Sharon Weinstein, MD
3 IF YOU'LL RAISE YOUR RIGHT HAND AND BE SWORN, PLEASE.
4 SHARON WEINSTEIN,
5 BEING FIRST DULY SWORN, WAS EXAMINED AND
6 TESTIFIED AS FOLLOWS:
7 THE COURT: JUST BE SEATED, PLEASE. IF YOU'LL COME
8 OVER HERE AND HAVE A SEAT.
9 IF YOU'LL STATE YOUR FULL NAME AND SPELL YOUR LAST NAME,
10 PLEASE.
11 THE WITNESS: MY NAME IS SHARON WEINSTEIN. THAT'S
12 W-E-I-N-S-T-E-I-N.
13 THE COURT: THANK YOU. YOU MAY PROCEED,
14 MS. ISAACSON.
15 DIRECT EXAMINATION
16 BY MS. ISAACSON:
17 Q. DR. WEINSTEIN, WHAT IS YOUR OCCUPATION?
18 A. I'M A PHYSICIAN. I'M A NEUROLOGIST.
19 Q. WHAT IS A NEUROLOGIST?
20 A. A NEUROLOGIST IS A DOCTOR WHO SPECIALIZES IN NERVOUS
21 SYSTEM DISORDERS, AND CONDITIONS AFFECTING THE BRAIN,
22 SPINAL CORD AND NERVES.
23 Q. AND WHERE ARE YOU PRESENTLY EMPLOYED?
24 A. EMPLOYED BY THE UNIVERSITY OF UTAH. I'M ON THE FACULTY
25 THERE. I DIRECT THE PAIN MEDICINE AND PALLIATIVE CARE
1 PROGRAM FOR THE HUNTSMAN CANCER INSTITUTE, AND ALSO FOR THE
2 VETERAN'S AFFAIRS MEDICAL CENTER HOSPITALS AND CLINICS.
3 Q. AND ARE YOU BOARD CERTIFIED?
4 A. YES, I AM.
5 Q. AND WHAT IS THAT BOARD CERTIFICATION?
6 A. I'M CERTIFIED AS A NEUROLOGIST BY THE AMERICAN BOARD OF
7 PSYCHIATRY AND NEUROLOGY. I ALSO HAVE A CERTIFICATE OF ADDED
8 QUALIFICATION IN PAIN MANAGEMENT FROM THE AMERICAN BOARD OF
9 PSYCHIATRY AND NEUROLOGY. AND I'M BOARD CERTIFIED BY THE
10 AMERICAN BOARD OF HOSPICE AND PALLIATIVE MEDICINE IN HOSPICE
11 AND PALLIATIVE MEDICINE.
12 Q. I PROMISE THAT I'M GETTING YOU SOME WATER.
13 A. THANK YOU.
14 Q. (BY MS. ISAACSON) WE'VE BEEN FIGHTING WITH THAT
15 MICROPHONE. IF YOU COULD GET JUST A LITTLE BIT CLOSER, BUT
16 NOT TOO CLOSE.
17 PRIOR TO YOUR WORK AT THE HUNTSMAN CANCER INSTITUTE AND
18 AT THE VETERANS' ADMINISTRATION HOSPITAL, WHAT OTHER WORK
19 EXPERIENCE HAVE YOU HAD?
20 A. I SPENT NINE YEARS AT THE UNIVERSITY OF TEXAS, M.D.
21 ANDERSON CANCER CENTER IN HOUSTON FOLLOWING MY TRAINING.
22 Q. AND DO I RECALL CORRECTLY THAT YOU'VE WORKED AT THE
23 MEMORIAL SLOAN-KETTERING CANCER CENTER IN NEW YORK?
24 A. I DID A FELLOWSHIP IN PAIN MEDICINE THERE.
25 Q. AND WHEN WAS THAT?
1 A. THIS WAS IN 1990.
2 Q. AND WHAT IS THAT CANCER CENTER, FOR THOSE WHO AREN'T
3 FAMILIAR WITH IT?
4 A. MEMORIAL SLOAN-KETTERING CANCER CENTER IS AFFILIATED WITH
5 CORNELL UNIVERSITY AND IS REPUTED AS ONE OF THE WORLD'S
6 LEADING CANCER CENTERS.
7 Q. CURRENTLY, THIS YEAR, 2002, WHAT'S YOUR DAY-TO-DAY WORK
8 LIKE?
9 A. I SEE PATIENTS NEARLY EVERY DAY. I PROVIDE 24 HOURS A
10 DAY, SEVEN DAYS A WEEK SERVICE COVERAGE FOR BOTH OF MY
11 PRACTICES. AND THAT INVOLVES SUPERVISING, OUT-PATIENT VISITS
12 FOR ABOUT 70 PATIENTS A WEEK. I ALSO HAVE AT ANY GIVEN TIME
13 5 TO 10 INPATIENTS IN EITHER HOSPITAL. WE ALSO SUPERVISE A
14 FAIR AMOUNT OF HOME CARE IN BOTH OF THOSE PROGRAMS THAT
15 INCLUDES HOSPICE CARE.
16 Q. AND SO IN YOUR DAY-TO-DAY WORK, DO YOU TREAT DYING
17 PATIENTS?
18 A. YES, I DO.
19 Q. AND AT THE HUNTSMAN CANCER INSTITUTE I ASSUME THOSE
20 PATIENTS ARE PRIMARILY CANCER PATIENTS?
21 A. THEY ARE PRIMARILY CANCER PATIENTS, BUT NOT EXCLUSIVELY.
22 Q. DO YOU TREAT PATIENTS WITH DEMENTIA?
23 A. YES, I DO.
24 Q. AND DO YOU TREAT PATIENTS WITH ADVANCED STAGE DEMENTIA?
25 A. YES, I DO.
1 Q. HAVE YOU PUBLISHED ARTICLES IN PEER REVIEW PUBLICATIONS?
2 A. YES.
3 Q. AND WHAT KIND OF THINGS, JUST GENERALLY, HAVE YOU WRITTEN
4 ABOUT?
5 A. I'VE WRITTEN ABOUT PAIN, ITS ASSESSMENT IN PEOPLE WHO
6 HAVE COMMUNICATION DIFFICULTIES, THE EVALUATION OF SIDE
7 EFFECTS OF MEDICATIONS, AND THE COMPLEX DRUG TREATMENT OF
8 PAIN AND OTHER SYMPTOMS, ESPECIALLY IN DYING PATIENTS.
9 Q. AND HAVE YOU CONDUCTED CLINICAL RESEARCH TRIALS?
10 A. YES.
11 Q. WHAT SORT OF TOPICS HAVE YOU RESEARCHED IN THAT AREA THAT
12 WOULD BE RELEVANT TO OUR DISCUSSION TODAY?
13 A. THE ASSESSMENT AND PREVENTION OF PAIN, AND THE
14 PHARMACOKINETICS AND PHARMACODYNAMICS OF PAIN-RELIEVING
15 DRUGS, PARTICULARLY NARCOTICS OR OPIOID ANALGESICS. AND I'VE
16 ALSO STUDIED PHYSICIANS' PRESCRIBING PRACTICES AND MEDICAL
17 STUDENTS ATTITUDES TOWARDS PRESCRIBING PRACTICES.
18 Q. YOU USED TWO TERMS, PHARMOCOKINETICS -- DID I SAY
19 THAT RIGHT?
20 A. PHARMACOKINETICS.
21 Q. PHARMACOKINETICS. AND WHAT WAS THE OTHER TERM?
22 A. PHARMACODYNAMICS.
23 Q. WHAT DO THOSE TWO TERMS MEAN?
24 A. PHARMACOKINETICS ARE THE -- THE ACTUAL MEASUREMENTS OF
25 THE DRUG EFFECTS IN THE PHYSIOLOGIC TERMS, THAT IS WHAT
1 HAPPENS TO THE DRUG WHEN IT GET INTO THE BODY, HOW IT IS
2 CIRCULATED AND HOW IT IS FINALLY BROKEN DOWN AND ELIMINATED.
3 AND PHARMACODYNAMICS ARE THE EFFECTS THAT WE CAN OBSERVE
4 SUCH AS PAIN RELIEF.
5 Q. NOW, IN THIS CASE HAVE YOU REVIEWED THE MEDICAL RECORDS
6 FROM THE GEROPSYCHIATRIC UNIT FOR ALL FIVE OF THE PATIENTS?
7 A. YES, I HAVE.
8 Q. WITH REGARD TO THE FIVE PATIENTS INVOLVED IN THIS CASE,
9 HOW WOULD YOU CHARACTERIZE THEIR LEVEL OF DEMENTIA?
10 A. SEVERE.
11 Q. DO YOU TREAT AND SEE PATIENTS WITH DEMENTIA AT THIS
12 SEVERITY?
13 A. YES.
14 Q. WE'VE -- WE'VE HEARD A LOT IN THE TRIAL ABOUT DIFFERENT
15 CAUSES OF DEMENTIA OR DIFFERENT TYPES OF DEMENTIA. WHAT KIND
16 OF DEMENTIA DID YOU SEE IN THE RECORDS WITH -- WITH REGARD TO
17 THESE PATIENTS?
18 A. THE TWO MOST COMMON TYPES WOULD BE ALZHEIMER-TYPE
19 DEMENTIA AND MULTI-INFARCT DEMENTIA.
20 Q. AND DID YOU SEE EVIDENCE IN THESE PATIENTS OF ONE OR BOTH
21 OF THOSE?
22 A. YES.
23 Q. OKAY. LET'S GO -- WE'VE FOUND SOME SLIDES THAT SHOW --
24 SHOW BRAINS; IS THAT RIGHT?
25 A. YES.
1 Q. NORMAL BRAINS AND -- AND BRAINS THAT ARE AFFECTED BY
2 DEMENTIA?
3 A. YES.
