Michael Crookston, MD
2 MR. WILSON: WE'D CALL DR. CROOKSTON TO THE STAND AT
3 THIS TIME, YOUR HONOR.
4 THE COURT: DR. CROOKSTON, IF YOU'D COME RIGHT UP
5 HERE, PLEASE. WOULD YOU RAISE YOUR RIGHT HAND, PLEASE, AND
6 FACE THE CLERK?
7 MICHAEL JAMES CROOKSTON,
8 BEING FIRST DULY SWORN, WAS EXAMINED AND
9 TESTIFIED AS FOLLOWS:
10 THE COURT: IF YOU'LL HAVE A SEAT UP HERE, PLEASE,
11 DOCTOR.
12 GIVE US YOUR FULL NAME AND SPELL YOUR LAST NAME, IF YOU
13 WOULD.
14 THE WITNESS: MICHAEL JAMES CROOKSTON,
15 C-R-O-O-K-S-T-O-N.
16 DIRECT EXAMINATION
17 BY MR. WILSON:
18 Q. DR. -- DR. CROOKSTON, WHERE ARE YOU CURRENTLY EMPLOYED?
19 A. PRIMARILY AT L.D.S. HOSPITAL, INTERMOUNTAIN HEALTH CARE.
20 Q. AND IN WHAT CAPACITY ARE YOU EMPLOYED THERE?
21 A. I'M A STAFF PSYCHIATRIST. I'M THE MEDICAL DIRECTOR OF
22 THE DAYSPRING DRUG AND ALCOHOL TREATMENT UNIT.
23 Q. AND WHAT -- THAT UNIT IS SET UP FOR WHAT PURPOSE?
24 A. MOSTLY DETOXIFICATION. AND THEN WE HAVE SUBSEQUENT
25 OUT-PATIENT PROGRAMS TO TREAT PEOPLE.
1 Q. OKAY. CAN YOU BRIEFLY GIVE US AN OVERVIEW OF YOUR
2 EDUCATIONAL BACKGROUND AS TO WHEN YOU GRADUATED FROM MEDICAL
3 SCHOOL AND WHERE THAT WAS?
4 A. I ATTENDED THE UNIVERSITY OF UTAH AND GRADUATED IN 1980.
5 I THEN ATTENDED AN ANESTHESIOLOGY INTERNSHIP AND RESIDENCY
6 ALSO AT THE UNIVERSITY OF UTAH. FINISHED THAT IN 1983. AND
7 THEN PRACTICED ANESTHESIA FOR A NUMBER OF YEARS IN LOGAN,
8 UTAH.
9 I THEN LEFT THAT FIELD AND RETURNED TO DO A RESIDENCY IN
10 PSYCHIATRY. AND SUBSEQUENTLY BECAME BOARD CERTIFIED IN ADULT
11 PSYCHIATRY, AND THEN AFTER TWO MORE YEARS, CHILD AND
12 ADOLESCENT PSYCHIATRY, AND THEN IN ADDICTION PSYCHIATRY.
13 Q. DO YOU HOLD A BOARD CERTIFICATION IN ANESTHESIOLOGY ALSO?
14 A. YES, I DO.
15 Q. OKAY. AND IN REFERENCE TO SINCE GRADUATING FROM MEDICAL
16 SCHOOL, YOU SAY YOU PRACTICED IN THE LOGAN AREA FOR A NUMBER
17 OF YEARS?
18 A. YES.
19 Q. AND WHEN DID YOU RETURN TO THIS AREA TO -- TO PRACTICE?
20 A. I RETURNED TO DO A PSYCHIATRIC RESIDENCY IN 1991.
21 Q. OKAY. AND YOU GRADUATED -- OR I SHOULDN'T SAY YOU
22 GRADUATED -- YOU GOT YOUR BOARD CERTIFICATION, WHAT YEAR WAS
23 THAT?
24 A. 1987, FOR PSYCHIATRY.
25 Q. IN -- IN PSYCHIATRY?
1 A. 1997. I'M SORRY.
2 Q. OKAY.
3 A. ADULT PSYCHIATRY, AND THEN CHILD-ADOLESCENT PSYCHIATRY.
4 Q. OKAY. IN THE EXPERIENCE -- DO YOU HAVE EXPERIENCE YOU
5 SAID IN ANESTHESIOLOGY AND THE ADMINISTRATION OF THOSE TYPES
6 OF MEDICATIONS?
7 A. YES.
8 Q. DOES THAT INCLUDE PAIN MANAGEMENT, SIR?
9 A. YES, IT DOES. PAIN MANAGEMENT CONTINUES TO BE A PART OF
10 MY PRACTICE TODAY.
11 Q. OKAY. IN TERMS OF YOUR -- YOUR PRACTICE, DO YOU EVER SEE
12 OR ATTEND TO GERIATRIC PATIENTS?
13 A. YES, I DO.
14 Q. CAN YOU TELL US HOW FREQUENTLY YOU -- YOU HAVE SEEN
15 GERIATRIC PATIENTS?
16 A. IN SPITE OF THE FACT THAT I'M A CHILD-ADOLESCENT
17 PSYCHIATRIST, THAT PART OF MY PRACTICE HAS BEEN GRADUALLY
18 DECLINING AS I TREAT MORE AND MORE ADULTS WITHIN THE
19 DAYSPRING DRUG AND ALCOHOL TREATMENT PROGRAMS. BUT I -- WE
20 DO GET THE ELDERLY ADMITTED FOR THE SAME REASONS TO THAT
21 UNIT. DRUG AND ALCOHOL PROBLEMS THAT REQUIRE DETOXIFICATION.
22 I ALSO HAVE SEVERAL OLDER PATIENTS THAT I SEE IN MY
23 OUT-PATIENT PRACTICE.
24 Q. OKAY. CAN YOU TELL US, AS FAR AS THE GERIATRIC PATIENTS
25 GO, DO YOU -- DO YOU SEE PATIENTS WHO ARE SUFFERING FROM
1 DEMENTIA?
2 A. FEWER OF THOSE AS A GENERAL RULE.
3 Q. OKAY. NOW, IN THE COURSE OF THESE -- PREPARING FOR THESE
4 PROCEEDINGS, DID YOU HAVE OCCASION TO REVIEW THE RECORDS OF
5 -- THE MEDICAL RECORDS OF THE VARIOUS PATIENTS THAT ARE
6 SUBJECT MATTER OF THE PROCEEDING HERE TODAY?
7 A. YES. I WAS GIVEN A COPY OF THE MEDICAL CHARTS OF ALL
8 FIVE OF THE PATIENTS.
9 Q. AND, PRIMARILY, WHERE WERE THOSE RECORDS FROM? DO YOU
10 REMEMBER?
11 A. DAVIS HOSPITAL.
12 Q. DID YOU RECEIVE ANY OTHER RECORDS IN THE COURSE OF YOUR
13 REVIEW, OTHER THAN THE ONES THAT WERE IDENTIFIED AS THE DAVIS
14 HOSPITAL RECORDS?
15 A. I WAS SUBSEQUENTLY PROVIDED WITH SOME AUTOPSY REPORT
16 MATERIAL.
17 Q. OKAY. AND BESIDES THAT, WERE THERE ANY OTHER RECORDS
18 THAT YOU CAN REMEMBER PERTAINING TO THESE PATIENTS THAT YOU
19 REVIEWED? NO NURSING HOME RECORDS OR ANYTHING OF THAT
20 NATURE?
21 A. NO, NO NURSING HOME RECORDS.
22 Q. OKAY. CAN YOU TELL US, SIR, DID YOU CONSULT ANY
23 PROFESSIONAL JOURNALS OR TEXTBOOKS IN THE COURSE OF FORMING
24 YOUR OPINIONS?
25 A. I DID, YES.
1 Q. CAN YOU DEFINE WHAT TEXTBOOKS AND JOURNALS THAT YOU
2 REFERENCED IN THE COURSE OF -- OF MAKING YOUR REVIEW OF THESE
3 MEDICAL RECORDS?
4 A. FIRST OF ALL THE 1995 AND 1996 EDITIONS OF THE
5 PHYSICIANS' DESK REFERENCE ON MEDICATIONS. THE 13TH --
6 Q. CAN YOU TELL US -- CAN YOU TELL US WHY YOU REFERENCED
7 THOSE PARTICULAR YEARS OF THE -- OF THE P.D.R.?
8 A. THEY SEEMED TO ME TO BE THE ONES THAT WOULD BE MOST
9 APPLICABLE TO THE TIME PERIOD IN QUESTION HERE.
10 Q. OKAY.
11 A. AND ALL EXCEPT FOR A DRUG CALLED SERZONE, THE OTHER DRUGS
12 WERE IN THE 1995 P.D.R. SERZONE DID NOT APPEAR UNTIL 1996.
13 Q. OKAY. CAN YOU TELL US IF YOU LOOKED AT -- YOU SAID YOU
14 REFERENCED OTHER PROFESSIONAL JOURNALS AND TEXTBOOKS IN
15 MAKING THIS REVIEW?
16 A. HARRISON'S PRINCIPLES OF INTERNAL MEDICINE, THE 13TH
17 EDITION, COPYRIGHTED IN 1994. GOODMAN AND GILMAN'S, THE
18 PHARMACOLOGICAL BASIS OF THERAPEUTICS, 9TH EDITION,
19 COPYRIGHTED IN 1996. THE KAPLAN AND SADDOCK
20 STANDARD TEXTBOOK OF PSYCHIATRY, COPYRIGHTED IN 1995. THAT
21 WOULD BE THE 6TH EDITION OF THE TEXTBOOK. AND THEN A
22 SYNOPSIS OF TREATMENTS OF PSYCHIATRIC DISORDERS, 2ND EDITION,
23 COPYRIGHTED IN 1996.
24 Q. ARE THESE ALL WELL-RECOGNIZED TEXTBOOKS AND AUTHORITIES
25 IN -- IN THOSE AREAS?
1 A. YES, THEY ARE.
2 Q. IN REFERENCE TO THE -- YOUR EXPERTISE, YOU DEAL WITH
3 PSYCHOTROPIC MEDICATIONS, I TAKE IT; IS THAT CORRECT?
4 A. EVERY DAY.
5 Q. AND HAVE YOU HAD OCCASION TO -- IN REVIEWING THE MEDICAL
6 RECORDS OF THESE FIVE INDIVIDUALS, DID YOU IDENTIFY CERTAIN
7 SUBSTANCES THAT WERE IDENTIFIED AS PSYCHOTROPIC MEDICATIONS
8 THAT WERE USED IN CONNECTION WITH THEIR TREATMENT?
9 A. YES. SEVERAL.
10 Q. I'M GOING TO SHOW YOU WHAT'S BEEN PREVIOUSLY MARKED AS
11 STATE'S EXHIBIT NUMBER 10 AND ASK YOU, IF YOU WOULD, MAYBE
12 YOU CAN STEP DOWN HERE AND WE CAN PUT IT UP AND LET THE JURY
13 TAKE A LOOK AT IT.
14 HAVE YOU SEEN THAT PARTICULAR --
15 THE COURT: CAN YOU SEE THAT, LADIES AND GENTLEMEN?
16 CAN YOU SEE THAT OKAY? ALL RIGHT.
17 Q. (BY MR. WILSON) HAVE YOU SEEN THAT PARTICULAR EXHIBIT
18 BEFORE, DOCTOR?
19 A. YES, I HAVE.
20 Q. AND CAN YOU TELL US WHAT -- WHAT DOES IT RELATE TO IN
21 THAT PARTICULAR EXHIBIT?
22 A. IT LISTS SEVERAL PSYCHOTROPIC MEDICATIONS AND ALSO PAIN
23 MEDICATIONS WITH ACCEPTED STANDARD ADULT STARTING DOSES AND
24 RECOMMENDED STARTING DOSES IN THE ELDERLY.
25 Q. OKAY.
1 MS. ISAACSON: YOUR HONOR, MAY WE APPROACH THE
2 BENCH?
3 THE COURT: YOU MAY.
4 (OFF-THE-RECORD DISCUSSION AT THE BENCH.)
