Scott Cunningham, DO
2 MS. BARLOW: WE'D CALL DR. SCOTT CUNNINGHAM.
3 THE COURT: DR. CUNNINGHAM, WOULD YOU STEP FORWARD
4 PLEASE? IF YOU'LL COME RIGHT UP HERE, RAISE YOUR RIGHT HAND
5 PLEASE AND FACE THE CLERK, SHE'LL PLACE YOU UNDER OATH.
6 SCOTT CUNNINGHAM,
7 BEING FIRST DULY SWORN, WAS EXAMINED
8 AND TESTIFIED AS FOLLOWS:
9 DIRECT EXAMINATION
10 THE COURT: IF YOU'LL HAVE A SEAT THERE PLEASE. IF
11 YOU'D GIVE US YOUR FULL NAME AND SPELL YOUR LAST NAME PLEASE.
12 A. THOMAS SCOTT CUNNINGHAM. C-U-N-N-I-N-G-H-A-M.
13 THE COURT: YOU MAY PROCEED, MRS. BARLOW.
14 MS. BARLOW: THANK YOU, JUDGE.
15 BY MS. BARLOW:
16 Q. GOOD MORNING, DR. CUNNINGHAM.
17 A. HI.
18 Q. CAN YOU TELL US WHERE YOU PRACTICE?
19 A. LOGAN, UTAH.
20 Q. AND HOW LONG HAVE YOU BEEN IN PRACTICE?
21 A. IN LOGAN?
22 Q. IN GENERAL.
23 A. I FINISHED MY RESIDENCY IN 1986. BEEN IN PRACTICE SINCE
24 THEN.
25 Q. WHAT TRAINING DID YOU RECEIVE FOR YOUR SPECIALTY OR YOUR
1 ABILITY?
2 A. I WENT TO SCHOOL AT THE UNIVERSITY OF HEALTH SCIENCE IN
3 KANSAS CITY, MISSOURI. I DID A YEAR OF A ROTATING INTERNSHIP
4 IN DETROIT, MICHIGAN. AND THEN I RECEIVED MY INTERNAL
5 MEDICINE TRAINING AT THE UNIVERSITY OF MISSOURI.
6 Q. ARE YOU BOARD CERTIFIED?
7 A. YES.
8 Q. ARE YOU AN M.D.?
9 A. I'M A D.O.
10 Q. WHAT IS A D.O.?
11 A. OSTEOPATHIC PHYSICIAN. WE HAVE -- IT'S A FOUR-YEAR
12 MEDICAL SCHOOL PROGRAM. OSTEOPATHIC PHYSICIANS HAVE THEIR
13 OWN MEDICAL SCHOOLS. TRAINING IS SIMILAR IN TERMS OF THE
14 MEDICAL INFORMATION WE RECEIVE. I DID A D.O. INTERNSHIP AND
15 SPENT A YEAR IN MICHIGAN, AS I SAID, AND THEN I DID AN M.D.
16 INTERNAL MEDICINE RESIDENCY AT MISSOURI.
17 Q. SO DO YOU HAVE THE SAME TRAINING AS AN M.D. FOR INTERNAL
18 MEDICINE?
19 A. YES. WELL, OTHER THAN A DIFFERENT MEDICAL SCHOOLS BUT
20 MY RESIDENCY TRAINING WAS THROUGH AN M.D. PROGRAM.
21 Q. ARE YOU -- WHAT IS YOUR CURRENT OCCUPATION TITLE,
22 SPECIALTY, THAT SORT OF THING?
23 A. I PRACTICE INTERNAL MEDICINE WHICH IS NONSURGICAL
24 TREATMENT OF ADULT HEALTH ISSUES. I AM IN PRIVATE PRACTICE.
25 I SEE BOTH HOSPITALIZED PATIENTS AND OFFICE PATIENTS FIVE
1 DAYS A WEEK.
2 Q. ARE YOU FAMILIAR WITH THE HOSPICE PROGRAM?
3 A. SURE.
4 Q. AND WHAT'S YOUR FAMILIARITY?
5 A. I'VE BEEN INVOLVED WITH THE HOSPICE IN CACHE VALLEY
6 SINCE APPROXIMATELY 1995. I'M THE MEDICAL DIRECTOR, SO WE
7 HAVE MEETINGS TWICE MONTHLY. WE DISCUSS OUR PATIENTS AND I
8 HELP ANSWER MEDICAL ISSUES THAT MIGHT ARISE WITH THESE
9 PATIENTS.
10 Q. DO YOU HANDS-ON TREAT HOSPICE PATIENTS?
11 A. I DO. GENERALLY. MANY OF THESE PATIENTS ARE COVERED BY
12 THEIR PHYSICIANS IN LOGAN. SOME OF THEM ARE MY OWN PATIENTS.
13 I GET INVOLVED IN ISSUES WHEN THE HOSPICE TEAM WOULD LIKE ME
14 TO INTERFACE WITH THE OTHER PHYSICIANS ABOUT THE PATIENTS AND
15 WHATEVER ISSUE THAT MIGHT BE PERTINENT.
16 Q. WHAT DOES THE TERM HOSPICE MEAN?
17 A. HOSPICE IS ESSENTIALLY A PHILOSOPHY OF DELIVERING
18 END-OF-LIFE CARE TO PATIENTS. IT'S A MULTIDISCIPLINARY TEAM
19 APPROACH, INCLUDING ISSUES REGARDING BEREAVEMENT, DYING
20 ISSUES. WE HAVE NURSING STAFF, WE HAVE SOCIAL WORKERS, WE
21 HAVE SPIRITUAL INDIVIDUALS INVOLVED IN DELIVERING CARE.
22 Q. IS THERE ANY PARTICULAR TIME FRAME THAT IS HOSPICE? I
23 DON'T KNOW HOW TO PHRASE IT OTHER THAN THAT.
24 A. SURE. CLINICIAN TRIES TO MAKE A DECISION AS TO WHETHER
25 THE PERSON INVOLVED'S LIFE DURATION IS APPROXIMATELY SIX
1 MONTHS OR LESS. THAT'S GENERALLY THE CRITERION THAT'S USED
2 BROADLY. THERE ARE OTHER SPECIFIC CRITERIA, BUT IN GENERAL
3 ANY DETERMINATION THAT SOMEONE'S LIFE MAY NOT LAST MORE THAN
4 SIX MONTHS IS CERTAINLY POTENTIALLY ELIGIBLE FOR HOSPICE.
5 Q. NO ONE CAN SAY FOR SURE JUST HOW LONG A PERSON'S LIFE
6 WILL BE, THOUGH, IS THAT CORRECT?
7 A. RIGHT.
8 Q. IS THERE -- DOES THE WORD TERMINAL OR TERMINALITY MEAN
9 ANYTHING IN THE CONTEXT OF HOSPICE?
10 A. SIMPLY -- YOU'RE TALKING ABOUT NEAR DEATH. GENERALLY
11 SIX MONTHS OR LESS IS THE CRITERION AGAIN WE CONSIDER.
12 Q. IS THERE ANY TERMINALITY END-OF-LIFE CONNECTION TO
13 DEMENTIA?
14 A. SURE.
15 Q. AND NOW DEMENTIA IS A MENTAL CONCERN USUALLY, ISN'T IT?
16 A. RIGHT.
17 Q. AND HOW DOES THAT FACTOR INTO HOSPICE AND TERMINALITY?
18 A. USING THE SAME CRITERION, WHEN WE DETERMINE THAT
19 SOMEONE'S HEALTH IS SUCH THAT THEY HAVE A GOOD PROBABILITY OF
20 DYING WITHIN SIX MONTHS, WHATEVER THE ILLNESS BE, COULD BE A
21 CANCER-RELATED ILLNESS, IT COULD BE NONCANCER ILLNESS
22 INCLUDING DEMENTIA.
23 Q. DEMENTIA IS AN ILLNESS THAT CAN CAUSE DEATH?
24 A. SURE.
25 Q. DEMENTIA IS USUALLY IN THE ELDERLY, IS THAT CORRECT?
1 A. GENERALLY, RIGHT.
2 Q. DOES DEMENTIA -- USUALLY ELDERLY PEOPLE HAVE MORE THAN
3 ONE ILLNESS, IS THAT CORRECT?
4 A. CORRECT.
5 Q. DOES DEMENTIA OFTEN TAKE PEOPLE OR IT IS USUALLY
6 SOMETHING -- SOME OTHER ILLNESS THAT MIGHT CAUSE THEIR DEATH?
7 A. IT'S USUALLY A COMPLICATION, SO IT'S USUALLY A
8 CO-EXISTING OR OCCURRING -- ACUTELY OCCURRING PROCESS THAT
9 RESULTS IN DEATH.
10 Q. DID YOU HAVE OCCASION TO PROVIDE MEDICAL SERVICES FOR
11 ENNIS ALLDREDGE?
12 A. YES.
13 Q. DO YOU RECALL WHEN YOU FIRST STARTED SEEING
14 MR. ALLDREDGE?
15 A. I SAW MR. ALLDREDGE IN -- BEGINNING IN 1995. MY FIRST
16 APPOINTMENT WITH HIM WAS IN APRIL.
17 Q. DO YOU HAVE YOUR MEDICAL CHART --
18 A. YES.
19 Q. -- FROM YOUR OFFICE FOR MR. ALLDREDGE? DO YOU KNOW
20 WHERE MR. ALLDREDGE WAS PRIOR TO WHEN YOU FIRST SAW HIM?
21 A. HE WAS LIVING IN SOUTHERN UTAH, FROM MY RECORDS, I
22 BELIEVE DELTA, UTAH.
23 Q. WAS HE SEEING A DOCTOR THERE?
24 A. YES.
25 Q. DID YOU RECEIVE ANY RECORDS FROM THOSE DOCTORS ABOUT
1 THEIR CARE PRIOR TO THE TIME YOU SAW HIM?
2 A. I DID RECE -- I DID RECEIVE RECORDS. I CAN'T STATE
3 EXACTLY WHEN IT WAS, BUT I DID RECEIVE RECORDS AND THEY ENDED
4 UP IN MY OFFICE NOTES.
5 Q. DID YOU -- WHEN WAS YOUR FIRST --
6 A. APRIL '95.
7 MS. BARLOW: OKAY. YOUR HONOR, I WILL BE ASKING HIM TO
8 DEAL WITH HIS CHART, HIS MEDICAL RECORDS WHICH ARE
9 DEFENDANT'S EXHIBIT NUMBER 12. AND I WILL BE REFERRING TO
10 NUMBERS C.U.N.N. AND THEN THE NUMBER FOR THE PAGE WITHIN THE
11 RECORDS SO WE HAVE COPIES OF THAT AND THEY'VE BEEN ADMITTED
12 AS DEFENDANT'S 12.
13 THE COURT: THANK YOU.
14 Q. (BY MS. BARLOW) I WOULD LIKE YOU -- DO YOU HAVE YOUR
15 RECORD FOR THAT APRIL 17TH --
16 A. YES.
17 Q. -- 1995? ALWAYS TAKES US A LITTLE WHILE TO GET THE
18 MACHINE REWORKING CORRECTLY. IS THAT BOTHERING ANYONE?
19 THE COURT: THE LIGHT'S ON THE SIDE.
20 MS. BARLOW: NOW IF WE CAN GET THE COMPUTER PART TO LET
21 THE --
22 A JUROR: IS THE LENS ON IT?
23 MS. BARLOW: NO, NO, THE LENS -- WE GET ONE PART WORKING
24 AND THE OTHER PART DOESN'T.
25 MR. BUGDEN: CHARLENE, ARE YOU GONNA USE THE APRIL 17TH
1 RECORD?
2 MS. BARLOW: YES.
3 MR. BUGDEN: WELL, WE CAN JUST DO IT FROM THE COMPUTER,
4 IT'S --
5 MS. BARLOW: I WILL BE USING SEVERAL OF THEM.
6 MR. BUGDEN: WE CAN HELP YOU. IF YOU JUST TELL US, WE
7 CAN -- WE CAN TAKE YOU THERE BECAUSE I'M SURE WE HAVE IT ON
8 THE COMPUTER.
9 MS. BARLOW: THERE WE GO. THE PROBLEM IS IT MAY NOT
10 BLOW UP THE SAME THINGS I WANNA BLOW UP, UNFORTUNATELY.
11 Q. (BY MS. BARLOW) WELL, LET'S -- WHILE THEY'R KIND OF
12 PLAYING WITH THE MACHINERY, LET ME ASK YOU A COUPLE OF
13 QUESTIONS. DID YOU TAKE A HISTORY OF MR. ALLDREDGE ON THE
14 17TH OF APRIL 1995?
