Bradford Hare, MD Physicians should note this quote>> And this one>>
14 BRADFORD HARE,
15 CALLED AS A WITNESS, BEING FIRST DULY SWORN TO TELL THE
16 TRUTH, WAS EXAMINED AND TESTIFIED AS FOLLOWS:
17 DIRECT EXAMINATION
18 BY MR. WILSON:
19 Q. DR. HARE, WOULD YOU STATE YOUR NAME FOR THE RECORD,
20 PLEASE.
21 A. BRADFORD D. HARE, H-A-R-E.
22 Q. AND WHERE ARE YOU CURRENTLY EMPLOYED, SIR?
23 A. I'M ON THE FACULTY AT THE UNIVERSITY OF UTAH IN THE
24 DEPARTMENT OF ANESTHESIOLOGY IN THE COLLEGE OF MEDICINE.
25 Q. OKAY. SIR, CAN YOU TELL US WHAT DEGREES DO YOU
2530
1 PRESENTLY HOLD?
2 A. I HAVE A B.S. DEGREE IN PHARMACY. I HAVE A PH.D. IN
3 PHARMACOLOGY. I HAVE AN M.D. DEGREE.
4 Q. AND CAN YOU TELL US WHEN YOU OBTAINED YOUR PH.D. IN
5 PHARMACOLOGY?
6 A. I THINK TECHNICALLY IT WAS IN 1974, BUT I RECEIVED THE
7 DEGREE AT THE SAME TIME I DID MY MEDICAL DEGREE, IN 1975.
8 Q. OKAY. SO YOU RECEIVED BOTH YOUR MEDICAL DEGREE AND YOUR
9 PH.D. IN PHARMACOLOGY ESSENTIALLY AT THE SAME TIME?
10 A. I DID.
11 Q. EXPLAIN TO THE JURY WHAT IS THE STUDY OF PHARMACOLOGY?
12 A. PHARMACOLOGY IS THE DISCIPLINE THAT STUDIES THE EFFECTS
13 OF DRUGS, MEDICATIONS.
14 Q. YOU SAID YOU HAD A B.S. DEGREE IN THAT PARTICULAR AREA
15 OF STUDY?
16 A. I ACTUALLY HAVE A PHARMACY DEGREE, WHICH WAS JUST FOR
17 THE PRACTICE OF PHARMACY. BUT THEN AFTER THAT I DID MY
18 GRADUATE WORK IN PHARMACOLOGY, WHICH IS A SUBSPECIALTY
19 WITHIN PHARMACY, I GUESS YOU COULD SAY.
20 Q. OKAY. AS TO THE MEDICAL DEGREE, DID YOU RECEIVE ANY
21 SPECIFIC TRAINING ALSO RELATED TO THE ADMINISTRATION OF
22 MEDICATIONS?
23 A. AS PART OF MY MEDICAL DEGREE I GUESS I HAD THE STANDARD
24 EXPERIENCE THAT MEDICAL STUDENTS DO. BUT THEN I HAD
25 TRAINING AFTER MEDICAL SCHOOL, A YEAR OF PEDIATRICS AND TWO
2531
1 YEARS OF ANESTHESIA TRAINING, AND THEN A YEAR OF TRAINING IN
2 THE SPECIALTY OF PAIN MANAGEMENT. IN THOSE AREAS I RECEIVED
3 MUCH MORE TRAINING IN GIVING MEDICATIONS AND THEIR EFFECTS.
4 Q. I'D LIKE YOU TO CONCENTRATE, AS TO YOUR GENERAL MEDICAL
5 DEGREE, WHAT TYPE OF TRAINING DID YOU RECEIVE IN RESPECT TO
6 THE ADMINISTRATION OF DRUGS?
7 A. WE HAD A CLASS IN PHARMACOLOGY WHICH DEALT WITH, AGAIN,
8 MEDICATIONS AND THEIR EFFECTS, SIDE EFFECTS AND SO ON. WE
9 HAD EXPERIENCES WITH PATIENTS IN OUR SECOND -- WELL, THE
10 THIRD AND FOURTH YEAR OF MEDICAL SCHOOL WHERE WE WERE
11 WORKING WITH PATIENTS IN A CLINICAL SETTING. IN THERE WE
12 WERE PRESCRIBING MEDICATIONS UNDER DIRECTION, SEEING THEIR
13 EFFECTS, WORKING WITH PATIENTS IN THAT REGARD.
14 Q. I SEE. YOU INDICATED THAT YOU HAD FURTHER TRAINING AS
15 RELATED TO SPECIALIZED TRAINING IN ANESTHESIOLOGY?
16 A. YES.
17 Q. ARE YOU BOARD CERTIFIED IN ANESTHESIOLOGY?
18 A. I AM.
19 Q. DO YOU HOLD ANY OTHER CERTIFICATES OR BOARD
20 CERTIFICATIONS?
21 A. I'M ALSO BOARD CERTIFIED IN PAIN MANAGEMENT AS PART OF
22 MY ANESTHESIOLOGY CERTIFICATION.
23 Q. OKAY. SO THIS WAS -- WHEN DID YOU RECEIVE THOSE
24 PARTICULAR BOARD CERTIFICATIONS?
25 A. MY BOARD CERTIFICATION IN ANESTHESIOLOGY WAS IN 1979.
2532
1 THE SPECIALTY CERTIFICATION IN PAIN MANAGEMENT WAS IN 1993.
2 Q. OKAY. AS TO YOUR ANESTHESIOLOGY BACKGROUND, CAN YOU
3 TELL ME HOW LONG HAVE YOU BEEN PRACTICING IN THAT PARTICULAR
4 SPECIALTY?
5 A. I'VE ACTUALLY BEEN OUT OF TRAINING AND IN PRACTICE --
6 THIS WOULD BE MY 21ST YEAR.
7 Q. CAN YOU TELL THE JURY, IF YOU WOULD, WHAT THAT TYPE OF
8 PRACTICE ENTAILS?
9 A. THE PRACTICE OF ANESTHESIOLOGY WOULD INVOLVE THE
10 ADMINISTRATION OF ANESTHETICS TO PATIENTS UNDERGOING
11 SURGERY. THAT'S AT LEAST A BIG PART OF IT. UNDER THOSE
12 CIRCUMSTANCES, YOU KNOW, I THINK EVERYONE REALIZES THAT
13 ANESTHESIOLOGY WOULD INVOLVE PUTTING PATIENTS TO SLEEP FOR
14 SURGERY.
15 BUT MORE IMPORTANTLY WE'RE CONSTANTLY STUDYING, UNDER
16 THOSE CIRCUMSTANCES, THE EFFECTS OF ANESTHETIC DRUGS AND
17 OTHER DRUGS ON THINGS LIKE BREATHING, BLOOD PRESSURE, HEART
18 RATE, VARIOUS OTHER VITAL FUNCTIONS. BECAUSE WHILE THE
19 PATIENT IS ASLEEP WE'RE IN CHARGE OF MAKING SURE THEY'RE
20 SAFE AND ALL THE BODY FUNCTIONS ARE WORKING WELL.
21 Q. I TAKE IT THAT AS PART OF THAT PARTICULAR SPECIALTY
22 YOU'RE CONVERSANT WITH AND EXPERIENCED IN READING THESE
23 TYPES OF TESTS THAT ARE MADE IN THE COURSE OF SURGERIES AND
24 AFTER SURGERIES?
25 A. THAT'S CORRECT.
2533
1 Q. AND THEY PERTAIN -- IN RESPECT TO THE ADMINISTRATION OF
2 THE MEDICATIONS OR THE DRUGS THAT YOU MAY HAVE ADMINISTERED
3 TO ANESTHETIZE THESE PATIENTS?
4 A. YES. THERE WOULD BE A WHOLE VARIETY OF DIFFERENT
5 MEDICATIONS WE MIGHT BE CALLED UPON TO GIVE. SOME WOULD BE
6 ANESTHETICS, SOME WOULD BE PAINKILLERS. SOME WOULD BE DRUGS
7 MEANT TO SUPPORT BLOOD PRESSURE, CHANGE BLOOD PRESSURE,
8 HEART RATE. A WHOLE HOST OF OTHER DRUGS. PLUS WE'RE GIVING
9 ANESTHETICS IN THE SETTING OF PATIENTS WITH MEDICAL
10 PROBLEMS, SO WE HAVE TO ACCOUNT FOR THE DRUGS THAT THEY'RE
11 ON AND HOW THAT MIGHT AFFECT OUR ANESTHETICS AND THEIR
12 REACTION TO THE DRUGS.
13 Q. ARE ANY OF THOSE PATIENTS WHAT YOU WOULD CONSIDER TO BE
14 GERIATRIC PATIENTS?
15 A. YES.
16 Q. OKAY. HOW MANY OCCASIONS WOULD YOU SAY, OVER THAT 21
17 YEARS OF EXPERIENCE, YOU'VE PARTICIPATED IN SURGERIES AND IN
18 MONITORING THESE PATIENTS? DO YOU HAVE ANY IDEA?
19 A. THOUSANDS. I CAN'T GIVE YOU AN EXACT NUMBER.
20 Q. YOU ALSO INDICATED THAT YOU DEVELOPED AN EXPERTISE AND A
21 BOARD CERTIFICATION IN PAIN MANAGEMENT?
22 A. YES.
23 Q. AND THAT OCCURRED IN 1993?
24 A. YES, IT DID. THAT WAS THE FIRST YEAR IT WAS OFFERED.
25 Q. OKAY. THAT WAS THE FIRST YEAR IT WAS OFFERED AS A
2534
1 CERTIFICATION?
2 A. YES.
3 Q. AND IN RESPECT TO PAIN MANAGEMENT, MAYBE YOU COULD
4 INDICATE TO US WHAT DOES THAT ENTAIL?
5 A. WELL, THE SUBSPECIALTY OF PAIN MANAGEMENT WOULD DEAL
6 WITH THE SEVERAL DIFFERENT KINDS OF PAIN. THERE WOULD BE
7 THE ACUTE PAIN, WHICH WOULD BE PAIN THAT WOULD OCCUR LIKE
8 AFTER SURGERY. THERE WOULD BE NONMALIGNANT CHRONIC PAIN,
9 WHICH WOULD BE CHRONIC HEADACHES, CHRONIC BACK PAIN,
10 DIFFERENT TYPES OF PROBLEMS LIKE THAT. AND THEN THERE WOULD
11 BE PAIN RELATED TO MALIGNANCY.
12 Q. OKAY.
13 A. CANCER PAIN.
14 Q. AND YOU PRACTICED IN THAT AREA FOR HOW LONG?
15 A. 21 YEARS.
16 Q. SO THAT WAS PART OF THE GENERAL PRACTICE THAT YOU HAD AS
17 IT RELATED TO ANESTHESIOLOGY?
18 A. YES. IT WAS A COMBINATION OF OR, ANESTHESIA AND PAIN
19 MANAGEMENT IN A PAIN CLINIC SETTING.
20 Q. YOU INDICATED THAT YOU'RE PRESENTLY ON THE STAFF AT THE
21 UNIVERSITY OF UTAH HOSPITAL?
22 A. THAT'S CORRECT.
23 Q. AND DO YOU DO TEACHING?
24 A. I DO.
25 Q. AND WHAT AREAS DO YOU TEACH?
2535
1 A. AGAIN, PAIN MANAGEMENT WOULD BE THE MAJORITY OF WHAT I
2 TEACH. THEN OPERATING ROOM ANESTHESIA.
3 Q. OKAY. IN THE COURSE OF YOUR PAIN MANAGEMENT EXPERIENCE,
4 HAVE YOU HAD OCCASION TO TREAT PATIENTS WHO ARE CATEGORIZED
5 IN THE GERIATRIC AGE GROUP?
6 A. I HAVE.
7 Q. OKAY. YOU'VE ALSO, HAVE YOU NOT, TESTIFIED AS AN EXPERT
8 IN OTHER PROCEEDINGS?
9 A. I HAVE.
10 Q. YOU'VE BEEN ASKED PREVIOUS TO THIS TIME TO REVIEW THE
11 MEDICAL RECORDS PERTAINING TO FIVE PATIENTS THAT ARE THE
12 SUBJECT MATTER OF THIS PARTICULAR CASE, IS THAT CORRECT?
13 A. THAT'S CORRECT.
14 Q. COULD YOU TELL THE JURY JUST WHAT MEDICAL RECORDS, IF
15 ANY, YOU'VE REVIEWED IN CONNECTION WITH YOUR TESTIMONY IN
16 THIS PROCEEDING?
17 A. I'VE REVIEWED THE MEDICAL RECORDS FROM THE DAVIS
18 HOSPITAL, FROM THE GERO-PSYCHIATRIC UNIT. I'VE REVIEWED
19 MEDICAL RECORDS FROM THE, I GUESS YOU COULD SAY, NURSING
20 HOMES FROM WHERE THESE PATIENTS CAME. I'VE REVIEWED SOME
21 ADDITIONAL RECORDS, INTERVIEWS, THAT WERE OBTAINED BY
22 DETECTIVE MORRISON.
23 Q. HAVE YOU HAD OCCASION --
24 A. I'VE REVIEWED AUTOPSY REPORTS.
25 Q. HAVE YOU HAD OCCASION TO CONSULT ANY JOURNALS, IN
2536
1 RESPECT TO THE VARIOUS CATEGORIES OF YOUR SPECIALIZED
2 TRAINING, IN CONNECTION WITH THIS REVIEW?
3 A. THERE HAVE BEEN SOME SPECIFIC NUMBERS AND FACTS THAT
4 I'VE LOOKED UP IN REGARDS TO THIS CASE, BUT MUCH OF IT I'VE
5 BEEN ABLE TO RELY ON MY ACCUMULATED KNOWLEDGE. Ha!
6 Q. AND YOU PREVIOUSLY TESTIFIED, DID YOU NOT, IN THIS
7 MATTER IN CONNECTION WITH THE PRELIMINARY HEARING?
8 A. I DID.
9 Q. AS TO THE MEDICAL RECORDS THEMSELVES, HOW MANY TIMES
10 WOULD YOU SAY YOU'VE HAD THE OPPORTUNITY TO REVIEW THOSE?
11 A. IN THEIR ENTIRETY I WOULD SAY I'VE BEEN THROUGH THEM AT
12 LEAST THREE TIMES; AND THEN I'VE REFERRED TO MULTIPLE
13 PORTIONS OF THEM MANY OTHER TIMES.
14 Q. OKAY. I NOTE THAT YOU BROUGHT WITH YOU SOME DOCUMENTS
15 HERE TODAY. CAN YOU TELL US WHAT THOSE DOCUMENTS ARE?
16 A. THESE ARE COPIES OF THE MEDICAL RECORDS FROM THE DAVIS
17 HOSPITAL AND FROM THE NURSING HOMES. IN ADDITION, I HAVE
18 SOME OTHER SUMMARIES, NOTES AND SO ON.
19 Q. DID YOU, SIR, IN THE COURSE OF YOUR EVALUATION OF THESE
20 PARTICULAR RECORDS, MAKE NOTES YOURSELF?
21 A. TO SOME DEGREE. IT WAS MORE NOTATIONS, I WOULD SAY,
22 RATHER THAN NOTES.
23 Q. OKAY. DID YOU HAVE OCCASION TO IDENTIFY, IN THAT
24 PARTICULAR EXHIBIT, CERTAIN AREAS THAT YOU FELT WERE
25 RELEVANT TO YOUR TESTIMONY HERE IN COURT TODAY?
2537
1 A. YES, I DID.
2 Q. OKAY. I WANT TO FIRST TALK TO YOU A LITTLE BIT ABOUT
3 YOUR SPECIALTY IN PHARMACOLOGY. I ASSUME THERE'S VARIOUS
4 CATEGORIES OF MEDICATIONS AND DRUGS, WOULD THAT BE A FAIR
5 STATEMENT?
6 A. YES.
7 Q. CAN YOU TELL US, ARE THERE DRUGS THAT ARE CLASSIFIED,
8 ESSENTIALLY, AS CENTRAL NERVOUS SYSTEM DEPRESSANTS?
9 A. THAT WOULD BE A VERY BROAD CATEGORY OF MEDICATIONS. IT
10 COULD INCLUDE A NUMBER OF DIFFERENT CLASSES OF DRUGS.
11 CENTRAL NERVOUS SYSTEM DEPRESSION IS A PROPERTY SHARED BY
12 MANY DIFFERENT KINDS OF MEDICATIONS.
13 Q. SPECIFICALLY, IN YOUR REVIEW OF THE MEDICAL RECORDS IN
14 THIS PARTICULAR CASE, CAN YOU TELL US WHETHER OR NOT THERE
15 WERE IN EFFECT DRUGS THAT WOULD FIT INTO THAT CATEGORY?
16 A. YES. IN MOST CASES THE PATIENTS INVOLVED IN THESE CASES
17 WERE RECEIVING MEDICATIONS THAT WOULD BE CLASSIFIED AS
18 CENTRAL NERVOUS SYSTEM DEPRESSANTS.
19 Q. I'M GOING TO SHOW YOU WHAT HAS BEEN MARKED FOR THE
20 RECORD AT THIS TIME AS STATE'S EXHIBIT NUMBER 39.
21 MR. WILSON: FOR THE RECORD, YOUR HONOR, I REVIEWED
22 THAT EXHIBIT WITH MR. STIRBA. I DON'T THINK HE HAS ANY
23 OBJECTION TO USING THIS AS A DEMONSTRATIVE AID AT THIS TIME.
24 MR. STIRBA: THAT IS TRUE, YOUR HONOR.
25 THE COURT: OKAY. GO AHEAD.
2538
1 Q. (BY MR. WILSON) CALLING YOUR ATTENTION TO THE EXHIBIT,
2 CAN YOU TELL US, DOCTOR, DID YOU DESIGN THAT PARTICULAR
3 EXHIBIT?
4 A. I HELPED DO THAT. THIS BASICALLY, I THINK, SUMMARIZES
5 SOME OF THE PREVIOUS TESTIMONY THAT I'VE GIVEN AND PUTS IT
