Byron Bair, MD
15 MS. BARLOW: WE'LL CALL DR. BYRON BAIR.
16 THE COURT: IS DR. BAIR PRESENT? WOULD YOU COME UP
17 PLEASE? IF YOU'LL COME RIGHT UP HERE, RAISE YOUR RIGHT HAND
18 PLEASE, AND FACE THE CLERK, SHE'LL PLACE YOU UNDER OATH.
19
20 IF YOU'LL HAVE A SEAT UP HERE PLEASE, RIGHT HERE.
21 THE WITNESS: CAN I GRAB SOME CHARTS?
22 THE COURT: SURE, GO AHEAD. IF YOU'LL STATE YOUR FULL
23 NAME AND SPELL YOUR LAST NAME PLEASE DOCTOR.
24 THE WITNESS: BYRON D. BAIR, B-A-I-R.
25 BY MS. BARLOW:
1 Q. MORNING, DR. BAIR. YOU HAVE TAKEN SOME FOLDERS UP WITH
2 YOU TO THE STAND. WOULD YOU TELL US WHAT THOSE ARE?
3 A. YES. THESE ARE FOLDERS OF FIVE SEPARATE PATIENTS THAT
4 WERE ADMITTED TO DAVIS NORTH HOSPITAL GEROPSYCHIATRIC UNIT.
5 Q. ARE THEY THE HOSPITAL RECORDS --
6 A. YES.
7 Q. -- FROM THAT ADMISSION? THANK YOU. DR. BAIR, WOULD YOU
8 PLEASE STATE WHAT YOUR CURRENT OCCUPATION IS?
9 A. I'M AN ASSOCIATE PROFESSOR OF INTERNAL MEDICINE AND
10 PSYCHIATRY AT THE UNIVERSITY OF UTAH. I'M THE ACTING
11 DIRECTOR OF THE GERIATRIC RESEARCH, EDUCATION, AND CLINICAL
12 CENTER AT THE SALT LAKE V.A. AND ALSO THE DIRECTOR OF
13 CLINICAL DEMONSTRATION PROGRAMS FOR THE GERIATRIC RESEARCH
14 EDUCATION, AND CLINICAL CENTER.
15 Q. WHAT IS YOUR EDUCATIONAL BACKGROUND?
16 A. I ATTENDED MEDICAL SCHOOL AT THE UNIVERSITY OF UTAH.
17 AND COMPLETED AN INTERNSHIP AND RESIDENCY IN INTERNAL
18 MEDICINE AND PSYCHIATRY AT WEST VIRGINIA UNIVERSITY. AND
19 THEN COMPLETED A TRAINING IN GERIATRIC INTERNAL MEDICINE AND
20 GERIATRIC PSYCHIATRY. AND HAVE BOARD CERTIFICATIONS IN
21 INTERNAL MEDICINE, GENERAL PSYCHIATRY, AS WELL AS ADDED
22 CERTIFICATION IN GERIATRIC INTERNAL MEDICINE AND GERIATRIC
23 PSYCHIATRY.
24 Q. WHEN DID YOU GRADUATE FROM MEDICAL SCHOOL AT THE
25 UNIVERSITY OF UTAH?
1 A. 1986.
2 Q. AND AFTER GRADUATION FROM MEDICAL SCHOOL, ARE YOU
3 REQUIRED TO TAKE A RESIDENCY TO BECOME A PHYSICIAN?
4 A. YOU'RE NOT REQUIRED, IT'S NOT MANDATORY, BUT FOR THE
5 PRACTICE OF MEDICINE, IT'S REQUIRED IN MOST STATES THAT YOU
6 HAVE AT LEAST ONE YEAR BEYOND MEDICAL SCHOOL TO OBTAIN A
7 LICENSE.
8 Q. AND YOU DID THAT RESIDENCY YOU SAID AT THE WEST
9 VIRGINA --
10 A. CORRECT.
11 Q. -- UNIVERSITY? HOW -- WHEN DID YOU FINISH THAT
12 RESIDENCY?
13 A. IN DECEMBER OF 1991.
14 Q. SO FROM '86 TO '91 YOU WERE IN RESIDENCY, IS THAT
15 CORRECT?
16 A. THAT'S CORRECT.
17 Q. OKAY. WHY DID IT TAKE MORE THAN ONE YEAR?
18 A. BECAUSE IT WAS A DUAL PROGRAM IN INTERNAL MEDICINE AS
19 WELL AS PSYCHIATRY TO FULFILL THE REQUIREMENTS OF BOTH BOARD
20 SPECIALITIES.
21 Q. ARE YOU REQUIRED AS A PHYSICIAN TO PRACTICE TO BE BOARD
22 CERTIFIED?
23 A. NO.
24 Q. WHAT IS A BOARD CERTIFICATION?
25 A. BOARD CERTIFICATION, THERE ARE NATIONAL BOARDS FOR THE
1 DIFFERENT SPECIALTIES IN MEDICINE AND SURGERY THAT ARE
2 TESTED. IN PSYCHIATRY IT CONSISTS OF AN ORAL BOARD AS WELL
3 AS A WRITTEN TEST. IN INTERNAL MEDICINE IT'S A WRITTEN TEST
4 TO DEMONSTRATE PROFICIENCY IN THE SUBSPECIALTIES.
5 Q. WHAT HAS BEEN YOUR PROFESSIONAL EXPERIENCE AS A
6 PHYSICIAN AND AS A PSYCHIATRIST?
7 A. MY PROFESSIONAL EXPERIENCE IS BASICALLY BEEN IN
8 GERIATRIC INTERNAL MEDICINE AND GERIATRIC PSYCHIATRY SINCE
9 1991.
