David Dienhart, MD
12 DAVID DIENHART,
13 BEING FIRST DULY SWORN, WAS EXAMINED AND TESTIFIED
14 AS FOLLOWS:
15 DIRECT EXAMINATION
16 BY MR. WILSON:
17 Q. GOOD MORNING, DOCTOR.
18 A. GOOD MORNING.
19 Q. WOULD YOU STATE YOUR FULL NAME?
20 A. DAVID GEORGE DIENHART.
21 Q. OKAY. AND WOULD YOU TELL US, DOCTOR, ARE YOU
22 SELF-EMPLOYED AT THE PRESENT TIME?
23 A. I'M A MEMBER OF A GROUP PRACTICE.
24 Q. OKAY.
25 A. IN SALT LAKE CITY.
1046
1 Q. AND WHERE IS THAT LOCATED?
2 A. MAIN OFFICE IS IN MURRAY, UTAH. WE HAVE A FEW OTHER
3 OFFICES. IT'S CALLED THE HEART AND LUNG INSTITUTE. I'M ONE
4 OF THE PULMONARY DOCTORS IN THAT GROUP.
5 Q. OKAY. HOW LONG HAVE YOU BEEN IN PRACTICE AT THAT
6 PARTICULAR LOCATION?
7 A. I STARTED THERE ALMOST THREE -- THREE YEARS AGO -- NOT
8 QUITE THREE YEARS AGO.
9 Q. AND PREVIOUS TO THAT TIME, WHERE DID YOU PRACTICE?
10 A. I WAS EMPLOYED AT DAVIS HOSPITAL. I WAS SELF-EMPLOYED.
11 Q. CAN YOU TELL ME HOW LONG YOU WERE IN PRACTICE AT THE
12 DAVIS HOSPITAL?
13 A. NOT -- NOT QUITE THREE YEARS.
14 Q. OKAY. CAN YOU GIVE US -- WELL, LET ME -- LET ME ASK IT
15 THIS WAY. WHAT IS YOUR EDUCATIONAL BACKGROUND?
16 A. MEDICAL SCHOOL, GRADUATED FROM MEDICAL SCHOOL. AND
17 RESIDENCIES IN INTERNAL MEDICINE AND FELLOWSHIPS IN
18 HEMATOLOGY, MEDICAL ONCOLOGY, PULMONARY, AND CRITICAL CARE
19 MEDICINE.
20 Q. YOU SPEAK RATHER SOFTLY. COULD I GET YOU TO SPEAK UP A
21 LITTLE BIT --
22 A. ABSOLUTELY.
23 Q. -- IF YOU WOULD, PLEASE?
24 THE COURT: MAYBE WE COULD JUST TURN OFF THAT
25 PROJECTOR UNTIL WE NEED IT. I THINK IT'S THE PROJECTOR
1047
1 ITSELF.
2 MR. STIRBA: SANDA?
3 THE COURT: MAYBE YOU BETTER NOT TOUCH THAT --
4 MR. STIRBA: I THINK IT'S BACK HERE.
5 MR. WILSON: I'M GLAD SOMEBODY KNOWS WHERE IT IS.
6 MR. STIRBA: WELL, I MAY NOT.
7 (ASSISTANT TURNS PROJECTOR OFF.)
