Michael Crookston, MD See the truth>> Duragesic error>>
11 MICHAEL CROOKSTON,
12 CALLED BY THE PLAINTIFF, HAVING BEEN FIRST DULY
13 SWORN, WAS EXAMINED AND TESTIFIED AS FOLLOWS:
14 DIRECT-EXAMINATION
15 BY MR. WILSON:
16 Q. DR. CROOKSTON, FOR THE RECORD, WOULD YOU STATE YOUR FULL
17 NAME, PLEASE.
18 A. MICHAEL CROOKSTON.
19 Q. WHERE DO YOU CURRENTLY PRACTICE, SIR?
20 A. SALT LAKE CITY.
21 Q. AND HOW LONG HAVE YOU PRACTICED IN SALT LAKE CITY?
22 A. I GRADUATED FROM MEDICAL SCHOOL IN 1980.
23 Q. AND DO YOU PRACTICE -- WHERE ARE YOU OFFICED AT, ANY
24 LOCATION IN PARTICULAR IN SALT LAKE CITY?
25 A. L.D.S. HOSPITAL.
2748
1 Q. OKAY. AND YOU ARE CURRENTLY PRACTICING IN WHAT FIELD?
2 A. PSYCHIATRY AND CHILD PSYCHIATRY AND ADDICTION
3 PSYCHIATRY.
4 Q. IN REFERENCE TO YOUR MEDICAL BACKGROUND, COULD YOU TELL
5 US A LITTLE BIT WHEN YOU FIRST RECEIVED YOUR MEDICAL DEGREE?
6 A. GRADUATED FROM THE UNIVERSITY OF UTAH SCHOOL OF MEDICINE
7 IN 1980.
8 Q. THAT WAS IN 1980 FROM THE UNIVERSITY OF UTAH?
9 A. YES.
10 Q. DID YOU GO ON FROM THERE FOR ANY KIND OF INTERNSHIP?
11 A. YES, I DID AN INTERNSHIP AND RESIDENCY ALSO AT THE
12 UNIVERSITY OF UTAH IN ANESTHESIOLOGY.
13 Q. ARE YOU BOARD CERTIFIED IN ANESTHESIOLOGY?
14 A. YES, I AM.
15 Q. AND WHEN WAS THE LAST TIME YOU PRACTICED ANESTHESIOLOGY
16 AS A GENERAL PRACTICE?
17 A. 1989.
18 Q. OKAY. ARE YOU -- DO YOU KEEP CURRENT WITH YOUR BOARD
19 CERTIFICATION?
20 A. BOARD CERTIFICATION IN ANESTHESIOLOGY AT THAT TIME WAS A
21 LIFETIME CERTIFICATION. I HAVE NOT RECERTIFIED, IT'S NOT
22 REQUIRED.
23 Q. OKAY. THERE'S NO REQUIREMENT FOR RECERTIFICATION, IS
24 WHAT YOU ARE TELLING ME?
25 A. NO.
2749
1 Q. OKAY. IN TERMS OF THAT PARTICULAR SPECIALTY, DO YOU
2 KEEP YOURSELF AWARE OF THE -- REFRESH YOURSELF CONCERNING
3 ASPECTS OF ANESTHESIOLOGY?
4 A. THEY ARE ASPECTS OF THAT TRAINING THAT I CONTINUE TO USE
5 IN MY PRACTICE TODAY.
6 Q. IN PARTICULAR, WHAT AREAS DO YOU CONTINUE TO USE THEM IN
7 YOUR PRACTICE?
8 A. PAIN MANAGEMENT.
9 Q. NOW YOU INDICATE THAT YOU ARE BOARD CERTIFIED IN GENERAL
10 PSYCHIATRY, WHEN DID THAT TAKE PLACE?
11 A. 1996 IF I REMEMBER CORRECTLY.
12 Q. DO YOU HOLD OTHER BOARD CERTIFICATIONS?
13 A. YES.
14 Q. IN ADOLESCENT PSYCHIATRY?
15 A. CHILD AND ADOLESCENT PSYCHIATRY.
16 Q. CHILD AND ADOLESCENT PSYCHIATRY. AND IN ADDICTION
17 PSYCHIATRY?
18 A. YES, SUBSPECIALTY CERTIFICATION IN ADDICTION PSYCHIATRY.
19 Q. ARE THEY ALL SUBSPECIALTIES OF THE GENERAL PSYCHIATRY?
20 A. NO. CHILD/ADOLESCENT PSYCHIATRY REQUIRES THAT YOU BE
21 CERTIFIED IN GENERAL PSYCHIATRY BEFORE YOU ARE ELIGIBLE TO
22 BE TESTED FOR THAT CERTIFICATION. ADDICTION PSYCHIATRY IS A
23 SUBSPECIALTY.
24 Q. HOW LONG HAVE YOU BEEN PRACTICING IN THE GENERAL AREA OF
25 PSYCHIATRY?
2750
1 A. I BEGAN MY TRAINING IN PSYCHIATRY IN 1991, FINISHED
2 GENERAL PSYCHIATRY TRAINING IN 1994, DID TWO ADDITIONAL
3 YEARS OF TRAINING IN CHILD PSYCHIATRY AND ALONG THE WAY
4 BEGAN WORKING IN ADDICTION PSYCHIATRY AND WAS ELIGIBLE FOR
5 THAT EXAMINATION AS WELL.
6 Q. OKAY. IN THE PSYCHIATRY AREA, DO YOU HAVE OCCASION TO
7 TREATMENT GERIATRIC PATIENTS AS PART OF YOUR --
8 A. I DO.
9 Q. -- GENERAL PRACTICE? AND DO YOU -- YOU SAY YOU ARE
10 OFFICED IN THE L.D.S. HOSPITAL. YOU WORK OUT OF THE L.D.S.
11 HOSPITAL, I ASSUME. DO YOU HAVE FUNCTIONS AND DUTIES AT THE
12 HOSPITAL IN TERMS OF ANY KIND OF CLINICAL RESPONSIBILITIES
13 AS FAR AS PATIENTS WHO ARE HOUSED THERE?
14 A. YES. I'M THE MEDICAL DIRECTOR FOR THE DAY SPRING
15 PROGRAM, WHICH IS A DRUG AND ALCOHOL TREATMENT PROGRAM, AND
16 AM PRIMARILY RESPONSIBLE FOR MEDICAL DETOXIFICATION OF
17 ADULTS OF ALL AGES, AND THEN SUPERVISING THEIR TREATMENT
18 THROUGH THE PROGRAMS THAT WE PROVIDE FOR TREATMENT OF
19 CHEMICAL DEPENDENCY.
20 Q. NOW, IN TERMS OF YOUR EDUCATIONAL TRAINING AND YOUR
21 EXPERIENCE, DO YOU RECEIVE ANY PARTICULAR TRAINING IN THE
22 USE OF PSYCHOTROPIC MEDICATIONS?
23 A. ITS MAJOR PART OF THE TRAINING IS FOCUS ON THE USE OF
24 MEDICATIONS THAT HAVE PSYCHIATRIC INDICATIONS.
25 Q. OKAY. AND CAN YOU BE A LITTLE BIT MORE SPECIFIC AS TO
2751
1 HOW -- HOW INTENSE THAT PARTICULAR EDUCATION REQUIREMENT IS?
2 A. WELL, PSYCHIATRISTS CAN DO THERAPY WHICH DOESN'T REQUIRE
3 MEDICATION AND THEN THEY CAN PROVIDE MEDICATION FOR THE
4 TREATMENT OF PSYCHIATRIC DISORDERS AND THE TRAINING PROGRAM
5 I WAS IN EMPHASIZED THE LATTER, USE OF MEDICATION. I ALSO
6 TRAINED IN THERAPIES AND THERE WERE A SERIES OF LECTURES AND
7 READINGS AND DISCUSSIONS AND A LOT OF PRACTICAL EXPERIENCE
8 IN PRESCRIBING.
9 Q. I TAKE IT THAT IN TERMS OF YOUR PRACTICE, THAT A
10 SUBSTANTIAL PART OF YOUR PRACTICE INVOLVES AROUND THE
11 ADMINISTRATION OF MEDICATIONS?
12 A. YES, ON A DAILY BASIS.
13 Q. OKAY. JUST DEFINE FOR US A LITTLE BIT MORE YOUR
14 EXPERIENCE IN TERMS OF TREATING GERIATRIC PATIENTS, IF YOU
15 WOULD, PLEASE. CAN YOU TELL US HOW OFTEN YOU TREAT
16 GERIATRIC PATIENTS?
17 A. AS A CHILD PSYCHIATRIST, I'VE TENDED TO FOCUS ON YOUNGER
18 AGE GROUPS. BUT AS AN ADDICTION PSYCHIATRIST, I TREAT ALL
19 AGES. FOR DETOXIFICATION ON OUR UNIT, I THINK THE OLDEST
20 PATIENT I TREATED WAS 89. I REGULARLY HAVE ELDERLY PEOPLE
21 ADMITTED WITH THAT KIND OF PROBLEM THAT REQUIRE THAT
22 TREATMENT AND I DO SEE SOME -- SOME OF MY OUTPATIENT
23 PRACTICE IS ALSO ADULTS AND OLDER ADULTS.
24 Q. SO YOU DO MAINTAIN AN OUTPATIENT PRACTICE IN ADDITION TO
25 YOUR CURRENT --
2752
1 A. YES.
2 Q. -- DUTIES AND RESPONSIBILITIES AT THE HOSPITAL?
3 A. YES.
4 Q. OKAY. NOW, WERE YOU ASKED TO REVIEW THE MEDICAL RECORDS
5 RELATED TO THIS PARTICULAR CASE?
6 A. YES.
7 Q. CAN YOU TELL US, DID YOU HAVE OCCASION TO MAKE A REVIEW
8 OF THE FIVE PATIENTS THAT WE'RE TALKING ABOUT HERE IN COURT?
9 A. I DID.
10 Q. CAN YOU TELL US WHAT RECORDS IN CONNECTION WITH THEIR
11 CARE AND TREATMENT YOU'VE HAD AN OPPORTUNITY TO REVIEW?
12 A. THE RECORDS THAT I WERE PROVIDED ARE PRIMARILY HOSPITAL
13 CHART RECORDS FROM THEIR ADMISSIONS TO THE HOSPITAL.
14 Q. TO DAVIS HOSPITAL?
15 A. YES.
16 Q. IS THAT THE GEROPSYCH UNIT, THE RECORDS THAT YOU'VE
17 REVIEWED?
18 A. YES.
19 Q. CAN YOU TELL US, INCLUDED IN THOSE RECORDS, WERE THERE
20 ANY RECORDS TO YOUR KNOWLEDGE THAT WERE RECORDS FROM CARE
21 CENTERS?
22 A. TO MY KNOWLEDGE, NO. THERE WERE REFERENCES TO THEIR
23 PREVIOUS CARE BUT I WAS NOT GIVEN NURSING HOME RECORDS.
24 Q. SO YOU DID NOT HAVE AN OPPORTUNITY TO REVIEW ANY NURSING
25 HOME RECORDS?
2753
1 A. NO.
2 Q. DID YOU HAVE AN OPPORTUNITY TO REVIEW ANY RECORDS THAT
3 PERTAIN TO THEIR TREATMENT OR CARE IN ANY HOSPITAL
4 FACILITIES AS TO EVENTS THAT YOU MAY HAVE NOTED IN THE
5 MEDICAL RECORDS FROM DAVIS HOSPITAL?
6 A. PREVIOUS HOSPITAL?
7 Q. YES.
8 A. WELL, SOME OF THE -- I BELIEVE SOME OF THOSE ARE
9 MENTIONED AS PART OF THEIR PAST HISTORY.
10 Q. AS PART OF THEIR PAST HISTORY BUT YOU DID NOT REVIEW
11 THOSE RECORDS, I TAKE IT?
12 A. NO.
13 Q. HAVE YOU HAD OCCASION, DR. CROOKSTON, TO REVIEW ANY
14 JOURNALS OR TEXTBOOKS IN CONNECTION WITH THE PREPARATION OF
15 YOUR OPINION IN THESE PROCEEDINGS?
16 A. I DID.
17 Q. OKAY. CAN YOU TELL US WHAT TYPE TEXTBOOKS YOU HAVE
18 REVIEWED IN CONNECTION WITH THESE PROCEEDINGS?
19 A. THERE'S A MAJOR TWO VOLUME TEXTBOOK CALLED CAPLIN AND
20 SADOCK COMPREHENSIVE TEXT BOOK OF PSYCHIATRY THAT I REVIEWED
21 FROM 1994, I BELIEVE, IS THE COPYRIGHT, AS WELL AS A
22 PHARMACOLOGY TEXT BOOK GOODMAN AND GILLMAN FROM 1990, AS
23 WELL AS HARRISON'S TEXT BOOK OF INTERNAL MEDICINE THE
24 CHAPTERS ON GERIATRIC MEDICINE. AND THEN I HAVE -- I HAVE
25 SEVERAL OTHER BOOKS THAT DEAL WITH MEDICATIONS.
2754
1 Q. OKAY. ON THE GERIATRIC DOSAGE HANDBOOK, CAN YOU TELL US
2 WHAT YEAR THAT PARTICULAR REFERENCE WAS?
3 A. THE GERIATRIC DOSAGE HANDBOOK THAT I BELIEVE HAS BEEN
4 REFERRED TO I DID NOT USE THAT AS A SOURCE.
5 Q. OKAY.
6 A. I HAVE A DRUG INFORMATION HANDBOOK WHICH PROVIDES I
7 THINK PROBABLY SIMILAR INFORMATION.
8 Q. ALL RIGHT. DID YOU HAVE OCCASION -- YOU INDICATED THE
9 TEXTBOOK THAT YOU REVIEWED WAS FROM 1990 AS I RECALL?
10 A. THE PSYCHIATRIC COMPREHENSIVE BOOK OF PSYCHIATRY WAS AS
11 I RECALL 1994.
12 Q. CAN YOU TELL US WHY YOU REVIEWED TEXTBOOKS FROM THAT
13 PARTICULAR YEAR?
14 A. THAT PARTICULAR VOLUME IS A NEW EDITION, IT COMES OUT
15 EVERY FOUR YEARS OR SO AND IT SEEMED RELEVANT TO ME TO
16 REVIEW THE TEXT BOOK THAT WOULD HAVE BEEN AVAILABLE AT THE
17 TIME.
18 Q. OKAY. AT THE TIME THAT THESE EVENTS TOOK PLACE?
19 A. THAT THESE -- YES.
20 Q. HAVE YOU HAD OCCASION CONSULT WITH ANY OTHER EXPERTS IN
21 CONNECTION WITH THESE IN YOUR REVIEW OF THE RECORDS?
22 A. NOT TO ANY SIGNIFICANT DEGREE.
23 Q. OKAY. HAVE YOU HAD OCCASION TO REVIEW CERTAIN CHARTS OR
24 TO PARTICIPATE IN THE CONSTRUCTION OF CERTAIN CHARTS THAT
25 ARE TO BE USED IN THESE PROCEEDINGS?
2755
1 A. I HAVE SEEN SOME OF THE VISUAL AIDS THAT HAVE BEEN
2 PROVIDED.
3 Q. OKAY. ALL RIGHT.
4 A. I DID NOT USE THOSE TO DRAW ANY CONCLUSIONS, THOUGH. I
5 BASED MY CONCLUSIONS ON THE RECORDS AS I REVIEWED THEM.
6 Q. SO YOUR CONCLUSION IS PRIMARILY BASED UPON THE RECORDS
7 AS YOU REVIEWED THEM?
8 A. YES.
9 Q. OKAY. THANK YOU, DOCTOR. LET'S TALK A LITTLE BIT ABOUT
10 PHARMACOLOGY IF WE CAN FOR JUST A MINUTE.
11 NOW, YOU INDICATE THAT YOU HAVE A FAMILIARITY WITH THE
12 USE OF CERTAIN PSYCHOTROPIC MEDICATIONS; IS THAT CORRECT?
13 A. YES.
14 Q. DO YOU ALSO HAVE EXPERIENCE IN THE USE OF CERTAIN PAIN
15 MEDICATIONS?
16 A. YES.
17 Q. NOW, I SHOW YOU WHAT'S BEEN MARKED AS STATE'S EXHIBIT 30
18 AND I'M JUST GOING TO PUT IT UP HERE AND ASK YOU TO TAKE A
19 LOOK AT THAT EXHIBIT, IF YOU WOULD.
20 FIRST OF ALL, HAVE YOU EVER SEEN THAT EXHIBIT BEFORE?
21 A. I HAVE GLANCED AT IT PREVIOUSLY, YES.
22 Q. OKAY. NOW, I'M GOING TO SHOW YOU WHAT'S BEEN MARKED AS
23 STATE'S EXHIBIT 32 AND ASK YOU TO TAKE A LOOK AT THAT
24 EXHIBIT, IF YOU WOULD, PLEASE.
25 HAVE YOU EVER HAD A CHANCE TO OBSERVE THAT PARTICULAR
2756
1 EXHIBIT?
2 A. I BELIEVE SO, YES.
3 Q. OKAY. IF YOU WOULD TAKE A SEAT, AGAIN.
4 THE EXHIBIT PROVIDES, EXHIBIT 30 PROVIDES FOR CERTAIN
5 DRUGS AND TALKS ABOUT PHARMACOLOGY IN THE ELDERLY. CAN YOU
6 TELL US WHETHER OR NOT IN GENERAL YOU AGREE WITH THE
7 STATEMENTS THAT ARE CONTAINED ON THAT EXHIBIT?
8 A. YES, I DO.
9 Q. OKAY. I WOULD LIKE TO YOU FOCUS, IF YOU WOULD, ON
10 CERTAIN PSYCHOTROPIC MEDICATIONS AND IF WE COULD JUST
11 BRIEFLY GO THROUGH. THERE WAS A NUMBER OF PSYCHOTROPIC
12 MEDICATIONS THAT WERE USED IN THE TREATMENT OF THESE
13 PATIENTS; IS THAT CORRECT?
14 A. YES.
15 Q. ONE OF THOSE BEING CLONIDINE THAT WAS USED. CAN YOU
16 TELL US FOR WHAT PURPOSE FROM A PSYCHIATRIC STANDPOINT IS
17 THE MEDICATION KLONOPIN USED?
18 A. CLONIDINE IS A BLOOD PRESSURE MEDICATION PRIMARILY.
19 IT'S USED OFF-LABEL MEANING THAT IT'S NOT AN OFFICIALLY
20 APPROVED USE IN PSYCHIATRY. I USE IT IN CHILD PSYCHIATRY TO
21 TREAT HYPERACTIVITY IN CHILDREN. IT'S USEFUL FOR THE
22 TREATMENT OF TICK DISORDERS. IT'S MAIN SIDE EFFECT IS
23 SEDATION OR MAKING A PERSON TIRED AND SLEEPY.
24 Q. OKAY.
25 A. IT CAN BE USED, AT LEAST IN CHILDREN, TO TREAT
2757
1 AGGRESSION.
2 Q. ARE YOU FAMILIAR WITH THE USES TO GERIATRIC PATIENTS?
3 A. I -- TO THE BEST OF MY KNOWLEDGE, IT'S NOT USED AS A
4 PSYCHIATRIC MEDICATION IN GERIATRICS. IT'S USED AS A BLOOD
5 PRESSURE MEDICATION PRIMARILY.
6 Q. ATIVAN, IS THAT A PSYCHOTROPIC MEDICATION?
7 A. YES. ATIVAN IS A MINOR TRANQUILIZER RELATED TO VALIUM
8 AND IT CAUSES A PERSON TO BE TIRED AND SLEEPY. IT'S
9 INDICATIONS IN PSYCHIATRY ARE PRIMARILY FOR THE TREATMENT OF
10 ANXIETY. IT'S ALSO USED TO TREAT INSOMNIA AND BESIDES
11 MAKING A PERSON VERY TIRED OR SLEEPY, IT CAN CAUSE CONFUSION
12 AND MEMORY LOSS. A MAJOR SIDE EFFECT IS THE IMPAIRMENT IN
13 MEMORY AND IN SUFFICIENT DOSES, PRESENTS A PERSON FROM
14 MAKING NEW MEMORIES WHILE IT'S ACTIVE.
15 Q. DOES THAT HAVE PARTICULAR SIGNIFICANCE IN THESE
16 PROCEEDINGS?
17 A. YES, IT DOES, BECAUSE THESE PATIENTS HAD HAD DIAGNOSES
18 OF DEMENTIA AND ALREADY HAD MEMORY PROBLEMS AND ATIVAN CAN
19 STILL BE USED BUT IT NEEDS TO BE USED VERY CAREFULLY AND
20 KEEPING IN MIND THAT IT CAN MAKE THEIR DEMENTIA AND THEIR
21 MEMORY PROBLEMS WORSE IF GIVEN IMPROPERLY.
22 Q. HALDOL, IS THAT A PSYCHOTROPIC MEDICATION?
23 A. YES. HALDOL IS A MAJOR TRANQUILIZER. IT'S AN
24 ANTIPSYCHOTIC MEDICATION USED TO TREAT HALLUCINATIONS AND
25 DELUSIONS OR FALSE BELIEFS. IT'S A VERY POTENT MEDICATION
2758
1 THAT HAS SOME VERY SIGNIFICANT SIDE EFFECTS. IT CAN CAUSE
2 PEOPLE TO HAVE A REACTION WHERE THEY BECOME VERY STIFF AND
3 DON'T MOVE QUICKLY. IT'S ONE OF THE DRUGS THAT PEOPLE WOULD
4 CONSIDER MAKES A PERSON APPEAR TO BE A ZOMBIE IF THEY
5 RECEIVE ENOUGH OF IT. IT CAN ALSO --
6 MR. STIRBA: YOUR HONOR, I'M NOT SURE I UNDERSTAND
7 WHAT IS THE PENDING QUESTION AT THIS POINT. IT'S JUST A
8 NARRATIVE.
9 THE COURT: LET'S PROCEED --
10 Q. (BY MR. WILSON) I THINK YOU WERE DESCRIBING SOME OF
11 THE RISKS OF HALDOL, WERE YOU, DOCTOR?
12 A. YES, YES.
13 Q. I'LL JUST CHARACTERIZE. YOU INDICATED THAT IT HAS A
14 NUMBER OF SIDE EFFECTS. IF YOU COULD, TELL US, IS THIS A --
15 IS THIS A MEDICATION THAT CONSTITUTES A CENTRAL NERVOUS
16 SYSTEM DEPRESSANT, DOES IT HAVE ANY OF THOSE EFFECTS?
17 A. YES, IT DOES. IT WOULD DECREASE A PERSON'S LEVEL OF
18 ALERTNESS AND CAN CAUSE SEDATION OR SLEEPINESS.
19 Q. IN TERMS OF THE DRUG TRAZODONE, CAN YOU TELL US DOES IT
20 HAVE ANY -- IS IT A PSYCHOTROPIC MEDICATION?
21 A. YES, IT IS. IT'S ORIGINALLY RELEASED AS AN
22 ANTIDEPRESSANT. ITS MAJOR SIDE EFFECT IS TO CAUSE
23 SLEEPINESS AND IN MY PRACTICE THAT'S THE ONLY REASON I
24 PRESCRIBE IT NOW IS FOR PEOPLE WHO CAN'T SLEEP.
25 Q. SO YOU DON'T USE IT AS A --
2759
1 A. NOT AS AN ANTIDEPRESSANT.
2 Q. PSYCHOTROPIC.
3 A. IT'S TOO SEDATING.
4 Q. RISPERDAL?
5 A. RISPERDAL IS A MAJOR TRANQUILIZER OR ANTIPSYCHOTIC LIKE
6 HALDOL. IT'S A NEWER WHAT WE CALL ATYPICAL NEUROLEPTIC OR
7 ANTIPSYCHOTIC.
8 Q. CAN YOU DESCRIBE THE RISKS OF THAT PARTICULAR --
9 A. SIMILAR TO HALDOL BUT IT HAS LESS SEDATION AND LESS
10 CHANCE OF CAUSING A PERSON TO BE STIFF.
11 Q. OKAY. DEPAKENE?
12 A. DEPAKENE IS --
13 Q. I DON'T THINK THAT'S LISTED UP THERE, IS IT? YES, IT
14 IS.
15 A. DEPAKENE IS AN ANTICONVULSANT, IT'S USED TO TREAT
16 EPILEPSY. IT HAS SUBSEQUENTLY THOUGH --
17 Q. IS IT AN ANTIPSYCHOTIC -- OR I MEAN A PSYCHOTROPIC
18 MEDICATION?
19 A. IT IS, YES.
20 Q. AND IT'S USED FOR WHAT PURPOSE AGAIN?
21 A. IT'S OFFICIALLY APPROVED AS A MOOD STABILIZER FOR THE
22 TREATMENT OF MANIC DEPRESSIVE ILLNESS. IT CAN ALSO BE USED
23 TO TREAT AGGRESSIVENESS. IT'S --
24 Q. WHAT ABOUT THE RISKS ASSOCIATED WITH SIDE EFFECTS FROM
25 DEPAKENE?
2760
1 A. DEPAKENE IS RELATED TO DEPAKOTE. DEPAKENE HAS
2 PARTICULAR STOMACH AND INTESTINAL SIDE EFFECTS OF CAUSING
3 NAUSEA AND UPSET STOMACH. IT'S ALSO A CENTRAL NERVOUS
4 SYSTEM DEPRESSANT, IT MAKES A PERSON TIRED AND SLEEPY. IT
5 CAN CAUSE CONFUSION AND CAN CAUSE A PERSON TO BE CLUMSY, THE
6 MEDICAL TERM WOULD BE ATAXIC, WOULD CAUSE A PERSON TO FALL.
7 Q. SERZONE?
8 A. SERZONE IS CHEMICALLY VERY CLOSELY RELATED TO TRAZODONE.
9 IT'S AN ANTIDEPRESSANT USED TO TREAT MOOD PROBLEMS.
10 Q. WHAT RISKS WOULD BE ASSOCIATED WITH THE USE OF SERZONE?
11 A. THE SAME AS TRAZODONE, IT'S VERY SEDATING. IT'S NOT AS
12 SEDATING AS TRAZODONE BUT THE SAME SORT -- IT'S A CENTRAL
13 NERVOUS SYSTEM DEPRESSANT, IT CAN CAUSE A PERSON TO BE
14 OVERLY SLEEPY OR TIRED.
15 Q. DO ALL OF THE DRUGS THAT YOU'VE DESCRIBED, ARE THEY ALL
16 CENTRAL NERVOUS SYSTEM DEPRESSANT DRUGS?
17 A. YES.
18 Q. CAN YOU TELL US, DOCTOR, IF ADMINISTERED IN CONJUNCTION
19 WITH ONE ANOTHER, DO THESE DRUGS HAVE ANY ENHANCED DEGREE OF
20 RISK?
21 A. ANY TIME TWO OR MORE CENTRAL NERVOUS DEPRESSANTS ARE
22 ADDED TOGETHER, YOU ARE GOING TO HAVE AN ADDITIVE EFFECT OF
23 AND A GREATER LIKELIHOOD OF MAKING THAT PERSON SEDATED OR
24 TIRED OR SLEEPY AND THE SIDE EFFECTS ARE INTENSIFIED.
25 Q. IN TERMS OF THE ADMINISTRATION OF THESE TYPE OF DRUGS TO
2761
1 GERIATRIC PATIENTS, IS THERE ANY INDICATION -- EXCUSE ME,
2 STRIKE THAT.
3 IN TERMS OF THE ADMINISTRATION TO GERIATRIC PATIENTS,
4 CAN YOU TELL US, ARE THERE ANY PROCEDURES THAT YOU FOLLOW IN
5 REFERENCE TO THE DOSAGES OR AMOUNTS THAT ARE TO BE GIVEN TO
6 GERIATRIC PATIENTS?
7 MR. STIRBA: I'M GOING TO OBJECT TO THE RELEVANCY
8 OF THE QUESTION IN THE FORM THAT IT WAS PHRASED TO THE
