Stratton Hill, MD
1 C. STRATTON HILL,
2 CALLED AS A WITNESS, BEING FIRST DULY
3 SWORN, WAS EXAMINED AND TESTIFIED AS FOLLOWS:
4 DIRECT EXAMINATION
5 BY MR. STIRBA:
6 Q. DR. HILL, PLEASE STATE YOUR FULL NAME AND SPELL YOUR
7 LAST NAME PLEASE.
8 A. CARY STRATTON HILL, JUNIOR. H-I DOUBLE L.
9 Q. AND WHERE DO YOU RESIDE, SIR?
10 A. AT -- IN HOUSTON, TEXAS.
11 Q. AND WHAT DO YOU DO IN HOUSTON?
12 A. I'M ON THE FACULTY OF THE UNIVERSITY OF TEXAS. M.D.
13 ANDERSON CANCER CENTER.
14 Q. AND AS A FACULTY MEMBER, WHAT DO YOU DO FOR THE
15 UNIVERSITY OF TEXAS?
16 A. I TREAT PATIENTS IN PAIN.
17 Q. AND HOW LONG HAVE YOU HELD SUCH A POSITION WITH THE
18 UNIVERSITY OF TEXAS?
19 A. 37 YEARS.
20 Q. AND ARE YOU AFFILIATED WITH ANY KIND OF RESEARCH GROUP
21 IN THE AREA OF PAIN WITH THE UNIVERSITY?
22 A. YES.
23 Q. AND WOULD YOU TELL US WHAT THAT AFFILIATION IS?
24 A. WELL, IT'S CALLED THE PAIN RESEARCH GROUP. AND IT'S
25 PART OF THE CLINICAL SECTION OF THE TREATMENT OF PAIN WHICH
3577
1 IS IN THE DIVISION OF ANESTHESIOLOGY AND CRITICAL CARE.
2 Q. AND M.D. ANDERSON IS WHAT COMPONENT OF THE UNIVERSITY OF
3 TEXAS?
4 A. IT'S A STANDALONE ENTITY THAT HAS CO-EQUAL STATUS WITH
5 THE VARIOUS HEALTH SCIENCE CENTERS. FOR INSTANCE, IN
6 HOUSTON, THERE'S THE UNIVERSITY OF TEXAS HEALTH SCIENCE
7 CENTER, WHICH IS THE MEDICAL SCHOOL, THE DENTAL SCHOOL, THE
8 NURSING SCHOOL, THE SCHOOL OF PUBLIC HEALTH, AND SO FORTH.
9 AND UNIVERSITY OF TEXAS M.D. ANDERSON CANCER CENTER IS
10 CO-EQUAL IN ITS RANKING, I SUPPOSE YOU'D SAY, WITH THAT
11 PARTICULAR UNIT, BUT IT'S A CATEGORICAL INSTITUTION THAT
12 JUST TREATS CANCER PATIENTS.
13 Q. ARE YOU A MEDICAL DOCTOR?
14 A. YES.
15 Q. AND WOULD YOU TELL US PLEASE YOUR EDUCATIONAL BACKGROUND
16 IN THE FIELD OF MEDICINE?
17 A. WELL, I ATTENDED MEDICAL SCHOOL AT THE UNIVERSITY OF
18 TENNESSEE IN MEMPHIS, AND GRADUATED THERE IN 1954. AFTER
19 THAT, I INTERNED IN A ROTATING INTERNSHIP AT THE UNIVERSITY
20 OF TEXAS MEDICAL BRANCH IN GALVESTON, TEXAS. THEN I ENTERED
21 THE UNITED STATES AIR FORCE AND WAS IN THEIR -- IN THE
22 MEDICAL SERVICE IN A MEDICAL OFFICER, GENERAL MEDICAL
23 OFFICER FOR ABOUT TWO AND A HALF YEARS. AND WHEN I WAS
24 DISCHARGED, I WAS -- I TOOK A RESIDENCY PROGRAM AT THE
25 MEMORIAL SLOAN-KETTERING CANCER CENTER IN NEW YORK CITY.
3578
1 Q. DO YOU HAVE EXPERIENCE AND TRAINING IN THE FIELD OF PAIN
2 OR PAIN MANAGEMENT?
3 A. YES.
4 Q. WOULD YOU TELL US PLEASE WHAT THAT IS?
5 A. WELL, AT THE MEMORIAL SLOAN-KETTERING CANCER CENTER,
6 THERE WAS A SECTION OF CLINICAL PHARMACOLOGY WHICH DID
7 PRIMARILY TESTING AND RESEARCH ON ANALGESIC DRUGS, DRUGS
8 THAT CONTROL PAIN. AND THAT WAS UNDER THE DIRECTION OF DR.
9 RAYMOND HOOD, WHO'S WORLD KNOWN AS A CLINICAL PHARMACOLOGIST
10 ON OPIOIDS.
11 Q. HAVE YOU HAD THE OCCASION TO TREAT PATIENTS IN A
12 CLINICAL SETTING FOR PAIN?
13 A. YES.
14 Q. TELL US ABOUT YOUR CLINICAL EXPERIENCE REGARDING PAIN
15 MANAGEMENT?
16 A. WELL, AS I THINK MOST EVERYBODY KNOWS, A GENERAL
17 KNOWLEDGE, AND THAT PATIENTS WHO HAVE CANCER HAVE PAIN. A
18 HIGH PERCENTAGE OF THEM. NOW, IT DOESN'T NECESSARILY MEAN
19 THAT THAT PAIN IS RELATED STRICTLY TO THEIR CANCER. SO WE
20 DON'T LIKE TO TALK ABOUT CANCER PAIN. WE LIKE TO TALK ABOUT
21 PAIN IN THE CANCER PATIENT. AND IT CAN BE DUE TO ABOUT FOUR
22 DIFFERENT THINGS. ONE IS THE EFFECT OF THE TUMOR AS IT
23 INVADES PAIN SENSITIVE STRUCTURES IN THE BODY, SUCH AS SOFT
24 TISSUES AND BONE. TREATMENT CAN RESULT IN A -- IN PAIN.
25 AND THIS IS -- RESULTS FROM THE FACT THAT THE TREATMENT WILL
3579
1 INJURE THE NERVOUS SYSTEM, EITHER THE PERIPHERAL NERVOUS
2 SYSTEM OR THE CENTRAL NERVOUS SYSTEM. AND THAT'S WHAT WE
3 CALL NEUROPATHIC PAIN, AND IT'S A DIFFERENT FROM THE PAIN
4 THAT WE ORDINARILY SEE, WHICH IS PAIN DUE TO TISSUE INJURY.
5 LIKE IF YOU GET TRAUMA, GET HIT WITH SOMETHING, AND DAMAGE
6 THE TISSUE, THEN YOU GET THAT TYPE OF PAIN, WHICH IS CALLED
7 NOCICEPTIVE PAIN. AND THE REASON THAT DIFFERENCE IS
8 IMPORTANT IS BECAUSE IT REQUIRES A DIFFERENCE IN THE WAY YOU
9 TREAT AND APPROACH PATIENTS WHO HAVE THIS TYPE OF PAIN.
10 IT --
11 Q. HAVE YOU -- I'M SORRY. GO AHEAD.
12 A. WELL, THE OTHER CAUSE OF PAIN CAN BE DUE TO STRUCTURAL
13 CHANGES THAT ARE IN THE BODY AS A RESULT OF A TUMOR. FOR
14 INSTANCE, IF A VERTEBRAE COLLAPSE, IT MAY THROW THE MUSCLES
15 IN THE BACK OUT OF BALANCE, AND THAT WILL CAUSE MUSCULAR
16 PAIN THAT USUALLY RESPONDS PRETTY WELL TO PHYSICAL THERAPY
17 AND THINGS OF THAT SORT.
18 AND THE OTHER THING IS PATIENTS WHO HAVE PAIN THAT
19 EVERYBODY ELSE HAS, THAT'S NOT RELATED TO CANCER. CAN BE A
20 DIABETIC NEUROPATHY, IT CAN BE FAILED BACK SYNDROME, THE
21 PEOPLE WHO'VE HAD SURGERY BEFORE THEY GOT CANCER AND THEY'VE
22 JUST GOT CHRONIC PAIN IN THE BACK.
23 IT CAN BE OTHER THINGS LIKE SO-CALLED POST HERPETIC
24 NEURALGIA, THAT'S DUE TO -- THIS IS TYPICALLY CALLED THE
25 SHINGLES. AND THINGS OF THIS SORT.
3580
1 SO THAT'S THE FOUR BASIC CATEGORIES OF PAIN THAT OCCURS
2 IN CANCER PATIENTS.
3 Q. HAVE YOU HAD EXPERIENCE CLINICALLY IN TREATING CHRONIC
4 PAIN PATIENTS?
5 A. YES. I WOULD SAY THAT ALL OF THESE PATIENTS ARE CHRONIC
6 PAIN PATIENTS.
7 Q. AND WHEN YOU SAY CHRONIC PAIN PATIENTS, YOU REFER TO IT,
8 WHAT DO YOU MEAN?
9 A. WELL, CHRONIC PAIN USUALLY MEANS THAT THE PAIN LASTS FOR
10 A LONGER TIME THAN IT WOULD BE EXPECTED TO LAST. SO IN ANY
11 CATEGORY THAT I'VE MENTIONED, WE CAN HAVE CHRONIC PAIN THAT
12 PERSISTS, AND ACTUALLY, THE CANCER CAN BE CURED, BUT IN THE
13 TREATMENT THAT WAS NECESSARY TO TREAT THE CANCER, CAUSES THE
14 PAIN, AND IT LASTS AS LONG AS THE PATIENT LIVES.
15 Q. HAVE YOU HAD EXPERIENCE IN TREATING PAIN RELATING TO
16 END-OF-LIFE CARE?
17 A. YES.
18 Q. AND TELL US PLEASE WHAT THAT EXPERIENCE IS.
19 A. WELL, THAT EXPERIENCE HAS BEEN TO APPROACH PATIENTS WHO
20 HAVE REACHED THAT POINT IN THEIR LIFE WHERE THEY ENTER THE
21 FINAL PHASE OF THEIR LIFE. MIGHT CALL IT TERMINAL, BUT IT'S
22 BASICALLY THE FINAL PHASE OF THEIR LIFE. AND YOU HAVE TO
23 BEGIN TO SET SOME GOALS. AND THAT IS, WILL THE GOAL BE TO
24 TREAT THE PAIN AT ALL COSTS THAT MIGHT CAUSE THE PATIENT NOT
25 TO BE ABLE TO HAVE AS MUCH ACTIVITY AS IT WOULD, OR DO YOU
3581
1 WANNA TRY TO BALANCE THAT PAIN WITH EQUAL ACTIVITY AND
2 THINGS OF THIS SORT? AND YOU DISCUSS THIS VERY CAREFULLY
3 WHICH THE PATIENT AND WITH THE PATIENT'S LOVED ONES, SO THAT
4 YOU'RE -- HAVE A CLEAR UNDERSTANDING AMONG ALL THE PARTIES
5 INVOLVED ABOUT WHAT EXPECTATIONS THEY HAVE. BECAUSE THE
6 THING THAT REALLY SEEMS TO CAUSE MORE PROBLEMS IN TAKING
7 CARE OF END-OF-LIFE ISSUES IS WHEN THE EXPECTATIONS ARE NOT
8 CLEAR BETWEEN THE HEALTHCARE PROVIDER AND THE FAMILY OR THE
9 PATIENT. SO THAT'S A VERY IMPORTANT THING TO CLEAR UP. AND
10 THEN YOU HAVE TO ADDRESS THE MYRIAD DISTRESSFUL SYMPTOMS
11 THAT MAY OCCUR IN THE DYING PROCESS. IT'S NOT ALL JUST
12 PAIN.
13 Q. DO YOU HAVE -- BEFORE WE GET THERE, CAN I JUST ASK YOU,
14 DO YOU HAVE ANY BOARD CERTIFICATIONS IN THE FIELD OF
15 MEDICINE?
16 A. NO. NO.
17 Q. DO YOU HAVE ANY SPECIAL CONSULTING ROLES IN THE FIELD OF
18 PAIN MANAGEMENT?
19 A. OH, YES. I'VE GOT A NUMBER OF THOSE.
20 Q. COULD YOU EXPLAIN TO US GENERALLY WHAT THOSE ARE?
21 A. WELL, I WAS ON THE PANEL OF THE AGENCY FOR HEALTHCARE
22 POLICY AND RESEARCH OF THE U.S. PUBLIC HEALTH DEPARTMENT TO
23 CREATE GUIDELINES FOR THE TREATMENT OF PAIN, FOR ACUTE PAIN
24 DUE TO TRAUMA, POST OPERATIVE PAIN, AND MEDICAL PROCEDURES.
25 I WAS ALSO ON THE PANEL TO DRAFT THE GUIDELINES FOR THE
3582
1 CANCER PAIN TREATMENT OF THE SAME AGENCY, WHICH IS ALSO AN
2 AGENCY OF THE U.S. PUBLIC HEALTH SERVICE. I WAS ON THE
3 COMMITTEE TO DEVELOP PAIN TREATMENT GUIDELINES FOR THE
4 AMERICAN SOCIETY OF CLINICAL ONCOLOGY. I BELONG TO THE
5 AMERICAN PAIN SOCIETY, THE INTERNATIONAL ASSOCIATION FOR THE
6 STUDY OF PAIN. I'M ON THE AMERICAN CANCER SOCIETY'S AD HOC
7 COMMITTEE ON THE TREATMENT OF PAIN. THE AMERICAN CANCER
8 SOCIETY GAVE ME THEIR HUMANITARIAN AWARD IN 1996. MAYBE IT
9 WAS 1995, I DON'T KNOW. AND I'VE PUBLISHED A BOOK ON THE
10 TREATMENT OF CANCER PAIN. I'VE CONTRIBUTED CHAPTERS TO
11 CANCER TEXTBOOK. I'VE JUST FINISHED THE CHAPTER ON PAIN FOR
12 THE AMERICAN CANCER SOCIETY'S TEXTBOOK OF ONCOLOGY. THAT'S
13 ALL I CAN THINK OF RIGHT NOW.
14 Q. THAT'S PLENTY. DOES MORPHINE HAVE A ROLE TO PLAY IN
15 END-OF-LIFE CARE?
16 A. YES, IT DOES.
17 Q. AND WOULD YOU TELL US WHAT ROLE IT HAS TO PLAY?
18 A. WELL, I THINK THE TWO MOST IMPORTANT ROLES THAT IT PLAYS
19 IS TO CONTROL PAIN, AND THEN AS I SAID EARLIER, THERE ARE
20 MORE THAN JUST PAIN THAT'S -- MORE SYMPTOMS THAN JUST PAIN
21 THAT ARE DISTRESSFUL IN THE END-OF-LIFE PERIOD. AND ONE OF
22 THEM IS SIMPLY BREATHLESSNESS OF DYING. NOBODY REALLY KNOWS
23 WHY THIS OCCURS AS IT DOES. NOW OFTENTIMES, IT'S AN OBVIOUS
24 CAUSE. THEY MAY HAVE PULMONARY EDEMA, THEY MAY HAVE
25 PNEUMONIA, THEY CAN HAVE ALL KINDS OF THINGS THAT INTERFERE
3583
1 WITH THE EXCHANGE OF AIR AND OXYGEN THAT GOES INTO THE BODY
2 THROUGH THE LUNGS. AND SO MORPHINE IS A VERY POTENT PAIN
3 RELIEVER AND HAS A ROLE IN THAT REGARD.
4 MORPHINE IS THE TREATMENT OF CHOICE FOR PEOPLE WHO HAVE
5 PULMONARY EDEMA. AND PULMONARY EDEMA IS WHEN FLUID FILLS
6 THE AIR SACS IN THE LUNG, AND THERE'S NO ROOM FOR THE AIR,
7 AND THEREFORE, PATIENTS GET VERY SHORT OF BREATH. MORPHINE
8 WILL REDUCE THIS, THIS FLUID IN THE LUNGS, AND IT WILL ALSO
9 SLOW THE RESPIRATORY RATE DOWN SO THAT THE AMOUNT OF AIR
10 THAT COMES INTO LUNGS IS MORE THAN IT WOULD BE IF THE
11 PATIENT CONTINUES TO BREATHE IN THIS RAPID WAY AND NOT
12 REALLY BRING IN ENOUGH AIR AND OXYGEN IN ORDER TO PROVIDE
13 THE BODY WITH WHAT IT NEEDS. SO THAT'S A SPECIFICATION. IT
14 HAS BEEN EVEN DEVELOPED THAT MORPHINE CAN BE ADMINISTERED BY
15 INHALATION. YOU CAN AEROSOL THE MORPHINE INTO THE LUNGS
16 LIKE YOU DO WITH A SPRAY FOR ASTHMA AND THINGS OF THIS SORT.
17 AND THIS HAS A VERY BENEFICIAL EFFECT --
18 MR. WILSON: YOUR HONOR, I THINK I'M GOING TO
19 OBJECT. MAYBE --
20 THE COURT: YEAH, LET'S PROCEED WITH QUESTIONS.
21 THANK YOU.
22 MR. STIRBA: FINE.
23 Q. DOCTOR, MORPHINE, IS THERE A RELATIONSHIP OF MORPHINE TO
24 A SIDE EFFECT OR RISK FACTOR CALLED RESPIRATORY DEPRESSION?
25 A. YES, YES.
3584
1 Q. AND COULD YOU EXPLAIN PRECISELY HOW MORPHINE AFFECTS
2 RESPIRATORY RATES AND DEPRESSION?
3 A. WELL, MORPHINE WILL DEPRESS THE RESPIRATORY CENTER WHICH
4 IS IN THE BRAIN STEM, THE PART THAT GOES DOWN THE -- RIGHT
5 BEFORE THE BRAIN STARTS GOING INTO THE SPINAL CORD. AND IT
6 CAN DEPRESS THAT PARTICULAR AREA. BUT IT ALSO -- MORPHINE
7 ALSO DEPRESSES THE HIGHER CORTEX, AND WHAT -- WHEN WE SAY
8 DEPRESS, WE MEAN THAT THE RESPIRATORY CENTER IN THE BRAIN
9 THAT CAUSES EVERYBODY TO INVOLUNTARILY BREATHE, IS -- IS
10 MADE INSENSITIVE TO THE CONCENTRATION OF CARBON DIOXIDE
11 BECAUSE CARBON DIOXIDE IS WHAT DRIVES THAT CENTER. THE
12 CENTER RESPONDS TO THE CONCENTRATION OF CARBON DIOXIDE, AND
13 AS THE CARBON DIOXIDE GOES UP, THE MORE THAT IT DRIVES THAT
14 CENTER TO MAKE THE PATIENT BREATHE. AN EXAMPLE OF THAT IS
15 WHEN A KID GETS IN A TANTRUM AND HOLDS HIS BREATH AND TURNS
16 BLUE, EVERYBODY THINKS HE GONNA DIE. THERE'S NO WAY HE CAN
17 DIE BECAUSE THAT CENTER'S GONNA MAKE HIM BREATHE.
18 Q. EXPLAIN PRECISELY THE MECHANISM THAT YOU WOULD ASSOCIATE
19 WITH AN MORPHINE-INDUCED RESPIRATORY DEPRESSANT DEATH.
20 A. WELL, FIRST OF ALL, THE FIRST DEPRESSION THAT OCCURS IN
21 THE CENTRAL NERVOUS SYSTEM WITH ANY OPIOID, PARTICULARLY
22 MORPHINE, IS THAT IT DEPRESSES THE HIGHER INTEGRATIVE
23 FUNCTIONS OF THE INDIVIDUAL. THIS IS THE ABILITY TO MAKE
24 DECISIONS, THE ABILITY TO RELATE INFORMATION, AND USE THAT
25 INFORMATION, AND THAT'S WHAT'S DEPRESSED FIRST. THEN AS
3585
1 THE -- IF THE DOSE GOES UP, THE NEXT THING THAT YOU WOULD
2 SEE WOULD BE INTERFERENCE WITH A MOTOR FUNCTION. YOU'D SEE
3 PEOPLE THAT FALL DOWN AND THEY CAN'T CONTROL THEIR ARMS AND
4 LEGS AS THEY SHOULD, AND THEY BECOME MUCH MORE GROGGY. THEY
5 BECOME OBTUNDED, MEANING THAT IT MAY BE HARD TO AROUSE THEM,