10 Q. WHERE HAVE YOU BEEN PRACTICING?
11 A. AT THE UNIVERSITY OF UTAH AND THE V.A. MEDICAL CENTER.
12 Q. THE V.A., THE VETERANS' ADMINISTRATION?
13 A. CORRECT.
14 Q. THANK YOU. DO YOU HAVE ANY TEACHING RESPONSIBILITIES OR
15 ASSIGNMENTS AT THIS TIME?
16 A. YES. WE HAVE A FARILY HEAVY TEACHING LOAD. WE TEACH
17 RESTIDENTS IN INTERNAL MEDICINE. I ALSO TEACH THE RESIDENTS
18 IN PSYCHIATRY. WE ALSO TEACH PROFESSIONALS IN SOCIAL WORK AS
19 WELL AS NURSING AND ADVANCED PRACTICE NURSING.
20 Q. WITH THE TEACHING THAT YOU DO, DO YOU HAVE ANY HANDS-ON
21 EXPERIENCE WITH PATIENTS?
22 A. IN FACT, THAT'S MOST OF WHAT OUR TEACHING IS. WE DO
23 HAVE SOME DIDACTIC CLASSES THAT WE TEACH FOR MEDICAL
24 STUDENTS, BUT THE MAJORITY OF OUR TEACHING GOES ON WITH HOUSE
25 STAFF. AND THAT IS AT THE BEDSIDE.
1 Q. AND WHERE DOES YOUR MEDICAL TEACHING AT THE BEDSIDE, THE
2 GERIATRIC PATIENTS, WHERE ARE THEY?
3 A. THE GERIATRIC PATIENTS OCCUR IN A VARIETY OF SETTINGS.
4 WE ALSO HAVE, I SHOULD MENTION, A GERIATRIC INTERNAL MEDICINE
5 FELLOWSHIP THAT WE TEACH FELLOWS --
6 THE COURT: DOCTOR, IF YOU CAN SLOW DOWN PLEASE.
7 THE WITNESS: OKAY. I'LL TRY TO.
8 MS. BARLOW: THANK YOU.
9 Q. (BY MS. BARLOW) YOU'RE NOT THE FIRST DOCTOR WHO'S BEEN
10 ASKED THAT.
11 A. I GO FAST. THE QUESTION AGAIN WAS?
12 Q. WHAT SETTINGS DO YOU TEACH --
13 A. UNDER WHICH SETTINS --
14 Q. -- GERIATRIC --
15 A. WE HAVE OUTPATIENT CLINICS WHERE PATIENTS COME IN AT
16 BOTH THE UNIVERSITY AND AT THE V.A. SITES. WE ALSO HAVE
17 INPATIENT CONSULTATION. WE ALSO SUPERVISE NURSING HOME CARE
18 AT TWO AREA NURSING HOMES THAT ARE AFFILIATED WITH THE
19 UNIVERSITY OF UTAH.
20 Q. DO YOU HAVE OCCASION THEN TO WORK WITH DEMENTED
21 PATIENTS?
22 A. THE MAJORITY OF OUR PRACTICE DOES INVOLVE PEOPLE WITH
23 DEMENTIA OR COGNITIVE PROBLEMS.
24 Q. IN ADDITION TO YOUR TEACHING ASSIGNMENTS, HAVE YOU
25 DONE -- HAVE YOU PUBLISHED ANY EITHER BOOKS OR PAPERS OR THAT
1 SORT OF THING?
2 A. YES. I HAVE PUPLISHED PAPERS ON DELIRIUM AND ALSO
3 PAPERS ON MAKING DIAGNOSIS IN PSYCHIATRIC GERIATRIC
4 PSYCHIATRY PATIENTS, AS WELL AS OTHER PUBLICATIONS CONCERNING
5 SYSTEMS OF CARE AND HOW TO DELIVER CARE TO OLDER INDIVIDUALS.
6 Q. HAVE YOU DONE ANY ORAL PRESENTATIONS?
7 A. YES, I'VE SPEAK FREQUENTLY ACROSS THE NATION AS WELL AS
8 REGIONALLY CONCERNING DEMENTIA AND DEPRESSION.
9 Q. DO YOU DO WHAT'S CALLED GRAND ROUNDS?
10 A. CORRECT.
11 Q. WHAT ARE THOSE?
12 A. GRAND ROUNDS ARE WHERE PROFESSIONALS, USUALLY IN A
13 HOSPITAL OR UNIVERSITY OR COMMUNITY HOSPITAL SETTING, HAVE
14 EDUCATIONAL PRESENTATIONS USUALLY FROM OUTSIDE SPEAKERS,
15 SOMETIMES WITHIN. AND THAT'S THE MAJORITY OF WHAT I DO IS GO
16 TO EDUCATE OTHER PHYSICIANS CONCERNING DEMENTIA, DEPRESSION,
17 DELIRIUM, DIAGNOSES FOR GERIATRIC PATIENTS.
18 Q. HAVE YOU BEEN ANYPLACE THIS WEEK DOING THAT?
19 A. AS A MATTER OF FACT, I JUST GOT BACK FROM SEATTLE WHERE
20 I WAS TALKING AT TWO DIFFERENT CLINICAL SITUATIONS FOR
21 GERIATRICIANS THERE HELPING THEM UNDERSTAND DIAGNOSIS ABOUT
22 DELIRIUM. AND THEN LATER ON THIS AFTERNOON, I'M GOING TO GO
23 TO DALLAS TO DO A SIMILAR THING.
24 MS. BARLOW: YOUR HONOR, I WOULD ASK THAT DR. BAIR BE
25 LISTED OR DESIGNATED AS AN EXPERT.
1 THE COURT: WELL, THE COURT DOESN'T DO THAT.
2 MS. BARLOW: OH, OKAY.
3 THE COURT: YOU CAN GO AHEAD AND ASK HIM SOME QUESTIONS.
4 MS. BARLOW: OKAY. THANK YOU.
5 Q. (BY MS. BARLOW) WHAT ARE THE RESPONSIBILITIES OF A
6 PHYSICIAN REGARDING OBSERVATION OF PATIENTS?
7 A. WELL, IT'S A COMPLEX DUTY I THINK THAT IS TAUGHT FROM
8 MEDICAL SCHOOL TO COLLECT INFORMATION FROM A VARIETY OF
9 SOURCES, AND THEN TO SYNTHESIZE THAT INFORMATION TO DEVELOP A
10 WORKING PLAN AND THEN BASED ON THAT WORKING PLAN, TO HAVE
11 INTERVENTIONS TO HELP YOU UNDERSTAND WHAT THINGS MAY BE GOING
12 ON, AND THEN TO INSTITUTE TREATMENTS.
13 Q. IS THERE ANY REQUIREMENT FOR DOCUMENTATION OF ANY OF
14 THESE STEPS THAT A PHYSICIAN MUST TAKE?
15 A. WE DO TEACH EXTENSIVELY TO DOCUMENT THE THOUGHT PROCESS
16 AND THE TEACHING IS BASICALLY THAT YOU'RE DOCUMENTING FOR
17 OTHERS, NOT JUST YOURSELF. IT'S BECOME INCREASINGLY
18 IMPORTANT ACTUALLY IN THE CURRENT ENVORONMENT BECAUSE OF
19 REIMBURSEMENT THAT ACTUALLY DEMANDS THAT YOU DOCUMENT WHAT
20 YOU DO SO THAT YOU CAN BE REIMBURSED FOR THOSE PROCEDURES OR
21 FOR THE THINGS THAT YOU TKHO.
22 Q. REIMBURSEMENT BY WHAT ENTITIES?
23 A. USUALLY THIRD PARTY PROVIDERS OR MEDICAID OR MEDICARE.
24 Q. UNFORTUNATELY, THE DOLLAR MATTERS IN TODAY'S WORLD. WHAT
25 ARE THE RISKS OF A PHYSICIAN'S FAILURE TO OBSERVE, EVALUATE,
1 INTERVENE OR DOCUMENT APPROPRIATELY THE CARE OF GERIATRIC
2 PATIENTS?
3 A. I THINK IT'S THE ESSENCE OF ANY KIND OF A PHYSICIAN TO
4 EVALUATE AND PERFORM THOSE THINGS THAT PHYSICIANS DO.
5 WITHOUT THAT I THINK YOU REALLY CEASE TO BE A PHYSICIAN.
6 Q. ARE THERE ANY RISKS, EXCUSE ME, TO THE PATIENT FROM A
7 DOCTOR OR PHYSICIAN FAILING TO DO THIS?
8 A. WELL, I THINK THERE ARE LOTS OF RISKS. IF PHYSICIANS
9 DON'T DO WHAT PHYSICIANS ARE EXPECTED TO DO, I THINK
10 OBVIOUSLY IT CAN HAVE DIRECT PATIENT IMPACT, DEPENDING UPON
11 WHAT'S GOING ON. ALSO, THERE'S A RESPONSIBILITY I THINK TO
12 PATIENTS AND THEIR FAMILIES TO DO INTERVENTIONS AND
13 EVALUATIONS BECAUSE THEY WOULDN'T BE COMING TO YOU UNLESS
14 THEY THOUGHT THAT YOU WOULD BE ABLE TO DO SOMETHING.
15 Q. NOW, YOU'RE TRAINED AND CERTIFIED AND YOU TEACH
16 GERIATRIC MEDICAL OR MEDICINE PRINCIPLES, IS THAT CORRECT?
17 A. CORRECT.
18 Q. WHAT ABOUT GERIATRIC PSYCHIATRY?
19 A. YES, GERIATRIC PSYCHIATRY AS WELL. I SUPERVISE
20 PSYCHIATRY RESIDENTS AS WELL AS PSYCHOLOGY INTERNS IN THE
21 TREATMENT AND EVALUATION OF GERIATRIC PATIENTS.
22 Q. IS THE TREATMENT OF GERIATRIC PATIENTS DIFFERENT FROM A
23 YOUNGER ADULT OR A CHILD?
24 A. IT ACTUALLY IS. THERE'S A LOT OF THINGS THAT GO ON.
25 PEOPLE -- IT'S ACTUALLY ONE OF THE GROUPS IN THE WORLD THAT
1 HAVE BEEN UNDERSTUDIED AND UNDERTREATED. THEY'RE USUALLY
2 EXCLUDED, THEY HAVE BEEN ROUTINELY EXCLUDED OFTENTIMES FROM
3 DIFFERENT TRIALS. AND SO WHAT WE TRY TO TEACH IS THAT THE
4 PHYSIOLOGY IS DIFFERENT AS WE AGE. OUR BODIES RESPOND
5 DIFFERENTLY TO MEDICATIONS BECAUSE OF CHANGES IN THE
6 CARDIOVASCULAR SYSTEM, THE KIDNEY SYSTEM, AND ALSO THE LIVER
7 AS WE EXCRETE. AND THAT'S VERY IMPORTANT WHEN IT COMES TO
8 MEDICATIONS AND HOW WITH HANDLE THEM. AND ALSO, MOST
9 PATIENTS OVER THE AGE OF 65 -- AND I USE THAT KIND OF
10 ARBITRARILY BECAUSE PEOPLE AGE 65 ARE NOT NECESSARILY OLD,
11 BUT IN ACADEMICS, THEY'RE TERMED GERIATRIC. THE CLOSER I GET
12 TO THAT, THE MORE I THINK THAT'S YOUNGER. HOWEVER, AS PEOPLE
13 GET OLDER, THEY DO HAVE MULTIPLE ILLNESSES SIMULTANEOUSLY.
14 SO IT'S UNUSUAL IN AN OLDER INDIVIDUAL TO HAVE ONE SINGLE
15 PROCESS GOING ON AT A TIME, WHERE IN A YOUNGER PERSON, IT'S
16 VERY COMMON TO HAVE ONE THING GOING ON SUCH AS SIMPLE
17 DIABETES OR SIMPLE HYPERTENSION, WHERE IN THE OLDER PERSON,
18 IT'S VERY COMMON TO HAVE MEDICAL ILLNESSES AND A PSYCHIATRIC
19 ILLNESSES THAT ARE OFTEN VERY DIFFICULT TO DISTINGUISH ONE
20 FROM ANOTHER. THE OTHER THING THAT'S VERY DIFFICULT IN
21 GERIATRICS THAT REQUIRES SPECIAL ATTENTION TO EVALUATION IS
22 THAT THE SYMPTOMS, THE PRESENTATION OF SYMPTOMS OFTEN VARIES
23 GREATLY FROM SYMPTOMS IN A YOUNGER PATIENT. AS AN EXAMPLE,
24 MYOCARDIAL INFARCTION OR HEART ATTACK IN A YOUNG PERSON,
25 PEOPLE GENERALLY KNOW THE SYMPTOMS OF CHEST PAIN, SHORTNESS
1 OF BREATH, AND SWEATING. HOWEVER, IN AN OLDER PERSON SAY
2 OVER THE AGE OF 80, THE MOST FREQUENT CHANGE IS A MENTAL
3 STATUS CHANGE. IN FACT, ONLY 20 PERCENT OF INDIVIDUALS HAVE
4 CHEST PAIN OVER THE AGE OF 80. AND SO BEING ABLE TO
5 RECOGNIZE THOSE SYSTEMS IN A YOUNGER PERSON, YOU HAVE TO
6 SHIFT AND KNOW A WHOLE DIFFERENT SET OF KNOWLEDGE TO BE ABLE
7 TO DIAGNOSE SAY A HEART ATTACK IN AN OLDER PERSON BECAUSE YOU
8 MIGHT MISS IT. FOR INSTANCE, WITH A HEART ATTACK, YOU MAY
9 MISTAKE THAT AS A PSYCHIATRIC PROBLEM BECAUSE OF THE CHANGE
10 IN MENTAL STATUS LEADS TO A CHANGE IN BEHAVIOR WHEN ACTUALLY
11 IT COULD BE A HEART ATTACK IS THE UNDERLYING PROBLEM SO IT'S
12 REALLY IMPORTANT TO KNOW THE DIFFERENCE AND TO KNOW THE
13 GERIATRIC PHYSIOLOGY AND CHANGES.
14 Q. SO KNOWING THE DIFFERENCE IN GERIATRIC PHYSIOLOGY, IF
15 YOU SEE A MENTAL STATUS, WHAT AS A PHYSICIAN WOULD YOU DO TO
16 DETERMINE WHETHER IT'S A HEART ATTACK OR, YOU KNOW, SOME
17 OTHER CAUSE OF THAT CHANGE IN MENTAL STATUS?
18 A. ONE OF THE THINGS THAT WE TEACH THAT'S VERY IMPORTANT IS
19 THE RECOGNITION OF DELIRIUM. AND IN OLDER INDIVIDUALS,
20 SYMPTOMS OFTEN MANIFEST THEMSELVES IN BEHAVIOR AND DELIRIUM
21 BY DEFINITION IS A CHANGE IN BEHAVIOR OVER ACUTE OR A SHORT
22 PERIOD OF TIME. AND BY DEFINITION, IT'S USUALLY TO AN
23 UNDERLYING MEDICAL CONDITION. AND THE FIRST THING THAT WE
24 TEACH OUR HOUSE STAFF TO DO WITH ANY KIND OF ADMISSION TO THE
25 HOSPITAL OR IN THE OUTPATIENT CLINIC IS IF THEY DEFECT THAT
1 THERE'S BEEN A CHANGE IN BEHAVIOR TO DO WHAT WE CALL A
2 DELIRIUM EVALUATION WHICH NOT ONLY CONSISTS OF A HISTORY TO
3 FIND OUT IS THIS REALLY A CHANGE RECENTLY, BUT ALSO TO DO A
4 PHYSICAL EXAM, AND ALSO THERE'S A LIST OF LABORATORY
5 EVALUATIONS THAT WE RECOMMEND BECAUSE OF THE DIFFERENT
6 PRESENTATION, ONE SYMPTOM CAN ACTUALLY BE CAUSED BY VERY -- A
7 VARIETY OF DIFFERENT CAUSES AND SO WE HAVE LIST OF SIMPLE
8 ROUTINE EVALUATIONS THAT WE RECOMMEND THAT PEOPLE DO TO BE
9 ABLE TO IDENTIFY WHAT MAY BE CAUSING THAT CHANGE IN MENTAL
10 STATUS OR DELIRIUM. AND INTERESTINGLY ENOUGH IN OLDER
11 INDIVIDUALS, THE DELIRIUM ONLY ABOUT 40 PERCENT OF THE TIME
12 IS CAUSED BY A SINGLE SOLITARY ILLNESS. IT'S USUALLY
13 MULTIPLE THINGS THAT ARE GOING ON. IN 60 PERCENT OF TIME,
14 YOU MAY NOT FIND A SINGLE CAUSE BUT MULTIPLE THINGS THAT
15 CONTRIBUTE.
16 Q. CAN YOU BRIEFLY EXPLAIN THE DIAGNOSIS OBSERVATION
17 EVALUATION INTERVENTION AND DOCUMENTATION OF DEMENTIA?
18 A. DEMENTIA, THERE ARE SEVERAL DIFFERENT KINDS OF DEMENTIA.
19 SO I'LL START WITH WHAT KINDS OF DEMENTIA THERE MAY BE. THE
20 MOST COMMON KIND OF DEMENTIA WHICH IS ABOUT 60 PERCENT OF
21 DEMENTIAS ROUGHLY DEPENDING UPON WHICH LITERATURE YOU READ IS
22 AN ALZHEIMER'S DEMENTIA. OTHER 15 TO 20 PERCENT IS A
23 VASCULAR OR MULTI INFARCT DEMENTIA. AND THEN THE NEXT MOST
24 COMMON TYPE IS A MIXED DEMENTIA, WHICH IS ANOTHER 15 TO 20
25 PERCENT WHICH IS A COMBINATION OF VASCULAR PLUS ALZHEIMER'S
1 DEMENTIA. SO BASICALLY ABOUT 90 TO 95 PERCENT OF ALL THE
2 DEMENTIAS THAT PEOPLE SEE IN CLINICAL PRACTICE ARE AN
3 ALZHEIMER'S DEMENTIA, MIXED DEMENTIA, OR A VASCULAR DEMENTIA.
4 THE MAIN HISTORY IN BEING ABLE TO IDENTIFY A DEMENTIA, BY
5 DEFINITION, A DEMENTIA IS COGNITIVE DEFICITS IN TWO SEPARATE
6 AREAS. COGNITION IS BASICALLY EVERYTHING THAT WE DO TO
7 INTERACT WITH THE INTERNAL WORLD AND EXTERNAL WORLD. SO FOR
8 INSTANCE, COGNITIVE FUNCTION HAS TO DO WITH MEMORY. IT HAS
9 TO DO WITH BEING ORIENTED. KNOWING WHERE YOU ARE. IT ALSO
10 HAS TO DO WITH BEING ABLE TO ADD AND SUBTRACT. BEING ABLE TO
11 ADD -- TAKE CARE OF YOUR CHECKBOOK. TO MANAGE MEDICATIONS.
12 THERE ARE A COUPLE OF VERY COMPLEX COGNITIVE FUNCTIONS THAT
13 ARE OFTENTIMES OVERLOOKED AND THAT IS JUDGMENT AND INSIGHT.
14 OFTENTIMES THOSE ARE COGNITIVE FUNCTIONS THAT DO CHANGE WITH
15 DEMENTIA EARLY AND CAUSE PROBLEMS. OTHER ONES ARE
16 PERSONALITY CHANGES AND BEHAVIOR CHANGES. YOU HAVE TO HAVE
17 TWO COGNITIVE DEFICITS. AND THEN OVER TIME THEY HAVE TO
18 DECLINE. IF THEY STAY THE SAME, THAT'S A FIXED COGNITIVE
19 DEMENTIA AND THAT'S NOT A DEMENTIA. DEMENTIA MUST DECLINE
20 OVER TIME. TYPICAL ALZHEIMER'S DEMENTIA OCCURS PRIOR TO
21 DIAGNOSIS AT LEAST FOUR TO FIVE YEARS AND SOMETIMES BY
22 DIAGNOSIS, IT'S BEEN GOING ON FOR QUITE A WHILE BEFORE.
23 AFTER DIAGNOSIS, THE TYPICAL SEVERITY OR THE STAGE OF
24 SEVERITY BY THE TIME OF DIAGNOSIS IS USUALLY THE NEIGHBORS
25 HAVE DIAGNOSED IT, AND THEN THE FAMILY BRINGS THE PATIENT IN
1 OR THE FAMILY MEMBERS SAYING SOMETHING'S WRONG. AT THAT
2 POINT IT'S USUALLY MODERATE SEVERE TO SEVERE STAGES OF
3 DEMENTIA. FROM THAT TIME UNTIL DEATH, IF IT'S AN ALZHEIMER'S
4 DEMENTIA IS APPROXIMATELY TEN YEARS. SO SOMEWHERE BETWEEN 15
5 AND 20 YEARS IS THE NATURAL TIME COURSE OF DEMENTIA. THAT'S
6 IMPORTANT TO KNOW BECAUSE AS YOU EVALUATE SOMEONE WITH
7 DEMENTIA, YOU HAVE EVALUATE THE HISTORY NOT ONLY OF THAT
8 PERSON, BUT IT'S IMPORTANT TO GET INFORMATION FROM FAMILY
9 MEMBERS. THEN IN ADDITION TO THAT, AN EVALUATION IS VERY
10 IMPORTANT TO DO A PHYSICAL EXAM AND THEN A ROUTINE BATTERY OF
11 LABORATORY AND RADIOLOGIC EXAMINATIONS ARE USUALLY UNDERTAKEN
12 TO DETERMINE IF THERE ARE OTHER REASONS THAT MAY BE CAUSING
13 THE DEMENTIA OR THIS CHANGE IN COGNITION TO BE WORSE. ALONG
14 WITH THAT, A CLOSE LOOK AT ALL THE MEDICATIONS PEOPLE ARE
15 VERY IMPORTANT AS WELL BECAUSE MEDICATIONS, EVEN ONES THAT
16 YOU MAY NOT THINK CAUSE PROBLEMS WITH FUNCTIONING MENTALLY
17 CAN OFTEN CAUSE THAT ROUTINE MEDICAL -- MEDICATIONS SUCH AS
18 BETA BLOCKERS OR SLEEPING AGENTS CAN CAUSE PROBLEMS AND SO WE
19 EVALUATE THOSE MEDICATIONS AS WELL.
20 Q. IS THERE ANY NECESSITY OF HANDS-ON EVALUATION BY A
21 PHYSICIAN?
22 A. I THINK THAT'S ONE CRITICAL PIECE OF INFORMATION THAT
23 PHYSICIANS NEED TO HAVE. IT'S VERY IMPORTANT TO GET
24 INFORMATION FROM OTHER PROFESSIONALS, SOCIAL WORKERS,
25 DIETICIANS, NURSING STAFF, ADVANCED PRACTICE NURSES. AS A
1 GERIATRICIAN, WE TRY TO GET INFORMATION FROM A LOT OF
2 DIFFERENT SOURCES AND THEN ALSO BECAUSE MEDICAL TRAINING IS
3 DIFFERENT THAN EVERY OTHER DISCIPLINE, WE HAVE TO PERFORM OUR
4 OWN EVALUATION. IT'S IMPORTANT THAT WE SYNTHESIZE THE
5 INFORMATON BUT TO RELY ON OTHER DISCIPLINES SOLELY USUALLY
6 LEADS TO INCOMPLETE INFORMATION AND WHEN YOU HAVE INCOMPLETE
7 INFORMATION, IT LEAVES YOU MORE SUSCEPTIBLE TO MAKING ERRORS
8 IN JUDGMENT.
9 Q. AS A PHYSICIAN, DO YOU SPEND 24 HOURS A DAY WITH ANY
10 PARTICULAR PATIENT?
11 A. ABSOLUTELY NOT. THAT'S WHY IT'S IMPORTANT TO SYNTHESIZE
12 THIS OTHER INFORMATION AND THEN USE YOUR OWN HANDS-ON
13 EVALUATION TO FORM A COMPLETE IDEA OF REALLY WHAT'S GOING ON.
14 IN FACT, IN GERIATRICS IT'S EXTRAORDINARILY IMPORTANT TO
15 LISTEN TO THE NURSING STAFF AND IT'S IMPORTANT TO HAVE
16 NURSING STAFF THAT YOU CAN RELY ON THAT CAN GIVE YOU
17 INFORMATION THAT'S IMPORTANT TO YOU.
18 Q. ARE YOU FAMILIAR WITH THE THE TERM GERIATRIC
19 PHARMACOLOGY?
20 A. YES.
21 Q. WHAT IS THAT?
22 A. GERIATRIC PHARMACOLOGY IS THE STUDY OF DRUGS OR
23 MEDICATIONS AND HOW THEY INTERACT WITH OLDER INDIVIDUALS.
24 Q. WHAT ARE SOME OF THE -- HAVE TO REPHRASE THAT BECAUSE
25 THE WORD I'M WANTING IS LEAVING ME. WHAT ARE SOME OF THE
1 PRINCIPLES OF GERIATRIC PHARMACOLOGY?
2 A. WELL, THERE'S -- ACTUALLY THIS IS -- THIS IS WHAT I
3 TEACH THE SECOND YEAR MEDICAL STUDENTS IN THEIR CLASSES. WE
4 CAN GET VERY TECHNICAL. I'M NOT SURE WHERE YOU WANT ME TO
5 GO.
6 Q. DON'T GET TOO TECHNICAL HERE.
7 A. BASICALLY, THE STUDY PHARMACOLOGY CAN BE DIVIDED EASILY
8 INTO TWO GROUPS. ONE IS WHAT THE MEDICATION DOES TO YOUR
9 BODY THAT HAS TO DO WITH RECEPTORS AND THEN ALSO WHAT YOUR
10 BODY DOES TO THE DRUG AFTERWARDS. IT'S CALLED
11 PHARMACODYNAMICS AND PHARMACOKINETICS.
12 Q. ARE THERE DIFFERENT STARTING DOSES FOR DIFFERENT DRUGS?
13 A. THERE ARE. BECAUSE OF THE CHANGES IN PHARMACOKINETICS
14 AND PHARMACODYNAMICS IN OLDER INDIVIDUALS, THE RECEPTOR
15 SENSITIVITY FOR SOME MEDICATIONS MAY INCREASE. RECEPTOR
16 SENSITIVY MAY DECREASE FOR OTHER MEDICATION. SO IT IMPORTANT
17 TO KNOW THE SPECIFIC MEDICATION. AN EXAMPLE WOULD BE BETA
18 BLOCKERS. THE RECEPTORS ACTUALLY AS WE GET OLDER DECREASE IN
19 SENSITIVITY. AND SO TO GET -- AND BETA BLOCKERS ARE USED TO
20 BLOCK HEART RATE. YOU MAY ACTUALLY NEED HIGHER DOSES OF A
21 BETA BLOCKER TO ACHIEVE THE SAME HEART RATE IN AN 80-YEAR-OLD
22 THAT YOU WOULD NEED IN A 40-YEAR-OLD. ON THE OTHER HAND,
23 RECEPTOR SENSITIVITY FOR OPIOIDS INCREASES AS WE GET OLDER SO
24 TO OBTAIN THE SAME ANALGESIC EFFECT YOU MAY ACTUALLY NEED
25 SMALLER DOSES OF OPIOIDS TO OBTAIN THE SAME EFFECT. AND THIS
1 IS WELL DOCUMENTED IN PHARMACOLOGY.
2 Q. IS THERE ANY -- ONLY ONE SINGLE DOSE FOR ALL
3 INDIVIDUALS?
4 A. NO. IN FACT, ONE OF THE THINGS THAT'S VERY IMPORTANT IS
5 TO INDIVIDUALIZE THE DOSES. THERE'S AN AXIOM IN GERIATRIC
6 PHARMACOLOGY THAT GENERALLY IS START LOW AND GO SLOW TO AVOID
7 PROBLEMS. NOW, OBVIOUSLY THAT'S A GENERALATION, BUT I THINK
8 IT EMPHASIZES THAT YOU HAVE TO INDIVIDUALIZE TO EACH PATIENT.
9 THE MORE FRAGILE THE PATIENT, I THINK THE MORE DIFFICULT THE
10 CLINICAL DECISIONS ARE BECAUSE AS SOMEONE GETS OLDER AND MORE
11 FRAGILE, THEIR ABILITY TO DEAL WITH DRUGS DIMINISHES. FOR
12 INSTANCE BODY SIZE DECREASES. AND THE BODY FAT DECREASES.
13 THAT HAS AN IMPACT ON MEDICATIONS AND HOW THEY'RE ABSORBED.
14 AND ALSO YOUR ABILITY GET RID OF MEDICATIONS DIMINISHES
15 BECAUSE THE FUNCTIONS OF THE KIDNEY ACTUALLY DIMINISH. AND
16 SOME OF THE LABORATORIES THAT WE ACTUALLY USE TO MEASURE
17 KIDNEY FUNCTION SUCH AS CREATININE MAY NOT CHANGE AS WE GET
18 OLDER BECAUSE OF SOME COMPLEX CHANGES THAT OCCUR IN THE BODY,
19 BUT IT DOESN'T -- AND THAT'S USUALLY WHAT WE USE TO REFLECT
20 KIDNEY FUNCTION. HOWEVER, WE HAVE TO GO THROUGH MORE COMPLEX
21 COMPUTATIONS TO ESTIMATE WHAT A CREATININE CLEARANCE IS. AND
22 A CREATININE CLEARANCE IS MUCH MORE ACCURATE OF WHAT HAPPENS
23 WITH THE BODY'S ABILITY TO GET RID OF MEDICATIONS AS YOU AGE.
24 THERE ARE ALSO CHANGES WITHIN THE LIVER. BASICALLY, THE TWO
25 MAIN WAYS YOU GET RID OF MEDICATIONS ARE THE LIVER AND THE
1 KIDNEY. AND THERE ARE CHANGES THAT OCCUR IN BOTH OF THOSE
2 THAT NEED TO BE COMPENSATED FOR WITH AGE AND ALSO BODY WEIGHT
3 AND ALSO GENDER. MALES AND FEMALES ARE NOT THE SAME. SO YOU
4 HAVE TO MAKE COMPUTATIONAL CHANGES TO ADJUST MEDICATION DOSES
5 TO MAKE IT APPROPRIATE.
6 Q. WHAT ABOUT THE CONCEPT OF MULTIPLE MEDICATIONS, HOW DOES
7 THAT FACTOR INTO GERIATRIC PHARMACOLOGY?
8 A. MULTIPLE MEDICATIONS ARE A PROBLEM. AS I MENTIONED
9 EARLIER, OFTENTIMES OLDER INDIVIDUALS HAVE MULTIPLE MEDICAL
10 AND PSYCHIATRIC PROBLEMS WHICH LEADS OFTENTIMES TO LOTS OF
11 DIFFERENT MEDICATIONS. POLYPHARMACY IS A HUGE PROBLEM. IT'S
12 ONE THAT WE'RE ACTUALLY STUDYING NOW. THE AVERAGE PATIENT AT
13 THE V.A. HAS AROUND EIGHT MEDICATIONS. THE AVERAGE PATIENT
14 ACROSS THE UNITED STATES HAS AROUND EIGHT MEDICATIONS AFTER
15 THE AGE OF 80 -- OR EXCUSE ME 65. ONE OF THE PROBLEMS WITH
16 POLYPHARMACY IS THAT ANY DRUG TEXT OR MOST OF THE STUDIES
17 LOOK AT WHAT HAPPENS WHEN YOU HAVE ONE MEDICATION INTERACTING
18 WITH ANOTHER MEDICATION, AND THEY CALL THOSE DRUG/DRUG
19 INTERACTIONS. THE COMPLEXITY BECOMES GREATER -- SOMETIMES WE
20 KNOW WHAT HAPPENS WHEN YOU HAVE TWO MEDICATIONS AND ANOTHER,
21 MEDICATION, BUT VERY SELDOM DO WE HAVE ANY INFORMATION OTHER
22 THAN JUST ANECDOTAL ABOUT WHAT HAPPENS WHEN YOU HAVE FOUR OR
23 MORE MEDICATIONS ACTING TOGETHER. IT'S VERY DIFFICULT TO
24 PREDICT WHAT WILL HAPPEN WITH THAT. AND SO THAT'S ANOTHER
25 REASON AS WE TALK ABOUT GERIATRIC PHARMACOLOGY IS WHEN WE
1 TALK ABOUT GO LOW -- OR START LOW AND GO SLOW, YOU'RE USUALLY
2 ADDING ANOTHER MEDICATION TO FOUR OR FIVE OTHER MEDICATIONS
3 AND IT'S VERY DIFFICULT TO PREDICT. AND SO SIDE EFFECTS ARE
4 SOMETHING THAT WE HAVE TO MONITOR VERY CLOSELY BECAUSE IT IS
5 A REAL PROBLEM THAT PLAGUES PATIENTS AND PHYSICIANS.
6 Q. ARE YOU FAMILIAR WITH WHAT ARE CALLED C.N.S.
7 MEDICATIONS?
8 A. YES.
9 Q. WHAT ARE THOSE?
10 A. C.N.S. MEDICATIONS ARE CENTRAL NERVOUS SYSTEM
11 MEDICATIONS OR MEDICATIONS THAT AFFECT THE BRAIN, BASICALLY,
12 AND HAVE IMPACT ON -- ON BEHAVIOR OR PROCESSES OF THINKING OR
13 LEVELS OF ALERTNESS.
14 Q. DO THEY HAVE ANY DIFFERENT EFFECT IN THE GERIATRIC
15 POPULATION?
16 A. AGAIN, BASED ON THE PHARMACODYNAMIC AND PHARMACOKINETEC
17 OR WHAT THE RECEPTORS AND WHAT YOU DO WITH THE MEDICATION CAN
18 HAVE DIFFERENT EFFECTS IN OLDER INDIVIDUALS. I CAN HAVE AN
19 ENHANCED TOXICITY IN C.N.S. ACTIVE AGENTS THAT CAN CAUSE
20 SEDATION. PARADOXICALLY ALSO IN CERTAIN MEDICAL CONDITIONS
21 SUCH AS DEMENTIA, AGENTS THAT YOU THINK MAY DO ONE THING WITH
22 THE BRAIN MAY DO SOMETHING VERY OPPOSITE. FOR INSTANCE,
23 BENZODIAZEPINES ARE ANOTHER WAY WE TALK ABOUT C.N.S. AGENTS
24 OR PSYCHOACTIVE OR -- PSYCHOACTIVE MEDICATIONS.
25 BENZODIAZEPINES SUCH AS VALIUM OR ATIVAN ARE MEDICATIONS THAT
1 ARE TRANQUILIZERS AND USUALLY HELP PEOPLE RELAX, OFTENTIMES
2 FALL ASLEEP AND OFTENTIMES IN GERIATRICS, IN DEMENTIA, YOU
3 FIND A PARADOXIC EFFECT WHERE PATIENTS WILL ACTUALLY BE MORE
4 AGITATED WITH A BENZODIAZEPINE RATHER THAN THE TYPICAL
5 RESPONSE.