9 EXPERT. WHAT HE DOES IS RELEVANT.
10 THE COURT: SUSTAINED. IT'S NOT HIS PRACTICES.
11 Q. (BY MR. WILSON) CAN YOU TELL US WHETHER THE LITERATURE
12 PROVIDES FOR RECOMMENDED DOSAGES IN GERIATRIC PATIENTS?
13 A. IT DOES.
14 Q. AND CAN YOU TELL US, IS THERE A GENERAL RULE IN THE
15 LITERATURE AS TO THE DOSES ADMINISTERED TO GERIATRIC
16 PATIENTS?
17 A. YES, THERE IS.
18 Q. AND WHAT IS THAT RULE?
19 A. VIRTUALLY EVERY SOURCE THAT I CONSULTED IT EMPHASIZES
20 THAT THE ELDERLY ARE MUCH MORE SUSCEPTIBLE TO THE SIDE
21 EFFECTS AND COMPLICATION OF MEDICATIONS, AND THAT ANY
22 MEDICATION PROVIDED TO THE ELDERLY, ANY PSYCHIATRIC
23 MEDICATION SHOULD BE STARTED AT LOWER DOSE, AND IF IT'S
24 INCREASED, SHOULD BE INCREASED AT A SLOWER RATE TO TRY AND
25 AVOID THOSE COMPLICATIONS OR SIDE EFFECTS.
2762
1 Q. OKAY. YOU'VE TALKED ABOUT SOME OF THE RISKS WITH EACH
2 ONE OF THESE MEDICATIONS. ARE THERE OTHER RISKS THAT ARE OF
3 A LONGER DURATION OR OF A PERMANENT TYPE OF RISK?
4 A. YES.
5 Q. AND WOULD THAT -- RATHER THAN GO THROUGH EACH DRUG, CAN
6 YOU TELL US WHETHER THERE'S ANY OF THE PARTICULAR DRUGS THAT
7 THOSE TYPES OF RISKS ARE GREATER THAN OTHER TYPES OF
8 PSYCHOTROPIC MEDICATIONS?
9 A. YES. THE MAJOR TRANQUILIZERS OR ANTIPSYCHOTICS SUCH AS
10 HALDOL AND RISPERDAL HAVE A RISK OF CAUSING PERMANENT
11 NEUROLOGICAL EFFECTS THAT MAY NOT GO AWAY WHEN THE DRUG IS
12 DISCONTINUED. AND IN THE CASE OF THOSE TWO DRUGS, THE RISK
13 IS WHAT'S CALLED TARDIVE DYSKINESIA WHICH IS A MOVEMENT
14 DISORDER OF THE LIPS AND THE MOUTH AND THE TONGUE WHICH CAN
15 PERSIST LONG AFTER THE DRUG IS DISCONTINUED. IN ADDITION,
16 ANY DRUG -- Worrying about tardive dyskinesia in a demented person!
17 MR. STIRBA: YOUR HONOR, I'M GOING TO HAVE TO
18 OBJECT. I HAVE HIS REPORT RIGHT HERE, THERE'S NO MENTION OF
19 THIS PARTICULAR KIND OF PROBLEM OR ANYTHING IN THAT REPORT.
20 I WOULD CLAIM IT'S IRRELEVANT AND UNFAIR SURPRISE AND BEYOND
21 THE SCOPE OF HIS REPORT.
22 THE COURT: OKAY. LET'S KEEP TO WHAT HIS REPORT
23 IS.
24 MR. WILSON: AND, YOUR HONOR, FOR PURPOSES OF THE
25 RECORD, I WOULD JUST LIKE OUR EXCEPTION NOTED AND WE WOULD
2763
1 LIKE TO ARGUE THAT AT A LATER TIME.
2 THE COURT: OKAY.
3 Q. (BY MR. WILSON) YOU INDICATED THAT YOU DO HAVE SOME
4 FAMILIARITY ALSO WITH THE PAIN MEDICATIONS; IS THAT CORRECT?
5 A. YES, IT IS.
6 Q. DO YOU HAVE FAMILIARITY WITH WHAT'S CALLED AND
7 REFERENCED AS THE DURAGESIC PATCH?
8 A. YES.
9 Q. OKAY. WHAT IS THAT PARTICULAR MEDICATION ADMINISTERED
10 FOR?
11 MR. STIRBA: YOUR HONOR, I'LL OBJECT AS TO
12 CUMULATIVE AND REDUNDANT.
13 THE COURT: OKAY. I THINK WE HAVE HEARD FROM DR.
14 FEHLAUER AND ALSO DR. HARE.
15 MR. WILSON: I THINK IT GOES TO HIS REPORT AND HE
16 REFERENCES THE DURAGESIC PATCH IN HIS REPORT, YOUR HONOR.
17 THE COURT: ALL RIGHT. I SAID I DON'T THINK WE
18 HAVE TO HAVE A BIG BACKGROUND BECAUSE WE'VE HAD A BACKGROUND
19 TWICE.
20 MR. WILSON: I APPRECIATE IT.
21 Q. (BY MR. WILSON) I'M GOING TO SHOW YOU WHAT'S MARKED AS
22 STATE'S EXHIBIT 42 AND ASK YOU IF YOU REFER TO THAT. THAT
23 REPRESENTS THE P.D.R. 49 EDITION, 1995. CAN YOU TELL US,
24 DOCTOR, ARE YOU FAMILIAR WITH THAT PARTICULAR REFERENCE?
25 A. YES.
2764
1 Q. OKAY. AND IN RESPECT TO DURAGESIC PATCHES, CAN YOU TELL
2 US WHETHER THAT COMPARISON ON THAT CHART ACCURATELY REFLECTS
3 WHAT YOU -- WELL STRIKE THAT.
4 CAN YOU TELL US, DO YOU DISAGREE OR AGREE WITH THE
5 REFERENCES ON THE CHART?
6 A. I WOULD AGREE WITH IT.
7 Q. OKAY. CAN YOU DESCRIBE FOR US JUST BRIEFLY, IF YOU
8 WOULD, WHAT A DURAGESIC PATCH IS?
9 MR. STIRBA: I'LL OBJECT, ONCE AGAIN, CUMULATIVE,
10 YOUR HONOR.
11 THE COURT: SUSTAINED.
12 Q. (BY MR. WILSON) ARE YOU FAMILIAR WITH THE USE OF
13 MORPHINE?
14 A. YES, I AM.
15 Q. DO YOU USE MORPHINE IN YOUR PRACTICE?
16 MR. STIRBA: I'LL OBJECT, FORM OF THE QUESTION,
17 IT'S ALSO CUMULATIVE.
18 Q. (BY MR. WILSON) ARE YOU FAMILIAR WITH WHETHER OR NOT
19 MORPHINE IS USED IN THE PRACTICE OF PSYCHIATRY?
20 A. IT CAN BE USED AS PART OF PAIN MANAGEMENT WHICH DOES
21 HAVE SOME APPLICATION IN PSYCHIATRY. Psychiatrists are physicians!
22 Q. OKAY. LET'S TURN NOW GOING ON TO YOUR EVALUATION OF
23 THESE PATIENT RECORD, IF YOU WOULD, PLEASE.
24 CAN YOU TELL US, DID YOU HAVE OCCASION TO REVIEW THE
25 RECORDS PERTAINING TO ELLEN ANDERSON?
2765
1 A. YES, I DID.
2 Q. AND, AGAIN, THE RECORDS YOU REVIEWED WERE THE HOSPITAL
3 RECORDS THAT WERE SUPPLIED TO YOU?
4 A. YES.
5 Q. OKAY. FIRST OF ALL, SIR, CAN YOU TELL US FROM YOUR
6 REVIEW OF THE RECORDS, DID YOU MAKE ANY NOTATION AS IT
7 RELATED TO THE PHYSICAL CONDITION OF THIS PATIENT ON
8 ADMISSION?
9 MR. STIRBA: I'LL OBJECT, YOUR HONOR, IT'S
10 CUMULATIVE I THINK WE'VE HAD BOTH EXPERTS --
11 THE COURT: IF YOU WANT TO GIVE A BRIEF BACKGROUND,
12 THAT'S FINE, BUT WE'VE HEARD THAT SEVERAL TIMES.
13 MR. WILSON: I APPRECIATE THAT, YOUR HONOR, BUT I
14 THINK THIS WITNESS HAS A RIGHT TO AT LEAST ELICIT ENOUGH
15 INFORMATION SO THAT HE CAN SUBSTANTIATE HIS OPINION.
16 THE COURT: GO AHEAD AND ASK THE NEXT QUESTION.
17 Q. (BY MR. WILSON) CAN YOU TELL US WHAT THE PHYSICAL
18 CONDITION OF THE PATIENT WAS?
19 A. ON ADMISSION MUCH OF THE INFORMATION COMES FROM THE
20 NURSING ASSESSMENT THAT REPORTED HER PAST MEDICAL
21 CONDITIONS, AND THAT THE REASONS FOR ADMISSION INCLUDED HER
22 SEVERE ANXIETY, DEMENTIA, BEING INCONSOLABLE, CRYING AND
23 SCREAMING.
24 Q. DID YOU NOTE IN THE RECORD ANY PHYSICAL CONDITIONS THAT
25 EXISTED AT THE TIME OF HER ADMISSION?
2766
1 A. SHE HAD BEEN DIAGNOSED AS HAVING OSTEOPOROSIS WITH A
2 COMPRESSION FRACTURE OF THE SPINE AND HAD HAD BILATERAL HIP
3 SURGERIES.
4 Q. DID YOU NOTE WHAT TYPES OF MEDICATIONS SHE WAS RECEIVING
5 PRIOR TO ADMISSION?
6 A. YES, I DID.
7 Q. AND WHAT WERE THOSE?
8 A. AMITRIPTYLINE, WHICH IS AN OLDER ANTIDEPRESSANT, AMBIEN,
9 WHICH IS A SLEEPING PILL, LASIX AND POTASSIUM. SHE HAD
10 RECENTLY RECEIVED BENADRYL FOR SOME HIVES, DULCOLAX FOR
11 CONSTIPATION, NITROSTAT FOR CHEST PAIN, I -- I PRESUME. AND
12 THEN SHE HAD BEEN OCCASIONALLY RECEIVING TYLENOL AND LORTAB,
13 WHICH IS A PAIN MEDICATION.
14 Q. IN PARTICULAR --
15 A. AND --
16 Q. -- AS TO THE TYLENOL AND THE LORTAB, NOW IS THE TYLENOL
17 THE GENERIC TYLENOL THAT YOU BUY OVER THE COUNTER?
18 A. YES, THAT WOULD BE ACETAMINOPHEN.
19 Q. THE LORTAB ITSELF, CAN YOU TELL US WHETHER OR NOT THAT
20 WAS A PRESCRIPTION MEDICATION?
21 A. LORTAB IS A SCHEDULE 3 PRESCRIPTION DRUG.
22 Q. OKAY. AND CAN YOU COMMENT AS TO THE PARTICULAR DOSAGE
23 THAT SHE HAD BEEN RECEIVING PRIOR TO COMING ON THE UNIT?
24 A. THE RECORD INDICATED IT WAS A LORTAB 5, WHICH WAS FIVE
25 MILLIGRAMS OF HYDROCODONE WHICH IS A RELATIVELY LOWER DOSE.
2767
1 IT COMES IN 7.5 AND 10 MILLIGRAM SIZES AS WELL.
2 Q. DOES IT COME ANY LOWER THAN THE FIVE?
3 A. I BELIEVE IT ALSO COMES IN A 2.5. I'M NOT SURE IF
4 THAT'S LORTAB OR A GENERIC.
5 Q. DID YOU REVIEW ANY PHYSICIAN'S ORDERS AS IT RELATED TO
6 THE ADMINISTRATION OF ANY DRUGS UPON HER ADMISSION TO THE
7 UNIT?
8 A. YES.
9 Q. CAN YOU TELL HER WHAT TYPE OF MEDICATIONS WERE
10 ORDERED -- OR TELL US WHAT KIND OF MEDICATIONS WERE ORDERED
11 IN RESPECT TO THOSE DRUGS?
12 MR. STIRBA: YOUR HONOR, I BELIEVE THAT WE HAVE
13 REPEATED THIS NOW TWICE GOING RIGHT DOWN THIS WHOLE LIST AND
14 I JUST THINK THIS IS CUMULATIVE.
15 THE COURT: OKAY. I THINK YOU CAN GO A BRIEF
16 BACKGROUND BUT WE HAVE HEARD THIS TWO OR THREE TIMES AND I
17 THINK IT IS CUMULATIVE --
18 Q. (BY MR. WILSON) IF YOU WOULD, DOCTOR, JUST BRIEFLY
19 LIST THE DRUGS THAT WERE ORDERED.
20 A. AMITRIPTYLINE, LASIX, POTASSIUM, NITROGLYCERIN, AMBIEN,
21 DULCOLAX, TRAZODONE, MYLANTA, MILK OF MAGNESIA, AND
22 MORPHINE.
23 Q. OKAY. WHAT WAS THE DOSAGE ADMINISTERED FOR OR
24 DOCUMENTED AS TO THE ORDER ON THE MORPHINE?
25 A. TEN MILLIGRAMS INTRAMUSCULARLY.
2768
1 Q. DID YOU IN YOUR REVIEW OF THE RECORDS THAT YOU HAD IN
2 FRONT OF YOU, WERE YOU ABLE TO ASCERTAIN WHETHER OR NOT THIS
3 PATIENT HAD ANY SIGNS OR SYMPTOMS OF PAIN?
4 A. THIS PATIENT HAD A HISTORY OF OSTEOPOROSIS. ON
5 ADMISSION IN THE NURSING ASSESSMENT THERE WAS NO RATING FOR
6 PAIN, IT WAS A STANDARD QUESTION THAT WAS ASKED AND IT WAS
7 NOT ANSWERED. SHE HAD SOME SIGNS AND SYMPTOMS THAT COULD BE
8 CONSISTENT WITH PAIN.
9 Q. OKAY. WHAT WERE THOSE?
10 A. THE CRYING AND -- PRIMARILY CRYING.
11 Q. PRIMARILY CRYING?
12 A. UH-HUH.
13 Q. AND IN RESPECT TO THAT, DID YOU FORM AN OPINION AS TO
14 WHETHER THE ADMINISTRATION OF MORPHINE IN THAT CONTEXT WAS
15 APPROPRIATE?
16 A. I DO NOT BELIEVE THAT MORPHINE WAS INDICATED OR
17 APPROPRIATE.
18 Q. OKAY. ARE THERE RISKS ASSOCIATED WITH THE USE OF
19 MORPHINE?
20 MR. STIRBA: OBJECT, YOUR HONOR, THAT'S CUMULATIVE.
21 THE COURT: BRIEFLY.
22 MR. WILSON: AGAIN, YOUR HONOR.
23 Q. (BY MR. WILSON) IF YOU COULD JUST STATE WHAT THOSE
24 RISKS ARE BRIEFLY.
25 A. YES. THAT THE PRIMARY RISK OF OPIATES LIKE MORPHINE IS
2769
1 THAT THEY DECREASE BREATHING AND CAN CAUSE A PERSON TO STOP
2 BREATHING. THEY ALSO LOWER BLOOD PRESSURE.
3 Q. YOU'VE HEARD THE TERM OPIATE -- I THINK IT WAS EXPRESSED
4 OPIATE NAIVE OR OPIATE -- IS THERE A TERM THAT DESCRIBES AN
5 INDIVIDUAL WHO HAS NOT RECEIVED THE ADMINISTRATION OF
6 OPIATES IN THE PAST?
7 A. THE TERM I WOULD USE WOULD BE A PERSON TO WHO DOES NOT
8 HAVE TOLERANCE TO THAT DRUG, WHICH IS --
9 Q. ALL RIGHT. DOES THAT ENHANCE OR DECREASE THE RISKS IN
10 REGARDS FOR THE ADMINISTRATION OF MORPHINE?
11 A. A LACK OF EXPERIENCE OR EXPOSURE TO AN OPIATE AND A LACK
12 OF TOLERANCE CAN INCREASE THE RISK DEPENDING ON THE DOSE
13 THAT'S ADMINISTERED.
14 Q. DID YOU FORM AN OPINION -- WELL, STRIKE THAT, BECAUSE
15 YOU'VE TESTIFIED.
16 IN RESPECT TO THE DOSAGE THAT WAS ADMINISTERED ON THIS
17 PARTICULAR OCCASION, CAN YOU TELL US WHETHER OR NOT THAT
18 DOSAGE WAS APPROPRIATE FOR THIS PARTICULAR PATIENT?
19 A. I DON'T BELIEVE THE MORPHINE WAS APPROPRIATE FOR THIS
20 PATIENT, AND IF MORPHINE IS GIVEN TO A PERSON HER AGE AND
21 SIZE AND WITH HER INFIRMITIES, I BELIEVE THAT THE DOSAGE
22 THAT WAS GIVEN WAS EXCESSIVE.
23 Q. ASSUMING MORPHINE HAD BEEN APPROPRIATE, WHAT DOSAGE
24 WOULD YOU RECOMMEND?
25 MR. STIRBA: I'LL OBJECT, YOUR HONOR, RELEVANCE.
2770
1 HE'S ALREADY POSED HIS OPINION.
2 THE COURT: SUSTAINED.
3 Q. (BY MR. WILSON) CAN YOU TELL US WHETHER ANY MORE
4 MORPHINE WAS ADMINISTERED TO THAT PARTICULAR PATIENTS?
5 A. YES, SHE RECEIVED A SECOND DOSE.
6 Q. WHICH WAS WHEN WAS THE FIRST DOSE ADMINISTERED?
7 A. AT 7:30 P.M. ON DECEMBER 29TH.
8 Q. OKAY. WAS THERE ANY VITAL SIGNS TAKEN SUBSEQUENT TO THE
9 FIRST DOSAGE?
10 A. I BELIEVE THERE WAS, IF I CAN FIND THAT QUICKLY. THE
11 VITAL SIGN CHART THAT I'M LOOKING AT, THE NEXT CHART OF
12 VITAL SIGNS ARE THE FOLLOWING MORNING.
13 Q. DID YOUR REVIEW OF THE RECORDS REFLECT ANY PROBLEMS
14 RELATIVE TO THE PATIENT THAT OCCURRED EARLIER IN THE DAY OF
15 THAT PARTICULAR MORNING?
16 A. AFTER THE INITIAL MORPHINE DOSE?
17 Q. YES.
18 A. SHE WAS DESCRIBED AS CALMER BUT STILL SCREAMING IF LEFT
19 ALONE AND THEN HER RESPIRATIONS BECAME ERRATIC. Six hours later.
20 Q. WHAT DO WE MEAN BY THAT, ERRATIC?
21 A. IRREGULAR.
22 Q. IS THAT HER BREATHING PATTERN --
23 A. YES --
24 Q. -- OR WHAT?
25 A. FASTER AND SLOWER.
2771
1 Q. AND WHEN WAS THAT NOTED, DOCTOR?
2 A. AT 1 O'CLOCK IN THE MORNING.
3 Q. THERE WAS A SECOND DOSE ADMINISTERED AT WHAT TIME?
4 A. AT 3:30 IN THE MORNING.
5 Q. WAS THERE A REFERENCE IN THE NOTES AS TO ANY CONDITION
6 OR SYMPTOM OF PAIN PRIOR TO THE ADMISSION OF THAT SECOND
7 DOSE?
8 A. YES, JUST PRIOR TO THAT TIME THE PATIENT WAS DESCRIBED
9 AS MOANING AND SCREAMING.
10 Q. OKAY. AGAIN, DOCTOR, BASED UPON YOUR REVIEW, DO YOU
11 HAVE AN OPINION AS TO THE APPROPRIATENESS OF THE
12 ADMINISTRATION OF A SECOND DOSE OF MORPHINE AT THAT TIME?
13 A. IT'S MY OPINION THAT MORPHINE WAS NOT NECESSARY.
14 Q. OKAY.
15 A. AND THIS PATIENT ALREADY HAD COMPROMISED BREATHING WHICH
16 MORPHINE WOULD BE EXPECTED TO WORSEN.
17 Q. YOU INDICATED THE PATIENT HAD COMPROMISED BREATHING,
18 WHAT CAUSES YOU TO BELIEVE THAT?
19 A. THE DESCRIPTION THAT HER RESPIRATIONS WERE ERRATIC.
20 Q. DID YOU REVIEW ANY OTHER RECORDS AS IT RELATED TO THIS
21 PATIENT WHICH DESCRIBED ANY TESTS OR PROCEDURES THAT
22 OCCURRED AFTER 3:30 IN THE MORNING?
23 A. YES, THERE WAS A CHEST X-RAY AND AN ELECTROCARDIOGRAM.
24 Q. CAN YOU TELL US WHETHER THERE WERE ANY SIGNS OR SYMPTOMS
25 AS IT RELATED TO MORPHINE TOXICITY AT THAT TIME?
2772
1 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT. THIS
2 IS, FIRST OF ALL, CUMULATIVE, AND SECOND OF ALL, I HAVE THE
3 DOCTOR'S REPORT HERE.
4 THE COURT: WHY DON'T WE GO TO ANOTHER AREA AND WE
5 CAN ADDRESS THAT AT THE BREAK.
6 MR. WILSON: OKAY.
7 Q. (BY MR. WILSON) YOU INDICATE IN YOUR REPORT, DOCTOR,
8 THAT YOU MADE NOTATION RELATIVE TO THE SCREAMING AND THE
9 RIGIDITY OF THIS PATIENT?
10 A. YES.
11 Q. WAS THAT TAKEN FROM A NURSE'S NOTE?
12 A. YES.
13 Q. CAN YOU TELL US, WOULD THAT BE AN INDICATION OF A CAUSE
14 OF CONCERN FOR YOU?
15 A. THE PATIENT'S HISTORY THAT WAS REPORTED WAS THAT THIS
16 WAS NOT A NEW BEHAVIOR, THE SCREAMING. I DIDN'T SEE ANY --
17 I DON'T RECALL ANYTHING FROM HER PAST HISTORY THAT TALKED
18 ABOUT RIGIDITY.
19 Q. LET'S MOVE ON TO THE NEXT PATIENT AT THIS TIME AND WE'LL
20 TALK ABOUT JUDITH LARSEN, IF YOU WOULD PLEASE.
21 HAVE YOU HAD OCCASION TO REVIEW THE RECORDS OF JUDITH
22 LARSEN?
23 A. YES, I HAVE.
24 Q. AND CAN YOU TELL US IN A BRIEF STATEMENT, IF YOU CAN, AS
25 TO WHAT HER PHYSICAL CONDITION WAS NOTED TO BE AT THE TIME
2773
1 OF HER ADMISSION TO THE GEROPSYCH UNIT?
2 A. SHORTLY AFTER ADMISSION SHE WAS EXAMINED BY DR. DIENHART
3 WHO FOUND AN ORAL YEAST INFECTION. HER DIAGNOSES INCLUDED
4 LOW THYROID, GLAUCOMA, AND A HISTORY OF A STROKE.
5 Q. OKAY. CAN YOU TELL US, DOCTOR, WHETHER THERE ARE ANY
6 SIGNS OR SYMPTOMS THAT YOU NOTED IN YOUR REVIEW OF THE
7 RECORD OF THIS PATIENT SUFFERING FROM ANY KIND OF PAIN?
8 A. THERE WAS NOT. NO PAIN WAS REPORTED.
9 Q. NOW, THIS PATIENT WAS IN -- WAS HOSPITALIZED FOR ALMOST
10 A MONTH PERIOD OF TIME; IS THAT CORRECT?
11 A. YES.
12 Q. CAN YOU TELL US UPON HER ADMISSION, WAS SHE ADMINISTERED
13 ANY REGIMEN OF MEDICATION -- OF THE MEDICATIONS YOU'VE
14 LISTED AS PSYCHOTROPIC MEDICATIONS?
15 A. YES.
16 Q. IF YOU WOULD JUST REFER TO THOSE MEDICATIONS, I WOULD
17 APPRECIATE IT.
18 A. DO YOU WANT ME TO LIST THOSE?
19 Q. IF YOU WOULD.
20 A. THE PSYCHIATRIC MEDICATIONS OR ALL OF THE MEDICATIONS?
21 Q. PARDON? MAYBE FOR PURPOSES OF YOUR TESTIMONY, LET ME
22 CALL YOUR ATTENTION TO STATE'S EXHIBIT NUMBER 38. HAVE YOU
23 HAD AN OPPORTUNITY TO REVIEW THAT EXHIBIT PRIOR TO THESE
24 PROCEEDINGS?
25 A. I HAVE SEEN A SMALLER VERSION OF IT, YES.
2774
1 Q. NOW, CALLING YOUR ATTENTION TO THE MEDICATIONS THAT ARE
2 LISTED ON THE LEFT-HAND SIDE, KLONOPIN, TRAZODONE, SERZONE,
3 RISPERIDONE AND ATIVAN. ARE THOSE THE MEDICATIONS THAT WERE
4 PRESCRIBED FOR THIS PARTICULAR PATIENT SUBSEQUENT TO HER
5 ADMISSION AT THE GEROPSYCH UNIT?
6 A. YES.
7 Q. NOW, IN REFERENCE TO THE PARTICULAR DOSAGES AND DATES
8 THAT THOSE DOSAGES SHOW ON THE EXHIBIT, CAN YOU TELL US
9 WHETHER THOSE CORRESPOND TO YOUR RECOLLECTION AS TO THE
10 DOSAGES THAT WERE ADMINISTERED TO THIS PARTICULAR PATIENT?
11 A. YES, IT APPEARS TO CORRESPOND.
12 Q. NOW, I CALL YOUR ATTENTION, AGAIN, TO THE LEFT-HAND SIDE
13 OF THE EXHIBIT WHERE THE -- AND ASK YOU TO STEP UP TO THE
14 BOARD, IF YOU WOULD, PLEASE.
15 DO YOU HAVE A RECOLLECTION AS TO THE AMOUNTS OF THE
16 DOSAGES THAT ARE RECOMMENDED FOR DAILY MAXIMUMS --
17 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT. THIS
18 HAS BEEN GONE OVER BY DR. FEHLAUER AND IT'S CUMULATIVE.
19 THE COURT: I THINK WHAT WE'LL DO, LADIES AND
20 GENTLEMEN, LET'S JUST TAKE -- WE'VE BEEN GOING ALMOST AN
21 HOUR. LET'S TAKE A MORNING BREAK NOW AND THEN WE CAN
22 RESOLVE SOME OF THESE ISSUES.
23 DURING THIS BREAK IT'S YOUR DUTY NOT TO CONVERSE AMONG
24 YOURSELVES OR TO CONVERSE WITH OR ALLOW YOURSELVES TO BE
25 ADDRESSED BY ANY OTHER PERSON ON THE SUBJECT OF THIS TRIAL.
2775
1 IT'S YOUR DUTY NOT TO FORM OR EXPRESS AN OPINION UNTIL THE
2 CASE HAS BEEN SUBMITTED TO YOU AND YOU'VE HEARD ALL THE
3 EVIDENCE. SO WHY DON'T WE COME BACK -- WHY DON'T WE COME
4 BACK AT QUARTER TO TEN AND THAT WILL GIVE US TIME TO DISCUSS
5 SOME OF THESE THINGS.
6 (WHEREUPON THE JURY WAS EXCUSED.)