15 A. YES.
16 Q. HOW DID YOU DO THAT?
17 A. HIS -- I ASKED HIM QUESTIONS. HIS WIFE WAS ALSO
18 PRESENT. I DON'T KNOW SPECIFICALLY HOW MUCH INFORMATION SHE
19 GAVE ME DURING THE VISIT, BUT SHE WAS AT THE VISIT.
20 Q. PART OF THAT HISTORY WAS THAT HE HAD HAD A HISTORY OF
21 MYCOSIS FUNGOIDES. DO YOU KNOW WHAT THAT IS?
22 A. I HAVE A VAGUE -- I HAVE A GENERAL IDEA ABOUT WHAT IT
23 IS.
24 Q. WHAT IS IT?
25 A. IT'S A FORM OF LYMPHOMA, NON-HODGKINS LYMPHOMA, WHICH IS
1 A CANCER. MYCOSIS FUNGOIDES IS PRIMARILY INVOLVED THE SKIN.
2 CAUSES AREAS ON THE SKIN THAT LOOK VERY LIKE -- VERY MUCH
3 LIKE ECZEMA. TENDS TO BE A SLOW, INDOLENT SLOW-GROWING
4 PROCESS. CAN SPREAD TO ORGANS BUT GENERALLY, AS IN HIS CASE,
5 I'M NOT AWARE THAT IT DID. HE RECEIVED RADIATION TREATMENTS
6 FOR THAT. AND MY UNDERSTANDING IS, IS THAT THAT WAS WELL
7 CONTROLLED AND NOT AN ACTIVE PROCESS.
8 Q. SO IT WAS NOT A TERMINAL CONDITION AT THAT POINT?
9 A. NO.
10 Q. WE ALWAYS THINK OF CANCER AS BEING SOMETHING --
11 A. YEAH, THAT WAS NOT THAT. THIS WAS A VERY INDOLENT
12 PROCESS AND SEEMED TO BE WELL CONTROLLED.
13 Q. WHAT WAS HIS GENERAL HEALTH? PHYSICAL HEALTH?
14 A. HE HAD OTHER MEDICAL PROBLEMS. HE HAD HAD A HISTORY OF
15 CORONARY ARTERY DISEASE. HE HAD A BYPASS IN 1982. HIS
16 CORONARY DISEASE WAS NOT ACTIVE. IN OTHER WORDS, HE WASN'T
17 HAVING PROBLEMS WITH CHEST PAIN, HE WASN'T HAVING PROBLEMS
18 WITH WEAKNESS OF HIS HEART SUCH THAT HE WAS IN --
19 PERIODICALLY IN CONGESTIVE HEART FAILURE. SO HIS CARDIAC
20 PROCESS WAS, QUOTE, STABLE. HE HAD DIABETES FOR WHICH HE WAS
21 ON INSULIN. HE HAD A HISTORY OF LOW THYROID, HYPOTHYROIDISM.
22 HE WAS ON THYROID MEDICATION FOR THAT. THAT WAS STABLE. HE
23 HAD HE HYPERTENSION WHICH WAS CONTROLLED ON MEDICATIONS.
24 Q. DID HE HAVE ANY IMMEDIATELY LIFE THREATENING CONDITIONS
25 AT THAT POINT?
1 A. NO.
2 Q. AND ON PAGE 13 OF YOUR -- 13 FOR ME, THE SECOND PAGE OF
3 YOUR EVALUATION ON THE 17TH OF APRIL, WHAT WAS YOUR FIRST
4 IMPRESSION OF HIS MEDICAL CONDITION?
5 A. UNDER THE IMPRESSIONS, I LISTED STABLE. MEDICALLY
6 STABLE. DIABETES, DEMENTIA, HIS MYCOSIS FUNGOIDES THAT WE'VE
7 SPOKEN ABOUT, HIS THYROID, LOT THYROID, HYPERTENSION.
8 Q. DID YOU HAVE HAVE OCCASION TO SEE MR. ALLDREDGE AFTER
9 THAT FIRST VISIT?
10 A. I SAW HIM AGAIN THE FOLLOWING MONTH.
11 Q. AND WHY WAS THE VISIT THAT QUICKLY AFTERWARDS?
12 A. HE HAD JUST MOVED INTO THE NURSING HOME, AND GENERALLY,
13 I SEE PATIENTS WITHIN THE NEXT FOUR WEEKS.
14 Q. DID YOU SEE ANY CHANGE IN HIS CONDITION AT THAT TIME?
15 A. I NOTED THAT HIS DIABETES, HIS BLOOD SUGARS WERE RUNNING
16 SLIGHTLY ELEVATED, PARTICULARLY IN THE AFTERNOONS. SO I MADE
17 SOME MODIFICATION IN HIS INSULIN. OTHERWISE, I DID NOT MAKE
18 ANY ANY OTHER CHANGES.
19 Q. HIS DIABETES THEN, WOULD YOU CALL IT UNDER CONTROL OR
20 WAS IT OUT OF CONTROL, WHAT --
21 A. I THINK IT WAS MILD -- IT WAS MILDLY OUT OF CONTROL. IT
22 WASN'T ANYTHING DRAMATIC. HIS BLOOD SUGARS WERE IN THE
23 LOW -- LOW TO MID 200'S IN THE AFTERNOON, WHICH IS MILDLY
24 ELEVATED. HIS MORNING BLOOD SUGARS WERE -- WERE WITHIN THE
25 100 RANGE, SO I THOUGHT THAT HIS BLOOD SUGARS WERE SLIGHTLY
1 ELEVATED, BUT NOTHING SUBSTANTIAL.
2 Q. DID YOU HAVE OCCASION TO HAVE AN OCCUPATIONAL THERAPIST
3 DO AN EVALUATION OF HIM?
4 A. AN OCCUPATIONAL THERAPIST SAW HIM IN APRIL.
5 Q. AND WHAT -- DID THEY REPORT BACK TO YOU THEIR FINDINGS?
6 A. YES.
7 Q. WHAT DID THEY FIND OR REPORT TO YOU?
8 A. I'LL TURN TO THE FORM, BUT GENERALLY THEY -- GENERALLY,
9 THEY FELT THAT -- MORE SPECIFICALLY, THEY NOTED THAT HE
10 REQUIRED SOME ASSIST WITH AMBULATION. HE REQUIRED VERBAL
11 CUES IN TERMS OF STANDING FROM HIS SEATED POSITION. HE
12 REQUIRED VERBAL CUES AND ONE-ARM ASSIST IN GETTING INTO THE
13 BATHTUB. THEY FELT THAT HIS STRENGTH WAS GOOD. HIS --
14 PARTICULARLY UPPER EXTREMITY STRENGTH THEY SPOKE ABOUT AND
15 SAID THAT WAS IN GOOD CONDITION. LET ME REFER TO THE FORM TO
16 SEE OTHER THINGS.
17 THEY COMMENTED THAT AT HOME HE AMBULATED WITH A WALKER,
18 AND THA TWAS CONSISTENT WITH HIS NEED FOR ONE-HAND ASSISTANCE
19 WITH WALKING. THEY RECOMMENDED SOME ASSISTANCE -- OR THEY
20 STATED HE NEEDEDED ASSISTANCE WHEN DOING SOME COMPLEX TASKS
21 SUCH AS BUTTONING HIS SHIRT, PULLING UP HIS PANTS. HE WAS
22 INDEPENDENT IN EATING, SO HE DID NOT NEED HELP WITH EATING.
23 Q. WHAT ABOUT HIS COGNITIVE ABILITIES, DID THEY REFER TO
24 THAT AT ALL?
25 A. I CAN JUST READ THEIR COMMENT, IF THAT WOULD BE --
1 Q. IF YOU WOULD PLEASE.
2 A. COGNITION, THE PATIENT DEMONSTRATES SEVERE COGNITIVE
3 DEFICITS. IS ORIENTED TO PERSON AND GENERALLY TO PLACE. HE
4 IS NOT ORIENTED TO TIME OR PURPOSE. HE DEMONSTRATES A FAIRLY
5 SHORT ATTENTION SPAN OF APPROXIMATELY ONE MINUTE OF BRIEF
6 TASKS. HE HAS VERY POOR IMMEDIATE AND SHORT-TERM MEMORY.
7 REMOTE AND DISTANT MEMORY ARE MORE FUNCTIONAL.
8 Q. IS THAT CONSISTENT WITH YOUR FINDING THAT HE HAD
9 DEMENTIA?
10 A. YES.
11 Q. DID YOU EVER MAKE A DETERMINATION OF WHAT HAD CAUSED THE
12 DEMENTIA?
13 A. IN REVIEWING THESE RECORDS, I -- MY INITIAL -- MY
14 INITIAL STATEMENT ON THE RECORD WAS ALZHEIMER'S DEMENTIA,
15 WHICH IS ONE FORM OF DEMENTIA. WHEN I WAS LOOKING THROUGH
16 THE RECORDS, DR. SMITH WHO WAS HIS PHYSICIAN IN DELTA, HAD
17 WRITTEN ON ONE OF THE SHEETS THAT, QUESTION MARK,
18 MULTI-INFARCT DEMENTIA. IN OTHER WORDS, HISTORY OF MULTIPLE
19 STROKES CAUSING MEMORY LOSS AND DEMENTIA, BUT I DID NOT SEE
20 ANY FURTHER DOCUMENTATION REGARDING THAT, SO I'M NOT EXACTLY
21 CERTAINLY THE SPECIFIC ORIGIN OF HIS DEMENTIA.
22 Q. IS THERE A DIFFERENCE BETWEEN A -- AN ALZHEIMER'S TYPE
23 DEMENTIA AND I GUESS WHAT'S A STROKE OR A C.V.A. KIND OF
24 DEMENTIA?
25 A. THEY -- THEY PRESENT GENERALLY OR CAN THE SAME WITH
1 SIGNIFICANT COGNITIVE LOSS. OBVIOUSLY, THE ORIGIN OF THE
2 DEMENTIA IS DIFFERENT. MULTI-INFARCT DEMENTIA IS BECAUSE OF
3 MULTIPLE STROKES. HE DIDN'T HAVE ANY FOCAL MOTOR WEAKNESS,
4 HE DIDN'T HAVE ANY FOCAL NEUROLOGICAL SIGNS THAT WOULD
5 SUGGEST TO ME CLEARLY THAT HE HAD HAD PREVIOUS STROKES.
6 THEY'RE BOTH PROGRESSIVE, THEY BOTH CAN CAUSE SEVERE DECLINE
7 AND SEVERE DEBILITY AND POTENTIALLY, AS WE'VE TALKED ABOUT
8 BEFORE, ULTIMATELY DEATH.
9 Q. DID YOU HAPPEN TO SEE MR. ALLDREDGE THEN IN AUGUST OF
10 1995?
