Maureen Frikke, MD
25 MR. WILSON: Thank you, Your Honor. We call Dr.
1 Maureen Frikke to the stand at this time.
2 THE COURT: Dr. Frikke, step up, please. Come right
3 up here, please, and be sworn.
4 MAUREEN FRIKKE,
5 being first duly sworn, was examined and
6 testified as follows:
7 THE COURT: Please take the witness stand. State
8 your name and spell the last name.
9 THE WITNESS: My name is Maureen Jane Frikke.
10 F-r-i-k-k-e.
11 THE COURT: Thank you. Go ahead, Mr. Wilson.
12 DIRECT EXAMINATION
13 BY MR. WILSON:
14 Q. Dr. Frikke, will you tell us where you are currently
15 employed, please.
16 A. I'm employed by the Office of the Medical Examiner, which
17 is part of the State Department of Health.
18 Q. And in what capacity are you so employed?
19 A. I'm the assistant medical examiner.
20 Q. Okay. And can you tell us, if you would, please,
21 relative to your -- a brief explanation as to your
22 educational background?
23 A. I have a doctor of medicine degree from Washington
24 University in St. Louis. I did my pathology training, which
25 was an internship and residency in anatomic and clinical
1 pathology, at the University of Florida in Gainsville,
2 Florida. I did one year of fellowship training in forensic
3 pathology at the Hennepin County medical examiner's office in
4 Hennepin County, which is the county that includes
5 Minneapolis, Minnesota. And after my fellowship training I
6 came to Utah.
7 Q. Okay. In term of your experience you say you came to
8 Utah after that training?
9 A. I did.
10 Q. And when did you come to Utah?
11 A. That was in August of 1991.
12 Q. Okay. Have you been with the medical examiner's office
13 since that time?
14 A. I have.
15 Q. And have you performed autopsies since that time?
16 A. I have.
17 Q. And can you tell us how many autopsies you've performed
18 over the time that you've been employed with the medical
19 examiner's office?
20 A. I do between three and four hundred patients per year.
21 That's 3300, 3500, somewhere in there.
22 Q. Okay. Have you testified in court proceedings before?
23 A. Yes, I have.
24 Q. And can you tell us how many times you've testified?
25 A. Probably about twice a month.
1 Q. All right. Calling your attention to the matter before
2 the court here, did you have occasion to perform an autopsy
3 examination relative to Mary Crane?
4 A. I did.
5 Q. Can you tell us when that took place?
6 A. That examination was on June 24th, 1999.
7 Q. And where was it conducted?
8 A. At the medical examiner's office in Salt Lake City.
9 Q. And can you tell us who was present on that occasion?
10 A. The official witness was Detective Joe Morrison.
11 Q. Okay. And do you know what department he's with?
12 A. He's with the Layton police department.
13 Q. Okay. The body, as I understand it, was presented to you
14 at that time?
15 A. It was.
16 Q. And can you tell us, was it in a casket at the time that
17 you first observed the body?
18 A. Yes.
19 Q. Okay. Now, you do autopsies with a set procedure, is
20 that correct?
21 A. It's fairly regular. It's subject to variation,
22 depending upon the specific needs of the case, but it's
23 fairly standard.
24 Q. And as I understand it, you make an external examination
25 of the body, is that correct?
1 A. Yes.
2 Q. And did you do so on this occasion?
3 A. I did.
4 Q. And can you tell us relative to -- strike that. I want
5 to step back one step further. Did you review any other
6 records or investigative reports prior to conducting this
7 autopsy?
8 A. I had a report that was prepared by the medical examiner
9 investigator that presented some of the facts regarding the
10 circumstances that resulted in this lady's exhumation.
11 Q. What about her medical records, do you know whether or
12 not you ever reviewed those medical records, hospital
13 records?
14 A. I have medical records for her. I don't remember if I
15 had them before the examination or right after it, but it was
16 about the time that I did her examination that I also had her
17 medical records.
18 Q. All right. So you're not sure whether you reviewed those
19 medical records previous to performing the autopsy, is that
20 correct?
21 A. Yes, I don't remember that.
22 Q. Okay. And in terms of the reports that you did make, did
23 that create any alteration in the procedure or did you
24 reference that report in terms of what you were going to be
25 looking for in terms of this autopsy?
1 A. Well, I knew what had been documented with respect to her
2 past medical history, so I could anticipate some of her
3 physical findings. But that doesn't particularly influence
4 the way I do the examination.
