Kathleen Kaufman
6 STATE READY TO PROCEED, MR. WILSON?
7 MR. WILSON: YES, YOUR HONOR, I THINK WE ARE.
8 THE COURT: DEFENDANT READY, MR. BUGDEN?
9 MS. BARLOW: WELL, UNFORTUNATELY, OUR WITNESS IS NOT
10 HERE YET.
11 MR. WILSON: I'M -- I APOLOGIZE, YOUR HONOR. I'M
12 WRONG.
13 THE COURT: BETTER CALL ANOTHER ONE THEN.
14 MR. WILSON: WE -- WE DON'T HAVE ANOTHER ONE AT
15 PRESENT EITHER. WE HAVE ANOTHER ONE SHOWING UP AT
16 NINE O'CLOCK AND WE HAVE NO UNDERSTANDING OF WHY THIS WITNESS
17 IS NOT HERE.
18 MS. BARLOW: I WAS SPEAKING TO THIS WITNESS AT 7:30
19 LAST NIGHT AND SHE WAS INTENDING TO BE HERE AT EIGHT THIS
20 MORNING, AND SO I DON'T KNOW WHAT'S THE HOLDUP.
21 THE COURT: DO YOU HAVE ANY NUMBER WHERE YOU CAN
22 REACH HER OR ANYTHING LIKE THAT?
23 MS. BARLOW: I'LL GO GIVE THAT A TRY.
24 (MS. BARLOW STEPS OUT MOMENTARILY.)
