVIDE IS COMFORT AT THE END OF LIFE, IS THAT TRUE?
A. IT'S COMMONLY USED FOR THAT PURPOSE, YES.
MS. ISAACSON: THAT'S ALL I HAVE.
THE COURT: RECROSS.
MR. MAJOR: NONE, YOUR HONOR.
THE COURT: YOU MAY STEP DOWN, DOCTOR. THANK YOU
FOR TESTIFYING.
THE WITNESS: THANK YOU, SIR.
THE COURT: MAY THIS WITNESS BE EXCUSED, MR. MAJOR?
MR. MAJOR: YES, SIR.
THE COURT: MS. ISAACSON?
MS. ISAACSON: YES.
THE COURT: THANK YOU. AND YOU MAY BE EXCUSED.
THANK YOU FOR TESTIFYING.