Charles Fehlauer, MD
18 CHARLES FEHLAUER,
19 CALLED BY THE PLAINTIFF, HAVING BEEN DULY
20 SWORN, WAS EXAMINED AND TESTIFIED AS FOLLOWS:
21 DIRECT EXAMINATION
22 BY MS. BARLOW:
23 Q. WOULD YOU PLEASE STATE YOUR NAME AND SPELL IT FOR THE
24 RECORD?
25 A. IT'S CHARLES STEVEN FEHLAUER. LAST NAME IS
2183
1 F-E-H-L-A-U-E-R.
2 Q. AND IS STEVEN WITH A "V"?
3 A. IT IS.
4 Q. AND WHAT IS YOUR OCCUPATION?
5 A. I'M A PHYSICIAN.
6 Q. HOW LONG HAVE YOU BEEN A PHYSICIAN?
7 A. I WAS LICENSED IN 1986. THAT WOULD BE 14 YEARS.
8 Q. WHAT EDUCATION DID YOU RECEIVE FOR YOUR OCCUPATION?
9 A. I WENT TO THE UNIVERSITY OF UTAH FOR MY MEDICAL SCHOOL
10 TRAINING. I COMPLETED A THREE-YEAR RESIDENCY IN INTERNAL
11 MEDICINE AT THE UNIVERSITY OF UTAH AND A TWO-YEAR FELLOWSHIP
12 IN GERIATRIC MEDICINE AT THE UNIVERSITY OF UTAH.
13 Q. WHAT IS GERIATRIC MEDICINE?
14 A. GERIATRIC MEDICINE IS THE TREATMENT OF ADULTS WHO ARE
15 ELDERLY, AND THERE'S NO DEFINITE DEFINITION OF A PERSON
16 WHO'S ELDERLY, BUT GENERALLY SPEAKING OVER THE AGE OF 70.
17 Q. SO THOSE OF US WHO ARE 50 ARE NOT SENIOR CITIZENS YET?
18 A. NO, NOT YET.
19 Q. HAVE YOU RECEIVED ANY OTHER TRAINING OTHER THAN THE
20 EDUCATIONAL BACKGROUND THAT YOU'VE JUST TESTIFIED TO IN
21 YOUR -- IN YOUR FIELD?
22 A. WELL, I HAVE HAD NUMEROUS CONTINUING MEDICAL EDUCATION
23 EVENTS ON AN ANNUAL OR MORE THAN ANNUAL BASIS. I HAVE HAD
24 EXTENSIVE EXPERIENCE IN THE RESEARCH INTO PEOPLE WITH
25 GERIATRIC DISEASES, DEMENTIA AND DELIRIUM, WHILE I WAS A
2184
1 RESEARCH INVESTIGATOR AT THE SALT LAKE V.A. HOSPITAL'S
2 GERIATRIC RESEARCH, EDUCATION AND CLINICAL CENTER.
3 Q. DO YOU HAVE ANY PARTICULAR CERTIFICATIONS IN YOUR
4 MEDICAL FIELD?
5 A. YEAH. I'M CERTIFIED BY THE AMERICAN BOARD OF INTERNAL
6 MEDICINE BOTH IN INTERNAL MEDICINE AND IN GERIATRICS.
7 Q. WHAT'S INTERNAL MEDICINE?
8 A. INTERNAL MEDICINE IS THE MANAGEMENT OF DISEASES OF
9 ADULTS.
10 Q. DO YOU HAVE ANY OTHER CREDENTIALS OTHER THAN THESE
11 CERTIFICATIONS?
12 A. I HOLD NUMEROUS POSITIONS AS MEDICAL DIRECTOR FOR
13 NURSING FACILITIES, AN INPATIENT PSYCHIATRIC HOSPITAL, A
14 SENIOR MEDICAL CENTER. I HAVE BEEN AN ADVISORY MEMBER OF
15 THE UTAH ALZHEIMER'S ASSOCIATION FOR MORE THAN 10 YEARS.
16 I'M A MEMBER OF PROFESSIONAL SOCIETIES RELATIVE TO MY
17 MEDICAL DIRECTORSHIPS.
18 Q. HAVE YOU EVER PUBLISHED IN THE FIELD OF GERIATRICS?
19 A. YEAH, I HAVE NUMEROUS ABSTRACTS, JOURNAL ARTICLES AND
20 BOOK CHAPTERS RELATIVE TO THE FIELD OF GERIATRICS, QUALITY
21 OF CARE AND DISEASES OF THE ELDERLY.
22 Q. ARE YOU FAMILIAR WITH THE TERM PALLIATIVE CARE?
23 A. I AM.
24 Q. AND WHAT IS THAT?
25 A. PALLIATIVE CARE IS THE CARE OF SOMEONE WHO HAS A DISEASE
2185
1 TO WHICH THERE IS NO CURE AND/OR THE PRESENCE OF AN ILLNESS
2 WHICH IS FELT TO BE TERMINAL.
3 AND THE PURPOSE OF PALLIATIVE CARE IS TO PROVIDE THAT
4 PATIENT WITH THE HIGHEST LEVEL OF FUNCTION, HIGHEST LEVEL OF
5 RELIEF OF SUFFERING OR PAIN SO THAT THEY CAN LIVE A QUALITY
6 AND -- AND AS LONG A LIFE AS THEY -- AS THEIR TIME ALLOWS.
7 Q. DO YOU KEEP UP WITH LITERATURE IN THE FIELD OF
8 GERIATRICS?
9 A. YES. I'M ACTIVELY INVOLVED IN REVIEWING LITERATURE AND
10 REVIEWING MATERIALS RELATIVE TO MY PRACTICE.
11 Q. DO YOU HAVE ANY TEACHING RESPONSIBILITIES?
12 A. I'M CURRENTLY A CLINICAL ASSISTANT PROFESSOR IN THE
13 COLLEGE OF NURSING. IT'S A RESEARCH APPOINTMENT AND I HAVE
14 NURSING STUDENTS OCCASIONALLY. IN MY POSITION AT THE SALT
15 LAKE REGIONAL MEDICAL CENTER WE HAVE HOUSE STAFF TRAINING
16 PROGRAM IN FAMILY PRACTICE AND ON A DAILY BASIS WE TEACH
17 CLINICALLY WITH THE FAMILY MEDICINE RESIDENTS THERE. I'M
18 RESPONSIBLE FOR EDUCATING STAFF IN MY NURSING FACILITIES.
19 I'M RESPONSIBLE FOR OVERSEEING THE CARE OF RESIDENTS IN MY
20 NURSING FACILITIES, AND EDUCATING PHYSICIANS RELATIVE TO THE
21 QUALITY OF CARE THAT'S BEING DELIVERED. I'M RESPONSIBLE FOR
22 EDUCATING NURSING ASSISTANTS AND -- AND ADMINISTRATORS IN
23 THE QUALITY OF CARE AND THE CARE DELIVERED IN THE NURSING
24 FACILITIES, THE HOSPITAL, AND MY MEDICAL CLINIC.
25 I'VE ALSO CONTINUED TO LECTURE BOTH TO THE COMMUNITY
2186
1 AND TO MEDICAL PHYSICIANS, IN PARTICULAR IN THE LAST FIVE
2 YEARS RELATIVE TO DEMENTIA AND DELIRIUM. AND AS RECENTLY AS
3 JANUARY OF THIS YEAR I WAS A SPEAKER AT THE UNIVERSITY OF
4 UTAH'S INTERNAL MEDICINE CONFERENCE THAT THEY PROVIDE AS AN
5 UPDATE TO INTERNAL MEDICINE.
6 Q. WHAT HAS BEEN YOUR EXPERIENCE IN THE CARE OF DEMENTED
7 PATIENTS?
8 A. WELL, I'VE HAD EXTENSIVE EXPERIENCE. I ENTERED MY
9 FELLOWSHIP IN 1989 AND JUST SHORTLY THEREAFTER WAS THE
10 FELLOW IN CLINIC AT THE UNIVERSITY OF UTAH'S COGNITIVE
11 DISORDERS CLINIC.
12 Q. WHAT'S A FELLOW?
13 A. A FELLOW IS SOMEONE WHO HAS COMPLETED A RESIDENCY OR THE
14 FIRST STATE OF TRAINING AFTER MEDICAL SCHOOL. AND THEN A
15 FELLOWSHIP IS ADDITIONAL TRAINING AFTER YOU'VE COMPLETED
16 YOUR SPECIALTY TRAINING. SO I'M A SPECIALIST IN INTERNAL
17 MEDICINE AND I'M A SUBSPECIALIST IN GERIATRICS. AND AS A
18 FELLOW YOU GET THAT TRAINING AS A SUBSPECIALIST.
19 SO IN 19 -- IN ANSWER TO YOUR QUESTION, IN 1989 I BEGAN
20 SERVING AS THE FELLOW OR THE TRAINEE IN THE COGNITIVE
21 DISORDERS OR MEMORY DISORDERS CLINIC AT THE UNIVERSITY OF
22 UTAH AND CONTINUED THAT UNTIL 1991. AND THEN FROM '91 TO
23 '95 I WAS AN ATTENDING PHYSICIAN; THAT IS, SOMEONE
24 PRINCIPALLY RESPONSIBLE FOR THE CARE OF THE PATIENTS IN THAT
25 CLINIC.
2187
1 FOR A PERIOD OF THREE YEARS I WAS A PRINCIPAL ATTENDING
2 PHYSICIAN AT GARDEN TERRACE, WHICH IS A NURSING FACILITY
3 SPECIALIZING IN THE CARE OF ALZHEIMER'S PATIENTS. AND FOR
4 THE LAST FIVE YEARS I'VE BEEN THE PRINCIPAL ATTENDING
5 PHYSICIAN AND MEDICAL DIRECTOR OF NURSING FACILITIES IN THE
6 SALT LAKE COUNTY WHERE I'VE CARED FOR OVER 3,000 INDIVIDUALS
7 IN THE LAST FIVE YEARS AND 1,000 OF WHOM HAVE SUFFERED FROM
8 DEMENTIA.
9 Q. IN THE COURSE OF THIS TRIAL WE'VE HEARD THE PHRASE
10 "CLINICAL" IN RELATIONSHIP TO THE PRACTICE OF MEDICINE. CAN
11 YOU EXPLAIN WHAT THAT -- THAT PHRASE -- OR THAT TERM MEANS?
12 A. WELL, YOU COULD SAY IT'S DERIVED FROM IN THE CLINIC. IT
13 MEANS THAT YOU ARE IN THE CLINIC OR YOU ARE PROVIDING SOME
14 SORT OF CARE THAT RELATES TO DIRECTLY CONTACTING A PATIENT.
15 WOULD BE OPPOSED TO BEING A -- A RESEARCH POSITION WHERE
16 THE -- THE INTERACTION YOU HAVE WITH A PATIENT IS -- IS
17 MEANT TO BE -- TO DISCOVER SOMETHING OR TO TEST SOMETHING.
18 A CLINICAL PERSON IS A PERSON WHO -- WHO PROVIDES DIRECT
19 CARE AND ASSESSMENT TO PATIENTS.
20 Q. AND HAVE YOU DONE BOTH OF THOSE, BOTH CLINICAL AND
21 RESEARCH?
22 A. YEAH. MY POSITION AT THE SALT LAKE V.A. WAS AS A
23 RESEARCH INVESTIGATOR. IT'S AN APPOINTMENT THAT WAS
24 INCLUDED IN THE CENTER GRANT THAT THE V.A. RECEIVED AFTER MY
25 APPLICATION WITH THE OTHER DOCTORS WAS ACCEPTED IN 1991.
2188
1 AND IN THAT POSITION MY PRINCIPLE STUDY WAS INVOLVED IN
2 USING NURSING RECORDS TO DETECT PATIENTS WHO ARE CONFUSED
3 AND CONFUSED IN A WAY THAT INDICATED THAT THEY HAD A
4 SYNDROME CALLED DELIRIUM. AND THAT RESEARCH CONTINUED FOR A
5 PERIOD OF FOUR YEARS UNTIL I LEFT THE V.A. IN 1995.
6 Q. HAVE YOU HAD THE OCCASION TO REVIEW ANY RECORDS
7 REGARDING THE FIVE VICTIMS IN THIS CASE?
8 A. YES, I HAVE.
9 Q. AND WHAT REVIEW HAVE YOU DONE?
10 A. WITH RESPECT TO ALL FIVE OF THE CASES, I HAVE BEEN
11 SUPPLIED WITH INFORMATION FROM HOSPITALIZATIONS AND NURSING
12 FACILITY RECORDS, DOCTOR'S OFFICE NOTES, PRIOR TO THEIR
13 ADMISSION TO DAVIS HOSPITAL, AND I'VE BEEN PROVIDED WITH
14 RECORDS FROM DAVIS HOSPITAL ITSELF.
15 Q. DO YOU RECALL LOOKING AT RECORDS INVOLVING ELLEN
16 ANDERSON?
17 A. YES, I DO.
18 Q. ARE THERE ANY FOLDERS UP THERE?
19 MS. BARLOW: IF I MAY APPROACH, YOUR HONOR?
20 THE COURT: YES.
21 Q. (BY MS. BARLOW) DR. FEHLAUER, THIS IS A BINDER THAT'S
22 STATE'S EXHIBIT NUMBER 6. WOULD YOU LOOK THROUGH THAT
23 QUICKLY AND SEE IF YOU RECOGNIZE WHAT THAT IS?
24 A. BASED ON EACH OF THE TABS, THIS APPEARS TO BE THE RECORD
25 THAT I WAS SUPPLIED RELATIVE TO ELLEN ANDERSON'S STAY AT
2189
1 DAVIS HOSPITAL.
2 Q. IN FORMULATING AN OPINION, A MEDICAL OPINION, WHAT DO
3 YOU NEED TO KNOW TO FORMULATE A MEDICAL OPINION SAY AS TO
4 INJURY OR -- OR CAUSE OF DEATH OR SOMETHING OF THAT SORT?
5 A. IF I'M FORMULATING MY OWN MEDICAL OPINION, IF I'M
6 ATTEMPTING TO, FROM EXAMINATION OF THE PATIENT OR THEIR
7 RECORDS, TO FORMULATE AN OPINION AS TO WHAT'S WRONG OR
8 WHAT'S HAPPENED OR WHAT WAS THE CAUSE OF DEATH, I NEED TO
9 HAVE INFORMATION RELATIVE TO THE PATIENT'S HISTORY: WHAT
10 HAPPENED TO THEM OR WHAT ARE THEY COMPLAINING OF OR WHAT
11 HAVE OTHERS' OBSERVATIONS OF THEM BEEN? I NEED TO EXAMINE
12 THE PATIENT.
13 IT'S CRITICALLY IMPORTANT TO BE ABLE TO UNDERSTAND
14 WHAT'S WRONG TO ACTUALLY LAY HANDS ON A PATIENT, TO USE THE
15 SKILLS THAT I'VE BEEN TRAINED WITH TO DISCERN WHAT HAS
16 OCCURRED, WHAT ILLNESS OR INJURY IS PRESENT. AND THEN IN
17 MAKING AN ASSESSMENT AS TO WHAT'S WRONG, I OBVIOUSLY WOULD
18 USE ANCILLARY INFORMATION FROM LABORATORIES AND X-RAYS AND
19 OTHER STUDIES THAT MAY HAVE BEEN DONE TO FORM THE OPINION AS
20 TO WHAT'S WRONG AND THEN BE ABLE TO FORMULATE A PLAN AS TO
21 WHAT'S RIGHT.
22 IN THE ABSENCE OF BEING ABLE TO FORMULATE AN ACCURATE
23 ASSESSMENT, YOU CAN'T REALLY FORMULATE A PLAN AS TO WHAT'S
24 THE RIGHT THING TO DO FOR A RESIDENT.
25 Q. WHAT TYPES OF DOCUMENTS WOULD YOU USE OR REVIEW TO -- TO
2190
1 MAKE AN ASSESSMENT?
2 A. I GET ASKED THAT ALL THE TIME BY PEOPLE WHO ACCEPT
3 PATIENTS TO THE FACILITIES WHERE I WORK BECAUSE I'M
4 CONTINUOUSLY SAYING TO THEM, I NEED MORE INFORMATION. THE
5 ANSWER IS, I'LL USE INFORMATION THAT'S BEEN PROVIDED BY THE
6 PATIENT THEMSELVES IN HISTORY, BY THEIR FAMILY MEMBERS IN
7 HISTORY, BY OBSERVATIONS OF PROFESSIONALS. AND, OF COURSE,
8 I'LL USE INFORMATION FROM OUTSIDE PHYSICIANS OR HOSPITAL
9 RECORDS OR I'LL USE INFORMATION FROM AN OUTSIDE OR
10 INDEPENDENT LABORATORY, WHATEVER INFORMATION IS AVAILABLE
11 THAT I CAN MAKE USE OF TO ASSIST THE PATIENT MOST
12 APPROPRIATELY.
13 Q. NOW, WE'VE BEEN TALKING IN THE ABSTRACT THERE. LET'S
14 SHIFT SLIGHTLY TO THE CIRCUMSTANCE YOU HAVE WITH THESE FIVE
15 PEOPLE. WHAT -- WHAT DOCUMENTS DID YOU NEED TO REVIEW TO
16 FORMULATE ANY OPINION ABOUT WHAT HAPPENED IN THE CARE OF
17 THESE FIVE PEOPLE?
18 A. BECAUSE THE QUESTION PUT TO ME WAS WHAT HAPPENED, I
19 ASKED FOR INFORMATION IN ADDITION TO THE HOSPITAL RECORDS I
20 WAS INITIALLY PROVIDED WITH, BUT INFORMATION FROM PRIOR
21 HISTORY. AND IN PARTICULAR I WAS INTERESTED IN THE SIX
22 MONTHS OF MATERIAL THAT LED UP TO THEIR ADMISSION TO THE
23 DAVIS HOSPITAL. THE INFORMATION THAT WAS AVAILABLE FROM
24 THOSE SIX MONTHS THAT WAS SUPPLIED TO ME WAS NURSING
25 FACILITY AND HOSPITAL RECORDS AND A FEW DOCTORS' OFFICE
2191
1 NOTES.
2 Q. DID YOU EVER TALK TO ANY OF THE PATIENTS' FAMILIES?
3 A. NO.
4 Q. DID YOU HAVE IN THE RECORDS ANY INDICATION OF PRIOR
5 HISTORY THAT YOU WOULD HAVE NORMALLY -- IF THESE PATIENTS
6 WERE STILL ALIVE, THAT YOU WOULD NORMALLY HAVE GOTTEN FROM
7 EITHER THE PATIENT OR FROM THE FAMILY?
8 A. I'M NOT SURE I UNDERSTAND YOUR QUESTION.
9 Q. IS THERE ANYTHING IN THE RECORD THAT GAVE YOU HISTORY
10 THAT WOULD HAVE COME NORMALLY FROM A PATIENT OR THEIR
11 FAMILY?
12 A. YES.
13 Q. PARTICULARLY MAYBE I'LL HAVE YOU LOOK AT -- UNDER
14 NURSES' NOTES, FOR EXAMPLE, WITH ELLEN ANDERSON, A SERIES OF
15 PAGES THAT START WITH MED-00178. DID YOU REVIEW THAT
16 DOCUMENT?
17 A. YES.
18 Q. ARE YOU COMPARING TWO DOCUMENTS UP THERE?
19 A. I HAVE THE COPIES OF THE MATERIALS THAT I WAS GIVEN FROM
20 THE DAVIS HOSPITAL AND FROM THE NURSING FACILITIES BECAUSE
21 I'VE MADE NOTES ON THESE DOCUMENTS AND HIGHLIGHTED THEM TO
22 ASSIST ME IN PROVIDING INFORMATION. I WOULD LIKE TO MAKE
23 SURE THAT WHEN YOU ASK A QUESTION OF HOW I REVIEWED IT THAT
24 I CAN USE MY OWN NOTES AND -- AND STATE AFFIRMATIVELY THAT
25 THIS WAS A DOCUMENT I REVIEWED.
2192
1 Q. AND YOU'VE COMPARED THAT TO WHAT IS IN -- I GUESS IT'S
2 STATE'S EXHIBIT 6?
3 A. THE FIRST TWO PAGES ARE SIMILAR. I CAN GO THROUGH ALL
4 THE PAGES.
5 Q. NO. THAT'S FINE. I -- I JUST WANT TO MAKE SURE THAT
6 THAT IS ONE THING THAT HAD BEEN PROVIDED FOR YOU.
7 THE DOCUMENTS THAT YOU REVIEWED IN THIS CASE INVOLVING
8 THESE FIVE PEOPLE, ARE THEY THE TYPES USUALLY RELIED ON BY
9 EXPERTS IN THE FIELD?
10 A. YES.
11 Q. TO RENDER AN OPINION ABOUT WHAT HAPPENED?
12 A. YES.
13 Q. NOW, THE GENERAL PRINCIPLES THAT YOU WILL BE TESTIFYING
14 ABOUT TODAY, ARE THEY -- ARE THEY GENERALLY ACCEPTED IN THE
15 RELEVANT MEDICAL COMMUNITY?
16 A. YES.
17 Q. AND AS WE TALK SPECIFICALLY ABOUT THOSE WE'LL -- WE'LL
18 GET INTO WHAT THEY ARE. BASED ON THE -- ON YOUR EXPERTISE
19 AND THE REVIEW OF THE RECORDS, DID YOU FORM AN OPINION
20 REGARDING THE ADMISSION DIAGNOSIS -- THE ADMISSION AND
21 DIAGNOSIS OF SAY ELLEN ANDERSON?
22 A. MY OPINION RELATIVE TO THE STATE OF ELLEN ANDERSON
23 VARIES AS TO THE TIME THAT WE'RE SPEAKING OF. IF YOU'RE
24 SPEAKING OF THE DATE THAT SHE WAS ADMITTED, I'LL GIVE A --
25 CAN GIVE YOU AN OPINION AS TO WHAT I THINK WAS WRONG AT THAT
2193
1 POINT, IF YOU GIVE ME A DATE.
2 Q. OKAY. I BELIEVE THAT DATE WAS THE 29TH OF -- OF
3 DECEMBER.
4 A. MY REVIEW OF THE RECORD ON 29 DECEMBER, INCLUSIVE OF
5 MATERIALS BEFORE THAT, IF I'M ALLOWED --
6 Q. YES. WHAT MATERIALS -- WELL, YOUR OPINION AS OF THAT
7 TIME BASED ON ALL THE RECORDS THAT YOU REVIEWED.
8 A. MY OPINION, BASED ON ALL THE RECORDS REVIEWED, WAS THAT
9 ELLEN ANDERSON SUFFERED FROM SENILE DEMENTIA, AND THAT AT
10 THE TIME THAT SHE WAS ADMITTED TO DAVIS HOSPITAL ON THE 29TH
11 THAT SHE CLEARLY WAS DELIRIOUS FROM MULTIPLE POTENTIAL
12 CAUSES. THAT IN ADDITION TO THOSE TWO PRINCIPLE DIAGNOSES
13 AS THE REASON FOR HER BEING ADMITTED TO THAT FACILITY, THAT
14 SHE HAD A HISTORY OF HAVING FALLEN AND HAD A FRACTURE AND A
15 REPAIR OF A FEMUR FRACTURE -- OR WHAT PEOPLE CALL A HIP
16 FRACTURE. THAT SHE HAD ANXIETY DISORDER OF SOME NUMBER OF
17 YEARS DURATION. THAT SHE HAD OSTEOPOROSIS -- OR LOSS OF
18 BONE MINERAL, THINNING OF THE BONES. THAT SHE HAD
19 EXPERIENCED WEIGHT LOSS, AND THAT SHE HAD HAD A COMPRESSION
20 FRACTURES OF HER SPINE SOMETIME IN THE PAST. Leaves out CAD, CHF, and pneumonia.
21 Q. AND BASED ON YOUR REVIEW OF THE RECORDS, WERE ANY OF
22 THOSE DIAGNOSES THAT YOU MADE BASED ON THOSE RECORDS
23 LIFE-THREATENING AT THAT POINT?
24 A. NO.
25 MS. BARLOW: YOUR HONOR, IF I MAY HAVE THIS CHART
2194
1 MARKED AS AN EXHIBIT, PLEASE. I BELIEVE IT IS EXHIBIT
2 NUMBER 29.
3 (WHEREUPON, THERE'S AN OFF-THE-RECORD DISCUSSION.)
4 MR. STIRBA: YOUR HONOR, I MAY NOT HAVE ANY PROBLEM
5 WITH THE EXHIBIT, BUT BEFORE IT'S DISPLAYED, COULD WE HAVE A
6 LITTLE FOUNDATION ABOUT WHAT IT IS AND WHAT IT PURPORTS TO
7 REPRESENT?
8 THE COURT: YES. WHY DON'T YOU GO AHEAD AND LAY A
9 FOUNDATION.
10 MS. BARLOW: I'D BE HAPPY TO DO THAT.
11 Q. (BY MS. BARLOW) DR. FEHLAUER -- NO. HOLD IT OVER JUST
12 FOR YOURSELF FIRST. HAVE YOU SEEN THIS CHART BEFORE?
13 A. YES.
14 Q. AND WHERE HAVE YOU SEEN IT?
15 A. THIS IS A CHART I PREPARED AND HAS BEEN PLACED ON THIS
16 BOARD DURING MY PREPARATION FOR TESTIMONY.
17 Q. AND WHERE DID YOU GET THE INFORMATION FROM THIS CHART --
18 THAT YOU PUT ON THIS CHART, EXCUSE ME?
19 A. THE INFORMATION FROM THIS CHART IS BASED ON LECTURES
20 THAT I GIVE TO COMMUNITY GROUPS, PHYSICIANS, NURSING STAFFS,
21 STUDENTS, RELATIVE TO UNDERSTANDING THE DIFFERENCE BETWEEN
22 DEMENTIA, A SYNDROME OF LONG DURATION ASSOCIATED WITH MEMORY
23 LOSS AND FUNCTIONAL LOSS; AND DELIRIUM, A SYNDROME OFTEN
24 OCCURRING IN DEMENTIA, BUT NOT EXCLUSIVELY, WHERE THE
25 PATIENT IS SUDDENLY WORSE, EXHIBITING SUDDEN CHANGES DURING
2195
1 A DAILY OR OTHERWISE TIME FRAME THAT'S REVERSIBLE AS OPPOSED
2 TO BEING PROGRESSIVE AND IRREVERSIBLE.
3 Q. DOES THIS ACCURATELY REFLECT THEN A SUMMARY OF WHAT YOU
4 ARE GOING TO TESTIFY TODAY?
5 A. YES.
6 MS. BARLOW: YOUR HONOR, I WOULD MOVE FOR ADMISSION
7 OF STATE'S EXHIBIT 29.
8 MR. STIRBA: YEAH. I HAVE AN OBJECTION AS TO
9 RELEVANCY, YOUR HONOR.
10 THE COURT: OKAY. IS THERE SOMETHING YOU CAN GO ON
11 AND THEN WE CAN -- OR IS THIS AT A POINT WHERE WE NEED TO --
12 MS. BARLOW: THIS IS PRETTY MUCH -- PRETTY BASIC,
13 YOUR HONOR.
14 THE COURT: OKAY. LADIES AND GENTLEMEN, WE WERE
15 HERE A HALF HOUR BEFORE WE TOOK THIS FIRST BREAK. AND IF
16 YOU WANT TO GO OUTSIDE TO TAKE A FIVE-MINUTE BREAK, I DON'T
17 THINK IT'S GOING TO BE MUCH MORE THAN FIVE MINUTES. SO THAT
18 JUST BE IN A PLACE WHERE WHEN THE BAILIFF NOTIFIES YOU TO
19 COME BACK IN, THAT YOU WILL COME IN.
20 DURING THIS BREAK REMEMBER IT'S YOUR DUTY NOT TO
21 CONVERSE AMONG YOURSELVES REGARDING THE CASE OR TO CONVERSE
22 WITH ANYONE ELSE ABOUT THE CASE OR TO ALLOW ANYONE TO
23 ADDRESS YOU REGARDING THE SUBJECT OF THIS TRIAL. AND -- AND
24 IT'S ALSO YOUR DUTY NOT TO FORM OR EXPRESS AN OPINION UNTIL
25 THE CASE IS FINALLY SUBMITTED.
2196
1 SO IF YOU'LL JUST -- WE'LL BE IN RECESS UNTIL YOU'RE
2 NOTIFIED.
3 (WHEREUPON, THE JURY'S EXCUSED.)