25 MS. BARLOW: CLOSURE ON THE FREEWAY SENT OUR WITNESS
1 A DIFFERENT DIRECTION, YOUR HONOR. SHE'S HERE NOW.
2 THE COURT: ALL RIGHT. WHO IS THAT WITNESS,
3 MS. BARLOW?
4 MS. BARLOW: OUR FIRST WITNESS IS KATHLEEN KAUFMAN.
5 THE COURT: MS. KAUFMAN, WOULD YOU COME UP HERE,
6 PLEASE? JUST COME RIGHT UP HERE. YOU CAN PUT YOUR STUFF
7 HERE ON THE BENCH AND THEN IF YOU'LL RAISE YOUR RIGHT HAND
8 AND FACE THE CLERK, SHE'LL PLACE YOU UNDER OATH.
9 KATHLEEN KAUFMAN,
10 BEING FIRST DULY SWORN, WAS EXAMINED AND
11 TESTIFIED AS FOLLOWS:
12 THE COURT: IF YOU'LL HAVE A SEAT UP HERE THEN.
13 GIVE US YOUR FULL NAME AND SPELL YOUR LAST NAME FOR US,
14 PLEASE.
15 THE WITNESS: KATHLEEN MARIE KAUFMAN, K-A-U-F-M-A-N.
16 THE COURT: THANK YOU.
17 DIRECT EXAMINATION
18 BY MS. BARLOW:
19 Q. GOOD MORNING, MS. KAUFMAN.
20 A. GOOD MORNING.
21 Q. SORRY ABOUT THE FREEWAYS.
22 WOULD YOU PLEASE TELL US WHAT CITY YOU RESIDE IN?
23 A. I RESIDE IN SALT LAKE CITY -- SALT LAKE COUNTY.
24 Q. AND WHAT IS YOUR OCCUPATION?
25 A. I AM -- NURSING FACULTY AT THE UNIVERSITY OF UTAH.
1 Q. WHAT IS YOUR EDUCATION FOR YOUR OCCUPATION?
2 A. I HAVE A MASTER'S OF SCIENCE DEGREE IN PHYSIOLOGICAL
3 NURSING.
4 Q. AND WHAT -- WHAT OTHER TRAINING, IF ANY, HAVE YOU HAD
5 BESIDES THE MASTER'S?
6 A. WELL, THE MASTER'S WAS FROM UNIVERSITY OF UTAH. THE -- I
7 HAVE A BACHELOR OF SCIENCE FROM THE UNIVERSITY OF MARYLAND IN
8 NURSING; A BACHELOR OF SCIENCE IN CHEMISTRY FROM GROVE CITY
9 COLLEGE IN PENNSYLVANIA. AND I'VE BEEN A NURSE FOR -- A
10 REGISTERED NURSE FOR ALMOST 25 YEARS NOW.
11 Q. WHAT'S YOUR PROFESSIONAL EXPERIENCE IN THE NURSING FIELD?
12 A. MY -- MY PRACTICE EXPERIENCE IN DIRECT CARE OF PATIENTS
13 HAS BEEN MIXED. I HAVE A CRITICAL CARE BACKGROUND. I'VE
14 WORKED WITH MEDICAL-SURGICAL PATIENTS. AND CURRENTLY, FOR
15 THE LAST 14 YEARS, I'VE BEEN TEACHING MED-SURG NURSING ON A
16 GENERAL SURGERY UNIT.
17 Q. WITH YOUR TEACHING, DO YOU DO ANY HANDS-ON PATIENT CARE
18 AS WELL?
19 A. ABSOLUTELY. I'M IN THE HOSPITAL TWO DAYS A WEEK FOR TWO
20 EIGHT-HOUR SHIFTS.
21 Q. AND HOW MANY STUDENTS DO YOU TEACH IN A --
22 A. EIGHT TO TEN PER ROTATION. I TEACH FOUR ROTATIONS A
23 YEAR.
24 Q. ARE YOU FAMILIAR WITH CHARTING DONE BY NURSES IN HOSPITAL
25 SETTINGS?
1 A. YES, I AM.
2 Q. AND HOW ARE YOU FAMILIAR WITH THAT?
3 A. WELL, I -- I TEACH MY STUDENTS TO DO CHARTING, AND -- AND
4 I ALSO TEACH -- I TEACH THEM VARIOUS TYPES OF CHARTING. AND
5 I'VE USED AN EXTENSIVE ARRAY OF CHARTING IN MY OWN PRACTICE.
6 Q. WHAT IS THE PURPOSE OF CHARTING?
7 A. CHARTING IS TO DOCUMENT WHAT HAS OCCURRED DURING THE --
8 DURING THE SHIFT, DURING THE PERIOD OF TIME IN WHICH A
9 PATIENT'S BEEN TAKEN CARE OF. AND IT ALSO INCLUDES AN
10 ASSESSMENT OF THE PATIENT.
11 Q. ARE THERE DIFFERENT FORMATS FOR CHARTING?
12 A. OH, THERE'S SEVERAL DIFFERENT FORMATS FOR CHARTING.
13 MS. BARLOW: IF I MAY HAVE JUST A MOMENT, YOUR
14 HONOR?
15 Q. (BY MS. BARLOW) I THINK WHAT I WILL DO IS PULL OUT A
16 PAGE FROM THE NURSING NOTES IN ONE OF THE PATIENTS IN THIS
17 CASE, SEE IF THAT WILL HELP US EXPLAIN THE FORMATS. I AM
18 SELECTING FROM ELLEN ANDERSON AND I BELIEVE THAT IS 2-B, AND
19 IT'S MED PAGE-190. I'M JUST SELECTING ONE AT RANDOM HERE.
20 AS I INDICATED, THIS IS JUST A PAGE SELECTED AT RANDOM.
21 USING THIS PAGE, CAN YOU TALK ABOUT THE DIFFERENT STYLES --
22 DIFFERENT FORMATS OF CHARTING?
23 A. YES. THERE ARE TWO TYPES -- TYPES OF CHARTING EXHIBITED
24 HERE. ON THE RIGHT SIDE OF THE PAGE IS WHAT YOU CONSIDER
25 NARRATIVE CHARTING. NARRATIVE CHARTING IS A -- A PROSE -- A
1 CONTINUOUS CHARTING OF WHAT'S OCCURRED DURING THE SHIFT. IT
2 CAN BE DONE IN TWO DIFFERENT WAYS. IT CAN BE CHARTED
3 ACCORDING TO EACH HOUR AS IT'S GONE ON DURING THE SHIFT, OR
4 YOU CAN DO A BLOCK CHARTING WHICH -- AND THESE -- THESE
5 CHARTS ARE COMPRISED OF A COMBINATION OF BLOCK CHARTING WHICH
6 IS WHAT'S HAPPENED OVER THE ENTIRE SHIFT, AS WELL AS CERTAIN
7 HOURLY CHARTINGS DURING THE SHIFT. AND THAT'S THE NARRATIVE
8 ON THE RIGHT SIDE.
9 NOW, ON THE LEFT SIDE, THE LEFT TWO COLUMNS IS WHAT I'D
10 CALL CHARTING BY EXCEPTION. IN THAT CASE YOU HAVE VARIOUS
11 CATEGORIES LISTED WITH KEY WORDS UNDERNEATH EACH CATEGORY.
12 AND IN THE CATEGORIES, THE CAREGIVER CAN CIRCLE THE
13 APPROPRIATE WORD THAT WOULD -- THAT WOULD APPLY TO THE
14 PATIENT. AND GENERALLY SPEAKING, THESE TWO LEFT COLUMNS TO
15 COINCIDE WITH THE RIGHT COLUMN AS FAR AS THE PERIOD OF TIME.
16 AT TIMES THE RIGHT COLUMN WILL GO ON FOR ANOTHER PAGE OR TWO
17 AND YOU'LL SEE A RELATIVELY EMPTY LEFT-SIDED COLUMN ON THOSE
18 PAGES.
19 AND SO THIS WOULD BE CHARTING BY EXCEPTION. AND IN MOST
20 CASES YOU'LL SEE THAT THERE IS A CORRELATION BETWEEN -- AND
21 THERE SHOULD BE A CORRELATION BETWEEN WHAT'S SAID IN THE
22 NARRATIVE CHARTING ON THE RIGHT AND IN A VARIETY OF
23 VOCABULARY, COMPARED TO THE WORDS THAT ARE CIRCLED. AND
24 THERE ARE VERY FEW WORDS ON THE LEFT IN THE VARIOUS
25 CATEGORIES.
1 AND IN THE LEFT YOU CAN WRITE INTO THAT IN VARIOUS
2 PLACES. THERE'S LINES AND IN SOME SELECTIONS YOU'LL SEE
3 PEOPLE HAVE SIMPLY WRITTEN IN BETWEEN THE LINES, A WORD THAT
4 THEY THOUGHT WAS BETTER THAN THE ONE THAT WAS AVAILABLE.
5 Q. OKAY. IS THERE ANOTHER KIND OF CHARTING THAT YOU SAW IN
6 THESE RECORDS?
7 A. THERE IS A THIRD TYPE OF CHARTING WHICH IS -- IN THESE
8 RECORDS IT'S CALLED A SPECIAL OBSERVATION RECORD. AND THESE
9 ARE CHARTED -- THESE ARE PAPERS THAT ARE SET UP SO THAT YOU
10 CAN OBSERVE THE PATIENT VERY FREQUENTLY FOR ANY NUMBER OF
11 DIFFERENT REASONS. AND, FOR INSTANCE, IF A PATIENT HAS
12 RESTRAINTS ON, THE STANDARD OF CARE WOULD BE TO CHECK THESE
13 PATIENTS EVERY 15 TO 30 MINUTES. AND SO THAT WOULD BE
14 DOCUMENTED ON THAT SHEET WITH A TIME AND WITH WHAT CONDITION
15 THE PATIENT WAS IN.
16 THOSE ALLOW FOR GREATER FREQUENCY OF CHARTING, BUT FOR
17 NOT VERY MUCH SPECIFICITY. THEY'RE LIMITED IN WHAT YOU
18 ACTUALLY CAN PUT ON THOSE PAGES. AND IN THIS PARTICULAR
19 FACILITY, THOSE PAGES -- THE DOCUMENTATION IS DONE WITH
20 SIMPLY INITIALS THAT CORRELATE TO A KEY THAT'S ON ONE SIDE OF
21 THAT PAGE WHICH --
22 Q. I'M TRYING TO FIND ONE TO --
23 A. LET'S SEE.
24 Q. -- TO PUT UP THERE. AND THIS IS IN JUDITH LARSEN'S WHICH
25 I BELIEVE IS 3-B.
1 MS. BARLOW: I APOLOGIZE, YOUR HONOR. I SHOULD HAVE
2 PULLED THESE OUT BEFORE I GOT HERE.
3 THE COURT: IT'S OKAY.
4 MS. BARLOW: BECAUSE FINDING THEM SOMETIMES TAKES A
5 LITTLE BIT OF TIME IN THE RECORDS. OH, I HAVE ONE RIGHT
6 HERE.
7 Q. (BY MS. BARLOW) AGAIN, THIS IS IN JUDITH LARSEN'S AND
8 I -- I BELIEVE IT'S 3-B AND THIS IS MED PAGE-694.
9 IS THIS WHAT YOU WERE REFERRING TO?
10 A. YES. THIS WOULD BE THE SPECIAL OBSERVATION RECORD. ON
11 THE LEFT-HAND COLUMN IS A -- PROBABLY FOCUSED FOR YOU -- BUT
12 IS A COLUMN OF KEY WORDS. AND ON THE RIGHT THREE COLUMNS ARE
13 THREE DIFFERENT COLUMNS FOR SHIFTS. AND THE PEOPLE CAN
14 DOCUMENT -- THE CAREGIVERS CAN DOCUMENT WHAT THE CONDITION OF
15 THE PATIENT WAS, WHERE THEY WERE LOCATED, AND A GENERAL
16 DESCRIPTION OF WHAT THEY'RE DOING.
17 THIS IS BASICALLY A SAFETY OBSERVATION-TYPE RECORD.
18 THERE'S A VARYING NUMBER OF THEM FOR EACH PATIENT. I THINK
19 FROM TWO UP TO SEVERAL FOR A PATIENT WHO IS IN RESTRAINTS.
20 Q. DID YOU HAVE OCCASION TO LOOK AT THE MEDICATION RECORDS
21 OF -- OF THE CHARTS OF THESE FIVE PATIENTS?
22 A. YES, I DID.
23 Q. AND CAN YOU BRIEFLY EXPLAIN HOW ORDERS -- MEDICATION
24 ORDERS, I.V. ORDERS, THAT SORT OF THING COME TO -- COME TO
25 THE HOSPITAL AND TO THE CHART AND HOW IT'S CHARTED?
1 A. OKAY. THE MOST COMMON AND DIRECT WAY THAT ORDERS ARRIVE
2 ON A CHART IS THAT THE PHYSICIAN WILL WRITE THOSE ORDERS ON
3 THE CHART. THAT'S THE -- THAT'S THE MOST COMMON PRACTICE.
4 NOW, WHEN A PHYSICIAN IS NOT IN -- IS NOT PRESENT FOR THE
5 ORDERS ON THAT CHART, THEY CAN CALL IN A TELEPHONE ORDER.
6 AND OCCASIONALLY THEY WILL GIVE A -- A VERBAL ORDER MIGHT BE
7 GIVEN IF A PHYSICIAN IS IN THE HOSPITAL OR ON THE UNIT, BUT
8 NOT ACTUALLY WRITING THE ORDER.
9 Q. IN FACT, I THINK I -- I HAVE ONE HERE I CAN SHOW. THIS
10 IS MED PAGE-451 FROM JUDITH LARSEN'S MEDICAL RECORD. HAS THE
11 DATE OF 12/6 AT THE TOP AND THEN THERE'S SOME WRITING DOWN AT
12 THE BOTTOM. CAN YOU EXPLAIN -- I BELIEVE THIS SAYS V.O. AT
13 THE TOP.
14 A. OKAY. THAT WOULD BE A VERBAL ORDER, AT THE VERY TOP.
15 AND THAT INDICATES THAT THESE -- THESE -- WHAT WAS WRITTEN
16 BEYOND THAT, IT SAYS VERBAL ORDER, DR. WEITZEL, TO LYNN LONG,
17 R.N. SO WHAT FOLLOWS THAT IS ALL VERBAL MATERIAL, ORDERS AND
18 IN SOME CASES COMMENTS THAT GIVES THE -- THE FACT THAT SHE'S
19 BEEN ADMITTED, WHAT THE PRELIMINARY DIAGNOSIS IS. THESE
20 THINGS HAVE BEEN -- HAVE BEEN VERBALLY TOLD TO THE R.N. AND
21 THEN THE R.N. HAS WRITTEN THEM DOWN. OKAY. AND WHEN THIS
22 HAPPENS, THEN THE PHYSICIAN WILL COME IN AT EARLIEST
23 OPPORTUNITY AND SIGN THOSE, CHECK THEM THAT THEY WERE WRITTEN
24 APPROPRIATELY AND THEN SIGN THEM. AND THESE ARE SIGNED DOWN
25 AT THE BOTTOM.
1 Q. AND THAT APPEARS TO BE ROBERT WEITZEL, M.D.?
2 A. UH-HUH.
3 Q. AND UNDERNEATH THAT IS A PHRASE, NOTED L. LONG, R.N.
4 WHAT -- WHAT DOES THAT MEAN?
5 A. WELL, AS YOU CAN SEE, AS YOU'RE COMING DOWN THE ORDERS
6 THERE'S LITTLE HATCH MARKS BESIDE THEM. THAT'S ONE WAY OF A
7 R.N. KEEPING TRACK OF WHAT THEY'VE READ AND THEY'VE
8 TRANSCRIBED. AND IN THIS PARTICULAR CASE THESE HAVE EITHER
9 BEEN TRANSCRIBED AND CHECKED BY THE R.N. OR THEY HAVE BEEN
10 TRANSCRIBED BY SOMEONE ELSE BUT CHECKED BY THE R.N., WHICH IS
11 THE METHOD YOU NEED TO GO THROUGH. YOU HAVE TO -- THE ORDERS
12 ARE TAKEN OFF INTO VARIOUS OTHER PLACES ON THE UNIT FOR --
13 LABS ARE SENT TO THE LAB AND THE BLOOD'S DRAWN. ORDERS --
14 MEDICATION ORDERS ARE TRANSCRIBED TO A MEDICATION RECORD.
15 AND THEN THE NURSE WILL COME AND CHECK EACH ONE OF THESE AND
16 INDICATE BY SIGNING AT THE BOTTOM THAT THEY HAVE CHECKED THEM
17 AND THEY'RE CORRECT AND TAKEN CARE OF, UNLESS THERE'S SOME
18 OTHER NOTATION ON THERE.
19 Q. AND IS THAT DATED AND TIMED?
20 A. AND IT IS DATED AND TIMED. ALL ORDERS NEED TO BE DATED
21 AND TIMED. USUALLY THE PHYSICIAN WHEN THEY WILL WRITE THE
22 ORDER WOULD DATE AND TIME IT AT THE TOP. AND THEN IN THIS
23 CASE SHE'S DATED AND TIMED AT THE TIME THAT SHE TOOK IT OFF
24 OR SHE CHECKED THEM. AND TAKING IT OFF WOULD BE THE SAME AS
25 TRANSCRIBING IT.
1 Q. NEXT PAGE, WHICH IS 452 IN THE SAME EXHIBIT, HAS A
2 NOTATION AT THE BOTTOM ON THE RIGHT. DO YOU RECOGNIZE WHAT
3 THAT IS? IT'S OXYGEN SATURATION?
4 A. ACTUALLY I CAN'T READ IT FROM THIS ANGLE.
5 Q. OH, OKAY.
6 THE COURT: YOU CAN STEP OVER THERE IF YOU NEED TO.
7 Q. (BY MS. BARLOW) I'M SORRY ABOUT THAT.
8 A. WHAT THAT IS IS A STAMP THAT THE RESPIRATORY THERAPIST OR
9 RESPIRATORY THERAPY DEPARTMENT WOULD PUT ON -- ON A CHART AND
10 THEY WOULD INDICATE THAT THEY'VE CHECKED THE OXYGEN
11 SATURATION IN THIS PARTICULAR CASE. AND THE OXYGEN
12 SATURATION IS THE AMOUNT OF OXYGEN, THE HEMOGLOBIN THAT'S
13 CARRIED IN THE EXTREMITIES. AND THERE'S A METHOD YOU CAN USE
14 TO CHECK THAT. AND THAT'S A RECORD OF THAT IN THIS CASE.
15 Q. AND THEN PAGE 456 OF THE SAME EXHIBIT HAS AN AUTOMATIC
16 DRUG STOP ORDER STAMP ON IT.
17 A. UH-HUH.
18 Q. DO YOU RECOGNIZE WHAT THAT IS?
19 A. AN AUTOMATIC DRUG STOP ORDER IS FOR CERTAIN
20 CLASSIFICATIONS OF DRUGS. THEY ARE ONLY ORDERED FOR A
21 LIMITED PERIOD OF TIME. AND SO THIS WE PUT ON THE CHART TO
22 INDICATE THAT THAT -- THAT DRUG WILL BE STOPPED AT A CERTAIN
23 DATE. AND IN MOST FACILITIES IT'S PUT THERE TO INDICATE TO
24 THE PHYSICIAN THAT THE DRUG IS -- YOU KNOW, THERE IS A
25 LIMITED TIME AND THAT THEY NEED TO -- WILL NEED TO REORDER IT
1 IF THEY WANT IT TO BE CONTINUED.
2 Q. AND SO IF THE DOCTOR WANTS TO IT CONTINUED, HE WOULD HAVE
3 TO ISSUE ANOTHER ORDER?
4 A. HE WOULD WRITE THE ORDER AGAIN. RIGHT.
5 Q. YOU TALKED ABOUT TAKING -- TAKING AN ORDER OFF. WHEN A
6 NURSE DOES THAT, WHAT DOES THE NURSE DO WITH THAT ORDER?
7 A. OKAY. THE NURSE WILL READ THE ORDER AND SEE THAT IT'S
8 COMPLETE AND -- AND MAKES SENSE. AND THEN THEY'LL TAKE --
9 THEY'LL -- THEY'LL TAKE THE ORDER AND IF -- WE'RE TALKING
10 ABOUT A MEDICATION? IS THAT WHAT YOU'RE --
11 Q. YES.
12 A. -- PARTICULARLY INTERESTED IN? WITH A MEDICATION, THEN
13 THEY WILL TAKE THAT -- THE NAME OF THE MEDICATION AND
14 TRANSCRIBE IT OR WRITE IT DOWN ONTO A MEDICATION RECORD.
15 THERE'S -- IN THIS FACILITY AND IN MANY FACILITIES IT'S
16 CALLED A MEDICATION ADMINISTRATION RECORD, AND WE TEND TO
17 CALL IT THE M.A.R.S. FOR SHORT. IF I SAY THAT, THAT'S WHAT
18 THAT MEANS.
19 THE NURSE WILL TRANSCRIBE THE DRUG AND THEY'LL
20 TRANSCRIBE IT ONTO A PAPER THAT HAS THE PATIENT'S
21 IDENTIFICATION ON IT, AND THEN THEY'LL TRANSCRIBE THE DRUG BY
22 THE NAME AS IT IS WRITTEN IN THE ORDER, BY THE DOSE, THE
23 ROUTE, AND THE FREQUENCY IT'S SUPPOSED TO BE ADMINISTERED.
24 AND THEN WITHIN EACH FACILITY YOU'LL HAVE SPECIFIC TIMES --
25 SAY IF A DRUG WAS ORDERED TO BE GIVEN TWICE A DAY THEN AT A
1 GIVEN FACILITY -- IN THIS FACILITY IT WOULD BE GIVEN AT 8
2 A.M. AND 20 -- 2000 WHICH WOULD BE --
3 Q. 8 P.M.?
4 A. -- 8 P.M., SO IT WOULD BE 12 HOURS APART. AND SO THAT'S
5 WHAT THE NURSE WOULD DO WHEN THEY PUT IT ONTO THE MEDICATION
6 RECORD.
7 Q. AND THIS IS MED-501, AGAIN, FROM JUDITH LARSEN'S RECORD.
8 AND IT HAS INDICATED A DATE THAT IT WAS ORDERED WHICH IS
9 12 -- LOOKS LIKE 7. TRAZODONE. WHAT IS THAT?
