Michael Sumko, MD
11 MS. BARLOW: WE CALL DR. MICHAEL SUMKO.
12 THE COURT: DR. SUMKO, WOULD YOU STEP UP, PLEASE?
13 RAISE YOUR RIGHT HAND AND FACE THE CLERK.
14 MICHAEL SUMKO,
15 BEING FIRST DULY SWORN, WAS EXAMINED AND
16 TESTIFIED AS FOLLOWS:
17 THE COURT: IF YOU'LL HAVE A SEAT UP HERE, PLEASE.
18 GIVE US YOUR FULL NAME AND SPELL YOUR LAST NAME, PLEASE.
19 THE WITNESS: I'M DR. MICHAEL HENRY SUMKO,
20 S-U-M-K-O.
21 DIRECT EXAMINATION
22 BY MS. BARLOW:
23 Q. SUMKO.
24 A. THAT'S CORRECT.
25 Q. MAKE SURE I SPELL IT CORRECTLY.
1 A. YES.
2 Q. THANK YOU, DR. SUMKO. AND THANK YOU FOR YOUR PATIENCE.
3 I KNOW YOU'VE BEEN WAITING OUTSIDE FOR A WHILE.
4 WHERE DO YOU WORK?
5 A. AT BRIGHAM CITY.
6 Q. AND WHAT IS YOUR OCCUPATION?
7 A. I'M AN ORTHOPEDIC SURGEON.
8 Q. AND THAT'S YOUR SPECIALTY?
9 A. YES.
10 Q. WHAT TRAINING DID YOU RECEIVE FOR YOUR SPECIALTY?
11 A. AFTER MEDICAL SCHOOL I HAD AN INTERNSHIP AT BROOK ARMY
12 MEDICAL CENTER IN SAN ANTONIO AND A FIVE-YEAR RESIDENCY IN
13 ORTHOPEDIC SURGERY.
14 Q. AND ARE YOU BOARD CERTIFIED?
15 A. I AM.
16 Q. WHAT DOES IT MEAN TO THE BOARD CERTIFIED?
17 A. BASICALLY IT MEANS THAT YOU HAVE TAKEN TWO EXAMINATIONS,
18 ONE WRITTEN, ONE ORAL. AND IN THOSE EXAMINATIONS BASICALLY
19 PASSED THEM. AND YOU ALSO AT THAT POINT IN TIME ARE -- YOUR
20 PEERS, MEANING ALL THE ORTHOPEDIC SURGEONS WHO ARE BOARD
21 CERTIFIED IN THE COUNTRY, TESTIFY TO YOUR CHARACTER AND YOUR
22 ABILITY TO PRACTICE BY COMPLETING THE RESIDENCY.
23 Q. IS IT REQUIRED TO BE BOARD CERTIFIED IN ORDER TO BE A
24 PHYSICIAN?
25 A. IT IS NOT.
1 Q. JUST ONE OF THOSE EXTRA THINGS?
2 A. IT'S ONE OF THOSE EXTRA THINGS.
3 Q. OKAY. WERE YOU WORKING IN BRIGHAM CITY IN JUNE OF 1995?
4 A. I WAS.
5 Q. DID YOU HAVE THE OCCASION TO SEE ELLEN ANDERSON?
6 A. I DID.
7 Q. DO YOU RECALL WHO REFERRED HER TO YOU?
8 A. I -- I BELIEVE SHE WAS SEEN ON THE DAY OF -- SHE WAS
9 REFERRED TO ME BY DR. MARKESON, JOHN MARKESON.
10 Q. AND IS HE A PARTNER WITH DR. WILDING?
11 A. HE IS.
12 Q. AND YOU'RE FAMILIAR WITH BOTH OF THESE DOCTORS?
13 A. YES.
14 Q. WHAT -- WHAT DIAGNOSIS DID YOU GIVE MRS. ANDERSON?
15 A. SHE HAD A DISPLACED FEMORAL NECK FRACTURE OR HIP
16 FRACTURE.
17 Q. CAN YOU BRIEFLY DESCRIBE WHERE THAT FRACTURE WAS?
18 A. EXACTLY. I -- I BROUGHT A LITTLE DEMONSTRATION SO
19 EVERYONE CAN UNDERSTAND.
20 Q. AUDIOVISUAL AID, AS IT WERE?
21 A. AUDIOVISUAL AID.
22 THIS IS THE FEMUR THAT CONNECTS TO YOUR PELVIS. WHERE
23 HER FRACTURE WAS WAS IN A LOCATION BETWEEN THE BALL AND WHERE
24 THE BALL CONNECTS WITH THE SHAFT, IN THE NECK AREA.
25 Q. COULD YOU TELL WHAT HAD CAUSED THE FRACTURE?
1 A. SHE HAD HAD A FALL, I BELIEVE BY HISTORY, ON THE 8TH
2 OF -- OF JUNE AND WENT TO HER DOCTORS. AT THAT TIME THEY
3 TOOK AN X-RAY, COULD NOT SEE THE FRACTURE, AS PROBABLY MOST
4 OF YOU AT THIS POINT IN TIME CAN'T SEE THAT THIS BONE HAS
5 A -- A FRACTURE WHICH I'M GOING TO DEMONSTRATE IN JUST A
6 MINUTE.
7 IT WAS SUBCLINICAL -- I MEAN, IT WAS -- IT WAS CLINICAL,
8 HOWEVER, IT WAS NOT SEEN ON THE RADIOLOGY. AND SO SHE
9 CONTINUED -- SHE WAS PLACED ON A WALKER AND WITH LIMITED
10 AMBULATION AND TRIED TO -- TOLD TO RETURN IF SHE HAD
11 INCREASED PAIN.
12 I BELIEVE SHE RETURNED ON THE -- THE DATE WAS THE
13 18TH -- 17TH OR 18TH -- 18TH, I BELIEVE, OF JUNE TO
14 DR. MARKESON'S OFFICE WHERE HE NOTED ON X-RAY THAT THIS
15 FRACTURE, BECAUSE OF HER WEIGHT BEARING ON THIS -- ON THIS
16 PARTICULAR PORTION OF THE HIP, HAD DISPLACED ITSELF. SO IT
17 WAS SOMETHING YOU COULDN'T SEE ON X-RAY, WHAT WE USED TO CALL
18 A HAIRLINE FRACTURE.
19 Q. UH-HUH.
20 A. THE HAIRLINE FRACTURE PROGRESSED ON WITH WEIGHT BEARING
21 TO THE POINT WHERE IT ACTUALLY FRACTURED THROUGH HERE
22 (INDICATING).
