Scott Southworth, MD
20 SCOTT SOUTHWORTH,
21 CALLED BY THE PLAINTIFF, HAVING BEEN DULY
22 SWORN, WAS EXAMINED AND TESTIFIED AS FOLLOWS:
23 DIRECT EXAMINATION
24 BY MR. WILSON:
25 Q. WOULD YOU STATE YOUR FULL NAME FOR THE RECORD,
584
1 DR. SOUTHWORTH?
2 A. SCOTT E. SOUTHWORTH.
3 Q. OKAY. AND YOU ARE EMPLOYED WHERE, SIR?
4 A. I'M SELF-EMPLOYED. I'M AN INTERNAL MEDICINE SPECIALIST
5 IN BOUNTIFUL.
6 Q. AND WHERE IS YOUR OFFICE LOCATED?
7 A. IT'S ACROSS THE STREET FROM LAKEVIEW HOSPITAL IN
8 BOUNTIFUL.
9 Q. OKAY. AND DOCTOR, CAN YOU BRIEFLY TELL US WHAT -- GIVE
10 US SOME INDICATION AS TO WHAT YOUR EDUCATIONAL BACKGROUND
11 IS?
12 A. WELL, I GRADUATED FROM MEDICAL SCHOOL AT THE UNIVERSITY
13 OF UTAH IN 1984. COMPLETED AN INTERNAL MEDICINE RESIDENCY
14 AT L.D.S. HOSPITAL AND THE UNIVERSITY IN 1987 AND I BEGAN
15 PRACTICING IN JULY OF 1987.
16 Q. YOU CURRENTLY HAVE ANY BOARD CERTIFICATIONS OR HOLD ANY
17 BOARD CERTIFICATIONS?
18 A. YES. I'M BOARD CERTIFIED IN INTERNAL MEDICINE.
19 Q. AND WHEN WAS THAT CERTIFICATION?
20 A. 1987.
21 Q. HAVE YOU BEEN PRACTICING IN THE SAME LOCATION SINCE
22 1987?