10 A. TRAZODONE IS AN ANTIDEPRESSANT.
11 Q. 150?
12 A. MILLIGRAMS.
13 Q. AND IT SAYS P.O.?
14 A. P.O. THAT WOULD BE BY MOUTH, ORALLY, IS P.O.
15 Q. AND IS THAT WHAT YOU MEAN BY ROUTE --
16 A. BY ROUTE. THAT WOULD BE.
17 Q. -- IT'S TO BE ADMINISTERED?
18 A. YEAH. AND MOST TYPICALLY YOUR -- YOUR ROUTES WOULD BE
19 ORALLY; BY INJECTION, WHICH WOULD BE INTRAMUSCULAR OR
20 SUBCUTANEOUS; AND ALSO INTRAVENOUS WOULD BE THE FOUR MAJOR --
21 AND THERE'S ALSO A TOPICAL ROUTE THAT BE USED FOR SOME DRUGS
22 WHERE YOU PUT IT ON THE SKIN.
23 Q. SO P.O. MEANS PER MOUTH, ORALLY?
24 A. UH-HUH.
25 Q. ARE THERE ABBREVIATIONS FOR INTRAMUSCULAR?
1 A. YES, THERE ARE? I.M. WOULD BE IN INTRAMUSCULAR. S.Q. OR
2 S.C. WOULD BE SUBCUTANEOUS. AND I.V. WOULD BE INTRAVENOUS.
3 Q. WHAT'S THE DIFFERENCE BETWEEN I.M., INTRAMUSCULARLY, AND
4 SUBCUTANEOUS?
5 A. WELL, INTRAMUSCULARLY IS GIVEN MUCH DEEPER INTO THE BELLY
6 OF THE MUSCLE. AND IT'S ABSORBED AT A DIFFERENT RATE THAN A
7 SUBCUTANEOUS INJECTION WOULD BE. SUBCUTANEOUS JUST GOES
8 BELOW THE SKIN AND IT'S A VERY SHORT AND SHARP NEEDLE THAT
9 YOU GIVE IT WITH.
10 Q. AND THEN THERE IS -- AND THEN IT SAYS Q.H.S. WHAT DOES
11 THAT MEAN?
12 A. THAT MEANS AN HOUR OF SLEEP. AND IN THIS CASE, THIS --
13 THIS MEDICATION IS SOMEWHAT SEDATING AND SO IT'S TYPICALLY
14 GIVEN IN THE EVENING SO THAT THAT EFFECT WOULD OCCUR DURING
15 THE NORMAL SLEEP CYCLE AT NIGHT.
16 Q. AND WHAT DOES THE ABBREVIATION Q. MEAN?
17 A. Q. MEANS EVERY. I'M NOT SURE IF -- THERE IS -- THERE
18 ARE -- YOU CAN -- Q.H. WOULD BE Q. HOUR, EVERY HOUR. Q.H.S.
19 HERE WOULD BE EVERY HOUR OF SLEEP, WHICH WOULD BE ONCE A
20 DAY -- OR ONCE EVERY EVENING. AND YOU COULD HAVE Q.O.D.
21 WHICH WOULD BE EVERY OTHER DAY. THERE'S ONE MEDICATION IN
22 THE CHART THAT'S ORDERED Q. THREE DAYS SO YOU WOULD GIVE THAT
23 MEDICATION EVERY THIRD DAY.
24 Q. AND THEN THERE IS A TIME COLUMN HERE, AND THIS SAYS 2000.
25 A. UH-HUH.
1 Q. THE NEXT ONE SAYS 0800, 2000. WHAT DOES THAT MEAN?
2 A. THOSE ARE THE TIMES THAT THE DRUG WOULD BE DESIGNATED TO
3 BE GIVEN. THEY ARE NOT ACTUALLY -- NOT ALWAYS ABSOLUTE, BUT
4 THOSE ARE THE TIMES THAT THEY'RE PLANNED TO BE GIVEN.
5 Q. OKAY.
6 A. AND SCHEDULED.
7 Q. AND THEN OFF TO I GUESS THE RIGHT OF THAT -- I CAN'T READ
8 THAT VERY WELL, WHAT THAT SAYS. IT SAYS DATE, AND THEN IT
9 HAS INITIALS. WHAT DOES THAT MEAN?
10 A. WHAT YOU HAVE IN THERE IS THE -- AT THE TOP OF THE COLUMN
11 YOU'LL HAVE A DATE, WHICH WILL INDICATE THE DAY THAT THE
12 MEDICATION WOULD BE GIVEN. THAT'S NOTATED UNDER THAT IN THE
13 COLUMN. AND THEN BESIDE EACH TIME YOU'LL HAVE THE INITIALS
14 OF THE NURSE WHO GAVE THE MEDICATION INDICATING THAT THAT
15 MEDICATION WAS GIVEN.
16 Q. AND WHO GAVE IT?
17 A. AND WHO GAVE IT.
18 Q. NOW, THERE IS ONE OVER HERE THAT APPEARS TO BE CIRCLED.
19 A. UH-HUH.
20 Q. DO YOU KNOW WHAT THAT MEANS?
21 A. THAT WOULD MEAN THAT THAT DRUG -- THAT DRUG WAS NOT GIVEN
22 AT THE ASSIGNED TIME. THERE SEEMS TO BE SOMETHING ELSE
23 WRITTEN THERE. I'LL HAVE TO LOOK AT IT.
24 Q. SAYS 1400.
25 A. OKAY. THAT DRUG WAS NOT GIVEN BY THE NURSE AT 0800,
1 PROBABLY WAS GIVEN AT 1400. THAT'S A LITTLE UNUSUAL TO
2 NOTATE IT AT THAT -- IN THAT WAY, BUT THAT'S CERTAINLY ONE
3 WAY TO DO IT, INDICATE THAT IT WAS GIVEN LATE AT ANOTHER
4 TIME, BUT NOT GIVEN AT THE SCHEDULE TIME.
5 Q. SO ANY TIME AN INITIAL IS CIRCLED, THAT MEANS WHAT?
6 A. IT MEANS THE DRUG'S BEEN HELD. NOT GIVEN.
7 Q. OR NOT GIVEN.
8 A. NOT GIVEN.
9 Q. NOW, THIS IS THE -- DOWN AT THE BOTTOM IT'S KIND OF CUT
10 OFF, BUT IT SAYS ROUTINE MEDICATION ADMINISTRATION RECORD.
11 WHAT DOES THAT MEAN?
12 A. THIS WOULD BE THE MEDICATION RECORD WHERE THE REGULAR
13 DRUGS, THE ROUTINE DRUGS ARE ORDERED TO BE GIVEN EVERY DAY
14 WOULD BE DOCUMENTED ON THIS PARTICULAR SHEET.
15 Q. OKAY. IS THERE A DIFFERENT MEDICATION ADMINISTRATION
16 RECORD SHEET?
17 A. THERE IS ONE FOR DRUGS THAT ARE ORDERED ONLY ONE TIME OR
18 ORDERED ON A P.R.N. OR AS-NEEDED BASIS. AND THAT IS CALLED
19 IN THIS CHART THE P.R.N. AND I.V. MEDICATION RECORD.
20 Q. I'M PUTTING ON 508, AGAIN, FROM THE SAME EXHIBIT. AND
21 WHAT IS THIS?
22 A. THIS WOULD BE THE P.R.N. AND I.V. MEDICATION RECORD.
23 Q. IT APPEARS THAT THERE'S ONLY ONE DRUG LISTED --
24 A. YEAH.
25 Q. -- AT THE TOP THERE. ATIVAN, LOOKS LIKE TWO MILLIGRAMS
1 P.O. OR I.M. Q6 HOURS, Q6 DEGREE. P.R.N. AGITATION. WHAT
2 DOES THAT MEAN?
3 A. ATIVAN'S THE DRUG. THE DOSE WOULD BE TWO, WHICH I TAKE
4 IT SAYS TWO BECAUSE I CAN'T REALLY SEE IT. YES. IT IS TWO.
5 A LITTLE LINE WITH TWO LINES UNDERNEATH IT AND TWO DOTS ABOVE
6 IT MEANS TWO. YOU MIGHT ALSO SEE A LINE WITH ONE LINE BELOW
7 IT AND ONE DOT ABOVE IT. THAT MEANS ONE IN THE SHORTHAND
8 THAT'S USED. THAT WOULD BE ATIVAN TWO MILLIGRAMS TO BE GIVEN
9 ORALLY OR INTRAMUSCULAR -- SO THERE'S A CHOICE IN THIS
10 SITUATION. AND A Q6 AND THE LITTLE DEGREE SIGN MEANS HOURS.
11 SO IT'S Q6 HOURS. P.R.N. IS AS NEEDED FOR AGITATION. A
12 P.R.N. MEDICATION SHOULD HAVE THE REASON THAT IT IS BEING
13 GIVEN ALSO WRITTEN WITH THAT ORDER. AND SO IN THIS CASE
14 ATIVAN WOULD BE GIVEN FOR AGITATION.
15 Q. NOW, OUT TO THE RIGHT OF THAT IT HAS DATES AND -- AND
16 BOXES, BUT NOTHING IS FILLED OUT. WHAT DOES THAT MEAN?
17 A. APPARENTLY THIS DRUG WAS TRANSCRIBED, IT WAS TAKEN OFF
18 WHEN THE ORDER WAS WRITTEN, BUT IT WASN'T ACTUALLY GIVEN AT
19 THIS -- FOR THIS PATIENT AT THIS POINT.
20 Q. DID YOU HAVE OCCASION -- AND I BELIEVE THAT PROBABLY IS
21 ALL THAT I'LL NEED THIS. THIS IS ANNOYING SO WE TAKE IT DOWN
22 WHEN WE'RE THROUGH WITH IT. THANK YOU.
23 DID YOU HAVE OCCASION TO LOOK AT THE RECORDS, THE
24 MEDICAL RECORDS OF THE FIVE PATIENTS INVOLVED IN THIS CASE?
25 A. YES, I DID.
1 Q. DID YOU -- DID YOU SPECIFICALLY LOOK AT THE MEDICATIONS
2 THAT WERE -- THAT WERE ORDERED AND GIVEN TO THESE PATIENTS?
3 A. YES, I DID.
4 Q. DID YOU SPECIFICALLY LOOK AT THE MEDICATION -- THE
5 PSYCHOTROPIC MEDICATIONS AND PAIN MEDICATIONS?
6 A. YES.
7 Q. DID YOU PREPARE ANY KIND OF DOCUMENT SHOWING THE -- THE
8 KINDS OF MEDICATION AND THE AMOUNTS OF MEDICATION ORDERED
9 AND -- AND/OR GIVEN FOR THESE PATIENTS?
10 A. YES.
11 Q. HOW DID YOU DO THAT?
12 A. WELL, I WENT THROUGH THE MEDICATION RECORDS VERY
13 CAREFULLY AND MADE DAY-BY-DAY NOTATIONS ON THE DRUGS THAT
14 WERE ORDERED FOR THE PATIENTS. THIS -- AND THEN LOOKING AT
15 THAT, THERE'S A VAST AMOUNT OF INFORMATION THERE. I THOUGHT
16 ABOUT AND DID CREATE A VISUAL FORMAT THAT YOU COULD ACTUALLY
17 LOOK AND SEE THE -- THE DRUGS THAT HAD BEEN PRESCRIBED AND
18 GIVEN TO THE PATIENTS IN THOSE TWO CATEGORIES.
19 Q. AND HOW DID YOU FORMULATE THAT VISUAL FORMAT?
20 A. I DEVELOPED ESSENTIALLY A BAR GRAPH SHOWING DOSES OF
21 MEDICATIONS FOR EACH DAY. AND THE DOSES OF MEDICATIONS HAD A
22 KEY TO THE SIDE, AND EACH DOSE OF MEDICATION WAS INDICATED
23 WITH -- INDICATED WITH A NUMBER OF MILLIGRAMS OR DOSAGE
24 PER -- PER ORDER. AND EACH OF THOSE ARE ILLUSTRATED IN THE
25 GRAPH WITH A PILL THAT HAS THE -- THE VALUE OF IT SET OUT AT
1 THE SIDE IN A KEY.
2 Q. LET ME SHOW YOU WHAT HAS BEEN MARKED STATE'S EXHIBIT 4-E.
3 A. OKAY.
4 Q. DO YOU RECOGNIZE THAT?
5 A. YES, I DO.
6 Q. WHAT IS THAT?
7 A. THAT'S THE -- THE MEDICATION RECORD FOR MARY CRANE.
8 Q. AND HAVE YOU CHECKED THIS TO SEE IF IT'S ACCURATE?
9 A. YES, I HAVE.
10 Q. AND WHAT MEANS DID YOU USE TO DO THAT?
11 A. AFTER IT WAS CONSTRUCTED I WENT THROUGH, COUNTED AGAIN,
12 LOOKED THROUGH THE CHARTS AND COUNTED EACH ONE OF THOSE
13 MEDICATIONS AS GIVEN. AND AT LEAST TWO IF NOT THREE OTHER
14 PEOPLE DID THE SAME THING.
15 MS. BARLOW: YOUR HONOR, I WOULD MOVE FOR ADMISSION
16 OF 4-E SO I CAN SHOW IT TO THE JURY.
17 THE COURT: HAVE YOU SEEN IT, MR. BUGDEN?
18 MR. BUGDEN: I HAVE, AND NO OBJECTION.
19 THE COURT: 4-E IS RECEIVED. YOU NEED THE EASEL?
20 BAILIFF, WILL YOU COME AND PUT UP THE EASEL FOR HER?
21 MS. BARLOW: WHERE WOULD BE THE BEST PLACE, YOUR
22 HONOR? WOULD IT BE BETTER OVER THERE?
23 THE COURT: PROBABLY OVER THERE AT THE JURY BOX.
24 MS. BARLOW: OKAY.
25 THE COURT: OR YOU CAN PUT IT OVER HERE. IT DOESN'T
1 MATTER TO ME, JUST SO THE JURY CAN SEE IT. THEY'RE THE ONES
2 WHO NEED TO BE ABLE TO SEE IT, AND THE WITNESS.
3 MS. BARLOW: MAYBE IF WE COULD SET IT RIGHT HERE FOR
4 NOW. CAN EVERYONE SEE THAT?
5 THE COURT: I'M NOT SURE YOUR WITNESS CAN. YOU MAY
6 NEED TO PULL IT SO FAR BACK THE JURY CAN'T.
7 MS. BARLOW: YEAH.
8 THE WITNESS: OKAY.
9 MS. BARLOW: MIGHT JUST SET IT RIGHT OVER THE COURT
10 REPORTER.
11 THE COURT: LAURIE, DOES THAT BOTHER YOU?
12 COURT REPORTER: NO, SIR.
13 THE COURT: CAN YOU SEE THAT, LADIES AND GENTLEMEN?
14 OKAY. CAN YOU SEE THAT NOW?
15 THE WITNESS: YES, I CAN.
16 THE COURT: ALL RIGHT.
17 MS. BARLOW: NOW, THIS IS --
18 THE COURT: MR. BUGDEN, YOU'RE WELCOME TO MOVE
19 WHEREVER YOU NEED.
20 MR. BUGDEN: OKAY. THANKS, JUDGE.
21 THE COURT: EXCEPT YOU CAN'T SIT DOWN BY THE JUROR.
22 MR. BUGDEN: CAN I STAND HERE?
23 THE COURT: YOU CAN SIT UP IN THE CORNER, IF YOU
24 WANT, EITHER WAY. OR STAND THERE. WHICHEVER YOU WANT.
25 MR. BUGDEN: THAT'S OKAY?
1 THE COURT: YES.
2 Q. (BY MS. BARLOW) YOU INDICATE THIS IS THE CHART FOR MARY
3 CRANE. ON THE RIGHT-HAND SIDE IS A KEY. AND WHAT ARE THOSE?
4 A. THOSE ARE A VARIETY OF -- OF ANTI-- MOSTLY ANTIPSYCHOTIC,
5 SEDATIVE, ANTIDEPRESSANT-TYPE MEDICATIONS, AND ALSO ANALGESIC
6 OR PAIN -- PAIN RELIEF MEDICATIONS.
7 Q. WHICH IS THE -- WHICH ARE THE PAIN RELIEF MEDICATIONS?
8 A. THE PAIN RELIEF MEDICATIONS ON THIS CHART ARE THE -- IS
9 THE DURAGESIC PATCH WHICH IS THE CIRCLE -- THE BLUE CIRCLE
10 WITH THE YELLOW CENTER. AND DURAGESIC PATCHES ARE -- ARE
11 TOPICAL SO THEY'RE PUT ON THE SKIN. AND THEN THERE'S ALSO
12 MORPHINE IN THE LITTLE BLUE CUBE AT THE BOTTOM.
13 Q. NOW, RISPERDAL IT SAYS ONE MILLIGRAM PER PILL; SERZONE,
14 100 MILLIGRAMS PER PILL; TRAZODONE, 50 MILLIGRAMS PER PILL;