6 TO WAKE 'EM UP, AND THEN THEY CAN FINALLY GO INTO A COMA,
7 AND YOU CAN'T WAKE 'EM UP.
8 AND THEN FINALLY, THE LAST THING THAT HAPPENS IS THAT
9 THERE'S -- THAT THE RESPIRATORY CENTER IS UNABLE TO RESPOND
10 TO THE CONCENTRATION OF CARBON DIOXIDE. AND I GUESS IF ONE
11 LOOKS AT THAT TELEOLOGICALLY, YOU COULD SAY I CREATE OR MADE
12 IT SO THAT THAT RESPIRATORY CENTER IS PROTECTED UNTIL THE
13 VERY LAST THING THAT GOES DOWN.
14 Q. IS THERE A RESPIRATORY RATE PATTERN THAT YOU WOULD
15 ASSOCIATE WITH MORPHINE INDUCING A RESPIRATORY DEPRESSING
16 DEATH?
17 A. YES, THE RESPIRATORY RATE WILL GRADUALLY DECREASE.
18 Q. AND CAN YOU EXPLAIN WHAT YOU MEAN BY GRADUALLY DECREASE?
19 A. WELL, IT WILL -- THERE IS NO, YOU KNOW, IT DOESN'T FALL
20 OFF IN CERTAIN INCREMENTS, BUT IT CAN -- IT JUST THE -- THE
21 RATE PER MINUTE, THE NUMBER OF TIMES THAT SOMEBODY BREATHES
22 PER MINUTE, GRADUALLY GOES DOWN. IF THERE -- THE RATE
23 NORMALLY YOU SEE ANYWHERE FROM 12 TO 20 A MINUTE DURING THE
24 WAKING HOURS. BUT IF YOU GO TO SLEEP, IT'S NOT NECESSARY
25 FOR YOUR BODY TO HAVE AS MUCH OXYGEN. SO WHEN YOU GO TO
3586
1 SLEEP, THE RESPIRATORY RATE AUTOMATICALLY GOES DOWN. IT MAY
2 GO DOWN TO EIGHT OR EVEN SIX A MINUTE. SO IT'S A DIFFERENCE
3 BETWEEN WHEN YOU'RE AWAKE AND WHEN YOU'RE ASLEEP AS FAR AS
4 THE RESPIRATORY RATE IS CONCERNED. BUT THEN AS THE LEVEL OF
5 CONSCIOUSNESS GOES DOWN, THERE'S A CONCOMITANT DROP IN THE
6 RESPIRATION RATE UNTIL IT GETS TO THE POINT WHERE THAT
7 RESPIRATORY CENTER WILL NOT RESPOND TO THE CARBON DIOXIDE
8 CONCENTRATION, AND THE PATIENT DIES.
9 Q. HAVE YOU REVIEWED RECORDS IN THIS CASE?
10 A. YES.
11 Q. AND THEY WERE MEDICAL RECORDS OF THE PATIENTS IN THE
12 DAVIS HOSPITAL?
13 A. YES.
14 Q. HAVE YOU SEEN IN THOSE RECORDS THE DESCRIPTION OF THE
15 PATTERN THAT YOU HAVE JUST DESCRIBED THAT YOU WOULD
16 ASSOCIATE WITH THE MORPHINE-INDUCED RESPIRATORY DEPRESSANT
17 DEATH?
18 A. NO, I HAVEN'T SEEN THAT.
19 Q. TELL US PLEASE WHY YOU SAY THAT.
20 A. WELL, IN LOOKING AT THE RESPIRATORY RATES DURING THE
21 COURSE THAT THEY WERE IN THE HOSPITAL, IT REMAINS PRETTY
22 CONSTANT THROUGHOUT. NOW, THAT DOESN'T MEAN THAT THE
23 RESPIRA -- THAT RESPIRATION WOULDN'T CHARACTERIZE IN OTHER
24 WAYS. THERE WAS A PLACE IN THE RECORDS TO REMARK WHETHER OR
25 NOT IT WAS LABORED. AND THAT'S A VERY SUBJECTIVE THING.
3587
1 I'M NOT SURE WHAT LABORED IS. MOST THE TIME IT'S THAT
2 SOMEBODY'S HAVING A HARD TIME GETTING AIR IN. ERRATIC
3 SOMETIMES. BUT YOU'VE GOT TO TAKE INTO CONSIDERATION THAT
4 THERE ARE A NUMBER OF THINGS THAT WERE GOING ON IN THESE
5 PATIENTS THAT THEY ALL HAD COMPLEX MEDICAL PROBLEMS. MANY
6 OF 'EM HAD STROKES, MANY OF 'EM HAD -- WERE THOUGHT TO HAVE
7 HAD MULTIPLE EMBOLI THROUGHOUT THE BRAIN SO THAT THE BRAIN
8 WOULD BE FUNCTIONING NORMALLY, UNRELATED TO ANY MEDICATION
9 THAT THEY MIGHT BE TAKING.
10 Q. DO YOU HAVE --
11 THE COURT: MR. STIRBA, WHY DON'T WE TAKE A BREAK.
12 I THINK THIS MIGHT BE A GOOD TIME.
13 (AFTER ADMONISHING THE JURY, THE COURT
14 EXCUSED THE JURY, FOLLOWING WHICH THE COURT
15 AND COUNSEL HAD A BRIEF SCHEDULING CONFERENCE.
16 THE COURT THEN TOOK A BRIEF RECESS.)
17 THE COURT: OKAY. PLEASE BE SEATED. RECORD WILL
18 REFLECT THAT THE JURY HAS RETURNED. WOULD YOU LIKE TO
19 CONTINUE?
20 MR. STIRBA: YES, YOUR HONOR. THANK YOU.
21 Q. DOCTOR, BASED UPON YOUR REVIEW OF THE RECORDS AND THE
22 INFORMATION PERTAINING TO THIS CASE, DO YOU HAVE AN OPINION
23 AS TO WHETHER ANY OF THESE PATIENTS DIED AS A RESULT OF A
24 MORPHINE-INDUCED RESPIRATORY DEPRESSANT DEATH?
25 A. YES, I DO.
3588
1 Q. AND WHAT IS YOUR OPINION?
2 A. MY OPINION IS THAT THEY DID NOT DIE A MORPHINE OR OPIOID
3 OVERDOSE DEATH.
4 Q. AND TELL US GENERALLY WHY YOU SAY THAT.
5 A. WELL, FROM THE RECORD, ONE CAN DETERMINE THE RESPIRATORY
6 RATE OF THE -- THAT THESE PATIENTS EXHIBITED UP UNTIL THEY
7 DIED. SECONDLY, THERE IS NOTHING IN THE RECORD TO INDICATE
8 THAT THE PATIENTS PROCEEDED THROUGH THIS SEQUENCE OF EVENTS
9 THAT I HAVE DESCRIBED EARLIER IN WHICH THE SENSORIUM, THE
10 COGNITIVE FUNCTION OF THE PATIENT -- OF COURSE IN THESE
11 CASES, WE COULDN'T USE THAT ANYWAY BECAUSE THEY HAD LOST ALL
12 OF THEIR REAL COGNITIVE FUNCTION AS A RESULT OF THEIR
13 ALZHEIMERS DISEASES. AND -- BUT THERE WAS NOTHING TO
14 INDICATE THAT THEY HAD PROGRESSED INTO A PERIOD OF
15 SOMNOLENCE, TORPOROUSNESS, OR OBTUNDATION, OR COMA, OR
16 ANYTHING OF THE SORT, TO MOVE ON DOWN INTO SOMETHING THAT
17 WOULD JUST -- WOULD STOP THE RESPIRATIONS. THESE ARE NOT
18 LETHAL MORPHINE DOSES.
19 Q. AND WHY DO YOU SAY THEY'RE NOT LETHAL MORPHINE DOSES?
20 A. BECAUSE THERE'S NO EVIDENCE THAT THEY PRODUCED ANY OF
21 THESE EFFECTS. IF ONE SHOULD TAKE THESE DOSES IN RELATION
22 TO ORDINARY DOSES THAT ARE PRESCRIBED IN OTHER
23 INDIVIDUALS -- I DON'T KNOW IF THAT HAS ANYTHING TO DO WITH
24 THIS, BUT THESE ARE RELATIVELY SMALL DOSES.
25 Q. WHAT WOULD BE IN YOUR OPINION A USUAL DOSAGE OF
3589
1 MORPHINE?
2 A. WELL, FOR PAIN THAT'S FAIRLY SEVERE, AS WE SEE IN
3 METABOLIC BONE DISORDERS LIKE OSTEOPOROSIS, I WOULD SAY THAT
4 A MINIMUM DOSE WOULD PROBABLY BE 10 MILLIGRAMS. AND I WOULD
5 EXPECT IT TO BE MUCH HIGHER THAN THAT, GIVEN PARENTERALLY;
6 THAT IS, EITHER INTRAMUSCULARLY OR INTRAVENOUSLY. NOW, IF
7 IT WAS AN ORAL DOSE, THE PHARMACOKINETICS; THAT IS, WHAT THE
8 BODY DOES TO THESE DRUGS WHEN YOU TAKE 'EM --
9 MR. WILSON: OBJECTION, YOUR HONOR. THE EVIDENCE
10 IS THERE IS NO --
11 THE COURT: I THINK THERE'S -- YEAH, THERE'S REALLY
12 NO EVIDENCE THAT THESE WERE GIVEN ORALLY, SO --
13 MR. STIRBA: BUT THE JURY HAS HEARD, YOUR HONOR,
14 ABOUT THIS CHART WHICH HAS ORAL DOSES. WE'LL ADDRESS THE
15 CHART DIRECTLY THEN.
16 THE COURT: ALL RIGHT.
17 Q. (BY MR. STIRBA) DOCTOR, HAVE YOU PREPARED OR HAVE SOME
18 CHARTS BEEN PREPARED AT YOUR DIRECTION WHICH ARE HELPFUL TO
19 ILLUSTRATE YOUR TESTIMONY CONCERNING YOUR FINDINGS OF THE
20 RESPIRATORY RATES?
21 A. YES.
22 Q. DO YOU HAVE THOSE WITH YOU?
23 A. YES, I DO. THEY'VE BEEN COMPILED FROM THE ACTUAL RECORD
24 OF THE HOSPITAL, PUT IN THIS CHART FORM, AND IT TRACKS THE
25 RESPIRATORY RATE I BELIEVE FROM THE DAY THAT THEY WERE
3590
1 ADMITTED UNTIL THE DAY THEY DIED.
2 MR. STIRBA: MAY I APPROACH, YOUR HONOR, PLEASE?
3 THE COURT: YES.
4 Q. (BY MR. STIRBA) IF YOU'LL HAND ME THE GRAPHS THAT
5 YOU'VE PREPARED. AND THESE DO ASSIST AND ILLUSTRATE YOUR
6 TESTIMONY, IS THAT RIGHT?
7 A. YES.
8 Q. DO YOU HAVE THE GRAPHS IN FRONT OF YOU?
9 A. THESE?
10 Q. YES.
11 A. YES.
12 Q. THE FIRST ONE PLACED ON THE SCREEN IS A COMPILATION OF
13 RESPIRATORY RATES OF ELLEN ANDERSON. AND COULD YOU JUST
14 TELL US WHAT IS DEPICTED THERE BASED UPON YOUR REVIEW OF THE
15 RECORDS CONCERNING HER?
16 A. WELL, THE FIRST NUMBER -- IT'S OVER IN THIS COLUMN UNDER
17 26, AND THE FIRST COLUMN THAT SHOWS THAT THE RESPIRATORY
18 RATE VARIED FROM 8 TO 16 AT 1 O'CLOCK IN THE MORNING, AT 12
19 O'CLOCK, AND -- I MEAN 12, YEAH, IT WAS 12 AT 7:30 IN THE
20 MORNING, SO THAT'S A TIME OF ABOUT SIX AND A HALF HOURS.
21 AND THE PATIENT DIED AT 8:55 OR ABOUT 35 MINUTES LATER. AND
22 I THINK IT WOULD BE IMPOSSIBLE FOR THE RESPIRATORY RATE TO
23 FALL FROM 12 TO A -- I SUPPOSE ZERO AT 35 MINUTES LATER.
24 THIS IS NOT CHARACTERISTIC OF MORPHINE.
25 Q. AND ANOTHER ONE OF THE CHARTS --
3591
1 THE COURT: CAN YOU LIFT IT UP JUST A LITTLE?
2 MR. STIRBA: YES, YOUR HONOR. THANK YOU.
3 Q. AND IF YOU COULD WALK US THROUGH THAT PLEASE.
4 A. WELL, ON THE 5TH OF JANUARY 1996, THE RESPIRATORY RATE
5 WAS 8 TO 12. AND THEN AT ANOTHER TIME, IT WAS 20. USUALLY
6 THESE RATES ARE RECORDED ON THESE CHARTS TWICE IN THE
7 24-HOUR PERIOD. ON THE 6TH IT WAS 18. AND THEN AT 4:05 IN
8 THE AFTERNOON, IT WAS 16. AND THEN ON THE 7TH, IT WAS 28.
9 AND I'M NOT SURE WHAT TIME THAT WAS, BUT SHE EXPIRED AT --
10 THAT WOULD BE 11:30 IN THE EVENING.
11 Q. YES. NOW, GIVEN THE INFORMATION CHARTED THERE, IS THAT
12 CONSISTENT WITH A LETHAL DOSE OF MORPHINE?
13 A. ABSOLUTELY NOT.
14 Q. AND WHY NOT?
15 A. BECAUSE THE RATES ACTUALLY HAVE GONE UP INSTEAD OF DOWN
16 FROM 12 TO 28. SO THAT WOULDN'T FIT.
17 Q. THIS IS PATIENT ENNIS ALLDREDGE. AND IF YOU COULD WALK
18 US THROUGH THAT PLEASE.
19 A. ON THE 10TH OF JANUARY 1996, IT WAS -- THE RESPIRATORY
20 RATE WAS RECORDED AT THREE DIFFERENT TIMES, AT 24, 16, AND
21 20. TWO DAYS LATER, IT WAS 18, 24. ONE DAY LATER, IT WAS
22 12 AND 16. AND ONE DAY LATER AT 8 O'CLOCK IN THE MORNING,
23 IT WAS 16. AND THE PATIENT EXPIRED AT 9:36, WHICH WOULD
24 JUST BE TOTALLY INCOMPATIBLE WITH THE -- WITH AN ACTION OF
25 MORPHINE.
3592
1 Q. THIS IS RESPIRATION RATE COMPILATION FOR LYDIA SMITH.
2 DO YOU SEE THAT?
3 A. YEAH. AND ON THAT OTHER ONE, I NOTED -- FORGOT TO
4 COMMENT ON THE FACT THAT THERE WAS SOME CHARACTERIZATION OF
5 THE RESPIRATIONS AS BEING LABORED OR SOMETHING LIKE THAT.
6 BUT IT SAYS EVEN UNLABORED SO THAT --
7 Q. WHAT IS THE SIGNIFICANCE OF THAT?
8 A. I WOULD SAY THAT, YOU KNOW, UNLABORED IS REALLY SORT OF
9 SUBJECTIVE. YOU HAVE TO INTERPRET THAT. BUT THERE WAS NO
10 EFFORT THAT THE PATIENT HAD TO STRUGGLE TO GET THE BREATH.
11 Q. THIS IS CALCULATION FOR LYDIA SMITH. LET ME SEE IF I
12 CAN GET THIS ALL IN ONE. HERE WE GO.
13 A. OKAY. ON THE 5TH OF JANUARY 1996, HER RESPIRATORY
14 RATE'S 16 TO 18. ON THE 6TH, IT'S 16, 16. ON 7TH, IT'S 16,
15 23. ON THE 8TH, IT'S 10 AND 12. AND IT SAYS AFTER 8 A.M.,
16 RESPIRATIONS 14 TO 16, SLOW, DEEP, AND REGULAR WITHOUT
17 WAXING AND WANING PATTERN. THIS MAY INDICATE THAT THERE'S
18 SOME BENEFICIAL EFFECT OF THE OPIOID OR MORPHINE ON THE
19 PATIENT BECAUSE THEY ARE ABLE TO TAKE MORE AIR INTO THEIR
20 LUNGS THAN THEY WOULD OTHERWISE.
21 Q. EXPLAIN THAT FURTHER PLEASE AS TO WHAT BENEFICIAL EFFECT
22 MORPHINE HAS IN END-OF-LIFE CARE IN TERMS OF BREATHING.
23 A. WELL, AS I SAID BEFORE, THERE IS A CONDITION CALLED
24 TERMINAL BREATHLESSNESS OR DYSPNEA WHERE PATIENTS HAVE TO
25 BREATHE -- OFTENTIMES BREATHE RAPIDLY. AND THAT TYPE OF
3593
1 BREATHING BECOMES INEFFICIENT BECAUSE TO BREATHE
2 EFFICIENTLY, YOU HAVE TO HAVE A SLOW RESPIRATION SO YOU CAN
3 BRING INTO THE LUNGS A HIGHER VOLUME OF AIR. IF IT'S JUST
4 GOING DOWN AND GETS ABOUT TO THE LEVEL OF THE TRACHEA, IT
5 DOESN'T GET INTO THE LUNGS. AND IF YOU TAKE ANOTHER BREATH
6 IT'S -- AND ALL YOU'RE DOING IS MOVING AIR UP LIKE THIS. IF
7 YOU SLOW IT DOWN AND THE PATIENT CAN MOVE A GREATER VOLUME
8 INTO THEIR LUNGS, THEY CAN OXYGENATE THE TISSUES MUCH
9 BETTER.
10 Q. IN END-OF-LIFE CARE, GIVEN THAT BENEFICIAL EFFECT, WHAT
11 SIGNIFICANCE DOES THAT HAVE IN TERMS OF WHETHER OR NOT
12 MORPHINE WOULD EITHER PROLONG LIFE OR HASTEN DEATH?
13 A. WELL, CERTAINLY IT WOULDN'T HASTEN IT. MATTER OF FACT,
14 IT -- WHETHER IT PROLONGED IT WOULD DEPEND UPON WHAT THE
15 BASIC PATHOLOGICAL OR DISEASE PROCESS IS THAT'S AFFECTING
16 THE PATIENT. BUT CERTAINLY, IT WOULD IMPROVE THE QUALITY OF
17 THE LIFE BECAUSE PATIENTS ALMOST PANIC ONCE THEY HAVE A
18 THREAT TO THE AMOUNT OF OXYGEN OR AIR THAT'S AVAILABLE TO
19 THEM. IT'S A VERY FRIGHTENING EXPERIENCE. AND MORPHINE
20 WILL CAUSE THEM TO BREATHE BETTER, REDUCE THAT ANXIETY, IN
21 ADDITION TO THE REDUCING THE ANXIETY THAT IT ORDINARILY DOES
22 ON THE CENTRAL NERVOUS SYSTEM.
23 Q. GIVEN THE PATTERN THAT IS REFLECTED CONCERNING PATIENT
24 LYDIA SMITH, IS THAT CONSISTENT WITH HER DEATH THROUGH
25 LETHAL DOSAGES OF MORPHINE?
3594
1 A. NO. ON THE 29TH OF DECEMBER 1995, RESPIRATORY RATE WAS
2 RECORDED TWICE, BOTH TIMES AT 22. ON THE 30TH, AT 18 AT
3 5:30 IN THE MORNING AND LATER ON TWO MORE TIMES AT 20 AND
4 16. ON THE 31ST, IT WAS 12 AT 6:30 IN THE EVENING. 12 AT
5 7:30 IN THE IN THE EVENING. 12 AT 8:30 IN THE EVENING. 16
6 AT 7:30 IN THE MORNING. SO AND 22 AND 18 AT SOME OTHER
7 TIMES DURING THE DAY. AND 10 AND 16 AT 11 P.M. AND --
8 Q. YEAH, FEEL FREE TO APPROACH THAT, DOCTOR.
9 A. OH, I GUESS THIS IS 7 A.M. THE M IS OFF. IT'S A AND
10 THEN ON THE 1ST OF JANUARY '96, IT WAS 12 TO 14 AT 11 P.M.
11 ON 11 P.M. -- I DON'T KNOW WHAT THAT 7 A. IS. 14, 16 AT
12 11:30.