23 A. YES, I HAVE.
24 Q. ARE YOU ACQUAINTED WITH AN INDIVIDUAL BY THE NAME OF
25 LYDIA SMITH?
585
1 A. YES. SHE WAS MY PATIENT.
2 Q. AND CAN YOU TELL US WHEN YOU FIRST ACQUIRED HER AS A
3 PATIENT?
4 A. SHE FIRST CAME TO SEE ME IN 1993 AND I BELIEVE THAT WAS
5 THROUGH A REFERRAL FROM LAKEVIEW HOSPITAL.
6 Q. DO YOU RECALL WHEN IN 1993 THAT OCCURRED?
7 A. I DON'T.
8 Q. HAVE YOU HAD OCCASION TO REVIEW YOUR MEDICAL RECORDS
9 THAT YOU MAINTAIN IN YOUR OFFICE?
10 A. YES, I HAVE. I HAVE LOOKED AT THOSE.
11 Q. HAVE YOU ALSO HAD OCCASION TO REVIEW OTHER RECORDS IN
12 CONNECTION WITH THESE PROCEEDINGS?
13 A. YES. I HAVE BRIEFLY LOOKED THROUGH THE LAKEVIEW
14 HOSPITAL RECORDS AND ALSO THE SOUTH DAVIS COMMUNITY HOSPITAL
15 RECORDS ON THIS PATIENT.
16 Q. IN REGARDS TO THE TREATMENT AND CARE OF LYDIA SMITH, DID
17 YOU -- WHAT WAS THE NATURE, I GUESS, OF YOUR RELATIONSHIP TO
18 HER?
19 A. I WAS -- I BECAME HER PRIMARY CARE PHYSICIAN. SHE WAS
20 BROUGHT TO ME BY HER FAMILY ON A PRETTY REGULAR BASIS FROM
21 1993 THROUGH 1995. I JUST WOULD ADDRESS THE VARIOUS MEDICAL
22 PROBLEMS THAT CAME UP.
23 Q. CAN YOU DESCRIBE FOR US HER CONDITION AT THE TIME THAT
24 YOU FIRST BEGAN TO SEE HER, PHYSICAL CONDITION?
25 A. I FIRST BEGAN TO SEE HER WITH A COMPLAINT OF CHEST PAIN.
586
1 SHE COMPLAINED OF CHEST PAIN QUITE FREQUENTLY AND WAS
2 ACTUALLY SEEN IN MY OFFICE AND AT THE HOSPITAL FOR THIS
3 COMPLAINT DURING THAT FIRST YEAR.
4 Q. THAT WOULD BE 1993?
5 A. YES.
6 Q. ANY OTHER COMPLAINTS THAT YOU ARE AWARE OF?
7 A. YES. SHE WAS QUITE ANXIOUS AND HER FAMILY OFTEN
8 REPORTED TO ME THAT SHE HAD A LOT OF ANXIETY. SHE HAD A LOT
9 OF COMPLAINTS IN GENERAL. SHE COMPLAINED OF FATIGUE AND
10 DIZZINESS AND JUST NOT FEELING WELL. SHE WASN'T A VERY
11 CONTENT PATIENT PHYSICALLY.
12 Q. WHAT ABOUT HER MENTAL CAPACITY AT THE TIME THAT YOU
13 FIRST STARTED SEEING HER?
14 A. AS I REMEMBER, SHE WAS FAIRLY LUCID EARLY ON, BUT BECAME
15 PROGRESSIVELY MORE DEMENTED DURING THE THREE OR FOUR YEARS
16 THAT I TOOK CARE OF HER, AND BY THE LAST YEAR SHE WAS FAIRLY
17 DEMENTED, VERY CONFUSED.
18 Q. WHAT DO WE MEAN BY DEMENTED?
19 A. CONFUSED, DISORIENTED, UNABLE TO GIVE APPROPRIATE
20 RESPONSES TO SITUATIONS OR QUESTIONS. OFTEN AGITATED.
21 Q. DID YOU, DURING 1993, PROVIDE ANY KIND OF TREATMENT TO
22 LYDIA?
23 A. QUITE A BIT OF TREATMENT. I DON'T REMEMBER THE
24 SPECIFICS, BUT I THINK SHE HAD A SERIES OF TESTS. I BELIEVE
25 THAT SHE WAS EVEN REFERRED TO A CARDIOLOGIST FOR EVALUATION
587
1 AND ANGIOGRAM BECAUSE OF HER CHEST PAIN. AND AS I REMEMBER,
2 SHE SAW ME AT LEAST ONCE A MONTH DURING THAT YEAR IN MY
3 OFFICE.
4 Q. WHAT TYPE OF MEDICATIONS, IF ANY, DID YOU PRESCRIBE?
5 A. SHE WAS ON VARIOUS CARDIAC MEDICATIONS. SHE WAS ON
6 NITROGLYCERIN. SHE WAS ON A DIURETIC. SHE WAS ON SOME
7 BLOOD PRESSURE MEDICINE.
8 Q. ANY PAIN MEDICATION PRESCRIBED FOR HER?
9 A. NOT TO MY KNOWLEDGE.
10 Q. WHAT ABOUT THE ANXIETY? WAS THERE ANY MEDICATION THAT
11 YOU GAVE TO HER FOR THE ANXIETY?
12 A. YES. WE TRIED A DRUG CALLED ATIVAN WHICH IS A SEDATIVE.
13 WE ALSO TRIED AN ANTIDEPRESSANT CALLED SERZONE WHICH IS
14 SUPPOSED TO HAVE ANTIDEPRESSANT AS WELL AS ANTIANXIETY
15 PROPERTIES.
16 Q. WAS THIS MEDICATION ADMINISTERED ON A REGULAR BASIS TO
17 HER OR PRESCRIBED FOR HER ON A REGULAR BASIS?
18 A. THE SERZONE WAS ADMINISTERED ON A ROUTINE BASIS. THE
19 ATIVAN WAS GIVEN ON AN AS-NEEDED BASIS. THAT WAS WHENEVER
20 SHE BECAME ESPECIALLY ANXIOUS IT WAS AVAILABLE.
21 Q. SO WHEN WE SAY ROUTINE, WHAT DO YOU MEAN BY THAT?
22 A. ROUTINE MEANING GIVEN ON A SET SCHEDULE.
23 Q. DO YOU RECALL WHAT THAT -- FROM YOUR REVIEW, WHAT THAT
24 SCHEDULE WAS?
25 A. I DON'T.
588
1 Q. THE ATIVAN OR DO YOU RECALL -- EXCUSE ME. GOING BACK TO
2 THE SERZONE. DO YOU RECALL THE DOSAGE FOR THAT
3 PARTICULAR --
4 A. NO. THE STANDARD DOSE THAT I WAS USING AT THE TIME WAS
5 150 MILLIGRAMS TWICE A DAY ON SERZONE, AND THE STANDARD DOSE
6 ON ATIVAN WOULD HAVE BEEN .5 MILLIGRAMS PROBABLY THREE TIMES
7 A DAY AS NEEDED. BUT THAT'S JUST MY STANDARD PATTERN. I
8 DON'T REMEMBER SPECIFICS WITH REGARD TO HER.
9 Q. I TAKE IT YOU SAW HER DURING THE TIME PERIODS THAT SHE
10 WAS RECEIVING THAT MEDICATION; IS THAT CORRECT?
11 A. YES.
12 Q. CAN YOU TELL THE COURT WHETHER OR NOT SHE CONTINUED ON
13 THAT REGIMEN OF SERZONE AND ATIVAN THROUGH 1993?
14 A. I DON'T ACTUALLY REMEMBER WHEN EACH DRUG WAS STARTED OR
15 STOPPED. THE SERZONE MAY HAVE BEEN A LATER INTERVENTION.
16 MAY NOT HAVE EVEN BEEN IN '93. MAY HAVE BEEN DOWN THE ROAD.
17 AND I CAN'T TELL YOU WHAT HER ATIVAN USAGE OR RESPONSE WAS.
18 I DON'T HAVE THAT INFORMATION.
19 Q. YOU JUST REMEMBER PRESCRIBING IT FOR HER?
20 A. YES. AND I REMEMBER THAT ANXIETY WAS A CONSISTENT
21 REPORT FROM THE FAMILY WITH EACH OFFICE VISIT.
22 Q. DID ANY EVENT BETWEEN THE TIME YOU FIRST STARTED SEEING
23 HER UP UNTIL THE TIME THAT YOU STOPPED SEEING HER -- FIRST
24 OF ALL, MAYBE WE SHOULD ESTABLISH, WHEN WAS THE LAST TIME
25 YOU HAD AN OPPORTUNITY TO MEET WITH HER?
589
1 A. PROBABLY IN DECEMBER OF 1995. SHE HAD A STROKE IN
2 NOVEMBER OF THAT YEAR AND SPENT ABOUT A MONTH AT SOUTH DAVIS
3 COMMUNITY HOSPITAL AFTER THAT STROKE.
4 Q. PREVIOUS TO THE STROKE IN NOVEMBER, DO YOU REMEMBER
5 WHERE SHE WAS RESIDING?
6 A. SHE WAS ALSO AT SOUTH DAVIS FROM JUNE THROUGH NOVEMBER.
7 Q. OF 1995?
8 A. YES.
9 Q. SO DID YOU SEE HER WHILE SHE WAS AT SOUTH DAVIS?
10 A. YES.
11 Q. WOULD YOU SEE HER AT THE SOUTH DAVIS CARE CENTER?
12 A. YES. I WOULD GO THERE ON A PRETTY REGULAR BASIS.
13 Q. AND WERE YOU PRESCRIBING ANY DIFFERENT MEDICATIONS TO
14 HER DURING THAT TIME FRAME, TO YOUR RECOLLECTION?
15 A. I LOOKED AT HER MEDICATIONS BEFORE I CAME IN AND SHE WAS
16 ON VASOTEC FOR HER HEART OR BLOOD PRESSURE. LASIX AND
17 POTASSIUM FOR FLUID RETENTION. SHE WAS ON ATIVAN. SHE WAS
18 ON SERZONE AT LEAST EARLY IN 1995.
19 Q. CAN YOU DESCRIBE HER PHYSICAL CONDITION JUST PREVIOUS TO
20 SUFFERING THE STROKE IN NOVEMBER OF 1995?
21 A. I WOULD LIKE TO DESCRIBE HER PHYSICAL AND HER MENTAL
22 CONDITION BECAUSE THEY KIND OF GO TOGETHER.