7 THE COURT: YOU MAY BE SEATED AND THE RECORD WILL
8 REFLECT THAT THE JURY HAS LEFT THE COURTROOM. WHY DON'T WE
9 GO BACK TO THE FIRST ISSUE. THERE WERE TWO ISSUES. THE
10 FIRST NOTE I HAVE THERE WAS AN OBJECTION OF BEING OUTSIDE
11 THE SCOPE OF THE REPORT AND I THINK THE QUESTION HAD
12 SOMETHING TO DO WITH LONG-TERM EFFECTS OF SOME OF THE
13 PSYCHOTROPIC MEDICATIONS, WAS THAT THE QUESTION?
14 MR. STIRBA: THAT'S THE WAY I REMEMBER IT, JUDGE.
15 THE COURT: OKAY. AND WHAT IS THE OBJECTION?
16 MR. STIRBA: WELL, IT'S REALLY NOT ANYTHING HE
17 OPINED IN HIS REPORT. AS A MATTER OF FACT, HE HASN'T
18 BASICALLY SAID ALMOST ANYTHING HE'S OPINED IN THE REPORT. I
19 HAVEN'T HEARD THE TESTIMONY YET, BUT THAT CERTAINLY ISN'T
20 ONE OF THEM, I DON'T KNOW WHERE THAT WAS GOING. IN FACT,
21 THERE'S NOTHING IN HERE AND I FORGET THE FANCY TERM THAT WAS
22 USED IN THE REPORT, HE JUST DIDN'T DO THAT.
23 BASICALLY WHAT HE DID IN HIS REPORT IS HE DID THE SAME
24 THING EVERYBODY ELSE HAS DONE IN A MORE PSYCHIATRICALLY
25 ORIENTED WAY. HE'S REVIEWED THE CHARTS, HE'S REVIEWED THE
2776
1 MEDICATIONS, HE BASICALLY THINKS THE MEDICATIONS WERE ALL --
2 WELL, NOT IN ALL INSTANCES, BUT MOST INSTANCES, EXCESSIVE.
3 HE RECOGNIZES THE DIFFICULTIES IN PRESCRIBING FOR THESE
4 FOLKS, AND BASICALLY THEN HE HAS A LITTLE PARAGRAPH ABOUT
5 MORPHINE AND MORPHINE'S USE IN PSYCHIATRY AND HE INDICATES
6 THAT MORPHINE WOULD HAVE CAUSED THE VERY THINGS THAT BOTH
7 DR. FEHLAUER AND DR. HARE HAVE ALREADY TESTIFIED TO. THAT'S
8 HIS REPORT.
9 THE COURT: OKAY. MR. WILSON?
10 MR. WILSON: YOUR HONOR, FROM THE STANDPOINT -- AND
11 I KNOW THE COURT HAS PREVIOUSLY RULED RELATIVE TO THIS
12 ISSUE. I WOULD ASK THE COURT TO CONSIDER THE FACT THAT IN A
13 REPORT, AN EXPERT IS OBVIOUSLY NOT GOING TO PUT DOWN
14 EVERYTHING THAT WOULD CONSTITUTE HIS TESTIMONY. I DON'T
15 THINK -- I DON'T THINK THAT THAT'S EVEN FEASIBLE, OTHERWISE
16 WHAT YOU WOULD NEED IS YOU WOULD NEED, LIKE WE HAVE WITH
17 DR. HARE, YOU WOULD NEED A PRELIMINARY HEARING AND YOU WOULD
18 NEED TO BE ABLE TO EXAMINE HIM AND CROSS-EXAMINE HIM AS TO
19 ALL ASPECTS OF HIS REVIEW IN ORDER TO CONSTITUTE THAT
20 REPORT.
21 THE REPORT IS SET FORTH TO GIVE COUNSEL NOTICE AS TO
22 SALIENT POINTS THAT THIS EXPERT WILL TESTIFY TO. IF, IN
23 FACT, HE FELT THAT THAT REPORT WAS NOT COMPLETE ENOUGH,
24 THERE IS A PROCEDURE BY WHERE HE COULD HAVE ASKED FOR A MORE
25 COMPLETE REPORT AS TO THIS PARTICULAR EXPERT.
2777
1 THE COURT: WELL, LET ME JUST ASK --
2 MR. WILSON: I ALSO --
3 THE COURT: LET ME JUST ASK A QUESTION ON THAT.
4 HOW DOES HE KNOW TO ASK FOR A MORE COMPLETE REPORT UNTIL THE
5 WITNESS IS PUT ON THE STAND AND SOMETHING COMES UP THAT
6 ISN'T IN THE REPORT? HOW IS HE SUPPOSED TO DIVINE THAT?
7 MR. WILSON: WELL, I THINK HE CAN DIVINE THAT JUST
8 FROM THE MERE FACT HE'S AN EXPERT. I THINK HE CAN DIVINE
9 THAT FROM THE MERE FACT THAT HE'S A VERY EXPERIENCED COUNSEL
10 AND HE KNOWS THAT EXPERTS ARE GOING TO GO ON PREPARING
11 BEFORE THEY TESTIFY IN COURT, THAT THEY ARE GOING TO MAKE
12 CHARTS, THAT THEY ARE GOING TO LOOK AT REFERENCES, THAT THEY
13 ARE GOING TO DO EVERYTHING THEY CAN TO MAKE SURE THAT THEIR
14 OPINION IS WELL-DOCUMENTED FROM THAT STANDPOINT. I DON'T
15 THINK THAT'S A MYSTERY FROM THAT STANDPOINT.
16 YOU KNOW, WE ARGUE THAT TRIAL BY AMBUSH. I THINK IF
17 THERE'S ANYTHING HERE -- WE'VE BEEN MORE THAN WILLING TO
18 PROVIDE MORE THAN -- MORE INFORMATION THAN I'VE EVER
19 PROVIDED IN ANY KIND OF CRIMINAL CONTEXT IN A PROSECUTION.
20 WE'VE GIVEN THEM -- WE'VE OPENED UP OUR FILES TO THEM, WE'VE
21 ALLOWED TO COME IN AND COPY WHATEVER THEY WANT, WE'VE
22 PROVIDED FURTHER DISCOVERY. Perry Fine, Mr. Wilson?
23 I THINK TO LIMIT US IN RESPECT TO WHETHER OR NOT THIS
24 DOCTOR SAID OR MADE A CERTAIN REFERENCE TO A CERTAIN ITEM IN
25 A REPORT, YOUR HONOR, IS -- IT JUST TIES OUR HANDS. IT
2778
1 DOESN'T ENABLE US TO PROPERLY INTRODUCE THE EVIDENCE THAT WE
2 THINK IS RELEVANT TO THESE PROCEEDINGS AND TO TIE OUR HANDS
3 IN RESPECT TO THE ABILITY TO EXAMINE THIS WITNESS.
4 THE COURT: WELL, IF -- HOW DO WE LOOK ON TYING
5 HANDS VERSUS DUE PROCESS OF SAYING DOES THE DEFENDANT HAVE
6 NOTICE OF THINGS? LIKE WE'RE TALKING ABOUT LONG-TERM
7 EFFECTS OF PSYCHOTROPIC MEDICATION. AND, YOU KNOW,
8 PARTICULARLY WITH THIS PERSON, ELLEN ANDERSON, IN HIS REPORT
9 HE SAYS THERE'S NOT ENOUGH INFORMATION IN THIS CASE TO DRAW
10 ANY CONCLUSIONS ABOUT THE EFFECT OF MORPHINE ON THE
11 PATIENT'S DEMISE. I DON'T EVEN SEE HOW HE'S GIVEN AN
12 OPINION ABOUT ELLEN ANDERSON IN HIS REPORT. HE SAYS SOME OF
13 THE DRUGS ARE HIGH AND THEN HE SAYS I CAN'T -- I CAN'T
14 GIVE -- I CAN'T DRAW ANY CONCLUSIONS. SO WHERE IS LONG-TERM
15 EFFECT OF PSYCHOTROPIC MEDICINE GOING WITH ELLEN ANDERSON?
16 I MEAN, WHERE WAS THAT QUESTION GOING?
17 MR. WILSON: WELL, I THINK IT GOES TO SHOW THAT THE
18 PATIENT WAS COMPROMISED, THAT HER HEALTH WAS COMPROMISED.
19 THE COURT: SO IS HE GOING TO GIVE AN OPINION THAT
20 THE LONG TERM OR THE PSYCHOTROPIC MEDICATION THAT ELLEN
21 ANDERSON WAS GIVEN HAD LONG-TERM EFFECTS THAT CAUSED HER
22 DEATH? Ellen Anderson received no psychotropics, only morphine.
23 MR. WILSON: I THINK HE'S GOING TO SAY THAT'S A
24 CONTRIBUTING FACTOR -- NOT ON ELLEN ANDERSON, EXCUSE ME,
25 YOUR HONOR, I'LL BACK OFF ON THAT.
2779
1 THE COURT: WELL, THAT'S WHERE THE QUESTIONS WERE
2 ASKING ASKED.
3 MR. WILSON: WELL, THE QUESTIONS I THINK WERE BEING
4 ASKED IN TERMS TO PSYCHOTROPIC -- THAT WAS A GENERAL
5 QUESTION AS TO PSYCHOTROPIC MEDICATIONS HAVING LONG-TERM AND
6 ENDURING EFFECTS. THAT WASN'T IN RESPECT TO ELLEN ANDERSON
7 AS I RECALL.
8 THE COURT: OKAY. WELL, HAS HE OR HAS HE NOT -- DO
9 YOU SEE THAT AS AN ISSUE IN THE REPORT WHERE HE SAYS THE
10 LONG-TERM EFFECTS OF GIVING PSYCHOTROPIC MEDICINES CAUSED OR
11 CONTRIBUTED TO THE DEATHS OF THESE FIVE PATIENTS?
12 MR. WILSON: I DO.
13 THE COURT: OKAY. WHERE IS THAT IN THE REPORT
14 THEN?
15 MR. WILSON: WELL, I DON'T KNOW IT'S CHARACTERIZED
16 IN THE REPORT. HE CAN OPINE AS TO THE CAUSE OF DEATH AND I
17 THINK THAT'S WHAT HE'S GOING TO OPINE TO. I THINK IN HIS
18 CONCLUSION HE INDICATES THAT, YOUR HONOR.
19 MR. STIRBA: WELL, SEE, AND THAT'S THE PROBLEM,
20 JUDGE. YOU KNOW, I AM EXPERIENCED IN SOME WAYS AND I HAVE
21 LET A LOT OF LATITUDE BECAUSE I UNDERSTAND PRECISELY WHAT
22 MR. WILSON IS SAYING. BUT THIS -- IF YOU READ THAT REPORT,
23 HIS OPINION AS TO CAUSATION IS THAT THE MORPHINE COMPROMISED
24 THE RESPIRATORY PROCESSES OF THESE PATIENTS AND THAT'S WHAT
25 CAUSED THE DEATH. THERE ISN'T ANYTHING IN THERE ABOUT NOW
2780
1 THE LONG TERM CONSEQUENCES AND LONG-TERM EFFECTS OF
2 PSYCHOTROPICS CAUSED THESE DEATHS.
3 THIS CASE HAS BEEN TRIED ON ONE BASIC THEORY THAT MR.
4 WILSON HAS ARTICULATED BEFORE WHICH THE COURT IS WELL AWARE
5 AND HEARD ALL THE EVIDENCE, SEDATION ON TOP OF SEDATION ON
6 TOP OF SEDATION AND THEN WHEN THE MORPHINE IS GIVEN IT
7 COMPROMISES THEIR RESPIRATORY SYSTEM AND THE PATIENTS DIE.
8 THAT'S BEEN THE THEORY. I'VE NEVER HEARD ANYBODY ARTICULATE
9 THAT, NO, NO, THERE'S SOME NOW LONG-TERM CONSEQUENCES OF
10 PSYCHOTROPIC MEDICATIONS WHICH WE NEED TO FACTOR IN FOR
11 PURPOSES OF THE CAUSE OF DEATH. AND I HAVE HIS REPORT RIGHT
12 HERE AND THAT'S WHAT I'M CONCERNED ABOUT. I'M NOT CONCERNED
13 ABOUT WHETHER OR NOT HE HAS EVERY LITTLE THING HE TESTIFIES
14 TO ON THE STAND IN HIS REPORT, BECAUSE THAT'S NOT
15 REASONABLE, AND I'M NOT SAYING THAT.
16 BUT IF YOU LOOK, FOR EXAMPLE, ENNIS ALLDREDGE HE SAYS
17 BASICALLY, EVEN IF THERE WERE OTHER PATHOLOGICAL PROCESSES
18 GOING ON, THESE DOSES OF MORPHINE IN THIS AGE GROUP WOULD
19 PARTICULARLY LEAD TO SERIOUS RESPIRATORY COMPROMISE AND
20 POSSIBLE DEATH. AND ESSENTIALLY THAT'S WHAT HE SAYS WITH
21 RESPECT TO EACH ONE OF THESE WITH THE EXCEPTION OF ELLEN
22 ANDERSON WHICH THE COURT HAS NOTED. THE REST OF THEM, IT'S
23 ALL THE SAME.
24 FOR EXAMPLE, ON MARY CRANE, HOWEVER EVEN WITHOUT
25 SEPSIS, THE ADDITION OF INCREASING DOSES OF DURAGESIC AND
2781
1 MORPHINE HAVE VERY SEDATING EFFECTS PSYCHOTROPIC MEDICATIONS
2 SUCH AS HIGH DOSES OF DEPAKENE CAN EXPLAIN THE PATIENT'S
3 DETERIORATION IN MENTAL STATUSES, AIRWAY AND CONTROLLED
4 BREATHING. IN OTHER WORDS, THAT'S BEEN THE CASE AND THAT'S
5 WHAT IS IN HIS REPORT. AND I WAS CONCERNED BECAUSE ALL OF A
6 SUDDEN WE'RE FACTORING IN SOME NEW COMPLICATIONS AS A RESULT
7 OF PSYCH MEDS WHICH, QUITE FRANKLY, HAVE NEVER BEEN PART OF
8 THIS CASE BEFORE AND THAT'S WHAT I'M CONCERNED ABOUT.
9 MR. WILSON: WELL, I WOULD BEG TO DIFFER. THE
10 PSYCH MEDS HAVE BEEN AN INTEGRAL PART OF THIS CASE AND I
11 THINK THE RISKS AND SIDE EFFECTS AND WHETHER THEY'RE
12 SHORT-TERM OR LONG-TERM DURATION ARE AN IMPORTANT ASPECT ON
13 THAT, YOUR HONOR.
14 THE COURT: WELL, HOW DOES LONG-TERM EFFECTS IF IT
15 DOESN'T -- ARE YOU SAYING THAT LONG-TERM EFFECTS WERE OR
16 WERE NOT ADDRESSED? LONG-TERM EFFECTS OF PSYCHOTROPIC
17 MEDICATION, WAS THAT OR NOT ADDRESSED IN HIS REPORT?
18 MR. WILSON: I DON'T KNOW IF IT'S ADDRESSED
19 SPECIFICALLY IN HIS REPORT, NO.
20 THE COURT: OKAY. AND THEN WHAT IS DETERMINED LONG
21 TERM? IF YOU ARE TALKING LONG-TERM EFFECTS FROM --
22 MR. WILSON: WELL, I THINK THE QUESTION WAS BOTH
23 ASKED LONG TERM AND PERMANENT DURATION. HE TESTIFIED AS TO
24 THE PERMANENT ASPECTS OF THE SIDE EFFECTS OF SOME OF THOSE
25 MEDICATIONS, I THINK IN PARTICULAR ATIVAN AND HALDOL.
2782
1 MR. STIRBA: AND THAT'S NOT IN THERE EITHER.
2 THE COURT: WELL, ARE YOU GOING TO ASK THIS WITNESS
3 THE QUESTION DID, THE LONG-TERM EFFECTS OF PSYCHOTROPIC
4 MEDICATION CAUSE OR CONTRIBUTE TO THE DEATHS OF THESE
5 PEOPLE?
6 MR. WILSON: I DON'T KNOW AS I'M GOING TO ASK THAT
7 QUESTION SPECIFICALLY, NO, YOUR HONOR. I'M GOING TO ASK
8 HIM, DOES HE HAVE AN OPINION BASED ON A REASONABLE DEGREE OF
9 MEDICAL CERTAINTY AS TO THE CAUSE OF DEATH AND THEN I'LL LET
10 HIM OPINE AND OPINE AS TO ANY CONTRIBUTING FACTORS THAT HE
11 MAY HAVE OBSERVED IN THE RECORD THAT HELPED OR HELPED CAUSED
12 THE DEATH.
13 THE COURT: OKAY. WAS THERE ANY OTHER ISSUE
14 OUTSIDE THE SCOPE? THERE WAS ONE OTHER --
15 MR. STIRBA: WELL, I GUESS I HAD SOME CUMULATIVE
16 OBJECTIONS; THAT IS, DR. FEHLAUER TESTIFIED FOR QUITE A
17 LENGTHY TIME ABOUT THE CHARTS, THE PSYCH MEDS, HE'S A
18 GERIATRICIAN. THIS GENTLEMAN DOESN'T EVEN HAVE GERIATRIC
19 EXPERTISE AND HE TESTIFIED ABOUT ALL THE THINGS, WHAT THEY
20 DO, HOW MUCH IS TOO MUCH. I MEAN, DR. HARE TESTIFIED TO IT.
21 MY ONLY CONCERN WAS IF WE'RE JUST GOING TO HAVE A REPEAT
22 ESSENTIALLY OF THE TESTIMONY, I THINK THAT'S CUMULATIVE.
23 MR. WILSON: MAYBE I CAN PUT COUNSEL'S MIND AT
24 EASE. ALL I WAS DOING WHEN I WAS REFERENCING THE LEFT SIDE
25 OF THE CHART IS I WANTED TO ELICIT TESTIMONY THAT HE AGREED
2783
1 WITH THOSE DAILY DOSAGES AS BEING THE APPROPRIATE DOSAGES
2 FOR PURPOSES OF MEDICATIONS TO BE RENDERED. AND THEN I HAD
3 ALREADY ASKED HIM THE QUESTION AS TO WHETHER OR NOT HE
4 AGREED THAT THE DOSAGES THAT WERE ADMINISTERED ON THOSE
5 PARTICULAR DATES WERE CONSISTENT WITH HIS REVIEW OF THE
6 RECORD.
7 THE COURT: OKAY. YEAH. AND I THINK WE DID SPEND
8 OVER A DAY WITH DR. FEHLAUER GOING OVER EVERY ONE OF THOSE
9 REPORTS AND EVERY ONE OF THE MEDICAL RECORDS AND EVERY ONE
10 OF THE NURSES' NOTES AND WE HAVE BEEN OVER AND OVER THAT, SO
11 I DON'T THINK IT NEEDS TO BE REPEATED.
12 MR. WILSON: I DON'T NEED TO GO DAY BY DAY.
13 THE COURT: NO. I THINK IF IT'S TO ORIENT HIM TO
14 SAY DO YOU AGREE THIS IS REPRESENTATIVE OF WHAT YOU
15 REVIEWED, THAT'S FINE, AND THEN JUST MOVE.
16 MR. WILSON: I APPRECIATE THAT.
17 THE COURT: AS TO THIS ISSUE ABOUT LONG-TERM
18 EFFECTS, I MEAN I THINK YOU CAN ASK THE QUESTION I MEAN WHAT
19 ARE THE EFFECTS, YOU KNOW, OF THIS AND THEN WHAT IS YOUR
20 OPINION AND THEN WHAT IS THE CONTRIBUTION THINGS. YOU KNOW,
21 I THINK IT'S CONSISTENT WITH WHAT I SAID EARLIER. YOU KNOW,
22 I THINK HIS MAJOR OPINIONS, YOU KNOW, CAN'T CHANGE. YOU
23 CAN'T, YOU KNOW, COME IN WITH A REPORT SAYING THIS IS MY
24 OPINION AND THEN COME IN AT THE TRIAL AND SAY AND THEN I
25 HAVE THIS OPINION, THAT'S A NEW OPINION. IF YOU ARE SIMPLY
2784
1 ASKING HIM TO SAY LONG -- SAME EFFECTS AND THEN HE'S NOT
2 GOING TO STATE THAT THAT WAS THE BASIS OF HIS OPINION THAT
3 THEY DIED BECAUSE OF THE LONG-TERM EFFECTS OF PSYCHOTROPIC
4 MEDICATION, THEN I DON'T KNOW WHAT RELEVANCE, YOU KNOW, IT
5 HAS. I MEAN, WE'RE TALKING ABOUT IT AND THEN HE'S NOT
6 GIVING AN OPINION ABOUT IT.
7 MR. WILSON: OKAY.
8 THE COURT: OKAY. THEN LET'S COME BACK AT 9:45.
9 (A BRIEF RECESS WAS TAKEN.)
10 THE COURT: OKAY. PLEASE BE SEATED. THE RECORD
11 WILL REFLECT THAT THE JURY IS BACK, THAT THE ATTORNEYS AND
12 THE DEFENDANT IS PRESENT. GO AHEAD, MR. WILSON.
13 MR. WILSON: THANK YOU, YOUR HONOR.
14 Q. (BY MR. WILSON) DOCTOR, I REFERRED YOU TO THE SIDE OF
15 THE CHART THERE AS TO THE VARIOUS DRUG NAMES AND THE DOSAGES
16 THAT WERE LISTED ON THERE, HAVE YOU HAD A CHANCE TO REVIEW
17 THAT?
18 A. YES.
19 Q. WOULD YOU AGREE THAT THOSE ARE REPRESENTATIVE OF THE
20 DOSAGES THAT WOULD BE PRESCRIBED IN THIS PARTICULAR CONTEXT?
21 A. THOSE ARE, YES, REPRESENTATIVE GUIDELINES.
22 Q. OKAY. WOULD YOU ALSO -- MAYBE YOU'VE ALREADY TESTIFIED,
23 BUT IN REVIEWING THE MEDICAL RECORDS IN TERMS OF YOUR
24 OBSERVATIONS OF THE DOSAGES OF THOSE PARTICULAR DRUGS THAT
25 WERE ADMINISTERED OVER THAT TIME FRAME, WOULD THAT COMPORT
2785
1 WITH YOUR RECOLLECTION AND NOTES?
2 A. YES.
3 Q. OKAY. NOW, LET'S TALK ABOUT -- ALSO WHILE WE'RE ON IT,
4 LET'S TALK ABOUT THE ADMINISTRATION OF THE DRUG MORPHINE.
5 AGAIN, REFERRING TO THE EXHIBIT, CAN YOU TELL US WHETHER OR
6 NOT THE DOSAGES THAT ARE LISTED THERE IN RED OR SHOWN IN RED
7 WOULD REPRESENT DOSAGE AMOUNTS THAT COMPORT WITH THE AMOUNTS
8 THAT SHOULD BE ADMINISTERED TO ELDERLY PATIENTS?
9 A. ON THE 25TH AND 26TH, SHE RECEIVED SOME SMALL DOSES OF
10 MORPHINE WHICH WOULD BE ACCEPTABLE DOSE AMOUNTS.
11 Q. OKAY.
12 A. LATER ON RECEIVED MUCH, MUCH HIGHER DOSES.
13 Q. OKAY. AND WOULD YOUR -- IN TERMS OF THE RED AND BLACK
14 DESIGNATIONS AS TO THE ADMINISTRATION OF MORPHINE, WOULD
15 THOSE PARTICULAR DOSAGE AMOUNTS THAT ARE LISTED THERE OR
16 SHOWN THERE ON THE CHART, WOULD THEY COMPORT WITH YOUR
17 RECOLLECTION OF THE AMOUNTS AS REFLECTED IN YOUR REVIEW OF
18 THE MEDICAL RECORDS?
19 A. THE TOTAL AMOUNT OF MORPHINE, IS WHAT YOU SAID?
20 Q. YES.
21 A. YES.
22 Q. OKAY. I DON'T KNOW WHETHER I CLARIFIED, FOR PURPOSES OF
23 JURY, I JUST CALL YOUR ATTENTION TO THE DOSAGE THAT'S LISTED
24 IN 15 MILLIGRAMS ON THE CHART. DOES THAT COMPORT WITH YOUR
25 REVIEW OF THE GERIATRIC DOSAGING, WOULD YOU SAY THAT -- OR
2786
1 WOULD YOU HAVE AN OPINION AS TO WHETHER OR NOT THAT
2 REPRESENTS THE MAXIMUM DAILY AMOUNT THAT SHOULD BE
3 ADMINISTERED?
4 A. I KNOW THAT THERE ARE GUIDELINES ABOUT DOSES AND
5 PARTICULARLY STARTING DOSES IN A PERSON WHO HAS NOT
6 PREVIOUSLY BECOME TOLERANT TO MORPHINE.
7 Q. OKAY.
8 A. BUT THE AMOUNT OF MORPHINE ADMINISTERED WOULD HAVE TO BE
9 BASED ON CLINICAL INDICATIONS AND WOULD DEPEND ON THE DEGREE
10 OF PAIN THAT YOU ARE TREATING.
11 Q. ALL RIGHT. SO DO I UNDERSTAND YOUR ANSWER TO BE, THAT
12 VARIES WITH YOUR CLINICAL ASSESSMENT?
13 A. IT VARIES AND I WOULD NOT ADHERE TO A FIXED NUMBER
14 SIMPLY BECAUSE IT'S A SUGGESTED GUIDELINE. IT WOULD DEPEND
15 ON THE PATIENT'S CONDITION.
16 Q. RELATIVE TO THE DOSAGES ADMINISTERED OF THE -- WHAT HAS
17 BEEN DESCRIBED AS A PSYCHOTROPIC MEDICATIONS OVER THE PERIOD
18 OF TIME EXTENDING FROM DECEMBER 6TH UP THROUGH
19 DECEMBER 29TH, CAN YOU TELL THE JURY WHETHER OR NOT YOU HAVE
20 ANY OPINION AS TO WHETHER OR NOT THOSE DOSAGES WERE
21 ADMINISTERED IN APPROPRIATE AMOUNTS?
22 A. YES. AND, FIRST OF ALL, IT'S -- IT'S HIGHLY UNUSUAL TO
23 PRESCRIBE TRAZODONE AND SERZONE TOGETHER BECAUSE THEY ARE
24 ESSENTIALLY THE SAME TYPE OF ANTIDEPRESSANT.
25 Q. OKAY.
2787
1 A. AND THEY WOULD -- IT CAN BE DONE BUT IT'S -- WOULD BE
2 VERY UNUSUAL. IT DOESN'T -- IT DOESN'T MAKE SENSE TO ME TO
3 DO THAT. How is this murder?
4 Q. OKAY.
5 A. AS FAR AS THE DOSAGE AMOUNTS THAT WERE GIVEN OR THAT
6 WERE ORDERED IT'S DIFFICULT TO EVALUATE BECAUSE THERE WERE
7 SEVERAL DAYS WHEN MULTIPLE DOSES WERE MISSED. AND ANY TIME
8 A MEDICATION IS PRESCRIBED AT A LOWER DOSE IN ANTICIPATION
9 OF INCREASING IT, THE INCREASES NEED TO BE BASED ON THE
10 PATIENT'S RESPONSE TO THE PREVIOUS DOSES, AND THAT'S -- ALL
11 OF THAT INFORMATION NEEDS TO BE TAKEN INTO ACCOUNT IN ORDER
12 TO MAKE AN ADEQUATE DECISION AS TO WHETHER OR NOT THEY ARE
13 RESPONDING TO THAT MEDICATION OR WHETHER OR NOT TO INCREASE
14 IT.
15 Q. DID YOU REVIEW -- IN YOUR REVIEW OF THE RECORDS, DID YOU
16 SEE ANY SIGNS OR SYMPTOMS DURING THAT TIME PERIOD EXTENDING
17 FROM JANUARY 6TH THROUGH DECEMBER 29TH SEDATION OR
18 OVERSEDATION IN THESE PATIENT -- THIS PARTICULAR PATIENT?
19 A. YES, I DID. THERE WERE FREQUENT REFERENCES TO TIME
20 PERIODS WHEN JUDITH LARSEN WAS LETHARGIC OR SLEEPING IN
21 GROUP THERAPY OR SEDATED IN --
22 Q. CAN YOU TELL US AS TO THE EFFECTS OF THAT PARTICULAR
23 REGIMEN -- STRIKE THAT.
24 CAN YOU TELL US, DOCTOR, AS TO IN RESPECT TO THE
25 VARIOUS PSYCHOTROPIC MEDICATIONS THAT WERE ADMINISTERED AS
2788
1 TO WHETHER OR NOT THEY WOULD HAVE ANY EFFECTS -- OR
2 DURATION, WHAT THE DURATION OF THOSE PARTICULAR DRUGS WOULD
3 BE IN A PATIENT?
4 A. DRUGS ARE REPORTED TO HAVE A HALF LIFE IN THE
5 BLOODSTREAM AND THE REPORTED NUMBERS ARE AVERAGES. THERE'S
6 A HIGH DEGREE OF VARIABILITY AMONG INDIVIDUALS AND SOME
7 PEOPLE ARE SLOW METABOLIZERS OF CERTAIN DRUGS AND OTHER
8 PEOPLE MUCH FASTER. IN ADDITION, SEDATIVE MEDICATIONS OR
9 CENTRAL NERVOUS SYSTEM DEPRESSANTS OR MEDICATIONS THAT MAKE
10 A PERSON TIRED AND SLEEPY, IN THE ELDERLY CAN HAVE A
11 PROFOUND EFFECT. WE KNOW THAT ANY TIME, AND ESPECIALLY THE
12 ELDERLY, ARE IMMOBILE OR AT BED REST FOR EVEN A FEW DAYS,
13 THAT THEY RAPIDLY LOOSE MUSCLE STRENGTH, THEIR
14 CARDIOVASCULAR RESERVE DECREASES AND IT CAN TAKE A MUCH
15 LONGER TIME TO RECOVER FROM THAT, SO THAT BED REST OR
16 IMMOBILITY IN AN ELDERLY PERSON CAN BE -- CAN EVENTUALLY BE
17 CATASTROPHIC.
18 Q. DID YOU SIGNS OR SYMPTOMS OF THOSE PARTICULAR EFFECTS IN
19 THIS PARTICULAR PATIENT?
20 A. SHE WAS FREQUENTLY SEDATED AND LETHARGIC AND SLEEPING.
21 Q. OKAY.
22 A. AND DURING THOSE TIMES WOULD NOT HAVE BEEN ACTIVE OR
23 ANTICIPATING.
24 Q. DID YOU -- REFERRING TO THE CHART ON DECEMBER THE 25TH,
25 DID YOU SEE OR IN YOUR REVIEW OF THE RECORDS ANY INDICATORS
2789
1 THAT THE PATIENT WAS SUFFERING FROM PAIN OR PAINFUL
2 CONDITION ON THAT DAY?
3 MR. STIRBA: I'M GOING TO OBJECT. THIS IS
4 CUMULATIVE. IT'S BEEN TESTIFIED TO BY TWO OTHER EXPERTS.
5 THE COURT: OKAY. BRIEFLY.
6 THE WITNESS: THERE'S A NOTE IN DR. WEITZEL'S
7 PROGRESS NOTE THAT SHE SEEMED TO BE IN PAIN TO HIM.
8 Q. (BY MR. WILSON) OKAY. THAT'S THE ONLY REFERENCE?
9 A. THAT'S THE ONLY ONE THAT COMES TO MIND AT THIS MOMENT.
10 Q. THE FOLLOWING DAY ON DECEMBER THE 26TH, THERE WAS AN
11 ADMINISTRATION OF MORPHINE ON THAT DAY TOO?
12 A. YES.
13 Q. DID YOU SEE ANY SIGNS OR SYMPTOMS OF PAIN ON THAT DAY?
14 A. NO. See nurse's note>>
15 Q. OKAY. IN RESPECT TO THE -- DID AN EVENT OCCUR ON THIS
16 PARTICULAR PATIENT ON DECEMBER THE 29TH OR DECEMBER 30TH?
17 A. THE PATIENT BEGAN VOMITING AND VOMITED COFFEE GROUND
18 EMESIS WHICH IS THE USUAL TERM TO DESCRIBE VOMITING BLOOD.
19 Q. AND WHAT DATE WAS THAT, SIR?
20 A. THE VOMITING BEGAN ON THE 29TH.
21 Q. DID YOU SEE ANY SYMPTOMS OR SIGNS OF PAIN THAT THAT
22 PATIENT MAY HAVE HAD ON THE 29TH?
23 A. NO.
24 Q. OKAY. NOW, EXTENDING FROM THE 30TH OF DECEMBER TO THE
25 3RD OF JANUARY, CAN YOU TELL US WHETHER OR NOT IN YOUR
2790
1 REVIEW OF THE RECORDS YOU'VE SEEN ANY SIGNS OR SYMPTOMS OF
2 PAIN OR COMPLAINTS OF PAIN THAT THE PATIENT REFERENCED
3 DURING THAT TIME FRAME?
4 A. WHICH TIME FRAME?
5 Q. FROM DECEMBER 30TH THROUGH JANUARY 3RD.
6 A. I WOULD NOTE THAT, IN FACT, ON THE 29TH THE NURSE WROTE
7 THERE WERE NO SIGNS OF SYMPTOMS OF PAIN OR DISTRESS.
8 Q. OKAY.
9 A. AND I DID NOT NOTE ANY -- ANYTHING IN THE NURSE'S NOTES
10 THAT WOULD REFERENCE PAIN DURING THAT TIME PERIOD.
11 Q. THAT WOULD BE THE TIME PERIOD FROM THE 30TH TO THE
12 31ST -- OR 3RD OF JANUARY?
13 A. YES.
14 Q. OKAY.
15 A. AND IN ADDITION ON THE 29TH THROUGH THE 31ST, I DON'T
16 SEE ANY INDICATION IN DR. WEITZEL'S NOTES ABOUT PAIN OTHER
17 THAN TO SAY THAT HE WANTED TO MAKE SURE SHE'S COMFORTABLE.
18 Q. OKAY.
19 A. AND THEN ON JANUARY 1ST HE NOTES THAT SHE SEEMED TO BE
20 IN SOME DISCOMFORT.
Indication of pain>> Indication of pain>> Indication of pain>> Indication of pain>> Indication of pain>> Indication of pain>> Indication of pain>> Indication of pain>>