4 Q. JUST TO HELP VISUALIZE WHAT WE'VE BEEN TALKING ABOUT FOR
5 A COUPLE OF WEEKS, COULD YOU EXPLAIN, FIRST OF ALL, TO THE
6 JURY WHAT WE'RE SEEING HERE -- FIRST OF ALL, WHAT TYPE OF
7 DEMENTIA ARE WE TALKING ABOUT AND WHAT ARE WE SEEING IN THE
8 BRAIN?
9 A. THESE PICTURES WOULD SHOW ON THE TOP A NORMAL BRAIN, AND
10 ON THE BOTTOM A BRAIN THAT IS SEVERELY WASTED OR ATROPHIED.
11 AND THAT FINDING OF -- A KIND OF WHAT WE CALL A GLOBAL
12 ATROPHY OR A -- OR A TOTAL WASTING OF THE BRAIN IS OFTEN SEEN
13 IN ALZHEIMER DEMENTIA.
14 Q. AND SO IN THIS PARTICULAR CASE, WE'RE SEEING THE
15 DIFFERENCE BETWEEN A NORMAL BRAIN AND AN ALZHEIMER AFFECTED
16 BRAIN?
17 A. RIGHT. THIS IS AN ALZHEIMER DISEASE BRAIN ON THE BOTTOM.
18 Q. OKAY. WOULD YOU MIND STEPPING DOWN AND JUST POINTING OUT
19 TO THE -- TO THE JURY SOME OF THE DIFFERENCES THAT YOU SEE?
20 A. WHAT YOU WOULD OBSERVE IN THE NORMAL BRAIN TISSUE AND THE
21 SPACES IN BETWEEN, HERE YOU CAN SEE VERY THIN SPACES BETWEEN
22 THE MASSES OF BRAIN TISSUE, AND DOWN HERE YOU SEE THE CRACKS
23 ARE MUCH WIDER. THAT INDICATES THAT THE BRAIN TISSUE HAS
24 SHRUNK. SO THE WHOLE BRAIN IS SMALLER, BUT YOU CAN ALSO SEE
25 THE PARTICULAR PARTS THAT HAVE SHRIVELED, ESPECIALLY HERE AND
1 HERE AND PROBABLY IN HERE (INDICATING).
2 Q. AND ALTHOUGH -- AND -- AND THE SYMPTOMS THAT WE'VE SEEN
3 IN THIS CASE, THE BEHAVIORS THAT YOU SEE IN THE RECORDS,
4 HOW -- HOW IS THAT DAMAGE CAUSING THOSE BEHAVIORS? WHAT'S
5 HAPPENING IN THE BRAIN?
6 A. WHAT HAPPENS AS THE HIGHER PARTS OF THE BRAIN OR THE
7 CORTEX, WHICH IS THE SURFACE OF THE BRAIN THAT WE'RE LOOKING
8 AT, AS THAT DEGENERATES THEN PATIENTS BECOME -- OR PEOPLE
9 BECOME MORE PRIMITIVE IN THEIR BEHAVIORS. AND SO THEY WILL
10 BE UNABLE TO PERFORM THE USUAL KINDS OF MENTAL ACTIVITIES,
11 AND THEN AS THE CONDITION PROGRESSES, EVEN THE MORE PRIMITIVE
12 PHYSICAL ACTIVITIES OF SELF-CARE.
13 AND FINALLY IN THE ADVANCED STAGES, PATIENTS WILL BE
14 MORE DIFFICULT TO FEED. THEY HAVE BEHAVIORS THAT ARE CALLED
15 FEEDING AVERSIVE; THAT IS, THEY WILL REFUSE TO ACCEPT FOOD OR
16 FLUIDS OR MEDICATIONS. THEY MAY TRY TO REMOVE THINGS FROM
17 THEIR BODY, AND BE UNABLE TO WALK OR MOVE THEIR LIMBS
18 NORMALLY, BE ABLE TO MANAGE THE SIMPLE TASKS OF LIFTING UP A
19 FORK OR KNOWING WHAT TO DO WITH A COMB OR BRUSH, THOSE TYPES
20 OF THINGS.
21 Q. I THINK OUR NEXT SLIDE SHOWS ANOTHER ALZHEIMER
22 AFFECTED -- ALZHEIMERS AFFECTED BRAIN. WHAT'S THE LEVEL OF
23 SEVERITY COMPARED TO WHAT WE SAW BEFORE?
24 A. THIS WOULD BE A MORE SEVERELY ATROPHIC OR WASTED BRAIN.
25 AGAIN, YOU CAN SEE THE DEEP CRACKS THROUGHOUT THE BRAIN
1 INDICATING THAT THE BRAIN TISSUE HAS SHRUNK AWAY.
2 Q. I BELIEVE WE ALSO HAVE A SLIDE THAT SHOWS THE OTHER TYPE
3 OF DEMENTIA THAT YOU MENTIONED. AND I THINK WE'VE HEARD TWO
4 DIFFERENT TERMS, VASCULAR OR MULTI-INFARCT DEMENTIA. ARE
5 THOSE BOTH ACCURATE TERMS?
6 A. YES.
7 Q. AND WHAT ARE THOSE -- WE'VE HEARD GENERALLY WHAT THAT
8 MEANS. COULD YOU DESCRIBE FOR US WHAT -- WHAT CAUSES THIS
9 TYPE OF DEMENTIA?
10 A. MULTIPLE STROKES. THE TERM MULTI-INFARCT MEANS MULTIPLE
11 STROKES. AND STROKES ARE CAUSED BY THE DEATH OF BRAIN
12 TISSUE, THAT IS EITHER NOT ENOUGH BLOOD TO THAT PART OF THE
13 BRAIN OR AN ACTUAL BLEEDING OR HEMORRHAGE. AND IN THIS
14 BRAIN -- SHOULD I STEP DOWN?
15 Q. SURE. AND, OF COURSE, THE OTHER PICTURE WE SAW WAS --
16 WAS THE PHOTOGRAPH OF THE OUTSIDE OF THE BRAIN, AND THIS IS
17 A CROSS-SECTION --
18 A. THIS IS A -- THIS IS A CUT SLICE, AND YOU CAN SEE ON THIS
19 PART WHERE ONE STROKE HAS OCCURRED AND THE BRAIN TISSUE IS --
20 IS LITERALLY DEAD. AND YOU CAN SEE THAT IF THERE WERE MORE
21 THAN ONE STROKE LIKE THAT, DIFFERENT PARTS OF THE BRAIN ARE
22 BEING LOST. SO THIS WOULD BE A SINGLE STROKE EVENT. BUT IN
23 A MULTI-INFARCT DEMENTIA MANY STROKES FINALLY ACCUMULATE AND
24 THE EFFECT IS AS IF THERE IS NO BRAIN TISSUE THEN LEFT TO
25 FUNCTION.
1 Q. WHAT DOES THE TERM TERMINAL MEAN?
2 A. WE USE THE WORD TERMINAL TO DESCRIBE A CONDITION FOR
3 WHICH THERE IS NO KNOWN CURE AND FROM WHICH WE EXPECT THE
4 PERSON TO DIE.
5 Q. AND WERE THESE PATIENTS TERMINAL?
6 A. YES.
7 Q. NOW, YOU'VE REVIEWED THE RECORDS AS TO HOW THESE PATIENTS
8 PRESENTED AT THE TIME OF ADMISSION. WHAT WOULD YOUR GENERAL
9 APPROACH HAVE BEEN IF YOU WERE PRESENTED WITH THESE TYPE OF
10 PATIENTS ON ADMISSION?
11 A. I WOULD EVALUATE THEM CLINICALLY, AND ALSO REVIEW THE
12 ADVANCE DIRECTIVES THAT WERE IN PLACE. AND THEN ESTABLISH
13 THE GOALS OF COMFORT CARE AND CARRY OUT TREATMENTS TO ACHIEVE
14 THE GOALS OF COMFORT CARE.
15 Q. DO YOU BELIEVE THAT THAT APPROACH WAS DONE IN EACH OF
16 THESE CASES?
17 A. YES.
18 Q. ARE YOU FAMILIAR WITH MORPHINE?
19 A. YES.
20 Q. DO YOU USE IT IN YOUR PRACTICE?
21 A. YES.
22 Q. HAVE YOU STUDIED ITS EFFECTS?
23 A. I HAVE.
24 Q. IS IT APPROPRIATE TO USE TO TREAT PAIN?
25 A. YES.
1 Q. IS IT APPROPRIATE FOR USE WHEN PEOPLE ARE DYING?
2 A. YES.
3 MS. BARLOW: OBJECTION, YOUR HONOR. THESE ARE
4 LEADING QUESTIONS.
5 THE COURT: THEY ARE.
6 Q. (BY MS. ISAACSON) YOU MENTIONED THAT YOU DO WORK WITH
7 BOTH CANCER PATIENTS AND OTHER DYING PATIENTS. IS MOR -- IS
8 MORPHINE SOMETHING THAT CAN BE USED FOR ANYONE AT THE END OF
9 LIFE?
10 A. YES.
11 Q. AND IS IT APPROPRIATE -- IS IT -- IS IT ONLY APPROPRIATE
12 FOR USE WITH CANCER PATIENTS?
13 A. NO.
14 Q. AND DO YOU USE IT IN NONCANCER PATIENTS?
15 A. YES.
16 Q. ROUTINELY?
17 A. YES.
18 MS. BARLOW: OBJECTION. THESE ARE LEADING
19 QUESTIONS.
20 THE COURT: SUSTAINED. MS. ISAACSON, THAT'S AS FAR
21 AS WE'LL GO WITH THOSE.