13 Q. WHAT THAT IS, DOCTOR, THAT'S A SHIFT.
14 A. OH, OH, OH.
15 Q. THE NIGHT SHIFT WAS 11 P.M. TO 7 A.M.
16 A. OH, OKAY. OH, YEAH. I SEE IT NOW. OKEY-DOKEY. 12 AT
17 8:45. ON THE 2ND, 12 -- 16 AT 11 TO 7 SHIFT AND 12 TO 16 AT
18 12:30 IN THE MORNING. AND THEN 6 TO 10 AT 3:30 IN THE
19 AFTERNOON.
20 Q. LET ME STOP YOU RIGHT THERE. FROM THAT POINT
21 CHRONOLOGICALLY FROM THE 2ND BACKWARDS IN TIME TO THE 29TH,
22 IS IT YOUR OPINION THAT HER RESPIRATION RATE IS WITHIN A
23 NORMAL RANGE?
24 A. YES, SIR.
25 Q. GO ON TO THE 3RD THEN. THE DAY SHE DIED.
3595
1 A. ON THE 3RD, IT WAS 5 AND 8 ON 11 TO 7 SHIFT. AND 10
2 AT -- WHAT IS 20 -- 8 O'CLOCK.
3 Q. I THINK 8 O'CLOCK, YES.
4 A. EXPIRED AT 8:10.
5 Q. WHAT IS THE SIGNIFICANCE OF THE FACT THAT HER
6 RESPIRATION RATE TEN MINUTES BEFORE SHE DIED AND LATER ON ON
7 THE DAY ON THE 3RD IS ACTUALLY INCREASED OVER WHAT WAS
8 RECORDED BY THE NIGHT SHIFT NURSE?
9 A. WELL, THAT'S INCOMPATIBLE WITH A MORPHINE DEATH.
10 Q. AND WHY IS THAT?
11 A. BECAUSE SHE'S GOT A RESPIRATORY RATE OF 10 PER MINUTE,
12 AND THAT'S ADEQUATE TO SUSTAIN LIFE.
13 Q. DOCTOR, I WANNA SHOW YOU THIS CHART. CAN YOU KIND OF
14 SEE IT FROM WHERE YOU ARE? IT HAS MORPHINE AT THE TOP.
15 A. YES.
16 Q. AND IT HAS IMMEDIATE EFFECTS AND LONG-TERM EFFECTS. DO
17 YOU SEE THAT?
18 A. YES.
19 Q. I WANNA DIRECT YOUR ATTENTION TO THE LONG-TERM EFFECTS
20 ON THIS CHART, AND THE FIRST THING IT SAYS IS PNEUMONIA. IS
21 PNEUMONIA A LONG-TERM EFFECT OF MORPHINE?
22 A. AS AN INTRINSIC CAUSE OF MORPHINE --
23 Q. YES.
24 A. -- I MEAN OF PNEUMONIA?
25 Q. YES.
3596
1 A. ABSOLUTELY NOT.
2 Q. AND WHY DO YOU SAY THAT?
3 A. IT JUST -- IT DOESN'T PRODUCE -- MORPHINE DOESN'T
4 PRODUCE AN INFECTION. PNEUMONIA IS AN INFECTION. IT'S
5 GOTTA HAVE SOME OF TYPE OF INFECTIOUS AGENT, EITHER A VIRUS
6 OR A BACTERIA OR SOMETHING LIKE THAT. BUT THE MORPHINE BY
7 ITSELF DOESN'T -- DOESN'T CAUSE AN INFECTION.
8 Q. WE HAVE ALSO UNDER LONG-TERM EFFECT, IT SAYS ORGAN
9 DAMAGE. I'M SORRY.
10 A. YEAH, I CAN SEE.
11 Q. LIKE AN EYE TEST HERE. ORGAN DAMAGE, HEART, BRAIN, AND
12 KIDNEYS. DO YOU SEE THAT?
13 A. YES, I DO.
14 Q. IS THAT A WELL-RECOGNIZED LONG-TERM EFFECT OF MORPHINE?
15 A. ABSOLUTELY NOT. AND IF I MIGHT SAY, IN A RECENT SEMINAR
16 THAT I PARTICIPATED IN, WE DETERMINED THAT THERE'S NO ORGAN
17 DAMAGE CAUSED BY ANY OPIOIDS, MORPHINE OR ANYTHING ELSE. NO
18 ORGAN IS -- IS DESTROYED AS A RESULT OF THESE DRUGS ALONE.
19 IT IS -- JUST DOESN'T HAPPEN. NOTHING. AND THERE ARE MANY
20 OTHER CLASSES OF DRUGS THAT DO DESTROY ORGANS, BUT THESE --
21 THESE DRUGS ARE PROBABLY THE MOST SAFEST DRUGS OR THE SAFEST
22 DRUGS THAT ONE COULD USE FROM THE STANDPOINT OF THEM CAUSING
23 ANY KIND OF ORGAN DAMAGE WHATSOEVER. NOT TO THE HEART, THE
24 KIDNEY THE BRAIN, THE LUNGS, OR G.I. TRACT, OR URINARY TRACT
25 SYSTEM, OR ANYTHING. NOTHING.
3597
1 Q. CAN YOU GIVE US AN EXAMPLE OF A DRUG THAT WE MAY BE
2 FAMILIAR WITH WHICH WOULD CAUSE -- IT'S WELL-RECOGNIZED
3 CAUSES ORGAN DAMAGE?
4 A. YES. THE CATEGORY OF DRUGS THAT PRODUCE THE HIGHEST
5 ADVERSE EFFECTS OF ANY CLASS OF DRUGS THAT WE HAVE. YOU ALL
6 KNOW THEM BECAUSE I SUSPECT PLENTY OF YOU TAKE 'EM, AND
7 THAT'S WHAT WE CALL N.S.A.I.D.'S, THE NONSTEROIDAL
8 ANTI-INFLAMMATORY DRUGS. THIS IS IBUPROFEN, ALEVE, ADVIL,
9 AND A WHOLE HOST OF DRUGS THAT ARE BY PRESCRIPTION. THOSE
10 YOU CAN BUY OVER THE COUNTER. BUT THIS CLASS OF DRUGS HAS
11 THE GREATEST INCIDENCE OF ADVERSE EFFECTS OF ANY OTHER
12 CATEGORY. IN 1997 -- OR IT MIGHT BE '98, BUT I THINK THE
13 LATEST FIGURES WE HAVE FROM 1997, IN THE UNITED STATES,
14 THERE WAS 107,000 PATIENTS ADMITTED TO HOSPITALS' EMERGENCY
15 ROOMS WITH LIFE-THREATENING COMPLICATIONS, MOST OF --
16 MR. WILSON: WELL, YOUR HONOR, I -- THIS IS NOT
17 RESPONSIVE TO THE QUESTION. HE'S GOING ON. I WOULD
18 APPRECIATE A QUESTION IN HERE.
19 MR. STIRBA: WELL --
20 THE COURT: I THINK WE'RE ASKING WHAT IS THE --
21 WHAT IS A COMMON DRUG THAT MIGHT CAUSE THAT --
22 MR. STIRBA: RIGHT, AND -- AND --
23 MR. WILSON: HE TESTIFIED --
24 THE COURT: I THINK YOU --
25 MR. STIRBA: OKAY. ALL RIGHT --
3598
1 THE WITNESS: ALL RIGHT. THE N.S.A.I.D.'S.
2 Q. (BY MR. STIRBA) OKAY. THEN WE HAVE ANOTHER LONG-TERM
3 EFFECT REFLECTED ON THIS, DEHYDRATION, MALNUTRITION. IS
4 THAT A LONG-TERM EFFECT OF MORPHINE?
5 A. NOT TO -- NOT TO MORPHINE OR ANY OTHER OPIOID PER SE.
6 Q. AND TELL US WHY.
7 A. BECAUSE IT SIMPLY HAS NO PHARMACOLOGICAL METHOD TO CAUSE
8 DEHYDRATION OR THE LOSS OF FLUID. IT'S NOT A DIURETIC. YOU
9 WOULDN'T PASS IT THROUGH THE URINE.
10 MALNUTRITION, I DON'T KNOW HOW IN THE WORLD A DRUG
11 COULD CAUSE SOMEBODY TO BE MALNOURISHED IN AND OF ITSELF.
12 AND THAT OTHER ONE, INCREASED SENSITIVITY TO
13 DRUGS?
14 Q. YES, THERE'S ANOTHER LONG-TERM EFFECT, INCREASED
15 SENSITIVE TO DRUG EFFECTS.
16 A. THAT IS SUCH A VAGUE STATEMENT THAT I REALLY DON'T KNOW
17 HOW TO RESPOND TO THAT BECAUSE I DON'T KNOW WHETHER THAT
18 MEANS AN ADDITIVE EFFECT THAT IF YOU TOOK AN ANTIBIOTIC,
19 THAT IT -- THAT TAKING THE MORPHINE WOULD CREATE A GREATER
20 SENSITIVITY. IF IT DOES, I'M TOTALLY UNAWARE OF THE
21 MECHANISM OF HOW IT COULD DO IT, OR ANY OTHER DRUG, THAT IT
22 COULD INCREASE THE SENSITIVITY OF SOMETHING LIKE AN
23 ANTIBIOTIC OR SOMETHING OF THAT SORT. OR ANY OTHER DRUG.
24 Q. ARE YOU AWARE OF ANY STUDIES -- AND YOU'VE TESTIFIED
25 ABOUT THE THINGS YOU HAVE WRITTEN AND SOME OF YOUR
3599
1 PUBLICATIONS, AND OF COURSE YOU'RE A PROFESSOR. ARE YOU
2 AWARE OF ANY STUDIES THAT STAND FOR THE PROPOSITION THAT THE
3 LONG-TERM EFFECTS INDICATED ON THIS CHART ARE CONSISTENT
4 WITH MORPHINE USE?
5 A. NO.
6 Q. NOW, THERE ARE SOME IMMEDIATE EFFECTS THAT ARE INDICATED
7 ON THIS CHART --
8 A. RIGHT.
9 Q. -- DO YOU SEE THOSE?
10 A. YEAH. PAIN RELIEF. HOPEFULLY THAT'S RIGHT. IT DOES
11 RELIEVE PAIN. IN SOME PEOPLE IT DOES PRODUCE SLEEPINESS.
12 BUT THAT'S USUALLY WITH THE ONSET OF THERAPY. WHEN YOU
13 START THE PATIENT ON THE DRUG, FOR A DAY OR TWO THEY BECOME
14 SLEEPY. BUT THEY RAPIDLY BECOME TOLERANT TO THAT EFFECT,
15 AND THAT DOESN'T HAPPEN ANYMORE. THE COMA IS A LATE EFFECT,
16 AS I SAID, OF THE MORPHINE THAT WOULD BE AN OVERDOSE. SO IT
17 CAN -- IT'S NOT AN IMMEDIATE EFFECT. IT'S A LONGER-TERM
18 EFFECT.
19 DECREASED BREATHING. IF THAT MEANS THAT IT CAN
20 DECREASE THE RESPIRATORY RATE, YES, THAT DOES HAPPEN,
21 DEPENDING ON THE DOSE AND HOW IT'S GIVEN.
22 LOSS OF COUGH REFLEX AND ASPIRATION. THAT MIGHT OCCUR
23 IF SOMEONE GOT REAL GROGGY OR SLEEPY AND WAS UNABLE TO
24 HANDLE THE SECRETIONS THAT THEY HAVE IN THEIR MOUTH, THEY
25 MIGHT ASPERATE, BUT THAT WOULD NOT BE A DIRECT EFFECT OF THE
3600
1 DRUG.
2 LOW BLOOD PRESSURE IS -- WOULD ONLY OCCUR IF THE
3 PATIENT WAS IN AN UPRIGHT POSITION BECAUSE THE ONLY EFFECT
4 OF MORPHINE ON THE CIRCULATORY SYSTEM, THE HEART, AND THE
5 BLOOD VESSELS, IS TO CAUSE VASODILATATION; THAT IS, THE
6 VESSELS WILL DILATE BECAUSE THE TONE IN THE VESSELS IS LOST.
7 NOW, IF THAT PATIENT STANDS UP, AND THE BLOOD VESSEL
8 CAN'T HOLD THE BLOOD IN PLACE AND IT FALLS DOWN, THEN YOU
9 WOULD GET LOW BLOOD PRESSURE. BUT THAT WOULD BE UNUSUAL.
10 YOU'D TELL THE PATIENT NOT TO GET UP OR GET UP VERY SLOWLY
11 TO SEE IF IT HAPPENS. IT DOESN'T HAPPEN IN EVERYBODY. SO
12 YOU WOULD HAVE TO SIMPLY SAY, IF YOU HAVE TO GET OUT OF BED,
13 DON'T JUST JUMP OUT OF BED, BUT SIT UP ON THE SIDE OF THE
14 BED AND SEE HOW YOU FEEL. IF YOU GET LIGHTHEADED, LIE BACK
15 DOWN. SO THAT'S NOT A GIVEN.
16 DECREASED FOOD AND WATER INTAKE AS A RESULT OF MORPHINE
17 PER SE. THERE MIGHT BE A SLIGHT DECREASE IN FOOD AND WATER.
18 BUT NOTHING THAT WOULD CAUSE ANY SIGNIFICANT ABNORMALITIES.
19 Q. NOW ALSO, DOCTOR, WE'VE SEEN ANOTHER -- ANOTHER SORT OF
20 DEMONSTRATIVE AID, AND IT'S THIS ONE HERE AND IT LOOKS LIKE
21 IT'S FROM THE P.D.R. AT LEAST IT PURPORTS TO BE FROM THE
22 P.D.R., 49TH EDITION, 1995. DO YOU SEE THAT?
23 A. YEAH.
24 Q. AND IT PURPORTS TO BE SOME KIND OF CONVERSION BETWEEN A
25 DURAGESIC PATCH AND ORAL MORPHINE. DO YOU SEE THAT?
3601
1 A. YES.
2 Q. FIRST OF ALL, WAS ORAL MORPHINE GIVEN IN THIS CASE?
3 A. I DON'T BELIEVE SO. I DON'T THINK IT WAS ALL GIVEN
4 PARENTERALLY.
5 Q. DO YOU HAVE AN OPINION ABOUT THE ACCURACY AND THE
6 VALIDITY OF THIS PARTICULAR TABLE?
7 A. I CERTAINLY DO.
8 Q. AND TELL US WHAT THAT OPINION IS PLEASE.
9 A. WELL, WE DID THE STUDIES ON THE TRANSDERMAL FENTANYL
10 THAT THEY'RE TALKING ABOUT THERE. THIS IS THE PATCH THAT
11 YOU HEAR ABOUT. AND FENTANYL IS A POTENT ANALGESIC, AND