6 Q. SO IF YOU'RE MONITORING SOMEONE WHO'S RECEIVED A
7 BENZO -- WELL, LET'S SAY ATIVAN BECAUSE I CAN SAY THAT MORE
8 EASILY, OR VALIUM. IF YOU'RE MONITORING THAT PERSON AND
9 THEIR AGITATION INCREASES RATHER THAN DECREASES, WHAT AS A
10 PHYSICIAN WOULD YOU DO IN A GERIATRIC PATIENT?
11 A. WELL, WHAT I TYPICALLY DO, AND I THINK IT'S APPROPRIATE
12 IF SOMEONE HAS ANXIOUS SYMPTOMS, TO USE AGENTS THAT ADDRESS
13 ANXIETY. BUT AT SMALL DOSES, IF PEOPLE DON'T RESPOND IF THEY
14 HAVE SIGNIFICANT BRAIN IMPAIRMENT, I QUESTION THE UTILITY OF
15 THOSE MEDICATIONS IN THOSE PATIENTS AND I MAY GO TO A
16 DIFFERENT AGENT. SO USUALLY YOU WOULD DECREASE THAT
17 MEDICATION OR STOP IT ALTOGETHER TO SEE IF ACTUALLY THE
18 MEDICATION WERE CAUSING THE SYMPTOMS THAT YOU'RE TRYING TO
19 TREAT MORE AGGRESSIVELY. SO IT BECOMES VERY COMPLEX.
20 Q. WOULD YOU JUST -- WOULD EVER JUST ADD A SECOND
21 MEDICATION?
22 A. IT SOMETIMES IS DONE, BUT ONE OF THE THINGS WITH
23 GERIATRICS IS WE TRY TO TEACH TO BE VERY CAREFUL IN DOING
24 THAT. AND OFTEN IT DOES REQUIRE A FAIR AMOUNT OF JUDGMENT
25 AND EXPERTISE AND THERE IS WHERE THE EVALUATION BECOMES VERY
1 IMPORTANT, THE HANDS-ON EVALUATION AND THE SYNTHESIS OF OTHER
2 INFORMATION BECAUSE IT DOES REQUIRE A GLOBAL PERSPECTIVE ON
3 WHAT ARE YOU GOING TO DO WITH THESE MEDICATION. IT'S NOT A
4 TRIVIAL MATTER TO EITHER START OR STOP A MEDICATION IN
5 SOMEONE WHO IS ILL. AND SO YOU WANNA HAVE THE BEST
6 INFORMATION THAT YOU CAN, AND YOU TRY TO TIE THAT IN TO NOT
7 ONLY THEIR SYMPTOMS BUT ALSO THEIR PHYSICAL EXAM AND WITH
8 ELSE IS GOING ON THROUGHOUT THE DAY.
9 Q. ARE YOU FAMILIAR WITH THE TERM HOSPICE?
10 A. YES.
11 Q. WHAT IS THAT?
12 A. HOSPICE IS ACTUALLY SOMETHING THAT IS A WONDERFUL THING.
13 IN MEDICINE OFTENTIMES PHYSICIANS HAVE BEEN TAUGHT THAT THE
14 ULTIMATE ENEMY IS DEATH AND WE'RE TO FIGHT IT AT ALL COSTS.
15 AND WE -- I THINK WE'VE RECOGNIZED IN -- ESPECIALLY IN
16 GERIATRICS THAT ACTUALLY DEATH IS NOT SOMETHING TO BE FOUGHT
17 AT ALL COSTS. THAT HOSPICE IS THE NOTION AND ALSO THE
18 PRACTICE OF PROVIDING CARE FOR INDIVIDUALS WHERE WE REALLY
19 DON'T HAVE ANYTHING ELSE TO OFFER THEM IN TERMS OF OUR
20 CURRENT MEDICAL SCIENCE. SO WE RECOGNIZE THAT THERE ARE
21 THINGS THAT ARE GOING ON THAT WE'RE NOT GOING TO BE ABLE TO
22 TREAT OR REVERSE AND BASED ON THAT, A DECISION IS MADE TO
23 IMPLEMENT WHAT WE CALL COMFORT CARE OR HOSPICE, WHICH DOES
24 ENTAIL COMFORT MEASURES. SO USUALLY THERE IS A TURNING AWAY
25 FROM THINGS THAT ARE AIMED AT AGGRESSIVELY DIAGNOSING AND
1 TREATING THINGS SUCH AS CANCER AND INSTITUTING THINGS INSTEAD
2 THAT PROMOTE QUALITY OF LIFE, DIGNITY, AND COMFORT.
3 Q. IS PART OF THAT COMFORT CARE ADMINISTERING SEDATIVES
4 SOMETIMES?
5 A. ABSOLUTELY. AND THERE'S LOTS OF DIFFERENT TYPES OF
6 SEDATIVES AND MEDICATIONS THAT CAN BE USED FOR THIS. IN
7 FACT, IN A HOSPICE SETTING, SOMEONE MAY ACTUALLY WANT TO
8 PROVIDE AS MUCH COMFORT AS POSSIBLE, AND EVEN WHEN WE TALK
9 ABOUT DELIRIUM, I USUALLY TALK ABOUT REVERSING DELIRIUM, BUT
10 IN A HOSPICE SETTING YOU ACTUALLY MAY WANNA PROMOTE A
11 DELIRIUM AND HAVE SOMEONE FEEL MUCH MORE COMFORTABLE.
12 USUALLY, WE WANNA -- IN THE DELIRIUM, THERE'S TWO KINDS OF
13 DELIRIUM. THERE'S AN AGITATED DELIRIUM WHICH IS NOT
14 COMFORTABLE, AND THEN THRE'S ALSO A HYPOACTIVE DELIRIUM OR A
15 DEL -- SOMEONE THAT LOOKS MORE LIKE THEY'RE SLEEPING. AND
16 THAT'S MORE OF WHAT WE WOULD LIKE TO HAVE IN SOMEONE IN A
17 HOSPICE SITUATION. BUT QUITE FRANKLY, THE MAIN GOAL IS TO
18 KEEP SOMEONE AS FUNCTIONAL AND COMFORTABLE AT THE SAME TIME
19 SO THAT OBVIOUSLY THEY WOULD BE ABLE TO INTERACT AS MUCH AS
20 POSSIBLE WITH THEIR LOVED ONES. FOR INSTANCE, IN SOMEONE
21 DYING OF CANCER, IT WOULD BE OPTIMAL TO HAVE THEM NOT HAVE
22 ANY PAIN AS WELL AS BE ABLE TO TALK WITH A LOVED ONE AND
23 FAMILY MEMBERS. SO THAT WOULD BE WHAT YOU'D SHOOT FOR.
24 OFTENTIMES THAT'S VERY DIFFICULT HOWEVER BECAUSE SEDATION
25 WITH OFTEN THE AGENTS THAT YOU USE CAUSE SEDATION AND
1 SLEEPING BUT AT THAT POINT IN HOSPICE, THE COMFORT, IT MAY BE
2 BETTER FOR SOMEONE TO BE ASLEEP RATHER THAN TO BE AWAKE AND
3 IN SO MUCH PAIN.
4 Q. BUT IF SOMEONE CAN BE AWAKE BUT NOT BE IN PAIN, IS YOUR
5 GOAL TO SEDATE THEM TO THE POINT OF NOT BEING AWAKE?
6 A. NO. THE OPTIMAL I THINK COURSE WOULD BE TO HAVE SOMEONE
7 AWAKE. BUT QUITE FRANKLY, BECAUSE OF THE COMPLEXITY IN
8 GERIATRICS, IT'S OFTENTIMES NOT OBTAINABLE, BUT THAT USUALLY
9 IS THE GOAL IS TO HAVE SOMEONE AS ALERT AS POSSIBLE BUT NOT
10 IN -- UNCOMFORTABLE.
11 Q. ARE YOU FAMILIAR WITH GEROPSYCHIATRIC UNITS?
12 A. YES.
13 Q. DO YOU WORK WITH ANY?
14 A. IN FACT, I'VE HELPED ESTABLISH AND CONSULT FOR SEVERAL
15 GEROPSYCHIATRIC UNITS. I THINK THE GEROPSYCHIATRIC
16 POPULATION ARE UNDERSERVED IN UTAH AND I'VE TRIED TO
17 FACILITATE GEROPSYCH UNITS AND THE ESTABLISHMENT ALONG THE
18 WASATCH FRONT OF SEVERAL OF THEM.
19 Q. GEROPSYCH UNITS, ARE THESE -- ARE THE PATIENTS ON
20 GEROPSYCH UNITS -- WELL, WHAT ABOUT THEIR MEDICAL STABILITY?
21 A. USUALLY AS I CONSULT WITH THE GEROPSYCH UNITS, ONE OF
22 THE FIRST THINGS THAT WE TALK ABOUT FOR ALL ADMISSIONS IS TO
23 DO A DELIRIUM EVALUATION. IN ABOUT 90 PERCENT OF THE
24 INDIVIDUALS, SOMEWHERE BETWEEN 80 AND 90 PERCENT OF ALL THE
25 INDIVIDUALS IN THE UNITS THAT I'VE BEEN TO, WHAT PROMPTS THE
1 ADMISSION TO A GEROPSYCH UNIT IS TYPICALLY A CHANGE IN
2 BEHAVIOR THAT EITHER AT HOME OR THE NURSING HOME, THEY'RE NOT
3 ABLE TO TAKE CARE OF THIS PERSON ANY LONGER. BY DEFINITION,
4 THAT IS A DELIRIUM. AND SO IT'S VERY IMPORTANT IN THE UNITS
5 THAT I'VE DEALT WITH TO HAVE A STANDARDIZED PROCEDURE THAT
6 WITHIN THE -- UPON ADMISSION, A TOTAL DELIRIUM EVALUATION IS
7 COMPLETED TO BE ABLE TO AGAIN SEPARATE THE MEDICAL AND THE
8 PSYCHIATRIC ISSUES. IT'S VERY COMMON FOR THESE INDIVIDUALS
9 TO HAVE SOMETHING LIKE A URINARY TRACT INFECTION OR A
10 PNEUMONIA THAT'S BEEN UNDETECTED, BUT BECAUSE THEIR BEHAVIOR
11 CHANGED AND THEY ACTED DIFFERENTLY, IT'S ASSUMED THAT THEY
12 HAVE A PRIMARY PSYCHIATRIC DISORDER, AND OFTENTIMES THE
13 MEDICAL DISORDER WHICH MAY CONTRIBUTE TO MAKING THAT
14 PSYCHIATRIC DISORDER WORSE IS IGNORED.
15 Q. A URINARY TRACT INFECTION OR PNEUMONIA AT THAT POINT,
16 WOULD YOU AS A PHYS -- IN A DEMENTED PERSON, WOULD YOU AS A
17 PHYSICIAN TREAT IT?
18 A. WELL, ACTUALLY I THINK IT'S VERY IMPORTANT TO TREAT
19 THOSE SIMPLE THINGS. AND THE THINGS THAT WE TRY TO -- TO
20 INSTRUCT AND DEMONSTRATE TO THE PEOPLE THAT WE'RE TRAINING IN
21 GERIATRICS IS THAT ESPECIALLY IN A DEMENTED INDIVIDUAL,
22 THEY'RE MORE SUSCEPTIBLE TO A DELIRIUM THAN PROBABLY ANY
23 OTHER POPULATION BECAUSE OF THEIR DECREASED MANTAL STATUS
24 ALREADY. AND SO THE DELIRIUM WHICH IS BY DEFINITION MEDICAL
25 ILLNESS CAUSES THOSE BEHAVIORAL CHANGES. THERE ARE COUPLE OF
1 VERY SIMPLE THINGS TO DO, LOOK FOR URINARY RETENTION, WHICH
2 IS --
3 Q. WHAT DOES THAT MEAN?
4 A. WHICH MEANS THAT YOU'RE NOT ABLE TO EMPTY YOUR BLADDER.
5 Q. IS THAT UNCOMFORTABLE?
6 A. YEAH. WE COULD DO AN EXPERIMENT. EVERYBODY DRINK A LOT
7 OF WATER TODAY AND THEN NOT URINATE UNTIL TOMORROW MORNING.
8 AND I THINK BY THE END OF THE DAY, YOU'D FEEL PRETTY
9 UNCOMFORTABLE NOT BE ABLE TO THINK VERY WELL. AND IT MAY
10 CHANGE YOUR BEHAVIOR QUITE -- YOU MAY DANCE, YOU MAY DO OTHER
11 THINGS THAT YOU DON'T NORMALLY DO. SO IT DOES CHANGE
12 BEHAVIOR. AND IN ELDERLY PATIENTS, OFTENTIMES THEY'RE GIVEN
13 MEDICATIONS THAT CAUSE URINARY RETENSION, NOT ABLE TO EMPTY
14 THE BLADDER. THOSE SAME MEDICATIONS CAN ALSO CAUSE
15 CONSTIPATION. AND YOU CAN HAVE SYMPTOMS SUCH AS WHITE COUNT
16 AND EVEN FEVER JUST FROM THAT NOT BEING ABLE TO HAVE A BOWEL
17 MOVEMENT. AND SO WE TELL OUR RESIDENTS AND ALSO THE
18 GEROPSYCH UNITS TO LOOK FOR THESE VERY SIMPLE THINGS. AND
19 QUITE FRANKLY, YOUD LOOK FOR THESE IN ANY PATIENT AS PART OF
20 THE DELIRIUM EVALUATION. THE OTHER THING THAT'S IMPORTANT I
21 THINK IS TO LOOK FOR PAIN. BECAUSE PAIN IS USUALLY
22 UNDERDIAGNOSED AND UNDERTREATED SO IF SOMEONE HAS SOME REASON
23 TO BE IN PAIN, WHETHER IT'S FROM THEIR ARTHRITIS THAT HASN'T
24 BEEN TREATED OR FROM A FALL, THEY -- WE'VE HAD SEVERAL
25 PATIENTS WHO HAVE HAD HIP FRACTURES THAT HAVE BEEN
1 UNDIAGNOSED, AND SO WE WANNA DIAGNOSE THAT AND THEN TREAT
2 THAT PAIN APPROPRIATELY.
3 Q. IF A PERSON IS IN THE GEROPSYCH UNIT AND A MEDICAL
4 EMERGENCY ARISES, WHAT OPTIONS ARE THERE -- SAY THE GEROPSYCH
5 UNIT IS WITHIN A HOSPITAL. WHAT OPTIONS ARE THERE FOR THAT
6 PATIENT?
7 A. THERE'S LOTS OF DIFFERENT OPTIONS DEPENDING UPON THE
8 PHYSICIAN OR THE PSYCHIATRIST. THE PSYCHIATRIST IS USUALLY
9 THE ONE RUNNING THE UNIT. IT'S IMPORTANT IN GEROPSYCHIATRIC
10 UNITS I THINK TO HAVE A CLOSE LIAISON WITH MEDICINE. MY OWN
11 TRAINING IS IN GERIATRIC MEDICINE AND GERIATRIC PSYCHIATRY
12 BECAUSE I THINK THE NECESSITY OF THESE PATIENTS, THEY PRESENT
13 WITH BOTH THINGS SIMULTANEOUSLY. AND SO I THINK THAT MY
14 TRAINING IS VERY UNUSUAL. THERE'S ACTUALLY -- I'M ONLY AWARE
15 OF ONE OTHER PERSON IN THE COUNTRY THAT HAS SIMILAR TRAINING
16 TO MINE, SO WE'RE NOT GONNA FIND THAT IN HOSPITALS, SO I
17 THINK THE ASSOCIATION BETWEEN MEDICINE AND PSYCHIATRY,
18 ESPECIALLY IN GERIATRIC UNITS IS VERY IMPORTANT. BASED ON
19 THOSE AFFILIATIONS THERE'S LOTS OF DIFFERENT THINGS THE
20 PHYSICIAN CAN DO. THE PHYSICIAN CAN CALL FOR A CONSULT FROM
21 INTERNAL MEDICINE OR FAMILY PRACTICE. OR SOMETIMES EMERGENCY
22 ROOMS ARE USED WHERE THE EMERGENCY ROOM WILL EVALUATE THE
23 PATIENT OR TRANSFER CAN OCCUR OR THE PSYCHIATRIST, IF THE
24 PSYCHIATRIST FEELS IT'S WITHIN THEIR DOMAIN, THEY COULD
25 ACTUALLY INITIATE AN EVALUATION AND PERFORM AND DO THINGS
1 THAT AN INTERNIST WOULD DO. YOU'RE NOT RESTRICTED FROM DOING
2 AN EVALUATION BEING A PSYCHIATRIST.
3 Q. JUST SO I'M CLEAR, IF A PERSON -- IF A MEDICAL EMERGENCY
4 ARISES ON A GEROPSYCH UNIT, THE ONLY OTHER OPTION IS NOT
5 I.C.U. AND TUBES AND ALL OF THAT SORT OF THING?
6 A. NO. IN FACT, ONE OF THE THINGS THAT'S -- THAT'S IN
7 GERIATRICS THAT WE TRY TO EMPHASIZE IN OUR PATIENTS ARE
8 THINGS LIKE ADVANCE DIRECTIVES AND DO NOT RESUSCITATE ORDERS.
9 THOSE ARE BASICALLY WHERE A PATIENT WHEN THEY HAVE THE
10 WHEREWITHAL TO MAKE DECISIONS AND THAT MEANS THAT THEY'RE
11 ABLE TO UNDERSTAND BASICALLY FOUR THINGS: THEIR MEDICAL
12 ILLNESSES, THE TREATMENT FOR THOSE ILLNESSES, THE
13 RISK/BENEFIT FOR THOSE TREATMENTS, AND ABLE TO VERBALIZE OR
14 COMMUNICATE A DECISION MEANS THEY HAVE DECISION-MAKING
15 CAPACITY. AND IF THEY HAVE DECISION-MAKING CAPACITY, THEY
16 CAN APPOINT SOMEONE THAT IF THEY LOSE THAT ABILITY TO MAKE
17 DECISIONS, THAT CAN MAKE DECISIONS FOR THEM. SO AN ADVANCE
18 DIRECTIVES MIGHT STATE, IF I'M NOT ABLE TO MAKE DECISIONS FOR
19 MYSELF, I WOULD LIKE MY WIFE TO MAKE THOSE DECISIONS AND I
20 DON'T WANNA HAVE MY HEART POUNDED UPON, I DON'T WANNA BE
21 RESUSCITATED, I DON'T WANNA BE FED ARTIFICALLY, AND I DON'T
22 WANT ANTIBIOTICS. AND YOU COULD YOU ESTABLISH THAT AHEAD OF
23 TIME. IF YOU HAVE ADVANCE DIRECTIVES, IT'S -- I THINK IT'S
24 IMPORTANT TO RESPECT THOSE ADVANCED DIRECTIVES AND NOT
25 INITIATE THAT. SO FOR INSTANCE, IF SOMEONE SAID, I DON'T
1 WANNA BE INTUBATED, THERE WOULD BE VERY LITTLE REASON TO GO
2 TO AN I.C.U. UNIT. HOWEVER, DO NOT RESUSCITATE DOES NOT MEAN
3 DO NOT CARE. AND ONE OF THE THINGS THAT WE TRY TO EMPHASIZE
4 WITH OUR HOUSE STAFF IS IF SOMEONE HAS SAID I DON'T WANNA BE
5 RESUSCITATED, DOESN'T NECESSARILY MEAN THAT THEY DON'T WANT A
6 LOT OF OTHER THINGS DONE TO CARE UNLESS WE HAVE A VERY
7 SPECIFIC CONVERSATION ON WHAT THOSE THINGS CONSIST OF.
8 Q. ESTABLISHMENT OF THIS ADVANCE DIRECTIVE, WHAT'S THE
9 PHYSICIAN'S ROLE IN THAT?
10 A. USUALLY, IT DEPENDS ON THE INSTITUTION. THE -- THERE
11 ARE PEOPLE WHO MAY INITIATE THE TALK ABOUT ADVANCE DIRECTIVES
12 SUCH AS A SOCIAL WORKER OR A NURSE, BUT THEN IT REQUIRES A
13 PHYSICIAN'S SIGNATURE FOR D.N.R. ORDER, AND I THINK THE
14 COMMON PRACTICE IS THAT IF A PHYSICIAN WANT TO GET THAT
15 INFORMATION USUALLY FROM A FAMILY MEMBER OR FROM THE PATIENT
16 IF THEY'RE ABLE TO MAKE THE DECISION THEMSELVES AND THEN TO
17 CONFIRM THAT THAT IS CORRECT BECAUSE THE DECISION ULTIMATELY
18 IS THE PHYSICIAN THAT ENACTS THAT. A EXAMPLE WOULD BE IF A
19 PATIENT CAME IN AND WANTED -- DID NOT WANT TO BE RESUSCITATED
20 AND WAS D.N.R., AND IF THE PHYSICIAN HAD NOT WRITTEN THAT
21 ORDER, THE NURSES WOULD BE BOUND BY LAW TO PERFORM C.P.R. ON
22 THAT PATIENT IF THEY ARRESTED BEFORE THAT ORDER BY MOST
23 HOSPITAL POLICIES. AND SO IT'S IMPORTANT THAT THE PHYSICIAN
24 WRITE THAT ORDER AND BE AWARE OF WHAT'S GOING ON. THAT'S A
25 VERY IMPORTANT THING. USUALLY IN THE NURSING HOME, WE WILL
1 CALL ACTUALLY A FAMILY MEMBER BECAUSE PATIENTS USUALLY WITH
2 DEMENTIA IN A NURSING HOME OFTENTIMES ARE NOT ABLE TO MAKE
3 INFORMED DECISIONS SO WE HAVE TO CONFIRM THOSE KIND OF
4 ADVANCE DIRECTIVES AND DO NOT RESUSCITATE WITH A SURROGATE
5 DECISION-MAKER.
6 Q. IF THERE WERE AN ADVANCE DIRECTIVE EITHER BY THE
7 INDIVIDUAL WHILE THE INDIVIDUAL WAS STILL COMPETENT OR
8 THROUGH A FAMILY MEMBER THAT SAYS, NO I.V. FOR MEDICATION,
9 AND YOU HAD A PERSON WHO WAS IN SUCH SEVERE PAIN THAT THEY
10 NEEDED MORPHONE BASICALLY AROUND THE CLOCK, WHAT'S THE BEST
11 WAY IN THAT CIRCUMSTANCE OF GETTING THE MORPHINE INTO THE
12 SYSTEM?
13 A. WELL, WHAT -- WHAT I'VE FOUND IS THERE'S A RELATIONSHIP
14 IN THOSE INSTANCES THAT DEVELOPS BETWEEN THE PHYSICIAN AND
15 THE FAMILY. AND AS YOU TALK, I THINK THE PHYSICIAN BASED ON
16 THE OPINIONS OF THE PHYSICIAN HAS GREAT LEEWAY OF HOW THOSE
17 ADVANCE DIRECTIVES ACTUALLY LOOK. AND I THINK THAT'S A
18 RESPONSIBILITY THAT PHYSICIAN HAS TO TAKE VERY SERIOUSLY
19 BECAUSE MOST INDIVIDUALS DON'T HAVE A LOT OF DEPTH OF MEDICAL
20 KNOWLEDGE AND SO THE INFORMATION THAT'S GIVEN, I THINK IT'S
21 IMPORTANT TO TRY TO GIVE AS CLEAR OF INFORMATION AS YOU NEED
22 SO, FOR INSTANCE, I.V. MEDICATIONS, OFTENTIMES PEOPLE WOULD
23 THINK THAT THOSE ARE PAINFUL AND IT DEPENDS ON THE SITUATION.
24 FOR INSTANCE, IF SOMEONE'S THASHING ABOUT AND YOU CAN'T KEEP
25 AN I.V. IN, AND YOU MIGHT HAVE TO TIE THEM UP, THAT MAY BE A
1 CRUEL THING TO DO TO SOMEONE WHERE THEY MAY BE CALM UNLESS
2 YOU WERE TO TIE THEM UP. AND SO I.V. MEDICATION MAY NOT BE
3 APPROPRIATE, BUT THERE ARE OTHER METHODS TO DELIVER
4 MEDICATION. THE -- ESPECIALLY THE OPIOIDS CAN BE GIVEN AND
5 ABSORBED IN THE MUCOSA. SO FOR INSTANCE, YOU CAN PUT
6 MEDICATION UNDER THE TONGUE OR EVEN MEDICATIONS CAN BE PLACED
7 IN THE RECTUM AND ABSORBED IN THE RECTUM. THRE ARE OTHER
8 WAYS. THERE'S A BUTTERFLY WHICH IS A VERY SMALL NEEDLE THAT
9 CAN BE INSERTED JUST SUBCUTANEOUSLY INTO THE SKIN THAT
10 ROUTINELY IN HOSPICE WE USE BUTTERFLY NEEDLES TO DELIVER
11 OPIOIDS IN THAT CASE RATHER THAN I.V. MEDICATION IF SOMEONE
12 IS DIFFICULT TO KEEP THE I.V. IN.
13 Q. DID YOU HAVE OCCASION TO REVIEW THE MEDICAL RECORDS FOR
14 ELLEN ANDERSON, JUDITH LARSEN, MARY CRANE, LYDIA SMITH, AND
15 ENNIS ALLDREDGE?
16 A. YES.
17 Q. LET'S TALK FIRST ABOUT ELLEN ANDERSON. DO YOU RECALL
18 WHAT HER CONDITION WAS UPON ADMISSION?
19 A. ACCORDING TO THE CHART, HER CONDITION ON ADMISSION --
20 AND I'M JUST GOING TO -- FOR ACCURACY SAKE, LOOK IN THE
21 INTAKE EVALUATION WHICH MENTIONED THAT SHE WAS HAVING ANXIETY
22 ATTACKS, SHE WAS NOT ABLE TO SPEAK, SHE WAS NOT EATING, AND
23 SHE WAS REQUIRING A LOT OF SUPERVISION FROM THE FAMILY ON
24 SITE AND THAT THIS HAD OCCURRED OVER THE PREVIOUS THREE
25 WEEKS. OR BECOME MUCH WORSE OVER THE PREVIOUS THREE WEEKS.
1 Q. DID YOU REVIEW THE RECORDS TO SEE WHAT THE DEFENDANT'S
2 OBSERVATION WAS OF THIS PATIENT?
3 A. THE -- ACCORDING TO THE CHART, THERE'S A DICTATION THAT
4 WAS VERBALLY DICTATED ON 12/29/95. HOWEVER, THE -- THE TIME
5 OF THE DICTATION NOTED BY THE PERSON WHO WAS ACTUALLY TAKING
6 THE DICTATION OFF WAS ACTUALLY 12/30/95 AT ABOUT 12:20 WHICH
7 WAS ACCORDING TO THE CHARTS THAT I LOOKED AT WAS AFTER THE
8 PATIENT HAD DIED AT 12:30 AT 8:55 A.M.
9 Q. WHO IS THE PERSON THAT DICTATED THAT PSYCHIATRIC
10 EVALUATION?
11 A. THAT WAS DR. ROBERT WEITZEL, AND THERE'S A SIGNATURE
12 APPEARING ABOVE THAT.
13 Q. DID YOU SEE ANYTHING IN THE RECORDS INDICATING THAT
14 DR. WEITZEL EVER ACTUALLY SAW OR EVALUATED THIS PATIENT?
15 A. ACCORDING TO THE TIMES THAT I CAN LOCATE IN THE CHART,
16 THERE'S NO EVIDENCE THAT THERE WAS -- THAT DR. WEITZEL
17 ACTUALLY SAW THIS PATIENT WHILE THEY WERE ALIVE.
18 Q. WHAT DIAGNOSIS DID YOU SEE OUT OF THE CHARTS OF THIS
19 PATIENT, OF ELLEN ANDERSON?
20 A. THE DICTATION THAT WAS DONE AFTER DEATH INDICATED THAT
21 THE DIAGNOSIS WAS MAJOR DEPRESSION WITH PSYCHOTIC FEATURES
22 AND ANXIETY DISORDER. AND THEN ALSO DEMENTIA, OSTEOPOROSIS,
23 HYPERTENSION, AND ANGINA.
24 Q. DID YOU SEE ANY DELIRIUM IN THIS PATIENT IN THE CHARTS?
25 A. WELL, THERE WERE SOME THINGS THAT LOOKING AT THE -- THE
1 GRAPHS, ONE OF THE THINGS THAT I LOOKED AT INITIALLY WAS THE
2 PULSE RATE AND THE BLOOD PRESSURE ON ADMISSION. THIS WOMAN
3 WAS 91 YEARS OLD. AND A PULSE RATE OF A HUNDRED IN A
4 17-YEAR-OLD IS NOT TOO BAD. PROBABLY GET THAT JUST LOOKING
5 AT THE OPPOSITE SEX. BUT IN A 91-YEAR-OLD, TO ESTIMATE THE
6 MAXIMAL HEART RATE WHICH IS WHERE PEOPLE ARE VERY, VERY
7 STRESSED, YOU TAKE 220 MINUS THE AGE. AND IF YOU TAKE 220
8 MINUS 91, YOU FIND THAT A HEART RATE OF 100 IS VERY, VERY
9 HIGH FOR THIS WOMAN. SO SHE'S IN PHYSIOLOGIC STRESS AT THAT
10 POINT. ALSO, THE BLOOD PRESSURE WAS 108 OVER 62. THE
11 QUESTION THAT I HAVE AS A GERIATRICIAN IS I DON'T KNOW WHAT
12 HER BLOOD PRESSURES WERE BEFORE THAT AND I WONDER IF THIS IS
13 LOW BLOOD PRESSURE FOR THIS WOMAN SO IT PUTS IN MY MIND THAT
14 SHE'S PROBABLY UNDER SOME PHYSIOLOGIC STRESS AT THIS POINT
15 AND I DON'T HAVE A GOOD REASON OF WHY SHE WOULD BE UNDER THAT
16 STRESS. SHE IS ON SOME MEDICATION THAT CAN CAUSE HEART RATE
17 TO GO FAST, SO THERE'S A LOT OF THINGS, THEN I START THINKING
18 WHAT'S -- WHAT'S GOING ON WITH THIS WOMAN.
19 Q. DID YOU SEE ANY DOCUMENTATION IN THE RECORDS OF THE
20 THOUGHT PROCESSES OF DR. WEITZEL ABOUT THIS PATIENT'S
21 CONDITION?
22 A. NO. IN ORDER TO TRY TO FIND OUT THE THOUGHT PROCESS
23 THAT WAS GOING ON ON ADMISSION, I HAD TO GO TO THE NURSING
24 NOTES. THERE WERE -- THERE WERE NO OTHER NOTES TO REFER TO
25 IN THE CHARTS THAT I SAW. AND IN THE NURSING NOTES, ON
1 EVALUATION, IT MENTIONS THAT THIS EXACERBATION IS AN ACUTE
2 CHANGE FROM BASELINE, WHICH AGAIN IS A CODE WORD FOR ME TO
3 THINK DELIRIUM. AND SO AT LEAST THE VITAL SIGNS SHOW THAT
4 SHE'S UNDER PHYSIOLOGIC STRESS. THERE'S ALSO EVIDENCE THAT
5 THIS IS AN ACUTE CHANGE WHICH MAKES ME THINK THIS IS A
6 DELIRIUM THAT NEEDS TO BE EVALUATED.
7 Q. WAS THAT DELERIUM EVALUATED?
8 A. I CAN SEE THAT THERE WERE -- THERE WAS AN E.K.G. AND A
9 CHEST X-RAY THAT WAS OBTAINED. I CAN SEE NO ORDERS FOR ANY
10 OTHER LABORATORY EVALUATION OR I CAN SEE NO RESULTS OF ANY
11 LABORATORIES THAT WOULD BE CONSISTENT WITH THE THOUGHT
12 PROCESS OF A DELERIUM EVALUATION. (SEE CHART)
13 Q. THE ADMISSION OF MRS. ANDERSON TO THE HOSPITAL AND THE
14 WAY IT WAS CONDUCTED, DID THAT DEVIATE FROM STANDARD MEDICAL
15 PRACTICE?
16 A. IN GERIATRICS, IT REALLY DOES. I THINK YOU HAVE THE
17 INFORMATION THAT HERE'S A WOMAN WHO'S UNDER PHYSIOLOGIC
18 STRESS. AND ACTUALLY, THE CHEST X-RAY THAT WAS OBTAINED DID
19 SHOW A BILATERAL PNEUMONIA, WHICH IN MY MIND AGAIN GIVES ME A
20 REASON MAYBE WHY THESE ACUTE MENTAL STATUS CHANGES WERE
21 EVIDENT. IT WAS LIKELY BECAUSE OF THE PNEUMONIA THAT CAUSED
22 HER BEHAVIORAL PROBLEMS TO CHANGE SO QUICKLY THAT SHE
23 COULDN'T BE MANAGED IN THE HOSPITAL -- I MEAN IN THE NURSING
24 HOME.
25 Q. AND IS THE PNEUMONIA SOMETHING THAT THAT COULD BE
1 TREATED?
2 A. IT CERTAINLY CAN BE, IT'S TREATABLE CONDITION
3 GENERALLY SPEAKING. OFTENTIMES IF PEOPLE HAVE BECOME TOO FAR
4 GONE, IT'S VERY DIFFICULT TO TREAT.
5 Q. WAS SHE IN A TERMINAL STATE SUCH THAT A -- IF THERE WERE
6 AN ADVANCE DIRECTIVE THAT SAYS DON'T GIVE ME ANTIBIOTICS --
7 AND I'M NOT SAYING THAT THERE WAS, BUT IF SHE WERE IN A
8 TERMINAL STATE AND SUCH AN ADVANCE DIRECTIVE -- WELL, WAS SHE
9 IN A TERMINAL STATE, I GUESS IS THE QUESTION?
10 A. I THINK IT'S -- JUST FROM THE INFORMATION THAT'S GIVEN,
11 SINCE THERE'S SO LITTLE EVALUATION AND THAT FROM WHAT I CAN
12 DETERMINE THERE'S NO PHYSICAL EXAMINATION OF THIS PERSON
13 WHILE SHE'S ALIVE IN THE ACUTE HOSPITAL SETTING, SHE WAS
14 SEVERELY ILL. I WOULD SAY THAT SHE'S -- SHE'S SEVERELY
15 MEDICALLY ILL ON ADMISSION TO THE GEROPSYCH UNIT. AND FROM
16 WHAT I CAN TELL, THERE WAS NO PHYSICAL EXAMINATION OR