15 DEPAKENE; ATIVAN, TWO MILLIGRAMS PER PILL; DURAGESIC, 25
16 MICROGRAMS PER HOUR. DID YOU HAVE OCCASION TO DETERMINE THE
17 AMOUNT THAT WOULD BE IN EACH PILL?
18 A. YES. WE NEEDED TO FIND A COMMON DENOMINATOR SO THAT ALL
19 THE CHARTS WOULD HAVE SOME REGULARITY IN THEM SO YOU COULD
20 LOOK FROM ONE TO ANOTHER OR LOOK WITHIN ONE AND SEE WHAT THE
21 DOSES WERE. SO BY -- IN ORDER TO ESTABLISH A COMMON
22 DENOMINATOR SO WE COULD MAKE THE GRAPH, I USED AS A REFERENCE
23 THE 1993 GERIATRIC DOSAGE HANDBOOK AND USED THE SUGGESTED
24 INITIAL DOSE.
25 MR. BUGDEN: YOUR HONOR, I'M GOING TO OBJECT.
1 THE COURT: SUSTAINED.
2 MS. BARLOW: YOUR HONOR, MAY WE APPROACH?
3 THE COURT: I WON'T LET YOU DO THAT, SO YOU NEED TO
4 FIND ANOTHER WAY.
5 Q. (BY MS. BARLOW) SO YOU DETERMINED THE AMOUNT OF THE PILL
6 FROM THE GERIATRIC DOSING HANDBOOK; IS THAT CORRECT?
7 A. SIMPLY TO ILLUSTRATE THE AMOUNT OF MEDICATION THAT WAS
8 GIVEN.
9 Q. OKAY. NOW, YOU INDICATE THAT YOU USED THE 1993 GERIATRIC
10 DOSING HANDBOOK. WHY THE 1993?
11 A. THAT HANDBOOK WAS AVAILABLE IN 1995 AND 1996 AS A
12 HANDBOOK THAT WOULD CARRY GERIATRIC DOSES FOR THESE
13 MEDICATIONS.
14 Q. WERE -- WERE THERE ANY DRUGS THAT WERE NOT IN THE
15 GERIATRIC DOSING MANUAL?
16 A. THERE WERE TWO THAT WAS NOT IN THAT HANDBOOK. THEY --
17 THAT WAS RISPERDAL AND SERZONE. AND I'VE USED THE DOSES FOR
18 THOSE FROM THE 1996 P.D.R. WHICH WOULD HAVE BEEN AVAILABLE IN
19 THE FALL OF 1995.
20 Q. AND DID YOU USE THE GERIATRIC DOSES OUT OF THE P.D.R. FOR
21 THOSE TWO DRUGS?
22 A. YES, I DID.
23 Q. NOW, ON THIS WE HAVE -- WE HAVE SOME -- IT SAYS -- IT
24 SHOWS IT'S PILLS. ARE ALL OF THESE DRUGS GIVEN AS PILLS?
25 A. NOT NECESSARILY. SOME OF THEM CAN BE GIVEN AS
1 INJECTIONS.
2 Q. SO YOU'RE JUST SHOWING A DOSAGE AMOUNT?
3 A. I'M SHOWING A DOSAGE, NOT A ROUTE NECESSARILY.
4 Q. SOME OF THESE ARE -- MOST OF THEM ARE FILLED IN, BUT SOME
5 OF THEM ARE CIRCLED IN A -- IN COLOR BUT NOT FILLED IN.
6 WHAT'S THE DIFFERENCE BETWEEN THOSE TWO?
7 A. THE PILLS THAT ARE FILLED IN IN COLOR, THAT ARE SOLID IN
8 COLOR ARE THE MEDICATIONS THAT ACTUALLY WERE GIVEN. AND THE
9 MEDICATIONS -- AND THE HOLLOW ONES OR THE ONES THAT AREN'T
10 FILLED IN BUT ARE OUTLINED IN COLOR -- OR OUTLINED IN THE
11 APPROPRIATE COLOR FOR THAT MEDICATION, BUT THESE WERE ORDERED
12 AND NOT GIVEN FOR SOME REASON.
13 Q. I'LL SHOW YOU WHAT'S BEEN MARKED STATE'S EXHIBIT 2-H FOR
14 IDENTIFICATION. DO YOU RECOGNIZE THAT DOCUMENT?
15 A. YES, I DO.
16 Q. WHAT IS THAT?
17 A. IT'S A MEDICAL -- THAT'S THE GRAPH SHOWING THE
18 MEDICATIONS ORDERED AND ADMINISTERED FOR ELLEN ANDERSON.
19 MS. BARLOW: YOUR HONOR, I WOULD MOVE FOR ADMISSION
20 OF 2-H.
21 THE COURT: MR. BUGDEN?
22 MR. BUGDEN: NO OBJECTION, JUDGE.
23 THE COURT: 2-H IS RECEIVED.
24 Q. (BY MS. BARLOW) NOW, THIS SHOWS 10 MILLIGRAMS OF
25 MORPHINE EACH DAY ON THE 29TH AND THE 30TH AND IT HAS SOME
1 EMPTY LOZENGES OR PILLS ABOVE ON THE 29TH. WHAT DOES THAT
2 MEAN?
3 A. IT MEANS THAT ON THE 29TH, THOSE WERE ORDERED MEDICATIONS
4 ACCORDING TO THE MEDICAL ADMINISTRATION RECORD, AND THEY WERE
5 NOT GIVEN, THE -- THE HOLLOW ONES.
6 Q. HAD THE ORDER FOR THESE MEDICATIONS BEEN DISCONTINUED BY
7 THE 30TH?
8 A. THE PATIENT HAD -- HAD DIED BEFORE THE TIME THAT THEY
9 WOULD HAVE BEEN GIVEN ON THAT DAY.
10 Q. IS THAT WHY YOU DIDN'T LIST THEM ON THE --
11 A. YES.
12 Q. THANK YOU.
13 I NEXT SHOW YOU STATE'S EXHIBIT 6-F FOR IDENTIFICATION.
14 DO YOU RECOGNIZE THAT DOCUMENT?
15 A. THAT'S THE GRAPH SHOWING THE MEDICATION RECORD OF ENNIS
16 ALLDREDGE.
17 Q. AND DID YOU PREPARE IT IN A SIMILAR FASHION AS THE OTHER
18 TWO?
19 A. YES, I DID.
20 MS. BARLOW: WE'D MOVE FOR ADMISSION OF 6-F, YOUR
21 HONOR.
22 MR. BUGDEN: NO OBJECTION, JUDGE.
23 THE COURT: 6-F IS RECEIVED.
24 Q. (BY MS. BARLOW) IT APPEARS THAT SOME OF THESE ATIVAN ARE
25 MARKED -- ARE -- ARE CUT IN HALF OR CUT IN 3/4THS. AND WHY
1 WAS THAT?
2 A. THE DOSAGE OF ATIVAN CAN VARY, AND THE DOSE THAT WAS USED
3 AS THE COMMON DENOMINATOR IS TWO MILLIGRAMS. AND THAT SHOWS
4 THAT HALF -- HALF OF THAT DOSE WAS ORDERED AND GIVEN AND THAT
5 WOULD HAVE BEEN A ONE MILLIGRAM DOSE.
6 Q. MOVE THESE OVER CLOSER.
7 I SHOW YOU WHAT'S BEEN MARKED STATE'S EXHIBIT 5-E FOR
8 IDENTIFICATION. DO YOU RECOGNIZE THAT DOCUMENT?
9 A. THAT'S THE MEDICATION RECORD GRAPH OF LYDIA SMITH.
10 Q. AND DID YOU PREPARE IT IN THE SAME FASHION?
11 A. YES, I DID.
12 MS. BARLOW: WE WOULD MOVE FOR ADMISSION OF 5-E,
13 YOUR HONOR.
14 MR. BUGDEN: NO OBJECTION, JUDGE.
15 THE COURT: 5-E IS RECEIVED.
16 Q. (BY MS. BARLOW) I BELIEVE WE HAVE SOME DEPAKENE ADDED ON
17 HERE. WHAT IS DEPAKENE?
18 A. DEPAKENE IS A MEDICATION -- IT'S VALPROIC ACID. AND IT'S
19 A MEDICATION THAT CAN BE GIVEN FOR A VARIETY OF REASONS,
20 ANTI-SEIZURE, MOOD -- MOOD STABILIZATION, AMONG THE OTHERS.
21 THOSE ARE THE MAIN ONES.
22 Q. AND HOW IS IT ADMINISTERED?
23 A. WELL, DEPAKENE IS GENERALLY TAKEN ORALLY, AND I BELIEVE
24 IN THIS PATIENT WAS AN ELIXIR, WHICH IS A -- A LIQUID.
25 Q. AND THEN I'LL SHOW YOU WHAT'S BEEN MARKED STATE'S
1 EXHIBIT 3-H FOR IDENTIFICATION. DO YOU RECOGNIZE THAT
2 DOCUMENT?
3 A. THAT'S THE MEDICATION RECORD OF JUDITH LARSEN IN GRAPHIC
4 FORM.
5 Q. AND DID YOU PREPARE IT IN THE SAME FASHION?
6 A. YES, I DID.
7 MS. BARLOW: WE WOULD MOVE --
8 MR. BUGDEN: NO OBJECTION.
9 MS. BARLOW: THANK YOU.
10 THE COURT: 3-H IS RECEIVED. YOU CAN MOVE THAT
11 CHART OVER -- THAT EASEL OVER, PUT THAT IN THE MIDDLE.
12 MS. BARLOW: OKAY.
13 THE COURT: CAN YOU STILL SEE IT, LADIES AND
14 GENTLEMEN?
15 Q. (BY MS. BARLOW) MRS. LARSEN WAS THE ONE WHO WAS IN THE
16 HOSPITAL THE LONGEST; IS THAT CORRECT?
17 A. YES.
18 Q. I WANT TO POINT OUT -- OR ASK YOU ABOUT -- IT APPEARS
19 THAT SOME MORPHINE WAS ORDERED AND ADMINISTERED ON THE 25TH
20 AND 26TH OF DECEMBER, BUT THEN WHEN WE GET TO THE 30TH OF
21 DECEMBER, THERE ARE NUMBERS DOWN AT THE BOTTOM HERE. ON THE
22 30TH OF DECEMBER IT SAYS 15 MILLIGRAMS. WHAT WERE THOSE
23 NUMBERS AT THE BOTTOM?
24 A. THOSE NUMBERS AT THE BOTTOM SHOW THE AMOUNT OF MORPHINE
25 THAT WAS ORDERED ON A GIVEN DAY.
1 Q. WE OVER HERE HAVE 45 ON THE 2ND OF JANUARY. WHAT DOES
2 THAT INDICATE?
3 A. THAT INDICATES THAT A TOTAL OF BOTH THE ROUTINE AND THE
4 P.R.N. DRUG THAT WAS GIVEN, THE ORDER WAS 45.
5 Q. OKAY. AND THEN IT HAS BLUE AND THEN 35, AND THEN IT'S
6 WHITE WITH 10 MILLIGRAMS. WHAT DOES THAT MEAN?
7 A. THAT MEANS ACTUALLY A TOTAL OF 35 MILLIGRAMS OF MORPHINE
8 WAS ADMINISTERED TO THE PATIENT ON THAT DAY. AND THEN THE
9 TWO WHITE AREAS ARE TWO DOSES THAT WERE HELD BY A NURSE.
10 Q. AND THEN ON THE 30 -- OR 3RD OF JANUARY WE HAVE 140
11 MILLIGRAMS AT THE BOTTOM. WHAT DOES THAT MEAN?
12 A. 140 MILLIGRAMS WAS THE TOTAL NUMBER THAT WERE ORDERED FOR
13 THAT DAY.
14 Q. AND HOW MANY WERE ACTUALLY ADMINISTERED?
15 A. 130.
16 Q. MS. KAUFMAN, DO YOU HAVE ANY EXPERIENCE WITH PATIENTS AT
17 DIFFERENT LEVELS OF AWARENESS?
18 A. YES, I DO.
19 Q. AND WHAT'S THAT EXPERIENCE?
20 A. MY EXPERIENCE IS -- IS IN A COMBINATION OF BOTH CRITICAL
21 CARE AND MEDICAL-SURGICAL NURSING, AND AMONG THE PATIENTS IN
22 THOSE POPULATIONS ARE BOTH PEOPLE WITH PHYSICAL AND MENTAL
23 ILLNESSES. TYPICALLY THEY WOULD HAVE A PHYSICAL ILLNESS AS
24 WELL AS A MENTAL ILLNESS, IF THAT WAS THE CASE.
25 Q. AND WHEN WE'RE TALKING ABOUT LEVELS OF ACTIVITY OR
1 AWARENESS, WHAT ARE WE TALKING ABOUT?
2 A. TALKING ABOUT A WHOLE RANGE OF ACTIVITIES. BASICALLY A
3 PERSON CAN BE DESCRIBED TO HAVE A LEVEL OF AROUSAL OR
4 ACTIVITY, AN AWARENESS -- THOSE ARE ALL VERY CLOSELY
5 RELATED -- AND IT CAN RANGE FROM ANYTHING FROM BEING
6 ESSENTIALLY NONRESPONSIVE TO ANY TYPE OF STIMULI, TO A PERSON
7 WHO IS SPONTANEOUSLY EXTREMELY PHYSICALLY AGITATED. AND
8 THAT'S WITHOUT AN EXTERNAL STIMULI. THEY'RE SIMPLY VERY
9 AGITATED. SO THERE'S A WHOLE RANGE OF ACTIVITIES AND
10 AWARENESS.
11 Q. DID YOU -- DID YOU HAVE OCCASION TO REVIEW THE CHARTS OF
12 THESE FIVE PATIENTS FOR THEIR LEVEL OF ACTIVITY OR AWARENESS?
13 A. YES, I DID.
14 Q. DID YOU PREPARE ANY KIND OF -- OF CHART ABOUT THE RANGE
15 BETWEEN THEIR LEVEL OF ACTIVITY?
16 A. YES, I DID.
17 Q. AND DID YOU ASSIGN ANY VALUES IN THAT RANGE?
18 A. WELL, THE VALUES THAT WERE ASSIGNED WOULD HAVE BEEN THE
19 VALUES THAT WERE DESCRIBED BY THE NURSES. AND SO THE LEVELS
20 OF AWARENESS OR ACTIVITY WERE BASED ON ACTUAL VOCABULARY THAT
21 WAS DOCUMENTED BY THE NURSES FOR THE PATIENTS' ACTIVITY
22 DURING THE SHIFTS.
23 Q. DID YOU PUT ANY POINTS ON THIS RANGE?
24 A. NO, I DID NOT.
25 Q. DID YOU GRAPH THE RANGE OF ACTIVITY?
1 A. I DID AS A CONTINUUM OF ACTIVITY.
2 Q. AND WHAT -- I DON'T KNOW HOW TO PHRASE THIS. WHAT WOULD
3 YOU CONSIDER A MIDPOINT IN THEIR LEVEL OF ACTIVITY OR
4 AWARENESS?
5 A. WELL, FOR PATIENT -- WHAT I CONSIDERED A MIDPOINT WOULD
6 BE WHAT I CONSIDER NORMAL BEHAVIOR FOR A PSYCHIATRIC PATIENT
7 AND THAT WOULD INVOLVE A VARIETY OF THINGS, ACTUALLY. ARE
8 THEY AWAKE WHEN YOU EXPECT THEM TO BE AWAKE? ARE THEY ASLEEP
9 AT NIGHT? HOWEVER THE BEHAVIOR MIGHT NOT BE COOPERATIVE AND
10 IT MAY BE -- FOR A PERSON WITHOUT A PSYCHIATRIC DIAGNOSIS --
11 CONSIDERED TO BE MORE ACTIVE THAN USUAL. BUT MANY PEOPLE
12 WITH PSYCHIATRIC DIAGNOSIS HAVE VERBALIZATION BEYOND NORMAL
13 VERBALIZATION AND THEY ALSO MAY HAVE REPETITIVE PHYSICAL
14 MOVEMENTS. AND SO THOSE WOULD BE ALL FITTING WITHIN THAT
15 NORMAL RANGE.
16 Q. DID YOU -- DID YOU MAKE A DISTINCTION OR PUT ANY
17 DISTINCTIONS BETWEEN THAT NORMAL RANGE AND -- WELL, LET ME
18 ASK IT THIS WAY. HOW DID YOU DESCRIBE THAT RANGE OF
19 ACTIVITY?
20 A. OKAY. IF YOU -- IF YOU LOOKED AT IT GOING FROM THE AREA
21 OF LEAST ACTIVE AND LEAST AWARE -- LEAST ACTIVE CERTAINLY
22 BECAUSE ACTIVITY IS REALLY WHAT WE WERE LOOKING AT, LEAST
23 ACTIVE IS A PERSON WHO IS NOT RESPONSIVE TO PHYSICAL STIMULI
24 OF TOUCH OR PAIN. PAIN WOULD BE THE MOST EXTENSIVE STIMULUS.
25 Q. AND HOW -- HOW WOULD YOU ASSESS WHETHER THEY WERE
1 NONRESPONSIVE TO PAIN?
2 A. WELL, THERE'S A WIDE VARIETY OF WAYS TO ASSESS THAT. IN
3 THE CHARTS AS THEY WERE DOCUMENTED, IT APPEARED THAT THE
4 PAINFUL STIMULI WERE GENERALLY INJECTIONS, AND IN AT LEAST
5 ONE CASE CATHETERIZATION. THERE ARE -- THERE ARE SEVERAL
6 OTHER WAYS TO ELICIT PAIN IN A PATIENT AND I DIDN'T SEE THAT
7 THAT WAS ACTUALLY DOCUMENTED.
8 Q. WHAT WAS THE NEXT LEVEL OF ACTIVITY?
9 A. OKAY. A PERSON WHO'S NOT RESPONSIVE -- WHO IS RESPONSIVE
10 TO PAIN CAN BE RESPONSIVE IN TWO WAYS. THEY CAN EITHER HAVE
11 A PURPOSEFUL RESPONSE, AND THAT WOULD BE SLIGHTLY HIGHER THAN
12 A REFLEXIVE RESPONSE. SO IF YOU ELICITED PAINFUL STIMULI AND
13 YOU HAVE A REFLEXIVE RESPONSE, A PERSON IS GOING TO GO
14 BACK -- THEY'RE GOING TO HAVE A RESPONSE THAT'S JUST
15 AUTOMATIC. AND -- AND THAT'S CONSIDERED THE LOWEST LEVEL OF
16 RESPONSE TO PAIN.
17 THE NEXT LEVEL WOULD BE AN -- AN INTENDED RESPONSE WHERE
18 THEY'D WITHDRAW FROM THE PAIN AS -- AS MOST PEOPLE WOULD.
19 AND THEN IF THEY ARE A LITTLE BIT MORE AROUSABLE, A LITTLE
20 MORE ACTIVE, THEY'LL BE AT A LEVEL WHERE THEY MAY RESPOND
21 TO -- TO VERBAL STIMULI. NOW, AT THAT LEVEL VERBAL STIMULI
22 CAN BE TYPICALLY VERY LOUD VERBAL STIMULI. AND -- AND THE
23 PERSON WILL -- WILL RESPOND TO IT IN ONE WAY OR ANOTHER.
24 Q. WHAT WAS THE NEXT LEVEL UP?
25 A. THE NEXT LEVEL -- AND THIS WAS A LEVEL I HADN'T ACTUALLY
1 INTENDED TO PUT IN THERE, BUT DOZING -- NO, LETHARGY SEEMED
2 TO BE THE NEXT APPROPRIATE LEVEL. AND LETHARGY IS WHEN A
3 PERSON IS AROUSABLE, BUT WITH DIFFICULTY. OKAY? NOT -- NOT
4 THE AMOUNT OF -- OF STIMULI YOU'D NEED TO WAKE A PERSON UP
5 WHO -- WHO REALLY NEEDS TO BE SEVERELY STIMULATED, BUT A
6 PERSON WHO IS -- WHO IS, YOU KNOW, FAIRLY DROWSY AND NOT
7 EASILY AROUSED, THAT WOULD BE A LETHARGIC STATE.
8 Q. WHAT'S THE NEXT LEVEL?
9 A. NEXT ONE I -- I FELT WAS THERE WAS A DOZING STATE.
10 DOZING IS A PERSON WHO IS SLEEPING BUT EASILY AROUSABLE.
11 TEND TO BE SLEEPING DURING THE DAY, SLEEPING AT A TIME YOU
12 MIGHT NOT EXPECT THEM TO OTHERWISE. AND THAT WAS -- AND
13 THAT'S RIGHT BELOW THE NORMAL BEHAVIOR.
14 Q. AND ABOVE NORMAL BEHAVIOR, WHAT -- WHAT LEVEL?
15 A. THERE -- I DEVELOPED THREE LEVELS ABOVE -- THREE LEVELS
16 ABOVE NORMAL BEHAVIOR. AND THE FIRST ONE WOULD HAVE BEEN
17 ANXIOUS AND RESTLESS. AND THIS WOULD BE ANXIOUS AND RESTLESS
18 OVER A PERIOD OF TIME BECAUSE WE HAVE TO LOOK AT THESE THINGS
19 AS ACTUALLY TRENDS AND NOT ISOLATED, SPORADIC FIVE-MINUTE
20 EPISODES. THEY HAVE TO BE THINGS THAT LAST A LITTLE BIT
21 LONGER. AND ANXIETY AND RESTLESSNESS IS -- WAS -- WAS
22 READILY DOCUMENTED THROUGHOUT THE CHARTS.
23 Q. AND NEXT?
24 A. AND THE NEXT ONE WOULD HAVE BEEN VERBALLY AGITATED.
25 VERBALLY AGITATED IS WHEN THE PERSON IS CRYING OUT,
1 SCREAMING -- WITH THE ANXIETY AND RESTLESS YOU MAY HAVE SOME
2 VERBALIZATION, SOME MOANING, SOME -- SOME SLIGHT CRYING,
3 WHIMPERING, SOME LARGE AMOUNTS OF REPEATED WORDS. BUT ABOVE
4 THAT THEN YOU HAVE VERBALLY AGITATED. THIS IS A PERSON WHO'S
5 SCREAMING, SHOUTING, AND DOING IT A PROLONGED PERIOD OF TIME.
6 Q. AND ABOVE THAT?
7 A. AND ABOVE THAT WOULD BE PHYSICALLY AGITATED. NOW,
8 PHYSICALLY AGITATED CAN COME FROM TWO SOURCES. AND SOME
9 PATIENTS WERE PHYSICALLY AGITATED UPON STIMULATION. FOR
10 INSTANCE, A PATIENT WHO WAS CATHETERIZED WAS VERY AGITATED AT
11 THE POINT THEY WERE CATHETERIZED AND THEN VERY -- AND IN THE
12 VERY SAME RECORD, THE NURSE NOTED THAT THE PATIENT TOLERATED
13 THE CATHETERIZATION WELL. SO IT WAS MORE OF AN EXPECTED
14 PHYSICAL AGITATION RESPONSE.
15 AND THEN THE VERY HIGHEST RESPONSE OF ACTIVITY WOULD BE
16 SPONTANEOUSLY PHYSICALLY AGITATED. AND THESE ARE PEOPLE WHO
17 ARE COMBATIVE, WHO ARE STRIKING OUT, AND WHO ARE DOING THIS
18 ON AN EXTENDED AND SIGNIFICANT BASIS.
19 I DID CORRELATE BOTH THE NARRATIVE AND THE CHARTING BY
20 EXCEPTION BOTH ALL THROUGH THOSE COLUMNS WHEN I TRIED TO
21 FIGURE OUT WHAT THE TREND WOULD BE FOR THE GIVEN SHIFT IN
22 BEHAVIOR.
23 Q. DID YOU HAVE OCCASION TO GRAPH THOSE --
24 A. YES, I DID.
25 Q. -- IN ANY FASHION.
1 OKAY. THANK YOU.
2 MS. BARLOW: THAT IS ALL THAT I HAVE OF THIS
3 WITNESS, YOUR HONOR.
4 THE COURT: YOU MAY CROSS-EXAMINE.
5 MR. BUGDEN: YOUR HONOR, I NEED -- I APOLOGIZE, BUT
6 I THINK I NEED JUST FIVE MINUTES BEFORE I CAN CROSS-EXAMINE.
7 THE COURT: DO WE NEED TO TAKE A RECESS TO DO THAT?
8 MR. BUGDEN: I COULD PROBABLY DO IT RIGHT HERE IF
9 YOU -- IF WE COULD JUST SIT HERE FOR A FEW MINUTES.
10 THE COURT: OKAY. LADIES AND GENTLEMEN, WHY DON'T
11 WE JUST TAKE A STRETCH FOR A FEW MOMENTS.
12 (PAUSE IN PROCEEDINGS.)
13 CROSS-EXAMINATION
14 BY MR. BUGDEN:
15 Q. GOOD MORNING, MS. KAUFMAN. I'M WALTER BUGDEN AND I
16 REPRESENT DR. WEITZEL. I'D LIKE TO ASK YOU SOME QUESTIONS
17 FIRST ABOUT YOUR BACKGROUND, IF I COULD?
18 A. UH-HUH.
19 Q. YOU DON'T HAVE A BACKGROUND IN AGING, DO YOU? DEALING
20 WITH GERIATRIC PATIENTS?
21 A. I TAKE CARE OF MANY GERIATRIC PATIENTS.
22 Q. YOU TAKE CARE OF GERIATRIC PATIENTS NOW?
23 A. OH, YES. DEFINITELY.
24 Q. AND YOU CONSIDER YOURSELF HAVING SPECIALIZATION IN THE
25 CARE OF GERIATRIC PATIENTS THEN?
1 A. NO. I HAVE SPECIALIZATION IN SURGICAL NURSING, TAKING
2 CARE OF --
3 Q. YOUR SPECIALIZATION IS IN SURGICAL NURSING AND INTENSIVE
4 CARE; IS THAT RIGHT?
5 A. AND AMONG THOSE, PROBABLY BETTER THAN 50 PERCENT OF THE
6 PATIENTS ARE GERIATRIC PATIENTS.
7 Q. YOU DON'T HAVE A BACKGROUND IN CARING FOR DEMENTED
8 PATIENTS, DO YOU?
9 A. I HAVE TAKEN CARE OF SOME DEMENTED PATIENTS, AMONG THE
10 PATIENTS I'VE -- I'VE HAD IN THOSE UNITS, YES.
11 Q. WELL, RIGHT NOW ARE YOU TAKING CARE OF ANY DEMENTED
12 PATIENTS, MA'AM?
13 A. NOT THIS WEEK.
14 Q. DO YOU HAVE ANY BACKGROUND IN PROVIDING WHAT'S CALLED
15 END-OF-LIFE CARE, MA'AM?
16 A. LIMITED IN THAT CASE.
17 Q. AND MOST OF YOUR BACKGROUND REALLY THEN IS WITH SURGERY
18 AND WITH INTENSIVE CARE UNIT?
19 A. AND THE -- THE UNIT IS NOT -- THE SURGERY IS NOT IN THE
20 OPERATING ROOM. IT'S TAKING CARE OF SURGICAL PATIENTS.
21 Q. DO YOU CONSIDER, MA'AM, THE JOURNAL OF GERONTOLOGICAL
22 NURSING TO BE A LEARNED TREATISE FOR NURSES?
23 A. I THINK IT'S A RELIABLE TREATISE.
24 Q. AND HOW ABOUT GERIATRIC NURSING? DO YOU CONSIDER THAT TO
25 BE AN AUTHORITATIVE TEXT FOR NURSES?
1 A. I'M NOT AS FAMILIAR WITH THAT ONE, SO I REALLY CAN'T GIVE
2 YOU AN OPINION.
3 Q. AND THE JOURNAL OF AMERICAN GERIATRIC SOCIETY? ARE YOU
4 FAMILIAR WITH THAT?
5 A. I AM FAMILIAR WITH ITS EXISTENCE. I AM NOT WIDELY READ
6 IN IT.
7 Q. AND THE CLINICAL JOURNAL OF PAIN, IS THAT AN
8 AUTHORITATIVE TEXT FOR NURSES?
9 A. I'M NOT FAMILIAR WITH THAT JOURNAL.
10 Q. AND CLINICS IN GERIATRIC MEDICINE, ARE YOU FAMILIAR WITH
11 THAT?
12 A. YES, I AM.
13 Q. DO YOU CONSIDER THAT TO BE A LEARNED TREATISE?
14 A. YES, I DO.
15 MR. BUGDEN: COULD WE -- WE HAVE THE FIRST SLIDE,
16 PLEASE?
17 Q. (BY MR. BUGDEN) THIS IS A CASE AS I'M SURE YOU KNOW
18 ABOUT --
19 MS. BARLOW: YOUR HONOR, I'M GOING TO OBJECT. I
20 THINK THIS IS BEYOND THE SCOPE OF DIRECT EXAMINATION.
21 THE COURT: IT MAYBE SOMEWHAT BEYOND THE SCOPE, BUT
22 IN THE INTEREST OF TIME I'M GOING TO ALLOW COUNSEL TO GO
23 AHEAD.
24 Q. (BY MR. BUGDEN) I'VE JUST ASKED YOU WHETHER OR NOT YOU
25 CONSIDERED VARIOUS JOURNALS SCHOLARLY JOURNALS OR LEARNED
1 TREATISES FOR NURSING. AND I'D LIKE TO ASK YOU NOW, IF I
2 COULD, HAVE YOU READ COMPLEXITIES OF PAIN ASSESSMENT IN THE
3 ELDERLY CLINICAL CONSIDERATIONS BY KEELA HERR? IS THAT A --
4 AN ARTICLE YOU'VE READ, MA'AM?
5 A. NOT RECENTLY.
6 Q. WELL EVER?
7 A. I'M NOT CERTAIN THAT I HAVE READ IT. IT'S FROM 1991.
8 Q. OKAY. AND HAVE YOU READ NIGHT LEG PAIN IN THE ELDERLY BY
9 KEELA HERR, A 1992 PUBLICATION?
10 A. NO, I HAVE NOT.
11 Q. HAVE YOU READ?
12 MR. BUGDEN: IF WE COULD MOVE TO THE NEXT SLIDE?
13 Q. (BY MR. BUGDEN) HAVE YOU READ DEPRESSION AND THE
14 EXPERIENCE OF CHRONIC BACK PAIN, A STUDY OF RELATED VARIABLES
15 AND AGE DIFFERENCES IN THE CLINICAL JOURNAL OF PAIN BY KEELA
16 HERR?
17 A. NO, I HAVE NOT.
18 MR. BUGDEN: COULD WE HAVE THE NEXT SLIDE?
19 Q. (BY MR. BUGDEN) HAVE YOU READ THE EVALUATION OF THE
20 FACES PAIN SCALE FOR USES WITH THE ELDERLY IN THE CLINICAL
21 JOURNAL OF PAIN BY KEELA HERR IN 1998?
22 A. I HAVE NOT READ ABOUT THAT SCALE IN THAT PARTICULAR
23 JOURNAL.
24 Q. HAVE YOU READ THE CLINICAL PRACTICE GUIDELINES, THE
25 MANAGEMENT OF CHRONIC PAIN IN OLDER PERSONS IN THE JOURNAL OF
1 AMERICAN GERIATRIC SOCIETY, AGAIN BY KEELA HERR?
2 A. NO, I HAVE NOT.
3 Q. AND LET ME TURN YOUR ATTENTION JUST TO ME FOR JUST A
4 SECOND AND THEN WE'LL TURN TO ANOTHER SLIDE.
5 HOW ABOUT BOOK? HAVE YOU READ BOOKS ON THE ASSESSMENT
6 OF PAIN IN THE DEMENTED POPULATION, MA'AM?
7 A. I HAVE READ ARTICLES, NOT BOOKS.
8 Q. ARE YOU --
9 MR. BUGDEN: COULD WE SEE THE NEXT SLIDE ON BOOKS?
10 BACK ONE.
11 Q. (BY MR. BUGDEN) ARE YOU FAMILIAR, MS. KAUFMAN, WITH A
12 BOOK CALLED GERIATRICS AT YOUR FINGERTIPS BY KEELA HERR?
13 A. NO, I'M NOT.
14 Q. HOW ABOUT PERSISTENT PAIN IN OLDER ADULTS, AN
15 INTERDISCIPLINARY GUIDE FOR TREATMENT, AGAIN BY KEELA HERR?
16 A. NO, I HAVE NOT.
17 Q. HAVE YOU READ THAT BOOK?
18 A. NO.
19 Q. HAVE YOU WRITTEN ANY ARTICLES THAT ARE WHAT ARE CALLED
20 PEER REVIEW ARTICLES, ARTICLES THAT ARE SUBMITTED TO AN
21 AUDIENCE OF YOUR FELLOW NURSES ON THE ISSUES OF RECOGNITION
22 OF PAIN IN THE ELDERLY DEMENTED POPULATION, MA'AM?
23 A. NO, I HAVE NOT.
24 Q. AND AM I RIGHT THAT THE ONLY -- ONLY THING THAT YOU'VE
25 WRITTEN DEALING WITH THE AREA OF RECOGNITION -- WELL, DEALING
1 WITH DEMENTED POPULATION ARE TWO POEMS? YOU'VE WRITTEN TWO
2 POEMS THAT DEAL WITH ALZHEIMERS?
3 A. YES, I HAVE, AS A MATTER OF FACT.
4 Q. OKAY.
5 MR. BUGDEN: NOW, COULD WE LOOK AT THE ENNIS
6 ALLDREDGE SLIDE FOR JUST A MOMENT, PLEASE?
7 THE COURT: THIS IS EXHIBIT?
8 MR. BUGDEN: LET'S SEE, JUDGE. IT WAS JUST
9 RECEIVED.
10 THE COURT: THAT WOULD BE 6-F.
11 MR. BUGDEN: THANK YOU, JUDGE. 6-F.
12 Q. (BY MR. BUGDEN) NOW, YOU'VE TOLD US THAT YOU DID SOME
13 SORT OF A CORRELATION BETWEEN LEVELS OF AROUSAL OR LEVELS OF
14 ALERTNESS THROUGHOUT THE -- I GUESS THE HOSPITAL STAY OF THE
15 DIFFERENT PATIENTS; IS THAT RIGHT?
16 A. YES, I DID.
17 Q. ONE OF THE OTHER THINGS THAT YOU'VE DONE THAT'S ON THE
18 CHART FOR THE -- OR ON THE SCREEN FOR THE JURY IS THAT YOU
19 DID PREPARE THE CHARTS THAT CORRESPOND TO EACH OF THE
20 PATIENTS. AND IN THAT CHART, BASICALLY, WHAT YOU ATTEMPTED
21 TO DO WAS TO DEPICT IN THIS CHART FORM THE DIFFERENT
22 MEDICATIONS THAT WERE ACTUALLY ADMINISTERED, AT LEAST THE
23 ONES THAT ARE FILLED IN WERE THE ONES THAT WERE ADMINISTERED
24 ON DIFFERENT DAYS FOR THE DIFFERENT PATIENTS, AM I RIGHT?
25 A. YES, SIR.
1 Q. DID YOU EVER DO A CORRELATION, FOR EXAMPLE, BETWEEN
2 LEVELS OF AGITATION OR LEVELS OF PAIN, FOR EXAMPLE --
3 LET'S -- LET'S STAY WITH AGITATION. DID YOU TRY TO CORRELATE
4 THE AMOUNT OF AGITATION OR THE COMBATIVENESS OR THE
5 UNCONTROLLABILITY OF THE PATIENT TO, FOR EXAMPLE, WITH
6 MR. ALLDREDGE ON JANUARY 10TH IT APPEARS THAT HE RECEIVED A
7 NUMBER OF PILLS OF HALDOL. DO YOU SEE THAT, MA'AM, ON THE
8 CHART?
9 A. YES, I DO. UH-HUH.
10 Q. AND IT LOOKS, AS WE JUST LOOK AT IT, LET'S SEE, 1, 2, 3,
11 4, 5, 6, 7, 8, 9, 10 PILLS THAT DAY OF HALDOL. AND HALDOL,
12 IS THAT AN ANTIPSYCHOTIC?
13 A. YES, IT IS.
14 Q. AND THAT WOULD BE SOMETHING THAT WOULD BE USED TO CONTROL
15 COMBATIVENESS; IS THAT RIGHT?
16 A. YES, IT WOULD.
17 Q. AND MEDICATIONS ARE PRESCRIBED TO TRY TO CONTROL
18 SYMPTOMS. AM I RIGHT, MA'AM?
19 A. YES, SIR.
20 Q. DID YOU LOOK, FOR EXAMPLE, AT THE MEDICATIONS THAT
21 MR. ALLDREDGE WAS ON OR THE BEHAVIORS THAT HE WAS EXHIBITING
22 JUST IMMEDIATELY BEFORE HIS ADMISSION TO THE GEROPSYCHIATRIC
23 UNIT? DID YOU EVER DO THAT?
24 A. DID I LOOK AT -- I'M --
25 Q. DID YOU LOOK AT THE NURSING HOME RECORDS, FOR EXAMPLE, SO
1 THAT YOU COULD SEE WHAT SORT OF MEDICATIONS AND WHAT LEVEL OF
2 COMBATIVENESS THE PATIENT HAD OR HAD DISPLAYED IMMEDIATELY
3 BEFORE HIS TRANSFER TO THE HOSPITAL?
4 A. NO. THE ONLY RECORDS THAT I RELIED WERE THE RECORDS IN
5 THE HOSPITAL.
6 Q. WELL SO, FOR EXAMPLE, WERE AWARE THAT MR. ALLDREDGE HAD
7 INJURED OTHER PATIENTS AT THE NURSING HOME JUST SHORTLY
8 BEFORE HE WAS TRANSFERRED TO THE GEROPSYCHIATRIC UNIT?
9 A. NOT ACTUALLY INJURED. I WASN'T AWARE OF THAT, NO.
10 Q. DID YOU KNOW THAT HE'D THROWN A WHEELCHAIR AT AN ELDERLY
11 PATIENT AND BROKEN -- BROKEN HER HIP?
12 A. NO, I WAS NOT AWARE OF THAT. I DID NOT REVIEW THOSE
13 RECORDS.
14 Q. OKAY.
15 MR. BUGDEN: COULD WE SEE NURSING HOME RECORD FOR
16 MR. ALLDREDGE?
17 2-A. IT'S EXHIBIT 2-A, JUDGE. AND IT'S PAGE 1986.
