Rebuttal - Bradford Hare, MD
Doctors, see a grossly misleading statement>>
9 BRADFORD HARE,
10 BEING PREVIOUSLY SWORN, WAS EXAMINED AND TESTIFIED
11 AS FOLLOWS:
12 DIRECT EXAMINATION (REBUTTAL)
13 BY MR. WILSON:
14 Q. DOCTOR, YOU'VE BEEN PREVIOUSLY SWORN. YOU'RE UNDER OATH
15 STILL, YOU UNDERSTAND THAT?
16 A. I DO.
17 Q. OKAY. STATE YOUR FULL NAME FOR THE RECORD, PLEASE.
18 A. BRADFORD D. HARE.
19 Q. AND YOUR PLACE OF EMPLOYMENT, SIR?
20 A. UNIVERSITY OF UTAH.
21 Q. OKAY. PREVIOUSLY YOU TESTIFIED IN THIS PROCEEDING, DID
22 YOU NOT?
23 A. I DID.
24 Q. HAVE YOU HAD OCCASION SINCE THAT TIME TO REVIEW
25 TRANSCRIPTS RELATING TO THE TESTIMONY OF CERTAIN EXPERTS ON
4086
1 BEHALF OF THE DEFENDANT?
2 A. I HAVE.
3 Q. AND CAN YOU TELL US WHAT TRANSCRIPTS YOU'VE REVIEWED IN
4 CONNECTION WITH PREPARATION FOR REBUTTAL TESTIMONY?
5 A. I REVIEWED THOSE OF DR. HILL AND DR. ROTHFEDER.
6 Q. OKAY. YOU WERE ALSO PRESENT IN COURT YESTERDAY FOR
7 CERTAIN PARTS OF THE TESTIMONY OF DR. WEITZEL, IS THAT
8 CORRECT?
9 A. THAT'S CORRECT.
10 Q. OKAY. NOW, PREVIOUSLY, DR. HARE, YOU TESTIFIED AS IT
11 RELATED TO THE USE OF THE DRUG MORPHINE, IS THAT CORRECT?
12 A. I DID.
13 Q. SOME OF THE DEFENDANT'S EXPERTS HAVE TESTIFIED
14 CONCERNING THE MORPHINE THAT ELLEN ANDERSON RECEIVED AT 3:30
15 ON THE 30TH COULD NOT HAVE CONTRIBUTED TO HER DEATH AT 8:55
16 IN THE MORNING. DID YOU SEE OR REVIEW TESTIMONY TO THAT
17 EFFECT?
18 A. YES, I DID.
19 Q. IS THERE ANY EVIDENCE, DOCTOR, IN THE NURSE'S NOTES THAT
20 THAT FIRST DOSE OF MORPHINE SHE HAD AT 1930 WAS IMPACTING
21 HER SOMETIME LATER?
22 A. ABSOLUTELY. VERY CLEAR INDICATIONS.
23 Q. WHAT WERE THOSE INDICATIONS?
24 A. THE SET OF VITAL SIGNS OBTAINED AT ABOUT ONE O'CLOCK IN
25 THE MORNING CLEARLY SHOWED THAT HER BLOOD PRESSURE WAS VERY
4087
1 LOW, HER MENTAL STATUS IS DRAMATICALLY DEPRESSED. SO I
2 THINK IT'S VERY CLEAR THAT EVEN SEVERAL HOURS AFTER SHE'S
3 DRAMATICALLY AFFECTED BY THAT.
4 Q. WOULD THE RESPIRATION RATE OF EIGHT TO 16 REFLECT ANY --
5 IS THAT OF ANY SIGNIFICANCE IN YOUR FINDINGS?
6 A. UNFORTUNATELY, UNDER THE CIRCUMSTANCES, THE VITAL SIGNS
7 WERE OBTAINED VERY INFREQUENTLY, ONLY EVERY EIGHT HOURS. SO
8 WHEN A FIGURE LIKE THAT IS INCLUDED IN THE CHART IT SUGGESTS
9 THAT OVER AN EIGHT HOUR PERIOD THE RESPIRATIONS VARIED FROM
10 EIGHT TO 16. SO A PATIENT WITH A DEPRESSED RESPIRATION FOR
11 EVEN A COUPLE OF HOURS CAN BE IN GREAT TROUBLE. SO THOSE
12 SORTS OF NUMBERS, YOU KNOW, DON'T TELL US THAT AN AVERAGE
13 NUMBER IS ACCEPTABLE.
14 Q. NOW, THIS WOULD BE -- IF THE SHOT WAS ADMINISTERED AT
15 1930 HOURS AND THESE RATES WERE REGISTERED AT ONE O'CLOCK IN
16 THE MORNING, HOW MANY HOURS LATER ARE WE TALKING ABOUT?
17 A. THAT WOULD BE ABOUT SIX HOURS OR SO LATER.
18 Q. OKAY. SO IN YOUR OPINION WAS THE FIRST DOSE, THEN,
19 IMPACTING HER AT THAT TIME?
20 A. I THINK IT'S VERY CLEAR THAT HER VITAL SIGNS WERE STILL
21 VERY MUCH AFFECTED. SINCE THAT WAS THE ONLY TREATMENT, THE
22 ONLY THING THAT HAD CHANGED FROM THE TIME OF ADMISSION, I What about sleeping?
23 THINK IT'S VERY CLEAR THAT THAT DOSE WAS MUCH AFFECTING HER.
24 Q. OKAY. THE DEFENDANT TESTIFIED AS TO AVERAGING THE RANGE
25 OF RESPIRATIONS BETWEEN EIGHT AND 16, BEING 12. IS
4088
1 AVERAGING A RANGE OF RESPIRATIONS A VALID WAY TO TELL IF A
2 PATIENT IS RECEIVING ADEQUATE OXYGENATION?
3 MR. STIRBA: I WOULD OBJECT. THAT MISCHARACTERIZES
4 THE TESTIMONY. I OBJECT TO THE FORM OF THE QUESTION.
5 THE COURT: DO YOU WANT TO REPHRASE IT?
6 Q. (BY MR. WILSON) LET ME REPHRASE IT THIS WAY. CAN YOU
7 AVERAGE A RANGE OF RESPIRATIONS, DOCTOR?
8 A. IT IS NOT VERY VALID. I THINK IT'S MUCH MORE IMPORTANT
9 TO KNOW AT A CERTAIN TIME WHAT THE ACTUAL RESPIRATIONS ARE.
10 SO WE'RE TALKING A RANGE OF EIGHT TO 16 OVER AN EIGHT HOUR
11 PERIOD. THAT COULD MEAN AT CERTAIN TIMES THAT THERE ARE
12 VERY LONG PERIODS OF SIGNIFICANTLY DEPRESSED RESPIRATIONS.
13 THAT CERTAINLY CAN'T BE IGNORED.
14 Q. YOU ALSO REVIEWED HER E.K.G. RESULTS, DID YOU NOT?
15 A. I DID.
16 Q. AND DID THE E.K.G. EVIDENCE ANY SIGNS OF MORPHINE
17 TOXICITY TO YOU?
18 MR. STIRBA: I'LL OBJECT. IT'S CUMULATIVE, YOUR
19 HONOR. HE'S ALREADY TESTIFIED TO IT ON HIS INITIAL
20 TESTIMONY.
21 THE COURT: I'LL ALLOW THAT QUESTION, BUT THEN MOVE
22 ON.
23 Q. (BY MR. WILSON) DID THE E.K.G. EVIDENCE ANY SIGNS OF
24 MORPHINE TOXICITY?
25 A. YES, I THINK IT DID.
4089
1 Q. WHAT WAS THAT, SIR?
2 A. AGAIN, THERE ARE CLEAR INDICATIONS THAT THE BLOOD
3 PRESSURE WAS DRAMATICALLY REDUCED, THE RESPIRATION RATE WAS
4 DRAMATICALLY REDUCED. THE HEART WAS LIKELY NOT GETTING
5 ENOUGH OXYGEN AFTER THE MORPHINE AND AS A RESULT THE E.K.G.
6 WAS ABNORMAL.
7 Q. OKAY. CAN YOU TELL US, DOCTOR, THE SECOND SHOT WAS
8 ADMINISTERED AT 3:30 AND THE TIME OF DEATH WAS 8:55. IS
9 THAT CONSISTENT WITH THE SECOND SHOT?
10 A. YES, IT IS. AGAIN, WE HAVE THE EVIDENCE FROM THE FIRST
11 SHOT --
12 MR. STIRBA: I'LL OBJECT HERE. IT'S NOT RESPONSIVE
13 TO THE QUESTION. THERE'S NO PENDING QUESTION.
14 THE COURT: ASK HIM A QUESTION.
15 Q. (BY MR. WILSON) DID THE SECOND SHOT -- DID THE TIME OF
16 DEATH, IN RELATIONSHIP TO THE SECOND SHOT, BEAR ANY
17 SIGNIFICANCE TO YOU AS TO MORPHINE TOXICITY?
18 A. YES.
19 Q. OKAY. WHAT WAS THAT, DOCTOR?
20 A. AGAIN, I THINK, FROM THE INITIAL DOSE OF MORPHINE IT'S
21 CLEAR THAT IN THIS PATIENT THE EFFECTS OF MORPHINE PERSISTED
22 FOR A LONGER PERIOD THAN WHAT MIGHT OTHERWISE BE EXPECTED.
23 SO I WOULD EXPECT THE SECOND SHOT OF MORPHINE CLEARLY WOULD
24 HAVE A DURATION SIMILAR TO THE FIRST SHOT, AND THAT CLEARLY
25 INCLUDES THE PERIOD OF WHEN THIS PATIENT DIED.
Doctors - this is five and a half hours later!!