5 Q. All right. So then you made the external -- going back
6 to the autopsy, you conducted the external examination. Did
7 I ask you the question, I can't remember if I did, was there
8 any significant findings in your mind related to this autopsy
9 as far as the external examination goes?
10 A. What was particularly striking about her, obviously, was
11 she'd been embalmed and entombed for quite some period of
12 time. There was a lot of changes on the external surface of
13 the body as a result of those procedures.
14 Q. All right. But in terms of any findings relative to the
15 external examination, was there anything significant to your
16 subsequent opinion that you rendered as far as this
17 examination goes?
18 A. No. The external features of her body were basically
19 pretty unremarkable.
20 Q. Okay. And then I assume you conducted an internal
21 examination of the body, is that correct?
22 A. I did.
23 Q. And you have a procedure you followed on this particular
24 occasion of examining certain parts of the internal organs?
25 A. Yes.
1 Q. Can you tell us what procedure you followed?
2 A. The basic procedure for the internal examination is that
3 the chest is opened and the abdomen is opened so that we can
4 remove all of the internal organs and separate them out and
5 dissect them and look at them organ by organ. In the process
6 of doing that, we do try to collect materials that would be
7 used for doing drug analysis. I collect tissue samples that
8 I would save so that I can look at selected organs under the
9 microscope.
10 Q. Following the chest area, do you also examine the brain?
11 A. I did.
12 Q. Okay. Any other areas that you examined in connection
13 with this autopsy?
14 A. Well, the chest organs were examined. The abdominal and
15 pelvic organs were examined. The neck organs are examined
16 and the brain.
17 Q. Okay. And on this particular occasion can you describe
18 for us, if you would, relative to your findings as it
19 pertained to any significant findings, let's put it that way,
20 or acute findings, relative to the internal organs that you
21 examined?
22 A. The organs that had visible signs of disease or
23 abnormality were her heart, her kidneys and her brain.
24 Q. Okay.
25 A. She had an enlarged heart. She had signs of high blood
1 pressure. And there was some narrowing of her coronary
2 arteries on gross examination.
3 Her kidneys, on gross examination, had some scarring that
4 can occur as a result of a couple of different disease
5 processes. She had evidence in her brain of having had a
6 stroke in the past.
7 Q. Okay. In respect to the heart organs, can you describe
8 whether or not there was any acute findings relative to any
9 damage to the heart?
10 A. Everything that I saw in her heart was old.
11 Q. Okay. In respect to the kidneys, can you tell us whether
12 or not there was any acute findings relative to damage to the
13 kidneys?
14 A. There were no new or acute disease processes in her
15 kidneys that I could identify.
16 Q. Okay. In respect to her brain, can you tell us whether
17 or not there were any acute findings as to your examination
18 of the brain?
19 A. No, there were not.
20 Q. Okay. If you could, did you prepare an autopsy report?
21 A. I did.
22 Q. Let me show you what has previously been marked as
23 state's exhibit C and ask you to take a look at that, please.
24 A. (Witness complied.)
25 Q. Can you identify that particular document?
1 A. (Pause.) I can.
2 Q. And would you do so, please.
3 A. This is a photocopy of the report of examination that I
4 prepared. Attached to it are the results of the toxicology
5 testing that was done by the department of health.
6 Q. Okay. Can you tell, Doctor, and turn to the second page
7 of that particular examination, did you prepare an opinion
8 relative to this autopsy?
9 A. Yes.
10 Q. Calling your attention to the first paragraph of that
11 page, in the last sentence, can you characterize for us what
12 your findings were relative to any disease processes?
13 A. What I stated in my opinion was that there were no
14 gross -- there was no gross, which is visible, or microscopic
15 evidence, which is evidence that requires the microscope to
16 see, that acute injury had occurred in any of the vital
17 organs.
18 Q. And in respect to the sentence just above that, in terms
19 of the disease processes, what was your notation there?
20 A. Okay. I indicated that no significant acute disease
21 processes which would have been likely to cause death were
22 identified.
23 Q. All right. Now, down at the bottom paragraph you make a
24 determination relative to cause of death and manner of death,
25 do you not?
1 A. I do.
2 Q. And can you tell us what your opinion was relative to any
3 cause of death?
4 A. My opinion was the cause of death was certified as
5 undetermined.
6 Q. And in respect to the manner of death, did you make
7 any -- form any opinion there?
8 A. I did.
9 Q. And what was that?
10 A. In my opinion the manner of death should be certified as
11 undetermined if injured.
