Rebuttal - Michael Crookston, MD
Doctors, see a grossly misleading statement by this "anesthesiologist">>
1 MICHAEL CROOKSTON,
2 CALLED BY THE PLAINTIFF, HAVING BEEN DULY
3 SWORN, WAS EXAMINED AND TESTIFIED AS FOLLOWS:
4 DIRECT EXAMINATION
5 BY MR. WILSON:
6 Q. DR. CROOKSTON, WILL YOU STATE YOUR FULL NAME FOR THE
7 RECORD, PLEASE.
8 A. MICHAEL JAMES CROOKSTON.
9 Q. AND, SIR, YOU'VE BEEN -- YOU'VE GIVEN PREVIOUS TESTIMONY
10 IN THIS MATTER AND HAVE BEEN SWORN BEFORE AND ARE UNDER OATH
11 AT THIS TIME. YOU UNDERSTAND THAT?
12 A. YES.
13 Q. OKAY. DR. CROOKSTON, I WOULD LIKE TO FIRST ASK YOU A
14 FEW QUESTIONS AS RELATES TO THE MEDICATION DEPAKENE. CAN
15 YOU TELL US WHAT TYPE OF MEDICATION THAT IS?
16 A. DEPAKENE IS AN ANTICONVULSANT THAT'S USED FOR TREATMENT
17 OF EPILEPSY. IT'S ALSO USED IN THE TREATMENT OF MOOD
18 DISORDERS, AS MOOD STABILIZERS. IT CAN ALSO BE USED TO
19 TREAT AGITATED OR AGGRESSIVE BEHAVIOR.
20 Q. NOW, YOU'RE CURRENTLY PRACTICING AS A PSYCHIATRIST; IS
21 THAT CORRECT?
22 A. YES, I AM.
23 Q. DO YOU USE THAT PARTICULAR MEDICATION IN THAT PRACTICE?
24 MR. STIRBA: I'M GOING TO OBJECT. IRRELEVANT, YOUR
25 HONOR.
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1 THE COURT: SUSTAINED.
2 Q. (BY MR. WILSON) IN RESPECT TO THE MEDICATION, SIR, CAN
3 YOU TELL US, ARE YOU FAMILIAR WITH THE TERM HALF LIFE?
4 A. YES, I AM.
5 Q. AND WHAT DOES THAT TERM MEAN?
6 A. HALF LIFE IS GENERALLY REFERRED TO AS THE AMOUNT OF TIME
7 THAT IT TAKES FOR A DRUG TO GET OUT OF THE BLOOD SYSTEM BY
8 HALF. SO IT'S THE NUMBER OF HOURS FOR THE BLOOD LEVEL TO
9 FALL BY 50 PERCENT.
10 Q. OKAY. AND DID YOU REFERENCE ANY SOURCE MATERIAL IN
11 RESPECT TO PREPARATION FOR THESE PROCEEDINGS HERE TODAY?
12 A. YES, I DID.
13 Q. CAN YOU TELL US WHAT SOURCE MATERIAL THAT WAS?
14 A. I REFERRED TO THE "PHYSICIANS DESK REFERENCE" FROM 1995.
15 I ALSO REFERRED TO GOODWIN AND GILLMAN, WHICH IS A STANDARD
16 TEXT ON PHARMACOLOGY. I ALSO REFERRED TO SEVERAL
17 PSYCHIATRIC TEXTS, INCLUDING THE "COMPREHENSIVE TEXTBOOK OF
18 PSYCHIATRY" BY KATHLINE SADAR, A VERY STANDARD REFERENCE.
19 Q. DOES YOUR REVIEW OF THE MEDICAL LITERATURE PROVIDE YOU
20 INFORMATION AS TO HALF LIFE?
21 A. YES.
22 Q. HAVE YOU ALSO HAD EXPERIENCE AS TO THE USE OF THIS DRUG?
23 A. YES, I HAVE.
24 MR. STIRBA: YOUR HONOR, I'M GOING TO OBJECT. IT'S
25 IRRELEVANT.
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1 THE COURT: SUSTAINED.