6 INTO A HOPEFULLY MORE EASILY UNDERSTANDABLE FORM.
7 Q. OKAY. CAN YOU TELL US WHAT THE EXHIBIT IS, OR PURPORTS
8 TO SHOW?
9 A. WHAT I HOPED TO DEMONSTRATE HERE WOULD BE THE IMMEDIATE
10 EFFECTS OF SOME OF THE MEDICATIONS, PARTICULARLY IN EXCESS.
11 AND THEN THE MORE LONG-TERM EFFECTS. IN OTHER WORDS, A
12 REFLECTION OF IF AN IMMEDIATE EFFECT PERSISTS, WHAT SORTS OF
13 THING MAY HAPPEN.
14 Q. OKAY. LET'S TALK ABOUT SOME SPECIFIC DRUGS AT THIS
15 TIME. ARE YOU FAMILIAR WITH A DRUG THAT IS CALLED ATIVAN?
16 A. YES.
17 Q. CAN YOU TELL US ABOUT ATIVAN? FIRST, DOES THAT HAVE ANY
18 OF THE CHARACTERISTICS OF A CENTRAL NERVOUS SYSTEM
19 DEPRESSANT?
20 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT. I
21 THINK IT'S CUMULATIVE.
22 THE COURT: GO AHEAD. OVERRULED.
23 MR. WILSON: THANK YOU, YOUR HONOR.
24 Q. (BY MR. WILSON) CAN YOU TELL US A LITTLE ABOUT ATIVAN?
25 A. YES. ATIVAN IS PART OF A GROUP OF MEDICATIONS CALLED
2539
1 BENZODIAZEPINES. IT INCLUDES THINGS LIKE VALIUM, A NUMBER
2 OF OTHER MEDICATIONS. TYPICALLY CONSIDERED TO BE MEDICINES
3 FOR ANXIETY. FOR PEOPLE WHO HAVE NERVES, I GUESS YOU COULD
4 SAY.
5 Q. DOES IT HAVE ANY SEDATING EFFECTS?
6 A. YES, IT DOES.
7 Q. I WANT YOU TO SPECIFICALLY FOCUS ON THE SEDATING EFFECTS
8 AND WHAT THAT MEANS AS TO THE DRUG ATIVAN?
9 A. CERTAINLY ONE OF THE MOST PROMINENT EFFECTS WOULD BE, IN
10 SMALL DOSES, TO RELIEVE ANXIETY OR NERVOUSNESS. IN HIGHER
11 DOSES IT WOULD CAUSE SLEEPINESS. HIGHER DOSES WOULD CAUSE
12 COMA OR SLEEPY -- I MEAN, GO FROM SLEEPINESS TO
13 UNCONSCIOUSNESS.
14 SOME OF THE OTHER THINGS I MENTIONED WILL FIT WITH THAT
15 IN MY IMMEDIATE EFFECT CATEGORY THERE. PATIENTS BECOME VERY
16 SLEEPY. THEIR ABILITY TO COUGH, TO SWALLOW PROPERLY, BEGINS
17 TO BECOME LOST. GASTRIC SECRETIONS, STOMACH CONTENTS, JUST
18 OTHER SECRETIONS IN THE MOUTH MAY GET PULLED DOWN INTO THE
19 LUNGS. SO ASPIRATION IS THE TECHNICAL TERM WE USE FOR THAT.
20 THESE MEDICINES CAN, AND PARTICULARLY IN LARGER DOSES,
21 DECREASE BLOOD PRESSURE. AND WHEN A PATIENT IS REALLY
22 SLEEPY THEY OFTEN TIMES JUST DON'T EAT OR DRINK MUCH. AS A
23 RESULT SOME OF THE LONG-TERM EFFECTS BEGIN TO OCCUR.
24 SO, STARTING WITH MY LAST STATEMENT ABOUT PATIENTS NOT
25 EATING OR DRINKING MUCH, EVENTUALLY THEY CAN BECOME
2540
1 DEHYDRATED, BECOME MALNOURISHED. THIS RESULTS IN EVEN A
2 FURTHER INCREASE IN THEIR SENSITIVITY TO THE DRUG. THE SAME
3 DOSE OF DRUG IS GOING TO EVEN CAUSE A GREATER EFFECT IN A
4 DEHYDRATED PATIENT.
5 THE COURT: EXCUSE ME. I THINK WE NEED TO PROCEED
6 BY QUESTION AND ANSWER.
7 Q. (BY MR. WILSON) YOU'VE INDICATED THE IMMEDIATE EFFECTS
8 AND LONG-TERM EFFECTS ON THE CHART. ARE ALL OF THESE ITEMS
9 THAT YOU'VE INDICATED, ARE THEY ALL EFFECTS OF -- THAT YOU
10 COULD EXPERIENCE RELATIVE TO THE ADMINISTRATION OF THIS
11 PARTICULAR DRUG?
12 A. YES, THEY ARE.
13 Q. AND AGAIN, AS I UNDERSTAND IT, YOUR TESTIMONY, YOU TALK
14 ABOUT DOSAGES, IS THAT CORRECT?
15 A. THAT'S RIGHT.
16 Q. SO THE EFFECTS THAT YOU'VE LISTED THERE, ARE THEY
17 RELATED TO THE AMOUNT OR DOSAGES THAT WOULD BE ADMINISTERED
18 TO A PATIENT?
19 A. YES, THEY ARE. SMALL DOSES WOULD, AGAIN, RESULT IN
20 PERHAPS JUST A PRETTY SELECTIVE ANTI-ANXIETY EFFECT. THE
21 PATIENT MIGHT NOT BE VERY SLEEPY. THEY CAN BE PRETTY ALERT.
22 THEY MAY EVEN FUNCTION BETTER BECAUSE THEY'RE NOT ANXIOUS
23 ANYMORE.
24 Q. I'LL SHOW YOU WHAT HAS BEEN PREVIOUSLY MARKED AS STATE'S
25 EXHIBIT NUMBER 31. I DON'T KNOW WHETHER YOU'VE HAD AN
2541
1 OPPORTUNITY TO -- WELL, TAKE A LOOK AT IT, PLEASE.
2 A. I THINK I CAN READ IT WITHOUT MY GLASSES.
3 Q. HAVE YOU SEEN THAT EXHIBIT BEFORE, DOCTOR?
4 A. I BELIEVE I HAVE. AT LEAST IN SOME FORM, YES.
5 Q. JUST READ THROUGH IT REAL QUICKLY AND TELL ME IF YOU
6 AGREE WITH THE VARIOUS DOSAGES THAT ARE STATED ON THE
7 EXHIBIT.
8 A. WELL, THIS PARTICULAR EXHIBIT COMPARES THE NORMAL ADULT
9 STARTING DOSE WITH THE STARTING DOSE THAT MIGHT BE GIVEN TO
10 AN ELDERLY PATIENT. FOR A NORMAL ADULT STARTING DOSE, IT'S
11 ONE TO 10 MILLIGRAMS BY MOUTH PER DAY IN THREE DOSES. A
12 NORMAL STARTING DOSE IN AN ELDERLY PATIENT IS MUCH LESS THAN
13 THAT. SO ONE-HALF TO ONE MILLIGRAM BY MOUTH A DAY IN
14 DIVIDED DOSES. NO MORE THAN TWO MILLIGRAMS PER DAY. A HUGE
15 REDUCTION FROM THE NORMAL DOSE.
16 THE COURT: WHAT WAS THE QUESTION?
17 Q. (BY MR. WILSON) DO YOU AGREE WITH THE STATED DOSAGES
18 ON THAT PARTICULAR CHART?
19 A. YES, I DO.
20 Q. AND IN YOUR EXPERT OPINION, WOULD THOSE REPRESENT WHAT
21 YOU FEEL ARE THE CORRECT DOSAGES? AND I WOULD ASK YOU TO
22 LOOK AT ALL THE DRUGS AS FAR AS THAT GOES.
23 A. (PAUSE.) I WOULD TEND TO AGREE WITH EVERYTHING. I
24 WOULD TEND TO BE MORE CONSERVATIVE ON THE DURAGESIC DOSE. I
25 WOULD SAY THE 25-MICROGRAM PATCH WOULD BE SUITABLE FOR
2542
1 SOMEBODY WITH FAIRLY SEVERE PAIN, BUT FOR JUST KIND OF
2 EVERYDAY NORMAL SORT OF USE THAT'S STILL A PRETTY HEFTY
3 DOSE.
4 Q. OKAY. LET'S TALK A LITTLE BIT ABOUT SOME OF THE OTHER
5 SUBSTANCES. IF WE CAN, IF COUNSEL WILL ALLOW ME TO LEAD YOU
6 A LITTLE BIT IN THE INTEREST OF TIME. TRAZODONE, DOES IT
7 HAVE ANY CENTRAL NERVOUS SYSTEM DEPRESSANT EFFECT?
8 A. YES, IT DOES.
9 Q. AND CAN YOU TELL US, RELATIVE TO THE EXHIBIT ON THE
10 BOARD ON THE CENTRAL NERVOUS SYSTEM DEPRESSANT, DO THOSE
11 REPRESENT THE EFFECTS, IMMEDIATE AND LONG-TERM EFFECTS, ONE
12 MIGHT EXPERIENCE WITH THE ADMINISTRATION OF TRAZODONE?
13 A. YES, THEY WOULD.
14 Q. OKAY. HALDOL, DOES THAT HAVE ANY CENTRAL NERVOUS SYSTEM
15 DEPRESSANT EFFECTS?
16 A. IT DOES.
17 Q. AN AGAIN, WOULD THE CHART THAT YOU HAVE ON THE BOARD
18 COMPORT WITH THE IMMEDIATE EFFECTS AND LONG-TERM EFFECTS OF
19 ONE RECEIVING DOSAGES OF HALDOL?
20 A. YES.
21 Q. IS HALDOL ADMINISTERED IN PILL FORM?
22 A. IT CAN BE.
23 Q. OKAY. WELL, LET ME BACK OFF THAT FOR A MINUTE. LET'S
24 GO THROUGH THE OTHERS. RISPERDAL, AGAIN, DOES THAT HAVE ANY
25 CENTRAL NERVOUS SYSTEM DEPRESSANT EFFECTS?
2543
1 A. IT HAS SOME, BUT PROBABLY NOT TO THE SAME DEGREE AS THE
2 MEDICATIONS WE'VE ALREADY SPOKEN ABOUT.
3 Q. ALL RIGHT. SO IT WOULD HAVE LESS EFFECT AS TO THE
4 IMMEDIATE EFFECTS AND LONG-TERM EFFECTS?
5 A. BY ITSELF IT WOULD, YES.
6 Q. OKAY. DEPAKENE, CAN YOU TELL US ABOUT DEPAKENE?
7 A. THAT'S A DRUG THAT WAS INTRODUCED AS AN ANTICONVULSANT,
8 A MEDICINE FOR EPILEPSY, BUT IT HAS BEEN USED IN PATIENTS
9 WITH MOOD DISTURBANCE. AND IT WOULD FIT IN THE CATEGORY OF
10 A CENTRAL NERVOUS SYSTEM DEPRESSANT, SO IT CAN CERTAINLY
11 CAUSE THE EFFECTS THAT I'VE LISTED THERE.
12 Q. OKAY. I WANT TO TALK A LITTLE BIT ABOUT WHAT IS
13 REFERRED TO AS A DURAGESIC PATCH. CAN YOU TELL US WHAT THAT
14 MEANS?
15 A. THE DURAGESIC PATCH IS -- DURAGESIC IS A BRAND NAME FOR
16 A DOSE FORM OF MEDICATION. A VERY POTENT NARCOTIC BY THE
17 NAME OF FENTANYL IS PLACED IN A PATCH FORM THAT WHEN ON THE
18 SKIN IS ABSORBED THROUGH THE SKIN INTO THE BLOOD STREAM AND
19 THAT'S HOW WE GET THE EFFECTS OF THE MEDICATION. SO IT'S A
20 NARCOTIC TYPE MEDICINE. IT CAN BE USED FOR, IN CERTAIN
21 CIRCUMSTANCES, FOR PAIN MANAGEMENT.
22 Q. I'M GOING TO PLACE ON THE BOARD, IF IT WILL STAY THERE,
23 CAN YOU TELL WHAT THAT IS, WHAT THAT EXHIBIT REPRESENTS?
24 A. THIS IS A PORTION, OR A BLOW-UP, I GUESS, OF SEVERAL
25 PORTIONS OF THE INFORMATION IN ONE OF THE REFERENCES WE
2544
1 COMMONLY USE ON MEDICATIONS CALLED THE PHYSICIANS DESK
2 REFERENCE. THIS IS ESSENTIALLY A -- THERE'S INFORMATION
3 THAT GOES ALONG WITH EACH MEDICATION CALLED THE PACKAGE
4 INSERT. IT INCLUDES INFORMATION AS TO THE CHEMICAL NATURE
5 OF THE DRUG, THE USES, THE SIDE EFFECTS, CAUTIONS. ALL
6 KINDS OF DIFFERENT THINGS. IT'S INCLUDED USUALLY IN TINY
7 LITTLE PRINT, AS SHOWN THERE.
8 BUT IN THAT IT'S REQUIRED BY THE F.D.A. THAT CERTAIN
9 IMPORTANT CAUTIONS BE INCLUDED JUST TO MAKE SURE THE
10 PRACTITIONER PRESCRIBING THE DRUGS IS AWARE OF PROBLEMS THAT
11 MIGHT OCCUR AND LIMITATIONS THAT MAY BE PLACED ON THAT DRUG.
12 Q. IT INDICATES P.D.R. 49 EDITION, 1995?
13 A. YES.
14 Q. WHAT DOES THAT MEAN?
15 A. THAT'S THE 1995 EDITION. THIS COMES OUT EVERY YEAR, SO
16 IT'S UPDATED EACH YEAR.
17 Q. OKAY. NOW, WE'VE BLOWN UP CERTAIN WARNINGS AND OTHER
18 CONTRAINDICATIONS AND GENERAL OBSERVATIONS THAT ARE MADE IN
19 THE CONTEXT OF THAT PARTICULAR REFERENCE ON THE SIDES. HAVE
20 YOU HAD OCCASION TO READ THOSE PARTICULAR WARNINGS AND
21 REFERENCES?
22 A. I HAVE.
23 Q. OKAY. WOULD YOUR TESTIMONY HERE TODAY AGREE WITH WHAT
24 IS CONTAINED IN THAT PARTICULAR DOCUMENT?
25 A. YES, IT WOULD.
2545
1 Q. OKAY. LET'S TALK A LITTLE BIT ABOUT THE DURAGESIC
2 WARNING. MAYBE YOU COULD READ THAT, PLEASE.
3 A. "DURAGESIC SHOULD BE PRESCRIBED ONLY BY PERSONS
4 KNOWLEDGEABLE IN THE CONTINUOUS ADMINISTRATION OF POTENT
5 OPIOIDS." THAT'S NARCOTIC TYPE PAIN MEDICINES. "IN THE
6 MANAGEMENT OF PATIENTS RECEIVING POTENT OPIOIDS FOR THE
7 TREATMENT OF PAIN AND IN THE DETECTION AND MANAGEMENT OF
8 HYPOVENTILATION INCLUDING THE USE OF OPIOID ANTAGONISTS."
9 Q. LET ME STOP YOU RIGHT THERE. WHAT IS HYPOVENTILATION?
10 A. THAT MEANS DECREASED BREATHING.
11 Q. OKAY.
12 THE COURT: ALSO, WHEN YOU READ, THE COURT REPORTER
13 HAS TO TAKE EVERYTHING DOWN. DOCTORS TEND TO READ FASTER
14 THAN THEY NORMALLY SPEAK, SO JUST GO SLOW.
15 THE WITNESS: THANK YOU. I WILL.
16 Q. (BY MR. WILSON) AS TO THE TERM THE USE OF OPIOID
17 ANTAGONISTS, WHAT DOES THAT MEAN?
18 A. NARCOTICS ACT IN CERTAIN SYSTEMS IN THE BODY. THERE ARE
19 OTHER DRUGS, ONE IN PARTICULAR CALLED NALOXONE OR NARCAN,
20 WHICH WILL COUNTERACT AS AN ANTIDOTE AGAINST THE EFFECTS OF
21 NARCOTICS.
22 Q. READ ON.
23 A. "THE CONCOMITANT USE OF OTHER CENTRAL NERVOUS SYSTEM
24 DEPRESSANTS, INCLUDING OTHER OPIOIDS, SEDATIVES OR
25 HYPNOTICS, GENERAL ANESTHETICS, PHENOTHIAZINES,
2546
1 TRANQUILIZERS, SKELETAL MUSCLE RELAXANTS, SEDATING
2 ANTIHISTAMINES, AND ALCOHOLIC BEVERAGES MAY PRODUCE ADDITIVE
3 DEPRESSANT EFFECTS."
4 Q. OKAY. LET ME STOP YOU THERE. WHAT DOES THAT MEAN,
5 DOCTOR?
6 A. WE TALKED EARLIER ABOUT GENERAL CENTRAL NERVOUS SYSTEM
7 DEPRESSANTS. IF ONE OF THOSE IS BEING USED AT THE SAME TIME
8 AS A SUBSTANCE SUCH AS FENTANYL IN THE DURAGESIC PATCH, THE
9 EFFECTS BECOME VERY UNPREDICTABLE. THE SIDE EFFECTS,
10 RESPIRATORY DEPRESSION, AND OTHER SORTS OF SIDE EFFECTS WITH
11 THE FENTANYL BECOME MUCH MORE EXAGGERATED.
12 Q. AND THEN THE LAST SENTENCE THERE.
13 A. "HYPOVENTILATION, HYPOTENSION AND PROFOUND SEDATION OR
14 COMA MAY OCCUR. WHEN SUCH COMBINED THERAPY IS CONTEMPLATED,
15 THE DOSE OF ONE OR BOTH AGENTS SHOULD BE REDUCED AT LEAST 50
16 PERCENT."