12 Q. I'm a little bit curious, what does the if injured mean?
13 A. That means that on the basis of the examination and the
14 information I had, I cannot make a determination, to a degree
15 of medical certainty, as to whether she died from something
16 natural, which would be her own natural diseases, or an
17 injury mechanism, something that would have been inflicted
18 upon her from outside of her own body.
19 Q. Now, you further qualify that particular determination,
20 do you not, in that last paragraph?
21 A. Yes.
22 Q. You address cardiac disease and what do you say about
23 that?
24 A. I say Mrs. Crane had cardiac disease which could have
25 resulted in sudden and unexpected death.
1 Q. And what did you mean by that, Doctor?
2 A. She had scarring on her heart. She'd had episodes of
3 heart attacks in the past. The tissue had healed so she had
4 scar tissue in her heart. People who have scar tissue in
5 their heart can develop chronic heart failure; or they can
6 develop sudden rhythm disturbances that will cause them to
7 die suddenly and unexpectedly.
8 Q. Okay. Now, would the medical history of that particular
9 patient be relevant to a determination if indeed a cardiac
10 disease had brought about her sudden death?
11 A. Her medical history would certainly be -- would indicate
12 if she had evidence of chronic congestive heart failure,
13 which is a process of slow failure of the heart.
14 Q. Okay. And in terms of records which would indicate
15 relative to how she died, when you describe a sudden death,
16 sudden and unexpected death, what do you mean by that?
17 A. What I mean is that the person would, to all observers,
18 appear to be in her usual ordinary state of health, and then
19 suddenly die.
20 Q. Okay. You also talk about -- form an opinion relative to
21 narcotic intoxication. Can you tell us what your opinion was
22 relative to that particular process?
23 A. My opinion was that narcotic intoxication cannot be
24 excluded as either the primary cause of death or as a factor
25 which contributed significantly to her death.
1 Q. Why is that, Doctor?
2 A. Because of the embalming process and the long interval
3 between embalming and examination, the ability to identify
4 drugs is greatly diminished.
5 Q. There are indeed drug screens that were run relative to
6 certain tissues that you sent to the state lab, is that
7 correct?
8 A. Yes.
9 Q. Did you get those screens back?
10 A. Yes.
11 Q. And can you tell us whether you have the ability to
12 interpret those screens?
13 A. I do.
14 Q. Okay. What were the results of the screens that were
15 done in respect to that particular patient?
16 A. Opiates, which are narcotic drugs, were identified in
17 fluid that we collected from a kidney cyst. She had a cyst
18 on one of her kidneys and we collected that fluid. That
19 fluid is basically urine. Opiates were present in that
20 fluid.
21 She had had -- we collected at autopsy a medication patch
22 that was on her back. They identified fentanyl in that
23 medication patch. The other materials that we collected were
24 embalmed blood, bile and embalmed brain. They could not
25 verify the presence of morphine in those materials.
1 Q. Okay. As to the screening test, you said that opiates
2 were identified relative to the urine sample?
3 A. That's correct.
4 Q. Okay. Was there ever an attempt to quantify those
5 opiates?
6 A. Not that I'm aware of. The sample that we had was very
7 small.
8 Q. Okay. Turning to the back page of the report, can you
9 look at the quantitative analysis there?
10 A. (Witness complied.)
11 Q. Have you got that, Doctor?
12 A. I do.
13 Q. Can you tell us whether that tells us anything under
14 quantitative?
15 A. What the laboratory reported was their attempts to
16 identify and quantitate morphine in the embalmed blood that
17 we collected out of the aorta, from the bile and from the
18 brain tissue. What they report is morphine -- for each of
19 these materials, less than 0.05 milligrams per liter.
20 Q. Okay. And is there any ability to correlate those
21 findings with what you read in the medical history?
22 A. No.
23 Q. Okay. Did you also, during the course of the autopsy,
24 have occasion to examine the body as relates to any evidence
25 of a vaginal fistula?
1 A. I did examine the pelvic organs to the best of my
2 ability, given that the lady had been embalmed several years
3 previously.
4 Q. So I understand from that that you weren't able to make
5 an examination?
6 A. I examined the tissue. I did not identify a disease
7 process there. It's very difficult to examine that part of
8 the body very well because of the effects of the embalming.
9 I did not identify a fistula.
10 Q. Can you tell us whether you made any examination relative
11 to a sepsis? And before you answer that, let me ask you what
12 is a sepsis?
13 A. Sepsis is a common term for blood poisoning. Bacteria
14 gets into the blood and travels all around the body and you
15 become very ill very rapidly.