22 MS. ISAACSON: I'LL TRY TO BE BETTER, YOUR HONOR. I
23 WILL BE BETTER.
24 Q. (BY MS. ISAACSON) DO YOU PRESCRIBE PSYCHOTROPICS IN YOUR
25 PRACTICE?
1 A. PSYCHOTROPIC MEDICATIONS? YES.
2 Q. YES. AND YOU'RE FAMILIAR WITH THE PSYCHOTROPICS THAT
3 WERE USED IN THIS CASE?
4 A. YES.
5 Q. LET'S TALK A LITTLE BIT ABOUT VITAL SIGNS. WHAT ARE
6 VITAL SIGNS?
7 A. VITAL SIGNS ARE THE MEASUREMENTS OF THE BODY FUNCTIONS
8 THAT ARE ESSENTIAL TO LIFE.
9 Q. AND WHAT VITAL SIGNS WERE CHARTED IN EACH OF THESE CASES?
10 A. THE BLOOD PRESSURE, PULSE, RESPIRATION AND TEMPERATURE.
11 Q. AND WHEN YOU LOOK AT A PATIENT'S VITAL SIGNS, CAN YOU --
12 FROM THOSE VITAL SIGNS -- IDENTIFY DRUG EFFECTS?
13 A. YES.
14 Q. AND WITH REGARD TO MORPHINE AND PSYCHOTROPICS THAT WERE
15 USED IN THIS CASE, HOW DO THEY AFFECT VITAL SIGNS?
16 A. THE DRUGS THAT WERE USED IN THESE PATIENTS CAN HAVE
17 CENTRAL NERVOUS SYSTEM DEPRESSANT EFFECTS. AND HOW THAT IS
18 FIRST OBSERVED IN A PATIENT IS -- IS A CHANGE IN THE MENTAL
19 STATUS OF THE PATIENT; THAT IS, THE PATIENT WOULD BECOME MORE
20 SLEEPY OR LESS ALERT. AND SUBSEQUENTLY, A SLOW DECLINE IN
21 THE RESPIRATORY RATE AND A -- AND A SLOW LOWERING OF THE
22 BLOOD PRESSURE, THAT WOULD MATCH THE DRUG PHARMACOKINETICS OR
23 THAT IS THE EFFECTS OF THE DRUG IN THE BODY PHYSICALLY.
24 Q. AND HOW DOES PULSE FACTOR IN?
25 A. THE PULSE RATE WOULD ALSO GO DOWN PREDICTABLY.
1 Q. SO DO YOU HAVE TRAINING AND EXPERIENCE IN HOW VITAL SIGNS
2 RELATE TO DOSAGES OF MORPHINE?
3 A. YES, I DO.
4 Q. IF SOMEONE HAD BEEN OVERMEDICATED OR OVERDOSED WITH
5 PSYCHOTROPICS OR MORPHINE, WHAT WOULD YOU EXPECT TO SEE WITH
6 REGARD TO THE VITAL SIGNS THAT WERE TAKEN IN THIS CASE?
7 A. DEPENDING ON THE TIME COURSE OF ACTION OF EACH DRUG, WE'D
8 EXPECT TO SEE MATCHED THOSE EFFECTS, THAT IS A GRADUAL
9 SLEEPINESS, LOWERING OF THE BLOOD PRESSURE, PULSE AND
10 RESPIRATORY RATE ACCORDING TO THE TIMING OF THE ONSET OF
11 ACTION OF THE DRUG.
12 Q. LET'S TALK SPECIFICALLY ABOUT THE PATIENTS IN THIS CASE.
13 I'LL START WITH ELLEN ANDERSON.
14 THE COURT: ELLEN?
15 MS. ISAACSON: ELLEN ANDERSON.
16 THE COURT: YES.
17 Q. (BY MS. ISAACSON) LET'S GO TO -- WELL, LET ME -- LET ME
18 START ACTUALLY BEFORE WE GO TO THE CHART, JUST GENERALLY
19 WE'VE HEARD A LOT ABOUT THE SYMPTOMS THAT WERE RECORDED IN
20 THE -- IN THE NURSING NOTES. DID YOU REVIEW WHAT THE NURSES
21 CHARTED OVER THE COURSE OF THE NIGHT THAT ELLEN ANDERSON WAS
22 THERE ON THE UNIT?
23 A. YES, I DID.
24 Q. AND WHAT -- WHAT DID YOU SEE IN THAT CHARTING THAT
25 INDICATED TO YOU WHETHER OR NOT THIS WOMAN WAS IN PAIN?
1 A. THE NURSES CHARTED THAT THE PATIENT WAS CRYING AND
2 SCREAMING.
3 Q. BASED UPON YOUR EXPERIENCE, IS IT -- IS THAT A SIGN OF
4 PAIN?
5 A. THAT CAN BE A PAIN BEHAVIOR.
6 Q. AND WHAT IS YOUR ASSESSMENT ABOUT WHETHER OR NOT THIS
7 PATIENT, ELLEN ANDERSON, WAS IN PAIN ON THE NIGHT OF HER STAY
8 AT THE UNIT?
9 MS. BARLOW: YOUR HONOR, I'M GOING TO OBJECT. I
10 THINK THIS IS CUMULATIVE. WE'VE HEARD IT FROM SOME OTHER
11 WITNESSES.
12 THE COURT: IT IS, BUT IT MAY BE A FOUNDATION FOR
13 WHAT THIS WITNESS IS GOING TO TESTIFY ABOUT. SO I'LL
14 OVERRULE THE OBJECTION.
15 CAUTION COUNSEL NOT TO BE REPETITIVE.
16 MS. ISAACSON: I'LL TRY NOT TO, YOUR HONOR.
17 A. I'M SORRY. WOULD YOU REPEAT THE QUESTION?
18 Q. (BY MS. ISAACSON) BASED -- MAYBE WE CAN GO THROUGH THE
19 VITAL SIGNS, GO THROUGH THE MEDICATIONS, AND THEN WE'LL COME
20 BACK TO THAT FINAL -- THAT FINAL QUESTION. LET'S GO TO
21 STATE'S 2-C, MED-190. YOU'VE -- YOU'VE REVIEWED THESE
22 NURSING NOTES?
23 A. YES, I HAVE.
24 Q. AND THIS IS THE FIRST NURSING NOTE FROM THE FIRST SHIFT
25 ON MS. ANDERSON'S STAY; IS THAT RIGHT?
1 A. I BELIEVE SO. ARE WE IN THE MIDDLE SECTION OF THAT PAGE
2 YOU JUST SHOWED?
3 Q. I THINK WE ARE. I THINK WE ARE.
4 A. YES. THAT IS -- THAT IS THE SHIFT NOTE.
5 Q. NOT TO BELABOR THE POINT, BUT BASED UPON WHAT YOU
6 REVIEWED HERE, THE NURSE'S NOTE OF SEVERE PAIN, PATIENT
7 SCREAMS, RIGID WHEN TOUCHED, AND A NOTE THAT MORPHINE WAS
8 PRESCRIBED VIA TELEPHONE ORDER, DO YOU HAVE AN OPINION AS TO
9 WHETHER OR NOT THAT WAS AN APPROPRIATE ORDER, GIVEN THE
10 SYMPTOMS?
11 A. I BELIEVE THAT WAS AN APPROPRIATE ORDER.
12 Q. NOW, WE GO TO THE SAME EXHIBIT, PAGE 191. I'M SORRY,
13 LET'S GO BACK. I'M TRYING TO BE ORGANIZED, BUT I'M HAVING A
14 HARD TIME.
15 OKAY. SO WE'VE TALKED ABOUT THE APPROPRIATENESS OF THE
16 ORDER. WHEN YOU'RE ADMINISTERING MORPHINE, WHEN YOU'RE
17 ADMINISTERING A PAIN MEDICATION, HOW DO YOU DECIDE OR HOW DO
18 YOU EVALUATE WHETHER OR NOT A DOSAGE WAS APPROPRIATE?
19 A. RELY ON THE OBSERVATION OF THE NURSES, IF I'M NOT
20 PHYSICALLY PRESENT WITH THE PATIENT AT THE TIME. AND SEE
21 WHAT THE PATIENT'S RESPONSE IS TO THE DOSE, AGAIN, EXPECTING
22 WHAT THE TIME COURSE OF ACTION OF THAT DOSE WILL BE. AND
23 THEN NOTING WHEN IT WEARS OFF.
24 Q. AND IN THIS NOTE THERE'S AN INDICATION THAT THE PATIENT
25 WAS CALMER TWO HOURS AFTER THE -- THE FIRST INJECTION. WHAT
1 DOES THAT SIGNIFY DO YOU?
2 A. THAT WOULD SIGNIFY TO ME THAT DURING THE EXPECTED TIME
3 COURSE OF ACTION OF PAIN RELIEF OF THAT DRUG THAT THAT
4 PATIENT WAS AT THAT TIME EXPERIENCING PAIN RELIEF.
5 Q. WE HAVE HEARD OF THE TERM PEAK EFFECT AND DURATION OF
6 EFFECT. WHAT IS THE PEAK EFFECT FOR MORPHINE?
7 MS. BARLOW: OBJECTION. THIS IS CUMULATIVE, YOUR
8 HONOR?
9 THE COURT: SUSTAINED. THEY KNOW IT AS WELL AS
10 MAYBE THIS WITNESS AT THIS POINT.
11 Q. (BY MS. ISAACSON) LET'S GO -- LET'S GO TO THE NEXT NOTE
12 191. AT THE TOP HERE -- I DON'T KNOW IF I HAVE A -- I DO.