17 Q. SO WHAT DOES THAT MEAN?
18 A. THAT MEANS THAT IF FOR SOME REASON IT IS NECESSARY TO
19 USE A GENERAL CENTRAL NERVOUS SYSTEM DEPRESSANT AND FENTANYL
20 TOGETHER THAT WE HAVE TO BE VERY CAREFUL, FOR STARTERS.
21 THAT GENERALLY WE WOULD HAVE TO MAKE A DRAMATIC REDUCTION IN
22 THOSE TO MAKE IT A SAFE THERAPY.
23 Q. OKAY. THE GENERAL OBSERVATION THAT IS MADE THERE ABOUT
24 DURAGESIC DOSAGES, COULD YOU READ THAT PARTICULAR PORTION OF
25 THE DOCUMENT.
2547
1 A. "DURAGESIC DOSES GREATER THAN 25 MICROGRAMS PER HOUR,"
2 THAT'S THE SMALLEST SIZE, "ARE TOO HIGH FOR INITIATION OF
3 THERAPY IN NON OPIOID-TOLERANT PATIENTS."
4 Q. OKAY. DEFINE NON OPIOID-TOLERANT PATIENTS, PLEASE.
5 A. IF A PATIENT HAS BEEN RECEIVING A NARCOTIC OR OPIOID
6 MEDICINE FOR A LONG PERIOD OF TIME, THE BODY BUILDS UP SOME
7 RESISTANCE TO IT. THIS IS GENERALLY AFTER A PERIOD OF
8 MONTHS. WE REFER TO THAT RESISTANCE AS TOLERANCE. SO THAT
9 MEANS THAT THE PATIENT CAN STAND A HIGHER DOSE AND NOT
10 DEVELOP PROBLEMS WITH IT.
11 Q. OKAY. HAVE A SEAT. WE'VE TALKED ABOUT -- OH, EXCUSE
12 ME. I DID WANT TO PUT ON THE BOARD WHAT IS MARKED AS
13 STATE'S EXHIBIT 42. I'D ASK YOU TO YOU TELL US, SIR, WHAT
14 THAT REPRESENTS?
15 A. THIS, AGAIN, IS FROM THE PHYSICIANS' DESK REFERENCE IN
16 REGARDS TO THE DURAGESIC PATCH. THIS GIVES A COMPARISON, ON
17 ONE SIDE, OF THE DOSE OF ORAL MORPHINE AND HOW THAT COMPARES
18 TO THE STRENGTH OF THE DURAGESIC PATCH. IN OTHER WORDS, IF
19 I WERE SEEING A PATIENT WHO WAS ALREADY ON ORAL MORPHINE AND
20 I WAS CONTEMPLATING SWITCHING THEM TO A DURAGESIC PATCH, IT
21 WOULD GIVE ME AN IDEA OF WHAT SORT OF CONVERSION TO MAKE,
22 HOW TO SWITCH FROM ONE TO THE OTHER SAFELY.
23 Q. THIS COMPARES AN ORAL 24 HOUR MORPHINE MILLIGRAM PER DAY
24 DOSE, DOES IT NOT, TO THE DURAGESIC DOSE?
25 A. IT DOES.
2548
1 Q. IS THERE A FACTOR THAT YOU CAN -- WELL, IF AN INDIVIDUAL
2 IS ADMINISTERED A DOSAGE OF MORPHINE INTERMUSCULARLY, AS WE
3 HAVE IN THIS CASE, DOES THAT COMPORT TO THE SAME DOSAGE
4 ORALLY?
5 A. NO. THE INTERMUSCULAR DOSE WOULD BE ABOUT ONE-THIRD OF
6 THE ORAL DOSE. SO, IN OTHER WORDS, IF WE DIVIDE THOSE
7 NUMBERS BY THREE, THEN WE WOULD HAVE A PRETTY GOOD IDEA OF
8 WHAT THE INTERMUSCULAR DOSE WOULD BE.
9 Q. SO ASSUMING AN INDIVIDUAL HAD A DURAGESIC PATCH PLACED
10 ON THEM OF 25 MICROGRAMS, WHAT WOULD THAT EQUATE TO IN TERMS
11 OF AN INTERMUSCULAR INJECTION?
12 A. THIS IS IN TERMS OF MILLIGRAMS OF MORPHINE PER DAY. NOT
13 PER INJECTION, BUT PER DAY. IT WOULD BE SOMEWHERE BETWEEN
14 15 AND 40 -- AROUND 40, 45, MILLIGRAMS OF INJECTABLE
15 MORPHINE PER DAY. SO THAT'S A PRETTY SIZEABLE DOSE. THAT
16 WOULD BE THE SORT OF A DOSE THAT I WOULD EXPECT A PATIENT
17 WHO HAS HAD FAIRLY MAJOR SURGERY TO REQUIRE.
18 Q. OKAY. SO THIS IS A POWERFUL PAINKILLER?
19 A. IT IS. THIS IS A STRONG DOSE. THIS IS REALLY A DOSE
20 DESIGNED FOR PATIENTS WITH SEVERE PAIN.
21 Q. AGAIN, THIS IS A P.D.R. REFERENCE EDITION FOR 1995, IS
22 THAT CORRECT?
23 A. THAT'S CORRECT.
24 Q. ALL RIGHT. THE CONVERSION, AS RELATES TO THE 75
25 MICROGRAMS, SEEMS TO BE A LOT HIGHER, REPRESENTATIVE WISE,
2549
1 AS TO THE 25. WOULD THE SAME CONVERSION RATE HOLD TRUE ON
2 AN INTERMUSCULAR INJECTION?
3 A. YES. WE WOULD DIVIDE THE NUMBERS THERE FOR THE ORAL
4 DOSE BY THREE. IN OTHER WORDS, WE WOULD BE WORKING ON A
5 DOSING OF SOMEWHERE BETWEEN 75 AND SOMEWHAT OVER A HUNDRED
6 MILLIGRAMS OF MORPHINE PER DAY. SO IT'S A LARGE AMOUNT.
7 Q. I'D LIKE TO TALK A LITTLE BIT ABOUT MORPHINE ITSELF.
8 MORPHINE IS ALSO A CENTRAL NERVOUS SYSTEM DEPRESSANT, IS IT
9 NOT?
10 A. IT IS.
11 Q. I CALL YOUR ATTENTION TO WHAT IS IDENTIFIED AS STATE'S
12 EXHIBIT 40. CAN YOU TELL US A LITTLE BIT ABOUT THAT CHART,
13 HOW THAT CHART WAS PREPARED?
14 A. THIS CHART WAS PREPARED IN A SIMILAR WAY AS THE OTHER
15 ONE. MORPHINE HAS SOME DIFFERENT CHARACTERISTICS AND
16 DIFFERENT PARTS OF THE CHART SHOULD BE EMPHASIZED. AGAIN,
17 THE IMMEDIATE EFFECTS ARE LISTED ON THE ONE SIDE AND THEN,
18 WITH PERSISTENT ADMINISTRATION, THE EFFECTS ARE LISTED UNDER
19 THE LONG-TERM EFFECTS.
20 I'VE, AGAIN, LISTED PAIN RELIEF AS ONE OF THE EFFECTS.
21 OF COURSE, IT IS. BUT THEN I'VE ALSO LISTED WHAT WOULD BE
22 THE COMMON SIDE EFFECTS, THE COMMON PROBLEMS THAT WE WOULD
23 RUN INTO, HAVE TO WATCH OUT FOR IF WE WERE PRESCRIBING
24 MORPHINE TO A PATIENT.
25 Q. WHEN YOU SAY THE PERSISTENT -- I'M TRYING TO REMEMBER
2550
1 WHAT YOUR STATEMENT WAS. MAYBE THE PERSISTENT USE OR
2 DOSAGES OF MORPHINE AS TO THE LONG TERM EFFECTS? DID I
3 CHARACTERIZE THAT RIGHT?
4 A. I GUESS WHAT I MEANT TO BRING OUT ON THIS CHART, WHEN A
5 DRUG LIKE MORPHINE IS GIVEN WE SEE SOME THINGS QUITE EARLY
6 ON. AGAIN, WHAT I'VE LISTED AS IMMEDIATE EFFECTS. THOSE
7 EFFECTS MAY COME ON WITHIN A PERIOD OF MINUTES. IF IT'S AN
8 I.M. INJECTION IT WILL PROBABLY TAKE HALF AN HOUR TO AN HOUR
9 FOR SOME OF THOSE EFFECTS TO COME ON.
10 OVER THE PERIOD, THOUGH, OF THE NEXT HOURS, OR DAYS, IF
11 THE PATIENT CONTINUES TO RECEIVE THE MEDICATION, AND
12 PARTICULARLY IF THE PATIENT IS RECEIVING EXCESSIVE AMOUNTS
13 OF THE MEDICATION, THEN SOME OF THE THINGS LISTED ON THE
14 OTHER SIDE, THE LONG-TERM EFFECTS, BEGIN TO OCCUR.
15 Q. OKAY. I ASSUME YOU'VE USED MORPHINE IN YOUR PRACTICE?
16 A. YES.
17 Q. HAVE YOU USED IT ON MANY OCCASIONS OR --
18 A. MANY OCCASIONS. IT'S ONE OF THE MOST COMMON MEDICINES
19 WE USE.
20 Q. IN FACT, IT'S SORT OF THE STANDARD FOR PAIN MEDICATIONS,
21 IS IT NOT?
22 A. IT IS. IT'S THE STANDARD BY WHICH OTHER PAIN
23 MEDICATIONS ARE COMPARED TO TYPICALLY.
24 Q. MORPHINE HAS BEEN AROUND FOR A LONG TIME?
25 A. A LONG TIME.
2551
1 Q. AND IT'S CLASSIFIED AS AN OPIOID?
2 A. OPIOID. IT'S AN OPIUM DERIVATIVE.
3 Q. I MAY BE GETTING INTO THE GUERILLA FAMILY HERE IF I KEEP
4 THIS UP. IN TERMS OF THE ADMINISTRATION OF MORPHINE, CAN
5 YOU TELL US FOR WHAT PURPOSE IS MORPHINE USED?
6 A. THE PRIMARY EFFECTS OF MORPHINE -- IT'S MAIN USE IS FOR
7 THE PURPOSE OF PAIN MANAGEMENT.
8 Q. OKAY. IS THERE ANY OTHER USE IN THE MEDICAL FIELD THAT
9 MORPHINE IS USED FOR?
10 A. TO A MUCH LESSER DEGREE MORPHINE HAS BEEN USED IN
11 HELPING WITH SOME OF THE BLOOD PRESSURE CHANGES, SOME
12 DIFFERENT THINGS THAT HAPPEN WITH PATIENTS WHO HAVE HAD
13 HEART ATTACKS. OCCASIONALLY, IN AN I.C.U. SETTING, IT CAN
14 BE USED TO SEDATE PATIENTS. MAKE THEM MORE TOLERANT OF A
15 BREATHING TUBE IF THEY'RE ON A VENTILATOR. UNDER THOSE
16 CIRCUMSTANCES, THOUGH, WE DON'T HAVE TO WORRY ABOUT
17 DECREASED BREATHING BECAUSE THE VENTILATOR TAKES CARE OF THE
18 BREATHING. THOSE ARE SOME OF THE MAIN THINGS.
19 Q. IN TERMS OF ITS PRIMARY USE, THOUGH, IT'S PAIN
20 MANAGEMENT?
21 A. YES.
22 Q. CAN YOU TELL US, IS IT RELATED TO SEVERITIES OF PAIN?
23 WHAT TYPES OF PAIN, I GUESS, IS THE QUESTION?
24 A. WE USUALLY DON'T THINK OF MORPHINE TO BE PRESCRIBED FOR
25 MILD PAIN. WE MIGHT BE ABLE TO USE A MEDICINE LIKE TYLENOL
2552
1 OR ACETAMINOPHEN OR IBUPROFEN OR SOMETHING LIKE THAT. WE
2 USUALLY THINK OF IT FOR MODERATE TO SEVERE PAIN.
3 Q. OKAY. I REALIZE THIS MAY BE A DIFFICULT QUESTION TO
4 ANSWER, BUT WHAT DO YOU MEAN BY MODERATE PAIN? CAN YOU
5 CLASSIFY THAT FOR US?
6 A. WELL, IT'S LESS THAN SEVERE. I GUESS WE GET INTO
7 DIFFERENT CLINICAL SETTINGS WHERE WE THINK OF INJURIES OR
8 SURGERIES AS RESULTING IN DIFFERENT DEGREES OF PAIN. IF
9 SOMEONE HAS A MILD INJURY, A CUT ON THE HAND, A MILD SPRAIN,
10 THEY'RE PROBABLY -- THEY MAY NOT TAKE ANY MEDICINE. THEY
11 MAY BE ABLE TO TAKE SOME IBUPROFEN OR SOMETHING AND IT WORKS
12 PRETTY WELL.
13 IF THAT BECOMES MORE PAINFUL THAN SOMETHING LIKE
14 IBUPROFEN MAY STILL WORK BUT NOT WELL ENOUGH. THEN THEY MAY
15 NEED SOMETHING A BIT STRONGER. SOME OF THE ORAL PAIN
16 MEDICATIONS, ANYTHING FROM DARVON TO PERCOCET, VICODIN, A
17 NUMBER OF THOSE DIFFERENT ORAL PAIN MEDICATIONS MIGHT BE
18 USED UNDER THOSE CIRCUMSTANCES.
19 Q. WHAT ABOUT CHRONIC PAIN, DOCTOR?
20 A. IN CHRONIC PAIN, LIKEWISE, SOME OF THESE MEDICINES, THE
21 OPIOID MEDICINES, CAN BE AN IMPORTANT PART OF THERAPY. MORE
22 SEVERE PAIN, I GUESS, WE THINK OF IN TERMS OF A MAJOR
23 SURGERY. A PATIENT HAS HAD A LARGE ABDOMINAL INCISION OR A
24 TOTAL KNEE PLACEMENT. WE WOULD CONSIDER THOSE THINGS TO BE
25 SEVERE PAIN. I THINK SOME OF THE PAIN OF CANCER CERTAINLY
2553
1 CAN FIT INTO THAT CATEGORY. NOT ALWAYS, BUT IT CERTAINLY
2 CAN.
3 Q. WHAT DOES THE TERM HALF LIFE MEAN TO YOU?
4 A. HALF LIFE IS ONE OF THE TERMS WE USE IN AN AREA CALLED
5 PHARMACOKINETICS. THAT'S A KIND OF COMPLICATED NAME TRYING
6 TO DESCRIBE WHAT HAPPENS WHEN WE TAKE A MEDICATION INTO OUR
7 BODY. HOW DOES THE BODY HANDLE THAT MEDICATION, HOW DOES
8 THE BODY FINALLY GET RID OF IT, HOW LONG DOES IT TAKE. THE
9 HALF LIFE IS ONE OF THE IDENTIFIABLE FACTORS THAT WE CAN
10 COME UP WITH. IF WE TAKE A MEDICATION IT WILL TAKE A
11 CERTAIN AMOUNT OF TIME FOR HALF THAT MEDICATION TO BE
12 ELIMINATED FROM OUR BODY. THAT NUMBER, GENERALLY IN TERMS
13 OF HOURS, IS CALLED THE HALF LIFE; ELIMINATION HALF LIFE.
14 Q. SO IS THERE ALSO -- IN RESPECT TO THE TERM DURATION,
15 DOES THAT HAVE ANY SIGNIFICANCE?
16 A. IT DOES. THE DRUGS THAT STAY IN THE BODY LONGER, THE
17 DRUGS THAT WOULD HAVE LONGER HALF LIVES, ARE GOING TO HAVE
18 LONGER EFFECT OR A LONGER DURATION OF EFFECT.
19 Q. OKAY. THE FACT OF A PERSON'S AGE AND WEIGHT, IS THAT
20 TAKEN INTO CONSIDERATION IN DETERMINING HALF LIVES OR
21 DURATION OF DRUGS?
22 A. AGE IN PARTICULAR IS QUITE IMPORTANT. WEIGHT PROBABLY
23 NOT SO MUCH SO, BUT CERTAINLY THERE IS SOME ROUGH
24 CORRELATION WITH BODY SIZE. IF SOMEBODY IS REALLY EXTREME
25 IN BODY SIZE THAT MAY MAKE THEM MORE OR LESS SENSITIVE TO A
2554
1 DRUG. BUT AS FAR AS HOW IT EFFECTS THE ELIMINATION OF THE
2 DRUG, IT'S PROBABLY NOT AS BIG A FACTOR.
3 BUT AGE IS VERY IMPORTANT. TYPICALLY ELDERLY PATIENTS
4 ARE MUCH SLOWER TO ELIMINATE DRUGS FROM THE BODY THAN
5 PATIENTS OF YOUNGER AGES.
6 THE COURT: MR. WILSON, YOU'RE ABOUT TO GET INTO
7 ANOTHER AREA?
8 MR. WILSON: I AM.
9 THE COURT: LADIES AND GENTLEMEN, LET'S TAKE -- I
10 THINK WE'LL TAKE OUR LAST BREAK FOR THE DAY AND THEN COME
11 BACK ABOUT FIVE MINUTES TO THREE. THEN WE'LL GO UNTIL 4:30
12 AS I EXPLAINED.
13 DURING THAT TIME REMEMBER THAT IT IS YOUR DUTY NOT TO
14 CONVERSE AMONG YOURSELVES OR WITH ANYONE ELSE ABOUT THIS
15 CASE. DO NOT ALLOW YOURSELVES TO BE ADDRESSED BY ANY PERSON
16 REGARDING THE SUBJECT OF THIS TRIAL. AGAIN, DO NOT FORM OR
17 EXPRESS AN OPINION UNTIL THE CASE IS FINALLY SUBMITTED TO
18 YOU. SO, PLEASE COME BACK AT FIVE MINUTES TO THREE.
19 (JURY OUT OF THE COURTROOM.)