8 MR. STIRBA: I WAS SORT OF RIGHT. THERE WE GO.
9 THE COURT: IT TOOK THREE PEOPLE TO TURN THAT OFF.
10 BUT IF YOU COULD, KEEP YOUR VOICE UP.
11 MR. WILSON: YOU'LL NOTICE IT WAS THE LEGAL
12 ASSISTANT THAT WAS FINALLY ABLE TO DO IT, YOUR HONOR.
13 THE COURT: THAT'S CORRECT. THAT'S RIGHT.
14 MR. STIRBA: WE'RE IN THE RIGHT PROFESSION.
15 Q. (BY MR. WILSON) SO YOU INDICATED YOU GRADUATED FROM
16 WHAT COLLEGE OF MEDICINE?
17 A. UNIVERSITY OF MISSOURI.
18 Q. OKAY.
19 A. 19 --
20 Q. AND WHEN WAS THAT?
21 A. 1980.
22 Q. OKAY. SUBSEQUENT TO THAT TIME, DID YOU -- DID YOU DO
23 ANY INTERNSHIPS?
24 A. YES. I -- I DID AN INTERNSHIP AND RESIDENCY IN INTERNAL
25 MEDICINE.
1048
1 Q. AT THE SAME SCHOOL?
2 A. NO, I'LL ELABORATE. AT THE MEDICAL COLLEGE OF VIRGINIA.
3 Q. OKAY. AND WHEN DID YOU FINISH THAT INTERNSHIP?
4 A. NINETEEN -- INTERNSHIP? IT'S ONE YEAR. 1981.
5 Q. OKAY. AND DO YOU HOLD ANY CERTIFICATIONS, BOARD
6 CERTIFICATIONS?
7 A. YES.
8 Q. CAN YOU ELABORATE FOR US, PLEASE?
9 A. INTERNAL MEDICINE, MEDICAL ONCOLOGY, HEMATOLOGY,
10 PULMONARY MEDICINE, AND CRITICAL CARE MEDICINE.
11 Q. AND ARE THOSE CERTIFICATIONS CURRENT AT THE PRESENT
12 TIME?
13 A. YES, UH-HUH.
14 Q. WERE THEY CURRENT BACK IN 1995?
15 A. YES. IN 1995 I HAD JUST BECOME CERTIFIED IN CRITICAL
16 CARE MEDICINE.
17 Q. OKAY. THAT WAS AT WHAT TIME IN '95?
18 A. THE TESTS ARE USUALLY IN THE FALL OF THE YEAR, SO
19 PROBABLY THE TEST WAS IN SEPTEMBER OR OCTOBER.
20 Q. OKAY. I WANT TO TALK TO YOU ABOUT EVENTS TRANSPIRING AT
21 THE DAVIS HOSPITAL BACK IN DECEMBER AND JANUARY -- DECEMBER
22 OF 1995 AND JANUARY OF 1996 -- WHICH CONCERNED SEVERAL
23 PATIENTS THAT YOU APPARENTLY HAD SOME CONTACT WITH. DO YOU
24 REMEMBER -- DO YOU HAVE A RECOLLECTION OF THAT TIME PERIOD,
25 DOCTOR?
1049
1 A. JUST FROM REVIEWING MY NOTES, YES.
2 Q. OKAY. YOU'VE HAD AN OPPORTUNITY TO REVIEW YOUR NOTES
3 PRIOR TO THESE PROCEEDINGS HERE TODAY?
4 A. YES.
5 Q. AND, FIRST OF ALL, LET ME ASK YOU, YOU SAID YOU WERE --
6 YOU WERE PRACTICING AT THE HOSPITAL. COULD YOU -- COULD YOU
7 CLARIFY THAT FOR US A LITTLE BIT AS TO JUST WHAT TYPE OF
8 RELATIONSHIP YOU HAD WITH THE HOSPITAL?
9 A. I WAS SELF-EMPLOYED. I WAS A PHYSICIAN THAT HAD AN
10 OFFICE IN AN OFFICE BUILDING ADJACENT TO THE HOSPITAL.
11 Q. IN AN OFFICE BUILDING ADJACENT TO THE HOSPITAL?
12 A. YES.
13 Q. OKAY. WAS THERE ANY CONTRACTUAL RELATIONSHIP WITH YOU
14 AND THE HOSPITAL AT THAT TIME TO DO ANY KIND OF WORK FOR THE
15 HOSPITAL?
16 A. I WAS DIRECTOR OF RESPIRATORY MEDICINE THERE, SO I HAD
17 A -- SOME -- SOME TYPE OF CONTRACT IN TERMS OF SUPPLYING
18 SUPERVISION FOR THAT DEPARTMENT, YES.
19 Q. WHAT TYPES OF DUTIES AND FUNCTIONS DID YOU DO AS THE
20 DIRECTOR OF RESPIRATORY MEDICINE?
21 A. I WOULD ATTEND A MONTHLY RESPIRATORY CARE MEETING WITH
22 THE RESPIRATORY THERAPISTS. IF THERE WERE PROBLEMS OR
23 SOMETIMES THINGS WOULD BE BROUGHT TO MY ATTENTION TO TRY AND
24 HELP OUT.
25 Q. DID YOU HAVE OTHER DUTIES AND FUNCTIONS THAT YOU
1050
1 PROVIDED AT THE HOSPITAL?
2 A. I WAS ON A CALL SCHEDULE.
3 Q. ON A CALL SCHEDULE. ALL RIGHT. AND WHAT DOES THAT
4 MEAN?
5 A. THERE WAS AN EMERGENCY ROOM CALL SCHEDULE. EVERY --
6 DEPENDING ON HOW MANY PEOPLE WERE TAKING CALL, I WOULD BE
7 ASSIGNED TO THAT CALL SO IF PATIENTS CAME IN I WOULD ADMIT
8 THOSE PATIENTS AND CARE FOR THEM.
9 I ALSO WAS THE PULMONOLOGIST AT THE HOSPITAL, SO I
10 WOULD VIRTUALLY BE ON CALL ALL THE TIME FOR THAT SERVICE IF
11 THERE WAS A NEED.
12 Q. AND THIS -- WERE YOU FAMILIAR WITH THE GEROPSYCHIATRIC
13 UNIT THAT WAS BEING OPERATED --
14 A. UH-HUH --
15 Q. -- AT THE HOSPITAL? DID YOU, IN YOUR RESPONSIBILITIES
16 AS AN ON-CALL PHYSICIAN, HAVE OCCASION TO ATTEND TO PATIENTS
17 AT THE GEROPSYCH UNIT?
18 A. UH-HUH. YES.
19 Q. OKAY. PRIMARILY, WHAT TYPE OF FUNCTIONS OR SERVICES DID
20 YOU PROVIDE FOR THE GEROPSYCH UNIT?
21 A. AS THE INTERNIST ON CALL FOR THAT DAY I WOULD GO IN AND
22 EVALUATE A PATIENT THAT WAS ADMITTED TO THE GEROPSYCHIATRIC
23 UNIT AND SUMMARIZE THEIR MEDICAL PROBLEMS, PROVIDE ANY
24 INSIGHT I COULD TO THEIR MEDICAL PROBLEMS.
25 Q. OKAY. WE'VE HAD A NUMBER OF INTERNISTS TESTIFY. MAYBE
1051
1 WE OUGHT TO DEFINE JUST EXACTLY WHAT IS THAT SPECIALTY?
2 WHAT -- WHAT DOES THAT SPECIALTY ENTAIL?
3 A. IT'S THE SPECIALTY OF INTERNAL MEDICINE. IT'S CALLED
4 INTERNAL MEDICINE. AND IT INVOLVES HEART, LUNGS,
5 GASTROENTEROLOGY, NEPHROLOGY, ENDOCRINOLOGY, HEMATOLOGY,
6 MEDICAL ONCOLOGY, PULMONARY CRITICAL AREA.
7 Q. OKAY.
8 A. A FEW -- A FEW OTHERS. IT'S JUST SORT OF A BROAD
9 DISCIPLINE IN MEDICINE.
10 Q. SO IN YOUR CAPACITY AS AN INTERNIST, YOU WOULD EVALUATE
11 THESE PATIENTS ON ADMISSION? THAT WAS ONE OF THE SERVICES
12 YOU PROVIDED?
13 A. YES. USUALLY WITHIN 24 HOURS OF ADMISSION. NOT
14 NECESSARILY ON THE VERY DAY OF ADMISSION.
15 Q. OKAY. AND THAT PROCESS OF EVALUATION, CAN YOU JUST TELL
16 US WHAT TYPE OF PROCESS YOU WOULD FOLLOW IN TERMS OF MAKING
17 THAT EVALUATION?
18 A. I WOULD GO IN AND INTERVIEW THE PATIENT, EXAMINE THE
19 PATIENT. IF THERE WAS ANY RECORDS I HAD ACCESS TO, I WOULD
20 TRY AND REVIEW THOSE RECORDS. ANYTHING I COULD DO TO
21 DETERMINE PAST MEDICAL HISTORY, PAST MEDICAL PROBLEMS. I
22 WOULD TRY AND OUTLINE THOSE PROBLEMS IN DETAIL AS I COULD.
23 IF THERE WAS ANYTHING I THOUGHT I SHOULD DO FROM A MEDICAL
24 POINT THEN I WOULD TRY AND INSTITUTE THAT, OR ORDERS OR NOT
25 ORDERS, OR OFTEN IT WAS A SUMMARY OF WHAT -- WHAT HAD
1052
1 HAPPENED IN THE PAST, WHAT RECORDS I COULD GET. AND THEN
2 ANY -- ANYTHING I THOUGHT THAT WAS APPROPRIATE TO DO AT THE
3 TIME FROM A MEDICAL POINT OF VIEW.
4 Q. IN YOUR CAPACITY OF DOING THAT EVALUATION, WOULD YOU --
5 WOULD YOU PERFORM SERVICES SUCH AS -- AS ORDER MEDICATION
6 OR -- OR DO ANY OF THOSE TYPES OF FUNCTIONS?
7 A. ANYTHING I THOUGHT WAS APPROPRIATE I WOULD -- I WOULD
8 DO.
9 Q. OKAY. WERE YOU THE ATTENDING PHYSICIAN FOR THAT
10 PARTICULAR PATIENT?
11 A. NO.
12 Q. CAN YOU TELL THE JURY WHAT -- WHAT IT MEANS TO BE THE
13 ATTENDING PHYSICIAN?
14 A. IN -- IN GENERAL THE WORD "ATTENDING PHYSICIAN" WOULD BE
15 THE ONE IN CHARGE OF THAT PATIENT DURING THE
16 HOSPITALIZATION. THAT -- THAT ATTENDING CONSULTS OTHER
17 PHYSICIANS TO GO SEE THE PATIENT, PROVIDE ANY SERVICES THAT
18 CAN BE PERFORMED. ANY MAJOR DECISIONS OFTENTIMES GO THROUGH
19 THE ATTENDING PHYSICIAN SO THAT THEY CAN DECIDE IF IT'S
20 APPROPRIATE. THEY GENERALLY HAVE PRETTY CLOSE CONTACT WITH
21 THE FAMILY. AND -- AND PROBABLY A BETTER RAPPORT OR -- OR
22 AT LEAST TO A LARGE EXTENT MORE RAPPORT WITH THE PATIENT AS
23 THEY SEE THE PATIENT ON A -- OFTENTIMES A DAILY BASIS.
24 Q. SO AS THE -- AS THE CONSULTANT TO THE ATTENDING
25 PHYSICIAN, WOULD YOU OCCUPY A DIFFERENT ROLE THEN?
1053
1 A. AS A -- AS A CONSULTANT I WOULD OFTENTIMES MAKE THE
2 INITIAL EVALUATION, OUTLINE PROBLEMS. IF I HAD ANY
3 SUGGESTIONS, LEAVE -- LEAVE THOSE SUGGESTIONS. IF I FELT
4 LIKE THEY WERE STRONG ENOUGH SUGGESTIONS I MIGHT EVEN LEAVE
5 SOME ORDERS AND RECOMMENDATIONS. I MIGHT FOLLOW UP ON THOSE
6 ORDERS AND RECOMMENDATIONS, IF I HAD MADE THEM, AND THEN
7 THAT MIGHT BE ALL MY INTERACTION. IT MIGHT BE A ONE-TIME
8 VISIT; IT MIGHT BE A VISIT THEN AND MAYBE ONE A DAY OR TWO
9 LATER TO FOLLOW UP ON THOSE INTERACTIONS. IT OFTENTIMES WAS
10 ONLY A ONE-TIME VISIT IN THAT UNIT, BUT IT -- OR IT MIGHT BE
11 A WEEK LATER JUST TO FOLLOW UP AND SEE HOW THINGS WERE
12 GOING.
13 Q. I'M GOING TO HAND YOU WHAT'S PREVIOUSLY BEEN MARKED AS
14 STATE'S EXHIBIT 3, WHICH IS AN EXHIBIT WHICH CONTAINS THE
15 MEDICAL RECORD FOR JUDITH LARSEN THAT WAS MAINTAINED AT
16 THE -- THE DAVIS HOSPITAL PERTAINING TO THE TIME PERIOD IN
17 DECEMBER OF 1995. I'D ASK YOU, FIRST OF ALL, IF YOU COULD
18 TAKE A LOOK -- IF YOU WOULD TURN TO -- IT WOULD BE UNDER MED
19 NUMBER-00447. I WOULD IMAGINE THAT -- THAT PERTAINS TO YOUR
20 REPORT OF CONSULTATION. CAN YOU FIND THAT?
21 A. YES, UH-HUH.
22 Q. OKAY.
23 MR. WILSON: CAN WE TURN THIS THING BACK ON NOW?
24 MR. STIRBA: I'M NOT SURE I CAN, BUT --
25 MR. WILSON: THANK YOU.
1054
1 Q. (BY MR. WILSON) FIRST OF ALL, DOCTOR, WHAT DATE IS --
2 DOES THAT BEAR? EXCUSE ME. I HAVEN'T PUT IT UP ON THE
3 SCREEN YET, BUT LOOKING AT THE EXHIBIT YOU HAVE IN FRONT OF
4 YOU.
5 A. 12/8/95.
6 Q. 12/8/95?
7 MR. WILSON: I ASSUME THAT WILL CLEAR UP IN A
8 MINUTE.
9 ASSISTANT: YOU TURNED THE PROJECTOR ON FIRST SO --
10 IT WILL COME ON. OKAY.
11 MR. WILSON: WE'RE HAVING TECHNICAL DIFFICULTIES.
12 Q. (BY MR. WILSON) HAVE YOU HAD AN OPPORTUNITY TO REVIEW
13 THE REPORT OF CONSULTATION?
14 A. YES, UH-HUH.
15 Q. PREVIOUS TO THESE PROCEEDINGS?
16 A. YES.
17 Q. SO I ASSUME THIS -- THIS IS THE DATE OF THE INITIAL
18 EVALUATION YOU CONDUCTED --
19 A. YES.
20 Q. -- ON JUDITH LARSEN?
21 A. YES.
22 Q. THE -- THE REPORT GOES THROUGH A VARIETY OF AREAS, DOES
23 IT NOT, IN TERMS OF WHAT YOU ADDRESSED IN -- IN EVALUATING
24 THIS PATIENT?
25 A. YES.
1055
1 Q. FIRST AREA, YOU TALK ABOUT THE HISTORY OF THE PATIENT
2 AND THE PAST MEDICAL HISTORY. WHERE DID YOU GET THAT
3 INFORMATION FROM? DO YOU REMEMBER?
4 A. PROBABLY FROM ANY RECORDS THAT CAME WITH THE PATIENT.
5 ANYTHING I HAD TO REVIEW I WOULD REVIEW IT AND -- LOOKS LIKE
6 I SUMMARIZED HISTORY OF PAST MEDICAL PROBLEMS. SOMETIMES
7 THEY WEREN'T VERY EXTENSIVE INFORMATION THAT I HAD
8 AVAILABLE, MAYBE AN OLD HISTORY AND PHYSICAL FROM SOME OTHER
9 PHYSICIAN I'D HAVE AND I'D DETAIL WHATEVER -- WHATEVER WAS
10 WRITTEN THERE.
11 Q. OKAY. AT THE BOTTOM OF PAGE 1 IT TALKS ABOUT
12 MEDICATIONS. ARE THOSE MEDICATIONS THAT SHE'D BEEN
13 RECEIVING IN THE PAST OR ARE THOSE MEDICATIONS THAT SHE'S
14 RECEIVING AT THE TIME OF HER ADMISSION?
15 A. I DON'T -- I DON'T KNOW.
16 Q. ALL RIGHT. LET ME TURN YOUR ATTENTION TO THE NEXT PAGE,
17 PAGE 2. AND YOU NOTE ON: THAT PAST HISTORY OF
18 CARDIOVASCULAR (SIC) ACCIDENT IN JANUARY OF 1995.
19 THE COURT: I DON'T THINK IT'S CARDIO.
20 Q. (BY MR. WILSON) WHAT DOES THAT MEAN?
21 A. CEREBRO --
22 THE WITNESS: YOU'RE RIGHT. IT'S CEREBRO.
23 Q. (BY MR. WILSON) PARDON?
24 A. IT'S A PAST CEREBROVASCULAR ACCIDENT.
25 Q. WHAT IS -- WHAT IS A CEREBROVASCULAR ACCIDENT?
1056
1 A. A STROKE.
2 Q. OKAY. AND THEN YOU -- YOU HAVE FURTHER NOTES THAT YOU
3 MAKE RELATIVE TO REVIEWING SOME C.T. SCANS, OR AT LEAST
4 NOTES THAT YOU'VE MADE AS TO THOSE C.T. SCANS.
5 A. YES.
6 Q. CAN YOU EXPLAIN WHAT YOUR FINDINGS WERE AS TO YOUR
7 REVIEW OF THOSE?
8 A. I DID NOT REVIEW THE C.T. SCANS. THOSE WOULD HAVE BEEN
9 ANY NOTES I HAD IN THE RECORD AVAILABLE THAT WERE IN
10 RELATION TO THOSE C.T. SCANS.
11 Q. SO THEY REFERENCE NOTES THAT YOU RECEIVED AS TO THE --
12 THE PRIOR MEDICAL HISTORY?
13 A. YES.
14 Q. DO THOSE NOTES HAVE ANY SIGNIFICANCE TO YOU IN TERMS OF
15 YOUR EVALUATION?
16 A. WELL, IT -- IT'S -- IT SUGGESTS TO ME THIS PATIENT HAD
17 AN OLD STROKE, AND THE C.T. SCAN WAS CONSISTENT WITH THAT.
18 Q. OKAY. THERE WAS NO -- NO EVIDENCE OF ANY RECENT
19 STROKES?
20 A. NOT BY THE REPORTS THAT I HAD IN FRONT OF ME.
21 Q. WHAT IS THE TERM -- DOWN IN THE SECOND PARAGRAPH YOU SAY
22 THERE IS A PAST MEDICAL HISTORY OF ISCHEMIC HEART DISEASE?
23 A. ISCHEMIC HEART DISEASE IS A CORONARY ARTERY DISEASE SUCH
24 THAT THAT MIGHT BE ASSOCIATED WITH THE POSSIBILITY FOR A
25 MYOCARDIAL INFARCTION OR FUTURE ISCHEMIC PROBLEMS IN THE
1057
1 HEART.
2 Q. SO YOU GO THROUGH THIS PAST MEDICAL HISTORY AS PART OF
3 YOUR EVALUATION AND THEN YOU DO AN ACTUAL PHYSICAL
4 EVALUATION OF THE PATIENT?
5 A. YES.
6 Q. AND THERE'S ALSO A VARIETY OF TESTS THAT ARE CONDUCTED
7 ON THE PATIENT, ARE THERE NOT, AT THAT TIME? LOOK AT
8 PAGE 3.
9 A. LOOKS LIKE I REVIEWED SOME LABORATORY THAT WAS CONDUCTED
10 ON -- A COUPLE OF DAYS EARLIER FROM 12/6.
11 Q. OKAY. SO YOU WOULD HAVE HAD THAT -- THAT INFORMATION IN
12 FRONT OF YOU AT THE TIME THAT YOU CONDUCTED THIS EVALUATION
13 ON THIS PARTICULAR PATIENT?
14 A. YES.
15 Q. OKAY. AND YOU ALSO HAD AVAILABLE TO YOU, APPARENTLY,
16 SOME CHEST X-RAYS?
17 A. YES. OR AT LEAST THE REPORT OF THE X-RAY.
18 Q. LET'S -- LET'S TALK A LITTLE BIT ABOUT THAT PARTICULAR
19 AREA OF YOUR EXAM. YOU INDICATE THERE'S NO EVIDENCE OF
20 INFILTRATE. CAN YOU TELL US WHAT THAT MEANS?
21 A. NO -- THAT WOULD BE SYNONYMOUS WITH PNEUMONIA. NO
22 EVIDENCE OF PNEUMONIA OR PARENCHYMA LUNG DISEASE. THE LUNGS
23 APPEARED CLEAR.
24 Q. LUNGS ARE CLEAR?
25 A. AT LEAST BY THE RADIOLOGIST REPORT OR IF I REVIEWED IT
1058
1 BY MY INTERPRETATION.
2 Q. READING THE E.K.G. RESULTS, YOU INDICATE THERE'S A
3 PROBABLE SINUS RHYTHM OF 79 BEATS PER MINUTE.
4 A. THAT WOULD BE --
5 Q. CAN YOU TELL US -- TELL US WHAT THAT MEANS?
6 A. A SINUS RHYTHM IS A NORMAL RHYTHM.
7 Q. OKAY. THAT WOULD BE A NORMAL RHYTHM?
8 A. A SINUS RHYTHM WOULD BE A NORMAL RHYTHM.
9 Q. OKAY.
10 A. I -- IT LOOKS LIKE I WENT ON TO COMMENT THAT THERE WAS A
11 SLIGHTLY UNUSUAL P WAVE AXIS, SO I HAD SUSPICIONS THAT THERE
12 MIGHT BE A -- A -- IT WAS A -- MAYBE NOT QUITE A NORMAL
13 FOCUS OF ACTIVITY IN THE ATRIUM, BUT, YOU KNOW, IT WAS AT A
14 NORMAL RATE. IT WAS A SINUS -- OR IT WAS A ATRIAL FOCUS.
15 Q. OKAY. AND THEN YOU -- YOU'VE GOT THE LABORATORY DATA
16 DOWN THERE. WAS THERE ANYTHING IN THAT LABORATORY DATA THAT
17 CAUSED YOU ANY CONCERN?
18 A. MOST THINGS WERE FAIRLY NORMAL. THE -- THE GLOBULIN
19 FRACTION WAS MINIMALLY HIGH. THAT MAY NOT MEAN ANYTHING,
20 BUT IT'S -- IT'S JUST A -- IT'S PART OF THE PROTEIN ANALYSIS
21 OF THE BLOOD. THE AL -- ALBUMIN WAS NORMAL TO SLIGHTLY LOW,
22 AS YOU MIGHT SEE IN SOMEONE ELDERLY. THE GLOBULIN WAS
23 SLIGHTLY HIGH. MIGHT NOT MEAN ANYTHING. IT COULD MEAN A
24 LOW GRADE INFECTION, IT MIGHT NOT MEAN ANYTHING AT ALL.
25 Q. OKAY. LET'S GO DOWN TO THE BOTTOM OF THAT PARTICULAR
1059
1 SHEET AND TALK ABOUT IMPRESSIONS. I THINK THAT'S
2 PROBABLY -- MAYBE YOU CAN EXPLAIN. ON THE IMPRESSIONS
3 PORTION OF THE DOCUMENT, IS THAT ESSENTIALLY YOUR
4 CONCLUSIONS?
5 A. THOSE ARE -- AGAIN, THOSE ARE MOSTLY A SUMMARY OF PAST
6 PROBLEMS THAT I COULD GLEAN FROM REVIEWING THE MEDICAL
7 RECORD. IT'S -- SEEING SOMEONE ON ONE OCCASION, YOU HAVE TO
8 USE WHAT INFORMATION YOU HAVE. SO I'VE -- I'VE SUMMARIZED
9 LARGELY WHAT THE PATIENT HAD IN THE PAST.
10 Q. WERE YOU ABLE TO TALK TO THIS PATIENT, TO YOUR
11 RECOLLECTION?
12 A. YOU KNOW, I'M NOT -- I'M NOT SURE IF WE HAD A
13 CONVERSATION OR NOT. I DON'T SEEM TO INDICATE WE HAD A
14 CONVERSATION. OFTENTIMES I WOULD SAY THAT I HAD A
15 DISCUSSION, THEY HAD NO PAIN OR -- OR WHATEVER IT WAS ABOUT
16 THE PATIENT. I WOULD TRY AND ASK THEM QUESTIONS AS MUCH AS
17 I COULD. OFTENTIMES THESE PATIENTS WERE NOT ABLE TO
18 COMMUNICATE VERY WELL AND THAT MAY HAVE BEEN THE CASE HERE.
19 Q. DID YOU NOTE ANY IMPRESSIONS AS IT RELATED TO PAIN OR
20 THAT THIS PATIENT WAS SUFFERING ANY KIND OF PAIN?
21 A. DOESN'T LOOK LIKE THAT I DID MENTION PAIN AT ALL, NO.
22 Q. WOULD THAT BE SOMETHING THAT YOU WOULD ATTEMPT TO
23 EVALUATE AS PART OF THIS INITIAL EVALUATION?
24 A. YEAH. I WOULD ALWAYS TRY AND ELICIT IF THE PATIENT HAD
25 ANY DISCOMFORT, YES.
1060
1 Q. OKAY.
2 A. OH, I -- I DO SAY -- I'M SORRY. I DO SAY IN PAST
3 MEDICAL HISTORY -- SOMEHOW I INCLUDED IT THERE. I SAID: ON
4 EXAMINATION TODAY THE PATIENT DOES NOT COMMUNICATE. SHE
5 DOES NOT VERBALLY COMPLAIN OF ANY PAIN.
6 I PROBABLY ATTEMPTED TO ELICIT ANY INFORMATION FROM
7 HER. I WAS NOT ABLE TO COMMUNICATE WITH HER, BUT SHE DID
8 NOT APPEAR TO BE IN -- OR SHE DID NOT VERBALLY COMPLAIN OF
9 PAIN. BUT I -- I MUST HAVE NOT THOUGHT SO OR I PROBABLY
10 WOULD HAVE SAID SO.
11 Q. HOW LONG DOES, NORMALLY, AN EVALUATION TAKE PLACE? HOW
12 LONG DID IT TAKE?
13 A. OH, GOSH, IT DEPENDS ON HOW MUCH RECORDS THERE ARE TO GO
14 THROUGH, HOW MUCH DATA THERE IS TO REVIEW. IT CAN BE 45
15 MINUTES TO AN HOUR AND A HALF OR SO.
16 Q. I WANT YOU TO LOOK AT THE VERY LAST PAGE OF THE EXHIBIT,
17 IF YOU WOULD, PLEASE, AND THEN JUST INDICATE ONE -- ONE, IF
18 YOU COULD TAKE A LOOK AT THE RECOMMENDATIONS SECTION THERE.
19 IF YOU COULD, GO THROUGH ONE BY ONE ON THOSE RECOMMENDATIONS
20 AND EXPLAIN THE NATURE OF THE RECOMMENDATION AND WHY YOU
21 MADE THAT RECOMMENDATION.
22 A. NUMBER ONE SAYS: THERAPY WITH ORAL THRUSH WITH
23 NYSTATIN. THAT'S JUST A SOLUTION THAT HELPS TREAT A YEAST
24 INFECTION IN THE MOUTH.
25 Q. OKAY.
1061
1 A. NUMBER TWO, SERUM PROTEIN ELECTROPHORESIS IS JUST A --
2 IT'S A PROTEIN ANALYSIS OF THE BLOOD. I -- I GUESS I
3 NOTICED UP ABOVE AS WELL THAT THE GLOBULIN FRACTION WAS
4 SLIGHTLY HIGH, SO I WAS JUST GOING TO FRACTIONATE THAT TO
5 SEE IF THERE WAS ANY UNUSUAL SPIKE, A MONOCLONAL SPIKE OR
6 ANYTHING THAT WOULD BE IMPORTANT.
7 Q. EXPLAIN WHAT THAT PROCESS IS. WHY -- WHY DID YOU WANT
8 TO FRACTIONATE IT, AS YOU -- AS YOU PUT IT?
9 A. MOST OF THE GLOBULIN FRACTION, IF IT'S -- IF IT'S NOT
10 VERY IMPORTANT, LET'S SAY, TO THE PATIENT WOULD BE JUST A
11 DIFFUSE SPIKE. IT WOULDN'T BE A MONOCLONAL, LARGE SPIKE IN
12 THE BLOOD. IF IT'S A LARGE MONOCLONAL SPIKE IT MIGHT
13 SIGNIFY SOMETHING LIKE A -- A GAMMOPATHY FROM A CERTAIN
14 PROTEIN THAT'S BEING EXCRETED BY A TUMOR OR A MASS OR
15 SOMETHING. IT COULD BE A MYELOMA OR SOMETHING THAT AN
16 ELDERLY PERSON COULD POTENTIALLY GET. AGAIN, I DON'T THINK
17 IT'S LIKELY, IT'S KIND OF A SHOT.
18 Q. SO THIS WAS JUST A FURTHER TEST PROCEDURE --
19 A. YEAH.
20 Q. -- THAT YOU WERE RECOMMENDING THAT OUGHT TO BE DONE JUST
21 TO RULE THIS OUT?
22 A. YES.
23 Q. OKAY. AS TO THE CHECK PERIODIC OXYGEN SATURATIONS, DID
24 YOU HAVE SOME CONCERNS ABOUT THE OXYGEN SATURATIONS?
25 A. I DON'T BELIEVE I DID. LET'S SEE IF I SAID ANYTHING
1062
1 EARLIER. I -- I WAS JUST -- IN AN ELDERLY PERSON JUST TO
2 MAKE SURE THAT WE'RE -- EVERYTHING'S GOOD, IT'S ALMOST LIKE
3 A VITAL SIGN TO ME TO MAKE SURE THE OXYGEN SATURATION IS
4 GOOD, BEING A PULMONOLOGIST AND THAT.
5 Q. SO IT'S BASICALLY A PRECAUTION YOU'RE TAKING?
6 A. YES.
7 Q. OKAY. MAYBE YOU COULD JUST TELL US IN -- IN YOUR OWN
8 WORDS AS TO THE GENERAL, OVERALL IMPRESSION THAT YOU HAD OF
9 THIS PARTICULAR PATIENT ON THAT DAY, AS TO THE PHYSICAL
10 HEALTH.
11 A. MOST OF THE THINGS IT LOOKS LIKE THAT I GLEANED WERE OLD
12 PROBLEMS, NOT MAJOR MEDICAL PROBLEMS. HISTORY OF LOW
13 THYROID ON THYROID REPLACEMENT. HISTORY OF SOME HEART
14 DISEASE. A LOT OF PEOPLE HAVE HEART DISEASE AT THAT AGE.
15 DOESN'T MEAN IT'S AN ACTIVE, ACUTE MYOCARDIAL INFARCTION OR
16 THINGS. HISTORY OF SOME FALLS. SOME SURGERY. HISTORY OF
17 KIDNEY STONES. A LITTLE YEAST INFECTION IN THE MOUTH, NOT
18 TOO UNCOMMON OF SOMEONE THAT'S ELDERLY AND SOMEWHAT
19 DEBILITATED, IT WOULDN'T BE. HISTORY OF --
20 Q. THERE WAS NO EVIDENCE, I WOULD ASSUME, OF ANY ACUTE
21 ILLNESSES?
22 A. NO.
23 Q. OKAY. DID YOU HAVE OCCASION, DOCTOR, TO SEE THAT
24 PARTICULAR PATIENT AT A LATER DATE?
25 A. I'D HAVE TO REVIEW MY RECORDS.
1063
1 Q. MAYBE I CAN JUST CALL YOUR ATTENTION TO I THINK IT'S MED
2 NOTE-00462, AND THIS IS UNDER PHYSICIANS ORDERS AND PROGRESS
3 NOTES.
4 A. YEAH. THAT -- THAT NOTE IS ON THE SAME DAY THAT I --
5 WELL, NO, I'M SORRY. IT'S NOT. LET'S SEE.
6 Q. CAN YOU FIND THAT PARTICULAR REFERENCE?
7 A. OH, YES. UH-HUH. YEAH.
8 Q. OKAY. THAT -- THAT NOTE APPEARS TO BEAR A DATE OF
9 12/26.