5 Q. (BY MR. WILSON) HAVING REVIEWED THAT PARTICULAR EXHIBIT,
6 SIR, CAN YOU TELL US, DO YOU AGREE OR DISAGREE WITH THE
7 REFERENCES AS TO THE ADULT STARTING DOSES AND THE ELDERLY
8 STARTING DOSES IN THAT PARTICULAR EXHIBIT?
9 A. IN GENERAL, WITH A COUPLE OF EXCEPTIONS.
10 Q. OKAY. WOULD YOU POINT OUT THOSE EXCEPTIONS, PLEASE?
11 A. FIRST OF ALL, DEPAKENE IS GENERALLY NOT STARTED IN EITHER
12 ADULTS OR THE ELDERLY AT FULL DOSE ON THE FIRST DAY.
13 Q. OKAY.
14 A. BECAUSE OF INCREASED POTENTIAL FOR SIDE EFFECTS, WHICH IS
15 FREQUENTLY GASTROINTESTINAL UPSET.
16 THE COURT: DOCTOR, YOU NEED TO SPEAK UP. AND SO DO
17 YOU, MR. WILSON, SO EVERYBODY CAN HEAR.
18 MR. WILSON: THANK YOU, YOUR HONOR.
19 THE COURT: ALL RIGHT. THANK YOU.
20 Q. (BY MR. WILSON) WHAT OTHER -- WHAT OTHER --
21 A. AND TRAZODONE IS THE OTHER ONE THAT MY EXPERIENCE IS
22 THAT'S A SIGNIFICANTLY SEDATING DOSE, EVEN FOR A HEALTHY
23 ADULT.
24 Q. COULD YOU SPEAK A LITTLE LOUDER, PLEASE?
25 A. AND I RARELY, IF EVER, WOULD START A PERSON ON THAT DOSE
1 THE FIRST DAY.
2 Q. OKAY. THANK YOU, DOCTOR. GO AHEAD AND HAVE A SEAT.
3 NOW, I'M GOING TO SHOW YOU WHAT'S DESIGNATED AS STATE'S
4 EXHIBIT NUMBER 9. CAN YOU SEE THAT FROM THERE, DOCTOR?
5 A. YES. I HAVE REVIEWED THIS EARLIER.
6 Q. OKAY. AND CAN YOU TELL US WHAT THAT EXHIBIT PORTRAYS?
7 A. IN GENERAL IT POINTS OUT THAT THE ACTION OF MEDICATIONS
8 IN THE ELDERLY IS DIFFERENT FROM THE GENERAL ADULT HEALTHY
9 PERSON, AND THAT DRUGS MAY HAVE LONGER HALF LIVES, MAY HAVE
10 MORE INTENSE EFFECTS, AND MORE LIKELY TO CAUSE SIDE EFFECTS
11 IN THE ELDERLY COMPARED TO THE AVERAGE PERSON.
12 Q. OKAY. NOW, YOU'VE REVIEWED THE EXHIBIT ITSELF. WOULD
13 YOU AGREE OR DISAGREE WITH THE -- THE PHARMACOLOGY IN THE
14 ELDERLY AND ALSO THE SPECIAL CONSIDERATIONS IN THE ELDERLY?
15 A. I -- I WOULD AGREE WITH IT.
16 Q. OKAY.
17 A. I WOULD HAVE ADDED ONE THING THOUGH.
18 Q. WHAT IS THAT, SIR?
19 A. ATIVAN, WHICH IS A BENZODIAZEPINE-TYPE DRUG, HAS THE
20 POTENTIAL TO JUST CAUSE PEOPLE TO BE DISINHIBITED OR TO LOSE
21 THEIR INHIBITIONS. AND THAT I THINK IS MORE LIKELY TO HAPPEN
22 IN AN ELDERLY PERSON THAN A YOUNG ADULT, BUT IT CAN HAPPEN IN
23 YOUNG ADULTS AS WELL.
24 Q. OKAY. THANK YOU.
25 I JUST WANT TO GO OVER SOME SPECIFIC PSYCHOTROPIC
1 MEDICATIONS WITH YOU AT THIS TIME, IF I MIGHT. THE
2 MEDICATION CLONIDINE OR KLONOPIN I THINK IT'S REFERRED TO AT
3 TIMES --
4 A. THOSE ARE -- I'M SORRY. THOSE ARE TWO SEPARATE
5 MEDICATIONS.
6 Q. OH, ARE THEY TWO SEPARATE? I'M SORRY. WELL, FIRST LET'S
7 REFERENCE CLONIDINE THEN. CAN YOU TELL US WHAT THAT
8 MEDICATION IS?
9 A. CLONIDINE IS A BLOOD PRESSURE MEDICATION.
10 Q. OKAY. THAT IS NOT A PSYCHOTROPIC MEDICATION THEN, I TAKE
11 IT?
12 A. IT'S USED AS A PSYCHOTROPIC MEDICATION.
13 Q. AND WHAT TYPE OF USE IS IT -- DOES IT PERTAIN TO?
14 A. IN CHILDREN IT CAN BE USED TO DECREASE HYPERACTIVITY,
15 ALSO IS SOMEWHAT SEDATING. IN ADULTS IT'S USED SOMETIMES TO
16 DECREASE ANXIETY OR REACTIVITY TO THEIR ENVIRONMENT. AND
17 SO IT -- IT CAN AND IS USED AS A PSYCHOTROPIC MEDICATION
18 DESPITE BEING LABELED A BLOOD PRESSURE PILL. IT'S ALSO USED
19 IN OPIATE WITHDRAWAL SYNDROMES TO DECREASE WITHDRAWAL SIDE
20 EFFECTS.
21 Q. LET ME ASK YOU ON THE -- ON THE DRUG KLONOPIN WHICH YOU
22 SAID IS A SEPARATE DRUG FROM CLONIDINE, CAN YOU TELL US, DOES
23 THAT HAVE ANY PSYCHOTROPIC APPLICATIONS?
24 A. KLONOPIN, OR CLONAZEPAM IS THE GENERIC NAME, IS ANOTHER
25 BENZODIAZEPINE DRUG WHICH IS USED FOR ANXIETY. IT WAS
1 ORIGINALLY RELEASED FOR THE TREATMENT OF SEIZURES, BUT HAS
2 FOUND MUCH WIDER SPREAD USE IN THE TREATMENT OF ANXIETY
3 SYNDROMES, PANIC DISORDER, FOR EXAMPLE, OR SEVERE ANXIETY.
4 IT'S FAIRLY SEDATING AND SOMETIMES IS ALSO USED TO HELP
5 PEOPLE SLEEP.
6 Q. SO THE SIDE EFFECTS ARE SEDATION?
7 A. AND OTHER SIDE EFFECTS INCLUDE EFFECTS ON MEMORY, EFFECTS
8 ON COORDINATION. IT CAN MAKE A PERSON BE MORE CLUMSY AND
9 FORGETFUL. IT CAN BE DISINHIBITING JUST LIKE THE ATIVAN WAS.
10 IT CAN CAUSE A PERSON WHO ORDINARILY WOULDN'T TAKE THEIR
11 CLOTHES OFF, MIGHT DO THAT.
12 Q. OKAY.
13 A. IT --
14 Q. NOW, YOU'VE TALKED A LITTLE BIT ABOUT ATIVAN. WHAT'S ITS
15 USE FOR IN -- IN A PSYCHIATRIC ARENA?
16 A. SIMILAR USES. MOSTLY TO TREAT ANXIETY AND AGITATION. IT
17 HAS SIMILAR SIDE EFFECTS, MEMORY PROBLEMS, COORDINATION
18 PROBLEMS. PEOPLE HAVE BEEN CHARGED WITH A D.U.I. WHEN
19 DRIVING UNDER THE INFLUENCE OF THESE MEDICATIONS BECAUSE IN
20 SUFFICIENT QUANTITY IN A PERSON WHO'S SUSCEPTIBLE TO IT,
21 THAT'S HOW THEY'LL APPEAR. THEY'LL APPEAR TO BE DRUNK.
22 Q. OKAY. HALDOL, THE DRUG HALDOL.
23 A. HALDOL IS A MAJOR TRANQUILIZER OR ANTIPSYCHOTIC OR
24 NEUROLEPTIC MEDICATION. WE CALL THEM BY DIFFERENT NAMES.
25 IT'S ONE OF THE OLDEST AND HAS BEEN USED FOR A LONG TIME TO
1 TREAT PSYCHOTIC, AGITATED OR AGGRESSIVE BEHAVIOR.
2 Q. DOES IT HAVE -- EXCUSE ME. GO AHEAD.
3 A. FOR A LONG TIME IT WAS THE ONLY INJECTABLE NEUROLEPTIC
4 MAJOR TRANQUILIZER THAT WE HAD.
5 Q. CAN YOU TELL US WHETHER OR NOT THERE ARE ANY RISKS OR
6 SIDE EFFECTS ASSOCIATED WITH ITS ADMINISTRATION?
7 A. IT IS A VERY POTENT DRUG. THERE ARE REPORTS OF DEATHS
8 FROM THAT DRUG FROM SIDE EFFECTS. THERE ARE REPORTS FROM
9 PNEUMONIA FROM THAT DRUG. ONE WAY TO THINK OF IT IS THAT
10 IT'S THE TYPE OF DRUG THAT GETS USED IN A MENTAL HOSPITAL
11 THAT MAKES PEOPLE LOOK LIKE A ZOMBIE BECAUSE IT SLOWS THEM
12 DOWN. IT CAN MAKE THEM VERY STIFF. IT CAN CAUSE A REACTION
13 CALLED DYSTONIA WHICH IS A VERY SEVERE SUDDEN MUSCLE CRAMP,
14 WHICH IF IT INVOLVES THE -- THE MUSCLES OF THE -- OF THE NECK
15 AND THE VOICE BOX CAN BE LIFE-THREATENING.
16 Q. DOES IT HAVE ANY SEDATING QUALITIES?
17 A. IT IS SEDATING, YES, AND IT'S MUCH MORE POTENT WHEN GIVEN
18 BY INJECTION THAN WHEN GIVEN ORALLY.
19 Q. TRAZODONE.
20 A. TRAZODONE IS AN OLDER DRUG ORIGINALLY RELEASED AND
21 MARKETED AS AN ANTIDEPRESSANT. AND IT IS NOT USED OFTEN AS
22 ANTIDEPRESSANT BECAUSE IT'S PRIMARY SIDE EFFECT IS SEDATION.
23 IT'S THE WIDELY -- IT'S THE MOST WIDELY PRESCRIBED SLEEP AID
24 AMONG PSYCHIATRISTS NOW IN SMALLER DOSES AND IT'S PRESCRIBED
25 SIMPLY TO HELP PEOPLE SLEEP RATHER THAN FOR THEIR DEPRESSION.
1 Q. OKAY. THE DRUG RISPERDAL, CAN YOU TELL US A LITTLE BIT
2 ABOUT IT?
3 A. RISPERDAL IS THE SAME CLASS OF DRUGS AS HALDOL. IT'S A
4 MAJOR TRANQUILIZER, NEUROLEPTIC, ANTIPSYCHOTIC DRUG. BUT IN
5 A NEWER GENERATION IT'S CALLED AN ATYPICAL BECAUSE IT HAS
6 FEWER OF SOME OF THE SEVERE SIDE EFFECTS AND IS LESS LIKELY
7 TO CAUSE SOME OF THE THOSE SIDE EFFECTS THAN HALDOL.
8 Q. OKAY.
9 A. STILL A VERY POTENT DRUG.
10 Q. THE DRUG DEPAKENE.
11 A. DEPAKENE IS A FORM OF VALPROIC ACID OR VALPROATE.
12 Q. WHAT DOES THAT MEAN?
13 A. IT'S AN ANTICONVULSANT. IT'S USED TO TREAT EPILEPSY IS
14 WHAT IT WAS DEVELOPED FOR. IN THAT FORM, IT'S PARTICULARLY
15 HARSH ON A PERSON'S STOMACH. PEOPLE DON'T TOLERATE IT VERY
16 WELL UNLESS IT'S GRADUALLY INCREASED. IT SUBSEQUENTLY WAS
17 REFORMULATED AS DEPAKOTE WHICH IS A MUCH EASIER FORM FOR
18 PEOPLE TO -- TO SWALLOW AND NOT GET SO MUCH UPSET STOMACH.
19 AND IT'S -- AND IT'S GAINED WIDESPREAD USE AS A MOOD
20 STABILIZER FOR TREATING BIPOLAR ILLNESS AND IT'S ALSO USED TO
21 TREAT AGGRESSION.
22 Q. OKAY. CAN YOU TELL US, DOCTOR, IN REFERENCE TO THE DRUGS
23 THAT WE'VE JUST GONE THROUGH, DO ALL OF THESE DRUGS HAVE
24 CENTRAL NERVOUS SYSTEM DEPRESSANT QUALITIES ABOUT THEM?
25 A. YES.
1 Q. OKAY. AND IN RESPECT TO THEIR USE IN THE GERIATRIC
2 ARENA, IS THERE -- IS THERE ANY OF THE SIDE EFFECTS -- OR CAN
3 YOU CHARACTERIZE FOR US WHETHER OR NOT THERE'S A DIFFERENCE
4 IN THE WAY YOU WOULD TREAT A GERIATRIC PATIENT WITH THESE
5 DRUGS THAN YOU WOULD WITH A HEALTHY, NORMAL ADULT?
6 A. THERE'S A VERY BIG DIFFERENCE. BECAUSE THE ELDERLY ARE
7 MORE SUSCEPTIBLE TO SIDE EFFECTS AND MORE SUSCEPTIBLE TO THE
8 PEAK EFFECTS OF THESE DRUGS, THE GENERAL RULE, THE STANDARD
9 DICTUM IN EVERY TEXTBOOK FOR TREATING -- THAT I'VE REVIEWED
10 IN EVERY TEXTBOOK THAT TALKS ABOUT TREATMENT FOR THE ELDERLY
11 IS THAT YOU START OUT A LOW DOSE AND YOU INCREASE IT VERY
12 SLOWLY. AND THAT TOO MUCH TOO FAST IS GOING TO CAUSE
13 PROBLEMS OR MAY CAUSE PROBLEMS IN THE ELDERLY.
14 Q. OKAY. ARE THERE ALSO -- WHEN YOU SAY PROBLEMS, CAN YOU
15 CHARACTERIZE FOR US WHAT THOSE PROBLEMS, THOSE RISKS ARE?
16 A. WELL, OVERSEDATION WOULD BE ONE. AND AN ELDERLY PERSON
17 THAT BECOMES OVERSEDATED BECOMES IMMOBILE, DOESN'T BREATHE AS
18 DEEPLY, DOESN'T CLEAR THEIR LUNGS AS FREQUENTLY. AND THAT'S
19 ONE OF THE WAYS THAT THESE DRUGS CAN ACTUALLY LEAD TO FATAL
20 CONSEQUENCES THAT CAN SET THE PERSON UP FOR PNEUMONIA. WE
21 KNOW THAT THE ELDERLY DON'T TOLERATE BED RESTS FOR PROLONGED
22 PERIODS OF TIME. THEY RAPIDLY HAVE WHAT WE CALL
23 DECONDITIONING AND THERE ARE CHANGES IN THEIR HEART FUNCTION
24 AND IN THEIR MUSCLE STRENGTH AND IN THEIR FLEXIBILITY. AND
25 THEY DON'T JUST BOUNCE BACK FROM THAT VERY QUICKLY. IT CAN
1 TAKE WEEKS OR MONTHS AFTER A PERIOD OF BED REST. SO ANY DRUG
2 THAT IMMOBILIZES AN ELDERLY PERSON PUTS THEM AT RISK FOR
3 OTHER SERIOUS MEDICAL PROBLEMS AND DEVELOPMENTS.
4 Q. OKAY. LET'S TALK A LITTLE BIT ABOUT SOME OF THE PAIN
5 MEDICATIONS AND SOME OF THEM WERE REPRESENTED ON THE EXHIBIT.
6 CAN YOU TELL US ANYTHING ABOUT THE DURAGESIC PATCH?
7 A. DURAGESIC PATCH IS A TRANSDERMAL SYSTEM FOR DELIVERING
8 THE OPIATE NARCOTIC FENTANYL WHICH IS A VERY POTENT PAIN
9 RELIEVER. IN THE PATCH SYSTEM THE PERSON WEARS IT ON THEIR
10 SKIN FOR UP TO THREE DAYS AT A TIME AND GETS A CONTINUOUS
11 DOSE OF THIS DRUG DURING THAT TIME PERIOD. IT IN MANY WAYS
12 IS A VERY CONVENIENT WAY TO PROVIDE PAIN MEDICATION TO A
13 PERSON WHO NEEDS IT AROUND THE CLOCK CONSTANTLY, WITHOUT
14 HAVING TO REMEMBER TO TAKE A PILL OR WITHOUT HAVING TO GIVE
15 THEM AN INJECTION.
16 Q. WHAT ARE THE SIDE EFFECTS OF DURAGESIC PATCH?
17 A. THE NUMBER ONE SIDE EFFECT OF ANY OPIATE IS THE POTENTIAL
18 FOR RESPIRATORY DEPRESSION OR TO SLOW DOWN OR DECREASE OR IN
19 AN ADEQUATE DOSE TO ACTUALLY STOP A PERSON'S BREATHING.
20 Q. AS TO THE DRUG MORPHINE, CAN YOU TELL US A LITTLE BIT
21 ABOUT IT, WHAT TYPE OF DRUG IT IS?
22 A. MORPHINE IS ALSO AN OPIATE, ANALGESIC OR PAIN MEDICATION.
23 IT'S ONE OF THE OLDEST ONES WE HAVE. IT'S THE -- THE
24 STANDARD OPIATE PAIN MEDICATION THAT ALL OTHERS ARE COMPARED
25 TO. IT'S AVAILABLE ORALLY, RECTALLY, INJECTION. I DON'T
1 BELIEVE THAT THERE'S A SKIN PATCH. BUT IT'S A COMMONLY USED
2 DRUG, BUT IT HAS ALL OF THOSE OTHER SAME SIDE EFFECTS.
3 Q. DOES IT HAVE ANY USE IN THE PSYCHIATRIC CONTEXT?
4 A. FOR THE TREATMENT OF PAIN.
5 Q. OKAY. IT ALSO -- DOES IT -- DOES IT HAVE RISKS
6 ASSOCIATED WITH ITS USE?
7 A. SIGNIFICANT RISKS. AND AGAIN, SEDATION,
8 UNRESPONSIVENESS, IMMOBILIZATION. AND IN ADEQUATE DOSAGE,
9 LACK OF EFFECTIVE BREATHING OR -- OR NOT BREATHING.
10 Q. OKAY.
11 A. CESSATION OF BREATHING.
12 Q. CAN YOU TELL US, IS THERE A RISK OF DEATH ASSOCIATED WITH
13 THE ADMINISTRATION OF ANY OF THESE C.N.S.D. MEDICATIONS? AND
14 BY C.N.S.D. I MEAN CENTRAL NERVOUS SYSTEM DEPRESSANT
15 MEDICATIONS.
16 A. YES, AND -- BUT I WOULD ADD THERE'S A RISK OF DEATH WITH
17 VIRTUALLY ALL MEDICATIONS.
18 Q. OKAY.
19 A. INCLUDING ASPIRIN. PEOPLE DIE WITH AN ASPIRIN OVERDOSE
20 OR ALLERGY. SO ALL MEDICATIONS NEED TO BE GIVEN DUE RESPECT.
21 Q. WOULD A PHYSICIAN BE AWARE -- OR WOULD A PHYSICIAN --
22 SHOULD A EXAMINATION BE AWARE OF THOSE RISKS?
23 A. ABSOLUTELY.
24 Q. OKAY. AND IS THAT RISK GREATER IN TREATING GERIATRIC
25 POPULATIONS?
1 A. YES.
2 Q. AND WHY IS THAT, SIR?
3 A. BECAUSE THEY'RE MORE FRAIL, MORE SUSCEPTIBLE TO SIDE
4 EFFECTS AND PROBLEMS FROM MEDICATION. THEY HAVE MORE
5 PNEUMATICAL PROBLEMS TO BEGIN WITH THAT CAN INTERACT WITH THE
6 MEDICATION.
7 Q. OKAY.
8 A. WHICH MAKES IT TECHNICALLY MORE DIFFICULT TO PROVIDE
9 MEDICATION AND REQUIRES MUCH MORE VIGILANCE AND SKILL TO DO
10 IT -- TO DO IT WELL.
11 Q. WHAT KIND OF PRECAUTIONS DOES A PHYSICIAN TAKE PRIOR TO
12 ADMINISTERING -- OR IN ADMINISTERING THOSE TYPES OF
13 MEDICATIONS?
14 A. IN GENERAL A PHYSICIAN WANTS A COMPLETE MEDICAL HISTORY
15 AND AN EXAMINATION OF THAT PATIENT SO THAT THEY HAVE AS MUCH
16 INFORMATION AS POSSIBLE. AND PART OF THE HISTORY WOULD BE
17 WHAT MEDICATIONS THEY HAVE TAKEN PREVIOUSLY, MEDICATIONS THAT
18 THEY'RE ALLERGIC TO, HOW THEY RESPONDED TO PREVIOUS
19 MEDICATIONS, AT WHAT DOSES. WHAT THEIR CURRENT MEDICAL
20 STATUS IS, THEIR VITAL SIGNS, THEIR LEVEL OF CONSCIOUSNESS OR
21 ALERTNESS. AND THEN WHAT IS THE BEHAVIOR OR THE SYMPTOM OR
22 THE DISORDER, DISEASE THAT YOU WANT TO TREAT. AND IN ALL
23 CASES IT'S A QUESTION OF BALANCING RISK VERSUS BENEFIT.
24 Q. ARE YOU FAMILIAR WITH THE TERM DURATION, DOCTOR?
25 A. YES.
1 Q. DOES IT HAVE APPLICABILITY TO THE ADMINISTRATION OF THESE
2 TYPES OF MEDICATIONS?
3 A. IT DOES, BUT IT NEEDS TO BE CLEAR WHETHER WE'RE TALKING
4 ABOUT HALF LIFE OR DURATION OF ACTION.
5 Q. LET'S TALK ABOUT HALF LIFE AND DURATION. CAN YOU TELL US
6 WHAT HALF LIFE MEANS, OR HALF LIFE OF A DRUG MEANS?
7 A. A HALF LIFE OF A DRUG IS A MEASURED NUMBER FROM A
8 PERSON'S BLOOD STREAM OF HOW LONG IT TAKES FOR ANY GIVEN
9 LEVEL OF THE DRUG TO DECREASE BY HALF IN ITS CONCENTRATION.
10 Q. OKAY. AND DOES THAT HALF LIFE IN REFERENCE TO -- TO
11 THESE TYPES OF DRUGS, DOES IT VARY ACCORDING TO -- PATIENT BY
12 PATIENT?
13 A. IT DOES. IT'S KNOWN THAT THERE -- FOR MANY DRUGS THERE
14 ARE PEOPLE WHO METABOLIZE IT NORMALLY AND THERE ARE OTHERS
15 WHO FOR -- DUE TO MODIFICATIONS IN THEIR OWN LIVER ENZYMES
16 ARE SLOW METABOLIZERS OR POOR METABOLIZERS, THEY'RE OUTLIERS.
17 IT'S ALSO KNOWN IN THE ELDERLY THE HALF LIFE EXTENDS BECAUSE
18 OF THE PHYSIOLOGIC CHANGES THAT ARE GOING ON IN THEIR
19 SYSTEMS.
20 Q. OKAY. SO WHEN WE TALK ABOUT HALF LIFE, ARE WE TALKING
21 ABOUT ONE IN THE SAME THING AS DURATION?
22 A. NO, BECAUSE THE HALF LIFE IS ONLY THE MEASUREMENT OF THE
23 DRUG CONCENTRATION IN THE BLOOD STREAM. THE DRUGS WE'RE
24 TALKING ABOUT WORK IN THE BRAIN. AND WHAT YOU REALLY WANT TO
25 KNOW IS HOW LONG ARE THEY ACTIVE AT THE SITE OF ACTION IN
1 THE BRAIN. AND THAT'S WHERE A SERUM HALF LIFE OR A BLOOD
2 HALF LIFE FOR HALDOL MIGHT BE A FEW HOURS AND IT MIGHT
3 ACTUALLY STILL BE IN THE BRAIN FOR A FEW DAYS.
4 Q. I SEE.
5 A. BUT YOU WOULDN'T BE ABLE TO MEASURE IT IN THE BLOOD
6 STREAM.
7 Q. IN TERMS OF WHEN YOU SAY IT STILL MIGHT BE ACTIVE IN THE
8 BRAIN, I -- I GUESS I NEED SOME CLARIFICATION AS TO -- AS TO
9 WHEN YOU -- HOW DO YOU DETERMINE WHETHER IT'S ACTIVE IN THE
10 BRAIN OR NOT?
11 A. WELL, ITS MERE PRESENCE THERE DOESN'T MEAN THAT IT'S
12 ACTIVE FOR THE PURPOSES THAT IT MIGHT HAVE BEEN GIVEN. AND
13 WHAT WE REALLY WOULD LIKE TO KNOW AND DON'T OFTEN HAVE GOOD
14 DATA FOR IS WHAT IS THE DURATION OF ACTION. IF YOU GIVE A
15 DRUG, IT DOESN'T MATTER HOW LONG IT'S IN THE BLOOD STREAM OR
16 WHEREVER IT'S AT IN THE BRAIN, IT'S HOW LONG DOES IT DOES WHAT
17 YOU WANT IT TO DO.
18 Q. SO AS A PHYSICIAN, HOW DO YOU DETERMINE THAT?
19 A. WELL, SOMETIMES IT'S NOT -- NOT -- SOMETIMES IT TRIAL AND
20 ERROR, HONESTLY.
21 Q. OKAY. LET'S TURN NOW, IF YOU WILL, TO YOUR REVIEW OF THE
22 SPECIFIC PATIENT RECORDS. I WANT TO GO FIRST TO PATIENT
23 ELLEN ANDERSON. ARE YOU FAMILIAR WITH HER RECORD?
24 A. YES.
25 Q. AND I TAKE IT YOU MADE NOTES?
1 A. I DID.
2 Q. AND YOU HAVE A COPY OF HER MEDICAL RECORDS WITH YOU AT
3 THIS TIME?
4 A. I DO.
5 Q. AND THOSE MEDICAL RECORDS, FOR PURPOSES OF OUR RECORD
6 HERE IN THESE PROCEEDINGS, I THINK WOULD BE THE DAVIS
7 HOSPITAL RECORDS AND THAT WOULD BE EXHIBIT 2-B.
8 MS. BARLOW: 2-B. UH-HUH. 2-C? 2-C?
9 Q. (BY MR. WILSON) YOU ALSO INDICATED IN -- IN YOUR REVIEW
10 YOU LOOKED AT THE AUTOPSY REPORT CONCERNING ELLEN ANDERSON;
11 IS THAT CORRECT?
12 A. YES.
13 Q. OKAY.
14 MS. BARLOW: EXCUSE ME. THAT'S 2-C, YOUR HONOR.
15 MR. WILSON: 2-C.
16 MS. BARLOW: I'M SORRY. I TOLD HIM WRONG.
17 Q. (BY MR. WILSON) IN CONNECTION WITH THE -- THE -- YOUR
18 REVIEW OF THE RECORDS, SIR, CAN YOU TELL US WHAT TYPE OF
19 MEDICATIONS OR WHAT INFORMATION YOU RECEIVED AS TO WHAT SHE
20 WAS RECEIVING MEDICATION-WISE PRIOR TO COMING TO THE DAVIS
21 HOSPITAL?
22 THE COURT: LET'S CLARIFY THE RECORD. THE DAVIS
23 HOSPITAL RECORD ON ELLEN ANDERSON IS 2-C; IS THAT RIGHT?
24 MS. BARLOW: 2-C.
25 MR. WILSON: 2-C. EXCUSE ME, YOUR HONOR.
1 THE COURT: OKAY.
2 Q. (BY MR. WILSON) CAN YOU TELL US WHAT INFORMATION YOU
3 RECEIVED RELATIVE TO WHAT MEDICATION SHE'D BEEN RECEIVING?
4 A. THERE WAS A TELEPHONE INTAKE FORM THAT LISTED HER
5 MEDICATIONS, AND THEN A NURSING ADMISSION FORM THAT AGAIN
6 LISTED THE MEDICATIONS THAT SHE HAD BEEN ON.
7 Q. AND LET ME -- LET ME CLARIFY THAT QUESTION. WOULD YOU
8 JUST INDICATE WHAT --
9 A. WHAT DRUGS SHE --
10 Q. -- PSYCHOTROPIC MEDICATIONS SHE WAS RECEIVING?
11 A. AMITRIPTYLINE, AMBIEN, HAD TAKEN XANAX, AND THEN THERE'S
12 SEVERAL OTHER DRUGS THAT SHE WAS TAKING FOR MEDICAL
13 CONDITIONS.
14 Q. WHAT ABOUT ANY -- ANY PRESCRIPTIONS FOR PAIN?
15 A. SHE HAD HAD A PRESCRIPTION FOR A SMALL DOSE OF LORTAB,
16 LORTAB 5 MILLIGRAMS. AND IT WAS MY UNDERSTANDING SHE HAD
17 UTILIZED THAT ONLY A COUPLE OF TIMES DURING THE PREVIOUS
18 COUPLE OF MONTH.
19 Q. OKAY. WAS THERE ANYTHING IN THE MEDICAL RECORD RELATIVE
20 TO THE LORTAB THAT LED YOU TO BELIEVE IT HADN'T BEEN
21 EFFECTIVE IN TREATING HER PAIN?
22 A. THAT IT HAD NOT BEEN EFFECTIVE?
23 Q. UH-HUH.
24 A. NO, THERE WASN'T.
25 Q. OKAY.
1 A. IN FACT THE FACT SHE DIDN'T TAKE IT VERY OFTEN WOULD LEAD
2 ME TO THINK THAT IT WAS EFFECTIVE, OR A LESSER MEDICATION
3 SUCH AS THE TYLENOL THAT WAS ALSO ORDERED FOR HER WAS
4 EFFECTIVE.
5 Q. NOW, YOU CHARACTERIZED THAT PARTICULAR DOSAGE AS LOW.
6 CAN YOU QUALIFY THAT FOR US AS TO WHY YOU -- YOUR OPINION IT
7 WAS LOW?
8 A. AN AVERAGE ADULT THAT GOES TO THE EMERGENCY ROOM, HAS A
9 PAINFUL CONDITION, IS GOING TO BE PRESCRIBED 7.5 MILLIGRAM
10 LORTAB, ONE OR TWO EVERY FOUR HOURS, AND MAYBE EVEN 10
11 MILLIGRAM LORTAB, ONE OR TWO EVERY FOUR HOURS DEPENDING ON
12 THE AMOUNT OF PAIN THAT THEY'RE HAVING.
13 Q. OKAY. DOES THE RECORD ALSO REFLECT WHAT MEDICATIONS WERE
14 ORDERED UPON HER ADMISSION TO THE -- EXCUSE ME. I'M GOING TO
15 QUALIFY THAT AGAIN.
16 THE COURT: COUNSEL, WE NEED TO PICK IT UP A
17 LITTLE -- WE NEED TO PICK IT UP A LITTLE, IF WE CAN, PLEASE.
18 Q. (BY MR. WILSON) OKAY. DOES THE RECORD INDICATE WHAT
19 PSYCHOTROPIC MEDICATIONS OR PAIN MEDICATIONS WERE ORDERED FOR
20 ELLEN ANDERSON UPON HER ADMISSION TO THE GEROPSYCH UNIT?
21 A. YES, IT DOES.
22 Q. AND WHAT WERE THOSE?
23 A. SHE WAS ORDERED AMITRIPTYLINE, LASIX, POTASSIUM,
24 NITROSTAT, AMBIEN, DULCOLAX, TRAZODONE, TYLENOL, MYLANTA,
25 MILK OF MAGNESIA, AND 10 MILLIGRAMS OF MORPHINE.
1 Q. OKAY. AND DO YOU KNOW WHEN THAT ORDER WAS ENTERED?
2 A. THERE'S A LITTLE DISCREPANCY FROM MY READING OF THE
3 RECORDS BECAUSE ON THE NURSE'S ORDERS SHE NOTES IT AT 2130
4 HOURS, BUT IN THE ACTUAL NURSES' NOTES, SHE SAYS IT WAS GIVEN
5 AT 8 P.M. AND ON THE MEDICATION SHEET, AS I RECALL, IT SAYS
6 IT WAS GIVEN AT 7:30.
7 Q. OKAY. WHAT WAS ACTUALLY GIVEN IN REFERENCE TO THE NOTE
8 YOU JUST REFERENCED?
9 A. TEN -- TEN MILLIGRAMS OF MORPHINE INTRAMUSCULARLY.
10 Q. DO YOU KNOW WHETHER ANY OF THE OTHER DRUGS THAT WERE
11 ORDERED WERE ADMINISTERED TO ELLEN ANDERSON ON THAT
12 PARTICULAR OCCASION?
13 A. THERE'S NO RECORD OF ANY OF THE OTHER MEDICATIONS BEING
14 GIVEN.
15 Q. OKAY. I CALL YOUR ATTENTION TO WHAT'S PREVIOUSLY BEEN
16 MARKED AS STATE'S EXHIBIT 2-H. CAN YOU IDENTIFY THAT EXHIBIT
17 FOR US, SIR?
18 A. YES.
19 Q. DO YOU HAVE A SMALL COPY OF THAT AVAILABLE?
20 A. YES, I DO.
21 Q. CAN YOU TELL US RELATIVE TO THE ADMINISTRATION OF THE
22 MORPHINE, DID YOU HAVE ANY CONCERNS AS -- AS IT RELATED TO
23 THE ADMINISTRATION OF THAT PARTICULAR DRUG AND -- AND THAT
24 PARTICULAR DOSAGE?
25 A. I DID. IT -- IT APPEARS FROM THE RECORDS THAT THIS WAS
1 A -- THIS WAS A NEW PATIENT ON THE UNIT THAT DAY THAT HAD NOT
2 YET BEEN EXAMINED OR SEEN BY A PHYSICIAN. AND THAT WHEN THIS
3 ORDER WAS GIVEN, IT WAS A TELEPHONE ORDER. IT'S VERY UNCLEAR
4 WHAT IF ANY INFORMATION THE PHYSICIAN HAD WHEN HE ORDERED
5 THAT DOSE. THE RECORD DOESN'T INDICATE EXACTLY WHAT HER
6 WEIGHT IS, BUT SHE WAS QUITE FRAIL. SHE'D LOST 20 POUNDS IN
7 THE PAST -- IN THE RECENT PAST. SHE ONLY WEIGHED 81 POUNDS
8 ON DECEMBER 21ST, ABOUT EIGHT DAYS BEFORE SHE WAS ADMITTED.
9 AND MY CONCERN IS THAT 10 MILLIGRAMS OF MORPHINE IN A
10 FRAIL, ELDERLY PERSON WHO ONLY WEIGHS 81 POUNDS, WHO
11 APPARENTLY HAS ONLY BEEN GETTING RARELY ANY OTHER OPIATES
12 SUCH OF THE LORTAB, THAT'S A SUBSTANTIAL DOSE.
13 Q. CAN -- CAN YOU CHARACTERIZE IN TERMS OF WHAT WOULD HAVE
14 BEEN AN APPROPRIATE DOSE OF MORPHINE?
15 A. WELL, I THINK THE MOST APPROPRIATE COURSE AT THE TIME IF
16 PHYSICIAN THOUGHT THAT THE PATIENT WAS IN PAIN WOULD BE TO
17 GIVE HER WHAT SHE HAD ALREADY BEEN GIVEN BEFORE, LORTAB.
18 Q. OKAY.
19 A. AND SEE HOW SHE RESPONDED TO IT.
20 Q. ASSUMING THAT SHE WAS IN PAIN, CAN YOU CHARACTERIZE WHAT
21 LEVEL OF DOSAGE YOU WOULD HAVE GIVEN HER IN RESPECT TO
22 MORPHINE?
23 A. WOULD START -- FIRST OF ALL I WOULD WANT TO KNOW WHY
24 SHE'S IN PAIN. AND I WOULD -- WOULD WANT MORE INFORMATION
25 ABOUT WHAT HAS HAPPENED THAT SHE'S IN PAIN NOW IF SHE WASN'T
1 WHEN -- BEFORE SHE CAME IN.
2 AND THEN IN GENERAL WITH AN ELDERLY PERSON LIKE THIS, IF
3 YOU WERE GOING TO GIVE AN INJECTABLE DOSE OF MORPHINE, YOU'D
4 PROBABLY START AT 2 MILLIGRAMS --
5 Q. OKAY.
6 A. -- AND WAIT TO SEE WHAT THE RESPONSE WAS.
7 Q. DID YOU HAVE OCCASION TO REVIEW HER MEDICAL RECORDS
8 RELATIVE TO WHAT OCCURRED OVER THE TIME PERIOD BETWEEN -- I
9 THINK IT WAS ABOUT -- THE FIRST SHOT WAS ADMINISTERED ABOUT
10 7:30 P.M. UP UNTIL THE TIME OF HER DEATH THE FOLLOWING
11 MORNING ON THE 30TH?
12 A. SHE BECAME CALM AFTER THAT INJECTION -- TWO HOURS AFTER
13 THAT INJECTION. AND THEN THE NURSES NOTE, HOWEVER, THAT SHE
14 WOULD SCREAM WHEN LEFT ALONE WHICH WAS AN OLD BEHAVIOR FOR
15 HER. SHE DREADED BEING ALONE.
16 BY ONE O'CLOCK IN THE MORNING, HER RESPIRATIONS WERE
17 VERY ERRATIC. THEY PAGED DR. WEITZEL. AT 3:15 SHE WAS
18 MOANING AND SCREAMING AGAIN. THEY PAGED DR. WEITZEL AGAIN.
19 AT 3:30 HE CALLED AND ORDERED A SECOND DOSE OF MORPHINE. AT
20 6:30 THE NURSE NOTES THAT PATIENT APPEARED TO SLEEP, BUT HER
21 RESPIRATIONS REMAINED ERRATIC. SHE HAD A CHEST X-RAY AND AN
22 E.K.G. DONE. AT 7:30 SHE WAS COLD. HER BODY TEMPERATURE WAS
23 97.9. HER RESPIRATIONS AVERAGED 12. HER PULSE WAS 60 AND
24 THEY COULDN'T MEASURE HER BLOOD PRESSURE.
25 Q. OKAY.
1 A. AND BY 8:55 SHE HAD EXPIRED.
2 Q. DO -- DO ANY OF THE NOTES THAT YOU OBSERVED THERE --
3 WELL, STRIKE THAT.
4 DO YOU HAVE AN OPINION, SIR, RELATIVE TO THE MORPHINE AS
5 TO WHETHER OR NOT THE PATIENT WAS SUFFERING ANY TOXIC EFFECTS
6 FROM THAT MORPHINE?
7 A. I THINK VERY CLEARLY THE MORPHINE AFFECTED HER
8 RESPIRATIONS WHICH BECAME VERY ERRATIC. MORPHINE -- WHICH I
9 DIDN'T MENTION EARLIER -- TENDS TO LOWER BLOOD PRESSURE. IT
10 HAS ANOTHER SIDE EFFECT THAT -- AND ESPECIALLY IN A
11 DEHYDRATED INDIVIDUAL CAN DROP THEIR BLOOD PRESSURE. AND
12 THEN THEY NOTE THAT THEY COULDN'T GET A BLOOD PRESSURE ON HER
13 AFTER THE SECOND DOSE. I THINK VERY CLEARLY THE MORPHINE HAD
14 QUITE A PROFOUND EFFECT ON HER.
15 Q. BASED UPON YOUR REVIEW OF THE MEDICAL RECORDS OF ELLEN
16 ANDERSON, DOCTOR, IN YOUR EXPERIENCE AND YOUR TRAINING, DID
17 YOU FORM AN OPINION AS TO WHETHER OR NOT THE CONDUCT OF THE
18 DEFENDANT AS TO THE TREATMENT AND CARE OF -- OF ELLEN
19 ANDERSON DEVIATED FROM THE STANDARDS OF CARE AS WOULD BE
20 EXERCISED BY A PHYSICIAN UNDER THOSE CIRCUMSTANCES?
21 A. I BELIEVE SO. YES.
22 Q. AND CAN YOU CHARACTERIZE FOR US SPECIFICALLY IN WHAT
23 AREAS DID YOU FEEL THAT CONDUCT DEVIATED FROM THE STANDARD OF
24 CARE?
25 A. THE -- THE LACK OF PROVIDING AN ADEQUATE ASSESSMENT OF
1 THE NEW PATIENT WHO BY DEFINITION IS COMPLICATED AND FRAIL
2 AND DEBILITATED. AND -- AND THEN ORDERING A DOSE OF
3 MEDICATION WHICH IS EXCESSIVE, UNDER THE CIRCUMSTANCES.
4 Q. FURTHERMORE, BASED UPON YOUR EXPERIENCE AND YOUR REVIEW
5 OF THE RECORDS, CAN YOU TELL US, DID YOU FORM AN OPINION TO A
6 REASONABLE DEGREE OF MEDICAL CERTAINTY AS TO THE CAUSE OF
7 ELLEN ANDERSON'S DEATH?
8 A. THERE'S PROBABLY MULTIPLE CAUSES BECAUSE SHE'S ELDERLY
9 AND FRAIL. APPARENTLY SHE HAD AN UNDERLYING PULMONARY
10 CONDITION, DEVELOPING PNEUMONIA, WHICH MADE HER EVEN MORE
11 SUSCEPTIBLE TO THE MORPHINE. BUT I BELIEVE THAT THE MORPHINE
12 PLAYED A PIVOTAL ROLE.
13 Q. OKAY. LET'S TURN NOW TO JUDITH LARSEN. CAN YOU TELL US
14 WHEN SHE ENTERED THE GEROPSYCH UNIT?
15 A. JUDITH LARSEN WAS ADMITTED AT 11:51 A.M. ON DECEMBER 6TH,
16 1995.