12 IT'S ABSORBED THROUGH THE SKIN INTO THIS -- INTO THE BODY.
13 AND WE DID THE ORIGINAL WORK TO STUDY ITS EFFECT ON THIS
14 BACK IN THE EARLY EIGHTIES. AND THE RECOMMENDED DOSAGE IS
15 WHAT THE MANUFACTURER HAS PUT IN THEIR PACKAGE INSERT. AND
16 WE TRIED AT THE TIME THAT THEY WERE DOING THIS TO CONVINCE
17 THEM THAT THAT WAS WRONG AND THEY SHOULDN'T DO THAT. THERE
18 ARE NO STUDIES THAT HAVE EVER BEEN DONE TO SHOW WHAT DOSE OF
19 MORPHINE IS EQUI-ANALGESIC -- THAT MEANS WOULD PRODUCE THE
20 SAME TYPE OF PAIN RELIEF AS A CERTAIN DOSE OF FENTANYL.
21 THEY SIMPLY HAVEN'T BEEN DONE.
22 NOW, THERE HAVE BEEN SOME STUDIES THAT HAVE BEEN DONE
23 THAT YOU CAN MAKE SOME JUDGMENT, BUT CERTAINLY THOSE
24 RECOMMENDATIONS WOULD BE SOMETHING THAT WE'D SAY, FORGET
25 ABOUT 'EM BECAUSE THEY'RE JUST INACCURATE.
3602
1 Q. I'M GONNA SHOW YOU, DOCTOR, THIS IS A REPRESENTATION IN
2 A CHART RELATING TO THE DOSING THAT WAS RECEIVED OF MORPHINE
3 BY PATIENT JUDITH LARSEN. AND IN REVIEWING THIS, DOES THIS
4 APPEAR TO BE A CORRECT REPRESENTATION OF WHAT YOU UNDERSTOOD
5 SHE RECEIVED?
6 A. AS I HAVE REVIEWED THE RECORDS, THAT WAS WHAT I CAME TO
7 THE CONCLUSION SHE GOT.
8 Q. NOW, SPECIFICALLY, I WANNA DIRECT YOUR ATTENTION TO --
9 IT WOULD BE THE 3RD. CAN YOU SEE THAT?
10 A. 3RD, OH, YEAH. JANUARY 3RD.
11 Q. AND THERE AN APPEARS TO BE A DIFFERENCE IN DOSING
12 PATTERN ON THE 3RD THAN THE OTHER DAYS WHEN SHE RECEIVED
13 MORPHINE.
14 A. THAT'S RIGHT.
15 Q. DO YOU HAVE AN OPINION BASED UPON YOUR REVIEW OF THE
16 RECORDS AND YOUR WORK IN PAIN MANAGEMENT AS TO WHY THE
17 DOSING WAS DIFFERENT ON THE 3RD THAN GENERALLY ON THE OTHER
18 DAYS WHEN SHE RECEIVED MORPHINE?
19 A. YES, I DO.
20 Q. AND PERHAPS YOU COULD -- DO YOU WANNA USE THIS TO
21 EXPLAIN?
22 A. YES. I THINK THAT IF YOU LOOK --
23 Q. WHY DON'T YOU COME FORWARD PLEASE, AND I'LL JUST HOLD IT
24 UP AND BE YOUR PROP?
25 A. OKAY. WELL, YOU -- IF YOU -- YOU COMPARE IT WITH THE
3603
1 DAY BEFORE. AND SHE GOT 5 MILLIGRAMS, WHICH IS A VERY SMALL
2 DOSE, AT 12:30 AND THEN ANOTHER ONE AT 3:30, THREE HOURS
3 LATER, 6:30, THREE -- NINE, SHE'S GETTING IT IN THREE-HOUR
4 INTERVALS UNTIL RIGHT HERE, SHE GOT THE LAST DOSE AT 6:30.
5 SO THROUGHOUT THE NIGHT, SHE HAD NOTHING. SO BY THE TIME
6 THAT SHE WAS -- THEY STARTED THE DOSING AGAIN, YOU SEE
7 FROM -- THIS IS 6:30 IN THE MORNING TO 7:30 THE NEXT
8 MORNING, THAT'S ABOUT 13 HOURS THAT SHE HAD NOTHING. SO I'M
9 SURE THAT THE INTENSITY OF THE PAIN HAD INCREASED SO MUCH
10 THAT IT TOOK MORE MEDICATION TO BRING THIS UNDER CONTROL
11 BECAUSE WE KNOW FROM OUR STUDIES AND FROM OUR DEALING IN
12 PATIENTS IN PAIN, WE ALWAYS TELL 'EM, DON'T WAIT TO TAKE
13 YOUR PAIN MEDICATION BECAUSE IF IT GETS OUT OF CONTROL, IT'S
14 GONNA BE MUCH HARDER, YOU'RE GONNA HAVE TO TAKE MORE
15 MEDICINE IN ORDER TO BRING IT BACK UNDER CONTROL. AND I
16 THINK THAT'S WHAT'S HAPPENED HERE.
17 Q. ARE YOU FAMILIAR WITH THE CONCEPT CALLED BREAKTHROUGH
18 PAIN?
19 A. YES.
20 Q. AND DOES THAT HAVE A RELATIONSHIP TO WHAT IS EVIDENCED
21 HERE?
22 A. WELL, I'M NOT SURE THAT THIS WOULD BE BREAKTHROUGH PAIN.
23 IT'S MORE THE FACT THAT THEY ARE HAVING A HARD TIME TO GET
24 AN ADEQUATE DOSE IN THERE. IT'S BEEN DONE CAUTIOUSLY, AND
25 YOU SEE, IT'S MORE FREQUENT HERE, THEIR REALITY FACTOR, AND
3604
1 SO THEY -- AND THEN HERE, IT'S SILL NOT HAPPENING AND SO THE
2 DOSE HAS BEEN INCREASED TO A CERTAIN EXTENT. SO BASED UPON
3 A CLINICAL PICTURE THAT WAS PRESENTED TO DR. WEITZEL, HE
4 REACTED AND RESPONDED ACCORDINGLY IN A RATIONAL WAY.
5 Q. SPEAKING OF THAT CLINICAL PICTURE, DOCTOR, IS IT OF
6 SIGNIFICANCE TO YOU IN TERMS OF EVALUATING THE USE OF PAIN
7 MEDICATION IN THIS CASE THAT THE PATIENTS WERE SEVERELY
8 DEMENTED OR OTHERWISE COULD NOT REPORT?
9 A. WELL, IT'S VERY IMPORTANT.
10 Q. AND TELL US WHY?
11 A. UNFORTUNATELY, THESE -- THE ALZHEIMERS HAD ROBBED THESE
12 PATIENTS OF THEIR ABILITY TO COMMUNICATE. ONE COMMON THING
13 ABOUT ALL OF THESE PATIENTS THAT I NOTED WHEN I REVIEWED THE
14 CHARTS, THAT IN THESE RECORDS, NEVER DO YOU SEE THE
15 RECORDING OF A SYMPTOM. NOW, IN MEDICINE WHAT WE CALL
16 SYMPTOMS IS WHAT PEOPLE COMPLAIN OF. YOU KNOW, IF YOU GOT A
17 HEADACHE, I'VE GOT A HEADACHE, THAT'S THE SYMPTOM. NOW, THE
18 SIGNS ARE WHAT THE PHYSICIAN OR THE HEALTHCARE PROVIDER CAN
19 OBSERVE. THESE PATIENTS WERE UNABLE TO COMMUNICATE ANY
20 SYMPTOMS, NOT JUST PAIN, BUT IF YOU LOOK THROUGH THE
21 RECORDS, THERE ARE NO SYMPTOMS WHATSOEVER RECORDED BY
22 ANYBODY. AND IN THE USUAL COURSE OF MEDICAL PRACTICE,
23 PARTICULARLY IN THE HOSPITAL, YOU -- THE NURSES WILL
24 ROUTINELY RECORD SYMPTOMS LIKE MAYBE MISS SMITH COMES BY THE
25 NURSES' STATION AND REPORTS THAT SHE HAS A HEADACHE AND SHE
3605
1 WANTS SOME TYLENOL FOR IT. THAT WOULD BE A SYMPTOM THAT WAS
2 REPORTED. THERE'S NOTHING IN THESE RECORDS WHERE ANY TIME,
3 ANY OF THESE PATIENTS WERE ABLE TO COMMUNICATE SIMPLY
4 BECAUSE THEY WERE ROBBED OF THIS CAPACITY AS HUMAN BEINGS BY
5 THE DISEASE. SO ALL THAT'S IN HERE ARE SYMPTOMS. AND
6 EVERYTHING HAS TO BE DONE BY WHAT THE HEALTHCARE PROVIDER'S
7 OBSERVED AND TOOK CUES FROM IN ORDER PROVIDE ADEQUATELY FOR
8 THE PATIENTS. AND I NOTICED, FOR INSTANCE, ONE EXAMPLE --
9 AND I CAN'T REMEMBER WHICH PATIENT WAS IN -- THAT
10 DR. WEITZEL THOUGHT THAT THEY MAYBE MIGHT BE HAVING MULTIPLE
11 INFARCTS BECAUSE HE COULDN'T GET ANY FEEDBACK FROM THESE
12 PATIENTS. ALL HE COULD DO WAS SEE HOW THEY WERE ACTING, AND
13 HE HAD TO COME TO SOME KIND OF CONCLUSION --
14 MR. WILSON: AGAIN, YOUR HONOR, I'M GONNA OBJECT TO
15 THE NARRATIVE --
16 THE COURT: LET'S PROCEED BY QUESTION.
17 MR. STIRBA: I THOUGHT HE -- I THOUGHT HE WAS, BUT
18 I'LL --
19 Q. COULD YOU EXPLAIN THAT CIRCUMSTANCE IF IT'S ILLUSTRATIVE
20 OF WHAT YOU WERE TRYING TO SAY ABOUT THE DIFFICULTY --
21 A. WELL, HE THOUGHT THAT WAS HAPPENING AND SO HE PRESCRIBED
22 ASPIRIN, WHICH WOULD BE INDICATED FOR THAT CONDITION. SO IT
23 WAS -- HERE I THINK IT'S A COMMON TERM, FLYING BY THE SEAT
24 OF YOUR PANTS IS WHAT WAS -- HE HAD TO DO, HE WAS FORCED TO
25 DO BY THE CONDITION OF THE PATIENT.
3606
1 Q. AND HAVE YOU ALSO LOOKED AT THE SITUATION OF PATIENT
2 ELLEN ANDERSON?
3 A. YES.
4 Q. AND DO YOU RECALL THE CIRCUMSTANCES OF THAT SITUATION
5 GENERALLY?
6 A. YES. SHE HAS SEVERE OSTEOPOROSIS, WHICH IS VERY A
7 PAINFUL CONDITION.
8 Q. AND DO YOU HAVE AN OPINION AS TO WHETHER OR NOT SHE DIED
9 AS A RESULT OF MORPHINE-INDUCED RESPIRATORY DEPRESSION?
10 A. I DO.
11 Q. AND WHAT IS YOUR OPINION?
12 A. MY OPINION IS THAT MORPHINE HAD NOTHING TO DO WITH IT.
13 SHE PROBABLY GOT THE LOWEST DOSE OF MORPHINE OF ANY PATIENT
14 THAT WAS THERE, AND SHE HAD THIS HORRIBLE OSTEOPOROSIS WHERE
15 THE NURSES HAD RECORDED IN THE CHART THAT SHE SCREAMED EVERY
16 TIME ANYBODY TOUCHED HER. SO -- AND SHE HAD A FRACTURE OF
17 THE WRIST, SHE'D HAD A FRACTURE OF HER HIP. SO THIS IS A
18 VERY PAINFUL CONDITION. AND SHE GOT 20 MILLIGRAMS OF
19 MORPHINE PER 24 HOURS. AND THAT'S A VERY LOW DOSE.
20 Q. ARE YOU AWARE OF ANY STUDIES THAT HAVE BEEN DONE IN THE
21 FIELD OF PAIN MANAGEMENT RELATING TO SEVERELY DEMENTED
22 PATIENTS?
23 A. YES, THERE'S BEEN A STUDY DONE COMPARING DEMENTED
24 PATIENTS WHO GOT A HIP FRACTURE WITH PEOPLE OF THE SAME AGE
25 AND THE SAME GENDER WHO HAD HIP FRACTURES BUT WERE NOT
3607
1 DEMENTED. AND IN THE GROUP THAT WERE DEMENTED, THEY GOT FAR
2 LESS PAIN MEDICATION THAN THE GROUP THAT WAS NOT DEMENTED,
3 THAT WAS ABLE TO COMMUNICATE THEIR SYMPTOMS AND RESPOND BY
4 SAYING, YES, THIS MAKES ME BETTER. THE DEMENTED PATIENTS
5 COULDN'T DO THAT. SO THE PEOPLE TAKING CARE OF THOSE
6 PARTICULAR PATIENTS HAD TO USE THEIR BEST JUDGMENT AS TO
7 WHAT WAS GOING ON. AND OUT OF THAT GROUP, THEY GOT FAR LESS
8 THAN THE GROUP THAT COULD COMMUNICATE.
9 Q. FINALLY, DOCTOR, IN TERMS OF PAIN ASSESSMENT OR PAIN
10 MANAGEMENT, CAN AN UNCONSCIOUS PERSON FEEL PAIN?
11 A. AN UNCONSCIOUS PERSON?
12 Q. YES.
13 A. PAIN IS A CON --
14 MR. WILSON: OBJECTION, YOUR HONOR, WITHOUT FURTHER
15 FOUNDATION.
16 MR. STIRBA: I DON'T KNOW WHAT MORE FOUNDATION I
17 CAN LAY IN TERMS OF HIS EXPERTISE IN THE AREA.
18 THE COURT: OVERRULED.
19 THE WITNESS: I'M SORRY, WHAT WAS THE QUESTION?
20 Q. (BY MR. STIRBA) THE QUESTION RELATES TO WHETHER OR NOT
21 IT IS ESTABLISHED THAT AN UNCONSCIOUS PERSON, CAN THEY FEEL
22 PAIN?
23 A. PAIN IS A CONSCIOUS EXPERIENCE. THEY CANNOT FEEL PAIN.
24 THAT'S THE REASON WHY YOU PUT PEOPLE TO SLEEP TO OPERATE ON
25 'EM.