21 Q. LET ME ASK YOU, DOCTOR, BASED UPON YOUR REVIEW OF THE
22 RECORDS AND YOUR TESTIMONY HERE AS TO THE ABSENCE OF ANY
23 PAIN COMPLAINTS FOR THE TIME PERIOD EXTENDING FROM
24 DECEMBER 30TH TO JANUARY 3RD, DO YOU HAVE AN OPINION AS TO
25 WHETHER OR NOT THE MORPHINE SHOULD HAVE BEEN ADMINISTERED ON
2791
1 THOSE PARTICULAR DATES?
2 MR. STIRBA: I'M GOING TO OBJECT, IT'S CUMULATIVE.
3 THE COURT: OVERRULED.
4 THE WITNESS: IT'S MY OPINION THAT MORPHINE SHOULD
5 NOT HAVE BEEN GIVEN.
6 Q. (BY MR. WILSON) OKAY. LET'S MOVE NOW TO I THINK IT
7 WOULD BE MARY CRANE. AGAIN, JUST CALLING YOUR ATTENTION TO
8 STATE'S EXHIBIT NUMBER 36, AGAIN, HAVE YOU -- FOR THE
9 RECORD, HAVE YOU HAD A CHANCE TO REVIEW THAT EXHIBIT?
10 A. YES, I HAVE.
11 Q. AND THE CHARTING OF THE MEDICATIONS ON THE SIDE, DO
12 THOSE DOSAGE AMOUNTS REFLECT WHAT YOUR TESTIMONY WOULD BE AS
13 TO MAXIMUM DAILY DOSAGES?
14 A. THOSE WOULD BE RECOMMENDED GUIDELINES.
15 Q. RECOMMENDED GUIDELINES? IN RESPECT TO THE -- YOUR
16 REVIEW OF THE RECORDS, CAN YOU TELL US WHETHER THE AMOUNTS
17 REFERENCED AS TO THE TYPES OF MEDICATIONS, AND PARTICULARLY
18 PSYCHOTROPIC MEDICATIONS, LET'S JUST REFER TO THOSE, THAT
19 WERE ADMINISTERED TO THIS PATIENT FROM DECEMBER 28TH THROUGH
20 JANUARY THE 7TH, DO THOSE REFLECT WHAT DOSAGES WERE
21 ADMINISTERED TO HER?
22 A. YES.
23 Q. OKAY. NOW, THERE IS A PARTICULAR DESIGNATION AS TO A
24 DURAGESIC PATCH ON THAT PARTICULAR EXHIBIT. DO YOUR REVIEW
25 OF THE RECORDS REFLECT THAT THERE WAS THE ADMINISTRATION OF
2792
1 THAT PARTICULAR MEDICATION TO THIS PATIENT?
2 A. YES.
3 Q. OKAY. AND, AGAIN, DO THEY ACCURATELY REFLECT THAT
4 DOSAGES OR AMOUNTS THAT WERE ADMINISTERED TO THAT PATIENT
5 OVER THAT PERIOD OF TIME EXTENDING FROM DECEMBER 28TH
6 THROUGH JANUARY 7TH?
7 A. YES.
8 Q. CAN YOU TELL US AS TO WHETHER OR NOT YOU FORMED AN
9 OPINION AS IT RELATES TO THE ADMINISTRATION OF THE
10 PSYCHOTROPIC MEDICATIONS AS TO THE APPROPRIATENESS OF THE
11 DOSAGES THAT WERE ADMINISTERED TO THIS PATIENT?
12 A. YES.
13 Q. AND WHAT WAS THAT OPINION, SIR?
14 A. THIS PATIENT WAS ALSO PRESCRIBED A COMBINATION OF
15 TRAZODONE AND SERZONE AND A RELATIVELY HIGHER DOSE OF
16 RISPERDAL THEN WOULD COMMONLY BE ACCEPTED OR RECOMMENDED TO
17 START OUT WITH. AND THEN AT ONE POINT DEPAKENE WAS ADDED.
18 AND DEPAKENE, BECAUSE OF ITS SIDE EFFECTS THAT INCLUDE UPSET
19 STOMACH OR GASTROINTESTINAL DISTRESS AND ITS SEDATION,
20 WHENEVER POSSIBLE, IS STARTED IN A GRADUALLY INCREASING
21 AMOUNT AND SHE WAS STARTED OUT AT A RELATIVELY HIGH DOSE
22 FROM THE BEGINNING.
23 Q. DID YOUR REVIEW OF THE MEDICAL RECORDS ON THE DAY OF
24 ADMISSION SHOW ANY OF THESE DRUGS HAD BEEN PREVIOUSLY
25 ADMINISTERED TO THIS PATIENT OR WERE BEING ADMINISTERED AT
2793
1 THE TIME OF HER ADMISSION?
2 A. I DON'T SHOW THAT ANY OF THEM WERE BEING PRESCRIBED
3 PRIOR TO ADMISSION SPECIFICALLY. They were.
4 Q. CAN YOU TELL US WHAT HER PHYSICAL CONDITION WAS ON
5 ADMISSION ACCORDING TO YOUR REVIEW OF THE RECORDS?
6 A. SHE HAD HAD A PREVIOUS STROKE, SHE HAD HIGH BLOOD
7 PRESSURE. SHE HAD A CONDITION THAT WE CALL PSYCHOGENIC
8 POLYDIPSIA WHERE SHE FELT COMPELLED TO DRINK LARGE AMOUNTS
9 OF WATER AND THAT PUT HER AT RISK FOR DILUTING ELECTROLYTES
10 AND CAUSING A SEIZURE WHICH SHE HAD PREVIOUSLY HAD. SHE
11 ALSO HAD A HISTORY OF MENINGITIS AND HEADACHES AND HIGH
12 BLOOD PRESSURE.
13 Q. OKAY.
14 A. AS WELL AS PEPTIC ULCER DISEASE WHICH WOULD INDICATE
15 THAT SHE HAD HAD SOME STOMACH PROBLEM BEFORE.
16 Q. DID YOU OBSERVE IN YOUR REVIEW ANY SIGNS OR COMPLAINTS
17 OR SYMPTOMS OF PAIN?
18 A. YES. SHE HAD THE HEADACHES AND THERE IS REFERENCE TO
19 LOW BACK PAIN.
20 Q. DO YOU KNOW WHETHER OR NOT SHE WAS RECEIVING ANY PAIN
21 MEDICATIONS AT THE TIME OF HER ADMISSION TO THE GEROPSYCH
22 UNIT?
23 A. SHE HAD BEEN PRESCRIBED HYPHEN WHICH IS A PRESCRIPTION
24 PAIN MEDICATION.
25 Q. DO YOU KNOW WHAT AMOUNT SHE WAS PRESCRIBED HYPHEN?
2794
1 A. IT WAS RECORDED ONLY AS ONE TABLET EVERY FOUR HOURS AS
2 NEEDED.
3 Q. IS THERE ANYTHING IN THE RECORDS THAT YOU REVIEWED
4 INDICATING HOW MUCH SHE WAS BEING ADMINISTERED TO ON A DAILY
5 BASIS?
6 A. NOT IN THE RECORDS THAT I REVIEWED.
7 Q. OKAY. NOW, DID YOU DURING THAT TIME PERIOD FROM
8 DECEMBER 28TH THROUGH JANUARY 7TH, OBSERVE ANY SIGNS OR
9 SYMPTOMS OF -- THAT THIS INDIVIDUAL WAS SUFFERING FROM THE
10 SIDE EFFECTS OF THE PSYCHOTROPIC MEDICATIONS BEING
11 ADMINISTERED?
12 A. YES.
13 Q. CAN YOU DESCRIBE THAT FOR US, IF YOU WOULD PLEASE.
14 A. DURING THE DAY SHE WAS DESCRIBED AS STARING OFF INTO
15 SPACE, BREATHING AS THOUGH SHE WERE SNORING BUT WITH HER
16 EYES WIDE OPEN, DROWSY, VERY DROWSY. ON THE 31ST THERE'S A
17 REFERENCE TO BEING ASLEEP MOST OF THE DAY. ON THE 1ST A
18 REFERENCE TO BEING LETHARGIC. AGAIN, ON THE 2ND, LETHARGIC
19 AND AGAIN ON THE 3RD BEING LETHARGIC.
20 Q. YOU'VE INDICATED PREVIOUSLY THIS DURAGESIC PATCH THAT
21 WAS USED IN CONNECTION WITH THIS PATIENT, ADMINISTERED TO
22 THIS PATIENT, CAN YOU TELL US WHETHER OR NOT THERE IS ANY
23 RISK ASSOCIATED WITH THE DURAGESIC PATCH AND THE
24 PSYCHOTROPIC MEDICATIONS BEING ADMINISTERED AT THE SAME
25 TIME?
2795
1 A. THEY ARE BOTH CENTRAL NERVOUS SYSTEM DEPRESSANT OR
2 SEDATIVES AND WOULD BE EXPECTED TO HAVE ADDED EFFECTS. THE
3 PSYCHOTROPIC OR PSYCHIATRIC MEDICATIONS WOULD PREDICTABLY
4 INTENSIFY THE SIDE EFFECTS OF DURAGESIC.
5 Q. DID YOU SEE ANYTHING IN YOUR REVIEW OF THE RECORDS -- OR
6 DID YOU FORM AN OPINION, LET'S SAY THIS, AS TO THE
7 APPROPRIATENESS OF THE ADMINISTRATION OF THE DURAGESIC PATCH
8 DURING THIS PARTICULAR TIME FRAME?
9 A. I DID.
10 Q. AND WHAT WAS THAT OPINION, SIR?
11 A. I DO NOT BELIEVE THAT IT WAS INDICATED.
12 Q. OKAY. AND WHY IS THAT?
13 A. DURAGESIC IS A FORM OF FENTANYL WHICH IS AN EXTREMELY
14 POTENT OPIATE NARCOTIC USED FOR PAIN RELIEF IN ANESTHESIA
15 PRIMARILY OR ORIGINALLY AND I DID NOT SEE THAT SHE HAD THAT
16 DEGREE OF PAIN THAT WOULD REQUIRE THAT TYPE OF PAIN RELIEF.
17 IT SEEMED TO BE EXCESSIVE FOR THE PAIN THAT SHE HAD AND THE
18 WAY IT HAD PREVIOUSLY BEEN TREATED.
19 Q. WHAT WAS THE DOSAGE AMOUNT THAT SHE RECEIVED ON THE
20 DURAGESIC PATCH, CAN YOU TELL US?
21 A. IT WAS ORIGINALLY ORDERED AS 25 MICROGRAMS PER HOUR,
22 THAT WAS NEVER APPLIED. SHE WAS STARTED AT 50 MICROGRAMS
23 PER HOUR AND IT WAS SUBSEQUENTLY INCREASED TO BE ONE AND A
24 HALF OR 75 MICROGRAMS PER HOUR.
25 Q. NOW, THE DURAGESIC PATCH IS PLACED ON AN INDIVIDUAL'S
2796
1 BODY FOR HOW LONG?
2 A. TYPICALLY THREE DAYS.
3 Q. IS THERE EQUIVALENCY BETWEEN THE DURAGESIC PATCH OF 50
4 MICROGRAMS AND THE ADMINISTRATION OF MORPHINE?
5 A. THERE ARE REPORTED TABLES SUCH AS THE ONE THAT YOU
6 SHOWED ME PREVIOUSLY.
7 Q. CAN YOU TELL US WHAT THE ADMINISTRATION OF THE 50
8 MICROGRAMS OF DURAGESIC PATCH WOULD EQUATE TO IN TERMS OF
9 MORPHINE SULFATE?
10 A. ROUGHLY 5 MILLIGRAMS OF MORPHINE EVERY HOUR AROUND THE
11 CLOCK.
12 Q. SO 120 MILLIGRAMS IN A 24-HOUR PERIOD?
13 A. YES.
14 Q. AND THAT WAS INCREASED TO 75 MICROGRAMS?
15 A. YES.
16 Q. NOW, THERE WAS ADMINISTRATION OF MORPHINE ALSO IN
17 CONJUNCTION WITH THIS PARTICULAR PATIENT, WAS THERE NOT?
18 A. YES, THERE WAS.
19 Q. IN REVIEWING, LOOKING AT THE CHART, IF YOU WOULD,
20 DOCTOR, CAN YOU TELL US, DOES THE ADMINISTRATION OF THE
21 MORPHINE THAT'S DESIGNATED ON THE CHART CORRESPOND WITH YOUR
22 RECOLLECTION AND REVIEW OF THE RECORDS?
23 A. YES.
24 Q. WAS THERE ANY SIGNS OR SYMPTOMS OF PAIN -- STRIKE THAT.
25 I'M JUST GOING TO ASK YOU: IN YOUR REVIEW OF THE
2797
1 RECORDS, CAN YOU COMMENT AS TO THE APPROPRIATENESS OF THE
2 ADMINISTRATION OF THE MORPHINE?
3 A. I BELIEVE THAT DR. WEITZEL --
4 MR. STIRBA: I'M GOING TO OBJECT, YOUR HONOR. I
5 OBJECT TO THE FORM OF THE QUESTION. IT'S HIS OPINION, NOT
6 COMMENT.
7 THE COURT: LET'S REPHRASE THE QUESTION.
8 Q. (BY MR. WILSON) IN YOUR OPINION -- DO YOU HAVE AN
9 OPINION AS TO WHETHER THE ADMINISTRATION OF MORPHINE WAS
10 INDICATED AS IT RELATED TO THIS PARTICULAR PATIENT?
11 A. IT WAS NOT INDICATED IN MY OPINION.
12 Q. OKAY. DO YOU HAVE AN OPINION AS TO WHETHER THE
13 ADMINISTRATION OF THE MORPHINE IN CONJUNCTION WITH THE
14 DURAGESIC PATCH ENHANCED THE EFFECTS ON THIS PATIENT?
15 A. THEY ARE BOTH OPIATE NARCOTICS, WOULD BE EXPECTED TO BE
16 ADDITIVE EFFECTS.
17 Q. WHAT ARE THE RISKS ASSOCIATED WITH THAT?
18 A. AGAIN, THE MAIN CONCERN WITH OPIATE PAIN MEDICATIONS IS
19 DEPRESSED BREATHING OR A PERSON NOT BREATHING AS WELL OR
20 EVEN STOPPING THEIR BREATHING.
21 Q. OKAY. FIRST OF ALL, DOCTOR, AS TO LYDIA SMITH, TURNING
22 TO HER MEDICAL RECORDS, IF YOU WOULD, PLEASE, FROM YOUR
23 NOTES. CAN YOU TELL US FROM YOUR REVIEW WHAT HER PHYSICAL
24 AND MENTAL CONDITION WAS ON ADMISSION TO THE GEROPSYCH UNIT?
25 A. LYDIA SMITH HAD AN AORTIC VALVE OR A HEART VALVE
2798
1 REPLACED, HIGH BLOOD PRESSURE, A HISTORY OF CONGESTIVE HEART
2 FAILURE. SHE HAD DIFFICULTY COMMUNICATING BECAUSE OF A
3 PREVIOUS STROKE AND SHE HAD AN IRREGULAR HEART BEAT.
4 Q. OKAY. DO YOUR -- OR YOUR REVIEW OF THE RECORDS INDICATE
5 MRS. SMITH WAS SUFFERING FROM ANY SIGNS OR SYMPTOMS OR
6 COMPLAINTS OF PAIN AT THE TIME OF ADMISSION?
7 A. AT THE TIME OF ADMISSION, NO. IT WAS REPORTED IN THE
8 NURSING ASSESSMENT THAT SHE WOULD TAKE AN OCCASIONAL
9 TYLENOL.
10 Q. AND BRIEFLY REFLECTING THE EXHIBIT WHICH IS THE STATE'S
11 EXHIBIT NUMBER 37, DO YOU AGREE WITH THE RECOMMENDED MAXIMUM
12 DAILY DOSAGES WHICH ARE ON THE LEFT-HAND SIDE OF THAT CHART?
13 A. ROUGHLY, YES, WITH THE EXCEPTION OF THE DEPAKENE.
14 Q. OKAY.
15 A. WHICH IS A -- WHICH WHENEVER POSSIBLE IS STARTED AT A
16 MUCH LOWER DOSE AND GRADUALLY INCREASED BECAUSE OF ITS SIDE
17 EFFECTS.
18 Q. SO THE DEPAKENE, WHAT WOULD -- YOU SAY WOULD BE STARTED
19 AT A LOWER DOSE THAN WHAT'S REFERENCED ON THE CHART?
20 A. YES.
21 Q. I DON'T KNOW WHAT THE DOSAGE IS, CAN YOU COMMENT ON
22 THAT?
23 A. 800 MILLIGRAMS WHICH I BELIEVE IS PROBABLY A CALCULATION
24 BASED ON HER WEIGHT.
25 Q. OKAY. WHAT DID THIS PATIENT WEIGH?
2799
1 A. 116 POUNDS.
2 Q. CAN YOU TELL US FROM YOUR REVIEW OF THE RECORDS AND THE
3 CHART, DOES IT ACCURATELY REFLECT IN YOUR RECOLLECTION THE
4 DOSAGES AND THE AMOUNTS THAT WERE ADMINISTERED TO THIS
5 PARTICULAR PATIENT FROM DECEMBER 20TH THROUGH JANUARY 8TH?
6 A. YES.
7 Q. NOW, WE'RE TALKING SPECIFICALLY ABOUT PSYCHOTROPIC
8 MEDICATIONS.
9 A. YES.
10 Q. OKAY. DID YOU IN YOUR REVIEW OF THE RECORDS SEE ANY
11 SIGNS OR SYMPTOMS OR COMPLAINTS OF PAIN EXTENDING OVER THAT
12 SAME TIME FRAME, FROM DECEMBER 20TH TO JANUARY 8TH?
13 A. THIS WAS A PATIENT WHO HAD DIFFICULTY COMMUNICATING WITH
14 STAFF AND SOME OF HER BEHAVIORS COULD BE INTERPRETED AS
15 BEING UNCOMFORTABLE OR IN PAIN.
16 Q. IN RESPECT TO THE ADMINISTRATION OF THE PARTICULAR
17 DOSAGE OF THE PSYCHOTROPIC MEDICATION, CAN YOU TELL US, DID
18 YOU SEE ANY SIGNS OR SYMPTOMS EXHIBITED BY THIS PATIENT
19 WHICH WOULD INDICATE TO YOU THAT THE PATIENT WAS SUFFERING
20 FROM THE SIDE EFFECTS FROM THOSE PARTICULAR DRUGS?
21 A. SHE WAS FREQUENTLY DESCRIBED AS AGITATED WHICH CAN BE A
22 SIDE EFFECT OF THESE MEDICATIONS AS WELL AS OTHER TIMES
23 BEING UNABLE TO AROUSE HER BECAUSE SHE WAS ASLEEP OR SO
24 SEDATED OR LETHARGIC. From the mouth of a "psychiatrist"!
25 MR. STIRBA: YOUR HONOR, DO WE HAVE A PAGE
2800
1 REFERENCE TO THESE, PLEASE?
2 THE COURT: ARE YOU REFERRING TO A PAGE?
3 THE WITNESS: I CAN -- THE NUMBERS IN MY RECORDS
4 ARE DIFFERENT; IS THAT CORRECT?
5 MR. WILSON: I THINK THE QUESTION IS -- IF COUNSEL
6 WANTS US TO START REFERRING TO THE EXACT PAGE NUMBERS AND
7 THAT, HE CAN QUESTION HIM ON CROSS-EXAMINATION.
8 THE COURT: GO AHEAD, GO AHEAD.
9 Q. (BY MR. WILSON) IN REFERENCE TO THE PSYCHOTROPIC
10 MEDICATIONS, YOU INDICATE THAT ONE OF THE SIDE EFFECTS IS
11 AGITATION?
12 A. YES.
13 Q. IS THERE A PARTICULAR MEDICATION THAT PRODUCES THAT SIDE
14 EFFECT?
15 A. IN THIS CASE, HALDOL.
16 Q. CAN YOU COMMENT ON THE DOSAGE OF HALDOL IN THIS
17 PARTICULAR CASE?
18 THE COURT: ARE YOU ASKING HIS OPINION?
19 MR. WILSON: YEAH.
20 Q. (BY MR. WILSON) DO YOU HAVE AN OPINION AS TO THE
21 APPROPRIATENESS OF THE DOSAGE IN THIS PARTICULAR PATIENT OF
22 HALDOL?
23 A. YES. AND SHE HAD RECEIVED INTERMITTENTLY SOME SMALLER
24 DOSES OF HALDOL, 2 AND 3 MILLIGRAMS EARLY IN THE
25 HOSPITALIZATION. AND THEN THERE'S A DAY WHEN SHE RECEIVED
2801
1 15 MILLIGRAMS OF HALDOL ON JANUARY 3RD.