4 THE COURT: YOU MAY BE SEATED. THE RECORD WILL
5 REFLECT THAT THE JURY HAS LEFT THE COURTROOM.
6 OKAY. WHAT IS THE -- WHERE ARE WE GOING WITH THIS AND
7 THEN WHAT IS THE OBJECTION?
8 MS. BARLOW: YOUR HONOR, I WAS GOING TO HAVE HIM --
9 HE'S GOING TO TESTIFY THAT WITH EACH ONE OF THESE PEOPLE
10 THERE WAS DEMENTIA, BUT OVERLYING THAT WAS DELIRIUM, BASED
11 ON HIS REVIEW OF THE RECORD.
12 HE WILL TESTIFY THAT DELIRIUM IS TREATABLE. HE WILL
13 TESTIFY THAT IT WAS NOT TREATED, THAT IT -- THAT IT FACTORED
14 INTO THE WHOLE DECLINE ALONG WITH THE MEDICATIONS.
15 ESPECIALLY -- HE'S GOING TO TESTIFY THAT DELIRIUM IS OFTEN
16 CAUSED BY -- OH, I CAN'T THINK OF THE WORD I WANT -- BY THE
17 MEDICINES THEMSELVES THAT -- THAT ARE USED FOR DEMENTIA AND
18 SPECIFICALLY THE MEDICINE -- THE MEDICATIONS THAT WERE USED
19 IN THIS CASE. AND THAT -- THAT THOSE MEDICATIONS CAN
20 CAUSE -- CAN CAUSE DELIRIUM.
21 AND THE WAY YOU TREAT THAT IS WHEN YOU SEE THE
22 DELIRIUM, YOU TAKE THEM OFF THE MEDICINES -- THE MEDICATIONS
23 TO SEE IF THE MEDICATIONS ARE CAUSING THE DELIRIUM. BUT
24 WHAT HAPPENED IN THIS CASE IS INSTEAD OF DIAGNOSING THE
25 DELIRIUM AND WITHDRAWING THE MEDICATIONS THAT CAN CAUSE THE
2197
1 DELIRIUM, THE MEDICATIONS WERE CONTINUED, SOMETIMES
2 INCREASED, AND -- AND THE SEDATING EFFECT OF THESE
3 MEDICATIONS LED TO THE DECLINE OF THESE PEOPLE UNTIL
4 EVENTUALLY THEY BECAME UNRESPONSIVE, COMATOSE. FAMILY
5 MEMBERS WERE TOLD THAT THEY WERE NEAR DEATH AND THEN
6 MORPHINE WAS ADMINISTERED.
7 AND THAT'S WHY THIS IS RELEVANT BECAUSE THE DELIRIUM
8 VERSUS THE DEMENTIA -- I MEAN, I DON'T KNOW THAT THERE'S ANY
9 QUESTION THAT THESE PEOPLE WERE DEMENTED, BUT DEMENTIA IS
10 NOT -- WHILE IT IS A TERMINAL ILLNESS -- IS NOT USUALLY A
11 SOON-TO-BE TERMINAL ILLNESS. It's always terminal.
12 AND SO THAT'S WHY THE DELIRIUM TESTIMONY WILL BE
13 SIGNIFICANT BECAUSE HE WILL TESTIFY THAT THE DELIRIUM IS
14 WHAT BROUGHT THEM TO THIS UNIT. THE DELIRIUM WAS NOT
15 TREATED IN AN EFFECTIVE -- IN AN APPROPRIATE MANNER AS THE
16 COURT -- THE TERM THE COURT USED -- WAS NOT TREATED IN AN
17 APPROPRIATE MANNER, AND SO THE CONDITION OF THESE PEOPLE
18 WORSENED AND WORSENED UNTIL FINALLY MORPHINE WAS
19 ADMINISTERED.
20 THE COURT: OKAY. ANY OBJECTION?
21 MR. STIRBA: YEAH. THIS IS WHERE I THINK WE GET
22 INTO THE TOTALITY PROBLEM. HE'S NOT TESTIFYING THAT
23 DELIRIUM CAUSED THE DEATH. DELIRIUM -- I MEAN, THE EVIDENCE
24 HAS BEEN OVERWHELMING IN THIS CASE ABOUT THE STATUS OF THESE
25 PATIENTS BY THEIR OWN TREATING PHYSICIAN BEFORE THEY WENT TO
2198
1 THE HOSPITAL. TO NOW ALLOW HIM TO TESTIFY, OH, BY THE WAY,
2 NOT ONLY WERE THEY DEMENTED, BUT I'M ALSO SAYING BASED UPON
3 A REVIEW OF THE RECORDS THEY WERE DELIRIOUS AS WELL, AND
4 THEN GO INTO ALL OF THAT, IT SEEMS TO ME THAT WE'RE INTO THE
5 AREA OF DEALING WITH WHETHER OR NOT THIS DOCTOR ENGAGED IN
6 SOME KIND OF CIVIL WRONGDOING AND NOT CRIMINAL WRONGDOING.
7 HE'S ALREADY TESTIFIED THAT HE THOUGHT THEY WERE
8 DELIRIOUS AS WELL AS DEMENTED ON ADMISSION. HE'S TESTIFIED
9 TO THAT. BUT HE CAN'T SAY, BECAUSE IT'S NOT -- IT'S NOT
10 LOGICAL TO SAY THIS -- THAT DELIRIUM CAUSED THE DEATH.
11 IF HE WANTS TO SAY THAT THE MEDICATIONS THAT WERE
12 PRESCRIBED THAT I SAW IN THE HOSPITAL WERE INAPPROPRIATE, I
13 MEAN, THEY WERE NOT THE CORRECT ONES, AND THE REASON WHY
14 THEY WEREN'T THE CORRECT ONES IS BECAUSE THEY WERE DELIRIOUS
15 AND NOT DEMENTED, I GUESS CONSISTENT WITH WHAT HAS BEEN
16 REPRESENTED TO THE COURT ABOUT THE THEORY AND WHAT I THINK
17 THE COURT SAID THAT CAN BE OFFERED, I THINK THAT'S PROPER.
18 BUT TO GET DOWN THIS PATH OF DELIRIUM VERSUS
19 DEMENTED -- WHAT DELIRIUM MEANS VERSUS DEMENTED, I MEAN, I
20 THINK IT'S IRRELEVANT TO THE ISSUES BEFORE THE COURT AND --
21 AND IT'S NOT A SITUATION WHERE HE'S GOING TO TESTIFY THAT
22 DELIRIUM CAUSED THE DEATH.
23 AND THERE ARE A NUMBER OF CRITICISMS THAT THIS DOCTOR
24 HAS OF DR. WEITZEL'S CARE, SOME OF WHICH MAY BE RELEVANT IN
25 THE MEDICATION WORLD, BUT SOME OF THEM ARE NOT RELEVANT FOR
2199
1 PURPOSES OF PRECISELY WHAT THIS CASE IS ALL ABOUT BECAUSE
2 THEN WE'RE INTO THE TOTALITY ISSUE, AND I'VE ADDRESSED THOSE
3 IN THE MEMO. THAT'S WHY I OBJECTED.
4 THE COURT: OKAY. MISS BARLOW?
5 MS. BARLOW: YES. THE COURT ORDERED THIS MORNING
6 THAT THE EXPERTS COULD GIVE AN OPINION AS TO WHETHER THE
7 CARE WAS OR WAS NOT APPROPRIATE, AND IF NOT, WHAT SHOULD
8 HAVE BEEN APPROPRIATE. AND THAT IS EXACTLY WHAT THIS
9 TESTIMONY IS RELEVANT TO. AND IT -- IT DOES TIE TO THE
10 MEDICATIONS DIRECTLY BECAUSE THESE --
11 THE COURT: OKAY. BUT IF IT'S A QUESTION THAT HE
12 MISDIAGNOSED -- I MEAN, WHAT I HEAR MR. STIRBA SAYING THAT
13 HE DOESN'T FIND INAPPROPRIATE, HIS POSITION IS THAT YOU CAN
14 SAY IS WHAT -- IS HOW DR. WEITZEL TREATED THIS PATIENT, WAS
15 THAT APPROPRIATE? AND HE CAN SAY NO, IT WASN'T. WHY WASN'T
16 IT APPROPRIATE? BECAUSE SHE REALLY HAD THIS INSTEAD OF
17 THAT.
18 MS. BARLOW: RIGHT.
19 THE COURT: OKAY. AND THEN -- AND TO TREAT, YOU
20 KNOW, THAT PERSON THEN WITH THESE DRUGS WAS INAPPROPRIATE.
21 OKAY. I DON'T THINK HE SAYS, YOU KNOW -- WHETHER HE DOESN'T
22 LIKE THAT OR NOT, HE SAYS HE'S AGREEABLE ON THAT. I GUESS
23 THE ISSUE IS, IF HE FAILED TO DIAGNOSE SOMETHING -- YOU
24 KNOW, THERE'S A FAILURE TO DIAGNOSE, OKAY, HOW DOES THAT
25 LEAD US? FAILURE TO DIAGNOSE DELIRIUM, HOW DOES IT LEAD TO
2200
1 MURDER WAS COMMITTED?
2 MS. BARLOW: FAILURE TO DIAGNOSE DELIRIUM -- YOU
3 KNOW, I'M NOT GOING TO SAY, WELL, DID HE FAIL TO DIAGNOSE
4 IT? FAILURE TO SEE WHAT WAS WRONG LEADS TO FAILURE TO
5 CORRECTLY TREAT -- APPROPRIATELY TREAT WHAT WAS WRONG LEADS
6 TO MEDICATIONS THAT ARE WRONG, AND THE MEDICATIONS LED TO
7 THE DEATH.
8 THE COURT: OKAY. BUT ALL OF THESE ISSUES THAT WE
9 HAVE TO PROVE, YOU KNOW, ALL THE MENTAL STATE, IF HE
10 DIDN'T -- IF HE IMPROPERLY OR DID NOT DIAGNOSE DELIRIUM, SO
11 HE WAS JUST A NEGLIGENT DOCTOR --
12 MS. BARLOW: NO, BECAUSE IT CRE -- THE NEXT STEP
13 WILL BE DOES THAT CREATE A RISK OF DEATH FOR THESE PEOPLE.
14 AND -- AND IT DOES BECAUSE NOT GIVING A DIAGNOSIS -- THE
15 DIAGNOSIS OF DELIRIUM WOULD MEAN THAT YOU WOULD TAKE THEM
16 OFF OF THESE MEDICATIONS. BY NOT DIAGNOSING THAT, HE DID
17 NOT TAKE THEM OFF THE MEDICATIONS. IN FACT, HE KEPT THEM
18 ON. HE -- HE INCREASED THE AMOUNTS, AND THOSE MEDICATIONS
19 LED TO THE SUPPRESSION OF RESPIRATION AND THE SUPPRESSION OF
20 THE CENTRAL NERVOUS SYSTEM, WHICH LED TO THE TERMINAL
21 COMATOSE STATE, AT WHICH TIME HE ADMINISTERED THE MORPHINE.
22 AND SO THAT -- THAT IS WHY IT'S RELEVANT. YOU KNOW,
23 I'M NOT SAYING HE WAS A BAD DOCTOR BECAUSE HE MISDIAGNOSED.
24 WHAT DR. FEHLAUER WILL TESTIFY TO IS THAT HERE IN THE
25 D.S.M., THIS DIAGNOSTIC AND STATISTICAL --
2201
1 THE COURT: I KNOW WHAT A D.S.M. IS.
2 MS. BARLOW: OKAY. THE D.S.M. HERE IN THE D.S.M.
3 IS DELIRIUM. HERE ARE THE -- THE SYMPTOMS OF DELIRIUM.
4 THOSE SYMPTOMS WERE PRESENT. DELIRIUM WAS NOT DIAGNOSED.
5 AND THEN UNDER THE D.S.M., HERE'S WHAT YOU DO FOR DELIRIUM.
6 ONE OF THE THINGS YOU LOOK AT VERY CLOSELY IS WHETHER
7 MEDICATIONS ARE CAUSING THE DELIRIUM. AND IF MEDICATIONS --
8 AND -- AND HOW DO YOU FIND OUT IF THE MEDICATIONS ARE
9 CAUSING THE DELIRIUM? YOU WITHDRAW THE MEDICATIONS. AND
10 THAT'S NOT WHAT HAPPENED HERE.
11 APPROPRIATELY, THE APPROPRIATE SITUATION AT THAT POINT
12 WOULD BE TO WITHDRAW THE MEDICATIONS TO SEE IF THAT'S
13 CAUSING THE DELIRIUM, WHICH IS THE ACUTE PROBLEM THAT
14 BROUGHT THEM TO THE HOSPITAL. AND IF YOU DON'T WITHDRAW THE
15 MEDICATIONS, BUT INSTEAD INCREASE THE MEDICATIONS -- AND
16 THEN HE WILL TESTIFY AS TO THE EFFECT ON THE ELDERLY OF
17 THESE MEDICATIONS.
18 AND THAT CLEARLY LEADS US TO THE FINDING -- I MEAN,
19 OKAY. I WILL ASK HIM, DID IT CREATE A RISK OF DEATH TO --
20 TO INCREASE MEDICATIONS INSTEAD OF DECREASE MEDICATIONS?
21 AND -- AND FROM THERE, YOU KNOW, GETS INTO -- I MEAN, IT
22 CONTINUES OUR THEORY OF THE CASE THAT MEDICATIONS -- --
23 OVERMEDICATION IS WHAT KILLED THESE PEOPLE.
24 THE COURT: OKAY. ANYTHING FURTHER?
25 MR. STIRBA: I JUST WANT TO SAY THIS, JUDGE. I
2202
1 THINK THE PROBLEM IS -- IT'S NOT THE ADDRESSING THE
2 MEDICATIONS. IT'S GOING DOWN THIS PATH OF DELIRIUM AS BEING
3 SOMEHOW RELEVANT TO THE DEATH. THE MEDICATIONS, AS I
4 UNDERSTAND IT, ARE RELEVANT TO THE DEATHS. IF THIS DOCTOR
5 WANTS TO SAY THE MEDICATIONS SHOULD NOT HAVE BEEN PRESCRIBED
6 BECAUSE IN MY OPINION THEY SUFFERED FROM DELIRIUM, I GUESS
7 HE CAN SAY THAT. I DON'T -- THAT'S NOT MY PROBLEM.
8 BUT GOING DOWN THIS EXTENSIVE PATH LIKE HE MISDIAGNOSED
9 OR HE DIDN'T SEE IT OR SOMETHING LIKE THAT, THAT'S WHERE I
10 HAVE A PROBLEM WITH THE QUESTIONING. I THINK IT SHOULD BE
11 POSED AFFIRMATIVELY IN TERMS OF: WOULD YOU HAVE PRESCRIBED
12 X ON SUCH AND SUCH A DAY?
13 AND THEN THE DOCTOR CAN SAY, I GUESS, NO.
14 WHY NOT?
15 BECAUSE I DON'T FEEL THAT WAS THE APPROPRIATE
16 MEDICATION BECAUSE I THOUGHT THEY WERE DELIRIOUS.
17 I MEAN, THAT IS NOT MY PROBLEM. IT'S GOING FURTHER IN
18 TERMS OF THE CONDUCT AND THE MISDIAGNOSIS -- OR THE APPARENT
19 MISDIAGNOSIS AND GOING DOWN THAT TRAIL WHERE I THINK WE
20 REALLY ARE LITIGATING A CIVIL CASE AND NOT A MURDER CASE.
21 MS. BARLOW: BUT CONDUCT HE CAN TESTIFY TO, YOUR
22 HONOR. I MEAN, THAT -- THAT'S NOT A VIOLATION OF 704.
23 THE COURT: NO, BUT I GUESS THE QUESTION IS
24 RELEVANCE. WHAT -- WHAT WE'RE TALKING ABOUT IS RELEVANCE
25 AND WHAT WE WERE TALKING ABOUT BEFORE AND WHAT I'VE SAID IS
2203
1 THAT IF SOMEBODY DIDN'T TAKE AN X-RAY, YOU KNOW, IS THAT --
2 WOULD THAT CAUSE THESE PEOPLE TO DIE? DID SOMEBODY -- YOU
3 KNOW, IF THEY ARE MISDIAGNOSIS -- IF THERE WAS A
4 MISDIAGNOSIS, DID THAT CAUSE SOMEBODY TO DIE?
5 MS. BARLOW: YOUR HONOR, IT -- IT'S NOT JUST --
6 IT'S NOTHING THAT YOU CAN SAY AT THIS POINT -- AND IT
7 WOULDN'T BE JUST AT THIS POINT THIS ONE THING CAUSED THE
8 DEATH, ALTHOUGH PERHAPS -- WELL, AND IT ISN'T. IT'S THE
9 OVERMEDICATION. BUT WHAT LED TO THE OVERMEDICATION IS
10 RELEVANT, AND I THINK THE JURY NEEDS TO BE INFORMED.
11 THE COURT: BUT -- BUT YOU'RE STARTING OUT --
12 AREN'T -- AREN'T YOU STARTING OUT WITH A NEGLIGENCE ISSUE?
13 IF YOU'RE SAYING THAT HE MISDIAGNOSED -- IF THIS WITNESS IS
14 GOING TO SAY HE MISDIAGNOSED THIS AS DEMENTIA WHEN IT WAS
15 DELIRIUM -- IS THAT WHAT HE'S GOING TO TESTIFY?
16 MS. BARLOW: I DON'T -- HE'S NOT GOING TO MAKE --
17 HE'S NOT GOING TO SAY THERE WAS A MISDIAGNOSIS.
18 THE COURT: WELL, WHY DO WE A BIG -- WHY DO WE HAVE
19 A BIG CHART ABOUT DEMENTIA AND DELIRIUM AND THE DIFFERENCES
20 BETWEEN THEM, AND HERE'S WHAT I GO OUT AND LECTURE ON.
21 MS. BARLOW: SO -- BECAUSE THE JURY -- THE JURY HAS
22 HEARD THE WORD DEMENTIA. YOU KNOW, THEY'RE GOING TO HEAR
23 THE WORD DELIRIUM. WHAT DOES THAT MEAN. THAT'S WHY WE HAVE
24 AN EXPERT HERE. WE HAVE AN EXPERT HERE TO EDUCATE THEM AS
25 TO WHAT DEMENTIA VERSUS DELIRIUM IS.
2204
1 THE COURT: OKAY. BUT WE GET BACK TO THE POINT
2 THAT WE HAVE TO HAVE SOME SORT OF INTENTIONAL CONDUCT TO
3 PROVE MURDER. AND YOU'RE SAYING THAT HOW WE GET TO THAT?
4 MS. BARLOW: OR KNOWING CONDUCT.
5 THE COURT: WELL, KNOWING CONDUCT. BUT IT'S NOT
6 KNOWING CONDUCT, IT'S NEGLIGENT CONDUCT IF A PERSON
7 MISDIAGNOSES DEMENTIA INSTEAD OF DELIRIUM.
8 MS. BARLOW: WELL, IT'S NOT AN INSTEAD OF. I MEAN,
9 OKAY, IT MAY BE NEGLIGENCE IF HE DOES IT WITH ONE PERSON,
10 BUT -- AND I CAN'T REMEMBER WHICH CASE IT IS IN OUR TRIAL
11 MEMORANDA, BUT -- NO, ACTUALLY IT'S -- IT'S THE WEINSTEIN
12 QUOTE, I BELIEVE, IN THE TRIAL MEMORANDUM ABOUT, YOU KNOW,
13 MAYBE ONCE IT HAPPENS IT MAY BE NEGLIGENCE, IT MAY BE A
14 MISTAKE, IT MAY BE INADVERTENCE, BUT WHEN YOU HAVE IN FIVE
15 CASES WITHIN A, YOU KNOW, JUST A SIX-WEEK PERIOD OF TIME,
16 WHERE THERE IS CLEAR EVIDENCE OF DELIRIUM AND EACH TIME THE
17 DEFENDANT JUST IGNORED -- AND AS A DOCTOR, HOLDING HIMSELF
18 AS A GERIATRIC SPECIALIST, HE SHOULD KNOW TO LOOK FOR
19 DELIRIUM. AND HE HOLDS -- SO -- SO WITH FIVE PATIENTS OVER
20 THIS SIX-WEEK PERIOD OF TIME, HE JUST DOESN'T -- I DON'T
21 KNOW IF HE DOESN'T SEE IT AND THAT WOULD PROBABLY BE
22 RECKLESSNESS --
23 THE COURT: OKAY. LET'S SAY WE HAD FIVE DEMENTED
24 PATIENTS --
25 MS. BARLOW: UH-HUH.
2205
1 THE COURT: -- AND HE SAYS OH, GEE. THEY ALL LOOK
2 DEMENTED TO ME, BUT, YOU KNOW, HE WAS WRONG. HE WAS WRONG
3 AND HE WAS NEGLIGENT BECAUSE HE SHOULD HAVE LOOKED UP
4 D.S.M.-III R. AND IF HE WOULD HAVE LOOKED UNDER DELIRIUM HE
5 WOULD HAVE SAID, OH, MY GOSH, WHAT I REALLY HAVE IS
6 DELIRIUM. INSTEAD OF SAYING, HEY, THESE GUYS HAVE DEMENTIA.
7 I REALLY KNOW THEY'VE GOT DELIRIUM, BUT I'M GOING TO SHOW --
8 I'M GOING TO TREAT THEM LIKE THEY'VE GOT DEMENTIA.
9 THOSE TO ME ARE TWO DIFFERENT ISSUES. ONE SHOWS
10 KNOWLEDGE AND INTENT. ONE SHOWS, HEY, HE WAS A BAD DOCTOR.
11 HE DIDN'T UNDERSTAND.
12 MS. BARLOW: WELL, AND YOUR HONOR, THEY MAY SHOW
13 THE SAME THING. BUT, I MEAN, IF WITH ONE PERSON, IF IT
14 HAPPENS WITH ONE PATIENT --
15 THE COURT: I KNOW, BUT IF YOU HAVE FIVE PATIENTS
16 THAT ARE EXACTLY THE SAME --
17 MS. BARLOW: AND THEY AREN'T EXACTLY THE SAME.
18 THE COURT: BUT, I MEAN, DEMENTIA VERSUS DELIRIUM.
19 MS. BARLOW: UH-HUH. IT'S NOT VERSUS. IT'S
20 DEMENTIA IN ADDITION TO DELIRIUM.
21 THE COURT: THEY ALL COME IN -- OKAY. BUT THEY ALL
22 COME IN HERE -- YOU KNOW, WHAT I'VE HEARD IS THAT THESE FIVE
23 PATIENTS BASICALLY CAME IN HERE, MOST OF THEM, FROM REST
24 HOMES. THEY WERE IN REST HOMES BECAUSE THEY WERE SUFFERING
25 EITHER ALZHEIMER'S OR DEMENTIA IN SOME FORM.
2206
1 MS. BARLOW: RIGHT.
2 THE COURT: IS THAT AGREED OR NOT?
3 MS. BARLOW: THAT'S AGREED. HE -- HE WILL --
4 THE COURT: OKAY. SO HE'S NOT --
5 MS. BARLOW: HE'S NOT GOING TO SAY THEY'RE NOT
6 DEMENTED.
7 THE COURT: YOU'VE GOT FIVE OLDER PEOPLE WHO ARE
8 SUFFERING FROM DIFFERENT FORMS OF DEMENTIA THAT COME IN
9 HERE. THEY'RE ALL -- LET'S SAY THEY'RE ALL IN THE SAME SORT
10 OF SITUATION. SO THAT SAY LIKE -- LET'S JUST SAY THIS. HE
11 SAYS THEY WERE MISDIAGNOSED. IT SHOULD HAVE BEEN DELIRIUM.
12 AND THEN THE JURY GOES IN THERE AND HOW DO THEY DEAL WITH
13 THAT. THE DOCTOR MISDIAGNOSED THEM, THEREFORE, HE MURDERED
14 THEM?
15 MS. BARLOW: NO, YOUR HONOR, BECAUSE THAT IS NOT
16 THE ONLY EVIDENCE. I MEAN, THIS IS JUST ONE PART OF THE
17 EVIDENCE.
18 THE COURT: I UNDERSTAND.
19 MS. BARLOW: AND WE -- AND WE HAVE TO -- YOU KNOW,
20 WE HAVE TO BUILD IT ONE UPON THE OTHER BECAUSE THIS IS NOT
21 SOMETHING THAT JUST ALL OF A SUDDEN A GUN WAS PULLED OUT AND
22 A SHOT WAS FIRED.
23 THE COURT: I UNDERSTAND THAT, BUT I MEAN, WHAT --
24 WHAT IS WRONG WITH ASKING THIS WITNESS, WAS IT
25 APPROPRIATE -- OKAY. WHAT YOU VIEWED -- YOU SAW THE RECORDS
2207
1 SIX MONTHS BEFORE, YOU SAW THE ADMISSION, AND YOU SAW THE
2 FIRST THING THAT DR. WEITZEL DID. WAS THAT APPROPRIATE?
3 NO, IT WASN'T APPROPRIATE.
4 WHY WASN'T IT APPROPRIATE?
5 BECAUSE IT REALLY WASN'T DEMENTIA. IT WAS DELIRIUM.
6 AND HE SHOULDN'T HAVE DONE THAT.
7 MS. BARLOW: AND THEN CAN HE EXPLAIN THE DIFFERENCE
8 BETWEEN DEMENTIA AND DELIRIUM?
9 THE COURT: WELL, BUT SEE, IF WE GET IN THE BIG
10 ISSUE --
11 MS. BARLOW: AND I'M FINE WITH THAT, YOUR HONOR.
12 THE COURT: -- ABOUT DEMENTIA AND DELIRIUM AND
13 MISDIAGNOSIS, THEN WE'VE GOT A NEGLIGENCE CASE.
14 MS. BARLOW: YOUR HONOR, I WILL -- I WILL BE HAPPY
15 TO ASK IT IN THAT WAY BECAUSE I THINK IT GETS US TO THE SAME
16 POINT THEN HE SHOULD BE ALLOWED TO --
17 THE COURT: CAN I SEE THE CHART, PLEASE?
18 MS. BARLOW: SURE.
19 THE COURT: THANK YOU.
20 OKAY. IN LIGHT OF WHAT -- IF HE ASKS THAT IT WAS
21 INAPPROPRIATE, AND THEN TO ILLUSTRATE HIS TESTIMONY HE SAYS
22 OKAY, HERE'S -- HERE'S DEMENTIA, HERE'S DELIRIUM, HERE'S WHY
23 I THINK IT WAS INAPPROPRIATE. WHAT IS YOUR RESPONSE TO
24 THAT -- AS TO THAT CHART SPECIFICALLY?
25 MR. STIRBA: WELL, IF WE'RE GOING TO PUT IT IN
2208
1 THAT -- IN THAT VEIN, YOUR HONOR, I THINK PROBABLY HE CAN
2 USE THAT TO ILLUSTRATE HIS TESTIMONY. I'M -- I'M JUST
3 CONCERNED ABOUT THE NEGATIVE, WHAT I'VE BEEN TALKING ABOUT,
4 VERSUS JUST WHAT WAS WRONG.
5 THE COURT: OKAY. WELL, WHAT -- WHAT I'M GOING TO
6 SAY IS THAT HE CAN SAY -- HE CAN TESTIFY REGARDING WHETHER
7 OR NOT WHAT DR. WEITZEL DID WAS APPROPRIATE, AND IF HE
8 DOESN'T FEEL IT WAS APPROPRIATE, HE CAN TESTIFY AS TO
9 WHAT -- WHAT SHOULD HAVE BEEN THE APPROPRIATE CARE.
10 MS. BARLOW: I'LL PHRASE IT THAT WAY, YOUR HONOR.
11 THE COURT: AND IF HE SAYS IT'S BECAUSE IT'S THIS
12 OTHER CONDITION AND THIS IS HOW YOU SHOULD HAVE TREATED IT,
13 YOU KNOW, THAT'S FINE. AND THEN BY SAYING THAT YOU -- BUT
14 IF YOU JUST SAY, YOU KNOW, HE MISDIAGNOSED IT AND THEN --
15 THEN THAT ADDED AND ADDED AND ADDED, THEN THAT'S NEGLIGENCE
16 AND IT DOESN'T LEAD -- YOU KNOW, IT WILL ALLOW THE JURY TO
17 DETERMINE IT ON NEGLIGENCE. I MEAN, YOU CAN SAY, YOU KNOW,
18 THOSE ISSUES, JUST AS I MENTIONED IT. YOU CAN GO FORWARD
19 AND SAY, WAS IT APPROPRIATE? WHY NOT? BECAUSE IT WAS THIS.
20 AND MAYBE THAT -- YOU OUGHT TO ASK THAT QUESTION FIRST AND
21 THEN SAY, CAN YOU TELL US THE DIFFERENCE?
22 MS. BARLOW: WAS THE TREATMENT APPROPRIATE?
23 THE COURT: YEAH, AND CAN YOU TELL US THE
24 DIFFERENCE BETWEEN DEMENTIA AND DELIRIUM?
25 YES, I CAN. HERE'S THE CHART.
2209
1 MS. BARLOW: BEFORE THE JURY COMES BACK IN, I GUESS
2 IF I ASK, WAS THE TREATMENT THAT YOU SAW GIVEN TO ELLEN
3 ANDERSON APPROPRIATE, YOU KNOW, RATHER THAN HAVE THE JURY
4 COME IN AND HAVE THAT BE OBJECTED TO --
5 THE COURT: NO, YOU CAN ASK --
6 MR. STIRBA: WELL, NO, THE TREATMENT IS -- THAT
7 WOULD BE VAGUE AND AMBIGUOUS. I MEAN, WE'RE TALKING ABOUT
8 SPECIFIC THINGS THAT OCCURRED.
9 THE COURT: WELL, YOU CAN ASK WHAT -- WHAT WAS
10 DONE.
11 MS. BARLOW: OKAY.
12 THE COURT: FIRST OF ALL, ASK HIM WHAT WAS DONE,
13 AND THEN YOU CAN ASK, WAS THAT APPROPRIATE.
14 ALL RIGHT. LET'S BRING THE JURY IN THEN.
15 (WHEREUPON, THERE'S AN OFF-THE-RECORD DISCUSSION, AFTER
16 WHICH THE JURY ENTERS THE COURTROOM.)
17 THE COURT: OKAY. SORRY, I GOT YOU IN HERE TOO
18 FAST BEFORE THE REPORTER ASKED ME THAT SHE COULD CHANGE HER
19 PAPER.
20 THE RECORD SHOULD NOW REFLECT THAT THE JURY IS BACK.
21 MISS BARLOW, WOULD YOU LIKE TO CONTINUE?
22 MS. BARLOW: YES. THANK YOU, YOUR HONOR.
23 Q. (BY MS. BARLOW) IN YOUR REVIEW OF THE RECORDS OF THE
24 TREATMENT OF ELLEN ANDERSON, DID YOU REVIEW WHAT -- WHAT WAS
25 DONE BY THE DOCTOR?
2210
1 A. I DID.
2 Q. AND WHAT WAS DONE BY THE DOCTOR, WAS THAT APPROPRIATE,
3 IN YOUR OPINION?
4 A. NO.
5 Q. AND WHY WAS IT NOT APPROPRIATE?
6 A. THERE WAS A FAILURE TO RECOGNIZE THE OCCURRENCE OF
7 DELIRIUM IN THIS PATIENT; AND, THEREFORE, A FAILURE TO
8 ADEQUATELY EVALUATE AND MANAGE THE PATIENT RELATIVE TO A
9 REVERSIBLE CONDITION.
10 Q. DOES STATE'S EXHIBIT 29 -- WHICH YOU'VE IDENTIFIED AS A
11 CHART THAT YOU PREPARED -- DOES IT DEMONSTRATE THE
12 DIFFERENCE BETWEEN DEMENTIA AND DELIRIUM?
13 A. THAT'S WHAT IT'S INTENDED TO DO, YES.
14 MS. BARLOW: YOUR HONOR, MAY -- I WOULD MOVE FOR
15 SUBMISSION OF STATE'S EXHIBIT 29.
16 MR. STIRBA: FOR ILLUSTRATIVE PURPOSES, I ASSUME?
17 MS. BARLOW: YES.
18 THE COURT: OKAY. YES.
19 MR. STIRBA: NO -- NO OBJECTION.
20 THE COURT: GO AHEAD.
21 Q. (BY MS. BARLOW) LET'S PUT THIS UP HERE AND ASK YOU TO
22 EXPLAIN TO THE JURY --
23 MS. BARLOW: CAN EVERYBODY SEE THAT OKAY?
24 THE WITNESS: DO YOU WANT ME TO SLIDE IT CLOSER?
25 MS. BARLOW: THAT MIGHT BE BETTER. IS THAT BETTER?
2211
1 A. THE ISSUE RELATIVE --
2 Q. (BY MS. BARLOW) MAYBE I'D BETTER ASK A QUESTION.
3 THE COURT: YEAH, WE NEED TO -- YEAH, PROCEED BY
4 QUESTION AND ANSWER. THAT'S GOOD.
5 Q. (BY MS. BARLOW) UNFORTUNATELY, YOU'RE NO LONGER IN
6 SCHOOL.
7 WHAT IS THIS CHART?
8 A. THIS CHART IS A CHART I PREPARED AND USE IN HANDOUTS
9 WHEN I LECTURE THAT IS MEANT TO HELP PEOPLE DISCRIMINATE
10 BETWEEN DEMENTIA AND DELIRIUM.
11 Q. AND OVER HERE IT SAYS FINDING. WHAT DOES THAT MEAN?
12 A. FINDING IS EITHER A SYMPTOM OR AN OBSERVATION THAT IS
13 MADE OF THE PATIENT.
14 Q. WHAT'S THE FIRST FINDING YOU LOOK FOR IN DETERMINING
15 DEMENTIA VERSUS DELIRIUM?
16 A. THE FIRST FINDING HERE IS ONSET. AND WHAT THAT
17 BASICALLY MEANS IS -- IS THE ONSET OR THE START OF THIS
18 ILLNESS, WHAT IS THAT CHARACTERIZED BY.
19 Q. AND WHAT'S THE DIFFERENCE BETWEEN DEMENTIA AND DELIRIUM
20 AS FAR AS ONSET'S CONCERNED?
21 A. IN ALZHEIMER'S DISEASE, FOR EXAMPLE, IS THE MOST COMMON
22 CAUSE OF DEMENTIA. THE ONSET OF THE ILLNESS IS INSIDIOUS.
23 IT'S USUALLY UNRECOGNIZED THAT SOMEONE IS BEGINNING TO LOSE
24 THEIR ABILITY TO REMEMBER THINGS OR TO FUNCTION BECAUSE IT'S
25 SO EXQUISITELY SMALL AND THERE'S SO MUCH CAPACITY TO -- OF
2212
1 THE BRAIN TO COMPENSATE FOR THAT, THAT IT VERY SLOWLY BEGINS
2 TO BE SEEN.
3 Q. AND WHAT ABOUT DELIRIUM?
4 A. DELIRIUM AS A MARKER FOR SERIOUS MEDICAL ILLNESS,
5 INTOXICATION WITH DRUGS OR WITHDRAWAL, IS USUALLY ACUTE. IT
6 CAN BE LIKE A LIGHT SWITCH. A PATIENT CAN BE WELL ONE DAY,
7 ONE MORNING, SICK THE NEXT HOUR, THE NEXT AFTERNOON, THE
8 NEXT DAY, AND EXHIBITS SYMPTOMS OF CONFUSION THAT MIMIC
9 DEMENTIA, BUT DO SO IN A SUDDEN WAY.
10 Q. WHAT ABOUT THE NEXT FINDING, STABILITY OF SYMPTOMS?
11 A. ARE THE SYMPTOMS THE SAME, RELATIVELY SPEAKING, OVER
12 TIME, TAKING INTO ACCOUNT NATURAL SMALL VARIATIONS. AND IN
13 DEMENTIA THE -- THE -- THE SYMPTOMS THAT THE PATIENT MIGHT
14 EXHIBIT, THEIR MEMORY LOSS OR THEIR INABILITY TO CARE FOR
15 THEMSELVES, ARE RELATIVELY STABLE. THEY SLOWLY PROGRESS,
16 BUT THEY DON'T WILDLY VARY FROM ONE PART OF THE DAY TO THE
17 NEXT, OR ONE WEEK TO THE NEXT. AND THAT'S A SYMPTOM OR A
18 HALLMARK OF DELIRIUM, THAT THEY'RE WILDLY FLUCTUATING IN
19 SYMPTOMS OR ABILITIES OR SIGNS.
20 Q. THEN LEVEL OF CONSCIOUSNESS?
21 A. THE LEVEL OF CONSCIOUSNESS IS -- IS HOW DO WE INTERACT
22 WITH EACH OTHER. ARE YOU AWARE OF YOUR ENVIRONMENT? DO YOU
23 INTERACT WITH YOUR ENVIRONMENT NORMALLY? AND GENERALLY
24 SPEAKING, PATIENTS WHO ARE DEMENTED, EVEN IN THE LATE
25 STAGES, ARE AWARE OF THEIR ENVIRONMENT AND RESPOND
2213
1 APPROPRIATELY TO THEIR ENVIRONMENT. THAT IS, THAT A PERSON
2 APPROACHES THEM, THEY RECOGNIZE THEM AS A PERSON. THEY
3 GREET THEM SOCIALLY LIKE THEY WOULD GREET A PERSON.
4 THEY'RE --
5 Q. BUT THEY MAY NOT NECESSARILY KNOW WHO THE PERSON IS.
6 A. THAT'S CORRECT. THEY ARE AWAKE WHEN THEY'RE SUPPOSED TO
7 BE AWAKE, THEY'RE ASLEEP WHEN THEY'RE SUPPOSED TO BE ASLEEP,
8 GENERALLY SPEAKING.
9 AND IN DELIRIUM THE LEVEL OF CONSCIOUSNESS IS IMPAIRED.
10 THEY HAVE A HARD TIME RELATING TO THEIR ENVIRONMENT, TO
11 PEOPLE WHO ARE IN IT OR THE THINGS THAT ARE IN IT. THEY
12 HAVE A HARD TIME MAINTAINING THEIR ABILITY TO ATTEND OR
13 INTERACT WITH WHAT'S GOING ON AROUND THEM.
14 Q. THE NEXT FINDING IS PSYCHOMOTOR ACTIVITY. WHAT IS THAT?
15 A. THAT IS A BIG $25 TERM MEANING, ARE YOU FIDGETY? ARE
16 YOU NORMALLY RESTING IN THE CHAIR, SITTING COMFORTABLY? ARE
17 YOU, WHEN YOU'RE UP AND MOVING, MOVING APPROPRIATELY?
18 AND THE LATE STAGES OF THE DEMENTIA CAN HAVE
19 RETARDATION AND -- AND FREQUENTLY DOES HAVE RETARDATION OF
20 PSYCHOMOTOR ACTIVITY. THAT IS TO SAY THAT PEOPLE BECOME
21 UNABLE TO STAND OR RISE AND WALK OR TO ACT QUICKLY ENOUGH OR
22 WITH FACILITY THAT THEY SHOULD IN CARING FOR THEMSELVES IN
23 DRESSING, FEEDING, THOSE KINDS OF THINGS.
24 IT ALSO HAS TO DO WITH THE INTERACTION TO THE
25 ENVIRONMENT, KIND OF THE WAY WE OBSERVE THEM. ARE THEY
2214
1 WITHDRAWN? THAT WOULD BE REDUCED PSYCHOMOTOR ACTIVITY. ARE
2 THEY HARD TO AROUSE, FOR EXAMPLE. OR ARE THEY PHYSICALLY
3 AGITATED? ARE THEY TOO ACTIVE OR HYPERACTIVE?
4 SO NORMALLY IN LATE DEMENTIA PATIENTS CAN BECOME
5 RETARDED OR CAN DEVELOP AGITATION, BUT LIKE THE OTHER
6 FINDINGS, IT TENDS TO BE SLOWLY PROGRESSIVE AND STABLE OVER
7 THE COURSE OF TIME.
8 IN DELIRIUM THEY ARE FREQUENTLY RETARDED OR AGITATED,
9 AND THIS DOES NOT REMAIN STABLE. IT'S USUALLY WILDLY
10 FLUCTUATING.
11 Q. SO ONE MINUTE THEY MAY BE NOT MOVING AT ALL OR VERY
12 LITTLE, AND THE NEXT THEY MAY BE --
13 MR. STIRBA: I'M GOING TO OBJECT, YOUR HONOR.
14 LEADING AND SUGGESTIVE.
15 THE COURT: SUSTAINED.
16 Q. (BY MS. BARLOW) WOULD YOU EXPLAIN THAT JUST A LITTLE
17 FURTHER?
18 A. THAT ONE MOMENT THEY MAY BE VERY RETARDED. THEY MAY BE
19 LYING IN BED UNAROUSABLE, AND WITHIN A FEW MOMENTS TO AN
20 HOUR, THEY MAY BE -- THEY MAY BE QUITE PHYSICALLY AGITATED,
21 FLINGING THEMSELVES ABOUT THE BED. THEY MAY BE PACING.
22 THEY MAY BE ATTEMPTING TO HIT SOMEONE. OKAY? AND THAT CAN
23 OCCUR WITHIN THE COURSE OF HOURS AND CERTAINLY WITHIN THE
24 COURSE OF A DAY.
25 Q. THE NEXT FINDING IS HALLUCINATIONS.
2215
1 A. HALLUCINATIONS ARE PERCEPTIONS OF THE ENVIRONMENT THAT
2 AREN'T REAL. SO IT'S USE OF YOUR SENSES. YOU CAN HAVE
3 HALLUCINATIONS GENERATED FROM YOUR NOSE. IT'S CALLED
4 OLFACTORY HALLUCINATIONS. THAT'S AMONG THE MOST BIZARRE
5 AND -- AND SHOWS THE MOST WILDLY DISORDERED BRAIN FUNCTION.
6 BUT COMMON ONES THAT PEOPLE THINK OF ARE AUDITORY
7 HALLUCINATIONS, HEARING VOICES OR SEEING THINGS THAT AREN'T
8 THERE. THOSE ARE RARELY PRESENT IN TRUE DEMENTIA. VISUAL
9 OR AUDITORY HALLUCINATIONS ARE RARELY PRESENT, BUT THEY ARE
10 FREQUENTLY PRESENT IN DELIRIOUS PATIENTS.
11 Q. NEXT FINDING IS SPEECH. WHAT DOES THAT MEAN?
12 A. THE PRODUCTION OF SPEECH IS OBVIOUSLY A HALLMARK OF
13 BEING A HUMAN BEING AND BEING A PERSON WHO CAN INTERACT AND
14 FULLY INTERACT WITH ALL OF THEIR CAPABILITIES. SPEECH
15 PRODUCTION EARLY ON IN ALZHEIMER'S DISEASE OR OTHER FORMS OF
16 DEMENTIA WHERE THE SPEECH CENTER HAS NOT BEEN DAMAGED
17 SPECIFICALLY IS INTACT. PEOPLE ARE ABLE TO HOLD
18 CONVERSATIONS. AND EVEN INTO THE LATE STAGES OF THE DISEASE
19 THE PATIENT OFTEN IS ABLE TO GENERATE COHERENT SPEECH. BUT
20 THE AMOUNT OF THAT SPEECH MAY BE REDUCED AND THE CONTENT --
21 THE BREADTH OF THE THINGS THAT THEY CAN BE CONVERSANT ABOUT
22 MAY BE REDUCED.
23 THE PATTERN OF SPEECH IN DELIRIOUS PATIENTS IS OFTEN
24 FREQUENTLY DISORGANIZED. THEIR SPEECH CAN MAKE NO SENSE.
25 IT CAN BE ONE NONSENSICAL WORD AFTER ANOTHER. YOU MAY BE
2216
1 ABLE TO UNDERSTAND IT, BUT THE WORDS DON'T LINK TO EACH
2 OTHER, IT DOESN'T MAKE SENSE WHERE THEIR THOUGHTS ARE GOING
3 AND THE SPEECH THAT THEY'RE GENERATING. OR IT CAN BE
4 DISORGANIZED COMPLETELY AND GARBLED. AND THIS, TOO, CAN
5 VARY THROUGHOUT THE DAY.
6 Q. REPETITIVE SPEECH. DOES THAT FIT INTO EITHER OF THESE
7 CATEGORIES?
8 A. IF SOMEONE IS REPETITIVELY CALLING OUT, THAT CAN BE
9 PRESENT IN -- IN DEMENTIA. WHAT I'M SPEAKING ABOUT IS -- IS
10 THE THOUGHTS AND THE ABILITY TO GENERATE THE SPEECH.
11 Q. THE NEXT FINDING IS SLEEP PATTERNS.
12 A. PEOPLE ARE MEANT TO BE AWAKE IN THE DAY AND MEANT TO
13 SLEEP AT NIGHT. OLDER PEOPLE -- NORMAL OLDER PEOPLE HAVE
14 DISORDERS OF SLEEP THAT'S -- THEIR SLEEP IS LESS RESTFUL,
15 THEY TEND TO HAVE MORE AWAKENINGS AND TEND TO NAP PART OF
16 THE DAY, IF THEY CAN.
17 DEMENTED PATIENTS USUALLY ACT LIKE NORMAL OLDER PEOPLE
18 RELATIVE TO THEIR SLEEP PATTERNS. THEY CAN HAVE ALTERATIONS
19 OF THEIR SLEEP PATTERNS AND HAVE MORE AWAKENINGS AT NIGHT
20 AND MORE SLEEPING DURING THE DAY. BUT AGAIN, IT'S USUALLY
21 FAIRLY PREDICTABLE, FAIRLY SLOW, FAIRLY STABLE.
22 A PATIENT WITH DEMENTIA -- I MEAN DELIRIUM HAS
23 INVARIABLY GOT DISTURBED SLEEP. INSTEAD OF SLEEPING AT
24 NIGHT, THEY'RE AWAKE. THEN WHEN THEY'RE SUPPOSED TO BE
25 AWAKE IN THE DAY, THEY'RE ASLEEP. AND THEY MAY SLEEP IN
2217
1 PATCHES. THEY MAY -- THEY MAY HAVE QUITE DISORGANIZED
2 SLEEP.
3 Q. THE FINAL FINDING IS MOOD DISTURBANCES.
4 A. MOOD DISTURBANCES, DEPRESSION, FOR EXAMPLE, OR ANXIETY
5 IS EXTREMELY COMMON IN PEOPLE WITH DEMENTIA. IT'S -- IN MY
6 NURSING HOME PATIENTS, 50 PERCENT OF THEM ARE ON ONE FORM OF
7 AN ANTIDEPRESSANT OR ANOTHER. BECAUSE THEY HAVE THESE MOOD
8 DISTURBANCES, THE TREATMENT IS NECESSARY. BUT THE TREATMENT
9 TENDS TO -- THE SYMPTOMS THAT THEY EXHIBIT TEND TO BE LIKE
10 ADULTS WITH DEPRESSION. IT TENDS TO BE RELATIVELY STABLE OR
11 PROGRESSIVE, BUT NOT WITH WILD FLUCTUATIONS AND IT'S
12 MANAGEABLE. THAT IS TO SAY, THAT THE MEDICATIONS WORK TO
13 TREAT A STANDARD SORT OF MOOD DISTURBANCE IN A PATIENT WITH
14 DEMENTIA.
15 THE DELIRIOUS PATIENT HAS MOOD DISTURBANCES WHICH VARY
16 WILDLY OVER THE COURSE OF DAYS OR HOURS. AND AT ONE POINT
17 THEY CAN BE CALM AND COOPERATIVE, TAKING THEIR MEDICATION,
18 SITTING CALMLY IN A CHAIR, AND THE NEXT MINUTE THEY MAY BE
19 ANGRY, VERY ANXIOUS, REPETITIVE. THEY MAY BE SUDDENLY VERY
20 SAD AND TEARFUL AND CRYING UNCONSOLABLY. AND ANOTHER HOUR
21 LATER, THOSE SYMPTOMS MAY BE GONE.
22 THAT'S THE NATURAL COURSE OF THIS DISEASE WHICH IS TO
23 SAY THAT THE BRAIN IS MALFUNCTIONING IN A WAY THAT CANNOT BE
24 PREDICTED OVER THE COURSE OF HOURS OR DAYS.
25 Q. DID YOU SEE IN YOUR REVIEW OF THE RECORDS INVOLVING
2218
1 ELLEN ANDERSON, THE ONES AT DAVIS NORTH AND THEN THE PRIOR
2 RECORDS FOR THE NURSING HOMES OR HOSPITALIZATIONS, ANY
3 SYMPTOMS OF DELIRIUM?
4 A. YES.
5 Q. WHAT SYMPTOMS DID YOU SEE?
6 A. CAN I REFER TO MY NOTES?
7 THE COURT: ARE -- ARE YOU DONE WITH THE CHART THAT
8 HE CAN TAKE THE CHAIR?
9 MS. BARLOW: I'LL MOVE IT BACK HERE.
10 A. I'VE REVIEWED NURSING FACILITY RECORDS FROM AUGUST 1995
11 THROUGH DECEMBER 29, 1995.
12 Q. (BY MS. BARLOW) OF ELLEN ANDERSON?
13 A. OF ELLEN ANDERSON.
14 Q. DID YOU SEE ANY SYMPTOMS OF DELIRIUM?
15 A. YES.
16 Q. WHAT SYMPTOMS DID YOU SEE?
17 A. EXAMINING THE RECORD I USED THE NURSING ASSESSMENTS,
18 PHYSICIAN'S NOTES, AND ANCILLARY NOTES BY THERAPISTS AND
19 OTHER PEOPLE TO SEE IF THERE WAS EVIDENCE OF DELIRIUM. THE
20 SYMPTOMS I'VE GIVEN YOU ON THIS CHART ARE A PORTION OF THE
21 DIAGNOSTIC CRITERIA IN THE D.S.M. MANUAL, THIS DIAGNOSTIC
22 AND STATISTICAL MANUAL, THAT IS PUT OUT BY THE AMERICAN
23 PSYCHIATRIC ASSOCIATION FOR DEFINING PSYCHIATRIC DISEASES.
24 Q. IS THAT ACCEPTED IN THE PSYCHIATRIC COMMUNITY, THAT
25 D.S.M.?
2219
1 A. YES. EXAMINING THE RECORDS I WANTED TO BE AS EXACT AS I
2 COULD OVER TIME DEFINING WHAT IT WAS THAT I SAW THERE. AND
3 IN ORDER TO DO THAT I USED A PUBLISHED AND STANDARD
4 INSTRUMENT THAT TAKES THE D.S.M. CRITERIA AND PUTS THEM ON A
5 SCALE SO THAT THEY CAN BE SCORED. THAT INSTRUMENT --
6 MR. STIRBA: YOUR HONOR, I DON'T MEAN TO INTERRUPT.
7 I HAVE A RELEVANCY OBJECTION IN TERMS OF THE FOUNDATION FOR
8 THE OPINION, IF IT'S NOT RELATED TO THE DAVIS HOSPITAL
9 RECORDS. I MEAN, HE'S -- HE'S RENDERED HIS OPINION AS TO
10 WHAT HE THINKS, BUT NOW TO GET INTO --
11 THE COURT: YEAH, LET'S NARROW -- LET'S GET TO THE
12 RECORDS THAT WERE AT THE DAVIS HOSPITAL.
13 Q. (BY MS. BARLOW) IN YOUR REVIEW OF THE RECORDS OF DAVIS
14 NORTH HOSPITAL, DID YOU SEE ANYTHING IN THOSE RECORDS
15 INDICATING DELIRIUM?
16 A. I DID.
17 Q. WHAT RECORDS DID YOU -- OR WHAT DID YOU SEE IN THOSE
18 RECORDS INDICATING DELIRIUM?
19 A. REVIEWING DR. WEITZEL'S ADMISSION ASSESSMENT, THE
20 NURSE'S ADMISSION ASSESSMENT, IT'S QUITE CLEAR THAT THE
21 PATIENT HAD DISTURBANCE IN -- IN HER -- THE ONSET. THAT THE
22 ONSET WAS WITHIN THE COURSE OF A MONTH OR SO. THAT THE
23 CHANGE IN BEHAVIOR THAT SHE WAS EXHIBITING WAS WITHIN A
24 MONTH OR SO. THAT THE PATIENT'S PERCEPTION OF THE A month. Delirium?
25 ENVIRONMENT WAS ALTERED. THAT THERE WAS EVIDENCE THAT SHE
2220
1 DID NOT UNDERSTAND WHERE SHE WAS OR WHAT WAS GOING ON. THE
2 PATIENT DID NOT EXHIBIT ANY HALLUCINATIONS OR DELUSIONS THAT
3 I COULD DETECT. THE PATIENT HAD PSYCHOMOTOR ACTIVITY THAT
4 WAS BOTH AGITATED AND WITHDRAWN DURING THE COURSE OF THE
5 SHORT TIME SHE WAS THERE. SHE WAS QUITE COGNITIVELY
6 IMPAIRED. DR. WEITZEL'S OWN NOTE INDICATES THAT SHE WAS
7 QUITE CONFUSED AND DISORIENTED.
8 THE PATIENT HAD, BY MY ESTIMATION, AT LEAST ONE
9 PHYSICAL CAUSE OF THE CHANGE IN HER MENTAL ACUITY AND THAT
10 WAS MEDICATIONS. THE PATIENT SHOWED LABILITY OF MOOD; THAT
11 IS TO SAY, THAT SHE WAS AT TIMES COOPERATIVE AND AT TIMES
12 VERY ANGRY AND ANXIOUS AND REPETITIVE, BUT THERE WERE
13 PERIODS OF TIME WHEN SHE WAS CALM. AND THEN, FINALLY, SHE
14 SHOWED VARIABILITY THAT OVER THE COURSE OF A FEW HOURS HER
15 SYMPTOMS VARIED.
16 THOSE ARE ALL FINDINGS OF DELIRIUM AND SHE DEFINITELY
17 MEETS CRITERIA BY D.S.M. STANDARDS. She also met criteria for severe dementia.
18 Q. WHAT CAUSES DELIRIUM?
19 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT.
20 RELEVANCY.
21 THE COURT: SUSTAINED.
22 Q. (BY MS. BARLOW) IS THERE ANYTHING THAT YOU SAW IN THE
23 RECORDS OF ELLEN ANDERSON THAT WOULD DEMONSTRATE A CAUSE OF
24 DELIRIUM IN HER IN DAVIS NORTH?
25 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT.
2221
1 RELEVANCY.
2 THE COURT: OKAY. CAN WE GO ON TO SOMETHING ELSE
3 AND WE CAN ADDRESS THIS AT A BREAK WHEN THE JURY'S OUT?
4 MS. BARLOW: EXCUSE ME, YOUR HONOR. I HAVE TO
5 WRITE MYSELF A NOTE. MY MEMORY'S GETTING WORSE.
6 THE COURT: OKAY. I'VE WRITTEN ONE.
7 Q. (BY MS. BARLOW) YOU TESTIFIED EARLIER THAT YOU DID NOT
8 THINK -- WELL, MAYBE I BETTER NOT SAY THAT BECAUSE I MIGHT
9 MISPHRASE IT.
10 WAS -- WAS WHAT WAS DONE AT DAVIS NORTH HOSPITAL FOR
11 ELLEN ANDERSON APPROPRIATE?
12 A. NO.
13 Q. WHY WAS IT NOT APPROPRIATE?
14 MR. STIRBA: WELL, IT'S VAGUE AND AMBIGUOUS, YOUR
15 HONOR. I'M NOT SURE --
16 THE COURT: ARE YOU -- ARE YOU ASKING DR. WEITZEL'S
17 TREATMENT? I MEAN, YOU SAID WHAT WAS DONE AT THE HOSPITAL.
18 MS. BARLOW: WELL, THAT WAS THE QUESTION THAT WE
19 DISCUSSED PHRASING AND I HAD PHRASED IT THAT WAY.
20 THE COURT: WELL, I THINK WHAT WE'RE INTERESTED IN
21 IS DR. WEITZEL'S CARE OF THIS PATIENT.
22 MS. BARLOW: I WILL DO THAT.
23 Q. (BY MS. BARLOW) DID YOU REVIEW WHAT DR. WEITZEL DID
24 FOR ELLEN ANDERSON AT DAVIS NORTH HOSPITAL?
25 A. I DID.
2222
1 Q. WAS THAT -- WAS WHAT DR. WEITZEL DID APPROPRIATE
2 TREATMENT OF ELLEN ANDERSON?
3 A. NO.
4 Q. WHY WAS IT NOT?
5 A. THERE WAS FAILURE TO PERFORM AN ADEQUATE EVALUATION.
6 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT.
7 RELEVANCY AND -- YOU KNOW.
8 THE COURT: OKAY. THAT -- LET'S GO ON TO THE -- GO
9 AHEAD. GO ON. ASK ANOTHER QUESTION.
10 Q. (BY MS. BARLOW) BASED ON YOUR REVIEW OF THE RECORD,
11 DID YOU SEE ANY -- ANYTHING IN THE RECORDS INDICATING
12 WHETHER OR NOT DR. WEITZEL SAW ELLEN ANDERSON?
13 MR. STIRBA: I'M GOING TO OBJECT, YOUR HONOR.
14 THAT'S NOT EXPERT TESTIMONY.
15 MS. BARLOW: IT'S FOUNDATIONAL, YOUR HONOR, FOR
16 GETTING INTO THE REST OF THE TESTIMONY.
17 THE COURT: OKAY. HOLD ON JUST A SECOND. OKAY.
18 WHY DON'T YOU GO ON TO SOMETHING ELSE. WE'VE GOT TWO OR
19 THREE THINGS WE'RE GOING TO NEED TO DISCUSS SO I'D JUST LIKE
20 TO NOT KEEP THE JURY GOING IN AND OUT.
21 Q. (BY MS. BARLOW) DID DR. WEITZEL WRITE ANY ORDER --
22 EXCUSE ME. I WON'T SAY WRITE.
23 DID DR. WEITZEL GIVE ANY ORDERS FOR THE TREATMENT OF
24 ELLEN ANDERSON?
25 A. YES.
2223
1 Q. WHAT ORDERS DID HE GIVE?
2 A. FROM THE DOCUMENTS ENTERED INTO EVIDENCE, THERE ARE
3 ADMISSION ORDERS THAT ARE SIGNED APPARENTLY BY DR. WEITZEL
4 AND ARE STANDARD ADMITTING ORDERS THAT ARE REQUIRED FOR
5 PLACING A PATIENT IN THE HOSPITAL.
6 Q. AND WHAT DID DR. WEITZEL ORDER FOR ELLEN ANDERSON?
7 A. HE ORDERED A ACTIVITY. HE WANTED HER UP IN A
8 WHEELCHAIR. HE ORDERED HER A DIET, WHICH WAS MECHANICAL
9 SOFT WHICH MEANS SOFT ENOUGH TO CHEW WITH DENTURES. HE
10 ORDERED LABORATORIES, A BLOOD COUNT, CHEMISTRY PROFILE,
11 R.P.R., WHICH IS A TEST FOR SYPHILIS, THYROID FUNCTION
12 TESTS, A URINALYSIS AND A CULTURE OF THAT URINE, AN E.K.G.
13 AND A CHEST X-RAY.
14 HE ORDERED SOMETHING CALLED THE AIMES WHICH IS A TEST
15 OF THE PATIENT'S EXHIBITION OF SYMPTOMS OF DRUG USE RELATIVE
16 TO ANTIPSYCHOTIC DRUGS. IT BASICALLY IS A TEST ADMINISTERED
17 TO MAKE SURE THE PATIENT ISN'T SUFFERING AN ADVERSE EFFECT
18 OF THE USE OF THE DRUG, AND IT'S SCORED SO IT CAN BE
19 MEASURED OVER TIME IF THE PATIENT'S ADMINISTERED THE DRUG
20 AND THE DEVELOPS SUCH SYMPTOMS.
21 HE ORDERED HER TO BE EVALUATED BY AN OCCUPATIONAL
22 THERAPIST. SPECIAL PRECAUTIONS ARE SOMETHING I'M NOT AWARE
23 OF WHAT THOSE ARE, BUT THEY WERE ORDERED 15 MINUTE CHECKS
24 FOR 24 HOURS. HE WANTED --
25 Q. WHAT -- EXCUSE ME. WHAT KIND OF CHECKS WOULD THOSE BE?
2224
1 DO YOU KNOW?
2 A. I'M -- I'M NOT AWARE OF WHAT THOSE CHECKS WOULD BE.
3 VITAL SIGNS WERE ORDERED TWICE A DAY. PATIENT WAS TO BE
4 WEIGHED WEEKLY. SHE DID NOT HAVE ANY ALLERGIES. THE
5 MEDICATIONS HE ORDERED WERE AMITRIPTYLINE, 25 MILLIGRAMS AT
6 BEDTIME. LASIX, WHICH IS A DIURETIC, 40 MILLIGRAMS EACH
7 DAY. NITROGLYCERIN, MEDICATION PLACED UNDER THE TONGUE TO
8 DILATE THE ARTERIES, FOR CORONARY ARTERY DISEASE. AMBIEN,
9 WHICH IS A BENZODIAZEPINE OR A DRUG LIKE VALIUM, SAME CLASS,
10 USED FOR SLEEP, FIVE MILLIGRAMS. DULCOLAX, FIVE MILLIGRAMS
11 BY MOUTH, IT'S A STIMULANT, LAXATIVE. TRAZODONE, AN
12 ANTIDEPRESSANT, 150 MILLIGRAMS AT BEDTIME. TYLENOL FOR PAIN
13 RELIEF, TWO TABS EVERY FOUR HOURS. MYLANTA FOR STOMACH
14 UPSET. MILK OF MAGNESIA FOR CONSTIPATION. AND THEN
15 MORPHINE SULFATE 10 MILLIGRAMS I.M. NOW FOR PAIN. THAT'S
16 THE WAY IT'S STATED. SIGNED DR. WEITZEL.
17 Q. IN MEDICAL PRACTICE DO PHYSICIANS EVER TELEPHONE IN
18 ORDERS?
19 A. YES, WE DO.
20 Q. WHAT -- HOW IS IT CHARTED IF A TELEPHONE ORDER IS GIVEN?
21 MR. STIRBA: OBJECT. RELEVANCY.
22 MS. BARLOW: YOUR HONOR, I -- I THINK IT EXPLAINS
23 THIS --
24 THE COURT: WELL, IS HE -- I GUESS YOU NEED TO LAY
25 A FOUNDATION IF HE KNOWS HOW IT WAS CHARTED IN THE DAVIS
2225
1 RECORDS VERSUS HIS OWN EXPERIENCE.
2 Q. (BY MS. BARLOW) IN YOUR REVIEW OF THE RECORDS, DO YOU
3 KNOW HOW A TELEPHONE ORDER LIKE THAT WAS CHARTED IN THESE
4 RECORDS?
5 A. LOOKING AT THIS RECORD OF 12/29/95, THE BOTTOM NOTATION
6 IS T.O., DR. WEITZEL. THAT ABBREVIATION T.O. IS INTERPRETED
7 AS TELEPHONE ORDER. THEN THERE'S A SIGNATURE OF A NURSE AND
8 THEN IT SAYS, IT'S NOTED. THE NURSE AGAIN SIGNS IT, DATES
9 AND TIMES THE NOTE.
10 Q. AND WHAT DOES IT MEAN TO BE NOTED?
11 A. THE NURSE FIRST TAKES IT DOWN, AND THEN HAVING
12 TRANSCRIBED IT, TELEPHONE ORDER DR. WEITZEL, SIGNS HER OR
13 HIS INITIALS TO THAT TELEPHONE ORDER.
14 THEN HAVING NOTED IT MEANS THAT THOSE ACTIONS HAVE BEEN
15 PUT IN PLACE. SO THE DIET'S BEEN ORDERED, THE MEDICATIONS
16 HAVE BEEN PLACED ON A RECORD TO SHOW THAT THEY NEED TO BE
17 ADMINISTERED, THEY'VE BEEN ORDERED FROM THE PHARMACY. IT
18 MEANS THAT THE -- THE NURSES HAVE DONE THEIR JOB RELATIVE TO
19 COMPLETING THESE ORDERS.
20 Q. LET'S LOOK AT THE MEDICATIONS. ARE ANY OF THESE ORDERED
21 P.R.N., OR AS NEEDED?
22 A. THE NITROGLYCERIN IS ORDERED AS NEEDED.
23 Q. AND -- AND WHAT'S NITROGLYCERIN USUALLY GIVEN FOR?
24 A. NITROGLYCERIN IS A SMALL TABLET USED TO OPEN ARTERIES.
25 IT DILATES THE ARTERIES. IT CAUSES THEM TO RELAX. AND IT'S
2226
1 USED FOR ANGINA OR HEART PAIN CAUSED BY NARROWING OF THE
2 CORONARY ARTERIES.
3 Q. SO IF THERE'S NO PAIN, WOULD YOU GIVE NITROGLYCERIN TO
4 ANYONE?
5 A. NO.
6 Q. WHAT ABOUT -- ARE ANY OF THE REST OF THEM AS NEEDED?
7 A. AMBIEN, THE SLEEPING PILL, IS AS NEEDED FOR SLEEP.
8 Q. ANY MORE?
9 A. THE TYLENOL IS AS NEEDED FOR PAIN. THE MYLANTA IS AS
10 NEEDED FOR DYSPEPSIA OR STOMACH UPSET. THE MILK OF MAGNESIA
11 IS AS NEEDED FOR CONSTIPATION.
12 Q. AND THEN YOU READ THAT THE MORPHINE SULFATE WAS NOTED AS
13 WHAT?
14 MR. STIRBA: YOUR HONOR, ASKED AND ANSWERED. IT'S
15 RIGHT THERE.
16 THE COURT: JUST GO AHEAD.
17 Q. (BY MS. BARLOW) LOOKING AT THAT LIST OF DRUGS --
18 EXCUSE ME -- MEDICATIONS, DO ANY OF THEM HAVE ANY
19 RELATIONSHIP TO DELIRIUM?
20 A. YES.
21 Q. AND WHICH DRUGS HAVE RELATIONSHIP TO DELIRIUM?
22 A. THE AMITRIPTYLINE, THE LASIX, THE AMBIEN, THE TRAZODONE,
23 THE MORPHINE.
24 Q. LET'S START WITH THE AMITRIPTYLINE. WHAT -- WHAT
25 RELATIONSHIP DOES THAT HAVE TO DELIRIUM?
2227
1 A. AMITRIPTYLINE IS AN ANTIDEPRESSANT MEDICATION, AND
2 MRS. ANDERSON HAD BEEN RECEIVING THAT AS -- AT THE NURSING
3 FACILITY. THE MEDICATION IS CALLED A TRICYCLIC
4 ANTIDEPRESSANT. MEDICATIONS OF -- OF THAT TYPE ARE
5 PRESCRIBED TO TREAT DEPRESSION. AND THEN ANOTHER USE IS TO
6 INDUCE SLEEP BECAUSE THEY'RE QUITE SEDATING.
7 Q. WHAT DO YOU MEAN BY SEDATING?
8 A. SEDATION MEANS THAT YOU FEEL SLEEPY. SO A SEDATING DRUG
9 IS ONE THAT INDUCES SLEEP OR MAKES THE PATIENT SLEEPY.
10 Q. WITH AMITRIPTYLINE, IS THAT AN EFFECT IN THE BRAIN? IS
11 IT IN ANY OTHER SYSTEM IN THE BODY?
12 A. THE AMITRIPTYLINE IS ACTIVE IN THE BRAIN AND HAS
13 ACTIVITIES ON OTHER ORGANS AS WELL. THE ACTION OF DRUGS
14 LIKE AMITRIPTYLINE TO PRODUCE THE EFFECT YOU WANT THEM TO
15 HAVE MEANS THAT THEY HAVE AN EFFECT ON BRAIN CHEMISTRY. AND
16 THE BODY CONSERVES THE MECHANISMS THAT IT USES TO
17 COMMUNICATE BETWEEN CELLS, SO IF A MESSAGE NEEDS TO BE SENT
18 FROM ONE CELL TO ANOTHER, AND THAT MESSAGE IS THAT YOU'RE
19 AWAKE OR THAT THERE'S A MEMORY YOU NEED TO FORM, THEN THAT
20 MESSENGER IS TRANSMITTED FROM ONE CELL TO ANOTHER IN THE
21 BRAIN.
22 THE BODY DOESN'T JUST USE THE MESSENGER THERE THOUGH.
23 THAT SAME MESSENGER, LET'S SAY IT'S ACETYLCHOLINE, THAT
24 TELLS THE BRAIN YOU'RE AWAKE OR YOU NEED TO FORM A MEMORY IS
25 ALSO USED TO STIMULATE MUSCLES TO CONTRACT. IT'S ALSO USED
2228
1 TO STIMULATE YOUR GUT TO CONTRACT AND EVACUATE. IT'S USED
2 TO EVACUATE YOUR BLADDER. IT'S USED TO CONTROL THE
3 SECRETIONS OF YOUR MOUTH AND IT'S USED TO CONTROL WHETHER
4 YOUR PUPILS DILATE OR CONSTRICT.
5 SO THE BODY KNOWS THAT WHEN IT SENDS A MESSAGE, OR IT
6 BLOCKS THAT MESSAGE, THAT IT'S -- THAT IT'S DOING IT FOR A
7 SPECIFIC EFFECT. BUT WHEN YOU ADMINISTER A MEDICATION, THAT
8 EFFECT IS NOT SPECIFIC TO THAT SINGLE SITE OR THAT SINGLE
9 ORGAN.
10 AND IN THE CASE OF AMITRIPTYLINE IT'S WHAT WE CALL A
11 POTENT ANTICHOLINERGIC. SO IF ACETYLCHOLINE IS A
12 TRANSMITTER YOUR BRAIN USES TO SAY I'M AWAKE OR I NEED TO
13 FORM A MEMORY, AND THIS MEDICATION BLOCKS THAT, THEN YOU'RE
14 GOING TO BE SEDATED OR YOU'RE GOING TO BE CONFUSED BECAUSE
15 YOU CAN'T FORM MEMORIES. UNFORTUNATELY, YOU ALSO MAY NOT BE
16 ABLE TO HAVE A BOWEL MOVEMENT, YOU MAY NOT BE ABLE TO
17 URINATE, YOU MAY NOT BE ABLE TO FORM SALIVA, AND YOU MAY NOT
18 BE ABLE TO SEE ACCURATELY.
19 Q. YOU SAID THE LASIX ALSO HAS AN EFFECT ON DELIRIUM. IN
20 WHAT WAY?
21 A. THE BEST STUDY OF DELIRIUM THAT'S BEEN PUBLISHED WAS BY
22 A DR. FRANCIS IN THE LATE 1980'S. DR. FRANCIS OBSERVED 225
23 HOSPITAL PATIENTS IN PITTSBURGH, AND THOSE 225 HOSPITAL
24 PATIENTS, A GOOD FRACTION OF THEM DEVELOPED DELIRIUM. AND
25 WHEN HE EXAMINED WHY THEY DEVELOPED DELIRIUM, ELECTROLYTE
2229
1 DISTURBANCES; THAT IS, THE COMPOSITION OF THE -- OF THE IONS
2 IN YOUR BLOOD WAS A COMMON PROBLEM, OR BEING DEHYDRATED WAS
3 A COMMON PROBLEM. THE LASIX IS A DIURETIC. A DIURETIC IS
4 MEANT TO CAUSE THE BODY TO WASTE OR EXCRETE SODIUM AND WATER
5 SO THAT THE FLUIDS THAT HAVE ACCUMULATED CAN BE REMOVED. IT
6 CARRIES WITH IT THE RISK OF CAUSING DEHYDRATION OR
7 ELECTROLYTE ABNORMALITIES, A LOW BLOOD SODIUM, A LOW BLOOD
8 POTASSIUM OR KIDNEY FAILURE.
9 Q. THAT HAS AN EFFECT ON DELIRIUM?
10 A. IF A PATIENT'S ELECTROLYTES ARE DISTURBED, IF THE
11 CHEMICAL COMPOSITION OF YOUR BLOOD HAS BEEN ALTERED, THEN
12 THE ABILITY TO THINK, THE ABILITY TO INTERACT, THE ABILITY
13 TO HOLD CONVERSATION OR TO CARE FOR YOURSELF OR THE ABILITY
14 TO MAINTAIN ALERTNESS OR INTERACT WITH THE ENVIRONMENT ARE
15 ALL DISTURBED. THAT IS HOW IT CAN INTERACT. AND BECAUSE IT
16 CAN CAUSE KIDNEY FAILURE IF THE PATIENT BECOMES DEHYDRATED,
17 THE EFFECTS OF THE ACCUMULATION OF TOXIC MATERIALS FROM THE
18 KIDNEY THAT IT CAN'T EXCRETE CAN AFFECT THE LEVEL OF YOUR
19 CONSCIOUSNESS, CAUSE THE CONFUSION AND LEAD TO DELIRIUM.
20 AND THEN FINALLY, IF YOU'VE BEEN ADMINISTERED TOO MUCH
21 AND YOUR BLOOD PRESSURE IS LOW, THEN THERE'S NOT ENOUGH
22 BLOOD FLOW TO THE BRAIN. THE BRAIN'S STARVED FOR ENOUGH
23 BLOOD AND OXYGEN, THEN IT CAN'T INTERACT AND RESPOND
24 APPROPRIATELY.
25 Q. AND I THINK YOU MENTIONED AMBIEN AS HAVING AN EFFECT ON
2230
1 DELIRIUM.
2 A. AMBIEN IS A BENZODIAZEPINE, A VALIUM-LIKE DRUG. NOT AS
3 STRONG AS VALIUM, SAFER THAN VALIUM FOR USE IN ADULTS AND
4 OLDER PEOPLE. FOR SLEEP IT'S -- IT'S A DRUG THAT INTERACTS
5 WITH WHAT ARE CALLED GABBA GABBA GAMMA AMINOBUTYRIC ACID
6 RECEPTORS IN THE BRAIN.
7 Q. MAYBE YOU'RE GETTING A LITTLE TOO COMPLEX FOR US.
8 THE COURT: YEAH, I THINK IT MIGHT HELP --
9 MS. BARLOW: ESPECIALLY FOR THE COURT REPORTER.
10 THE COURT: -- IF WE -- IF YOU COULD JUST MAYBE
11 JUST ANSWER THE QUESTION, WHAT EFFECT DOES THAT HAVE AS
12 OPPOSED TO GIVE US AN EXPLANATION.
13 THE WITNESS: IT'S -- IT'S A SLEEPING PILL -- OKAY.
14 GO AHEAD.
15 Q. (BY MS. BARLOW) YEAH. I -- I THINK YOU HAVE A
16 TENDENCY TO TEACH US HERE LIKE SOME OF YOUR STUDENTS. AND
17 SO IF WE CAN -- SO IT'S A SLEEPING PILL, YOU SAY?
18 A. IT'S A SLEEPING PILL THAT CAUSES SEDATION.
19 Q. OKAY. AND HOW DOES THAT AFFECT DELIRIUM?
20 A. WELL, AGAIN, IT INTERACTS AT YET ANOTHER RECEPTOR, THEN
21 THE AMITRIPTYLINE, THE ELAVIL, AND THEREBY CAUSES THE BRAIN
22 TO BE LESS ACTIVE. IT CAUSES SEDATION. THE BRAIN IS ACTIVE
23 AND ELECTRICALLY ALERT. IF THIS MEDICINE IS ADMINISTERED IT
24 REDUCES ELECTRICAL ACTIVITY, IT REDUCES THE LEVEL OF
25 CONSCIOUSNESS, CAUSES YOU TO FEEL SLEEPY. YOU CAN FALL
2231
1 ASLEEP EASIER.
2 Q. THEN I THINK YOU SAID TRAZODONE WAS THE NEXT ONE THAT
3 HAS AN EFFECT ON DELIRIUM?
4 A. YEAH. TRAZODONE IS AN ANTIDEPRESSANT MEDICATION FOR
5 WHICH THE EXACT MECHANISM BY WHICH IT WORKS IS UNKNOWN.
6 IT'S CALLED AN ATYPICAL ANTIDEPRESSANT, DIFFERENT FROM THE
7 AMITRIPTYLINE. ITS EFFECT IN CAUSING CONFUSION OR DELIRIUM
8 IS THAT IT IS -- IT IS POTENTLY SEDATING AND CAUSES
9 CONFUSION, COMMONLY.
10 Q. THEN I BELIEVE YOU ALSO SAID THE MORPHINE CAN HAVE SOME
11 IMPACT ON DELIRIUM?
12 A. MORPHINE IS A PAIN RELIEVER OF THE NARCOTIC CLASS. IT'S
13 AMONG THE MOST POTENT OF THE PAIN RELIEVERS THAT WE HAVE
14 AVAILABLE. IT INTERACTS WITH WHAT ARE CALLED OPIATE
15 RECEPTORS. THERE ARE OPIATE RECEPTORS THROUGHOUT THE BODY.
16 THE BRAIN IS FULL OF THEM, PARTICULARLY THE SPINAL CHORD IN
17 THE BASE OF THE BRAIN WHERE PAIN IS SENSED. WHEN MORPHINE
18 INTERACTS WITH THE OPIATE RECEPTORS IT REDUCES THE RESPONSE
19 OF THOSE CELLS SO THAT THE SENSATION OF PAIN IS MASKED. IT
20 PREVENTS THE CELLS FROM TELLING THE BODY, I'M EXPERIENCING
21 PAIN.
22 IT HAS, LIKE ALL DRUGS OF ITS CLASS AND TYPE, EFFECTS
23 ON OTHER PARTS OF THE BRAIN THAN JUST ON PAIN AND IT CAUSES
24 SEDATION. IT ACTUALLY INTERACTS WITH RECEPTORS IN THE BASE
25 OF THE BRAIN THAT CONTROL BREATHING AND HEART RATE AND BLOOD
2232
1 PRESSURE, AND CAN, IF GIVEN INAPPROPRIATELY, CAUSE THE
2 STOPPAGE OF BREATHING ABRUPTLY AND COMPLETELY.
3 Q. GIVEN THE INTERACTION OF THOSE DRUGS THAT -- OR THOSE
4 MEDICATIONS, DRUGS THAT YOU LISTED WITH DELIRIUM --
5 MR. STIRBA: YOUR HONOR, MAY WE HAVE SOME MORE
6 FOUNDATION AS TO WHETHER OR NOT THESE DRUGS WERE EVEN GIVEN
7 TO THIS PATIENT?
8 THE COURT: WELL, FIRST OF ALL, I THINK WE'VE BEEN
9 GOING FOR QUITE A WHILE, LADIES AND GENTLEMEN. I THINK
10 WE'LL TAKE OUR LAST MORNING BREAK. SO LET'S COME BACK --
11 I'LL ASK YOU TO COME BACK AT 11:15.
12 AND DURING THE TIME THAT YOU ARE OUT, REMEMBER IT'S
13 YOUR DUTY NOT TO CONVERSE AMONG YOURSELVES ABOUT THIS CASE
14 OR TO CONVERSE WITH ANYONE ELSE ABOUT IT, OR EVEN TO ALLOW
15 ANYONE TO ADDRESS YOU ABOUT THE SUBJECT OF THIS TRIAL. IT'S
16 ALSO YOUR DUTY NOT TO FORM OR EXPRESS AN OPINION UNTIL YOU
17 HAVE THE CASE FINALLY SUBMITTED TO YOU.
18 SO IF YOU'LL COME BACK AT 11:15.
19 (WHEREUPON, THE JURY LEAVES THE COURTROOM.)
20 THE COURT: YOU MAY BE SEATED.
21 THE RECORD WILL REFLECT THAT THE JURY HAS LEFT THE
22 COURTROOM.
23 OKAY. LET'S JUST GO BACK TO SOME OF THESE ISSUES THAT
24 WE SAID WE WOULD ADDRESS AFTER THE JURY HAD BEEN OUT OF THE
25 COURTROOM. I THINK THE FIRST QUESTION WAS, YOU ASKED A
2233
1 QUESTION ABOUT DELIRIUM, WHAT CAUSED HER DELIRIUM. AND
2 THERE WAS A -- OKAY. WHAT WAS THE OBJECTION?
3 MR. STIRBA: RELEVANCY.
4 THE COURT: OKAY. WHAT DO YOU CLAIM IS THE
5 RELEVANCY OF THE CAUSE OF HER DELIRIUM? NOT THAT SHE HAD
6 IT, BUT WHETHER -- WHAT CAUSED IT.
7 MS. BARLOW: BECAUSE THE MEDICATIONS -- I'M NOT --
8 WELL, YEAH. MAYBE I DID ASK IT THAT WAY. THE MEDICATIONS
9 THAT SHE WAS GIVEN AT THE NURSING HOME AND THEN -- I MEAN,
10 THE MORPHINE WAS GIVEN HERE -- CAN CAUSE DELIRIUM. THAT ONE
11 OF THE MAIN CAUSES OF DELIRIUM IS WHAT'S CALLED MEDICATION
12 INTOXICATION.
13 THE COURT: OKAY. BUT --
14 MS. BARLOW: THEY'RE GETTING TOO MUCH OF WHATEVER
15 THE MEDICATION IS THAT'S SUPPOSED TO BE HELPING THEM.
16 THE COURT: WELL, HIS TESTIMONY IS THAT SHE HAD
17 DELIRIUM WHEN SHE ARRIVED?
18 MS. BARLOW: THAT -- YES, IF I CAN ASK THAT. I WAS
19 LIMITED -- I COULDN'T GET INTO IT.
20 THE COURT: OKAY. WELL, BUT IF IT -- WELL, IF THE
21 DELIRIUM -- I MEAN, WHAT CAUSED IT -- IF IT -- IF IT WAS
22 SOMETHING THAT WAS CAUSED BEFORE SHE GOT THERE --
23 MS. BARLOW: UH-HUH.
24 THE COURT: -- WHAT RELEVANCE IS THAT?
25 MS. BARLOW: WELL, SHE CAME IN WITH DELIRIUM.
2234
1 THE COURT: OKAY. WELL, HE'S TESTIFIED ABOUT THAT.
2 IT'S NOT -- I MEAN, WHAT -- WHAT IS THE RELEVANCE OF WHAT
3 CAUSED THE DELIRIUM?
4 MS. BARLOW: WELL, WHAT -- AND -- AND I THINK I WAS
5 TRYING TO GET IN WHAT CAN CAUSE DELIRIUM TO GET IN THE FACT
6 THAT -- THAT --
7 THE COURT: WELL, THE ACTION --
8 MS. BARLOW: -- THE MEDICATION OVERDOSE CAN CAUSE
9 IT. AND I SEE WHERE -- OKAY. MAYBE I CAN REPHRASE IT. I
10 THINK I UNDERSTAND WHAT THE COURT'S CONCERN IS BY THE
11 QUESTION THAT YOU JUST ASKED. PERHAPS THEN I CAN -- RATHER
12 THAN ASK ABOUT THE CAUSE OF HER DELIRIUM, AND I GO STRAIGHT
13 TO THE TREATMENT OF THE DELIRIUM THAT SHE WAS EXHIBITING --
14 THE COURT: WELL, I THINK WHAT -- WHAT YOU COULD --
15 I MEAN, WHAT WE'VE BEEN SAYING IS THAT -- OKAY. HOW DID
16 DR. WEITZEL TREAT THIS PATIENT? WAS IT APPROPRIATE OR NOT
17 APPROPRIATE? HE CAN SAY IT'S NOT APPROPRIATE. AND THEN HIS
18 FIRST QUESTION (SIC) WAS BECAUSE HE DIDN'T DIAGNOSE IT.
19 MS. BARLOW: RIGHT.
20 THE COURT: AND THEN WE GET RIGHT BACK TO
21 NEGLIGENCE.
22 MS. BARLOW: WELL, YOU KNOW, AND I -- I WASN'T -- I
23 WASN'T INTENDING TO GET THAT. THE QUESTION MAY HAVE BEEN
24 INARTFUL. YES.
25 THE COURT: WELL, MAYBE YOU MIGHT WANT TO TALK TO
2235
1 HIM AT A BREAK OR SOMETHING WHEN WE TAKE A BREAK BECAUSE
2 THAT'S -- IF -- IF THOSE ANSWERS KEEP COMING OUT -- YOU
3 KNOW, YOU DIDN'T INTEND IT, BUT THEN HE ASKS -- HE KEEPS
4 COMING OUT WITH A DIAGNOSE -- YOU KNOW, FAILURE TO DIAGNOSE,
5 FAILURE TO DIAGNOSE, FAILURE TO DIAGNOSE DELIRIUM. THAT IS
6 A PROBLEM. THAT'S WHAT I JUST RULED ABOUT SAYING THAT
7 THAT'S NEGLIGENCE, AND FAILURE TO DIAGNOSE IS NOT GOING TO
8 COME IN.
9 IF HE WANTS TO SAY HE DIDN'T -- HE DIDN'T SEE THAT AND
10 HE TREATED IT THIS WAY, THE APPROPRIATE TREATMENT WAS THIS.
11 THAT'S ALL FINE. AND HE DIDN'T DO -- AND GIVING THEM THIS
12 WASN'T APPROPRIATE, YOU KNOW, WHATEVER IS FINE. BUT NOT HE
13 FAILED TO DIAGNOSE, FAILED TO DIAGNOSE.
14 MS. BARLOW: FINE.
15 THE COURT: AND THEN IS THIS -- AND MAYBE JUST LET
16 ME KNOW. IS THIS WITNESS GOING TO TESTIFY REGARDING THE
17 DEATH OF THESE PATIENTS? THAT --
18 MS. BARLOW: YES.
19 THE COURT: -- GIVING THE MEDICATION AND THE
20 TREATMENT THAT DR. WEITZEL DID GIVE?
21 MS. BARLOW: YES.
22 THE COURT: OKAY.
23 MS. BARLOW: BUT THIS IS PART OF IT.
24 THE COURT: OKAY.
25 MS. BARLOW: I MEAN, THE FAILURE TO NOT DIAGNOSE,
2236
1 BUT -- BUT THE GIVING OF THESE DRUGS, THE FAILURE TO
2 WITHHOLD THESE DRUGS WHICH COULD BE CAUSING THE DELIRIUM,
3 LEADS TO AND IS PART OF CAUSING THE DEATH OF THESE PEOPLE.
4 AND THAT'S THE RELEVANCE.
5 THE COURT: WELL, OKAY. MR. STIRBA?
6 MR. STIRBA: YEAH, I -- NO. I HAVE A PROBLEM WITH
7 THAT. WHY CAN'T WE JUST SAY -- I THOUGHT WE HAD AN
8 AGREEMENT. HE SAYS, IN MY OPINION SHE HAS DELIRIUM. OKAY,
9 FINE. HE PRESCRIBES X OR ORDERS X. WOULD YOU HAVE
10 PRESCRIBED THAT FOR DELIRIUM? NO. WHY NOT? BECAUSE IT'S
11 NOT THE, YOU KNOW, THE CORRECT DRUG OR WHATEVER YOU WANT TO
12 SAY.
13 BUT THIS FAILURE TO -- YOU KNOW, THERE'S GOING TO BE A
14 MOTION HERE. I -- I JUST HELD BACK BECAUSE I HEARD IT AND I
15 KNEW EXACTLY WHAT HAPPENED. BUT, I MEAN, WE'RE NOT GOING TO
16 GET INTO THIS FAILURE TO DO THIS, FAILURE TO DO THAT.
17 THAT'S ALL NEGLIGENCE. HE CAN DO IT AFFIRMATIVELY AND YOU
18 CAN GET THE SAME RESULT, BUT CORRECTLY. THAT IS, DELIRIUM,
19 OKAY. HERE'S THE TREATMENT. WOULD THIS BE TREATMENT FOR
20 DELIRIUM AS YOU'VE DIAGNOSED IT? NO. WHY NOT? WELL,
21 BECAUSE THIS, THAT, AND THE OTHER. THAT TO ME IS QUITE A
22 BIT DIFFERENT THAN SAYING FAILURE TO DO THIS, FAILURE TO DO
23 THAT.
24 THE COURT: AND MY UNDERSTANDING -- AND IF I DIDN'T
25 EXPLAIN IT -- MY UNDERSTANDING WAS WHAT WE WERE GOING TO DO
2237
1 IS SAY, WHAT THIS WITNESS -- WHAT THIS DOCTOR DID, WHETHER
2 THAT WAS APPROPRIATE; AND IF IT WASN'T APPROPRIATE, WHAT
3 SHOULD HAVE BEEN DONE? ISN'T THAT -- IS THAT WHAT YOU'VE
4 JUST DESCRIBED?
5 MR. STIRBA: GENERALLY, YES.
6 THE COURT: OKAY.
7 MS. BARLOW: AND I APOLOGIZE, YOUR HONOR. I
8 THOUGHT THAT'S WHAT I WAS DOING. CLEARLY THAT ISN'T WHAT
9 I'M DOING. I'LL -- I'LL TRY TO REFOCUS THE WAY I DO IT.
10 THE COURT: OKAY. WELL THEN LET'S -- OKAY. ALL
11 RIGHT. WELL, WE'LL -- LET'S TAKE A BREAK TO 11:15 AND THEN
12 WE'LL COME BACK AT THAT POINT.
13 (WHEREUPON, COURT'S IN RECESS.)
14 THE COURT: PLEASE BE SEATED.
15 THE RECORD WILL REFLECT THAT THE JURY HAS RETURNED.
16 IF YOU'D LIKE TO CONTINUE, MISS BARLOW.
17 MS. BARLOW: THANK YOU, YOUR HONOR.
18 Q. (BY MS. BARLOW) DR. FEHLAUER, YOU TESTIFIED ABOUT
19 WHAT'S CALLED THE D.S.M. AND WHAT DOES THAT STAND FOR?
20 A. THE DIAGNOSTIC AND STATISTICAL MANUAL.
21 Q. WAS THERE ONE IN EFFECT -- WELL, LET'S SAY IN USE IN
22 1995?
23 A. YES. THE D.S.M.-IV WAS IN USE.
24 Q. IS THAT GENERALLY ACCEPTED BY THE MEDICAL COMMUNITY?
25 A. YES.
2238
1 Q. DOES IT INCLUDE ANYTHING ABOUT PROPER -- OR APPROPRIATE
2 TREATMENT FOR THE DISEASES OR ILLNESSES THAT ARE LISTED?
3 A. IT'S MEANT MOSTLY AS A -- AS A DIAGNOSIS AID, BUT IT
4 DOES TALK ABOUT IN THE DISCUSSION SECTIONS MATERIALS
5 RELEVANT TO THE DIAGNOSIS THAT IT'S REFERRING TO.
6 Q. AND WHAT ABOUT TREATMENT?
7 A. TREATMENT IS -- IS NOT PART OF THIS STATISTICAL MANUAL.
8 Q. THANK YOU. CAN THE ACTIONS OF A PHYSICIAN CAUSE DEATH?
9 A. YES.
10 Q. CAN THE INACTIONS OF A PHYSICIAN CAUSE DEATH?
11 MR. STIRBA: YOUR HONOR, RELEVANCY. IT'S AN
12 IMPROPER HYPOTHETICAL.
13 THE COURT: SUSTAINED.
14 Q. (BY MS. BARLOW) YOU WENT THROUGH THE LIST OF
15 MEDICATIONS THAT WERE ORDERED FOR ELLEN ANDERSON?
16 A. YES.
17 Q. HAVE YOU LOOKED TO SEE WHICH MEDICATIONS WERE ACTUALLY
18 GIVEN?
19 A. YES, I HAVE.
20 Q. AND WHICH MEDICATIONS WERE ACTUALLY GIVEN TO ELLEN
21 ANDERSON?
22 A. FROM THE HOSPITAL RECORDS ENTERED INTO EVIDENCE, THE
23 MEDICATIONS ACTUALLY DOCUMENTED AS ADMINISTERED IS MORPHINE
24 SULFATE, 10 MILLIGRAMS I.M. NOW FOR PAIN, 12/29 AT 1930.
25 AND MORPHINE SULFATE 10 MILLIGRAMS I TIMES ONE -- I'M
2239
1 ASSUMING I.M. -- NOW FOR PAIN 12/30, 0330 IN THE MORNING.
2 Q. WHEN YOU SAY 12/30, THAT'S NOT THE TIME. THAT'S THE
3 DATE?
4 A. THAT'S THE DATE, DECEMBER 30.
5 Q. 30TH OF DECEMBER. OKAY. WERE THOSE MEDICATIONS
6 APPROPRIATE FOR THIS PATIENT?
7 A. NO.
8 Q. WHY WERE THEY NOT?
9 A. THERE ARE A HOST OF REASONS.
10 Q. FIRST ONE?
11 A. THERE IS NO EVIDENCE FROM THE RECORD THAT THE PATIENT
12 HAD A PAINFUL CONDITION REQUIRING MORPHINE.
13 Q. WHAT'S -- WHAT'S ANOTHER REASON?
14 A. THE DOSE OF THE MORPHINE WAS AT LEAST TWO TO FOUR TIMES
15 HIGHER THAN THE USUAL DOSE OF MORPHINE FOR ADMINISTRATION TO
16 AN OLDER PERSON AS THE FIRST DOSE.
17 Q. ANY OTHER REASONS?
18 A. THE PATIENT DIDN'T EXHIBIT ANY PAIN.
19 Q. OKAY. YOU'VE MENTIONED THAT ONE AND YOU'VE MENTIONED
20 DOSAGE. YOU SAID A HOST OF REASONS. WERE THERE ANY OTHER
21 REASONS? I GUESS YES OR NO IS --
22 A. YES. THE MORPHINE COULD CONTRIBUTE TO FURTHER
23 CONFUSION, SEDATION, WHICH WOULD HAVE BEEN INAPPROPRIATE FOR
24 THIS PATIENT.
25 MS. BARLOW: IF I MAY HAVE ANOTHER EXHIBIT MARKED,
2240
1 YOUR HONOR. YOUR HONOR, EXCUSE ME.
2 I'M SORRY, PETER. THAT'S NOT THE ONE I WANT TO USE
3 RIGHT NOW. THIS IS THE ONE. THEY BOTH KIND OF START OUT
4 THE SAME.
5 SO IT'S STATE'S EXHIBIT 31 IS THE ONE I WAS GOING TO
6 HAVE YOU LOOK AT FIRST.
7 THE COURT: DID YOU WANT TO SHOW THAT TO THIS
8 WITNESS?
9 MS. BARLOW: AS SOON AS MR. STIRBA'S HAD A CHANCE
10 TO LOOK AT IT --
11 THE COURT: OKAY.
12 MS. BARLOW: -- I WILL, YOUR HONOR.
13 Q. (BY MS. BARLOW) DR. FEHLAUER, I'VE ASKED YOU TO
14 IDENTIFY THIS. THIS IS STATE'S EXHIBIT 31, I BELIEVE.
15 DON'T SHOW IT TO THE JURY YET UNTIL YOU'VE IDENTIFIED IT.
16 WHAT IS THIS?
17 A. THIS IS A DOCUMENT THAT I HAVE PREPARED IN PREPARATION
18 FOR TESTIMONY, THAT THE STATE HAS PUT INTO THIS FORM, THAT
19 DESCRIBES DRUGS, THE USUAL ADULT STARTING DOSE AND THE USUAL
20 ELDERLY STARTING DOSE.
21 Q. DOES THIS ACCURATELY REFLECT WHAT YOU'VE PUT TOGETHER
22 FOR THIS CASE?
23 A. YES.
24 Q. NOW, THE DRUGS THAT ARE LISTED, ARE THEY RELEVANT TO
25 THIS CASE? WELL, LET ME -- DON'T ASK -- LET ME NOT ASK IT
2241
1 THAT WAY. HOW DID YOU ARRIVE AT THE DRUGS THAT YOU'VE
2 LISTED ON HERE?
3 A. I ARRIVED AT THE DRUGS ON THIS TABLE BASED ON THE DRUGS
4 ADMINISTERED TO THE PATIENTS, THE FIVE DIFFERENT CASES.
5 MS. BARLOW: YOUR HONOR, I WOULD MOVE FOR ADMISSION
6 OF STATE'S EXHIBIT 31.
7 MR. STIRBA: MAY I VOIR DIRE, YOUR HONOR?
8 THE COURT: YES.
9 VOIR DIRE EXAMINATION
10 BY MR. STIRBA:
11 Q. DOCTOR, I NOTICE ON THE EXHIBIT THERE'S NO REFERENCE TO
12 A SOURCE FOR THAT INFORMATION. IS THERE A PARTICULAR SOURCE
13 THAT YOU'RE RELYING ON?
14 A. YES.
15 Q. AND WHAT SOURCE IS THAT?
16 A. TWO SOURCES. THE FIRST IS THE 1995 PHYSICIAN'S DESK
17 REFERENCE, COMMONLY CALLED THE P.D.R.; AND THE SECOND IS THE
18 1993 EDITION OF THE GERIATRIC DOSAGE HANDBOOK.