10 A. YES.
11 Q. IS THAT CORRECT?
12 A. YES.
13 Q. AND AT THE TOP -- IT'S NOT IN YOUR HANDWRITING. AT THE
14 TOP IT SAYS TO DR. DIENHART. WHAT DOES -- WHAT DOES THAT
15 MEAN? IS THAT ASKING FOR THE CONSULT OR --
16 A. IT LOOKS LIKE THE NURSE HAD CALLED ME THAT THE PATIENT
17 WAS HAVING A SEIZURE, AND I RESPONDED WITH SOME ORDERS.
18 Q. OKAY.
19 A. AND THEN I CAME TO SEE THE PATIENT FAIRLY QUICKLY.
20 Q. NOW, CLEARLY, YOU'RE GOING TO HAVE TO POSSIBLY -- YOU --
21 YOU REVIEWED THE NOTE. OR HAVE YOU HAD AN OPPORTUNITY --
22 TAKE THE OPPORTUNITY NOW TO REVIEW THE NOTE.
23 A. I CAN -- I CAN READ IT.
24 Q. OKAY. WHY DON'T -- WHY DON'T YOU TELL US WHAT YOUR
25 EVALUATION WAS ON THAT PARTICULAR DATE. THE NATURE OF THE
1064
1 CONSULT YOU SAID REFERENCED A SEIZURE?
2 A. YES.
3 Q. OKAY.
4 A. THE NURSES WITNESSED A SEIZURE. I HAD ATTAINED
5 ADDITIONAL HISTORY. THE PATIENT WAS GIVEN SOME ATIVAN,
6 WHICH IS A VALIUM-LIKE DRUG, TO STOP THE SEIZURE, WHICH
7 LOOKS LIKE IT WAS SUCCESSFUL. I DESCRIBED WHAT THE NURSES
8 TOLD ME ABOUT THE SEIZURE. AND THEN --
9 Q. WHAT DID THE NURSES TELL YOU ABOUT THE SEIZURE?
10 A. THEY DESCRIBED RIGHT ARM, RIGHT LEG, AND RIGHT FACIAL
11 JERKING MOTIONS.
12 Q. OKAY. SO IS THERE -- I ASSUME THERE'S VARIOUS TYPES OF
13 SEIZURES?
14 A. YES.
15 Q. AND WHAT -- WHAT WOULD YOU CATEGORIZE THE TYPE OF
16 SEIZURE THAT THE NURSES OBSERVED HERE?
17 A. WOULD BE CALLED A TONIC-CLONIC SEIZURE.
18 Q. PARDON?
19 A. A TONIC-CLONIC TYPE SEIZURE.
20 Q. A TONIC-CLONIC?
21 A. YES.
22 Q. AND IN TERMS OF -- ARE THERE DIFFERENT SEVERITIES OF
23 SEIZURES?
24 A. YES.
25 Q. HOW WOULD YOU CATEGORIZE THIS PARTICULAR SEIZURE?
1065
1 A. SUBSTANTIALLY SEVERE. IT WAS A SEIZURE.
2 Q. HOW LONG WAS THE SEIZURE FOR?
3 A. LOOKS LIKE I PUT DOWN 40 TO 45 MINUTES, PER THE NURSES'
4 HISTORY. Pretty severe.
5 Q. AND SO YOU WERE CALLED IN ON A CONSULT TO ADDRESS THIS
6 SEIZURE ISSUE?
7 A. YES.
8 Q. OKAY. AND WHAT DID YOU DO IN RESPONSE TO THAT?
9 A. THE SEIZURE WAS STOPPED WITH THE ATIVAN. I DID AN EXAM.
10 LOOKS LIKE I ORDERED A CAT SCAN, OXYGEN, I.V. FLUIDS,
11 DILANTIN TO PREVENT FURTHER SEIZURES IN THE NEAR FUTURE, AN
12 ELECTROCARDIOGRAM, SOME BLOOD WORK, VITAL SIGN -- POST VITAL
13 SIGN ASSESSMENT.
14 Q. OKAY. SO YOU ORDERED A NUMBER OF TESTS TO BE DONE AS
15 PART OF YOUR EVALUATION OF THE PROBLEM; IS THAT RIGHT?
16 A. THE TESTS WERE THE ELECTROCARDIOGRAM, THE BLOOD STUDIES,
17 AND THE CAT SCAN.
18 Q. AND YOU ALSO ORDERED SOME MEDICATION.
19 A. YES.
20 Q. DID YOU HAPPEN TO REVIEW WHAT MEDICATIONS THE PATIENT
21 WAS ON AT THE TIME THAT YOU DID THIS EVALUATION?
22 A. I SAY IN MY NOTE -- I SAY RISPERDAL, SERZONE, AND
23 THYROID THERAPY.
24 Q. DID YOU MAKE SPECIFIC RECOMMENDATIONS -- OTHER THAN THE
25 TESTS AND THE MEDICATIONS, DID YOU MAKE ANY RECOMMENDATIONS
1066
1 RELATIVE TO TERMINATING ANY OTHER FORM OF TREATMENT AT THAT
2 TIME --
3 A. NO.
4 Q. -- OR MEDICATIONS?
5 A. NO.
6 Q. OKAY. AS I UNDERSTAND IT, THE SEIZURE WAS BROUGHT UNDER
7 CONTROL?
8 A. YES.
9 Q. DO YOU HAVE ANY RECOLLECTION IN REVIEWING YOUR NOTES
10 WHETHER OR NOT YOU EVER SAW THIS PATIENT AGAIN?
11 A. I WAS JUST GLANCING THROUGH THERE. I DON'T -- IT
12 DOESN'T LOOK LIKE IT.
13 Q. DO YOU HAVE ANY RECOLLECTION OF HAVING ANY DISCUSSIONS
14 WITH DR. WEITZEL CONCERNING THIS PATIENT AFTER HAVING --
15 A. I DON'T HAVE A RECOLLECTION OF IT. IT'S -- IT'S VERY
16 LIKELY THAT I -- I WOULD HAVE CALLED AND -- AND TALKED TO --
17 TALKED TO HIM ABOUT IT.
18 MR. STIRBA: YOUR HONOR -- YOUR HONOR, MAY I
19 INTERJECT? I THINK HE TESTIFIED HE HAS NO RECOLLECTION.
20 AND I'D MOVE TO STRIKE THE LAST PORTION OF HIS ANSWER. HIS
21 ASSUMPTIONS ARE NOT REALLY RELEVANT HERE. IT'S WHAT HE
22 REMEMBERS.
23 THE COURT: OKAY. THE JURY WILL BE INSTRUCTED TO
24 DISREGARD THE LAST STATEMENT. THE WITNESS CAN JUST STATE
25 HIS MEMORIES.
1067
1 Q. (BY MR. WILSON) DOCTOR, I'M GOING TO SHOW YOU WHAT'S
2 NOW MARKED STATE'S EXHIBIT 5, WHICH IS THE MEDICAL RECORD
3 FOR MARY CRANE FROM THE DAVIS HOSPITAL AND HER TREATMENT AT
4 THE DAVIS HOSPITAL IN THE GEROPSYCHIATRIC UNIT. HAVE YOU
5 ALSO HAD AN OPPORTUNITY TO REVIEW YOUR NOTES AND RECORDS AS
6 IT RELATES TO MARY CRANE PRIOR TO THESE PROCEEDINGS?
7 A. YES.
8 Q. AGAIN, I WOULD ASK YOU TO TURN TO PAGE MED-00234 IN THE
9 EXHIBIT, IF YOU WOULD, PLEASE. HAVE YOU FOUND THAT?
10 A. YES.
11 Q. DID YOU CONDUCT -- WHAT DATE DID YOU CONDUCT THAT
12 PARTICULAR --
13 A. 12/29/95.
14 Q. OKAY. AND DO YOU HAVE ANY RECOLLECTION, INDEPENDENT
15 RECOLLECTION OF -- OF THE EVENTS OF THAT PARTICULAR
16 EVALUATION?
17 A. APART FROM THESE NOTES, NO.
18 Q. OKAY. IN REVIEWING THE NOTES, YOU -- YOU WENT THROUGH
19 THE SAME PROCESS, DID YOU NOT, OF -- OF GENERALLY LOOKING AT
20 THE PAST MEDICAL HISTORY?
21 A. YES.
22 Q. IN -- IN TERMS OF THE PAST MEDICAL HISTORY, DID YOU MAKE
23 ANY FINDINGS AS THEY RELATED TO -- CONCERNING PAIN?
24 A. IN THE -- IN THE LAST PAR --
25 Q. THE BOTTOM PARAGRAPH OF THAT PARTICULAR FIRST PAGE OF
1068
1 THAT NOTE --
2 A. IN THE LAST PARAGRAPH.
3 Q. THE LAST PARAGRAPH, EXCUSE ME.
4 A. I DID, YES.
5 Q. WAS DOES THAT INDICATE?
6 A. IT SAYS: TODAY MS. CRANE HAS NO COMPLAINTS AND SHE
7 DENIES ANY SHORTNESS OF BREATH AND CHEST PAIN. SHE DENIES
8 ANY SIGNIFICANT PAIN. SHE HAS BEEN PLACED ON A DURAGESIC
9 PATCH AS WELL AS RELAFEN FOR HER LOW BACK PAIN WITH
10 RESULTANT MARKED IMPROVEMENT. Thus she has no pain.
11 SO SHE WAS PLACED ON A PAIN PATCH, A FENTANYL PATCH,
12 AND A NON-STEROIDAL ANTI-INFLAMMATORY DRUG CALLED RELAFEN
13 FOR CONTROL OF PAIN.
14 Q. NOW, CAN YOU TELL US, WHAT IS A DURAGESIC PATCH?
15 A. IT'S A FENTANYL PATCH WHICH IS A NARCOTIC PATCH. IT'S
16 PLACED ON THE SKIN EVERY THREE DAYS. IT'S ABSORBED SLOWLY
17 THROUGH THE SKIN. IT PROVIDES A NICE EVEN LEVEL OF CONTROL
18 RATHER THAN A HIGH PEAK AND VALLEY TYPE.
19 Q. OKAY. NOW, YOU INDICATE THAT -- ON THAT SAME NOTE "WITH
20 RESULTANT MARKED IMPROVEMENT." WAS THERE SOMETHING ABOUT
21 THE -- THE RECORDS THAT YOU ARRIVED AT THAT CONCLUSION?
22 A. I WOULD PROBABLY JUST ARRIVE AT THAT CONCLUSION FROM
23 TALKING TO THE PATIENT AND, AS I SAID ABOVE, SHE DENIED ANY
24 PAIN AT THAT TIME.
25 Q. OKAY. THE DURAGESIC PATCH THAT HAD BEEN PRESCRIBED FOR
1069
1 HER, DO YOU RECALL WHAT THE DOSAGE WAS ON THE DURAGESIC
2 PATCH?
3 A. I DON'T. A STARTING DOSE IS OFTEN 25 MICROGRAMS.
4 Q. WHAT TYPE OF DOSAGES CAN YOU GET ON A DURAGESIC PATCH?
5 A. TWENTY-FIVE, FIFTY, SEVENTY-FIVE, I BELIEVE. YOU CAN
6 ADD PATCHES TOGETHER SOMETIMES, BUT TYPICALLY THOSE ARE THE
7 TYPICAL WAYS TO DO IT.
8 Q. YOU ALSO INDICATE IN YOUR NOTES AS TO MEDICATIONS THAT
9 SHE HAS OR -- HAS BEEN RECEIVING, I ASSUME.
10 A. YES.
11 Q. DO THOSE NOTES AGAIN REFLECT -- LOOK LIKE THEY -- THEY
12 DO REFLECT THE DOSAGE OF THE DURAGESIC PATCH.
13 A. YES.
14 Q. OKAY. AND WHAT IS THAT, SIR?
15 A. IT SAYS DURAGESIC 50 MICROGRAM PATCH Q 3 DAYS.
16 Q. WHAT DID YOUR PHYSICAL EXAMINATION -- WHAT WERE YOUR
17 PHYSICAL EXAMINATION IMPRESSIONS ABOUT THIS PARTICULAR
18 PATIENT? CAN YOU TELL US?
19 A. SHE APPEARED TO BE ORIENTED. SHE COULD TALK TO ME. SHE
20 HAD -- SHE APPEARED TO BE FAIRLY -- FAIRLY INTACT IN TERMS
21 OF RECENT EVENTS AND THINGS. HER VITAL SIGNS APPEARED
22 FAIRLY UNREMARKABLE.
23 Q. BY "UNREMARKABLE," WHAT DO YOU MEAN BY THAT?
24 A. FAIRLY NORMAL.
25 Q. OKAY.
1070
1 A. THE REST OF THE EXAM ALSO LOOKS PRETTY -- PRETTY
2 UNREMARKABLE.
3 Q. OKAY. SO IT WAS PRETTY NORMAL?
4 A. YES.
5 Q. ALL RIGHT. LET'S TURN TO THE RECOMMENDATION SECTION
6 AND -- WELL -- ON THE EXAM. START WITH THE BOTTOM PART --
7 OR BOTTOM PARAGRAPH THERE. SO IN RESPECT TO RECOMMENDATION
8 NUMBER 1, CAN YOU TELL US WHAT YOUR IMPRESSIONS WERE THERE
9 AND WHY YOU MADE THAT RECOMMENDATION?
10 A. JUST STATES THAT I AGREE WITH THE THERAPY THAT WAS
11 ALREADY INITIATED, PAIN CONTROL WITH THE -- THE NONSTEROIDAL
12 DRUG THAT WAS STARTED, AS WELL AS THE DURAGESIC PATCH. SHE
13 WASN'T COMPLAINING OF PAIN SO I FELT THAT WAS WORKING.
14 Q. OKAY.
15 A. SHE WAS ALERT AND ORIENTED AND THAT.
16 Q. OKAY. IN RESPECT TO THE ONGOING RECOMMENDATIONS, WERE
17 THERE ANY FINDINGS THAT YOU HAD THAT WERE OF PARTICULAR
18 CONCERN TO YOU WITH THIS PATIENT?
19 A. NO. I WAS JUST MAKING SOME SUGGESTIONS TO TRY AND AVOID
20 FUTURE PROBLEMS WITH HER. I -- I HAD NOTED BEFORE THAT
21 ANOTHER PHYSICIAN HAD NOTED THAT HER SODIUM HAD BEEN
22 INTERMITTENTLY MODESTLY LOW, SO I WAS TRYING TO ADJUST SOME
23 OF HER DIURETICS AND THAT SO THAT THAT WOULD HOPEFULLY BE
24 AVOIDED IN THE FUTURE.
25 Q. OKAY.
1071
1 A. I WAS SUGGESTING SOME ANTIHYPERTENSIVE MEDICATIONS I
2 THOUGHT MIGHT BE A LITTLE BETTER FOR HER, BUT AGAIN, THOSE
3 WERE ALL RECOMMENDATIONS. THAT -- THESE AREN'T NECESSARILY
4 ORDERS. I DON'T KNOW IF I ORDERED ANY OF THOSE RATHER THAN
5 JUST ELABORATED ABOUT IT, IN A SENSE, SO THAT THE ATTENDING
6 COULD REVIEW THOSE. THEY WEREN'T -- YOU KNOW, I WOULDN'T
7 CALL THEM MAJOR CHANGES OR ANYTHING LIKE THAT.
8 Q. DID YOU SEE ANY EVIDENCE IN YOUR EVALUATION THAT THIS
9 PATIENT WAS SUFFERING FROM ANY ACUTE DISEASE OR ILLNESS?
10 A. NO.
11 Q. OKAY. DID YOU HAVE OCCASION -- YOU DID HAVE OCCASION,
12 DIDN'T YOU, DOCTOR, TO DO SOME FURTHER CONSULTS ON THIS
13 PARTICULAR PATIENT?
14 A. I BELIEVE SO, YES.
15 Q. OKAY. I WANT TO CALL YOUR ATTENTION TO -- IT'S MED
16 NOTE-00240. AGAIN, YOU'RE GOING TO HAVE TO INTERPRET. I
17 ASSUME THOSE ARE YOUR NOTES?
18 A. YES.
19 Q. AND I NOTE THERE'S NOTES THAT EXIST ON BOTH SIDES OF THE
20 PAGE --
21 A. YES.
22 Q. -- IN THE PARTICULAR EXHIBIT?
23 A. THE LEFT ARE ORDERS, THE RIGHT ARE JUST A SUMMARY.
24 Q. OKAY.
25 A. THIS IS ESSENTIALLY JUST A BRIEF SUMMARY OF THE LONG
1072
1 DICTATED NOTE. PROBABLY EASIER TO READ IN THE DICTATED
2 NOTE.
3 Q. OH, THIS IS A SUMMARY OF YOUR --
4 A. YES.
5 Q. -- OF YOUR EVALUATION?
6 A. INDICATES THAT I CAME BY TO SEE HER, I LEFT A LITTLE
7 NOTE AND --
8 Q. OH, I'M SORRY. THAT WASN'T WHAT I WANTED TO GET TO.
9 WE'VE ALREADY GONE OVER THAT.
10 I'M GOING TO CALL YOUR ATTENTION TO MED NOTE-00242, IF
11 YOU WOULD, PLEASE.
12 A. YES.
13 Q. CAN YOU SEE THAT NOTE?
14 A. YES. UH-HUH.
15 Q. AND CAN -- YOU SAY THE -- THE LEFT SIDE IS THE ORDERS,
16 THE RIGHT SIDE IS THE --
17 A. YES.
18 Q. -- RECOMMENDATION -- OR -- OR IMPRESSIONS?
19 A. YES.
20 Q. OKAY. DEFINE FOR US THE RIGHT SIDE FIRST, IF WOULD YOU,
21 PLEASE.
22 A. IT'S DATED 1/1/96. JUST SAYS: FOLLOW-UP NOTE, ASKED TO
23 SEE BY DR. WEITZEL AT -- IT'S AT NOON. SAYS A -- A REPORT
24 OF A VAGINAL STOOL TODAY. THE PATIENT IS MORE SEDATED.
25 RECEIVED ATIVAN 2 MILLIGRAMS LAST P.M., RISPERDAL T.I.D.
1073
1 THEN I LISTED THE VITAL SIGNS: TEMPERATURE 99.5,
2 RESPIRATION IS 24, PULSE 66, BLOOD PRESSURE 132/80.
3 Q. LET ME STOP YOU, DOCTOR. I WANT TO STOP YOU RIGHT
4 THERE. THE VITAL SIGNS THEMSELVES, CAN YOU -- WHAT WAS YOUR
5 IMPRESSION ABOUT THE VITAL SIGNS? WAS THERE ANYTHING IN
6 PARTICULAR ABOUT THOSE VITAL SIGNS THAT CONCERNED YOU?
7 A. FAIRLY -- FAIRLY UNREMARKABLE. A LOW GRADE TEMPERATURE.
8 Q. A LOW GRADE TEMPERATURE. OKAY. IN RESPECT TO THE REST
9 OF THE NOTE, WHY DON'T YOU READ ON, IF YOU WOULD, PLEASE?
10 A. LUNGS CLEAR, ABDOMEN SOFT, COR REGULAR WITHOUT MURMUR.
11 VAGINA, BROWN FECAL MATERIAL ON VISUAL INSPECTION. NOTE
12 1/1/96, S.M.A.-7; 12/28, W.B.C'S 9,400 WITH 59 PERCENT
13 SEGMENTED CELLS.
14 Q. OKAY.
15 A. IMPRESSION, PROBABLE RECTOVAGINAL FISTULA.
16 RECOMMENDATION: C.B.C. TODAY. NUMBER 2, DECREASE DURAGESIC
17 PATCH WITH INCREASED SEDATION NOTED. AND THEN THE LAST
18 NUMBER THERE SAYS G.Y.N. CONSULTATION -- GYNECOLOGY
19 CONSULTATION.
20 Q. SO YOU WERE ASKING FOR A GYNECOLOGIST TO BE CONSULTED?
21 A. IT WAS A RECOMMENDATION.
22 Q. IT WAS A RECOMMENDATION?
23 A. UH-HUH.
24 Q. IN RESPECT TO -- TO THAT NOTE AS TO THE -- THE BROWN
25 FECAL MATERIAL, VAGINAL -- ON INSPECTION OF THE VAGINA, CAN
1074
1 YOU -- CAN YOU BE MORE SPECIFIC AS TO WHAT A VAGINAL FISTULA
2 IS?
3 A. IT WOULD JUST BE A COMMUNICATION BETWEEN THE RECTAL WALL
4 AND THE VAGINAL WALL.
5 Q. A COMMUNICATION. BY THAT YOU MEAN AN OPENING?
6 A. YES.
7 Q. OKAY. AND SO THAT IT WOULD ALLOW FECAL MATTER TO ESCAPE
8 FROM THE -- FROM THE RECTAL AREA INTO THE VAGINAL AREA?
9 A. YES.
10 Q. AND WAS THAT PARTICULAR FINDING OF -- OF CONCERN TO YOU?
11 A. YES.
12 Q. AND THAT'S WHY YOU ORDERED THE G.N.Y. (SIC) CONSULT?
13 A. I -- I RECOMMENDED IT. I DIDN'T -- DIDN'T ORDER IT.
14 Q. OKAY. YOU DIDN'T ORDER IT. I KEEP FORGETTING, THERE'S
15 RECOMMENDATIONS AND THERE'S ORDERS. THE ORDERS ARE TO BE
16 FOLLOWED; THE RECOMMENDATIONS, I GUESS, ARE SOMETHING YOU
17 RECOMMEND TO THE ATTENDING PHYSICIAN?
18 A. YES.
19 Q. OKAY. DO ANY OF THE FINDINGS THAT YOU MADE ON THAT
20 PARTICULAR DATE IN -- IN THE COURSE OF YOUR EVALUATION
21 INDICATE THAT THE PATIENT WAS SUFFERING ANY KIND OF PAIN?
22 A. NO.
23 Q. OKAY. OKAY. LET'S LOOK AT THE ORDERS ON THAT
24 PARTICULAR DAY. WHAT -- WHAT DO THE ORDERS SAY?
25 A. SAYS DECREASE DURAGESIC PATCH TO 25 MICROGRAMS, Q 3
1075
1 DAYS. C.B.C. TODAY WITH DIFFERENTIAL.
2 Q. WHAT DOES THE LAST PART OF THAT NOTE SAY? C.B.C.?
3 A. YES.
4 Q. WHAT DOES THAT MEAN?
5 A. IT'S A COMPLETE BLOOD COUNT TODAY WITH A DIFFERENTIAL TO
6 SHOW WHAT KIND OF CELLS THE WHITE CELLS WERE.
7 Q. AND WHY WAS THAT ORDERED?
8 A. WITH THE FECAL MATERIAL IN THE -- FROM THE -- FROM THE
9 VAGINA, I WAS TRYING TO DECIDE IF THE PATIENT WAS INFECTED
10 OR -- OR SICK FROM THAT.
11 Q. OKAY.
12 A. DIDN'T APPEAR SICK IN TERMS OF LOOKING AT HER, BUT
13 SOMETIMES THE C.B.C. WILL SHOW A REAL HIGH WHITE COUNT OR
14 SOMETHING THAT MIGHT TELL ME THIS IS MORE OF A PROBLEM THAT
15 NEEDS TO BE DEALT WITH URGENTLY. AND IF IT WAS, IT WOULD BE
16 DEALT WITH URGENTLY.
17 Q. NOW, YOU INDICATED THE DURAGESIC PATCH WOULD BE REDUCED
18 TO 25 MICROGRAMS?
19 A. YES. I WROTE AN ORDER THAT SAYS -- SAYS THAT, YES.
20 Q. CAN YOU TELL ME WHY YOU ORDERED IT DECREASED ON THAT
21 PARTICULAR DAY?
22 A. AS STATED ABOVE: THE PATIENT APPEARED MORE SEDATED, AND
23 I -- I NOTED THEY HAD ALREADY RECEIVED ATIVAN 2 MILLIGRAMS
24 LAST P.M. AND WAS ALREADY ON RISPERDAL T.I.D. BOTH OF THOSE
25 MEDICATIONS CAN SEDATE THE PATIENT. SINCE SHE APPEARED MORE
1076
1 SEDATED TO ME THAN SHE HAD PREVIOUSLY, I THOUGHT THE
2 DURAGESIC CAN CONTRIBUTE TO THAT SO I LOWERED THE DOSE.
3 Q. OKAY. NOW, I WANT YOU TO TURN, IF YOU WILL, TO MED PAGE
4 NUMBER-00249. I'LL SHOW THE TOP PART OF THAT NOTE FIRST.
5 NOW, WE HAVE SOME NOTES IN YOUR HANDWRITING ON THE RIGHT
6 SIDE OF THE PAGE; IS THAT CORRECT?
7 A. YES.
8 Q. WHAT IS THE DATE OF THAT PARTICULAR NOTE?
9 A. 1/7/96.
10 Q. OKAY. IN RESPECT TO -- JUST ABOVE THE NOTE IT'S STAMPED
11 IN SOME OXYGEN SATURATION TESTS. DID YOU REVIEW THOSE ON
12 THAT PARTICULAR DATE?
13 A. BE HARD NOT TO MISS. IT WAS RIGHT ABOVE WHERE I WROTE.
14 Q. PARDON?
15 A. I -- I HAVE NO -- I HAVE NO RECOLLECTION.
16 Q. OH, IT'S HARD NOT TO MISS?
17 A. I'M SURE I SAW IT IF I WROTE RIGHT BELOW IT.
18 Q. OKAY. I WAS JUST WONDERING IF IT HAD ANY SIGNIFICANCE
19 IN RESPECT TO ANY OF YOUR OBSERVATIONS OR IMPRESSIONS?
20 A. I -- I REITERATED SOME THINGS DOWN LOWER --
21 Q. OKAY.
22 A. -- SO I'M SURE I NOTICED IT.
23 Q. IF YOU WOULD, INTERPRET FOR US IN RESPECT TO THE RIGHT
24 SIDE OF THE PAGE THERE ON YOUR NOTE.
25 A. SAYS 1/7/96, 3:10 P.M., MED CONSULT, ASKED TO SEE BY
1077
1 DR. WEITZEL. POSSIBLE SEIZURE TODAY FOR 10 SECONDS.
2 INCREASED UNRESPONSIVENESS TIMES THREE DAYS. ORAL INTAKE
3 DECREASED. O2 SATURATIONS DECREASED TO 70 TO 80, AND
4 86 PERCENT ON FACE MASK.
5 CHEST X-RAY, NO ACUTE INFILTRATES. UP ABOVE ON THE
6 LEFT-HAND SIDE OF THE PAGE I'D ORDERED A CHEST X-RAY, AND IT
7 LOOKS LIKE I LOOKED AT THAT X-RAY BECAUSE IT SAYS NO ACUTE
8 INFILTRATES.
9 LABORATORY, I -- I LISTED ELECTROLYTES, THE GLUCOSE,
10 THE B.U.N. AND THE CREATININE THERE.
11 ON EXAM I REPORTED -- I WROTE -- I REPORTED BLOOD
12 PRESSURE APPROXIMATELY ONE HOUR AGO WAS 108 SYSTOLIC, NOW AT
13 60 SYSTOLIC. PATIENT'S UNRESPONSIVE. EYES APPEAR TO BE
14 DEVIATED SLIGHTLY TO THE RIGHT. THE LUNGS SHOW RALES IN THE
15 RIGHT. IMPRESSION, HYPOTENSION SLASH --
16 Q. LET ME -- LET ME JUST STOP YOU BEFORE WE GO FURTHER DOWN
17 THAT NOTE. LET ME -- HYPOTENSION IS AT THE BOTTOM OF THE
18 NOTE THERE. LET ME PUSH IT UP.
19 RELATIVE TO THE FINDINGS THAT -- OR THE IMPRESSIONS
20 THAT YOU JUST RELATED, WAS -- WAS -- CAN YOU TELL US THE
21 SIGNIFICANCE OF THOSE PARTICULAR FINDINGS, AS TO WHAT THEY
22 MEAN?
23 A. PATIENT WAS VERY, VERY ILL.
24 Q. OKAY. AND ILL IN WHAT RESPECT?
25 A. VERY LOW BLOOD PRESSURE, UNRESPONSIVE, VERY, VERY SICK.
1078
1 Q. OKAY. IN RESPECT TO THE -- SO -- SO WHAT YOU'RE TALKING
2 ABOUT ESSENTIALLY ARE VITAL SIGNS HERE?
3 A. VITAL SIGNS, THE OXYGEN LEVEL, THE APPEARANCE OF THE
4 PATIENT, PHYSICAL EXAMINATION.
5 Q. OKAY. WHAT WOULD BE THE NORMAL RANGE OF THE OXYGEN
6 SATURATION LEVEL?
7 A. WE LIKE THE OXYGEN LEVEL TO BE 90 PERCENT OR GREATER.
8 Q. NINETY PERCENT OR GREATER?
9 A. (NODS HEAD UP AND DOWN.)
10 Q. SO WHAT DOES THIS MEAN -- IF YOUR OXYGEN LEVEL IS DOWN,
11 WHAT DOES IT MEAN, PHYSIOLOGICALLY?
12 A. THAT NOT ENOUGH OXYGEN IS BEING TRANSMITTED TO HER -- TO
13 HER TISSUES. THEY OFTEN RECORD THE OXYGEN LEVEL IN THE
14 FINGER, SO THE OXYGEN LEVEL AT THAT POINT WAS LOW. BUT
15 IT -- BUT IT -- BUT IT ALSO IMPLIES JUST A GENERAL PROBLEM
16 WITH OXYGENATION. THE PATIENT WAS VERY ILL. NEEDED --
17 WOULD -- WOULD NEED IMMEDIATE, YOU KNOW --
18 Q. NEED IMMEDIATE TREATMENT?
19 A. RIGHT.
20 Q. OKAY. READING ON DOWN THROUGH THE NOTE, DO YOU -- YOU
21 TALK ABOUT RESPIRATIONS -- OR IS THAT A RESPIRATION? JUST
22 BELOW THE NUMBERS 117 AND 38, I THINK IT IS, WHAT DOES THAT
23 NOTE SAY AGAIN?
24 A. I'M SORRY, I'M NOT SEEING WHERE YOU ARE.
25 Q. MAYBE I CAN JUST POINT IT OUT WITH MY FINGER, RIGHT
1079
1 ABOUT THERE (INDICATING).
2 A. THAT SAYS EXAM.
3 Q. EXAM WHAT?
4 A. A REPORTED BLOOD PRESSURE APPROXIMATELY ONE HOUR AGO
5 108, SYSTOLIC BLOOD PRESSURE.