18 MS. BARLOW: YOUR HONOR, I'M GOING TO OBJECT. SHE'S
19 INDICATED SHE HASN'T REVIEWED THESE RECORDS AND IT HAS
20 NOTHING TO DO WITH THE AMOUNTS OF MEDICATIONS GIVEN AT THE
21 HOSPITAL.
22 THE COURT: WHAT IS THE RELEVANCY, MR. BUGDEN?
23 MR. BUGDEN: I THINK IT'S RELEVANT, YOUR HONOR, SO
24 THAT THE JURY DOES HAVE SOME UNDERSTANDING ABOUT THE LEVEL OF
25 AROUSAL AND THE MEDICATIONS THAT THE PATIENT WAS ON THE DAY
1 OR TWO BEFORE THE PATIENT ARRIVED SO THAT THE JURY CAN
2 UNDERSTAND THAT THE PATIENT DIDN'T START FROM GROUND ZERO ON
3 MEDICATIONS AND THAT THERE WERE BEHAVIORS THAT DR. WEITZEL
4 AND THE NURSING STAFF AT THE GEROPSYCH UNIT WERE TRYING TO
5 CONTROL. AND I'M GOING TO RELATE IT AGAIN TO JANUARY 10TH
6 WHERE WE'VE SEEN A TALL COLUMN OF HALDOL.
7 THE COURT: OVERRULE THE OBJECTION. MAY HAVE SOME
8 RELEVANCE TO THE JURY. GO AHEAD.
9 MR. BUGDEN: IS THERE A BLOWUP ON THAT PAGE?
10 Q. (BY MR. BUGDEN) IT'S PROBABLY HARD FOR YOU TO SEE,
11 MA'AM.
12 A. WELL, IT'S NOT EASY.
13 Q. BUT LET'S JUST READ TOGETHER ON 1 -- ON 1/8. THE 1'S OFF
14 THE PAGE, BUT IT'S AT THE VERY TIPITY TOP. DOCTOR CALLED,
15 INCREASED -- DOES THE ARROW MEAN INCREASED?
16 A. YES, IT DOES. UH-HUH.
17 Q. INCREASED RISPERDAL TO -- WHAT IS IT? ONE MILLIGRAM? IS
18 THAT --
19 A. THAT'S WHAT IT LOOKS LIKE, YEAH?
20 Q. B.I.D. WHAT'S B.I.D., PLEASE?
21 A. TWICE A DAY.
22 Q. THANK YOU. PATIENT VERY RESTLESS. HURTING STAFF AND
23 RESIDENTS.
24 THEN DOWN A LITTLE BIT LATER, HALF AN HOUR LATER, IF I
25 READ IT CORRECTLY, HITTING THREE RESIDENTS.
1 DO YOU SEE THAT, MA'AM?
2 A. YES, I DO.
3 Q. AND THEN A LITTLE BIT LATER, 1545, DR. CUNNINGHAM
4 RETURNED THE CALL AND ORDERED THREE MORE MILLIGRAMS OF ATIVAN
5 NOW. A NOW ORDER MEANS TO RESPOND TO THE SITUATION; IS THAT
6 RIGHT?
7 A. YES, IT DOES.
8 Q. SO IN THIS CASE WE CAN INTERPRET THE CHART TO MEAN THAT
9 CUNNINGHAM GOT THE REPORT THAT THE ONE MILLIGRAM WASN'T -- HE
10 WASN'T RESPONDING TO ONE MILLIGRAM, HE WAS HURTING RESIDENTS,
11 AND SO HE ORDERED 3 MILLIGRAMS RIGHT NOW -- WELL, IT SAYS
12 NOW.
13 A. WELL, SINCE I CAN'T SEE THE FIRST MILLIGRAM, IT'S -- IT'S
14 DIFFICULT FOR ME TO ANSWER THAT --
15 Q. WELL, DIDN'T WE JUST READ IT RIGHT HERE?
16 A. THAT'S RISPERDAL. IT'S NOT THE SAME THING.
17 Q. OH, I'M SORRY. SO HE ADDED ANOTHER --
18 A. HE ADDED 3 -- HE ADDED 3 MILLIGRAMS OF ATIVAN,
19 APPARENTLY.
20 Q. THANK YOU. SO HE'S ON RISPERDAL NOW AND THEN HE HAD --
21 THEN THE DOCTOR DECIDED THAT THE RIGHT THING TO DO WAS TO
22 ALSO ADD 3 MILLIGRAMS OF ATIVAN. AM I RIGHT?
23 A. APPARENTLY, YES.
24 Q. AND THEN AT 1700 HOURS, STILL RESTLESS. DR. CUNNINGHAM
25 CALLED AND ORDERED ANOTHER 3 MILLIGRAM OF ATIVAN.
1 A. UH-HUH.
2 Q. IS THAT RIGHT?
3 A. YES.
4 Q. SO HE -- DR. CUNNINGHAM TRYING TO RESPOND TO THE
5 SITUATION, HE'S REALLY GIVING HIM SIGNIFICANT LEVELS OF
6 ATIVAN AT THAT POINT. AM I RIGHT?
7 A. YES.
8 MR. BUGDEN: CAN WE TURN TO THE ADMINISTRATION LOG?
9 IS THERE A BLOWUP OF THAT?
10 THE COURT: WHAT EXHIBIT IS THIS?
11 MR. BUGDEN: IT'S THE -- IT'S THE SAME EXHIBIT, AND
12 IT'S NOW ON PAGE -- STILL 2-A, JUDGE, AND IT'S NOW NURSING
13 HOME-139.
14 THE COURT: OKAY.
15 Q. (BY MR. BUGDEN) SO LET'S JUST LOOK AT 1/9, THAT'S THE
16 DAY BEFORE WE GO TO THE HOSPITAL. HOW MUCH ATIVAN THEN DID
17 THE MAN RECEIVE?
18 A. 1/9, LOOKS LIKE 12 MILLIGRAMS TO ME.
19 Q. AND IT'S ALL BECAUSE OF ALL THIS YOU CAN SEE OVER HERE --
20 A. UH-HUH.
21 Q. -- ALTHOUGH IT'S NOT PERFECTLY PRECISELY FOCUSED, BUT IT
22 SAYS CRYING AND COMBATIVE, HITTING, HITTING, SPITTING.
23 A. UH-HUH. YES.
24 Q. WILD BEHAVIORS, IN OTHER WORDS; IS THAT RIGHT?
25 A. ABSOLUTELY.
1 Q. SO THE PATIENT -- NOW WE'RE GOING TO GO BACK TO YOUR
2 SLIDE, IF WE COULD.
3 MR. BUGDEN: I'M SORRY. BACK TO THE COLOR CHART.
4 MS. ISAACSON: OH, SORRY.
5 Q. (BY MR. BUGDEN) SO ALTHOUGH MR. ALLDREDGE RECEIVED A
6 SIGNIFICANT AMOUNT OF HALDOL, YOU CAN SEE THAT WHEN HE CAME
7 TO THE UNIT, HE WAS EXTREMELY AGITATED. DO YOU SEE THAT,
8 MA'AM?
9 A. DEFINITELY.
10 MR. BUGDEN: AND THEN COULD WE SEE -- SORRY TO HAVE
11 YOU MOVE AROUND.
12 MS. ISAACSON: IT'S OKAY.
13 MR. BUGDEN: EXHIBIT 2-C, AND IT'S MEDICAL-60B AND
14 61B. WE'LL LOOK AT TWO SLIDES. IS THERE A BLOWUP?