16 Q. Is there any way to determine pathologically in an
17 autopsy whether or not an individual has had a sepsis or
18 infection of that nature in their body?
19 A. When we have the opportunity to do the examination on a
20 body that is not embalmed, it's very easy to do because we
21 can collect blood, cerebral spinal fluid, different fluids
22 from the body, and actually submit them to the laboratory for
23 bacterial cultures, just like you would do with a living
24 person who you suspect might have sepsis. And we do that
25 regularly. That's a very common practice in our office.
1 Sepsis is blood infection. Once a person is embalmed --
2 first of all the goal, one of the goals of embalming, is to
3 wash away all the blood and to replace it with fluids that
4 preserve the tissues. So the blood is gone, or most of it is
5 gone, after the embalming process. The embalming process
6 also kills the bacteria and that's part of what keeps you all
7 in one piece after you are buried. So the embalmed person is
8 a very poor candidate for looking for sepsis.
9 The only information we could find that we would be
10 looking for in a patient like this is evidence that infection
11 had actually been set up in tissues, like the lung and the
12 heart and brain and kidneys.
13 Q. Did you see any evidence of that nature?
14 A. She had a very small amount of infection, basically a
15 bronchitis, in one of her lungs. I did not see evidence of
16 infection in her other organs.
17 Q. Okay. Doctor, I'm going to show you now what has been
18 marked as state's exhibit 4D and ask you to identify that
19 particular exhibit if you would, please.
20 A. This exhibit is a copy of an official State of Utah death
21 certificate.
22 Q. That's on the first page?
23 A. Correct.
24 Q. Is there an amended certificate attached?
25 A. There is.
1 Q. And can you identify that particular portion of the
2 exhibit?
3 A. Yes. The second page is an official State of Utah
4 Department of Health amendment to a death certificate.
5 Q. And was that your amendment to the death certificate?
6 A. Dr. Grey signed it.
7 Q. Okay. Relative to the first page, that was the original
8 death certificate as I understand it?
9 A. That's my understanding also.
10 Q. Do you know what the cause of death was listed relative
11 to that?
12 A. There is a cause of death listed, yes.
13 Q. Can you tell us what that is?
14 A. The cause of death that is listed on the original death
15 certificate is cardiac arrest due to respiratory arrest, due
16 to seizure, due to -- as the consequence of CVA.
17 Q. Okay. Can you interpret that for us?
18 A. What this says is that the heart stopped because the
19 lungs stopped because of a seizure because of a stroke.
20 Q. Okay. Did you find any evidence of an acute stroke, in
21 terms of your findings, as far as the autopsy was concerned?
22 A. No.
23 MR. WILSON: Thank you, Doctor.
24 THE COURT: Cross-examine.
25 MS. ISSACSON: If we could have a moment?
1 THE COURT: Sure.
2 (Pause in the proceedings.)
3 CROSS-EXAMINATION
4 BY MS. ISAACSON:
5 Q. Dr. Frikke, my name is Tara Isaacson. I'm one of the
6 attorneys representing Dr. Weitzel.
7 One of the major findings in your opinion is that Mrs.
8 Crane had cardiac disease which could have resulted in her
9 sudden and unexpected death?
10 A. That's correct.
11 Q. You also noted in your examination that Mrs. Crane had
12 evidence of a stroke from the past?
13 A. That's true.
14 Q. And there are certainly strokes that a patient can have
15 that are subacute or that you cannot detect by your autopsy
16 examination?
17 A. I don't necessarily agree with that statement.
18 Q. Okay. It's not -- in this case, given the level of
19 decomposition and given the condition of this patient's
20 brain, it is possible that there could be a subacute event in
21 this brain that you could not detect?
22 A. Her tissues were extremely well preserved. The funeral
23 director did a good job of embalming her. Her tissues were
24 not decomposed. She had mold on her outside, but her tissues
25 were extremely well preserved.
1 Q. But it is true, isn't it, that there are subacute events
2 in a brain that you cannot detect that could have occurred
3 shortly before her death or after death?
4 A. If you're talking about strokes, I don't think I would
5 agree with that statement.
6 Q. How about a subacute event in the brain, something short
7 of an actual stroke?
8 A. Certainly there can be such events.
9 Q. And this brain you noted was unusually small?
10 A. It was.
11 Q. And you're aware that in this case, because you reviewed
12 the medical records, Dr. Dienhart reported a possible seizure
13 on January 7th?
14 A. I think I recall that. His handwriting is almost
15 impossible to read, though.