2 MR. WILSON: I THINK IT GOES TO HIS TESTIMONY, YOUR
3 HONOR.
4 MR. STIRBA: NO. IT'S HALF LIFE.
5 THE COURT: THE HALF LIFE WAS THE QUESTION AND HOW
6 IT RELATES TO --
7 MR. WILSON: I THINK IT RELATES TO HIS EXPERIENCE
8 ALSO, YOUR HONOR.
9 THE COURT: OKAY. I SUSTAINED THE OBJECTION.
10 Q. (BY MR. WILSON) BASED UPON YOUR REVIEW, DOCTOR, CAN
11 YOU TELL US, DO YOU HAVE AN OPINION AS TO WHAT THE HALF LIFE
12 OF THIS PARTICULAR MEDICATION IS?
13 A. OF DEPAKENE, THE PUBLISHED HALF LIFE VARIES FROM SIX TO
14 16 HOURS OR SO, DEPENDING ON OTHER MEDICATIONS THAT A PERSON
15 IS TAKING. TYPICALLY AN EPILEPTIC PERSON, IF THEY WERE
16 TAKING OTHER ANTICONVULSANT DRUGS THAT CAUSE THE LIVER TO
17 METABOLIZE DRUGS FASTER, IT HAS A SHORTER HALF LIFE. IN THE
18 AVERAGE PERSON WHO'S TAKING ONLY DEPAKENE OR DEPAKOTE AS AN
19 ANTI-CONVULSANT OR MOOD STABILIZER, THE HALF LIFE IS AT THE
20 HIGHER END. IT'S 16 HOURS OR SO. AND WE KNOW THAT IN THE
21 ELDERLY THAT HALF LIFE IS EXTENDED EVEN LONGER.
22 Q. CAN YOU TELL US, DOCTOR, HAVE YOU HAD OCCASION TO REVIEW
23 MARY CRANE'S RECORDS?
24 A. YES, I HAVE.
25 Q. AND CALLING YOUR ATTENTION TO, I THINK IT WAS JANUARY 6,
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1 1996, CAN YOU TELL US WHETHER OR NOT SHE RECEIVED THE
2 MEDICATION DEPAKENE DURING THAT TIME PERIOD?
3 A. YES. ON JANUARY 6 SHE RECEIVED A TOTAL OF A THOUSAND
4 MILLIGRAMS OF DEPAKENE.
5 Q. OKAY. AND IN RESPECT TO THE FOLLOWING DAY, JANUARY THE
6 7TH, DO YOU KNOW WHETHER OR NOT SHE WAS ADMINISTERED ANY OF
7 THE DRUG DEPAKENE?
8 A. SHE WAS GIVEN ANOTHER DOSE AT EIGHT O'CLOCK IN THE
9 MORNING ON THE 7TH.
10 Q. OKAY. YOU'VE ALSO REVIEWED THE OTHER MEDICATIONS THAT
11 WERE ADMINISTERED TO HER IN THIS SAME TIME FRAME; IS THAT
12 CORRECT?
13 A. YES, SIR.
14 Q. BASED UPON YOUR REVIEW OF THE RECORDS WOULD YOU HAVE AN
15 OPINION AS TO WHEN -- AS TO WHETHER OR NOT THE MEDICATION
16 DEPAKENE WAS STILL IN HER SYSTEM AS OF THE TIME OF HER DEATH
17 ON THE 7TH OF JANUARY?
18 A. I THINK IT MOST DEFINITELY WAS STILL PRESENT.
19 Q. ARE YOU FAMILIAR WITH THE MEDICATION OF SERZONE AND
20 TRAZODONE?
21 A. YES, I AM. THEY ARE COMMON PSYCHIATRIC MEDICATIONS.
22 Q. AND IN RESPECT TO THEIR USE AT CERTAIN TIMES OF THE DAY,
23 DOES ONE MEDICATION HAVE MORE SEDATING EFFECT THAN THE OTHER
24 MEDICATION?
25 A. TRAZODONE IS SOMEWHAT MORE SEDATING THAN SERZONE, BUT
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1 THEY ARE BOTH QUITE SEDATING. AND THAT'S THE LIMITING SIDE