23 Q. WHAT DID YOU DECIDE WAS THE BEST TREATMENT AT THAT POINT?
24 A. THE ONLY -- THE ONLY TREATMENT YOU REALLY -- OPTION YOU
25 HAVE, IF IT'S DISPLACED, IS YOU HAVE TO REPLACE THIS BALL.
1 THE PRIMARY REASON FOR THAT IS IS BECAUSE THE BLOOD SUPPLY TO
2 THIS BALL COMES PRIMARILY THROUGH THIS SHAFT AND THROUGH THIS
3 NECK. IF YOU BREAK THROUGH THAT SHAFT, WHICH I'LL DO FOR YOU
4 RIGHT NOW, AND THAT DISPLACES, THE BLOOD SUPPLY TO THIS BALL
5 IS DISRUPTED. IT WILL EVENTUALLY DIE AND BECOME AN
6 ARTHRITIC, PAINFUL HIP.
7 Q. AND WOULD THAT CAUSE A PERSON NOT TO BE ABLE TO AMBULATE
8 ANYMORE WITH THAT PROBLEM?
9 A. YES.
10 Q. DID YOU SPEAK WITH MRS. ANDERSON AND/OR HER DAUGHTERS
11 ABOUT WHAT NEEDED TO BE DONE?
12 A. I DID. AND RECOMMENDED TO THEM THAT THE BALL BE
13 REPLACED.
14 Q. DID THEY AGREE TO DO THAT?
15 A. THEY DID.
16 Q. DO YOU RECALL WHEN THE SURGERY WAS DONE?
17 A. IT WAS DONE I BELIEVE THE SAME DAY I SAW HER ON THE 18TH
18 OF JUNE.
19 Q. SO YOU WERE ABLE TO GET RIGHT IN TO DO IT THAT FAST?
20 A. NORMALLY WE LOOK TO DO THEM WITHIN THE FIRST 24 HOURS,
21 DECREASING THE RISK OF COMPLICATIONS.
22 Q. OKAY. WHAT -- IF YOU CAN BRIEFLY TELL US WHAT THE
23 SURGERY INVOLVES.
24 A. THE SURGERY BASICALLY INVOLVES MAKING AN INCISION OVER
25 THE BUTTOCK AREA, JUST ALMOST TO THE SIDE OF YOUR HIP IN THIS
1 DIRECTION HERE, AND THEN TAKING THE MUSCLES OFF OF THE BONE,
2 EXPOSING THIS PORTION OF THE BONE AND HOLLOWING THE CANAL OUT
3 SO THAT A PROTHESES MUCH SIMILAR -- VERY MUCH SIMILAR TO THIS
4 CAN BE PLACED DOWN INTO THE SHAFT REPLACING THE BALL. AND
5 THAT'S USUALLY CEMENTED IN POSITION SO THAT IT'S SOLID.
6 Q. DID YOU HAVE ANY CONCERNS ABOUT PERFORMING THIS SURGERY
7 ON A 91-YEAR-OLD LADY?
8 A. WE DO. THE -- THE OBVIOUS CONCERNS ARE OBVIOUSLY WITH
9 AGE THERE ARE THINGS -- CARDIOVASCULAR PROBLEMS OCCUR. WITH
10 HER HISTORY, SHE HAD ACTUALLY HAD SOME ATHEROSCLEROTIC
11 CORONARY ARTERY DISEASE WHICH WAS NOTED ON X-RAY ON
12 ADMISSION.
13 Q. AND WHAT DOES THAT MEAN?
14 A. WHAT THAT MEANS IS THAT THERE'S CALCIFICATION OF THE
15 CORONARY ARTERIES AROUND THE HEART AND SO THERE'S AN
16 INCREASED RISK THAT IF SOMETHING OCCURS DURING THE SURGICAL
17 PROCEDURE --
18 THE WITNESS: AM I TALKING TOO FAST? I AM. THAT
19 ALWAYS HAPPENS.
20 A. IF SOMETHING OCCURS DURING THE SURGICAL PROCEDURE WHICH
21 STRESSES THE SYSTEM -- MEANING BASICALLY THE HEART BECAUSE
22 IT'S PROVIDING THE CARDIOVASCULAR, THE BLOOD SUPPLY TO THE
23 REST OF THE BODY. IF SOMETHING OCCURS DURING THAT PROCEDURE
24 THEN THE BLOOD PRESSURE MAY DROP SIGNIFICANTLY ENOUGH THAT
25 THOSE CORONARY ARTERIES DO NOT SUPPLY ENOUGH BLOOD TO THE
1 HEART MUSCLE, AND SUBSEQUENTLY THE PATIENT WOULD HAVE A HEART
2 ATTACK.
3 SO THAT'S PROBABLY THE MAIN COMPLICATION DURING THE
4 SURGERY RY.
5 Q. IS THERE ANYTHING YOU DID WITH MRS. ANDERSON PRIOR TO HER
6 SURGERY TO -- TO ADDRESS THAT CONCERN?
7 A. USUALLY WE DO THE INITIAL PREOPERATIVE EVALUATION WHICH
8 INCLUDES AN INTERNAL MEDICINE EVALUATION BY HER PRIMARY CARE
9 DOCTOR --
10 Q. UH-HUH.
11 A. -- DR. MARKESON OR DR. WILDING, AND WE'LL DO AN E.K.G.,
12 CHEST X-RAY --
13 Q. UH-HUH.
14 A. -- AS WELL. BOTH OF THOSE KIND OF GIVE US AN IDEA IF
15 THERE'S ANY SUSPICIOUS ABNORMALITIES THAT WE REALLY HAVE TO
16 BE CAUTIOUS ABOUT IN THE PROCESS OF DOING THE SURGERY. AND
17 SOMETIMES THAT WILL ALSO DICTATE THE TYPE OF ANESTHESIA WHICH
18 WE CAN GIVE TO THEM. WITH A -- WITH A LARGE AMOUNT OF
19 CORONARY ARTERY PROBLEMS, WHAT WE'LL HAVE TO DO IS USUALLY
20 GIVE THEM A SPINAL ANESTHETIC.
21 Q. UH-HUH.
22 A. IF -- IF THEY FEEL LIKE THEY CAN GET INTO THE SPINE WITH
23 A -- THE APPROPRIATE NEEDLE TO NUMB THEM FROM THE WAIST DOWN
24 SO THAT THEY DON'T -- THEY DON'T FEEL OUR SURGERY.
25 OCCASIONALLY THERE'S SO MUCH ARTHRITIS IN THE SPINE THAT YOU
1 MUST GO ON TO A GENERAL ANESTHETIC. AND THAT INCREASES THE
2 RISK, OF COURSE, OF -- OF PROBLEMS IN THE RESPIRATORY AND
3 CARDIOVASCULAR SYSTEM.
4 Q. DO YOU --
5 THE COURT: DOCTOR, LET ME ASK YOU TO STOP FOR JUST
6 A MOMENT.
7 CAN YOU PUT THE ARMS DOWN ON THAT DEVICE SO THE JURORS
8 CAN SEE THE WITNESS A LITTLE BETTER? THANK YOU.
9 MS. BARLOW: SPECIAL WAY TO DO THOSE.
10 THE COURT: THANK YOU.
11 Q. (BY MS. BARLOW) WERE THERE ANY PARTICULAR CONCERNS -- OR
12 NOT -- I WON'T SAY CONCERNS. IS THERE ANY PARTICULAR
13 PRECAUTIONS YOU'D TAKE -- STRIKE THAT.
14 WHICH -- DO YOU RECALL WHICH ANESTHETIC YOU USED WITH
15 ELLEN ANDERSON?
16 A. SHE HAD A GENERAL ANESTHETIC AND I WOULD ASSUME AT THE
17 TIME WHICH I --
18 MR. BUGDEN: YOUR HONOR, I'M GOING TO ASK THAT THE
19 WITNESS NOT ASSUME. I'LL OBJECT.
20 THE WITNESS: OKAY.
21 THE COURT: SUSTAINED.
22 A. NORMALLY WE DO NOT DO GENERAL ANESTHETICS IN 91 YEAR OLDS
23 UNLESS, FOR SOME REASON, THEY -- AS I INDICATED BEFORE, THEY
24 CAN'T HAVE A SPINAL ANESTHETIC WHERE THE SPINAL NEEDLE CAN'T
25 GET IN THERE BECAUSE THERE'S SO MUCH ARTHRITIS.
1 Q. (BY MS. BARLOW) UH-HUH.
2 A. SO IN THIS SITUATION SHE HAD A GENERAL. AND, AGAIN, I
3 DON'T HAVE THE HOSPITAL RECORDS TO TELL YOU. YOU'D HAVE TO
4 GET THE ANESTHETIC RECORDS TO SEE IF THEY ATTEMPTED A SPINAL
5 FIRST, WHICH WE USUALLY DO.
6 Q. BUT SHE DID USE A GENERAL -- YOU DID USE A GENERAL --
7 A. DID USE A GENERAL.
8 Q. -- WITH HER.
9 DOES THAT -- DOES THAT CAUSE YOU TO TAKE EXTRA
10 PRECAUTIONS OR ANY -- ANY DIFFERENT PRECAUTIONS DURING THE
11 SURGERY?
12 A. IT DOES IN THAT DURING THE SURGERY WHEN WE PUT THE GLUE
13 IN TO GLUE THIS PROSTHESIS DOWN IN THE CANAL, AT THAT POINT
14 IN TIME USUALLY THEIR BLOOD PRESSURE WILL DROP GREATLY
15 BECAUSE THE GLUE HAS ACTUALLY A TOXIC EFFECT FOR ABOUT 15
16 MINUTES. IT WILL DROP THEIR BLOOD PRESSURE AND SO THE RISK
17 OF CORONARY ARTERY COLLAPSE AND/OR HEART ATTACK OR EVEN A
18 STROKE BECAUSE OF LACK OF CIRCULATION TO THE BRAIN CAN OCCUR.
19 Q. UH-HUH.
20 A. AND SUBSEQUENTLY THEY -- THE RISK OF DYING IS -- IS MUCH