23 Q. OKAY.
24 A. SHE WAS INTERMITTENTLY CONFUSED DURING THE FOUR OR FIVE
25 MONTHS PRIOR TO HER STROKE. DURING THE TWO WEEKS PRIOR TO
590
1 HER STROKE SHE WAS CONFUSED MOST OF THE TIME AND BECAME
2 INCONTINENT. SHE ALSO BECAME VERY RESTLESS AND SOMEWHAT
3 ANGRY DURING THOSE WEEKS TO MONTHS BEFORE HER STROKE.
4 Q. OKAY.
5 A. LITTLE MORE DEMANDING FROM THE NURSING STAFF. TENDED TO
6 PACE AND TO SEEM LIKE SHE WAS LOOKING FOR SOMETHING OR LIKE
7 SHE WAS FRUSTRATED BY SOMETHING.
8 Q. DID YOU HAVE CONVERSATIONS WITH THE NURSING STAFF AT THE
9 CARE CENTER?
10 A. I'M SURE I DID, BUT I DON'T REMEMBER ANY SPECIFICS.
11 Q. BUT YOU WOULD, I ASSUME, UPON SEEING YOUR PATIENT THEN
12 PRESCRIBE OR DETERMINE WHAT HER TREATMENT REGIMEN WOULD BE?
13 A. YES. IN TERMS OF TREATABLE CONDITIONS AS WE SAW HER
14 CONFUSION GRADUALLY WORSENING, I DON'T REMEMBER THAT WE HAD
15 ANY INTERVENTIONS TO REVERSE THAT TREND.
16 Q. DID YOU MAKE A DIAGNOSIS OF HER RELATIVE TO HER --
17 A. YES. IN ADDITION TO HER CORONARY DISEASE AND HER
18 CONGESTIVE HEART FAILURE DIAGNOSIS, SHE HAD A DIAGNOSIS OF
19 CEREBROVASCULAR DEMENTIA WHICH REFERS TO CONFUSION AND
20 MENTAL STATUS CHANGES BASED ON INADEQUATE BLOOD FLOW TO THE
21 BRAIN AND POSSIBLY TO EVEN SMALL STROKES.
22 Q. NOW, YOU SAY SHE SUFFERED A STROKE IN NOVEMBER OF 1995.
23 CAN YOU DESCRIBE THAT PARTICULAR STROKE FOR US?
24 A. I WAS ACTUALLY NOT THE ADMITTING PHYSICIAN. ONE OF MY
25 COLLEAGUES ADMITTED HER. SHE WAS AT THE NURSING HOME. HAD
591
1 A MARKED DECLINE IN HER MENTAL STATUS AND DEVELOPED A FEVER.
2 THEY CALLED THE ON-CALL PHYSICIAN WHO FELT THAT SHE SHOULD
3 BE SEEN IN THE EMERGENCY DEPARTMENT AT LAKEVIEW HOSPITAL.
4 SHE WAS TRANSFERRED THERE WHERE A C.T. SCAN WAS DONE AND THE
5 C.T. SCAN SHOWED A PARIETAL HEMORRHAGE WHICH IS A KIND OF
6 STROKE.
7 Q. WHEN YOU SAY A KIND OF STROKE, WHAT DO YOU MEAN BY THAT?
8 A. WELL, THERE ARE ISCHEMIC STROKES OR THROMBOTIC STROKES
9 WHERE AN ARTERY BECOMES BLOCKED. AND THERE ARE HEMORRHAGIC
10 STROKES WHERE AN ARTERY ACTUALLY BREAKS OR RUPTURES. AND
11 THIS WAS OF THE LATTER TYPE.
12 Q. CAN YOU DESCRIBE, IF YOU WILL, THE SEVERITY OF THIS
13 PARTICULAR STROKE?
14 A. THE STROKE WAS NOT PARTICULARLY LARGE AND THE NEUROLOGIC
15 DEFICITS WERE NOT MARKEDLY SEVERE. SHE HAD NO MOTOR
16 FUNCTION LOSS. IN OTHER WORDS, SHE DIDN'T BECOME PARALYZED
17 ON ONE SIDE. SHE DID LOSE HER ABILITY TO SPEAK AS A RESULT
18 OF THIS STROKE.
19 Q. WHAT IS THE MEDICAL TERM?
20 A. SHE HAD WHAT WE CALL EXPRESSIVE APHASIA WHICH MEANS THAT
21 SHE MAY KNOW WHAT HE SHE WANTS TO SAY, BUT SHE CAN'T FORM
22 THE WORDS AND COMMUNICATE HER THOUGHTS.
23 Q. SO THAT WOULD BE THE STROKE IMPACTING THAT PART OF THE
24 BRAIN?
25 A. THAT'S CORRECT.
592
1 Q. OKAY. SUBSEQUENT TO THE STROKE, DID YOU CONTINUE TO SEE
2 HER?
3 A. YES. SHE WAS TRANSFERRED BACK TO SOUTH DAVIS HOSPITAL
4 AND REMAINED THERE FOR ABOUT FOUR WEEKS.
5 Q. DID YOU SEE HER IN THE HOSPITAL SETTING?
6 A. I SAW HER EVERY DAY AT LAKEVIEW HOSPITAL.
7 Q. HOW MANY DAYS WAS SHE HOSPITALIZED?
8 A. THREE OR FOUR.
9 Q. THEN SHE WAS TRANSFERRED BACK TO THE CARE CENTER?
10 A. YES.
11 Q. CAN YOU DESCRIBE FOR THE JURY HER PHYSICAL AND MENTAL
12 STATE AT THE TIME SHE RETURNED FROM THE HOSPITAL?
13 A. FOLLOWING HER STROKE, SHE REMAINED CONFUSED AND OF
14 COURSE NOW HAD THE ADDED PROBLEM OF BEING UNABLE TO
15 COMMUNICATE AT ALL. SHE -- INSTEAD OF BEING RESTLESS
16 CONFUSED, SHE BECAME COMBATIVELY CONFUSED. LET ME EXPLAIN
17 WHAT I MEAN. DURING THE FEW MONTHS PRIOR TO HER STROKE, SHE
18 WAS ONE TO FIDGET, TO WANT ATTENTION FROM THE NURSES, TO
19 PACE THE HALLS, TO LOOK INTO OTHER PATIENTS' ROOMS, TO FEEL
20 THAT THERE WAS SOMETHING MISSING OR SOMETHING THAT NEEDED TO
21 BE DONE. AND USUALLY WITH A LITTLE BIT OF REASSURANCE AND
22 SOME CALMING INFLUENCE SHE COULD BE REORIENTED TO HER
23 SITUATION. AFTER HER STROKE SHE WAS COMBATIVE. SHE WOULD
24 STRIKE AT THE STAFF. IN FACT, THE CHART SAYS THAT SHE WOULD
25 STRIKE, BITE, HIT, SPIT, DO ALL KINDS OF AGGRESSIVE
593
1 BEHAVIORS TOWARD THE NURSING STAFF AND TOWARD OTHER
2 PATIENTS. AND THAT WAS NEW.
3 Q. SOUNDS LIKE SHE WAS A PRETTY ACTIVE LADY.
4 A. SHE WAS. IN FACT, EVEN AFTER HER STROKE ONE OF THE
5 PROBLEMS SHE HAD IS THAT SHE KEPT TRYING TO ESCAPE THE
6 FACILITY AND THEY WERE WORRIED THAT SHE WOULD GET OUT INTO
7 THE STREET, AND BASICALLY THEY NEEDED A NURSE IN A SITUATION
8 THEY CALL ONE-ON-ONE. IN OTHER WORDS, IN A NORMAL NURSING
9 HOME SITUATION EACH NURSE MAY HAVE TEN OR 12 PATIENTS. IN
10 HER CASE THEY ASSIGNED A NURSE TO FOLLOW HER WHEREVER SHE
11 WENT BECAUSE SHE WAS SO PRONE TO LEAVING THE FACILITY.
12 Q. AS A RESULT OF THAT NEW BEHAVIORAL PATTERN, WAS THERE
13 ANY ACTION TAKEN?
14 A. YES. WE TRIED A MEDICATION CALLED HALDOL TO TRY AND
15 CALM DOWN SOME OF HER AGGRESSIVE OR COMBATIVE BEHAVIORS. WE
16 TRIED IT IN ORAL FORM AND IN INJECTION FORM. I DON'T
17 REMEMBER THAT WE WERE PARTICULARLY SUCCESSFUL WITH THAT
18 INTERVENTION. ALL OF THE CHART NOTES THAT I READ SAY THAT
19 SHE CONTINUED TO CLUTCH AT, STRIKE AT OR SPIT AT STAFF,
20 ROOMMATES, ET CETERA.
21 Q. SO DID YOU CONSIDER ANY OTHER ALTERNATIVES AT THAT
22 POINT?
23 A. YES. WHEN A PATIENT IS FAILING TO RESPOND TO SIMPLE
24 INTERVENTIONS, ESPECIALLY WHEN THEY ARE FELT TO BE A RISK OR
25 DANGER TO THE OTHER PATIENTS OR TO THE STAFF, WE USUALLY
594
1 REFER TO A MORE SECURE FACILITY SUCH AS GEROPSYCHIATRIC
2 UNIT.
3 Q. WERE YOU FAMILIAR WITH THE DAVIS GEROPSYCHIATRIC UNIT?
4 A. YES.
5 Q. HOW HAD YOU ACQUIRED ANY FAMILIARITY WITH THAT?
6 A. AT THE TIME IT WAS THE ONLY LOCAL GEROPSYCH UNIT
7 AVAILABLE AND I HAD SENT OTHER PATIENTS THERE.
8 Q. SO DID YOU -- DID YOU MAKE INQUIRY OR DID SOMEBODY MAKE
9 INQUIRY AS TO THE ADMISSION TO THE GEROPSYCH UNIT?
10 A. ACTUALLY IT WAS PROBABLY SOUTH DAVIS HOSPITAL STAFF THAT
11 MADE THE INQUIRIES. IN FACT, THEY CALLED ME AND SAID, WE
12 CAN'T KEEP HER HERE ANYMORE. SHE WAS A DANGER AND WE WOULD
13 LIKE TO TRANSFER HER. AND I AGREED AT THAT POINT, AGREED TO
14 THAT PLAN.