17 APPROPRIATE LABORATORY EVALUATION DONE. IF THERE WERE
18 ADVANCE DIRECTIVES AHEAD OF TIME SAYING IF THIS OCCURRED, WE
19 DO NOT WANT THIS DONE, IT WOULD HAVE BEEN TOTALLY APPROPRIATE
20 NOT TO DO THESE EVALATIONS AND IT WOULD HAVE BEEN APPROPRIATE
21 NOT TO INSTITUTE ANTIBIOTICS.
22 Q. WAS MRS. ANDERSON ADMITTED FOR HOSPICE OR TERMINAL CARE?
23 A. NO. SHE WAS ADMITTED BECAUSE OF THE BEHAVIORAL PROBLEMS
24 WITH THE INTENT TO A GEROPSYCH UNIT USUALLY TO GO BACK TO THE
25 NURSING HOME ONCE THOSE BEHAVIORS ARE CONTROLLED.
1 Q. DID YOU SEE ANY INTERVENTION BY DEFENDANT IN THIS
2 PATIENT'S CARE?
3 A. THERE WERE VERBAL ORDERS THAT WERE GIVEN FROM WHAT I CAN
4 TELL WITHOUT EVER EXAMINING THE PATIENT. AND THOSE VERBAL
5 ORDERS CONSISTED OF ADMISSION ORDERS WHICH THERE WERE SEVERAL
6 MEDICATIONS GIVEN. SOME OF THOSE AT LEAST IN GERIATRICS I
7 WOULD WANNA EVALUATE. AND OFTENTIMES, WHEN WE GET PATIENTS
8 THAT ARE ADMITTED WITH MULTIPLE MEDICATIONS, WE ACTUALLY DO
9 STOP THEM WHEN THEY'RE HAVING A CHANGE OF MENTAL STATUS. AND
10 THEN THE ONLY OTHER MEDICATIONS THAT I CAN SEE THAT WERE
11 ORDERED OTHER THAN THOSE MEDICATIONS THAT SHE WAS ON AT THE
12 NURSING HOME WAS MORPHINE.
13 Q. AND IF THE RECORDS SHOW THAT SHE DID NOT EVEN -- THAT
14 SHE DID NOT RECEIVE WHILE AT THE HOSPITAL THOSE OTHER
15 MEDICATIONS THAT HAD BEEN ORDERED AT THE NURSING HOME, WHAT
16 MEDICATIONS THEN, WHAT INTERVENTION DID SHE ACTUALLY RECEIVE?
17 A. WELL, IT APPEARS FROM THE DOCUMENTATION THAT'S HERE THAT
18 SHE RECEIVED MORPHINE.
19 Q. OKAY. WHAT WAS THE APPROPRIATENESS IN YOUR MIND OF THE
20 ORDERS FOR MORPHINE FOR THIS PATIENT IN THIS CONDITION?
21 A. WELL, THIS IS WHERE I DISAGREE WITH THE CARE THAT WAS
22 DELIVERED. AND ACTUALLY, IT SEEMS LIKE AN ABSENCE OF CARE.
23 THERE WAS NOT A PHYSICAL EXAMINATION. THERE WAS NOT LAYING
24 HANDS ON THE PATIENT TO DETERMINE WHAT WAS GOING ON. AND
25 THERE WAS SOME VERY AGGRESSIVE INTERVENTIONS THAT BASED ON NO
1 PHYSICIAN INPUT THAT I CAN SEE AT LEAST DOCUMENTED HERE. THE
2 STARTING OF THE MORPHINE IN MY OWN MIND AS I THINK ABOUT THIS
3 PATIENT AND TRY TO GET IN MY MIND WHY WOULD I DO THAT, I
4 WANNA BE ABLE TO HAVE GOOD EVIDENCE FROM WHAT I'VE SEEN AND
5 WHAT I'VE PALPATED AND EXAMINED BEFORE I WOULD START AN
6 INTERVENTION SUCH AS MORPHINE. EVEN IN A TERMINAL PATIENT, I
7 WANT TO EXAMINE THAT PATIENT SO THAT I KNOW WHAT'S GOING ON,
8 THAT I CAN HAVE A GOOD FEEL FOR WHAT I'M TRYING TOO.
9 Q. WHAT ABOUT THE DOSES THAT WERE ORDERED, 10 MILLIGRAMS?
10 A. WELL, THE DOSES OF MORPHINE WAS -- SPECIFICALLY WAS --
11 THERE WAS AN I.M. DOSE OF 10 MILLIGRAMS NOW ORDERED VERBALLY,
12 WHICH MEANS BY THE PHONE. AT THE SAME TIME, THE D.N.R. ORDER
13 WAS WRITTEN. USUALLY, FOR SOMEONE WHO'S NAIVE OR HASN'T
14 TAKEN OPIOIDS BEFORE, ESPECIALLY A 91-YEAR-OLD -- AND BY THE
15 DOCUMENTATION IT SOUNDS LIKE A FRAGILE PERSON -- THAT WOULD
16 BE A RATHER LARGE DOSE TO START WITH. TYPICALLY, I WOULD
17 PROBABLY START WITH A MUCH LOWER DOSE, LIKE A MILLIGRAM OF
18 MORPHINE AND THEN TITRATE THAT UP TO MAKE SURE THAT I WAS
19 COVERING THE APPROPRIATE AMOUNT OF PAIN. SO IT'S A DIFFERENT
20 DOSE THAN I WOULD USE AND I THINK DIFFERENT DOSE THAT WOULD
21 BE SUGGESTED BY MOST GERIATRICIANS.
22 Q. ARE YOU FAMILIAR WITH THE STANDARD OF CARE FOR GERIATRIC
23 PATIENTS?
24 A. CORRECT, I AM.
25 Q. BASED UPON YOUR REVIEW OF THE MEDICAL RECORDS OF ELLEN
1 ANDERSON, YOUR EXPERIENCE, TRAINING, AND EXPERTISE, DID YOU
2 FORM AN OPINION AS TO WHETHER THE CONDUCT OF THE DEFENDANT AS
3 TO THE TREATMENT AND CARE OF ELLEN ANDERSON DEVIATED FROM THE
4 STANDARDS OF CARE AS WOULD BE EXERCISED BY A PHYSICIAN, A
5 GERIATRICIAN, PSYCHIATRIC GERIATRICIAN IN THE SAME
6 CIRCUMSTANCES?
7 A. WELL, I THINK BASED ON THE INFORMATION THAT I HAVE
8 THAT'S DOCUMENTED, THIS IS VERY UNUSUAL FOR A PHYSICIAN NOT
9 TO EXAMINE A PATIENT THAT --
10 THE COURT: DOCTOR, THAT'S A YES OR NO QUESTION.
11 THE WITNESS: SORRY.
12 THE COURT: ASK THE QUESTION.
13 Q. (BY MS. BARLOW) DID YOU FORM AN OPINION.
14 A. YES.
15 Q. OKAY. AND THEN I GET TO ASK THE NEXT ONE.
16 A. OKAY.
17 Q. CAN YOU CHARACTERIZE US SPECIFICALLY IN WHAT AREAS
18 DEFENDANT'S CONDUCT DEVIATED FROM THE STANDARDS OF CARE
19 EXERCISED BY A PHYSICIAN IN THE SAME CIRCUMSTANCES?
20 A. WELL, I THINK PERFORMING A HANDS-ON PHYSICAL EXAMINATION
21 OF THE PATIENT AND JUST A VERBAL OBSERVATION OF THE PATIENT
22 REALLY DEVIATES FROM I THINK THE STANDARD CARE FOR SOMEONE
23 WHO'S -- WHO'S SERIOUSLY ILL AND UNDER PHYSIOLOGIC STRESSES
24 AS THIS WOMAN PRESENTED. AND I THINK THAT'S A DEVIATION FROM
25 THE STANDARD OF PRACTICE THAT MOST PHYSICIANS WOULD APPLY TO.
1 Q. LET'S NEXT TALK ABOUT JUDITH LARSEN. YOU HAVE HER
2 RECORDS. DID YOU --
3 A. YES.
4 Q. -- HAVE OCCASION TO REVIEW THOSE?
5 A. YES.
6 Q. AND WHAT WAS JUDITH LARSEN'S CONDITION UPON ADMISSION AT
7 THE GEROPSYCH UNIT?
8 A. ON THE ADMISSION EVALUATION INTAKE, WHICH WAS A PHONE
9 INTAKE FROM THE TOP OF THE PAPERS, IT MENTIONED THAT THIS IS
10 A WOMAN WHO HAS BEEN RECENTLY HAVING BIZARRE BEHAVIOR, AND
11 HAS BEEN INCREASED IN HER UPSET. SHE'S BE MORE AGITATED AND
12 SCREAMING AND SHOUTING. AND HAS BEEN MORE INACTIVE OVER THE
13 RECENT PAST.
14 Q. DID YOU FROM THE RECORDS SEE WHAT DEFENDANT'S
15 OBSERVATION AND EVALUATION OF THIS PATIENT WAS?
16 A. THE ADMISSION OCCURRED ON 12/6/95 AT 1500 HOURS. AND
17 ORDERS WERE GIVEN VERBALLY BY THE PHONE. THE ACTUAL
18 PSYCHIATRIC ADMISSION NOTE WAS TIMED AS WHEN IT WAS DICTATED
19 AT 12/7/95 AT 2107, THE NEXT DAY.
20 Q. AND WHAT'S SIGNIFICANT ABOUT THAT?
21 A. I THINK IT'S SIGNIFICANT THAT THE EVALUATION WAS DONE
22 OVER 24 HOURS AFTER THE PATIENT WAS ACTUALLY ADMITTED TO THE
23 HOSPITAL, WHICH IS UNUSUAL. OFTENTIMES IN PSYCHIATRIC UNITS,
24 IT MAY BE THE CASE IN YOUNGER INDIVIDUALS WHERE PATIENTS ARE
25 ADMITTED IN THE EVENING AND THEY MAY BE SEEN THE NEXT MORNING
1 SO THERE MAY BE A SPAN OF EIGHT TO TEN OR 12 HOURS THAT
2 PASSES, BUT I THINK IT IS UNUSUAL ESPECIALLY WITH A
3 93-YEAR-OLD FEMALE THAT'S COMING IN WITH, AGAIN, WITH
4 BEHAVIOR CHANGES, MENTAL STATUS CHANGES, NOT TO SEE THAT
5 PERSON FOR OVER 24 HOURS.
6 Q. WERE THERE ANY SYMPTOMS OF DELIRIUM PRESENT WITH
7 MRS. LARSEN?
8 A. WELL, I THINK BASED ON WHAT I CAN SEE FROM THE NOTES,
9 THERE WAS A FLUCTUATION IN MENTAL STATUS, THERE WAS A CHANGE
10 IN HER BEHAVIOR WHICH INDICATES TO ME THAT SHE WAS HAVING
11 PROBABLY A DELIRIUM ON TOP OF A VERY DIFFICULT PATIENT TO
12 BEGIN WITH.
13 Q. WAS THERE ANY EVALUATION OR TREATMENT DONE OF THE
14 DELIRIUM UPON ADMISSION?
15 A. FROM WHAT I CAN SEE, THERE'S NOT WHAT I WOULD CALL A
16 TOTAL DELIRIUM EVALUATION. THERE WAS A PHYSICAL EXAM BY A --
17 ANOTHER INTERNIST WHO WAS NOT A GERIATRIC INTERNIST, AND DID
18 MAKE SEVERAL RECOMMENDATIONS AND OBSERVATIONS.
19 Q. WERE THOSE RECOMMENDATIONS FOLLOWED ACCORDING TO THE
20 RECORDS?
21 A. NO, NOT EVERY ONE. BUT I HAVE TO SAY ALSO THAT
22 SOMETIMES CONSULTANTS ARE NOT LISTENED TO BY THE ATTENDING
23 PHYSICIAN AND THAT'S -- THAT'S NOT UNUSUAL.
24 Q. WAS THERE ANY CHANGE IN MRS. LARSEN'S CONDITION ON THE
25 22ND OF DECEMBER?
1 A. YES. ON THE 22ND OF DECEMBER, IT WAS NOTED THAT THE
2 PATIENT WAS HAVING DIFFICULTY FORMING WORDS, WAS STARING AT
3 THE CEILING, HAD DEVELOPED SOME NYSTAGMUS AND HAND TREMORS.
4 AND ALL OF THE SUDDEN HAD REQUIRED TWO-PERSON ASSIST WHERE
5 SHE HADN'T PREVIOUSLY AT LEAST BEEN DOCUMENTED TO HAVE THAT.
6 AND SHE WAS ALSO LEANING TO THE RIGHT WITH AMBULATION.
7 ALTHOUGH SHE WAS ABLE TO GRIP EQUALLY, BUT SHE WAS HAVING
8 SOME STIFF MOVEMENTS.
9 Q. AND AS A PHYSICIAN, IF THOSE SYMPTOMS WERE PRESENTED TO
10 YOU, WHAT -- WHAT WOULD BE YOUR FIRST THOUGHT?
11 A. WELL, I THINK -- I THINK THAT THERE'S SOMETHING GOING ON
12 CENTRALLY OR THERE'S MEDICATIONS THAT ARE GOING ON THAT MAY BE
13 INTERFERING. THERE'S SOMETHING GOING ON TO CHANGE THIS
14 PERSON'S NEUROLOGIC STATUS BECAUSE AT THIS POINT SHE'S HAVING
15 FOCAL NEUROLOGIC DEFICITS, WHICH MEANS AGAIN, NOT ONLY SHE
16 MAY HAVE HAD CHANGES AGAIN, THIS ALSO INDICATES A DELIRIUM
17 WHICH REQUIRES EVALUATION.
18 Q. WHAT WOULD YOU DO TO DETERMINE WHAT WAS CAUSING THIS
19 CHANGE IN CONDITION?
20 A. WELL, I THINK ONE OF THE THINGS WOULD BE A REVIEW OF THE
21 MEDICATIONS. AT THIS TIME I THINK BECAUSE THERE HAS BEEN
22 FOCAL NEUROLOGICAL DEFICITS, IT'S CLEAR THAT SHE NEEDS HEAD
23 IMAGING AT THIS POINT. AGAIN, I THINK A PHYSICAL EXAM, YOU'D
24 WANNA MAKE SURE THAT SHE CAN EMPTY HER BLADDER, THAT SHE CAN
25 ALSO -- HAS BEEN HAVING BOWEL MOVEMENTS, THAT THAT'S NOT
1 CONTRIBUTING. ALSO, I WOULD PROBABLY GET ELECTROLYTES AS
2 WELL AS A C.B.C. AND --
3 Q. AND THOSE ARE LABORATORY TESTS?
4 A. LABORATORY SERUM TESTS OF THE BLOOD TO DETECT IS THERE
5 ANYTHING ELSE THAT MIGHT CONTRIBUTING TO THIS PICTURE.
6 Q. DID YOU SEE ANY OF THOSE KINDS OF ORDERS?
7 A. NOT AT THAT TIME. I DIDN'T SEE THOSE ORDERS OR THAT
8 EVALUATION OR A PHYSICAL EXAM AT THAT TIME DOCUMENTED IN THE
9 CHART.
10 Q. WHEN DID YOU SEE ONE?
11 A. I DID SEE A NOTATION THE NEXT DAY THAT FROM THE M.D.
12 NOTE THAT THE PATIENT WAS STABLE WHICH WAS CONFUSING TO ME
13 BECAUSE IT SEEMS IN THE PAST 24 HOURS THAT THERE WAS
14 INSTABILITY. THEN I NOTICED THAT IT WASN'T UNTIL AROUND THE
15 25TH AND 26TH WHERE AN ACTUAL EVALUATION OF THE HEAD WAS DONE
16 WITH THE C.T. EXAM.
17 Q. AND WHAT DID THAT EVALUATION SHOW?
18 A. THE RADIOLOGY REPORT OF THE HEAD C.T., THE IMPRESSION
19 FROM RADIOLOGIST WAS ATROPHY AND FAIRLY PRONOUNCED SMALL
20 VESSEL ISCHEMIC CHANGES, TWO FOCAL ZONES OF DECREASED DENSITY
21 NOTED IN THE LEFT FRONTAL REGION MAY SHOW SOME MINIMAL
22 INCREASE IN DENSITY WHICH MAY REFLECT SOME LUXURY PERFUSION
23 WHICH MAY REFLECT MORE OF A SUBACUTE TYPE PROCESS. CLINICAL
24 CORRELATION IS RECOMMENDED.
25 Q. WHAT DOES THAT ALL MEAN TO YOU AS A PHYSICIAN?
1 A. WHAT THAT MEANS IS ON -- WHEN THIS WAS PERFORMED ON
2 12/26, THE SUBACUTE PROCESS, IT PROBABLY STARTED BACK ON THE
3 22ND WHEN THOSE FOCAL NEUROLOGIC CHANGES AND HENCE THE
4 RADIOLOGIST BEING ABLE TO LOOK AT THIS GROSSLY SAYING IT'S
5 SUBACUTE RATHER THAN ACUTE, WHICH MEANS IT PROBABLY HAD
6 HAPPENED A FEW DAYS BEFORE.
7 Q. WAS THERE ANYTHING THAT OCCURRED IN HER PHYSICAL
8 CONDITION ON THE 26TH THAT WAS OUT OF THE ORDINARY?
9 A. THERE IS A NOTE THAT THE PATIENT WAS QUITE LETHARGIC AND
10 SEEMS MUCH LESS RESPONSIVE THAN ONE WEEK AGO. THIS WAS FROM
11 THE PHYSICIAN'S NOTE. AND ON THE 26TH, THERE IS ALSO A VOICE
12 ORDER FROM DR. DIENHART TO START I.V. FLUID AND TO INITIATE
13 TREATMENT FOR A SEIZURE THAT HAD OCCURRED PREVIOUSLY TO THAT.
14 Q. IS THERE ANY -- IN YOUR MIND AS A PHYSICIAN, IS THERE
15 ANY CONNECTION BETWEEN THE SEIZURE ON THE 26TH AND THE --
16 MAYBE THE -- THE ALTERED STATE ON THE 22ND?
17 A. IT'S NOT UNCOMMON FOR PEOPLE WHO DO HAVE STROKES. ANY
18 TIME YOU HAVE A DEFORMITY IN BRAIN TISSUE, IT CAN BECOME A
19 LOCUS OR A CAUSE OF SEIZURE ACTIVITY. SO IT'S NOT SURPRISING
20 THAT SHE MAY DEVELOP A SEIZURE AS AN AFTER EFFECT OF THE
21 STROKE.
22 Q. DID YOU SEE ANY INTERVENTIONS OR EVALUATIONS BY
23 DR. WEITZEL OF THE -- OF THE STROKE THAT SHOWS UP ON THE
24 26TH?
25 A. I DID SEE THAT ON THE 26TH DR. DIENHART INITIATED
1 TREATMENT. I DID SEE THAT ON THE 26TH. THE HEAD C.T. WAS
2 ACTUALLY OBTAINED AFTER THE SEIZURE, AND THAT'S WHEN THAT
3 INFORMATION WAS OBTAINED. BUT I DIDN'T SEE ANY ACTIVE
4 INTERVENTION OTHER THAN THE M.D. NOTES THAT SEIZURE IN THE
5 A.M. WAS STARTED ON DILANTIN. THERE WAS NO INDICATION OF A
6 NEUROLOGIC EXAM THAT WAS DONE BY THE M.D. AT THAT POINT. IT
7 WAS NOTED THAT THEY HAD AN UNSTABLE HEALTH STATUS AND THE
8 PLAN WAS TO CONTINUE CURRENT MEDICATIONS. BUT THERE WAS
9 REALLY NO EXPLANATION OR WAY TO THINK WHAT WAS GOING IN -- IN
10 THE MIND OF DR. WEITZEL AT THAT POINT, AND THERE WAS NO
11 INDICATION OF WHAT ANYTHING FURTHER WOULD BE DONE, FOR
12 INSTANCE.
13 Q. ARE THERE THINGS THAT COULD HAVE BEEN DONE?
14 A. AT THAT POINT, WITH THE SEIZURE, I THINK IT'S
15 APPROPRIATE TO CONTROL THE SEIZURE AND THEN ANY TIME YOU HAVE
16 AN INSULT ON THE BRAIN, I THINK YOU HAVE TO RE-EVALUATE ALL
17 OF THE OTHER MEDICATIONS THAT MAY AFFECT BRAIN FUNCTION AT
18 THAT POINT BECAUSE THE BRAIN IS IN A MUCH MORE FRAGILE STATE
19 THAN IT WAS BEFORE AND IS MUCH MORE SUSCEPTIBLE TO TOXIC
20 EFFECTS OF MEDICATIONS THAT ARE EFFECTIVE IN THE BRAIN.
21 Q. DO YOU SEE ANY INDICATION OF DR. WEITZEL DOING THAT?
22 A. I ACTUALLY DON'T SEE ANY DOCUMENTATION WHERE THAT
23 THOUGHT PROCESS WAS -- WAS GONE THROUGH OR ANY CHANGES AT
24 THAT POINT.
25 Q. NOW, THERE WAS ANOTHER OCCASION ON THE 30TH OF DECEMBER
1 WHEN THERE WAS ANOTHER CHANGE IN -- 29TH AND 30TH OF
2 DECEMBER, ANOTHER CHANGE IN JUDITH LARSEN'S CONDITION. DO
3 YOU RECALL WHAT THAT WAS?
4 A. ON THE 340TH, ACCORDING TO MY NOTES AND IN THE CHART,
5 THE NURSING NOTES REPORT THAT THE PATIENT WAS UNRESPONSIVE AT
6 7:30 A.M. AND THEN AT 9:20 A.M. SHE HAD COFFEE GROUND EMESIS.
7 COFFEE GROUND EMESIS IS INDICATIVE OF BLEEDING THAT OCCURS IN
8 THE STOMACH AND BECAUSE OF THE ACID IN THE STOMACH, IT TURNS
9 IT TO LOOK LIKE COFFEE GROUNDS.
10 Q. LET'S GO BACK TO THE 29TH. DO YOU SEE ANY INDICATION OF
11 VOMITING THERE?
12 A. ON THE 29TH THE NURSES NOTE ON TWO OCCASIONS THAT THERE
13 WERE -- THERE WAS EMESIS AND THERE WAS ACTUALLY EMESIS TIMES
14 SEVEN, EXCUSE ME, NOTED. AND THAT THE PATIENT WAS
15 DIAPHORETIC AND THAT HER TEMPERATURE WAS 99.5 AND THE EMESIS
16 OR THE VOMITING WAS SO BAD THAT THE BED HAD TO BE CHANGED
17 THREE TIMES BECAUSE OF THE VOMITING.
18 Q. WERE THERE ANY INDICATIONS OF ATTEMPTS TO CONTACT
19 DR. WEITZEL ABOUT THIS CONDITION?
20 A. THE NURSES INDICATE THAT THEY TRIED AT 1900 HOURS, 2100
21 HOURS, 2130, 24, AND AT 3:30 THE NEXT MORNING, DR. WEITZEL
22 CALLED AND WAS MADE AWARE OF THE PATIENT'S CONDITION
23 ACCORDING TO THE NURSING NOTES.
24 Q. IS THERE ANYTHING THAT COULD HAVE BEEN DONE FOR
25 MRS. LARSEN'S VOMITING AT THAT TIME?
1 A. WELL, I THINK IT'S ALWAYS A CAUSE OF GREAT CONCERN AFTER
2 SOMEONE HAS A STROKE AND THEN INITIATES VOMITING OF THIS
3 MAGNITUDE. IT CAN INDICATE THAT THE STROKE WHICH INITIALLY
4 MAY HAVE BEEN NONHEMORRHAGE, WITH MEANS THAT THERE WAS NOT
5 CAUSED BY BLEEDING OFTENTIMES IS THE -- THE STROKE WHICH
6 CAUSES DEATH IN THE TISSUES, IS THAT DEATH OR THOSE TISSUES
7 DIE. IT ALSO CAN HAVE BLEEDING INTO THE TISSUE. THIS COULD
8 MEAN THAT THE ACTUAL BLEEDING HAD EXTENDED INTO THE BRAIN AND
9 WAS ACTUALLY CAUSING AN INCREASED PRESSURE IN THE BRAIN WHEN
10 ONE OF THOSE MANIFESTATIONS IS INTRACTABLE VOMITING. ANOTHER
11 POSSIBLE CAUSE VERY WELL COULD HAVE BEEN PART OF THE
12 MEDICATIONS THAT WERE GOING ON AS WELL.
13 Q. AS A PHYSICIAN, IF THIS HAD BEEN PRESENTED TO YOU, WHAT
14 IF ANY ACTION WOULD YOU TAKE?
15 A. WELL, I THINK THIS IS A VERY GRAVE SITUATION. WE HAVE A
16 PERSON WHO IS VOMITING, SOUNDS LIKE INTRACTABLY, THEY'VE JUST
17 HAD A STROKE, AND ALSO THE COFFEE GROUND EMESIS INDICATES
18 THAT SHE MAY HAVE DEVELOPED WHAT WE WOULD CALL A STRESS
19 ULCER. IT'S NOT UNCOMMON FOR PEOPLE WHO HAVE HAD SEVERE
20 INJURIES TO HAVE STRESS ULCERS OR BLEEDING INTO THE STOMACH.
21 AND THIS WOMAN IS SEVERELY ILL AT THIS POINT AND I WOULD WANT
22 TO TALK WITH THE FAMILY, ESPECIALLY IN A 93-YEAR-OLD OF HOW
23 WE SHOULD -- HOW WE SHOLD PROCEED IN THIS WAY. AND PROBABLY
24 WOULD WANNA EXAMINE THE PATIENT PERSONALLY AS WELL. OR AT
25 LEAST HAVE SOMEONE, IF I DIDN'T FEEL COMFORTABLE, DO THAT.
1 Q. IS THERE ANYTHING -- I MEAN IF YOU'RE AT THE POINT THAT
2 YOU WERE JUST GIVING COMFORT CARE, IS VOMITING COMFORTABLE?
3 A. NO.
4 Q. IS THERE ANYTHING YOU CAN DO TO STOP -- TO MAKE A PERSON
5 MORE COMFORTABLE WHO IS VOMITING IN THIS FASHION?
6 A. AGAIN, IT DEPENDS UPON THE REASONS THAT THEY'RE VOMITING
7 IF IT'S BECAUSE OF THE BRAIN STEM BEING -- HAVING PRESSURE
8 ON, THAT'S VERY DIFFICULT TO TREAT. IF IT'S THE ULCER THAT'S
9 CAUSING THE VOMITING, WHICH SHE MAY HAVE HAD AN ULCER AT THE
10 SAME TIME AS WELL, THERE MAY BE SOME OTHER AGENTS THAT YOU
11 COULD TRY SUCH AS COMPAZINE OR AGENTS THAT WOULD STOP THE
12 VOMITING. YOU WOULD ALSO WANNA STOP ANY MEDICATIONS THAT
13 COULD CAUSE VOMITING AND NAUSEA.
14 Q. WAS SHE TAKING ANY MEDICATIONS THAT COULD CAUSE VOMITING
15 AND NAUSEA AT THAT TIME?
16 A. WELL, ONE OF THE THINGS THAT WAS NOTED WAS MORPHINE.
17 AND ONE OF THE COMPLICATIONS OF MORPHINE CAN BE NAUSEA AND
18 VOMITING. SO I'D WANNA BE CAREFUL I THINK IN SOMEONE LIKE
19 THIS WITH OPIOIDS IN GENERAL UNTIL I KIND OF DETERMINED WHAT
20 I THOUGHT THE ETIOLOGY OF THE BLEEDING WAS.
21 Q. DO YOU SEE ANYTHING IN THE RECORDS INDICATING THAT
22 DR. WEITZEL TOOK ANY ACTION IN -- EITHER -- FOR EITHER
23 MEDICAL TREATMENT OR COMFORT CARE FOR JUDITH LARSEN?
24 A. NO. THE ONLY THINGS THAT I CAN SEE IS THAT MORPHINE WAS
25 ORDERED AROUND THE CLOCK. AND THAT THERE WAS RECOGNITION THE
1 NEXT DAY OR 12/31 THAT THERE WAS MELENA AND THERE WAS A G.I.
2 BLEED AND THAT COMFORT MEASURE WOULD BE INSTITUTED.
3 Q. AND WHAT WOULD BE COMFORT MEASURES FOR A G.I. BLEED?
4 A. WELL, COMFORT MEASURES IN A G.I. BLEED MAY INCLUDE
5 MORPHINE, BUT ALSO THEY MAY INCLUDE OTHER SEDATIVES AND OTHER
6 MEDICATIONS THAT MAY STOP THE BLEEDING. AGAIN, IT DEPENDS
7 UPON WHETHER YOU'RE LOOKING AT RESTORATIVE TREATMENTS OR
8 COMFORT TREATMENTS. COMFORT TREATMENTS WOULD BE MORE TO
9 PROTECT THAT PERSON FROM PAIN AND SUFFERING AND THAT WOULD
10 REQUIRE EVALUATION, FOR INSTANCE, LOOKING AT THEIR FACIAL
11 MUSCLES, LOOKING IF THEY'RE TENSE, IF THEY'RE TENSE OR NOT
12 AND TRYING TO GIVE THEM AS MUCH COMFORT AS POSSIBLE WITH
13 MEDICATIONS THAT YOU COULD FIND.
14 Q. DO YOU SEE ANY DOCUMENTATON OF PAIN IN JUDITH LARSEN AT
15 THAT TIME?
16 A. ACTUALLY, IN THE NOTES I DON'T SEE ANY NOTES THAT
17 INDICATED TO ME FROM ABOUT THE 30TH THAT SHE WAS IN PAIN.
18 THERE WERE MANY NOTES THAT SAID SHE WAS UNRESPONSIVE AND THAT
19 SPECIFICALLY, THAT DIDN'T SOUND LIKE -- DIDN'T LOOK LIKE SHE
20 WAS IN PAIN.
21 Q. IT'S NOT EASY TO EVALUATE PAIN IN THE DEMENTED ELDERLY?
22 A. NO. IT SOMETIMES CAN BE DIFFICULT, AND I THINK THAT'S
23 ONE OF THE IMPORTANT THINGS ABOUT DOING THE HANDS-ON
24 EVALUATION BECAUSE THERE ARE SUBTLE CUES, TO MOVEMENTS OF THE
25 BODY AS YOU OBSERVE SOMEONE, FACIAL GRIMMACING, CLENCHING OF
1 THE FIST. IT DEPENDS UPON WHAT NEUROLOGIC FUNCTIONS ARE
2 INTACT ON HOW -- IF YOU'RE ABLE TO DETECT PAIN. AND THINK
3 YOU WANNA BE VERY CAREFUL TO TREAT ANY KIND OF SYMPTOMS THAT
4 YOU MAY OBSERVE OR LOOK FOR. BUT IF SOMEONE LOOKS PEACEFUL
5 AND CALM, USUALLY THEY ARE PEACEFUL AND CALM, I THINK.
6 Q. DID YOU EVER SEE AN OCCASION WITH MRS. LARSEN WHEN HER
7 OXYGEN LEVELS WERE LOW?
8 A. IT LOOKS AS APPEARS THAT THE OXYGEN LEVELS WERE LOW AND
9 THE PATIENT AT THIS TIME WAS ALSO ON TWO DIFFERENT
10 BENZODIAZEPINES OR MEDICATIONS THAT CAN CAUSE SEDATION. AND
11 ONE OF THE QUESTIONS THAT WAS NOT ANSWERED LOOKING AT THE
12 REVIEW OF THE CHART IS, IS WHILE SOMEONE HAD LOW OXYGENATION,
13 WHY TO CONTINUE TWO BENZODIAZEPINES. ONE OF THE REASONS IS
14 BECAUSE AGAIN, IN GERIATRIC PHYSIOLOGY, ESPECIALLY IN
15 DEMENTED INDIVIDUALS, THEY'RE INSTITUTIONALIZED. THEY HAVE A
16 DISORDER CALLED SLEEP APNEA THAT OCCURS IN 70 PERCENT OF
17 INDIVIDUALS IN THAT CONDITION. BENZODIAZEPINES ARE ACTUALLY
18 CONTRAINDICATED IN SLEEP APNEA BECAUSE THEY ACTUALLY MAKE --
19 AND SLEEP APNEA IS UNABLE TO BREATHE, BASICALLY, AND
20 OXYGENATE. IT MAKES THAT -- THE PERSON UNABLE TO BREATHE TO
21 A GREATER EXTENT. AND ALSO PARADOXICALLY, ESPECIALLY IN
22 THOSE PATIENTS, IT ACTUALLY CAUSES -- CAN CAUSE MORE
23 AGITATION IN THOSE PATIENTS. SO IF I SEE SOMEONE ON TWO
24 BENZODIAZEPINES AND THEIR OXYGENATION GOING DOWN, I USUALLY
25 TAKE THEM OFF OF AT LEAST THE ONE BENZODIAZEPINE. I'M NOT
1 AWARE OF ANY LITERATURE THAT SUGGESTS THAT TWO
2 BENZODIAZEPINES ARE BETTER THAN ONE.
3 Q. DID YOU SEE ANY INDICATON OF ANY MEDICAL CONSULTS OR
4 EVALUATIONS DONE ON MRS. LARSEN?
5 A. THERE WAS A MEDICAL EVALUATION DONE ON THE 26TH BY
6 DR. DIENHART. AND ALSO, THERE WAS A CONSULTATION OBTAINED
7 FROM DR. DIENHART ON ADMISSION.
8 Q. DID YOU SEE ANYTHING IN HER CONDITION, LET'S SAY AFTER
9 THE 26TH OF DECEMBER, THAT INDICATES A MEDICAL --
10 MR. BUGDEN: EXCUSE US. APOLOGIZE. MAY WE APPROACH THE
11 BENCH?
12 THE COURT: YOU MAY.
13 (A CONFERENCE WAS HELD AT THE BENCH.)
14 THE COURT: LET'S TAKE A RECESS AT THIS TIME. YOU MAY
15 STEP DOWN IF WOULD YOU, DOCTOR. LADIES AND GENTLEMEN, WE'LL
16 TAKE A BRIEF RECESS. WE'LL BE IN RECESS UNTIL 20 AFTER TEN.
17 REMIND YOU OF MY PRIOR ADMONITION. WE'LL SEE YOU BACK IN A
18 FEW MINUTES.
19 (WHEREUPON THE COURT TOOK A RECESS.)
