Robert Bitner, MD
19 MR. WILSON: Call Robert Bitner to the stand, Dr.
20 Robert Bitner.
21 THE COURT: Dr. Bitner, come up here, please. Raise
22 your right hand and face the clerk to be placed under oath.
23 DR. ROBERT BITNER,
24 being first duly sworn, was examined and
25 testified as follows:
1 THE COURT: Please have a seat over here, Doctor.
2 State your name and spell your last name. Mr. Wilson, are
3 there exhibits up there we don't need? It's getting a little
4 cluttered up there.
5 (Pause in the proceedings.)
6 THE WITNESS: My name is Robert Felt Bitner.
7 B-i-t-n-e-r.
8 THE COURT: Thank you. Go ahead, Mr. Wilson.
9 DIRECT EXAMINATION
10 BY MR. WILSON:
11 Q. Where do you currently reside, Dr. Bitner?
12 A. In Layton.
13 THE COURT: Let's have you pull your chair up a
14 little closer to the microphone. There you go.
15 Q. (BY MR. WILSON) Are you a practicing physician at this
16 time?
17 A. No, sir. I'm retired.
18 Q. How long have you been retired?
19 A. About six years.
20 Q. Okay. But you were in 1995 a practicing physician?
21 A. Yes.
22 Q. And what area did you practice in, Doctor?
23 A. Primary internal medicine with an emphasis on cardiology.
24 Q. Okay. Did you have clinical privileges at the Davis
25 Hospital in Layton?
1 A. Yes. Complete privileges.
2 Q. Okay. Now, I'm going to hand to you what has been
3 identified as state's exhibit 5B, which are medical records
4 at the Davis Hospital pertaining to Lydia Smith.
5 While you were practicing at the hospital, did you act in
6 any kind of consultant capacity for the hospital?
7 A. Yes. That was kind of an occasional, but not routine
8 thing.
9 Q. Okay. In respect to patients who were admitted to the
10 geriatric psychiatric unit at the Davis Hospital, did you
11 have occasion, on occasion, to assist them in doing physical
12 examinations, history and physical examinations?
13 A. Yes, sir. There was a routine following the admission of
14 a patient to the geropsych unit that one of the internists
15 who was on call would be called in to do a physical exam and
16 history and whatever information was necessary to determine
17 the general condition of the patient relative to her being --
18 to he or she being in the hospital for care, and particularly
19 in that area.
20 Q. Okay. Now, calling your attention, and you can probably
21 turn to the exhibit to -- it's designated at medical page
22 703. I've got it tabbed there, I believe.
23 THE COURT: Why don't you come up and help him find
24 it?
25 Q. (BY MR. WILSON) Here we go right here.
1 A. Okay.
2 Q. Have you had a chance to review that particular report?
3 A. Yes, I have.
4 Q. And is this one that was prepared by you, sir?
5 A. Yes.
6 Q. In connection with an evaluation on whom?
7 A. On this patient, Lydia Smith.
8 Q. Can you tell us when you conducted that particular
9 history and physical examination?
10 A. I believe that she was admitted either the -- probably
11 the evening or afternoon of the day before. I saw her, as I
12 recall, the next day in the morning.
13 Q. Okay. And where did you see her at?
14 A. She was in -- she was one of the patients in the
15 geropsych.
16 Q. So you would conduct your examinations there at the
17 geropsych unit?
18 A. Yes. At her bedside.
19 Q. Okay. And on this particular date you have designated in
20 your report a history of this lady. Where did you get the
21 information related to the history, can you tell us that?
22 A. I didn't have much source material except for what was on
23 the chart from her care by the nurses there. I didn't have
24 any conversation with the family. But I did understand that
25 she had some problems that I indicated on this history.
1 Q. Okay. And apparently you also indicated some of the
2 problems from the past history related to what you were able
3 to observe about her, is that correct?
4 A. Yes, that's right.
5 Q. You indicate in the -- on the second page, if you would
6 turn to the next page of your report, that the history tells
7 us she's lost about 30 pounds in the past year and there's
8 some question about her appetite. Do you know where that
9 information came from?
10 A. No, sir, I don't. I can't tell you that except as I was
11 able to observe her and see her. She was very thin and gave
12 evidence of considerable weight loss.
13 Q. Okay. I understand that you had a difficult time
14 conducting this particular examination, is that correct?
15 A. Yes, sir.
16 Q. And why was that, sir?
17 A. Almost immediately when I went into the room she appeared
18 to be very angry and resentful and confused. And she really
19 refused to -- even though I explained to her carefully and
20 tried to make friends with her, she wouldn't allow me to
21 really get close to her. I wasn't able to give an
22 examination like I would ordinarily do to see how she was
23 faring at that time.