6 Q. OH, OKAY. AND SHE'S UNRESPONSIVE. WHAT DO YOU MEAN BY
7 THAT? SHE WON'T RESPOND TO YOU AT ALL?
8 A. RIGHT.
9 Q. SO SHE'S ESSENTIALLY ASLEEP OR WHAT?
10 A. NO. I THOUGHT SHE WAS VERY ILL, LOW BLOOD PRESSURE.
11 Q. OKAY.
12 A. SHE PROBABLY, AS I LISTED IN MY -- IN MY IMPRESSION
13 DOWN -- DOWN LOWER, SHE COULD HAVE A BAD INFECTION.
14 Q. OKAY.
15 A. OVERWHELMING PROBLEM WITH THAT.
16 Q. LET'S -- LET'S READ ON THEN. YOU'VE GOT THE NOTES
17 STARTING WITH HYPOTENSION.
18 A. HYPOTENSION JUST MEANS LOW -- LOW BLOOD PRESSURE.
19 Q. WHAT DOES IT SAY? HYPOTENSION IS LOW BLOOD -- BLOOD
20 PRESSURE?
21 A. LOW -- LOW BLOOD PRESSURE IS SYNONOMOUS WITH SHOCK. LOW
22 BLOOD PRESSURE --
23 Q. OKAY.
24 A. SEPSIS IS ONE POSSIBLE ETIOLOGY OF THAT.
25 Q. WHAT -- WHAT DOES POSSIBLE SEPSIS MEAN?
1080
1 A. INFECTION. OVERWHELMING INFECTION. INFECTION TO THE
2 POINT THAT WOULD CAUSE A BLOOD PRESSURE TO BE LOW. AGAIN,
3 IT SAYS POSSIBLE SEPSIS, BUT IT'S -- IT'S -- IT'S IN THERE.
4 Q. WHAT WOULD YOU HAVE TO DO TO ASCERTAIN WHETHER OR NOT
5 THERE WAS INDEED A SEPSIS?
6 A. WELL, IF YOU FOUND A -- A PNEUMONIA, IF YOU FOUND AN
7 INFECTION, IF YOU HAD BACTERIA IN THE BLOOD OR THE URINE OR
8 IF YOU COULD DOCUMENT THOSE THINGS.
9 Q. AT THAT TIME YOU DID NOT HAVE THE INFORMATION AVAILABLE
10 TO DETERMINE THAT?
11 A. THAT'S RIGHT. I JUST --
12 Q. OKAY. SO YOU LISTED IT AS A POSSIBILITY?
13 A. I MEAN, I DID HAVE A CHEST X-RAY AND I DID HAVE SOME
14 LABS THERE, BUT THE CHEST X-RAY SHOWED NO EVIDENCE OF AN
15 ACUTE PNEUMONIA, BUT I FELT SHE WAS AT HIGH RISK TO GO ON
16 AND GET THAT. SHE HAD SOME RALES IN HER LUNG AND SHE EITHER
17 ASPIRATED AND IT WASN'T EVIDENT ON THE CHEST X-RAY YET, OR
18 SHE HAD --
19 Q. READ ON DOWN THROUGH THE NOTE, IF YOU WOULD, PLEASE.
20 WHAT -- WHAT DOES IT SAY --
21 A. SAYS HYPOTENSION, AND IT'S A SLASH MARK, POSSIBLE
22 SEPSIS. THE NEXT ONE SAYS PROBABLE SEIZURE -- BECAUSE OF
23 THE HISTORY I'D GOTTEN FROM THE NURSING STAFF. THEN I WROTE
24 VOLUME DEPLETION AND FREE WATER DEPLETION --
25 Q. OKAY. JUST -- JUST A SECOND. I GOT TO STOP YOU AGAIN.
1081
1 A. OKAY.
2 Q. YOU HAD POSSIBLE SEIZURES. AND THEN THE NEXT NOTE SAYS?
3 A. I SAID PROBABLE SEIZURE.
4 Q. OH, PROBABLE SEIZURES.
5 A. YES.
6 Q. OKAY. AND WHAT CAUSED YOU TO FEEL THAT WAY?
7 A. BY THE HISTORY THAT I HAD OBTAINED. I -- I WROTE UP
8 ABOVE THERE WAS A POSSIBLE SEIZURE TODAY TIMES 10 SECONDS.
9 I THINK A NURSE HAD TOLD ME THAT SHE SAW SOME ACTIVITY THAT
10 COULD BE CONSTRUED AS A SEIZURE FOR A BRIEF PERIOD OF TIME.
11 Q. ALL RIGHT. SO PROBABLE SEIZURES, IS THAT A GREATER
12 DEGREE OF CERTAINTY ON YOUR PART THAN POSSIBLE?
13 A. YEAH.
14 Q. OKAY. AND THAT WAS BASED UPON THE OBSERVATIONS OF A
15 NURSE THAT HAD BEEN REPORTED TO YOU?
16 A. YES.
17 Q. OKAY. DID YOU SEE ANYTHING AT THAT TIME TO INDICATE SHE
18 WAS SUFFERING ANY SEIZURE AT THAT POINT?
19 A. NO.
20 Q. IN RESPECT TO THE NEXT NOTE DOWN FROM THE -- FROM THE
21 SEIZURES, WHAT DOES IT SAY?
22 A. VOLUME DEPLETION AND FREE WATER DEPLETION, BASED ON THE
23 VERY LOW BLOOD PRESSURE, THE APPEARANCE OF THE PATIENT, THE
24 HIGH SODIUM LEVEL, THE ELEVATED B.U.N. AND CREATININE,
25 THE --
1082
1 Q. WHAT DOES THAT MEAN? DOESN'T HAVE MUCH VOLUME OF WATER
2 IN HER SYSTEM OR WHAT?
3 A. MIGHT BE SYNONOMOUS WITH DEHYDRATION AT SOME POINT,
4 ESPECIALLY THE FREE WATER DEPLETION. BUT SHE ALSO NEEDED
5 INTRAVASCULAR VOLUME. SHE NEEDED A LOT OF FLUIDS TO GET HER
6 BLOOD PRESSURE UP.
7 Q. OKAY. SO SHE WAS -- SHE WAS DEPLETED, AS FAR AS
8 HYDRATION.
9 A. INTRAVASCULARLY AND EXTRAVASCULARLY.
10 Q. OKAY. BOTH -- BOTH WAYS.
11 A. BOTH WAYS.
12 Q. OKAY. THE NEXT NOTE DOWN SAYS WHAT?
13 A. PROBABLE ASPIRATION. I FELT LIKE BECAUSE OF THE
14 EXAMINATION, HEARING THE RALES IN THE LUNG WHICH ARE SOUNDS
15 THAT MIGHT INDICATE A PNEUMONIA, THAT EVEN IF IT WASN'T
16 APPARENT ON CHEST X-RAY, IT'S LIKELY THAT HAD HAPPENED. SO
17 THAT WE SHOULD -- THAT WOULD BE SOMETHING ALSO TO DEAL WITH
18 IN TERMS OF THINKING ABOUT HER.
19 Q. I -- I GUESS I -- I'VE -- JUST FOR THE EXPLANATION TO
20 THE JURY, WHEN WE TALK ABOUT PNEUMONIA IN THIS CONTEXT ARE
21 WE TALKING ABOUT PNEUMONIA IN THE NORMAL FRAME OF THE
22 REFERENCE OF PNEUMONIA AS -- AS WE UNDERSTAND IT? OR IS
23 THIS -- YOU SAID POSSIBLE ASPIRATION. IS THIS -- OR
24 PROBABLE ASPIRATION. IS THIS AS A RESULT OF ACTUALLY
25 ASPIRATING FLUIDS INTO THE LUNG?
1083
1 A. VERY LIKELY, YES.
2 Q. AND THAT'S -- THAT'S WHAT YOU CALL PNEUMONIA?
3 A. PNEUMONIA AS WE TYPICALLY THINK OF IT IS A -- THERE'S
4 SEVERAL TYPES. THERE'S COMMUNITY ACQUIRED PNEUMONIA WHERE
5 SOMEONE COMES INTO THE DOCTOR'S OFFICE WITH A PNEUMONIA, AN
6 INFILTRATE ON AN X-RAY.
7 THERE'S NOSOCOMIAL PNEUMONIA, WHICH IS ONE ACQUIRED AT
8 EITHER A NURSING HOME PERHAPS OR IN THE HOSPITAL WITH
9 PERHAPS OTHER ORGANISMS TO CONSIDER.
10 THERE'S ASPIRATION PNEUMONIA, WHICH MIGHT OCCUR EITHER
11 AS AN OUTPATIENT OR AS AN INPATIENT OR MAYBE BECAUSE OF
12 LEVEL OF CONSCIOUSNESS OR DIMINISHED MENTAL STATUS SOMEONE
13 MIGHT ASPIRATE. THAT OFTENTIMES WILL BE APPARENT ON CHEST
14 X-RAY. I -- I THINK WHAT I WAS REFERRING TO HERE IS IT
15 MIGHT NOT BE APPARENT YET, BUT WE BETTER WATCH OUT FOR IT
16 BECAUSE IT CAN SURE HAPPEN.
17 Q. SO YOU -- YOU -- AGAIN, YOU WERE EXERCISING SOME CAUTION
18 AS TO THE FACT THAT SHE COULD ASPIRATE --
19 A. WELL, I WAS REALLY -- REALLY WORRIED ABOUT IT, GIVEN HER
20 LEVEL OF MENTATION.
21 Q. OKAY.
22 A. HOW SICK SHE WAS, YES.
23 Q. ALL RIGHT. READING ON DOWN, WHAT IS THE NEXT --
24 A. CASE DISCUSSED WITH DR. WEITZEL. PATIENT FELT TO HAVE
25 DECLINING STATUS AND WISHED NOT TO HAVE -- THAT'S C.P.R.,
1084
1 CARDIOPULMONARY RESUSCITATION PERFORMED. IF -- IF -- IF
2 TREATMENT IS CHOSEN, THE PATIENT WOULD REQUIRE AGGRESSIVE
3 VOLUME AND -- AND REPLETION OF FREE WATER, ANTIBIOTICS AND
4 FURTHER AGGRESSIVE AND SUPPORTIVE CARE.
5 BECAUSE I THOUGHT SHE MIGHT NEED TO BE ON A VENTILATOR,
6 BE IN THE INTENSIVE CARE UNIT, BE ON APPROPRIATE AGGRESSIVE
7 THERAPY.
8 Q. SO DID YOU HAVE AN IMPRESSION WHETHER THIS WAS A --
9 WHETHER THIS COULD BE TREATED?
10 A. SOMEONE THIS ILL? YEAH, YOU CAN TREAT IT. IT'S --
11 SOMEONE ALREADY THIS ILL, IT COULD BE A REALLY TOUGH TIME
12 TREATING IT. IT MAY OR MAY NOT -- MAY OR MAY NOT BE
13 SUCCESSFUL.
14 Q. WITH AGGRESSIVE TREATMENT, I THINK IS WHAT YOU REFERRED
15 TO.
16 A. EVEN -- EVEN WITH AGGRESSIVE TREATMENT, YES.
17 Q. ALL RIGHT. THE NOTE CONTINUES ON TO THE NEXT PAGE ON
18 PAGE 250. CAN YOU INTERPRET THAT NOTE FOR US, IF YOU WOULD,
19 PLEASE?
20 A. IT SAYS FURTHER AGGRESSIVE SUPPORTIVE -- I THINK I WAS
21 CONTINUING FROM THE PREVIOUS PAGE, BUT IT SAID I WOULD NEED
22 VOLUME REPLETION, FREE WATER REPLETION, ANTIBIOTICS AND
23 FURTHER AGGRESSIVE SUPPORTIVE CARE. I SUSPECT SHE MAY DIE
24 SOON. ADVISE FAMILY NOTIFICATION.
25 Q. OKAY. SO YOU WERE RECOMMENDING FAMILY NOTIFICATION AT
1085
1 THAT TIME?
2 A. YES. AFTER MY DISCUSSION WITH DR. WEITZEL IT INDICATED
3 THAT.
4 Q. YOU DID NOT TALK TO THE FAMILY MEMBERS, DID YOU?
5 A. I DON'T BELIEVE SO, NO.
6 Q. OKAY. OKAY. CAN I TAKE THOSE EXHIBITS?
7 MR. WILSON: MAY I HAVE JUST A MOMENT, YOUR HONOR?
8 THE COURT: YES.
9 (WHEREUPON, THERE'S AN OFF-THE-RECORD DISCUSSION BETWEEN
10 MR. WILSON AND MR. MAJOR.)
11 Q. (BY MR. WILSON) DOCTOR, I'M JUST GOING TO PUT BACK ON
12 THE BOARD -- I DON'T -- YOU DON'T HAVE THE EXHIBIT AND
13 YOU'LL HAVE TO REFER TO THE BOARD. THIS IS THE SAME NOTE
14 THAT YOU MADE ON JANUARY 7, 1996. DO YOU KNOW WHETHER OR
15 NOT HER -- THOSE NOTES REFLECT ANYTHING ABOUT THE
16 TEMPERATURE OF THIS PARTICULAR PATIENT ON THAT DAY?
17 A. I -- I DON'T THINK THEY DO, NO.
18 Q. OKAY. SO YOU DIDN'T HAVE ANY INFORMATION AT THAT TIME
19 RELATING TO TEMPERATURE?
20 A. I WOULD HAVE REVIEWED ANYTHING I HAD AVAILABLE --
21 AVAILABLE TO ME, YES.
22 Q. OKAY. IF A PERSON WERE SUFFERING FROM A SEPSIS, WOULD
23 THE TEMPERATURE OF THE PERSON HAVE ANY RELEVANCE?
24 A. SOMETIMES IT IS HIGH, SOMETIMES IT'S NORMAL, SOMETIMES
25 IT'S VERY LOW.
1086
1 Q. OKAY. SO IT COULD VARY?
2 A. COULD VARY QUITE GREATLY, YES.
3 Q. ALL RIGHT. NOW, I SHOW YOU WHAT'S BEEN MARKED AS
4 STATE'S EXHIBIT 7 AND ASK YOU TO TAKE A LOOK AT THAT
5 PARTICULAR EXHIBIT, IF YOU WOULD, PLEASE. THIS PURPORTS --
6 OR IS THE DAVIS HOSPITAL MEDICAL CENTER MEDICAL RECORDS FOR
7 A PATIENT BY THE NAME OF ENNIS ALLDREDGE. IT'S TRUE, IS IT
8 NOT, YOU ALSO HAD OCCASION TO EVALUATE HIM UPON ADMISSION TO
9 THE -- OR AFTER ADMISSION TO THE HOSPITAL?
10 A. UH-HUH.
11 Q. CAN YOU TELL US WHEN THAT PARTICULAR CONSULTATION TOOK
12 PLACE?
13 A. 1/10/96.
14 Q. DO YOU HAVE ANY INDEPENDENT RECOLLECTION OF THIS
15 PARTICULAR EVALUATION, OTHER THAN YOUR MEDICAL RECORDS?
16 A. NO.
17 Q. HAVE YOU HAD OCCASION TO REVIEW THOSE RECORDS?
18 A. YES.
19 Q. I WANT TO TURN TO THE -- PAGE TWO OF THAT PARTICULAR
20 EXHIBIT. FIRST OF ALL, CAN YOU TELL US AS TO RECENT
21 MEDICATIONS, AGAIN, ARE ANY OF THOSE MEDICATIONS -- ARE ALL
22 OF THOSE MEDICATIONS THAT ARE LISTED ON THAT PARTICULAR
23 PAGE, ARE THEY MEDICATIONS THAT WERE REPORTED TO YOU GIVEN
24 TO HIM SOME -- IN SOME OTHER FACILITY?
25 A. YES.
1087
1 Q. OKAY. DO YOU KNOW WHETHER OR NOT HE WAS ON ANY
2 MEDICATIONS AT THE TIME OF HIS ADMISSION THAT WERE -- THAT
3 WERE DIRECTED BY THE HOSPITAL OR PERSONNEL AT THE HOSPITAL?
4 A. HE -- HE MOST LIKELY WAS, YES.
5 Q. OKAY. LET'S TAKE A LOOK AT THE VERY BOTTOM OF THAT PAGE
6 WHERE IT TALKS ABOUT PHYSICAL EXAM. YOU INDICATE ON THAT
7 PARTICULAR REPORT THAT THE PATIENT IS AN ELDERLY MALE,
8 SUPINE IN BED WITH CHEYNE-STOKES RESPIRATIONS PATTERN. CAN
9 YOU EXPLAIN WHAT THAT MEANS TO THE JURY?
10 A. IT'S A TYPE OF BREATHING PATTERN WITH FAIRLY EITHER SLOW
11 OR -- OR PERHAPS RAPID RESPIRATIONS FOR A PERIOD OF TIME,
12 AND THEN A SLOWING DOWN OF RESPIRATIONS AND SOMETIMES A
13 COMPLETE CESSATION OF -- OF BREATHING FOR A PERIOD OF TIME.
14 THEN THE BREATHING STARTS AGAIN AND THEN IT GOES UP IN A
15 CYCLICAL FASHION AND THAT'S REPETITIVE.
16 Q. OKAY. NOW, WHEN YOU FORMED THIS IMPRESSION, CAN YOU
17 TELL US FROM THE NOTE, WAS THE PATIENT SPEAKING TO YOU AT
18 THAT TIME OR WAS HE LAYING IN BED AT THAT TIME? WAS HE
19 CONVERSING WITH YOU OR COMMUNICATING WITH YOU?
20 A. YEAH. FROM MY RECOLLECTION IN REVIEWING THIS NOTE HE
21 WAS NOT -- NOT COMMUNICATING. HE WAS -- AT THAT POINT HE
22 WAS SEDATED.
23 Q. SO HE WAS -- HE WAS SEDATED AT THAT POINT?
24 A. YES.
25 Q. OKAY. IS THERE ANY PARTICULAR SIGNIFICANCE TO YOUR
1088
1 IMPRESSIONS AS TO THE CHEYNE-STOKES RESPIRATIONS THAT CAUSED
2 YOU CONCERN WITH THIS PATIENT?
3 A. CHEYNE-STOKES RESPIRATIONS COULD BE -- COULD BE A SIGN
4 OF AN UNDERLYING HEART PROBLEM, OF SEVERE HEART FAILURE. IT
5 COULD BE A CENTRAL NERVOUS SYSTEM PROBLEM, A STROKE IN THE
6 PAST. IT COULD BE RELATED TO -- TO RECEIVING SEDATION
7 AND -- AND SOME UNDERLYING LESION PERHAPS BEING MORE -- MORE
8 APPARENT BY THAT. SOME PEOPLE HAVE CHEYNE-STOKES
9 RESPIRATIONS FOR LONG PERIODS OF TIMES AND THEY'RE UP AND
10 ABOUT AND WALKING AND TALKING AND IT'S NOT NECESSARILY AN
11 OMINOUS SIGN.
12 Q. SO IT WAS SOMETHING THAT YOU FELT SIGNIFICANT ENOUGH TO
13 NOTE -- MAKE NOTE OF, BUT --
14 A. YES.
15 Q. DID YOU RECOMMEND ANY FOLLOW-UP ON THAT?
16 A. UNDER -- UNDER MY RECOMMENDATIONS I AGREED WITH SOME
17 SCREENING LABORATORIES AS THEY'D BEEN PERFORMED. I
18 SUGGESTED ASPIRATION PRECAUTIONS BECAUSE I'D EVEN MADE A
19 NOTE THAT HE HAD DIMINISHED MENTAL STATUS AND A DIMINISHED
20 GAG REFLEX ON EXAM. SO, AGAIN, I WAS WORRIED BY POSSIBLE
21 ASPIRATION.
22 Q. OKAY.
23 A. BECAUSE OF HIS BREATHING PATTERN I ALSO MADE AN
24 ADDITIONAL NOTE UNDER NUMBER 4: CONSIDER OXYGEN SATURATION
25 FOR AN INTERVAL OF TIME, GIVEN THE EVIDENCE OF THE PERIODIC
1089
1 BREATHING, AS I CALLED IT, OR THE CHEYNE-STOKES
2 RESPIRATIONS. I WAS -- YOU KNOW, I JUST WANTED TO MAKE SURE
3 HE DIDN'T DROP HIS OXYGEN LEVEL. IF HE DID, LET'S PUT HIM
4 ON OXYGEN.
5 Q. NOW, YOU INDICATED THAT HE WAS SEDATED AT THE TIME THAT
6 YOU EXAMINED HIM. DO YOU KNOW WHAT TYPE OF SEDATIVE WAS
7 BEING ADMINISTERED TO HIM?
8 A. I'M SURE I REVIEWED THOSE AND FELT LIKE IT WAS SOMETHING
9 HE HAD JUST RECEIVED, YES.
10 Q. OKAY.
11 A. OR RECEIVED WITHIN SEVERAL HOURS.
12 Q. WOULD A -- WOULD A SEDATIVE HAVE ANY EFFECT ON THE
13 PROBLEM YOU PERCEIVED WITH THE CHEYNE-STOKES RESPIRATIONS?
14 A. IT -- IT COULD. IT COULD CAUSE A DIMINISHED RATE OF
15 RESPIRATION. IT'S CONCEIVABLE IT COULD BRING OUT THAT
16 MANIFESTATION IN CHEYNE-STOKES RESPIRATION. IT DOESN'T
17 NECESSARILY ALWAYS CAUSE THAT. THERE MAY BE AN UNDERLYING
18 PROBLEM, BUT IT -- IT CERTAINLY CAN MAKE RESPIRATIONS WORSE,
19 IT COULD SLOW DOWN RESPIRATIONS, IT MIGHT -- I FELT LIKE IT
20 MIGHT BRING THAT OUT PERHAPS.
21 Q. LET'S TURN TO THE NEXT PAGE ON THAT PARTICULAR EXHIBIT,
22 IF YOU WOULD, PLEASE. I THINK IT'S MED-0009. YOU INDICATE
23 ON ITEM --
24 THE COURT: WOULD YOU JUST MOVE THAT A LITTLE OVER
25 TO THE LEFT SO THEY CAN --
1090
1 MR. WILSON: TO THE LEFT?
2 THE COURT: YEAH.
3 MR. WILSON: THIS WAY, YOUR HONOR?
4 THE COURT: YEAH. FINE.
5 Q. (BY MR. WILSON) OKAY. YOU INDICATE AT THE TOP OF THE
6 PAGE UNDER -- UNDER 9, ITEM 9, URINARY INCONTINENCE. CAN
7 YOU EXPLAIN WHAT THAT MEANS?
8 A. IT JUST MEANS THE PATIENT WAS -- WAS INCONTINENT OF
9 URINE. HE DID NOT HAVE CONTROL OVER THAT. IT MAY HAVE BEEN
10 A HISTORY I'D OBTAINED OR IT MAY HAVE BEEN SOMETHING THAT A
11 NURSE HAD TOLD ME ABOUT.
12 Q. OKAY. AND THEN YOU'VE GOT AT THE LAST THERE, PROBABLY
13 EARLY ORAL THRUSH.
14 A. AGAIN, THAT'S A YEAST INFECTION OF THE MOUTH.
15 Q. OKAY. UNDER YOUR RECOMMENDATION, DO YOU -- YOU TALK
16 ABOUT A STRAIGHT CATHETERIZED URINALYSIS TO OBTAIN
17 URINALYSIS AND CULTURE AND SENSITIVITY. WHAT WERE YOU --
18 WHAT WERE YOU ASKING FOR THEN?
19 A. A URINE SAMPLE JUST TO SEE IF THERE WAS ANY EVIDENCE OF
20 ABNORMAL URINE SEDIMENT, ANY EVIDENCE OF INFECTION.
21 Q. WAS THERE ANYTHING ABOUT YOUR EVALUATION THAT YOU FELT
22 THERE WAS SOME KIND OF A PROBLEM RELATIVE TO --
23 A. I HAD NOTED ABOVE THE PATIENT HAD A HISTORY OF SOME
24 RENAL INSUFFICIENCY. I WAS -- I THINK I WAS MORE OR LESS
25 JUST BEING COMPLETE.
1091
1 Q. WHAT WOULD THAT MEAN? WHAT WERE YOU LOOKING FOR,
2 DOCTOR? WHAT WERE YOU TRYING TO RULE OUT?
3 A. ANY EVIDENCE OF ABNORMAL URINE SEDIMENT, ANY EVIDENCE OF
4 INFECTION IN THE URINE.
5 Q. OKAY. CAN YOU TELL US BASED UPON YOUR EVALUATION OF
6 THIS PARTICULAR PATIENT, WERE THERE ANY FINDINGS AS RELATED
7 TO HIS PHYSICAL EXAMINATION AND HIS -- THAT YOU MADE ON THAT
8 PARTICULAR DATE WHICH WOULD LEAD OR CAUSE YOU TO BELIEVE HE
9 WAS SUFFERING FROM ANY ACUTE ILLNESS?
10 A. NOT IN A MEDICAL SENSE. I THINK SOME OF THE SEDATION
11 WAS FROM MEDICATIONS HE HAD ALREADY RECEIVED.
12 Q. OKAY.
13 MR. WILSON: I HAVE NO FURTHER QUESTIONS, YOUR
14 HONOR.
15 THE COURT: OKAY. WHY DON'T WE -- LADIES AND
16 GENTLEMEN, WE'VE BEEN GOING FOR A LITTLE BIT OVER AN HOUR.
17 LET'S TAKE A BREAK BEFORE CROSS-EXAMINATION.
18 DURING THAT BREAK BETWEEN NOW AND FIVE MINUTES TO
19 10:00, REMEMBER IT'S YOUR DUTY NOT TO CONVERSE AMONG
20 YOURSELVES OR TO CONVERSE WITH OR ALLOW YOURSELVES TO BE
21 ADDRESSED BY ANY OTHER PERSON ON THE SUBJECT OF THIS TRIAL.
22 ALSO, YOUR DUTY NOT TO FORM OR EXPRESS AN OPINION THEREON
23 UNTIL THE CASE IS FINALLY SUBMITTED TO YOU.