16 MR. BUGDEN: That's been well documented.
17 THE WITNESS: If he thought he saw a seizure. I'm
18 not sure that I could read his handwriting. It's really bad.
19 Q. (BY MS. ISSACSON) Would you agree that within the
20 medical records that were notes from both nurses and from Dr.
21 Dienhart that indicated a potential seizure, symptoms of a
22 seizure?
23 A. That may be. I couldn't verify it from his writing,
24 though.
25 THE COURT: Assume that that has been the testimony.
1 Q. (BY MS. ISSACSON) You would agree that a seizure is a
2 clinical determination?
3 A. It is.
4 Q. And it's not something that you're going to have a
5 finding on during an autopsy?
6 A. No, not the seizure itself.
7 Q. And we've already heard on direct examination that you
8 were unable, given what you had to work with, to rule out
9 sepsis in this patient?
10 A. That's correct.
11 Q. And of course there are certain conditions that you
12 simply can't detect after decomposition?
13 A. That's true.
14 Q. And in this case, for example, we all know, we've heard
15 the testimony, that there was a rectal/vaginal fistula, but
16 you weren't able to see that when you performed the
17 examination even though you were looking for it?
18 A. That's correct.
19 Q. And do I understand correctly that there were actually
20 two Duragesic patches found on the upper back of Mrs. Crane?
21 A. That's correct.
22 Q. So in this case you can't rule out heart problems or
23 cardiac disease as a cause of death?
24 A. True.
25 Q. You can't rule out sepsis?
1 A. True.
2 Q. And you're unable to make a determination about the
3 seizure?
4 A. That's true.
5 Q. Part of your report, in addition to these physical
6 findings, what you're actually able to see, you make mention
7 in your opinion section that Mary Crane had only been treated
8 for her pain previously with nonprescription medication. You
9 actually write, Mary Crane had a past history of rupture of
10 an intervertebral disk in 1984 and pain relief was
11 accomplished with nonprescription medications in the
12 convalescent center in which she'd resided. That was part of
13 your opinion in this case, is that right?
14 A. That is medical history that I am citing as part of my
15 rationale for why the death certificate was amended to what
16 it was.
17 Q. And would you be surprised to hear that in fact Mrs.
18 Crane had been treated with prescription medications in the
19 nursing home where she resided?
20 A. It wasn't in the records that I had.
21 Q. Let me show you what is marked as defendant's exhibit 97.
22 Please take a look at that. Have you ever seen that record
23 before in conjunction with your autopsy of Mary Crane?
24 A. No.
25 Q. What does it -- does it appear to be a controlled drug
1 record of Mary Crane?
2 A. What it is is a lot of columns with no signatures on it.
3 And then signatures, some of which are legible and some which
4 aren't.
5 Q. Let's start with the top page. You would agree that in
6 the bottom right corner there is reference to the patient
7 Mary Crane next to the exhibit marker?
8 THE COURT: That's a yes or no answer.
9 THE WITNESS: Yes.
10 Q. (BY MS. ISSACSON) And isn't it true that it says below
11 that ordered as Darvocet, and then there's a DSPDT of 4/8/91,
12 a dispense date of 4/8 of '91? Is that writing on the front
13 of that medication log?
14 A. Okay. The bottom line, yeah.
15 Q. And you would agree that Darvocet prescribed to Mary
16 Crane in 1991 would count as a prescription pain medication
17 certainly?
18 A. It is.
19 Q. And it's actually an opiate based pain medication?
20 A. It is.
21 Q. And is a relative of morphine?
22 A. It is a congener of it, yes.
23 Q. And I won't have you go through page by page, but at
24 least this first page starts in 1991. And then if you look
25 at the end page, or as you flip through, we go up to Mary
1 Crane and we go up to September of 1995. There are all of
2 these logs, and we won't go through them day by day, but of
3 this patient receiving pain medications for years prior to
4 her admission to the geropsych unit. Would you agree it
5 appears, at least from your review of that exhibit, that Mary
6 Crane in fact had been prescribed pain medications for pain
7 prior to her admission?
8 A. If this is a part of her record. This was not -- the
9 records that I have from the care center where she was had
10 medications lists with them. This drug was not included on
11 that medication list. And in fact this record stops in 1994.
12 Q. With regard to the records that you actually reviewed,
13 did you review the medical records from Davis Hospital in
14 conjunction with the nursing home records or just the medical
15 records from the hospital?
16 A. I had records from the care center and records from Davis
17 Hospital.
18 Q. And no where in your review of those records did you note
19 or see an on going prescription for opiate type pain
20 medications?