3608
1 Q. IS THERE A PROTOCOL WITH RESPECT TO A COMATOSE PATIENT
2 IN TERMS OF WHETHER OR NOT THEY ARE PROVIDED PAIN MANAGEMENT
3 IN SURGERY?
4 A. WELL, INSOFAR AS A PATIENT, LET'S SAY, WHO'S TOLERANT TO
5 AN OPIOID, MORPHINE, AND THEY BECOME COMATOSE, AND --
6 MR. WILSON: YOUR HONOR, I'M GONNA OBJECT ON
7 RELEVANCY.
8 THE COURT: SUSTAINED.
9 Q. (BY MR. STIRBA) CAN A COMATOSE PATIENT FEEL PAIN?
10 A. NO.
11 MR. STIRBA: THAT'S ALL.
12 THE COURT: OKAY. MR. WILSON.
13 CROSS-EXAMINATION
14 BY MR. WILSON:
15 Q. GOOD AFTERNOON, DOCTOR.
16 A. GOOD AFTERNOON.
17 Q. DOCTOR, IN LOOKING OVER YOUR CURRICULUM VITAE THAT
18 YOU'VE ATTACHED, IT APPEARS THAT YOU'VE HAD EXTENSIVE
19 EXPERIENCE AND IT'S BEEN PRIMARILY RELATED TO THE TREATMENT
20 OF CANCER PATIENTS. IS THAT AN ACCURATE STATEMENT?
21 A. I DON'T KNOW THAT YOU'D CALL IT TREMENDOUS EXPERIENCE,
22 BUT I SPENT THE FIRST PART OF MY CAREER TREATING CANCER
23 PATIENTS, AND THEN MOVED INTO THE FIELD OF PAIN.
24 Q. IN LOOKING AT THE PAIN MANAGEMENT THAT YOU'VE BEEN
25 INVOLVED IN, HAS THAT PRIMARILY BEEN INVOLVED WITH
3609
1 MANAGEMENT OF PAIN IN CANCER PATIENTS?
2 A. YES. AND I'D EMPHASIZE PAIN IN CANCER PATIENTS, NOT
3 CANCER PAIN BECAUSE THAT ENCOMPASSES --
4 Q. I APPRECIATE THAT --
5 A. -- ALL TYPES OF PAIN.
6 Q. EXCUSE ME, I'LL TRY TO REFER TO THAT. THE OTHER AREA
7 THAT I NOTE THAT YOU'VE PUBLISHED ON QUITE EXTENSIVELY
8 RELATES TO THYROID CANCER AND THYROID DISEASE?
9 A. RIGHT.
10 Q. HAVE YOU EVER PUBLISHED ANYTHING IN RESPECT TO THE AREA
11 OF GERIATRIC OR PAIN MANAGEMENT IN THE GERIATRIC?
12 A. NO.
13 Q. HAVE YOU EVER DONE OR PARTICIPATED IN ANY STUDIES AS IT
14 RELATES TO THE TREATMENT OF PAIN IN GERIATRIC --
15 A. NO.
16 Q. -- PATIENTS? HAVE YOU EVER DONE ANY STUDIES AS IT
17 RELATES TO PSYCHIATRY AND THE TREATMENT OF GERIATRIC
18 PATIENTS --
19 A. NO.
20 Q. -- PSYCHOLOGICAL -- OKAY. YOU UNDERSTOOD THE
21 QUESTION --
22 THE COURT: WAIT UNTIL HE ASKS THE QUESTION.
23 THE WITNESS: ALL RIGHT.
24 Q. (BY MR. WILSON) HAVE YOU EVER DONE ANY TREATMENT OR
25 DONE ANY STUDIES IN THE GEROPSYCHIATRIC AREA?
3610
1 A. NO.
2 Q. OKAY. NOW, IN RESPECT TO THE -- AND YOU'VE DONE
3 NUMEROUS -- IT APPEARS THAT YOU'VE LECTURED FOR YEARS AND
4 YEARS IN CONNECTION WITH PAIN MANAGEMENT.
5 A. RIGHT.
6 Q. WOULD THAT BE AN ACCURATE STATEMENT?
7 A. YES.
8 Q. AND I TAKE IT YOU'RE A STRONG ADVOCATE FOR PAIN
9 MANAGEMENT. IS THAT AN ACCURATE STATEMENT?
10 A. VERY ACCURATE.
11 Q. AND I ALSO TAKE IT FROM WHAT I'VE BEEN ABLE TO GATHER
12 FROM SOME OF THE TOPICS THAT YOU HAVE SOME FAIRLY STRONG
13 FEELINGS ABOUT THE UNDERTREATMENT OF PAIN. WOULD THAT BE A
14 FAIR STATEMENT?
15 A. THAT WOULD BE A VERY FAIR STATEMENT.
16 Q. AND THAT YOU FEEL STRONGLY THAT WE NEED TO BE MAYBE NOT
17 LIBERAL, BUT AT LEAST WE NEED TO DEREGULATE AND ALLOW THE
18 PHYSICIAN MORE DISCRETION IN THE USE OF VARIOUS MEDICATIONS
19 FOR THE TREATMENT OF PAIN?
20 A. ASK THAT OVER, WOULD YOU PLEASE?
21 Q. I'LL TRY AND REFINE THE QUESTION.
22 A. OKAY.
23 Q. DO YOU BELIEVE THAT A PHYSICIAN AT THE PRESENT TIME IS
24 RESTRICTED RELATIVE TO HIS ABILITY TO MANAGE PAIN?
25 A. YES.
3611
1 Q. AND DO YOU FEEL STRONGLY ABOUT THAT PARTICULAR TOPIC?
2 A. YES.
3 Q. OKAY. IS THAT ONE OF THE REASONS WHY YOU'RE HERE
4 TESTIFYING IN THIS COURTROOM TODAY?
5 A. I SUPPOSE SO.
6 Q. OKAY. AS I UNDERSTAND IT, YOU'VE BEEN DOING THAT FOR
7 ALMOST 20 SOME ODD YEARS, IS THAT CORRECT --
8 A. THAT'S RIGHT.
9 Q. -- AND EVEN LONGER.
10 A. RIGHT.
11 Q. OKAY. I WAS GONNA TELL YOU, I'VE GOT A LITTLE PAIN IN
12 MY LEFT LEG. I WAS WONDERING MAYBE YOU COULD EVALUATE ME
13 AFTER.
14 A. I DON'T THINK YOU COULD AFFORD --
15 THE COURT: CAN WE DO THAT AFTER?
16 THE WITNESS: I DON'T THINK YOU COULD AFFORD MY
17 FEES.
18 Q. (BY MR. WILSON) WELL, MAYBE I OUGHTA ASK YOU THAT
19 QUESTION RIGHT NOW. I ASSUME YOU'VE MADE ARRANGEMENTS FOR A
20 FEE IN THIS -- IN THESE PROCEEDINGS?
21 A. YEAH, WE TALKED ABOUT THAT.
22 Q. OKAY. CAN YOU TELL US WHAT YOUR CHARGES ARE?
23 A. WELL, MY CHARGES ARE -- I HAVE -- I STATE TO ANYBODY
24 THAT IT'S $400 AN HOUR.
25 Q. OKAY.
3612
1 A. AND WHETHER I GET THAT OR NOT'S SOMETHING ELSE.
2 Q. I APPRECIATE THAT. AND HOW MANY HOURS HAVE YOU SPENT AT
3 THE PRESENT TIME IN REVIEWING THESE RECORDS?
4 A. WELL, YOU KNOW, I'M NOT REALLY SURE. I -- IT'S BEEN
5 GOING ON A WHILE, SO -- I'M NOT A VERY GOOD RECORDKEEPER,
6 AND SO I'D HAVE TO SORT OF LOOK OVER WHATEVER NOTES I'VE GOT
7 IN THAT REGARD TO TRY TO COME TO SOME CONCLUSION.
8 Q. WELL, I APPRECIATE THAT. COULD I ASK YOU, DOCTOR, YOU
9 INDICATED I THINK IN YOUR EARLIER TESTIMONY THAT YOU
10 PARTICIPATED ON A NUMBER OF COMMITTEES TO PREPARE AND
11 PUBLISH GUIDELINES FOR MANAGEMENT OF PAIN.
12 A. RIGHT.
13 Q. ONE OF THOSE GUIDELINES THAT YOU'VE PREPARED REFERRED TO
14 THE MANAGEMENT OF CANCER PAIN IN ADULTS. YOU PARTICIPATED
15 ON THAT?
16 A. UH-HUH.
17 Q. I HAVE A COPY OF THAT THAT I'VE REVIEWED FOR THESE
18 PROCEEDINGS. AND I DON'T KNOW WHETHER YOU CAN RECALL THOSE
19 PARTICULAR GUIDELINES, BUT I'D LIKE TO ASK YOU SOME
20 QUESTIONS ABOUT THEM --
21 A. OKAY.
22 Q. -- IF I MIGHT.
23 A. I DON'T REALLY KNOW WHAT YOU'RE REFERRING TO, BUT IF I
24 WROTE IT, I GUESS I WROTE IT.
25 Q. LET ME SEE IF I CAN ORIENTATE YOU ON THAT. IT APPEARS
3613
1 THAT IT'S FAIRLY RECENT IN ORIGIN. THE --
2 A. WAS IT IN THE JOURNAL OF PAIN AND SYMPTOM MANAGEMENT?
3 Q. IT SAYS, A QUICK REFERENCE GUIDE FOR CIRCULARS NUMBER
4 NINE, MANAGEMENT OF CANCER PAIN IN ADULTS. AND I THOUGHT IT
5 WAS PUBLISHED HERE JUST RECENTLY. UP IN THE LEFT-HAND
6 CORNER, IT HAS COTTAGE HEALTH SYSTEMS.
7 A. IS WHAT?
8 Q. MAYBE I CAN SHOW IT --
9 A. MAYBE THERE'S SOME PLAGIARISM HERE.
10 Q. WELL, THEN YOU CAN HIRE MR. STIRBA.
11 MR. STIRBA: HE COULDN'T AFFORD MY RATES.
12 THE WITNESS: OH, OKAY.
13 Q. (BY MR. WILSON) DO YOU RECOGNIZE THAT PARTICULAR --
14 A. I RECOGNIZE THIS. THIS IS A -- THIS IS WITH THE
15 A.C.P.R., AGENCY FOR HEALTHCARE POLICY AND RESEARCH.
16 THEY'VE CHANGED THE NAME OF IT RECENTLY. THIS IS U.S.
17 DEPARTMENT OF HEALTH AND HUMAN SERVICES. THIS IS --
18 ACCOMPANIED -- THE MAIN GUIDELINE WAS MANAGEMENT OF CANCER
19 PAIN. THEN THERE WAS A SUBSET THAT WAS SEPARATED OUT AND
20 PUBLISHED AS MANAGEMENT OF CANCER PAIN IN ADULTS. AND THEN
21 IT WAS MANAGEMENT OF CANCER PAIN IN CHILDREN.
22 Q. OKAY.
23 A. AND THEN IT WAS A PAMPHLET FOR THE PATIENTS --
24 Q. OKAY.
25 A. -- TO KNOW. SO THIS IS PART OF THAT --
3614
1 Q. THAT PUBLICATION --
2 A. -- FOUR DIFFERENT LITTLE PAMPHLETS THAT WENT ALONG WITH
3 IT.
4 Q. OKAY. ARE YOU FAMILIAR WITH THE DOCUMENT ITSELF, AND
5 YOU WERE ONE OF THE CONTRIBUTORS APPARENTLY TO THAT
6 DOCUMENT.
7 A. RIGHT, RIGHT.
8 Q. AND YOU AGREE, I ASSUME, WITH THE CONCEPTS AND THE
9 PROCESSES THAT ARE -- THE PROCEDURES THAT ARE RECOMMENDED IN
10 THE DOCUMENT?
11 A. YES, I DO.
12 Q. OKAY. AND IF I MIGHT JUST TALK A LITTLE BIT ABOUT
13 THOSE, AND YOU'VE ALLUDED TO SOME OF THEM IN YOUR EARLIER
14 TESTIMONY, BUT YOU TALK ABOUT SITTING DOWN -- ONE OF THE
15 MOST IMPORTANT THINGS IN THE TREATMENT OF PAIN IS TO SIT
16 DOWN AND DISCUSS THE PAIN MANAGEMENT WITH THE FAMILY OR WITH
17 THE PATIENT.
18 A. YES.
19 Q. AND IN THIS PARTICULAR CASE, THAT WAS VERY PROBLEMATICAL
20 AS YOU'VE TESTIFIED TO --
21 A. WHICH CASE ARE YOU REFERRING TO?
22 Q. WELL, IN TERMS OF THE FIVE PATIENTS THAT WE'RE TALKING
23 ABOUT HERE IN THIS PARTICULAR PROCEEDINGS.
24 A. WELL. THERE ARE NOTES IN RECORD WHERE DR. WEITZEL HAS
25 SAID, I TALKED TO THE SON OR THE DAUGHTER, AND SO FORTH.
3615
1 AND I BELIEVE -- I'D HAVE TO CHECK THROUGH HERE FOR SURE --
2 Q. WELL, MAYBE YOU DIDN'T UNDERSTOOD MY QUESTION. MY
3 QUESTION WAS, AS TO THE PATIENTS THEMSELVES, IN SPEAKING
4 WITH THEM, I THINK YOU'VE TESTIFIED THAT THESE PATIENTS WERE
5 SUFFERING FROM VARIOUS FORMS OR VARIOUS STAGES OF DEMENTIA
6 THAT MADE IT -- AND MAYBE I'M MISCHARACTERIZING, BUT MADE IT
7 NEARLY IMPOSSIBLE FOR A DOCTOR TO EVALUATE OR GET FEEDBACK
8 AS TO THEIR SYMPTOMS. IS THAT RIGHT?
9 A. THEY DIDN'T GET ANYTHING FOR THEIR SYMPTOMS.
10 Q. OKAY. SO HE HAD TO RELY ON WHATEVER OTHER HISTORY THAT
11 COULD BE PROVIDED HIM, IS THAT --
12 A. AND --
13 Q. -- CORRECT?
14 A. AND THE ACTIONS AND -- OF THE PATIENTS.
15 Q. RIGHT. AND THE ACTIONS --
16 A. THE BEHAVIOR.
17 Q. NOW, YOU SAY IN THIS ARTICLE THAT IN THE INITIAL
18 ASSESSMENT, THE GOAL OF THE INITIAL ASSESSMENT OF PAIN IS TO
19 CHARACTERIZE THE PAIN BY LOCATION, INTENSITY, AND ETIOLOGY.
20 NOW, WHAT DOES ETIOLOGY MEAN?
21 A. CAUSE OF.
22 Q. OKAY. AND THEN YOU GO DOWN AND THERE'S A DETAILED --
23 YOU INDICATE IN ORDER TO DO THAT, YOU NEED A DETAILED
24 HISTORY, YOU NEED A PHYSICAL EXAMINATION, YOU NEED A
25 PSYCHOSOCIAL ASSESSMENT, OR MAYBE EVEN A PSYCHIATRIC
3616
1 ASSESSMENT, AS IN THIS CASE. WOULD THAT BE APPROPRIATE?
2 A. YES, IT WOULD. HOWEVER, THESE PATIENTS WERE UNABLE TO
3 GIVE A HISTORY WHETHER IT WAS ABOUT THE PRESENT ILLNESS OR
4 PAST ILLNESSES, THEIR PSYCHOLOGICAL PROBLEMS OR ANYTHING.
5 THERE WAS NO WAY THAT ANY OF THIS COULD BE DONE.
6 Q. OKAY.
7 A. THIS WAS -- THEY DIDN'T HAVE THE LUXURY OF THAT
8 ASSESSMENT.
9 Q. WELL, LET ME ASK YOU, IS THERE OTHER WAYS TO GET
10 DETAILED HISTORIES?
11 A. NOT REALLY. BECAUSE THE RELATIVES WOULD ONLY KNOW ABOUT
12 WHAT THEY KNOW ABOUT. THEY WOULDN'T KNOW EXACTLY, AND SO --
13 Q. ISN'T IT TRUE, DOCTOR, THAT YOU CAN GET HISTORIES FROM
14 THEIR PRIOR CARE PROVIDERS?
15 A. YES, CONCERNING THE SITUATION THAT'S EXISTED AT THAT
16 TIME.
17 Q. OKAY. WEREN'T THOSE -- WEREN'T ALL OF THESE PATIENTS
18 INDIVIDUALS WHO HAD BEEN IN CARE CENTERS JUST PRIOR TO THEIR
19 ADMISSION TO THE GEROPSYCH UNIT?
20 A. YES, BUT I DON'T KNOW WHAT THEIR CONDITION WAS AT THE
21 TIME THAT THEY WENT INTO THOSE CARE CENTERS.
22 Q. SO YOU DIDN'T REVIEW ANY OF THOSE RECORDS.
23 A. NO.
24 Q. AND YOU DIDN'T REVIEW ANY OF THE RECORDS AT THE CARE
25 CENTER, IS THAT CORRECT?
3617
1 A. NO, NO, THAT'S RIGHT.
2 Q. WOULD THAT INFORMATION HAVE -- WOULD HAVE BEEN HELPFUL