17 Q. OKAY. AND DID YOU, IN REVIEWING THE RECORDS, FORM ANY
18 OPINION RELATED TO HER MEDICAL STABILITY AT THE TIME OF HER
19 ADMISSION TO THE GEROPSYCH UNIT?
20 A. SHE HAD SEVERAL MEDICAL PROBLEMS, ASIDE FROM HER
21 DEMENTIA. SHE WAS ALSO -- HAD HAD A THYROIDECTOMY AND WAS --
22 HAD BEEN HYPOTHYROID. SHE HAD GLAUCOMA. SHE HAD A
23 PSYCHIATRIC HISTORY THAT INCLUDED SEVERE DEPRESSION AND
24 ANXIETY. SHE HAD HAD PREVIOUS STROKES OR CEREBROVASCULAR
25 ACCIDENTS. SHE HAD BEEN HOSPITALIZED IN 1958 WITH A NERVOUS
1 BREAKDOWN AND HAD RECEIVED SHOCK THERAPY.
2 Q. OKAY.
3 A. SHE WAS KNOWN TO HAVE HEART DISEASE, A HISTORY OF KIDNEY
4 STONES, A HISTORY OF HIATAL HERNIA AND REFLUX. SOME INCREASE
5 IN HER BLOOD GLUCOSE LEVELS.
6 Q. DID ANY OF THOSE CONDITIONS APPEAR TO YOU TO BE
7 LIFE-THREATENING AT THAT TIME?
8 A. NOT -- NOT AT THAT TIME.
9 Q. OKAY.
10 A. HAD THEY BEEN LIFE-THREATENING IN THE VERY NEAR FUTURE,
11 THERE WOULD HAVE BEEN NO POINT IN ADMITTING SOMEBODY TO A
12 PSYCHIATRIC UNIT.
13 Q. OKAY. CAN YOU TELL US IN RESPECT TO JUDITH LARSEN, WAS
14 SHE STARTED ON ANY TYPE OF PSYCHOTROPIC MEDICATIONS?
15 A. SHE WAS.
16 Q. NOW, I WANT TO YOU TO CALL YOUR ATTENTION TO THE BOARD
17 THERE, EXHIBIT --
18 THE COURT: 3-H.
19 MR. WILSON: 3-H -- OR 2-H?
20 THE COURT: I BELIEVE IT IS 3-H.
21 MR. WILSON: 3-H, EXCUSE ME.
22 Q. (BY MR. WILSON) AND YOU HAVE A COPY OF THAT I THINK IN
23 FRONT OF YOU; IS THAT CORRECT?
24 A. YES.
25 Q. THE DOSAGES OR THE AMOUNTS OF DOSES THAT SHE WAS
1 ADMINISTERED AND THAT ARE REFLECTED ON THAT PARTICULAR GRAPH;
2 IS THAT CORRECT, DOCTOR?
3 A. YES.
4 Q. AND THESE REPRESENT -- ARE THESE ACCURATE ACCORDING TO
5 YOUR REVIEW OF THE RECORDS?
6 A. YES.
7 Q. AND YOU UNDERSTAND THAT THOSE PARTICULAR PILLS THAT ARE
8 DEPICTED THAT ARE -- THAT HAVE NOTHING IN THEM WERE ORDERED
9 BUT NOT GIVEN?
10 A. CORRECT.
11 Q. OKAY. CAN YOU CHARACTERIZE FOR US, IF YOU WOULD, DOCTOR,
12 THE TYPES OF DRUGS THAT SHE WAS GENERALLY ADMINISTERED?
13 A. BEFORE HER ADMISSION THERE SHE HAD BEEN GIVEN XANAX AND
14 TRAZODONE AND ATIVAN ON OCCASION.
15 Q. OKAY.
16 A. ON HER ADMISSION TO THE PSYCH UNIT SHE WAS ORDERED ATIVAN
17 AND CLON -- ATIVAN AND TRAZODONE AGAIN AND CLONOPIN, AND THEN
18 SERZONE AND RISPERDAL WERE ADDED.
19 Q. OKAY. CAN YOU TELL US, DID YOU HAVE ANY CONCERNS
20 RELATIVE TO THE TYPES OF DOSAGES THAT WERE BEING ADMINISTERED
21 TO HER OVER THE COURSE OF THAT TREATMENT PERIOD AND THE --
22 THE TYPES OF DRUGS THAT WERE BEING PROVIDED TO HER?
23 A. YES. SHE WAS -- FROM THE RECORDS I HAVE SHE HAD NEVER
24 BEEN ON A DRUG LIKE RISPERDAL BEFORE.
25 Q. OKAY.
1 A. AND A MORE COMMON STARTING DOSE WOULD BE HALF A MILLIGRAM
2 TWICE A DAY.
3 Q. WAS THERE ANY CONCERN RELATIVE TO THE FACT THAT YOU'RE
4 GIVEN HER DRUGS THAT ARE ALL ANTIDEPRESSANTS ON TOP OF ONE
5 ANOTHER?
6 A. YEAH. ANY -- ANY DRUG THAT IS DEPRESSING OR SEDATING IS
7 GOING TO BE ADDITIVE TO OTHER DRUGS THAT ARE DEPRESSING OR
8 SEDATING TO THE BRAIN.
9 Q. AND IS THAT A PARTICULAR CONCERN WITH GERIATRIC PATIENTS?
10 A. IT'S VERY EASY TO OVERSHOOT AND HAVE AN IMMOBILE,
11 UNRESPONSIVE PATIENT WHO CAN'T PARTICIPATE IN THERAPY AND
12 CAN'T BENEFIT FROM BEING THERE.
13 Q. CALLING YOUR ATTENTION TO THE TIME PERIOD FROM
14 DECEMBER 6TH UP UNTIL THE TIME PERIOD DECEMBER 28TH, CAN YOU
15 TELL US, SIR, DID YOU SEE ANY SIGNS OR SYMPTOMS OF
16 OVERSEDATION IN THOSE MEDICAL RECORDS?
17 A. YEAH. THERE WERE FREQUENTLY TIMES THAT THE NURSES
18 CHARTED THAT SHE WAS LETHARGIC, SOMNOLENT MOST OF THE
19 EVENING, ASLEEP IN THE DAY, UNRESPONSIVE, LETHARGIC AND
20 SLEEPY, SOMNOLENT, LETHARGIC. THIS IS DAY AFTER DAY. SLEPT
21 THROUGH GROUP. COMPLETELY OUT OF IT. RESPONDS ONLY TO PAIN.
22 RESPIRATIONS LABORED. SLEPT BUT WAKES -- WAKES UP FOR
23 MEDICATIONS. NEEDS TO BE LESS -- EXCUSE ME. THERE WERE
24 TIMES WHEN SHE WAS MORE AWAKE AND MORE ALERT BUT IN -- BUT IN
25 GENERAL SHE WAS FREQUENTLY LETHARGIC AND SEDATED. THOSE
1 TERMS WERE USED REPEATEDLY IN HER MEDICAL RECORD.
2 Q. NOW, IN REGARDS TO THESE DRUGS THAT WERE BEING
3 ADMINISTERED TO HER, WE PREVIOUSLY TALKED ABOUT DURATION OF
4 EFFECT. DOES THE FACT THAT THERE WERE MULTIPLE DOSAGES OF
5 CENTRAL NERVOUS SYSTEM DEPRESSANTS ON TOP OF ONE ANOTHER ALSO
6 HAVE AN IMPACT RELATIVE TO DURATION?
7 A. I'M NOT SURE QUITE WHAT YOU MEAN BECAUSE --
8 Q. OKAY. THEN MAYBE --
9 A. SEDATING A PERSON DEEPER, THEY'RE GOING TO STAY SEDATED
10 LONGER. I DON'T KNOW OF SPECIFIC DRUG INTERACTIONS THAT ONE
11 OF THESE MEDICATIONS WOULD HAVE PROLONGED THE OTHER IN A
12 PHARMACOLOGICAL WAY.
13 Q. OKAY. MAYBE WHAT I'LL DO AT THIS JUNCTURE IS JUST ASK
14 YOU, DOCTOR, BASED UPON YOUR REVIEW OF THE RECORDS AND YOUR
15 EXPERIENCE, TRAINING AND EXPERTISE, DID YOU FORM AN OPINION
16 AS TO WHETHER THE CONDUCT OF THE DEFENDANT IN THE
17 ADMINISTRATION OF THESE DRUGS AND HIS CARE OF THIS PATIENT
18 DEVIATED FROM THE STANDARDS OF CARE AS WOULD BE EXERCISED BY
19 A PHYSICIAN IN -- IN HIS -- IN THE SAME SITUATION?
20 A. YES. I'LL QUALIFY IT A LITTLE BIT THOUGH. THAT I
21 UNDERSTAND THAT THESE ARE VERY DIFFICULT PATIENTS TO TREAT,
22 AND THAT THEY CAN REQUIRE MULTIPLE MEDICATIONS TO TRY AND
23 HELP THEM ACHIEVE THE MOST STABLE COMFORT LEVEL POSSIBLE.
24 BUT WHEN THAT'S EXCESSIVE MEDICATION AND IT'S OVERSHOT, THEN
25 YOU JUST HAVE A PERSON WHO'S ASLEEP.
1 Q. OKAY.
2 A. AND THAT'S GENERALLY NOT WHY PEOPLE GO TO THESE UNITS TO
3 JUST REST AND GET SLEEP.
4 THE FACT THAT THE PERSON REMAINS SEDATED DAY AFTER DAY
5 AFTER DAY I THINK IS A VARIATION FROM THE STANDARD OF CARE.
6 THERE WAS SOME EVIDENCE IN THE CHART OF TRYING TO ADJUST
7 THOSE DOSES, AND THERE WERE TIMES WHEN THE PATIENT WAS
8 AGITATED. BUT IN THOSE CASES THE PHYSICIAN NEEDS TO LOOK FOR
9 REASONS WHY THE PERSON -- THE PERSON IS AGITATED. DO THEY
10 HAVE A FULL BLADDER? ARE THEY CONSTIPATED?
11 THERE CAN BE A NUMBER OF THINGS THAT MIGHT BE MAKING
12 THEM UPSET AND THESE ARE PEOPLE WHO AREN'T VERY CAPABLE OF
13 EXPRESSING THEIR NEEDS. AND THE PHYSICIAN NEEDS TO TAKE A
14 MUCH, MUCH CLOSER, CAREFUL LOOK AT WHAT'S GOING ON BEFORE
15 MAKING DECISIONS.
16 Q. OKAY. RELATIVE TO THE -- THE CARE THAT WAS GIVEN HERE,
17 CAN YOU BE MORE SPECIFIC AS IT RELATES TO -- STRIKE THAT.
18 LET ME JUST ASK YOU, IN REFERENCE TO THE TIME PERIOD
19 THAT WE'VE BEEN TALKING ABOUT FROM DECEMBER 6TH THROUGH
20 DECEMBER 28TH, WAS THERE A TIME WHEN MORPHINE WAS -- WAS
21 ORDERED BUT NOT GIVEN?
22 A. I NEED TO REFRESH MY MEMORY QUICKLY.
23 THE COURT: LOOK AT THE CHART.
24 MR. WILSON: IT'S NOT ON THE CHART.
25 A. YES.
1 THE COURT: IT'S ON THE CHART.
2 A. THERE WAS AN ORDER ON THE 16TH FOR MORPHINE.
3 Q. (BY MR. WILSON) DO YOU KNOW HOW MUCH THAT ORDER WAS FOR?
4 A. IT WAS FOR 15 MILLIGRAMS EVERY FOUR HOURS, AS NEEDED.
5 Q. CAN YOU -- DID YOU NOTE OR REFERENCE ANYTHING IN THE --
6 IN THE NOTES AS TO THE REASON FOR THAT PARTICULAR ORDER?
7 A. NO.
8 Q. DID YOU SAY NO?
9 A. NO.
10 Q. OKAY. DID THERE COME A TIME ON CHRISTMAS DAY WHEN, IN
11 FACT, MORPHINE WAS GIVEN?
12 A. YES.
13 Q. AND CAN YOU CHARACTERIZE THE AMOUNT OF MORPHINE THAT WAS
14 ADMINISTERED ON THAT DAY?
15 A. TWO -- TWO MILLIGRAM DOSES, THREE OF THEM.
16 Q. OKAY. DID YOU SEE ANYTHING IN THE CHARTS THAT WOULD
17 INDICATE -- OR IN THE -- IN THE HOSPITAL RECORDS THAT WOULD
18 INDICATE A NECESSITY FOR THE ADMINISTRATION OF MORPHINE ON
19 THAT DAY?
20 A. THE PRIOR DAY WAS ONE OF THOSE DAYS BEING VERY SLEEPY, NO
21 SIGNS OF AGITATION, LETHARGIC, HARD TO AROUSE. IN GROUP ON
22 THAT DAY DIDN'T ANSWER, WAS SOBBING. LESS RESPONSIVE. AND
23 WEITZEL, IN HIS NOTE, WROTE SEEMS TO BE IN PAIN.
24 Q. OKAY.
25 A. AS I RECALL, THAT'S THE ONLY NOTATION ANYWHERE DURING
1 THAT TIME PERIOD OF ANYBODY WHO THOUGHT THAT THE PATIENT
2 MIGHT BE IN PAIN.
3 Q. DID THERE COME AN EVENT THAT TOOK PLACE ON OR ABOUT THE
4 29TH OR 30TH OF DECEMBER IN THE RECORDS CONCERNING JUDITH
5 LARSEN?
6 A. WELL, ON THE 26TH DR. WEITZEL SUSPECTED THAT SHE HAD HAD
7 SEIZURE ACTIVITY.
8 Q. OKAY. WHAT HAPPENED ON THE -- WHAT -- WHAT WAS DONE IN
9 RESPONSE TO THAT SEIZURE ACTIVITY?
10 A. SHE WAS TO GET A C.T. SCAN. AND WAS STARTED ON DILANTIN
11 WHICH IS ANTICONVULSANT FOR SEIZURES.
12 Q. DID YOU SEE ANYTHING WRONG WITH THAT PARTICULAR REGIMEN
13 OF MEDICATIONS?
14 A. NO.
15 Q. DID YOU SEE ANY FOLLOW-UP RELATIVE TO THAT PARTICULAR
16 REGIMEN OF MEDICATIONS?
17 A. THE DILANTIN WASN'T CONTINUED, AS I RECALL.
18 Q. DO YOU KNOW WHY THAT WAS, SIR?
19 A. THE DECISION WAS MADE AND AN ORDER ENTERED BY DR. WEITZEL
20 TO STOP I.V. THERAPY.
21 Q. OKAY.
22 A. AND OBSERVE FOR SYMPTOMS OF PAIN.
23 Q. NOW, I WANT TO JUST CALL YOUR ATTENTION FROM -- FROM THAT
24 DATE FORWARD, CAN YOU TELL US DID YOU SEE SIGNS OR SYMPTOMS
25 OF PAIN RELATED TO THE MEDICAL RECORDS OF ELLEN ANDERSON?
1 A. WELL, ON THE 27TH DR. WEITZEL WROTE NO EVIDENCE OF PAIN,
2 QUITE LETHARGIC. SHE CONTINUED TO BE VERY LETHARGIC AND
3 DIFFICULT TO AROUSE. QUIET, UNRESPONSIVE, DIFFICULT TO
4 AROUSE, STARING OFF.
5 AND THEN ON THE 29TH HAD SEVERAL HOURS OF NAUSEA AND
6 VOMITING OF COFFEE GROUND MATERIAL WHICH WOULD BE COMMONLY
7 UNDERSTOOD TO CONTAIN BLOOD FROM HER STOMACH.
8 Q. OKAY. AND WHAT WAS DONE IF ANYTHING IN RESPONSE TO THE
9 EPISODE OF VOMITING?
10 A. THE DECISION WAS MADE TO JUST KEEP HER COMFORTABLE AND
11 PROVIDE MORPHINE.
12 Q. THERE WERE NO MEDICATIONS GIVEN SPECIFICALLY FOR -- FOR
13 THE VOMITING EPISODE ITSELF THAT YOU'RE AWARE OF?
14 A. NO.
15 Q. RELATIVE --
16 A. WHICH WAS KIND OF INTERESTING SINCE MORPHINE CAUSES
17 NAUSEA FREQUENTLY, BUT --
18 Q. SO FROM THE 30TH OF DECEMBER UP UNTIL THE DATE OF HER
19 DEATH, CAN YOU CHARACTERIZE WHAT MEDICATIONS SHE RECEIVED
20 DURING THAT TIMEFRAME?
21 A. EXCLUSIVELY MORPHINE WITH THE EXCEPTION OF ONE DOSE OF
22 SERZONE ON JANUARY 2ND FOR REASONS THAT ARE UNCLEAR TO ME,
23 BUT IT WAS CHARTED.
24 Q. SIR, BASED UPON YOUR EXPERIENCE AND YOUR REVIEW OF THE
25 RECORDS, DID YOU FORM AN OPINION BASED UPON A REASONABLE
1 DEGREE OF MEDICAL CERTAINTY AS TO THE CAUSE OF ELLEN -- OR
2 EXCUSE ME, OF JUDITH LARSEN'S DEATH?
3 A. YES.
4 Q. AND CAN YOU TELL US, DOCTOR, WHAT THAT IS?
5 A. I THINK, AGAIN, IT WAS A COMBINATION OF EVENTS INCLUDING
6 BEING OLD AND DEBILITATED AND FRAIL, HAVING A SEIZURE, AND
7 THEN SUFFERING A GASTROINTESTINAL BLEED. AND THEN RECEIVING
8 QUITE HIGH DOSES OF MORPHINE. I ALSO THINK THAT EVENTS
9 LEADING UP TO THAT MAY HAVE CONTRIBUTED. KEEPING HER SEDATED
10 AND LETHARGIC FOR SO LONG MAY HAVE HELPED SET THIS UP.
11 Q. OKAY. SO DO I UNDERSTAND IN REGARDS TO YOUR OPINION, WAS
12 THE MORPHINE THE PRIMARY CAUSE OF DEATH?
13 MS. ISAACSON: OBJECTION. LEADING.
14 THE COURT: SUSTAINED.
15 Q. (BY MR. WILSON) CAN YOU TELL US WHAT YOU FEEL WAS, IN
16 YOUR OPINION, THE PRIMARY CAUSE OF HER DEATH?
17 A. YEAH. THE REASON SHE STOPPED BREATHING WHEN SHE DID WAS
18 THE DOSE OF MORPHINE THAT SHE WAS RECEIVING.
19 Q. OKAY. LET'S TURN TO PATIENT MARY CRANE. HAVE YOU HAD A
20 CHANCE TO REVIEW HER RECORDS?
21 A. YES.
22 Q. AND I SHOW YOU WHAT'S BEEN MARKED AS STATE'S EXHIBIT 4-E
23 AND ASK IF YOU'VE SEEN THAT EXHIBIT?
24 A. YES.
25 Q. AND YOU HAVE A COPY OF IT?
1 A. YES.
2 Q. MARY CRANE WAS ADMITTED ON DECEMBER 28TH TO THE GEROPSYCH
3 UNIT?
4 A. YES.
5 Q. CAN YOU TELL US PRIOR TO THAT TIME, WHAT TYPE OF
6 MEDICATIONS SHE WAS RECEIVING?
7 A. EXCUSE ME JUST A SECOND. LET ME MAKE SURE I GET THIS
8 EXACTLY RIGHT. SHE HAD BEEN ON IN THE PAST THORAZINE, WHICH
9 IS AN OLDER -- OR OLDER ANTIPSYCHOTIC NEUROLEPTIC DRUG; AND
10 TRANXENE, WHICH IS ANOTHER BENZODIAZEPINE SEDATIVE DRUG
11 APPARENTLY FOR A 40 YEAR PERIOD OF TIME.
12 SHE WAS -- ALSO HAD BEEN TAKING ZOLOFT, AND -- AND THEN
13 ALSO TYLENOL, LOMOTIL, A PAIN MEDICATION CALLED HYPHEN WHICH
14 CONTAINS HYDROCODONE SIMILAR TO LORTAB, AND CALCIUM.
15 Q. OKAY. AND IN RESPECT TO THE -- THOSE DRUGS, YOU SAY
16 THERE WAS -- THERE WAS HYPHEN AND THAT IS A PAIN MEDICATION;
17 IS THAT CORRECT?
18 A. YES.
19 Q. AND THEN I THINK YOU LISTED THE ONLY PSYCHOTROPIC
20 MEDICATIONS WERE THE --
21 A. TRANXENE, ZOLOFT, AND THORAZINE.
22 Q. OKAY. NOW, YOU'VE REVIEWED THE MEDICAL RECORDS AS TO THE
23 ADMINISTRATION OF THE DRUGS THAT SHE RECEIVED AT THE
24 GEROPSYCH UNIT; IS THAT CORRECT?
25 A. YES.
1 Q. OVER THE PERIOD OF TIME -- AND SHE WAS IN THE GEROPSYCH
2 FROM DECEMBER 28TH TILL JANUARY 7TH; IS THAT CORRECT?
3 A. YES.
4 Q. TO YOUR KNOWLEDGE, UPON HER ADMISSION WAS THERE ANY SIGNS
5 OR COMPLAINTS OF PAIN BY MARY CRANE?
6 A. THE NURSING INTAKE DID NOT NOTE SIGNIFICANT PAIN.
7 Q. OKAY.
8 A. THE DOCTOR THAT DID THE PHYSICAL EXAM, DR. DIENHART,
9 WROTE, QUOTE, SHE DENIES ANY SIGNIFICANT PAIN, CLOSE QUOTE.
10 AND DR. WEITZEL'S EVALUATION INDICATES THAT SHE HAD HAD A
11 HERNIATED DISC IN 1984 AND HAD HAD POOR CONTROL OF PAIN SINCE
12 THAT TIME. I WAS UNABLE TO FIND CORROBORATION FOR THAT PIECE
13 OF THE HISTORY.
14 Q. ALL RIGHT. NOW, SHE WAS -- SHE WAS GIVEN CERTAIN
15 MEDICATIONS FOR PAIN KILLERS AND PSYCHOTROPIC MEDICATIONS
16 OVER THE COURSE OF HER TREATMENT; IS THAT CORRECT?
17 A. YES.
18 Q. AND THE PAIN MEDICATION THAT SHE WAS INITIALLY GIVEN WAS
19 WHAT, DOCTOR?
20 A. A DURAGESIC PATCH.
21 Q. OKAY.
22 A. WHICH IS THE FENTANYL TRANSDERMAL SYSTEM FOR DELIVERING A
23 CONTINUOUS DOSE OF FENTANYL TO A PERSON THROUGH A SKIN PATCH.
24 Q. CAN YOU TELL US IN RELATIONSHIP TO THE DRUG MORPHINE,
25 WHAT THE 50 MICROGRAM DURAGESIC PATCH EQUATES TO? IS
1 THERE -- IS THERE A COMPARISON CHART, A WAY TO COMPARE THAT?
2 A. THERE -- THERE ARE COMPARISON CHARTS, AND BECAUSE THEY'RE
3 DIFFERENT DRUGS, THEY'RE APPROXIMATIONS. BUT A 50 MICROGRAM
4 DURAGESIC PATCH WOULD BE EXPECTED TO GIVE THE EQUIVALENT OF 5
5 MILLIGRAMS OF MORPHINE PAIN RELIEF EVERY HOUR, TWENTY-FOUR
6 HOURS A DAY.
7 Q. SO IF MY -- IF MY MATH IS CORRECT THAT WOULD BE
8 APPROXIMATELY 120 MILLIGRAMS OF MORPHINE PER DAY?
9 A. UH-HUH.
10 Q. OKAY. DID YOU SEE ANY REASON FOR THE PATIENT TO BE
11 ADMINISTERED MORPHINE -- OR NOT MORPHINE, A DURAGESIC PATCH
12 IN THAT AMOUNT?
13 A. NO. THAT'S QUITE A LEAP TO GO FROM AN OCCASIONAL
14 HY-PHEN, AS I UNDERSTOOD IT, TO A DURAGESIC PATCH.
15 Q. NOW, THESE OTHER PSYCHOTROPIC CHEMICALS THAT WERE BEING
16 ADMINISTERED, WERE THEY ALSO OF A SEDATING EFFECT?
17 A. YES.
18 Q. DID YOU SEE SIGNS AND SYMPTOMS OF LETHARGY IN THIS
19 PATIENT DURING THAT TIMEFRAME?
20 A. YES. BUT MAY I BACK UP AND CORRECT A STATEMENT I MADE
21 EARLIER?
22 Q. YES, YOU MAY.
23 A. I THINK I SAID IN THE NURSING ASSESSMENT THAT THERE WAS
24 NO EVIDENCE OF PAIN, AND I WAS MISTAKEN.
25 Q. OKAY. WHAT WAS THAT, DOCTOR?
1 A. THE NURSING ASSESSMENT RATED HER AS HAVING PAIN.
2 Q. OKAY.
3 A. AT A FIVE ON A ONE TO FIVE SCALE.
4 Q. DO YOU KNOW HOW THE NURSING -- NURSING ASSESSMENT WAS
5 MADE?
6 A. THEY JUST ASK A PATIENT.
7 Q. OKAY. SO THEY ASKED MARY CRANE TO RATE HER PAIN?
8 A. UH-HUH.
9 Q. OKAY. RELATIVE TO THE, AGAIN, THE QUESTION AS IT RELATED
10 TO DURING THE COURSE OF HER TREATMENT, DID YOU OBSERVE ANY
11 SIGNS ACROSS THAT TIMEFRAME OF -- OF PAIN OR SYMPTOMS OF
12 PAIN?
13 A. ANY SIGNS OF LETHARGY?
14 Q. OH, EXCUSE ME, IT WAS LETHARGY. YES. I APOLOGIZE.
15 A. YEAH. THE NURSES DESCRIBED HER AS AGITATED AND
16 LETHARGIC. AND ON 12/31, DROWSY, VERY DROWSY. ASLEEP MOST
17 OF THE DAY. LETHARGIC. AGITATED LATER. LETHARGIC. BUT
18 WHEN SHE DID WAKE UP, SHE'D BE MOANING AND WAILING.
19 Q. NOW, AS I UNDERSTAND THIS PATIENT WAS 72 YEARS OF AGE?
20 A. YES.
21 Q. RELATIVE TO THE DRUGS THAT WERE ADMINISTERED, DOCTOR, CAN
22 YOU TELL US, DID YOU HAVE ANY CONCERNS ABOUT THE COMBINATIONS
23 OF SERZONE, RISPERDAL, TRAZ -- I THINK IT'S TRAZODONE AND
24 DURAGESIC PATCH IN COMBINATION WITH ONE ANOTHER?
25 A. YES. IT'S NOT THAT IT CAN'T BE DONE, BUT THAT IT NEEDS
1 TO BE DONE VERY CAREFULLY WATCHING THE PATIENT'S RESPONSE.
2 AND IN GENERAL, AGAIN, THESE MEDICATIONS WOULD HAVE BEEN
3 STARTED AT LOWER DOSES AND INCREASED GRADUALLY. IT IS AN
4 UNUSUAL COMBINATION TO PRESCRIBE SERZONE AND TRAZODONE
5 TOGETHER BECAUSE THEY COME FROM THE SAME CLASS -- CHEMICAL
6 CLASS AND THAT IT'S RARE TO USE BOTH THOSE DRUGS INSTEAD OF
7 ONE OR THE OTHER.
8 Q. WHAT ABOUT WHEN THEY ADDED THE ATIVAN?
9 A. I'M SORRY. WHAT -- WHAT'S THE QUESTION?
10 Q. ON DECEMBER 31ST THERE'S ATIVAN THAT WAS ADDED TO THE
11 OTHER REGIMEN OF -- OF SERZONE, RISPERDAL, AND TRAZODONE; IS
12 THAT CORRECT?
13 A. YES. AND THAT OCCURRED AFTER AN EPISODE WHEN SHE WAS
14 AGITATED.
15 Q. IN TERMS OF AGITATION, CAN YOU TELL US WHETHER OR NOT
16 THESE -- ANY OF THESE DRUGS WOULD HAVE SIDE EFFECTS THAT
17 WOULD POSSIBLY PRODUCE AGITATION?
18 A. EACH OF THEM CAN. AND IT'S THE -- THE PARADOX OF THESE
19 MEDICATIONS THAT THEY CAN CAUSE SOME OF THE VERY SYMPTOMS
20 THAT THEY'RE GIVEN FOR. AND THAT HAS TO ALWAYS BE IN THE
21 BACK OF A PHYSICIAN'S MIND THAT IF THIS PATIENT IS GETTING
22 WORSE ON THIS MEDICATION, IS THE MEDICATION CAUSING WHAT
23 WE'RE TRYING TO TREAT. AND ESPECIALLY THE ANTIPSYCHOTIC
24 DRUGS ARE CAPABLE OF AGITATING PEOPLE. THERE'S A SIDE EFFECT
25 CALLED AKATHISIA WHICH IS A VERY UNCOMFORTABLE,
1 INTOLERABLE FEELING OF NOT BEING ABLE TO SIT STILL OR STAY
2 STILL. AND IT'S BEEN THOUGHT TO BE ONE OF THE REASONS WHY
3 SOME PEOPLE COMMIT SUICIDE WHO ARE ON THESE DRUGS.
4 Q. OKAY. IN REFERENCE TO THE CONTINUED TREATMENT, I SEE
5 THAT DEPAKENE IS ALSO PROVIDED TO THIS PATIENT ON JANUARY THE
6 3RD. IS THAT -- DOES THAT REFLECT THE RECORD IN YOUR MIND?