20 THE COURT: THE RECORD WILL REFLECT THAT JURY HAS
21 LEFT THE COURTROOM. HOW MUCH TIME DO YOU THINK -- OBVIOUSLY
22 WE WON'T GET DONE WITH HIM TODAY?
23 MR. WILSON: I THINK I WILL.
24 THE COURT: SO WE MIGHT BE DONE BY 4:30 ON DIRECT?
25 MR. WILSON: THAT'S CORRECT.
2555
1 THE COURT: LET'S COME BACK AT FIVE MINUTES TO
2 THREE, THEN WE'LL GO UNTIL 4:30.
3 (AFTERNOON RECESS.)
4 THE COURT: THE RECORD WILL REFLECT THAT COUNSEL
5 AND THE DEFENDANT AND THE JURY ARE PRESENT. MR. WILSON, YOU
6 MAY GO AHEAD.
7 MR. WILSON: THANK YOU, YOUR HONOR.
8 Q. (BY MR. WILSON) DR. HARE, I'D LIKE TO TALK A LITTLE
9 BIT ABOUT THE PROCESS INVOLVED IN ADMINISTERING MEDICATIONS
10 TO A PATIENT, PARTICULARLY CENTRAL NERVOUS SYSTEM DEPRESSANT
11 MEDICATIONS. CAN YOU TELL US, IS THERE A PROCESS OR
12 PROCEDURE THAT YOU FOLLOW AS A PHYSICIAN IN EVALUATING A
13 PARTICULAR PATIENT'S NEEDS?
14 A. WELL, OF COURSE THE FIRST STEP BEFORE A MEDICATION IS
15 ADMINISTERED IS IN ONE WAY OR ANOTHER COMING TO THE
16 CONCLUSION THAT THE PATIENT HAS THE RIGHT DIAGNOSIS TO
17 RECEIVE THAT MEDICATION.
18 INFORMATION REGARDING THE DIAGNOSIS CAN BE OBTAINED IN
19 LOTS OF DIFFERENT WAYS. THE PATIENT HISTORY. IF THE
20 PATIENT'S UNABLE TO GIVE A HISTORY, HISTORY FROM FAMILY
21 MEMBERS, HISTORY FROM PREVIOUS TREATING DOCTORS. OF COURSE
22 PHYSICAL EXAMINATION, YOUR OWN PERSONAL OBSERVATIONS OF THE
23 PATIENT. THE RESULTS OF DIAGNOSTIC TESTINGS. ALL DIFFERENT
24 SORTS OF THINGS CAN BE USED AND TAKEN INTO ACCOUNT TO COME
25 TO THE CONCLUSION THAT A PATIENT NEEDS A PARTICULAR
2556
1 MEDICATION.
2 Q. OKAY. SO THERE'S A NUMBER OF RECORDS THAT YOU MIGHT
3 REVIEW OR INFORMATION THAT YOU MIGHT RECEIVE IN EVALUATING
4 WHETHER OR NOT CERTAIN MEDICATIONS ARE INDICATED?
5 A. YES.
6 Q. THE PROCESS THAT YOU GO THROUGH IN DOING THAT, AND I
7 WANT YOU TO RELATE IT SPECIFICALLY TO PAIN MEDICATIONS, IF
8 YOU WILL, IS THERE ANYTHING DIFFERENT ABOUT THAT PROCESS AS
9 YOU LOOK AT WHETHER OR NOT TO ADMINISTER A PAIN MEDICATION?
10 A. WELL, AGAIN, FIRST YOU WOULD WANT TO COME TO THE
11 CONCLUSION, IN SOME WAY OR ANOTHER, THAT THE PATIENT IS
12 HAVING PAIN. IN SOME CASES, LIKE WITH SOME OF THE PATIENTS
13 WHO HAVE HAD SURGERY, IT'S VERY EASY TO SEE WHY THEY'RE
14 HAVING PAIN AND THAT THEY NEED TREATMENT. WITH MANY CANCER
15 PATIENTS IT'S VERY EASY TO UNDERSTAND HOW THE PATHOLOGY OF
16 THE CANCER AND THEIR PAIN CORRESPOND VERY WELL.
17 ALSO, IN SOME OF THE NON-CANCER CHRONIC PAIN PATIENTS
18 WE SEE, SOMETIMES IT'S A LITTLE MORE DIFFICULT TO PUT IT ALL
19 TOGETHER, BUT VERY OFTEN IT'S EASY TO UNDERSTAND AT LEAST
20 WHY THEY'RE HAVING SOME OF THE COMPLAINTS THAT THEY HAVE.
21 Q. NOW, A CENTRAL NERVOUS SYSTEM DEPRESSANT, IS THERE
22 DIFFERENT TYPES OF PAIN WITH THAT?
23 A. THERE ARE. THERE'S LOTS OF DIFFERENT KINDS. AGAIN,
24 DEPENDING ON THE DIAGNOSIS, ONE TYPE OF MEDICATION MIGHT BE
25 RECOMMENDED OVER ANOTHER. IN OTHER WORDS, NARCOTIC
2557
1 MEDICINES ARE NOT NECESSARILY THE MEDICINE OF CHOICE FOR A
2 LOT OF DIFFERENT TYPES OF PAIN.
3 Q. OKAY. AS TO ACTUAL PHYSICAL PAIN, WHERE MAYBE AN
4 INDIVIDUAL BREAKS A LEG OR HAS SOME OPERATION, I ASSUME
5 THERE IS -- WELL, MAYBE I DON'T. STRIKE THAT.
6 LET ME JUST ASK YOU, IN CONNECTION WITH THAT PROCESS,
7 ONCE YOU HAVE REVIEWED THE RECORDS, OR WHATEVER INFORMATION
8 THAT YOU HAVE DETERMINED IS AVAILABLE TO YOU, DO YOU ASSESS
9 THE NATURE OF THE PAIN?
10 A. YES. YOU TRY TO UNDERSTAND WHY THE PATIENT IS HAVING
11 THE PAIN AND HOPEFULLY THAT UNDERSTANDING WILL LEAD TO MORE
12 SPECIFIC TREATMENT.
13 Q. OKAY. IN TERMS OF -- WHAT IS THE ULTIMATE GOAL THAT
14 YOU'RE TRYING TO ARRIVE AT IN TERMS OF PAIN MANAGEMENT?
15 A. GENERALLY IT'S VERY DIFFICULT TO ELIMINATE PAIN
16 ALTOGETHER. THE GOAL IS TO GET THE PAIN DOWN TO A TOLERABLE
17 LEVEL. THAT'S REALLY, I THINK, THE REALISTIC GOAL THAT WE
18 SHOOT FOR. SOMETIMES WE ARE ABLE TO GET RID OF ALL THE
19 PAIN, BUT THAT'S NOT NECESSARILY THE GOAL.
20 Q. WHAT DOES THE TERM THERAPEUTIC EFFECT MEAN?
21 A. WELL, THE THERAPEUTIC EFFECT WOULD BE THE DESIRED EFFECT
22 OF A MEDICATION. IN OTHER WORDS, WE MAKE A DIAGNOSIS, WE
23 GIVE A MEDICATION FOR THAT DIAGNOSIS AND HOPEFULLY THE
24 MEDICATION HELPS THAT PARTICULAR PROBLEM.
25 Q. SO IF A PERSON IS EXHIBITING SIGNS OR SYMPTOMS OF PAIN,
2558
1 THEN THE RELIEF OF THAT PAIN WOULD CONSTITUTE THE
2 THERAPEUTIC EFFECT?
3 A. YES.
4 Q. IN LOOKING AT THAT ASSESSMENT, DO YOU TAKE INTO
5 CONSIDERATION, IN MAKING THAT, OTHER MEDICATIONS THAT THIS
6 PATIENT MAY BE RECEIVING?
7 A. UMM, THE OTHER MEDICATIONS, OF COURSE, COULD AFFECT THE
8 FINDINGS. IF A PATIENT IS ALREADY ON PAIN MEDICATION, FOR
9 INSTANCE, AND THEY'RE COMPLAINING OF SOME PAIN, IT MIGHT
10 AFFECT MY PHYSICAL EXAMINATION; IT MIGHT AFFECT HOW WELL I
11 CAN RECOGNIZE WHAT THE UNDERLYING PROBLEM MIGHT BE. A
12 PATIENT COULD BE ON A SEDATING MEDICATION, SOMETHING THAT
13 AFFECTS THEIR ABILITY TO VERY WELL REPORT TO ME WHAT THEIR
14 PAIN IS LIKE, WHERE IT'S LOCATED, THE CHARACTERISTICS OF IT.
15 THAT MIGHT MAKE IT DIFFICULT FOR ME TO MAKE SENSE OUT OF IT
16 AND PROPERLY DIAGNOSE AND TREAT THEIR PROBLEM.
17 Q. OKAY. IF A PATIENT IS UNABLE TO REPORT TO YOU, EITHER
18 THEY'RE SEDATED OR MAYBE SUFFERING FROM SOME KIND OF MENTAL
19 DISABILITY, HOW DO YOU GO ABOUT EVALUATING THEIR PAIN?
20 A. THE ONE THING WOULD BE -- AGAIN IT DEPENDS ON THE
21 SETTING. IF THE PATIENT HAS AN ACUTE INJURY, LIKE AN
22 ELDERLY PATIENT IN A NURSING HOME FALLS AND BREAKS THEIR
23 HIP, I THINK IT'S PRETTY EASY TO UNDERSTAND THAT THEY WOULD
24 HAVE PAIN AND THAT THAT MIGHT NEED TREATMENT.
25 IF WE'RE TALKING MORE OF A LONG STANDING PAIN, WHERE
2559
1 THE PHYSICAL FINDINGS -- IN OTHER WORDS, WHAT WE CAN FIND ON
2 A PHYSICAL EXAMINATION ISN'T AS CLEAR, IT ISN'T LIKE A
3 BROKEN BONE. THE PATIENT SAYS THEY HAVE A HEADACHE OR BACK
4 PAIN OR SOMETHING LIKE THIS, THEN IT BECOMES A BIT MORE
5 DIFFICULT, PARTICULARLY IF THE PATIENT CAN'T TELL YOU THAT.
6 MAYBE THERE'S SOME INDICATION THAT THEY HAVE THAT PROBLEM.
7 THERE I WOULD PROBABLY MORE RELY ON THE PEOPLE CLOSEST TO
8 THAT PATIENT. THE FAMILY MEMBERS, THE NURSES WHO HAVE TAKEN
9 CARE OF THE PATIENT, AND TRY TO GET AN IDEA FROM THEM AS TO
10 WHAT THEY THINK THE PROBLEM IS. IF IT SEEMS PRETTY
11 CONSISTENTLY THAT A CERTAIN AREA OF THE BODY IS AFFECTED BY
12 PAIN AND THE PATIENT COMPLAINS UNDER CERTAIN CIRCUMSTANCES,
13 THEN THAT MAY WELL BE SOMETHING THAT NEEDS TO BE TREATED.
14 ON THE OTHER HAND, IF THE OBSERVATIONS ARE SUCH THAT
15 THERE REALLY DOESN'T SEEM TO BE A LOT OF RHYME OR REASON,
16 THE PATIENT COMPLAINS -- KIND OF INDICATES THEIR HEAD HURTS
17 FOR A LITTLE BIT AND THEN IT'S THEIR HAND AND THEN THE FOOT
18 AND IT BOUNCES ALL OVER, THEN THAT MAY BE SOMETHING THAT'S
19 MORE DIFFICULT TO IDENTIFY AND KNOW HOW TO TREAT.
20 Q. OKAY. IF YOU MAKE A DECISION TO ADMINISTER A PAIN
21 MEDICATION, WHAT IS THE PROCESS INVOLVED AFTER THAT?
22 A. UMM, YOU WOULD HAVE TO DECIDE HOW -- WHICH PAIN
23 MEDICATION FIRST OF ALL, AND THAT WOULD BE BASED ON THE
24 PERCEIVED SEVERITY OF PAIN. AGAIN, EITHER THE PATIENT'S
25 REPORTS OR AT LEAST SOME, I GUESS, GESTALT THAT YOU HAVE
2560
1 ABOUT THE PATIENT AND WHAT MAY BE CAUSING THEIR PAIN.
2 Q. WHAT DO YOU MEAN BY GESTALT?
3 A. WELL, YOU GET A SENSE OUT OF HOW MUCH DISTRESS THE
4 PATIENT IS HAVING. WHAT SORTS OF -- HOW SEVERE THE PAIN MAY
5 BE. IF IT APPEARS THAT IT'S A BIT QUESTIONABLE HOW MUCH
6 PAIN THEY'RE HAVING AND YOU WANT TO SEE HOW WELL THEY
7 RESPOND TO A MEDICINE, YOU PERHAPS MIGHT START WITH
8 SOMETHING MILD. ON THE OTHER HAND, IF IT'S A PATIENT WHO
9 CLEARLY HAS GOOD REASON TO HAVE A LOT OF PAIN, THEN YOU'LL
10 BE MORE AGGRESSIVE WITH THE MEDICINE. SO EVEN THE INITIAL
11 CHOICE OF MEDICINE, GETTING BACK TO WHAT WE TALKED ABOUT
12 WITH MILD, MODERATE AND SEVERE PAIN, THAT WOULD GIVE ME SOME
13 GUIDELINE AS TO WHICH MEDICATION TO CHOOSE.
14 Q. OKAY. ONCE YOU'VE ADMINISTERED A PAIN MEDICATION, DO
15 YOU MONITOR THAT PAIN MEDICATION?
16 A. YOU DO. YOU HAVE TO HAVE KNOWLEDGE OF THE PAIN MEDICINE
17 AND WHAT ITS SIDE EFFECTS MAY BE. SO WE'RE NOT ONLY LOOKING
18 FOR THE BENEFICIAL EFFECT, WE CERTAINLY WANT TO SEE RELIEF
19 OF PAIN, BUT WE ALSO HAVE TO BE CAUTIOUS THAT THAT MEDICINE
20 MAY CARRY SOME DOWN SIDES WITH IT. YOU KNOW, EVEN MEDICINES
21 LIKE IBUPROFEN CAN IRRITATE THE STOMACH. WE TALKED ABOUT
22 SOME OF THE OTHER PAIN MEDICATIONS THAT CAN CAUSE SEDATION,
23 RESPIRATORY DEPRESSION. SO WE'RE ALWAYS USING OUR
24 THERAPEUTIC EFFECT, OR LOOKING FOR THE THERAPEUTIC EFFECT,
25 BUT TEMPERING THAT KNOWING THAT WE MAY GET SIDE EFFECTS WE
2561
1 DON'T WANT.
2 Q. WHAT DOES THE TERM TITRATION MEAN?
3 A. TITRATION MEANS THAT -- WELL, ESSENTIALLY, THAT YOU
4 ALTER THE DOSE TO TRY TO BEST MEET THE PATIENT'S NEEDS. IN
5 OTHER WORDS, YOU MAY MAKE YOUR BEST GUESS AS TO WHAT THE
6 STARTING DOSE OF MEDICATION WOULD BE. IF THAT DOESN'T SEEM
7 TO BE QUITE ENOUGH THEN YOU ADD SLOWLY TO THAT. YOU TRY TO
8 WORK IT UP TO THE POINT WHERE IT'S EFFECTIVE. OR IF THE
9 INITIAL DOSE SEEMS TO BE A BIT HIGH, TOO MANY SIDE EFFECTS,
10 THE PATIENT IS GETTING RELIEF BUT TOO MANY SIDE EFFECTS, YOU
11 BACK DOWN A BIT, BUT NOT TOO MUCH.
12 Q. DOES THE MEDICATION ADMINISTERED -- IS THERE A DIFFERENT
13 PROCESS, IN TERMS OF MONITORING, THAT YOU WOULD GO THROUGH
14 IN TERMS OF CERTAIN TYPES OF MEDICATIONS?
15 A. CERTAINLY. THE SIDE EFFECTS OF THE DIFFERENT TYPES OF
16 PAIN MEDICINE ARE REALLY PRETTY WELL DOCUMENTED. THOSE
17 WOULD BE THE MAIN THINGS YOU WOULD CONCENTRATE ON. A
18 MEDICINE LIKE IBUPROFEN, WE'D BE INTERESTED IN MAKING SURE
19 THE KIDNEYS ARE WORKING AND THE STOMACH DOESN'T GET
20 IRRITATED. A MEDICINE LIKE MORPHINE, WE'RE MORE INTERESTED
21 IN SEDATION, RESPIRATORY DEPRESSION, NAUSEA, CONSTIPATION.
22 THOSE ARE MORE THE SIDE EFFECTS THAT WE'RE WORRIED ABOUT.
23 Q. OKAY. IF YOU WILL, I WOULD LIKE TO GO THROUGH YOUR
24 REVIEW OF THE PARTICULAR PATIENTS THAT ARE PART OF THE
25 SUBJECT MATTER OF THIS CASE. I'M GOING TO PLACE ON THE