21 GREATER DURING THAT PERIOD OF TIME, ESPECIALLY UNDER GENERAL
22 ANESTHETIC BECAUSE AT THAT POINT THEIR CARDIOVASCULAR SYSTEM
23 IS ALWAYS STRESSED BY THE ANESTHESIA.
24 Q. HOW DID THE SURGERY GO WITH MRS. ANDERSON?
25 A. VERY, VERY WELL. SHE HAD NO PROBLEMS DURING THE SURGERY.
1 WE WERE ABLE TO PUT THE GLUE IN. SHE HAD NO SIGNIFICANT
2 DROPS IN HER BLOOD PRESSURE. AND SHE DID WELL FROM THE TIME
3 WE CUT THE SKIN UNTIL THE TIME WE CLOSED THE SKIN AND TOOK
4 HER TO THE RECOVERY ROOM.
5 Q. OTHER THAN THE HIP FRACTURE THAT SHE HAD, WHAT WAS HER
6 HEALTH GENERALLY?
7 A. GENERALLY SHE WAS IN VERY GOOD HEALTH. I BELIEVE THE
8 ONLY MEDICATION SHE CAME INTO THE HOSPITAL WITH WERE
9 DARVOCET, WHICH SHE WAS USING FOR PAIN, WHICH I BELIEVE HAD
10 BEEN PRESCRIBED BY DR. WILDING. AND ALSO SHE WAS ON
11 AMITRIPTYLINE. AMITRIPTYLINE IS AN ANTIDEPRESSANT. IT
12 HAS -- IT CAN BE USED FOR CHRONIC PAIN. THERE'S MULTIPLE
13 USES FOR IT. BUT SHE WAS ON THE ANTIDEPRESSANT AND THE
14 DARVOCET I BELIEVE ARE THE ONLY TWO MEDICATIONS.
15 Q. OKAY. AND DARVOCET IS A PAIN MEDICATION?
16 A. IT IS. IT'S A VERY MILD NARCOTIC MEDICATION.
17 Q. IS IT COM -- IS IT AN OPIOID?
18 A. IT'S A -- IT'S A SYNTHETIC TYPE OF OPIOID. IT'S
19 PROPOXYPHENE AND IT'S -- IT'S NOT MADE FROM THE TYPE OF
20 MEDICATIONS THAT MORPHINE, DEMEROL AND OTHER ONES ARE MADE
21 FROM. IT'S -- IT'S A LITTLE BIT ON A DIFFERENT LINE. IT HAS
22 A SIMILAR EFFECT IN THAT IT IS A PAIN BLOCKING MEDICATION.
23 Q. AND WE'VE TALKED ABOUT OPIOID A LITTLE BIT. WHAT IS --
24 THAT WORD? WHAT DOES OPIOID MEAN?
25 A. OPIOID MEANS IT HAS A -- IT HAS ITS BASIS IN -- IN
1 MORPHINE AND THOSE TYPE OF DRUGS WHICH ARE DERIVED FROM -- A
2 NATURAL DERIVATIVE OF -- OF PLANTS WHICH PRODUCE PAIN
3 MEDICATIONS. AND -- AND THE ONES THAT ARE SYNTHETIC, USUALLY
4 THEY TRY TO DUPLICATE THOSE TYPE OF DRUGS IN THE CHEMICAL
5 STRUCTURE, BUT THEY STAY ENOUGH AWAY FROM THEM THAT THEY TRY
6 TO GET AWAY FROM SOME OF THE OTHER SIDE EFFECTS WHICH OCCUR
7 WITH OPIOID MEDICATIONS.
8 Q. WITH A 91-YEAR-OLD WOMAN AS WITH MRS. ANDERSON, WAS THERE
9 PAIN AFTER SHE HAD THE SURGERY?
10 A. YES, THERE -- THERE NATURALLY IS.
11 Q. WHAT KIND OF PAIN WOULD THAT BE?
12 A. MOST PEOPLE DESCRIBE IT AS A -- A DEEP TOOTHACHE TYPE OF
13 PAIN BECAUSE WHAT WE'VE DONE IS GONE -- WE'VE GONE INTO THE
14 BONE. THE BONE HAS WITHIN ITS INNER LINING AND WITHIN THE
15 OUTER LINING OF THE BONE THERE ARE PAIN SENSORS. AND HAVING
16 GONE IN THERE AND DONE OBVIOUSLY WHAT I'VE JUST SHOWN YOU IN
17 THE PROCEDURE, WHAT WE DO, THOSE PAIN SENSORS ARE OBVIOUSLY
18 DISRUPTED AND THEN THERE IS PAIN.
19 SO THE PAIN IS USUALLY A DEEP ACHING PAIN. THERE IS
20 SOME PAIN AS WELL FROM MUSCLE DISRUPTION BECAUSE WE ACTUALLY
21 TAKE SOME OF THE MUSCLES OFF OF THE BONE --
22 Q. UH-HUH.
23 A. -- AND WE SPREAD THE MUSCLES AS WE GO IN THERE TO REPLACE
24 THE -- THAT PORTION OF THE HIP. SO THAT THE PAIN IS USUALLY
25 FAIRLY SIGNIFICANT.
1 Q. DID YOU GIVE HER ANY MEDICATION FOR THAT PAIN?
2 A. WE NORMALLY DO. POST-OPERATIVE WE -- WE GIVE --
3 TYPICALLY WE'LL GIVE I.M. MEDICATIONS.
4 Q. I.M. MEANING WHAT?
5 A. INTRAMUSCULAR. I'M SORRY. INTRAMUSCULAR MEDICATIONS,
6 INJECTIONS WHICH A LOT OF TIMES WILL HAVE OPIOID BASIS SUCH
7 AS DEMEROL. DEMEROL AND PHENERGAN ARE USUALLY MOST OPERATIVE
8 -- MOST COMMONLY USED POST-OPERATIVE FOR PAIN. AND THEN WE
9 ATTEMPT TO AS RAPIDLY AS POSSIBLE PUT THEM ON ORAL
10 MEDICATIONS INSTEAD OF THE I.M. MEDICATIONS.
11 Q. DID YOU PUT HER ON MORPHINE?
12 A. NO, WE DID NOT.
13 Q. WHY NOT?
14 A. I DON'T USE MORPHINE IN MY PRACTICE OF MEDICINE AND
15 THERE'S A REASON. VERY, VERY RARELY -- I WON'T SAY I DON'T
16 USE IT. VERY RARELY. THEY -- IT HAS ITS SPECIFIC USES, BUT
17 IN MY OPINION MORPHINE HAS TOO MANY SEDATIVE EFFECTS. AND,
18 TOO, IT'S VERY WONDERFUL FOR THE USE IN PATIENTS WITH
19 CARDIOVASCULAR PROBLEMS BECAUSE WITH HYPERTENSION IT DROPS
20 THEIR BLOOD PRESSURE VERY NICELY, CAUSES VASODILATATION --
21 MEANING THE BLOOD VESSELS DILATE. AND YOU CAN GET SOMEONE
22 WHO'S HAD A HEART ATTACH OR A STROKE TO LOWER THEIR PRESSURE
23 VERY QUICKLY BY GIVING THEM MORPHINE.
24 IT ALSO HAS A LOT OF SEDATIVE EFFECTS WHICH
25 POST-OPERATIVELY IN SOMEONE WHO'S HAD HIP SURGERY, WE LIKE TO
1 KEEP AWAY FROM THAT. AND THE REASONS ARE -- THERE IS
2 MULTIPLE REASONS. ONE IS THE -- THE PATIENTS A LOT OF TIMES
3 GO INTO A RESPIRATORY DEPRESSION WHERE THEY'LL START
4 BREATHING LESS BECAUSE OF THE EFFECTS OF THE MORPHINE. THE
5 OTHER REASON IS IS BECAUSE A LOT OF FAMILIES WILL COME IN AND
6 SAY WHY IS MY MOTHER OR MY GRANDMA SO OUT IT.
7 Q. UH-HUH.
8 A. AND THOSE MEDICATIONS HAVE A TENDENCY TO BE SO SEDATIVE
9 THAT A LOT OF TIMES THEY WILL IN OLDER PEOPLE, THE REACTION
10 IS SO SEDATIVE THAT THEY WILL -- FAMILIES QUESTION THAT.
11 SO IN MY EXPERIENCE -- AND I'VE DONE HUNDREDS AND
12 HUNDREDS OF HIPS -- I ACTUALLY LET THEM HAVE A LITTLE BIT OF
13 PAIN. IT KEEPS THEM AWAKE, IT KEEPS THEM BREATHING. IF
14 SOMEONE'S IN PAIN THEY'RE BREATHING DEEPER. THEY'RE LESS
15 LIKELY TO GET PNEUMONIA AND SOME OF THE OTHER COMPLICATIONS.
16 SO IT MAY SOUND A LITTLE CRUEL THAT WE KEEP THEM IN SOME
17 PAIN, BUT IT'S BETTER TO HAVE TO GO IN AND SAY, ALL RIGHT,
18 ARE YOU HAVING PAIN, AND THEY SAY YES; THAN TO GO IN AND SAY
19 ARE YOU HAVING PAIN AND THEY DON'T RESPOND.
20 Q. OKAY. HOW LONG WAS SHE IN THE HOSPITAL AFTER THE HIP
21 SURGERY?
22 A. I BELIEVE IT WAS FOUR DAYS, BUT I'D -- I'D HAVE TO LOOK
23 AT THE -- AGAIN, THE HOSPITAL RECORDS. USUALLY THE TYPICAL
24 POST-OPERATIVE COURSE IS THREE TO FOUR DAYS, PRIMARILY FOR
25 ANTIBIOTICS AND FOR SOME OTHER -- LOOKING FOR SOME OF THE
1 RESPIRATORY EFFECTS THAT OCCUR WITH GENERAL ANESTHETICS.
2 Q. UH-HUH.
3 A. SUCH AS PNEUMONIA, BLOOD CLOTS, THOSE TYPE OF THINGS.
4 Q. DID YOU SEE HER EVERY DAY AT THE HOSPITAL?
5 A. I -- I SEE THEM EVERY DAY POST-OPERATIVELY.
6 Q. WAS SHE HAVING ANY EXCESSIVE PAIN, IF YOU RECALL?