7 A. YES.
8 Q. CAN YOU TELL US, DID YOU HAVE ANY CONCERNS ABOUT THAT NOW
9 BEING ADDED TO THIS REGIMEN OF MEDICATIONS ALONG WITH
10 APPARENTLY SHE WAS GIVEN 8 MILLIGRAMS OF MORPHINE ON THAT
11 DATE; IS THAT CORRECT?
12 A. THAT'S CORRECT. THAT'S GOING TO FURTHER SEDATE HER.
13 DEPAKENE IS A SEDATING DRUG.
14 Q. AND SHE RECEIVES A SIMILAR DOSAGE THE FOLLOWING DAY ON
15 THE 4TH; IS THAT CORRECT?
16 A. OF THE DEPAKENE?
17 Q. UH-HUH.
18 A. YES.
19 Q. IN FACT, IT'S INCREASED AS -- AS I UNDERSTAND IT.
20 A. YES.
21 Q. THE DURAGESIC PATCH IS ALSO INCREASED ON THAT DATE; IS
22 THAT CORRECT?
23 A. YES.
24 Q. NOW, FROM THE JANUARY 4TH ON UP UNTIL THE DATE OF HER
25 DEATH, DID YOU OBSERVE SIGNS OF LETHARGY WITH THIS PATIENT?
1 A. YES. ON JANUARY 5TH SHE WAS DESCRIBED AS HAVING SLEPT,
2 LETHARGIC, UNRESPONSIVE, BUT AT OTHER TIMES AGITATED, CALLING
3 OUT.
4 Q. DOES UNRESPONSIVE DESIGNATE ANYTHING TO YOU AS FAR AS
5 THAT --
6 A. IT HAS TO BE QUALIFIED BY WHAT THE STIMULUS IS.
7 Q. OKAY.
8 A. IF YOU CALL TO SOMEBODY WHO'S ASLEEP AND THEY DON'T WAKE
9 UP, THEY DIDN'T RESPOND TO YOU, THAT'S NOT QUITE THE SAME
10 THING AS IF YOU GO OVER AND POUND ON THEIR CREST.
11 Q. OKAY. IS THERE ANY INDICATION AS TO WHAT TYPE OF
12 STIMULUS WAS USED ON THAT PARTICULAR DAY?
13 A. I DIDN'T. NO, I DIDN'T SEE THAT.
14 Q. OKAY. THAT REGIMEN CONTINUES THROUGHOUT UNTIL THE -- THE
15 DATE OF THE 7TH; IS THAT CORRECT?
16 A. YES.
17 Q. DOCTOR, BASED UPON YOUR EXPERTISE AND YOUR EXPERIENCE,
18 DID YOU FORM AN OPINION AS TO WHETHER THE CONDUCT OF THE
19 DEFENDANT AS TO THE TREATMENT AND CARE OF MARY CRANE DEVIATED
20 FROM THE STANDARDS OF CARE AS WOULD BE EXERCISED BY A
21 PHYSICIAN IN THE SAME CIRCUMSTANCES?
22 A. YES.
23 Q. AND CAN YOU CHARACTERIZE FOR US, IF YOU WOULD, WHERE
24 THAT -- IN YOUR OPINION, THE DEVIATION TOOK PLACE?
25 A. I THINK IT ONCE AGAIN INVOLVES OVERMEDICATION AND
1 INADEQUATE MONITORING OF THE EFFECTS OF MEDICATION WHICH
2 LEADS TO A STATE OF BEING WAY OVERSEDATED, UNABLE TO TAKE IN
3 FLUIDS, WHICH LEADS TO FURTHER DEHYDRATION AND EVENTUALLY
4 THIS PATIENT'S DEMISE. CONTRIBUTES TO IT.
5 Q. AND DID YOU FORM THAT OPINION TO A REASONABLE DEGREE OF
6 MEDICAL CERTAINTY AS THE CAUSE OF -- OF MARY CRANE'S DEATH?
7 A. ONCE AGAIN, SHE HAD MEDICAL PROBLEMS, SEIZURES, A
8 POSSIBLE INFECTION. BUT AT THE END WHEN SHE WAS SO SEDATED,
9 SHE WAS NOT CLEARING HER SECRETIONS. AND THE -- AND THE
10 RECORD STATES THAT SHE HAD THICK, DRY SECRETIONS, THAT SHE
11 WAS -- HER RESPIRATIONS WERE ERRATIC ON THE 5TH, AUDIBLY
12 RATTLING AND GURGLY. THAT SHE HAD TO BE SUCTIONED ON THE 5TH
13 BECAUSE SHE WAS TOO SEDATED TO CLEAR HER OWN SECRETIONS.
14 Q. WHAT SIGNIFICANCE IS THAT TO YOU?
15 A. THAT SHE'S VERY SEDATED.
16 Q. OKAY. AND I DON'T KNOW WHETHER YOU RENDERED YOUR OPINION
17 RELATIVE TO THE CAUSE OF DEATH. WOULD YOU -- WOULD YOU DO
18 THAT, PLEASE?
19 A. AGAIN, I THINK MORPHINE MADE A DIRECT CONTRIBUTION TO HER
20 DEATH IN THE CONTEXT OF HER PREVIOUS MEDICAL PROBLEMS.
21 Q. WHAT ABOUT THE DURAGESIC PATCH?
22 A. AND I WOULD INCLUDE -- I SHOULD SAY OPIATES RATHER THAN
23 SPECIFICALLY MORPHINE. MORPHINE AND DURAGESIC WHICH IS MORE
24 POTENT OPIATE.
25 Q. OKAY.
1 THE COURT: TAKE OUR LUNCH BREAK AT THIS TIME,
2 MR. WILSON.
3 MR. WILSON: THANK YOU, YOUR HONOR.
4 THE COURT: LADIES AND GENTLEMEN, WE'LL TAKE A LUNCH
5 BREAK TO 1:15. REMIND YOU, LADIES AND GENTLEMEN OF THE JURY,
6 OF MY PRIOR ADMONITION.
7 DR. CROOKSTON, YOU MAY STEP DOWN. WE'LL SEE YOU BACK AT
8 1:15.
9 MR. BUGDEN: JUDGE, COULD WE APPROACH -- COUNSEL
10 APPROACH THE BENCH?
11 THE COURT: YOU CAN GO AHEAD AND GO, IF YOU'D LIKE.
12 YOU CAN STEP DOWN, DR. CROOKSTON.
13 (RECESS TAKEN)