4090
1 Q. OKAY. DOCTOR, ASSUMING THAT DR. CANNON TESTIFIED THAT
2 HE DOUBTED THAT PEOPLE CAN BECOME SO SEDATED THEY HAVE TO BE
3 TOLD TO BREATHE, IS THIS SOMETHING YOU DEAL WITH ON A
4 REGULAR BASIS AS AN ANESTHESIOLOGIST?
5 A. I DO.
6 MR. STIRBA: I'LL OBJECT, YOUR HONOR. IT'S BEYOND
7 THE SCOPE OF THE PROFFER AND IT'S NOT REBUTTAL.
8 THE COURT: OVERRULED. LET ME HEAR THE NEXT
9 QUESTION.
10 Q. (BY MR. WILSON) YOU DO DEAL WITH THAT ON A REGULAR
11 BASIS?
12 A. I DO.
13 Q. DOES THIS JUST HAPPEN WITH PEOPLE WHO RECEIVE NARCOTICS?
14 A. WITH A SUFFICIENT DOSE OF NARCOTICS THIS IS A COMMON
15 EFFECT. RESPIRATIONS CAN BE EVEN ELIMINATED. PATIENTS HAVE
16 TO BE REMINDED TO BREATHE. WE SEE THAT EVERY DAY IN THE
17 OPERATING ROOM WHEN WE'RE BEING VERY AGGRESSIVE WITH OUR
18 NARCOTIC DOSING.
19 Q. DOES IT HAPPEN WHEN PEOPLE HAVE A NON-NARCOTIC BUT OTHER
20 CENTRAL NERVOUS SYSTEM DEPRESSANT ON BOARD?
21 MR. STIRBA: I'LL OBJECT AGAIN. IT'S ALREADY BEEN
22 TESTIFIED TO ONCE IN HIS INITIAL TESTIMONY.
23 THE COURT: SUSTAINED.
24 Q. (BY MR. WILSON) DR. SUPERNAW TESTIFIED HE HAS DEALT
25 WITH PAIN MANAGEMENT TREATMENT FAILURES FOR MANY YEARS. IN
4091
1 YOUR OPINION, WERE ANY OF THESE FIVE PATIENTS WHO DIED
2 SUFFERING FROM PAIN MANAGEMENT FAILURES?
3 A. I DON'T BELIEVE SO. I THINK PAIN AT MOST WAS A VERY
4 SECONDARY COMPLAINT IN THESE PATIENTS. MANY OF THEM HAD NO
5 CLEAR PAIN COMPLAINTS.
6 Q. OKAY. DO YOU USE MORPHINE IN YOUR PRACTICE?
7 A. I DO.
8 Q. ARE YOU OPPOSED TO USING MORPHINE?
9 MR. STIRBA: OBJECT, YOUR HONOR.
10 THE COURT: SUSTAINED.
11 Q. (BY MR. WILSON) DO YOU HAVE ANY BELIEFS AS TO ITS
12 APPROPRIATE USE WITH PATIENTS WHO ARE DYING?
13 MR. STIRBA: OBJECTION. BEYOND THE SCOPE.
14 THE COURT: SUSTAINED.
15 Q. (BY MR. WILSON) ARE YOU FAMILIAR WITH THE CONCEPT OF
16 DOUBLE EFFECT, DOCTOR?
17 A. I AM.
18 Q. AND WHAT IS THAT CONCEPT?
19 A. IN GENERAL THE CONCEPT WOULD SAY THAT IN AN ATTEMPT TO
20 ACHIEVE A THERAPEUTIC EFFECT, FOR INSTANCE WITH MORPHINE, IN
21 ORDER TO ACHIEVE PAIN RELIEF, THAT IT CAN BE POSSIBLE AT
22 TIMES TO COMPROMISE THE OTHER VITAL SIGNS. FOR INSTANCE,
23 BLOOD PRESSURE, BREATHING, SOMETHING LIKE THIS.
24 Q. SO WHAT VITAL SIGNS NEED TO BE MONITORED OR DOCUMENTED
25 WHEN MORPHINE IS BEING USED IN THIS CONTEXT?
4092
1 MR. STIRBA: OBJECTION. IT'S NOT REBUTTAL.
2 THE COURT: OVERRULED AS TO THAT QUESTION.
3 Q. (BY MR. WILSON) DID YOU UNDERSTAND THE QUESTION?
4 A. I'M SORRY. CAN YOU RE-ASK IT?
5 Q. WHAT VITAL SIGNS NEED TO BE MONITORED OR DOCUMENTED WHEN
6 MORPHINE IS BEING ORDERED IN THE CONCEPT OF DOUBLE EFFECT?
7 A. AT FREQUENT INTERVALS. IN OTHER WORDS, FREQUENT ENOUGH
8 TO CATCH THE PEAK EFFECT OF THE MORPHINE. THINGS LIKE
9 BREATHING RATE, OXYGENATION, BLOOD PRESSURE, LEVEL OF
10 CONSCIOUSNESS, ALL OF THOSE THINGS WOULD HAVE TO BE
11 MONITORED. This has nothing to do with the doctrine of double effect.
12 Q. WHEN YOU SAY AT A FREQUENT RATE, WHAT DO YOU MEAN?
13 A. I THINK, BEING AGGRESSIVE WITH OPIOIDS, MEASURING THESE
14 THINGS AT LEAST EVERY HOUR IS APPROPRIATE. IN SOME CASES
15 EVEN MORE OFTEN THAN EVERY HOUR.
16 Q. IN YOUR EXPERIENCE HAVE YOU DEALT WITH PATIENTS WHO WERE
17 IN THE PROCESS OF DYING?
18 A. YES.
19 MR. STIRBA: I'M GOING TO OBJECT, YOUR HONOR. NOT
20 REBUTTAL.
21 MR. WILSON: YOUR HONOR, MY ARGUMENT WOULD BE IT
22 GOES TO THE TESTIMONY AS RELATES TO EACH ONE OF THESE
23 PATIENTS.
24 THE COURT: ASK A SPECIFIC QUESTION.
25 Q. (BY MR. WILSON) YOU SAID YES?
4093
1 A. YES.
2 Q. AND OVER HOW MANY YEARS HAVE YOU BEEN IN THE PRACTICE
3 WHERE YOU'VE OBSERVED PATIENTS IN THE DYING PROCESS?
4 A. OVER 20.
5 Q. OKAY. HAVE YOU EVER SEEN A PATIENT WHO IS DYING WHO IS
6 THRASHING ABOUT?
7 A. NO, NOT REALLY.
8 Q. THERE'S TESTIMONY THAT LYDIA SMITH WAS THRASHING ABOUT
9 ON JANUARY 7TH. IS THAT CONSISTENT WITH THE DYING PROCESS?
10 MR. STIRBA: OBJECTION.
11 THE COURT: SUSTAINED.
12 Q. (BY MR. WILSON) WE'VE HEARD TESTIMONY, DOCTOR, THAT
13 MARY CRANE WAS OPIOID TOLERANT. HAVE YOU REVIEWED HER
14 MEDICATION RECORDS FROM THE NURSING HOME?
15 A. YES, I HAVE.
16 Q. AND DO THOSE MEDICATIONS DATE BACK TO 1991?
17 A. THAT'S CORRECT.
18 Q. BASED UPON YOUR REVIEW OF THOSE RECORDS, DO YOU HAVE AN
19 OPINION AS TO WHETHER OR NOT SHE WAS OPIOID TOLERANT?
20 A. I DO.
21 Q. AND WHAT IS THAT OPINION, SIR?
22 A. I DO NOT BELIEVE SHE, BY ANY STRETCH OF THE IMAGINATION,
23 WAS OPIOID TOLERANT. AT MOST SHE WAS RECEIVING ONE PAIN
24 PILL A DAY.
25 MR. STIRBA: HE ANSWERED THE QUESTION. NOW IT'S
4094
1 NARRATIVE.
2 MR. WILSON: I THINK HE CAN CHARACTERIZE IT, BUT
3 I'LL ASK A FURTHER QUESTION.
4 Q. (BY MR. WILSON) WHY DO YOU HAVE THAT OPINION, SIR?
5 A. AT MOST SHE WAS RECEIVING ONE PAIN TABLET A DAY. THIS
6 IS NOT SUFFICIENT TO CAUSE TOLERANCE.
7 Q. THE TABLET THAT SHE WAS RECEIVING A DAY JUST PRIOR TO
8 HER ADMISSION TO THE GERO-PSYCH UNIT, DO YOU REMEMBER WHAT
9 KIND OF PRESCRIPTION TABLET THAT WAS?
10 A. YES, I DO.
11 MR. STIRBA: I'LL OBJECT. THIS IS BEYOND THE SCOPE
12 OF REBUTTAL.
13 THE COURT: OVERRULED AS TO THAT QUESTION.
14 Q. (BY MR. WILSON) CAN YOU CHARACTERIZE THE TYPE OF
15 TABLET IT WAS?
16 A. YES. IT WAS ONE OF THE -- I BELIEVE IT WAS VICODIN.
17 IT'S A HYDROCODONE TYLENOL CONTAINING COMBINATION AT THE
18 LOWEST STRENGTH.
19 Q. AT THE LOWEST STRENGTH?
20 A. YES.
21 Q. OKAY. THERE'S TESTIMONY BY DR. ROTHFEDER THAT IF --
22 MR. STIRBA: I'M GOING TO OBJECT TO THE
23 CHARACTERIZATION OF THE TESTIMONY. THIS IS DIRECT
24 EXAMINATION. IT'S LEADING AND SUGGESTIVE AND IT
25 MISCHARACTERIZES THE TESTIMONY.
4095
1 THE COURT: JUST ASK THE QUESTION THAT REBUTS
2 WHATEVER YOU'RE TRYING TO REBUT.
3 Q. (BY MR. WILSON) LET ME ASK YOU THIS, DOCTOR. IS IT
4 YOUR OPINION THAT IF DOCTORS FOLLOWED THE P.D.R. THEY
5 WOULDN'T GIVE ANY DRUGS?
6 A. ABSOLUTELY NOT.
7 Q. WHY DID YOU REFERENCE THE P.D.R. FOR THE DURAGESIC?
8 A. I BELIEVE THE P.D.R. GIVES VERY SAFE, PROVEN GUIDELINES
9 AS TO HOW MEDICATIONS CAN BE USED. I THINK IT CERTAINLY IS
10 A GOOD INITIAL STARTING POINT FOR DRUG THERAPY. I BELIEVE
11 THAT, IN THE CASE OF DURAGESIC PATCHES, THE INFORMATION
12 CONTAINED IS ACCURATE. I THINK IT GIVES VERY CLEAR
13 GUIDELINES AS TO HOW THIS PARTICULAR PRODUCT SHOULD BE USED.
14 Q. OKAY. THERE IS ALSO TESTIMONY --
15 MR. STIRBA: I'M GOING TO OBJECT, YOUR HONOR.
16 THE COURT: JUST ASK THE QUESTION, DON'T PREFACE.
17 Q. (BY MR. WILSON) ARE THERE TWO DIFFERENT KINDS OF PAIN,
18 IN YOUR OPINION?
19 A. THERE ARE LOTS OF DIFFERENT KINDS OF PAIN.
20 Q. IF A PATIENT BECOMES DEHYDRATED AND HAS MULTIPLE DISEASE
21 PROCESSES GOING ON, WOULD THAT CREATE AN ANGUISHED DEATH, IN
22 YOUR OPINION?
23 MR. STIRBA: I'LL OBJECT TO THAT AS BEING BEYOND
24 THE SCOPE.
25 THE COURT: OVERRULED.
4096
1 Q. (BY MR. WILSON) MAYBE THE QUESTION -- DID YOU
2 UNDERSTAND THE QUESTION, DOCTOR?
3 A. I THINK THAT THERE'S CERTAINLY DISCOMFORT THAT WOULD BE
4 ASSOCIATED WITH THINGS LIKE DEHYDRATION AND SOME OTHER
5 ISSUES THAT MIGHT COME UP IN A DYING PATIENT.
6 Q. YOU'VE REVIEWED THE FILE OF ENNIS ALLDREDGE. IF THE
7 I.V. WAS DISCONTINUED IN RESPECT TO ENNIS ALLDREDGE, WOULD
8 THAT CREATE AN ANGUISHED DEATH?
9 MR. STIRBA: OBJECT. IT'S NOT REBUTTAL. HE'S
10 ALREADY TESTIFIED TO THAT.
11 THE COURT: SUSTAINED.
12 Q. (BY MR. WILSON) IS THERE ANY CORRELATION BETWEEN
13 SODIUM LEVELS AND THIRST, DOCTOR?
14 A. THERE CERTAINLY IS, YES.
15 Q. IS LETTING A PATIENT'S SODIUM LEVEL GET HIGH CONSISTENT
16 WITH COMFORT CARE?
17 A. I WOULD SAY NOT.
18 Q. WHY IS THAT?
19 A. THAT WOULD CLEARLY LEAD TO SIGNIFICANT THIRST. IT WOULD
20 POTENTIALLY LEAD TO CONFUSION IN THE PATIENT, AGITATION, AND
21 SOME OF THE OTHER THINGS THAT WERE PRESENT IN THESE
22 PATIENTS. He had an advance directive: NO IV'S!
23 Q. CAN YOU TELL US, DOCTOR, IF A PATIENT IS EXHIBITING
24 SIGNS OF CHEYNE-STOKING, IS THAT A SIGN THAT THEY ARE NOT
25 SUFFERING FROM MORPHINE INTOXICATION?
4097
1 MR. STIRBA: OBJECT. IT'S AN IRRELEVANT
2 HYPOTHETICAL. IT DOESN'T HAVE ANY RELATIONSHIP SPECIFICALLY
3 TO A PATIENT OR SPECIFICALLY TO ANY TESTIMONY.
4 THE COURT: SUSTAINED.
5 Q. (BY MR. WILSON) I'LL ASK IT THIS WAY, DOCTOR. IN THE
6 MEDICAL RECORDS OF SEVERAL OF THE PATIENTS THERE'S REFERENCE
7 AS TO CHEYNE-STOKES BREATHING, IS THAT CORRECT?
8 A. THAT'S CORRECT.
9 Q. AND IN RESPECT TO THE CHEYNE-STOKING BREATHING, CAN YOU
10 TELL US WHETHER OR NOT THAT'S CONSISTENT OR INCONSISTENT
11 WITH MORPHINE INTOXICATION?
12 MR. STIRBA: I'M GOING TO OBJECT. HE TESTIFIED TO
13 THIS VERY POINT ON HIS INITIAL TESTIMONY.
14 THE COURT: SUSTAINED.
15 Q. (BY MR. WILSON) ARE THERE OTHER -- IF YOU HAVE OTHER
16 DRUGS ON BOARD, DOES THAT CHANGE THE -- SUCH AS OTHER
17 CENTRAL NERVOUS SYSTEM DEPRESSANTS AS WE HAVE IN THIS
18 PARTICULAR CASE, DOES THAT CHANGE THE BREATHING PATTERN OR
19 RESPIRATION PATTERNS IN ANY WAY?
20 MR. STIRBA: OBJECTION AGAIN. CUMULATIVE,
21 REPETITIVE.
22 THE COURT: SUSTAINED.
23 Q. (BY MR. WILSON) AS YOU RECALL, WERE ANY OF THESE
24 PATIENTS GIVEN NO OTHER DRUGS BUT MORPHINE?
25 MR. STIRBA: THAT'S NOT A REBUTTAL QUESTION. IT'S
4098
1 IRRELEVANT.
2 THE COURT: SUSTAINED. WHAT IS THE RELEVANCE OF
3 THAT IN REBUTTAL?
4 MR. WILSON: I THINK IT PERTAINS TO THE FORMER
5 QUESTION, YOUR HONOR. I'M JUST TRYING TO GO ABOUT GETTING
6 BACK TO THE RESPIRATION RATES IN RESPECT TO THESE PATIENTS
7 AND WHETHER OR NOT THEY'RE CONSISTENT WITH MORPHINE.
8 THERE'S BEEN TESTIMONY --
9 THE COURT: OKAY. JUST ASK THE NEXT QUESTION.
10 MR. WILSON: I'LL TAKE EXCEPTION TO THE RULING ON
11 THAT, YOUR HONOR AND THEN ARGUE IT LATER.
12 THE COURT: I HAVEN'T -- WELL, MAYBE WHAT WE CAN
13 DO, LADIES AND GENTLEMEN, MAYBE WE'LL GET SOMETHING
14 CLARIFIED AT THIS POINT SO THINGS WILL GO A LITTLE QUICKER.
15 LET'S TAKE A SHORT BREAK.
16 DURING THIS BREAK IT'S YOUR DUTY NOT TO CONVERSE AMONG
17 YOURSELVES OR TO CONVERSE WITH OR ALLOW YOURSELVES TO BE
18 ADDRESSED BY ANY PERSON ON THE SUBJECT OF THE TRIAL. IT IS
19 YOUR DUTY NOT TO FORM OR EXPRESS AN OPINION UNTIL THE CASE
20 IS FINALLY SUBMITTED TO YOU. THE BAILIFF WILL LET YOU KNOW
21 WHEN TO COME BACK.
22 (JURY OUT OF THE COURTROOM.)