2562
1 BOARD WHAT HAS BEEN PREVIOUSLY MARKED AS STATE'S EXHIBIT 34.
2 I'LL ASK YOU TO TAKE A LOOK AT THAT, PLEASE.
3 A. (WITNESS COMPLIED.)
4 Q. CAN YOU TELL US, HAVE YOU HAD OCCASION TO REVIEW THAT
5 EXHIBIT PRIOR TO YOUR TESTIMONY HERE RIGHT NOW?
6 A. I HAVE.
7 Q. OKAY. AND THIS PURPORTS TO BE THE EXHIBIT PERTAINING TO
8 ELLEN ANDERSON. IN LOOKING AT THAT CHART, DOES THE CHART
9 BEAR ANY CORRELATION TO THE MEDICATIONS THAT YOU REVIEWED
10 THAT WERE ADMINISTERED TO HER IN CONNECTION WITH THE MEDICAL
11 RECORDS YOU REVIEWED?
12 A. YES, IT DOES.
13 Q. OKAY. NOW, ON THE SIDE OF THAT CHART THERE'S A DRUG
14 NAME IN PILL FORM AND THEN THERE'S ALSO A DRUG NAME IN THE
15 RED BOX. I'D JUST CALL YOUR ATTENTION TO ELLEN ANDERSON'S
16 RECORDS RIGHT NOW. DID YOU HAVE OCCASION TO THOROUGHLY
17 REVIEW HER RECORDS?
18 A. YES, I DID.
19 Q. CAN YOU TELL US, DID YOU REVIEW ANY RECORDS PERTAINING
20 TO HER ADMISSION AT THE GERO-PSYCH UNIT?
21 A. YES.
22 Q. DID YOU REVIEW ANY RECORDS PERTAINING TO HER EARLIER
23 RECORDS, AS FAR AS HER NURSING HOME RECORDS OR PRIOR CARE
24 RECORDS?
25 A. YES, I DID.
2563
1 Q. OKAY. AT THE TIME OF ADMISSION, DOCTOR, CAN YOU TELL US
2 WHETHER OR NOT THERE WAS ANY INDICATION IN THE RECORDS
3 THEMSELVES WHICH TO YOU INDICATED THAT THE PATIENT WAS
4 EXPERIENCING ANY PAIN?
5 A. THERE SEEMED, BY THE REPORTS IN THE RECORDS, THAT THE
6 PATIENT'S PAIN COMPLAINTS, IF ANY, WERE MINIMAL. IT SEEMED
7 THAT THE RECORDS REFLECTED MORE THAN ANXIETY WAS HER MAJOR
8 ISSUE. ANY TIME, THOUGH, THAT SHE COMPLAINED OF SOMETHING
9 THAT SEEMED TO BE A PAIN COMPLAINT --
10 MR. STIRBA: I'M GOING TO OBJECT. THE RECORDS
11 SPEAK FOR THEMSELVES. HE'S JUST CHARACTERIZING WHAT HE'S
12 READING. IF HE WANTS TO READ IT, FINE, OR ASK A MORE
13 SPECIFIC QUESTION.
14 THE COURT: LET'S PROCEED BY ANOTHER QUESTION.
15 Q. (BY MR. WILSON) IN RESPECT TO THE PHYSICAL CONDITION,
16 AS YOU REFERENCED FROM THE RECORDS, CAN YOU TELL US WHAT HER
17 PHYSICAL CONDITION WAS?
18 A. SHE HAD SOME MEDICAL PROBLEMS, BUT NONE WERE LIFE
19 THREATENING. SHE WAS MEDICALLY STABLE AT THE TIME SHE
20 ENTERED THE GERO-PSYCH UNIT.
21 Q. OKAY. NOW, WHEN WAS SHE ADMITTED TO THE UNIT?
22 A. ON DECEMBER 29TH, 1995.
23 Q. DO YOU KNOW WHETHER THERE WAS ACTUALLY ANY PHYSICAL
24 EVALUATION CONDUCTED ON THIS PATIENT?
25 A. ACCORDING TO THE RECORDS, IT APPEARS THAT THE PHYSICAL
2564
1 EXAM -- NOT THE PHYSICAL EXAM, BUT THE ADMISSION PAPERWORK
2 WAS DONE AFTER THE PATIENT'S DEATH.
3 Q. CAN YOU TELL US, DOCTOR, IS THERE ANYTHING IN PARTICULAR
4 IN THE MEDICAL RECORDS WHICH REFERENCES THIS PATIENT
5 COMPLAINING OF PAIN?
6 A. NOT ANYTHING THAT INDICATED THAT SHE SPECIFICALLY HAD
7 PAIN COMPLAINTS. SHE DID HAVE A HISTORY OF OSTEOPOROSIS AND
8 SHE'D HAD SOME PROBLEMS RELATED TO THAT. BUT IN THE PERIOD
9 PRIOR TO HER ADMISSION TO THE HOSPITAL THERE DIDN'T SEEM TO
10 BE ANY -- YOU KNOW, ANY CLEAR ONGOING PAIN COMPLAINTS.
11 Q. OKAY. DID YOU SEE, IN YOUR REVIEW OF THE RECORDS, AND
12 PARTICULARLY THE NURSE'S NOTES ON THAT PARTICULAR DATE,
13 AFTER ADMISSION, THAT WOULD IN YOUR MIND INDICATE ANY SIGNS
14 OR SYMPTOMS OF PAIN?
15 A. NONE THAT I SAW. See Nurse's Notes>>
16 Q. IN RESPECT TO THE ADMINISTRATION OF MORPHINE, CAN YOU
17 TELL US WHETHER OR NOT THERE WAS ANY MORPHINE ORDERED FOR
18 THIS PATIENT?
19 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT. THIS
20 IS CUMULATIVE.
21 THE COURT: ASK THE QUESTION AGAIN.
22 Q. (BY MR. WILSON) THE QUESTION WAS, WAS THERE ANY
23 MORPHINE THAT WAS ORDERED IN RESPECT TO BE ADMINISTERED TO
24 THIS PATIENT?
25 MR. STIRBA: AND I'LL OBJECT. DR. FEHLAUER'S
2565
1 TESTIMONY IS CUMULATIVE AND THIS IS REDUNDANT.
2 THE COURT: IT'S OVERRULED RIGHT NOW, BUT LET'S NOT
3 REPEAT WHAT THE LAST WITNESS SAID.
4 Q. (BY MR. WILSON) CALLING YOUR ATTENTION TO THE EXHIBIT
5 ON THE BOARD, DOES THE EXHIBIT SHOW TWO INJECTIONS OF
6 MORPHINE THAT WERE ADMINISTERED TO THIS PATIENT?
7 A. YES.
8 Q. CAN YOU TELL US WHEN THE FIRST INJECTION WAS
9 ADMINISTERED?
10 A. THE FIRST WAS INJECTED AT ABOUT 7:30 IN THE EVENING.
11 Q. OKAY. IN YOUR OPINION, WAS THERE ANY MEDICAL REASON TO
12 ADMINISTER THE DRUG MORPHINE?
13 A. NONE THAT I COULD FIND IN THE RECORDS.
14 Q. OKAY. WHAT AMOUNT WAS ADMINISTERED ON THE FIRST
15 INJECTION?
16 A. TEN MILLIGRAMS INTERMUSCULARLY.
17 Q. DO YOU HAVE AN OPINION AS TO WHETHER THAT WAS AN
18 APPROPRIATE DOSAGE FOR THIS PARTICULAR PATIENT?
19 A. I GUESS, UNDER CIRCUMSTANCES WHERE MORPHINE MIGHT BE
20 INDICATED, WHICH IN THIS CASE IT DIDN'T SEEM TO BE, A MUCH
21 SMALLER DOSE WOULD HAVE BEEN A REASONABLE STARTING DOSE.
22 PERHAPS TWO MILLIGRAMS, THREE MILLIGRAMS. A FRACTION OF THE
23 DOSE THAT SHE RECEIVED.
24 Q. OKAY. IN THE NURSE'S NOTES AND FROM THE RECORDS, DID
25 YOU MAKE ANY NOTATIONS OR OBSERVATIONS RELATIVE TO ANY SIGNS
2566
1 OR EFFECTS OF TOXICITY OF THE DRUG?
2 A. UMM, YES. WELL, THE ONE DOWNSIDE IS THAT THE PATIENT
3 RECEIVED THE MEDICATION AT 7:30 IN THE EVENING AND I --
4 MR. STIRBA: I'M GOING TO OBJECT. THE QUESTION WAS
5 TOXICITY SIGNS AND SYMPTOMS FROM THE NURSING NOTES.
6 THE COURT: JUST ANSWER THE QUESTION.
7 Q. (BY MR. WILSON) OKAY. SPECIFICALLY, CAN YOU REFERENCE
8 WHAT NOTES, IF ANYTHING, INDICATED ANY PROBLEMS WITH
9 TOXICITY AS RELATES TO MORPHINE?
10 A. IT APPEARS THAT THE FIRST TIME THE PATIENT WAS CHECKED,
11 AFTER THE 7:30 IN THE EVENING DOSE, WAS AT ONE O'CLOCK IN
12 THE MORNING. AT THAT POINT IT'S DESCRIBED THAT THE
13 BREATHING WAS ERRATIC. A RATE OF ABOUT EIGHT TO 16 PER
14 MINUTE. THE BLOOD PRESSURE IS 70 OVER 50, WHICH IS
15 EXTREMELY LOW. THE PULSE RATE IS HIGH AT 120.
16 Q. OKAY.
17 A. SO THESE EFFECTS WOULD BE VERY CONSISTENT WITH THE
18 EFFECTS OF A LARGE DOSE OF MORPHINE.
19 Q. THAT WAS THE FIRST NOTE AFTER THE ADMINISTRATION OF THE
20 MORPHINE AT 7:30?
21 A. THAT'S CORRECT. See the reality ("patient calmer 2hrs after MS inj")>>
22 Q. IN RESPECT TO OTHER NOTES, CAN YOU TELL US WHETHER OR
23 NOT THERE WAS ANY FURTHER INJECTIONS PRESCRIBED FOR THIS
24 PATIENT AND GIVEN TO THE PATIENT?
25 A. THE PATIENT THEN RECEIVED A SECOND DOSE AT, I BELIEVE,
2567
1 3:30 IN THE MORNING. SO THIS WOULD HAVE BEEN TWO,
2 TWO-AND-A-HALF HOURS, LATER. ANOTHER 10 MILLIGRAMS WAS
3 ORDERED TO BE GIVEN BY DR. WEITZEL.
4 Q. OKAY. IN THE NURSE'S NOTES DO YOU SEE ANYTHING BETWEEN
5 1:30 AND 3:30 THAT WOULD BE INDICATIVE OF ANY SIGNS OF --
6 THAT THIS PATIENT WAS EXPERIENCING ANY KIND OF PAIN?
7 A. IT IS NOTED THAT THE PATIENT AWAKENED, SEEMED TO BE
8 THRASHING HER ARMS AND WAS MOANING, SCREAMING. THAT
9 WOULDN'T NECESSARILY BE AN INDICATION OF PAIN. IT APPEARS
10 THAT THE PATIENT WAS DISTRESSED OR CONFUSED, OR WHO KNOWS
11 WHAT, BUT CERTAINLY NOT A SPECIFIC INDICATION OF THE PATIENT
12 BEING IN PAIN.
13 Q. DID YOU SEE ANYTHING THERE THAT WOULD BE INDICATIVE OF
14 THE NEED OR NECESSITY TO ADMINISTER MORPHINE TO THAT
15 PATIENT?
16 A. I WOULD NOT.
17 Q. AGAIN, HOW MUCH WAS THAT PARTICULAR INJECTION?
18 A. THAT WAS ANOTHER 10 MILLIGRAMS.
19 Q. WERE THERE ANY VITAL SIGNS OF THE PATIENT TAKEN AT 3:30
20 IN THE MORNING?
21 A. NO.
22 Q. WHEN IS THE NEXT -- LET ME ASK YOU THIS. WHEN WAS THE
23 NEXT NOTE RELATED IN THE RECORD THAT WOULD BE INDICATIVE TO
24 YOU THAT THIS PATIENT MAY BE SUFFERING THE EFFECTS OF
25 TOXICITY OF THE MORPHINE?
2568
1 A. IT'S NOTED AT 6:30 THAT THE PATIENT SEEMS TO HAVE
2 BEEN -- APPEARED TO BE ASLEEP SINCE RECEIVING THE MORPHINE.
3 BUT THEN AT 7:30 IT'S NOTED THAT THE RESPIRATORY RATE IS 12.
4 Q. CAN YOU COMMENT ON THAT?
5 A. THAT'S KIND OF BORDER LINE LOW. THE PULSE RATE IS 60 Unbelievable.
6 AND THE NURSE WAS UNABLE TO GET A BLOOD PRESSURE. THE
7 PATIENT WASN'T RESPONSIVE TO VERBAL OR TACTILE TOUCH,
8 MEANING THAT THEY TRIED TO STIMULATE THE PATIENT AND THE
9 PATIENT WASN'T RESPONSIVE AT ALL. THE PATIENT WAS UNABLE TO
10 BLINK HER EYES. AT THAT POINT THEY FELT THAT THE PATIENT
11 PROBABLY HAD DIED. DIED? WITH A PULSE AND RESPIRATIONS?
12 Q. CAN YOU TELL US, DOCTOR, IN RESPECT TO -- WERE THERE ANY
13 TESTS ADMINISTERED TO THE PATIENT PRIOR TO THE 7:30 TIME
14 THAT THAT NOTE IS TAKEN?
15 A. THE PATIENT HAD HAD AN ELECTROCARDIOGRAM AND A CHEST
16 X-RAY ORDERED THE DAY BEFORE AT THE TIME OF ADMISSION.
17 THOSE WERE ORDERED TO BE DONE THE NEXT MORNING. SO AT 5:20
18 IN THE MORNING SHE DID HAVE AN E.K.G. IN OTHER WORDS, A
19 HEART TRACING. THAT SHOWED SOME MARKED ABNORMALITIES AT
20 THAT POINT.
21 Q. CAN YOU CLARIFY WHAT YOU MEAN BY MARKED ABNORMALITIES?
22 A. UMM, THE HEART WAS BEATING VERY FAST. I CAN SAY
23 PRECISELY WHAT IT WAS. THE TACHYCARDIA WITH MARKED SINUS
24 ARRHYTHMIA. THAT MEANS THE HEART WAS BEATING FAST BUT
25 IRREGULARLY. THERE WERE NONSPECIFIC T-WAVE ABNORMALITIES.
2569
1 THAT CAN MEAN THAT THERE IS -- THAT THE HEART ISN'T GETTING
2 ENOUGH OXYGEN.
3 Q. OKAY. ARE THOSE SIGNS CONSISTENT WITH MORPHINE
4 TOXICITY?
5 A. THEY CERTAINLY WOULD BE. MORE THE LONG-TERM EFFECTS.
6 IN OTHER WORDS, IF THE PATIENT ISN'T BREATHING WELL, THE
7 PATIENT'S BLOOD PRESSURE IS LOW, THE HEART ISN'T GETTING
8 ENOUGH OXYGEN, THE REACTION OF THE HEART IS TO SHOW THESE
9 ABNORMALITIES.
10 Q. SO WHEN IN FACT WAS THE PATIENT PRONOUNCED DEAD, DO YOU
11 KNOW?
12 A. I BELIEVE IT WASN'T UNTIL ABOUT 8:55 IN THE MORNING.
13 Q. WERE THERE ANY OTHER FURTHER NOTES, AFTER THE 7:30 NOTE,
14 THAT INDICATED TO YOU ANY SIGNS OF MORPHINE TOXICITY?
15 A. ONLY AT 8:55 THE PATIENT HAD NO BREATHING AND NO HEART
16 RATE.
17 Q. OKAY.
18 A. BUT AT 7:30 THEY THOUGHT THAT THE PATIENT HAD DIED, SO I
19 GUESS THAT'S EXPECTED.
20 Q. NOW, AS TO A CENTRAL NERVOUS SYSTEM DEPRESSANT, IS THAT
21 CONSISTENT -- OR MORPHINE, IS THAT CONSISTENT WITH THE
22 SHUTTING DOWN OF THE RESPIRATION SYSTEM?
23 A. IT IS. PARTICULARLY WITH THE MORPHINE-LIKE PAIN
24 MEDICINES, THE EFFECTS ARE MUCH MORE ON RESPIRATION THAN
25 JUST THE GENERAL CENTRAL NERVOUS SYSTEM DEPRESSANTS. SO ONE
2570
1 OF THE MOST PROMINENT PROBLEMS WITH A DRUG LIKE MORPHINE IS
2 RESPIRATORY DEPRESSION, OR A DECREASE IN THE DESIRE TO