21 A. Not at the care center.
22 Q. Of course, you would have received the records and
23 information from the state? You would have received those
24 from the investigating agency? That's where you would have
25 received the records from?
1 A. They were provided to me and I assumed that they came
2 from the Layton police department.
3 Q. You certainly didn't get any records from Dr. Weitzel?
4 A. No.
5 Q. And you didn't actually speak to any treating physicians
6 or anything like that?
7 A. No.
8 Q. And you relied on the state to provide you with a
9 complete picture of this patient's medical history?
10 A. I reviewed the material that was provided to me.
11 Q. At least the material that was provided to you did not
12 include any information about previous opiate pain
13 medication?
14 A. The medical record I got from the care center had
15 medication lists and administration times and nursing
16 signatures. There were not opiate pain medications there.
17 Q. And you found this fact, this lack of prior pain
18 medication, the fact that this patient had never had that
19 before, significant enough to include as a separate paragraph
20 in your opinion of your report of autopsy?
21 A. Previous experience with a narcotic pain medication is
22 important.
23 Q. That was an important thing for you to know before you
24 went into this autopsy?
25 A. It has everything to do with assessing one's tolerance to
1 a narcotic pain medication.
2 Q. Now, you've indicated that you actually did review
3 nursing home records, is that right?
4 A. I did.
5 Q. Were you aware that in fact Ms. Crane had been treated
6 previously with morphine for a headache in March of 1994?
7 A. You know, medication history five years before you die is
8 totally irrelevant with respect to narcotics.
9 Q. Well, Ms. Crane actually --
10 A. Or two years before.
11 Q. Well, you indicated in your opinion that you did not
12 think that Ms. Crane, in essence, had any conditions that
13 would have caused her pain, is that right?
14 A. I saw no evidence of it. And in the nursing home records
15 they were not dwelling on the fact that she had pain either.
16 Q. Despite the fact that apparently she was receiving opiate
17 pain medication for years?
18 A. Well, based on my experience with people, there are a lot
19 of people in this state who get opiate pain medications, to
20 the point of death, who don't have pain.
21 Q. So you were unaware that this patient had been treated
22 with eight milligrams of morphine for a headache in March of
23 1994?
24 A. No. If she got morphine two years before she died, it's
25 an irrelevant fact.
1 Q. You certainly would have indicated that prior opiate
2 experience for a patient is important to consider when
3 administering opiate medications?
4 A. You need to know if your patient is tolerant to that
5 drug. If they had been getting regular treatments with that
6 drug, it changes their tolerance to the drug. If you use a
7 lot of opiates, you get less effect for the same amount.
8 Q. Okay. So let's say that we don't even consider the
9 morphine that was given. Let's talk about just opiates just
10 before her admission to the unit. We talked about the years
11 of records that we have here. Let's talk about just prior,
12 two months prior. You've indicated that you did review the
13 nursing home records?
14 A. I reviewed the records that were given to me, yes.
15 Q. Okay. Let's go to state's exhibit 4A. This is nursing
16 home record page 851. This is a narcotic record included in
17 the nursing home records from Sandy Regional. You can step
18 down if you would like to see it better. This is a
19 prescription for Mary Crane for hydrocodone, which is an
20 opiate based prescription pain medication. There's a date
21 here of 10/12/95, just two months before her admission to the
22 unit.
23 Do you see here that starting on 10/21, almost on a daily
24 basis, this patient is receiving hydrocodone, or Lortab, for
25 pain?
1 A. I see that, yes.
2 Q. And you would have reviewed this at some point, if the
3 state provided it to you, when you made your findings and
4 your conclusions in this case?
5 A. If they had provided it to me, yes, but I don't have
6 that. It's not included in the medication records that I
7 have.
8 Q. Would you disagree, Doctor, that there were certainly
9 symptoms of pain in Mary Crane while she was on the unit?
10 A. The nursing notes that I read, it was very unclear that
11 she had pain. The one comment that I remember specifically
12 was the nurse gave her acetaminophen, which is Tylenol, and
13 talked to her for a bit and she seemed to be much better
14 then.
15 Q. Let's go to the records. You said you reviewed them and
16 looked at the medical records for the geropsych unit. Were
17 you aware that when she was assessed -- when she was admitted
18 on December 28th, 1995, they asked Ms. Crane to rate her pain
19 on a one to five scale and she rated it a five?
