David Dienhart, MD

1       MS. BARLOW:  WE'D CALL DR. DIENHART.

 

 2       THE COURT:  DR. DIENHART, WOULD YOU STEP UP PLEASE?  IF

 

 3  YOU'D COME RIGHT UP HERE AND RAISE YOUR RIGHT HAND PLEASE AND

 

 4  FACE THE CLERK AND SHE'LL PLACE YOU UNDER OATH.

 

 5                        DAVID DIENHART,

 

 6            BEING FIRST DULY SWORN, WAS EXAMINED

 

 7            AND TESTIFIED AS FOLLOWS:

 

 8                        DIRECT EXAMINATION

 

 9       THE COURT:  IF YOU'LL HAVE A SEAT HERE PLEASE, DOCTOR.

 

10  AND TELL US YOUR FULL NAME AND SPELL YOUR LAST NAME FOR US,

 

11  IF YOU WOULD.

 

12  A.   MY FIRST NAME'S DAVID GEORGE DIENHART.  D-I-E-N-H-A-R-T.

 

13       THE COURT:  YOU MAY PROCEED, MS. BARLOW.

 

14       MS. BARLOW:  YOUR HONOR, MAY I APPROACH THE WITNESS?

 

15  I'M GOING TO GIVE HIM STATE'S EXHIBITS 3-B.  WE'LL BE TALKING

 

16  ABOUT THESE MEDICAL RECORDS, AND SO I'LL HAVE HIM A COPY IF I

 

17  MAY.

 

18       THE COURT:  YOU MAY.

 

19       THE WITNESS:  THANKS.

 

20  Q.  (BY MS. BARLOW)  MORNING, DR. DIENHART.

 

21  A.   MORNING.

 

22  Q.   WE'LL ASK YOU TO MAKE SURE YOU KEEP YOUR VOICE UP.  WE

 

23  HAVE TO HAVE THIS MACHINERY RUNNING SOMETIME AND, YEAH, IF

 

24  YOU'LL SIT UP CLOSE.  THANK YOU.  DR. DIENHART, WHAT IS YOUR

 

25  CURRENT PRACTICE?

 

 1  A.   I'M IN PULMONARY AND CRITICAL CARE MEDICINE IN MURRAY,

 

 2  UTAH.

 

 3  Q.   BACK IN -- WELL, LET'S START WITH, WHAT EDUCATION AND

 

 4  TRAINING DID YOU RECEIVE FOR YOUR MEDICAL DEGREE?

 

 5  A.   MEDICAL DEGREE AND FOLLOWED BY RESIDENCY INTERNAL

 

 6  MEDICINE.  THEN I'VE DONE SUBSPECIALTY TRAINING IN

 

 7  HEMATOLOGY, MEDICAL ONCOLOGY, CRITICAL CARE MEDICINE, AND

 

 8  PULMONARY MEDICINE, AND FINALLY SLEEP MEDICINE.

 

 9  Q.   AND FINALLY WHAT?

 

10  A.   SLEEP MEDICINE.

 

11  Q.   SLEEP MEDICINE?  WHAT DOES PULMONARY MEAN?

 

12  A.   HAVING TO DO WITH STUDY OF THE LUNGS OR DISEASES OF THE

 

13  LUNGS.

 

14  Q.   YOU'RE NOW IN -- ARE YOU BOARD CERTIFIED IN ANY OF THESE

 

15  SPECIALTIES?

 

16  A.   IN ALL OF THE ONES I'VE MENTIONED.

 

17  Q.   YOU'RE CURRENTLY IN MURRAY IN PULMONARY, DID YOU SAY?

 

18  A.   YES.

 

19  Q.   IN 19 -- LATE 1995, EARLY 1996, WHERE YOU WERE WORKING?

 

20  A.   AT DAVIS HOSPITAL IN LAYTON.

 

21  Q.   WHAT WAS YOUR -- WHAT WERE YOUR DUTIES THERE AT THE

 

22  HOSPITAL?

 

23  A.   I WAS DIRECTOR OF THE RESPIRATORY THERAPY PROGRAM THERE.

 

24  AND I DID EMERGENCY ROOM ON-CALL DUTIES WITH -- I SHARED THAT

 

25  WITH THE OTHER INTERNIST ON STAFF.

 

1  Q.   DID YOU HAVE ANY RESPONSIBILITIES IN REGARD TO THE

 

 2  GERO-PSYCH UNIT AT DAVIS NORTH?

 

 3  A.   WE WOULD GET CALLED TO CONSULT ON THOSE PATIENTS FROM

 

 4  TIME TO TIME AS OUR CALL DUTIES CAME UP.

 

 5  Q.   COULD I ASK YOU TO MOVE OVER JUST CLOSER TO THAT

 

 6  MICROPHONE?  I'M SORRY, BUT IT'S HARD FOR PEOPLE TO HEAR --

 

 7       THE COURT:  I THINK IT WILL WORK BETTER IF YOU PUSH IT

 

 8  BACK A LITTLE WAYS, ACTUALLY.  AND THEN TIP IT DOWN.  THERE

 

 9  YOU GO.  NOW TRY TO SEE IF THAT PICKS IT UP BETTER.

 

10       THE WITNESS:  OKAY.

 

11  Q.  (BY MS. BARLOW)  WHAT WERE YOUR DUTIES AS FAR AS

 

12  CONSULTING WITH GERO-PSYCH?

 

13  A.   WHEN PATIENTS WERE ADMITTED, THE INTERNIST ON CALL WOULD

 

14  GET CALLED TO CONSULT ON THOSE PATIENTS AS A MATTER OF

 

15  ROUTINE.

 

16  Q.   WHAT KIND OF CONSULT WAS THAT?  WHAT WERE YOU SUPPOSED

 

17  TO DO?

 

18  A.   IT WAS A MEDICINE CONSULT, SO IT'D BE GATHERING OLD

 

19  INFORMATION REGARDING THE PATIENT'S PAST HISTORY, PAST

 

20  MEDICAL PROBLEMS, HOW THAT WAS RELEVANT, AND BASICALLY IT WAS

 

21  A SUMMARY OF ALL THE PAST INFORMATION INSOFAR AS I HAD

 

22  AVAILABLE, REVIEW OF OLD RECORDS, EXAMINING THE PATIENT, AND

 

23  THEN GIVING AN IMPRESSION THEN ANY ADVICE AT THAT TIME.

 

24  Q.   WERE YOU MAKING ANY ORDERS TO -- FOR MEDICATION OR

 

25  ANYTHING OF THAT SORT AS YOU WERE DOING THE CONSULT?

 

 1  A.   ON OCCASION.  TYPICALLY NOT.  IT WAS MORE OF A -- SORT

 

 2  OF A SUMMARY OF MEDICAL PROBLEMS AND ANY RECOMMENDATIONS THAT

 

 3  I SAW FIT.  I WOULDN'T -- I PROBABLY WOULDN'T TYPICALLY ORDER

 

 4  THINGS, BUT I WOULD ON OCCASION ORDER THINGS AS I SAW THE

 

 5  NEED.

 

 6  Q.   NORMALLY YOU WOULD RECOMMEND?

 

 7  A.   YES.

 

 8  Q.   AND THE UNIT AS FAR AS A MEDICAL TREATMENT ON THE UNIT

 

 9  WAS BEING HEADED UP BY A PSYCHIATRIST, IS THAT CORRECT?

 

10  A.   YES.

 

11  Q.   PSYCHIATRISTS HAVE AN M.D.?

 

12  A.   YES.

 

13  Q.   SO THE PSYCHIATRIST COULD DO MEDICAL DIAGNOSES, IS THAT

 

14  CORRECT?

 

15  A.   OF COURSE.

 

16  Q.   DO YOU KNOW WHY THE UNIT WAS SET UP SO THAT THERE WOULD

 

17  BE A MEDICAL CONSULT BY AN INTERNIST?

 

18  A.   MAY OF THESE PATIENTS WERE ELDERLY AND HAD OTHER PAST

 

19  MEDICAL PROBLEMS, SO IT WAS FELT THAT IT WAS IMPORTANT TO

 

20  REVIEW THOSE PROBLEMS AND DOCUMENT WHAT THEY WERE, HOW THEY

 

21  MIGHT HAVE IMPACTED ON THEIR CURRENT STATUS OR PAST STATUS.

 

22  Q.   I DON'T BELIEVE YOU EVER SAW ELLEN ANDERSON OR LYDIA

 

23  SMITH AT THAT UNIT, DO YOU RECALL?

 

24  A.   I DON'T BELIEVE SO.

 

25  Q.   OKAY.  DO THE NAMES ENNIS ALLDREDGE, MARY CRANE, AND

 

 1  JUDITH LARSEN RING A BELL FOR YOU AT ALL AT THIS POINT?

 

 2  A.   YES.

 

 3  Q.   DO YOU RECALL THEM SPECIFICALLY?

 

 4  A.   JUST FROM REVIEW OF RECORDS, BUT NOT IN SO MUCH OF THE

 

 5  ACTUAL VISITS AT THAT TIME, NO.

 

 6  Q.   YOU DID MORE THAN ONE MEDICAL CONSULT FOR THE GERO-PSYCH

 

 7  UNIT OVER THE COURSE OF TIME IT WAS OPEN?

 

 8  A.   YES.

 

 9  Q.   OKAY.  THANK YOU.  WERE YOU EVER CALLED IF AN ACUTE

 

10  MEDICAL PROBLEM AROSE WITH ANY PATIENTS ON THE GERO-PSYCH

 

11  UNIT?

 

12  A.   YES.

 

13  Q.   IF AN ACUTE MEDICAL PROBLEM THAT NEEDED MEDICAL

 

14  INTERVENTION OCCURRED THAT COULDN'T BE DONE ON THE UNIT, WAS

 

15  THERE ANYWHERE ELSE IN THE HOSPITAL THEY COULD BE TRANSFERRED

 

16  TO?

 

17  A.   YES.  THE REGULAR MEDICAL FLOORS WERE ADJACENT AND VERY

 

18  CLOSE TO GERO-PSYCH UNIT SO THE PATIENTS COULD BE TRANSFERRED

 

19  OR --

 

20  Q.   SO THE INTENSIVE CARE OR CRITICAL CARE UNIT WAS NOT THE

 

21  ONLY OTHER UNIT THEY COULD BE TRANSFERRED TO?

 

22  A.   THAT'S RIGHT.

 

23  Q.   AND WHAT CARE WOULD BE DIFFERENT ON THE MEDICAL UNIT AS

 

24  OPPOSED TO THE GERO-PSYCH UNIT?

 

25  A.   IT WOULD BE IF PROBLEMS ON THE GERO-PSYCHIATRIC UNIT

 

 1  WERE THOSE THAT FELT THEY COULD NOT BE HANDLED, IT WAS

 

 2  DESIGNED MORE TO TREAT THE PSYCHIATRIC PROBLEMS OF THE

 

 3  PATIENT.  THE MEDICAL FLOORS WERE MORE DESIGNED AT TREATING

 

 4  OTHER MEDICAL PROBLEMS AND THE FOCUS WAS DIFFERENT.

 

 5  Q.   DO YOU KNOW WHETHER -- WELL, ON THE MEDICAL FLOOR, IS

 

 6  THERE EASY ACCESS TO OXYGEN?

 

 7  A.   YES.

 

 8  Q.   WAS THERE THE SAME ACCESS ON THE GERO-PSYCH UNIT TO YOUR

 

 9  KNOWLEDGE?

 

10  A.   I BELIEVE THE FLOOR WAS SET UP VERY SIMILARLY IN TERMS

 

11  OF ACCESS TO THINGS, YES.

 

12  Q.   THANK YOU.  WE'LL LOOK AT EXHIBIT 3-B THAT I BELIEVE IS

 

13  IN FRONT OF YOU, AND THESE ARE THE MEDICAL RECORDS FROM DAVIS

 

14  NORTH HOSPITAL OF JUDITH LARSEN.  I'LL DRAW YOUR ATTENTION

 

15  FIRST TO -- PAGE NUMBER WILL BE AT THE BOTTOM OF 453, MED

 

16  453.  AND IT IS BEHIND THE TAB CALLED PHYSICIAN ORDERS, I

 

17  BELIEVE.  ARE YOU THERE WITH ME?  THANK YOU VERY MUCH.  ARE

 

18  YOU FAMILIAR WITH THIS DOCUMENT?

 

19  A.   YES.

 

20  Q.   DOES IT CONTAIN ANY OF YOUR HANDWRITING?

 

21  A.   YES, IT DOES.

 

22  Q.   I'LL BE SETTING THIS UP.  AGAIN, IT'S PAGE 453.

 

23       THE COURT:  DO YOU NEED TO TURN OFF THE LIGHT, MS.

 

24  BARLOW?

 

25  Q.  (BY MS. BARLOW)  THIS IS A DOCUMENT CALLED PHYSICIAN'S

 

 1  ORDERS AND PROGRESS RECORD AT THE TOP.  ARE YOU FAMILIAR WITH

 

 2  THIS DOCUMENT?

 

 3  A.   YES.

 

 4  Q.   WHAT IS THE PURPOSE OF THIS DOCUMENT IN A MEDICAL CHART?

 

 5  A.   IN THIS CASE IT HAS OFF TO THE RIGHT THE PROGRESS NOTES

 

 6  WHERE I MAY HAVE WRITTEN HISTORY AND OTHER INFORMATION, AND

 

 7  THEN ON THE LEFT SIDE IT HAS A PLACE FOR ORDERS WHERE I CAN

 

 8  WRITE ORDERS OR WHO -- THE ATTENDING PHYSICIAN CAN WRITE

 

 9  ORDERS.

 

10  Q.   YOU INDICATE THAT THIS WRITING ON THE RIGHT IS YOURS?

 

11  A.   MOST OF IT IS, YES.

 

12  Q.   OKAY.  I'M SORRY, WE'RE GONNA HAVE TO ASK YOU TO READ IT

 

13  BECAUSE I REALLY HAVE NOT BEEN ABLE TO.  WOULD YOU START AT

 

14  THE TOP AND READ WHAT YOU'VE WRITTEN ON THE RIGHT THERE?

 

15  A.   IMPRESSION NUMBER 1, SEVERE DEMENTIA SLASH CONFUSION.

 

16  Q.   AND WHERE ARE WE HERE?

 

17  A.   OH, I'M SORRY, YOU WANT ME TO START AT THE VERY TOP?

 

18  Q.   IF YOU'D START AT THE VERY TOP, THE DATE --

 

19  A.   I'M SORRY, THE TOP LINE'S NOT MINE.  THE NEXT LINE SAYS

 

20  12/9/95, 8 A.M., MEDICAL CONSULT NOTE.  IN PARENTHESES, ASKED

 

21  TO SEE BY DR. WEITZEL, PARENTHESES.

 

22  Q.   THEN IF YOU'D GO DOWN TO THE NEXT PORTION THERE --

 

23  A.   IT SAYS --

 

24  Q.   -- IMPRESSION.

 

25  A.   YES.  IMPRESSION NUMBER 1, SEVERE DEMENTIA SLASH

 

 1  CONFUSION.

 

 2  Q.   IF YOU'D JUST READ ON DOWN THERE.

 

 3  A.   NUMBER 2, HISTORY OF C.V.A. 1/95.  NUMBER 3, HISTORY OF

 

 4  ISCHEMIC HEARTS DISEASE WITH ANGINA.  NUMBER 4,

 

 5  HYPOTHYROIDISM --

 

 6       THE COURT:  DOCTOR, COULD WE ASK YOU TO SPEAK UP PLEASE.

 

 7       THE WITNESS:  NUMBER 4, HYPOTHYROIDISM.  STATUS POST

 

 8  THYROIDECTOMY.  NUMBER 5, STATUS POST MULTIPLE FALLS --

 

 9       THE COURT:  DOCTOR, IF YOU'LL SLOW DOWN JUST A LITTLE.

 

10       THE WITNESS:  NUMBER 6, CARDIOMEGALY.  NUMBER 7, STATUS

 

11  POST HYSTERECTOMY.  NUMBER 8, STATUS POST NEPHROLITHIASIS.

 

12  NUMBER 9, PROBABLE ORAL THRUSH.  NUMBER 10, LARGE HIATAL

 

13  HERNIA.  HISTORY OF GASTROESOPHAGEAL REFLUX DISEASE.  NUMBER

 

14  11, DECREASED ALBUMIN.  INCREASED GLOBULINS.  NUMBER 12, A

 

15  QUESTIONABLE DECREASED OXYGEN SATURATION ON ADMIT.  NUMBER

 

16  13, HISTORY OF INCREASED GLUCOSE, 995.

 

17  Q.  (BY MS. BARLOW)  SO THOSE WERE IMPRESSIONS THAT YOU GOT

 

18  FROM WHAT BASICALLY?

 

19  A.   THAT WAS FROM A REVIEW OF THE PAST RECORD, ANY PAST

 

20  RECORD I HAD TO REVIEW AT THAT TIME.

 

21  Q.   AS PEOPLE WERE ADMITTED TO THE GERO-PSYCH UNIT, ARE YOU

 

22  AWARE WHETHER THE NURSING HOME OR WHATEVER PRIOR DOCTOR THAT

 

23  PERSON WAS SEEING WOULD SUPPLY ANY HISTORY IN THAT FASHION?

 

24  A.   I -- I DON'T KNOW THE MECHANISM THEREOF, BUT THERE WAS

 

25  OFTEN RECORDS AVAILABLE.  THERE WAS OFTEN NOT RECORDS

 

 1  AVAILABLE, IN MY RECOLLECTION.  IF I HAD RECORDS, THEN I

 

 2  WOULD ALWAYS REVIEW THOSE RECORDS.

 

 3  Q.   AND THAT'S WHAT YOU WOULD PUT ON YOUR IMPRESSIONS?

 

 4  A.   BY AND LARGE, YES.

 

 5  Q.   AND THEN THE ORAL THRUSH, WHAT IS THAT?

 

 6  A.   THAT'S JUST AN ORAL YEAST INFECTION (UNINTELLIGIBLE)

 

 7  CANDIDA.

 

 8  Q.   WOULD THAT HAVE COME FROM PREVIOUS RECORDS?

 

 9  A.   IT -- LET'S SEE, WHERE WAS THAT.  THAT WAS LIKELY FROM

 

10  MY EXAMINATION.

 

11  Q.   SO IN ADDITION TO REVIEWING RECORDS, YOU WOULD DO AN

 

12  EXAM?

 

13  A.   YES.

 

14  Q.   AND THEN UNDERNEATH THE IMPRESSIONS, WHAT HAVE YOU

 

15  WRITTEN?

 

16  A.   SAYS, RECOMMENDATIONS, NUMBER 1, THERAPY OF ORAL THRUSH

 

17  WITH NYSTATIN.  NUMBER 2, SERUM PROTEIN ELECTROPHORESIS.

 

18  SCREEN FOR MONOCLONAL GAMMOPATHY.  AFTER THAT, FEW LINES DOWN

 

19  IT SAYS, ELDERLY FEMALE WITH INCREASING DEMENTIA SINCE 1/95.

 

20  COMMA C.V.A.  APPARENTLY LIVING IN A RETIREMENT CENTER IN

 

21  7/95.  WORSENED OVER THE PAST THREE WEEKS.  CERTAINLY

 

22  COMPONENT OF DEMENTIA MAY BE DUE TO MULTI-INFARCTS.  CARDIAC

 

23  FAILURE APPEARS TO BE COMPENSATED.  QUESTIONABLE INTERMITTENT

 

24  DECREASED OXYGEN SATURATION.  AND I HAVE A NOTE THAT LABS,

 

25  THYROID FUNCTION DECREASED ALBUMIN INCREASED GLOBULIN NOTED.

 

 1  CHEST X-RAYS INCREASED CORE.  POSITIVE HIATAL HERNIA.  NO

 

 2  INFILTRATES.  E.K.G. SINUS COMMA QUESTIONABLE ECTOPIC FOCUS

 

 3  REST PER DICTATION THANKS DIENHART.

 

 4  Q.   DID YOU WRITE ANY ORDERS AFTER YOU DID THIS EVALUATION?

 

 5  A.   THERE IS SOME ORDERS AT THE TOP OF THAT PAGE IN THE

 

 6  LEFT-HAND COLUMN.

 

 7  Q.   LEFT-HAND SIDE?  WHAT ORDERS DID YOU WRITE?

 

 8  A.   NUMBER 1, NYSTATIN SWAB TO MOUTH, TONGUE Q.I.D. OR

 

 9  NYSTATIN 10 C.C.'S SWISH AND SPIT Q.I.D.  AND NEXT WEEK.

 

10  NEXT ONE IS SERUM ELECTROPHORESIS.  AND THE NEXT ONE IS

 

11  OXYGEN SATURATION.  CHECK AT H.S. WHILE SLEEPING.  THE NEXT

 

12  ONE IS GLYCOSYLATED HEMOGLOBIN.

 

13  Q.   SO YOU ORDERED SOME LABS AND SOME DIFFERENT TESTS TO BE

 

14  RUN IN ADDITION TO THE NYSTATIN?

 

15  A.   YES.

 

16  Q.   AFTER YOU WROTE THIS IN THE PROGRESS REPORT, DID YOU

 

17  PREPARE A REPORT OF CONSULTATION?

 

18  A.   YES, I WOULD HAVE DICTATED A CONSULTATION NOTE.

 

19  Q.   AND HOW WOULD YOU DICTATE THAT?

 

20  A.   ON THE PHONE SYSTEM.

 

21  Q.   PICK UP THE PHONE, DIAL IN THE NUMBER?

 

22  A.   YES.

 

23  Q.   THIS IS PAGE -- WE'LL BE DEALING WITH PAGES 447 THROUGH

 

24  450.  IS THIS WHAT YOU DICTATED THEN AFTER YOUR EVALUATION?

 

25  A.   YES.

 

 1  Q.   ON PAGE 447.  DID YOU GO INTO ANY MORE DETAIL IN HERE

 

 2  THAN YOU DID IN YOUR WRITTEN NOTES ABOUT WHAT YOUR

 

 3  IMPRESSIONS WERE, WHAT YOU SAW, THE HISTORY, THAT SORT OF

 

 4  THING?

 

 5  A.   YES.

 

 6  Q.   WHAT DID YOU LIST AS THE REASON FOR CONSULTATION?

 

 7  A.   EVALUATION OF MEDICAL PROBLEMS.

 

 8  Q.   AND YOU INDICATE THAT ADMISSION IS FOR WORSENED

 

 9  DEMENTIA, PROVISIONAL PSYCHOSIS.  WERE YOU AWARE THAT THIS

 

10  WAS AN ACUTE EVENT OR A RECENT PROBLEM OR A WORSENING OF A

 

11  CHRONIC PROBLEM?

 

12  A.   JUST FROM WHAT I GLEANED FROM MY HISTORY JUST NOW, I

 

13  GATHERED IT WAS A WORSENING PROBLEM OF SOME LENGTH OF TIME,

 

14  BUT I WASN'T REALLY EVALUATING THAT.

 

15  Q.   YOU LIST THE HISTORY THEN.  YOU INDICATE HER PAST

 

16  MEDICAL HISTORY, REMARKABLE FOR CEREBROVASCULAR ACCIDENTS.

 

17  WHAT ARE THOSE?

 

18  A.   SUCH AS A STROKE.

 

19  Q.   AND THEN UNDER PAST MEDICAL HISTORY, WOULD YOU READ THAT

 

20  SECOND PARAGRAPH FOR US?

 

21  A.   ON EXAMINATION TODAY THE PATIENT DOES NOT COMMUNICATE --

 

22       THE COURT:  SLOW DOWN PLEASE, DOCTOR.

 

23       THE WITNESS:  I'LL START OVER.  ON EXAMINATION TODAY THE

 

24  PATIENT DOES NOT COMMUNICATE.  SHE DOES NOT VERBALLY COMPLAIN

 

25  OF ANY PAIN.

 

 1  Q.  (BY MS. BARLOW)  THEN YOU LIST ALL THE MEDICATIONS SHE IS

 

 2  ON.  DID YOU GET THAT FROM THE NURSING HOME OR FROM PRIOR

 

 3  RECORDS?

 

 4  A.   I WOULD HAVE GOT IT FROM LIKELY THE PRIOR RECORDS OR I

 

 5  MAY HAVE GOTTEN IT FROM ORDERS THAT WERE ALREADY WRITTEN IN

 

 6  THE CHART, ONE OF THE TWO.

 

 7  Q.   FOR EXAMPLE, PAGE 451, THERE IS A LIST OF ORDERS ON THE

 

 8  DAILY ORDERS.  WOULD YOU HAVE RECEIVED IT FROM THERE?

 

 9  A.   IT LOOKS LIKE I VERY WELL COULD HAVE, YES.  IT DOES LOOK

 

10  THAT WAY.

 

11  Q.   NOW THIS APPEARS TO BE WRITTEN ON THE 6TH OF DECEMBER,

 

12  1995.  WOULD YOU ASSUME THAT WAS UPON ADMIT?