19 Q. WE ARE IN SYNC. AND DID YOU TAKE THE INFORMATION, FOR
20 EXAMPLE, OUT OF THE GERIATRIC DOSING HANDBOOK AND JUST TAKE
21 THAT INFORMATION AND TRANSPOSE IT DIRECTLY ONTO THAT
22 EXHIBIT?
23 A. YES.
24 Q. WITHOUT MAKING ANY CHANGES?
25 A. YES.
2242
1 Q. ALL RIGHT.
2 THE COURT: DID YOU HAVE ANY OBJECTION?
3 MR. STIRBA: I'D LIKE HIM TO TESTIFY AND THEN
4 PERHAPS THE FOUNDATION WILL BE LAID IN TERMS OF -- I MEAN,
5 HE HASN'T TESTIFIED AS TO THE SPECIFICS, YOUR HONOR.
6 THE COURT: OKAY. WHY DON'T YOU GO AHEAD.
7 DIRECT EXAMINATION, CONT'D
8 BY MS. BARLOW:
9 Q. FOR ELLEN ANDERSON YOU MENTIONED THAT -- OR YOU SAID
10 THAT SHE GOT MORPHINE SULFATE. WHAT, UNDER THE P.D.R., IS
11 AN APPROPRIATE STARTING DOSAGE AMOUNT FOR AN ADULT?
12 A. UNDER THE P.D.R. THERE IS NO SPECIFIC APPROPRIATE DOSE
13 FOR MORPHINE.
14 Q. HOW DID YOU ARRIVE AT 10 MILLIGRAM INTRAMUSCULAR EVERY
15 FOUR HOURS AS NEEDED?
16 A. I ARRIVED AT THAT USING THE GERIATRIC DOSAGE HANDBOOK.
17 THE REASON THAT THERE IS NOT AN ENTRY IN THE P.D.R. RELATIVE
18 TO DOSING MORPHINE INTRAMUSCULARLY IS THAT MORPHINE IS SUCH
19 AN OLD DRUG THAT THE COMPANIES THAT MAKE MORPHINE AREN'T
20 REQUIRED TO CREATE THAT PACKAGE INSERT THAT YOU GET.
21 WHENEVER YOU GET A DRUG FROM THE DOCTOR YOU GET THIS PACKAGE
22 INSERT. WELL, THOSE PACKAGE INSERTS ARE BOUND TOGETHER AND
23 INDEXED AND PUT INTO THE P.D.R. THAT'S WHAT THE P.D.R. IS.
24 IT'S JUST BASICALLY A COMPILATION OF ALL THE PACKAGE
25 INSERTS. THERE IS NO PACKAGE INSERTS FOR MORPHINE
2243
1 ADMINISTERED I.M. BY INJECTION. SO I USED THE DOSAGE
2 HANDBOOK AS THE REFERENCE MANUAL FOR THIS DOSE.
3 Q. AND DO YOU KNOW HOW THE DOSE OF 10 MILLIGRAMS WAS
4 ARRIVED AT FOR AN ADULT STARTING DOSE?
5 A. I DON'T HAVE A CLUE.
6 Q. IS IT GENERALLY ACCEPTED IN THE MEDICAL COMMUNITY THAT
7 THAT'S AN ADULT STARTING DOSE?
8 A. YES.
9 Q. THEN WE HAVE THE ELDERLY STARTING DOSE. HOW DID YOU
10 ARRIVE AT THAT?
11 A. THAT'S DERIVED FROM THE GERIATRIC DOSAGE HANDBOOK.
12 Q. HOW MUCH IS THE ELDERLY STARTING DOSE?
13 A. 2.5 MILLIGRAMS ADMINISTERED AT INTERVALS.
14 Q. AND IT SAYS EVERY FOUR TO SIX HOURS AS NEEDED; IS THAT
15 CORRECT?
16 A. YES.
17 Q. WHY IS THERE A DIFFERENCE BETWEEN THE ADULT STARTING
18 DOSE AND THE ELDERLY STARTING DOSE?
19 A. OLDER ADULTS ARE JUST -- ARE NOT JUST CHRONOLOGICALLY
20 DIFFERENT. I MEAN, A 40-YEAR-OLD MAN AND AN 80-YEAR-OLD MAN
21 ARE DIFFERENT PHYSIOLOGICALLY. THEY HAVE DIFFERENT
22 METABOLIC PROCESSES GOING ON IN THEIR BODIES. AND THE DOSE
23 HAS BEEN DETERMINED AND IS DIFFERENT FROM YOUNG ADULTS
24 BECAUSE OF THOSE PHYSIOLOGICAL DIFFERENCES.
25 MS. BARLOW: IF I MAY HAVE THIS MARKED. THIS IS
2244
1 NUMBER 32.
2 MAY I APPROACH, YOUR HONOR?
3 THE COURT: YES.
4 Q. (BY MS. BARLOW) SHOW YOU WHAT'S BEEN MARKED STATE'S
5 EXHIBIT 32. DO YOU RECOGNIZE THAT -- DON'T TURN IT FOR THE
6 JURY YET. DO YOU RECOGNIZE WHAT THAT IS?
7 A. THIS IS A TABLE I PREPARED FOR TESTIMONY THAT THE STATE
8 HAS PLACED ON THIS BOARD. THAT IS A COMPILATION OF
9 MATERIALS RELEVANT TO ADMINISTERING DRUGS TO OLDER PERSONS.
10 Q. WHERE DID YOU GET THE MATERIAL THAT YOU PUT ON THIS?
11 A. THIS MATERIAL IS -- IS BASED ON INFORMATION CONTAINED IN
12 THE GERIATRIC DOSAGE HANDBOOK. IT'S ALSO CONTAINED IN
13 TEXTBOOKS RELEVANT TO THE -- TO THE CARE OF THE ELDERLY.
14 IT'S DERIVED FROM LECTURES AND HANDOUTS THAT I GAVE AS A
15 FACULTY MEMBER AT THE UNIVERSITY OF UTAH IN THE TIME PERIOD
16 OF 1991 TO 1995, AND REPRESENTS -- FROM MY OWN LECTURES --
17 THE MATERIAL NECESSARY TO UNDERSTAND THE BASIC PHARMACOLOGY
18 OF THE AGED.
19 Q. AND IS THIS GENERALLY ACCEPTED IN THE MEDICAL COMMUNITY,
20 THIS INFORMATION?
21 A. YES.
22 MS. BARLOW: YOUR HONOR, I'D MOVE FOR ADMISSION --
23 ADMISSION OF STATE'S EXHIBIT 32.
24 MR. STIRBA: FOUNDATION. IT'S HEARSAY, IT'S
25 SELF-SERVING, AND HE'S HERE AND CAN TESTIFY, YOUR HONOR.
2245
1 IT'S REALLY NOT A SUMMARY, IF YOU WILL, OF HIS TESTIMONY.
2 MS. BARLOW: YOUR HONOR?
3 THE COURT: OKAY. DO YOU OBJECT TO IT BEING USED
4 ILLUSTRATIVELY?
5 MR. STIRBA: YES. AS LONG AS IT'S NOT INTRODUCED
6 INTO EVIDENCE, I GUESS HE COULD USE IT TO ILLUSTRATE HIS
7 TESTIMONY.
8 THE COURT: OKAY. WELL, LET'S USE IT TO DO HIS
9 TESTIMONY AND THEN WE CAN ADDRESS THE OTHER POINT LATER.
10 MS. BARLOW: BE HAPPY TO, YOUR HONOR. MAYBE IF WE
11 CAN MOVE THIS UP CLOSER FOR THE JURY.
12 Q. (BY MS. BARLOW) WHAT -- WHAT IS THIS CHART?
13 A. THIS CHART IS A BRIEF SUMMARY OF THE INFORMATION THAT
14 PHYSICIANS USE WHEN PRESCRIBING DRUGS FOR BOTH YOUNG ADULTS
15 AND OLDER ADULTS.
16 Q. WE HAVE SOME TERMS THAT ARE DEFINED UP HERE AT THE TOP.
17 THE FIRST IS HALF LIFE. WHAT IS HALF LIFE?
18 A. HALF LIFE AS IS WRITTEN ON THE CHART IS THE AMOUNT OF
19 TIME THAT -- IN HOURS -- THAT IT TAKES THE BLOOD
20 CONCENTRATION OF A DRUG TO FALL BY HALF. SO IF THE LIFE OF
21 A DRUG IN YOUR BODY IS X NUMBER OF HOURS LONG, THE TIME IT
22 TAKES FOR THAT DRUG TO REACH ITS -- FROM ITS PEAK
23 CONCENTRATION TO HALF THAT PEAK CONCENTRATION IS THE HALF
24 LIFE.
25 Q. WHY IS THAT SIGNIFICANT?
2246
1 A. WELL, HALF LIFE HAS TO DO WITH HOW LONG THE DRUG IS IN
2 THE BLOOD STREAM. IT HAS TO DO WITH HOW LONG THE DRUG IS IN
3 AND PRESENT IN THE BODY.
4 Q. AND THEN DURATION OF EFFECT IS THE NEXT TERM.
5 A. THE DURATION OF EFFECT CAN BE DEFINED AS THE AMOUNT OF
6 TIME IN HOURS THAT A DRUG HAS ACTIVITY IN THE BODY. YOU'LL
7 NOTICE THAT HALF LIFE IS ABOUT THE BLOOD, BUT DURATION OF
8 EFFECT IS ACTIVITY IN THE BODY. IF YOU SWALLOW A PILL NOW,
9 THE DRUG GETS ABSORBED INTO YOUR BLOODSTREAM AND THEN IT'S
10 TRANSPORTED AROUND YOUR BODY IN THE BLOOD. IT'S DELIVERED
11 TO TISSUES WHERE IT GOES INTO THE TISSUES THEMSELVES AND
12 DISSOLVES IN THE FLUID AROUND THE TISSUE OR IS ABSORBED INTO
13 THE INSIDE OF A CELL. SO IT'S STILL IN THE BODY. IN FACT,
14 THAT'S WHERE IT HAS ITS ACTIVITY.
15 AND SO DURATION OF EFFECT HAS TO DO NOT WITH HOW LONG
16 THE BLOOD CARRIES THIS DRUG AROUND, BUT AFTER IT'S DELIVERED
17 TO THE TISSUES OR AFTER IT'S RELEASED FROM TISSUES AFTER
18 IT'S BEEN STORED THERE AND HAS MORE ACTIVITY, THAT'S HOW
19 LONG THE DRUG IS DOING SOMETHING. HALF LIFE RELATES TO WHAT
20 YOU MEASURE. DURATION OF EFFECT RELATES TO BIOLOGICAL
21 ACTIVITY.
22 Q. DRUGS DON'T STAY IN THE BODY FOREVER; IS THAT CORRECT?
23 A. CORRECT.
24 Q. AND SO UNDER HERE UNDER TERM, WE HAVE DRUG METABOLISM,
25 DRUG EXCRETION, PROTEIN BINDING, LEAN BODY MASS, FAT BODY
2247
1 MASS. HOW DOES A DRUG METABOLISM AFFECT THE DURATION OF
2 EFFECT OF A DRUG?
3 A. WELL, DRUG METABOLISM IS A BREAKDOWN OF DRUGS. AND THIS
4 OCCURS PRINCIPALLY IN THE LIVER. THE LIVER RECEIVES THE
5 DRUG THROUGH THE BLOOD FLOW AND -- AND ACTS ON IT TO BREAK
6 IT DOWN INTO INACTIVE OR EVEN ACTIVE PARTICLES.
7 THE BREAKDOWN OF THE DRUG INTO INACTIVE OR -- OR OTHER
8 PARTICLES THAT CAN BE REMOVED CAN CHANGE THE -- THE ACTIVITY
9 OF THE DRUG AND ALLOWS IT TO BE REMOVED FROM THE BODY OR
10 REMOVES ITS -- ITS EFFECT. IF THE -- DO YOU WANT TO ASK --
11 Q. NO. GO AHEAD.
12 A. THE REASON THAT THIS CHART'S PREPARED RELATIVE TO ITS
13 EFFECT ON AGING IS BECAUSE OLDER ADULTS ARE NOT JUST OLDER
14 VERSIONS OF YOUNG ADULTS. THEY'RE PHYSIOLOGICALLY
15 DIFFERENT. AND WITH AGING, THE LIVER'S ABILITY TO
16 METABOLIZE DRUGS IS REDUCED AND SO THAT RESULTS IN A
17 PROLONGATION OF THE HALF LIFE. THE DRUG IS NOT REMOVED FROM
18 THE BLOODSTREAM AS FAST BECAUSE THE LIVER CAN'T REMOVE IT.
19 AND IT PROLONGS THE DURATION OF EFFECT BECAUSE AS THE HALF
20 LIFE LENGTHENS, THE DRUG STILL IS IN THE SYSTEM LONGER AND
21 SO THE EFFECT IS LONGER.
22 Q. AND SO THAT'S WHAT HAPPENS INTERNALLY. WHAT DOES THAT
23 MEAN -- HOW DO I PHRASE THIS? WHAT DOES THAT MEAN, FOR
24 EXAMPLE, IF YOU GET A SHOT OF MORPHINE AT 1930 HOURS, A -- A
25 NORMAL ADULT, LET'S SAY THREE HOURS LATER, AS OPPOSED TO AN
2248
1 ELDERLY ADULT THAT SAME SHOT THREE HOURS LATER? WHAT DOES
2 THAT MEAN?
3 MR. STIRBA: I WOULD OBJECT. RELEVANCY, YOUR
4 HONOR. WE HAVE A SPECIFIC PATIENT.
5 THE COURT: OKAY. I THINK THIS IS BACKGROUND.
6 OVERRULED.
7 Q. (BY MS. BARLOW) SO IF A -- IF A NORMAL, YOUNG ADULT --
8 MAYBE NOT YOUNG, 40 -- NOT AN ELDERLY ADULT. IF JUST AN
9 ADULT GETS A SHOT OF MORPHINE SAY AT 9:30, AND AN ELDERLY
10 PERSON GETS A SHOT OF MORPHINE, SAME AMOUNT, AT 1930, THREE
11 HOURS LATER, WHAT WOULD BE THE DIFFERENCE BETWEEN THE NORMAL
12 ADULT AND THE ELDERLY ADULT AS FAR AS THAT SHOT OF MORPHINE?
13 A. WELL, THE MEASURABLE DIFFERENCE IS THAT THE -- THE HALF
14 LIFE OR THE AMOUNT OF THE DRUG THAT'S STILL PRESENT IN THE
15 SYSTEM WOULD BE HIGHER.
16 Q. IN?
17 A. YOU WOULD EXPECT IT TO BE -- STILL BE HIGHER IN AN OLDER
18 PERSON. AND THE DURATION OF THE EFFECT, BASED ON OTHER
19 FACTORS, WOULD LEAD YOU TO BELIEVE THAT IT WOULD BE A LONGER
20 DURATION OF EFFECT IN AN OLDER PERSON.
21 Q. AND THE EFFECT WOULD BE PAIN RELIEF, FOR MORPHINE?
22 A. BENEFICIAL EFFECT WOULD BE PAIN RELIEF.
23 Q. LET'S -- LET'S LOOK AT DRUG EXCRETION THEN. WHAT --
24 WHAT DOES THAT MEAN?
25 A. SO THE DRUG IS -- PASSES BY THE LIVER OR IS CARRIED IN
2249
1 THE BLOODSTREAM AND IS METABOLIZED. IT NEEDS TO BE
2 ELIMINATED FROM THE BODY SOMEHOW. SOME OF IT OCCURS THROUGH
3 THE BILE. THE -- THE LIVER ACTUALLY EXCRETES THE MATERIAL
4 OUT OF THE -- OUT OF THE LIVER INTO THE BILE SYSTEM AND INTO
5 THE INTESTINES, OR THE KIDNEYS WHICH DO THE BULK OF THIS,
6 TAKE THE MATERIAL AND EXCRETE IT OUT THROUGH THE URINE.
7 Q. WHAT'S THE EFFECT OF AGING ON DRUG EXCRETION?
8 A. THE -- GENERALLY THE KIDNEYS' ABILITY TO EXCRETE DRUGS
9 IS REDUCED IN OLDER PERSONS.
10 Q. AND THEN THE EFFECT?
11 A. THAT WOULD -- IT CAN'T BE EXCRETED. IT WOULD STAY IN
12 THE BLOODSTREAM LONGER. IF IT STAYS IN THE BODY LONGER,
13 THEN THE DURATION OF EFFECT IS LONGER. SO IT PROLONGS THE
14 HALF LIFE AND PROLONGS THE DURATION OF ACTION.
15 Q. THE NEXT TERM IS PROTEIN BINDING. WHAT DOES THAT MEAN?
16 A. WHEN A DRUG IS ABSORBED INTO YOUR BLOODSTREAM, IT'S NOT
17 JUST DISSOLVED. IT IS ALSO ATTACHED TO PROTEINS. AND, IN
18 FACT, THE PROTEINS SERVE AS A STORE HOUSE FOR DRUGS AND
19 CARRY THEM AROUND THROUGHOUT THE BODY. THE AMOUNT OF DRUG
20 THAT'S LEFT FLOATING FREE IN THE BLOODSTREAM IS THE AMOUNT
21 THAT'S ACTIVE. IT'S THE AMOUNT THAT CAN BE DISSOLVED
22 SOMEWHERE ELSE. SO IF IT'S BOUND UP TO A PROTEIN, IT'S NOT
23 ACTIVE.
24 SO FOR ANY GIVEN DOSE OF MEDICINE, IF YOU HAVE A LOWER
25 AMOUNT OF PROTEIN IN YOUR BLOOD, MORE OF THAT DOSE OF
2250
1 MEDICINE IS GOING TO BE DISSOLVED IN THE BLOOD. SO THAT IF
2 BLOOD PROTEINS ARE REDUCED, WHICH THEY ARE IN THE ELDERLY,
3 THAT MEANS THERE'S MORE FREE DRUG PRESENT IN THE BODY. AND
4 THEN THAT MEANS THAT IT PROLONGS THE DURATION OF EFFECT OF
5 THE MEDICATIONS.
6 Q. WHAT IS LEAN BODY MASS?
7 A. LEAN BODY MASS IS THAT PORTION OF THE BODY INTO WHICH
8 WATER SOLUBLE DRUGS CAN BE DISSOLVED. IT'S -- LEAN BODY
9 MASS IS -- IS BASICALLY MUSCLE AND BONE. IT'S DECREASED IN
10 THE ELDERLY. AND SO THERE'S LESS VOLUME OF WATER FOR DRUGS
11 THAT ARE DISSOLVED IN WATER. SO, FOR EXAMPLE, IF ONE PERSON
12 HAS A CERTAIN AMOUNT OF WATER AND -- AND ANOTHER HAS LESS
13 AMOUNT OF WATER AND THEY'RE GIVEN THE SAME DOSE OF A DRUG
14 THAT DISSOLVES IN WATER, THEN THE PERSON WITH LESS WATER
15 WILL HAVE A HIGHER CONCENTRATION OF THE DRUG. IT'S -- IT'S
16 LIKE DROPPING A TABLET INTO A SMALLER VOLUME. TAKE ONE DROP
17 OF -- OF LIQUID FOOD COLORING AND PUT IT IN ONE VOLUME AND
18 IT HAS A CERTAIN COLOR. IF THE VOLUME IS LOWER AND YOU PUT
19 ONE DROP IN THERE, IT HAS A DARKER COLOR.
20 Q. AND THEN THE EFFECT?
21 A. OF?
22 Q. WELL, OF DRUGS IN LEAN BODY MASS.
23 A. OH, LESS VOLUME MEANS THERE'S -- THERE'S MORE SOLUBLE
24 DRUG AND IT INCREASES THE DRUG EFFECT.
25 Q. AND THEN FAT BODY MASS?
2251
1 A. FAT BODY MASS IS THAT PORTION THAT'S NOT LEAN BODY MASS.
2 IT'S -- IT'S THE COMPONENT OF THE BODY THAT'S COMPOSED OF
3 FAT TISSUES. THE BRAIN IS A FAT TISSUE. OBVIOUSLY, FAT
4 TISSUES ARE IN THE GUT AND ELSEWHERE. THAT PROPORTION IS
5 INCREASED IN THE ELDERLY. OKAY.
6 AND SO IF YOU ADMINISTER A DRUG THAT IS ABSORBED INTO
7 FAT, BECAUSE FLUIDS FLOW MORE SLOWLY IN AND OUT OF FAT --
8 AND YOU CAN SEE THAT WHEN YOU -- WHEN MIXING UP A SALAD
9 DRESSING YOU CAN SEE THAT THE SEPARATION OCCURS, SERVES AS A
10 RESERVOIR. A FAT SOLUBLE DRUG GETS STORED IN THERE AND CAN
11 BE RELEASED SLOWLY OVER TIME. SO SOMEONE WITH A LARGER FAT
12 RESERVOIR TAKES UP MORE OF A FAT SOLUBLE DRUG AND IT STAYS
13 IN THE BODY LONGER, SO IT SERVES AS A RESERVOIR FOR SLOWLY
14 RELEASING THE DRUG OVER A LONGER PERIOD OF TIME.
15 AND THAT PROLONGS THE HALF LIFE AND THE DURATION OF
16 EFFECT, AND THAT'S WHAT OCCURS IN THE ELDERLY.
17 MS. BARLOW: YOUR HONOR, I WOULD REMOVE FOR
18 ADMISSION OF 32 AS ILLUSTRATIVE OF HIS TESTIMONY.
19 MR. STIRBA: WELL, SAME OBJECTION.
20 THE COURT: MAYBE WE CAN DISCUSS THAT AT THE BREAK.
21 Q. (BY MS. BARLOW) LET ME SHOW YOU WHAT'S BEEN MARKED
22 STATE'S EXHIBIT 30. DO YOU RECOGNIZE THAT DOCUMENT?
23 A. YES, I DO.
24 Q. WHAT IS IT?
25 A. THIS IS A DOCUMENT PREPARED BY MYSELF AND PLACED ON THIS
2252
1 CHART THAT RELATES THE DRUG TO THE EFFECTS SEEN IN THE
2 ELDERLY, AND SPECIAL CONSIDERATIONS THAT ARE IMPORTANT BASED
3 ON THE EFFECT OF THE PHARMACOLOGY IN THE ELDERLY.
4 Q. WHERE DID YOU GET THE LIST OF DRUGS?
5 A. THE LIST OF DRUGS IS DERIVED FROM MEDICATIONS WHICH WERE
6 ADMINISTERED TO ONE OR MORE OF THE FIVE PATIENTS IN THE
7 CASE.
8 Q. WHERE DID YOU GET THE INFORMATION REGARDING THE
9 PHARMACOLOGY IN THE ELDERLY AND SPECIAL CONSIDERATIONS?
10 A. THE PHARMACOLOGY IN THE ELDERLY IS DERIVED, AGAIN, FROM
11 THE GERIATRIC DOSAGE HANDBOOK AND THE P.D.R., WHERE
12 APPROPRIATE. THE SPECIAL CONSIDERATIONS ARE DERIVED FROM
13 THE GERIATRIC DOSAGE HANDBOOK AND THE P.D.R., WHERE
14 APPROPRIATE.
15 MS. BARLOW: YOUR HONOR, I'D MOVE FOR ADMISSION OF
16 STATE'S EXHIBIT 30.
17 MR. STIRBA: I'M GOING TO OBJECT. SELF-SERVING,
18 HEARSAY, AND HE'S HERE TO TESTIFY.
19 THE COURT: OKAY.
20 MS. BARLOW: FOR ILLUSTRATIVE --
21 THE COURT: ARE YOU OBJECTING THAT IT CAN BE USED
22 WHILE HE TESTIFIES?
23 MR. STIRBA: NO, I DON'T HAVE AN OBJECTION TO THAT.
24 THE COURT: OKAY. THEN GO AHEAD.
25 Q. (BY MS. BARLOW) LET'S JUST TALK ABOUT THE MORPHINE
2253
1 SULFATE. YOU HAVE DRUG NAME AND USE. WHAT'S THE USE OF
2 MORPHINE SULFATE?
3 A. IT'S USED AS A PAIN RELIEVER.
4 Q. AND PHARM -- WHAT DOES PHARMACOLOGY MEAN? I MEAN, WE
5 THROW THAT WORD AROUND HERE.
6 A. PHARMACOLOGY IS THE SCIENCE OF THE WAY A DRUG IS -- ITS
7 ACTIONS, ITS ADMINISTRATION, HOW LONG IT STAYS IN THE BODY,
8 THE WAY IT'S METABOLIZED, THE WAY IT'S EXCRETED, HOW IT
9 SHOULD BE USED, AND ANY SPECIAL PRECAUTIONS OR ADVERSE
10 EFFECTS. IT'S A SCIENCE OF THE STUDY OF DRUGS.
11 Q. THIS SAYS PHARMACOLOGY IN THE ELDERLY. WHAT IS --
12 WHAT -- WHAT IS MORPHINE SULFATE? WHAT IS THE PHARMACOLOGY
13 IN THE ELDERLY OF MORPHINE SULFATE?
14 A. MORPHINE SULFATE IS A NARCOTIC PAIN RELIEVER. MORPHINE
15 SULFATE, THE DESCRIPTION FROM THE REFERENCED TEXT AND MY OWN
16 EXPERIENCE IS THAT THE DURATION OF ACTION IS PROLONGED IN
17 THE ELDERLY. RELATIVE TO A YOUNG PERSON, THE AMOUNT OF TIME
18 THAT THE DRUG HAS ITS EFFECTS IN THE BODY, BOTH GOOD AND
19 BAD, IS PROLONGED.
20 Q. AND THEN SPECIAL CONSIDERATIONS IN THE ELDERLY?
21 A. THE -- THE GERIATRIC DOSAGE HANDBOOK SPECIFICALLY
22 STATES -- AND MY EXPERIENCE HAS BEEN -- THAT THE ELDERLY
23 GENERALLY HAVE MORE SUSCEPTIBILITY TO THE CENTRAL NERVOUS
24 SYSTEM DEPRESSANT EFFECTS OF THE NARCOTICS.
25 Q. WHAT'S THE CENTRAL NERVOUS SYSTEM?
2254
1 A. THE CENTRAL NERVOUS SYSTEM INCLUDES THE BRAIN AND THE
2 SPINAL CORD.
3 Q. AND WHAT DO YOU MEAN BY CENTRAL NERVOUS SYSTEM
4 DEPRESSANT EFFECT?
5 A. THE DEPRESSANT EFFECT, AS WE'VE TALKED EARLIER, WOULD BE
6 EXHIBITED BY SEDATION. OKAY. THAT WOULD BE THE PRESENCE OF
7 SLEEPINESS. BUT MORE IMPORTANTLY, THE -- THE CENTRAL
8 NERVOUS SYSTEM EFFECTS OF DEPRESSING VITAL SERVICES,
9 SERVICES TO MAINTAIN BLOOD PRESSURE, HEART RATE, AND
10 RESPIRATIONS.
11 Q. LET'S GO BACK TO ELLEN ANDERSON. I BELIEVE YOU'VE
12 TESTIFIED AS TO WHAT DRUGS WERE ACTUALLY ADMINISTERED TO
13 HER. IN YOUR EXPERT OPINION, WHAT WOULD BE THE EFFECT --
14 WELL, LET'S GO BACK.
15 YOU SAID THAT -- I THINK YOU SAID SOMETHING ABOUT
16 DOSAGE, ABOUT THE AMOUNT OF MORPHINE THAT WAS ADMINISTERED
17 TO ELLEN ANDERSON IN EACH SHOT. HOW MUCH WAS GIVEN IN EACH
18 SHOT?
19 A. FROM THE ADMINISTRATION RECORD, 10 MILLIGRAMS AT -- ON
20 DECEMBER 29TH AT 1930 AND 10 MILLIGRAMS ON DECEMBER 30TH AT
21 0330.
22 Q. WERE THOSE APPROPRIATE AMOUNTS?
23 A. NO.
24 Q. WHY NOT?
25 A. THEY WOULD HAVE BEEN TWO TO FOUR TIMES --
2255
1 MR. STIRBA: I'M GOING TO OBJECT, YOUR HONOR. HE'S
2 ALREADY TESTIFIED TO THIS. ASKED AND ANSWERED.
3 THE COURT: I THINK HE TESTIFIED ABOUT THE FIRST
4 ONE; I DON'T THINK ABOUT THE SECOND ONE. OVERRULED.
5 Q. (BY MS. BARLOW) SO WHY WERE THEY NOT APPROPRIATE?
6 A. IT WOULD HAVE BEEN ADMINISTERED AT TWO TO FOUR TIMES THE
7 USUAL STARTING DOSE FOR AN OLDER PERSON.
8 Q. NOW, THERE'S WHAT, FOUR HOURS BETWEEN THOSE TWO
9 ADMINISTRATIONS?
10 A. 1930 TO 0330 WOULD BE --
11 Q. EXCUSE ME. THAT'S --
12 A. -- SEVEN HOURS.
13 Q. SEVEN HOURS. THANK YOU.
14 A. IS THAT -- IS MY MATH CORRECT?
15 Q. I THINK SO. MINE IS INCORRECT.
16 BASED ON YOUR TRAINING, YOUR KNOWLEDGE OF THE P.D.R.
17 AND OF THE GERIATRIC DOSING, AND YOUR EXPERIENCE, WOULD HER
18 BODY HAVE EXCRETED OR HAVE -- WHAT WOULD BE THE EFFECT AT
19 THE TIME OF THE SECOND DOSE STILL IN THE BODY OF THE FIRST
20 DOSE?
21 A. WELL, IT IS MY EXPECTATION THAT --
22 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT.
23 IT'S -- IT CALLS FOR SPECULATION. WE HAVE THE RECORDS OF
24 THIS PATIENT.
25 MS. BARLOW: YOUR HONOR, BUT THIS IS THE EFFECT AND
2256
1 THERE'S NOTHING IN THE RECORDS OF -- BASED ON WHAT HE'S
2 TESTIFIED TO AS WHAT THESE DRUGS DO AS FAR AS DURATION OF
3 EFFECT. AND THAT'S WHAT I'M -- WILL NOT BE FOUND IN THE
4 RECORD.
5 THE COURT: OKAY. WELL, THEN -- OKAY. WHY DON'T
6 YOU GO ON TO SOMETHING ELSE AND WE'LL DISCUSS THIS AT THE
7 NOON HOUR.
8 Q. (BY MS. BARLOW) YOU TALKED ABOUT DOSES. WERE THESE --
9 THE ADMINISTRATION OF THESE TWO SHOTS APPROPRIATE TREATMENT
10 OF ELLEN ANDERSON?
11 A. NO.
12 Q. WHY NOT?
13 A. I HAVE NO INFORMATION FROM DR. WEITZEL'S OWN NOTES
14 RELATIVE TO A DIAGNOSIS FOR ADMINISTERING THIS MEDICATION TO
15 THIS PATIENT.
16 Q. DID YOU FORM AN OPINION BASED ON YOUR REVIEW OF THE
17 RECORDS AND ON YOUR -- YOUR EXPERTISE, DID YOU FORM AN
18 OPINION AS TO A DEGREE OF MEDICAL CERTAINTY AS TO WHAT
19 CAUSED THE DEATH OF ELLEN ANDERSON?
20 A. YES.
21 Q. WHAT IS THAT OPINION?
22 A. IT'S MY OPINION THAT ELLEN ANDERSON'S DEATH RESULTED
23 FROM LACK OF BLOOD PRESSURE, LACK OF RESPIRATIONS AFTER THE
24 ADMINISTRATION OF THE MORPHINE SULFATE.
25 Q. AND WHAT CAUSED THE LACK OF BLOOD PRESSURE AND THE LACK
2257
1 OF RESPIRATIONS?
2 A. THE MORPHINE SULFATE ACTIONS ON THE CENTRAL NERVOUS
3 SYSTEM TO SUPPRESS THE BREATHING CENTER AND SUPPRESS THE
4 BODY'S ABILITY TO GENERATE A BLOOD PRESSURE AND A HEART
5 BEAT.
6 Q. IS DELIRIUM A TERMINAL ILLNESS?
7 A. PEOPLE WHO ARE DELIRIOUS CAN DIE.
8 Q. DO THEY DIE FROM DELIRIUM?
9 A. NO.
10 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT.
11 RELEVANCY.
12 THE COURT: OKAY. IT'S BEEN ANSWERED. MOVE ON.
13 Q. (BY MS. BARLOW) WHAT ABOUT DEMENTIA? IS IT A TERMINAL
14 ILLNESS?
15 A. YES.
16 MS. BARLOW: MAY I HAVE THIS MARKED?
17 Q. (BY MS. BARLOW) WHILE MR. STIRBA IS LOOKING AT THAT,
18 FROM YOUR REVIEW OF THE RECORDS AND YOUR EXPERIENCE, DID
19 ELLEN ANDERSON SUFFER FROM DEMENTIA WHILE SHE WAS AT DAVIS
20 NORTH?
21 A. YES.
22 Q. WAS HER DEMENTIA TERMINAL AT THE TIME SHE WAS AT DAVIS
23 NORTH?
24 A. NO.
25 Q. WHAT IS THAT OPINION BASED ON?
2258
1 A. THAT OPINION IS BASED ON THE MEDICAL LITERATURE. IN
2 PARTICULAR IT'S BASED ON STUDIES PUBLISHED TO HELP DEFINE
3 THE COURSE OF THE ILLNESS AND THE PRESENCE OF THE TERMINAL
4 STATE TO ASSIST PHYSICIANS AND HOSPICE AGENCIES, IN
5 PARTICULAR, IN PROVIDING PALLIATIVE CARE IN THE TERMINAL
6 STATE. IT'S BASED ON MY OWN EXTENSIVE EXPERIENCE.
7 Q. IS THERE A PROGRESSION TO DEMENTIA?
8 A. YES.
9 Q. IS IT CONSISTENT?
10 A. EACH PERSON WITH DEMENTIA IS AN INDIVIDUAL. EACH
11 PERSON'S DEMENTIA IS RELATIVELY CONSISTENT INTERNALLY. WHAT
12 I TELL FAMILIES IS THAT YOU GET MORE OF WHAT YOU'VE HAD. IF
13 THE DISEASE HAS BEEN RAPIDLY PROGRESSIVE, THEN IT TENDS TO
14 CONTINUE TO BE RAPIDLY PROGRESSIVE. IF THE DISEASE HAS BEEN
15 STABLE AND SLOW IN ITS PROGRESSION, IT TENDS TO STAY THE
16 SAME.
17 Q. FROM YOUR REVIEW OF ELLEN ANDERSON'S RECORDS, DO YOU
18 KNOW WHETHER HERS WAS RAPID OR SLOW?
19 MR. STIRBA: YOUR HONOR, I'M GOING -- I'M GOING TO
20 OBJECT. NO NOTICE, NOT IN REPORT, AND I THINK WE'RE
21 ENTITLED TO HAVE THAT. THIS IS BEYOND THE SCOPE OF THAT
22 REPORT.
23 THE COURT: OKAY. WHY DON'T WE GO ON TO SOMETHING
24 ELSE AND TAKE THAT UP AT THE NOON HOUR.
25 MS. BARLOW: MAY I APPROACH THE WITNESS, YOUR
2259
1 HONOR?
2 THE COURT: YES.
3 Q. (BY MS. BARLOW) SHOW YOU WHAT'S BEEN MARKED STATE'S
4 EXHIBIT 33. HAVE YOU SEEN THIS CHART BEFORE?
5 A. YES. THIS CHART WAS PREPARED BY MYSELF AND PLACED ON
6 THIS BOARD AT MY REQUEST, MEANT TO SERVE THE PURPOSE OF
7 HELPING THE JURY TO UNDERSTAND THE TYPICAL TIME COURSE OF
8 ALZHEIMER'S DISEASE AND SPECIFICALLY UNDERSTAND THE
9 TESTIMONY I'M GOING TO GIVE RELATIVE TO WHETHER THESE
10 PATIENTS WERE TERMINALLY ILL OR NOT.
11 Q. WHERE DID YOU GET THIS INFORMATION?
12 A. THIS INFORMATION IS DERIVED FROM THE NATIONAL HOSPICE
13 ORGANIZATIONS HOSPICE CARE PHYSICIAN'S GUIDE. IT'S A MANUAL
14 HOSPICE ORGANIZATION PUTS OUT.
15 Q. WHAT IS -- WHAT IS HOSPICE?
16 A. HOSPICE IS A -- AS A TERM MEANS THAT THE ORGANIZATION OR
17 THE PROCESS OR THE PHILOSOPHY OF CARING FOR PEOPLE WHO ARE
18 TERMINALLY ILL. IT'S ALSO DERIVED FROM FUNCTIONAL
19 ASSESSMENT AND STAGING BY BARRY REISBERG. THIS WAS
20 PUBLISHED AND IS REFERENCED ON THE -- THE MATERIALS. AND
21 FINALLY IT'S FROM THE OXFORD TEXTBOOK OF PALLIATIVE MEDICINE
22 WHERE IT'S ALSO REFERENCED AND INCLUDED.
23 Q. IS THIS ACCEPTED -- GENERALLY ACCEPTED BY THE MEDICAL
24 COMMUNITY AS ACCURATE INFORMATION?
25 A. IT'S NOT ONLY ACCEPTED BY THE MEDICAL COMMUNITY, IT'S
2260
1 USED BY THE GOVERNMENT IN MEDICARE IN HELPING TO DETERMINE
2 WHETHER A PATIENT IS APPROPRIATELY REFERRED FOR HOSPICE
3 SERVICES UNDER THE MEDICARE PROGRAM.
4 MS. BARLOW: YOUR HONOR, I WOULD MOVE FOR ADMISSION
5 OF STATE'S EXHIBIT 33.
6 MR. STIRBA: SAME OBJECTION AS BEFORE AS TO ANY
7 TESTIMONY ABOUT THE EXHIBIT. NO NOTICE, NO REPORT, BEYOND
8 THE SCOPE OF THIS EXPERT.
9 THE COURT: OKAY. SO ARE YOU SAYING WITH THAT YOU
10 DON'T WANT IT USED AS ILLUSTRATIVE?
11 MR. STIRBA: YES, THIS WHOLE AREA I -- I WOULD LIKE
12 TO ADDRESS WITH THE COURT.
13 THE COURT: OKAY. ALL RIGHT. LADIES AND
14 GENTLEMEN, I THINK WHAT WE'LL DO IS WE HAVE SOME THINGS THAT
15 WE NEED TO DISCUSS AND WE'RE ABOUT FIVE MINUTES TO NOON. SO
16 I THINK WHAT I'LL DO IS HAVE YOU TAKE YOUR LUNCH BREAK NOW
17 AND COME BACK AT 1:30.
18 DURING THE TIME THAT YOU ARE AWAY, REMEMBER, DO NOT
19 CONVERSE EITHER AMONG YOURSELVES OR WITH ANYONE ELSE
20 REGARDING THE SUBJECT OF THIS TRIAL. ALSO, DO NOT FORM OR
21 EXPRESS AN OPINION UNTIL THE CASE IS FINALLY SUBMITTED TO
22 YOU.
23 AGAIN, DON'T LISTEN TO RADIO, TELEVISION REPORTS, OR
24 ANY NEWSPAPER, MAGAZINE, OR INTERNET REPORTS REGARDING THIS
25 TRIAL. AND WE'LL SEE YOU BACK AT 1:30.
2261
1 (WHEREUPON, THE JURY LEAVES THE COURTROOM.)
2 THE COURT: OKAY. THE RECORD WILL REFLECT THAT THE
3 JURY HAS LEFT AND EVERYONE CAN BE SEATED.
4 OKAY. I HAVEN'T BEEN ABLE TO KEEP SCORE OF ALL OF THE
5 POINTS THAT WE'RE MAKING AS WE WENT ALONG SO --
6 MS. BARLOW: THE SCORE'S ONE TO NOTHING.
7 THE COURT: NOW, WHICH ORDER DO YOU WANT TO GO IN
8 TERMS OF -- I MEAN, THERE WERE -- THERE WERE SOME POINTS I
9 THINK BEFORE WE GOT TO THIS LAST ISSUE AND THE -- THE
10 QUESTIONS IMMEDIATELY BEFORE THE CHART.
11 MR. STIRBA: CAN -- CAN WE GO IN REVERSE ORDER?
12 THE COURT: WHATEVER IS --
13 MS. BARLOW: THAT'S FINE WITH ME, YOUR HONOR.
14 THE COURT: WHICHEVER IS AGREEABLE.
15 MS. BARLOW: THAT'S FINE.
16 THE COURT: OKAY. SO THE -- OKAY. GO AHEAD THEN.
17 AND THAT RELATES TO PLAINTIFF'S EXHIBIT 33 AND THE QUESTIONS
18 THAT WERE BEING ASKED ABOUT THAT ISSUE.
19 MR. STIRBA: YEAH. THE PROBLEM I HAVE IS THAT WE
20 HAVE THE REPORT FROM DR. FEHLAUER, HAVE IT RIGHT HERE. AND
21 THERE'S NOTHING IN HERE THAT TELLS ME THAT HE WAS GOING TO
22 TESTIFY AS AN EXPERT CONCERNING ALZHEIMER'S DISEASE, THE
23 DETERIORATION OF DEMENTIA. HE WAS GOING TO REFER TO SOME
24 KIND OF F.A.S. STAGE OR F.A.S. SUBSTAGE OR ANY OF THESE
25 AREAS.
2262
1 AND, YOU KNOW, I'LL TELL YOU WHAT THE PROBLEM IS,
2 JUDGE. THEY HAVE OUR HOSPICE EXPERT'S REPORT, AND IN THERE
3 SHE'S VERY, VERY SPECIFIC. IT'S ABOUT A FOUR OR FIVE PAGE
4 REPORT WHERE SHE TELLS THEM EXACTLY THE SOURCES OF HER -- OF
5 HER OPINION. SHE HAS A COMPLETE CALCULATION, WHICH IS
6 SOMEWHAT RELATED TO THIS, QUITE FRANKLY. AND SHE TELLS THEM
7 EVERYTHING THAT SHE'S GOING TO TESTIFY TO IN THIS TRIAL.
8 THERE'S NONE OF THIS IN THIS GENTLEMAN'S REPORT. IN
9 FACT, HIS -- HIS REPORT IS FAIRLY CURSORY. I THINK I'VE
10 SHOWED IT TO YOUR HONOR BEFORE. AND THERE'S NONE OF THIS IN
11 HERE. AND IT SEEMS TO ME IT'S PRETTY CLEAR WHAT WE HAVE IS
12 NOW THEY WANT TO HAVE SOMEBODY RESPOND ESSENTIALLY TO WHAT
13 OUR HOSPICE EXPERT PROVIDED. AND, YOU KNOW, TACTICALLY THAT
14 MIGHT BE FINE. BUT GUESS WHAT? THE RULES OF THE GAME ARE
15 EXPERT REPORTS WERE DUE ON THE 5TH OF MAY. AND IF IT'S
16 ESSENTIALLY NOT IN THOSE EXPERT REPORTS, YOU CAN'T TESTIFY
17 TO IT.
18 AND I HAVE NEVER SEEN ANY OF THIS BEFORE. I HAD NO
19 IDEA THAT HE WAS GOING TO TESTIFY TO THIS. IN FACT, I'LL
20 TELL YOU, THE ONLY THING REALLY HE SAYS IN HIS REPORT --
21 IT'S PRETTY MUCH -- IT'S BASICALLY THE SAME IN EVERY ONE.
22 HE TALKS ABOUT HE FINDS A DIAGNOSIS OF DELIRIUM WITH RESPECT
23 TO EVERY ONE OF THESE PATIENTS. THEN HE GOES ON TO SAY A
24 COUPLE OF THINGS ABOUT HOW DR. WEITZEL DIDN'T DO WHAT HE WAS
25 SUPPOSED TO DO. AND THEN HE FINALLY SAYS, BASICALLY, WHAT
2263
1 HIS OPINION IS AS TO CAUSE OF DEATH. THAT'S IT.
2 HE DOESN'T TALK ABOUT ALZHEIMER'S. DOESN'T TALK ABOUT
3 THIS. DOESN'T TALK ABOUT ANY OF THIS ANALYSIS OF DEMENTIA,
4 THE PROGRESSIVE STAGES OF DEMENTIA, WHETHER ALZHEIMER'S IS
5 TERMINAL, WHETHER DEMENTIA IS TERMINAL. I MEAN, THIS --
6 THIS IS COMPLETELY BEYOND THE SCOPE OF HIS REPORT.
7 AND I -- I WOULD REPEAT IT AGAIN BECAUSE IT'S A -- IT'S
8 A PATTERN AND IT'S VERY DIFFICULT. YOU KNOW, WE -- WE GOT
9 TO DO A TRIAL BASED UPON THE RULES THAT ARE SET WELL BEFORE
10 THIS. WE'VE TRIED TO COMPLY WITH THOSE RULES AND OUR EXPERT
11 REPORTS ARE VERY THOROUGH, AND QUITE FRANKLY, MAYBE TOO
12 THOROUGH FOR OUR OWN GOOD BECAUSE THEY'RE VERY COMPLETE.
13 THIS GENTLEMAN'S IS VERY CURSORY, VERY SIMPLE, AND VERY
14 LACKING IN INFORMATION. BUT I TOLD YOU GENERALLY WHAT HE
15 HAS IN HERE. AND THAT'S GENERALLY WHY I DIDN'T OBJECT ON
16 THE DELIRIUM THING 'CAUSE LEAST HE SAYS SOMETHING ABOUT
17 DELIRIUM IN HERE, IN TERMS OF BEING BEYOND THE SCOPE OF HIS
18 REPORT. HE DOES INDICATE A CAUSE OF DEATH IN HERE, AND HE
19 HAS SOME OTHER THINGS IN HERE ABOUT DR. WEITZEL'S CONDUCT.
20 AND, ALSO, THEY HAVE TOLD ME THAT HE WAS GOING TO
21 TESTIFY ABOUT SOME MEDICATIONS, AND HE HAS SOME REFERENCE TO
22 SOME MEDICATIONS IN A VERY GENERAL WAY HERE. BUT THIS, THIS
23 IS A WHOLE OTHER AREA FOR WHICH THERE'S NOTHING THAT YOU CAN
24 GLEAN OUT OF THIS REPORT CONCERNING IT.
25 AND -- AND IF I COULD, MAY I JUST GIVE YOU THIS, JUDGE?
2264
1 THE COURT: YES.
2 MR. STIRBA: BECAUSE IT MAY HELP TO SEE WHAT I'M
3 TALKING ABOUT.
4 THE COURT: OKAY. MISS BARLOW?
5 MS. BARLOW: YOUR HONOR, THE C.V. PROVIDED FOR
6 DR. FEHLAUER INDICATES THAT HE IS A GERIATRIC SPECIALIST.
7 THIS IS AN AREA OF GERIATRICS THAT -- I MEAN, I DON'T THINK
8 IT'S ANY SURPRISE THAT DEMENTIA IS PART OF A GERIATRICS
9 SPECIALTY.
10 THE COURT: WELL, I -- THE C.V. ISN'T THE ISSUE.
11 THE ISSUE IS --
12 MS. BARLOW: WELL, BUT --
13 THE COURT: -- WHETHER OR NOT THERE'S A REPORT --
14 IS IT IN THE REPORT OR NOT BECAUSE IF A PERSON HAS THAT
15 BACKGROUND, THAT'S WHAT A C.V. SAYS. IT SAYS WHAT'S THEIR
16 BACKGROUND. A C.V., JUST BECAUSE A PERSON DEALS WITH
17 GERIATRICS, DOESN'T MEAN THAT HE'S GOING TO COME IN HERE AND
18 GIVE A TESTIMONY ABOUT THIS ASPECT OF ALZHEIMER'S DISEASE.
19 I MEAN, THAT'S --
20 MS. BARLOW: YOUR HONOR, HE IS -- HE IS AN EXPERT
21 WHO WE -- WE BROUGHT HIM HERE TO TRY TO EDUCATE THE JURY.
22 THE WORD DEMENTIA HAS BEEN THROWN AROUND AND USED A LOT.
23 THE COURT: WELL, HE'S -- HE'S TESTIFIED ABOUT
24 THAT.
25 MS. BARLOW: RIGHT.
2265
1 THE COURT: I MEAN, HE'S DESCRIBED WHAT DEMENTIA
2 IS. HE'S DESCRIBED WHAT DELIRIUM IS. HE'S PROBABLY GONE
3 MORE -- AND IF THERE WOULD HAVE BEEN AN OBJECTION SAYING,
4 YOU KNOW, JUST ANSWER THE DIRECT QUESTION, HE GIVES -- YOU
5 KNOW, HE'S TAUGHT THEM.
6 MS. BARLOW: RIGHT.
7 THE COURT: THERE'S NO QUESTION ABOUT THAT. BUT, I
8 MEAN, THE OBJECTION IS WHETHER OR NOT THIS IS BEYOND THE
9 SCOPE OF WHAT'S IN HIS REPORT OR -- OR WERE THEY GIVEN
10 NOTICE THAT THIS WAS IN THIS REPORT.
11 MS. BARLOW: HE DIDN'T USE THE WORD DEMENTIA, I
12 AGREE. HE DIDN'T SAY ANYTHING ABOUT THIS CHART IN HIS
13 REPORT, I AGREE. AND IF THAT IS WHAT THE OBJECTION IS THEN
14 WE CERTAINLY CANNOT -- WE CAN CERTAINLY NOT GET INTO THIS
15 MATERIAL AT THIS POINT. I THINK THAT IT WOULD BE HELPFUL
16 FOR THE JURY TO KNOW, BUT, YOU KNOW, WE AT THIS TIME I GUESS
17 CAN GIVE THE DEFENDANT NOTICE THAT WE WOULD LIKE TO HAVE HIM
18 TALK ABOUT THIS MATERIAL. WE CAN HAVE HIM DO IT LATER ON
19 TOWARDS THE END OF HIS -- TOWARDS THE END OF HIS TESTIMONY.
20 THE REMEDY, AS IT WERE, IF THE -- IF MATERIAL SOMEHOW
21 WAS NOT DIVINED OR -- OR WAS NOT GIVEN OR WHATEVER, IS TO
22 ALLOW TIME FOR PREPARATION. IT IS NOT TO EXCLUDE THE
23 EVIDENCE. AND I'M NOT ASKING --
24 THE COURT: WELL, DO YOU AGREE -- DO YOU AGREE
25 THAT -- THAT COMMENT MAY BE IF IT'S BEFORE TRIAL THAT THE
2266
1 REMEDY IS LIKE THAT. BUT WE HAD SOME OF THE MOTIONS BEFORE
2 TRIAL. I REMEMBER SPECIFICALLY ONE OF THOSE 25 MOTIONS IN
3 LIMINE THAT WE ARGUED THE WEEK -- THE TWO WEEKS BEFORE THE
4 TRIAL. ONE OF THOSE WAS THAT VERY ISSUE. AND I ASKED THE
5 DEFENDANT, OKAY, DO YOU NEED MORE TIME ON THAT OR NOT?
6 BECAUSE THAT WAS THE APPROPRIATE THING. BUT WHEN WE'RE IN
7 THE MIDDLE OF A TRIAL THAT HAS BEEN GOING ON NOW FOR TWO OR
8 THREE WEEKS, AND THEN WE SAY HERE IS SOMETHING THAT WAS
9 SUPPOSED TO BE GIVEN 30 DAYS BEFORE THE TRIAL, WHICH WAS
10 MAY 5TH GOING TO JUNE 5TH. IT WASN'T GIVEN. AND THEN SAY,
11 OKAY, NOW THE RESULT IS -- WE'RE GOING TO TELL YOU -- WE'RE
12 GIVING YOU NOTICE NOW, AND THE RULES SAY HE GETS 30 DAYS TO
13 RESPOND. DO WE JUST PUT THIS TRIAL ON HOLD OR WHAT DO WE
14 DO?
15 MS. BARLOW: WELL, YOUR HONOR, THERE IS CASE LAW
16 THAT SAYS IF -- IF THERE IS UNFAIR SURPRISE IN THE MIDDLE OF
17 A TRIAL THAT THAT IS ONE OF THE REMEDIES.
18 THE COURT: WELL, THE OTHER REMEDY IS NOT TO ALLOW
19 IT.
20 MS. BARLOW: I RECOGNIZE THAT. BUT I -- AND, YOUR
21 HONOR, THERE IS NO INTENTION OR BAD FAITH ON THE PART OF THE
22 STATE NOT TO -- NOT TO GIVE NOTICE. I GUESS WE ASSUMED THAT
23 SINCE WE'RE TALKING ABOUT DEMENTED PEOPLE IT WOULDN'T BE A
24 TERRIBLE SURPRISE THAT WE MIGHT TALK ABOUT DEMENTIA. AND
25 MAYBE IT'S JUST ONE OF THOSE THINGS THAT'S SO BASIC WE
2267
1 ASSUMED THAT WE DIDN'T HAVE TO PUT IN ANY REPORT.
2 THE COURT: WELL, TALKING ABOUT DEMENTIA IS
3 DIFFERENT THAN THIS EXHIBIT, PLAINTIFF'S EXHIBIT 33, THAT
4 BASICALLY SAYS YEARS TO DEATH, WHETHER THERE'S A F.A.S.
5 STAGE OR SOMETHING ELSE. NOW, THAT'S DIFFERENT THAN TALKING
6 ABOUT DEMENTIA AND HOW IT CAN PROGRESS AND WHAT HE'S ALREADY
7 TESTIFIED THAT IF IT WAS -- IF IT'S BEEN A SLOW ONSET, IT
8 WILL CONTINUE SLOW. IF IT'S BEEN A QUICKER ONSET, IT WILL
9 CONTINUE QUICK. THAT'S ONE ISSUE.
10 THE OTHER ISSUE IS -- IS THIS, YOU KNOW, AND SO -- SO
11 WHAT IS YOUR RESPONSE THEN IN TERMS OF HIS OBJECTION IS --
12 IS YOU'RE SAYING WE SHOULD TAKE A BREAK IN THE TRIAL, IF HE
13 NEEDS MORE TIME?
14 MS. BARLOW: WELL, YOU KNOW, I CAN'T, OF COURSE,
15 SPEAK FOR MR. STIRBA.
16 THE COURT: WELL, NO, I'M NOT ASKING YOU TO SPEAK
17 FOR HIM. I'M ASKING YOU TO SAY WHAT -- WHAT -- EITHER -- I
18 THINK THERE'S TWO -- TWO WAYS TO DO THIS. ONE IS TO SAY,
19 YOU KNOW, YES, WE TOLD HIM ABOUT THIS AND HE WAS ON NOTICE
20 ABOUT THIS AND IT'S IN THE REPORT, OR HE SHOULD HAVE KNOWN
21 OR WHATEVER ELSE. OR IT'S NOT IN THE REPORT AND WE'RE
22 GIVING HIM NOTICE NOW AND WE GAVE HIM NOTICE YESTERDAY WHEN
23 WE SHOWED THE ONE EXHIBIT.
24 WAS THIS ONE OF THE EXHIBITS THAT WAS SHOWN YESTERDAY?
25 MS. BARLOW: YES. YES.
2268
1 MR. STIRBA: NO, NO. THAT HAS NEVER BEEN SEEN
2 UNTIL RIGHT NOW IN THIS COURTROOM BY ME.
3 MS. BARLOW: I'M SORRY, YOUR HONOR. I THOUGHT WE
4 BROUGHT THEM ALL IN LAST NIGHT, DIDN'T WE?
5 MR. STIRBA: IN FACT, THESE HAVEN'T BEEN SEEN
6 EITHER, BUT I -- YOU KNOW, I MEAN THE ONE HAS. THE DELIRIUM
7 THING WAS THERE YESTERDAY, BUT THE REST OF THEM IT'S ALL
8 FIRST TODAY.
9 MS. BARLOW: EXCUSE ME. YES. YES, YOUR HONOR.
10 MR. STIRBA: AND THAT'S ALSO PART OF THE PROBLEM.
11 THE COURT: WHETHER IT WAS -- WHETHER IT WAS
12 YESTERDAY OR TODAY, IT'S WITHIN 24 HOURS.
13 MS. BARLOW: YES.
14 THE COURT: OKAY. SO THEN WHAT -- WHAT IS YOUR
15 POSITION?
16 MS. BARLOW: YOUR HONOR, I WOULD ASK THAT WE BE
17 ALLOWED -- OKAY. WE WON'T TALK ABOUT THIS CHART NOW. WE
18 CAN BRING IT UP AT THE END OF HIS TESTIMONY, OR WE COULD
19 PERHAPS BRING IT IN IN REBUTTAL WHICH WOULD GIVE DEFENDANT
20 TIME TO DO WHATEVER PREPARATION HE NEEDS IN THIS ARENA
21 WITHOUT HAVING TO SEND THE JURY HOME FOR A DAY OR TWO OR
22 HOWEVER LONG IT TAKES.
23 THE COURT: OKAY. WHAT IS YOUR RESPONSE?
24 MR. STIRBA: WELL, IT'S -- THAT'S ABSURD. I MEAN,
25 FIRST OF ALL, WE'RE NOT TALKING ABOUT THE RULE. WE'RE
2269
1 TALKING ABOUT THE COURT'S SCHEDULING ORDER. AND I READ HILL
2 VERSUS DICKINSON QUITE CLEARLY. AND THE COURT HAD A
3 SCHEDULING ORDER. THEY DIDN'T DO WHAT THEY WERE SUPPOSED TO
4 DO, THE REMEDY IS TO EXCLUDE IT. WE'RE RIGHT IN THE MIDDLE
5 OF TRIAL AND I DON'T UNDERSTAND THIS CONCEPT THAT SOMEHOW
6 NOW THE DEFENSE TEAM'S GOING TO FIGURE OUT IN SIX HOURS HOW
7 TO DEAL WITH ALL THIS. THAT'S COMPLETELY IMPRACTICAL.
8 I THINK IT'S VERY SIMPLE. IT JUST DOESN'T COME IN.
9 THAT'S THE ONLY FAIR WAY TO DEAL WITH IT. AND I FULLY
10 EXPECT THAT IF THERE'S ANY PROBLEM WITH OUR WITNESSES IN THE
11 SAME VEIN, I WOULD FULLY EXPECT THAT WILL BE PRECISELY THE
12 REMEDY OF THE COURT AS WELL. AND I -- I CAN ASSURE YOU THAT
13 THAT ISN'T GOING TO HAPPEN.
14 THE COURT: WELL, I -- I BELIEVE IN THE RULE OF THE
15 GOOSE AND THE GANDER.
16 MR. STIRBA: SURE.
17 THE COURT: WHATEVER IS GOOD FOR ONE SIDE IS GOING
18 TO BE CONSISTENT FOR BOTH. IT'S NOT GOING TO BE ONE WAY FOR
19 ONE AND ONE FOR THE OTHER.
20 MR. STIRBA: AND SO THAT'S -- THAT'S -- THAT'S -- I
21 MEAN, YOU KNOW, IT CAN'T. I MEAN, YOU KNOW, YOU PREPARE
22 THESE REPORTS. AND I'LL TELL YOU, JUDGE, IT'S VERY SIMPLE.
23 IT'S TRUE. AFTER -- AFTER THE REPORTS ALL COME IN AND I'M
24 SURE THE TRIAL STARTS, PEOPLE THINK GEE, I WISH THAT WAS IN
25 THE REPORT. GEE, I WISH OUR EXPERT COULD GO IN THIS AREA.
2270
1 BUT YOU KNOW WHAT? THE RULE'S THE RULE. I HAVE THE
2 SAME PROBLEM. DON'T YOU THINK I'M LOOKING AT OUR EXPERTS
3 AND SAYING, WELL, GEE, MAYBE THEY COULD TALK ABOUT THIS OR
4 MAYBE I SHOULD HAVE COVERED THAT. BUT GUESS WHAT? WATER
5 UNDER THE BRIDGE. THE COURT HAD A SCHEDULING ORDER, IT IS
6 WHAT IT IS. WE ALL HAVE TO LIVE WITH IT. THAT'S BASICALLY
7 WHAT WE GOT HERE.
8 THE COURT: ALL RIGHT. OKAY. FINAL WORD, MISS
9 BARLOW?
10 MS. BARLOW: I'LL SUBMIT IT, YOUR HONOR.
11 THE COURT: OKAY. THIS IS WHAT I'M GOING TO DO.
12 FIRST OF ALL, WHEN THIS CASE GOT STARTED WE BASICALLY GOT
13 TOGETHER AFTER WE HAD AN ARRAIGNMENT. WELL, THERE WAS A
14 PRELIMINARY HEARING, THEN THERE WAS AN ARRAIGNMENT. AFTER
15 THE ARRAIGNMENT THERE WAS A SCHEDULING CONFERENCE. THE
16 ARRAIGNMENT WAS HERE AND THE SCHEDULING CONFERENCE WAS AT
17 THE COURT IN LAYTON THAT I'M USUALLY AT. AND AT THAT POINT
18 WE TALKED ABOUT THE LENGTH OF TIME THAT WE NEEDED. THERE
19 WAS A DISCUSSION ABOUT, YOU KNOW, WHETHER WE NEEDED A YEAR
20 FROM NOW TO PUT ON THE CASE OR WHETHER THAT WAS GOING TO BE
21 A SPEEDY TRIAL. WE SET THE TRIAL WHEN WE DID; I SET THE
22 SCHEDULE WHEN WE DID.
23 ONE OF THE THINGS THAT I HAVE NOTICED THROUGHOUT THIS
24 TRIAL IS THAT I HAVE BASICALLY HANDLED ALL THE MOTIONS IN
25 LIMINE, 25 OF THEM BEFORE THIS CASE STARTED. I RULED ON
2271
1 EVERY ONE OF THOSE SO PEOPLE COULD KNOW WHERE WE WERE GOING
2 WITH THE CASE. I HAVE COME HERE NEARLY EVERY DAY OF THIS
3 TRIAL AND HAD TO DEAL WITH ISSUE UPON ISSUE UPON ISSUE.
4 AND -- AND SOMETIMES THOSE ISSUES ARISE, BUT SOMETIMES --
5 AND I'M GETTING TO THE POINT WHERE I DON'T THINK A LOT OF
6 THESE THINGS EITHER COULD HAVE BEEN ANTICIPATED OR DEALT
7 WITH.
8 BUT I'M GOING TO SAY THIS RIGHT NOW. I'M GOING ON THE
9 EXPERT REPORTS, AND IF IT'S NOT IN THE EXPERT REPORTS, IT'S
10 NOT GOING TO BE IN HERE. AND IF I HEAR ONE MORE TIME THAT
11 SOMETHING HASN'T BEEN SHOWN THAT HAD AN OBLIGATION TO BE
12 SHOWN, LIKE AS IT RELATED TO AN EXPERT, WHAT THEIR TESTIMONY
13 WAS GOING TO BE, THE RESULT IS GOING TO BE THAT THAT EXPERT
14 WILL NOT TESTIFY ABOUT THAT. THAT'S GOING TO HAPPEN FOR THE
15 PLAINTIFF; IT'S GOING TO HAPPEN FOR THE DEFENDANT.
16 BUT I'M NOT GOING TO REINVENT AND ARGUE EACH ONE OF
17 THESE ISSUES. I'LL GIVE YOU AN EXAMPLE OF AN ISSUE THAT
18 WE'VE REARGUED THREE OR FOUR TIMES. WE GET AN ISSUE ABOUT
19 WHETHER A TREATER IS GOING TO TESTIFY ABOUT AN EXPERT
20 OPINION. THE FIRST TIME THAT THAT WAS BROUGHT UP I SAID
21 OKAY. IT'S GOING TO BE CUMULATIVE AND IF YOU WANT TO GIVE
22 UP ONE OF YOUR EXPERTS FOR THAT, THAT WILL BE FINE.
23 THEN THE NEXT ISSUE THAT CAME UP WAS, OKAY, WHAT ABOUT
24 THIS -- RAISED THE ISSUE AND THE ISSUE WAS THAT WE DON'T
25 HAVE AN EXPERT REPORT. SO I THEN RULED THAT IF THEY DON'T
2272
1 HAVE AN EXPERT REPORT, THEY'RE NOT GIVING EXPERT OPINION.
2 THEN I HAD IT BROUGHT UP A THIRD OR A FOURTH TIME THAT VERY
3 ISSUE.
4 I AM NOT GOING TO KEEP REDOING THE SAME ISSUES FOUR OR
5 FIVE TIMES. IF I MAKE A RULING -- FROM NOW ON, IF I'VE MADE
6 A RULING, THEN I'M NOT GOING TO TAKE A BREAK AND SEND THE
7 JURY OUT. THERE'S GOING TO BE AN OBJECTION. YOU CAN MAKE
8 YOUR RESPONSE. I'M GOING TO RULE.
9 BUT I AM GOING TO STATE THAT THINGS THAT ARE NOT IN
10 REPORTS -- YOU KNOW, THAT WEREN'T IN REPORTS, AND THIS THING
11 SPECIFICALLY, IS NOT COMING INTO EVIDENCE -- PLAINTIFF'S
12 EXHIBIT 33. THIS WITNESS IS NOT GOING TO TESTIFY ABOUT THIS
13 IN THE CASE-IN-CHIEF. AND IF ANY OF THE OTHER ONES ARE THE
14 SAME THING, I BELIEVE FIRMLY THAT PEOPLE WHO ARE PREPARED
15 AND READY TO GO SHOULD NOT BE PREJUDICED BY PEOPLE WHO DO
16 NOT OBEY THE RULES. NOW, WHAT I MEAN BY THAT IS IF SOMEBODY
17 DOES THE RULES AND SOMEBODY DOESN'T DO THE RULES, THEN THE
18 RESPONSE IS WELL, THAT PERSON SHOULD JUST HAVE MORE TIME.
19 THIS CASE HAS BEEN -- WE'VE BEEN GOING FOR THREE WEEKS.
20 THIS CASE HAS BEEN SET FOR AN ENORMOUS PERIOD OF TIME. I
21 HAD TO GET EVERY ONE OF MY CASES REASSIGNED TO OTHER JUDGES
22 SO I COULD DO THIS FOR SIX -- FIVE OR SIX WEEKS OR EIGHT
23 WEEKS, HOWEVER LONG IT TOOK. AND TO SEND THE JURY OUT RIGHT
24 NOW AND TO GIVE A DEFENDANT FIVE DAYS OR FIVE HOURS TO DO
25 THIS WHEN THE RULES GIVE HIM 30, THAT'S WHAT'S GOING TO
2273
1 HAPPEN.
2 AND SO IF -- IF WE COME UP WITH ANOTHER CHART WITH
3 ANOTHER EXPERT AND IT'S NOT IN THEIR REPORT, ALL YOU'RE
4 GOING TO HAVE TO SAY IS IT'S NOT IN THE REPORT. AND IF WE
5 HAVE TO -- SOMEBODY GIVE ME THE REPORTS IN ADVANCE SO THAT I
6 CAN RULE UPON THAT BECAUSE I'M NOT GOING TO KEEP TAKING
7 BREAKS.
8 I MEAN, TODAY WAS A PERFECT EXAMPLE. WE HAVE -- YOU
9 KNOW, THERE ARE -- A LOT OF THESE ISSUES ARE DIFFICULT. A
10 LOT OF THEM ARE HARD. I'M TRYING TO MAKE THE BEST DECISION
11 I CAN BASED UPON WHAT YOU GIVE ME AND WHAT I'VE REVIEWED.
12 SOMEBODY -- SOMEBODY SAID THIS MORNING THEY WERE UP
13 TILL 1:30. WELL, YOU KNOW, FOR YOUR INFORMATION, I'VE BEEN
14 HERE FROM 7 A.M. IN THE MORNING TILL MIDNIGHT AND AFTER
15 READING YOUR CASES, DOING EVERYTHING, EVERY NIGHT. THEY'RE
16 NOT PAYING ME ENOUGH, YOU KNOW, FOR DOING THAT.
17 AND ALL I'M TELLING YOU IS THAT I WANT THE THINGS IN
18 ADVANCE SO THAT I CAN RULE ON THEM. I DON'T WANT THEM --
19 YOU KNOW, AND MOST OF THESE THINGS HAVE HAPPENED BECAUSE WE
20 GET AN EXHIBIT, THEN WE GET AN OBJECTION, AND IT HAS TO BE
21 DISCUSSED.
22 BUT RIGHT NOW, LET'S PUT ON THE WITNESSES. LET'S PUT
23 ON THE EXPERTS ABOUT WHAT THEY SAID THEY WERE GOING TO
24 TESTIFY ABOUT, CONSISTENT WITH THE RULINGS THAT HAVE BEEN
25 PREVIOUSLY MADE. I'M NOT GOING TO REVISIT EVERY RULING THAT
2274
1 I'VE MADE IN THIS CASE.
2 SO IS THERE ANY QUESTION ABOUT WHERE WE'RE GOING?
3 MR. STIRBA: NONE.
4 MS. BARLOW: NO, YOUR HONOR.
5 THE COURT: OKAY. THEN LET'S BE BACK HERE AT 1:30.
6 (WHEREUPON, THE MORNING SESSION ENDS.)
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
2275
1 (WHEREUPON, THE AFTERNOON SESSION BEGINS.)
2 THE COURT: YOU CAN BE SEATED BUT THEN WHEN THE
3 JURY COMES IN JUST STAND.
4 (WHEREUPON THE JURY ENTERS THE COURTROOM.)
5 THE COURT: OKAY. PLEASE BE SEATED. THE RECORD
6 WILL REFLECT THAT THE PARTIES, THE DEFENDANT AND THE JURY
7 ARE PRESENT. MS. BARLOW, IF YOU WOULD LIKE TO CONTINUE.
8 MS. BARLOW: THANK YOU, YOUR HONOR.
9 DIRECT EXAMINATION, CONT'D
10 BY MS. BARLOW:
11 Q. DR. FEHLAUER, DID YOU HAVE OCCASION TO REVIEW THE
12 RECORDS OF ENNIS ALLDREDGE?
13 A. I DID.
14 Q. IT APPEARS THAT MR. ALLDREDGE WAS ADMITTED TO THE
15 HOSPITAL ON THE 10TH OF JANUARY OF 1996. IN REVIEW OF HIS
16 RECORD AND BASED ON YOUR EXPERIENCE AND TRAINING, DO YOU
17 HAVE AN OPINION -- WELL, YES, DO YOU HAVE AN OPINION AS TO A
18 DEGREE OF -- A CERTAIN DEGREE OF MEDICAL CERTAINTY -- THAT'S
19 TOO MANY CERTAINS -- TO A DEGREE OF MEDICAL CERTAINTY AS TO
20 WHAT CAUSED THE DEATH OF MR. ALLDREDGE?
21 A. YEAH. BASED ON THE EVIDENCE PROVIDED, I BELIEVE THAT
22 MR. ALLDREDGE DIED AS A RESULT OF UNTREATED PNEUMONIA,
23 HYPOXIA OR LOW BLOOD OXYGEN WITH RESPIRATORY FAILURE DUE TO
24 LOW BLOOD OXYGEN SUPPLY TO THE BRAIN AND RESULTS OF SEDATIVE
25 MEDICATION.
2276
1 Q. DID YOU HAVE OCCASION TO SEE WHAT EVALUATION WAS DONE OF
2 MR. ALLDREDGE WHEN HE CAME INTO DAVIS NORTH?
3 A. YES.
4 Q. WHO DID THE EVALUATIONS?
5 A. IT WAS PERFORMED BY NURSING STAFF AND DR. WEITZEL AND IF
6 I CAN GET MY RECORDS OUT I'LL --
7 Q. OKAY.
8 A. THERE'S AN EXAMINATION BY DR. WEITZEL ON 1/10/96, AN
9 EXAMINATION BY DR. DIENHART ON 1/10/96 AND THERE ARE
10 ADMISSION ASSESSMENTS AND NURSING PROGRESS NOTES ON THAT
11 DATE AS WELL.
12 Q. IN THOSE EVALUATIONS AND ASSESSMENTS, IS THERE ANY
13 INDICATION OF ANY TERMINALITY FOR MR. ALLDREDGE ON THE 10TH
14 OF JANUARY?
15 A. FROM DR. WEITZEL'S NOTE THE ESTIMATED LENGTH OF
16 HOSPITALIZATION WAS TWO TO THREE WEEKS. PLAN WAS TO BACK TO
17 SUNSHINE TERRACE, THE NURSING FACILITY HE WAS AT BEFORE.
18 Q. OKAY. DID YOU LOOK AT THE ADMISSION -- THE PHYSICIAN'S
19 ORDERS ON ADMISSION FOR MR. ALLDREDGE?
20 A. YES. I'M WORKING FROM MY COPY OF THE RECORDS. DO YOU
21 WANT ME TO WORK FROM THE RECORDS IN --
22 Q. PROBABLY WE BETTER USE THE OFFICIAL ONE. I THINK THIS
23 IS EXHIBIT --
24 A. THIS IS ELLEN ANDERSON'S.
25 Q. OKAY. I'M SORRY. I THOUGHT...THIS IS STATE'S EXHIBIT
2277
1 NO. 7, THESE ARE MEDICAL RECORDS FOR ENNIS ALLDREDGE. IF
2 YOU WOULD OPEN TO PAGE NUMBER MED-0010.
3 A. OKAY.
4 Q. AND WHAT IS ON THAT PAGE?
5 A. THIS IS A PHYSICIAN ORDERS AND PROGRESS RECORD DATED
6 1/10/96. AT THE TOP OF THE PAGE, ENNIS ALLDREDGE IS THE
7 PATIENT NAMED MARKED AND THESE ARE ORDERS FOR ADMISSION TO
8 THE GEROPSYCHIATRIC UNIT.
9 Q. AND WHAT PHYSICIAN ISSUED THOSE ORDERS?
10 A. THE SIGNATURE APPEARS TO BE THAT OF DR. WEITZEL'S.
11 Q. WAS THIS IN PERSON OR A TELEPHONE ORDER, CAN YOU TELL?
12 A. AGAIN, AT THE BOTTOM OF THE PAGE IT SAYS T.O. DR.
13 WEITZEL SLASH L. LONG, R.N. AND THEN THERE'S A SIGNATURE.
14 Q. WHAT WAS ORDERED ON HIS ADMIT?
15 A. DO YOU WANT ME TO READ THE ENTIRE ADMISSION ORDERS?
16 Q. WELL, ARE THERE SOME THAT YOU SAW IN -- IN YOUR REVIEW
17 OF THE RECORD, NOT THE MEDICATIONS, LEAVING ASIDE THE
18 MEDICATIONS. WERE ANY OF THE OTHER MATERIALS ORDERED
19 STANDARD FOR ALL OF THESE PATIENTS?
20 A. I WOULD SAY, YES, THEY ARE. THE LABORATORIES, THE AIMES
21 TEST, THE DIET, CHEST X-RAY, THE VITAL SIGNS ARE ALL
22 ESSENTIALLY VERY SIMILAR TO THOSE FOR THE PRIOR CASE.
23 Q. AND ARE THOSE ORDERS, NOT THE MEDS BUT THE OTHER ONES,
24 RELEVANT TO YOUR OPINION OF WHAT CAUSED THE DEATH OF ENNIS
25 ALLDREDGE?
2278
1 A. YES.
2 Q. IN WHAT WAY ARE THEY RELEVANT?
3 A. THE CHEST X-RAY REQUEST IS RELEVANT TO THE OPINION THAT
4 THERE WAS AN UNTREATED PNEUMONIA.
5 Q. BEFORE WE GET INTO THAT, LET'S LOOK AT THE MEDICATIONS
6 THAT WERE ORDERED FOR MR. ALLDREDGE. WOULD YOU GO THROUGH
7 THOSE, PLEASE.
8 A. THE ENTIRE LIST IS SOME --
9 Q. WELL, LET'S START WITH THE FIRST ONE, TYLENOL.
10 A. -- SEVENTEEN ITEMS LONG. TYLENOL, ONE OR TWO TABLETS
11 EVERY FOUR HOURS BY MOUTH P.R.N. PAIN; MYLANTA, 30 C.C.'S BY
12 MOUTH P.R.N.; MILK OF MAGNESIA BY MOUTH, P.R.N.; LENTE
13 INSULIN, IT'S A FORM OF INSULIN THAT LASTS APPROXIMATELY 12
14 HOURS IN THE BODY FOR TREATMENT OF DIABETES, 20 UNITS EACH
15 MORNING; LENTE INSULIN, FIVE UNITS EACH EVENING. CHECK THE
16 BLOOD SUGAR FOUR TIMES A DAY AT MEAL TIMES AND BEDTIME;
17 RISPERDAL, AN ANTIPSYCHOTIC MEDICATION, ONE MILLIGRAM EACH
18 MORNING AT 1700 AND AT BEDTIME; PEPCID, SAME MATERIAL THAT
19 YOU CAN BUY OVER THE COUNTER FOR HEARTBURN, 20 MILLIGRAMS
20 EACH DAY; LEVOTHYROXINE, A SYNTHROID HORMONE FOR TREATMENT
21 OF LOW BLOOD THYROID, 0.1 MILLIGRAMS EACH MORNING;
22 TRAZODONE, AN ANTIDEPRESSANT, 100 MILLIGRAMS AT BEDTIME, MAY
23 REPEAT TIMES ONE IF AS NEEDED FOR INSOMNIA; BUMETADINE OR
24 BUMEX WHICH IS A DIURETIC, SIMILAR TO LASIX, 1 MILLIGRAM
25 EACH MORNING; ENTERIC COATED ASPIRIN, 325 MILLIGRAMS TWICE
2279
1 EACH DAY; OXYBUTYNIN WHICH IS A MEDICATION WHICH IS AN
2 ANTICHOLINERGIC AND SMOOTH MUSCLE RELAXANT. AGAIN,
3 ANTICHOLINERGIC, MEANING BLOCKING ACETYLCHOLINE THAT'S MEANT
4 TO RELAX A BLADDER, A BLADDER THAT'S OVER CONTRACTING,
5 5 MILLIGRAMS OF THAT TWICE A DAY; MICRO-K OR POTASSIUM, TEN
6 MILLIEQUIVALENT, ONE EACH DAY. HYTRIN, A MEDICATION WHICH
7 BLOCKS THE CONTRACTION OF ARTERIES AND ALSO BLOCKS THE
8 CONTRACTION OF THE PROSTATE GLAND, IN THIS CASE USED FOR
9 PROSTATE ENLARGEMENT, 5 MILLIGRAMS AT BEDTIME. COLACE, A
10 STOOL SOFTENER MEANT TO HELP AS A LAXATIVE, 100 MILLIGRAMS,
11 TWICE A DAY. BUSPAR, A MEDICATION USED FOR ANXIETY,
12 10 MILLIGRAMS THREE TIMES A DAY. AND THEN THERE'S ONE
13 THAT'S CROSSED OUT.
14 Q. AND ERROR IS WRITTEN TO THE SIDE?
15 A. YES.
16 Q. FROM YOUR REVIEW OF THE RECORDS AND YOUR EXPERIENCE AND
17 EXPERTISE, DID YOU FORM AN OPINION AS TO WHETHER MR.
18 ALLDREDGE WAS SUFFERING FROM DELIRIUM?
19 A. YES.
20 Q. AND WHAT WAS THAT OPINION?
21 A. THE OPINION WAS THAT HE DID SUFFER FROM DELIRIUM PRIOR
22 TO HIS ADMISSION TO THE DAVIS HOSPITAL AND AT THE TIME OF
23 HIS ADMISSION TO THE DAVIS HOSPITAL.
24 Q. AND WHAT DID YOU BASE THAT OPINION ON?
25 A. I BASED THAT OPINION ON THE CRITERIA THAT WE'VE
2280
1 DISCUSSED BEFORE WITH THE PATIENT'S FLUCTUATING MENTAL
2 STATUS, HIS AGITATION, HIS WITHDRAWAL AND LETHARGY AT TIMES.
3 I BASED IT ON THE MOOD DISTURBANCES AND ANGER AND AGGRESSIVE
4 BEHAVIORS THAT HE EXHIBITED. I BASED IT ON HIS IMPAIRMENT
5 IN COGNITION, HIS UNINTELLIGIBLE SPEECH WHICH WERE ALL
6 PRESENT ON AND OFF IN VARYING AMOUNTS UP TO THE TIME OF
7 ADMISSION AND AT THE TIME OF ADMISSION.
8 Q. DID YOU FORM AN OPINION AS TO WHAT CAUSED THAT DELIRIUM?
9 A. IN MR. ALLDREDGE'S CASE --
10 MR. STIRBA: RELEVANCY, YOUR HONOR.
11 THE COURT: SUSTAINED.
12 Q. (BY MS. BARLOW) LET'S LOOK AT THE MEDICATIONS ON
13 MED-PAGE NUMBER TEN. ARE ANY OF THOSE MEDICATIONS -- LET ME
14 REPHRASE THAT.
15 DO ANY OF THOSE MEDICATIONS HAVE ANY EFFECT ON
16 DELIRIUM?
17 A. YES.
18 Q. WHICH MEDICATIONS?
19 A. RISPERDAL, INSULIN, TRAZODONE, BUMETADINE, OXYBUTYNIN,
20 HYTRIN, BUSPAR.
21 Q. AND IS THAT ALL?
22 A. YES.
23 Q. OKAY. THANK YOU. LET'S START WITH INSULIN. YOU SAID
24 INSULIN WAS GIVEN FOR DIABETES. WHAT EFFECT DOES THAT HAVE
25 ON DELIRIUM?
2281
1 A. INSULIN OBVIOUSLY IS USED TO REGULATE BLOOD SUGAR.
2 BLOOD SUGAR IT'S PRESENT IN THE BODY IS USED AS AN ENERGY
3 SOURCE. THE BRAIN IN ESSENCE USES BLOOD SUGAR, GLUCOSE, AS
4 ITS ONLY ENERGY SOURCE. THERE ARE NOT ANY INTERNAL
5 MECHANISMS FOR PRODUCING A SIGNIFICANT AMOUNT OF ENERGY
6 WITHIN THE BRAIN LOCALLY. THERE'S NO FAT STORES, THERE'S
7 NOT A LOT OF PROTEIN THAT CAN BE CONVERTED LOCALLY INTO FUEL
8 SOURCE SO THE PRESENCE OF BLOOD SUGAR IS CRITICALLY
9 IMPORTANT TO THE BRAIN IN FUNCTIONING.
10 SECONDLY, THE -- SO IF INSULIN IS ADMINISTERED AND THE
11 BLOOD SUGAR DROPS TOO LOW BECAUSE THE INSULIN HAS BEEN
12 INCORPORATED INTO CELLS AND CAUSES THE BLOOD SUGAR TO BE
13 METABOLIZED AND SO IT DROPS, THEN THE BRAIN WILL
14 MALFUNCTION. THE BRAIN WILL NOT BE ABLE TO PERFORM NORMALLY
15 IN ITS ABILITY TO THINK AND DIRECT THE BODY IN ITS
16 ACTIVITIES.
17 Q. LET'S DROP DOWN TO WHAT I THINK YOU SAID BUMEX WHICH IS
18 EASIER FOR ME TO PRONOUNCE THEN HOW IT'S WRITTEN HERE. WHAT
19 EFFECT DOES THAT HAVE ON DELIRIUM?
20 A. VERY SIMILAR TO THE DISCUSSION BEFORE WITH THE LASIX, IT
21 ALTERS ELECTROLYTES IN THE BLOOD, THE SODIUM MAY DROP,
22 POTASSIUM MAY DROP, IT MAY CAUSE DEHYDRATION, IT MAY CAUSE
23 KIDNEY FAILURE AND THOSE EFFECTS MAKE THE ABILITY OF THE
24 BRAIN TO FUNCTION NORMALLY IN ITS CHEMICAL ENVIRONMENT MORE
25 DIFFICULT.
2282
1 Q. THE OXYBUTYNIN, WHAT EFFECT DOES THAT HAVE ON DELIRIUM?
2 A. THE MECHANISM BY WHICH IT WORKS IS TO BLOCK
3 ACETYLCHOLINE. ACETYLCHOLINE IS NECESSARY TO TELL THE BRAIN
4 THAT IT'S AWAKE AND IT'S ALERT AND IF YOU BLOCK THAT
5 RECEPTOR IT CAUSES THE BRAIN TO BE SEDATED. IT ALSO IS USED
6 TO FORM MEMORIES AND TO INTERACT NORMALLY IN THE
7 ENVIRONMENT, AND SO IF YOU BLOCK A ACETYLCHOLINE, THE BRAIN
8 WILL BECOME CONFUSED, UNABLE TO INTERACT AND RESPOND TO THE
9 ENVIRONMENT ABNORMALLY; THAT IS TO SAY, THAT IT CAN CAUSE
10 THE KIND OF CONFUSION THAT LEAVES YOU UNABLE TO PERCEIVE THE
11 ENVIRONMENT.
12 Q. YOU ALSO MENTIONED HYTRIN HAS EFFECT ON DELIRIUM.
13 A. HYTRIN'S PRINCIPLE PURPOSE IS TO LOWER BLOOD PRESSURE
14 BUT IT'S ALSO INDICATED IN THE TREATMENT OF PROSTRATE
15 HYPERTROPHY. IT ALLOWS THE PROSTRATE TO RELAX. THE
16 PROSTRATE GLAD CONTAINS SMOOTH MUSCLE AND IT'S SMOOTH MUSCLE
17 BLOCKAGE THAT THE HYTRIN EFFECTS. IT BLOCKS A SUBSTANCE
18 CALLED NOREPINEPHRINE EPINEPHRINE THAT THE BRAIN USES TO
19 COMMUNICATE CELLS TO CELL, AND SINCE IT BLOCKS THAT
20 COMMUNICATION, IT CAN RESULT IN IMPAIRMENT OF THE BRAIN'S
21 ABILITY FOR CELLS TO COMMUNICATE WITH EACH OTHER. IT ALSO
22 LOWER BLOOD PRESSURE AND IF BLOOD PRESSURE IS LOWERED ENOUGH
23 THAT THE BRAIN DOESN'T RECEIVE BLOOD FLOW --
24 THE REPORTER: CAN YOU SLOW DOWN, PLEASE.
25 THE WITNESS: SO IF THE BRAIN DOESN'T RECEIVE BLOOD
2283
1 FLOW, THEN THE BRAIN CAN MALFUNCTION.
2 Q. (BY MS. BARLOW) AND LET ME GO BACK UP TO THE
3 RISPERDAL. HAVE YOU PUT THAT ON YOUR CHART?
4 A. I HAVE.
5 Q. LET'S SET THAT UP HERE AND IF YOU WOULD STEP DOWN HERE.
6 THIS IS THE CHART WHICH IS HAS BEEN MARKED STATE'S EXHIBIT
7 30. WHAT IS THE PHARMACOLOGY OF RISPERDAL IN THE ELDERLY?