2 EFFECT FREQUENTLY, HOW MUCH A PERSON CAN TAKE. IT MAKES
3 THEM TOO TIRED AND SLEEPY.
4 Q. IN RESPECT TO THE PRACTICE OF ADMINISTERING SERZONE
5 DURING THE DAYTIME AND TRAZODONE AT NIGHT, CAN YOU COMMENT
6 ON AND THAT PARTICULAR PRACTICE?
7 A. THEY ARE BOTH THE SAME TYPE OF DRUG FROM THE SAME
8 CHEMICAL FAMILY. THEY ARE BOTH ANTIDEPRESSANTS. I KNOW OF
9 NO GOOD PHARMACOLOGICAL REASON TO PRESCRIBE THEM IN
10 COMBINATION THAT WAY. AND IN GENERAL A PSYCHIATRIST WOULD
11 CHOOSE ONE OR THE OTHER TO TREAT A PATIENT WITH. MURDER!
12 Q. OKAY. LET'S TALK A LITTLE BIT ABOUT THE MEDICATIONS
13 RISPERDAL AND HALDOL. CAN YOU TELL US, ARE THOSE DRUGS
14 SIMILAR IN THE DESIRED EFFECTS?
15 A. YES. THEY ARE BOTH ANTIPSYCHOTIC MEDICATIONS OR
16 NEUROLEPTIC MEDICATIONS. RISPERDAL IS CONSIDERED IN THE
17 CLASS THAT'S CALLED ATYPICAL NEUROLEPTIC. IT'S A NEWER
18 MEDICATION THAN HALDOL. BUT THEY ARE BOTH USED FOR THE SAME
19 PURPOSE.
20 Q. AND WHAT IS THAT, SIR?
21 A. THE PRIMARY PURPOSE IS TO TREAT PSYCHOSES FROM
22 HALLUCINATIONS OR BEING OUT OF TOUCH WITH REALITY OR HAVING
23 DELUSIONAL OR FALSE BELIEFS THAT ARE INCONSISTENT WITH
24 REALITY.
25 Q. CAN YOU TELL US, SIR, IS THERE A -- IS THERE MEDICAL
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1 LITERATURE THAT YOU'VE REVIEWED IN CONNECTION WITH THESE
2 PROCEEDINGS AS TO THE -- IF YOU ARE GOING TO CHANGE FROM ONE
3 DRUG TO THE OTHER, ANY CONVERSION RATE?
4 A. YES. I REVIEWED THE RELATIVE POTENCY OF THESE DRUGS AS
5 TO CONVERTING FROM ONE DRUG TO THE OTHER. AND IN GENERAL
6 RISPERDAL IS SLIGHTLY STRONGER THAN HALDOL, BUT NOT A LOT.
7 AND SO IF YOU WERE GOING TO CHANGE FROM ONE MILLIGRAM OF
8 RISPERDAL TO HALDOL, THE EQUIVALENT WOULD BE ONE-AND-A-THIRD
9 TO ONE-AND-A-HALF MILLIGRAMS OF HALDOL.
10 Q. ONE-AND-A-THIRD TO ONE-AND-HALF GRAMS OF HALDOL?
11 A. MILLIGRAMS.
12 Q. MILLIGRAMS. IN YOUR REVIEW OF THE CASES HERE, DID YOU
13 SEE ANY CONVERSION FROM RISPERDAL TO HALDOL?
14 A. YES, I DID.
15 Q. CAN YOU BE SPECIFIC AS TO WHAT PATIENT THAT WAS OR WAS
16 IT MORE THAN ONE PATIENT?
17 A. I BELIEVE IT WAS MORE THAN ONE PATIENT. BUT I'LL --
18 ENNIS ALLDREDGE IN PARTICULAR, THERE'S AN ORDER ON JANUARY
19 10 THAT SAYS HALDOL, FIVE MILLIGRAMS INTRAMUSCULARLY, IN THE
20 MORNING; AND FIVE P.M. AT BEDTIME TO BE GIVEN IF THE PATIENT
21 REFUSES RISPERDAL. THE RISPERDAL DOSE THAT WAS ORDERED WAS
22 ONE MILLIGRAM. AND SO INSTEAD OF CHANGING ONE MILLIGRAM OF