15 Q. SO DID YOU FILL OUT ANY FORMS OR ANYTHING TO ACCOMMODATE
16 THAT TRANSFER?
17 A. I DON'T REMEMBER ANY SPECIFIC PAPERWORK.
18 Q. BUT YOU AGREED WITH THE TRANSFER?
19 A. YES, AND MOST OF THE FORMS WERE FILLED OUT BY NURSING
20 STAFF.
21 Q. TO YOUR UNDERSTANDING, WHAT WAS THE PURPOSE FOR THE
22 TRANSFER?
23 A. TO DO A MORE INTENSE EVALUATION OF HER PSYCHIATRIC
24 BEHAVIORS AND TO REFER TO PEOPLE EXPERT IN THE USE OF
25 MEDICATIONS THAT MIGHT BE USED TO CALM HER.
595
1 Q. NOW, THE GEROPSYCH UNIT IS LOCATED AT THE DAVIS
2 HOSPITAL, IS IT NOT?
3 A. CORRECT.
4 Q. AND IS THERE ANYTHING RELATIVE TO THE FACILITY ITSELF
5 THAT YOU FELT IT WAS MORE APPROPRIATE THAN ANY OTHER TYPE OF
6 FACILITY?
7 A. IT WAS CLOSE.
8 Q. WHAT ABOUT THE SECURITY AND THE SUPERVISION IN THAT
9 FACILITY?
10 A. I HAD ACTUALLY NEVER BEEN TO THE FACILITY AND JUST
11 ASSUMED THAT SINCE THAT'S WHAT THEY SPECIALIZED IN THAT THEY
12 WOULD HAVE ADEQUATE SECURITY AND EXPERTISE.
13 Q. DID YOU HAVE ANY IMPRESSION AS TO HOW LONG LYDIA WOULD
14 BE AT THIS FACILITY?
15 A. ONLY BASED ON PREVIOUS EXPERIENCE. AS A RULE, PATIENTS
16 WERE USUALLY AT THE GEROPSYCH UNIT FOR TWO TO THREE WEEKS.
17 SOME LESS, SOME MORE, BUT THAT WAS AN AVERAGE.
18 Q. WAS THERE ANY PLAN IN EFFECT AT THAT TIME, TO YOUR
19 KNOWLEDGE, TO RETURN HER TO THE SOUTH DAVIS FACILITY?
20 A. IF SHE COULD BE DEEMED SAFE. IN OTHER WORDS, AFTER AN
21 INTENSE EVALUATION AND VARIOUS MEDICATIONS ADJUSTMENTS, IF
22 SHE WAS NOT A THREAT TO RESIDENTS AND STAFF, THAT WOULD BE
23 THE PLAN FOR HER TO RETURN.
24 Q. LET ME JUST ASK YOU A FEW OTHER QUESTIONS AS THEY RELATE
25 TO HER PHYSICAL CONDITION. DURING YOUR COURSE OF TREATMENT
596
1 FROM '93 UP UNTIL THE TIME THAT SHE WAS TRANSFERRED TO THE
2 GEROPSYCH UNIT, DID YOU EVER TREAT LYDIA SMITH WITH ANY PAIN
3 MEDICATIONS?
4 A. I DON'T REMEMBER AND I HAVEN'T FOUND ANY CHARTING THAT I
5 DID. WE TREATED HER SYMPTOMS BUT HER PAIN INITIALLY WAS
6 MOSTLY HEART PAIN AND WE TREATED THAT WITH HEART
7 MEDICATIONS.
8 Q. DID SHE MAKE ANY OTHER SPECIFIC COMPLAINTS TO YOUR
9 RECOLLECTION ABOUT PAIN ASSOCIATED WITH ANY OTHER PARTS?
10 A. SHE FELL ONCE AND STRAINED HER GROIN AND COMPLAINED OF
11 SOME HIP AND GROIN PAIN. I DON'T REMEMBER WHAT WAS USED TO
12 TREAT THAT. I WOULD ASSUME AN ANTIINFLAMMATORY OF SOME
13 KIND. HER PAIN WAS FELT, AT LEAST ACCORDING TO WHAT I
14 CHARTED, TO BE A TEMPORARY SITUATION. IN OTHER WORDS, SHE
15 FELL, SHE STRAINED HER LIGAMENTS, AND WAS EXPECTED TO
16 RESOLVE.
17 Q. WERE YOU AWARE OF ANY PROBLEMS WHICH WOULD BE DESCRIBED
18 AS CHRONIC PAIN PROBLEMS WITH LYDIA?
19 A. NO.
20 Q. AT THE TIME THAT SHE WAS TRANSFERRED FROM SOUTH DAVIS
21 COMMUNITY, OTHER THAN THE DESCRIPTION OF HER COMBATIVENESS,
22 WAS THERE ANYTHING PHYSICALLY THAT YOU OBSERVED ABOUT HER
23 WHERE SHE WAS SUFFERING FROM ANY KIND OF DISABILITY?
24 A. SHE SEEMED TO SUFFER MORE FROM AN ANXIETY DISORDER. SHE
25 SEEMED ALWAYS RESTLESS AND FIDGETY AND NERVOUS AND
597
1 OFTENTIMES WOULD TALK VERY RAPIDLY. AND AT ONE POINT I
2 WROTE THAT SHE TENDED TO SOMATICIZE OR TO HAVE A LOT OF
3 SOMATIC COMPLAINTS. IN OTHER WORDS, WHEN I WOULD SEE HER
4 SHE WOULD TELL ME THAT SHE WAS DIZZY, THAT SHE WAS WEAK,
5 THAT SHE DIDN'T FEEL GOOD, ET CETERA. BUT THEY WERE KIND OF
6 VAGUE.
7 MR. WILSON: MAY I HAVE JUST A MINUTE, YOUR HONOR?
8 THE COURT: YES.
9 Q. (BY MR. WILSON) PERHAPS YOU COULD DEFINE FOR US WHAT
10 YOU MEAN BY THE TERM SOMATIC.
11 A. WELL, IN OTHER WORDS, ANOTHER WORD FOR THAT IS
12 FUNCTIONAL COMPLAINT. THERE WERE COMPLAINTS THAT ARE VAGUE.
13 THEY ARE OFTEN SEEN IN PEOPLE WHO ARE ANXIOUS. COMPLAINTS
14 OF FATIGUE, FOR EXAMPLE. DIZZINESS. GENERAL MALAISE OR A
15 LACK OF WELL-BEING. THEY ARE HARD TO PINPOINT TO A SPECIFIC
16 ORGAN SYSTEM OR TO A SPECIFIC CAUSE.
17 MR. WILSON: I DON'T THINK I HAVE FURTHER QUESTIONS
18 AT THIS TIME, YOUR HONOR.
19 THE COURT: MR. STIRBA.
20 CROSS-EXAMINATION
21 BY MR. STIRBA:
22 Q. GOOD MORNING, DOCTOR. YOU TESTIFIED ABOUT THE
23 CONDITION, I GUESS IT'S CALLED APHASIA. DO YOU REMEMBER
24 THAT?
25 A. YES.
598
1 Q. AND APHASIA AGAIN IS WHAT?
2 A. APHASIA IS AN INABILITY TO EXPRESS ONESELF.
3 Q. AND THAT TYPICALLY OCCURS AFTER A STROKE; IS THAT RIGHT?
4 A. YES.
5 Q. AND IT'S TRUE, IS IT NOT, THAT AFTER THE STROKE WHICH
6 SHE EXPERIENCED ON NOVEMBER 18 OF 1995, THAT WAS A CONDITION
7 THAT LYDIA SUFFERED FROM?
8 A. YES.
9 Q. AND IS IT FAIR TO SAY THAT AT LEAST INSOFAR AS YOU SAW
10 HER PRIOR TO HER DEATH SHE SUFFERED FROM THAT CONDITION?
11 A. DURING THAT LAST FOUR WEEKS, YES, FROM MID-NOVEMBER TO
12 MID-DECEMBER OF '95.
13 Q. THAT MADE IT REALLY DIFFICULT FOR HER TO COMMUNICATE, IS
14 THAT TRUE?
15 A. SHE WOULD TALK IN FRAGMENTS OF SYLLABLES THAT MADE NO
16 SENSE.
17 Q. NOW, YOU SAW HER THEN WHEN SHE WAS AT LAKEVIEW AFTER THE
18 STROKE EVENT, TRUE?
19 A. YES.
20 Q. AND IN FACT YOU MADE A DIAGNOSIS AT THAT TIME THAT SHE
21 SUFFERED A STROKE, CORRECT?
22 A. THE DIAGNOSIS HAD ACTUALLY BEEN MADE BY MY COLLEAGUE
23 WHEN SHE WAS ADMITTED.
24 Q. ON THE DIAGNOSIS, DISCHARGE DIAGNOSIS FROM LAKEVIEW
25 HOSPITAL WHERE IT INDICATES YOU WERE THE ATTENDING
599
1 PHYSICIAN; IS THAT TRUE?
2 A. I ASSUMED HER CARE THE NEXT DAY.
3 Q. THE DIAGNOSIS STATES HEMORRHAGIC PARIETAL STROKE?
4 A. YES.
5 Q. WHAT IS HEMORRHAGIC PARIETAL STROKE?
6 A. IT'S A STROKE IN THE PARIETAL REGION OF THE BRAIN WHICH
7 IS ROUGHLY HERE. HEMORRHAGE MEANS THAT THE VESSEL HAS
8 RUPTURED AND THERE'S BLOOD THAT IS IN -- THAT HAS LEAKED OUT
9 INTO -- LEAKED OUT INTO THE BRAIN TISSUE.
10 Q. AND IT ALSO INDICATES HYPERTENSION AS A DISCHARGE
11 DIAGNOSIS. DID YOU MAKE SUCH A DIAGNOSIS?
12 A. YES.
13 Q. WHAT IS HYPERTENSION?
14 A. HIGH BLOOD PRESSURE.
15 Q. NOW, ALSO DURING THE TIME PERIOD THAT SHE WAS ADMITTED,
16 DR. JOE JENSEN ATTENDED TO HER AS WELL. DO YOU KNOW WHO
17 DR. JENSEN IS?
18 A. YES. HE WAS ON CALL FOR ME THE DAY OF HER ADMISSION.
19 Q. AND IS THAT THE GENTLEMAN YOU ARE TALKING ABOUT WHO
20 ACTUALLY SAW HER INITIALLY?
21 A. HE DID THE INITIAL WORKUP AND REVIEWED THE C.T. FINDING