SOU V. WEITZEL 991700983
11-13-02 P.M. SESSION
10 THE COURT: PARTIES AND COUNSEL ARE PRESENT. JURY IS IN
11 THE JURY BOX. DR. CROOKSTON IS ON THE STAND. DR. CROOKSTON,
12 I REMIND YOU THAT YOU ARE STILL UNDER OATH. YOU MAY CONTINUE
13 WITH YOUR DIRECT EXAMINATION, MR. WILSON.
14 MR. WILSON: THANK YOU, YOUR HONOR.
15 Q. (BY MR. WILSON) DR. CROOKSTON, I WANT YOU TO REFER NOW
16 TO PATIENT LYDIA SMITH, IF WOULD YOU PLEASE. AND I ASSUME
17 YOU HAD THE OPPORTUNITY TO ALSO REVIEW THE MEDICAL RECORDS
18 FROM THE DAVIS HOSPITAL CONCERNING MS. SMITH?
19 A. YES.
20 Q. AND I SHOW YOU WHAT'S BEEN MARKED AS STATE'S EXHIBIT 5-E
21 AND ASK YOU IF YOU'VE SEEN THAT EXHIBIT PRIOR TO THESE
22 PROCEEDINGS?
23 A. YES.
24 Q. DO YOU HAVE A SMALL COPY OF THAT IN FRONT OF YOU DOCTOR?
25 A. I DO.
1 Q. OKAY. FIRST OF ALL, CAN YOU TELL US FROM YOUR REVIEW OF
2 THAT PARTICULAR EXHIBIT, DO THE DOSAGES THAT ARE REFERENCED
3 ON THAT CHART APPEAR TO BE ACCURATE ACCORDING TO YOUR NOTES
4 AND REVIEW?
5 A. YES, THEY DO.
6 Q. OKAY. AND CAN YOU TELL US RELATIVE TO THE RECORDS
7 THEMSELVES WHEN MS. SMITH WAS ADMITTED TO THE GEROPSYCH UNIT
8 AT DAVIS HOSPITAL?
9 A. AT 3:57 P.M. ON DECEMBER 20TH, 1995.
10 Q. AND DO YOU KNOW WHAT THE PURPOSE OF HER ADMISSION WAS
11 FOR?
12 A. SHE HAD BECOME INCREASINGLY DEMANDING, NEEDING CONSTANT
13 ATTENTION FROM HER FAMILY, AND FOR TWO WEEKS HAD BEEN
14 AGITATED, COMBATIVE, ASSAULTIVE.
15 Q. WAS SHE ON ADMISSION TAKING ANY MEDICATIONS RELATIVE TO
16 THE PSYCHTROPIC MEDICATIONS THAT --
17 A. HER PAST MEDICATIONS WERE LISTED HALDOL, HALF A
18 MILLIGRAM THREE TIMES A DAY. AND 1 TO 2 MILLIGRAMS BY
19 INJECTION IF NEEDED. SHE ALSO WAS TAKING LASIX AND
20 POTASSIUM. DIGOXIN, NORMODYNE, AND VASOTEC FOR HIGH BLOOD
21 PRESSURE. PLAIN TYLENOL. AND SERZONE 100 MILLIGRAMS TWICE A
22 DAY.
23 Q. NOW, THE TYLENOL YOU SAID WAS JUST REGULAR TYLENOL?
24 A. YES.
25 Q. THAT'S OVER-THE-COUNTER TYLENOL?
1 A. YES.
2 Q. AND THAT WAS FOR PAIN?
3 A. PRESUMABLY.
4 Q. OKAY. DID YOU MAKE ANY NOTATIONS IN YOUR REVIEW
5 RELATIVE TO ANY COMPLAINTS DURING THE TIME PERIOD THAT SHE
6 WAS HOSPITALIZED AT DAVIS HOSPITAL RELATIVE TO PAIN?
7 A. THE NURSING ASSESSMENT LEFT THE PAIN SCALE BLANK,
8 PROBABLY BECAUSE THE PATIENT HAD DIFFICULTY EXPRESSING
9 HERSELF. SHE HAD HAD A STROKE AND WAS UNABLE TO EXPRESS
10 HERSELF VERY WELL. BUT THE PHYSICAL EXAM BY DR. BITNER
11 STATED THAT, QUOTE, SHE COMPLAINED OF NO PAIN ANYWHERE.
12 Q. OKAY. WAS THERE CHANGES MADE IN HER MEDICATION REGIMEN
13 AT THE TIME OF ADMISSION, DO YOU KNOW?
14 A. YES. DR. WEITZEL CHANGED HER TO RISPERDAL HALF A
15 MILLIGRAM THREE TIMES A DAY INSTEAD OF HALDOL. CONTINUED THE
16 SERZONE. AND ALSO ORDERED ATIVAN 1 OR 2 MILLIGRAMS BY
17 INJECTION AS NEEDED EVERY SIX HOURS.
18 Q. DID YOU SEE ANYTHING RELATIVE TO THAT PARTICULAR CHANGE
19 IN HER MEDICATION THAT CAUSED YOU ANY KIND OF CONCERN?
20 A. SHE WAS INITIALLY SLEEPY IN ONE GROUP, BUT SHE WAS ALSO
21 AT OTHER TIMES QUITE ACTIVE AND QUITE AGITATED. IT WASN'T A
22 BIG CHANGE AT THAT TIME INITIALLY.
23 Q. CAN YOU CHARACTERIZE THE DOSAGE OF RISPERDAL FOR US IF
24 YOU WOULD PLEASE AS TO THE AMOUNT THAT WAS GIVEN TO HER ON
25 THAT PARTICULAR DAY?
1 A. ON WHICH DAY?
2 Q. WELL, APPEARS THE FOLLOWING DAY AFTER ADMISSION SHE WAS
3 GIVEN RISPERDAL.
4 A. ON THE 21ST?
5 Q. YES.
6 A. SHE GOT TWO DOSES IN THE MORNING AND AT NIGHT. AND
7 THAT'S A MODEST DOSE.
8 Q. OKAY.
9 A. IT'S A STARTING DOSE.
10 Q. OKAY.
11 A. AND ROUGHLY EQUIVALENT TO THE HALDOL THAT SHE'D BEEN
12 GETTING PRIOR TO ADMISSION.
13 Q. NOW, DID YOU SHE ANY CHANGE IN HER MEDICATION REGIMEN
14 THAT OCCURRED DOWN THE ROAD IN TERMS OF THOSE SUBSTANCES SHE
15 WAS GIVEN?
16 A. DR. WEITZEL INCREASED THE DOSE OF THE RISPERDAL TO 1
17 MILLIGRAM THREE TIMES A DAY, DOUBLED THE DOSE. ON THE 22ND,
18 HE NOTICED HIMSELF THAT SHE WAS, QUOTE, PRETTY LETHARGIC,
19 CLOSE QUOTE. AND THEN ON THE 23RD, QUOTE, MUCH LESS
20 LETHARGIC, CLOSE QUOTE. THERE WAS SOME FLUCTUATION IN HER
21 LEVEL OF ALERTNESS.
22 Q. NOW, IN TERMS OF CHANGING THE RISPERDAL, DID THAT -- AS
23 TO THE DOSAGES THAT WERE GIVEN TO HER BACK ON THE -- I
24 GUESS -- WHEN WAS IT YOU SAID HE CHANGED IT TO THE 1
25 MILLIGRAM A DAY?
1 A. WELL, THE ORDER WAS ON THE 21ST. SHE DIDN'T START
2 RECEIVING THE HIGHER DOSE UNTIL THE FOLLOWING DAY.
3 Q. YOU SAY THEY NOTE LETHARGIC --
4 A. PRETTY LETHARGIC --
5 Q. -- THE FOLLOWING DAY?
6 A. YES.
7 Q. OKAY. DID SHE EVER START RECEIVING HALDOL?
8 A. ON THE 25TH THERE WAS AN ORDER BY TELEPHONE THAT IF SHE
9 REFUSED TO TAKE THE RISPERDAL, IT WAS TO BE REPLACED WITH 2
10 MILLIGRAMS OF HALDOL INTRAMUSCULARLY.
11 Q. CAN YOU CHARACTERIZE FOR US WHETHER OR NOT THAT WAS AN
12 APPROPRIATE DOSAGE IN YOUR OPINION?
13 A. IT'S A BIT MUCH MORE HALDOL THAN WOULD BE EQUIVALENT,
14 BUT CLOSE ENOUGH TO ME.
15 Q. OKAY.
16 A. THE IDEA WAS THAT IF SHE'S SO OUT OF CONTROL SHE CAN'T
17 TAKE AN ORAL MEDICATION THAT YOU'D USE AN INJECTABLE ONE TO
18 TRY TO REPLACE IT.
19 Q. WHAT IF ANYTHING -- ANYTIME DURING THE COURSE OF HER HER
20 TREATMENT DID YOU NOTE CHANGES IN HER MEDICATION WHICH WERE
21 OF CONCERN TO YOU?
22 A. SHE CONTINUED TO BE INTERMITTENTLY AGITATED AND AT TIMES
23 DIFFICULT TO AROUSE. SHE CONTINUED TO HAVE A LOT OF TROUBLE
24 WITH HER BEHAVIORS, WHICH INCLUDED REMOVING HER CLOTHES
25 FREQUENTLY. AND SHE WOULD FREQUENTLY REFUSE HER MEDICATIONS
1 WHICH MADE IT DIFFICULT TO GET HER TO TAKE WHAT THEY WANTED
2 HER TO TAKE.
3 Q. WAS DEPAKENE EVER ADDED TO HER REGIMEN?
4 A. YES. ON THE 29TH AN ORDER INCREASE THE HALDOL AND
5 DEPAKENE WAS ADDED.
6 Q. AND DO YOU KNOW WHY FROM YOUR REVIEW OF THE RECORDS THAT
7 THAT TOOK PLACE?
8 A. DR. WEITZEL WROTE THAT SHE WAS UNSTABLE AND
9 INTERMITTENTLY AGGRESSIVE, RESPONDING --
10 Q. IN TERMS OF THE AMOUNT OF DEPAKENE THAT WAS ORDERED,
11 DOCTOR, DO YOU HAVE AN OPINION AS TO WHETHER OR NOT THAT WAS
12 AN APPROPRIATE STARTING DOSE FOR DEPAKENE?
13 A. LET ME JUST DOUBLE-CHECK THE DOSE. IT WAS TOTAL DOSE OF
14 750 MILLIGRAMS THE FIRST DAY. AND THAT'S A ROBUST DOSE IN A
15 GERIATRIC PATIENT.
16 Q. IF GIVEN IN COMBINATION WITH THESE OTHER HE SEDATING
17 DRUGS, DOES THAT INCREASE THE RISK OF THE SIDE EFFECTS --
18 A. YES.
19 Q. -- FOR THAT PARTICULAR DRUG?
20 A. YES, DEFINITELY INCREASE THE AMOUNT OF SEDATION.
21 Q. DID YOU SEE SIDE EFFECTS WHICH WOULD EVIDENCE A REACTION
22 TO THAT PARTICULAR --
23 A. SHE BEGAN TO BE SLEEPING MORE. SHE WAS -- NURSES
24 DESCRIBED HER AS SLEEPING AND THEN SITTING ON THE FLOOR. SHE
25 HAD TO BE RESTRAINED WITH A POSEY RESTRAINT VEST.
1 Q. CAN YOU TELL US WHETHER OR NOT THE REGIMEN OF DRUGS THAT
2 SHE WAS RECEIVING, WHETHER THAT WOULD HAVE -- COULD HAVE
3 RESULTED IN HER AGITATION AS WELL AS THE LETHARGIC?
4 A. IT COULD HAVE. THERE'S SO MANY FACTORS THAT CAN
5 CONTRIBUTE TO AGITATION THAT THAT HAS TO BE CONSIDERED AS ONE
6 OF THE OPTIONS, THAT MAYBE THE MEDICATION IS ADDING TO HER
7 AGITATION.
8 Q. OKAY. DID SOMETHING OCCUR WHO DECEMBER 31ST RELATIVE TO
9 THE MEDICATION?
10 A. BY THE 31ST, SHE WAS VERY DROWSY, UNABLE TO PARTICIPATE
11 IN GROUPS, LETHARGIC. BUT AT OTHER TIMES AGITATED.
12 OCCASIONALLY REFUSED MEDS. AND THEN SHE BEGAN TAKING THE
13 DOSES OF MEDICATIONS MUCH BETTER AND -- AND THAT MEANT A
14 SUDDEN INCREASE IN THE AMOUNT OF MEDICATION THAT SHE
15 PREVIOUSLY HAD BEEN REFUSING.
16 Q. DID YOU SEE ALSO DIFFERENT -- A DIFFERENT DRUG ADDED
17 TO -- TO THE -- WAS THERE AN INCREASE IN THE DEPAKENE, I
18 SHOULD SAY?
19 A. THE DEPAKENE WAS INCREASED TO A THOUSAND MILLIGRAMS.
20 Q. AND THEN THE FOLLOWING DAY WAS THERE ADDITIONAL DRUGS
21 THAT WERE ADDED ON TO THE REGIMEN?
22 A. REFERRING TO THE ATIVAN?
23 Q. YES?
24 A. ATIVAN WAS ADDED. AND THE HALDOL DOSE WAS INCREASED.
25 Q. CALLING YOUR ATTENTION TO THE 3RD OF JANUARY, CAN YOU
1 TELL US DID SHE RECEIVE A SIGNIFICANT DOSAGE OF HALDOL ON
2 THAT PARTICULAR DAY?
3 A. SHE GOT 5-MILLIGRAM DOSES OF HALDOL INTRAMUSCULARLY
4 THREE TIMES THAT DAY. THAT'S A DOSE OF 15 MILLIGRAMS, WHICH
5 IS A DRAMATIC CHANGE WHEN ADDED ON TOP OF THE PREVIOUS
6 MEDICATIONS.
7 Q. NOW, IS THE FACT THAT SHE GOT IT INTRAMUSCULARLY, DOES
8 THAT BEAR SOME KIND OF SIGNIFICANCE TO YOU?
9 A. THAT'S ABOUT TWICE AS STRONG AS BY MOUTH.
10 Q. OKAY. DID YOU SEE ANY REACTIONS OR ANY SEDATIONS ON THE
11 PART OF LYDIA SMITH AT THAT TIME?
12 A. LATER IN THAT DAY SHE WAS DESCRIBED AS VERY DROWSY AND
13 LETHARGIC. SLEEPING AT WRAP-UP TIME.
14 Q. OKAY. DID YOU SEE ANYTHING -- ANY REASON -- WELL,
15 STRIKE THAT. CAN YOU TELL US, DOCTOR, AS TO THE REGIMEN OF
16 DRUGS, WAS THERE A -- IN YOUR REVIEW, A BASIS FOR GIVING THE
17 DRUGS IN THAT PARTICULAR ORDER AND THAT PARTICULAR DOSAGE AND
18 AMOUNTS?
19 A. IF I UNDERSTAND THE QUESTION CORRECTLY, THERE WAS A
20 BASIS FOR IT. IT WAS IN RESPONSE TO HER CONTINUED AGITATION
21 AND BEHAVIOR.
22 Q. OKAY. IN TERMS OF THE --
23 A. BUT --
24 Q. -- THE PURPOSE FOR WHICH SHE WAS AT THE GEROPSYCH UNIT,
25 WAS THERE A TREATMENT PLAN IN PLACE?
1 A. YES.
2 Q. DID THIS DRUG REGIMEN IN YOUR OPINION CORRESPOND WITH
3 WHAT WAS -- WHAT WAS THE PURPOSE OF THAT TREATMENT PLAN? OR
4 WHAT THE OUTCOME WAS?
5 A. NO, TO THE EXTENT IT THAT IF SHE'S ASLEEP ALL THE TIME
6 AND UNABLE TO PARTICIPATE, SHE'S NOT LIKELY TO BENEFIT FROM
7 ANY OF THE GROUP INTERACTION OR ACTIVITIES THAT THEY WOULD
8 PLAN ON THAT KIND OF UNIT.
9 Q. DID YOU EVER SEE NOTES REFLECTING HER PARTICIPATION IN
10 GROUP THERAPY?
11 A. THEIR -- THEY COMMENTED ON HER ATTENDANCE AT GROUP
12 FREQUENTLY. AND SHE WAS EITHER AGGRESSIVE OR SLEEPING OR
13 TAKING OFF HER CLOTHES, WAS THE MOST COMMON --
14 Q. THIS TAKING OFF THE CLOTHES SYMPTOM, IS IT RELATED TO
15 ANY OF THESE DRUGS THAT YOU COULD IDENTIFY HERE THAT SHE WAS
16 BEING GIVEN?
17 A. MAYBE. IT'S HARD TO SAY. THE BENZODIAZEPINES LIKE
18 ATIVAN DISINHIBIT PEOPLE AND THEY'LL DO THINGS THEY THEY
19 WOULD OTHERWISE BE EMBARRASSED TO TO.
20 Q. OKAY?
21 A. BUT I THINK THIS BEHAVIOR STARTED BEFORE SHE RECEIVED
22 THE ATIVAN.
23 Q. DID SHE CONTINUE TO -- OR DID YOU CONTINUE TO SEE SIGNS
24 OR SYMPTOMS OF HER BEING LETHARGIC DURING THIS TIME FRAME?
25 A. YEAH. ON JANUARY 6TH, NURSES NOTED THAT SHE'D SLEPT
1 QUIETLY, THEN SLEPT MOST OF THE DAY, WAS NOT AGGRESSIVE, WAS
2 QUIET. SLEPT MOST OF THE SHIFT. SHE WAS NOT COMBATIVE. AND
3 THEN BY THE NEXT DAY, SHE WAS MINIMALLY RESPONSIVE AND NOT
4 SWALLOWING OR RESPONDING TO STAFF. UNRESPONSIVE. WITH
5 SHALLOW RESPIRATIONS.
6 Q. RELATIVE TO THE EATING AND DRINKING, DOES THAT -- NOT
7 EATING AND DRINKING, DOES THAT BEAR ANY SIGNIFICANCE TO -- TO
8 THE DRUGS THAT SHE WAS RECEIVING DURING THIS TIME FRAME?
9 A. IT'S GONNA CAUSE MORE PROBLEMS IF SHE GETS DEHYDRATED.
10 MEDICATION'S GONNA HAVE A MORE PRONOUNCED EFFECT ON HER.
11 Q. DOES THE MEDICATION IMPACT HER ABILITY TO EAT AND DRINK?
12 A. ABSOLUTELY. SUFFICIENT DOSES OF ANY OF THESE
13 MEDICATIONS WOULD RENDER A PERSON UNINTERESTED AND UNABLE TO
14 EAT OR DRINK.
15 Q. AND AS A RESULT OF THAT THEY BECOME DEHYDRATED, IS THAT
16 CORRECT?
17 A. CORRECT, AND NOT BREATHING WELL.
18 Q. AND DOES THAT AGAIN INCREASE THEIR SENSITIVITY TO THESE
19 DRUGS?
20 A. WELL, IT FURTHER COMPROMISES THEM AND MAKES THEM LESS
21 ABLE TO DEAL WITH ANY FURTHER INSULTS. AND LESS ABLE TO
22 HANDLE MORE MEDICATION.
23 Q. OKAY. NOW, THE PATIENT, YOU DESCRIBED HER AS BEING
24 UNRESPONSIVE AND LETHARGIC ON THE 6TH. WHAT DO THE NOTES
25 REFLECT HER STATE OF ACTIVITY WAS ON JANUARY THE 7TH?
1 A. ACTUALLY, IT WAS THE 7TH I THINK WHEN SHE WAS
2 UNRESPONSIVE AND NOT SWALLOWING.
3 Q. OKAY. ALL RIGHT. DO YOU KNOW WHETHER OR NOT SHE WAS
4 GIVEN ANY OTHER DRUGS ON THAT PARTICULAR DATE RELATIVE TO HER
5 CONDITION?
6 A. SHE WAS GIVEN MORPHINE.
7 Q. AND WHEN DID THAT OCCUR, SIR?
8 A. A DOSE AT 9 P.M. AND A DOSE AT 11:30 P.M.
9 Q. DID YOU SEE ANYTHING RELATED TO THIS PATIENT AND THE
10 REPORTS AND THE REVIEW YOU MADE OF THE RECORDS THAT SHE HAD
11 SUFFERED ANY KIND OF A CRITICAL EVENT OR A CRISIS?
12 A. NO.
13 Q. DID YOU SEE ANY -- WAS THERE ANY NOTES THAT REFLECTED OR
14 IDENTIFIED ANYTHING ABOUT HER CONDITION AS THAT SHE WAS IN A
15 DYING STATE?
16 A. THERE IS A NOTE ON THE 7TH, THE DAY WHEN SHE WAS
17 MINIMALLY RESPONSIVE, WHEN DR. WEITZEL DESCRIBES HER AS BEING
18 WEAK AND NOT EATING, NO URINE, AND SEEMS TO BE IN PAIN OR
19 HAVING ANXIETY.
20 Q. THE FACT THAT THERE WAS NO URINE, WOULD THAT BE
21 CONSISTENT OR INCONSISTENT WITH THE EFFECTS OF THESE DRUGS?
22 A. THERE ARE MULTIPLE CAUSES OF NO URINE, THE FIRST ONE
23 BEING DEHYDRATION BY NOT TAKING IN FLUIDS WHICH COULD BE A
24 RESULT OF BEING OVERSEDATED WITH THESE MEDICATIONS.
25 Q. OKAY.
1 A. ELDERLY PEOPLE SOMETIMES HAVE DIFFICULTY EMPTYING THEIR
2 BLADDERS, AND THAT CAN BE A CAUSE OF AGITATION. THEY HAVE A
3 FULL BLADDER AND THEY'RE UNABLE TO GET IT EMPTY, AND IT'S
4 UNCOMFORTABLE.
5 Q. THANK YOU. DOCTOR, BASED UPON YOUR REVIEW OF THE
6 MEDICAL RECORDS, YOUR EXPERIENCE AND TRAINING, DID YOU FORM
7 AN OPINION AS TO WHETHER THE DEFENDANT'S PRACTICES AND
8 CONDUCT AS TO THE TREATMENT AND CARE OF LYDIA SMITH DEVIATED
9 FROM THE STANDARDS OF CARE AS WOULD BE EXERCISED BY A
10 PHYSICIAN IF THE SAME CIRCUMSTANCE?
11 A. I THINK SO, YES.
12 Q. AND WHAT IS THAT OPINION, SIR?
13 A. THE TURNING POINT IN THIS WOMAN'S HOSPITALIZATION
14 OCCURRED THE DAY THAT SHOULD SHE GOT SO MUCH HALDOL AND 2
15 MILLIGRAMS OF ATIVAN AND CLONIDINE, THE BLOOD PRESSURE
16 MEDICATION. SHE NEVER QUITE RECOVERED FROM THAT. AND I
17 THINK THAT THAT WAS A -- THAT THAT WAS THE WRONG DOSE, THAT
18 WAS AN EXCESSIVE DOSE.
19 Q. OKAY. RELATIVE TO THE ADMINISTRATION OF THE MORPHINE ON
20 THE FINAL DAY OF HER LIFE, DO YOU HAVE AN OPINION AS TO
21 WHETHER OR NOT THAT WAS WARRANTED OR WAS APPROPRIATE UNDER
22 THE CIRCUMSTANCES?
23 A. I COULD NOT THINK OF A REASON TO GIVE THE MORPHINE OTHER
24 THAN TO HASTEN DEATH.
25 THE COURT: DOCTOR, CAN YOU SPEAK UP PLEASE? SOME OF
1 THE JURORS ARE HAVING DIFFICULTY HEARING YOU.
2 THE WITNESS: I COULD NOT FIND A REASON, OTHER THAN
3 DR. WEITZEL'S STATEMENT THAT SHE SEEMED TO BE IN PAIN.
4 Q. (BY MR. WILSON) AND DO YOU HAVE AN OPINION RELATED TO
5 THE -- TO A DEGREE OF MEDICAL CERTAINTY RELATED TO THE CAUSE
6 OF DEATH?
7 A. YEAH, I THINK THAT THE IMMEDIATE PRIMARY CAUSE OF DEATH
8 WAS THE MORPHINE THAT SHE WAS GIVEN IN THAT WEAKENED STATE.
9 Q. OKAY. DO YOU HAVE AN OPINION RELATED TO ANY OTHER
10 CONTRIBUTORY FACTORS TO HER DEATH?
11 A. WELL, SHE WAS AN ELDERLY, FRAIL PERSON. AND SHE'D
12 PREVIOUSLY HAD STROKES AND SHE'D HAD HEART DISEASE AND AN
13 AORTIC VALVE REPLACEMENT. SHE WASN'T A YOUNG, STRONG PERSON.
14 SHE'S FRAGILE.
15 Q. DID THE -- DID THE DRUGS THAT SHE HAD BEEN ADMINISTERED
16 OVER THIS PERIOD OF TIME PLAY ANY PART IN CAUSING HER DEATH?
17 A. I BELIEVE SO, YES.
18 Q. AND HOW DID THEY DO THAT, SIR?
19 A. WELL, BY SEDATING HER TO THE POINT THAT SHE WAS NOT
20 TAKING FLUIDS AND NOT ABLE TO PARTICIPATE, THAT WOULD START A
21 SERIES OF CHANGES AND EVENTS IN HER THAT SHE WASN'T ABLE TO
22 RECOVER FROM. GETTING DEHYDRATED, GETTING SICKER AND SICKER,
23 WEAKER AND WEAKER. AND THEN ADDING MORPHINE ON TOP OF IT IS
24 THE FINAL BLOW.
25 Q. THANK YOU, DOCTOR. NOW, I CALL YOUR ATTENTION TO THE
1 PATIENT ENNIS ALLDREDGE. AND ASK YOU AGAIN, HAVE YOU HAD AN
2 OPPORTUNITY TO REVIEW HIS MEDICAL RECORDS --
3 A. YES.
4 Q. -- AT THE DAVIS HOSPITAL -- EXCUSE ME. AT THE HOSPITAL?
5 A. YES.
6 Q. I ALSO WOULD REFERENCE EXHIBIT 6 --
7 THE COURT: F.
8 Q. (BY MR. WILSON) -- F. AND ASK YOU, DO YOU HAVE A COPY OF
9 THAT PARTICULAR EXHIBIT IN YOUR POSSESSION?
10 A. YES, I DO.
11 Q. AND YOU'VE SEEN IT?
12 A. YES.
13 Q. AND REVIEWED IT?
14 A. YES.
15 Q. AND CAN YOU TELL US IF THE MEDICATIONS THAT ARE LISTED
16 ON THAT PARTICULAR EXHIBIT, ARE THEY ACCURATE ACCORDING TO
17 THE -- YOUR REVIEW?
18 A. YES.
19 Q. OKAY. NOW, WHEN DID MR. ALLDREDGE -- WHEN WAS
20 MR. ALLDREDGE ADMITTED TO THE UNIT?
21 A. JANUARY 10TH, 1996 AT 12:03 P.M.
22 Q. AND DO YOU KNOW WHY HE WAS ADMITTED TO THE UNIT?
23 A. HE HAD PREVIOUSLY BEEN AT SUNSHINE TERRACE WHERE HE HAD
24 BECOME AGGRESSIVE. AND BECAUSE HE WAS A STRONG PERSON, WHEN
25 HE WOULD BE COMBATIVE, HE HAD THE ABILITY TO HURT OTHER
1 NURSING HOME RESIDENTS.
2 Q. OKAY. AND DID THEY INDICATE ALSO ON ADMISSION WHAT TYPE
3 OF MEDICATIONS HE'D BEEN ON PREVIOUS TO THAT TIME?
4 A. HE HAD BEEN ON HALDOL, MELLARIL, WHICH IS ANOTHER
5 NEUROLEPTIC ANTIPSYCHOTIC MEDICATION. ATIVAN, RISPERDAL,
6 BENADRYL, AND THEN SOME BLOOD PRESSURE AND POTASSIUM
7 MEDICATIONS. AND RESTORIL WHICH IS A BENZODIAZEPINE
8 SEDATIVE, SLEEPING PILL. AND HE WAS ALSO ON INSULIN FOR HIS
9 DIABETES.
10 Q. OKAY. WERE THOSE MEDICATIONS CHANGED AT ALL UPON HIS
11 ADMISSION TO THE GEROPSYCH UNIT?
12 A. HE WAS PLACED ON RISPERDAL 1 MILLIGRAM THREE TIMES A
13 DAY. TRAZODONE 100 MILLIGRAMS AT NIGHT WHICH COULD BE
14 REPEATED ONCE AS NECESSARY. AND BUSPAR 10 MILLIGRAMS THREE
15 TIMES A DAY, WHICH IS AN ANTIANXIETY MEDICATION.
16 Q. CAN YOU TELL US, DOCTOR, DID HE EXHIBIT ANY SIGNS OF
17 SEDATION OR OVERLY -- OVERSEDATION ON THE DATE OF HIS
18 ADMISSION?
19 A. ON THE DATE OF HIS ADMISSION, BECAUSE OF SOME AGITATION,
20 HE WAS GIVEN 10 MILLIGRAMS OF HALDOL AS ONE-TIME SHOT ALONG
21 WITH 1 MILLIGRAM OF ATIVAN.
22 Q. CAN YOU CHARACTERIZE THE APPROPRIATENESS OF THE HALDOL?
23 A. THAT'S A MASSIVE DOSE IN A GERIATRIC PATIENT.
24 Q. DID THAT CONCERN YOU?
25 A. YES. AND THE RESULT WAS THAT HE WAS -- WHEN DR.
1 DIENHART SAW HIM SHORTLY AFTER THAT, HE WROTE THAT HE WAS
2 LETHARGIC, UNAROUSABLE ONLY TO PAINFUL STIMULI. AND HIS
3 BREATHING WAS IRREGULAR WITH PAUSES OF UP TO 20 TO 40 SECONDS
4 BETWEEN BREATHS.
5 Q. IS THERE A DESCRIPTION THAT'S GIVEN TO THOSE TYPES OF
6 BREATHS?
7 A. IT'S CALLED CHEYNE-STOKES BREATHING.
8 Q. AND WHAT DOES IT SIGNIFY OR WHAT'S ITS IMPORTANCE?
9 THE COURT: MR. WILSON, THE JURY'S HEARD THAT MANY
10 TIMES. WE DON'T NEED TO GO OVER THESE THINGS THAT THEY'VE
11 HEARD A NUMBER OF TIMES.
12 MR. WILSON: OKAY. THANK YOU, YOUR HONOR.
13 THE COURT: THEY KNOW THE DEFINITIONS. WE DON'T NEED TO
14 REPEAT IT.
15 MR. WILSON: APPRECIATE THAT, JUDGE.
16 Q. (BY MR. WILSON) THE FOLLOWING DAY, CAN YOU TELL US
17 WHETHER THERE WERE ANY SIGNS OF OVERSEDATION?
18 A. THE NURSES DESCRIBED HIM AS LETHARGIC, DISORIENTED, AND
19 UNRESPONSIVE AFTER -- EXCUSE ME, ON THAT -- ON THE 10. ON
20 THE 11TH, THE NURSES DESCRIBED HIM AS LETHARGIC, BUT WOULD
21 SOMETIMES, WHEN HE WAS AGITATED AND CRYING, HE WAS FALLING
22 ASLEEP IN HIS CHAIR. AT 8 P.M. HE WAS ASLEEP AND WOULD NOT
23 AWAKEN. HOWEVER, SHORT TIME AFTER THAT, HE WAS GIVEN ATIVAN
24 AND CALMED DOWN. AND THEN JUST BEFORE MIDNIGHT, HE WAS
25 ACTING OUT AGAIN AND SMEARING FECES .
1 Q. AND ON THE 12TH, AGAIN, COULD YOU DESCRIBE HIS ACTIVITY
2 LEVEL?
3 A. THE PHYSICAL THERAPIST THAT SAW HIM SAID HE WAS VERY
4 CONFUSED AND BARELY AWAKE AND HEAVILY MEDICATED. CONFUSED
5 AND AGITATED. DR. WEITZEL DESCRIBED HIM AS, QUOTE, REMAINS
6 QUITE DEMENTED, COMBATIVE, MUMBLES INCOHERENTLY, AND CRIES
7 OUT. THE SOCIAL WORKER SAID, QUOTE, SLEEPING AGAIN, CLOSE
8 QUOTE. TRAY AGAIN NEXT WEEK. AND DR. DIENHART SUGGESTED
9 SUPPPLEMENTAL OXYGEN BECAUSE HE WASN'T BREATHING VERY WELL.
10 Q. OKAY. SUBSEQUENT TO THAT TIME, WAS THERE ANY TESTS THAT
11 WERE CONDUCTED OR ANY CHANGE IN HIS STATUS ON THE 12TH?
12 A. HE WAS SENT FOR A BRAIN SCAN.
13 Q. OKAY. DO YOU KNOW WHY HE WAS SENT FOR A BRAIN SCAN?
14 A. APPARENTLY TO EVALUATE THIS CHANGE IN HIS CONDITION AND
15 BECAUSE HE HAD A HISTORY OF TRANSIENT ISCHEMIC ATTACKS, WHICH
16 ARE -- SOME PEOPLE CALL MINI STROKES. AND HE'D ALSO HAD A
17 LEFT OCCIPITAL STROKE -- I'M SORRY, TAKE TAKE BACK. HE HAD
18 THIS HISTORY OF T.I.A.'S.
19 Q. A HISTORY OF T.I.A.'S?
20 A. YES.
21 Q. THOSE ARE THE MINI STROKES?
22 A. YES.
23 Q. DO YOU KNOW WHETHER THERE WAS ANY FINDINGS RELATIVE TO
24 THE CHEST -- OR NOT THE CHEST X-RAY, BUT THE M.R.I.?
25 A. THE M.R.I. STATED THAT THERE WAS A QUESTION OF AN
1 INFARCTION INVOLVING THE LEFT OCCIPITAL GREY MATTER. AND
2 THAT THERE MAY BE A SMALL AREA OF INFARCTION.
3 Q. WHAT DO YOU SEE NEXT IN TERMS OF THE TREATMENT AS FAR AS
4 ENNIS ALLDREDGE IS CONCERNED AS FAR AS THE DRUGS THAT WERE
5 ADMINISTERED TO HIM? THAT'S ON THE -- I THINK ON THE 12TH.
6 A. HIS MEDICATIONS WERE HELD. MY UNDERSTANDING IS THAT THE
7 FAMILY WAS TOLD THAT HE WAS DYING.
8 Q. EXCUSE ME, COULD YOU SPEAK A LITTLE LOUDER?
9 A. MY UNDERSTANDING IS THAT THE FAMILY WAS TOLD THAT HE WAS
10 DYING OF A STROKE.
11 Q. OKAY.
12 A. AND SHORTLY AFTER THAT, HE WAS STARTED ON MORPHINE.
13 Q. DID YOU OBSERVE IN THE MEDICAL RECORDS THEMSELVES
14 ANYTHING SIGNS OR SYMPTOMS OF PAIN RELATED TO HIS CONDITION
15 ON THE -- ON THE 12TH AND THE 13TH?
16 A. NO SPECIFIC SIGNS, NO.
17 Q. CAN YOU TELL US, DOCTOR, WHETHER OR NOT, DO YOU HAVE AN
18 OPINION RELATIVE TO THE APPROPRIATENESS OF THE USE OF
19 MORPHINE ON THE 13TH?
20 A. I THINK IT WAS UNNECESSARY AND INAPPROPRIATE.
21 Q. OKAY. NOW, DO YOU HAVE AN OPINION, DOCTOR, RELATED TO
22 THE -- YOUR TRAINING AND EXPERTISE AS TO THE -- THESE
23 MEDICATION PRACTICES BY THE DEFENDANT AS TO WHETHER OR NOT
24 THEY WERE -- WERE WITHIN OR WITHOUT THE STANDARD OF CARE FOR
25 A PHYSICIAN IN THE SAME CIRCUMSTANCE?
1 A. I BELIEVE IT'S OUTSIDE THE STANDARD OF CARE FOR THIS
2 CIRCUMSTANCE.
3 Q. AND CAN YOU BE SPECIFIC AS TO WHY YOU BELIEVE THAT, SIR?
4 A. THAT DOSE OF HALDOL IS SUCH A LARGE DOSE FOR A GERIATRIC
5 PATIENT.
6 Q. OKAY.
7 A. AND HAD THE EFFECT OF -- OF MAKING HIM VERY LETHARGIC
8 AND UNRESPONSIVE AND NOT BREATHING VERY WELL. AND THEN HE
9 WAS GIVEN ADDITIONAL DOSES OF HALDOL AND ATIVAN. AND THEN
10 WHEN IT WAS APPARENT THAT HE COULDN'T SWALLOW AND THAT THERE
11 MAY HAVE BEEN A CHANGE ON HIS BRAIN SCAN, THEN HE WAS STARTED
12 ON MORPHINE.
13 Q. DO YOU HAVE AN OPINION TO A REASONABLE DEGREE OF MEDICAL
14 CERTAINTY AS TO THE CAUSE OF DEATH?
15 A. I THINK AT THAT POINT IN TIME, IT WAS THE MORPHINE.
16 MR. WILSON: THANK YOU, DOCTOR. I HAVE NO FURTHER
17 QUESTIONS.
18 THE COURT: CROSS-EXAMINE.
19 CROSS-EXAMINATION
20 BY MS. ISAACSON:
21 Q. GOOD AFTERNOON, DR. CROOKSTON. MY NAME IS TARA
22 ISAACSON. I'M ONE OF THE ATTORNEYS THAT REPRESENTS
23 DR. WEITZEL. I'D LIKE TO GO OVER FOR THE JURY WITH YOU A
24 LITTLE BIT ABOUT YOUR TRAINING AND EXPERIENCE. NOW, YOU WERE
25 ORIGINALLY EDUCATED AND TRAINED AS AN ANESTHESIOLOGIST, IS
1 THAT RIGHT?
2 A. THAT'S CORRECT.
3 Q. AND IN 1989 YOU STOPPED PRACTICING ANESTHESIOLOGY.
4 A. THAT'S CORRECT.
5 Q. AND SWITCHED TO PSYCHIATRY.
6 A. YES.
7 Q. YOU ACTUALLY STARTED YOUR TRAINING IN PSYCHIATRY IN
8 1991.
9 A. THAT'S CORRECT.
10 Q. AND AS AN EXPERT CALLED TO TESTIFY IN THIS CASE, YOU'RE
11 HERE TO EVALUATE AND OFFER OPINIONS ABOUT DR. WEITZEL'S
12 MEDICAL CARE IN DECEMBER OF 1995, IN JANUARY OF 1996.
13 A. YES.
14 Q. WE'VE ALL HEARD ABOUT THIS TERM, STANDARD OF CARE, AND
15 THAT TERM MEANS THE RANGE OF ACCEPTABLE CARE FOR A GIVEN TIME
16 PERIOD IN A GIVEN -- WITH GIVEN PATIENTS AND GIVEN
17 CIRCUMSTANCES, IS THAT RIGHT?
18 A. YES.
19 Q. GENERALLY?
20 A. GENERALLY, YES.
21 Q. AND SO WHEN WE'RE JUDGING MEDICAL CARE IN 1995 AND '96,
22 IT'S ONLY FAIR TO JUDGE THAT CARE BASED UPON WHAT WE KNEW,
23 WHAT RESEARCH WAS AVAILABLE, WHAT WE KNEW ABOUT THESE
24 MEDICATIONS AT THAT TIME AS OPPOSED TO WHAT WE KNOW IN 2002.
25 A. ABSOLUTELY.
1 Q. AND CERTAINLY, HOPEFULLY, OVER TIME, WE LEARN MORE ABOUT
2 PSYCHIATRIC CARE AND OUR CARE HOPEFULLY IMPROVES OVER TIME.
3 A. YES.
4 Q. OKAY. BUT AGAIN, WE'RE GOING TO JUDGE IN THIS CASE BY
5 THE STANDARDS AND WHAT WE KNEW IN 1995 AND '96.
6 A. CORRECT.
7 Q. NOW, WITH REGARD TO YOUR TRAINING AND YOUR BACKGROUND,
8 YOU WEREN'T ACTUALLY BOARD CERTIFIED IN PSYCHIATRY UNTIL
9 1996.
10 A. THAT'S CORRECT.
11 Q. AND REALLY, AT THE TIME THAT THIS CARE WAS TAKING PLACE,
12 YOU WERE JUST UNDERGOING TRAINING IN PSYCHIATRY.
13 A. I HAD COMPLETED A RESIDENCY IN ADULT PSYCHIATRY AND WAS
14 ELIGIBLE TO TAKE THE BOARD EXAMINATIONS AND ELECTED TO DELAY
15 THEM BECAUSE I WAS -- HAD STARTED A TWO-YEAR FELLOWSHIP OF
16 ADDITIONAL TRAINING IN CHILD AND ADOLESCENT PSYCHIATRY.
17 Q. OKAY. NOW, LET'S TALK A LITTLE BIT ABOUT YOUR AREA OF
18 EXPERTISE, CHILD AND ADOLESCENT PSYCHIATRY. REALLY YOUR --
19 YOUR SPECIALTY IS CHILD PSYCHIATRY AND ADDICTION TREATMENT,
20 IS THAT RIGHT?
21 A. NOT QUITE TRUE, NO. IN ORDER TO BECOME A CHILD
22 PSYCHIATRIST, YOU HAVE TO FIRST BE BOARD CERTIFIED IN ADULT
23 PSYCHIATRY.
24 Q. OKAY.
25 A. THERE'S NO WAY TO BE A CHILD PSYCHIATRIST WITHOUT BEING
1 AN ADULT GENERAL PSYCHIATRIST FIRST. MY CURRENT PRACTICE IS
2 AND HAS BEEN FOR SOME TIME BEEN MOSTLY ADULTS. I DO STILL
3 SEE A NUMBER OF CHILDREN IN MY PRACTICE, BUT ABOUT 70 PERCENT
4 OF MY TIME INVOLVES THE TREATMENT OF ADULTS. AND A LARGE
5 PORTION OF THAT IS ADULTS BEING DETOXIFIED FROM VARIOUS DRUGS
6 INCLUDING MORPHINE.
7 Q. AND ONE OF YOUR PRIMARY POSITIONS RIGHT NOW IS THAT YOU
8 ARE THE MEDICAL DIRECTOR FOR DAYSPRING DRUG AND ALCOHOL
9 TREATMENT.
10 A. THAT'S CORRECT.
11 Q. AND IN THAT UNIT OR IN THAT TREATMENT FACILITY, YOU'RE
12 TREATING DRUG ADDICTION.
13 A. I AS A PSYCHIATRIST AM THERE TO TREAT THEIR DRUG
14 ADDICTION AS WELL AS THEIR PSYCHIATRIC DISORDERS. WE CALL
15 THAT A DUAL DIAGNOSIS.
16 Q. OKAY.
17 A. AND SO I SPEND A LOT OF MY TIME DEALING WITH ADULT
18 PSYCHIATRIC DISORDERS.
19 Q. AND OF COURSE YOU'RE AWARE THAT IN THIS CASE --
20 A. MAY I ADD ONE OTHER THING?
21 Q. GO AHEAD?
22 A. THERE'S A SIGNIFICANT PART OF MY PRACTICE THAT BECAUSE
23 OF MY BACKGROUND IN ANESTHESIA, BECAUSE OF MY KNOWLEDGE OF
24 ADDICTION AND THE DRUGS INVOLVED, I SEE PAIN PATIENTS. AND I
25 HAVE CONSULTED FOR THE DIVISION OF PROFESSIONAL LICENSING ON
1 THE MANAGEMENT OF PAIN PATIENTS --
2 Q. OKAY.
3 A. -- RECENTLY. SO THAT'S ANOTHER AREA THAT I HOLD MYSELF
4 OUT AS SOMEWHAT EXPERT IN.
5 Q. YOU ALSO WORK AT PRIMARY CHILDREN'S MEDICAL CENTER?
6 A. I'M ON CALL ONE NIGHT A MONTH FOR PRIMARY CHILDREN'S
7 MEDICAL CENTER.
8 Q. AND ARE YOU STILL THE MEDICAL DIRECTOR FOR THE
9 ADOLESCENT ODYSSEY HOUSE TREATMENT CENTER?
10 A. YES, I AM. I SUPERVISE A CHILD PSYCHIATRY RESIDENT OR
11 TRIPLE BOARD RESIDENT THERE FOR ONE HOUR A WEEK. AND I SPEND
12 ANYWHERE FROM TWO TO FOUR HOURS AT THAT FACILITY SEEING SOME
13 OF THE ADOLESCENTS THAT ARE LIVING THERE.
14 Q. WERE YOU -- YOU'RE AWARE THAT IN THIS CASE, THE PATIENTS
15 WE'RE TALKING ABOUT ARE IN THEIR 70'S, 80'S, AND '90'S.
16 A. YES, I AM.
17 Q. AND CERTAINLY, YOUR DAY-TO-DAY EXPERIENCE AND YOUR
18 DAY-TO-DAY CLINICAL EXPERTISE DOES NOT DEAL, NUMBER ONE, WITH
19 PATIENTS WHO ARE IN THEIR 70'S, 80'S, AND 90'S PRIMARILY?
20 A. NOT AS A MAJORITY OF MY PATIENTS MBUT THEY STILL DO COME
21 TO MY UNIT AND I STILL TREAT PEOPLE WHO ARE IN THEIR 80'S AND
22 90'S.