20 A. I'm aware that there is one comment in there about pain.
21 Q. In fact, there are two comments about pain by Mary Crane.
22 Do you recall the second comment?
23 A. The one that I recall was her statement that says what do
24 you want to have changed, or something like this. The
25 handwriting is from the person who is doing the assessment.
1 It says pain.
2 Q. So although you could not in your autopsy see something,
3 some magical thing on the body that would indicate, in your
4 opinion, pain, you do not dispute that at least this patient
5 on admission reported being in pain?
6 A. My interpretation is this woman was --
7 Q. I'm asking you if you base -- if you disagree that she
8 reported that she was in pain?
9 A. I think she probably did say that.
10 Q. Okay. Let's go to the nurse's notes and what they
11 observed. Again, you would have reviewed the nurse's notes
12 and those would have been relevant to your opinion?
13 A. Correct.
14 Q. I'll skip over -- we talked about this. Well, let's go
15 back. This is part of the rate your pain scale. I will
16 point out, and you reviewed this record before you made your
17 opinion, but this is a woman with a history of back pain, a
18 hip fracture on the right side, and frequent falls. So,
19 again, these are all things that certainly could cause pain
20 in this patient?
21 A. They could.
22 Q. Let's go to January 3rd, and this is state's exhibit
23 four, med 319. January 3rd, patient crying out in group,
24 groaning, yelling, grimacing. Would you agree that those
25 sound like a patient who could be in pain?
1 A. They could be.
2 Q. And we'll go to state's four, med 321. Patient who,
3 although she's already on the Duragesic patch at this time,
4 continues to moan and is given Tylenol that has little
5 effect.
6 A. That's what it says.
7 Q. And a patient who says I hurt?
8 A. That's what it says.
9 Q. You would have reviewed these as part of your examination
10 and report to the state?
11 A. I did review these.
12 Q. We'll go now to 326. You would agree that after this
13 patient was administered morphine she appeared to get some
14 relief. The quote is "patient appears more comfortable after
15 receiving morphine."
16 A. Morphine is a very powerful sedative drug. It can
17 relieve pain and can also put you to sleep despite your pain,
18 or no pain.
19 Q. You would agree that one way to tell if someone is in
20 pain is to give them a pain medication and see if they
21 respond?
22 A. Well, you don't know if it's a therapeutic effect or
23 placebo effect.
24 Q. The question I have to you is, if a patient -- if you
25 have a patient that is moaning, grimacing, that sort of
1 thing?
2 A. That's right. And we have a patient who has Alzheimer's
3 and who is rated as being demented.
4 Q. And this kind of patient has a difficult time expressing
5 how they hurt or where they hurt or if they hurt?
6 A. That I don't know for a fact.
7 Q. But we actually see moaning and grimacing and those are
8 sort of universally accepted symptoms of pain?
9 A. They are symptoms of a lot of things.
10 Q. So is it ultimately your opinion that this woman had no
11 pain?
12 A. I don't know that this proves that she has pain.
13 THE COURT: That's not the question.
14 THE WITNESS: She could have pain and it could be a
15 symptom of pain.
16 Q. (BY MS. ISAACSON) And you would agree that you were
17 completely oblivious to the fact that at least her previous
18 physicians had treated her with pain medications?
19 A. I saw Tylenol and that sort of treatment in her nursing
20 home chart. It was not -- the narcotic pain medications were
21 not included in the records from the nursing home that I had
22 prior to her being admitted to Davis.
23 Q. The bottom line is that this woman could have died of a
24 number of natural causes?
25 A. She could have, yes.
1 Q. And the bottom line is you were unaware of her pain
2 condition and her past pain medication treatment?
3 A. No. I am aware that when she came into Davis Hospital
4 pain was added to her diagnosis list.
5 Q. Ma'am, we've looked at the records. Do you deny that she
6 was on pain medications, opiate based pain medications, for
7 years prior to being admitted to the unit?
8 A. No, I'm not denying these records. These are here. And
9 this set of records stops in 1994.
10 Q. Well, we looked together up on the screen at the last two
11 months, and we could go through page by page, but you would
12 agree that there is a record from her nursing home where this
13 is a woman who had been treated with opiates?
14 A. I agree with that.
15 Q. And you said before that it's important for you to know,
16 if this woman ultimately gets morphine, as to whether or not
17 she had opiates before, because her -- if she has a tolerance
18 it makes a difference?
19 MR. WILSON: I'll object. I think we've been over
20 this territory time and time again.