11 A. YES.
12 Q. DO YOU RECALL WHAT DAY THAT WAS?
13 A. I SAW HIM TWICE IN AUGUST. I SAW HIM IN EARLY AUGUST,
14 THEN I SUBSEQUENTLY SAW HIM TOWARDS THE END OF AUGUST. I
15 BELIEVE THE SUBSEQUENT VISIT LATER IN AUGUST WAS BECAUSE HE
16 WAS ADMITTED TO A NURSING HOME JUST PRIOR TO THAT, AND IT'S
17 PRETTY STANDARD FOR ME TO SEE THE PATIENT AGAIN ONCE THEY'VE
18 BEEN ADMITTED TO THE NURSING. SO IN AUGUST, I SAW HIM ON
19 AUGUST 3RD, 1995 --
20 THE COURT: MRS. BARLOW, WILL YOU TURN ORR THE LIGHT IF
21 YOU'RE GONNA USE THAT SO THE JURY CAN SEE. JUST TURN OFF THE
22 ONE.
23 MS. BARLOW: THIS ONE OR THE OTHER ONE?
24 THE COURT: THE OTHER ONE. DO YOU NEED 'EM BOTH OFF,
25 LADIES AND GENTLEMEN? NEED 'EM BOTH OFF. THERE YOU GO.
1 MS. BARLOW: I WILL BE KIND OF GOING BACK AND FORTH A
2 LITTLE BIT WITH THESE, YOUR HONOR.
3 THE COURT: WE'LL LEAVE IT OFF FOR A WHILE.
4 Q. (BY MS. BARLOW) OKAY. THERE IS YOUR AUGUST 3RD, 1995.
5 YOUR PHYSICAL EXAM, WAS THERE ANYTHING UNUSUAL OR A PROBLEM
6 WITH ANYTHING YOU SAW IN YOUR PHYSICAL EXAM?
7 A. I FELT THINGS PHYSICALLY WERE ESSENTIALLY THE SAME AS
8 BEFORE.
9 Q. HAD HE LOST ANY WEIGHT?
10 A. HE WEIGHED 203 POUNDS. WHEN HE CAME -- WHEN I INITIALLY
11 SAW HIM, I BELIEVE HE WEIGHED TWO OH -- WELL, LET ME LOOK.
12 WEIGHT WAS THE SAME. HE WEIGHED 203 IN APRIL. HE WEIGHED
13 203 IN MAY. IN AUGUST, ON AUGUST 3RD, HE WEIGHED 203. JUST
14 FOR INFORMATION’S SAKE FOR EVERYBODY, WHEN HE -- WHEN --
15 THE LAST WEIGHT I HAVE ON HIM WAS ON OCTOBER 12 AND HE
16 WEIGHED 199, SO THERE'S A LITTLE BIT OF A DISCREPANCY IN
17 WEIGHTS THERE.
18 Q. SO HE'D LOST ABOUT FOUR POUNDS OVER THE COURSE OF APRIL
19 TO OCTOBER?
20 A. RIGHT.
21 Q. IS THAT UNUSUAL? WELL --
22 A. NO.
23 Q. -- DID IT CAUSE YOU ANY CONCERN?
24 A. NO. NO.
25 Q. HE'S A PRETTY GOOD-SIZED MAN, IT SOUNDS LIKE?
1 A. RIGHT.
2 Q. INDICATED THAT THERE WAS NOTHING REALLY THAT YOU WANTED
3 TO CHANGE ABOUT HIS MEDICAL REGIMEN AT THE TIME?
4 A. I ORDERED AN ECHOCARDIOGRAM, I BELIEVE GIVEN HIS CARDIAC
5 DISEASE. AN ECHOCARDIOGRAM IS AN IMAGE OF THE HEART. IT'S
6 AN ULTRASOUND. YOU CAN SEE THE HEART VALVES, YOU CAN SEE THE
7 STRENGTH OF THE VENTRICULAR CONTRACTIONS. HIS
8 ECHOCARDIOGRAM -- VOILA -- WAS -- HIS PUMP FUNCTION WAS 55
9 PERCENT. THAT WAS DESCRIBED BY DR. HAWS, ONE OF THE LOCAL
10 CARDIOLOGISTS, AS MILDLY DECREASED. THAT'S VERY CLOSE TO
11 NORMAL. I DON'T THINK THAT'S -- THAT'S A FAIRLY GOOD
12 EJECTION FRACTION. HE --
13 THE COURT: MS. BARLOW, IF YOU'RE GONNA REFER TO THESE
14 EXHIBITS, WE NEED TO MAKE A RECORD --
15 MS. BARLOW: I APOLOGIZE, YOUR HONOR.
16 THE COURT: -- ON THE NUMBER AND WHAT WE'RE TALKING
17 ABOUT. I ASSUME THEY'RE ALL FROM THE SAME GENERAL EXHIBIT
18 BUT DIFFERENT PAGES?
19 MS. BARLOW: THEY ARE. D-12, AND AND THIS IS PAGE 26.
20 I APOLOGIZE. I'LL TRY TO REMEMBER TO DO THAT.
21 THE COURT: THANK YOU.
22 Q. (BY MS. BARLOW) WAS THERE ANYTHING ABOUT THIS
23 ECHOCARDIOGRAM THAT GAVE YOU CONCERNS AS HIS PHYSICIAN?
24 A. NO.
25 Q. DID HE HAVE THE HEART OF A 20-YEAR-OLD?
1 A. HARDLY.
2 Q. SO THERE WERE PROBLEMS.
3 A. WELL, SURE, HE HAD -- YEAH, HE HAD, AS I SAID BEFORE,
4 HE'D HAD HIS BYPASS IN 1982. SO HE HAD CORONARY ARTERY
5 DISEASE.
6 Q. AND WHAT IS CORONARY ARTERY DISEASE?
7 A. THAT IS ABNORMALITIES INVOLVING THE CORONARY ARTERIES,
8 WITH FAT DEPOSITION, NARROWING OF THE ARTERIES.
9 Q. IS THAT UNUSUAL IN A MAN OF HIS AGE?
10 A. IT'S A FREQUENT FINDING IN AN 82-YEAR-OLD.
11 Q. YOU INDICATED YOU SAW HIM AGAIN ON THE -- AT THE END OF
12 AUGUST. WAS THERE ANY CHANGE IN HIS CONDITION AT THAT TIME?
13 A. I THOUGHT, BASED UPON MY REVIEW OF THE NOTES, I THOUGHT
14 THAT HIS MENTAL STATUS HAD BEGUN TO DETERIORATE FURTHER.
15 I COMMENTED ABOUT HE WAS -- HE WAS MORE DISORIENTED. I ASKED
16 HIM TO DO SOME SIMPLE MATHEMATICAL CALCULATIONS THAT HE
17 WASN'T ABLE TO DO. BY THAT I MEAN ADDING SOME SIMPLE
18 NUMBERS. HIS SPEECH WAS NOT AS CLEAR TO ME. HE WAS -- HE
19 SEEMED TO BE MORE CONFUSED IN HIS CONVERSATION WITH ME. SO I
20 THOUGHT THERE WERE CLEARLY MENTAL STATUS CHANGES AT THAT
21 POINT COMPARED TO OUR EARLIER VISITS.
22 Q. WHAT ABOUT HIS PHYSICAL CONDITION, HAD IT DETERIORATED?
23 A. I MADE NO COMMENTS ABOUT ANY PHYSICAL PROBLEMS THAT HE
24 WAS HAVING. IN TERMS OF STRENGTH AND HIS OTHER MEDICAL
25 PROBLEMS THAT WE'VE DISCUSSED, THOSE WERE ESSENTIALLY THE
1 SAME. THROUGHOUT THE TIME THAT I WAS TAKING CARE OF HIM, WE
2 WERE CONTINUOUSLY MONITORING HIS BLOOD SUGARS AND OFTENTIMES
3 HIS NUMBERS WOULD BE ELEVATED IN THE AFTERNOONS, AND WE WERE
4 UPPING HIS INSULIN PROGRAM TO TRY TO GET A LITTLE MORE
5 PRECISE CONTROL. SO THROUGHOUT HIS TIME WITH ME, WE WERE
6 DOING THAT.
7 MS. BARLOW: YOUR HONOR, THIS IS PAGE 27.
8 THE COURT: THANK YOU.
9 MS. BARLOW: I NEGLECTED TO SAY THAT. I APOLOGIZE.
10 Q. (BY MS. BARLOW) IN THE MIDDLE UNDER PAST MEDICAL
11 HISTORY, IT SAYS, HE VOICES NO COMPLAINTS. DO YOU RECALL HIM
12 COMPLAINING ABOUT PAIN DURING THAT VISIT?
13 A. ALL I CAN SAY IS I DIDN'T MAKE ANY COMMENTS IN MY RECORD
14 ABOUT HIM DISCUSSING PAIN, PAINFUL PROCESSES. I WOULD USUALLY
15 DO THAT IF HE DID.
16 Q. FACT, IN EACH OF THESE VISITS THAT YOU HAD WITH HIM, DID
17 YOU EVER HAVE HIM COMPLAIN OF ANY PARTICULAR PAIN? DO YOU
18 EVER RECALL HIM COMPLAINING?
19 A. I DON'T -- I DON'T RECALL ANY COMPLAINTS OF PAIN. WHEN
20 I SAW HIM IN OCTOBER, HE CAME TO SEE ME BECAUSE HE WAS HAVING
21 A PROBLEM OVER THE PRECEDING DAY OF NAUSEA AND VOMITING. I
22 DON'T HAVE ANY NOTATION IN MY RECORDS ABOUT HIM COMPLAINING
23 ABOUT ABDOMINAL PAIN IN ASSOCIATION WITH THAT OR ANY OTHER
24 TYPES OF PAIN. SO THE ANSWER I -- TO YOUR QUESTION IS NO.
25 Q. SO OCTOBER 12TH YOU SAW HIM?
1 A. CORRECT.
2 Q. AND WHAT DID YOU THINK -- WHAT DIAGNOSIS DID YOU GIVE
3 FOR THE COMPLAINTS HE HAD AT THAT TIME?
4 A. WELL, I -- I LISTED A NONSPECIFIC DIAGNOSIS OF
5 GASTROENTERITIS. I WASN'T ENTIRELY SURE WHY HE WAS HAVING
6 THIS ABRUPT ONSET OF NAUSEA AND VOMITING. HIS PHYSICAL
7 EXAMINATION DIDN'T GIVE ME ANY IDEA. HIS ABDOMINAL EXAM WAS
8 FINE. HIS OTHER PHYSICAL EXAMINATION, HIS LUNGS, HIS HEART
9 WERE STABLE AND WERE NOT SUGGESTIVE OF ANY PARTICULAR THAT HE
10 HAD CAUSING THIS ABRUPT ONSET OF THE NAUSEA AND VOMITING. I
11 DID SOME LABORATORY TESTS INCLUDING A CHEMISTRY ANALYSIS.
12 LIVER FUNCTIONS, KIDNEY FUNCTIONS, ELECTROLYTES, COMPLETE
13 BLOOD COUNT, WHICH LOOKS FOR ANEMIA, WHITE BLOOD CELL COUNT,
14 WHICH ELEVATED MIGHT SUGGEST A INFLAMMATORY OR INFECTIOUS
15 PROCESS. AND THOSE WERE -- THOSE WERE NONINDICATIVE OF ANY
16 SIGNIFICANT PROBLEM. SO I BASICALLY DECIDED TO NOT INTERVENE
17 ANY FURTHERMORE AND JUST WATCH HIM.
18 MS. BARLOW: THIS IS PAGE 28, YOUR HONOR, OF THE D-12.
19 Q. (BY MS. BARLOW) WHEN YOU AREN'T REALLY SURE WHAT A
20 PERSON'S PROBLEM IS, IS IT COMMON THEN TO ORDER OTHER TESTS
21 AND THAT SORT OF THING?
22 A. WELL, IT DEPENDS ON THE SITUATION. IF YOU'RE -- IF IT'S
23 AN ABRUPT ONSET OF A PROBLEM, WHICH IS NOT ALL THAT UNUSUAL
24 OF A PROBLEM, I THINK WE'VE ALL HAD NAUSEA AND VOMITING IN
25 OUR LIFETIME. IF THE EXAMINATION IS UNREMARKABLE, IF THE
1 LABORATORY STUDIES DON'T SUGGEST ANY SERIOUS PROCESS -- AND
2 THAT'S WHAT YOU'RE TRYING TO DETERMINE, IS THERE A SERIOUS
3 PROBLEM GOING ON HERE. IF YOU DON'T FIND ANY OF THOSE,
4 OFTENTIMES IT'S REASONABLE TO JUST KINDA STEP BACK AND WATCH
5 AND SEE HOW THINGS PROCEED. IF THEY BECOME SICKER OR IF THE
6 PROCESS CONTINUES, THEN CERTAINLY YOU DO OTHER TESTS.
7 OFTENTIMES THE PROCESS JUST RESOLVES AND NO FURTHER
8 INTERVENTION IS NEEDED.
9 Q. DID THIS PROCESS RESOLVE?
10 A. YES.