23 Q. HOW MANY ARTICLES HAVE YOU PUBLISHED ABOUT PSYCHIATRIC
24 TREATMENT OF THE ELDERLY?
25 A. I HAVE NOT.
1 Q. HOW MANY ARTICLES HAVE YOU PUBLISHED ABOUT THE USE OF
2 PSYCHOTROPIC DRUGS?
3 A. I HAVE NOT.
4 Q. HOW MANY ARTICLES HAVE YOU PUBLISHED ABOUT DEMENTIA IN
5 ELDERLY PATIENTS?
6 A. I HAVE NOT.
7 Q. DO YOU BELONG TO ANY ORGANIZATIONS THAT SPECIALIZE IN
8 GERIATRIC PSYCHIATRY?
9 A. NO.
10 Q. NOW, I ASSUME THAT SINCE YOU'RE TESTIFYING AS AN EXPERT
11 IN THIS CASE THAT YOU HAVE ON OCCASION CARED FOR
12 GEROPSYCHIATRIC PATIENTS WITH DEMENTIA.
13 A. YES.
14 Q. AND YOU WOULD AGREE THAT EVERY PATIENT IN THIS CASE HAS
15 SEVERE DEMENTIA?
16 A. YES.
17 Q. HOW MANY ELDERLY PATIENTS WITH SEVERE DEMENTIA HAVE YOU
18 TREATED IN YOUR CAREER?
19 A. I HAVEN'T KEPT A RUNNING TOTAL, BUT A ROUGH ESTIMATE
20 WOULD BE SEVERAL DOZEN.
21 Q. AND HOW MANY OF THOSE ELDERLY PATIENTS HAD DEMENTIA AS
22 SEVERE AS WE SEE IN THIS CASE?
23 A. SOME WORSE.
24 Q. AND WHAT YEAR WOULD THAT HAVE BEEN?
25 A. IT WOULD HAVE BEEN DURING MY RESIDENCY TRAINING.
1 Q. WHERE WOULD THAT HAVE BEEN?
2 A. V.A. HOSPITAL. WAS ONE OF THE TRAINING SITES.
3 Q. NOW, WITH REGARD TO DEMENTIA AND PATIENTS WHO HAVE
4 SEVERE DEMENTIA AS THESE PATIENTS DO IN THIS CASE, YOU AGREE
5 THAT THE PURPOSE IN ADMITTING THEM TO THE GEROPSYCHIATRIC
6 UNIT WAS TO MEDICATE THEM?
7 A. OR TO MANAGE THEIR BEHAVIOR IN SUCH A WAY THAT THEY
8 COULD BE RETURNED FROM WHERE THEY CAME FROM.
9 Q. WELL, WITH PATIENTS --
10 A. IT DOESN'T ALWAYS INVOLVE JUST MEDICATION BECAUSE THERE
11 ARE OTHER REASONS THAT A DEMENTED ELDERLY PERSON CAN BE --
12 CAN DECOMPENSATE.
13 Q. WELL, YOU WOULD AGREE IN THIS CASE THAT EVERY SINGLE
14 PATIENT HAD COME FROM A FACILITY WHO -- WHO HAD TRIED TO DEAL
15 WITH EXTREME AGITATION AND HAD FAILED.
16 A. I'M ASSUMING THAT THAT'S THE CASE, SO I DIDN'T REVIEW
17 ANY OF THOSE RECORDS.
18 Q. AND IN THIS CASE YOU WOULD AGREE THAT PSYCHOTROPICS AND
19 THE USE OF PSYCHOTROPIC THERAPIES WAS EXPECTED AND WARRANTED
20 IN EACH ONE OF THESE CASES.
21 A. IT WAS EXPECTED TO BE A PART OF THEIR TREATMENT THERE,
22 ABSOLUTELY.
23 Q. AND THERE -- WHEN SOMEONE HAS SEVERE DEMENTIA, THEY HAVE
24 A DISEASE OF THE BRAIN, THEY HAVE A PROBLEM WITH THEIR BRAIN
25 THAT IS PROGRESSIVELY GETTING WORSE OVER TIME.
1 A. MOST DEMENTIAS DO DETERIORATE, YES.
2 Q. AND EVERY PATIENT IN THIS CASE HAD SEVERE DEMENTIA THAT
3 WAS NOT GOING TO GET CURED.
4 A. RIGHT.
5 Q. AND THERE'S NOT A MAGIC PILL THAT DR. WEITZEL OR ANY
6 OTHER DOCTOR INCLUDING YOU CAN GIVE TO A PATIENT WITH SEVERE
7 DEMENTIA TO MAKE THEM WHOLE AGAIN, TO MAKE THEM NOT AGITATED,
8 BUT NOT TOO LETHARGIC.
9 A. NOT YET.
10 Q. AND THE IDEA WITH THESE PSYCHOTROPICS THAT YOU'VE AGREED
11 ARE APPROPRIATE ON THE UNIT IS TO SOMEHOW STABLIZE THESE
12 PATIENTS AND HOPEFULLY GET THEM TO THE POINT WHERE THEY CAN
13 GO BACK TO A NURSING HOME.
14 A. CORRECT.
15 Q. BUT THERE'S NOT A MAGIC NUMBER FOR ANY ONE OF THESE
16 GIVEN PATIENTS?
17 A. MAGIC NUMBER OF?
18 Q. OF TYPES OF PILLS, KINDS OF PILLS, COMBINATIONS OF
19 PILLS. THERE'S NO MAGIC FORMULA, THERE'S NO WAY FOR YOU OR
20 DR. WEITZEL TO LOOK A MARY CRANE AND SAY, BY LOOKING AT HER,
21 WE SHOULD GIVE HER THIS LEVEL, THIS LEVEL, AND THIS, AND BAM,
22 SHE'S PERFECT AGAIN. THERE'S NO WAY TO DO THAT.
23 A. CORRECT.
24 Q. AND ON YOUR DIRECT TESTIMONY, YOU SAID IT'S TRIAL AND
25 ERROR.
1 A. FREQUENTLY.
2 Q. AND IT'S REALLY EASY TO OVERSHOOT WHEN YOU'RE APPLYING
3 THESE MEDICATIONS.
4 A. IT'S POSSIBLE. THAT'S WHY THE GENERALLY ACCEPTED DICTUM
5 IS THAT YOU START LOW AND GO SLOW SO THAT YOU DON'T OVERSHOOT
6 DRAMATICALLY.
7 Q. BUT EVERY -- EVERY PHYSICIAN IS DIFFERENT, WOULD YOU
8 AGREE?
9 A. YEAH.
10 Q. AND EVERY PHYSICIAN'S APPROACH TO PATIENTS AND APPROACH
11 TO MEDICATIONS IS DIFFERENT?
12 A. IN SOME WAY PROBABLY.
13 Q. AND YOU HAVE TO LOOK AT THE INDIVIDUAL PATIENT AND YOU
14 YOU HAVE TO LOOK AND SEE HOW THEY RESPOND AND ADJUST
15 ACCORDINGLY.
16 A. YES.
17 Q. NOW, LET'S TALK ABOUT MORPHINE FOR A MINUTE. YOU WOULD
18 ALSO AGREE WITH MORPHINE THERE IS NO MAGIC NUMBER. THERE IS
19 NO MAGIC DOSE FOR EVERY PATIENT OR STANDARD DOSE FOR EVERY
20 SINGLE PATIENT THAT EVERY DOCTOR AGREES ON.
21 A. THAT'S CORRECT.
22 Q. AND YOU WOULD AGREE THAT DOSAGES OF ANY PAIN MEDICATION
23 HAVE TO BE INDIVIDUALIZED AND TEMPERED AGAINST THE RESPONSE
24 OF THE PATIENT.
25 A. CORRECT.
1 Q. AND A PATIENT WHO DISPLAYS EXTREME AND EXTRAORDINARY
2 PAIN, YOU MIGHT HAVE ONE DOSING LEVEL FOR AS OPPOSED TO
3 SOMEONE WHO SEEMED TO HAVE A LOWER LEVEL OF PAIN?
4 A. IN GENERAL, YES.
5 Q. NOW, BACK TO THIS ISSUE OF DEMENTIA, YOU WOULD ALSO
6 AGREE THAT ALL OF THESE PATIENTS HAD SEVERE DIFFICULTIES
7 COMMUNICATING WITH ANYONE, WITH EVERYONE.
8 A. BY DEFINITION, THAT'S PART OF DEMENTIA.
9 Q. PART OF DEMENTIA IS THAT YOUR BRAIN IS DETERIORATING AND
10 AND IT'S AFFECTING YOU IN ALL SORTS OF WAYS, AND ONE OF THEM
11 IS COMMUNICATING, ONE OF THEM IS SPEECH.
12 A. UH-HUH.
13 Q. CORRECT?
14 A. CORRECT.
15 Q. AND IT IS VERY DIFFICULT FOR YOU AS A PSYCHIATRIST OR
16 ANY PHYSICIAN TO TREAT A PATIENT WHO CAN'T COMMUNICATE
17 EFFECTIVELY.
18 A. IT IS MORE DIFFICULT.
19 Q. IT'S EXTREMELY DIFFICULT.
20 A. I WILL TAKE ISSUE WITH EXTREMELY BECAUSE, SINCE YOU
21 POINTED OUT, I'M ALSO A CHILD PSYCHIATRIST. I DEAL WITH
22 CHILDREN WHO AREN'T OFTEN VERY ADEPT OR ARTICULATE ABOUT
23 TELLING ME THEIR SYMPTOMS. I THINK IT REQUIRES A HIGHER
24 LEVEL OF TRAINING AND EXPERTISE BUT --
25 Q. BUT YOU WOULD AGREE --
1 A. BUT IT CAN BE DONE AND IS DONE.
2 Q. COMPARING --
3 A. AND VETERINARIANS TAKE CARE OF PEOPLE WHO -- OR ANIMALS
4 WHO CAN'T SPEAK ALL THE TIME. IT IS -- IT'S POSSIBLE AND
5 IT'S NOT -- I GUESS I JUST WON'T SAY EXTREMELY DIFFICULT.
6 Q. WELL, LET'S TALK ABOUT PAIN FOR A MOMENT. PAIN OF
7 COURSE IS A VERY SUBJECTIVE EXPERIENCE.
8 A. YES.
9 Q. AND OFTENTIMES YOU CAN'T TELL THAT SOMEONE IS IN PAIN
10 UNTIL THEY TELL YOU.
11 A. THAT CAN BE TRUE.
12 Q. SOMEONE CAN HAVE A TERRIBLE, HORRIBLE HEADACHE, FOR
13 EXAMPLE, I COULD HAVE A TERRIBLE HEADACHE RIGHT NOW, AND IF I
14 DON'T SAY ANYTHING, NO ONE IN THE ROOM WOULD KNOW.
15 A. THAT CAN BE TRUE, YES.
16 Q. AND IF YOU HAVE PATIENTS WHO ARE SEVERELY DEMENTED AND
17 HAVE DIFFICULTY COMMUNICATING, IT CAN BE VERY DIFFICULT FOR A
18 TREATING PHYSICIAN TO KNOW THAT THEY'RE IN PAIN.
19 A. IT IS MORE DIFFICULT, YES.
20 Q. AND SO YOU HAVE TO USE YOUR CLINICAL JUDGMENT, YOU HAVE
21 TO LOOK AT THAT PATIENT AND TRY TO ASSESS WHETHER THERE'S
22 PAIN.
23 A. YES.
24 Q. I'D LIKE TO GO TO SOME OF THE PATIENTS. I'LL NEED TO
25 SET UP MY --
1 DOCTOR, I'M GONNA SET UP MY COMPUTER SYSTEM HERE SO THAT
2 I CAN PROJECT THE MEDICAL RECORDS ONTO THE SCREEN SO THAT THE
3 JURY CAN FOLLOW ALONG WITH US AS WE TALK.
4 WE'VE ALREADY TALKED ABOUT YOUR C.V. WHICH I'VE PUT UP
5 HERE ON THE SCREEN. LET ME SEE IF THERE'S ANYTHING THAT --
6 LET'S JUST JUMP BACK FOR A SECOND. AND THIS HAS BEEN MARKED
7 AS DEFENDANT'S EXHIBIT 98. THIS IS A COPY OF YOUR C.V. THAT
8 WAS PROVIDED THROUGH THE PROSECUTOR. DOES THIS APPEAR TO BE
9 AN ACCURATE REFLECTION OF AT LEAST A PORTION OF IT?
10 A. YES.
11 Q. AND AGAIN, WITH REGARD -- IS THAT FOCUS OFF A LITTLE
12 BIT? CAN EVERYONE SEE IT? OKAY. WITH REGARD TO YOUR
13 TRAINING, AGAIN, A FELLOWSHIP IN CHILD PSYCHIATRY. SOME OF
14 YOUR BACKGROUND FURTHER BACK. AND THEN DOWN HERE IN YOUR
15 CURRENT POSITIONS AGAIN, WE TALKED ABOUT DAYSPRING, CHILD AND
16 ADOLESCENT PSYCHIATRIST. ADOLESCENT ODYSSEY HOUSE,
17 CONSULTANT. AND THEN DIVISION SUBSTANCE ABUSE. DRUG AND
18 ALCOHOL POLICY ADVISORY GROUP. THESE WERE JUST THE THINGS WE
19 TALKED ABOUT, KIND OF AN INTRO OF THE EXAMINATION.
20 LOOK A LITTLE FUZZY TO YOU, WALLY? GOT A LITTLE BUTTON
21 HERE. WALLY'S MY TECHNICAL CONSULTANT, WHICH IS A SCARY THING.
22 OKAY. I THINK WE'RE A LITTLE BIT MORE IN FOCUS.
23 NOW, WITH REGARD TO -- LET'S KEEP MOVING FORWARD HERE.
24 WITH REGARD TO ELLEN ANDERSON, I GUESS YOUR QUESTION WITH
25 HER -- THERE'S NOT AN ISSUE OF PSYCHOTROPIC DRUGS WITH THIS
1 PATIENT, CORRECT? THIS IS THE PATIENT WHO WAS ONLY ON THE
2 UNIT FOR A VERY SHORT PERIOD OF TIME BEFORE SHE PASSED AWAY.
3 A. YES.
4 Q. AND JUST FOR REFERENCE SO THE JURY CAN SEE THIS WHILE
5 WE'RE CHATTING, REMIND YOU, THIS IS STATE'S EXHIBITS 2-H,
6 CHART THAT TALKS ABOUT ELLEN ANDERSON'S MEDICATION HISTORY.
7 CAN EVERYONE SEE THAT? VERY WELL.
8 YOUR CONCERN WITH HER TREATMENT I GUESS NUMBER ONE IS
9 THAT YOU QUESTIONED WHETHER SHE WAS REALLY IN SEVERE PAIN, IS
10 THAT RIGHT?
11 A. ACTUALLY, I DON'T RECALL COMMENTING ON THAT, BUT --
12 Q. WELL, YOU DISAGREE WITH THE ADMINISTRATION --
13 A. OF THE MORPHINE.
14 Q. -- OF MORPHINE IN THIS CASE, DON'T YOU?
15 THE COURT: YOU NEED TO SPEAK UP, DOCTOR.
16 THE WITNESS: THAT'S TRUE. ONE OF THE REASONS I HAVE
17 CONCERNS ABOUT IT IS, AS YOU JUST MENTIONED, IT REQUIRES
18 INDIVIDUAL ASSESSMENT AND EVALUATION. AND THAT'S TECHNICALLY
19 DIFFICULT TO DO OVER THE PHONE.
20 Q. (BY MS. ISAACSON) WELL, LET'S TALK ABOUT THE
21 CIRCUMSTANCES OF MS. ANDERSON'S ADMISSION. SHE COMES ON TO
22 THE UNIT, AND OF COURSE HAD SHE BEEN THERE 24 HOURS, THE
23 ASSUMPTION WOULD BE THAT SHE WOULD HAVE HAD A PHYSICAL
24 EXAMINATION BY AN INTERNIST, BUT SHE WAS ONLY THERE FOR I
25 THINK 17 HOURS OR SOMETHING ALONG THOSE LINES?
1 A. (WITNESS NODS.)
2 Q. SO IN THE INTERIM, NURSES ARE PROVIDING HER CARE, NURSES
3 ARE OBSERVING HER, NURSES ARE CARING FOR HER. AND LET'S GO
4 TO THE CHART AND LOOK -- LET THE JURY SEE AND WE MAY HAVE
5 TALKED ABOUT THIS A LITTLE BIT BEFORE. WE'RE GOING TO
6 MED-190. THIS IS STATE'S 2-C. AND DOCTOR, THIS IS A NOTE
7 FROM DECEMBER 29TH. THIS OF COURSE IS THE NIGHT THAT ELLEN
8 ANDERSON IS ADMITTED. AND THE NURSE IS SO CONCERNED BECAUSE
9 THE PATIENT BECOMES RIGID AND SCREAMS WHEN SHE IS TOUCHED, SO
10 THE NURSE ACTUALLY TAKES IT UPON HERSELF, SHE'S CONCERNED,
11 THIS SEEMS LIKE AN EMERGENCY TO HER, AND SHE CALLS
12 DR. WEITZEL AND SAYS, WE'VE GOTTA DO SOMETHING. THIS PATIENT
13 IS IN EXTREME PAIN. ISN'T THAT ESSENTIALLY WHAT'S REFLECTED
14 IN THE CHART?
15 A. YES.
16 Q. AND SO DR. WEITZEL GETTING THIS INFORMATION OVER THE
17 PHONE, I MEAN IN A PERFECT WORLD, HE WOULD HAVE BEEN SITTING
18 THERE WHEN SHE WAS ADMITTED, BUT PHYSICIANS ARE OFTEN NOT
19 THERE WHEN PATIENTS ARE ADMITTED, IS THAT RIGHT?
20 A. YEAH, I'M NOT AT MY WORK TODAY.
21 Q. OKAY. AND IF YOU GOT -- IF YOU GET AN EMERGENCY CALL,
22 YOU HAVE TO LISTEN TO WHAT THE CIRCUMSTANCES ARE AND RESPOND
23 ACCORDINGLY.
24 A. (WITNESS NODS.)
25 Q. AND DR. WEITZEL IN THIS CASE, IN RESPONSE TO
1 MS. WILLSON'S CALL AND HER DESCRIPTION OF EXTREME PAIN,
2 ORDERS MORPHINE. RIGHT? IS THAT CORRECT?
3 A. THAT'S WHAT HE DID, YES.
4 Q. AND AGAIN, TELEPHONE ORDERS ARE NOT THE BEST
5 CIRCUMSTANCES, BUT THEY OCCUR ESPECIAL IN EMERGENCY
6 UNEXPECTED CIRCUMSTANCES.
7 A. YES.
8 Q. NOW, YOUR CRITICISM I GUESS IS THAT THE DOSE -- YOU FELT
9 THAT THE 10-MILLIGRAM DOSE WAS EXCESSIVE. YOU WOULD NOT HAVE
10 GIVEN A 10-MILLIGRAM DOSE.
11 A. (WITNESS SHAKES HEAD.)
12 Q. BUT THE REALITY IS, DOCTOR --
13 MR. BUGDEN: EXCUSE ME, COUNSEL. LET ME JUST --
14 OCCASIONALLY THE DOCTOR SHAKES HIS HEAD AND -- COULD YOU
15 ANSWER OUT LOUD FOR THE RECORD?
16 THE WITNESS: I'LL TRY TO REMEMBER.
17 MR. BUGDEN: I THINK EVERYBODY SEES YOU DO THAT.
18 SOMETIMES YOUR VOICE IS QUITE LOW, BUT --
19 THE WITNESS: OKAY.
20 MR. BUGDEN: -- IN PARTICULAR, WE NEED AN AUDIBLE
21 RESPONSE.
22 THE WITNESS: THANK YOU.
23 Q. (BY MS. ISAACSON) YOU WOULD NOT --
24 A. NO, I WOULD NOT HAVE GIVEN 10 MILLIGRAMS OF MORPHINE.
25 Q. OKAY. NOW, YOU ARE AWARE THAT THE REALITY IS, IS IF
1 THERE WAS GOING TO BE A PROBLEM, IF THERE WAS GOING TO BE A
2 SERIOUS NEGATIVE RESPONSE BY THIS PATIENT, DEATH -- DEATH IN
3 THIS PATIENT, YOU WOULD EXPECT HER TO DIE BECAUSE OF THIS
4 DOSE, WOULDN'T YOU?
5 A. I'M -- I MISSED SOMETHING THERE.
6 Q. EXPECT --
7 A. IF SHE'S GONNA DIE, SHE WILL DIE FROM THIS DOSE --
8 Q. IF THIS DOSE IS SO EXCESSIVE, THEN YOU WOULD EXPECT --
9 IF THIS IS SO CLEARLY TO YOU AN OVERDOSE, THEN YOU WOULD
10 EXPECT THAT THE RESPONSE TO THIS WOULD BE THAT SHE WOULD DIE.
11 A. NO, I DON'T AGREE WITH THAT.
12 Q. YOU DON'T AGREE WITH THAT.
13 A. NO.
14 Q. AND THAT -- OBVIOUSLY, THAT DIDN'T HAPPEN IN THIS CASE.
15 A. RIGHT.
16 Q. AND IN FACT, WHAT WE SEE IS CHARTED AND NOTED, RELIEF --
17 LET'S SEE, I THINK IT GOES ON TO THE NEXT DAY. WE'LL COME
18 BACK TO THAT IN A SECOND. WHAT WE SEE IN THE CHART AND WHAT
19 THE NURSE NOTES IS THAT THERE'S SOME RELIEF AFTER THE
20 MORPHINE, THE PATIENT SLEEPS, GOES TO SLEEP, AND THE
21 RESPIRATIONS ARE ACTUALLY EIGHT TO 16. YOU WOULD AGREE THAT
22 NORMAL RESPIRATIONS CAN VARY ANYWHERE FROM EIGHT TO 20.
23 A. CORRECT.
24 Q. SO WE DON'T HAVE DEPRESSED RESPIRATIONS AFTER THE FIRST
25 DOSE, AND IN FACT, WE GET RELIEF FROM THE PAIN.
1 A. WELL, I -- IF YOU WANNA PUT THAT BACK UP --
2 Q. SURE.
3 A. -- IT DOES SAY A LITTLE BIT LOWER THAT SHE IS -- PATIENT
4 CALMER TWO HOURS AFTER M.S. INJECTION. VERY NEEDY OF STAFF
5 ATTENTION. SCREAMS WHEN LEFT ALONE. SHE CONTINUES TO
6 SCREAM.
7 Q. UH-HUH.
8 A. AND ONE EXPLANATION IS THAT IT WASN'T PAIN THAT SHE WAS
9 SCREAMING ABOUT IN THE FIRST PLACE.
10 Q. WELL, YOU WOULD AGREE THAT SHE'S CALMER AT LEAST AND
11 ULTIMATELY SHE --
12 A. TEMPORARILY.
13 Q. AND THEN ULTIMATELY SHE DOES SLEEP.
14 A. AND THEN HER RESPIRATIONS MAY TOTAL A NORMAL NUMBER PER
15 MINUTE, BUT THEY'RE STILL CLEARLY LABELED ERRATIC.
16 Q. BUT THE RESPIRATION RATES THEMSELVES --
17 A. THE RATE IS NORMAL.
18 Q. -- ARE NOT DANGEROUSLY LOW.
19 A. NO.
20 Q. OKAY.
21 A. HER BLOOD PRESSURE IS.
22 Q. AND --
23 A. AND HER PULSE IS ELEVATED.
24 Q. OKAY.
25 A. ALL OF WHICH LEADS ME TO BELIEVE THAT SHE'S NOT DOING
1 VERY WELL --
2 Q. WELL, YOU WOULD --
3 A. -- WHICH MAKES GIVING A SECOND DOSE EVEN MORE
4 QUESTIONABLE.
5 Q. WELL, LET'S TALK ABOUT THE SECOND DOSE. WE HAVE A NEW
6 NURSE. WE HAVE A DIFFERENT NURSE. WE GO TO THE 20TH. SO
7 THERE'S THE AFTERNOON BEFORE, THE EVENING BEFORE, AND THEN WE
8 GO TO THE 20 -- TO THE 30TH, EXCUSE ME. AND THIS IS MED-191,
9 SAME EXHIBIT. GO DOWN AND AGAIN, WE HAVE A NEW NURSE WHO AT
10 3:15 NOTES THAT THE PATIENT AWAKENS, IS THRASHING ARMS AND
11 ATTEMPTING TO THROW BODY. PATIENT IS MOANING AND SCREAMING.
12 SHE PAGES DR. WEITZEL. AGAIN, THIS IS A NURSE WHO FEELS LIKE