 

13  A.   YES.  THE -- WHICH ARE YOU -- MY CONSULT?

 

14  Q.   451, NO, THE PHYSICIAN ORDERS THAT WE WERE TALKING

 

15  ABOUT.

 

16  A.   YES.  THAT'S DATED 12/6/95 AT THE TOP.

 

17  Q.   AND IT HAS UNDER 12/6/95, V.O. DR. WEITZEL TO LYNN LONG

 

18  R.N.?

 

19  A.   YES.

 

20  Q.   WHAT DOES THAT LINE MEAN?

 

21  A.   VERBAL ORDER DR. WEITZEL TO LYNN LONG, R.N.

 

22  Q.   AND DOWN BELOW IT LOOKS LIKE IT'S BEEN SIGNED BY

 

23  DR. WEITZEL, IS THAT CORRECT?

 

24  A.   AS FAR AS I KNOW HIS SIGNATURE.

 

25  Q.   OKAY.  IS THAT AN UNUSUAL WAY OF ORDERS BEING WRITTEN ON

 

 1  HERE, WRITTEN ON A DAILY ORDER?

 

 2  A.   NO.

 

 3  Q.   HOW WOULD -- WELL, I GUESS -- IF YOU WERE TO TELEPHONE

 

 4  IN AN ORDER FOR A PATIENT, WHAT WOULD YOU DO THE NEXT TIME

 

 5  YOU WENT INTO THE HOSPITAL TO THAT PATIENT'S CHART?

 

 6  A.   I WOULD SIGN THE ORDERS AND I MIGHT WRITE MORE ORDERS.

 

 7  I MIGHT WRITE A NOTE, YOU KNOW, WHATEVER I WOULD -- IF IT WAS

 

 8  THE FIRST TIME, YOU'D PROBABLY DICTATE A CONSULT OR IF YOU

 

 9  WERE THE ATTENDING, YOU'D DICTATE THE HISTORY AND PHYSICAL OR

 

10  THAT.

 

11  Q.   BUT YOU WOULD SIGN IT INDICATING YOU DID VERIFY THAT

 

12  YOU -- YOU'RE VERIFYING BASICALLY THAT YOU DID GIVE THAT

 

13  ORDER?

 

14  A.   YES.

 

15  Q.   IF YOU WOULD TURN TO PAGE 448, THIS IS FURTHER --

 

16  FURTHER ON IN YOUR REPORT OF CONSULTATION.  YOU DID A

 

17  PHYSICAL EXAMINATION OF MRS. LARSEN, IS THAT CORRECT?

 

18  A.   YES.

 

19  Q.   WHAT DID YOU FIND IN GENERAL?

 

20  A.   THAT SHE WAS A THIN LADY THIN THAT WAS -- THAT HAD BEEN

 

21  OBSERVED TO AMBULATE WITH A VERY SMALL GAIT, SHUFFLE, AND

 

22  WITH ASSISTANCE.  HER VITAL SIGNS APPEARED TO BE FAIRLY

 

23  UNREMARKABLE.  THE REST OF THE EXAM FROM WHAT I CAN TELL WAS

 

24  NOT VERY -- WAS NOT REMARKABLE.

 

25  Q.   SO YOU SAW -- DID YOU SEE ANY --

 

 1  A.   APART FROM THE EARLY YEAST INFECTION IN THE MOUTH.

 

 2  Q.   THE YEAST INFECTION.  DID YOU SEE ANY MEDICAL REASON FOR

 

 3  HER NOT TO BE ADMITTED TO THE UNIT?

 

 4  A.   NO.

 

 5  Q.   THEN ON PAGE 449, THERE WAS A CHEST X-RAY GIVEN, IS THAT

 

 6  CORRECT?

 

 7  A.   YES.

 

 8  Q.   AND WAS THERE ANYTHING ABNORMAL ABOUT THAT CHEST X-RAY?

 

 9  A.   I SAID HER HEART WAS ENLARGED.  THAT'S WHAT THE TERM

 

10  CARDIOMEGALY MEANS.  AND THERE WAS PROBABLY A LARGE HIATAL

 

11  HERNIA.  AND THE LUNGS APPEARED CLEAR.

 

12  Q.   WAS THERE ANYTHING IMMEDIATELY LIFE-THREATENING ABOUT

 

13  WHAT YOU SAW IN THE CHEST X-RAY?

 

14  A.   NO.

 

15  Q.   THEN YOU WROTE YOUR IMPRESSIONS WHICH I BELIEVE THAT

 

16  YOU'VE JUST GONE THROUGH IN YOUR HANDWRITTEN PART.  IS THERE

 

17  ANYTHING DIFFERENT IN YOUR DICTATION THAN WHAT YOU HAD IN

 

18  YOUR HANDWRITTEN PART?

 

19  A.   I'LL HAVE TO REVIEW -- ALWAYS PERHAPS A BIT MORE

 

20  DESCRIPTIVE IN THE TYPEWRITTEN FORM.  CAN DICTATE MORE RATHER

 

21  THAN WRITE.  WHEN I WRITE IT DOWN, I'M VERY BRIEF AND TO THE

 

22  POINT.

 

23  Q.   PARTICULARLY ON PAGE 450, I'D LIKE YOU TO LOOK AT NUMBER

 

24  11 OF YOUR IMPRESSIONS.  WOULD YOU READ THAT AND MAYBE

 

25  EXPLAIN IT A LITTLE FURTHER?

 

 1  A.   I HAVE TO READ IT FIRST.  IT SAYS, HYPOALBUMINEMIA,

 

 2  HYPERGAMMAGLOBULINEMIA --

 

 3       THE COURT:  SLOW DOWN, DOCTOR.

 

 4       THE WITNESS:  I'LL START AGAIN.  HYPOALBUMINEMIA COMMA

 

 5  HYPERGAMMAGLOBULINEMIA COMMA ETIOLOGY OF INCREASED GLOBULIN

 

 6  FRACTION UNCLEAR COMMA MAY BE SECONDARY TO INFLAMMATORY

 

 7  PROCESS OR UNCONTROLLED GLUCOSE OR EVIDENCE OF A MONOCLONAL

 

 8  GAMMOPATHY.  THERE'S A TYPO THERE.  SNF THAT ESSENTIALLY

 

 9  MEANS I NOTED THE PATIENT'S ALBUMIN WAS A LITTLE BIT LOW,

 

10  WHICH WAS 3.3, AND THAT'S REALLY ONLY MILDLY LOW.  AND WITH

 

11  THE TOTAL PROTEIN BEING IN THE NORMAL RANGE, IT GAVE HER

 

12  GLOBULIN FRACTION A SLIGHT ELEVATION.

 

13  Q.  (BY MS. BARLOW)  DID YOU SEE ANY REASON TO RECOMMEND

 

14  SOMETHING TO CHECK TO SEE IF IT'S AN INFLAMMATORY PROCESS OR

 

15  UNCONTROLLED GLYCOSE?

 

16  A.   I DID ORDER I THINK A SERUM ELECTRIC -- SERUM PROTEIN

 

17  ELECTROPHORESIS, YES.

 

18  Q.   DID YOU HAVE ANY -- DID YOU GET ANY REPORTS OF

 

19  SUBSEQUENT TO THIS THAT THAT -- LET ME BACK UP A MINUTE.  YOU

 

20  THEN HAVE WRITTEN RECOMMENDATIONS.  NOW, YOU DID ORDER

 

21  NYSTATIN FOR THE ORAL THRUSH.  YOU DID ORDER THE

 

22  ELECTROPHORESIS?

 

23  A.   YES.

 

24  Q.   DO YOU KNOW WHETHER THOSE WERE DONE?

 

25  A.   I WOULD ASSUME THEY WERE DONE, BUT I DO NOT HAVE THAT --

 

 1  UNLESS FROM THE MEDICAL RECORDS, I COULD LOOK AT IT FOR YOU.

 

 2  Q.   ON NUMBER 3, IS THAT ANOTHER TEST THAT YOU RECOMMENDED

 

 3  OR ORDERED?

 

 4  A.   GLYCOSYLATED HEMOGLOBIN, YES, IT IS.

 

 5  Q.   DID YOU PERSONALLY EVER RECEIVE A REPORT BACK FROM THESE

 

 6  TESTS BEING DONE?

 

 7  A.   IT'S -- IT WAS THE HABIT AT THE HOSPITAL TO SEND COPIES

 

 8  OF ALL LAB REPORTS TO OUR OFFICE.

 

 9  Q.   DID YOU ORDER -- DID YOU FIND ANYTHING FROM THAT REPORT

 

10  THAT CAUSED YOU TO SAY, YOU KNOW, THIS IS LIFE-THREATENING, I

 

11  NEED TO FOLLOW UP AND DO SOMETHING WITH THIS?

 

12  A.   NO, I DON'T BELIEVE SO.

 

13  Q.   IF WE WOULD TURN NOW TO PAGE 462 IN THE MEDICAL RECORDS,

 

14  THE DAVIS NORTH HOSPITAL RECORDS.  DO YOU RECALL A TIME WHEN

 

15  YOU RECEIVED A PHONE CALL FROM THE NURSES INDICATING THAT

 

16  THERE WAS A PROBLEM WITH MRS. LARSEN?

 

17  A.   YES.

 

18  Q.   AND WHERE DID THAT PHONE CALL ORIGINATE, DO YOU KNOW?

 

19  A.   FROM THE NURSING STATION.

 

20  Q.   WHAT IF ANYTHING WERE YOU TOLD ABOUT HER CONDITION?

 

21  A.   THAT SHE WAS HAVING A SEIZURE OR JUST HAD A SEIZURE.

 

22  Q.   DID YOU DO ANYTHING WITH THAT INFORMATION?

 

23  A.   YES.  I ORDERED SOME MEDICATION TO STOP SEIZURES OR STOP

 

24  RECURRENT SEIZURES AND THEN I CAME IN IMMEDIATELY TO EVALUATE

 

25  HER.

 

 1  Q.   NOW, IT APPEARS AT THE TOP HERE THAT IT WAS 12/26/95.

 

 2  AND IT SAYS, 0605.  WHAT IS THAT?

 

 3  A.   THAT'S THE DATE AND THE TIME.

 

 4  Q.   THAT THE NURSE CALLED YOU?

 

 5  A.   I -- I --

 

 6  Q.   OR YOU -- YOU GAVE --

 

 7  A.   -- I -- I'M ASSUMING THAT'S --

 

 8  Q.   -- A NOTE BECAUSE IT TAKES T.O.  WHAT DOES THAT MEAN?

 

 9  A.   COULD YOU REPEAT THAT PLEASE?

 

10  Q.   UNDER THE DATE AND TIME IT SAYS T.O., DR. DIENHART.

 

11  A.   I DON'T KNOW WHAT T.O. REFERS TO.

 

12  Q.   AND THEN IT SAYS IV D5

 

13  A.   IT MIGHT -- IT MIGHT MIGHT REFER TO TELEPHONE ORDER IN

 

14  MAYBE THAT NURSE'S DESCRIPTION OF THAT.

 

15  Q.   DID YOU ORDER THEN I V  D 5?

 

16  A.   YES.

 

17  Q.   WHAT IS THAT?

 

18  A.   IT'S JUST A SOLUTION THAT HAS A DEXTROSE IN IT, IN THE

 

19  VEIN.

 

20  Q.   ON THE -- EXCUSE ME.

 

21  A.   IT'S JUST AN I.V. SOLUTION CONTAINING DEXTROSE, 5

 

22  PERCENT.

 

23  Q.   OKAY.  AND THEN UNDER THAT IS ATIVAN I.V., TITRATE.

 

24  EXCUSE ME.

 

25  A.   SAYS ATIVAN I.V. TITRATE 1 TO 3 MILLIGRAMS OVER FIVE

 

 1  MINUTES UNTIL SEIZURE STOPPED.

 

 2  Q.   IS THAT WHAT YOU ORDERED?

 

 3  A.   YES.

 

 4  Q.   DID YOU THEN GO IN TO SEE MRS. LARSEN?

 

 5  A.   YES.

 

 6  Q.   DO YOU RECALL WHAT TIME THAT WAS?  OR CAN YOU TELL FROM

 

 7  THE NOTE?

 

 8  A.   YES.  MY -- I MEAN I MAY HAVE BEEN THERE BEFORE THAT,

 

 9  BUT MY -- MY NOTE IS TIMED AT 0650 A.M. WHEN I WROTE THE

 

10  NOTE.

 

11  Q.   AND CAN YOU AGAIN -- SORRY, BUT CAN YOU AGAIN READ IT

 

12  FOR US?

 

13  A.   YES.  IT SAY, MEDICAL CONSULT NOTE.  ASKED TO SEE BY

 

14  DR. WEITZEL.  93-YEAR-OLD FEMALE ADMITTED 12/26 TO THE

 

15  GERO-PSYCH UNIT FOR INCREASE --

 

16       THE COURT:  SLOW DOWN PLEASE.

 

17       THE WITNESS:  I'M SORRY.  I'LL REPEAT.  93-YEAR-OLD

 

18  FEMALE ADMITTED 12/26/95 TO THE GERO-PSYCH UNIT FOR INCREASED

 

19  DEMENTIA.  PAST MEDICAL HISTORY, SIGNIFICANT PAST C.V.A.

 

20  CALLED TO SEE FOR NURSING WITNESSED TONIC/CLONIC SEIZURE TOTAL

 

21  DURATION 40 TO 45 MINUTES.  RELIEVED AFTER ATIVAN 4

 

22  MILLIGRAMS SLOW I.V.  DESCRIBED RIGHT ARM AND RIGHT LEG AND

 

23  RIGHT FACIAL JERKING.  NOTE, RISPERDAL, SERZONE, THYROID

 

24  TREATMENT.  NOW APPARENTLY POST ICTAL DURING SEIZURE.  ONE

 

25  SIXTY OVER ONE HUNDRED NINETY-TWO NOW DURING DILANTIN,

 

 1  MEANING THE DILANTIN INFUSION, THE BLOOD PRESSURE WAS 104

 

 2  OVER 60.  MOUTH DECREASED GAG.  POOR LOWER DENTITION.  NO

 

 3  VISIBLE BLEEDING.  LUNGS DECREASED BREATH SOUNDS.  ABDOMEN

 

 4  SOFT.  NEURO TWO PLUS EQUIVALENT BICEP IN BICEPS AND KNEES --

 

 5  Q.   LET'S --

 

 6  A.   -- REFLEXES --

 

 7  Q.   LET'S STOP THERE.  WHAT HAD THE NURSE TOLD YOU HAD

 

 8  HAPPENED WITH MRS. LARSEN?

 

 9  A.   THAT THE PATIENT HAD A SEIZURE ESSENTIALLY.

 

10  Q.   WHAT A TONIC/CLONIC SEIZURE?

 

11  A.   IT JUST MEANS A SHAKING OF THE EXTREMITIES, SORT OF A

 

12  PULSE LIKE FASHION.  A RAPID JERKING OFTENTIMES.  THERE CAN

 

13  BE DEVIATION OF THE EYES OR THE TONGUE.  THEY'RE TYPICALLY

 

14  UNCONSCIOUS.  UNAWARE OF WHAT'S GOING ON AND --

 

15  Q.   DO YOU KNOW IF THAT'S UNCOMFORTABLE TO THE PERSON HAVING

 

16  THE SEIZURE?

 

17  A.   PROBABLY NOT WHILE THEY'RE HAVING THE SEIZURE BECAUSE

 

18  THEY'RE UNCONSCIOUS AND NOT AWARE OF THAT.

 

19  Q.   WHAT ABOUT POST SEIZURE?

 

20  A.   POST SEIZURE IS WHEN SOMEONE WAKES UP, THEY'RE TYPICALLY

 

21  VERY GROGGY IN A POST SEIZURE-LIKE STATE FOR FIVE MINUTES TO

 

22  30 MINUTES, SOMETIMES MORE.

 

23  Q.   DID YOU ORDER ANYTHING OTHER THAN THE ATIVAN FOR THE

 

24  SEIZURE?

 

25  A.   I ORDERED DILANTIN.

 

 1  Q.   WHAT IS DILANTIN?

 

 2  A.   IT'S ANOTHER SEIZURE MEDICATION.

 

 3  Q.   HOW IS IT ADMINISTERED?

 

 4  A.   INTRAVENOUSLY.  IT ALSO CAN BE GIVEN BY MOUTH, BUT IN

 

 5  THAT SETTING, WE GAVE IT INTRAVENOUSLY, I BELIEVE.

 

 6  Q.   DID YOU AT THAT POINT KNOW WHAT HAD CAUSED THIS SEIZURE?

 

 7  A.   NO.  WITH HER HISTORY OF A PRIOR STROKE, IT WAS LIKELY

 

 8  THERE WAS SOME FOCUS THAT WAS POORLY PERFUSED OR A FOCUS FOR

 

 9  A POTENTIAL SEIZURE.

 

10  Q.   WHAT DOES FOCUS POORLY PERFUSED MEAN?

 

11  A.   MAYBE THERE WAS DECREASED BLOOD SUPPLY TO THAT AREA OF

 

12  THE BRAIN AND IT SET OFF A SEIZURE.

 

13  Q.   WHAT DID YOU WRITE HERE UNDER IMPRESSION?

 

14  A.   GENERALIZED SEIZURE SLASH POST ICTAL, JUST MEANS POST --

 

15  POST SEIZURE.  RIGHT-SIDED ACTIVITY RULED OUT.  RULE OUT LEFT

 

16  EVENT.

 

17  Q.   WHAT DO YOU MEAN BY RULE OUT LEFT EVENT?

 

18  A.   MAYBE A LEFT HEMISPHERIC FOCUS WITH THE SEIZURE, LEFT

 

19  STROKE.  MAYBE THERE WAS AN OLD LEFT STROKE AND NOW IT WAS

 

20  THE FOCUS FOR THE EVENT.

 

21  Q.   BECAUSE LEFT SIDE IS WHAT CAUSES PROBLEMS ON THE RIGHT

 

22  SIDE OF THE -- THE BRAIN IS JUST OPPOSITE, I GUESS OF --

 

23  A.   OFTENTIMES.

 

24  Q.   AND THEN YOU RECOMMENDED CERTAIN THINGS.  WHAT DID YOU

 

25  RECOMMEND?

 

 1  A.   OXYGEN SATURATION AND OXYGEN TO BE DELIVERED AT 2 LITERS

 

 2  PER NASAL CANULA.  TITRATE THE OXYGEN SATURATION TO GREATER

 

 3  THAN OR EQUAL TO 90 PERCENT.  INTRAVENOUS D 5 HALF NORMAL

 

 4  SALINE AT 70 C.C.'S PER HOUR WITH THE DILANTIN INFUSION.

 

 5  DILANTIN 1 GRAM I.V. LOAD OVER 40 MINUTES IN NORMAL SALINE

 

 6  LINE.  AND THEN 100 MILLIGRAMS I.V. EVERY EIGHT HOURS.  AN

 

 7  E.K.G., CHEMISTRY PANEL, C.B.C., C.T. SCAN OF THE HEAD.

 

 8  DILANTIN LEVEL.  AND THEN BLOOD PRESSURE CHECKS DURING THE

 

 9  DILANTIN INFUSION AS A CON --

 

10  Q.   THESE ARE THE ORDERS THAT YOU WROTE ON --

 

11  A.   YES.

 

12  Q.   -- THE LEFT SIDE.  WHAT WAS YOUR PURPOSE IN ORDERING

 

13  THESE THINGS?

 

14  A.   TO TRY AND CONTROL THE RECENT SEIZURE AND TRY AND

 

15  PREVENT MORE SEIZURES FROM OCCURRING.

 

16  Q.   DOWN HERE IN YOUR PROGRESS NOTES YOU HAD WRITTEN

 

17  RECOMMENDATIONS.  WHAT WERE YOU RECOMMENDATIONS?

 

18  A.   RULE OUT C.V.A. NEW EVENT WITH C.T. SCAN TRYING TO

 

19  EXCLUDE -- MAYBE THERE WAS AN ACUTE BLEED OR A REASON FOR

 

20  THAT SEIZURE TO OCCUR AT THAT POINT.  OR IS IT JUST THE OLD

 

21  FOCUS OF AN OLD STROKE REGION.  AND THEN I PUT DOWN MAINTAIN

 

22  DILANTIN AT 100 MILLIGRAMS T.I.D. FOR NOW.  TRY AND PREVENT

 

23  MORE FUTURE EVENTS GIVEN THE RECENT SEIZURE.  OXYGEN AS

 

24  NEEDED.  CHECK FOR E.K.G.  ELECTROLYTE IS WITH THE LABS AND

 

25  THE E.K.G.

 

 1  Q.   DO YOU PERSONALLY KNOW WHETHER ANY OF THESE THINGS WERE

 

 2  DONE?  WAS IT REPORTED TO YOU -- I GUESS I'LL PUT IT THAT

 

 3  WAY.  WAS IT EVER REPORTED TO YOU THAT ANY OF THESE TESTS OR

 

 4  SCANS WERE DONE?

 

 5  A.   I'M SURE I CALLED BACK AND CHECKED ON IT.

 

 6  Q.   NOW, IF THIS WAS AT 6:50 IN THE MORNING, YOU HAD

 

 7  INDICATED YOU WANTED THE DILANTIN TO CONTINUE FOR NOW TO

 

 8  FORESTALL ANY FURTHER STROKES, IS THAT WHAT YOU SAID?

 

 9  A.   TO -- TO TRY AND PREVENT MORE SEIZURE ACTIVITY

 

10  FROM ACUTELY OCCURING --

 

11  Q.   EXCUSE ME, I MEANT -- I DIDN'T MEAN STROKES.  I'M SORRY.

 

12  I MISSPOKE.  THIS IS PAGE 463.  UP AT THE TOP APPEARS TO BE A

 

13  TELEPHONE ORDER ON 12/26/95 ON PAGE 463?

 

14  A.   YES, I SEE THAT.

 

15  Q.   AND NUMBER 2 SAYS WHAT?

 

16  A.   STOP I.V. THERAPY.

 

17  Q.   AND UNDERNEATH, IT SAYS NOTED 12/26/95, LOOKS LIKE 0800.

 

18  DO YOU KNOW WHAT THAT MEANS?

 

19  A.   I'M SORRY, YOU'LL HAVE TO SHOW ME WHERE YOU'RE REFERRING

 

20  TO ON THAT SECOND --

 

21       MS. BARLOW:  IF I MAY APPROACH, YOUR HONOR?

 

22       THE COURT:  MAY.

 

23  Q.  (BY MS. BARLOW)  RIGHT THERE.

 

24  A.   OKAY.  THAT WAS AN ORDER GIVEN BY DR. WEITZEL AT -- I

 

25  WOULD ASSUME APPROXIMATELY THAT TIME AND THE NURSE SIGNED IT

 

 1  UNDERNEATH IT, I WOULD ASSUME.

 

 2  Q.   WITH THE I.V. THERAPY STOPPED, WAS THE DILANTIN

 

 3  CONTINUING?

 

 4  A.   I WROTE TWO ORDERS.  ONE FOR I.V. FLUID AND ONE FOR I.V.

 

 5  DILANTIN.  SO THAT DOESN'T SAY ANYTHING ABOUT DILANTIN THAT I

 

 6  CAN SEE.

 

 7  Q.   BUT THE I.V. DILANTIN WAS NO LONGER BEING ADMINISTERED.

 

 8  A.   I DON'T KNOW THAT.  IT MAY HAVE ALREADY BEEN GIVEN.  IT

 

 9  WAS A LOAD OVER A CERTAIN AMOUNT OF TIME.  SO IT MAY HAVE

 

10  ALREADY BEEN COMPLETED.  I DON'T KNOW.

 

11  Q.   DOWN AT THE BOTTOM OF THAT PAGE, IT SAYS 12/29.  D.

 

12  SLASH C. DILANTIN.

 

13  A.   YES.

 

14  Q.   WHAT DOES D. SLASH C. MEAN?

 

15  A.   THAT MEANS DISCONTINUE.

 

16  Q.   BUT YOU DON'T HAVE ANY PERSONAL KNOWLEDGE OF WHEN THE

 

17  DILANTIN WAS ACTUALLY DISCONTINUED.

 

18  A.   BY THE ORDERS I SEE, I WOULD ASSUME IT WAS DISCONTINUED

 

19  ON 12/29.

 

20  Q.   NOW, THERE WAS A C.T. SCAN -- IF YOU WILL TURN TO PAGE

 

21  489 -- DONE OF MRS. LARSEN ON THE 26TH OF DECEMBER.  AND THIS

 

22  IS THE REPORT OF THAT C.T. SCAN.  WOULD YOU HAVE RECEIVED A

 

23  COPY OF THAT REPORT?

 

24  A.   I MIGHT NOT HAVE BECAUSE IT SAYS IT WENT TO DR. WEITZEL

 

25  AT THE TOP.  BUT IF I ORDERED THE CAT SCAN, I WOULD HAVE

 

 1  CHECKED ON IT LATER THAT MORNING TO FIND OUT THE RESULT.  BUT

 

 2  I MAY HAVE NOT GOT A COPY OF THIS REPORT, SO I CAN'T TELL YOU

 

 3  THAT MY OFFICE GOT THAT.

 

 4  Q.   SO THIS IS WHAT THE RADIOLOGIST HAS READ OF THE C.T.

 

 5  SCAN, IS THAT CORRECT?

 

 6  A.   YES.

 

 7  Q.   AND IS THAT TYPICAL, YOU DON'T USUALLY READ THE C.T.

 

 8  SCANS, YOU HAVE A RADIOLOGIST DO IT?

 

 9  A.   ABSOLUTELY.

 

10  Q.   THAT'S THEIR EXPERTISE?

 

11  A.   RIGHT.

 

12       MR. BUGDEN:  COUNSEL, EXCUSE ME, COULD YOU TELL ME WHAT

 

13  NUMBER THAT WAS?

 

14       MS. BARLOW:  THAT NUMBER, THANK YOU, IS 489.

 

15       MR. BUGDEN:  THANK YOU.

 

16  Q.  (BY MS. BARLOW)  UNDER CLINICAL HISTORY, PSYCHOSIS.  RULE

 

17  OUT BLEED.  WHAT DOES RULE OUT BLEED MEAN?

 

18  A.   A STROKE WHERE THERE MAY HAVE BEEN INTRACEREBRAL

 

19  BLEEDING.  BLOOD IN THE BRAIN OR AROUND THE BRAIN OR SUBDURAL

 

20  ON A SUBARACHNOID OR INTRACEREBRAL HEMORRHAGE FROM A STROKE.

 

21  Q.   SO A STROKE CAN OR CANNOT HAVE A HEMORRHAGE, IS THAT

 

22  CORRECT?

 

23  A.   THAT'S CORRECT.

 

24  Q.   AND WOULD YOU TREAT IT DIFFERENTLY IF THERE WERE

 

25  HEMORRHAGING, BLEEDING WITHIN THE BRAIN THAN --

 