23 THE COURT: THE RECORD WILL REFLECT THAT THE JURY
24 HAS LEFT THE COURTROOM. OKAY. THE LAST QUESTION, WOULD YOU
25 REPEAT IT TO ME AGAIN.
4099
1 MR. WILSON: THE LAST QUESTION RELATED TO WERE ANY
2 OF THESE PATIENTS GIVEN NO OTHER DRUGS BUT MORPHINE.
3 ACTUALLY, I WAS GETTING -- THE QUESTION THAT I HAD ASKED
4 PREVIOUS TO THAT WAS RELATIVE TO CHEYNE-STOKING, YOUR HONOR.
5 I WOULD SUBMIT THAT THE TESTIMONY OF BOTH DR. STRATTON, HILL
6 AND DR. HERBST WAS TO THE EFFECT THAT CHEYNE-STOKING WAS NOT
7 CONSISTENT WITH MORPHINE INTOXICATION. I WANTED THIS DOCTOR
8 TO BE ABLE TO TESTIFY RELATED TO THAT SPECIFICALLY AND THE
9 FACT THAT OTHER DRUGS THAT ARE ON BOARD HAVE A SIGNIFICANCE
10 TO THAT BREATHING PATTERN. I THINK IT'S APPROPRIATE
11 REBUTTAL.
12 THE COURT: WHAT'S THE RESPONSE ON THAT?
13 MR. STIRBA: I GUESS THE RESPONSE IS I THOUGHT -- I
14 UNDERSTOOD THERE WAS A PROFFER AND I'M JUST HAVING A LITTLE
15 HARD TIME FIGURING OUT WHAT'S REBUTTAL AND WHAT ISN'T. I
16 DON'T MEAN TO KEEP OBJECTING, BUT IT'S VERY DIFFICULT TO
17 BASICALLY UNDERSTAND WHERE WE'RE GOING. AND IF I DON'T HAVE
18 AN UNDERSTANDING AS TO THE PROFFER WHAT IS PRECISELY
19 REBUTTAL.
20 IN TERMS OF THAT PARTICULAR ISSUE, I WILL SAY THAT DR.
21 HARE TESTIFIED, QUITE EXTENSIVELY IN HIS INITIAL TESTIMONY,
22 ABOUT MORPHINE TOXICITY, THE SYMPTOMS OF MORPHINE TOXICITY,
23 THE CAUSES OF MORPHINE TOXICITY, HIS OPINION THAT MORPHINE
24 TOXICITY CAUSED THESE DEATHS AND WHY. SO WE'RE JUST
25 ESSENTIALLY REDOING EVERYTHING AND THAT'S MY CONCERN.
4100
1 THE COURT: MR. WILSON.
2 MR. WILSON: I THINK MY QUESTIONS GO SPECIFICALLY
3 AS TO THE TESTIMONY THAT THE TWO EXPERT WITNESSES FOR THE
4 DEFENDANT TESTIFIED THAT CHEYNE-STOKING WAS NOT CONSISTENT
5 WITH MORPHINE TOXICITY, OR IN RESPECT TO WHAT THEY OBSERVED
6 IN THESE PATIENTS' RECORDS. I THINK WE HAVE A RIGHT TO
7 REBUT THAT.
8 I AGREE, COUNSEL IS RIGHT, WE HAVE HAD TESTIMONY, AS IT
9 RELATES WITH DR. HARE, AS TO THE EFFECTS OF MORPHINE
10 TOXICITY, BUT -- WHEN HE TALKS ABOUT THE PROFFER, AS THE
11 COURT IS WELL AWARE, I HAVE NOT HAD TIME TO PREPARE THIS
12 WITNESS. I DID NOT ANTICIPATE PREPARING THIS WITNESS.
13 WELL, I DID ANTICIPATE PREPARING THIS WITNESS WHILE OTHER
14 WITNESSES WERE BEING PRESENTED. IT'S MY UNDERSTANDING THAT
15 WE ARE NOT GOING TO BE ALLOWED TO PRESENT THOSE OTHER
16 WITNESSES THAT WE'D INITIALLY LISTED AND WERE ANTICIPATING
17 TO PUT ON. I'M SORT OF SHOOTING IN THE DARK HERE, YOUR
18 HONOR. I APPRECIATE SOME LEEWAY THERE. AS INDICATED BY MR.
19 MAJOR, IT'S SORT OF HARD TO MAKE A PROFFER OF EVERYTHING
20 THAT YOU WANT TO TRY AND ADDRESS.
21 THE COURT: HERE'S THE CONCERN THAT I HAVE. AS OF
22 LAST FRIDAY THE STATE KNEW THAT THE DEFENDANT HAD ONE MORE
23 DAY FOR THEIR CASE. WE HAD JURY INSTRUCTIONS ON MONDAY. ON
24 WEDNESDAY THEY CAME AND, BUT FOR COMPLETING THE
25 CROSS-EXAMINATION OF THE DEFENDANT THURSDAY MORNING, WHICH
4101
1 IS TODAY, THAT AS OF FRIDAY SOMEBODY SHOULD HAVE KNOWN THAT
2 YOU WOULD BE PUTTING ON YOUR CASE PROBABLY COME THURSDAY.
3 WE DISCUSSED THAT ON MONDAY, THAT THAT WOULD HAPPEN THURSDAY
4 AND FRIDAY.
5 SO WE HAVE THIS MOTION EARLIER AND THIS MOTION
6 BASICALLY SAYS TELL US WHAT YOU'RE GOING TO DO. AND THEN A
7 PROFFER CAN'T BE GIVEN SO I SAY, OKAY, LET'S JUST PUT ON THE
8 WITNESS. THE WITNESS GETS ON AND THEN IF THE DEFENDANT HAS
9 TO MAKE AN OBJECTION EVERY TIME WITH EVERY QUESTION -- I
10 MEAN, I'M GOING TO HAVE TO HAVE A PROFFER, BECAUSE I'M NOT
11 GOING TO REQUIRE THAT WE PUT A WITNESS ON AND THEN EVERY
12 OBJECTION IS GOING TO BE SUSTAINED AND YOU ASK 25 QUESTIONS
13 OR 30 QUESTIONS. BASICALLY THE JURY IS SAYING WHAT IS GOING
14 ON HERE, WHAT ARE WE DOING.
15 SO IF YOU CAN NOW TELL ME WHAT ELSE YOU'RE GOING TO --
16 YOU'VE TOLD ME ABOUT THE CHEYNE-STOKES BREATHING. WHAT ELSE
17 DO YOU WANT TO GO THROUGH WITH THIS WITNESS AND ALL THE
18 OTHER WITNESSES? THIS IS A CASE THAT'S GOING FORWARD. WHEN
19 THE DEFENSE RESTS THE REBUTTAL BEGINS. WE DON'T TAKE A FEW
20 DAYS TO GET SET. THIS JURY, WE'VE HAD THEM HERE FOR -- THIS
21 IS THE FIFTH WEEK. WE SAID IT WOULD BE SIX WEEKS. IF IT
22 CAN BE ANY SHORTER, WE'LL MAKE IT SHORTER.
23 I NEED TO KNOW -- YOU SAY YOU'RE SHOOTING IN THE DARK.
24 THAT'S TRUE AND IF YOU JUST KEEP REPEATING EVERYTHING BACK
25 BECAUSE YOU DON'T HAVE A LIST OF EACH ITEM YOU WANT TO GO
4102
1 THROUGH, SO TELL ME WHAT THE ITEMS ARE THAT YOU WANT TO ASK
2 THIS WITNESS OUTSIDE THE PRESENCE OF THE JURY SO WE CAN
3 DISCUSS IT.
4 MR. WILSON: AS I'VE INDICATED TO THE COURT, I WANT
5 TO ASK QUESTIONS AS RELATED TO THE CHEYNE-STOKING. I WANT
6 TO ASK QUESTIONS AS TO THE BALANCING OF MEDS, WHICH WAS
7 TESTIFIED AS RELATED TO LYDIA SMITH.
8 THE COURT: WHAT SPECIFICALLY DOES THAT REBUT OR
9 WHERE DOES THAT GO?
10 MR. WILSON: THAT REBUTS THE DEFENDANT'S TESTIMONY
11 AS RELATES THAT HE WAS TESTIFYING THAT HE WAS BALANCING THE
12 MEDICATIONS FOR LYDIA SMITH. I WOULD PROFFER THAT DR. HARE
13 WILL TESTIFY THAT HE DID NOT SEE ANY INDICATIONS IN THE
14 CHARTS AS RELATES TO BALANCING THOSE MEDICATIONS.
15 I WANT TO ASK HIM QUESTIONS ABOUT THE USE OF ATIVAN AND
16 MORPHINE, AS IT RELATES TO THE CASE OF ENNIS ALLDREDGE, AND
17 THE FACT THAT THE DEFENDANT HAS TESTIFIED THAT IT WOULDN'T
18 HAVE THE ADVERSE EFFECT OF CREATING ANY BIGGER POTENTIAL FOR
19 DEATH.
20 I WANT TO TALK TO HIM ABOUT DYSPNEA AND WHAT KIND OF
21 DOSES YOU USE FOR THAT PROBLEM AND HOW THE PATIENT IS
22 MONITORED FOR DYSPNEA. THAT'S BEEN THE TESTIMONY OF THE
23 EXPERTS STRATTON, HILL. AND I THINK ALSO HERBST TESTIFIED
24 AS TO DYSPNEA.
25 THE COURT: IS HE GOING TO SAY -- DID THESE OTHER
4103
1 DOCTORS SAY THAT THEY HAD DYSPNEA?
2 MR. WILSON: AS I RECALL THEY DID.
3 THE COURT: AND IS THIS DOCTOR GOING TO SAY THEY
4 DIDN'T HAVE IT?
5 MR. WILSON: AS I UNDERSTAND IT, THAT'S CORRECT,
6 THAT THEY DID NOT HAVE DYSPNEA. MAYBE I CAN ASK HIM THAT