7 A. NOT EXCESSIVE. SHE HAD PAIN, BUT NOT EXCESSIVE. IN
8 FACT, IT WAS TO THE POINT WHERE WE WERE ABLE TO, PRIOR TO HER
9 DISCHARGE OR TRANSFER TO THE NURSING FACILITY, WE WERE ABLE
10 TO HAVE HER ON ORAL MEDICATIONS, LORTAB, WHICH IS
11 HYDROCODONE.
12 Q. UH-HUH.
13 A. IT'S ON ORAL MEDICATION. KIND OF A MIDDLE-OF-THE-ROAD
14 NARCOTIC. FAIRLY MILD. SHE WAS ON LORTAB-5'S WHICH IS, AS I
15 INDICATED, A FAIRLY MILD MEDICATION.
16 Q. AFTER SHE LEFT THE HOSPITAL, WHERE DID SHE GO?
17 A. I BELIEVE SHE WENT TO PIONEER CARE CENTER.
18 Q. AND WHAT WAS THE PURPOSE OF PUTTING HER IN A CARE CENTER?
19 A. WHEN WE PUT THEM IN CARE CENTERS, THE PRIMARY REASON IS
20 TO CONTINUE POST-OPERATIVE REHABILITATION. IN OTHER WORDS,
21 INCREASE THE -- ALLOW A PHYSICAL THERAPY REGIME TO TAKE PLACE
22 THAT WILL GET THEM BACK TO THEIR PRE-OPERATIVE STATUS.
23 AMBULATING, STRENGTH, AND ALSO TO PROVIDE FOR THEM THE CARE
24 WHICH A LOT OF TIMES WHEN THEY LIVE AT HOME THEY CAN'T
25 PROVIDE FOR THEMSELVES.
1 Q. DID YOU SEE HER IN FOLLOW-UP AT ALL?
2 A. THAT'S A GOOD QUESTION. I DON'T HAVE MY RECORDS. I'M
3 NOT SURE. I -- I BELIEVE I DID.
4 Q. DO YOU RECALL ANYTHING ABOUT HER APPEARANCE OR THE WAY
5 SHE ACTED OR ANYTHING OF THAT SORT IF YOU DID FOLLOW UP WITH
6 HER?
7 A. NOTHING SIGNIFICANT.
8 Q. OKAY.
9 MS. BARLOW: YOUR HONOR, MAY I APPROACH THE WITNESS?
10 THE COURT: YOU MAY.
11 MR. BUGDEN: THAT'S FINE. THANKS.
12 Q. (BY MS. BARLOW) I'M SHOWING YOU WHAT IS FROM EXHIBIT 2-A
13 AND IT'S NH -- IT'S TWO PAGES CALLED NH515 AND NH516. DO YOU
14 RECOGNIZE THOSE?
15 A. THOSE ARE -- THOSE ARE -- THIS IS A DIRECTIVE. IT'S
16 CALLED A MEDICAL TREATMENT PLAN. IT IS A -- A DIRECTIVE TO
17 ALLOW FOR CARE OF A PATIENT PREOPERATIVELY AND
18 POST-OPERATIVELY TO MANAGE THEIR CARE, AND A LOT OF
19 SITUATIONS WHERE WE FIND THAT THE PATIENT IS NOT CAPABLE OF
20 MAKING THE DECISIONS OR WE FEEL MAY NOT BE CAPABLE OF MAKING
21 DECISIONS FOLLOWING THE CARE. IN THE ELDERLY ALMOST ALWAYS
22 WHEN PATIENTS COME IN WITH HIP FRACTURES BECAUSE OF THE
23 COMPLICATION RATES AND THINGS, AND -- AND BESIDES THAT THE --
24 THE TIME PERIOD AFTER THE SURGERY FOR A LOT -- IN A LOT OF
25 CASES THERE IS SOME DISORIENTATION THAT TAKES PLACE.
1 AS A RESULT, MOST FAMILIES WILL HAVE US -- AND WE'LL
2 RECOMMEND TO THEM THAT THE -- EITHER THE PATIENT OR THE
3 PATIENT'S REPRESENTATIVE, WHICH IS USUALLY A FAMILY MEMBER,
4 SIGN ONE OF THESE DIRECTIVES ALLOWING US TO DO THE
5 APPROPRIATE TREATMENTS AND DIRECTING US AS TO WHO WILL TAKE
6 RESPONSIBILITY FOR THE DECISIONS FOR THE CARE FOLLOWING THE
7 PROCEDURE, IF SOMETHING SHOULD OCCUR THAT THE PATIENT CAN'T
8 MAKE THOSE APPROPRIATE DECISIONS.
9 Q. OKAY. THIS IS PAGE 515 -- I NEED TO FOCUS - THAT YOU
10 INDICATE IS A MEDICAL TREATMENT PLAN.
11 A. THAT'S CORRECT.
12 Q. THE TOP PART THERE -- FOCUS IS NOT REALLY GOOD. MAYBE
13 THAT WILL HELP A LITTLE BIT.
14 THE TOP PART, IT SAYS, I, MICHAEL H. SUMKO, CERTIFY THAT
15 I AM THE ATTENDING PHYSICIAN FOR ELLEN T. ANDERSON.
16 DID YOU FILL OUT THAT PART?
17 A. I DID NOT FILL THAT PORTION OUT.
18 Q. OKAY. AND THEN IT -- IT -- I CAN'T SEEM TO GET THAT --
19 MAYBE IT'S MY EYES.
20 IT SAYS THE DECLARANT, THE ABOVE-NAMED PATIENT, IS
21 CURRENTLY SUFFERING FROM THE FOLLOWING INJURY, DISEASE, OR
22 ILLNESS. AND DID YOU WRITE --
23 A. THAT'S --
24 Q. -- THAT PART?
25 A. I DID WRITE RIGHT HIP FRACTURE.
1 Q. AND YOU CERTIFY YOU'VE EXPLAINED, TO THE EXTENT ABLE TO
2 UNDERSTAND, THE AVAILABLE -- EXCUSE ME, THE REASONABLY
3 AVAILABLE ALTERNATIVES FOR CARE AND TREATMENT. AND YOU HAVE
4 CHECKED ONE OF THOSE BOXES. WHAT DOES THAT MEAN?
5 A. IT INDICATES BASICALLY THAT THE PATIENT, AS YOU'LL SEE
6 THERE, IS NOT CAPABLE OF MAKING OR IS -- THE FAMILY MEMBER
7 FEELS THAT THEY'RE NOT CAPABLE OR MAY NOT BE CAPABLE IN THE
8 FUTURE OF MAKING DECISIONS THAT WOULD BE IN THEIR BENEFIT
9 TOWARDS THEIR -- THEIR CARE.
10 Q. AND THIS IS CALLED AN ADVANCE DIRECTIVE?
11 A. EXACTLY.
12 Q. IT'S WHAT DIRECTS MEDICAL CARE OR WITHHOLDING OF MEDICAL
13 CARE?
14 A. EXACTLY. AND SOME OF THOSE DESCRIPTIONS IN THAT
15 PARAGRAPH, THE VERY LOWEST PARAGRAPH, KIND OF TELL WHAT
16 THEY -- THE FAMILY WANTS DONE AS FAR AS THEY DON'T WANT ANY
17 EXCESSIVE CARDIAC RESUSCITATION AND THINGS LIKE THAT. ONCE
18 IN A WHILE WE'LL GET THESE -- ALMOST ALWAYS WE'LL GET THEM
19 PRIOR TO SURGERY, THE DAY OF SURGERY OR PRIOR TO SURGERY.
20 THIS ONE WAS DONE, AS YOU'LL NOTE, ON THE 17TH OF JULY.
21 NORMALLY THAT'S BECAUSE THE PIONEER CARE CENTER WHERE SHE'S
22 AT WILL ASK THE FAMILY -- SOMETIMES THEY'LL APPROACH THEM AND
23 SAY, YOU KNOW, SHE'S 91 YEARS OLD, WOULD YOU LIKE US TO HAVE
24 A MEDICAL DIRECTIVE ON THE CHART? AND THAT'S SOMETIMES
25 WHEN -- THE FIRST TIME THEY'LL HAVE A MEDICAL DIRECTIVE.
1 A LOT OF TIMES THOUGH IN THE HOSPITAL, IF THEY'RE VERY
2 HIGH RISK FOR SURGERY, ALMOST ALWAYS WE'LL GET THAT PRIOR TO
3 THE PROCEDURE.
4 Q. DID YOU SUGGEST ANY OF THESE THINGS THAT THEY --
5 A. NO, SOMEONE ELSE WROTE THAT IN THERE. I'M NOT SURE
6 WHOSE -- USUALLY THAT'S THE FAMILY OR IT WILL BE ONE OF THE
7 NURSES AT THE CARE CENTER. THE -- WHOEVER WROTE DAUGHTER
8 THERE, IT LOOKS LIKE IT'S THE SAME HANDWRITING. I WOULD
9 IMAGINE -- I'M NOT SURE.
10 Q. OKAY. WOULD YOU CALL WHAT THEY PUT IN HERE HEROIC
11 MEASURES, AS THAT TERM IS OFTEN USED?
12 A. I WOULD THINK THAT'S -- YES. THOSE ARE MEASURES THAT WE
13 TAKE TO THE POINT WHERE WE FEEL EVERYTHING HAS BEEN EXHAUSTED
14 IN ATTEMPTING TO SAVE THIS PERSON'S LIFE.
15 Q. AND WHAT WAS THE PURPOSE OF THE ADVANCE DIRECTIVE IN
16 RELATIONSHIP TO HEROIC MEASURES THEN?
17 A. IT ALLOWS A -- IT ALLOWS A -- A PHYSICIAN TO NOT HAVE TO
18 MAKE THAT DECISION THAT ALL THOSE HEROIC METHODS BE APPLIED
19 TO THE PATIENT IN THE PROCESS OF TRYING TO SAVE THEIR LIVES.
20 IN OTHER WORDS IT SAYS, WHAT YOU'RE GOING TO DO IS SOME BASIC
21 THINGS, BUT YOU'RE NOT GOING TO DO ALL THESE, PUT THEM ON A