23 RISPERDAL TO MAYBE ONE-AND-A-HALF OF HALDOL, FIVE MILLIGRAMS
24 WERE ORDERED, WHICH WOULD BE AT LEAST THREE TIMES AS MUCH AS
25 THE EQUIVALENT DOSE. MURDER!
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1 Q. DOCTOR, IN YOUR PROFESSION DO YOU MEET WITH FAMILIES OF
2 INDIVIDUALS THAT YOU ARE TREATING?
3 A. FREQUENTLY.
4 Q. IN CONNECTION WITH THOSE FAMILY MEETINGS, DO YOU DISCUSS
5 THE TREATMENT OF THE PATIENT?
6 A. YES. WITH THE PATIENT'S PERMISSION OF COURSE.
7 Q. IN RESPECT TO THE APPROPRIATENESS OR INAPPROPRIATENESS
8 OF INCREASING MEDICATIONS BASED UPON FAMILY DESIRES, IS THAT
9 SOMETHING YOU DO IN YOUR PRACTICE?
10 A. I LISTEN TO THE FAMILY'S CONCERNS, BUT THE DECISION
11 ABOUT MEDICATION HAS TO BE MADE ON A MEDICAL AND PSYCHIATRIC
12 BASIS AND NOT JUST BECAUSE A FAMILY MEMBER IS REQUESTING IT.
13 Q. OKAY. I WANT TO TALK A LITTLE BIT ABOUT GOING BACK
14 TO -- YOU PREVIOUSLY TESTIFIED ABOUT THE ADMINISTRATION OF
15 MORPHINE; IS THAT CORRECT?
16 A. YES.
17 Q. CAN YOU TELL US, SIR, BASED UPON YOUR REVIEW OF THE
18 LITERATURE, AS TO THE -- WELL, FIRST OF ALL, DOES MORPHINE
19 HAVE A PEAK EFFECT AFTER BEING ADMINISTERED?
20 A. THE PEAK EFFECT DEPENDS ON HOW THE MORPHINE IS
21 ADMINISTERED. WITH AN INTRAMUSCULAR INJECTION IT'S
22 GENERALLY UNDERSTOOD THAT THE PEAK EFFECT OCCURS VERY
23 RAPIDLY, LESS THAN A HALF HOUR. HOWEVER, THE EFFECT
24 CONTINUES FOR SEVERAL HOURS. AND ITS EFFECT ON A PERSON'S
25 BREATHING CAN LAST AT LEAST FOUR TO FIVE HOURS. AND THESE
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1 NUMBERS THAT GET BROUGHT UP ARE ALL AVERAGES OF GENERALLY
2 HEALTHY YOUNGER ADULTS.
3 MR. STIRBA: YOUR HONOR, COULD WE HAVE A QUESTION,
4 PLEASE?
5 THE COURT: ASK ANOTHER QUESTION.
6 Q. (BY MR. WILSON) IN RESPECT TO THE PEAK EFFECT, DOES
7 AGE HAVE ANY RELEVANCE ON THE PEAK EFFECT?
8 A. AGE MAKES A PERSON MORE SENSITIVE TO THE EFFECTS WHICH
9 WOULD OCCUR AT THE PEAK, MORE SUSCEPTIBLE TO SIDE EFFECTS.
10 Q. IS THERE ANY OTHER PHYSICAL FACTORS OF A PERSON'S BODY
11 THAT WOULD HAVE AN IMPACT ON THE PEAK EFFECT?
12 A. YES. IN THE CASE OF MORPHINE WHEN IT'S INJECTED INTO A
13 MUSCLE, INTRAMUSCULAR, ITS ABSORPTION INTO THE BLOOD STREAM
14 DEPENDS ON THE BLOOD FLOW TO THAT MUSCLE. IF A PERSON IS
15 COLD OR IF THEY HAVE LOW BLOOD PRESSURE, THAT PEAK EFFECT IS
16 GOING TO BE DELAYED, AND IT CAN BE DELAYED SIGNIFICANTLY,
17 UNTIL THE BLOOD FLOW IS ABLE TO CAUSE THE ABSORPTION FROM