22 AND CONFIRMED THAT SHE INDEED HAD HAD A PARIETAL STROKE.
23 Q. DR. JENSEN INDICATES UNDER IMPRESSION, APHASIA
24 EXPRESSIVE AND RECEPTIVE OF 12 HOURS DURATION. POSSIBLY
25 EMBOLIC FOCUS FROM THE NECK OR THE AORTIC VALVE NEED TO BE
600
1 CONSIDERED. DO YOU AGREE WITH HIS IMPRESSION?
2 A. YES.
3 Q. AND THE APHASIA, YOU'VE ALREADY TOLD US WHAT THAT IS.
4 WHAT DOES HE MEAN POSSIBLE EMBOLIC FOCUS FROM THE NECK OR
5 AORTIC VALVE NEED TO BE CONSIDERED?
6 A. THERE ARE TWO KINDS OF STROKES, IF YOU SIMPLIFY IT, AND
7 THE TWO KINDS ARE THROMBOTIC OR EMBOLIC. EMBOLIC STROKE IS
8 WHERE A CLOT OR PIECE OF DEBRIS BREAKS FREE FROM A DISTANT
9 SOURCE, TRAVELS THROUGH THE BLOOD STREAM AND LODGES IN ONE
10 OF THE CEREBRAL ARTERIES. SO SUCH AN EMBOLISM COULD COME
11 FROM A HEART VALVE, COULD COME FROM AN AORTIC CALCIFICATION
12 OR COULD COME FROM A PLAQUE WHICH IS BUILDUP OF CHOLESTEROL
13 AND DEBRIS IN A CAROTID ARTERY, BREAK FREE GOING INTO THE
14 BRAIN AND THEN CAUSE THE RESULTANT STROKE.
15 Q. YOU MENTIONED A HEART VALVE AND YOU ARE AWARE, ARE YOU
16 NOT, THAT MISS SMITH HAD A HEART VALVE REPLACEMENT?
17 A. I VAGUELY REMEMBER THAT.
18 Q. AND SO THEREFORE, AT LEAST CONSISTENT WITH WHAT YOU JUST
19 TESTIFIED TO, THAT MIGHT BE A PLAUSIBLE EXPLANATION OF WHERE
20 THAT EMBOLISM FORMED; IS THAT CORRECT?
21 A. ABSOLUTELY, YES.
22 Q. THEN ALSO HE INDICATES FEVER OF UNCERTAIN ETIOLOGY. THE
23 FEVER COULD BE THE RESULT OF CEREBROVASCULAR ISCHEMIA. DO
24 YOU AGREE WITH THAT IMPRESSION?
25 A. LOW GRADE FEVERS DO OCCUR IN CONJUNCTION WITH STROKES.
601
1 Q. IN FACT, YOU'VE TESTIFIED I BELIEVE ON DIRECT THAT
2 CEREBROVASCULAR DISEASE IS SOMETHING THAT MISS SMITH
3 SUFFERED FROM?
4 A. THAT WAS MY ASSESSMENT EVEN PRIOR TO HER STROKE.
5 Q. NOW, WHEN IT SAYS CEREBROVASCULAR ISCHEMIA, CAN YOU TELL
6 US, PLEASE, WHAT THAT MEANS?
7 A. ISCHEMIA REFERS TO AN INADEQUACY OF BLOOD FLOW TO THE
8 BRAIN. INFARCTION REFERS TO A COMPLETE OBSTRUCTION OF BLOOD
9 FLOW TO THE BRAIN. SO ISCHEMIA MAY CAUSE A PERSON TO BE
10 TEMPORARILY CONFUSED OR TEMPORARILY NEUROLOGICALLY IMPAIRED,
11 BUT THE PROBLEM WOULD RESOLVE. THE INFARCTION CAUSES A
12 RELATIVELY PERMANENT IMPAIRMENT.
13 Q. AND IT'S TRUE, IS IT NOT, THAT A STROKE CERTAINLY CAN BE
14 THE CAUSE OF ONE'S DEATH?
15 A. CERTAINLY.
16 Q. AND CEREBROVASCULAR DISEASE COULD BE THE ORIGINATOR OF
17 AN ACTUAL STROKE EVENT?
18 A. YES.
19 Q. NOW, ALSO THE DOCTOR, DR. JENSEN, STATES UNDERLYING
20 DEMENTIA AND DEPRESSION. YOU'VE TESTIFIED ABOUT THAT. YOU
21 AGREE WITH THAT IMPRESSION?
22 A. YES. THOSE WERE PREEXISTENT.
23 Q. HE ALSO HAS UNDER FOUR, ORGANIC HEART DISEASE WITH
24 CHRONIC CONGESTIVE HEART FAILURE. DO YOU AGREE WITH THAT
25 IMPRESSION?
602
1 A. I DO.
2 Q. TELL ME PLEASE, FIRST OF ALL, AND TELL US WHAT IS
3 ORGANIC HEART DISEASE?
4 A. ORGANIC HEART DISEASE IS A FAIRLY GENERAL TERM THAT
5 REFERS TO A VARIETY OF CONDITIONS. IT COULD REFER TO
6 CORONARY DISEASE, WHICH SHE HAD. IT COULD REFER TO VALVULAR
7 HEART DISEASE, WHICH SHE HAD. IT COULD REFER TO IMPAIRED
8 VENTRICULAR FUNCTION AND CONGESTIVE HEART FAILURE, WHICH SHE
9 HAD. SO IT WAS A WAY OF ENCOMPASSING ALL OF HER CARDIAC
10 DIAGNOSES INTO ONE.
11 Q. THE CORONARY DISEASE THAT YOU JUST TESTIFIED SHE HAD,
12 COULD YOU TELL US PLEASE WHAT THAT IS?
13 A. CORONARY DISEASE IS NARROWING OR BLOCKAGE OF CORONARY
14 ARTERIES THAT FEED THE HEART MUSCLE. AS THEY BECOME MORE
15 AND MORE NARROW PEOPLE BEGIN TO GET CHEST PAIN WHICH WE CALL
16 ANGINA, WHICH ONE OF THOSE ARTERIES OCCLUDES, THEN THEY
17 DEVELOP AN INFARCTION VERY SIMILAR TO WHAT I TALKED ABOUT
18 WITH THE BRAIN AND THAT WOULD BE A MYOCARDIAL INFARCTION.
19 SHE HAD CORONARY NARROWINGS, ACTUALLY HAD AN ANGIOGRAM AND I
20 BELIEVE HAD AN ANGIOPLASTY WHICH IS A DILATION, BALLOON
21 DILATION OF THE NARROWED CORONARY SEGMENTS, IN AN EFFORT TO
22 RESTORE BLOOD FLOW TO HER HEART.
23 Q. CAN SOMEONE DIE FROM CORONARY ARTERY DISEASE?
24 A. YES.
25 Q. AND COULD CORONARY ARTERY DISEASE, THE EXISTENCE OF IT,
603
1 BE RESPONSIBLE FOR ONE'S SUDDEN DEATH?
2 A. ABSOLUTELY.
3 Q. THE NEXT THING YOU INDICATED SHE HAD VALVULAR DISEASE.
4 TELL US WHAT THAT IS, PLEASE.
5 A. AS WE TALKED ABOUT EARLIER, SHE HAD HAD A VALVE REPLACED
6 SO SHE HAD AN ARTIFICIAL VALVE AND I BELIEVE SHE WAS
7 ANTICOAGULATED BECAUSE OF THAT.
8 Q. NOW, THAT'S ONE OF THOSE FANCY WORDS.
9 A. SHE WAS ON BLOOD THINNER TO REDUCE THE RISK OF CLOTS AND
10 STROKES.
11 Q. THE VALVULAR DISEASE THAT SHE HAD, THAT'S A HEART VALVE
12 DISEASE; IS THAT RIGHT?
13 A. YES.
14 Q. COULD THAT BE THE CAUSE OF ONE'S DEATH?
15 A. NOT BY ITSELF.
16 Q. WHAT OTHER CONDITIONS WOULD HAVE TO BE PRESENT IN ORDER
17 TO CAUSE DEATH FROM VALVULAR DISEASE?
18 A. WELL, VALVULAR DISEASE CAN REFER TO A VALVE THAT LEAKS
19 OR TO A VALVE THAT IS NARROWED. BUT BY ITSELF A VALVULAR
20 HEART PROBLEM IS NOY LIKELY TO CAUSE A PATIENT'S DEATH.
21 Q. IN CONJUNCTION WITH THE EXISTENCE OF CORONARY ARTERY
22 DISEASE?
23 A. YES, MIGHT PUT MORE STRAIN ON THE HEART.
24 Q. THAT CERTAINLY COULD COMPLICATE THINGS CAUSING DEATH,
25 COULD IT NOT?
604
1 A. YES.
2 Q. AND HOW ABOUT WITH CONGESTIVE HEART DISEASE OR
3 CONGESTIVE HEART FAILURE?
4 A. A LEAKY VALVE OR A VALVE WOULD WORSEN CONGESTIVE HEART
5 FAILURE.
6 Q. COULD CERTAINLY CAUSE A DEATH THAT WOULD ARISE FROM
7 THOSE COMPLICATIONS; IS THAT RIGHT?
8 A. AS THAT CONGESTIVE HEART FAILURE OR CORONARY DISEASE
9 BECAME WORSE, YES.
10 Q. YOU HAVE TESTIFIED THAT MISS SMITH HAD CONGESTIVE HEART
11 FAILURE.
12 A. YES.
13 Q. COULD YOU TELL US, PLEASE, WHAT YOU MEAN BY THAT?
14 A. CONGESTIVE HEART FAILURE REFERS TO A HEART THAT WAS
15 UNABLE TO PUMP ADEQUATE BLOOD TO THE TISSUES. A BETTER WAY
16 OF LOOKING AT IT IS A WEEK PUMP. THE PATIENT MAY LIVE FOR
17 MANY YEARS WITH CONGESTIVE HEART FAILURE, AND THERE ARE
18 VARIOUS DEGREES OF CONGESTIVE HEART FAILURE FROM VERY MILD
19 TO LIFE THREATENING OR SEVERE. MOST PATIENTS WITH
20 CONGESTIVE HEART FAILURE HAVE TO TAKE A DIERETIC BECAUSE
21 THEY TEND TO RETAIN WATER. SO THEY TAKE A WATER PILL TO GET
22 RID OF THE EXCESSIVE WATER RETENTION.