3 TO YOU IN ASSESSING THEIR PAIN?
4 A. I DOUBT IT.
5 Q. OKAY.
6 A. IT WOULD HAVE TO BE SOMETHING FAIRLY UNUSUAL. WE
7 HAVE --
8 Q. THERE'S ALSO A PROVISION AS TO A DIAGNOSTIC EVALUATION
9 AND -- THAT TAKES PLACE IN THIS PROCESS OF EVALUATING THE
10 PAIN, IS THAT RIGHT?
11 A. I'M SORRY, REPEAT THAT AGAIN?
12 Q. THIS'S ALSO ONE OF THE -- ONE OF THE ESSENTIALS FOR
13 INITIAL ASSESSMENT INCLUDES A DIAGNOSTIC EVALUATION, IS THAT
14 CORRECT?
15 A. YEAH, THAT'S WHAT YOU WANNA DO.
16 Q. OKAY.
17 A. I'M NOT SURE WHAT THAT MEANS IN THAT QUESTION.
18 Q. WELL, I'M JUST QUOTING FROM THE ARTICLE. IT LISTS THE
19 GOAL OF THE INITIAL ASSESSMENT IS TO CHARACTERIZE THE PAIN
20 BY LOCATION, INTENSITY, AND ETIOLOGY, AND THEN THEY LIST
21 ESSENTIAL TO THAT INITIAL ASSESSMENT ARE DETAILED HISTORY,
22 PHYSICAL EXAMINATION, PSYCHOSOCIAL ASSESSMENT, AND
23 DIAGNOSTIC EVALUATION.
24 A. WE'RE NOT TALKING ABOUT DEMENTIA -- DEMENTED PATIENTS,
25 IF THAT'S IN THAT SIT -- CONTEXT. IT'S IMPOSSIBLE TO GET
3618
1 THAT IN A DEMENTED PATIENT.
2 Q. NOW, THE NEXT THING, AS I UNDERSTAND IT, THAT YOU TRY TO
3 DO IS YOU DO FOLLOW-UP ASSESSMENTS, YOU TRY TO ASCERTAIN THE
4 INTENSITY AND SEVERITY OF THE PAIN.
5 A. YEAH, BUT YOU CAN'T DO THAT WITH SOMEBODY WHO'S
6 DEMENTED. THEY CAN'T TELL YOU.
7 Q. HOW MANY DEMENTED PATIENTS DO YOU TREAT IN YOUR
8 PRACTICE?
9 A. NOT MANY.
10 Q. OKAY.
11 A. WELL, THERE'S DIFFERENT DEGREES OF DEMENTIA. SOME OF
12 THEM HAVE VERY MILD DEMENTIA.
13 Q. AND SO YOU CAN GET --
14 A. YOU CAN GET A HISTORY --
15 Q. -- RECORDING FROM --
16 A. YEAH, YOU CAN --
17 Q. -- THOSE PATIENTS --
18 A. YOU CAN GET A HISTORY, BUT ONCE THAT'S BEEN ROBBED FROM
19 THE PATIENT, YOU CAN'T GET IT.
20 Q. YOU CAN ALSO -- YOU INDICATE ONCE YOU'VE MADE THAT
21 DECISION --
22 A. UH-HUH.
23 Q. -- ONCE YOU'VE COME TO A CONCLUSION AS A PHYSICIAN THAT
24 THIS PERSON IS SUFFERING PAIN, THEN AS I UNDERSTAND IT, YOU
25 START OUT WITH THE SIMPLEST DOSAGE SCHEDULES AND THE LEAST
3619
1 INVASIVE PAIN MANAGEMENT PROCESS, IS THAT RIGHT?
2 A. THAT'S RIGHT.
3 Q. OKAY.
4 A. I DON'T KNOW WHAT YOU'RE IMPLYING BY THAT. IF SOMEBODY
5 CAME INTO THE EMERGENCY ROOM WITH A BROKEN COMPOUND FRACTURE
6 OF THE FEMUR, YOU WOULDN'T GIVE THEM AN ASPIRIN --
7 Q. THAT'S RIGHT.
8 A. -- YOU'D GIVE 'EM A SHOT OF MORPHINE, SO THAT'S THE
9 SIMPLEST THING THAT WOULD BE EFFECTIVE UNDER THOSE
10 CONDITIONS. AND WE CAN'T GET AWAY FROM THE CLINICAL
11 CONDITION THAT WE'RE TALKING ABOUT. IT'S NOT TO ROUTINELY
12 TAKE -- GO THROUGH A LITANY OF INEFFECTIVE TREATMENT WHEN
13 SOMEBODY IS IN SEVERE PAIN.
14 Q. WELL, LET'S TALK ABOUT SOME OF THE PARTICULAR PATIENTS
15 THAT YOU REVIEWED THEIR RECORDS.
16 A. OKAY.
17 Q. IF YOU'RE GOING TO USE AN OPOID -- OPIOID I GUESS IS THE
18 CORRECT WAY TO SAY IT, IN THE TREATMENT OF A PATIENT, SUCH
19 AS MORPHINE, IS THE PATIENT'S WEIGHT A SIGNIFICANT FACTOR?
20 A. NO, NOT REALLY.
21 Q. NOW, IN THE CHARTS ATTACHED TO THIS ARTICLE, YOU TALK
22 ABOUT PATIENTS WHO HAVE A 50-KILOGRAM BODY WEIGHT OR BETTER.
23 IS THAT RIGHT?
24 A. YEAH, BUT THAT WAS TO DISTINGUISH THEM FROM CHILDREN.
25 Q. WELL, ASSUME FOR A MINUTE, IF YOU HAVE AN ELDERLY
3620
1 PATIENT WHO'S 81 YEARS OF AGE, AND WHO WEIGHS 81 POUNDS, I
2 THINK THE CONVERSION RATE THERE WOULD BE PRETTY CLOSE TO 37
3 KILOGRAMS, WOULD IT NOT?
4 A. YOU SAY SHE'S 81 POUNDS? YEAH, SOMETHING LIKE THAT.
5 Q. 81 POUNDS?
6 A. UH-HUH.
7 Q. NOW, WOULD THAT BEAR ANY SIGNIFICANCE TO YOU AS TO THE
8 DOSAGE THAT WOULD BE APPROPRIATELY ADMINISTERED TO THAT
9 PARTICULAR PATIENT OF AN --
10 A. THE MOST IMPORTANT CONSIDERATION THAT A PHYSICIAN HAS TO
11 LOOK AT WHEN THEY'RE DEALING WITH AN EMACIATED PATIENT IS
12 HOW DO YOU GET THEY DRUG INTO THE BODY. IF YOU GIVE IT
13 I.M., THERE IS NOT MUCH TISSUE THERE TO GIVE. YOU MAY WANNA
14 GIVE IT RECTALLY, YOU MAY WANNA GIVE IT BY A TRANSBUCOS --
15 TRANSDERMAL ROUTE OR SOMETHING LIKE THAT. DEPENDS UPON THE
16 SEVERITY OF THE PAIN.
17 Q. WELL, LET'S TALK ABOUT ELLEN --
18 A. THE SEVERITY OF THE PAIN.
19 Q. -- ANDERSON. ELLEN ANDERSON.
20 A. OKAY.
21 Q. NOW --
22 A. THE WEIGHT --
23 Q. JUST A MINUTE. LET ME ASK THE QUESTIONS --
24 A. OKAY.
25 Q. -- WOULD YOU PLEASE? WOULD HER HISTORY OF PRIOR OPIOID
3621
1 USE BE RELEVANT?
2 A. YES.
3 Q. WOULD HER HISTORY AS RELATED BY THE FAMILY THAT HER
4 SCREAMING AND YELLING AND COMPLAINTS OF WHEN SHE WAS LEFT
5 ALONE, WOULD THAT BE RELEVANT?
6 A. THAT WOULD BE A FACTOR TO TAKE INTO CONSIDERATION, YES.
7 Q. AND WOULD IT --
8 A. I DON'T KNOW HOW RELEVANT --
9 Q. AND WOULD IT ALSO RELATE TO THE FACT IF THE NURSES
10 OBSERVED THE SAME BEHAVIOR BE RELEVANT?
11 A. IT WOULD BE RELEVANT TO TAKE IT INTO CONSIDERATION,
12 YEAH.
13 Q. OKAY.
14 A. I DON'T KNOW WHAT WEIGHT YOU'D PUT ON IT.
15 Q. WOULD THE FACT THAT YOU HAVEN'T HAD AN OPPORTUNITY TO
16 HAVE THEM PHYSICALLY EVALUATED, NO PHYSICAL EVALUATION, BE
17 RELEVANT?
18 A. I DON'T THINK THAT OCCURRED.
19 Q. YOU DON'T THINK THAT OCCURRED?
20 A. I DON'T THINK -- I THINK JUST HER COMING INTO THE
21 HOSPITAL AND SEEING THAT SHE WAS EMACIATED WITH A HISTORY
22 THAT SHE GOT OSTEOPOROSIS, HAD FRACTURES OF THE WRIST AND
23 THE HIP, WOULD -- THAT WOULD BE SOMETHING THAT COULD BE, BY
24 AN EXPERIENCED PHYSICIAN, WOULD BE A PHYSICAL EVALUATION IN
25 SHORT ORDER, THAT THIS PATIENT WAS SICK AND HAD TO HAVE
3622
1 WHATEVER WAS NECESSARY TO RELIEVE THE PAIN. AND THE WEIGHT
2 WOULD BE SOME FACTOR, BUT BASICALLY, THE ULTIMATE FACTOR
3 WOULD BE, IS THE PAIN RELIEVED OR NOT.
4 Q. LET ME ASK YOU THIS: IN MAKING THAT EVALUATION, YOU
5 JUST TALKED ABOUT A PHYSICIAN SEEING THAT INDIVIDUAL, IS
6 THAT RIGHT?
7 A. I ASSUME WE'RE TALKING ABOUT THAT.
8 Q. OKAY. IF THIS INDIVIDUAL, FOUR FOOT NINE, DOES 81
9 POUNDS NECESSARILY MEAN SHE'S EMACIATED?
10 A. NO, NOT REALLY.
11 Q. IF HAD YOU BEFORE YOU A MEDICATION LIST WHICH SHOWED
12 THAT IN THE PAST HER PAIN COMPLAINTS HAD BEEN HANDLED WITH
13 LORTAB, WOULD THAT BE SIGNIFICANT TO YOU?
14 A. THAT WOULD BE MEANINGLESS.
15 Q. THAT WOULD BE MEANINGLESS TO YOU.
16 A. YOU DON'T KNOW WHETHER THAT -- THAT LORTAB RELIEVED THE
17 PAIN OR NOT. AND IF IT DIDN'T, AND THE CHANCES ARE IT
18 DIDN'T, THEN THAT WOULD BE IRRELEVANT.
19 Q. OKAY. WOULD YOU AS A PHYSICIAN THEN -- STRIKE THAT.
20 LET'S JUST IN CONNECTION WITH ELLEN ANDERSON, YOU'VE HEARD A
21 LOT OF STATEMENTS ABOUT NITROSTAT THAT IS GIVEN FOR CHEST
22 PAIN. IS THAT A PAINKILLER? IS THAT AN ANALGESIC?
23 A. NO, IT'S NOT AN ANALGESIC, BUT IT MIGHT RELIEVE PAIN.
24 Q. OKAY. IT OPENS UP THE BLOOD VESSELS --
25 A. ISCHEMIC PAIN --
3623
1 Q. -- THAT --
2 A. -- ISCHEMIC PAIN, WHERE THE BLOOD IS CUT OFF.
3 Q. ALL RIGHT. BUT IT'S NOT A CENTRAL NERVOUS DEPRESSANT.
4 A. NO.
5 Q. LET'S GO BACK AGAIN TO THE ARTICLE, AND I'LL JUST ASK
6 YOU IF YOU AGREE WITH A NUMBER OF THESE THINGS THAT ARE IN
7 THERE. THERE'S A STATEMENT THAT'S MADE THAT OPIOIDS --
8 OPIOIDS, THE MAJOR CLASS OF ANALGESICS -- ANALGESICS USED IN
9 THE MANAGEMENT OF MODERATE TO SEVERE PAIN ARE EFFECTIVELY
10 EASILY TITRATED AND HAVE A FAVORABLE BENEFIT-TO-RISK RATIO.
11 DO YOU AGREE WITH THAT STATEMENT?
12 A. ABSOLUTELY.
13 Q. THEN IT GOES ON TO TALK ABOUT OPIOIDS AND TITRATION.
14 WOULD YOU AGREE THAT IN DETERMINING THE DOSAGE THAT THE
15 PATIENT SHOULD BE GIVEN, THAT IT'S APPROPRIATE -- THAT WHAT
16 YOUR GOAL IS, YOUR GOAL IS THE APPROPRIATE DOSE IN THE
17 AMOUNT THAT CONTROLS THE PAIN WITH THE FEWEST SIDE EFFECTS,
18 IS THAT RIGHT?
19 A. RIGHT, RIGHT.
20 Q. YOU AGREE WITH THAT.
21 A. I AGREE WITH IT.
22 Q. UNDER TITRATION, YOU INDICATE TO INCREASE OR DECREASE
23 THE NEXT DOSE BY ONE-QUARTER TO ONE-HALF OF THE PREVIOUS
24 DOSE?
25 A. RIGHT.
3624
1 Q. IN ORDER TO DO THAT, YOU'VE GOT TO MONITOR THE PATIENT,
2 I ASSUME.
3 A. THERE'S SOME TYPE OF MONITORING GOING ON ALL THE TIME.
4 Q. AND YOU'VE GOT TO BE AWARE OF WHAT THAT MONITORING IS,
5 DON'T YOU?
6 A. WELL, YEAH, TO MAKE SURE THAT THAT'S SATISFACTORY
7 MONITORING.
8 Q. OKAY. AND THE MONITORING THAT GOES ON, PARTICULARLY IF
9 YOU HAVE AN OPIOID NAIVE PATIENT, I ASSUME, IS EVEN MORE
10 SIGNIFICANT AT THAT POINT, IS THAT RIGHT?
11 A. YES, THAT WOULD BE.
12 Q. OKAY. AND THOSE THINGS THAT YOU WOULD WANT TO MONITOR I
13 ASSUME WOULD BE THE -- FOR POSSIBLE SIDE EFFECTS OF THE
14 DRUG, IS THAT CORRECT?
15 A. YES.
16 Q. AND SO THOSE WOULD BE IMPORTANT PROCESSES FOR YOU TO BE
17 AWARE OF IN THIS PROCESS OF ADMINISTERING MEDICATIONS TO A
18 PATIENT, IS THAT RIGHT?
19 A. YES. AND THAT'S USUALLY DONE BY THE NURSING STAFF, AND
20 YOU'RE AWARE OF THEIR TRAINING AND THEIR EXPERTISE AS TO HOW
21 THEY CAN DO THAT. AND THEY'VE BEEN TRAINED TO DO THAT. IF
22 YOU'VE GOT SOME QUESTION ABOUT IT IN YOUR OWN HOSPITAL, THEN
23 THERE IS A PROBLEM. BUT IT WOULD BE COMMON KNOWLEDGE TO THE
24 PEOPLE ON THE STAFF OF THAT HOSPITAL ABOUT THE LEVEL OF
25 COMPETENCY OF THEIR NURSING STAFF.
3625
1 Q. NOW, YOU'RE AWARE FROM YOUR REVIEW OF THE RECORDS THAT
2 ELLEN ANDERSON -- THAT DR. WEITZEL DID NOT SEE HER ON THAT
3 PARTICULAR DAY.
4 MR. STIRBA: YOUR HONOR, I'M GONNA OBJECT. THAT'S
5 ASSUMING FACTS INTO EVIDENCE. NO PROOF OF THAT. HE
6 WOULDN'T KNOW THAT.
7 THE COURT: OKAY. SUSTAINED. DO YOU WANNA
8 REPHRASE IT?
9 Q. (BY MR. WILSON) DID YOU SEE ANYTHING IN YOUR REVIEW IN
10 THE RECORDS THAT DR. WEITZEL EVER PERSONALLY SEEN THIS
11 PATIENT?
12 A. NO, I DIDN'T. I'D HAVE TO ASSUME THAT HE WRITES A NOTE,
13 THAT HE HAD SOME KIND OF CONTACT WITH HIM, BUT I DON'T -- I
14 DON'T KNOW ONE WAY OR THE OTHER.
15 Q. DO YOU THINK IT'S IMPORTANT FOR THE PHYSICIAN TO
16 EVALUATE THE PATIENT BEFORE ADMINISTERING MORPHINE?
17 A. OF COURSE. AND THAT EVALUATION CAN TAKE MANY FORMS. IF
18 YOU ARE WORKING CLOSELY WITH NURSING OR OTHER STAFF, YOU
19 KNOW THEIR ABILITY TO ASSESS SOMEBODY AND YOU HAVE LEARNED
20 THAT YOU CAN RELY ON THAT ASSESSMENT. AND IT MIGHT NOT
21 BE -- AS I RECALL, SHE WASN'T IN THE HOSPITAL VERY LONG.
22 AND IT MIGHT BE THAT SHE -- SHE MIGHT HAVE DIED BEFORE THIS