13 SO THE -- WE CAN TALK ABOUT THE FIRST DOSE OF MORPHINE AT
14 APPROXIMATELY 7:30 OR 8 O'CLOCK. AND THEN THERE'S A NOTE FOR
15 1 O'CLOCK. WHAT IS -- WHAT DOES ERRATIC RESPIRATIONS SIGNIFY
16 TO YOU?
17 A. ERRATIC RESPIRATIONS ARE A PART OF WHAT WE CALL THE
18 AGONAL PROCESS, THAT IS THE PROCESS IN WHICH THE PATIENT IS
19 APPROACHING DEATH. AND YOU CAN SEE THERE THE RATE WAS
20 RANGING QUITE CONSIDERABLY. THAT HAS BEEN DESCRIBED OR
21 TERMED CHEYNE-STOKES RESPIRATIONS.
22 Q. AND SO AT 1 O'CLOCK, AT LEAST -- I GUESS FIVE HOURS HAD
23 PASSED SINCE THE INITIAL DOSE?
24 A. FIVE TO SIX HOURS.
25 Q. WOULD YOU EXPECT -- NUMBER ONE, DOES MORPHINE CAUSE
1 ERRATIC BREATHING?
2 A. IT DOES NOT.
3 Q. AND SO THE NOTE ABOUT ERRATIC BREATHING WOULD HAVE NO
4 CORRELATION -- EXCUSE ME. WHAT -- DOES THE -- DOES THE
5 ERRATIC NOTE HAVE ANYTHING TO DO WITH THE ADMINISTRATION OF
6 MORPHINE, IN YOUR EXPERIENCE?
7 A. NO.
8 Q. AND IS THE RANGE OF RESPIRATIONS IN THE NORMAL RANGE?
9 A. IT IS.
10 Q. IF -- IF THIS PATIENT WERE RESPONDING TO THE MORPHINE,
11 WOULD YOU EXPECT TO SEE A PULSE IN THAT RANGE AT 1:20?
12 A. NO.
13 Q. WHAT ABOUT THE TIMING OF THIS RESPONSE?
14 A. I WOULD SAY THESE VITAL SIGNS WERE RECORDED AFTER THE
15 DOSE HAD ALREADY WORN OFF.
16 Q. SO IS IT YOUR OPINION -- WHAT IS YOUR OPINION ABOUT
17 WHETHER OR NOT MORPHINE WAS ACTUALLY EVEN IN MS. ANDERSON'S
18 SYSTEM AT ONE 1 A.M.?
19 A. WE COULD HAVE MEASURED BREAK-DOWN PRODUCTS AND PROBABLY
20 SOME OF THE PARENT DRUG MORPHINE STILL AT THAT TIME.
21 Q. AND THEN AT 3:15 THERE ARE SOME MORE SYMPTOMS NOTED. IN
22 YOUR MIND -- IN YOUR EXPERIENCE, WHAT IS THE SIGNIFICANCE OF
23 THE NOTING OF THESE SYMPTOMS OF THRASHING ARMS AND MOANING
24 AND SCREAMING AT 3:15?
25 A. I WOULD HAVE INTERPRETED THAT AS A SIGN THAT THE PATIENT
1 WAS EXPERIENCING PAIN AGAIN SINCE BY THEN THE PHARMACODYNAMIC
2 EFFECT OF THE DRUG WOULD HAVE COMPLETELY WORN OFF.
3 Q. BASED UPON THE VITAL SIGNS THAT WE SEE AT 1 A.M.
4 RECORDED, DO YOU HAVE AN OPINION TO A DEGREE OF REASONABLE
5 MEDICAL CERTAINTY AS TO WHETHER OR NOT THIS PATIENT WAS
6 SUFFERING FROM A MORPHINE OVERDOSE AT 1 A.M.?
7 A. I DO HAVE AN OPINION.
8 Q. AND WHAT IS THAT OPINION?
9 A. I DO NOT BELIEVE THE PATIENT WAS EXPERIENCING THE EFFECTS
10 OF A MORPHINE OVERDOSE AT THAT TIME.
11 Q. AND THEN AT 3:30, ANOTHER 10 MILLIGRAMS IS -- IS GIVEN;
12 IS THAT RIGHT?
13 A. THAT'S CORRECT.
14 Q. NOW, THIS IS IN THE SAME EXHIBIT 173. APPARENTLY AN
15 E.K.G. WAS PERFORMED. DOES THAT SOUND FAMILIAR WITH REGARD
16 TO THIS PATIENT?
17 A. YES.
18 Q. AND AT WHAT TIME DID THAT TAKE PLACE?
19 A. THAT WAS RECORDED AT ABOUT 5:20 IN THE MORNING.
20 Q. NOW, THIS IS REALLY HARD FOR EVERYONE TO SEE, BUT THE
21 SECOND DOSE HAS BEEN GIVEN AT 3:30. AND WHAT ARE THE
22 RESULTS -- WHAT DO WE SEE HERE AT 5:20, ALMOST TWO HOURS
23 LATER?
24 A. THIS IS A MECHANICAL READOUT WITH THE INTERPRETATION
25 THAT'S DONE BY THE E.K.G. MACHINE.
1 Q. AND -- AND HOW WOULD THAT HAVE BEEN DONE?
2 A. A TECHNICIAN HAS THE E.K.G. MACHINE ON A CART AND COMES
3 TO THE PATIENT'S BEDSIDE AND APPLIES THE E.K. -- WHAT WE CALL
4 THE E.K.G. LEADS WHICH ARE THE WIRES TO THE PATIENT'S LIMBS
5 AND MEASURES THE HEART RECORDING. AND THAT IS AUTOMATICALLY
6 PRINTED OUT ON A PAPER STRIP. AND THIS IS A PORTION OF THE
7 PAPER STRIP.
8 THE MACHINE ALSO INTERPRETS THE MEASUREMENTS OF THE
9 E.K.G. AND -- AND THE WORDING THERE IS THE -- IS THE
10 INTERPRETATION OF THE E.K.G. RHYTHM OR THE HEART RHYTHM.
11 Q. AND SO WHAT -- WHAT DO THESE WORDS HERE MEAN?
12 A. THAT SAYS SINUS TACHYCARDIA WITH MARKED SINUS ARRHYTHMIA.
13 SO THE ELECTRICAL SYSTEM OF THE HEART IS NOW NOT WORKING
14 EFFECTIVELY. THE PATIENT'S HAVING A FAST HEART RATE AND ALSO
15 AN IRREGULAR HEART RATE.
16 Q. NUMBER ONE, IS THE HIGH -- DID YOU SAY HEART RATE?
17 A. HEART RATE.
18 Q. IS THAT CONSISTENT WITH AN OVERDOSE OF MORPHINE?
19 A. NO.
20 Q. HOW ABOUT THE HEART ARE ARRHYTHMIA? CAN THAT BE CAUSED
21 BY MORPHINE?
22 A. NO.
23 Q. WHAT IS THAT CAUSED BY?
24 A. WELL, THAT MAY BE A CONDITION THAT THE PATIENT HAS
25 ACQUIRED OVER TIME. THAT MAY BE AGE RELATED.
1 Q. DO YOU SEE ANY EVIDENCE IN THE VITAL SIGNS OR IN THE
2 E.K.G. OF A MORPHINE OVERDOSE OF ELLEN ANDERSON?
3 A. I DO NOT.
4 Q. WOULD YOU EXPECT TO SEE -- WELL, STRIKE THAT.
5 WAS IT A BREACH OF THE STANDARD OF CARE, IN YOUR
6 OPINION, TO A REASONABLE DEGREE OF MEDICAL CERTAINTY FOR
7 DR. WEITZEL TO ADMINISTER MORPHINE TO THIS PATIENT?
8 A. NO.
9 Q. WHAT ABOUT THE AMOUNT OF MORPHINE? WAS THAT A BREACH OF
10 THE STANDARD OF CARE?
11 A. NO.
12 Q. DO YOU HAVE AN OPINION TO A DEGREE OF REASONABLE MEDICAL
13 CERTAINTY AS TO WHETHER MORPHINE CONTRIBUTED TO OR CAUSED THE
14 DEATH OF ELLEN ANDERSON?
15 A. I HAVE AN OPINION.
16 Q. WHAT IS THAT OPINION?
17 A. IS THAT THE MORPHINE DID NOT CAUSE OR CONTRIBUTE TO THE
18 DEATH OF THIS PATIENT.
19 Q. DO YOU RECALL THE TIME THAT MS. ANDERSON PASSED AWAY?
20 A. I BELIEVE IT WAS ABOUT EIGHT IN THE MORNING.
21 Q. AND WITH REGARD TO THE DURATION OF THE EFFECT OF
22 MORPHINE, WHAT IS YOUR OPINION ABOUT WHAT THE LEVEL OR -- OR
23 THE DURATION OF THE MORPHINE WOULD HAVE BEEN IN THAT PATIENT
24 AT THAT TIME?
25 A. AGAIN, THAT WOULD HAVE BEEN AFTER THE EXPECTED DURATION
1 OF ACTION OF THE DRUG, AND IT WOULD HAVE ALREADY WORN OFF.
2 Q. LET'S TALK ABOUT JUDITH LARSEN. I WON'T HAVE YOU LIST
3 THEM, BUT DID YOU SEE THINGS IN THE MEDICAL RECORDS THAT
4 WOULD GIVE SUPPORT OR THAT WOULD SUGGEST TO YOU THAT THIS WAS
5 A PATIENT WHO WOULD SUFFER FROM PAIN?
6 A. YES.
7 Q. I WANT TO FOCUS AGAIN WITH HER ON THE VITAL SIGNS ISSUE.
8 WITH REGARD TO ELLEN ANDERSON, THERE WERE NO PSYCHOTROPIC
9 DRUGS ACTUALLY ADMINISTERED TO HER; IS THAT RIGHT?
10 A. OTHER THAN MORPHINE, YES.
11 Q. OKAY. AND WE'VE HEARD TALK THAT THE PSYCHOTROPIC DRUGS
12 CAN BE CENTRAL NERVOUS SYSTEM DEPRESSANTS; IS THAT RIGHT?
13 A. THAT'S CORRECT.
14 Q. AND SO WOULD YOU EXPECT -- WHAT WOULD YOU EXPECT TO SEE
15 IF THERE WAS AN OVERDOSE OF PSYCHOTROPIC MEDICATIONS -- IN
16 THE VITAL SIGNS?
17 A. AGAIN, DEPENDING ON THE SPECIFIC DRUG ADMINISTERED, THOSE
18 EFFECTS THAT I'VE DESCRIBED AS BEING THE EFFECTS OF THE
19 CENTRAL NERVOUS SYSTEM DEPRESSION WOULD OCCUR GRADUALLY IN
20 ACCORDANCE WITH THE PHARMACOKINETICS OF THAT DRUG.
21 Q. AND SO YOU WOULD SEE -- WHAT WERE THEY AGAIN? PULSE?
22 A. THE -- THE SLOWING OF THE PULSE AND RESPIRATORY RATE, AND
23 LOWERING OF THE BLOOD PRESSURE.
24 Q. OKAY. AND JUST GENERALLY, HAVE YOU REVIEWED THE VITAL
25 SIGNS FOR JUDITH LARSEN OVER THE COURSE OF HER STAY?
1 A. YES, I HAVE.
2 Q. AND DID YOU SEE ANY DEPRESSION OF THOSE VITAL SIGNS
3 CONSISTENT WITH OVERMEDICATION OF PSYCHOTROPICS?
4 A. I DID NOT.
5 Q. LET'S GO TO JANUARY 9TH AND 10TH. LET'S GO TO STATE'S
6 3-B, MED-491. AND THIS IS -- WHAT DOES THIS GRAPHIC CHART
7 REPRESENT?
8 A. THE GRAPHIC CHART IS WHERE THE VITAL SIGNS ARE RECORDED
9 IN A CONTINUOUS FASHION. AND FOR THE TEMPERATURE AND THE
10 PULSE, THOSE LINES ARE CONNECTED BETWEEN THE DOTS AT WHICH
11 THE TIME THOSE MEASUREMENTS ARE TAKEN.
12 Q. AND LET'S -- WHY DON'T I HAVE YOU STEP DOWN FOR A MOMENT,
13 DOWN BY THIS CHART. THIS IS STATE'S EXHIBIT 3-H AND THIS IS
14 A SUMMARY CHART OF THE MEDICATIONS THAT WERE GIVEN --
15 PSYCHOTROPIC MEDICATIONS THAT WERE GIVEN TO JUDITH LARSEN.
16 AND WHY DON'T WE FOCUS ON DECEMBER 9TH AND 10TH ARE TWO DAYS
17 WHERE WE SAW PROBABLY THE HIGHER LEVELS OF -- OF PSYCHOTROPIC
18 GIVEN. DOES THAT -- DOES THAT LOOK RIGHT?
19 A. YES.
20 Q. WHY DON'T WE GO NOW TO THE GRAPHIC CHART ON THE 9TH AND
21 10TH AND I'LL BLOW THAT UP SO WE CAN ALL SEE A LITTLE BIT
22 BETTER. IF THERE WAS AN OVERDOSE, IF THERE WAS ON