3 BREATHE.
4 Q. IN THE DESIRE TO BREATHE?
5 A. UH-HUH.
6 Q. SO WHAT PORTION OF THE BODY DOES -- I MEAN, HOW DOES IT
7 IMPACT YOUR DESIRE TO BREATHE?
8 A. THERE ARE CERTAIN CENTERS IN THE BRAIN THAT ARE CALLED
9 THE RESPIRATORY DRIVE CENTER. MORPHINE HAS A VERY SELECTIVE
10 EFFECT ON THAT CENTER TO MAKE IT LESS ACTIVE. SO PATIENTS
11 WHO HAVE RECEIVED -- THIS IS SOMETHING WE SEE IN THE
12 OPERATING ROOM. WE CAN GIVE PATIENTS LARGE DOSES OF A
13 MEDICINE LIKE FENTANYL OR MORPHINE. UNLESS WE REMIND THEM
14 TO BREATHE THEY WON'T. OF COURSE, WE AT SOME POINT TAKE
15 OVER THEIR BREATHING FOR THEM. BUT IT'S A VERY INTERESTING
16 PHENOMENON. THEY CAN BE AWAKE AND YET NOT WANTING TO
17 BREATHE.
18 Q. SO ESSENTIALLY YOU JUST DON'T BREATHE?
19 A. YES.
20 Q. BASED UPON YOUR EXPERIENCE, TRAINING, YOUR EXPERTISE,
21 YOUR REVIEW OF THESE MEDICAL RECORDS, HAVE YOU FORMED AN
22 OPINION, BASED UPON A REASONABLE DEGREE OF MEDICAL
23 CERTAINTY, AS TO THE CAUSE OF DEATH OF ELLEN ANDERSON?
24 MR. STIRBA: OBJECTION. CUMULATIVE.
25 THE COURT: OVERRULED.
2571
1 Q. (BY MR. WILSON) ANSWER THE QUESTION YES OR NO.
2 A. YES, I HAVE.
3 Q. OKAY. WHAT IS THAT OPINION, SIR?
4 A. I BELIEVE THAT ELLEN ANDERSON SUCCUMBED BECAUSE OF
5 EXCESSIVE DOSING OF MORPHINE.
6 Q. OKAY. LET'S TURN TO THE NEXT PATIENT, THAT BEING JUDITH
7 LARSEN. I WOULD AGAIN CALL YOUR ATTENTION TO WHAT IS MARKED
8 AS STATE'S EXHIBIT 38 AND ASK YOU IF YOU HAVE FAMILIARIZED
9 YOURSELF WITH THAT EXHIBIT?
10 A. YES, I HAVE.
11 Q. AND YOU'VE ALSO -- THIS PERTAINS TO THE MEDICAL RECORDS
12 OF JUDITH LARSEN, DOES IT NOT?
13 A. YES. I WOULD SAY THIS FAIRLY REPRESENTS THE MEDICATIONS
14 IN THE MEDICAL RECORDS.
15 Q. OKAY. NOW, THIS EXTENDS OVER A TIME PERIOD FROM
16 DECEMBER 6TH UP TO JANUARY 3RD. DOES THAT CORRESPOND WITH
17 YOUR REVIEW OF THE MEDICAL RECORDS?
18 A. YES, IT DOES.
19 Q. WHEN WAS SHE ADMITTED TO THE GERO-PSYCH UNIT, SIR?
20 A. SHE WAS ADMITTED ON DECEMBER 6TH.
21 Q. OKAY.
22 A. 1995.
23 Q. DID YOU REVIEW HER RECORDS AT THAT TIME? I MEAN, DID
24 YOU REVIEW HER RECORDS PERTINENT TO THAT TIME?
25 A. I DID, YES.
2572
1 Q. AND CAN YOU TELL US, AT THE TIME OF HER ADMISSION,
2 WHETHER OR NOT YOU FORMED ANY OPINION AS TO WHAT HER
3 PHYSICAL CONDITION WAS?
4 A. THERE SEEMED -- EVEN THOUGH SHE HAD HAD --
5 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT. THE
6 RECORDS INDICATE WHAT HER PHYSICAL CONDITION WAS BASED UPON
7 THE PEOPLE WHO WERE THERE AT THE TIME. I DON'T THINK HIS
8 OPINION AS A PAIN EXPERT IS RELEVANT TO WHAT HER PHYSICAL
9 CONDITION WAS AT THE TIME. HE DOESN'T HAVE THAT EXPERTISE.
10 THE COURT: LET'S GET TO HIS OPINION AS TO WHAT HE
11 WAS CALLED FOR.
12 MR. WILSON: LET ME ASK IT THIS WAY, THEN.
13 Q. (BY MR. WILSON) WAS THERE ANY DISEASE PROCESSES THAT
14 YOU WERE AWARE OF WHICH, IN YOUR REVIEW OF THOSE RECORDS,
15 WOULD BE INDICATIVE OF PAIN?
16 A. THERE WERE NOT.
17 Q. OKAY. WERE THERE ANY DISEASE PROCESSES, IN YOUR
18 OPINION, WHICH WOULD BE REPRESENTATIVE THAT SHE WAS
19 SUFFERING FROM ANY TERMINAL STATE?
20 A. NO.
21 Q. IN RESPECT TO THE INITIAL ADMINISTRATION OF THE
22 MEDICATIONS, CAN YOU TELL US WHAT TYPES OF MEDICATIONS WERE
23 INITIALLY GIVEN TO HER? DO YOU WANT TO STEP TO THE BOARD?
24 A. MAY I ASK, HAS THE JURY SEEN THIS CHART BEFORE?
25 Q. THEY HAVE.
2573
1 A. OKAY. THESE ARE THE VARIETY OF DIFFERENT MEDICATIONS IN
2 THE DIFFERENT COLORS. KLONOPIN, TRAZODONE, SERZONE,
3 RISPERDAL, ATIVAN. THIS WOULD REFLECT THE INITIAL
4 MEDICATIONS THAT SHE RECEIVED, KLONOPIN, TRAZODONE, ATIVAN.
5 Q. NOW, SHE APPARENTLY RECEIVED THOSE OVER A FAIRLY
6 SIGNIFICANT PERIOD OF TIME, IS THAT CORRECT?
7 A. SHE DID.
8 Q. AND IN RESPECT TO THOSE PARTICULAR MEDICATIONS, DOCTOR,
9 AND YOUR REVIEW OF THE MEDICAL RECORDS AS TO -- WOULD THESE
10 MEDICATIONS, IN YOUR OPINION, HAVE ANY SEDATING SIDE
11 EFFECTS?
12 A. YES, THEY WOULD.
13 Q. OKAY. AND DO THEY HAVE ANY CENTRAL NERVOUS SYSTEM
14 DEPRESSANT SIDE EFFECTS?
15 A. YES, THEY WOULD.
16 Q. OKAY. GO AHEAD AND TAKE YOUR SEAT, IF YOU WOULD,
17 PLEASE.
18 A. (WITNESS COMPLIED.)
19 Q. THE DOSAGE AMOUNTS THAT ARE LISTED OVER THAT PARTICULAR
20 TIME FRAME, DOES THAT BEAR ANY SIGNIFICANCE IN YOUR MIND?
21 A. UMM, WELL, THERE WERE CERTAINLY, AT LEAST INITIALLY, AN
22 UPWARD TREND IN THE AMOUNT OF MEDICATION THAT SHE RECEIVED
23 OVER THE FIRST FEW DAYS. I THINK THAT, DEPENDING ON WHAT
24 SORT OF REACTION SHE HAD TO THAT, WOULD CERTAINLY BE AN
25 IMPORTANT PART OF THIS.
2574
1 Q. OKAY. IN YOUR REVIEW OF THE RECORDS, DID YOU SEE ANY
2 SIGNS OR SYMPTOMS WHICH WOULD INDICATE TO YOU THAT THIS
3 PATIENT WAS OVERLY SEDATED?
4 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT.
5 THAT'S VAGUE AND AMBIGUOUS.
6 THE COURT: DO YOU WANT TO REPHRASE THAT? I DON'T
7 KNOW IF THAT'S AN ADEQUATE QUESTION.
8 Q. (BY MR. WILSON) LET ME REPHRASE IT THIS WAY. DID YOU
9 SEE ANY SIGNS OR SYMPTOMS, RELATED TO THIS PARTICULAR
10 PATIENT, THAT SHE WAS HAVING ANY ADVERSE REACTION TO THE
11 ADMINISTRATION OF THESE PARTICULAR MEDICATIONS?
12 A. ON DECEMBER 8TH, AND THIS WOULD BE TWO DAYS AFTER
13 ADMISSION, THE NURSE'S NOTES REFLECT THAT THE PATIENT SLEPT
14 THE FULL SHIFT. THIS WAS AT NIGHT, SO I GUESS THAT'S
15 PROBABLY OKAY.
16 ON DECEMBER 9TH THE NOTES WOULD MENTION, THOUGH, THAT
17 IN THIS SITUATION SHE WAS SLEEPING ALL DAY. DECEMBER 10TH,
18 SOMNOLENT MOST OF THE SHIFT. IN OTHER WORDS, VERY SLEEPY
19 MOST OF THE SHIFT.
20 Q. DID THERE COME A TIME DURING THIS TIME PERIOD THAT THE
21 PATIENT SEEMED TO IMPROVE?
22 A. MORE OR LESS IN THE MIDDLE OF THIS, SOMEWHERE ALONG THE
23 WAY THERE, SHE SEEMED TO IMPROVE. THE REASON FOR THAT, I
24 THINK ON DECEMBER 14TH --
25 MR. STIRBA: I THINK THE QUESTION WAS WAS THERE A
2575
1 TIME PERIOD WHEN SHE SEEMED TO IMPROVE. I THINK THE DOCTOR
2 ANSWERED IT.
3 THE COURT: SUSTAINED.
4 Q. (BY MR. WILSON) IN RESPECT TO THAT PERIOD OF TIME, DID
5 YOU OBSERVE ANY SIGNS OR COMPLAINTS IN THE MEDICAL RECORDS
6 THAT YOU REVIEWED CONCERNING PAIN?
7 MR. STIRBA: CAN WE HAVE SOME MORE FOUNDATION?
8 DURING WHAT PERIOD OF TIME?
9 THE COURT: WHICH DAYS?
10 Q. (BY MR. WILSON) LET'S EXTEND IT FROM THE TIME PERIOD
11 OF THE 6TH OF DECEMBER UP TO, SAY, THE 24TH OF DECEMBER?
12 A. THERE WAS NO INDICATION IN THE RECORD THAT PAIN WAS A
13 PROBLEM.
14 Q. OKAY. CAN YOU TELL US WHETHER OR NOT THIS PARTICULAR
15 PATIENT RECEIVED ANY INJECTION OF MORPHINE ON THE 25TH OF
16 DECEMBER?
17 A. SHE DID. OR SHE HAD -- LET ME CHECK HERE. (PAUSE.) ON
18 THE 25TH SHE DID RECEIVE TWO SMALL DOSES OF MORPHINE. TWO
19 MILLIGRAM DOSES ABOUT TWO HOURS APART. I'M SORRY, THREE
20 DOSES OVER ABOUT A FOUR HOUR PERIOD.
21 Q. OKAY. OVER ABOUT A FOUR HOUR PERIOD?
22 A. YES.
23 Q. DO YOU KNOW WHAT THAT WAS FOR?
24 A. I'M NOT AWARE THERE WAS A SPECIFIC INDICATION FOR IT.
25 Q. OKAY. See indication>>
2576
1 A. THE NOTE SAID THAT PATIENT BECAME MORE ALERT AS THE
2 SHIFT PROGRESSED AND SHE WAS MEDICATED WITH MORPHINE.
3 Q. WHEN WAS THE NEXT DOSAGE OF MORPHINE, ACCORDING TO YOUR
4 REVIEW OF THE RECORDS?
5 A. THE PATIENT RECEIVED ONE MORE DOSE ON THE MORNING OF THE
6 26TH; ANOTHER TWO MILLIGRAM DOSE.
7 Q. WAS THERE ANY PARTICULAR EVENT, ACUTE EVENT, THAT
8 OCCURRED IN THE RECORDS THAT YOU REVIEWED ABOUT THAT TIME?
9 A. ON THE MORNING OF THE 26TH THE PATIENT WAS THOUGHT TO
10 HAVE HAD A SEIZURE.
11 Q. OKAY.
12 A. AND SHE WAS TREATED AS IF THAT HAD HAPPENED.
13 Q. OKAY. IS MORPHINE USED IN THE TREATMENT OF SEIZURES?
14 A. NO, IT'S NOT.
15 Q. OKAY. IN RESPECT TO THE USE OF MORPHINE IN THAT
16 CONTEXT, IN A SUSPECTED SEIZURE, WOULD MORPHINE CREATE ANY
17 PROBLEMS?
18 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT TO THE
19 QUESTION. I DON'T THINK THERE'S BEEN A FOUNDATION LAID BY
20 THIS DOCTOR THAT THE MORPHINE WAS USED IN THE CONTEXT OF
21 TREATING THE SEIZURE.
22 THE COURT: SUSTAINED.
23 Q. (BY MR. WILSON) LET ME JUST PHRASE IT THIS WAY. I'LL
24 STRIKE THAT, RATHER. LET'S JUST MOVE ON. WHEN IS THE NEXT
25 TIME MORPHINE IS USED?
2577
1 A. UMM, THE NEXT DOSE THAT IS SHOWN ON THE CHART AND IN MY
2 RECORDS WOULD BE ON DECEMBER 30TH.
3 Q. OKAY. CAN YOU TELL US, BETWEEN DECEMBER 27TH, OR 26TH,
4 EXCUSE ME, BETWEEN DECEMBER 26TH AND THE 30TH, WERE THERE
5 ANY INDICATIONS IN THE RECORD OF SIGNS OR SYMPTOMS OF PAIN?
6 A. THERE WERE NOT.
7 Q. ON THE 30TH ITSELF DID YOU SEE ANY RECORD THAT WOULD
8 EXHIBIT SIGNS OR SYMPTOMS OF PAIN?
9 A. NO.
10 Q. OKAY. DO YOU KNOW WHY THE MORPHINE WAS ADMINISTERED ON
11 THAT PARTICULAR DAY?
12 MR. STIRBA: OBJECTION, YOUR HONOR. THE QUESTION
13 IS AMBIGUOUS AS TO WHY. HE CAN TESTIFY AS TO WHAT THE
14 RECORDS SHOW.
15 THE COURT: HE'S ASKING HIM IF HE KNOWS WHY.
16 OVERRULED.
17 Q. (BY MR. WILSON) FROM YOUR REVIEW OF THE RECORDS, DOES
18 IT INDICATE THE PURPOSE FOR THE ADMINISTRATION OF THE
19 MORPHINE?
20 A. IT APPEARS THAT ON THE MORNING OF THE 30TH THE PATIENT
21 VOMITED AND THE VOMITUS APPEARED TO CONTAIN BLOOD,
22 SUGGESTING THAT THE PATIENT WAS BLEEDING INTERNALLY. WITH
23 THAT, DR. WEITZEL APPROACHED THE FAMILY AND PRESENTED,
24 APPARENTLY, THAT HE THOUGHT THE PATIENT'S PHYSICAL CONDITION
25 HAD GONE WAY DOWNHILL AND THAT MORPHINE OUGHT TO BE GIVEN
2578
1 FOR COMFORT CARE.
2 Q. DID YOU SEE ANYTHING IN THE MEDICAL RECORDS AT THAT TIME
3 WHICH WOULD INDICATE TO YOU A MEDICAL NECESSITY OF
4 PRESCRIBING MORPHINE?
5 A. ALL THE NOTES INDICATE THAT THE PATIENT IS UNRESPONSIVE.
6 IT DOESN'T REALLY SEEM THAT THE PATIENT -- THAT THERE'S ANY
7 INDICATION FOR GIVING THE MORPHINE IN THE CHART.
8 Q. DID YOU SEE ANYTHING IN THE MEDICAL RECORD WHICH WOULD
9 BE INDICATIVE TO YOU THAT THIS PATIENT WAS IN A TERMINAL
10 STATE?
11 A. THE PATIENT AT THIS TIME WAS HEAVILY SEDATED, OR
12 APPEARED TO BE HEAVILY SEDATED FROM MEDICATIONS RECEIVED.
13 THAT SEEMED TO BE A LARGE CONTRIBUTOR TO THE POOR OUTLOOK.
14 MR. STIRBA: YOUR HONOR, I'M NOT SO SURE HE'S
15 ANSWERING THE QUESTION. WHAT TIME PERIOD, THE 30TH, THE
16 29TH, THE 31ST? IT'S VERY CRITICAL TESTIMONY.