15 Q. (BY MR. BUGDEN) NOW, THIS IS THE SAME DAY.
16 A. UH-HUH.
17 Q. I'LL JUST TELL YOU.
18 A. OKAY.
19 Q. PATIENT AGITATED, TRYING TO HIT. SQUEEZE HANDS OF
20 CAREGIVERS. TRYING TO BITE. YELLING INCOMPREHENSIVELY.
21 PATIENT MEDICATED. T. MEANS WITH? AM I RIGHT?
22 A. THAT'S A C. ACTUALLY WITH A LINE OVER IT, BUT THAT'S
23 WITH. RIGHT.
24 Q. OH, OKAY. BUT IT MEANS WITH.
25 A. YEAH. UH-HUH.
1 Q. HALDOL 10-MILLIGRAMS I.M., AND THE ATIVAN. RESULTS ARE
2 PENDING. IS THE RESULT PENDING MEAN THAT THE NURSE IS GOING
3 TO LOOK TO SEE IF THE PATIENT RESPONDS FAVORABLY?
4 A. YES, THAT'S WHAT IT MEANS.
5 Q. AND THEN --
6 THE COURT: ARE WE TALKING ABOUT ENNIS ALLDREDGE
7 HERE?
8 MR. BUGDEN: YES, SIR.
9 THE COURT: I THINK THAT IS EXHIBIT 6-A AND NOT 2-A.
10 MR. BUGDEN: OKAY.
11 THE COURT: SO WHERE WE'VE BEEN REFERRING TO --
12 MR. BUGDEN: NO. NO. I'M SORRY, JUDGE. I -- I --
13 THIS -- THIS RIGHT NOW, 2-C ARE THE DAVIS HOSPITAL
14 GEROPSYCHIATRIC --
15 THE COURT: I THINK THAT'S ELLEN ANDERSON, I THINK.
16 MR. BUGDEN: OKAY. SORRY.
17 MS. ISAACSON: I COULD BE WRONG. MY FAULT.
18 MR. BUGDEN: I GAVE YOU THE WRONG NUMBER.
19 THE COURT: IT IS 6 -- RATHER THAN 2-C IT IS 6-A,
20 AND IT WOULD BE THE CORRESPONDING PAGES, BUT IT'S JUST A
21 DIFFERENT EXHIBIT. SO IT IS EXHIBIT -- ACTUALLY IT'S 6-A
22 THAT WE'VE BEEN TALKING ABOUT, AND 6-C, IF IT'S ENNIS
23 ALLDREDGE.
24 MR. BUGDEN: I AM TALKING ABOUT ENNIS. THANK YOU,
25 JUDGE.
1 NOW, COULD WE SEE THE SLIDE ON MR. ALLDREDGE AGAIN? I'M
2 SORRY. I DON'T MEAN TO JUMP BACK. MAYBE -- YOU KNOW, DON'T
3 JUDGE BACK. HERE'S WHAT I'M GOING TO DO.
4 THE COURT: THAT IS 6-F?
5 MR. BUGDEN: NOW I AM GOING TO USE 6-F. AND I'M
6 GOING TO MOVE THIS CLOSER TO THE JURY.
7 Q. (BY MR. BUGDEN) DO YOU HAVE A SMALLER VERSION --
8 A. YES, I DO.
9 Q. -- THAT YOU CAN LOOK AT?
10 A. YES, I DO.
11 Q. PERFECT.
12 THE COURT: YOU MAY NEED TO TURN THAT A LITTLE BIT.
13 CAN YOU SEE THAT OKAY?
14 MR. BUGDEN: SORRY.
15 THE COURT: THAT'S BETTER.
16 MR. BUGDEN: OKAY.
17 THE COURT: MS. BARLOW, IF YOU NEED TO MOVE OVER
18 YOU'RE WELCOME TO.
19 MS. BARLOW: I -- I HAVE A SMALLER VERSION AS WELL.
20 THANK YOU.
21 THE COURT: OKAY.
22 MR. BUGDEN: SORRY, JUDGE.
23 THE COURT: OKAY.
24 Q. (BY MR. BUGDEN) NOW, WHAT I WANT TO DO IS I WANT TO JUST
25 CORRELATE -- IF WE CAN -- TOGETHER JANUARY 12TH WHERE, AGAIN,
1 THERE'S A NUMBER OF PILLS OF HALDOL THAT WERE GIVEN.
2 A. UH-HUH.
3 Q. AND YOU HAVE LOOKED AT THE MEDICAL RECORDS.
4 A. YES.
5 Q. THE GEROPSYCHIATRIC MEDICAL RECORDS, AM I RIGHT?
6 A. YES, SIR.
7 Q. OKAY. COULD WE LOOK AT SLIDE 18, THAT'S MR. ALLDREDGE'S
8 RECORDS THAT I THINK THE JUDGE JUST CORRECTED ME ARE 6-A, BUT
9 IT'S MED PAGE-71B THAT I WANT TO LOOK AT.
10 MR. BUGDEN: ARE WE THERE NOW? IS THERE A BLOWUP?
11 Q. (BY MR. BUGDEN) SO, AGAIN, THIS IS A DAY THE PATIENT
12 RECEIVED A LOT OF HALDOL, BUT THE NURSES HAVE CHARTED, AS
13 YOU'VE DESCRIBED -- LET'S TALK ABOUT THAT FOR JUST A SECOND.
14 A. UH-HUH.
15 Q. THE NURSES ARE TRYING TO DESCRIBE WITH SOME DETAIL THE
16 BEHAVIORS THAT THEY'RE OBSERVING; IS THAT RIGHT?
17 A. THAT'S CORRECT. UH-HUH.
18 Q. AND IT'S CERTAINLY TRUE IN THE -- IN THE BUSINESS OF
19 CARING FOR PATIENTS THAT DOCTORS RELY ON THE CHARTED NOTES OF
20 NURSES; ISN'T THAT RIGHT?
21 A. THAT'S CORRECT.
22 Q. DOCTORS CAN'T BE AT THE HOSPITAL 24-7 SO THEIR EYES AND
23 EARS 24-7 ARE THE NURSES THAT ARE THERE AND ABLE TO CHART THE
24 NOTES; IS THAT RIGHT?
25 A. CORRECT.
1 Q. AND SO ON THIS OCCASION, ON JANUARY 12TH OR 13, ONE OF
2 THE NURSES CHARTED THE PATIENT HAS BEEN AGITATED, RESTLESS --
3 I'M NOT SURE WHAT THAT WORD IS.
4 A. REMOVING, I THINK.
5 Q. REMOVING DIAPER. MOVED DINNER --
6 A. REMOVED --
7 Q. DINNER -- SOMETHING MONITOR?
8 A. NO. REMOVED FINGER MONITOR.
9 Q. OH. LET'S TALK -- SO THE JURY UNDERSTANDS, THAT'S JUST A
10 LITTLE CUFF OR JUST A LITTLE SOMETHING THAT GOES ON THE
11 FINGER; IS THAT RIGHT?
12 A. YEAH. IT'S A LITTLE SMOOTH, LIGHTWEIGHT CLAMP THAT YOU
13 MEASURE OXYGEN SATURATION WITH.
14 Q. SO THE PATIENT WAS SO AGITATED THAT HE WAS TAKING OFF HIS
15 DIAPER AND HE WAS TAKING OFF THE FINGER MONITOR, THE ITEMS
16 THAT WOULD BE USED TO HELP EVALUATE THE PATIENTS VITAL SIGNS.
17 A. WELL, ONE -- ONE. RIGHT.
18 Q. ONE VITAL SIGN.
19 A. YEAH. UH-HUH.
20 Q. AND THEN THE NURSE COULDN'T PUT IT BACK ON. UNABLE TO
21 REPLACE; IS THAT RIGHT?
22 A. UH-HUH.
23 Q. AND I THINK THAT THERE'S ONE OTHER SLIDE FROM THAT DAY,
24 ONE OTHER NURSING NOTE?
25 MR. BUGDEN: IS THERE A BLOWUP?
1 Q. (BY MR. BUGDEN) THE PATIENT WAS RELEASED FROM POSEY
2 RESTRAINT FOR -- I'M NOT SURE WHAT THAT IS.
3 A. CIRCULATION CHECK.
4 Q. OKAY. LET'S STOP. I THINK THE JURY UNDERSTANDS, BUT THE
5 POSEY RESTRAINT MEANS THAT THE PATIENT HAS TO BE TIED DOWN AT
6 THAT POINT.
7 A. ALTHOUGH NOT BY HIS ARMS ACTUALLY.
8 Q. OKAY. DESCRIBE IT FOR US.
9 A. A POSEY RESTRAINT IS LIKE A VEST. IF YOU HAD A VEST THAT
10 CROSSED OVER, AND IT COULD BE -- THAT'S ONE STYLE. BUT IT'S
11 A VEST RESTRAINT THAT ACTUALLY HOLDS THE TOP PART OF THE
12 PATIENT'S BODY TO THE BED SO THEY CAN'T CLIMB OUT OF BED.
13 Q. SO THIS PATIENT WAS RECEIVING THE HALDOL AND STILL HAD TO
14 BE IN THE POSEY RESTRAINT.
15 A. YES.
16 Q. OKAY. SO YOU SAID THAT HE -- HE WAS REMOVING THE -- OR
17 THEY TOOK THE POSEY RESTRAINT OFF TO TRY TO DO A CIRCULATION
18 CHECK. OFFERED O2, PERI CARE. IS THAT DENTAL CARE?
19 A. NO.
20 Q. PERI CARE?
21 A. PERI CARE WOULD BE CARE OF THE PERINEAL AREA, THE
22 GENITALS.
23 Q. OH. THANK YOU. PATIENT AGITATED WHEN CARE IS DONE.
24 PINCHING, HITTING, NOT RESPONDING TO REDIRECTION.
25 REDIRECTION IS WHEN YOU TRY TO BE SOOTH -- I SUPPOSE
1 SOOTHING AND COMFORTING VERBALLY AS YOU AS A NURSE CAN BE TO
2 TRY TO MAKE THE PATIENT BE COMFORTABLE AND TRY TO EXPLAIN
3 WHAT YOU'RE DOING? AM I ABOUT RIGHT?
4 A. TRY TO EXPLAIN WHAT YOU'RE DOING AND ENCOURAGE THEM NOT
5 TO DO WHATEVER IT IS THEY'RE DOING THAT YOU DON'T WANT THEM
6 TO DO.
7 Q. AND SO THE TALKING APPROACH DIDN'T WORK?
8 A. UH-HUH.
9 Q. AM I RIGHT?
10 A. THAT WOULD BE WHAT THAT'S SAYING.
11 Q. SO THE RESTRAINTS HAD TO BE REAPPLIED FOR SAFETY AS THE
12 PATIENT TRIES TO GET UP WITH ASSIST?
13 A. WITHOUT ASSISTANCE. AN S. WITH A LINE OVER IT IS
14 WITHOUT.
15 Q. THANKS. THANK YOU FOR YOUR HELP READING THAT. OKAY.
16 MR. BUGDEN: NOW I'M GOING TO TALK ABOUT 4-E, JUDGE.
17 MARY CRANE. CAN EVERYBODY SEE THAT?
18 Q. (BY MR. BUGDEN) OKAY. COULD YOU TURN TO YOUR MARY
19 CRANE?
20 A. YES, I HAVE. UH-HUH.
21 Q. THANK YOU. LET'S LOOK AT DECEMBER 31ST. I'M GOING TO
22 ASK YOU A COUPLE OF QUESTIONS ABOUT THAT. ON DECEMBER 31ST
23 MRS. CRANE RECEIVED A NUMBER OF PILLS OF BOTH RISPERDAL,
24 SERZONE, TRAZODONE AND ATIVAN, PLUS SHE HAD THE DURAGESIC
25 PATCH.
1 A. THAT'S CORRECT.
2 Q. DURAGESIC I THINK THE JURY UNDERSTANDS IS A THREE-DAY
3 PATCH THAT RE -- RELEASES MORPHINE CONSTANTLY?
4 A. WELL, IT ACTUALLY RELEASES FENTANYL.
5 Q. FENTANYL. THANK YOU. THANK YOU FOR YOUR CLARIFICATION.
6 THE OTHER DRUGS ARE ALL BASICALLY ANTIPSYCHOTICS,
7 PSYCHOTROPICS?
8 A. BASICALLY PSYCHOTROPICS OF ONE TYPE OR ANOTHER.
9 Q. OKAY. SO JANUARY 31ST -- OR I'M SORRY, DECEMBER 31ST SHE
10 RECEIVES A FAIR AMOUNT OF MEDICATION.
11 MR. BUGDEN: COULD WE LOOK AT 4-D, I THINK IS THE
12 EXHIBIT NUMBER -- OR I'M SORRY. 4-B I THINK IS THE EXHIBIT
13 NUMBER, JUDGE. I'M TRYING TO REFER TO --
14 THE COURT: IT IS THE EXHIBIT NUMBER.
15 MR. BUGDEN: OKAY. THANK YOU.
16 THE COURT: OF THE HOSPITAL RECORD.
17 MR. BUGDEN: THANK YOU. AND MED PAGE-312 IS WHAT
18 I'M NOW TALKING ABOUT. AND WAIT. GO BACK JUST SO THAT WE
19 CAN ALL SEE I'M ON THE RIGHT PAGE.
20 Q. (BY MR. BUGDEN) WE ARE TALKING ABOUT DECEMBER 31ST.
21 A. OKAY.
22 Q. AND FOR YOU, MA'AM -- WELL, I THINK IT'S EASIEST IF I CAN
23 HAVE YOU HELP ME READ THE WRITING AND THEN --
24 A. OKAY.
25 THE COURT: YOU'RE WELCOME TO MOVE YOUR CHAIR OVER
1 THERE, IF YOU'D LIKE, A LITTLE FURTHER.
2 THE WITNESS: WELL, IF IT'S BIG I CAN SEE IT.
3 THE COURT: OKAY. WHATEVER YOU NEED TO DO,
4 MS. KAUFMAN.
5 Q. (BY MR. BUGDEN) CAN YOU -- CAN YOU READ IT WITH ME?
6 A. YEAH. UH-HUH.
7 Q. FREE -- THE FREE TEXT?
8 A. FREE TEXT.
9 Q. THE PATIENT WAS INCREASINGLY AGITATED?
10 A. UH-HUH. FROM --
11 Q. FROM 1900 -- THAT'S SEVEN O'CLOCK AT NIGHT; IS THAT
12 RIGHT?
13 A. RIGHT.
14 Q. ON. SCREAMING -- SO LET'S JUST STOP THERE. ON YOUR
15 CHART OR THE WAY YOU TRY TO GRAPH SOMETHING THAT THE JURY
16 HASN'T SEEN BUT YOU'VE TOLD US ABOUT, I SUPPOSE ON YOUR --
17 YOUR ARBITRARY SYSTEM THAT YOU CAME UP WITH, THIS WOULD BE AT
18 THE HIGHEST LEVEL OF AROUSAL SINCE SHE'S SCREAMING?
19 A. WELL, NO. IT WOULD BE -- SCREAMING WOULD BE AT THE --
20 THE NEXT MAJOR LEVEL WHICH WOULD BE VERBALLY AGITATED.
21 Q. THIS IS JUST SOME GRADATION SCALE THAT YOU CREATED. WE
22 HAVEN'T SEEN IT, BUT WE'VE HEARD ABOUT IT. YOU KNOW, WHERE
23 YOU HAVE FOUR LEVELS OF SORT OF DROWSINESS OR LETHARGY THAT
24 ARE BELOW WHAT YOU CALL THE BASELINE AND THEN THERE ARE THREE
25 LEVELS ABOVE THE BASELINE THAT CORRESPOND TO INCREASING
1 AGITATION; IS THAT RIGHT?
2 A. UH-HUH. UH-HUH.
3 Q. YOU HAVE TO ANSWER OUT LOUD.
4 A. YES. YES. SORRY.
5 Q. I SAW YOU NODDING YOUR HEAD.
6 A. YES.
7 Q. AND SO ON OUR ARBITRARY SCALE, SCREAMING AND TRYING TO
8 HIT PEOPLE, THAT WOULD BE ON YOUR -- YOUR SECOND LEVEL OF
9 AROUSAL? IT WOULDN'T BE ON YOUR TOP, YOUR TIP-TOP?
10 A. NO, THE SCREAMING -- YOU ASKED ME ABOUT THE SCREAMING
11 INITIALLY. THE SCREAMING WOULD BE ON THE VERBALLY AGITATED
12 LEVEL. HITTING PEOPLE -- HITTING OUT AT PEOPLE SPONTANEOUSLY
13 WOULD BE AT THE PHYSICALLY AGITATED.
14 Q. SO WE'RE AT THE TOP OF YOUR CHART -- THAT WE HAVEN'T
15 SEEN.
16 A. MOST LIKELY YOU WILL BE. I DON'T KNOW WHAT PRECEDES
17 THIS, BUT PROBABLY YOU ARE.
18 Q. WELL, WHAT IF JUST BEFORE THIS SHE WAS LETHARGIC? WHAT
19 IF SHE'D GONE FROM LETHARGIC -- I'M JUST TRYING TO UNDERSTAND
20 WHAT THE JURY, I GUESS, MIGHT LATER ONE DAY SEE.
21 WHAT IF SHE WAS LETHARGIC, THE WAY YOU'VE DESCRIBED IT,
22 THE PATIENT IS AROUSED, AND THEN IS BEHAVING LIKE THIS IN A
23 ONE HOUR PERIOD OF TIME. SHE'S SCREAMING, TRYING TO HIT THE
24 C.N.A. HOW WOULD YOU CHART THAT?
25 A. IF I HAVE A PATIENT WHO IS LETHARGIC AND THEN HAS -- THIS
1 IS A SIGNIFICANT EPISODE OF ACTIVITY, THEN I WOULD PUT A
2 SPIKE IN IT. AND IT IS -- THERE'S A -- IT'S OVER A VERY
3 LONG -- 24 HOURS IS A LONG PERIOD OF TIME SO IT'S DIFFICULT
4 TO HAVE SPIKES FOR ABSOLUTELY EVERY INSTANCE, BUT I THINK A
5 SPIKE WOULD BE APPROPRIATE.
6 Q. OKAY. AND THEN IT SAYS DOCTOR NOTIFIED. PATIENT
7 MEDICATED WITH ATIVAN 2 MILLIGRAMS I.M.
8 IS THAT THE WITH?
9 A. WITH. WITH. RIGHT.
10 Q. WITH GOOD RESULTS. SO THEY GAVE THE ATIVAN AND -- AND WE
11 GOT THE DESIRED RESULT ON THIS DAY, DECEMBER 31ST --
12 A. UH-HUH?
13 Q. -- ACCORDING TO THE WAY LYNN LONG HAS CHARTED IT. AM I
14 RIGHT?
15 A. YES.
16 Q. PATIENT SETTLED DOWN AND AGREED TO TAKE HER EVENING
17 MEDICATION.
18 A. CORRECT.
19 Q. SO THE MEDICATION WORKED.
20 A. THAT'S WHAT THAT SAYS.
21 Q. OKAY. THEN IF WE COULD LOOK FOR A MOMENT ON JANUARY 2ND?
22 AND ON JANUARY 2ND, AGAIN WE HAVE SERZONE, RISPERDAL,
23 TRAZODONE AND THE DURAGESIC.
24 A. UH-HUH.
25 Q. IS THAT RIGHT, MA'AM?
1 A. YES. YES, YOU DO.
2 MR. BUGDEN: AND THEN JUST SO THAT THE JURY CAN
3 UNDERSTAND HOW THE BEHAVIORS CORRESPONDED, WHAT'S ON -- ON
4 THE SCREEN FOR THE JURY, YOUR HONOR, IS MED-315. SAME
5 EXHIBIT THAT WE'VE REFERRED TO BEFORE, JUDGE. 4-D.
6 Q. (BY MR. BUGDEN) SO LET'S JUST READ THAT TOGETHER, IF WE
7 COULD.
8 PATIENT HAS BEEN HITTING, THROWING FOOD --
9 A. FOOD TRAY, I THINK.
10 Q. THANK YOU. FOOD TRAY ON FLOOR AND KICKING STAFF.
11 OKAY. IS THIS AT THE HIGH LEVEL OF YOUR SCALE OF
12 AROUSAL WHERE YOU'RE KICKING THE STAFF?
13 A. I WOULD THINK SO.
14 Q. OKAY. PATIENT HAS BEEN UNCOOPERATIVE -- I THINK THAT
15 WORD IS WITH STAFF. PATIENT HAS BEEN ALERT AND DISORIENTED.
16 A. YES.
17 Q. OKAY. OKAY. THANK YOU. AND THEN TURN TO LYDIA SMITH.
18 THE COURT: THAT WILL BE 5-E.
19 Q. (BY MR. BUGDEN) OKAY. WE ARE LOOKING AT 5-E. I JUST
20 WANT TO ASK YOU ABOUT JANUARY 3RD, IF WE CAN GET THERE.
21 A. I'M WORKING ON IT HERE.
22 Q. I'M GOING TO BE ABLE TO GIVE YOU A PAGE, I THINK. LET ME
23 GET MY NOTES. BUT I WANT YOU TO JUST LOOK AT YOUR CHART.
24 A. IT WOULD HELP IF I COULD SEE THE TOP OF THE PAGE.
25 Q. YOU DON'T NEED TO TURN YET TO THE PAGE. I JUST --
1 JANUARY 3RD IS THE DAY THAT MRS. SMITH RECEIVED AGAIN A FAIR
2 AMOUNT OF HALDOL. SHE HAS TRAZODONE AND DEPAKENE. IS THAT
3 RIGHT, MA'AM?
4 A. YES.
5 MR. BUGDEN: NOW, YOUR HONOR, I'M GOING TO TURN TO I
6 THINK 5-B, MED PAGE-792.
7 Q. (BY MR. BUGDEN) AND FOR YOU, MA'AM, IT'S SLIDE -- IN THE
8 DOCUMENTS I GAVE YOU IT'S NUMBER 29.
9 A. OKAY.
10 Q. IT'S NOT A NUMBER FOR THE JUDGE. IT'S A NUMBER FOR YOU,
11 MA'AM.
12 THE COURT: HAVE YOU GOT THAT, MS. KAUFMAN?
13 THE WITNESS: YES, I DO.
14 THE COURT: ALL RIGHT.
15 THE WITNESS: THANK YOU.
16 Q. (BY MR. BUGDEN) IF WE COULD READ THIS TOGETHER. AGAIN,
17 WHEN YOU JUST LOOK AT THE DRUGS THAT THE -- THE MEDICATIONS,
18 YOU KNOW, IT'S A REALLY TALL COLUMN.
19 A. UH-HUH.
20 Q. BUT LET'S LOOK AT WHAT HAPPENED THAT DAY, IF WE CAN. SO
21 WAS TRYING TO HIT AND SPIT AT THE STAFF AND OTHER PATIENTS.
22 PATIENT MEDICATED WITH HALDOL 5 MILLIGRAMS I.M. THAT'S LYNN
23 LONG.
24 AND THE FREE TEXT, PATIENT STILL -- STILL REFUSING
25 MEDICATION OR ANYTHING OFFERED BY STAFF. IS DEMENT -- I
1 THINK THAT WORD IS IS.
2 A. I THINK IT'S IN DEMENTED DISORIENTED.
3 Q. IN -- OH. THANK YOU. IN DEMENTED DISORIENTED FASHION.
4 MUTTERING INCOHERENTLY BUT AUTOMATICALLY TRYING TO SLAP AWAY