23 OVERMEDICATION OF PSYCHOTROPICS, WHAT WOULD YOU EXPECT TO SEE
24 HERE ON THESE DAYS?
25 A. AGAIN, WE WOULD SEE A LOWERING OF THE PULSE AND
1 RESPIRATORY RATE AND A FALL IN THE BLOOD PRESSURE.
2 Q. I DON'T KNOW IF ANY -- EVERYONE CAN SEE THESE VERY WELL,
3 BUT WILL YOU STEP DOWN AND TALK A LITTLE BIT ABOUT WHAT YOU
4 SEE HERE AS FAR AS RESPIRATIONS?
5 SO ON THE 9TH AND 10TH, I THINK THERE'S A PERIOD HERE
6 FOR SOME REASON THERE'S NOT VITALS, BUT --
7 A. MISSED A SHIFT IN HERE.
8 Q. SO STARTING HERE ON A DAY WHERE -- WHERE WE HAVE ONE OF
9 THE HIGHER LEVELS OF PSYCHOTROPICS, WHAT -- WHAT DO YOU SEE
10 WITH REGARD TO BLOOD PRESSURE AND RESPIRATIONS?
11 A. THOSE ARE STILL IN THE NORMAL RANGE.
12 Q. HOW ABOUT THE PULSE?
13 A. IN THE NORMAL RANGE.
14 Q. AND DO THESE ALL -- THROUGHOUT THESE DAYS, DO YOU SEE ANY
15 DEVIATION FROM THE NORMAL RANGE?
16 A. NO.
17 Q. AGAIN, IF THE IDEA IS IF YOU'RE BEING OVERMEDICATED, YOU
18 WOULD EXPECT TO SEE A GRADUAL LOWERING --
19 MS. BARLOW: OBJECTION. LEADING, YOUR HONOR.
20 THE COURT: SUSTAINED.
21 MS. ISAACSON: SORRY.
22 Q. (BY MS. ISAACSON) LET'S TALK ABOUT THE VITAL SIGN
23 RESPONSES TO MORPHINE. LET'S TALK ABOUT, SPECIFICALLY, THE
24 LAST FEW DAYS OF MRS. LARSEN'S LIFE. FIRST, WITH REGARD TO
25 MRS. LARSEN, DO YOU BELIEVE OR DO YOU HAVE AN OPINION TO A
1 REASONABLE DEGREE OF MEDICAL CERTAINTY AS TO WHETHER THE
2 ADMINISTRATION OF MORPHINE IN HER CASE WAS APPROPRIATE?
3 A. I HAVE AN OPINION.
4 Q. AND WHAT IS THAT OPINION?
5 A. THAT THE ADMINISTRATION OF MORPHINE WAS APPROPRIATE IN
6 HER CASE.
7 Q. AND WHY WAS IT APPROPRIATE IN HER CASE?
8 A. WELL, WE DID SEE SOME DOCUMENTATION IN HER RECORD THAT
9 HER CONDITION ACTUALLY IMPROVED WITH THE ADMINISTRATION OF
10 MORPHINE.
11 Q. AND WHEN -- WHEN WOULD THAT HAVE BEEN?
12 A. NURSING DOCUMENTED THAT SHE WAS DOING MUCH BETTER -- AND
13 I THINK IT'S PAGE NUMBER 565. THE NURSE DOCUMENTED THAT HER
14 LEVEL OF ALERTNESS IMPROVED AFTER THE ADMINISTRATION OF
15 MORPHINE, AND SHE WAS MORE OF A PARTICIPANT IN THE GROUP
16 ACTIVITY.
17 Q. I THINK I CAN GO TO THAT PAGE. THIS IS, AGAIN, THE
18 SAME -- THIS IS JUDITH LARSEN WHO IS STATE'S 3-B, MED-565.
19 AND IT LOOKS LIKE THE DATE OF THIS WAS DECEMBER 25TH, RIGHT
20 HERE.
21 AND THE RESPONSE NOTED WAS THAT THERE WAS A POSITIVE
22 RESPONSE TO THE -- THE MORPHINE?
23 A. YES.
24 Q. AND DID YOU SEE A SEDATING OR ANY SORT OF EVIDENCE OF
25 C.N.S. DEPRESSION IN THAT NOTE?
1 A. NO.
2 Q. WHAT WAS RECORDED WITH REGARD TO HER ALERTNESS OR HER
3 MENTAL STATUS?
4 A. THE NOTE READS THE PATIENT'S LEVEL OF ALERTNESS WAS
5 INCREASING THROUGHOUT THE MORNING AND CONTINUING THROUGHOUT
6 THE SHIFT. AND ALTHOUGH THE PATIENT WAS NOT SPEAKING, SHE
7 WATCHED THE MOVIE AND REMAINED AWAKE -- REMAINED AWAKE AND
8 ALERT.
9 Q. AND IS THIS WITH MULTIPLE DOSES OF MORPHINE?
10 A. THAT WAS FOLLOWING THE ADMINISTRATION OF 2 MILLIGRAMS
11 I.M. THREE TIMES.
12 Q. HOW WOULD YOU INTERPRET HER RESPONSE TO THE MORPHINE?
13 A. THAT I WOULD INTERPRET AS A PAIN-RELIEVING RESPONSE AND
14 THE PATIENT WAS BETTER ABLE TO ATTEND TO THE STIMULI IN HER
15 ENVIRONMENTAL BECAUSE SHE WAS NOT AFFECTED BY THE PAIN.
16 Q. AND THEN AT A CERTAIN POINT DURING HER STAY, WAS MORPHINE
17 AGAIN ADMINISTERED?
18 A. YES, IT WAS.
19 Q. FIRST WITH REGARD TO THE -- THE MORPHINE THAT WAS
20 ADMINISTERED ON THE LAST FEW DAYS, DO YOU HAVE AN OPINION AS
21 TO WHETHER THE ADMINISTRATION WAS APPROPRIATE AT THAT TIME?
22 A. YES, I HAVE AN OPINION.
23 Q. AND WHAT IS THAT OPINION?
24 A. THAT IT WAS AN APPROPRIATE ADMINISTRATION OF MORPHINE.
25 Q. AND WHAT WAS THE PURPOSE AT THAT TIME?
1 A. TO RELIEVE HER PAIN.
2 Q. LET'S LOOK AT STATE'S 3-B, MED-495. THESE ARE HER VITAL
3 SIGNS FOR HER LAST DAY, JANUARY 3RD. AND, AGAIN, THIS IS THE
4 SAME SORT OF GRAPHIC WE LOOKED AT BEFORE AND I'LL BLOW IT UP
5 SO IT'S A LITTLE BIT EASIER FOR THE JURY TO SEE. AND, AGAIN,
6 THIS IS ON THE LAST DAY WHERE MORPHINE IS BEING ADMINISTERED.
7 IF -- WHAT WOULD YOU EXPECT TO SEE ON THIS CHART IF THERE
8 WERE EXCESSIVE DOSES OF MORPHINE?
9 A. GRADUAL LOWERING OF THE PULSE, RESPIRATORY RATE, AND
10 BLOOD PRESSURE.
11 Q. WHAT DO YOU SEE WITH REGARD TO THE PULSE?
12 A. SEE THE PULSE INCREASING.
13 Q. AND WHAT DO YOU SEE WITH REGARD TO THE BLOOD PRESSURE?
14 A. THAT IT'S STILL WITHIN THE NORMAL RANGE.
15 Q. AND SO BASED UPON THE VITAL SIGNS THAT YOU SEE ON THE
16 VERY LAST DAY AND WHEN MORPHINE IS BEING ADMINISTERED, DO YOU
17 HAVE AN OPINION TO A REASONABLE DEGREE OF MEDICAL CERTAINTY
18 AS TO WHETHER THERE WAS AN OVERDOSE OF MORPHINE THAT CAUSED
19 THE DEATH OF MRS. LARSEN?
20 A. I DO HAVE AN OPINION.
21 Q. AND WHAT IS THAT OPINION?
22 A. THAT THE MORPHINE DID NOT CAUSE OR CONTRIBUTE TO HER
23 DEATH.
24 Q. LET'S GO TO MARY CRANE. GENERALLY, DID YOU SEE THINGS
25 CHARTED IN THE RECORDS THAT WOULD SUGGEST TO YOU REASONS FOR
1 THIS PATIENT TO BE IN PAIN?
2 A. YES, I DID.
3 Q. LET'S TALK ABOUT THE PSYCHOTROPICS FOR HER. LET'S GO TO
4 STATE'S 4-B, MED-279. THIS IS, AGAIN, HER VITAL SIGNS CHART.
5 WE'LL JUST COMPARE IT WITH THE PSYCHOTROPICS SHE WAS BEING
6 GIVEN AT THE SAME TIME. LOOKS LIKE MAYBE DECEMBER 31ST --
7 WOULD YOU MIND STEPPING DOWN? WOULD YOU AGREE THAT MAYBE --
8 WOULD YOU PICK OUT A DAY THAT HAS ONE OF THE HIGHER LEVELS OF
9 PSYCHOTROPICS?
10 A. CERTAINLY THE 31ST OF DECEMBER OR 3RD OF JANUARY.
11 Q. AND IF THERE WERE EXCESSIVE DOSES -- IF THOSE DOSES WERE
12 EXCESSIVE, WHAT WOULD YOU EXPECT TO SEE ON THIS CHART?
13 A. I WOULD EXPECT TO SEE THE SLOWING OF THE PULSE AND
14 RESPIRATORY RATE AND THE LOWERING OF THE BLOOD PRESSURE.
15 Q. AND WHAT DO YOU SEE IN THIS -- IN THIS TIME RANGE?
16 A. ON THE 31ST OF DECEMBER HER VITAL SIGNS ARE WITHIN THE
17 NORMAL RANGE.
18 Q. THE RESPIRATION, PULSE, AND BLOOD PRESSURE?
19 A. CORRECT.
20 Q. BASED UPON THAT, BASED UPON YOUR EXPERIENCE, DO YOU HAVE
21 AN OPINION TO A REASONABLE DEGREE OF MEDICAL CERTAINTY AS TO
22 WHETHER OR NOT MRS. CRANE WAS OVERMEDICATED WITH PSYCHOTROPIC
23 MEDICATIONS?
24 A. I DO HAVE AN OPINION.
25 Q. AND WHAT IS THAT OPINION?
1 A. I BELIEVE SHE WAS NOT OVERMEDICATED WITH PSYCHOTROPIC
2 MEDICATIONS.
3 Q. LET'S MOVE ON TO THE MORPHINE AND FENTANYL THAT WAS
4 PRESCRIBED TO HER. GENERALLY, BASED UPON YOUR REVIEW, DO YOU
5 THINK THAT THE USE OF THE DURAGESIC PATCH AND THE USE OF
6 MORPHINE IN HER CASE WERE WARRANTED AND APPROPRIATE?
7 A. YES, THEY WERE.
8 Q. LET'S GO TO HER VITAL SIGNS. THIS WILL BE STATE'S 4-B AT
9 MED-280. AND IT LOOKS LIKE WE CAN -- WHAT -- WHAT DATE DOES
10 THAT GO THROUGH?
11 A. JANUARY THE 7TH.
12 Q. AND SO THAT'S THE -- THE LAST DAY? WOULD YOU MIND
13 STEPPING DOWN AGAIN? SO, AGAIN, WE SEE ON THESE LAST FEW
14 DAYS DURAGESIC AND MORPHINE?
15 A. YES.
16 Q. WHAT WOULD YOU EXPECT TO SEE ON THESE VITAL SIGNS
17 REFLECTED IN THIS CHART IF THESE LEVELS WERE EXCESSIVE OR AN
18 OVERDOSE? WHAT WOULD YOU EXPECT TO SEE UP HERE ON THIS
19 CHART?
20 A. AGAIN, THE SLOWING OF THE RESPIRATORY RATE AND PULSE AND
21 THE LOWERING OF THE BLOOD PRESSURE.
22 Q. AND -- AND WHAT DO WE SEE HERE?
23 A. THOSE VITAL SIGNS ARE MAINTAINED WITHIN THE NORMAL RANGE.
24 Q. ANY INDICATION OF OVER -- OVERDOSE FROM THOSE PAIN
25 MEDICATIONS?
1 A. NO.
2 Q. DO YOU HAVE AN OPINION TO A REASONABLE DEGREE OF MEDICAL
3 CERTAINTY AS TO WHETHER THE ADMINISTRATION OF MORPHINE,
4 FENTANYL, OR PSYCHOTROPICS CONTRIBUTED TO OR CAUSED THE DEATH
5 OF MRS. CRANE?
6 A. I DO.
7 Q. AND WHAT IS THAT OPINION?
8 A. MY OPINION IS THAT THE ADMINISTRATION OF THOSE
9 MEDICATIONS DID NOT CONTRIBUTE TO OR CAUSE HER DEATH.
10 MS. ISAACSON: AND THIS IS, FOR THE RECORD, STATE'S
11 5-E, THE MEDICAL ADMINISTRATION SUMMARY FOR LYDIA SMITH.