20 IN CHAMBERS
21 THE COURT: IN THE MATTER OF STATE OF UTAH VERSUS ROBERT
22 WEITZEL. WE'VE JUST BEEN NOTIFIED THAT ONE OF THE JURORS HAS
23 A CHILD THAT WAS JUST TAKEN TO THE HOSPITAL. MY
24 UNDERSTANDING IS THAT IS NUMBER -- JUROR NUMBER 24 AND
25 MR. POWELL. MR. WILSON, WERE YOU ABLE TO VERIFY WHO IT WAS?
1 MR. WILSON: ALL I KNOW IS IT WAS ONE OF THE TWO
2 ALTERNATES AND --
3 MR. BUGDEN: SHALL WE HAVE THEM COME IN?
4 THE COURT: HE WILL BRING HIM IN.
5 MR. WILSON: -- IDENTIFIED TO ME AS BEING A BISHOP --
6 MR. BUGDEN: THAT IS NUMBER 1, ALTERNATE NUMBER 1.
7 THE COURT: YEAH, NUMBER 24, MR. POWELL IS ACTUALLY --
8 DO YOU KNOW WHICH HOSPITAL OR ANYTHING, MEL?
9 MR. WILSON: I DON'T. AND I'M SORRY, JUDGE --
10 MR. BUGDEN: BUT YOUR OFFICE PROBABLY KNOWS.
11 MR. WILSON: YEAH.
12 THE COURT: WHY DON'T YOU GET ON THE PHONE AND FIND OUT
13 WHAT YOU CAN.
14 MR. BUGDEN: DO YOU WANT TO FIND THAT OUT BEFORE WE
15 BRING HIM IN?
16 (BRIEF RECESS.)
17 A VOICE: GOOD MORNING, YOUR HONOR. THIS IS
18 (UNINTELLIGIBLE) HE WORKS IN THE PROBATION OFFICE OVER THERE.
19 HE'S IN THE WARD OF THIS BISHOP.
20 A VOICE: WELL, MY WIFE WORKS AT THE TANNER CLINIC.
21 HIS WIFE GOES THERE. SHE SEEN THE DOCTOR AND THE -- HIS
22 LITTLE SON'S BEEN SICK, A CONTINUAL SICKNESS, HE'S HAD
23 PNEUMONIA, HAD THE CHICKEN POX. I THINK NOW HE HAS STREP
24 THROAT. AND SO THEY WENT IN FOR A CHECKUP LAST MONDAY AND I
25 BELIEVE THEY SAID IF HE HASN'T IMPROVED, THEY HAVE TO ADMIT
1 HIM TO THE HOSPITAL AND PUT HIM ON I.V.'S AND SO AT THE
2 CHECKUP TODAY THE DOCTOR SAID HE HAS TO GO INTO THE HOSPITAL
3 TODAY.
4 THE COURT: OKAY.
5 A VOICE: AND SO --
6 THE COURT: ALL RIGHT. I APPRECIATE THAT.
7 A VOICE: -- SHE CALLED TO SEE IF HE'D BE THERE AT LUNCH
8 TO GIVE A BLESSING THAT -- I'M NOT SURE HOW SERIOUS IT IS.
9 THEY'RE TRYING TO FIGURE THAT OUT RIGHT NOW. I THINK HE'S
10 PLANNING TO GO DURING LUNCHTIME AND GIVE HIS SON A BLESSING.
11 THE COURT: DID YOU TALK TO HIM?
12 A VOICE: TO --
13 THE COURT: MR. POWELL?
14 A VOICE: YEAH, I JUST TOLD HIM RIGHT NOW.
15 THE COURT: HOW COME YOU TOLD HIM?
16 A VOICE: I -- NO, WHEN HE CAME OUT, I DIALED THE NUMBER
17 TO HIS WIFE. HE GAVE ME THE NUMBER WHERE HIS WIFE IS AT AND
18 THEN THAT'S --
19 THE COURT: ALL RIGHT. LET ME BRING HIM IN.
20 A VOICE: -- HE STILL --
21 (BRIEF RECESS.)
22 THE COURT: WOULD YOU HAVE A SEAT PLEASE? YOUR NAME IS
23 MR. POWELL, RIGHT?
24 A JUROR: CORRECT.
25 THE COURT: MR. POWELL, THERE'S SOME INFORMATION THAT
1 WE'VE JUST RECEIVED NOTIFYING US THAT THEY TOOK YOUR SON TO
2 THE HOSPITAL TODAY. APPARENTLY THE ILLNESS HAS BEEN GOING ON
3 FOR A LITTLE WHILE, IS THAT RIGHT?
4 A JUROR: A WEEK.
5 THE COURT: WE'LL LEAVE IT UP TO YOU IF YOU FEEL THAT
6 YOU'D LIKE TO BE EXCUSED AND GO BE WITH HIM, WE'LL ALLOW YOU
7 TO DO THAT. OR IF YOU THINK IT'S SOMETHING THAT WILL TAKE
8 CARE OF ITSELF, HOW DO YOU FEEL ABOUT THAT?
9 A JUROR: WELL, A WEEK AGO HE DEVELOPED SORT OF AN
10 INFECTION AND STARTED GETTING GRIZZLY AND BAD AND IT'S BEEN
11 PROGRESSING DURING THE WEEK. WE HAVEN'T HAD MUCH SLEEP AT
12 NIGHT, BUT WHEN SHE TOOK HIM IN TO THE DOCTOR THIS MORNING,
13 HE FEELS THAT IT'S POSSIBLY A FORM OF HERPES. AND SHE'S NOT
14 AT THE HOSPITAL YET WITH HIM. SHE'S GOING UP THERE. WHAT
15 I'D LIKE TO DO, IF IT'S ALL RIGHT, IS GO UP AT THE LUNCH
16 BREAK --
17 THE COURT: SURE.
18 A JUROR: -- AND SEE HIM. IF THEY FEEL THAT THEY
19 HAVE CONTROL OF WHAT'S GOING ON --
20 THE COURT: ALL RIGHT.
21 A JUROR: -- AND IF IT SEEMS STABILIZED, BECAUSE THEY'RE
22 CONCERNED ABOUT HYDRATION AND THINGS -- THAT'S WHY THEY'RE
23 ADMITTING HIM -- IF I FEEL THAT THAT'S UNDER CONTROL, THEN
24 I'D LIKE TO FINISH.
25 THE COURT: ALL RIGHT.
1 A JUROR: BUT IF NOT, THEN, YEAH, I WOULD WANT TO BE
2 EXCUSED.
3 THE COURT: WE'LL LEAVE THAT CHOICE UP TO YOU, AND WE'LL
4 JUST GO AHEAD AND ALLOW YOU TO DO THAT AT NOON. YOU FEEL ALL
5 RIGHT ABOUT THAT, MR. WILSON.
6 MR. WILSON: YES, YES.
7 THE COURT: MR. BUGDEN?
8 MR. BUGDEN: SURE.
9 THE COURT: ALL RIGHT. LET'S JUST GO AHEAD THEN AND
10 TAKE THE REST OF YOUR BREAK, AND THEN AT NOON YOU CAN RUN UP
11 AND CHECK ON THAT AND WE'LL WAIT FOR A REPORT FROM YOU.
12 OKAY?
13 A JUROR: OKAY.
14 THE COURT: ALL RIGHT. HOPE EVERYTHING'S OKAY.
15 A JUROR: SO DO I. THANK YOU.
16 THE COURT: THANK YOU.
17 MR. WILSON: CAN WE HAVE AN ADDITIONAL TEN MINUTES?
18 THE COURT: OF COURSE. SURE.
19 IN OPEN COURT
20 MS. BARLOW: WE'RE MINUS ONE VERY IMPORTANT PERSON, YOUR
21 HONOR. DR. BAIR IS BEING LOOKED FOR. I GUESS WE'RE MINUS A
22 COUPLE OTHER VERY IMPORTANT PEOPLE.
23 THE COURT: DOCTOR, IF YOU'LL STEP UP PLEASE. THE COURT
24 REMINDS YOU THAT YOU'RE STILL UNDER OATH.
25 Q. (BY MS. BARLOW) THANK YOU, DR. BAIR. WHAT ABOUT THE
1 PHARMACOLOGY FOR JUDITH LARSEN?
2 A. IN -- IN -- COULD YOU --
3 Q. IN CONTEXT OF THE MEDICATIONS THAT SHE WAS -- THAT SHE
4 WAS BEING GIVEN.
5 A. SHE WAS GIVEN MULTIPLE DIFFERENT MEDICATIONS. AND MANY
6 OF THEM DID HAVE IMPACT ON -- OR POTENTIAL IMPACT ON
7 COGNITION AS WELL AS HER MEDICAL ILLNESSES AS WELL. SHE WAS
8 ON MANY DIFFERENT MEDICATIONS.
9 Q. AS A PHYSICIAN, SEEING SOME OF THE MEDICAL PROBLEMS THAT
10 CAME UP WITH JUDITH LARSEN DURING HER STAY AT THE HOSPITAL,
11 WHAT IF ANYTHING WOULD YOU HAVE DONE ABOUT THE MEDICATION SHE
12 WAS ON?
13 A. I THINK ONE OF THE THINGS IS TO EVALUATE THOSE
14 MEDICATIONS VERY CAREFULLY. AND ESPECIALLY AFTER A STROKE
15 AND AFTER THE BRAIN HAS BEEN DAMAGED, IT'S NOT UNCOMMON TO
16 REMOVE MEDICATIONS THAT HAVE EFFECTS ON SEDATION OF THE BRAIN
17 TO FIND OUT WHAT IS THE NEUROLOGIC DEFICITS. ONE OF THE
18 THINGS THAT BECOMES VERY IMPORTANT IS TO EVALUATE WHAT IS THE
19 EXTENT OF THE DAMAGE THAT'S BEEN DONE AND TO DO THAT YOU NEED
20 TO DO EVALUATIONS. IF THERE ARE LOTS OF MEDICATIONS THAT
21 CAUSE SEDATION, IT'S HARD TO EVALUATE THE PATIENT. SO I THINK
22 THRE HAS TO BE AN EVALUATION OF WHAT TO MAINTAIN ON BOARD AND
23 THEN WHAT TO REMOVE IN ORDER TO EVALUATE THE PATIENT'S
24 STATUS.
25 Q. DID YOU SEE THAT HAPPEN AFTER HER C.V.A.?
1 A. I DID NOT SEE THAT. OR ANY THOUGHT PROCESS DOCUMENTED
2 THAT THAT WAS A CONCERN AT ALL.
3 Q. A CONCERN FOR WHOM?
4 A. FOR THE PHYSICIAN, THE ATTENDING PHYSICIAN.
5 Q. AND THAT WAS DR. WEITZEL?
6 A. DR. WEITZEL.
7 Q. EXCUSE ME. DID YOU SEE ANY DOCUMENTATION OF A
8 DIFFERENCE OF OPINION BETWEEN DR. WEITZEL AND THE NURSES
9 ABOUT, WELL, SPECIFICALLY ABOUT THE MORPHINE?
10 A. THERE WAS AN INDICATION OF ONE NURSING NOTE THAT
11 INDICATED THAT THE MORPHINE WAS HELD THREE TIMES BECAUSE THE
12 PATIENT WAS UNRESPONSIVE. DR. WEITZEL GAVE ORDERS AT THAT
13 TIME THAT ALL MORPHINE DOSES WERE TO BE GIVEN UNLESS HE WAS
14 PAGED, WHICH I THINK IN THIS CASE, IS KIND OF DIFFICULT
15 BECAUSE HE'S ALREADY DEMONSTRATED TO THE NURSES THAT HE'S
16 ALMO -- HE'S VERY DIFFICULT TO GET A HOLD OF. IT TOOK THEM
17 ABOUT SEVEN AND A HALF HOURS TO PAGE HIM LAST TIME, AND THAT
18 PUTS NURSES IN A VERY DIFFICULT POSITION WHEN THEY SEE AN
19 ACUTE CHANGE, IT ALMOST IS LIKE PUTTING SOMETHING ON AUTO
20 PILOT TO SAY, NURSES OFTEN TRY TO GET FEEDBACK AND INPUT FROM
21 PHYSICIANS BECAUSE THERE IS DIFFERENT LEVELS OF TRAINING AND
22 SO NURSES TYPICALLY WOULD REPORT THAT AND I THINK THE NURSES
23 WERE PLACE IN A VERY DIFFICULTY POSITION. THEIR EXAMINATION
24 OF THE PATIENT WAS CALM, WAS UNRESPONSIVE, DIDN'T NEED
25 ANYTHING ELSE, AND THEY WERE TOLD TO CONTACT A PHYSICIAN WHO
1 IS DIFFICULT TO GET A HOLD OF.
2 Q. AS A GERIATRIC PHYSICIAN, DOES THAT RAISE ANY CONCERNS
3 FOR YOU?
4 A. WELL, IT DOES. AGAIN, IT SEEMS LIKE THERE'S A
5 DIFFICULTY ON THE TEAM, THE TREATMENT TEAM, KIND OF READING
6 BETWEEN THE LINES. THAT THE PHYSICIANS AND THE NURSES WERE
7 NOT EXACTLY ON THE SAME PAGE CONCERNING THE CARE OF THIS
8 PATIENT, WHICH ALWAYS RAISES FLAGS TO ME. I DON'T ALWAYS
9 AGREE WITH MY NURSES. MY NURSES DON'T ALWAYS AGREE WITH
10 ME --
11 MR. BUGDEN: YOUR HONOR, I WONDER IF WE MAY PROCEED BY
12 QUESTION AND ANSWER.
13 THE COURT: SUSTAINED. SLOW DOWN ON THE NARRATIVE.
14 THE WITNESS: I'M SORRY.
15 THE COURT: ASK YOUR QUESTION, COUNSEL.
16 MS. BARLOW: I WILL DO THAT, YOUR HONOR.
17 Q. (BY MS. BARLOW) DO YOU RECALL HOW MUCH MORPHINE
18 MRS. LARSEN GOT THE LAST DAY OF HER -- THE LAST 24 HOURS OF
19 HER LIFE?
20 A. THE -- NOT SURE I'VE ADDED THAT UP.
21 Q. I'LL REPRESENT TO YOU THAT IT'S BEEN ADDED UP AS 130
22 MILLIGRAMS.
23 A. THE LAST 24 HOURS?
24 Q. THE LAST 24 HOURS. IS THERE ANY CONCERN TO YOU AS A
25 GERIATRICIAN FOR THAT AMOUNT OF MORPHINE WITH THIS PATIENT?
1 A. WELL, GIVEN THE NURSING NOTES AND THE DISCREPANCY, AND
2 THE NURSES WERE THE ONES THAT EVALUATE -- WERE EVALUATING THE
3 PATIENT, MORPHINE IS USUALLY GIVEN JUST TO EASE THE PAIN. IF
4 SOMEONE'S UNRESPONSIVE, TO ME, I'M NOT SURE THAT THAT LEVEL
5 OF MORPHINE IS REQUIRED. SO THE CONCEPT I THINK IS MORE
6 LOOKING AT THE PATIENT AND SEEING, ARE WE DOING WHAT'S RIGHT
7 FOR THE PATIENT. THERE ARE CASES WHERE PATIENTS DO REQUIRE
8 LARGE AMOUNTS OF MORPHINE. HOWEVER, I DON'T SEE THE
9 INDICATION AT LEAST DOCUMENTED WHY THIS PERSON RECEIVED THOSE
10 DOSES OF MORPHINE AND WHEN THE NURSES EXPRESSED CONCERN THAT
11 THEY NOT GIVE MORPHINE, IN FACT, THEY HELD THREE DOSES, THAT
12 THEY WERE INSTRUCTED TO CONTINUE TO GIVE MORPHINE EVEN IF THE
13 PATIENT WAS UNRESPONSIVE. I'M NOT -- I DON'T UNDERSTAND THAT
14 AND IT'S NOT CLEAR FROM THE DOCUMENTATION WHY YOU'D WANT TO
15 DO THAT.
16 Q. DO YOU RECALL THE LAST NOTE THAT DR. WEITZEL WROTE FOR
17 JUDITH LARSEN?
18 A. THE LAST NOTE THAT I HAVE RECORDED WAS ON THE 4TH AFTER
19 THE PATIENT'S DEATH, AND THE NOTE STATES THAT THE PATIENT WAS
20 GIVEN LARGE AMOUNTS OF MORPHINE YESTERDAY AFTERNOON FOR
21 COMFORT. FINALLY, SHE EXPIRED AT 8 P.M. APPEARED TO BE IN
22 NO PAIN. THE ASSESSMENT WAS THAT THERE WAS RESPIRATORY
23 DECREASE AND POOR BLOOD PRESSURE SECONDARY TO DEHYDRATION
24 LEADING TO CARDIAC ARREST AND THE PLAN WAS TO RELEASE THE
25 BODY TO THE FAMILY.
1 Q. IS THERE ANY CONCERN TO YOU AS A GERIATRICIAN ABOUT THAT
2 LAST NOTE?
3 A. THE ONLY CONCERN I WOULD HAVE IS AGAIN, BASED ON
4 PREVIOUS -- IT'S -- IT'S THE CARE OF THE PATIENT AND
5 EVALUATION. I DON'T SEE ANY EVALUATION, HANDS-ON EVALUATION
6 TO DETERMINE WHETHER THE M.D. HAD ACTUALLY EVEN TOUCHED THE
7 PATIENT TO DETERMINE IF THEY WERE IN PAIN. AND OFTENTIMES
8 THAT IS AS SIMPLE AS LOOKING AT THE PATIENT, BUT ALSO IT
9 INCLUDES SOMETIMES MOVING THE PATIENT'S ARMS OR LEGS TO SEE
10 IF THERE'S -- THEY'RE RESPONDING TO ANY PAIN. I DON'T SEE
11 ANY INDICATION OF ANY EVALUATION, PHYSICAL EXAMINATION OF THE
12 PATIENT.
13 Q. I BELIEVE IT'S BEEN ADDED UP THAT THE 130 MILLIGRAMS IN
14 THE DOSES THAT THEY WERE GIVEN WAS ADMINISTERED BY ABOUT 28
15 INJECTIONS OVER THAT LAST 24 HOURS. IN YOUR OPINION, IS THAT
16 COMFORT -- COMFORTABLE FOR A PATIENT?
17 A. IN MY OWN PRACTICE AND WHAT I TRY TO TEACH OTHER
18 PHYSICIANS, GERIATRIC -- GERIATRICIANS AS WELL AS
19 NONGERIATRICIANS IS THAT I.M. INJECTIONS ARE NOT THE BEST
20 MODE OF COMFORT CARE. THERE ARE OTHER METHODS TO DELIVER
21 MEDICATION THAT ARE LESS CLUMSY AND ARE MORE COMFORTABLE TO
22 PATIENTS. SO IT IS A WAY OF DELIVERING IT, BUT IT'S NOT A
23 PREFERRED METHOD FOR COMFORT MEASURES TO GIVE I.M. INJECTIONS
24 OF MEDICATIONS UNLESS ALL OTHER METHODS HAVE BEEN TRIED AND
25 NOT ABLE TO BE ACCOMPLISHED.
1 Q. IF JUDITH LARSEN HAD A NO I.V. IN HER ADVANCE
2 DIRECTIVES, IS THERE ANY OTHER WAY OF DOING IT? I -- OTHER
3 THAN ESTABLISHING AN I.V. FOR THE ADMINISTRATION OF THESE
4 MEDICATIONS?
5 A. THERE ARE. AND AGAIN, A BUTTERFLY, WHICH IS
6 SUBCUTANEOUS AND NOT INTRNAVENOUS IS NOT I.V. THAT'S A VERY
7 ACCEPTED WAY. THE OTHER THING IS, IS ORALLY. THERE ARE
8 DROPS. AGAIN, IT'S ABSORBED IN THE MUCOSA OR IN THE MOUTH OR
9 EVEN RECTALLY, IT CAN BE GIVEN THAT WAY AS WELL.
10 Q. WOULD YOU AS A PHYSICIAN EVER APPROACH A FAMILY -- THE
11 FAMILY, THE COMPETENT FAMILY MEMBERS, THE ONES WHO COULD MAKE
12 THE DECISIONS AND SAY, I RECOGNIZE THE ADVANCE DIRECTIVE SAYS
13 NO I.V., HOWEVER, THAT WOULD BE THE MOST COMFORTABLE WAY OF
14 ADMINISTERING THE --
15 MR. BUGDEN: OBJECTION, LEADING.
16 THE COURT: SUSTAINED.
17 Q. (BY MS. BARLOW) HAVE YOU EVER -- WOULD YOU HAVE -- WOULD
18 YOU EVER APPROACH A FAMILY MEMBER ASKING FOR ANY KIND OF
19 CHANGE FROM AN ADVANCE DIRECTIVE?
20 A. YES. I THINK THERE ARE CASES WHERE YOU WOULD APPROACH A
21 FAMILY MEMBER BASED ON YOUR MEDICAL JUDGMENT. IT WOULD BE
22 COMFORTABLE -- AND THAT IS THE AIM OF THE ADVANCE DIRECTIVE
23 IS TO PROVIDE COMFORT -- TO MAYBE CHANGE SOME THINGS AND
24 PREVENT -- PRESENT THEM WITH INFORMATION THAT THEY MAY NOT BE
25 PRIVY TO BECAUSE OF YOUR MEDICAL EXPERTISE AND PROVIDE THEM
1 WITH INFORMATION THAT OTHER OPTIONS MAY BE AVAILABLE SUCH AS
2 I.V.'S MAY NOT BE A BAD CONTINUING PER SE IN CERTAIN
3 INSTANCES, GIVEN CERTAIN CLINICAL SITUATIONS.
4 Q. BASED UPON YOUR REVIEW OF THE MEDICAL RECORDS OF JUDITH
5 LARSEN, YOUR EXPERIENCE, TRAINING, AND EXPERTISE, DID YOU --
6 AND THIS IS JUST A YES OR NO QUESTION -- DID YOU FORM AN
7 OPINION AS TO WHETHER THE CONDUCT OF THE DEFENDANT AS TO THE
8 TREATMENT AND CARE OF JUDITH LARSEN DEVIATED FROM THE
9 STANDARDS OF CARE AS WOULD BE EXERCIZED BY A PHYSICIAN IN THE
10 SAME CIRCUMSTANCES?
11 A. YES.
12 Q. CAN YOU CHARACTERIZE FOR US WHAT -- IN WHAT AREAS THE
13 DEFENDANT'S CONDUCT DEVIATED FROM THAT STANDARD OF CARE?
14 A. I THINK THERE WERE DEVIATONS IN TERMS OF PHYSICAL
15 EXAMINATIONS, EVALUATION, HANDS-ON EVALUATION OF THE PATIENT
16 AS DOCUMENTED IN THE CHART. I ALSO THINK THAT THERE WERE
17 DIFFERENCES CONCERNING GERIATRIC PHAMACOLOGY AND GERIATRIC
18 PHYSIOLOGY CONCERNING POTENIALLY SOME MEDICATIONS. AND ALSO
19 THE EVALUATION AND DOCUMENTATION AND INTERVENTION WITH
20 DELIRIUM.
21 Q. DID THE CONDUCT OF THE DEFENDANT IN THIS CIRCUMSTANCE
22 FALL BELOW THE STANDARD OF CARE --
23 A. YES.
24 Q. -- OF A -- OF A PHYSICIAN?
25 A. YES.
1 Q. AND I THINK I NEGLECTED TO ASK YOU THAT IN ELLEN
2 ANDERSON'S CASE, DID HIS --
3 THE COURT: YOU DID ASK THAT.
4 MS. BARLOW: OH, DID I? THANK YOU, YOUR HONOR.
5 THE COURT: IF THAT'S THE SAME QUESTION.
6 MS. BARLOW: THE QUESTION IS, IS DID IT FALL BELOW THE
7 STANDARD OF CARE.
8 THE COURT: I THINK YOU ASKED THAT.
9 MS. BARLOW: OKAY. THANK YOU, YOUR HONOR. GET TO THE
10 POINT WHERE YOU DIDN'T REMEMBER SOMETIMES.
11 THE COURT: I UNDERSTAND THAT.
12 Q. (BY MS. BARLOW) IF YOU WOULD NOW GO WITH ME TO TALK
13 ABOUT MARY CRANE. DID YOU HAVE OCCASION TO EXAMINE HER
14 RECORDS?
15 A. YES.
16 Q. WHAT WAS HER CONDITION UPON ADMISSION?
17 A. ACCORDING TO THE INTAKE EVALUATION IN THE CHART, THE
18 PHYSIC -- THE PATIENT WAS ADMITTED BECAUSE OF HER INCREASE IN
19 AGGRESSION AND ANGER IN GROUPS. SHE WAS SPITTING, SHE WAS
20 REPORTED AS DRINKING OUT OF A TOILET, BEING MANIPULATIVE,
21 HITTING, VERBALLY ABUSIVE, STICKING HER FINGERS DOWN HER
22 THROAT TO THROW UP.
23 Q. DID YOU SEE ANY SYMPTOMS OF DELIRIUM IN THAT LIST?
24 A. THE QUESTION I ALWAYS ASK MYSELF IS WHY DOES SOMEONE ALL
25 OF THE SUDDEN NEED TO BE HOSPITALIZED, AND IN THIS CASE, IT
1 APPEARS THAT THIS BEHAVIOR IS WORSE THAN IT HAD BEEN IN THE
2 PAST, WHICH TO ME ALSO SIGNIFIES THAT THAT THIS CHANGE IN
3 BEHAVIOR MAY BE DUE TO A DELIRIUM, AGAIN WITH UNDERLYING
4 MEDICAL CAUSES MAYBE EXACERBATING THIS.
5 Q. DID YOU SEE ANY INDICATION OF THE DEFENDANT'S
6 OBSERVATION AND/OR EVALUATION OF THIS PATIENT?
7 A. YES, THERE IS A PSYCHIATRIC EVALUATION THAT IS DATED
8 AFTER THE ADMISSION ON 12/28/95 WHERE A REPEAT OF THE
9 OBSERVATIONS ON THE INTAKE EVALUATION WAS MENTIONED IN THE
10 HISTORY AND THE ON THE DIAGNOSIS WAS MAJOR DEPRESSION WITH
11 PSYCHOTIC FEATUARES. ALSO CEREBROVASCULAR ACCIDENT, PROBABLY
12 MULTI-INFARCT DEMENTIA WITH A HISTORY OF G.I. BLEEDS,
13 HYPERTENSION, AND ADULT ONSET DIABETES.
14 Q. SEE ANY INDICATIONS HANDS-ON IN THAT EVALUATION BY
15 DEFENDANT?
16 A. THERE IS NO INDICATION IN THIS DOCUMENTATION OF A
17 PHYSICAL EXAM PERFORMED BY DR. WEITZEL.
18 Q. WAS ONE DONE BY ANOTHER PHYSICIAN?
19 A. YES. DR. DIENHART AROUND THE SAME TIME PERFORMED A
20 MEDICINE EVALUATION OF MARY CRANE.
21 Q. DO YOU SEE ANY RECOMMENDATIONS BY THE MEDICAL
22 CONSULTANT, DR. DIENHART?
23 A. THERE WERE NUMEROUS, AGAIN, MEDICAL CONCERNS WITH THIS
24 PATIENT BECAUSE OF LABORATORY ABNORMALITIES. THE IMPRESSION
25 FROM DR. DIENHART WAS THAT THE PATIENT SUFFERED FROM A MILD
1 ANEMIA, HYPONATREMIA, HYPOKALEMIA, METABOLIC -- A MILD
2 METABOLIC ALKALOSIS, HYPOALBUMINEMIA, LOW SERUM IRON, CHRONIC
3 LOW BACK PAIN, HYPERTENSION, HISTORY OF PEPTIC ULCER DISEASE,
4 RIGHT SHOULDER DENSITY THAT WAS UNCLEAR IN ETIOLOGY, AND A
5 CARDIAC SILHOUETTE THAT WAS ENLARGED.
6 Q. DO YOU SEE ANY INTERVENTIONS ORDERED BY -- WELL, WERE
7 ANY RECOMMENDED, ANY INTERVENTIONS RECOMMENDED BY
8 DR. DIENHART?
9 A. YES. HE RECOMMENDED PAIN CONTROL WITH NONSTEROIDAL
10 ANTIINFLAMMATORY DRUGS AND DURAGESIC PATCH. HOWEVER, HE
11 LISTED A CAUTION WITH THE NONSTEROIDALS, APPROPRIATELY SO I
12 THINK BECAUSE OF THE TENDENCY FOR THIS PATIENT TO HAVE PEPTIC
13 ULCER DISEASE, NOTSTEROIDALS CAN MAKE THAT WORSE UNLESS YOU
14 ADD OTHER MEDICATIONS THAT MIGHT PREVENT THOSE KIND OF
15 OCCURRENCES BECAUSE OF THE SIDE EFFECTS OF THAT MEDICATION.
16 HE ALSO TALKED ABOUT HER WATER DRINKING AND HER SODIUM LEVEL
17 AND HER POTASSIUM LEVEL, AND RECOMMENDED SOME INTERVENTIONS
18 FOR THAT. HE ALSO RECOMMENDED SOME CHANGES IN HER
19 MEDICATIONS OR H2 BLOCKER WHICH IS A MEDICATION THAT STOPS
20 THE PRODUCTION OF ACID IN THE STOMACH THAT MAY BE
21 CONTRIBUTING TO HER CHANGE IN MENTAL STATUS THAT HE WAS
22 RECOGNIZING ON HIS EXAM.
23 Q. WERE THOSE RECOMMENDATIONS FOLLOWED BY DR.WEITZEL?
24 A. SOME OF THEM WERE AND SOME OF THEM WERE NOT.
25 Q. ON THE -- LET'S SEE, ON THE 29TH OF DECEMBER, THERE WAS
1 A NOTE BY DR. WEITZEL ABOUT LABORATORIES BEING WITHIN NORMAL
2 LIMITS. DID YOU FIND THAT THAT IS WHAT WHAT THE LABORATORY
3 SHOWED?
4 A. NO. ACTUALLY, THERE WERE SEVERAL ABNORMALITIES IN HER
5 LABORATORIES AT THAT TIME. AND WE'RE NOT SURE WHY IT WAS
6 DOCUMENTED THAT THERE WERE -- ALL THE LABORATORIES WERE
7 WITHIN NORMAL LIMITIS. THERE WERE SEVERAL ABNORMALITIES,
8 SOME OF THEM MILD, SOME OF THEM NOT SO MILD. THERE WAS A
9 MILD DECREASE IN HER HEMOGLOBIN. THERE WAS A LOW ALBUMIN
10 LEVEL WHICH IS INDICATIVE IN THIS CASE POSSIBLY OF
11 MALNUTRITION. HER SODIUM WAS ALSO AT A LOW LEVEL. IRON WAS
12 MILDLY LOW. HER CREATININE WAS ACTUALLY LISTED IN THE NORMAL
13 RANGE; HOWEVER, IT WAS HIGH NORMAL. AND FOR A 72-YEAR-OLD,
14 THAT'S PROBLEMATIC FOR, AGAIN, BEING ABLE TO GET RID OF
15 MEDICATIONS, SO SHE DID HAVE PROBLEMS WITH RENAL FUNCTION.
16 AND HER B.U.N. OR A MEASURE OF BLOOD UREA NITROGEN WAS ALSO
17 ELEVATED, AND HER TOTAL PROTEIN WAS ALSO LOW.
18 Q. WHAT -- THE B.U.N. BEING ELEVATED, WHAT'S THAT
19 INDICATIVE OF?
20 A. WELL, THERE CAN BE LOTS OF REASONS THAT A B.U.N. CAN BE
21 ELEVATED. PROBABLY THE TWO MOST COMMON CAUSES WOULD BE
22 DEHYDRATION OR AN UPPER G.I. BLEED WHICH CAUSES THE BLOOD TO
23 BE BROKEN DOWN WITHIN THE STOMACH, CAUSING AN INCREASE IN THE
24 B.U.N., OR THE BLOOD UREA NITROGEN. AND THAT'S SIGNIFICANT
25 IN THIS WOMAN BECAUSE SHE WAS ON A NONSTEROIDAL. SHE HAD A
1 HISTORY OF PEPTIC ULCER DISEASE, AND SHE WAS ACTUALLY NOT ON
2 APPROPRIATE MEDICATIONS TO PREVENT THE SIDE EFFECTS OF ULCER
3 DISEASES. AN H2 BLOCKER WHICH SHE WAS ON ACTUALLY DOES NOT
4 PREVENT THAT, FROM STUDIES. THE ONLY APPROPRIATE
5 INTERVENTIONS TO PREVENT THAT KIND OF SIDE EFFECT WOULD BE A
6 PROTON PUMP INHIBITOR, WHICH IS ANOTHER CLASS OF MEDICATION,
7 OR A PROSTAGLANDIN E2 MEDICATION WHICH WOULD PREVENT THAT.
8 SO I THINK THAT'S SIGNIFICANT AT LEAST IN EVALUATION TO
9 DETERMINE IS SHE DEHYDRATED OR IS IT POSSIBLE SHE MAY HAVE AN
10 UPPER G.I. BLEED. ALSO SUPPORTING THAT WOULD BE A MILD
11 DECREASE IN THE HEMOGLOBIN. HEMOGLOBIN IS SENSITIVE TO THAT,
12 EVEN THOUGH IT'S MILD, SHE DOES HAVE A MILD ANEMIA THAT MAY
13 NEED TO BE LOOKED INTO.
14 Q. WAS THERE A LAB REPORT ON A URINALYSIS?
15 A. THERE WAS A LAB REPORT ON A URINALYSIS. AND IT GREW OUT
16 A SPECIES OF BACTERIA THAT IS A GRAM NEGATIVE BACTERIA THAT'S
17 COMMON IN FECES.
18 Q. AND THAT CAME OUT OF THE URINALYSIS.
19 A. IT CAME OUT OF THE URINALYSIS.
20 Q. THERE WAS AN ORDER FOR CIPRO FOR A URINARY TRACT
21 INFECTION. DID -- WOULD CIPRO ADDRESS THE CULTURE THAT CAME
22 OUT OF THE U.A.?
23 A. I DON'T HAVE ACCESS TO THE SENSITIVITIES, BUT OFTENTIMES
24 CIPRO WILL TREAT A GRAM-NEGATIVE ORGANISM. AND THAT'S
25 ACTUALLY NOT AN ATYPICAL ORGANISM TO BE FOUND IN THE URINE.
1 Q. NOW, THERE COMES A POINT WHEN MRS. CRANE IS FOUND TO
2 HAVE A FISTULA, IS THAT CORRECT?
3 A. YES.
4 Q. WHAT IF ANYTHING WAS DONE, WHAT INTERVENTIONS WERE DONE
5 ABOUT THE FISTULA?
6 A. WELL, JUST TO PREFACE THAT, PRIOR TO --
7 MR. BUGDEN: YOUR HONOR, I DON'T BELIEVE THAT THAT'S
8 RESPONSIVE.
9 THE COURT: SUSTAINED. LISTEN TO THE QUESTION --
10 THE WITNESS: OKAY. ON THE NURSING NOTE ON JANUARY 1ST,
11 1996 NOTED A BOWEL MOVEMENT FROM THE VAGINAL AREA.