5 HAND BY STAFF -- OR OF STAFF. NO DISCERNIBLE DECREASE IN
6 AGITATION SINCE RECEIVING -- SINCE HALDOL I.M.
7 A. UH-HUH.
8 Q. IS THAT RIGHT?
9 A. YES.
10 Q. THEN IT ACTUALLY SAYS PATIENT'S AGITATION INCREASING.
11 HITTING AND BITING, KICKING, SPITTING AT STAFF AND OTHER
12 PATIENTS. PATIENT MEDICATED WITH ATIVAN 2 MILLIGRAM I.M.
13 WITH IMMEDIATE RESULTS. PATIENT CALM. NOT AGITATED OR
14 AGGRESSIVE.
15 A. CORRECT.
16 Q. SO THIS WOULD PROBABLY BE WHAT WE CALL AN EXAMPLE OF
17 TITRATING TO EFFECT WHERE THE PATIENT'S BEHAVIOR WAS HIGHLY
18 AGITATED. THEY GIVE THE HALDOL. THE HALDOL, THE FIRST 5
19 MILLIGRAMS DON'T PRODUCE A BENEFICIAL RESULT, THEN ANOTHER
20 TWO MILLIGRAMS ARE GIVEN AND THEN WE SEE A -- A GOOD RESULT.
21 PATIENT WITH IMMEDIATE RESULTS.
22 A. WELL, YOU'RE GIVING TWO DIFFERENT MEDICATIONS, BUT YOU DO
23 SEE A RESULT. YOU'RE GIVING HALDOL INITIALLY AND THEN YOU'RE
24 GIVING ATIVAN.
25 Q. THANK YOU FOR MAKING THAT CLEAR, BUT THE HALDOL DIDN'T
1 GET THE JOB DONE AND SO THEN THEY USED THE ATIVAN --
2 A. CORRECT.
3 Q. -- IN COMBINATION WITH THE HALDOL AND THEN THAT WORKED.
4 AM I RIGHT?
5 A. YES.
6 MR. BUGDEN: THEN, YOUR HONOR, I'M GOING TO ASK A
7 FEW QUESTIONS ABOUT 2-H, WHICH IS ELLEN ANDERSON.
8 Q. (BY MR. BUGDEN) DO YOU HAVE YOUR COLOR GRAPH, MA'AM?
9 A. YES, I DO.
10 Q. MRS. ANDERSON WAS A PATIENT FOR LESS THAN A DAY. HER
11 HOSPITALIZATION STARTED ON DECEMBER 29TH. AND THE ONLY
12 MEDICATIONS SHE ACTUALLY RECEIVED WERE THE TWO DIFFERENT
13 SHOTS OF MORPHINE. DOES THAT SOUND -- COMPORT --
14 A. THAT'S CORRECT.
15 Q. -- WITH YOUR MEMORY?
16 A. YES.
17 MR. BUGDEN: NOW, IS THERE A -- AND, YOUR HONOR,
18 WE'RE LOOKING AT 2 -- 2-C, PAGE 191 -- MED PAGE-191.
19 Q. (BY MR. BUGDEN) THIS ACTUALLY CORRESPONDS, I BELIEVE, TO
20 THE -- THE SECOND SHOT.
21 AT 3:15 THE PATIENT --
22 A. YES, UH-HUH.
23 Q. -- AWAKENED, THRASHING ARMS --
24 A. UH-HUH.
25 Q. -- AND ATTEMPTING TO THROW BODY.
1 LET ME JUST STOP AND UNDERSTAND. WHERE WOULD THAT BE ON
2 YOUR ARBITRARY CHART?
3 A. THAT WOULD BE PHYSICALLY AGITATED.
4 Q. WAS THAT AT THE TOP?
5 A. UH-HUH.
6 Q. THAT'S AT THE TOP. PATIENT MOANING AND SCREAMING.
7 DR. WEITZEL PAGED AGAIN. THEN AT 3:30 DR. WEITZEL -- I'M NOT
8 SURE -- RETURNED PAGE, I THINK IT SAYS.
9 A. THAT'S WHAT IT LOOKS LIKE. IT'S AN ABBREVIATION FOR
10 RETURNED, I THINK.
11 Q. INFORMED OF PATIENT'S CONDITION.
12 A. UH-HUH.
13 Q. MORPHINE 10 MILLIGRAMS I.M. GIVEN PER M.D. ORDER.
14 SO THIS IS A SITUATION WHERE THE -- THE NURSE CONTACTED
15 DR. WEITZEL AND DESCRIBED THE PATIENT'S THROWING HER BODY,
16 THRASHING AROUND, AND THEN DR. WEITZEL GAVE MEDICATION --
17 A. CORRECT.
18 Q. -- IS THAT RIGHT?
19 A. UH-HUH.
20 MR. BUGDEN: I JUST HAVE ONE OTHER LINE OF
21 QUESTIONS, JUDGE. I'VE GONE BACK TO THE MARY CRANE CHART,
22 JUDGE.
23 THE COURT: BACK TO 4-E.
24 Q. (BY MR. BUGDEN) I'D LIKE TO ASK YOU JUST SOME QUESTIONS
25 ABOUT A BLOWUP. THIS IS ON 1/7, WHICH IS THE LAST COLUMN.
1 A. UH-HUH.
2 Q. 1/7 OF '96. LOOK AT THIS -- AND YOU'VE GOT THE LAST
3 COLUMN THERE.
4 A. YES, I DO.
5 Q. NOW, THE EMPTY PILLS ARE SUPPOSED TO REPRESENT
6 MEDICATIONS THAT DR. WEITZEL ORDERED BUT THAT WERE NOT GIVEN?
7 A. CORRECT.
8 Q. IS THAT RIGHT?
9 A. YES.
10 Q. OKAY. WERE YOU AWARE THAT DR. WEITZEL HAD ACTUALLY
11 STOPPED ALL ORDERS -- STOPPED ALL PREVIOUS MEDICATIONS AT
12 SEVEN P.M. THAT EVENING?
13 A. THE EVENING OF JANUARY 7TH?
14 Q. RIGHT.
15 A. WELL, THAT WOULD STILL INCLUDE THESE DRUGS.
16 Q. BUT HE -- HE ENTERED A STOP ORDER.
17 A. OKAY.
18 MR. BUGDEN: IS THERE A BLOWUP?
19 A. HOLD ALL ABOVE MEDICATIONS.
20 Q. (BY MR. BUGDEN) HOLD ALL ABOVE MEDS.
21 A. (NODS HEAD.)
22 Q. AND THE ONLY MEDICATION HE WANTED GIVEN WAS THE MORPHINE;
23 IS THAT RIGHT?
24 A. THAT'S CORRECT.
25 Q. MORPHINE? SO THERE WAS ACTUALLY A STOP ORDER IN PLACE
1 FROM THE DOCTOR SO THAT THE ONLY THING THE PATIENT WAS TO
2 RECEIVE WAS THE MORPHINE INTRAMUSCULARLY.
3 A. THAT'S WHAT THAT SAYS.
4 Q. AND I'M SURE YOU'RE AWARE HAVING REVIEWED ALL OF THE
5 CHARTS THAT THE DURAGESIC PATCH, THAT SHOULD HAVE BEEN
6 REMOVED, AND A NURSE GOOFED UP BY NOT TAKING THE DURAGESIC
7 PATCH OFF.
8 MS. BARLOW: OBJECTION, YOUR HONOR. THERE'S NO
9 EVIDENCE OF THAT.
10 THE COURT: I'LL SUSTAIN THE OBJECTION AT THIS TIME.
11 Q. (BY MR. BUGDEN) WELL, ARE YOU AWARE, MA'AM, HAVING
12 REVIEWED THE RECORDS THAT WHEN AN AUTOPSY WAS PERFORMED THAT
13 MRS. CRANE HAD A DURAGESIC PATCH ON HER BODY?
14 A. I CAN'T SAY I DIRECTLY REMEMBER THAT.
15 Q. OKAY.
16 MR. BUGDEN: THAT'S ALL I HAVE.
17 THE COURT: REDIRECT?
18 MS. BARLOW: YES, YOUR HONOR.
19 THE COURT: ARE YOU GOING TO USE THE -- DO WE NEED
20 THE LIGHTS OFF STILL?
21 MS. BARLOW: YES, BECAUSE I AM GOING TO --
22 THE COURT: ALL RIGHT.
23 MS. BARLOW: -- USE THE PROJECTOR.
24 REDIRECT EXAMINATION
25 BY MS. BARLOW:
1 Q. LET'S MOVE BACKWARDS FROM THE LAST SET OF QUESTIONS THAT
2 DEFENSE COUNSEL WAS ASKING YOU. DO YOU HAVE THE PHYSICIAN'S
3 ORDERS FOR MARY CRANE?
4 THE COURT: LET ME JUST ASK ONE QUESTION,
5 MS. BARLOW. HOW LONG WILL YOUR REDIRECT LAST?
6 MS. BARLOW: THIS MAY TAKE A WHILE, YOUR HONOR.
7 THE COURT: LET'S TAKE OUR BREAK AT THIS TIME BEFORE
8 WE START THAT.
9 YOU MAY STEP DOWN, MS. KAUFMAN.
10 THE WITNESS: THANK YOU.
11 THE COURT: LADIES AND GENTLEMEN, I AGAIN REMIND YOU
12 OF MY PRIOR ADMONITION.
13 WE'LL BE IN RECESS UNTIL 10:20.
14 (RECESS TAKEN)
15 THE COURT: PARTIES AND COUNSEL ARE PRESENT. THE
16 JURY IS IN THE JURY BOX. MS. KAUFMAN IS BACK ON THE STAND.
17 AND I REMIND YOU THAT YOU'RE STILL UNDER OATH.
18 THE WITNESS: YES, SIR.
19 THE COURT: YOU MAY PROCEED, MS. BARLOW.
20 MS. BARLOW: THANK YOU, YOUR HONOR.
21 REDIRECT EXAMINATION
22 BY MS. BARLOW:
23 Q. MS. KAUFMAN, LET'S MOVE BACKWARDS FROM WHAT DEFENSE
24 COUNSEL HAS JUST GONE THROUGH. AND LET'S LOOK AT MARY CRANE.
25 DO YOU HAVE THOSE RECORDS IN FRONT OF YOU?
1 A. YES, I DO.
2 Q. DO YOU HAVE THE PHYSICIANS' ORDERS?
3 A. YES.
4 THE COURT: EXHIBIT NUMBER?
5 MS. BARLOW: THIS IS EXHIBIT -- IT'S I BELIEVE 4-B
6 FROM THE NURSING HOME RECORDS FOR MARY CRANE.
7 THE COURT: OKAY.
8 MS. BARLOW: YES. UP AT THE TOP IT SAYS 12/28.
9 THIS IS PAGE MED-239, YOUR HONOR.
10 Q. (BY MS. BARLOW) THERE'S AN ORDER FOR A DURAGESIC PATCH.
11 DO YOU SEE THAT?
12 A. YES, I DO.
13 Q. AND IT'S FOR HOW MUCH?
14 A. THIS IS A DURAGESIC -- DURAGESIC PATCH FOR 25 MICROGRAMS.
15 Q. AND WHAT IS A DURAGESIC PATCH?
16 A. A DURAGESIC PATCH IS A -- SORT OF LIKE A BAND-AID THAT'S
17 BEEN -- THAT HAS THE MEDICATION SATURATED INTO THE CENTER
18 PART OF IT, AND YOU PUT IT AGAINST THE SKIN. IT'S A TOPICAL
19 APPLICATION OF AN ANALGESIC OF A PAIN MEDICATION.
20 Q. AND WHAT IS THE PAIN MEDICATION?
21 A. IT'S FENTANYL.
22 Q. NOT MORPHINE.
23 A. NOT MORPHINE, NO.
24 Q. AND WHY IS IT ADMINISTERED IN THAT FASHION RATHER THAN A
25 SHOT SAY?
1 A. WELL --
2 MR. BUGDEN: YOUR HONOR, I THINK WE'VE HEARD THIS
3 FROM DR. DIENHART.
4 THE COURT: WE HAVE.
5 MR. BUGDEN: I'M NOT SURE THAT SHE --
6 THE COURT: BUT YOU CAN GO AHEAD AGAIN.
7 A. IT'S -- IT'S CONVENIENT AND IT'S SLOWLY RELEASED OVER
8 TIME. AND GENERALLY IT'S EVERY TWO, THREE DAYS THAT IT'S
9 ORDERED.
10 Q. (BY MS. BARLOW) IS IT A STEADY RELEASE OR HOW DOES
11 THAT --
12 A. IT'S A STEADY RELEASE.
13 Q. SO ON THE 28TH -- AND THAT WAS NOTED -- TAKEN OFF AT WHAT
14 TIME?
15 A. 1900, LOOK LIKE.
16 Q. WHICH IS WHAT? SEVEN P.M.?
17 A. SEVEN P.M. UH-HUH.
18 Q. AND THEN DOWN BELOW, AGAIN, 12/28, SAYS CHANGE THE
19 DURAGESIC TO 5 MICROGRAMS. WHAT DOES THAT EFFECTIVELY DO?
20 A. NO, IT'S ACTUALLY --
21 Q. OR EXCUSE ME.
22 A. IT'S ACTUALLY 50 MICROGRAMS.
23 Q. FIFTY MICROGRAMS.
24 A. SO IT DOUBLES THE AMOUNT OF MEDICATION IN THAT
25 APPLICATION.
1 Q. AND THAT WAS NOTED AT WHAT TIME?
2 A. IT SAYS 1900. WELL, LET'S SEE, IT'S NOTED AT -- NOTED AT
3 2100.
4 Q. AND HOW -- AND Q3 DAYS MEANS WHAT?
5 A. MEANS IT'S REPLACED EVERY THIRD DAY.
6 Q. DO YOU SEE A STOP ORDER FOR THE DURAGESIC PATCH?
7 MS. BARLOW: I'LL DRAW THE COURT'S ATTENTION AND
8 COUNSEL'S ATTENTION TO 242.
9 Q. (BY MS. BARLOW) FIRST OF JANUARY, I BELIEVE?
10 A. OKAY. YES, I SEE IT.
11 Q. AND WHAT DID THAT DO TO THAT DURAGESIC PATCH ORDER?
12 A. WHAT THAT -- WHAT THAT IS IS AN INDICATION THAT THIS DRUG
13 IS -- ORDER IS ABOUT TO EXPIRE, AND IT'S BEEN SIGNED BY THE
14 PHYSICIAN. SO THAT WOULD EFFECTIVELY ACKNOWLEDGE THAT THE
15 EXPIRATION WOULD OCCUR, BUT THAT THEY WANT IT TO CONTINUE.
16 Q. SO IS THAT A REORDERING OR IS THAT --
17 A. IT'S NOT -- IT'S ONE WAY OF DOING IT.
18 Q. IN FACT, IF YOU TURN TO THE NEXT PAGE WHICH IS OUR
19 MED-243, AT THE TOP IT SAYS 1/1/96. AND WHAT IS NUMBER 3 ON
20 THAT?
21 A. NUMBER 3 IS DURAGESIC 50 MICROGRAMS Q3 DAYS.
22 Q. AND WAS THAT REORDERED?
23 A. THAT WOULD DEFINITELY BE A REORDER.
24 Q. AGAIN, FOR THREE DAYS?
25 A. FOR THREE DAYS -- EVERY THREE DAYS.
1 Q. NOW, IF YOU -- ABOUT THREE MORE PAGES ON OUR MED-246
2 THERE'S ANOTHER STOP ORDER FOR THE DURAGESIC PATCH, I BELIEVE
3 THE 4TH OF JANUARY. WAS THERE A REORDER THERE?
4 A. THERE'S A REORDER DIRECTLY BELOW IT ON THE 4TH OF
5 JANUARY.
6 Q. AND WHAT WAS THAT ORDER FOR?
7 A. THAT DURAGESIC PATCH WAS FOR 75 MICROGRAMS EVERY THREE
8 DAYS.
9 Q. SO THAT INCREASES THE AMOUNT OF DURAGESIC?
10 A. YES, IT DOES.
11 Q. AND THEN I BELIEVE COUNSEL SHOWED YOU THAT ON THE 7TH
12 OF -- OF JANUARY THERE WAS A HOLD ALL ABOVE MEDS; IS THAT
13 CORRECT?
14 A. YES, THAT'S CORRECT.
15 Q. WHEN WAS THAT NOTED?
16 A. THAT WAS NOTED AT 2100.
17 Q. WHICH IS WHAT TIME OF DAY?
18 A. THAT'S AT SEVEN O'CLOCK AT NIGHT. NINE O'CLOCK AT NIGHT.
19 THE COURT: 2100 IS --
20 A. NINE O'CLOCK AT NIGHT.
21 Q. (BY MS. BARLOW) NINE O'CLOCK AT NIGHT. CONVERTING TO
22 MILITARY TIME FOR US NONMILITARY PEOPLE ISN'T ALWAYS EASY.
23 IF YOU WOULD TURN TO THE MEDICAL -- MEDICATION
24 ADMINISTRATION RECORDS TO OUR PAGE 285.
25 THE COURT: IS THAT STILL IN 4-B?
1 MS. BARLOW: STILL IN 4-B, YOUR HONOR.
2 A. WHICH -- I'M TRYING TO SEE A DATE OR SOMETHING.
3 Q. (BY MS. BARLOW) THERE'S A DATE AT THE TOP OF 1/1. AND
4 IT SAYS DURAGESIC PATCH 50 MICROGRAMS, BUT THERE ARE EMPTY
5 BOXES HERE. WHAT DOES THAT MEAN ON THAT PAGE?
6 A. ON THAT PAGE THAT WOULD BE THE DAYS THAT YOU WOULD EXPECT
7 TO CHANGE IT, AND THEY ARE NOT FILLED IN. SO THAT SHOULD
8 INDICATE THAT THAT WASN'T DONE ON THAT -- WITH THAT
9 DOCUMENTATION.
10 Q. THEN LET'S TURN THE PAGE TO THE NEXT PAGE WHICH IS 286.
11 WAIT A MINUTE. HAVE I GOT THE RIGHT ONE?
12 MS. BARLOW: EXCUSE ME JUST A MOMENT.
13 Q. (BY MS. BARLOW) AH, YES.
14 A. YEAH, THAT WAS IT.
15 Q. I DO HAVE 286. COULDN'T SEE IT ONCE I GOT IT ON THERE.
16 IS THERE A DURAGESIC PATCH ON THAT ONE?
17 A. IT'S RIGHT SEVERAL LINES DOWN FROM THE TOP. DURAGESIC 50
18 MILL -- MICROGRAMS.
19 Q. NOW, IT HAS L.L. DO YOU KNOW WHO THAT IS?
20 A. THAT'S LYNN LONG.
21 Q. LYNN LONG. SHE'S ONE OF THE NURSES --
22 A. UH-HUH.
23 Q. -- THAT DEALT WITH THESE PATIENTS?
24 NOW, IT'S NOT CIRCLED, BUT IT IS -- THE BOX IS OUTLINED.
25 DOES THAT MEAN IT WAS HELD OR WHAT DOES THAT MEAN?
1 A. THAT MEANS THAT IT WOULD -- THAT WOULD BE THE DAY IT
2 WOULD BE SCHEDULED TO BE -- TO BE GIVEN. THIS IS AN ORDER
3 THAT HAS BEEN MOVED TO THIS PAGE PROBABLY FOR CONVENIENCE.
4 AND IT'S BEEN -- IT'S BEEN WRITTEN FROM THE PREVIOUS PAGE.
5 IT'S THE SAME ORDER, AND IT HAS BEEN GIVEN ON THE 1ST. ON
6 PREVIOUS PAGE IT'S NOT SIGNED IN, BUT ON THIS PAGE IT IS
7 SIGNED IN AS HAVING BEEN GIVEN. AND THOSE INITIALS INDICATE
8 THAT IT HAS BEEN GIVEN. A SQUARE SIMPLY EMPHASIZES TO THE
9 NURSE THAT THAT'S THE DAY YOU'RE SUPPOSED TO CHANGE THE
10 PATCH.
11 Q. NOW, IF YOU WILL GO OVER ONE, TWO, THREE -- THREE OR FOUR
12 PAGES OVER TO OUR PAGE 289. THIS WILL BE FOR THE -- I
13 CAN'T -- OKAY. THIS IS FOR THE 7TH -- FOR THE 5TH, 6TH AND
14 7TH OF JANUARY, AND THEN ON THE 8TH IT HAS HOLD WRITTEN. BUT
15 DOWN AT THE BOTTOM IT SAYS DURAGESIC PATCH. WHAT TIME WAS
16 THAT GIVEN ON THE 7TH -- OR EXCUSE ME, APPLIED ON THE 7TH OF
17 JANUARY?
18 A. I'M TRYING TO FIND THE PAGE STILL.
19 Q. I BELIEVE IT'S THE LAST M.A.R.S. PAGE.
20 A. OKAY. NOW, WHAT WAS THE QUESTION? I'M SORRY.
21 Q. THE QUESTION IS IS WHAT TIME OF DAY WAS THAT PATCH
22 APPLIED -- REAPPLIED?
23 A. THE DURAGESIC PATCH DOWN AT THE BOTTOM?
24 Q. YES.
25 A. THAT'S -- IT'S INDICATED THAT IT WAS GIVEN AT
1 EIGHT O'CLOCK.
2 Q. AND WHEN -- WHEN WAS THE HOLD ALL MEDICATIONS ORDER
3 GIVEN?
4 A. THAT WAS IN THE EVENING AT 2100.
5 Q. I BETTER LEAVE IT UP. I'M GOING TO NEED IT AGAIN IN A
6 MINUTE. SORRY ABOUT THAT.
7 IF THE DURAGESIC PATCH WERE TO HAVE BEEN REMOVED AT
8 NINE O'CLOCK THAT NIGHT, WOULD THAT HAVE STOPPED --
9 IMMEDIATELY STOPPED THE ADMINISTRATION -- OR THE BODY'S --
10 THE FENTANYL IN THE BODY, ITS EFFECT?
11 MR. BUGDEN: YOUR HONOR, I'M GOING TO OBJECT. I
12 DON'T THINK --
13 A. NO.
14 MR. BUGDEN: -- THAT SHE'S QUALIFIED TO TESTIFY AS
15 TO THIS AREA.
16 THE COURT: I WILL OVERRULE THE OBJECTION. GO
17 AHEAD.
18 A. WHEN THIS -- FENTANYL IS ABSORBED INTO THE CIRCULATION SO
19 WHATEVER WAS IN THE BODY WOULD STILL BE HAVING EFFECT.
20 Q. (BY MS. BARLOW) NOW, IF WE WOULD -- YOU WERE ASKED
21 SOME -- ABOUT THE MORPHINE FOR MRS. ANDERSON. AND YOU WERE
22 SHOWN SOME -- SOME DOCUMENTS. I WOULD LIKE YOU TO TURN TO --
23 TO MRS. ANDERSON'S RECORDS, IF YOU WOULD.
24 A. OKAY.
25 Q. NOW, MRS. ANDERSON WAS IN THE HOSPITAL A VERY SHORT TIME;
1 IS THAT CORRECT?
2 A. YES, THAT'S CORRECT.
3 Q. BEFORE SHE --
4 A. UH-HUH.
5 Q. BEFORE SHE PASSED AWAY. YOU'VE BEEN SHOWN A COUPLE OF
6 THE DOCUMENTS. I'D LIKE TO SHOW YOU --
7 MS. BARLOW: AND I BELIEVE, YOUR HONOR, THAT THIS IS
8 2-H. NO, EXCUSE ME, THIS IS 2-B.