7 RIGHT NOW. THAT'S MY UNDERSTANDING OF WHAT HIS TESTIMONY
8 WOULD BE. IS THAT CORRECT, DOCTOR?
9 THE WITNESS: THAT'S CORRECT.
10 MR. WILSON: I'M GOING TO ASK ABOUT -- I WANTED TO
11 ASK ABOUT WHETHER A SIGN OF MOANING IS A SYMPTOM OF PAIN.
12 THE COURT: HAVEN'T WE BEEN THROUGH THAT? I'VE
13 HEARD THAT QUESTION ASKED NUMEROUS TIMES. I THINK EVERY
14 NURSE HAS TESTIFIED AND THE EXPERTS TESTIFIED AND ALL GAVE
15 THEIR OPINION, IF IT IS OR IF IT ISN'T. SO I DON'T THINK WE
16 NEED TO GO OVER THAT GROUND AGAIN.
17 MR. WILSON: I'M GOING TO ASK, AS TO MS. SMITH,
18 QUESTIONS AS RELATES TO THE MEDICATIONS MAKING HER UNABLE TO
19 TAKE FLUIDS, OR WHETHER HE HAS AN OPINION AS TO WHETHER THE
20 MEDICATIONS CONTRIBUTED TO HER INABILITY TO TAKE FLUIDS.
21 THE COURT: WHO DOES THAT REBUT?
22 MR. WILSON: THAT WOULD BE REBUTTING, I THINK
23 PRIMARILY, THE TESTIMONY OF -- I THINK IT RELATES TO THE
24 TESTIMONY, AS I RECALL, THAT SHE WAS -- WAS IT CONSISTENT
25 WITH HER CARDIAC PROBLEM.
4104
1 THEN I WANTED TO ASK HIM QUESTIONS AS TO THE TESTIMONY
2 AS IT RELATED TO JUDITH LARSEN, AS TO GIVING THE HIGHER
3 DOSAGES ON THE LAST DAY AFTER THE NURSES HAD WITHHELD, OR ON
4 THE DAY BEFORE, AFTER THE NURSES HAD WITHHELD MEDS AND TO
5 GET HER PAIN UNDER CONTROL, WHETHER OR NOT THAT'S A PROPER
6 WAY TO -- A PROCEDURE THAT YOU DO TO GET PAIN UNDER CONTROL.
7 THE COURT: ANYTHING ELSE?
8 MR. WILSON: I THINK I WANTED TO ASK HIM SOME
9 GENERAL QUESTIONS AS TO COMFORT CARE, THE OFFERING OF IV'S
10 AND COMFORT CARE. THAT GOES TO REBUT THE TESTIMONY OF THE
11 DEFENDANT, YOUR HONOR.
12 THE COURT: ANY OTHER AREAS?
13 MR. WILSON: I THINK THAT'S PRETTY MUCH IT, YOUR
14 HONOR, AS I CAN REMEMBER IT.
15 THE COURT: WELL, I HAVE CHEYNE-STOKES BREATHING,
16 BALANCING OF MEDS, USE OF ATIVAN AND MORPHINE IN MR.
17 ALLDREDGE, WHETHER THAT HAD AN ADVERSE EFFECT. HIS OPINION
18 ABOUT WHETHER THE PATIENTS HAD DYSPNEA. MRS. SMITH TAKING
19 MEDS TO TAKE FLUIDS. SOMETHING ABOUT THE EXISTENCE OF A
20 CARDIAC PROBLEM. I DIDN'T REALLY FOLLOW THAT ONE. HIGHER
21 DOSES WITH MS. LARSEN AFTER THE NURSES WITHHELD A DOSE,
22 WHETHER THAT CAUSES -- THAT WOULD CAUSE PAIN OR WHAT THE
23 EFFECT WOULD BE. AND THEN WHETHER -- WERE YOU GOING TO ASK
24 HIM IF YOU TAKE OUT I.V.'S TO PROVIDE COMFORT CARE?
25 MR. WILSON: YES. OR DO YOU USE I.V.'S IN THE
4105
1 PROCESS OF COMFORT CARE.
2 THE COURT: OKAY. ARE THERE ANY OTHER AREAS WITH
3 THIS WITNESS, MR. WILSON?
4 MR. WILSON: ALSO, AS TO ELLEN ANDERSON'S
5 MEDICATIONS PRIOR TO ENTERING THE UNIT, AND THAT GOES TO
6 REBUT, I THINK, OTHER TESTIMONY.
7 THE COURT: OKAY. ABOUT WHAT?
8 MR. WILSON: PARDON?
9 THE COURT: FINISH THAT. I DIDN'T UNDERSTAND WHAT
10 YOU WERE SAYING.
11 MR. WILSON: I THINK THERE WAS TESTIMONY THAT -- I
12 CAN'T REMEMBER WHO IT WAS BY. IT MAY HAVE BEEN BY DR.
13 WEITZEL. I'M TRYING TO REMEMBER. BUT THERE WAS TESTIMONY
14 THAT THE OTHER MEDICATIONS THAT SHE'D BEEN RECEIVING JUST
15 PRIOR TO ENTERING THE UNIT WOULDN'T HAVE BEEN IN HER BLOOD
16 STREAM AND WOULDN'T HAVE HAD ANY EFFECT AS IT RELATES TO THE
17 USE OF MORPHINE ON THAT PARTICULAR DAY.
18 THE COURT: ANYTHING ELSE?
19 MR. WILSON: I THINK THAT'S IT.
20 THE COURT: OKAY. MR. STIRBA, ANY RESPONSE?
21 MR. STIRBA: YES, YOUR HONOR. FIRST, AS FAR AS THE
22 CHEYNE-STOKES BREATHING PATTERN, I GUESS THERE WAS SOME
23 TESTIMONY CONCERNING THAT. I GUESS IF THE QUESTIONS ARE PUT
24 WITH SOME SPECIFICITY I CAN'T SAY THAT THAT ISN'T AN AREA
25 FOR REBUTTAL.
4106
1 AS FAR AS BALANCING THE MEDS, QUITE FRANKLY THAT'S AN
2 ARGUMENT. I MEAN, THE FACTS ARE WHAT THE FACTS ARE. THE
3 MEDS ARE WHAT THE MEDS ARE. THE MEDS ARE IN THE AMOUNTS AND
4 DOSES OF WHAT THEY WERE. WE'VE HAD MORE THAN ADEQUATE
5 TESTIMONY ALL OVER THE PLACE ON THAT.
6 TO JUST HAVE SOMEBODY COME IN AND SAY IT DOESN'T LOOK
7 LIKE BALANCING TO ME, ESPECIALLY FROM A PAIN MANAGEMENT
8 EXPERT. REMEMBER, THIS ISN'T AN END OF LIFE CARE EXPERT,
9 THIS IS NOT A PSYCHIATRIST. THIS THE PAIN GUY. TO HAVE HIM
10 COME IN AND TALK AS IF HE'S AN EXPERT IN ALL OF THESE AREAS
11 I DON'T THINK HELPS THE JURY.
12 BALANCING THE MEDS, THAT'S ARGUMENT. THEY CAN MAKE AN
13 ARGUMENT BASED UPON THE FACTS.
14 THE USE OF ATIVAN AND MORPHINE AND ADVERSE EFFECTS,
15 REALLY, I DON'T THINK, THE QUESTION WAS EVER PUT NOR WAS THE
16 ANSWER GIVEN RELATING TO WHETHER OR NOT THAT WOULD CREATE AN
17 ADDITIONAL DEGREE OF PROBLEM THAT MAY RESULT IN DEATH. SO
18 IF HE'S GOING TO ANSWER IT THAT WAY, I DON'T THINK THAT'S
19 REBUTTAL.
20 THERE HAS BEEN TESTIMONY BY DR. SUPERNAW ABOUT THE USE
21 OF ATIVAN IN CONJUNCTION WITH MORPHINE. I BELIEVE DR.
22 WEITZEL HAD SOME TESTIMONY HIMSELF ON THAT. BUT IT HAD
23 NOTHING TO DO WITH CAUSATION AND DEATH. IF HE'S GOING TO
24 ANSWER IT THAT WAY I DON'T THINK IT'S ADEQUATE REBUTTAL.
25 AS FAR AS DYSPNEA IS CONCERNED, I DON'T RECALL ANYBODY
4107
1 SAYING THAT THAT WAS IN FACT WHAT WAS GOING ON WITH THESE
2 PATIENTS. THERE ARE SOME DESCRIPTIONS OF GASPING, SOME
3 NURSING NOTES RELATING TO GASPING IN MR. ALLDREDGE'S CHART.
4 THERE HAS BEEN SOME TESTIMONY THAT GASPING IS SYMPTOMATIC OF
5 THAT PHENOMENON, BUT I DON'T THINK ANYONE HAS SAID THAT THAT
6 PERSON HAD DYSPNEA, OR HOWEVER IT'S PRONOUNCED, AND
7 THEREFORE THOSE DOSES ARE NECESSARILY DIRECTLY APPROPRIATE
8 FOR THAT PURPOSE. I DON'T KNOW WHAT HE'S REBUTTING THERE.
9 AS FAR AS THE MEDICATION IN TERMS OF -- I THINK IT WAS
10 RELATING TO LYDIA SMITH.
11 MR. WILSON: LARSEN.
12 THE COURT: YOU SAID SMITH. IT WAS SOMETHING ABOUT
13 MEDICATIONS TO TAKE FLUIDS.
14 MR. STIRBA: YES. OKAY. I REMEMBER NOW. I THINK,
15 ONCE AGAIN, THAT'S CUMULATIVE. IF YOU'LL RECALL, THAT VERY
16 CHART, DR. HARE WENT OVER WHAT. THESE ARE THE LONG-TERM
17 EFFECTS, THE SHORT-TERM EFFECTS. ONE OF THEM WAS FLUID LOSS
18 AND INABILITY TO EAT. OKAY. HE SAYS WHATEVER HE WANTS TO