24 AND I WILL HAVE YOU BACK AT FIVE MINUTES TO 10:00.
25 (WHEREUPON, AT THIS TIME THE JURY LEAVES THE
1092
1 COURTROOM.)
2 THE COURT: THE RECORD WILL REFLECT THAT THE JURY
3 HAS LEFT. CAN YOU TELL ME HOW MUCH TIME YOU ANTICIPATE WITH
4 THIS WITNESS ON CROSS-EXAMINATION?
5 MR. STIRBA: IT'S DIFFICULT, JUDGE. MAYBE HALF AN
6 HOUR, 45 MINUTES.
7 THE COURT: ARE THE OTHER DOCTORS THAT YOU
8 MENTIONED YESTERDAY, THE OTHER THREE TREATERS, ARE THEY
9 GOING TO BE LONGER OR SHORTER THAN THIS ONE?
10 MR. WILSON: SHORTER.
11 THE COURT: OKAY. ALL RIGHT. THEN WE'LL SEE YOU
12 BACK AT FIVE MINUTES TO 10:00.
13 (WHEREUPON, AT THIS TIME THERE'S A RECESS, AFTER WHICH
14 PROCEEDINGS RESUME IN THE HEARING OF THE JURY, AS
15 FOLLOWS:)
16 THE COURT: OKAY. I'VE BEEN GIVEN A NOTE FROM THE
17 JURY THAT ASKS IF -- MR. WILSON, IF YOU COULD SPEAK UP. IT
18 SAYS SOME OF THE JURORS ARE HAVING A HARD TIME HEARING.
19 SO I THINK THAT GOES FOR WITNESSES, EVERYBODY, YOU
20 KNOW, WE NEED TO -- WE HAVE THAT PROJECTOR ON TO SHOW SOME
21 OF THE EXHIBITS, BUT IF EVERYBODY COULD KEEP THEIR VOICE UP,
22 I THINK IT WOULD BE HELPFUL SO THAT THE JURY CAN MAKE SURE
23 THEY CAN HEAR EVERYONE.
24 OKAY, MR. STIRBA?
25 MR. STIRBA: THANK YOU, YOUR HONOR.
1093
1 CROSS-EXAMINATION
2 BY MR. STIRBA:
3 Q. GOOD MORNING, DOCTOR.
4 A. GOOD MORNING.
5 Q. IN YOUR TESTIMONY I THINK YOU SAID THAT AS FAR AS YOUR
6 ROLE IS CONCERNED AT THE HOSPITAL THAT ESSENTIALLY YOU COULD
7 DO WHATEVER YOU THOUGHT WAS APPROPRIATE TO BE DONE; IS THAT
8 TRUE?
9 A. THAT'S WHAT I FELT.
10 Q. SO IN OTHER WORDS, IF YOU THOUGHT SOME CARE WAS
11 APPROPRIATE BASED UPON YOUR MEDICAL TRAINING AND EXPERIENCE,
12 YOU COULD, IN FACT, ORDER THAT THAT CARE BE PROVIDED; IS
13 THAT CORRECT?
14 A. YES. ABSOLUTELY.
15 Q. AND IT'S TRUE, IS IT NOT, THAT THAT CARE ALSO COULD
16 INCLUDE AT TIMES THE ORDERING OF MEDICATIONS? CORRECT?
17 A. YES.
18 Q. FOR EXAMPLE, YOU'VE TOLD US ABOUT THE SITUATION WITH
19 MS. LARSEN WHO HAD THE -- AS YOU PUT IT -- SUBSTANTIALLY
20 SEVERE SEIZURE AND YOU ORDERED DILANTIN TO BE PRESCRIBED AT
21 THAT POINT TO ASSIST WITH THE -- DEALING WITH THAT
22 PROBLEM --
23 A. YES.
24 Q. -- IS THAT CORRECT. AND YOU'VE TESTIFIED ABOUT A NUMBER
25 OF THINGS ON YOUR CONSULT REPORTS WHICH YOU HAVE DESCRIBED
1094
1 AS RECOMMENDATIONS; IS THAT TRUE?
2 A. YES.
3 Q. IN OTHER WORDS, THERE'S A DIFFERENCE BETWEEN YOU COMING
4 IN AND ADVISING BASED UPON YOUR EXPERIENCE THAT PERHAPS
5 CERTAIN THINGS SHOULD BE DONE, AND WHAT YOU IN FACT WOULD
6 ORDER TO BE DONE BECAUSE YOU THOUGHT IT WAS NECESSARY AND
7 MEDICALLY APPROPRIATE, CORRECT?
8 A. YES. MANY -- MANY TIMES AS A CONSULTANT YOU'LL LEAVE
9 RECOMMENDATIONS. YOU WON'T WRITE A SINGLE ORDER.
10 SOMETIMES -- SOMETIMES I WILL JUST AS A COURTESY TO THAT
11 PHYSICIAN SO THEY DON'T HAVE TO DO IT OR SO IT'S HELPING GET
12 THE PROCESS ALONG. IF I FEEL IT'S MORE URGENT THEN I'LL
13 ENFORCE THE ORDER RIGHT AWAY.
14 Q. NOW, OF THE -- OF THE MATERIALS THAT YOU SAW ON DIRECT
15 EXAMINATION, OTHER THAN THE CIRCUMSTANCE WHERE YOU
16 INTERVENED WITH RESPECT TO MS. LARSEN, CAN YOU TELL ME
17 ANOTHER EXAMPLE WHERE YOU HAD A SPECIFIC ORDER THAT YOU
18 THOUGHT OUGHT TO BE COMPLIED WITH IN ORDER TO PROVIDE
19 APPROPRIATE MEDICAL CARE?
20 A. CAN YOU BE MORE SPECIFIC WITH THE INSTANCE?
21 Q. I CAN'T. YOU'VE SEEN THE -- THE CONSULT REPORTS. DO
22 YOU REMEMBER ANY OTHER INSTANCE WHERE YOU ORDERED THAT
23 SOMETHING BE DONE?
24 A. WHAT -- WHAT WAS THE EXAMPLE YOU GAVE AGAIN?
25 Q. WELL, WITH MS. -- WITH MS. LARSEN, OBVIOUSLY YOU ORDERED
1095
1 DILANTIN, TRUE?
2 A. YES.
3 Q. AND YOU THOUGHT THAT WAS APPROPRIATE FOR THE SEIZURE,
4 CORRECT?
5 A. I THINK I ORDERED ATIVAN, OXYGEN, I ORDERED SOME
6 STUDIES.
7 Q. SURE. SURE. I'M NOT TRYING TO LIMIT IT, BUT YOU
8 OBVIOUSLY INTERVENED IN THAT MEDICAL SITUATION --
9 A. YES.
10 Q. -- BECAUSE YOU THOUGHT IT WAS NECESSARY AND APPROPRIATE;
11 ISN'T THAT CORRECT?
12 A. OF COURSE.
13 Q. AND THEN WHAT I WAS TRYING TO GET OUT, SIR, IS DO YOU
14 REMEMBER ANY OTHER INSTANCES FROM THE REPORTS, FROM THE
15 CONSULTS YOU PROVIDED WITH RESPECT TO MR. ALLDREDGE,
16 MS. CRANE, OR MS. LARSEN, OTHER THAN WHAT YOU -- WE JUST
17 TALKED ABOUT WHERE YOU ACTUALLY ORDERED THAT SOMETHING BE
18 DONE?
19 A. OTHER THAN WHAT WE'VE DISCUSSED HERE TODAY ALREADY? NO,
20 EVERYTHING'S BEEN DISCUSSED PRETTY -- PRETTY THOROUGHLY. I
21 THINK AT ONE POINT I DECREASED A DURAGESIC PATCH. I WROTE
22 SOME OTHER, YOU KNOW, KIND OF MODEST ORDERS AND THINGS.
23 Q. OKAY. BUT GENERALLY IS IT FAIR TO SAY THAT MOST OF WHAT
24 YOU TOLD THE JURY WERE ESSENTIALLY RECOMMENDATIONS THAT YOU
25 MADE?
1096
1 A. TO A -- TO A LARGE EXTENT. THERE WERE -- THERE WERE
2 SOME ORDERS THAT I MADE, BUT TO A LARGE EXTENT MANY OF THE
3 THINGS WERE IN THE LONG NOTE THAT I WROTE WHEN I FIRST -- I
4 WROTE WHEN I FIRST SAW THE PATIENT, THOSE WERE ALL
5 RECOMMENDATIONS.
6 Q. RECOMMENDATIONS. AND IT'S TRUE, IS IT NOT, THAT TO A
7 GREAT EXTENT WHAT YOU HAD IN YOUR CONSULT REPORTS WHERE YOU
8 USE THE WORD "POSSIBLE" OR "PROBABLE" WERE NOT NECESSARILY
9 DEFINITIVE DIAGNOSES OR CONCLUSIONS BY YOU; IS THAT CORRECT?
10 A. THEY WERE DEFINITIVE IN THAT CONTEXT. OFTENTIMES WHEN I
11 SAY PROBABLE I HAVE A PRETTY GOOD INDEX OF SUSPICION THAT
12 SOMETHING EXISTS, YES.
13 Q. OKAY. WELL, LET'S -- LET'S ASK YOU THEN THIS. YOU PUT
14 IN THAT ONE NOTE POSSIBLE SEPSIS. DO YOU MEAN TO TELL THE
15 JURY THAT YOU CAME TO A CONCLUSION BASED UPON YOUR MEDICAL
16 TRAINING AND EXPERIENCE THAT MS. CRANE AT THAT POINT WAS
17 SEPTIC?
18 A. WHAT I -- WHAT I MEANT WAS THERE'S MANY THINGS THAT CAN
19 CAUSE THE LOW BLOOD PRESSURE. SEPSIS IS ONE OF THOSE. AND
20 IT'S IN A HOSPITAL PATIENT THAT COULD ACQUIRE AN INFECTION.
21 THAT'S NOT A BAD BET. BUT THERE CAN BE MANY THINGS THAT CAN
22 CAUSE THAT, INCLUDING THE VOLUME DEPLETION, THE
23 INTRAVASCULAR VOLUME DEPLETION, DRUGS, SEDATIVES, ET CETERA.
24 Q. OKAY. SO ARE YOU SAYING THAT IN YOUR REASONED JUDGMENT
25 AT THE TIME, YOU'RE BASICALLY SAYING THAT THAT IS SOMETHING
1097
1 THAT YOU THOUGHT HAD OCCURRED; IS THAT RIGHT?
2 A. WHAT -- NO. WHAT I'M SAYING IS THAT'S ONE OF THE
3 POSSIBILITIES AND THAT I WOULD TREAT THAT PATIENT FOR THAT
4 PROBLEM -- IF ALLOWED TO GO ON AND TREAT THAT PATIENT
5 AGGRESSIVELY, THAT WOULD BE ONE OF THE THINGS HIGH ON MY
6 LIST OF THINGS TO TREAT. I WOULD TREAT ALL THOSE PROBLEMS.
7 Q. HOW -- HOW ABOUT WHEN YOU SAY -- USE THE WORD PROBABLE?
8 DO YOU MEAN THAT YOU CONCLUDED THAT THAT EVENT HAD OCCURRED,
9 IF YOU USED THE WORD PROBABLE IN YOUR CONSULT?
10 A. AGAIN, IT'S SORT OF AN INDEX OF SUSPICION. I'D SAY
11 THAT'S A PRETTY -- HIGHER INDEX OF SUSPICION.
12 Q. AND IT'S TRUE, IS IT NOT, THAT DURING THESE CONSULTS
13 WHEN YOU SAW THE PATIENTS, YOU HAD ESSENTIALLY FREE ACCESS,
14 FIRST OF ALL, TO THE ACTUAL PATIENT THEMSELVES; IS THAT
15 RIGHT?
16 A. YES.
17 Q. YOU COULD COME IN AND MAKE AN EXAMINATION --
18 A. SURE.
19 Q. -- AND DO WHATEVER YOU NEEDED TO DO TO PROVIDE THE CARE;
20 IS THAT TRUE?
21 A. YES.
22 Q. AND IT'S TRUE, IS IT NOT, THAT YOU ALSO HAD ACCESS --
23 TOTAL ACCESS TO THE PATIENT'S MEDICAL CHART?
24 A. YES.
25 Q. IN FACT, IT WOULD BE IMPORTANT TO YOU TO HAVE THAT
1098
1 INFORMATION FOR PURPOSES OF PROVIDING ANY ORDERS OR ORDERING
2 ANY CARE; ISN'T THAT CORRECT?
3 A. AS I ALREADY SAID, I'D REVIEW ANYTHING I COULD, YOU
4 KNOW, REVIEW.
5 Q. AND IT'S TRUE, IS IT NOT, IN THE MEDICAL CHART THAT
6 WOULD INCLUDE MEDICATIONS THAT THE PATIENT WAS ON? IS THAT
7 CORRECT?
8 A. YES.
9 Q. AND IT'S TRUE IT WOULD BE IMPORTANT FOR YOU TO REVIEW
10 THE MEDICATION STATUS OF THE PATIENT, CERTAINLY BEFORE YOU
11 ORDER ANY MEDICATIONS FOR THAT PATIENT; ISN'T THAT CORRECT?
12 A. IF I FELT LIKE THE PROBLEM I WAS SEEING THE PATIENT FOR
13 SHOULD DO THAT, I WOULD DO THAT. NOT NECESSARILY FOR
14 EVERYTHING I WOULD SEE THE PATIENT FOR, BUT FOR CERTAIN
15 PROBLEMS I WOULD REVIEW THE ENTIRE MEDICATION LIST, YES.
16 Q. WELL, FOR EXAMPLE, YOU ORDERED DILANTIN FOR THE SEIZURE
17 OF MS. LARSEN. DO YOU REMEMBER THAT?
18 A. UH-HUH.
19 Q. AND IT'S TRUE THAT DILANTIN HAS CERTAIN SIDE EFFECTS.
20 IT MAY BE SEDATING IN NATURE --
21 A. UH-HUH.
22 Q. -- ISN'T THAT CORRECT?
23 A. IT'S NOT A TYPICAL SEDATIVE, NO, BUT IT DOES HAVE THAT
24 SIDE EFFECT, YES.
25 Q. IT DOES HAVE THAT SIDE EFFECT. SO IT WOULD BE IMPORTANT
1099
1 FOR YOU AS A PHYSICIAN BEFORE PRESCRIBING THAT TO REVIEW THE
2 MEDICATIONS SHE WAS ON; ISN'T THAT TRUE?
3 A. I THINK THAT'S TRUE, YES.
4 Q. AND IT'S TRUE, IS IT NOT, THAT THE CONCERN WOULD BE, OF
5 COURSE, THAT IF YOU ORDERED DILANTIN, WHICH HAD SEDATING
6 EFFECTS, AND SHE WAS ON SOME OTHER MEDICATIONS WHICH WERE
7 SEDATING, YOU MIGHT CAUSE A PROBLEM WITH THE PATIENT CARE;
8 ISN'T THAT CORRECT?
9 A. DILANTIN'S NOT A STRONG SEDATIVE, BUT I TAKE ALL THAT
10 INTO ACCOUNT WHEN I ORDER MEDICATIONS, YES.
11 Q. AND YOU HAVE NO -- NO QUESTION IN YOUR MIND YOU DID THAT
12 AT THE TIME?
13 A. YES. I THINK I WOULD REVIEW THE PATIENT'S MEDICATIONS,
14 YES.
15 Q. AND IT'S TRUE, ALSO, IN TERMS OF PROVIDING THESE
16 CONSULTS THAT YOU COULD TALK TO DR. WEITZEL, THE ATTENDING
17 PHYSICIAN, AT ANY TIME?
18 A. I WOULD -- I WOULD OFTEN PAGE HIM AND TALK TO HIM IF I
19 FELT LIKE IT WAS AN IMPORTANT PROBLEM, YES.
20 Q. SURE. I MEAN, THAT WAS NOT A PROBLEM AND IF YOU NEEDED
21 A CONSULT TO CONSULT WITH HIM, YOU DID THAT, TRUE?
22 A. I WOULD OFTEN DO THAT BECAUSE I WAS THE CONSULTANT AND
23 HE WAS THE PRIMARY, SO I WOULD CALL HIM AND LET HIM KNOW, AS
24 I DID ON -- AS INDICATED IN THE CHART.
25 Q. SURE. IN FACT, FOR EXAMPLE, LIKE THE SITUATION WITH
1100
1 MS. CRANE, YOU INDICATE IN YOUR NOTE THAT YOU HAD A
2 CONVERSATION WITH DR. WEITZEL.
3 A. (NODS HEAD UP AND DOWN.)
4 Q. AND ISN'T IT ALSO TRUE THAT IN THE CONSULT NOTES THAT
5 YOU PUT IN THE HANDWRITTEN SECTION OF THE PROGRESS ORDERS,
6 TYPICALLY YOU WOULD START: ASKED TO SEE PATIENT BY
7 DR. WEITZEL; ISN'T THAT CORRECT?
8 A. AS A CONSULTANT I WAS TRYING TO INDICATE I WAS THAT
9 CONSULTANT AND THAT HE WAS THE PRIMARY. SOMETIMES IT MIGHT
10 NOT BE THAT HE ASKED ME 10 MINUTES BEFORE THAT TO SEE THE
11 PATIENT. OFTENTIMES IT WAS A NURSE CALLING ME, NOT
12 DR. WEITZEL, THAT THE PATIENT NEEDED TO HAVE MY ASSESSMENT.
13 BUT I WOULD INDICATE THAT BECAUSE THAT'S THE FORMALITY OF
14 THE RECORD AND HE WAS THE ATTENDING AND I WAS THE
15 CONSULTANT. I WAS TRYING TO ESTABLISH MY ROLE THERE, I
16 GUESS.
17 Q. WELL, I GUESS -- I GUESS WHAT I'M -- WHAT I'M ASKING IS,
18 IF YOU PUT IN YOUR NOTE, ASKED TO SEE PATIENT BY
19 DR. WEITZEL, IS THAT A TRUE STATEMENT OR NOT?
20 A. YES.
21 Q. NOW, I WANT TO TALK FIRST ABOUT MR. ALLDREDGE, AND I
22 THINK I PUT THE BINDER UP THERE, DOCTOR --
23 A. IT'S RIGHT HERE.
24 Q. -- SO YOU MIGHT WANT TO REFER TO THAT. AND
25 MR. ALLDREDGE YOU SAW THE ONE TIME, THE CONSULT, ON
1101
1 JANUARY 10 OF 1996; IS THAT CORRECT?
2 A. YES.
3 Q. AND CAN YOU TELL THE JURY WHAT TIME OF THE DAY YOU SAW
4 MR. ALLDREDGE FOR THAT CONSULTATIVE EXAMINATION?
5 A. LOOKS LIKE IT WAS 9:00 -- IN MY NOTE IT LOOKS LIKE 9:00
6 P.M.
7 Q. 9:00 P.M. AND IT'S TRUE, IS IT NOT, AS YOU -- AS YOU
8 TOLD US, AS YOU SIT HERE TODAY YOU HAVE NO INDEPENDENT
9 RECOLLECTION OF THESE EVENTS OTHER THAN WHAT IS CONTAINED IN
10 YOUR NOTES; IS THAT RIGHT?
11 A. IF -- IF I DO, IT'S VAGUE. I -- THAT'S WHY IT'S VERY
12 MUCH MORE ACCURATE TO GO BY WHAT'S WRITTEN IN THE NOTE.
13 I -- THAT LONG AGO, IT'S VERY HARD TO RETAIN INDEPENDENT,
14 CLEAR THINGS ABOUT THESE PATIENTS.
15 Q. OKAY. AND WITH RESPECT TO MR. ALLDREDGE YOU SAW HIM AT
16 9 O'CLOCK -- THAT WOULD BE P.M., IS THAT RIGHT, IN THE
17 EVENING?
18 A. YES.
19 Q. AND IT'S TRUE, IS IT NOT, THERE'S NOTHING ON THE CONSULT
20 THAT WOULD INDICATE WHAT MEDICATIONS, IF ANY, HE WAS ON AT
21 THAT TIME WHEN YOU SAW HIM ON THE 10TH? CORRECT?
22 A. YES. WHAT -- WHAT I -- WHAT I WOULD HAVE DONE IS LOOKED
23 AT THE CHART. IT LOOKS LIKE RIGHT -- RIGHT ABOVE THE NOTE
24 IT INDICATES THE PATIENT HAD BEEN PRESCRIBED HALDOL AND
25 ATIVAN. IF I SAW THE PATIENT WAS SEDATED, I ASKED THE
1102
1 NURSES, DID HE RECEIVE THAT? ANSWER IS YES. SO THEN I
2 INDICATE THAT IN MY DICTATION, THE PATIENT WAS SEDATED FROM
3 THOSE MEDICATIONS.
4 Q. OKAY. AND I'LL GO BACK AND ASK MY QUESTION AGAIN.
5 THERE'S NOTHING IN YOUR CONSULT NOTE THAT INDICATES WHAT
6 MEDICATIONS, IF ANY, MR. ALLDREDGE WAS ON AT THAT TIME;
7 ISN'T THAT CORRECT?
8 A. I'M NOT SURE THAT'S CORRECT OR NOT. I'D HAVE TO REVIEW
9 THAT AGAIN.
10 Q. ALL RIGHT.
11 A. BUT I -- I THINK I DID INDICATE THE PATIENT WAS SEDATED
12 AT THAT TIME, IN MY NOTE.
13 Q. AND YOU'RE REFERRING TO YOUR CONSULT REPORT OR YOUR
14 PROGRESS NOTE?
15 A. RIGHT -- RIGHT NOW I'M LOOKING AT THE CONSULT NOTE.
16 Q. THE DICTATION, CORRECT?
17 A. YES. NUMBER 3 ON THE RECOMMENDATIONS: ADVISE
18 ASPIRATION PRECAUTIONS WITH THE PATIENT'S DIMINISHED MENTAL
19 STATUS AND DIMINISHED GAG REFLEX, IS ONE THING I HAD SAID
20 THERE.
21 Q. OKAY. WELL, LET ME STOP YOU RIGHT THERE. YOU JUST TOLD
22 US WITH RESPECT TO 3: ADVISE ASPIRATION PRECAUTIONS WITH
23 THE PATIENT'S DIMINISHED MENTAL STATUS AND DIMINISHED GAG
24 REFLEX.
25 NOW, CERTAINLY A DIMINISHED GAG REFLEX DOES NOT EQUATE
1103
1 TO SEDATION, DOES IT?
2 A. IT OFTEN DOES, YES.
3 Q. WELL, IT DOESN'T MEAN SEDATION, DOES IT, SIR?
4 A. SEDATION IN TERMS OF THE PATIENT BEING IN A SEDATED
5 STATUS, YES.
6 Q. OKAY. SO YOU'RE SAYING A GAG REFLEX MEANS SEDATION?
7 A. NO.
8 Q. THAT'S WHAT I WAS ASKING.
9 AND IT'S ALSO TRUE, IS IT NOT, THAT MR. ALLDREDGE --
10 WHEN YOU SAY HE HAD A DIMINISHED MENTAL STATUS, YOU ALSO
11 DIAGNOSED HIM OR HAD AN IMPRESSION HE SUFFERED FROM SEVERE
12 DEMENTIA, DID YOU NOT?
13 A. YES. THAT WAS THE HISTORY I HAD OBTAINED PRIOR TO THAT.
14 Q. AND, CERTAINLY, A DIMINISHED MENTAL STATUS WOULD BE
15 CONSISTENT WITH SOMEBODY WHO WAS SEVERELY DEMENTED; ISN'T
16 THAT TRUE?
17 A. BUT, YOU KNOW, I -- I GUESS THE -- WHAT I WAS GETTING
18 AT, THE PATIENT HAD BEEN DESCRIBED TO BE AGITATED, COMBATIVE
19 EARLIER, AND NOW ON MY EXAMINATION HE WAS SEDATED. SO I
20 WAS -- AND I HAD NOTED THAT HE HAD HAD THE MEDICATION
21 EARLIER, SO I WAS TRYING TO SAY THAT THAT MIGHT BE A CAUSE
22 EFFECT. IF YOU LOOK AT MY WRITTEN NOTE INSTEAD OF THE TYPED
23 NOTE --
24 Q. OKAY. SO WE'RE BACK TO --
25 A. -- DATED 1/10/96.
1104
1 Q. -- THE WRITTEN NOTE. ALL RIGHT.
2 A. I GUESS IT'S 0011, SORT OF DOWN IN THE BOTTOM PART OF
3 THE PAGE, IF I MAY READ IT.
4 Q. SURE.
5 A. IT SAYS: CURRENTLY LETHARGIC. AROUSABLE ONLY TO
6 PAINFUL STIMULI FOLLOWING ATIVAN/HALDOL INJECTION FOR
7 COMBATIVENESS.
8 Q. RIGHT. AND SO YOUR -- YOU WERE AWARE THAT HE HAD
9 RECEIVED AN INJECTION FOR HALDOL AND ATIVAN, CORRECT?
10 A. YES.
11 Q. AND THAT WAS A P.R.N. INJECTION. IN OTHER WORDS, IT WAS
12 AN AS NEEDED INJECTION, WAS IT NOT?
13 A. I -- I DIDN'T SPECIFY WHETHER IT WAS P.R.N. OR NOT, BUT
14 THE PATIENT HAD RECEIVED THAT MEDICATION.
15 Q. OKAY. AND YOU WERE THERE AT 9 O'CLOCK. CAN YOU TELL ME
16 WHAT TIME OF THE DAY HE RECEIVED THE HALDOL AND HE RECEIVED
17 THE ATIVAN?
18 A. IF I'M -- IF YOU LOOK AT THE TOP OF THE SAME PAGE, IT'S
19 NOTED BY THE NURSE AT 2:30 P.M. IT SAID HALDOL 10
20 MILLIGRAMS I.M. NOW, THEN IT GIVES A P.R.N. ATIVAN ORDER.
21 THEN IT ALSO SAID, HALDOL FIVE MILLIGRAMS I.M. Q.A.M. AT
22 5:00 P.M. AND BEFORE BEDTIME.