23 Q. CAN THE COMPLICATIONS FROM CONGESTIVE HEART FAILURE
24 CAUSE SUDDEN DEATH?
25 A. MOST PATIENTS WITH CONGESTIVE HEART FAILURE HAVE
605
1 UNDERLYING HEART PROBLEMS AND THE MOST COMMON UNDERLYING
2 PROBLEM IS CORONARY DISEASE. SO THE SUDDEN DEATH IS NOT SO
3 MUCH FROM THE CONGESTIVE HEART FAILURE AS IT IS FROM THE
4 UNDERLYING CONDITION, CORONARY ARTERY DISEASE, HYPERTENSIVE
5 HEART DISEASE, ET CETERA.
6 Q. WOULD AN ARRHYTHMIA BE ALSO THE CAUSE OF SUDDEN DEATH?
7 A. YES. AND PATIENTS WITH IMPAIRED HEART FUNCTION ARE MORE
8 PREDISPOSED TO ARRHYTHMIAS.
9 Q. AND TELL US PLEASE WHAT AN ARRHYTHMIA IS?
10 A. ARRHYTHMIA IS WHEN THE HEART QUITS BEATING IN A REGULAR
11 FASHION AND FIBRILLATES AND FLUTTERS IN A WAY THAT IS NOT
12 CAPABLE OF PUMPING BLOOD. NOW, THERE ARE BENIGN ARRHYTHMIAS
13 WHERE THE HEART CAN SIMPLY SKIP A BEAT OR RACE AND THE BLOOD
14 PUMPS JUST FINE. SO THERE ARE VARIOUS KINDS OF ARRHYTHMIAS.
15 Q. SURE. AND BASICALLY ARRHYTHMIAS HAVE TO DO WITH SORT OF
16 THE ELECTRICAL IMPULSES ASSOCIATED WITH THE PUMPING FUNCTION
17 OF THE HEART; IS THAT RIGHT?
18 A. YES.
19 Q. AND ARRHYTHMIA IS BASICALLY AN IRREGULAR IMPULSE, TRUE?
20 A. THAT'S RIGHT.
21 Q. AND IN THE WORST CASE SCENARIO WHERE AN ARRHYTHMIA MAY
22 CAUSE DEATH, IT'S BECAUSE ESSENTIALLY THE HEART JUST
23 FLUTTERS AND DOES NOT PUMP; IS THAT RIGHT?
24 A. THE WORST ARRHYTHMIA IS CALLED VENTRICULAR FIBRILLATION
25 AND IT IS A CASE WHERE THE HEART DOESN'T EVEN FLUTTER. IT
606
1 QUIVERS AND THERE IS NO BLOOD BEING PUMPED AT ALL AND THE
2 ELECTRICAL ACTIVITY IS COMPLETELY DISORGANIZED.
3 Q. NOW, IN YOUR NOTE FOR THE TIME THAT SHE WAS THERE AT THE
4 HOSPITAL, LAKEVIEW, THE DISCHARGE SUMMARY, YOU'VE REVIEWED
5 THAT; IS THAT RIGHT?
6 A. I'VE LOOKED AT IT.
7 Q. DO YOU WANT TO SEE IT AGAIN OR --
8 A. GO AHEAD AND ASK AND I'LL ASK FOR IT IF I DON'T KNOW.
9 Q. SURE. YOU STATE UNDER HOSPITAL COURSE, IT SAYS THE
10 PATIENT RECEIVED A C.T. SCAN. TELL US WHAT THAT IS, PLEASE.
11 A. A C.T. SCAN IS OFTEN CALLED A CAT SCAN BY LAY PEOPLE.
12 IT'S A COMPUTERIZED THREE-DIMENSIONAL IMAGE OF WHATEVER BODY
13 PART IS BEING SCANNED, IN THIS CASE THE BRAIN.
14 Q. AND IT IS A TOOL TO ASSIST IN DIAGNOSING STROKE EVENTS;
15 IS THAT RIGHT?
16 A. YES. IT'S HIGH TECH X-RAY.
17 Q. WHICH SHOWED A HEMORRHAGE IN THE LEFT PARIETAL AREA.
18 YOU'VE TOLD US ABOUT THAT.
19 A. THAT'S RIGHT.
20 Q. THEN YOU GO ON TO SAY ANTICOAGULATION WAS THEREFORE
21 WITHHELD. YOU EXPLAINED WHAT ANTICOAGULATION IS.
22 A. A PATIENT WHO HAS HAD A HEMORRHAGE WOULD NOT DO WELL ON
23 A BLOOD THINNER.
24 Q. AND YOU SAY ON HER SECOND HOSPITAL DAY SHE BECAME FAIRLY
25 OBTUNDED? WHAT DOES OBTUNDED MEAN?
607
1 A. OBTUNDED IS A WORD THAT WOULD REFER TO AN UNRESPONSIVE
2 STATE WHERE SHE WOULD NOT RESPOND TO VOICE OR TOUCH OR TO
3 BEING SHAKEN. IN OTHER WORDS, ALMOST COMATOSE.
4 Q. AT THAT POINT GIVEN THE CLINICAL ASSESSMENT THAT YOU
5 MADE, DID YOU BELIEVE THAT IN YOUR OPINION SHE WAS CLOSE OR
6 NEAR DEATH?
7 A. AT THAT TIME I DID.
8 Q. AND YOU GO ON TO SAY, "AND HAD SOME CHEYNE-STOKES
9 BREATHING." YOU ARE GOING TO HAVE TO TELL US WHAT
10 CHEYNE-STOKES BREATHING IS?
11 A. CHEYNE-STOKES BREATHING IS IRREGULAR BREATHING PATTERN
12 THAT IS OFTEN SEEN IN TERMINAL PATIENTS. IN PEOPLE WITH
13 SEVERE STROKES IT'S FAIRLY COMMON. IN PEOPLE WITH SEVERE
14 HEART DISEASE, ESPECIALLY END-STAGE HEART DISEASE, WE SEE
15 IT.
16 Q. END STAGE MEANING TERMINAL STAGE OR NEAR DEATH?
17 A. NEAR DEATH.
18 Q. AND I DON'T KNOW WHETHER YOU HAVE DESCRIBED IT FOR US,
19 BUT COULD YOU TELL US SYMPTOMATICALLY WHAT IS CHEYNE-STOKES
20 BREATHING?
21 A. WELL, THE PATIENT ISN'T REALLY -- PROBABLY ISN'T EVEN
22 AWARE THAT THEY ARE DOING IT, BUT IT'S A PATTERN OF
23 BREATHING WHERE THERE ARE DEEP RAPID RESPIRATIONS ALMOST IN
24 A SENSE OF WHAT WE CALL AIR HUNGER. IT LOOKS LIKE SOMEBODY
25 IS GASPING FOR BREATH. AND THEN THERE WILL BE A PATTERN
608
1 WHERE THAT LEVELS OFF AND THEY ALMOST SEEM LIKE THEY ARE NOT
2 BREATHING AT ALL. AND THEN IT CYCLES BACK INTO THAT GASPING
3 PATTERN. SO IT'S A RAPID BREATHING FOLLOWED BY A VERY
4 SHALLOW BREATHING FOLLOWED BY A RAPID BREATHING.
5 Q. IT'S TRUE, IS IT NOT, THAT CHEYNE-STOKES BREATHING, AS
6 YOU'VE JUST DESCRIBED IT, IS A SYMPTOM THAT YOU ASSOCIATE
7 WITH THE DEATH AND DYING PROCESS?
8 A. WELL, IT'S NOT A SYMPTOM BECAUSE A SYMPTOM IS SOMETHING
9 THAT A PATIENT COMPLAINS OF. WE'D CALL IT A SIGN.
10 Q. A SIGN?
11 A. IT'S A SIGN OF SERIOUS VASCULAR PROBLEMS, SERIOUS
12 CIRCULATORY PROBLEMS. IT ISN'T NECESSARILY ASSOCIATED WITH
13 A PATIENT WHO'S GOING TO DIE. I'VE HAD MANY PATIENTS WHO
14 HAD CHEYNE-STOKES BREATHING WHO RECOVERED VERY NICELY. BUT
15 IT'S A WORRISOME SIGN.
16 Q. AND CERTAINLY WHEN YOU SAW THE OBTUNDEDNESS THAT YOU
17 TESTIFIED TO IN CONJUNCTION WITH THIS BREATHING PATTERN IN
18 NOVEMBER OF 1995, YOU WERE FEARFUL THAT PERHAPS MISS SMITH
19 WAS TERMINAL?
20 A. YES. I THOUGHT SHE MAY HAVE ONLY A FEW DAYS AT THAT
21 TIME.
22 Q. AND DO YOU KNOW IN THE HOSPITAL THEY HAVE A CODE. IT'S
23 CALLED AN N.C.R.?
24 A. YES.
25 Q. DO YOU KNOW WHAT THAT IS?
609
1 A. REFERS TO NO CARDIAC RESUSCITATION.
2 Q. AND DO YOU KNOW AT THE TIME OF THESE EVENTS IN NOVEMBER
3 OF 1995 IF A DISCUSSION ENSUED WITH LYDIA'S FAMILY
4 CONCERNING AN N.C.R.?
5 A. MY MEMORY IS THEY DID NOT WANT ANY HEROIC ISSUES, BUT I
6 DON'T REMEMBER A SPECIFIC DISCUSSION.
7 Q. YOU WERE NOT THE PHYSICIAN WHO WAS INVOLVED IN THOSE
8 DISCUSSIONS?
9 A. I DON'T REMEMBER THAT DISCUSSION, AT LEAST NOT AT THAT
10 TIME.
11 Q. YOU REMEMBER THERE WAS SOME DISCUSSION ABOUT THIS, BUT
12 YOU DON'T HAVE ANY RECOLLECTION OF THE SPECIFICS?
13 A. YES. SHE WAS NINETY YEARS OLD AND HAD VERY POOR HEALTH,
14 AND TO MY MEMORY THE FAMILY DID NOT WANT HEROICS TO TRY AND
15 PROLONG HER LIFE.
16 Q. AND WHEN YOU USE THE TERM HEROICS, CAN YOU TELL US,
17 PLEASE, WHAT YOU MEAN WHEN YOU USE THE TERM HEROICS?
18 A. SHOCKING THE HEART, PUMPING ON THE HEART TO TRY TO GET
19 IT TO BEAT AGAIN, PUTTING PEOPLE ON LIFE SUPPORT MACHINES.