19 SAY ON HIS EXAMINATION.
20 THEN DR. HILL GETS UP AND DR. HILL WAS ASKED THE SAME
21 THINGS. IN FACT, HE WAS EVEN CROSSED ON IT. THE SAME
22 CHART. NO, NO, YES, YES. I MEAN, THIS IS JUST ADDITIVE AND
23 CUMULATIVE. I SEE NO PURPOSE TO BE SERVED BY HAVING HIM NOW
24 TESTIFY AS TO THAT SYMPTOM OR WHATEVER HE THINKS IF IT'S
25 RELATED TO MORPHINE. WE HAVE A CHART ON IT, HIS CHART, AND
4108
1 IT'S NOT REBUTTAL.
2 JUDITH LARSEN, IN TERMS OF THE DOSES, I THINK THAT MAY
3 BE APPROPRIATE REBUTTAL.
4 AS FAR AS THE COMFORT CARE AND THE I.V.S, ONCE AGAIN, I
5 DON'T THINK THAT THERE'S ANY INDICATION THAT ANYBODY HAS
6 REALLY TESTIFIED PER SE THAT THERE'S ANY RELATIONSHIP TO
7 IV'S AND COMFORT CARE. HE ISN'T THAT KIND OF EXPERT. I
8 WOULD SUGGEST THAT THERE'S NOTHING REALLY THERE TO REBUT,
9 OTHER THAN IF HE WANTS TO JUST GIVE HIS RANK OPINION THAT HE
10 DOESN'T THINK THE WITHDRAWAL OF AN I.V. UNDER THESE
11 CIRCUMSTANCES WAS APPROPRIATE. BUT, QUITE FRANKLY, I THINK
12 THAT'S A FACTUAL ISSUE, BASED UPON THE FACTS THAT PEOPLE
13 HAVE TESTIFIED TO. THAT'S THEN ARGUMENT. THAT'S BASICALLY
14 WHAT THAT IS. IT'S NOT EXPERT OPINION. IT DOESN'T ASSIST
15 THE JURY IN ANY WAY.
16 AS FAR AS ELLEN ANDERSON IS CONCERNED, THAT ALSO IS
17 ARGUMENT. THE FACTS ARE WHAT THE FACTS ARE AS DR. WEITZEL
18 KNEW THEM. AND THE EVIDENCE IS BEFORE THE JURY. THERE'S NO
19 QUESTION THAT THERE WAS AN INDICATION IN THE NURSING
20 ASSESSMENT FORM THAT SHE HAD A PRN FOR LORTAB. THERE'S NO
21 QUESTION THAT SHE HAD NITROSTAT FOR CHEST PAIN. THOSE
22 ORDERS ARE IN THE FILE.
23 THERE IS NO INDICATION, NONE, AND I DON'T THINK
24 ANYBODY'S TESTIFIED TO IT, THAT ANYBODY TRULY KNOWS AT THE
25 TIME OF HER ADMISSION AND AT THE TIME OF THOSE INJECTIONS
4109
1 PRECISELY WHAT THE MEDICATION HISTORY WAS WITH RESPECT TO
2 HER RECEIVING LORTAB OR RECEIVING NITROSTAT. SO, QUITE
3 FRANKLY, THERE'S NOTHING THERE TO REBUT.
4 IT'S IRRELEVANT BECAUSE DR. WEITZEL DIDN'T TESTIFY TO
5 THAT FACT. WHAT HE TESTIFIED TO WERE THE FACTS THAT WERE IN
6 THE HOSPITAL RECORD, FACTS WHICH CERTAINLY LED HIM TO
7 BELIEVE THAT IN CONJUNCTION WITH WHAT THE NURSES TOLD HIM
8 SHE WAS IN FACT IN PAIN. THAT'S ALL HE'S TESTIFIED TO. I
9 DON'T KNOW WHETHER HER MEDICATION HISTORY ON LORTAB IS
10 REALLY REMOTELY RELEVANT TO ANYTHING TESTIFIED TO BECAUSE IT
11 HASN'T BEEN TESTIFIED TO.
12 THE COURT: MR. WILSON.
13 MR. WILSON: I THINK THE MEDICATIONS THAT WE'RE
14 TALKING ABOUT AS FAR AS THE LORTAB IS THE SIGNIFICANT ISSUE
15 THERE. I THINK WHAT IT RELATES TO IS, AS I RECALL, THE
16 MEDICATION WAS FOR TRAZODONE AND SHE HAD RECEIVED A DOSAGE
17 OF TRAZODONE. I GUESS I CAN ASK THE WITNESS, IS THAT WHERE
18 YOUR TESTIMONY WOULD GO TO?
19 THE WITNESS: NOW, THIS IS ON WHICH PATIENT? Who's on first?
20 Q. (BY MR. WILSON) ELLEN ANDERSON. DID YOU REVIEW HER
21 NURSING CARE RECORDS? MAYBE YOU CAN'T ANSWER THAT QUESTION
22 OR MAYBE I'M MISUNDERSTANDING.
23 A. I DON'T REMEMBER ON ELLEN ANDERSON IF SHE RECEIVED
24 TRAZODONE. SHE GOT THE MORPHINE.
25 MR. WILSON: I GUESS I MISSPOKE, YOUR HONOR. MAYBE
4110
1 IT WAS AS TO THE LORTAB. What's on second? Hopelessly confused.
2 THE COURT: THE ONLY OTHER QUESTION WAS AS TO THE
3 USE OF ATIVAN AND MORPHINE IN MR. ALLDREDGE. WHAT WAS HE
4 GOING TO TESTIFY ABOUT RELATING TO THAT?
5 MR. WILSON: I THINK I CAN JUST ASK HIM THAT.
6 THE COURT: GO AHEAD.
7 Q. (BY MR. WILSON) AS IT RELATES TO THE USE OF ATIVAN
8 WITH MORPHINE, DOCTOR --
9 MR. WILSON: I MIGHT JUST ARGUE TO THE COURT FOR A
10 SECOND HERE, THERE WAS TESTIMONY THAT WAS ELICITED ON CROSS
11 FROM DR. WEITZEL AS RELATED TO THE USE -- AS TO WHETHER OR
12 NOT THOSE TWO DRUGS TOGETHER WOULD HAVE HAD AN ENHANCING
13 EFFECT AND WHETHER THEY WOULD HAVE CAUSED THE DEATH OF ENNIS
14 ALLDREDGE. THAT WAS THE QUESTION I WAS GOING TO PROPOSE TO
15 THE DOCTOR AS TO WHETHER ATIVAN HAD AN ENHANCING EFFECT AS
16 RELATED TO THE MORPHINE.
17 MR. STIRBA: IF IT'S JUST ENHANCING MAYBE THAT'S
18 NARROW ENOUGH. HE'S ALREADY TESTIFIED TO THE CAUSE OF DEATH
19 AND HE INCLUDED ATIVAN IN HIS INITIAL TESTIMONY. TO HAVE
20 HIM REPEAT HIS OPINION IS NOT REBUTTAL.
21 THE COURT: WHAT I'LL DO IS YOU CAN ASK ABOUT THE
22 CHEYNE-STOKES BREATHING AND ABOUT THE BALANCING OF MEDS, IF
23 HE HAS AN OPINION, IF THAT'S WHAT IT LOOKS LIKE. YOU CAN
24 ASK ABOUT THE ENHANCING EFFECT OF USING ATIVAN WITH
25 MORPHINE. YOU CAN ASK ABOUT, HOWEVER YOU PRONOUNCE THE D
4111
1 WORD, DYSPNEA, WHATEVER IT'S CALLED. YOU MAKE SURE TO
2 PRONOUNCE IT THE RIGHT WAY. Amazing. Mangling medicine.
3 THE NEXT ONE, ON MS. SMITH TAKING FLUIDS, I'M JUST
4 GOING TO -- THAT'S OUT. MS. LARSEN, GIVING THE HIGHER DOSE
5 AND WITHHOLDING, THAT'S FINE. AND THE QUESTION ABOUT THE
6 I.V. CARE YOU CAN GO INTO. THE OTHER ONE ABOUT ELLEN
7 ANDERSON I WON'T.
8 MR. WILSON: THE QUESTIONS ON -- I DID ALSO WANT TO
9 PROFFER THAT THERE WAS TESTIMONY, AGAIN BY EXPERTS, THAT
10 MORPHINE DOES NOT CAUSE ORGAN DAMAGE. I WANTED THE DOCTOR
11 TO CLARIFY WHAT HE MEANT IN THE CHART AS TO ORGAN DAMAGE. I
12 DON'T THINK THAT HAS BEEN TESTIFIED TO.
13 MR. STIRBA: THAT'S THE SAME PROBLEM WITH THE
14 OTHER. HE TESTIFIED TO IT IN HIS EXAMINATION AND HE WAS
15 SHOWN -- DR. HILL WAS SHOWN THAT CHART. HE WENT OVER IT ON
16 CROSS-EXAMINATION.
17 THE COURT: HE'S TESTIFIED EARLIER THAT IT DOES
18 CAUSE ORGAN DAMAGE. THE OTHER EXPERT SAYS IT DIDN'T. THEY
19 JUST HAVE DIFFERENT OPINIONS.
20 MR. WILSON: I GUESS I WANTED TO EXPLORE HOW IT
21 CAUSES ORGAN DAMAGE SO THE JURY CAN HAVE THAT EXPLANATION.
22 THE COURT: COULDN'T THAT HAVE BEEN ANTICIPATED
23 BEFORE WHEN HE WAS ASKED DOES IT CAUSE ORGAN DAMAGE? I'M
24 NOT GOING TO ALLOW THAT.
25 ANYTHING ELSE TO DISCUSS BEFORE THE JURY COMES BACK IN?
4112
1 MR. WILSON: I THINK NOT.
2 MR. STIRBA: NOTHING, YOUR HONOR.
3 THE COURT: OKAY. LET'S HAVE THE JURY COME BACK
4 IN.
5 (JURY BACK INTO THE COURTROOM.)
