Rebuttal - Hare
14 MS. BARLOW: On rebuttal we'd call Dr. Brad Hare.
15 THE COURT: Dr. Hare, step up, please. Raise your
16 right hand and face the clerk.
17 BRADFORD HARE,
18 being first duly sworn, was examined and
19 testified as follows:
20 THE COURT: State your name and spell the last name,
21 please.
22 THE WITNESS: My name is Bradford D. Hare, H A R E.
23 DIRECT EXAMINATION (Rebuttal)
24 BY MS. BARLOW:
25 Q. Dr. Hare, good morning. Thank you for returning. Are
1 you familiar with the graphic charts that show temperature,
2 pulse, respiration, blood pressure, that sort of thing in the
3 medical records of these patients?
4 A. Yes, I am.
5 Q. I'm going to put up a chart of seven days for Mary Crane
6 up here.
7 THE COURT: Does that have an exhibit number?
8 MS. BARLOW: Yes. It is 279, Your Honor.
9 Q. (BY MS. BARLOW) Have you seen a chart such as this in
10 the medical records?
11 A. Yes, I have.
12 Q. Can you describe the manner in which the respiration rate
13 was -- well, all the vital signs were taken, or recorded, I
14 should say, documented?
15 A. The chart would show the days, the dates, at the very
16 top. So each of the segments underneath that date would
17 represent a 24 hour period. And then the various points or
18 numbers charted can be traced back up to the top and
19 approximated as to when that bit of information was charted.
20 Q. Charting in this manner, is that a good indicator of the
21 effects of psychotropic drugs or analgesics drugs on a
22 patient?
23 A. It certainly can be.
24 Q. And why is that?
25 A. Well, again, these medications have the potential to
1 alter the state of consciousness, alter blood pressure, alter
2 breathing. I think under the influence of these medications
3 it's very important to chart this type of information. If
4 the patient is very mildly affected by them --
5 MR. BUGDEN: I think he's answered the question.
6 THE COURT: Sustained.
7 Q. (BY MS. BARLOW) Is there any reason for the charting
8 being twice a day?
9 A. I think it depends on the circumstances. If the effects
10 of medicines are minimal, twice a day is probably fine. If
11 the patient's level of consciousness is altered, in other
12 words if the patient is noted to do be unresponsive,
13 lethargic, then these vital signs need to be monitored much
14 more than that.
15 Q. Why is that?
16 A. Again, along with the state of consciousness, there's
17 much more likely effect on blood pressure, breathing, and the
18 various vital signs are much more likely to be affected.
19 This is a standard way of monitoring medications.
20 Q. If the chartings do not show a respiration or a heart
21 rate going down towards the end of a person's life, what does
22 that mean to you as a physician?
23 A. Umm, there can be various meanings to that. At least
24 part of that, you know, could be that the body begins to kick
25 in compensatory mechanisms, kind of life saving mechanisms to
1 try and keep the blood pressure and the heart rate up under
2 adverse circumstances. So those things may not change that
3 much under circumstances where the patient is very adversely
4 affected by medications. At the same time it's important to
5 trace those, to keep track of them.
6 Q. When you say keep track of them, are you talking about
7 more than twice a day?
8 A. Yes.
9 MR. BUGDEN: Objection. Leading.
10 THE COURT: Sustained. And stricken.
11 Q. (BY MS. BARLOW) Are you aware of the standard of care
12 for monitoring people who are on central nervous system
13 depressants?
14 A. Yes.
15 Q. What is that standard of care?
16 A. To monitor them often enough to ensure the safety of the
17 effects of those medications.
18 Q. Would that change -- how would that impact doing it twice
19 a day?
20 A. If there was very little effect to make a patient sleepy
21 or to change a patient's activity with medicines, twice a day
22 is probably okay. If, on the other hand, a patient is
23 lethargic, unresponsive, you know, even approaching almost a
24 general anesthetic state, as an anesthesiologist we monitor
25 those patients every five minutes. Of course, in a psych
1 ward that's obviously not practical, but certainly monitoring
2 more than every 12 hours is very much indicated and would be
3 the standard of care.