 1  A.   YOU --

 

 2  Q.   -- YOU WOULD IF IT WERE NOT?

 

 3  A.   YOU MIGHT OR MIGHT NOT, BUT THE -- IT -- IT WOULD -- IT

 

 4  WOULD SET YOU THINKING DIFFERENTLY, SO YES.

 

 5  Q.   WOULD YOU READ THAT FIRST PARAGRAPH UNDER CLINICAL

 

 6  HISTORY FOR US?

 

 7  A.   MULTIPLE AXIAL SCANS OBTAINED OF THE HEAD WITHOUT I.V.

 

 8  CONTRAST.  VENTRICLES AND SULCI ARE VERY PROMINENT,

 

 9  CONSISTENT WITH CEREBRAL ATROPHY.  ALSO IDENTIFIED IS SOME

 

10  DECREASED DENSITY IN THE LEFT FRONTAL LOBE WHICH MAY REFLECT

 

11  A SUBACUTE INSULT SLASH C.V.A.

 

12  Q.   WHAT DOES THAT MEAN TO YOU AS A DOCTOR?

 

13  A.   THAT THE -- THERE'S ATROPHY OF THE BRAIN AND THE

 

14  RADIOLOGIST BELIEVES THERE MAY BE A STROKE, BUT HE'S NOT SURE

 

15  OF THE AGE, IF IT'S OLD OR NEW OR IT WAS IN EVOLUTION OR HAD

 

16  BEEN KIND OF GOING ON FOR A FEW DAYS OR HOURS OR -- HE

 

17  DOESN'T KNOW, I THINK --

 

18  Q.   THAT'S WHAT SUBACUTE MEANS?

 

19  A.   SUBACUTE, IT MIGHT BE BEST TO ASK THE RADIOLOGIST, BUT

 

20  IT MAY -- BUT IT MAY MEAN IT'S NOT JUST RIGHT THEN.  IT

 

21  OCCURRED SOMETIME BEFORE THAT POINT.  AND THEY WOULD PROBABLY

 

22  BE ABLE TO DEFINE BETTER THAT LENGTH OF TIME, BUT IT MIGHT BE

 

23  DAYS OR HOURS OR -- IT'S PRETTY VARIABLE IN MY INTERPRETATION

 

24  OF THAT IN A C.T. HEAD FINDING.

 

25  Q.   THEN IF YOU'D READ THE NEXT PARAGRAPH.

 

 1  A.   ALSO IDENTIFIED IS SOME VASCULAR CALCIFICATONS.  NO

 

 2  EVIDENCE OF MIDLINE SHIFT IS IDENTIFIED.  NO EVIDENCE OF

 

 3  INTRACRANIAL HEMORRHAGE IS NOTED.  ALSO NOTED IS SOME

 

 4  DECREASED DENSITY IN THE LEFT OCCIPITAL LOBE, ALSO CONSISTENT

 

 5  PERHAPS WITH SUBACUTE TO CHRONIC INSULT.

 

 6  Q.   THEN THE IMPRESSION OF THE RADIOLOGIST.

 

 7  A.   ATROPHY AND FAIR PRONOUNCED SMALL VESSEL ISCHEMIC

 

 8  CHANGES.  TWO FOCAL ZONES OF DECREASED DENSITY NOTED IN THE

 

 9  LEFT FRONTAL LOBE AND IN THE LEFT OCCIPITAL LOBE.

 

10  Q.   LET'S STOP THERE AND MAYBE EXPLAIN WHAT THAT MEANS.

 

11  WHAT DOES IT MEAN TWO FOCAL ZONES OF DECREASED DENSITY?

 

12  A.   I THINK IT JUST GOES BACK AS A SUMMARY OF WHAT HE WAS

 

13  TALKING ABOUT IN THE BODY OF THE REPORT.  THERE WAS PROBABLY

 

14  AN OLD STROKE AND IT'S -- THEY'RE UNABLE TO SAY THE AGE OF

 

15  THAT EVENT, WHETHER IT WAS SUBACUTE OR HOW LONG -- EXACT AGE,

 

16  BUT --

 

17  Q.   THEN IF YOU'D READ THE NEXT SENTENCE FOR US PLEASE.

 

18  A.   THE LEFT FRONTAL LOBE REGION MAY SHOW SOME MINIMAL

 

19  INCREASE IN DENSITY WHICH MAY REFLECT SOME LUXURY PERFUSION

 

20  WHICH MAY REFLECT A MORE OF A SUBACUTE TYPE PROCESS.

 

21  Q.   WHAT IS LUXURY PERFUSION?

 

22  A.   I -- I -- IT'S NOT A TERM THAT I -- THAT I TYPICALLY

 

23  USE, SO --

 

24  Q.   DO YOU EVER USE PERFUSION WHEN -- IN YOUR -- WHEN YOU'RE

 

25  TALKING ABOUT THE BRAIN?

 

 1  A.   SURE.

 

 2  Q.   WHAT DOES PERFUSION MEAN?

 

 3  A.   BLOOD FLOW.

 

 4  Q.   AGAIN, SUBACUTE TYPE PROCESS.  CLINICAL CORRELATION IS

 

 5  RECOMMENDED.  WHAT DOES THAT MEAN?

 

 6  A.   WELL, IT JUST MEANS THAT HOW'S THE PATIENT DOING, DO

 

 7  THEY LOOK LIKE THEY'VE HAD A STROKE OR JUST WHAT THE

 

 8  SITUATION WAS.

 

 9  Q.   SO NOT IN TERMS OF LOOK INSIDE THE HEAD, BUT JUST

 

10  OBSERVING THE PATIENT, YOU -- YOU WANT SOME CLINICAL

 

11  OBSERVATION?

 

12  A.   RIGHT.

 

13  Q.   THEN IF WOULD YOU NEXT TURN TO PAGE 575.  NOW, THIS IS A

 

14  NURSING NOTE.  IF YOU WOULD READ -- WELL, DOWN TO WHERE IT

 

15  SAYS, TEMPERATURE ROSE TO.  IF YOU'D READ THAT FIRST SENTENCE

 

16  BASICALLY.

 

17  A.   THIS IS NOT MY WRITING BUT --

 

18  Q.   RIGHT, YEAH.

 

19  A.   -- I'M NOT SURE WHAT THE CIRCLE IS UP THERE, BUT I THINK

 

20  IT SAYS PATIENT ATTENDED GROUPS BUT SLEPT -- AM I -- IS IT

 

21  575?

 

22  Q.   YES, IF YOU WOULD PLEASE.  I KNOW THIS IS A NURSING

 

23  NOTE, THIS IS NOT YOURS.

 

24  A.   PATIENT ATTENDED GROUPS BUT SLEPT THROUGH THEM.  AT 1600

 

25  PATIENT BEGAN A FIVE-HOUR CYCLE OF SEVERE EMESIS TIMES SEVEN

 

 1  AND DIAPH -- I ASSUME HE MEANS OR SHE MEANS DIAPHORESIS.  I

 

 2  CAN'T READ SOME OF THAT.  THEN IT SAYS SKIN TO TOUCH.  VITAL

 

 3  SIGNS TAKEN.  TEMPERATURE ROSE TO 99.5 AT 2200.

 

 4  Q.   WHAT IS EMESIS?

 

 5  A.   VOMIT.

 

 6  Q.   BUT WHAT -- WHAT -- HAVING READ THIS, WHAT DOES THIS

 

 7  TELL YOU IS GOING ON WITH MRS. LARSEN AT THAT TIME?

 

 8  A.   THAT THE PATIENT HAD SEVEN EPISODES OF EMESIS AND

 

 9  BECAUSE OF EMESIS WAS SOMEWHAT SWEATY AND HAD A LOW-GRADE

 

10  TEMPERATURE.  AND I GUESS EARLIER IN THE DAY, THEY'RE

 

11  INFERRING THE PATIENT SLEPT THROUGH SOME OF HER -- I WOULD

 

12  ASSUME SOME OF HER PSYCHIATRIC THERAPY GROUP, GROUP SESSIONS.

 

13  Q.   NOW, THEY INDICATED THAT AT 1600 PATIENT BEGAN A

 

14  FIVE-HOUR CYCLE.  1600 IS WHAT, 4:00 P.M.?

 

15  A.   YES.

 

16  Q.   THEN IF YOU'LL TURN THE PAGE OVER TO 576.

 

17  A.   YES.

 

18  Q.   AND I'LL SET THIS ON HERE IF I MAY.  AGAIN, THIS IS NOT

 

19  YOUR HANDWRITING.  IT IS A NURSING NOTE.  AT THE TOP IT

 

20  SAYS -- ITS'S HARD FOR US TO READ BECAUSE IT'S GOT SOME -- AT

 

21  2400 FREETEXT PATIENT VOMITING EMESIS COFFEE GROUND LIKE IN

 

22  APPEARANCE.  WHAT DOES THAT MEAN TO YOU AS A DOCTOR?

 

23  A.   IT MEANS THE EMESIS HAD THE APPEARANCE OF COFFEE GROUND

 

24  LIKE MATERIAL TO THE NURSE THAT -- THAT CAN MEAN THERE'S

 

25  BLOOD IN IT.  IT MAY NOT MEAN THAT.  IT CAN BE MISINTERPRETED

 

 1  OR INTERPRETED CORRECTLY.  USUALLY IF YOU SAW THAT, YOU WOULD

 

 2  TEST IT FOR BLOOD AND SEE IF IT HAD BLOOD IN IT.  BUT IT --

 

 3  BUT IT -- AND IT USUALLY WOULD REFER IF IT IS BLOOD TO OLD

 

 4  BLOOD.

 

 5  Q.   AND WHAT WOULD CAUSE THAT KIND OF APPEARNCE OR THAT KIND

 

 6  OF VOMITING?

 

 7  A.   IF -- IF IT --

 

 8       MR. BUGDEN:  YOUR HONOR, IF I CAN INTERRUPT FOR JUST A

 

 9  MOMENT, I THINK THAT THE AUTHOR OF THIS DOCUMENT IS GOING TO

 

10  LATER TESTIFY.  I DON'T BELIEVE THAT THIS WITNESS HAD ANY

 

11  INVOLVEMENT WITH THE PATIENT ON THIS DAY, HAS SEEN THIS NOTE,

 

12  OR REVIEWED THIS NOTE OTHER THAN LOOKING AT IT ON THE STAND

 

13  TODAY.

 

14       THE COURT:  WELL, I THINK IF IT HAS SOME RELEVANCY TO

 

15  WHAT HIS TESTIMONY WOULD BE, HE CAN GO AHEAD.  BUT IF YOU'RE

 

16  JUST DOING THAT TO GET IT IN THE RECORD, THEN YOU NEED TO DO

 

17  IT THROUGH THE NURSE.

 

18       MS. BARLOW:  NO, I'M JUST ASKING -- I'M ASKING HIM TO

 

19  EXPLAIN WHAT COFFEE GROUND EMESIS IS AND WHAT CAUSES IT.

 

20       THE COURT:  HE CAN DO THAT.  OVERRULE THE OBJECTION.

 

21       MS. BARLOW:  THANK YOU.

 

22  Q.  (BY MS. BARLOW)  CAN YOU EXPLAIN WHAT COFFEE GROUND

 

23  EMESIS IS AND WHAT MAY CAUSE IT?

 

24       THE COURT:  I THINK HE'S ALREADY EXPLAINED WHAT IT IS.

 

25       MS. BARLOW:  EXCUSE ME.

 

 1       THE COURT:  HE CAN EXPLAIN TO US WHAT COULD CAUSE IT.

 

 2  Q.  (BY MS. BARLOW)  YES, WHAT COULD CAUSE COFFEE GROUND

 

 3  EMESIS?

 

 4  A.   IF THE COFFEE GROUND EMESIS WAS FROM BLOOD OR OLD BLOOD,

 

 5  IT COULD BE FROM AN ULCER OR A GASTROINTESTINAL BLEED

 

 6  SOMEWHERE PROXIMAL TO THE LI -- TO THE LIGAMENT OF

 

 7  TRITES IN THE -- IN THE -- SO IT'S AN UPPER INTESTINAL

 

 8  BLEED IF IT'S FROM BLOOD.

 

 9  Q.   RIGHT.

 

10  A.   YOU KNOW, THAT WOULD HAVE TO BE DOCUMENTED THAT THAT WAS

 

11  BLOOD.

 

12  Q.   IS THERE ANY TREATMENT FOR THIS KIND OF CONDITION?

 

13  A.   IF -- IF THERE'S AN ULCER BLEEDING, A GASTROENTEROLOGIST

 

14  COULD DO AN UPPER ENDOSCOPY, IDENTIFY THAT ULCER.  IF THERE'S

 

15  AN ACTIVE BLEEDING VESSEL, IT COULD BE STOPPED.  HE COULD PUT

 

16  PATIENT ON ANTACIDS.  I.V. ANTACIDS, ORAL ANTACIDS, THINGS

 

17  LIKE THAT.

 

18  Q.   WHAT ABOUT THE VOMITING ITSELF, DO YOU ALLOW IT TO

 

19  CONTINUE OR DO YOU TRY TO STOP IT IN SOME WAY?

 

20  A.   IN EMESIS, YOU KNOW, YOU COULD GIVE ANTI-EMETIC

 

21  THERAPIES THAT CAN STOP VOMITING.  THERE'S SUPPOSITORIES AND

 

22  THERE'S SEVERAL INTRAVENOUS PREPARATIONS AND MEDICATIONS YOU

 

23  CAN GIVE TO STOP VOMITING.

 

24  Q.   IS VOMITING UNCOMFORTABLE FOR PEOPLE?

 

25  A.   GENERALLY IS.

 

 1  Q.   OKAY.  THANK YOU.  IF WE COULD TURN NOW TO MARY CRANE,

 

 2  WHICH IS PLAINTIFF'S EXHIBIT 4-B.  I'LL BRING YOU THAT ONE.

 

 3  PERHAPS BEFORE I TOTALLY LEAVE JUDITH LARSEN, WERE YOU CALLED

 

 4  IN TO CONSULT ON THAT -- IF THERE ARE NO INDICATIONS IN THE

 

 5  RECORD, NONE OF YOUR HANDWRITING IN THE RECORD FOR THAT DAY,

 

 6  WERE YOU CALLED IN TO CONSULT?

 

 7  A.   ON WHICH DAY IS THAT AGAIN?

 

 8  Q.   IT WAS THE 30TH OF DECEMBER.

 

 9  A.   I DON'T -- CAN YOU DIRECT ME TO THE PAGE?  I DON'T

 

10  BELIEVE SO, BUT I --

 

11       THE COURT:  WAS PAGE 576.

 

12  Q.  (BY MS. BARLOW)  I WANTED TO --

 

13  A.   THAT'S THE NURSE'S NOTES, BUT I -- I BELIEVE THAT DAY I

 

14  HAD SEEN HER WAS PRIOR TO THAT.  I DON'T BELIEVE SO.

 

15  Q.   IF YOU WOULD LOOK AT -- I BELIEVE THE DATE FOR

 

16  PHYSICIAN'S ORDERS IS ON PAGE 464.  DO YOU HAVE ANY

 

17  INDICATION IN THERE THAT YOU SAW HER FOR THAT EMESIS?

 

18  A.   NO.

 

19  Q.   DO YOU RECALL SEEING HER?

 

20  A.   NO.

 

21  Q.   OKAY.  IF YOU WILL NOW TURN TO EXHIBIT 4-B, WHICH IS

 

22  MARY CRANE'S.  AND IF YOU WILL TURN TO 240.  I THINK WE'LL

 

23  WALK YOU THROUGH THE HANDWRITING AGAIN, DOCTOR.  WERE YOU

 

24  CALLED IN CONSULT ON MARY CRANE?

 

25  A.   YES.

 

1  Q.   WHAT DAY WAS THAT?

 

 2  A.   12/29/95.

 

 3  Q.   AT WHAT TIME?

 

 4  A.   ONE P.M.

 

 5  Q.   YOU WERE ASKED TO CONSULT BY DR. WEITZEL.  WHAT ARE YOUR

 

 6  IMPRESSIONS OF YOUR MEETING WITH MRS. CRANE?

 

 7  A.   DO YOU WANT ME TO READ THIS?

 

 8  Q.   YES PLEASE.

 

 9  A.   NUMBER 1, HISTORY OF RIGHT THALAMIC C.V.A. 1990 WITH

 

10  RESIDUAL PARTIAL LEFT PARALYSIS.  NUMBER 2, HISTORY OF

 

11  HYPERTENSION.  INCREASED CORE ON CHEST X-RAY.  NUMBER 3,

 

12  HISTORY OF CHRONIC HYPONATREMIA.  QUESTION MARK, POLYDIPSIA.

 

13  NUMBER 4, PERIPHERAL PEPTIC ULCER DISEASE.  EXCUSE ME PEPTIC

 

14  ULCER DISEASE.  STATUS POST PARTIAL GASTRECTOMY AND VAGOTOMY.

 

15  NUMBER 5, HISTORY OF LUMBAR DISK SURGERY AND CHRONIC LOW BACK

 

16  PAIN.  NUMBER 6, RIGHT SHOULDER.  QUESTIONABLE ABNORMAL --

 

17  ABNORMAL DENSITY ON CHEST RADIOGRAM.

 

18  Q.   AND THEN UNDER THAT YOU HAVE PUT RECOMMENDATIONS.  WHAT

 

19  ARE THOSE?

 

20  A.   NUMBER 1, AGREE WITH THE NONSTEROIDAL ANTIINFLAMMATORY

 

21  DRUGS AND DURAGESIC PATCH.  NUMBER 2, CONSIDER DECREASE IN

 

22  LASIX TO DAILY DOSE OF 20 TO 40 MILLIGRAMS.  NUMBER 3,

 

23  CONSIDER DISCONTINUATION OF DYAZIDE.  NUMBER 4, IF MORE

 

24  ANTIHYPERTENSIVE CONTROL IS REQUIRED, CONSIDER LOW DOSE ACE

 

25  INHIBITOR COMMA THAT IS ZESTRIL 10 MILLIGRAMS ESPECIALLY IF

 

 1  INCREASED CORE SIZE ON CHEST RADIOGRAPH.  NEXT NUMBER, FLUID

 

 2  RESTRICTED TO 1400 C.C.S PER DAY IF NEEDED FOR A DECREASED

 

 3  SODIUM.  NEXT NUMBER --

 

 4       THE COURT:  SLOW DOWN A LITTLE BIT, DOCTOR.

 

 5       THE WITNESS:  SORRY.  NEXT NUMBER, K.C.L. CAN PROBABLY

 

 6  BE DECREASED IF LASIX DECREASED AND DYAZIDE STOPPED, I

 

 7  BELIEVE.

 

 8  Q.  (BY MS. BARLOW)  THAT'S ONE THAT --

 

 9  A.   MINE IS CUT OFF BEYOND --

 

10  Q.   IT IS ON MINE AS WELL.  DID YOU MAKE SOME ORDERS ON THE

 

11  LEFT-HAND SIDE OF THE PAGE?

 

12  A.   YES.  SAME DATE AND TIME, NUMBER 1, CHECK WITH FAMILY

 

13  REGARDING PAST RIGHT SHOULDER INJURY AND EVALUATION.  IF

 

14  NONE, PERFORM X-RAYS RIGHT SHOULDER PER DR. DEDRICKSON, WHO

 

15  IS A RADIOLOGIST.  I BELIEVE I LOOKED AT THIS PATIENT'S X-RAY

 

16  WITH DR. DEDRICKSON IN THE RADIOLOGY DEPARTMENT.  NUMBER 2,

 

17  HEMOCCULT STOOLS.

 

18  Q.   NOW, LET'S TURN TO YOUR WRITTEN CONSULT, WHICH IS A

 

19  LITTLE EASIER FOR US TO READ.  THAT IS PAGE 234.

 

20       THE COURT:  LET ME JUST ASK, COUNSEL, IS THERE ANY

 

21  REASON TO GO THROUGH THE HAND WRITTEN PORTION IF WE'RE GOING

 

22  TO HIS WRITTEN CONSULT?

 

23       MS. BARLOW:  YOUR HONOR, I -- WE WON'T -- I WON'T DO

 

24  THAT AGAIN.  THERE'S ONLY ONE OTHER PATIENT WHERE IT'S --

 

25       THE COURT:  WELL, LET'S DON'T DO THAT IN THE FUTURE --

 

 1       MS. BARLOW:  OKAY.  THAT'S --

 

 2       THE COURT:  -- UNLESS IT'S REQUIRED.

 

 3       MS. BARLOW:  -- RIGHT.  I -- I WILL NOT DO THAT ON THE

 

 4  LAST PATIENT THEN.

 

 5  Q.  (BY MS. BARLOW)  PAGE 234 IS YOUR REPORT OF CONSULTATION.

 

 6  YOU DO A HISTORY AND PHYSICAL AT THE TOP -- EXCUSE ME, H.P.I.

 

 7  I GUESS, IS THAT HISTORY AND PHYSICAL?

 

 8  A.   IT'S HISTORY OF PRESENT ILLNESS.

 

 9  Q.   OH, HISTORY OF PRESENT ILLNESS.  SHE COMES TO THE

 

10  GERO-PSYCH UNIT WITH HISTORY OF RECENT AGGRESSIVENESS.  IS

 

11  THAT THE WAY YOU UNDERSTOOD IT TO BE, A RECENT PROBLEM?

 

12  A.   YES, THAT'S WHAT I PUT DOWN.

 

13  Q.   WHAT'S WHAT YOU WROTE IN YOUR -- YOU GO THROUGH HER

 

14  MEDICAL HISTORY WHICH YOU'VE DONE ALREADY FOR US.  YOU

 

15  INDICATED THAT SHE HAD HAD -- I'M SORRY, I DON'T -- I DON'T

 

16  HAVE THE WORD FOR IT, BUT I BELIEVE IT'S A STOMACH SURGERY,

 

17  IS THAT CORRECT?  ACTUALLY, IT'S ON PAGE 235 THAT IT TALKS

 

18  ABOUT THAT.

 

19  A.   YES, IT SAYS PARTIAL GASTRECTOMY, VAGOTOMY.

 

20  Q.   WHAT'S THAT?

 

21  A.   IT'S A -- USING ULCER SURGERY FOR A BLEEDING ULCER, FOR

 

22  A VERY PAINFUL ULCER WHERE THEY TAKE OUT PART OF THE STOMACH

 

23  AND THEY CUT THE VAGUS NERVE IN AN EFFORT TO STOP ACID

 

24  PRODUCTION.

 

25  Q.   NOW, ON PAGE 234 AT THE BOTTOM, WOULD YOU READ THAT

 

 1  PARAGRAPH UNDER NEATH THE NUMBERED --

 

 2  A.   TODAY -- TODAY MRS. CRANE HAS NO COMPLAINTS AND SHE

 

 3  DENIES ANY SHORTNESS OF BREATH AND CHEST PAIN.  SHE DENIES

 

 4  ANY SIGNIFICANT PAIN.  SHE HAS BEEN PLACED ON A DURAGESIC

 

 5  PATCH AS WELL AS RELAFEN FOR HER LOW BACK PAIN WITH RESULTANT

 

 6  MARKED IMPROVEMENT.

 

 7  Q.   SO BY THEN SHE WAS ON A DURAGESIC PATCH.

 

 8  A.   YES.  YOU KNOW, I -- I MIGHT HAVE GOTTEN THAT FROM THE

 

 9  ORDERS IF THAT WAS THE DAY SHE CAME IN, I -- I DON'T KNOW IF

 

10  I VISIBLY SAW THE DURAGESIC PATCH, BUT MY -- I'M PRETTY

 

11  CERTAIN SHE WAS ALREADY ON IT.

 

12  Q.   THANK YOU.  IF YOU'D TURN TO PAGE 236.  AN E.K.G. HAS

 

13  BEEN DONE, IS THAT CORRECT?

 

14  A.   YES.

 

15  Q.   IS THERE ANY PROBLEM WITH THE E.K.G.?

 

16  A.   I DIDN'T THINK SO OR THE INTERPRETATION I GOT FROM THE

 

17  CHART DIDN'T THINK SO.

 

18  Q.   AND THEN YOU HAVE THE CHEST X-RAY.  ENLARGED CARDIAC

 

19  SILHOUETTE?

 

20  A.   YES.

 

21  Q.   WAS THERE ANYTHING ABOUT THIS X-RAY THAT CAUSED YOU

 

22  CONCERNS?

 

23  A.   THE LUNG FIELDS APPEARED CLEAR.  I NOTICED THAT THE

 

24  DENSITY IN THE RIGHT SHOULDER WHICH I HAD REVIEWED WITH

 

25  DR. DEDRICKSON, AND HE, AS I RECALL, WASN'T SURE IF THAT

 

 1  COULD JUST BE REALLY BAD OLD ARTHRITIS OR DEGENERATIVE

 

 2  DISEASE OR IN THE RIGHT SCENARIO I SUPPOSE IT COULD HAVE

 

 3  REPRESENTED SOME METASTATIC FOCUS OF CANCER OR THAT.

 

 4  PROBABLY MORE LIKELY TO BE AN OLD -- OLD ARTHRITITY IN THAT,

 

 5  BUT --

 

 6  Q.   THEN AT THE BOTTOM YOU HAVE YOUR RECOMMENDATIONS, AND

 

 7  YOU AGREE WITH ADEQUATE PAIN CONTROL WITH NON -- WELL,

 

 8  NONSTER -- YOU SAY THAT IF YOU WOULD PLEASE.

 

 9  A.   CAN YOU POINT TO ME TO MY -- WHERE I'M --

 

10  Q.   RECOMMENDATIONS ON PAGE --

 

11  A.   OKAY.  AGREE WITH ADEQUATE PAIN CONTROL WITH

 

12  NONSTEROIDAL ANTIINFLAMMATORY DRUGS AND DURAGESIC.  HOWEVER,

 

13  IT HAS LISTED -- I MUST HAVE SEEN AN ALLERGY SOMEWHERE TO

 