12 THE COURT: IT'S A YES OR NO QUESTION, DOCTOR.
13 THE WITNESS: YES.
14 Q. (BY MS. BARLOW) AND WHAT INTERVENTION WAS DONE FOR THIS
15 FINDING?
16 A. AT THAT TIME, AN O.B.-G.Y.N. CONSULT WAS CONTACTED
17 CONCERNING THE FISTULA.
18 Q. WHAT DID THE CONSULT RECOMMEND FOR TREATMENT?
19 A. THE CONSULT RECOMMENDED ONE OF TWO OPTIONS, EITHER
20 SURGERY IF THE PATIENT COULD BE CLEARED BY INTERNAL MEDICINE,
21 OR TO START BROAD SPECTRUM ANTIBIOTICS.
22 Q. DO YOU SEE ANYTHING IN THE RECORD INDICATING THAT THERE
23 WAS A ATTEMPT TO CLEAR HER FOR SURGERY?
24 A. I SEE NO DOCUMENTATION OF AN ATTEMPT TO CLEAR HER FOR
25 SURGERY.
1 Q. ANYTHING INDICATING DR. WEITZEL ASKED ANYONE TO LOOK AT
2 HER FOR THAT?
3 A. NO DOCUMENTATION THAT I COULD SEE.
4 Q. WHAT ABOUT THE BROAD SPECTRUM ANTIBIOTIC, IS THERE
5 ANYTHING IN THE RECORD INDICATING AN ORDER FOR THAT?
6 A. THERE WAS AN ORDER FOR KEFLEX THAT WAS ORDERED A FEW
7 DAYS AFTER THE RECOMMENDATION. KEFLEX IS A MEDICATION, AN
8 ANTIBIOTIC THAT PRIMARILY COVERS GRAM-POSITIVE ORGANISMS. AT
9 THAT TIME THE CIPROFLOXACIN HAD ACTUALLY BEEN DISCONTINUED.
10 TYPICALLY WITH BROAD SPECTRUM ANTIBIOTICS, WHAT IS MEANT IS
11 ANTIBIOTICS THAT WILL COVER GRAM-POSITIVE, GRAM-NEGATIVE, AND
12 ALSO ANAEROBIC BACTERIA. AND SO OFTENTIMES THAT REQUIRES A
13 LEAST TWO IF NOT THREE CONCURRENT ANTIBIOTICS TO TREAT
14 APPROPRIATELY.
15 Q. DID YOU SEE AN INDICATION IN THE RECORD OF A DIFFERENCE
16 OF OPINION BETWEEN THE DOCTORS ABOUT THE AMOUNT OF DURAGESIC
17 PATCH IN THE -- THE AMOUNT OF FENTANYL IN THE DURAGESIC PATCH
18 FOR MRS. CRANE?
19 A. YES, THERE WAS A DISCREPANCY BETWEEN DR. DIENHART AND
20 DR. WEITZEL ON THE AMOUNT OF DURAGESIC THAT WAS NEEDED.
21 DR. WEITZEL ACTUALLY DECREASED THE DOSE AFTER HIS PHYSICAL
22 EXAMINATION --
23 Q. I THINK YOU SAID DR. WEITZEL.
24 A. EXCUSE ME. DR. DIENHART DECREASED THE DOSE OF FENTANYL
25 PATCH THINKING IT WAS MAYBE SEDATING PATIENT ON HIS
1 EXAMINATION. THE NEXT DAY DR. WEITZEL FELT THAT THE
2 DURAGESIC PATCH WAS NOT SEDATING THE PATIENT AND INCREASED
3 THE DOSE OF THE FENTANYL PATCH OR THE DURAGESIC PATCH BACK UP
4 TO THE PREVIOUS LEVEL.
5 Q. WAS THERE A FURTHER INCREASE OF THE AMOUNT OF THE
6 DURAGESIC PATCH IN HER STAY IN THE HOSPITAL?
7 A. YES, THERE WAS. DURING OTHER STA -- LATER STAGES, THE
8 FENTANYL PATCH WAS INCREASED.
9 Q. DID YOU SEE ANY REASONS GIVEN IN THE CHARTS FOR THAT
10 INCREASE?
11 A. THE DOCUMENT -- THE M.D. DOCUMENTATION IS VERY SHORT.
12 AND THERE WAS NOT GOOD INDICATIONS EACH TIME FOLLOW -- BEING
13 ABLE TO FOLLOW THE THOUGHT PROCESS THAT DR. WEITZEL MIGHT
14 HAVE BEEN USING.
15 Q. DO YOU SEE ANY INDICATION OF DR. WEITZEL EVALUATING ANY
16 MEDICAL REASONS FOR THE SYMPTOMS THAT MARY CRANE WAS
17 EXHIBITING?
18 A. NO. AFTER THE O.B.-G.Y.N. EXAM, I DON'T SEE MEDICAL
19 EXAM -- OR PHYSICAL EXAMINATIONS TO TRY TO LOCATE THE PAIN OR
20 MAYBE THE CAUSE OF THE PAIN. AND I THINK THAT ACTUALLY IS A
21 VERY IMPORTANT POINT BECAUSE WHEN YOU NOTICE FECES COMING OUT
22 OF A VAGINA, THAT'S NOT NORMAL. AND IT DOESN'T OCCUR
23 NORMALLY. AND THAT USUALLY RAISES A QUESTION OF WHY WOULD
24 THAT OCCUR. AND PREVIOUS TO THE FECES BEING NOTED, IT WAS
25 NOTICED THAT SHE WAS IN A FAIR AMOUNT OF PAIN, PROBABLY MORE
1 THAN YOU WOULD EXPECT FROM HER CHRONIC LOW BACK PAIN, WHICH
2 WOULD AGAIN INDICATE TO ME THAT SOMETHING ELSE IS GOING ON
3 THAT NEEDS TO BE EVALUATED. AND IT WAS IN FACT FOUND THAT
4 FISTULA WAS THERE. AND A FISTULA IS BASICALLY A CONNECTION
5 BETWEEN THE BOWEL AND THE VAGINA. AND FOR A FISTULA TO
6 OCCUR, THERE HAS TO BE SOME PROCESS SET UP AN INFLAMMATION
7 WHERE THE BOWEL AND THE VAGINA ACTUALLY UNITE AND FORM A
8 CONNECTION. AND TYPICALLY, THAT HAPPENS IN PROCESSES SUCH AS
9 POTENTIAL CANCERS, OR IN ABSENCES OR INFECTIONS THAT COULD BE
10 FROM A DIVERTICULI, FROM THE BOWEL. THAT'S IMPORTANT TO NOTE
11 BECAUSE THAT NOT ONLY BEING VERY PAINFUL, WHICH SHE DOES
12 EXHIBIT A LOT OF PAIN HERE, IT'S ALSO IMPORTANT TO INTERVENE
13 APPROPRIATELY WITH THOSE CASES IF THERE WAS AN ABDOMINAL
14 ABCESS, FOR INSTANCE. BY DEFINITION THAT WOULD HAVE TO
15 SIMPLY BE DRAINED. WITH THE EXAMINATION OF THE O.B.-G.Y.N.
16 HIS INDICATION FOR SURGERY WAS SIMPLY TO CLOSE THE FISTULA.
17 HOWEVER, AT THAT POINT, THERE HADN'T BEEN ANY EVALUATION
18 DONE, FOR INSTANCE, A C.T. OF THE ABDOMEN TO SHOW WHAT WAS
19 CAUSING THE FISTULA. IF THERE INDEED WAS AN ABSCESS OR
20 SOMETHING ELSE THAT WOULD REQUIRE OTHER KINDS OF
21 INTERVENTION.
22 Q. DID YOU SEE ANY INDICATION IN THE RECORDS THAT
23 DR. WEITZEL DID ANYTHING TO TRY TO EVALUATE WHAT HAD CAUSED
24 THE FISTULA?
25 A. NO, THERE WAS NO INDICATION.
1 Q. SO IS A FISTULA OR A DISEASE PROCESS LIKE THAT, CAN IT
2 BE PAINFUL?
3 A. IT CAN BE EXTRAORDINARILY PAINFUL. THE ABDOMINAL
4 PROCESSES THAT CAN CAUSE THE FISTULA CAN BE EXCRUCIATINGLY
5 PAINFUL. AND OFTENTIMES, EVEN IF A COMFORT MODE, TO FIND OUT
6 WHAT'S CAUSING THAT IS VERY IMPORTANT TO BE ABLE TO RELIEVE
7 THE PAIN. AN EXAMPLE MIGHT BE IN TERMINAL CANCER OF THE
8 COLON WHERE SOMEONE IS COMPACTED OR THEY'RE NOT ABLE TO HAVE
9 ANY BOWEL MOVEMENTS, EVEN IN TERMINAL CANCER, SURGICAL
10 PROCEDURES CAN BE DONE TO ALLOW THE BOWEL TO EMPTY BECAUSE
11 IT'S A VERY PAINFUL DEATH TO DIE OF BOWEL, BASICALLY, NOT BEING
12 ABLE TO HAVE BOWEL MOVEMENTS. SO EVEN IN THOSE CASES, THERE
13 IS HOSPICE KIND OF SURGERIES THAT CAN BE DONE QUITE SIMPLY TO
14 DRAIN THE BOWEL OR FIND OUT WHAT CAN CAUSE -- RELIEVE THAT
15 PAIN.
16 Q. SO IF THERE HAD BEEN -- WELL, IF THERE WAS A DISEASE
17 PROCESS, WHAT WOULD YOU HAVE DONE -- WELL, OKAY. YOU WOULD
18 HAVE EVALUATED. WHAT INTERVENTION WOULD YOU HAVE RECOMMENDED
19 TO TRY TO ADDRESS WHAT IS CAUSING THE FISTULA?
20 A. WELL, I THINK IT'S IMPORTANT TO DO RADIOLOGIC EXAM OF
21 THE ABDOMEN AT THAT POINT TO SEE WHAT IS GOING ON BECAUSE THE
22 APPROPRIATE INTERVENTION WOULD DEPEND UPON WHAT THE PROCESS
23 MIGHT BE. AND WE SIMPLY DON'T KNOW IT WAS --
24 MR. BUGDEN: I BELIEVE HE'S ANSWERED THE QUESTION, YOUR
25 HONOR.
1 THE COURT: OVERRULED.
2 Q. (BY MS. BARLOW) GO AHEAD.
3 A. WE SIMPLY DON'T KNOW WHAT WAS GOING ON. THE WHOLE
4 SYMPTOM OF WHAT WAS GOING ON IN THE ABDOMEN WAS SIMPLY
5 IGNORED, AT LEAST FROM THE DOCUMENTATION IN THE CHART. AND
6 THEN IT'S VERY DIFFICULT TO GUESS WHAT KIND OF INTERVENTION
7 TO DO. IN THOSE CASES, EVEN LARGE DOSES OF MORPHINE MAY NOT
8 HELP THE PAIN.
9 Q. BUT CAN YOU DO SOMETHING TO HELP THE PAIN OTHER THAN
10 MORPHINE?
11 A. CORRECT. AS I'VE MENTIONED BEFORE, DEPENDING UPON WHAT
12 IS GOING ON, WHETHER IT'S AN ABSCESS, WHETHER IT IS A COLON
13 CANCER, SOMETHING'S GOING ON WITHIN THE BELLY THAT WAS SIMPLY
14 NOT EVALUATED. AND IT APPEARS FROM THE DOCUMENTATION,
15 IGNORED.
16 Q. COULD SUCH AN INFECTIOUS PROCESS IN THE ABDOMEN LEAD TO
17 SEPSIS?
18 A. IT CERTAINLY COULD. IT ACTUALLY MAY HAVE ACTUALLY BEEN
19 THE SOURCE OF THE URINARY TRACT INFECTION THAT WAS INITIALLY
20 DETECTED. THE ACTUAL ORGANISM, WHILE IT WAS A GRAM-NEGATIVE
21 ORGANISM, WHICH IS USUAL, THE SPECIFIC SPECIES OF THE
22 ORGANISM WAS A LITTLE BIT UNUSUAL FOR A TYPICAL URINARY TRACT
23 INFECTION.
24 Q. LET US NOW TALK ABOUT LYDIA SMITH -- OH, BEFORE I LEAVE
25 THAT, I NEED IT ASK YOU SOME -- MY STANDARD QUESTIONS HERE.
1 BASED UPON YOUR REVIEW OF THE MEDICAL RECORDS OF MARY CRANE,
2 YOUR EXPERIENCE, TRAINING, AND EXPERTISE -- AGAIN, YES OR
3 NO -- DID YOU FORM AN OPINION AS TO WHETHER THE CONDUCT OF
4 DEFENDANT AS TO THE TREATMENT AND CARE OF MARY CRANE DEVIATED
5 FROM THE STANDARDS OF CARE AS WOULD BE EXCERCISED BY A
6 PHYSICIAN IN THE SAME CIRCUMSTANCE?
7 A. YES.
8 Q. WHAT IS -- IN WHAT WAY DID THE DEFENDANT'S CONDUCT
9 DEVIATE FROM THAT STANDARD CARE?
10 A. I THINK IN THE PRINCIPLES OF EVALUATION AND DIAGNOSIS
11 AND DETERMINING THE ETIOLOGY OF THE SYMPTOMS OR WHERE THE
12 SYMPTOMS CAME FROM. I THINK THERE WAS ALSO A IGNORING OF
13 VAGINAL FISTULA AND ALSO INAPPROPRIATE ANTIBIOTICS ORDERED.
14 Q. DID THAT FALL BELOW THE STANDARD OF CARE?
15 A. YES.
16 Q. NOW, IF WE COULD TALK ABOUT LYDIA SMITH. DO YOU RECALL
17 HER CONDITION UPON ENTRY INTO THE HOSPITAL?
18 A. YES.
19 Q. DO YOU HAVE RECORD OF DEFENDANT'S OBSERVATION AND
20 EVALUATION OF THIS PATIENT UPON ADMISSION?
21 A. YES. THE ADMIT ORDERS WERE RECEIVED BY THE R.N., AND
22 THEN COUNTERSIGNED LATER BY THE PHYSICIAN ON 12/20/95 AT 1815
23 HOURS. AND THE PSYCHIATRIC EVALUATION WAS DONE ON 12/21/95
24 AT 2238, APPROXIMATELY 24 HOURS LATER.
25 Q. IS THERE ANYTHING UNUSUAL -- WELL, I SHOULDN'T SAY
1 UNUSUAL. IS THERE ANYTHING CONCERNING YOU ABOUT THAT?
2 A. IT DOES CONCERN ME THAT THE PATIENT ADMITTED TO AN ACUTE
3 PSYCHIATRIC UNIT DID NOT RECEIVE ANY EVALUATION FOR OVER ONE
4 DAY.
5 Q. DID YOU SEE ANYTHING ELSE THAT SUGGESTED POSSIBLE
6 PHYSICIAN NEGLECT OF THIS PATIENT?
7 MR. BUGDEN: WOULD YOU DO ME A FAVOR, COUNSEL, AND
8 REPEAT YOUR QUESTION?
9 MS. BARLOW: I ASKED IF HE SAW ANY POSSIBLE PHYSICIAN
10 NEGLECT.
11 MR. BUGDEN: THANK YOU.
12 MS. BARLOW: IN THIS PATIENT.
13 THE WITNESS: I THINK IN ADDITION TO NOT EVALUATING THE
14 PATIENT FOR APPROXIMATELY 28 HOURS AFTER ADMISSION, THERE WAS
15 A TIME ON JANUARY 7TH WHEN THE PHYSICIAN WAS UNAVAILABLE FOR
16 ABOUT SEVEN AND A HALF HOURS TO EVALUATE WHAT THE NURSING
17 ASSESSMENT HAD INDICATED WAS AN UNRESPONS -- NONRESPONSIVE
18 AND FRAGILE PATIENT.
19 Q. (BY MS. BARLOW) DID YOU REVIEW THESE RECORDS FOR ANY
20 GERIATRIC PHARMACOLOGY FOR THIS PATIENT?
21 A. I DID.
22 Q. AND WHAT DID YOU FIND?
23 A. THAT THERE WERE LARGE DOSES OF PSYCHOTROPIC MEDICATIONS
24 ORDERED THAT WERE CERTAINLY LARGER THAN STARTING DOSES, WHAT
25 NORMAL GERIATRIC PSYCHIATRISTS WOULD PRESCRIBE.
1 Q. DID YOU COUNT HOW MANY -- NOT DOSES, BUT HOW MANY
2 DIFFERENT PSYCHOATRIC -- PSYCHOACTING DRUGS SHE WAS ON?
3 A. I DID A REVIEW OF THE LAST FIVE DAYS OF THE MEDICATIONS
4 THAT SHE WAS ON PRI -- PREVIOUS TO HER DYING, AND SHE ON AT
5 THAT POINT, IN ADDITION TO OTHER MEDICATIONS THAT HAD BEEN
6 ORDERED, SEVEN DIFFERENT MEDICATIONS THAT HAD INFLUENCE IN
7 AFFECTING PROCESSES IN THE BRAIN.
8 Q. IS THERE ANY RISK TO HER FROM THAT NUMBER AND DOSES OF
9 PSYCHOACTIVE MEDICATIONS?
10 A. AGAIN, THERE -- BECAUSE OF ALL THE MEDICATIONS, IT'S
11 VERY DIFFICULT TO PREDICT IN AN EXPERIMENT WHAT WOULD HAPPEN
12 IF YOU DID THIS TO SOME WOMAN IN THIS STAGE. AGAIN, SHE WAS
13 A 90-YEAR-HOLD FRAIL WOMAN, FRAIL-LOOKING WOMAN, AND THESE
14 SEEM TO BE VERY, VERY LARGE DOSES THAT WERE PRESCRIBED OF
15 VARIOUS DIFFERENT MEDICATIONS FROM ANTIDEPRESSANTS TO ALSO
16 ANTIPSYCHOTIC MEDICATIONS AND ANTICONVULSANT MEDICATIONS.
17 Q. DO ANY OF THESE DRUGS HAVE A CENTRAL NERVOUS SYSTEM
18 DEPRESSANT EFFECT?
19 A. YES. ALL OF THEM POTENTIALLY CAN DEPRESS THE CENTRAL
20 NERVOUS SYSTEM. JUST AS ONE EXAMPLE, ONE OF MEDICATIONS --
21 MR. BUGDEN: THERE'S NO QUESTION RIGHT NOW.
22 THE COURT: OVERRULED.
23 MS. BARLOW: COULD YOU GIVE US ONE -- EXCUSE ME, GO
24 AHEAD --
25 THE COURT: GO AHEAD.
1 Q. (BY MS. BARLOW) DOCTOR.
2 A. AS AN EXAMPLE, MEDICATION THAT CAN CAUSE SEDATION WAS
3 STARTED AND THE DOSE ON THE 3RD OF JANUARY WAS 15 MILLIGRAMS
4 OF HALDOL I.M. IN A 90-YEAR-OLD FRAIL INDIVIDUAL, THAT'S A
5 VERY LARGE DOSE. THE EQUIVALENT DOSE ORALLY WOULD BE 30
6 MILLIGRAMS. TYPICAL DOSES THAT I USUALLY START WITH ARE
7 ABOUT A HALF OF A MILLIGRAM IN A GERIATRIC PATIENT. THE I.M.
8 DOSE ACTUALLY DOUBLES THE EFFECTIVE STRENGTH OF HALDOL, AND
9 SO THE DIFFERENCE BETWEEN ORAL AND I.M. IS DOUBLE, AND SHE'S
10 GETTING 15 MILLIGRAMS I.M. WHICH IS LARGE DOSE.
11 Q. DID YOU SEE ANY SYMPTOMS OF DELIRIUM IN MRS. SMITH?
12 A. THERE ACTUALLY WAS SYMPTOMS OF DELIRIUM. HER MENTAL
13 STATUS DID CHANGE. SHE SEEMED TO HAVE TIMES WHEN SHE WAS
14 MORE ALERT THAN OTHER TIMES, WHICH IS A CHANGE IN MENTAL
15 STATUS AGAIN INDICATING A DELERIUM FROM A POTENTIAL OF MANY
16 DIFFERENT SOURCES.
17 Q. IS THERE ANY NOTATION OR ANY INDICATION IN THE RECORDS
18 THAT DR. WEITZEL RECOGNIZED HER DELIRIUM?
19 A. THERE'S NO INDICATION IN THE RECORD THAT DELERIUM WAS
20 IDENTIFIED OR EVALUATED.
21 Q. DID HE DO ANY INTERVENTIONS FOR DELIRIUM?
22 A. AGAIN, I COULD FIND NO EVIDENCE FROM THE CHART THAT
23 DELERIUM WAS BEING ADDRESSED SPECIFICALLY.
24 Q. AT ONE NOTE ON THE 7TH OF JANUARY, THE NOTE OF THE
25 REGISTERED NURSE INDICATES THERE ARE NO WET DIAPERS. IS THAT
1 SIGNIFICANT AT ALL?
2 A. I THINK IT IS IN THE EVALUATION OF THIS PATIENT. NO WET
3 DIAPERS COULD MEAN A COUPLE OF THINGS: ONE, SHE'S NOT
4 URINATING. AND THEN THE CAUSE, WHY ISN'T SHE URINATING,
5 COULD BE DUE TO A COUPLE OF THINGS. EITHER THERE'S NO URINE,
6 WHICH MAY MEAN SHE'S DEHYDRATED OR THERE'S NO URINE THAT'S
7 ABLE TO GET OUT OF THE BLADDER, WHICH MEANS THAT SHE'S
8 RETAINING URINE WHICH COULD INCREASE PAIN AS WELL.
9 Q. WHAT MIGHT CAUSE A RETENTION OF URINE?
10 A. ACTUALLY, THE MEDICATIONS THAT SHE'S ON, SHE'S ON
11 SEVERAL DIFFERENT MEDICATIONS THAT COULD CAUSE URINARY
12 RETENTION AS WELL. SHE'S ALSO ON MEDICATION THAT CAN ALSO
13 CAUSE DEHYDRATION.
14 Q. AND DEHYDRATED PERSON IN THIS CONDITION, WOULD YOU
15 HYDRATE OR NOT?
16 A. I THINK AGAIN, IT'S A CLINICAL DECISION BASED ON AN
17 EVALUATION. THE HYDRATION, IF IT'S BECAUSE OF MEDICATIONS IN
18 PATIENT'S TOO SEDATED TO DRINK OR TAKE MEDICATIONS, YOU MAY
19 WANT TO REDUCE THE AMOUNT OF THAT MEDICATION SO PATIENTS CAN
20 DRINK AND BE HYDRATED. IF -- AGAIN, IF YOU'RE IN A TERMINAL
21 MODE, YOU MAY NOT BE TOO CONCERNED ABOUT HYDRATION. YOU MAY
22 ALLOW SOMEONE TO BE -- GO INTO DEHYDRATION AND INTO A CALM
23 DELIRIUM AS A MEANS OF A CALM EXIT.
24 Q. DID YOU SEE ANY LOSS OF WEIGHT FOR THE WHAT, 18 DAYS
25 THAT MRS. SMITH WAS ON THE UNIT?
1 A. YES, THERE WAS A LOT LOSS OF WEIGHT FROM APPROXIMATELY
2 116 POUNDS ON ADMISSION TO 107.8 POUNDS DURING THE 18-DAY
3 STAY.
4 Q. DOES THAT CAUGHT YOU ANY CONCERN AS A PHYSICIAN?
5 A. WELL, IT DOES. IT BRINGS UP THE CONCERN OF THE
6 DEHYDRATION CERTAINLY AS WELL AS MALNUTRITION.
7 Q. IS THERE ANY TREATMENT OF EITHER OF THOSE CONDITIONS,
8 ANY INTERVENTIONS?
9 A. THE TREATMENT IS USUALLY DICTATED BY THE EVALUATION AND
10 THE IDEA OF WHY THE PERSON MIGHT NOT BE EATING OR MIGHT BE
11 DEHYDRATED. AND ONE OF THE FIRST THINGS I THINK ABOUT IS TO
12 EVALUATE THE DELERIUM TO SEE IF THERE ARE REVERSIBLE CAUSES.
13 AND SO DOING THAT I THINK IS IMPORTANT TO FIND OUT IF
14 SOMEBODY CANN'T -- HAS A URINARY TRACT INFECTION OR THEY'RE
15 RETAINING URINE OR THEY'RE ON MEDICATIONS THAT MAY CAUSE
16 DEHYDRATION, SUCH AS A DIURETIC MEDICATION OR SOME HIGH BLOOD
17 PRESSURE MEDICATION COULD DO THAT.
18 Q. DID YOU SEE THAT KIND OF EVALUATION FROM DR. WEITZEL?
19 A. I DIDN'T SEE ANY EVALUATION OF POSSIBLE CAUSES OF THIS
20 DEHYDRATION OR MALNUTRITION.
21 Q. CAN DEHYDRATION AND MALNUTRITION BE UNCOMFORTABLE?
22 A. IN STATES OF DELIRIUM IN TERMINAL PHASES, WE ACTUALLY
23 MAY WANT TO NOT HAVE SOMEONE HYDRATED BECAUSE THAT MAKES THE
24 DELIRIUM -- DEEPENS THE DELIRIUM, DEEPENS THE STATE OF SLEEP,
25 IF YOU, AND ALSO THE SENSATION TO PAIN IS MUTED IN A DEEP
1 DELIRIUM. SO FEEDING AND HYDRATION MAY NOT BE SOMETHING
2 YOU'D WANT TO DO IN A TERMINAL PATIENT. HOWEVER, IF YOU HAD
3 A DELIRIOUS PATIENT THAT YOU WERE TRYING TO FIND OUT WHAT WAS
4 GOING ON, IT'S VERY IMPORTANT TO FIND OUT WHAT IS GOING ON TO
5 SEE IF THERE'S SOMETHING REVERSIBLE.
6 Q. DID MRS. SMITH COME INTO THE GEROPSYCH UNIT FOR TERMINAL
7 CARE?
8 A. FROM EVERY INSTANCE THAT I CAN SEE, SHE WAS ADMITTED FOR
9 A PRIMARY PSYCHIATRIC DIAGNOSIS AND NOT FOR TERMINAL CARE.
10 Q. BASED UPON YOUR REVIEIW OF THE MEDICAL RECORDS OF LYDIA
11 SMITH, YOUR EXPERIENCE, TRAINING, AND EXPERTISE, DID YOU FORM
12 AN OPINION AS TO WHETHER THE CONDUCT OF THE DEFENDANT AS TO
13 THE TREATMENT AND CARE OF LYDIA SMITH DEVIATED FROM THE
14 STANDARDS OF CARE AS WOULD BE EXERCISED BY A PHYSICIAN IN THE
15 SAME CIRCUMSTANCES?
16 A. YES.
17 Q. AND WHAT -- IN WHAT AREAS DID THE DEFENDANT'S CONDUCT
18 DEVIATE?
19 A. I THINK THE AREAS OF CONDUCT INCLUDED NOT PAYING
20 ATTENTION DURING THE FIRST TIMES OF ADMISSION, NOT BEING
21 AVAILABLE FOR APPROXIMATELY 28 HOURS, AND THEN ALSO, NOT
22 BEING ABLE TO BE AVAILABLE FOR THE NURSES FOR WHATEVER REASON
23 FOR ABOUT A SEVEN AND A HALF HOUR PERIOD. ALSO, PRINCIPLES
24 OF GERIATRIC PHARMACOLOGY SEEMED NOT TO BE ADHERED TO IN THIS
25 CASE. AND ALSO THE RECOGNITION AND EVALUATION OF DELIRIUM IS
1 POSSIBLY A CONFOUNDING FACTOR IN THE PATIENT'S UNDERLYING
2 CONDITION, WAS NOT RECOGNIZED OR EVALUATED.
3 Q. DID YOU HAVE -- WELL, DID THE STANDARD OF -- EXCUSE ME.
4 DID DEFENDANT'S CONDUCT FALL BELOW THE STANDARD OF CARE?
5 A. YES.
6 Q. IF WOULD YOU NOW TURN TO ENNIS ALLDREDGE. DID YOU HAVE
7 OCCASION TO LOOK AT HIS RECORDS?
8 A. YES.
9 Q. WHAT WAS HIS CONDITION UPON ADMISSION?
10 A. ACCORDING TO THE INTAKE EVALUATION, HE WAS VERY
11 AGRESSIVE, HE WAS COMBATIVE, HE WAS KICKING, HE WAS BITING,
12 AND HE WAS HAVING TO BE RESTRAINED IN A GERIATRIC CHAIR. OR A
13 GERI-CHAIR.
14 Q. DO YOU SEE ANY INDICATON THAT DR. WEITZEL SAW
15 MR. ALLDREDGE, YOU KNOW, ACTUAL HANDS-ON WITHIN THE FIRST 24
16 HOURS OF HIS ADMISSION?
17 A. THE ADMISSION ORDERS WERE WRITTEN ON 1/10/96 AT 1300
18 HOURS WITH A VERBAL ORDER AND THE PSYCHIATRIC CONSULTATION
19 WAS ACTUALLY NOT -- EXCUSE ME. WAS DONE ON 1/10/96 AT 1625.
20 Q. SO THE EVALUATION WAS DONE, WHAT --
21 A. THE SAME DAY, APPROXIMATELY THREE AND A HALF HOURS AFTER
22 ADMISSION.
23 Q. AND THERE'S NO PROBLEM WITH THAT IN YOUR MIND, IS THAT
24 CORRECT?
25 A. THAT'S CORRECT. THAT'S NOT AN UNUSUAL TIME FRAME.
1 Q. DID YOU SEE ANY INDICATION OF CONCERNS WITH GERIATRIC
2 PHARMACOLOGY WITH MR. ALLDREDGE?
3 A. I DO. AND ON THAT SAME DAY, A LITTLE LATER, AN
4 EVALUATION THAT WAS DONE BY DR. DIENHART NOTED THAT THE
5 PATIENT HAD CHEYNE-STOKES RESPIRATION AND APNEA LASTING FROM
6 20 TO 40 SECONDS. DIMINISHED BREATH SOUNDS, A POOR BAG
7 REFLEX, AND SIGNIFICANT SEDATION FROM HIS MEDICATION REGIMEN
8 THAT HAD BEEN STARTED.
9 Q. AND AS A PHYSICIAN, WOULD THAT CAUSE YOU CONCERN?
10 A. IT CERTAINLY WOULD. ACCORDING TO DR. DIENHART, HE FELT
11 THAT IT WAS THE MEDICAL REGIMEN THAT WAS CAUSING THIS. HE
12 ALSO NOTED THAT THERE WERE SEVERAL LABORATORIES ABNORMALITIES
13 THAT WERE NOTED AS WELL.
14 Q. DID YOU SEE ANY INDICATION IN THE RECORDS THAT
15 DR. WEITZEL ADDRESSED ANY OF THESE CONCERNS?
16 A. ACCORDING TO THE NOTES THAT I REVIEWED, THERE'S NOT ANY
17 DIRECT ADDRESSING OF THE CONCERNS THAT DR. DIENHART SAW.
18 Q. DOES THAT CONCERN YOU AS A PHYSICIAN?
19 A. IT DOES BECAUSE I THINK CHEYNE-STOKES RESPIRATIONS, IF
20 THE CONTEXT IS APPROPRIATE, IS OFTENTIMES RESPIRATIONS THAT
21 OCCUR IN PEOPLE WHO ARE DYING.
22 Q. WAS THERE A CHEST X-RAY ADMINISTERED UPON ADMISSION?
23 A. THERE WAS A CHEST X-RAY THAT WAS GOTTEN ON THE SAME DAY
24 OF ADMISSION. AND THE IMPRESSION FROM THE RADIOLOGIST WAS
25 THAT THERE WAS SOME LEFT LOWER LOBE ATELECTASIS OR PERHAPS
1 INFILTRATE. AND THERE WAS ALSO A SUGGESTION OF SOME LEFT
2 PLEURAL EFFUSION WHICH TO ME POINT AS A GERIATRICIAN SUGGESTS
3 THAT THERE MAY HAVE BEEN A PHEUMONIA ON ADMISSION.
4 Q. DO SEE ANY INDICATION IN THE RECORD THAT DR. WEITZEL DID
5 ANYTHING ABOUT THAT POSSIBLE PNEUMONIA?
6 A. I SEE NO INDICATION THAT THERE WAS A RECOGNITION OF THAT
7 TEST.
8 Q. CAN ANYTHING BE DONE ABOUT PHEUMONIA IN THAT
9 CIRCUMSTANCE?
10 A. YES. PNEUMONIA IS VERY TREATABLE DISEASE.
11 Q. WAS HE TERMINAL AT THAT POINT WHERE YOU WOULDN'T WANNA
12 TREAT IT?
13 A. AT THAT POINT, AND AGAIN, GOING OFF THE RECOMMENDATIONS
14 FROM DR. DIENHART, IT DOESN'T APPEAR THAT HE WAS TERMINAL,
15 BUT HE WAS POTENTIALLY OVERSEDATED BECAUSE OF HIS MEDICATIONS
16 WHICH COULD ALSO MAKE THE PNEUMONIA WORSE. WHEN YOU'RE
17 SEDATED, OFTENTIMES SECRETIONS CAN GET INTO THE LUNGS AS WELL
18 AND SO IT MAY HAVE BEEN SOMETHING THAT WOULD CONTRIBUTE TO
19 THAT AND YOU'D WANNA REVERSE IN ORDER TO TREAT PNEUMONIA, MAY
20 BE APPROPRIATE WITH ANTIBIOTICS AND THEN NOT AS MUCH
21 SEDATION.
22 Q. WOULD THAT HAVE TO BE I.V. ANTIBIOTICS?
23 A. NOT NECESSARILY. THERE ARE ORAL ANTIBIOTICS THAT COULD
24 BE GIVEN IF PEOPLE WILL TAKE ORAL.
25 Q. OKAY. ON THE 11TH, I BELIEVE THERE IS A NOTATION OF A
1 FEVER. DID YOU SEE ANY NOTATION OR ANY INDICATION THAT
2 DR. WEITZEL DID ANYTHING ABOUT THAT FEVER?
3 A. NO. ACCORDING TO DR. WEITZEL'S NOTE ON THE 11TH, HE DID
4 NOTE A FEVER. HE NOTICED ALSO SODIUM AND WHITE BLOOD COUNT
5 AND GLUCOSE LEVELS WERE NOTED. HIS ASSESSMENT THAT THIS WAS
6 PSYCHOSIS NOT OTHERWISE SPECIFIED AND TO CONTINUE CURRENT
7 CARE, THERE'S NO -- AT LEAST IN THE NOTE, NO RECOGNITION OF
8 THE MEDICAL PROBLEMS THAT ARE GOING ON WITH THIS PERSON OR
9 POTENTIALLY. A FEVER IN A PERSON OF 82 YEARS OLD OR ACTUALLY
10 OVER THE AGE OF 65 IS INDICATIVE OF INFECTION ABOUT 99
11 PERCENT OF THE TIME WITH 99 PERCENT SENSITIVITY.
12 Q. THEN ON THE 13TH -- WELL, ON THE 12TH, THERE'S AN M.R.I.
13 ORDERED. IS THERE ANY INDICATION WHY DR. WEITZEL ORDERED AN
14 M.R.I. FOR MR. ALLDREDGE?
15 A. IT'S UNCLEAR FOR ME WHY THE M.R.I. WAS ORDERED. IT IS
16 NOTED, THE M.D. NOTES ON THE 12TH INDICATE THAT THE PATIENT
17 WHAT COMBATIVE, REFUSING MEDICATIONS, AND HALDOL WAS
18 INCREASED. THE NEXT DAY IS WHEN THE M.R.I. WAS ORDERED, BUT
19 THERE'S NO RATIONALE OR DOCUMENTATION OF WHY THAT WAS GOING
20 ON.
21 Q. AND DID YOU READ THE RESULTS OF THE M.R.I.?
22 A. YES. THE RESULTS OF THE M.R.I. WERE SUBOPTIMAL BECAUSE
23 OF THE MOVEMENTS OF THE PATIENT ON THE 12TH, BUT IT DID
24 SUGGEST A SUBACUTE OR AN ACUTE C.N.S. EVENT.
25 Q. AND WHAT IS THAT?
1 A. AGAIN, IN -- SOMETHING IN THE BRAIN HAD GONE BAD. HE
2 HAD HAD A STROKE OR POTENTIALLY A BLEED OR SOMETHING OF THAT
3 NATURE HAD OCCURRED.
4 Q. DID ANYTHING IN THAT REPORT INDICATE TO YOU THAT
5 MR. ALLDREDGE HAD HAD A MASSIVE STROKE AND WAS GOING TO NOT
6 LIVE THROUGH THE NIGHT?
7 MR. BUGDEN: THAT'S TWO QUESTIONS.
8 THE COURT: SUSTAINED.
9 Q. (BY MS. BARLOW) OKAY. WAS THERE ANYTHING IN THAT REPORT
10 THAT INDICATED TO YOU THAT MR. ALLDREDGE HAD HAD A MASSIVE
11 STROKE?
12 A. IT'S DIFFICULT TO ASSESS THAT BECAUSE THERE'S NO
13 PHYSICAL OR NEUROLOGIC EXAMINATION DOCUMENTED IN THE CHART.
14 THE ONLY THING THAT I WAS ABLE TO GLEAN IS ON THE SAME DAY,
15 THE NURSES NOTED THAT EVENING AT AROUND TEN O'CLOCK THAT THE
16 PATIENT WAS UNABLE TO SWALLOW. THAT'S THE ONLY NEUROLOGIC
17 EXAM THAT I HAVE, WHICH I FIND DISCONCERTING.
18 Q. AND WHY IS IT DISCONCERTING?
19 A. BECAUSE WITH THAT KIND OF INFORMATION, CERTAINLY THERE
20 WAS SOME REASON THAT THE M.R.I. WAS ORDERED AND THEN YOU'D
21 WANT TO DOCUMENT IF A PROCESS WAS GOING ON IN THE BRAIN, WITH
22 SERIAL NEUROLOGIC EXAMINATIONS, WHAT WAS THE PROGRESSION OF
23 THAT, WAS IT STABILIZING, WAS IT GETTING BETTER, TO BE ABLE
24 TO GIVE SOME KIND OF IDEA ON PROGNOSIS OR WHAT WOULD BE THE
25 OUTCOME OF THIS EVENT. AND THAT WOULD BASED ON A PHYSICAL
1 EXAMINATION AND I REALLY DON'T SEE THE PHYSICAL EXAMINATION
2 DOCUMENTING WHICH WAY THIS EVENT IS GOING.
3 Q. BASED ON THE REPORTS OF THE M.R.I., DID YOU SEE ANY
4 INDICATION THAT MR. ALLDREDGE WOULD NOT LIVE THROUGH THE
5 NIGHT?
6 A. BASED ON THE DOCUMENTATION, I DIDN'T SEE ANYTHING
7 DOCUMENTED THAT MADE ME THINK THAT HE WAS GOING DIE
8 IMMEDIATELY.
9 Q. ON THE 14TH, MORPHINE IS ORDERED. DO YOU HAVE ANY -- IS
10 THERE ANY DOCUMENTATION OR ANY INDICATION IN THE RECORD ABOUT
11 WHY MORPHINE WAS BEING ORDERED?
12 A. NO. THERE WAS ON THE 14TH, THE INDICATION WAS A NURSING
13 NOTE THAT A VERBAL ORDER WAS TAKEN FOR MORPHINE AS A
14 10-MILLIGRAM DOSE NOW THAT WAS GIVEN AT SIX O'CLOCK IN THE
15 LEFT GLUTEUS. THE NURSES DO RECORD, HOWEVER, THAT THERE WAS
16 NO RESPONSE TO THE PATIENT FROM THAT NEEDLE STICK.
17 Q. WHAT DOES THAT TELL YOU ABOUT THE PATIENT'S CONDITION?
18 A. THAT INDICATES THAT THEY'RE NOT RESPONDING TO PAIN.
19 Q. WHAT DOES THAT TELL YOU?
20 A. THAT THERE'S SOMETHING GOING ON THAT NEEDS TO BE
21 EVALUATED, WHETHER IT'S SEDATION OR IT'S PROGRESSION OF THE
22 STROKE, SOMETHING'S GOING ON THERE THAT I'M NOT SURE THE THE
23 INDICATION FOR MORPHINE IF SOMEONE'S NOT RESPONDING TO PAIN.
24 Q. WAS ANY -- IS THERE ANY RECORD IN THE -- IN THE CHART OF
25 AN EVALUATION BY DR. WEITZEL OF WHAT'S GOING ON THERE?
1 A. NO. THERE'S NO REPORT FROM -- NO M.D. EVALUATION.
2 HOWEVER, PRIOR TO GIVING THE MORPHINE, THE NURSE DOES
3 DOCUMENT THAT THE PATIENT HAS CHEYNE-STOKE RESPIRATIONS AND
4 PERIODS OF APNEA.
5 Q. DOES MORPHINE HELP THAT PROBLEM?
6 A. NO. ACTUALLY, MORPHINE MAY MAKE THAT SITUATION MUCH
7 WORSE.
8 Q. NOW, THERE WAS AN ORDER FOR A DOSE OF MORPHINE AND ALSO
9 ATIVAN AT 9:20, I THINK IT'S THE MORNING OF THE 14TH. IS
10 THERE ANYTHING UNUSUAL ABOUT THAT IN YOUR MIND?
11 A. WELL, IT -- IT IS UNUSUAL TO ME THAT THE ATIVAN WAS
12 ADDED TO THE MORPHINE AT THAT TIME. THE PHYSICIAN WAS NOT
13 PRESENT, IT WAS GIVEN AS A VERBAL ORDER, AND THERE WAS NO
14 ASSESSMENT TO SAY WHY THAT THAT WAS NEEDED TO ADD THE ATIVAN
15 AT THAT TIME. THE PHYSICAL VITAL SIGNS WERE THAT THE PATIENT
16 WAS HAVING APNEA AT THAT POINT LASTING UP TO 60 SECONDS,
17 WHICH MEANS THAT PATIENT WASN'T BREATHING FOR UP TO 60
18 SECONDS, AND ALSO THAT THEY HAD WHAT THE NURSES DOCUMENT AS A
19 TACHY AND THREADY HEART RATE.
20 Q. WHAT WOULD BE THE EFFECT OF ATIVAN AND MORPHINE UPON HIS
21 CONDITION AT THAT -- HIS BREATHING CONDITION AT THE TIME?
22 A. WELL, THEY WOULD HAVE SYNERGISTIC EFFECTS ON FURTHER
23 SUPPRESSION OF BREATHING AND ALSO OTHER -- OTHER FUNCTIONS
24 AND SEDATION. AND BY SYNERGISTIC, I MEAN MORE THAN JUST
25 ADDITIVE. IT WOULD BE MORE THAN JUST ADDITIVE. IN EITHER
1 ONE ALONE, THEY WOULD HAVE A MUCH GREATER EFFECT THAN ANY
2 MEDICATION SINGALLY.
3 Q. AND I BELIEVE THE RECORDS SHOW THAT DIED AT 9:36 --
4 A. THAT'S RIGHT.
5 Q. -- ABOUT 16 MINUTES LATER, IS THAT CORRECT?
6 A. THAT'S CORRECT.
7 Q. BASED UPON YOUR REVIEW OF THE MEDICAL RECORDS OF ENNIS
8 ALLDREDGE AND YOUR EXPERIENCE, TRAINING, AND EXPERTISE, DID
9 YOU FORM AN OPINION AS TO WHETHER THE CONDUCT OF THE
10 DEFENDANT AS TO THE TREATMENT AND CARE OF ENNIS ALLDREDGE
11 DEVIATED FROM THE STANDARDS OF CARE AS WOULD BE EXERCISED BY