9 THE COURT: BE 2-B.
10 MS. BARLOW: AND THIS IS PAGE MED-190.
11 THE COURT: THAT WOULD BE THE PHYSICIANS' RECORDS?
12 IS THAT WHAT YOU WANT TO GO TO? OR THE NURSES' RECORDS?
13 MS. BARLOW: THE NURSES' NOTES, YOUR HONOR.
14 THE COURT: THEN IT'S 2-A.
15 MS. BARLOW: 2-A IS THE NURSING HOME RECORDS. THIS
16 IS THE -- THE HOSPITAL RECORDS, WHICH IS 2-B.
17 THE COURT: BE 2-C.
18 MS. BARLOW: 2-C?
19 THE COURT: THIS IS ELLEN ANDERSON, DAVIS HOSPITAL
20 RECORD. IS THAT WHAT YOU WANT?
21 MS. BARLOW: YES, YOUR HONOR. I APOLOGIZE. I HAVE
22 IT WRONG.
23 Q. (BY MS. BARLOW) DO YOU HAVE THE SAME PAGE, WHICH IS THE
24 FIRST PAGE OF THE NURSING NOTES?
25 A. YES, I DO.
1 Q. NOW, ABOUT HALFWAY DOWN IT SAYS MED NOTE TO THE LEFT ON
2 THE NARRATIVE. DO YOU SEE THAT?
3 A. MED NOTE? OH, YES. YES.
4 Q. AND WHAT WAS THE MED NOTE THAT WAS -- WHAT WAS -- WHAT
5 MEDICATION WAS ADMINISTERED AT THAT TIME?
6 A. IT SAYS MORPHINE 10 MILLIGRAMS I.M. AT 2000.
7 Q. FOR WHAT REASON?
8 A. FOR SEVERE PAIN.
9 Q. THEN IT LOOKS LIKE SOMETHING IS ADDED OUT AT THE SIDE.
10 HAVE YOU BEEN ABLE TO READ THAT?
11 A. IT'S -- IT'S VERY DIFFICULT. I THINK IT SAYS PATIENT
12 BECOMES RIGID AND SCREAMS WHEN TOUCHED. IT'S PRETTY HARD TO
13 READ.
14 Q. SO THAT'S AN INSERTION. DO YOU KNOW WHO MADE THAT
15 INSERTION?
16 A. I HAVE NO IDEA.
17 Q. THIS PAGE IS SIGNED BY L. WILSON. ARE YOU FAMILIAR WITH
18 LAURIE WILSON AS -- NOT PERSONALLY, AS ONE OF THE NURSES?
19 A. I'M FAMILIAR WITH THE NAME.
20 Q. SO THAT WAS AT 2000 WHICH IS WHAT TIME IN REAL TIME?
21 A. EIGHT P.M.
22 Q. THEN ON THE NEXT PAGE WHICH IS OUR MED-191, AT THE TOP WE
23 HAVE A NOTE AT ONE O'CLOCK WHICH IS WHAT? FIVE HOURS LATER?
24 IS THAT CORRECT?
25 A. YES.
1 Q. AND WHAT IS THAT NOTE?
2 A. THAT NOTE SAYS PATIENT'S RESPIRATIONS HAVE BEEN VERY
3 ERRATIC AND RANGING FROM 8 TO 16 PER MINUTE.
4 Q. AS A NURSE, WOULD THAT CAUSE YOU CONCERN, THAT KIND OF
5 RESPIRATION?
6 A. WELL, IT WOULD CONCERN -- CONCERN ME.
7 Q. WHY?
8 A. YOU WOULD HOPE THAT A REGULAR RESPIRATION -- A PERSON
9 WOULD HAVE REGULAR RESPIRATIONS. THE RATE, 8 -- 8 TO 16
10 PER MINUTE IS NOT PARTICULARLY A BAD RATE, BUT THE ERRATIC
11 NATURE OF IT WOULD BE.
12 Q. THEN THERE WAS PAGING OF DR. WEITZEL. BUT AT 3:15, WHICH
13 IS WHAT YOU READ WITH MR. BUGDEN, SHE HAD AWAKENED AGAIN.
14 A. UH-HUH. YES.
15 Q. NOW, AT 0100, WHAT -- WHERE WOULD SHE HAVE BEEN ON YOUR
16 SCALE?
17 A. WELL, THEY'RE PRIMARILY TALKING ABOUT HER RESPIRATIONS,
18 SO IT LOOKS -- JUST BASED ON RESPIRATIONS IT'S DIFFICULT TO
19 PUT HER ON A SCALE. IF I ALSO LOOK OVER AT THE SIDE CHARTING
20 WHICH HAS SOME INDICATION OF ACTIVITY, I DO HAVE HER -- HER
21 LEVEL OF CONSCIOUSNESS INDICATED AS UNRESPONSIVE. AND THAT'S
22 ABOUT WHAT I CAN TELL FROM THAT PARTICULAR PAGE.
23 IS THAT WHAT YOU WANT TO KNOW?
24 Q. YEAH. AND THEN AT 3:15 YOU READ ABOUT SHE WAS AWAKENED,
25 THRASHING, ATTEMPTING TO THROW HER BODY, MOANING AND
1 SCREAMING. DR. WEITZEL WAS PAGED AGAIN.
2 AT 3:30 HE RETURNED THE PAGE AND ORDERED MORPHINE. AND
3 THEN AT 6:30 IN THE MORNING -- YOU'VE READ PART OF THIS, BUT
4 WOULD YOU READ THAT WHOLE FOR 6:30 IN THE MORNING?
5 A. PATIENT HAS APPEARED TO SLEEP SINCE RECEIVING M.S. --
6 MORPHINE. RESPIRATIONS REMAIN ERRATIC. E.K.G. AND CHEST
7 X-RAY DONE.
8 Q. IS THERE ANY CONNECTION -- AS A NURSE, DO YOU KNOW IF
9 THERE'S ANY CONNECTION BETWEEN MORPHINE AND ERRATIC
10 RESPIRATIONS?
11 A. THAT'S ONE OF THE MAJOR SIDE EFFECTS OF MORPHINE IS AN
12 EFFECT -- DEPRESSANT EFFECT ON RESPIRATIONS. AND WHEN
13 THEY'RE DEPRESSED THEY CAN BECOME ERRATIC AS WELL.
14 Q. AND IF YOU'D TURN TO THE NEXT PAGE. NOW THE MORPHINE WAS
15 GIVEN AT 3:30 IN MORNING, AND AT 8:55 THAT MORNING IT SAYS
16 PATIENT WITH WHAT?
17 A. PATIENT WITH NO RESPIRATIONS, NO HEART RATE, TIMES --
18 IT'S EITHER FIVE OR EIGHT MINUTES.
19 Q. SO BASICALLY SHE'D PASSED AWAY BY NINE O'CLOCK.
20 A. YES, SHE HAD.
21 Q. AND HOW LONG IS THAT AFTER THE 3:30 SHOT OF MORPHINE?
22 A. ABOUT -- ABOUT FIVE AND A HALF HOURS.
23 Q. AND I BELIEVE YOU WERE ASKED ABOUT LYDIA SMITH.
24 MS. BARLOW: YOUR HONOR, THIS IS 5-B. AND YOU WERE
25 SHOWN PAGE -- OUR MED NUMBER-792 WHICH IS AT JANUARY 3RD.
1 A. WE'RE ON NURSES' NOTES. OKAY.
2 Q. (BY MS. BARLOW) AND YOU WERE ASKED ABOUT THE HALDOL AND
3 ATIVAN THAT WERE GIVEN. NOW, THIS WAS OVER WHAT TIME PERIOD?
4 FROM 800 TO 1300?
5 A. OH, THIS IS ABOUT -- IT'S FIVE HOURS.
6 Q. AND WHAT SHIFT IS THAT?
7 A. THAT'S THE DAY SHIFT.
8 Q. AND THE SHIFT WOULD CHANGE AT WHAT, THREE P.M.?
9 A. THREE P.M.
10 Q. SHOW YOU THE NEXT PAGE WHICH IS OUR 793. THIS APPEARS TO
11 BE A DIFFERENT NURSE'S HANDWRITING. AND WHAT DOES THIS
12 NURSE -- NURSE NOTE ABOUT -- AND I THINK THAT THIS IS THE
13 P.M. SHIFT IT SAYS OVER HERE IN THE CHARTING BY EXCEPTION.
14 A. OKAY.
15 Q. I DON'T BELIEVE IT'S GIVEN US A TIME, DOES IT?
16 A. IT DOESN'T SAY A TIME IN THE COLUMNS, NO.
17 Q. WHAT'S THE P.M. SHIFT?
18 A. P.M. SHIFT IS THREE TO ELEVEN.
19 Q. SO WHAT DID THIS NURSE NOTE AFTER ALL THE ATIVAN AND
20 HALDOL WAS GIVEN?
21 A. PATIENT VERY DROWSY. IN THE GERI CHAIR AT START OF
22 SHIFT. PATIENT DID NOT EAT DINNER DUE TO LETHARGIC STATE.
23 Q. IS THERE ANYTHING ELSE IN THAT NOTE ABOUT LETHARGY OR A
24 DEPRESSANT EFFECT?
25 A. LET'S SEE. WHEN TAKEN TO BATHROOM PATIENT WOULD PICK UP
1 BOTH LEGS AND BEND THEM. STAFF HAD TO SUPPORT FOR THE ENTIRE
2 AMBULATION TRANSACTION. THAT REFERS TO IT.
3 Q. LET'S SEE.
4 A. AND I GUESS THAT WAS IT.
5 Q. SO WAS THERE A CHANGE IN MRS. SMITH'S CONDITION BETWEEN
6 THE -- THE EARLIER NOTES WITH THE HALDOL AND THE ATIVAN AND
7 THEN THE LATER NOTES?
8 A. WELL, YES. SHE WENT FROM BEING COMBATIVE TO -- TO BEING
9 LETHARGIC.
10 Q. IS THERE ANY CONNECTION BETWEEN ATIVAN AND HALDOL AND
11 LETHARGY?
12 A. YES.
13 Q. WHAT IS THAT?
14 A. THEY -- THEY TEND TO DEPRESS THE CENTRAL NERVOUS SYSTEM
15 AND THE PERSON BECOMES LESS RESPONSIVE.
16 Q. NOW, IF WE COULD TURN TO MR. ALLDREDGE. YOU WERE SHOWN
17 SOME NOTES THAT INDICATE HE WAS GIVEN -- ON THE 8TH OF
18 JANUARY IN THE NURSING HOME NOTES IN 6-A, THE 8TH OF JANUARY
19 HE WAS GIVEN 3 MILLIGRAMS OF ATIVAN. ON THE 9TH OF JANUARY
20 HE WAS GIVEN 12 MILLIGRAMS OF ATIVAN. THESE ARE THE NURSING
21 HOME RECORDS THAT YOU DON'T HAVE.
22 A. OH, OKAY.
23 Q. AND THEN YOU WERE SHOWN THAT ON THE 10TH -- AND IN FACT
24 YOU INDICATED ON THE CHART THAT HE RECEIVED QUITE A BIT OF
25 HALDOL; IS THAT CORRECT?
1 A. YES. THAT IS CORRECT.
2 Q. DID YOU HAVE OCCASION TO READ DR. DIENHART'S NOTES --
3 PROGRESS NOTES ABOUT HIS CONSULTATION, HIS CHECKING OF
4 MR. ALLDREDGE ON THE 10TH OF JANUARY AT NINE P.M.?
5 A. I HAVE. I HAVE TO LOCATE IT THOUGH.
6 Q. IT'S IN THE PHYSICIANS' PROGRESS NOTE.
7 A. ACTUALLY I THINK THAT'S PROBABLY ON THE ORDER SHEET, NOT
8 ON THE PHYSICIANS' PROGRESS NOTES.
9 Q. YES, EXCUSE ME. IT IS ON THE ORDER SHEET.
10 MS. BARLOW: AND, YOUR HONOR, OUR MED NUMBER IS 11.
11 Q. (BY MS. BARLOW) AND I KNOW IT'S HARD TO WRITE -- READ
12 THIS AND WE HAD DR. DIENHART HERE, BUT IF YOU WOULD LOOK
13 AT -- ON THE RIGHT-HAND SIDE ABOUT TWO-THIRDS OF THE PAGE
14 DOWN IT SAYS CURRENTLY --
15 A. OKAY.
16 Q. -- LETHARGIC. CAN YOU READ HIS NOTE THERE?
17 A. SAYS CURRENTLY LETHARGIC, AROUSABLE ONLY TO PAINFUL
18 STIMULI. FOLLOWING ATIVAN, HALDOL, INJECTIONS FOR THE
19 COMBATIVENESS.
20 Q. OKAY. FROM YOUR EXPERIENCE AND KNOWLEDGE AS A NURSE, IS
21 THERE ANY CONNECTION BETWEEN ATIVAN AND HALDOL AND LETHARGY?
22 A. YES.
23 MR. BUGDEN: SHE JUST TESTIFIED TO THAT.
24 THE COURT: ASKED AND ANSWERED.
25 DON'T WASTE OUR TIME, MS. BARLOW.
1 MS. BARLOW: THANK YOU. I COULDN'T REMEMBER IF IT
2 WAS THE SAME DRUGS, YOUR HONOR.
3 WITH THAT, I BELIEVE THAT'S ALL THE QUESTIONS I HAD,
4 YOUR HONOR.
5 THE COURT: RECROSS?
6 MR. BUGDEN: JUST A COUPLE.
7 RECROSS EXAMINATION
8 BY MR. BUGDEN:
9 Q. SO ON ELLEN ANDERSON, COUNSEL AND I BOTH HAVE WALKED YOU
10 THROUGH THE TWO SHOTS OF MORPHINE THAT MRS. ANDERSON
11 RECEIVED. HER FIRST SHOT WAS AT EIGHT P.M. IS THAT WHAT YOU
12 TESTIFIED TO?
13 MR. BUGDEN: I DON'T NEED ANY SLIDES FOR THIS.
14 A. I BELIEVE IT WAS APPROXIMATELY THAT, YEAH.
15 Q. (BY MR. BUGDEN) AND IT WAS IN RESPONSE TO A NURSE
16 CALLING DR. WEITZEL AND REPORTING TO DR. WEITZEL THAT THE
17 PATIENT HAD SEVERE PAIN.
18 ISN'T THAT WHAT YOU READ TO THE JURY?
19 A. YES.
20 Q. OKAY. AND THEN SHE DOESN'T RECEIVE ANOTHER SHOT UNTIL
21 3:30; IS THAT RIGHT?
22 A. THAT'S CORRECT.
23 Q. AND THEN THAT SHOT ALSO IS IN RESPONSE TO A NURSE
24 CONTACTING DR. WEITZEL AND REPORTING SYMPTOMS THAT THE NURSE
25 INTERPRETED AS SYMPTOMS OF PAIN; ISN'T THAT RIGHT?
1 A. THE NURSE DESCRIBES THE SYMPTOMS AND -- DOESN'T ACTUALLY
2 CALL THEM PAIN, BUT DESCRIBES THE SYMPTOM, YES.
3 Q. WELL, WOULD IT SURPRISE -- WELL -- THAT PARTICULAR NURSE
4 HAS GIVEN TESTIMONY, SWORN TESTIMONY UNDER OATH ON A PRIOR
5 OCCASION. AND IN THAT TESTIMONY THAT NURSE NAMED TRACY
6 SCHOLL TESTIFIED UNDER OATH THAT SHE CONTACTED DR. WEITZEL
7 AND REPORTED THAT THE PATIENT WAS IN SEVERE, EXTREME PAIN,
8 AND THAT THAT'S WHY SHE WANTED THE SECOND SHOT OF MORPHINE.
9 ARE YOU AWARE OF THAT?
10 A. NO. I DID NOT HEAR HER TESTIMONY.
11 Q. OKAY.
12 A. SHE SIMPLY DOESN'T WRITE IT ON THIS PAGE.
13 Q. I'M JUST ASKING YOU IF YOU WERE AWARE OF THAT, MA'AM.
14 THEN WITH REGARD TO LYDIA SMITH, COUNSEL JUST SHOWED YOU
15 MED PAGE-793. AND THAT WAS ON -- ON JANUARY 3RD WHEN
16 MRS. SMITH HAD RECEIVED A FAIR AMOUNT OF HALDOL. WE WENT
17 THROUGH WHEN I WAS ASKING YOU QUESTIONS THAT SHE WAS
18 EXTREMELY AGITATED SO THE HALDOL WAS GIVEN TO TITRATE TO
19 EFFECT TO RESPOND TO HER AGITATION; IS THAT RIGHT?
20 A. YES.
21 MR. BUGDEN: AND THEN IF WE COULD SEE MED-793,
22 PLEASE?
23 Q. (BY MR. BUGDEN) AND WHAT YOU JUST TOLD THE JURY WAS THAT
24 THEN AFTER SHE RECEIVED SOME OF THE HALDOL THAT THEN THERE
25 WAS SOME SYMPTOMS OF LETHARGY. AM I RIGHT? THAT'S WHAT YOU
1 DESCRIBED FOR THE JURY?
2 A. I BELIEVE THAT'S WHAT WE JUST READ. YEAH?
3 Q. OKAY. AND THEN -- LET'S SEE HERE. BUT LATER ON THAT
4 SAME PAGE --
5 MR. BUGDEN: COULD YOU SHOW THE FULL PAGE SO THAT
6 THE JURY CAN SEE THAT WE'RE TALKING ABOUT THE VERY SAME PAGE
7 THAT MS. BARLOW HAD HER READ FROM.
8 Q. (BY MR. BUGDEN) THIS IS THE PATIENT IN LETHARGIC STATE.
9 PATIENT VERY DROWSY.
10 DO YOU SEE THAT?
11 A. UH-HUH.
12 Q. MA'AM?
13 A. YES, I DO.
14 Q. THANK YOU. BUT THEN LATER ON THE SAME PAGE IT POINTS OUT
15 THAT --
16 MR. BUGDEN: CAN WE GO DOWN TO THERE, PLEASE? THANK
17 YOU.
18 Q. (BY MR. BUGDEN) PATIENT CLAMPED TEETH SHUT AND ATTEMPTED
19 TO GRAB AT STAFF?
20 A. UH-HUH. YES.
21 Q. SO ALTHOUGH THE PATIENT HAD BEEN LETHARGIC DURING THE
22 SAME SHIFT, THE PATIENT THEN BECAME AGITATED AGAIN, WAS
23 GRABBING AT THE STAFF?
24 A. WELL, THE PATIENT BECAME ACTIVE AGAIN.
25 Q. OKAY. ACTIVE.
1 A. BECAUSE THE LETHARGY -- YOU ARE ROUSABLE IN LETHARGY.
2 Q. PATIENT GOT OUT OF BED TIMES -- TIMES TWO. TWO TIMES?
3 IS THAT WHAT THAT MEANS?
4 A. THAT'S -- THAT'S A -- HAS PATIENT GOT OUT OF BED TIMES
5 TWO, SITTING ON EDGE, AND WOULD NOT AMBULATE WITH
6 STAFF ASSIST -- WITH STAFF ASSISTANCE.
7 I INTERPRET THAT TO MEAN THAT THE STAFF GOT THE PATIENT
8 OUT OF BED TIMES TWO, WHICH WOULD BE THE STANDARD OF CARE FOR
9 THIS TYPE OF PATIENT.
10 Q. WHAT IS TIMES TWO THOUGH?
11 A. OH, THAT MEANS WITH TWO PEOPLE ASSISTING.
12 Q. THANK FOR YOU YOUR HELP.
13 AND THEN IT SAYS DEFIANT OF STAFF'S EFFORTS -- I'M NOT
14 SURE.
15 A. DEFIANT OF --
16 Q. OH, DISPLAYED BY RAISING LEGS WHILE AMBULATING?
17 A. THAT'S WHAT IT SAYS.
18 Q. AND THEN WHAT'S THE REST ABOUT THE HALDOL? CAN YOU HELP
19 ME WITH THAT?
20 A. LET'S SEE. PATIENT GIVEN 5 HALDOL, 5 MILLIGRAMS WHEN
21 MEDS REFUSED, PER DOCTOR'S ORDER.
22 Q. IS THAT --
23 A. SHE WOULDN'T LET MEDS IN -- SHE WOULDN'T TAKE MEDS ORALLY
24 SO THEY GAVE HER AN INJECTION OF IT.
25 Q. SO THE STANDING ORDER FROM THE PHYSICIAN WAS THAT IF --
1 IF SOME OF THESE DEMENTED PATIENTS REFUSED THE ORAL
2 MEDICATION THAT THEY WOULD BE GIVEN AN INTRAMUSCULAR
3 INJECTION? IS THAT WHAT THAT SAYS?
4 A. THAT APPEARS TO THE PRACTICE ON THAT UNIT.
5 Q. THANK YOU VERY MUCH.
6 MR. BUGDEN: THAT'S ALL I HAVE.
7 THE COURT: REDIRECT?
8 MS. BARLOW: NO, NOTHING FURTHER, YOUR HONOR.
9 THE COURT: YOU MAY STEP DOWN, MS. KAUFMAN. AND
10 THANK YOU FOR TESTIFYING.
11 THE WITNESS: THANK YOU, JUDGE.
12 MS. BARLOW: YOUR HONOR --
13 THE COURT: MAY SHE BE EXCUSED?
14 MS. BARLOW: -- WE ASK THAT SHE STILL BE UNDER
15 SUBPOENA. THERE MIGHT BE A COUPLE OF JUST MINOR MATTERS --
16 THE COURT: ALL RIGHT.
17 MS. BARLOW: -- WE NEED TO BRING HER BACK FOR.
18 THE COURT: YOU'RE NOT TO DISCUSS YOUR TESTIMONY
19 WITH ANYBODY AS YOU LEAVE TODAY. YOU MAY BE RECALLED IN THIS
20 MATTER. AND DON'T LET ANYONE DISCUSS THE CASE IN YOUR
21 PRESENCE. ALL RIGHT?
22 THE WITNESS: OKAY.
23 THE COURT: WE'LL SEE YOU BACK THEN POSSIBLY. THANK
24 YOU, MS. KAUFMAN.