23 I CAN'T SAY IF THEY GAVE THAT BEFORE THE -- THE
24 VISIT -- TO MY VISIT EXCEPT FROM WHAT THE ORDER SAYS. IT'S
25 VERY SUSPICIOUS THAT HE GOT A DOSE OF ATIVAN -- HALDOL
1105
1 EARLIER --
2 Q. WHERE ARE YOU READING -- READING, SIR, WHEN YOU SAY THE
3 NURSE'S ORDERS? YOUR PROGRESS NOTES --
4 A. THE NURSE'S NOTATION OF DR. WEITZEL'S ORDERS AT THE TOP
5 OF THE PAGE.
6 Q. OKAY. THAT'S -- THAT'S A DOCTOR'S ORDER, THAT'S TRUE.
7 THERE'S NO QUESTION THERE WAS AN ORDER FOR ATIVAN P.R.N. AND
8 AN ORDER FOR HALDOL; ISN'T THAT CORRECT?
9 A. THE HALDOL ORDER WAS A NOW ORDER. THAT MEANS IT WOULD
10 HAVE BEEN GIVEN AT THAT TIME IT WAS WRITTEN. THE NURSE
11 NOTED THAT AT 1430. I MEAN, I DON'T HAVE --
12 Q. IT SAYS --
13 A. -- THE NURSE'S MEDICATION LIST TO KNOW WHEN SHE GAVE IT,
14 BUT SHE TOOK IT OFF AT THAT TIME.
15 Q. OKAY.
16 A. BUT HE ALSO WROTE AN ORDER FOR HALDOL TO BE GIVEN AT
17 7:00 A.M., 1700, AND H.S. AND THEN IN MY NOTE I SAY THAT
18 PATIENT HAD RECEIVED ATIVAN AND HALDOL. THAT IMPLIES TO ME
19 THAT I HAD DISCUSSED WITH THE NURSE THE PATIENT RECEIVED
20 HALDOL AND ATIVAN.
21 Q. LET'S JUST MAKE SURE THAT WE UNDERSTAND ONE ANOTHER.
22 OFF TO THE LEFT IS WHAT YOU'RE --
23 A. YES.
24 Q. -- REFERRING TO. AND IT SAYS 1/10/96, AND THEN IT
25 SAYS -- THERE'S A CIRCLE, I DON'T KNOW WHAT THAT MEANS.
1106
1 A. IT'S NUMBER 1, IT LOOKS LIKE TO ME.
2 Q. OKAY. NUMBER 1, ATIVAN 1 MILLIGRAM AND HALDOL 10
3 MILLIGRAMS I.M. NOW.
4 A. SO THAT EVEN -- THAT -- THAT'S --
5 Q. SO THAT'S -- THAT'S THE NOW --
6 A. -- THAT'S WHERE THE ATIVAN CAME FROM, TOO, YES.
7 Q. -- NOW ORDER BY THE PHYSICIAN. AND THEN IT GOES ON TO
8 SAY: ATIVAN 1 TO 2 MILLIGRAMS I.M. AT, I GUESS, Q 4 HOURS,
9 P.R.N. FOR SEVERE AGITATION. THAT'S A P.R.N. ORDER.
10 A. YES.
11 Q. AND THEN WE HAVE HALDOL 5 MILLIGRAMS I.M. Q SOMETHING
12 1700.
13 A. IN THE -- Q A.M., IN THE MORNING; AT 1700, AT 5:00 P.M.;
14 AND BEFORE BEDTIME.
15 Q. OKAY.
16 A. SO THAT IMPLIES TO ME --
17 Q. GIVE P.R.N. IF PATIENT REFUSES RISPERDAL. AND THEN IT
18 SAYS THANKS, AND THERE'S A SIGNATURE. THAT'S DR. WEITZEL'S
19 SIGNATURE, CORRECT?
20 A. YES.
21 Q. AND THEN YOU -- YOU SAY THAT THERE'S -- THERE'S A
22 P.T. -- THAT WOULD BE A PHYSICAL THERAPY CONSULT --
23 REAMBULATION, THEN THERE'S ROBERT WEITZEL'S SIGNATURE,
24 CORRECT?
25 A. RIGHT.
1107
1 Q. AND THEN YOU HAVE NOTED LYNN LONG, R.N., 1/10/96 AT 1430
2 OR 2:30 IN THE AFTERNOON. DO YOU SEE THAT?
3 A. YEAH. IT -- AS I --
4 Q. SO I GUESS THE REAL QUESTION, DOCTOR, I'M ASKING YOU,
5 BASED UPON WHAT YOU HAVE IN FRONT OF YOU OR YOUR
6 RECOLLECTION, CAN YOU TELL THE JURY WHAT MEDICATIONS
7 MR. ALLDREDGE HAD RECEIVED THAT DAY BEFORE YOU SAW HIM AT
8 9 O'CLOCK, AND WHAT TIME OF THE DAY HE RECEIVED THOSE
9 MEDICATIONS?
10 A. AT A MINIMUM I WOULD SURMISE HALDOL 10 MILLIGRAMS I.M.,
11 AS WELL AS ATIVAN 1 MILLIGRAM.
12 Q. AND WOULD YOU ALSO SURMISE THAT THAT WOULD HAVE BEEN
13 DONE AT 2:30 P.M.?
14 A. I -- I DON'T KNOW THE TIME. I DON'T HAVE THE MEDICATION
15 NOTES.
16 Q. OKAY. AND SO IT COULD HAVE BEEN ANY TIME BEFORE YOUR
17 9 O'CLOCK CONSULT --
18 A. YES.
19 Q. -- IS THAT CORRECT?
20 A. YES.
21 Q. NOW, MR. ALLDREDGE, WHEN YOU EXAMINED HIM -- DO YOU HAVE
22 THAT DICTATED CONSULT THING?
23 A. YES.
24 Q. AND, FIRST OF ALL, YOU INDICATE HE HAS -- MR. ALLDREDGE
25 IS AN 83-YEAR-OLD CAUCASIAN MALE WITH A HISTORY OF SEVERE
1108
1 DEMENTIA. THAT WAS THE HISTORY THAT YOU HAD, TRUE?
2 A. YES.
3 Q. AND CERTAINLY SEVERE DEMENTIA WOULD BE CONSISTENT WITH A
4 DIMINISHED MENTAL STATE; ISN'T THAT RIGHT?
5 A. YES.
6 Q. AND THEN YOU GO ON TO SAY IN THE SECOND PARAGRAPH:
7 HIS -- HIS MEDICAL HISTORY IS REMARKABLE FOR DEMENTIA.
8 THEN YOU GO ON TO STATE THAT: MEDICAL NOTE FROM
9 DR. CUNNINGHAM, 4/17/95, WHICH STATES THE PATIENT HAS A
10 CLEAR LOSS OF RECENT MEMORY. HE WAS UNABLE TO STATE THE
11 PRESIDENT OF THE UNITED STATES. WHEN HE WAS ASKED AT THAT
12 TIME THE SIMILARITIES BETWEEN A BOWLING BALL AND AN ORANGE,
13 HE STATED YOU COULD GET JUICE OUT OF A BALLING BALL.
14 DID I READ THAT CORRECTLY?
15 A. YES.
16 Q. AND THEN YOU GO ON TO STATE DOWN AT THE BOTTOM: HE WAS
17 UNABLE -- WHOOPS. HE WAS UNABLE TO TALK IN A LUCID MANNER.
18 HIS COMMUNICATION WAS WITHOUT SIGNIFICANT MEANING. TRUE?
19 A. YES, UH-HUH.
20 Q. AND THEN ON PAGE 2 UNDER GENERAL YOU STATE: THE PATIENT
21 IS AN ELDERLY MAN, SUPINE IN BED, WITH CHEYNE-STOKES
22 RESPIRATION PATTERN WITH APNEA PERIODS FROM 20 TO 40
23 SECONDS.
24 THAT WAS A FINDING APPARENTLY YOU MADE AT ABOUT
25 9 O'CLOCK THAT NIGHT, TRUE?
1109
1 A. YES.
2 Q. AND YOU'RE NOT TELLING US, IF I UNDERSTAND YOUR
3 TESTIMONY FROM DIRECT, THAT YOU, AS YOU SIT HERE TODAY, KNOW
4 THE REASONS WHY HE WAS CHEYNE-STOKING, TRUE?
5 A. APART FROM WHAT I'VE ALREADY DETAILED.
6 Q. AND YOU'VE DETAILED THERE COULD BE AN UNDERLYING DISEASE
7 PROCESS THAT CAUSES THAT; IS THAT CORRECT?
8 A. (NODS HEAD UP AND DOWN.)
9 Q. AND ONE OF THOSE DISEASE PROCESSES COULD HAVE BEEN
10 ESSENTIALLY A CARDIAC PROBLEM, TRUE?
11 A. TRUE. TRUE.
12 Q. COULD HAVE BEEN A PULMONARY PROBLEM, CORRECT?
13 A. POSSIBLE.
14 Q. AND COULD HAVE BEEN AN NEUROLOGICAL ISSUE, TRUE?
15 A. YES.
16 Q. AND THEN YOU ALSO TESTIFIED, I BELIEVE, THAT IT ALSO
17 COULD HAVE BEEN RELATED TO THE MEDICATION, BUT YOU DON'T
18 KNOW, DO YOU, AS YOU SIT HERE TODAY?
19 A. THAT'S -- THAT'S CORRECT. I BELIEVE I TESTIFIED I
20 THOUGHT THAT MIGHT EXACERBATE THE UNDERLYING PROBLEM.
21 Q. BUT CERTAINLY APNEA UNDER CERTAIN CIRCUMSTANCES CAN BE
22 ASSISTED OR HELPED WITH RESPECT TO CERTAIN MEDICATIONS;
23 ISN'T THAT CORRECT?
24 A. YES.
25 Q. IN OTHER WORDS, THERE'S CERTAIN TIMES WHEN YOU MAY BE
1110
1 GASPING FOR AIR AND A SEDATING MEDICATION ACTUALLY RELAXES
2 YOU SUCH THAT IT'S EASIER FOR YOU TO BREATHE; ISN'T THAT
3 TRUE?
4 A. YES.
5 Q. THE FACT OF THE MATTER IS YOU MADE THE FINDING, YOU KNOW
6 YOU MADE THE FINDING, BUT YOU'RE NOT PREPARED TO TELL US AS
7 YOU SIT HERE TODAY WHAT THE CAUSE OF THAT WAS OR WHAT WAS
8 CAUSING THAT, TRUE?
9 A. AGAIN, APART FROM WHAT I'VE ALREADY SAID.
10 Q. SURE. AND -- AND YOU DID HAVE SOME CONCERNS ABOUT
11 ESSENTIALLY MR. ALLDREDGE'S ABILITY TO -- I GUESS BECAUSE OF
12 THIS -- OXYGENATE HIMSELF; IS THAT RIGHT?
13 A. THAT WAS MORE OF A ROUTINE ORDER, BUT BECAUSE OF THAT --
14 THAT BREATHING STATUS, I WANTED TO MAKE SURE THAT THAT WAS
15 THE CASE, THAT HE COULD OXYGENATE PROPERLY, YES.
16 Q. AND YOU TESTIFIED THAT CERTAINLY WHEN YOU DO A TEST FOR
17 OXYGEN, IF YOU'RE ESSENTIALLY ABOVE 90 PERCENT OR 90 PERCENT
18 AND ABOVE, THAT'S NORMAL, CORRECT?
19 A. YES.
20 Q. WHY DON'T YOU TURN TO MED-0012. NOW THIS IS, ONCE
21 AGAIN, FROM THE MEDICAL FILE OF MR. ALLDREDGE. ARE YOU WITH
22 ME, SIR?
23 A. YES. YES, I AM.
24 Q. AND IT'S IN THE PROGRESS NOTES SECTION, AND THERE IS AN
25 OXYGENATION, PULSE OXIMETRY TEST RESULT. DO YOU SEE THAT?
1111
1 A. YES.
2 Q. AND THAT'S TO THE RIGHT, CORRECT?
3 A. YES.
4 Q. APPEARS TO BE DONE 1/12/96 AT 8:30 A.M., TRUE?
5 A. 8:35, YES.
6 Q. I'M SORRY. AND IT'S -- THIS WOULD BE TWO DAYS AFTER YOU
7 SAW HIM.
8 A. YES.
9 Q. AND, OF COURSE, YOU ONLY SAW HIM ONCE IN THE HOSPITAL.
10 AND IT APPEARS THERE'S A REPORT OUT ON THAT OXYGENATION
11 STUDY OF 96 PERCENT. DID I READ THAT CORRECTLY?
12 A. YES.
13 Q. NOW, YOU TESTIFIED A LITTLE BIT ABOUT PNEUMONIA. AND
14 IT'S TRUE THAT GENERALLY SPEAKING PNEUMONIA IS WHAT WE CALL
15 AN ACUTE INFLAMMATION OF THE LUNGS. IS THAT A FAIR
16 STATEMENT?
17 A. THAT'S -- THAT'S ONE DEFINITION, YES.
18 Q. AND IT'S TRUE, IS IT NOT, THAT PNEUMONIA IS A PROBLEM
19 BECAUSE ESSENTIALLY IT'S A BACTERIAL FORMULATION IN THE LUNG
20 TISSUE ITSELF?
21 A. NO, IT DOESN'T HAVE TO BE BACTERIAL, BUT IT'S OFTENTIMES
22 BACTERIAL IN THE COMMON SENSE OF THE -- THAT PEOPLE THINK
23 ABOUT.
24 Q. WELL, SURE. THERE COULD -- THERE COULD BE A CHEMICAL
25 IRRITATION, TRUE?
1112
1 A. COULD BE CHEMICAL, BACTERIAL, VIRAL. THERE'S A --
2 ATYPICAL PNEUMONIAS. THERE'S --
3 Q. OKAY. AND A CHEMICAL -- A CHEMICAL IRRITATION OF THE
4 LUNGS, THAT ISN'T SOMETHING THAT YOU'RE GOING TO PRESCRIBE
5 ANTIBIOTICS FOR, TRUE?
6 A. PROBABLY GETS DONE A LOT. DON'T NECESSARILY THINK THAT
7 WOULD BE -- YOU WOULD HAVE TO DO THAT, THAT'S RIGHT.
8 Q. NO, BECAUSE ANTIBIOTICS TREATS BACTERIA.
9 A. RIGHT.
10 Q. IT DOESN'T TREAT CHEMICALS, TRUE?
11 A. RIGHT.
12 Q. AND, TYPICALLY, A CHEMICAL IRRITATION OF THE LUNGS IS
13 NOT SOMETHING THAT'S GOING TO HAVE A LONG-TERM MEDICAL
14 SIGNIFICANCE FOR A PATIENT IF UNTREATED, TRUE?
15 A. IT COULD, YES. COULD HAVE A VERY LONG-TERM
16 SIGNIFICANCE, YES.
17 Q. WELL, IT COULD, BUT NORMALLY UNDER CERTAIN
18 CIRCUMSTANCES, IF IT'S NOT PARTICULARLY SEVERE, IT'S NOT
19 GOING TO CREATE ANY KIND OF INFECTIOUS DISEASE PROCESS WITH
20 THE PATIENT, IS IT?
21 A. PROBABLY NOT.
22 MR. WILSON: OBJECTION, YOUR HONOR.
23 A. YOU'D HAVE TO BE MORE SPECIFIC.
24 MR. WILSON: I THINK THIS IS --
25 MR. STIRBA: I'M GETTING THERE.
1113
1 MR. WILSON: I'D LIKE TO KNOW THE RELEVANCY OF THIS
2 PARTICULAR AREA.
3 MR. STIRBA: I'M -- I'M GETTING THERE. HE
4 TESTIFIED ABOUT PNEUMONIA. I THINK I'M ENTITLED TO ASK HIM
5 AND I'M GETTING THERE, YOUR HONOR.
6 THE COURT: OKAY. MOVE ALONG.
7 Q. (BY MR. STIRBA) AND IT'S TRUE, IS IT NOT, THAT ONE OF
8 THE WAYS THAT YOU TEST FOR PNEUMONIA, YOU DIAGNOSE PNEUMONIA
9 IS YOU DO A CHEST X-RAY.
10 A. YES.
11 Q. THAT'S SORT OF THE STANDARD DIAGNOSTIC TOOL FOR
12 ASCERTAINING WHETHER OR NOT YOU HAVE COMPLICATIONS IN THE
13 LUNGS THAT SOMEONE COULD DIAGNOSE AS BEING BACTERIAL OR
14 PNEUMONIA, TRUE?
15 A. YES.
16 Q. AND IT'S ALSO TRUE THAT PNEUMONIA IS SOMETHING YOU HAVE
17 TO TREAT, CORRECT?
18 A. IF IT'S A -- IF IT'S AN INFECTION, YES.
19 Q. CERTAINLY. BECAUSE IF YOU DON'T TREAT IT, IT COULD BE
20 ULTIMATELY FATAL; ISN'T THAT CORRECT?
21 A. YES. AGAIN, IF YOU'RE TALKING ABOUT AN INFECTION FROM A
22 BACTERIAL PNEUMONIA.
23 Q. NOW, DO YOU HAVE MARY CRANE'S BINDER?
24 A. YES.
25 THE COURT: WHICH NUMBER IS THAT?
1114
1 MR. STIRBA: I'M SORRY, JUDGE. IT'S A STATE'S
2 EXHIBIT.
3 THE COURT: I THINK IT'S 5.
4 MR. STIRBA: DOCTOR, IS THAT --
5 THE WITNESS: IT'S MARY CRANE'S, YES.
6 MR. STIRBA: IS THAT --
7 THE WITNESS: FIVE.
8 MR. STIRBA: YES, IT IS, YOUR HONOR. THANK YOU.
9 Q. (BY MR. STIRBA) AND YOU'RE AWARE THAT THERE WERE
10 CERTAIN CHEST X-RAYS DONE TO DIAGNOSE CERTAIN PROBLEMS WITH
11 RESPECT TO MS. CRANE?
12 A. YES.
13 Q. I'LL ASK YOU TO TURN TO THE RADIOLOGY SECTION TAB THERE.
14 AND, IN FACT, THREE OF THE X-RAYS WERE DONE. THERE WAS ONE
15 DONE ON THE 29TH OF DECEMBER, ONE DONE ON THE 5TH OF
16 JANUARY, AND ONE DONE ON THE 7TH OF JANUARY OF 1996, TRUE?
17 A. YES, UH-HUH.
18 Q. AND -- AND, BY THE WAY, JUST SO WE UNDERSTAND, IT
19 REFERENCES "PORTABLE" WITH RESPECT TO THESE REPORTS. DOES
20 THAT MEAN THAT THE ACTUAL X-RAY IS DONE IN THE PATIENT'S
21 ROOM?
22 A. YES. MOST OFTEN, YES. UH-HUH.
23 Q. IN OTHER WORDS, THERE'S A MACHINE THAT'S PORTABLE AND
24 THEY BRING IT --
25 A. YEAH, THERE'S A PORTABLE MACHINE THEY BRING UP. IT'S
1115
1 VERY ADEQUATE, BUT IT'S NOT QUITE AS GOOD AS HAVING THE
2 PATIENT GO DOWN TO THE RADIOLOGY DEPARTMENT. YOU CAN'T GET
3 TWO VIEWS, YOU CAN ONLY GET ONE, THE ANTERIOR/POSTERIOR VIEW
4 INSTEAD OF THE NORMAL WAY OF DOING A POSTERIOR/ANTERIOR
5 VIEW, AND THEN ALSO A LATERAL VIEW DOWNSTAIRS.
6 Q. NOW, THE FIRST ONE WAS DONE ON THE 29TH. IT SAYS DATE
7 OF EXAM, 12/29/95. DO YOU SEE THAT?
8 A. YES.
9 Q. AND IT INDICATES, I GUESS ON THE SECOND LINE THERE, IT
10 SAYS: THE LUNGS ARE CLEAR.
11 DID I READ THAT CORRECTLY?
12 A. YES.
13 Q. AND THEN UNDER IMPRESSION, AFTER IT SAYS: ENLARGED
14 HEART WITH TORTUOUS AOTA -- AORTA, RATHER. NO EVIDENCE OF
15 FOCAL CONSOLIDATIVE LUNG PROCESS.
16 DO YOU SEE THAT?
17 A. YES.
18 Q. NOW, THE NEXT ONE ON THE 5TH, THERE'S ANOTHER CHEST
19 X-RAY. AND THAT SAYS, ONCE AGAIN, DATE OF EXAM 1/5/96.
20 UNDER CHEST IT SAYS: A.P. PORTABLE CHEST IS COMPARED WITH
21 PRIOR EXAMINATION 12/29/95 -- REFERRING TO THE PREVIOUS
22 CHEST X-RAY. AND ONCE AGAIN, THIS ONE SAYS: THE LUNGS ARE
23 CLEAR OF FOCAL IN -- INFILTRATES.
24 DID I READ THAT CORRECTLY?
25 A. YES.
1116
1 Q. AND THEN THE FINAL ONE WHICH WAS DONE ON THE 7TH -- AND
2 I BELIEVE, IF I UNDERSTOOD YOUR TESTIMONY, BECAUSE YOU HAD A
3 NOTE AND YOU HAD A PNEUMONIA, YOU HAD A QUESTION MARK ON THE
4 7TH WHEN YOU SAW MS. CRANE. DO YOU REMEMBER THAT?
5 A. YES.
6 Q. AND I BELIEVE YOU SAID ON DIRECT THAT THERE WAS NO
7 INDICATION OF ACUTE PNEUMONIA.
8 A. YES. TO REITERATE I SAID THE CHEST X-RAY SHOWED NO
9 EVIDENCE OF PNEUMONIA. I HEARD RALES -- I BELIEVE I -- I
10 BELIEVE I SAID I HEARD RALES IN THE LUNG. THAT COULD
11 INDICATE EITHER THE PATIENT HAS SOME SECRETIONS OR PERHAPS A
12 PNEUMONIA MIGHT FORM. AND I WAS CONCERNED BECAUSE OF HER
13 MENTAL STATUS THAT SHE WAS -- MAY DEVELOP, YOU KNOW, A
14 PNEUMONIA.
15 Q. OKAY. SO -- SO YOU WERE CONCERNED ABOUT THE
16 DEVELOPMENT, BUT YOU'RE NOT --
17 A. BUT -- BUT -- BUT -- BUT -- BUT IN TERMS OF THE X-RAY,
18 THE X-RAY IS CLEAR. AND YOU'RE RIGHT, THAT WOULD IMPLY
19 THERE'S NO ACUTE, OVERWHELMING, YOU KNOW, BAD INFILTRATE --
20 Q. PULMONARY COMPLICATION.
21 A. -- PNEUMONIA IN THE LUNG, BUT YET --
22 THE COURT: WOULD YOU BOTH --
23 A. -- THE APPROPRIATE RESPONSES --
24 THE COURT: -- KIND OF WAIT UNTIL ONE IS FINISHED
25 SPEAKING BECAUSE YOU'RE BOTH SPEAKING OVER ONE ANOTHER AND
1117
1 IT'S HARD FOR THE COURT REPORTER TO TAKE IT DOWN. SO IF
2 YOU'D MAYBE JUST PAUSE AFTER THE QUESTION AND AFTER THE
3 ANSWER.
4 MR. STIRBA: I WILL. I APOLOGIZE, YOUR HONOR. I
5 APOLOGIZE TO YOU, DOCTOR.
6 Q. (BY MR. STIRBA) SO LET'S LOOK AT THE ONE ON THE 7TH,
7 AND THAT'S THE ONE -- THE REPORT OF THE EXAMINATION. AND,
8 ONCE AGAIN, THAT ONE INDICATES: LUNGS ARE CLEAR WITHOUT
9 EVIDENCE OF FOCAL INFILTRATES.
10 DID I READ THAT CORRECTLY?
11 A. YES. YES.
12 Q. NOW, AS FAR AS MS. CRANE IS CONCERNED, YOU SAW HER
13 INITIALLY FOR A EVALUATION AND -- AND ESSENTIALLY YOUR --
14 YOUR CONSULT TO EVALUATE HER MEDICAL CONDITION ON 12/29 OF
15 1995.
16 A. YES.
17 Q. TRUE?
18 A. YES.
19 Q. AND THEN YOU ALSO SAW HER AGAIN AT THE REQUEST OF
20 DR. WEITZEL FOR A CONSULT CONCERNING THE DEVELOPMENT OF HER
21 VAGINAL FISTULA, CORRECT?
22 A. YES.
23 Q. AND THAT WOULD HAVE BEEN ON JANUARY 1 OF 1996?
24 A. YES.
25 Q. AND ABOUT HOW LONG DID YOU SEE MS. CRANE ON JANUARY 1 OF
1118
1 1996 WHEN YOU EXAMINED HER?