11 Q. WHAT WAS THE NEXT TIME THAT YOU SAW MR. ALLDREDGE?
12 A. I SAW HIM ON NOVEMBER 16TH.
13 Q. WAS THERE ANY CHANGE IN HIS CONDITION AT THAT TIME? NOT
14 FROM GASTROENTERITIS, BUT FROM HIS GENERAL OVERALL CONDITION
15 FROM THE TIME YOU'D SEEN HIM IN APRIL?
16 A. I FELT THAT HE WAS CONTINUING TO DEMONSTRATE SUBSTANTIAL
17 DEMENTIA SIGNS, SYMPTOMS. HIS SPEECH WAS DIFFICULT TO MAKE
18 ANY SENSE OUT OF. I WRITE, HE HAD EXPRESSIVE APHASIA, WHICH
19 MEANS HE WAS UNABLE TO COMMUNICATE WITH ME VERBALLY IN ANY
20 MEANINGFUL WAY. I WROTE THAT HE HAD -- HE SEEMED TO
21 UNDERSTAND WHAT I SAID TO HIM, SO USUALLY I'LL ASK SOMEBODY
22 TO CLOSE THEIR EYES, RAISE THEIR HAND, OR SOMETHING LIKE THAT
23 JUST TO SEE IF I CAN -- IF WHAT I'M SAYING TO HIM REGISTERS.
24 AND BY ME SAYING HE SEEMS TO UNDERSTAND THE SPOKEN WORD TO
25 HIM, IT IMPLIES THAT DURING THAT EXAMINATION, HE SEEMED TO
1 UNDERSTAND WHAT I WAS SAYING. HE JUST COULDN'T TALK TO ME IN
2 ANY INTELLIGENT MANNER.
3 Q. DO YOU RECALL WHETHER HE EXHIBITED ANY FRUSTRATION FROM
4 HIS INABILITY TO EXPRESS HIMSELF?
5 A. I DON'T RECALL. I CAN'T ANSWER THAT.
6 Q. THEN YOU NEXT SAW HIM ON JANUARY 4TH, 1996?
7 A. CORRECT.
8 Q. WAS THAT ROUTINE OR WAS IT A REQUEST FROM THE NURSING
9 HOME?
10 A. THAT WAS MY REQUEST TO THE NURSING HOME. HE WAS --
11 BEGINNING IN EARLY DECEMBER, HIS BEHAVIOR HAD BECOME QUITE
12 AGITATED, COMBATIVE, OCCASIONALLY PHYSICALLY VIOLENT. AND
13 THROUGHOUT -- THROUGHOUT DECEMBER, WE WERE ATTEMPTING TO
14 CONTROL HIS AGITATED, COMBATIVE, PHYSICALLY ABUSIVE BEHAVIOR
15 WITH MEDICATIONS. THINGS WEREN'T GETTING UNDER CONTROL. IT
16 WAS CONTINUED TO MANIFEST THAT TYPE OF BEHAVIOR, SO I HAD HIM
17 COME INTO MY OFFICE ON JANUARY 4TH TO EXAMINE HIM AND TRY TO
18 DETERMINE IF THERE IS ANY OTHER UNDERLYING MEDICAL PROBLEM
19 THAT MIGHT BE PROVOKING THIS BEHAVIOR.
20 Q. DID YOU FIND ANY SUCH UNDERLYING MEDICAL PROBLEM?
21 A. I DIDN'T FIND ANY -- ANY SPECIFIC PROBLEM THAT I COULD
22 PUT MY FINGER ON TO EXPLAIN HIS INCREASING AGITATION OVER
23 DECEMBER. THERE WAS -- THERE WAS SOME CONCERN THAT THERE
24 MIGHT HAVE BEEN SOME MEDICATIONS THAT HE HAD BEEN ON THAT
25 COULD BE CAUSING A CONFUSIONAL STATE. ONE OF THEM WAS
1 TAGAMET, HE HAD BEEN ON FOR REFLUX. SO I STOPPED THAT.
2 Q. IS THAT COMMON FOR TAGAMET TO CAUSE AGITATION?
3 A. IT CAN, IT CAN.
4 Q. THAT'S NOT --
5 A. I WOULDN'T SAY IT'S COMMON, BUT IT DOES OCCUR.
6 Q. OKAY.
7 A. SO WE STOPPED THE TAGAMET, AND HIS BEHAVIOR DIDN'T
8 REALLY CHANGE. HE CONTINUED TO PHYSICALLY BEHAVE THIS WAY.
9 SO I DIDN'T BELIEVE THAT TAGAMET NECESS -- -- WAS ULTIMATELY
10 RESPONSIBLE FOR THAT GIVEN THE FACT THAT HIS BEHAVIOR DIDN'T
11 NECESSARILY CHANGE UPON DISCONTINUING IT.
12 Q. DID YOU MAKE ANY OTHER MODIFICATIONS IN HIS MEDICAL
13 REGIMEN?
14 A. I CHANGED -- I CHANGED HIS MEDICATIONS. I PUT HIM ON --
15 EARLIER IN DECEMBER WE HAD PUT HIM ON AN ANTIPSYCHOTIC
16 MEDICATION CALLED MELLARIL, WHICH IS USED TO TRY TO SUBDUE
17 THESE BEHAVIORS.
18 Q. HAD THAT BEEN SUCCESSFUL?
19 A. NO.
20 Q. WHAT DID YOU DO THEN?
21 A. I SWITCHED ON JANUARY -- I'M SORRY, I'M CONFUSING YOU
22 GUYS. I CHANGED HIM FROM THE MELLARIL TO THE -- TO THIS
23 OTHER AGENT SEVERAL DAYS AFTER THAT BECAUSE I RECEIVED A
24 PHONE CALL FROM THE NURSING HOME AGAIN TELLING ME THAT HE WAS
25 BECOMING QUITE AGITATED AND ABUSIVE. SO I SWITCHED HIM FROM
1 MELLARIL AT THAT POINT TO A DIFFERENT AGENT, RISPERIDAL.
2 Q. AND WHAT DAY WAS THAT?
3 A. THAT WAS JANUARY 8TH.
4 MS. BARLOW: YOUR HONOR, I'M PUTTING UP PAGE NUMBER 36.
5 THE COURT: THANK YOU.
6 Q. (BY MS. BARLOW) DO YOU RECALL THIS TELEPHONE
7 CONVERSATION THAT'S REFERRED TO ON PAGE 30 -- OR ON PAGE 36?
8 A. YES.
9 Q. HOW DID THAT COME ABOUT? DO YOU RECALL WHETHER THEY
10 CALLED YOU OR YOU CALLED THEM?
11 A. I HAVE A NOTE IN MY RECORD FROM JANUARY 8TH THAT SAYS,
12 THE PATIENT HIT AIDE IN THE ABDOMEN, THREW A BINGO GAME ALL
13 OVER HIM, AND -- WELL, I'M REALLY CONFUSING PEOPLE HERE. HE
14 HAD BEEN ON RISPERIDAL APPARENTLY AFTER OUR JANUARY 4 VISIT,
15 AND THEN WHEN THEY CALLED ME ON JANUARY 8TH WITH THESE
16 ADDITIONAL BEHAVIORS, I UPPED THE DOES OF THE RISPERIDAL FROM
17 A HALF A MILLIGRAM TWICE A DAY TO ONE MILLIGRAM TWICE A DAY,
18 AND I ASKED THEM TO GIVE HIM SOME ATIVAN AT THAT POINT IN
19 TIME TRYING TO CONTROL HIS BEHAVIOR.
20 Q. WHAT IS ATIVAN?
21 A. IT'S A -- IT'S A SEDATIVE.
22 Q. WHAT ABOUT RISPERIDAL?
23 A. ANITPSYCHOTIC.
24 Q. AND THEN YOU ALSO INDICATE SOME BUSPAR, 10 MILLIGRAMS,
25 IS THAT T.I.D., THREE TIMES A DAY?
1 A. RIGHT.
2 Q. AND WHAT'S --
3 A. THAT'S AN ANTIANXITEY TYPE OF MEDICATION, AGAIN, TRYING
4 TO CONTROL HIS AGITATED BEHAVIOR.
5 Q. DO YOU KNOW WHETHER THIS WAS SUCCESSFUL ON THE 8TH? DID
6 YOU RECEIVE ANY FURTHER PHONE CALLS FROM THE NURSING HOME?
7 A. I DON'T HAVE ANY RECORDS OF ANY FURTHER INFORMATION FROM
8 THE NURSING HOME AFTER THE 8TH. I SUGGESTED ON THE 8TH GIVEN
9 MY DIFFICULTY CONTROLLING HIS BEHAVIOR AND THE FACT THAT HE
10 HAD ACTUALLY INJURED SOMEONE -- ANOTHER RESIDENT IN THE
11 PROCESS, THAT WE MAKE ARRANGEMENTS FOR HIM TO BE TRANSFERRED
12 DOWN TO DAVIS.
13 Q. HE WAS A STRONG MAN, WASN'T HE? BIG MAN?
14 A. WELL, HE WEIGHED A HUNDRED AND WHAT, 90 --
15 Q. 199.
16 A. 199.
17 Q. DID YOU EVER SEE HIM AGAIN AFTER THIS PHONE CONVERSATION
18 ON THE 8TH OF JANUARY?
19 A. WELL, I DIDN'T SEE HIM -- MY LAST VISUALIZATION OF
20 MR. ALLDREDGE WAS ON JANUARY 4TH.
21 Q. DID YOU EVER HEAR ANYTHING FURTHER ABOUT HIM BEING
22 TRANSFERRED?
23 A. ON THE 9TH, WE RECEIVED A -- ON THE 9TH -- 9TH, I HAVE A
24 NOTE IN MY CHART FROM MY NURSE WHO SAID THAT SHE SPOKE WITH
25 THE -- WITH A SOCIAL WORKER -- I DON'T KNOW WHETHER THE
1 SOCIAL WORKER WAS AT DAVIS HOSPITAL OR WHETHER THE SOCIAL
2 WORKER WAS AT THE NURSING HOME -- DISCUSSING THE PLANS FOR
3 ADMITTED MR. ALLDREDGE TO DAVIS ON THE FOLLOWING DAY, WHICH
4 WOULD HAVE BEEN THE 10TH. AND THAT'S THE LAST NOTATION I
5 HAVE OF -- WITH THE CIRCUMSTANCES.
6 Q. WHAT HAD BEEN REPORTED TO YOU AS HIS -- FIGURE OUT HOW
7 TO PHRASE THIS -- AS HIS ACTING OUT AT THE NURSING HOME THAT
8 LAST MONTH IN SAY DECEMBER AND JANUARY?
9 A. WELL, HIS -- I WOULD RECEIVE PHONE CALLS FROM NURSING
10 HOME TALKING ABOUT HOW HE WAS MORE AGITATED. HE WAS THROWING
11 THINGS. HE THREW -- HE WAS THROWING WALKERS. I DON'T HAVE
12 ANY SPECIFIC INFORMATION EXACTLY MECHANICALLY HOW THAT
13 OCCURRED. I DON'T KNOW WHAT POSITION HE WAS IN WHEN HE WAS
14 DOING THAT. HE HAD IN SOME MANNER -- TO BE PRECISE AS BEST I
15 CAN HERE, ON DECEMBER 28TH, I HAVE A NOTE FROM THE NURSING
16 HOME THAT SAID, PATIENT VERY AGITATED. THROWING WHEELCHAIR
17 YESTERDAY. CAUSED A PATIENT TO FALL. PATIENT BROKE HIP.
18 PATIENT IS UNABLE TO ATTEND ACTIVITIES, TOO COMBATIVE. AND
19 THAT WAS THE -- THAT WAS THE VISIT THAT I MODIFIED HIS
20 MELLARIL AT THAT POINT, AND THEN ASKED THAT HE COME IN AND BE
21 SEEN.
22 Q. HAD YOU WRITTEN ANY ORDERS FOR P.R.N. MEDICATIONS TO
23 CALM HIM DOWN, IF YOU RECALL? P.R.N. MEANING AS NEEDED, THE
24 NURSES COULD DECIDE WHEN IT WAS REQUIRED?
25 A. ON DECEMBER 18TH I WROTE, WHEN -- WHEN PATIENT VERY
1 COMBATIVE, MAY GIVE 5 MILLIGRAM HALDOL. I THINK TO BE
2 PRECISE, YOU'D HAVE TO LOOK AT THE NURSING RECORDS AND SEE
3 WHAT THEY HAD ORDERED ON THEIR RECORDS AS TO WHETHER HE HAD
4 AN AS NEEDED MEDICATION ORDERED. THE IMPLICATION FROM THAT
5 NOTE IN MY CHART WAS THAT HE DID HAVE AN AS NEEDED ORDER, BUT
6 I CAN'T CONFIRM THAT OTHERWISE.
7 Q. AND WHAT IS HALDOL?
8 A. IT'S ANOTHER ANTIPSYCHOTIC MEDICATION THAT WE USE FOR
9 TREATMENT OF AGITATION OFTENTIMES IN DEMENTED PATIENTS.