14  NONSTEROIDAL ANTIINFLAMMATORY DRUGS ON A PAST MEDICATION

 

15  LIST.  SHOULD I KEEP READING?

 

16  Q.   NO, LET'S STOP RIGHT THERE.  WHAT ARE NONSTEROIDAL -- I

 

17  CAN'T SAY --

 

18  A.   THINGS LIKE IBUPROFEN OR VIOXX OR CELEBREX OR NAPROXEN

 

19  OR --

 

20  Q.   BUT DID YOU AGREE THAT SHE SHOULD BE ON SOMETHING TO

 

21  CONTROL THE LOW BACK PAIN?

 

22  A.   YES.

 

23  Q.   YOU SAW IT ON A PAST MEDICATION LIST, I THINK IS WHAT

 

24  YOU WROTE, AND THEN THIS MAY BE -- IF YOU'D READ THE REST OF

 

25  THAT ON THE NEXT PAGE WHICH IS 237.

 

 1  A.   MEDICATION LIST.  THIS MAY BEEN FROM HER PAST HISTORY OF

 

 2  PEPTIC ULCER DISEASE.  IF SHE HAS HAD A VAGOTOMY AND PARTIAL

 

 3  GASTRECTOMY, THIS MAY NO LONGER BE PROBLEMATIC.  THE USE OF A

 

 4  NONSTEROIDAL MAY FURTHER IMPROVE HER TOLERANCE OF PAIN.

 

 5  Q.   WHY DID YOU ADD THAT LAST SENTENCE, THE USE OF --

 

 6  A.   IT'S -- IT'S COMMON TO USE A NONSTEROIDAL IN COMBINATION

 

 7  WITH NARCOTICS TO HELP WITH PAIN.

 

 8  Q.   NONSTEROIDAL BEING WHAT?

 

 9  A.   IBUPROFEN OR WHATEVER IBUPRO -- WHATEVER NONSTEROIDAL

 

10  SHE WAS ON.

 

11  Q.   THEN YOU TALK ABOUT DISCONTINUING CERTAIN MEDICATIONS

 

12  THAT SHE MAY NOT NEEDING THEM OR DECREASING CERTAIN

 

13  MEDICATIONS.

 

14  A.   YES, I BELIEVE THAT'S RIGHT.

 

15  Q.   INCLUDING I THINK YOU TALKED ABOUT DECREASING THE LASIX.

 

16  WHAT IS THE LASIX?

 

17  A.   LASIX IS A DIURETIC PRIMARILY.

 

18  Q.   WHY WOULD YOU RECOMMEND THAT?

 

19  A.   I MIGHT HAVE BEEN WORRIED ABOUT HER BECOMING VOLUME

 

20  DEPLETED OR OVERDIURESED IF SHE'D WASN'T VERY EDEMATOUS, AND

 

21  IT LOOKS LIKE IN MY IMPRESSION, SHE HAD A MILD METABOLIC

 

22  ALKALOSIS.  I WAS JUST -- IT'S PROBABLY A SOFT

 

23  RECOMMENDATION, BUT I JUST -- A CAUTIOUS RECOMMENDATION.

 

24  Q.   IF YOU WOULD TURN TO PAGE 242.

 

25       YOUR HONOR, THERE'S NOT A TYPED REPORT OF THIS --

 

 1       THE COURT:  OKAY.

 

 2       MS. BARLOW:  -- SO I WILL ASK HIM TO READ THROUGH THIS

 

 3  FOR US.

 

 4  Q.  (BY MS. BARLOW)  DOWN BOTTOM AT THE THERE IT'S -- I

 

 5  BELIEVE IT'S THE 1ST OF JANUARY, IS THAT IN YOUR HANDWRITING?

 

 6  A.   YES.

 

 7  Q.   DO YOU RECALL WHAT BROUGHT YOU TO THE UNIT ON THE 1ST OF

 

 8  JANUARY?

 

 9  A.   I BELIEVE I RECEIVED A CALL FROM THE NURSES OR PERHAPS

 

10  INSTIGATED BY DR. WEITZEL FOR ME TO, YOU KNOW, I -- ANYWAY, I

 

11  RECEIVED A CALL FROM THE UNIT TO SEE THE PATIENT.

 

12  Q.   WHAT WAS PRESENTING ITSELF IN THE -- AT THAT TIME?

 

13  A.   THE NURSES HAD NOTED A VAGINAL STOOL THAT DAY.

 

14  Q.   WELL, WHAT DOES A MEAN?

 

15  A.   IT MEANS STOOL WAS COMING FROM HER VAGINA RATHER THAN

 

16  HER RECTUM.

 

17  Q.   AND THAT'S NOT NORMAL.

 

18  A.   CORRECT.

 

19  Q.   ALL RIGHT.  WHAT DID YOU RECOMMEND TO DEAL WITH THAT

 

20  PROBLEM?

 

21  A.   I -- I -- IN MY ORDERS, DO YOU WANT ME TO READ --

 

22  Q.   WELL, I BELIEVE YOU HAVE A RECOMMENDATION.

 

23  A.   YEAH, IN MY RECOMMENDATION AT THE BOTTOM I ORDERED A

 

24  C.B.C. TODAY.  I DECREASED THE DURAGESIC PATCH WITH SOME

 

25  INCREASED SEDATION THAT I HAD NOTED, AND I CAN'T -- MY --

 

 1  MINE'S CUT OFF.  THERE'S SOMETHING DOWN AT THE BOTTOM OF MINE

 

 2  HERE.  AND IT -- LET ME SEE --

 

 3  Q.   I'M NOT SURE --

 

 4  A.   IT LOOKS LIKE NUMBER 2, G.Y.N. CONSULTATION, AND THAT'S

 

 5  CUT OFF ON MY COPY.

 

 6  Q.   AND WHY WOULD YOU RECOMMEND AN O.B.-G.Y.N. CONSULTATION?

 

 7  A.   WELL, IT'S AN SURGICAL PROBLEM IN TERMS OF HOW TO MANAGE

 

 8  THAT, WHAT'S THE BEST WAY TO MANAGE IT, DOES THE PATIENT NEED

 

 9  SURGERY, IS SHE FIT FOR SURGERY, THAT KIND OF ISSUE.  IT'S

 

10  NOT A PROBLEM I TYPICALLY WOULD EVER DEAL WITH.

 

11  Q.   SEPARATE FROM THE VAGINAL STOOL PROBLEM, YOU DID

 

12  DECREASE THE DURAGESIC.  WHY DID YOU DO THAT?

 

13  A.   I SAY UP ABOVE, THE PATIENT IS MORE SEDATED.  RECEIVED

 

14  ATIVAN 2 MILLIGRAMS LAST P.M. AND RISPERDAL T.I.D.  I FELT

 

15  LIKE SHE WAS MORE SEDATED WHEN I EXAMINED HER AND THAT

 

16  PERHAPS IF WE DECREASED THAT, SHE MIGHT BECOME MORE LUCID.

 

17  Q.   DID YOU GO AHEAD AND ORDER THAT OR DID YOU RECOMMEND IT?

 

18  A.   I -- IN THIS CASE, I DID DECREASE THE DURAGESIC PATCH.

 

19  I -- TO 25 MICROGRAMS.

 

20  Q.   APPROXIMATELY WHAT TIME WAS THAT NOTED?

 

21  A.   NOON.

 

22  Q.   WERE YOU AWARE THAT AT -- LOOKS LIKE 1700 THAT EVENING,

 

23  DR. WEITZEL INCREASED THE DURAGESIC PATCH BACK UP TO 50

 

24  MICROGRAMS?

 

25  A.   NO.

 

 1  Q.   DID HE CONSULT WITH YOU BEFORE HE DID THAT?

 

 2  A.   I DON'T BELIEVE SO.

 

 3  Q.   THEN IF YOU WOULD TURN TO PAGE 240 -- WELL, 244 WAS --

 

 4  IS THERE A RECORD OF AN O.B.-G.Y.N. CONSULT?  OR G.Y.N.

 

 5  CONSULT?

 

 6  A.   YES.

 

 7  Q.   AND THAT'S GYNECOLOGICAL?

 

 8  A.   YES.

 

 9  Q.   CONSULT.

 

10       THE COURT:  WHAT PAGE IS THAT?

 

11       MS. BARLOW:  THAT IS PAGE 244.

 

12  Q.  (BY MS. BARLOW)  NOW, IF YOU'D TURN TO PAGE 245.  MAYBE

 

13  WE COULD -- WHAT WAS THE GYNECOLOGICAL CONSULT?  WHAT DID HE

 

14  RECOMMEND, DO YOUR RECALL?

 

15  A.   YOU WOULD LIKE ME TO READ HIS CONSULT?

 

16  Q.   YES, PLEASE.

 

17  A.   1/2/96, G.Y.N. CONSULT.  72-YEAR-OLD WITH COMPLAINT OF

 

18  FECAL MATTER OUT OF VAGINA.  ON EXAM WAS A HIGH

 

19  RECTAL/VAGINAL FISTULA.  CAN REPAIR UNDER SPINAL ANESTHETIC

 

20  IF PATIENT CLEARED FOR SURGERY BY HER INTERNIST.  ALSO MAY

 

21  TRY TO HEAL SPONTANEOUSLY.  PARENTHESES, PROBABILITY 25 TO 35

 

22  PERCENT BY TREATING WITH BROAD SPECTRUM ANTIBIOTICS AND LOW

 

23  RESIDUE DIET, PARENTHESES, CONSTIPATING.  THANKS.  STEVEN

 

24  MEEKS.  THE PHONE NUMBER.

 

25  Q.   DID ANYONE SPEAK WITH YOU ABOUT CLEARING HER FOR ANY

 

 1  KIND OF SURGERY?

 

 2  A.   I SPOKE WITH DR. MEEKS BY PHONE.  I'M SORRY, I CAN'T

 

 3  RECALL THE DAY.  BUT I SPOKE WITH HIM BY PHONE ON EITHER THAT

 

 4  DAY OR LATER THE NEXT DAY, I WOULD THINK.

 

 5  Q.   DID YOU CLEAR HER FOR SURGERY?

 

 6  A.   DID -- THAT'S A TOUGH ISSUE.  HE MOSTLY WANTED TO KNOW

 

 7  ABOUT HER MEDICAL PROBLEMS.  I BELIEVE I PROBABLY HAD MY

 

 8  CONSULT IN HAND AND I PROBABLY REVIEWED ALL OF HER MEDICAL

 

 9  PROBLEMS AND I SUSPECT I SAID SOMETHING THAT, YOU KNOW,

 

10  THERE'S A LOT OF OLD PROBLEMS HERE, BUT THERE WAS NOTHING

 

11  IMMEDIATELY IMMINENT, AND SURGERY WOULD BE UP TO HIM.  I'M

 

12  NOT THE ONE THAT WOULD DO THAT.

 

13  Q.   WERE YOU MARY CRANE'S ATTENDING PHYSICIAN?

 

14  A.   NO.

 

15  Q.   WOULD THE ATTENDING PHYSICIAN MAKE THE FINAL CALL ABOUT

 

16  WHETHER TO DO SURGERY OR TO LET IT HEAL SPONTANEOUSLY?

 

17  A.   TYPICALLY, THAT WOULD BE BETWEEN THE ATTENDING PHYSICIAN

 

18  AND THAT CONSULTANT.

 

19  Q.   WE HAVE A NOTE ON PAGE 245, WHICH IS THE 3RD OF JANUARY,

 

20  THE NEXT DAY AFTER THE G.Y.N. CONSULT.  AND IT READS, PLEASE

 

21  HAVE DR. DIENHART MADE AWARE OF GYNECOLOGIST'S

 

22  RECOMMENDATION, QUOTE, GIVE HIM MY PHONE NUMBER -- THEN THE

 

23  NUMBER IS WRITTEN OUT SO HE CAN CALL ME IF NECESSARY.  DID

 

24  YOU RECEIVE SUCH A CALL?

 

25  A.   NO.

 

 1  Q.   TO THE RIGHT OF THAT IS -- IN HANDWRITING IT SAYS L.

 

 2  LONG, R.N.  1/3/96.  DR. DIENHART'S SECRETARY NOTIFIED OF

 

 3  PHONE NUMBER CHANGE.  DID THAT MESSAGE GET TO YOU ABOUT THE

 

 4  PHONE NUMBER CHANGE?

 

 5  A.   NOT -- NOT THAT I CAN EVER RECALL, NO.

 

 6  Q.   DID DR. WEITZEL EVER TALK TO YOU ABOUT WHETHER SURGERY

 

 7  SHOULD HAPPEN OR WHETHER IT OUGHTA BE HEALING SPONTANEOUSLY?

 

 8  A.   I DON'T THINK SO.

 

 9  Q.   WOULD YOU HAVE ORDERED THE -- BECAUSE UP ABOVE IT SAYS,

 

10  LOW FIBER, LOW RESIDUE DIET IS PART OF HIS ORDER.  AND THAT

 

11  WAS PART OF THE RECOMMENDATION OF DR. MEEK, ISN'T THAT

 

12  CORRECT?

 

13  A.   YES, I BELIEVE IT WAS.

 

14  Q.   WHO WOULD HAVE ORDERED ANTIBIOTICS FOR HER?

 

15  A.   THAT WOULD BE UP TO THE ATTENDING PHYSICIAN OR EVEN

 

16  DR. MEEKS SINCE THAT WAS A PROBLEM THAT HE WAS THE

 

17  GYNECOLOGIST ON CALL OR --

 

18  Q.   IF YOU HAD BEEN ASKED TO ORDER THE ANTIBIOTIC, WOULD YOU

 

19  HAVE DONE IT?

 

20  A.   YES.

 

21  Q.   AND THEN FINALLY WE HAVE A CONSULT ON THE 7TH OF JANUARY

 

22  WHICH IS PAGES 249 AND 250.  AND AGAIN, WE HAVE YOUR

 

23  HANDWRITING HERE BUT NOT A WRITTEN REPORT.  DO YOU RECALL

 

24  BEING CALLED IN TO SEE MARY CRANE ON THE 7TH OF JANUARY?

 

25  A.   BY MY NOTES, YES.

 

 1  Q.   WHAT TIME DID THAT OCCUR?  WHEN DID YOU COME IN?

 

 2  A.   IT LOOKS LIKE 3:10 P.M.

 

 3  Q.   DO YOU RECALL WHAT BROUGHT YOU IN OR WHY YOU WERE CALLED

 

 4  IN?

 

 5  A.   IT SAYS, I SUSPECT IT WAS POSSIBLE SEIZURE TODAY TIMES

 

 6  TEN SECONDS.  IT WAS BECAUSE OF A SEIZURE.  AND THEN I HAVE

 

 7  DOWN, INCREASED UNRESPONSIVENESS TIMES THREE DAYS.  ORAL

 

 8  INTAKE DECREASED.  AND HER OXYGEN SATURATIONS WERE LOW.

 

 9  Q.   WHAT WAS THAT TELLING YOU WHEN YOU SAW THOSE THINGS?

 

10  A.   SHE WAS VERY SICK AT THAT POINT.

 

11  Q.   AND THEN YOU HAVE AN IMPRESSION.  WHAT WAS YOUR

 

12  IMPRESSION?

 

13  A.   HYPOTENSION.  POSSIBLE SEPSIS.  PROBABLE SEIZURE.

 

14  VOLUME DEPLETION AND FREE WATER DEPLETION.  PROBABLE

 

15  ASPIRATION.

 

16  Q.   LET'S GO BACK.  WHAT'S HYPOTENSION?

 

17  A.   A VERY LOW BLOOD PRESSURE.

 

18  Q.   IS THAT CONCERNING TO YOU AS A PHYSICIAN?

 

19  A.   OF COURSE.

 

20  Q.   POSSIBLE SEPSIS.  WHAT'S SEPSIS?

 

21  A.   IT'S INFECTION OR SOON-TO-BE OVERWHELMING INFECTION AND

 

22  RESULTING IN DEATH.

 

23  Q.   AND THEN PROBABLE SEIZURE.  IS THAT BASED ON ANYTHING

 

24  YOU SAW OR WAS IT REPORTED?

 

25  A.   I THINK IT WAS BY A REPORT.  IT SAID ON THE VERY TOP

 

 1  TIMES TEN SECONDS.  SO IT MAY OR MAY NOT HAVE BEEN A SEIZURE,

 

 2  BUT IT VERY WELL COULD HAVE BEEN.

 

 3  Q.   AND THEN VOLUME DEPLETION.  WHAT DOES THAT MEAN?

 

 4  A.   IT MEANS HER VASCULAR VOLUME OR HER BLOOD FLOWS WAS

 

 5  DIMINISHED IN PART PROBABLY FROM SOME DEHYDRATION AND NEED

 

 6  FOR FLUID, WHICH COULD BE COMPOUNDED OBVIOUSLY BY INFECTION

 

 7  AND --

 

 8  Q.   PROBABLE ASPIRATION.  WHAT DOES THAT MEAN?

 

 9  A.   IT MEANS SHE MAY BE ASPIRATING TOWARDS GETTING A

 

10  PHEUMONIA OR MORE INFECTION.

 

11  Q.   ASPIRATING MEANS SHE'S SWALLOWING FLUID OR INHALING

 

12  FLUIDS --

 

13  A.   HER SECRETIONS OR --

 

14  Q.   HER SECRETIONS --

 

15  A.   -- OTHER MATERIAL OR WHAT SHE WAS EATING.

 

16  Q.   ARE ANY OF THESE LIFE-THREATENING?

 

17  A.   OF COURSE.  SHE --

 

18  Q.   WHAT ABOUT IN CONJUNCTION?

 

19  A.   YEAH, SHE WAS VERY ILL AND IN A VERY HIGH LIKELIHOOD OF

 

20  DYING.

 

21  Q.   AND THEN UNDERNEATH THAT, I'M SORRY, I CAN'T -- IS THAT

 

22  RECOMMENDATION?  I CAN'T TELL WHAT --

 

23  A.   THAT'S SAYS, CASE DISCUSSED WITH DR. WEITZEL.

 

24  Q.   EXCUSE ME?

 

25  A.   AND TO KEEP ON READING, PATIENT FELT TO HAVE DECLINING

 

 1  STATUS.  AND WISHED NOT TO HAVE C.P.R. PERFORMED.  IF THERAPY

 

 2  CHOSEN WOULD REQUIRE AGGRESSIVE VOLUME REPLETION, FREE WATER

 

 3  REPLETION, ANTIBIOTICS, AND FURTHER AGRESSIVE SUPPORTIVE

 

 4  CARE, I SUSPECT SHE MAY DIE SOON.  AND I -- IT LOOKS ADVISE

 

 5  FAMILY, NO NOTIFICATION.

 

 6  Q.   SO YOU THOUGHT THEN SHE WAS CLOSE TO DEATH?

 

 7  A.   UH-HUH.

 

 8  Q.   AND IN FACT, SHE DID PASS AWAY SHORTLY THEREAFTER, IS

 

 9  THAT CORRECT?

 

10  A.   I BELIEVE IT WAS WITHIN NEXT SEVEN OR EIGHT HOURS, YEAH.

 

11  Q.   SO YOU'RE -- YOU'RE BASICALLY SAYING IN THAT LAST NOTE

 

12  THAT IN ORDER TO BRING HER OUT OF IT AT THIS POINT, IT WOULD

 

13  TAKE SOME PRETTY AGGRESSIVE MEASURES, IS THAT CORRECT?

 

14  A.   THAT'S RIGHT.  AND IT WOULD HAVE BEEN TOUGH AT HER AGE

 

15  WITH THOSE PROBLEMS FOR HER TO SURVIVE, IN ANY EVENT, I

 

16  THINK.

 

17  Q.   DID YOU SEE HER MEDICAL TREATMENT PLAN OR LIVING WILL OR

 

18  ADVANCE DIRECTIVE OR ANYTHING OF THAT SORT?

 

19  A.   I CAN'T RECALL SPECIFICALLY.  I MIGHT HAVE LOOKED

 

20  THROUGH THE CHART AND THAT.  IF THERE IS ONE ON, I MIGHT

 

21  HAVE -- I MIGHT HAVE SEEN IT.

 

22  Q.   AND YOU WOULD RESPECT HERS AND HER FAMILY WISHES --

 

23  A.   YES, OF COURSE.

 

24  Q.   -- IF SHE DIDN'T WANT AGGRESSIVE TREATMENT?

 

25  A.   OF COURSE.

 

 1  Q.   THANK YOU.  WE'LL NOW TURN TO ENNIS ALLDREDGE, WHICH IS

 

 2  PATIENT 6-B.

 

 3       THE COURT:  BEFORE WE START THAT, LET'S TAKE A LITTLE

 

 4  BREAK, LADIES AND GENTLEMEN.  YOU CAN STAND AND STRETCH IF

 

 5  YOU'D LIKE TO AND GET YOUR CIRCULATION GOING AGAIN.  ALL OF

 

 6  YOU, IF YOU'D LIKE OR NEED TO.

 

 7       MS. BARLOW:  WON'T BE QUITE AS LONG WITH THIS NEXT ONE.

 

 8       THE COURT:  JUST WANNA MAKE SURE EVERYONE'S STILL

 

 9  FUNCTIONING.  OKAY.

 

10       LET'S GO AHEAD.

 

11       MS. BARLOW:  IF I MAY APPROACH WITH 6-B, YOUR HONOR.

 

12  Q.  (BY MS. BARLOW)  DR. DIENHART, 6-B IS THE DAVIS NORTH

 

13  MEDICAL RECORDS OF ENNIS ALLDREDGE.  AND I WON'T -- I WON'T

 

14  ASK YOU TO READ YOUR HANDWRITING FOR US BECAUSE WE DO HAVE

 

15  THE CONSULT WHICH IS PAGE NUMBER 6.  DO YOU HAVE THAT?

 

16  A.   YES.

 

17  Q.   THERE ARE SEVERAL PAGES HERE, 6 THROUGH 9.  I'LL ASK YOU

 

18  TO GO THROUGH THEM.  MR. ALLDREDGE WAS ADMITTED TO THE

 

19  GERO-PSYCH UNIT.  IF YOU WOULD READ THE FIRST SENTENCE UNDER

 

20  HISTORY PLEASE?

 

21  A.   MR. ALLDREDGE IS AN 83-YEAR-OLD CAUCASIAN MALE WITH A

 

22  HISTORY OF SEVERE DEMENTIA ADMITTED NOW TO THE

 

23  GERO-PSYCHIATRIC UNIT FOR INCREASED AGITATION AND

 

24  COMBATIVENESS --

 

25       THE COURT:  SLOW DOWN PLEASE.

 

 1       THE WITNESS:  SORRY.  IN TRANSFER FROM THE SUNSHINE

 

 2  TERRACE NURSING CENTER.  IT IS FELT THAT HE IS AN INCREASED

 

 3  RISK TO OTHER RESIDENTS.  HIS COMBATIVENESS INCLUDES BITING

 

 4  AND KICKING.

 

 5  Q.  (BY MS. BARLOW)  DO YOU RECALL SEEING MR. ALLDREDGE?

 

 6  A.   FROM MY NOTES.

 

 7  Q.   JUST FROM YOUR NOTES.  DO YOU RECALL IF HE WAS COMBATIVE

 

 8  AT THE TIME YOU SAW HIM?

 

 9  A.   HE WAS NOT.

 

10  Q.   AND HOW DO YOU RECALL HIS STATUS AT THE TIME YOU SAW

 

11  HIM?

 

12  A.   I BELIEVE HE WAS SEDATED AT THAT TIME.  AND I WOULD BE

 

13  GOING OVER MY NOTES HERE, BUT I BELIEVE HE HAD BEEN SOMEWHAT

 

14  SEDATED AND WAS --

 

15  Q.   IF YOU WOULD LOOK AT NUMBER -- PAGE NUMBER 11, I THINK

 

16  IS YOUR NOTES ABOUT HIS --

 

17  A.   CAN YOU GIVE ME THE PAGE?  I'M SORRY?

 

18  Q.   11, EXCUSE ME.  YOUR HONOR, I DIDN'T MEAN TO LIE ABOUT

 

19  NOT GOING TO THAT.  BUT THERE ARE SOME THINGS WRITTEN ON HERE

 

20  THAT WERE NOT --

 

21  A.   OKAY.  I SEE IT.  IN MY --

 

22  Q.   I BELIEVE IT'S -- LET'S SEE, WE HAVE -- WHAT IS THIS?

 

23  IS THAT RECOMMENDATION?

 

24  A.   YES.

 

25  Q.   OKAY.  WHAT DOES IT SAY UNDER RECOMMENDATION?

 

1  A.   AGREE WITH SCREEN LABORATORIES.  RULE OUT U.T.I.

 

 2  ASPIRATION PRECAUTIONS.  INCREASE HEAD OF BED.

 

 3  Q.   WHAT'S U.T.I.?

 

 4  A.   URINARY TRACT INFECTION.

 

 5  Q.   WHAT'S ASPIRATION PRECAUTIONS?

 

 6  A.   TO TRY AND PREVENT PHEUMONIA, FROM ASPIRATING

 

 7  SECRETIONS.

 

 8  Q.   THEN UNDERNEATH THAT WHAT HAVE YOU WRITTEN?

 

 9  A.   DEMENTED 82-YEAR-OLD MALE ADMITTED FOR COMBATIVENESS,

 

10  AGITATION.  CURRENTLY LETHARGIC.  AROUSABLE ONLY TO PAINFUL

 

11  STIMULI.  FOLLOWING ATIVAN, HALDOL INJECTION FOR

 

12  COMBATIVENESS.

 

13  Q.   SO BY THE TIME YOU SAW HIM, HE WAS NOT COMBATIVE, HE WAS

 

14  LETHARGIC?

 

15  A.   YES.

 

16  Q.   WHAT DOES IT MEAN BY AROUSABLE ONLY TO PAINFUL STIMULI?

 

17  A.   IT MEANS HE WAS -- HE WAS -- HE WAS SEDATED ENOUGH THAT

 