18 WHERE THE INJECTION WAS MADE. SO THE PEAK EFFECT, RATHER
19 THAN OCCURRING WITHIN A HALF HOUR, MIGHT OCCUR EVEN HOURS
20 LATER.
21 Q. DID YOU REVIEW THE CASE OF ELLEN ANDERSON?
22 A. YES.
23 Q. CAN YOU TELL US WHETHER OR NOT YOU SEE ANYTHING IN THE
24 RECORD RELATED TO HER AGE OR, I GUESS IT WOULD BE, BLOOD
25 PRESSURE THAT YOU'VE JUST TESTIFIED TO; IS THAT CORRECT?
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1 MR. STIRBA: I WOULD OBJECT, YOUR HONOR. IT'S
2 CUMULATIVE AND BEYOND THE SCOPE. IT WASN'T IN THE PROFFER.
3 THE COURT: I'LL SUSTAIN THAT OBJECTION.
4 MR. WILSON: THANK YOU. DOCTOR, I HAVE NO FURTHER
5 QUESTIONS?
6 THE COURT: ANY CROSS-EXAMINATION?
7 MR. STIRBA: YES.
8 CROSS-EXAMINATION
9 BY MR. STIRBA:
10 Q. DOCTOR, YOU JUST TESTIFIED, DID YOU NOT, THAT THE PEAK
11 EFFECT IN AN I.M. INJECTION IS RAPID AND NORMALLY LESS THAN
12 ONE HALF HOUR; IS THAT TRUE?
13 A. GENERALLY, YES.
14 Q. AND IT'S TRUE, IS IT NOT, THAT INDIVIDUAL MEDICATIONS
15 AFFECT INDIVIDUALS DIFFERENTLY, CORRECT?
16 A. YES, SIR.
17 Q. SO IT'S TRUE, IS IT NOT, THAT THE PEAK EFFECT, AS YOU
18 JUST TESTIFIED TO, COULD VARY DEPENDING UPON THE INDIVIDUAL,
19 CORRECT?
20 A. YES, SIR.
21 Q. BUT YOU FEEL COMFORTABLE SAYING THAT IN AN I.M.
22 INJECTION THE NORMAL PEAK EFFECT WOULD BE REACHED IN LESS
23 THAN A HALF HOUR, TRUE?
24 A. YES.
25 Q. AND IT'S TRUE, IS IT NOT, THAT THE MAXIMUM RESPIRATORY
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1 DEPRESSANT IN AN INDIVIDUAL WOULD OCCUR AT THE PEAK?
2 A. THAT DEPENDS ON SEVERAL OTHER FACTORS INCLUDING THE
3 PATIENT'S PHYSICAL STATUS AND INCLUDING OTHER MEDICATIONS
4 THAT THEY ARE TAKING. BUT IN GENERAL, YES, THE PEAK
5 RESPIRATORY DEPRESSION WOULD OCCUR NEAR THE PEAK EFFECT OF
6 THE DRUG.
7 Q. SURE.
8 A. AND THEN LAST FOR SEVERAL HOURS GENERALLY.
Peak effect lasts for several hours, "generally" - !!!
9 Q. NOW, DEPAKENE, YOU HAVE -- DID YOU LOOK AT THE GERIATRIC
10 DOSAGE HANDBOOK FOR PURPOSES OF HALF LIFE?
11 A. NO, SIR.
12 Q. WOULD YOU AGREE THAT IF I READ TO YOU THAT IN THE
13 GERIATRIC DOSAGE HANDBOOK THE HALF LIFE OF DEPAKENE IS EIGHT
14 TO 17 HOURS AND THE ONLY CLARIFICATION OR QUALIFICATION THEY
15 HAVE IS INCREASED HALF LIFE IN PATIENT WITH LIVER DISEASE,
16 WOULD YOU AGREE WITH THAT STATEMENT?
17 A. NO, SIR.
18 MR. STIRBA: THAT'S ALL I HAVE. THANK YOU.
19 THE COURT: ANY REDIRECT?
20 MR. WILSON: NO FURTHER REDIRECT.
21 THE COURT: MAY THIS WITNESS BE EXCUSED?
22 MR. WILSON: HE MAY.