10 Q. DOES IT SEDATE A PATIENT?
11 A. IT CAN.
12 Q. IT CAN. GIVEN HIS COMBATIVENESS, DID THEY -- DID ANYONE
13 CONTACT YOU ABOUT SEDATING HIM IN ORDER TO TRANSFER HIM TO
14 DAVIS NORTH, THAT YOU KNOW OF?
15 A. NOT THAT I KNOW OF. I HAVE NO RECORD OF THAT.
16 Q. YOU DIDN'T ORDER ANYTHING TO SEDATE HIM FOR TRANSFER?
17 A. I DON'T RECALL HAVING DONE THAT. IT'S OBVIOUSLY BEEN A
18 LONG TIME AGO. I DON'T RECALL IT. I HAVE NO NOTATION OF
19 THAT, SO I WOULD SAY LIKELY NOT.
20 Q. IF THE NURSING HOME HAD WANTED SOME KIND OF SEDATIVE IN
21 ORDER TO TRANSFER HIM, COULD THEY HAVE CALLED A DIFFERENT
22 DOCTOR --
23 A. POSSIBLE.
24 Q. -- ORDERED THAT?
25 A. WELL, SOMEONE COVERING FOR ME, IF IT WOULD HAVE BEEN
1 AFTER HOURS OR IF IT WOULD HAVE BEEN MY AFTERNOON OFF, THEY
2 MIGHT HAVE CONTACTED SOMEONE ELSE. THAT WOULD BE THE
3 CIRCUMSTANCE THEY WOULD HAVE DONE THAT. THEY MAY HAVE HAD A
4 P.R.N. ORDER, AS NEEDED ORDER, FOR MEDICATION TO BE GIVEN AND
5 THEY COULDN'T HAVE DONE IT IN THAT MANNER.
6 MS. BARLOW: THANK YOU. THOSE ARE ARE THE QUESTIONS I
7 HAVE, YOUR HONOR.
8 THE COURT: CROSS-EXMINE, MR. BUGDEN.
9 CROSS-EXAMINATION
10 BY MR. BUGDEN:
11 Q. GOOD MORNING, DR. CUNNINGHAM.
12 A. HI.
13 Q. I'M WALTER BUGDEN. I'M ONE OF THE LAWYERS REPRESENTING
14 DR. WEITZEL. I'D LIKE TO BEGIN WITH SORT OF SOME BIG PICTURE
15 QUESTIONS AND THEN WE WILL WALK THROUGH THE CHARTS AGAIN. I
16 APOLOGIZE.
17 A. THAT'S FINE.
18 Q. DR. CUNNINGHAM, THIS PATIENT, MR. ALLDREDGE, HAD
19 END-STATE DEMENTIA, IS THAT RIGHT?
20 A. HE HAD -- HE HAD SERIOUS -- HE HAD SEVERE DEMENTIA.
21 END-STAGE? THAT'S KIND OF A VAGUE TERM, BUT I'D SAY HIS
22 DEMENTIA WAS SEVERE.
23 Q. OVER THE PERIOD OF TIME THAT YOU'VE DESCRIBED FOR US
24 THAT YOU TREATED ENNIS ALLDREDGE, YOU SAW A PROGRESSIVE
25 DECLINE IN HIS MENTAL FUNCTIONING, ISN'T THAT RIGHT?
1 A. CORRECT.
2 Q. WE'RE GONNA TALK ABOUT THAT IN JUST A MOMENT, BUT IT
3 WENT FROM A LOT OF DISORIENTATION IN THE VERY BEGINNING OF
4 YOUR INTERACTION WITH THIS PATIENT TO, BY THE END, BY THE
5 NOVEMBER VISIT THAT YOU HAD WITH HIM, HE WAS EXTREMELY
6 DISORIENTED, COULDN'T RESPOND TO QUESTIONS, AM I RIGHT?
7 A. I THINK THAT WHEN I INITIALLY SAW HIM, I WAS AT LEAST
8 THROUGH MY RECORDS AND INTERPRETING MY RECORDS, I WAS ABLE TO
9 CONVERSE WITH HIM.
10 Q. IN THE BEGINNING.
11 A. IN THE BEGINNING.
12 Q. BY THE END YOU WERE --
13 A. BY THE END, HE HAD SUBSTANTIALLY DECLINED. HE WAS TO
14 THE POINT WHERE HE COULD NOT TALK. I COULD NOT HOLD A
15 COMMUNICATION WITH HIM. HIS SPEECH WAS TOTALLY INCOHERENT.
16 SO THERE WAS A DR -- THERE WAS A SUBSTANTIAL CHANGE IN HIS
17 MENTAL STATUS BETWEEN APRIL OF '95 AND JANUARY OF 1996.
18 Q. AND IN THE LAST FEW MONTHS, IN NOVEMBER AND DECEMBER
19 LEADING UP TO JANUARY 4TH, IN ADDITION TO THE DISORIENTATION
20 OR HIS INABILITY TO COMMUNICATE WITH YOU, ANOTHER CHANGE IN
21 THIS MAN'S BEHAVIOR WAS THAT HE BECAME EXTREMELY COMBATIVE,
22 AM I RIGHT?
23 A. IN MY RECORDS I -- WHEN I WAS REVIEWING MY RECORDS, I
24 NOTED THAT HIS COMBATIVENESS, HIS AGITATION, COMBATIVENESS
25 SEEMED TO START IN DECEMBER.
1 Q. WELL, LET'S TAKE IT RIGHT THERE.
2 A. UH-HUH.
3 Q. IN DECEMBER, BY DECEMBER, THOUGH, WE HAVE AN INCREASING
4 PATTERN OF HIM INJURING PEOPLE?
5 A. CORRECT.
6 Q. STRIKING OUT AT THE CARE PROVIDERS.
7 A. RIGHT.
8 Q. AND COUNSEL JUST ASKED YOU ABOUT THIS GENTLEMAN'S
9 STRENGTH. I MEAN, THIS WAS AN 82-YEAR-OLD MAN WHO WEIGHED
10 ABOUT 200 POUNDS. AND IN SPITE OF BEING 82 YEARS OLD, IN
11 LATE DECEMBER HE WAS ABLE TO PICK UP A WHEELCHAIR AND THROW
12 THAT AT ANOTHER RESIDENT BREAKING THAT RESIDENT'S HIP, IS
13 THAT RIGHT?
14 A. WHAT -- ALL I CAN STATE IS THAT SOMEHOW A WHEELCHAIR
15 ENDED UP INTO A PATIENT, AND WHETHER HE PICKED IT UP OR
16 PUSHED IT OUT, I DON'T KNOW THAT MECHANISM HE USED, BUT HE
17 HAD -- HE WAS STRONG ENOUGH TO ALLOW THAT TO OCCUR. I GUESS
18 THAT'S AS BEST I CAN SAY.
19 Q. DOCTOR, WE HAVE -- THESE ARE GONNA BE PROBABLY THE SAME
20 RECORDS THAT WE'VE BEEN TALKING ABOUT, BUT THEY'RE ORGANIZED
21 IN A DIFFERENT WAY.
22 A. OKAY.
23 Q. AND LET ME JUST SHOW YOU. EXCUSE ME, I SOMETIMES MORE
24 OFTEN THAN NOT WILL USE THIS NUMBER TO IDENTIFY IT FOR THE
25 JUDGE. BUT IT MAY BE EASIER TO BRING YOU TO THE PAGE I WANNA
1 TALK ABOUT --
2 A. OKAY.
3 Q. -- BY TALKING ABOUT THAT NUMBER IN THE --
4 A. THAT'S FINE.
5 Q. -- RIGHT-HAND SIDE CORNER. YOU FIRST SAW MR. ALLDREDGE
6 IN APRIL, AM I RIGHT, APRIL 17TH?
7 A. CORRECT.
8 Q. AND AT THAT TIME HE WAS BROUGHT TO YOUR OFFICE BY VONDA,
9 HIS WIFE, IS THAT RIGHT?
10 A. CORRECT.
11 Q. SHE WAS A 78-YEAR-OLD WOMAN, DOES IT SAY THAT?
12 A. AS I UNDERSTAND, RIGHT.
13 Q. AND DURING THAT FIRST VISIT, MRS. ALLDREDGE WAS UPSET,
14 IS THAT RIGHT?
15 A. CORRECT.
16 Q. SHE WAS TEARFUL IN YOUR OFFICE, IS THAT RIGHT?
17 A. CORRECT.
18 Q. AND THE STRESS OF TAKING CARE OF MR. ALLDREDGE REALLY
19 HAD BECOME TOO MUCH FOR HER, IT WAS QUITE OVERWHELMING.
20 A. RIGHT.
21 Q. AND YOU THEN DID A MEDICAL EXAMINATION AND YOU'VE TOLD
22 US ABOUT SOME OF THE FINDINGS THAT YOU MADE. ONE OF THE
23 FINDINGS -- THIS WAS PROBABLY JUST THE HISTORY THAT WAS
24 GIVEN -- WAS THAT HE HAD THE MYCOSIS FUNGOIDES, IS THAT
25 RIGHT?
1 A. RIGHT.
2 Q. HE ALSO HAD DIABETES?
3 A. CORRECT.
4 Q. AND THAT HAD TO BE TREATED WITH -- OR HE HAD TO RECEIVE
5 SHOTS?
6 A. WITH INSULIN, RIGHT.
7 Q. WITH INSULIN. THE PRINCIPAL DIAGNOSIS -- AND I THINK,
8 YOUR HONOR AND COUNSEL, THIS IS STATE'S EXHIBIT 6-A, AND IT'S
9 THE NURSING HOME RECORD 1 -- OR 13-B-2. AND IT LOOKS TO ME,
10 DOCTOR, LIKE THAT'S SLIDE 2 FOR YOU. OR ACTUALLY IT'S --
11 LET'S SEE HERE, SLIDE 4 OR PICTURE 4 FOR YOU. AM I CORRECT
12 THAT YOU DID MAKE THE DIAGNOSIS OF DEMENTIA ON THAT DATE?
13 A. I FELT THAT THE WAY HE PRESENTED, IT WAS CONSISTENT WITH
14 DEMENTIA. I HAD BEEN TOLD EITHER BY HIS WIFE OR HIMSELF THAT
15 HE HAD A PREVIOUS HISTORY OF DEMENTIA, SO I DIDN'T
16 NECESSARILY MAKE THE DIAGNOSIS. IT HAD ALREADY BEEN
17 CONCLUDED. BUT I FELT HIS PRESENTATION WAS DEFINITELY
18 CONSISTENT WITH THAT.
19 Q. AND HE ALSO HAD CORONARY ARTERY DISEASE, IS THAT RIGHT?
20 A. RIGHT.
21 Q. AND YOU TALKED ABOUT, HE WASN'T IN ACUSE DISTRESS IN
22 YOUR OFFICE, FOR EXAMPLE, WITH THE CORONARY ARTERY DISEASE,
23 THIS WAS AN 82-YEAR-OLD MAN. THIS IS SOMEONE WHO COULD
24 SUFFER A HEART ATTACK REALLY AT ANY APPOINTMENT AT THAT AGE
25 WOULD --
1 A. CORRECT.
2 Q. -- WOULD THAT -- IS THAT RIGHT?
3 A. SURE, CORRECT.
4 Q. THEN IF I CAN ASK YOU SOME QUESTIONS ABOUT DEMENTIA,
5 WITH THIS VERY PATIENT USE -- DEMENTIA IS A PROGRESSIVE
6 DISEASE, ISN'T IT?
7 A. YES.
8 Q. AND WITH THIS VERY PATIENT, YOU COULD SEE THE
9 PROGRESSIVE NATURE OF HIS LOSS OF MENTAL FUNCTIONING.
10 A. CORRECT.
11 Q. IN THE INITIAL EXAMINATION, IT WAS REPORTED TO YOU THAT
12 THERE HAD BEEN I GUESS A RECENT MENTAL STATUS CHANGE, IS THAT
13 WHAT HIS WIFE TOLD YOU? MAYBE FOR YOU, DOCTOR, PAGE 5.
14 A. WELL, I'D HAVE TO -- I'D HAVE -- I THINK I KNOW WHAT
15 YOU'RE REFERRING TO --
16 Q. WELL, LET ME JUST --
17 A. I HAD TOLD HIM HE HAD REC -- HE HAD PROBLEMS WITH RECENT
18 MEMORY LOSS, MEANING, IT'S HARD FOR ME TO INTERPRET EXACTLY
19 WHETHER THAT MEANS HE -- SHE HAD NOTED PROGRESSIVE LOSS OF
20 MEMORY MORE SO THAN SHE HAD NOTED BEFORE OR WHETHER THIS WAS
21 JUST A STATEMENT OF SAYING THAT HE LOST HIS MEMORY.
22 Q. OKAY.
23 A. SO I DON'T KNOW.
24 Q. DURING THE EXAMINATION ON THAT DATE, YOU DID TRY TO ASK
25 A FEW QUESTIONS THAT WERE DESIGNED TO SEE WHAT SORT OF FUND
1 OF GENERAL INFORMATION --
2 A. RIGHT.
3 Q. AND FOR EXAMPLE, HE WAS UNABLE TO TELL YOU WHO THE