24 Q. Were you able to understand her?
25 A. No. She talked, but I didn't quite know what she was
1 saying. While I was there she was pretty difficult to
2 handle. I observed her -- she kicked at the nurse. She was
3 able to walk somewhat with help, so I knew that she could be
4 up and around. And she didn't seem to be in any particular
5 pain, but she was really agitated and just in no -- I just
6 couldn't do any examination that was of much help on her, as
7 far as her general health was concerned.
8 Q. Okay. The only vital sign that you make reference to, or
9 the only vital signs, is the blood pressure and the pulse.
10 Was that something that you were able to accomplish or
11 something that was reported to you?
12 A. Umm, I think I took her pulse. I don't think she liked
13 it and I don't know how accurate it was, because she would
14 pull her hand away. I couldn't put a stethoscope on her to
15 see how her breathing was or her heart function. Her color
16 was generally good for her age. I found out later that she
17 did have literally an atrial fibrillation. And her blood
18 pressure was in the range that's quite reasonable for a
19 person of her age.
20 Q. Okay. That was the 130 over 60?
21 A. Yes.
22 Q. Was the pulse within the normal range?
23 A. Yes. It was acceptable.
24 Q. Okay. You indicate down in the further section as to the
25 diagnosis. If you could just go over that with us. The
1 first word there I don't dare pronounce, Doctor.
2 A. It's arteriosclerotic cardiovascular disease. That means
3 sort of hardening of the arteries, maybe some obstruction of
4 the vascular system, especially in the heart area.
5 As far as her behavior was concerned, I felt she
6 exhibited some dementia. I felt that some of this -- that
7 the diagnosis was proper on observation, but she perhaps did
8 have cerebral arteriosclerosis as well as the heart
9 situation.
10 Q. And that was the second part of this particular
11 diagnosis?
12 A. Yes, sir.
13 Q. In respect to your observations of her, you indicated
14 earlier that you could see no evidence that she was
15 experiencing any kind of pain at that time?
16 A. She didn't appear to have pain. She moved around and
17 seemed to be able to do that. I wasn't able to check the
18 movement of her limbs, arms, legs, or anything like, which I
19 would ordinarily check, but she did move and seemed to be
20 quite strong and able at that time.
21 Q. Did you find any evidence that would suggest to you, or
22 make any observations, that would suggest to you that she was
23 experiencing at that time any kind of condition which might
24 be life-threatening in nature?
25 A. Well --
1 Q. Maybe I'm not making myself clear.
2 A. Generally speaking, she was 90 years old. She was
3 underweight. She was not functioning well. But other than
4 that, I had no evidence of any immediate threat of her life.
5 Q. Okay. In terms of not functioning very well, was that in
6 connection with her mental state?
7 A. Yes.
8 Q. Okay. Your recommendations in the report indicate
9 general care as outlined as far as nutrition and medications
10 and just general supportive care, is that correct?
11 A. Yes, sir, that's right.
12 Q. And essentially what does that mean, Doctor?
13 A. That means close observation by the nurses, attention to
14 her intake of fluids and passing fluids and so on. The
15 exchange of fluids and her nutrition and her general
16 behavior. To protect her against hurting herself or
17 injuring -- causing any interruption in her general care.
18 I'm not sure to what extent this was carried on. That was
19 just the first day after I saw her, but I expected -- they
20 all had instructions relative to trying to make the patient
21 comfortable and trying to settle her down as far as her
22 mental disturbance was concerned and her worry and so on
23 about what was happening.
24 MR. WILSON: I pressure that, Doctor. I have no
25 further questions. Thank you.
1 THE COURT: Cross-examination, Mr. Bugden.
2 CROSS-EXAMINATION
3 BY MR. BUGDEN:
4 Q. Doctor Bitner, my name is Walter Bugden. I'm one of the
5 lawyers representing Dr. Weitzel. How are you today?
6 A. Fine, thank you.
7 Q. Thank you for being here today. I just have a few
8 questions. You did this physical examination, I guess, the
9 day after Ms. Smith was received at the hospital, admitted to
10 the hospital?
11 A. Yes, sir.
12 Q. And would it be correct to say that you really almost
13 weren't able to perform a physical examination because of her
14 resistance?
15 A. It was limited, yes, sir.
16 Q. You told us that she seemed confused and angry,
17 resentful. You tried to present yourself as nonthreatening,
18 as comforting?
19 A. Yes. I sat down at the bedside and tried to talk to her
20 and explain to her that I was a friend. I don't think she
21 responded to that very well.
22 Q. I'll ask you to keep your voice up. She apparently never
23 was able -- you weren't really able to carry on a
24 conversation with this woman, were you?
25 A. No, I wasn't.
1 Q. And you told the jury that she appeared to you to be
2 demented. I mean, her mental functioning was completely
3 impaired by the dementia, isn't that true?
4 A. Yes, that appeared to be so.
5 Q. So that even when you tried to be comforting and make
6 this as nonfrightening of an experience as possible for this
7 elderly woman, she never did calm down during the time that
8 you spent with her?