12 Q. (BY MS. ISAACSON) DID YOU SEE INDICATIONS IN THE RECORD
13 THAT WOULD INDICATE THAT LYDIA SMITH WAS IN PAIN?
14 A. YES.
15 Q. WAS THERE ANYTHING THAT -- AS -- AS A NEUROLOGIST THAT
16 YOU SAW IN THE -- IN THE RECORDS THAT INDICATED TO YOU HOW
17 SEVERE HER DEMENTIA WAS?
18 A. YES.
19 Q. WHAT WAS THAT, IN PARTICULAR?
20 A. HER BEHAVIORS PRIOR TO TRANSFER, AS WELL AS HER BEHAVIORS
21 FOLLOWING TRANSFER TO THE UNIT.
22 Q. WAS THERE SOMETHING THAT YOU SAW IN THE RECORDS THAT AS A
23 NEUROLOGIST THAT STOOD OUT TO YOU THAT MAYBE WOULDN'T STAND
24 OUT TO OTHER PROFESSIONALS?
25 A. YES. IN THE NURSING NOTES THERE'S A MENTION OF THE
1 PATIENT HAVING SOMETHING CALLED A SNOUT REFLEX.
2 Q. AND WHAT IS -- WHAT IS THAT?
3 A. THAT, AGAIN, IS EVIDENCE THAT THE HIGHER PARTS OF THE
4 BRAIN HAVE DEGENERATED AWAY, AND THAT IS A PRIMITIVE REFLEX.
5 WHEN ONE WOULD TRY TO FEED OR TOUCH THE PATIENT'S FACE, YOU
6 SEE A KIND OF MOVEMENT OF THE MOUTH. THAT WOULD BE, AGAIN, A
7 PRIMITIVE REFLEX THAT YOU MIGHT SEE IN A NEWBORN BABY THAT'S
8 ASSOCIATED WITH A NURSING REFLEX.
9 Q. LET'S TALK ABOUT THE MORPHINE THAT MRS. SMITH RECEIVED.
10 LET'S GO TO STATE'S 5-B, MED-734. AND IF YOU WOULDN'T MIND
11 STEPPING DOWN AGAIN, JUST SO WE'RE ALL ON THE SAME -- SAME
12 PAGE HERE. THIS -- THIS GRAPHIC UP HERE SHOWS THE LAST I
13 THINK FOUR DAYS OF HER LIFE; IS THAT RIGHT?
14 A. YEAH, UNTIL THE FIFTH DAY.
15 Q. AND ON THE LAST TWO DAYS ARE INDICATIONS THAT MORPHINE
16 WAS ADMINISTERED?
17 A. YES.
18 Q. IF THIS PATIENT WERE TO BE SUFFERING FROM A MORPHINE
19 OVERDOSE, WHAT WOULD YOU EXPECT TO SEE IN THESE VITAL SIGNS
20 HERE?
21 A. THEN WE WOULD SEE A SLOWING OF THE PULSE AND RESPIRATORY
22 RATE AND A LOWERING OF THE BLOOD PRESSURE.
23 Q. AND WHAT DO YOU SEE HERE?
24 A. I SEE THE VITAL SIGNS MAINTAINED IN THE NORMAL RANGE.
25 Q. DO YOU HAVE AN OPINION TO A REASONABLE DEGREE OF
1 MEDICAL -- MEDICAL CERTAINTY -- I'M SORRY, WE DIDN'T TALK
2 ABOUT THE -- ABOUT THE PSYCHOTROPICS. SHE IS RECEIVING
3 LEVELS OF PSYCHOTROPICS, I'M SORRY, ON ALL THESE DAYS THAT
4 ARE -- THAT ARE SHOWN UP HERE. AGAIN, SAME THING FOR THE
5 PSYCHOTROPICS AS FOR THE MORPHINE. IS THERE ANY INDICATION
6 FROM WHAT WE'VE JUST REVIEWED THAT THERE WAS AN
7 OVERMEDICATION OF PSYCHOTROPICS?
8 A. NO.
9 Q. AND DO YOU HAVE AN OPINION TO A REASONABLE DEGREE OF
10 MEDICAL CERTAINTY AS TO WHETHER THE ADMINISTRATION OF
11 MORPHINE OR PSYCHOTROPICS WERE IN EXCESSIVE DOSES AND
12 CONTRIBUTED OR CAUSED THE DEATH OF MRS. SMITH?
13 A. I HAVE AN OPINION.
14 Q. AND WHAT IS THAT OPINION?
15 A. IS THAT THE ADMINISTRATION OF PSYCHOTROPIC DRUGS AND
16 MORPHINE DID NOT CONTRIBUTE TO HER DEATH.
17 Q. FINALLY, ENNIS ALLDREDGE. AGAIN, BASED UPON YOUR REVIEW
18 OF THE RECORDS, DID HE HAVE INDICATIONS OF PAIN?
19 A. YES.
20 Q. WITH REGARD TO -- TO THIS PATIENT THERE HAS BEEN TALK
21 ABOUT AN M.R.I. THAT WAS ADMINISTERED ON THIS PATIENT. HAVE
22 YOU ACTUALLY LOOKED AT THE M.R.I. FILM IN THIS CASE?
23 A. I -- I DID.
24 Q. AND WHAT WERE YOU ABLE -- WHAT WERE YOU ABLE TO CONCLUDE
25 FROM YOUR REVIEW OF THE ACTUAL FILM?
1 A. I WOULD HAVE AGREED WITH THE RADIOLOGIST INTERPRETATION
2 THAT THERE WAS A PROBABLE STROKE.
3 Q. AND IN YOUR OPINION, WAS IT REASONABLE NOT TO ORDER
4 ANOTHER M.R.I.?
5 A. YES.
6 Q. AND WHY IS THAT?
7 A. WELL, WHENEVER WE CONSIDER ORDERING A DIAGNOSTIC TEST,
8 THAT WOULD BE TO OBTAIN INFORMATION THAT WILL HELP IN THE
9 TREATMENT OF THE PATIENT. AND AT THAT POINT IN TIME, THE
10 RESULTS OF THE M.R.I., IF THEY WERE CONCLUSIVE FOR A STROKE,
11 WOULD NOT HAVE LED TO A CHANGE IN THE THERAPEUTIC PLAN. AND
12 IN ORDER TO OBTAIN A VERY GOOD PICTURE ON THE M.R.I. SCAN, IT
13 IS MORE THAN LIKELY THAT THE PATIENT WOULD HAVE HAD TO HAVE
14 BEEN SEDATED QUITE HEAVILY OR PERHAPS EVEN GIVEN GENERAL
15 ANESTHESIA IN ORDER TO LIE STILL FOR THE M.R.I. I WOULD HAVE
16 CONSIDERED THAT AN EXCESSIVE RISK AND I MIGHT NOT HAVE BEEN
17 ABLE TO FIND AN ANESTHESIOLOGIST WILLING TO PUT THE PATIENT
18 IN THAT CONDITION UNDER GENERAL ANESTHESIA FOR THAT PURPOSE
19 OF A SCAN.
20 Q. BASED UPON WHAT DR. WEITZEL HAD KNOWN AT THAT TIME, WHAT
21 HE WAS -- WHAT HE SAW IN THE REPORT, WAS IT REASONABLE FOR
22 DR. WEITZEL TO INFORM THE FAMILY THAT MR. ALLDREDGE WAS IN
23 THE DYING PROCESS?
24 A. YES.
25 Q. QUICKLY, LET'S TRY TO GO THROUGH THE VITAL SIGNS OF
1 MR. ALLDREDGE. AND THIS IS STATE'S 6-B, MED-41. LOOKS LIKE
2 THAT'S -- THAT'S A SUMMARY FOR HIS ENTIRE STAY. WE CAN SEE
3 HERE WHAT DRUGS WERE ADMINISTERED, THE PSYCHOTROPICS AND THE
4 MORPHINE. WHAT DO WE SEE HERE WITH REGARD TO VITAL SIGNS?
5 A. WE SEE THE VITAL SIGNS ARE MAINTAINED -- ARE YOU SURE
6 THIS IS THE CORRECT EXHIBIT?
7 Q. EXCUSE ME. JANUARY 3RD.
8 A. I'M SORRY. THIS IS THE PREVIOUS PATIENT.
9 Q. SORRY. GREAT. THANK YOU.
10 A. UH-HUH. SURELY.
11 Q. OKAY. WHAT DO WE SEE WITH REGARD TO HIS VITAL SIGNS?
12 A. AGAIN, WE SEE THE VITAL SIGNS MAINTAINED HERE WITHIN THE
13 NORMAL RANGE.
14 THE COURT: CAN WE ASK YOU TO SPEAK UP, PLEASE?
15 A. SORRY. THE VITAL SIGNS ARE MAINTAINED WITHIN THE NORMAL
16 RANGE.
17 Q. (BY MS. ISAACSON) DO YOU SEE ANY INDICATION IN THESE
18 VITAL SIGN RECORDS OF OVERMEDICATION OF PSYCHOTROPIC
19 MEDICATIONS OR OF MORPHINE?
20 A. I DO NOT.
21 Q. AND IF MORPHINE CAUSED HIS DEATH, WHAT WOULD YOU EXPECT
22 TO SEE IN THIS FINAL DAY?