4 PRESENT PRESIDENT OF THE UNITED STATES WAS, IS THAT RIGHT?
5 A. CORRECT.
6 Q. AND THEN YOU ALSO ASKED HIM IF HE COME IDENTIFY WHAT THE
7 SIMILARITY MIGHT BE BETWEEN A BOWLING BALL AND AN ORANGE.
8 AND HIS RESPONSE WAS THAT YOU CAN GET JUICE OUT OF A BOWLING
9 BALL?
10 A. RIGHT.
11 Q. SO OBVIOUSLY, THERE WAS A DISCONNECT THERE?
12 A. CORRECT.
13 Q. THEN AS I UNDERSTAND IT, YOU DID SEE HIM ALMOST EVERY
14 DAY -- OR I'M SORRY, EVERY MONTH FROM ONCE HE WAS -- IS THAT
15 RIGHT?
16 A. I SAW HIM APRIL. I SAW HIM A MONTH LATER IN MAY. I SAW
17 HIM IN EARLY AUGUST. HE WAS ADMITTED TO A NURSING HOME AT
18 THE END OF AUGUST, SO I SAW HIM JUST AFTER HE HAD BEEN
19 ADMITTED IN THE NURSING HOME IN AUGUST. I SAW HIM IN OCTOBER
20 FOR THE NAUSEA AND VOMITING EPISODE THAT WE'VE TALKED ABOUT.
21 I SAW HIM IN I BELIEVE NOVEMBER. DECEMBER HE HAD ALL OF
22 THESE EPISODES OF AGITATION, COMBATIVENESS, THAT WE WERE
23 TRYING TO SUBDUE WITH MEDICATION --
24 Q. DOCTOR, WE'RE GONNA WALK THROUGH SOME OF THOSE
25 EXAMINATIONS. YOU DID SEE HIM IN OCTOBER, AM I RIGHT?
1 OCTOBER 12TH?
2 A. RIGHT.
3 Q. AND IF I COULD ASK YOU TO TURN TO PAGE 6?
4 A. OKAY.
5 Q. NOW, HE WAS LIVING IN THE SUNSHINE TERRACE NURSING HOME
6 BY THEN IS THAT RIGHT?
7 A. CORRECT.
8 Q. BY THAT TIME HIS SPEECH WAS -- WELL, HE WASN'T ABLE TO
9 SPEAK AS LUCIDLY, IS THAT WHAT YOU'VE WRITTEN?
10 A. RIGHT.
11 Q. IS THERE A BLOW-UP OF THAT? AND BY THIS TIME WAS HE
12 BEGINNING TO HAVE APHASIA, SIR?
13 A. HE WAS DEFINITELY HAVING SIGNIFICANT DIFFICULTIES WITH
14 COMMUNICATION. IT WAS DIFFICULT TO UNDERSTAND EXACTLY WHAT
15 HE WAS SAYING.
16 Q. OKAY. THEN YOU SAW HIM AGAIN AFTER -- IN NOVEMBER, IS
17 THAT RIGHT? NOVEMBER 16TH?
18 A. CORRECT.
19 Q. I THINK THAT THAT'S YOUR SLIDE OR YOUR NUMBER 8. AND
20 THIS IS N.H. 20, JUDGE. AGAIN, HE WAS HAVING -- IS THERE A
21 BLOW-UP OF THAT PAGE PLEASE? EXPRESSIVE APHASIA. THAT MEANS
22 HE COULDN'T -- COULDN'T SPEAK CLEARLY OR HE COULDN'T SPEAK
23 REALLY AT ALL?
24 A. HE WOULD -- HE COULD NOT -- IT WOULD NOT BE THAT HE
25 COULD NOT VERBALLY UTTER SOMETHING; IT WAS NONSENSICAL.
1 Q. OKAY. NOW, ON THAT DATE, DO YOU RECALL, DOCTOR, THAT
2 YOU AND MRS. ALLDREDGE FILLED OUT A MEDICAL TREATMENT PLAN?
3 A. (WITNESS SHAKES HEAD.)
4 Q. DID YOU DO THAT, DOCTOR?
5 A. I DON'T KNOW.
6 Q. COULD WE LOOK -- WOULD YOU LOOK AT NUMBER 10, AND,
7 JUDGE, THIS IS N.H. 278. IS THERE A BLOW-UP OF THIS PAGE AS
8 WELL? OH, LET'S GO BACK TO THE BIGGER PICTURE THEN. DO YOU
9 HAVE A COPY AS WELL THAT YOU COULD LOOK AT OR USING YOUR
10 REPORT, DOCTOR?
11 A. I DON'T HAVE THAT BUT, I'M QUITE FAMILIAR WITH THOSE.
12 THE COURT: MOVE YOUR CHAIR OVER, DOCTOR, IF YOU NEED TO
13 SO YOU CAN --
14 A.
15 THE WITNESS: LET ME SEE IF I HAVE ONE -- CHART.
16 Q. (BY MR. BUGDEN) THAT'S NOT IN THE DOCUMENT YOU HAVE?
17 A. I DON'T THINK SO. I DON'T REMEMBER SEEING IT, BUT LET
18 ME --
19 Q. THE ONES I GAVE YOU? PAGE 10?
20 A. OKAY. I HAVE THAT. GO AHEAD.
21 Q. BEARS YOUR NAME AT THE TOP.
22 A. UH-HUH.
23 Q. CAN YOU RECOGNIZE ANY OF THIS WRITING? FOR EXAMPLE, IS
24 THIS YOUR SIGNATURE DOWN WHERE IT SAYS TEN ELEVEN?
25 A. THAT IS MY SIGNATURE.
1 Q. AND AT THAT TIME WHEN YOU FILLED THIS OUT ON OCTOBER
2 11TH, YOU SAID THAT MR. ALLDREDGE WAS SUFFERING FROM
3 ALZHEIMER'S, AND YOU'VE CHECKED OFF THE BOX THAT HE WAS IN A
4 CONDITION WHICH RENDERED HIM INCAPABLE OF MAKING MEDICAL
5 DECISIONS, IS THAT RIGHT?
6 A. CORRECT.
7 Q. AND THEN MRS. ALLDREDGE, THE WIFE, SIGNED ON BEHALF OF
8 MR. ALLDREDGE, IS THAT RIGHT?
9 A. THAT'S CORRECT.
10 Q. AND YOU'VE EXPLAINED TO US THAT BY THIS TIME, YOU'D
11 BEGUN TO SEE THE MENTAL DECLINE AND THE EXPRESSIVE APHASIA.
12 DO YOU BELIEVE THAT BECAUSE OF THE MENTAL DECLINE WITH
13 PATIENT, THAT THAT MAY BE WHY YOU AND MRS. ALLDREDGE FILLED
14 OUT A MEDICAL TREATMENT PLAN ON THAT OCCASION?
15 A. I WOULD SAY THAT THAT THAT'S TRUE, THAT HIS DEMENTIA HAD
16 PROGRESSED. HIS WIFE OBVIOUSLY WAS LIVING WITH IT EVERY DAY
17 UP UNTIL HE WAS ADMITTED THE NURSING HOME. RECOGNIZED THAT
18 HIS CONDITION WAS DETERIORATING. AND RECOGNIZED THAT HE WAS
19 INCAPABLE OF PROVIDING AN ANSWER TO THE ISSUE OF
20 RESUSCITATIVE MEASURES. SHE MADE THE DECISION BASED UPON
21 THAT INFORMATION.
22 Q. AND BECAUSE OF THE DECLINE AND DETERIORATING CONDITION,
23 DO YOU THINK YOU WOULD HAVE TALKED WITH MRS. ALLDREDGE ABOUT
24 WHAT HE WOULD LIKE TO DO IN THE EVENT THAT SOME MEDICAL ACUTE
25 PROBLEM OCCURS AND YOU WOULD HAVE TALKED ABOUT THE NO C.P.R.,
1 NO RESPIRATORS?
2 A. SOMETIMES WE DISCUSS THIS DIRECTLY. SOMETIMES THE
3 CAREGIVERS, THE WIFE, THE RESPONSIBLE PERSON TAKES IT UPON
4 THEMSELVES TO FILL THIS INFORMATION OUT BASED UPON THE
5 PATIENT'S MEDICAL CONDITION. I DON'T KNOW WHICH ONE OF THOSE
6 CIRCUMSTANCES OCCURRED HERE.
7 Q. OKAY. NOW, YOU'VE TALKED ABOUT HIS DETERIORATING
8 CONDITION. AT 82 YEARS OLD, DR. CUNNINGHAM, A PERSON WITH
9 LONG -- I MEAN HE DID HAVE LONGSTANDING DIABETES, HE HAD THE
10 BYPASS SURGERY, HE WAS SUFFERING FROM DEMENTIA WHERE YOU
11 COULD SEE A PROGRESSIVE CHANGE, HE HAD CORONARY ARTERY
12 DISEASE, HYPOTHYROIDISM. WOULD YOU SAY THAT ALL OF THOSE
13 CONDITIONS TOGETHER WOULD MAKE MR. ALLDREDGE SOMEONE WHO
14 WOULD BE SUSCEPTIBLE TO OR A CANDIDATE FOR A STROKE?
15 A. PEOPLE WITH CORONARY ARTERY DISEASE AND HYPERTENSION
16 HAVE AN INCREASED INCIDENCE OF STROKE, SO I THINK HIS RISKS
17 FOR HAVING THAT HAPPEN WERE -- WOULD BE GREATER THAN SOMEONE
18 WITHOUT THOSE, CORRECT.
19 Q. AND --
20 A. AND DIABETES.
21 Q. -- DOCTOR, WITH -- WITH THIS POPULA -- OR THIS AGE GROUP
22 OF PATIENT, ELDERLY PEOPLE, WHEN THEY BECOME ACUTELY ILL --
23 WELL, FIRST LET ME ASK YOU, IT DOESN'T REALLY TAKE MUCH OF AN
24 INFECTION OR MUCH OF A PROBLEM FOR PEOPLE AT THIS AGE GROUP
25 TO BECOME VERY ILL. WOULD YOU AGREE WITH THAT?
1 A. YES.
2 Q. THEN YOU ALSO SAW THE PATIENT ON JANUARY 4TH, IS THAT
3 RIGHT?
4 A. CORRECT.
5 Q. AND BY THIS TIME, MR. ALLDREDGE HAD BEGUN TO DEMONSTRATE
6 THESE COMBATIVE BEHAVIORS THAT WE'VE TALKED ABOUT, THE
7 VIOLENT BEHAVIOR, IS THAT RIGHT?
8 A. CORRECT.
9 Q. BY THAT TIME, HE'D INJURED ANOTHER PATIENT AT THE
10 NURSING HOME, IS THAT RIGHT?
11 A. RIGHT.
12 Q. AND IT'D BEEN REPORTED TO YOU THAT HE'D STRUCK OUT OR
13 HIT HIS CARE PROVIDERS, IS THAT RIGHT? COULD I ASK YOU TO
14 TURN TO PAGE 12 THAT I'VE GIVEN YOU THERE, AND IT'S N.H. 21?
15 A. I HAVE THAT.
16 Q. COULD YOU JUST READ THE HISTORY SECTION, AND THEN I MAY
17 INTERRUPT YOU OCCASIONALLY AS YOU'RE READING IT TO THE JURY?
18 A. OKAY. 82-YEAR-OLD MALE WHO HAD BEEN HAVING DIFFICULTY
19 CONTROLLING HIS DEMENTIA AND AGITATION OVER THE PRECEDING
20 MONTH. WE HAVE BEEN ACCELERATING HIS MELLARIL UP TO A DOSE
21 CURRENTLY OF 15 MILLIGRAMS THREE TIMES DAILY WITH THE
22 ADDITION OF --
23 THE COURT: SLOW DOWN PLEASE, IF YOU YOU WOULD.
24 THE WITNESS: -- WITH THE ADDITION OF BUSPAR
25 APPROXIMATELY TWO WEEKS AGO OF 10 MILLIGRAMS THREE TIMES
1 DAILY. HE CONTINUES TO BE COMBATIVE AND DIFFICULT TO MANAGE.
2 A NOTE FROM THE NURSING STAFF WAS RECEIVED. IT STATED THAT
3 HE IS STILL HAVING OUTBURSTS OF CONFUSION, AND SOME APPARENT
4 OCCASIONAL DEPRESSED CRYING EPISODES.
5 Q. (BY MR. BUGDEN) NOW, YOU CHANGED HIS MEDICATION. HE HAD
6 BEEN ON MELLARIL, IS THAT RIGHT?
7 A. HE HAD BEEN ON MELLARIL.
8 Q. LET ME STOP YOU THERE. AND IS THAT AN ANTIPSYCHOTIC,
9 DOCTOR?
10 A. YES.
11 Q. AND DID YOU DISCONTINUE THE MELLARIL AND START HIM ON
12 RISPERDAL?
13 A. YES, AT -- AT THAT VISIT.
14 Q. AND HE ALSO WAS ON THE BUSPAR?
15 A. CORRECT.
16 Q. WHAT IS BUSPAR PLEASE?
17 A. THAT'S AN ANTI-ANXIETY.
18 Q. SO AND THE RISPERDAL IS ALSO AN ANTI-ANXIETY, IS IT?