9 A. No, she did not.
10 Q. She remained highly agitated and restless during your
11 attempts to examine her?
12 A. Yes. At any of my attempts to examine her. And even
13 with the nurses, as they came in to help her, she was very
14 hostile to any apparent help that we attempted to give her.
15 Q. Am I correct that you really did not even touch her? You
16 couldn't even actually touch the woman because of her
17 combativeness, or at least discomfort with you?
18 A. I think that's true. I don't believe I was able to
19 really touch her at all. I think I might have taken her
20 pulse, but as I recall she pulled her arm away and didn't --
21 I really didn't get much information there. So I had to get
22 the information that I had, as far as blood pressure and
23 pulse and so on, from the nurse's record.
24 Q. But she really was kind of resentful of anything that you
25 tried to do that day?
1 A. Yes, she was, that's right.
2 Q. Even though I'm sure you tried to be patient and explain
3 who you were, what you were trying to do?
4 A. Yes.
5 Q. And although it was hard to conduct the physical
6 examination, you were able to at least obtain some background
7 information on her medical history, am I right? And maybe it
8 came from the records that came with her?
9 A. I'm not sure. It must have, because I didn't have much
10 information to go on.
11 Q. Like the weight --
12 A. She did have an injury to her shoulder, for instance.
13 Q. Let's stop there. She did have this frozen shoulder from
14 an accident. How do you think you obtained that information,
15 Dr. Bitner?
16 A. I think I got it from the chart.
17 Q. Okay. And you said that she didn't actually complain of
18 any pain that day, but you weren't able to ask this woman do
19 you hurt here or do you hurt there, because her mental
20 functioning was so impaired that she couldn't -- you never
21 communicated?
22 A. That's right. She was busy keeping us all away from her,
23 me and the nurses. She didn't express any pain any place.
24 By her actions I could observe that she didn't seem to be
25 favoring her arms or legs or anything else as far as being
1 painful.
2 Q. The overwhelming observation, I suppose, during the whole
3 time you were with her, is that she was highly agitated, is
4 that right?
5 A. That's right.
6 Q. You described -- you told the jury just now about the
7 diagnosis. Number one, everything you saw was consistent
8 with this woman having dementia, right?
9 A. Yes.
10 Q. And she had arteriosclerotic cardiovascular disease?
11 A. Yes.
12 Q. And that's hardening of the arteries?
13 A. Yes.
14 Q. And a heart problem, a weak heart?
15 A. Yes. In reading over her record, she had an enlarged
16 heart. And the electrocardiogram showed that she did have
17 atrial fibrillation.
18 Q. And what does that mean?
19 A. That means that the upper part of the heart, in the
20 atrium, from which the impulse goes into the ventricle, which
21 is the lower part, the muscular part which does the pumping.
22 The upper part determines the rhythm. The upper part in this
23 case is the atrium or the atrial area. It wasn't sending the
24 proper signal to the ventricle. Sometimes the ventricle just
25 takes over and beats as it wants to and it's irregular. On
1 the electrocardiogram it showed that the atrium was also
2 irregular in its process.
3 Q. With this irregular atrial and ventricular activity that
4 you've just explained to us, would this 90-year-old woman be
5 a candidate for a heart attack?
6 A. Not necessarily.
7 Q. She's someone that could, from that condition, from that
8 heart disease you described, she's someone that could suffer
9 a heart attack?
10 A. Could, yes.
11 Q. And although, again, the physical exam what you did was
12 limited because you couldn't really touch this woman or
13 communicate with her, you did not recommend against admitting
14 her? You supported admitting this woman to the geropsych
15 unit?
16 A. Yes. I felt that she was there properly.
17 Q. To try and deal with this state of agitation?
18 A. Yes, that's right.
19 MR. BUGDEN: Thank you very much. Nothing further.
20 THE COURT: Redirect, Mr. Wilson?
21 REDIRECT EXAMINATION
22 BY MR. WILSON:
23 Q. As a consultant, do you have any authority over the
24 admission process as to whether or not she should be
25 continued to be admitted to the hospital or transferred to a
1 different portion of the hospital?
2 A. Yes, I think I could express an opinion on that.
3 Q. Okay.
4 A. I didn't feel at the time that I should -- I felt that
5 she was admitted there properly and --
6 Q. I was just wondering, in terms of who would make the
7 final decision in terms of your recommendation, would that be
8 the attending physician's call as to whether or not you would
9 follow -- that he would follow that recommendation?
10 A. Yes, I think so.
11 MR. WILSON: Okay. Thank you, Doctor. No further
12 questions.
13 THE COURT: Anything further, Mr. Bugden?
14 MR. BUGDEN: No, sir.
15 THE COURT: You may step down, Dr. Bitner. Thank
16 for coming in and testifying. May this witness be excused?
17 MR. WILSON: He may.
18 MR. BUGDEN: Yes, Your Honor.
19 THE COURT: You are excused, Doctor.