8 A. RISPERDAL IS HERE ON THIS LINE, I'LL MARK IT FOR YOU,
9 WE'VE TALKED ABOUT IT. FROM THE P.D.R. AND THE GERIATRIC
10 DOSAGE HANDBOOK, REAL CLEARANCE IS DECREASED AND THE HALF
11 LIFE IS INCREASED. BASICALLY THAT MEANS THAT THE KIDNEY
12 DOESN'T EXCRETE RISPERDAL AS QUICKLY IN OLDER PEOPLE AS IT
13 DOES IN YOUNG PEOPLE AND THEREFORE THE HALF LIFE IS LONGER.
14 Q. WHAT ABOUT THE DURATION OF EFFECT?
15 A. BECAUSE THE HALF LIFE IS LONGER YOU CAN INFER THAT THE
16 DURATION OF EFFECT OF THE DRUG WILL BE LONGER AS WELL.
17 Q. AND ARE THERE ANY SPECIAL CONSIDERATIONS IF YOU ARE
18 GOING TO ORDER RISPERDAL FOR THE ELDERLY?
19 A. WELL, GENERALLY SPEAKING, WHAT I WAS TAUGHT IN MEDICAL
20 SCHOOL AND SUBSEQUENTLY USED MANY TIMES WAS THAT WHEN
21 MEDICATING AN OLDER PERSON, YOU START LOW AND GO SLOW; WHICH
22 IS TO SAY, THAT YOU USE THE LOWEST POSSIBLE EFFECTIVE DOSE
23 TO GET THE BENEFICIAL EFFECT YOU WANT AND THEN YOU DON'T
24 INCREASE THE DOSE TOO RAPIDLY BECAUSE THE DRUG MAY
25 ACCUMULATE AND TOXIC EFFECTS MAY OCCUR.
2284
1 Q. AND THEN ARE THERE ANY OTHER PROBLEMS THAT ARISE OR CAN
2 ARISE IN THE ELDERLY FROM RISPERDAL?
3 A. YES. UNDER THE SPECIAL CONSIDERATIONS CATEGORY WE FIND
4 THAT COMMON SIDE EFFECTS WITH RISPERDAL ARE ANXIETY,
5 PARKINSON'S SYNDROME AND SEDATION. PARKINSON'S SYNDROME IS
6 NOT LIKE PARKINSON'S DISEASE. IT'S A PHYSIOLOGIC EFFECT
7 THAT MIMICS PARKINSON'S DISEASE. PARKINSON'S DISEASE BEING
8 A DISEASE THAT AFFECTS THE BRAIN AND RESULTS IN VERY SLOW
9 MOVEMENTS, HAND TREMORS, VERY RIGID LIMBS THAT ARE HARD TO
10 MOVE, PATIENTS HAVE IMPAIRED ABILITIES TO WALK AND STAND.
11 THEY FREQUENTLY WILL HAVE IMPAIRED ABILITIES TO CHEW AND
12 SWALLOW FOOD.
13 Q. HOW DOES SEDATION COMPARE WITH THE DEPRESSION OF THE
14 CENTRAL NERVOUS SYSTEM THAT YOU PREVIOUSLY TESTIFIED TO?
15 A. AGAIN, SUPRESSION OF CENTRAL NERVOUS SYSTEM CAN -- IT'S
16 A SIMILAR TERM. THE SEDATIVE EFFECT HERE IS TRULY LIKE
17 FEELING SLEEPY AND BEING MADE TO SLEEP. SUPRESSION OF
18 CENTRAL NERVOUS SYSTEM FUNCTION RELATIVE TO OTHER FUNCTIONS
19 LIKE BLOOD PRESSURE AND THINGS CAN OCCUR WITH THE RISPERDAL
20 AS WELL.
21 Q. OKAY. AND WHILE WE'RE HERE I'LL PUT UP WHAT'S BEEN
22 MARKED STATE'S EXHIBIT 31. IS RISPERDAL ON THIS CHART AS
23 WELL?
24 A. YES. AGAIN, I'LL MARK THAT FOR YOU WHEN WE TALKED ABOUT
25 RISPERDAL AND WE TALKED PREVIOUSLY ABOUT MORPHINE.
2285
1 Q. WHAT IS THE ADULT STARTING DOSE FOR RISPERDAL?
2 A. THE ADULT STARTING DOSE IS ONE MILLIGRAM BY MOUTH, TWICE
3 A DAY.
4 Q. AND WITH THE ELDERLY?
5 A. 0.5 MILLIGRAMS OR ONE HALF THE AMOUNT, TWICE A DAY.
6 Q. AND WHY IS IT ONE HALF THE AMOUNT?
7 A. BECAUSE OF THE EFFECTS FROM THE OTHER CHART WITH THE
8 LONG HALF LIFE AND THE PARTICULAR SENSITIVITY TO THE
9 ANXIETY, SEDATION AND THE PARKINSON'S EFFECTS AND OBVIOUSLY
10 THE PROLONGATION OF DURATION OF EFFECT.
11 Q. THANK YOU.
12 YOU MENTIONED THAT -- YOU MENTIONED STARTING LOW AND
13 GOING SLOW, IS THAT -- IS THERE A WORD FOR THAT?
14 A. WELL, YOU KNOW, THE WORD I WAS -- I WOULD USE IS
15 CONSERVATIVE.
16 Q. OKAY.
17 A. AND APPROPRIATE.
18 Q. BUT IS THERE A MEDICAL TERM WHEN YOU ADMINISTER
19 MEDICATIONS IN THAT WAY, STARTING LOW AND GOING SLOW?
20 A. IT'S APPROPRIATE.
21 Q. OKAY. THANK YOU.
22 SO THAT'S RISPERDAL AND -- OH, I'M SORRY. WHILE WE
23 WERE UP THERE I THINK YOU MENTIONED BUSPAR, IS THAT ON THIS
24 CHART AS WELL?
25 A. YEAH, BUSPIRONE.
2286
1 Q. WHAT'S THE ADULT STARTING DOSE FOR BUSPAR?
2 A. 5 MILLIGRAMS BY MOUTH, THREE TIMES A DAY.
3 Q. AND WHAT ABOUT THE ELDERLY?
4 A. REDUCED BY ONE-THIRD, 5 MILLIGRAMS BY MOUTH, TWICE A
5 DAY.
6 Q. THAT WAS EXHIBIT 31 AND NOW WE'RE ON 30. IS BUSPAR ON
7 THERE?
8 A. YES.
9 Q. WHAT'S THE PHARMACOLOGY OF BUSPAR?
10 A. FROM THE P.D.R. AND THE GERIATRIC DOSING HANDBOOK IT
11 LISTS SIMILAR TO THE YOUNG. SO THOSE TWO AUTHORITIES SAY
12 THAT THERE'S NOT MUCH OF A DIFFERENCE IN THE WAY THAT THE
13 DRUG IS METABOLIZED AND HANDLED IN THE BODY.
14 Q. AND THEN SPECIAL CONSIDERATIONS IN THE ELDERLY?
15 A. WELL, IT'S BEEN SAID THAT IT'S LESS SEDATING THAN THE
16 OTHER ANTIANXIETY DRUGS SO IT HAS HAD A PLACE AND USE IN THE
17 OLDER PEOPLE BECAUSE IT SEEMS TO HAVE LESS OF AN EFFECT.
18 Q. THANK YOU. IS DELIRIUM TREATABLE?
19 A. IF YOU TREAT THE UNDERLYING CAUSE OF THE DELIRIUM, YES,
20 IT'S TREATABLE.
21 Q. AND HOW DO YOU TREAT DELIRIUM?
22 A. WELL, FIRST YOU FIND OUT WHAT'S CAUSING IT.
23 Q. DID YOU SEE WHAT CAUSED THE DELIRIUM IN MR. ALLDREDGE?
24 MR. STIRBA: I'M GOING TO OBJECT, YOUR HONOR, ONCE
25 AGAIN, RELEVANCY.
2287
1 THE COURT: OVERRULED, IT'S JUST A BAD QUESTION.
2 THE WITNESS: SORRY. I HAVE TO USE MY NOTES.
3 THERE'S AN AWFUL LOT OF MATERIAL HERE.
4 MS. BARLOW: I UNDERSTAND THAT I THINK.
5 THE WITNESS: AT THE TIME THAT MR. ALLDREDGE WAS
6 ADMITTED TO DAVIS HOSPITAL, BASED ON MY OWN REVIEW OF THE
7 RECORDS AND THE OUTSIDE RECORDS, THE PATIENT WAS LIKELY
8 DELIRIOUS FROM THE USE OF OXYBUTYNIN, THE USE OF RISPERDAL,
9 THE USE OF ATIVAN, THE USE OF RESTORIL, AND THEN THERE ARE
10 OTHER ABNORMALITIES ON HIS ADMISSION LABORATORIES AND X-RAYS
11 THAT LEAD ME TO ADDITIONAL FINDINGS.
12 Q. (BY MS. BARLOW) GIVEN THE FACT THAT -- AND THOSE --
13 OTHER THAN THE ABNORMALITIES ON THE LABS THAT WE'LL LOOK AT
14 IN A MINUTE, ARE ALL THOSE THINGS THAT YOU USE LISTED
15 MEDICATIONS?
16 A. YES.
17 Q. GIVEN THE FACT YOU SAY THAT THEY -- WELL, WHAT WOULD YOU
18 DO TO TREAT MR. ALLDREDGE AT THAT POINT?
19 A. WELL, BASED ON THE MEDICATION USAGE ALONE AND BASED ON
20 MY REVIEW OF HIS CLINICAL COURSE PRIOR TO ADMISSION, I WAS
21 QUITE CONVINCED THAT MR. ALLDREDGE NEEDED A DRUG HOLIDAY, IN
22 ESSENCE. HE NEEDED TO HAVE THE MEDICATIONS SLOWLY TAPERED
23 IF APPROPRIATE OR STOPPED ABRUPTLY IF APPROPRIATE AND SEE
24 WHAT HIS NATIVE BEHAVIORS WERE. HIS BRAIN WAS UNDER THE
25 INFLUENCE OF SO MANY DIFFERENT DRUGS THAT THERE WAS NO WAY
2288
1 TO KNOW WHAT HIS NATURAL BRAIN STATE WAS AT THAT POINT, AND
2 SO I WOULD HAVE ATTEMPTED TO ELIMINATE ALL MEDICATIONS THAT
3 WEREN'T ESSENTIAL. Like insulin, Bumex, and the rest?
4 Q. WAS MR. ALLDREDGE PUT ON A DRUG HOLIDAY AT DAVIS NORTH?
5 A. NO, HE WAS NOT.
6 Q. LET'S LOOK AT THE LABS. WAS THERE ANYTHING IN THE LABS
7 CONDUCTED ON MR. ALLDREDGE'S ADMISSION OR SUBSEQUENTLY?
8 A. I'M REVIEWING FROM THE EVIDENCE IN ADMISSION
9 LABORATORIES FROM JANUARY 20TH, '96 HE HAS A COMPLETE BLOOD
10 COUNT CELL COUNTS, WHICH IS NORMAL. THERE'S A MARKAGE HERE
11 OF PART OF THE WHITE BLOOD CELL LINE THAT INDICATES
12 INFECTION IS VERY SLIGHTLY HIGH WITH A REDUCTION IN OTHER
13 CELL LINED THAT USUALLY GOES ALONG WITH THE RISE ON THE ONE.
14 THE TOTAL WHITE BLOOD COUNT, THE NUMBER OF CELLS WASN'T
15 INCREASED. IT'S JUST WHAT WE CALL SHIFTED TO THE LEFT OR
16 SHIFTED TO YOUNGER CELLS AND CELLS THAT FIGHT INFECTION OF A
17 BACTERIAL NATURE.
18 AGAIN, FROM THAT SAME DATE 1/10/96, I HAVE ELECTROLYTES
19 AND CHEMISTRY PROFILES AND LIVER FUNCTION TESTS WHICH SHOW
20 THE SERUM SODIUM SLIGHTLY HIGH AND THAT CAN BE A SIGN OF
21 RELATIVE DEHYDRATION. THE SERUM CHLORIDE IS SLIGHTLY HIGH,
22 AGAIN A SIGN OF DEHYDRATION. HIS BLOOD GLUCOSE IS ELEVATED
23 BUT NOT DANGEROUSLY SO OR NOT IN A WAY THAT'S UNCOMMON FOR A
24 PATIENT WITH DIABETES UNDER TREATMENT. HIS UREA NITROGEN
25 COUNT, A MEASURE OF KIDNEY FUNCTION IS NORMAL. HIS
2289
1 CREATININE IS NORMAL SO HIS KIDNEY FUNCTIONS ARE NORMAL. HE
2 HAS MILD ELEVATION OF ONE LIVER ENZYME AND HE APPEARS
3 ADEQUATELY NOURISHED, HIS SERUM ALBUMIN IS OKAY SO HE
4 DOESN'T HAVE A PRONOUNCED REDUCTION IN HIS SERUM PROTEINS.
5 IN ADDITION TO THOSE THERE ARE THYROID FUNCTION TESTS
6 WHICH ARE NORMAL. AND FROM THE 25TH -- EXCUSE ME, FROM THE
7 NEXT DAY WE HAVE A URINALYSIS REPORT WHICH SHOWS SOME
8 PROTEIN COMMON IN DIABETICS --
9 MR. STIRBA: YOUR HONOR, YOUR HONOR, CAN I HAVE
10 SOME QUESTIONS HERE? IT'S HARD FOR ME TO TRACK THE
11 RELEVANCE OF THIS TESTIMONY.
12 THE COURT: YEAH, PROCEED BY QUESTION AND ANSWER,
13 PLEASE.
14 Q. (BY MS. BARLOW) SO HAVE YOU LOOKED AT ALL OF THE LABS
15 FOR THE 10TH?
16 A. I HAVE.
17 Q. WAS THERE ANYTHING ABNORMAL ABOUT THOSE LABS?
18 MR. STIRBA: I'LL OBJECT, RELEVANCY, YOUR HONOR.
19 THE COURT: COULD WE CONFINE IT TO WHAT CARE WAS
20 GIVEN AND WHAT'S THE TESTIMONY OF WHAT CARE SHOULD HAVE BEEN
21 GIVEN, PLEASE.
22 Q. (BY MS. BARLOW) WAS THERE ANYTHING IN THE LABS THAT
23 INDICATED ANY CARE THAT SHOULD HAVE BEEN GIVEN TO MR.
24 ALLDREDGE BASED ON WHAT WAS IN THE LAB REPORTS?
25 A. THE LABORATORIES THEMSELVES, NO.
2290
1 Q. WERE THERE ANY OTHER STUDIES DONE, NOT LABS, BUT
2 E.K.G.'S, THAT SORT OF THING?
3 A. YES, THERE WAS A CHEST X-RAY PERFORMED.
4 Q. HAVE YOU REVIEWED AT LEAST A REPORT OF THAT CHEST X-RAY?
5 A. YES, I HAVE.
6 Q. WAS THERE ANYTHING IN THAT THAT INDICATED ANY TREATMENT
7 THAT SHOULD HAVE BEEN DONE?
8 A. YES.
9 Q. WHAT WAS THERE IN THAT REPORT?
10 A. I'M READING FROM THE CHEST X-RAY REPORT, DATE OF EXAM
11 1/10/96. SOME BI-BASILAR FINDINGS ARE NOTED WHICH ARE MOST
12 PROMINENT WITHIN THE LEFT LOWER LOBE, ALSO SOME HAZINESS
13 ALONG THE LEFT LATERAL --
14 THE REPORTER: PLEASE SLOW DOWN.
15 MS. BARLOW: YOU NEED TO SLOW DOWN.
16 THE WITNESS: SOME HAZINESS ALONG THE LEFT LATERAL
17 COSTOCHONDRAL ANGLE NOTED CONSISTENT WITH A POTENTIAL SMALL
18 PLURAL AFFUSION.
19 Q. (BY MS. BARLOW) CAN YOU TELL US IN LAYMAN TERMS WHAT
20 THAT MEANS?
21 A. I'LL READ THE REPORT SINCE I DIDN'T EXAMINE THE X-RAY
22 ITSELF. THE IMPRESSION SAYS, LOWER LEFT LOWER LOBE
23 ATELECTASIS OR PERHAPS SOME INFILTRATE.
24 Q. WHAT DOES THAT MEAN?
25 A. INFILTRATE IS A TERM FOR FLUID OR CONGESTION IN THE LUNG
2291
1 USUALLY ASSOCIATED WITH PNEUMONIA.
2 Q. OKAY. BASED ON WHAT YOU READ IN THIS REPORT, WHAT
3 ACTION SHOULD HAVE BEEN TAKEN FOR MR. ALLDREDGE?
4 A. SHOULD HAVE BEEN TREATED FOR POSSIBLE PNEUMONIA OR MORE
5 FULLY EVALUATED.
6 Q. AND HOW DO YOU TREAT PNEUMONIA?
7 A. WELL, FIRST I WOULD PERFORM AN ASSESSMENT TO SEE IF I
8 THOUGHT CLINICALLY PNEUMONIA WAS PRESENT. THE X-RAY ITSELF
9 IS HELPFUL BUT FIRST I WOULD NEED TO ASSESS THE PATIENT AND
10 DETERMINE IF I BY EXAMINATION FELT PNEUMONIA WAS PRESENT.
11 Q. AND YOU WOULD DO THAT BY WHAT, LISTENING TO THE LUNGS OR
12 I GUESS I DON'T KNOW WHAT YOU MEAN BY -- WHAT DO YOU MEAN BY
13 YOU WOULD DO A PERSONAL ASSESSMENT?
14 A. A PERSONAL ASSESSMENT WOULD BE EXAMINATION OF THE CHEST
15 USING A STETHOSCOPE, EXAMINATION OF THE RESPIRATORY
16 MOVEMENTS, INTERVIEWING THE PATIENT TO FIND OUT IF THERE ARE
17 SYMPTOMS OF PNEUMONIA, COUGH, PRODUCTION OF MUCUS OR PHLEGM,
18 PRESENCE OF FEVERS, REVIEW OF THE VITAL SIGNS, REVIEW OF
19 EVIDENCE OF LOW BLOOD OXYGEN FROM PNEUMONIA, CHECKING THE
20 OXYGEN BY PULSE OXIMETRY.
21 Q. LET'S GO BACK TO THE PROGRESS NOTES. THE PROGRESS NOTES
22 WERE WRITTEN BY WHOM?
23 A. I'M LOOKING AT THE PROGRESS NOTES SECTION DATED 1/10/96
24 IT SAYS, M.D., APPEARS TO BE THE SIGNATURE OF DR. WEITZEL.
25 THE PROGRESS NOTES SECTION INDICATES THE PATIENT SEEN SLASH
2292
1 EXAMINED, PSYCH EVAL DICTATED, INCREASE RISPERDAL, CONTINUE
2 BUSPAR, USE HALDOL I.M. IF PATIENT UNWILLING TO TAKE
3 RISPERDAL, POSSIBLE DEPAKOTE.
4 Q. LET'S TALK ABOUT HALDOL, THEN, EVEN THOUGH IT'S NOT
5 INITIAL ORDERS HE DOES INDICATE HERE TO USE THAT. WHY WOULD
6 YOU ORDER HALDOL I.M. IF PATIENT UNWILLING TO TAKE
7 RISPERDAL?
8 A. IT WOULD DEPEND ON WHAT BENEFICIAL EFFECT YOU THOUGHT
9 YOU WERE GOING TO GET.
10 Q. AND WHAT BENEFICIAL EFFECT DO YOU GET FROM RISPERDAL?
11 A. IT'S ANTIPSYCHOTIC, IT'S MEANT TO REMOVE FALSE THOUGHTS
12 OR DELUSIONS OR SUPPRESS HALLUCINATIONS.
13 Q. WHAT BENEFICIAL EFFECT ARE YOU LOOKING FOR FROM HALDOL?
14 A. THEY ARE IN THE SAME CLASS OF DRUGS, ANTIPSYCHOTIC SO IT
15 WOULD BE USED FOR THOSE SAME INDICATIONS.
16 Q. AND IN YOUR REVIEW OF THE RECORDS, DID YOU SEE
17 INDICATIONS OF PSYCHOTIC PROBLEMS WITH MR. ALLDREDGE?
18 A. I'M GOING TO TURN TO THE PSYCH EVALUATION AND THIS IS
19 FROM 1/10/96 ROBERT A. WEITZEL, M.D., IS TYPED IN AND HIS
20 SIGNATURE IS PLACED ABOVE. I'M LOOKING SPECIFICALLY FOR
21 EVIDENCE THAT THE PATIENT HAS FALSE THOUGHTS OR PARANOIA OR
22 THAT THE PATIENT IS HALLUCINATING.
23 HERE WE HAVE LOOSENING OF THOUGHT PROCESS, THAT'S
24 ANOTHER USE FOR THE ANTIPSYCHOTIC. SO I'M READING FROM THE
25 NOTES, THOUGHT PROCESS QUITE LOOSE AND EXHIBITS BLOCKING.
2293
1 THOUGHT CONTENT, THAT WOULD BE WHAT IS HE THINKING, IS
2 DIFFICULT TO ASCERTAIN SECONDARY TO THE PATIENT BEING
3 UNCOOPERATIVE. AND THOSE ARE THE TWO PORTIONS OF THE
4 EXAMINATION THAT WOULD FOCUS ON THAT.
5 FROM THE HISTORY PORTION THERE'S NO MENTION OF A
6 DELUSION OR A LOOSENING OF THOUGHT PROCESS OR HALLUCINATIONS
7 AND THE DIAGNOSIS LISTED IS PSYCHOSIS N.O.S OR NOT OTHERWISE
8 SPECIFIED. SO I FIND ONE, ONE POSSIBLE TARGET BEHAVIOR OR
9 FINDING FOR THE USE OF RISPERDAL AND HALDOL.
10 Q. IN YOUR OPINION, WAS THE RISPERDAL OR HALDOL APPROPRIATE
11 MEDICATIONS AT THAT POINT?
12 A. IN MY OPINION, NO.
13 Q. YOU'VE TALKED ABOUT RISPERDAL BUT YOU MENTIONED -- BUT
14 LET'S TALK ABOUT HALDOL WITH YOUR CHART HERE AGAIN.
15 WHAT'S THE PHARMACOLOGY IN THE ELDERLY FOR HALDOL?
16 A. FROM THE GERIATRIC DOSAGE HANDBOOK AND FROM THE P.D.R.,
17 THE DESCRIPTION IS THAT THE HALF LIFE OF 20 TO 40 HOURS AND
18 THAT'S IN THE NORMAL ADULT MAY BE PROLONGED IN THE ELDERLY.
19 Q. DO YOU HAVE ANY IDEA OF HOW LONG IT IS PROLONGED?
20 A. I CAN GIVE YOU MY OWN OPINION, PROFESSIONAL OPINION.
21 Q. YES.
22 A. THE DURATION OF THE EFFECT RELATED TO HALF LIFE IS DAYS
23 IN LENGTH; THAT IS TO SAY, THAT GIVING A SINGLE DOSE OF
24 HALDOL CAN HAVE DAYS WORTH OF EFFECTS, IT MAY BE AS LONG AS
25 FIVE DAYS, HALF LIFE.
2294
1 Q. AND THEN SPECIAL CONSIDERATIONS IN THE ELDERLY FOR
2 HALDOL?
3 A. WELL, THIS IS -- I TOOK PORTIONS OF IT BUT INCREASED
4 CONFUSION, MEMORY LOSS, PSYCHIATRIC BEHAVIOR, AGITATION,
5 SEDATION, AGAIN, THE PARKINSON SYNDROME. THEY ARE IN THE
6 SAME CLASS, RISPERDAL AND HALDOL. AKATHISIA, AKATHISIA IS
7 AN INTERESTING PROBLEM THAT DEVELOPS WITH THE USE OF DRUGS
8 LIKE HALDOL. IT IS A RESTLESS PURPOSELESS HYPERACTIVITY, I
9 MEAN, IT'S A SIDE EFFECT THAT THESE PEOPLE CAN HAVE. THEY
10 CAN'T SIT STILL, THEY FIDGET, THEY ARE PHYSICALLY AGITATED
11 AND THOSE ARE ALL LISTED AS COMMON SIDE EFFECTS.
12 Q. THEN LET'S LOOK AT THE DOSAGE AMOUNT ON THE NUMBER 31 ON
13 HALDOL. WHAT IS THE ADULT STARTING DOSE?
14 A. THE ADULT STARTING DOSE IS LISTED AS 0.5 TO 5 MILLIGRAMS
15 BY MOUTH OR IT CAN BE GIVEN I.M., SAME DOSAGE, TWO TO THREE
16 TIMES PER DAY, 15 MILLIGRAMS PER DAY IS THE MAXIMUM STARTING
17 DOSE RECOMMENDED.
18 Q. WHAT ABOUT ELDERLY STARTING DOSE?
19 A. QUARTER OF A MILLIGRAM 0.25 TO .5 MILLIGRAMS. SO THE
20 TOP AMOUNT EVEN RECOMMENDED IN THAT RANGE IS ONE-TENTH OF
21 WHAT THE ADULT DOSE IS. ONE TO TWO TIMES PER DAY WITH
22 1 MILLIGRAM PER DAY BEING A MAXIMUM DOSE THAT A PATIENT
23 SHOULD RECEIVE STARTING DOSE.
24 Q. OVER HERE I BELIEVE WE'VE GOT TRAZODONE WAS MENTIONED
25 WITH MR. ALLDREDGE, WAS IT NOT?
2295
1 A. YES, TRAZODONE WAS ON THE ADMITTING ORDERS.
2 Q. AND WHAT DOES THAT DRUG DO?
3 A. TRAZODONE IS LOCATED HERE. TO REFRESH YOUR MEMORIES
4 IT'S AN ANTIDEPRESSANT AND SO IT'S USED TO TREAT DEPRESSION.
5 Q. AND THE ADULT STARTING DOSE?
6 A. THE ADULT STARTING DOSE IS 50 MILLIGRAMS BY MOUTH THREE
7 TIMES A DAY OR 150 MILLIGRAMS TOTAL.
8 Q. AND THE ELDERLY STARTING DOSE?
9 A. 25 TO 50 MILLIGRAMS AND STARTED BY MOUTH AT BEDTIME
10 ONLY.
11 Q. AND WE HAVE TRAZODONE ON CHART WHICH IS NUMBER 30.
12 WHAT'S THE PHARMACOLOGY IN THE ELDERLY OF TRAZODONE?
13 A. FROM THE LITERATURE IT'S DESCRIBED AS A HALF LIFE OF
14 NEARLY TWICE THAT OF YOUNGER PATIENTS.
15 Q. AND ANY SPECIAL CONSIDERATIONS FOR THE ELDERLY?
16 A. IT'S VERY SEDATING, WHICH IT IS.
17 Q. DOES IT DEPRESS THE CENTRAL NERVOUS SYSTEM?
18 A. YES, IT WILL. IT WILL HAVE EFFECTS ON CENTRAL NERVOUS
19 SYSTEM FUNCTIONING, BOTH WITH LEVEL OF ALERTNESS AND IN
20 TERMS OF BEING AWAKE AND OTHER FUNCTIONS OF THE CENTRAL
21 NERVOUS SYSTEM.
22 Q. DID THE AMOUNT OF ANY OF THESE DRUGS BEING -- DID THE
23 ORDER -- DID AN ORDER FOR THE AMOUNT OF ANY OF THESE DRUGS
24 COME IN AFTER THE 10TH OF JANUARY THAT CHANGED THE AMOUNTS
25 THAT WAS TO BE GIVEN TO MR. ALLDREDGE?
2296
1 A. SO YOU ARE ASKING WERE THERE CHANGES IN THE ORDERS?
2 Q. YES, THAT WAS A MUCH EASIER WAY OF SAYING IT.
3 WERE THERE CHANGES IN THE ORDER OF ANY OF THESE DRUGS
4 THAT HAVE AN EFFECT ON DELIRIUM?
5 A. STILL ON THE 10TH BUT BELOW THE TELEPHONE ORDER
6 STATEMENT FROM WHAT I READ TO YOU BEFORE WE HAVE AN ORDER
7 FOR ATIVAN, ONE MILLIGRAM AND HALDOL, 10 MILLIGRAMS I.M.
8 NOW. SECOND ORDER, ATIVAN ONE TO TWO MILLIGRAMS I.M. Q 4
9 HOURS, EVERY FOUR HOURS, AS NEEDED SEVERE AGITATION. AND
10 THREE, HALDOL 5 MILLIGRAMS I.M. EACH MORNING AT 1700 AND
11 BEDTIME TO BE GIVEN P.R.N. IF PATIENT REFUSES RISPERDAL. SO
12 THAT'S AN AS NEEDED ORDER IF HE'S REFUSING THE RISPERDAL
13 TABLETS.
14 Q. ATIVAN IS ALSO ONE OF THE DRUGS THAT YOU'VE --
15 A. LORAZEPAM IS THE GENERIC NAME.
16 Q. OKAY. WHAT DOES ATIVAN DO?
17 A. ATIVAN IS AN ANTIANXIETY DRUG SO IT'S MEANT TO BE USED
18 TO RELIEVE ANXIETY.
19 Q. WHAT'S THE PHARMACOLOGY IN THE ELDERLY?
20 A. FROM THE REFERENCE MATERIALS IT'S 85 PERCENT PROTEIN
21 BOUND. SO WHAT THAT SAYS IS THAT OF ANY GIVEN DOSE ONLY
22 15 PERCENT OF THE DOSE RESIDES FREE IN THE SYSTEM AND THE
23 REST OF IT IS BOUND TO THE PROTEIN WHERE IT CIRCULATES
24 AROUND AND AROUND AND AROUND. SO COMPARING A YOUNG PERSON
25 TO AN OLDER PERSON, THE OLDER PERSON WITH THE REDUCTION IN
2297
1 THE AMOUNT OF THEIR SERUM PROTEINS WOULD HAVE A HIGHER FREE
2 AMOUNT BECAUSE THE DRUG IS SO HIGHLY PROTEIN BOUND THAT LESS
3 PROTEIN, MORE FREE DRUG WOULD BE IN THE SYSTEM COMPARED TO A
4 YOUNG PERSON.
5 Q. ANY SPECIAL CONSIDERATIONS IN THE ELDERLY?
6 A. IT'S -- THE ADVANTAGES OF THE DRUG AND THE REASON IT'S
7 USED WHEN IT'S CLINICALLY APPROPRIATE IS THAT THE DRUG IS
8 RELATIVELY SHORT-ACTING AND IS METABOLIZED BY THE LIVER INTO
9 SUBSTANCES WHICH DON'T HAVE THE EFFECTS ON THE BRAIN
10 FUNCTION OR OTHER FUNCTIONS SO IT'S PREFERRED.
11 Q. AND THEN LET'S PULL -- BEFORE YOU -- LET'S PULL THIS ONE
12 UP AND LOOK AT THE STARTING DOSES FOR ATIVAN. WHAT'S THE
13 STARTING DOSE FOR A NORMAL ADULT?
14 A. FOR A USUAL ADULT STARTING DOSE WOULD BE ONE, TWO
15 10 MILLIGRAMS BY MOUTH PER DAY IN THREE DOSES. THERE'S A
16 WIDE RANGE THERE OF POSSIBLE STARTING DOSES.
17 Q. WHAT ABOUT FOR THE ELDERLY?
18 A. IN THE ELDERLY THE RANGE IS MUCH NARROWER, 0.5 TO
19 1 MILLIGRAM BY MOUTH PER DAY IN DIVIDED DOSES. AND THEN
20 THERE'S AN EXTRA LITTLE STATEMENT THAT SAYS THE INITIAL
21 TOTAL DOSE SHOULD NOT EXCEED 2 MILLIGRAMS PER DAY.
22 Q. BASED ON WHAT YOU SEE IN THE RECORDS AS TO THE INITIAL
23 ORDERS FOR THESE DRUGS FOR MR. ALLDREDGE, DO YOU HAVE AN
24 OPINION AS TO WHETHER THESE DOSAGE AMOUNTS WERE APPROPRIATE?
25 LET'S START WITH THE TRAZODONE.
2298
1 A. WE HAVE TRAZODONE IN THE ELDERLY 25 OR 50 MILLIGRAMS AT
2 BEDTIME. THE TRAZODONE WAS ORDERED AS ROUTINE AT
3 100 MILLIGRAMS, SO THAT WOULD BE TWO TO FOUR TIMES THE USUAL
4 DOSE.
5 Q. AND THEN WAS THERE A FURTHER DOSE OR A FURTHER ORDER FOR
6 TRAZODONE?
7 A. YEA, THE PATIENT, IF THE NURSES THOUGHT THAT HE NEEDED
8 IT, COULD HAVE HAD AN ADDITIONAL 100 MILLIGRAM DOSE.
9 Q. A TOTAL OF HOW MUCH?
10 A. IT WOULD HAVE BEEN A TOTAL OF 200 MILLIGRAMS.
11 Q. WHAT ABOUT THE BUSPAR ORDER, WAS THAT APPROPRIATE?
12 A. APPROPRIATE CLINICALLY?
13 Q. CLINICALLY. WELL, LET'S START WITH THE CHART.
14 A. THE DOSAGE ORDERED BY DR. WEITZEL -- IT WOULD BE EASIER
15 TO WORK FROM HIS ORDERS. 10 MILLIGRAMS, THREE TIMES A DAY.
16 BUSPAR WOULD BE 5 MILLIGRAMS TWICE A DAY SO THAT'S THREE
17 TIMES THE USUAL STARTING DOSE.
18 Q. WHAT ABOUT THE ATIVAN?
19 A. THE SINGLE DOSE THAT WAS GIVEN AS A NOW ORDER WAS
20 1 MILLIGRAM, IT'S HERE AND THE INTRAMUSCULAR INJECTION
21 EQUIVALENT ESSENTIALLY TO THE ORAL AMOUNT. SO A ONE-TIME
22 DOSE OF 1 MILLIGRAM WOULD HAVE BEEN APPROPRIATE. THE ONE TO
23 2 MILLIGRAMS EVERY FOUR HOURS AS NEEDED, I GUESS THE PATIENT
24 COULD HAVE RECEIVED SIX DOSES OF 2 MILLIGRAMS WHICH WOULD
25 HAVE BEEN 12 MILLIGRAMS.
2299
1 Q. WOULD THAT HAVE BEEN APPROPRIATE?
2 MR. STIRBA: YOUR HONOR, YOUR HONOR, I'M GOING TO
3 OBJECT. THIS IS -- IT SHOULD BE FOCUSING ON WHAT ACTUALLY
4 THE PATIENT GOT, NOT HYPOTHETICAL AND --
5 THE COURT: SUSTAINED. LET'S GO TO WHAT WAS
6 ACTUALLY GIVEN.
7 Q. (BY MS. BARLOW) LET'S LOOK AT THE HALDOL THAT WAS
8 ACTUALLY GIVEN.
9 A. OKAY.
10 Q. I'M GOING TO MOVE TO THE MEDICATION ADMINISTRATION
11 SECTION. IS THAT THE MULTIPLE M.A.R.S. THAT WE'VE HEARD
12 ABOUT FROM OTHER PEOPLE?
13 A. YES.
14 Q. OKAY.
15 A. DATE 1/10/96, LOOKING AT HALDOL, 10 MILLIGRAMS I.M. NOW.
16 Q. WAS THAT GIVEN?
17 A. ON 1-10 -- EXCUSE -- YEAH. 1/10/96 AT 2:15 P.M.
18 10 MILLIGRAMS WITH 1 MILLIGRAM PER DAY MAXIMUM WOULD HAVE
19 BEEN TEN TIMES THE DAILY MAXIMUM USUAL DOSE.
20 Q. WAS HALDOL ADMINISTERED SUBSEQUENT TO THAT ON ANY DAYS
21 THAT YOU CAN SEE?
22 A. 1/12/96 AT 0820, HALDOL 5 MILLIGRAMS I.M. THAT WOULD
23 HAVE BEEN FIVE TIMES THE USUAL DAILY DOSE.
24 Q. WERE THERE ANY --
25 A. -- DOSE.
2300
1 Q. EXCUSE ME. WERE THERE ANY OTHER ADMINISTRATIONS OF
2 HALDOL TO MR. ALLDREDGE?
3 A. WELL, THE ORDER WAS CHANGED ON 1/12/96.
4 Q. AND WHAT WAS IT CHANGED TO?
5 A. I'M READING 1/12/96 FROM THE PHYSICIAN'S ORDERS,
6 INCREASE HALDOL TO 10 MILLIGRAMS I.M. P.R.N., PATIENT
7 REFUSING ORAL MEDS, GIVE AT A.M. 1700 AND H.S. AS NEEDED.
8 Q. AND DID YOU SEE WHETHER THAT WAS ADMINISTERED PURSUANT
9 TO THAT ORDER?
10 A. I DO NOT SEE AN ADMINISTRATION UNDER THAT LINE OF THE
11 ORDERS.
12 Q. OKAY. LET'S LOOK AT THE TRAZODONE OR THE ADMINISTRATION
13 OF THE TRAZODONE.
14 A. TRAZODONE 100 MILLIGRAMS AT BEDTIME P.R.N. AND TRAZODONE
15 100 MILLIGRAMS AT BEDTIME.
16 Q. WAS THAT THE ORDER THAT YOU JUST READ?
17 A. OKAY.
18 Q. IF YOU WOULD LOOK AT PAGE NUMBER 45, MED NUMBER 45.
19 A. UH-HUH.
20 Q. DOES THAT SHOW TRAZODONE HAVING BEEN ADMINISTERED?
21 A. HERE WE HAVE DATE 1/11/96 AT 2220, THIS IS THE P.R.N.
22 DOSE, 100 MILLIGRAMS ADMINISTERED.
23 Q. AND IT APPEARS TO BE WRITTEN ON 43 BUT CIRCLED, DO YOU
24 KNOW WHAT -- INITIALS ARE IN BUT CIRCLED, DO YOU KNOW WHAT
25 THAT MEANS?
2301
1 A. I -- IT WOULD BE MY OPINION, I DON'T KNOW FOR A FACT
2 WHAT IT MEANS, IT USUALLY MEANS THE MEDICATION WAS NOT
3 ADMINISTERED.
4 Q. SO IF WE HAVE EVIDENCE ALREADY PRESENTED TO THE COURT
5 THAT THAT'S INDEED WHAT IT MEANS, THAT WOULD NOT SURPRISE
6 YOU?
7 A. CORRECT.
8 Q. LET'S LOOK AT THE BUSPAR ADMINISTRATION.
9 A. BUSPAR, 10 MILLIGRAMS, THREE TIMES A DAY ON 1/10/96.
10 THERE WERE NO ADMINISTRATIONS. ON 1/11 THERE WERE TWO DOSES
11 ADMINISTERED, WHICH WOULD BE 20 MILLIGRAMS. ON 1/12 THERE
12 WERE TWO DOSES ADMINISTERED WHICH WOULD BE 20 MILLIGRAMS.
13 ON EACH OF THOSE DAYS THERE'S A CIRCLED DOSE WHICH WOULD, I
14 GUESS, MEAN THAT IT WAS NOT ADMINISTERED.
15 Q. NOW, YOU SAY THERE WERE TWO ADMINISTERED AND THEN
16 THERE'S A SEPARATE CIRCLED DOSE; IS THAT CORRECT?
17 A. YES.
18 Q. OKAY. SO THAT'S 20 MILLIGRAMS EACH DAY, IS THAT WITHIN
19 THE ELDERLY STARTING DOSE?
20 A. FOR THE BUSPAR, IT'S DOUBLE THE USUAL STARTING DOSE.
21 Q. WHAT ABOUT THE ATIVAN?
22 A. ON 1/10 AT 2:15 WE HAVE THE ONE MILLIGRAM ADMINISTERED
23 NOW. WE HAVE THE AS NEEDED ORDER FOR 1 MILLIGRAM I.M. Q4
24 HOURS ON 1/11 AT 2230 IT'S ADMINISTERED. ON 1/12 AT 014 --
25 0415 IT'S ADMINISTERED. ON 1/12 AT 12:15 IT'S ADMINISTERED.
2302
1 SO HE APPEARS TO HAVE RECEIVED 1 MILLIGRAM ON 1/11 AND
2 4 MILLIGRAMS ON 1/12.
3 Q. IS THAT WITHIN THE NORMAL ELDERLY STARTING DOSE?
4 A. USUALLY SHOULD NOT EXCEED 2 MILLIGRAMS PER DAY, SO, NO.
5 Q. THEN IF YOU WOULD LOOK AT NUMBER OR PAGE NUMBER 47,
6 MED-NUMBER 47, THIS WAS WRITTEN -- EVIDENTLY THE ORDER DATE
7 IS 13TH OF JANUARY FOR ATIVAN?
8 A. YES.
9 Q. AND WHAT WAS THE ORDER?
10 A. ATIVAN 0.5 MILLIGRAMS I.M. Q 3 HOURS.
11 Q. AND HOW MUCH WAS GIVEN THAT DAY OF ATIVAN?
12 A. DOSE AT 08, 11, 14, 17, 20, 2300, 0200 THE NEXT DAY SO
13 HE STOPPED THERE. SO THAT'S ONE, TWO, THREE, FOUR, FIVE,
14 SIX DOSES ON THE 13TH. I GUESS THE COLUMN STILL CONTINUES
15 WITH THE 13TH SO I'M ASSUMING THAT THAT WAS THE SAME DATE
16 THEN. SO THAT WOULD HAVE BEEN 0200 IN THE MORNING THE 13TH,
17 IS THAT THE WAY I'M SUPPOSED TO READ THIS?
18 Q. NO. I THINK THE 0200 AND 0500 THE INITIAL SHOULD HAVE
19 MOVED OVER TO THE 14TH.
20 A. OKAY.
21 Q. BUT HOW MANY DOSES WERE GIVEN?
22 A. SIX DOSES OF 0.5 MILLIGRAMS.
23 Q. A TOTAL OF HOW MANY?
24 A. THREE MILLIGRAMS.
25 Q. AND IS THAT APPROPRIATE FOR MR. ALLDREDGE?
2303
1 A. THE 3 MILLIGRAM DOSE WOULD HAVE BEEN 50 PERCENT GREATER
2 THAN THE 2 MILLIGRAMS PER DAY MAXIMUM.
3 Q. THE NEXT ONE DOWN IS HALDOL. WILL YOU LOOK AND SEE WHAT
4 MR. ALLDREDGE WAS GIVEN AS TO HALDOL?
5 A. I HAVE LOOKING AT THE MED-RANGE WE HAVE I THINK COVERED
6 THE HALDOL, 5 MILLIGRAMS I.M. TIMES ONE AND 10 MILLIGRAMS
7 I.M. TIMES ONE. AND THEN ON THAT SAME PAGE, MED-0046
8 THERE'S HALDOL 10 MILLIGRAMS A.M. 1700 H.S. AS NEEDED WHICH
9 NONE WAS GIVEN. HALDOL 10 MILLIGRAMS I.M. Q 4 HOURS,
10 P.R.N., NONE GIVEN.
11 Q. WHAT ABOUT THE RISPERDAL?
12 A. RISPERDAL 1 MILLIGRAM EACH MORNING 1700 AND H.S. ON
13 1/10 THERE IS A DOSE OF 1 MILLIGRAM ADMINISTERED, TWO DOSES
14 ARE CIRCLED SO THAT WOULD BE 1 MILLIGRAM THAT WOULD BE
15 WITHIN THE TOTAL DAILY. AND THEN ON 1/11 TWO DOSES ARE
16 ADMINISTERED, ONE IS CIRCLED WHICH WOULD BE TWICE THE DOSE
17 AT 2 MILLIGRAMS. THEN ON 1/12 ALL THREE DOSES ARE HELD OR
18 CIRCLED.
19 Q. ANY OTHER INDICATIONS OF RISPERDAL BEING ADMINISTERED TO
20 MR. ALLDREDGE?
21 A. NO.
22 Q. DID THERE COME A POINT -- YOU COULD PROBABLY SIT BACK
23 DOWN AGAIN.
24 DID THERE COME A POINT WHEN MORPHINE WAS ORDERED FOR
25 MR. ALLDREDGE?
2304
1 A. YES.
2 Q. DO YOU RECALL WHEN THAT WAS?
3 A. FROM THE RECORD?
4 Q. YES.
5 A. FIRST DOSE THAT I FIND IS ON 1/13/96. YES, 1/13/96.
6 Q. BASED ON WHAT YOU SAW IN THE RECORDS ABOUT THE
7 ADMINISTRATION OF THE TRAZODONE, BUSPAR, ATIVAN, HALDOL AND
8 RISPERDAL --
9 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT. I
10 THINK THAT MISCHARACTERIZES THE TESTIMONY. I DON'T THINK
11 THIS PATIENT IT WAS TESTIFIED RECEIVED ANY TRAZODONE. I
12 THINK HE JUST TESTIFIED TO THAT.
13 THE COURT: DO YOU WANT TO REPHRASE THE QUESTION?
14 MS. BARLOW: YES, I WILL, I'M SORRY AND I WILL
15 RETRACK THE TRAZODONE I'M SORRY ABOUT THAT.
16 THE WITNESS: UM --
17 MS. BARLOW: EXCUSE ME.
18 Q. (BY MS. BARLOW) DID YOU FIND ANY TRAZODONE BEING
19 GIVEN?
20 A. YES.
21 Q. WHAT DAY?
22 A. ADMINISTERED ON 1/11/96. AND I THINK I COVERED THIS.
23 Q. I THINK YOU DID, TOO, I'M SORRY. I NEED TO KEEP MY
24 THINKING STRAIGHT.
25 A. TRAZODONE 100 MILLIGRAMS P.O. TIMES ONE AFTER H.S. DOSE
2305
1 P.R.N. INSOMNIA, SIGNED OFF AT 2220 AND INITIALLED.
2 Q. THANK YOU. SO I WILL GO BACK TO MY ORIGINAL QUESTION.
3 GIVEN THE --
4 MR. STIRBA: YOUR HONOR, MAY I VOIR DIRE THE
5 WITNESS ON THAT? I THINK THERE'S A CONFUSION HERE.
6 THE COURT: YES.
7 VOIR DIRE EXAMINATION
8 BY MR. STIRBA:
9 Q. THE ENTRY THAT YOU ARE REFERRING TO, DOCTOR, IS ON
10 MED-0045, TRUE?
11 A. YES.
12 Q. AND IT'S ACTUALLY IN THE SECTION AND IT HAS 1/11/96 AND
13 IT IS INITIALED AND IT SAYS TRAZODONE 100 MILLIGRAMS P.O.,
14 THAT WOULD BE BY MOUTH, AND IT'S A P.R.N. ORDER, CORRECT?
15 A. YES.
16 Q. AND THEN THERE'S A TWO CIRCLED, IS THERE NOT, RIGHT
17 ACROSS FROM THE DATE?
18 A. YES.
19 Q. AND IT'S TRUE, IS IT NOT, THAT THERE IS A
20 NONADMINISTRATIVE CODE ON THAT PARTICULAR DOCUMENT UP AT THE
21 TOP AND WHEN IT SAYS TWO IT MEANS REFUSED, TRUE?
22 A. YES.
23 Q. SO IT'S FAIR TO SAY, SIR, THAT BASED UPON WHAT YOU HAVE
24 IN FRONT OF YOU, YOU CAN'T SAY WHETHER THAT WAS RECEIVED OR
25 GIVEN, CAN YOU?
2306
1 A. THAT'S TRUE.
2 MR. STIRBA: THANK YOU.
3 MS. BARLOW: THEN I WILL GO FROM THERE.
4 DIRECT EXAMINATION, CONT'D
5 BY MS. BARLOW:
6 Q. LET'S LEAVE OFF THE TRAZODONE SINCE THERE SEEMS TO BE A
7 QUESTION AS TO WHETHER OR NOT IT WAS ACTUALLY ADMINISTERED.
8 THAT'S FINE, LET'S GO ON TO THE OTHERS.
9 BUSPAR, ATIVAN, HALDOL, RISPERDAL, WERE THESE ALL
10 ADMINISTERED TO MR. ALLDREDGE BETWEEN THE 10TH AND THE 13TH
11 OF JANUARY?
12 A. YES.
13 Q. WHAT EFFECT, IF ANY, WOULD THAT HAVE ON HIS BEHAVIOR IN
14 THE DOSAGES THAT WE'RE TALKING ABOUT HERE?
15 A. AS I'VE PRESENTED THE INFORMATION OF THE KNOWN EFFECTS
16 OF THESE DRUGS, THE PATIENT WOULD HAVE BEEN SEDATED, COULD
17 HAVE BEEN AGITATED, COULD HAVE LOST THE ABILITY TO CHEW,
18 SWALLOW APPROPRIATELY. HE COULD HAVE EXHIBITED EXTREME
19 CONFUSION, HE COULD HAVE EXHIBITED DISORDER ELIMINATION AS
20 FAR AS CONTINENCE OF BOWL OR BLADDER.
21 Q. IN YOUR REVIEW OF THE RECORDS, DID YOU SEE INDICATIONS
22 OF ANY OF THOSE THINGS IN THE NOTES OF HIS BEHAVIOR?
23 A. YES.
24 MS. BARLOW: YOUR HONOR, I WOULD LIKE THIS MARKED
25 FOR ILLUSTRATIVE PURPOSES.
2307
1 MR. STIRBA: YOUR HONOR, THIS IS A MATTER WE TALKED
2 ABOUT THIS MORNING. I HAVE THE SAME OBJECTIONS TO IT. I
3 THOUGHT IT WAS RESOLVED THIS MORNING BUT THEY --
4 MS. BARLOW: YOUR HONOR, WE HAVE REDACTED --
5 THE COURT: MAYBE WHAT WE OUGHT TO DO, LADIES AND
6 GENTLEMEN, WE'VE BEEN HERE FOR ABOUT AN HOUR. WHY DON'T WE
7 TAKE OUR FIRST AFTERNOON BREAK. DURING THIS TIME REMEMBER
8 IT IS YOUR DUTY NOT TO CONVERSE AMONG YOURSELVES OR TO
9 CONVERSE WITH OR ALLOW YOURSELVES TO BE ADDRESSED BY ANY
10 OTHER PERSON ON THE SUBJECT OF THE TRIAL. IT'S ALSO YOUR
11 DUTY NOT TO FORM OR EXPRESS AN OPINION UNTIL THE CASE HAS
12 BEEN FINALLY SUBMITTED TO YOU UNTIL AFTER YOU'VE HEARD ALL
13 THE EVIDENCE SO WHY DON'T YOU COME BACK, PLEASE AT 2:45.
14 (WHEREUPON THE JURY WAS EXCUSED.)
15 THE COURT: OKAY. PLEASE BE SEATED, THE RECORD
16 WILL REFLECT THAT THE JURY HAS LEFT. WHAT IS THE OBJECTION?
17 MR. STIRBA: YES. YOUR HONOR, I THOUGHT THAT WE
18 ADDRESSED THIS THIS MORNING, IF I MAY SEE THE DOCUMENT. THE
19 PROBLEM AS WE ADDRESSED IT THIS MORNING WAS THAT THIS IS A
20 MISLEADING, NONHELPFUL AID, IF YOU WANT TO CALL IT THAT.
21 NOW GRANTED THE GRAPH IS OUT, THAT WAS CLEAR. BUT ONCE
22 AGAIN, WE HAVE REFERENCES TO TRAZODONE WHICH I THINK WE ALL
23 PROBABLY AGREE NOW WERE NEVER RECEIVED BY MR. ALLDREDGE.
24 MS. BARLOW: YOUR HONOR, IF I CAN ADDRESS --
25 MR. STIRBA: IF I MAY FINISH.
2308
1 MS. BARLOW: WELL, IT DOESN'T SHOW THAT THE
2 TRAZODONE WAS GIVEN, I JUST WANTED TO CLARIFY.
3 MR. STIRBA: AND SEE, THAT'S THE PROBLEM, JUDGE. I
4 REALIZE THAT'S WHAT THEY WANT TO SAY, THEY WANT TO EXPLAIN
5 THE WHOLE THING. BUT MY POINT IS IT HAS TO BE IN THE NATURE
6 OF NOT BEING MISLEADING IN THE FIRST INSTANCE IN ORDER TO BE
7 SHOWN TO THE JURY AND WE HAVE TRAZODONE MENTIONED WHICH
8 NEVER WAS EVEN GIVEN. WE HAD THESE PILLS, ONCE AGAIN AS I
9 INDICATED TO THE COURT, HALDOL WAS NEVER GIVEN BY PILL FORM
10 TO MR. ALLDREDGE. IT DIDN'T HAPPEN. THOSE WERE ALL I.M.
11 INJECTIONS. SIMILARLY, ATIVAN WAS ALL I.M. INJECTIONS. I
12 MEAN, THESE ARE INDICATED LIKE PILLS AND THEY WEREN'T PILLS.
13 AND SO IT ISN'T, AS I THOUGHT THE COURT RULED THIS
14 MORNING, A JUST NAKED SUMMARY OF THE MEDICATIONS THAT WERE,
15 IN FACT, GIVEN AND THE DOSAGES. THIS IS SOMETHING THAT IS
16 ATTEMPTING TO DEMONSTRATE GRAPHICALLY SOMETHING ABOUT THE
17 NATURE OF WHAT HAPPENED, WHICH ISN'T ACCURATE. AND SO WE
18 OUGHT NOT TO DISPLAY IT IN FRONT OF THE JURY, WHETHER IT'S
19 AN AID, EXHIBIT, I DON'T CARE, IT'S NOT ACCURATE. AND WHAT
20 I THOUGHT THE COURT WAS SAYING IS TAKE ESSENTIALLY, SIMILAR
21 TO SOMETHING LIKE THIS WHERE YOU HAVE THE ACTUAL DRUG NAME
22 OR WHATEVER THE MEDICATION WAS, YOU HAVE THE AMOUNT, YOU
23 HAVE THE DAY, AND IT'S NEUTRAL AND IT'S FACTUAL AND IT
24 DOESN'T HAVE THESE GRAPHICS WHICH ARE MISLEADING AND
25 INACCURATE.
2309
1 AND I REALLY DON'T THINK IT HELPS THE PROCESS TO HAVE
2 THE WITNESS THEN SAY -- YOU KNOW, THEY DISPLAY IT TO THE
3 JURY, OKAY, HERE IS THE JURY AND THEY PUT IT UP HERE AND
4 THEN THE WITNESS JUST SAYS, WELL, WAIT A MINUTE, WELL, YEAH,
5 IT WASN'T REALLY IN PILL FORM AND THESE THINGS WERE NEVER
6 GIVEN AND THAT DA-DA-DA, BECAUSE THAT DOESN'T REALLY HELP
7 THE PROCESS. IT OUGHT TO BE STRAIGHT FORWARD, CLEAR,
8 WITHOUT ANY AMBIGUITIES AND THAT'S THE PROBLEM I HAVE WITH
9 EVEN DISPLAYING THIS TO THE JURY.
10 THE COURT: MS. BARLOW?
11 MS. BARLOW: YES. THANK YOU, YOUR HONOR. WHAT
12 THIS DOES -- I MEAN, IT COULD HAVE BEEN IN BOXES. THEY ARE
13 NOT BOXES, THEY ARE ROUND. THEY AREN'T SQUARE BLOCKS, THEY
14 ARE ROUND BLOCKS. ALL THAT DOES IS SHOW AMOUNTS. IT
15 DOESN'T SHOW HOW THEY WERE ADMINISTERED. IT DOESN'T MATTER
16 HOW THEY WERE ADMINISTERED. IT JUST SHOWS THAT THESE
17 AMOUNTS WERE ADMINISTERED. FOR EXAMPLE, THE HALDOL WHICH IS
18 IN BLUE, 1 MILLIGRAM PER DAY IS THE -- I THINK THE CORRECT
19 STARTING DOSE FOR THE ELDERLY.
20 AND SO WHAT THIS SHOWS IS THAT ON THIS DAY NOT JUST ONE
21 BUT ONE, TWO, THREE, FOUR, FIVE, SIX, SEVEN, EIGHT, NINE,
22 TEN, MILLIGRAMS WERE ADMINISTERED. THEN WE HAVE THE
23 RISPERDAL, 1 MILLIGRAM WAS ADMINISTERED. THE REASON WE HAVE
24 THESE OTHERS IS IT'S -- I THINK IT'S RELEVANT THAT THESE
25 WERE ORDERED, EVEN THOUGH THEY WEREN'T GIVEN. THEY WERE NOT
2310
1 GIVEN BECAUSE THEY WERE P.R.N. AND THE NURSES HELD THEM.
2 AND I THINK THAT HAS BEEN MADE RELEVANT IN THE COURSE OF
3 CROSS-EXAMINATION OF THE NURSES. WELL, DID YOU GIVE THAT,
4 WHY DIDN'T YOU GIVE THAT?
5 WHAT IS RELEVANT HERE, IN ADDITION TO WHETHER IT WAS
6 GIVEN OR NOT, IS THAT THE FACT THAT THE DEFENDANT ORDERED
7 IT. HE DIDN'T ORDER JUST ONE WHICH MIGHT BE APPROPRIATE
8 UNDER THE ELDERLY STARTING DOSE. HE ORDERED THREE, BUT THE
9 NURSES HELD TWO OF THEM. AND THAT'S WHY THESE THAT ARE
10 CIRCLED OR OUTLINED IN THE CERTAIN COLOR SHOWS THAT THAT WAS
11 RISPERDAL BUT IT WASN'T GIVEN BECAUSE IT'S BLANK, IT WAS
12 HELD.
13 THIS IS ILLUSTRATIVE OF THE TESTIMONY THAT DR. FEHLAUER
14 JUST GAVE AS TO WHAT HAPPENED ON THAT DAY. TRAZODONE, TWO
15 WERE ORDERED. ONE IS APPROPRIATE ELDERLY STARTING DOSE.
16 TWO WERE ORDERED BUT THEY ARE BLANK IN THE MIDDLE WHICH
17 MEANS, AND I THINK THE JURY CAN UNDERSTAND THIS AND IT'S NOT
18 MISLEADING, THAT THEY WERE NOT GIVEN BECAUSE HE'S ALREADY
19 TESTIFIED, THEY WERE HELD, THEY WERE NOT GIVEN BY THE NURSE.
20 PARTIAL PILL HERE WE HAVE ATIVAN, 2 MILLIGRAM PER DAY IS THE
21 INITIAL DAILY MAX. ONLY HALF WAS GIVEN THE FIRST DAY AND
22 THEN THE SECOND DAY.
23 BUT I THINK THIS IS VERY HELPFUL TO THE JURY AND I
24 DON'T THINK IT'S CONFUSING OR MISLEADING. THEY CAN
25 UNDERSTAND THAT A HALF A -- A HALF A DOSE DOWN HERE MEANS A
2311
1 HALF DOSE AND THAT EACH ONE OF THESE BLOCKS SIGNIFIES A
2 DIFFERENT -- A CERTAIN DOSAGE AMOUNT AND THAT EACH ONE THAT
3 IS BLANK IN THE MIDDLE BUT HAS A CERTAIN COLOR AROUND IT
4 MEANS THAT WAS ORDERED, WHICH IS VERY RELEVANT BECAUSE THE
5 DEFENDANT ORDERED IT, BUT IT WAS HELD AND NOT GIVEN, WHICH,
6 AGAIN, IS RELEVANT AS TO WHAT THEY ACTUALLY RECEIVED.
7 THEN WE'LL GET OVER HERE TO THE LAST DAY WHEN ALL OF
8 THESE OTHERS WERE HELD AND THEN YOU HAVE MORPHINE
9 15 MILLIGRAMS IS AN APPROPRIATE STARTING DOSE FOR THESE
10 PEOPLE. THEN YOU HAVE AN ADDITIONAL 45 MILLIGRAMS WHICH IS
11 WHAT THE DEFENDANT ORDERED, IT WAS 60 MILLIGRAMS TOTAL. AND
12 ON TOP OF THAT YOU HAVE IT LOOKS LIKE A DOSE AND A HALF OF
13 ATIVAN. I DON'T THINK THIS IS CONFUSING OR MISLEADING OR,
14 YOU KNOW, LEADING THE JURY ASTRAY. THEY CAN UNDERSTAND IT,
15 IF IT'S BLANK IT MEANS IT WAS ORDERED BUT NOT GIVEN. AND
16 IT'S RELEVANT THAT IT WAS ORDERED BECAUSE THE DEFENDANT DID
17 ORDER THESE DOSES THAT ARE BEYOND WHAT HE SHOULD HAVE BEEN
18 ORDERING.
19 SO, YES, IT'S VERY RELEVANT AS TO WHAT HE ACTUALLY GOT
20 BUT AS TO -- AS TO EVIDENCE OF WHAT THE DEFENDANT HAD IN
21 MIND. IT'S ALSO RELEVANT TO KNOW WHAT HE ORDERED IN
22 ADDITION TO WHAT WAS ACTUALLY RECEIVED.
23 THE COURT: BUT IF SOMETHING IS ORDERED THAT SAYS,
24 OKAY, WHAT WE'VE DESCRIBED AS P.R.N. --
25 MS. BARLOW: RIGHT.
2312
1 THE COURT: SO THAT THAT PLACES THE NURSE AS THE
2 PERSON WHO SAYS, OKAY, I OBSERVED THE PATIENT AND I MAKE A
3 DECISION BASED UPON WHAT I OBSERVED IN THE PATIENT, WHETHER
4 IT'S GIVEN OR NOT, AND IF I OBSERVED IT SHOULDN'T BE GIVEN
5 BECAUSE THE CONDITION THAT THE PRESCRIPTION IS FOR IS NOT
6 NEEDED RIGHT NOW, I DON'T GIVE IT. OKAY. THE PATIENT NEVER
7 GOT IT, EVEN THOUGH IT WAS ORDERED, THE PATIENT HASN'T
8 GOTTEN IT BECAUSE IT WAS A P.R.N. ORDER.
9 MS. BARLOW: BUT EVEN A P.R.N. ORDER THAT IS WELL
10 IN EXCESS OF WHAT THE ORDER SHOULD HAVE BEEN. I MEAN, MAYBE
11 ALL OF THESE SHOULD --
12 THE COURT: OKAY. A P.R.N. ORDER THAT WASN'T
13 ACTUALLY GIVEN IS RELEVANT TO WHAT?
14 MS. BARLOW: IT IS RELEVANT TO SHOW THAT THE
15 DEFENDANT ORDERED EXCESSIVE AMOUNTS OF MEDICATION FOR THESE
16 PEOPLE EVEN P.R.N. BECAUSE I MEAN A PHYSICIAN --
17 THE COURT: HOW IS IT CAUSALLY LINKED TO IF THESE
18 PATIENTS DIDN'T GET THAT MEDICATION THAT THAT WAS PART OF
19 THE CONSCIOUS, AWARE, KNOWLEDGE OR AWARENESS THAT HAVE TO BE
20 IN ANY OF THIS INTENTIONALLY, KNOWINGLY DEPRAVED
21 INDIFFERENCE OR RECKLESSLY FOR MANSLAUGHTER THAT WE GET FROM
22 SOMETHING THAT WAS DONE -- SOMETHING THAT WAS ORDERED THAT
23 DIDN'T HAPPEN?
24 MS. BARLOW: HE DIDN'T KNOW THAT IT WASN'T GOING TO
25 HAPPEN SO IT GOES DIRECTLY TO HIS KNOWLEDGE AND INTENT AND,
2313
1 YOU KNOW, DEPRAVED INDIFFERENCE, IF YOU WILL. HE ORDERED
2 IT; IT WASN'T GIVEN. NOT BECAUSE HE SAID DON'T GIVE IT. I
3 MEAN, THAT IS SO DIRECTLY GOING TO HIS KNOWLEDGE. HE, AS A
4 PHYSICIAN, A GERIATRIC SPECIALIST WITH THE GERIATRIC
5 STARTING DOSE HANDBOOK, SHOULD LOOK AT THIS AND SAY THIS
6 RISPERDAL THE MOST I SHOULD ORDER EVEN P.R.N. IS 1 MILLIGRAM
7 PER DAY. HE ORDERS THREE. NOW, HE DOESN'T THEN COME IN AND
8 SAY DON'T GIVE THE OTHER TWO BECAUSE IT'S DANGEROUS TO GIVE
9 THIS MUCH DRUG TO THIS PERSON. HE WITH THE HANDBOOK, LOOKS
10 AT IT AND SAYS, YOU KNOW, ONE IS OKAY, I'M GOING TO ORDER
11 THREE AND IF THE NURSES GIVE IT, GREAT. AND SO THAT -- I
12 THINK THAT IS VERY TELLING OF HIS MENTAL STATE.
13 HE DOESN'T ORDER WHAT IS A CORRECT DOSE. HE ORDERS
14 THREE TIMES THE CORRECT DOSE. AND IT'S ONLY FORTUNATE FOR
15 MR. ALLDREDGE THAT THE NURSES DON'T GIVE IT. BUT HE DOESN'T
16 ORDER IT AND THEN SAY, OH, BY THE WAY, DON'T GIVE THE OTHER
17 TWO DOSES BECAUSE THAT'S TOO HIGH. HE ORDERS IT AND THEN
18 JUST LEAVES IT UP TO FATE, I GUESS, WHETHER THE NURSES GIVE
19 IT OR NOT. SO I THINK THAT'S MOST RELEVANT ABOUT HIS MENTAL
20 STATE.
21 THE COURT: OKAY. MR. STIRBA?
22 MR. STIRBA: WELL, JUST IN TERMS OF THAT P.R.N --
23 SEE, I'M SORRY, I DON'T FOLLOW THIS LOGICALLY. WE KNOW WHAT
24 A P.R.N. ORDER IS. IT'S AN ORDER BY A PHYSICIAN GIVING THE
25 NURSE THE DISCRETION AS TO WHETHER OR NOT IF SHE ASSESSES
2314
1 CERTAIN THINGS TO GIVE THE MEDICATION OR NOT. IT'S TOTALLY
2 OUT OF HIS CONTROL. SO I DON'T UNDERSTAND THE PURPOSE TO BE
3 SERVED BY HAVING P.R.N. ORDERS WHICH WERE NEVER GIVEN, WHICH
4 ARE GIVEN AT THE DISCRETION OF THE NURSE ON THIS CHART.
5 AND MOREOVER, IT'S JUST GOING TO TEND TO CONFUSE THINGS
6 BY EVEN INCLUDING THINGS WHICH ARE NOT REALLY GIVEN. I
7 MEAN, IF YOU WANT TO PUT IN THINGS THAT WERE GIVEN, THAT'S
8 FINE, I GUESS. BUT IF YOU ARE GOING TO PUT IN THINGS THAT
9 WEREN'T GIVEN AND THEN YOU DON'T HAVE ANY INDICATION THEY
10 ARE P.R.N. AND I KNOW THE DOCTOR WAS JUST SHAKING HIS HEAD,
11 BUT I'VE HEARD THE TESTIMONY IN THIS COURTROOM AND I THINK
12 YOUR HONOR HAS HEARD THE TESTIMONY IN THIS COURTROOM, WE ALL
13 KNOW WHAT A P.R.N. ORDER IS BASED UPON WHAT THE NURSES HAVE
14 ALREADY SAID AND, YOU KNOW, THERE'S NO EXPLANATION OF THAT
15 IN THERE.
16 THIS IS AN ARGUMENTATIVE AID, THAT'S WHAT THIS IS. IT
17 OUGHT TO BE COME IN AND BE USED IN CLOSING SUMMATION ANYWAY
18 THEY WANT TO. BUT TO ACT AS IF THIS IS SOME NEUTRAL FACTUAL
19 RECITATION AND SUMMARY, I THINK BELIES THE GRAPHICS AND
20 BELIES BASICALLY WHAT WE HAVE HERE.
21 MS. BARLOW: YOUR HONOR, THAT IS NOT OUTSIDE OF HIS
22 POWER. IN FACT, THAT IS EXACTLY HIS POWER. IT IS HIS POWER
23 TO ORDER THREE TIMES THE NORMAL DOSE AND THIS CORRECTLY
24 DEMONSTRATES HIS CONDUCT. HE ORDERED THREE TIMES THE NORMAL
25 DOSE P.R.N. NOW, IF THE NURSES HAD GIVEN IT, THEN IT WOULD
2315
1 HAVE BEEN GIVEN. THAT'S NOT WHAT'S AT ISSUE HERE.
2 WHAT IS AT ISSUE IS WHAT DID THE DEFENDANT DO TO
3 EVIDENCE HIS MENTAL STATE. ORDERING THREE TIMES THE NORMAL
4 DOSE OR TWO TIMES THE NORMAL DOSE OR -- YEAH, I'LL SAY TWO
5 TIMES THE NORMAL DOSE OR THREE -- OKAY, I'VE SAID THAT.
6 THE COURT: OKAY. WELL, THE QUESTION IS -- THERE'S
7 TWO QUESTIONS. ONE IS WHETHER THIS WITNESS CAN TESTIFY
8 ABOUT THOSE ORDERS WERE GIVEN, WHETHER THE ACTUAL MEDICATION
9 WAS RECEIVED OR NOT.
10 MS. BARLOW: YES.
11 THE COURT: HE CAN TESTIFY AND HE'S ALREADY
12 TESTIFIED ABOUT THAT. THE OTHER ISSUE IS WHETHER THIS
13 SHOULD BE ILLUSTRATIVE FOR THE JURY WITH THE WAY THAT IT'S
14 STILL FORMATTED. I MEAN, WHAT YOU DID IS YOU TOOK OFF THE --
15 MS. BARLOW: SYRINGES.
16 THE COURT: -- SYRINGES AND YOU TOOK OFF THE BOTTOM
17 OF THE CHART AND I JUST -- I HADN'T LOOKED AT EACH ONE OF
18 THESE ISSUES TO SEE WHAT BLANKS ONES MEANT. I JUST THOUGHT
19 THE PILLS WERE THERE, SO THAT'S AN ISSUE. WE NEED A BREAK
20 FOR THE COURT REPORTER AND EVERYONE ELSE. LET'S COME BACK
21 IN ABOUT FIVE MINUTES AND THEN I WILL RULE ON IT.
22 (A BRIEF RECESS WAS TAKEN.)