2 Q. WHAT IS THE RISK TO A PATIENT ASSOCIATED WITH THAT
3 PARTICULAR DOSAGE, DOCTOR?
4 A. HALDOL CAN CAUSE AGITATION BECAUSE IT -- PEOPLE CAN HAVE
5 A REACTION TO IT WHERE THEY HAVE THIS INTERNAL RESTLESSNESS
6 CALLED AKATHISIA THAT THEY CAN'T EXPRESS VERY WELL AND IT'S
7 A VERY UNCOMFORTABLE FEELING AND THE 15 MILLIGRAMS IS A VERY
8 HIGH DOSE FOR AN ELDERLY PERSON. THIS TYPE OF MEDICATION,
9 HALDOL IN PARTICULAR, HAS BEEN KNOWN TO MAKE PEOPLE STOP
10 TALKING, STOP WALKING, STOP EATING AND SWALLOWING. IT'S A
11 VERY POTENT TRANQUILIZER.
12 Q. DID THE PATIENT SUBSEQUENTLY EXHIBIT -- STRIKE THAT.
13 WAS THIS PATIENT SUBSEQUENTLY ADMINISTERED MORPHINE?
14 A. YES.
15 Q. AND THAT OCCURRED ON JANUARY 7TH; IS THAT CORRECT?
16 A. THAT'S CORRECT.
17 Q. DID YOU SEE ANY SIGNS OR SYMPTOMS WHICH WOULD BE
18 INDICATIVE OF PAIN OR ASSOCIATED WITH PAIN ON THAT
19 PARTICULAR DAY FROM YOUR REVIEW OF THE RECORDS?
20 A. NO.
21 Q. DID YOU HAVE AN OPINION AS TO THE -- AS TO WHETHER OR
22 NOT MORPHINE WAS APPROPRIATELY USED IN THIS CONTEXT?
23 A. I DON'T BELIEVE IT WAS USED APPROPRIATELY.
24 Q. IN RESPECT TO JANUARY THE 8TH, THE SAME QUESTION, WAS
25 THERE ANY SIGNS OR SYMPTOMS INDICATIVE OF PAIN ON THAT
2802
1 PARTICULAR DAY?
2 A. THE ONLY REFERENCE I HAVE IS DR. WEITZEL'S STATEMENT IN
3 HIS NOTE THAT SHE OCCASIONALLY APPEARED TO BE IN DISCOMFORT.
4 Q. DID YOU SEE ANYTHING IN YOUR OPINION WHICH WOULD
5 INDICATE THE APPROPRIATE USE OF MORPHINE?
6 A. NO.
7 Q. CAN YOU TELL US WHAT THE RISKS ARE ASSOCIATED WITH THE
8 MORPHINE TO THIS PARTICULAR PATIENT ON THAT DATE?
9 A. THIS PATIENT WAS ALREADY VERY SEDATED. SHE RECEIVED
10 THAT LARGE DOSE OF HALDOL ON JANUARY 3RD. PREVIOUS TO THAT
11 TIME, SHE HAD BEEN MISSING SEVERAL DOSES OF SERZONE AND
12 TRAZODONE WHICH IS ARE TWO VERY SIMILAR MEDICATIONS.
13 SHORTLY AFTER THAT SHE RECEIVED ALL OF THE --
14 MR. STIRBA: YOUR HONOR, YOUR HONOR, I'M SORRY.
15 THE QUESTION WAS THE RISK ON THE PATIENT FROM THAT DAY FROM
16 THE MORPHINE. I DON'T KNOW WHERE WE'RE GOING WITH THIS.
17 MR. WILSON: I THINK HE WAS ANSWERING THE QUESTION,
18 IS WHERE WE'RE GOING WITH IT, BUT I'LL REPHRASE -- I'LL
19 STRIKE THAT QUESTION AND ASK HIM ANOTHER QUESTION.
20 Q. (BY MR. WILSON) NOW, I'M GOING TO GO BACK TO THE
21 QUESTION, DOCTOR, DID YOU SEE ANY INDICATIONS AS I RECALL OF
22 THE APPROPRIATENESS OF THE USE OF MORPHINE IN YOUR OPINION,
23 THE USE OF MORPHINE ON JANUARY THE 8TH?
24 MR. STIRBA: I'LL OBJECT, ASKED AND ANSWERED.
25 THE COURT: OVERRULED.
2803
1 THE WITNESS: I DID NOT SEE ANY INDICATIONS FOR
2 APPROPRIATE USE OF MORPHINE.
3 Q. (BY MR. WILSON) OKAY. LET'S MOVE ON TO THE NEXT.
4 SHOW YOU WHAT'S BEEN MARKED AS STATE'S EXHIBIT 35 AND ASK IF
5 YOU WOULD REFER TO THAT PARTICULAR EXHIBIT. THIS PURPORTS
6 THE CHART FOR ENNIS ALLDREDGE?
7 A. YES.
8 Q. HAVE YOU LOOKED AT THE DOSAGES ON THE LEFT-HAND SIDE OF
9 THE CHART?
10 A. YES.
11 Q. DO THEY CORRESPOND WITH THE -- WHAT YOUR OPINION WOULD
12 BE AS TO THE RECOMMENDED DOSAGES?
13 A. YES.
14 Q. OKAY. YOU CAN HAVE A SEAT AGAIN, IF YOU WOULD, PLEASE.
15 AGAIN, AS TO THE ADMISSION OF -- ON THE DATE OF
16 ADMISSION OF ENNIS ALLDREDGE ON JANUARY THE 10TH, CAN YOU
17 TELL US WHAT THE RECORDS REFLECT AS TO HIS PHYSICAL AND
18 MENTAL CONDITION?
19 A. HE WAS ADMITTED IN A WHEELCHAIR, WAS NOT BEING ABLE TO
20 AMBULATE OR TO WALK. HE HAD BEEN AGGRESSIVE, HE WAS HITTING
21 AND KICKING AND SPITTING. HIS MEDICAL DIAGNOSES INCLUDED
22 MYCOSIS FUNGOIDES WHICH IS A FORM OF LYMPHOMA. HE HAD HAD
23 TRANSIENT ISCHEMIC ATTACKS WHICH ARE SOMETIMES CALLED MINI
24 STROKES OR TEMPORARY ATTACKS. DIABETES, HIGH BLOOD
25 PRESSURE, LOW THYROID, GASTROESOPHAGEAL REFLUX, WHICH IS
2804
1 HEARTBURN, CORONARY ARTERY DISEASE OR HEART PROBLEMS, AND AT
2 ADMISSION, HE WAS ALSO FOUND TO HAVE AN ORAL YEAST
3 INFECTION.
4 Q. WERE THERE ANY SIGNS OR SYMPTOMS OF THE COMPLAINTS OF
5 PAIN AT THAT TIME?
6 A. NO.
7 Q. DO YOU KNOW WHAT MEDICATIONS HE WAS RECEIVING JUST PRIOR
8 TO COMING INTO THE GEROPSYCH UNIT FROM YOUR REVIEW OF THE
9 RECORDS?
10 A. YES. AND --
11 Q. WERE ANY OF THOSE MEDICATIONS THAT WERE BEING
12 ADMINISTERED PRIOR TO HIM COMING ON THE UNIT INDICATED IN
13 THE CHART IN EXHIBIT 28 I THINK IT IS -- NO, IT'S 35, EXCUSE
14 ME.
15 A. MEDICATIONS THAT HE WAS RECEIVING PRIOR TO ADMISSION?
16 Q. YES.
17 A. IF I CAN FIND IT, QUICKLY. I'M LOOKING FOR THE INTAKE
18 FORM --
19 Q. HAVE YOU GOT THE EXHIBITS --
20 A. -- THAT WAS FILLED OUT PRIOR TO ADMISSION.
21 Q. HE HAS IT.
22 ARE YOU REFERRING TO THE EXHIBIT -- STATE'S EXHIBIT OR
23 ARE YOU REFERRING TO YOUR OWN NOTES?
24 A. I'M REFERRING TO MY OWN.
25 Q. WELL, LET'S JUST MOVE ON FROM THAT PARTICULAR -- WE'LL
2805
1 GO BACK TO IT, DOCTOR, IF YOU CAN'T FIND IT.
2 A. OKAY.
3 Q. IN LOOKING AT THE CHART, DO THE DOSAGES ADMINISTERED OF
4 THE PSYCHOTROPIC MEDICATIONS, ARE THEY ACCURATELY REFLECTED
5 ON THAT CHART IN THE AMOUNT ACCORDING TO YOUR RECOLLECTION?
6 A. YES.
7 Q. THE TYPES OF MEDICATIONS THAT WERE ADMINISTERED TO THE
8 DEFENDANT -- OR EXCUSE ME, TO THE DEFENDANT, YEAH -- I'M
9 GETTING A LITTLE RUMMY HERE -- TO THE PATIENT ON THAT
10 PARTICULAR DATE, IT APPEARS TO BE HALDOL WAS ADMINISTERED;
11 IS THAT CORRECT?
12 A. YES.
13 Q. AND DO YOU HAVE AN OPINION AS TO THE APPROPRIATENESS OF
14 THE DOSAGE AMOUNT OF HALDOL THAT WAS ADMINISTERED TO ENNIS
15 ALLDREDGE ON THE -- JANUARY 10TH?
16 A. YES, IT WAS A VERY HIGH DOSE.
17 Q. AS TO OTHER DRUGS THAT WERE ADMINISTERED ON THAT DATE,
18 WHAT OTHER DRUGS WERE ADMINISTERED ON THE 10TH?
19 A. HE ALSO RECEIVED RISPERDAL WHICH, AGAIN, IS VERY SIMILAR
20 TO HALDOL AND ATIVAN OR LORAZEPAM. This is a psychiatrist?
21 Q. IN RESPECT TO THE ADMINISTRATION OF THE DRUGS IN THOSE
22 COMBINATIONS, DO THEY CREATE ANY RISKS TO THE PATIENT?
23 A. YES.
24 Q. WHAT TYPE OF RISKS?
25 A. OVERSEDATION.
2806
1 Q. DID YOU SEE SIGNS OR SYMPTOMS REFLECTING THE EFFECTS OF
2 THESE DRUGS ON THAT PARTICULAR PATIENT?
3 A. YES. DR. DIENHART EXAMINED THE PATIENT LATER IN THE DAY
4 AND DESCRIBED HIM AS HAVING CHEYNE-STOKES RESPIRATIONS OR
5 IRREGULAR BREATHING WITH PERIODS OF NOT BREATHING AND
6 INDICATED THAT THAT MAY BE RELATED TO THE -- WHAT HE CALLED
7 THE RECENT SIGNIFICANT SEDATION FROM THE EFFECTS OF THE
8 HALDOL AND ATIVAN.
9 Q. ON THE NEXT DAY -- LET ME ASK YOU FIRST OF ALL BEFORE I
10 GET OFF THAT TOPIC, WHAT IS THE DURATION OF HALDOL?
11 A. HALDOL HAS A FAIRLY LONG DURATION OF ACTION AND IT
12 DEPENDS ON THE PERSON. THERE IS SOME INDIVIDUAL
13 VARIABILITY. ITS ACUTE EFFECTS OF SEDATION, IF I REMEMBER
14 CORRECTLY, ONE OF THE HALF LIFE REFERENCES SAYS ABOUT 20
15 HOURS; MEANING THAT IT WOULD TAKE FOUR OR FIVE TIMES THAT
16 LONG FOR THE HALDOL TO CLEAR FROM THE BLOODSTREAM. BUT IF ?? Steady state!!
17 IT CAUSES A PERSON TO BE SO SEDATED THAT THEY ARE NOT MOVING
18 AND NOT BREATHING DEEPLY, THAT COULD CAUSE OTHER PROBLEMS
19 THAT WOULD PERSIST EVEN AFTER THE HALDOL.
20 Q. IN CONNECTION WITH THE NEXT DATE THERE WAS ANOTHER
21 REGIMEN OF DRUGS THAT WERE ADMINISTERED; IS THAT CORRECT?
22 A. YES.
23 Q. WHAT DRUGS WERE ADMINISTERED ON THAT DATE?
24 A. ON THE 11TH RISPERDAL AND BUSPAR AND ATIVAN AGAIN.
25 Q. OKAY. AGAIN, DID YOU SEE ANY SIGNS OR SYMPTOMS OF THE
2807
1 EFFECTS OF THOSE PARTICULAR DRUGS ON THAT DAY?
2 A. YES.
3 Q. WHAT SIGNS OR SYMPTOMS WERE THOSE?
4 A. THAT HE WAS DIFFICULT TO WAKE UP, WAS UNRESPONSIVE TO
5 QUESTIONS, FALL ASLEEP AND COULDN'T BE AWAKENED.
6 Q. NOW GOING TO JANUARY THE 12TH, IT APPEARS WE HAVE THE
7 ADMINISTRATION OF HALDOL AND ATIVAN TOGETHER ON THAT DATE?
8 A. YES.
9 Q. AGAIN, DID YOU SEE ANY SIGNS OR SYMPTOMS AS TO THE
10 EFFECTS OF THOSE PARTICULAR DRUGS THAT WERE ADMINISTERED ON
11 THAT DAY?
12 A. YES. ONCE AGAIN, HE WAS VERY SEDATED, VERY LETHARGIC
13 AND AT TIMES DESCRIBED AS UNRESPONSIVE.
14 Q. DID YOU SEE OR OBSERVE IN YOUR REVIEW ANY SIGNS OR
15 SYMPTOMS OR COMPLAINTS OF PAIN FROM JANUARY THE 12TH THROUGH
16 JANUARY THE -- EXCUSE ME, JANUARY THE 10TH THROUGH JANUARY
17 THE 12TH?
18 A. ONE OF THE NURSING NOTES REPORTS THAT HE WOULD RESPOND
19 TO THE NEEDLE STICKS OR INJECTIONS THAT WERE EVIDENTLY
20 PAINFUL.
21 Q. OKAY. THAT WAS ON WHAT DATE, SIR?
22 A. ON THE 12TH.
23 Q. ON THE 12TH? HOW IS HALDOL ADMINISTERED?
24 A. HALDOL CAN BE GIVEN ORALLY OR INTRAMUSCULARLY BY
25 INJECTION AND OCCASIONALLY INTRAVENOUSLY.
2808
1 Q. DO YOU KNOW HOW IT WAS ADMINISTERED TO THIS PARTICULAR
2 PATIENT?
3 A. IT WAS GIVEN INTRAMUSCULARLY.
4 Q. IS THERE ANY DIFFERENCE BETWEEN THE PILL FORM AND THE
5 INTRAMUSCULAR FORM?
6 A. THE DOSE IS EQUIVALENT, INTRAMUSCULAR FORM WOULD BE --
7 WOULD HAVE A FASTER ONSET OF ACTION, IT WOULD TAKE EFFECT
8 FASTER.
9 Q. AS TO THE ATIVAN, HOW IS IT ADMINISTERED?
10 A. THE ATIVAN WAS ALSO ADMINISTERED INTRAMUSCULARLY.
11 Q. IS IT NORMALLY ADMINISTERED IN THAT FASHION?
12 MR. STIRBA: I'M GOING TO OBJECT, YOUR HONOR,
13 BEYOND THE SCOPE OF WHAT HE'S ALREADY REPRESENTED --
14 MR. WILSON: I'LL STRIKE THE QUESTION, YOUR HONOR.
15 WITHDRAW THE QUESTION, I SHOULD SAY.
16 Q. (BY MR. WILSON) ON THE 13TH OF JANUARY THERE WAS THE
17 ADMINISTRATION OF MORPHINE, WAS THERE NOT?
18 A. YES.
19 Q. DID YOU SEE -- FIRST OF ALL, WAS THERE ANY OTHER DRUG
20 ADMINISTERED IN AT THAT TIME?
21 A. ON THE 13TH?
22 Q. YES.
23 A. ATIVAN AGAIN.
24 Q. FROM YOUR REVIEW -- WELL, LET'S JUST TAKE THE 13TH AND
25 THE 14TH. THERE WAS ALSO THE ADMINISTRATION OF MORPHINE ON
2809
1 THOSE DATES; IS THAT CORRECT?
2 A. YES.
3 Q. AND THERE WAS THE ADDITION OF ATIVAN ON THOSE DATES?
4 A. YES.
5 Q. DID YOU SEE ANYTHING IN THE MEDICAL RECORDS OR REVIEW OF
6 THOSE RECORDS WHICH WOULD CAUSE YOU TO FORM AN OPINION AS TO
7 THE APPROPRIATENESS OF THE USE OF MORPHINE AS TO THIS
8 PARTICULAR PATIENT ON THOSE DATES?
9 A. YES. I DO NOT BELIEVE MORPHINE WAS NECESSARY OR
10 INDICATED.
11 Q. OKAY. IS THERE ADDITIONAL RISKS ASSOCIATED WITH THE USE
12 OF MORPHINE WITH ATIVAN?
13 A. YES. THEY ARE BOTH CENTRAL NERVOUS SYSTEM DEPRESSANTS.
14 ATIVAN WOULD INCREASE THE EFFECT OF MORPHINE IN DEPRESSING A
15 PERSON, INCLUDING THEIR BREATHING.
16 MR. WILSON: YOUR HONOR, I HAVE ABOUT TEN MORE
17 MINUTES I THINK THAT I WOULD BE WITH THIS WITNESS, I DON'T
18 KNOW WHETHER THE COURT WANTS TO --
19 THE COURT: THAT'S FINE. I THINK WE STARTED AT
20 9:45 SO THAT WOULD JUST TAKE US TO AN HOUR SO IF YOU WANT TO
21 CONTINUE.
22 MR. WILSON: THANK YOU, YOUR HONOR.
23 Q. (BY MR. WILSON) DOCTOR, I WANT YOU TO GO BACK NOW AND
24 REFER TO ELLEN ANDERSON.
25 BASED UPON YOUR REVIEW OF THE MEDICAL RECORDS, YOUR
2810
1 EXPERIENCE AND TRAINING, DID YOU FORM AN OPINION, SIR, AS TO
2 A REASONABLE DEGREE OF MEDICAL CERTAINTY AS TO THE CAUSE OF
3 DEATH AS IT RELATES TO ELLEN ANDERSON?
4 MR. STIRBA: I'M GOING TO OBJECT, CUMULATIVE, YOUR
5 HONOR.
6 THE COURT: OVERRULED.
7 THE WITNESS: YES, I DID.
8 Q. (BY MR. WILSON) WHAT IS THAT OPINION, SIR?
9 A. I BELIEVE THAT THE MORPHINE WAS RESPONSIBLE FOR HER
10 DEATH.
11 Q. WERE THERE ANY CONTRIBUTING FACTORS AS IT RELATES TO
12 THAT OPINION ON ELLEN ANDERSON?
13 A. YES. SHE HAD BEEN RECEIVING OTHER MEDICATIONS PRIOR TO
14 ADMISSION THAT COULD HAVE STILL BEEN PRESENT IN HER BODY AS
15 WELL AS A CHEST X-RAY WHICH SHOWED A SUGGESTION OF A
16 POSSIBLE PNEUMONIA.
17 Q. IN RESPECT TO THE PATIENT JUDITH LARSEN, BASED UPON YOUR
18 REVIEW OF THE RECORDS, YOUR EXPERIENCE AND TRAINING, CAN YOU
19 TELL US, DOCTOR, WHETHER YOU FORMED AN OPINION BASED TO A
20 REASONABLE DEGREE OF MEDICAL CERTAINTY AS TO THE CAUSE OF
21 DEATH OF JUDITH LARSEN?
22 A. YES.
23 Q. WOULD YOU STATE THAT OPINION, PLEASE.
24 A. I BELIEVE IT WAS MORPHINE INTOXICATION.
25 Q. CAN YOU TELL US WHETHER OR NOT THERE WERE ANY
2811
1 CONTRIBUTING FACTORS TO HER CAUSE OF DEATH?
2 A. YES, THERE WERE. SHE HAD HAD SOME BLEEDING FROM HER
3 DIGESTIVE TRACT AND LOST BLOOD --
4 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT. THIS
5 IS BEYOND THE SCOPE OF ANY REPORT AND ANY REPRESENTATION IN
6 THE REPORT.
7 THE COURT: OKAY. LET'S -- WE'LL REFER TO THAT ON
8 THE BREAK.
9 Q. (BY MR. WILSON) IN RESPECT TO THE PATIENT MARY CRANE,
10 CAN YOU TELL US, BASED UPON YOUR EXPERIENCE, YOUR TRAINING
11 AND YOUR REVIEW OF THE MEDICAL RECORDS OF MARY CRANE WHETHER
12 OR NOT YOU FORMED AN OPINION AS TO THE CAUSE OF DEATH OF
13 MARY CRANE?
14 A. YES.
15 Q. WOULD YOU STATE THAT OPINION, PLEASE.
16 A. I BELIEVE THAT THE COMBINATION OF MORPHINE AND THE OTHER
17 PSYCHOTROPIC MEDICATIONS THAT SHE WAS PRESCRIBED CONTRIBUTED
18 DIRECTLY TO HER DEATH.
19 Q. OKAY. WHEN YOU SAY, "THE OTHER PSYCHOTROPIC
20 MEDICATIONS," DO YOU INCLUDE WITH THAT THE DURAGESIC PATCH?
21 A. YES.
22 Q. IN RESPECT TO THE PATIENT LYDIA SMITH, AGAIN, BASED UPON
23 YOUR EXPERIENCE, YOUR TRAINING AND YOUR REVIEW OF THE
24 MEDICAL RECORDS, CAN YOU TELL US WHETHER OR NOT YOU FORMED
25 AN OPINION TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AS TO
2812
1 THE CAUSE OF DEATH OF LYDIA SMITH?
2 A. YES.
3 Q. WHAT IS THAT, SIR?
4 A. AGAIN, THE MORPHINE IN COMBINATION WITH THE OTHER
5 MEDICATIONS THAT SHE HAD BEEN PRESCRIBED.
6 Q. OKAY. AS TO THE PATIENT ENNIS ALLDREDGE, CAN YOU TELL
7 US, DOCTOR, BASED UPON YOUR TRAINING, YOUR EDUCATION, YOUR
8 EXPERTISE AND YOUR REVIEW OF THE MEDICAL RECORDS OF ENNIS
9 ALLDREDGE, DID YOU FORM AN OPINION TO A REASONABLE DEGREE OF
10 MEDICAL CERTAINTY AS TO THE CAUSE OF DEATH OF ENNIS
11 ALLDREDGE?
12 A. YES.
13 Q. AND WOULD YOU STATE YOUR OPINION, SIR?
14 A. I, AGAIN, BELIEVE THAT IT WAS THE MORPHINE THAT CAUSED
15 HIS DEATH.
16 Q. WERE THERE ANY CONTRIBUTING FACTORS?
17 MR. STIRBA: I'M GOING TO OBJECT, YOUR HONOR. SAME
18 OBJECTION I HAD BEFORE WITH RESPECT TO --
19 THE COURT: WE CAN DISCUSS THAT AT BREAK.
20 MR. WILSON: I DIDN'T HEAR THE COURT, YOUR HONOR.
21 THE COURT: I SAID WE CAN DISCUSS -- WE'LL TAKE A
22 BREAK AND WE CAN DISCUSS THAT THEN.
23 MR. WILSON: I DON'T THINK I HAVE ANY FURTHER
24 QUESTIONS -- JUST A MINUTE, YOUR HONOR, IF I MIGHT.
25 I HAVE NO FURTHER QUESTIONS AT THIS TIME, YOUR HONOR.
2813
1 THE COURT: LADIES AND GENTLEMEN, WHY DON'T WE TAKE
2 OUR BREAK NOW AND IT MAY BE THAT WE MAY GO A LITTLE PAST
3 NOON TO GET DONE WITH WHATEVER WITNESSES WE HAVE THIS
4 MORNING BUT AS I MENTIONED TO YOU BEFORE THAT YOU WOULDN'T
5 NECESSARILY BE HERE THIS AFTERNOON. LET'S COME BACK -- WHY
6 DON'T WE COME BACK AT FIVE MINUTES TO 11.
7 DURING THIS TIME THAT YOU ARE OUT, IT'S YOUR DUTY NOT
8 TO CONVERSE AMONG YOURSELVES OR TO CONVERSE WITH OR ALLOW
9 YOURSELVES TO BE ADDRESSED BY ANY OTHER PERSON ON THE
10 SUBJECT OF THIS TRIAL. IT'S YOUR DUTY NOT TO FORM OR
11 EXPRESS AN OPINION UNTIL THE CASE IS FINALLY SUBMITTED TO
12 YOU, AND WE'LL BE BACK, THEN, AT FIVE MINUTES TO 11.
13 (WHEREUPON THE JURY WAS EXCUSED.)
14 THE COURT: ALL RIGHT. YOU MAY BE SEATED. THE
15 RECORD WILL REFLECT THAT THE JURY HAS LEFT.
16 MR. WILSON: YOUR HONOR, I'M JUST GOING TO WITHDRAW
17 THOSE QUESTIONS. I WON'T PURSUE THOSE QUESTIONS.
18 THE COURT: OKAY. THAT WAS ON JUDITH LARSEN AND
19 ENNIS ALLDREDGE. OKAY. HOW MUCH TIME DO YOU THINK YOU'LL
20 BE WITH THIS WITNESS?
21 MR. STIRBA: HOPEFULLY I'LL BE DONE BY NOON, YOUR
22 HONOR.
23 THE COURT: AND THEN, MR. WILSON, DID YOU SAY YOU
24 HAD THE OFFICER AGAIN?
25 MR. WILSON: I DO. IT SHOULD BE BRIEF TESTIMONY,
2814
1 YOUR HONOR.
2 THE COURT: WELL, WHAT I WOULD LIKE TO DO IS EVEN
3 IF WE GO PAST NOON, LET'S GET DONE WITH WHATEVER AND THEN
4 ARE THERE ANY OTHER WITNESSES BESIDES THE OFFICER?
5 MR. WILSON: NOT THAT WE ANTICIPATE RIGHT NOW. WE
6 DO HAVE A MOTION THAT WE NEED TO FILE WITH THE COURT AT THIS
7 TIME. I'M SURE THAT DELIGHTS THE COURT.
8 THE COURT: WELL, YOU KNOW, THE MORE THE MERRIER,
9 THE MORE THE MERRIER. I MEAN, I DON'T HAVE ANYTHING TO DO
10 AT LUNCH TODAY SO. HAVE YOU PROVIDED THAT TO THE DEFENDANT?
11 MR. STIRBA: NO.
12 THE COURT: OKAY. AND THEN ASSUMING WE GET DONE
13 WITH THE TESTIMONY AND THE STATE'S CASE, THEN, WHAT DO WE DO
14 REGARDING -- DO YOU HAVE A WRITTEN MOTION THAT YOU ARE GOING
15 TO GIVE TO THE STATE?
16 MR. STIRBA: YEAH, IT LOOKS LIKE WE MIGHT HAVE TO
17 RESOLVE THIS ONE FIRST, YOUR HONOR.
18 THE COURT: OKAY.
19 MR. STIRBA: BECAUSE I GUESS IT RELATES TO A
20 RECONSIDERATION OF SOME TESTIMONY AND SO WHEN THE STATE
21 RESTS, WE'LL BE PREPARED TO GO.
22 THE COURT: ALL RIGHT. LET'S COME BACK AT FIVE TO
23 11.
24 (A BRIEF RECESS WAS TAKEN.)
25 THE COURT: PLEASE BE SEATED. THE RECORD WILL
2815
1 REFLECT THAT THE JURY IS PRESENT. ARE THERE ANY
2 QUESTIONS -- ANY FURTHER QUESTIONS, MR. WILSON, YOU HAVE OF
3 THIS WITNESS?
4 MR. WILSON: THE STATE HAS NO FURTHER QUESTIONS AT
5 THIS TIME, YOUR HONOR.
6 THE COURT: MR. STIRBA?
7 MR. STIRBA: THANK YOU, YOUR HONOR.
8 CROSS-EXAMINATION
9 BY MR. STIRBA:
10 Q. GOOD MORNING, DOCTOR. YOU WOULD AGREE, WOULD YOU NOT,
11 THAT IN THE PRESCRIBING OF PSYCHOTROPIC MEDICATIONS THE
12 PHYSICIAN HAS TO MAKE SOME CLINICAL JUDGMENTS AS TO THE
13 PROPRIETY OF THE DOSING LEVELS?
14 A. YES.
15 Q. IN FACT, WHAT YOU ARE TRYING TO DO, OF COURSE, IS TO
16 DOSE SO THAT YOU GET AN EFFICACIOUS OR GOOD RESULT; ISN'T
17 THAT TRUE?
18 A. YES, TRUE.
19 Q. AND CERTAINLY THAT'S WHY YOU TESTIFIED WHEN ASKED ABOUT
20 MAXIMUM LEVELS OF MORPHINE OR DOSING LEVELS ON A DAILY
21 BASIS, YOU COULDN'T ANSWER THAT QUESTION BECAUSE, ONCE
22 AGAIN, YOU WOULD HAVE TO BE PRESENTED WITH A REAL PATIENT IN
23 REAL PAIN TO DETERMINE WHAT WOULD BE THE APPROPRIATE DOSE,
24 TRUE?
25 A. IT SHOULD BE INDIVIDUALIZED, YES.
2816
1 Q. AND THAT'S BASICALLY HOW PHYSICIANS FUNCTION; THAT IS,
2 THEY PROVIDE INDIVIDUAL CARE AND THEY PRESCRIBE BASED UPON
3 AN INDIVIDUAL BASIS, CORRECT? IS THAT TRUE?
4 A. YES, WITHIN CERTAIN PARAMETERS. THERE ARE STILL GENERAL
5 GUIDELINES OF WHAT'S ACCEPTABLE AND WHAT IS NOT.
6 Q. SURE. AND YOU TESTIFIED THAT THERE ARE SOME GUIDELINES
7 BUT YOU TESTIFIED THAT YOU CONSIDER THEM, YOU PERSONALLY
8 CONSIDER THEM GUIDELINES AND BASICALLY YOU ARE ATTEMPTING TO
9 TREAT THE PATIENT, TRUE?
10 A. YES.
11 Q. AND YOU DOSE ACCORDINGLY, CORRECT?
12 A. YES.
13 Q. AND, IN FACT, FOR EXAMPLE, WITH RESPECT TO PATIENT
14 JUDITH LARSEN, YOU BELIEVE, DO YOU NOT, THAT THE PRESCRIBING
15 OF PSYCHOTROPIC MEDICATIONS TO HER WAS, IN FACT,
16 CHALLENGING?
17 A. YES.
18 Q. AND, IN FACT, IT IS YOUR OPINION THAT IN HER PARTICULAR
19 CASE THE PRESCRIPTION OF PSYCHOTROPIC MEDICATIONS WAS, TO
20 USE YOUR WORD, QUITE GENEROUS DOSES, BUT AN EFFORT WAS MADE
21 TO ADJUST THEM ACCORDING TO THE PATIENT'S NEEDS, TRUE?
22 A. THAT APPEARED TO BE CORRECT DURING PART OF THAT
23 HOSPITALIZATION, YES.
24 Q. IN FACT, THAT IS WHAT YOU STATED IN YOUR REPORT, AN
25 EFFORT WAS MADE TO ADJUST THEM ACCORDING TO THE PATIENT'S
2817
1 NEEDS, TRUE?
2 A. YES.
3 Q. AND SIMILARLY WITH RESPECT TO MS. ANDERSON WHO YOU
4 TESTIFIED THAT YOU REVIEWED HER RECORDS; IS THAT RIGHT?
5 A. YES.
6 Q. AND YOU TESTIFIED THAT YOU DID NOT FIND ANY SIGNS OR
7 SYMPTOMS OF PAIN, TRUE?
8 A. NO. IN ELLEN ANDERSON THERE WAS A POSSIBILITY OF SOME
9 PAIN.
10 Q. AND WHEN YOU SAY A POSSIBILITY, SIR, YOU ARE AWARE
11 CERTAINLY THAT SHE WAS PRESCRIBED MEDICATION FOR CHEST PAIN?
12 A. YES.
13 Q. YOU ARE AWARE THAT SHE WAS PRESCRIBED A MEDICATION
14 LORTAB WHICH IS A PAIN MEDICATION?
15 A. YES.
16 Q. YOU ARE ALSO AWARE, ARE YOU NOT, THAT THE NURSE AND THE
17 7:30 DOSE OF MORPHINE CHARTED SPECIFICALLY THAT THE PATIENT;
18 THAT IS, ELLEN ANDERSON, APPEARED TO BE IN SEVERE PAIN,
19 TRUE?
20 A. THAT WAS THE 7:30 DOSE --
21 Q. YES.
22 A. -- THE NIGHT THAT SHE CAME IN. IF I CAN JUST DOUBLE
23 CHECK THAT. YES.
24 Q. AND IT'S TRUE, IS IT NOT, THAT ALSO YOU DIDN'T DESCRIBE
25 TOTALLY WHAT THE NURSE SAID ON THE ENTRY ON 3:15 WHICH I
2818
1 BELIEVE YOU TESTIFIED YOU THOUGHT INDICATED PAIN, CORRECT?
2 A. ON WHICH, AT 0315 THE NEXT MORNING?
3 Q. YES. YES. YOU THOUGHT THAT WAS INDICATING PAIN, TRUE?
4 A. A POSSIBILITY.
5 Q. A POSSIBILITY OF PAIN. ARE YOU AWARE, SIR, THAT THAT
6 NURSE TESTIFIED IN THIS COURTROOM THAT SHE TOLD DR. WEITZEL
7 IN A TELEPHONE CONVERSATION THAT DAY THAT SHE THOUGHT THE
8 PATIENT WAS IN SEVERE PAIN?
9 A. I'M NOT AWARE OF THAT.
10 Q. YOU ARE NOT AWARE OF THAT?
11 A. NO, SIR.
12 Q. ASSUME THAT TO BE TRUE, SIR, GIVEN THAT FACT, ARE YOU
13 STILL TELLING THE JURY BASED UPON THE RECORD YOU HAVE IN
14 FRONT OF YOU AND WHAT THAT NURSE HAS ALREADY TESTIFIED TO TO
15 THIS JURY THAT YOU THINK IT WAS JUST A POSSIBILITY OF PAIN
16 AT 3:15?
17 A. YES, I WOULD STILL SAY THAT.
18 Q. AND, IN FACT, SHE CHARTS, DOES SHE NOT, AT 3:15 THAT THE
19 PATIENT WAS TRASHING ARMS AND ATTEMPTING TO THROW BODY,
20 PATIENT MOANING AND SCREAMING, CORRECT?
21 A. YES.
22 Q. IS THERE -- SIR, GIVEN WHAT I'VE JUST TOLD YOU, IS THERE
23 ANY DOUBT IN YOUR MIND AS YOU SIT HERE THAT THAT PATIENT WAS
24 NOT, IN FACT, IN PAIN?
25 A. YES, THERE IS SOME DOUBT.
2819
1 Q. IS THERE ANY DOUBT IN YOUR MIND AS YOU SIT HERE THAT
2 NURSE SCHOLL DID NOT PERCEIVE AND ASSESS THAT THAT PATIENT
3 WAS, IN FACT, IN PAIN?
4 A. IS THERE ANY DOUBT THAT SHE DID NOT?
5 Q. NO. THAT SHE DID, IN FACT, PERCEIVE AND ASSESS THAT
6 ELLEN ANDERSON WAS IN PAIN?
7 MR. WILSON: OBJECTION, YOUR HONOR, CALLS FOR
8 SPECULATION.
9 MR. STIRBA: HE'S ALREADY TESTIFIED ABOUT IT, YOUR
10 HONOR.
11 THE WITNESS: I DON'T KNOW --
12 THE COURT: CAN YOU ANSWER THE QUESTION?
13 THE WITNESS: I DON'T KNOW THAT SHE -- THAT SHE
14 TOLD DR. WEITZEL ANYTHING. YOU ARE TELLING ME THAT SHE DID.
15 Q. (BY MR. STIRBA) NO, I'M NOT TELLING YOU ANYTHING.
16 THE QUESTION I ASKED YOU WAS: IS THERE ANY DOUBT IN
17 YOUR MIND, BASED UPON THE RECORD YOU HAVE IN FRONT OF YOU,
18 AND ASSUMING THAT SHE HAS TOLD DR. WEITZEL AND TESTIFIED
19 THAT THAT PATIENT WAS IN SEVERE PAIN AT 3:15 A.M. IN THE
20 MORNING, IS THERE ANY DOUBT IN YOUR MIND THAT SHE, IN FACT,
21 PERCEIVED THAT ELLEN ANDERSON WAS IN PAIN AND ASSESSED PAIN?
22 A. WELL, THE NURSE MAY HAVE PERCEIVED THAT OR MADE THAT
23 ASSESSMENT. I STILL HAVE DOUBT THAT SHE WAS ACTUALLY IN
24 PAIN BECAUSE THOSE SAME BEHAVIORS WERE PRESENT BEFORE AND
25 HAD BEEN ATTRIBUTED TO HER ANXIETY, NOT TO PAIN.
2820
1 Q. BUT MY QUESTION IS NOT WHETHER YOU THINK SHE WAS IN
2 PAIN. MY QUESTION IS DO YOU HAVE ANY DOUBT THAT THE NURSE
3 THOUGHT SHE WAS IN PAIN, YES OR NO?
4 MR. WILSON: AGAIN, OBJECTION, YOUR HONOR, IT CALLS
5 FOR THE STATE OF MIND OF THE NURSE AND I DON'T THINK HE CAN
6 SPECULATE TO THAT.
7 MR. STIRBA: HE'S REVIEWED THE RECORDS --
8 THE COURT: OVERRULED, OVERRULED.
9 THE WITNESS: I -- YOU ARE THE ONE TELLING ME THAT
10 SHE THOUGHT THE PATIENT WAS IN PAIN. I DON'T SEE THAT
11 CHARTED AT 0315, ANYTHING ABOUT PAIN AND SO --
12 Q. (BY MR. STIRBA) OKAY. SO BASED UPON THE QUESTION I'VE
13 ASKED YOU AND BASED UPON THE ASSUMPTION I'VE ASKED YOU TO
14 MAKE, ARE YOU TELLING THE JURY, YES, YOU HAVE A DOUBT THAT
15 THAT NURSE PERCEIVED AND ASSESSED PAIN?
16 A. WELL, ONCE AGAIN, I -- YOU ARE ASKING ME TO DIVINE WHAT
17 THE NURSE DIDN'T WRITE DOWN IN THE CHART AND I HAVE A DOUBT
18 THAT THE PATIENT WAS HAVING PAIN.
19 Q. OKAY. BUT YOU, SIR, THOUGH HAVE JUST REVIEWED THE
20 RECORDS, RIGHT?
21 A. THAT'S CORRECT.
22 Q. AND YOU, SIR, COME INTO THIS COURTROOM AND YOU'VE MADE
23 ALL KINDS OF INTERPRETATIONS ABOUT WHAT'S IN THOSE RECORDS,
24 TRUE?
25 A. YES, YES.
2821
1 Q. SO FIRST OF ALL, YOU HAVE A RECORD IN FRONT OF YOU WHERE
2 THE NURSE IS SAYING THAT THE PATIENT IS THRASHING, MOANING
3 AND SCREAMING, CORRECT?
4 A. MOANING AND SCREAMING AND ATTEMPTING TO THROW HER BODY.
5 Q. RIGHT. THAT'S WHAT SHE'S CHARTED, TRUE, YOU HAVE THAT
6 IN FRONT OF YOU, TRUE?
7 A. YES.
8 Q. AND THEN I SAID, ASSUMING ALSO THAT SHE HAS TESTIFIED
9 AND TOLD DR. WEITZEL THAT SHE SAID THE PATIENT WAS IN SEVERE
10 PAIN, ASSUME THAT, SIR, YOU ARE AN EXPERT, CAN YOU ASSUME
11 THAT?
12 A. OKAY.
13 Q. NOW, GIVEN THOSE FACTS, I WANT YOU TO TELL THE JURY, IS
14 THERE ANY DOUBT IN YOUR MIND THAT THAT NURSE AT THAT TIME
15 THOUGHT THAT MS. ANDERSON WAS, IN FACT, IN PAIN?
16 A. WITH THOSE ASSUMPTIONS, NO.
17 Q. AND IT'S SIMILARLY TRUE, DO YOU HAVE ANY DOUBT IN YOUR
18 MIND BASED UPON WHAT IS CHARTED AT 7:30 OR 2000 HOURS WHERE
19 THE NURSE REPORTS THAT MS. ANDERSON WAS, IN FACT, CRYING AND
20 SCREAMING AND THEN SHE PUTS MORPHINE 10 MILLIGRAMS
21 INTRAMUSCULAR AT 2000 FOR SEVERE PAIN, PATIENT BECOMES RIGID
22 AND SCREAMS WHEN TOUCHED. IS THERE ANY DOUBT IN YOUR MIND
23 THAT THAT NURSE THOUGHT AND ASSESSED THAT MS. ANDERSON WAS,
24 IN FACT, IN PAIN?
25 MR. WILSON: SAME OBJECTION, YOUR HONOR.
2822
1 THE COURT: OVERRULED.
2 THE WITNESS: THE NURSE CHARTED SEVERE PAIN.
3 Q. (BY MR. STIRBA) THAT WASN'T MY QUESTION.
4 IS THERE ANY DOUBT IN YOUR MIND THAT THAT NURSE THOUGHT
5 AND ASSESSED THAT MS. ANDERSON WAS IN PAIN?
6 A. NO, AT THAT TIME.
7 Q. AND, IN FACT, ISN'T IT TRUE THAT YOU WROTE A REPORT AND
8 YOUR OPINION IN THAT REPORT WAS, THERE IS NOT ENOUGH
9 INFORMATION IN THIS CASE TO DRAW ANY CONCLUSIONS ABOUT THE
10 EFFECT OF MORPHINE ON THE PATIENT'S DEMISE?
11 A. I WROTE THAT, YES.
12 Q. NOW, DOCTOR, YOU'VE TESTIFIED A LITTLE BIT ABOUT THESE
13 CHARTS AND FIRST OF ALL, YOU TESTIFIED A LITTLE BIT ABOUT
14 THIS P.D.R. REFERENCE, CORRECT?
15 A. YES.
16 Q. NOW, THIS P.D.R. REFERENCE HAS -- IT SAYS ORAL 24 HOUR
17 MORPHINE MILLIGRAMS A DAY, TRUE?
18 A. YES.
19 Q. AND IT'S TRUE, IS IT NOT, THAT THE MORPHINE GIVEN TO THE
20 PATIENTS IN THIS CASE WAS NOT GIVEN ORALLY, CORRECT?
21 A. THAT'S CORRECT.
22 Q. IT'S ALSO TRUE, IS IT NOT, SIR, THAT THERE'S A
23 DIFFERENCE BETWEEN CALCULATIONS WHEN MORPHINE IS GIVEN
24 ORALLY VERSUS WHEN MORPHINE IS IN FACT GIVEN
25 INTRAMUSCULARLY; ISN'T THAT TRUE?
2823
1 A. THAT'S TRUE.
2 Q. AND, IN FACT, IF YOU LOOK AT THIS CHART, THERE'S NOTHING
3 TO INDICATE ON THIS CHART THE CALCULATIONS FOR A MORPHINE
4 COMPUTATION BASED UPON AN INTRAMUSCULAR INJECTION, IS THERE?
5 A. IT DOESN'T SAY INTRAMUSCULAR, NO.
6 Q. AND SINCE WE ARE DEALING WITH, IN FACT, INTRAMUSCULAR
7 INJECTIONS IN THIS CASE, ISN'T IT TRUE THAT THIS CHART IS
8 ESSENTIALLY MISLEADING?
9 MR. WILSON: OBJECTION, YOUR HONOR, CALLS FOR A
10 LEGAL CONCLUSION.
11 THE COURT: OVERRULED.
12 THE WITNESS: MISLEADING IN -- I MEAN, THE CHART IS
13 TAKEN OUT OF THE P.D.R.
14 Q. (BY MR. STIRBA) YEAH, THE CHART IS TAKEN OUT OF THE
15 P.D.R., SIR, BUT THERE ARE DIFFERENCES BETWEEN COMPUTATIONS
16 WHEN YOU ARE LOOKING AT AN ORAL DOSE OF MORPHINE AND AN
17 INTRAMUSCULAR DOSE OF MORPHINE; ISN'T THAT TRUE?
18 A. YES.
19 Q. IN FACT, IT CAN BE A DIFFERENCE OF SIX TIMES LESS WHEN
20 YOU ARE DEALING WITH AN INTRAMUSCULAR INJECTION THAN WHEN
21 YOU ARE DEALING WITH AN ORAL CALCULATION; ISN'T THAT TRUE?
22 A. I DON'T -- NO, THAT'S NOT TRUE.
23 Q. YOU DON'T BELIEVE THAT TO BE TRUE?
24 A. NO, NOT IN MY EXPERIENCE AND NOT IN MY REVIEW OF OPIATE
25 NARCOTICS.
2824
1 Q. AND IT'S CERTAINLY TRUE, IS IT NOT, THAT IT IS A
2 SIGNIFICANTLY DIFFERENT CALCULATION THAT IS MADE IN TERMS OF
3 THE COMPARISON OF AN INTRAMUSCULAR INJECTION OF MORPHINE IN
4 CALCULATING OUT A DURAGESIC DOSE; ISN'T THAT TRUE?
5 A. THAT WOULD BE DIFFERENT, YES.
6 Q. AND, IN FACT, IT NOT ONLY WOULD BE DIFFERENT, IT WOULD
7 BE LESS, WOULDN'T IT?
8 A. LESS MORPHINE?
9 Q. YES.
10 A. THAT'S CORRECT.
11 Q. AND IT'S ALSO TRUE, IS IT NOT -- YOU TESTIFIED ABOUT THE
12 DURAGESIC PATCH. YOU ARE AWARE THAT DR. DIENHART WHEN HE
13 DID HIS CONSULT CONCERNING MARY CRANE THAT HE, IN FACT,
14 APPROVED EXPRESSLY IN HIS CONSULT NOTE THE USE OF THE
15 DURAGESIC PATCH?
16 A. YES, HE AGREED WITH ITS USE FOR PAIN CONTROL.
17 Q. AND NOT ONLY DID HE AGREE WITH THE USE FOR PAIN CONTROL,
18 HE, IN FACT, AGREED WITH THE USE OF A 50 MICROGRAM PATCH;
19 ISN'T THAT TRUE?
20 A. AT LEAST INITIALLY.
21 Q. AND SIMILARLY, SIR, WHEN WE TALK ABOUT THESE CHARTS,
22 WHICH YOU'VE TESTIFIED ABOUT, IT'S TRUE, IS IT NOT, THAT THE
23 CHART HAS ESSENTIALLY A REPRESENTATION OF WHAT IS AN INITIAL
24 DAILY DOSE, CORRECT?
25 A. YES.
2825
1 Q. IN OTHER WORDS, THE JURY -- AND YOU ARE A PSYCHIATRIST
2 AND YOU CERTAINLY UNDERSTAND THAT, THAT FOR EXAMPLE, YOU
3 MIGHT HAVE A DOSE OF SERZONE AND THERE ARE DIFFERENT
4 GUIDELINES FOR THE INITIAL DOSING LEVEL OF SERZONE AND WHAT
5 MAY BE APPROPRIATE TWO WEEKS OR THREE WEEKS DOWN THE ROAD;
6 ISN'T THAT TRUE?
7 A. THAT'S CORRECT.
8 Q. AND IT'S ALSO TRUE, IS IT NOT, THAT THE DIFFERENCES
9 BETWEEN AN INITIAL DAILY DOSE, FOR EXAMPLE, SERZONE, AND
10 WHAT MIGHT BE APPROPRIATE TWO OR THREE WEEKS DOWN THE ROAD
11 CAN BE QUITE MATERIAL IN TERMS OF DOSING LEVELS; ISN'T THAT
12 TRUE?
13 A. AT WHICH DOSING LEVEL ARE YOU REFERRING TO?
14 Q. SERZONE, FOR EXAMPLE.
15 A. OKAY.
16 Q. YOU MIGHT HAVE AS INITIAL STARTING DOSE -- FOR EXAMPLE,
17 OVER HERE YOU MIGHT HAVE 50 MILLIGRAMS. IT MAY BE TRUE
18 THREE WEEKS LATER THAT AN APPROPRIATE DOSE MIGHT BE
19 200 MILLIGRAMS; ISN'T THAT CORRECT?