2 A. I DON'T RECALL THE TIME.
3 Q. AND THAT IS EVIDENCED BY A NOTE THAT YOU WROTE THAT HAS
4 BEEN DISPLAYED ALREADY TO THE JURY, A PROGRESS NOTE BY YOU;
5 IS THAT RIGHT?
6 A. YES.
7 Q. IT'S NOT A DICTATED --
8 A. NO.
9 Q. -- NOTE.
10 A. YOU TYPICALLY ONLY DICTATE THE INITIAL NOTE AND -- AND
11 FROM THEN ON YOU WRITE IN THE PROGRESS NOTES YOUR FOLLOW-UP.
12 Q. AND THEN AFTER THE FIRST OF JANUARY YOU NEXT SAW
13 MS. CRANE ON THE 7TH OF JANUARY OF 1996.
14 A. YES.
15 Q. AND THAT WOULD HAVE BEEN AT APPROXIMATELY 3:10 P.M. IN
16 THE AFTERNOON, TRUE?
17 A. YES. YES.
18 Q. I -- I PUT UP ON THE SCREEN YOUR DICTATED REPORT OF YOUR
19 INITIAL EVALUATION. AND YOU INDICATE UNDER GENERAL IN TERMS
20 OF HER PAST HISTORY THAT SHE HAD A RIGHT CEREBROVASCULAR
21 ACCIDENT, 11/90, RIGHT THALAMIC REGION RESULTING IN LEFT
22 HEMIPARESIS. T
23 WHAT IS HEMIPARESIS?
24 A. ESSENTIALLY A PARALYSIS. HEMIPARESIS MEANS IT'S
25 LOCALIZED TO ONE SIDE OF THE BODY RATHER THAN BOTH SIDES OF
1119
1 THE BODY.
2 Q. AND THEN YOU ALSO: SHE IS CURRENTLY LIMITED TO THE
3 WHEELCHAIR AND BED ACTIVITIES WITH SIGNIFICANT LEFT PARTIAL
4 PARALYSIS. SHE IS ALSO DEBILITATED BY CHRONIC LOW BACK PAIN
5 WITH HISTORY OF PRIOR LOW BACK SURGERY.
6 DID I READ THAT CORRECTLY?
7 A. YES.
8 Q. THEN YOU GO ON TO SAY THAT SHE HAS A HISTORY OF CHRONIC
9 HYPERNATREMIA -- AND THAT'S THE SODIUM LEVEL ISSUE; IS THAT
10 RIGHT?
11 A. AND THAT'S A -- YES. AND IF I MAY SAY, THAT'S A TYPO.
12 IT SHOULD BE HYPONATREMIA.
13 Q. OKAY. INSTEAD OF HYPER; IT SHOULD BE HYPO?
14 A. YES.
15 Q. OKAY. THANK YOU. AND THEN YOU GO ON UNDER 6 YOU SAY: A
16 HISTORY OF TRANSIENT -- TRANSIENT ISCHEMIC ATTACKS.
17 COULD YOU TELL US PLEASE WHAT TRANSIENT ISCHEMIC
18 ATTACKS ARE?
19 A. THAT TYPICALLY REFERS TO AN EVENT THAT MIGHT -- MIGHT BE
20 CONSTRUED AS A -- AS A STROKE, BUT IT DOESN'T COMPLETE
21 ITSELF. SOMEONE'S NOT LEFT WITH A PARALYSIS OR A
22 HEMIPARESIS OR ONE SIDE OF THE BODY THEY CAN'T MOVE. IT
23 LASTS FOR 24 HOURS OR -- OR LESS. THERE'S DIFFERENT
24 TERMINOLOGIES FOR IT, BUT IT'S -- BUT IT'S -- ESSENTIALLY IT
25 LOOKS LIKE SOMETHING THAT'S GOING TO BECOME A STROKE AND IT
1120
1 RESOLVES.
2 SO IT'S A SHORT TERM. IT MAY LAST A MINUTE, AN HOUR,
3 USUALLY LESS THAN 24 HOURS, AND SOMEONE HAS A RESOLUTION OF
4 THAT. IT -- IT COULD BE CONSTRUED AS SOMETHING THAT MIGHT
5 BE WORRISOME FOR THE FUTURE, TO HAVE A STROKE.
6 Q. DOES ISCHEMIA IN MEDICAL PARLANCE RELATE TO A BLOOD
7 DEFICIENCY OR A VASCULAR DEFICIENCY?
8 A. YES. EITHER -- EITHER DIMINISHED BLOOD FLOW OR
9 DIMINISHED BLOOD FLOW WITH OXYGEN CONTENT TO THAT AREA, SO
10 THERE'S LOW PROFUSION SO THAT THAT ORGAN OR THAT EXTREMITY
11 OR THAT PART OF THE BODY OR THAT BRAIN DOESN'T PROFUSE WELL.
12 A HEART ATTACK HAS ISCHEMIA. DOESN'T GET BLOOD SO YOU HAVE
13 AN INFARCTION, DEATH OF TISSUE. A STROKE DOESN'T GET BLOOD
14 FLOW SO YOU GET DEATH OF TISSUE FOR A STROKE. SAME THING
15 COULD HAPPEN IN ANY ORGAN SYSTEM.
16 Q. AND THEN YOU HAVE UNDERNEATH THERE, IT SAYS: TODAY
17 MS. CRANE HAS -- HAS NO COMPLAINTS AND SHE DENIES ANY
18 SHORTNESS OF BREATH AND CHEST PAIN; SHE DENIES ANY
19 SIGNIFICANT PAIN.
20 THEN YOU GO ON TO SAY: SHE HAS BEEN PLACED ON
21 DURAGESIC PATCH AS WELL AS RELAFEN.
22 A. YES.
23 Q. WHAT IS RELAFEN?
24 A. IT'S A -- IT'S A NONSTEROIDAL ANTI-INFLAMMATORY DRUG.
25 IT'S -- IT'S SORT OF LIKE IBUPROFEN, MOTRIN, ADVIL. IT'S --
1121
1 IT'S IN THAT SAME CLASS OF DRUGS. IT'S -- IT'S A VERY GOOD
2 MEDICATION FOR DISCOMFORT AND ARTHRITIC-TYPE PAINS, BACK
3 PAIN. IN FACT, MANY PEOPLE ARE ON THAT. IT'S USED IN
4 COMBINATION OFTENTIMES WITH DRUGS LIKE DURAGESIC OR FENTANYL
5 AND THAT TO -- TO HELP POTENTIATE CONTROL OF PAIN. SO IT'S
6 A GOOD -- IT'S A GOOD CHOICE FOR SOMETHING YOU USE IN
7 ADJUNCT WITH THAT TO CONTROL DISCOMFORT.
8 Q. AND THEN YOU GO ON TO SAY: FOR HER LOW BACK PAIN WITH
9 RESULTANT MARKED IMPROVEMENT.
10 AND THEN IF I TURN TO PAGE 2, UNDER MEDICATIONS DOWN
11 TOWARDS THE BOTTOM, IT SAYS: GIVEN ON 12/28/95 AND -- IT
12 PROBABLY SHOULD BE AN --
13 A. CAN YOU SHOW ME AGAIN WHERE THAT IS? I'M SORRY.
14 Q. YES, I -- I CAN. MAYBE I'LL POINT IT OUT TO YOU.
15 A. YES, I SEE IT.
16 Q. RIGHT DOWN AT THE BOTTOM THERE, SIR.
17 A. YES.
18 Q. IT SAYS: GIVEN ON 12/28/95 AND DURAGESIC 50 -- AND THAT
19 SHOULD PROBABLY BE M.G., SHOULD IT NOT?
20 A. I -- THEY'VE DONE IT -- THEY'VE DONE IT THE BEST THEY
21 CAN. THAT "U" SHOULD BE A MU FOR -- A SIGN, THE LATIN FOR
22 MICROGRAMS.
23 Q. MICROGRAMS.
24 A. IT SHOULDN'T BE AN "M" BECAUSE THAT WOULD BE MILLIGRAMS.
25 THAT WOULD BE A THOUSAND FULL MORE. BUT THE -- THE "U" IS
1122
1 PROBABLY THE BEST THEIR TYPEWRITER COULD DO. IT SHOULD BE
2 THAT MU SIGN, YOU KNOW, THAT -- THAT MEANS MICROGRAMS.
3 THAT'S WHAT THEY'VE TRIED TO DO. THEY SHOULD HAVE PROBABLY
4 SPELLED IT OUT, MICROGRAMS.
5 Q. OKAY. AND I BELIEVE YOU TESTIFIED EARLIER THAT THE
6 PATCH COMES IN A 25 MICROGRAM COMBINATION, A 50 MICROGRAM --
7 A. TO MY --
8 Q. -- COMBINATION.
9 A. -- TO MY -- TO MY RECOLLECTION. THERE MIGHT BE MORE
10 NOW. I HAVEN'T LOOKED AT THAT RECENTLY, BUT THAT'S WHAT MY
11 RECOLLECTION IS, YES.
12 Q. OKAY. AND HERE YOU WERE AWARE ON 12/28/95 OF THE
13 DURAGESIC PATCH IN A 50 MICROGRAM --
14 A. YES.
15 Q. -- DOSAGE, Q 3 DAYS. DO YOU SEE THAT?
16 A. YES.
17 Q. AND IT'S TRUE, IS IT NOT, AS YOU INDICATED LATER ON,
18 ESSENTIALLY UNDER YOUR RECOMMENDATIONS IN THE SAME REPORT
19 YOU STATE YOU AGREE WITH ADEQUATE PAIN CONTROL AND
20 NONSTEROIDAL ANTI-INFLAMMATORY DRUGS AND DURAGESIC?
21 A. THAT'S CORRECT.
22 Q. IN OTHER WORDS, AT THE TIME, GIVEN WHAT YOU EXAMINED
23 WITH RESPECT TO MS. CRANE AND YOUR KNOWLEDGE THAT SHE HAD
24 BEEN GIVEN A 50 MICROGRAM DURAGESIC PATCH, YOU HAD NO
25 PROBLEM WITH THE ADMINISTRATION OF THAT PATCH AT THAT TIME;
1123
1 IS THAT CORRECT?
2 A. THAT'S CORRECT. YES.
3 Q. NOW, ALSO ON THIS PAGE, WHICH IS PAGE 3, UNDER THE
4 AREA -- IT'S -- IT'S -- UNDER DIAGNOSTIC STUDIES, RIGHT DOWN
5 THE LAST PARAGRAPH --
6 A. YES.
7 Q. -- THERE IS -- THERE'S A COUPLE STARTING WITH W.B.C.'S.
8 A. THAT'S WHITE BLOOD CELL COUNT.
9 Q. THAT'S WHAT I WAS GOING TO ASK YOU ABOUT. COULD YOU
10 TELL US, PLEASE -- W.B.C. STANDS FOR WHITE BLOOD CELL COUNT?
11 A. YES.
12 Q. AND TELL US, PLEASE, HOW THAT'S MEASURED AND WHY THAT
13 HAS SOME SIGNIFICANCE.
14 A. THAT'S -- THAT'S PERFORMED BY A BLOOD DRAW. IT JUST
15 MEASURES THE LEVEL -- WHITE CELLS ARE THOSE BLOOD CELLS THAT
16 HELP FIGHT INFECTION IN THE BLOOD. WE CAN ALSO DO A
17 DIFFERENTIAL ON THOSE WHITE CELLS TO SEE WHAT TYPES THEY
18 ARE.
19 BUT IN GENERAL, A NORMAL WHITE COUNT SUCH AS THIS IS
20 GOOD. IT MEANS THERE'S PROBABLY NO SERIOUS ACTIVE INFECTION
21 GOING ON OR STRESS OR INFLAMMATION OR STEROID TREATMENT OR
22 THINGS. A HIGH WHITE COUNT MIGHT INDICATE THE PATIENT'S
23 UNDER SOME TYPE OF UNDUE STRESS, BEING TREATED WITH
24 CORTICOSTEROIDS OR BEING TREATED -- OR HAS AN INFECTION.
25 Q. AND THE NEXT -- THE NEXT WORD NEXT TO THAT IS -- WELL,
1124
1 LET ME ASK YOU, IT HAS A COUNT THERE. LOOKS LIKE 9,400.
2 A. YES.
3 Q. CAN YOU ORIENT US, PLEASE, AS TO WHAT THAT MEANS IN
4 RELATIONSHIP TO THE CELL COUNT?
5 A. IT -- IT DEPENDS ON THE -- ON THE LABORATORY, BUT MOST
6 NORMAL RANGES FOR WHITE CELLS ARE IN THE RANGE OF FOUR TO
7 11,000 OR FOUR TO 10,000, FOUR TO 12,000, AND THAT DEPENDS
8 ON THE LABORATORY. I CAN'T REMEMBER WHAT DAVIS HOSPITAL'S
9 NORMAL RANGE WAS, BUT I WOULD CALL THAT A NORMAL WHITE
10 COUNT.
11 Q. OKAY. AND THEN YOU HAVE HEMATOCRIT.
12 A. YES.
13 Q. AND IT -- IT HAS 35.7. COULD YOU TELL US, PLEASE, WHAT
14 A HEMATOCRIT IS?
15 A. HEMATOCRIT MEASURES THE -- THEY -- THEY SPIN THE BLOOD
16 DOWN AND THEY MEASURE THE PACKED CELL, THE RED CELL RELATIVE
17 TO THE PLASMA. IT'S -- IT'S ESSENTIALLY A MEASURE OF THE
18 PATIENT'S -- WHETHER THE PATIENT IS ANEMIC OR NOT, IN THAT
19 SENSE OF THINGS.
20 AND THAT'S A FAIRLY NORMAL HEMATOCRIT. IT'S PROBABLY
21 AT THE LOWER RANGE, BUT IT'S -- IT'S ESSENTIALLY PRETTY --
22 PRETTY NORMAL.
23 Q. AND THEN, ONCE AGAIN, YOU HAVE HISTORY, YOU HAVE --
24 UNDER 7 YOU MAKE REFERENCE TO THE -- TO THE CEREBROVASCULAR
25 ACCIDENT AND THE OTHER THINGS THAT YOU REFERENCED INITIALLY.
1125
1 AND THEN UNDER 8 YOU HAVE, ONCE AGAIN, THE CHRONIC LOW BACK
2 PAIN SECONDARY TO DISK DISEASE.
3 AND THEN UNDER 12 YOU HAVE CARDIAC SIL -- SILHOUETTE
4 ENLARGEMENT BY PORTABLE CHEST X-RAY. THAT WAS APPARENTLY
5 DONE PURSUANT TO ONE OF THOSE X-RAYS. THEN YOU SAY:
6 POSSIBLY SECONDARY TO HYPERTENSIVE CARDIOVASCULAR DISEASE,
7 UNKNOWN, LEFT VENTRICULAR FUNCTION.
8 COULD YOU, FIRST OF ALL, TELL US, PLEASE, WHAT
9 HYPERTENSIVE CARDIOVASCULAR DISEASE IS?
10 A. OKAY. HYPERTENSION JUST REFERS TO AN ELEVATED BLOOD
11 PRESSURE, NOT -- NOTHING MORE THAN THAT. A VERY COMMON FORM
12 OF AN -- AN ENLARGED HEART SIZE WOULD BE HYPERTENSION.
13 PROBABLY THE MOST COMMON FORM. THAT JUST MEANS THAT THE
14 HEART'S A LITTLE BIT THICKENED. IT CAUSES INCREASED SHADOW
15 IN THE X-RAY, AND IT MEANS NOTHING MORE THAN THAT. THERE'S
16 MANY CAUSES OF AN ENLARGED HEART, HYPERTENSION PROBABLY
17 BEING THE MOST COMMON.
18 SOMETIMES THE HEART DOESN'T BEAT EFFECTIVELY. IF
19 SOMEONE GETS MANY HEART ATTACKS, THEIR HEART MAY NOT BEAT
20 EFFECTIVELY. IT WILL DILATE. INSTEAD OF BEING THICKENED,
21 THE HEART WILL BE DILATED AND MAY NOT BEAT AS WELL. THAT
22 COULD BE ANOTHER CAUSE.
23 THERE'S INFILTRATE OF CAUSES OF THE HEART TO BE
24 ENLARGED -- THERE'S MANY CAUSES FOR THE HEART TO BE
25 ENLARGED. IF I WAS TRYING TO THINK ABOUT THAT I WOULD SAY
1126
1 THE HEART'S ENLARGED, THE PATIENT HAS HYPERTENSION. THE
2 MOST COMMON REASON IS BECAUSE OF THE HYPERTENSION OR THE
3 HIGH BLOOD PRESSURE.
4 BUT IN -- IN MY MIND I WAS ALSO THINKING, WELL, IT WAS
5 A PORTABLE X-RAY. PORTABLE X-RAYS TEND TO ACCENTUATE THE
6 SIZE OF THE HEART. MIGHT BE NICE IF YOU COULD GO DOWN LATER
7 FOR A REGULAR CHEST X-RAY BY THE STANDARD TECHNIQUE.
8 ALSO, I WAS -- I WAS SAYING, WELL, THE HEART'S
9 ENLARGED. I DON'T KNOW WHAT THE PATIENT'S LEFT VENTRICULAR
10 FUNCTION -- HOW STRONG THE HEART IS. THAT MIGHT BE
11 SOMETHING TO CONSIDER FOR THE FUTURE, TOO.
12 BUT THE MOST COMMON THINGS BEING COMMON, THE PATIENT
13 HAS HYPERTENSION, THE HEART WAS PROBABLY BIG -- IF IT WAS
14 BIG ON A REAL X-RAY THERE, NOT JUST A PORTABLE X-RAY -- BUT
15 IF IT WAS BIG IT WAS PROBABLY FROM THE HYPERTENSION.
16 Q. AND THEN YOU SAY: UNKNOWN, LEFT VENTRICULAR FUNCTION.
17 WHAT -- WHAT DO YOU MEAN BY THAT?
18 A. I MEAN I DIDN'T -- THERE WAS -- THERE WAS NO DATA TO
19 TELL ME IF THE PATIENT HAD A NORMAL CONTRACTILE FUNCTION.
20 IS THE HEART A STRONG MUSCLE BEATING, OR IS IT -- OR IS IT
21 NOT? IF -- IF SOMEONE HAD AN ENLARGED HEART JUST FROM
22 HYPERTENSION, ORDINARILY THE HEART WOULD BE BEATING QUITE
23 EFFECTIVELY, BE VERY STRONG, NORMAL LEFT VENTRICULAR
24 FUNCTION.
25 IF THE LEFT VENTRICULAR FUNCTION WAS DIMINISHED, THE
1127
1 HEART COULD BE BIG, THE PATIENT COULD STILL HAVE
2 HYPERTENSION, BUT IT MIGHT BE SOMETHING ELSE THAT MIGHT
3 DIRECT YOUR MEDICINES, HOW TO ADMINISTER THOSE. YOU WOULD
4 TREAT THE HYPERTENSION WITH CERTAIN MEDS. YOU MIGHT TREAT
5 LEFT VENTRICULAR DYSFUNCTION A LITTLE BIT DIFFERENTLY WITH A
6 DIFFERENT CHOICE OF MEDICINES, TRY AND IMPROVE THAT TO MAKE
7 IT MORE OPTIMUM.
8 Q. NOW, YOU TESTIFIED ABOUT THE EVENTS OF THE 7TH, AND WHEN
9 YOU -- WHEN YOU SAW MS. CRANE THAT DAY. AND YOU -- YOU
10 TESTIFIED ON DIRECT SHE WAS VERY, VERY ILL. DID I QUOTE YOU
11 CORRECTLY?
12 A. YES.
13 Q. AND YOUR OPINION WAS THAT EVEN IF THERE WERE THE
14 AGGRESSIVE MEASURES TAKEN, SOME OF WHICH YOU ENUMERATED AND
15 IDENTIFIED IN YOUR PROGRESS NOTE, YOU WEREN'T SURE THAT YOU
16 COULD SAVE HER; IS THAT CORRECT?
17 A. THAT'S CORRECT.
18 Q. NOW, MS. JUDITH LARSEN YOU SAW FOR THE INITIAL
19 EVALUATION, WHICH WAS DICTATED BY YOUR CONSULT NOTE, ON
20 12/8/95; IS THAT TRUE?