6 THE COURT: THE RECORD WILL REFLECT THAT THE JURY
7 IS BACK. OKAY, MR. WILSON, WOULD YOU LIKE TO CONTINUE?
8 MR. WILSON: YES, YOUR HONOR. THANK YOU.
9 Q. (BY MR. WILSON) DOCTOR, AS IT RELATES TO CHEYNE-STOKES
10 BREATHING, CAN YOU TELL US, IN RESPECT TO THESE FIVE
11 PATIENTS, DID YOU OBSERVE IN THE MEDICAL RECORDS INCIDENCES
12 WHERE THEY WERE BREATHING IN THAT FASHION OR DESCRIBED IN
13 THAT FASHION?
14 A. YES, I DID.
15 Q. CAN YOU TELL US IS THAT CONSISTENT OR INCONSISTENT WITH
16 MORPHINE INTOXICATION?
17 A. IN A GENERAL SENSE IT IS CONSISTENT WITH THE EFFECTS OF
18 MORPHINE.
19 Q. IS THERE ANYTHING OTHER THAN THAT, THE USE OF MORPHINE,
20 WHERE PATIENTS HAVE OTHER DRUGS ON BOARD, DOES THAT CREATE
21 ANY CHANGE IN YOUR OPINION?
22 A. I THINK, ALONG WITH THE MORPHINE, OTHER DRUGS, SOME OF
23 THE ORGAN DAMAGE THAT I REFERRED TO PREVIOUSLY, AS FAR AS
24 DAMAGE FROM HYPOXIA, DAMAGE FROM LOW BLOOD PRESSURE, A
25 COMBINATION OF THOSE THINGS CLEARLY CAN RESULT IN
4113
1 CHEYNE-STOKES BREATHING.
2 Q. OKAY. IN RESPECT TO THE PATIENT LYDIA SMITH, THERE'S
3 BEEN TESTIMONY ABOUT BALANCING MEDS. CAN YOU TELL US WHAT
4 THAT MEANS TO YOU?
5 A. THAT'S NOT A COMMON TERM, BUT I WOULD INTERPRET THAT TO
6 MEAN THAT THE BENEFICIAL EFFECTS AND THE DETRIMENTAL EFFECTS
7 OF MEDICATIONS, AND COMBINATIONS OF MEDICATIONS, ARE KIND OF
8 WEIGHED AND CHANGED TO TRY TO EFFECT THE BEST RESULT.
9 Q. OKAY. LET ME FIND HER CHART HERE. (PAUSE.) I'LL REFER
10 YOU TO WHAT WAS PREVIOUSLY MARKED AS STATE'S EXHIBIT 37.
11 CAN YOU TELL US, DOCTOR, IN LOOKING AT THAT PARTICULAR
12 EXHIBIT, CAN YOU CHARACTERIZE WHETHER OR NOT THE MEDS WERE
13 BEING BALANCED IN THIS PARTICULAR SITUATION?
14 MR. STIRBA: I'LL OBJECT. LACK OF FOUNDATION.
15 THE COURT: LAY A FOUNDATION.
16 Q. (BY MR. WILSON) DOCTOR, HAVE YOU HAD AN OPPORTUNITY TO
17 REVIEW THE CHART THAT'S BEFORE YOU THERE?
18 A. I HAVE.
19 Q. AND YOU'VE ALSO HAD AN OPPORTUNITY TO REVIEW THE RECORDS
20 OF LYDIA SMITH?
21 A. YES, I HAVE.
22 Q. AND DO THE DOSAGE AMOUNTS THAT YOU SEE ON THE CHART
23 BEFORE YOU CORRESPOND TO YOUR RECOLLECTION AS TO THE AMOUNTS
24 YOU REVIEWED IN THE RECORD?
25 A. YES.
4114
1 Q. YOU PREVIOUSLY TESTIFIED, I THINK, AND HAVE REVIEWED
2 THAT CHART ON OTHER OCCASIONS, IS THAT CORRECT?
3 A. THAT'S CORRECT.
4 Q. OKAY. BASED UPON YOUR REVIEW OF THE CHARTS AND YOUR
5 REVIEW OF THE MEDICATIONS THAT -- A REVIEW OF THAT CHART AND
6 THE MEDICATIONS IN THE RECORD, DO YOU HAVE AN OPINION AS TO
7 WHETHER OR NOT THERE WAS ANY BALANCING OF THE MEDICATIONS AS
8 YOU'VE PREVIOUSLY DESCRIBED IT HEREIN?
9 A. AGAIN, THIS WOULD -- CERTAINLY THE TREND OF THE CHART IS
10 AN EVER INCREASING DOSING OF MEDICATIONS AND PRESCRIBING OF
11 MEDICATIONS. AT THE SAME TIME THE CHART -- THE HOSPITAL
12 RECORD WOULD INDICATE AN EVER INCREASING AMOUNT OF SIDE
13 EFFECTS, PROBLEMS, COMPROMISES OF THE PATIENT. I WOULDN'T
14 CALL THAT BALANCING AT ALL, NO.
15 Q. OKAY. DOCTOR, ARE YOU FAMILIAR WITH THE TERM DYSPNEA?
16 A. I AM.
17 Q. AND CAN YOU TELL US WHAT THAT MEANS?
18 A. THAT MEANS LABORED OR UNCOMFORTABLE BREATHING, I THINK
19 IS PROBABLY THE BEST WAY TO PUT IT.
20 Q. DO YOU EVER PRESCRIBE MORPHINE FOR DYSPNEA?
21 A. I HAVE.
22 Q. IN YOUR REVIEW OF THE MEDICAL RECORDS OF THESE FIVE
23 PATIENTS, CAN YOU TELL US WHETHER YOU SAW ANY SIGNS OR
24 SYMPTOMS THAT THESE PATIENTS WERE SUFFERING FROM DYSPNEA?
25 A. I SAW NO INDICATION THAT THEY WERE.
4115
1 Q. OKAY. I DON'T KNOW IF I NEED TO -- YOU ARE FAMILIAR
2 WITH THE RECORDS OF JUDITH LARSEN, IS THAT CORRECT?
3 A. YES, I AM.
4 Q. ARE YOU FAMILIAR THAT THERE WERE CERTAIN SHOTS OF
5 MORPHINE WITHHELD -- MAYBE WE OUGHT TO GET HER CHART OUT.
6 (PAUSE.) ARE YOU FAMILIAR WITH THE FACT THAT THERE WERE
7 CERTAIN MORPHINE SHOTS WITHHELD BY A NURSE IN CONNECTION
8 WITH, I THINK, JANUARY 2ND, OR MAYBE THE 3RD?
9 A. THERE WERE TIMES ON THE 3RD WHEN MORPHINE WAS WITHHELD,
10 YES.
11 Q. OKAY. NOW, THERE WAS ADDITIONAL SHOTS OF MORPHINE
12 ORDERED SUBSEQUENT TO THAT WITHHOLDING, WAS THERE NOT?
13 A. YES.
14 Q. FROM YOUR REVIEW OF THE RECORDS, CAN YOU TELL US WHETHER
15 OR NOT YOU HAVE AN OPINION AS TO WHETHER OR NOT THE
16 ADDITIONAL SHOTS THAT WERE ADMINISTERED WERE TO GET THE PAIN
17 UNDER CONTROL? MAYBE I CAN REPHRASE THE QUESTION.
18 THE COURT: GO AHEAD.
19 Q. (BY MR. WILSON) ASSUMING THAT THE SHOTS WERE WITHHELD
20 IN CONNECTION WITH JUDITH LARSEN, DID YOU SEE OR OBSERVE
21 ANYTHING IN THE RECORD WHICH WOULD REFLECT THE NECESSITY OF
22 GIVING ADDITIONAL SHOTS TO BRING THE PAIN UNDER CONTROL?
23 A. NO, I SAW NO INDICATION THAT THAT WAS NECESSARY.
24 Q. OKAY. DID YOU SEE -- THERE WAS ALSO RECORDS OF
25 ADDITIONAL SHOTS. DID YOU SEE A NECESSITY FOR GIVING
4116
1 ADDITIONAL SHOTS IN ADDITION TO THAT?
2 A. NO, I SAW NO INDICATION THAT THIS NEEDED TO BE DONE.
Indication of pain>> Indication of pain>> Indication of pain>> Indication of pain>> Indication of pain>> Indication of pain>> Indication of pain>> Indication of pain>>