23 A. WE'D EXPECT TO SEE A REDUCTION OF THE PULSE RATE AND
24 RESPIRATORY RATE AND A LOWERING OF THE BLOOD PRESSURE.
25 Q. WITH REGARD TO ALL OF THESE PATIENTS, DO YOU HAVE AN
1 OPINION TO A DEGREE OF REASONABLE MEDICAL CERTAINTY THAT,
2 NUMBER ONE, IT WAS REASONABLE -- THAT IT WAS APPROPRIATE AND
3 MET THE STANDARD OF CARE FOR DR. WEITZEL TO TREAT PAIN IN ALL
4 OF THESE PATIENTS?
5 A. YES, I DO.
6 Q. AND WHAT IS THAT OPINION?
7 A. IT WAS APPROPRIATE TO TREAT PAIN IN ALL OF THESE
8 PATIENTS.
9 Q. SECOND, AFTER HAVING REVIEWED THE LEVELS OF PSYCHOTROPIC
10 MEDICATIONS AND AFTER REVIEWING THE VITAL SIGNS OF EACH OF
11 THESE PATIENTS, DO YOU HAVE AN OPINION TO A DEGREE OF
12 REASONABLE MEDICAL CERTAINTY AS TO WHETHER THE ADMINISTRATION
13 BY DR. WEITZEL OF PSYCHOTROPIC MEDICATIONS CONTRIBUTED TO OR
14 CAUSED THE DEATH OF THESE PATIENTS?
15 MS. BARLOW: OBJECTION, YOUR HONOR. IT'S BEEN ASKED
16 AND ANSWERED.
17 THE COURT: WELL, SHE HASN'T AS TO MR. ALLDREDGE, SO
18 SHE CAN ASK AS TO ALL.
19 Q. (BY MS. ISAACSON) WITH REGARD TO EVERY PATIENT,
20 INCLUDING MR. ALLDREDGE.
21 A. YES, I HAVE AN OPINION.
22 Q. AND WHAT IS THAT OPINION?
23 A. MY OPINION IS THAT THE ADMINISTRATION OF PSYCHOTROPIC
24 MEDICATIONS DID NOT CONTRIBUTE TO OR CAUSE THE DEATH IN ANY
25 OF THESE PATIENTS.
1 Q. DO YOU HAVE AN OPINION TO A DEGREE OF REASONABLE MEDICAL
2 CERTAINTY AS TO WHETHER MORPHINE CAUSED OR CONTRIBUTED TO THE
3 DEATH OF ANY OF THESE PATIENTS?
4 MS. BARLOW: OBJECTION. IT'S BEEN ASKED AND
5 ANSWERED.
6 THE COURT: NOT AS TO MR. ALLDREDGE. GO AHEAD.
7 Q. (BY MS. ISAACSON) WHAT IS -- DO YOU HAVE AN OPINION?
8 A. YES, I DO.
9 Q. AND WHAT IS THAT OPINION?
10 A. MY OPINION IS THAT THE ADMINISTRATION OF MORPHINE DID NOT
11 CONTRIBUTE TO OR CAUSE THE DEATH OF ANY OF THESE PATIENTS.
12 MS. ISAACSON: THAT'S ALL I HAVE.
13 THE COURT: LADIES AND GENTLEMEN, THAT WILL CONCLUDE
14 OUR TESTIMONY FOR TODAY.
15 DOCTOR, CAN YOU COME BACK IN THE MORNING?
16 THE WITNESS: YES, YOUR HONOR, I MAY.
17 THE COURT: WE'LL BE IN RECESS UNTIL TOMORROW
18 MORNING AT 8:30. AGAIN, REMIND YOU, LADIES AND GENTLEMEN, OF
19 MY PRIOR ADMONITION. SEE YOU BACK AT 8:30.
20 AND JUROR 8, CAN I SEE YOU FOR A FEW MOMENTS BEFORE YOU
21 LEAVE?
22 WE'LL BE IN RECESS.
23 (PROCEEDINGS CONCLUDE.)
1 November 21, 2002. State of Utah versus Dr. Robert
2 Weitzel.
3 THE COURT: Good morning, ladies and gentlemen. The
4 record should note that the parties and counsel are present.
5 The jury is in the jury box. We'll ask Dr. Weinstein to come
6 back to the stand, please. Doctor, I'll ask you to be
7 resworn for today's testimony. If you'll raise your right
8 hand.
9
10 being first duly sworn, was examined and
11 testified as follows:
12 THE COURT: If you'll have a seat there, please.
13 CROSS-EXAMINATION
14 BY MS. BARLOW:
15 Q. Good morning, Dr. Weinstein. My name is Charlene Barlow.
16 I'm one of the prosecutors in this matter. Your experience
17 is, or your expertise, is mainly in cancer pain, is that not
18 correct?
19 A. I do have expertise in cancer pain.
20 Q. In fact, most of your writings are in cancer and oncology
21 pain, is that correct?
22 A. Many are, yes.
23 Q. You talked about the vital signs yesterday. As you
24 looked through these records it was clear -- the graphs that
25 you were talking about, the vital signs were taken once every
1 12 hours, isn't that correct?
2 A. According to the nursing shifts.
3 Q. The graphs show vital signs being recorded on the graphs
4 once every 12 hours, isn't that correct?
5 A. Generally, yes.
6 Q. And if a psychotropic -- a central nervous system
7 depressant drug was given early in that 12 hours and the
8 vital signs were taken maybe after six hours, you wouldn't
9 expect to see any effect of the central nervous system
10 depressant drug in that vital sign, would you?
11 A. If the effect of the drug had already worn off, you would
12 not see its effect at the time that the vital signs
13 measurement was taken.
14 Q. Different people metabolize drugs differently, isn't that
15 correct?
16 A. Yes.
17 Q. Especially the elderly?
18 A. Yes.
19 Q. Kidney function causes metabolism of the drug to vary,
20 isn't that correct?
21 A. That is one of the factors, yes.
22 Q. And dehydration could be another factor?
23 A. Yes.
24 Q. And so a person -- even though the peak effect is
25 generally at one hour after administration of the drug, that
1 can vary based on the metabolic rate of the person who has
2 been administered the drug, isn't that correct?
3 A. There's always some variation, yes.
4 Q. And the same for the duration, the four hours?
5 A. That would be the pharmacodynamic effect. It wouldn't
6 vary as much probably as the pharmacokinetic effect.
7 Q. Thank you. You talked a little bit about the high pulse
8 rate with some of these victims that showed up on the medical
9 graphs. There are things that can cause a high pulse rate,
10 isn't that correct, medical conditions?
11 A. Many things, yes.
12 Q. For example, shock can cause a person to have a high
13 pulse rate?
14 A. Yes.
15 Q. And sometimes drugs can cause a person to go into shock,
16 isn't that correct?
17 A. I'm not -- you'd have to be more specific about what you
18 mean by shock.
19 Q. Well, shock is a condition in which the systemic blood
20 pressure is too low to maintain adequate tissue profusion?