13 THIS IS AN EMERGENCY SITUATION. THIS PATIENT IS SO AGITATED
14 AND SO UPSET THAT SHE'S NOT -- SHE WANTS SOMETHING TO HAPPEN
15 NOW. SO SHE -- DR. WEITZEL RETURNS THE PAGE AND SHE EXPLAINS
16 TO HIM WHAT IS HAPPENING. AND AGAIN, BECAUSE HE -- BECAUSE
17 IT'S BEEN REPORTED THAT THE MORPHINE HAS WORKED BEFORE
18 SOMEWHAT --
19 MR. WILSON: YOUR HONOR, I'M GONNA OBJECT TO THE FORM OF
20 THE QUESTION BECAUSE COUNSEL'S TESTIFYING AS TO WHAT WAS IN
21 THE NURSE'S MIND AND ALSO CHARACTERIZING WHAT IS ON THAT
22 PAGE, AND I THINK INAPPROPRIATELY. I DON'T -- I DON'T
23 THINK -- I THINK IT SAYS WHAT IT SAYS.
24 THE COURT: SUSTAIN THE OBJECTION. WE DON'T KNOW WHAT
25 DR. WEITZEL KNEW.
1 Q. (BY MS. ISAACSON) DR. CROOKSTON, I'M GONNA READ YOU --
2 THIS -- THIS NURSE HERE IS TRACY SCHOLL, AND SHE HAS
3 PREVIOUSLY SWORN UNDER OATH THAT ON THIS OCCASION, REFERRING
4 TO THIS NOTE, THEN THERE WAS AN ADDITIONAL PROBLEM THAT SHE
5 AWAKENED WITH -- AND, COUNSEL, I'M SORRY, THIS IS PAGE 1317
6 OF THE TRANSCRIPT, LINES 12 THROUGH 19. THEN THERE WAS THE
7 ADDITIONAL PROBLEM THAT SHE WAKENED WITH THE SCREAMING AND
8 MOANING AND THROWING HER BODY, AND TO ME, SHE APPEARED TO BE
9 IN A GREAT DEAL OF PAIN. QUESTION, AND DID SHE TELL YOU SHE
10 WAS IN PAIN? ANSWER, NO SHE DID NOT. QUESTION, WAS SHE ABLE
11 IT COMMUNICATE VERBALLY WITH YOU AT ALL. ANSWER, NO SHE WAS
12 NOT.
13 MR. WILSON: ARE YOU GOING TO ADMIT THIS INTO EVIDENCE,
14 COUNSEL?
15 MS. ISAACSON: WELL, I'M TAKING -- I TRYING TO ASK
16 DR. CROOKSTON ABOUT THE CIRCUMSTANCES AND WHAT THE NURSES DID
17 IN RESPONSE TO THE CIRCUMSTANCES AND WHETHER OR NOT THAT WAS
18 REASONABLE.
19 Q. (BY MS. ISAACSON) SO UNDER THOSE CIRCUMSTANCES, GIVEN
20 WHAT'S HAPPENED PRIOR, DR. WEITZEL MAKES A CLINICAL JUDGMENT
21 AND ORDERS 10 MILLIGRAMS OF MORPHINE AGAIN. IS THAT RIGHT?
22 A. CORRECT.
23 Q. AND IT'S TRUE, ISN'T IT, DR. CROOKSTON, THAT THE PEAK
24 EFFECT, THE MAXIMUM EFFECT AFTER MORPHINE IS GIVEN, IS ONE
25 HOUR AFTER DOSING.
1 A. USUALLY.
2 Q. THAT IF THE MORPHINE WAS THE -- WAS THE CAUSE OF DEATH
3 FOR MS. ANDERSON, THAT SHE WOULD HAVE DIED AFTER ONE HOUR.
4 A. I'M GLAD YOU'RE BRINGING THIS UP BECAUSE THERE'S AN
5 EXPLANATION.
6 Q. LET ME -- LET ME ASK THE QUESTION, AND IF YOU --
7 A. ALL RIGHT.
8 Q. -- IF YOU WANNA ADDRESS THAT WITH MR. WILSON, YOU'RE
9 WELCOME TO. THIS PATIENT DIED FIVE AND A HALF HOURS AFTER
10 THE SECOND DOSE.
11 A. UH-HUH.
12 Q. DO I HAVE THAT RIGHT?
13 A. UH-HUH.
14 Q. AND YOUR CRITICISM I THINK YOU SAID, WELL, I MAYBE WOULD
15 HAVE GIVEN 2 MILLIGRAMS. IF YOU WERE GOING TO GIVE MORPHINE
16 IN THIS SITUATION, YOUR APPROACH WOULD BE TO GIVE 2
17 MILLIGRAMS.
18 A. I WOULD START AT A LOWER DOSE ABSOLUTELY.
19 Q. OKAY. AND AGAIN --
20 A. AND BEYOND THAT, I WOULD HAVE ASKED, WHAT HAS SHE BEEN
21 TAKING. AND WHEN I FOUND OUT SHE'S BEEN TAKING LORTAB, I
22 WOULD HAVE SAID, WELL, GIVE HER LORTAB AND WE'LL SEE HOW SHE
23 IS. AND I WOULD WORK ON UP FROM THERE.
24 Q. YOU WOULD AGREE THAT THERE ARE PHYSICIANS WHO CAN REVIEW
25 THESE MEDICAL RECORDS, COULD REVIEW THIS CIRCUMSTANCE, AND
1 WHO COULD DISAGREE WITH YOU.
2 A. OBVIOUSLY.
3 Q. AND THERE ARE MANY COMPETENT PHYSICIANS WHO YOU WOULD --
4 WHO WOULD REVIEW THIS CHART, WHO WOULD REVIEW HER HISTORY,
5 WHO WOULD REVIEW THESE DOSES --
6 MR. WILSON: YOUR HONOR, AGAIN, I'M GONNA OBJECT AS TO
7 THE FORM OF THE QUESTION. SHE'S TESTIFYING AS TO WHAT OTHER
8 PHYSICIAN MAY OR MAY NOT DO.
9 THE COURT: OVERRULED. SHE CAN ASK THE QUESTION.
10 Q. (BY MS. ISAACSON) OTHER PHYSICIANS CAN LOOK AT THIS AND
11 SAY, I THINK 10 MILLIGRAMS IS PERFECTLY APPROPRIATE UNDER THE
12 CIRCUMSTANCES, COULDN'T THEY?
13 A. I SUPPOSE. I DON'T KNOW ANY THAT WOULD, BUT THAT'S
14 POSSIBLE.
15 Q. NOT ALL DOCTORS AGREE ON DOSAGES FOR MEDICATIONS.
16 A. CORRECT.
17 Q. AND THERE IS A WIDE RANGE OF OPINION AND PRACTICE WHEN
18 IT COMES TO ADMINISTRATION OF PAIN MEDICATIONS AND OTHER
19 MEDICATIONS.
20 A. THAT'S CORRECT.
21 Q. AND CERTAINLY YOUR BACKGROUND AND YOUR CURRENT
22 EXPERIENCE IS DEALING WITH DRUG ADDICTION AS OPPOSED TO THE
23 TREATMENT OF PAIN. THAT'S THE FOCUS OF YOUR PRACTICE RIGHT
24 NOW.
25 A. THE PRIMARILY FOCUS RIGHT NOW.
1 Q. AND THERE COULD BE, YOU WOULD AGREE, DOCTORS WHO
2 SPECIALIZE FULL TIME IN END-OF-LIFE PAIN MANAGEMENT, WHO
3 WOULD AGREE THAT THIS DOSAGE IS PERFECTLY APPROPRIATE UNDER
4 THE CIRCUMSTANCES.
5 A. WAS THAT A QUESTION?
6 Q. IT WAS.
7 A. ARE THERE DOCTORS WHO WOULD AGREE?
8 Q. YES.
9 A. I THINK THERE ARE.
10 Q. BUT YOUR TESTIMONY TODAY IS THAT IF SOMEONE HAS A
11 DIFFERENT OPINION FROM ME, THAT'S A BREACH OF THE STANDARD OF
12 CARE.
13 A. THAT'S NOT QUITE HOW I CHARACTERIZED IT, BUT WHEN I WAS
14 ASKED THE QUESTION, AND HAVING READ THROUGH THE ENTIRE
15 RECORD, THIS IS NOT STANDARD OF CARE THAT I WOULD HOLD MYSELF
16 TO. AND IT'S NOT THE STANDARD OF CARE THAT ANYBODY I WOULD
17 CARE TO WORK WITH WOULD HOLD THEMSELVES TO.
18 Q. OKAY. BUT YOU WOULD AGREE -- SO YOUR OPINION WOULD BE
19 THAT IF A PHYSICIAN DOES REVIEW THESE CHARTS AND SAYS 10
20 MILLIGRAMS IS APPROPRIATE, AND THAT WAS AN APPROPRIATE
21 RESPONSE TO REPORTS OF PAIN, THAT THAT PERSON -- THAT
22 PERSON'S OPINION BREACHES THE STANDARD OF CARE, THAT
23 PHYSICIAN BREACHES THE STANDARD OF CARE BY RECOMMENDING THAT
24 SORT OF TREATMENT.
25 A. I CAN'T -- CAN'T SPEAK TO THAT.
1 Q. WELL, TODAY HERE, YOU'RE TELLING THIS JURY THAT
2 DR. WEITZEL HAS BREACHED THE STANDARD OF CARE.
3 THE COURT: WAIT A MINUTE. REPHRASE YOUR QUESTION.
4 LISTEN CAREFULLY, DOCTOR, AND SIT UP SO THE JURY CAN HEAR
5 YOU. THANK YOU. OKAY.
6 Q. (BY MS. ISAACSON) THE WHOLE PURPOSE OF YOUR TESTIMONY
7 HERE TODAY IS TO SAY, THIS IS THE STANDARD OF CARE. AND THAT
8 THIS PHYSICIAN BREACHED THE STANDARD OF CARE. THAT'S PART OF
9 WHAT YOU'RE HERE TODAY FOR.
10 A. OKAY.
11 Q. AND BUT YOU'RE ACKNOWLEDGING THAT THERE ARE PHYSICIANS
12 OUT THERE WHO DISAGREE WITH YOU.
13 A. WHO MAY DISAGREE. I --
14 Q. DOCTORS HAVE TO MAKE A JUDGMENT CALL WITH EVERY
15 INDIVIDUAL PATIENT.
16 A. THAT'S TRUE.
17 Q. AND EVERY DOCTOR HAS A DIFFERENT APPROACH AND A
18 DIFFERENT OPINION ABOUT WHAT'S APPROPRIATE.
19 A. AND EVERY DOCTOR HAS TO BE ACCOUNTABLE FOR THE DECISIONS
20 HE MAKES.
21 Q. IN THIS CASE, I BELIEVE THE QUOTE IS YOU SAID, MORPHINE
22 PLAYED A PIVOTAL ROLE IN THIS PATIENT'S DEATH.
23 A. (WITNESS NODS.)
24 Q. BUT YOU CAN'T SAY WITH ANY DEGREE OF MEDICAL CERTAINTY
25 THAT MORPHINE WAS THE SOLE CAUSE OF HER DEATH.
1 A. I DON'T THINK I SAID IT WAS THE SOLE CAUSE. SHE HAD
2 OTHER MEDICAL PROBLEMS.
3 Q. EXACTLY. SHE HAD PHEUMONIA APPARENTLY. SHE HAD
4 CONGESTIVE HEART FAILURE. AND ALL YOU CAN SAY IS THAT IN
5 YOUR OPINION, MORPHINE PLAYED SOME ROLE, BUT YOU CAN'T FERRET
6 OUT EVEN A PERCENTAGE OF WHAT ROLE THAT PLAYED. TO ANY
7 DEGREE OF REASONABLE MEDICAL CERTAINTY.
8 A. I'D BE RELUCTANT TO TRY AND COME UP WITH A PERCENTAGE.
9 Q. LET'S MOVE ON TO JUDITH LARSEN. NOW, THESE OTHER
10 PATIENTS DO INVOLVE PRESCRIBING PSYCHOTROPIC MEDICATIONS.
11 AGAIN, AS WITH MORPHINE, YOU WOULD AGREE THAT YOU HAVE TO
12 DOSE EACH INDIVIDUAL PATIENT ACCORDING TO THEIR SYMPTOMS.
13 THE COURT: JUST A MINUTE, DOCTOR. HAVE YOU GOT YOUR
14 EXHIBITS WHERE YOU NEED 'EM?
15 THE WITNESS: YES.
16 THE COURT: OKAY. GO AHEAD, COUNSEL.
17 THE WITNESS: THAT THEY NEED TO BE DOSED INDIVIDUALLY?
18 Q. (BY MS. ISAACSON) YES.
19 A. YES.
20 Q. AND THERE IS AGAIN, AS WE TALKED ABOUT BEFORE, THERE'S
21 NO MAGIC PILL, THERE'S NO MAGIC DOSE. YOU'VE GOTTA LOOK AT
22 THE PATIENT AND TRY TO CREATE A DRUG MIX THAT WORKS FOR THAT
23 PATIENT.
24 A. CORRECT.
25 Q. MRS. LARSEN HAD BEEN TREATED PREVIOUS TO HER ADMISSION
1 WITH OTHER PSYCHOTROPICS, TRAZODONE, KLONOPIN, AND ATIVAN, IS
2 THAT RIGHT?
3 A. YES.
4 Q. AND OBVIOUSLY, SHE WAS COMING TO THE GEROPSYCHIATRIC
5 UNIT BECAUSE WHATEVER COMBINATION HER PHYSICIANS HAD TRIED
6 BEFORE DIDN'T WORK.
7 A. I ASSUME THAT TO BE TRUE, YES.
8 Q. AND IN THIS CASE, AFTER MRS. LARSEN WAS ADMITTED, SHE
9 HAD BEEN TREATED WITH PSYCHOTROPICS AND AGITATION SYMPTOMS
10 DIDN'T GO AWAY. IS THAT AN ACCURATE STATEMENT?
11 A. ARE YOU REFERRING TO A SPECIFIC TIME IN HER TREATMENT.
12 Q. WELL, VARYING TIMES IN HER TREATMENT. SHE WAS THERE FOR
13 A WHILE.
14 A. YEAH.
15 Q. AND FOR THE RECORD, I'M PUTTING UP JUDITH LARSEN'S
16 SUMMARY MEDICATION CHART THAT IS STATE'S 3-H FOR THE
17 REFERENCE OF THE JURY. SO ALTHOUGH YOU WOULD AGREE THAT WITH
18 JUDITH LARSEN, OVER THE COURSE OF HER STAY, WHICH IS DECEMBER
19 6TH TO JANUARY 3RD, WE SEE UPS AND DOWNS IN HER AGITATION AND
20 HER BEHAVIOR.
21 A. YES.
22 Q. AND ONE REASONABLE CONCLUSION BY A PSYCHIATRIST, BY
23 DR. WEITZEL, WAS THAT IF SHE'S NOT RESPONDING --
24 MR. WILSON: OBJECTION, YOUR HONOR, AS TO CONCLUSION BY
25 DR. WEITZEL.
1 THE COURT: SUSTAINED.
2 Q. (BY MS. ISAACSON) DR. CROOKSTON, WHEN -- IF YOU WERE TO
3 OBSERVE -- OR ONE CONCLUSION THAT A PHYSICIAN COULD MAKE, IF
4 A -- IF A PATIENT IS NOT RESPONDING TO PSYCHOTROPICS, FOR
5 EXAMPLE, AS IN THIS CASE, AND SHE'S STILL EXTREMELY AGITATED,
6 ONE REASONABLE DIFFERENTIAL DIAGNOSIS WOULD BE THAT SHE'S IN
7 PAIN.
8 A. CAN YOU REPEAT THAT FOR ME?
9 Q. IF SOMEONE'S AGITATED LIKE JUDITH LARSEN, YOU GIVE HER
10 PSYCHOTROPICS, SHE'S STILL AGITATED. YOU LOOK FOR OTHER
11 EXPLANATIONS FOR HER AGITATION. AND IN A WOMAN WHO'S 93
12 YEARS OLD, A VERY ELDERLY WOMAN, WITH A HISTORY OF ALL SORTS
13 OF MEDICAL PROBLEMS, IT WOULD CERTAINLY BE REASONABLE FOR HER
14 PHYSICIAN TO LOOK TO PAIN AS A POSSIBLE EXPLANATION FOR HER
15 AGITATION. WOULD YOU AGREE?
16 A. THAT WOULD BE ONE OF THE POSSIBILITIES ON A LIST TO
17 CONSIDER.
18 Q. OKAY. I'M GONNA MOVE ON TO HER MEDICAL RECORDS HERE.
19 AND THIS IS MED-531 DATED DECEMBER 9TH --
20 THE COURT: WHAT IS THE EXHIBIT NUMBER?
21 MS. ISAACSON: THIS IS JUDITH LARSEN, 3-B.
22 THE COURT: PAGE NUMBER AGAIN?
23 MS. ISAACSON: AND WE'RE ON 531. SO JUST AN EXAMPLE, ON
24 DECEMBER 9TH, SHE'S GIVEN ATIVAN BECAUSE SHE'S STILL
25 AGITATED.
1 THE COURT: ARE YOU THERE, DOCTOR? YOU CAN LOOK AT THE
2 BOARD IF YOU NEED TO, THE SCREEN.
3 THE WITNESS: APPARENTLY, I HAVE A DIFFERENT NUMBERING
4 SYSTEM.
5 Q. (BY MS. ISAACSON) LET ME SEE. AGITATION ON 12/9/95.
6 ATIVAN IS GIVEN. AND SHE'S CRYING OUT. THIS IS FOUR DAYS
7 IN. SHE'S -- SHE'S CRYING OUT AND VERBALLY AGITATED. LET ME
8 JUST KEEP GOING THROUGH THE RECORDS HERE. AND I JUST WANNA
9 TALK WITH YOU A LITTLE BIT ABOUT THE AGITATION THAT WE'RE
10 CONTINUING TO SEE. SAME -- SAME EXHIBIT NUMBER, AND WE'RE
11 GONNA GO TO 12/16. AGAIN, AND THIS IS DURING THE TIME THAT
12 THE MEDICATIONS ARE BEING ADMINISTERED. WE START OUT LOWER
13 HERE AND THERE'S INCREASES OF THIS COMBINATION OF
14 PSYCHOTROPICS, BUT EVEN WITH THESE LEVELS HERE, WHAT WE'RE
15 SEEING ON THIS DATE IS PATIENT IS AGITATED, CRYING, CALLING
16 FOR HER HUSBAND. WHY DID I HAVE TO GET OLD. STILL CRYING
17 OUT. AND THERE'S -- THEY'RE GIVING HER ATIVAN AGAIN. BUT
18 AGAIN, THE AGITATION KEEPS RETURNING OVER THE COURSE OF THIS
19 FIRST I GUESS WEEK OR SO OF HER STAY.
20 THE COURT: MS. ISAACSON, DO YOU HAVE SOME QUESTIONS YOU
21 WANNA ASK THE WITNESS?
22 MS. ISAACSON: I DO. I'M SORRY, YOUR HONOR.
23 Q. (BY MS. ISAACSON) I WANNA JUST CONFIRM WITH YOU, DOCTOR,
24 THAT DURING THIS TIME PERIOD, MS. LARSEN CONTINUES TO BE
25 AGITATED DESPITE ALL THE PSYCHOTROPICS THAT SHE'S BEING
1 GIVEN.
2 A. INTERMITTENTLY, YES, WHEN SHE'S AWAKE.
3 Q. I THINK WE GO TO DECEMBER 26TH, WHERE WE'RE TALKING
4 ABOUT -- LET'S SEE, AGAIN, THERE'S QUESTIONS ABOUT HER
5 AGITATION CONTINUING, AND YOU'VE SAID THAT IF THE AGITATION
6 CONTINUES, AND WE'VE GOT THE PSYCHOTROPICS, AN APPROPRIATE
7 THING TO LOOK AT WOULD BE PAIN, IS THAT RIGHT?
8 A. THAT WOULD BE ONE OF THE CONSIDERATIONS, YES.
9 Q. AND YOUR TESTIMONY ON DIRECT WAS PART OF THIS IS TRIAL
10 AND ERROR WITH THESE KIND OF PATIENTS, SEEING WHAT WORKS,
11 SEEING WHAT DOESN'T WORK.
12 A. SOMETIMES.
13 Q. AND IN FACT, DR. WEITZEL TRIED THAT. HE GAVE JUDITH
14 LARSEN 2 MILLIGRAMS OF MORPHINE HERE ON THE 26TH. SO --
15 A. I THINK --
16 Q. -- WE'RE ON MED-569, SAME EXHIBIT, 12/26. SO MORPHINE
17 AT THIS TIME IS GIVEN --
18 THE COURT: WAIT A MINUTE. LET'S SEE IF HE CAN GET
19 WHERE HE NEEDS TO BE. WORKS BETTER, DOCTOR, IF YOU CAN'T
20 FIND IT THERE, THAT YOU LOOK AT THE SCREEN.
21 THE WITNESS: YES, OKAY.
22 THE COURT: SO WE'RE ALL ON SAME EXHIBIT.
23 THE WITNESS: OKAY. GOT IT.
24 Q. (BY MS. ISAACSON) SO AT LEAST WOULD YOU AGREE, DOCTOR,
25 THAT IT WAS APPROPRIATE FOR DR. WEITZEL TO EXPLORE THIS
1 OPTION OF MS. LARSEN BEING IN PAIN ON DECEMBER 25TH AND 26TH
2 TO SEE IF SHE GOT SOME RELIEF.
3 A. THIS WASN'T THE INITIAL EXPERIMENT. SHE GOT THREE DOSES
4 THE DAY BEFORE.
5 Q. WELL, THAT HAPPENS ON THE 26TH. THAT'S THE ONE I'VE GOT
6 IN FRONT OF YOU. BUT YOU WOULD AGREE THAT DURING THIS TIME
7 THERE'S CONTINUED AGITATION, THE PSYCHOTROPICS AREN'T TAKING
8 CARE OF IT COMPLETELY.
9 A. RIGHT.
10 Q. SO THERE IS AN EXPERIMENT. THERE'S -- THEY TRY ON
11 DECEMBER 25TH AND A LITTLE BIT ON DECEMBER 26 TO SEE IF
12 THERE'S A GOOD RESPONSE TO THE MORPHINE.
13 A. RIGHT.
14 Q. AND YOU WOULDN'T -- AGAIN, YOU WOULDN'T FAULT SOMEONE,
15 FAULT A PHYSICIAN FOR TRYING TO SEE IF MAYBE PAIN COULD
16 EXPLAIN HER AGITATION.
17 A. NO.
18 Q. AND YOU ARE AWARE OF COURSE THAT SHE HAD A SEIZURE?
19 A. YES.
20 Q. AND AT THAT TIME, YOU'RE AWARE THAT MS. LARSEN HAD AN
21 ADVANCE DIRECTIVE IN PLACE THAT WAS FROM SEPTEMBER OF 1995.
22 THE COURT: IS THAT A QUESTION?
23 MS. ISAACSON: YES.
24 THE WITNESS: WHEN?
25 Q. (BY MS. ISAACSON) SEPTEMBER OF 1995. IT SHOULD BE PART
1 OF THE MEDICAL RECORDS.
2 A. I HAVE ONE THAT I BELIEVE SAYS SEPTEMBER OF 1985 AND
3 THEN MAY OF '95.
4 Q. I THINK, IF I COULD INDICATE, COUNSEL, THAT FOR THE
5 RECORD WE'VE -- WE'VE LEARNED FROM PREVIOUS TESTIMONY THAT
6 THAT WAS ACTUALLY A MISPRINT BY A FAMILY MEMBER. BUT WERE
7 YOU AWARE, WHETHER IT WAS '85 OR '95, THAT THERE WAS
8 SPECIFICALLY AN ADVANCE THE DIRECTIVE IN PLACE FOR
9 MS. LARSEN?
10 A. YES.
11 Q. AND YOU MADE SOME MENTION ON YOUR DIRECT TESTIMONY THAT
12 AFTER THE SEIZURE, SHE WAS GIVEN DILANTIN, AND THEN THE I.V.
13 WAS STOPPED.
14 A. YES.
15 Q. AND IN THAT ADVANCE DIRECTIVE, DO YOU SEE THERE THAT IN
16 FACT THE REQUEST WAS ON MS. LARSEN'S BEHALF THAT IF SHE
17 BECAME TERMINAL, NO I.V.'S BE USED?
18 A. PART OF THAT SAME DIRECTIVE, THE ONE THAT I HAVE LABELED
19 1995 SAYS ORAL PAIN MEDICATION MAY BE GIVEN.