12 A PHYSICIAN IN THE SAME CIRCUMSTANCES?
13 A. YES.
14 Q. IN WHAT WAY, IN WHAT AREAS DID THE DEFENDANT'S CONDUCT
15 DEVIATE?
16 A. I THINK THAT THE CONDUCT DEVIATED IN TERMS OF
17 RECOGNITION AND EVALUATION OF MEDICAL SYMPTOMATOLOGY. AND
18 ALSO PHARMACOLOGICAL INTERACTIONS AS WELL AS DOCUMENTATION
19 CONCERNING THE REASON OF THE DOSING AND THE TIMING OF DOSING,
20 GIVING THE PATIENT'S STATUS OF HAVING APNEA AND ALSO HAVING A
21 THREADY HEART RATE.
22 Q. AND IN YOUR OPINION, DID DEFENDANT'S CARE OF ENNIS
23 ALLDREDGE FALL BELOW THE STANDARD OF CARE?
24 A. YES.
25 MS. BARLOW: BELIEVE THAT'S ALL I HAVE, YOUR HONOR.
1 THE COURT: CROSS-EXAMINE. BUT LADIES AND GENTLEMEN,
2 LET'S ALL STAND AND STRETCH FOR A MINUTE BEFORE WE START WITH
3 CROSS-EXAMINATION.
4 OKAY. LET'S GO AHEAD.
5 MR. BUGDEN: I'M NOT QUITE READY.
6 BY MR. BUGDEN:
7 Q. GOOD MORNING.
8 A. MORNING.
9 Q. I'M WALLY BUGDEN. WE INTRODUCED OURSELVES A COUPLE OF
10 HOURS AGO NOW. I'M ONE OF THE LAWYERS THAT REPRESENTS
11 DR. WEITZEL, AND I'M GONNA ASK YOU SOME QUESTIONS FOR A
12 WHILE, DOCTOR.
13 DOCTOR, AM I CORRECT THAT YOU DO NOT BELIEVE THAT
14 MORPHINE CAUSED THE DEATH OF ANY OF THESE PATIENTS?
15 MS. BARLOW: YOUR HONOR, I OBJECT. THIS WITNESS IS NOT
16 AN EXPERT FOR CAUSE OF DEATH.
17 THE COURT: OVERRULED. HE CAN GIVE HIS OPINION.
18 THE WITNESS: I THINK THE CAUSE OF DEATH IN EACH ONE OF
19 THESE PATIENTS WAS A COMPLEX --
20 Q. (BY MR. BUGDEN) LET ME MAKE --
21 A. -- SET OF EVENTS.
22 Q. LET ME MAKE SURE THAT YOU UNDERSTAND MY QUESTION. AND
23 I'M GONNA ASK YOU FROM TIME TO TIME JUST TO ANSWER MY
24 QUESTION, DOCTOR. RIGHT NOW I'M ASKING YOU A VERY SPECIFIC
25 QUESTION. IT'S A QUESTION I ASKED YOU BEFORE YOU TOOK THE
1 STAND THIS MORNING. AND THAT IS, YOU DO NOT BELIEVE TO A
2 REASONABLE DEGREE OF MEDICAL CERTAINTY THAT A MORPHINE
3 OVERDOSE CAUSED THE DEATH OF A SINGLE ONE OF THESE PATIENTS,
4 ISN'T THAT TRUE?
5 A. AS I INDICATED BEFORE, IT WAS A COMPLEX SET OF
6 CIRCUMSTANCES. I CAN GIVE YOU MY OPINION OF WHAT I THINK,
7 BUT IT WAS A COMBINATION OF EVENTS THAT CAUSED THE DEATHS.
8 Q. YOU DON'T BELIEVE THAT MORPHINE OVERDOSE CAUSED THE
9 DEATH OF ANY OF THESE PATIENTS, ISN'T THAT TRUE?
10 A. IN THE MAJORITY OF PATIENTS, I THINK THAT IS TRUE. I
11 HAVE ONE QUESTION ON ONE PATIENT.
12 Q. WHICH PATIENT IS THAT?
13 A. THE PATIENT THAT WE HAD JUST TALKED ABOUT.
14 Q. MR. ALLDREDGE?
15 A. MR. ALLDREDGE.
16 Q. OKAY. SO ON THE OTHER FOUR PATIENTS, IT'S YOUR OPINION
17 THAT MORPHINE OVERDOSE DID NOT CAUSE DEATH.
18 A. I DO NOT BELIEVE THAT THE MORPHINE WAS RESPONSIBLE FOR
19 THEIR DEATHS SOLELY.
20 Q. YOU DON'T BELIEVE THAT THE MORPHINE OVERDOSE CAUSED THE
21 DEATH OF ELLEN ANDERSON --
22 MS. BARLOW: OBJECTION, YOUR HONOR. IT'S BEEN ASKED AND
23 ANSWERED.
24 THE COURT: OVERRULED.
25 Q. (BY MR. BUGDEN) JUST STAY WITH ME PLEASE, DOCTOR --
1 DR. BAIR. YOU DO NOT BELIEVE THAT ELLEN ANDERSON DIED FROM A
2 MORPHINE OVERDOSE, ISN'T THAT TRUE?
3 A. THAT'S CORRECT.
4 Q. YOU DO NOT BELIEVE THAT LYDIA SMITH DIED FROM A MORPHINE
5 OVERDOSE, ISN'T THAT TRUE?
6 A. THAT'S CORRECT. BUT I WOULD --
7 Q. YOU DO NOT BELIEVE --
8 A. -- IN ORDER TO ANSWER THE QUESTION --
9 Q. DOCTOR, I'M GONNA ASK YOU TO ANSWER --
10 THE COURT: NOW, WAIT A MINUTE, MR. BUGDEN. ANSWER THE
11 QUESTION. IF COUNSEL WANTS TO GO INTO THAT, THEY CAN DO IT
12 ON REDIRECT.
13 THE WITNESS: THANK YOU.
14 THE COURT: SO ANSWER THE QUESTIONS AS BEST YOU CAN.
15 Q. (BY MR. BUGDEN) YOU DO NOT BELIEVE THAT JUDITH LARSEN
16 DIED FROM A MORPHINE OVERDOSE, ISN'T THAT TRUE?
17 A. IT'S NOT THE SOLE CAUSE OF DEATH.
18 Q. YOU DO NOT BELIEVE THAT MARY CRANE DIED FROM A MORPHINE
19 OVERDOSE, ISN'T THAT TRUE?
20 A. IT WAS NOT THE SOLE CAUSE OF DEATH.
21 Q. DOCTOR, IN YOUR PRACTICE, IN YOUR GERIATRIC PRACTICE,
22 YOU TREAT PATIENTS WITH MORPHINE, ISN'T THAT TRUE?
23 A. THAT'S CORRECT.
24 Q. AND YOU TREAT PATIENTS IN END STAGES OF THEIR LIFE WITH
25 MORPHINE, ISN'T THAT TRUE, DR. BAIR?
1 A. THAT ALSO CORRECT.
2 Q. AND ISN'T IT TRUE, DR. BAIR, THAT YOU HAVE TREATED
3 PATIENTS WITH MORPHINE SULFATE WHO HAVE THEN DIED WITH
4 MORPHINE SULFATE ON BOARD?
5 A. THAT IS CORRECT.
6 Q. THANK YOU, DOCTOR. DOCTOR, I'D LIKE TO ASK YOU SOME
7 QUESTIONS ABOUT DEMENTIA. PEOPLE WITH DEMENTIA DIE AS A
8 RESULT OF COMPLICATIONS SECONDARY TO THEIR DEMENTIA, ISN'T
9 THAT TRUE?
10 A. THAT'S CORRECT.
11 Q. PEOPLE DIE -- DEMENTED PATIENTS DIE FROM BODY WASTING,
12 ISN'T THAT TRUE?
13 A. SOME OF THEM DO, YES.
14 Q. AND ISN'T IT TRUE THAT SOME DEMENTED PATIENTS DIE FROM A
15 DIMINISHED GAG REFLEX, DR. BAIR?
16 A. THAT IS TRUE.
17 Q. AND ISN'T IT TRUE THAT SOME DEMENTED PATIENTS DIE FROM A
18 DISCOORDINATED SWALLOWING?
19 A. THAT IS CORRECT.
20 Q. AND ISN'T IT TRUE THAT THE DISCOORDINATED SWALLOWING CAN
21 LEAD TO WHAT'S CALLED ASPIRATION PHEUMONIA, DR. BAIR?
22 A. THAT'S CORRECT.
23 Q. AND ASPIRATION PNEUMONIA, I THINK THE JURORS UNDERSTAND
24 IT, BUT IT IS WHEN YOU INHALE SOMETHING INTO THE WRONG TUBE
25 AND IT ENDS UP IN YOUR LUNG?
1 A. THAT'S CORRECT.
2 Q. AND THEN THAT DECREASES THE RESPIRATORY FUNCTION OR THE
3 INHALATION, THE ABILITY OF THE LUNG TO TAKE ON OXYGEN?
4 A. THAT'S CORRECT.
5 Q. AND FILL UP PROPERLY?
6 A. THAT'S CORRECT.
7 Q. AND THAT'S A FREQUENT CAUSE OF DEATH IN OLDER PEOPLE,
8 ISN'T THAT TRUE?
9 A. IN ALL OLDER PEOPLE, THAT'S CORRECT.
10 Q. AND DISCOORDINATED SWALLOWING AND THE ASPIRATION
11 PNEUMON -- I'M SORRY, DIFFERENT QUESTION. ISN'T IT ALSO TRUE
12 THAT PEOPLE WITH DEMENTIA FREQUENTLY DIE FROM URINARY TRACT
13 INFECTIONS?
14 A. THEY CAN, YES.
15 Q. WHEN THE BRAIN BEGINS TO STOP WORKING IN THE DEMENTED
16 PERSON, THAT AFFECTS THE BODY, DOESN'T IT?
17 A. ABSOLUTELY. THE BRAIN CONTROLS ALL BODILY FUNCTIONS.
18 Q. THE BRAIN IN A SIMPLE WAY, TO MY SIMPLE MIND, THE BRAIN
19 IS THE CENTER OF THE UNIVERSE OF OUR BODY, IS THAT RIGHT?
20 A. THAT'S CORRECT. IT CONTROLS ALL THE BODILY FUNCTIONS.
21 Q. IT'S THE COMPUTER THAT RUNS NOT JUST THE MENTAL
22 FUNCTIONING, BUT IT OPERATES THE PHYSICAL SYM -- I'M SORRY,
23 THE DIFFERENT SYSTEMS THAT WE HAVE, WHETHER IT BE RESPIRATION
24 OR THE HEART, IT ALSO OPERATES THOSE THINGS AS WELL.
25 A. THAT'S CORRECT.
1 Q. AND SO AS THE -- AS AN INDIVIDUAL BECOMES MORE
2 DEMENTED -- AND DO YOU AGREE, DOCTOR, THAT DEMENTIA IS A
3 PROGRESSIVE DISEASE?
4 A. YES, BY DEFINITION IT IS A PROGRESSIVE DISEASE.
5 Q. AND SO AS THE PERSON BECOMES MORE AND MORE DEMENTED, THE
6 BRAIN IS -- IT'S BECOMING MORE AND MORE DISCOORDINATED OR
7 UNCOORDINATED.
8 A. CORRECT.
9 Q. MORE DIS -- DYSFUNCTIONAL.
10 A. CORRECT.
11 Q. AND SO NOT ONLY DOES THAT AFFECT THINGS LIKE SPEECH, BUT
12 IT ALSO AFFECTS ALL OF THE OTHER SYSTEMS ON BOARD, IS THAT
13 RIGHT?
14 A. THAT'S CORRECT.
15 Q. AND WITH DEMENTED PATIENTS, IT'S REALLY NOT ACCURATE TO
16 THINK IN TERMS OF AN INDIVIDUAL'S MENTAL FUNCTIONING IS
17 IMPAIRED, BUT THAT THEIR BODY REMAINS HEALTHY. IF A BRAIN
18 BEGINS TO DISINTEGRATE, AS THE BRAIN BEGINS TO BECOME
19 DISORIENTED, AGAIN, IT CONTROLS ALL THOSE FUNCTIONS, THE
20 PHYSICAL FUNCTIONS AS WELL AS THE MENTAL, ISN'T THAT RIGHT,
21 DOCTOR?
22 A. THAT'S NOT A QUESTION THAT CAN ACTUALLY BE ANSWERED WITH
23 A YES/NO ANSWER.
24 Q. ALL OF THESE PATIENTS, DOCTOR, WERE TRANSFERRED TO THE
25 HOSPITAL BECAUSE THEIR DEMENTEDING BEHAVIORS WERE MAKING THEM
1 TOO MUCH TO HANDLE IN THEIR NURSING HOME OR LONG-TERM CARE
2 FACILLITIES, ISN'T THAT TRUE?
3 A. FROM MY EVALUATION OF THEIR RECORDS, YES, THAT'S TRUE.
4 Q. THESE PATIENTS, EVERY ONE OF THEM, YOU EXPLAINED TO JURY
5 THAT THERE HAD BEEN A CHANGE IN THEIR MENTAL FUNCTIONING, IS
6 THAT RIGHT?
7 A. THAT THERE HAD BEEN AN ACUTE CHANGE IN THEIR MENTAL
8 FUNCTION OR A SUBACUTE CHANGE.
9 Q. AND THAT WAS MANIFESTING ITSELF, AMONG OTHER THINGS,
10 WITH KICKING, SCREAMING, BITING, LASHING OUT AT CARE
11 PROVIDERS, IS THAT RIGHT?
12 A. CORRECT.
13 Q. DID YOU KNOW -- AND WE'LL COME TO MR. ALL -- WE MAY
14 COME TO ALLDREDGE, BUT DID YOU KNOW, FOR EXAMPLE, THAT
15 MR. ALLDREDGE HAD ACTUALLY THROWN A WHEELCHAIR AT ANOTHER
16 PATIENT AT AT HIS LONG-TERM CARE FACILITY THAT RESULTED IN
17 THE BREAKING OF THE HIP OF THAT PATIENT?
18 A. YES. IT WAS IN THE NURSING HOME CHART.
19 Q. SO MR. ALLDREDGE, FOR EXAMPLE, WAS SOMEONE WHO WAS A
20 DANGER TO OTHERS, IS THAT RIGHT?
21 A. FROM HIS BEHAVIOR, YES.
22 Q. WELL, WERE YOU AWARE, DOCTOR, WHILE I'M ON MR. ALLDREDGE
23 FOR A SECOND, WERE YOU AWARE THAT HIS TREATING PHYSICIAN HAD
24 USED AN INCREASING REGIMEN OF ANTIPSYCHOTIC MEDICATION TO TRY
25 TO GET THAT AGITATION UNDER CONTROL?
1 A. YES.
2 Q. WERE YOU AWARE THAT HE USED LARGE DOSES OF ATIVAN ON THE
3 DAY BEFORE ADMISSIN TO THE NORTH DAVIS HOSPITAL?
4 A. CORRECT. I WAS AWARE OF THAT.
5 Q. AND HE USED -- HE HAD BEEN ON BUSPAR. AM I SAYING THAT
6 RIGHT?
7 A. THAT'S RIGHT.
8 Q. HE'D BEEN ON A COMBINATION OF ANTIPSYCHOTIC DRUGS.
9 A. RIGHT.
10 Q. TO TRY TO CONTROL THAT AGITATION, IS THAT RIGHT?
11 A. THAT'S RIGHT.
12 Q. AND WITH MR. ALLDREDGE AS WITH ALL OF THE PATIENTS, THEY
13 WERE SENT TO THE GEROPSYCH UNIT FOR THE SPECIFIC PURPOSE OF
14 RECEIVING ANTIPSYCHOTIC PSYCHOTROPIC MEDICATION TO TRY TO
15 CONTROL THESE SYMPTOMS OF AGITATION, ISN'T THAT TRUE?
16 A. MY UNDERSTANDING IS THEY WERE ADMITTED TO THE
17 PSYCHIATRIC UNIT TO CONTROL THE BEHAVIOR.
18 Q. AND CONTROLLING THE BEHAVIOR, AS PRACTICAL MATTER,
19 DIDN'T THAT MEAN EITHER PHYSICALLY RESTRAINING THEM OR
20 ALTERNATIVELY USING PSYCHOTROPIC MEDICATIONS TO TRY TO
21 CHEMICALLY CONTROL THAT AGITATION, ISN'T THAT TRUE, DR. BAIR?
22 A. NO.
23 Q. WHAT ELSE WAS THERE FOR THESE PATIENTS?
24 A. IN -- IN OUR RESEARCH ACTUALLY, WE FIND THAT THERE ARE
25 THREE TYPES OF INTERVENTIONS FOR DEMENTIA BEHAVIOR. ONE IS
1 PHARMACOLOGIC, THE OTHER IS PSYCHOSOCIAL, AND THE OTHER IS
2 ENVIRONMENTAL.
3 Q. LET'S TALK ABOUT THAT. THANK YOU FOR YOUR HELP THERE.
4 THE NURSING NOTES AT THE GEROPSYCH UNIT SHOW THAT ABSOLUTELY
5 NONE OF THESE PATIENTS RESPONDED TO ENVIRONMENTAL CONTROLS,
6 ISN'T THAT TRUE?
7 A. I DON'T SEE DOCUMENTATION OF THAT, NO.
8 Q. OKAY. THAT'S YOU VIEW?
9 A. I DON'T SEE THE DOCUMENTATION --
10 Q. NO DOCUMENTATION THAT THEY DID RESPOND TO ENVIRONMENTAL
11 CONTROLS?
12 A. I DON'T SEE THE DOCUMENTATION WHERE THAT WAS ATTEMPTED.
13 Q. YOU THINK MR. ALLDREDGE, FOR EXAMPLE, ON THE DAY OF HIS
14 ADMISSION, DO YOU THINK THAT THAT PATIENT COULD BE TREATED
15 WITH THERAPY BY PUTTING HIM IN A LITTLE GROUP AND THAT HE WAS
16 GONNA RESPOND TO GROUP ON JANUARY 10TH, 1996?
17 A. WELL, YOUR QUESTION INDICATES THAT YOU DON'T UNDERSTAND
18 THE PSYCHOSOCIAL INTERVENTIONS.
19 Q. MAYBE I DON'T, BUT I'M ASKING YOU TO ANSWER MY
20 QUESTION --
21 A. SO --
22 Q. -- RATHER THAN CRITICIZE --
23 A. -- WHAT I'D LIKE TO DO --
24 THE COURT: LISTEN, DOCTOR --
25 THE WITNESS: WHAT --
1 THE COURT: ANSWER THE QUESTION.
2 A. WHAT I'D LIKE TO DO IS EXPLAIN THE PSYCHOSOCIAL
3 INTERVENTION COURSE --
4 Q. (BY MR. BUGDEN) I'D LIKE YOU TO ANSWER MY QUESTION,
5 DR. BAIR --
6 A. PLEASE RESTATE THE QUESTION. MAYBE I DON'T UNDERSTAND
7 YOUR QUESTION.
8 Q. I'M ASKING YOU, DO YOU BELIEVE THAT MR. ALLDREDGE COULD
9 HAVE BEEN TREATED WITH THERAPY ON JANUARY 10TH?
10 A. I DO NOT BELIEVE THAT VERBAL THERAPY, SUCH AS
11 INTERPERSONAL THERAPY WOULD HAVE WORKED, BUT THAT IS NOT THE
12 ONLY PSYCHOSOCIAL INTERVENTION.
13 Q. THANK YOU. ALSO TALKING ABOUT MR. ALLDREDGE, IT IS
14 YOUR -- YOUR EXPERT OPINION THAT MR. ALLDREDGE ON JANUARY
15 10TH SHOULD HAVE BEEN TAKEN OFF ALL MEDICATIONS IN ORDER TO
16 ANALYZE WHETHER OR NOT HE WAS DELIRIOUS?
17 A. NO. MY CONTENTION IS, IS THAT AN EVALUATION SHOULD HAVE
18 BEEN DONE TO EVALUATE WHAT SHOULD HAVE BEEN DONE VIA PHYSICAL
19 EXAMINATION, LABORATORY EXAMINATIONS, AND THEN DICTATE WHAT
20 SHOULD HAVE BEEN DONE.
21 Q. I'D LIKE TO ASK YOU -- LET'S SEE HERE, I NEED TO ASK YOU
22 TO HOLD ON. I'M NOT QUITE READY TO ASK YOU. GIVE ME A
23 MINUTE.
24 I'M GONNA ASK YOU A FEW QUESTIONS ABOUT LYDIA SMITH.
25 AND ALTHOUGH YOU'RE WELCOME TO USE WHATEVER DOCUMENTS YOU
1 HAVE IN FRONT OF YOU, DOCTOR, I MAY -- I MAY TURN THE LIGHTS
2 OFF AND USE SOME OF THE MEDICAL RECORDS THAT YOU ALREADY
3 HAVE.
4 AM I CORRECT, DOCTOR, THAT YOU BEGIN YOUR CRITICISM OF
5 DR. WEITZEL, YOUR WRITTEN CRITICISM ANYWAY, BY SAYING THAT
6 THIS WAS A VERY DIFFICULT PATIENT?
7 A. ABSOLUTELY. SHE SEEMED A VERY DIFFICULT PATIENT.
8 Q. SHE PRESENTED WITH A MULTITUDE OF BEHAVIORAL PROBLEMS,
9 WOULD YOU AGREE WITH THAT?
10 A. YES.
11 Q. WOULD YOU AGREE, DR. BAIR, THAT THOSE BEHAVIORAL
12 PROBLEMS PERSISTED REALLY THROUGHOUT HER HOSPITAL STAY?
13 A. YES, UNTIL APPROXIMATELY THE 6TH OF JANUARY.
14 Q. OKAY. OKAY. AND WOULD YOU AGREE WITH ME, DOCTOR, THAT
15 SHE REALLY REMAINED EXTREMELY AGITATED UP UNTIL JANUARY 6TH
16 THEN?
17 A. YES.
18 Q. THANK YOU, DOCTOR. WELL, LET ME TALK TO YOU FOR JUST A
19 SECOND ABOUT DOSING DECISIONS. DO YOU AGREE WITH ME, DOCTOR,
20 THAT A DOSING DECISION, THAT THE DECISION THAT THE PHYSICIAN
21 MAKES WHEN THEY DECIDE HOW MUCH TO PRESCRIBE OF A PARTICULAR
22 MEDICINE, THAT THAT'S A MEDICAL JUDGMENT FOR THE CLINICIAN?
23 A. YES, IT IS.
24 Q. AND WOULD YOU AGREE WITH ME, DOCTOR, THAT THERE IS
25 ONE -- NO ONE DOSAGE THAT IS RIGHT?
1 A. THAT IS CORRECT.
2 Q. WOULD YOU AGREE WITH ME THAT REASONABLY COMPETENT
3 DOCTORS SUCH AS YOURSELF COULD DISAGREE ON WHAT DOSAGE OR
4 WHAT COMBINATIONS OF MEDICINES TO USE WITH A COMLETELY
5 DEMENTED PATIENT LIKE LYDIA SMITH?
6 A. YES.
7 Q. WOULD YOU AGREE WITH ME, DOCTOR, THAT YOUR OPINION --
8 YOU'VE EXPRESSED TO THIS JURY NUMEROUS OPINIONS, SOME OF
9 WHICH WE'RE GONNA TALK ABOUT TODAY, BUT WOULD YOU AGREE WITH
10 ME, DOCTOR, THAT YOUR OPINION ISN'T THE STANDARD OF CARE.
11 THE STANDARD OF CARE IS BROADER THAN DOC -- WHAT DR. BAIR
12 SAYS IT IS. DO YOU AGREE WITH THAT?
13 A. I DON'T THINK I CAN ANSWER THAT YES/NO QUESTION.
14 Q. DO YOU AGREE WITH ME THAT THERE ARE DIFFERENT WAYS FOR
15 DOCTORS TO APPROACH ANY MEDICAL PATIENT?
16 A. THAT ALSO IS NOT A YES/NO QUESTION.
17 Q. WOULD YOU THINK THAT THE STANDARD OF CARE INCLUDES A
18 RANGE OF BEHAVIORS THAT ARE ACCEPTABLE? OR DO YOU THINK
19 THERE'S ONLY ONE -- ONE WAY TO TREAT A PATIENT, AND THAT'S
20 THE STANDARD OF CARE? AND IF YOU DON'T DO IT THAT ONE WAY,
21 YOU'VE BREACHED THE STANDARD OF CARE?
22 A. AGAIN, THAT'S NOT A YES/NO QUESTION THAT I COULD ANSWER.
23 Q. WELL, I'M TO UNDERSTAND YOUR OPINION THAT YOU'VE
24 EXPRESSED TO THE JURY. IS THERE ONLY ONE WAY TO TREAT LYDIA
25 SMITH OR ARE THERE DIFFERENT APPROACHES TO TREATING LYDIA
1 SMITH, A VERY DIFFICULT PATIENT?
2 A. AGAIN, THAT'S NOT A YES/NO QUESTION. WOULD YOU LIKE ME
3 TO ADDRESS THAT AS --
4 Q. NO. IF YOU CAN'T -- IF YOU CAN'T ANSWER THAT, THAT
5 THERE'S MORE THAN ONE WAY TO TREAT THIS PATIENT, THAT'S FINE.
6 THAT'S YOUR OPINION?
7 A. MY OPINION IS, IS THAT IT'S NOT A YES/NO QUESTION.
8 Q. OKAY. NOW, YOU TOLD THE JURY, AS I UNDERSTAND IT, THAT
9 ONE OF THE DEVIATIONS BY DR. WEITZEL WAS THAT YOU DON'T --
10 WAS THAT HE SAW THIS PATIENT WITHIN 28 HOURS INSTEAD OF 24
11 HOURS OF HER ADMISSION?
12 A. NO, ACTU --
13 Q. IS THAT ONE OF YOUR STATEMENTS?
14 A. I THINK WHAT I SAID WAS THAT HE DID NOT EVALUATE THEM
15 WITHIN THAT TIME PERIOD, YES.
16 Q. LYDIA, I'M TALKING ABOUT LYDIA. DIDN'T YOU TELL US THAT
17 ONE OF YOUR DEVIATIONS FOR DR. WEITZEL, ONE OF THE WAYS IN
18 WHICH HE FAILED TO MEET DR. BAIR'S STANDARD OF CARE WAS THAT
19 HE DID NOT SEE THE PATIENT WITHIN 24 HOURS OF ADMISSION?
20 A. YES. IN FACT, I THINK I STATED IT WAS 28 HOURS.
21 Q. THANK YOU. ARE YOU TELLING THE JURY THAT BY DELAYING
22 SEEING THIS PATIENT BY FOUR HOURS -- IF IT WAS 24 HOURS, IF
23 HE HAD SEEN -- LET'S JUST STAY ON THE PAGE WITH ME, DOCTOR.
24 SO IF HE HAD SEEN LYDIA SMITH WITHIN 24 HOURS, HE WOULD HAVE
25 MET THE STANDARD OF CARE FOR YOU? ON THAT ISSUE, ON THE ONE
1 ISSUE?
2 A. NO, THAT'S NOT WHAT MY INTENDED COMMENT WAS TO MAKE A
3 POINT ABOUT.
4 Q. WELL, WHAT DOES THE 28 HOURS MEAN? I DON'T GET IT. WHY
5 ARE YOU SAYING THAT BECAUSE HE DIDN'T SEE HER FOR 28 HOURS
6 THAT THAT WAS A BREACH OF THE STANDARD CARE, AND I'M NOW
7 ASKING YOU IF HE'D SEEN HER HYPOTHETICALLY WITHIN 12 HOURS,
8 WOULD THAT THEN BREACH THE STANDARD OF CARE, TOO?
9 A. AGAIN, THAT'S NOT A YES/NO QUESTION I CAN ANSWER.
10 Q. WELL, WHAT DOES 28 HOURS MEAN? WHAT IS YOUR POINT TO
11 THE JURY? WHAT IS THE POINT OF SAYING THAT HE BREACHED THE
12 STANDARD OF CARE BECAUSE HE DIDN'T SEE HER FOR 28 HOURS?
13 A. THE POINT IS, IS THAT THERE'S AN EXPECTATION ON AN ACUTE
14 ADMISSION TO A HOSPITAL THAT YOU'RE SEEN AND EVALUATED BY A
15 PHYSICIAN. THE PURPOSE OF GOING TO AN ACUTE FACILITY IS
16 BECAUSE SOMETHING'S PROMPTED THAT. I THINK THERE'S A MORAL
17 OBLIGATION FOR A PHYSICIAN --
18 Q. I'M NOT ASKING YOU ABOUT A MORAL OBLIGATION. I'M
19 ASKING -- AND I'M SURE THAT THE STANDARD OF CARE DOES NOT
20 IMPLY A MORAL OBLIGATION. I'M TALKING ABOUT QUALITY OF CARE.
21 A. CORRECT.
22 Q. THAT'S WHAT WE'RE HERE TO TALK ABOUT. WE'RE NOT TALKING
23 ABOUT MORALITY TODAY --
24 A. CORRECT.
25 Q. -- DOCTOR.
1 A. THAT'S CORRECT.
2 Q. SO HOW DOES SEEING A PATIENT AT 28 HOURS INSTEAD OF 23
3 HOURS MAKE ANY DIFFERENCE?
4 A. THAT IS NOT A YES/NO QUESTION I CAN ANSWER.
5 Q. OKAY. LET ME ASK THIS QUESTION: DO YOU THINK THAT
6 SEEING THE PATIENT ON THE 28TH HOUR AFTER ADMISSION CHANGED
7 THE OUTCOME FOR THIS PATIENT? DID IT ALTER THE OUTCOME IN
8 THE LEAST?
9 A. I THINK IT'S INDICATIVE OF THE APPROACH TO A PATIENT.
10 Q. THAT'S NOT MY QUESTION.
11 A. IT'S NOT A YES/NO QUESTION I CAN ANSWER THEN.
12 Q. YOU THINK THAT SEEING THE PATIENT -- DELAYING SEEING THE
13 PATIENT BY FOUR HOURS RESULTED IN HER DEATH? IS THAT WHAT
14 YOU'RE SAYING?
15 A. THAT IS NOT A YES/NO QUESTION I CAN RESPOND TO.
16 Q. THAT'S FINE. THANK YOU. I'M GONNA ASK YOU A FEW
17 QUESTIONS ABOUT JUDITH LARSEN. ARE YOU READY?
18 A. JUST A MINUTE. YES.
19 Q. ONE OF YOUR CRITICISMS AGAIN IS THAT DR. WEITZEL DID NOT
20 SEE HER WITHIN 24 HOURS, IS THAT RIGHT?
21 A. THAT'S CORRECT.
22 Q. AND I BELIEVE YOU EXPLAINED TO THE JURY THAT
23 DR. DIENHART WHO PERFORMED A HISTORY AND PHYSICAL, THAT HE
24 DIDN'T SEE HER UNTIL DECEMBER 8TH. THAT WAS TWO DAYS AFTER
25 HER ADMISSION, IS THAT CORRECT?
1 LET ME JUST TELL YOU THAT DECEMBER 6TH WAS THE DATE THAT
2 SHE WAS ADMITTED.
3 A. CORRECT.
4 Q. LET'S JUST ASSUME THAT FOR THIS CONVERSATION. IS THAT
5 RIGHT, DOCTOR?
6 A. THAT'S CORRECT, AND THAT IS CORRECT, THE MEDICAL
7 EXAMINATION WAS DONE ON THE 8TH.
8 Q. SO DID DR. DIENHART BREACH THE STANDARD OF CARE BY NOT
9 PERFORMING THE PHYSICAL EXAMINATION SINCE THERE IS A MORAL
10 INDICATION THAT THE DOCTOR SHOULD DO SOMETHING WITHIN 24
11 HOURS, DID DR. DIENHART ALSO BREACH THE STANDARD OF CARE?
12 A. THAT'S NOT A YES/NO QUESTION I CAN ANSWER.
13 Q. THANK YOU. ONE OF YOUR CRITICISMS THROUGHOUT -- BUT I'M
14 STILL STAYING WITH JUDITH LARSEN -- IS THAT DR. DIENHART
15 DIDN'T ADJUST MEDICATIONS TO YOUR SATISFACTION, IS THAT
16 RIGHT?
17 A. NO, THAT'S NOT CORRECT.
18 THE COURT: YOU'RE TALKING ABOUT DR. DIENHART OR
19 DR. WEITZEL?
20 MR. BUGDEN: DID I JUST SAY DIENHART? I'M SORRY. I
21 APOLOGIZE.
22 Q. (BY MR. BUGDEN) ONE OF YOUR CRITICISMS -- THANK YOU,
23 JUDGE -- OF DR. WEITZEL IS THAT DR. WEITZEL DID NOT ADJUST
24 THE MEDICATIONS TO YOUR SATISFACTION?
25 A. WHAT I SAID WAS, IS THAT IT DIDN'T APPEAR THAT THERE WAS
1 ANY DOCUMENTATION OF ADHERENCE TO GERIATRIC PHAMACOLOGY OR
2 PHYSIOLOGY PRINCIPLES.
3 Q. DO YOU REMEMBER SEEING A NOTE, DOCTOR -- AND WE CAN LOOK
4 AT THE NOTES IF YOU DON'T REMEMBER THIS. AND YOU EASILY
5 MIGHT NOT. THERE ARE A LOT OF PAGES TO REVIEW. BUT DO YOU
6 REMEMBER THAT ON DECEMBER 22ND, ONE OF THE NURSES CALLED
7 DR. WEITZEL TO REPORT THAT THE PATIENT APPEARED TO BE
8 LETHARGIC TO THE NURSE AND THAT DR. WEITZEL THEN HELD THE
9 DOSES OF RISPERDAL?
10 A. SORRY, WHICH PATIENT ARE YOU REFERRING TO?
11 Q. STILL ON JUDITH LARSEN. DO YOU REMEMBER THAT? IF YOU
12 DON'T REMEMBER THAT, I'LL JUST PUT IT RIGHT UP ON THE --
13 A. I RECALL THAT THERE WERE INSTANCES, YES, OF THAT NATURE,
14 YES.
15 Q. SO THERE WERE INSTANCES WHEN HE DID RESPOND TO THE
16 NURSES' REPORTS OF A CHANGE IN BEHAVIORS BY THE PATIENT, IS
17 THAT RIGHT?
18 A. ABSOLUTELY.
19 Q. OKAY. AND THEN BY DECEMBER 29TH, THE PATIENT HAD A G.I.
20 BLEED, GASTROINTESTINAL BLEED, IS THAT RIGHT?
21 A. THAT WAS WHAT WAS THOUGHT WAS HAPPENING.
22 Q. NOW, THIS WAS A PATIENT THAT HAD SUFFERED TWO STROKES IN
23 THE LAST YEAR. WERE YOU AWARE OF THAT, DOCTOR?
24 A. YES.
25 Q. ONE STROKE IN JANUARY AND THEN ANOTHER STROKE IN AUGUST
1 OF 1995 --
2 A. CORRECT.
3 Q. -- DID YOU KNOW THAT?
4 A. CORRECT.
5 Q. AND DID YOU KNOW THAT WHEN SHE WAS TRANSFERRED FROM THE
6 HOSPITAL AFTER THE AUGUST STROKE, SHE WAS TRANSFERRED TO A
7 LONG-TERM CARE FACILLITY FOR TERMINAL CARE; DID YOU KNOW
8 THAT?
9 A. SHE WAS -- THE ADMITTING DIAGNOSIS THAT I SAW WAS FOR
10 REHABILITATION.
11 Q. I'M NOT TALKING ABOUT THE GEROPSYCHIATRIC UNIT.
12 A. NO, I WAS TALKING ABOUT THE NURSING HOME UNIT.
13 Q. I'M SORRY?
14 A. I WAS TALKING ABOUT THE NURSING HOME ADMISSION. MY
15 RECOLLECTION IS IT WAS FOR A REHABILITATION. POST STROKE.
16 Q. IF I COULD SHOW YOU A NOTE THEN THAT INDICATED THAT SHE
17 WAS TRANSFERRED TO THE LONG-TERM CARE FACILITY WITH A NO CODE
18 STATUS FOR TERMINAL CARE, THAT WOULD BE A SURPRISE TO YOU?
19 A. NO, IT WOULDN'T BE A SURPIRSE.
20 Q. OKAY, THAT'S NINE. BUT YOU WEREN'T AWARE OF IT, THOUGH.
21 A. I DON'T RECALL IT. I'M SURE I READ IT, BUT I DON'T
22 RECALL THAT SPECIFICALLY.
23 Q. OKAY. THANK YOU. DOCTOR, DO YOU AGREE WITH ME THAT THE
24 TREATMENT CHOICES THAT THE PATIENTS THEMSELVES HAVE MADE OR
25 THAT THEIR -- THAT THEIR REPRESENTATIVE HAS MADE ON THEIR
1 BEHALF, THAT THOSE SHOULD BE RESPECTED BY THE PHYSICIAN
2 TREATING THE PATIENT?
3 A. GENERALLY.
4 Q. WELL, IF A PATIENT OR THE PATIENT'S LOVED ONE HAS FILLED
5 OUT AN ADVANCE DIRECTIVE, I THOUGHT I HEARD THAT IN YOUR
6 TESTIMONY ON DIRECT EXAMINATION, THAT IN FACT IT IS PART OF A
7 DOCTOR'S JOB TO RESPECT THE WISHES OF THE PATIENT AND THE
8 FAMILY'S WISHES ABOUT THE TREATMENT CHOICES, AM I NOT RIGHT?
9 A. AGAIN, THAT'S NOT A YES/NO QUESTION IN MY EXPLANATION.
10 Q. OKAY. WERE YOU AWARE THAT THIS FAMILY OF JUDITH
11 LARSEN -- I'M STILL ON JUDITH LARSEN. WERE YOU AWARE THAT
12 JUDITH LARSEN HAD INDICATED TO THE HOSPITAL STAFF OVER AND
13 OVER AGAIN THAT THEY DID NOT WANT MEDICAL INTERVENTIONS TO
14 PROLONG THE DYING PROCESS FOR THIS PATIENT? WERE YOU AWARE
15 OF THAT?
16 A. I DID SEE DOCUMENTATION IN THE HOSPITAL CHART.
17 Q. LET ME JUST RUN THROUGH A SERIES OF THINGS AND ASK YOU
18 IF YOU REMEMBER THEM. YOU DON'T NEED TO LOOK BECAUSE IF YOU
19 DON'T REMEMBER IT, I'LL PUT IT RIGHT -- I HAVE IT RIGHT HERE
20 AND I CAN PUT IT RIGHT ON THE SCREEN FOR YOU. DID YOU KNOW
21 THAT WHEN SHE WAS -- WHEN SHE WAS ADMITTED AT THE HOSPITAL,
22 THAT HER SON INDICATED TO THE NURSING STAFF THAT WE HAVE
23 HOPES, BUT NO FANTASIES IN REGARD TO THE PATIENT'S CHANCES
24 FOR IMPROVEMENT --
25 A. YES.
1 Q. -- DID YOU KNOW THAT?
2 A. YES.
3 Q. DID YOU KNOW THAT ON DECEMBER 10TH, THE FAMILY REPEATED
4 TO THE NURSING STAFF THAT THEY WANTED THEIR MOTHER MAINTAINED
5 ON A D.N.R., A DO NOT RESUSCITATE STATUS, DID YOU KNOW THAT?
6 A. YES.
7 Q. DID YOU KNOW THAT THE VERY NEXT DAY, DECEMBER 11TH, THE
8 SON MERLIN LARSEN INDICATED TO THE NURSING STAFF, THEY JUST
9 WANTED TO LET HER GO, DID YOU KNOW THAT?
10 A. YES.
11 Q. DID YOU KNOW THAT SAME DAY THAT THE FAMILY WAS RELIEVED
12 THAT THEIR MOTHER WAS NOT SCREAMING OR AGITATED CURRENTLY?
13 DID YOU KNOW THAT?
14 A. I DON'T BELIEVE I SAW DOCUMENTATION TO THAT EFFECT.
15 Q. DID YOU KNOW THAT BY DECEMBER 30TH, THAT'S AFTER --
16 THAT'S THE DAY AFTER THE COFFEE GROUNDS EMESIS HAD BEGUN,
17 THAT ON DECEMBER 30TH, THE SAME SON INDICATED THAT THEY ONLY
18 WISHED TO KEEP THEIR MOTHER COMFORTABLE? DID YOU KNOW THAT?
19 A. YES.
20 Q. NOW, YOU'VE OFFERED THE JURY A LOT OF CRITICISMS ABOUT
21 OTHER THINGS THAT COULD HAVE BEEN DONE AFTER DECEMBER 29TH
22 WHEN THIS PATIENT WHO HAD APPARENTLY SUFFERED A SEIZURE --
23 AND YOU AGREE THAT IT LOOKS LIKE THE PATIENT SUFFERED A
24 STROKE IN THE HOSPITAL?
25 A. IT APPEARS THAT THAT'S WHAT HAPPENED.
1 Q. OKAY. SO THE PATIENT HAD SUFFERED A STROKE IN THE
2 HOSPITAL, NOW HAD PERHAPS COFFEE GROUNDS EMESIS WHICH MIGHT
3 INDICATE GASTROINTESTINAL BLEEDING, IS THAT RIGHT?
4 A. CORRECT.
5 Q. AND YOU HAD FAMILY MEMBERS, SON MERLIN LARSEN,
6 INDICATING THAT ALL THE TIMES I'VE JUST REVIEWED WITH YOU,
7 DR. BAIR, THAT THE FAMILY JUST WANTED TO LET THEIR MOTHER GO,
8 DR. WEITZEL THE TREATING PHYSICIAN, YOU A AGREE, HE -- HE
9 NEEDED TO HONOR THE WISHES OF THE FAMILY. DON'T YOU AGREE
10 WITH THAT, DOCTOR?
11 A. GENERALLY SPEAKING, YES.
12 Q. DID I UNDERSTAND YOU TO SAY THAT YOU NEVER SAW ANY
13 INDICATION OF PAIN IN MRS. LARSEN?
14 A. NO.
15 Q. YOU DIDN'T?
16 A. NO. THAT'S -- YOU MISUNDERSTOOD ME IF THAT'S WHAT YOU
17 UNDERSTOOD.
18 Q. MISUNDERSTOOD -- YOU DID -- YOU DID SEE SYMPTOMS OF PAIN?
19 A. I SAW IN THE CHART THAT THERE WERE TIMES THAT SHE DID
20 LOOK AGITATED THAT -- WHICH COULD BE LOOKED AT AS PAIN.
21 Q. WELL, I THINK YOU WERE SPECIFICALLY ASKED THE QUESTION,
22 AFTER THE COFFEE GROUNDS EMESIS EPISODE BEGAN ON DECEMBER
23 29TH UNTIL THE TIME OF HER PASSING, WHETHER OR NOT YOU EVER
24 DURING TIME FRAME EVER SAW ANY SYMPTOMS OF PAIN?
25 A. AFTER THE 30TH?
1 Q. OKAY. LET'S SAY THE 30TH. AND AFTER THE 30TH, IT'S
2 YOUR TESTIMONY THAT YOU NEVER SAW ANY SYMPTOMS OF PAIN, IS
3 THAT RIGHT?
4 A. IN THE DOCUMENTATION FROM THE M.D. AND THE NURSES, WHAT
5 I SAW WAS UNRESPONSIVENESS.
6 Q. JUDITH LARSEN'S MEDICAL RECORDS ARE FOUND AT -- THIS IS
7 FOR THE JUDGE AND NOT REALLY FOR YOU, DOCTOR.
8 A. OKAY.
9 THE COURT: IT'S 3-B.
10 MR. BUGDEN: 3-B. IS THERE A LARGE PICTURE OF THIS
11 BEFORE THE BLOWUP?
12 MS. ISAACSON: THERE IT IS. IT'S 584.
13 Q. (BY MR. BUGDEN) OKAY. SO JUST SO WE'RE ON THE SAME
14 PAGE, DR. BAIR, YOU'VE JUST TOLD THE JURY THAT AFTER DECEMBER
15 30TH, YOU NEVER SAW THESE SYMPTOMS, RIGHT.