18  HE WOULD NOT TALK TO YOU AND WOULD NOT EASILY AROUSE IN ORDER

 

19  TO GET A MEANINGFUL RESPONSE.  SOME TYPE OF UNCOMFORTABLE

 

20  TYPE SENSATION HAD TO BE INDUCED TO GET HIM TO RESPOND AT

 

21  ALL.

 

22  Q.   AND THAT WAS DUE TO I BELIEVE YOU SAID THERE WERE

 

23  CERTAIN MEDICATIONS THAT HAD BEEN INJECTED INTO HIM THAT

 

24  CAUSED THIS SEDATION?

 

25  A.   I FELT LIKE THAT WAS CONTRIBUTING, YES.

 

 1  Q.   DO YOU RECALL WHAT TIME OR CAN YOU LOOK AT THAT AND SAY

 

 2  WHAT TIME IT IS THAT YOU WROTE THAT NOTE?

 

 3  A.   IT'S A RATHER POOR COPY, IT'S -- AT THE TOP IT SAYS,

 

 4  1/10/96, AND I BELIEVE IT'S AT 9 P.M., BUT MY COPY'S NOT BAD

 

 5  BUT THE ORDERS READ 9 P.M. SO I'M ASSUME THAT'S THE SAME.

 

 6  Q.   SO IT WAS NINE O'CLOCK THAT EVENING THAT YOU ACTUALLY

 

 7  SAW HIM.  OKAY.  IF YOU WOULD LOOK AT HIS MEDICAL HISTORY

 

 8  JUST -- AGAIN, WHERE DID YOU GET THE MEDICAL HISTORY?

 

 9  A.   I THINK THERE WERE RECORDS AVAILABLE FROM OUTSIDE

 

10  SOURCES THAT I -- THAT I GLEANED THIS INFORMATION FROM.

 

11  Q.   DID YOU SEE ANY ACUTE OR IMMEDIATE PROBLEM WITH ANYTHING

 

12  ON THE MEDICAL HISTORY?

 

13  A.   IT LOOKS LIKE I JUST NOTED OLD PROBLEMS IN THE PAST

 

14  MEDICAL HISTORY, INCLUDING HYPERTENSION, CORONARY DISEASE,

 

15  PAST SURGERY, RENAL INSUFFICIENCY, ET CETERA.

 

16  Q.   THEN IN YOUR PHYSICAL EXAM ON PAGE 7, WHAT DID YOU WRITE

 

17  AS HIS GENERAL CONDITION?

 

18  A.   THE PATIENT'S AN ELDERLY MALE, SUPINE IN BED, WITH

 

19  CHEYNE-STOKES RESPIRATION PATTERN WITH APNEA PERIODS FROM 20

 

20  TO 40 SECONDS.

 

21  Q.   SUPINE IN BED MEANING HE'S LYING IN BED?

 

22  A.   MEANS HE'S FLAT IN BED ON HIS BACK.

 

23  Q.   WHAT'S CHEYNE-STOKES RESPIRATION PATTERN?

 

24  A.   IT'S A -- IT'S A TYPE OF BREATHING PATTERN THAT'S --

 

25  SPEEDS UP AND THEN SLOWS DOWN, OFTEN WITH APNEIC SPELLS WHERE

 

 1  THE PATIENT MAY NOT BE BREATHING FOR PERIODS DURING -- AFTER

 

 2  THE -- AFTER THE FAST PHASE, TYPICALLY.

 

 3  Q.   SO WOULD THAT BE A PERIOD FROM 20 TO 30 SECONDS, HE

 

 4  WOULD NOT BREATHE FOR 20 TO 30 SECONDS?

 

 5  A.   20 TO 40, YES.

 

 6  Q.   20 TO 40, SORRY.  WHAT DOES THAT TELL YOU AS A

 

 7  PHYSICIAN?

 

 8  A.   CHEYNE-STOKES RESPIRATION IS A OBSERVATION.  IT CAN BE

 

 9  FROM MANY CAUSES.  I CAN ELABORATE ON THOSE.

 

10  Q.   YES, IF YOU WOULD.

 

11  A.   IT COULD BE OF -- IT COULD HAVE BEEN HIS INHERENT

 

12  BREATHING PATTERN FOR A LONG TIME, ALTHOUGH A LOT OF PATIENTS

 

13  WITH CHRONIC HEART FAILURE PROBLEMS HAVE CHEYNE-STOKES

 

14  RESPIRATIONS.  IT'S BROUGHT ON BY SLEEP, OFTENTIMES

 

15  ASSOCIATED WITH CENTRAL APNEAS WHICH ARE SOMEWHAT SIMILAR TO

 

16  CHEYNE-STOKES RESPIRATIONS.  IT COULD BE MANIFEST IN SOMEONE

 

17  WITH CEREBROVASCULAR DISEASE OR SMALL VESSEL DISEASE THAT IS

 

18  SEDATED.  MAYBE HE WAS SEDATED AND THAT BROUGHT IT OUT MORE.

 

19  MAYBE HE DOESN'T HAVE THOSE WHEN HE'S, YOU KNOW, AWAKE, THAT

 

20  KIND OF THING.  SO THERE IS -- THERE ARE MANY REASONS.

 

21  Q.   SO HE WAS LETHARGIC, HAD BEEN SEDATED.  COULD THAT HAVE

 

22  BEEN RELATED TO HIS SEDATION?

 

23  A.   YES, FOR SURE.

 

24  Q.   WAS THERE ANYTHING ABOUT HIS TEMPERATURE, PULSE,

 

25  RESPIRATION, BLOOD PRESSURE -- LET'S NOT SAY RESPIRATION

 

 1  BECAUSE WE TALKED ABOUT THAT, BUT BLOOD PRESSURE THAT CAUSED

 

 2  YOU CONCERN?

 

 3  A.   HIS BLOOD PRESSURE WAS -- I WROTE DOWN WAS 160 OVER A

 

 4  HUNDRED, SO IT'S A LITTLE ELEVATED, NOT -- NOT VERY ELEVATED.

 

 5  Q.   THEN IF YOU'D TURN TO PAGE 8, YOU'VE GOT YOUR

 

 6  IMPRESSION.  LET'S WALK THROUGH THAT BRIEFLY.  NUMBER 1,

 

 7  SEVERE DEMENTIA.  WAS THAT SOMETHING YOU SAW OR SOMETHING

 

 8  REPORTED TO YOU?

 

 9  A.   THAT WAS THE REPORT.

 

10  Q.   AND NUMBER 2 --

 

11  A.   ATHEROSCLEROTIC --

 

12  Q.   ATHEROSCLEROTIC?

 

13  A.   YES, ATHEROSCLEROTIC CARDIOVASCULAR DISEASE STATUS POST

 

14  CORONARY ARTERY BYPASS GRAFTING --

 

15       THE COURT:  SLOW DOWN PLEASE.

 

16       THE WITNESS:  IT -- I'LL REPEAT IT.  ATHEROSCLEROTIC

 

17  CARDIOVASCULAR DISEASE, STATUS POST CORONARY ARTERY BYPASS

 

18  GRAFTING 1982.

 

19  Q.  (BY MS. BARLOW)  WAS THAT REPORTED TO YOU?

 

20  A.   YES.

 

21  Q.   WHAT IS THAT KIND OF CARDIOVASCULAR DISEASE?

 

22  A.   IT'S COMMONLY KNOWN AS A BYPASS SURGERY FOR CORONARY

 

23  DISEASE, FOR NARROWING FROM PLAQUES AND --

 

24  Q.   AND IT'S ARTHER – ATHEROSCLEROTIC.  WHAT DOES THAT

 

25  MEAN?

 

 1  A.   IT JUST A TYPE OF PROGRESSION OF THE DISEASE IN THE

 

 2  CORONARY ARTERIES FROM CHOLESTEROL TYPICALLY AND LIPIDS AND

 

 3  THAT.

 

 4  Q.   IT INDICATES A HISTORY OF HYPERTENSION, WHICH IS HIGH

 

 5  BLOOD PRESSURE.  HE'S ON MEDICATION FOR THAT.

 

 6  A.   WHY.

 

 7  Q.   WHAT ABOUT THE DIABETES, HE'S ON MEDICATION FOR THAT.

 

 8  A.   YES.

 

 9  Q.   DID YOU SEE ANY PARTICULAR CONCERNS ABOUT ANY OF THAT

 

10  FOR IMMEDIATE LIFE-THREATENING PROBLEMS?  JUST ON THOSE FOUR

 

11  FIRST.

 

12  A.   AND AGAIN, MOST OF ALL THOSE WERE JUST OBSERVATIONAL

 

13  NOTES.  IT WASN'T -- THAT'S ALL IT WAS.

 

14  Q.   AND THEN ON THE NEXT PAGE, WHICH IS PAGE 9, YOU'VE GOT

 

15  RENAL INSUFFICIENCY.  WHAT IS THAT?

 

16  A.   I EXPECT I MEANT THAT HIS CREATININE AND HIS B.U.N.  IN TERMS

 

17  OF LABORATORY TESTS WERE A LITTLE BIT ELEVATED FROM A PAST

 

18  LAB THAT I HAD BEEN ABLE TO GET FROM THE OLD RECORD.

 

19  Q.   IT INDICATED IT WAS FAIRLY, IT DIDN'T CAUSE YOU ANY

 

20  IMMEDIATE CONCERNS?

 

21  A.   CORRECT.

 

22  Q.   RENAL INSUFFICIENCY CAN BE A PROBLEM, THOUGH, OF COURSE?

 

23  A.   IT'S NOT TYPICALLY A PROBLEM IF IT'S VERY MILD, BUT IF

 

24  IT GOT WORSE TO THE POINT THAT THERE WAS RENAL FAILURE, YES.

 

25  Q.   RENAL FAILURE MEANS WHAT HAS FAILED?

 

 1  A.   HIS KIDNEYS.

 

 2  Q.   G.E.R.D.  LET GO DOWN TO THE RECOMMENDATION.  SO YOU

 

 3  AGREE WITH THE SCREENING LABORATORIES AS PERFORMED.  THEY'D

 

 4  ALREADY BEEN ORDERED, IS THAT CORRECT?

 

 5  A.   I BELIEVE SO, YES.

 

 6  Q.   THEN YOU ASK FOR STRAIGHT CATHETERIZED URINALYSIS.  WHY

 

 7  THAT?

 

 8  A.   I MUST HAVE HAD A CONCERN THAT HE HAD A URINARY TRACT

 

 9  INFECTION, AND THAT IN ORDER TO REALLY TELL IF HE DID OR NOT,

 

10  I WANTED TO GET A MORE STERILE SAMPLE, AND THAT'S THE ONLY

 

11  WAY TO GET A REAL STERILE SAMPLE IN SOMEONE THAT'S NOT

 

12  COOPERATIVE, AND HE WAS SEDATED AND NOT RESPONDING.

 

13  Q.   RIGHT.  OKAY.  THANK YOU.  THEN AS YOU INDICATED, ADVISE

 

14  ASPIRATION PRECAUTIONS.  YOU DON'T WANT THEM ASPIRATING,

 

15  CAUSING PNEUMONIA.

 

16  A.   CORRECT.

 

17  Q.   AND THEN 4, CONSIDER OXYGEN SATURATION FOR AN INTERVAL

 

18  OF TIME DURING HIS PERIODIC BREATHING.  WHAT WERE YOU

 

19  ADDRESSING THERE?

 

20  A.   WELL, I WAS JUST CURIOUS IF HIS OXYGEN LEVEL WAS

 

21  ADEQUATE.  OFTENTIMES A LOW OXYGEN LEVEL MIGHT -- MIGHT

 

22  PRECIPITATE THAT KIND OF BREATHING PATTERN IN -- IN MANY

 

23  PEOPLE, EVEN WITHOUT HEART DISEASE OR CEREBROVASCULAR

 

24  DISEASE, SO -- AND IT'S OFTENTIME A THERAPY AS WELL, SO I MAY

 

25  HAVE ASKED FOR OXYGEN TO BE PLACED ON THE PATIENT AT THE TIME

 

 1  TO TREAT THAT TYPE OF BREATHING.  IT'S A COMMON TREATMENT TO

 

 2  BE USED FOR PEOPLE WITH THAT TYPE OF BREATHING.

 

 3  Q.   AND THAT WAS BECAUSE HE WAS CHEYNE-STOKES BREATHING?

 

 4  A.   YES.  AND TO ASSURE HE HAD ADEQUATE OXYGEN LEVELS.

 

 5  Q.   BECAUSE WHAT HAPPENS WITH LOW OXYGEN LEVEL?

 

 6  A.   IT DEPENDS ON HOW LOW.  IF THE OXYGEN LEVEL'S LOW

 

 7  ENOUGH, IT CAN CAUSE ALL KINDS OF HAVOC.  HAVE POOR PERFUSION

 

 8  OF THE BRAIN, YOU COULD HAVE A STROKE OR HEART ATTACK OR --

 

 9  Q.   NOW, I JUST HAVE --

 

10  A.   -- MANY TYPES OF THINGS.

 

11  Q.   -- ONE OTHER THING HERE TO -- THAT I'D LIKE TO SHOW YOU

 

12  OUT OF THE MEDICAL RECORD, AND THIS IS PAGE MED 164.10.  DO

 

13  YOU RECALL SEEING THIS IN HIS RECORD?  IF IT'S JUST AS EASY

 

14  TO SEE IT HERE, THAT'S FINE, TOO.

 

15  A.   YEAH, I -- I DON'T RECALL SEEING THAT, NO.

 

16  Q.   IS THIS THE TYPICAL WAY THAT YOU WOULD MAYBE GET RECORDS

 

17  FROM A PRIOR NURSING HOME OR SOMETHING, HAVE IT FAXED?

 

18  A.   IT COULD BE, YES.

 

19  Q.   AND IF IT'S INCLUDED IF THE RECORD, THEN IT WOULD BE

 

20  THERE AVAILABLE FOR YOU TO KNOW WHAT -- WHAT THE PRIOR

 

21  HISTORY IS.

 

22  A.   IF IT WAS THERE AT THE TIME, YES.

 

23       MS. BARLOW:  THANK YOU.  YOUR HONOR, I THINK THAT IS ALL

 

24  I HAVE OF THIS WITNESS ON DIRECT.

 

25       THE COURT:  MAY CROSS-EXAMINE, MR. BUGDEN.

 

 1                        CROSS-EXAMINATION

 

 2  BY MR. BUGDEN:

 

 3  Q.   DR. DIENHART, I'M WALLY BUGDEN.  ONE OF THE LAWYERS

 

 4  REPRESENTING DR. WEITZEL.  I'M GONNA ASK YOU QUESTIONS AND

 

 5  I'M GONNA TRY TO MOVE THROUGH THIS AS QUICKLY AS WE CAN.  THE

 

 6  JURY'S BEEN HERE A LONG TIME THIS MORNING.  LET ME SHOW YOU

 

 7  SOME DOCUMENTS, DOCTOR.  THEY'RE THE SAME DOCUMENTS YOU'VE

 

 8  BEEN LOOKING AT, BUT JUST PRESENTED TO YOU IN A DIFFERENT

 

 9  WAY, ALL RIGHT?  AND JUST SO THAT YOU UNDERSTAND HOW I'LL TRY

 

10  TO INDICATE PAGINATION TO YOU, THERE ARE NUMBERS DOWN HERE,

 

11  BUT WHEN I MENTION THOSE, I'LL REALLY BE TALKING TO THE JUDGE

 

12  OR THE COURT REPORTER AND THE PROSECUTOR.  BUT THIS IS THE

 

13  PAGE THAT I'LL FREQUENTLY REFER TO TO TRY TO MOVE YOU ALONG.

 

14  IS THAT ALL RIGHT, DOCTOR?

 

15  A.   YES.

 

16  Q.   DOCTOR, WERE YOU AWARE THAT ALL THREE OF THE PATIENTS

 

17  THAT YOU DID THE PHYSICAL AND EXAMINATIONS ON, ALL OF THESE

 

18  PEOPLE WERE TRANSFERRED TO THE GERO-PSYCHIATRIC UNIT BECAUSE

 

19  OF INCREASING AGITATION OR INCREASING BEHAVIOR PROBLEMS?

 

20  THAT GENERALLY THE KNOWLEDGE THAT YOU HAVE?

 

21  A.   YES, THAT'S GENERALLY CORRECT FROM WHAT -- THE NOTES

 

22  WE'VE REVIEWED TODAY.

 

23  Q.   WOULD IT BE TYPICAL FROM YOUR UNDERSTANDING THAT IN THAT

 

24  SITUATION THAT PATIENTS WOULD BE SENT TO THE GERO-PSYCH UNIT

 

25  SPECIFICALLY FOR THE PURPOSE OF RECEIVING PSYCHOTROPIC

 

 1  MEDICATION TO TRY TO CONTROL THAT AGITATION?

 

 2  A.   PERHAPS, YES, THAT'S TRUE.

 

 3  Q.   JUST TYPICALLY, IS THAT RIGHT?

 

 4  A.   YES, YES.

 

 5  Q.   I WANNA BEGIN BY TALKING ABOUT JUDITH LARSEN, DOCTOR.

 

 6  AND IF I CAN ASK YOU TO TURN TO PAGE --

 

 7       YOUR HONOR, THIS IS EXHIBIT 3-B, AND I'M GONNA START

 

 8  WITH PAGE 447.

 

 9       AND FOR YOU, DOCTOR, THAT'S PAGE 3.  SO AS YOU TOLD US,

 

10  YOU SAW THIS PATIENT ON DECEMBER 8TH, IS THAT RIGHT?

 

11  A.   YES, I BELIEVE SO.

 

12  Q.   AND I BELIEVE THAT THIS WAS TWO DAYS AFTER HER

 

13  ADMISSION.  I THINK SHE WAS ADMITTED ON DECEMBER 6TH.  WOULD

 

14  IT BE PARTICULARLY UNUSUAL THAT THERE MIGHT HAVE BEEN A

 

15  TWO-DAY LAG BEFORE YOU COULD HAVE COMPLETED THE PHYSICAL AND

 

16  THE EXAMINATION ON THE PATIENT?  THAT AN UNUSUAL

 

17  CIRCUMSTANCE?

 

18  A.   THAT WOULD BE.  IT WAS TYPICAL IF I GOT CALLED, I WOULD

 

19  SEE THE PATIENT THE SAME DAY.  I THINK IN GENERAL, THEY

 

20  WANTED, YOU KNOW, WHEN YOU DID A CONSULT FOR THAT UNIT, THEY

 

21  WANTED SORT OF A 24-HOUR THING.  IT SUGGESTS TO ME THAT MAYBE

 

22  SOMEONE ELSE WAS CALLED AND MAYBE I GOT CALLED BECAUSE THEY

 

23  WEREN'T SEEN OR SOMETHING, BUT I DON'T -- I DON'T KNOW WHAT

 

24  THE REASON WAS IN THIS CASE.

 

25  Q.   OKAY.  I AM GONNA ASK YOU SOME QUESTIONS FROM THE

 

 1  HISTORY WHICH MIGHT BE FOR YOU, DOCTOR, THE NEXT SLIDE OR

 

 2  PICTURE, PAGE 4.  SO --

 

 3       THE COURT:  NEXT PAGE, 447 --

 

 4       MR. BUGDEN:  IT'S THE SAME PAGE, JUDGE --

 

 5       THE COURT:  -- 448?

 

 6       MR. BUGDEN:  -- IT'S A BLOW-UP.

 

 7       THE COURT:  YOU'LL TELL ME WHEN WE'RE TO ANOTHER PAGE.

 

 8       MR. BUGDEN:  WHEN I'M MOVING TO ANOTHER PAGE, I'LL LET

 

 9  YOU KNOW, JUDGE.  I'LL TRY TO REMIND MYSELF, IF I REMEMBER.

 

10  Q.  (BY MR. BUGDEN)  SO THIS WOMAN HAD HISTORY OF A

 

11  CEREBROVASCULAR ACCIDENT IN JANUARY OF 1995, IS THAT RIGHT?

 

12  A.   YES.

 

13  Q.   AND THAT'S A STROKE, IS THAT RIGHT?

 

14  A.   YES.

 

15  Q.   AND SHE HAD INCREASED DEMENTIA THAT HAD WORSENING, IS

 

16  THAT RIGHT, IN THE LAST SEVERAL WEEKS?

 

17  A.   IT DOESN'T SAY THAT ON THAT PAGE.  LET'S SEE --

 

18  Q.   I THINK I WROTE THAT DOWN ACTUALLY FROM YOUR TESTIMONY

 

19  AS YOU WERE ANSWERING QUESTIONS FOR THE PROSECUTOR.  DOES A

 

20  SOUND RIGHT?

 

21  A.   IT VERY WELL COULD BE CORRECT, YES.

 

22  Q.   AND AGAIN IN THIS HISTORY SECTION, IN AUGUST OF 1995 OR

 

23  SINCE AUGUST OF 1995, THIS WOMAN HAD ESSENTIALLY HAD NO

 

24  SPEECH, IS THAT RIGHT?

 

25  A.   YES.

 

 1  Q.   SHE HAD TO BE RESTRAINED IN BED, IS THAT RIGHT?

 

 2  A.   YES.

 

 3  Q.   AND SHE WAS -- THEY'D HAD A PROBLEM OF HER FALLING OUT

 

 4  OF BED AND THEN GETTING HEAD LACERATIONS, IS THAT TRUE,

 

 5  DOCTOR?

 

 6  A.   YES, YES.

 

 7  Q.   AND IT ALSO INDICATES THAT SHE HAD ISCHEMIC HEART

 

 8  PROBLEMS, IS THAT RIGHT?

 

 9  A.   ARE YOU ON A -- ARE YOU ON A DIFFERENT PAGE NOW?

 

10  Q.   I THINK I'M ACTUALLY ON ANOTHER --

 

11  A.   YEAH, ON PAGE 5, THAT'S TRUE.

 

12  Q.   IT'S STILL THE SAME PAGE, JUDGE.  IT'S A DIFFERENT

 

13  BLOW-UP OF THE PAST MEDICAL HISTORY.  THE ISCHEMIC HEART

 

14  DISEASE, IS THAT CORONARY ARTERY DISEASE?

 

15  A.   YES.

 

16  Q.   AND IN SPITE OF THESE -- THIS MEDICAL HISTORY, DID YOU

 

17  BELIEVE THAT SHE WAS AN APPROPRIATE PATIENT, DOCTOR, FOR THE

 

18  GERO-PSYCH UNIT?

 

19  A.   YES.

 

20  Q.   AND I BELIEVE YOU INDICATED THAT EARLIER YOU TOLD THE

 

21  JURY THAT ON EXAMINATION, THE PATIENT DID NOT COMMUNICATE, IS

 

22  THAT RIGHT?  DO YOU REMEMBER THAT?

 

23  A.   YES.

 

24  Q.   SO ALTHOUGH SHE DID NOT VERBALLY REPORT ANY PAIN TO YOU,

 

25  THIS WAS ALSO A PATIENT THAT WAS PRESENTING UNABLE TO

 

 1  COMMUNICATE, IS THAT RIGHT, DOCTOR?

 

 2  A.   YES.

 

 3  Q.   SO SHE COULD NOT SELF-REPORT PAIN TO YOU, ISN'T THAT

 

 4  TRUE, DOCTOR?

 

 5  A.   THAT'S TRUE.

 

 6  Q.   AND WITH THE NONCOMMUNICATIVE, DEMENTED PATIENT, YOU

 

 7  CAN'T REALLY RELY ON THE PATIENT'S SELF-REPORT BECAUSE

 

 8  THEY'RE NOT ABLE TO COMMUNICATE WITH YOU, IS THAT RIGHT?

 

 9  A.   THAT'S TRUE.

 

10  Q.   AND WOULD YOU AGREE THAT THAT DOES PRESENT A TOUGH

 

11  TREATING PROBLEM FOR THE PHYSICIAN AND THE PATIENTS THAT

 

12  CAN'T SELF-REPORT THE PAIN?

 

13  A.   YES.

 

14       THE COURT:  YOU NEED TO ANSWER A LITTLE LOUDER, DOCTOR.

 

15       THE WITNESS:  SORRY.  YES.

 

16  Q.  (BY MR. BUGDEN)  NOW, I THINK YOU ALSO TOLD US ABOUT

 

17  HER -- HER RESPIRATIONS, AND I THINK THAT THAT IS ON MED 448.

 

18  BUT I'M NOT SURE, DOCTOR, I'M GONNA SEE IF WE CAN -- FROM OUT

 

19  TABLE WE CAN FIND THAT PAGE.

 

20  A.   CAN I JUST PULL IT OUT OF THE BOOKS?

 

21  Q.   NO, I DON'T -- MAYBE YOU'LL NEED TO GO THERE, BUT MAYBE

 

22  NOT.  LET ME JUST ASK YOU THIS -- WE MAY NOT BE ABLE TO FIND

 

23  THE PAGE RIGHT JOHNNY ON THE SPOT --

 

24       MS. ISAACSON:  DO WANT THAT PAGE?

 

25       MS. ISAACSON:  YES, PLEASE.

 

 1  Q.  (BY MR. BUGDEN)  I WANNA TRY TO FIND WHERE YOU'VE WRITTEN

 

 2  DOWN ABOUT THE RESPIRATIONS.  CAN WE FIND THAT SECTION AND

 

 3  BLOW THAT UP SO IT'S EASIER FOR ALL OF US TO SEE IT?

 

 4       ON THE RESPIRATIONS, DOCTOR, WHERE IT'S 16 TO 20 PER

 

 5  MINUTE, WHAT WOULD BE NORMAL RESPIRATION RIGHT -- WHAT'S THE

 

 6  RANGE?

 

 7  A.   PROBABLY EIGHT TO 20.

 

 8  Q.   EIGHT TO 20?

 

 9  A.   SOMETHING LIKE THAT.  MAYBE A LITTLE HIGHER IN SOME

 

10  PEOPLE.  BUT DEPENDING ON HOW THEY ARE, YOU KNOW, BUT ROUGHLY

 

11  THAT RANGE.

 

12  Q.   AND, DOCTOR, WHEN WE'RE SLEEPING, WHEN FOLKS ARE

 

13  SLEEPING, WHAT WOULD BE A TYPICAL OR NORMAL RESPIRATION RATE?

 

14  A.   PROBABLY AROUND -- PROBABLY THE SAME, PROBABLY EIGHT TO

 

15  15 TO 16, SOMETHING LIKE THAT.