21 THE COURT: Overruled. We need a straight answer.
22 Q. (BY MS. ISSACSON) You said in your report that the
23 occurrence of a new condition requiring a narcotic analgesia
24 was not documented?
25 A. That's true.
1 Q. A big part of your opinion is, number one, that she's not
2 in pain; and, number two, she had never had anything other
3 than Tylenol. That's a big part of your opinion, would you
4 agree?
5 A. No, I wouldn't say that.
6 Q. Well, let's go through the report, then. You have two
7 whole sections -- most of the report talks about pain relief
8 was accomplished with nonprescription medication in the
9 convalescent center at which she'd reside?
10 A. That's what is documented in the records that I have.
11 Q. And you were wrong?
12 A. Well, then you would have to say that the records I have,
13 which are her day to day medical records where the nurses are
14 noting what they give her, are wrong.
15 Q. The state didn't give you the record of her prior opiate
16 use, did not provide that information to you?
17 A. Okay. So she's getting two Lortabs a day according to
18 the records that you gave me.
19 Q. The state did not inform you that this woman had been on
20 opiates for years prior to her admission?
21 A. That's true.
22 Q. And you were wrong in your report when you said she'd
23 only been treated with nonprescription pain medication? You
24 were wrong?
25 A. That's right. That's true, then.
1 Q. And although you say there's no new condition requiring
2 narcotic analgesics, that's based upon your assumption that
3 she'd never been treated with narcotics before?
4 A. No. We're talking about the medical history once she got
5 into Davis Hospital, a new condition.
6 Q. But you have indicated and it is part -- you agree that
7 if someone is on opiates before, then it's a different
8 analysis if she's given opiates when she's there on the unit?
9 A. It has to do with her tolerance and her ability to
10 withstand the sedating and respiratory depressing effects of
11 those drugs.
12 Q. And although you could not see a new condition in the
13 autopsy, you would agree that in the chart notes and in the
14 report from the patient there are symptoms of pain? There
15 are reports of pain and observations of behaviors consistent
16 with pain?
17 A. There are.
18 Q. And that pain was treated?
19 A. Those same observations of moaning and groaning were
20 present in Sandy. I don't know that that's new.
21 Q. And those symptoms, the moaning, the groaning, were
22 alleviated when morphine was administered to this patient?
23 A. That's true.
24 MS. ISSACSON: I have nothing further.
25 THE COURT: Redirect.
1 MR. WILSON: Just a couple of questions.
2 REDIRECT EXAMINATION
3 BY MR. WILSON:
4 Q. You skated that there were two Duragesic patches which
5 were located on the back of this body, is that correct?
6 A. Yes.
7 Q. Can you tell us the dosage on those patches?
8 A. Umm, one of them was labeled 50 micrograms per hour and
9 the other one was labeled 25 micrograms per hour.
10 Q. Can you characterize for us, Doctor, in your experience
11 the strength of those dosages?
12 MS. ISSACSON: Objection. Beyond the scope of
13 cross.
14 THE COURT: Overruled.
15 THE WITNESS: 25 micrograms per hour is the starting
16 dose. The doses at which the drugs increase are at 25 -- I
17 think at 25 microgram increments. I think a hundred is the
18 largest that is made.
19 Q. (BY MR. WILSON) Okay. Now, assume, if you would, that
20 the evidence shows that there was an average of one Lortab or
21 Hy-Phen that was administered to Mary Crane over the last two
22 months that she was in the nursing home prior to entering the
23 geropsych unit. Can you tell us, Doctor, would that -- and
24 these were five milligram tablets. Can you tell us would
25 that change your opinion in any way as relates to your
1 autopsy findings?
2 A. No.
3 Q. And why is that, Doctor?
4 A. First of all, that's a fairly low dose of hydrocodone.
5 And being given on a regular basis like that it doesn't -- if
6 she's been given it years on end, there's no evidence that
7 she's accelerating her use of it. She's not getting
8 tolerant. She's not metabolizing the drug and getting less
9 effect, if they're able to accomplish what they want with
10 just the same dose for years on end. And when she was
11 admitted to Davis she was getting Fentanyl, which is a much
12 more potent drug. She was being given morphine by injection.
13 This is a very accelerated rate of administration of
14 narcotics.
15 MR. WILSON: Thank you. Nothing further.
16 MS. ISSACSON: Nothing further, Your Honor.
17 THE COURT: You may step down, Doctor. Thank you
18 for testifying. May this witness be excused?
19 MR. WILSON: We would so request, Your Honor.
20 MS. ISSACSON: No objection.
21 THE COURT: You are excused. Thank you.