19 A. IT'S AN ANTI-PSYCHOTIC SIMILAR TO MELLARIL.
20 Q. SO AT THAT POINT YOU HAD HIM ON THE BUSPAR AND THE
21 RISPERDAL, ALL TRYING TO CONTROL THIS AGITATION?
22 A. CORRECT.
23 Q. AND YOU WERE AWARE THAT BOTH OF THOSE, THE BUSPAR AND
24 RISPERDAL, THEY DO HAVE A POSSIBLE SEDATING EFFECT, IS THAT
25 RIGHT?
1 A. SURE.
2 Q. AND IN FACT, THAT WAS THE GOAL, WAS TO TRY TO GET THE
3 AGITATION UNDER CONTROL AND TO MELLOW HIM OUT, IS THAT RIGHT?
4 A. RIGHT, CORRECT.
5 Q. AND COULD WE TURN TO -- I THINK IT'S PAGE 14, DOCTOR.
6 A. I'M THERE.
7 Q. IN FACT, THERE MAY BE A BLOW-UP OF THAT.
8 THE COURT: WHAT'S THE NUMBER FOR THE COURT'S BENEFIT?
9 MR. BUGDEN: IT'S N.H. 22, JUDGE.
10 Q. (BY MR. BUGDEN) THE NOTE SAYS THAT YOU'RE GONNA
11 DISCONTINUE THE MELLARIL, AND THEN IT SAYS, WILL TRY THE
12 RESPECTFUL -- THAT'S ACTUALLY THE RISPERDAL --
13 A. RIGHT.
14 Q. -- RIGHT? THEN THE NOTE ALSO SAYS, OBVIOUSLY IF THIS
15 MEDICINE CAUSES OVERSEDATION, WE'LL DISCONTINUE IT. IS THAT
16 RIGHT?
17 A. RIGHT.
18 Q. SO THE IDEA WAS, YOU HAD TO RESPOND TO THE SYMPTOMS AT
19 THAT POINT, YOU'RE TRYING TO RESPOND TO THE REPORTS AND THEN
20 YOU -- IF MEDICATION IS TOO STRONG FOR THE PATIENT, THEN YOU
21 LOWER THE DOSAGE.
22 A. RIGHT. AND I START AT AN EXTREMELY LOW DOSE, WITH THE
23 PLANS OF WORKING UP ON THE DOSAGE AS NECESSARY.
24 Q. OKAY. THEN ON JANUARY 8TH, THAT'S WHEN THE -- BY THAT
25 TIME, LET'S SEE HERE, FROM JANUARY 4TH TO JANUARY 8TH, HE'D
1 BEEN ON THE RISPERDAL AND THE BUSPAR AND THEY HADN'T WORKED,
2 RIGHT? THEY HADN'T GOTTEN THE CONTROL OR GOTTEN CONTROL OF
3 HIS AGITATION.
4 A. CORRECT.
5 Q. AND THAT'S WHEN YOU GOT THE PHONE CALL FROM THE NURSING
6 HOME?
7 A. RIGHT. HE'D APPARENTLY HIT AN AIDE IN THE ABDOMEN AND
8 HE THREW A BINGO GAME --
9 Q. SO EVEN WITH THE RISPERDAL AND THE BUSPAR, HE WAS EVEN
10 MORE COMBATIVE. OR THE LEAST HE STRUCK OUT.
11 A. WELL, HE WAS STILL COMBATIVE. I DON'T KNOW TO WHAT
12 DEGREE HE WAS COMPARATIVELY, BUT HE WAS STILL COMBATIVE.
13 Q. OKAY. AND THEN ON THAT DATE, YOU INCREASED THE
14 RISPERDAL TO ONE MILLIGRAM, AM I RIGHT?
15 A. CORRECT.
16 Q. AND ALSO TO TRY TO DEAL WITH THE IMMEDIATE NATURE OF THE
17 PROBLEM, YOU ORDERED THAT HE BE -- THAT HE BE STARTED ON 3
18 MILLIGRAMS OF ATIVAN, IS THAT RIGHT?
19 A. CORRECT. THAT WAS BASED UPON THE WAY I'VE WRITTEN THIS,
20 IT WAS A ONE-TIME ORDER. 3 MILLIGRAM I.M.
21 Q. INTRAMUSCULAR, IS THAT --
22 A. CORRECT.
23 Q. -- WHAT I.M. MEANS?
24 A. CORRECT.
25 Q. AND THEN YOU RECOMMENDED THAT HE BE TRANSFERRED TO THE
1 DAVIS HOSPITAL BECAUSE OF THE AGITATION?
2 A. RIGHT.
3 Q. BECAUSE IN SPITE OF THE INCREASING MEDICATIONS THAT
4 YOU'D TRIED OR THE DIFFERENT COMBINATIONS OF MEDICATIONS THAT
5 YOU'D TRIED, YOU JUST WEREN'T ABLE TO CONTROL THE
6 COMBATIVENESS?
7 A. I WASN'T ABLE TO CONTROL HIM. HE WAS CONTINUING TO
8 INJURE OTHER INDIVIDUALS AT THE NURSING HOME.
9 Q. AND THAT, FOR EXAMPLE, THE PATIENT THAT APPARENTLY HAD A
10 BROKEN HIP AS A RESULT OF THE WHEELCHAIR COLLISION, THAT
11 POSES A SIGNIFICANT HEALTH PROBLEM FOR THE OTHER PATIENTS,
12 DOESN'T IT?
13 A. SURE.
14 Q. AND THE NURSING HOME JUST COULDN'T HANDLE THIS MAN AT
15 THAT POINT.
16 A. I COULDN'T HANDLE THIS MAN.
17 MR. BUGDEN: OKAY. THANK YOU VERY MUCH.
18 THE WITNESS: SURE.
19 THE COURT: REDIRECT, MS. BARLOW.
20 MS. BARLOW: THANK YOU, YOUR HONOR.
21 REDIRECT EXAMINATION
22 BY MS. BARLOW:
23 Q. DR. CUNNINGHAM, I WANT TO JUST FOLLOW UP ON A FEW
24 MATTERS HERE. MR. BUGDEN ASKED YOU ABOUT END-STAGE DEMENTIA.
25 AND YOU SAID THAT'S A VAGUE TERM. HAVE THERE BEEN ANY
1 STUDIES DONE ABOUT DEMENTIA AND LIFE EXPECTANCY?
2 A. I'M NOT QUALIFIED TO ANSWER THAT. I DON'T KNOW OF ANY
3 SPECIFIC STUDIES. A NEUROLOGIST MIGHT HAVE A BETTER WORKING
4 KNOWLEDGE OF THE --
5 Q. OKAY.
6 A. -- LITERATURE. I DON'T.
7 Q. BUT IT IS PROGRESSIVE?
8 A. RIGHT.
9 Q. CAN YOU EVER LOOK AT A PATIENT'S POSITION OR STAGE AND
10 SAY, THEY'RE NO LONGER ABLE TO DO THIS, YOU SAY THAT'S MORE
11 SEVERE. CAN YOU EVER SAY HOW MANY MORE YEARS THEY HAVE TO
12 LIVE FROM WHAT THEY CAN DO OR CANNOT DO?
13 A. THERE IS -- THE CRITERION I'M -- I'M KNOWLEDGEABLE OF IS
14 USED WITH HOSPICE. MEDICARE HAS SPECIFIC CRITERION THEY USE
15 IN TERMS OF TRYING TO OBJECTIVELY DETERMINE WHEN SOMEBODY'S
16 AN APPROPRIATE HOSPITAL CANDIDATE -- A HOSPICE, EXCUSE ME,
17 HOSPICE CANDIDATE.
18 Q. MEANING SIX MONTHS LEFT TO LIVE.
19 A. CORRECT. THESE ARE NOT MEANT TO BE STRICT CRITERION, SO
20 IF SOMEONE DOESN'T ABSOLUTELY MEET THESE CRITERION, YOU CAN
21 STILL ADMIT THEM TO HOSPICE. YOU HAVE TO DOCUMENT CONTINUED
22 PHYSICAL OR MENTAL DETERIORATION TO CONTINUE TO QUALIFY FOR
23 THEM FOR HOSPICE IN THE FUTURE. BUT THERE ARE SPECIFIC
24 CRITERION THAT ARE USED TO HELP OBJECTIVELY DETERMINE WHETHER
25 SOMEONE MEETS THIS SIX-MONTH CRITERION. THIS HAS TO DO WITH
1 FUNCTIONAL CAPACITY, IT HAS TO DO WITH SPEECH, IT HAS TO DO
2 WITH AMBULATION, IT HAS TO DO WITH BOWEL AND BLADDER
3 CONTINENCE. HE -- MR. ALLDREDGE -- WHEN I REVIEWED THESE
4 CRITERION RECENTLY, HE MET THE FUNCTIONAL CRITERION. THEY
5 HAD A SECOND CRITERION THAT ADDRESSED THINGS SUCH AS ACUTE
6 ILL -- ACUTE MEDICAL PROBLEMS, AND THEY INCLUDED
7 PYELONEPHRITIS, WHICH IS RENAL INFECTION, FEVER, PNEUMONIA,
8 ASPIRATION. THERE WERE SOME CRITERION, AND BASED ON THESE
9 CRITERION, YOU'RE SUPPOSED TO SATISFY BOTH. I -- IN
10 REVIEWING THOSE CRITERION, HE DIDN'T FIT THE SECOND
11 CRITERION, SO HE MET SOME BUT NOT ALL. BUT AGAIN, THOSE ARE
12 NOT MEANT TO BE SPECIFICALLY EXCLUSIVE IN THAT IT WOULD STILL
13 BE UP TO THE INDIVIDUAL CAREGIVER TO DETERMINE IF THEY
14 THOUGHT HE WAS AN APPROPRIATE CANDIDATE. IT'S A LONG ANSWER
15 TO A QUESTION.
16 Q. BUT I APPRECIATE IT. I THINK THAT HELPS US. YOU
17 ORDERED BUSPAR AND MELLARIL AND, WELL, AND THEN RISPERDAL.
18 YOU INDICATE THEY HAVE SEDATING EFFECTS. YOU ORDERED THEM
19 THREE TIMES A DAY AT CERTAIN DOSAGE. IS THAT LESS SEDATING
20 TO DO IT THREE TIMES A DAY AS OPPOSED TO JUST ONE SHOT AT A
21 CERTAIN TIME?
22 A. YOU'RE TRYING TO BE -- CONTROL A SPECIFIC SITUATION,
23 SUCH AS HIS BEHAVIOR, AND INTERMITTENTLY GIVING DOSAGES
24 DOESN'T ALLOW A CONTROL, IT ALLOWS BREAKTHROUGH TO OCCUR. SO
25 YOU DOSE THOSE MEDICATIONS, AND THAT'S A TYPICAL DOSING
1 PROGRAM, TO TRY TO MAINTAIN A SPECIFIC SITUATION, SUCH AS
2 TRYING TO MAINTAIN A CONTROL OF HIS AGITATION AND BEHAVIOR,
3 COMBATIVENESS.
4 Q. YOU HAD WRITTEN ON JANUARY 4TH, WE WILL DISCONTINUE
5 MELLARIL AND TRY -- WELL, IT SAYS RESPECTFUL, BUT I THINK IT
6 WAS PROBABLY RISPERDAL.
7 A. CORRECT.
8 Q. YOU DICTATED THIS, SOMEONE ELSE TYPED IT. OBVIOUSLY, IF
9 THIS MEDICINE CAUSES OVERSEDATION, WE WILL HAVE TO
10 DISCONTINUE IT. IS THAT SOMETHING YOU LOOK FOR IN
11 ANTIPSYCHOTICS AND ANTI-ANXIETY MEDICATIONS?
12 A. I MEAN IT'S CERTAINLY -- WHEN YOU READ ABOUT THESE
13 MEDICATIONS, THEY ALWAYS TALK ABOUT THE POTENTIAL FOR
14 SEDATION. THAT'S PART OF THE EFFECT YOU'RE TRYING ACHIEVE IS
15 SEDATION IN SOMEONE WHO'S BEHAVING IN A COMBATIVE OR
16 AGGRESSIVE MANNER, SO THE EFFECTS OF SEDATION ARE A POSITIVE
17 EFFECT, BUT YOU HAVE TO BE CAREFUL BECAUSE YOU OBVIOUSLY
18 DON'T WANNA OVERSEDATE SOMEONE. AND THEREFORE, YOU START AT
19 A RELATIVELY LOW DOSE AND GRADUALLY WORK THE DOSE UP TO TRY
20 TO AVOID OVERSEDATING SOMEONE.
21 Q. WHAT HAPPENS IF YOU OVERSEDATE SOMEONE?
22 A. WELL, THERE ARE -- THERE ARE POTENTIALS FOR RESPIRATORY
23 INFECTIONS. PEOPLE CAN'T CONTROL THEIR SECRETIONS AS WELL
24 WHEN WHEN THEY'RE OVERSEDATED, SO THERE'S A POTENTIAL FOR
25 PNEUMONIA. THEIR FUNTIONAL CAPACITY IS SUBSTANTIALLY