3 Q. DID YOU SEE A NEED TO PROVIDE ADDITIONAL MORPHINE TO
4 JUDITH LARSEN ON THAT PARTICULAR DAY?
5 A. NO, I DID NOT.
6 Q. DOCTOR, IN YOUR PRACTICE HAVE YOU HAD OCCASION TO
7 PROVIDE COMFORT CARE TO DYING PATIENTS?
8 A. I HAVE.
9 Q. AND CAN YOU TELL US WHETHER OR NOT I.V.S ARE USED IN
10 CONNECTION WITH PROVIDING COMFORT CARE?
11 A. QUITE OFTEN THEY ARE, YES.
12 Q. OKAY. CAN YOU TELL US WHAT A -- I THINK IT'S CALLED A
13 PUMP DEVICE, IS?
14 A. ONE MEANS OF ADMINISTERING DRUGS LIKE MORPHINE TO A
15 PATIENT IN A COMFORT CARE SITUATION COULD BE USING A PUMP
16 DEVICE THAT GIVES A CONSTANT DOSE.
17 Q. CAN YOU TELL US WHETHER OR NOT, IN YOUR PRACTICE, THE
18 ADMINISTERING OF MORPHINE IN THAT FASHION IS MORE
19 COMFORTABLE THAN GIVING AN I.M. INJECTION?
20 MR. STIRBA: OBJECTION. RELEVANCY AS TO THE
21 STANDARD.
22 THE COURT: SUSTAINED.
23 MR. WILSON: I DON'T THINK I HAVE ANY FURTHER
24 QUESTIONS, YOUR HONOR.
25 THE COURT: MR. STIRBA.
4117
1 CROSS-EXAMINATION (REBUTTAL)
2 BY MR. STIRBA:
3 Q. DOCTOR, YOU TESTIFIED ABOUT DOUBLE EFFECT AND THAT THAT
4 USUALLY IS USED IN CONJUNCTION WITH MEDICATION, IS THAT
5 RIGHT?
6 A. THAT'S RIGHT.
7 Q. SPECIFICALLY, WHAT DOUBLE EFFECT MEANS IS THAT YOU GIVE
8 SOME MEDICATION FOR A THERAPEUTIC PURPOSE, KNOWING THAT
9 THERE IS A RISK THAT MAY BE ENCOUNTERED WHICH MAY BE
10 DETRIMENTAL, IS THAT TRUE?
11 A. THAT'S RIGHT.
12 Q. FOR EXAMPLE, WHEN YOU GIVE MORPHINE, YOU GIVE MORPHINE
13 KNOWING THAT THERE IS A RISK OF RESPIRATORY DEPRESSION,
14 WHICH CAN BE IN FACT TERMINAL. SOMETIMES YOU GIVE THE
15 MORPHINE TO DEAL WITH THE PAIN, RUNNING THE RISK THAT THERE
16 MAY BE A TERMINAL RESULT AS A RESULT OF THE USE OF MORPHINE,
17 ISN'T THAT TRUE?
18 A. THAT'S TRUE.
19 Q. FOR EXAMPLE, YOU TESTIFIED ALREADY THAT YOU AGREE WITH
20 THIS STATEMENT, PROMULGATED BY THE AMA, WHICH RELATES TO
21 THIS VERY SAME THING OF DOUBLE EFFECT. THAT IS, "PHYSICIANS
22 HAVE AN OBLIGATION TO RELIEVE PAIN AND SUFFERING AND TO
23 PROMOTE THE DIGNITY AND AUTONOMY OF DYING PATIENTS IN THEIR
24 CARE." YOU AGREE WITH THAT, CORRECT?
25 A. YES.
4118
1 Q. "THIS INCLUDES PROVIDING EFFECTIVE PALLIATIVE TREATMENT
2 EVEN THOUGH IT MAY FORESEEABLY HASTEN DEATH." DO YOU AGREE
3 WITH THAT STATEMENT?
4 A. I DO, YES.
5 Q. NOW, YOU TESTIFIED ABOUT, I THINK YOU SAID, WHEN YOU
6 LOOKED AT THE RECORD YOU SAW NO COMPLAINTS OF PAIN, DO YOU
7 REMEMBER THAT?
8 A. IN REGARD TO?
9 Q. IN REGARD TO A QUESTION THAT MR. WILSON JUST ASKED YOU.
10 A. I'M SORRY, I DON'T REMEMBER THE CONTEXT OF THAT
11 QUESTION.
12 Q. OKAY. BUT YOU HAVE TESTIFIED ABOUT LOOKING IN THE
13 RECORDS AND SEEING NO COMPLAINTS OF PAIN, HAVEN'T YOU?
14 A. AGAIN, I'M NOT SURE IN REGARDS TO WHICH PATIENT.
15 Q. HOW ABOUT WITH RESPECT TO ANY ONE OF THESE FIVE
16 PATIENTS?
17 A. WELL, I THINK, FIRST OF ALL, THESE PATIENTS,
18 PARTICULARLY IN THE LATTER PART OF THEIR HOSPITALIZATIONS,
19 WERE LARGELY UNCONSCIOUS AND TECHNICALLY COULD NOT COMPLAIN
20 OF PAIN.
21 Q. THAT'S ALSO TRUE AT THE BEGINNING OF THEIR
22 HOSPITALIZATION, ISN'T THAT TRUE?
23 A. THE PATIENTS, ACCORDING TO RECORDS PRIOR TO COMING INTO
24 THE HOSPITAL, CERTAIN OF THE PATIENTS COULD IN FACT ANSWER
25 QUESTIONS.
4119
1 Q. THAT WASN'T MY QUESTION, SIR. IT'S TRUE, IS IT NOT --
2 A. THEY COULD ANSWER --
3 THE COURT: EXCUSE ME. YOU DON'T BOTH TALK AT THE
4 SAME TIME.
5 Q. (BY MR. STIRBA) IT'S TRUE, IS IT NOT, THAT THAT'S ONE
6 OF THE PROBLEMS OF PEOPLE WHO ARE SEVERELY DEMENTED, THAT
7 THEY CAN'T SELF REPORT AND COMPLAIN OF PAIN, ISN'T THAT
8 CORRECT?
9 A. IT JUST DEPENDS ON THEIR PRESENTATION. SOME OF THESE
10 PATIENTS COULD IN FACT, ON INITIAL EVALUATION, IT WAS FELT
11 GIVE A REPORT WHETHER THEY WERE HAVING PAIN OR NOT.
12 Q. YES. THAT WAS MARY CRANE, THAT'S THE ONLY ONE, ISN'T
13 THAT TRUE?
14 A. I REMEMBER AT LEAST THAT ONE, YES.
15 Q. AND IN FACT MARY CRANE WAS THE ONLY ONE AND SHE IN FACT
16 COMPLAINED OF SIGNIFICANT PAIN, ISN'T THAT TRUE?
17 A. THERE MUST BE ANOTHER ONE THEN, BECAUSE I KNOW THERE WAS
18 AT LEAST ONE OTHER THAT HAD NO COMPLAINTS AT THE TIME OF
19 ADMISSION. Lydia Smith, completely aphasic, indeed "had no complaints."
20 Q. YES. IN OTHER WORDS, ONCE AGAIN, SEVERELY DEMENTED SO
21 THAT THEY COULDN'T ARTICULATE WHAT PRECISELY WAS GOING ON IN
22 TERMS OF THEIR PAIN, ISN'T THAT TRUE?
23 A. I THINK THAT'S VERY MUCH A JUDGMENT CALL. IF THE
24 PATIENT -- YOU KNOW, YOU CAN ASK IF YOU FEEL PAIN AND YOU
25 CAN GET AN ANSWER FROM A PATIENT AND THAT PATIENT SAYS --
4120
1 RESPONDS IN A NEGATIVE WAY TO A QUESTION OF WHETHER THEY'RE
2 HAVING PAIN. YOU CAN SAY THEY'RE DEMENTED, THEY DON'T KNOW
3 WHAT THEY'RE TALKING ABOUT, OR YOU CAN ACCEPT THAT ANSWER.
4 Q. SURE. YOU SAY IT'S A JUDGMENT CALL. YOU UNDERSTAND
5 THAT THERE HAVE BEEN SOME STUDIES IN THIS VERY AREA OF
6 DEALING WITH PAIN MANAGEMENT AND SEVERELY DEMENTED PEOPLE,
7 ARE YOU NOT?
8 A. I AM.
9 Q. IN FACT, YOU KNOW, DO YOU NOT, THAT THE AMERICAN MEDICAL
10 ASSOCIATION JUST LAST WEEK, IN THEIR OWN JOURNAL, HAD A
11 STUDY DEALING WITH SEVERELY DEMENTED PEOPLE AND WHETHER OR
12 NOT THEY WERE GETTING TREATED ADEQUATELY FOR THEIR PAIN?
13 ARE YOU AWARE OF THAT?
14 A. I'M AWARE THAT THERE WAS ONE, YES.
15 Q. ARE YOU AWARE OF THE FINDING IN THAT STUDY THAT THE
16 AUTHORS THEORIZED, BECAUSE OF THEIR STUDY, THAT DOCTORS
17 WITHHELD PAINKILLERS OUT OF THE MISTAKEN ASSUMPTION THAT
18 SEVERELY DEMENTED PATIENTS WEREN'T IN PAIN BECAUSE THEY
19 COULD NOT ARTICULATE THE PAIN, ARE YOU AWARE OF THAT?
20 A. I HAVE NOT SEEN THAT STUDY. I'VE NOT HAD A CHANCE TO
21 REVIEW IT. I CANNOT COMMENT ON IT BECAUSE I DO NOT KNOW IF
22 THE METHODOLOGY IS VALID. Last refuge...
23 Q. YOU TESTIFIED ABOUT CHEYNE-STOKES BREATHING. IT'S TRUE,
24 IS IT NOT, DOCTOR, THAT CHEYNE-STOKES BREATHING IS A DEATH
25 AND DYING PHENOMENON, CORRECT?
4121
1 A. IT CAN BE, BUT NOT EXCLUSIVELY.
2 Q. IT'S TRUE, IS IT NOT, THAT, FOR EXAMPLE, ELLEN ANDERSON,
3 WHEN IT WAS REPORTED BY THE NURSE AT ONE O'CLOCK A.M. ON THE
4 30TH OF DECEMBER THAT SHE HAD A LOW BLOOD PRESSURE, I THINK
5 70 OVER 50, THAT CERTAINLY COULD HAVE BEEN THE RESULT OF THE
6 FACT THAT SHE HAD PNEUMONIA AT THAT TIME, TRUE?