20 VENTILATOR, FOR EXAMPLE, TO BREATHE FOR THE PATIENT. THOSE
21 ARE HEROICS.
22 Q. NOW DOCTOR, YOU TESTIFIED ABOUT SOME MEDICATIONS THAT
23 LYDIA WAS ON DURING THE TIME THAT YOU TOOK CARE OF HER. AND
24 I'M SPECIFICALLY REFERRING TO -- I BELIEVE YOU TOLD US THAT
25 HALDOL WAS ONE THAT YOU TRIED.
610
1 A. YES.
2 Q. WAS THIS BEFORE THE STROKE OR AFTER THE STROKE?
3 A. I THINK IT WAS AFTER THE STROKE.
4 Q. AND HALDOL IS AN ANTIPSYCHOTIC MEDICATION?
5 A. IT IS.
6 Q. AND IT'S TRUE, IS IT NOT, THAT HALDOL IS --
7 THE COURT: COULD YOU EXPLAIN TO THE JURY WHAT
8 ANTIPSYCHOTIC MEANS.
9 MR. STIRBA: THANK YOU, YOUR HONOR.
10 Q. PLEASE EXPLAIN.
11 A. ANTIPSYCHOTIC MEDICATIONS ARE USED TO HELP PEOPLE WHO
12 ARE DELUSIONAL, WHO MAY BE HALLUCINATING, WHO ARE CONFUSED
13 OR DISORIENTED OR ACTING ON PERCEPTIONS THAT MAY NOT BE
14 REAL. SO ANTIPSYCHOTIC PATIENTS, FOR EXAMPLE, MAY FEEL
15 THINGS ARE HAPPENING TO THEM THAT ARE NOT REALLY HAPPENING
16 AND THEIR BEHAVIOR IS THEREFORE RELATED. AND ANTIPSYCHOTIC
17 MEDICATIONS AS A RULE ARE SEDATING, CALMING, AND IF USED IN
18 HIGH ENOUGH DOSES CAN ACTUALLY MAKE PEOPLE UNCONSCIOUS.
19 Q. AND WHEN YOU SAY SEDATING, ARE YOU MEANING THAT IT HAS A
20 PHARMACOLOGY QUALITY SUCH THAT IT AFFECTS THE CENTRAL
21 NERVOUS SYSTEM?
22 A. THAT'S CORRECT.
23 Q. AND DEPRESSES IT?
24 A. YES.
25 Q. AND WOULD THE SAME BE TRUE OF SERZONE?
611
1 A. NO.
2 Q. IS THAT ALSO A SEDATING MEDICATION?
3 A. SERZONE IS AN ANTIDEPRESSANT THAT DOES NOT HAVE
4 ANTIPSYCHOTIC PROPERTIES AND IS MILDLY SEDATING. BUT PEOPLE
5 CAN STILL DRIVE CARS AND GO TO WORK WHEN THEY ARE ON
6 SERZONE. IT IS NOT REALLY CONSIDERED A SEDATIVE.
7 Q. IT IS NOT?
8 A. IT IS NOT.
9 Q. YOU SAID IT'S AN ANTIDEPRESSANT. PERHAPS YOU COULD
10 EXPLAIN TO US THE DIFFERENCE BETWEEN AN ANTIPSYCHOTIC AND
11 ANTIDEPRESSANT.
12 A. ANTIDEPRESSANTS ARE MOOD ELEVATORS FOR SOMEONE WHO'S
13 SAD, DISCOURAGED, APATHETIC, FATIGUED. WAYS OF SORT OF
14 REVVING UP THEIR EMOTIONAL SYSTEM. FOR PEOPLE THAT HAVE
15 FEELINGS OF DEPRESSION OR HOPELESSNESS OR EVEN SUICIDAL
16 THOUGHTS. THESE CAN HELP TO RESTORE A BALANCE IN THEIR
17 THINKING. BUT DEPRESSED PEOPLE AS A RULE ARE NOT
18 DELUSIONAL. THEY ARE NOT PSYCHOTIC. THEY ARE VERY WELL
19 ORIENTED TO REALITY. A DEPRESSED PATIENT, FOR EXAMPLE,
20 WOULD TEND TO HALLUCINATE AND WOULD RESPOND MORE TO AN
21 ANTIDEPRESSANT THAN AN ANTIPSYCHOTIC.
22 Q. IS IT TRUE THAT, FOR EXAMPLE, WITH THE HALDOL, ONE OF
23 THE REASONS WHY YOU WERE PRESCRIBING IT WAS IN AN ATTEMPT TO
24 GAIN CONTROL OVER LYDIA'S BEHAVIOR?
25 A. YES. SHE WAS -- SHE WAS VERY AGGRESSIVE AND COMBATIVE
612
1 AND IT WAS IN AN ATTEMPT TO PROTECT HER AND TO PROTECT OTHER
2 RESIDENTS AND THE STAFF.
3 Q. AND IS IT TRUE THAT ONE OF THE PROPERTIES; THAT IS, THE
4 SEDATING PROPERTY IS ONE OF THE BENEFITS OF THAT DRUG IN
5 TERMS OF CONTROLLING BEHAVIOR?
6 A. YES.
7 Q. IN OTHER WORDS, THE SEDATING QUALITY HELPS TO CONTROL
8 THE BEHAVIOR THAT WAS IMPROPER?
9 A. THAT'S CORRECT.
10 Q. AND THEN YOU MENTIONED ATIVAN. WOULD YOU TELL US WHAT
11 KIND OF MEDICATION ATIVAN IS?
12 A. ATIVAN WOULD PROBABLY BE CALLED A TRANQUILIZER OR A
13 NERVE PILL BY MOST LAY PEOPLE. IT'S A CALMING OR A SEDATING
14 MEDICATION SIMILAR TO VALIUM. IT DOESN'T HAVE ANTIPSYCHOTIC
15 PROPERTIES. IT DOESN'T HAVE ANTIDEPRESSANT PROPERTIES.
16 IT'S SIMPLY A WAY OF CALMING SOMEONE WHO IS VERY ANXIOUS OR
17 NERVOUS.
18 Q. AND IS THIS ALSO, AS YOU SAY, SEDATING MEANING THAT IT
19 HAS A DEPRESSING EFFECT ON THE CENTRAL NERVOUS SYSTEM?
20 A. YES.
21 Q. NOW, WERE -- YOU, I BELIEVE, DOCTOR, STARTED YOUR
22 TREATMENT, I THINK YOU SAID IN 1993. IS THAT ABOUT RIGHT?
23 A. THAT'S WHEN I FIRST HAD OFFICE RECORDS OF LYDIA SMITH.
24 Q. AND THEN YOU TREATED LYDIA THROUGH 1995; IS THAT RIGHT?
25 A. THAT'S RIGHT.
613
1 Q. AND ARE YOU AWARE DURING THAT TIME PERIOD OF OTHER
2 HOSPITAL ADMISSIONS BY HER AT THE LAKEVIEW HOSPITAL?
3 A. I THINK SHE HAD HER GALL BLADDER REMOVED IN JUNE OF
4 1995. I THINK SHE MAY HAVE BEEN ADMITTED A FEW TIMES IN
5 1993 FOR CARDIAC TESTS FOR EVALUATION OF CHEST PAIN AND SO
6 FORTH.
7 MR. STIRBA: THANK YOU, DOCTOR. THAT'S ALL I HAVE.
8 THE COURT: ANYTHING FURTHER FOR THIS WITNESS?
9 REDIRECT EXAMINATION
10 BY MR. WILSON:
11 Q. DOCTOR, COUNSEL ASKED YOU A NUMBER OF QUESTIONS ON
12 CROSS-EXAMINATION DEALING WITH CORONARY HEART DISEASE AND
13 CONGESTIVE HEART FAILURE. I WOULD LIKE SOME CLARIFICATION.
14 DID YOU INDICATE IN YOUR DIAGNOSIS OR IN RESPECT TO LYDIA
15 SMITH THAT SHE HAD CORONARY HEART DISEASE?
16 A. YES, SHE DID.
17 Q. AND CAN YOU DESCRIBE FOR US OR DO YOU HAVE AN OPINION AS
18 TO THE DEGREE OR SEVERITY OF THAT CORONARY HEART DISEASE?
19 A. I READ THE CATH REPORT YESTERDAY -- A CATH IS AN
20 ANGIOGRAM A CARDIOLOGIST DOES TO TAKE PICTURES OF THE
21 CORONARIES. I REMEMBER SHE HAD TWO SIGNIFICANT LESIONS IN
22 HER CORONARY ARTERIES. I THINK ONE WAS 75 PERCENT NARROWING
23 AND ONE WAS AN 80 PERCENT NARROWING. THIS WAS IN 1993.
24 Q. THIS WAS IN 1993?
25 A. THAT'S RIGHT.
614
1 Q. WHEN WAS THE VALVE REPLACEMENT?
2 A. I DON'T KNOW. I THINK THAT HAPPENED BEFORE SHE WAS MY
3 PATIENT.
4 Q. OKAY. NOW, DID YOU -- YOU ALSO TALKED ABOUT THE HEART
5 LEAKING AS TO WHETHER OR NOT THAT WOULD CAUSE THE DEATH OF
6 AN INDIVIDUAL. DID YOU NOTE ANYTHING ABOUT HER --
7 A. NO. HER VALVE FUNCTION SEEMED TO BE GOOD. I NEVER HAD
8 ANY REASON TO SUSPECT VALVE MALFUNCTION.
9 Q. OKAY. IN RESPECT TO THE CONGESTIVE HEART FAILURE THAT
10 YOU DIAGNOSED, I'M HAVING A LITTLE BIT OF DIFFICULTY
11 UNDERSTANDING THIS. IN TERMS OF CONGESTIVE HEART FAILURE,
12 IS THAT A NUMBER OF FACTORS DEALING WITH THE HEART?
13 A. THERE ARE DIFFERENT THINGS THAT CAN CAUSE CONGESTIVE
14 HEART FAILURE. THE BOTTOM LINE OR THE COMMON DENOMINATOR IS
15 FLUID RETENTION, WHICH I THINK IS WHY WE USE THE WORD
16 CONGESTIVE. PATIENTS' LUNGS TEND TO BE FILLED WITH FLUID OR
17 CONGESTED WITH FLUID BECAUSE THE HEART ISN'T MOVING THE
18 FLUID THROUGH ADEQUATELY.
19 Q. SO WHEN YOU SAY A PATIENT HAS CONGESTIVE HEART FAILURE,
20 WHAT DOES THAT MEAN.