23 THE COURT: WE'RE ON THIS ISSUE WITHOUT THE JURY
24 BEING PRESENT REGARDING -- WHAT WAS THE NUMBER OF THE
25 EXHIBIT?
2316
1 MS. BARLOW: WHAT NUMBER IS THAT? LET'S SEE, IT IS
2 35.
3 THE COURT: OKAY. PLAINTIFF'S EXHIBIT 35. OKAY.
4 MR. STIRBA, ARE YOU MAKING AN OBJECTION THAT EVIDENCE CAN'T
5 BE GIVEN THAT THINGS WERE ORDERED BUT NOT GIVEN OR JUST THAT
6 THE WAY THE CHART DISPLAYS IT?
7 MR. STIRBA: NO. I THINK THEY CAN AND HE HAS
8 TESTIFIED ABOUT THINGS THAT WERE ORDERED AND NOT GIVEN. I'M
9 CONCERNED THE WAY THE CHART DISPLAYS IT. AND AS I SAY, I
10 THINK IT'S MISLEADING IN NATURE AND ONLY TENDS TO CONFUSE
11 THE ISSUES BEFORE THE JURY.
12 THE COURT: WELL, I GUESS HERE IS WHAT I'M GOING TO
13 SAY. I DON'T THINK IT'S THE CLEAREST THING. I'LL ALLOW IT
14 TO BE USED ON THIS BASIS: IF YOU HAVEN'T NOTICED, WHEN
15 YOU'VE BEEN TALKING ABOUT THINGS THAT PUT PEOPLE TO SLEEP OR
16 SLOW PEOPLE DOWN, TWO OR THREE OF THE JURORS HAVE HAD THEIR
17 HEADS NODDED, YOU KNOW. IT SEEMS TO ME THAT WE ARE JUST --
18 YOU KNOW, CAN'T WE GET TO THE POINT WHERE WE SAY DO YOU HAVE
19 AN OPINION AS TO WHAT HAPPENED TO THESE PEOPLE, WHAT CAUSED
20 THEIR DEATH, WHAT IS IT AND, YOU KNOW, GET ON. I THINK
21 WE'RE JUST -- YOU KNOW, WE'RE GOING LIKE THIS IN A
22 WHIRLPOOL, SLOWLY, SLOWLY, SLOWLY. WE'RE DOWN TO THE SECOND
23 WITNESS, HE'S GOT THREE MORE -- SECOND PATIENT, WE'VE GOT
24 THREE MORE TO GO. IS HIS TESTIMONY ANTICIPATED TO BE THREE
25 DAYS, FOUR DAYS OR --
2317
1 MS. BARLOW: NO, YOUR HONOR.
2 THE COURT: -- OR ONE DAY? BECAUSE I DON'T SEE IT
3 GETTING DONE TODAY. I DON'T EVEN SEE IT GETTING DONE ON
4 DIRECT TODAY, DO YOU, OR DO YOU?
5 MS. BARLOW: I THINK WE'RE CLOSER TO IT. I MEAN,
6 THE THINGS LIKE, YOU KNOW, WHAT THE DRUGS DO TAKE A LITTLE
7 BIT OF TIME --
8 THE COURT: I KNOW BUT WE'VE DONE -- THIS IS THE
9 SECOND PERSON THAT HOPEFULLY -- THE SECOND PATIENT, WE HAVE
10 THREE MORE TO GO.
11 MS. BARLOW: AND, YOUR HONOR, IF I CAN USE THESE AS
12 INDICATED BY THE COURT, YOU KNOW, MAYBE I'LL JUST JUMP
13 STRAIGHT TO THESE RATHER THAN GO THROUGH THE MED RECORDS
14 THAT WE WERE JUST DOING HERE.
15 THE COURT: THAT'S FINE. I'LL SAY ONE THING FOR
16 THIS WITNESS. THIS WITNESS IS VERY GOOD SAYING WHERE THE
17 EXHIBIT -- YOU KNOW, WHERE HE'S LOOKING AT IN THE RECORD.
18 BUT IF YOU ASK A QUESTION WAS SOMETHING GIVEN HE CAN SAY
19 YES. HE DOESN'T HAVE TO SAY I'M LOOKING AT DR. WEITZEL, HE
20 GAVE THIS NOTE ON THIS DAY, IT WAS A TELEPHONE ORDER. YOU
21 KNOW, WE DON'T HAVE TO DO THAT. IT'S JUST -- WAS IT GIVEN,
22 YES IT WAS. SHOULD IT HAVE BEEN GIVEN, NO, IT SHOULDN'T OR
23 WHATEVER HIS TESTIMONY IS GOING TO BE. BUT I THINK WE'RE
24 BOGGED DOWN INTO THINGS. GIVE THE ANSWER AND IF ANYBODY
25 WANTS TO QUESTION ABOUT WHETHER IF HE'S SAYING IT RIGHT OR
2318
1 NOT, THEY CAN QUESTION ABOUT IT, BUT I THINK WE NEED TO MOVE
2 IT. I THINK WE'RE GETTING BOGGED DOWN. SO YOU CAN USE IT.
3 ONE THING I'M NOT GOING TO ALLOW IS THAT FOR HIM TO GIVE HIS
4 TESTIMONY AND THEN TO GIVE IT A SECOND TIME WITH THE CHART.
5 MS. BARLOW: RIGHT. AND, YOUR HONOR, IN THE FUTURE
6 I WILL JUST GO STRAIGHT TO THE CHART AND WE'LL GO THAT WAY.
7 THE COURT: ALL RIGHT.
8 MR. STIRBA: JUST REAL QUICK. THAT'S NOT EVIDENCE,
9 IT'S JUST ILLUSTRATIVE?
10 THE COURT: IT'S ILLUSTRATIVE, ABSOLUTELY. YEAH,
11 I'M NOT MAKING ANY RULING ABOUT EVIDENCE. I'M SAYING THAT
12 IT CAN BE USED WITH THIS WITNESS'S TESTIMONY, THAT'S WHAT I
13 WAS ADDRESSING. OKAY. DAVE, COULD YOU PLEASE CONTACT THE
14 OTHER BAILIFF ABOUT THE JURY, PLEASE?
15 ONE THING I WAS ALSO GOING TO ASK COUNSEL, DO YOU HAVE
16 ANY PROBLEM TOMORROW IF WE START AT 8 O'CLOCK AND FINISH AT
17 4:30 TOMORROW ON FRIDAY?
18 MR. STIRBA: I HAVE NO PROBLEM WITH THAT, JUDGE.
19 MS. BARLOW: I GUESS I SHOULDN'T SPEAK FOR MR.
20 WILSON, HE HAS THE NEXT WITNESS. WE'LL CERTAINLY TRY TO GET
21 OUR --
22 THE COURT: THIS WITNESS WILL STILL BE ON THE STAND
23 AT 8 O'CLOCK UNLESS SOME MIRACLE HAPPENS. HOW IS OUR COURT
24 REPORTER?
25 (WHEREUPON THE JURY ENTERS THE COURTROOM.)
2319
1 THE COURT: PLEASE BE SEATED. THE RECORD WILL
2 REFLECT THAT THE JURY HAS RETURNED. LADIES AND GENTLEMEN, I
3 WAS GOING TO ASK YOU AND I ASKED THE ATTORNEYS PRIOR TO YOU
4 COMING BACK, WOULD ANYBODY BE HEARTBROKEN IF WE START AT 8
5 A.M. AND END AT 4:30 INSTEAD OF STARTING AT 8:30 AND GOING
6 TO FIVE? OR IS ANYBODY NOT ABLE TO BE HERE AT EIGHT BECAUSE
7 OF YOUR SCHEDULE? THEN WHAT WE WILL DO TOMORROW WE'LL SAY
8 THAT AT THE END OF THE DAY, TOO, BUT WE'LL START AT 8 A.M.
9 AND THEN WE'LL CONCLUDE AT 4:30. WE JUST HAD A QUESTION
10 FROM THE JURY WONDERING IF THEY COULD HAVE A DAY WHERE THEY
11 COULD WEAR SHORTS.
12 MR. STIRBA: IF WE CAN, TOO.
13 MS. BARLOW: NOT WITH MY --
14 THE COURT: NOT WITH SOME OF YOUR LEGS, NO.
15 MS. BARLOW: NOT ME.
16 THE COURT: AND NOBODY WANTS TO SEE MINE SO...THE
17 QUESTION WAS CAN WE WEAR SHORTS AND ALSO WONDERING IF WE
18 COULD HAVE SOME KIND OF PICNIC UMBRELLA AND CHAIRS PLACED
19 OUTSIDE FOR SHADE. I DON'T KNOW ABOUT THAT. I WILL ASK IF
20 THERE'S ANYTHING OR IF ANYBODY WANTS TO BRING SOMETHING, I
21 DON'T THINK THERE'S ANY PROBLEM ABOUT THAT. BUT DOES
22 ANYBODY OPPOSE IF THERE'S A DAY WHERE THE JURORS AGREE THAT
23 WE WEAR SHORTS, IS THAT A PROBLEM?
24 MS. BARLOW: CASUAL FRIDAY WORKS FOR THE STATE,
25 YOUR HONOR.
2320
1 THE COURT: OKAY. IF YOU WANT TO DO THAT. I WILL
2 CHECK TO SEE -- I DON'T KNOW IF WE HAVE ANY PICNIC UMBRELLAS
3 OR ANYTHING OUT HERE. IF YOU HAVE SOMETHING YOU WANT TO
4 BRING, I KNOW IT'S SUNNY OUT THERE AND THERE ARE NO TREES
5 BUT THAT'S ALL I CAN SAY. I CAN'T -- I CAN'T SPEAK TO THE
6 UMBRELLA, PICNIC UMBRELLA, SO...OKAY. IF YOU WOULD LIKE TO
7 GO AHEAD, MS. BARLOW.
8 MS. BARLOW: THANK YOU, YOUR HONOR.
9 Q. (BY MS. BARLOW) DR. FEHLAUER, I'LL SHOW YOU WHAT'S
10 BEEN MARKED NUMBER 35. DO YOU KNOW WHAT THIS IS?
11 A. YES, I DO.
12 Q. DID YOU PREPARE IT?
13 A. I WAS INVOLVED IN THE PREPARATION OF THIS, YES.
14 Q. HAVE YOU REVIEWED IT FOR ACCURACY?
15 A. I HAVE REVIEWED IT FOR ACCURACY.
16 Q. TO THE BEST OF YOUR KNOWLEDGE, DOES IT ACCURATELY
17 REFLECT WHAT IS FOUND IN THE MEDICAL RECORDS OF THIS CASE?
18 A. TO THE BEST OF MY KNOWLEDGE, YES.
19 Q. AND HAVE YOU CHECKED FOR THAT?
20 A. I PERSONALLY HAVE NOT CHECKED THIS CHART FOR THE EXACT
21 DOSAGES ADMINISTERED, NO.
22 Q. DID YOU CHECK THE SMALL -- BEFORE IT WAS BLOWN UP?
23 A. I DID NOT CHECK THESE CHARTS FOR EXACT DOSAGES, NO.
24 MS. BARLOW: OKAY. IF WE MAY DISPLAY THIS TO THE
25 JURY, YOUR HONOR.
2321
1 THE COURT: OKAY.
2 Q. (BY MS. BARLOW) THANK YOU. DR. FEHLAUER, IF YOU WILL
3 STEP DOWN HERE. LET'S PUT THIS ON HERE. YOU'VE TESTIFIED
4 AS TO THE AMOUNT OF MEDICATION THAT WAS ADMINISTERED. YOU
5 TESTIFIED TO THE ATIVAN. PERHAPS IF FIRST WE CAN EXPLAIN.
6 THE PINK IS ATIVAN AND WHAT DOES ONE ROUND LOZENGE LOOKING
7 THING REPRESENT?
8 A. THE ONE ROUND LOZENGE LOOKING LIKE PURPLE ITEM HERE
9 REPRESENTS THE MAXIMUM DAILY AMOUNT FOR AN ELDERLY PERSON OF
10 THE DRUG ATIVAN, OKAY? SO ONE LOZENGE REPRESENTS ONE
11 MAXIMUM DAILY DOSE.
12 Q. THE ATIVAN IT SEEMS TO BE CUT IN HALF, WHAT DOES THAT
13 MEAN?
14 A. THAT REPRESENTS THE FACT THAT THE PATIENT WAS
15 ADMINISTERED ONE HALF OF THE MAXIMUM DAILY USUAL DOSE FOR AN
16 OLDER PERSON.
17 Q. AND HALDOL IS IN BLUE AND IT APPEARS TO BE ONE, TWO,
18 THREE, FOUR, FIVE, SIX, SEVEN, EIGHT, NINE, TEN LOZENGES,
19 WHAT DOES THAT --
20 MR. STIRBA: YOUR HONOR, YOUR HONOR, I THINK I HAVE
21 A FOUNDATIONAL -- IF WE'RE GOING TO TALK ABOUT MAXIMUM
22 DOSING, I DON'T THINK THERE'S BEEN ANY TESTIMONY ON THAT. I
23 DIDN'T UNDERSTAND THAT THAT CHART DISPLAYS THAT. COULD WE
24 HAVE SOME FOUNDATION, PLEASE?
25 THE COURT: OKAY. IF YOU WOULD LIKE TO LAY A
2322
1 FOUNDATION.
2 MS. BARLOW: WELL, YOUR HONOR, HE HAS TESTIFIED AS
3 TO WHAT THE MAXIMUM ELDERLY STARTING DOSE FOR ALL OF THESE
4 DRUGS IS, THAT WAS THE EARLIER CHART.
5 MR. STIRBA: BUT I UNDERSTOOD HE WAS TESTIFYING AS
6 TO THE MAXIMUM DAILY DOSE WHICH IS DIFFERENT THAN THE
7 INITIAL STARTING DOSE WHICH I DO BELIEVE HE'S TESTIFIED TO.
8 I THINK WE NEED TO BE CLEAR.
9 MS. BARLOW: OKAY. I WILL ASK THAT.
10 THE COURT: THEN LET'S --
11 MS. BARLOW: OKAY. THEN I WILL ASK THAT.
12 Q. (BY MS. BARLOW) YOU'VE TESTIFIED ABOUT THE INITIAL
13 STARTING DOSE. DOES THAT DIFFER FROM THE MAXIMUM DAILY DOSE
14 FOR ELDERLY PATIENTS?
15 A. THE CHART THAT WE HAVE BEEN OVER SHOWED THE USUAL
16 STARTING DOSE, HOW MANY TIMES A DAY THAT USUAL DOSE WOULD BE
17 GIVEN AND I'VE TALKED ABOUT THE MAXIMUM USUAL STARTING DAILY
18 DOSE.
19 Q. AND HOW DOES THAT DIFFER FROM WHAT YOU ARE TESTIFYING
20 HERE?
21 A. WHAT THIS IS IS THE USUAL STARTING DAILY DOSE MAXIMUM,
22 SO THE AMOUNT THAT WOULD NOT USUALLY BE RECOMMENDED TO BE
23 EXCEEDED OF THE STARTING DOSE IN A DAY.
24 Q. AND WE HAVE THIS OCCASION, WE HAVE THREE DAYS WHERE THIS
25 IS GIVEN. WOULD THE AMOUNT -- THE MAXIMUM DAILY AMOUNT VARY
2323
1 FROM ONE DAY TO THE NEXT FROM A STARTING DOSE TO MAYBE BEING
2 ON IT FOR A FEW DAYS?
3 A. IT VARIES WITH THE DRUG AND THAT IS TO SAY WHAT INTERVAL
4 SHOULD YOU USE TO DECIDE THAT, WELL, NOW WE'RE NOT AT THE
5 STARTING DOSE, OKAY? IS THE SECOND DAY THE INTERVAL THAT
6 THE STARTING DOSE SHOULD BE CHANGED? ARE WE NOW NOT AT
7 STARTING DOSE, WE'RE -- WHAT'S THE NEXT USUAL DOSE OR IS IT
8 THE THIRD DAY OR IS IT THE FIFTH DAY?
9 Q. WELL --
10 A. AND THAT VARIES FROM DRUG TO DRUG.
11 Q. WITH THE DRUGS WE'RE TALKING ABOUT HERE, WERE WE BEYOND
12 WHAT WOULD BE THE INITIAL STARTING DOSE THAT YOU COULD HAVE
13 GIVEN MORE?
14 A. THE ATIVAN IS AT ONE HALF THE MAXIMUM, THAT'S
15 APPROPRIATE. THE HALDOL IS ONE, TWO, THREE, FOUR, FIVE,
16 SIX, SEVEN, EIGHT, NINE TEN TIMES ON THE FIRST DAY THE
17 STARTING DAY. THE RISPERDAL IS GIVEN, THIS DARK CIRCLE AT
18 ONE TIME OR EQUAL TO THE DAILY DOSE MAXIMUM.
19 Q. AND THEN WE HAVE -- THE RISPERDAL APPEARS TO BE KIND OF
20 IN AN ORANGE AND THEN WE HAVE TWO LOZENGES THAT ARE OUTLINED
21 WITH ORANGE BUT ARE BLANK IN THE MIDDLE, WHAT DOES THAT
22 MEAN?
23 A. THAT MEANS THAT IT WAS PRESCRIBED, THE ORDER WAS WRITTEN
24 BY THE DOCTOR THAT IT COULD BE GIVEN IF THE NURSE IS WILLING
25 TO ADMINISTERED IT AND BECAUSE IT'S OUTLINED, IT WAS NOT
2324
1 ADMINISTERED. IT WAS ORDERED BUT NOT ADMINISTERED.
2 Q. AND THE TRAZODONE IS GREEN BUT IT IS JUST OUTLINED, WHAT
3 DOES THAT MEAN?
4 A. AGAIN, IT MEANS THAT IT WAS ORDERED BUT IT WAS NOT
5 ADMINISTERED.
6 Q. SO THAT'S THE DISCUSSION WE HAD EARLIER ABOUT THE
7 TRAZODONE; IS THAT CORRECT?
8 A. YES.
9 Q. SO THAT IS THE 10TH OF JANUARY. ON THE 11TH OF JANUARY
10 DOES THIS -- DOES THIS DOSAGE AND ORDER AMOUNT COMPORT WITH
11 WHAT YOU FOUND IN THE RECORDS, THAT ATIVAN WAS HALF DOSE, ET
12 CETERA?
13 A. TO THE BEST OF MY KNOWLEDGE, THIS REPRESENTS ACCURATELY
14 THE AMOUNTS ADMINISTERED AND ORDERED.
15 Q. SO WE HAD ATIVAN WAS HALF. HOW MUCH BUSPAR WAS ORDERED?
16 A. EACH ONE OF THESE CYLINDRICAL GRAYISH GREEN REPRESENTS
17 10 MILLIGRAMS INITIAL DAILY MAXIMUM DOSE AND WE HAVE TWO OF
18 THOSE, SO THAT WOULD BE TWO TIMES GIVEN. AND WE HAVE A
19 THIRD BLANK ONE WHICH INDICATES NOT ADMINISTERED BUT ORDERED
20 AND SO THE AMOUNT ORDERED WAS THREE TIMES ACTUALLY
21 ADMINISTERED WAS TWO TIMES THE USUAL DAILY MAXIMUM.
22 Q. WITH THE RISPERDAL, HOW MUCH WAS ORDERED?
23 A. RISPERDAL BEING THE ORANGE --
24 Q. UH-HUH.
25 A. -- CYLINDERS, 1 MILLIGRAM PER DAY MAXIMUM USUAL INITIAL
2325
1 DAILY DOSE. ONE, TWO, THREE ORDERED, TWO ADMINISTERED.
2 Q. WHAT ABOUT THE TRAZODONE?
3 A. TRAZODONE IS NOT APPARENT ON THIS ITEM.
4 Q. THIS IS NOT TRAZODONE?
5 A. OH, EXCUSE ME.
6 Q. SORRY.
7 A. TRAZODONE, THE GRAYISH GREEN, I GOT IT CONFUSED WITH THE
8 BUSPAR AGAIN. THE MAXIMUM DAILY WOULD BE 50 MILLIGRAMS
9 THAT'S WHAT EACH ONE OF THESE CYLINDERS REPRESENT. TWO OF
10 THE CYLINDERS MEANS THAT 200 MILLIGRAMS WAS ADMINISTERED OR
11 TWO TIMES THE MAXIMUM.
12 Q. ON THE NEXT DAY, THE 12TH, WERE EXCESSIVE AMOUNTS OF
13 ATIVAN ORDERED AND ADMINISTERED?
14 A. YES. BASED ON MY PRIOR TESTIMONY, THE GIVEN -- THE
15 USUAL MAXIMUM DAILY DOSE, AT LEAST TWO TIMES THE AMOUNT OF
16 ATIVAN WAS ADMINISTERED RELATIVE TO THE USUAL.
17 Q. WHAT ABOUT THE HALDOL?
18 A. HALDOL, TEN TIMES.
19 Q. BUSPAR?
20 A. AGAIN, TWO TIMES.
21 Q. WAS IT ACTUALLY ADMINISTERED? WHAT ABOUT ORDERED?
22 A. TWO TIMES ADMINISTERED, THREE TIMES ORDERED.
23 Q. WAS RISPERDAL ORDERED?
24 A. RISPERDAL WAS ORDERED BUT NOT ADMINISTERED.
25 Q. TRAZODONE?
2326
1 A. TRAZODONE ORDERED BUT NOT ADMINISTERED.
2 Q. WAS THERE A CHANGE -- WELL, ON THE 13TH OF JANUARY, WAS
3 THERE A CHANGE IN THE MEDICAL ORDER?
4 A. YES, THERE WAS.
5 Q. AND BASED ON THIS CHART, WHAT WAS ADMINISTERED ON THE
6 13TH AS FAR AS MEDICATION IS CONCERNED?
7 A. AT THE VERY TOP OF THE CHART WE HAVE THE ATIVAN, THE
8 2 MILLIGRAMS DAILY MAXIMUM BEING A FULL CIRCLE, THE ONE HALF
9 CUT BEING A 1 MILLIGRAM. SO THIS WOULD BE 50 PERCENT
10 GREATER THAN THE USUAL DAILY MAXIMUM STARTING DOSE.
11 Q. THEN ON THE 13TH ALSO WE HAVE IT APPEARS THAT MORPHINE
12 IS BEGUN THAT DAY. WHAT'S THE MAXIMUM DAILY DOSE OF
13 MORPHINE?
14 A. WELL, MORPHINE IS ADMINISTERED FOR A BENEFICIAL EFFECT
15 AND THE AMOUNT TO BE ADMINISTERED CAN BE CALCULATED FOR
16 VARIOUS PURPOSES, BUT WHAT'S LISTED IN THE TEXTS THAT I USED
17 WAS THE DOSE OF 10 MILLIGRAMS EVERY FOUR HOURS AS A USUAL
18 STARTING DOSE AND 2.5 MILLIGRAMS BY INJECTION EVERY FOUR TO
19 SIX HOURS AS A STARTING DOSE.
20 Q. BASED ON THAT, WHAT IS THE MAXIMUM STARTING DOSE FOR THE
21 ELDERLY?
22 A. WELL, BASED ON THAT CALCULATION --
23 MR. STIRBA: YOUR HONOR, THE QUESTION IS VAGUE AND
24 AMBIGUOUS. I THOUGHT THE WITNESS TESTIFIED THERE IS NO SUCH
25 THING AS A MAXIMUM DOSE AND HE'S TESTIFYING ABOUT THE
2327
1 STARTING DOSE INDICATED IN THE DOSING HANDBOOK. THE
2 QUESTION WAS, WHAT IS THE MAXIMUM STARTING DOSE? I DON'T
3 THINK WE HAVE THAT, I DON'T THINK HE'S TESTIFIED TO THAT.
4 THE COURT: OKAY. REPHRASE THE QUESTION.
5 Q. (BY MS. BARLOW) ACCORDING TO THE GERIATRIC DOSING
6 HANDBOOK, WHAT IS THE MAXIMUM AMOUNT OF MORPHINE, STARTING
7 DOSE OF MORPHINE THAT SHOULD BE GIVEN A DAY -- PER DAY FOR
8 THE ELDERLY?
9 A. IF YOU TAKE THE DOSE OF 2.5 MILLIGRAMS EVERY FOUR HOURS,
10 THAT WOULD BE SIX ADMINISTRATIONS A DAY, THAT WOULD BE
11 15 MILLIGRAMS.
12 Q. IS THAT WHAT IS REPRESENTED BY THE RED PORTION ON EACH
13 ONE OF THESE?
14 A. THE RED PORTION ON EACH ONE OF THESE REPRESENTS A 15
15 MILLIGRAM DAILY DOSE.
16 Q. WHAT IS REPRESENTED IN THE BLACK PORTION?
17 A. THE BLACK PORTION REPRESENTS THE AMOUNT OF DRUG IN
18 EXCESS OF THE 15 MILLIGRAMS PER DAY THAT MR. ALLDREDGE
19 ACTUALLY RECEIVED.
20 Q. AND WHAT IS THIS WRITTEN DOWN HERE AT THE BOTTOM?
21 A. AT THE BOTTOM THE TOTAL AMOUNT ACTUALLY ADMINISTERED WAS
22 60 MILLIGRAMS.
23 Q. AND THEN ON THE 14TH WE HAVE A BLANK SPACE AT THE TOP
24 HERE, WHAT DOES THAT MEAN?
25 A. THE BLANK SPACE INDICATES THAT THE MEDICATION WAS NOT
2328
1 ADMINISTERED BUT WAS ORDERED.
2 Q. OKAY. AGAIN, WE HAVE 15 MILLIGRAMS WHICH IS THE INITIAL
3 STARTING DOSE MAXIMUM. HOW MUCH WAS ACTUALLY GIVEN ON THE
4 14TH?
5 A. FIFTY -- IT APPEARS THAT THE TOTAL ADMINISTERED WAS 40
6 MILLIGRAMS. IT'S NOT CLEAR THAT THIS 10 MILLIGRAMS WAS
7 ADMINISTERED.
8 Q. AND THE ATIVAN, HOW MUCH OF THAT?
9 A. THREE QUARTERS OF THE MAXIMUM INITIAL DOSE OR ONE AND A
10 HALF MILLIGRAMS.
11 Q. THANK YOU.
12 IN YOUR REVIEW OF THE MEDICAL RECORDS FOR MR.
13 ALLDREDGE, DID YOU SEE THE CHANGE IN ORDER TO MORPHINE ON
14 THE 13TH?
15 A. YES, I DID.
16 Q. DID YOU SEE ANYTHING IN THE RECORDS INDICATING WHY THAT
17 ORDER WAS CHANGED?
18 A. FROM THE PROGRESS NOTES OF THE 13TH DR. WEITZEL'S NOTE
19 INDICATES THAT THE PATIENT --
20 MR. STIRBA: WELL, HE'S GOING TO READ IT BUT NOT
21 CHARACTERIZE IT, YOUR HONOR. IF HE WANTS TO READ IT, THAT'S
22 FINE.
23 Q. (BY MS. BARLOW) YES, IF YOU WILL READ HIS NOTE OF THE
24 13TH. THANK YOU.
25 A. I WILL. PATIENT SEEMS INCOHERENT, UNRESPONSIVE, CRYING,
2329
1 NEEDS RESTRAINT. M.R.I., MAGNETIC RESONANCE IMAGING, SHOWS
2 LEFT OCCIPITAL INFARCT, U.A. IS PYURIC.
3 Q. WHAT DOES PYURIC MEAN?
4 A. CONTAINS BLOOD CELLS EVIDENCE OF INFLAMMATION OR
5 INFECTION. GLUCOSE LEVEL AT 40 PER ACCU-CHECKS.
6 Q. AND WHAT DOES GLUCOSE LEVEL AT 40 MEAN?
7 A. GLUCOSE LEVEL OF 40 IS VERY LOW.
8 Q. IF YOU WOULD GO ON.
9 A. HE IS AFEBRILE.
10 Q. MEANING?
11 A. WITHOUT FEVER. V.S.S.
12 Q. DO YOU KNOW WHAT THAT MEANS?
13 A. VITAL SIGNS STABLE. CHEM SEVEN REVEALS GLUCOSE OF 226.
14 Q. WHAT DOES THAT MEAN?
15 A. THE BLOOD SUGAR WAS THEN ELEVATED ABOVE NORMAL.
16 Q. OKAY.
17 A. N.A., SODIUM, INCREASED AT 148, K+ AND I CAN'T
18 DEFINITELY INTERPRET THAT. I BELIEVE IT'S ADEQUATE.
19 Q. WHAT'S K+?
20 A. POTASSIUM.
21 Q. OKAY.
22 A. A WITH A CIRCLE AROUND IT. ASSESSMENT: CVA, CEREBRAL
23 VASCULAR ACCIDENT OR STROKE; U.T.I., URINARY TRACT
24 INFECTION; DEHYDRATION. APPEARS TO BE QUITE UNCOMFORTABLE.
25 I.D.D.M., INSULIN DEPENDENT DIABETES MELLITUS; MYCOSIS
2330
1 FUNGOIDES.
2 Q. WHAT'S THAT?
3 A. MYCOSIS FUNGOIDES IS A FORM OF LYMPHOMA. IT'S A
4 LOW-GRADE LYMPHOMA THAT INVADES THE SKIN, IT CAN INVADE
5 OTHER ORGANS. PATIENTS CAN SURVIVE A NUMBER OF YEARS
6 WITHOUT SIGNIFICANT TREATMENT IN ITS LOWEST STAGES AND CAN
7 SURVIVE QUITE LONG AFTER TREATMENT EVEN WHEN IT'S IN A MORE
8 ADVANCED STAGE.
9 Q. AND THEN P?
10 A. P CIRCLED, PLAN: WILL ATTEMPT TO CALL WIFE WORK OUT A
11 PLAN WITH HER, SIGNATURE DR. WEITZEL.
12 Q. LET'S GO BACK TO THAT. DO YOU SEE ANYTHING IN THERE
13 JUSTIFYING THE ADMINISTRATION OF MORPHINE?
14 A. THE MATERIAL THAT SUPPORTS THE USE OF MORPHINE IS THE
15 STATEMENT "APPEARS TO BE QUITE UNCOMFORTABLE."
16 Q. DID YOU HAVE OCCASION TO LOOK AT THE M.R.I. REPORT?
17 A. I DID.
18 Q. DID IT SHOW A CVA?
19 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT.
20 THAT'S BEEN A SUBJECT OF SOME DISCUSSION AND I DON'T THINK
21 IT'S RELEVANT AND I THINK IT'S BEYOND THE SCOPE. AND I
22 THINK IT'S 403.
23 THE COURT: IF YOU COULD GO ON TO SOMETHING ELSE.
24 Q. (BY MS. BARLOW) OKAY. APPEARS TO BE QUITE
25 UNCOMFORTABLE. IS THAT A SYMPTOM OF PAIN?
2331
1 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT. I
2 DON'T THINK THAT LENDS ITSELF TO AN OPINION, AN EXPERT
3 OPINION INTERPRETING THE DOCTOR'S NOTES.
4 THE COURT: I THINK IT DOES CALL FOR SPECULATION,
5 THAT'S SUSTAINED.
6 Q. (BY MS. BARLOW) DID YOU SEE ANYTHING IN THE MEDICAL
7 RECORDS OF MR. ALLDREDGE THAT COULD SHOW SIGNS OF PAIN?
8 A. YES. I DID IN THE NURSES' NOTES, NOT IN THE PHYSICIAN'S
9 NOTES.
10 Q. WHAT DID YOU FIND IN THE NURSES' NOTES THAT COULD BE
11 SIGNS OF PAIN?
12 A. FROM THE 13TH...THAT'S SURPRISING. CAN I HAVE
13 CLARIFICATION? MED-0076 IN THIS RECORD, I CAN'T READ THE
14 DATE.
15 Q. ACTUALLY, I CAN'T READ IT EITHER BUT I THINK IT CAME
16 FROM THE RECORD AS AFTER, YOU KNOW, THE PREVIOUS ONE WHICH
17 IS THE 13TH AND BEFORE THE FOLLOWING ONE WHICH IS THE 14TH
18 SO I THINK WE ALL ASSUMED IT WAS THE 13TH.
19 A. 2400 NURSING NOTE: PATIENT IS WAKE FOR RESTLESS IN BED,
20 MOVING ALL LIMBS WHILE IN POSEY BELT AND WRIST RESTRAINT.
21 AT RISK TO FALL OUT OF BED, AT RISK TO PULL OUT I.V.
22 INFUSING IN LEFT FOREARM.
23 Q. IS THAT A SIGN -- COULD THAT BE A SIGN OF PAIN?
24 A. THE RESTLESSNESS CAN BE A SIGN OF PAIN IN SOMEONE WHO IS
25 NOT COMMUNICATIVE.
2332
1 Q. IS THAT THE ONLY CAUSE OF RESTLESSNESS?
2 A. NO. I THINK I'VE MADE IT CLEAR THAT THE PRESENCE OF
3 DELIRIUM OR THE CONFUSED STATE THAT THE BRAIN CAN BE IN ON
4 THE BASIS OF ADMINISTRATION OF MEDICATIONS OR DEHYDRATION OR
5 LOW BLOOD OXYGEN OR LOW BLOOD SUGAR CAN RESULT IN PHYSICAL
6 AGITATION OR RESTLESSNESS. SO, NO, RESTLESSNESS IS NOT ONLY
7 A SIGN OF PAIN IN SOMEONE WHO IS NOT COMMUNICATIVE.
8 Q. DO YOU SEE ANYTHING -- ANY OTHER SIGNS OF POSSIBLE PAIN
9 IN THE RECORD?
10 A. WELL, IT'S -- FROM THE 13TH, THE PATIENT IS
11 UNRESPONSIVE, NURSES' NOTE.
12 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT TO
13 CONTEXTUALLY OBSERVING WHAT IS IN THE NURSES' NOTE IN THAT
14 FASHION, BECAUSE I HAVE THAT SAME NOTE IN FRONT OF ME AND
15 IT'S QUITE A FULL NOTE AND IT SAYS A LOT MORE THAN JUST
16 UNRESPONSIVE AND I THINK IT'S JUST UNFAIR FOR THE WITNESS TO
17 CHARACTERIZE IT LIKE THAT.
18 THE COURT: OKAY. LET'S -- IF YOU'RE REFERRING TO
19 THE SECTION OF THE MEDICAL RECORDS WHY DON'T YOU READ IT
20 COMPLETELY.
21 Q. (BY MS. BARLOW) LET'S LOOK BACK AT 74. WHAT DATE WAS
22 THAT?
23 A. 1/13/96.
24 Q. AND IF YOU WOULD READ THE FIRST LINE OF 0800.
25 A. PATIENT UNRESPONSIVE, FAMILY WITH PATIENT, POSEY AND
2333
1 RESTRAINT TAKEN OFF.
2 Q. OKAY. LET'S JUMP DOWN TO 1500. WOULD YOU READ WHAT'S
3 WRITTEN UNDER "B"?
4 A. PATIENT HAS BEEN UNRESPONSIVE THE WHOLE SHIFT.
5 Q. AND THEN DOWN TO "R"?
6 A. RESPIRATIONS IRREGULAR WITH PERIODS OF APNEA, COLOR
7 PALE.
8 Q. IS THERE ANYTHING MEDICALLY SIGNIFICANT ABOUT IRREGULAR
9 RESPIRATIONS WITH PERIODS OF APNEA AND PALE COLOR?
10 A. THE PERIODS OF APNEA AND IRREGULAR RESPIRATIONS ARE
11 SIGNS THAT THE BRAIN IS NOT CONTROLLING SMOOTHLY THE
12 BREATHING PATTERN. NORMALLY EACH OF US AT REST WOULD HAVE
13 OUR BREATHING PATTERN VERY CONSISTENT. IF THE BREATHING
14 PATTERN IS IRREGULAR AND THERE ARE PERIODS OF APNEA OR NOT
15 BREATHING AT ALL, IT MEANS THAT THE BRAIN IS NOT CONTROLLING
16 THE BREATHING PATTERN.
17 Q. AND THEN ON PAGE 75, IF YOU WOULD READ THE FIRST LINE --
18 AGAIN, WHAT DAY IS THIS?
19 A. 1/13/96.
20 Q. AND THE FIRST LINE?
21 A. CIRCLED B: PATIENT UNRESPONSIVE THIS SHIFT DURING CARES
22 AND I.M. MEDICATION ADMINISTRATION. NO RESPONSE TO
23 MINISTRATION OR FAMILY MEMBERS PRESENT AT BED SIDE.
24 Q. THEN DOWN TO "R", WOULD YOU READ THAT?
25 A. CIRCLE R: PATIENT UNRESPONSIVE WITH LONG PERIODS OF
2334
1 APNEA, Q OR EVERY ONE TO TWO MINUTES. NO DISCOMFORT NOTED
2 DURING CARES.
3 Q. SO FOR THE 13TH AND 14TH, DID YOU SEE ANY INDICATION OF
4 SIGNS OF PAIN IN THESE RECORDS?
5 A. ANY INDICATION IS THE MATERIAL I SAID BEFORE AND FROM
6 THE NURSES' NOTES AND FROM DR. WEITZEL'S NOTES, YES.
7 Q. DID YOU SEE ANYTHING IN THE NURSES' NOTES ABOUT MR.
8 ALLDREDGE MOANING?
9 A. THE 1/13 NOTE MED-00076, THERE'S ADDITIONAL INFORMATION
10 THERE, NO MENTION OF MOANING. AND THE OTHER NOTES I DON'T
11 SEE MOANING.
12 Q. DID YOU FORMULATE AN OPINION AS TO THE CAUSE OF MR.
13 ALLDREDGE'S DEATH TO A DEGREE OF MEDICAL CERTAINTY?
14 MR. STIRBA: YOUR HONOR, I THINK IT'S BEEN ASKED
15 AND ANSWERED. REDUNDANT.
16 THE COURT: I THINK YOU DID IT AT THE FIRST.
17 MS. BARLOW: OKAY. THANK YOU. WHEN YOU GET SO
18 MANY THINGS IN YOUR BRAIN YOU FORGET WHAT YOU'VE ALREADY
19 DONE.
20 Q. (BY MS. BARLOW) WHAT CAUSED THE DEATH?
21 A. I BELIEVE THE DEATH WAS DUE TO UNTREATED PNEUMONIA,
22 HYPOXIA, CEREBRAL HYPOXIA AND ADMINISTRATION OF SEDATIVE AND
23 NARCOTIC MEDICATIONS.
24 Q. WHAT SEDATIVE AND NARCOTIC MEDICATIONS CAUSED THIS
25 PROBLEM?
2335
1 A. WE HAVE THE CHART. WE HAVE THE ADMINISTRATION OF
2 HALDOL, BUSPAR, TRAZODONE, RISPERDAL, ATIVAN AND MORPHINE
3 ALL IN COMBINATION OVER A COURSE OF A FIVE-DAY PERIOD.
4 Q. DO YOU HAVE MARY CRANE'S EXHIBIT -- NO, YOU DON'T. I'M
5 SORRY. I KEEP FORGETTING THEY ARE OVER HERE. I'LL SHOW YOU
6 STATE'S EXHIBIT 5.
7 DID YOU REVIEW THE RECORDS OF MARY CRANE?
8 A. I DID.
9 Q. DID YOU FORM AN OPINION AS TO -- WITH A CERTAIN A DEGREE
10 OF -- OR WITH A DEGREE OF MEDICAL CERTAINTY AS TO THE CAUSE
11 OF HER DEATH?
12 A. I HAVE.
13 Q. AND WHAT IS THAT OPINION BASED ON?
14 A. I BELIEVE THAT BASED ON THE EVIDENCE PROVIDED THAT MARY
15 CRANE DIED AS A RESULT OF AN ASPIRATION PNEUMONIA DUE TO
16 SEDATION, LOSS OF THE ABILITY TO CHEW AND SWALLOW CORRECTLY,
17 SWALLOWING FOOD AND VOMITUS INTO HER LUNGS AS A RESULT OF
18 OVERMEDICATION WITH SEDATIVE DRUGS, MORPHINE AND DURAGESIC.
19 Q. WERE ORDERS ENTERED FOR MEDICATIONS FOR MARY CRANE ON
20 HER ADMISSION ON THE 28TH OF DECEMBER?
21 A. YES, THEY WERE.
22 Q. WERE THERE ANY DRUGS ORDERED HERE THAT WE HAVEN'T
23 ALREADY SEEN IN SOME OF THE PREVIOUS CHARTS?
24 A. YES, THERE ARE.
25 Q. WELL, THAT HAVE AN EFFECT ON DELIRIUM?
2336
1 A. YES, THEY ARE.
2 Q. AND WHICH DRUGS DO WE SEE HERE THAT WE HAVEN'T SEEN
3 BEFORE OF THAT AN EFFECT ON DELIRIUM?
4 A. SERZONE.
5 Q. IF YOU WOULD STEP DOWN HERE AND LET'S TALK ABOUT SERZONE
6 JUST BRIEFLY. WHAT IS SERZONE?
7 A. SERZONE IS AN ANTIDEPRESSANT DRUG RELATED TO TRAZODONE.
8 Q. WHAT'S THE ADULT STARTING DOSE?
9 A. THE ADULT STARTING DOSE IS 100 MILLIGRAMS BY MOUTH TWICE
10 A DAY.
11 Q. A TOTAL OF HOW MUCH?
12 A. THAT WOULD BE 200 MILLIGRAMS A DAY.
13 Q. WHAT ABOUT IN THE ELDERLY, STARTING DOSES?
14 A. 50 MILLIGRAMS BY MOUTH TWICE A DAY.
15 Q. A TOTAL OF HOW MUCH IN A DAY?
16 A. 100 MILLIGRAMS.
17 Q. NOW WE'RE LOOKING AT NUMBER 31, IS SERZONE ON HERE?
18 A. YES, IT IS.
19 Q. AND WHAT IS THE PHARMACOLOGY IN THE ELDERLY?
20 A. FROM THE P.D.R. AND FROM THE GERIATRIC DOSAGE HANDBOOK
21 IT'S DESCRIBED AS GREATER THAN 99 PERCENT PROTEIN BOUND. SO
22 THAT IF YOU GIVE A YOUNG PERSON A 50 MILLIGRAM DOSE, THE
23 PROTEIN BINDING WOULD BE GREATER, MORE FREE DRUG. IN AN
24 ELDERLY PERSON BECAUSE THE PROTEIN BINDING IS LESS, THERE'S
25 MORE FREE DRUG AVAILABLE. FREE DRUG LEVELS HAVE BEEN
2337
1 MEASURED AND ARE TWO TIMES HIGHER IN THE ELDERLY AND THE
2 P.D.R. ITSELF SAYS TREATMENT SHOULD BE INITIATED AT ONE HALF
3 THE USUAL ADULT DOSE.
4 Q. AND WHAT ABOUT SPECIAL CONSIDERATIONS IN THE ELDERLY?
5 A. IT'S A PROFOUNDLY SEDATING MEDICATION WITH CONFUSION AS
6 A COMMON SIDE EFFECT.
7 Q. WERE THERE ANY OTHER DRUGS THAT WE HAVEN'T TALKED
8 ABOUT -- OH, THERE IS. EXCUSE ME. THERE'S THE DURAGESIC, I
9 BELIEVE.
10 A. YES.
11 Q. WHAT IS DURAGESIC?
12 A. DURAGESIC IS THE FORM OF FENTANYL SODIUM, A NARCOTIC
13 PAIN RELIEVER.
14 Q. AND WHAT IS THE PURPOSE -- WELL, I GUESS YOU'VE SAID
15 WHAT THE PURPOSE OF IT IS. WHAT'S THE ADULT STARTING DOSE?
16 A. IN SOMEONE WHO HAS NOT RECEIVED NARCOTIC PAIN MEDICATION
17 IN AN AMOUNT DESCRIBED IN THE P.D.R., IN A SIGNIFICANT
18 AMOUNT, THE STARTING DOSE WOULD BE 25 MICROGRAMS PER HOUR,
19 THAT'S THE WAY IT'S RELEASED FROM A PATCH BECAUSE IT'S A
20 PATCH MEDICINE. SO IT'S RELEASED THROUGH THE PATCH MEMBRANE
21 IN CONCENTRATIONS AND DESCRIBED PER HOUR. 25 MICROGRAMS PER
22 HOUR, CHANGE IT EVERY THREE DAYS AND IT'S LISTED AS
23 INCREASED IF NECESSARY AFTER THREE DAYS.
24 Q. WHAT ABOUT THE ELDERLY STARTING DOSE?
25 A. THE STARTING DOSE IS AGAIN 25 MICROGRAMS PER HOUR EVERY
2338
1 72 HOURS, INCREASE IF NECESSARY AFTER THREE DAYS.