 

16  Q.   THANK YOU.  AND I WILL JUST REMIND YOU, DOCTOR, YOU HAVE

 

17  A VERY SOFT VOICE.  AND I'M JUST GONNA REMIND YOU TO

 

18  OCCASIONALLY -- NOT TRYING TO BE IMPOLITE -- TRY TO KEEP YOUR

 

19  VOICE UP IF YOU WOULD.

 

20       THEN REALLY YOUR NEXT INVOLVEMENT WITH THIS PATIENT I

 

21  BELIEVE WAS ON 12/26, AND THIS IS MED PAGE 567.  THAT'S PAGE

 

22  7 FOR YOU, DR. DIENHART, IN THE LOWER RIGHT-HAND CORNER.  ARE

 

23  WE THERE?

 

24  A.   PAGE 7, YES.

 

25  Q.   JUST IN THE LOWER RIGHT-HAND --

 

 1  A.   YES.

 

 2  Q.   OKAY.  ON DECEMBER 26TH, A NURSE BY THE NAME OF TRACY

 

 3  SCHOLL -- DO WE HAVE A BLOW-UP OF THAT PAGE?  THANK YOU.

 

 4  TRACY SCHOLL CONTACTED YOU BECAUSE MRS. LARSEN WAS SUFFERING

 

 5  OR HAVING A SEIZURE AT THE TIME, IS THAT RIGHT?

 

 6  A.   YES.

 

 7  Q.   AND I GUESS IT WAS DESCRIBED THAT SHE WAS -- THAT THERE

 

 8  WAS A JERKING AND TONIC/CLONIC SEIZURE, IS THAT RIGHT?

 

 9  A.   YES.

 

10  Q.   AND I BELIEVE IN YOUR NOTE -- I DON'T THINK WE'RE GONNA

 

11  FLIP TO IT RIGHT NOW, BUT I BELIEVE IN YOUR -- A NOTE YOU

 

12  WROTE, THE SEIZURE MAY HAVE GONE ON FOR 40 TO 45 MINUTES.

 

13  DOES THAT SOUND RIGHT?

 

14  A.   YES.

 

15  Q.   AND WOULD THAT BE CONSIDERED A SUBSTANTIALLY SEVERE

 

16  SEIZURE TO GO ON THAT LONG, DOCTOR?

 

17  A.   YES.

 

18  Q.   NOW, YOU PRESCRIBED -- YOU TOLD US A LITTLE BIT ABOUT

 

19  THIS -- ATIVAN, IS THAT RIGHT, DOCTOR?

 

20  A.   YES.

 

21  Q.   AND ALSO THE DILANTIN, IS THAT RIGHT?

 

22  A.   YES.

 

23  Q.   BOTH OF THOSE WERE TO TRY TO CONTROL THE SEIZURE, IS

 

24  THAT RIGHT?

 

25  A.   YES.

 

 1  Q.   AND YOU PRESCRIBED OR ORDERED 3 MILLIGRAMS OF ATIVAN, IS

 

 2  THAT RIGHT, DOCTOR?

 

 3  A.   IT WAS THREE TO FOUR, YES.

 

 4  Q.   AND I THINK THE WAY IT ACTUALLY MAY HAVE HAPPENED --

 

 5  JUST HELP ME OR CORRECT ME IF I'M WRONG -- YOU MAY HAVE

 

 6  INITIALLY SAID 3 MILLIGRAMS AND THEN HAD MORE CONTACT WITH

 

 7  THE NURSE, A REPORT BY THE NURSE OVER THE -- AND THIS IS OVER

 

 8  THE PHONE.  YOU HAD TO DO THIS OVER THE PHONE, AM I RIGHT?

 

 9  A.   THE FIRST ORDER WAS OVER THE PHONE AND THEN I CAME RIGHT

 

10  IN, SO I DON'T KNOW WHERE -- WHERE SHE STOPPED WRITING ORDERS

 

11  AND I STARTED EXACTLY, BUT --

 

12  Q.   OKAY.  THAT'S FINE.  AND THEN BECAUSE OF WHAT YOU COULD

 

13  SEE OR WHAT NURSE REPORTED, YOU ADDED ANOTHER MILLIGRAM OF

 

14  ATIVAN, TOO --

 

15  A.   YES.

 

16  Q.   -- IS THAT RIGHT?

 

17  A.   YES.

 

18  Q.   AND 3 MILLIGRAMS OF ATIVAN, THAT'S ACTUALLY HIGHER THAN

 

19  THE SUGGESTED STARTING GERIATRIC DOSAGE, IS THAT TRUE?

 

20  A.   I DON'T THINK THERE IS A SUGGESTED STARTING GERIATRIC

 

21  DOSE FOR --

 

22  Q.   FOR ATIVAN?

 

23  A.   FOR SEIZURE CONTOL.

 

24  Q.   WELL, THAT EXACTLY MY POINT.  IN A -- THIS URGENT

 

25  SITUATION, IN THIS EMERGENCY SITUATION, YOU'RE RESPONDING TO

 

 1  THE SITUATION, IS THAT RIGHT --

 

 2  A.   YES.

 

 3  Q.   -- DR. DIENHART?  AND SO BECAUSE OF THE SITUATION, LET'S

 

 4  JUST ASSUME FOR THE SAKE OF THIS CON -- WELL, WOULD YOU AGREE

 

 5  THAT THERE ARE BOOKS OUT THERE THAT HAVE SUGGESTED INITIAL

 

 6  GERIATRIC STARTING DOSAGES?

 

 7       MS. BARLOW:  YOUR HONOR, I OBJECT.  I DON'T SEE WHAT

 

 8  RELEVANCE THIS HAS.  HE'S A TREATING PHYSICIAN.  THE

 

 9  GERIATRIC STARTING DOSE IS REALLY NOT RELEVANT AT THIS POINT.

 

10       THE COURT:  OVERRULED.  I THINK THAT'S OF KEY RELEVANCY

 

11  TO THIS JURY AS WE GO THROUGH THESE MATTERS.

 

12       THE WITNESS:  I'M NOT AWARE OF THAT INFORMATION.  I

 

13  PROBABLY WOULDN'T ARGUE IT, BUT I WOULD ARGUE THAT IN THAT

 

14  CONTEXT OF A SEIZURE THAT THAT IS A RELATIVELY LOW DOSE.

 

15  Q.  (BY MR. BUGDEN)  AND YOU'RE TRYING TO RESPOND TO THE

 

16  MEDICAL SITUATION, IS THAT RIGHT DOCTOR?

 

17  A.   YES.

 

18  Q.   AND YOU USED YOUR BEST MEDICAL JUDGMENT IN THAT

 

19  CIRCUMSTANCE AND YOU BELIEVE THE INITIAL 3 MILLIGRAMS WAS THE

 

20  THING AND THEN YOU EVEN ADDED ONE MORE.

 

21  A.   YES.

 

22  Q.   AND THAT MIGHT EVEN BE AN EXAMPLE OF -- WE'VE HEARD A

 

23  PHRASE NOW, WE'VE BEEN INTRODUCED TO IT IF NOT TODAY,

 

24  EARLIER -- TITRATING TO EFFECT.  THAT IS YOU'RE CHANGING

 

25  YOUR DOSAGE DEPENDING ON THE MEDICAL CIRCUMSTANCE OF THE

 

 1  PATIENT, IS THAT RIGHT DOCTOR?

 

 2  A.   YES.

 

 3  Q.   NOW, THE DILANTIN ALONG WITH THE ATIVAN WERE ORDERED TO

 

 4  TRY TO PREVENT SEIZURE ACTIVITY, IS THAT RIGHT?

 

 5  A.   YES.

 

 6  Q.   AND MRS. OR MS. BARLOW ASKED YOU WHETHER DR. WEITZEL --

 

 7  WELL, SHE SHOWED YOU A NOTE THAT DR. WEITZEL STOPPED THE I.V.

 

 8  THERAPY WHICH INCLUDED THE DILANTIN APPARENTLY.  THAT'S THE

 

 9  SUGGESTION FROM THE STATE.

 

10  A.   I BELIEVE THE DILANTIN WAS LATER ON -- THE CESSATION OF

 

11  DILANTIN.  I'M JUST RECALLING FROM GOING OR THAT EARLIER THIS

 

12  MORNING.

 

13  Q.   AND BY THE TIME DR. WEITZEL HAD STOPPED OR ENTERED AN

 

14  ORDER TO STOP THE I.V. TREATMENT, IT'S LIKELY OR IT'S VERY --

 

15  IT'S VERY POSSIBLE THAT THE DILANTIN HAD ALREADY BEEN GIVEN,

 

16  IS THAT RIGHT?

 

17  A.   YES.

 

18  Q.   AND THEN THE DISCONTINUATION --

 

19  A.   THAT INFORMATION SHOULD BE IN THE NURSE'S NOTES.

 

20  Q.   THE ACTUAL DISCONTINUATION OF THE DILANTIN, THAT

 

21  ACTUALLY CAME THREE DAYS LATER --

 

22  A.   I BELIEVE THAT --

 

23  Q.   -- FROM DR. WEITZEL --

 

24  A.   -- I BELIEVE I DID -- WE DID GO OVER THAT, YES.

 

25  Q.   NOW, MS. BARLOW ALSO ASKED YOU SOME QUESTIONS ABOUT THE

 

 1  C.T. SCAN AND I'M NOT GONNA PUT THAT BACK UP.  BUT YOU

 

 2  INTERPRETED THAT FOR ALL OF US BECAUSE IT WAS LANGUAGE THAT

 

 3  NONE OF US ARE FAMILIAR WITH.  AND AT LEAST ONE OF THE

 

 4  PHRASES THAT THE RADIOLOGIST HAD USED -- AND I BELIEVE YOU

 

 5  REPEATED IT FOR US -- WAS THAT THERE WAS ATROPHY OF THE

 

 6  BRAIN, IS THAT RIGHT?

 

 7  A.   YES.

 

 8  Q.   AND IS THERE A WAY THAT YOU CAN HELP US TO UNDERSTAND,

 

 9  WAS THIS AN UNHEALTHY LOOKING BRAIN?  WAS THIS, YOU KNOW, AT

 

10  LEAST BASED ON THE RADIOLOGIST'S REPORT, WAS THIS A DISEASED

 

11  BRAIN THAT HAD BEEN PHOTOGRAPHED, X-RAYED?

 

12  A.   IT'S FAIRLY COMMON TO DESCRIBE ATROPHY IN THE BRAIN.

 

13  IT'S PROBABLY A RADIOLOGICAL DISCUSSION IN TERMS OF AGE AND

 

14  WHAT PERCENT OF ATROPHY YOU EXPECT.  IN TERMS OF HAVING THE

 

15  STROKES, THAT WOULD BE VIEWED AS -- PAST STROKES WOULD BE

 

16  VIEWED AS HAVING AN UNHEALTHY APPEARING BRAIN, YES.

 

17  Q.   NOW, I'M GONNA TURN OUR ATTENTION, DOCTOR, TO MARY

 

18  CRANE.  AND YOU DON'T NEED TO MOVE YET.  DON'T NEED TO MOVE

 

19  THE PAGES.  BUT THIS, JUDGE, IS EXHIBIT 4-B, AND I'M GONNA BE

 

20  TALKING ABOUT MED PAGE 234.  DOCTOR, FOR YOU, IT'S JUST THE

 

21  FIRST PAGE AFTER THE MARY CRANE BREAK.  PAGE 10?

 

22  A.   OKAY.

 

23  Q.   ARE YOU THERE?

 

24  A.   YES.

 

25  Q.   THAT YOU, DOCTOR.  SO ON DECEMBER 29TH, 1995, YOU DID AN

 

 1  EXAMINATION OF THIS PATIENT, HISTORY AND PHYSICAL, IS THAT

 

 2  RIGHT?

 

 3  A.   YES.

 

 4  Q.   AM I CORRECT THAT YOU DON'T REALLY HAVE AN INDEPENDENT

 

 5  RECOLLECTION OF THIS EVENT APART FROM THE NOTES?

 

 6  A.   YES.

 

 7  Q.   AND IN THE FINDINGS, YOU FOUND THAT THERE WAS HISTORY OF

 

 8  RIGHT THALAMIC STROKE IN 1990.  WHAT'S THE SIGNIFICANT OF THE

 

 9  ADJECTIVE THALAMIC?

 

10  A.   IT JUST DESCRIBES THE PART OF THE BRAIN INVOLVED.

 

11  Q.   AND THEN THAT HAD LEFT HER WITH PARTIAL PARALYSIS, IS

 

12  THAT RIGHT?

 

13  A.   YES.

 

14  Q.   AND THEN SHE HAD A HISTORY OF LUMBAR DISK SURGERY.

 

15  SOMEONE HAD BROUGHT THAT TO YOUR ATTENTION?

 

16  A.   YES.

 

17  Q.   AND SHE ALSO SUFFERED -- WELL, SHE HAD CHRONIC LOW BACK

 

18  PAIN.  THAT'S SOMETHING THAT HAD BEEN BROUGHT TO YOUR

 

19  ATTENTION, IS THAT RIGHT, DOCTOR?

 

20  A.   YES, I SEE THE -- YES.

 

21  Q.   SHE HAD HYPERTENSION.  WHAT IS THAT AGAIN PLEASE?

 

22  A.   HIGH BLOOD PRESSURE.

 

23  Q.   AND SHE HAD HYPO -- OR I'M SORRY, YEAH, HYPONATREMIA, IS

 

24  THAT RIGHT?

 

25  A.   I'LL HAVE TO GO TO THAT PART WHERE I -- THAT'S PRESENT.

 

 1  YES.  THERE'S A TYPO IN THIS PARTICULAR DICTATION, BUT IT WAS

 

 2  HYPO, YES.

 

 3  Q.   AND HYPONATREMIA MEANS LOW SODIUM, IS THAT RIGHT?

 

 4  A.   YES.

 

 5  Q.   AND THEN IS THE HISTORY AND THE PHYSICAL PORTION OF YOUR

 

 6  REPORT -- AND I THINK THIS IS MED 236, THE SAME EXHIBIT,

 

 7  JUDGE -- BECAUSE OF THIS WOMAN'S CHRONIC LOW BACK PAIN,

 

 8  DR. WEITZEL HAD PLACED HER ON A DURAGESIC PATCH, AND YOU

 

 9  AGREED WITH THAT, IS THAT CORRECT?

 

10  A.   YES.

 

11  Q.   AND SHE WASN'T COMPLAINING OF PAIN AT THE TIME THAT YOU

 

12  SAW THE PATIENT, AM I RIGHT ABOUT THAT?

 

13  A.   THAT'S TRUE.

 

14  Q.   BUT IN FACT, SHE'D ALREADY BEEN STARTED ON A DURAGESIC

 

15  PATCH BY TIME YOU SAW HER.

 

16  A.   THAT'S VERY LIKELY.

 

17  Q.   NOW, THE BENEFIT OF A DURAGESIC PATCH IS THAT THIS

 

18  PROVIDES CONTINUOUS DOSING, CONTINUOUS PAIN RELIEF, IS THAT

 

19  CORRECT?

 

20  A.   YES.

 

21  Q.   AND ONE OF THE BENEFITS OF THE DURAGESIC PATCH IS THAT

 

22  IT PREVENTS THE HILLS AND THE VALLEYS, IT PREVENTS THE UPS

 

23  AND DOWNS FROM PAIN MANAGEMENT, IS THAT RIGHT?

 

24  A.   YES.

 

25  Q.   YOU HAVE TO ANSWER OUT LOUD.

 

 1  A.   YES.

 

 2  Q.   THANK YOU.  I MEAN I SAW YOU SHAKING YOUR HEAD, BUT --

 

 3  AND THE OBJECT WITH PAIN MANAGEMENT, WOULD YOU AGREE, IS TO

 

 4  PREVENT PAIN FROM RETURNING?

 

 5  A.   YES.

 

 6  Q.   AND SO IF YOU PHYSICIANS OR IF THE ATTENDING PHYSICIAN

 

 7  IS DOING HIS JOB, THE SYMPTOMS OF PAIN WON'T RETURN; THAT'S

 

 8  THE GOAL OF PAIN MANAGEMENT, IS THAT RIGHT?

 

 9  A.   YES.

 

10  Q.   AND THAT'S ONE OF THE REASONS THAT YOU BELIEVE THAT A

 

11  DURAGESIC WAS A GOOD IDEA FOR THIS PATIENT, IS THAT RIGHT?

 

12  A.   YES.

 

13  Q.   NOW, ON MED 234, I GUESS WE'RE GONNA GO IN THERE.  YOU

 

14  DID SOME -- A LEAST PART OF THE PHYSICAL HAD TO DO WITH HER

 

15  MENTAL FUNCTIONING, AM I CORRECT ON THAT?

 

16  A.   YES.

 

17  Q.   YOU ASKED HER, FOR EXAMPLE, IF SHE KNEW WHO THE

 

18  PRESIDENT WAS, AND SHE DID NOT KNOW WHO THE PRESIDENT WAS, IS

 

19  THAT RIGHT?

 

20  A.   HAVE TO SEE MY EXAMINATION.  CAN YOU REFER ME TO MY PAGE

 

21  OF MY EXAM PLEASE?

 

22  Q.   I'M GONNA HAVE TO PAUSE MYSELF FOR JUST A SECOND.  IS

 

23  THERE A BLOW-UP OF THIS PAGE AND MAYBE THAT'LL SHOW IT.

 

24  A.   NO, THAT'S NOT THE PHYSICAL.

 

25       MS. BARLOW:  PAGE 235 RATHER THAN  234.

 

 1       THE COURT:  234, I THINK IS WHAT HE'S TALKING ABOUT.

 

 2       THE WITNESS:  YEAH, I DON'T THINK IT'S IN MY PAPERS.

 

 3  Q.  (BY MR. BUGDEN)  COULD YOU TURN TO MY SLIDE 14?  AND THIS

 

 4  WON'T HAVE THE QUESTION I JUST ASKED YOU, BUT IT'S A

 

 5  DIFFERENT QUESTION I'LL ASK YOU.  SO SLIDE 14, DOCTOR, ARE

 

 6  YOU THERE?

 

 7  A.   YES.

 

 8  Q.   ARE YOU FAMILIAR WITH WHAT'S CALLED A MINI MENTAL EXAM?

 

 9  A.   YEAH, WE'RE -- I'M NOT AS -- NOT AS FAMILIAR AS A

 

10  PSYCHIATRIST WOULD BE, BUT YES.

 

11  Q.   IS A MINI MENTAL EXAM SOMETHING THAT IS ADMINISTERED TO

 

12  TRY TO SEE WHAT KIND OF MENTTAL FUNCTIONING THE PATIENT MIGHT

 

13  HAVE?

 

14  A.   YES.

 

15  Q.   AND THIS PATIENT SCORED, OUT OF 30, SCORED A 14, IS THAT

 

16  RIGHT, DOCTOR?

 

17  A.   THAT'S WHAT IT LOOKS LIKE, YES.

 

18  Q.   THAT WOULD BE A SCORE ON THE MENTAL STATUS EXAM THAT

 

19  WOULD BE CONSISTENT WITH DEMENTIA, IS THAT CORRECT, DOCTOR?

 

20  A.   I'M NOT -- I CAN'T COMMENT.  I DON'T -- I DON'T KNOW

 

21  THAT SCORE FOR THAT.

 

22  Q.   OKAY.  WERE YOU ABLE TO FIND PAGE 235?  WELL, THE PAGE

 

23  ABOUT NOT KNOWING THE PRESIDENT?  DO YOU HAVE IT?

 

24       MS. BARLOW:  IT'S 235.

 

25       MR. BUGDEN:  CAN I JUST BORROW YOURS, CHARLENE?

 

 1       MS. BARLOW:  SURE.

 

 2       MR. BUGDEN:  AND I'LL GIVE IT RIGHT BACK.  GOT IT RIGHT

 

 3  HERE FOR YOU.  THIS IS THE SAME EXHIBIT, JUDGE.  I'LL GIVE

 

 4  THIS TO YOU, THEN I'LL GIVE IT BACK TO YOU, MS. BARLOW --

 

 5       MS. BARLOW:  NO PROBLEM.

 

 6       MR. BUGDEN:  -- IN JUST A SECOND.

 

 7  Q.  (BY MR. BUGDEN)  IF IT'S EASIER FOR YOU TO LOOK AT IT

 

 8  THERE, BY ALL MEANS, LOOK AT IT THERE.  BUT I GUESS ONE OF

 

 9  THE THINGS YOU WOULD HAVE DONE IS ASK HER WHETHER OR NOT SHE

 

10  KNEW WHO THE PRESIDENT WAS.  SHE COULDN'T RECALL, IS THAT

 

11  RIGHT?

 

12  A.   RIGHT, THAT'S CORRECT.

 

13  Q.   WHEN YOU SAW -- THANK YOU, DOCTOR.  WHEN YOU SAW THE

 

14  PATIENT DID SHE APPEAR TO YOU TO HAVE COGNITIVE IMPAIRMENT?

 

15  A.   IT WOULD BE HELPFUL TO SEE MY EXAMINATION IN TOTAL AND

 

16  MY CONSULTATION IN TOTAL, IF I COULD.

 

17  Q.   YOU DON'T -- YOU CAN'T RECALL TODAY?

 

18  A.   JUST FROM EVERYTHING WE'VE DISCUSSED, THE ANSWER WOULD

 

19  BE YES.

 

20  Q.   NOW, I'D LIKE TO ASK YOU SOME QUESTIONS ABOUT JANUARY

 

21  1ST OF 1996, AND WOULD BE WHEN YOU DID A FOLLOW-UP

 

22  EXAMINATION ON THE PATIENT, AND IT'S PAGE 16 TO YOU.  IT'S

 

23  MED PAGE 242, JUDGE, SAME EXHIBIT NUMBER.  AND THIS WAS A

 

24  SITUATION WHERE DR. WEITZEL -- OR AT LEAST THE

 

25  GERO-PSYCHIATRIC UNIT HAD ASKED YOU TO SEE THE PATIENT, IS

 

 1  THAT RIGHT?

 

 2  A.   YES.

 

 3  Q.   CAN YOU -- CAN YOU READ YOUR -- YOUR BLOW-UP?  CAN YOU

 

 4  READ YOUR NOTE TO US?

 

 5  A.   YES.  1/1/96 MED FOLLOW-UP, PARENTHESES, ASKED TO SEE BY

 

 6  DR. WEITZEL.  NOON --

 

 7  Q.   KEEP YOUR VOICE UP SUPPOSE.

 

 8  A.   NOON.  REPORT OF VAGINAL STOOL TODAY.  PATIENT MORE

 

 9  SEDATED.  RECEIVED ATIVAN 2 MILLIGRAMS LAST P.M. AND

 

10  RISPERDAL T.I.D.  OBJECTIVE TEMPERATURE NINE NINE FIVE.

 

11  RESPIRATIONS 24.  I BELIEVE IT'S A 16 RESPIRATORY RATE.  AND

 

12  BLOOD PRESSURE 132 OVER 80.  LUNGS CLEAR.  ABDOMEN SOFT.

 

13  CORE REGULAR WITHOUT MURMUR.  A VAGINA BROWN FECAL MATERIAL

 

14  ON VISUAL INSPECTON.  NOTE 1/1/96 S.M.A. SEVEN AND TEN -- AND

 

15  TWELVE TWENTY-EIGHT W.B.C.'S 9,459 PERCENT SEGMENTED CELLS --

 

16  Q.   LET ME STOP YOU, THAT'S FAR ENOUGH.  AND SO YOU COULD --

 

17  YOU COULD SEE THE -- WHAT WAS A PROBABLE RECTAL/VAGINAL

 

18  FISTULA, IS THAT RIGHT, DOCTOR?

 

19  A.   YEAH, I COULDN'T TELL FOR SURE IT WAS A FISTULA, BUT IT

 

20  WAS VERY SUSPICIOUS.

 

21  Q.   OKAY.  AND I BELIEVE ON THAT SAME DAY, YOU MADE THE

 

22  RECOMMENDATION THAT THE DURAGESIC PATCH SHOULD PERHAPS BE

 

23  DECREASED, IS THAT RIGHT?

 

24  A.   THAT'S CORRECT.

 

25  Q.   NOW, IF THE PATIENT WAS -- HAD BEEN SUFFERING FROM

 

 1  BREAK-THROUGH PAIN ON THE 50 MICROGRAMS, WHICH HAD BEEN THE

 

 2  PRIOR ORDER, STANDING ORDER ON THE DURAGESIC, WOULD THAT

 

 3  EXPLAIN TO YOU WHY DR. WEITZEL WOULD HAVE INCREASED THE

 

 4  DOSAGE BACK TO THE 50 MICROGRAMS?

 

 5       MS. BARLOW:  YOUR HONOR, I BELIEVE THAT CALLS FOR

 

 6  SPECULATION.

 

 7       THE COURT:  OVERRULED.  GIVE HIS OPINION.

 

 8  Q.  (BY MR. BUGDEN)  DO YOU WANT ME TO RESTATE THAT FOR YOU?

 

 9  A.   YEAH, BECAUSE IT DIDN'T MAKE SENSE, JUST WHAT YOU SAID.

 

10  YOU SAID --

 

11  Q.   I'M SAYING TO YOU, IF THIS PATIENT BEFORE THE DAY YOU

 

12  SAW HER HAD EVIDENCE OF BREAK-THROUGH PAIN, AND THEN YOU

 

13  ENTERED THE ORDER OR THE RECOMMENDATION TO LOWER THE

 

14  DURAGESIC AND DR. WEITZEL HAVING BEEN TREATING THIS PATIENT

 

15  FOR THE LAST FEW DAYS BELIEVED THAT SHE NEEDED TO HAVE THE 50

 

16  MICROGRAMS, CONTROL HER PAIN LEVEL, DOES THAT MAKE SENSE TO

 

17  YOU THAT IF THE PATIENT WAS HAVING THE BREAK-THROUGH PAIN?

 

18  A.   IN RESPONSE TO WHAT I DID, I LOWERED IT BECAUSE OF THE

 

19  SEDATION AT THE TIME I EXAMINED HER.  I NO DOUBT DIDN'T THINK

 

20  SHE WAS IN SIGNIFICANT PAIN AT THAT TIME EITHER.  BUT IF HE

 

21  INCREASED IT LATER, THAT'S HIS -- THAT'S HIS PREROGATIVE.  IS

 

22  THAT WHAT YOU'RE ASKING, SIR?

 

23  Q.   WELL, IT'S HIS PREROGATIVE BECAUSE HE'S THE ATTENDING

 

24  PHYSICIAN, IS THAT RIGHT?

 

25  A.   WELL, YES.  AND IF I SAW THE PATIENT AND THEY WERE

 

 1  HAVING PAIN, I MIGHT CHANGE THE ORDER, TOO.

 

 2  Q.   OKAY.  SO THE PHYSICIAN WHO'S TREATING THE PATIENT AT

 

 3  THE TIME IS CERTAINLY THE PERSON WHO'S IN THE BEST POSITION

 

 4  TO DECIDE WHAT MEDICATION --

 

 5  A.   RIGHT.  I -- WHAT I DID WAS BECAUSE THE PATIENT WAS

 

 6  SEDATED AT THAT POINT IN TIME.  AND I --

 

 7  Q.   OKAY.

 

 8  A.   IT WAS PROBABLY A SMALL CHANGE IN REALISTICALLY LOOKING

 

 9  AT THAT.

 

10  Q.   THE 50 TO 25 OR THE --

 

11  A.   YEAH.

 

12  Q.   -- 25 BACK TO 50, WAS ACTUALLY A SMALL CHANGE.

 

13  A.   EITHER ONE'S KIND OF SMALL.

 

14  Q.   THANK YOU, DOCTOR.  NOW, I'D LIKE TO ASK YOU SOME

 

15  QUESTIONS ABOUT JANUARY 7TH, AND THIS WOULD BE MED PAGE 249.

 

16  AND FOR YOU, DOCTOR, IT'S GOING TO BE PAGE 19 OF THE PAGES

 

17  THAT YOU HAVE.  IS THERE A BLOW-UP OF THAT PAGE?

 

18       NOW, ON JANUARY 7TH, YOU WERE ASKED TO DO A MEDICAL

 

19  CONSULTATION BY DR. WEITZEL, IS THAT RIGHT?

 

20  A.   YEAH, THIS WAS A FOLLOW-UP VISIT.

 

21  Q.   AND SHE HAD -- PATIENT HAD SUFFERED A POSSIBLE STROKE

 

22  FOR TEN SECOND, IS THAT RIGHT?

 

23  A.   NO.  IT WAS A POSSIBLE SEIZURE --

 

24  Q.   I'M SORRY, I MISSPOKE.

 

25  A.   -- I -- THE NURSE HAD NOTED A POSSIBLE SEIZURE.

 

 1  Q.   THANK YOU.  AND HER OXYGEN SATURATIONS WERE DOWN TO

 

 2  70 -- 70 TO 80, IS THAT RIGHT?