20 A. THAT COULD BE, YES.
21 Q. AND IT'S ALSO TRUE, IS IT NOT, THAT THERE ISN'T REALLY,
22 ESPECIALLY BASED UPON AN INDIVIDUALIZED CARE AND TREATMENT
23 OF A PATIENT, THERE ISN'T SUCH A THING AS A MAXIMUM DAILY
24 DOSE, IS THERE?
25 A. OF WHICH DRUG?
2826
1 Q. OF MORPHINE.
2 A. OF MORPHINE? ON AN INDIVIDUAL BASIS, THERE WOULD BE A
3 MAXIMUM. THAT WOULD BE REACHED WHEN THE PERSON IS HAVING
4 INTOLERABLE OR DANGEROUS SIDE EFFECTS OR COMPLICATIONS.
5 Q. OKAY. BUT IT ISN'T GOING TO BE SOMETHING THAT YOU CAN
6 QUANTIFY BY, FOR EXAMPLE, SAYING 15 MILLIGRAMS?
7 A. THAT THAT WOULD BE A MAXIMUM?
8 Q. RIGHT.
9 A. NO.
10 Q. OR 60 MILLIGRAMS?
11 A. AS I THINK I SAID BEFORE, THAT DOSE HAS TO BE
12 INDIVIDUALIZED AND TEMPERED AGAINST THE RESPONSE OF THE
13 PATIENT TO THE PREVIOUS DOSES.
14 Q. AND ALSO THE EFFECT OF THE DRUG WHETHER IT'S ACHIEVING A
15 POSITIVE RESULT?
16 A. AND IT'S EFFECT OF IT, ABSOLUTELY.
17 Q. SO, IN OTHER WORDS, A PATIENT WHO IS IN EXTREME AND
18 EXTRAORDINARY PAIN YOU MIGHT HAVE ONE DOSING LEVEL THAT IS
19 TOTALLY APPROPRIATE WHICH WOULD NOT BE APPROPRIATE FOR SOME
20 PATIENT WHO IS PERHAPS IN LESS PAIN; ISN'T THAT TRUE?
21 A. IN GENERAL, YES.
22 Q. AND SIMILARLY WITH RESPECT TO THE PSYCHOTROPIC DRUGS,
23 THEY HAVE TO BE INDIVIDUALLY TAILORED TO MEET A PATIENT'S
24 NEEDS, CORRECT?
25 A. YES.
2827
1 Q. AND IT'S ALSO TRUE THAT THERE ARE ONLY GUIDELINES WITH
2 RESPECT TO WHAT MIGHT BE A USUAL OR CUSTOMARY MAINTENANCE
3 DOSE; ISN'T THAT CORRECT?
4 A. YES.
5 Q. AND THOSE USUAL AND CUSTOMARY MAINTENANCE DOSES, IN
6 FACT, IN MANY INSTANCES WOULD BE DIFFERENT THAN WHAT IS
7 REPRESENTED ON THAT CHART WHICH IS THE INITIAL STARTING
8 DOSE, TRUE?
9 A. SUBSEQUENT, MAINTENANCE DOSES --
10 Q. YEAH, SURE.
11 A. -- WOULD BE DIFFERENT FROM THE STARTING DOSE.
12 Q. SURE. IN OTHER WORDS, JUST SO CLEAR WE'RE CLEAR,
13 DOCTOR, THERE'S NO DIFFERENCE TO ATTEMPT TO DELINEATE THAT
14 OR DISTINGUISH THAT ON THE CHART. WE'RE JUST TALKING ABOUT
15 INITIAL DAILY DOSES; IS THAT TRUE?
16 A. YES, THOSE ARE....
17 Q. AND, IN FACT, WOULDN'T IT AFFECT YOU AS A PSYCHIATRIST
18 IN TERMS OF YOUR PRESCRIBING PRACTICES -- LET'S SAY YOU HAVE
19 ONE OF THESE PATIENTS THAT I BELIEVE IT WAS JUDITH LARSEN
20 WHO CAME ON ADMISSION HAVING ALREADY HAD TRAZODONE
21 PRESCRIBED FOR HER. AND ASSUMING THAT TO BE TRUE, SIR,
22 WOULDN'T YOUR PRESCRIBING PERHAPS REGIMEN ON ADMISSION BE
23 DIFFERENT BECAUSE SHE HAD ALREADY HAD A PRESCRIPTION AND
24 ALREADY WAS ON TRAZODONE ON ADMISSION?
25 A. YES, DEPENDING ON HOW SHE HAD RESPONDED TO THAT OR HOW
2828
1 WELL SHE WAS TOLERATING IT.
2 Q. SURE. IN OTHER WORDS, THAT'S A RELEVANT FACTOR IN TERMS
3 OF WHAT YOU ARE GOING TO ACTUALLY START HER ON WHEN SHE
4 ACTUALLY IS ADMITTED TO THE HOSPITAL; ISN'T THAT CORRECT?
5 A. THAT'S CORRECT.
6 Q. AND THE SAME WOULD BE TRUE, FOR EXAMPLE, OF HALDOL?
7 A. IF A PERSON WAS ALREADY ON THE HALDOL?
8 Q. YES.
9 A. IN REGULAR DAILY DOSES?
10 Q. YES.
11 A. THAT WOULD NEED TO BE TAKEN INTO ACCOUNT, YES.
12 Q. AND THE SAME WOULD BE TRUE WITH RISPERDAL?
13 A. YES.
14 Q. AND THE SAME ESSENTIALLY WOULD BE TRUE WITH ALL THE
15 DRUGS THAT YOU'VE TESTIFIED CONCERNING THE MEDICAL HISTORY
16 IS, IN FACT, IMPORTANT; ISN'T THAT CORRECT?
17 A. IT WOULD NO LONGER BE A STARTING DOSE. IT WOULD BE MORE
18 IN THE CATEGORY OF A MAINTENANCE DOSE.
19 Q. A MAINTENANCE DOSE, THAT'S RIGHT.
20 NOW, IN TERMS OF THE MEDICAL CIRCUMSTANCES THAT YOU
21 TESTIFIED CONCERNING SOME OF THESE PATIENTS ON ADMISSION,
22 IT'S TRUE THAT WHEN MARY CRANE JUST -- BEFORE I ASK YOU THAT
23 QUESTION.
24 IF I UNDERSTOOD YOUR DIRECT TESTIMONY, YOU'VE REVIEWED
25 THE DAVIS HOSPITAL RECORDS; IS THAT RIGHT?
2829
1 A. YES, SIR.
2 Q. YOU HAVE NOT REVIEWED THE MEDICAL HISTORY RECORDS, FOR
3 EXAMPLE, WITH RESPECT TO EACH ONE OF THESE PATIENTS; IS THAT
4 RIGHT?
5 A. PREVIOUS TO THEIR ADMISSION TO THE HOSPITAL?
6 Q. YES.
7 A. I DID NOT HAVE THOSE RECORDS TO REVIEW.
8 Q. THEY WERE NOT PROVIDED TO YOU?
9 A. NO.
10 Q. SO, FOR EXAMPLE, LYDIA SMITH IS ONE OF THE PATIENTS AND
11 YOU HAVE NOT REVIEWED HER ADMISSION TO LAKEVIEW HOSPITAL IN
12 NOVEMBER 18 OF 1995, HAVE YOU?
13 A. NO.
14 Q. AND YOU ARE NOT AWARE, THEN, THAT SHE SUFFERED A STROKE
15 AND WAS HOSPITALIZED ON THAT OCCASION, ARE YOU?
16 A. I WAS AWARE OF THAT, YES.
17 Q. ARE YOU AWARE ALSO THAT SHE ALMOST DIED IN THAT
18 PARTICULAR ADMISSION?
19 A. I DID NOT KNOW THAT, NO.
20 Q. AND IT'S TRUE, IS IT NOT, THAT FOR PURPOSES OF RENDERING
21 ANY KIND OF MEDICAL OPINION, IT IS CERTAINLY HELPFUL TO HAVE
22 MEDICAL HISTORY CONCERNING A PATIENT?
23 A. THAT DEPENDS ON THE QUESTION IN AN OPINION.
24 Q. WELL, IN THIS PARTICULAR CASE, WOULDN'T IT HAVE BEEN
25 HELPFUL TO YOU TO HAVE SOME MEDICAL HISTORY RECORDS TO
2830
1 REVIEW FOR PURPOSES OF RENDERING YOUR OPINION IN THIS CASE?
2 A. I DON'T BELIEVE THAT WOULD HAVE CHANGED MY CONCLUSIONS,
3 NO.
4 Q. WELL, I DON'T KNOW WHETHER IT WOULD CHANGE YOUR
5 CONCLUSIONS, SIR, BUT IT CERTAINLY WOULD CHANGE YOUR
6 TESTIMONY PERHAPS ABOUT THESE PSYCHOTROPIC MEDICATIONS;
7 ISN'T THAT CORRECT?
8 A. IN WHAT WAY, SIR?
9 Q. WOULDN'T IT HAVE CHANGED IF YOU KNEW THAT THEY WERE
10 ALREADY ON A PARTICULAR DOSING REGIMEN COMING IN? YOU JUST
11 TESTIFIED THAT WOULD NOT BE A STARTING DOSE, THAT WOULD
12 CHANGE YOUR OPINION, TRUE?
13 A. THEIR MEDICATION HISTORY WOULD BE HELPFUL, YES.
14 Q. AND WHAT IF YOU KNEW, DOCTOR, THAT SOMEBODY, FOR
15 EXAMPLE, LIKE LYDIA SMITH WAS SO SIGNIFICANTLY COMPROMISED
16 BY CEREBRAL VASCULAR DISEASE SUCH THAT SHE ALMOST DIED FIVE
17 WEEKS BEFORE SHE WAS ADMITTED TO THE HOSPITAL, ARE YOU
18 TELLING US THAT WOULDN'T HAVE ANY IMPACT ON YOUR OPINION AS
19 TO HER CAUSE OF DEATH?
20 A. I WOULDN'T SAY NOT ANY IMPACT. BUT CERTAINLY PEOPLE
21 HAVE NEAR -- NEAR FATAL EVENTS IN HOSPITALS AND THEN RECOVER
22 FROM THEM.
23 Q. WELL, ONE OF THE THINGS YOU SAID IN YOUR REPORT, FOR
24 EXAMPLE, ABOUT ELLEN ANDERSON, NOT ONLY YOU COULDN'T COME TO
25 A CONCLUSION AS TO WHAT ROLE IF ANY MORPHINE PLAYED IN HER
2831
1 CAUSE OF DEATH, BUT YOU WENT ON TO INDICATE BECAUSE YOU
2 WEREN'T REALLY AWARE OF WHAT THE HISTORY WAS WITH RESPECT TO
3 A PULMONARY PROBLEM WHICH SHOWED UP ON HER X-RAY, ISN'T THAT
4 TRUE?
5 A. THAT WAS TRUE AT THAT POINT IN TIME, YES.
6 Q. AND WOULDN'T IT HAVE BEEN HELPFUL TO YOU TO RESOLVE THAT
7 PROBLEM TO HAVE REVIEWED, FOR EXAMPLE, DR. WILDING'S RECORDS
8 TO KNOW PRECISELY WHAT HER MEDICAL HISTORY WAS AND WHETHER,
9 IN FACT, SHE RECENTLY HAD BEEN ASSESSED AND DIAGNOSED AS
10 HAVING PNEUMONIA?
11 A. THAT INFORMATION WOULD HAVE BEEN TAKEN INTO ACCOUNT IF I
12 HAD IT, YES.
13 Q. BECAUSE CERTAINLY WHAT YOU WERE ASKING IN YOUR REPORT IS
14 YOU WANTED TO KNOW WHETHER THAT PNEUMONIA WHICH WAS
15 DIAGNOSED BY THE CHEST X-RAY ON ADMISSION PRE-EXISTED HER
16 ADMISSION, TRUE?
17 A. THAT WAS ONE OF THE QUESTIONS.
18 Q. AND THE WAY YOU ANSWERED THAT QUESTION IS TO GO AND GET
19 PREEXISTING RECORDS; ISN'T THAT ALSO TRUE?
20 A. TO ANSWER THAT PARTICULAR QUESTION. I MIGHT ADD,
21 THOUGH, THAT THE X-RAY WAS A SUGGESTION OF A BILATERAL
22 INFILTRATIVE PROCESS AND PNEUMONIA WAS NOT THE ONLY
23 POSSIBILITY.
24 Q. NOW, FOR EXAMPLE, MARY CRANE THERE WAS A -- AN
25 ASSESSMENT DONE BY DR. DIENHART AND HE INDICATED THE
2832
1 FOLLOWING WITH RESPECT TO HER ADMISSION, I'M NOT SO SURE YOU
2 TESTIFIED TO THIS, I WANT TO MAKE SURE IT'S CLEAR. HE
3 TESTIFIED, FIRST OF ALL, THAT SHE WAS ANEMIC, IT'S MED-236
4 IF YOU WANT TO REVIEW IT WITH ME.
5 A. THIS IS AT ADMISSION?
6 Q. YES.
7 A. ON MARY CRANE?
8 Q. YES.
9 A. IT SAYS ANEMIA, MILD.
10 Q. ANEMIA MILD. HYPONATREMIA, DID I READ THAT CORRECTLY?
11 A. YES.
12 Q. HYPOKALEMIA?
13 A. YES.
14 Q. MILD METABOLIC ALKALOSIS, TRUE?
15 A. YES.
16 Q. HYPOALBUMINEMIA?
17 A. HYPOALBUMINEMIA, YES.
18 Q. THANK YOU. LOW SERUM IRON MAY REPRESENT ANEMIA OF
19 CHRONIC DISEASE, CORRECT?
20 A. YES.
21 Q. HISTORY, RIGHT CEREBROVASCULAR ACCIDENT, RIGHT THALAMIC
22 REGION, 11/90, WITH RESIDUAL LEFT HEMIPARALYSIS, DID I READ
23 THAT CORRECTLY?
24 A. YES, SIR.
25 Q. EIGHT: CHRONIC LOW BACK PAIN SECONDARY TO DISK DISEASE?
2833
1 A. YES.
2 Q. NINE: HYPERTENSION?
3 A. YES.
4 Q. TEN: HISTORY OF PEPTIC ULCER DISEASE, STATUS
5 POST-PARTIAL GAS --
6 A. GASTRECTOMY VAGOTOMY.
7 Q. THANK YOU.
8 ELEVEN: RIGHT SHOULDER DENSITY UNCLEAR ETIOLOGY,
9 CORRECT?
10 A. YES.
11 Q. AND, FINALLY, CARDIAC SILHOUETTE ENLARGEMENT BY PORTABLE
12 AP CHEST X-RAY, POSSIBLY SECONDARY TO HYPERTENSIVE
13 CARDIOVASCULAR DISEASE, UNKNOWN, LEFT VENTRICULAR FUNCTION,
14 DID I READ THAT CORRECTLY?
15 A. YES, SIR.
16 Q. AND THOSE ARE THE IMPRESSIONS THAT DR. DIENHART HAD OF
17 HER MEDICAL HISTORY AND MEDICAL CONDITION ON ADMISSION;
18 ISN'T THAT TRUE?
19 A. YES.
20 Q. AND IT'S TRUE, IS IT NOT, THAT ON THE 7TH OF JANUARY IN
21 THE AFTERNOON BOTH A NURSE COZZENS AND DR. DIENHART AND DR.
22 WEITZEL BECAME CONCERNED ABOUT HER CONDITION; ISN'T THAT
23 CORRECT?
24 A. YES.
25 Q. AND, IN FACT, IF YOU LOOK AT WHAT DR. DIENHART DID, HE
2834
1 ORDERED UP A CHEST X-RAY, A BLOOD TEST AND AN OXYGEN
2 SATURATION TEST; ISN'T THAT TRUE?
3 A. ON THE 7TH?
4 Q. IN THE AFTERNOON OF THE 7TH.
5 A. YES, HE DID.
6 Q. AND IT'S TRUE, IS IT NOT, THAT HE NOTES POSSIBLE SEPSIS,
7 CORRECT?
8 A. YES.
9 Q. AND, IN FACT, AT 3:10 IN THE AFTERNOON HE SAYS IN HIS
10 NOTE, I SUSPECT PATIENT MAY DIE SOON, TRUE?
11 A. YOU ARE REFERRING TO A NOTE THAT'S IN THE PHYSICIAN'S
12 ORDERS?
13 Q. YES.
14 A. YES, SIR.
15 Q. NOW, BASED UPON YOUR REVIEW OF THE RECORDS, SPECIFICALLY
16 WHAT THE NURSE CHARTED ON THAT DAY AND THAT AFTERNOON, WHAT
17 DR. DIENHART INDICATED IN HIS NOTE AND WHAT OTHER
18 INFORMATION YOU HAVE, IS THERE ANY DOUBT IN YOUR MIND AS YOU
19 SIT HERE TODAY THAT, IN FACT, MARY CRANE WAS DYING AS OF
20 3:10 IN THE AFTERNOON ON JANUARY 7TH?