22 VENTILATOR WHICH WILL -- COULD MEAN THAT SHE COULD BE ON THAT
23 VENTILATOR FOR YEARS WHICH MAINTAINS HER LIFE, BUT THE
24 QUALITY OF LIVING OBVIOUSLY IS ZERO.
25 MR. BUGDEN: COUNSEL, I'M GOING TO USE IT, IF YOU'RE
1 ALMOST DONE.
2 MS. BARLOW: OH. YES, I AM ALMOST DONE SO -- IN
3 FACT, I THINK THOSE ARE ALL THE QUESTIONS I HAVE. THANK YOU,
4 DR. SUMKO.
5 THE COURT: CROSS-EXAMINE, MR. BUGDEN?
6 MR. BUGDEN: YES, SIR.
7 CROSS-EXAMINATION
8 BY MR. BUGDEN:
9 Q. DR. SUMKO, I'M WALTER BUGDEN. I'M ONE OF THE LAWYERS
10 REPRESENTING DR. WEITZEL. I'VE GOT A FEW QUESTIONS FOR YOU,
11 DR. SUMKO.
12 THIS PATIENT HAD OSTEOPOROSIS; IS THAT RIGHT?
13 A. THAT'S -- NORMALLY AT AGE 91 THEY -- EVERYONE'S BONES DO
14 THIN OUT, SO I WOULD -- HAVING NOT DONE A BONE DENSITY TEST
15 ON HER, I COULDN'T TELL YOU THAT FOR SURE, BUT I WOULD SAY
16 THAT IT'S HIGHLY LIKELY.
17 Q. THERE'S BEEN OTHER TESTIMONY THAT SHE HAD THAT, OTHER
18 TESTIMONY THAT SHE HAD COMPRESSION FRACTURES OF THE SPINE?
19 A. WHICH ARE TYPICAL OF THE CLINICAL -- THE CLINICAL
20 PRESENTATION OF OSTEOPOROSIS.
21 Q. OKAY. NOW, THIS 91-YEAR-OLD WOMAN FRACTURED HER HIP AS
22 YOU'VE EXPLAINED IT; IS THAT RIGHT?
23 A. THAT'S CORRECT.
24 Q. AND SURGERY ON A 91-YEAR-OLD PERSON IS NOT REALLY A
25 DESIRABLE THING; IS THAT RIGHT?
1 A. NO.
2 Q. I MEAN, IT'S -- BOTH BECAUSE OF JUST THE REALITY OF THE
3 SITUATION THAT THE PATIENT'S VERY, VERY OLD; IS THAT RIGHT?
4 A. THAT'S CORRECT.
5 Q. AND SURGERY IS DANGEROUS FOR ALL OF US.
6 A. EXACTLY.
7 Q. MORE DANGEROUS FOR AN OLDER PERSON.
8 A. THAT'S CORRECT.
9 Q. AND, IN FACT, WITH HIP SURGERIES THERE -- THERE IS A
10 KNOWN MORTALITY RATE FROM THE HIP SURGERY ITSELF, ISN'T IT?
11 A. 3.1 PERCENT OF ALL PATIENTS WHO HAVE HIP FRACTURES WILL
12 DIE WITHIN THE FIRST YEAR.
13 Q. OKAY. AND SO FOR THIS -- FOR THIS PATIENT YOU MET WITH
14 THE FAMILY AND THE DECISION WAS MADE THAT IN ORDER FOR THIS
15 PATIENT TO NOT SUFFER PAIN THE REST OF HER LIFE, REALLY THE
16 OPTION WAS TO HAVE THE SURGERY.
17 A. THAT'S CORRECT.
18 Q. AND TO ACCEPT THE CONSEQUENCES, POSSIBLY THE NEGATIVE
19 CONSEQUENCES OF SURGERY.
20 A. THAT'S CORRECT.
21 Q. AND NOT TO PUT TOO FINE A POINT ON IT, BUT, I MEAN, WHAT
22 COULD -- THE -- THE BAD THING THAT COULD HAPPEN IS THAT THE
23 PATIENT COULD PASS AWAY.
24 A. THAT'S CORRECT.
25 Q. SO IN ORDER TO ENSURE POSSIBLY A PAIN-FREE REMAINDER OF
1 HER LIFE, THE FAMILY'S THE ONE THAT DECIDED ON HIP SURGERY.
2 A. AT -- AT THIS POINT, I CAN'T RECALL. AGAIN, I'D HAVE TO
3 LOOK AND SEE WHO SIGNED IT, BUT I -- NORMALLY WE DISCUSS IT
4 WITH A FAMILY MEMBER AS WELL AS THE PATIENT.
5 Q. OKAY. NOW, AM I RIGHT, DOCTOR, THAT NORMALLY PHYSICIANS
6 WOULD HAVE THE MEDICAL TREATMENT PLAN IN PLACE OR ADVANCE
7 DIRECTIVE IN PLACE BEFORE YOU DO SURGERY?
8 A. THAT'S CORRECT. NORMALLY THE FAMILY WILL REQUEST IT OR
9 THE NURSING STAFF, BEFORE WE DO THE PROCEDURE, WILL SUGGEST
10 IT, PARTICULARLY IF WE FEEL THEY'RE AN EXTREMELY HIGH RISK AT
11 SURGERY -- AT THE TIME OF SURGERY.
12 Q. AND FOR SOME REASON IN THIS CASE THE MEDICAL TREATMENT
13 PLAN THAT I'LL SHOW YOU IN A MOMENT THAT WE'VE JUST TALKED
14 ABOUT, THAT WASN'T ACTUALLY EXECUTED BY ONE OF THE DAUGHTERS
15 UNTIL JULY 17TH.
16 A. THAT'S CORRECT. MORE THAN LIKELY THE NURSING HOME
17 REQUESTED THAT.
18 Q. THANK YOU. AND THAT'S ABOUT A MONTH AFTER --
19 POST-SURGERY; IS THAT RIGHT?
20 A. THAT'S CORRECT. UH-HUH.
21 Q. AND -- NOW, BEFORE YOU DID THE SURGERY I THINK YOU
22 EXPLAINED TO THE JURY THAT THERE WAS AN X-RAY, A PRESURGERY
23 X-RAY THAT WAS DONE?
24 A. YES. CHEST X-RAYS ARE DONE PRIMARILY AS A BASELINE TO
25 SHOW US WHAT -- IF -- IF SOMETHING OCCURS WITHIN THIS -- THE
1 RELATIVE POST-OPERATIVE PERIOD, THE FIRST FEW DAYS AND
2 USUALLY PNEUMONIA, WE WANT TO KNOW WHAT THE CHEST LOOKED LIKE
3 PRIOR TO THAT BECAUSE A LOT OF TIMES OLDER PEOPLE WILL
4 HAVE -- ALREADY HAVE SOME ATELECTASIS, WHICH IS KIND OF A
5 COLLAPSING OF THE SMALL PORTIONS OF THE LUNG, AND -- OR THEY
6 ALREADY HAVE SOME OF THE SIGNS THAT THE LUNGS AREN'T
7 COMPLETELY FILLING. AND SO YOU WANT -- IF YOU TAKE A
8 POST-OPERATIVE X-RAY, YOU CAN'T TELL SOMETIMES WHAT'S
9 PNEUMONIA AND WHAT ISN'T.
10 Q. SO YOU NEED --
11 A. SO AS A BASELINE.
12 Q. RIGHT. YOU NEED THE BASELINE SO YOU CAN COMPARE.
13 A. EXACTLY.
14 Q. OKAY. AND WITH THE BASELINE, PRESURGERY X-RAY, WHAT YOU
15 FOUND WAS THAT THIS PATIENT DID HAVE EVIDENCE OF
16 ATHEROSCLEROTIC VASCULAR DISEASE.
17 A. THAT'S CORRECT.
18 Q. AND ATHEROSCLEROTIC VASCULAR DISEASE IS THE CALCIFICATION
19 OF THE ARTERIES?
20 A. THAT'S CORRECT.
21 Q. AND THE CALCIFICATION OF THE ARTERIES OBVIOUSLY MEANS THE
22 NARROWING OF -- OF THE ARTERIES?
23 A. THAT'S CORRECT.
24 Q. AND SO THAT'S A FORM OF CORONARY ARTERY DISEASE?
25 A. THAT'S CORRECT.
1 Q. AND THAT IS A SITUATION THEN THAT CAN LEAD TO A HEART
2 ATTACK?
3 A. IT CAN.
4 Q. OKAY. AND, DOCTOR, YOU'VE INDICATED TO THE JURY THAT
5 THIS PERSON -- WELL, OF COURSE, THE JURY ALREADY KNOWS THAT
6 THIS WOMAN WAS 91 YEARS OLD. AND AT 91 YEARS OLD,
7 PARTICULARLY SOMEONE WHO DOES SUFFER FROM OR HAS THE
8 CONDITION OF ATHEROSCLEROTIC VASCULAR DISEASE, THAT'S SOMEONE
9 THAT COULD PASS AWAY TOMORROW.
10 A. SURELY COULD.
11 Q. AND THEY COULD -- 91 IS A FAR ADVANCED AGE.
12 A. EXACTLY.
13 Q. THIS WAS A FRAIL WOMAN; IS THAT RIGHT?
14 A. EXACTLY.
15 Q. AND WITH THAT KIND OF A HEART DISEASE, THE PERSON COULD
16 APPEAR TO BE HEALTHY TODAY, BUT THEY COULD PASS AWAY --
17 A. THAT'S A POSSIBILITY.
18 Q. -- FROM THAT HEART DISEASE TOMORROW.
19 A. EXACTLY. AND THEN WE'RE DOING A SURGERY WHICH OBVIOUSLY
20 IS GOING TO PUT STRESS ON THE SYSTEM. THERE'S AN INCREASED
21 RISK OF THAT. THE MEDICATION WHICH I GIVE HER AFTERWARDS,
22 INCREASED RISK OF THAT. THE STRESS WHICH SHE'LL BE UNDER FOR
23 PHYSICAL THERAPY AFTERWARDS, INCREASED RISK. ALL THESE
24 THINGS ARE THINGS WHICH WILL STRESS HER SYSTEM OVER THE FIRST
25 30 DAYS AFTER SURGERY.