2 Q. THEN IS THAT RIGHT NUMBER 30, WHAT IS THE PHARMACOLOGY
3 IN THE ELDERLY OF DURAGESIC?
4 A. FROM THE REFERENCED TEXT THE CLEARANCE OF FENTANYL IS
5 DECREASED AND THE HALF LIFE IS INCREASED. SO THE DRUG IS
6 TAKEN FROM THE BODY MORE SLOWLY AND, THEREFORE, IT STAYS IN
7 THE BODY LONGER.
8 Q. AND SPECIAL CONSIDERATIONS IN THE ELDERLY?
9 A. IT'S THE SAME STATEMENT MADE FOR MORPHINE AND THAT IS
10 THAT THE ELDERLY GENERALLY HAVE MORE SUSEPTIBILITY TO THE
11 CENTRAL NERVOUS SYSTEM DEPRESSANT EFFECTS OF THE NARCOTICS.
12 Q. HAVE YOU LOOKED AT THE DRUG ADMINISTRATIONS AND ORDERS
13 FOR MARY CRANE?
14 A. YES, I HAVE.
15 Q. I DON'T KNOW IF WE CAN SEE THAT VERY WELL, IT'S NOT AS
16 BIG AS IT APPEARS FROM UP HERE. MAYBE OUR BEST BET IS TO
17 PULL THIS UP HERE. IF YOU COULD STEP DOWN HERE, DOCTOR, AND
18 TALK ABOUT THIS.
19 WHAT DATE WAS SHE ADMITTED?
20 A. DECEMBER 28TH.
21 Q. AND WAS THERE ANY ASSESSMENT OF HER BY DR. WEITZEL?
22 A. YES, THERE WAS.
23 Q. WAS THERE ANY INDICATION OF TERMINALITY IN HER LIFE WHEN
24 SHE FIRST CAME TO DAVIS NORTH?
25 A. NOT BY MY ASSESSMENT OF THE RECORDS OF HER STAY IN THE
2339
1 NURSING FACILITY PRIOR TO HER TRANSFER TO DAVIS NORTH. FROM
2 DR. WEITZEL'S RECORD, THE ASSESSMENT, THE DIAGNOSIS WAS AXIS
3 I, I'M READING FROM MED-00233, MAJOR DEPRESSION WITH
4 PSYCHOTIC FEATURES. AXIS -- EXCUSE ME AXIS III, C.V.A.
5 PROBABLE M.I.D. OR MULTIPLE INFARCT DEMENTIA, HISTORY OF
6 G.I. BLEEDS, HYPERTENSION AND ADULT ONSET DIABETES.
7 DISCUSSION AND RECOMMENDATIONS: PATIENT WAS STARTED ON
8 SERZONE AND RISPERDAL TO TREAT HER DEPRESSION AND PSYCHOTIC
9 FEATURES. SHE WILL ALSO BE ON TRAZODONE FOR SLEEP. I WILL
10 GIVE HER A DURAGESIC PATCH IN A LOW DOSE FOR HER PAIN.
11 GIVEN HER --
12 MR. STIRBA: YOUR HONOR, YOUR HONOR, I'M SORRY, I'M
13 NOT SURE THIS IS RESPONSIVE TO ANY QUESTION. HE'S JUST
14 READING THE REPORT, I'M NOT SURE WHERE WE ARE.
15 THE COURT: WHY DON'T YOU JUST PROCEED BY QUESTION
16 AND ANSWER.
17 Q. (BY MS. BARLOW) NOW, WHAT'S THE ESTIMATED LENGTH OF
18 HOSPITALIZATION?
19 A. TWO TO THREE WEEKS.
20 Q. AND THE DISCHARGE PLAN?
21 A. BACK TO HER PREVIOUS CARE CENTER.
22 Q. DID YOU LOOK AT THE DRUGS THAT WERE ADMINISTERED TO HER?
23 A. I HAVE.
24 Q. AND LET'S STEP DOWN ON THIS CHART. ON THE FIRST DAY,
25 THE 28TH, WHAT WAS SHE GIVEN?
2340
1 A. AGAIN, THIS CHART IS DESCRIBING THE MAXIMUM DAILY
2 RECOMMENDED USUAL STARTING DOSE REPRESENTED BY THESE
3 TABLETS. ON THE FIRST DAY WE HAVE AN ORDER FOR SERZONE.
4 THE SERZONE MAXIMUM DAILY DOSE IS 100 MILLIGRAMS INITIAL.
5 IT APPEARS THAT 50 MILLIGRAMS WAS ADMINISTERED.
6 Q. WAS THE RISPERDAL AMOUNT APPROPRIATE?
7 A. YES.
8 Q. WHAT ABOUT THE TRAZODONE AMOUNT?
9 A. TRAZODONE AMOUNT AT 50 MILLIGRAMS PER DAY REPRESENTED BY
10 ONE BOX. THERE ARE TWO SO THAT WOULD BE TWICE THE USUAL
11 RECOMMENDED.
12 Q. WHAT ABOUT THE DURAGESIC?
13 A. THE DURAGESIC, ONE HALF PATCH IS -- REPRESENTS THE USUAL
14 RECOMMENDED STARTING DOSE AND IT WAS A FULL PATCH.
15 Q. WHAT THE ABOUT THE NEXT DAY, THE SERZONE, WAS THAT
16 APPROPRIATE?
17 A. THE SERZONE IS AT THE USUAL MAX DOSE, YES.
18 Q. WHAT ABOUT THE RISPERDAL?
19 A. RISPERDAL REPRESENTED HERE ADMINISTERED THREE TIMES THE
20 USUAL.
21 Q. AND THE TRAZODONE?
22 A. TWO TIMES.
23 Q. AND THE DURAGESIC PATCH?
24 A. TWO TIMES.
25 Q. IT LOOKS LIKE THE NEXT DATE, THE 30TH, EVERYTHING WAS
2341
1 EXACTLY THE SAME; IS THAT CORRECT?
2 A. YES.
3 Q. WHAT ABOUT THE 31ST, WHAT HAPPENED TO THE DRUG
4 ADMINISTRATION ON THAT DAY?
5 A. THE SERZONE WAS MARKEDLY INCREASED. AFTER JUST THREE
6 DAYS OF ADMINISTRATION TO ONE AND ONE TABLET, TWO TABLETS
7 HALF, AND SO SLIGHTLY MORE THAN 50 PERCENT GREATER THAN THE
8 USUAL MAX.
9 Q. AND THE RISPERDAL IT LOOKS LIKE IT STAYED THE SAME.
10 WHAT ABOUT THE TRAZODONE?
11 A. THE TRAZODONE WAS AT ONE, TWO, THREE, FOUR, FIVE TIMES.
12 Q. AND SOMETHING ELSE IS ADDED THERE, WHAT WAS THAT?
13 A. AND ATIVAN HAS BEEN STARTED ON THAT DAY AT THE MAX DOSE.
14 Q. DID THE PATCH, DURAGESIC PATCH AMOUNT CHANGE?
15 A. NO, IT'S REMAINED THE SAME SINCE IT WAS STARTED AT 50
16 MICROGRAMS AND THIS IS NOW THE FOURTH DAY THAT IT'S BEEN
17 ADMINISTERED.
18 Q. IT LOOKS LIKE JANUARY 1ST AND 2ND HAD THE SAME AMOUNTS
19 OF EACH OF THE DRUGS. HOW MUCH SERZONE?
20 A. THE SERZONE WAS TWO TIMES.
21 Q. RISPERDAL?
22 A. THREE TIMES.
23 Q. TRAZODONE?
24 A. FOUR TIMES.
25 Q. AND THEN THE DURAGESIC PATCH STAYED THE SAME -- WELL, IT
2342
1 WAS AT MORE THAN IT SHOULD HAVE BEEN?
2 A. AT THIS POINT IT COULD HAVE BEEN INCREASED AFTER THREE
3 DAYS IF IT HAD BEEN CLINICALLY INDICATED.
4 Q. DID YOU SEE ANY CLINICAL INDICATION FOR -- WELL, IT
5 WASN'T CHANGED, SO NEVER MIND. STRIKE THAT.
6 ON THE 3RD OF JANUARY WE HAVE SERZONE OF HOW MUCH?
7 A. 3RD OF JANUARY IS HERE, WE HAVE SERZONE PRESCRIBED
8 AMOUNT OF TWO TIMES, ONE -- EQUIVALENT TO ONE ADMINISTERED,
9 SO WHAT WAS ADMINISTERED WAS THE USUAL MAXIMUM DAILY.
10 Q. DID THE AMOUNT OF RISPERDAL ORDERED VARY?
11 A. IT HAS NOT.
12 Q. AND WHAT ABOUT THE TRAZODONE?
13 A. IT HAS NOT.
14 Q. WAS THERE ANY CHANGE IN THE DURAGESIC PATCH?
15 A. THE DURAGESIC PATCH ON THAT DAY WAS STILL 50 MACROGRAMS.
16 Q. WERE THERE ANY OTHER DRUGS ADDED?
17 A. ON THIS DAY A DRUG NAMED DEPAKENE WAS ADDED.
18 Q. I BELIEVE WE HAVE THAT ON THE CHART HERE. WHAT IS
19 DEPAKENE?
20 A. DEPAKENE IS AN ANTICONVULSANT DRUG THAT'S USED TO TREAT
21 SEIZURES.
22 Q. DID YOU SEE EVIDENCE OF A SEIZURE IN THE RECORDS?
23 A. I'LL HAVE TO REVIEW THE RECORDS TO ASSURE MYSELF.
24 Q. WE'LL GO BACK TO THAT WHEN YOU GET BACK THERE. WHAT IS
25 THE PHARMACOLOGY IN THE ELDERLY?
2343
1 A. DEPAKENE IS NOT LISTED EITHER IN THE P.D.R. OR THE
2 GERIATRIC DOSING HANDBOOK AS HAVING A DIFFERENCE IN
3 PHARMACOLOGICAL CHARACTERISTICS IN THE ELDERLY.
4 Q. WHAT ARE THE SPECIAL CONSIDERATIONS?
5 A. IT'S A VERY SEDATING DRUG.
6 Q. AND THEN WE HAVE NUMBER 31 HERE, DEPAKENE IS ON THERE.
7 WHAT'S THE ADULT STARTING DOSE?
8 A. IT'S CALCULATED. SO YOU TAKE A PATIENT'S WEIGHT IN
9 KILOGRAMS AND YOU MULTIPLE THAT TIMES 10 OR 15 MILLIGRAMS
10 DEPENDING ON THE SITUATION AND THEN YOU GIVE THAT IN DIVIDED
11 DOSES. SO YOU TAKE THE TOTAL AMOUNT AND DIVIDE IT UP EITHER
12 TWO OR THREE TIMES A DAY.
13 Q. WHAT ABOUT THE ELDERLY STARTING DOSE?
14 A. SAME.
15 Q. HOW MUCH MORPHINE WAS GIVEN ON THE 3RD OF JANUARY?
16 A. 8 MILLIGRAMS WAS ADMINISTERED.
17 Q. OKAY. LET'S GO TO THE 4TH OF JANUARY. HOW MUCH
18 MORPHINE WAS ADMINISTERED THAT DAY?
19 A. 5 MILLIGRAMS.
20 Q. DID THE AMOUNT OF SERZONE CHANGE?
21 A. THE DAY BEFORE THE AMOUNT ORDERED WAS TWO TIMES AS IT
22 HAD BEEN, THE ONE DOSE WAS NOT ADMINISTERED. AND ON THIS
23 DATE, STILL TWO TIMES ORDERED AND BOTH WERE ADMINISTERED.
24 Q. ANY CHANGE IN THE RISPERDAL?
25 A. NO CHANGE.
2344
1 Q. THE TRAZODONE?
2 A. NO CHANGE.
3 Q. ANY CHANGE IN THE DEPAKENE?
4 A. YEAH. THE DEPAKENE TOTAL DOSE ADMINISTERED THIS DAY WAS
5 GREATER BECAUSE OF THE WAY IT WAS STARTED HERE. SO
6 1,000 MILLIGRAMS WAS WHAT WAS ORDERED BUT NOT ADMINISTERED
7 HERE.
8 Q. WHAT ABOUT THE DURAGESIC PATCH?
9 A. THE DURAGESIC PATCH WAS INCREASED BY 50 PERCENT TO 75
10 MICROGRAMS PER HOUR.
11 Q. WHICH IS HOW MUCH TIMES WHAT THE NORMAL DOSE IS?
12 A. WELL, AT THIS POINT, IF YOU ARE USING EVERY THREE-DAY
13 INTERVALS AS APPROPRIATE FOR POSSIBLY INCREASE IN THE DRUG,
14 IF CLINICALLY APPROPRIATE, IT SHOULD HAVE BEEN 25 HERE
15 POSSIBLY, 50, 75 SO IT'S IN LINE.
16 Q. WOULD YOU AUTOMATICALLY JUST KEEPING INCREASING THE
17 DOSAGE OF DURAGESIC?
18 A. WELL, YOU SHOULD HAVE A THERAPEUTIC INPUT. THERE SHOULD
19 BE A REASON TO GIVE THE DRUG, NUMBER ONE AND YOU SHOULD BE
20 ABLE TO ASSESS WHY IT IS YOU ARE GIVING THE DRUG AND MEASURE
21 THAT SOMEHOW.
22 Q. SO YOU DON'T JUST AUTOMATICALLY RATCHET IT UP EVERY
23 THREE DAYS?
24 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT,
25 THAT'S LEADING AND SUGGESTIVE.
2345
1 THE COURT: SUSTAINED.
2 Q. (BY MS. BARLOW) WHAT ABOUT THE ON THE 6TH OF JANUARY,
3 WHAT WAS DIFFERENT ABOUT THE DRUG DOSAGES ON THAT DAY?
4 A. THERE WAS NO MORPHINE ADMINISTERED THAT DAY.
5 Q. WELL, I THINK I SKIPPED OVER THE 5TH OF JANUARY. WHAT
6 WAS DIFFERENT THAT DAY?
7 A. ON THE 5TH OF JANUARY THE TRAZODONE WAS WITHHELD.
8 Q. AND THEN LET'S GO TO THE 7TH OF JANUARY. WHAT WAS
9 DIFFERENT ON THAT DAY?
10 A. ON THE 7TH OF JANUARY 10 MILLIGRAMS OF MORPHINE WAS
11 ADMINISTERED, TWO DOSES -- TWO-THIRDS OF THE DOSE OF
12 RISPERDAL POSSIBLY ORDERED WAS NOT GIVEN. TRAZODONE WAS
13 WITHHELD.
14 Q. OKAY.
15 A. DEPAKENE WAS CHANGED TO A DIFFERENT DOSAGE.
16 Q. OKAY. THANK YOU.
17 IS THERE ANY SIMILARITY BETWEEN DURAGESIC AND MORPHINE?
18 A. WELL, THEY ARE BOTH NARCOTIC PAIN RELIEVERS, YES.
19 Q. ARE THEY USUALLY USED IN CONJUNCTION WITH EACH OTHER?
20 A. THEY CAN BE.
21 Q. LET'S -- I BELIEVE IT'S JANUARY THE 3RD THAT MORPHINE
22 WAS -- WELL, LET'S GO BACK TO THE VERY FIRST DAY.
23 DID YOU SEE INDICATIONS IN THE RECORDS OF A NEED FOR
24 DURAGESIC PATCH?
25 A. I'M SOMEWHAT HANDICAPPED BECAUSE MY NOTES ARE NOT IN THE
2346
1 BOX THAT'S WITH ME. IT'S IN THE OFFICE.
2 Q. OH. WELL, LET'S GO ON AND MAYBE WE'LL...
3 A. SO I WOULD LIKE TO HAVE THOSE NOTES TO MAKE AN ACCURATE
4 TESTIMONY TO THIS. IT WOULD BE SPEEDER FOR THE COURT IF I
5 HAD MY NOTES BECAUSE OTHERWISE I'M GOING TO HAVE TO --
6 MS. BARLOW: YOUR HONOR, CAN WE ASK -- I'LL TRY TO
7 GET ONTO SOME OTHER THINGS. IS IT IN THE CONFERENCE ROOM
8 THERE?
9 THE WITNESS: YES, IT'S IN THE CONFERENCE ROOM.
10 MS. BARLOW: THANK YOU.
11 THE COURT: OKAY.
12 Q. (BY MS. BARLOW) DID YOU SEE ANY INDICATIONS OF
13 DELIRIUM IN MARY CRANE?
14 A. I DID.
15 Q. WHAT INDICATIONS DID YOU SEE?
16 A. AGAIN, REFERENCING MY NOTE MATERIALS, I CAN MAKE AN
17 ACCURATE STATEMENT.
18 MS. BARLOW: YOU CAN ANSWER THAT BETTER. OKAY.
19 MAY WE HAVE A MINUTE FOR PEOPLE JUST TO STAND UP, YOUR
20 HONOR.
21 THE COURT: DO YOU HAVE ANYTHING ELSE YOU CAN GO
22 OVER WHILE WE'RE WAITING?
23 MS. BARLOW: WITHOUT HIS NOTES, HE PROBABLY WON'T
24 BE ABLE TO FULLY ANSWER BECAUSE IT'S GOING TO BE IN THE
25 NOTES. WELL, MAY BE WE COULD GO TO LABS.
2347
1 Q. (BY MS. BARLOW) DO YOU -- JUST IN GENERAL DID YOU SEE
2 ANYTHING IN THE LABS INDICATING A HEALTH PROBLEM THAT SHOULD
3 BE ADDRESSED?
4 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT TO THE
5 FORM OF THE QUESTION, VAGUE AND AMBIGUOUS AND I THINK IT'S
6 ALSO IRRELEVANT TO HIS TESTIMONY.
7 THE COURT: SUSTAINED.
8 Q. (BY MS. BARLOW) CAN YOU TURN TO THE RADIOLOGY REPORT
9 WHICH -- THE RADIOLOGY REPORT WHICH IS 270, WHAT WAS THAT AN
10 X-RAY OF?
11 A. THIS IS AN X-RAY OF THE CHEST.
12 Q. AND WHAT DID -- WHAT DID THAT X-RAY SHOW ABOUT HER
13 HEART?
14 A. IT SHOWED THAT THE HEART WAS ENLARGED.
15 Q. WHAT DOES THAT MEAN?
16 A. THESE TYPE OF EXAMINATIONS --
17 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT TO THE
18 RELEVANCY OF THIS PARTICULAR ONE QUESTION RELATING TO HIS
19 OPINION.
20 Q. (BY MS. BARLOW) IS THIS WHAT YOU WERE LOOKING FOR?
21 A. IF I COULD HAVE THE WHOLE BOX.
22 Q. CAN YOU GET THE WHOLE BOX?
23 THE COURT: RELATING TO HIS OPINION --
24 MR. STIRBA: YES, I UNDERSTOOD HIS OPINION AS TO
25 CAUSE OF DEATH. HE'S ADDRESSING THE HEART ISSUES I DON'T
2348
1 SEE THE RELEVANCE, YOUR HONOR.
2 MS. BARLOW: IT RULES OUT OTHER THINGS, YOUR HONOR.
3 MR. STIRBA: YEAH. BUT, YOUR HONOR, WE'VE
4 ADDRESSED THIS IN A MOTION IN TERMS OF --
5 THE COURT: OKAY. IF THAT'S NOT THE REPORT AND
6 ALSO THE PREVIOUS RULINGS, GO ON.
7 Q. (BY MS. BARLOW) DO YOU HAVE ENOUGH TO ANSWER SOME OF
8 MY QUESTIONS YET, DR. FEHLAUER?
9 A. I DO, I'M READY.
10 Q. OKAY. THANK YOU. NOW I HAVE TO REMEMBER WHAT I WAS
11 ASKING.
12 DO YOU SEE ANYTHING IN THE RECORDS INDICATING THE NEED
13 FOR DURAGESIC PATCH ON THE FIRST DAY THAT MARY CRANE WENT
14 INTO DAVIS NORTH?
15 A. WELL, MARY CRANE HAD A HISTORY OF A THALAMIC C.V.A. OR A
16 STROKE IN THE RIGHT SIDE OF THE BRAIN. SHE ALSO HAD A
17 HISTORY OF DISK SURGERY ON HER BACK, HAD A HISTORY OF
18 CHRONIC HEADACHES AND CHRONIC LOW BACK PAIN. SO THE ANSWER
19 IS, YES, SHE HAD -- SHE HAD CONDITIONS WHICH COULD HAVE BEEN
20 PAINFUL. FROM THE RECORD OF DR. WEITZEL --
21 MR. STIRBA: YOUR HONOR, I'M NOT SURE THERE'S A
22 PENDING QUESTION.
23 MS. BARLOW: WELL, LET ME --
24 THE COURT: YEAH, LET'S PROCEED BY QUESTION.
25 Q. (BY MS. BARLOW) DID YOU SEE ANYTHING IN DR. WEITZEL'S
2349
1 RECORDS INDICATING PAIN ON THE DAY THAT MARY CRANE CAME INTO
2 DAVIS NORTH?
3 A. ON 00231, HISTORY: COMPLAINS OF LOW BACK PAIN AND
4 HEADACHES. PAST MEDICAL HISTORY: HAS A HERNIATED DISK IN
5 1994 AND POOR CONTROL OF HER PAIN SINCE THEN. THOSE ARE THE
6 INDICATIONS FROM THE HISTORY AND PAST MEDICAL.
7 Q. NOW, A THALAMIC C.V.A., I THINK YOU'VE DESCRIBED WHAT
8 THAT WAS. DOES THAT HAVE ANY RELEVANCE TO COMPLAINTS OF
9 PAIN?
10 A. YES, IT DOES.
11 Q. WHAT RELEVANCE THERE?
12 A. A THALAMUS IS A PORTION OF THE BRAIN THROUGH WHICH THE
13 PERCEPTION OF PAIN IS COORDINATED AND ENHANCED; THAT IS TO
14 SAY THE SENSORY FIBERS FROM THE BODY THAT CARRY THE SIGNALS
15 THAT IT MAY INDICATE PAIN ARE PASSING THROUGH THERE AND
16 INTEGRATING THERE AND SO IF THE THALAMUS IS DISRUPTED OR
17 INJURED, PAIN PERCEPTION CAN BE ALTERED, FREQUENTLY REDUCED
18 OR FREQUENTLY INCREASED JUST AS OFTEN. SO PAIN PERCEPTION
19 CAN BE ALTERED BY A THALAMIC C.V.A.
20 Q. DID YOU SEE ANY BEHAVIOR IN MARY CRANE INDICATING
21 EFFECTS FROM HER THALAMIC C.V.A.?
22 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT. IT'S
23 BEYOND THE SCOPE OF THE REPORT.
24 THE COURT: OKAY. SUSTAINED.
25 Q. (BY MS. BARLOW) DID YOU SEE ANY INDICATIONS OF
2350
1 DELIRIUM IN MARY CRANE?
2 A. YES, I DID.
3 Q. WHAT INDICATIONS DID YOU SEE?
4 A. FROM RECORDS IN THE NURSING FACILITY AND FROM THE
5 INITIAL AND SUBSEQUENT REPORTS OF THE NURSES AND DR.
6 WEITZEL, THERE'S EVIDENCE THAT THE PATIENT WAS MARKEDLY
7 DISTURBED IN HER PERCEPTIONS OF THE ENVIRONMENT, THAT SHE
8 MISINTERPRETED THE ENVIRONMENT, THAT SHE HAD PSYCHOMOTOR
9 AGITATION; THAT IS, MOVEMENTS, RESPONSES TO STAFF, INCLUDING
10 PHYSICAL AGGRESSION AND AGITATION. SHE HAD DISTURBANCE OF
11 HER SLEEP WAKE CYCLE. SHE WAS FLUCTUATING BETWEEN BEING
12 EXCESSIVELY SEDATED AND ALERT AND AGITATED. SHE WAS
13 EXHIBITING QUITE A LOT OF VARIABILITY OF HER MOOD WITH
14 ANXIETY AND TEARFULNESS AND ANGER AND THESE SYMPTOMS VARIED
15 THROUGHOUT THE COURSE OF A FEW HOURS TO A DAY.
16 Q. DID YOU SEE ANY TREATMENT OF THE DELIRIUM?
17 A. I DID NOT.
18 Q. WHAT -- WHAT WOULD BE DONE TO TREAT THE DELIRIUM?
19 A. WELL, RELATIVE TO A SINGLE POINT ABOUT THAT IS THE
20 QUESTION OF MEDICATIONS AND THEIR RELATION TO THE DELIRIUM.
21 Q. THE MEDICATIONS THAT SHE WAS ON, WHAT WOULD THEY DO TO
22 THE DELIRIUM?
23 A. MEDICATIONS SHE WAS RECEIVING WHILE A RESIDENT OF THE
24 NURSING FACILITY WERE THORAZINE, TRANXENE, GLUCOTROL,
25 ZOLOFT, XANAX. ON ADMISSION THE PATIENT WAS PLACED ON
2351
1 ALTERNATIVE DRUGS IN EVEN HIGHER AND MORE SEDATING DOSES OF
2 THE SERZONE, THE TRAZODONE.
3 Q. WHAT SHOULD HAVE BEEN DONE?
4 A. WELL, AGAIN, MY FIRST AND PRINCIPLE POINT OF VIEW
5 RELATIVE TO PEOPLE WHO ARE ON THESE MEDICATIONS WHICH CAN
6 LEAD TO CONFUSION AND AGITATION AND AN INABILITY TO INTERACT
7 AND CAUSE DELIRIUM IS TO GIVE THEM A DRUG HOLIDAY IF AT ALL
8 POSSIBLE AND SEE WHAT THE NATURAL BRAIN FUNCTION OF THESE
9 PEOPLE WOULD BE.
10 Q. WHAT EFFECT WOULD THE DURAGESIC PATCH HAVE ON HER
11 ABILITY TO FUNCTION?
12 A. THE DURAGESIC IS EQUIVALENT TO THE MORPHINE IN ITS
13 ACTIONS ON THE CENTRAL NERVOUS SYSTEM, IT CAUSES SEDATION,
14 IT CAUSES CONFUSION, SO YOU WOULD EXPECT HER TO BE MORE
15 CONFUSED AND AGITATED AND POSSIBLY SEDATED.
16 Q. WHAT EFFECT WOULD THE MEDICATIONS HAVE ON WHAT YOU
17 CONSIDER THE CAUSE OF HER DEATH?
18 A. WELL, THE COMBINATION OF MEDICATIONS ADMINISTERED I
19 BELIEVE LED TO HER BEING UNABLE TO SWALLOW APPROPRIATELY,
20 REFUSING FOOD AND WATER, DEVELOPING AN ASPIRATION PNEUMONIA
21 AND ULTIMATELY DEVELOPING FAILURE, BOTH OF A PULMONARY AND
22 KIDNEY ORIGIN RELATIVE TO THESE MEDICATIONS.
23 Q. WHAT'S ASPIRATION PNEUMONIA?
24 A. THE SWALLOWING MECHANISM ALLOWS TO YOU PLACE FOOD IN
25 YOUR ESOPHAGUS RATHER THAN IN YOUR AIR PIPE. IF YOU SWALLOW
2352
1 SOMETHING INTO YOUR AIR PIPE, THAT'S ASPIRATION AND IF IT
2 IRRITATES THE LUNG IT CAN CAUSE INFLAMMATION AND IF IT'S
3 ASSOCIATED WITH BACTERIA IT CAN CAUSE PNEUMONIA.
4 Q. NOW, IT APPEARS THE DURAGESIC PATCH WAS PLACED ON AT
5 FIRST, JANUARY 3RD MORPHINE WAS ADDED AND ALSO DEPAKENE. DO
6 YOU SEE ANYTHING IN THE RECORD INDICATING A NEED FOR ADDING
7 MORPHINE AT THAT POINT?
8 A. ON THE 3RD OF JANUARY 1995 MORPHINE IS -- 1996 MORPHINE
9 IS ADDED. FROM -- NO, I CAN'T.
10 Q. WAS IT APPROPRIATE TO ADD MORPHINE AT THAT POINT?
11 A. IN MY OPINION, WITHOUT AN INDICATION, NO.
12 Q. WITHOUT AN INDICATION OF WHAT?
13 A. OF THE NEED FOR THE MORPHINE, IF THERE'S SOME BENEFIT TO
14 BE DERIVED FROM ADMINISTERING THE MORPHINE.
15 Q. IF YOU'LL NOW TURN TO I BELIEVE IT'S -- LET'S LOOK AT
16 LYDIA SMITH, THIS IS EXHIBIT NUMBER 4. DID YOU REVIEW THE
17 RECORDS OF LYDIA SMITH?
18 A. YES, I HAVE.
19 Q. AND WHICH RECORDS DID YOU REVIEW?
20 A. I REVIEWED HOSPITAL AND NURSING FACILITY AND DAVIS
21 HOSPITAL RECORDS.
22 Q. AND BASED ON YOUR REVIEW AND YOUR BACKGROUND, CAN YOU
23 SAY TO A MEDICAL CERTAINTY WHAT CAUSED HER DEATH?
24 A. IN THE CASE OF LYDIA SMITH IT'S MY CONCLUSION THAT DEATH
25 OCCURRED AS A RESULT OF DEHYDRATION AND RESPIRATORY FAILURE
2353
1 AS A RESULT OF OVERMEDICATION WITH SEDATIVE ANTIPSYCHOTIC
2 AND PSYCHOTIC MEDICATIONS.
3 Q. WAS THERE AN INDICATION OF TERMINALITY FOR LYDIA SMITH
4 WHEN SHE CAME INTO DAVIS NORTH?
5 A. I'M READING FROM DR. WEITZEL'S NOTES. ESTIMATED LENGTH
6 OF HOSPITALIZATION THREE WEEKS. DISCHARGE PLAN: BACK TO
7 ROCKY MOUNTAIN CARE CENTER.
8 Q. IS THERE ANY DRUG THAT WAS ADMINISTERED TO LYDIA SMITH
9 THAT WE HAVE NOT ALREADY TALKED ABOUT?
10 A. COGENTIN.
11 Q. WOULD YOU STEP DOWN HERE AND WE'LL SEE IF WE CAN'T GO
12 THROUGH THAT. HERE IS NUMBER 30. WHAT IS COGENTIN?
13 A. COGENTIN IS ANOTHER ANTICHOLINERGIC DRUG, YOU'VE HEARD
14 ME SAY THAT MANY TIMES TODAY. AND ITS PURPOSE ORIGINALLY
15 WAS THE TREATMENT OF PARKINSON'S DISEASE OR THE PREVENTION
16 OF THE TREMOR ASSOCIATED WITH PARKINSON'S DISEASE. IT HAS
17 BECOME USED TO SUPPRESS OR MASK THE PARKINSON'S TREMOR THAT
18 PEOPLE WHO ARE RECEIVING ANTIPSYCHOTIC DRUGS LIKE RISPERDAL
19 AND HALDOL CAN DEVELOP AS A SIDE EFFECT OR ADVERSE EFFECT OF
20 THE USE OF THOSE DRUGS.
21 Q. WHAT IS THE PHARMACOLOGY IN THE ELDERLY?
22 A. GENERALLY SPEAKING, THERE ISN'T ANY RECOMMENDATIONS
23 RELATIVE TO DIFFERENCES IN METABOLISM OR EXCRETION.
24 Q. WHAT ABOUT SPECIAL CONSIDERATIONS?
25 A. FROM THE GERIATRIC DOSAGE HANDBOOK AND FROM MY OWN
2354
1 CLINICAL PRACTICE AND EXPERIENCE, IT'S GENERALLY NOT WELL
2 TOLERATED IN THE ELDERLY AND SHOULD BE AVOIDED IF AT ALL
3 POSSIBLE.
4 Q. WHAT DO YOU MEAN BY WELL TOLERATED?
5 A. WELL, THERE'S A STATEMENT ABOUT ANTICHOLINERGIC DRUGS
6 THAT THEY TEACH TO MEDICAL STUDENTS AND MOST DOCTORS ARE
7 FAMILIAR WITH; MAD AS A HATTER, RED AS A BEET. BASICALLY
8 WHAT THAT MEANS IS THAT IT AFFECTS THE ABILITY TO THINK, THE
9 ABILITY TO CONTROL BLOOD VESSELS AND DEBILITATION, DRY AS A
10 BONE. THE SIDE EFFECTS ARE REALLY QUITE UNCOMFORTABLE AND
11 GENERALLY MUCH WORSE IN ELDERLY PEOPLE.
12 Q. LET'S LOOK AT THE DOSE AMOUNTS ON NUMBER 31 HERE.
13 WHAT'S THE ADULT STARTING DOSE TO COGENTIN?
14 A. 1 TO 4 MILLIGRAMS PER DOSE BY MOUTH ONE TO TWO TIMES PER
15 DAY, SO A MAXIMUM DAILY DOSE COULD BE 8 MILLIGRAMS IN AN
16 ADULT.
17 Q. AND THE ELDERLY STARTING DOSE?
18 A. ONE HALF MILLIGRAM BY MOUTH ONCE OR TWICE A DAY SO A
19 MILLIGRAM A DAY.
20 Q. DID YOU LOOK AT -- WELL, LET'S GO DIRECTLY TO THE CHART
21 HERE. DID YOU REVIEW ALL THE DRUGS THAT WERE GIVEN TO LYDIA
22 SMITH?
23 A. I HAVE.
24 Q. IT LOOKS LIKE SHE WAS ADMITTED ON THE 20TH OF DECEMBER
25 AND WHAT DRUGS IN WHAT AMOUNTS WERE ORDERED FOR HER?
2355
1 A. WELL, ON THE 20TH OF DECEMBER WE HAVE ORDERED ATIVAN AT
2 ONE HALF THE MAX DOSE, SERZONE AT TWO TIMES, ADMINISTERED
3 ONE TIME AND RISPERDAL AT -- ADMINISTERED AT ONE HALF THE
4 USUAL MAX DOSE.
5 Q. IS ANY OF THAT INAPPROPRIATE?
6 A. WHAT WAS ADMINISTERED IS APPROPRIATE. THE SERZONE WAS
7 ORDERED AT TWO TIMES THE MAX.
8 Q. WHAT ABOUT THE NEXT DAY?
9 A. THE NEXT DAY THE ATIVAN IS ADMINISTERED AT HALF MAX
10 WHICH IS APPROPRIATE. THE SERZONE AT TWO TIMES WHICH WOULD
11 NOT BE APPROPRIATE AND THE RISPERDAL IS ADMINISTERED AT LESS
12 THAN THE MAX DOSE AND ORDERED AT 50 PERCENT GREATER THAN THE
13 MAX DOSE.
14 Q. AND THE 22ND AND IT LOOKS LIKE THE 23RD ARE THE SAME.
15 A. THE 22ND AND 23RD THE SAME, TWO TIMES THE AMOUNT OF
16 SERZONE AND THREE TIMES THE AMOUNT ADMINISTERED OF
17 RISPERDAL.
18 Q. WOULD THAT KIND OF DOUBLE AND TRIPLE DOSING CAUSE HER
19 PROBLEMS?
20 A. WELL, THE SERZONE IS QUITE SEDATING. THE RISPERDAL CAN
21 BE QUITE SEDATING AND THE RISPERDAL CARRIES WITH IT THE RISK
22 OF DRUG INDUCED PARKINSON'S WITH DIFFICULTIES IN CHEWING AND
23 SWALLOWING.
24 Q. THEN THE 24TH IT LOOKS LIKE TRAZODONE IS ADDED ON THERE
25 IN WHAT FASHION?
2356
1 A. TRAZODONE APPEARS TO HAVE BEEN ADDED ON AS AN AS NEEDED
2 MEDICATION AT TWO TIMES. IT WAS NOT ADMINISTERED.
3 Q. AND THE SERZONE?
4 A. SERZONE ONE DOSE WAS NOT ADMINISTERED BUT THE AMOUNT
5 RECEIVED IS EQUAL TO THE MAXIMUM DAILY DOSE.
6 Q. THE RISPERDAL?
7 A. ONE DOSE WAS NOT RECEIVED. TWO TIMES THE MAXIMUM DAILY
8 DOSE WAS RECEIVED.
9 Q. ON THE 25TH, WHAT'S DIFFERENT ABOUT THE DRUG
10 ADMINISTRATION ON THAT DAY?
11 A. WELL, WHAT'S DIFFERENT IS THAT THE ATIVAN IS NOW GIVEN
12 AT THE MAXIMUM DOSE WHERE AS IT HAD BEEN IN HALF. THE
13 TRAZODONE WAS NOT ADMINISTERED, SERZONE WAS NOT
14 ADMINISTERED, AND HALDOL HAS NOW BEEN ORDERED AND
15 ADMINISTERED AT FOUR TIMES THE MAX DOSE WHERE RISPERDAL IS
16 NOT ADMINISTERED.
17 Q. THE NEXT DAY, THE 26TH?
18 A. THE ATIVAN AT HALF DOSE, THE TRAZODONE IS AT TWO TIMES,
19 SERZONE AT TWO TIMES, RISPERDAL AT THREE TIMES.
20 Q. THE 27TH, WHAT'S DIFFERENT ABOUT THAT DAY?
21 A. ON THAT DAY THE HALDOL IS ADMINISTERED FOUR TIMES.
22 Q. AND LOOKING AT THE 27TH, WITH THE AMOUNTS THAT WERE
23 ADMINISTERED, WOULD THEY BE CAUSING PROBLEMS?
24 A. WELL, AGAIN --
25 MR. STIRBA: YOUR HONOR, I THINK THE QUESTION IS
2357
1 DID THEY CAUSE PROBLEMS, THAT'S WHAT HE'S HERE FOR, NOT
2 COULD.
3 THE COURT: WHY DON'T YOU REPHRASE THE QUESTION.
4 Q. (BY MS. BARLOW) DID THEY CAUSE PROBLEMS ON THE 27TH?
5 A. FROM THE RECORD?
6 Q. YES.
7 A. FROM THE RECORD, DR. WEITZEL'S NOTES OF THE 27TH, THE
8 PATIENT IS CONTINUES TO BE AGGRESSIVE AND PSYCHOTIC,
9 DEMENTED, MOOD DYSPHORIC.
10 Q. WHAT DOES DYSPHORIC MEAN?
11 A. IT MEANS UNHAPPY.
12 Q. OKAY.
13 A. THE PATIENT WAS -- FROM THE NURSING NOTES, MED-772 0900
14 NOTE, PATIENT WAS AGITATED IN THE MORNING THEN AFTER HALDOL
15 WAS GIVEN, PATIENT CALMED DOWN.
16 THE REPORTER: PLEASE SLOW DOWN.
17 THE WITNESS: PATIENT WAS AGITATED IN THE MORNING,
18 THEN AFTER HALDOL WAS GIVEN PATIENT CALMED DOWN. PATIENT
19 WAS UNCOOPERATIVE WITH STAFF WHEN STAFF TRIED TO BUTTON UP
20 SHIRT. PATIENT HAS BEEN DROWSY AFTER MEDS WERE GIVEN.
21 FARTHER DOWN, R: PATIENT NEEDED MAX ASSIST WITH ACTIVITIES
22 OF DAILY LIVING. PATIENT ATE 5 PERCENT OF BREAKFAST AND
23 40 PERCENT OF LUNCH.
24 MY CONCLUSION BASED ON THESE ENTRIES IS THAT THE
25 PATIENT HAS EXCESSIVE SEDATION FROM ADMINISTRATION OF THE
2358
1 MEDICATIONS, THAT SHE'S AGITATED AT TIMES, UNABLE TO EAT AT
2 TIMES. SO, YES, I THINK THAT THEY ARE CAUSING PROBLEMS.
3 THE COURT: WHY DON'T WE TAKE OUR LAST BREAK,
4 LADIES AND GENTLEMEN. I THINK WE'VE BEEN GOING FOR MORE
5 THAN AN HOUR. AS WE DO, REMEMBER IT'S YOUR DUTY NOT TO
6 CONVERSE AMONG YOURSELVES OR CONVERSE WITH ANYONE ELSE
7 REGARDING THE SUBJECT OF THIS TRIAL. IT'S YOUR DUTY NOT TO
8 FORM OR EXPRESS AN OPINION THEREON UNTIL THE CASE IS FINALLY
9 SUBMITTED TO YOU.
10 ALSO IF YOU ARE INTERESTED IN SHADE, LET ME TELL WHERE
11 YOU SOME SHADE IS. IF YOU GO OUT THE DOOR AND YOU TURN LEFT
12 THERE'S A PATH THAT RUNS RIGHT ALONG KIND LIKE A LITTLE
13 CREEK THERE'S BIG TREES AND IT'S MOSTLY IN THE SHADE. SO IF
14 YOU WANT TO HAVE SOME SHADE, TAKES YOU LESS THAN FIVE
15 MINUTES TO WALK OVER THERE SO LET'S COME BACK AT 4:15.
16 (A BRIEF RECESS WAS TAKEN.)
17 THE COURT: PLEASE BE SEATED. THE RECORD WILL
18 REFLECT THAT THE JURY HAS RETURNED. WE WILL GO, LADIES AND
19 GENTLEMEN, UNTIL 5 O'CLOCK TODAY AND SO THE KEY ALWAYS IN AN
20 AFTERNOON IS TO STAY AWAKE AND STAY ALERT. YOU HAVE BEEN
21 DOING THAT I AND JUST COMMEND YOU FOR THAT AND I JUST SAY
22 KEEP IT UP. OKAY. MS. BARLOW?
23 MS. BARLOW: THANK YOU, YOUR HONOR.
24 Q. (BY MS. BARLOW) DR. FEHLAUER, WE'RE TALKING ABOUT
25 LYDIA SMITH.
2359
1 A. UH-HUH.
2 Q. IT APPEARS THAT THE FIRST TWO DAYS THAT SHE WAS ON THE
3 UNIT HER DRUG DOSAGE WAS PRETTY CONSISTENT BETWEEN THOSE TWO
4 DAYS. ON THE THIRD DAY IT APPEARS THAT SHE THEN STARTED
5 GETTING WELL --
6 MR. STIRBA: YOUR HONOR, THIS IS DIRECT
7 EXAMINATION.
8 THE COURT: LET'S JUST ASK A QUESTION.
9 MS. BARLOW: I'M JUST TRYING TO GET HIM WHERE I'M
10 GOING. OKAY.
11 Q. (BY MS. BARLOW) THERE'S A CHANGE IN MEDICATION ON THE
12 22ND. DID YOU SEE ANY REASON OR ANYTHING IN THE RECORD THAT
13 WOULD SUPPORT THAT CHANGE IN MEDICATION? IT'S MORE AMOUNTS
14 THAN ANYTHING BUT.
15 A. 22ND OF?
16 Q. OF DECEMBER.
17 A. ORDERS -- THE REASON THAT THE AMOUNTS ARE DIFFERENT IS
18 BECAUSE THE PATIENT WAS ADMITTED IN THE AFTERNOON OF THE
19 21ST AND RECEIVES A PARTIAL DAILY DOSE. THESE ARE TOTAL
20 DAILY DOSES, SO THE 22ND REPRESENTS THE FIRST FULL DAY OF
21 HOSPITALIZATION AND THE FIRST FULL DAY OF RECEIVING THE
22 DOSES ORDERED AND ADMINISTERED.
23 Q. THE 23RD IT WAS THE SAME AS THE 22ND. THE ORDERS WERE
24 DIFFERENT ON THE 24TH. IT LOOKS LIKE THE TRAZODONE WAS
25 ORDERED BUT NOT GIVEN?
2360
1 A. RIGHT. THE MEDICATIONS ON THE 24TH REPRESENT THE
2 ADDITION OF THE TRAZODONE.
3 Q. DID YOU SEE ANYTHING IN THE MEDICAL RECORDS EXPLAINING
4 WHY THE TRAZODONE WAS ADDED AT THAT POINT?
5 A. READING FROM THE 23RD MED-000713 THE DAY BEFORE DR.
6 WEITZEL'S NOTE, VITAL SIGNS STABLE, AFEBRILE, MUCH LESS
7 LETHARGIC, VERY DEMENTED, DIG LEVEL OKAY. T.F.T. IS THYROID
8 FUNCTION TEST NORMAL DESPITE PYURIA, URINE CULTURE REVEALS
9 NO PATHOGEN, TOLERATING MEDS WELL. PLAN: CONTINUE CURRENT
10 CARE. DR. WEITZEL'S NOTE FROM THE 24TH, NEEDED A LOT OF
11 ATIVAN LAST NIGHT, STRIKING OUT STILL, SEEMS TO SUNDOWN.
12 VITAL SIGNS STABLE, AFEBRILE. ASSESSMENT: STABLE. PLAN:
13 TRAZODONE ROUTINE AND P.R.N.
14 Q. WHAT JUSTIFIES THE ADDITION TRAZODONE?
15 A. THE -- FROM THIS NOTE, THE AGITATION AND THE STRIKING
16 OUT APPEARS TO BE THE REASON. I DON'T HAVE A JUSTIFICATION
17 FOR STARTING THE TRAZODONE BASED ON THIS SMALL NOTE.
18 Q. THAT WAS THE 24TH. ON THE 25TH IT APPEARS THAT SERZONE
19 WAS NOT -- WELL, 25TH HALDOL WAS ADDED. DO YOU SEE ANYTHING
20 IN THE RECORD JUSTIFYING THE ADDITION OF HALDOL?
21 A. ON THE 25TH, WEITZEL'S NOTE, DIDN'T NEED POSEY LAST
22 NIGHT, RESTRAIN, AND HAS BEEN CONTINENT THROUGH NIGHT.
23 APPARENTLY CALMS QUITE NICELY WHEN HER FAMILY IS AROUND BUT
24 CAN BE VERY AGGRESSIVE OR VEGETATIVE LATER. TOLERATING MEDS
25 WELL, VITAL SIGNS STABLE, AFEBRILE --
2361
1 MR. STIRBA: YOU KNOW, I THINK THAT WAS A
2 MISSTATEMENT OF THE NOTE.
3 MS. BARLOW: I THINK IT'S AGGRESSIVE/NEGATIVE, IS
4 THAT THE WAY YOU READ IT TOO?
5 MR. STIRBA: YES, ABSOLUTELY.
6 THE WITNESS: AGGRESSIVE SLASH NEGATIVE LATER, I'M
7 SORRY.
8 MS. BARLOW: I GUESS IF WE BOTH SEE IT THAT WAY
9 THEN WE'LL ASK YOU TO TOO.
10 THE WITNESS: TOLERATING MEDS WELL, VITAL SIGNS
11 STABLE, AFEBRILE. ASSESSMENT: STABLE. PLAN: CONTINUE
12 CURRENT CARE.
13 Q. (BY MS. BARLOW) DO YOU SEE ANYTHING IN THAT --
14 A. SO --
15 Q. -- NOTE THAT JUSTIFIES THE ADDITION OF HALDOL ON THE
16 25TH OF DECEMBER?
17 A. NOT IN MY OPINION.
18 Q. WHAT WOULD HALDOL DO?
19 A. HALDOL WOULD BE USED TO TREAT PSYCHOSIS IN THE -- IN
20 THIS CASE, THE HALDOL COULD RESULT IN FURTHER AGITATION OR
21 AGGRESSION OR CONFUSION.
22 Q. IT LOOKS LIKE THE NEXT DAY, THE 26TH, THE HALDOL WAS NOT
23 ADMINISTERED BUT THE TRAZODONE WHICH HAD BEEN ORDERED BEFORE
24 BUT NOT -- DO YOU SEE ANY EFFECT OF THE HALDOL NOT BEING
25 ADMINISTERED ON THE 26TH?
2362
1 A. ON THE 25TH THE PATIENT RECEIVED NO HALDOL. ON THE 26TH
2 THE PATIENT RECEIVED QUITE A LOT OF HALDOL.
3 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT TO
4 THAT KIND OF CHARACTERIZATION. IT'S NOT REALLY A MEDICAL
5 TERM, "QUITE A LOT". WHAT WAS IT?
6 THE COURT: OKAY. I THINK IF WE'RE TALKING ABOUT
7 MEDICATIONS, YES, LET'S TALK IN TERMS OF AMOUNTS.
8 THE WITNESS: OKAY.
9 Q. (BY MS. BARLOW) ON THE 25TH, RECEIVED HOW MUCH HALDOL?
10 A. RECEIVED FOUR TIMES THE USUAL MAXIMUM DAILY DOSE OR WHAT
11 APPEARS TO BE 4 MILLIGRAMS.
12 Q. AND THEN ON THE 26TH IT APPEARS HAD NOT RECEIVED ANY
13 HALDOL. COULD YOU FROM THE RECORD DISCERN WHY THE HALDOL
14 WAS NOT GIVEN ON THE 26TH?
15 A. WELL, THE HALDOL IS ORDERED AS NEEDED. THE NURSES'
16 NOTES FROM THE 26TH INDICATE THAT THE PATIENT IS DELIRIOUS,
17 IN MY OPINION, IS AGITATED, IS AT TIMES CALM, AT TIMES
18 WITHDRAWN, AT TIMES THROWING THINGS, AT TIMES COOPERATIVE.
19 Q. AND AT THAT POINT, WHAT SHOULD HAVE BEEN DONE FOR LYDIA
20 SMITH?
21 A. AGAIN, MY OPINION IS, IS THAT THESE MEDICINES IN
22 COMBINATION IN A PATIENT WHO IS EXHIBITING ALTERATIONS IN
23 MENTAL ACUITY AND STATUS SHOULD HAVE BEEN WITHDRAWN OR
24 DIMINISHED TO SEE WHAT THE NATURAL STATE OF HER DEMENTING
25 PROCESS AND HER MENTAL STATE WAS.
2363
1 Q. AND THAT WAS WHAT DATE?
2 A. THAT WAS THE 26TH.
3 Q. ON THE 27TH HALDOL IS ADDED BACK AGAIN. IT LOOKS LIKE
4 ATIVAN IS DISCONTINUED. DO YOU SEE -- DID YOU SEE IN THE
5 RECORDS ANY REASON FOR THE HALDOL TO GO BACK IN AGAIN?
6 A. WELL, IT'S -- AGAIN, IT'S GIVEN AS NEEDED BASED ON THE
7 NURSES' INTERPRETATION OF DR. WEITZEL'S ORDER. THE PATIENT
8 IS CONTINUING TO EXHIBIT THESE BEHAVIORAL CHANGES OF
9 PHYSICAL AGITATION, CONFUSION, AGGRESSIVENESS, HITTING AND
10 SPITTING AND KICKING AND THEN WHEN MEDICATED IS SEDATE AND
11 CALM AND POORLY RESPONSIVE. IT'S -- THE NURSES ARE USING
12 THE DISCRETION PROVIDED BY DR. WEITZEL'S AUTHORITY TO USE
13 THIS MEDICINE.
14 Q. IS THAT THE CORRECT TREATMENT OF THE DELIRIUM THAT SHE
15 WAS SUFFERING FROM AT THE TIME?
16 A. NO.
17 Q. WHAT WOULD BE CORRECT TREATMENT?
18 A. WELL, AGAIN, IT'S A MATTER OF -- IN RESPECT TO THE
19 MEDICATIONS, WITHDRAWING OR DISCONTINUING OR MINIMIZING TO
20 ASSESS THE EFFECTS OF THAT ON THE PATIENT'S MENTAL ACUITY
21 AND WELL-BEING.
22 Q. WOULD ANY OF THE ADVERSE EFFECTS THAT YOU'VE INDICATED
23 ON SOME OF THESE DRUGS HAVE EXACERBATED THE PROBLEMS THAT
24 WERE BEING CHARTED BY THE NURSES?
25 A. THE REPETITIVE BEHAVIORS ARE A SIGN OF AKATHISIA, THE
2364
1 RESTLESSNESS THAT THE HALDOL INDUCES AND THE RISPERDAL HAS
2 POTENTIAL TO INDUCE. THE CONFUSION, THE DISORIENTATION TO
3 EXTERNAL REALITY ARE MANIFESTATIONS OF THE SEDATIVE EFFECTS
4 OF THE ATIVAN AND THE OTHER MEDICINES, YES.
5 Q. IT LOOKS LIKE THE 28TH SOME DECREASED DOSAGES. THE 29TH
6 DEPAKENE WAS ADDED, DO YOU SEE ANYTHING IN THE RECORD
7 JUSTIFYING THE ADDITION OF DEPAKENE AT THAT POINT?
8 A. 29 IS THE DATE OF THE ORDER FOR THE DEPAKENE. ON THE
9 27TH I DON'T SEE ANYTHING. ON THE 28TH DR. WEITZEL'S NOTE,
10 DOING BETTER, MUCH LESS IRRITABLE, HAS HIT NO ONE TODAY,
11 VITAL SIGNS STABLE, AFEBRILE, QUITE DEMENTED. ASSESSMENT:
12 STABLE. PLAN: CONTINUE CURRENT CARE. 12/29, ONCE AGAIN IS
13 IRRITABLE TODAY, HAS BEEN HITTING OUT AGAIN, VERY DEMENTED.
14 SPOKE WITH HER DAUGHTER REGARDING TREATMENT AND PROGNOSIS.
15 VITAL SIGNS STABLE, AFEBRILE. ASSESSMENT: INTERMITTENTLY
16 QUITE AGGRESSIVE, THIS WOULD BLOCK PLACEMENT. PLAN:
17 DEPAKENE, INCREASE HALDOL I.M., WHEN IF RISPERDAL REFUSED,
18 HALDOL P.R.N.
19 Q. DO YOU SEE ANY JUSTIFICATION IN THOSE NOTES FOR THE
20 ADDITION OF DEPAKENE AT THIS POINT?
21 A. DEPAKENE IS AN ANTICONVULSANT, NO.
22 Q. DOES IT HAVE ANY ADVERSE EFFECTS?
23 A. THE DEPAKENE IS SEDATING, IT CAN CAUSE CONFUSION.
24 Q. AGITATION? I DON'T WANT TO PUT WORDS IN YOUR MOUTH, BUT
25 DOES IT HAVE ANY EFFECT ON AGITATION?
2365
1 A. THE PICKING OUT OF AN ISOLATED EFFECT IN THESE
2 COMBINATION OF MEDICINES IS HARD. THE MOST COMMON SIDE
3 EFFECT OF THE DEPAKENE WOULD BE SEDATION.
4 Q. THESE DRUGS THAT WE'RE TALKING ABOUT ON THE 29TH,
5 DEPAKENE, TRAZODONE, SERZONE, HALDOL AND RISPERDAL, DO ANY
6 OF THOSE HAVE ADVERSE SIDE EFFECTS?
7 A. YES. THE DEPAKENE CAUSES SEDATION AND CONFUSION, THE
8 RISPERDAL AND HALDOL IN COMBINATION RESULT IN MOVEMENT
9 DISORDERS, DIFFICULTY IN PRODUCING SMOOTH AND VOLUNTARY
10 MOVEMENTS, DIFFICULTIES POTENTIALLY IN CHEWING AND
11 SWALLOWING, SEDATION, URINARY RETENTION, CONSTIPATION, DRY
12 MOUTH, DRY EYES, PHYSICAL AGITATION, POTENTIAL FOR
13 AGGRESSION, MISPERCEPTION OF THE ENVIRONMENT.
14 Q. DO THE RECORDS SHOW THAT THAT WAS WHAT SHE WAS SUFFERING
15 FROM AT THE TIME, AGITATION, THE --
16 A. THE NURSING NOTES ARE DEFINITELY SHOWING THESE VARIABLE
17 SYMPTOMS OF WHAT I'VE JUST DESCRIBED, YES.
18 Q. THE 30TH THE HALDOL WAS NOT ADMINISTERED. IT LOOKS LIKE
19 THE 31ST THE HALDOL WAS ADMINISTERED AGAIN BUT THE REAL -- I
20 MEAN, THE NEXT MAJOR CHANGE I GUESS IN THE MEDICATIONS WAS
21 JANUARY 1ST. WHAT ABOUT THE DRUGS THAT WERE ORDERED ON
22 JANUARY 1ST? WHAT DRUGS -- HOW IS IT DIFFERENT?
23 A. ON JANUARY 1ST '96, DEPAKENE DOSE WAS INCREASED AND THE
24 HALDOL DOSE WAS REITERATED AND CLARIFIED. SO AT THAT POINT
25 DEPAKENE WAS INCREASED, COGENTIN WAS ALREADY PRESENT IT
2366
1 LOOKS LIKE.
2 Q. LET'S LOOK AT THE MEDS AND GRAPHS FOR THE 1ST OF JANUARY
3 AND LOOK AT THE AMOUNT OF HALDOL THAT WAS ACTUALLY
4 ADMINISTERED. IF YOU WOULD FIRST LOOK AT 00745. DO YOU SEE
5 ANY DOSES OF HALDOL ADMINISTERED AT THAT TIME ON THE 1ST OF
6 JANUARY?
7 A. YES, I DO.
8 Q. WHAT WAS ADMINISTERED ON THE 1ST OF JANUARY?
9 A. IF I READ THE ORDER CORRECTLY IT'S HALDOL THREE
10 MILLIGRAMS I.M. IF PATIENT REFUSES RISPERDAL P.O. DOSES.
11 SO ON THE 1ST OF JANUARY, THAT WOULD BE A DOSE ONE, TWO --
12 IT LOOKS LIKE 6 MILLIGRAMS.
13 Q. SORRY, BUT THESE GET REALLY CONFUSING TO GO THROUGH
14 SOMETIMES. EASIEST WAY MAY BE TO -- ON THE CHART IT
15 INDICATES ONE, TWO, THREE, FOUR, FIVE, SIX LOZENGES, WHAT
16 DOES THAT INDICATE?
17 A. SIX LOZENGES WERE IT RELATIVE TO THE HALDOL WOULD
18 INDICATE 6 MILLIGRAMS.
19 Q. AND WHAT IS THAT IN RELATIONSHIP TO WHAT A NORMAL DOSE
20 IS?
21 A. WELL, THE USUAL MAXIMUM STARTING DOSE WOULD BE A
22 MILLIGRAM, THAT'S SIX TIMES THE DOSE.
23 Q. DO YOU SEE ANYTHING IN THE RECORDS INDICATING OR
24 JUSTIFYING SIX TIMES THE NORMAL DOSE OF HALDOL ON THAT DAY?
25 A. ON JANUARY 1ST?
2367
1 Q. JANUARY 1ST.
2 A. DR. WEITZEL'S NOTE JANUARY 1ST '96, SLEPT THROUGH THE
3 NIGHT, HAS BEEN REFUSING MEDS AGAIN AND WAS QUITE
4 RECALCITRANT, GOT AGGRESSIVE THIS P.M. AND RECEIVED ATIVAN
5 WHICH HELPED. VITAL SIGNS STABLE, AFEBRILE, REMAINS LABILE
6 AND INTERMITTENTLY AGGRESSIVE. PLAN: INCREASE DEPAKOTE,
7 DEPAKENE.
8 Q. IT LOOKS LIKE DEPAKOTE IS CROSSED OUT AND DEPAKENE IS
9 ADDED IN THERE?
10 A. YES, I AGREE. SO FROM THIS NOTE THE PATIENT'S
11 AGGRESSION WOULD BE WHAT I WOULD GUESS THE NURSES WERE
12 ADMINISTERING THE HALDOL IN THOSE DOSES FOR.
13 Q. COULD THE NURSES ADMINISTER THOSE DOSES WITHOUT A
14 DOCTOR'S ORDER?
15 A. COULD THEY HAVE GIVEN 6 MILLIGRAMS OF HALDOL WITHOUT A
16 DOCTOR'S ORDER?
17 Q. RIGHT.
18 A. NO.
19 Q. WHAT WOULD BE THE BENEFICIAL EFFECT OF 6 MILLIGRAMS OF
20 HALDOL ON THAT DAY?
21 A. FROM THIS NOTE THERE'S NO EVIDENCE OF PSYCHOSIS.
22 THERE'S AGGRESSION, BUT THERE'S NO PSYCHOSIS.
23 Q. DOES HALDOL DO ANYTHING FOR AGGRESSION? DOES IT TREAT
24 AGGRESSION?
25 A. NO, IT DOES NOT TREAT AGGRESSION.
2368
1 Q. JANUARY 2ND IT LOOKED LIKE LESS MEDICATIONS WERE GIVEN
2 BUT THEN WE HAVE JANUARY 3RD. CAN YOU LOOK AT JANUARY 3RD,
3 SEE IF THERE ARE ANY CHANGES IN THE ORDERS?
4 A. ON JANUARY 3RD THERE ARE -- THERE IS A NEW ORDER FOR
5 SERZONE 150 MILLIGRAMS TWICE A DAY, TRAZODONE 50 MILLIGRAMS
6 MORNING, 50 MILLIGRAMS 1700 AND 150 MILLIGRAMS AT BEDTIME.
7 Q. FOR A TOTAL OF HOW MANY MILLIGRAMS?
8 A. THAT WOULD BE A TOTAL OF 200 MILLIGRAMS A DAY ORDERED.
9 Q. AND IS THAT P.R.N.?
10 A. NO.
11 Q. WAS THERE ANY NEW ORDER FOR HALDOL?
12 A. ON 1/3/96 I DO NOT SEE A NEW ORDER FOR HALDOL.
13 Q. WHAT WAS THE STANDING ORDER FOR HALDOL, DO YOU RECALL?
14 A. ON THAT DATE MY RECORDS INDICATE THAT THE HALDOL WAS
15 5 MILLIGRAMS P.O. OR I.M Q 6 HOURS P.R.N.
16 Q. IT APPEARS THAT ONE, TWO, THREE, FOUR, FIVE, SIX, SEVEN,
17 EIGHT, NINE, TEN, ELEVEN, TWELVE, THIRTEEN, FOURTEEN,
18 FIFTEEN TIMES OR 15 LOZENGES ARE ON THERE OF HALDOL, WHAT
19 DOES THAT MEAN?
20 A. ON THAT DAY THE PATIENT WAS ADMINISTERED 15 MILLIGRAMS
21 OF HALDOL.
22 Q. DO YOU SEE ANYTHING IN THE RECORDS INDICATING A NEED OR
23 A JUSTIFICATION FOR 15 MILLIGRAMS OF HALDOL?
24 A. THIS IS THE 5TH OF JANUARY?
25 Q. NO, IT'S THE 3RD.
2369
1 A. 3RD OF JANUARY. DR. WEITZEL'S NOTES 3RD OF JANUARY,
2 APPARENTLY MISSES MANY OF HER DOSES OF MEDS SECONDARY TO
3 NONCOMPLIANCE THEN IS -- AND I DON'T KNOW IF THIS IS WILDLY
4 OR MILDLY LABILE.
5 MR. STIRBA: I THINK THAT'S MILDLY.
6 MS. BARLOW: MILDLY?
7 MR. STIRBA: YEAH.
8 MS. BARLOW: HE THINKS IT'S MILDLY, LET'S USE MR.
9 STIRBA'S.
10 THE WITNESS: MILDLY LABILE AND IRRITABLE. VITAL
11 SIGNS STABLE, AFEBRILE, STILL QUITE DYSPHORIC AND
12 INTERMITTENTLY PSYCHOTIC. PLAN: INCREASE SERZONE ADD
13 TRAZODONE IN DAY, CLONIDINE PATCH NIGHT -- MIGHT, EXCUSE
14 ME -- HELP.
15 Q. (BY MS. BARLOW) WHAT'S A CLONIDINE PATCH?
16 A. CLONIDINE IS A HIGH BLOOD PRESSURE TREATING MEDICINE
17 IT'S ANTIHYPERTENSIVE.
18 Q. SEE ANY INDICATION FOR A NEED OF CLONIDINE --
19 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT TO
20 THAT, YOUR HONOR? IT'S BEYOND THE SCOPE OF THE REPORT, IT'S
21 IRRELEVANT.
22 THE COURT: SUSTAINED.
23 Q. (BY MS. BARLOW) DOES CLONIDINE HAVE ANY ADVERSE EFFECT
24 IN THE ELDERLY?
25 MR. STIRBA: OBJECTION, YOUR HONOR, SAME OBJECTION.
2370
1 THE COURT: SUSTAINED.
2 Q. (BY MS. BARLOW) DO YOU SEE ANYTHING THAT INDICATES A
3 JUSTIFICATION FOR 15 MILLIGRAMS OF HALDOL THAT DAY?
4 A. THE PATIENT CONTINUES TO EXHIBIT PERIODS OF CONFUSION,
5 AGITATION REFUSAL OF MEDICATIONS, IS RECEIVING MEDICATIONS
6 THAT WOULD INTERFERE WITH HER ABILITY TO INTERACT WITH THE
7 ENVIRONMENT AND UNDERSTAND IT CAUSE THESE ACTIONS. I'M
8 STILL UNCLEAR ON WHY YOU WOULD KEEP ADMINISTERING
9 MEDICATIONS LIKE THIS TO THAT PATIENT. DR. WEITZEL'S
10 JUSTIFICATION IS THAT THE PATIENT IS PSYCHOTIC,
11 INTERMITTENTLY PSYCHOTIC. BUT THE -- FROM THE NOTE I CAN'T
12 DETERMINE THAT.
13 Q. DID YOU SEE ANYTHING IN ELSEWHERE IN THE RECORD THAT
14 JUSTIFIED 15 MILLIGRAMS OF HALDOL THAT DAY?
15 A. THIS IS THE 3RD OF JANUARY THE NURSES' NOTES, MED-00791.
16 11 TO 7, FREE TEXT PATIENT VERY RESTLESS SITTING UP IN BED
17 REPEATEDLY ATTEMPTING TO GET OUT OF BED. PATIENT UP
18 AMBULATING IN HALL WITH ASSISTANCE, STRIKING OUT, KICKING
19 STAFF AND ATTEMPTING TO SLAP -- I CAN'T READ THE EDGE OF
20 THAT.
21 Q. I THINK THAT'S STEP.
22 A. -- STEP ON STAFF. I.M. HALDOL GIVEN AS ORDERED FOR
23 SEVERE AGITATION. PATIENT SLEPT QUIETLY REMAINDER OF NIGHT.
24 BELOW, PATIENT HAS BEEN VERY AGGRESSIVE, HITTING AND KICKING
25 AND BITING STAFF, IS VERY DIFFICULT TO REDIRECT. R CIRCLED,
2371
1 VERY AGGRESSIVE AND AGITATED, PACING, VERY CONFUSED, NOT
2 ORIENTED TO TIME, PLACE, OR PERSON. PLAN: MEDS AS PER
3 DOCTOR, SAFE THERAPEUTIC ENVIRONMENT.
4 Q. ANYTHING IN THAT INDICATE PSYCHOSIS?
5 A. THESE FINDINGS INDICATE PHYSICAL AGITATION, SOME
6 AGGRESSION BUT, NO, THERE'S -- THERE'S NOTHING HERE THAT
7 TELLS ME THIS PATIENT IS PSYCHOTIC.
8 Q. 793 APPEARS TO BE ANOTHER SHIFT ON THE 3RD OF JANUARY.
9 DO YOU SEE ANYTHING ON 793 INDICATING OR JUSTIFYING A NEED
10 FOR THAT MUCH HALDOL?
11 A. READING B: PATIENT VERY DROWSY, IN GERICHAIR AT START
12 OF SHIFT. PATIENT DID NOT EAT DINNER DUE TO LETHARGIC
13 STATE.
14 Q. AS YOU READ THROUGH THAT, DO YOU SEE ANYTHING INDICATING
15 PSYCHOSIS?
16 MR. STIRBA: YOUR HONOR, I HATE TO DO THIS. I
17 THOUGHT THE QUESTION BEFORE WAS IS THERE ANYTHING IN THAT
18 NOTE THAT INDICATES A REASON TO GIVE HALDOL?
19 MS. BARLOW: I'LL REPHRASE IT THAT WAY, YOUR HONOR.
20 MR. STIRBA: AND THERE'S A SPECIFIC REFERENCE IN
21 THAT NOTE AS TO WHY IT'S GIVEN.
22 THE COURT: IF YOU WOULD REPHRASE IT, PLEASE.
23 Q. (BY MS. BARLOW) IS THERE ANYTHING IN THIS NOTE
24 INDICATING A JUSTIFICATION FOR ADMINISTERING 15 MILLIGRAMS
25 OF HALDOL THAT DAY?
2372
1 A. IN THIS NOTE OF 1/3/96, YES.
2 Q. WHAT?
3 A. UNDER I CIRCLE IT SAYS, GAVE HALDOL I.M. DUE TO PATIENT
4 NOT TAKING MEDS P.O.
5 Q. IS THAT A JUSTIFICATION FOR ACTUALLY ADMINISTERING THE
6 DRUG?
7 A. WELL, NOT IN MY MIND IT'S NOT BUT THERE'S AN ORDER.
8 Q. AND WHAT WAS THAT ORDER?
9 A. ORDER DATED 1/1/96 MED-00709, T.O. DR. WEITZEL, IF
10 PATIENT REFUSES RISPERDAL GIVE 5 MILLIGRAMS I.M. HALDOL. SO
11 I GUESS THE JUSTIFICATION IN THE NURSES' NOTES FOR
12 ADMINISTERING IT IS BECAUSE THE PATIENT WOULDN'T TAKE HER
13 ORAL MEDICINES, THAT'S IT.
14 Q. IS THAT A CLINICAL REASON FOR GIVING HALDOL?
15 A. HALDOL IS A SPECIFIC INDICATION FOR TREATMENT OF
16 PSYCHOSIS. BECAUSE THEY REFUSE ANOTHER MEDICINE IS NOT A
17 REASON TO GIVE THE MEDICINE.
18 Q. NEXT DAY NO HALDOL WAS GIVEN. THE FOLLOWING DAY LOOKS
19 LIKE DEPAKENE, TRAZODONE, SERZONE, HALDOL AND RISPERDAL,
20 RISPERDAL IN AMOUNTS -- IN CERTAIN AMOUNTS. LET'S JUMP OVER
21 TO THE 7TH OF JANUARY. IS THERE A NEW DRUG ADDED AND
22 ADMINISTERED TO LYDIA SMITH ON THE 7TH OF JANUARY?
23 A. YES, THERE WAS.
24 Q. WHAT WAS THAT?
25 A. READING MED-00711, 1/7/96, DOCTOR'S ORDERS MORPHINE
2373
1 SULFATE 5 MILLIGRAMS I.M. Q 3 HOURS AROUND THE CLOCK.
2 Q. WHAT JUSTIFIES ORDERING MORPHINE IN THIS ORDER?
3 A. IT DOESN'T SAY FOR PAIN, IT DOESN'T SAY AS NEEDED FOR
4 PAIN. IT JUST SAYS GIVE MORPHINE AROUND THE CLOCK.
5 Q. DO YOU SEE ANYTHING IN THE NOTES INDICATING A
6 JUSTIFICATION FOR THAT ORDER? IF YOU WOULD LOOK ON 719 AND
7 IF YOU WOULD READ DR. WEITZEL'S NOTE OF THE 6TH OF JANUARY.
8 A. I HAVE TROUBLE WITH THE FIRST TWO WORDS. THE THIRD WORD
9 IS LETHARGIC. I THINK THE FIRST TWO WORDS ARE FEELING
10 POORLY. AMBULATING A BIT, VITAL SIGNS STABLE, AFEBRILE.
11 ASSESSMENT: STABLE, CONTINUE CURRENT CARE.
12 Q. THEN THE 7TH, IS THERE ANYTHING IN THAT NOTE THAT
13 JUSTIFIES THE ADDITION OF MORPHINE AT THIS POINT?
14 A. PART WAY DOWN THE NOTE, AT TIMES --
15 MR. STIRBA: COULD WE HAVE THE WHOLE NOTE?
16 THE WITNESS: OKAY. YEAH, I WOULD BE GLAD TO.
17 MR. STIRBA: IF WE'RE GOING TO HAVE HIM COMMENTING
18 ON JUSTIFICATION, I THINK THE JURY OUGHT TO HEAR THE WHOLE
19 NOTE.
20 THE COURT: SUSTAINED.
21 MS. BARLOW: YEAH, LET'S --
22 THE WITNESS: I AGREE. I'M SORRY. VERY WEAK, NOT
23 TAKING ANY NOURISHMENT, NO URINE OUTPUT, FAMILY DISCUSSION
24 WITH TWO -- NOT SURE.
25 MS. BARLOW: I THINK THAT'S SONS.
2374
1 THE WITNESS: TWO SONS AND DAUGHTER. IS THAT
2 REVEALS?
3 MR. STIRBA: YES.
4 MS. BARLOW: IS IT, OKAY?
5 THE WITNESS: THAT THEY DON'T WANT HER LIFE
6 PROLONGED BUT ARE READY TO LET HER GO. AT TIMES SHE
7 THRASHES ABOUT, SEEMS TO BE IN PAIN SLASH ANXIETY.
8 ASSESSMENT: QUITE ILL. PLAN: HOLD MEDS, MORPHINE SULFATE
9 5 MILLIGRAMS Q 3 HOURS I.M.
10 THE ANSWER TO THE QUESTION IS THERE EVIDENCE OF AN
11 INDICATION FOR THE USE OF THE MORPHINE, THERE'S -- THERE'S
12 APPEARS TO BE -- SEEMS TO BE IN PAIN AND ANXIETY.
13 Q. (BY MS. BARLOW) THRASHING ABOUT, CAN THAT BE AN
14 INDICATION OR SIGN OR SYMPTOM OF PAIN?
15 A. YES.
16 Q. CAN OTHER THINGS CAUSE THRASHING ABOUT?
17 A. CERTAINLY THE PATIENT'S CONFUSED STATE CAN RESULT IN
18 THRASHING ABOUT.
19 Q. DO YOU SEE ANY OTHER -- ANYTHING ELSE IN THE RECORD
20 SUPPORTING THIS NOTE THAT SAYS, SEEMS TO BE IN PAIN SLASH
21 ANXIETY?
22 A. WELL, NO. THE...
23 Q. DID YOU SEE ANYTHING IN THE NURSING NOTES SUPPORTING
24 THAT OR CORROBORATING, LET'S PUT CORROBORATING. IF YOU
25 WOULD TURN TO 800. CAN YOU READ THE 11 TO 7 ON THAT?
2375
1 A. IT'S MED-00800?
2 Q. YES.
3 A. NIGHT SHIFT FREE TEXT, PATIENT RESTED QUIETLY THROUGH
4 SHIFT.
5 Q. I THINK THAT'S MINIMALLY.
6 A. IS IT MINIMALLY RESPONSIVE TO P.M. CARES, BED -- I CAN'T
7 READ IT. WEIGHT, VITAL SIGNS, DIAPER CHANGE, RESPIRATION
8 SLOW, DEEP AND REGULAR, KEEPS EYES CLOSED MOST OF THE TIME,
9 NO COMBATIVE BEHAVIOR. POSTURE IS RIGID AT TIMES.
10 Q. WHAT ABOUT RIGID POSTURE, CAN THAT BE A SYMPTOM OF PAIN?
11 A. THE DESCRIPTION IS LIMITED. PATIENT RIGID IN BED,
12 MEDICATED AS THIS PATIENT WAS, MY SUSPICION IS IT'S AN
13 EFFECT OF THE HALDOL AND RISPERDAL, NOT A MANIFESTATION OF
14 PAIN.
15 Q. UNDER 1400 WHAT IS WRITTEN?
16 A. CIRCLE B: PATIENT NOT ABLE TO TAKE MEDS, PATIENT
17 LETHARGIC AND UNRESPONSIVE, PATIENT NOT SWALLOWING OR
18 RESPONDING TO STAFF. CIRCLE I: PATIENT'S FAMILY NOTIFIED
19 OF PATIENT'S CONDITION, FAMILY IN TO BE WITH PATIENT, ORAL
20 CARE GIVEN, DOCTOR CALLED TIMES TWO WITHOUT CALLING BACK.
21 THERE'S SOMETHING BETWEEN CALLED TIMES TWO, IT MAY BE
22 BITNER.
23 Q. I THINK IT IS BITNER, YES.
24 A. OKAY. SO DOCTOR CALLED BITNER TIMES TWO WITHOUT CALLING
25 BACK. CIRCLE R: NO WET DIAPERS, NO P.O. INTAKE.
2376
1 Q. WHAT DOES THAT MEAN?
2 A. NO WET DIAPERS MEANS THAT THE PATIENT IS DIAPERED LYING
3 IN BED BUT THERE'S NO URINE OUTPUT, NO STOOL OUTPUT. NO
4 ORAL INTAKE. TURNED Q 2 HOURS, GOOD A.D.L., CARE, FOLLOW
5 DOCTOR'S ORDERS.
6 Q. AND I THINK THE LAST ENTRY 801 IS ALSO FOR THE 7TH OF
7 JANUARY, WOULD YOU READ THAT?
8 A. CIRCLE B: PATIENT NOT ABLE TO TAKE ANY MEDS, PATIENT
9 UNRESPONSIVE MOST THE SHIFT. CIRCLE I, SUPPORT ONE-TO-ONE
10 TIME, MEDS AS PER DOCTOR. FAMILY AND DOCTOR NOTIFIED OF
11 PATIENT'S CONDITION. RESPONSE, CIRCLE R, FAMILY AND DR.
12 WEITZEL INTO SEE PATIENT, RESPIRATIONS SHALLOW. CIRCLE P
13 COMFORT MEASURES.
14 Q. DO YOU ANYTHING IN THOSE RECORDS FOR THE 7TH OF JANUARY
15 THAT JUSTIFY THE ADMINISTRATION OF MORPHINE?
16 A. NO.
17 Q. AND IT APPEARS THAT THERE'S A RED IT SAYS 5 MILLIGRAMS
18 AND THEN THERE IS A WHITE BOX THAT SAYS 5 MILLIGRAMS, WHAT
19 DOES THAT MEAN?
20 A. 7TH OF JANUARY?
21 Q. YES.
22 A. 7TH OF JANUARY M.S. 5 MILLIGRAMS I.M. Q 3 HOURS FROM
23 MED-00742. 2100, 2400, 0300, 0600 ARE UNDER 1/7. IT WOULD
24 APPEAR THAT ONE DOSE WAS HELD, NOT ADMINISTERED. ONE -- AND
25 TWO DOSES WERE ADMINISTERED AND THE TIMES CONFUSED ME WITH
2377
1 THE DATE.
2 Q. WELL, AND BASICALLY YOU HAVE THE ORDER FOR THE MORPHINE
3 COMING AT WHAT TIME, THAT'S ON 711?
4 A. IT'S SIGNED BY THE NURSE AT 2130.
5 Q. ON THE 7TH?
6 A. YES.
7 Q. AND THEN ON MED-742 THAT YOU'VE JUST LOOKED AT YOU HAVE
8 A 2100 AND THERE'S -- ARE INITIALS NEXT TO THAT?
9 A. YES.
10 Q. MEANING WHAT?
11 A. DOSE WAS GIVEN 5 MILLIGRAMS.
12 Q. AND THEN AT 2400 BECAUSE IT'S EVERY THREE HOURS, THERE
13 ARE INITIALS BUT IT'S CIRCLED WITH A NUMBER OUT TO THE SIDE,
14 WHAT DOES THAT MEAN?
15 A. IT'S HELD, NOT ADMINISTERED AND THE SIX, ACCORDING TO
16 THE NONADMINISTRATION CODES, MEANS SEE NURSES' NOTES.
17 Q. THEN THE 0300 AND 0600 EVEN THOUGH THEY ARE UNDER 1/7,
18 COULD THEY HAVE BEEN ADMINISTERED AT 3 AND 6 IN THE MORNING
19 ON THE 7TH WHEN THE ORDER DIDN'T COME UNTIL THAT NIGHT?
20 A. COULD HAVE, YES.
21 Q. LIKELY?
22 A. NO, NOT LIKELY.
23 Q. COULD THIS BE A CHARTING ERROR WHERE THEY WERE PUT UNDER
24 THE 7TH INSTEAD OF THE 8TH?
25 A. COULD BE, YES.
2378
1 Q. BECAUSE WE SHOW ON THE 8TH THAT THE ONLY MEDICATION
2 GIVEN WAS IT LOOKS LIKE 30 MILLIGRAMS OF MORPHINE. WAS
3 THERE AN ORDER TO HOLD ALL THE OTHER MORPHINE -- EXCUSE ME,
4 ALL THE OTHER MEDICATIONS?
5 A. YES, ON 1/7/96, 0711, HOLD ALL OTHER MEDS OTHER THAN
6 M.S., D.N.R., DR. WEITZEL.
7 Q. AND MED-00712, WAS THERE A CHANGE IN THE AMOUNT OF
8 MORPHINE TO BE GIVEN?
9 A. CHANGE M.S ORDER TO M.S 10 MILLIGRAMS Q 3 HOURS AROUND
10 THE CLOCK.
11 Q. SO THE TOTAL GIVEN WAS 30 MILLIGRAMS -- WHAT IS AN
12 APPROPRIATE DOSE OF MORPHINE PER DAY?
13 A. WELL, A TOTAL -- USUAL TOTAL DAILY DOSE MAXIMUM IN THIS
14 POPULATION WE'VE SAID WOULD BE 15 MILLIGRAMS.
15 Q. SO THAT IS HOW MUCH -- HOW MANY TIMES WHAT'S --
16 A. IT WOULD BE TWO TIMES.
17 Q. DO YOU SEE ANYTHING IN THE RECORDS JUSTIFYING AN ORDER
18 OF MORPHINE IN THAT AMOUNT? I BELIEVE IT'S 720.
19 A. 1/8/96,M.D. PATIENT REMAINS UNRESPONSIVE, TAKES NO
20 FLUIDS, HER VITAL SIGNS REMAINS STRONG, SHE IS AFEBRILE.
21 ASSESSMENT: PROBABLY TERMINAL. PLAN: INCREASE MORPHINE
22 SULFATE. SHE IS OCCASIONALLY, O-C-C- APOSTROPHE L-Y,
23 APPEARING TO BE IN DISCOMFORT, DR. WEITZEL.
24 Q. IN YOUR REVIEW OF THE RECORDS, DID YOU FIND ANYTHING
25 THAT CORROBORATED THIS NOTE ABOUT APPEARING TO BE IN
2379
1 DISCOMFORT?
2 A. NO.
3 Q. DID YOU SEE ANY JUSTIFICATION FOR GIVING TWICE THE
4 REGULAR OR THE NORMAL DOSE OF MORPHINE TO LYDIA SMITH THAT
5 DAY ON THE 8TH OF JANUARY?
6 A. NO.
7 Q. WHEN DID SHE DIE?
8 A. FROM THE NURSES' NOTES 00802, 12:45, PATIENT'S DAUGHTER
9 REQUESTED US TO CHECK PATIENT, STATES, QUOTE, I DON'T THINK
10 SHE'S BREATHING, END QUOTE. PATIENT CHECKED, NO
11 RESPIRATIONS OR PULSE. PATIENT PLACED ON HER BACK WITH
12 HANDS TO SIDE, TEETH PLACED IN MOUTH, THAT WOULD HAVE BEEN
13 12:45 ON 1/8/96.
14 Q. SO WHEN WE'RE TALKING ABOUT 30 MILLIGRAMS OF MORPHINE
15 ADMINISTERED ON 1/8, JANUARY 8TH OF 1996, THAT WAS IN HOW
16 MANY HOURS IN THAT DAY IF SHE DIED AT 12:45?
17 A. I SHOULD JUST KEEP MY FINGER ON ALL OF IT.
18 Q. IF YOU WOULD LOOK AT 742 I BELIEVE.
19 A. DIED AT 12:45 FROM MIDNIGHT TO 12:45 IT APPEARS THAT IT
20 WAS 30 MILLIGRAMS.
21 Q. AND THAT'S HOW MANY HOURS, FROM MIDNIGHT TO 12:45 IN THE
22 AFTERNOON?
23 A. THAT WOULD BE 12 HOURS AND 45 MINUTES.
24 Q. OKAY. THANK YOU.
25 MS. BARLOW: YOUR HONOR, THAT CONCLUDES THIS
2380
1 PATIENT. MAYBE IT MIGHT BE A GOOD TIME TO --
2 THE COURT: ALL RIGHT. THANK YOU. OKAY. LADIES
3 AND GENTLEMEN, WHEN I GIVE WHAT I'M SUPPOSED TO TELL YOU AT
4 THE END OF THE DAY I THINK OF WHAT MY SON ALWAYS TELLS ME,
5 IF YOU KEEP TELLING ME THE SAME THING I IGNORE IT, SO WE
6 CAN'T HAVE YOU IGNORING. THINK OF THIS: YOU'VE NEVER HEARD
7 IT BEFORE.
8 IT'S YOUR DUTY NOT TO CONVERSE AMONG YOURSELVES AND TO
9 CONVERSE WITH OR ALLOW YOURSELVES TO BE ADDRESSED BY ANY
10 OTHER PERSON ON ANY SUBJECT OF THE TRIAL AND IT'S YOUR DUTY
11 NOT TO FORM OR EXPRESS AN OPINION THEREON UNTIL THE CASE IS
12 SUBMITTED TO YOU.
13 ALSO, I WANT TO INSIST AGAIN THAT NO RADIO, TELEVISION
14 REPORTS REGARDING THIS TRIAL, ANY NEWS REPORTS OF ANY TYPE,
15 YOU NEED TO AVOID. YOU CAN'T LISTEN, WATCH THE TV AND HAVE
16 THE MUTE ON AND SEE SOMETHING ABOUT THIS TRIAL OR HAVE
17 SOMEBODY SAY TO YOU, YEAH, DID YOU HEAR ABOUT THAT IN THE
18 PAPER? NONE OF THOSE THINGS SHOULD BE DONE.
19 SO AS WE MENTIONED BEFORE, WE'LL START TOMORROW AT
20 8 O'CLOCK AND WE'LL END TOMORROW AT 4:30. SO WE'LL BE IN
21 RECESS UNTIL THAT TIME.
22 (WHEREUPON THE JURY WAS EXCUSED.)
23 THE COURT: YOU MAY BE SEATED. THE RECORD WILL
24 REFLECT THAT THE JURY HAS LEFT. HOW MUCH MORE TIME DO YOU
25 ANTICIPATE WITH THIS WITNESS ON DIRECT?
2381
1 MS. BARLOW: YOUR HONOR, THE LAST CHART INVOLVES
2 JUDITH LARSEN WHO WAS IN THERE --
3 THE COURT: LONGER.
4 MS. BARLOW: -- A LONGER PERIOD OF TIME BUT I --
5 YOU KNOW, I DON'T -- I HOPE THAT LESS THAN AN HOUR I WOULD
6 FINISH UP DIRECT.
7 THE COURT: OKAY. AND THEN DO YOU HAVE ANY
8 ANTICIPATION JUST SO WE CAN GAUGE ABOUT HOW MANY WITNESSES
9 WE'RE GOING TO BE TOMORROW.
10 MR. STIRBA: I'M ALWAYS LESS THAN AN HOUR. I DON'T
11 KNOW, HALF HOUR, 45 MINUTES, SOMETHING LIKE THAT.
12 THE COURT: WHO WOULD THE STATE CALL AFTER THIS
13 WITNESS.
14 MR. MAJOR: THE ONLY WITNESS WE ANTICIPATE TOMORROW
15 IS BRAD HARE, YOUR HONOR. WE ANTICIPATE HE WOULD TAKE MOST
16 OF THE DAY.
17 THE COURT: ALL RIGHT. WE'LL SEE YOU AT --
18 MR. STIRBA: ONE POINT OF ORDER BECAUSE IT MIGHT
19 HELP US.
20 THE COURT: SURE.
21 MR. STIRBA: IS IT APPROPRIATE TO FIND OUT KIND OF
22 WHERE THE STATE IS WITH RESPECT TO THEIR PRESENTATION,
23 BECAUSE WE'VE GOT TO PUT ON OUR CASE. IF I IF I HAD SOME
24 NOTICE, IT WOULD BE HELPFUL.
25 THE COURT: THAT WOULD BE -- CAN YOU SPEAK TO THAT?
2382
1 MR. MAJOR: YES. I BELIEVE RIGHT NOW WE HAVE BRAD
2 HARE WILL BE CALLED TOMORROW AND THEN DR. CROOKSTON WILL BE
3 CALLED AND I THINK AND THAT CONCLUDES THE STATE'S WITNESSES,
4 I BELIEVE.
5 THE COURT: SO DR --
6 MR. MAJOR: THERE MIGHT BE ONE OR TWO MINOR ONES
7 THAT MAY COME IN FOR ABOUT AN HOUR OR SO.
8 MS. BARLOW: LIKE DETECTIVE MORRISON MIGHT COME IN
9 TO SEEK ADMISSION OF CERTAIN DOCUMENTS.
10 THE COURT: OKAY.
11 MS. BARLOW: BUT THEY WON'T BE LONG, EXTENSIVE
12 ONES.
13 THE COURT: DO YOU THINK BY MONDAY AT NOON OR HOW
14 LONG IS DR. CROOKSTON? EXCUSE ME.
15 MR. MAJOR: THAT WOULD BE HARD. I WOULD PROBABLY
16 SAY -- PROBABLY BY TUESDAY MORNING WE WOULD BE PREPARED FOR
17 DEFENSE'S SIDE.
18 THE COURT: IS THAT ENOUGH NOTICE?
19 MR. STIRBA: YEAH, THAT'S HELPFUL, JUDGE. AND IF
20 WE COULD DISCUSS WHEN WE'RE SUPPOSED TO START AS WE SEE SORT
21 OF HOW THIS IS. I'LL PLAN ON TUESDAY MORNING.
22 THE COURT: MORE LIKE I GUESS BY MONDAY -- WELL,
23 AFTER FRIDAY WE'LL SEE WHERE WE'RE AT ON FRIDAY BUT THEN BY
24 MONDAY WE'LL KNOW.
25 MR. MAJOR: WE SHOULD KNOW BY MONDAY AFTERNOON
2383
1 WHERE WE'RE AT.
2 MR. STIRBA: THANK YOU.
3 THE COURT: WE'LL SEE YOU AT 8 O'CLOCK IN THE
4 MORNING. IS THAT OKAY WITH THE WITNESS?
5 THE WITNESS: YES.
6 THE COURT: WE ASKED EVERYONE EXCEPT YOU.
7 THE WITNESS: I'M JUST FINE WITH IT, JUDGE. THANK
8 YOU, JUDGE.
9 (WHEREUPON, THE AFTERNOON SESSION ENDS.)
10
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2384
1 IN THE DISTRICT COURT OF DAVIS COUNTY
2 STATE OF UTAH
3
*****
4 ______________________________
)
5 STATE OF UTAH, )
)
6 PLAINTIFF, )
)
7 ) REPORTER'S TRANSCRIPT
VS. )
8 ) CASE NO. 991700983
ROBERT ALLEN WEITZEL, )
9 )
DEFENDANT. )
10 ______________________________)
11 *****
12 TRIAL VOLUME 11 OF 21
13 JUNE 23, 2000
14 HONORABLE THOMAS L. KAY
15
*****
16
17 APPEARANCES:
18 FOR THE STATE: MR. MELVIN C. WILSON
MR. STEVEN V. MAJOR
19 MS. CHARLENE BARLOW
20
FOR THE DEFENDANT: MR. PETER STIRBA
21 MR. JOHN WARREN MAY
22
23
24
25
2385
1 (WHEREUPON, THE MORNING SESSION BEGINS.)