4 MS. BARLOW: Thank you. That's all I have.
5 THE COURT: Cross-examine.
6 CROSS-EXAMINATION (Rebuttal)
7 BY MR. BUGDEN:
8 Q. (BY MR. BUGDEN) Dr. Hare, do you understand that as
9 relates to Mary Crane, you would agree that her vital signs
10 on this graphic chart are not consistent with morphine
11 overdose? Her vital signs do not show respiratory
12 depression?
13 A. Well, the respiratory rate is one indication.
14 Q. But that wasn't my question.
15 THE COURT: Please listen to the question.
16 Q. (BY MR. BUGDEN) Her respiratory rate is not depressed on
17 this graphic chart?
18 A. That's right.
19 Q. Her other vital signs, blood pressure, heart rate, they
20 are not depressed on this graphic chart, isn't that true?
21 A. Only the time that this is monitored, yes.
22 Q. And you testified last week that what you would expect if
23 you had a morphine overdose would be that the vital signs,
24 respiratory rate, heart rate, blood pressure, that those
25 things would show a depressed effect, wasn't that your
1 testimony last week, Doctor?
2 A. It depends on the circumstances. The acute effects of
3 morphine would be to show those sorts of effects. The more
4 chronic damaging effects of morphine, the accumulation of
5 other drugs, all bets are off what you're going to say.
6 Q. All bets are off. With Mary Crane, for example, is the
7 gist of your testimony that although we have graphic evidence
8 over a period of days, and it being charted every 12 hours,
9 that although every 12 hours her vital signs are not
10 consistent with morphine overdose, is the gist of your
11 testimony that somehow in between the charting there was a
12 life threatening event and a life threatening depressed
13 effect on her respiratory and other vital signs and it's just
14 that she phased right out of it so that at the moment that
15 she was charted everything was fine again?
16 A. I guess we don't know, because it wasn't charted.
17 Q. But isn't that the gist of what you're trying to imply to
18 the jury?
19 A. I'm staying there isn't enough information charted to be
20 able to safely -- to say that these medications were given
21 safely.
22 Q. Judith Larsen, remember that patient?
23 A. Yes.
24 Q. Are you aware from the records that after she received a
25 trial dose of morphine, Dr. Weitzel charted that he saw pain,
1 was going to try morphine to see if that improved her
2 condition; and on the very first day he gave Judith Larsen
3 morphine, or ordered morphine for that patient, that she
4 then -- her alertness increased?
5 MS. BARLOW: Objection. That's not in these charts.
6 THE COURT: Sustained.
7 MR. BUGDEN: It's in the medical records
8 THE COURT: You can refer to the medical records as
9 long as you identify them.
10 Q. (BY MR. BUGDEN) Haven't you seen that in the medical
11 records?
12 A. Yes.
13 Q. So she received a morphine dose and then became more
14 alert after that morphine dose and was able to actually watch
15 a movie?
16 A. As I remember, those were two milligram doses of
17 morphine, yes.
18 Q. Okay. So your supposition with regard to the depressant
19 effects of the morphine with regard to Mary Crane, for
20 example, is that in the middle of the shift you suspect that
21 perhaps Mary Crane, for example, with this graphic chart, may
22 have had some life threatening problems, but the measurements
23 you agree did return to the normal range at every 12 hours
24 that they were checked, is that right?
25 A. I think what I'm saying is that the monitoring was
1 inadequate. I don't know what went on between. It could
2 have. But the monitoring is inadequate. That's my point.
3 Q. But you don't know what went on in between so you
4 certainly can't say, to a degree of reasonable medical
5 certainty, that this was a life threatening effect caused by
6 a morphine overdose in between the two 12 hour checks of the
7 vitals, you can't say that?
8 A. No, I can't say that.
9 MR. BUGDEN: Thank you. That's all I have.
10 MS. BARLOW: No further questions, Your Honor.
11 THE COURT: You may step down.
12 MS. BARLOW: We have no further witnesses, Your
13 Honor.
14 THE COURT: Ladies and gentlemen, that concludes the
15 evidence in this case.