17 THE COURT: WHY DON'T YOU REPHRASE THE QUESTION.
18 MR. WILSON: I'LL REPHRASE THE QUESTION.
19 Q. (BY MR. WILSON) AS TO THE 30TH OF DECEMBER, DOCTOR,
20 DID YOU SEE ANYTHING IN THE MEDICAL RECORDS WHICH WOULD
21 INDICATE THAT THIS PATIENT WAS IN A TERMINAL STATE? MAYBE I
22 BETTER ASK A PREDICATE QUESTION TO THAT. WHAT DOES THE TERM
23 TERMINAL MEAN?
24 A. IT MEANS THAT WITHOUT -- I MEAN EVEN WITH MEDICAL
25 INTERVENTION THE PATIENT WILL NOT RECOVER FROM THEIR MEDICAL
2579
1 PROBLEMS.
2 Q. OKAY.
3 A. IT GENERALLY IMPLIES A SHORT TERM NATURE OF THIS
4 DETERIORATION.
5 Q. OKAY. AND WHEN WE SPEAK OF SHORT TERM, WHAT ARE WE
6 TALKING ABOUT TIMEWISE?
7 A. PROBABLY HOURS TO DAYS.
8 Q. HOURS TO DAYS. OKAY. AGAIN, THE QUESTION IS ON
9 DECEMBER THE 30TH DID YOU SEE ANYTHING IN THE MEDICAL RECORD
10 WHICH WOULD INDICATE TO YOU THAT THIS PATIENT WAS TERMINAL?
11 A. NOT REALLY, NO.
12 Q. OKAY. DID YOU SEE ANYTHING IN THE MEDICAL RECORD
13 INDICATIVE OF PAIN ON THAT PARTICULAR DAY?
14 A. NO, I DID NOT.
15 Q. NOW, LET'S GO THROUGH THE TIME PERIOD EXTENDING FROM, I
16 THINK, DECEMBER THE 30TH, OR DECEMBER 31ST, RATHER, UP TO
17 JANUARY 3RD. HAVE YOU REVIEWED THOSE MEDICAL RECORDS?
18 A. YES, I HAVE.
19 Q. OKAY. AGAIN, THE QUESTION WOULD BE, DURING THAT TIME
20 PERIOD, DOCTOR, DID YOU SEE ANY EVIDENCE, OR I SHOULD SAY
21 SIGNS OR SYMPTOMS IN THE MEDICAL RECORDS THAT YOU REVIEWED
22 WHICH WOULD INDICATE TO YOU THAT THIS PATIENT WAS SUFFERING
23 PAIN?
24 A. I FOUND NO INDICATION OF THAT. THE PATIENT SEEMED TO BE
25 MINIMALLY RESPONSIVE TO ANY SORT OF STIMULUS DURING THIS Indication of pain>> Indication of pain>> Indication of pain>> Indication of pain>> Indication of pain>> Indication of pain>> Indication of pain>> Indication of pain>>
2580
1 TIME.
2 Q. OKAY. DID YOU SEE ANY EVIDENCE -- EXCUSE ME. STRIKE
3 THAT. DID YOU SEE ANY SIGNS OR SYMPTOMS THAT THIS PATIENT
4 WAS SUFFERING FROM MORPHINE TOXICITY DURING THAT TIME FRAME?
5 A. WELL, THE PATIENT REMAINED, AS I SAID, UNRESPONSIVE. SO
6 CERTAINLY ONE SIGN OF MORPHINE TOXICITY WOULD BE
7 UNCONSCIOUSNESS. THE PATIENT'S BREATHING RATE WAS SLOW. IT
8 WAS AROUND -- WELL, THE FEW TIMES IT'S NOTED HERE IT WAS
9 AROUND 12, WHICH IS ON THE LOW SIDE.
10 Q. YOU INDICATE THE FEW TIMES IT'S NOTED?
11 A. YES.
12 Q. WAS IT NOTED OR MONITORED ON A REGULAR BASIS, DOCTOR,
13 ACCORDING TO THE MEDICAL RECORDS?
14 A. IT APPEARS THAT AT MOST IT WAS ABOUT EVERY EIGHT HOURS.
15 Q. OKAY. WHAT TYPE OF DOSAGES WAS THIS PATIENT RECEIVING
16 ON THE 31ST OF DECEMBER?
17 A. THE PATIENT ON THE 31ST WAS RECEIVING FIVE MILLIGRAMS OF
18 MORPHINE ROUND THE CLOCK EVERY FOUR HOURS. SO AUTOMATICALLY
19 EVERY FOUR HOURS SHE WOULD GET ANOTHER FIVE MILLIGRAMS.
20 Q. DID THAT DOSAGE EVER INCREASE?
21 A. THERE WAS AN EXTRA FIVE MILLIGRAM DOSE THROWN IN THERE.
22 SO IN ADDITION TO THE REGULAR DOSING THE PATIENT DID RECEIVE
23 AN EXTRA ONE.
24 Q. OKAY. REFERRING TO THE 1ST OF JANUARY?
25 A. THEN ON JANUARY 1ST THE INTERVAL FOR DOSING WAS CHANGED
2581
1 FROM FIVE MILLIGRAMS EVERY FOUR HOURS TO FIVE MILLIGRAMS
2 EVERY THREE HOURS. SO EFFECTIVELY INCREASING THE DOSE THAT
3 THE PATIENT WAS RECEIVING.
4 Q. IN RESPECT TO THAT PARTICULAR TYPE OF INTERVAL, DOES
5 THAT BEAR ANY SIGNIFICANCE IN YOUR MIND?
6 A. WELL, THE FOUR HOUR DOSE, IN THE NORMAL CLINICAL
7 SETTING, IS GENERALLY CONSIDERED STANDARD FOR A DOSE OF
8 MORPHINE TO RUN ITS COURSE. IT'S INJECTED OR ADMINISTERED
9 AND FOUR HOURS LATER IT'S KIND OF ON THE DOWN SLOPE AND IT'S
10 TIME TO GIVE ANOTHER DOSE.
11 IF IT'S GIVEN THREE HOURS APART, THEN THE DOSES WILL
12 BEGIN TO PILE ON TOP OF ONE ANOTHER. THE MORPHINE IS NOT
13 SUFFICIENTLY CLEARED, SO THE NEXT DOSE IS GOING TO HAVE A
14 GREATER EFFECT AND THE NEXT ONE EVEN GREATER AND IT WILL
15 START TO PILE UP. Even the first-year med student could not fail to be appalled.
16 Q. THAT WAS WHAT OCCURRED ON THE 31ST OF -- EXCUSE ME, THE
17 1ST OF JANUARY?