21 A. YES.
22 Q. AND THEN ALSO, AS I UNDERSTAND IT, YOU SAW HER ONE OTHER
23 TIME AND THAT WAS ON THE 26TH OF DECEMBER OF 1995 WHEN SHE
24 SUSTAINED A SEIZURE THAT YOU REPORTED WAS IN DURATION OF 40
25 TO 45 MINUTES; IS THAT TRUE?
1128
1 A. YES.
2 Q. AND IT'S TRUE, IS IT NOT, THAT THE SEIZURE DISORDER, ONE
3 OF YOUR INTERVENTIONS WAS TO PRESCRIBE DILANTIN FOR HER?
4 A. YES.
5 Q. AND IT'S TRUE, IS IT NOT, THAT ALSO YOU PRESCRIBED
6 ATIVAN FOR HER AT THAT TIME?
7 A. YES.
8 Q. AND AM I CORRECT THAT THE REASON WHY YOU PRESCRIBED
9 ATIVAN FOR HER AT THAT TIME WAS ESSENTIALLY TO TRY TO CALM
10 HER OR SEDATE HER TO ASSIST HER IN DEALING WITH THE SEIZURE
11 THAT SHE HAD EXPERIENCED?
12 A. NO. THE -- THE ATIVAN IS THE PREFERRED THERAPY FOR THE
13 ACUTE SEIZURE TO STOP THE SEIZURE. SO THE ATIVAN WAS DIRECT
14 AT THE SEIZURE. VERY COMMON SIDE EFFECT TO BE SEDATED FROM
15 THE ATIVAN, AS WE'VE ALREADY DISCUSSED. BUT IT -- BUT IT --
16 BUT IT WAS REALLY DIRECTED AT STOPPING THE SEIZURE, TRYING
17 TO PREVENT ANY MORE SEIZURES FROM OCCURRING, YOU KNOW,
18 WHATSOEVER.
19 THEN THE DILANTIN IS ALSO GIVEN TO KIND OF MAINTAIN
20 THAT, PREVENT SEIZURES FROM OCCURRING AFTER THAT. THE
21 ATIVAN WOULD BE A MUCH SHORTER DURATION; THE DILANTIN HAS A
22 MUCH LONGER HALF LIFE SO IT STAYS IN THE SYSTEM LONGER,
23 PREVENTS FUTURE SEIZURE. BUT THE ATIVAN IS AN ACUTE
24 MEDICINE, DEFINITELY -- DEFINITELY WOULD BE, YOU KNOW,
25 NUMBER ONE, TWO, OR SOME MEDICATION TO GIVE ACUTELY TO STOP
1129
1 THE SEIZURES.
2 Q. AND -- AND THEN -- IF -- IF YOU -- YOU'VE REVIEWED THESE
3 RECORDS FOR THE PURPOSES OF THIS MORNING'S TESTIMONY, HAVE
4 YOU NOT?
5 A. YES.
6 Q. AND DO YOU RECALL THAT THERE WAS FIRST AN INITIAL ORDER
7 OF ATIVAN BY YOU, AND THEN APPARENTLY IN RESPONSE TO WHAT
8 THE NURSES TOLD YOU, YOU INCREASED THE ATIVAN BY ANOTHER
9 MILLIGRAM?
10 A. I DON'T RECALL THAT. I -- JUST WHAT I GOT IN FRONT OF
11 ME. I DID -- I GOT A PHONE CALL SAYING THE PATIENT HAD A
12 SEIZURE. I ORDERED THE I.V. FLUIDS, THE ATIVAN TO STOP THE
13 SEIZURES. AND THEN -- AND THEN IT -- IT SAYS -- JUST TRYING
14 TO READ THE -- IT'S HARD TO READ THE NURSE'S NOTE UP THERE,
15 BUT THERE'S A NOTE AT 0605 HOURS THAT SAID I ORDERED THE
16 I.V. FLUIDS, THE ATIVAN, TITRATE 1 TO 3 MILLIGRAMS UNTIL
17 SEIZURE STOPPED. IT LOOKS LIKE THERE'S ANOTHER NOTE AT 6:20
18 IN THE MORNING: GIVE ADDITIONAL 1 MILLIGRAM.
19 Q. THAT'S THE ONE.
20 A. IT LOOKS LIKE IT SAYS DILANTIN, BUT IT DOESN'T MAKE
21 SENSE WHY THAT WOULD BE SUCH. AND THEN UNDER THAT IT SAYS
22 ATIVAN. SO I MUST HAVE HAD HER GIVE HER ANOTHER MILLIGRAM
23 OF ATIVAN TO MAKE SURE THAT WE KEEP THE SEIZURES FROM
24 REOCCURRING AT THAT POINT.
25 Q. AND IT'S -- DID YOU AT ALL DURING THE TIME THAT YOU
1130
1 PRESCRIBED THE ATIVAN OR ORDERED THE DILANTIN TO CONTROL THE
2 SEIZURE, DID YOU ORDER -- ENTER AN ORDER DISCONTINUING ANY
3 OF THE OTHER MEDICATIONS THAT SHE WAS ON?
4 A. NO. THIS WAS AN ACUTE PROBLEM I NEEDED TO DEAL WITH AND
5 I DEALT WITH THAT.
6 Q. OKAY. AND IT'S TRUE THAT -- THAT AFTER THE 26TH AND
7 DEALING WITH THE SIGNIFICANTLY SEVERE -- OR SUBSTANTIALLY
8 SEVERE SEIZURE, AS YOU DESCRIBED IT, YOU DID NOT SEE
9 MS. LARSEN AFTER THAT; IS THAT RIGHT?
10 A. I BELIEVE THAT'S TRUE, YES.
11 Q. NOW, I'M GOING TO SHOW YOU YOUR DICTATED CONSULT FOR --
12 FOR MS. LARSEN. AND I -- I WASN'T QUITE SURE I UNDERSTOOD
13 WHAT YOU WERE SAYING ABOUT MS. LARSEN COMPLAINING OF PAIN.
14 YOUR -- YOUR -- UNDER PAST MEDICAL HISTORY RIGHT IN THE
15 MIDDLE THERE, YOU SAY: ON EXAMINATION TODAY THE PATIENT
16 DOES NOT COMMUNICATE.
17 NOW, IT'S TRUE, IS IT NOT, IF THE PATIENT DOES NOT
18 COMMUNICATE, SHE WOULDN'T HAVE BEEN COMMUNICATING TO YOU
19 COMPLAINTS OF PAIN?
20 A. I THINK THAT'S TRUE. I -- I THINK I WAS TRYING TO
21 PORTRAY -- PERHAPS NOT WORDED VERY WELL -- THAT I TRIED TO
22 ELICIT FROM THE PATIENT WHETHER SHE HAD PAIN AND I COULD
23 NOT. EVEN THOUGH TRYING I COULDN'T -- I -- I MIGHT ASK HER,
24 ARE YOU HAVING PAIN? AND THEN SHE WOULDN'T RESPOND. AND
25 SOME PEOPLE CAN SHAKE THEIR HEADS EVEN IF THEY CAN'T
1131
1 COMMUNICATE. I WAS TRYING TO GET SOME INDICATION THAT I FELT
2 THAT SHE WAS UNCOMFORTABLE OR IN PAIN.
3 AND PERHAPS NOT WORDED VERY WELL, BUT THAT'S -- I THINK
4 THAT'S WHAT I IMPLIED, THAT I COULDN'T FEEL -- I DID NOT
5 FEEL THAT SHE WAS IN ANY PAIN.
6 Q. FAIR TO SAY THAT WHEN A PATIENT CAN'T COMMUNICATE LIKE
7 MS. LARSEN, YOUR CLINICAL ASSESSMENT OF PAIN IS COMPROMISED?
8 A. VERY -- VERY TRUE. Point well taken.
9 Q. VERY DIFFICULT TO MAKE THAT ASSESSMENT BECAUSE YOU
10 NORMALLY RELY ON A SELF-REPORT BY THE PATIENT, CORRECT?
11 A. THAT'S -- THAT'S TRUE. UH-HUH.
12 Q. THIS IS PAGE 2 AND YOU HAVE -- YOU HAVE HERE -- I WANT
13 TO DIRECT YOUR ATTENTION, FIRST OF ALL, THE FIRST PARAGRAPH
14 WHERE IT SAYS: ON EXAMINATION THERE IS DIFFUSE WHITE MATTER
15 CHANGES AND SMALL VESSEL DISEASE.
16 WHAT SMALL VESSEL DISEASE ARE YOU REFERRING TO? IT'S
17 SORT OF TOWARDS THE END OF THE FIRST PARAGRAPH.
18 A. I SEE THAT. I -- I WOULD HAVE BEEN READING OFF THE
19 RADIOLOGIST REPORT. I WOULD NOT HAVE INTERPRETED THE CAT
20 SCAN MYSELF. THAT WOULD HAVE BEEN READING THE
21 RADIOLOGIST --
22 Q. SO YOU'RE JUST REPORTING WHAT THE REPORT SAID?
23 A. YES. THAT'S IN THE HISTORY AND I WAS JUST READING WHAT
24 WAS AVAILABLE TO ME.
25 Q. CAN -- CAN YOU TELL US IF YOU HAVE ANY UNDERSTANDING OF
1132
1 WHAT THAT SMALL VESSEL DISEASE IS?
2 A. IN SOMEONE THIS AGE IT'S -- IT'S -- IT'S PROBABLY JUST
3 ATHEROSCLEROTIC DISEASE. AS WE GET OLDER OUR VESSELS
4 NARROW, THEY GET SMALLER. YOU CAN HAVE SMALL STROKES OR
5 THINGS ALONG THAT -- THAT LINE. AND THAT HAS AN APPEARANCE
6 TO THE RADIOLOGIST AND THEY USE THAT TERM PRETTY FREQUENTLY
7 THAT SAYS SMALL VESSEL DISEASE. I -- I COULDN'T LOOK AT THE
8 CAT SCAN AND TELL YOU THAT. I WOULD HAVE READ THAT OFF THE
9 REPORT.
10 Q. AND THAT -- THAT -- I NEVER COULD SAY THIS WORD -- BUT
11 ESSENTIALLY YOU'RE TALKING ABOUT HARDENING --
12 A. YES.
13 Q. -- OF THE VESSELS?
14 A. NARROWING, VERY -- VERY COMMON AS WE GET OLDER,
15 PARTICULARLY AT THIS AGE. BUT, YOU KNOW, EVEN AT -- YOU
16 KNOW, 60'S, 70'S, AND 80'S IT HAPPENS AND PEOPLE GET STROKES
17 AT ALL AGES, OF COURSE. BUT IT'S --
18 Q. ALL RIGHT. THANK YOU.
19 A. SO DIMINISHED BLOOD FLOW BECAUSE OF THAT.
20 Q. AND THEN YOU GO ON TO SAY: THERE IS A PAST MEDICAL
21 HISTORY OF ISCHEMIC HEART DISEASE WITH ANGINA, UNDEFINED IN
22 THE MEDICAL RECORD.
23 ISCHEMIC HEART DISEASE IS WHAT?
24 A. CORONARY ARTERY DISEASE. AGAIN, NARROWING OF THE
25 VESSEL, DIMINISHED BLOOD FLOW PERHAPS LEADING TO CHEST PAIN,
1133
1 WHICH IS ANGINA, OR A HEART ATTACK OR MYOCARDIAL INFARCTION.
2 AGAIN, IT WAS -- THE REASON WHY I PUT "UNDEFINED" IN THE
3 MEDICAL RECORD IT WASN'T CLEAR TO ME -- ANY OF THAT. IT WAS
4 JUST SOMEBODY HAD SOMETHING, ISCHEMIC HEART DISEASE. IT WAS
5 NOT A VERY GOOD -- PROBABLY NOT -- PROBABLY NOT A VERY GOOD
6 HISTORY AND PHYSICAL SOMEONE HAD WRITTEN AND I JUST WAS
7 TRYING TO GLEAN ANYTHING I COULD FROM THE -- THE RECORD IN
8 TERMS OF PAST HISTORY.
9 BUT IT LOOKS LIKE I DIDN'T KNOW IF THE PATIENT HAD A
10 PRIOR HEART ATTACK OR KNOW WHAT THEIR HEART, YOU KNOW, WAS
11 EXACTLY LIKE, APART FROM THAT IN THE MEDICAL RECORD.
12 Q. BUT THERE WAS -- AND YOU'VE TESTIFIED TO IT -- THERE WAS
13 AN E.K.G. GIVEN DURING THE TIME THAT MS. LARSEN WAS IN THE
14 HOSPITAL?
15 A. YES.
16 Q. AND -- AND THAT E.K.G., I GUESS YOU REPORT SOME OF THE
17 RESULTS IN YOUR -- IN YOUR --
18 A. RIGHT.
19 Q. -- DICTATED CONSULT NOTE, TRUE?
20 A. THAT'S RIGHT.
21 Q. AND THE E.K.G. IS A TEST THAT ESSENTIALLY DOES SOME
22 TESTING OF THE ELECTRICAL CURRENTS --
23 A. THAT'S TRUE.
24 Q. -- THROUGH THE HEART; IS THAT CORRECT?
25 A. YES.
1134
1 Q. IT'S -- IT'S SOMEWHAT DIAGNOSTIC OF CERTAIN KINDS OF
2 CARDIAC MALFUNCTION, TRUE?
3 A. IT CERTAINLY CAN BE.
4 Q. AND -- AND THAT PARTICULAR E.K.G. REFERENCED A POSSIBLE
5 SEPTAL INFARCT WHICH YOU REFER TO IN YOUR CONSULT NOTE.
6 A. I PROBABLY WORDED THAT AS OLD SEPTAL. I'M NOT SURE, LET
7 ME FIND THAT. YEAH, I -- THE WAY THE ELECTRICAL ACTIVITY
8 APPEARED, IT'S NOT DEFINITIVE BY ANY STRETCH, BUT IT
9 SUGGESTED THE PATIENT COULD HAVE HAD AN OLD HEART ATTACK IN
10 A CERTAIN PART OF HER HEART.
11 AGAIN, THE -- THIS -- THIS IS NOT DEFINITIVE. IT
12 DOESN'T LOOK AT THE HEART MUSCLE AND SAY THE HEART MUSCLE IS
13 NOT MOVING IN THAT REGION, IT HAD A PRIOR HEART ATTACK. BUT
14 THE ELECTRICAL ACTIVITIES SUGGESTED THAT PART OF THE HEART
15 MIGHT NOT BE MOVING A WELL. SOMETIMES A FINDING LIKE THAT
16 ON A -- ON AN ELECTROCARDIOGRAM MAY NOT MEAN AN OLD HEART
17 ATTACK, SO IT'S NOT THE BEST TEST TO DO.
18 BUT IT -- BUT IT -- BUT IT -- YOU KNOW, GIVEN THAT
19 HISTORY AND THE HISTORY THAT WE'VE ALREADY WENT OVER IN THE
20 PAST MEDICAL HISTORY, IT'S POSSIBLE.
21 Q. IN FACT, THE -- THE -- THE EXAMINER OR THE PERSON WHO
22 RAN THE TEST SAID SUGGESTIVE OF OLD SEPTAL INFARCT, CORRECT?
23 A. I -- YOU KNOW, I'M -- I'M READING FROM MY DICTATION
24 HERE. I DON'T KNOW IF THOSE WERE MY WORDS -- I'M LOOKING AT
25 THE ELECTROCARDIOGRAM -- OR THOSE WERE THE WORDS OF THE
1135
1 REPORT I HAD.
2 Q. OKAY. CAN YOU TELL US WHAT A SEPTAL INFARCT IS?
3 A. THE SEPTUM OF THE HEART IS JUST THE MIDDLE PART OF THE
4 HEART WHERE THE -- THERE'S THE LEFT SIDE OF THE HEART, THE
5 RIGHT SIDE OF THE HEART, THE LEFT VENTRICLE WHERE MOST OF
6 THE MAJOR HEART ATTACKS MIGHT BE CONSTRUED TO OCCUR. THE
7 SEPTUM IS SORT OF THE MIDDLE PART OF THAT LEFT SIDE OF THE
8 HEART. SO IT'S -- YOU KNOW, THERE'S -- THERE'S FOUR
9 CHAMBERS. THE SEPTUM DIVIDES THE HEART ESSENTIALLY IN TWO.
10 AND WE'D BE TALKING ABOUT THE SEPTUM IN THE LOWER PART OF
11 THE HEART WHERE THE LEFT VENTRICLE IS WHERE MOST OF THE
12 MAJOR HEART ATTACKS WOULD OCCUR.
13 Q. IF YOU COULD GO BACK TO THE BINDER ON MS. CRANE, AND IF
14 YOU COULD LOOK IN THE -- THE PHYSICIAN'S ORDER SECTION --
15 AND I'LL SEE IF I CAN GET YOU A PAGE NUMBER HERE. YEAH. IF
16 YOU'D GO TO MED-00243, PLEASE. DOWN AT THE BOTTOM THERE IS
17 AN ENTRY 1/1/96. NOW, THIS WAS THE DAY WHEN YOU SAW
18 MS. CRANE CONCERNING HER FISTULA. AND IT SAYS: 2000
19 TELEPHONE CONVERSATION, DR. HALL, ON-CALL GYNECOLOGIST
20 TANNER CLINIC CONTACTED. NOTIFIED OF LARGE AMOUNT OF FECAL
21 MATTER EXCRETED FROM VAGINA. DOCTOR ADVISED GETTING CONSULT
22 IN A.M. AS PLANNED SINCE PATIENT'S -- I GUESS THAT'S VITAL
23 SIGNS -- ARE STABLE AT THIS TIME AND NO INFECTION INDICATED.
24 AND THEN IT SAYS LYNN LONG, R.N.
25 WOULD YOU BE THE DOCTOR THAT MS. LONG IS REFERRING TO
1136
1 IN THAT NOTE ABOUT GETTING A CONSULT?
2 A. I DON'T THINK SO.
3 Q. AND WHY DO YOU SAY THAT?
4 A. BECAUSE RIGHT ABOVE IT IT TALKED ABOUT DR. HALL. I
5 WOULD THINK IT WAS IN REFERENCE TO PROBABLY HER CONVERSATION
6 WITH DR. HALL.
7 Q. OKAY. AND THEN IF YOU WOULD TURN TO THE NEXT PAGE WHICH
8 IS MED-00244, WHICH IS, ONCE AGAIN, THE PROGRESS NOTE
9 SECTION. AND IT HAS THERE 1/2/96, AND IT SAYS: G.Y.N. -- I
10 GUESS THAT STANDS FOR GYNECOLOGIST, CORRECT?
11 A. YES.
12 Q. CONSULT 72-YEAR-OLD -- I -- I GUESS THAT'S THE MEDICAL
13 FOR WOMAN OR FEMALE, I'M NOT SURE.
14 A. HE DOESN'T -- IT JUST SAYS "WITH."
15 Q. OKAY. AND THEN: C/O, COMPLAINS OF FECAL MATTER OUT OF
16 VAGINA. ON EXAM HAS A HIGH RECTOVAGINAL FISTULA. CAN
17 REPAIR UNDER SPINAL ANESTHETIC IF PATIENT CLEARED FOR
18 SURGERY BY HER INTERNIST. ALSO MAY TRY TO HEAL
19 SPONTANEOUSLY, PROBABILITY 25 TO 35 PERCENT, BY TREATING
20 WITH BROAD SPECTRUM -- IT LOOKS LIKE A.B.S. -- THAT STANDS
21 FOR ANTIBIOTICS, DOES IT NOT?
22 A. YES.
23 Q. AND LOW --
24 A. RESIDUE DIET.
25 Q. -- RESIDUE DIET, AND THEN, PAREN, CONSTIPATE. AND THEN
1137
1 IT SAYS THANKS, STEVEN MEEKS, THEN A TELEPHONE NUMBER.
2 THAT APPARENTLY IS THE CONSULT FOR -- BY THE
3 GYNECOLOGIST, AND HE REFERS TO HER INTERNIST. DO YOU RECALL
4 IF DR. MEEKS TALKED TO YOU ABOUT WHETHER OR NOT SHE SHOULD
5 BE CLEARED FOR SURGERY -- SURGERY?
6 A. I THINK HE DID CALL ME IN THE OFFICE. I DON'T KNOW IF
7 IT WAS THAT DAY OR ANOTHER -- IT MIGHT HAVE BEEN A DAY
8 LATER, BUT -- BUT I BELIEVE HE DID TALK TO ME ABOUT HER,
9 YES.
10 Q. OKAY. AND -- AND DURING THAT -- I MEAN, IN THAT
11 CONVERSATION WAS THERE A DISCUSSION ABOUT WHETHER OR NOT SHE
12 SHOULD BE CLEARED FOR SURGERY?
13 A. YEAH. I -- YES, THERE WAS, AND -- AND -- AND IT -- AND
14 IT HAD TO DO WITH WHAT MY FEELINGS WERE ABOUT THE PATIENT.
15 I THINK I PROBABLY HAD MY CONSULT IN FRONT OF ME SO I JUST
16 REVIEWED WITH HIM WHAT I KNEW ABOUT HER, THAT IN TERMS OF
17 OTHER THINGS EVERYTHING APPEARED TO BE PRETTY -- PRETTY
18 STABLE AT THAT TIME IN MY INITIAL CONSULTATION AND THAT --
19 THAT WAS A NEW FINDING.
20 AND I -- I DON'T HAVE ANY KNOWLEDGE ABOUT WHEN A
21 RECTOVAGINAL FISTULA SHOULD BE REPAIRED, SO THAT WAS KIND OF
22 LEFT UP TO HIM, BUT I DIDN'T SEE A OVERWHELMING REASON NOT
23 TO -- NOT TO GO TO SURGERY.
24 Q. OKAY. AND SO THE TREATMENT THEN WOULD HAVE BEEN TO
25 PRESCRIBE FOR HER, AS HE INDICATES, ANTIBIOTICS --
1138
1 PARTICULARLY BROAD SPECTRUM ANTIBIOTICS, CORRECT?
2 A. HE HAD -- HE GAVE TWO OPTIONS, EITHER SURGERY OR TRY TO
3 LET IT HEAL SPONTANEOUSLY, IT LOOKS LIKE.
4 Q. RIGHT. AND I -- IF I UNDERSTAND WHAT YOU'RE SAYING,
5 YOU'RE SAYING YOU RECALL THAT GIVEN THE NATURE OF HOW YOU
6 PERCEIVED HER CONDITION AT THE TIME, YOU DIDN'T THINK
7 SURGERY WAS NECESSARY. THEN THE OTHER OPTION WOULD BE
8 TREATING WITH BROAD SPECTRUM ANTIBIOTICS, TRUE?
9 A. THAT -- THAT WAS HIS OPINION. I -- I DIDN'T HAVE ANY --
10 I WASN'T -- I DON'T -- I DON'T KNOW HOW TO TREAT A
11 RECTOVAGINAL FISTULA. I WOULDN'T -- I WOULDN'T ORDINARILY
12 PRESCRIBE ANTIBIOTICS FOR THAT PROBLEM; I WOULD NOT DO
13 SURGERY ON ANYTHING LIKE THAT SO --
14 Q. SO YOU -- YOU DID NOT THEN TREAT HER WITH BROAD SPECTRUM
15 ANTIBIOTICS FOR THIS PARTICULAR PROBLEM?
16 A. NO, OF COURSE NOT. I WOULD NOT HAVE TREATED HER MYSELF
17 FOR THAT PROBLEM. THAT WOULD HAVE BEEN HIS RECOMMENDATION.
18 Q. OKAY.
19 MR. STIRBA: THAT'S ALL I HAVE, JUDGE. THANK YOU.
20 THE COURT: ANYTHING FURTHER, MR. WILSON, OF THIS
21 WITNESS?
22 MR. WILSON: JUST A COUPLE OF QUESTIONS.
23 REDIRECT EXAMINATION
24 BY MR. WILSON:
25 Q. AS A FOLLOW-UP TO THAT LAST QUESTION, DID I UNDERSTAND
1139
1 YOUR TESTIMONY TO BE THAT YOU DIDN'T RECOMMEND AGAINST
2 SURGERY, DID YOU?
3 A. NO, I -- I DIDN'T. NO.
4 Q. OKAY. AND YOU DIDN'T SEE ANYTHING ABOUT THIS PARTICULAR
5 PATIENT THAT WOULD CAUSE YOU CONCERN IF SHE --
6 A. WELL, I REVIEWED THE MEDICAL PROBLEMS AND I'D HAVE TO
7 KIND OF GO OVER THOSE AGAIN, BUT EVERYTHING IS KIND OF
8 RELATIVE: A HISTORY OF HYPERTENSION, A HISTORY OF
9 HYPERNATREMIA, ALL -- HISTORY OF CEREBROVASCULAR DISEASE.
10 EVERYTHING IS KIND OF RELATIVE. HE WOULD HAVE TO WEIGH THAT
11 IN HIS MIND WHETHER HE FELT THAT WOULD BE AN ACCEPTABLE RISK
12 OR NOT. ALL OF THOSE ARE MORE OR LESS OLD PROBLEMS, MORE OR
13 LESS STABLE, CHRONIC.
14 BUT, YOU KNOW, EVERY -- EVERYTHING ADDS UP AND I -- IT
15 WOULD PROBABLY PUT HER AT SOMEWHAT OF AN INCREASED RISK, BUT
16 NOT -- YOU KNOW, IT WASN'T -- AGAIN, THERE WERE THOSE LITTLE
17 CHRONIC PROBLEMS AND YOU'VE GOT TO CHOOSE -- IF YOU -- IF
18 YOU NEED THE SURGERY YOU HAVE TO CHOOSE TO DO IT SOMETIME
19 AND I -- I COULDN'T TELL HIM WHEN THE BEST TIME WAS TO DO
20 THAT, BUT I COULDN'T SEE ANYTHING, AT LEAST IN MY INITIAL
21 EVALUATION, THAT WAS A NEW, ACUTE PROBLEM APART FROM NOW THE
22 RECTOVAGINAL FISTULA.
23 Q. THAT WOULD PROHIBIT THE SURGERY?
24 A. RIGHT.
25 Q. OKAY. JUST FOR A POINT OF CLARIFICATION, I WANT YOU TO
1140
1 TURN IN MARY CRANE'S MEDICAL RECORDS AGAIN TO THE NOTE WHICH
2 APPEARS ON MED-00249. YOU'LL NOTE, I'VE GOT A LITTLE
3 ASTERISK -- CAN YOU SEE WHERE I'M POINTING MY FINGER RIGHT
4 THERE?
5 A. YES.
6 Q. WOULD YOU INTERPRET THAT NOTE RIGHT TO THE SIDE OF IT
7 AGAIN?
8 A. IT SAY'S PROBABLE SEIZURE.
9 Q. IS THAT PROBABLE OR IS IT RISK?
10 A. I -- IT'S -- IT'S PROBABLE.
11 Q. OKAY.
12 MR. WILSON: THANK YOU, DOCTOR.
13 THE WITNESS: THANK YOU.
14 MR. STIRBA: NO -- NO OTHER QUESTIONS, YOUR HONOR.
15 THANK YOU.
16 THE COURT: MAY THIS WITNESS BE EXCUSED?
17 MR. WILSON: HE CAN, YOUR HONOR.