23 COULD HAPPEN, BUT SHE SHOULDN'T BE DENIED PAIN MEDICATION IF
24 YOU ARE CONFIDENT THAT THE PERSON WHO IS GIVING THAT
25 INFORMATION IS KNOWLEDGEABLE.
3626
1 Q. FROM YOUR PREVIOUS TESTIMONY, I ASSUME THAT YOU'RE
2 ADVISED THAT HER RESPIRATIONS ARE VARYING FROM 8 TO 16, THAT
3 THAT WOULD NOT CONTRAINDICATE TO YOU THE USE OF ADDITIONAL
4 DOSAGE OF MORPHINE, IS THAT CORRECT?
5 A. THAT'S RIGHT.
6 Q. IT WOULD ALSO NOT IN YOUR TESTIMONY BE REPRESENTATIVE OF
7 ANY INDICATION THAT SHE WAS IN DISTRESS FROM MORPHINE, IS
8 THAT CORRECT?
9 A. THAT'S RIGHT.
10 Q. FACT OF MATTER IS, YOU DON'T KNOW WHAT SHE WAS IN
11 DISTRESS WITH, DO YOU, DOCTOR?
12 A. ELLEN ANDERSON? SHE WAS BLEEDING, SHE HAD -- SHE
13 VOMITED UP 200 C.C.'S OF COFFEE GROUND MATERIAL, AND WHAT
14 THAT MEANS IS THAT THAT'S BLOOD THAT HAS MIXED WITH THE ACID
15 IN THE STOMACH AND TURNED BROWN, LIKE GROUNDS. SHE VOMITED
16 UP 200 C.C.'S. THAT'S TWO UNITS OF BLOOD PRACTICALLY. AND
17 THEN SHE HAD MELENA, WHICH IS BLOOD IN THE STOOL, SO SHE WAS
18 BLEEDING TO DEATH.
19 Q. ELLEN ANDERSON WAS?
20 A. I BELIEVE SO.
21 Q. OKAY.
22 A. SHE WAS HAVING -- THAT WAS SORT OF A TERMINAL EVENT.
23 AND I'M SURE THAT'S WHAT DISTURBED HER CARDIOVASCULAR
24 SYSTEM.
25 Q. I SEE, DOCTOR. IN EACH ONE OF THESE PARTICULAR
3627
1 PATIENTS, THERE WAS A TERMINAL EVENT, IS THAT RIGHT?
2 A. WELL, I'M ASSUMING THERE SURE WAS, BUT I'M -- I'D HAVE
3 TO REVIEW TO SEE WHAT I THOUGHT WAS THE TERMINAL EVENT.
4 BECAUSE SOME OF THE AUTOPSIES WERE INCONCLUSIVE. THEY
5 DIDN'T KNOW WHAT KILLED HER.
6 Q. WOULD YOU AGREE THAT THERE'S A CERTAIN ENHANCING EFFECT
7 ON CENTRAL NERVOUS SYSTEM DEPRESSANTS IF THEY'RE GIVEN IN
8 COMBINATION WITH ONE ANOTHER?
9 A. BY CENTRAL NERVOUS SYSTEM DEPRESSANTS, ARE YOU TALKING
10 ABOUT THE BENZODIAZEPINES OR --
11 Q. WELL --
12 A. -- THE ANTIDEPRESSANTS --
13 Q. -- YOU'VE GOT ME THERE, DOCTOR. I DON'T KNOW WHAT I'M
14 TALKING ABOUT. BUT LET ME JUST ASK YOU SOME QUICK
15 QUESTIONS. ARE YOU FAMILIAR WITH THE DRUG HALDOL?
16 A. YES.
17 Q. DOES IT HAVE CENTRAL NERVOUS SYSTEM DEPRESSANT EFFECTS?
18 A. YES, IT DOES.
19 Q. OKAY. AND THE DRUG ATIVAN?
20 A. YES.
21 Q. AND THE DRUG SERZONE?
22 A. YES. ALL OF THOSE --
23 Q. AND TRAZODONE?
24 A. ALL OF THOSE ARE PSYCHOACTIVE DRUGS.
25 Q. OKAY. THOSE ARE ALL PSYCHOTROPIC TYPE OF MEDICATIONS --
3628
1 A. RIGHT.
2 Q. -- RIGHT?
3 A. RIGHT.
4 Q. AND DO YOU USE THOSE TYPES OF MEDICATIONS?
5 A. YES, I DO.
6 Q. AND DO YOU USE THEM FREQUENTLY IN YOUR -- IN YOUR PAIN
7 MANAGEMENT?
8 A. YES, I DO.
9 Q. OKAY. AND DO YOU USE THOSE IN CONJUNCTION WITH OTHER
10 OPIOID-BASED --
11 A. YES.
12 Q. -- DRUGS? AND CAN YOU TELL US, IS THERE AN ENHANCED
13 EFFECT THAT YOU AS A PHYSICIAN HAVE TO BE AWARE OF IN USING
14 THOSE IN CONJUNCTION WITH EACH OTHER?
15 A. YES.
16 Q. AND AGAIN, ISN'T IT TRUE THAT THAT PROCESS THAT YOU GO
17 THROUGH IN TERMS OF MONITORING AND TITRATING THOSE DRUGS IS
18 AN IMPORTANT PROCESS, IS THAT RIGHT?
19 A. THAT'S RIGHT.
20 Q. OKAY. CAN YOU TELL US, DOES A ROUTINE ORDER TO BEGIN
21 WITH ON A PATIENT EVERY FOUR HOURS, DOES THAT EQUATE TO
22 TITRATION?
23 A. I DON'T REALLY KNOW. I THINK YOU'D HAVE TO DESCRIBE THE
24 CLINICAL SITUATION. IF A PATIENT THAT COMES FROM ANOTHER
25 INSTITUTION AND THEY'RE GETTING SOMETHING EVERY FOUR HOURS,
3629
1 ALL YOU DO IS CONTINUE THAT. YOU DON'T HAVE TO TITRATE
2 ANYTHING.
3 Q. OKAY.
4 A. AND SO --
5 Q. ASSUMING THE PATIENT IS NOT -- ASSUMING THE PATIENT IS
6 BEING ADMINISTERED MORPHINE FOR THE FIRST TIME, DO YOU
7 TITRATE THE DRUG MORPHINE?
8 A. TITRATE JUST MEANS THAT YOU ACHIEVE THE PROPER DOSE.
9 YOU EITHER TITRATE IT UPWARD OR YOU TITRATE IT DOWNWARD. IT
10 MEANS YOU MOVE DOWN THE DOSE IF YOU'RE GONNA GO DOWNWARD OR
11 YOU MOVE UP THE DOSE IF YOU'RE GONNA GO UP.
12 Q. OKAY.
13 A. IT DEPENDS UPON YOUR ASSESSMENT OF THE OUTCOME. IF WHAT
14 YOU GAVE THEM THE FIRST TIME IS EFFECTIVE, YOU DON'T HAVE TO
15 TITRATE ANYTHING.
16 Q. OKAY. AND -- AND ASSUMING THAT THE FIRST ORDER THAT IS
17 ENTERED FOR THE MORPHINE IS ENTERED AS AN ORDER, A ROUTINE
18 ORDER OF SO MUCH MORPHINE EVERY THREE OR FOUR HOURS --
19 A. YES.
20 Q. -- DOES THAT REPRESENT TO YOU THAT THERE IS A TITRATION
21 PROCESS GOING ON THERE?
22 A. THAT QUESTION TAKEN ALONE I DON'T BELIEVE CAN BE
23 ANSWERED. BECAUSE TITRATION MIGHT COME FOUR HOURS LATER.
24 AND WE HAVE ALWAYS RECOMMENDED THAT MEDICATION SUCH AS PAIN
25 MEDICATIONS AND MORPHINE AND SO FORTH BE GIVEN ON AN
3630
1 AROUND-THE-CLOCK BASIS, NOT BY AS NEEDED BASIS, PARTICULARLY
2 IN A DEMENTED PATIENT. THEY CAN'T TELL YOU ANYTHING ABOUT
3 THE RESULTS. AND THEY CAN'T ASK FOR ANOTHER DOSE. SO YES,
4 THIS IS A VALID WAY TO APPROACH ON DAY ONE.
5 Q. DOCTOR, YOU PREVIOUSLY TESTIFIED HOW THE DRUG MORPHINE
6 SUPPRESSES THE VARIOUS FUNCTIONS OF THE BRAIN AND EVENTUALLY
7 RESULTS UP IN IMPACTING THE RESPIRATORY --
8 A. CENTER.
9 Q. -- CENTER, WHICH IS IN THE LOWER BACK OF THE NECK, I
10 GUESS --
11 A. CALLED THE BRAIN STEM.
12 Q. THE BRAIN STEM. AND I THINK YOU TESTIFIED THAT THE
13 THINGS THAT YOU WOULD SEE IS YOU WOULD SEE A REDUCED
14 BREATHING RATE, IS THAT RIGHT?
15 A. YES, GRADUAL.
16 Q. GRADUAL REDUCTION IN BREATHING. AND YOU WOULD ALSO
17 SEE -- THIS PERSON COULD LAPSE INTO I GUESS A COMA
18 EVENTUALLY, IS THAT RIGHT?
19 A. YES.
20 Q. AND I GUESS FOR OUR PURPOSES IN TERMS OF A COMA, DOES
21 THAT MEAN THAT THE PATIENT WILL NOT RESPOND TO ANY KIND OF
22 STIMULI?
23 A. DEPENDS UPON THE DEPTH OF THE COMA. AND YOU HAVE TO USE
24 CERTAIN TECHNIQUES TO SEE HOW RESPONSIVE THEY ARE. ONE IS
25 TO PUSH ON THE NERVE, THE SUPRAORBITAL NERVE THAT COMES OUT
3631
1 HERE.
2 Q. NOW, IF A PATIENT IS JUST BEGINNING TO FALL INTO THAT
3 TYPE OF A STATE --
4 A. YEAH.
5 Q. -- WILL THEY RESPOND TO ANYBODY AROUND THEM NORMALLY?
6 A. DEPENDS UPON DEPTH OF THE --
7 Q. OF THE COMA.
8 A. -- COMA, YEAH.
9 Q. SO I WOULD ASSUME YOU WOULD SEE A PROGRESSION THAT WOULD
10 MAYBE GO FROM BEING LETHARGIC TO BEING APPEARING TO BE
11 ASLEEP, TO FINALLY JUST BEING IN THIS COMA, IS THAT RIGHT?
12 A. RIGHT, RIGHT.
13 Q. AND THAT'S THE PROCESS THAT YOU WOULD OBSERVE IN A
14 PATIENT WHO WAS BEING -- OR SUFFERING FROM THE SIDE EFFECTS
15 OF MORPHINE TOXICITY, IS THAT RIGHT?
16 A. RIGHT.
17 Q. OKAY. NOW, YOUR TESTIMONY WAS TO THE EFFECT THAT ALSO
18 THAT AN UNCONSCIOUS PERSON CANNOT PERCEIVE PAIN.
19 A. RIGHT.
20 Q. IS THAT RIGHT? THAT DOESN'T NECESSARILY MEAN THAT THE
21 MECHANISM THAT WOULD CREATE PAIN IS NOT THERE. THAT JUST
22 MEANS THAT AN UNCONSCIOUS PERSON CANNOT PERCEIVE PAIN.
23 A. THAT'S RIGHT.
24 Q. SO THERE IS NO ABILITY FOR ANYBODY TO EVALUATE WHETHER
25 THIS PATIENT IS IN PAIN, CORRECT?
3632
1 A. AT THAT POINT, YES.
2 Q. AT THAT POINT. I MEAN EVEN THE PHYSICIAN OR THE NURSES
3 OR ANYBODY ELSE WOULD NOT BE ABLE TO ASCERTAIN WHETHER THIS
4 PATIENT WAS IN PAIN. NOW, WE'VE HAD TESTIMONY FROM SOME
5 FAMILY MEMBERS, IN PARTICULAR FROM JUDITH LARSEN'S FAMILY,
6 TO THE EFFECT THAT THEIR MOTHER WAS TOTALLY UNRESPONSIVE
7 WHEN THEY WENT TO VISIT HER THE LAST DAY OF HER LIFE. WOULD
8 THAT OBSERVATION BE CONSISTENT WITH A PERSON WHO SUFFERING
9 FROM MORPHINE TOXICITY?
10 A. I SUPPOSE YOU'D HAVE TO CONSIDER THAT AS ONE OPTION, BUT
11 IN HER PARTICULAR CASE, I THINK HER G.I. TRACT BLEEDING WAS
12 MUCH MORE SIGNIFICANT IN THE FINAL -- BECAUSE SHE'S LOSING
13 THE OXYGEN-CARRYING COMPONENTS OF THE BLOOD, THE RED BLOOD
14 CELLS. AND SO THAT IN AND OF ITSELF IS GONNA CUT DOWN ON
15 THE OXYGEN THAT'S AVAILABLE TO HER. NOT HAVING ANYTHING TO
16 DO WITH THE MORPHINE.
17 Q. SO THE MORPHINE WOULDN'T HAVE ANY CONTRIBUTING FACTOR TO
18 HER DEATH --
19 A. WELL, I DIDN'T --
20 Q. -- IN YOUR OPINION?
21 A. -- I DIDN'T GO THAT FAR BUT, YOU KNOW, THERE'S JUST --
22 IT'S A COMPLEX ISSUE. I DON'T KNOW HOW TO PARTITION OFF
23 WHAT EACH OF THESE THINGS, THE INSULTS THAT SHE WAS
24 SUFFERING CONTRIBUTED TO HER CLINICAL CONDITION. I DON'T
25 KNOW THAT ANYBODY COULD DO THAT.
3633
1 Q. CAN YOU TELL US, DOCTOR, IS THE DRUG MORPHINE RESERVED
2 FOR PAIN CONTROL?
3 A. NO.
4 Q. SO IN YOUR OPINION, YOU CAN USE IT FOR OTHER PURPOSES?
5 A. IT'S THE BEST TREATMENT FOR DIARRHEA GOING.
6 Q. OKAY. SO YOU WOULD USE IT FOR DIARRHEA?
7 A. MORPHINE HAS SAVED COUNTLESS LIVES IN PATIENTS WHERE
8 THERE HAVE BEEN EPIDEMICS OF CHOLERA AND OTHER
9 DIARRHEA-PRODUCING DRUGS -- I MEAN DISEASES. SO THAT WAS
10 THE FIRST THING THAT PEOPLE NOTICED IN, YOU KNOW,
11 MORPHINE -- OPIUM WAS FOUND FOUR MILLENNIA B.C., 4,000 YEARS
12 BEFORE CHRIST, SO IT'S BEEN AROUND A LONG TIME.
13 Q. I TAKE IT THEN, YOU WOULD DISAGREE WITH EXPERTS WHO
14 TESTIFIED THAT IT'S RESERVED IN THE CLINICAL SETTING FOR
15 SEVERE TO MAYBE MODERATE PAIN?
16 MR. STIRBA: I'M GONNA OBJECT, YOUR HONOR. I THINK
17 THIS IS AN IMPROPERLY FORMED QUESTION.
18 Q. (BY MR. WILSON) WELL, I THINK YOU PREVIOUSLY
19 TESTIFIED, DID YOU NOT, THAT FROM THE ARTICLE, THE OPIOIDS
20 ARE USED FOR SEVERE TO MODERATE PAIN, IS THAT CORRECT?
21 A. THAT'S RIGHT. BUT I DON'T KNOW -- YOU SAID SOMETHING
22 ABOUT RESERVED --
23 Q. WELL, LET'S PUT IT THIS WAY: IN YOUR PRACTICE, YOU USE
24 IT FOR OTHER PURPOSES. IS THAT RIGHT?
25 A. YES. NOT OFTEN, BUT I DO.
3634
1 Q. WHEN YOU REVIEWED THESE MEDICAL RECORDS -- LET ME SHOW
2 YOU WHAT'S BEEN MARKED AS STATE'S EXHIBIT 36. ASK YOU TO
3 TAKE A LOOK AT THAT, IF YOU WOULD.
4 A. THESE ARE THE DIFFERENT DRUGS, AND THEN I ASSUME THAT
5 WHEN IT CHANGES THAT THAT MEANS A DOSE WAS INCREASED.
6 Q. THAT'S CORRECT.
7 A. OKAY. LIKE THIS. YEAH.
8 Q. OKAY .
9 A. WELL --
10 Q. NOW -- WELL, LET ME -- LET ME JUST ORIENTATE YOU TO THE
11 LEFT-HAND SIDE WHERE THE DRUGS ARE LISTED.
12 A. OH, OKAY.
13 Q. ARE YOU FAMILIAR WITH THE GERIATRIC HAND -- DOSING
14 HANDBOOK?
15 A. YES.
16 Q. DO YOU AGREE WITH THE DOSAGES THAT ARE REFERENCED IN THE
17 GERIATRIC HANDBOOK, DOSING HANDBOOK?
18 A. I SAID I WAS FAMILIAR WITH IT, BUT I DIDN'T SAY I KNEW
19 WHAT THE DOSAGES WERE.