21 A. GIVEN THE FACT THAT SHE DID DIE LATER THAT DAY, YES.
22 Q. SO YOUR TESTIMONY IS, YES, YOU THINK IN YOUR OPINION SHE
23 WAS DYING AT THAT POINT IN TIME; IS THAT CORRECT?
24 A. DYING IS A RELATIVE TERM. IF YOU MEAN THE RISK OF DEATH
25 WAS IMMINENT, YES.
2835
1 Q. YES. OKAY. I APPRECIATE THAT.
2 AND IT'S ALSO TRUE, IS IT NOT, THAT HER RISK OF DEATH
3 WAS IMMINENT AT THAT POINT IN TIME -- IT'S TRUE, IS IT NOT,
4 THAT THE FIRST MORPHINE INJECTION WAS GIVEN TO HER AT 2000
5 HOURS ON THE 7TH, CORRECT?
6 A. I BELIEVE THAT TO BE CORRECT.
7 Q. IN OTHER WORDS, ALMOST FIVE HOURS LATER FROM THE TIME
8 WHEN YOUR OPINION IS THAT HER RISK OF DEATH WAS IMMINENT,
9 TRUE?
10 A. YES.
11 Q. JUDITH LARSEN, SIMILARLY THERE WAS A CONSULTATION DONE
12 BY DR. DIENHART, AND YOU MIGHT WANT TO TURN TO THAT AND
13 FOLLOW ALONG. AND HE REPRESENTS HER PAST MEDICAL HISTORY AS
14 BEING REMARKABLE FOR CEREBROVASCULAR ACCIDENTS, ESSENTIALLY
15 STROKES, TRUE?
16 A. YES, SIR.
17 Q. DIAGNOSIS OF ISCHEMIC HEART DISEASE, HISTORY OF ANGINA,
18 THAT'S HEART PAIN, CORRECT?
19 A. YES.
20 Q. HYPOTHYROIDISM, STATUS POST-THYROIDECTOMY, HISTORY OF --
21 I'M NOT GOING TO TOUCH IT, WHAT DOES IT SAY?
22 A. KIDNEY STONES.
23 Q. OKAY.
24 A. NEPHROLITHIASIS.
25 Q. THANK YOU.
2836
1 AND HISTORY OF HERNIA WITH GASTROESOPHAGEAL REFLUX
2 DISEASE, DID I READ THAT CORRECTLY?
3 A. YES, SIR.
4 Q. AND HE GOES ON TO INDICATE THE MEDICATIONS THAT SHE WAS
5 ON ON ADMISSION, IN OTHER WORDS BEFORE SHE EVER GOT TO THE
6 HOSPITAL, SHE WAS RECEIVING KLONOPIN, TRUE?
7 A. YES.
8 Q. TRAZODONE?
9 A. YES.
10 Q. TRUE? ATIVAN TRUE?
11 A. YES. THE ATIVAN WAS ORDERED AS NEEDED. I DON'T -- I
12 DON'T KNOW HOW MUCH SHE HAD RECEIVED.
13 Q. SURE. IT'S JUST CHARTED THERE AS A MEDICATION THAT SHE
14 APPARENTLY EITHER WAS RECEIVING OR WAS RECEIVING ON A P.R.N.
15 BASIS ON ADMISSION, CORRECT?
16 A. OR WAS ORDERED FOR HER, CORRECT.
17 Q. AND IT'S ALSO TRUE THAT THERE'S ANOTHER MEDICATION WHICH
18 IS A SEDATING MEDICATION THAT SHE WAS ON ON ADMISSION, OR IN
19 OTHER WORDS WAS ORDERED FOR HER, XANAX, DID YOU SEE THAT IN
20 THE RECORDS?
21 A. YES, I HAD SEEN THAT.
22 Q. NOW, IT'S TRUE, IS IT NOT, THAT JUDITH LARSEN STARTED TO
23 HAVE A SEIZURE AND, IN FACT, HAD A SEIZURE EVENT ON THE 26TH
24 OF DECEMBER OF 1995?
25 A. YES.
2837
1 Q. AND IT'S TRUE, IS IT NOT, THAT THAT SEIZURE EVENT
2 OCCURRED APPROXIMATELY IN THE EARLY HOURS OF THE MORNING OF
3 THE 26TH, CORRECT?
4 A. YES.
5 Q. AND IT'S TRUE THAT SHE RECEIVED, AS YOU DESCRIBED IT,
6 SOME SMALL DOSES OF MORPHINE ON THE 25TH, CORRECT?
7 A. YES.
8 Q. AND, IN FACT, THE NURSE CHARTED THAT THOSE SMALL DOSES
9 OF MORPHINE ESSENTIALLY MADE HER ALERT, IN OTHER WORDS SHE
10 WAS ALERT THE WHOLE DAY; ISN'T THAT RIGHT?
11 A. THAT'S CORRECT.
12 Q. AND IT'S TRUE, IS IT NOT, SHE RECEIVED ANOTHER SMALL
13 DOSE OF MORPHINE ON THE 26TH OF DECEMBER AND THAT WAS FOR
14 PAIN AS INDICATED IN THE NURSING NOTE, TRUE?
15 A. IT DOESN'T SAY PAIN. IT SAYS --
16 Q. IT SAYS DISCOMFORT, YES.
17 A. IT SAYS APPEARS TO BE IN SOME DISCOMFORT.
18 Q. THANK YOU. I THINK YOU ARE CORRECT ON THAT.
19 AND THEN SHE LATER ON NOTES ABOUT FOUR OR FIVE HOURS
20 LATER THAT THE PATIENT APPEARED MORE COMFORTABLE AS A RESULT
21 OF THE MORPHINE SHE WAS GIVEN ON THE 26TH, ISN'T THAT
22 CORRECT?
23 A. YES. AND SHE ALSO NOTES SHORTLY AFTER THE INJECTION
24 THAT SHE WAS UNRESPONSIVE EVEN TO DEEP PAIN.
25 Q. WELL, LET'S JUST READ THE NOTE BECAUSE I WANT TO MAKE
2838
1 SURE THAT WE'RE ON THE SAME PAGE, IT WAS ON THE 26TH AND
2 DOESN'T THE NURSE SAY APPEARED COMPLAINT OF MOANING, THAT'S
3 WHAT TRIGGERED THE APPEARS TO BE IN DISCOMFORT. AND THEN
4 SHE GOES ON TO SAY, PATIENT HAS APPEARED COMFORTABLE SINCE
5 RECEIVING MORPHINE, DOESN'T THE NURSE SAY THAT?
6 A. YES, SHE DOES.
7 Q. AND, IN FACT, SIR, ISN'T IT TRUE -- AND SURE, YOU CAN
8 PLAY THIS SORT OF AN ANALYSIS. YOU CAN SORT OF PICK A DAY
9 HERE AND PICK A DAY THERE AND PICK A DAY HERE AND TRY TO
10 SAY, OKAY, WELL, THERE'S LETHARGY AND THERE'S LETHARGY AND
11 THERE'S THIS. BUT ISN'T IT TRUE THAT THESE PATIENTS, ALL OF
12 THEM THEY HAD EBBS AND FLOWS IN THEIR BEHAVIOR AT THE
13 HOSPITAL?
14 A. ARE TALKING ABOUT BEHAVIOR OR ALERTNESS?
15 Q. BEHAVIOR AND/OR ALERTNESS?
16 A. THAT FLUCTUATED, YES.
17 Q. AND IT'S TRUE, IS IT NOT, IN YOUR CARE OF ELDERLY
18 PATIENTS, ESPECIALLY THOSE WHO ARE SEVERELY DEMENTED, THAT
19 THEIR MEDICAL CONDITIONS AND THEIR PSYCHOLOGICAL CONDITIONS
20 CAN CHANGE ESSENTIALLY FROM MINUTE TO MINUTE; ISN'T THAT
21 TRUE?
22 A. AT LEAST PHYSICALLY THEY ARE MUCH MORE FRAGILE, YES.
23 Q. IN OTHER WORDS, IT CAN CERTAINLY CHANGE HOUR TO HOUR,
24 WOULD THAT BE YOUR EXPERIENCE?
25 A. THEIR MEDICAL CONDITION?
2839
1 Q. YEAH.
2 A. YES.
3 Q. AND, IN FACT, THAT'S SORT OF REFLECTED AS YOU READ ALL
4 OF THE NURSES' NOTES, YOU'LL HAVE ONE SHIFT, FOR EXAMPLE,
5 YOU MIGHT HAVE THE NIGHT SHIFT OR THE 7 TO THREE 3 AND THE
6 NURSE WILL CHART PATIENT BITING, PATIENT KICKING, PATIENT
7 SCREAMING, AND THEN YOU'LL HAVE THE 3 TO 10 SHIFT AND THE
8 NURSE WILL CHART PATIENT SLEEPY, PATIENT SOMNOLENT, PATIENT
9 NOT AGITATED, THAT MIGHT BE A REPRESENTATIVE ENTRY; ISN'T
10 THAT TRUE?
11 A. YES, YES.
12 Q. AND SOMETIMES THAT MAY BE, IN FACT, RELATED TO
13 MEDICATION, CORRECT?
14 A. CORRECT.
15 Q. AND SOMETIMES IT MAY BE TOTALLY UNRELATED TO MEDICATION;
16 ISN'T THAT TRUE?
17 A. YES.
18 Q. FOR EXAMPLE, IN JUDITH LARSEN'S CASE NOW SHE WAS THERE
19 FOR ALMOST 30 DAYS, IT'S TRUE, IS IT NOT, THAT IF YOU COULD
20 LOOK OVER THOSE ENTIRE 30 DAYS, THERE WERE TIMES WHEN JUDITH
21 WAS DOING VERY WELL AND THERE ARE TIMES WHEN SHE WASN'T
22 DOING SO WELL; ISN'T THAT CORRECT?
23 A. THERE WERE TIMES SHE WAS DOING BETTER, YES.
24 Q. AND, IN FACT, ON THE 14TH OF DECEMBER OF 1995, DR.
25 WEITZEL CHARTS THAT SHE HAS MADE A MIRACULOUS RECOVERY;
2840
1 ISN'T THAT TRUE?
2 A. YES, SIR.
3 Q. IT'S TRUE, IS IT NOT, THAT THEREAFTER SHE'S EATING WELL,
4 CORRECT?
5 A. I DON'T RECALL THE REFERENCE TO EATING WELL.
6 Q. HER VITAL SIGNS ARE STABLE?
7 A. I DON'T RECALL THAT OFF THE TOP OF MY HEAD. DO YOU WANT
8 ME TO LOOK THAT UP?
9 Q. OKAY. BUT THE POINT I'M TRYING TO MAKE, SIR, YOU WOULD
10 AGREE THAT SHE HAD AN UP AND DOWN EXPERIENCE AT THE HOSPITAL
11 IN TERMS OF HER MEDICAL CONDITION, CORRECT?
12 A. I DON'T WANT TO CONFUSE MEDICAL CONDITION WITH HER LEVEL
13 OF ALERTNESS WHICH MAY BE MORE RELATED TO HER MEDICATION AND
14 HER PSYCHIATRIC CONDITION.
15 Q. WELL, LET'S JUST SORT OF TAKE A TIME OUT AND I JUST WANT
16 TO -- YOU SAID, FOR EXAMPLE, IN MARY CRANE YOU SAID ON THE
17 31ST IT LOOKED LIKE OF SEPT -- DECEMBER, RATHER, THAT SHE
18 LOOKED LIKE SHE WAS LETHARGIC. AND I'M GOING TO READ YOU A
19 NOTE ON THE 31ST FROM A NURSE AT 1625 HOURS AND BASICALLY
20 SHE DESCRIBES HER BEHAVIOR. SHE SAYS, PATIENT HAS BEEN UP
21 IN CHAIR THIS EVENING WITH SOME AGGRESSIVE BEHAVIOR TOWARDS
22 STAFF. AND THEN SHE GOES ON TO DESCRIBE SOME OTHER
23 CIRCUMSTANCES OF HER BEHAVIOR. AND THEN THE NURSE LATER ON
24 AFTER THAT AFTER SHE SAYS THAT, PATIENT WAS IN INCREASINGLY
25 AGITATED FROM 7 P.M. ON, SCREAMING, TRYING TO HIT, BITING,
2841
1 CNA.
2 NOW THAT WAS THE VERY THING YOU TOLD THIS JURY THAT DAY
3 THE 31ST ON MARY CRANE THAT SHE WAS LETHARGIC; IS THAT TRUE?
4 A. I'M SORRY. CAN YOU REPEAT THAT QUESTION FOR ME?
5 Q. YEAH. I JUST READ YOU SOME ENTRIES FROM 12/31/95 WHICH
6 IS THE DATE YOU TOLD THE JURY YOU POINT OUT SHE WAS
7 LETHARGIC AND I JUST READ YOU SOME NURSES' ENTRIES FROM 1625
8 AND FROM 1625 TO 2300, AND I'M READING FROM MED-00312.
9 A. OKAY.
10 Q. AND THEN AND -- AND THAT IS THE DAY THAT YOU SAID SHE
11 WAS LETHARGIC, CORRECT?
12 A. YES. THERE'S A NOTATION IN THE LOWER LEFT-HAND CORNER
13 THAT REFERS TO LEVEL OF CONSCIOUSNESS AND LETHARGIC WAS
14 CIRCLED.
15 Q. SURE. AND I'M NOT DISPUTING THAT, SIR. BUT, ONCE
16 AGAIN, DOESN'T IT HIGHLIGHT THE POINT THAT THE PATIENT'S
17 BEHAVIOR CHANGED ON SHIFT TO SHIFT AND SOMETIMES THEY MAY BE
18 LETHARGIC AND OTHER TIMES THEY WOULD BE QUITE COMBATIVE AND
19 AGITATED; ISN'T THAT CORRECT?
20 A. YES, SIR.
21 Q. AND YOU CAN BASICALLY GO THROUGHOUT THE NURSES' NOTES
22 AND PICK AND CHOOSE AS YOU WANT FROM DAY TO DAY, GENERALLY;
23 ISN'T THAT TRUE?
24 A. YOU CAN -- YOU COULD DO THAT OR YOU CAN LOOK AT TRENDS.
25 Q. PARDON ME?
2842
1 A. YOU COULD LOOK AT TRENDS.
2 Q. SURE. FOR EXAMPLE, ON 1/1 WHICH WAS ANOTHER DAY THAT
3 YOU SAID MARY CRANE WAS LETHARGIC ON DIRECT, IF I LOOK AT
4 1430 HOURS IT SAYS, PATIENT KICKING, BITING STAFF'S FINGERS
5 WHEN PLACING DENTURES IN MOUTH. PATIENT WOULD NOT STAY
6 PLACED IN WHEELCHAIR, KEPT SLIDING DOWN, GRABBED OTHER
7 PATIENT'S MEAL TRAYS AND IT CONTINUES. THAT'S MED-313, DID
8 I READ THAT CORRECTLY?
9 A. YES, SIR.
10 Q. NOW, GOING BACK TO JUDITH LARSEN, THERE WERE SOME
11 EVENTS, THOUGH, WERE THERE NOT, WHERE THERE WAS INDEED A
12 TREND IN HER MEDICAL CONDITION AND IT STARTED ON THE 26TH --
13 I'M SORRY. YES, ON THE 26TH WITH HER SEIZURE; ISN'T THAT
14 CORRECT?
15 A. THAT APPEARED TO BE A TURNING POINT, YES.
16 Q. YES. AND IT'S TRUE, IS IT NOT, THAT ON THE 29TH I
17 BELIEVE IN THE AFTERNOON THE 29TH OF DECEMBER IS WHEN SHE
18 STARTED TO, IN FACT, THROW UP REPEATEDLY; ISN'T THAT
19 CORRECT?
20 A. YES.
21 Q. AND, IN FACT, SHE WAS THROWING UP REPEATEDLY BLOOD;
22 ISN'T THAT TRUE?
23 A. IT WAS DESCRIBED AS COFFEE GROUNDS WHICH IS GENERALLY
24 ACCEPTED TO BE BLOOD.
25 Q. AND IT'S TRUE, IS IT NOT, THAT SOMEBODY IN HER CONDITION
2843
1 AT THAT TIME THROWING UP REPEATEDLY OVER A MORE THAN 12-HOUR
2 PERIOD BLOOD, WOULD INDEED BE SUFFERING PAIN, WOULDN'T SHE?
3 A. WELL, NO. VOMITING IS NOT NECESSARILY PAINFUL. IT'S
4 UNCOMFORTABLE.
5 Q. YOU THINK IT'S JUST UNCOMFORTABLE, SIR, THE CONDITIONS
6 THAT MS. LARSEN WAS EXPERIENCING ON THE 29TH AND 30TH?
7 A. IT'S NOT SOMETHING I WOULD TREAT WITH OPIATE NARCOTICS,
8 NO.
9 Q. THAT WASN'T MY QUESTION.
10 DO YOU FEEL THAT SHE WAS MERELY UNCOMFORTABLE WHEN SHE
11 HAD VOMITED FOR A PERIOD OF OVER 12 HOURS CONTINUOUSLY
12 ESSENTIALLY BLOOD FROM HER GUT?
13 A. I WOULDN'T SAY MERELY UNCOMFORTABLE, BUT I WOULDN'T
14 CHARACTERIZE IT AS PAIN THAT REQUIRES NARCOTICS.
15 Q. YOU -- WOULD YOU CALL IT SUFFERING?
16 A. OH, YES. BUT I MAKE A DISTINCTION BETWEEN THAT AND
17 PAIN.
18 Q. SOMETIMES SUFFERING CAN, IN FACT, BE PAIN; ISN'T THAT
19 TRUE?
20 A. THERE ARE DIFFERENT VARIETIES OF PAIN, YES.
21 Q. IN OTHER WORDS, SOMETIMES SUFFERING CAN, IN FACT, BE
22 PAIN; ISN'T THAT CORRECT?
23 A. YES.
24 Q. IT'S DIFFICULT, ISN'T IT, AS A CLINICIAN SOMETIMES TO
25 DETERMINE THE DIFFERENCES BETWEEN PAIN AND SUFFERING AND IN
2844
1 A PATIENT?
2 A. I'M SORRY, THE DIFFERENCE BETWEEN PAIN AND SUFFERING?
3 Q. SURE.
4 A. PAIN IS SUFFERING. THERE IS NO -- I MEAN, IN SOME SENSE
5 THERE IS NO DIFFERENCE.
6 Q. AND CERTAINLY AS A CLINICIAN IT WOULD BE ESPECIALLY, AS
7 YOU PUT IT, CHALLENGING WHEN YOU ARE DEALING WITH SOMEBODY
8 WHO ESSENTIALLY CAN'T COMMUNICATE EFFECTIVELY?
9 A. YES, SIR.
10 Q. BECAUSE TYPICALLY YOU RELY AS A PHYSICIAN ON WHAT PEOPLE
11 REPORT; IS THAT RIGHT?
12 A. YES, AS PART OF YOUR ASSESSMENT.
13 Q. AND CERTAINLY WHEN THE PATIENTS LIKE THESE PATIENTS WHO
14 WERE SEVERELY DEMENTED COULDN'T PROVIDE THAT KIND OF
15 INFORMATION, THAT CERTAINLY COMPLICATES THE JUDGMENT OF THE
16 PHYSICIAN; ISN'T THAT TRUE?
17 A. IT MAKES IT MORE CHALLENGING, YES.
18 Q. AND IT'S TRUE, IS IT NOT, THAT -- YOU AGREE, DO YOU NOT,
19 THAT BASED UPON YOUR REVIEW OF THE RECORDS THAT MS. LARSEN,
20 IN FACT, WAS HAVING A GASTROINTESTINAL BLEED AS OF THE TIME
21 THAT SHE STARTED THROWING UP OR BEFORE?
22 A. SOMETIME BEFORE THAT, YES.
23 Q. AND YOU CERTAINLY ARE AWARE, ARE YOU NOT, LOOKING AT THE
24 LAB STUDIES, THERE'S A WAY THAT YOU CAN ACTUALLY TEST
25 WHETHER THERE'S BLOOD LOSS, ARE YOU AWARE OF THAT?
2845
1 A. YES.
2 Q. AND THERE'S A PARTICULAR COMPONENT OF A BLOOD TEST, IT'S
3 CALLED A HEMATOCRIT?
4 A. YES.
5 Q. AND YOU READ THOSE HEMATOCRITS AND THAT CAN TELL A
6 PHYSICIAN WHETHER SOMEBODY HAS LOST VOLUME IN THEIR BLOOD;
7 ISN'T THAT TRUE?
8 A. IT'S A USEFUL APPROXIMATION, YES.
9 Q. AND THE TREND WITH MS. LARSEN AFTER HER SEIZURE AND
10 AFTER HER VOMITING STARTING ON THE 29TH WAS, IN FACT,
11 DOWNWARD, IS THAT YOUR TESTIMONY?
12 A. YES, SIR.
13 Q. AND IT'S TRUE, IS IT NOT, THAT THE MORPHINE THAT YOU'VE
14 TESTIFIED ABOUT DID NOT START UNTIL AFTER THE SEIZURE AND
15 AFTER SHE STOPPED VOMITING ON THE 30TH OF DECEMBER OF 1995;
16 ISN'T THAT CORRECT?
17 A. NO, SIR. SHE DID RECEIVE MORPHINE ON THE 25TH.
18 Q. I APPRECIATE THAT AND WE TALKED ABOUT THOSE. THE
19 MORPHINE, THOUGH, THE REGIMEN THAT HAD IN IT REPEATED DOSES
20 STARTED ON THE 30TH; ISN'T THAT CORRECT?
21 A. YES, SIR.
22 Q. AND, IN FACT, IT NOT ONLY WAS STARTED ON THE 30TH BUT
23 THERE ARE REFERENCES THROUGHOUT THAT DAY ABOUT DISCUSSIONS
24 WITH THE FAMILY; ISN'T THAT TRUE?
25 A. THERE WERE DISCUSSIONS. I WOULD HAVE TO DOUBLE CHECK TO
2846
1 SEE IF THAT WAS THE DAY THAT IT OCCURRED.
2 Q. SURE. YOU ARE AWARE, ARE YOU NOT, AS YOU REVIEWED THOSE
3 RECORDS THAT THERE ARE NUMEROUS REFERENCES IN THOSE RECORDS
4 WHERE A FAMILY MEMBER OR FAMILY MEMBERS HAS INDICATED TO A
5 NURSE OR SOMEBODY ELSE THAT THEY DID NOT WANT ANY
6 EXTRAORDINARY MEASURES TAKEN FOR PURPOSES OF TRYING TO
7 CONTINUE THE LIFE PROCESS, ARE YOU AWARE OF THAT?
8 A. YES.
9 Q. IN OTHER WORDS, I THINK THE FAMILY USES THE WORD JUST
10 KEEPING JUDITH COMFORTABLE, DO YOU REMEMBER REFERENCES IN
11 THE NURSING NOTES TO THAT?
12 A. I WOULD HAVE TO DOUBLE CHECK THAT TO BE ABSOLUTELY SURE
13 BUT THAT SOUNDS CONSISTENT WITH WHAT I REMEMBER.
14 Q. OKAY. NOW, YOU TESTIFIED ABOUT MR. ALLDREDGE AND MR.
15 ALLDREDGE IF YOU GO TO MED-007, HE ALSO -- THERE IS A REPORT
16 OF CONSULTATION DONE AND I DON'T BELIEVE WE COVERED
17 EVERYTHING, BUT THAT'S DR. DIENHART'S CONSULTATION NOTE ON
18 THE 10TH. AND HE INDICATED THAT ON ADMISSION MR. ALLDREDGE
19 HAD A HISTORY OF HYPERTENSION WITH CORONARY ARTERY DISEASE,
20 TRUE?
21 A. ARE YOU READING FROM HIS IMPRESSIONS?
22 Q. 007, MEDICAL HISTORY.
23 A. HISTORY OF THE HYPERTENSION, YES.
24 Q. WITH CORONARY ARTERY DISEASE, CORRECT?
25 A. WHAT I HAVE HERE IS ATHEROSCLEROTIC CARDIOVASCULAR
2847
1 DISEASE WHICH IS THE SAME THING.
2 Q. OKAY. THEN HE GOES STATUS POST CORONARY ARTERY BYPASS
3 GRAFTING IN 1992?
4 A. I HAVE '82.
5 Q. '82, THAT'S RIGHT, I APPRECIATE THAT.
6 OLD E.K.G. IN APRIL OF '95 SHOWED SINUS RHYTHM WITH
7 CHANGES CONSISTENT WITH L.V.H., NONSPECIFIC S.T. T-WAVE
8 CHANGES AND PROMINENT Q-WAVES IN LEADS TWO, THREE, A.V.F.
9 E.K.G. NOT SEEN BUT REPORTED E.K.G. IN OLD MEDICAL RECORD.
10 DID I READ THAT CORRECTLY?
11 A. YES, SIR.
12 Q. HE THEN GOES ON TO TALK ABOUT A RENAL INSUFFICIENCY,
13 TRUE?
14 A. YES.
15 Q. HE CHARTS A HISTORY OF GASTROESOPHAGEAL REFLUX, TRUE?
16 A. YES.
17 Q. AND THEN HE SAYS HISTORY OF MYCOSIS FUNGOIDES, TRUE?
18 A. YES.
19 Q. AND THAT'S THE -- IT'S A CANCER, CORRECT?
20 A. COULD BE CALLED A CANCER. IT'S A LYMPHOMA.
21 Q. IT'S A LYMPHOMA. AND HE HAS THERE AFTER THAT -- BY THE
22 WAY, YOU CAN DIE FROM MYCOSIS FUNGOIDES, CORRECT?
23 A. I'M NOT AN EXPERT IN THAT.
24 Q. AND HE SAYS, THOUGH, RIGHT AFTER THAT HE PUTS, END
25 STAGE, TRUE?
2848
1 A. YES, SIR.
2 Q. MEANING WE'RE AT THE STAGE IN THE PROGRESSION OF THE
3 DISEASE PROCESS WHERE ESSENTIALLY WE'RE AT THE END, CORRECT?
4 A. YEAH.
5 Q. AND GENERALLY END STAGE MEANS TERMINAL, TRUE?
6 A. MY UNDERSTANDING OF MYCOSIS FUNGOIDES IS THAT PEOPLE
7 LIVE FOR LONG PERIODS OF TIME WITH IT WITHOUT DYING FROM IT.
8 Q. OH, AND THAT MAY VERY WELL BE TRUE, BUT THAT'S NOT WHAT
9 HE'S SAYING HERE. HE'S SAYING HISTORY OF MYCOSIS FUNGOIDES
10 AND THEN HE PUTS END STAGE?
11 A. YES, HE DOES.
12 Q. IN OTHER WORDS, HE MAY HAVE LIVED QUITE A LONG PERIOD OF
13 TIME WITH THIS LYMPHOMA, BUT NOW DR. DIENHART IS INDICATING
14 WE'RE AT THE END, TRUE?
15 A. HE SAYS END STAGE, IS ALL I WOULD GATHER FROM THAT. END
16 STAGE CAN GO ON FOR A LONG TIME.
17 Q. SO YOU DON'T KNOW BASED UPON THAT NOTE?
18 A. NO.
19 Q. MEDICAL RECORD INDICATES PATIENT HAD TOTAL BODY
20 RADIATION AT ONE POINT, HISTORY OF HYPOTHYROIDISM, HISTORY
21 OF URINARY INCONTINENCE AND THAT IS WHAT HE STATES, CORRECT?
22 A. YES, SIR.
23 Q. NOW, IT'S TRUE THAT THERE WERE SOME MEDICATIONS THAT MR.
24 ALLDREDGE HAD ON ADMISSION, CORRECT?
25 A. YES.
2849
1 Q. AND, IN FACT, SOME OF THOSE MEDICATIONS WERE MEDICATIONS
2 WHICH WERE PSYCHOTROPIC IN NATURE, TRUE?
3 A. YES.
4 Q. IN FACT, ON ADMISSION BEFORE HE EVER GOT TO THE
5 HOSPITAL, MR. ALLDREDGE WAS RECEIVING OR HAD RECEIVED
6 ATIVAN, CORRECT?
7 A. YES.
8 Q. RISPERDAL, TRUE?
9 A. ACTUALLY, IT SAYS ATIVAN P.R.N., MEANING IT WAS POSSIBLE
10 THAT HE COULD HAVE RECEIVED IT.
11 Q. ORDERED FOR HIM? YOU DON'T KNOW?
12 A. NO, SIR.
13 Q. RISPERDAL, TRUE?
14 A. YES.
15 Q. BUSPAR, CORRECT?
16 A. I DON'T SEE BUSPAR. I SEE BUMEX WHICH IS NOT A
17 PSYCHIATRIC MEDICATION.
18 Q. NOW, IT'S TRUE, IS IT NOT, YOU HAVEN'T REVIEWED THE
19 NURSING HOME RECORDS CONCERNING MR. ALLDREDGE, CORRECT?
20 A. THAT'S TRUE.
21 Q. AND IT WOULD ALSO BE TRUE THAT DR. CUNNINGHAM, HIS
22 TREATING PHYSICIAN, YOU HAVE NOT LOOKED AT THOSE RECORDS
23 EITHER, CORRECT?
24 A. CORRECT.
25 Q. SO YOU WOULDN'T KNOW WHETHER OR NOT MR. ALLDREDGE WAS
2850
1 ALSO ON MELLARIL, WHICH IS A PSYCHOTROPIC MEDICATION,
2 CORRECT?
3 A. IN THE INTAKE FORM IT SAYS THAT HE HAD BEEN ON IT BUT IT
4 HAD BEEN DISCONTINUED.
5 Q. AND HALDOL?
6 A. YES, SIR.
7 Q. YOU ARE AWARE THAT HE WAS ON HALDOL ON ADMISSION,
8 CORRECT?
9 A. I'M ONLY AWARE THAT IT HAD BEEN DISCONTINUED SOME TIME
10 IN THE PAST.
11 Q. YOU ARE NOT AWARE THAT HE WAS, IN FACT, ON HALDOL ON
12 ADMISSION, IS THAT YOUR TESTIMONY?
13 A. THE RECORDS I HAVE DO NOT SAY HE WAS ON IT. IT SAYS
14 DISCONTINUED.
15 Q. OKAY. NOW, ALSO THERE'S AN INTERESTING ENTRY ON THE
16 REPORT OF CONSULTATION BY DR. DIENHART ON THE 10TH OF
17 JANUARY. IT'S DOWN AT THE BOTTOM WHERE HE STATES, GENERAL.
18 AND HE STATES, THE PATIENT IS AN ELDERLY MALE, SUPINE IN BED
19 WITH CHEYNE-STOKES RESPIRATION PATTERN WITH APNEA PERIODS
20 FROM 20 TO 40 SECONDS. DID I READ THAT CORRECTLY?
21 A. YES, SIR.
22 Q. AND THAT IS BEFORE -- THAT'S DR. DIENHART ASSESSING HIM,
23 THAT'S BEFORE ANY MORPHINE IS GIVEN TO MR. ALLDREDGE,
24 CORRECT?
25 A. CORRECT, IT'S AFTER HE RECEIVED THE HALDOL.
2851
1 Q. IN FACT, IT'S FOUR DAYS BEFORE ANY MORPHINE IS GIVEN TO
2 MR. ALLDREDGE, TRUE?
3 A. YES, SIR.
4 Q. NOW YOU JUST VOLUNTEERED -- YOU ARE ATTRIBUTING THAT TO
5 HALDOL THAT HE RECEIVED ON ADMISSION?
6 A. DR. DIENHART HIMSELF WRITES, HIS CURRENT OBSERVED
7 BREATHING PATTERN MAY BE SECONDARY TO HIS RECENT SIGNIFICANT
8 SEDATION.
9 Q. RIGHT. HE DOESN'T SAY IT WAS. HE SAYS MAYBE. HE
10 DOESN'T KNOW DOES HE, TRUE?
11 A. HE SAYS IT MAY BE.
12 Q. MAY BE. IT MEANS HE DOESN'T KNOW, CORRECT?
13 A. I ASSUME.
14 Q. AND IT'S TRUE, IS IT NOT, THAT YOU HAVEN'T REVIEWED DR.
15 CUNNINGHAM'S RECORDS TO KNOW PRECISELY WHAT MEDICATION WHICH
16 MAY INCLUDE HALDOL MR. ALLDREDGE WAS ON ON HIS ADMISSION;
17 ISN'T THAT CORRECT?
18 A. I DID NOT REVIEW DR. CUNNINGHAM'S RECORDS. I HAVE THE
19 LIST OF MEDICATIONS THAT WERE REPORTED TO THE INTAKE WORKER.
20 Q. NOW, IT'S ALSO TRUE, IS IT NOT, THAT THERE WAS AN E.K.G.
21 OR A SERIES OF E.K.G.'S DONE ON THE 10TH OF JANUARY
22 CONCERNING MR. ALLDREDGE, CORRECT?
23 A. YES.
24 Q. AND IN FACT, EVERY -- AND THOSE ARE TESTS TO SORT OF
25 TEST CERTAIN ELECTRICAL IMPULSES CONCERNING THE HEART, TRUE?
2852
1 A. YES.
2 Q. IT'S A WAY TO DIAGNOSE CERTAIN THINGS AND ABNORMALITIES
3 CONCERNING THE HEART, CORRECT?
4 A. IT'S ONE WAY, YES.
5 Q. AND IT'S TRUE, IS IT NOT, THAT EVERY ONE OF THE E.K.G.'S
6 THAT WAS GIVEN ON THE 10TH TO MR. ALLDREDGE SHOWED A HEART
7 ABNORMALITY, CORRECT?
8 A. YES, SIR.
9 Q. IN FACT, THE REPORTS OF THE E.K.G.'S INDICATED WHAT IS
10 CALLED AN INFERIOR INFARCT, CORRECT?
11 A. YES.
12 Q. AND AN INFARCT IS ACTUALLY WHERE THE HEART MUSCLE
13 EVIDENCES DAMAGE, TRUE?
14 A. YES, SIR.
15 Q. AND THE DAMAGE IS CAUSED BECAUSE THE MUSCLE DOESN'T GET
16 ADEQUATE BLOOD, SO ESSENTIALLY THE TISSUES DIE FROM LACK OF
17 OXYGEN, CORRECT?
18 A. COMMONLY CALLED A HEART ATTACK.
19 Q. COMMONLY CALLED A HEART ATTACK. AND ON THESE E.K.G.'S
20 THEY ARE TALKING ABOUT THIS INFERIOR INFARCT, AGE
21 UNDETERMINED, CORRECT?
22 A. CORRECT.
23 Q. IN OTHER WORDS, THEY DON'T KNOW WHAT HAPPENED OTHER THAN
24 THERE IS EVIDENCE OF AN INFARCT AND THEY DON'T KNOW WHAT IT
25 OCCURRED, CORRECT?
2853
1 A. THAT'S CORRECT.
2 Q. COULD VERY WELL HAVE OCCURRED THE DAY BEFORE HE WAS
3 ADMITTED; ISN'T THAT TRUE?
4 A. ACTUALLY, PROBABLY NOT BECAUSE THERE ARE DIFFERENT
5 E.K.G. CHANGES IN AN ACUTE EVENT THAN THERE ARE IN AN OLDER
6 EVENT.
7 Q. BUT THIS REPORT BASED UPON SOMEBODY WHO HAS EXPERTISE IN
8 RUNNING E.K.G.'S IT SAYS, IN FACT, INFERIOR INFARCT, AGE
9 UNDETERMINED, CORRECT?
10 A. YES, IT DOES.
11 Q. NOW, IN LYDIA SMITH'S CASE, YOU TALKED ABOUT TRENDS AND
12 YOU TALKED ABOUT YOU SEE CERTAIN TRENDS. IT'S TRUE, IS IT
13 NOT, THAT ANY TREND THAT YOU SEE WITH RESPECT TO LYDIA SMITH
14 IS THAT LYDIA SMITH WAS COMBATIVE, WAS FIGHTING, WAS
15 AGGRESSIVE, WAS BITING, WAS KICKING AND MANIFESTING
16 AGGRESSIVE BEHAVIOR THROUGHOUT HER STAY AT THE HOSPITAL
17 UNTIL ABOUT THE 5TH OR 6TH OF JANUARY OF 1995; ISN'T THAT
18 CORRECT?
19 A. INTERMITTENTLY, YES.
20 Q. AND, IN FACT, IT GOT TO THE POINT WHERE HER FAMILY WAS
21 CONCERNED ABOUT HER AGGRESSION SUCH THAT A NURSE NOTED THAT
22 THE FAMILY WAS CONCERNED ABOUT THE INABILITY TO CONTROL IT
23 BECAUSE THEY WANTED TO DISCHARGE HER TO A NURSING HOME AND
24 THEY WERE CONCERNED BECAUSE IT HADN'T BEEN CONTROLLED; ISN'T
25 THAT TRUE?
2854
1 A. I DON'T RECALL THE EXACT REFERENCE TO THAT.
2 Q. WELL, LET'S SEE IF I CAN FIND IT FOR YOU. IT WOULD BE
3 ON THE 28TH OF DECEMBER AND IT'S A SOCIAL WORK NOTE IN THE
4 PROGRESS NOTE SECTION AND THE SOCIAL WORKER STATES, FAMILY
5 VERBALIZED CONCERN REGARDING DISCHARGE PLANS. THEY
6 EMPHASIZE IMPORTANCE OF DECREASE IN PATIENT'S AGGRESSIVE
7 BEHAVIOR IF SHE IS TO BE ADMITTED TO ROCKY MOUNTAIN
8 BOUNTIFUL AFTER DISCHARGE. DO YOU SEE THAT?
9 A. YES, SIR.
10 Q. AND IT'S TRUE, IS IT NOT, THAT ON ADMISSION TO THE
11 HOSPITAL, IN OTHER WORDS, BEFORE SHE EVER GOT TO DAVIS
12 HOSPITAL, SHE ALSO WAS ON SOME PSYCHOTROPIC SEDATING
13 MEDICATIONS; ISN'T THAT CORRECT?
14 A. YES, SIR.
15 Q. IN FACT, SHE WAS ON HALDOL, TRUE?
16 A. YES, AT A VERY MUCH LOWER DOSE.
17 Q. OKAY. SHE WAS ON HALDOL, ISN'T THAT CORRECT?
18 A. YES.
19 Q. AND SHE WAS ALSO ON SERZONE?
20 A. YES.
21 Q. AND SERZONE YOU TESTIFIED YOU DON'T THINK IS
22 PARTICULARLY SEDATING?
23 A. IT'S NOT AS SEDATING AS TRAZODONE. IT'S STILL A VERY
24 SEDATING DRUG.
25 Q. THE FACT OF THE MATTER IS, IT ISN'T A VERY SEDATING
2855
1 DRUG; ISN'T THAT TRUE?
2 A. NOT IN MY EXPERIENCE, NO, SIR.
3 Q. SO YOU AGREE, DO YOU NOT, THAT ON THE 7TH OF JANUARY OF
4 1995 THAT IT'S CLEAR THAT LYDIA SMITH HAS STOPPED EATING?
5 A. YES.
6 Q. AND YOU ALSO AGREE THAT SHE HAS ESSENTIALLY NO KIDNEY
7 FUNCTION BECAUSE SHE HAS NO URINE OUTPUT?
8 A. THOSE TWO ARE NOT SYNONYMOUS. I WOULD JUST SAY SHE HAS
9 NO URINE.
10 Q. YOU AGREE THAT OCCURRED, CORRECT?
11 A. YES.
12 Q. AND WOULD YOU ALSO AGREE THAT GIVEN THE STAY IN THE
13 HOSPITAL, THOSE TWO EVENTS WERE DIFFERENT THAN PREVIOUSLY
14 WHAT HAD BEEN SEEN AND EXHIBITED BY HER UP UNTIL THOSE DAYS?
15 A. THAT THAT WAS DIFFERENT? YES.
16 Q. AND, IN FACT, THOSE WOULD BE THE KINDS OF THINGS WHEN
17 SOMEBODY WHO WOULD BE, I THINK SHE WAS 91 YEARS OLD, STOPS
18 EATING AND HAS NO URINE OUTPUT, THOSE ARE THINGS THAT WOULD
19 BE A MATERIAL MEDICAL CHANGE IN HER CONDITION, CORRECT?
20 A. YES.
21 Q. AND IT'S TRUE -- YOU TESTIFIED YOU HAVEN'T REVIEWED THE
22 HISTORICAL RECORDS, YOU DON'T KNOW ANYTHING ABOUT WHAT
23 HAPPENED IN HER STROKE EVENT AND HER HOSPITALIZATION AT
24 LAKEVIEW. DO YOU KNOW ANYTHING ABOUT HER HEART DISEASE?
25 A. THAT WOULD -- YES. THAT WAS MENTIONED DURING THE
2856
1 ADMISSION EVALUATION THAT SHE HAD AN AORTIC VALVE, THAT SHE
2 HAD ATRIAL FIBRILLATION WHICH IS AN IRREGULARITY OF THE
3 HEART RHYTHM, AND ON HER CHEST X-RAY SHE HAD A LARGE HEART.
4 Q. ARE YOU AWARE THAT NOT ONLY DID SHE HAVE THE VALVULAR
5 DISEASE, BUT SHE HAD CONGESTIVE HEART DISEASE?
6 A. YES.
7 Q. AND CORONARY ARTERY DISEASE?
8 A. I DIDN'T WRITE DOWN CORONARY ARTERY DISEASE. I WOULD
9 HAVE TO LOOK AT THAT EVALUATION. I WOULD ASSUME SO.
10 Q. AND IT'S TRUE, IS IT NOT THAT, THAT THE ATRIAL
11 FIBRILLATION THAT YOU ARE TALKING ABOUT WAS, ONCE AGAIN, ONE
12 OF THESE E.K.G.'S THAT WAS DONE WHILE SHE WAS IN THE
13 HOSPITAL, CORRECT?
14 A. YES.
15 Q. AND, IN FACT, AN ATRIAL FIBRILLATION CAN, IN FACT, BE A
16 TERMINAL EVENT, TRUE?
17 A. IT WOULD BE POSSIBLE.
18 Q. IN OTHER WORDS, AN ATRIAL FIBRILLATION IS AN ABNORMAL
19 ELECTRICAL FLUTTERING OF THE HEART, CORRECT?
20 A. THAT'S CORRECT.
21 Q. AND IT'S TRUE, IS IT NOT, THAT IF THAT ABNORMAL
22 ELECTRICAL FLUTTERING OF THE HEART, IT CAN VERY WELL LEAD TO
23 WHAT IS CALLED AN ARRHYTHMIA, CORRECT?
24 A. IT IS BY DEFINITION AN ARRHYTHMIA.
25 Q. AND AN ARRHYTHMIA CAN CERTAINLY BE A FATAL EVENT,
2857
1 CORRECT?
2 A. YES. ON THE OTHER HAND, A LOT OF PEOPLE HAVE ATRIAL
3 FIBRILLATION FOR YEARS AND YEARS AND DON'T HAVE ANY PROBLEMS
4 WITH IT.
5 Q. SURE. BUT THEY ARE NOT PEOPLE WHO HAVE CONGESTIVE HEART
6 FAILURE TO GO WITH IT, ARE THEY?
7 A. QUITE FREQUENTLY, YES.
8 Q. AND PEOPLE WITH VALVULAR DISEASE, TRUE?
9 A. IT'S OFTEN ASSOCIATED WITH VALVULAR DISEASE.
10 Q. OKAY. ARE YOU TELLING THIS JURY THAT BASED UPON WHAT
11 YOU'VE JUST SAID AND THE KNOWLEDGE THAT YOU HAD THAT SHE HAD
12 AN ATRIAL FIBRILLATION DIAGNOSED AND TESTED AT THE HOSPITAL,
13 YOU SAID YOU ASSUMED SHE HAS CORONARY ARTERY DISEASE, YOU
14 KNOW SHE HAS VALVULAR DISEASE AND YOU ALSO KNOW SHE HAS
15 CONGESTIVE HEART FAILURE DISEASE, ARE YOU TRYING TO TELL THE
16 JURY THAT SHE WAS MEDICALLY IN GOOD SHAPE WITH RESPECT TO
17 HER CARDIAC FUNCTIONING?
18 A. NO, I'M NOT SAYING THAT.
19 Q. SHE WAS SEVERELY COMPROMISED; ISN'T THAT TRUE?
20 A. I DON'T KNOW THAT I WOULD SAY HER HEART FUNCTION --
21 SHE'S COMPROMISED, YES. YES, I WOULD AGREE.
22 Q. AND WHY IS IT, SIR, THAT YOU WOULD HESITATE THAT GIVEN
23 HER AGE AND GIVEN THE CIRCUMSTANCES THAT YOU KNOW THAT
24 CARDIOLOGY-WISE, SHE ISN'T SEVERELY COMPROMISED?
25 A. I DON'T WANT TO SAY THAT SHE'S NOT SEVERELY COMPROMISED.
2858
1 Q. AND IT'S TRUE, IS IT NOT, THAT THE MORPHINE THAT WAS
2 GIVEN TO HER STARTED ON THE 7TH OF JANUARY OF 1995, CORRECT?
3 A. YES, SIR.
4 Q. AND IT WAS AFTER THE TIME WHEN THERE WAS OBSERVATIONS
5 MADE AS YOU'VE JUST TESTIFIED TO THAT SHE HAD STOPPED EATING
6 AND THERE WAS NO URINE OUTPUT; ISN'T THAT CORRECT?
7 A. YES.
8 Q. AND IT WAS AFTER THIS CHANGE WAS IDENTIFIED WHICH WAS A
9 MATERIAL CHANGE AND A DIFFERENT CHANGE THAN WHAT SHE HAD
10 SHOWN IN THE HOSPITAL PRIOR TO THAT DAY; ISN'T THAT TRUE?
11 A. THAT THE MORPHINE WAS STARTED? YES.
12 Q. DOCTOR, YOU HAVE BEEN RETAINED AS AN EXPERT IN THIS CASE
13 BY THE STATE; IS THAT RIGHT?
14 A. YES, SIR.
15 Q. DO YOU HAVE SOME TERMS FOR YOUR COMPENSATION?
16 A. YES.
17 Q. AND WHAT ARE THOSE TERMS?
18 A. $200 AN HOUR.
19 Q. OKAY.
20 MR. STIRBA: THANK YOU. THAT'S ALL I HAVE YOUR
21 HONOR.
22 THE COURT: MR. WILSON?
23 MR. WILSON: MAY WE APPROACH, YOUR HONOR?
24 (A DISCUSSION WAS HELD OFF THE RECORD.)
25 THE COURT: LADIES AND GENTLEMEN, WHAT WE'RE GOING
2859
1 TO DO IS JUST TAKE A 10 MINUTE BREAK AND CAN THE COURT
2 REPORTER TELL ME WHEN OUR OTHER COURT REPORTER IS COMING?
3 THEN WHAT I WOULD LIKE TO DO IT JUST TAKE A 10 MINUTE BREAK,
4 LET'S COME BACK AT 12:10. WHAT I WANT TO DO IS FINISH THE
5 WITNESSES THAT WE HAVE FOR THIS MORNING EVEN IF IT GOES PAST
6 NOON A LITTLE BIT. IT WILL BE BETTER TO GET THOSE DONE NOW
7 AND YOU COULD TAKE THE REST OF THE DAY OFF.
8 SO WHAT I'M GOING TO ASK YOU TO DO IS REMEMBER NOT TO
9 CONVERSE AMONG YOURSELVES OR WITH ANYONE ELSE REGARDING THE
10 SUBJECT OF THIS TRIAL. DO NOT FORM OR EXPRESS AN OPINION
11 UNTIL THE CASE IS FINALLY SUBMITTED TO YOU AND IF YOU'LL A
12 COME BACK AT TEN AFTER 12.
13 (A BRIEF RECESS WAS TAKEN.)