1 Q. I'M MYS -- HOLD ON.
2 A. I'M SORRY?
3 Q. I'M MYSTIFIED HERE.
4 MS. BARLOW: LIGHTS.
5 Q. (BY MR. BUGDEN) OKAY. THIS IS THE -- LET'S SEE. SORRY
6 FOR STEPPING IN FRONT OF YOU HERE.
7 THIS IS THE SAME MEDICAL TREATMENT PLAN YOU'VE ALREADY
8 TALKED ABOUT, DOCTOR. I'M GOING TO JUST ASK YOU --
9 A. OKAY.
10 Q. -- NOT TOO MUCH MORE. HEY. THANK YOU.
11 SO THIS WAS THE ADVANCE DIRECTIVE OR THE MEDICAL
12 DIRECTIVE THAT WAS PUT IN PLACE POST-SURGERY.
13 A. THAT'S CORRECT.
14 Q. AND IT'S -- IT'S OFF THE SCREEN NOW, BUT YOU CERTIFIED AS
15 THE ATTENDING PHYSICIAN THAT MRS. ANDERSON WAS NOT ABLE TO
16 SIGN FOR HERSELF AT THAT POINT.
17 A. I WOULD HAVE TO SAY YES ONLY BECAUSE -- AGAIN, I DON'T
18 RECALL THE CIRCUMSTANCES, BUT AS I -- AS I INDICATED A LOT OF
19 TIMES WHAT WILL OCCUR IS THAT THE NURSING HOME -- NURSING
20 HOME WILL, AS PART OF THEIR PROCEDURE ON A PATIENT, HAVE ONE
21 OF THESE AT THE -- AT THE PERMISSION AS WELL AS THE
22 PATIENT -- OF A PATIENT TO HAVE ONE OF THESE ON THEIR RECORD
23 IN CASE, AGAIN, SOMETHING POST-OPERATIVELY OCCURS
24 COMPLICATION-WISE.
25 Q. I APPRECIATE THAT. LET ME -- YOU HAVE THE FULL DOCUMENT
1 AND THE JURY DOESN'T QUITE HAVE THIS THE WAY WE'VE SET THIS
2 UP, BUT, I MEAN, WHAT'S BEEN CHECKED OFF AND THEN YOU SIGNED,
3 IT'S JUST ABOVE YOUR SIGNATURE --
4 A. UH-HUH.
5 Q. -- BUT I THINK YOU HAVE IT IN FRONT OF YOU.
6 A. I DON'T HAVE IT IN FRONT OF ME.
7 MR. BUGDEN: MAY I APPROACH THE WITNESS, JUDGE?
8 THE COURT: YOU MAY.
9 Q. (BY MR. BUGDEN) THERE'S A CHECK MARK --
10 A. THAT'S RIGHT.
11 Q. -- AND THAT CHECK MARK IS TO A PARAGRAPH THAT SAYS THAT
12 THE DECLARANT HAS A PHYSICAL OR MEDICAL CONDITION WHICH
13 RENDERS HIM/HER UNABLE TO GIVE PERSONAL DIRECTIVES FOR CARE
14 AND TREATMENT. THAT THE CARE AND TREATMENT ALTERNATIVES
15 DIRECTED BELOW ARE IN MY OPINION AND IN THE OPINION OF THE
16 DECLARANT'S PROXY WHAT THE DECLARANT WOULD PROBABLY DECIDE IF
17 ABLE TO GIVE CURRENT DIRECTIONS CONCERNING HIS/HER CARE AND
18 TREATMENT.
19 A. THAT'S CORRECT.
20 Q. AND THEN YOU CERTIFIED THAT THAT SITUATION EXISTED. AND
21 THEN BARBARA POELMAN, A DAUGHTER OF ELLEN ANDERSON, SIGNED ON
22 BEHALF OF MRS. ANDERSON.
23 A. THAT'S CORRECT.
24 Q. AND THIS IS ABOUT A MONTH POST-SURGERY THAT THIS WAS
25 DONE, RIGHT?
1 A. THAT'S CORRECT.
2 Q. AND COUNSEL HAS TALKED ABOUT NO HEROIC MEASURES THAT --
3 THAT -- SHE SORT OF SUMMARIZED THIS AND I THINK YOU AGREED
4 THAT ESSENTIALLY WHAT WAS AGREED ON BY THE FAMILY WAS THAT NO
5 HEROIC MEASURES WOULD BE TAKEN; IS THAT RIGHT?
6 A. THAT'S CORRECT.
7 Q. AND WHAT THE DOCUMENT ACTUALLY PROVIDED FOR IN TERMS OF
8 HOW MUCH THE FAMILY WANTED TO DO WITH THEIR MOM WAS FIRST,
9 WITHHOLD OXYGEN THERAPY, WITHHOLD RESPIRATION TREATMENTS.
10 A. RESPIRATOR TREATMENTS.
11 Q. RES -- RESPIRATOR TREATMENTS.
12 A. RIGHT. WHICH IS LIKE A VENTILATOR WHICH MEANS IT
13 MECHANICALLY BREATHES FOR YOU.
14 Q. NO SUCTIONING. DOES IT SAY THAT?
15 A. THAT'S CORRECT.
16 Q. NO MECHANICAL VENTILATION.
17 A. CORRECT.
18 Q. VENTILATOR SUPPORT.
19 A. CORRECT.
20 Q. NO C.P.R.
21 A. CORRECT.
22 Q. NO CHEST COMPRESSIONS, NO CARDIAC MEDICATIONS DURING
23 C.P.R., NO DEFIBRILLATION, NO CHEMO THERAPY/RADIATION, NO
24 ADDITIONAL SURGERY.
25 A. THAT'S CORRECT.
1 Q. SHE'S HAD YOUR SURGERY.
2 A. THAT'S CORRECT.
3 Q. YOUR HIP SURGERY. BUT IT ALSO SAYS NO I.V. FLUIDS,
4 RIGHT?
5 A. THAT'S CORRECT.
6 Q. I.V. FLUIDS ARE A PRETTY NORMAL THING TO TREAT ALL KINDS
7 OF PROBLEMS; ISN'T THAT TRUE?
8 A. THEY ARE, BUT DURING THE PROCESS OF RESUSCITATION THAT'S
9 THE PRIMARY MEANS BY WHICH WE GET MEDICATIONS TO THE
10 CIRCULATION OF THE HEART SYSTEM AND THE CARDIOVASCULAR SYSTEM
11 GIVEN THROUGH THE I.V. FLUIDS.
12 Q. WELL, THE CHEMOTHERAPY/RADIATION, THOSE ARE LONG-TERM
13 TREATMENTS.
14 A. THAT'S CORRECT.
15 Q. THAT'S NOT A -- AN URGENT, EMERGENT PROBLEM, RIGHT?
16 A. NO. THAT'S CORRECT.
17 Q. AN N.G. GASTRIC TUBE.
18 A. THOSE ARE FOR FEEDING, LONG-TERM FEEDING THINGS.
19 Q. SO THEY DIDN'T WANT THAT.
20 A. THEY DIDN'T WANT THAT.
21 Q. AND THEY EVEN WANTED SOMEONE TO SPEAK WITH MRS. POELMAN
22 OR AN AUTHORIZED BEFORE USING ANTIBIOTICS.
23 A. THAT'S CORRECT.
24 Q. SO THE FAMILY HAD PUT SOME -- SOME CONSIDERATION, SOME
25 THOUGHT INTO WHAT THEY WANTED TO BE DONE AND THEY DIDN'T EVEN
1 WANT I.V. -- I.V. TREATMENTS GIVEN TO THEIR MOM; IS THAT
2 RIGHT?
3 A. EXACTLY.
4 Q. NOW, ONE OF THE DAUGHTERS AND PERHAPS BOTH OF THE
5 DAUGHTERS HAVE TESTIFIED THAT POST SURGERY THEY REALLY SAW A
6 MENTAL DECLINE IN THEIR MOTHER. IS THERE ANY WAY TO
7 CORRELATE THAT TO THE SURGERY OR WAS THAT --
8 A. IT CAN -- IT CAN BE CORRELATED TO THE SURGERY.
9 OCCASIONALLY IT IS DUE TO POST-OPERATIVE MEDICATIONS. WHEN
10 WE -- WHEN THEY ARE, AGAIN, UNDER THE INFLUENCE OF STRONGER
11 NARCOTICS THAN THEY HAVE BEEN ON BEFORE, AND SHE -- AS I