2 THE COURT: OKAY. THE RECORD SHOULD REFLECT THAT
3 THE JURY IS PRESENT, THE PARTIES AND ATTORNEYS ARE ALL
4 PRESENT.
5 AND LADIES AND GENTLEMEN AND EVERYONE, THANK YOU VERY
6 MUCH FOR BEING HERE AT AN EARLIER HOUR THAN WE NORMALLY
7 HAVE.
8 OKAY. WE HAVE A MESSAGE HERE FROM ONE OF THE JURORS
9 ASKING SOME CLARIFICATION ON SOME QUESTIONS AND WONDERING
10 IF, YOU KNOW, THEY'RE TO GARNER INFORMATION FROM THE
11 TESTIMONY OR -- OR ARE QUESTIONS ALLOWED. AND I DON'T KNOW
12 IF YOU WANT ME TO READ THESE TO THE COUNSEL.
13 I -- I GUESS IN ANSWER TO THE QUESTION: ARE QUESTIONS
14 ALLOWED, SOMETIMES QUESTIONS CAN BE ALLOWED BY JURY MEMBERS,
15 SOMETIMES THEY CAN'T. IT ALL DEPENDS ON THE TYPE OF CASE.
16 AND GENERALLY IN A CRIMINAL CASE QUESTIONS AREN'T ASKED FROM
17 THE -- THE JURY.
18 BUT I DIDN'T KNOW IF COUNSEL WANTS TO SEE THIS.
19 MS. BARLOW: YOUR HONOR, I -- CERTAINLY THE JURY
20 ALREADY KNOWS WHAT THE QUESTIONS ARE. I DON'T KNOW IT WOULD
21 HURT TO READ THEM OUT LOUD AND THEN -- BUT IF WE'RE GOING TO
22 DISCUSS THEM, PERHAPS WE DON'T WANT TO DO THAT IN FRONT OF
23 THE JURY.
24 THE COURT: NO.
25 MR. STIRBA: I WOULD SUGGEST, COULD WE DO THIS
2386
1 MAYBE AT A RECESS?
2 THE COURT: OKAY.
3 MR. STIRBA: THAT WILL BE GOOD.
4 THE COURT: WE'LL DO THAT.
5 MR. STIRBA: THANK YOU.
6 THE COURT: AND THEN -- WE'LL DO THAT AND THEN --
7 MS. BARLOW: YOUR HONOR, EXCUSE ME. IF AT RECESS
8 WE'RE THROUGH WITH DR. FEHLAUER, CAN WE RECALL HIM IF THERE
9 ARE THINGS THAT WE CAN CLEAR UP?
10 MR. STIRBA: I'M SURE WE WON'T WITHIN -- YOU KNOW,
11 THE FIRST RECESS WE WON'T BE THROUGH WITH HIM, I'M SURE.
12 THE COURT: OKAY.
13 MS. BARLOW: THANK YOU.
14 THE COURT: ALL RIGHT. DR. FEHLAUER, YOU'RE STILL
15 UNDER OATH. YOU UNDERSTAND THAT?
16 THE WITNESS: YES.
17 THE COURT: OKAY. AND, MS. BARLOW, IF YOU'D LIKE
18 TO CONTINUE.
19 MS. BARLOW: THANK YOU, YOUR HONOR.
20 DIRECT EXAMINATION, CONT'D
21 BY MS. BARLOW:
22 Q. GOOD MORNING, DOCTOR.
23 A. GOOD MORNING.
24 Q. I'D LIKE TO CLEAR UP A COUPLE OF MATTERS THAT I'M NOT
25 SURE I WAS CLEAR ENOUGH ON YESTERDAY. LET'S LOOK AT
2387
1 MR. ALLDREDGE'S RECORDS AGAIN. THIS IS STATE'S EXHIBIT 7.
2 YOU TESTIFIED YESTERDAY ABOUT THE ORIGINAL ADMITTING ORDERS.
3 DID THOSE ORDERS EVER CHANGE?
4 A. YES, THEY DID.
5 Q. AND, SPECIFICALLY, THE ORDERS FOR MEDICATIONS?
6 A. YES.
7 Q. WHEN DID THEY CHANGE?
8 A. SUBSEQUENT TO THE ORIGINAL TELEPHONE ORDER ON 1/10/96,
9 THERE'S A HANDWRITTEN ORDER FOR ATIVAN AND HALDOL.
10 Q. DID YOU SEE ANYTHING IN THE RECORD THAT JUSTIFIED THAT
11 CHANGE?
12 A. REFERRING TO DR. WEITZEL'S ADMISSION EVALUATION.
13 Q. IS THAT THE PSYCHIATRIC EVALUATION?
14 A. YES. MED-0003, 4, AND 5: THOUGHT PROCESS, QUITE LOOSE
15 AND EXHIBITS BLOCKING. THOUGHT CONTENT -- WOULD YOU WANT ME
16 TO READ THE ENTIRE SECTION?
17 MR. STIRBA: YOUR HONOR, I BELIEVE THIS IS GONE
18 OVER. THAT'S THE SAME NOTE THAT HE READ ON DIRECT EARLIER
19 IN HIS TESTIMONY. THIS IS CUMULATIVE.
20 MS. BARLOW: YOUR HONOR, I ASKED IF ANYTHING
21 JUSTIFIED THE CHANGE, WHICH I DID NOT ASK YESTERDAY.
22 THE COURT: OKAY. CONTINUE, BUT LET'S TRY TO MOVE
23 ON AS WELL.
24 MS. BARLOW: I WILL.
25 Q. (BY MS. BARLOW) NO, DON'T READ THE WHOLE PARAGRAPH,
2388
1 JUST WHAT -- IS THERE ANYTHING IN THAT RECORD THAT JUSTIFIED
2 THE CHANGE IN ORDERS -- MEDICATION ORDERS?
3 A. YES.
4 Q. WHAT WAS THERE?
5 A. THERE'S EVIDENCE OF PSYCHOSIS ON HIS EXAMINATION OF THE
6 PATIENT.
7 Q. WAS THERE A SUBSEQUENT CHANGE?
8 A. ON 1/12/96 HALDOL IS CHANGED.
9 Q. AND HOW WAS IT CHANGED?
10 A. INCREASE HALDOL TO 10 MILLIGRAMS I.R.N. (SIC). PATIENT
11 REFUSING ORAL MEDS. GIVE AT A.M. 1700 AND H.S. P.R.N.
12 Q. AND DO YOU SEE ANYTHING IN THE RECORDS JUSTIFYING THAT
13 CHANGE?
14 A. THERE'S NO CLEAR EVIDENCE OF PSYCHOSIS, NO.
15 Q. IS THERE ANY EVIDENCE OF DELIRIUM?
16 A. YES.
17 Q. WHAT EVIDENCE WAS THERE?
18 A. THE PATIENT IS -- ON THE BASIS OF DR. WEITZEL'S NOTE AND
19 ON THE BASIS OF THE NURSES' NOTES -- EXHIBITING CLEAR
20 EVIDENCE OF LOSS OF ABILITY TO INTERACT AND PERCEIVE THE
21 ENVIRONMENT NORMALLY, PSYCHOMOTOR AGITATION, RESTLESSNESS,
22 WITHDRAWAL, LETHARGY, CONFUSION.
23 Q. AND BASED ON YOUR EXPERIENCE AND TRAINING AND YOUR
24 REVIEW OF THE RECORDS, CAN YOU DETERMINE A CAUSE OF THAT
25 DELIRIUM?
2389
1 MR. STIRBA: I'M GOING TO OBJECT, YOUR HONOR.
2 CUMULATIVE. ASKED AND ANSWERED.
3 THE COURT: SUSTAINED.
4 Q. (BY MS. BARLOW) WAS THERE ANOTHER CHANGE IN THE
5 MEDICINES ORDER?
6 A. YES, LATER THAT DAY. 1/12/96.
7 Q. WHAT WAS THAT CHANGE?
8 A. ATIVAN 1 MILLIGRAM I.M. NOW, HALDOL 5 MILLIGRAMS I.M.
9 NOW.
10 Q. DO YOU SEE ANYTHING IN THE RECORDS JUSTIFYING THAT
11 CHANGE IN THE ORDERS?
12 A. AS STATED BEFORE, I FIND NO EVIDENCE OF PSYCHOSIS.
13 MR. STIRBA: YOUR HONOR, I'M -- I'M GOING -- I'M
14 GOING TO OBJECT.
15 THE COURT: COULD WE JUST MOVE ALONG? I THINK IF
16 HE SAYS I'VE STATED BEFORE, WE'VE BEEN OVER THIS BEFORE.
17 Q. (BY MS. BARLOW) WELL, HAVE YOU STATED THAT BEFORE ON
18 THIS WITNESS --
19 A. REGARDS TO THE --
20 Q. -- OR THIS VICTIM? EXCUSE ME.
21 A. WITH REGARDS TO THE HALDOL, YES, BUT NOT THE ATIVAN IN
22 THIS -- IN THIS QUESTION.
23 Q. DO YOU SEE ANYTHING -- DO YOU SEE ANYTHING JUSTIFYING
24 THE ADDITION OF ATIVAN AT THAT POINT?
25 A. YES. THE AGITATION.
2390
1 Q. WAS THERE A SUBSEQUENT CHANGE IN MEDICATIONS ORDERED?
2 A. YES. ON 1/13/96.
3 Q. SO WHAT? THE FOURTH DAY THAT HE WAS IN?
4 A. YES.
5 Q. OKAY. WHAT WAS THAT CHANGE?
6 A. MORPHINE SULFATE 10 MILLIGRAMS I.M. Q 3 HOURS.
7 Q. OKAY.
8 A. ATIVAN 0.5 MILLIGRAMS I.M. Q 3 HOURS.
9 Q. ARE THOSE P.R.N.?
10 A. THERE IS NO P.R.N.
11 Q. NO AS NEEDEDS. ANY OTHER CHANGE IN THE MEDICATIONS?
12 A. D/C ALL ORAL MEDS.
13 Q. MEANING WHAT?
14 A. MEDICATIONS GIVEN BY MOUTH ARE ALL DISCONTINUED, NOT TO
15 BE GIVEN. D/C HALDOL P.R.N. AS WRITTEN. HALDOL 10
16 MILLIGRAMS I.M. Q 4 HOURS, P.R.N. SEVERE AGITATION.
17 Q. DO YOU SEE ANYTHING IN THE RECORDS JUSTIFYING THIS
18 CHANGE?
19 MR. STIRBA: I'M GOING TO OBJECT, YOUR HONOR. I
20 THINK THAT WAS ASKED YESTERDAY. CUMULATIVE.
21 MS. BARLOW: YOUR HONOR, IT WAS NOT ASKED OF THIS
22 VICTIM.
23 THE COURT: OKAY. WELL, ONE OF THE THINGS THAT I'M
24 CONCERNED ABOUT IS THAT WE'VE BEEN A LONG TIME WITH THIS
25 WITNESS AND I DON'T WANT TO JUST REPEAT THINGS THAT THE
2391
1 WITNESS HAS SAID BEFORE.
2 MS. BARLOW: I AGREE.
3 THE COURT: AND SO LET'S TRY TO MOVE ALONG AS MUCH
4 AS WE CAN. I THOUGHT -- AS I UNDERSTOOD, WHEN WE ENDED WE
5 HAD ONE MORE PATIENT TO TALK ABOUT, SO LET'S KEEP MOVING.
6 MS. BARLOW: YOUR HONOR, THIS IS NOT REPETITIVE
7 BECAUSE THESE --
8 THE COURT: OKAY. THEN ASK THE QUESTION AND THEN
9 JUST KEEP MOVING. I'M JUST SAYING THAT I DON'T WANT TO
10 REPEAT. I MEAN, WE -- WE WENT THROUGH FOUR PATIENTS
11 YESTERDAY AND -- ABOUT CUMULATIVE EVIDENCE, THAT WE CAN'T
12 KEEP JUST GOING OVER FOUR PATIENTS YESTERDAY AND THEN COMING
13 BACK TO THOSE SAME FOUR PATIENTS AND REPEATING IT.
14 MS. BARLOW: I DON'T INTEND TO, YOUR HONOR.
15 THE COURT: AND I DON'T WANT TO HAVE TO HAVE
16 EVERYBODY KEEP MAKING OBJECTIONS BECAUSE WE'RE REPEATING
17 THINGS. SO GO AHEAD.
18 Q. (BY MS. BARLOW) THE QUESTION I'M ASKING TODAY IS DO
19 YOU SEE ANYTHING IN THE RECORDS JUSTIFYING THAT CHANGE IN
20 ORDERS?
21 A. THE DISCONTINUATION OF THE ORAL MEDICATIONS AND THE
22 HALDOL P.R.N. AS WRITTEN MAKES PERFECT SENSE TO ME IN THE
23 SETTING OF THIS PATIENT'S CONFUSED STATE. HIS AGITATION,
24 WITHDRAWAL AND LETHARGY THAT COULD BE INDUCED BY THE
25 MEDICATIONS. YES.
2392
1 Q. WHAT ABOUT THE ADDITION OF THE MORPHINE SULFATE?
2 A. DOCTORS -- DR. WEITZEL'S NOTES INCLUDE EVIDENCE OF THE
3 PATIENT BEING UNCOMFORTABLE BY HIS OBSERVATION.
4 Q. AND DID YOU SEE ANYTHING ELSEWHERE IN THE RECORDS THAT
5 SUPPORTED THAT CONCLUSION?
6 A. READING FROM THE NURSES' NOTES 1/13/96, MED-00074:
7 11-7, PLEASE SEE Q 2 HOUR CHARTING ON ATTACHED SHEET FOR 11
8 TO 7 SHIFT.
9 0800, PATIENT UNRESPONSIVE. FAMILY WITH PATIENT.
10 POSEY AND RESTRAINT TAKEN OFF. I.V.'S D/C'D. COMFORT
11 MEASURES GIVEN. DR. WEITZEL TALKED WITH FAMILY.
12 DR. DIENHART NOTIFIED OF PATIENT'S DECLINING CONDITION.
13 CIRCLE B, PATIENT HAS BEEN UNRESPONSIVE THE WHOLE
14 SHIFT. TURN Q 2 HOURS. COMFORT MEASURES. ORAL CARE.
15 CIRCLE R, RESPIRATIONS IRREGULAR WITH PERIODS OF APNEA.
16 COLOR PALE.
17 CIRCLE P, COMFORT MEASURES, FAMILY SUPPORT.
18 00075: 1/13/96, CIRCLE B, PATIENT UNRESPONSIVE THIS
19 SHIFT DURING CARES AND I.M. MEDICATIONS ADMINISTERED. NO
20 RESPONSE TO ADMINISTRATION -- TO MINISTRATION OF FAMILY
21 MEMBERS, PRESENT AT BEDSIDE.
22 CIRCLE R, PATIENT UNRESPONSIVE WITH LONG PERIODS OF
23 APNEA, Q 1 TO 2 MINUTES. NO DISCOMFORT NOTED DURING CARES.
24 Q. IS THERE ANYTHING IN THAT THAT JUSTIFIED OR SUPPORTS THE
25 PROGRESS NOTE WRITTEN BY THE DOCTOR?
2393
1 A. NO.
2 Q. LET'S LOOK AT MARY CRANE JUST BRIEFLY. THIS IS STATE'S
3 EXHIBIT 5. THERE APPEARS TO HAVE BEEN A CHANGE IN THE
4 MEDICATIONS ORDERED ON THE 31ST OF DECEMBER, THE FOURTH DAY
5 THAT SHE WAS ON THE UNIT. DO YOU SEE ANYTHING -- DO YOU SEE
6 THAT CHANGE IN THE ORDERS IN THE RECORD?
7 A. YES, I DO. DOCTOR'S ORDERS MED-000241: 12/31/95, 1930,
8 T.O. DR. WEITZEL. CIRCLE 1, IF PATIENT REFUSES RISPERDAL,
9 GIVE HALDOL 5 MILLIGRAM I.M.
10 CIRCLE 2, ATIVAN, 1 TO 2 MILLIGRAM P.O. OR I.M. Q 4
11 HOURS P.R.N. SEVERE AGITATION.
12 Q. DO YOU SEE ANYTHING IN THE RECORD JUSTIFYING THAT
13 CHANGE?
14 A. FROM 12/31 DR. WEITZEL'S NOTES, NO. FROM 12/31 THE
15 NURSES' NOTES, MED-00312: 1625 TO 2300, FREE TEXT, PATIENT
16 WAS INCREASINGLY AGITATED FROM 1900 ON. SCREAMING, TRYING
17 TO HIT, BITING C.N.A. DOCTOR NOTIFIED. PATIENT MEDICATED
18 WITH ATIVAN 2 MILLIGRAMS I.M. WITH GOOD RESULTS. PATIENT
19 SETTLED DOWN AND AGREED TO TAKE HER P.M. MEDS.
20 YES, I FIND THAT WAS NECESSARY.
21 Q. THEN THE NEXT CHANGE WAS THE 3RD OF JANUARY. DO YOU
22 NOTE THE CHANGE IN MEDICATIONS ON THAT DAY?
23 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT ON
24 THAT ONE. I THINK THAT WAS TALKED ABOUT. OBJECT.
25 CUMULATIVE AND ASKED AND ANSWERED.
2394
1 THE COURT: YOU KNOW, I --
2 MS. BARLOW: YOUR HONOR, I DID NOT ASK IF THERE WAS
3 ANYTHING THAT JUSTIFIED THAT, AND THAT'S WHAT I WAS GOING TO
4 ASK NEXT.
5 THE COURT: OKAY. WELL THEN LET'S -- I GUESS WHAT
6 WE NEED TO DO IS THAT WE'VE TALKED ABOUT FOUR OF THE
7 PATIENTS YESTERDAY AND IT TOOK MOST OF THE DAY TO DO THAT,
8 SO I'M NOT GOING TO LET YOU CONTINUE TO JUST REDO EACH
9 PATIENT WITH THIS WITNESS. IF YOU WANT TO ASK SOME SPECIFIC
10 QUESTIONS DIRECTLY -- AND I REALLY DON'T -- THE RECORDS ARE
11 IN HERE THAT HE KEEPS READING, AND WHEN HE ASK -- YOU ASK
12 HIM A QUESTION HE READS THE RECORD. WE'VE HEARD THAT
13 RECORD -- SOME OF THOSE RECORDS FOUR OR FIVE TIMES, AND SO
14 THAT IS CUMULATIVE.
15 Q. (BY MS. BARLOW) THE CHANGES IN MEDICATION FOR MARY
16 CRANE, DID YOU SEE JUSTIFICATION -- WITHOUT READING WHAT
17 THOSE RECORDS SAY -- DID YOU SEE JUSTIFICATION FOR THE
18 CHANGE ON THE 3RD OF JANUARY?
19 MR. STIRBA: I'M GOING TO RENEW -- I'M GOING TO
20 RENEW MY OBJECTION. HE WAS ASKED THAT YESTERDAY.
21 MS. BARLOW: I DON'T BELIEVE HE WAS.
22 THE COURT: OKAY. I'LL ASK (SIC) THAT QUESTION AND
23 THEN WE'RE GOING TO MOVE ON TO THE NEXT WITNESS -- OR I
24 MEANT THE NEXT PATIENT.
25 MS. BARLOW: WELL, IF I'M ALLOWED ONE QUESTION, MAY
2395
1 I ASK ABOUT THE 5TH -- THE CHANGE ON THE 5TH INSTEAD OF THE
2 CHANGE ON THE 3RD, YOUR HONOR?
3 THE COURT: FINE. GO AHEAD.
4 Q. (BY MS. BARLOW) DO YOU SEE ANY JUSTIFICATION FOR THE
5 CHANGE ON THE 5TH?
6 A. CHANGE ON THE 5TH BEING THE MORPHINE DURAGESIC PATCH?
7 Q. YES.
8 A. NO CLEAR INDICATION.
9 Q. LET'S THEN TURN TO JUDITH LARSEN, THE LAST VICTIM IN
10 THIS MATTER.
11 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT TO THE
12 CHARACTERIZATION AND USE OF THAT WORD. ALLEGED VICTIM.
13 THAT'S A LEGAL CONCLUSION. THERE'S BEEN NO PROOF THAT THERE
14 ARE ANY VICTIMS IN THIS CASE.
15 THE COURT: OKAY.
16 MS. BARLOW: I'LL REPHRASE IT, YOUR HONOR.
17 THE COURT: ALL RIGHT. GO AHEAD.
18 Q. (BY MS. BARLOW) I GUESS I BETTER -- BETTER BRING UP
19 THE RIGHT ONE FOR YOU. IT WILL BE MORE HELPFUL.
20 THIS IS STATE'S EXHIBIT 6, THE RECORDS OF JUDITH
21 LARSEN. DID YOU REVIEW THOSE RECORDS?
22 A. YES, I HAVE.
23 Q. DID YOU REVIEW OTHER RECORDS REGARDING JUDITH LARSEN?
24 A. YES, I HAVE. I'VE REVIEWED TWO HOSPITAL ADMISSIONS,
25 NURSING FACILITY RECORDS FOR THE SIX MONTHS PRIOR TO HER
2396
1 ADMISSION.
2 Q. BASED ON THAT REVIEW, DID YOU FORM AN OPINION TO A
3 DEGREE OF MEDICAL CERTAINTY ABOUT THE CAUSE OF JUDITH
4 LARSEN'S DEATH?
5 A. I'D LIKE TO DEFER TO THE FINDINGS OF THE MEDICAL
6 EXAMINER.
7 Q. AND THOSE ARE ALREADY IN EVIDENCE. ARE YOU AWARE WHAT
8 THEY ARE?
9 A. YES.
10 Q. AND WHAT DID THE MEDICAL EXAMINER FIND?
11 THE COURT: OVERRULED. THE MEDICAL EXAMINER --
12 MR. STIRBA: I'M -- I'M GOING TO OBJECT, YOUR
13 HONOR.
14 THE COURT: -- HAS TESTIFIED. IF THIS WITNESS HAS
15 AN OPINION ABOUT --
16 MR. STIRBA: RIGHT.
17 THE COURT: -- THE CAUSE OF DEATH OF JUDITH LARSEN,
18 HE CAN GIVE IT. IF HE'S DEFERRING AND HE'S NOT -- JUST
19 GOING TO REPEAT WHAT ANOTHER WITNESS HAS SAID, THAT'S NOT
20 HIS OPINION.
21 Q. (BY MS. BARLOW) DO YOU HAVE YOUR OWN OPINION BASED ON
22 YOUR REVIEW OF THE RECORDS --
23 A. YES.
24 Q. -- OF THE CAUSE OF DEATH? AND WHAT IS YOUR OPINION, TO
25 A DEGREE OF MEDICAL CERTAINTY, OF THE CAUSE OF DEATH OF
2397
1 JUDITH LARSEN?
2 A. MY OPINION AGREES WITH THAT OF THE MEDICAL EXAMINER AND
3 IS THAT THE PATIENT SUCCUMBED DUE TO THE ADMINISTRATION OF
4 MORPHINE SULFATE.
5 Q. DO YOU HAVE THE ADMISSION OF JUDITH LARSEN IN FRONT OF?
6 A. YES.
7 Q. IS THERE ANY INDICATION OF TERMINAL DISEASE IN JUDITH
8 LARSEN -- I SHOULDN'T SAY TERMINAL. LET ME REPHRASE THAT.
9 IS THERE ANY INDICATION THAT JUDITH LARSEN WAS IN A TERMINAL
10 STATE WHEN SHE CAME TO DAVIS NORTH?
11 A. REVIEW OF DR. WEITZEL'S EVALUATION REVEALS THAT HE FELT
12 THAT SHE WOULD REMAIN IN THE HOSPITAL FOR APPROXIMATELY TWO
13 WEEKS AND BE DISCHARGED BACK TO HER CARE CENTER.
14 Q. FROM YOUR REVIEW OF THE RECORDS, WAS MRS. LARSEN
15 DELIRIOUS WHEN SHE CAME TO DAVIS NORTH?
16 A. YES.
17 Q. WHAT DO YOU BASE THAT CONCLUSION ON?
18 A. I BASE THAT CONCLUSION ON THE REVIEW OF THE DISCHARGE
19 RECORDS FROM HOLLADAY HEALTH CARE AND FROM THE ADMISSION
20 RECORDS OF DAVIS HOSPITAL WHERE THE PATIENT EXHIBITED CLEAR
21 CHANGE IN HER CONDITION OVER A THREE-WEEK PERIOD, AS
22 DOCUMENTED IN THE NURSING NOTES. THAT SHE WAS OBVIOUSLY
23 DISTURBED ABOUT HER PERCEPTIONS OF THE ENVIRONMENT. THAT
24 SHE HAD DELUSIONS, AS DOCUMENTED BY THE NURSES. THAT SHE
25 WAS PSYCHOMOTOR AGITATED AND IMPAIRED RATHER PROFOUNDLY IN
2398
1 HER ABILITY TO THINK AND -- AND RESPOND WITH HER MEMORY.
2 THAT SHE HAD DISTURBANCE OF HER SLEEP/WAKE CYCLE WITH
3 PERIODS OF DAYTIME SLEEPING AND NIGHTTIME AWAKENING. THAT
4 HER MOOD WAS QUITE LABILE THROUGHOUT THE DAY WITH PERIODS OF
5 CALMNESS AND PERIODS OF RATHER PROFOUND ANGER AND ANXIETY
6 AND AGITATION. CLEARLY MEETING THE CRITERIA FOR DELIRIUM.
7 Q. WHAT IS YOUR ASSESSMENT OF THE CAUSE OF THAT DELIRIUM?
8 A. MY ASSESSMENT IS THAT THE PATIENT WAS DELIRIOUS DUE TO
9 THE ADMINISTRATION OF TRAZODONE AND XANAX.
10 Q. I DON'T THINK XANAX IS A DRUG WE'VE TALKED ABOUT YET.
11 WHAT IS XANAX?
12 A. XANAX IS A BENZODIAZEPINE IN THE VALIUM CLASS OF DRUGS.
13 IT'S DIFFERENT FROM VALIUM IN THAT IT'S VERY SHORT ACTING.
14 Q. ANYTHING ELSE CAUSING THAT DELIRIUM?
15 A. BASED ON THE ADMISSION ASSESSMENTS PERFORMED, NOTHING
16 CLEARLY IS EVIDENT.
17 Q. WE HAVE THE ADMISSION ORDERS FOR JUDITH LARSEN. HAVE
18 YOU REVIEWED THOSE?
19 A. YES, I HAVE.
20 Q. WHAT WAS ORDERED UPON ADMISSION? LET'S -- NOT GOING
21 THROUGH ALL THE LABS, BUT WERE LABS ORDERED AND THAT SORT OF
22 THING AND SOME OF THE GENERAL -- WERE -- WERE THE SAME
23 GENERAL KINDS OF THINGS: LABS, ORDERS, TESTS, THAT SORT OF
24 THING, ENTERED FOR JUDITH LARSEN?
25 A. YES, THEY WERE.
2399
1 Q. WHAT ABOUT THE MEDICATIONS? WERE THERE ANY THAT WERE
2 SPECIFIC TO MRS. LARSEN?
3 A. YES.
4 Q. WOULD YOU PLEASE ON MED-00451, STARTING AFTER SPECIAL
5 PRECAUTIONS -- I MEAN, BEFORE THAT YOU HAVE TYLENOL,
6 MYLANTA, ET CETERA. WHAT -- WHAT OTHER MEDICATIONS WERE
7 ORDERED FOR MRS. LARSEN?
8 A. BETAGAN, WHICH IS A GLAUCOMA EYE DROP; SURFAK, WHICH IS
9 STOOL SOFTENER; KLONOPIN 0.5 MILLIGRAMS P.O. 3 TIMES A DAY;
10 TRAZODONE 100 MILLIGRAMS Q H.S.; SYNTHROID 0.088
11 MILLIGRAMS --
12 Q. WHAT IS SYNTHROID?
13 A. SYNTHROID IS -- IS THE THYROID HORMONE FOR HORMONE
14 REPLACEMENT, ONCE A DAY. BABY ASPIRIN ONCE A DAY.
15 ISOSORBIDE 10 MILLIGRAMS TWICE A DAY; ATIVAN 1 TO 2
16 MILLIGRAMS P.O. OR BY MOUTH OR INJECTION Q 6 HOURS AS
17 NEEDED; AND TRAZODONE 100 MILLIGRAMS P.O. TIMES 1 P.R.N.
18 AFTER H.S. DOSE.
19 Q. AND I BELIEVE THAT THERE IS ANOTHER ONE UNDERNEATH THAT,
20 ZANTAC?
21 A. ZANTAC, YES, 150 MILLIGRAMS EACH DAY.
22 Q. WHAT IS ISO -- ISOSORBIDE?
23 A. ISOSORBIDE IS A FORM OF NITROGLYCERIN THAT IS
24 ADMINISTERED ORALLY AND DILATES THE ARTERIES MUCH LIKE A
25 TABLET UNDER THE TONGUE WOULD.
2400
1 Q. WHAT ABOUT ZANTAC?
2 A. ZANTAC IS THE MEDICINE RANITIDINE THAT'S USED TO TREAT
3 DYSPEPSIA OR HEARTBURN.
4 Q. AND THEN I BELIEVE -- WELL, LET'S GO -- GO UP TO
5 KLONOPIN. WHAT IS KLONOPIN?
6 A. KLONOPIN IS A LONG-ACTING BENZODIAZEPINE ANTICONVULSANT
7 THAT IS SIMILAR TO VALIUM.
8 Q. DO YOU HAVE -- DO YOU KNOW WHAT THE ADULT STARTING DOSE
9 IS FOR KLONOPIN?
10 A. IT'S 0.5 MILLIGRAMS TWO OR THREE TIMES A DAY.
11 Q. IS IT DIFFERENT FOR THE ELDERLY?
12 A. NO.
13 Q. WOULD -- WHEN MRS. LARSEN CAME ONTO THE UNIT, WAS SHE
14 SUFFERING FROM DELIRIUM?
15 A. YES.
16 Q. OH, I'M SORRY. I AM REPEATING MYSELF AND I WILL STOP
17 DOING THAT.
18 IS THERE ANYTHING IN THIS LIST OF MEDICATIONS THAT
19 WOULD CAUSE DELIRIUM?
20 A. YES.
21 Q. WHICH MEDICATIONS?
22 A. KLONOPIN, TRAZODONE. THOSE WOULD BE THE TWO MOST
23 LIKELY.
24 Q. OKAY. WHAT IS THE GERIATRIC PHARMACOLOGY FOR KLONOPIN?
25 WHAT ARE YOU REFERRING TO, DOCTOR?
2401
1 A. THE 1993 EDITION OF THE GERIATRIC DOSAGE HANDBOOK.
2 MR. STIRBA: YOUR HONOR, I -- I DO BELIEVE THIS WAS
3 TESTIFIED TO YESTERDAY. I THINK HE WENT OVER KLONOPIN AND I
4 THINK THERE WAS A DISPLAY ON THERE AND I THINK HE TESTIFIED
5 ABOUT IT.
6 MS. BARLOW: YOUR HONOR, IT'S NOT ON THE DISPLAY
7 AND I BELIEVE THAT THERE WAS AN OBJECTION YESTERDAY AND WE
8 WERE NOT ALLOWED TO GET INTO IT.
9 THE COURT: ALL RIGHT. JUST GO AHEAD.
10 A. THERE IS NO MENTIONED DIFFERENCE IN THE PHARMACOLOGY OF
11 THE DRUG IN THE ELDERLY.
12 Q. (BY MS. BARLOW) OKAY. ARE THERE ANY SPECIAL
13 CONSIDERATIONS FOR THE ELDERLY?
14 A. HEPATIC CLEARANCE MAY BE DECREASED ALLOWING ACCUMULATION
15 OF THE ACTIVE DRUG.
16 Q. AND WHAT EFFECT WOULD THAT HAVE ON HALF LIFE AND
17 DURATION OF EFFECT?
18 A. IT WOULD PROLONG HALF LIFE AND DURATION OF EFFECT.
19 Q. CAN YOU TELL FROM THE RECORDS WHICH OF THESE DRUGS THAT
20 WERE ORDERED WERE ACTUALLY ADMINISTERED?
21 A. YES, I CAN.
22 Q. WAS THE KLONOPIN ADMINISTERED?
23 A. YES, IT WAS.
24 Q. DOES KLONOPIN HAVE ANY EFFECT ON DELIRIUM?
25 A. YES, IT CAN.
2402
1 Q. WHAT EFFECT?
2 A. KLONOPIN, AS A DRUG THAT CAUSES SEDATION AND IS USED TO
3 TREAT ANXIETY, WOULD LEAD TO A DECREASED LEVEL OF
4 CONSCIOUSNESS OR FEELINGS OF -- OF SOMNOLENCE OR SLEEPINESS.
5 Q. WAS ATIVAN ADMINISTERED?
6 A. YES, IT WAS.
7 Q. DOES ATIVAN HAVE ANY EFFECT UPON DELIRIUM?
8 A. YES, IT DOES.
9 Q. WHAT EFFECT?
10 A. ATIVAN IS SIMILAR TO KLONOPIN IN ITS EFFECTS.
11 Q. WHAT ABOUT TRAZODONE? WAS THAT ADMINISTERED?
12 A. YES, IT WAS.
13 Q. HAD SHE BEEN ON TRAZODONE BEFORE SHE CAME TO DAVIS
14 NORTH?
15 A. YES, SHE WAS.
16 Q. WOULD THAT AFFECT THE DOSAGE AMOUNT THAT WOULD BE
17 APPROPRIATE FOR HER AT DAVIS NORTH?
18 A. YES, IT WOULD.
19 Q. IN WHAT WAY?
20 A. THE DOSAGE AMOUNTS THAT WE'VE INFORMED YOU OF ARE THE
21 USUAL ADULT AND GERIATRIC STARTING DOSES. SHE HAD BEEN ON
22 THE MEDICINE FOR SOME TIME, SO THE USUAL ADULT AND STARTING
23 DOSES WOULDN'T APPLY.
24 Q. SO CAN YOU TELL WHAT WOULD BE AN APPROPRIATE DOSAGE OF
25 TRAZODONE FOR SOMEONE WHO HAD BEEN ON IT BEFORE AT THIS
2403
1 JUNCTURE?
2 A. HER DOSE PRIOR TO ADMISSION WAS 100 MILLIGRAMS A DAY AND
3 THAT'S WHAT WAS ORDERED. SO THAT WOULD BE APPROPRIATE.
4 Q. IN YOUR REVIEW OF THE RECORDS, HAVE YOU FOUND ANYTHING
5 THAT JUSTIFIED OR SHOWS A NEED FOR TRAZODONE?
6 A. YES.
7 Q. WHAT DO YOU FIND?
8 A. I FIND THAT THERE'S EVIDENCE THE PATIENT WAS DEPRESSED.
9 Q. WAS THERE A NEED FOR KLONOPIN IN THE RECORDS -- YOU
10 COULD SEE IN THE RECORDS?
11 A. YES.
12 Q. WHAT WAS THAT?
13 A. THERE'S EVIDENCE THAT THE PATIENT WAS AGITATED.
14 Q. IS THERE A NEED FOR ATIVAN FOUND IN THE RECORDS?
15 A. YES.
16 Q. AND WHAT WAS THAT?
17 A. THERE'S EVIDENCE THAT THE PATIENT WAS AGITATED.
18 Q. WAS THERE A SUBSEQUENT CHANGE IN THE ORDER OF
19 MEDICATIONS?
20 A. YES.
21 Q. WHAT WAS THAT CHANGE?
22 A. ON 12/7/95, SERZONE 50 MILLIGRAMS P.O. B.I.D. UNTIL
23 12/9/95, THEN START 100 MILLIGRAMS TWICE A DAY.
24 Q. WHAT DOES SERZONE DO?
25 A. SERZONE IS AN ANTIDEPRESSANT MEDICATION, VERY SIMILAR TO
2404
1 TRAZODONE.
2 Q. ARE THOSE APPROPRIATE DOSES, THOSE ORDERS?
3 A. SERZONE ADMINISTRATION AT 100 MILLIGRAMS A DAY IS
4 APPROPRIATE.
5 Q. DID YOU SEE ANYTHING IN THE RECORDS THAT JUSTIFY OR
6 SHOWS A NEED FOR SERZONE?
7 A. THE PATIENT WAS ALREADY RECEIVING A DRUG VERY SIMILAR TO
8 SERZONE IN TRAZODONE, SO USING THE TWO DRUGS TOGETHER
9 WOULDN'T BE CONTRAINDICATED.
10 Q. AND WHAT DO YOU MEAN BY "CONTRAINDICATED? THAT'S A
11 LEGAL TERM -- OR A MEDICAL TERM I NOTE YOU'VE USED A LOT.
12 A. THE GENERALLY ACCEPTED MEDICAL STANDARD IS THAT THEY
13 WOULDN'T BE COMBINED USUALLY.
14 Q. AND WHY IS THAT?
15 A. BECAUSE THEY HAVE CUMULATIVE EFFECTS TOGETHER. THEY'RE
16 BOTH IN THE SAME CLASS OF MEDICATION. YOU'RE ESSENTIALLY
17 GIVING THE SAME DRUG IN TWO DIFFERENT FORMS. AND GENERALLY
18 YOU WOULD NOT SELECT THE ADDITION OF A DRUG, YOU'D CHANGE
19 THE DOSE OF THE OTHER DRUG IF YOU FELT IT WAS INDICATED.
20 Q. WHAT IS THE OTHER DRUG THAT WAS ALREADY BEING
21 ADMINISTERED THAT --
22 A. TRAZODONE.
23 Q. TRAZODONE. ARE THERE ANY RISKS OF TRAZODONE IN THE
24 ELDERLY?
25 A. TRAZODONE IS QUITE SEDATING DRUG, CAN LEAD TO CONFUSION,
2405
1 CAN LEAD TO AGITATION.
2 Q. WHAT ABOUT SERZONE? ARE THERE ANY RISKS IN THE ELDERLY
3 FOR SERZONE?
4 A. WELL, IT'S -- IT'S EVEN MORE POTENTLY SEDATING THAN THE
5 TRAZODONE AND -- AND CAN LEAD TO CONFUSION, SLEEPINESS,
6 AGITATION.
7 Q. OKAY. THEN THERE CAME TIME FOR -- THERE WAS A CHANGE IN
8 ORDERS SUBSEQUENT TO THAT. DO YOU KNOW WHEN THAT WAS?
9 ORDERS OF MEDICATIONS?
10 A. ON 12/8/95.
11 Q. WHAT WAS THAT CHANGE?
12 A. KLONOPIN DECREASED TO 0.5 MILLIGRAMS P.O. OR BY MOUTH
13 TWICE A DAY TODAY THROUGH 12/12/95, THEN ON 12/13/95 BEGIN
14 KLONOPIN 0.25 MILLIGRAMS BY MOUTH TWICE A DAY FOR ONE WEEK.
15 Q. DO YOU SEE ANYTHING IN THE RECORDS JUSTIFYING THAT
16 CHANGE IN ORDERS?
17 A. YES. DR. WEITZEL AND THE NURSES --
18 Q. IF YOU WOULD --
19 A. -- DESCRIBE --
20 Q. EXCUSE ME.
21 A. EXCUSE ME. DESCRIBE THE PATIENT AS LETHARGIC AND
22 CALMER.
23 Q. IF YOU WOULD LOOK AT 00452. YOU TALKED ABOUT THE
24 SERZONE AND I THINK THERE'S ANOTHER DRUG ADMITTED -- OR
25 ADDED THERE THAT I DIDN'T TALK TO YOU ABOUT.
2406
1 A. RISPERDAL 1 MILLIGRAM EACH MORNING, AT 5 O'CLOCK IN THE
2 EVENING AND AT BEDTIME.
3 Q. AND WHAT'S RISPERDAL ORDERED FOR?
4 A. RISPERDAL IS USED AS AN ANTIPSYCHOTIC.
5 Q. WAS THIS AN APPROPRIATE DOSAGE FOR THE ELDERLY?
6 A. RISPERDAL'S USUAL MAXIMUM DAILY STARTING DOSE WOULD BE A
7 MILLIGRAM A DAY. THREE MILLIGRAMS A DAY WAS ORDERED AND
8 GIVEN.
9 Q. IS THERE ANYTHING IN THE RECORD INDICATING A NEED FOR
10 RISPERDAL AT THAT POINT?
11 A. FROM THE ADMISSION ASSESSMENT THERE WAS EVIDENCE OF
12 DELUSIONS AND PSYCHOSIS.
13 Q. DO YOU SEE ANYTHING IN EITHER THE DOCTOR'S NOTES OR THE
14 NURSES' NOTES ABOUT DELUSION OR PSYCHOSIS -- OR DELUSIONS,
15 LET'S SAY?
16 A. DR. WEITZEL ASSESSED THE PATIENT HAS PSYCHOTIC.
17 Q. WHAT ABOUT SUBSEQUENTLY? ANYTHING IN THE NOTES
18 INDICATING DELUSIONS?
19 A. SUBSEQUENT TO THAT DATE?
20 Q. YES. UP UNTIL THE 8TH, I GUESS, WHICH IS --
21 A. WOULD BE ONE DAY. ON THAT DATE THERE IS EVIDENCE OF
22 PSYCHOSIS FROM THE NURSING NOTES.
23 Q. WAS THERE A CHANGE ON THE 9TH OF DECEMBER IN THE ORDERS?
24 A. YES, THERE WAS.
25 Q. WHAT WAS THAT CHANGE?
2407
1 A. RISPERDAL 1 MILLIGRAM EACH MORNING, 2 MILLIGRAMS AT
2 5 O'CLOCK, AND 2 MILLIGRAMS AT BEDTIME; AND TRAZODONE 150
3 MILLIGRAMS AT BEDTIME.
4 Q. LET'S LOOK AT THE RISPERDAL. SO THAT'S 1 MILLIGRAM IN
5 THE MORNING, 2 AT 5 O'CLOCK AND 2 AT BEDTIME. IS THAT AN
6 APPROPRIATE DOSAGE IN THE ELDERLY?
7 A. NO.
8 Q. WHY NOT?
9 A. THAT WOULD EXCEED WHAT I WOULD USUALLY CONSIDER THE
10 MAXIMUM DAILY DOSE.
11 Q. WHICH IS?
12 A. FOUR MILLIGRAMS.
13 Q. AND THEN THE TRAZODONE, IS THAT A CHANGE?
14 A. YES, IT IS.
15 Q. OKAY. IN WHAT WAY DID IT CHANGE?
16 A. IT'S AN INCREASE.
17 Q. OKAY. IS THAT AN APPROPRIATE DOSAGE FOR THE ELDERLY?
18 A. IN COMBINATION WITH THE SERZONE, WHICH WAS SET TO
19 INCREASE THAT SAME DAY BY HIS PREVIOUS ORDER, HE'S
20 INCREASING TWO DRUGS WHICH ACT BY THE SAME MECHANISM ON THE
21 SAME DAYS. I WOULD SAY NO.
22 Q. DO YOU SEE ANYTHING IN THE RECORDS JUSTIFYING THE CHANGE
23 IN THE RISPERDAL ORDER?
24 A. YES. THERE'S EVIDENCE OF BEHAVIORS THAT MAY BE
25 PSYCHOTIC.
2408
1 Q. WHAT ABOUT IS -- IS THERE ANYTHING IN THE RECORDS TO
2 JUSTIFY THE INCREASE IN THE TRAZODONE?
3 A. YES.
4 Q. WHAT IS THAT?
5 A. THE PATIENT HAS EVIDENCE OF -- OF DEPRESSION.
6 Q. ALSO ON THE 9TH OF DECEMBER THERE WAS A -- AN
7 ADMINISTRATION OF ATIVAN 2 MILLIGRAMS I.M. NOW. DID YOU SEE
8 A NEED IN THE RECORD FOR THAT?
9 A. FROM THE NURSES' NOTES, IT WAS GIVEN FOR AGITATION.
10 YES.
11 Q. 12/11 THERE WAS A DECREASE IN THE RISPERDAL. DID YOU
12 SEE ANYTHING IN THE RECORDS INDICATING A NEED FOR THAT?
13 A. YES. THERE'S STRONG EVIDENCE FROM DR. WEITZEL'S NOTES
14 THAT THE MEDICATION SHOULD BE REDUCED.
15 Q. BECAUSE OF WHY?
16 A. THE PATIENT WAS TAKING ORAL FLUIDS VERY POORLY. HER
17 OXYGEN SATURATION WAS LOW. SHE WAS WITHOUT INTELLIGIBLE
18 RESPONSES, QUITE CONFUSED.
19 Q. IF YOU HAD SEEN THAT SAME BEHAVIOR IN JUDITH LARSEN THAT
20 DAY, WHAT WOULD YOU HAVE DONE WITH RISPERDAL?
21 A. I WOULD HAVE DISCONTINUED IT.
22 Q. WHAT ABOUT THE TRAZODONE?
23 A. I WOULD HAVE DISCONTINUED OR HELD IT, WHICH MEANS FOR A
24 PERIOD OF TIME NOT ADMINISTERED THE MEDICATION.
25 Q. WHAT ABOUT THE SERZONE?
2409
1 A. I WOULD HAVE DISCONTINUED OR HELD IT FOR A PERIOD OF
2 TIME.
3 Q. AND IS SHE STILL RECEIVING HALDOL AT THIS POINT? I
4 WON'T ASK ABOUT THE HALDOL, IT DOESN'T LOOK LIKE, BUT THERE
5 IS KLONOPIN THERE. WHAT WOULD YOU HAVE DONE WITH THE
6 KLONOPIN ORDER?
7 A. I WOULD HAVE CONTINUED THE TAPERING THAT DR. WEITZEL
8 STARTED. I WOULD NOT HAVE DISCONTINUED IT SUDDENLY.
9 Q. ON THE 13TH THERE WAS AN ORDER FOR A NEW MEDICATION,
10 WHAT WAS THAT? 00456.
11 A. MORPHINE SULFATE 15 MILLIGRAMS I.M. Q 4 HOURS P.R.N.,
12 SEVERE PAIN/AGITATION.
13 Q. NOW, WE DON'T WANT TO MISLEAD THE JURY. WAS THAT EVER
14 ADMINISTERED ON THE 13TH?
15 A. NO.
16 Q. BUT IT WAS ORDERED?
17 A. YES.
18 Q. DO YOU SEE ANYTHING IN THE RECORDS INDICATING A NEED FOR
19 MORPHINE ON THE 13TH OF DECEMBER? I REFER YOU TO 00470.
20 A. THERE'S NO DIRECT EVIDENCE FROM 00470, WHICH WAS
21 DR. WEITZEL'S PROGRESS NOTE.
22 Q. IS THERE ANY INDICATION IN THE NURSING NOTES OF PAIN OR
23 A NEED FOR MORPHINE?
24 A. NO.
25 Q. WAS THAT ORDER EVER DISCONTINUED FOR MORPHINE?
2410
1 A. YES, IT WAS.
2 Q. WHAT DAY WAS THAT?
3 A. 12/19/95.
4 Q. IS THERE ANYTHING IN THE RECORD INDICATING THAT MORPHINE
5 WAS EVER ACTUALLY ADMINISTERED TO JUDITH LARSEN BETWEEN THE
6 13TH AND THE 19TH?
7 A. NO.
8 Q. AS A PHYSICIAN, WHAT DOES THAT TELL YOU?
9 A. THAT IT WASN'T NECESSARY.
10 Q. ON THE 18TH, THERE WAS A CHANGE IN THE RISPERDAL; IS
11 THAT CORRECT? ORDER, AT LEAST?
12 A. YES.
13 Q. WHAT WAS THAT CHANGE?
14 A. RISPERDAL 0.5 MILLIGRAMS EACH MORNING AT 5 O'CLOCK AND
15 BEDTIME.
16 Q. IS THAT WHAT, A DECREASE IN RISPERDAL?
17 A. YES.
18 Q. AND DID YOU SEE ANYTHING IN THE RECORD JUSTIFYING THAT
19 CHANGE?
20 A. YES.
21 Q. AND WHAT WAS THAT?
22 A. FROM DR. WEITZEL'S NOTE, PATIENT HAD MADE A MIRACULOUS
23 RECOVERY. AMBULATED YESTERDAY AND WAS TAKING FOOD WELL.
24 Q. WAS THERE AN ORDER TO DISCONTINUE THE KLONOPIN?
25 A. YES.
2411
1 Q. AND WAS THERE ANY JUSTIFICATION FOR THAT
2 DISCONTINUATION?
3 A. YES.
4 Q. WHAT WAS THAT JUSTIFICATION?
5 A. MY INTERPRETATION OF THE REASON IT WAS DISCONTINUED WAS
6 IT WAS PERCEIVED AS A MEDICINE THAT THE PATIENT DIDN'T NEED,
7 AND I WOULD AGREE.
8 Q. LET'S NOW LOOK AT THE 22ND OF DECEMBER. WERE THERE ANY
9 CHANGES IN THE MEDICATION ORDERS ON THE 22ND OF DECEMBER?
10 A. YES.
11 Q. WHAT WERE THOSE CHANGES?
12 A. HOLD 1700 AND 2000 RISPERDAL, 12/22/95.
13 Q. AND WHEN YOU SAY 1700 AND 2000, YOU MEAN WHAT?
14 A. 5 P.M. AND 8 P.M.
15 Q. OKAY. AND HOW DID THAT ORDER COME?
16 A. AS A TELEPHONE ORDER.
17 Q. AND ANYTHING ELSE?
18 A. ANOTHER TELEPHONE ORDER: HOLD ALL MEDS TONIGHT.
19 Q. DO YOU SEE ANY JUSTIFICATION FOR THE HOLDING OF THOSE
20 MEDICATIONS ON THE 22ND OF DECEMBER?
21 A. YES, I DO.
22 Q. AND WHAT WAS THE JUSTIFICATION?
23 A. THE PATIENT WAS VERY WITHDRAWN, QUIET, HARDLY SPEAKING
24 OR MOVING.
25 Q. AND WAS THAT APPROPRIATE --
2412
1 A. ABSOLUTELY.
2 Q. -- TO HOLD THEM? IT LOOKS LIKE THE NEXT DAY THEY WENT
3 RIGHT BACK TO THE REGULAR ORDERS, AND FOR THE NEXT COUPLE OF
4 DAYS THE REGULAR ORDERS WERE IN PLACE. BUT ON THE 25TH OF
5 DECEMBER -- WAS THERE A CHANGE IN THE MEDICATION ORDERS ON
6 THE 25TH?
7 A. THERE WERE CHANGES ON THE 24TH AND 25TH.
8 Q. OKAY. WHAT WAS THE CHANGE ON THE 24TH?
9 A. DECREASE RISPERDAL -- RISPERDAL TO 0.5 MILLIGRAMS AT
10 5:00 P.M. AND BEDTIME. CHANGE TRAZODONE TO 50 MILLIGRAMS AT
11 BEDTIME, P.R.N. MAY REPEAT TIMES ONE.
12 Q. AND HOW WAS THAT A CHANGE?
13 A. THE TRAZODONE WAS DECREASED AND THE RISPERDAL WAS
14 DECREASED.
15 Q. WAS THAT APPROPRIATE?
16 A. YES.
17 Q. WHY?
18 A. THE PATIENT WAS DESCRIBED BOTH BY DR. WEITZEL AND THE
19 NURSES AS LETHARGIC, AND THE NURSES AS SLEEPY.
20 Q. COULD THAT HAVE BEEN CAUSED BY THE MEDICATIONS SHE WAS
21 ON?
22 A. YES.
23 Q. THERE THEN IS ANOTHER CHANGE ON THE 25TH, AND WHAT IS
24 THAT CHANGE?
25 A. TELEPHONE ORDER, DR. WEITZEL TO L. LONG, R.N.: MORPHINE
2413
1 SULFATE 2 MILLIGRAMS I.M. NOW.
2 THAT'S THE BOTTOM OF THE PAGE, I'M SORRY. FARTHER UP:
3 MORPHINE SULFATE 2 MILLIGRAMS I.M. NOW. DR. WEITZEL'S
4 SIGNATURE.
5 Q. THAT'S MED-00460?
6 A. YES.
7 Q. THE ORDER IN THE MIDDLE OF THE PAGE, WHAT TIME WAS THAT
8 NOTED OR TAKEN OFF, ADMINISTERED, WHATEVER YOU WANT TO SAY?
9 A. IT WAS NOTED L. LONG, 12/25/95, 0730.
10 Q. AND WHAT ABOUT THE ONE AT THE BOTTOM OF THE PAGE? WHEN
11 WAS THAT NOTED?
12 A. NOTED L. LONG, R.N., 12/25/95, 9:30.
13 Q. 9:30 IN THE MORNING?
14 A. YES. 0930.
15 Q. THE TOP OF THE NEXT PAGE, 00461, IS THERE ANOTHER ORDER
16 FOR MORPHINE?
17 A. TELEPHONE ORDER DR. WEITZEL, L. LONG, R.N.: MORPHINE
18 SULFATE 2 MILLIGRAMS NOW.
19 Q. EACH ONE OF THEM IS A 2 MILLIGRAM DOSE. IS THAT
20 APPROPRIATE FOR A WOMAN WHO IS 93-YEARS-OLD -- APPROPRIATE
21 DOSING?
22 A. ACCORDING TO THE MATERIAL WE'VE PUT IN -- I'VE PUT IN
23 EVIDENCE, YES.
24 Q. SO THE AMOUNT'S APPROPRIATE?
25 A. YES.
2414
1 Q. WHAT ABOUT THE FACT THAT THEY'RE TWO HOURS APART? IS
2 THAT APPROPRIATE?
3 A. IF THERE'S AN INDICATION.
4 Q. AND LET'S GO TO THAT. IS THERE ANYTHING IN THE RECORD
5 INDICATING A NEED FOR MORPHINE ON THE 25TH OF DECEMBER?
6 A. THERE'S NO OBJECTIVE EVIDENCE FROM DR. WEITZEL'S NOTE.
7 NO.
8 Q. WHEN YOU SAY FROM DR. WEITZEL'S NOTE THERE'S NO
9 OBJECTIVE EVIDENCE, DOES IT SAY ANYTHING ABOUT PAIN IN
10 THERE?
11 MR. STIRBA: WELL, IF WE'RE GOING TO -- IF WE'RE
12 GOING TO ASK IT THAT WAY, COULD WE READ THE NOTE, PLEASE?
13 THE COURT: YES. GO AHEAD.
14 A. 12/25/95 M.D: PATIENT -- EXCUSE ME. REMAINS LESS
15 RESPONSIVE THAN ONE WEEK AGO AFTER THE INITIAL IMPROVEMENT.
16 NO AGITATION. SLEPT WELL. VITAL SIGNS STABLE, AFEBRILE.
17 ASSESSMENT, STABLE. PLAN, CONTINUE CURRENT TREATMENT.
18 ADDENDUM, PATIENT SEEMS TO BE IN PAIN ONCE WOKEN. WILL TRY
19 SOME LOW DOSE M.S. AT FREQUENT INTERVALS TO SEE IF THIS IS
20 THE PROBLEM.
21 Q. (BY MS. BARLOW) SO WHAT DID YOU MEAN WHEN YOU SAID
22 THERE WAS NO OBJECTIVE INDICATION IN THE RECORD OF PAIN?
23 A. THERE'S A -- HIS OBSERVATION THAT SHE SEEMS TO BE IN
24 PAIN, BUT THERE'S NO EVIDENCE FROM EXAMINATION OR HISTORICAL
25 EVIDENCE RECORDED FROM THE PATIENT THAT INDICATES SHE
2415
1 COMPLAINED OF PAIN.
2 Q. AND DID YOU SEE ANYTHING IN THE NURSING NOTES ABOUT
3 PAIN?
4 A. NO.
5 Q. THEN ON THE 26TH OF DECEMBER THERE'S A -- AN EVENT THAT
6 JUDITH LARSEN HAD NOT HAD BEFORE. DO YOU RECALL WHAT THAT
7 IS?
8 A. YES.
9 Q. WHAT WAS IT?
10 A. ON THE 26TH OF DECEMBER JUDITH LARSEN EXPERIENCED WHAT
11 APPEARS TO HAVE BEEN A SEIZURE WITH A PERIOD OF LOSS OF
12 CONSCIOUSNESS AND JERKING MOVEMENTS OF HER LIMBS.
13 Q. AS A PHYSICIAN, DO YOU KNOW WHAT CAN CAUSE SEIZURES?
14 A. YES.
15 Q. AND WHAT CAN CAUSE SEIZURES?
16 A. SEIZURES CAN BE THE RESULT OF THE BRAIN HAVING BEEN
17 INJURED. IT CAN BE A RESULT OF THE BRAIN HAVING
18 SPONTANEOUSLY DEVELOPED A SEIZURE DISORDER, ALTHOUGH THAT'S
19 MORE COMMON IN YOUNG PEOPLE THAN IN OLDER PEOPLE. IT CAN BE
20 THE RESULT OF WITHDRAWAL, FOR EXAMPLE, FROM ALCOHOL OR OTHER
21 MEDICATIONS LIKE BENZODIAZEPINES. IT CAN BE THE RESULT OF A
22 LOW BLOOD SUGAR, THE RESULT OF LOW BLOOD OXYGEN, THE RESULT
23 OF A LOW BLOOD PRESSURE, THE RESULT OF LOW SERUM CALCIUM OR
24 ABNORMAL SERUM SODIUM, AS A RESULT OF HEPATIC FAILURE, CAN
25 BE AS A RESULT OF KIDNEY FAILURE.
2416
1 Q. IS -- CAN MORPHINE CAUSE ANY OF THESE -- WELL, NOT --
2 THE SEIZURE IS THE RESULT. CAN MORPHINE CAUSE ANY OF THE
3 THINGS THAT YOU'VE JUST BEEN TALKING ABOUT?
4 A. MORPHINE LOWERS THE SEIZURE THRESHOLD; THAT IS, IT MAKES
5 THE BRAIN MORE SUSCEPTIBLE TO SEIZURES.
6 Q. NOW, ON THE 26TH IT APPEARS THAT THERE WAS -- LET'S GET
7 TO THE -- AN ADMINISTRATION OF MORPHINE. LET'S GET TO THE
8 RECORD OF THAT ADMINISTRATION, WHICH IS 00463. CAN YOU TELL
9 FROM THE NOTES WHETHER THAT MORPHINE WAS GIVEN BEFORE OR
10 AFTER THE SEIZURE?
11 A. 00463 IS THE PHYSICIAN ORDERS. I CANNOT TELL IF IT WAS
12 GIVEN BEFORE OR AFTER.
13 Q. LET'S LOOK AT 00462. WAS THERE A CONSULTATION DONE
14 REGARDING THE SEIZURE?
15 A. YES.
16 Q. WHO DID THAT MEDICAL CONSULTATION?
17 A. DR. DIENHART.
18 Q. AND WHAT DID HE ORDER?
19 A. I.V. FLUIDS AND DILANTIN AND BLOOD TESTS AND A CAT SCAN.
20 Q. HAVE YOU LOOKED AT THE RECORDS TO SEE WHETHER A CAT SCAN
21 WAS DONE?
22 A. YES.
23 Q. WAS ONE DONE?
24 A. YES.
25 Q. OKAY. WHAT DOES THE DILANTIN DO? WHAT -- WAS THAT --
2417
1 WAS THAT AN APPROPRIATE RESPONSE TO THE SEIZURE ACTIVITY?
2 A. YES.
3 Q. IT APPEARS THAT THAT WAS ORDERED ON THE -- AT 6 O'CLOCK
4 THE MORNING OF THE 26TH.
5 THEN ON 463 YOU HAVE THE -- WE HAVE THE ORDER THAT YOU
6 JUST REFERENCED WHICH WAS NOTED AT 8 O'CLOCK. IN ADDITION
7 TO THE MORPHINE, WHAT WAS THE OTHER -- WHAT OTHER ORDERS
8 CAME FROM DR. WEITZEL ON THE -- AT 8 O'CLOCK ON THE 26TH?
9 A. OH, THERE IS A NOTATION. OKAY.
10 GIVE MORPHINE SULFATE 2 MILLIGRAMS I.M. NOW. STOP I.V.
11 THERAPY. OBSERVE FOR SYMPTOMS OF PAIN. TELEPHONE ORDER,
12 DR. WEITZEL. AND IT IS NOTED AT 0800.
13 I'M SORRY, I MISSED THAT.
14 Q. THAT'S FINE. IF A PERSON HAS HAD A SEIZURE EARLIER IN
15 THE MORNING, WAS IT APPROPRIATE TO ORDER MORPHINE AT THAT
16 POINT?
17 A. I WOULD NOT CONSIDER IT APPROPRIATE.
18 Q. WHY?
19 A. I'D NEED OBJECTIVE EVIDENCE OF THE NEED FOR THE
20 MEDICATION. IT MAY BE CONTRAINDICATED RELATIVE TO ITS
21 LOWERING OF SEIZURE THRESHOLD.
22 Q. DO YOU SEE ANYTHING IN THE RECORDS SUPPORTING OR
23 JUSTIFYING THE GIVING OF MORPHINE THAT MORNING AT 8 O'CLOCK?
24 A. FROM THE DOCTOR'S PROGRESS NOTES, I DO NOT.
25 Q. DO YOU SEE ANYTHING FROM THE NURSES' NOTES?
2418
1 A. FROM THE 25TH AND 26TH, I DO NOT.
2 Q. LET'S LOOK BACK AT MED-00474 WHICH IS THE DOCTOR'S
3 PROGRESS NOTES ON THE 26TH OF DECEMBER. CAN YOU READ WHAT
4 HE WROTE THERE?
5 A. 12/26/95, M.D: YESTERDAY MORPHINE SULFATE WAS TRIED FOR
6 COMFORT CARE. SHE HAD A SEIZURE THIS A.M. WAS STARTED ON
7 DILANTIN. LOOKED PRETTY ILL AT FIRST. BLOOD PRESSURE DOWN.
8 NOW FEEDING SELF AGAIN. ASSESSMENT, UNSTABLE HEALTH STATUS.
9 PLAN, CONTINUE CURRENT MEDS AND TREATMENT.
10 Q. GIVEN THAT NOTATION, WAS IT APPROPRIATE TO GIVE FURTHER
11 MORPHINE ON THE 26TH?
12 A. NO.
13 Q. APPEARS THAT FOR A FEW DAYS THERE WERE FEW DRUGS --
14 RELATIVELY FEWER DRUGS GIVEN. LET'S NOW LOOK AT THE
15 DECEMBER 30TH. WAS THERE -- WELL, BEFORE I GET TO THAT.
16 YOU -- YOU DID SAY DR. DIENHART ORDERED DILANTIN AND THAT --
17 AND THE PURPOSE OF THAT WAS WHAT?
18 A. DILANTIN IS AN ANTI-SEIZURE DRUG. IT'S A VERY OLD DRUG
19 THAT IS COMMONLY USED TO TREAT SEIZURES.
20 Q. AND THAT WAS ON THE MORNING OF THE 26TH AND IT LOOKS
21 LIKE AT 6:05 A.M.?
22 A. 6:50 A.M.
23 Q. OKAY. ON THE 26TH OF DECEMBER YOU READ THAT DR. WEITZEL
24 ORDERED TO STOP THE I.V. THERAPY AT 8 A.M. WHAT EFFECT
25 WOULD THAT HAVE ON THE DILANTIN?
2419
1 A. THE PATIENT WAS TO RECEIVE THE DILANTIN I.V.
2 Q. SO IF YOU STOP THE I.V. THERAPY, WHAT DOES IT DO WITH
3 THE DILANTIN?
4 A. IT WOULD STOP THE DILANTIN.
5 Q. AND AT THE BOTTOM OF 00463, LOOKS LIKE THREE DAYS LATER
6 ON THE 29TH, WHAT DID DR. WEITZEL -- DR. WEITZEL WRITE AS A
7 NEW ORDER?
8 A. TO DISCONTINUE THE DILANTIN.
9 Q. DO YOU SEE ANY INCONSISTENCY BETWEEN THE ORDERS OF THE
10 26TH AND THE 29TH IN REFERENCE TO THE DILANTIN?
11 A. I THINK THE TELEPHONE ORDER ON THE 26TH IS UNCLEAR AS TO
12 WHAT DISCONTINUING THE I.V. THERAPY WAS. YES.
13 Q. DO YOU KNOW WHETHER DILANTIN WAS GIVEN AFTER THE 26TH?
14 A. NO. NOT THAT I CAN SEE.
15 Q. BUT TO BE FAIR, THERE WERE NO FURTHER SEIZURES; IS THAT
16 CORRECT?
17 A. YES.
18 Q. NOW, LET'S LOOK AT THE 30TH. IS THERE A CHANGE IN THE
19 ORDER -- THE PHYSICIAN'S ORDERS ON THE 30TH OF DECEMBER?
20 A. YES.
21 Q. WHAT WAS THAT ORDER?
22 A. MORPHINE SULFATE 5 MILLIGRAMS I.M. Q 4 HOURS AROUND THE
23 CLOCK. DR. WEITZEL.
24 Q. WAS THAT WRITTEN AS NEEDED?
25 A. NO.
2420
1 Q. WAS IT ADMINISTERED? 00497, THE MED CHART.
2 A. YES, IT WAS.
3 Q. HOW MANY DOSES -- AND THE DOSAGE WAS HOW MUCH? FIVE
4 MILLIGRAMS, ISN'T IT?
5 A. FIVE MILLIGRAMS.
6 Q. OKAY. HOW MUCH DOSES WERE GIVEN ON THE 30TH OF
7 DECEMBER?
8 A. THREE DOSES.
9 Q. AND HOW MANY DOSES WERE GIVEN ON THE 31ST OF DECEMBER?
10 A. SIX DOSES.
11 Q. AND ON THE 1ST OF JANUARY, AT LEAST ON THIS CHART?
12 A. FOUR DOSES.
13 Q. SO THREE DOSES IS 15 MILLIGRAMS ON THE 30TH OF DECEMBER.
14 IS THAT AN APPROPRIATE DOSAGE FOR AN ELDERLY PERSON, A TOTAL
15 DOSE, I GUESS?
16 A. IN A 24-HOUR INTERVAL, 15 MILLIGRAMS WOULD BE
17 APPROPRIATE.
18 Q. WHAT WAS -- WITHIN THAT 24-HOUR PERIOD OF THE 30TH --
19 WELL, STRIKE THAT.
20 LET'S LOOK AT THE 31ST THEN. AND USING 00497, YOU SAID
21 THAT THERE WAS SIX DOSES GIVEN THAT DAY?
22 A. YES.
23 Q. OR AT LEAST BASED ON THIS. HOW MANY MILLIGRAMS IS THAT
24 AT 5 MILLIGRAMS EACH?
25 A. THIRTY MILLIGRAMS.
2421
1 Q. LET'S LOOK BACK AT THE -- SORRY WE HAVE TO GO BACK AND
2 FORTH, BUT THESE ARE THE WAY THEY'RE WRITTEN.
3 LET'S LOOK BACK AT 00464, WHICH IS THE PHYSICIAN'S
4 ORDERS. WAS ANY OTHER MORPHINE GIVEN BESIDES THE AMOUNT
5 LISTED ON THIS SCHEDULED DOSAGE?
6 A. CAN YOU CLARIFY THAT QUESTION?
7 Q. ON 464 WAS THERE AN ORDER ON THE 31ST OF DECEMBER TO
8 GIVE ANY OTHER MORPHINE?
9 A. YES.
10 Q. AND WHAT WAS THAT ORDER?
11 A. MORPHINE SULFATE 5 MILLIGRAMS I.M. Q 4 HOURS AROUND THE
12 CLOCK, AND 5 MILLIGRAMS I.M. Q 2 HOURS P.R.N., PAIN.
13 Q. DO YOU KNOW WHETHER ANY MORPHINE, IN ADDITION TO THE 30
14 MILLIGRAMS YOU'VE JUST TALKED ABOUT, WAS ADMINISTERED TO
15 JUDITH LARSEN ON THE 31ST OF DECEMBER?
16 A. YES.
17 Q. AND HOW MUCH MORE WAS ADMINISTERED?
18 A. FIVE MILLIGRAMS.
19 Q. OKAY. SO A TOTAL OF HOW MANY MILLIGRAMS THAT DAY WERE
20 GIVEN TO JUDITH LARSEN?
21 A. SIX DOSES OF 5 ROUTINELY AND ONE 5 MILLIGRAM DOSE WOULD
22 BE 35 MILLIGRAMS.
23 Q. IS THAT APPROPRIATE FOR A 93-YEAR-OLD WOMAN?
24 A. IT CAN BE, IF THERE'S AN INDICATION.
25 Q. IS THERE ANY INDICATION IN THE RECORD OF PAIN FOR THE
2422
1 31ST OF DECEMBER FOR JUDITH LARSEN?
2 A. ON THE 30TH AND 31ST, FROM THE DOCTOR'S RECORD I FIND NO
3 EVIDENCE FOR THE NEED FOR MORPHINE. Look at the nurse's notes>>.
4 Q. IF YOU WOULD TURN TO 00476, THE 31ST OF DECEMBER. CAN
5 YOU READ THE DOCTOR'S NOTE FOR THAT DAY?
6 A. 12/30/95?
7 Q. 12/31/95.
8 A. 12/31/95, M.D.: UNRESPONSIVE. MELENA DURING THE NIGHT.
9 Q. WHAT -- WHAT IS MELENA?
10 A. MELENA IS THE PASSAGE OF DARK BLACK MATERIAL FROM THE
11 RECTUM. IT'S A DARK BLACK STOOL.
12 Q. DOES THAT HAVE ANY CLINICAL SIGNIFICANCE?
13 A. DARK BLACK MATERIAL FROM THE RECTUM CAN BE A SIGN OF
14 INTERNAL HEMORRHAGE. IT COULD ALSO BE A SIGN OF -- OF
15 MATERIAL RESIDING IN THE COLON FOR A LONG TIME OR THE
16 ADMINISTRATION OF PEPTO-BISMOL. DEPENDS ON IF IT WAS TESTED
17 FOR BLOOD.
18 Q. DO THE RECORDS INDICATE WHETHER IT WAS TESTED FOR BLOOD?
19 A. NO.
20 Q. OKAY. MELENA DURING THE NIGHT. AND THEN WHAT DOES IT
21 SAY?
22 A. BLOOD PRESSURE FLUCTUATES AND IS LOW GENERALLY. TAKING
23 NO ORAL FLUIDS OR NOURISHMENT. IS RECEIVING ORAL CARE. I
24 SPOKE WITH HER SON PER TELEPHONE THIS MORNING AND AM MEETING
25 WITH SON AND DAUGHTER SOON. AFEBRILE. ASSESSMENT, G.I.
2423
1 BLEED, GASTROINTESTINAL BLEED. LOW BLOOD PRESSURE.
2 UNRESPONSIVE. PLAN, CONTINUE COMFORT CARE.
3 Q. IS THERE ANYTHING IN THERE INDICATING A NEED FOR
4 MORPHINE?
5 A. NO.
6 Q. AND, IN FACT, AS A PHYSICIAN, IF YOU SAW BLOOD PRESSURE
7 WAS FLUCTUATING --
8 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT.
9 LEADING AND SUGGESTIVE.
10 THE COURT: SUSTAINED.
11 Q. (BY MS. BARLOW) HE WRITES: BLOOD PRESSURE FLUCTUATES
12 AND IS LOW GENERALLY. WHAT WOULD THAT TELL YOU ABOUT THE
13 ADMINISTRATION OF MORPHINE?
14 A. I'M TRYING TO FIND YOUR REFERENCE.
15 Q. IT'S ON 476. IT SAYS: UNRESPONSIVE. MELENA DURING THE
16 NIGHT. THEN B.P. FLUCTUATES AND IS LOW GENERALLY, ON THE
17 31ST.