14 THE COURT: OKAY. PLEASE BE SEATED. THE RECORD
15 WILL REFLECT THAT COUNSEL, THE DEFENDANT AND THE JURY ARE
16 PRESENT. MR. WILSON?
17 MR. WILSON: THANK YOU, YOUR HONOR.
18 REDIRECT EXAMINATION
19 BY MR. WILSON:
20 Q. DOCTOR, ON CROSS-EXAMINATION YOU INDICATED IN REFERENCE
21 TO COUNSEL'S QUESTIONS ABOUT YOUR OPINION LETTER THAT YOUR
22 OPINION HAD CHANGED AS IT RELATED TO ELLEN ANDERSON?
23 MR. STIRBA: I'M GOING TO OBJECT.
24 MR. WILSON: YOUR HONOR, I THINK I HAVE AN
25 OPPORTUNITY TO ASK HIM A QUESTION --
2860
1 THE COURT: OVERRULED.
2 MR. WILSON: -- AS IT RELATES -- THANK YOU.
3 Q. (BY MR. WILSON) CAN YOU TELL US WHY YOUR OPINION
4 CHANGED?
5 A. I WAS GIVEN SOME ADDITIONAL INFORMATION.
6 Q. WHAT WAS THAT, DOCTOR?
7 A. IN PARTICULAR, IT WAS HER WEIGHT.
8 Q. DO YOU RECALL WHAT THAT WEIGHT WAS?
9 A. 81 POUNDS.
10 Q. WHY WAS THIS IMPORTANT TO YOU?
11 A. BECAUSE THAT MAKES A 10 MILLIGRAM DOSE OF MORPHINE MUCH
12 MORE SIGNIFICANT.
13 Q. WAS THERE ANY OTHER FACTOR THAT ENTERED INTO THAT
14 CHANGED IN YOUR OPINION?
15 A. I BELIEVE THAT WAS THE PRIMARY --
16 Q. OKAY.
17 A. -- PIECE OF INFORMATION.
18 Q. LET'S TALK A LITTLE BIT ABOUT SOME QUESTIONS AS IT
19 RELATES TO MARY CRANE. YOU RECALL REVIEWING IN YOUR NOTES
20 RELATIVE TO DR. DIENHART'S INITIAL CONSULTATION OR PHYSICAL
21 EXAMINATION OF MARY CRANE?
22 A. YES.
23 Q. DO YOU RECALL THE REFERENCE TO THE DURAGESIC PATCH?
24 A. YES.
25 Q. DID DR. DIENHART INDICATE IN THAT REFERENCE WHAT THE
2861
1 AMOUNT OF THE PATCH WAS THAT HAD BEEN ADMINISTERED TO MARY
2 CRANE AT THAT TIME?
3 A. HIS NOTE IS -- SIMPLY SAYS, AGREE WITH NONSTEROIDAL
4 ANTI-INFLAMMATORY DRUGS AND DURAGESIC PATCH.
5 Q. DO YOU KNOW WHAT THE MICROGRAM WAS -- MICROGRAM CONTENT
6 OF THE PATCH WAS THAT WAS ORDERED BY DR. WEITZEL INITIALLY?
7 A. HE INITIALLY ORDERED A 25 MICROGRAM PATCH.
8 Q. OKAY. THERE'S ALSO FURTHER CONSULTATION AS IT RELATES
9 TO MARY CRANE BY DR. DIENHART I THINK IT TAKES PLACE AROUND
10 THE 1ST OF JANUARY, IS THAT ACCURATE?
11 A. YES.
12 Q. AT THAT TIME, DOES DR. DIENHART RECOMMEND ANY REDUCTION
13 IN THE PATCH?
14 A. YES, HE DOES. HE WRITES AN ORDER IN THE CHART SAYING
15 THAT THE PATCH SHOULD BE DECREASED BY HALF TO 25 MICROGRAMS
16 BECAUSE THE PATIENT IS SEDATED.
17 Q. DO YOU KNOW WHETHER THAT ORDERED -- OR RECOMMENDATION
18 WAS EVER FOLLOWED?
19 A. THAT ORDER WAS COUNTERED NOT TOO LONG AFTER THAT BY DR.
20 WEITZEL WHO AGAIN WROTE FOR THE HIGHER DOSE.
21 Q. OKAY. BEING WHAT?
22 A. 50 MICROGRAMS PER HOUR.
23 Q. OKAY. NOW, YOU TESTIFIED THAT I THINK IT WAS REFERENCED
24 AT APPROXIMATELY 3 P.M. DR. -- ON THE JANUARY 7TH, EXCUSE
25 ME, DR. DIENHART NOTES THAT MARY CRANE IS IN THE PROCESS OF
2862
1 DYING, IS THAT ACCURATE?
2 A. ON THE 7TH, YES.
3 Q. AND WHAT WERE THE SYMPTOMS THAT SHE WAS EVIDENCING AT
4 THAT TIME THAT RELATE TO THAT NOTE, CAN YOU TELL US?
5 A. THAT SHE HAD BEEN UNRESPONSIVE. HE WRITES, UNRESPONSIVE
6 FOR THREE DAYS, BUT THAT MAY BE PROCEEDED BY AN INCREASED
7 UNRESPONSIVENESS FOR THREE DAYS, DECREASE IN HER ORAL INTAKE
8 AND HER OXYGENATION IS MARKEDLY DECREASED EVEN THOUGH SHE'S
9 RECEIVING A HIGH FLOW OF OXYGEN.
10 Q. OKAY. IS THERE -- I THINK COUNSEL ASKED YOU THE
11 QUESTION AS TO HER SUFFERING FROM SEPSIS AT THAT TIME AND HE
12 INDICATES A PROBABLE SEPSIS?
13 MR. STIRBA: I'M GOING TO OBJECT, I DIDN'T SAY
14 THAT. YOU MISCHARACTERIZED MY QUESTION. IT WOULD BE BETTER
15 IF WE PROCEEDED BY DIRECT EXAMINATION QUESTIONS --
16 THE COURT: ALL RIGHT. JUST MAKE THE OBJECTION.
17 I'LL SUSTAIN --
18 MR. WILSON: I'LL REPHRASE THE QUESTION.
19 Q. (BY MR. WILSON) WAS THERE A REFERENCE BY DR. DIENHART
20 AS TO A POSSIBLE SEPSIS?
21 A. HE DOES WRITE POSSIBLE SEPSIS.
22 Q. AS TO THE SYMPTOMS THAT YOU OBSERVED IN THE RECORD, IS
23 THERE ANOTHER EXPLANATION OR DO YOU HAVE AN OPINION AS TO
24 ANOTHER EXPLANATION AS TO WHY MARY CRANE WAS SUFFERING THOSE
25 PARTICULAR SYMPTOMS?
2863
1 MR. STIRBA: OBJECT, BEYOND THE SCOPE OF HIS
2 EXPERTISE, YOUR HONOR, UNLESS IT'S CONSISTENT WITH WHAT HE'S
3 ALREADY TESTIFIED TO.
4 MR. WILSON: YOUR HONOR, I THINK --
5 THE COURT: WHY DON'T YOU LAY THE FOUNDATION IF
6 HE'S SAYING ABOUT FOUNDATION.
7 MR. WILSON: WELL, HE WAS ASKED THE QUESTION ON
8 EXAMINATION AS TO WHETHER OR NOT SHE WAS THOUGHT TO BE IN
9 THE DYING PROCESS. AND THE ANSWER WAS, THAT ACCORDING TO
10 DR. DIENHART'S NOTE, SHE WAS AND HIS OPINION WAS THAT SHE
11 WAS IN THE PROCESS OF DYING. MY QUESTION GOES TO WHY WOULD
12 HE BE OF THAT OPINION AND IF THERE IS AN EXPLANATION OTHER
13 THAN THE SEPSIS.
14 THE COURT: OKAY. CAN YOU ANSWER THAT QUESTION
15 WITH YOUR BACKGROUND?
16 THE WITNESS: YES.
17 MR. WILSON: OKAY.
18 THE WITNESS: HIS ASSESSMENT APPEARS TO BE AT LEAST
19 PARTIALLY BASED ON THE FACT THAT SHE'S UNRESPONSIVE AND NOT
20 TAKING IN FLUIDS OR NUTRITION, AND I BELIEVE THAT THAT'S A
21 DIRECT RESULT OF BEING OVERSEDATED WITH THE MEDICATION SHE'S
22 RECEIVING.
23 Q. (BY MR. WILSON) ITS TRUE, IS IT NOT, THAT -- IF YOU
24 CAN GO TO THE REFERENCE IN THE RECORD ON THE 4TH OF JANUARY,
25 IF YOU COULD.
2864
1 A. IS THAT THE NURSING RECORD OR THE PROGRESS NOTE?
2 Q. WELL, I WANT TO -- THE QUESTION I'M GOING TO ASK YOU,
3 DID MARY CRANE RECEIVE ANY MORPHINE INJECTION ON THE 4TH OF
4 JANUARY?
5 A. SHE DID.
6 Q. OKAY. WAS THAT THE FIRST -- EXCUSE ME. I SHOW YOU
7 WHAT'S BEEN MARKED AS STATE'S EXHIBIT 36. WHEN WAS THE
8 FIRST MORPHINE ADMINISTERED TO MARY CRANE?
9 A. APPEARS TO BE JANUARY 3RD.
10 Q. SO PRIOR TO THE 7TH, HOW MANY -- HOW MUCH MORPHINE WAS
11 ADMINISTERED TO HER?
12 A. SHE GOT 3 MILLIGRAMS AND 5 MILLIGRAMS ON THE 3RD. 5
13 MORE MILLIGRAMS ON THE 4TH. 5 MILLIGRAMS TWO TIMES ON THE
14 5TH AND THEN I DIDN'T SEE THAT THERE WAS ANY MORPHINE GIVEN
15 ON THE 6TH. AND THEN SHE GOT TWO MORE DOSES ON THE 7TH ON
16 TOP OF THE DURAGESIC. Duragesic ordered stopped, but nurse failed to remove it.
17 Q. IN REFERENCE TO THE NOTE THAT YOU WERE ASKED ABOUT ON
18 THE 1ST ON THE KICKING AND BITING ON MARY CRANE?
19 A. YES, I HAVE THAT.
20 Q. CAN YOU TELL US WHETHER OR NOT YOU HAVE AN OPINION AS TO
21 THAT PARTICULAR BEHAVIOR THAT WAS OBSERVED COULD BE CAUSED
22 BY ANYTHING AS IT RELATES TO THE MEDICATIONS SHE WAS BEING
23 ADMINISTERED?
24 A. YES. THE COMBINATIONS OF MEDICATION CAN CAUSE CONFUSION
25 AND AGITATION AND RESULT IN THE PATIENT STRIKING OUT,
2865
1 ESPECIALLY SOMEONE WHO HAS TROUBLE EXPRESSING THEMSELVES.
2 Q. OKAY. LET'S TURN TO ENNIS ALLDREDGE, IF YOU WOULD FOR
3 JUST A MINUTE, PLEASE. YOU WERE ASKED SOME QUESTIONS AS IT
4 RELATED TO YOUR REVIEW OF AN E.K.G. THAT SHOWED SOME FORM OF
5 HEART ABNORMALITY; IS THAT CORRECT?
6 A. YES.
7 Q. AND WHAT WAS THAT E.K.G. ABNORMALITY DESCRIBED AS,
8 DOCTOR?
9 A. IT'S INTERPRETED AS A NORMAL SINUS RHYTHM OF THE HEART
10 WITH A FIRST DEGREE A.V. BLOCK, THAT BEING A SLIGHT DELAY
11 BETWEEN THE CONTRACTION OF THE UPPER CHAMBERS AND THE LOWER
12 CHAMBERS OF THE HEART. AND THEN VOLTAGE CRITERIA FOR AN
13 ENLARGED HEART OR LEFT VENTRICULAR HYPERTROPHY AND THEN AN
14 INFERIOR INFARCT OF INDETERMINATE AGE AND A PROLONGED Q.T.,
15 WHICH IS ANOTHER INTERVAL IN THE HEART ELECTRICAL ACTIVITY.
16 Q. ASSUMING THOSE CONDITIONS ARE PRESENT, CAN YOU TELL US
17 WHETHER OR NOT YOU HAVE AN OPINION AS TO WHETHER OR NOT THAT
18 INDIVIDUAL WOULD BE EXHIBITING OR COMPLAINING OF SIGNS OF
19 PAIN?
20 A. NO.
21 Q. DO YOU HAVE AN OPINION AS IT RELATES TO THE
22 ADMINISTRATION OF MORPHINE AS TO THE RISKS TO A PERSON
23 SUFFERING FROM THOSE CONDITIONS?
24 A. A PERSON WHO HAS HEART DISEASE AND RECEIVES A CENTRAL
25 NERVOUS SYSTEM DEPRESSANT LIKE MORPHINE THAT MIGHT IMPAIR
2866
1 THEIR BREATHING AND THEIR OXYGENATION, LACK OF OXYGEN WOULD
2 BE EXPECTED TO MAKE -- TO HAVE AN EFFECT ON THEIR HEART.
3 Q. TURNING TO LYDIA SMITH, IF YOU WOULD. IT WAS REFERENCED
4 IN CROSS-EXAMINATION OF A NOTE ABOUT FAMILY VERBALIZING
5 CONCERNS AS TO DISCHARGE, DO YOU REMEMBER THAT --
6 A. YES.
7 Q. -- REFERENCE? AS I UNDERSTOOD IT, THE REFERENCE WAS TO
8 HER ACTING OUT?
9 A. YES.
10 Q. AND THEN THE REFERENCE WAS MADE TO JANUARY 7TH OF '96 AS
11 HAVING STOPPED EATING. DO YOU HAVE AN OPINION, SIR, BASED
12 UPON YOUR REVIEW OF THE RECORDS AS TO WHY WE GO FROM ACTING
13 OUT AS IT'S REFERENCED ON THE 1ST TO JANUARY 7TH OF STOPPING
14 EATING?
15 A. YES, I DO.
16 Q. WHAT IS THAT EXPLANATION?
17 A. I THINK IT'S DIRECTLY LINKED TO THE HIGH DOSE OF HALDOL
18 THAT SHE GOT ON JANUARY 3RD AND THEN SUBSEQUENTLY GETTING
19 ALMOST TWICE THE AMOUNT OF TRAZODONE AND SERZONE ON A DAILY
20 BASIS. SHE PREVIOUSLY TO THAT HAD BEEN MISSING DOSES, AND
21 ADDING THOSE TWO TOGETHER, SHE AT MOST HAD GOTTEN
22 300 MILLIGRAMS. AFTER THAT SHE GOT 500 AND 550 MILLIGRAMS,
23 AND SINCE THOSE ARE BOTH QUITE SEDATING, I THINK THAT IN
24 COMBINATION OF WITH THE HALDOL WOULD EXPLAIN HER LAPSE INTO
25 INACTIVITY.
2867
1 Q. JUST A COUPLE OF OTHER QUESTIONS. I THINK YOU INDICATED
2 TO COUNSEL A CLINICAL ASSESSMENT AS IT RELATES TO DOSAGES IS
3 AN IMPORTANT ASPECT OF THE PROCESS; IS THAT CORRECT?
4 A. YES.
5 Q. AND YOU ANSWERED SOME QUESTIONS AS TO A PATIENT WHO HAS
6 BEEN ON CERTAIN MEDICATIONS, THE MAINTENANCE DOSAGE MAY BE
7 DIFFERENT THAN THE INITIAL DOSE AND RECOMMENDED IN THE
8 P.D.R. AND OTHER LITERATURE; IS THAT CORRECT?
9 A. YES.
10 MR. STIRBA: YOUR HONOR, THIS IS REDIRECT. THOSE
11 ARE LEADING AND SUGGESTIVE.
12 THE COURT: YEAH, COULD YOU NOT LEAD?
13 MR. WILSON: OKAY.
14 Q. (BY MR. WILSON) CAN YOU TELL US, WITH A PATIENT
15 EXHIBITING THE -- OR SUFFERING FROM THE DISEASES AND
16 DISORDERS OF THESE PATIENTS, WOULD THAT CLINICAL ASSESSMENT
17 BE ANY MORE DIFFICULT TO MAKE THAN WITH A NORMAL, HEALTHY
18 ADULT?
19 A. AS TO WHAT THE APPROPRIATE DOSE WOULD BE?
20 Q. LET'S TALK ABOUT THE -- LET'S TALK ABOUT THE ASSESSMENT
21 OF PAIN.
22 MR. STIRBA: YOUR HONOR, BEYOND THE SCOPE OF
23 CROSS-EXAMINATION AND ALSO BEYOND HIS QUALIFICATIONS.
24 MR. WILSON: FIRST OF ALL, YOUR HONOR, I WOULD
25 RESPOND TO THAT BY SAYING HE WAS ASKED THE QUESTION --
2868
1 THE COURT: WELL, I'M NOT ASKING FOR AN ARGUMENT.
2 JUST ASK THE QUESTION AGAIN, PLEASE.
3 Q. (BY MR. WILSON) OKAY. LET ME SEE IF I CAN PHRASE IT
4 BETTER.
5 WHAT IS THE PROCESS -- IS THERE A DIFFERENT PROCESS FOR
6 EVALUATING A GERIATRIC PATIENT OR ASSESSING A GERIATRIC
7 PATIENT FOR PURPOSES OF MEDICATION THAN THE PROCESS THAT YOU
8 WOULD DO WITH A NORMAL, HEALTHY ADULT?
9 A. THE OVERALL PROCESS WOULD BE THE SAME. YOU NEED A FULL
10 EVALUATION OF THE PATIENT, INCLUDING THEIR PAST HISTORY AND
11 THEIR MEDICAL CONDITIONS AND PREVIOUS MEDICATIONS AND
12 RESPONSE TO THOSE MEDICATIONS. BUT IT BECOMES MORE
13 COMPLICATED BECAUSE ELDERLY PATIENTS ARE MORE FRAGILE, THEY
14 ARE MORE SUSCEPTIBLE TO THE EFFECTS OF MEDICATIONS AND THEY
15 ARE ON MORE MEDICATIONS TO START WITH. THERE IS OPPORTUNITY
16 FOR MORE DRUG INTERACTIONS.
17 Q. IN RESPECT TO THE PATIENT WHO IS MENTALLY COMPROMISED,
18 DOES IT CREATE EVEN MORE DIFFICULTY?
19 A. COMMUNICATING WITH THE PATIENT BECOMES MUCH MORE
20 DIFFICULT IF THEY HAVE LOST THE ABILITY TO EXPRESS
21 THEMSELVES.
22 Q. AND SO DOES THE INDIVIDUAL ASSESSMENT BY THE DOCTOR
23 BECOME MORE IMPORTANT IN THOSE CIRCUMSTANCES?
24 A. YES, IT'S IMPORTANT --
25 Q. DOES THE MONITORING OF THE PATIENT BECOME MORE IMPORTANT
2869
1 IN THOSE CIRCUMSTANCES?
2 A. YES.
3 MR. WILSON: THANK YOU, DOCTOR. I HAVE NO FURTHER
4 QUESTIONS.
5 THE COURT: ANYTHING FURTHER?
6 MR. STIRBA: I DO, YOUR HONOR.
7 RECROSS-EXAMINATION
8 BY MR. STIRBA:
9 Q. DOCTOR, IT'S TRUE THAT THE E.K.G.'S THAT WERE DONE ON
10 MR. ALLDREDGE, THE REPORT SAYS ABNORMAL E.K.G., DOES IT NOT?
11 A. YES, IT DOES.
12 Q. AND IT'S ALSO TRUE, IS IT NOT, THAT WHEN DR. DIENHART
13 WROTE HIS CONSULTATIVE NOTE ON 12/29 OF 1995 CONCERNING
14 MS. CRANE, HE SAID HE AGREES WITH ADEQUATE PAIN CONTROL WITH
15 NONSTEROIDAL ANTI-INFLAMMATORY DRUGS AND DURAGESIC, CORRECT?
16 A. YES.
17 Q. AND IT'S ALSO TRUE IN THAT REPORT ON PAGE TWO HE
18 SPECIFICALLY IDENTIFIES UNDER MEDICATIONS, DURAGESIC PATCH Q
19 3 DAYS, CORRECT?
20 A. YES, HE DOES.
21 Q. THE FACT OF THE MATTER IS, SIR, WHEN HE WROTE THAT
22 REPORT AND HE WROTE THAT RECOMMENDATION, HE KNEW, IN FACT,
23 AND WAS APPROVING THE USE A 50 MICROGRAM DURAGESIC PATCH,
24 TRUE?
25 A. YES, SIR, ON THAT DAY.
2870
1 Q. AND IT'S ALSO TRUE, IS IT NOT -- YOU JUST TOLD THE JURY
2 ABOUT LYDIA SMITH AND YOU WANTED TO SAY, WELL, WHAT YOU SAW
3 ON THE 7TH WAS THE RESULT OF TRAZODONE AND SERZONE AND
4 HALDOL. IT'S TRUE, IS IT NOT, WHEN YOU REVIEW THE
5 MEDICATIONS, IF WE START WITH 1/4 OF '96?
6 A. UH-HUH.
7 Q. WHICH IS THREE -- ACTUALLY FOUR DAYS BEFORE MS. SMITH
8 DIED, SHE GOT RISPERDAL, DEPAKENE AND ATIVAN, CORRECT?
9 A. ON 1/4?
10 Q. YES.
11 A. LYDIA SMITH?
12 Q. YES.
13 A. SHE GOT THOSE AND OTHERS.
14 Q. SHE GOT OTHERS. WHAT OTHERS DO YOU THINK SHE GOT, SIR?
15 A. I HAVE A RECORD HERE THAT SAYS SERZONE 150 MILLIGRAMS AT
16 0800 AND 2000 HOURS. TRAZODONE 50 MILLIGRAMS AT 0800.
17 TRAZODONE 150 MILLIGRAMS AT 2100.
18 Q. WHAT MED ARE YOU REFERRING TO OR ARE THOSE YOUR NOTES?
19 A. NO, THIS IS A COPY OF THE MED RECORD. I BELIEVE THAT MY
20 NUMBERS DON'T CORRESPOND WITH YOURS BUT...
21 Q. BUT YOU BELIEVE BASED UPON WHAT YOU ARE LOOKING AT THAT
22 SHE GOT TRAZODONE AND SERZONE AT 8 O'CLOCK IN THE MORNING ON
23 THE 4TH, IS THAT YOUR TESTIMONY?
24 A. THAT'S WHAT'S RECORDED HERE.
25 Q. AND IT'S TRUE, IS IT NOT, THAT ON THE 5TH SHE DIDN'T GET
2871
1 ANY TRAZODONE OR SERZONE, DID SHE?
2 A. THAT'S NOT TRUE.
3 Q. IT'S TRUE, IS IT NOT, ON THE 6TH SHE DIDN'T GET ANY
4 TRAZODONE OR SERZONE, DID SHE?
5 A. THAT'S NOT TRUE. SHE DID, ACCORDING TO THIS RECORD.
6 Q. THE RECORD YOU ARE REFERRING TO IS A MEDICATION
7 ADMINISTRATIVE RECORD, SIR?
8 A. YES, ROUTINE MEDICATION ADMINISTRATION RECORD.
9 Q. WHAT TIME ARE YOU SHOWING?
10 A. THAT THE MEDICATIONS WERE ADMINISTERED?
11 Q. YES.
12 A. 0800 AND 2000 AND ALSO AT 1700 AND 2100.
13 Q. AND IT'S TRUE, IS IT NOT, THAT AS OF THE 7TH SHE DID NOT
14 RECEIVE ANY OF THOSE PSYCHOTROPIC MEDICATIONS, CORRECT?
15 A. THERE IS A NOTATION ON THE 7TH FOR RISPERDAL, DEPAKENE,
16 SERZONE AND TRAZODONE.
17 Q. BUT SHE DID SHE RECEIVE, SIR, THAT'S THE QUESTION. THE
18 FACT OF THE MATTER IS, SHE DIDN'T, DID SHE?
19 A. WELL, IT'S CHARTED AS THOUGH SHE DID.
20 Q. YOU BELIEVE SHE RECEIVED THEM ON THE 7TH?
21 A. THAT'S HOW I INTERPRET THE RECORD, YES.
22 Q. IT'S TRUE, IS IT NOT, THAT EACH ONE OF THOSE DRUGS HAS A
23 HALF LIFE, TRUE?
24 A. YES.
25 Q. AND THOSE HALF LIVES ARE DESCRIBED IN BOOKS WHERE THEY
2872
1 SHOW PHARMACOLOGICALLY GENERALLY WHAT THE GUIDELINES ARE FOR
2 HALF LIVES?
3 A. THEY ARE IN SOME GENERAL --
4 Q. SO THAT'S SOMETHING AS A PHYSICIAN THAT YOU COULD TAKE
5 THE GENERAL GUIDELINES AND YOU COULD ACTUALLY PLOT OUT
6 ESSENTIALLY THE METABOLISM AND THE CIRCUMSTANCES OF THOSE
7 DRUGS REMAINING IN SOMEBODY'S SYSTEM OVER A PERIOD OF TIME;
8 ISN'T THAT TRUE?
9 A. ONLY IN A HYPOTHETICAL SITUATION BECAUSE THERE'S SO MUCH
10 INTER-INDIVIDUAL VARIABILITY AND YOU MAY METABOLIZE THINGS
11 FASTER THAN I DO AND WITHOUT MEASURING THAT, IT'S DIFFICULT
12 TO MAKE THAT ASSUMPTION THAT WE'RE BOTH AVERAGE.
13 Q. YEAH. BUT YOU'VE MADE IT BECAUSE YOU'VE TOLD THE JURY
14 ABOUT CERTAIN ADDITIVE EFFECTS AND CERTAIN ONGOING SEDATING
15 EFFECTS; ISN'T THAT TRUE?
16 A. YES, AND --
17 Q. AND YET YOU HAVEN'T, HAVE YOU, SIR, GONE AND ACTUALLY
18 DONE THE COMPUTATION TO SEE WHETHER OR NOT YOUR OPINION IS
19 SUBSTANTIATED BY WHAT YOU'VE JUST TESTIFIED TO; ISN'T THAT
20 CORRECT?
21 A. I'M NOT SURE THE QUESTION MAKES SENSE TO ME BECAUSE
22 THOSE COMPUTATIONS CAN'T BE DONE.
23 Q. WELL, IF THEY CAN'T BE DONE BASED UPON GUIDELINES AND
24 PHARMACOLOGICAL BOOKS ABOUT THE DRUGS, SIR, THEN YOU CAN'T
25 MAKE THEM FROM THE STAND BASICALLY JUST UPON YOUR OPINION
2873
1 WITHOUT LOOKING AT THE OVERALL SITUATION, CAN YOU?
2 A. I HAVE NOT GIVEN ANY SPECIFIC DURATION OF ACTION OR HALF
3 LIFE FOR ANY OF THESE DRUGS TO YOU BECAUSE -- AND I HAVE
4 TRIED TO EMPHASIZE, THAT IN THE ELDERLY IN GENERAL THE HALF
5 LIFE IS LONGER FOR VARIOUS REASONS AND THE DRUGS HAVE A
6 GREATER EFFECT.
7 Q. OKAY. BUT YOU JUST TOLD US WITH LYDIA SMITH THAT YOU
8 BELIEVE THAT CERTAIN MANIFESTATIONS WHICH SHE WAS SHOWING
9 WERE THE RESULT OF SOME MEDICATIONS WHICH WERE STILL IN HER
10 SYSTEM DAYS LATER, DIDN'T YOU?
11 A. WELL, SHE CONTINUED TO GET THEM DURING THOSE DAYS.
12 Q. THE FACT OF THE MATTER IS, FOR EXAMPLE, IF WE LOOK AT
13 THIS CHART, YOU REALLY CAN'T TELL, YOU ARE NOT TELLING THE
14 JURY THAT, FOR EXAMPLE, SOME MEDICATIONS THAT WERE GIVEN ON
15 JANUARY 1 WOULD HAVE STILL BEEN EXISTING AND HAVING AN
16 EFFECT ON THE PATIENT IN JANUARY 7, ARE YOU?
17 A. I DON'T BELIEVE I SAID THEY WERE STILL THERE, BUT THEY
18 CAN STILL HAVE AN EFFECT, YES, SIR.
19 Q. DO YOU KNOW THAT FOR A FACT THAT THAT WAS OCCURRING
20 WITHOUT ACTUALLY DOING SOME KIND OF HALF-LIFE ANALYSIS?
21 A. I DON'T BELIEVE I NEED A HALF-LIFE ANALYSIS TO BE ABLE
22 TO MAKE THAT CONCLUSION WITH THESE MEDICATIONS. I'M BASING
23 THAT --
24 Q. WELL, THEY HAVE HALF LIVES, DON'T THEY, SIR?
25 A. YES, THEY DO.
2874
1 Q. AND HALF LIVES MEAN THAT THEY DETERIORATE IN THE BODY
2 OVER A PERIOD OF TIME, CORRECT?
3 A. HALF LIFE DOES NOT DIRECTLY CORRESPOND TO DURATION OF
4 ACTION IN THE BODY.
5 Q. WELL, I UNDERSTAND THAT. BUT YOU ARE MAKING SOME KIND
6 OF DETERMINATION THAT, IN FACT, THAT HAS OCCURRED JUST BY
7 RENDERING AN OPINION THAT A DRUG WILL STILL HAVE AN EFFECT
8 DAYS LATER, AREN'T YOU?
9 A. I'M NOT MAKING A STATEMENT ABOUT THE HALF LIFE. I'M
10 TALKING ABOUT IT STILL HAVING AN EFFECT.
11 Q. WELL, LET'S ASSUME, FOR EXAMPLE, MORPHINE. YOU'D AGREE
12 THAT GENERALLY THE LITERATURE SUPPORTS A HALF LIFE OF TWO TO
13 FOUR -- FOUR TO SIX -- TWO TO FOUR HOURS, RATHER?
14 A. IN A YOUNG, HEALTHY ADULT. THAT WOULD NOT BE TRUE IN AN
15 OLDER PERSON.
16 Q. DO YOU KNOW WHAT THE HALF LIFE IS WITH RESPECT TO ANY
17 ONE OF THESE PATIENTS CONCERNING MORPHINE?
18 A. THE INDIVIDUAL PATIENT?
19 Q. YES.
20 A. NO, I DO NOT.
21 Q. DO YOU KNOW WHAT THE HALF LIFE IS WITH RESPECT TO ANY
22 ONE OF THESE INDIVIDUAL PATIENTS WITH HIS RESPECT TO
23 TRAZODONE?
24 A. SPECIFICALLY, NO.
25 Q. SERZONE?
2875
1 A. NO.
2 Q. RISPERDAL?
3 A. IT WOULD BE THE SAME WITH ANY DRUG.
4 Q. YOU DON'T KNOW?
5 A. THAT I DON'T KNOW EXACTLY WHAT THE HALF LIFE IS, NO.
6 Q. SO YOU -- SO GIVEN THAT FACT THAT YOU DON'T KNOW WHAT
7 THE HALF LIFE IS WITH RESPECT TO ANY OF THESE DRUGS, FOR
8 EXAMPLE IN LYDIA SMITH, THEN YOU CAN'T TELL US, CAN YOU,
9 WHAT EFFECT CERTAIN DRUGS MAY HAVE DAYS LATER, CAN YOU?
10 A. I BELIEVE I DID TELL YOU. I THINK THAT THERE WAS AN
11 EFFECT DAYS LATER AS SHE CONTINUED TO RECEIVE THOSE.
12 Q. EVEN THOUGH, AS YOU JUST TOLD US, YOU CAN'T TELL US WHAT
13 THE HALF LIFE OF THAT MEDICATION WAS CONCERNING LYDIA SMITH?
14 A. EVEN THOUGH I CAN'T TELL YOU THE EXACT HALF LIFE, THAT'S
15 CORRECT.
16 MR. STIRBA: THAT'S ALL.
17 THE COURT: ANYTHING FURTHER OF THIS WITNESS?
18 FURTHER REDIRECT EXAMINATION
19 BY MR. WILSON:
20 Q. WHAT DOES DURATION OF THE DRUG MEAN IN RESPECT TO THE
21 HALF LIFE?
22 A. THE HALF LIFE IS A MEASURED NUMBER BY CHECKING THE BLOOD
23 LEVELS IN AN INDIVIDUAL PERSON. AND THE REPORTED HALF LIVES
24 IN THE LITERATURE OR IN THESE MANUALS OR BOOKS WOULD BE
25 BASED ON AN AVERAGE OF A GROUP OF PEOPLE.
2876
1 THE ACTUAL EFFECT OF THE DRUG DOES NOT -- WELL, FOR
2 PSYCHIATRIC DRUGS DOES NOT TAKE PLACE IN THE BLOODSTREAM AS
3 MUCH AS IT TAKES PLACE IN THE BRAIN. ONCE THE DRUG ENTERS
4 THE BRAIN, IT CAN BIND OR ATTACH ITSELF TO RECEPTORS THERE
5 AND STAY THERE FOR A LONG TIME AND THE BLOOD LEVEL MAY BE
6 MEASURED AS ZERO OR NEGLIGIBLE AND THE DRUG IS STILL PRESENT
7 IN THE BRAIN AND STILL HAVING AN EFFECT.
8 Q. AND HOW DO YOU EVAL --
9 A. THAT'S ESPECIALLY TRUE OF HALDOL.
10 Q. HOW DO YOU EVALUATE THAT IN A PATIENT AS TO THE DRUG
11 STILL HAVING AN EFFECT?
12 A. WELL, KNOWING WHAT THE CAUSE OR THE EFFECT OF THE DRUG
13 IS SUPPOSED TO BE AND WHAT YOU ARE TREATING AND IF THE
14 PATIENT IS RESPONDING TO THE DRUG AND THEN THE SIDE EFFECTS
15 WHICH CAN ALSO PERSIST.
16 MR. WILSON: I HAVE NO FURTHER QUESTIONS, YOUR
17 HONOR.
18 THE COURT: ANYTHING FURTHER OF THIS WITNESS?
19 MR. STIRBA: NO, YOUR HONOR. THANK YOU.
20 THE COURT: MAY THIS WITNESS BE EXCUSED?
21 MR. WILSON: HE MAY, YOUR HONOR.