12 ORIGINALLY INDICATED SHE WAS ON DARVOCET WHICH IS A VERY
13 MILD, MILD FORM OF NARCOT -- NARCOTIC. WHEN THEY'RE ON
14 NARCOTICS SUCH AS EVEN LORTAB, ANY CHANGE IN THEIR REGIMENT
15 DRUG-WISE CAN CAUSE DISORIENTATION. ALSO, THE FACT THAT
16 THEY'RE IN STRANGE CIRCUMSTANCES. THEY'VE HAD A STRANGE
17 ENVIRONMENT. THEY HAVE NOT BEEN IN THEIR OWN HOME. IN
18 ELDERLY PEOPLE THAT CAN CAUSE DISORIENTATION. THEY -- WE
19 USUALLY CALL IT SUNDOWNING. IT SEEMS LIKE AT NIGHTTIME THEY
20 JUST GET CONFUSED AND HAVE NO IDEA WHERE THEY'RE AT,
21 SOMETIMES DUE TO THE MEDICATION, SOMETIME DUE TO THE
22 ENVIRONMENT. SOME STRANGE PERSON COMES IN EVERY COUPLE OF
23 HOURS AND TAKES THEIR TEMPERATURE AND CHECKS THEM AND CHECKS
24 THEIR POSITION IN BED OR TURNS THEM OVER THEN, COULD BE
25 THINGS LIKE THAT. SO THERE'S A LOT OF REASON FOR THAT TO
1 OCCUR.
2 Q. THERE WAS NO EVIDENCE OF PNEUMONIA WHEN YOU WERE TREATING
3 THE PATIENT.
4 A. NO.
5 Q. THE LUNGS WERE OKAY AT THAT TIME?
6 A. THEY WERE.
7 MR. BUGDEN: DOCTOR, THANK YOU VERY MUCH.
8 THE COURT: REDIRECT?
9 MS. BARLOW: JUST A COUPLE OF MATTERS I THINK TO
10 HELP TO CLARIFY.
11 REDIRECT EXAMINATION
12 BY MS. BARLOW:
13 Q. YOU INDICATED THAT YOU NORMALLY DID A MEDICAL TREATMENT
14 PLAN, A ADVANCE DIRECTIVE BEFORE SURGERY IF YOU THOUGHT A
15 PATIENT WAS HIGH RISK.
16 A. NORMALLY DID, ESPECIALLY IF THEY'RE HIGH RISK. WE -- WE
17 REQUEST IT IF THEY'RE HIGH RISK. IF I FEEL LIKE I'M GOING
18 INTO THAT SURGERY WITH THE RISK THAT SHE MAY NOT COME OUT OF
19 THAT SURGERY, I WILL DO AN ADVANCE DIRECTIVE BEFORE. AND I
20 ALMOST ALWAYS -- WE -- WE CALL IT HANGING THE CREPE, SO TO
21 SPEAK. WE ALWAYS HANG THAT BLACK CREPE IF THERE'S A CHANCE
22 DURING THE SURGERY THAT SHE MAY NOT SURVIVE IT. IT'S GOING
23 TO BE A LOT OF STRESS ON HER SYSTEM AND THERE'S A -- THERE'S
24 A CHANCE SHE MAY NOT SURVIVE IT.
25 SO WE'LL DO THAT UNLESS WE FEEL THE PATIENT IS -- IS
1 PHYSICALLY IN PRETTY GOOD SHAPE AND IS OBVIOUSLY GOING TO --
2 A HIGH RISK THAT SHE WILL -- SHE WILL SURVIVE THE SURGERY.
3 Q. YOU'VE MENTIONED A LITTLE BIT ABOUT ATELECTASIS. WHAT
4 TREATMENT IS THERE FOR ATELECTASIS, THIS -- THIS -- WHAT?
5 COLLAPSES OF THE --
6 A. COLLAPSING OF THE LITTLE -- THE LITTLE ALVEOLI OF THE
7 LUNGS, THE VERY SMALL LITTLE SACS IN THE LUNGS, MICROSCOPIC
8 SACS. THEY WILL COLLAPSE WHEN -- FOR UNDER VARIOUS REASONS.
9 WHEN THEY'RE GIVEN MEDICATIONS THAT SUPPRESS THEIR BREATHING,
10 THOSE LITTLE SACS DON'T GET IN -- OR DON'T GET INFLATED WITH
11 AIR. AS A RESULT, THEY START TO COLLAPSE.
12 THERE IS A STICKY SUBSTANCE WITHIN THAT LITTLE ALVEOLI
13 THAT ONCE THEY COLLAPSE ON ITSELF, HAS A HARD TIME GETTING
14 REINFLATED. SO A LOT OF TIMES WHAT WE'LL DO IS IMMEDIATELY
15 AFTER SURGERY WE'LL PUT THEM ON A SENSE BAROMETRY WHICH IS
16 EVERY TWO HOURS THE -- THE NURSE WILL COME IN OR THE
17 RESPIRATORY THERAPIST WILL COME IN WITH A LITTLE MECHANISM
18 WHICH THEY BREATHE INTO. AND IT REQUIRES THEM TO TAKE DEEP
19 BREATHS AND BLOW OUT AND FORCE A LITTLE BALL UP TOWARDS A --
20 AN ALTITUDE OFF OF A FLAT SURFACE WHICH ALLOWS YOU TO SEE HOW
21 MUCH THEY'RE EXPIRING AND -- AND INSPIRING.
22 Q. AND IS THE DEEP BREATH HELPFUL FOR THE ATELECTASIS?
23 A. IT IS. IT IS. OBVIOUSLY THOSE LITTLE AIRWAYS THAT ARE
24 COLLAPSING, IT WILL ATTEMPT TO PUT POSITIVE PRESSURE BEHIND
25 THAT TO -- TO CAUSE THOSE TO EXPAND.
1 MS. BARLOW: MAY I APPROACH THE WITNESS, YOUR HONOR?
2 THE COURT: YOU MAY.
3 MS. BARLOW: THIS IS FROM 2-A AND IT'S NURSING
4 HOME 296.
5 Q. (BY MS. BARLOW) DR. SUMKO, I'M SHOWING YOU A DOCUMENT
6 THAT IS FROM THE BRIGHAM CITY COMMUNITY HOSPITAL.
7 THE COURT: THAT IS EXHIBIT 2-A, MS. BARLOW?
8 MS. BARLOW: IT'S OUT OF 2-A, PAGE 296.
9 A. THIS IS HER ADMISSION HISTORY AND PHYSICAL EXAMINATION.
10 Q. (BY MS. BARLOW) DID YOU DO THAT HISTORY AND PHYSICAL?
11 A. I DID.
12 Q. I THINK HALFWAY DOWN THE PAGE --
13 A. UH-HUH.
14 Q. -- THERE'S A SECTION --
15 A. PHYSICAL?
16 Q. -- PAST MEDICAL HISTORY.
17 A. THAT'S CORRECT.
18 Q. CAN YOU READ WHAT -- WHAT YOU WROTE AT THAT TIME?
19 A. IT'S NOT SIGNIFICANT FOR ANY HEART, LUNG, LIVER, KIDNEY
20 OR BLOOD PRESSURE PROBLEMS. SO SHE WAS NOT ON ANY
21 MEDICATIONS TO MAINTAIN ANY HEART, LUNG, LIVER, OR KIDNEY OR
22 BLOOD PRESSURE PROBLEMS. THOSE ARE THE PRIMARY SYSTEMS WE
23 LOOK AT PRIOR TO SURGERY WHICH CAN OBVIOUSLY COLLAPSE OR HAVE
24 PROBLEMS AFTER SURGERY.
25 SHE'S ESSENTIALLY HEALTHY, WHICH SHE WAS. SHE TAKES
1 AMITRIPTYLINE AT BEDTIME AND DARVOCET FOR PAIN. THOSE ARE
2 THE TWO MEDICATIONS. SHE HAS NO ALLERGIES TO MEDICATIONS.
3 SHE'S HAD TWO SURGERIES IN THE PAST, A CHOLECYSTECTOMY,
4 WHICH IS REMOVAL OF GALLBLADDER; AND A COLON RESECTION WHICH
5 OBVIOUSLY SOME GENERAL SURGEON TOOK A PORTION OF HER LARGE
6 INTESTINES OUT BECAUSE THERE WAS SOME PROBLEM.
7 SHE DOES NOT SMOKE.
8 (COURT REPORTERS ASK WITNESS TO SPEAK SLOWER.)