18 A. YES.
19 Q. OKAY.
20 A. AND SHE DID GET SOME EXTRA DOSES THROWN IN THERE ALSO,
21 SO ADDITIONAL DOSES.
22 Q. IN RESPECT TO THE 1ST OF JANUARY, DOCTOR, CAN YOU TELL
23 US WAS THERE ANY INDICATIONS IN THE MEDICAL RECORD RELATIVE
24 TO ANY COMPLAINTS OR SIGNS AND SYMPTOMS OF PAIN?
25 A. THERE SEEMED TO BE NO CLEAR INDICATION THAT THE PATIENT
2582
1 WAS HAVING PAIN.
2 Q. OKAY. WAS THERE ANY SIGNS OR SYMPTOMS THAT THIS PATIENT
3 WAS SUFFERING FROM ANY TOXICITY FROM THE INJECTIONS OF
4 MORPHINE?
5 A. AGAIN, THE PATIENT WAS UNRESPONSIVE. THE BREATHING RATE
6 WAS SLOW. BLOOD PRESSURE WAS FAIRLY NORMAL, BUT THAT
7 DOESN'T NECESSARILY FIT ONE WAY OR ANOTHER. SO THERE
8 DEFINITELY WERE SIGNS THERE THAT THE PATIENT IS BEING
9 AFFECTED BY THE DRUG.
10 Q. GO TO JANUARY 2ND. WERE THERE ADDITIONAL -- WAS THERE
11 ADDITIONAL MORPHINE ADMINISTERED ON THAT DAY?
12 A. IT APPEARS ON THE 2ND THAT THE PATIENT CONTINUED TO GET
13 THE EVERY THREE HOUR DOSING OF THE MORPHINE, SO IT WAS GIVEN
14 AT -- WITH EXCESSIVE FREQUENCY.
15 Q. WAS THERE ANY MORPHINE ORDERED BUT WITHHELD ON THAT
16 PARTICULAR DAY? See withheld morphine>>
17 A. (PAUSE.) I DON'T SEE ANY THAT WERE WITHHELD, NO.
18 Q. OKAY. LET'S GO TO THE 3RD OF JANUARY. CAN YOU TELL US,
19 DID THE PATIENT DIE ON THAT DAY?
20 A. YES, SHE DID.
21 Q. WHAT TIME DID SHE DIE?
22 A. IT WAS ABOUT EIGHT O'CLOCK IN THE EVENING. 8:10 TO BE
23 EXACT.
24 Q. ON THAT PARTICULAR DATE, DOCTOR, DID SHE RECEIVE ANY
25 INJECTIONS OF MORPHINE?
2583
1 A. UMM, YES. THE DOSE OF MORPHINE ON THAT DAY, LATER IN
2 THE DAY -- THROUGH MOST OF THE DAY THE PATIENT CONTINUED TO
3 RECEIVE THE FIVE MILLIGRAMS EVERY THREE HOURS. BUT THEN AT
4 ABOUT 6:30 IN THE EVENING THAT DOSE WAS INCREASED, DOUBLED.
5 INCREASED TO 10 MILLIGRAMS EVERY THREE HOURS ROUND THE
6 CLOCK.
7 Q. WERE THERE ADDITIONAL DOSAGES GIVEN TO THE PATIENT ON
8 THAT PARTICULAR DAY?
9 A. YES. IN ADDITION TO THE 10 MILLIGRAMS EVERY THREE
10 HOURS, THE PATIENT RECEIVED ANOTHER 25 MILLIGRAMS AT TEN IN
11 THE MORNING. SHE RECEIVED AN ADDITIONAL 15 MILLIGRAMS AT
12 6:30 IN THE EVENING AND 30 MILLIGRAMS AT, I BELIEVE, ELEVEN
13 O'CLOCK.
14 Q. IN THE MORNING?
15 A. I BELIEVE SO, YES.
16 Q. OKAY.
17 A. SO SHE WAS NOT ONLY GETTING A LOT OF MEDICATION ON A
18 REGULAR BASIS, BUT SHE WAS GETTING WHAT I WOULD CONSIDER TO
19 BE VERY LARGE DOSES INTERMITTENTLY ON TOP OF THAT.
20 Q. DID YOU SEE ANY SIGNS OR SYMPTOMS OF MORPHINE TOXICITY
21 ON THE 3RD OF JANUARY?
22 A. AGAIN, THE PATIENT WAS UNRESPONSIVE. BLOOD PRESSURE IS
23 VERY LOW. I'M SORRY, THE HEART RATE -- I JUMPED AHEAD OF
24 MYSELF. IT'S LISTED HERE THAT THE FINGERS WERE CYANOTIC,
25 WHICH COULD BE AN INDICATION OF POOR CIRCULATION OR LACK OF
2584
1 OXYGEN. THE PATIENT DOESN'T RESPOND. AND THEN FINALLY, AT
2 8:10, THE PATIENT IS NOT -- IT SAYS PATIENT WITHOUT VITAL
3 SIGNS. SO NO BLOOD PRESSURE, NO RESPIRATORY, NO HEART RATE.
4 Q. OKAY. BASED ON YOUR EXPERIENCE, TRAINING AND EXPERTISE,
5 AND FROM YOUR REVIEW OF THESE MEDICAL RECORDS, DO YOU HAVE
6 AN OPINION, OR HAVE YOU FORMED AN OPINION, BASED TO A
7 REASONABLE DEGREE OF MEDICAL CERTAINTY, AS TO THE CAUSE OF
8 DEATH OF JUDITH LARSEN? ANSWER THAT YES OR NO.
9 A. YES.
10 Q. OKAY. AND WHAT IS THAT OPINION?
11 A. I BELIEVE THAT THE PATIENT ULTIMATELY DIED FROM
12 EXCESSIVE MORPHINE DOSES, BUT WAS WEAKENED BY THE CUMULATIVE
13 EFFECTS OF SEDATING MEDICATIONS UP UNTIL THE TIME THE
14 MORPHINE WAS GIVEN.
15 Q. LET'S TURN TO THE RECORDS OF MARY CRANE. I SHOW YOU
16 WHAT HAS BEEN MARKED AS STATE'S EXHIBIT NUMBER 36 AND ASK
17 YOU IF CAN IDENTIFY THAT EXHIBIT, PLEASE?
18 A. THIS, AGAIN, IS A GRAPHIC PRESENTATION OF THE
19 MEDICATIONS RECEIVED BY MARY CRANE DURING HER
20 HOSPITALIZATION AT THE GERO-PSYCH UNIT.
21 Q. ARE THOSE MEDICATIONS LISTED THERE CENTRAL -- DO THEY
22 HAVE -- LET ME START OVER. THE MEDICATIONS LISTED THERE,
23 HAVE YOU REVIEWED THEM?
24 A. YES, I HAVE.
25 Q. AND DO THOSE MEDICATIONS INDICATE MEDICATIONS WHICH HAVE
2585
1 SEDATING SIDE EFFECTS?
2 A. YES, THEY ARE.
3 Q. OKAY. THERE'S ALSO A MEDICATION ON THERE THAT IS
4 DESIGNATED AS THE DURAGESIC PATCH, IS THAT CORRECT?
5 A. YES.
6 Q. THAT IS THE MEDICATION YOU PREVIOUSLY TESTIFIED TO AS
7 FENTANYL?
8 A. YES, IT IS.
9 Q. OKAY. IN THE INTEREST OF TIME, I'M JUST GOING TO ASK
10 YOU, DOCTOR, YOU REVIEWED THESE RECORDS IN RESPECT TO THE
11 MEDICATIONS THAT WERE ADMINISTERED TO MARY CRANE EXTENDING
12 OVER THE TIME PERIOD FROM DECEMBER 28TH THROUGH JANUARY 7TH,
13 IS THAT CORRECT?
14 A. YES, IT IS.
15 Q. CAN YOU TELL US, FIRST OF ALL, DURING THAT PARTICULAR
16 TIME PERIOD DID YOU SEE IN THE MEDICAL RECORD ITSELF ANY
17 SIGNS OR SYMPTOMS WHICH WOULD BE INDICATIVE OF PAIN?
18 A. IN THIS PARTICULAR CASE THE PATIENT DID HAVE A HISTORY
19 OF COMPLAINING OF HEADACHES AND DID HAVE A HISTORY OF LOW
20 BACK PAIN PRIOR TO COMING INTO THE HOSPITAL. AS FAR AS
21 CLEAR SIGNS OF PAIN, YOU KNOW, ONCE SHE WAS IN THE CARE
22 CENTER HERE THERE WERE MINIMAL INDICATIONS OF THAT, IF ANY.
23 Q. IN RESPECT TO THE RECORDS YOU REVIEWED PRIOR TO HER
24 ADMISSION, YOU INDICATE THAT SHE HAD SUFFERED FROM SOME KIND
25 OF CHRONIC BACK PAIN?
2586
1 A. YES.
2 Q. OKAY. CAN YOU TELL US, DID YOU OBSERVE IN THOSE RECORDS
3 AS TO HOW THAT BACK PAIN WAS MEDICATED?
4 A. USUALLY WITH TYLENOL. SHE COMPLAINED OF LOW BACK PAIN,
5 HEADACHES. I THINK THERE WAS A SHOULDER PAIN COMPLAINT
6 ALSO. REGARDLESS OF WHICH OF THESE SHE COMPLAINED OF, MOST
7 OF THE TIME TYLENOL TOOK CARE OF THE PAIN. She got Lortab every day.
8 Q. OKAY. DID YOU SEE ANYTHING, RELATED TO THE MEDICAL
9 RECORDS YOU OBSERVED, AFTER ADMISSION WHICH WOULD INDICATE
10 TO YOU ANY MEDICAL NECESSITY FOR TREATMENT WITH MORPHINE?
11 A. NO, I DID NOT.
12 Q. DID YOU SEE ANY SIGNS OR SYMPTOMS IN THE MEDICAL RECORD
13 OF PAIN WHICH WOULD INDICATE TO YOU THE NECESSITY OF USING
14 THE DURAGESIC PATCH?
15 A. NO, I DID NOT. See one>> See another>> And another>> (All ON Duragesic)
16 Q. OKAY. IN RESPECT TO THIS PARTICULAR PATIENT, DOCTOR,
17 CAN YOU TELL US, FIRST OF ALL, THE EFFECTIVE TIME PERIOD A
18 DURAGESIC PATCH IS -- MAYBE I NEED TO REPHRASE THIS.
19 JUST EXPLAIN TO US AGAIN WHAT A DURAGESIC PATCH IS, HOW
20 IT WORKS?
21 A. AS I MENTIONED EARLIER, THE DURAGESIC PATCH CONTAINS THE
22 NARCOTIC FENTANYL AND IS PLACED ON THE SKIN. THE DRUG GOES
23 THROUGH THE SKIN INTO THE BLOODSTREAM AND THAT'S HOW IT
24 CAUSES ITS EFFECTS.
25 IT'S A UNIQUE DOSE FORM IN THAT IT TAKES PROBABLY
2587
1 TWO-THIRDS OF A DAY, SOMETHING LIKE 17 OR 18 HOURS, ONCE
2 IT'S PLACED ON THE SKIN FOR THE BLOOD LEVELS TO BUILD UP TO
3 WHATEVER LEVEL THEY'RE GOING TO GET. IN OTHER WORDS, TO
4 ACHIEVE WHATEVER EFFECT THEY MAY. SO IT'S A VERY SLOW SORT
5 OF A DOSE FORM. IT'S RATHER HARD TO REGULATE, ALSO,
6 PARTICULARLY TO BEGIN WITH. SO, IN OTHER WORDS, IF YOU PUT
7 THE PATCH ON IT'S LIKE 18 HOURS LATER WHEN YOU CAN ASSESS
8 HOW WELL IT'S WORKING AND WHAT YOUR MAXIMUM EFFECTS ARE
9 GOING TO BE.
10 Q. OKAY. DO YOU KNOW WHAT TYPE OF DURAGESIC PATCH WAS
11 PLACED ON THIS PARTICULAR PATIENT?
12 A. SHE INITIALLY HAD A 25-MICROGRAM PER HOUR PATCH PLACED,
13 WHICH IS THE LOWEST CONCENTRATION. BUT THEN ABOUT, I
14 BELIEVE, THREE HOURS LATER THAT 25-MICROGRAM PATCH WAS
15 CHANGED TO A 50-MICROGRAM PATCH.
16 Q. WERE THERE FURTHER PATCHES THAT WERE ADMINISTERED OVER
17 THIS PERIOD OF TIME?
18 A. EVENTUALLY SHE WAS PLACED ON A 75-MICROGRAM PATCH.
19 Q. AND WHEN DID THAT OCCUR, TO YOUR REVIEW?
20 A. LET ME LOOK AT MY NOTES HERE. (PAUSE.) JANUARY 3RD SHE
21 WAS ON THE 50. ON JANUARY 4TH SHE WAS ON 75. SHE REMAINED
22 ON THAT THROUGH THE REST OF THE HOSPITALIZATION.
23 Q. OKAY. SO YOU SAY THE EFFECTIVENESS OF THAT PATCH IS
24 SOME 18 HOURS AFTER THE PATCH IS PLACED ON THE INDIVIDUAL?
25 A. YES. THE MAXIMUM EFFECT.
2588
1 Q. OKAY. AND IT LASTS FOR HOW LONG?
2 A. EACH OF THE PATCHES WILL LAST ABOUT THREE DAYS.
3 Q. THE QUESTION I HAVE, WHEN DID THIS PATIENT PASS AWAY?
4 A. THE PATIENT DIED ON JANUARY 8TH. I THINK IT WAS VERY
5 EARLY ON JANUARY 8TH. PERHAPS LATE ON THE 7TH, BUT RIGHT
6 AROUND MIDNIGHT ON THE 8TH.
7 Q. CAN YOU TELL US WHETHER OR NOT YOU OBSERVED DURING THIS
8 TIME PERIOD THAT SHE'S ON -- FROM, AGAIN, DECEMBER 28TH UP
9 UNTIL THE 7TH OF JANUARY, WHETHER SHE EXHIBITED ANY SIGNS OR
10 SYMPTOMS RELATED TO TOXICITY FROM EITHER THE DURAGESIC PATCH
11 OR THE MORPHINE INJECTIONS?
12 A. (PAUSE.) THERE ARE NOTATIONS OF THE PATIENT BEING
13 LETHARGIC, NONRESPONSIVE. SHE WAS REQUIRING SUPPLEMENTAL
14 OXYGEN, SO HER BREATHING WAS DECREASED IF SHE WAS REQUIRING
15 OXYGEN. ON THE 7TH SHE'S DESCRIBED AS BEING LETHARGIC ALL
16 SHIFT. HER BLOOD OXYGEN SATURATIONS AT THAT TIME WERE IN
17 THE 70 TO 80 RANGE, WHICH IS REALLY NOT COMPATIBLE WITH
18 LIFE. IT'S MUCH LOWER THAN WHAT WOULD SUSTAIN ANY SORT OF
19 NORMAL BODY FUNCTIONS. SHE'S DESCRIBED AS CYANOTIC, WHICH
20 WOULD JUST REFLECT NOT MUCH OXYGEN IN THE BLOOD. AND THEN
21 SHORTLY AFTER THAT IS WHEN SHE DIED.
22 Q. OKAY. DOCTOR, BASED UPON YOUR EXPERIENCE AND TRAINING,
23 AND YOUR EXPERTISE AND YOUR REVIEW OF THESE RECORDS, HAVE
24 YOU FORMED AN OPINION, BASED UPON A REASONABLE DEGREE OF
25 MEDICAL CERTAINTY, AS TO THE CAUSE OF DEATH OF MARY CRANE?
2589
1 ANSWER THAT YES OR NO.
2 A. YES.
3 Q. AND WHAT IS THAT OPINION, SIR?
4 A. I FEEL THAT MARY CRANE WAS ADVERSELY AFFECTED BY A
5 NUMBER OF THE CENTRAL NERVOUS SYSTEM DRUGS THAT SHE
6 RECEIVED. SHE SUFFERED MEDICAL COMPLICATIONS, INCLUDING
7 ASPIRATION OF PNEUMONIA BECAUSE OF THE MEDICATIONS. SHE
8 ULTIMATELY SUCCUMBED BECAUSE OF LARGE DOSES OF NARCOTIC.
9 Q. THOSE NARCOTICS BEING?
10 A. FENTANYL AND MORPHINE.
11 Q. OKAY. THANK YOU, DOCTOR. I SHOW YOU WHAT'S BEEN MARKED
12 AS STATE'S EXHIBIT 37. I'LL ASK YOU IF YOU HAVE HAD
13 OCCASION TO REVIEW THAT PARTICULAR EXHIBIT?
14 A. I HAVE.
15 Q. CAN YOU TELL US, IN RESPECT TO YOUR REVIEW, DOES THAT --
16 THE MEDICATIONS THAT ARE LISTED THERE, DOES THAT COMPORT
17 WITH THE NOTES AND REVIEW THAT YOU MADE OF THE MEDICAL
18 RECORD AT THE HOSPITAL?
19 A. YES, IT DOES.
20 Q. OKAY. CAN YOU ALSO TELL US WHETHER OR NOT YOU REVIEWED
21 ANY OTHER NURSING HOME RECORDS IN CONNECTION WITH LYDIA
22 SMITH?
23 A. YES, I DID.
24 Q. CAN YOU TELL US, DOCTOR, IN YOUR OPINION, BASED UPON
25 THOSE REVIEWS, AT THE TIME OF HER ADMISSION WAS SHE
2590
1 SUFFERING FROM ANY MEDICAL CONDITION OR SIGNS OR SYMPTOMS
2 WHICH EVIDENCED THAT SHE WAS SUFFERING ANY PAIN?
3 A. NO, THERE WAS NO INDICATION OF THAT.
4 Q. OKAY. CAN YOU TELL US AS TO WHETHER OR NOT SHE WAS
5 SUFFERING FROM ANY CONDITION, FROM YOUR REVIEW, THAT YOU
6 WOULD CATEGORIZE AS TERMINAL?
7 A. THERE DID NOT SEEM TO BE ANY INDICATION OF THAT EITHER.
8 SHE WAS MEDICALLY STABLE. !!
9 Q. NOW, YOU'VE REVIEWED THE REGIMEN OF TREATMENT THAT WAS
10 ADMINISTERED TO THIS PATIENT OVER THIS COURSE OF TIME AND
11 CAN YOU TELL US WHAT TYPES OF MEDICATIONS SHE WAS
12 ADMINISTERED?
13 A. AGAIN, SHE WAS ADMINISTERED A WHOLE RANGE OF DIFFERENT
14 MEDICINES. RISPERDAL, THAT'S A TYPICAL ANTIPSYCHOTIC.
15 HALDOL, WHICH WAS AN ANTIPSYCHOTIC DRUG. SERZONE, WHICH IS
16 A COMBINATION SEDATIVE AND ANTIDEPRESSANT. TRAZODONE, WHICH
17 IS A SEDATIVE AND MAY BE AN ANTIDEPRESSANT. DEPAKENE, WHICH
18 IS AN ANTICONVULSANT AND IS ALSO USED FOR MOOD MANAGEMENT AS
19 I MENTIONED EARLIER. AND ATIVAN, WHICH IS A BENZODIAZEPINE
20 AND ANTIANXIETY DRUG.
21 Q. CAN YOU TELL US WHETHER OR NOT THOSE PARTICULAR
22 MEDICATIONS THAT YOU'VE JUST REFERENCED HAVE ANY CENTRAL
23 NERVOUS SYSTEM DEPRESSION SIDE EFFECTS?
24 A. THEY WOULD ALL HAVE CENTRAL NERVOUS SYSTEM DEPRESSANT
25 EFFECTS.
2591
1 Q. OKAY. GO AHEAD AND HAVE YOUR SEAT AGAIN.
2 A. (WITNESS COMPLIED.)
3 Q. IN YOUR REVIEW OF THE RECORDS DURING THIS TIME PERIOD,
4 FROM DECEMBER 20TH UNTIL JANUARY THE 8TH, DID YOU SEE,
5 DURING THAT TIME PERIOD, ANY SIGNS OR SYMPTOMS AS THEY
6 RELATE TO THE TOXIC EFFECT OF THE SEDATING DRUGS?
7 A. YES, I DID.
8 Q. OKAY. CAN YOU DESCRIBE FOR US WHAT SIGNS OR SYMPTOMS
9 YOU OBSERVED?
10 A. WELL, THIS PATIENT, EARLY ON IN HER HOSPITALIZATION,
11 ACTUALLY DIDN'T SHOW MUCH SIGN OF PROBLEMS. AS THE DOSE OF
12 MEDICATIONS WAS INCREASED ON AND AROUND DECEMBER 30TH THE
13 NURSING NOTES WOULD INCREASE -- WOULD INDICATE AN INCREASE
14 IN SLEEPINESS AND THE DEPRESSANT EFFECTS OF THESE MEDICINES.
15 SLEPT ON AND OFF MOST OF THE AFTERNOON. THOSE SORTS OF
16 NOTES BEGAN TO APPEAR ABOUT THAT TIME.
17 Q. ABOUT WHAT TIME WAS THAT?
18 A. THIS WAS ABOUT TEN DAYS INTO HER HOSPITALIZATION.
19 Q. OKAY. NOW, DO THOSE SIGNS OR SYMPTOMS, REFLECTED IN THE
20 NURSING NOTES, DO THEY CHANGE IN ANY WAY?
21 A. AS THE MEDICATION DOSES CONTINUE TO GO UP, AS THEY BEGAN
22 TO DO AT ABOUT THAT TIME, THERE BEGAN TO BE SOME PRETTY GOOD
23 DOSE INCREASES. THEN, FOR INSTANCE, ON JANUARY 2ND SHE'S
24 NOT EATING, SHE'S VERY DROWSY, STILL HAVING SOME AGGRESSIVE
25 BEHAVIOR. BUT, AGAIN, DEFINITELY SHOWING SIGNS IN THE OTHER
2592
1 DIRECTION. BY THIS TIME HER DOSES OF MEDICATION HAD BEEN
2 INCREASED QUITE A BIT.
3 ON JANUARY 3RD SHE'S DESCRIBED AS VERY DROWSY. DID NOT
4 EAT DINNER DUE TO LETHARGIC STATE. AND THEN GAVE HALDOL
5 I.M. NOT TAKING MEDS. I THINK THAT WAS BECAUSE SHE WAS
6 DROWSY.
7 MR. STIRBA: I'M NOT SO SURE WHAT THE QUESTION IS,
8 IF THERE'S A PENDING QUESTION. ALSO, I THINK IN FAIRNESS --
9 MR. WILSON: I THINK HE WAS DESCRIBING THE SIGNS OR
10 SYMPTOMS THAT HE SAW AS WE PROGRESSED THROUGH THIS TIME
11 PERIOD.
12 THE COURT: GO AHEAD AND PROCEED WITH ANOTHER
13 QUESTION.
14 Q. (BY MR. WILSON) YOU INDICATED HALDOL I.M. AND WHAT
15 DATE WAS THAT?
16 A. JANUARY 3RD.
17 Q. JANUARY 3RD. I'M TRYING TO LOOK AT THE CHART HERE. CAN
18 YOU COMMENT ON THE DOSAGE OF HALDOL THAT WAS ADMINISTERED ON
19 THAT DAY?
20 A. FIVE MILLIGRAMS WAS GIVEN TWICE ON THAT DAY.
21 Q. WHAT WOULD BE THE NORMAL DOSAGE?
22 MR. STIRBA: I'LL OBJECT. THAT'S CUMULATIVE. HE'S
23 HERE AS A PAIN EXPERT, NOT ON PSYCHOTROPICS.
24 THE COURT: LET'S GO ON.
25 MR. WILSON: YOUR HONOR, HE'S TESTIFIED AS TO THE
2593
1 SEDATING SIDE EFFECTS OF THAT PARTICULAR DRUG. I WANT TO
2 FIND OUT, IN TERMS OF THE DOSAGE THAT WAS ADMINISTERED ON
3 THAT DATE, AS TO ITS POTENTIAL FOR SEDATING SIDE EFFECTS.
4 MR. STIRBA: BUT IT'S ALREADY BEEN TESTIFIED TO.
5 THE COURT: OKAY. I'LL LET YOU ASK THAT QUESTION,
6 BUT WE HAD DR. FEHLAUER HERE FOR A DAY AND A HALF GOING
7 THROUGH THE SAME THING.
8 Q. (BY MR. WILSON) AS TO THE POTENTIAL SIDE EFFECTS OF
9 HALDOL ADMINISTERED IN THAT AMOUNT, WHAT IS THE POTENTIAL
10 FOR SEDATING SIDE EFFECTS?
11 A. IT'S A LARGE DOSE AND IT WOULD HAVE VERY SIGNIFICANT
12 POTENTIAL FOR SEDATING SIDE EFFECTS.
13 Q. OKAY. GOING ON NOW TO JANUARY 7TH, I THINK, WAS
14 MORPHINE ADMINISTERED ON THAT PARTICULAR DAY?
15 A. YES, IT WAS.
16 Q. DO YOU RECALL WHEN THE MEDICAL RECORDS INDICATE IT WAS
17 FIRST ADMINISTERED?
18 A. THE FIRST DOSE, MORPHINE FIVE MILLIGRAMS I.M., WAS
19 ORDERED ON AN EVERY THREE HOUR BASIS. THE FIRST DOSE WAS
20 GIVEN AT NINE O'CLOCK IN THE EVENING.
21 Q. OKAY. CAN YOU TELL US, DOCTOR, WERE THERE ANY
22 INDICATIONS IN THE MEDICAL RECORDS THAT YOU OBSERVED OF ANY
23 SIGNS OR SYMPTOMS OF PAIN ON THAT PARTICULAR DATE, JANUARY
24 THE 7TH?
25 A. NO. ON THE CONTRARY, THE PATIENT IS DESCRIBED AS
2594
1 MINIMALLY RESPONSIVE, NOT ABLE TO TAKE MEDS, LETHARGIC,
2 UNRESPONSIVE, NOT SWALLOWING, NOT TAKING ANYTHING BY MOUTH,
3 NO WET DIAPERS. SO THE PATIENT APPEARS TO BE HEAVILY
4 SEDATED AND PROBABLY DEHYDRATED AT THAT POINT.
5 Q. CAN YOU TELL US WHETHER OR NOT YOU SAW ANYTHING IN
6 THAT -- ON JANUARY THE 7TH OR JANUARY THE 6TH WHICH WOULD
7 INDICATE TO YOU THAT THIS PATIENT WAS IN A TERMINAL STATE?
8 A. THERE SEEMED TO BE NO CLEAR CHANGE IN HER MEDICAL
9 CONDITION. NOTHING NEW THAT WOULD SUGGEST AN ACUTE CHANGE
10 IN HER CONDITION THAT WOULD CAUSE HER TO BE IN A TERMINAL
11 STATE. !!!
12 Q. OKAY. ON JANUARY THE 8TH WAS THERE FURTHER MORPHINE
13 GIVEN?
14 A. YES, THERE WAS. SHE RECEIVED -- CONTINUED TO RECEIVE
15 THE FIVE MILLIGRAMS ON A REGULAR SCHEDULE. AND THEN ALSO
16 SHE RECEIVED SEVERAL 10 MILLIGRAM DOSES.
17 Q. WHEN WAS THE LAST SHOT ADMINISTERED OF MORPHINE?
18 A. IT APPEARS THAT IT WAS ADMINISTERED ABOUT NOON.
19 Q. OKAY. CAN YOU TELL US WHEN THE PATIENT DIED?
20 A. IT STATES IN THE NOTES THAT AT 12:45, AND THIS IS A
21 NURSING NOTE, THE DAUGHTER REQUESTED I CHECK PATIENT.
22 QUOTE, I DON'T THINK SHE'S BREATHING, END OF QUOTE. THE
23 PATIENT WAS PRONOUNCED DEAD.
24 Q. AGAIN, BASED UPON YOUR EXPERIENCE, YOUR TRAINING AND
25 EXPERTISE AND YOUR REVIEW OF THE MEDICA