16 A. I SAID THAT I DID NOT SEE ANY DOCUMENTATION OF PAIN PER
17 SE.
18 Q. OKAY. THANK YOU. THIS IS ON 1/1/96, THEN WE'RE GONNA
19 LOOK AT A BLOWUP OF IT. ARE YOU ABLE TO SEE IT FROM WERE YOU
20 ARE?
21 A. I THINK SO, YES.
22 Q. DO YOU AGREE THAT GROANING AND TWITCHING, THEY WOULD ALL
23 BE SYMPTOMS OF PAIN --
24 A. IT'S POSSIBLE THAT THEY COULD BE.
25 Q. THANK YOU. SO WE SEE THE NOTE THAT AT 1600 IT TALKS
1 ABOUT THE PATIENT IS GROANING AND TWITCHING AND THEN LATER --
2 THINK I'M READING THAT RIGHT -- 1730, BUT I MIGHT BE
3 MISREADING IT. PATIENT GROANING WHEN TURNED FOR PERI CARE.
4 GROANING AGAIN, AND YOU WOULD AGREE THAT THAT MAY BE A
5 SYMPTOM OF PAIN.
6 A. IT MAY BE.
7 Q. THANK YOU. OF COURSE YOU WEREN'T THERE, YOU'RE JUST
8 LOOKING AT THE MEDICAL RECORDS SIX YEARS LATER, RIGHT?
9 A. I WAS NOT THERE.
10 Q. THANK YOU. AND WE SEE THE NEXT FULL PAGE? TRYING TO
11 READ THE DATE, 1/2/96. OKAY. VERY NEXT DAY. CAN WE SEE A
12 BLOWUP? TRYING TO READ IT MYSELF. WELL, I LOOKS LIKE
13 THERE'S MORE MOANING IS WHAT IT IS, 12/30 ON THE NEXT DAY.
14 LET'S LOOK AT THE NEXT PAGE PLEASE. IS THERE A BLOWUP OF
15 THAT PAGE?
16 NOW, THEN THIS IS THE NEXT DAY AND THE PATIENT EYES
17 OPEN, STARING, JERKING ALL EXTREMITIES, AND MOANING. WOULD
18 JERKING -- JERKING OF ALL EXTREMITIES, MIGHT THAT BE AN
19 IDICATION OF PAIN, DR. BAIR?
20 A. IT'S POSSIBLE. IT COULD ALSO SYMPTOM OF OTHER THINGS.
21 Q. THANK YOU. YOU ALSO MENTIONED THAT DR. WEITZEL HAD
22 NOTED WHEN PATIENT PASSED AWAY, IN HIS CHART NOTE, THAT THE
23 PATIENT HAD FINALLY PASSED AWAY, IS THAT RIGHT?
24 A. THAT'S CORRECT.
25 Q. WOULD YOU AGREE WITH ME AS WE'VE -- AND THIS PATIENT WAS
1 IN THE HOSPITAL FOR ABOUT FIVE WEEKS, I BELIEVE.
2 A. CORRECT.
3 Q. AND HAD A NUMBER OF PROBLEMS. SHE WAS VERY ILL EARLY ON
4 IN HER HOSPITAL STAY, DO YOU REMEMBER THAT?
5 A. YES.
6 Q. THEN SHE IMPROVED AND THEN AFTER IMPROVEMENT THEN SHE
7 HAD WHAT APPEARS TO BE WHAT YOU THINK WAS A STROKE, IS THAT
8 RIGHT?
9 A. IT'S POSSIBLE.
10 Q. OKAY. THEN SHE HAD WHAT MAY HAVE BEEN THE -- WELL, AT
11 LEAST SHE HAD THE COFFEE GROUNDS EMESIS, IS THAT RIGHT?
12 A. CORRECT.
13 Q. AND THEN WE REVIEWED TOGETHER THAT THE FAMILY THROUGHOUT
14 THIS PROCESS WAS TELLING THE NURSING STAFF, WE JUST WANNA LET
15 OUR MOM GO, IS THAT RIGHT?
16 A. CORRECT.
17 Q. AND THEN DO YOU AGREE -- AND I THOUGHT -- I THOUGHT I
18 EVEN HEARD YOU SAY THIS ON DIRECT EXAMINATION, THAT CERTAINLY
19 IN MANY CIRCUMSTANCES WHEN PATIENTS PASS AWAY, IT'S A
20 BLESSING. DO YOU AGREE WITH THAT?
21 A. I DON'T THINK I SAID THAT, BUT YES, IT CAN BE A RELIEF.
22 Q. I DON'T THINK YOU USED THAT WORD --
23 A. RIGHT.
24 Q. -- THAT WORD. AND IF A PATIENT HAS A LONG SUFFERING OR
25 LONG DYING PROCESS, MIGHT IT BE A RELIEF TO BOTH THE PATIENT
1 AND THE PATIENT'S FAMILY FOR A PATIENT TO FINALLY EXPIRE?
2 A. CERTAINLY.
3 Q. THANK YOU, DOCTOR. NOW, WITH ELLEN ANDERSON, I GUESS
4 WHAT YOU'RE -- WHAT YOU'VE TOLD US IS THAT ALTHOUGH THE
5 PATIENTS DIDN'T PICK IT UP, AS YOU REVIEW THE MEDICAL RECORDS
6 TODAY, SIX YEARS LATER, YOU BELIEVE THAT THIS PATIENT WAS IN
7 CRITICAL CONDITION UPON HER ADMISSION, IS THAT WHAT YOU'RE
8 SAYING?
9 A. YES.
10 Q. AND SO SHE WAS REALLY IN A LIFE-THREATENING SITUATION IN
11 YOUR VIEW FROM THE MOMENT SHE WENT TO THE HOSPITAL?
12 A. IT IS POSSIBLE SHE WAS, YES.
13 Q. IT IS POSSIBLE SHE WAS. OKAY.
14 A. I SHOULD -- EXCUSE ME, I SHOULD CORRECT THAT TO LIKELY.
15 Q. OKAY. WOULD YOU AGREE, DOCTOR, THAT IT'S NOT UNCOMMON
16 WITH PSYCHIATRIC ADMISSIONS FOR THE DOCTOR TO NOT SEE THE
17 PATIENT -- IN THIS CASE IT WAS A LATE AFTERNOON ADMISSION.
18 WOULD YOU AGREE WITH ME -- LET ME JUST ASK YOU TO ASSUME
19 THAT, DOCTOR. WOULD YOU AGREE THAT WITH PSYCHIATRIC
20 ADMISSIONS, IT'S EVEN TOO UNUSUAL FOR THE PATIENT TO BE SEEN
21 THE MORNING AFTER BY THE DOCTOR?
22 A. FOR MEDICALLY STABLE PATIENTS, THAT'S CORRECT.
23 Q. OKAY. BUT THE NURSES DIDN'T PERCEIVE THAT THIS WAS A
24 MEDICALLY UNSTABLE PATIENT, DO YOU AGREE WITH THAT?
25 A. FROM THE DOCUMENTATION, IT APPEARS THE NURSES WERE
1 REPORTING SYMPTOMS. I DON'T SEE ANY DIAGNOSTIC EVALUATION
2 FROM THE NURSES.
3 Q. OKAY. DIDN'T THIS PATIENT, AS IT TURNED OUT
4 UNFORTUNATELY EXPIRE IN A VERY SHORT PERIOD OF TIME BEFORE
5 THE DOCTOR EVER HAD A CHANCE TO SEE THIS PATIENT?
6 A. SHE EXPIRED WITHIN A RELATIVELY SHORT TIME OF ADMISSION,
7 AROUND 24, 30 HOURS, YES.
8 Q. OKAY. WOULD YOU AGREE AS YOU'VE REVIEWED THE CHART NOTE
9 THAT THE THE FIRST SHOT OF MORPHINE WAS GIVEN WHEN A NURSE AT
10 7:30 REPORTED TO DR. WEITZEL THAT THE PATIENT WAS IN SEVERE
11 PAIN? HAVE YOU SEEN THAT NOTE?
12 A. YES, I DID SEE THAT NOTE.
13 Q. OKAY. WOULD YOU AGREE THAT TREATING THE PAIN -- DO YOU
14 THINK TREATING THE PAIN WAS A BREACH OF THE STANDARD OF CARE
15 AT THAT POINT?
16 A. I DON'T BELIEVE THAT'S A YES/NO QUESTION I CAN RESPOND
17 TO.
18 Q. OKAY. DO YOU -- DO YOU THINK IT'S A BREACH OF THE
19 STANDARD OF CARE FOR THE DOCTORS TO ENTER ORDERS OVER THE
20 TELEPHONE?
21 A. NO.
22 Q. DO YOU THINK IT'S A BREACH OF THE STANDARD OF CARE, FOR
23 EXAMPLE, HERE WITH ELLEN ANDERSON, SHE WAS CON -- OR
24 DR. WEITZEL WAS CONTACTED AT 3:30 IN THE MORNING, AGAIN WHEN
25 A NURSE REPORTED TO THE DOCTOR THAT THE PATIENT WAS IN
1 EXTREME PAIN, DO YOU THINK IT WAS A BREACH OF THE STANDARD OF
2 CARE FOR DR. WEITZEL TO PRESCRIBE PAIN RELIEF WITHOUT
3 GOING -- DRIVING TO THE HOSPITAL AT 3:30 IN THE MORNING,
4 THAT -- DO YOU THINK THAT'S A BREACH OF THE STANDARD OF CARE?
5 A. I DON'T THINK THAT'S A YES/NO QUESTION THAT I CAN
6 ANSWER.
7 Q. OKAY. WELL, YOU SEE, I'M JUST TRYING TO UNDERSTAND HOW
8 IT IS THAT DR. WEITZEL BREACHED THE STANDARD CARE. YOU'VE
9 TOLD THE JURY THAT THIS DOCTOR BREACHED THE STANDARD OF CARE
10 AND THERE'S SOME -- SEVERAL THINGS THAT WE'RE TALKING ABOUT
11 WITH THE TREATMENT OF ELLEN ANDERSON.
12 A. CORRECT.
13 Q. EITHER IT IS OR IT ISN'T A BREACH OF THE STANDARD OF
14 CARE. YOU DON'T -- WAS IT A BREACH OF THE STANDARD OF CARE
15 FOR HIM TO TREAT THIS SYMPTOM OF PAIN WITHOUT COMING IN --
16 A. NO.
17 Q. -- AT 3:30 IN THE MORNING?
18 A. WHAT I'M SAYING, YOUR QUESTION'S NOT A YES/NO QUESTION.
19 Q. OKAY. WHEN WE TALK ABOUT ADVANCE DIRECTIVES, AGAIN,
20 THAT'S ANOTHER EXAMPLE OF WHERE YOU THINK THERE'S NO SIMPLE
21 YES OR NO ANSWERS HONORING ADVANCE DIRECTIVES, IS THAT RIGHT?
22 A. I THINK IT'S MORE COMPLICATED THAN A YES/NO, YES, THAT'S
23 CORRECT.
24 Q. YOU THINK DOCTORS HAVE THE PREROGATIVE TO DISREGARD
25 ADVANCE DIRECTIVES?
1 A. THERE ARE CIRCUMSTANCES THAT ARE -- ETHICALLY, YOU'RE
2 NOT BOUND BY THOSE, THAT'S CORRECT.
3 Q. OKAY. THANK YOU. I'D LIKE TO SHOW YOU DEFENDANT'S
4 EXHIBIT 95. CAN YOU READ IT AS WELL, DOCTOR -- THIS IS A
5 LIVING WILL FROM ENNIS ALLDREDGE. CAN YOU --
6 THE COURT: THERE'S AN EASEL RIGHT THERE IF YOU WANNA
7 USE IT.
8 MR. BUGDEN: THANKS, JUDGE. I'M SORT OF RUNNING AROUND
9 HERE.
10 THE COURT: CAN YOU SEE THAT, LADIES AND GENTLEMEN?
11 DOCTOR, CAN YOU SEE OKAY?
12 THE WITNESS: YES, THANK YOU.
13 Q. (BY MR. BUGDEN) CAN YOU READ IT?
14 A. YES.
15 Q. CAN YOU SEE IT?
16 A. THANK YOU.
17 Q. SO THIS IS ENNIS ALLDREDGE, FEW YEARS BEFORE HIS
18 ADMISSION. WOULD YOU READ PARAGRAPH 3 ALOUD?
19 A. YES. IT SAYS, IF AT ANY TIME I SHOULD HAVE A TERMINAL
20 CONDITION AND MY ATTENDING PHYSICIAN HAS DETERMINED THAT
21 THERE CAN BE NO RECOVERY FROM SUCH CONDITION, AND MY DEATH IS
22 IMMINENT, WHERE THE APPLICATION OF LIFE-PROLONGING PROCEDURES
23 AND HEROIC MEASURES WOULD SERVE ONLY TO ARTIFICIALLY PROLONG
24 THE DYING PROCESS, I DIRCT THAT SUCH PROCEDURES BE WITHHELD
25 OR WITHDRAWN AND THAT I BE PERMITTED TO DIE NATURALLY. I DO
1 NOT FEAR DEATH ITSELF AS MUCH AS THE INDIGNITIES OR
2 DETERIORATION, DEPENDENCE AND HOPELESS PAIN. I THEREFORE ASK
3 THAT MEDICATION BE MERCIFULLY ADMINISTERED TO ME AND THAT ANY
4 MEDICAL PROCEDURES BE PERFORMED ON ME WHICH ARE DEEMED
5 NECESSARY AS TO PROVIDE ME WITH COMFORT CARE OR TO ALLEVIATE
6 PAIN.
7 Q. DOCTOR, DO YOU THINK THAT THAT'S A FAIRLY POWERFUL
8 STATEMENT BY MR. ALLDREDGE WHEN HE WAS CAPABLE OF MAKING
9 DECISIONS ABOUT HIS OWN MEDICAL TREATMENT, THAT HE DIDN'T
10 WANT EXTRAORDINARY MEASURES IF HE WAS AT DEATH'S DOOR?
11 A. IF HE INDEED WERE OF SOUND MIND, THAT IS A POWERFUL
12 STATEMENT.
13 Q. THANK YOU VERY MUCH. AND ALTHOUGH -- YOU RECOGNIZE THAT
14 A STROKE MAY BE A LIFE-THREATENING SITUATION, IS THAT RIGHT?
15 A. YES, THAT'S CORRECT.
16 Q. AND YOU BELIEVE THAT ENNIS ALLDREDGE APPARENTLY DID
17 SUFFER A STROKE, IS THAT RIGHT, IN THE HOSPITAL?
18 A. APPARENTLY, YES.
19 Q. AND ALTHOUGH YOU DON'T BELIEVE THAT THE STROKE WAS A
20 LIFE-THREATENING SITUATION FOR MR. ALLDREDGE, WOULD YOU AGREE
21 THAT COMPETENT DOCTORS COULD DISAGREE WITH YOU OR REACH A
22 DIFFERENT CONCLUSION ABOUT WHETHER MR. ALLDREDGE WAS ABOUT TO
23 DIE? WOULD YOU AGREE WITH THAT?
24 A. THERE ARE MULTIPLE QUESTIONS WITHIN THAT THAT I DON'T
25 THINK IS YES/NO TO ALL TOGETHER.
1 Q. DO YOU BELIEVE THAT THERE ARE OTHER COMPETENT PHYSICIANS
2 IN THE WORLD BESIDES YOU, DR. BAIR? LET'S START THERE.
3 A. ABSOLUTELY.
4 Q. DO YOU BELIEVE THAT OTHER COMPETENT PHYSICIANS IN THE
5 WORLD COULD REACH THE CONCLUSION ON THE DATA AVAILABLE TO
6 THEM THAT MR. ALLDREDGE WAS ABOUT TO DIE ON JANUARY 13TH?
7 A. I THINK THERE CERTAINLY COULD BE DIFFERENT OPINIONS,
8 ABSOLUTELY.
9 Q. AND DO YOU BELIEVE THAT A DIFFERENCE OF OPINION FROM YOU
10 COULD BE REACHED TO THE STANDARD OF CARE, DR. BAIR?
11 A. I THINK A DIFFERENCE OF OPINION BASED ON EVALUATION
12 WOULD BE IMPORTANT TO MAKE.
13 Q. THANK YOU. NOW, WITH MARY CRANE, YOU BELIEVE -- WELL
14 LET ME ASK THIS FIRST: DO YOU DISAGREE WITH THE DECISION TO
15 TREAT THIS PATIENT WITH A DURAGESIC PATCH, DO YOU THINK IT
16 WAS A BREACH OF THE STANDARD OF CARE FOR DR. WEITZEL TO USE A
17 DURAGESIC PATCH TO PROVIDE CONTINUOUS PAIN RELIEF TO THIS
18 PATIENT?
19 A. THAT'S ACTUALLY NOT A YES/NO QUESTION THAT I CAN ANSWER.
20 Q. OKAY. THAT'S FINE. THANKS. DR. DIENHART BELIEVED THAT
21 A DURAGESIC PATCH WAS APPROPRIATE. DID YOU SEE THAT IN THE
22 NOTE?
23 A. I SAW THAT HE THOUGHT IT WAS APPROPRIATE.
24 Q. THANK YOU. AND WOULD YOU AGREE -- DR. DIENHART
25 TESTIFIED LAST WEEK THAT HE DIDN'T BELIEVE THAT THE CHANGE
1 BETWEEN 25 MICROGRAMS AND 50 MICROGRAMS WAS A SIGNIFICANT
2 CHANGE. DO YOU DISAGREE WITH DR. DIENHART?
3 A. I'M NOT ABLE TO ANSWER THAT QUESTION. I DID NOT EXAMINE
4 THE PATIENT.
5 Q. OKAY. SO NOT HAVING EXAMINED THE PATIENT, YOU WOULDN'T
6 BE ABLE TO OFFER AN EXPERT OPINION ON THAT.
7 A. I THINK EXAMINING THE PATIENT IS CRITICAL TO MAKING
8 MEDICAL DECISIONS.
9 Q. SO WITH REGARD TO ALL OF YOUR TESTIMONY WHERE YOU WERE
10 NOT ABLE TO ACTUALLY EXAMINE ANY OF THESE PATIENTS, ALL OF
11 YOUR OPINIONS ARE ACTUALLY SUBJECT TO THE -- NOW ARE WEAKENED
12 BY THE FACT THAT YOU'RE SECOND GUESSING ALL OF DR. WEITZEL'S
13 DECISIONS WITHOUT EVER HAVING SEEN ONE OF THESE PATIENTS --
14 A. I DO NOT --
15 Q. -- IS THAT RIGHT?
16 A. I DO NOT AGREE WITH THAT, NO.
17 Q. OH, OKAY. DR. DIENHART TESTIFIED LAST WEEK THAT HE
18 BELIEVES IT WAS ABSOLUTELY WITHIN THE PREROGATIVE OF THE
19 TREATING, ATTENDING PHYSICIAN TO MAKE A CHANGE ON SOMETHING
20 LIKE THE DURAGESIC PATCH. DO YOU DISAGREE WITH THAT?
21 A. NO. ABSOLUTELY, I THINK THE ATTENDING PHYSICIAN IS THE
22 ULTIMATE RESPONSIBLE PARTY.
23 Q. THANK YOU. SO NOW WITH THE RECTAL/VAGINAL FISTULA WITH
24 THIS PATIENT, DO YOU BELIEVE THAT SHE MAY HAVE HAD EXTREME
25 PAIN FROM THAT CONDITION?
1 A. VERY MUCH SO.
2 Q. OKAY. AND SO TREATMENT OF PAIN WOULD CERTAINLY BE IN
3 KEEPING WITH THE DOCTOR'S OBLIGATION, IS THAT RIGHT?
4 A. VERY MUCH.
5 Q. YOU THINK THAT SHE WAS PROBABLY IN PAIN WHEN SHE CAME IN
6 THE HOSPITAL, THAT THE RECTAL/VAGINAL FISTULA EXISTED EVEN
7 EVEN THEN OR WAS ABOUT ERUPT?
8 A. IT'S LIKELY THAT IT DID.
9 Q. THANK YOU. AND THEN YOU'VE INDICATED AS, WELL,
10 GERIATRIC INTERNIST, PSYCHIATRIST, SPECIALIST THAT YOU ARE,
11 THAT THE PROCESSES THAT LEAD TO THE FISTULA THAT WERE
12 PROBABLY OCCURRING BEFORE HER ADMISSION COULD HAVE INCLUDED
13 DIVERTICULITIS, IS THAT RIGHT?
14 A. THAT'S CORRECT.
15 Q. SO WHAT WOULD YOU SAY, WHAT'S THE APPROPRIATE RESPONSE
16 TO DIVERTICULITIS? SURGERY? FOR THIS 72-YEAR-OLD DEMENTED
17 WOMAN? IS THAT -- WOULD THAT BE THE TREATMENT REGIMEN?
18 A. AGAIN, I THINK A DECISION FOR INTERVENTION HAS TO BE
19 BASED ON EVALUATION.
20 Q. AND ABDOMINAL ABSCESSES, YOU SAID THAT WAS POSSIBLY
21 ANOTHER EXPLANATION?
22 A. THAT'S POSSIBLE.
23 Q. AND AGAIN, WOULD YOU SAY THAT THAT WOULD HAVE TO BE
24 TREATED WITH SURGERY?
25 A. AGAIN, I THINK THE EXACT INTERVENTION WOULD HAVE TO BE
1 BASED ON EVALUATION AND COLLECTION OF FURTHER INFORMATION
2 THAT IS AVAILABLE.
3 Q. AND THEN YOU ALSO I THINK INDICATED THAT MAYBE IT WAS
4 EVEN DUE TO A NEOPLASM. THAT'S A CANCER, ISN'T THAT RIGHT?
5 A. IT'S POSSIBLE.
6 Q. SO AGAIN, ALTHOUGH IT REQUIRES EVALUATING THE BEST
7 OPTION FOR THE PATIENT, WOULD YOU SAY CHEMOTHERAPY WOULD BE
8 APPROPRIATE FOR THIS 72-YEAR-OLD WOMAN, THIS 72-YEAR-OLD
9 DEMENTED WOMAN?
10 A. MY THINKING IS, IS THAT YOU NEED TO HAVE INFORMATION
11 BEFORE YOU MAKE MEDICAL DECISIONS.
12 Q. OKAY. IN FACT, DR. WEITZEL DID GET CONSULTATIONS FROM
13 BOT DR. DIENHART, THE INTERNIST, AND THE O.B.-G.Y.N.,
14 DR. MEEKS, IS THAT RIGHT?
15 A. THAT'S CORRECT.
16 Q. AND CIPRO AND KEFLEX WERE PRESCRIBED TO TRY TO TREAT
17 WHAT APPEARED TO BE THE BACTERIA, IS THAT RIGHT?
18 A. IT'S NOT CLEAR FROM DOCUMENTATION EXACTLY WHY THE
19 SPECIFIC ANTIBIOTICS WERE PRESCRIBED AND --
20 Q. OKAY.
21 A. -- THEY WERE NOT PRESCRIBED IN OVERLAPPING FASHION.
22 Q. KEFLEX AND CIPRO, WE HEARD TESTIMONY FROM THE
23 GYNECOLOGIST DR. MEEKS LAST WEEK THAT BOTH ARE GOOD BROAD
24 SPECTRUM ANTIBIOTICS TO TREAT THIS CONDITION WITH THIS
25 PATIENT. DO YOU DISAGREE WITH THAT?
1 HE SAW THE PATIENT.
2 A. RIGHT.
3 Q. YOU DIDN'T --
4 A. SH --
5 Q. DO YOU AGREE OR DISAGREE THAT KEFLEX AND CIPRO WOULD BE
6 A GOOD CHOICE --
7 MS. BARLOW: YOUR HONOR, COULD HE BE ALLOWED TO ANSWER
8 THE QUESTION?
9 THE COURT: HE WILL BE YES.
10 MS. BARLOW: THANK YOU.
11 THE COURT: ASK THE QUESTION. HE CAN ANSWER IT.
12 THE WITNESS: AGAIN, I'M NOT ABLE TO ANSWER THAT
13 QUESTION IN JUST A YES/NO FASHION ADEQUATELY.
14 Q. (BY MR. BUGDEN) AND REALLY ULTIMATELY, YOUR VIEW WITH
15 MARY CRANE IS THAT THERE JUST WEREN'T ENOUGH TESTS DONE,
16 ISN'T THAT RIGHT?
17 A. THAT AGAIN IS NOT A QUESTION THAT I CAN ASK WITH A
18 YES/NO ANSWER.
19 Q. OKAY. DOCTOR, IS THERE A DIFFERENCE IN THE STANDARD OF
20 CARE IN YOUR VIEW BETWEEN THE STANDARD OF CARE FOR GERIATRIC
21 PATIENTS VERSUS FRAIL, ELDERLY, DEMENTED PATIENTS? OR IS IT
22 ALL THE SAME STANDARD OF CARE FOR YOU?
23 A. AGAIN, I DON'T THINK THAT'S QUESTION THAT LENDS ITSELF
24 TO A YES/NO ANSWER.
25 Q. OKAY. AND THEN YOU AGREE THAT DEMENTED PATIENTS ARE A
1 COMPLEX, DIFFICULT POPULATION OF PATIENTS TO TREAT, IS THAT
2 RIGHT?
3 A. YES.
4 Q. AND DO YOU AGREE THAT THERE REALLY IS NO COOKBOOK
5 FORMULA FOR THE TREATMENT OF DEMENTED PATIENTS?
6 A. THAT'S CORRECT.
7 Q. THERE IS NO MAGIC PILL THAT JUST ABSOLUTELY LETS YOU
8 DIAL IN NOT AGITATED AND NOT -- AND NOT TOO LETHARGIC?
9 A. THAT'S CORRECT.
10 Q. AND IT'S HARD, IT'S VERY DIFFICULT, COMPLICATED
11 PHARMACOLOGY, IS WHAT YOU'VE TOLD US?
12 A. THAT IS VERY CORRECT.
13 Q. IN FACT, YOU'RE ONE OF ONLY TWO PEOPLE IF THE WHOLE DARN
14 COUNTRY THAT HAS YOUR SPECIAL QUALIFICATIONS, OF COMBINATION
15 OF PSYCHIATRIST, INTERNIST, PHARMACOLOGIST, IS THAT RIGHT?
16 A. THE YES/NO ANSWER TO THAT WOULD BE CONFUSING I THINK TO
17 THE JURY.
18 Q. OKAY. WELL, WE'RE NOT GONNA HOLD DR. WEITZEL OR ANY
19 OTHER PSYCHIATRIST TO THE SAME LEVEL OF EXPERTISE AS YOU, ARE
20 WE? AREN'T WE GONNA TREAT -- JUDGE DR. WEITZEL BY THE
21 STANDARD OF CARE OF PHYSICIANS THAT TREATED THIS PATIENT
22 POPULATION?
23 SOMETHING LESS THAN EVERYTHING DR. BAIR WOULD DO.
24 A. I'M NOT ABLE TO ANSWER THAT IN AN UNCONFUSING WAY WITH
25 YES OR NO ANSWER.
1 Q. OKAY. THANK YOU. DO YOU AGREE THAT THERE'S NO
2 PUBLISHED STANDARD OF CARE FOR THE TREATMENT OF GERIATRIC
3 PATIENTS LIKE ENNIS ALLDREDGE, LIKE ELLEN ANDERSON, LIKE
4 LYDIA SMITH, LIKE MARY CRANE, THERE'S NO BOOK WE CAN TURN TO
5 THAT SAYS HOW TO TREAT -- WHAT THE STANDARD OF CARE IS FOR
6 THESE DEMENTED PATIENTS?
7 A. THAT'S CORRECT.
8 Q. SO I GUESS YOU WOULD AGREE, ALTHOUGH YOU'RE ABLE TO
9 IDENTIFY AND SAY THAT THE STANDARD OF CARE IS RIGHT HERE, BUT
10 YOU WOULD AGREE THAT IT'S NOT BLACK AND WHITE, IS THAT RIGHT,
11 DOCTOR?
12 A. NO. I THINK THE YES/NO ANSWER TO THAT QUESTION WOULD BE
13 CONFUSING.
14 Q. DO YOU THINK THAT THERE ARE MULTIPLE SCHOOLS OF THOUGHT,
15 DIFFERENT APPROACHES TO THE TREATMENT OF GERIATRIC DEMENTED
16 PATIENTS LIKE THESE THAT COULD FULFILL THE STANDARD OF CARE?
17 A. CERTAINLY.
18 THE COURT: MR. BUGDEN, IS THIS A GOOD TIME --
19 MR. BUGDEN: I HAVE ONE QUESTION, JUDGE.
20 THE COURT: ALL RIGHT.
21 MR. BUGDEN: HONEST. I KNOW LAWYERS DON'T OFTEN --
22 THE COURT: THAT IS TRUE.
23 Q. (BY MR. BUGDEN) WOULD YOU AGREE THAT THE PRACTICE OF
24 MEDICINE IS STILL AN ART?
25 A. LARGELY, THAT'S TRUE.
1 MR. BUGDEN: THAT'S ALL I HAVE.
2 THE COURT: HOW LONG IS YOUR REDIRECT GONNA TAKE,
3 MRS. BARLOW?
4 MS. BARLOW: COULD TAKE ABOUT A HALF HOUR, YOUR HONOR.
5 THE COURT: LET'S TAKE OUR LUNCH BREAK AT THIS TIME.
6 YOU MAY STEP DOWN, DOCTOR. LADIES AND GENTLEMEN, I REMIND
7 YOU OF MY PRIOR ADMONITION ON THE MATTER. WE'LL EXCUSE YOU
8 FOR LUNCH. ASK YOU BACK AT 1:15. SEE YOU BACK THEN.
9 (MORNING SESSION ENDED.)
(IN CHAMBERS)
3 THE COURT: WE ARE IN CHAMBERS IN THE MATTER OF
4 STATE OF UTAH VERSUS ROBERT WEITZEL. MR. BUGDEN,
5 MS. ISAACSON ARE PRESENT ALONG WITH THE DEFENDANT.
6 MS. BARLOW AND MR. MAJOR ARE HERE REPRESENTING THE STATE.
7 I RECEIVED A NOTE FROM A JUROR AFTER THE LAST WITNESS --
8 THAT WAS IN REGARD TO DR. BAIR. AND THIS IS JUROR NUMBER 23,
9 MR. ELLIOT, THAT SITS ON THE LEFT FRONT.
10 MR. BUGDEN: OKAY.
11 THE COURT: AND HE SAYS, REFERRING TO THE DOCTOR, I
12 DON'T KNOW HIM PERSONALLY. I KNOW HIM FROM LIVING IN OUR
13 NEIGHBORHOOD. I DON'T ASSOCIATE WITH HIM OR ANYTHING LIKE
14 THAT, MAYBE A WAVE IF HE DRIVES BY. THIS HAS NO BEARING ON
15 THE CASE AS FAR AS I'M CONCERNED.
16 AND I JUST WANTED TO KNOW WHETHER YOU WANT ME TO TALK TO
17 HIM OR NOT.
18 MR. BUGDEN: MAY I ASK YOU ONE MORE TIME? I THINK I
19 KNOW, IT'S THE GENTLEMAN WITH THE SHORT CROPPED GRAYING HAIR
20 CLOSEST TO THE CORNER?
21 MS. BARLOW: KIND OF A GOATEE?
22 THE COURT: ON THE FRONT.
23 THE DEFENDANT: I DON'T LIVE IN --
24 THE COURT: IT'S NOT YOU. IT'S DR. BAIR.
25 THE DEFENDANT: THAT DOCTOR.
1 THE COURT: I DON'T SEE ANYTHING ABOUT THIS THAT
2 WOULD DISQUALIFY HIM, BUT I WANTED TO DISCLOSE IT TO ALL OF
3 YOU.
4 OKAY. TELL HIM IT'S FINE. HE WAS JUST CONCERNED, I
5 GUESS.
6 MR. BUGDEN: THANKS.
7 MS. ISAACSON: ANYTHING BACK FROM OUR OTHER JUROR?
8 THE COURT: HE'S BACK AND WANTS TO GO.
9 MR. BUGDEN: BACK AND WANTS TO GO.
10 THE COURT: WHAT WE'RE GOING TO DO IS SEE OVER THE
11 WEEKEND. IF THERE'S A PROBLEM, WE'LL DEAL WITH HIM MONDAY.
12 HOW LONG IS YOUR --
13 MR. BUGDEN: I'M DONE, REMEMBER?
14 THE COURT: YOU'RE DONE. HOW LONG IS YOUR
15 RECROSS -- REDIRECT?
16 MS. BARLOW: POSSIBLY ABOUT 15 MINUTES. I THOUGHT A
17 HALF HOUR, BUT MAYBE 15 MINUTES.
18 THE COURT: WHO'S NEXT, DR. HARE? CAN WE GET
19 THROUGH WITH HIM TODAY?
20 MS. BARLOW: MEL SAYS WE CAN.
21 MR. BUGDEN: WE'VE GOT TO BECAUSE OF THE
22 OUT-OF-TOWNERS.
23 THE COURT: IF YOU WANT TO GO HOME.
24 MS. BARLOW: AND MEL WANTS TO GO HOME, SO I'M SURE
25 WE WILL.
1 THE COURT: ALL RIGHT. WE'LL BE RIGHT OUT.
2 (PROCEEDINGS RESUME IN OPEN COURT.)
3 THE COURT: THE RECORD SHOULD NOTE PARTIES AND
4 COUNSEL ARE PRESENT. THE JURY IS IN THE JURY BOX; DR. BAIR
5 IS ON THE STAND.
6 DOCTOR, I REMIND YOU THAT YOU'RE STILL UNDER OATH.
7 YOU MAY REDIRECT.
8 MS. BARLOW: THANK YOU, YOUR HONOR.
9 REDIRECT EXAMINATION
10 BY MS. BARLOW:
11 Q. DR. BAIR, YOU MENTIONED THAT THERE WERE THREE TYPES OF
12 INTERVENTIONS THAT COULD BE DONE FOR DEMENTIA.
13 PHARMACOLOGICAL -- WOULD YOU NAME THOSE THREE FOR US, PLEASE?
14 A. YES. PHARMACOLOGICAL INTERVENTIONS OR MEDICATIONS,
15 PSYCHOSOCIAL INTERVENTIONS, OR THERE'S SOME VERBAL
16 INTERACTIONS WITH DEMENTED INDIVIDUALS THAT CAN HELP. AND,
17 ALSO, THERE IS ENVIRONMENTAL INTERVENTIONS THAT CAN ASSIST
18 WITH DIFFICULT BEHAVIORS.
19 Q. IN THESE CASES, DID YOU SEE PHARMACOLOGICAL INTERVENTION?
20 A. YES, THERE WERE PHARMACOLOGIC INTERVENTIONS.
21 Q. DID YOU SEE ANY PSYCHOSOCIAL INTERVENTIONS?
22 A. I DIDN'T SEE ANY DOCUMENTED, AND I DIDN'T SEE
23 ENVIRONMENTAL OTHER THAN A TRANSFER FROM ONE ENVIRONMENT TO
24 THE OTHER, BEING FROM THE NURSING HOME TO THE ACUTE
25 PSYCHIATRIC UNIT.
1 Q. WHAT ARE PSYCHOSOCIAL INTERVENTIONS, JUST BRIEFLY?
2 A. JUST BRIEFLY, REMINISCENCE AND VALIDATION THERAPY
3 OFTENTIMES ARE USEFUL IN AGITATED, DEMENTED INDIVIDUALS. - !!!
4 AND, BASICALLY, IT'S NOT REORIENTING THEM EACH TIME THEY
5 COMPLAIN, BUT ALLOWING THEM TO BE IN THEIR OWN FRAME OF
6 REFERENCE, WHEREVER THAT MAY BE.
7 Q. AND BRIEFLY, WHAT ARE ENVIRONMENTAL INTERVENTIONS?
8 A. I THINK MOST PSYCHIATRIC UNITS TRY TO EMPHASIZE THE
9 ENVIRONMENTAL ASPECT, CALM, SOOTHING ENVIRONMENT, A HOME-LIKE
10 ENVIRONMENT WITH FURNITURE AND THINGS AND LIGHTING THAT ARE
11 MORE CONDUCIVE TO A SOOTHING ENVIRONMENT RATHER THAN ONE WITH
12 BRIGHT LIGHTS, LOTS OF NOISE, THOSE KIND OF THINGS.
13 Q. THANK YOU. YOU WERE ASKED ABOUT AND TOLD ABOUT DOSES OF
14 PSYCHOTROPIC DRUGS THAT WERE GIVEN TO MR. ALLDREDGE BEFORE
15 HIS TRANSFER TO THE DAVIS HOSPITAL. DID YOU SEE THAT THOSE
16 WERE EFFECTIVE?
17 A. NO. IN FACT, SOME OF THE MEDICATIONS MAY ACTUALLY HAVE
18 CONTRIBUTED TO SOME OF HIS PROBLEMS. ONE OF THE MEDICATIONS,
19 OXYBUTYNIN, WHICH IS USED TO TREAT BLADDER SPASMS, ACTUALLY
20 HAS ONE AS A SIDE EFFECT, IT AFFECTS THE BRAIN IN SUCH A WAY
21 THAT CAN CAUSE CONFUSION, URINARY RETENTION, AND ALSO
22 CONSTIPATION.
23 MR. BUGDEN: COUNSEL, IF THIS WOULD HELP YOU?
24 MS. BARLOW: OH, THANKS. I'VE GOT ONE OVER HERE.
25 MR. BUGDEN: POURED IT JUST FOR YOU.
1 MS. BARLOW: I APPRECIATE THAT.
2 Q. (BY MS. BARLOW) IF LARGE DOSES OF PSYCHOTROPIC DRUGS ARE
3 NOT EFFECTIVE, WHAT WOULD BE YOUR RESPONSE TO THAT
4 INEFFECTIVENESS?
5 A. USUALLY IT WOULD BE TO DO A COUPLE OF THINGS. ONE, LOOK
6 AT THE UNDERLYING MEDICAL CAUSES THAT WERE GOING ON THAT
7 OFTENTIMES EXACERBATE THE PSYCHIATRIC SYMPTOMS, AND SO -- THE
8 DELIRIUM, FOR INSTANCE, TO TRY TO TREAT THOSE INSTANCES. AND
9 THEN, ALSO, MAYBE REDUCING THOSE MEDICATIONS AND TRYING
10 DIFFERENT CLASSES OR DIFFERENT TYPES OF MEDICATIONS IN
11 DIFFERENT DOSES.
12 Q. DID YOU SEE ANY OF THAT OCCURRING IN THIS -- IN
13 MR. ALLDREDGE?
14 A. NO.
15 Q. NOW, YOU'VE BEEN SHOWN DEFENDANT'S EXHIBIT 95 WHICH IS
16 A -- A LIVING WILL OF ENNIS ALLDREDGE. IS THAT LIVING
17 WILL -- WAS THAT LIVING WILL IN THE MEDICAL RECORDS OF ENNIS
18 ALLDREDGE?
19 A. IT WAS NOT IN THE RECORDS THAT I EXAMINED. EXCUSE ME, I
20 SHOULD CLARIFY. IT WAS NOT IN THE HOSPITAL RECORDS THAT I
21 EXAMINED.
22 Q. THE HOSPITAL RECORDS.
23 A. CORRECT.
24 Q. THANK YOU. WERE ANY RECORDS FROM THE NURSING HOME
25 TRANSMITTED TO THE HOSPITAL WITH MR. ALLDREDGE'S TRANSFER
1 THERE?
2 A. I'M NOT AWARE OF DOCUMENTATION STATING WHAT THEY DID OR
3 DID NOT GET IN TRANSFER.
4 Q. IF THERE WERE A -- IF THIS LIVING WILL WERE SIGNED AT A
5 CERTAIN TIME WHEN WE'LL PRESUME THAT MR. ALLDREDGE WAS
6 COMPETENT TO SIGN IT, BUT HE HAD SUBSEQUENTLY SIGNED A POWER
7 OF ATTORNEY FOR HIS WIFE TO MAKE MEDICAL DIRECTIVES ON HIS
8 BEHALF, WHAT EFFECT WOULD THAT HAVE? DO YOU KNOW?
9 A. WELL, ACCORDING TO UTAH LAW, THE --
10 MR. BUGDEN: YOUR HONOR, I'M NOT SURE THAT HE'S
11 QUALIFIED --
12 THE COURT: SUSTAINED.
13 A. ACCORDING TO MY UNDERSTANDING, THE SURROGATE
14 DECISION-MAKER WOULD TAKE PRECEDENT OVER ANY OTHER DECISIONS
15 THAT HAD BEEN MADE PREVIOUSLY TO THAT. SO THE SURROGATE
16 DECISION-MAKER WOULD MAKE NEW DECISIONS. IT COULD BE IN
17 AGREEMENT OR DISAGREE WITH THE PREVIOUS LIVING WILL.
18 Q. (BY MS. BARLOW) OKAY. THANK YOU. YOU INDICATED THAT
19 WITH MRS. SMITH SHE WAS EXTREMELY AGITATED UP TO THE 6TH OF
20 JANUARY. WAS SHE GETTING MEDICATIONS FOR THAT AGITATION?
21 A. YES.
22 Q. WERE THEY WORKING?
23 A. UP UNTIL THAT POINT IT SEEMS THAT HER SYMPTOMS HAD BEEN
24 VERY REFRACTORY AND WAS A VERY DIFFICULT PATIENT TO TREAT.
25 Q. REFRACTORY MEANING?
1 A. THAT SHE WAS NOT RESPONDING TO THE MEDICATIONS BEING
2 ADMINISTERED.
3 Q. WHAT RESPONSE WOULD YOU HAVE MADE WHEN THE MEDICATIONS
4 WERE NOT EFFECTIVE?
5 A. ONE OF THE THINGS THAT'S DIFFICULT IS EXAMINING THE
6 CHARTS IS THAT THERE'S NOT AN ONGOING --
7 MR. BUGDEN: I DON'T THINK THAT THIS IS RESPONSIVE,
8 YOUR HONOR.
9 THE COURT: SUSTAINED.
10 Q. (BY MS. BARLOW) WHAT WOULD YOU HAVE DONE WITH
11 MEDICATIONS NOT BEING EFFECTIVE?
12 A. I WOULD HAVE LOOKED FOR MAYBE SOME REASONS THAT THOSE
13 MEDICATIONS WEREN'T BEING EFFECTIVE SUCH AS UNDERLYING
14 MEDICAL CONDITIONS OR TAPER AND DISCONTINUE THOSE MEDICATIONS
15 AND TRY OTHER MEDICATIONS.
16 Q. DID YOU SEE THAT HAPPENING IN THE RECORDS?
17 A. NO.
18 Q. YOU TALKED ABOUT THESE BEING ACUTE ADMISSIONS. WHAT DOES
19 THAT MEAN?
20 A. ACUTE ADMISSIONS DIFFER FROM LONGER TERM ADMISSIONS IN
21 THAT SOMEONE HAS MADE A DECISION THAT THEY NEED TO GO TO THE
22 HOSPITAL NOW AS OPPOSED TO LET'S WAIT A FEW DAYS AND SEE WHAT
23 HAPPENS.
24 SO IT USUALLY INFERS THAT THE PROBLEM IS NO LONGER ABLE
25 TO BE TAKEN CARE OF IN THE -- IN THE ENVIRONMENT WHERE THE
1 PERSON CAME FROM, WHETHER IT'S AT HOME OR A NURSING HOME AND
2 THAT EVALUATION AND INTERVENTIONS NEED TO TAKE PLACE AT A
3 HIGHER LEVEL OF ACUITY.
4 Q. AND WHAT ARE THE EXPECTATIONS ABOUT WHEN THAT WOULD OCCUR
5 IN AN ACUTE ADMISSION?
6 A. WELL, IN AN ACUTE ADMISSION IT -- IT DOES VARY DEPENDING
7 UPON THE SPECIALTY WE'RE TALKING ABOUT. IN INTERNAL MEDICINE
8 THE EXPECT -- OR IN THE EMERGENCY ROOM, THE EXPECTATION THAT
9 IT WOULD BE FAIRLY IMMEDIATE THAT YOU'D LOOK AT THAT.
10 IN ADULT PSYCHIATRIC UNITS IT'S VERY COMMON FOR PEOPLE
11 TO SEE THE PATIENT THE NEXT DAY. IN GEROPSYCHIATRIC UNITS, I
12 THINK THAT IT'S VERY IMPORTANT THAT THE PATIENT BE EVALUATED
13 RATHER RAPIDLY BECAUSE OF THE HIGH INCIDENCE OF OTHER MEDICAL
14 ILLNESSES.
15 MR. BUGDEN: I DON'T THINK THIS IS RESPONSIVE, YOUR
16 HONOR.
17 THE COURT: SUSTAINED.
18 Q. (BY MS. BARLOW) LET ME GO ON TO ANOTHER QUESTION. YOU
19 WERE ASKED IF DR. DIENHART HAD BREACHED THE STANDARD OF CARE
20 BY NOT SEEING THE PATIENT WITHIN 24 HOURS -- JUDITH LARSEN
21 WITHIN 24 HOURS OF HER ADMISSION. YOU SAID YOU WEREN'T ABLE
22 TO GIVE A YES OR NO ANSWER TO THAT. CAN YOU GIVE AN EXPANDED
23 ANSWER TO THAT?
24 A. THE -- THE ANSWER -- IT'S -- IT'S NOT AS CLEAR-CUT AS A
25 YES OR NO BECAUSE IN EACH ADMISSION THERE IS AN ATTENDING OF
1 RECORD, AND THAT ATTENDING OF RECORD IS RESPONSIBLE FOR THE
2 CARE OF THE PATIENT. DR. DIENHART WAS COMING IN AS A
3 CONSULTANT. THE RESPONSIBILITIES OF THE CONSULTANT ARE
4 DIFFERENT THAN THAT OF AN ATTENDING PHYSICIAN.
5 Q. THANK YOU. YOU WERE ALSO ASKED ABOUT JUDITH LARSEN,
6 ABOUT A TERMINAL DIAGNOSIS AFTER HER STROKE IN AUGUST. DID
7 SHE PASS AWAY SHORTLY AFTER THAT STROKE?
8 A. NO, SHE DID NOT.
9 Q. IF SHE WERE TERMINAL, WOULD THAT HAVE AFFECTED OR COULD
10 THAT HAVE AFFECTED HER ADMISSION TO THE GEROPSYCH UNIT IN
11 DECEMBER OF 1995?
12 A. IT -- IT COULD HAVE BECAUSE THE POLICIES FOR PSYCHIATRIC
13 UNITS PROHIBIT PATIENTS COMING ON FOR MEDICAL REASONS OR FOR
14 OTHER REASONS OTHER THAN PSYCHIATRIC REASONS.
15 Q. OKAY. YOU WERE ASKED -- I'LL GO ON TO ANOTHER ONE.
16 YOU -- YOU WERE SHOWN FROM EXHIBIT 3-B TWO INDICATIONS OF
17 NURSING NOTES, ONE ON 584 WHERE JUDITH LARSEN WAS SAID TO BE
18 GROANING AND MOANING, AND ONE ON 587 WHERE SHE HAD JERKING
19 EXTREMITIES, HER EYES WERE OPEN, BUT SHE WAS MOANING.
20 DID YOU SEE AN EVALUATION OF WHAT WAS CAUSING THAT --
21 THOSE SYMPTOMS?
22 A. NO.
23 Q. WHAT KIND OF CAUSES COULD THERE BE FOR THOSE SYMPTOMS?
24 A. THERE CAN BE A VARIETY OF CAUSES. THOSE ARE SYMPTOMS AND
25 WHEN YOU HAVE SYMPTOMS, IT'S IMPORTANT TO EVALUATE THEM.
1 MOANING CAN BE CAUSED FROM A LOT OF REASONS. ONE OF
2 THEM COULD BE PAIN. THAT'S WHAT MAKES IT A VERY DIFFICULT
3 QUESTION YES OR NO. IT REQUIRES A MEDICAL EVALUATION REALLY
4 TO ASSESS THAT.
5 THE TWITCHING, QUITE FRANKLY, IS A COMMON SIDE EFFECT OF
6 MORPHINE. MORPHINE CAN CAUSE TWITCHING IN OLDER INDIVIDUALS.
7 SO IT, BY ITSELF, IS NOT NECESSARILY A SIGN OF PAIN. IT'S A
8 SIGN THAT SOMETHING'S GOING ON AND IT NEEDS AN EVALUATION.
9 THE SAME WITH MOANING.
10 Q. YOU WERE ASKED AS FAR AS MRS. ANDERSON IS CONCERNED ABOUT
11 THE MORPHINE BEING ORDERED OVER THE TELEPHONE FIRST AT, I
12 BELIEVE IT WAS EITHER 7:30 OR 8 O'CLOCK THE NIGHT OF THE
13 29TH, AND WHETHER THAT WAS AN APPROPRIATE TREATMENT FOR PAIN.
14 DO YOU RECALL THAT QUESTION?
15 A. YES.
16 Q. WAS THERE ANYTHING ABOUT THAT THAT BREACHED THE STANDARD
17 OF CARE, ABOUT THAT CIRCUMSTANCE?
18 A. WELL, AGAIN, THE -- I BELIEVE I RESPONDED TO THE ANSWER
19 PREVIOUSLY THAT IT WAS NOT A YES/NO QUESTION WHETHER THAT
20 BREACHED THE STANDARD OF CARE. IT DEPENDS UPON THE
21 EVALUATION THAT OCCURS PREVIOUSLY. WHAT WAS DELIVERED OVER
22 THE PHONE WERE SYMPTOMS. THE EVALUATION OF THOSE SYMPTOMS, I
23 DIDN'T SEE EVIDENCE OF WHAT THOSE WERE, WHAT THE EVALUATION
24 WAS.
25 ONE CONCLUSION COULD BE PAIN, BUT THERE COULD BE OTHER
1 THINGS GOING ON. AND I THINK THE HEART OF WHAT I SEE IS
2 BASICALLY A LACK OF EVALUATION OVER A PERIOD OF TIME. IT'S
3 VERY DIFFICULT THEN TO MAKE INTERVENTIONS WITHOUT COLLECTING
4 THE INFORMATION AND MAKING THE EVALUATION.
5 SO TO DETERMINE WHETHER THAT WAS AN APPROPRIATE RESPONSE
6 OR NOT APPROPRIATE RESPONSE, THERE'S SIMPLY NOT THE
7 INFORMATION IN THE CHART THAT WOULD ALLOW YOU TO SAY IS THAT
8 GOOD OR BAD. THERE'S JUST NOT THE EVALUATION.
9 TALKING ABOUT MARY CRANE AND THE DURAGESIC PATCH, YOU
10 WERE ASKED WHETHER THAT BREACHED THE STANDARD OF CARE. COULD
11 YOU ANSWER THAT?
12 A. I THINK I CAN ANSWER IT, BUT AGAIN, IT'S NOT A YES/NO
13 QUESTION. THE STANDARD OF CARE THAT -- THAT I REFER TO IS
14 NOT ONE THAT BECAUSE I HAVE A BUNCH OF DEGREES AND DO THIS
15 ALL THE TIME IS AT THE SAME STANDARD OF CARE I HOLD EVERYONE
16 TO. I -- I DON'T THINK THAT A CARDIAC THORACIC SURGEON CAN
17 HOLD A GENERAL PRACTITIONER TO THE SAME STANDARD OF CARE.
18 BUT I DO THINK THERE'S A PRINCIPLE OF CARE THAT I THINK
19 IS FUNDAMENTAL AND I THINK THAT'S WHAT IS DIFFERENT IN -- IN
20 THIS CASE. AND IT'S -- IT'S A STANDARD OF CARE --
21 MR. BUGDEN: YOUR HONOR, WE SHOULD ONLY BE TALKING
22 ABOUT MARY CRANE AND NOT SOME SORT OF GLOBAL RESPONSE. IT'S
23 NOT RESPONSIVE.
24 THE COURT: SUSTAIN THE OBJECTION. ANSWER THE
25 QUESTION.
1 A. LET ME RESPOND TO IT IN TERMS OF MARY CRANE. THERE IS
2 A -- IN RESPONSE TO MARY CRANE, THERE ARE SYMPTOMS. AND
3 AFTER THE COLLECTION OF SYMPTOMS, IT REALLY REQUIRES
4 COLLECTION OF MORE INFORMATION FROM VARIOUS SOURCES,
5 INCLUDING A MEDICAL EVALUATION, HANDS-ON EVALUATION THAT
6 WOULD INCLUDE AN EVALUATION. AND THEN YOU WOULD FORM SOME
7 KIND OF A MEDICAL OPINION WHERE YOU MAY OR MAY NOT ORDER
8 FURTHER INVESTIGATION SUCH AS LABORATORY RADIOLOGIC EXAMS.
9 AND AT THAT POINT YOU WOULD DO INTERVENTIONS.
10 THE COURT: SLOW DOWN, PLEASE, DOCTOR.
11 THE WITNESS: THANK YOU.
12 A. AFTER THE INTERVENTIONS, THEN YOU WOULD OBSERVE AGAIN
13 WHAT THE SYMPTOMS WERE AND START THAT PROCESS AGAIN.
14 WHAT I NOTICED IN THE CASE OF MARY CRANE IS THAT THE
15 PIECE OF COLLECTING THE INFORMATION WITH MEDICAL EVALUATION
16 IS NOT DOCUMENTED AND I CAN'T SUBSTANTIATE THAT THERE WAS
17 ONE.
18 Q. (BY MS. BARLOW) YOU WERE ASKED ABOUT CIPRO AND KEFLEX
19 WHICH ARE BOTH -- EXCUSE ME -- BOTH ANTIBIOTICS; IS THAT
20 CORRECT?
21 A. CORRECT.
22 Q. WHAT KIND OF INFECTIOUS -- INFECTION HAD BEEN FOUND IN
23 THE URINALYSIS?
24 A. IT WAS A GRAM-NEGATIVE BACTERIA THAT WAS FOUND IN THE
25 URINALYSIS.
1 Q. AND WHAT ABOUT KEFLEX? DOES THAT -- DOES THAT TREAT
2 GRAM-NEGATIVE?
3 A. NO. GRAM --
4 Q. OR POSITIVE --
5 A. -- KEFLEX IS TYPICALLY TREATING GRAM-POSITIVE. IT HAS
6 LIMITED ABILITY TO TREAT GRAM-NEGATIVE ORGANISMS.
7 Q. SO WHEN A BROAD SPECTRUM ANTIBIOTIC IS ORDERED, WHAT
8 ARE -- WHAT ARE YOU TALKING ABOUT?
9 A. USUALLY YOU WOULD WANT TO COMBINE AGENTS THAT WOULD TREAT
10 NOT ONLY GRAM-NEGATIVE AND GRAM-POSITIVE, BUT ALSO ANAEROBIC
11 BACTERIA IN THIS CASE, IN WHICH CASE YOU'D WANT TO AT LEAST
12 GIVE THE CIPRO AND THE KEFLEX TOGETHER. THEY WERE NOT
13 SIMULTANEOUSLY GIVEN ACCORDING TO THE RECORDS THAT I
14 REVIEWED.
15 Q. COULD YOU TELL FROM THE RECORDS HOW OFTEN THE DEFENDANT
16 WOULD BE IN TO SEE THESE PATIENTS?
17 A. FROM THE RECORDS IT APPEARED THAT THERE WERE DAILY M.D.
18 NOTES.
19 Q. CAN YOU --
20 A. BUT I CAN NOT TELL -- THEY WERE -- THEY WERE VERY SHORT
21 NOTES. I DO NOT KNOW HOW LONG THE M.D. WAS THERE EVALUATING
22 THE PATIENTS.
23 Q. DO YOU BELIEVE THAT THE MORPHINE, AS WELL AS THE OTHER
24 CENTRAL NERVOUS SYSTEM DEPRESSANTS, THE OTHER PSYCHOACTIVE
25 DRUGS, PLAYED A ROLE IN THE DEATH OR IN HASTENING THE DEATH OF
1 THESE PATIENTS?
2 MR. BUGDEN: OBJECTION, LEADING.
3 THE COURT: SUSTAINED.
4 Q. (BY MS. BARLOW) DID THE MORPHINE AND/OR THE PSYCHOACTIVE
5 DRUGS HAVE ANY IMPACT OR ANY EFFECT ON THE DEATH OF THESE
6 PATIENTS?
7 A. I THINK THE MEDICATIONS -- ALL OF THE MEDICATIONS, IN
8 ADDITION TO THE MEDICAL AND THE DEMENTIA THAT WAS GOING ON,
9 ALL WERE CONTRIBUTING FACTORS TO THE DEATH.
10 Q. WHAT IMPACT OF -- OF THE LACK OF PROPER MEDICAL CARE IN
11 RESPECT TO THESE PATIENTS DID THAT HAVE ON THEIR DEATH -- ON
12 THE CAUSE OF THEIR DEATHS?
13 A. IN THE EVALUATION I DON'T SEE MEDICAL EVALUATION WITH
14 HANDS-ON EVALUATION OF THE PATIENTS CONSISTENTLY BEING DONE
15 IN ORDER TO GET OTHER INFORMATION AND SYNTHESIZE THAT
16 INFORMATION INTO PLANS. I DON'T SEE THE DOCUMENTATION OF
17 THAT.
18 Q. COULD THAT HAVE CONTRIBUTED TO THEIR DEATHS?
19 A. YES.
20 Q. IN WHAT --
21 MR. BUGDEN: YOUR HONOR, I -- I WOULD ASK THAT THAT
22 BE STRICKEN. IT'S AN IMPROPER QUESTION AND IT'S NOT -- IT'S
23 NOT THE REASONABLE DEGREE OF MEDICAL CERTAINTY. ANYTHING'S
24 POSSIBLE.
25 THE COURT: IT IS, BUT I WILL OVERRULE THE
1 OBJECTION.
2 Q. (BY MS. BARLOW) HAS YOUR OPINION CHANGED ABOUT THE
3 MEDICAL -- WHETHER THE MEDICAL CARE PROVIDED TO THESE
4 PATIENTS FELL BELOW THE STANDARD OF CARE OF A ORDINARY
5 PHYSICIAN IN THE SAME CIRCUMSTANCES AS DEFENDANT?
6 A. NO.
7 MS. BARLOW: THOSE ARE ALL THE QUESTIONS I HAVE,
8 YOUR HONOR.
9 THE COURT: RECROSS?
10 MR. BUGDEN: NO, SIR.
11 THE COURT: YOU MAY STEP DOWN, DOCTOR. THANK YOU
12 FOR TESTIFYING.
13 MAY THIS WITNESS BE EXCUSED, MS. BARLOW?
14 MS. BARLOW: YES, YOUR HONOR.
15 THE COURT: MR. BUGDEN?
16 MR. BUGDEN: THAT'S FINE WITH ME AS WELL.
17 THE COURT: YOU MAY BE EXCUSED AND THANK YOU,
18 DOCTOR.