7 A. THIS PATIENT WAS ADMITTED A FEW HOURS EARLIER TO THE
8 HOSPITAL AND HAD NO CLINICAL INDICATIONS OF PNEUMONIA. I
9 WOULD SAY NO.
10 Q. OKAY. JUST SO I UNDERSTAND THIS, YOU UNDERSTAND THAT
11 THERE WAS A CHEST X-RAY DONE AT 5:00 A.M. IN THE MORNING
12 THAT SHOWED ACUTE PNEUMONIA, ARE YOU AWARE OF THAT?
13 A. THERE WAS A CHEST FILM DONE AFTER THIS PATIENT HAD BEEN
14 HYPOXIC FOR MANY HOURS, HAD BEEN RUNNING A VERY LOW BLOOD
15 PRESSURE FOR MANY HOURS. I WOULD SAY AT THAT POINT IT WOULD
16 BE HARD TO MAKE ANY CONCLUSIONS.
17 Q. LET ME ASK YOU THIS QUESTION. YOU WERE AWARE OF A CHEST
18 X-RAY AT 5:00 A.M.?
19 A. YES.
20 Q. YOU'RE AWARE THAT THAT SHOWED PNEUMONIA?
21 A. I DON'T REMEMBER THE EXACT WORDING ON THAT. ATELECTASIS
22 VERSUS PNEUMONIA.
23 Q. YOU'RE AWARE --
24 A. AS I SAY, I DON'T REMEMBER. IF THAT'S THE CASE THAT
25 DOESN'T NECESSARILY SAY THERE WAS PNEUMONIA.
4122
1 Q. SO YOUR OPINION IS SHE DIDN'T HAVE PNEUMONIA, IS THAT
2 WHAT YOU'RE TELLING US?
3 A. THERE CERTAINLY DIDN'T SEEM TO BE ANY CLINICAL
4 INDICATION AT THE TIME OF ADMISSION.
5 Q. ARE YOU AWARE OF THE CORONER'S REPORT WITH RESPECT TO
6 HIS FINDINGS IN THE AUTOPSY AND THE CONDITION OF HER LUNGS?
7 ARE YOU AWARE OF THAT, SIR?
8 A. I AM. I'D HAVE TO LOOK AT IT AGAIN.
9 Q. ARE YOU AWARE OF THE FACT THAT HE DETERMINED, AS A
10 RESULT OF HIS AUTOPSY, THAT SHE WAS SUFFERING ACUTE
11 PULMONARY PROBLEMS AT THE TIME OF HER DEATH, ARE YOU AWARE
12 OF THAT?
13 A. I THINK, BECAUSE OF THE COMPROMISE IN HER BREATHING --
14 Q. I DIDN'T ASK YOU THAT, SIR. I ASKED YOU ARE YOU AWARE
15 OF THAT FACT?
16 THE COURT: LET HIM FINISH.
17 Q. (BY MR. STIRBA) ARE YOU AWARE OF THAT FACT?
18 THE WITNESS: WHO GETS TO FINISH?
19 THE COURT: YOU FINISH YOUR ANSWER. WAIT UNTIL
20 HE'S DONE AND DON'T TALK OVER EACH OTHER. FINISH YOUR
21 ANSWER.
22 THE WITNESS: I THINK ANY SORT OF ACUTE PULMONARY
23 PROBLEM CAN EASILY BE EXPLAINED BY A PATIENT WHO HAS HAD
24 HYPOXIA, A PATIENT WHO HAS HAD A VERY LOW BLOOD PRESSURE, A
25 PATIENT WHO HAS PROBABLY SUSTAINED CARDIAC DAMAGE DUE TO
4123
1 THOSE THINGS. A PATIENT WHO THEN IS GOING TO HAVE
2 CONGESTION IN THE LUNGS DUE TO CARDIAC DAMAGE RESULTING FROM
3 ALL -- ALL OF THIS RESULTING FROM THE MORPHINE.
4 Q. (BY MR. STIRBA) SURE. WE'RE AWARE EVERYTHING IS
5 RELATED TO MORPHINE IN YOUR OPINION. BUT YOU'RE AWARE THAT
6 MS. ANDERSON HAD CONGESTIVE HEART FAILURE BEFORE SHE EVER
7 ENTERED THE UNIT?
8 A. SHE WAS NOT ACUTELY ILL FROM CONGESTIVE HEART FAILURE.
9 Q. I DIDN'T SAY THAT, SIR. I ASKED ARE YOU AWARE, BASED
10 UPON YOUR REVIEW OF THE HISTORICAL RECORDS, WHICH YOU DID
11 NOT REVIEW IN YOUR PRIOR TESTIMONY, PERHAPS YOU HAVE NOW,
12 THAT DR. WILDING DIAGNOSED HER AS HAVING CONGESTIVE HEART
13 FAILURE? ARE YOU AWARE OF THAT?
14 A. SHE HAD A HISTORY OF THAT.
15 Q. AND ISN'T IT TRUE THAT IF YOU HAVE CONGESTIVE HEART
16 FAILURE, YOU MAY VERY WELL HAVE A LOW BLOOD PRESSURE OF 70
17 OVER 50, ISN'T THAT TRUE?
18 A. AGAIN, THAT IS NOT THE CONDITION THIS PATIENT CAME INTO
19 THE HOSPITAL WITH, SO I WOULD SAY THAT WAS NOT THE REASON
20 FOR HER PROBLEMS, THAT WAS NOT THE REASON FOR HER DEMISE.
21 Q. NOW, IN TERMS OF A RESPIRATION RATE, IT'S TRUE, IS IT
22 NOT, AS A MATTER OF FACT, WITH THE RECORDS THAT YOU HAVE
23 REVIEWED, THAT HER RESPIRATION RATES, AS CHARTED BY THE
24 NURSES, WERE 26, 16; AND, AS CHARTED BY NURSE SCHOLLS AT ONE
25 A.M., EIGHT TO 16? THOSE ARE THE ONLY RESPIRATION
4124
1 REFERENCES IN THE ENTIRE CHART, ISN'T THAT TRUE?
2 A. THAT'S CORRECT.
3 Q. AND IT'S TRUE, IS IT NOT, YOU DO NOT KNOW, AS YOU SIT
4 HERE NOW, WHEN NURSE SCHOLLS SAID AT ONE A.M. RESPIRATION
5 RATE SIX TO 18 -- I'M SORRY, EIGHT TO 16 -- YOU DON'T
6 PRECISELY KNOW WHEN SHE TOOK THOSE RESPIRATIONS, DO YOU?
7 A. I DON'T.
8 Q. NOW, IT'S TRUE, IS IT NOT, DOCTOR, THAT ENNIS ALLDREDGE,
9 AT THE END -- TOWARDS THE END OF HIS LIFE WAS GASPING FOR
10 BREATH AS NOTED BY NURSE HARDEY?
11 A. HE WAS UNCONSCIOUS, AS I RECALL.
12 Q. OKAY. MY QUESTION IS DO YOU REMEMBER THAT TOWARDS THE
13 END OF MR. ALLDREDGE'S LIFE HE WAS GASPING FOR BREATH, AS
14 NOTED BY NURSE HARDEY?
15 A. I CAN REVIEW THOSE RECORDS AGAIN. I SUSPECT, SINCE
16 YOU'RE BRINGING THAT UP, THAT YOU COULD POINT ME TO IT.
17 Q. I'M NOT GOING TO. YOU EITHER KNOW IT OR YOU DON'T.
18 A. I'M SORRY, I DIDN'T MEMORIZE ALL OF THESE RECORDS AND
19 EVERY LITTLE DETAIL.
20 Q. AND IT'S TRUE, IS IT NOT, THAT GASPING IS IN FACT A
21 SYMPTOM, OR CAN BE A SYMPTOM, OF THIS D WORD, TRUE?
22 A. IN A CONSCIOUS PATIENT, PERHAPS.
23 Q. WELL, IS IT OR IS IT NOT SYMPTOMATIC OF THE PHENOMENON
24 DYSPNEA, TRUE OR NOT?
25 A. DYSPNEA CARRIES WITH IT A LEVEL OF DISTRESS, A LEVEL OF
4125
1 DISCOMFORT, A CONSCIOUS LEVEL OF DISCOMFORT. IN A PATIENT
2 WHO IS UNCONSCIOUS, BY DEFINITION THEY CANNOT HAVE DYSPNEA.
3 Q. OKAY. I DIDN'T ASK YOU THAT, SIR.
4 A. THEY CAN HAVE LABORED BREATHING.
5 Q. IT'S TRUE, IS IT NOT, THAT DYSPNEA IS AIR HUNGER?
6 A. AGAIN, AIR HUNGER IMPLIES A CONSCIOUS ANXIETY, DISTRESS
7 AROUND BREATHING.
8 Q. RIGHT. GASPING FOR BREATH, ISN'T THAT WHAT WE MEAN WHEN
9 WE SAY AIR HUNGER?
10 A. IT IS.
11 MR. STIRBA: THAT'S ALL.
12 THE COURT: ANY REDIRECT?
13 MR. WILSON: JUST A COUPLE OF QUESTIONS.
14 REDIRECT EXAMINATION (REBUTTAL)
15 BY MR. WILSON:
16 Q. DOCTOR, YOU WERE ASKED ABOUT DOUBLE EFFECT. DID YOU SEE
17 THAT PARTICULAR METHODOLOGY USED IN CONNECTION WITH ANY OF
18 THESE FIVE PATIENTS?
19 A. I DID NOT.
20 Q. I REFER YOU -- HAVE YOU GOT ENNIS ALLDREDGE'S FILE
21 THERE?
22 A. YES, I DO.
23 Q. TAKE A LOOK AT PAGE -- MED PAGE 78 IN HIS FILE.
24 A. (WITNESS COMPLIED.)
25 Q. IT BEARS THE DATE OF 1/14/96.
4126
1 A. I HAVE THAT PAGE IN FRONT OF ME.
2 Q. OKAY. REFERRING DOWN TO THE NOTE AT 0930 HOURS, CAN YOU
3 READ THAT NOTE, PLEASE.
4 A. YES, I CAN. "PATIENT CONDITION DECLINING. RESPIRATIONS
5 Q 80 SECONDS," OR EVERY 80 SECONDS, "WITH GASPING NOTED."
6 Q. DOES THAT REFLECT THE CONDITION OF DYSPNEA TO YOU?
7 A. ABSOLUTELY NOT. THIS IS WHAT WE REFER TO AS AGONAL
8 BREATHING. IN A PATIENT WHO IS ABOUT TO DIE THE PATIENT
9 ONCE IN A WHILE TAKES A BREATH.
10 MR. WILSON: ALL RIGHT. THANK YOU, DOCTOR.
11 NOTHING FURTHER.
12 MR. STIRBA: NOTHING FURTHER, YOUR HONOR. THANK
13 YOU.