 

 3  A.   YES.

 

 4  Q.   COULD YOU READ THAT PORTION OF THE NOTE?

 

 5  A.   STARTING AT WHICH LINE?

 

 6  Q.   JUST THE OXYGEN SATURATION?

 

 7  A.   02 SATURATIONS DECREASED TO 70 TO 80 DASH AND 86 PERCENT

 

 8  ON FACE MASK.  SO THE PATIENT WAS ALREADY ON OXYGEN AT THE

 

 9  TIME.  OR I HAD PUT THE PATIENT -- SOMEONE HAD PUT THE

 

10  PATIENT ON OXYGEN AFTER I HAD SEEN, AND THE STATS WERE STILL

 

11  LOW DESPITE OXYGEN ADMINISTRATION.

 

12  Q.   AND AT THAT TIME DID SHE ALSO HAVE THE LOW -- LOW BLOOD

 

13  PRESSURE, SIR?

 

14  A.   YES.

 

15  Q.   AND SHE WAS UNRESPONSIVE?

 

16  A.   YES.  WELL, SHE WAS -- YES, SHE WAS -- I -- THAT'S TRUE,

 

17  YES.

 

18  Q.   NOW, AT LEAST ON THIS DATE, THIS PATIENT, WOULD YOU

 

19  AGREE, WAS VERY ILL?

 

20  A.   ABSOLUTELY, YES.

 

21  Q.   AND IT WAS YOUR VIEW, OBSERVING THE PATIENT, THAT THERE

 

22  WAS A HIGH LIKELIHOOD THAT THIS WOMAN WAS GOING PASS AWAY?

 

23  A.   YES.

 

24  Q.   THE LOW BLOOD PRESSURE THAT WE'VE JUST TALKED ABOUT, IS

 

25  THAT SYNONYMOUS WITH SHOCK?

 

 1  A.   YES.

 

 2  Q.   IS THAT SOMETHING THAT COULD CAUSE SHOCK, DOCTOR?

 

 3  A.   IT -- IT'S SYNONYMOUS WITH SHOCK.  IT CAN BE FOR OTHER

 

 4  REASONS.  THE PATIENT WAS PROBABLY VOLUME DEPLETED AND MIGHT

 

 5  RESPOND TO FLUIDS, BUT SHE MIGHT AS -- SHE MIGHT ALSO BE IN

 

 6  SHOCK FROM INFECTION.

 

 7  Q.   DID YOU BELIEVE THAT SEPSIS WAS A POSSIBILITY AT THAT

 

 8  POINT WITH THIS PATIENT?

 

 9  A.   YES.

 

10  Q.   AND SEPSIS, AS I UNDERSTAND IT, IS SOMETHING THAT'S AN

 

11  INFECTION THAT SOON COULD BE SORT OF AN OVERWHELMING

 

12  INFECTION?

 

13  A.   YES.

 

14  Q.   AGAIN, ONE OF THE SERIOUS CONDITIONS THAT -- FOR THIS

 

15  PATIENT THAT COULD LEAD TO DEATH?

 

16  A.   ABSOLUTELY, YES.

 

17  Q.   AND THERE WAS ALSO THE POSSIBILITY IN YOUR VIEW THAT SHE

 

18  MIGHT HAVE ASPIRATED FLUIDS INTO HER LUNGS; THAT'S THE

 

19  ASPIRATION PNEUMONIA?

 

20  A.   YES.

 

21  Q.   AND AT THIS POINT, DID YOU EVEN -- IS IT POSSIBLE THAT

 

22  SHE HAD A URINARY TRACT INFECTION?

 

23  A.   IT -- IT WOULD BE POSSIBLE.

 

24  Q.   COULD YOU BECOME SEPTIC FROM URINARY TRACT INFECTION,

 

25  DOCTOR?

 

 1  A.   YES.

 

 2  Q.   DID YOU FORM ANY OPINIONS ABOUT WHETHER OR NOT THE

 

 3  PATIENT HAD SUFFERED A SEIZURE THAT WE'VE EARLIER TALKED

 

 4  ABOUT THAT THE NURSE REPORTED?

 

 5  A.   NO.  I THOUGHT IT WAS VERY POSSIBLE.  I DON'T --

 

 6  Q.   YOU DIDN'T --

 

 7  A.   -- DENY WHAT THE NURSES WOULD TELL ME AND WOULD BELIEVE

 

 8  IT TO BE VERY BELIEVABLE.

 

 9  Q.   NOW, THE PATIENT -- THIS IS MED PAGE 261.  AND THAT TO

 

10  YOU, DOCTOR, IS PAGE 22.

 

11  A.   YES.

 

12  Q.   IS THERE A BLOW-UP THAT WOULD HELP US TO READ THAT?

 

13  THANK YOU.  DOCTOR, PATIENT HAD A FEVER AT THIS POINT, IS

 

14  THAT RIGHT?

 

15  A.   I WOULD NEED HER VITAL SIGNS FOR THAT.

 

16  Q.   I'M GONNA ASK A DIFFERENT QUESTION BECAUSE I'M NOT GONNA

 

17  TRY TO GO BACK --

 

18  A.   I'M NOT SURE IT MATTERS.  YOU CAN BE INFECTED OR BE

 

19  NEAR --

 

20  Q.   OKAY.

 

21  A.   -- DYING WITH OR WITHOUT A FEVER.

 

22  Q.   THE SODIUM, THAT'S THE FIRST, THAT N.A., IS THAT RIGHT?

 

23  A.   YES.

 

24  Q.   AND HER SODIUM WAS 159.  IS THAT QUITE HIGH,

 

25  DR. DIENHART?

 

 1  A.   IT'S -- IT'S MODERATELY HIGH, YES.

 

 2  Q.   AND WOULD THAT BE CONSIDERED HIGH IN THE FACE OF HER LOW

 

 3  SODIUM SITUATION?

 

 4  A.   IT'S -- IT'S NOT A LOW SODIUM; IT'S A MODERATELY HIGH

 

 5  SODIUM.

 

 6  Q.   OH, I MISSPOKE.  AND WHAT ABOUT HER BLOOD -- WHITE BLOOD

 

 7  CELL COUNT, DOCTOR?

 

 8  A.   I DON'T SEE THAT ON THERE.

 

 9  Q.   IS THERE ANOTHER SLIDE?  IS THERE A BLOW-UP UP --

 

10  A.   THAT WAS IT.

 

11       MS. ISAACSON:  NO, SIR.

 

12       MR. BUGDEN:  NO BLOW-UP OF THAT?

 

13       MS. ISAACSON:  NO, SIR.

 

14       THE WITNESS:  IT LOOKS HIGH ON THAT DATE OF 1 -- IF I'M

 

15  READING IT RIGHT, 1/8 OR 1/7, IS THAT CORRECT?  WHAT'S THE

 

16  DATE AT THE TOP OF THAT?

 

17  Q.  (BY MR. BUGDEN)  CAN I GET UP -- IT LOOKS LIKE 1.

 

18  A.   I CAN'T READ THE DATE UP HERE, BUT IT'D BE THE DAY --

 

19  THIS ONE'S HIGH.  IT'D BE LESS (UNINTELLIGIBLE) THAN NORMAL.

 

20  Q.   CAN YOU -- CAN YOU TELL US, DOCTOR, WHAT A LEFT SHIFT

 

21  IS?

 

22  A.   A LEFT -- A LEFT SHIFT WOULD BE IF THE NEUTROPHILS WERE

 

23  HIGH OR THERE WERE BANDS IN THE BLOOD, IT -- IT SIGNIFIES

 

24  EITHER STRESS OR MORE LIKELY INFECTION.

 

25  Q.   DID THIS PATIENT HAVE A LEFT SHIFT?

 

 1  A.   THIS IS AN AUTOMATED DIFFERENTIAL, SO IT MAKES IT

 

 2  DIFFICULT, BUT THE NEUTROPHILS ARE ELEVATED, SO YOU COULD --

 

 3  YOU COULD HAVE A GOOD BET THERE PROBABLY WAS A LEFT SHIFT.

 

 4  Q.   DOCTOR, TO REVERSE THIS PATIENT'S CONDITION, WOULD YOU

 

 5  AGREE THAT AT THIS POINT, AGRESSIVE MEASURES WOULD HAVE BEEN

 

 6  NECESSARY?

 

 7  A.   YES.  IF YOU COULD REVERSE IT, YES.

 

 8  Q.   AND THAT'S IF YOU COULD REVERSE THIS SITUATION.

 

 9  A.   THAT'S RIGHT, YES.

 

10  Q.   NOW, THIS PATIENT HAD A D.N.R. ORDER IN PLACE FROM THE

 

11  DATE OF HER ADMISSION; WERE YOU AWARE OF THAT?

 

12  A.   I -- I CAN'T RECALL IF I WAS AWARE OF IT AT THE TIME.

 

13  Q.   I'LL JUST SHOW YOU THAT THERE WAS ACTUALLY A D.N.R.

 

14  DATED 12/28, DOCTOR.  AND THE D.N.R. -- DO YOU REMEMBER THAT

 

15  YOU HAD A CONSULT WITH DR. WEITZEL?

 

16  A.   I BELIEVE MY NOTES INDICATED THAT I SPOKE TO HIM AT THAT

 

17  TIME, YES.

 

18  Q.   AND YOU DECIDED ON NO FURTHER MEDICAL INTERVENTIONS FOR

 

19  THE PATIENT, IS THAT RIGHT?

 

20  A.   YES.

 

21  Q.   AND THE PATIENT -- THERE YOU SEE THERE WAS THE D.N.R.

 

22  AND YOU CONCLUDED YOUR OWN NOTE ON THAT DATE BY SAYING THAT

 

23  YOU -- YOU MIGHT HAVE TO READ THAT TO US, BUT I BELIEVE IT IS

 

24  THAT YOU SUSPECT THAT SHE MAY DIE SOON --

 

25  A.   YES.

 

 1  Q.   -- IS THAT RIGHT?

 

 2  A.   YES.

 

 3  Q.   AND YOU CERTAINLY AGREE THAT IT WAS THE RIGHT OF THE

 

 4  FAMILY TO NOT PUT THE FAM -- OR THE RIGHT OF THE FAMILY TO

 

 5  NOT PUT THE PATIENT THROUGH ANY MORE SUFFERING, IS THAT

 

 6  RIGHT?

 

 7  A.   OF COURSE.

 

 8  Q.   AND YOU BELIEVED IT WAS OKAY AND APPROPRIATE UNDER THE

 

 9  CIRCUMSTANCES TO LET THIS PATIENT PASS AWAY.

 

10  A.   OF COURSE.

 

11  Q.   IS THAT RIGHT?

 

12  A.   YES.

 

13  Q.   AND IT WAS NOTHING OUT OF THE ORDINARY IN TERMS OF THE

 

14  DECISION MAKING THAT DOCTORS HAVE TO DO WHEN YOU AND

 

15  DR. WEITZEL DISCUSSED WHETHER OR NOT AGGRESSIVE INTERVENTIONS

 

16  WERE APPROPRIATE.

 

17  A.   CORRECT.

 

18  Q.   AND IT WAS NOTHING OUT OF THE ORDINARY IN YOUR MIND WHEN

 

19  YOU AND DR. WEITZEL CONCLUDED THAT UNDER THE MEDICAL

 

20  CIRCUMSTANCES OF THIS PATIENT, IT WAS APPROPRIATE TO WITHHOLD

 

21  TREATMENT.

 

22  A.   CORRECT.  AT -- AT THAT JUNCTURE, I THINK DR. WEITZEL

 

23  WAS GOING TO HAVE FURTHER DISCUSSIONS WITH THE FAMILY, SO

 

24  IT'D ALWAYS BE CONTINGENT ON THOSE DISCUSSIONS.

 

25  Q.   RIGHT.

 

 1  A.   BUT -- BUT IN THE GESTALT WHAT ALL -- OF ALL YOU'RE

 

 2  SAYING I THINK IS TRUE, YES.

 

 3  Q.   AND YOU DIDN'T -- I MEAN YOU JOINED IN THAT CONCLUSION,

 

 4  IS THAT RIGHT?

 

 5  A.   I WASN'T PARTICIPATING IN THOSE DISCUSSIONS, NO.

 

 6  Q.   NOT WITH THE FAMILY, BUT WITH DR. WEITZEL.

 

 7  A.   YES.  I -- I WOULD NOT ARGUE AGAINST THAT TACT, NO.

 

 8  Q.   AND YOU DIDN'T ARGUE AGAINST IT WITH DR. WEITZEL.

 

 9  A.   NO.

 

10  Q.   AND IF YOU -- YOU CERTAINLY WOULD HAVE VOICED YOUR OWN

 

11  OPINION, YOU WOULD HAVE SPOKEN UP TO DR. WEITZEL IF YOU

 

12  THOUGHT THAT HE WAS DOING SOMETHING WRONG.

 

13  A.   ABSOLUTELY.

 

14  Q.   THANK YOU.  NOW, I WANNA ASK YOU SOME QUESTIONS ABOUT --

 

15       THE COURT:  THIS MIGHT BE A GOOD TIME TO TAKE OUR LUNCH

 

16  BREAK.  THERE'S STILL CONSIDERABLE TESTIMONY I'M SURE FROM

 

17  THIS WITNESS.

 

18       MR. BUGDEN:  I'M ACTUALLY VERY CLOSE, JUDGE.

 

19       THE COURT:  YOU MIGHT BE, BUT I'M SURE MS. BARLOW ISN'T.

 

20       MR. BUGDEN:  OH.

 

21       THE COURT:  THAT CORRECT?

 

22       MS. BARLOW:  WELL, IT MAKES IT SOUND LIKE I'M GONNA TAKE

 

23  HOURS, BUT IT IS CORRECT, I DO HAVE QUESTIONS, YES.

 

24       THE COURT:  WE'LL TAKE OUR LUNCH BREAK AT THIS TIME.

 

25  WE'LL BE BACK AT 1:15.  I REMIND YOU OF MY PRIOR ADMONITION,

 

 1  LADIES AND GENTLEMEN OF JURY.  DOCTOR, YOU MAY STEP DOWN.

 

 2  WE'D ASK THAT YOU COME BACK AFTER LUNCH.  THANK YOU.  WE'LL

 

 3  BE IN RECESS.

 

 4            (THE MORNING SESSION ENDED.)

 

 

11 – 8 – 2002   P.M.

 

       1              THE COURT:  DR. DIENHART, WOULD YOU STEP BACK UP,

 

       2     PLEASE?  THE COURT REMINDS THAT YOU YOU'RE STILL UNDER OATH.

 

       3     THE RECORD SHOULD NOTE THE PARTIES AND COUNSEL ARE PRESENT.

 

       4     THE JURY IS IN THE JURY BOX AND YOU MAY PROCEED, MR. BUGDEN.

 

       5     Q.  (BY MR. BUGDEN)  DOCTOR, WE'RE GOING TO TURN TO TALKING

 

       6     ABOUT MR. ALLDREDGE.  YOU SAW HIM ONE TIME, IS THAT RIGHT?

 

       7     A.  YES.

 

       8              MR. BUGDEN:  YOUR HONOR, I'M GOING TO NOW BE

 

       9     REFERRING TO EXHIBIT 6B.  AND FOR YOUR BENEFIT, DOCTOR, IT'S

 

      10     THE FIRST SLIDE THE FIRST PICTURE YOU HAVE THERE.  AND YOU

 

      11     SAW HIM ON JANUARY 10TH, WHICH WAS THE FIRST DAY OF HIS

 

      12     ADMISSION, IS THAT RIGHT?

 

      13              THE COURT:  IS THERE A PAGE TO THAT EXHIBIT?

 

      14              MR. BUGDEN:  PAGE 6, JUDGE.  EXHIBIT 6B IN MED SIX.

 

      15              THE COURT:  MED 6?  OKAY.

 

      16     Q.  (BY MR. BUGDEN)  IS IT NOT THERE?  PAGE 31 FOR YOU.

 

      17     A.  IS THIS JUDITH LARSEN?

 

      18     Q.  PAGE 31.

 

      19     A.  SORRY.

 

      20     Q.  SORRY.

 

      21     A.  GOT YOU.

 

      22     Q.  THANK YOU.  LET ME JUST MAKE SURE WE'RE TOGETHER ON THIS.

 

      23     YOU SAW HIM ON JANUARY 10TH, IS THAT RIGHT?

 

      24     A.  YES.

 

      25     Q.  AND YOU JUST SAW HIM ONE DAY, IS THAT RIGHT?

 

       1     A.  YES.

 

       2     Q.  AND HE HAD A HISTORY OF SEVERE DEMENTIA, THAT'S WHAT HAD

 

       3     BEEN REPORTED TO YOU, IS THAT RIGHT?

 

       4     A.  YES.

 

       5     Q.  HAD BEEN TRANSPORT TO THE HOSPITAL BECAUSE OF HIS -- TO

 

       6     THE GEROPSYCH UNIT BECAUSE THE AGITATION, IS THAT RIGHT?

 

       7     A.  THAT WAS ESSENTIALLY IT, YES.

 

       8     Q.  AND I BELIEVE YOU INDICATED TO THE JURY BEFORE THE BREAK

 

       9     THAT'S APPEARED TO YOU TO BE SOMEWHAT SEDATED WHEN YOU WERE

 

      10     EXAMINING HIM, IS THAT RIGHT?

 

      11     A.  THAT'S CORRECT.

 

      12     Q.  IN FACT, HE HAD JUST RECEIVED BOTH ATIVAN AND HALDOL IS

 

      13     THAT RIGHT, DOCTOR?

 

      14     A.  VERY CLOSE TO THAT TIME I BELIEVE, YES.

 

      15     Q.  SO YOU WOULD EXPECT THOSE MEDICATIONS TO HAVE A SEDATING

 

      16     EFFECT, IS THAT RIGHT?

 

      17     A.  YES.

 

      18     Q.  DID YOU HAPPEN TO KNOW THAT THIS PATIENT HAD BEEN

 

      19     TRANSFERRED FROM THE NURSING HOME BECAUSE OF, YOU KNOW, VERY

 

      20     COMBATIVE BEHAVIORS THAT INCLUDED INJURING OTHER PATIENTS?

 

      21     A.  I DIDN'T KNOW ABOUT INJURY TO OTHER PATIENTS BUT THE OTHER

 

      22     PART I HAVE -- I'M READING IN MY NOTE IN FRONT OF ME, YES.

 

      23     Q.  AND THIS GENTLEMAN HAD WHAT YOU NOTICED WERE

 

      24     CHEYNE-STOKES RESPIRATIONS, IS THAT RIGHT?

 

      25     A.  YES.

 

       1     Q.  AND THE PERIODS OF APNEA, 20 TO 40 SECONDS WHEN

 

       2     MR. ALLDREDGE WAS NOT TAKING A BREATH, IS THAT -- THAT THAT

 

       3     CHEYNE-STOKE BREATHING AND THAT PERIOD OF APNEA, MIGHT THAT

 

       4     BE A SIGN OF DETERIORATING BRAIN FUNCTION?  THE BRAIN WAS NOT

 

       5     FUNCTIONING PROPERLY?

 

       6     A.  IT AS I'VE ALREADY -- I GUESS I WON'T GO INTO THE ENTIRE

 

       7     THING THAT CAN CAUSE CHEYNE-STOKES RESPIRATIONS.  BUT THE

 

       8     SEDATION COMBINED WITH UNDERLYING BRAIN DYSFUNCTION OR

 

       9     CHRONIC HEART PROBLEMS, OR LOW OXYGEN LEVELS OR ANY

 

      10     COMBINATION OF THOSE COULD PRODUCE CHEYNE-STOKES

 

      11     RESPIRATIONS.

 

      12     Q.  AND LET ME SHOW YOU WHAT'S MARKED AS MED 12.  IT'S THE

 

      13     SAME EXHIBIT NUMBER, JUDGE.  IT'S NOT A SLIDE THAT YOU HAVE.

 

      14         ON JANUARY 12TH, THIS PATIENT HAD A SATURATION TEST THAT

 

      15     WAS DONE AND THE SATURATION LEVEL WAS AT WHAT PERCENT?

 

      16     A.  NINETY-SIX.

 

      17     Q.  IS THAT GOOD, DOCTOR?

 

      18     A.  YES.

 

      19     Q.  THAT MEANS HE WAS BREATHING ALL RIGHT OR HE WAS GETTING

 

      20     ENOUGH OXYGEN?

 

      21     A.  NO.

 

      22     Q.  DOES IT MEAN HE WAS RECEIVING IT?

 

      23     A.  IT MEANS HIS OXYGEN SATURATION WAS GOOD.  IT DOESN'T SAY

 

      24     HOW MUCH OXYGEN WAS ON OR NOT ON ON OXYGEN BUT THAT

 

      25     SATURATION IS GOOD.

 

       1     Q.  OKAY.  DR. DIENHART, WHEN OLDER PEOPLE BECOME SICK, WOULD

 

       2     YOU AGREE THAT OFTENTIMES IT DOESN'T TAKE MUCH FOR THESE

 

       3     OLDER PEOPLE UNFORTUNATELY TO DIE?

 

       4     A.  THAT'S TRUE.

 

       5     Q.  IS THAT RIGHT?

 

       6     A.  YES.

 

       7              MR. BUGDEN:  THAT'S ALL I HAVE.  THANK YOU.

 

       8              THE COURT:  REDIRECT.

 

       9              MS. BARLOW:  YES.  THANK YOU, YOUR HONOR.

 

      10              MR. BUGDEN:  DO YOU WANT LIGHTS ON OR OFF?

 

      11              MS. BARLOW:  LET'S LEAVE THEM OFF FOR NOW.

 

      12              MR. BUGDEN:  OKAY.

 

      13                         REDIRECT EXAMINATION

 

      14    BY MS. BARLOW:

 

      15     Q.  LET'S GO BACKWARD WITH WHAT YOU'VE JUST BEEN SPEAK

 

      16     ABOUT --

 

      17              MS. BARLOW:  VAL, I THINK I'LL NEED THOSE LEFT

 

      18     OFF -- I MAY BE USING THOSE.  THANK YOU.

 

      19     Q.  YOU'VE JUST SPOKE WITH THE OXYGEN SATURATION LEVEL, 96

 

      20     PERCENT IS GOOD?

 

      21     A.  YES.

 

      22     Q.  BUT THAT WAS DONE TWO DAYS LATER, TWO DAYS AFTER YOU HAD

 

      23     SEEN HIM WITH THE CHEYNE-STOKING AND THAT SORT OF THING?

 