9 A. OH, I'M SORRY.
10 SHE HAS DOES NOT SMOKE OR DRINK ALCOHOL.
11 Q. THANK YOU.
12 WELL, THEN I -- I THINK I WILL HAVE YOU JUST READ THE
13 PHYSICAL EXAMINATION AS WELL.
14 A. OKAY. I WILL.
15 Q. SLOWLY, PLEASE.
16 A. SLOWLY. SHE'S ALERT AND COOPERATIVE. SHE'S A ORIENTED
17 FEMALE. SO I -- BY THOSE STATEMENTS I INDICATE TO HER THAT
18 IF I GO IN AND TALK TO HER AND SAY WHO ARE YOU --
19 MR. BUGDEN: HE WAS ASKED TO READ THE DOCUMENT
20 AND --
21 THE COURT: WELL, I'LL OVERRULE THE OBJECTION. GO
22 AHEAD.
23 A. SHE -- SHE'S ALERT, COOPERATIVE, ORIENTED. SHE HAS MILD
24 PROBLEMS WITH ORIENTATION OCCASIONALLY. AND USUALLY THAT
25 ORIENTATION MEANS THAT I'LL ASK THEM WHERE THEY'RE AT OR WHAT
1 THE DATE IS, AND SOMETIMES THEY'LL GIVE ME THE WRONG,
2 INCORRECT DATE OR THEY'LL SAY I'M AT HOME, WHICH DOESN'T MEAN
3 THEY'RE -- THEY'RE SO TOTALLY OUT OF IT THAT I SAY THEY'RE --
4 YOU KNOW, THEY'RE DEMENTED, BUT THEY'RE DISORIENTED AND
5 SOMETIMES THAT CAN OCCUR WITH PAIN -- WITH MEDICATIONS.
6 BUT SHE HAS PROBLEMS WITH ORIENTATIONS OCCASIONALLY
7 WHICH MEANS I MUST HAVE DURING THE PHYSICAL EXAM ASKED HER
8 SOME QUESTIONS, AND SHE INDICATED TO ME EITHER ANSWERS THAT
9 WERE NOT TOTALLY CORRECT OR INCORRECT TO THE POINT WHERE I
10 INDICATED THAT.
11 HER EXAMINATION OF HER HEAD, EYES, EARS, NOSE AND THROAT
12 WERE UNREMARKABLE.
13 Q. SLOWLY. SLOWLY.
14 A. OKAY. HER CHEST WAS CLEAR OF AUSCULTATION WHICH
15 BASICALLY MEANT THAT I DID NOT HEAR ANY RALES OR BRONCHI
16 INDICATIVE OF DECREASED BREATH SOUNDS OR PNEUMONIA OR
17 ATELECTASIS AT THAT POINT. AND I THINK THAT'S VERIFIED BY
18 HER CHEST X-RAY. HER CHEST -- ESSENTIALLY HER LUNGS WERE
19 CLEAR. HER HEART HAD A REGULAR RATE AND RHYTHM, SO WHICH
20 MEANT THAT I COULD HEAR EACH INDIVIDUAL BEAT AND EACH BEAT
21 WAS NOT STARRED BY ANY OTHER ABNORMAL SOUNDS. HER ABDOMEN
22 WAS SOFT, NON-TENDER. SHE HAD NORMAL BOWEL SOUNDS AND THERE
23 WERE NO MASSES PRESENT.
24 AND THEN I GO THROUGH THE EXTREMITY EXAM WHICH IS A
25 PORTION OF THE EXAM THAT -- WHERE I -- IT OBVIOUSLY GETS A
1 LOT MORE INVOLVED BECAUSE I'M CONCERNED WITH THE EXTREMITIES.
2 THE UPPER EXTREMITIES HAVE A FULL RANGE OF MOTION OF THE
3 SHOULDERS, WHICH MEANS SHE WAS ABLE TO MOVE THEM FOR ME AS I
4 ASKED HER TO MOVE THEM. HER ELBOWS, WRISTS --
5 Q. SLOWLY. SLOWLY, PLEASE.
6 A. ELBOWS, HER WRISTS AND HANDS, NORMAL SENSATION AND NORMAL
7 PULSES. HER LOWER EXTREMITIES HAVE FULL OF RANGE OF MOTION
8 OF THE KNEES AND ANKLES, HOWEVER, THE RIGHT HIP HAS A LIMITED
9 RANGE OF MOTION, SECONDARILY OR PRIMARILY TO THE PAIN WHICH
10 SHE HAS AT THE HIP FRACTURE.
11 Q. AND WHAT DAY DID YOU DO THIS --
12 A. I DID THIS ON THE DATE OF ADMISSION WHICH WOULD HAVE BEEN
13 THE 19TH OF JUNE.
14 Q. OF WHAT YEAR?
15 A. 1995.
16 Q. THANK YOU.
17 AS SHE LEFT YOUR CARE, HAD HER PHYSICAL HEALTH DECLINED
18 AT ALL?
19 A. PHYSICALLY I DON'T BELIEVE SHE HAD GREATLY DECLINED. I
20 KNOW -- I BELIEVE SHE WAS ON THE SAME MEDICATION WHEN SHE
21 CAME IN WITH THE EXCEPTION THAT SHE WAS PLACED ON LORTAB
22 INSTEAD OF DARVOCET WHICH IS A LITTLE STRONGER MEDICATION FOR
23 PAIN.
24 AGAIN, I DON'T RECALL AT THIS TIME IF THERE WERE ANY
25 OTHER SIGNIFICANT PROBLEMS. I DON'T BELIEVE THERE WAS ANY
1 PNEUMONIA. WE NORMALLY DON'T SEND THEM OUT OF THE HOSPITAL
2 WITH THINGS LIKE CLINICAL PNEUMONIA.
3 Q. OKAY.
4 A. SOMETIMES THEY'LL HAVE ATELECTASIS WHICH IS, AGAIN, SOME
5 OF THE MILD COLLAPSE, BUT IT'S NOT ANY COLLECTION OF FLUID,
6 WHICH IS PNEUMONIA. AND AS A RESULT, SOMETIMES I'LL SEE
7 ATELECTASIS AND WE'LL SEND THEM OUT WITH THAT. AND THAT'S
8 NOT AGAIN A -- A SIGNIFICANT CLINICAL PROBLEMS BECAUSE MOST
9 TIMES WITH EXERCISE AND WITH THE BREATHING TREATMENTS, THAT
10 ATELECTASIS WILL CLEAR UP.
11 Q. OKAY.
12 A. THEY DON'T HAVE A FEVER, INDICATIVE AGAIN OF OTHER
13 COMPLICATIONS. THEY DON'T HAVE A FEVER AND THEY DON'T HAVE
14 OBVIOUSLY CHANGES ON THEIR BREATH SOUNDS WITH PNEUMONIA OR
15 CHANGES ON THE CHEST X-RAY, THEN USUALLY WE'LL SEND THEM OUT
16 WITH THOSE TYPE OF -- IN THAT TYPE OF SITUATION.
17 Q. THANK YOU.
18 MS. BARLOW: NO FURTHER QUESTIONS.
19 THE COURT: RECROSS?
20 RECROSS-EXAMINATION
21 BY MR. BUGDEN:
22 Q. WE TALKED ABOUT THE MEDICAL TREATMENT DIRECTIVE AND THAT
23 WAS APPARENTLY -- I'M NOT SURE OF THE DATE, BUT IT WAS JULY
24 27TH --
25 A. JULY 17TH, I BELIEVE.
1 Q. JULY 17TH. THANK YOU.
2 AND AT LEAST BY WAY OF CHART NOTES, YOU -- IT DOESN'T
3 APPEAR THAT YOU SAW ELLEN ANDERSON AGAIN AFTER THAT DATE.
4 A. AFTER THE 17TH, I DON'T BELIEVE I DID. NORMALLY --
5 NORMALLY, WE'LL SEE THEM ONE WEEK POST-OP, FOUR WEEKS
6 POST-OP, AND SIX WEEKS POST-OP.
7 Q. AND SO YOU DIDN'T SEE HER IN AUGUST, SEPTEMBER,
8 OCTOBER --
9 A. I DON'T BELIEVE I DID.
10 Q. -- NOVEMBER, DECEMBER?
11 A. I DON'T BELIEVE I DID.
12 Q. SO FIVE MORE MONTHS PASSED BEFORE SHE PASSED AWAY.
13 A. I WOULD ASSUME SO, YES.
14 Q. AND YOU THOUGHT THAT SHE WAS ONLY MILDLY DISORIENTED WHEN
15 YOU DID YOUR INTAKE EVALUATION ON THE PATIENT --
16 A. THAT'S CORRECT.
17 Q. -- IS THAT CORRECT?
18 A. THAT'S CORRECT.
19 Q. AND WHEN YOU SAW THE PATIENT, SHE WAS NEVER IN THE
20 SITUATION WHERE SHE WAS SAYING THINGS LIKE I, I, I, I, I OVER
21 AND OVER AND OVER AGAIN, WAS SHE?
22 A. NOT THAT I RECALL, NO.
23 Q. SHE WASN'T CHANTING OUT LOUD.
24 A. NOT THAT I RECALL, NO.
25 Q. AND AT LEAST YOU DON'T HAVE A MEMORY TODAY OF THE
1 DAUGHTERS POINTING OUT TO YOU THAT THEY WERE CONCERNED THAT
2 THEIR MOTHER'S MENTAL HEALTH HAD DECLINED SINCE THE SURGERY.
3 YOU DON'T REMEMBER THAT TODAY.
4 A. I DON'T REMEMBER THAT, NO.
5 MR. BUGDEN: THANK YOU.
6 MS. BARLOW: NO FURTHER QUESTIONS, YOUR HONOR.
7 THE COURT: YOU MAY STEP DOWN, DOCTOR.
8 THE WITNESS: THANK YOU.
9 THE COURT: MAY DR. SUMKO BE EXCUSED?
10 MS. BARLOW: YES, YOUR HONOR.
11 THE COURT: MR. BUGDEN?
12 MR. BUGDEN: YES.
13 THE COURT: YOU MAY BE EXCUSED, DOCTOR. THANK YOU
14 FOR COMING.