18 A. YES. OKAY. I SEE IT NOW. WHAT WAS THE QUESTION AGAIN?
19 Q. WHAT WOULD THAT TELL YOU AS A PHYSICIAN ABOUT THE
20 ADMINISTRATION OF MORPHINE?
21 A. IT WOULD BE CONTRAINDICATED BECAUSE MORPHINE CAN CAUSE
22 THE BLOOD PRESSURE TO FALL DUE TO DILATION OF BLOOD VESSELS,
23 SO IT WOULD -- WOULD BE CONTRAINDICATED.
24 Q. MEANING?
25 A. YOU WOULD NOT ADMINISTER IT. YOU SHOULD NOT ADMINISTER
2424
1 IT.
2 Q. IS 35 MILLIGRAMS -- WELL, I THINK WE'VE ASKED THAT.
3 LET'S GO ON TO THE 1ST OF JANUARY. WAS THERE ANY CHANGE IN
4 THE ORDERS ON THE 1ST OF JANUARY?
5 A. YES.
6 Q. WHAT WAS THAT CHANGE?
7 A. THERE WERE TWO SEPARATE SETS OF ORDERS. FIRST IS
8 MORPHINE SULFATE 5 MILLIGRAMS I.M. NOW; MORPHINE SULFATE 5
9 MILLIGRAMS I.M. Q 3 HOURS ROUTINE AROUND THE CLOCK.
10 DR. WEITZEL.
11 Q. HOW IS THAT SECOND ONE A CHANGE FROM WHAT IT WAS BEFORE?
12 A. IT'S AN INCREASE IN THE AMOUNT BY DECREASING THE
13 INTERVAL BETWEEN THE INJECTIONS FROM 4 TO 3 HOURS.
14 Q. AND THEN IS THERE A SUBSEQUENT ORDER FOR MORPHINE?
15 A. AT 2300 OR 11 P.M.: MORPHINE SULFATE 5 MILLIGRAMS I.M.
16 NOW.
17 Q. ON THE 1ST OF JANUARY THEN, DO YOU -- CAN YOU TELL
18 WHETHER AND HOW MUCH MORPHINE WAS ACTUALLY ADMINISTERED?
19 A. I'LL ATTEMPT TO.
20 Q. OKAY. I'LL REFER YOU FIRST TO MED-00497. IS THIS A
21 CONTINUATION OF THE ORIGINAL EVERY FOUR HOUR ORDER FOR
22 MORPHINE?
23 A. YES.
24 Q. AND HOW MANY DOSES WERE GIVEN ON THE 1ST OF JANUARY?
25 A. FOUR.
2425
1 Q. THAT'S FOUR OF HOW MANY MILLIGRAMS?
2 A. FIVE MILLIGRAM.
3 Q. AND THEN I'LL REFER YOU OVER TO 00507. HOW MANY DOSES
4 WERE GIVEN ON -- EVERY 3 HOURS?
5 A. TWO.
6 Q. AND HOW MANY -- HOW MUCH IN EACH DOSAGE?
7 A. FIVE MILLIGRAMS.
8 Q. AND I BELIEVE THERE WERE TWO OTHER ORDERS FOR 5
9 MILLIGRAM I.M. NOW ON THE 1ST OF -- WERE THOSE ADMINISTERED?
10 A. YES.
11 Q. BOTH OF THEM?
12 A. YES.
13 Q. SO IF WE ADD THOSE UP THERE WERE 4 TIMES 5 MILLIGRAM IS
14 20; 2 TIMES 5 IS 10; ANOTHER 2 TIMES 5 IS 10, WHICH IS A
15 TOTAL OF 40 MILLIGRAMS OF MORPHINE ORDERED AND ADMINISTERED.
16 THE COURT: IS THAT A QUESTION?
17 MS. BARLOW: YES. THAT IS A QUESTION.
18 Q. (BY MS. BARLOW) DO THE RECORDS SHOW THAT THERE WERE AT
19 LEAST 40 MILLIGRAMS OF MORPHINE ADMINISTERED --
20 A. YES.
21 Q. -- TO JUDITH LARSEN THAT DAY?
22 A. YES.
23 Q. IS THAT AN APPROPRIATE DOSAGE?
24 A. IF THERE WAS AN INDICATION.
25 Q. DO YOU SEE ANY INDICATION OF A NEED FOR THAT -- FOR 40
2426
1 MILLIGRAMS OF MORPHINE ON THE 1ST OF JANUARY?
2 A. FROM THE PHYSICIAN'S NOTE, NO OBJECTIVE EVIDENCE. NO,
3 NOT -- NOT REASONS I WOULD ADMINISTER MORPHINE, FROM THE
4 NURSING NOTES.
5 THE COURT: HOW -- HOW MUCH MORE TIME DO YOU HAVE
6 WITH THIS WITNESS?
7 MS. BARLOW: PROBABLY ANOTHER 15, 20 MINUTES, YOUR
8 HONOR.
9 THE COURT: OKAY. THEN LADIES AND GENTLEMEN, WHY
10 DON'T WE TAKE OUR FIRST MORNING BREAK.
11 DURING THIS TIME, REMEMBER THAT IT'S YOUR DUTY NOT TO
12 CONVERSE AMONG YOURSELVES OR TO CONVERSE WITH OR ALLOW
13 YOURSELVES TO BE ADDRESSED BY ANY OTHER PERSON REGARDING THE
14 SUBJECT OF THIS TRIAL. IT'S ALSO YOUR DUTY NOT TO FORM OR
15 EXPRESS ANY OPINION UNTIL THE CASE IS FINALLY SUBMITTED TO
16 YOU.
17 AND LET'S COME BACK AT 9:30.
18 (WHEREUPON, AT THIS TIME THE JURY LEAVES THE
19 COURTROOM.)
20 THE COURT: THE RECORD WILL REFLECT THAT THE JURY
21 HAS LEFT THE COURTROOM. WE HAVE THIS QUESTION -- I MEAN, WE
22 HAVE A JURY THAT SOMETIMES LOVES TO GIVE NOTES HERE. WHEN
23 WE, FIRST OF ALL, STARTED OUR SCHEDULING CONFERENCE AND ALSO
24 OTHER HEARINGS BEFORE THE -- THE TRIAL, I TOLD BOTH SIDES
25 THAT IT WAS MY PRACTICE IN CASES, OH, FOR THE LAST, YOU
2427
1 KNOW, 8 OR 10 MONTHS TO ALLOW JURIES -- JUROR MEMBERS TO ASK
2 QUESTIONS, AND I GAVE A DESCRIPTION OF HOW I DID THAT.
3 HOW I DID THAT WOULD BE IF ONE WITNESS -- IF ONE
4 ATTORNEY DID THE DIRECT EXAMINATION OF A WITNESS AND THEN
5 THERE WAS CROSS-EXAMINATION AND ANY REDIRECT EXAMINATION, I
6 ASKED THE JURY AT THAT POINT, DO YOU HAVE ANY QUESTIONS?
7 WHICH THEY WOULD THEN WRITE DOWN IN THEIR NOTEBOOK, GIVE TO
8 THE BAILIFF, I WOULD REVIEW THEM, SHOW THEM TO COUNSEL SO
9 THEY COULD MAKE ANY OBJECTIONS, THEN ASK THE QUESTIONS.
10 I ASKED BOTH SIDES THIS TWICE AND THEY SAID LET'S THINK
11 ABOUT IT, AND THEN FINALLY BOTH SIDES SAID IN THIS TYPE OF
12 CASE THEY DIDN'T WANT QUESTIONS ASKED.
13 SO NOW WE'VE GOT A JUROR THAT'S ASKED THREE OR FOUR
14 QUESTIONS. MY REVIEW OF THEM IS BASICALLY THAT THEY'RE --
15 THEY'RE OUTSIDE ANYTHING THAT'S IMPORTANT OR RELEVANT IN
16 THIS LAWSUIT. IT SOUNDS LIKE SOMEBODY HAS SOME BACKGROUND.
17 BUT IF I READ THESE QUESTIONS AND THEN WE DON'T ASK THEM
18 FROM THE JURY, OR THEN IF ONE OF THE COUNSEL ASKS THE
19 QUESTIONS AND THEN I SAY THAT THEY'RE IRRELEVANT, YOU KNOW,
20 I DON'T KNOW WHAT TO DO. BOTH SIDES TOLD ME THEY DIDN'T
21 WANT QUESTIONS FROM THE JURY, SO EITHER -- I CAN'T SEE HOW
22 WE COULD CHANGE IT MIDSTREAM.
23 MR. STIRBA: AND ESPECIALLY --
24 MS. BARLOW: I DON'T THINK YOU CAN, YOUR HONOR.
25 MR. STIRBA: -- ESPECIALLY, JUDGE, IF YOU HAVE MADE
2428
1 THE DETERMINATION IT'S OUTSIDE THE BOUNDS, I DON'T SEE ANY
2 REAL PURPOSE OF -- OF ADDRESSING IT.
3 THE COURT: WELL, I -- I HAVE TO SAY THAT LOOKING
4 AT THESE I CAN'T EVEN UNDERSTAND WHAT THEY'RE TALKING ABOUT.
5 MR. STIRBA: OKAY.
6 THE COURT: I MEAN, IT HAS NOTHING TO DO WITH
7 ANYTHING THAT'S BEEN DONE. I MEAN, I DON'T EVEN SEE WHERE
8 THE QUESTIONS ARE COMING FROM.
9 AND SO WHAT I WOULD SAY IS MAYBE JUST MAKE ANOTHER
10 STATEMENT THAT THE DECISION WAS MADE BY BOTH COUNSEL THAT
11 QUESTIONS WOULDN'T BE ASKED, AND SO EVERYTHING THAT YOU NEED
12 TO HEAR WILL BE PRESENTED BY THE ATTORNEYS. AND IF YOU
13 THINK YOU HAVE A QUESTION ABOUT SOMETHING THAT YOU HAVEN'T
14 HAD ADDRESSED, IT DOESN'T NEED TO BE ADDRESSED FOR PURPOSES
15 OF DECIDING THE CASE.
16 IS THAT APPROPRIATE?
17 MR. STIRBA: THAT'S -- THAT'S FINE.
18 MS. BARLOW: I THINK THAT'S CONSISTENT, YOUR HONOR.
19 THE COURT: OKAY. THEN I WILL DO THAT AND JUST
20 MAKE THAT AS WE COME BACK. SO WE'LL SEE YOU AT 9:30.
21 MR. STIRBA: THANK YOU, JUDGE.
22 (WHEREUPON, AT THIS TIME THERE'S A RECESS, AFTER WHICH
23 PROCEEDINGS RESUME, AS FOLLOWS:)
24 THE COURT: THE RECORD WILL REFLECT THAT THE JURY
25 HAS RETURNED AND EVERYONE ELSE IS PRESENT.
2429
1 LADIES AND GENTLEMEN, THERE WAS A QUESTION FROM ONE OF
2 THE JURORS THIS MORNING ABOUT WHETHER QUESTIONS ARE ALLOWED,
3 AND I DISCUSSED THAT WITH THE ATTORNEYS. PRIOR TO THIS
4 TRIAL THAT ISSUE WAS DISCUSSED AND IT WAS DECIDED BY BOTH
5 SIDES THAT THEY SAID THAT THEY WOULD PRESENT EVERYTHING THAT
6 YOU NEEDED TO HAVE IN ORDER TO MAKE YOUR DECISION IN THIS
7 CASE AND THAT THEY CHOSE NOT TO HAVE JURY QUESTIONS.
8 SO IN RESPONSE TO THE QUESTIONS THAT WERE GIVEN, IF YOU
9 DO NOT HEAR -- YOU KNOW, BOTH SIDES HAVE PREPARED THEIR
10 CASES AND IT WILL GIVE YOU ALL THE INFORMATION THAT YOU
11 NEED. IF THERE'S SOMETHING THAT YOU DON'T FEEL THAT YOU'VE
12 RECEIVED, NEITHER PARTY THOUGHT THAT THAT WAS IMPORTANT.
13 AND SO I -- IN OTHER WORDS, YOU'RE GOING TO GET WHAT YOU
14 NEED TO HAVE TO DECIDE THE CASE.
15 AND SO WE WILL JUST HAVE IT THAT THERE CAN'T -- WON'T
16 BE ANY QUESTIONS FROM THE JURY. SO THAT'S -- BUT THAT WAS
17 DECIDED IN ADVANCE OF THE TRIAL, WEEKS BEFORE, BY BOTH
18 SIDES.
19 SO MS. BARLOW, IF YOU'D LIKE TO CONTINUE.
20 MS. BARLOW: THANK YOU, YOUR HONOR.
21 Q. (BY MS. BARLOW) WE WERE FINISHING UP ON JANUARY 1ST
22 WHEN WE BROKE. HAVE YOU SEEN THE NURSING NOTES FOR -- FOR
23 JANUARY 1ST?
24 A. YES, I HAVE.
25 Q. AS A PHYSICIAN -- DOES A PHYSICIAN LOOK TO THESE NURSING
2430
1 NOTES FOR INFORMATION ABOUT THE -- THE CONDITION OF A
2 PATIENT?
3 A. WE DEPEND ON THEM.
4 Q. AND WHY IS THAT?
5 A. DURING THE PERIOD WHERE YOU ARE NOT ACTUALLY WITH THE
6 PATIENT WHICH IS, YOU KNOW, A SMALL FRACTION OF THE DAY,
7 THERE'S INFORMATION GATHERED ABOUT THE PATIENT'S CONDITION,
8 THE SYMPTOMS THEY EXHIBIT, THE SIGNS OR FINDINGS THAT THE
9 NURSES OBSERVE AND RECORD, AND THAT INFORMATION IS VERY
10 USEFUL IN DETERMINING WHAT'S WRONG AND WHAT TO DO ABOUT IT.
11 SO YES, YOU DEPEND ON IT.
12 Q. OKAY. WOULD YOU TURN TO MED-00583, WHICH IS THE 1ST OF
13 JANUARY NURSING NOTES?
14 A. YES.
15 Q. THE 11:00 TO 7:00 SHIFT, WHAT WAS WRITTEN?
16 A. NIGHT SHIFT, FREE TEXT NOTE: PATIENT CONTINUES TO
17 EXHIBIT CHEYNE-STOKES RESPIRATION, PERIODS OF APNEA OF 15 TO
18 20 SECONDS. HAS REFLEXIVE HAND GRASP, BUT THIS IS ONLY
19 CLEAR RESPONSE TO ENVIRONMENTAL STIMULI. TEMPERATURE
20 MAXIMUM 100.4 AT MIDNIGHT, 97.0 AT 0230. MORPHINE SULFATE 5
21 MILLIGRAMS GIVEN Q 4 HOURS I.M. FOR COMFORT. PULSE MAX
22 RATE -- THE MAXIMUM PULSE RATE 120, LOWEST 60. BLOOD
23 PRESSURE 120/60 TO 130/60.
24 Q. OKAY. LET'S -- LOOKING AT THAT --
25 MR. STIRBA: ARE WE GOING TO FINISH THE NOTE?
2431
1 Q. (BY MS. BARLOW) I DON'T KNOW THAT IT'S RELEVANT, BUT
2 GO AHEAD AND FINISH THE NOTE.
3 A. TURNED Q 2 HOURS. DUODERM APPLIED TO REDDENED AREA AT
4 COCCYX. I CAN'T READ THE NEXT WORD.
5 Q. IS IT AREA IS?
6 A. OKAY. AREA IS 1 1/2 BY 2 INCH SQUARE. SKIN IS NOT
7 ABRADED OR BROKEN. MOUTH CARE AND COMFORT MEASURES PROVIDED
8 AS NEEDED. NO FAMILY VISITORS TONIGHT.
9 Q. OKAY. BEGINS WITH: THE PATIENT EXHIBITING
10 CHEYNE-STOKES RESPIRATIONS. IF YOU READ -- READ THAT IN A
11 NOTE, WHAT WOULD THAT DO TO YOUR DECISION TO ADMINISTER
12 MORPHINE?
13 A. IT WOULD BE AN INDICATION OF TOXICITY OF MORPHINE. I
14 WOULD QUESTION WHETHER THE DOSE WAS APPROPRIATE OR THE USE
15 OF MORPHINE WAS APPROPRIATE.
16 Q. WHAT DO YOU MEAN BY TOXICITY OF MORPHINE?
17 A. MORPHINE IS A CENTRAL NERVOUS SYSTEM DEPRESSANT. IT
18 INTERACTS WITH THE VITAL CENTERS OF THE BASE OF THE BRAIN
19 THAT CONTROL YOUR BREATHING, YOUR HEART RATE, AND YOUR BLOOD
20 PRESSURE.
21 Q. THEN IT SAYS: HAS REFLEXIVE HAND GRASP. WHAT IS THAT?
22 A. A REFLEXIVE HAND GRASP IS WHAT WE CALL A PRIMITIVE
23 REFLEX WHICH MEANS THAT WHEN SOMEONE IS IN A STATE WHERE
24 THEIR BRAIN FUNCTION IS SUPPRESSED, THE REFLEXES THAT ARE
25 APPARENT AT YOUNGER AGES BECOME UNMASKED. AND A HAND GRASP
2432
1 REFLEX IS WHAT A BABY WILL DO IF YOU PASS YOUR HAND -- YOUR
2 FINGERS THROUGH THEIR HAND AND THEY GRAB ON VERY TIGHTLY TO
3 HOLD ON. SO IT'S THAT TYPE OF PRIMITIVE REFLEX.
4 Q. DO YOU SEE ANY INDICATION OF PAIN IN THAT NOTE?
5 A. NO.
6 Q. DO YOU SEE ANYTHING THAT JUSTIFIES THE USE OF MORPHINE
7 IN THAT NOTE?
8 A. NO.
9 Q. BACK TO A DOCTOR SEEING THAT NOTE WOULD DO WHAT WITH
10 MORPHINE?
11 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT.
12 THAT'S LEADING AND SUGGESTIVE, AND I ALSO THINK IT'S
13 IRRELEVANT.
14 THE COURT: OKAY. REPHRASE THE QUESTION.
15 Q. (BY MS. BARLOW) OKAY. GIVEN YOUR EXPERT OPINION --
16 WELL, GIVEN YOUR EXPERTISE, YOUR TRAINING, YOUR EXPERIENCE,
17 WOULD A DOCTOR KNOW --
18 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT.
19 MS. BARLOW: EXCUSE ME, YOUR HONOR. I -- I'M
20 SORRY.
21 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT.
22 MS. BARLOW: I'M SORRY.
23 MR. STIRBA: WE'VE ALREADY HAD THIS DISCUSSION.
24 MS. BARLOW: I WILL GO ON TO SOMETHING ELSE, YOUR
25 HONOR. I'M NOT SURE I CAN PHRASE IT TO GET AROUND THE
2433
1 OBJECTION.
2 Q. (BY MS. BARLOW) THEN AT 7:30, 0730, THE NOTE, WOULD
3 YOU -- WOULD YOU READ THE 0730 FOR THE 1ST OF JANUARY, READ
4 THAT NOTE?
5 A. PATIENT REPOSITIONED. ORAL CARE GIVEN. SKIN WARM TO
6 TOUCH. PATIENT RIGID WITH EXTREMITY MOVEMENT. DIAPER DRY.
7 Q. PATIENT RIGID -- WELL, THAT NOTE ITSELF, DOES THAT
8 INDICATE -- DOES THAT SHOW ANY SIGNS OF PAIN?
9 A. NO.
10 Q. SEEING THAT NOTE, WHAT WOULD IT TELL YOU ABOUT THE
11 ADMINISTRATION OF MORPHINE?
12 A. THERE'S NO INDICATION OF PAIN TO GIVE THE MEDICATION AT
13 THAT TIME.
14 Q. THEN AT 0935, WHAT DOES THAT NOTE READ?
15 A. PATIENT REPOSITIONED. ORAL CARE GIVEN. PULSE SLOW,
16 IRREGULAR, EVEN -- IRREGULAR, EVEN, UNLABORED BREATHING.
17 Q. DO YOU SEE ANY INDICATION OF PAIN?
18 A. NO.
19 Q. LET'S TURN THE PAGE TO 0085 -- OR 584, EXCUSE ME. WOULD
20 YOU READ THE NOTE FOR 11:30?
21 A. IT STARTS ON THE PRIOR PAGE: PATIENT REPOSITIONED.
22 ORAL CARE GIVEN. DUODERM REMAINS IN PLACE ON COCCYX.
23 FAMILY IN TO VISIT. PATIENT WITHOUT PAIN. M.S. GIVEN Q 4
24 HOURS AS SCHEDULED. COMFORT MEASURES PROVIDED. NO P.O.
25 ORAL INTAKE. VITAL SIGNS 112/70. FOURTEEN WOULD BE
2434
1 RESPIRATIONS, 66 WOULD BE HEART RATE, 100.3 WOULD BE
2 TEMPERATURE.
3 Q. ANY INDICATION OF THE NEED FOR MORPHINE IN THAT NOTE?
4 A. NO.
5 Q. WOULD YOU READ THE NOTE FOR 1400 HOURS?
6 A. PATIENT GIVEN COMFORT CARES. RIGID MOVEMENTS WITH
7 EXTREMITIES.
8 CIRCLE I: PROVIDED MEDICATION INJECTIONS, COMFORT
9 CARE.
10 CIRCLE R: PATIENT REMAINS UNRESPONSIVE TO STIMULI.
11 EYES OPEN, STARING.
12 CIRCLE P: CONTINUE COMFORT MEASURES.
13 Q. RIGID MOVEMENTS, IS THAT WITH EXTREMITIES?
14 A. RIGID MOVEMENTS WITH EXTREMITIES, YES.
15 Q. WHAT -- WHAT DOES THAT MEAN?
16 A. IT MEANS THAT THE LIMBS ARE HARD TO -- TO BEND.
17 Q. LET'S GO DOWN TO 15 -- 1500 TO 2300. WOULD YOU READ
18 THAT?
19 A. CIRCLE B: PATIENT UNRESPONSIVE EXCEPT TO PAINFUL
20 STIMULI. GROANS AS INJECTIONS GIVEN. PATIENT OFTEN GROANED
21 WHEN TURNED FOR PERI OR MOUTH CARE OR DURING SHOTS.
22 CIRCLE I: GAVE M.S. AS SCHEDULED AND P.R.N. WHEN
23 PATIENT GROANING. PATIENT TURNED Q 2 HOURS, COMFORT CARE
24 GIVEN.
25 CIRCLE R: PATIENT RESPONDED AS DESCRIBED ABOVE. EYES
2435
1 OPEN, STARING.
2 CIRCLE P: COMFORT MEASURES.
3 Q. WHAT ABOUT THE GROANING? DOES -- DO YOU HAVE ANY IDEA
4 WHAT'S CAUSING THAT GROANING?
5 A. IT'S UNCLEAR FROM THE RECORD WHAT THE GROANING COULD BE
6 DUE TO.
7 Q. WHAT KINDS OF THINGS CAUSE A PATIENT TO GROAN?
8 A. A PATIENT WHO'S ALERT AND COOPERATIVE CAN GROAN WHEN YOU
9 TELL A BAD JOKE. A PATIENT CAN GROAN DURING THE
10 ADMINISTRATION OF MEDICATIONS AS AN INDICATION OF PAIN, AS
11 MAY HAVE BEEN THE CASE HERE. A PATIENT CAN -- CAN HAVE
12 VERBAL SOUNDS THAT AREN'T RELATED TO ANYTHING THAT THE BRAIN
13 IS CONNECTED TO, BUT ARE THE MANIFESTATIONS OF THE BREATHING
14 PROCESS AND LEAD TO A SORT OF A SOUND AT THE VOICE THAT CAN
15 BE INTERPRETED AS A GROAN.
16 IT DEPENDS ON WHETHER IT'S VOLITIONAL; THAT IS TO SAY
17 SOMETHING THAT SOMEONE PUTS OUT THEMSELVES OR WHETHER IT'S
18 THE RESULT OF SOME ACTIVITY OR INTERNAL DISCOMFORT OR JUST
19 THE RESULT OF SOMEONE WHO'S PROFOUNDLY ILL WITH THE WAY
20 THEY'RE BREATHING.
21 Q. COULD YOU TELL WHAT WAS CAUSING THIS GROANING?
22 A. THE NURSE DOES MENTION THAT THE PATIENT GROANS WITH THE
23 INJECTIONS. IT COULD BE A SIGN OF PAIN.
24 Q. PAIN CAUSED BY WHAT?
25 A. THE INJECTION.
2436
1 Q. AND THEN I THINK THAT THAT IS 1600. IT'S EITHER 16 OR
2 1700. IT LOOKS LIKE IT'S WRITTEN OVER. COULD YOU READ THAT
3 NOTE FOR US, PLEASE?
4 A. FREE TEXT MED NOTE: PATIENT GROANING, TWITCHING.
5 PATIENT MEDICATED WITH M.S. 5 MILLIGRAMS I.M. WITH LESS --
6 SLIGHTLY LESS TWITCHING OBSERVED 30 MINUTES AFTER M.S.
7 Q. CAN YOU TELL FROM THAT NOTE WHAT'S CAUSING THE GROANING
8 AND TWITCHING?
9 A. IT'S -- IT'S UNCLEAR FROM THE NOTE.
10 Q. WHAT COULD CAUSE THE GROANING AND TWITCHING?
11 A. WELL, THE PATIENT HAD HAD SEIZURES PREVIOUSLY, AND I'VE
12 TESTIFIED THAT THE MORPHINE REDUCES SEIZURE THRESHOLD. THE
13 TWITCHING AND GROANING COULD BE MANIFESTATIONS OF THE
14 PRESENCE OF SMALL SEIZURES.
15 Q. GIVEN WHAT YOU'VE READ IN THESE TWO PAGES, WAS THE
16 ADMINISTRATION OF MORPHINE IN THIS CONTEXT APPROPRIATE?
17 A. IN THE WAY IT WAS ADMINISTERED, NO, NOT IN MY MIND.
18 Q. WHY IS THAT?
19 A. THE PRESENCE OF THE GROANING ALONE AS A REASON TO
20 ADMINISTER THE MORPHINE IS -- IS NOT ENOUGH FOR ME TO BE THE
21 PRESCRIBING PHYSICIAN. I WOULD NEED OBJECTIVE EVIDENCE
22 RELATIVE TO MY EXAMINING THE PATIENT THAT THERE WAS PAIN IN
23 A PATIENT WHO CAN'T SPEAK AS EXPRESSED BY THEIR FACE
24 CONTORTING OR THEM RESISTING THE EXAMINATION OR EVIDENCE ON
25 EXAMINATION OF A SPECIFIC PART OF THE BODY THAT THAT WAS
2437
1 PAINFUL. THOSE WOULD BE THE KINDS OF THINGS THAT I COULD
2 USE FOR THAT AS DIRECT EVIDENCE TO PRESCRIBE THE MORPHINE
3 AND ADMINISTER IT.
4 Q. OKAY. AND WHY WOULD YOU WANT TO HAVE THAT DIRECT
5 EVIDENCE BEFORE YOU PRESCRIBED OR ADMINISTERED THE MORPHONE?
6 A. WELL, THE MORPHINE IS A DRUG WHICH CAN BE FATAL WHEN
7 ADMINISTERED TO A PATIENT. AND THE -- THE ADMINISTRATION OF
8 THE MEDICINE NEEDS TO BE DONE IN A WAY THAT'S SAFE AND
9 APPROPRIATE. AND THIS PATIENT IS SO UNRESPONSIVE AND SO
10 PROFOUNDLY CLOSE TO DEATH AT THIS POINT THAT THE
11 ADMINISTRATION OF THE MORPHINE COULD LEAD TO DEATH.
12 Q. OKAY. WERE THERE ANY CHANGES IN THE ORDERS ON THE 2ND
13 OF JANUARY?
14 A. I DON'T SEE ANY.
15 Q. PURSUANT TO THE EARLIER ORDERS, WAS MORPHINE
16 ADMINISTERED ON THE 2ND OF JANUARY?
17 A. YES.
18 Q. AND THAT IS WHAT, 00507? ARE WE LOOKING AT THE SAME
19 PAGE?
20 A. YES.
21 Q. HOW MUCH MORPHINE WAS ADMINISTERED PURSUANT TO THE
22 SCHEDULED ORDER ON THE 2ND OF JANUARY?
23 A. FIVE DOSES OF 5 MILLIGRAMS.
24 Q. THAT'S WHAT, 25 TOTAL?
25 A. YES.
2438
1 Q. WERE THERE ANY OTHER AS NEEDED DOSES ADMINISTERED ON THE
2 2ND OF JANUARY?
3 A. I DO NOT BELIEVE SO.
4 Q. DID YOU SEE ANYTHING IN THE NURSES' NOTES JUSTIFYING THE
5 ADMINISTRATION OF MORPHINE ON THE 2ND OF JANUARY? WELL,
6 LET'S SAY IN -- IN THE RECORD, THE TOTAL RECORD. I SAID
7 NURSING NOTES, BUT LET'S SAY TOTAL RECORD.
8 A. THE NURSES WRITE MOANING AND GROANING. THERE'S, AGAIN,
9 THE JERKING OF ALL EXTREMITIES AND THE MOANING. AND I'M NOT
10 SURE THAT THAT'S AN INDICATION, AS I STATED BEFORE.
11 Q. WOULD THAT JUSTIFY THE ADMINISTRATION OF MORPHINE?
12 A. I'M -- I'M NOT SURE THAT THAT'S A JUSTIFICATION, BASED
13 ON MY PRIOR STATEMENTS.
14 Q. ANYTHING IN THE DOCTOR'S NOTES?
15 A. NO. NOT ON THE 2ND.
16 Q. WAS THERE A CHANGE IN THE ORDER ON THE 3RD OF JANUARY?
17 A. YES.
18 Q. WHAT CHANGE DO YOU SEE ON THE 3RD OF JANUARY IN THE
19 MEDICATIONS ORDERED?
20 A. 00465: MORPHINE SULFATE 25 MILLIGRAMS I.M. NOW.
21 Q. AT WHAT TIME?
22 A. APPEARS TO BE 10 O'CLOCK.
23 Q. ANYTHING ELSE ON THE 3RD?
24 A. IF MORPHINE SULFATE -- IF ANY MORPHINE SULFATE IS TO BE
25 WITHHELD, PLEASE CALL ME FIRST. DR. WEITZEL.
2439
1 Q. CAN YOU TELL WHEN THAT WAS NOTED?
2 A. AT 10:30 ON THE 3RD.
3 Q. ANY OTHER INDICATIONS OF ORDERS?
4 A. AT 11 -- APPEARS TO BE 11 O'CLOCK IN THE MORNING:
5 MORPHINE SULFATE 30 MILLIGRAMS I.M. NOW. NATURAL TEARS TO
6 BOTH EYES 4 TIMES A DAY.
7 Q. IS THERE ANOTHER ORDER AT 11 O'CLOCK?
8 A. VITAL SIGNS TO EVERY SHIFT, PLEASE. DR. WEITZEL.
9 Q. WHAT DOES THAT MEAN?
10 A. I'M NOT QUITE CLEAR -- WELL, I'LL TELL YOU EXACTLY WHAT
11 THAT MEANS. IT MEANS THAT EVERY TIME THERE'S A CHANGE IN
12 THE NURSING STAFF AND THERE'S A NEW SHIFT OF NURSES WORKING,
13 IT'S DURING THAT SHIFT ONE TIME THE VITAL SIGNS SHOULD BE
14 DONE.
15 Q. GIVEN THE STATE OF MRS. LARSEN AT THAT TIME, IS THERE
16 ANYTHING UNUSUAL ABOUT THAT ORDER?
17 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT.
18 UNUSUAL IS NOT WITHIN THE PROVINCE OF AN EXPERT. IF HE
19 WANTS TO --
20 THE COURT: SUSTAINED.
21 Q. (BY MS. BARLOW) IS THERE ANYTHING -- IS THAT ORDER
22 APPROPRIATE GIVEN THE STATUS OF MRS. LARSEN PHYSICALLY AT
23 THAT TIME?
24 A. I'D SAY NO FOR A REASON.
25 Q. AND WHAT'S THE REASON?
2440
1 A. THE -- THE NURSES SHOULD USE THEIR PROFESSIONAL
2 JUDGMENTS AS TO WHEN VITAL SIGNS SHOULD BE DONE. THIS ORDER
3 JUST SAYS THAT THEY NEED TO BE DONE EVERY SHIFT. IT DOESN'T
4 PREVENT THEM FROM DOING THEM MORE OFTEN. IT JUST MEANS MAKE
5 SURE YOU DO THEM AT LEAST EVERY SHIFT.
6 Q. DO YOU HAVE ANY INDICATION FROM THE RECORDS THAT -- THAT
7 THE VITAL SIGNS WERE NOT BEING TAKEN AT LEAST EVERY SHIFT?
8 A. NO.
9 Q. SO THAT WAS AT 11 O'CLOCK, 30 MILLIGRAMS. WHAT'S THE
10 NEXT ORDER?
11 A. AT 2:25: TELEPHONE ORDER, DR. WEITZEL. MORPHINE
12 SULFATE 30 MILLIGRAMS I.M. NOW.
13 Q. AND THE NEXT ORDER?
14 A. 6:20 P.M., MORPHINE SULFATE 15 MILLIGRAMS I.M. NOW;
15 MORPHINE SULFATE 10 MILLIGRAMS I.M. Q 3 HOURS. TELEPHONE
16 ORDER, DR. WEITZEL.
17 Q. IS THAT THE LAST OF THE ORDERS FOR MEDICATIONS?
18 A. YES.
19 Q. LET'S LOOK BACK AT THE MEDICAL RECORDS THEN FOR THE 3RD
20 OF JANUARY. CAN YOU TELL FROM THOSE MEDICAL RECORDS WHAT
21 MORPHINE WAS ADMINISTERED ON THE 3RD OF JANUARY?
22 A. I CAN ATTEMPT TO TRY. FROM 00510, WE HAVE 25
23 MILLIGRAMS, THEN 30 MILLIGRAMS, THEN 30 MILLIGRAMS -- THAT
24 WOULD BE 85 MILLIGRAMS. FROM 00509 WE HAVE 15 MILLIGRAMS.
25 THAT MAKES A TOTAL OF 100. AND FROM 00507 WE HAVE 10
2441
1 MILLIGRAMS. THAT'S 110. AND THEN ONE, TWO, THREE, FOUR --
2 FOUR DOSES OF 5, WHICH IS ANOTHER 20. THAT BRINGS MY TOTAL
3 TO 130 MILLIGRAMS.
4 Q. IS THERE ANY INDICATION ON 507 THAT ANY DOSAGES WERE --
5 WERE HELD, NOT GIVEN?
6 A. THERE ARE TWO INITIALS CIRCLED ON 507 AT 0030 AND 0330.
7 Q. SO THAT'S A 130 MILLIGRAMS. IS -- IS THAT AN
8 APPROPRIATE DOSAGE AMOUNT IN A 24-HOUR PERIOD --
9 A. IT --
10 Q. -- FOR A 93-YEAR-OLD WOMAN?
11 A. IT CAN BE IF IT'S INDICATED.
12 Q. DO YOU SEE ANY INDICATION OF NEED FOR 130 MILLIGRAMS OF
13 MORPHINE ON THE 3RD OF JANUARY FOR JUDITH LARSEN?
14 A. DOCTOR'S NOTES AND THE NURSES' NOTES CONTAIN GROANING AS
15 AN OBSERVATION.
16 Q. GIVEN THAT OBSERVATION, WAS THE ADMINISTRATION OF
17 130 MILLIGRAMS OF MORPHINE ON THE 3RD OF JANUARY
18 APPROPRIATE?
19 A. NOT IN MY MIND.
20 Q. WHY?
21 A. THERE'S NO OTHER OBJECTIVE EVIDENCE OF THE PATIENT'S
22 NEED FOR THE MEDICATION IN THAT DOSAGE.
23 Q. IF YOU'D TURN TO 00477. WOULD YOU READ THE NOTE FOR THE
24 3RD OF JANUARY FROM DR. WEITZEL?
25 A. M.D.: DESPITE 5 MILLIGRAMS OF I.M. MORPHINE SULFATE AT
2442
1 7:30 AND 9:38, PATIENT HAS NOT RESPONDED AT ALL. EYES OPEN,
2 GROANING. APPEARS IN SOME PAIN. UNFORTUNATELY NURSING
3 STAFF HAVE BEEN HOLDING MORPHINE SULFATE FOR LOW RESPIRATORY
4 STATED -- RATE. REMAINS UNRESPONSIVE TO ANY QUESTIONS.
5 VITAL SIGNS STABLE ACTUALLY, AND SHE'S AFEBRILE.
6 ASSESSMENT, STABLE. PLAN, MORPHINE SULFATE 25 NOW, CONTINUE
7 5 Q 3 HOURS P.R.N. AS NEEDED.
8 Q. HE WROTE: UNFORTUNATELY NURSING STAFF HAVE BEEN HOLDING
9 M.S. FOR LOW RESPIRATION RATE?
10 A. YES.
11 Q. IS THAT APPROPRIATE BEHAVIOR FOR A NURSE?
12 A. YES.
13 Q. WHY?
14 A. THE MORPHINE SULFATE SUPPRESSES THE VITAL CENTERS
15 RELATIVE TO CONTROLLING RESPIRATION. IF THE RESPIRATORY
16 RATE IS LOW, IT'S AN INDICATION OF THE MORPHINE SULFATE
17 BEING TOXIC OR CAUSING THE RESPIRATIONS TO BE TOO SLOW.
18 Q. IF A NURSE IN THE CIRCUMSTANCES OF THE RESPIRATION RATE
19 BEING LOW WERE TO WITHHOLD MORPHINE SULFATE, WHAT IF
20 ANYTHING WOULD YOU SAY TO HER ABOUT DOING THAT?
21 MR. STIRBA: I'M GOING TO OBJECT, YOUR HONOR.
22 IRRELEVANT HYPOTHETICAL. HE'S HERE TO RENDER AN EXPERT
23 OPINION, NOT HIS PERSONAL OPINION.
24 THE COURT: SUSTAINED.
25 Q. (BY MS. BARLOW) WOULD YOU PLEASE READ THE NOTE FOR THE
2443
1 4TH OF JANUARY?
2 A. M.D.: PATIENT GIVEN LARGE AMOUNTS OF MORPHINE SULFATE
3 YESTERDAY P.M. FOR COMFORT. FINALLY, SHE EXPIRED AT 8 P.M.
4 APPEARED TO BE IN NO PAIN. ASSESSMENT, RESPIRATIONS
5 DECREASED, POOR BLOOD PRESSURE SECONDARY TO DEHYDRATION
6 LEADING TO CARDIAC ARREST.
7 THERE'S AN ARROW THAT I'M INTERPRETING AS LEADING TO
8 CARDIAC ARREST.
9 PLAN, RELEASE TO FAMILY.
10 Q. DID YOU SEE IN YOUR REVIEW OF THE RECORD ANY INDICATION
11 THAT MRS. LARSEN NEEDED COMFORT -- MORPHINE FOR COMFORT ON
12 THE 3RD OF JANUARY?
13 A. NO.
14 Q. CAN THE ADMINISTRATION OF MORPHINE CAUSE CARDIAC ARREST?
15 A. YES.
16 Q. IN WHAT WAY?
17 A. IT CAN CAUSE IT BY SUPPRESSION OF RESPIRATIONS LEADING
18 TO ABSENCE OF THE MOVEMENT OF THE LUNGS TO EXCHANGE AIR.
19 FALLING OXYGEN. THE HEART WOULD THEN STOP IN THE ABSENCE OF
20 OXYGEN.
21 Q. BASED ON YOUR REVIEW OF THE RECORDS AND YOUR EXPERIENCE,
22 HAVE YOU FORMULATED AN OPINION TO A DEGREE OF MEDICAL
23 CERTAINTY AS TO THE CAUSE OF DEATH OF JUDITH LARSEN?
24 MR. STIRBA: ASKED AND ANSWERED, YOUR HONOR.
25 THE COURT: SUSTAINED.
2444
1 MS. BARLOW: YOUR HONOR, HE RESERVED THE ANSWER.
2 MR. STIRBA: NO, WE'RE NOT GOING TO --
3 THE WITNESS: NO, I DIDN'T.
4 MS. BARLOW: DIDN'T YOU? I'M SORRY.
5 MR. STIRBA: HE ANSWERED.
6 MS. BARLOW: I'M SORRY. MY MEMORY IS GETTING VERY
7 POOR.
8 WITH THAT, I HAVE NO FURTHER QUESTIONS, YOUR HONOR.
9 THE COURT: OKAY. MR. STIRBA?
10 MR. STIRBA: YES. THANK YOU, YOUR HONOR.
11 CROSS-EXAMINATION
12 BY MR. STIRBA:
13 Q. DOCTOR, YOU TESTIFIED THAT YOU BELIEVE THAT MS. LARSEN,
14 PATIENT JUDITH LARSEN WAS PROFOUNDLY CLOSE TO DEATH AS OF
15 JANUARY 1 OF 1996. IS YOUR OPINION SIMILAR THAT AS OF
16 DECEMBER 30, 1995, SHE WAS PROFOUNDLY CLOSE TO DEATH?
17 A. ON DECEMBER 30, 1995, BLOOD -- PATIENT HAD A NORMAL
18 BLOOD PRESSURE AND A NORMAL HEART RATE. I WOULD SAY SHE WAS
19 NOT.
20 Q. SO YOUR OPINION IS THAT SHE WAS PROFOUNDLY CLOSE TO
21 DEATH ON THE 1ST, BUT SHE WASN'T PROFOUNDLY CLOSE TO DEATH
22 ON THE 30TH; IS THAT RIGHT?
23 MS. BARLOW: ASKED AND ANSWERED, YOUR HONOR.
24 THE COURT: OVERRULED.
25 A. THAT'S CORRECT.
2445
1 Q. (BY MR. STIRBA) AND YOU DON'T BELIEVE THAT SHE WAS
2 DYING THEN ON THE 30TH, DO YOU? IS THAT WHAT YOU'RE TELLING
3 THIS JURY?
4 A. YES.
5 Q. AND YOU TOLD THE JURY YESTERDAY A LITTLE BIT ABOUT ELLEN
6 ANDERSON. AND YOU WERE ASKED A QUESTION, WAS THERE ANY
7 INDICATION OF PAIN THAT YOU SAW IN THE MEDICAL RECORDS? DO
8 YOU REMEMBER THAT QUESTION?
9 A. I DO.
10 Q. AND YOU REMEMBER YOU TOLD THE JURY NO. TRUE?
11 A. TRUE.
12 Q. IT'S TRUE, IS IT NOT THOUGH, SIR, THAT THERE IS IN FACT
13 AN INDICATION BY THE FIRST NURSE THAT ELLEN ANDERSON WAS IN
14 SEVERE PAIN AND SO CHARTED IT? ISN'T THAT TRUE, SIR?
15 A. IF I CAN HAVE THE RECORD TO REVIEW, I'LL ANSWER THE
16 QUESTION.
17 Q. ARE -- ARE YOU TELLING ME THAT WITHOUT LOOKING AT THE
18 RECORD, AS YOU SIT HERE RIGHT NOW, EVEN THOUGH YOU MADE THAT
19 TESTIMONY YESTERDAY TO THIS JURY, YOU CAN'T ANSWER THE
20 QUESTION WITHOUT LOOKING AT THE RECORD?
21 MS. BARLOW: OBJECTION, YOUR HONOR. HE ASKED IF
22 THE NURSE CHARTED THAT, AND DR. FEHLAUER WOULD HAVE TO SEE
23 THE CHART TO SEE IF SHE CHARTED THAT.
24 THE COURT: THE QUESTION IS PROPER. OVERRULED.
25 MR. STIRBA: WOULD YOU READ BACK THE QUESTION,
2446
1 PLEASE, TO THE GOOD DOCTOR?
2 (WHEREUPON, THE PREVIOUS QUESTION WAS READ BY THE COURT
3 REPORTER.)
4 A. THE ANSWER IS YES, I CAN'T ANSWER THAT QUESTION WITHOUT
5 LOOKING AT THE RECORD.
6 Q. (BY MR. STIRBA) DO YOU HAVE THE ELLEN ANDERSON BINDER
7 IN FRONT OF YOU, DOCTOR?
8 MS. BARLOW: HERE IT IS.
9 Q. (BY MR. STIRBA) IN FACT, WHAT BINDERS DO YOU HAVE? WE
10 OUGHT TO HAVE THEM ALL UP HERE.
11 MS. BARLOW: I'LL BRING THEM UP.
12 MR. STIRBA: ALL THE NOTES AND EVERYTHING ELSE WE
13 NEED BECAUSE I WANT TO PROCEED WITH THE EXAMINATION.
14 Q. (BY MR. STIRBA) YOU HAVE THAT ELLEN ANDERSON EXHIBIT
15 IN FRONT OF YOU, TRUE?
16 A. I DO.
17 Q. AND YOU NEED TO TURN THEN, IF YOU WOULD, TO MED-00190
18 WHICH IS A NURSING NOTE DONE ON 12/29 OF 1995. DO YOU HAVE
19 THAT IN FRONT OF YOU, SIR?
20 A. I DO.
21 Q. AND, OF COURSE, YOU REVIEWED THESE RECORDS BEFORE
22 TESTIFYING YESTERDAY AND TODAY; ISN'T THAT TRUE?
23 A. YES.
24 Q. AND YOU DID, ONCE AGAIN, TELL THE JURY YOU SAW NO
25 INDICATION OF PAIN BASED UPON YOUR REVIEW OF THE RECORDS,
2447
1 TRUE?
2 A. TRUE.
3 Q. IF YOU LOOK AT THE MED NOTE, WHICH IS SORT OF DOWN
4 TOWARDS THE MIDDLE OF THE PAGE, THE NURSE STATES: M.S. 10
5 MILLIGRAMS I.M. AT 2000.
6 DO YOU SEE THAT?
7 A. I DO.
8 Q. NEXT WORDS: FOR SEVERE PAIN.
9 DO YOU SEE THAT?
10 A. I CERTAINLY DO.
11 Q. AND, IN FACT, OVER HERE IT'S KIND OF DIFFICULT TO READ,
12 BUT I BELIEVE IT SAYS: PATIENT SCREAMS AND BECOMES RIGID
13 WHEN TOUCHED.
14 DO YOU UNDERSTAND IT SAYS THAT?
15 A. YES.
16 Q. NOW, JUST SO I UNDERSTAND YOUR TESTIMONY YESTERDAY, ARE
17 YOU SAYING TO THIS JURY THAT YOU DIDN'T SEE THIS ENTRY?
18 A. NO, I SAW THAT ENTRY.
19 Q. AND ARE YOU TELLING THIS JURY THAT THIS NURSE DIDN'T
20 ACCURATELY ASSESS WHAT WAS GOING ON AT THE TIME BASED UPON
21 HER PROFESSIONAL EXPERIENCE?
22 A. THAT'S WHAT I'VE TOLD -- THAT'S WHAT MY TESTIMONY WOULD
23 SAY, YES.
24 Q. SO -- SO ARE YOU TELLING THIS JURY THAT EVEN THOUGH THE
25 NURSE MADE THIS ASSESSMENT AND SHE WAS THERE AND SHE WAS
2448
1 WITH MS. ANDERSON AT 2000 HOURS ON THIS DAY, YOU'RE SAYING
2 THAT YOU'RE GOING TO SIT HERE AND SAY THAT SHE DIDN'T
3 PROPERLY ASSESS SEVERE PAIN? IS THAT WHAT YOU'RE TELLING
4 THE JURY?
5 MS. BARLOW: OBJECTION, YOUR HONOR. THAT'S ASKED
6 AND ANSWERED.
7 THE COURT: OVERRULED.
8 Q. (BY MR. STIRBA) IS THAT WHAT YOU'RE TELLING THE JURY?
9 A. YES, THAT'S WHAT I'M TELLING THE JURY.
10 Q. NOW, IT'S TRUE, IS IT NOT, SIR, THAT YOU NEVER -- AND
11 YOU TESTIFIED YESTERDAY HOW IMPORTANT IT IS TO LAY THE HANDS
12 ON THE PATIENT TO REALLY GET A GOOD UNDERSTANDING OF WHAT'S
13 GOING ON. YOU SAID THAT, DIDN'T YOU?
14 A. (NO RESPONSE.)
15 Q. AND YOU DIDN'T LAY ANY HANDS ON ELLEN ANDERSON, DID YOU?
16 A. NO.
17 Q. THE FACT OF THE MATTER IS, ALL YOU'VE DONE, SIR, IS
18 YOU'VE REVIEWED A BUNCH OF RECORDS AND COME IN AND PROVIDED
19 YOUR TESTIMONY; ISN'T THAT RIGHT?
20 A. YES, THAT'S TRUE.
21 Q. YOU NEVER SAW THE PATIENTS, TRUE?
22 A. TRUE.
23 Q. YOU NEVER TALKED TO THE FAMILIES, TRUE?
24 A. TRUE.
25 Q. AND, IN FACT, YOU NEVER MADE WHAT YOU TESTIFIED
2449
1 YESTERDAY IS A CLINICAL ASSESSMENT, DID YOU?
2 A. NO.
3 Q. ARE YOU TELLING THIS JURY THAT YOU'RE IN A BETTER
4 POSITION AS YOU SIT HERE IN THIS COURTROOM TO FIGURE OUT --
5 MS. BARLOW: YOUR HONOR, THIS QUESTION IS
6 ARGUMENTATIVE. I OBJECT TO THE TONE OF THE QUESTION.
7 THE COURT: I HAVEN'T -- WELL, THAT'S NO OBJECTION
8 TO TONE, AND THEIR QUESTION -- THE QUESTION HASN'T BEEN
9 FINISHED SO WAIT UNTIL THE QUESTION IS DONE.
10 MR. STIRBA: THANK YOU.
11 Q. (BY MR. STIRBA) ARE YOU TELLING THIS JURY, AS YOU SIT
12 HERE IN THIS COURTROOM, THAT YOU ARE IN A BETTER POSITION TO
13 ASSESS WHETHER OR NOT ELLEN ANDERSON WAS IN SEVERE PAIN THAN
14 THIS NURSE WHO WAS THERE ON DECEMBER 29TH OF 1995 WITH THE
15 PATIENT?
16 MS. BARLOW: OBJECTION. ARGUMENTATIVE, YOUR HONOR.
17 THE COURT: OVERRULED.
18 A. RESTATE THE QUESTION.
19 MR. STIRBA: READ IT BACK TO HIM.
20 (WHEREUPON, THE PREVIOUS QUESTION WAS READ BY THE COURT
21 REPORTER.)
22 A. BETTER POSITION? NO.
23 Q. (BY MR. STIRBA) NOW, ASSUME, DOCTOR, THAT THERE'S
24 ANOTHER NURSE -- AND YOU'RE AWARE THAT THERE WAS ANOTHER
25 NURSE THAT SAW MS. ANDERSON ON THE 30TH OF DECEMBER, ARE YOU
2450
1 NOT?
2 A. (NO RESPONSE.)
3 Q. AND I'LL JUST POINT OUT THAT THERE IS A LITTLE BIT
4 DIFFERENT INITIAL THERE, AND I CAN REPRESENT TO YOU THAT'S
5 NURSE TRACY SCHOLLS.
6 A. OKAY.
7 Q. ASSUMING THAT TRACY SCHOLLS SAID THAT SHE TALKED TO
8 DR. WEITZEL AND TOLD HIM AS OF 3:15 A.M. IN THE MORNING ON
9 THE 30TH THAT ELLEN ANDERSON WAS IN SEVERE PAIN, WOULD YOU
10 TAKE THE POSITION THAT THERE'S --
11 MS. BARLOW: OBJECTION, YOUR HONOR. THAT WAS NOT
12 THE TESTIMONY, NEITHER IS THAT WHAT WAS SAID IN THE RECORD.
13 MR. STIRBA: I'M JUST ASKING --
14 THE COURT: IT'S A HYPOTHETICAL QUESTION.
15 MR. STIRBA: IT'S A HYPOTHETICAL.
16 THE COURT: IT'S PHRASED AS AN ASSUMPTION.
17 MS. BARLOW: WELL, YOUR HONOR IT'S AN INAPPROPRIATE
18 HYPOTHETICAL BECAUSE THE RECORDS DON'T SAY THAT.
19 THE COURT: OVERRULED.
20 Q. (BY MR. STIRBA) ASSUMING, SIR, THAT THAT IS -- THAT IS
21 WHAT MS. SCHOLLS OBSERVED AND COMMUNICATED THAT TO
22 DR. WEITZEL, THAT THE NURSE IS SAYING THAT THE PATIENT WAS
23 IN SEVERE PAIN -- WHICH I WILL SHOW YOU. SHE HAS INDICATED:
24 PATIENT AWAKENS, THRASHING ARMS AND ATTEMPTING TO THROW
25 BODY. PATIENT MOANING/SCREAMING.
2451
1 THAT'S WHAT SHE DOCUMENTED. BUT ASSUMING THAT SHE TOLD
2 DR. WEITZEL THEN AT 3:15 A.M. ON THE 30TH THAT THE PATIENT
3 WAS IN SEVERE PAIN --
4 MS. BARLOW: YOUR HONOR, THERE IS NO EVIDENCE OF
5 THAT BEING SAID TO DR. WEITZEL. THAT IS NOT EVIDENCE BEFORE
6 THIS COURT AND I OBJECT TO HIM USING A HYPOTHETICAL THAT IS
7 NOT BASED ON THE EVIDENCE.
8 THE COURT: OKAY. IT'S A HYPOTHETICAL -- IT'S AN
9 ASSUMPTION THAT HE'S ASKING AND HE CAN PROBE THIS
10 WITNESS'S --
11 Q. (BY MR. STIRBA) AND GIVEN WHAT HAS BEEN --
12 THE COURT: -- BACKGROUND.
13 MR. STIRBA: SORRY, JUDGE.
14 THE COURT: GO AHEAD.
15 Q. (BY MR. STIRBA) AND GIVEN WHAT HAS BEEN CHARTED, IS IT
16 YOUR OPINION THAT THE GIVING OF A PAIN MEDICATION; THAT IS,
17 MORPHINE, AS OF THAT TIME AND AS OF THAT DATE WAS
18 INAPPROPRIATE?
19 A. DO YOU WANT ME TO RESTATE THE CIRCUMSTANCE? IT WAS A
20 VERY LONG STATEMENT.
21 Q. DOCTOR, I'VE ASKED YOU A QUESTION. WE CAN HAVE IT READ
22 BACK TO YOU AND YOU CAN ANSWER IT. DO YOU WANT THAT?
23 A. SURE.
24 MR. STIRBA: OKAY. CAN YOU READ IT BACK, PLEASE?
25 I'M SORRY.
2452
1 (WHEREUPON, THE PREVIOUS TWO COMPLETE QUESTIONS WERE
2 READ BY THE COURT REPORTER.)
3 A. YES.
4 Q. (BY MR. STIRBA) NOW, IT'S TRUE, IS IT NOT, YOU -- YOU
5 TOLD US A LITTLE BIT ABOUT MORPHINE, AND YOU'RE RELYING ON
6 THE GERIATRIC DOSING HANDBOOK; IS THAT RIGHT?
7 A. DOSAGE HANDBOOK, YES.
8 Q. DOSAGE HANDBOOK. AND I BELIEVE YOU TOLD US THAT THAT
9 WAS THE 1993 EDITION; IS THAT TRUE?
10 A. THAT'S TRUE.
11 Q. AND YOU HAD A LITTLE CHART WHICH YOU MADE -- SEE IF I
12 CAN FIND IT. YEAH -- NO, THAT'S NOT IT. YEAH, THIS IS IT.
13 AND YOU HAVE ON YOUR CHART -- YOU HAVE: ELDERLY
14 STARTING DOSE 2.5 MILLIGRAMS INTRAMUSCULAR EVERY FOUR TO SIX
15 HOURS AS NEEDED, TRUE?
16 A. TRUE.
17 Q. AND YOU RECALL, I ASKED YOU YESTERDAY IF THAT
18 INFORMATION WAS TAKEN DIRECTLY FROM THE GERIATRIC DOSAGE
19 HANDBOOK. REMEMBER THAT?
20 A. YES.
21 Q. AND YOU SAID YES; ISN'T THAT RIGHT?
22 A. YES.
23 Q. NOW, IT'S TRUE, IS IT NOT, SIR, THAT AS FAR AS THE
24 HANDBOOK IS CONCERNED, IT SAYS THE GERIATRIC STARTING DOSE
25 IS ACTUALLY 2.5 TO 5 MILLIGRAMS; ISN'T THAT TRUE?
2453
1 A. YES.
2 Q. AND, IN FACT, YOU DON'T HAVE ON YOUR LITTLE CHART HERE
3 AND NEVER TOLD THIS JURY 2.5 TO 5 MILLIGRAMS, DID YOU?
4 A. IS THAT -- DID I TELL THE JURY THAT IT WAS 2.5 TO 5?
5 Q. RIGHT. THE RANGE IS 2.5 TO 5 MILLIGRAMS, TRUE?
6 A. YES.
7 Q. AND YOU'RE TALKING ABOUT A STARTING DOSE, ARE YOU NOT?
8 A. YES.
9 Q. AND IT'S TRUE, IS IT NOT, THAT YOUR CALCULATIONS AS TO
10 WHAT WOULD BE A MAXIMUM -- AS YOU PUT IT -- STARTING DOSE IN
11 A 24-HOUR PERIOD WOULD BE MORE THAN 15 MILLIGRAMS OF
12 MORPHINE IF YOU'RE ACTUALLY TALKING ABOUT A RANGE OF 2.5 TO
13 5 MILLIGRAMS; ISN'T THAT TRUE?
14 A. YES.
15 Q. SO IT'S TRUE, IS IT NOT, THAT INSOFAR AS MORPHINE IS
16 CONCERNED, THAT CHART SHOULD NOT READ 2.5 AS A STARTING
17 DOSE, BUT IT SHOULD READ FOR GERIATRIC PATIENTS, STARTING
18 DOSE IS ACTUALLY 2.5 TO 5 MILLIGRAMS EVERY FOUR TO SIX HOURS
19 AS INDICATED IN THE GERIATRIC DOSAGE HANDBOOK, TRUE?
20 A. YES.
21 Q. AND IT'S TRUE, IS IT NOT, THAT YOU'VE TOLD THE JURY
22 ABOUT A STARTING DOSE, AND IT'S TRUE THAT THE GERIATRIC
23 DOSAGE HANDBOOK HAS OTHER DOSING LEVELS SHOWN WITH RESPECT
24 TO GERIATRIC PATIENTS; ISN'T THAT CORRECT?
25 A. OTHER THAN -- OTHER THAN WHAT?
2454
1 Q. OTHER THAN A STARTING DOSE, SIR.
2 A. YES, THEY -- IT CAN. YES.
3 Q. YEAH. IN OTHER WORDS, YOU TESTIFIED I THINK THIS
4 MORNING THAT SOME OF THESE DRUGS YOU HAVE A STARTING DOSE --
5 THAT IS, THE INITIAL DOSE -- AND THEN THE DRUGS CAN BE
6 CHANGED IN DOSING LEVELS OVER A PERIOD OF TIME, AND THAT'S
7 WELL-RECOGNIZED AND WELL-ACCEPTED PRACTICE; ISN'T THAT TRUE?
8 A. YES, IT IS.
9 Q. IN FACT, IN YOUR HANDBOOK AS YOU HAVE IT IN FRONT OF
10 YOU, IT HAS IN MANY INSTANCES WHAT IS CALLED A MAINTENANCE
11 DOSE. YOU UNDERSTAND THAT?
12 A. ABSOLUTELY.
13 Q. AND IT ALSO HAS IN IT WHAT THEY CALL A USUAL DOSE; ISN'T
14 THAT TRUE?
15 A. YES.
16 Q. AND IT'S TRUE, IS IT NOT, THAT ALL OF THESE CHARTS ARE
17 PREMISED ON WHAT THE DOSING HANDBOOK HAS AS A STARTING
18 DOSE --
19 A. YES.
20 Q. -- CORRECT?
21 A. THAT'S CORRECT.
22 Q. SO, FOR EXAMPLE, LET'S TAKE THIS ONE, I THINK THIS IS
23 PATIENT JUDITH LARSEN. YOU MIGHT HAVE A STARTING DOSE --
24 WHICH WOULD BE THE FIRST DOSE THAT YOU GIVE THE PATIENT --
25 AT A CERTAIN LEVEL, BUT SEE MAYBE 10 OR 15 DAYS LATER YOU
2455
1 MIGHT HAVE A DIFFERENT DOSING LEVEL THAT IS TOTALLY
2 APPROPRIATE CONSISTENT WITH THE HANDBOOK; ISN'T THAT TRUE?
3 A. FOR EACH OF THOSE I'D HAVE TO REVIEW THE HANDBOOK TO
4 MAKE THAT DIRECT COMPARISON.
5 Q. LET'S JUST REVIEW THEM THEN. YOU'RE AWARE, ARE YOU
6 NOT -- AND YOU CAN PULL OUT THE BOOK.
7 A. I WILL.
8 Q. WE CAN READ RIGHT ALONG. KLONOPIN, YOU TESTIFIED ABOUT
9 THAT. YOU'RE AWARE THAT THE BOOK SAYS THAT THE USUAL
10 MAINTENANCE DOSE IS .05 TO .02 MILLIGRAMS. AND THEN IT HAS
11 K.G. -- I'M NOT SURE I KNOW WHAT THAT IS -- AND IT SAYS, DO
12 NOT EXCEED 20 MILLIGRAMS A DAY. ARE YOU AWARE OF THAT?
13 A. I CAN'T ANSWER THE QUESTION THE WAY IT'S PHRASED.
14 THERE'S MORE INFORMATION THAT NEEDS TO BE GIVEN.
15 Q. DO YOU HAVE THE BOOK IN FRONT OF YOU?
16 A. YES.
17 Q. CAN YOU TURN TO KLONOPIN?
18 A. YES.
19 Q. DID I READ THAT CORRECTLY?
20 A. OKAY.
21 Q. USUAL MAINTENANCE DOSE, DO NOT EXCEED 20 MILLIGRAMS A
22 DAY, TRUE?
23 A. UH-HUH. BUT IT ALSO SAYS AHEAD OF THAT: UNTIL SEIZURES
24 ARE CONTROLLED.
25 Q. OH, I'M SURE THERE'S ALL KINDS OF AREAS FOR WHICH THERE
2456
1 ARE DISTINCTIONS AND VARIATIONS AND WHAT HAVE YOU CONTAINED
2 IN THE BOOK, BUT YOU'VE TOLD THIS JURY JUST ABOUT A STARTING
3 DOSE. THE JURY'S ENTITLED TO HEAR ABOUT OTHER DOSING LEVELS
4 IN THE BOOK. THAT'S WHAT I'M ASKING YOU ABOUT.
5 A. YES, SIR.
6 Q. IT'S TRUE, IS IT NOT, THAT TRAZODONE -- FOR EXAMPLE,
7 YOU'VE TESTIFIED ABOUT THAT. AND IT SAYS THAT THE USUAL
8 DOSE OF TRAZODONE IS 75 TO 100 -- 150 MILLIGRAMS A DAY IN
9 THREE DIVIDED DOSES. DO YOU UNDERSTAND THAT TO BE TRUE?
10 A. THAT IS WHAT THE BOOK SAYS.
11 Q. ATIVAN, THE INITIAL DOSE SHOULD NOT EXCEED 2 MILLIGRAMS
12 A DAY. AND THEN IT SAYS: THERE ARE VARIATIONS ON DOSAGE
13 FOR CERTAIN CONDITIONS, IN PARENTHESIS. ISN'T THAT TRUE, AS
14 THE BOOK INDICATES IT?
15 A. PAGE 414 OF THIS MANUAL DATED 1993 --
16 Q. I HAVE THE 2000 EDITION, BUT MAYBE YOUR '93 SAYS
17 SOMETHING DIFFERENT.
18 A. WELL, IT'S --
19 Q. TWO MILLIGRAMS A DAY.
20 A. THESE ARE CASES FROM 1995. IT STOPS AT 2 MILLIGRAMS PER
21 DAY.
22 Q. RIGHT. SERZONE. NOW, SERZONE THE BOOK SAYS THAT
23 INITIAL 50 MILLIGRAM DOSE TWICE DAILY. YOU CAN INCREASE
24 THAT DOSE 100 MILLIGRAMS TWICE DAILY IN TWO WEEKS. THE
25 USUAL MAINTENANCE DOSE IS 200 TO 400 MILLIGRAMS A DAY.
2457
1 TRUE?
2 A. DO YOU HAVE A PAGE NUMBER --
3 Q. I DON'T.
4 A. -- TO MAKE THIS FASTER? OKAY. THEN I'LL LOOK IT UP.
5 THE 1993 EDITION OF THIS MANUAL DOES NOT LIST SERZONE.
6 Q. OKAY. DO YOU HAVE ANY -- ARE YOU GOING TO DISPUTE WHAT
7 I'VE JUST STATED TO YOU THAT SERZONE, THAT A MAIN -- USUAL
8 MAINTENANCE DOSE IS 200 TO 400 MILLIGRAMS A DAY, AND THAT
9 THE INITIAL 50 MILLIGRAMS TWICE DAILY CAN BE INCREASED A
10 DOSE TO 100 MILLIGRAMS TWICE DAILY IN TWO WEEKS?
11 A. WELL, I'LL -- I'LL AGREE WITH THAT 50 MILLIGRAMS TWICE A
12 DAY AND THEN IN TWO WEEKS CHANGE IT TO 100 TWICE A DAY.
13 ABSOLUTELY.
14 Q. USUAL MAINTENANCE DOSE, 200 TO 400 MILLIGRAMS A DAY?
15 A. MAINTENANCE DOSE MEANS MAINTENANCE. IT DOESN'T MEAN
16 INITIAL.
17 Q. WELL, I DIDN'T ASK YOU THAT, SIR. I SAID, DO YOU -- DO
18 YOU AGREE THAT 200 TO 400 MILLIGRAMS A DAY IS THE
19 MAINTENANCE DOSE FOR SERZONE?
20 A. IT MAY BE IN ADULTS.
21 Q. NO, I'M TALKING ABOUT A GERIATRIC PATIENT AS IN THE
22 BOOK.
23 A. WITH -- WITH REFERENCE TO THE YEAR 2000 MANUAL THAT --
24 THAT'S PROBABLY TRUE.
25 Q. AND IT'S TRUE --
2458
1 A. I'LL ASSERT THAT YOU HAVE THAT IN FRONT OF YOU.
2 Q. I DO. AND IT'S TRUE, IS IT NOT, THAT SERZONE IS REALLY
3 NOT A VERY SEDATING MEDICATION; ISN'T THAT CORRECT?
4 A. THE -- THAT IS NOT MY EXPERIENCE.
5 Q. IN FACT, SERZONE, YOU TESTIFIED, WAS PURELY AN
6 ANTIPSYCHOTIC, TRUE?
7 A. NO. I TESTIFIED THAT IT WAS AN ANTIDEPRESSANT.
8 Q. ANTIDEPRESSANT, BUT IT'S -- IT'S USED TO TREAT GERIATRIC
9 DEMENTIA, IS IT NOT?
10 A. IT'S USED TO TREAT DEPRESSION.
11 Q. IT IS NOT USED TO TREAT SYMPTOMATOLOGY ASSOCIATED WITH
12 GERIATRIC DEMENTIA?
13 A. IT CAN BE. IT'S AN UNLABELLED USE.
14 Q. IF IT'S IN THE GERIATRIC DOSING HANDBOOK FOR THE YEAR
15 2000, WOULD YOU AGREE THAT THAT'S AN APPROPRIATE --
16 MS. BARLOW: YOUR HONOR, I OBJECT BECAUSE WE'RE
17 TALKING 1995. SERZONE WASN'T IN THERE.
18 THE COURT: SUSTAINED.
19 Q. (BY MR. STIRBA) NOW, IT'S TRUE, IS IT NOT, THAT
20 RISPERDAL HAS A TARGET DOSE OF 3 MILLIGRAMS TWICE DAILY AND
21 BASICALLY CALLS FOR A RAPID ESCALATION OF THE DRUG? INITIAL
22 INCREASES CAN BE AT 1 MILLIGRAM TWICE DAILY FOR THREE DAYS?
23 A. RISPERIDONE IS ALSO NOT IN THE 1993 MANUAL. MATERIALS
24 THAT I PRESENTED WERE BASED ON THE P.D.R.
25 Q. OKAY.
2459
1 A. I WOULD NOT AGREE WITH THAT STATEMENT FOR GERIATRIC
2 PATIENTS.
3 Q. AND WOULD YOU AGREE THAT THE MAXIMUM DAILY DOSE OF
4 HALDOL IN THE GERIATRIC DOSAGE HANDBOOK IS 4 MILLIGRAMS?
5 A. INITIAL STARTING DOSE.
6 Q. I DIDN'T SAY INITIAL STARTING DOSE. I SAID THE MAXIMUM.
7 IT SAYS: MAXIMUM DAILY DOSE 4 MILLIGRAMS, HALDOL.
8 A. FROM THE 2000 BOOK?
9 Q. YES.
10 A. I'LL ACCEPT THAT.
11 Q. OKAY. NOW, IT'S TRUE, ALSO, YOU TESTIFIED ABOUT A CAUSE
12 OF DEATH FOR ELLEN ANDERSON, CORRECT?
13 A. YES.
14 Q. AND IT'S TRUE, IS IT NOT, YOU TESTIFIED YOU REVIEWED A
15 BUNCH OF RECORDS CONCERNING THE MEDICAL HISTORY OF THESE
16 PATIENTS; IS THAT CORRECT?
17 A. I REVIEWED THE MATERIALS FROM THE SIX MONTHS PRIOR TO
18 THE PATIENT'S ADMISSION TO DAVIS HOSPITAL.
19 Q. SURE. AND THAT WOULD HAVE INCLUDED HER PERSONAL
20 PHYSICIAN'S RECORDS, I ASSUME; THAT IS, DR. WILDING?
21 A. YES.
22 Q. AND DR. KELLER?
23 A. YES.
24 Q. YOU'RE AWARE THAT ON 11/18 OF 1995 DR. KELLER REPORTS
25 THAT THE PATIENT -- THAT IS, MS. ANDERSON -- FELL ON HER
2460
1 RIGHT SIDE YESTERDAY AFTERNOON, COMPLAINS OF PAIN IN RIGHT
2 RIB CAGE AREA, LORTAB GIVEN?
3 A. YES, I'M AWARE OF THAT.
4 Q. YOU'RE ALSO AWARE THAT HE STATED IN HIS NOTE -- OR
5 DR. KELLER'S NOTE, RATHER, THAT ON X-RAY THEY THOUGHT THERE
6 WAS A POSSIBLE LUNG TUMOR, TRUE?
7 A. OH, YES, I'M AWARE OF THAT.
8 Q. AND YOU'RE CERTAINLY AWARE, ARE YOU NOT, THAT THEY
9 ACTUALLY DID AN X-RAY ON OR ABOUT NOVEMBER 18TH OF 1995, AND
10 THIS IS THE X-RAY REPORT. AND THE GENTLEMAN WHO DID THE
11 X-RAY UNDER IMPRESSION FOUND: BI-BASILAR ATELECTASIS AND/OR
12 PNEUMONIA, RIGHT GREATER THAN LEFT.
13 DID I READ THAT CORRECTLY?
14 A. YES.
15 Q. AND YOU'RE ALSO AWARE THAT THAT WENT UNTREATED?
16 A. I HAVE AN OPINION AS TO WHAT THAT REALLY WAS.
17 Q. YOU'RE AWARE --
18 A. BUT I'M AWARE THAT THAT WENT UNTREATED, YES.
19 Q. -- THAT THAT WENT UNTREATED. AND YOU'RE ALSO AWARE, ARE
20 YOU NOT, SIR, THAT WHEN SHE GOT IN THE DAVIS HOSPITAL THERE
21 WAS A CHEST X-RAY DONE SOMETIME APPROXIMATELY 5:00 TO
22 6:00 A.M. IN THE MORNING ON THE 30TH?
23 A. YES, I'M AWARE.
24 Q. AND YOU'RE AWARE THAT THAT PARTICULAR X-RAY SHO