20 Q. AND SO YOU BELIEVE THAT ACTUALLY GIVING INTRAMUSCULAR
21 PAIN MEDICATION WAS A VIOLATION OF HER ADVANCE DIRECTIVE?
22 A. I DON'T KNOW.
23 Q. THERE'S AN INDICATION ON THAT ADVANCE DIRECTIVE THAT THE
24 PATIENT, EVEN WHEN THEY'RE TERMINAL, DOES WANT PAIN
25 MEDICATION.
1 A. PAIN MEDICATION, YES, THERE IS.
2 Q. AND LET'S JUST -- LET'S GO TO IT RIGHT NOW. IT'S
3 MED-597. SAME EXHIBIT. AND AGAIN, I'VE INDICATED FOR THE
4 RECORD, WE'VE LEARNED THAT THAT'S '95. BUT AT THIS STAGE,
5 MS. LARSEN HAS CONTINUED TO HAVE AGITATION, AND SHE'S NOW HAD
6 A SEIZURE. AND THIS IS IN PLACE, THIS IS IN HER FILE. AND
7 WITH REFERENCE TO YOUR COMMENT, WELL, NO I.V.'S FOR
8 NUTRITION, HYDRATION, OR MEDICATION. SO THE REMOVAL OF THE
9 DILANTIN I.V. CERTAINLY WOULD BE IN FULFILLMENT OF THIS
10 DIRECTIVE.
11 A. APPARENTLY, YES.
12 Q. AND SPECIFICALLY, THERE'S A NOTATION HERE THAT ORAL
13 MEDICATION MAY BE GIVEN FOR RELIEF OF PAIN AND HER COMFORT.
14 A. YES.
15 Q. AND YOU WOULD AGREE, WOULDN'T YOU, DR. CROOKSTON, THAT
16 ADVANCE DIRECTIVES AND LIVING WILLS MUST BE HONORED BY
17 PHYSICIANS?
18 A. YES.
19 Q. AND IT'S YOUR OBLIGATION AS A PHYSICIAN TO HONOR THE
20 WISHES OF BOTH YOUR PATIENT AND YOUR PATIENT'S FAMILY IF
21 THEY'RE AUTHORIZED TO DO.
22 A. YES.
23 Q. AND WOULD YOU AGREE THAT DEMENTIA IS ULTIMATELY A
24 TERMINAL CONDITION.
25 A. ULTIMATELY.
1 Q. AND EVERY SINGLE ONE OF THESE PATIENTS HAD SEVERE
2 DEMENTIA.
3 A. CORRECT.
4 Q. WERE YOU AWARE THAT THE FAMILY MADE REPEATED REQUESTS IN
5 THIS CASE THAT MS. LARSEN BE MADE COMFORTABLE?
6 A. IS THAT SPECIFICALLY IN THE RECORDS I REVIEWED?
7 Q. IT ABSOLUTELY IS.
8 A. OKAY. YES.
9 Q. DO YOU RECALL ANY -- REVIEWING REQUESTS FROM THE FAMILY
10 THAT MS. LARSEN BE MADE COMFORTABLE?
11 A. I DON'T RECALL AT WHICH SPECIFIC ONES, UNLESS YOU WANNA
12 DIRECT ME TO A PAGE NUMBER.
13 Q. I DON'T THINK WE NEED TO DO THAT.
14 A. OKAY.
15 Q. LET'S MOVE ON TO MARY CRANE. NOW, YOU ACKNOWLEDGED --
16 YOU CLARIFIED YOUR TESTIMONY AFTER A FEW MINUTES, REALIZED
17 YOU HAD MISSPOKE ABOUT MARY CRANE'S REPORT OF PAIN WHEN SHE
18 WAS INTRODUCED INTO THE UNIT, IS THAT RIGHT?
19 A. YES.
20 Q. YOU HAD FORGOTTEN THAT SHE HAD RATED HER PAIN OF FIVE
21 OUT OF FIVE WHEN SHE WAS ASKED ABOUT HER PAIN WHEN SHE WAS
22 BROUGHT ON TO THE UNIT.
23 A. SHE DID.
24 Q. AND FOR THE RECORD, I'M PUTTING UP HERE MARY CRANE'S
25 MEDICATION SUMMARY, STATE'S 4-E. THIS WAS NOT QUITE AS EASY
1 TO SEE, BUT THINK IT'LL BE OKAY. AND OF COURSE, DO YOU HAVE
2 THOSE RECORDS NOW?
3 A. (WITNESS NODS.)
4 Q. OF COURSE THIS IS A WOMAN WITH A HISTORY OF HEADACHES, A
5 HISTORY OF BACK PAIN, AND IN ADDITION TO THE FIVE OUT OF FIVE
6 IN THE NURSING ASSESSMENT, DO YOU RECALL THAT SHE REPORTED
7 THAT IF SHE COULD CHANGE ONE THING, SHE WOULD CHANGE HER
8 PAIN?
9 A. YES, THAT'S CORRECT.
10 Q. AND DO YOU RECALL, WERE YOU AWARE, THAT MS. CRANE WHILE
11 SHE WAS IN THE SANDY REGIONAL NURSING HOME, HAD BEEN ON
12 HYDROCODONE OR LORTAB OR DARVOCET ONGOING FOR A COUPLE OF
13 YEARS?
14 A. YES, I DID REVIEW THOSE RECORDS JUST RECENTLY.
15 Q. AND SHE HAD A PILL, A PAIN MEDICATION, A PRESCRIPTION
16 OPIATE PAIN MEDICATION ALMOST DAILY REALLY FOR FOUR YEARS
17 BEFORE SHE CAME ON TO THE UNIT.
18 A. CLOSER TO TWO OUT OF THREE DAYS. IT WASN'T EVERY DAY.
19 Q. AND AGAIN WITH MS. CRANE, I GUESS YOU CRITIZIZE THE
20 LEVELS OF MEDICATIONS FOR HER?
21 A. IF HER PAIN HAD BEEN MANAGED WITH ONE PILL, NOT EVEN
22 EVERY DAY PRIOR TO ADMISSION, THEN MY QUESTION IS, IS IT
23 NECESSARY TO JUMP TO THIS LEVEL OF OPIATE ANALGESIA.
24 Q. WELL, YOU WERE AWARE THAT SHE -- WELL, FIRST OF ALL,
25 LET'S GO BACK. THIS IS A PATIENT WHO WHEN SHE'S ADMITTED
1 SAYS, IF I COULD CHANGE ANYTHING ABOUT MY LIFE, I WOULD
2 CHANGE MY PAIN. I MEAN --
3 A. CORRECT.
4 Q. -- THAT'S WHAT SHE SAID.
5 A. YES. BUT WE ALSO ALL KNOW THAT ELDERLY DEMENTED PEOPLE
6 WHEN THEY CHANGE THEIR ENVIRONMENT BECOME MORE AGITATED AND
7 MORE ANXIOUS AND THAT MAY NOT BE THE FAIREST TIME TO ASK IT.
8 Q. SO HOW DO YOU KNOW THAT SHE -- SHE DOESN'T KNOW ANYTHING
9 ABOUT HER OWN PAIN?
10 A. I -- I DON'T KNOW THAT. I WOULD LIKE TO HAVE KNOWN
11 MORE, FOR EXAMPLE, AT THAT POINT --
12 Q. WELL, WASN'T IT APPROPRIATE FOR THE NURSING STAFF AND
13 FOR THE DOCTORS TO SAY THIS WOMAN SAYS SHE HAS SERIOUS PAIN
14 AND TO RESPOND ACCORDINGLY?
15 A. YES, IT IS.
16 Q. BUT YOU FELT LIKE THE DURAGESIC PATCH JUST WAS
17 UNNECESSARY FOR THIS PATIENT DESPITE HER REPORTS OF PAIN.
18 A. I DON'T BELIEVE I SAID UNNECESSARY.
19 Q. YOU SAID IT WAS INAPPROPRIATE? IT BREACHED THE STANDARD
20 OF CARE?
21 A. THE DURAGESIC?
22 Q. UH-HUH?
23 A. I DON'T BELIEVE I SAID THAT ABOUT --
24 Q. YOU --
25 A. -- THE DURAGESIC.
1 Q. YOU WOULD HAVE APPROACHED IT DIFFERENTLY.
2 A. I WOULD HAVE, YES.
3 Q. OKAY. AND OTHER DOCTORS WOULD APPROACH IT ANOTHER WAY.
4 A. RIGHT.
5 Q. AND IN FACT IN THIS CASE, THERE WAS AN INTERNAL MEDICINE
6 DOCTOR WHO CONSULTED ON MARY CRANE'S CASE AND HE APPROVED THE
7 USE OF THE DURAGESIC PATCH. HE FELT LIKE IT WAS APPROPRIATE
8 FOR PAIN CONTROL --
9 A. INITIALLY.
10 Q. -- ISN'T THAT RIGHT?
11 A. YES.
12 Q. NOW, WITH REGARD TO MS. CRANE, AGAIN THE SAME QUESTION,
13 YOU CAN'T SAY TO A REASONABLE DEGREE OF MEDICAL CERTAINTY
14 THAT MORPHINE ALONE CAUSED HER DEATH.
15 A. NO.
16 Q. SHE HAD A NUMBER OF PROBLEMS AND MEDICAL CONDITIONS THAT
17 ALL COULD HAVE CAUSED HER DEATH EASILY.
18 A. OR CONTRIBUTED TO IT, YES.
19 Q. AND AGAIN WITH REGARD TO THE STANDARD OF CARE IN THIS
20 CASE, YOU WOULD HAVE HANDLED THIS PATIENT DIFFERENTLY.
21 A. YES.
22 Q. AND IF THERE ARE OTHER PHYSICIANS WHO HAVE REVIEWED
23 THESE RECORDS AND LOOKED AT THESE DOSAGES AND LOOKED AT THIS
24 PATIENT AND THINK THEY'RE APPROPRIATE, THEY'RE BREACHING THE
25 STANDARD OF CARE AS WELL.
1 A. I DON'T BELIEVE I CAN SAY THAT ABOUT OTHER PHYSICIANS
2 BASED ON YOUR SAYING SO, BUT --
3 Q. WELL, LET'S TALK ABOUT LYDIA SMITH. AND FOR THE RECORD,
4 THIS IS STATE'S 5-E, LYDIA SMITH MEDICATION SUMMARY CHART.
5 NOW, YOU WERE AWARE THAT THIS -- THIS PATIENT HAD PREVIOUSLY
6 BEEN TREATED WITH ATIVAN AND HALDOL.
7 A. YES.
8 Q. AND WERE YOU AWARE THAT THEY ABSOLUTELY HAD NO EFFECT ON
9 HER AGITATION?
10 A. UNLESS THAT'S IN THE RECORDS I REVIEWED, I WOULDN'T HAVE
11 KNOWN THAT.
12 Q. WE HEARD FROM HER PHYSICIAN, DR. SOUTHWOR -- SOUTHWORTH,
13 LAST WEEK. NOW, JUST TELL ME IF -- IF PREVIOUS USES OF
14 PSYCHOTROPICS IMPACT YOUR ASESSMENT OF EACH OF THESE CASES.
15 A. IT CAN, YES.
16 Q. AND SO IF YOU WERE AWARE THAT DR. SOUTHWORTH HAD TRIED
17 WITH LYDIA SMITH BOTH ATIVAN AND HALDOL AND IT STILL DIDN'T
18 PUT A DENT IN HER BEHAVIOR, YOU WOULD WANNA KNOW THAT AND
19 TAKE THAT INTO ACCOUNT IN ASSESSING WHAT WAS DONE ONCE SHE
20 GOT ON TO THE UNIT.
21 A. ABSOLUTELY.
22 Q. AND YOU WOULD AGREE THAT LYDIA SMITH HAD EXTREME --
23 WELL, YOU WOULD AGREE THAT LYDIA SMITH WAS COMBATIVE,
24 FIGHTING, AGGRESSIVE, BITING, KICKING, THROUGHOUT HER STAY
25 UNTIL ABOUT JANUARY 6TH.
1 A. YES.
2 Q. SO CLEAR UP EVEN PAST THE JANUARY 3RD DATE, CLEAR UP
3 UNTIL RIGHT HERE, WITH ALL OF THESE PSYCHOTROPICS THAT ARE
4 GIVEN ON A DAILY BASIS, DIFFERENT COMBINATIONS TRIED, WE
5 STILL SEE INTERMITTENT AGITATION FROM THIS WOMAN.
6 A. UH-HUH, YES.
7 Q. AGAIN, SEVERELY DEMENTED?
8 A. YES.
9 Q. SO DESPITE THESE INCREASING DOSES, WE STILL SEE
10 AGITATION.
11 A. YES.
12 Q. CORRECT?
13 THE COURT: THIS WAS ASKED AND ANSWERED.
14 Q. (BY MS. ISAACSON) THEN WE GET TO JANUARY 7TH AND AT THIS
15 POINT, MS. SMITH HAS REFUSED TO EAT, IS THAT CORRECT?
16 A. THAT'S RIGHT.
17 Q. AND IT'S HARD TO SAY -- ONE OF THE THINGS WITH DEMENTIA
18 IS SOMETIMES DEMENTED PATIENTS WON'T EAT AND WON'T DRINK.
19 THEY'LL REFUSE DO THOSE THINGS, WON'T THEY?
20 A. THAT'S TRUE.
21 Q. AND YOU'LL SEE -- YOU WILL SEE A HISTORY IF YOU LOOK
22 THROUGH THESE MEDICAL RECORDS OF VARYING TIMES WHERE THESE
23 PATIENTS WILL REFUSE MEDICATIONS, REFUSE FOOD, AND REFUSE
24 WATER.
25 A. THAT'S TRUE.
1 Q. AND YOU WOULD AGREE THAT AT THIS POINT ON JANUARY 7TH
2 BEFORE SHE'D RECEIVED ANY MORPHINE, THERE'S BEEN A MATERIAL
3 CHANGE IN HER MEDICAL CONDITION BECAUSE OF HER REFUSAL TO
4 EAT.
5 A. I -- I DON'T KNOW THAT I AGREE THAT IT'S ALL BECAUSE OF
6 HER REFUSAL TO EAT.
7 Q. YOU WOULD AGREE THAT ON JANUARY 7TH THERE'S BEEN A
8 MATERIAL CHANGE IN HER MEDICAL CONDITION --
9 A. YES.
10 Q. -- RELATED IN PART TO HER REFUSAL TO EAT?
11 A. RELATED IN PART. AND ON JANUARY 6TH, DR. WEITZEL SAID
12 SHE WAS FEEDING POORLY, WHICH WOULD IMPLY THAT SHE IS FEEDING
13 SOME.
14 Q. OKAY. NOW, AGAIN THIS IS A WOMAN WHO'S 90 YEARS OLD.
15 SHE'S HAD A SERIOUS STROKE A MONTH PRIOR TO HER ADMISSION.
16 SHE HAS CONGESTIVE HEART FAILURE. AND SHE'S CONTINUED TO BE
17 AGITATED. AND NOW SHE HAS DETERIORATED. IS THAT AN
18 APPROPRIATE OR ACCURATE SUMMARY?
19 A. YES.
20 Q. SO AT THIS POINT, SHE COULD BE FORCE FED.
21 A. COULD BE.
22 Q. COULDN'T SHE? THAT WAS ONE OPTION.
23 A. (WITNESS NODS.)
24 Q. SHE COULD HAVE HAD I.V.'S STUCK INTO HER AND SHE COULD
25 HAVE BEEN GIVEN FLUIDS. COULDN'T SHE?
1 A. IF HER ADVANCE DIRECTIVE ALLOWED THAT.
2 Q. BUT IN THIS CASE, DR. WEITZEL WENT TO THE FAMILY AND
3 THEY MADE A DECISION ABOUT WHAT THEY WANTED TO HAVE HAPPEN ON
4 JANUARY 7TH. YOU'RE AWARE OF THAT BECAUSE I'M -- IT'S IN THE
5 MEDICAL RECORDS THERE.
6 A. OKAY.
7 Q. YOU DON'T DISPUTE THAT.
8 A. NO. THAT'S THE DAY THAT THE ADVANCE DIRECTIVE WAS
9 SIGNED BY DR. WEITZEL.
10 Q. AND IN HER CASE, MORPHINE IS NOT STARTED UNTIL JANUARY
11 7TH.
12 A. THAT'S CORRECT.
13 Q. AND AGAIN WITH REGARD TO HER, YOU CAN'T SAY THAT
14 MORPHINE CAUSED HER DEATH SOLELY.
15 A. SOLELY, NO, I CAN'T SAY THAT.
16 Q. AGAIN, THERE ARE A NUMBER OF THINGS THAT COULD HAVE
17 CAUSED THIS PATIENT'S DEATH.
18 A. SHE HAD MULTIPLE MEDICAL PROBLEMS.
19 Q. THERE'S SOME SIMILARITY WITH THE PATIENTS' SCENARIOS, SO
20 I DON'T WANNA GO THROUGH EVERY -- EVERY CHART NOTE, BUT LET'S
21 TALK ABOUT ENNIS ALLDREDGE FINALLY. AGAIN, THIS IS A PATIENT
22 WHO COMES ON TO THE UNIT JUST INCREDIBLY AGITATED. AND
23 INCREDIBLY VIOLENT.
24 MR. WILSON: YOUR HONOR, I'M GONNA OBJECT TO THE
25 CHARACTERIZATION OF VIOLENT.
1 THE COURT: SUSTAINED.
2 Q. (BY MS. ISAACSON) THIS IS A PATIENT WHO HAD ACTUALLY
3 INJURED ANOTHER PATIENT BY THROWING A WHEELCHAIR IN HIS
4 NURSING HOME. WERE YOU AWARE OF THAT?
5 A. I WAS.
6 Q. AND HE HAD RECEIVED ATIVAN, RISPERDAL, BUSPAR, MELLARIL,
7 AND HALDOL BEFORE HE EVER SET FOOT ON THIS UNIT.
8 THE COURT: ARE YOU ASKING A QUESTION?
9 MS. ISAACSON: YES.
10 THE WITNESS: YES, HE HAD.
11 Q. (BY MS. ISAACSON) SO THEN HE'S ADMITTED TO THE UNIT AND
12 AGAIN, HE IS SO AGITATED -- THIS IS MED-62, IT'S EXHIBIT 6-B.
13 LET'S SEE, AND HE'S SO AGITATED, HE HAS TO BE RESTRAINED.
14 HE'S ASSAULTIVE, HITTING, TRYING TO KICK, BITE. AND LET'S
15 SEE, LET ME JUST CONFIRM THE DATE HERE. WE'RE TALKING ON THE
16 DATE -- DATE OF ADMISSION. SO HERE ON THE DATE OF ADMISSION
17 HE'S SO EXTREMELY AGITATED, SOMETHING HAS TO BE DONE, ISN'T
18 THAT RIGHT, DR. CROOKSTON? I MEAN YOU HAVE TO -- WHEN
19 SOMEONE'S THIS AGITATED AND THIS AGGRESSIVE TOWARDS OTHER
20 PEOPLE, THE OPTIONS ARE TYING THEM UP, RESTRAINING THEM, NOT
21 MEDICATING THEM, BUT JUST TYING THEM UP AND LETTING THEM
22 SCREAM OR TRYING TO DO A MIX OF MEDICATIONS THAT WILL GET
23 THAT AGITATION UNDER CONTROL.
24 A. THOSE ARE TWO OPTIONS, YES.
25 Q. AND WOULD YOU AGREE THAT CHEMICAL OPTIONS ARE ALWAYS
1 PREFERABLE TO TYING A PATIENT LIKE THIS DOWN?
2 A. I WOULD SAY ALMOST ALWAYS.
3 Q. I DON'T THINK WE NEED TO LOOK AT THE CHARTS ANYMORE.
4 YOU WOULD AGREE THAT IN EACH PATIENT 70'S, 80'S, 90-YEAR-OLD
5 PATIENTS, THEY ALL HAD SIGNIFICANT MEDICAL PROBLEMS.
6 A. YES, THEY DID.
7 Q. AND THEY ALL HAD SEVERE DEMENTIA.
8 A. YES.
9 Q. THAT WAS TERMINAL.
10 A. YES.
11 Q. AND WITH EACH PATIENT, YOU CAN'T SAY THAT MORPHINE ALONE
12 CAUSED THEIR DEATH.
13 A. NO.
14 Q. YOU WOULDN'T HAVE PROVIDED CARE IN THIS SAME WAY.
15 A. THAT'S CORRECT.
16 Q. YOU WOULD NOT HAVE USED THESE DOSAGES.
17 A. THAT'S CORRECT.
18 Q. BUT YOU AGREE, AS WE DISCUSSED BEFORE, THAT OTHER --
19 OTHER DOCTORS, OTHER COMPETENT DOCTORS, COULD DISAGREE WITH
20 YOU AND COULD AGREE WITH THE CARE THAT WAS GIVEN. DO YOU
21 AGREE WITH THAT?
22 A. THAT SOMEBODY ELSE MIGHT DISAGREE WITH ME?
23 Q. YES.
24 A. YES.
25 Q. AND THERE'S A LOT OF DISAGREEMENT IN THE MEDICAL
1 COMMUNITY ABOUT HOW TO CARE FOR THESE PATIENTS. THERE'S A
2 WIDE RANGE OF OPINION AMONG PHYSICIANS ABOUT THE OPTIMAL WAY
3 TO DEAL WITH THESE TYPE OF DIFFICULT PATIENTS.
4 A. I THINK THAT'S TRUE.
5 Q. AND AGAIN, THE STANDARD OF CARE HERE IS HOW TO TREAT
6 ELDERLY, SEVERELY DEMENTED, EXTREMELY AGITATED PATIENTS WHO
7 HAVE SERIOUS MEDICAL PROBLEMS.
8 A. YES.
9 Q. AND YOU IN FACT HAVE NEVER WORKED ON A GEROPSYCHIATRIC
10 UNIT AND HAD TO DEAL WITH THIS PRESENTATION OF SYMPTOMS.
11 A. THAT'S NOT TRUE.
12 Q. YOU HAVE NEVER BEEN PRESENTED WITH PATIENTS OF THIS AGE,
13 WITH THIS DEMENTIA, WITH THESE -- THIS UNDERLYING MEDICAL
14 PROBLEMS SINCE YOU'VE BEEN A LICENSED PSYCHIATRIST. AND YOU
15 CERTAINLY DIDN'T DO IT IN 1995.
16 A. AS YOU STATE IT THAT WAY, THAT'S TRUE. BUT I HAVE
17 WORKED ON A GEROPSYCH UNIT AS PART OF MY TRAINING AND TAKEN
18 CARE OF VERY SIMILAR PATIENTS AND STUDIED THIS AND HAD THIS
19 SIMILAR EXPERIENCES OF TRYING TO DETERMINE WHAT'S THE BEST
20 COURSE OF ACTION FOR THESE TYPES OF PATIENTS.
21 Q. AND LET'S JUST MAKE IT CLEAR, YOU WERE NOT BOARD
22 CERTIFIED TO EVEN BE A PSYCHIATRIST UNTIL AFTER THIS CASE WAS
23 OVER AND UNTIL AFTER THIS CASE WAS GIVEN -- UNTIL AFTER THIS
24 CARE WAS GIVEN.
25 A. I WAS NOT BOARD CERTIFIED UNTIL AFTER THIS CASE. I WAS
1 ELIGIBLE AND WAS A PSYCHIATRIST LONG BEFORE THIS CASE.
2 MS. ISAACSON: THAT'S ALL I HAVE.
3 THE COURT: REDIRECT, MR. WILSON.
4 MR. WILSON: THANK YOU, YOUR HONOR.
5 REDIRECT EXAMINATION
6 BY MR. WILSON:
7 Q. JUST A FEW QUESTIONS, DOCTOR. AS RELATED TO YOUR
8 OPINION AS TO THE ROLE THAT MORPHINE PLAYED IN THE DEATHS OF
9 THESE PATIENTS, AND IN SPECIFICALLY AS TO THE DURAGESIC PATCH
10 IN RESPECT TO MARY CRANE, CAN YOU TELL US WHAT ROLE YOU --
11 WELL, LET'S JUST SPECIFICALLY -- WHAT ROLE DID MORPHINE PLAY
12 IN COMBINATION WITH THE OTHER FACTORS IN THE DEATH OF ELLEN
13 ANDERSON?
14 A. IT WAS IN COMBINATION WITH OTHER FACTORS, BUT I THINK IT
15 WAS THE FINAL BLOW --
16 Q. OKAY.
17 A. -- THAT ENDED HER LIFE.
18 Q. AND IN RESPECT TO JUDITH LARSEN, CAN YOU TELL US IN YOUR
19 OPINION WHAT ROLE MORPHINE PLAYED IN RESPECT TO HER DEATH IN
20 COMBINATION WITH THE OTHER FACTORS?
21 A. SIMILARLY, I THINK IT'S THE FINAL BLOW THAT TOOK HER
22 LIFE.
23 Q. OKAY. AND IN RESPECT IT MARY CRANE, WHAT ROLE DID THE
24 DURAGESIC PATCH AND THE MORPHINE PLAY IN CONNECTION WITH THE
25 OTHER FACTORS?
1 A. IN MARY CRANE?
2 Q. YES.
3 A. I THINK THEY MADE A CONTRIBUTION TO WEAKENING HER AND
4 ACCELERATING HER DEATH, AND THEN THE MORPHINE THAT WAS ADDED
5 AT THE END WAS A DIRECT CONTRIBUTOR.
6 Q. OKAY. IN RESPECT TO THE PATIENT LYDIA SMITH, CAN YOU
7 TELL US WHAT ROLE THE MORPHINE PLAYED IN CONNECTION WITH HER
8 DEATH?
9 A. SAME.
10 Q. SAME IN WHAT RE --
11 A. IT'S A CONTRIBUTING FACTOR, BUT AT THE END IT WAS THE
12 PRIMARY FACTOR.
13 Q. OKAY. AND IN CONNECTION WITH ENNIS ALLDREDGE, CAN YOU
14 TELL US WHAT ROLE MORPHINE PLAYED IN CONNECTION WITH HIS
15 DEATH?
16 A. IN HIS ALREADY WEAKENED STATE, IT IS WHAT CAUSED HIM TO
17 SUCCUMB AS WELL.
18 Q. OKAY. NOW, IN EACH ONE OF THESE CASES, DID YOU SEE ANY
19 MEDICAL REASON FOR THE ADMINISTRATION OF MORPHINE TO ANY OF
20 THESE PATIENTS?
21 A. I'M HESITATING BECAUSE --
22 Q. SHOULD WE TAKE 'EM ONE BY ONE?
23 A. YEAH.
24 Q. OKAY. IN RESPECT TO ELLEN ANDERSON, DID YOU SEE ANY
25 MEDICAL REASON FOR THE ADMINISTRATION OF MORPHINE IN HER
1 CASE?
2 A. MORPHINE SPECIFICALLY NO. AS WAS POINTED OUT, POSSIBLE
3 PAIN IS A CONSIDERATION AND THIS PERSON HAD TAKEN PAIN
4 MEDICATION IN THE PAST.
5 Q. LET'S TALK A LITTLE BIT MORE ABOUT THAT. IN TERMS OF
6 HER PAIN, WAS THERE ANYTHING IN THE RECORD THAT YOU OBSERVED
7 OTHER THAN THE NURSES' STATEMENTS WHICH WOULD CORROBORATE
8 THAT THIS PATIENT WAS EXPERIENCING PAIN?
9 A. NO.
10 Q. OKAY.
11 A. AND -- AND THAT I WANNA EMPHASIZE WAS ONE POSSIBILITY
12 BECAUSE SHE HAD A HISTORY OF SIMILAR BEHAVIOR FOR SOME TIME
13 THAT WAS KNOWN TO BE RELATED TO ANXIETY AND PANIC, AND IN
14 FACT, THAT AS I RECALL WAS DR. WEITZEL'S INITIAL DIAGNOSIS,
15 PANIC DISORDER. AND THAT BEHAVIOR WAS QUITE CLEARLY RELATED
16 TO HER ANXIETY AND NOT TO PAIN. BUT ANY TIME A PATIENT
17 PRESENTS, THE OTHER POSSIBILITIES HAVE TO BE CONSIDERED
18 AGAIN.
19 Q. APPRECIATE THAT. RELATIVE TO JUDITH LARSEN, DID YOU SEE
20 ANY MEDICAL REASON FOR THE ADMINISTRATION OF MORPHINE IN
21 RESPECT TO -- IN RESPECT TO THAT PATIENT?
22 A. COULD YOU ASK THAT AGAIN PLEASE?
23 Q. IN RESPECT TO JUDITH LARSEN, DID YOU SEE ANY MEDICAL
24 REASON WHICH WOULD -- WHICH WOULD REQUIRE THE USE OF MORPHINE
25 IN HER CASE?
1 A. NO, I DID NOT.
2 Q. IN RESPECT TO MARY CRANE, DID YOU SEE ANY MEDICAL REASON
3 FOR THE USE OF THE DURAGESIC PATCH IN CONNECTION WITH HER
4 TREATMENT AS WELL AS THE MORPHINE? MEDICAL REASON.
5 A. THERE WAS A MEDICAL REASON TO BE TREATED FOR PAIN. SHE
6 HAD A HISTORY OF PAIN. SHE HAD A HISTORY OF RECEIVING PAIN
7 MEDICATION. MY DISAGREEMENT IS WITH THE INTENSITY AND THE
8 LEVEL OF MEDICATION GIVEN. AND GIVEN THE FACT THAT SHE WAS
9 RECEIVING A MUCH HIGHER DOSE OF MORPHINE EQUIVALENT WITH THE
10 DURAGESIC, I SAW NO REASON TO GIVE ADDITIONAL MORPHINE.
11 Q. IN RESPECT TO THE PATIENT LYDIA SMITH, DID YOU OBSERVE
12 OR SEE ANYTHING IN THE MEDICAL RECORDS WHICH WOULD OF MEDICAL
13 NECESSITY REQUIRE THE ADMINISTRATION OF MORPHINE?
14 A. NO.
15 Q. OKAY. AND IN RESPECT TO THE PATIENT ENNIS ALLDREDGE,
16 AGAIN, DID YOU SEE ANYTHING IN HIS MEDICAL RECORDS INDICATIVE
17 OF A MEDICAL REASON WHICH WOULD NECESSITY THE ADMINISTRATION
18 OF MORPHINE?
19 A. NO, I DID NOT.
20 Q. AS A PHYSICIAN, YOU ANSWERED A QUESTION IN REGARDS TO
21 THE ADVANCE DIRECTIVES OF A PATIENT AND HONORING THOSE
22 ADVANCED DIRECTIVES. YOU WERE SHOWN AN EXHIBIT OF AN
23 ADVANCED DIRECTIVE RELATING TO THINK IT WAS JUDITH LARSEN
24 WHICH HAD BEEN EXECUTED ON SEPTEMBER THE 19TH, 1995. DO YOU
25 RECALL THAT EXHIBIT?
1 A. YES.
2 Q. CAN YOU TELL US, SIR, IN RESPECT TO THAT PARTICULAR
3 ADVANCE DIRECTIVE, IF YOU WERE THE PHYSICIAN TREATING HER IN
4 DECEMBER AND EARLY PART OF JANUARY OF 1996, DECEMBER OF 1995
5 AND JANUARY OF '96, WOULD YOU HAVE DONE ANYTHING IN ADDITION
6 TO JUST LOOKING AT THAT ADVANCED DIRECTIVE AS FAR AS -- IN
7 HONORING THAT?
8 A. WELL, FIRST OF ALL, IT STILL DOES SAY 1985, AND I HAVE
9 NO OTHER INFORMATION TO COUNTERACT THAT OTHER THAN FROM THE
10 DEFENSE COUNSEL.
11 THE COURT: ASSUME IT'S '95. GO AHEAD.
12 THE WITNESS: '95?
13 Q. (BY MR. WILSON) ASSUME IT'S '95.
14 A. THERE'S A PREVIOUS ONE FROM MAY 25TH. I WOULD TAKE BOTH
15 OF THOSE TOGETHER AND SPEND TIME WITH THE FAMILY MEMBERS
16 CLARIFYING WHAT THEIR WISHES WERE.
17 Q. OKAY. SO YOU WOULD TAKE TIME TO FIND OUT WHAT IT IS
18 THAT THEY WANTED YOU TO DO.
19 A. UNDER THE CIRCUMSTANCES.
20 Q. WHAT IS IT YOU WOULD EXPLAIN TO THEM?
21 A. WELL, IN GENERAL TERMS, IF A PERSON HAS A TEMPORARY
22 PROBLEM THAT CAN BE EASILY CORRECTED, I WOULD BE RELUCTANT TO
23 WITHDRAW ALL SUPPORT AND LET THAT BE A TERMINAL EVENT UNLESS
24 THAT WERE THE EXPLICIT WISHES OF THE FAMILY AND THE PERSON
25 INVOLVED. WHILE ALL OF THESE PATIENTS WERE TERMINAL, IN SOME
1 SENSE, ALL OF US ARE TERMINAL. WE'RE ALL GONNA DIE SOME DAY.
2 NONE OF THESE PATIENTS, IS MY UNDERSTANDING, WERE EXPECTED TO
3 DIE VERY SOON WHEN THEY ENTERED THE HOSPITAL.
4 Q. OKAY. SO YOU WOULD EXPLAIN THE ALTERNATIVES TO 'EM, IS
5 THAT CORRECT?
6 A. YES.
7 MR. WILSON: THANK YOU, DOCTOR.
8 THE COURT: MS. ISAACSON.
9 MS. ISAACSON: NOTHING FURTHER, YOUR HONOR.
10 THE COURT: MAY STEP DOWN DOCTOR. MAY THIS WITNESS BE
11 EXCUSED, MR. WILSON?
12 MR. WILSON: HE MAY, YOUR HONOR.
13 MS. ISAACSON: YES.
14 THE COURT: MAY BE EXCUSED. THANK YOU FOR COMING.