21 In other words, not enough -- the blood pressure is so low
22 that the oxygenation is not happening in the body, is that
23 correct?
24 A. Yes. And if I may answer the question, if the blood
25 pressure falls then one of the responses to that might be a
1 faster heart rate.
2 Q. And tachycardia is what?
3 A. That's a fast heart rate.
4 Q. And some of the causes of that are pain, is that correct,
5 or pain can cause tachycardia?
6 A. Yes.
7 Q. Emotions, fear, anger or anxiety can cause a rapid heart
8 rate?
9 A. Yes.
10 Q. In fact, isn't that the adrenaline rush that people get
11 when they're in fear, that increases of the heart rate?
12 A. It can, yes.
13 Q. And elevated body temperature, i.e., someone has an
14 infection and their body temperature goes up as the body
15 fights the infection, that can cause tachycardia?
16 A. Yes.
17 Q. And a condition known as hypoxia can also cause
18 tachycardia, can it not?
19 A. Yes.
20 Q. And hypoxia is a poor oxygenation of the blood?
21 A. Correct.
22 Q. And a might be caused in the lungs -- well, let's say
23 pneumonia, can that cause a hypoxia, that the oxygen is not
24 getting into the system?
25 A. That's correct.
1 Q. A lower respiration rate, people aren't breathing, that
2 can cause hypoxia?
3 A. Yes, it can.
4 Q. Hypoxia can cause a fast heart rate, isn't that correct?
5 A. It can.
6 Q. So when some of these people had a high heart rate, it
7 could have been hypoxia, could it not?
8 A. It could have been.
9 Q. And central nervous system depressant drugs, if they're
10 overmedicated with central nervous system drugs and
11 oversedated, then they aren't breathing as well and not
12 getting as much oxygen, isn't that correct?
13 A. That can happen.
14 Q. And that can cause hypoxia?
15 A. Yes, it can.
16 Q. And that can lead to the tachycardia and to the rapid
17 pulse rate?
18 A. Yes, it can.
19 Q. Now, as far as Mr. Alldredge was concerned, you indicated
20 that you agreed with the radiologist who looked at the film
21 about what was seen on the film, is that correct?
22 A. Yes.
23 Q. And you said yesterday that the radiologist had said it
24 was a probable stroke, or C V A, isn't that correct?
25 A. That's what was written on the interpretation.
1 Q. Not to argue with you, but the word probable is found in
2 Dr. Weitzel's progress notes, but the word possible is found
3 in the radiologist report. Do you recall that?
4 A. I'm sorry, I do not recall that detail.
5 Q. Okay. Are you aware that when the radiologist, who reads
6 that report, was on the stand he said he thought the stroke,
7 if it was a stroke, was mild at best?
8 A. I was not aware of that testimony, no.
9 Q. Are you familiar with Dr. Byron Bair?
10 A. Yes, I am.
11 Q. You work at the V A hospital, not -- I shouldn't say
12 occasionally, but that's part of your duties is the V A
13 hospital?
14 A. Yes. I direct the pain medicine care program there.
15 Q. And Dr. Bair also works at the VA hospital?
16 A. I've never seen him at the hospital.
17 Q. So you don't know him from the VA hospital?
18 A. We do not work together at the VA hospital.
19 Q. Do you recall a few weeks ago calling Dr. Bair on the
20 telephone about this case?
21 A. Yes.
22 Q. You knew Dr. Bair was an expert witness for the
23 prosecution, isn't that correct?
24 A. Yes, I did.
25 Q. And you called him to inform him what the Utah medical
1 association had passed a resolution about called the criminalization
2 of medical practice?
3 A. That was not the purpose of my call.
4 Q. But you did talk to him about that resolution whether you
5 called him?
6 A. Yes, I does.
7 Q. And UMA is the Utah Medical Association?
8 A. Yes.
9 Q. Does a physician have to belong to the UMA in order to be
10 a physician in Utah?
11 A. No.
12 Q. But do most doctors in Utah belong to the organization?
13 A. I believe so.
14 Q. Okay. It's a professional organizaton just like many
15 others, is that correct?
16 A. That's correct.
17 Q. Andl in this resolution, and I believe you were on the
18 task force that drafted this resolution, isn't that correct?
19 A. I was on a blue ribbon task force for pain management for
20 the Utah Medical Association.
21 Q. And you drafted -- that task force drafted this
22 resolution for adoption?
23 A. The task force did. I did not co-author that resolution.
24 Q. But you had input in it?
25 A. Yes.
1 Q. Dr. Perry Fine have had input in it?
2 A. In that resolution he did not.
3 Q. And in this resolution, I'll just read part and and ask
4 if you agree with this. "We do not believe that the
5 professional assessment of medical competence necessary to
6 discriminate between medical incompetence and criminal
7 negligence can be judged fairly and knowledgeably before a
8 lay jury in criminal court in the manner contemplated in
9 State versus Warden, which is a Utah case. Do you agree with
10 that statement?
11 A. Yes.
12 Q. And you also -- and the resolution also says, "Lastly, we
13 believe that when a medical expert admonishes a prosecutor
14 against filing a criminal complaint, it behooves the
15 prosecutor to reconsider his position and seek the opinion of
16 the Utah Medical Association, the Physician Licensings Board,
17 or some other regularly established and constituted panel of
18 medical peers. Neither Utah's physicians nor their patients
19 can afford this type of judicial embarrassment. It is a
20 serious threat to good patient care for all Utah citizens."
21 Do you agree with that statement?
22 A. Yes, I do.
23 Q. Are you aware that prosecutors such as Mr. Wilson are
24 elected officials?
25 A. Yes.
1 Q. And they are answerable to the public in this county?
2 A. Yes.
3 Q. But the Utah Medical Association and the Physician's
4 Licensing Board are not elected officials, are they?
5 A. No.
6 Q. And they are not answerable to the people of this county?
7 A. I wouldn't agree that the Physician Licensing Board is
8 not answerable to the public.
9 Q. But to the people of this county as an elected official?
10 A. You have a different set of responsibilities than those
11 elected officials, but the Physician Licensing Board is
12 responsible for maintaining the public health and welfare.
13 Q. If a physician falls below the standard of care, there
14 may be a licensing action taken against them, isn't that
15 correct?
16 A. It would be our obligation to protects the public by
17 removing that physician's license, yes.
18 Q. Are you currently on that licensing board?
19 A. I was appointed in July of this year.
20 MS. BARLOW: Thank you, Dr. Weinstein. That's all I
21 have.
22 THE COURT: Redirect.
23 REDIRECT EXAMINATION
24 BY MS. ISAACSON:
25 Q. Dr. Weinstein, with with regard to Mr. Alldredge's MRI,
1 you actually looked at the actual film that the report relied
2 on, is that right?
3 A. That's correct.
4 Q. And so you were able to actually look at the film
5 yourself and interpret it yourself, is that right?
6 A. That's correct.
7 Q. And what was your interpretation of that film?
8 A. The film had what we call motion artifact, that is the
9 fine details of the imaging could not be discriminated when a
10 person is moving around during the time that the image is
11 taken. However, even with a blurry picture at times you can
12 discriminate abnormalities on the film. I was able to do
13 that on that picture.
14 Q. Yesterday we talked about the vital signs that we saw in
15 each one of these patients. The state's experts have
16 testified -- some of them have testified that there were
17 overdoses of psychotropic medication and of morphine. Did
18 you see anything in the vital signs that would scientifically
19 corroborate those opinions by the state's experts?
20 A. I did not.
21 Q. And why are you testifying?
22 A. After reviewing the charts, I was convinced that the care
23 that was delivered to these patients was compassionate and I
24 don't believe that Dr. Weitzel did anything wrong.
25 MS. ISSACSON: That's all I have.
1 THE COURT: Any recross?
2 MS. BARLOW: Just briefly, Your Honor.
3 RECROSS-EXAMINATION
4 BY MS. BARLOW:
5 Q. Dr. Weinstein, you're not a radiologist, is that correct?
6 A. That's correct.
7 Q. That's not your specialty?
8 A. That's correct.
9 Q. You rely upon radiologists to read MRI reports, isn't
10 that correct?
11 A. Yes. They give the expert opinion.
12 Q. And you, of course, can look at them yourself?
13 A. I routinely have looked at head images since 1986.
14 Q. And in talking about the vital signs we've indicated that
15 they were taken once every 12 hours, which is not exactly
16 once every shift, because a shift is eight hours, but twice a
17 day they were taken. If you have recorded a central nervous
18 system depressant drug for an individual, do you ask the
19 nurses to take vital signs more often to check for any side
20 effects of the depressing effects of these kinds of drugs?
21 A. Generally, if the patient has never been on any
22 medication in that class, and we are concerned with the
23 timing of the analgesic effect, we might have the analgesic
24 affect assessed when we expect the peak effect of the drug to
25 occur. I do not routinely ask them to measure vital signs.
1 Q. But if they were to see some distress in the patient that
2 might be caused by the central nerves system depressant, you
3 would expect them to look at that, would you not?
4 A. I would expect the nurses to assess the patient, yes, and
5 make a determination.
6 Q. Have you been paid for your participation in this case?
7 A. At the conclusion I will look at my hours and submit my
8 customary fee.
9 Q. And your customary fee is how much?
10 A. $300 an hour.
11 MS. BARLOW: That's all I have. Thank you.
12 FURTHE REDIRECT EXAMINATION
13 BY MS. ISAACSON:
14 Q. Whether or not vital signs were taken, or were recorded
15 once every four hours, once every eight hour or 12 hours, if
16 these patients were overdosed would you still expect to see a
17 pattern that would indicate an overdose?
18 A. It's very difficult to pick out the effect of one drug
19 when a patient is receiving many drugs; and also when their
20 physiology is as complex as it is under these circumstances.
21 So what we look for is a pattern, and in particular if the
22 effects of drugs are accumulating a sustained effect beyond
23 an individual measurement or shift. I did not see anything
24 like that in these records.
25 MS. ISSACSON: Thank you.
1 MS. BARLOW: No further questions, Your Honor.
2 THE COURT: You may step down, Doctor. May the
3 Doctor be excused?
4 MS. ISSACSON: She may.
5 MS. BARLOW: No objection.
6 THE COURT: You are excused, Doctor. Thank you for
7 testifying.