1 LIMITED, SO THEY'RE USUALLY IN BED. THAT'S NOT A GOOD
2 SITUATION IF YOU CAN AVOID IT.
3 Q. BETTER TO BE UP AND WALKING AS MUCH AS POSSIBLE?
4 A. IT IS UNLESS YOU'RE COMBATIVE AND THROWING THINGS AROUND
5 AND --
6 Q. RIGHT. YOU SAY -- WELL, YOU SAID, HOPEFULLY HE WILL
7 TOLERATE THIS LOW DOSE. IS THAT IN TERMS OF THE SEDATION?
8 A. CORRECT.
9 Q. YOU WANT HIM DOWN, BUT NOT TOO FAR DOWN.
10 A. RIGHT.
11 Q. OKAY. AND TITRATE ACCORDING FOR -- ACCORDINGLY FOR
12 AGITATION. WHAT DOES TITRATION MEAN?
13 A. INCREASED BASED UPON THE RESPONSE. IF HE CONTINUES TO
14 BE QUITE AGITATED, YOU UP THE DOSE. AND I HAD BEEN DOING
15 THAT WITH MELLARIL.
16 Q. THEN IF THE -- IF A CERTAIN MEDICATION'S NOT WORKING,
17 YOU MIGHT TRY SOMETHING ELSE AS YOU DID HERE?
18 A. RIGHT.
19 MS. BARLOW: THAT'S ALL I HAVE, YOUR HONOR.
20 THE COURT: RECROSS?
21 RECROSS-EXAMINATION
22 BY MR. BUGDEN:
23 Q. DOCTOR, WHEN YOU ENTER ORDERS FOR DIFFERENT DOSAGES OF
24 MEDICATIONS, AGAIN, YOU'RE TRYING GENERALLY SPEAKING TO
25 RESPOND TO THE PATIENT'S SYMPTOMS AND TO TREAT THOSE
1 SYMPTOMS.
2 A. CORRECT.
3 Q. AND WITH ENNIS ALLDREDGE, WHEN WE -- WHEN YOU WERE
4 CONFRONTED WITH SITUATIONS WHERE HE WAS EXTREMELY COMBATIVE
5 OR HIGHLY AGITATED, THEN YOU HAD TO AT LEAST HAVE A RESPONSE
6 TO THAT AGITATION WITH MEDICATION, OR AT LEAST THAT'S WHAT
7 YOU WERE TRYING TO DO.
8 A. RIGHT.
9 Q. AND WITH THE BUSPAR, WHERE YOU -- WHERE YOU ORDERED 10
10 MILLIGRAMS THREE TIMES A DAY --
11 A. UH-HUH.
12 Q. -- THAT ACTUALLY IS ABOVE THE -- WHAT'S CONSIDERED THE
13 SUGGESTED GERIATRIC STARTING DOSAGE, ISN'T IT?
14 A. THE STARTING DOSE, I THINK WRITTEN IS PROBABLY WHAT, 15
15 MILLIGRAMS, SO THAT IS A LARGER DOSE.
16 Q. AND THE REASON YOU DID THAT WAS BECAUSE YOU'RE TRYING TO
17 DEAL WITH THIS URGENT SITUATION, THIS PRESENTING PROBLEM OF
18 THE PATIENT BEING AGITATED, RIGHT?
19 A. CORRECT. HE HAD NOT RESPONDED TO REASONABLE DOSAGES OF
20 AN ANTIPSYCHOTIC, AND MOST LIKELY MY THINKING WAS, IS LET'S
21 START WITH A LARGER DOSE RATHER THAN A SMALLER DOSE OF THE
22 BUSPAR, GIVEN THE FAILURE OF THE OTHER MEDICATION TO -- TO
23 BRING ABOUT ANY EFFECT. SO I SUSPECT THAT WAS MY RATIONALE
24 FOR STARTING AT A LARGER DOSE RATHER THAN A SMALLER DOSE IN
25 THAT CIRCUMSTANCE.
1 Q. SO AGAIN, THAT ALSO WOULD SORT OF FIT IN THE GENERAL
2 IDEA OF TITRATING TO EFFECT. YOU'VE BEEN USING OTHER
3 ANTIPSYCHOTICS. THEY WERE NOT EFFECTIVE, SO YOU -- AND THIS
4 WAS A BIG MAN AND WHO PRESENTED WITH ALL THIS AGITATION, SO
5 YOU USED A LARGER DOSE, TRYING TO AGAIN TREAT THIS AGITATION.
6 A. RIGHT. IT WAS A LARGER DOSE. IT WAS STILL WITHIN
7 ACCEPTABLE RANGES. IT WASN'T IN -- IT WASN'T A DOSE OUT OF
8 THE RECOMMENDATION IN ITEMS OF TOTAL DOSAGE. BUT AS YOU --
9 YOU'RE CORRECT, I USED -- I STARTED WITH A HIGHER DOSE RATHER
10 THAN A LOWER DOSE.
11 THE COURT: MR. BUGDEN, THE JURY MIGHT LIKE TO KNOW WHAT
12 TITRATE TO EFFECT MEANS.
13 Q. (BY MR. BUGDEN) WOULD YOU TELL US WHAT THAT PHRASE
14 MEANS?
15 A. TITRATE TO EFFECT WOULD MEAN THAT IF YOU'RE -- WHATEVER
16 PROCESS YOU'RE TRYING TO TREAT -- FOR EXAMPLE, IN THIS CASE,
17 HE'S THROWING WHEELCHAIRS AND COMBATIVE AND AGITATED, THEN
18 YOU INCREASE THE MEDICATION IN TERMS OF TRYING TO SUBDUE --
19 YOUR GOAL IS TO CALM THIS GENTLEMAN DOWN, SO TITRATE TO
20 EFFECT IS, IS YOU UP THE DOSAGE GRADUALLY UNTIL YOU'VE
21 ACHIEVED THE ELEMENT OF BEHAVIOR THAT YOU'RE SEEKING. SO IN
22 HIS CASE, SO HE'S NOT COMBATIVE AND AGITATED.
23 MR. BUGDEN: MAY I APPROACH THE WITNESS, YOUR HONOR?
24 THE COURT: YOU MAY.
25 Q. (BY MR. BUGDEN) LOOKS LIKE THE GERATRIC DOSAGE HANDBOOK,
1 THESE ARE SUGGESTIONS. DO YOU AGREE WITH THAT, DOCTOR?
2 A. SURE.
3 Q. AND YOU AS THE CLINICIAN, YOU AS THE TREATING PHYSICIAN,
4 YOU KNOW WHAT THE PATIENT'S CIRCUMSTANCE IS, YOU KNOW WHAT'S
5 BEEN TRIED BEFORE, AND THEN YOU MAKE YOUR BEST MEDICAL
6 JUDGMENT ABOUT WHERE TO START A START -- FOR EXAMPLE, WHERE
7 TO BEGIN WITH A STARTING DOSAGE, IS THAT CORRECT?
8 A. CORRECT.
9 Q. WITH BUSPAR, DOES THIS COMPORT WITH YOUR MEMORY --
10 MS. BARLOW: YOUR HONOR, I THINK I'M GOING TO OBJECT AT
11 THIS POINT. THIS MAN IS NOT AN EXPERT. HE'S A TREATING
12 PHYSICIAN. I DON'T KNOW THAT WE NEED TO GET INTO GERIATRIC
13 DOSAGE HANDBOOK.
14 THE COURT: I WILL SUSTAIN THE OBJECTION UNLESS IT CAN
15 BE ESTABLISHED THAT YOU'RE WILLING TO ACCEPT THIS TREATISE AS
16 ONE THAT IS GENERALLY USED WITHIN THE FIELD AND ONE THAT THIS
17 DOCTOR USES IN CONJUNCTION WITH HIS PRACTICE. IF YOU
18 ESTABLISH THAT, THEN THE COURT'S GONNA ALLOW IT IN.
19 MS. BARLOW: THAT'S FINE, IF THIS IS THE 1995 OR --
20 THE COURT: IS IT?
21 MS. BARLOW: -- THE ONE THAT WAS IN EFFECT IN 1995.
22 Q. (BY MR. BUGDEN) THIS IS 1998. BUT LET ME ASK YOU,
23 DOCTOR, ARE YOU FAMILIAR WITH THE GERIATRIC DOSAGE HANDBOOK?
24 A. I DON'T HAVE THAT BOOK. THERE ARE MULTIPLE BOOKS
25 REGARDING DOSING. I DON'T -- I DON'T HAVE THAT, SPECIFICALLY
1 THAT BOOK. I WOULDN'T NECESSARILY DISAGREE WITH WHAT THE
2 INFORMATION IS IN THERE.
3 Q. SO IF THIS SUGGESTED THAT THE INITIAL STARTING DOSAGE,
4 GERIATRIC STARTING DOSAGE WAS 5 MILLIGRAMS TWICE A DAY,
5 THAT'S JUST A SUGGESTION, AND IN YOUR CASE, YOU RECOMMENDED
6 THAT THE BUSPAR BE STARTED AT 10 MILLIGRAMS THREE TIMES A
7 DAY.
8 A. CORRECT.
9 Q. AND AGAIN, YOU WERE JUST TREATING THE SYMPTOM.
10 A. RIGHT.
11 Q. AND WITH THE ATIVAN --
12 A. I THINK THERE'S A MAXIMUM -- THINK THERE'S A MAXIMUM
13 RECOMMENDED DOSAGE WITH THESE MEDICATIONS, AND YOU DON'T TRY
14 TO EXCEED THAT. BUT I THINK IT'S AN INDIVIDUAL'S JUDGMENT AS
15 TO WHAT STARTING DOSE TO USE. I HAD STARTED ON LOW DOSAGES
16 OF OTHER MEDICATIONS AND I GOT NOWHERE, SO I FELT IN THIS
17 CASE, MY THINKING PROBABLY WAS THAT LET'S GO WITH THE LARGER
18 DOSE RATHER THAN THE SMALLER DOSE INITIALLY WITH -- WITH
19 BUSPAR.
20 Q. AND WITH THE ATIVAN, YOU RECOMMENDED 3 MILLIGRAMS. AND
21 AGAIN, WOULD YOU AGREE THAT THAT'S AGGRESSIVE --
22 A. THAT'S A HIGH DOSE.
23 Q. -- THAT'S A HIGH DOSE.
24 A. THAT'S A HIGH DOSE.
25 Q. BUT AGAIN, IT WAS A HIGH DOSAGE WHERE YOU HAD MADE A
1 CLINICAL MEDICAL JUDGMENT THAT WE NEED TO USE A HIGH DOSAGE
2 TO TRY TO CONTROL MR. ALLDREDGE'S AGITATION.
3 A. CORRECT.
4 Q. YOU CERTAINLY WEREN'T TRYING TO OVERDOSE THE PATIENT.
5 MS. BARLOW: OBJECTION, YOUR HONOR. I DON'T THINK
6 THAT --
7 THE COURT: SUSTAINED.
8 MS. BARLOW: -- THAT'S AN APPROPRIATE QUESTION.
9 Q. (BY MR. BUGDEN) YOU WERE USING YOUR BEST JUDGMENT ABOUT
10 HOW TO TREAT THIS MAN'S AGITATION, ISN'T THAT RIGHT?
11 A. CORRECT.
12 MR. BUGDEN: THANK YOU.
13 THE COURT: REDIRECT?
14 REDIRECT EXAMINATION
15 BY MS. BARLOW:
16 Q. JUST ONE QUESTION. YOU ORDERED THE INCREASE IN
17 RISPERDAL ON THE 8TH OF JANUARY, IS THAT CORRECT. 1
18 A. RIGHT.
19 Q. WERE YOU ABLE TO LEARN WHAT THE EFFECT WAS BEFORE
20 MR. ALLDREDGE LEFT THE NURSING HOME AND LEFT YOUR CARE? 2
21 A. I DON'T KNOW WHAT -- I HAVE NO INFORMATION ABOUT WHAT HE
22 WAS LIKE THE DAY HE LEFT TO GO TO DAVIS.
23 Q. SO WHEN YOU'RE TITRATING TO EFFECT, YOU WERE NEVER ABLE
24 TO SEE THE EFFECT OF THE AMOUNT OF DRUGS THAT -- THE AMOUNT
25 OF RISPERDAL AND BUSPAR THAT YOU HAD ORDERED FOR HIM ON THE
1 8TH OF JANUARY, IS THAT CORRECT? 3
2 A. CORRECT.
3 MS. BARLOW: OKAY. THANK YOU. NO FURTHER QUESTIONS,
4 YOUR HONOR.
5 MR. BUGDEN: NOTHING FURTHER.
6 THE COURT: RECROSS? YOU MAY STEP DOWN, DOCTOR.
7 THE WITNESS: THANK YOU.
8 THE COURT: MAY THIS WITNESS BE EXCUSED, MS. BARLOW?
9 MS. BARLOW: YES, YOUR HONOR.
10 THE COURT: MR. BUGDEN?
11 MR. BUGDEN: YES, SIR.
12 THE COURT: DR. CUNNINGHAM, YOU MAY BE EXCUSED, AND
13 THANK YOU FOR TESTIFYING.