20 Q. OKAY. SO YOU DON'T USE THEM IN YOUR PRACTICE?
21 A. WELL, I DON'T USE THAT PARTICULAR ONE. BUT IF YOU LOOK
22 IN THE PREFACE OF THAT BOOK, IT JUST SAYS THAT'S A
23 GUIDELINE. NONE OF IT HAS BEEN -- NONE OF IT IS
24 EVIDENCE-BASED. THEY SAY THAT UP FRONT. THERE'S NEVER BEEN
25 ANY STUDIES TO SHOW THAT THESE ARE DOSES THAT ARE BASED UPON
3635
1 EVIDENCE THAT THEY ARE THE PROPER DOSES. IT'S JUST THAT --
2 IT'S BASED UPON THE EXPERIENCE OF THE PEOPLE WHO WROTE THE
3 BOOK AND THEIR CONSULTANTS.
4 Q. OKAY. AND SO YOU DON'T NECESSARILY DISAGREE WITH THAT.
5 A. I DON'T DISAGREE WITH IT, I DON'T AGREE WITH IT. I
6 THINK IT'S A GUIDELINE AND I WOULD USE IT TO -- IF I WAS
7 UNFAMILIAR WITH A DRUG, THAT'S A GOOD STARTING POINT. ALL
8 OF THESE GUIDELINES, THAT'S ALL THEY ARE. THEY ARE JUST --
9 GIVES THE HEALTHCARE PROVIDER A REASONABLE DOSE TO START OFF
10 WITH, AND THEY SHOULD THEN MAKE WHATEVER CHANGES ARE
11 NECESSARY BASED UPON THE OUTCOME. WHAT YOU WANT IS PAIN
12 RELIEF.
13 Q. OKAY.
14 A. AND YOU'RE NOT INTERESTED IN THE PROCESS OR THE DOSES OR
15 ANYTHING. JUST WHATEVER IT TAKES TO RELIEVE THE PAIN.
16 Q. NOW, YOU'VE -- COUNSEL SHOWED YOU SOME CHARTS THAT HAVE
17 BEEN PREPARED RELATIVE TO THE DOSAGES OF MORPHINE SULFATE
18 THAT WERE ADMINISTERED TO JUDITH LARSEN. DO YOU RECALL
19 THAT?
20 A. YES.
21 Q. AND THIS WAS A CHART THAT WAS REFERENCING, AS I
22 UNDERSTAND IT, THE RESPIRATION RECORDS. IS THAT RIGHT?
23 A. YEAH, I GUESS --
24 Q. EXCUSE ME, THAT'S THE WRONG CHART.
25 THE COURT: I THINK THOSE ARE THE PAPERS SHOWN ON
3636
1 THE OVERHEAD.
2 MR. STIRBA: MR. WILSON.
3 MR. WILSON: THANK YOU. LET ME TAKE THIS OTHER
4 EXHIBIT DOWN.
5 Q. NOW, YOUR TESTIMONY, AS I UNDERSTAND IT, IS BASED ON THE
6 RESPIRATIONS THAT WERE RECORDED ON THOSE VARIOUS DATES AND
7 THESE WERE RECORDED AT REGULAR INTERVALS, THE SHIFT
8 INTERVALS, IS THAT CORRECT?
9 A. YES, I'M SURE THEY --
10 Q. DO YOU HAVE THOSE CHARTS --
11 A. YEAH, I DO, MATTER OF FACT.
12 Q. -- IN FRONT OF YOU? COULD YOU TURN TO JUDITH LARSEN'S
13 CHART?
14 A. YES.
15 THE COURT: ARE YOU TALKING ABOUT THE BOOKS?
16 THE WITNESS: THIS?
17 MR. WILSON: YES, THAT CHART THERE.
18 THE COURT: OKAY.
19 THE WITNESS: YEAH.
20 Q. (BY MR. WILSON) I'M GONNA TAKE THAT OFF FOR JUST A
21 SECOND. DO YOU HAVE THE CHART THAT'S GOT MED RECORD 495 ON
22 IT?
23 A. IT SAYS 492.
24 Q. DO YOU HAVE 495 AVAILABLE THERE?
25 A. OH, YEAH. OKAY. HERE, THAT'S THE LAST SHEET.
3637
1 Q. CAN YOU JUST READ DOWN AT THE BOTTOM WHAT THOSE
2 RESPIRATION RATES ARE AS RECORDED?
3 A. IT LOOKS LIKE 6, 6 AND THAT THAT'S IT. I DON'T KNOW
4 WHAT THAT OTHER THING THERE IS.
5 Q. THEN YOU'VE GOT THE MED-494 WHICH IS THE PAGE JUST IN
6 FRONT OF THAT.
7 A. YES.
8 Q. WHAT'S THE LAST RESPIRATION RATE THERE?
9 A. 6.
10 Q. OKAY.
11 A. ON THE 2ND.
12 Q. SO THERE WAS -- THERE WAS ESSENTIALLY -- THESE
13 RESPIRATIONS WERE TAKEN IN EIGHT-HOUR INCREMENTS, WERE THEY
14 NOT?
15 A. YEAH, IT LOOKS LIKE ON THAT DAY, THERE WAS ONE THAT WAS
16 TAKEN AT 12 A.M., WHICH WOULD BE EARLY IN THE MORNING, AND
17 THAT WAS 12.
18 Q. OKAY.
19 A. AND --
20 Q. AND THE ONE TAKEN NEXT AFTER THAT WAS --
21 A. AND AT 4 P.M. --
22 Q. -- WHAT TIME?
23 A. -- WAS 6.
24 Q. AND THEN THE FOLLOWING MORNING --
25 A. IT WAS 6 --
3638
1 Q. -- YOUR TESTIMONY IS --
2 A. -- 6 --
3 Q. -- 6 AND 6, RIGHT?
4 A. -- RIGHT. 12 MIDNIGHT AND 6 IN THE MORNING -- NO, 4 IN
5 THE MORNING -- NO 8 IN THE MORNING. EXCUSE ME.
6 Q. AND THEN SHE PASSED AWAY.
7 A. RIGHT.
8 Q. NOW, IS A 6 A DEPRESSED RESPIRATORY RATE?
9 A. COULD BE. IT COULD BE.
10 Q. IF THAT 6 WAS ALSO IN CONJUNCTION WITH -- SHE WASN'T
11 RESPONDING TO ANY TOUCH OR ANY KIND OF STIMULI, WOULD THAT
12 ALSO BE CONSISTENT WITH THAT PARTICULAR LOW RESPIRATORY
13 RATE?
14 A. HARD TO SAY. I'M NOT SAYING THAT THAT COULD BE A
15 DEPRESSED, BUT THAT -- I DIDN'T SAY THAT COULDN'T SUSTAIN
16 LIFE. AND YOU'VE GOT TO TAKE INTO ACCOUNT THAT SHE'S
17 BLEEDING ACTIVELY AT THIS TIME, LOSING THE OXYGEN-CARRYING
18 CAPACITY OF HER BLOOD. SO THIS IS A FAR MORE SERIOUS THING
19 THAN THE -- NOW, YOU ADD THAT TO 6 RATE, PROBABLY SHE'S NOT
20 OXYGENATING VERY WELL.
21 Q. DID YOU REVIEW THE AUTOPSY REPORTS --
22 A. I DID.
23 Q. -- IN CONNECTION WITH THESE PROCEEDINGS?
24 A. YEAH. LET'S SEE, YEAH, HERE SHE IS.
25 Q. CAN YOU TELL US WHETHER YOU'VE SEEN ANYTHING IN THE
3639
1 AUTOPSY REPORT THAT INDICATED THAT SHE WAS SUFFERING FROM
2 ANY BLEEDING OF THE -- IN THE GASTROINTESTINAL TRACT?
3 A. THEY DON'T MENTION ANYTHING ABOUT THE GASTROINTESTINAL
4 TRACT.
5 Q. YOU DON'T SEE ANYTHING MENTIONED.
6 A. NOT IN THE FINAL PATHOLOGICAL DIAGNOSIS.
7 Q. OKAY.
8 A. NOW, IF IT'S IN THE -- HERE, DO YOU WANT ME TO READ YOU
9 WHAT IT SAYS? YOU'VE READ IT.
10 Q. WHAT DOES IT SAY?
11 A. THE ESOPHAGUS -- THIS IS AFTER THREE AND A HALF YEARS
12 THAT SHE'S BEEN BURIED. THE ESOPHAGUS IS LINED WITH -- BY
13 DECOMPOSING AND EMBALMED APPEARING MUCOSA WITH NO FOCAL
14 ABNORMALITIES. NO FOREIGN MATERIALS ARE PRESENT WITHIN THE
15 ESOPHAGUS. THE STOMACH HAS MULTIPLE TROCAR PUNCTURES, WHICH
16 IS THE EMBALMING PROCESS. THEY PUT A BIG TROCAR, AND IT'S
17 GOT MULTIPLE TROCAR PUNCTURE SITES AND DECOMPOSITIONAL
18 CHANGES. THE GASTRIC LUMEN IS EMPTY. THE SMALL AND LARGE
19 BOWEL HAVE MULTIPLE TROCAR PUNCTURING SITES AND DECOMPOSING
20 CHANGES AS WELL AS PARTIAL FIXATION WITH NO OTHER
21 ABNORMALITIES IDENTIFIED. APPENDIX IS PRESENT. THE
22 PANCREAS HAS A PARTIALLY --
23 Q. WELL, THAT -- YOU DON'T NEED TO READ ANY FURTHER.
24 YOU'VE READ THE STOMACH PART, HAVEN'T YOU?
25 A. YEAH.
3640
1 Q. OKAY.
2 A. AND THE INTESTINE, SO --
3 Q. NOW, DOCTOR, IN RESPECT TO THE TYPES OF PAIN MEDICATIONS
4 THAT ARE USED, IT'S MY UNDERSTANDING THAT THE PROCEDURE ONE
5 WOULD NORMALLY FOLLOW WOULD BE ONE OF IDENTIFYING THE
6 SEVERITY AND THE LOCATION, INTENSITY OF THE PAIN, RIGHT?
7 A. FOR PAIN, YES.
8 Q. IF THERE WAS NO PAIN PRESENT IN ANY OF THESE PATIENTS,
9 WOULD THERE BE ANY INDICATION OR ANY MEDICAL NECESSITY FOR
10 THE USE OF MORPHINE?
11 A. LIKE I SAY, I USE THINGS PAIN -- I MEAN MORPHINE FOR
12 THINGS OTHER THAN PAIN. IT'S A VERY GOOD ANXIETY REDUCER --
13 THE COURT: I THINK THE QUESTION'S ABOUT THESE
14 PATIENTS, IS THAT CORRECT?
15 MR. WILSON: ON THESE PATIENTS.
16 Q. DID YOU, SIR, IF THERE -- ASSUMING THERE WAS NO PAIN
17 PRESENT IN ANY OF THESE PATIENTS, WOULD THERE BE IN YOUR
18 POSITION -- OR IN YOUR POSITION -- OR OPINION, LET'S PUT IT
19 THAT WAY, A MEDICAL REASON FOR ADMINISTERING MORPHINE?
20 A. THAT QUESTION'S SO HYPOTHETICAL, I CAN'T ANSWER IT.
21 Q. SO YOU CAN'T ANSWER THE QUESTION AS IF THERE WAS NO PAIN
22 PRESENT?
23 A. YOU'RE ASSUMING SOMETHING, I DON'T KNOW -- I DON'T THINK
24 THAT'S THE CASE, SO I CAN'T ASSUME THAT.
25 Q. WELL, I'M JUST ASKING YOU, IF YOU WERE TO ASSUME --
3641
1 A. IS THIS AN ABSTRACT QUESTION?
2 Q. OKAY. SO IN OTHER WORDS, YOU CAN'T ANSWER THE QUESTION.
3 A. RIGHT.
4 MR. WILSON: I HAVE NO FURTHER QUESTIONS.
5 THE COURT: ANY REDIRECT?
6 MR. STIRBA: YES, YOUR HONOR.
7 REDIRECT EXAMINATION
8 BY MR. STIRBA:
9 Q. DO YOU HAVE MS. LARSEN'S BINDER IN FRONT OF YOU, SIR?
10 A. YEAH.
11 Q. DOCTOR, I WANT YOU TO --
12 A. WAIT A MINUTE, YEAH. LET ME SEE HERE. YEAH, HERE SHE
13 IS.
14 Q. TURN TO THE NURSES' NOTES SECTION IN THE BINDER --
15 THE COURT: I THINK HE'S REFERRING TO THESE
16 BINDERS.
17 MR. STIRBA: MAY I ASSIST, YOUR HONOR?
18 THE WITNESS: WHAT BINDER? OH. YEAH, I DIDN'T
19 EVEN SEE THESE.
20 Q. (BY MR. STIRBA) TURN TO THE NURSES' NOTES SECTION. IT
21 WOULD BE 587 PLEASE.
22 A. 587. IS THAT A PAGE?
23 Q. YES.
24 MAY I ASSIST, YOUR HONOR?
25 THE COURT: YES.
3642
1 THE WITNESS: THERE'S A NUMBER. THERE'S A LOT OF
2 NUMBERS.
3 Q. (BY MR. STIRBA) DO YOU HAVE 587 DOWN AT THE BOTTOM IN
4 FRONT OF YOU?
5 A. YES.
6 Q. AND THAT'S A NURSE'S NOTE.
7 A. YEAH.
8 Q. AND APPEARS TO BE FOR THE DATE OF JANUARY 2ND OF '96?
9 A. YES. RIGHT UP AT THE TOP.
10 Q. AND DO YOU SEE A REFERENCE IN THAT NOTE WHERE THE NURSE
11 HAS CHARTED A RESPIRATION RATE?
12 A. YEAH, RESPIRATION IS 12 TO 16.
13 Q. THEN IF YOU'LL TURN THE NEXT PAGE TO 589.
14 A. YEAH.
15 Q. AND ALSO AT THE TOP, DO YOU SEE A REFERENCE TO A
16 RESPIRATION RATE?
17 A. AT THE TOP?
18 Q. YES.
19 A. OH, YEAH. RESPIRATIONS HERE.
20 Q. AND WHAT DOES IT SAY --
21 A. 5 TO 8.
22 Q. PARDON ME?
23 A. 5 TO 8.
24 Q. 5 TO 8. IF YOU'LL TURN TO THE NEXT PAGE, WHICH IS ALSO
25 THE 3RD, AND IF YOU GO DOWN TO 2000 HOURS. DO YOU SEE
3643
1 ANOTHER RESPIRATION RATE THAT WAS RECORDED BY THE NURSE?
2 A. YEAH, DEEP RESPIRATIONS, 10.
3 Q. NOW, DOCTOR, DO YOU HAVE YOUR NOTES IN FRONT OF YOU
4 CONCERNING ELLEN ANDERSON?
5 A. MY NOTES OR THIS ONE?
6 Q. NO, YOUR NOTES, SIR.
7 A. YEAH.
8 Q. OKAY. NOW, YOU TESTIFIED ON CROSS-EXAMINATION, I
9 BELIEVE YOU WERE ASKED A QUESTION ABOUT PATIENT ELLEN
10 ANDERSON, AND YOU SAID THAT SHE SUFFERED FROM A
11 GASTROINTESTINAL BLEED.
12 A. YES.
13 Q. I THINK THERE WAS A -- YOU WERE CONFUSING HER WITH
14 ANOTHER PATIENT.
15 A. OH.
16 Q. WOULD YOU JUST REVIEW THAT TO MAKE SURE WE --
17 A. DID I SAY ELLEN ANDERSON WAS THE GASTROINTESTINAL BLEED?
18 Q. YES.
19 A. YEAH, I THINK YOU'RE RIGHT BECAUSE I DON'T SEE ANYTHING
20 HERE ON -- THAT WAS JUDITH LARSEN THAT WAS BLEEDING.
21 Q. YES, I BELIEVE IT WAS.
22 A. OKAY. I APOLOGIZE.
23 Q. SO REVIEWING YOUR NOTES THERE, DOES THAT REFRESH YOUR
24 RECOLLECTION --
25 A. YES.
3644
1 Q. -- CONCERNING ELLEN ANDERSON'S CIRCUMSTANCES?
2 A. YEAH, THERE'S NOTHING HERE THAT I HAVE THAT SAYS -- I
3 SAY THAT PAIN MEDS RELATED TO OSTEOPOROSIS, FRACTURES OF THE
4 WRIST AND ANKLE, AND RELATED TO THE FRACTURE THAT SHE HAD IN
5 JUNE OF 1995, WHICH WOULD BE APPROXIMATELY -- LET'S SEE,
6 SHE -- YEAH, SIX MONTHS BEFORE SHE WAS ADMITTED. WHICH
7 WOULD REFLECT I THINK A CONSEQUENCE OF HER OSTEOPOROSIS.
8 MR. STIRBA: OKAY. THANK YOU, DOCTOR. I HAVE NO
9 FURTHER QUESTIONS.
10 THE COURT: ANYTHING FURTHER, MR. WILSON?
11 MR. WILSON: NO, YOUR HONOR. WE CAN EXCUSE THE
12 WITNESS. THANK YOU, DOCTOR.