      24     A.  YES.

 

      25     Q.  DO YOU KNOW WHAT MEDICATIONS HE WAS ON AT THAT TIME?  IF

 

       1     YOU'D LOOK BACK TO PAGE 11.

 

       2     A.  OH, I'M SORRY.

 

       3     Q.  PAGE 11 IN THE EXHIBIT THAT WE WERE TAKING ABOUT, THAT'S

 

       4     MR. ALLDREDGE'S WHICH IS 6B.

 

       5     A.  OKAY.

 

       6     Q.  AND IT -- THAT'S THE ONE THAT HAD YOUR NOTE ON IT.  BUT

 

       7     IN THE UPPER LEFT-HAND CORNER WERE THE DAILY ORDERS BY

 

       8     DR. WEITZEL.  AND IN THAT, ON THE 10TH OF JANUARY AND THAT

 

       9     WAS NOTED AT 1430 WHICH IS 2:30 IN THE AFTERNOON, IS THAT

 

      10     CORRECT?

 

      11     A.  YES.

 

      12     Q.  WHAT MEDICATIONS DID HE ORDER TO BE GIVEN RIGHT THAT

 

      13     MOMENT?

 

      14     A.  THAT WAS A NOTE BY THE NURSE AT THAT HOUR.  I DON'T

 

      15     KNOW -- I CAN'T TELL -- THERE WASN'T AN ORDER AT THE TOP

 

      16     SAYING WHAT TIME IT WAS ORDERED.  THERE WAS A DATE BUT NO

 

      17     TIME.

 

      18              MS. BARLOW:  IF I MAY APPROACH, YOUR HONOR.

 

      19              THE WITNESS:  BUT THE NURSE NOTED IT AT THAT HOUR.

 

      20     Q.  (BY MS. BARLOW)  RIGHT.  THE NURSE NOTED IT AT THAT HOUR

 

      21     EXCUSE ME.

 

      22         WHAT WAS THE HOUR THAT SHE NOTED AT IS THAT HOUR?

 

      23     A.  IT LOOKS LIKE SHE NOTED ME -- DO YOU WANT ME TO READ THE

 

      24     ENTIRE LIST?

 

      25     Q.  JUST THE FIRST ONE.

 

       1     A.  ATIVAN, 1 MILLIGRAM AND HALDOL, IT'S EITHER TEN OR 20.

 

       2     PRESUMPTIVELY 10 MILLIGRAMS, IM NOW.

 

       3     Q.  MEANING INTRAMUSCULARLY?

 

       4     A.  YES.

 

       5     Q.  SO THAT'S THE -- THAT'S MEDICATION THAT YOU TALKED ABOUT

 

       6     MR. ALLDREDGE ALREADY HAVING ON BOARD WHEN YOU WENT TO --

 

       7     WHEN YOU SAW HIM WHEN HE WAS LETHARGIC AND SEDATED?

 

       8     A.  IT WOULD PROBABLY BE IMPORTANT TO LOOK AT THE NURSES'

 

       9     NOTES TO SEE WHAT THEY GAVE THERE.  THERE'S ANOTHER PRN ORDER

 

      10     FOR ATIVAN AND SCHEDULED HALDOL ORDER IT LOOKS LIKE -- NO

 

      11     BELOW THAT.  BUT I'D HAVE TO LOOK AT THERE'S A MEDICATION

 

      12     LIST WHERE YOU CAN GO THROUGH AND FIND OUT WHAT MEDICATIONS

 

      13     THEY RECEIVED AND I WOULD LIKE TO HAVE DONE THAT BUT I

 

      14     DON'T --

 

      15     Q.  YOU DON'T RECALL RIGHT NOW?

 

      16     A.  YES.

 

      17     Q.  RIGHT.  NUMBER THREE ON THAT SAME ORDER, THE DEFENDANT

 

      18     ORDERED HALDOL 5-MILLIGRAM EVERY AM, MEANING MORNING, PERHAPS

 

      19     8 O'CLOCK, 1705 P.M. AND HAS, WHICH IS AT NIGHT, IS THAT

 

      20     CORRECT?

 

      21     A.  YES.

 

      22     Q.  NOW, THERE WAS NOT AN OXYGEN SATURATION DONE AT THE TIME

 

      23     THAT YOU WERE SEEING THE CHEYNE-STOKING RESPIRATIONS, IS THAT

 

      24     CORRECT?

 

      25     A.  UNLESS I HAD ONE DOCUMENTED IN MY TYPED NOTE OR IN THIS

 

       1     WRITTEN NOTE.  IT LOOKS LIKE I ORDERED ONE AND WE COULD

 

       2     CHECK.

 

       3     Q.  THOSE CHARTS ARE REALLY THE BIBLE, AREN'T THEY, FOR

 

       4     WHAT'S HAPPENED?

 

       5     A.  YES.

 

       6     Q.  DO YOU SEE ANY INDICATION OF AN O2 SATURATION FOR THE

 

       7     10TH OF JANUARY?

 

       8     A.  ON PAGE 11?

 

       9     Q.  ON PAGE 11.

 

      10     A.  I DO NOT.

 

      11     Q.  OKAY.  AND ON PAGE 12, WHICH IS THE NEXT PAGE, DO YOU

 

      12     SEE -- DO YOU SEE THE O2 SATURATION THAT SHOWS UP ON THE

 

      13     12TH, IS THAT CORRECT?

 

      14     A.  YES, YES.  THAT'S WHAT I WAS ASKED ABOUT FIVE MINUTES

 

      15     AGO.

 

      16     Q.  RIGHT.  YEAH.

 

      17         SO THAT WAS TWO DAYS LATER?

 

      18     A.  YES.

 

      19     Q.  AND YOU CAN'T TELL FROM THIS WHAT MEDICATIONS WERE GIVEN

 

      20     OTHER THAN -- WELL, YOU CAN'T WITHOUT THE MEDICAL

 

      21     ADMINISTRATION RECORD?

 

      22     A.  THAT'S CORRECT.  JUST SURMISING FROM THE ORDERS BUT YOU

 

      23     WOULD NEED THAT MEDICATION DELIVERY LIST TO SEE WHICH ONES

 

      24     WERE INITIALED AS BEING GIVEN.

 

      25     Q.  LET'S TALK A LITTLE BIT ABOUT MARY CRANE NEXT.  IF YOU

 

       1     HAVE HERS, I BELIEVE IT IS NUMBER 4B.

 

       2     A.  I HAVE IT.

 

       3     Q.  IT IS THE EXHIBIT.  THANK YOU.

 

       4     A.  YES.

 

       5     Q.  YOU HAD WRITTEN THAT THERE WAS A THALAMIC STROKE?

 

       6     A.  YES.

 

       7     Q.  DO THALAMIC STROKES HAVE ANY CONNECTION WITH PHANTOM PAIN

 

       8     ANYTHING OF THAT SORT THAT YOU'RE AWARE OF?

 

       9     A.  I DON'T KNOW THAT IT -- I DON'T KNOW THAT IT DOES.

 

      10     Q.  THANK YOU.

 

      11         MRS. CRANE WAS ORDERED A DURAGESIC PATCH WAS ORDERED AND

 

      12     ADMINISTERED TO MRS. CRANE WHEN SHE ENTERED THE HOSPITAL.  DO

 

      13     YOU KNOW HOW LONG -- WHAT PERIOD OF TIME IT TAKES FOR THE DUR

 

      14     -- SORRY -- DURAGESIC PATCH TO START RELEASING THE MEDICATION

 

      15     INTO THE SYSTEM?

 

      16     A.  IT'S A SLOW RELEASE PREPARATION SO IT'S RELEASED, BY

 

      17     INTENT, OVER 72 HOURS.  AND I WOULD GUESS WITHIN THE FIRST

 

      18     HOUR YOU WOULD HAVE SOME SUPPLY OF PAIN RELIEF FROM THAT, BUT

 

      19     I DON'T KNOW THE EXACT PHARMACOKINETICS OF THAT.

 

      20     Q.  YOU DON'T KNOW THE PEAK EFFECT?  WHEN IT REACHES ITS PEAK

 

      21     EFFECT AND HOPEFULLY LEVELS OUT BECAUSE THAT'S WHY YOU'RE

 

      22     DOING THE PATCH?

 

      23     A.  YOU'RE DOING THE PATCH SO YOU'RE TRYING TO MAINTAIN AS

 

      24     STEADY LEVEL AS YOU CAN FOR THAT PERIOD OF THREE DAYS.

 

      25     TOWARDS THE END OF THAT THREE DAYS I'M SURE THAT YOU -- HENCE

 

       1     YOU CHANGE PATCHES AT THAT PERIOD OF TIME.

 

       2     Q.  BUT I'M TALKING ABOUT HOW LONG IT TAKES TO GET IT UP TO

 

       3     THE THAT LEVEL THAT YOU WANT.

 

       4     A.  I DON'T KNOW THE EXACT PHARMACOKINETICS.

 

       5     Q.  THANK YOU.

 

       6         IF YOU WOULD TURN TO PAGE 242 IN THAT DOCUMENT.  WE'VE

 

       7     TALKED ABOUT THIS BEFORE.  THIS IS THE DAY THAT THE STOOL WAS

 

       8     NOTICED AND YOU CAME INTO CONSULT, DO YOU RECALL THAT?

 

       9     A.  YES.

 

      10     Q.  NOW, YOU HAVE -- I BELIEVE SOME LABORATORY TESTS WERE

 

      11     RUN, IS THAT CORRECT?

 

      12     A.  YES.

 

      13     Q.  WERE ANY OF THOSE LABORATORY TESTS ABNORMAL?

 

      14     A.  THE ONLY ONE I ORDERED WAS THE CBC.  IS THAT WHAT YOU'RE

 

      15     REFERRING TO?

 

      16     Q.  YES.

 

      17     A.  YES.  I DON'T BELIEVE IT WAS ABNORMAL, NO.

 

      18     Q.  HAVING -- AND THEN ON THE NEXT DAY, THE 2ND OF JANUARY IS

 

      19     WHEN THE GYNECOLOGIST DR. MEEK CAME IN AND DID A CONSULT.

 

      20     HAVING A FISTULA THAT HE FOUND, IS THERE ANY CONNECTION

 

      21     BETWEEN THAT AND THE POSSIBILITY OF INFECTION?

 

      22     A.  WELL, THAT'S KIND OF THE QUESTION, IF HE THOUGHT THERE

 

      23     WAS OR NOT.  THE WHITE COUNT THAT WE ORDERED EARLIER WAS

 

      24     NORMAL BUT, YOU KNOW, IT DEPENDS ON HOW THAT -- HE GAVE

 

      25     OPTIONS FOR WHAT HE THOUGHT HOW IT SHOULD BE HANDLED, BUT

 

       1     COULD IT CAUSE INFECTION?  I SUPPOSE IT COULD.  IF HE GAVE

 

       2     ANOTHER PROBABILITY THAT IT MIGHT SPONTANEOUSLY REMIT, BUT I

 

       3     CAN'T SPEAK FOR HIM EXACTLY.

 

       4     Q.  RIGHT, AND I UNDERSTAND.  BUT HE DID RECOMMEND AN

 

       5     ANTIBIOTIC?

 

       6     A.  YEAH.  HE SAID THAT THEY ALSO MAY HEAL SPONTANEOUSLY

 

       7     PROBABLY 25, 35 PERCENT BY TREATING BROAD-SPECTRUM

 

       8     ANTIBIOTICS AND LOW RESIDUE DIET.

 

       9     Q.  SO YOU RECOMMENDED THE ANTIBIOTIC.  IF YOU WOULD TURN TO

 

      10     MED PAGE 248 IN THAT SAME DOCUMENT, DO YOU SEE WHAT DATE

 

      11     ANTIBIOTIC WAS ACTUALLY ORDERED?

 

      12     A.  THERE'S A NOTE AT THE TOP 159630, 1930, PRESUMABLY

 

      13     TELEPHONE ORDER, DR. WEITZEL, KEFLEX, 250 MILLIGRAMS, QID PO.

 

      14     Q.  IS THAT AN ANTIBIOTIC?

 

      15     A.  YES.

 

      16     Q.  THE ANTIBIOTIC WAS ORDERED ON THE 5TH AND BY THE 7TH YOU

 

      17     SAY SHE WAS POSSIBLY SEPTIC, POSSIBLY INFECTIOUS?

 

      18     A.  YES.  I BELIEVE THE PATIENT WAS ON ANTIBIOTIC AS WELL

 

      19     EARLIER FOR A URINARY TRACT, FOR A PRESUMPTIVE URINARY TRACT

 

      20     INFECTION.

 

      21     Q.  I'M NOT SURE I HAVE A DOCUMENT THAT HAS THAT UP HERE WITH

 

      22     ME.

 

      23         DEFENSE COUNSEL ASKED YOU ABOUT BREAKTHROUGH PAIN, WOULD

 

      24     YOU DEFINE THAT FOR US?

 

      25     A.  IF YOU'RE ALREADY ON ANY TYPE OF PAIN MEDICATION

 

       1     BREAKTHROUGH PAIN WOULD BE ANY PAIN WHILE YOU'RE ON THAT

 

       2     MEDICATION.  IT WOULD BE --

 

       3     Q.  DO YOU KNOW WHY THEY CALL IT BREAKTHROUGH PAIN?

 

       4     A.  IT'S KIND OF A VAGUE TERM.  BUT I SUPPOSE IT COULD BE

 

       5     CONSTRUED THAT THE PAIN SUPPORT THAT'S BEING GIVEN WASN'T

 

       6     ADEQUATE, OR PRIOR TO THAT NEXT DOSE DELIVERED THERE WAS PAIN

 

       7     THAT CAME THROUGH THAT'S WHY THE DURAGESIC PATCH, FOR

 

       8     EXAMPLE, GIVES MAYBE A MORE SMOOTH LEVEL.

 

       9     Q.  BREAKTHROUGH PAIN KIND OF IMPLYING THAT IT BREAKS THROUGH

 

      10     THE MEDICATION AND CAUSES THE PAIN?

 

      11     A.  YES, YES.

 

      12     Q.  WITH PAIN MEDICATIONS YOU'RE WALKING A FINE LINE, ISN'T

 

      13     THAT CORRECT?

 

      14     A.  YES.

 

      15              MR. BUGDEN:  OBJECTION LEADING.

 

      16              THE COURT:  SUSTAINED.

 

      17              MS. BARLOW:  EXCUSE ME.

 

      18     Q.  (BY MS. BARLOW)  WHAT IS YOUR GOAL WITH PAIN MEDICATION?

 

      19     A.  TO ALLEVIATE PAIN, SUFFERING AS THE BEST YOU CAN KEEPING

 

      20     IN CONSIDERATION ALL OF THE OTHER ISSUES WITH THE PATIENT AND

 

      21     QUALITY OF LIFE.

 

      22     Q.  WHAT ABOUT SIDE EFFECTS OF PAIN MEDICATION?

 

      23     A.  DROWSINESS, NAUSEA.  YOU KNOW, DEPENDING ON THE LEVEL OF

 

      24     DROWSINESS AND THE LEVEL OF SEDATION, OTHER THINGS COULD

 

      25     HAPPEN.  YOU KNOW, IF YOU WERE SO FAR SEDATED THAT YOU COULD

 

       1     ASPIRATE WHICH WE ALREADY WENT OVER A LITTLE BIT AND THOSE

 

       2     KINDS OF ISSUES.  YOUR BLOOD PRESSURE, I SUPPOSE, COULD DROP

 

       3     IF YOU RECEIVE TOO MUCH OF A REAL STRONG NARCOTIC AT A

 

       4     CERTAIN TIME.

 

       5     Q.  SO YOU HAVE TO TAKE ALL THOSE FACTORS INTO ACCOUNT WHEN

 

       6     YOU'RE ORDERING A PAIN MEDICATION OR ADMINISTERING PAIN

 

       7     MEDICATION?

 

       8     A.  SURE, SURE.

 

       9     Q.  AND THEN LET'S TALK ABOUT MRS. LARSEN.  YOU INDICATED IN

 

      10     YOUR INITIAL CONSULTATION AND AGAIN THIS IS I BELIEVE IT'S 3B

 

      11     THAT THERE WAS NO VERBAL COMPLAINT OF PAIN.  DO YOU RECALL

 

      12     SEEING ANY SIGNS OR SYMPTOMS THE NONVERBAL COMMUNICATIONS OF

 

      13     PAIN?  I'M SORRY AND I DON'T HAVE THAT PAGE NUMBER.

 

      14     A.  I HAVE IT.

 

      15     Q.  WHAT PAGE NUMBER IS THAT ON?

 

      16     A.  447.

 

      17     Q.  THANK YOU.

 

      18     A.  THAT WAS ON THE INITIAL EVALUATION AND, NO, I DON'T

 

      19     RECALL SEEING ANY.

 

      20     Q.  WHEN YOU'RE TALKING ABOUT -- YOU'VE TALKED ABOUT ORDERING

 

      21     ATIVAN FOR SEIZURE CONTROL, IS THAT DIFFERENT THAN ORDERING

 

      22     ATIVAN FOR AGITATION?

 

      23     A.  YES.  BOTH ARE USED TO AFFECT WHAT YOU'RE LOOKING TO

 

      24     CONTROL.  WITH SEIZURES, MANY TIMES ATIVAN HAS TO BE TITRATED

 

      25     TO A LEVEL THAT YOU MIGHT OTHERWISE THINK WOULD BE QUITE --

 

       1     YOU KNOW, QUITE HIGH.  BUT SOMEBODY STILL HAVING SEIZURES

 

       2     IT'S PROBABLY ONE OF -- THE MEDICINE OR ONE OF THE TOP FEW

 

       3     MEDICINES OF CHOICE TO GIVE TO STOP THOSE SEIZURES IN THE

 

       4     IMMEDIATE SENSE.

 

       5     Q.  I BELIEVE YOU ORDERED ON PAGE 462 ATIVAN IV TITRATE ONE

 

       6     TO 3 MILLIGRAM OVER FIVE MINUTES UNTIL SEIZURE STOPPED AND

 

       7     THEN THERE WAS A SUBSEQUENT --

 

       8     A.  RIGHT.

 

       9     Q.  -- EXCUSE ME.  DOES THAT SOUND FAMILIAR?

 

      10     A.  YES.

 

      11     Q.  AND THEN SUBSEQUENTLY -- THAT WAS AT 6:05.  AT 6:20

 

      12     ANOTHER ORDER TELEPHONE ORDER TO GIVE AN ADDITIONAL 1

 

      13     MILLIGRAM.

 

      14     A.  YES.

 

      15     Q.  IF YOU WERE CONTROLLING AGITATION WOULD YOU HAVE MOVED

 

      16     THE TITRATION UP THAT QUICKLY?

 

      17     A.  IT SOUNDS LIKE THERE WAS A PHONE ORDER GIVEN -- OR A

 

      18     PHONE CALL SAYING MAYBE THE 3 MILLIGRAMS WASN'T ENOUGH SO

 

      19     THEN ANOTHER MILLIGRAM WAS GIVEN.  IF YOU'RE DOING AGITATION

 

      20     YOU COULD CONCEIVABLY DO THE SAME THING.  IF YOU GAVE THREE

 

      21     AND IT WASN'T ADEQUATE, YOU COULD GIVE MORE.  THOSE DOSES FOR

 

      22     EITHER SCENARIO ARE NOT LARGE DOSES TO GIVE.  PEOPLE TAKING

 

      23     THAT MUCH THAT UNDERGO OUTPATIENT PROCEDURES AND SOME PEOPLE

 

      24     IT'S ALL TO EFFECT -- AGAIN, I DON'T WANT TO BRING UP THAT

 

      25     TITRATE WORD, IT SOUNDS LIKE YOU'VE BEEN OVER THAT.  BUT IT'S

 

       1     TRUE AND 3 MILLIGRAMS FOR ONE PERSON IS DIFFERENT THEN 10 FOR

 

       2     ANOTHER AND IT'S --

 

       3     Q.  SO YOU START LOW, YOU MONITOR, AND IF IT'S NOT EFFECTIVE,

 

       4     YOU GIVE MORE?

 

       5     A.  RIGHT.

 

       6     Q.  AND IF IT'S EFFECTIVE, WHAT DO YOU DO THEN?  DO YOU GIVE

 

       7     MORE?

 

       8     A.  IF IT IS EFFECTIVE?

 

       9     Q.  IF IT HAS BEEN EFFECTIVE.

 

      10     A.  THEN YOU LOOK FOR SOMETHING TO KEEP THE AMOUNT OF CONTROL

 

      11     OR CONTROL THE SEIZURE OR THE EVENT WHERE YOU WOULD LIKE TO

 

      12     HAVE IT WITHOUT GOING TOO FAR WITH ONE CERTAIN MEDICATION

 

      13     LIKE, YOU KNOW, THE EVENTUAL SIDE EFFECT OF ATIVAN WOULD BE

 

      14     TO PUT SOMEONE TO SLEEP, SO YOU WOULD STOP BEFORE YOU GOT TO

 

      15     THAT POINT AND USE OTHER MEDICATIONS TO CONTROL THE SEIZURES

 

      16     SUCH AS DILANTIN OR MAYBE OTHERS THERE'S OTHER ANTI-SEIZURE

 

      17     MEDICATIONS YOU CAN CHOOSE.

 

      18     Q.  DO YOU HAVE 462 IN FRONT OF YOU, PAGE 462?

 

      19     A.  YES.

 

      20     Q.  ON THE LEFT SIDE HALFWAY DOWN THE ORDERS THAT YOU WROTE

 

      21     YOU'VE WRITTEN DILANTIN, ONE GRAM, IS THAT IV?

 

      22     A.  YES.

 

      23     Q.  AND WOULD YOU PLEASE READ THE REST OF THAT PARAGRAPH?

 

      24     A.  LOAD OVER 40 MINUTES AND NORMAL SALINE LINE, THEN 100

 

      25     MILLIGRAMS IV Q8 HOURS.

 

       1     Q.  IF YOU WOULD STOP THERE.  SO YOU DID A FAST LOAD FIRST,

 

       2     IS THAT CORRECT, OR RELATIVELY FAST?

 

       3     A.  IT'S INTENTIONALLY NOT GIVEN FAST.  BUT IT'S GIVEN OVER A

 

       4     40 MINUTE INTERVAL SO YOU DON'T GET HYPOTENSION OR BLOOD

 

       5     PRESSURE PROBLEMS.

 

       6     Q.  BUT THEN YOU PUT THEN 100-MILLIGRAM IV EVERY EIGHT HOURS,

 

       7     WAS THAT A STANDING ORDER THEN FOR EVERY EIGHT HOURS?

 

       8     A.  YES.

 

       9     Q.  AND THAT IS THE ORDER THAT WAS DISCONTINUED ON THE 29TH?

 

      10     A.  YES.

 

      11              MS. BARLOW:  THAT'S ALL I HAVE.  THANK YOU, YOUR

 

      12     HONOR.  THANK YOU, DR. DIENHART.

 

      13              THE COURT:  RECROSS.

 

      14              MR. BUGDEN:  JUST A COUPLE OF QUESTIONS.

 

      15                         RECROSS-EXAMINATION

 

      16    BY MR. BUGDEN:

 

      17     Q.  WITH REGARD TO MARY CRANE, AS COUNSEL JUST ASKED YOU, ON

 

      18     THIS THEME OF TREATING INFECTION ON I THINK IT WAS DECEMBER

 

      19     30TH, DR. WEITZEL ORDERED THAT THE PATIENT BE GIVEN AN

 

      20     ANTIBIOTIC CALLED CIPRO, IS THAT RIGHT?

 

      21     A.  I DON'T HAVE THAT IN FRONT OF ME I --

 

      22     Q.  WOULD YOU TURN THAT ON?

 

      23     A.  YES.

 

      24     Q.  I'M SORRY.

 

      25         SO DR. WEITZEL ORDERED THE TREATMENT OF THE INFECTION

 

       1     CONDITION ON DECEMBER 30TH WITH CIPRO, RIGHT?

 

       2     A.  YES.

 

       3     Q.  AND THEN IT WAS DR. WEITZEL THAT THEN ORDERED AN

 

       4     ADDITIONAL ANTIBIOTIC ON JANUARY 5TH, THAT WAS THE KEFLEX, IS

 

       5     THAT RIGHT?

 

       6     A.  I BELIEVE SO, YES.

 

       7     Q.  SO HE WAS RESPONDING TO THE PATIENT'S SYMPTOMS IN TWO

 

       8     DIFFERENT CASES TRYING TO TREAT THE INFECTION WITH

 

       9     ANTIBIOTICS, IS THAT RIGHT?

 

      10     A.  TWO DIFFERENT TIMES ANTIBIOTICS WERE ORDERED, YES.

 

      11     Q.  OKAY.

 

      12              MR. BUGDEN:  THAT'S ALL I HAVE.  THANK YOU VERY

 

      13     MUCH.

 

      14              MS. BARLOW:  JUST ONE QUESTION, YOUR HONOR.  DR.

 

      15     DIENHART, I PROMISE JUST ONE LAST QUESTION.

 

      16                         REDIRECT EXAMINATION

 

      17    BY MS. BARLOW:

 

      18     Q.  THESE THREE PATIENTS THAT YOU DID THE MED --

 

      19              MR. BUGDEN:  THIS IS BEYOND THE SCOPE.

 

      20              THE COURT:  SUSTAINED.

 

      21              MS. BARLOW:  NO QUESTIONS.  THANK YOU.

 

      22              THE COURT:  MAY THIS WITNESS STEP DOWN?

 

      23              MS. BARLOW:  YES, YOUR HONOR.

 

      24              MR. BUGDEN:  YES.

 

      25              THE COURT:  YOU MAY STEP DOWN.  THANK YOU FOR

 

       1     TESTIFYING.  MAY HE BE EXCUSED, I ASSUME?

 

       2              MS. BARLOW:  YES, YOUR HONOR.

 

       3              THE COURT:  THANKS FOR COMING, DOCTOR. 

<<Back to Home Page