21 A. IT MEANS THEIR PUMP IS NOT KEEPING UP WITH ITS LOAD.
22 Q. OKAY. DO YOU HAVE AN OPINION AS TO WHAT TYPE OF OR WHAT
23 SEVERITY OR DEGREE OF CONGESTIVE HEART FAILURE LYDIA SMITH
24 HAD AT THIS PARTICULAR TIME?
25 A. I WOULD CLASSIFY HERS AS MILD AND RELATIVELY STABLE. AS
615
1 I REVIEW MY NOTES I DON'T SEE THAT WE MADE A LOT OF
2 MEDICATION ADJUSTMENTS TO HER DIURETIC DOSE OR CONGESTIVE
3 HEART FAILURE MEDICATION. SHE WAS KEPT PRETTY MUCH ON THE
4 SAME HEART REGIMEN THROUGHOUT THE TIME THAT I TOOK CARE OF
5 HER.
6 Q. NOW, ON THE NOVEMBER HOSPITALIZATION WITH THE STROKE,
7 WAS THERE AN INDICATION IN THE MEDICAL RECORDS OF ANY
8 ARRHYTHMIA?
9 A. NO.
10 Q. DO YOU HAVE ANY INDICATION THAT IN YOUR REVIEW OF YOUR
11 RECORDS THAT LYDIA SMITH EVER SUFFERED FROM ANY ARRHYTHMIA?
12 A. NO.
13 Q. THERE WAS A NUMBER OF QUESTIONS ALSO ASKED ABOUT
14 CHEYNE-STOKES RESPIRATIONS, AND I THINK YOU ELABORATED FOR
15 THE JURY THAT THERE COULD BE A VARIETY OF CAUSES THAT WOULD
16 CREATE A SCENARIO OF THAT SORT WHERE A PERSON WOULD EXHIBIT
17 THOSE SIGNS.
18 A. THAT'S CORRECT.
19 Q. WOULD A -- COULD A DEPRESSION OF THE CENTRAL NERVOUS
20 SYSTEM RESULT IN CHEYNE-STOKES RESPIRATIONS?
21 A. THE TWO SCENARIOS WHERE I SEE CHEYNE-STOKES MOST OFTEN
22 ARE IN SEVERE HEART DISEASE OR IN SEVERE NEUROLOGIC INJURY.
23 Q. OKAY. NOW, DID I UNDERSTAND YOU TO SAY A SEDATIVE DOES
24 HAVE A DEPRESSING EFFECT ON THE RESPIRATORY SYSTEM?
25 A. YES. I DON'T KNOW IF I SAID THAT, BUT THEY DO.
616
1 MR. WILSON: I HAVE NO FURTHER QUESTIONS, YOUR
2 HONOR.
3 MR. STIRBA: I HAVE A FEW MORE, YOUR HONOR.
4 RECROSS-EXAMINATION
5 BY MR. STIRBA:
6 Q. THAT OCCLUSION THAT YOU TALKED ABOUT BASED UPON THE
7 REVIEW OF THE ANGIOGRAM I THINK YOU SAID 75 PERCENT IN ONE
8 AND 80 PERCENT IN THE OTHER.
9 A. YES.
10 Q. THAT'S A SERIOUS OCCLUSION, IS IT NOT?
11 A. THAT WOULD BE CONSIDERED MODERATELY SERIOUS.
12 Q. IN FACT, THAT WAS CERTAINLY SIGNIFICANT ENOUGH THAT IT
13 CONFIRMS YOUR DIAGNOSIS OF CORONARY ARTERY DISEASE; IS THAT
14 RIGHT?
15 A. ABSOLUTELY.
16 Q. NOW, IT'S TRUE, IS IT NOT, THAT AN ARRHYTHMIA IS
17 ESSENTIALLY AN EVENT THAT OCCURS, NOT NECESSARILY
18 ANATOMICAL, BUT IT'S PHYSIOLOGICAL?
19 A. IT'S AN ELECTRICAL EVENT.
20 Q. IT'S TRUE, IS IT NOT, THAT IT'S ONLY GOING TO BE
21 DIAGNOSED BASED UPON THE CLINICAL ASSESSMENT CONSIDERING A
22 NUMBER OF DIFFERENT FACTORS?
23 A. WELL, I'M SURE THERE ARE PEOPLE IN THIS ROOM HAVING
24 ARRHYTHMIAS RIGHT NOW AND THEY DON'T KNOW IT. YOU WOULD
25 HAVE TO HAVE A HEART MONITOR HOOKED UP TO DETECT THOSE KINDS
617
1 OF THINGS. A SERIOUS OR LIFE-THREATENING ARRHYTHMIA CAN BE
2 DIAGNOSED BECAUSE THE PATIENT LOSES CONSCIOUSNESS.
3 Q. AND CERTAINLY CONGESTIVE HEART FAILURE, AS YOU JUST
4 INDICATED, MAY BE A PRECURSOR TO ARRHYTHMIA OR ARRHYTHMIC
5 EVENT; IS THAT TRUE?
6 A. THAT'S TRUE.
7 Q. AND CERTAINLY THAT ARRHYTHMIC EVENT COULD BE THE CAUSE
8 OF ONE'S SUDDEN DEATH; IS THAT TRUE?
9 A. THAT'S TRUE.
10 Q. IT'S TRUE, IS IT NOT, THERE WAS AN E.K.G. DONE WHEN
11 LYDIA WAS ADMITTED TO LAKEVIEW IN NOVEMBER OF 1995?
12 A. THAT WOULD HAVE BEEN ROUTINE.
13 Q. COULD YOU PLEASE TELL US WHAT THAT TEST IS?
14 A. ELECTROCARDIOGRAM IS JUST AN ELECTRICAL WAY OF LOOKING
15 AT THE HEART FROM SEVERAL DIFFERENT ANGLES. WE DETERMINE
16 FROM THE ELECTROCARDIOGRAM WHETHER THERE IS ANY STRAIN ON
17 THE HEART OR WHETHER RHYTHM IS REGULAR. WE CAN ALSO
18 ESTIMATE THE SIZE OF THE HEART CHAMBERS FROM LOOKING AT AN
19 E.K.G. AND WE WOULD SEE ARRHYTHMIA ON THAT TEST IF IT WERE
20 PRESENT.
21 Q. NOW, HAVE YOU REVIEWED THAT PARTICULAR TEST RESULT FOR
22 PURPOSES OF COMING HERE THIS AFTERNOON?
23 A. I FLIPPED THROUGH IT, BUT I DIDN'T LOOK AT IT IN DETAIL.
24 Q. LET ME JUST INDICATE WHAT IT SAYS. FIRST, THE TOP HAS
25 SINUS ARRHYTHMIA WITH FREQUENT -- I THINK IT'S TACKS. DO
618
1 YOU KNOW WHAT THAT IS IN REFERENCE TO THE TEST?
2 A. SINUS ARRHYTHMIA WITH FREQUENT P.A.B. THOSE ARE
3 PREMATURE ATRIAL BEATS THAT HAPPEN WHEN A HEART IS
4 IRRITABLE.
5 Q. CONSIDER LEFT ATRIAL ABNORMALITY. DO YOU KNOW WHAT THAT
6 MEANS IN REFERENCE TO THIS TEST?
7 A. PROBABLY REFERRING TO A POSSIBLY ENLARGED LEFT ATRIUM.
8 Q. THEN HAS I.V. CONDUCTION DEFECT OF RIGHT BUNDLE BRANCH
9 BLOCK TYPE. PROBABLE SEPTAL INFARCTION, AGE UNDETERMINED.
10 A. THE RIGHT BUNDLE BRANCH BLOCK IS AN ELECTRICAL
11 PHENOMENON WHERE THE ELECTRICAL IMPULSE HAS TO TAKE A
12 DIFFERENT ROUTE BECAUSE THE NATURAL TRACT IS IMPAIRED FOR
13 SOME REASON. IT'S A FAIRLY COMMON FINDING IN
14 ELECTROCARDIOGRAMS IN ELDERLY PEOPLE, NOT NECESSARILY
15 ASSOCIATED WITH A SERIOUS PROBLEM. THE PREVIOUS SEPTAL
16 INFARCTION MEANS THAT THERE IS AN ELECTRICAL SEGMENT OR
17 ELECTRICAL BUMP THAT IS MISSING FROM THE E.K.G. AND SUGGESTS
18 THAT THIS PATIENT MAY HAVE HAD A HEART ATTACK AT SOME POINT
19 IN THE PAST. E.K.G. CAN'T TELL YOU WHEN IT WAS. IT COULD
20 HAVE BEEN MONTHS PRIOR OR TEN YEARS PRIOR TO THE E.K.G.
21 Q. THEN IT GOES ON TO SAY, INFERIOR AND LATERAL S.T. DASH
22 T. CHANGES.
23 A. THAT IS JUST A REFERENCE TO SOME NON-SPECIFIC CHANGES
24 THAT DON'T REALLY DIAGNOSIS ANYTHING. IT JUST MEANS THEY
25 WERE NOT COMPLETELY NORMAL.
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1 Q. AND THEN IT SAYS, STRONGLY SUGGEST MYOCARDIAL INJURY
2 SLASH ISCHEMIA. THEN HAS VERSUS L.V.H.E. STRAIN?
3 A. THOSE S.T. AND T. WAVE CHANGES COULD SUGGEST THAT THE
4 HEART IS UNDER SOME SORT OF STRAIN. IT COULD BE UNDER THAT
5 KIND OF A STRAIN BECAUSE IT'S ENLARGED. IT COULD BE UNDER
6 THAT KIND OF A STRAIN BECAUSE THE PATIENT IS HAVING A HEART
7 ATTACK OR HAVING ISCHEMIA WHICH IS THE PRECURSOR TO A HEART
8 ATTACK.
9 Q. AND THEN IT SAYS, SUMMARY, ABNORMAL. THEN GOES ON TO
10 SAY WARNING, DATA QUALITY MAY AFFECT INTERPRETATION. IT IS
11 ABNORMAL E.K.G. WOULD THAT BE CONSISTENT WITH WHAT I JUST
12 READ TO YOU? THAT WOULD BE A FINDING?
13 A. YES.
14 MR. STIRBA: THANK YOU. THAT'S ALL I HAVE.
15 MR. WILSON: NO FURTHER QUESTIONS.
16 THE COURT: THANK YOU VERY MUCH. MAY THIS WITNESS
17 BE EXCUSED.
18 MR. WILSON: WE WOULD ASK HE BE EXCUSED.
19 MR. STIRBA: THAT'S FINE.